Feedback for the Adolescent Development Products and We Think Twice™ Digital Media Campaign

Request for Approval under the “Generic Clearance for the Collection of Customer Feedback” (OMB Control Number: 0970-0401)

PAPERWORK REDUCTION ACT OF 1995 (Public Law 104-13) STATEMENT OF PUBLIC BURDEN The purpose of this information collection is to help us recruit and engage participants who are representative of the intended audiences for the We Think Twice™ campaign in order to request feedback specific to the campaign. Public reporting burden for this collection of information is estimated to take no more than 10 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0401 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Kaitlin Dixon at [email protected].

Registration Survey for We Think Twice™ Insider Recruitment

First name

Last name

What is your current gender identity? (Select ALL that apply)

• Male

• Female

• Transgender Male/Transman/FTM

• Transgender Female/Transwoman/MTF

• Genderqueer

• Another category

• Prefer not to answer

Date of birth

What sex were you assigned at birth? (Select one)

• Male

• Female

• Prefer not to answer

Zip code

What is your race? (You may select one or more races)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

• Don’t know

• Prefer not to answer

• Other

Are you of Hispanic or Latino origin? (Select one)

• Yes

• No

What type of school do you attend?

• Public

• Private

• Charter

• Boarding

• Other

Tell us something about yourself

Age

Gift Card Preference

• Starbucks

• Amazon

• iTunes

For some Insider activities, we’ll be asking about your ideas and experiences. Can we quote you on our website and/or social media page?

• Yes, you can quote me anonymously

• No, you cannot quote me