3 Initial Survey

Attachment D - SFW Customer Satisfaction Study

03.10.2014

Initial Survey

OMB No.: 0925-0046

Expiration Date:  05/31/2016

Collection of this information is authorized by The Public Health Service Act, Section 410 (285) and Section 412 (285a-1). 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 under the Privacy Act of 1974, as amended, 5 U.S.C. 552a (SORN #09-25-0156). 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.  You are being contacted by the National Cancer Institute to provide feedback on its tobacco cessation website.

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 (0925-0046). Do not return the completed form to this address.

Initial Survey – Smokefree Women Customer Satisfaction Study

You are eligible to participate in this study to help improve quit smoking resources for women. To start the study, complete the short survey.

The survey will take about 10 minutes to complete. Thank you for taking the time to complete this survey.

1. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day? If you’re not sure, give your best guess. Type in the number of cigarettes per day: ___. [input box capable of capturing 3 digits]

2. Overall, how interested are you in stopping smoking in the next 30 days?

   1. Not at all interested

   2. Mildly interested

   3. Moderately interested

   4. Very interested

   5. Extremely interested

3. Using the scale below, please indicate how much each statement about stopping smoking is true for you:

1 2 3 4 5

Not at all Neutral Very true

True

1. I don't want to stop smoking.

2. I would stop smoking because others want me to stop smoking.

3. I would stop smoking because I would feel bad about myself if I did not.

4. I would stop smoking because I have carefully thought about it and I believe it is very important for me to stop smoking

5. I would stop smoking because stopping smoking is consistent with other goals and things that are important in my life.

4. How many times during the past 12 months have you stopped smoking for one day or longer because you were trying to quit smoking?

   1. I have not smoked in the past 12 months

   2. I have not tried to quit

   3. 1 time

   4. 2 times

   5. 3 to 5 times

   6. 6 to 9 times

   7. 10 or more times

5. About how tall are you without shoes? ___ Feet ___ Inches

6. About how much do you weigh without shoes? ___ pounds

7. About how many cups of fruit (including 100% pure fruit juice) do you eat or drink each day?

   

   1 cup of fruit could be:

   • 1 small apple

   • 1 large banana

   • 1 large orange

   • 8 large strawberries

   • 1 medium pear

   • 2 large plums

   • 32 seedless grapes

   • 1 cup (8 oz.) fruit juice

   • ½ cup dried fruit

   • 1 inch-thick wedge of watermelon

   1. None

   2. ½ cup or less

   3. ½ cup to 1 cup

   4. 1 to 2 cups

   5. 2 to 3 cups

   6. 3 to 4 cups

   7. 4 cups or more

1 cup of vegetables could be:

• 3 broccoli spears

• 1 cup cooked leafy greens

• 2 cups lettuce or raw greens

• 12 baby carrots

• 1 medium potato

• 1 large sweet potato

• 1 large ear of corn

• 1 large raw tomato

• 2 large celery sticks

• 1 cup of cooked beans

8. About how many cups of vegetables (including 100% pure vegetable juice) do you eat or drink each day?

   1. None

   2. ½ cup or less

   3. ½ cup to 1 cup

   4. 1 to 2 cups

   5. 2 to 3 cups

   6. 3 to 4 cups

   7. 4 cups or more

9. Using the scale below, please indicate how much each statement about eating fruits and vegetables is true for you:

1 2 3 4 5

Not at all Neutral Very true

True

1. I don't want to eat more fruits and vegetables.

2. I would eat more fruits and vegetables because others want me to.

3. I would eat more fruits and vegetables because I would feel bad about myself if I did not.

4. I would eat more fruits and vegetables because I have carefully thought about it and I believe it is very important for me to eat more fruits and vegetables.

5. I would eat more fruits and vegetables because eating more fruits and vegetables is consistent with other goals and things that are important in my life.

10. In a typical week, how many days do you do any physical activity or exercise of at least moderate intensity, such as brisk walking, bicycling at a regular pace, and swimming at a regular pace?

    1. None

    2. 1 Day

    3. 2 Days

    4. 3 Days

    5. 4 Days

    6. 5 Days

    7. 6 Days

    8. 7 Days

11. On the days that you do any physical activity or exercise of at least moderate intensity, how long do you typically do these activities?

__________ Minutes _____________ Hours

12. In a typical week, outside of your job or work around the house, how many days do you do leisure-time physical activities specifically designed to strengthen your muscles such as lifting weights or circuit training (do not include cardio exercise such as walking, biking, or swimming)?

    1. None

    2. 1 Day

    3. 2 Days

    4. 3 Days

    5. 4 Days

    6. 5 Days

    7. 6 Days

    8. 7 Days

13. Using the scale below, please indicate how much each statement about physical activity is true for you:

1 2 3 4 5

Not at all Neutral Very true

True

1. I don't want to be physically active (exercise) on a regular basis.

2. I would be physically active (exercise) on a regular basis because others want me to.

3. I would be physically active (exercise) on a regular basis because I would feel bad about myself if I did not.

4. I would be physically active (exercise) on a regular basis because I have carefully thought about it and I believe it is very important for me to be physically active (exercise).

5. I would be physically active (exercise) on a regular basis because being physically active (exercising) is consistent with other goals and things that are important in my life.

14. Which of these best describes your ethnicity (choose one)?

    1. Hispanic or Latino

    2. Not Hispanic or Latino

15. Which of these best describes your race (choose one or more)?

    1. American Indian/Alaska Native

    2. Asian

    3. Black or African American

    4. Native Hawaiian/Other Pacific Islander

    5. White

16. What is the highest level of school you have completed or the highest degree you have received?

    1. Less than 12^th grade

    2. High school graduate or GED

    3. Some college but no college degree

    4. Associate’s degree

    5. Bachelor’s degree (i.e., B.A., B.S.)

    6. Graduate or Professional school degree (M.D., J.D., D.D.S.)

Thank you for completing this short survey. Please click “Next” to complete this survey. Check your email for additional study instructions. Remember, as a thank your for participating you will be entered into a lottery to receive a $20 in Amazon e-gift card at the end of the 4 week study.

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Initial Survey Screenshots

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