Att. 3m - ETP Attachment 9 Survey Questionnaire Eligibility Screener (9.24.21)

Form Approved

OMB No. 0920-0910

Exp. Date 01/31/2024

Emerging Tobacco Products Communication Initiative

Survey Questionnaire Eligibility Screener

Public reporting burden of this collection of information is estimated to average 2 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0910).

Thank you for your interest in this study. Please answer the following questions to determine if you are eligible to participate.

	Programming Notes. [THESE WILL NOT APPEAR ON SCREEN].
What is your current age? [Open-ended]	If S1 < 18, skip to ineligibility statement.
Which of the following best describes your occupation? Teacher School administrator (e.g., principal, vice principal) Guidance counselor School staff (e.g., office manager, custodian) Other education professional Other non-education professional	Quota of 200 teachers Quota of 200 administrators and guidance counselors
Do you coach any sports or extracurricular activities? Yes, I am a sports/athletic coach (e.g., football, basketball, baseball, softball, volleyball, track, field, lacrosse) Yes, I am an extracurricular coach (e.g., chess, speech/debate, United Nations, engineering or robotics, match/science competitions) No, I am not a coach	If S2 = “school staff” or “other” selections AND S3 = “not a coach,” skip to ineligibility statement. If S2 = “school staff” or “other” AND S3= “Yes”, skip to S6. Quota of 200 who identify as coaches (regardless of whether they also identify as educators). Quota of 100 who identify as “sports/athletic coach”
[If teacher, administrator, or counselor] What percentage of your professional time do you spend in direct contact with students? Your best estimate is fine.  50% or higher Less than 50%	If 50% or higher, skip to S6. If less than 50%, continue to S5.
[If less than 50% time in contact with students] Do you oversee school operations, such as curriculum development, or school policy? Yes No	If S3 = “not a coach” and S5 = “no”, skip to ineligibility statement.
What is the grade-level of the school where you currently work?  Elementary school Middle school High school Other	If S6 = “middle school,” continue. (Quota of 300.) If S6 = “high school,” continue. (Quota of 300.) If S6 = “elementary school” or “other,” skip to ineligibility statement.
In what state do you currently reside?   [Drop down menu]	If “outside U.S.”, skip to ineligibility statement. Minimum quota of 120 per U.S. Census region (Northeast, South, Midwest, West).
How many years of professional experience do you have in your role as an educator? Less than 5 years 5-10 years More than 10 years	Minimum quota of 120 per category.
Which of the following best describes the location of the school where you work?    Urban Suburban Rural	Minimum quota of 150 per category.
How do you describe your ethnicity? Hispanic or Latino Not Hispanic or Latino	Minimum quota of 120 Hispanic/Latino participants. Permit overlap for ethnicity and race categories (S10 and S11). For example, if we enroll an African-American Hispanic participant, this person would count toward both the race and ethnicity quotas.
How do you describe your race? (select all that apply) American Indian or Alaskan Native Asian Black or African American Native Hawaiian or other Pacific Islander White	Minimum quota of 120 non-White participants. Permit overlap for ethnicity and race categories (S10 and S11). For example, if we enroll an African-American Hispanic participant, this person would count toward both the race and ethnicity quotas.
What sex were you assigned at birth, on your original birth certificate?  Male Female Refused I don’t know
Do you currently describe yourself as male, female, or transgender? Male Female Transgender None of these	Minimum quota of 240 male participants. Minimum quota of 240 female participants.
Eligibility statement: Thank you for completing these questions. You are eligible for this study and will now be taken to the consent form and survey. Ineligibility statement: Thank you for completing these questions. You are not eligible for this study.

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