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pdfOMB# 0910-0674
Exp. 3/31/2016
Check-In Survey
Please fill out this survey. Any information you share about your
attitudes, beliefs, and behaviors will not be shared with your school
or parents/guardians. No one outside the research team will know
what you write. There are no right or wrong answers to these
questions. Read the instructions for each question carefully and let
us know if you have any questions.
Thank you very much for your help.
Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to
average of 5 minutes per response to complete the survey (the time estimated to read and complete). Send comments
regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden,
to { HYPERLINK "mailto:PRAStaff@fda.hhs.gov" \h }
CONTINUE
OMB# 0910-0674
Exp. 3/31/2016
Unique ID:
2) Have you ever tried cigarette smoking, even one or two
puffs?
1) What grade are you currently in?
a. 6th grade
e. 10th grade
b. 7th grade
f. 11th grade
c. 8th grade
g. 12th grade
d. 9th grade
h. Ungraded or other grade
a. Yes
b. No
For the following questions, please circle ONE answer in each row.
During the past 30 days, how many of your FRIENDS did this?
3)
Used Twitter
None
Some
About Half
Most
All
4)
Smoked cigarettes
None
Some
About Half
Most
All
5)
Used an App on their cell phone
None
Some
About Half
Most
All
6)
Logged into Facebook
None
Some
About Half
Most
All
7)
Used chewing tobacco, snuff, or dip, such
as Redman, Levi Garrett, Beechnut, Skoal,
Skoal Bandits, or Copenhagen
None
Some
About Half
Most
All
8)
Listened to music on Pandora or Spotify
None
Some
About Half
Most
All
9)
Smoked cigars, cigarillos, or little cigars like
Black and Milds or Swisher Sweets
None
Some
About Half
Most
All
10)
Visited a Tumblr page
None
Some
About Half
Most
All
11)
Posted a picture on Instagram
None
Some
About Half
Most
All
12)
Smoked menthol or mint cigarettes like
Kool, Newport, or Salem
None
Some
About Half
Most
All
CONTINUE ON NEXT PAGE
OMB# 0910-0674
Exp. 3/31/2016
Unique ID:
For the following questions, please circle ONE answer in each row.
During the past 30 days, on how many days did YOU do this?
13)
14)
15)
16)
17)
18)
19)
20)
21)
22)
Used Twitter
Smoked cigarettes
Used an App on your cell phone
Logged into Facebook
Used chewing tobacco, snuff, or dip, such
as Redman, Levi Garrett, Beechnut, Skoal,
Skoal Bandits, or Copenhagen
Listened to music on Pandora or Spotify
Smoked cigars, cigarillos, or little cigars
like Black and Milds or Swisher Sweets
Visited a Tumbler page
Posted a picture on Instagram
Smoked menthol or mint cigarettes like
Kool, Newport, or Salem
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
Thank You! Please let a researcher know that you are finished.
| File Type | application/pdf |
| File Title | Check-In Survey Part 1 |
| Author | Walker, Matthew |
| File Modified | 2014-10-22 |
| File Created | 2014-10-22 |