0920-0621 Cognitive Testing Yourh Recruitment Screener

Form Approved

OMB No. 0920-0621

Exp. Date 01/31/2024

2024 National Youth Tobacco Survey (NYTS)

Cognitive Testing Parent Recruitment Screener Questionnaire

Your child is invited to participate in an interview. The Centers for Disease Control and Prevention (CDC) has hired Deloitte to interview 24-30 youth to participate in two rounds of testing, with each interview scheduled approximately 2-4 weeks apart. Deloitte is a company that is assisting CDC with conducting health surveillance. The purpose of the interviews is to help CDC test questions on health and tobacco product use. The first interview will test the original questionnaire, and the second interview will test the modifications made to the questionnaire based on the first round. We will conduct the interviews in [INSERT DATE], and each interview will last up to, but no more than 1 hour. If your child participates in the interview, they will receive one $50 Amazon gift card per interview in appreciation of their time.

This survey will be used to identify eligible youth participants for the interviews. This survey should take about 10 minutes to complete. Your responses to the survey are private. This survey involves no known risks. There is no penalty for not doing the interview. You can skip questions you don’t want to answer or end the survey at any time.

If you agree to participate in this survey select “yes, I agree” below.

01 Yes, I agree

02 No, I do not agree [TERMINATE]

If you have any questions about the survey or this study, email Deloitte’s Project Manager, Lauren Degiorgi at [email protected].

CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 (0920-0621).

//Ask All//

INTRO2. To determine your child’s eligibility to participate in an interview, please complete the following questions. If you have more than one child up to age 18, please think about the child with the next birthday.

//Ask All//

CHILD. Are you the parent or legal guardian of the child who would be participating in the interview?

01 Yes

02 No [TERMINATE]

//Ask All//

AGE. How old is your child?

[NUMBER BOX] [RANGE 0-18] [TERMINATE IF AGE=0-10]

//Ask All//

GRADE. What is your child’s grade level in school?

01 6^th grade

02 7^th grade

03 8^th grade

04 9^th grade

05 10^th grade

06 11^th grade

07 12^th grade

08 Other, please specify: [TEXT BOX]

97 Prefer not to answer [TERMINATE]

//Ask All//

RACE AND ETHNICITY. What is your child’s race and/or ethnicity? Select all that apply.

1. American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe of the Blackfeet

Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome

Eskimo Community, Aztec, Maya, etc.

2. Asian For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

3. Black or African American For example, African American, Jamaican, Haitian, Nigerian,

Ethiopian, Somali, etc.

4. Hispanic or Latino For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican,

Guatemalan, etc.

5. Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli,

etc.

6. Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan,

Fijian, Marshallese, etc.

7. White For example, English, German, Irish, Italian, Polish, Scottish, etc.

//Ask All//

SEX. What sex was your child assigned at birth, on their original birth certificate?

01 Male

02 Female

//Ask All//

INCOME. What is your annual household income?

01 Less than $10,000

02. $10,000 to $29,999

03 $30,000 to $39,999

04 $40,000 to $49,999

05 $50,000 to $99,999

06 $100,000 or above

Does your child receive free or reduced lunch in schools?

01 Yes

02 No

//Ask All//

Tobacco use: Does your child use any tobacco products?

01 Yes

02 No

03 Don’t know

Do any of your child’s friends use tobacco products?

01 Yes

02 No

03 Don’t know

How familiar is your child with tobacco products like cigarettes, e-cigarettes, or vape pens?

1. Very familiar

2. Somewhat familiar

3. Unfamiliar

4. Don’t know

//Ask All//

Geographic location: Where do you live? ¹

1. City: ____________________________

2. State: [selected from drop down list]

//Ask All//

CONTACT. Please provide your contact information below so that we can reach out to schedule the interview if your child is selected to participate.

Parent / Guardian’s Full Name: [TEXT BOX]

Child’s Full Name: [TEXT BOX]

Parent / Guardian’s Phone Number: [NUMBER BOX]

Parent / Guardian’s Email Address: [EMAIL TEXT BOX]

//Ask All//

CLOSE. Thank you for completing this survey. If your child is selected to participate, we will reach out to you shortly to gather a little more information and schedule a time for the interview.

2024 National Youth Tobacco Survey (NYTS)

Cognitive Interviews Youth Recruitment Screener Questionnaire

Thanks for your interest in this study! Answer the following questions to see if you qualify for the interviews. The questions should take 5-10 minutes to answer. Your answers are private.

The Centers for Disease Control and Prevention (CDC) has hired Deloitte to interview 24-30 youth to participate in two interviews, with each interview scheduled approximately 2-4 weeks apart. Deloitte is a company that is assisting CDC with conducting health surveillance (maybe include a brief definition here). The interviews will help CDC design questions about health and tobacco product use. If you are selected to participate you will receive one $50 Amazon gift card per interview (total of two $50 gift cards) for your participation.

Completing this survey involves little to no risk, though some questions may be sensitive or personal. Your participation in the survey and interviews are voluntary. There is no penalty for not participating. You can skip questions you don’t want to answer. You can end the survey or interview at any time. However, you will not qualify for the interviews if you do not complete the survey. Completing this survey does not guarantee that you will be invited to the interviews.

If you agree to participate in this survey select “yes, I agree” below.

01 Yes, I agree

02 No, I do not agree [TERMINATE]

If you have any questions about the survey or this study, email Deloitte’s Project Manager, Lauren Degiorgi at [email protected].

CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 (0920-0621).

//Ask All//

INTRO2. Please complete the following questions. The health surveillance will help improve survey questions that go to thousands of youths across the United States. Topics include health behaviors, attitudes of youth, and tobacco (including e-cigarette) use.

The interviews will be conducted through Zoom at a time that is convenient to you. You will be asked to answer survey questions during the interviews, and the interviewer will ask you questions about how you answered the survey questions.

//Ask All//

RACE AND ETHNICITY. What is your race and/or ethnicity? Select all that apply.

1. American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe of the Blackfeet

Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome

Eskimo Community, Aztec, Maya, etc.

2. Asian For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

3. Black or African American For example, African American, Jamaican, Haitian, Nigerian,

Ethiopian, Somali, etc.

4. Hispanic or Latino For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican,

Guatemalan, etc.

5. Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli,

etc.

6. Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan,

Fijian, Marshallese, etc.

7. White For example, English, German, Irish, Italian, Polish, Scottish, etc.

//Ask All//

Geographic location: Where do you live? ²

1. City: ____________________________

2. State: [selected from drop down list]

//Ask All//

ENVI. Thinking about your neighborhood, how would you compare how safe you feel in your neighborhood compared to other people?

01 A lot safer

02 A little safer

03 About the same

05 A little less safe

06 A lot less safe

//Ask All//

SO. Sexual orientation is a person’s emotional, romantic, and/or sexual attraction to another person. There are many ways a person can describe their sexual orientation and many labels a person can use. Which of these options best describes your sexual orientation?

01 Straight or heterosexual

02 Gay or lesbian

03 Bisexual, pansexual, or queer

04 Asexual

05 I am not sure or I am questioning

06 I do not know what this question means

07 Something else not included here [Specify:________________] : [TEXT BOX]

08 Decline to answer

//Ask All//

GI. Some people describe themselves as transgender when their sex at birth does not match the way they think or feel about their gender. Are you transgender?

01 No, I am not transgender

02 Yes, I am transgender

03 I am not sure if I am transgender

04 I do not know what this question is asking

//Ask All//

SOCIAL. Which of the following social media do you use? (Please select all that apply)

01 Facebook

02 Twitter

03 YouTube

04 Instagram

05 Reddit

06 TikTok

07 Snapchat

08 Twitch

09 Other (please specify): ______[SMALL TEXTBOX]________

10 None [exclusive response]

//Ask All//

USE1. Have you ever tried any of the following? (Please select all that apply.)

1. E-cigarettes, vapes, or vape pens

2. Heated tobacco products

3. Cigarettes

4. Cigars

5. Marijuana cigars (blunts)

6. Hookah

7. Roll-your-own cigarettes

8. Pipe tobacco

9. Bidis

10. Chewing tobacco, snuff, or dip

11. Snus

12. Nicotine pouches

13. Other oral nicotine products (including dissolvable tobacco products)

14. I have not tried any of these products [exclusive response]

//IF USE1 = 01-13//

USE2. During the past 30 days, have you used any of the following? (Please select all that apply.)

1. E-cigarettes, vapes, or vape pens

2. Heated tobacco products

3. Cigarettes, even one or two puffs

4. Cigars

5. Marijuana cigars (blunts)

6. Hookah

7. Roll-your-own cigarettes

8. Pipe tobacco

9. Bidis

10. Chewing tobacco, snuff, or dip

11. Snus

12. Nicotine pouches

13. Other oral nicotine products (including dissolvable tobacco products)

14. None, I no longer use tobacco products [exclusive response]

1 We will use the Robert Wood Johnson Foundation’s County Health Rankings to understand participant’s surrounding community.

2 We will use the Robert Wood Johnson Foundation’s County Health Rankings to understand participant’s surrounding community.