Child Follow-up

Attachment_11_-_Data_collection_instrument_-_Child_questionnaire_Followup_MDF[1].pdf

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

Child Follow-up

OMB: 0925-0685

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Attachment 11
Data collection instrument: Child Questionnaire - Follow-up 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 PRIVATE to the extent permitted by law. Do not worry about your parents, teachers, or
anyone else finding out what you said. We don’t need names on the questionnaires because we’re only interested in how
most people your age feel as a group, not any one person’s answers.

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 are uncomfortable answering a particular question, you may skip it. THIS QUESTIONNAIRE IS NOT A TEST.
You will not be graded and there are no right or wrong answers.

If at any time during this questionnaire you would like to quit, then please 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 help!

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Screen 1 of 52

First, please have the parent who is with you today enter your secret number here:

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

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Screen 2 of 52

Now we want to know a little bit about your background. Click on the bubble to select your answer.
1. How old are you?

7 years old

8 years old

9 years old

10 years old

11 years old

12 years old

2. What grade are you in? If you are in between grades, what grade will you be in next school year?
3rd Grade

4th Grade

5th Grade

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3. What grades did you get on your last report card?

Mostly As

Mostly Bs

Mostly Cs

Mostly Ds

Mostly Fs

Now, we would like to ask you some questions about some conversations you may have had, and behaviors
that some people do.
4. In general, how often has the parent who is with you today talked with you about alcohol use?

Never

Rarely

Sometimes

Often

Extremely
often

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5. How often would you say that the parent who is with you today has done the following specific things?

The parent who is with me today:

Has lectured me or given me a
speech about drinking alcohol
Has warned me about the dangers of
drinking alcohol

Never

Once

A few

A lot of

times

Has talked to me about how to handle
offers of alcoholic drinks
Has given me rules to obey about
drinking alcohol
Will make a comment to me about
how drinking alcohol is bad if a
character on TV is drinking or drunk
Tells me stories of people who drank
alcohol or have been drunk

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The parent who is with me today:

Never

Tells me he or she would be
disappointed in me if I drink alcohol

Once

A few

A lot of

times

Shows me information on the web,
TV, or in the news about the dangers
of drinking alcohol
Asks about my thoughts and opinions
about drinking alcohol

6. In general, how often has the parent who is with you today talked with you about tobacco use (cigarettes,
chewing tobacco, or other forms of tobacco)?

Never

Rarely

Sometimes

Often

Extremely
often

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7. How often would you say that the parent who is with you today has done the following specific things?

The parent who is with me today:

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

Never

Once

A few

A lot of

times

Will make a comment to me about
how tobacco use is bad if a character
on TV is smoking or using other forms
of tobacco
Tells me stories of people who smoke
or use other forms of tobacco

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The parent who is with me today:

Never

Once

A few

A lot of

times

Tells me he or she would be
disappointed in me if I smoked
cigarettes or used other forms of

tobacco
Shows me information on the web,
TV, or in the news about the dangers
of using tobacco products
Asks about my thoughts and opinions
about smoking or using other forms of
tobacco

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8. How much do you agree with the following statements?

Disagree a

Disagree

lot

Neither

Agree

agree

Agree a
lot

nor
disagree
The parent with me today listens to
my point of view
The parent with me today says it’s
important to get my ideas across even

if others don’t like it
The parent with me today asks for my
opinion when our family is discussing
something.

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The next few questions ask you to think about what you might or might not do in the future.
9. Before you are 21 years old, do you think you will:

Drink beer, wine, or liquor (more than
just a few sips)?
Get drunk or drink a lot of alcohol at
one time?

10.

I definitely

will

probably

definitely

will

will not

Before you are 18 years old, do you think you will:

Smoke cigarettes?

I definitely

will

probably

definitely

will

will not

Use smokeless tobacco? (This
includes chewing tobacco, snuff, or
dip, such as Redman, Levi Garrett,
Beechnut, Skoal, Skoal Bandits, or
Copenhagen.)
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11.

During the next year, do you think you will:
I definitely

will

probably

definitely

will

will not

Smoke cigarettes?

Use smokeless tobacco? (chewing

Drink beer, wine, or liquor (more than
just a few sips)?
Get drunk or drink a lot of alcohol at
one time?

tobacco, snuff, or dip)

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Screen 11 of 52

Here are some questions about things that could happen to kids.
12.

Suppose you were with a group of kids and there were some cigarettes you could have if you wanted.

How willing would you be to do the following things?

How willing would you be to:

Not at all

Slightly

Moderately

Very

willing

Take one puff?

Smoke a whole cigarette?

Take some cigarettes to try later?

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13.

Suppose you were with a group of kids and there was alcohol you could have if you wanted. How

willing would you be to do the following things?

How willing would you be to:

Not at all

Slightly

Moderately

Very

willing

Take a sip?

Drink the whole drink?

Take some alcohol home to try later?

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14.

Suppose you were with a group of kids and there was chewing tobacco or dip you could have if you

wanted. How willing would you be to do the following things?

How willing would you be to:

Use the smokeless tobacco (chewing
tobacco, snuff, or dip)?

Not at all

Slightly

Moderately

Very

willing

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15. Now we are going to ask you about some behaviors.

During the past 30 days, how often did
you…

0
days

1-2

3-5

6-9

days days days

10-

20-

All

days

days days

Drink alcohol (more than just a sip)?

О О О О О О О

Smoke cigarettes?

О О О О О О О

Use smokeless tobacco? (This includes
chewing tobacco, snuff, or dip, such as
Redman, Levi Garrett, Beechnut, Skoal,

О О О О О О О

Skoal Bandits, or Copenhagen.)
Drink an energy drink (like Red Bull,
Monster, or Rock Star), which are
drinks with high amounts of caffeine?

О О О О О О О

This does not include sports drinks (like
Gatorade) or vitamin waters.

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16. [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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17. [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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18. [If yes to energy drinks] How much do you usually drink energy drinks per day?

1 drink

2 drinks

3 drinks

4 drinks

5 or more drinks

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19. In your LIFETIME have you ever:

Had a drink of alcohol (more than just a
few sips)?
Smoked a cigarette?

Yes

Used smokeless tobacco? (This
includes chewing tobacco, snuff, or dip,
such as Redman, Levi Garrett,
Beechnut, Skoal, Skoal Bandits, or
Copenhagen.)
Drunk an energy drink (like Red Bull,
Monster, or Rock Star), which are
drinks with high amounts of caffeine?
This does not include sports drinks (like
Gatorade) or vitamin waters

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Screen 19 of 52

20. How much do you agree with the following statements?

How much do you agree:

Strongly

Disagree

disagree

Neither

Agree

agree

Strongly
agree

nor
disagree
I can resist pressure from friends to
use alcohol or tobacco.
I won't feel pressured to use alcohol
or tobacco even if my friends are

doing it.
I know what things I can say to refuse
alcohol or tobacco.
I can say no to someone who is
pressuring me to use alcohol or
tobacco.
If all my friends were using alcohol or
tobacco, I probably would too.

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Screen 20 of 52

21. Please look at the advertisement on the next screen and answer questions about it that follow. To answer the
questions, you will type in your responses (words or sentences).

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Screen 21 of 52

Ad #1

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Screen 22 of 52

Tell me about this advertisement (Ad #1) in the space below (the more detail the better).

A. What is being sold in this ad?

B. What type of person do you think would like this ad (male or female, kid or adult)? Explain your answer.

C. What is the purpose of this ad?

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D. What did the people who made this ad do to make people stop and look at this ad?

E. What do they want you to think about this product? Finish this sentence: If I get this product, then…

F. Is there anything this ad is not telling you about the product that you would need to know before buying or
using it? Explain your answer.

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22. Now, please look at a different advertisement on the next screen and answer the questions about it that
follow. Again, you will type in your responses (words or sentences).

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Screen 25 of 52

Ad #2

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Screen 26 of 52

Tell me about this advertisement (Ad #2) in the space below (the more detail the better).

A. What is being sold in this ad?

B. What type of person do you think would like this ad (male or female, kid or adult)? Explain your answer.

C. What is the purpose of this ad?

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Screen 27 of 52

D. What did the people who made this ad do to make people stop and look at this ad?

E. What do they want you to think about this product? Finish this sentence: If I get this product, then…

F. Is there anything this ad is not telling you about the product that you would need to know before buying or
using it? Explain your answer.

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The next question is about advertising in general.

23. How much do you agree with the following statements?

How much do you agree:

Strongly

Disagree

disagree

Neither

Agree

agree

Strongly
agree

nor
disagree
Advertisers want you to buy the
product even if it isn't good for you to

have.
Advertisers care more about making
money than about what is good for
you.
Advertising doesn't change the way I
think.

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Now we are going to ask you some questions about advertisements for alcohol and tobacco products.

24. How much do you agree that people in ALCOHOL advertisements:

Strongly

Disagree

disagree

Neither

Agree

agree

Strongly
agree

nor
disagree
Do things that most people who drink
alcohol do.
Look like most people who drink
alcohol.
Act like most people act when they
drink alcohol.

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Screen 30 of 52

25. How much do you agree that people in TOBACCO advertisements:

Strongly

Disagree

disagree

Neither

Agree

agree

Strongly
agree

nor
disagree
Do things that most people who use
tobacco do.
Look like most people who use
tobacco.
Act like most people act when they
use tobacco.

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Screen 31 of 52

26. How much do you agree or disagree with the following statements?

How much do you agree or disagree:

Strongly

Disagree

disagree

Neither

Agree

agree

Strongly
agree

nor
disagree
I want to do the things that people in
alcohol advertisements do.
I want to look like the people I see in
alcohol advertisements.
I would like to be like the people I see in
alcohol advertisements.
I want to do the things that people in
tobacco advertisements do.
I want to look like the people I see in
tobacco advertisements.
I would like to be like the people I see in
tobacco advertisements.

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Screen 32 of 52

How much do you agree or disagree:

Strongly

Disagree

disagree

Neither

Agree

agree

Strongly
agree

nor
disagree

Alcohol ads get my attention.

The things I see in alcohol ads seem like

I like the kinds of things that people in
alcohol advertisements like.
People in alcohol advertisements are
similar to people in my family.
I like the kinds of things that people in
tobacco advertisements like.
People in tobacco advertisements are
similar to people in my family.

fun.

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Screen 33 of 52

How much do you agree or disagree:

Strongly

Disagree

disagree

Neither

Agree

agree

Strongly
agree

nor
disagree
The people in alcohol ads are attractive.

Tobacco ads get my attention.

The things I see in tobacco ads seem like

fun.
The people in tobacco ads are attractive.

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The next few questions ask about alcohol and tobacco.

27. How many of the kids at school or in the neighborhood have tried a drink of alcohol (beer, wine, or hard
liquor)?
None

Some

Most

All

28. Do you have any friends who drink alcohol?
Yes

29. How many of the kids at school or in the neighborhood smoke or have tried smoking cigarettes or cigars?
None

Some

Most

All

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Screen 35 of 52

30. Do you have any friends who smoke cigarettes or cigars?

Yes

31. How many of the kids at school or in the neighborhood have used smokeless tobacco (chewing tobacco,
snuff, or dip)?

None

Some

Most

All

32. Do you have any friends who have used smokeless tobacco (chewing tobacco, snuff, or dip)?

Yes

О
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Screen 36 of 52

33.
How would your best friend act
toward you if you…

Very

Friendly

Unfriendly

friendly

Very
unfriendly

Drank alcohol?

Smoked cigarettes?

Used smokeless tobacco (chewing

tobacco, snuff, or dip)?

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34.
How angry would your parent(s) be

Very

if they found out you…

angry

Angry

Somewhat

Not angry

angry

at all

Drank alcohol?

Smoked cigarettes?

Used smokeless tobacco (chewing

tobacco, snuff, or dip)?

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35. How much do you agree with the following statements:

How much do you agree or

Strongly

disagree:

disagree

Disagree

Neither

Agree

agree

Strongly
agree

nor
disagree
If I were to drink alcohol, I would have
fun.
If I were to drink alcohol, I would be
invited to more activities or parties.
If I were to drink alcohol, I would be
better at sports.
If I were to drink alcohol, other kids
would think I'm tough.
If I were to use tobacco, I would have
fun.
If I were to use tobacco, I would be
invited to more activities or parties.

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How much do you agree or

Strongly

disagree:

disagree

Disagree

Neither

Agree

agree

Strongly
agree

nor
disagree
If I were to use tobacco, I would be
better at sports.
If I were to use tobacco, other kids
would think I'm tough.

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36. How much do you agree with the following statements:

How much do you agree or

Strongly

disagree:

disagree

Disagree

Neither

Agree

agree

Strongly
agree

nor
disagree
If I were to use alcohol, I would feel
sick.
If I were to use alcohol, it would slow
me down.
If I were to use tobacco, I would feel
sick.
If I were to use tobacco, I would have
bad breath.

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Finally, we would like to get your opinions about the Media Detective Family program.
37. Would you say that the length of the Media Detective Family program (5 cases) was…

Too short

Too long

Just right

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38. Please answer the following questions about the Media Detective Family program.

Yes, a lot

Very

A little

Not at all

much

Were the cases interesting?

Are you glad you learned the material

Did you learn anything new in the
program?

in the program?
Would you tell your friends to try the
program?

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39. Please answer the following questions about the extension activities of Media Detective Family.

Yes, a lot

Very

A little

Not at all

much
Did you like the extension activities—
the activities where you and your
parent took what you learned and

investigated advertising that you see?

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40. Did you use Media Detective Family with just the parent who is with you today, or with other people, too?
Mark all the people who did Media Detective Family with you:

This parent

My other parent (mom, dad, stepmom,

stepdad)
My parent’s boyfriend or girlfriend

My grandparent (grandmother or grandfather)

My aunt or uncle

My brother or sister

My friends

Someone else: _________________

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41. What did you like best about Media Detective Family?

42. What did you like least about Media Detective Family?

THANK YOU FOR COMPLETING THIS QUESTIONNAIRE!
CLICK ‘NEXT’ TO FINISH.

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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