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Exp. 6/30/2018
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 PRAStaff@fda.hhs.gov.
CONTINUE
Unique ID: ______________
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
For the following questions, please circle ONE answer in each row
During the PAST 30 DAYS, on how many days did YOU do this?
2)
Used Twitter
0 days
1-2 days
3-5 days
6-9 days
10-19 days
20-29 days
All 30 days
3)
Smoked cigarettes
0 days
1-2 days
3-5 days
6-9 days
10-19 days
20-29 days
All 30 days
4)
Used an App on your cell phone
0 days
1-2 days
3-5 days
6-9 days
10-19 days
20-29 days
All 30 days
5)
Smoked tobacco from a hookah or
waterpipe
0 days
1-2 days
3-5 days
6-9 days
10-19 days
20-29 days
All 30 days
6)
Logged into Facebook
0 days
1-2 days
3-5 days
6-9 days
10-19 days
20-29 days
All 30 days
7)
Smoked electronic cigarettes, ecigarettes, vape pens, or hookah
pens, such as Fin, NJOY, e-Go, or
Vuse
0 days
1-2 days
3-5 days
6-9 days
10-19 days
20-29 days
All 30 days
8)
Listened to music on Pandora or
Spotify
0 days
1-2 days
3-5 days
6-9 days
10-19 days
20-29 days
All 30 days
9)
Smoked cigars, cigarillos, or little
cigars, such as Black and Milds,
Swisher Sweets, Dutch Masters,
White Owl, or Phillies Blunts
0 days
1-2 days
3-5 days
6-9 days
10-19 days
20-29 days
All 30 days
10)
Visited a Tumblr page
0 days
1-2 days
3-5 days
6-9 days
10-19 days
20-29 days
All 30 days
11)
Posted a picture on Instagram
0 days
1-2 days
3-5 days
6-9 days
10-19 days
20-29 days
All 30 days
12)
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
CONTINUE ON NEXT PAGE
Unique ID: ______________
Circle ONE answer for each question. Your best guess is fine.
13) In the last 12 months, on how many
occasions (if any) did you SMOKE
TOBACCO FROM A HOOKAH OR
WATERPIPE?
14) In the last 12 months, on how many
occasions (if any) did you USE
TWITTER?
a. 0
b. 1-2
c. 3-5
d. 6-9
e. 10-19
f. 20-39
g. 40 or more
a. 0
b. 1-2
c. 3-5
d. 6-9
e. 10-19
f. 20-39
g. 40 or more
15) In the last 12 months, on how many
occasions (if any) did you SMOKE
ELECTRONIC CIGARETTES, ECIGARETTES, VAPE PENS, OR
HOOKAH PENS?
16) In the last 12 months, on how many
occasions (if any) did you POST A
PICTURE ON INSTAGRAM?
a. 0
b. 1-2
c. 3-5
d. 6-9
e. 10-19
f. 20-39
g. 40 or more
a. 0
b. 1-2
c. 3-5
d. 6-9
e. 10-19
f. 20-39
g. 40 or more
17) In the last 12 months, on how many
occasions (if any) did you SMOKE
CIGARS, CIGARILLOS, OR LITTLE
CIGARS?
a. 0
b. 1-2
c. 3-5
d. 6-9
e. 10-19
f. 20-39
g. 40 or more
CONTINUE ON NEXT PAGE
Unique ID: ______________
For the following questions, please circle ONE answer in each row.
During the PAST 30 DAYS, how many of your
FRIENDS did this?
18)
Used Twitter
None
Some
About Half
Most
All
19)
Smoked cigarettes
None
Some
About Half
Most
All
20)
Used an App on their cell phone
None
Some
About Half
Most
All
21)
Smoked tobacco from a hookah or
waterpipe
None
Some
About Half
Most
All
22)
Logged into Facebook
None
Some
About Half
Most
All
23)
Smoked electronic cigarettes, e-cigarettes,
vape pens, or hookah pens
None
Some
About Half
Most
All
24)
Listened to music on Pandora or Spotify
None
Some
About Half
Most
All
25)
Smoked cigars, cigarillos, or little cigars
None
Some
About Half
Most
All
26)
Visited a Tumblr page
None
Some
About Half
Most
All
27)
Posted a picture on Instagram
None
Some
About Half
Most
All
28)
Smoked menthol or mint cigarettes
None
Some
About Half
Most
All
Thank You! Please let a researcher know that you are finished.
| File Type | application/pdf |
| File Title | 2. Check-In Survey - Creative Development_REVISED.pages |
| File Modified | 2015-10-15 |
| File Created | 2015-08-14 |