Focus Group

Screening Questionnaire: Community Focus Group

SCREENING QUESTIONNAIRE FOR COMMUNITY FOCUS GROUP¹ Form Approved

OMB No. 0920-xxxx

Expiration Date: XX/XX/XXXX

Screening Questions²

The Centers for Disease Control and Prevention (CDC) is looking for adults ages 18 years and older to participate in web-based focus groups for a study evaluating policies that restrict access to menthol-flavored tobacco products. In the focus groups, we will ask participants about their knowledge, perceptions, and behaviors related to menthol-flavored and non-flavored tobacco products. You are being screened to participate in a focus group because you live in one of the communities selected for this 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?	Boston, MA Columbus, OH 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 have access to a laptop with video call capabilities (i.e., a microphone and camera)?	Yes No
4	Do you currently, or have you ever, used menthol or similarly flavored tobacco products (mint, clove, spice, wintergreen, spearmint) “fairly regularly”? “Fairly regularly” is defined as using these tobacco products on a routine basis rather than trying them only once or twice. Some examples of flavored tobacco products are: cigarettes; e-cigarettes or vapes; e-liquids; cigars; cigarillos; chewing tobacco; pipes; hookahs; or nicotine pouches.	Yes No
5	What is your race and/or ethnicity? Select all that apply and enter additional details in the free text space.	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. [free-text]  Asian Chinese Asian Indian Filipino Vietnamese Korean Japanese Enter, for example, Pakistani, Hmong, Afghan, ect. [free-text]  Black or African American African American, Jamaican Haitian Nigerian Ethiopian Somali Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc. [free-text]  Hispanic or Latino Mexican Puerto Rican Salvadoran Cuban Dominican Guatemala Enter, for example, Columbian, Honduran, Spaniard, etc. [free-text]  Middle Eastern or North African Lebanese Iranian Egyptian Iranian Syrian Iraqi Israeli Enter, for example, Moroccan, Yemeni, Krudish, etc. [free-text]  Native Hawaiian or Other Pacific Islander Native Hawaiian Samoan Chamorro Tongan Fijian Marshallese Enter, for example, Chuukese, Palauan, Tahitian, etc. [free-text] White English German Irish Italian Polish Scottish Enter, for example, French, Swedish, Norweigian, etc. [free-text] I don’t know Prefer not to say
6	How do you currently describe yourself (mark all that apply)?	Female Male Transgender I use a different term [free-text] Prefer not to say
7	Which of the following best represents how you think of yourself?	Gay (lesbian or gay) Straight; that is not gay (or lesbian or gay) Bisexual Something else I don’t know Prefer not to say

Thank you for completing this focus group screening questionnaire. If you meet evaluation screening guidelines, a representative from Qualtrics will reach out to you soon to for focus group scheduling.

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 focus group participants to confirm respondent eligibility. Any responses that disqualify an individual from participating in one of the planned focus groups will end the screening survey.