Form A-1 Recruitment Screener

O MB Control Number: 0925-0663
Expiration Date: 11/30/2015

PATH Wave 4 Cognitive Testing

Adult Recruitment Screener

Westat, a research firm located in Rockville, MD, is doing research for the National Institutes of Health in partnership with the Food and Drug Administration for a study about tobacco use. If you are eligible and you agree to participate, we will give you $40 as a thank you to complete an in-person interview that should last about an hour. In order to find out if you are eligible to be interviewed, I need to ask you a few questions. Your answers to these questions will only be used to determine whether you are eligible to participate in the interview. Some of these questions are personal. We will keep your answers confidential, but if you would prefer not to answer any of the questions, just let me know.

1. May I go ahead?

• YES

• NO TERMINATE

2. How old are you?

• Under 25  INELIGIBLE

• _________

3. How many individual interviews or focus groups have you participated in at survey research companies in the past year?

• 0

• 1-2

• MORE THAN 2 TERMINATE

4. Which of the following tobacco products do you currently use?

• Cigarettes

• Cigars or cigarillos
  Examples: Black & Milds, Swisher Sweets, Dutch Masters, White Owl, Phillies Blunts

• Chewing tobacco, snuff, or dip
  Examples: Skoal, Cophenhagen, Grizzly, Levi Garrett, Red Man, Day’s Work

• Snus
  Pronounced to rhyme with goose

• Pipe

• Hookah

• Do not use any tobacco products

5. Do you use social media, such as Facebook, Twitter, Instagram, Pinterest, or Snapchat?

• Yes

• no

6. Have you ever used an app related to tobacco products, e-cigarettes, or other electronic nicotine products?

• Yes

• no

7. Are you male or female?

• male

• female

8. Are you Hispanic, Latino, Latina, or of Spanish origin?

• YES

• NO

9. What is your race? CHOOSE ALL THAT APPLY.

• AMERICAN INDIAN OR ALASKA NATIVE

• ASIAN

• BLACK OR AFRICAN AMERICAN

• NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

• WHITE

10. What is the highest level of education you have completed?

• Less than high school

• Completed 12^th grade/high school graduate

• Some college/2-year college/technical school

• College degree

• Graduate or professional school

if ineligible

Thank you for your interest, but you are not eligible for this study. Thank you very much for your time. We will destroy the information you have provided.

if eligible

Thank you for answering all my questions. We will contact you if you are selected to participate. Can I have your name, address, phone number and/or email so that we can get in touch with you?

COLLECT RESPONDENT NAME, ADDRESS, AND PHONE NUMBER/EMAIL.

Name: _____________________________________________________________

Address: _____________________________________________________________

City: _________________________________ State: ______ Zip Code: __________

Phone: _________________________________

Email: _________________________________

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0663). Do not return the completed form to this address.