A-2 Recruitment Screener

O MB Control Number: 0925-0675
Expiration Date: 05/31/2016

PATH Wave 4 Focus Groups

Social Media Recruitment Screener

Parent or Guardian for Respondents Ages 12-15:

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. We are recruiting youth between the ages of 12 and 15. Youth are not required to use to tobacco in order to participate.

If your child is eligible and you agree to allow them to participate, we will give them $30 as a thank you for participating in a focus group discussion that should last about an hour and a half. You will need to attend the beginning of the group in order to give written permission for your child to participate, but you will be asked to leave the room during the focus group itself. You will receive $10 for any travel expenses.

In order to find out if your child is eligible to participate, I need to ask them a few questions. Their answers to these questions will only be used to determine whether they are eligible to participate in the focus group. Some of these questions are personal. We will keep your child’s answers confidential, but they may choose not to answer any questions if they would prefer not to.

1. May I ask your child a few questions to determine if they are eligible to participate in this study?

• YES  ASK TO SPEAK WITH YOUTH

• NO TERMINATE

Youth Ages 12-15:

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 $30 as a thank you to participate in a focus group that should last about an hour and a half. Your parent or guardian will need to attend the beginning of the focus group in order to give written permission for you to participate, but they will be asked to leave the room during the group itself.

In order to find out if you are eligible to participate, 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 group. 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.

2. May I go ahead?

• YES  Q4

• NO TERMINATE

Young Adults, ages 18-24

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 $50 as a thank you to participate in a focus group discussion that should last about an hour and a half. 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.

3. May I go ahead?

• YES

• NO TERMINATE

4. How old are you?

• under 12 INELIGIBLE

• _________

• 16-17 INELIGIBLE

• _________

• over 24 INELIGIBLE

5. 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

6. ASK ADULTS ONLY, 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

• E-cigarettes, e-cigars, e-hookahs, e-pipes, or other electronic nicotine products

• Do not use any tobacco or electronic nicotine products

7. How often do you use social media, such as Facebook, Twitter, Instagram, Pinterest, or Snapchat? Would you say…

• Every day

• Most days

• Some days

• Rarely, or  INELIGIBLE

• Never?  INELIGIBLE

8. Have you seen tobacco products, e-cigarettes, or other electronic nicotine products on social media sites? This could include advertisements, videos, friends’ posts, or messages.

• Yes

• no  INELIGIBLE

9. Are you male or female?

• male

• female

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

• YES

• NO

11. 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

IF ADULT  GO TO Q13

12. What grade are you currently in?

• _________  GO TO Q14

13. 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

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 (0925-0675). Do not return the completed form to this address.