Form 7 Exit Scripts and Survey for Ineligibles

SFTXT – Attachment 13: Exit Scripts and Survey for Ineligibles

Exit Script Page 2

Word Questions Page 3

Screenshots Pages 5 to 8

EXIT SCRIPTS AND SURVEY FOR INELIGIBLES

[text to go on study website]

OMB No.: 0925-XXXX

Expiration Date:  xx/xx/20xx

Collection of this information is authorized by The Public Health Service Act, Section 410 (285) and Section 412 (285a-1). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private to the extent provided by law.  Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries.  In order to provide feedback on its tobacco cessation services, the National Cancer Institute has asked you to complete this voluntary survey.

Public reporting burden for this collection of information is estimated to average 5 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-XXXX). Do not return the completed form to this address.

Exit Intro [text to go on study website]

For individuals who are not eligible due to one of their answers from the screener. Once it has been determined that they are ineligible, they are immediately told they are ineligible and then are taken to the exit survey.

Thank you for your interest in this study. We are sorry to say that you are not eligible to participate in the study.

We have just a few more questions to ask you so that we can better understand the types of people who are interested in this study but are not eligible at this time. It should just take 2-3 minutes for you to answer the questions. Please click here.

Exit Intro [text to go on study website]

For individuals who are ineligible because he or she will not provide contact information.

We are sorry, but in order to participate in this study you will need to provide contact information so that we can reach you to verify your identity and to send you study information.

If you would still like to participate, please click here to provide your contact information [link back to contact info collection page]. If you have any questions about the need for your contact information, please call Dr. Linda Squiers at 1-800-334-8571 extension 5128.

If you are sure that you do not want to provide contact information, we would still like to ask you a few more questions so that we can better understand the types of people who end up not being eligible for this study. This should just take 2-3 minutes. If you are still interested in smoking cessation services, you can find more information on Smokefree.gov.

Please click here to continue.

Exit Survey [text to go on study website]

We just have a few more questions about you. Although we cannot reimburse you for this, we would greatly appreciate you answering 4 more brief questions:

1. What is your sex? (YTS and NCI suggested)

1. Male

2. Female

2. Are you:

1. Hispanic or Latino

2. Not Hispanic or Latino

3. What is your race? (One or more categories may be selected)

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or other Pacific Islander

4. What is the highest level of education you have completed? (RTI Developed)

1. Less than High School

2. High School/GED

3. Some College

4. 2-Year College Degree (Associates)

5. 4-Year College Degree (BA, BS)

6. Master’s Degree

7. Doctoral Degree

8. Professional Degree (MD, JD)

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