Adult Pretest

Attachment_1_-_Data_collection_instrument_-_Adult_questionnaire_-_Pretest_MDF[1].pdf

Web-based Media Literacy Parent Training for Substance Use Prevention in Rural Locations

Adult Pretest

OMB: 0925-0685

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Attachment 1
Data collection instrument: Adult questionnaire – Pretest MDF

OMB Control Number: 0925-XXXX

Expiration Date: XX/XX/XXXX

Public reporting burden for this collection of information is estimated to average 50 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-XXXX). Do
not return the completed form to this address.

Introduction to the questionnaire

Thank you for agreeing to complete this questionnaire. Instead of using your name on this questionnaire, you will use a secret
number. Because you are using a number instead of your name, your answers will be kept private to the extent permitted by
law.

If you have more than one child, please answer the questions with respect to the child who is participating in this research
study with you.

Be sure to answer ALL of the questions honestly and carefully. If you are unsure of an answer, please give your best guess.
However, if you do not want to answer a particular question, you may skip it. The questionnaire is not a test—there are no
right or wrong answers.

If at any time during this questionnaire you would like to quit, then please click on the link in the corner of your screen that
says "Exit This Questionnaire" in order to exit the questionnaire.

Please ask a project staff member if you have questions while completing this questionnaire.

Thanks again for your assistance!

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First, please enter your secret number here. The same number is used for you and your child who is
participating in this study.

To be sure that the number was entered correctly, please enter the secret number again here:

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Now we would like to know a little bit about your media use.

1. How many of the following devices are there in your home?
# in your home
TVs
DVD players
DVRs (e.g., TiVo)
Radios
CD players
Video game consoles (e.g., Xbox, Playstation, Wii)
Computers (e.g., desktop, laptop)
Tablet computers (e.g., iPad, Samsung Galaxy tablet)
MP3-type music players (e.g., iPod, Zune, Sansa Clip)
Smartphones (e.g., iPhone, Blackberry, Android,
Windows phone)

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2. How many different NEWSPAPERS do you get each WEEK?
More
0

than
5

3. How many different MAGAZINES do you get each MONTH?
More
0

than
5

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4. Which technology device you currently own would you be most likely to use to access a program for parents
and kids to use together? Mark ONE:

Home computer (desktop or laptop)

Tablet computer (e.g., iPad, Samsung Galaxy

tablet)
О

Smartphone (e.g., iPhone, Blackberry,
Android, Windows phone)

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5. Which of the following types of Internet access do you have at home? Mark all that apply.

Do not have Internet access at home.

Dial-up

DSL broadband

Cable broadband

Mobile broadband (3G/4G/etc. service through

a cellular provider)
Satellite internet

Other [Specify: ______________]

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6. [If reported having a tablet computer in #4] Which of the following ways do you connect your tablet computer
to the Internet? Mark all that apply.

WiFi at home
WiFi outside of home (e.g., at school,

coffeeshops, libraries, etc.)
Mobile broadband (3G/4G/etc. service through

a cellular provider)
I don’t connect my Tablet to the Internet

Don’t know

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7. [If reported having a Smartphone in #4] Which of the following ways do you connect your Smartphone to the
Internet? Mark all that apply.

WiFi at home
WiFi outside of home (e.g., at school,

coffeeshops, libraries, etc.)
Mobile broadband (3G/4G/etc. service through

a cellular provider)
I don’t connect my Smartphone to the Internet

Don’t know

8. Do you have unlimited data service through your cellphone provider?

Yes

I don’t know

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Now we would like to ask a few questions about media and technology that YOUR CHILD may use.

9. Which of the following does your child who is participating in this study have?

Yes

A television in his or her bedroom?

A computer in his or her bedroom?

His or her own cellphone?

10. [If reported that child has own cellphone in #9] Which kinds of capabilities does this child’s cellphone have?

Only telephone calls

Telephone calls and text messages

Telephone calls, text messages, and Internet

access
I don’t know

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11. Which of the following social networking websites (if any) does your child who is participating in this study
use? Mark all that apply.

Facebook

Club Penguin

Togetherville

Ohanarama

Fooz Kids

KidzVuz

YourSphere

Other [Specify: ______________]

None. My child does not use any

social networking websites.
I don’t know

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Now we are going to ask questions about your background and your child’s background.

12. What is your sex?
Male

Female

13. What is your relationship to the child who is participating in this study?

Biological mother/father

Adoptive mother/father

Stepmother/stepfather

Grandmother/grandfather

Sister/brother or stepsister/stepbrother

Other relative or in-law [Specify:__________]

Foster parent

Parent’s partner

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14. Is this child a boy or a girl?
Boy

Girl

15. What is this child’s age?
Child’s age
in years

16. Is this child Hispanic or Latino?

Yes, this child is Hispanic or Latino

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17. What is this child’s race? Please select one or more.

White/Anglo/Caucasian

Black/African American

American Indian/Alaska Native

Asian

Native Hawaiian or other Pacific Islander

18. What is YOUR age?
Age in
years

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19. Are you Hispanic or Latino?

Yes, I am Hispanic or Latino

20. What is your race? Please select one or more.

White/Anglo/Caucasian

Black/African American

American Indian/Alaska Native

Asian

Native Hawaiian or other Pacific Islander

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21. What is the highest level of education that you have completed?

Elementary school

Some high school

High school or GED

Some college

Two-year college degree

Four-year college degree

Graduate or professional degree

22. What type of work are you doing?

Type of work

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23. Which of the following best describes your household?

Two parent (married)

Two parent (not married)

Single parent

Other [specify:____________________]

24. How many children under age 18 live in your household?
Number of children
under age 18

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25. [For two-parent households] What is the highest level of education that YOUR PARTNER has completed?

Elementary school

Some high school

High school or GED

Some college

Two-year college degree

Four-year college degree

Graduate or professional degree

26. [For two-parent households] What type of work is YOUR PARTNER doing?
Type of work

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27. What is your annual household income? Include all sources of income (wages and salaries, unemployment
compensation, disability payments, child support payments received, etc.)

Annual
household
income

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28. [If respondent attempts to skip income question] Would you say your yearly household income is…

Higher than

Lower than

$40,000

[Then]

[or]

Higher than

Lower than

Higher than

Lower than

$20,000

$60,000

[Then]

[or]

Higher than

Lower than

Higher than

Lower than

$30,000

$10,000

[OR]

[or]

Higher than

Lower than

Higher than

Lower than

$80,000

$50,000

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29. How many people in your household are supported by this income? Include all adults and children who are
supported by this income.
# of people supported
by this income

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In the next set of questions, we are going to ask you about some behaviors.

30. During the past 30 days, how often did you do the following things?

During the past 30 days,
how often did you…

0
days

1-2

3-5

6-9

days days days

10-

20-

All

days
Drink alcohol (more than
just a sip)?
Smoke cigarettes?

days days

Use smokeless tobacco?
(This includes products like
chewing tobacco, snuff, or
dip.)

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31. [If yes to cigarettes] How much do you usually smoke per day?

Less than 1 cigarette per day

1-5 cigarettes per day

About ½ a pack per day

1 pack per day

More than 1 pack per day

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32. [If yes to smokeless tobacco] How much do you usually use smokeless tobacco per day?

1-2 times a day

3-4 times a day

5-6 times a day

7-8 times a day

9-10 times a day

More than 10 times a day

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33. In the last month have you had [males=5, females=4] or more drinks in a row?

Yes, and I do not intend to stop drinking 5/4 or
more drinks in a row

Yes, but I intend to stop drinking 5/4 or more
drinks in a row in the next 6 months

Yes, but I intend to stop drinking 5/4 or more
drinks in a row during the next 30 days

No, but I have had 5/4 or more drinks in a row
in the past 6 months

No, and I have not had 5/4 or more drinks in a
row in the past 6 months

No, I have never had 5/4 or more drinks in a
row.

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34. Are you currently a smoker?

Yes, I currently smoke

No, I quit within the last 6 months

No, I quit more than 6 months ago

No, I have never smoked

35. [For current smokers only] In the last year, how many times have you quit smoking for at least 24 hours?
# of times in past year
you quit for at least
24 hours

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36. [For current smokers only] Are you seriously thinking of quitting smoking?

Yes, within the next 30 days

Yes, within the next 6 months

No, not thinking of quitting

Now we have some questions about advertisements.

37. Please look at the advertisement on the next screen and answer questions about it that follow. The questions
are open-ended, which means you will type in your responses.

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Ad #1
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A. Tell me about Ad #1 (the more detail the better).

B. What are some possible messages that the advertisers want the viewer to think after looking at Ad #1?

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C. How can you tell?

D. What type of person might be interested in Ad #1?

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You have finished questions about Ad #1.
38. Now, please look at a different advertisement on the next screen and answer questions about it that follow.
Again, the questions are open-ended, which means you will type in your responses.

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Ad #2
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A. Tell me about Ad #2 (the more detail the better).

B. What are some possible messages that the advertisers want the viewer to think after looking at Ad #2?

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C. How can you tell?

D. What type of person might be interested in Ad #2?

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You have finished questions about Ad #2.
The next few questions are about media and advertising in general.

39. There are many types of media. Which of the following best shows an example of a medium?

Letter to the Editor of a newspaper

Letter to your grandparents

40. Why might it be important for children to learn about who pays for TV shows and why?

To increase media concern

To increase media skepticism

To increase media awareness

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41. Fill in the blank to define "target audience":
The target audience is the people the advertisement is meant to____________.

…show using the product.

… write favorable online reviews of
the product.
…convince to purchase the product.

42. What do you think best describes “hidden messages” in advertising?

Ways that advertisers try to made
ads desirable to target audiences
Clues that help solve the mystery of
advertising
Hints that ads are not realistic

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43. Which of the following steps are involved in the production of a counter-ad for alcohol and tobacco?

(A) Identifying the missing information in a
preexisting alcohol or tobacco ad
(B) Finding a clever way of inserting the
missing information into the counter-ad
(C) Learning about the health
consequences of alcohol and tobacco

(D) A and B only

(E) A, B, and C

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44. Below you will find a number of questions about television advertising. We would like to ask you how you
deal with advertising directed at your child who is participating in this study. Can you indicate how often you
act in each of the following ways?
How often do you tell your child…

Almost

Sometimes

Often

never
That advertising depicts products as
better than they really are?
That advertising does not always tell
the truth?
That the purpose of advertising is to
sell products?
That not all advertised products are
of good quality?
That some advertised products are
not good for children?

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How often do you tell your child…

Almost

Sometimes

Often

never
To turn off the television when s/he
is watching commercials?
That s/he should not watch
commercial networks because they
broadcast too many commercials?
To switch to a channel that
broadcasts fewer commercials?
That s/he should not watch
television advertising at all?
To watch specific networks that
broadcast relatively few
commercials?

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45. How often do you use an alternative means of watching TV (e.g., DVDs, DVRs, or services like Netflix or Hulu)
to limit this child’s exposure to commercials?
Never

Rarely

Sometimes

Often

Extremely
much

46. Do you put any controls on the TELEVISIONS in your home to ensure that this child is not watching any
inappropriate content? Please mark ONE.

No
Yes; I use a device that blocks programs

based on ratings
Yes; I only allow my child to watch television

when I am present

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47. Do you put any controls on the COMPUTER OR INTERNET BROWSER to ensure that this child is not viewing
any inappropriate content? Please mark ONE.

No
Yes; I use a device that blocks websites based

on ratings
Yes; I only allow my child to use the computer

when I am present

48. Do you put any controls on the VIDEO GAME CONSOLES in your home to ensure that this child is not
watching any inappropriate content?

No
Yes; I use a device that blocks games based

on ratings
Yes; I only allow my child to play video games

that I approve

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49. Do you monitor the MOVIES that this child watches to ensure he or she is not watching any inappropriate
content?

No
Yes; I use a device that blocks movies on my

TV/DVD/DVR based on ratings
Yes; I only allow my child to watch movies

when I am present

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The next set of questions ask about alcohol and tobacco.

50. How often is alcohol present in your home?

Never

Occasionally

Fairly often

Very often

Always

51. Do you keep track of the alcohol supply in your home?

Yes

52. Do you keep alcohol locked up?

Yes

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53. How difficult would it be for your child who is participating in this study to obtain alcohol from your home?
Very

Difficult

Neutral

Easy

Very easy

difficult

There is no
alcohol in
my home

54. In general, how often have you talked with this child about alcohol use?
Never

Rarely

Sometimes

Often

Extremely
often

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55. How often would you say you have done the following specific things? As before, “your child” refers to the
child who is participating in this study with you.
Never

Have lectured or given your child a
speech about drinking alcohol
Have warned your child about the
dangers of drinking alcohol
Have talked to your child about how to
handle offers of alcoholic drinks
Have given your child rules to obey
about drinking alcohol

Once

A few

A lot of

times

Have made a comment to your child
about how drinking alcohol is bad if a
character on TV is drinking or drunk
Tell your child stories of people who
drank alcohol or have been drunk

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How often would you say you…

Never

Once

A few

A lot of

times

Tell your child that you would be
disappointed if he or she drank

alcohol
Show your child information on the
web, TV, or in the news about the
dangers of drinking alcohol
Ask for your child’s thoughts and
opinions about drinking alcohol.

56. In general, how often have you talked with this child about tobacco use (cigarettes, chewing tobacco, or other
forms of tobacco)?
Never

Rarely

Sometimes

Often

Extremely
often

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57. How often would you say you have done the following specific things? As before, “your child” refers to the
child who is participating in this study with you.
Never

Have lectured or given your child a
speech about tobacco use
Have warned your child about the
dangers of tobacco use
Have talked to your child about how to
handle offers of tobacco products
Have given your child rules to obey
about tobacco use

Once

A few

A lot of

times

Have made a comment to your child
about how tobacco use is bad if a
character on TV is smoking or using
other forms of tobacco
Tell your child stories of people who
smoke or use other forms of tobacco

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How often would you say you…

Never

Once

A few

A lot of

times

Tell your child that you would be
disappointed if he or she smoked
cigarettes or used other forms of

tobacco
Show your child information on the
web, TV, or in the news about the
dangers of using tobacco products
Ask for your child’s thoughts and
opinions about smoking or using other
forms of tobacco

THANK YOU FOR COMPLETING THIS QUESTIONNAIRE.
CLICK ‘NEXT’ TO SUBMIT YOUR RESPONSES AND EXIT.

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File Type	application/pdf
File Title	Parent Follow-Up Questionnaire
Author	Jennifer Erausquin
File Modified	2013-11-06
File Created	2013-11-05