LGBT Young Adult Tobacco Use Prevention Campaign: Copy Testing

OMB# 0910-0674 Exp. 3/31/2016

LGBT Young Adult Tobacco Prevention Campaign: Copy Testing | Electronic Screener

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average
5 minutes per response to complete the screener (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 PRAStaff@fda.hhs.gov

WELCOME PAGE

[TEXT PRESENTED TO ONSITE PARTICIPANTS]: “We are looking for people to be part of a survey about LGBT culture and health. In order to be selected, participants must answer this short screener survey to see if they qualify. You will find out if you have been selected at the end of this screener survey. If you are selected, you will be asked to decide if you want to participate in the full survey and get your $25 cash incentive. There are no right or wrong answers to these questions. Thank you very much for your help!”

[TEXT PRESENTED TO ONLINE PARTICIPANTS]: “We are looking for people to be part of a survey about LGBT culture and health. In order to be selected, participants must answer this short screener survey to see if they qualify. You will find out if you have been selected at the end of this screener survey. If you are selected, you will be directed to the full survey and you will get your $25 online gift card incentive upon submission. There are no right or wrong answers to these questions. Thank you very much for your help!”

[TEXT PRESENTED TO ONLINE RESEARCH PANEL PARTICIPANTS]: “We are looking for people to be part of a survey about LGBT culture and health. In order to be selected, participants must answer this short screener survey to see if they qualify. You will find out if you have been selected at the end of this screener survey. If you are selected, you will be directed to the full survey and you will get your $25 online gift card incentive [or panel equivalent] upon submission. There are no right or wrong answers to these questions. Thank you very much for your help!”

[Each item on the Copy Testing Questionnaire will be presented in a separate page, separated by a “NEXT” button.]

1. Out of the last 30 days, on how many days did you exercise for at least 30 minutes?

0. 0 days

1. 1 to 10 days

2. 11 to 20 days

3. 21 to 29 days

4. All 30 days

2. In the past 30 days, on how many days did you go to an LGBT party, night, club, bar or event?

0. 0 days

1. 1 to 3 days

2. 4 to 6 days

3. 7 or more days

4. Don’t know how many days

3. When were you born? (please fill in the blanks)

Month (MM): __

Day (DD): __

Year (YYYY): ____

4. What is the 5-digit zip code where you CURRENTLY live?

__ __ __ __ __

5. What is your current gender identity? (Choose one response)

1. Male

2. Female

3. Trans male/ Trans man

4. Trans female/ Trans woman

5. Genderqueer/ Gender non-conforming

6. Different identity (please state): ________________

7. Prefer not to answer

6. What sex were you assigned at birth, on your original birth certificate?

1. Female

2. Male

7. Prefer not to answer

7. How often do you visit websites for LGBT people, such as Queerty, Homorazzi, Autostraddle, Towleroad, or After Ellen?

                 Never (1)                           Often (5)

                                

8. On how many days of the PAST 30 DAYS did you smoke cigarettes?

Number of days (0-30) _______

88. Don’t know

9. Have you ever received money or gift cards from a company for sharing your opinions about LGBT health in a discussion group, interview, or survey?

1. Yes, WITHIN the past 9 months

2. Yes, MORE THAN 9 months ago

3. No

4. I’m not sure

10. Which of the following best represents how you think of yourself?

1. Lesbian

2. Gay

3. Straight, that is, not lesbian or gay

4. Bisexual

5. Queer, pansexual, trisexual, or omnisexual

6. Something else (please specify) ________________________

7. Prefer not to answer

88. I don’t know the answer

11. How many LGBT celebrities, athletes, musicians, or artists do you follow on social media, such as Connor Franta, Ruby Rose, Laverne Cox, Ellen Page, RuPaul, Angel Haze, Tom Daley, Janet Mock, Tegan & Sara, or Chaz Bono?

0. 0

1. 1 - 2

2. 3 - 4

3. 5 +

12. Do you or any member of your immediate family or a close friend work for …? Select all that apply

1. A market research company

2. The tobacco industry (manufacturers, distributors, or importers of tobacco products)

3. An advertising agency or public relations firm

4. The media (TV/radio/newspapers/magazines)

5. A healthcare professional (doctor, nurse, pharmacist, dietician, etc.)

6. None of these

13. Are you Hispanic or Latino? (Choose one response)

1. Yes

2. No

14. What race or races do you consider yourself to be? (Choose all that apply)

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

6. Other

15. Your cell phone number: (___) ___-____

16. Your e-mail address: __________________

[15-16 = For onsite and social media recruitment only; 15 = Only for onsite recruitment]

[TEXT PRESENTED TO DISQUALIFIED PARTICIPANTS]: “Thank you for answering our questions! Unfortunately, you are not invited to take part in the survey. Have a great day!”

[TEXT PRESENTED TO QUALIFIED ONSITE PARTICIPANTS]: “Congrats! You qualify to participate in the survey! Please see a member of the survey team to get more information.”

[TEXT PRESENTED TO QUALIFIED ONLINE PARTICIPANTS]: “Thank you! You qualify to proceed with the survey. Upon survey completion, you will receive a $25 online gift card! Please click the “Next” button to continue with the survey.”

[TEXT PRESENTED TO QUALIFIED ONLINE RESEARCH PANEL PARTICIPANTS]: “Thank you! You qualify to proceed with the survey. Please click the “Next” button to continue with the survey.”

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Appendix A: Electronic Screener