0920-1083 Nonsmoker Survey - Wave C

NONSMOKER WAVE A-I SURVEY
Form Approved
OMB No. 0920-1083
Exp. Date XX/XX/20XX
Extended Evaluation of the National Tobacco Prevention and Control Public Education
Campaign Nonsmoker Questionnaire
Public reporting burden of this collection of information is estimated to average 20 minutes per
response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to
a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600
Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1083).

SUBJECTS FOR QUESTIONNAIRE
SECTION A:
SECTION B:
SECTION C:
SECTION D:
SECTION E:
SECTION F:

PREVIOUS TOBACCO USE
TOBACCO USE QUESTIONS
ATTITUDES AND BELIEFS
SECONDHAND SMOKE
MEDIA USE AND AWARENESS
CLOSING QUESTIONS

SECTION A: PREVIOUS TOBACCO USE
NA4.

Have you smoked cigarettes at all, even one puff, in the past 12 months?
1.Yes
2. No

1

NA4_X
Was the last time you smoked a cigarette, even one or two puffs…?
1.
2.
3.
4.
5.
6.
7.

NA5.

Within the past 24 hours
Within the past 7 days
Within the past 30 days
Within the past 3 months
Within the past 6 months
Within the past 1 year
More than 1 year ago

Have you quit smoking cigarettes completely in the past 6 months?
1. Yes
2. No

SECTION B: TOBACCO USE QUESTIONS
NB2.

During the past 3 months, how many times have you stopped smoking for one
day or longer because you were trying to quit smoking cigarettes for good?
Number of times

NB2a.

During the past 6 months, that is since [FILL LAUNCH DATE], how many times
have you stopped smoking for one day or longer because you were trying to quit
smoking cigarettes for good?
Number of times

NB1.

During the past 12 months, that is, since [DATE FILL], how many times have you
stopped smoking for one day or longer because you were trying to quit smoking
cigarettes for good?
Number of times

NB3c.

In the past 12 months, have you used any of the following medications to help
you quit smoking: nicotine skin patch, nicotine gum, nicotine lozenges, nicotine
nasal spray, a nicotine inhaler, or pills such as Wellbutrin, Zyban, buproprion,
Chantix, or varenicline?
1. Yes
2. No

2

NB4.

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

2. No

NB4_1. Give up cigarettes all at once
NB4_2. Gradually cut back on cigarettes
NB4_3. Switch completely to vaping (using e-cigarettes, vape pens, JUULs, mods,
or other personal vaporizers)
NB4_4. Substitute smoking some of your regular cigarettes with vaping (using ecigarettes, vape pens, JUULs, mods, or other personal vaporizers)
NB4_5. Switch to mild or some other brand of cigarettes
NB4_6. Use nicotine replacements like the nicotine patch, nicotine gum, nicotine
lozenges, nicotine nasal spray, or nicotine inhaler
NB4_7. Use medications like Wellbutrin, Zyban, buproprion, Chantix, or varenicline
NB4_8. Get help from a telephone quit line
NB4_9. Get help from a website such as Smokefree.gov or CDC.gov/Tips
NB4_10. Get help from a doctor or other health professional
NB4_11. Get help from a pharmacist

3

NB5.

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

2. No

NB5_1. A family member or friend encouraged me to try to quit
NB5_2. Television commercials, radio ads, or other types of
advertisements that focus on the health consequences of
smoking
NB5_3. My doctor or other health professional advised me to quit
smoking
NB5_4. Workplace restrictions on smoking
NB5_5. Other, specify

Electronic Vapor Product Questions
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.

NB8.

Have you ever vaped, even one time?
1. Yes
2. No
4

NB8a.

During the past 30 days, on how many days did you vape?
1.
2.
3.
4.
5.
6.
7.

NB9.

0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days

Do you now vape…
1. Every day
2. Some days
3. Not at all

NB9a. On the days that you vape, how often do you vape?
1.
2.
3.
4.

Rarely
Sometimes
Often
Very Often

5

NB9a.

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

NB9b_1.

When you vape, does the liquid/contents usually contain nicotine?
1. Yes
2. No

6

NB10.

Are any of the following a reason why you first tried/currently vape?
1. Yes

2. No

NB10_1. I can vape when or where smoking cigarettes is not allowed
NB10_2. Vaping might be less harmful to me than smoking cigarettes
NB10_3. I like the flavors
NB10_4. Vaping can help me quit or cut back on smoking cigarettes
NB10_5. Vaping helps me deal with cravings to smoke
NB10_6. A friend or family member suggested I vape as a way to quit smoking
NB10_7. A friend or family member [IF B9=3 INSERT: shared/ IF B9=1 OR 2
INSERT: shares] their vaping device with me
NB10_8. Vaping is popular among people my age
NB10_9. I [IF B9=3 INSERT: was/ IF B9=1 OR 2 INSERT: am] curious about vaping
NB10_10. Other, specify

NB13.

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

NB14.

Do you want to quit vaping for good?
1. Yes
2. No

7

Quitline Use and Awareness
Now, we are going to ask you some additional questions about regular cigarettes.

NE9a.

A telephone quitline is a free telephone-based service that connects people
who smoke cigarettes with someone who can help them quit.
In the past 3 months, that is since [FILL DATE], have you recommended any
family members or friends that smoke to call a telephone quitline?
1. Yes
2. No

NE10.

NE10a.

NE11.

Have you heard of 1-800-QUIT-NOW?
1. Yes
2. No

In the past 3 months, that is since [FILL DATE], have you recommended any
family members or friends that smoke to call 1-800-QUIT-NOW?
1. Yes
2. No

In the past 3 months, did you recommend your family and friends to ask about
the following free medications when calling 1-800-QUIT-NOW: nicotine patches,
gum, lozenges, nasal spray, inhaler, or pills such as Wellbutrin, Zyban,
buproprion, Chantix, or varenicline?
1. Yes
2. No

8

SECTION C: ATTITUDES AND BELIEFS
Social Norms of Smoking and SHS
The next few questions will ask about your opinions related to smoking and
tobacco use.

ND19.

Please tell us if you strongly disagree, disagree, agree, or strongly agree with the
following statement.
Smoking cigarettes can cause medical complications and diseases that require
surgeries and medical procedures to treat.
1.
2.
3.
4.

NC1.

Strongly disagree
Disagree
Agree
Strongly agree

Do you believe cigarette smoking is related to:
1. Yes

2. No

NC1_1. Lung Cancer
NC1_2. Cancer of the mouth or throat
NC1_3. Heart Disease
NC1_4. Diabetes
NC1_5. Emphysema
NC1_6. Stroke
NC1_7. Hole in throat (stoma or tracheotomy)
NC1_8. Buerger’s Disease
NC1_9. Amputations (removal of limbs)
NC1_10. Asthma
NC1_11. Gallstones
NC1_12. COPD or Chronic bronchitis
NC1_13. Periodontal or Gum Disease
NC1_14. Premature birth
NC1_15. Colorectal Cancer
NC1_16. Macular degeneration or blindness
NC1_17. Depression
NC1_18. Anxiety disorder
NC1_19. Colon Cancer

NC2.

How likely do you think a smoker will develop a smoking-related disease as a
result of smoking?

9

1.
2.
3.
4.
5.

Extremely likely
Very likely
Somewhat likely
Very unlikely
Extremely unlikely

10

SECTION D: SECONDHAND SMOKE & PEER COMMUNICATION
The next few questions ask your opinion about smoke from other people’s
cigarettes and other tobacco products.

NC4a.
How likely do you think it 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

ND1.

Other than yourself, does anyone who lives in your home smoke cigarettes now?
1. Yes
2. No

ND4.

During the past 3 months, that is since [FILL DATE], have you talked to any
family members or friends about the dangers of smoking?
1. Yes
2. No

ND5a.

During the past 3 months, that is since [FILL DATE], did you encourage a friend
or family member to quit smoking?
1. Yes
2. No

NE8b.

Not counting decks, porches, or garages, inside your home, is smoking….
3. Always allowed
4. Allowed only at some times or in some places
5. Never allowed
11

NE9_1.

Are you seriously considering increasing restrictions on smoking in your
household?
3. Definitely yes
4. Probably yes
5. Probably not
6. Definitely not

12

SECTION E: MEDIA USE AND AWARENESS
NE1.

On an average day, how much television do you watch?
1. None
2. Less than one hour
3. About 1 hour
4. About 2 hours
5. About 3 hours
6. About 4 hours
7. 5 hours or more

NE2.

On an average day, how many hours do you listen to the radio?
1. None
2. Less than one hour
3. About 1 hour
4. About 2 hours
5. About 3 hours
6. About 4 hours
7. 5 hours or more

NE3.

On an average day, how many hours do you use the Internet for personal
reasons?
1. None
2. Less than one hour
3. About 1 hour
4. About 2 hours
5. About 3 hours
6. About 4 hours
7. 5 hours or more

NE4.

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

NE14.

Have you heard of the Website www.cdc.gov/Tips?
1. Yes
2. No

13

NE14a.

Have you visited www.cdc.gov/Tips in the past [FILL MONTHS], since [FILL
1. Yes
2. No

NE14c.

In the past [FILL MONTHS], that is since [FILL DATE], have you
recommended any family members or friends that smoke to visit
www.cdc.gov/Tips?
1. Yes
2. No

NE14d.

In the past [FILL MONTHS], that is since [FILL DATE], have you seen or heard
advertisements for medications or products to help people quit smoking such as
Chantix, nicotine patches, or nicotine gums?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Always

NE18.

In the past [FILL MONTHS PLANNED CAMPAIGN DURATION] months, since
[FILL DATE], have you seen or heard of any ads on television or radio with the
following themes or slogans?
1. Yes 2. No
NE18_1. TIPS FROM FORMER SMOKERS
NE18_2. TRUTH
NE18_3. BECOME AN EX
NE18_4. EVERY CIGARETTE IS DOING YOU DAMAGE
NE18_5. TOBACCO FREE LIVING
NE18_6. THE REAL COST

14

NF19_1.

Have you seen any of the following Facebook page or group when you have
been online in the past [FILL MONTHS], since [FILL DATE]?
1.Yes
2. No

NF19_2.

Have you seen the following YouTube channel or page when you have been
online in the past [FILL MONTHS], since [FILL DATE]?
1.Yes
2. No

NF19_3.

Have you seen the following Twitter page when you have been online in the
past [FILL MONTHS], since [FILL DATE]?
[SHOW IMAGE “Tips_Twitter”]
1.Yes
2. No

NF20.

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?
1. Yes 2. No
NF20_1. Looked for information about quitting smoking
NF20_2. Looked for information about vaping (using e-cigarettes or other vaping
products)
NF20_3. Looked for information about nicotine replacement therapies (e.g.,
patches, gum, lozenges)
NF20_4. Downloaded a mobile App to help you quit smoking
NF20_5. Signed up for a texting program to help you quit smoking
NF20_6. Created an online plan to help you quit smoking

15

Exposure and Reaction to TV Ads
Now, we would like you to view a series of advertisements that have been
shown on television and online in the U.S. Please make sure your computer’s
volume is set to an appropriate level. You may be prompted by your computer
to download a program enabling video playback. If the videos do not work,
you’ll still be able to see images and descriptions of the advertisements. When
you are ready, please click on the link below to view the first advertisement.
There is a total of [FILL # TOTAL ADS] ads to view. After you view each ad,
there will be a few questions that ask about your opinions of the ad.

NF21_x.

Were you able to view this video?
2. Yes
3. No

NF23_x.

Now we would like to show you some screen shots from a television
advertisement that has been shown in the U.S. Once you have viewed the
images displayed below, please click on the forward arrow below to continue
with the survey.

NF24_x.

Have you seen this ad on television or online in the past [FILL # MONTHS
SINCE CAMPAIGN LAUNCH] months, since [CAMPAIGN LAUNCH DATE]?
1. Yes
2. No

NF24a_x_TV
.

In the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH] months, how
frequently have you seen this ad on television?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very often

16

NF24a_x_ In the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH] months, how
COMPUTER. frequently have you seen this ad on a laptop or desktop computer?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very often

NF24a_x_
MOBILE.

In the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH] months, how
frequently have you seen this ad on a tablet or smartphone?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very Often

NF25_x.

Please tell us if you strongly disagree, disagree, neither agree nor disagree,
agree, or strongly agree with the following statements.
1. Strongly disagree
2. Disagree
3. Neither agree nor disagree
4. Agree
5. Strongly agree
NF25a_x. This ad is worth remembering.
NF25b_x. This ad grabbed my attention.
NF25c_x. This ad is powerful.
NF25d_x. This ad is informative.
NF25e_x. This ad is meaningful to me.
NF25f_x.
This ad is convincing.

17

NF26_x.

On scale of 1 to 5, where 1 means “not at all” and 5 means “very,” please
indicate how much this ad made you feel…
1
2
3
4
5
Not at all
Very
NF26a_x.
NF26b_x.
NF26d_x.
NF26f_x.
NF26g_x.
NF26h_x.

Sad
Afraid
Ashamed
Hopeful
Motivated
Understood

Exposure to Radio Ads
Now, we would like you to listen to a radio advertisement that has aired in the
U.S. Please make sure your computer’s volume is set to an appropriate level.
You may be prompted by your computer to download a program enabling
audio playback. If you cannot hear the audio, you’ll still be able to read a
description of the advertisement. There is a total of [FILL # TOTAL RADIO
ADS] radio ads to listen to. When you are ready, please click on the link below
to listen to the ad. After you listen to the ad, there will be a few questions that
ask about your recent recall of the ad.

NF32_x.

Were you able to listen to this ad?
1. Yes
2. No

NF34_x.

Now we would like to show you a script from a radio advertisement that has
been shown in the U.S. Once you have read the script displayed below, please
click on the forward arrow below to continue with the survey.

18

NF35_x.

Have you heard this ad on the radio in the past [FILL MONTHS] months, since
[CAMPAIGN LAUNCH DATE]?
1. Yes
2. No

Exposure to Display, Print, and Out-of-Home
Next, you will see some advertisements that have recently appeared in
magazines, on websites, and on signs in areas such as bus shelters, bus
interiors, billboards and other public places. There are 3 sets of images to
view, followed by a few questions about whether you have seen these ads
before. When you are ready to view them, please click “Next.”

NE36.

In the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH], since
CAMPAIGN LAUNCH DATE], have you seen any of these ads in magazines,
on Websites, or in public places outside your home?
1. Yes
2. No

NE37.

Where did you see these advertisements?
1. Yes

2. No

NE37_1. Magazines or print publications
NE37_2. Websites online

NE37
a.

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

19

Awareness of E-cigarette Ads
NF38.

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

20

SECTION F: CLOSING QUESTIONS
NG1.

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

NG5.

What is the highest level of school you have completed?
1. No formal education
2. 1st, 2nd, 3rd, or 4th grade
3. 5th or 6th grade
4. 7th grade or 8th grade
5. 9th grade
6. 10th grade
7. 11th grade
8. 12th grade, no diploma
9. High school graduate – high school Diploma or the equivalent (GED)
10. Some college, no degree
11. Associate degree
12. Bachelor’s degree
13. Master’s degree
14. Professional or Doctorate degree

NG6.

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

21

NG6a.

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

NG6b.

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

NG7.

Are you now…
1.
2.
3.
4.
5.

Married
Widowed
Divorced
Separated
Never married

22

NG8. Which statement best describes your current employment status?
1. Working – as a paid employee
2. Working – self-employed
3. Not working – on temporary layoff from a job
4. Not working – looking for work
5. Not working – retired
6. Not working –- disabled
7. Not working – other

NG8a.

In your MAIN job, what kind of work do you do? Select one answer only.
1. Medical Doctor (such as physician, surgeon, dentist, veterinarian)
2. Other Health Care Practitioner (such as nurse, pharmacist,
chiropractor, dietician)
3. Health Technologist or Technician (such as paramedic, lab technician)
4. Health Care Support (such as nursing aide, orderly, dental assistant)
5. Protective Service ( police, firefighters)
6. Food Preparation and Serving
7. Building and Grounds Cleaning and Maintenance
8. Personal Care and Service(hair stylists, gaming workers,
entertainment)
9. Sales Representative
10. Retail Sales
11. Other Sales
12. Office and Administrative Support
13. Farming, Forestry, and Fishing
14. Construction and Extraction
15. Installation, Maintenance, and Repair
16. Precision Production (such as machinist, welder, baker, printer,
tailor)
17. Transportation and Material Moving
18. Armed Forces
19. Management
20. Business and Financial Operations Professional
21. Computer and Mathematical
22. Architecture and Engineering
23. Life, Physical, and Social Sciences
24. Community and Social Services
25. Lawyer or Judge
26. Teacher, except college and university
27. Teacher, college and university
28. Other, please specify _____________.

23

NG9.

How many smoking or tobacco related web surveys like this have you
completed during the past year?
1. None
2. 1 survey
3. 2 surveys
4. 3 surveys
5. 4 surveys
6. 5 or more surveys

NG7a. Are you currently living with a partner to whom you are not married?
1. Yes
2. No

24

NG10

Please indicate your current military service status (select one).
1.
2.
3.
4.
5.
6.

NG11.

Active duty
Reserves
National Guard
Veteran or Armed Services Retiree
Veteran or Retiree with a service connected disability
Civilian: NO military service record

Are you CURRENTLY covered by any of the following types of
health insurance or health coverage plans? Mark “yes” or “no” for
each type of coverage.
1. Yes

2. No

NG15_1. Insurance through a current or former employer or union
NG15_2. Insurance purchased directly from an insurance company
NG15_3. Medicare, for people age 65 and over, or people with certain
disabilities
NG15_4. Medicaid, or any kind of government assistance plan for those with
low incomes or disability
NG15_5. TRICARE or other military health care
NG15_6. VA (including those who have ever enrolled for or
used VA health care
NG15_7. Indian Health Service
NG15_8. Any other type of health insurance or health
coverage plan

NG15.

Have you been diagnosed by a physician or other qualified medical
professional with any of the following medical conditions?
1. Yes

25

2. No

NG15_1.
NG15_2.
NG15_3.
NG15_4.
NG15_5.
NG15_6.
NG15_7.
NG15_8.
NG15_9.
NG15_10.
NG15_11.
NG15_12.
NG15_13.
NG15_14.
NG15_15.
NG15_16.
NG15_17.
NG15_18.
NG15_19.
NG15_20.
NG15_21.
NG15_22.
NG15_23.
NG15_24.

Acid reflux disease
ADHD or ADD
Anxiety disorder
Asthma, chronic bronchitis, or COPD
Cancer (any type except skin cancer)
Chronic pain (such as low back pain, neck pain, or
Fibromyalgia)
Depression
Diabetes
Heart attack
Heart disease
High blood pressure
High cholesterol
HIV/AIDS
Kidney disease
Mental health condition
Multiple sclerosis
Osteoarthritis, joint pain or inflammation
Osteoporosis or osteopenia
Rheumatoid arthritis
Seasonal allergies
Skin cancer
Sleep disorders such as sleep apnea or insomnia
Stroke
Something else

26

NG20.

Do you or anyone in this household connect to the Internet from home?
1. Yes
2. No

NG21.

Do you live in a metro or non-metro area?
1. Non-metro (rural)
2. Suburban
3. Urban

NG22.

Using the scale below, please tell us how much you agree or disagree with the
following statements.
1. Strongly agree
2. Somewhat agree
3. Neither agree nor disagree
4. Somewhat disagree
5. Strongly disagree
NG20a. I usually try new products before other people do.
NG20b. I often try new brands because I like variety and get
bored with the same old thing.
NG20c. When I shop I look for what is new.
NG20d. I like to be the first among my friends and family to try
something new.
NG20e. I like to tell others about new brands or technology.

NG23.

Do you consider yourself to be…
1. Heterosexual or straight
2. Gay
3. Lesbian
4. Bisexual
5. Other, please specify

Thank you for completing today’s survey. Your input will greatly help
researchers assess the impact of television ads about quitting smoking.
You will be awarded [AMOUNT] bonus points credited to your
KnowledgePanel account for completing the survey. A follow-up survey will be
sent to you in about [FILL # MONTHS PLANNED CAMPAIGN DURATION]
and you will be awarded [AMOUNT] bonus points for completing that survey.

27

NADD1.

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

NADD1_1. Please type in the name to whom you’d like us to send the incentive check:
Name ___________________

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NADD1_2.

Please type in the address to where we should send the incentive check:
Street Address:
City:
State:
Zip Code:

NADD2.

Is the contact information below now up-to-date?
1. Yes
2. No

NCONTA Thank you for your participation in this important study! If you entered your
CT_A.
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

NCONTA Is this the address where you would like us to send your next CDC survey
CT_A1. invitation?
1.Yes
2. No

NCONTA Please provide us with the address that you would like us to use to send you
CT_A2. your next CDC survey invitation
Street Address:
City:
State:
Zip Code:

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NCONTA So that you can participate in the future if you choose to do so, please provide
CT_B.
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:

NCONTA In case we are unable to reach you through the email address or phone number
CT2_A. 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:

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