Attachment 1: Questions to be cognitively tested
Form Approved
OMB No. 0920-0222
Exp. Date: 01/31/2026
Notice - CDC estimates the average public reporting burden for this collection of information as 55 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 H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-0222).
Assurance of Confidentiality: We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act (44 U.S.C. 3561-3583). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.
Proposed Questions:
The next question asks about CBD products, that is, cannabis products that are not intended to get you “high.” These products are generally derived from hemp. Do not count cannabis products that are intended to get you “high” when answering this question.
During the past 30 days, on how many days did you use CBD products?
[0-30]
For the rest of the survey, we will refer to these types of cannabis products as “CBD products.”
When you used a CBD product during the past 30 days, how did you use it? (Check all that apply)
Did you:
Apply it to the skin (for example, in a lotion, gel, oil, balm, or bath salt)
Smoke it (for example, in a joint, blunt, or cigar)
Eat it or drink it, including drops, sprays, or tinctures (for example, in edibles like brownies or gummies or in capsules, or in tea, cola, or alcohol)
Vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device)
Dab it (for example, using a dabbing rig, knife, or dab pen)
Use it some other way
In the past 30 days, how did you get the CBD products you use? Do you: (Check all that apply)
buy it from a medical or retail dispensary
buy it from a smoke shop, grocery store, gas station, mall, or other convenience store
buy it from a friend or acquaintance
get it for free or share someone else's
grow it yourself at home or have someone grow it for you
have it delivered to you (from the internet, mail order, or delivery service)
get it from somewhere else
I did not obtain CBD products from any source in the past 30 days.
The next set of questions ask about marijuana, that is, the kind of cannabis that is intended to get you “high,” including products like delta-8 THC. During the past 30 days, on how many days did you use marijuana?
[0-30]
For the rest of the survey, we will refer to these types of cannabis products as “marijuana.”
In the past 30 days, how did you get the marijuana you use? Did you: (Check all that apply)
buy it from a medical or retail dispensary
buy it from a grocery store, gas station, mall, or other convenience store
buy it from a dealer (in person) or friend
get it for free or share someone else's
grow it yourself at home or have someone grow it for you
have it delivered to you (from the internet, mail order, or delivery service)
get it from somewhere else
I did not obtain marijuana from any source in the past 30 days.
When you used marijuana in the past 30 days, did you use any of the following substances at the same time or within a few hours? (Select all that apply)
A tobacco or nicotine product like a cigarette, cigar, blunt, or vape
Alcohol
Prescription medications, including opioids taken as directed by your doctor
Prescription opioids not prescribed to you or not used as directed by your doctor
Psychedelics, such as LSD, acid, or mushrooms
Other drugs, including heroin or illicit fentanyl
I did not use marijuana with other substances
When you used marijuana in the past 30 days, did you try to replace your use of any of the following substances? Please include only substances that you began replacing within the past 30 days. (Select all that apply)
A tobacco or nicotine product like a cigarette, cigar, blunt, or vape
Alcohol
Prescription medications, including opioids taken as directed by your doctor
Prescription opioids not prescribed to you or not used as directed by your doctor
Psychedelics, such as LSD, acid, or mushrooms
Other drugs, including heroin or illicit fentanyl
I did not use marijuana with other substances
During the past 30 days, have you driven a vehicle while high from marijuana use?
Yes
No
In the past 12 months, has a health professional, such as a doctor, nurse, or mental health professional, asked you about your marijuana use? Do not include office intake forms completed prior to an appointment.
Yes
No
I haven’t seen a health professional in the past 12 months
In the past 12 months, has a health professional, such as a doctor, nurse, or therapist, done any of the following? Select all that apply.
Told you to cut back on or not use marijuana
Recommended medical marijuana or encouraged you to seek out marijuana for treatment purposes
Told you to change the way you use marijuana, for example, from smoking to edibles
Given you other advice about use of marijuana
They did not provide any advice about marijuana use
I have not seen a health professional in the past 12 months
During the past 12 months, were you able to cut down on or stop using marijuana every time you wanted to or tried to?
Yes
No
I did not want or try to cut down on or stop using marijuana
I rarely or never use marijuana
Does anyone who currently lives with you use marijuana?
Yes
No
Don’t know
For the next two questions, please only consider marijuana, that is, the kind of cannabis that is intended to get you “high,” including products like delta-8 THC. Do not include CBD products.
During the past 30 days, how often have you seen or heard an advertisement for marijuana products or stores or seen a marijuana storefront? (Include TV, radio, signs and billboards, newspapers and magazines, pamphlets or flyers, streetside marketing like sign spinners or sandwich boards, online or cell phone advertisements, and dispensary newsletters or rewards programs.)
A few of the past 30 days
About half of the past 30 days
Nearly all of the past 30 days
I have not seen or heard marijuana product advertising in the past 30 days
During the past 30 days, how often have you seen or heard an advertisement, message, or product label about preventing harmful marijuana use or avoiding marijuana use? (Include TV, radio, signs and billboards, newspapers and magazines, pamphlets or flyers, streetside marketing, and online or cell phone advertisements.)
A few of the past 30 days
About half of the past 30 days
Nearly all of the past 30 days
I have not seen or heard marijuana prevention advertising or messaging in the past 30 days
In the past 12 months, did you seek help for adverse or negative health effects caused by marijuana at any of these places? Select all that apply.
Emergency department
Poison control center
Doctor or other health professional
Walk-in clinic
Telephone health service/helpline
Addiction support service
Other (please specify): _______
Version 1: [State name] [legalized/decriminalized] marijuana [for adult use/medical use] in [year]. Overall, how has [state name]’s [legalization] of [adult-use/medical-use] marijuana affected the quantity of marijuana you use, if at all?
Legalization has not affected my use of marijuana
My marijuana use has increased
My marijuana use has decreased
My marijuana use has stayed about the same
I never or rarely use marijuana
Version 2: [State name] [legalized/decriminalized] marijuana [for adult use/medical use] in [year]. Overall, after [state name] [legalized] [adult-use/medical-use] marijuana, how has the quantity of marijuana you use changed, if at all?
My marijuana use has increased
My marijuana use has decreased
My marijuana use has stayed about the same
I never or rarely use marijuana
When you use CBD or marijuana products, which of the following best describes the product you use most often? Your best guess is fine.
High THC, Low CBD
High THC, High CBD
Low THC, Low CBD
Low THC, High CBD
Other
Not sure
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Massey, Meredith (CDC/DDPHSS/NCHS/DRM) |
File Modified | 0000-00-00 |
File Created | 2025-05-19 |