Changes to Smoker Survey

Attachment D-3. Changes to Wave A-I Smoker Survey Updated.docx

Extended Evaluation of the National Tobacco Prevention and Control Public Education Campaign

Changes to Smoker Survey

OMB: 0920-1083

Document [docx]
Download: docx | pdf

Attachment D-3. Changes to Waves A-I Smoker Survey

Item

Currently Approved Question Text

Currently Approved Responses

Revision Type

Revised Question Text

Revised Responses

C4

When you last tried to quit smoking, did you do any of the following?

Across:

  1. Yes

  2. No


Down:


C4_1. Give up cigarettes all at once

C4_2. Gradually cut back on cigarettes

C4_3. Switch completely to electronic vapor products such as e-cigarettes, vape-pens, hookah-pens, electronic hookahs (e-hookahs), electronic cigars (e-cigars), electronic pipes (e-pipes), e-vaporizers, or tank systems

C4_4. Substitute some of your regular cigarettes with electronic vapor products such as e-cigarettes, vape-pens, hookah-pens, electronic hookahs (e-hookahs), electronic cigars (e-cigars), electronic pipes (e-pipes), e-vaporizers, or tanksystems

C4_5. Switch to mild or some other brand of cigarettes

C4_6. Use nicotine replacements like the nicotine patch, nicotine gum, nicotine lozenges, nicotine nasal spray, or nicotine inhaler

C4_7. Use medications like Wellbutrin, Zyban, buproprion, Chantix, or varenicline

C4_8. Get help from a telephone quit line

C4_9. Get help from a website such as Smokefree.gov or CDC.gov/Tips

C4_10. Get help from a doctor or other health professional

C4_11. Get help from a pharmacist

Revision

When you last tried to quit smoking, did you do any of the following?

Across:

1. Yes

2. No


Down:


C4_1. Give up cigarettes all at once

C4_2. Gradually cut back on cigarettes

C4_3. Switch completely to vaping (using e-cigarettes, vape pens, JUULs, mods, or other personal vaporizers)

C4_4. Substitute smoking some of your regular cigarettes with vaping (using e-cigarettes, vape pens, JUULs, mods, or other personal vaporizers)

C4_5. Switch to mild or some other brand of cigarettes

C4_6. Use nicotine replacements like the nicotine patch, nicotine gum, nicotine lozenges, nicotine nasal spray, or nicotine inhaler

C4_7. Use medications like Wellbutrin, Zyban, buproprion, Chantix, or varenicline

C4_8. Get help from a telephone quit line

C4_9. Get help from a website such as Smokefree.gov or CDC.gov/Tips

C4_10. Get help from a doctor or other health professional

C4_11. Get help from a pharmacist

C4_12. Use a mobile App to help you quit smoking

C4_13. Use a texting program to help you quit smoking

C5

When you last tried to quit smoking, did any of the following motivate you to try to quit?

Across:


1. Yes

2. No


Down:


C5_1. A family member or friend encouraged me to try to quit

C5_2. Television commercials, radio ads, or other types of advertisements that focus on the health consequences of smoking

C5_3. My doctor or other health professional advised me to quit smoking

C5_4. Workplace restrictions on smoking

C5_5. Other, please specify:__[text]_________


Revision

When you last tried to quit smoking, did any of the following motivate you to try to quit?

Across:


1. Yes

2. No


Down:


C5_1. A family member or friend encouraged me to try to quit

C5_2. Anti-tobacco television commercials, online ads or videos, radio ads, or other types of advertisements that focus on the health consequences of smoking

C5_3. My doctor or other health professional advised me to quit smoking

C5_4. Workplace restrictions on smoking

C5_5. Cost of cigarettes is too high

C5_6. Other, please specify:__[text]_________


C12

How worried are you that smoking will damage your health in the future?

1. Not at all worried

2. A little worried

3. Somewhat worried

4. Very worried

Deletion

N/A

N/A

E-Cig Intro

The next questions are about electronic vapor products. These are devices that usually contain a nicotine-based liquid that is vaporized and inhaled. You may also know them as e-cigarettes, vape-pens, hookah-pens, electronic hookahs (e-hookahs), electronic cigars (e-cigars), electronic pipes (e-pipes), or e-vaporizers. Some brand examples are Blu, NJOY, Vuse, MarkTen, Fin, and Logic. Some examples of electronic vapor products are pictured below.

Revision

The next questions are about vaping (using e-cigarettes, vape pens, JUULs, mods, other personal vaporizers). Vaping products are battery-powered and produce vapor instead of smoke. They typically use a nicotine liquid, although the amount of nicotine can vary and some may not contain any nicotine at all. Some common brands are JUUL, Vuse, MarkTen, Logic, and Blu.


These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.


B8

Have you ever used electronic vapor products, even one time?

1. Yes

2. No

Revision

Have you ever vaped, even one time?

1. Yes

2. No

B8a

During the past 30 days, on how many days did you use electronic vapor products?

1. 0 days

2. 1 or 2 days

3. 3 to 5 days

4. 6 to 9 days

5. 10 to 19 days

6. 20 to 29 days

7. All 30 days

Revision

During the past 30 days, on how many days did you vape?

1. 0 days

2. 1 or 2 days

3. 3 to 5 days

4. 6 to 9 days

5. 10 to 19 days

6. 20 to 29 days

7. All 30 days

B9

Do you now use electronic vapor products…

1. Every day

2. Some days

3. Not at all

Revision

Do you now vape…

1. Every day

2. Some days

3. Not at all

B9a

On the days that you use electronic vapor products, how often do you use them?

1. Rarely

2. Sometimes

3. Often

4. Very Often

Revision

On the days that you vape, how often do you vape?

1. Rarely

2. Sometimes

3. Often

4. Very Often

B9_date

How long ago did you first try an electronic vapor product?

1. 1 to 2 weeks ago

2. 3 to 4 weeks ago

3. 1 to 3 months ago

4. 4 to 6 months ago

5. 7 to 12 months ago

6. More than 1 year ago

Deletion

N/A

N/A

B9a_date

How long have you been using electronic vapor products every day or some days?

1. 1 to 2 weeks ago

2. 3 to 4 weeks ago

3. 1 to 3 months ago

4. 4 to 6 months ago

5. 7 to 12 months ago

6. More than 1 year ago

Deletion

N/A

N/A

B9a

Do you usually use disposable electronic vapor products, rechargeable vapor products that use cartridges, or rechargeable vapor products that use refillable tanks?


Please indicate the type of electronic vapor product that you use the most.


1. Disposable devices that are not rechargeable or refillable

2. Rechargeable devices that are used with non-refillable cartridges

3. Rechargeable devices that have small refillable cartridges for e-liquid

4. Rechargeable devices that have large refillable tanks for e-liquid

5. Unknown device type


Revision

Do you usually vape with disposable devices, rechargeable devices that use pods or cartridges, or rechargeable devices that use large refillable tanks?


Please indicate the type of device that you vape most often.


1. Disposable devices that are not rechargeable or refillable

2. Rechargeable devices that use pods or cartridges, like JUULs

3. Rechargeable devices that have large refillable tanks

4. Unknown device type

B9b

On average, about how many do you now use each week?


_________[ENTER NUMBER]

Deletion

N/A

N/A







B9b_1

When you use your electronic vapor product, does the liquid/contents usually contain nicotine?

1. Yes

2. No

3. Don’t know

Revision

When you vape, does the liquid/contents usually contain nicotine?

1. Yes

2. No

3. Don’t know

B9c

Where did you get or buy the electronic vapor products that you have used?

B9c_1. A gas station or convenience store

B9c_2. A grocery store

B9c_3. A drugstore

B9c_4. A mall or shopping center kiosk/stand

B9c_5. Over the Internet

B9c_6. A store that sells electronic vapor products, such as a “vape shop”

B9c_11. Mass merchandisers or supercenters like Walmart, Target, or Costco

B9c_8. From a family member

B9c_9. From a friend

B9c_10. Some other person that is not a family member or a friend

B9c_7. Other, specify [text]_______[anchor]

Deletion

N/A

N/A

B9d

Which of those is the main way you usually get your electronic vapor products?

[Show list of responses provided in B9c]

Deletion

N/A

N/A

B10

Are any of the following a reason why you first tried/currently use electronic vapor products?

B10_1. They cost less than other forms of tobacco

B10_2. They can be used in places where smoking cigarettes isn’t allowed

B10_3. They might be less harmful to me than regular cigarettes

B10_4. They might be less harmful to people around me than regular cigarettes

B10_5. Electronic vapor products come in flavors I like

B10_6. Electronic vapor products can help me quit smoking regular cigarettes

B10_7. Electronic vapor products can help me reduce the number of regular cigarettes I smoke

B10_8. Electronic vapor products don’t smell

B10_9. Using an electronic vapor product feels like smoking a regular cigarette

B10_10. Electronic vapor products don’t bother people who don’t use tobacco

B10_11. The advertising for electronic vapor products appeals to me

B10_12. They help me deal with cravings to smoke

B10_13. I have a friend or family member who suggested I use electronic vapor products as a way to quit smoking

B10_14. I was curious about electronic vapor products

B10_15. Other, specify

Revision

Are any of the following a reason why you [IF B9=3 INSERT: first tried vaping; IF B9=1 or 2 INSERT: currently vape]?

B10_1. I can vape when or where smoking cigarettes is not allowed

B10_2. Vaping might be less harmful to me than smoking cigarettes

B10_3. I like the flavors

B10_4. Vaping can help me quit or cut back on smoking cigarettes

B10_5. Vaping helps me deal with cravings to smoke

B10_6. A friend or family member suggested I vape as a way to quit smoking

B10_7. A friend or family member [IF B9=3 insert: shared/ IF B9=1 or 2 insert: shares] their vaping device with me

B10_8. Vaping is popular among people my age

B10_9. I [IF B9=3 insert: was/ IF B9=1 or 2 insert: am] curious about vaping

B10_10. Other, specify


B11

Which of those is the main reason you first tried/currently use electronic vapor products?

[Show list of responses provided in B10]

Deletion

N/A

N/A

B11a

You indicated previously that you have tried electronic vapor products before but do not currently use them every day or some days. Please indicate the reasons why you do not use electronic vapor products now

B11a_1. I only use them temporarily when regular cigarettes are not allowed or not wanted

B11a_2. I have quit smoking both regular cigarettes and electronic vapor products

B11a_3. They are too expensive

B11a_4. They do not satisfy my cravings

B11a_5. They are not like real cigarettes (e.g., too heavy, do not feel real)

B11a_6. They taste bad

B11a_7. I am concerned about the health effects of electronic vapor products

B11a_8. I was only curious about electronic vapor products when I tried them

B11a_9. They are inconvenient (e.g., difficult to charge, difficult to refill)

B11a_10. They are too strong

B11a_11. Other, specify

Deletion

N/A

N/A

B11b

You indicated previously that you currently smoke cigarettes and also currently use electronic vapor products. Please indicate your reasons for not switching completely from regular cigarettes to electronic vapor products.

B11b_1. I am still addicted to real cigarettes

B11b_2. Electronic vapor products are too expensive

B11b_3. I am still in the process of switching to vaping

B11b_4. Electronic vapor products are not like real cigarettes (e.g., too heavy, do not feel real)

B11b_5. Electronic vapor products taste bad

B11b_6. I am concerned about the health effects of electronic vapor products

B11b_7. Electronic vapor products are inconvenient (e.g., difficult to charge, difficult to refill)

B11b_8. My peers still use regular cigarettes

B11b_9. I only use electronic vapor products temporarily when regular cigarettes are not allowed or not wanted

B11b_10. Other, specify

Deletion

N/A

N/A

B12

Do you use electronic vapor products in places where smoking regular cigarettes is not allowed?

1. Yes

2. No

Deletion

N/A

N/A

B12a

Do you use electronic vapor products in any of the following places?

B12a_1. Restaurants or bars

B12a_2. Stores or shopping malls

B12a_3. Airplanes

B12a_4. Beaches, parks, or other outdoor places

B12a_5. In your car or other type of vehicle

B12a_6. In your home

B12a_7. Somewhere else, specify

Deletion

N/A

N/A

B13

As far as you know or believe is the use of electronic vapor products in combination with regular cigarettes less harmful than smoking only regular cigarettes, more harmful than smoking only regular cigarettes, or equally as harmful as smoking only regular cigarettes?


Please indicate your answer on a scale of 1 to 5, where one is much less harmful, 3 is the same as regular cigarettes, and 5 is much more harmful.


1.Much less harmful than smoking only regular cigarettes

2. Slightly less harmful than smoking regular cigarettes

3. Equally harmful as smoking only regular cigarettes

4. Slightly more harmful than smoking regular cigarettes

5. Much more harmful than smoking only regular cigarettes

Revision

In your opinion, regularly vaping and smoking cigarettes is…

1.Much less harmful to one’s health than only smoking cigarettes

2. Slightly less harmful to one’s health than only smoking cigarettes

3. Equally harmful to one’s health as only smoking cigarettes

4. Slightly more harmful to one’s health than only smoking cigarettes

5. Much more harmful to one’s health than only smoking cigarettes

B14

Do you want to quit using electronic vapor products for good?

1.Yes, after I have successfully stopped smoking cigarettes

2. Yes, but I will continue to smoke cigarettes

3. No

Revision

Do you want to quit vaping for good?

1. Yes

2. No

B15

Do you plan to quit using electronic vapor products….

1. In the next 7 days,

2. In the next 30 days,

3. In the next 6 months,

4. In the next 1 year, or

5. More than 1 year from now?

6. I do not plan to quit using electronic vapor products for good

7. Not sure/Uncertain

Deletion

N/A

N/A

D17

On a scale from 1 to 5, with 1 begin the “lowest” and 5 being the “highest,” how would you rate quitting smoking as a priority in your life?

1. Lowest

2.

3.

4.

5. Highest

Deletion

N/A

N/A

D22

How likely do you think it is that smoking will worsen medical complications from diabetes such as blindness, renal failure, or amputations?

1. Extremely likely

2. Very likely

3. Somewhat likely

4. Very unlikely

5. Extremely unlikely

Deletion

N/A

N/A

E7

Do you think that breathing smoking from other people’s cigarettes or from other tobacco products is…

1. Not at all harmful to one’s health

2. Somewhat harmful to one’s health

3. Very harmful to one’s health

Deletion

N/A

N/A

E8a

How likely is it that regularly breathing secondhand tobacco smoke would cause nonsmokers to have asthma, infections, or lung damage?

1. Extremely likely

2. Very likely

3. Somewhat likely

4. Very unlikely

5. Extremely unlikely

Revision

In your opinion how likely is it that regularly breathing secondhand tobacco smoke would worsen asthma or cause infections or lung damage among nonsmokers?

1. Extremely likely

2. Very likely

3. Somewhat likely

4. Very unlikely

5. Extremely unlikely

F4

What type of Internet connection do you have for your home computer or other primary computer?

1.Cable/DSL/Broadband/High-Speed

2. Dial-Up

3. Not Sure

Deletion

N/A

N/A

F18

Where have you seen or heard about the TIPS campaign?

Across:


1. Yes

2. No


Down:


F18_1. On TV

F18_2. On the radio

F18_3. In newspapers or magazines

F18_4. On the Internet

F18_5. Billboards or other outdoor ads

Deletion

N/A

N/A

F20

Sometimes people use the Internet specifically for health-related reasons. In the past 30 days, have you used the Internet for any of the following reasons?

Across:


1. Yes

2. No


Down:


F20_1. Looked for information about quitting smoking

F20_2. Looked for information about electronic vapor products (e.g., e-cigarettes, e-vaporizers)

F20_3. Looked for information about nicotine replacement therapies (e.g., patches, gum, lozenges)

F20_4. Downloaded a mobile App to help you quit smoking

Revision

Sometimes people use the Internet specifically for health-related reasons. In the past 30 days, have you used the Internet for any of the following reasons?

Across:


1. Yes

2. No


Down:


F20_1. Looked for information about quitting smoking

F20_2. Looked for information about vaping (using e-cigarettes or other vaping products)

F20_3. Looked for information about nicotine replacement therapies (e.g., patches, gum, lozenges)

F20_4. Downloaded a mobile App to help you quit smoking

F20_5. Signed up for a texting program to help you quit smoking

F20_6. Created an online plan to help you quit smoking

F21

In the past 30 days, have you shared information via email, social media, blog or online forum/support group about any of the following?

Across:


1. Yes

2. No


Down:


F21_1. How to quit smoking

F21_2. CDC Tips campaign messages/videos

F21_3. Electronic vapor products (e.g., e-cigarettes, e-vaporizers)

F21_4. Nicotine replacement therapies (e.g., patches, gum, lozenges)

Deletion

N/A

N/A

F28_a

In the past [FILL MONTHS SINCE CAMPAIGN LAUNCH] months, have these ads stopped you from having a cigarette when you were about to smoke one? Would you say…

1. Never

2. Once

3. A few times

4. Many times

Deletion

N/A

N/A

F28_x

Would this ad make you want to quit smoking?

1. Yes

2. No

Deletion

N/A

N/A

F28_1x

On a scale of 1 (not at all) to 5 (extremely), to what degree did the ad focus on the benefits of quitting smoking cigarettes?

1. Not at all

2. Slightly

3. Moderately

4. Very

5. Extremely

Deletion

N/A

N/A

F28_2x

On a scale of 1 (not at all) to 5 (extremely), to what degree did the ad focus on the consequences of continuing to smoke cigarettes?

1. Not at all

2. Slightly

3. Moderately

4. Very

5. Extremely

Deletion

N/A

N/A

F28_3x

Please rate the overall tone of the ad on a scale from 1 (extremely negative) to 5 (extremely positive)

1. Extremely negative

2. Slightly negative

3. Neither negative nor positive

4. Slightly positive

5. Extremely positive

Deletion

N/A

N/A

F30

For the next few question think about all the advertisements you just viewed and recalled seeing in the past 3 months.


Did you talk to anyone about any of these ads?

1. Yes

2. No

Deletion

N/A

N/A

F31

When you talked about the ads, did the person talking to you about the ads encourage you to stop smoking?

1. Yes

2. No

Deletion

N/A

N/A

F31_x

Did seeing these ads make you want to do any of the following?

1. Quit smoking

2. Cut back on the number of cigarettes I smoke

3. Use electronic vapor products, such as e-cigarettes, vape-pens, hookah-pens, electronic hookahs (e-hookahs), electronic cigars (e-cigars), electronic pipes (e-pipes), or e-vaporizers

4. Switch to mild or some other brand of cigarettes

5. Use nicotine replacements like the nicotine patch, nicotine gum, nicotine lozenges, nicotine nasal spray, or nicotine inhaler

6. Use medications like Wellbutrin, Zyban, buproprion, Chantix, or varenicline

7. Call a telephone quitline

8. Visit a web site such as Smokefree.gov or CDC.gov/Tips

9. Talk to a doctor or other health professional about quitting

Deletion

N/A

N/A

F37

Where did you see these advertisements?

Across:

1.Yes

2.No


Down:


F37_1. Magazines or print publications

F37_2. Websites online

F37_3. Public places such as bus shelters, bus interiors, outdoor bulletins, etc.

Revision

Where did you see these advertisements?

F37_1. Magazines or print publications

F37_2. Websites online


F37a

N/A

N/A

Addition

In the past XX Months, since [DATE], have you seen any of these ads in public places outside your home such as billboards, bus shelters, or bus interiors?

1. Yes

2. No

F38

When you go to a convenience store, supermarket, or gas station, how often do you see ads or promotions for electronic cigarettes or e-cigarettes?

1. I never go to a convenience store, supermarket, or gas station

2. Never

3. Rarely

4. Sometimes

5. Most of the time

6. Always

Revision

When you go to a convenience store, supermarket, or gas station, how often do you see ads or promotions for vaping products?

1. I never go to a convenience store, supermarket, or gas station

2. Never

3. Rarely

4. Sometimes

5. Most of the time

6. Always

G1

How many children aged 17 or younger live in your household 6 months or more of the year?

_______Number of children

Revision

How many people are 17 years of age or younger and currently live in your household at least 50% of the time? If none, enter “0.” Include babies and small children. Your answer will help represent the entire U.S. population and will be kept confidential. Thank you!

________Number of children

G6

The next question is about the total income of YOUR HOUSEHOLD for the PAST 12 MONTHS. Please include your income PLUS the income of all members living in your household (including cohabiting partners and armed forces members living at home). Please count income BEFORE TAXES and from all sources (such as wages, salaries, tips, net income from a business, interest, dividends, child support, alimony, and Social Security, public assistance, pensions, or retirement benefits).


Was your total HOUSEHOLD income in the past 12 months…

1. Below $35,000

2. $35,000 or more

3. Don’t Know

Revision

How much is the combined income of all members of YOUR HOUSEHOLD for the PAST 12 MONTHS? Please include your income PLUS the income of all members living in your household (including cohabiting partners and armed forces members living at home). Please count income BEFORE TAXES and from all sources (such as wages, salaries, tips, net income from a business, interest, dividends, child support, alimony, and Social Security, public assistance, pensions, or retirement benefits).

1. Below $50,000

2. $50,000 or more

3. Don’t Know

G6a

We would like to get a better estimate of your total HOUSEHOLD income in the past 12 months before taxes. Was it…

1.Less than $5,000

2. $5,000 to $7,499

3. $7,500 to $9,999

4. $10,000 to $12,499

5. $12,500 to $14,999

6. $15,000 to $19,999

7. $20,000 to $24,999

8. $25,000 to $29,999

9. $30,000 to $34,999


Revision

We would like to get a better estimate of your total HOUSEHOLD income in the past 12 months before taxes. Was it…

1.Less than $5,000

2. $5,000 to $7,499

3. $7,500 to $9,999

4. $10,000 to $12,499

5. $12,500 to $14,999

6. $15,000 to $19,999

7. $20,000 to $24,999

8. $25,000 to $29,999

9. $30,000 to $34,999

10. $35,000 to $39,999

11. 40,000 to $49,999


G6b

We would like to get a better estimate of your total HOUSEHOLD income in the past 12 months before taxes. Was it…

1. $35,000 to $39,999

2. $40,000 to $49,999

3. $50,000 to $59,999

4. $60,000 to $74,999

5. $75,000 to $84,999

6. $85,000 to $99,999

7. $100,000 to $124,999

8. $125,000 to $149,999

9. $150,000 to $174,999

10. $175,000 or more

Revision

We would like to get a better estimate of your total HOUSEHOLD income in the past 12 months before taxes. Was it…

1. $50,000 to $59,999

2. $60,000 to $74,999

3. $75,000 to $84,999

6. $85,000 to $99,999

4. $100,000 to $124,999

5. $125,000 to $149,999

6. $150,000 to $174,999

10. $175,000 to $199,999

11. $200,000 to $249,999

12. $250,000 or more

G7

Are you now married, widowed, divorced, separated, never married, or living with a partner?

1.Married

2. Widowed

3. Divorced

4. Separated

5. Never married

6. Living with a partner

Revision

Are you now…

1. Married

2. Widowed

3. Divorced

4. Separated

5. Never married

G7a

N/A

N/A

Addition

Are you currently living with a partner to whom you are not married?

1.Yes

2. No

ADD1

Those are all of our questions. Thanks so much for your participation in our survey. As a token of our appreciation, we would like to send you [IF SAMPLE

= KP WITHDRAWN, “$15”; IF SAMPLE=ABS, “$20”]. Would you please

provide your name and mailing address so that we can put the check in the mail. This information will not be connected with your survey responses in any way.


After you have entered your information, please make sure to click “Next.”

Name (First/Last):

Street Address (If applicable, include unit number):

City:

State:

Zip Code:

Revision

Those are all of our questions.  Thanks so much for your participation in our survey.  As a token of our appreciation, we would like to send you $[IF SAMPLE = KP WITHDRAWN, $15; IF SAMPLE=ABS, INSERT INCENTIVE VALUE FROM LOOKUP TABLE based on MNO; IF SAMPLE=ABS and incentive value is missing from lookup table, insert: $20]. 

Please verify your name and mailing address so that we can put the check in the mail. To ensure that you will be able to deposit or cash the check, please be sure to provide us with your full first AND last name; if you provide incomplete or inaccurate information, you may not be able to deposit the check. This information will not be connected with your survey responses in any way.

Please select the field(s) that you’d like to update. If all of the information is correct, please select “All of the above are correct”.

1.Name (First/Last):

2.Mailing Address:

3.All of the above are correct


ADD1_1

N/A

N/A

Addition

Please type in the name to whom you’d like us to send the incentive check:

Name___________

ADD1_2

N/A

N/A

Addition

Please type in the address to where we should send the incentive check:

Street Address:

City:

State:

Zip Code:

ADD2

N/A

N/A

Addition

Is the contact information below now up-to-date?

1. Yes

2. No

CONTACT_A

N/A

N/A

Addition

Thank you for your participation in this important study! If you entered your address information on the previous question, your check for participation will arrive in the next 4 – 6 weeks.

The CDC will also have the opportunity to do at least one more survey in the future, with additional rewards and prizes for participation. Would you be willing to participate in another survey for the CDC?

1. Yes

2. No

CONTACT_A1

N/A

N/A

Addition

Is this the address where you would like us to send your next CDC survey invitation?

1. Yes

2. No

CONTACT_A2

N/A

N/A

Addition

Please provide us with the address that you would like us to use to send you your next CDC survey invitation

Street Address:

City:

State:

Zip Code:

CONTACT_B

N/A

N/A

Addition

So that you can participate in the future if you choose to do so, please provide your e-mail address and best phone number to reach you below. Remember, you can decline to do any survey at that time if you do not want to do it.

My email address is:

The best phone number to reach me:

CONTACT2_A

N/A

N/A

Addition

In case we are unable to reach you through the email address or phone number you provided in the previous question, is there an alternate email address or a phone number to be able to reach?

It is very important for us to hear back from you for future surveys that we will be sending out so we can ensure that the researchers have complete data for this new and important study.

Alternate Email:

Alternate phone number to reach you:



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorDavis, Kevin C.
File Modified0000-00-00
File Created2021-06-08

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