Adult Follow-up

Attachment_5_-_Data_collection_instrument_-_Adult_questionnaire_Followup_MDF[1].pdf

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

Adult Follow-up

OMB: 0925-0685

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Attachment 5
Data collection instrument: Adult Questionnaire – Followup MDF

OMB Control Number: 0925-XXXX

Expiration Date: 09/13/2014

Public reporting burden for this collection of information is estimated to average 45 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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In the first set of questions for today, we are going to ask you about some behaviors.

1. 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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2. [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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3. [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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4. 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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5. 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

6. [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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7. [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

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Now we have some questions about advertisements.

8. 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.
9. 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?

C. How can you tell?
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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.

10. 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

11. 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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12. 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.

13. 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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14. 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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15. 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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16. 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

17. 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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18. 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

19. 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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20. 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.

21. How often is alcohol present in your home?

Never

Occasionally

Fairly often

Very often

Always

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

Yes

23. Do you keep alcohol locked up?

Yes

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24. 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

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

Rarely

Sometimes

Often

Extremely
often

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26. 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.

27. 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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28. 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

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Now, we would like to ask a few questions about your use of the computer program you were given.

29. Did you bring your completed Program Usage Log (the paper where you wrote down the dates, times, and
participants when you used the computer program) with you today?

Yes

[If YES to completed Program Usage Log with the respondent today] Please take out the log now. You will use
it to answer a few questions.

30. [If YES to completed Program Usage Log with the respondent today] First, please count up the number times
you used the computer program in the past 3 months. Enter that number here:

Number of times used
computer program in
past 3 months

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31. [If YES to completed Program Usage Log with the respondent today] Please fill in the following information
from your log: [the number of rows that appear will correspond to the answer given in #30, above]

Date of Program

How long

Who used the program?

Use

did you use

(select all the people who used the program this

the

time)

program
this time
(minutes)
1.

Me
The child who is participating in
the study with me

This child’s other parent

My boyfriend or girlfriend

This child’s grandparent(s)

This child’s aunt(s) or uncle(s)

This child’s sibling(s)

This child’s friend(s)

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Date of Program

How long

Who used the program?

Use

did you use

(select all the people who used the program this

the

time)

program
this time
(minutes)
2.

Me
The child who is participating in
the study with me

This child’s other parent

My boyfriend or girlfriend

This child’s grandparent(s)

This child’s aunt(s) or uncle(s)

This child’s sibling(s)

This child’s friend(s)

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Date of Program

How long

Who used the program?

Use

did you use

(select all the people who used the program this

the

time)

program
this time
(minutes)
3.

Me
The child who is participating in
the study with me

This child’s other parent

My boyfriend or girlfriend

This child’s grandparent(s)

This child’s aunt(s) or uncle(s)

This child’s sibling(s)

This child’s friend(s)

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Date of Program

How long

Who used the program?

Use

did you use

(select all the people who used the program this

the

time)

program
this time
(minutes)
4.

Me
The child who is participating in
the study with me

This child’s other parent

My boyfriend or girlfriend

This child’s grandparent(s)

This child’s aunt(s) or uncle(s)

This child’s sibling(s)

This child’s friend(s)

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32. [If NO to completed Program Usage Log with the respondent today] You last completed a questionnaire 3
months ago. In the past 3 months, do you remember how often you used [the assigned computer program]?

Never. We didn’t use the program during the

past month.
We used the computer program, and I am able

to remember the number of times we used it.
We used the computer program, and I can

estimate the number of times we used it by
selecting from a range of choices.

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33. [If NO to completed Program Usage Log with the respondent today, but ability to REMEMBER number of
times indicated in #32] How many times did you use the computer program in the past 3 months? Enter that
number here:

Number of times used
computer program in
past 3 months

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34. [If NO to completed Program Usage Log with the respondent today, but ability to ESTIMATE RANGE of times
indicated in #32] How many times did you use the computer program in the past 3 months?

Never. We didn’t use the program during the

past 3 months.
Once

2-3 times

4-7 times

8-10 times

More than 10 times

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35. [If NO to completed Program Usage Log with the respondent today, but some computer program use
indicated] In the past 3 months, how much time did you typically spend on the assigned computer program
when you used it?

Less than 15 minutes

Between 15 and 30 minutes

Between 30 and 45 minutes

Between 45 minutes and 1 hour

More than 1 hour

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36. [If NO to completed Program Usage Log with the respondent today, but some computer program use
indicated] In the past 3 months, who has used the assigned computer program? Mark all the people who have
used the assigned computer program together at least once.

Me
The child who is participating in the study with

me
This child’s other parent (mom, dad, stepmom,

stepdad)

My boyfriend or girlfriend
This child’s grandparent (grandmother or

grandfather)
This child’s aunt or uncle

This child’s siblings (brothers/sisters or

stepbrothers/stepsisters)
This child’s friends

Someone else: _________________

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Now, we would like to get your opinions on different aspects of the Media Detective Family program.

37. As compared to before the Media Detective Family program, how would you describe your READINESS in
each area? As before, “your child” refers to the child who is participating in this study with you.
Much

Less

less
Talking with this child about media messages

About

the same

Much
more

Identifying ways that advertisements target
specific age groups, people with particular
interests, etc.
Assessing the realism of advertising
Being aware of the health risk information left
out of ads for tobacco and alcohol
Monitoring this child’s media exposure
Monitoring media exposure for other children
in the household

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As compared to before the MDF program, how would you describe your READINESS in each area?
Much

Less

less
Talking with this child about substance use

About

the same

Much
more

Talking with this child about your
expectations for his/her behavior regarding
substance use
Helping this child understand the purpose of
advertising
Selecting age-appropriate TV shows, movies,
video games, Internet content, etc. for this
child
Changing how you yourself use substances
(e.g., changing the frequency of use or
changing use in situations where children are
present)
Changing the availability of substances to
children in your household (e.g., locking
cabinets where alcohol is stored, keeping
count of your cigarettes)
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38. How would you evaluate the Media Detective Family program in the following areas?
Poor

Fair

Good

Very

Excellent

good
Ease of use

Convenience

Thoroughness

Amount of content

Topic appropriateness

Quality of media

Appeal

Motivational/inspiring to parents

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39. Please tell us one or two specific aspects of the Media Detective Family program that you think we could
improve. We are particularly interested in how you think we can make the program more useful for families
who live in rural areas.

40. How would you evaluate the extension activities in the following areas?
Poor

Fair

Good

Very

Excellent

good
Ease of use

Convenience

Topic appropriateness

Appeal

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41. Which was the primary format for the extension activities that you used?

Paper and pen or pencil

Tablet computer

Smartphone

Did not complete any extension activities

42. How would you rate the overall experience with this program?
Not at all

Somewhat

satisfied

unsatisfied

Satisfied

Very
satisfied

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43. How did this program benefit you? Choose all that apply.

Time saving

No travel needed to access or use the materials

Convenience

Start and stop when needed

Engaged the child who is participating in this study

Engaged other members of the family

Answered my questions

Answered this child’s questions

Provided information I didn’t know I needed

Gave our family time to reflect

Gave me confidence in talking about substance use with this child

Extension activities helped to guide conversations

Was a fun activity to do as a family

О
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44. Please check any of the following that you would say are TRUE for you. Choose as many as apply.

I prefer in-person family training to online
I would like additional online trainings about

media literacy and health

I would like additional extension activities
I plan to do the extension activities again with

other children in the household

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