Form 0920-23FN Survey Eligibility Screener

Screening Questionnaire: Web-Based Survey

SCREENING QUESTIONNAIRE FOR WEB-BASED SURVEY¹ Form Approved

OMB No. 0920-xxxx

Expiration Date: XX/XX/XXXX

Screening Questions²

The Centers for Disease Control and Prevention (CDC) is asking adults ages 18 years and older to participate in a web-based survey for a study evaluating policies that restrict access to menthol-flavored tobacco products. The survey will ask about knowledge, perceptions, and behaviors related to menthol-flavored and non-flavored tobacco products. You are being screened for this survey because you live in one of the communities selected for the study.

#	Question	Responses
1	Are you 18 years of age or older?	Yes No
2	In which of the following cities do you currently live?	Atlanta, GA Baltimore, MD Boston, MA Cleveland, OH Columbus, OH Detroit, MI Milwaukee, WI Oakland, CA Portland, OR San Diego, CA St. Paul, MN or Minneapolis, MN Washington, DC I do not currently live in any of these cities.
3	Do you now, or have you ever used any tobacco products “fairly regularly”? “Fairly regularly” is defined as using any tobacco products on a routine basis rather than trying a tobacco product only once or twice. Some examples of tobacco products include: cigarettes; e-cigarettes or vapes; cigars; cigarillos; chewing tobacco; pipes; hookahs; or nicotine pouches.	Yes No

1 Public reporting burden for this collection of information is estimated to average 2 minutes per response, including 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, GA 30333, ATTN:PRA (0920-xxxx).

2 Screening questions will be administered to potential survey participants prior to survey distribution to confirm respondent eligibility. Any responses that disqualify an individual from participating in the web-based survey will end the screening survey.

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