Parent and Child Screeners

OMB No. 0920-1154

Expiration Date 3/31/2026

GenIC Clearance for CDC/ATSDR

Formative Research and Tool Development

Youth Audience Message Testing of Substance Use Prevention Messages

Attachment 1 - Screener

Contact: Jasmine Kenney, MPH

Communication Branch

Division of Overdose Prevention (DOP)

National Center for Injury Prevention and Control (NCIPC)

Centers for Disease Control and Prevention (CDC)

4770 Buford Hwy NE, MS S106

Atlanta, Georgia 30341

Phone: 770-488-5423

Email: [email protected]

CDC estimates the average public reporting burden for this collection of information as 15 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1154).

PARENT SCREENER (P100)

[INTRO PROMPT]

Thank you for your interest in this project! For this project, we’re going to ask you some questions to see if you or someone in your household qualifies to take part in an online journal. The online journal will take place via a secure platform called itracks and will last approximately two weeks. Upon completion, you (or your household member) will receive up to $250.

Does this sound like a study in which you would like to participate?

1. Yes

2. No [SCREENOUT]

[BASE: ALL RESPONDENTS]

P100. What is your birth date?

1. Month

2. Day

3. Year

[SCREENOUT AGES 11 AND UNDER AND 18-29; NOTE THAT WE MUST SCREEN THROUGH A PARENT]

[IF 12 TO 17 AND DID NOT COMPLETE A PARENT SCREENER FIRST, ASK TO SPEAK TO A PARENT AND SKIP TO D1XX]

[BASE: AGE 30+]

P105. Are you the parent or legal guardian of a 12-17-year-old?

1. Yes

2. No [SCREENOUT]

[BASE: PARENT]

P110. For this project, we are interested in hearing from kids and teens. We will provide thorough information on the project shortly, but in the meantime, please share the name(s), gender(s), birth date(s) and grade level(s) of your child/ren ages 12-17 currently living in your home.

[RECORD CHILDREN’S NAMES, BIRTH DATE(S), GENDERS AND GRADE LEVELS; SCREENOUT IF THEY DO NOT HAVE AT LEAST ONE CHILD AGES 12 TO 17 (STUDY TO FIELD ON DATES; PLEASE ENSURE CHILD/REN ARE AGES 13-17 FOR THE FIELDWORK DATES).]

[CHECK QUOTAS BEFORE DECIDING WHICH CHILD TO INVITE]

[BASE: ALL RESPONDENTS]

P115. Great! For this project, we’d love to talk to [INSERT TEEN NAME]. Before we do that, we want to tell you a little more about this project as well as get some more information from you as well.

For this project, we want to talk to a range of teens ages 13 to 17 about substance use, prevention and mental health and hear their thoughts, feelings, and perceptions. We understand the sensitivity of this topic; as such, we will not be talking to your children about whether they have used drugs. This research will be conducted by YPulse on behalf of Fors Marsh, which are both independent research firms conducting research for the Centers for Disease Control (CDC). Insights from this journal will help us create a range of content and messages for a CDC educational campaign.

If your child takes part, they will complete four online activities over the course of 2 weeks in a secure online journal or message board called itracks. The study will be completely anonymous and your child will be compensated for their time.

If your child qualifies, we will send you and your child some forms with more information about the study and ways to contact us with any questions. We will need both you and your child to sign and send these forms back to us in order for your child to take part in this project.

Do we have your permission to speak to [INSERT TEEN NAME] to see if they qualify?

1. Yes

2. No [SCREENOUT]

[BASE: ALL RESPONDENTS]

P120. Great! Before we speak to your child, we have a few more questions that we’d love to get your responses to in order to make sure we speak to a diverse group of people.

To get started, where does [INSERT TEEN NAME] live?

[RECRUIT 5+ PER REGION; AIM FOR A REPRESENTATION ACROSS THE US]

[SCREENOUT IF NOT IN U.S. OR D.C.]

[BASE: ALL RESPONDENTS]

P125. Which best describes the area where [INSERT TEEN NAME] lives?

1. Big urban city (> 1 million people)

2. Small urban city (< 1 million people)

3. Suburbs (outside of a city / developed area)

4. Rural (small town / village / country)

[BASE: ALL RESPONDENTS]

P130. Which best describes your highest level of education?

1. Less than high school

2. High school graduate / GED

3. Some college – did not finish

4. College graduate

5. Graduate school (e.g. MBA, Master’s, PhD)

6. Other, please specify:

7. Unsure

[BASE: ALL RESPONDENTS]

P135. Which range captures your household income before taxes? An estimate is fine!

1. Less than $20,000

2. $20,000 - $29,999

3. $30,000 - $39,999

4. $40,000 - $49,999

5. $50,000 - $59,999

6. $60,000 - $69,999

7. $70,000 - $79,999

8. $80,000 - $99,999

9. $100,000 - $149,999

10. More than $150,000

11. Prefer not to answer

[BASE: ALL RESPONDENTS]

P140. Awesome – thank you! Now we’d like to speak to [INSERT TEEN NAME]. If they’re not available right now, [INSERT RECONTACT INSTRUCTIONS HERE].

CHILD SCREENER (C200)

[INTRO PROMPT]

Thank you for your interest in this project! For this project, we’re going to ask you some questions to see if you qualify to take part in an online journal. If you qualify, you’ll get the chance to join an online journal where you can earn money and share your thoughts, feelings, and perceptions of drug use and mental health.

Sound good? Let’s get started!

[BASE: ALL RESPONDENTS]

C200. What is your birth date?

1. Month

2. Day

3. Year

[MUST BE 13 TO 17 AND MATCH AGE FROM THE PARENT SCREENER; IF NOT, ASK TO GET THEIR SIBLING WHO MATCHES THE AGE FROM THE PARENT SCREENER. BACK CHECK TO P110.]

[BASE: ALL RESPONDENTS]

C205. What grade are you in?

1. 6^th Grade

2. 7^th Grade

3. 8^th Grade

4. 9^th Grade / Freshman

5. 10^th Grade / Sophomore

6. 11^th Grade / Junior

7. 12^th Grade / Senior

8. College

[SENSE CHECK WITH AGE. BACK CHECK TO P110.]

[BASE: ALL RESPONDENTS]

[MULTIPLE RESPONSE]

C210. What is your race and/or ethnicity?

Select all that apply.

1. American Indian or Alaskan Native

2. Asian

3. Black or African American

4. Hispanic or Latino

5. Middle Eastern or North African

6. Native Hawaiian or Pacific Islander

7. White

8. Prefer not to answer [EXCLUSIVE]

[CHECK WITH QUOTAS ON PAGE 1]

[BASE: ALL RESPONDENTS]

C215. Which of these best describes how well you speak English?

1. Fluent / native speaker

2. Very well

3. Well

4. Not well [SCREENOUT]

5. Not at all / I don’t speak English [SCREENOUT]

[BASE: ALL RESPONDENTS]

C220. Which of these best describes how well you read in English?

1. Fluent / native reader

2. Very well

3. Well

4. Not well [SCREENOUT]

5. Not at all / I don’t read English [SCREENOUT]

[BASE: ALL RESPONDENTS]

C225. Great! As mentioned previously, we are interested in talking to a range of teens ages 13 to 17 about drug use prevention and mental health and hear their thoughts, feelings, and perceptions. This research will be conducted by YPulse on behalf of Fors Marsh. What we learn from this study will help us create a range of ads for a Centers for Disease Control and Prevention (CDC) educational campaign.

In order to see if you qualify, we’re going to ask you a quick question about drugs. While we will not be asking about your personal use of drugs, we will be asking general questions about whether or not you know people who have used drugs. Your responses will be completely anonymous and confidential. Everything you share will be kept private, except in the case of reports of harm to yourself or others. We will report any reports of self harm or harm to others to your parents or caregivers.

To get started:

Do you think any of your friends sometimes use illicit drugs? When referring to illicit drugs, this includes drugs such as, cocaine, methamphetamine (ecstasy, molly), or opioids (including heroin or fentanyl). This does not include alcohol or marijuana alone.

1. Yes [CODE AS EXPERIENCED]

2. No [CODE AS NOVICE]

[CHECK QUOTAS FOR NOVICE AND EXPERIENCED]

[BASE: ALL RESPONDENTS]

Almost done! Just a few additional questions for our records.

[BASE: ALL RESPONDENTS]

C230. What sex were you assigned at birth, on your original birth certificate?

1. Male

2. Female

[BASE: ALL RESPONDENTS]

C235. How do you describe your gender identity?

1. Male

2. Female

3. Male to female transgender (MTF)

4. Female to male transgender (FTM)

5. Other gender identity

[BASE: ALL RESPONDENTS]

C240. Which of the following best represents how you think of yourself?

1. Lesbian or gay

2. Straight, that is not gay or lesbian

3. Bisexual

4. Something else

ARTICULATION (A300)

[BASE: ALL RESPONDENTS]

A300. We have another question to see if you qualify. I’m going to read you two sentences and you pick which one better describes you. There is no right or wrong answer. We want to speak to a wide

range of people, and your answer will help us make sure we do. Just make sure you’re answering honestly.

We’ll do three pairs. Let’s go!

[RANDOMIZE THE PAIRS]

1. I’m not afraid to talk with a stranger about the things that matter to me. OR I don’t feel comfortable talking to strangers about the things I care about.

2. I take part in a lot of after school groups and activities. OR I don’t take part in a lot of after school activities.

3. I’m always the first person to try something new. OR I usually wait until something new is a little more established before trying it out myself.

[RESPONDENTS MUST SELECT AT LEAST 2 HIGHLIGHTED STATEMENTS; OTHERWISE SCREENOUT]

[BASE: ALL RESPONDENTS]

A305. Tell us about something that you were stressed about recently. It can be something big or small. What was the stressor? How did you cope with the stress?

[BASE: ALL RESPONDENTS]

A310. Now, on the flip side, tell us what is something that you’ve been excited about recently? Why are you so excited about that?

[MAKE SURE THAT THEY ARE ENTHUSIASTIC, ENGAGED, WILLING TO TALK, AND SHOW AN APPROPRIATE LEVEL OF COMFORT WITH ENGLISH.]

INVITATION (I400)

[BASE: RECRUITS]

I400. Great job, you’re finished! Your responses have qualified you to take part in our online journal!

For this project, we want to talk to you about drug use prevention and mental health and hear their thoughts, feelings, and perceptions. As mentioned previously this research will be conducted by YPulse on behalf of Fors Marsh. Insights from this community will help us create a range of content and messages for a Centers for Disease Control and Prevention (CDC) educational campaign.

If you decide to take part, you will complete four online activities over the course of 2 weeks (DATE TO DATE) via a secure online journal or message board called itracks. Each activity will take about 45 minutes to complete, and we’ll ask you some follow-ups to answer based on your responses. You will not have to answer any questions that you do not want to and you may choose to exit the study. It will be around 3 hours of total work. The study will be completely anonymous. Everything you share will be kept private, except in the case of reports of harm to yourself or others. We will report any reports of self harm or harm to others to your parents or caregivers.

If you agree to take part, we’ll send you and your parent(s) some forms with more information about the study and ways to contact us with any questions. We will need those to be signed and sent back to us in order for you to take part.

You can earn up to $250 for taking part and completing all four activities.

Are you interested in participating?

1. Yes

2. No [SCREENOUT]

[BASE: ALL RESPONDENTS]

I405. In order to participate in the online journal, you will need:

• A laptop, desktop computer, or internet-enabled tablet or smartphone. If you use a tablet or smartphone, we recommend downloading the itracks app.

• High-speed Internet access

Do you have all of the items mentioned above?

1. Yes

2. No [SCREENOUT]

[BASE: I405 = 1]

[3 TEXT FIELDS]

I410. Great! Please share your first name and last initial, email address, and the best phone number at which to reach you in order to be invited.

Please also get your parents so we can get their contact info as well.

This information will be used to invite you to the online journal as well as follow-up with you in case we have any additional questions or need to share any additional information with you or your parents.

1. Child’s name:

2. Child’s email: [VALID EMAIL ADDRESS REQUIRED]

3. Child’s phone number (XXX-XXX-XXXX): [PHONE NUMBER FORMAT REQUIRED]

4. Parent’s name:

5. Parent’s email: [VALID EMAIL ADDRESS REQUIRED]

6. Parent’s phone number (XXX-XXX-XXXX): [PHONE NUMBER FORMAT REQUIRED]