LGBT Campaign: Wave 1B Online Quantitative Study Designed to Prevent Young Adult Tobacco Use

OMB# 0910-0810

Exp. 11/30/2018

LGBT Campaign: Wave 1B Online Quantitative Study Designed to

Prevent Young Adult Tobacco Use

Appendix B: Screener

WELCOME PAGE

[TEXT FOR PARTICIPANTS]:

LGBT CULTURE & HEALTH SURVEY

1. Answer a few questions to see if you qualify for the full survey.

2. Receive a $15 online gift card as thank you for your time after you complete the full survey.

Everyone who qualifies and completes the full survey will receive a $15 online gift card as a thank you.

READY TO START?

YES [radio button]

All information will be kept private to the fullest extent allowed by law.

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

1. 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

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

Month (MM): __

Year (YYYY): ____

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

__ __ __ __ __

4. 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

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

1. Male

2. Female

7. Prefer not to answer

6. 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

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

                 Never (1)                           Often (5)

                                

8. 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

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

Number of days (0-30) _______

88. Don’t know

10. 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 6 months

2. Yes, MORE THAN 6 months ago

3. No

4. I’m not sure

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. What is your current age?

Age:  ___ ___

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

__ __ __ __ __

17. Your e-mail address: __________________

Please re-enter your e-mail address: __________________

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

[TEXT PRESENTED TO QUALIFIED PARTICIPANTS]: Congratulations! You are invited to complete the full survey. Once the full survey is complete, you will receive a $15 online gift card! Please click the “Next” button to continue with the survey.

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 4 minutes per response to complete this 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.

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