Form NSDUH Online FG Sc NSDUH Online FG Sc NSDUH Online FG Screening Instrument

ONLINE SCREENER – NSDUH

INTRO.
Please complete this short questionnaire to determine your eligibility to participate in a one-hour virtual
focus group to provide input on materials used on a large drug and health study sponsored by the
federal government. Before you begin, please ensure you are in a private location where no one else
can see your responses.
-----------------------------------------------------------------------------------------------------------------------------------------Q1. Would you be willing to take part in a one-hour virtual focus group if selected?
1. Yes
2. No – [TERMINATE. Thank you for your time.]
-----------------------------------------------------------------------------------------------------------------------------------------Q2. During the virtual focus group, we will be displaying some visuals on screen. All participants must
participate using a desktop or laptop computer with the necessary software for audio and video
capabilities on Zoom.
Do you have access to a desktop or laptop computer with the necessary software for audio and video
capabilities?
1. Yes
2. No – [TERMINATE. Thank you for your time.]
-----------------------------------------------------------------------------------------------------------------------------------------Q3. The next few questions are about you to help ensure we gather feedback from a variety of people.
This information will be kept confidential and you can refuse to answer any of the questions.
What is your age group?
1.
2.
3.
4.
5.
6.

12 – 17 [TERMINATE. Thank you for your time.]
18 – 25
26 – 34
35 – 49
50+
Prefer not to answer

-----------------------------------------------------------------------------------------------------------------------------------------Q4. Do you describe yourself as male, female, transgender, or do you use a different term? (select all
that apply)
1. Male
2. Female
3. Transgender

4. Use a different term – [IF Q4=4] Q4a. What term do you use? [OPEN FIELD]
5. Prefer not to answer
-----------------------------------------------------------------------------------------------------------------------------------------Q5. Are you of Hispanic, Latino or Spanish origin?
1. Yes
2. No
3. Prefer not to answer
[IF Q5=1] – Q5a. Which language do you tend to speak at home?
1. English
2. Spanish
3. Both equally
4. Other – Specify [OPEN FIELD]
5. Prefer not to answer
-----------------------------------------------------------------------------------------------------------------------------------------Q6. What is your race? Please select all that apply.
1.
2.
3.
4.
5.
6.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian/other Pacific Islander
White
Prefer not to answer

--------------------------------------------------------------------------------------------------------------------Q7. What is the highest grade or year of school you have completed?
0 No schooling completed
1 1st grade completed
2 2nd grade completed
3 3rd grade completed
4 4th grade completed
5 5th grade completed
6 6th grade completed
7 7th grade completed
8 8th grade completed
9 9th grade completed
10 10th grade completed
11 11th grade completed
12 Regular high school diploma
13 12th grade, no diploma
14 GED certificate of high school completion
15 Some college credit, but no degree
16 Associate’s degree (for example, AA, AS)

17 Bachelor’s degree (for example, BA, BS)
18 Master’s degree (for example, MA, MS, MENG, M. Ed, MSW, MBA)
19 Doctorate degree (for example, PhD, EdD)
20 Professional degree beyond a bachelor’s degree (for example, MD, DDS, DVM, LLB, JD)
21 Prefer not to answer
-----------------------------------------------------------------------------------------------------------------------------------------Q8. Please provide the city and state in which you live:
If you live in D.C., please enter “D.C.” for the city and state.
If you live in Puerto Rico, please tell us which city, and then enter “Puerto Rico” for state.
[OPEN] City
[OPEN] State
-----------------------------------------------------------------------------------------------------------------------------------------Q9. Please provide the following contact information in case you are selected for the focus group:
Q9a. First name: [OPEN FIELD]
Q9b. Email address: [OPEN FIELD]
Q9c. Telephone number: [OPEN FIELD]
-----------------------------------------------------------------------------------------------------------------------------------------Q10. If you are selected for the focus group discussion, we will ask participants to allow us to record
audio and video of the discussion to ensure our notes are correct.
Are you willing to be recorded during the discussion?
1. Yes [GO TO THANK YOU]
2. No
-----------------------------------------------------------------------------------------------------------------------------------------Q11_REFUSE.
In order to participate in the focus group, we are asking all participants to allow audio and video
recording. We understand if you have concerns, but this is a necessary requirement to ensure accuracy
of our notes. Please provide any concerns that you might have in the box below.
[OPEN FIELD – ALLOW 300]
-----------------------------------------------------------------------------------------------------------------------------------------THANK YOU
Thank you. We will review your responses and reach out to you if you are selected for the focus group
discussion. Please press [SUBMIT] to submit your responses. [EXIT SCREENER – COMPLETED]
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TERMINATE.
Thank you for your time. [EXIT SCREENER – INELIGIBLE]
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