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pdfATTACHMENT 1.
QUESTIONNAIRES: ENGLISH-LANGUAGE VERSIONS
Attachment 1-1. Mail Screener
TCS IDID
NSTP
OMB Number:
Expiration Date:
0910-0815
06/30/2019
Thank you for filling out this short survey. Your household’s answers to the questions will be kept
private to the fullest extent allowable by law. They will be used to determine if someone in your
household may be eligible to take part in an important study for the U.S. Food and Drug Administration
(FDA). Your participation is voluntary and the survey will only take 1-2 minutes of your time to
complete.
Start Here. Please use blue or black ink to complete the survey.
MS1. Please think about everyone who currently lives at this address. How many adults 18 years of age or older
live at this address?
Adults 18 years of age or older
MS2. Does anyone 18 years of age or older living at this address now smoke cigarettes?
1
2
Yes
No
MS3. Does anyone 18 years of age or older living at this address now smoke regular cigars, cigarillos, or little
filtered cigars? “Cigarillos” are medium cigars that sometimes are sold with plastic or wooden tips. Some
common brands are Black and Mild, Swisher Sweets, Dutch Masters, and Phillies Blunts. Cigarillos are
usually sold individually or in packs of 5 or fewer. Little filtered cigars look like cigarettes and are usually
brown in color. Like cigarettes, little filtered cigars have a spongy filter and are sold in packs of 20. Some
common brands are Prime Time and Winchester.
1
2
Yes
No
MS4. Does anyone 18 years of age or older living at this address now use smokeless tobacco products? Smokeless
tobacco products are placed in the mouth or nose and can include chewing tobacco, snuff, dip, snus (snoose)
or dissolvable tobacco. Some common brand names are Skoal, Copenhagen, Grizzly, Levi Garrett, or Red Man.
1
2
Yes
No
MS5. Can you connect to the Internet at this address?
1
2
Yes
No
Thank you for completing the survey!
Please place your questionnaire in the provided envelope and return to RTI International. If the envelope has been
misplaced, please mail the questionnaire to:
RTI International – 0212926.017.000.005
3040 Cornwallis Rd.
Research Triangle Park, NC 27709
Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 2 minutes per response to complete
the survey questions. Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden,
to PRAStaff@fda.hhs.gov.
FORM ID
Attachment 1-2: Field Screening Instrument
National Panel of Tobacco Consumer Studies
Field Screening (SC) Instrument
RTI_Mobile Platform
OMB Number: 0910-0815
Expiration Date: 06/30/2019
A. INTRODUCTION / ADDRESS VERIFICATION
CONFIRM YOU HAVE OPENED THE CORRECT CASE. IF YOU ARE NOT IN THE
CORRECT CASE, BREAK OFF AND LOCATE THE CORRECT CASE
SCBLANG: INTERVIEWER: WHAT LANGUAGE IS BEING USED TO CONDUCT THIS
INTERVIEW?
1
2
ENGLISH
SPANISH
SCBINTRO: Hello, my name is __________ from Research Triangle Institute in
North Carolina. We are conducting a nationwide study sponsored by the U.S. Food
and Drug Administration (FDA). You should have received a letter prior to my visit.
HAND R COPY OF LETTER IF NECESSARY. ALLOW TIME TO READ.
SCB1. For survey purposes, I need to confirm that I have the correct address. Is it
[FILL ADDRESS]?
1
2
3
YES, VERIFIED ADDRESS IS CORRECT
NO, EXIT AND FIND CORRECT ADDRESS
GO TO SCEXIT2
ADDRESS CORRECT, MINOR EDITS NEEDED. GO TO SCEXIT2A
[DISPLAY ADDRESS]
1
2
3
4
5
6
7
STREET NUMBER
STREET NAME
APARTMENT NUMBER
CITY
STATE
ZIP
NONE GO TO SCB2
PROGRAM EACH ADDRESS UPDATE ELEMENT AS SINGLE QUESTION AS NEEDED. SCB1B =
STREET NUMBER, SCB1C = STREET NAME, SCB1D = CITY, SCB1E =STATE, SCB1F= ZIP
1
SCB2. INTERVIEWER: IDENTIFY KNOWLEDGEABLE ADULT RESIDENT TO SCREEN.
First let me verify: do you live here? (Are you a member of this household?)
(IF NOT OBVIOUS): And are you 18 years of age or older?
[IF NO TO EITHER, ASK FOR A KNOWLEDGEABLE ADULT RESIDENT AND BEGIN
INTRO AGAIN.]
1
2
3
ADULT SCREENING R AVAILABLE, CONTINUE
SCBCONSENT
ADULT SCREENING R NOT CURRENTLY AVAILABLE
NO HH RESIDENTS 18+
GO TO
GO TO SCEXIT3
GO TO SCB3
SCB3. Just to confirm, is there anyone living in this household who is 18 years of
age or older?
1
2
YES
NO
ASK FOR ADULT RESIDENT, GO BACK TO INTRO
GO TO SCEXIT4
SCBCONSENT. SCREENER INFORMED CONSENT: We are working with the FDA to
create a large, national survey panel as part of the National Panel of Tobacco
Consumer Studies, or TCS. This address is one of more than 30,000 addresses
across the U.S. that has been randomly selected. We are contacting this household
to determine if anyone who lives here may be eligible for the panel. My questions
will only take 5-10 minutes of your time. Your answers to the questions will be
kept private to the fullest extent allowable by law, and your participation is
voluntary. If we select someone from your household to take part in the panel,
that person will have the chance to receive cash payments for participating in the
TCS surveys.
CONTINUE
SCB4. Are there any other living quarters within this structure or at this address,
such as a separate apartment with a separate entrance?
1
2
YES
NO
GO TO SCCINTRO
SCB5. Do the occupants of the other living quarters live and eat separately from
the residents of this household? (PROBE IF NEEDED: In other words, do the
occupants live on their own or do they share common space and food?)
1
2
YES, OCCUPANTS LIVE SEPARATELY
NO, OCCUPANTS SHARE COMMON FOOD/SPACE
GO TO SCCINTRO
SCB6. Do the occupants of the additional living quarters have direct access from
the outside or through a common hall?
1
2
YES
NO
GO TO SCCINTRO
2
SCB7A. FI: DID YOU FIND 5 OR MORE NEW LQs?
1
2
YES
NO
GO TO SCB7
SCB7AA. PLEASE COLLECT DETAILED INFO ABOUT ADDITIONAL LQS (5+ LQS) AND
CONTACT YOUR FS UPON LEAVING THE HOME.
CONTINUE GO TO SCCINTRO
SCB7. INTERVIEWER: OCCUPANTS OF ADDITIONAL LQs LIVE ON OWN AND HAVE
DIRECT ACCESS FROM OUTSIDE/COMMON HALL. ENTER ADDRESS OF
SEPARATE LQs. INCLUDE STREET NUMBER, NAME, AND UNIT OR
APARTMENT NUMBER.
[COLLECT UP TO 4]
LQ
LQ
LQ
LQ
1
2
3
4
STREET
STREET
STREET
STREET
NUMBER:___________
NUMBER:___________
NUMBER:___________
NUMBER:___________
STREET
STREET
STREET
STREET
NAME:______________________
NAME:______________________
NAME:______________________
NAME:______________________
[INTERVIEWER: RECORD A DESCRIPTION IF ADDRESS IS NOT KNOWN.]
SCEXIT2. Thank you for answering our questions, but I have the wrong address.
Have a nice day/evening. [EXIT SURVEY. DO NOT ASSIGN EVENT. KEEP AT
MOST CURRENT STATUS/EVENT CODE.]
SCEXIT2A. INTERVIEWER: TAP EXIT. THEN TAP MENU. EDIT ADDRESS AND
MODIFY ADDRESS. TAP MENU AGAIN TO UPDATE. RETURN TO SCREENING
INSTRUMENT. SELECT ‘YES, VERIFIED ADDRESS IS CORRECT’ AND
PROCEED. [DO NOT ASSIGN EVENT. KEEP AT MOST CURRENT
STATUS/EVENT CODE.]
SCEXIT3. [EXIT/BREAKOFF] OBTAIN NAME, DATE, TIME TO RETURN
B. HOUSEHOLD ROSTER
SCCINTRO: Next I would like to ask a few questions about you and your
household.
(TASK 1. BUILD LIST 1: ADULT HOUSEHOLD MEMBERS)
SCC1. First, including yourself, how many adults 18 years or age or older are living
or staying at this address? [IF SCB6 = 1 OR SCB7 = 1, FILL]: Please do not
include persons who live on their own in separate living quarters at this
address or within this structure, such as a separate apartment with a
separate entrance.
3
[FILL SAMPLE ADDRESS FOR REFERENCE. USE UPDATED ADDRESS FROM
SECTION A IF APPLICABLE.]
INTERVIEWER PROBE IF NEEDED:
INCLUDE adults who are away at school or college, lodgers, boarders, or
people you employ who live here.
INCLUDE adults who usually stay here but are temporarily away for reasons
such as visiting friends, traveling for their jobs, or in “general” hospitals.
[DISPLAY IF SCB5 = 2 OR SCB6 = 2 OR SCB7 = 2]: INCLUDE adults who
share common food or space but that live in other living quarters at the
address.
SCC2. [LOOP 1]: What is your name?
[LOOP 2 (IF SCC1 = 2 OR MORE)]: Please give me the names of all the other
adults age 18 and older who live or stay at this address. [PROBE: What are
the names of the other adults who live or stay here? Let’s start with the
oldest and work down to the youngest adult in this household.]
INTERVIEWER: ASK FOR FULL NAMES, BUT ACCEPT FIRST NAMES, NICKNAMES OR
INITIALS IF NECESSARY. TRY TO DISTINGUISH NAMES (Tom vs. Tom Jr.). ASSURE
R OF PRIVACY.
SCC3. Do any other adults age 18 or older usually live here or stay here?
1
YES
ADD NAME(S) TO ROSTER
2
NO
GO TO CHECK BOX 1
INTERVIEWER: RECORD ALL NAMES. ASK FOR FULL NAMES, BUT ACCEPT FIRST
NAMES, NICKNAMES OR INITIALS IF NECESSARY. TRY TO DISTINGUISH NAMES
(Tom vs. Tom Jr.). ASSURE R OF PRIVACY.
NAMEDUP. [NAME ENTERED] HAS BEEN PREVIOUSLY ENTERED. PROBE FOR
UNIQUE NAME, AND RE-ENTER.
TASK 2. DETERMINE "HOUSEHOLDER" (HHNAME FILL) FOR RELATIONSHIP
MAPPING)
CHECK BOX 1:
IF ROSTER CONTAINS ONLY 1 ADULT GO TO CHECK BOX 2.
IF ROSTER CONTAINS 2 OR MORE ADULTS CONTINUE
SCC4. Please tell me the name of the adult or one of the adults living here who
owns or rents this home. We’ll refer to this person as the “householder.”
INTERVIEWER: PICK “HOUSEHOLDER” FROM DISPLAYED ROSTER. IF SCREENING
RESPONDENT IS ONE OF THE “HOUSEHOLDERS,” SELECT HIM/HER FROM ROSTER.
[PROGRAMMER: IDENTIFY SELECTED “HOUSEHOLDER” AS “HHNAME” FILL.]
4
SCC5INTRO. Now I have a few questions about the adults who live in this
household. Let’s start with you.
(TASK 3. GATHER KEY CHARACTERISTICS OF EVERYONE ON LIST 1)
CHECK BOX 2:
IF ROSTER CONTAINS ONLY 1 ADULT CODE THE ADULT AS “HOUSEHOLDER (0)” IN SCC5
AND GO TO SCC6.
IF ROSTER CONTAINS 2 OR MORE ADULTS ASK SCC5-SCD4 FOR EACH ADULT ON LIST 1.
SCC5.
[IF LOOP 1 (SCREENING R)]: How are you related to the householder, [FILL
HHNAME NAME]?
[IF LOOP 2+]: [IF LOOP 2: Now let's talk about the other adults in the
household.] How is [FILL NAME] related to [IF SCREENING R IS
HOUSEHOLDER IN SCC4, FILL: “you”/ELSE, FILL “[HHNAME]”?]
[DISPLAY OPTION 0 (HOUSEHOLDER) ONLY UNTIL SELECTED.]
0
HOUSEHOLDER (OWNS OR RENTS HOME)
1
HUSBAND
2
5
WIFE
SON (INCLUDES STEP)
DAUGHTER (INCLUDES STEP)
SON-IN-LAW/DAUGHTER-IN-LAW
6
BROTHER (INCLUDES STEP)
7
SISTER (INCLUDES STEP)
PARENT/GUARDIAN (INCLUDING STEP)
GRANDPARENT
3
4
8
9
13
GRANDCHILD
LIVE-IN PARTNER
FRIEND/ROOMMATE
OTHER RELATIVE
14
OTHER NON-RELATIVE
15
RELATIONSHIP UNSPECIFIED
10
11
12
SCC6. [IF LOOP 1]: INTERVIEWER: CODE GENDER OF R.
[IF LOOP 2+]: ASK IF NECESSARY: Is [FILL NAME] male or female?
1
2
MALE
FEMALE
SCC7. [IF LOOP 1]: How old are you? [IF LOOP 2+]: How old is [FILL NAME]?
5
_____ AGE (RANGE: 18-110)
[If DK, REF then ask SCC7A]
SCC7A. Providing an age is important. This ensures we can accurately determine
whether [you are] or [fill person name] is] eligible to participate in the
panel. Can you confirm which of the following age categories [you
belong/[fill person name] belongs] to?
1
2
3
4
5
-1
-2
18-25
26-34
35-49
50-74
75 +
DON’T KNOW
REFUSED
[IF STILL DK, REF, CONTINUE WITH SCC8] NOTE: THIS PERSON WOULD NOT BE
CONSIDERED IN THE HH.
SCC8. [IF LOOP 1, FILL]: Are you/ELSE: Is [FILL NAME]] currently serving on
active duty in the U.S. Armed Forces, Military Reserves or National Guard?
[FILL FOR LOOP 1 ONLY]: Active duty for the Reserves or National Guard
does not include the regular training for the Reserves or Guard. It does
include being activated for deployment such as for the war in Afghanistan.
1
2
YES
NO
INTERVIEWER: IF ASKED, THE US ARMED FORCES ARE ARMY, NAVY, AIR FORCE,
AND MARINE CORPS.
CHECK BOX 3:
IF SCC5 = 1 OR 2 FOR ADULT BEING DISCUSSED SET SCC9 TO 1 (MARRIED) GO TO SCC10.
SCC9. [IF LOOP 1, FILL: Are you/ELSE FILL: Is [IF SCC6 = 1, FILL: he/IF SCC6 = 2
FILL: she]…[READ LIST]?
1
2
3
Married or living with a partner
Widowed
Divorced
4
Separated
5
Never married
SCC10. What is the highest grade or year of school (IF LOOP 1, FILL "you have",
ELSE FILL "[NAME] has") completed?
6
INTERVIEWER: FOR THOSE CURRENTLY IN SCHOOL, THIS DOES NOT INCLUDE THE
CURRENT YEAR OF SCHOOL, UNLESS IT IS ALREADY COMPLETED.
1
2
3
4
5
LESS THAN HIGH SCHOOL
HIGH SCHOOL GRADUATE OR GED
SOME COLLEGE/VOCATIONAL SCHOOL (NO DEGREE)
2-YEAR COLLEGE/VOCATIONAL/ASSOCIATE’S DEGREE
4-YEAR COLLEGE DEGREE OR HIGHER(E.G., BA, BS, MA, MS, Ph.D)
SCC11. In the past 30 days, did (IF LOOP 1, FILL "you", ELSE FILL "[NAME]") do
any work for pay, including both full-time and part-time work?
1
2
YES
NO
SCC12. (IF LOOP 1, FILL "Are you", ELSE FILL "Is [NAME]") Hispanic, [IF SCC6 =1,
FILL: Latino / IF SCC6 = 2, FILL: Latina], or of Spanish origin?
1
2
YES
NO
SCC13. What is (IF LOOP 1, FILL "your", ELSE IF SCC6 = 1, FILL: his/IF SCC6 = 2,
FILL her) race? I'm going to read a list. Please select one or more.
1
2
3
4
5
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
SCC14. (IF LOOP 1, FILL "Do you", ELSE FILL "Does [NAME]") live here full time or
part time? PROBE: (IF LOOP 1, FILL "Do you", ELSE FILL "Does [FILL
NAME] spend half or more of (IF LOOP 1, FILL "your", ELSE IF SCC6=1, FILL
"his", ELSE IF SCC6 = 2, FILL "her") time in this household?)
1
2
FULL TIME (SPENDS HALF TIME OR MORE IN THIS HH)
PART TIME (SPENDS LESS THAN HALF TIME IN THIS HH)
C. TOBACCO USE SCREENER
CHECK BOX 4:
PROGRAMMER: CONTINUE WITH SCD1 – SCD4 FOR THE SCREENING RESPONDENT; THEN
LOOP BACK TO QUESTION SCC5 AND COMPLETE SCC5 THROUGH SCD4 FOR ALL OTHER
ADULTS LISTED IN HH ROSTER.
Cigarettes
7
SCDINTRO: The next questions are about tobacco products (IF LOOP 1, FILL "you
use"/ELSE FILL "[NAME] uses") and how often (IF LOOP 1, FILL "you use" if SR;
ELSE FILL "he uses” if Male “she uses” if Female) them.
The first question is about cigarettes.
SCD1. [ASK ONLY OF SCREENING R (LOOP 1)]: Have you smoked at least 100
cigarettes in your entire life?
1
2
YES
NO GO TO CHECK BOX 5
PROGRAMMER NOTE: IF SCD1 = 2, SET SCD2 TO 3 (NOT AT ALL) FOR PURPOSES
OF CIGARETTE USE CLASSIFICATION IN CHECK BOX 5. SCD2 VALUE CAN BE
RECODED TO “LEGITIMATE SKIP” FOR DATA DELIVERY.
SCD2. (IF LOOP 1, FILL: Do you/ELSE FILL: Does [NAME]) now smoke cigarettes
every day, some days, or not at all?
1
2
3
-1
-2
EVERY DAY
SOME DAYS
NOT AT ALL
DON’T KNOW
REFUSED
CHECK BOX 5:
IF SCREENING R: CLASSIFY AS TOBACCO USER (SMOKER) IF SCD2 = 1 OR 2). ELSE,
CLASSIFY AS NON-SMOKER.
IF OTHER ADULT IN HH: CLASSIFY AS TOBACCO USER (SMOKER) IF SCD2 = 1 OR 2. ELSE,
CLASSIFY AS NON-SMOKER.
Regular Cigars/Cigarillos/Little Filtered Cigars
SCD3INTRO: The next question is about tobacco products that (IF LOOP 1, FILL:
you smoke/ELSE FILL: [NAME] smokes) other than cigarettes, specifically regular
cigars, cigarillos and little filtered cigars. [IF LOOP 2+, FILL: READ IF
NECESSARY:] “Cigarillos” are medium cigars that sometimes are sold with plastic
or wooden tips. Some common brands are Black and Mild, Swisher Sweets, Dutch
Masters, and Phillies Blunts. Cigarillos are usually sold individually or in packs of 5
or fewer. Little filtered cigars look like cigarettes and are usually brown in color.
Like cigarettes, little filtered cigars have a spongy filter and are sold in packs of
20. Some common brands are Prime Time and Winchester.
SCD3. (IF LOOP 1, FILL: Do you/ELSE FILL: Does [NAME]) now smoke regular
cigars, cigarillos, or little filtered cigars every day, some days, or not at all?
1
2
3
-1
-2
EVERY DAY
SOME DAYS
NOT AT ALL
DON’T KNOW
REFUSED
CHECK BOX 6:
8
IF SMOKING BEHAVIOR OF NAMED HH MEMBER (SCD3) = 1 OR 2, CLASSIFY AS TOBACCO
USER (CIGAR SMOKER). ELSE, CLASSIFY AS NON-CIGAR SMOKER.
Noncombustible (smokeless) tobacco products
SCD4INTRO: Now we’d like to ask you about smokeless tobacco products,
specifically chewing tobacco, snuff, dip, snus (snoose), or dissolvable tobacco. [IF
LOOP 2+, FILL: READ IF NECESSARY:]Some examples of these product brands are
Skoal, Copenhagen, Grizzly, Levi Garrett, or Red Man.
SCD4. (IF LOOP 1, FILL: Do you/ELSE FILL: Does [NAME]) now use smokeless
tobacco every day, some days, or not at all?
1
2
3
-1
-2
EVERY DAY
SOME DAYS
NOT AT ALL
DON’T KNOW
REFUSED
CHECK BOX 7:
IF SMOKING BEHAVIOR OF NAMED HH MEMBER (SCD4) = 1 OR 2, CLASSIFY AS TOBACCO
USER (SMOKELESS USER). ELSE, CLASSIFY AS NON-SMOKELESS USER.
CHECK BOX 8: LIST 1 LOOP END
REPEAT QUESTIONS SCC6 THROUGH SCD4 FOR ALL OTHER ADULTS LISTED IN HH ROSTER.
THEN CONTINUE WITH SECTION E.
(TASK 4. BUILD LIST 2: FULL LIST OF HOUSEHOLD MEMBERS AGES 13-17)
D. ROSTER OF CHILDREN/YOUTH AGES 13-17
SCE1. Now I’d like to ask you a few questions about the children living or staying
at this address. Are there any children between the ages of 13 and 17 who
spend more than half of their time living in this household?
1
2
YES
NO
GO TO SCE6
SCE2. How many children age 13-17 spend more than half of their time living in
this household?
____ CHILDREN 13-17 (RANGE 1-10)
SCE3. To make sure I keep people straight, can you give me their initials? We will
keep this and all other answers private.
INTERVIEWER: RECORD ALL FIRST INITIALS.
(TASK 5. GATHER AGE AND GENDER OF CHILDREN 13-17)
CHECK BOX 9:
LIST 2 LOOP BEGIN. ASK SCE4-SCE5 FOR EACH CHILD IN LIST 2.
9
SCE4. How old is [INITIALS]?
____ ____ YEARS OF AGE (RANGE 13-17)
SCE5. Is [INITIALS] male or female?
1
2
MALE
FEMALE
LIST 2 LOOP END
SCE6. Are there any children 12 or younger who spend more than half of their time
living in this household?
1
2
YES
NO
GO TO SCE8
SCE7. How many children 12 or younger spend more than half of their time living
in this household?
_______ CHILDREN 12 OR YOUNGER
(TASK 6. DETERMINE WHETHER HOUSEHOLD INCOME IS < $30,000)
SCE8. What was the total combined income of all members of your family during
the past 12 months? This includes money from jobs, net income from
business, farm or rent, pensions, dividends, interest, social security
payments and any other money income received by members of your family
who are 18 years of age or older. Would you say it was…
1
2
-1
-2
Less than $30,000 a year
$30,000 a year or more
DON’T KNOW
REFUSED
(TASK 8. PANEL MEMBER SELECTION)
E. PANEL MEMBER SELECTION
CHECK BOX 10: SELECT SAMPLED ADULT, APPLYING OVERSAMPLING OF 18-25 YEAR OLDS
AND HIGHER PROBABILITY FOR SMOKELESS USERS. SELECT 1 ALTERNATE ELIGIBLE IN HH
(IF ANY) IN CASE FIRST SAMPLED ADULT IS INELIGIBLE PER FI ENROLLMENT SURVEY
MODULE. ONCE SELECTED, GO TO SCF1. ELSE, IF NO ELIGIBLES IN HH, GO TO SCEXIT4.
ANY PERSON
� 18 OR OLDER or DK/REF on age
AND
� NOT ON ACTIVE DUTY (SCC9=5) SCC8 = 2
AND
10
� LIVES IN HH FULL TIME (SCC14=1)
AND
� CURRENT TOBACCO USER (CLASSIFIED AS SMOKER, CIGAR SMOKER, OR
SMOKELESS USER IN CHECK BOX 5, 6, OR 7. ADULT MAY BE CLASSIFIED AS MORE
THAN ONE TYPE OF USER.)
END OF SELECTION.
SCF1. The computer has selected [READ DISPLAYED NAME] for the study. I want
to make sure I have (your/his/her) full name before we continue.
[DISPLAY NAME, AGE, GENDER OF SAMPLED ADULT SO FI ASKS FOR CORRECT
PERSON]
INTERVIEWER: UPDATE NAME AS NEEDED.
INTERVIEWER: ASK TO SPEAK WITH SAMPLED ADULT IF DIFFERENT FROM
SCREENING RESPONDENT. PROCEED TO FI ENROLLMENT SURVEY.
1
NAME CORRECT AS IS
2
UPDATE NAME
3
UPDATE GENDER
GO TO CHECK BOX 11
SCF2. INTERVIEWER: PLEASE OBTAIN/VERIFY [primary sampled adult]’s FULL
NAME.
NAME: __________________________________
SCF3. INTERVIEWER: PLEASE VERIFY [primary sampled adult]’s GENDER.
GENDER:_______
SCF4. INTERVIEWER: OBTAIN A GOOD PHONE NUMBER FOR THE SAMPLED ADULT.
GO TO CHECK BOX 11
SCEXIT4. Thank you for answering our survey. [IF NO ONE ELIGIBLE, FILL “IF
ASKED, EXPLAIN THAT NO ONE WAS ELIGIBLE FOR THE STUDY.”; IF NO ONE
18+, FILL “We are only interviewing adults age 18 and older for this study.”
If SCC8 = 2 (active military) FILL “We are only interviewing non-active
service members for this study.” or SCC14 = 2 (part-time HH), FILL”We are
only interviewing household members who are full-time residents for this
study”.
Someone may contact you to check on the quality of my work. May I please
confirm your name and obtain your telephone number? (This is solely to
monitor that I’ve done my job correctly. It is the only way my supervisor
can check on the quality of my work – your name and number would not be
used for any other purpose.)
11
1
2
YES GO TO SCEXIT4A
NO/REFUSED
SCEXIT4END Have a nice day/evening. [EXIT SURVEY. ASSIGN FINAL SCREENING
INELIGIBLE CODE 2601 IF INELIGIBLE – NO ONE 18+; ASSIGN FINAL
SCREENING CODE 2605 IF INELIGIBLE – NO ELIGIBLE TOBACCO USERS
SAMPLED]
SCEXIT4A. May I please [IF NO ONE 18+, FILL “have”, IF NO ONE SELECTED, FILL
“confirm”] your first and last name?
FIRST and LAST NAME: ____________________________
SCEXIT4B. May I please [IF NO ONE 18+ or only 1 person in household and SCC8 =
2 (active military ) or SCC14 = 2 ( part-time HH, FILL “have”, IF NO ONE
SELECTED, FILL “confirm”] your phone number?
PHONE NUMBER: ______________________________
Have a nice day/evening.
[EXIT SURVEY. ASSIGN FINAL SCREENING INELIGIBLE CODE 2601 IF
INELIGIBLE – NO ONE 18+; ASSIGN FINAL SCREENING CODE 2605 IF
INELIGIBLE – NO ELIGIBLE HOUSEHOLD MEMBERS SAMPLED]
CHECK BOX 11:
CONTINUE WITH ENROLLMENT SURVEY MODULE ON FI TABLET TO EXTEND PANEL
INVITATION, OBTAIN CONSENT, AND COLLECT BASELINE DATA FOR SELECTED PANELIST.
ASSIGN COMPLETED SCREENING CODE 2610 (Screening Complete - One Selected), 2620
(SCREENING COMPLETE - One Plus One Alternate Selected), or 2607 (Screening Complete unknown eligibility – DK/REF on age for all HH)
OUTPUT VARIABLES TO PASS TO FI BASELINE SURVEY MODULE:
-
SAMPLED HH MEMBER’S NAME (FROM ROSTER OR F1 UPDATE)
SAMPLED HH MEMBER’S DEMOGRAPHICS FROM ROSTER (ALL - AGE, RACE, GENDER,
MARITAL STATUS, EDUCATION)
TOBACCO USE CLASSIFICATION(S) FOR SAMPLED HH MEMBER: E.G., SMOKER, CIGAR
SMOKER, SMOKELESS USER.
WHETHER SAMPLED HH MEMBER WAS THE SCREENING RESPONDENT (SET FLAG)
IF APPLICABLE: ALTERNATE ELIGIBLE HH MEMBER’S NAME (FROM ROSTER)
IF APPLICABLE: ALTERNATE ELIGIBLE HH MEMBER’S DEMOGRAPHICS FROM ROSTER
(ALL – AGE, RACE, GENDER, MARITAL STATUS, EDUCATION)
IF APPLICABLE: TOBACCO USE CLASSIFICATION(S) FOR ALTERNATE ELIGIBLE HH
MEMBER: E.G., SMOKER, CIGAR SMOKER, SMOKELESS USER.
Paperwork Reduction Act Statement: The public reporting burden for this information collection has
been estimated to average 10 minutes per response to complete the survey questions. Send comments
regarding this burden estimate or any other aspects of this information collection, including suggestions
for reducing burden, to PRAStaff@fda.hhs.gov.
12
Attachment 1-3. Enrollment Survey
National Panel of Tobacco Consumer Studies
Enrollment Survey (ES)
RTI_Mobile Platform
OMB Number: 0910-0815
Expiration Date: 06/30/2019
PROGRAMMER: DISPLAY CASE ID, SAMPLED ADULT, AND SAMPLED ADDRESS TO
CONFIRM THE CORRECT CASE IS BEING OPENED BY THE INTERVIEWER.
FI: CONFIRM YOU HAVE OPENED THE CORRECT CASE. IF YOU ARE NOT IN THE
CORRECT CASE, BREAK OFF AND LOCATE THE CORRECT CASE.
GPS CAPTURE: IMPLEMENT PASSIVE GPS & BEARING CAPTURE FOR SAMPLED ADDRESS.
ASK ALL
ESLANG: INTERVIEWER: WHAT LANGUAGE IS BEING USED TO CONDUCT THIS
INTERVIEW?
1
2
ENGLISH
SPANISH
CHECK BOX 1:
IF SAMPLED ADULT = SCREENING RESPONDENT GO TO ESBINTRO.
IF SAMPLED ADULT IS NOT THE SCREENING RESPONDENT GO TO ESINTRO.
ESINTRO: (Hello, my name is…). I’m part of a team working with the FDA to
create a large, national survey panel as part of the National Panel of Tobacco
Consumer Studies, or TCS. This address is one of more than 30,000 addresses
across the U.S. that has been randomly selected for participation. We are speaking
with you because the household summary information provided by [NAME/your
household] indicates you may be eligible to take part in the panel. My questions
will only take 5-10 minutes of your time. Your answers to the questions will be
kept private to the fullest extent allowable by law, and your participation is
voluntary. If we verify you are eligible, you will have the chance to receive cash
payments as a token of appreciation for participating in the TCS surveys.
ESINTROA. First, I want to make sure I have (your) full name before we continue.
INTERVIEWER: PLEASE OBTAIN/VERIFY [Alternate sampled adult]’s FULL NAME.
1
[DISPLAY SAMPLED ADULT’S NAME:______________________________]
FI: DOES NAME NEED TO BE UPDATED?
YES, UPDATE
NO, NAME IS CORRECT
1
2
A.
ELIGIBILITY VERIFICATION (if Sampled Adult not Screening Respondent)
ESA1. Next, I need to verify you are eligible to participate in the survey panel.
(IF NOT OBVIOUS) Do you live here? (Are you a member of this household?)
[DISPLAY SAMPLED ADDRESS]
1
2
YES
NO GO TO CHECK BOX 3
ESA2. (IF NOT OBVIOUS): And are you 18 years of age or older?
1
2
YES
NO GO TO CHECK BOX 3
ESA3. Have you smoked at least 100 cigarettes in your entire life?
1
2
YES
NO GO TO ESA5INTRO
PROGRAMMER NOTE: IF ESA3 = 2 (NO), SET ESA4 TO 3 (NOT AT ALL) FOR
PURPOSES OF CIGARETTE USE CLASSIFICATION IN CHECK BOX 2. ESA4 CAN BE
RECODED TO “LEGITIMATE SKIP” FOR DATA DELIVERY PURPOSES.
ESA4. Do you now smoke cigarettes every day, some days, or not at all?
1
2
3
-2
EVERY DAY
SOME DAYS
NOT AT ALL
REFUSED
ESA5INTRO. The next questions are about tobacco products that you smoke other
than cigarettes, specifically regular cigars, cigarillos and little filtered cigars.
“Cigarillos” are medium cigars that sometimes are sold with plastic or wooden
tips. Some common brands are Black and Mild, Swisher Sweets, Dutch Masters,
and Phillies Blunts. Cigarillos are usually sold individually or in packs of 5 or
fewer. Little filtered cigars look like cigarettes and are usually brown in color. Like
2
cigarettes, little filtered cigars have a spongy filter and are sold in packs of 20.
Some common brands are Prime Time and Winchester.
ESA5. Do you now smoke regular cigars, cigarillos, or little filtered cigars every
day, some days, or not at all?
1
2
3
-2
EVERY DAY
SOME DAYS
NOT AT ALL
REFUSED
ESA6INTRO: Now we’d like to ask you about smokeless tobacco products.
Smokeless tobacco products are placed in the mouth or nose and can include
chewing tobacco, snuff, dip, snus (snoose), or dissolvable tobacco. Some examples
of these product brands are Skoal, Copenhagen, Grizzly, Levi Garrett, or Red Man.
ESA6. Do you now use smokeless tobacco every day, some days, or not at all?
1
2
3
-2
EVERY DAY
SOME DAYS
NOT AT ALL
REFUSED
CHECK BOX 2: UPDATE SMOKING CLASSIFICATION OF SAMPLED ADULT WHO IS NOT
SCREENING R (IF NEEDED):
CLASSIFY AS TOBACCO USER (SMOKER) IF ESA4 = 1 OR 2 ). ELSE, CLASSIFY AS
NON-SMOKER.
CLASSIFY AS TOBACCO USER (CIGAR SMOKER) IF ESA5 = 1 OR 2. ELSE, CLASSIFY
AS NON-CIGAR SMOKER.
CLASSIFY AS TOBACCO USER (SMOKELESS USER) IF ESA6 = 1 OR 2. ELSE, CLASSIFY
AS NON-SMOKELESS USER.
GO TO CHECK BOX 3.
CHECK BOX 3: DETERMINE ELIGIBILITY OF NON-SCREENING R.
-> IF R REFUSED ALL (? ) ESA4, ESA5,ESA6, GO TO ESAEXT4 (UNKNOWN INELIGIBLE)
IF (ESA1 = 1) AND (ESA2 = 1) AND (R IS CLASSIFIED AS SMOKER, CIGAR SMOKER, OR
SMOKELESS USER PER CHECK BOX 2), SAMPLE MEMBER IS CONFIRMED ELIGIBLE:
GO TO ESBINTRO B FOR PANEL CONSENT
ELSE, SAMPLE MEMBER IS NOT ELIGIBLE. CHECK FOR ALTERNATE ELIGIBLE IN HH.
IF ALTERNATE
IF ESA1 = 2 (DOES NOT LIVE AT ADDRESS), GO TO ESAALT1
IF ESA2 = 2 (NOT AGE 18+), GO TO ESAALT2
IF R NOT A TOBACCO USER PER CHECK BOX 2, GO TO ESAALT3
3
CREATE variable to track whether ineligible.
ineligible.
1 = 1 person ineligible, 2 = 2 persons (both)
IF NO (REMAINING) ALTERNATE:
IF ESA1 = 2 (DOES NOT LIVE AT ADDRESS), GO TO ESAEXT1
IF ESA2 = 2 (NOT AGE 18+), GO TO ESAEXT2
IF R NOT A TOBACCO USER PER CHECK BOX 2, If there is an alternate go to ESAALT3
ELSE GO TO ESAEXT3
ESAEXT1: These are all the questions I have. Because we are only interviewing
persons who usually live at this address, you are not eligible to participate in the
survey panel. Thank you for your time, and have a nice day/evening.
[EXIT SURVEY – ASSIGN PENDING CODE 1323 – INELIGIBLE, DOES NOT RESIDE AT
SAMPLED ADDRESS]
ESAEXT2: These are all the questions I have. Because we are only interviewing
persons who are 18 years of age or older, you are not eligible to participate in the
survey panel. Thank you for your time and have a nice day/evening.
[EXIT SURVEY – ASSIGN PENDING CODE 1321 – INELIGIBLE, 17 YEARS OF AGE OR
YOUNGER]
ESAEXT3: These are all the questions I have. Because we are only interviewing
adults who regularly use these tobacco products, you are not eligible to participate
in the survey panel. Thank you for your time, and have a nice day/evening.
[EXIT SURVEY – ASSIGN PENDING CODE 1322 – INELIGIBLE, DO NOT REGULARLY
USE]
ESAEXT4: These are all the questions I have. We are unable to confirm your
eligibility for the panel at this time. Thank you for your time, and have a nice
day/evening.
[EXIT SURVEY – ASSIGN FINAL CODE 1324 – UNKNOWN REFUSED TO ANSWER
TOBACCO Qs]
ESAALT1: These are all the questions I have. Because we are only interviewing
persons who usually live at this address, you are not eligible to participate in the
survey panel. However, our records indicate another adult in your household may
be eligible to take part. May I please speak to [FILL ALTERNATE NAME]?
1
2
YES FLAG PRIMARY SAMPLED ADULT AS 1323 INELIGIBLE – DOES NOT
RESIDE AT SAMPLE. RETURN TO ESINTRO AND LOOP THROUGH SECTION A FOR
ALTERNATE ADULT.
NO BREAKOFF AND SCHEDULE RETURN VISIT [ASSIGN PENDING CODE
1323 INELIGIBLE – DOES NOT RESIDE AT SAMPLE]
ESAALT2: These are all the questions I have. Because we are only interviewing
persons who are 18 years of age or older, you are not eligible to participate in the
4
survey panel. However, our records indicate another adult in your household may
be eligible to take part. May I please speak to [FILL ALTERNATE NAME]?
1
2
YES FLAG PRIMARY SAMPLED ADULT AS 1321 INELIGIBLE – 17 YEARS OF
AGE OR YOUNGER. RETURN TO ESINTRO
AND LOOP THROUGH SECTION A FOR ALTERNATE ADULT.
NO BREAKOFF AND SCHEDULE RETURN VISIT [ASSIGN PENDING CODE
1321 INELIGIBLE – 17 YEARS OF AGE OR YOUNGER]
ESAALT3: These are all the questions I have. Because we are only interviewing
adults who regularly use these tobacco products, you are not eligible to participate
in the survey panel. However, our records indicate another adult in your
household may be eligible to take part. May I please speak to [FILL ALTERNATE
NAME]?
1
2
B.
YES FLAG PRIMARY SAMPLED ADULT AS 1322 INELIGIBLE – DOES NOT
REGULARLY USE TOBACCO PRODUCTS. RETURN TO ESINTRO
AND LOOP THROUGH SECTION A FOR ALTERNATE ADULT.
NO BREAKOFF AND SCHEDULE RETURN VISIT [ASSIGN PENDING CODE
1322, INELIGIBLE – DOES NOT REGULARLY USE TOBACCO PRODUCTS]
PANEL MODE DETERMINATION/INFORMED CONSENT
ESBINTRO: [IF SAMPLED ADULT IS NOT SCREENING R, FILL: Thank you. Based on
the information you’ve provided, you are eligible to participate in the survey
panel for the National Panel of Tobacco Consumer Studies]
[ALL]: I’d like to tell you more about the TCS survey panel and determine
the most convenient way for you to take part. If you agree to enroll in the
panel, you will have the opportunity to receive cash payments as a token of
our appreciation for participating in the surveys.
So that my supervisor can review my work, some parts of this interview
may be recorded for quality control purposes. Is this okay with you?
1
2
YES
NO
ENABLE CARI
DISABLE CARI
ACTIVATE CARI RECORDING THROUGH ESB9.
ESB1. First, I have some questions that will help me determine the best way for
you to participate in the survey panel.
Do you have an Internet connection in your home?
1
2
YES
NO GO TO ESB3
5
ESB2. Which of the following do you use to connect to the internet from home?
Please select all that apply.
1
2
3
4
5
6
7
Dial Up
DSL
Cable (through TV or phone company)
Fiber optic (FIOS)
Satellite
Data plan (for cell phone, smart phone, tablet or computer)
WiFi (including wireless hotspot, wireless router)
ESB3. Do you regularly access the Internet outside of your home?
YES
NO GO TO ESB5
1
2
ESB4. Where do you regularly access the Internet outside of your home? Please
select all that apply.
1
2
3
4
5
6
7
At work
At school
At the library
At a coffee shop/restaurant/or other WiFi enabled public location
At a friend’s/neighbor’s/family member’s house
Can access anywhere via phone/tablet/computer
Other location (Please specify) _______________
ESB5. Overall, would you say you can successfully connect to the Internet
whenever you need? (PROMPT IF NEEDED: That is, you can connect to the
Internet at home or outside the home whenever you need to.)
YES
NO GO TO ESB7
1
2
ESB6. Which of the following devices do you usually use to access the Internet?
Please select all that apply.
1
2
3
Desktop or laptop computer
Tablet computer
Cell phone/smart phone
ESB7. Do you have a personal e-mail address? This may include a home email
address that you share with others in your household.
1
2
YES
NO
ES8INTRO. Next, I’d like to tell you more about what your participation in the
National Panel of Tobacco Consumer Studies would involve. By joining the panel
6
you will have the opportunity to participate in several short surveys for the Food
and Drug Administration (FDA) over a 3-year period. You will be asked to
complete about 3 surveys a year and your participation in each survey is
voluntary. The surveys will only take about 15 to 20 minutes to complete. If you
complete the panel enrollment process with me, you will receive a $35 cash
payment as a token of our appreciation for joining the panel. As a panel member,
you will also receive a $15 cash payment for each of the short surveys you
complete.
CONTINUE
ESB8. [IF ESB5 = 1, FILL: Based on the information you’ve provided, it appears
you have convenient access to the Internet. This means you can complete
the short surveys online through the secure TCS panel website.]
[ELSE, FILL: Based on the information you’ve provided, it appears the best
way for you to participate in the panel is by mail. This means we can mail
you a paper questionnaire for each of the short surveys. Once you answer
the questions, you can simply return the questionnaire to us in the postagepaid envelope we provide.]
[ALL]: Is this a convenient way for you to participate in the panel?
YES GO TO ESB10
NO IF ESB5 = 1, GO TO ESB9CHK, ELSE, CHECK BOX 4.
1
2
ESB9CHK: FI: ENCOURAGE WEB PARTICIPATION. ENTER “1” IF R SAYS WEB
PARTICIPATION IS CONVENIENT. ELSE, ENTER “2” TO MOVE TO MAIL MODE
OFFER.
WEB MODE IS CONVENIENT FOR R GO TO ESB10
WEB MODE IS NOT CONVENIENT FOR R GO TO CHECK BOX 4.
1
2
CHECK BOX 4: CONSIDER ALTERNATE MODE OFFER.
IF WEB OFFERED: ESB5 = 1, ESB8 = 2, ESB3 = 1 GO TO ESB9.
IF MAIL OFFERED, POTENTIAL TABLET: ESB5 = 2, ESB8 = 2, ESB3 = 1 GO TO ESBEXT2.
IF MAIL OFFERED, NO TABLET: ESB5 = 2, ESB8 = 2, ESB3 = 2 GO TO ESBEXT1.
ESB9: You can also participate in the panel by mail. This means each of the short
surveys you are asked to complete can be mailed to you. Once you answer
the questions, you would simply return the questionnaire to us in the
postage-paid envelope we provide.
Is mail a more convenient way for you to participate?
1
2
YES
NO / R REFUSED MAIL GO TO ESBEXT1
7
FI: ENCOURAGE R’S PARTICIPATION BY MAIL.
DISCONTINUE CARI RECORDING.
ESB10. FI: CONFIRM R’S CONVENIENT MODE OF PARTICIPATION:
1
2
WEB GO TO ESB11
MAIL GO TO ESB11
ESBEXT1: Thank you for your time. Have a nice day/evening.
[ASSIGN PENDING CODE 1296, BREAKOFF, NO APPT MADE]
ESBEXT2: We would really like you to join the TCS panel. I will talk to my
supervisor to see if there is another way for you to participate. I will
contact you again once I speak with him/her.
What would be the best telephone number for me to contact you at?
FI: ENTER 9 FOR DK/REF
Phone Number: ___________________
Thank you for your time today.
FI: ANSWER CLOSING QUESTIONS AFTER LEAVING THE HOUSEHOLD.
ESBEXT2A: WHAT IS THE MAIN REASON THE SAMPLED ADULT CANNOT/WILL NOT
PARTICIPATE BY WEB OR MAIL? (CHECK ALL THAT APPLY)
1
2
3
4
NO PERSONAL DEVICE/INTERNET, NO ACCESS TO OTHER INTERNETENABLED DEVICE
NOT COMFORTABLE USING ELECTRONIC DEVICES/ACCESSING THE
INTERNET
COMPLETING AND MAILING A HARDCOPY FORM IS TOO MUCH WORK OR IS
NOT CONVENIENT (E.G., DIFFICULT TO SEND/RECEIVE USPS MAIL)
OTHER (SPECIFY): _______
ESBEXT2B: IF KNOWN, DOES THE SAMPLED ADULT HAVE ANY EXPERIENCE WITH
USING ANY OF THE FOLLOWING DEVICES? (CHECK ALL THE APPLY)
1
2
3
4
5
DESKTOP OR LAPTOP COMPUTER
TABLET COMPUTER
CELL PHONE/SMART PHONE
ELECTRONIC READER (E.G., KINDLE, NOOK)
UNKNOWN
ESBEXT2C: WHAT IS YOUR OPINION OF THE PM’S COMFORT LEVEL WITH
COMPUTERS?
1
VERY COMFORTABLE
8
COMFORTABLE
SOMEWHAT COMFORTABLE
SOMEWHAT UNCOMFORTABLE
UNCOMFORTABLE
VERY UNCOMFORTABLE
UNKNOWN
2
3
4
5
6
7
ESBEXT2D: WHAT IS YOUR OPINION OF THE PM’S COMFORT LEVEL WITH THE
INTERNET?
VERY COMFORTABLE
COMFORTABLE
SOMEWHAT COMFORTABLE
SOMEWHAT UNCOMFORTABLE
UNCOMFORTABLE
VERY UNCOMFORTABLE
UNKNOWN
1
2
3
4
5
6
7
ESBEXT2E: IN YOUR OPINION, HOW LIKELY IS IT THAT THE PM WILL JOIN THE
PANEL IF OFFERED A LOANER TABLET?
VERY LIKELY
LIKELY
SOMEWHAT LIKELY
SOMEWHAT UNLIKELY
UNLIKELY
VERY UNLIKELY
1
2
3
4
5
6
[ASSIGN PENDING CODE 1693, PENDING TABLET LOANER DECISION FROM RTI]
ACTIVATE CARI RECORDING THROUGH ESB11B.
ESB11: Now that we’ve determined the most convenient way for you to
participate, I’d like to review the panel consent form with you and have you
sign and date it.
READ CORRECT VERSION OF CONSENT FORM TO R: STANDARD WEB/MAIL
OR TABLET. OBTAIN PM’S SIGNATURE/DATE.
a. FI: DID PM CONSENT TO JOIN THE PANEL?
1
2
YES
NO GO TO ESBEXT3
b. FI: CONFIRM MODE OF PARTICIPATION FROM CONSENT:
1
2
3
WEB, WITH PERSONAL DEVICE
MAIL SURVEY
WEB, WITH STUDY TABLET
GO TO ESCINTRO
GO TO ESCINTRO
GO TO ESB12
ESB12: FI: RECORD ID OF LOANED STUDY TABLET BELOW.
9
a. TABLET ID NUMBER:
b. VERIFY ID NUMBER:
_____________
_____________
[CHECK ESB11a & b MATCH; ELSE, REQUIRE REENTRY.]
ESB13 FI: READ EQUIPMENT AGREEMENT FORM TO PM. THEN ALLOW TIME FOR
THEM TO REVIEW IT ON THEIR OWN AND SIGN.
DID THE PM SIGN THE EQUIPMENT AGREEMENT FORM?
1
2
YES
NO GO TO ESBEXT4
ESB14. FI: (ASK IF NECESSARY): WHAT IS PM’S PREFERRED LANGUAGE OF
PARTICIPATION?
1
2
ENGLISH
SPANISH
DISCONTINUE CARI RECORDING.
ESBEXT3: Thank you for your time. Have a nice day/evening.
[ASSIGN PENDING CODE 1440, REFUSAL BY SM, BREAKOFF]
ESBEXT4: Thank you for your time. Have a nice day/evening.
[ASSIGN PENDING CODE 1446, TABLET OFFER REFUSED]
C.
PANEL MEMBER DEMOGRAPHICS
ESCINTRO: Thank you for consenting to join the TCS panel. Now I have a few
background questions about you.
ESC1. In general, would you say your health is excellent, very good, good, fair, or
poor?
1
2
3
4
5
EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
CHECK BOX 5: IF SCREENING R = PANEL MEMBER GO TO ESC2 AND CONFIRM SCREENER
DEMOGRAPHICS. ELSE, FOR ALL OTHER PANEL MEMBERS GO TO ESC3.
ESC2. Let me confirm the information collected earlier.
GENDER: [FILL FROM SCREENER SCC6]
10
AGE: [FILL FROM SCREENER SCC7/SCC7A]
MILITARY SERVICE: [FILL FROM SCREENER SCC8]
MARITAL STATUS: [FILL FROM SCREENER SCC9]
HIGHEST SCHOOL GRADE/YEAR: [FILL FROM SCREENER SCC10]
WORK FOR PAY IN PAST 30 DAYS: [FILL FROM SCREENER SCC11]
HISPANIC ORIGIN: [FILL FROM SCREENER SCC12]
RACE: [FILL FROM SCREENER SCC13]
FULL TIME PART TIME STATUS: [FILL FROM SCREENER SCC14]
SELECT ITEMS TO UPDATE:
1
2
3
4
5
6
7
8
9
10
GENDER
AGE
MILITARY SERVICE
MARITAL STATUS
HIGHEST SCHOOL GRADE/YEAR
WORK FOR PAY IN PAST 30 DAYS
HISPANIC ORIGIN
RACE
FULL TIME/PART TIME STATUS
NONE GO TO ESC12INTRO
FI: ENTER 999 WHEN ALL UPDATES ARE COMPLETED.
[WHEN 999 IS ENTERED, GO TO ESC3]
ROUTE EACH UPDATE ELEMENT AS TO APPROPRIATE VARIABLE ESC3 – ESC11 UNTIL ALL
SELECTED ELEMENTS ARE COMPLETE.
ESC3. INTERVIEWER: CONFIRM GENDER OF PANEL MEMBER.
1
2
MALE
FEMALE
ESC4. How old are you?
[PROGRAMMER: IF AGE IS 17 or LESS, GO TO ESAEXT2 (IF NO ALTERNATE
AVAILABLE or ESAALT2 IF ALTERNATE AVAILABLE]
FI: ENTER 9 for DK/REF
_____ AGE (RANGE 18-110)
[If DK, REF (9) then ask ESC4A]
ESC4A. Providing your age is important. This ensures we can accurately
determine whether you/or [fill person name] is/are eligible to participate
in the panel. Can you confirm which of the following age categories
you/[fill person name] belong to?
11
1
2
3
4
5
-1
-2
18-25
26-34
35-49
50-74
75 +
DON’T KNOW
REFUSED
[IF STILL DK, REF THEN BREAKOFF AND SET INITIAL REFUSAL (REFUSAL CODE
1429)]
ESC5. Are you currently serving on active duty in the U.S. Armed Forces, Military
Reserves or National Guard? Active duty for the Reserves or National Guard
does not include the regular training for the Reserves or Guard. It does
include being activated for deployment such as for the war in Afghanistan.
1
2
YES
NO
INTERVIEWER: IF ASKED, THE US ARMED FORCES INCLUDE ARMY, NAVY, AIR
FORCE, AND MARINE CORPS.
ESC6. Are you currently…[READ LIST]?
1
Married or living with a partner,
2
Widowed,
Divorced,
Separated, or
Never married?
3
4
5
ESC7. What is the highest grade or year of school you have completed?
INTERVIEWER NOTE: FOR THOSE CURRENTLY IN SCHOOL, THIS DOES NOT
INCLUDE THE CURRENT YEAR OF SCHOOL, UNLESS IT IS ALREADY COMPLETED.
1
2
3
4
5
LESS THAN HIGH SCHOOL
HIGH SCHOOL GRADUATE OR GED
SOME COLLEGE/VOCATIONAL SCHOOL (NO DEGREE)
2-YEAR COLLEGE/VOCATIONAL/ASSOCIATE’S DEGREE
4-YEAR COLLEGE DEGREE OR HIGHER(E.G., BA, BS, MA, NS, Ph.D)
12
ESC8. In the past 30 days, did you do any work for pay, including both full-time
and part-time work?
1
2
YES
NO
ESC9. Are you Hispanic, [IF ESC3 not blank, then IF ESC3 =1, FILL: Latino / IF
ESC3 = 2, FILL: Latina else if primary then GENDER
(Male=Latino/Female=Latina) from DATA05, if alternate then GENDER
(Male=Latino/Female=Latina) from DATA06]], or of Spanish origin?
1
2
YES
NO
ESC10. What is your race? I’m going to read a list. Please select one or more.
(READ LIST. SELECT ALL THAT APPLY.)
1
2
3
4
5
White
Black or African American
American Indian or Alaska Native
Asian, or
Native Hawaiian or Other Pacific Islander?
ESC11. Do you live here full time or part time? PROBE: Do you spend half or more
of your time in this household?)
1
2
FULL TIME (SPENDS HALF TIME OR MORE IN THIS HH)
PART TIME (SPENDS LESS THAN HALF TIME IN THIS HH)
ESC12INTRO: Thank you. I have one additional follow-up question for you
regarding your household income.
ACTIVATE CARI RECORDING THROUGH ESC13.
ESC12. What was the total combined income of all members of your family during
the past 12 months? This includes money from jobs, net income from
business, farm or rent, pensions, dividends, interest, social security
payments and any other money income received by members of your family
who are 18 years of age or older. Would you say it was…
1
2
3
4
5
6
7
8
9
Under $30,000
$30,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 or more
DON’T KNOW
REFUSED
GO
GO
GO
GO
GO
GO
GO
13
TO
TO
TO
TO
TO
TO
TO
ESDINTRO
ESDINTRO
ESDINTRO
ESDINTRO
ESDINTRO
ESDINTRO
ESDINTRO
ESC13. It is very important that we have some measure of your household’s
income. Would you say the total combined income of all members of your
household during the past 12 months was less than $30,000 or $30,000 or
more?
1
2
8
9
LESS THAN $30,000
$30,000 OR MORE
DON’T KNOW
REFUSED
DISCONTINUE CARI RECORDING.
D.
CONTACT AND TRACKING QUESTIONS
ESDINTRO: It is important that we have accurate contact information for you so
that we can stay in touch regularly throughout your time in the TCS panel.
ESD1. First, let me confirm your full name and street address: [CONFIRM OR COLLECT IF
MISSING.]
NAME
ADDRESS
CITY
STATE
ZIP
INTERVIEWER: VERIFY SPELLING OF NAME, STREET, & CITY. OBTAIN STREET
ADDRESS, NOT P.O. BOX NUMBER.
SELECT ITEMS TO UPDATE:
1
2
3
4
5
6
7
8
NAME
STREET NUMBER
STREET NAME
APT NUMBER
CITY
STATE
ZIP
NONE GO TO ESD2
PROGRAM EACH ADDRESS UPDATE ELEMENT AS SINGLE QUESTION AS NEEDED.
ESD1A = NAME, ESD1B – STREET NUMBER, ESD1C = STREET NAME, ESD1D = APT
NUM, ESD1E = CITY, ESD1F = STATE, ESD1G = ZIP.
ESD1AA. Is this also your mailing address?
1
2
YES GO TO ESD2
NO COLLECT MAILING ADDRESS
14
Programmer Note: For Street Number/PO BOX NUMBER screen include FI
message in ALL CAPS: “IF PO BOX NUMBER, PLEASE INCLUDE ‘PO BOX’ BEFORE
THE NUMBER”
STREET NUMBER/ PO BOX NUMBER
Programmer Note: For Street Name create a warning screen with the following in
ALL CAPS screen include FI message in CAPS: “STREET NAME NOT PROVIDED.
CONFIRMED YOU HAVE CORRECTLY ENTERED THE ADDRESS BEFORE
PROCEEDING.”
STREET NAME
APT NUMBER
CITY
STATE
ZIP
ESD2. What is the best telephone number to use to reach you?
FI: ENTER 9 for REFUSED.
ESD2A. Providing your telephone number is important. This ensures we can reach
you in the future to let you know about upcoming surveys. Your telephone
information will be securely stored and only used for TCS panel related purposes.
It will not be shared with anyone outside of the research team.
BEST#:
FI: ENTER 9 for REFUSED.
ESD3. Is this a home, work or cell phone number?
1
2
3
4
HOME NUMBER
WORK NUMBER
CELL NUMBER
OTHER NUMBER (E.G., FAMILY, NEIGHBOR)
IF ESD3 = 3 and ((ESD2 ne Blank and ne ‘9’) or (ESD2A ne Blank and ne ‘9’)), ASK
ESD3A.
ESD3A. Can we send text messages to your cell phone, [fill cell phone number
from ESD2/ESD2A]?
YES
2
NO
ESD4. Please provide other telephone numbers where you can be reached (PROBE
FOR HOME, WORK, AND CELL NUMBERS).
a. HOME#:
b. WORK#:
c. CELL#:
15
d. ALTERNATE CELL #:
FOR ESD4, PROGRAM EACH PHONE ELEMENT AS SINGLE QUESTION:
ESD4a = Home #, ESD4b = Work #, etc.
CHECK BOX 7: IF ESD4c NE BLANK and ESD4 ne ‘9’, ASK ESD5. ELSE, GO TO CHECK BOX 6.
ESD5. Can we send text messages to your cell phone number, [fill cell phone (ESD4C)]?
1
2
YES
NO
CHECK BOX 8: IF ESD4d NE BLANK and ESD4D ne ‘9’, ASK ESD6. ELSE, GO TO ESD7.
ESD6. You gave us a second cell phone number [fill second cell phone (ESD4D)].
Can we send text messages to this cell number?
1
2
YES
NO
ESD7. One of the primary ways we plan to contact panel members is through
email. Do you have a personal, home, or other email address where you can
receive panel information regularly?
1
2
3
YES ESD8
NO GO TO ESD11A
PM REFUSED USE OF HIS/HER EMAIL FOR PANEL Go to ESD7A.
ESD7A. Providing your email address is important. This ensures we can reach you
in the future to let you know about upcoming surveys. Your email information will
be securely stored and only used for TCS panel related purposes. It will not be
shared with anyone outside of the research team.
Do you have a personal, home, or other email address where you can receive panel
information?
1
2
3
YES ESD8
NO GO TO ESD11A
PM REFUSED USE OF HIS/HER EMAIL FOR PANEL Go to ESD11A.
ESD8. What is the best email address to use to reach you?
BEST EMAIL:
RE-ENTER EMAIL:
FI: CONFIRM SPELLING/ACCURACY OF EMAIL ADDRESS.
ESD8a. Is this your personal or work email address?
16
1
2
3
PERSONAL/HOME EMAIL
WORK EMAIL
OTHER EMAIL
ESD8b. How often do you check this email address? Would you say…
1
2
3
4
5
Every day
A few times per week
About once a week
About once a month
Less often than once a month
ESD9. Is there another email address where you can receive messages?
1
2
YES
NO GO TO ESD12
ESD10. Please provide the other email where you can receive messages.
OTHER EMAIL:
FI: CONFIRM SPELLING/ACCURACY OF EMAIL ADDRESS.
ESD10a. Is this a personal or work email address?
1
2
3
PERSONAL/HOME EMAIL
WORK EMAIL
OTHER EMAIL
ESD10b. How frequently do you check this other email address? Would you say…
1
2
3
4
5
Every day
A few times per week
About once a week
About once a month
Less often than once a month
GO TO ESD12
ESD11A. I’d like to work with you to set up a simple Google email address that we
can use to contact you while you are in the panel. This would let us notify
you when a new survey is ready to be completed.
[IMPLEMENT GMAIL PROTOCOL]
a. WAS GMAIL ADDRESS CREATED?
1
2
YES
NO
ESD11b. ENTER GMAIL ADDRESS:
ESD11c. CONFIRM GMAIL ADDRESS:
17
[CHECK ESD11b & c MATCH; ELSE, REQUIRE REENTRY.]
ESD12. If you happen to move while you are in the panel, would you please give
me the names of two close relatives or friends living outside this household
who would likely know where you can be reached?
1
2
YES GO TO ESD14
NO
FI: ASSURE PM WE WILL CONTACT THESE INDIVIDUALS ONLY IN THE EVENT
HE/SHE MOVES AND WE NEED HELP CONTACTING HIM/HER. ALLOW PM TO LOOK UP
ADDRESSES AND PHONE NUMBERS.
ESD13. It is very important that we be able to reach you if your contact
information changes while you are in the TCS panel. Would you reconsider
and give me the name of a friend or relative outside this household who
would know how to reach you?
1
2
YES, WILL GIVE NAME
NO, WILL NOT GIVE NAME GO TO CHECK BOX 8
FOR ESD14 PROGRAM EACH ADDRESS ELEMENT AS SINGLE QUESTION. ESD14A = NAME,
ESD14B = RELATIONSHIP TO R, ESD14C = STREET ADDRESS, ESD14D = CITY, ESD14E =
STATE, ESD14F = ZIP, ESD14G = HOME#, ESD14H = CELL#
ESD14. FIRST CONTACT PERSON (COLLECT ALL INFO, INCLUDING PHONE. CANNOT
LIVE AT SAME ADDRESS AS R):
a.
b.
c.
d.
e.
f.
g.
h.
i.
NAME: _________________________________
RELATIONSHIP TO R: _____________________
STREET NUMBER: _______________________
STREET NAME: _______________________
APT # _______________________
CITY: ___________
STATE: ______
ZIP: ______
HOME #: ___________________________
CELL#: _________________________________
FOR ESD15 PROGRAM EACH ADDRESS ELEMENT AS SINGLE QUESTION. ESD15A = NAME,
ESD15B = RELATIONSHIP TO R, ESD15C = STREET ADDRESS, ESD15D = CITY, ESD15E =
STATE, ESD15F = ZIP, ESD15G = HOME#, ESD15H = CELL#
ESD15. SECOND CONTACT PERSON (COLLECT ALL INFO, INCLUDING PHONE.
CANNOT LIVE AT SAME ADDRESS AS R):
a.
b.
c.
d.
e.
NAME: _________________________________
RELATIONSHIP TO R: _____________________
STREET NUMBER: _______________________
STREET NAME _______________________________
APT # ______________________________
18
f.
g.
h.
i.
j.
CITY: ___________
STATE: ______
ZIP: ______
HOME #: ___________________________
CELL#: _________________________________
CHECK BOX 8:
If ESD2a = 9 OR (ESD7A = 3 AND ESD11A = 2) GOT TO ESD15AA
ELSE PROCEED TO CHECK BOX 9
ESD 15AA. FI: PLEASE REVIEW AND CONFIRM THE PM’S PHONE AND EMAIL
INFORMATION. UPDATE AS NEEDED
[DISPLAY BEST PHONE NUMBER]
[DISPLAY BEST EMAIL ADDRESS]
1
2
3
4
Update Best Phone Number Go to ESD2
Update Email Address ESD8
Refused to provide new information GO TO CHECK BOX 9
No updates needed GO TO CHECK BOX 9
ESD 15AA1. ENTER PHONE NUMBER ________________________
Enter 9 for REFUSED
ESD 15AA2. ENTER BEST EMAIL ADDRESS: ________________________
CHECK BOX 9: CREATE 3-DIGIT SURVEY INITIATION CODE FROM BEST INFORMATION
(SCREENER OR UPDATED STATUS FROM CHECK BOX 2). EACH DIGIT REPRESENTS STATUS
OF A SPECIFIC TOBACCO PRODUCT USE.
Digit 1 Smoker:
Digit 2 Cigar smoker
Digit 3 Smokeless user
[0,1,2,9]
[0,1,2,9]
[0,1,2,9]
0 = DOES NOT USE PRODUCT
1 = USES PRODUCT EVERY DAY
2 = USES PRODUCT SOME DAYS 9 = DON’T KNOW/REFUSED
CHECK BOX 10:
IF ESB11b = 1 (PERSONAL DEVICE USE) GO TO ESD16
IF ESB11b = 2 (MAIL MODE) GO TO ESDEV2
IF ESB11b = 3 (STUDY TABLET) GO TO ESDEV1
ESD16. FI: WHAT TYPE OF PERSONAL DEVICE IS PM PLANNING TO USE FOR
PANEL?
19
1
2
3
4
SMART PHONE OR CELL PHONE (e.g., iPhone, Android)
TABLET COMPUTER (e.g., iPad, iPad Mini, Galaxy, Nexus)
LAPTOP OR DESKTOP COMPUTER
OTHER DEVICE (SPECIFY:_____________________)
ESDEV1: Thank you for answering my questions. Now I’d like to show you how to
access the TCS web site. We want to make sure you can log in successfully
at home. We’ll then have you answer a few final tobacco use questions on
your own to complete the enrollment process.
GO TO ESINIT1
ESDEV2: Thank you for answering my questions. To complete your enrollment
process for the TCS panel, I have a few final questions about the tobacco
products you currently use.
GO TO ESINIT2
ESINIT1: WEB BASELINE SURVEY INITIATION STEPS:
GIVE PM THE PANEL MEMBER INFORMATION SHEET WITH ACCESS CODE
(CASE ID) AND SURVEY INITIATION CODE
SURVEY INITIATION CODE:
GO TO CHECK BOX 11
ESINIT2: MAIL BASELINE SURVEY INITIATION STEPS:
GIVE PM THE PANEL MEMBER INFORMATION SHEET WITH ACCESS CODE
(CASE ID) AND SURVEY INITIATION CODE
SURVEY INITIATION CODE:
ESEND: EXIT AND TRANSMIT IMMEDIATELY
CHECK BOX 11: OUTPUT VARIABLES TO PASS TO HATTERAS BASELINE MODULE
TCS ID
BASELINE INITIATION CODE (SURVINIT)
SURVINIT
MODE: WEB, MAIL
MODE
EXPERIMENTAL GROUP (FOR INCENTIVE LISTING AT THE END OF THE HATTERAS
INSTRUMENTS)
WAS PM SCREENING RESPONDENT?
SCREENRESP
PANEL MEMBER FIRST NAME
ENRNAME
PANEL MEMBER LAST NAME *** NAME IS NOT BROKEN INTO FIRST & LAST DATA
FIELDS
PHYSICAL ADDRESS – STREET NUMBER
STNUM
PHYSICAL ADDRESS – STREET NAME
STNAME
PHYSICAL ADDRESS – UNIT/APT
UNIT
PHYSICAL ADDRESS – CITY
CITY
PHYSICAL ADDRESS – STATE
STATE
PHYSICAL ADDRESS - ZIP/ STATE/ ZIP
ZIPCODE
MAILING ADDRESS – STREET NUMBER
MSTNUM
MAILING ADDRESS – STREET NAME
MSTNAME
MAILING ADDRESS – UNIT/APT
MUNIT
20
-
MAILING ADDRESS – CITY
MAILING ADDRESS – STATE
MAILING ADDRESS - ZIP/ STATE/ ZIP
HOME PHONE NUMBER
WORK PHONE NUMBER
CELL PHONE NUMBER
ALTERNATE CELL PHONE NUMBER
OTHER PHONE
EMAIL ADDRESS
ALTERNATE EMAIL ADDRESS
MCITY
MSTATE
MZIPCODE
HOMEPHONE
WORKPHONE
CELLPHONE
ALTCELLPHONE
OTHERPHONE
EMAIL
ALTEMAIL
Paperwork Reduction Act Statement: The public reporting burden for this information
collection has been estimated to average 10 minutes per response to complete the survey
questions. Send comments regarding this burden estimate or any other aspects of this
information collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov.
21
Attachment 1-4: Baseline Survey
National Panel of Tobacco Consumer Studies
Panelist Baseline (PB) Survey
Hatteras Web Platform
OMB Number: 0910-0815
Expiration Date: 06/30/2019
[HATTERAS SURVEY BANNER SHOULD DISPLAY PANEL MEMBER’S UNIQUE CASE ID
AND NAME TO VERIFY THE CORRECT SURVEY HAS BEEN ACCESSED.]
PBINTRO: Thank you for joining the survey panel for the National Panel of Tobacco
Consumer Studies, or TCS. The information you provide will be very important to
FDA’s research. This first survey will introduce you to some of the features of our
web surveys. It will also collect more detailed information about the tobacco
products you are currently using. If you have any questions about how to answer
a question or need help moving through the survey, please let the interviewer
know.
PROGRAMMER: If SURVEY INITIATION CODE is available (passed to the Hatteras instrument), then GO TO
PBINIT1A, ELSE PBINIT1B
PBINTIT1A: Your survey initiation code is:
[DISPLAY SURVEY INITIATION CODE] display in bold:
If this code differs from the code given to you by your interviewer, please let him
or her know before proceeding.
1) CODE IS CORRECT, CONTINUE (goto PBINIT2 -- going the name
verification ... skipping the next one)
2) CODE IS INCORRECT, (goto PBINIT1B – and then going to the name
verification)
PBINIT1B: To begin, please enter the 3-digit survey initiation code provided by the
interviewer.
SURVEY INITIATION CODE:
If no code is entered, display “Please enter your survey initiation code provided
by your interviewer.”
PBINIT2.
Please verify first and last name.
1
[PROVIDE TEXTBOXES FOR PANEL MEMBER TO ENTER FIRST AND LAST NAMES.]
[FIRST NAME]
____________________________
[LAST NAME]
__________________________
A. WEB SURVEY TUTORIAL
PROGRAMMER: SKIP TUTORIAL IF BASELINE SURVEY IS BEING FI-ADMINISTERED THROUGH HIS/HER STUDY
LOGIN. GO TO SECTION B.
PBA1. Now, let’s review how to move from one question to another in the web
survey. The navigation buttons in the bottom tool bar will help you move
through the survey.
The [NEXT] button at the bottom right side of your screen will allow you
to move forward from one question to the next.
The [PREVIOUS] button at the bottom left side of your screen will let you
back up and change an answer to a previous question. You can then click
the [NEXT] button to go to the next question you need to answer.
The LOG OUT button at the top of your screen can be used if you need to
exit the survey and finish it at a later time. Any information you have
already entered will be saved.
Click the [NEXT] button to continue.
PBA2. While you are in the panel, you will be asked different types of survey
questions. We have a short 6-question tutorial that will let you practice
entering answers to several types of items. Would you like to use the
tutorial to practice answering questions, or skip the tutorial?
1
2
Use the tutorial to answer practice questions
Skip the tutorial GO TO PBBROWSER
Click [NEXT] to continue.
PBA3. In a survey, some questions will ask you to pick one answer from a list of
answer choices. To pick your answer, simply click the radio button beside
your answer choice. The circle will be filled beside the answer you have
selected. Once your answer is selected, click [NEXT] to move to the next
question. Practice picking an answer for the following question.
Do you like ice cream?
2
1
2
Yes
No
PBA4. You may also see “Yes” and “No” questions presented in a grid format. This
format lets you pick “Yes” or “No” for a list of related items on the same
survey screen. In the example question below, practice answering “Yes” or
“No” to each answer choice. Click on the correct radio button for each
answer choice; then click [NEXT] when done.
In the past 30 days, have you purchased any of the following items? Answer
“Yes” or “No” for each.
YES
NO
1
2
a.
Ice cream
1
2
b.
Frozen yogurt or sorbet
1
2
c.
Other frozen desserts (e.g., pies, cakes)
PBA5. Some questions may ask you to select all the answers that apply to you
from a list. These questions will have this instruction: “Select all that
apply.” You can pick one or more than one answer choice. Simply click the
box beside each answer you want to select. If you pick an answer by
mistake, just click the box beside that answer again to remove the check
mark. Once you have selected all your answers, click [NEXT] to continue.
Practice selecting more than one answer to this example question:
Which of the following ice cream flavors do you like? Select all that apply.
1
2
3
4
5
6
Vanilla
Chocolate
Strawberry
Peach
Cookies & Cream
None of the above/Do not eat ice cream
PBA6. You may also be asked to type your answer rather than pick it from a list.
For example, you may be asked to enter a numeric answer—that is, a
number or dollar amount—using the number keys on the keypad or
keyboard. Use the number keys to answer the following example question.
Then click [NEXT] to continue.
On average, about how many hours of TV do you watch each day?
_________ Hours watch TV (RANGE 0-24)
PBA7. Occasionally, you may be asked to pick your answer using drop down lists.
For example, you may be asked to pick the month and year something
happened using drop down lists. Click the arrow beside the “month” item,
3
and then click on the month you want to select as your answer. Repeat
these steps to select the year.
Practice using drop down boxes to enter your date of birth. Then click
[NEXT] to continue.
What is your date of birth? Please select the month, day, and year.
Month (1-12)
Day (1-31) Year (1909-1996)
PBA8. Finally, some questions may ask you to type a text answer using the
alphabetical (letter) keys on the keypad or keyboard. Use the letter keys to
answer the practice question below. Then click [NEXT] to continue.
What is your favorite color? Please enter your answer in the space below.
_________________________________
PBTUTOREND: You have reached the end of the practice questions. Please click
[NEXT] to continue.
PBBROWSER: Please don’t click your browser’s back button during the survey.
Use the navigation buttons at the bottom of the survey instead.
Click [NEXT] to continue.
B. TOBACCO USE QUESTIONS
PBBINTRO: Now we’d like to collect more information about the tobacco products
you currently use.
Please click [NEXT] to continue.
CHECK BOX 1: BASED ON SURVEY INITIATION CODE
R CLASSIFIED AS “EVERY DAY” SMOKER, GO TO PBB1
R CLASSIFIED AS “SOME DAY” SMOKER”, GO TO PBB2
R NOT CLASSIFIED AS “SMOKER” (EVERY DAY, SOME DAYS), GO TO CHECK BOX
2 (CIGARS)
CIGARETTES
PROGRAMMER NOTE: INSERT BANNER—“CIGARETTES”— AT THE TOP OF SCREENS FOR PBB1
THROUGH PBB8.
PBB1. Let’s begin with cigarettes.
On the average, about how many cigarettes do you now smoke a day?
4
Please enter the number of cigarettes below. You can use the chart below,
which tells you how many cigarettes are in a pack.
¼ PACK = 5
1¼ PACKS = 25
2¼ PACKS = 45
½ PACK = 10
1½ PACKS = 30
2½ PACKS = 50
¾ PACK = 15
1¾ PACKS = 35
2¾ PACKS = 55
1 PACK = 20
2 PACKS = 40
3 PACKS = 60
______ Number of cigarettes (RANGE 1-99)
RANGE CHECK: Please enter a number between 1 and 99.
PROGRAMMER NOTE: ALL RESPONDENTS WHO ANSWERED PBB1 SHOULD SKIP TO PBB4. (PBB2 AND
PBB3 ARE FOR NON-DAILY SMOKERS.)
ELSE, IF R LEAVES PBB1 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB1
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB4
PBB2. On how many of the past 30 days did you smoke a cigarette?
_____ Number of days (RANGE 0-30)
RANGE CHECK: Please enter a number between 0 and 30.
PROGRAMMER NOTE: IF R LEAVES PBB2 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB2
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB3
PBB3. On the average, on days when you smoked cigarettes during the past 30
days, about how many did you smoke a day?
Please enter the number of cigarettes below. You can use the chart below,
which tells you how many cigarettes are in a pack.
¼ PACK = 5
1¼ PACKS = 25
2¼ PACKS = 45
½ PACK = 10
1½ PACKS = 30
2½ PACKS = 50
¾ PACK = 15
1¾ PACKS = 35
2¾ PACKS = 55
1 PACK = 20
2 PACKS = 40
3 PACKS = 60
5
______ Number of cigarettes (RANGE 1-99)
RANGE CHECK: Please enter a number between 1 and 99.
PROGRAMMER NOTE: IF R LEAVES PBB3 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB3
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB4
PBB4. Do you usually smoke menthol or non-menthol cigarettes?
1
2
3
Menthol
Non-Menthol
No usual type
PROGRAMMER NOTE: IF R LEAVES PBB4 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB4
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB5
PBB5. How soon after you wake up do you usually have your first cigarette?
1
2
3
4
Within 5 minutes
From 6 to 30 minutes
From more than 30 minutes to 1 hour
After more than 1 hour
PROGRAMMER NOTE: IF R LEAVES PBB5 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB5
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB6
PBB6. Are you planning to stop smoking cigarettes within the next 30 days?
1
2
Yes
No
PROGRAMMER NOTE: IF R LEAVES PBB6 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB6
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO CHECK BOX 2
6
CHECK BOX 2: BASED ON SURVEY INITIATION CODE:
R CLASSIFIED AS “CIGAR SMOKER” (EVERY DAY OR SOME DAYS), GO TO
PBB7INTRO
R NOT CLASSIFIED AS “CIGAR SMOKER”, GO TO CHECK BOX 4 (SMOKELESS)
REGULAR CIGARS/CIGARILLOS/LITTLE FILTERED CIGARS
PBB7INTRO: [IF PBB6 NE BLANK, FILL: The next/ELSE, FILL: These] questions are
about regular cigars, cigarillos and little filtered cigars. “Cigarillos” are medium
cigars that sometimes are sold with plastic or wooden tips. Some common brands
are Black and Mild, Swisher Sweets, Dutch Masters, and Phillies Blunts. Cigarillos
are usually sold individually or in packs of 5 or fewer. Little filtered cigars look like
cigarettes and are usually brown in color. Like cigarettes, little filtered cigars have
a spongy filter and are sold in packs of 20. Some common brands are Prime Time
and Winchester.
PROGRAMMER NOTE: INSERT BANNER—“REGULAR CIGARS/CIGARILLOS/LITTLE FILTERED
CIGARS”— AT THE TOP OF SCREENS SHOWING PBB7INTRO THROUGH PBB11.
PBB7. Have you smoked at least 50 regular cigars, cigarillos, or little filtered cigars
in your entire life?
1
2
Yes
No
CHECK BOX 3: BASED ON SURVEY INITIATION CODE:
R CLASSIFIED AS “EVERY DAY” CIGAR SMOKER, GO TO PBB8
R CLASSIFIED AS “SOME DAY” CIGAR SMOKER”, GO TO PBB9
PBB8. On the average, about how many regular cigars, cigarillos, or little filtered
cigars do you now smoke a day?
____ Number of regular cigars, cigarillos, or little filtered cigars (RANGE = 1-99)
RANGE CHECK: Please enter a number between 1 and 99.
PROGRAMMER NOTE: ALL RESPONDENTS WHO ANSWERED PBB8 SHOULD SKIP TO PBB10a. (PBB9
AND PBB10 ARE FOR NON-DAILY CIGAR SMOKERS.)
IF R LEAVES PBB8 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB8
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB10a
PBB9. On how many of the past 30 days did you smoke regular cigars, cigarillos,
or little filtered cigars?
7
____ Number of days (RANGE 0-30)
RANGE CHECK: Please enter a number between 1 and 30.
PROGRAMMER NOTE: IF R LEAVES PBB9 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB9
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB10
PBB10. On the average, on days when you smoked regular cigars, cigarillos, or
little filtered cigars during the past 30 days, about how many did you smoke
a day?
____ Number of regular cigars, cigarillos, or little filtered cigars (RANGE = 1-99)
RANGE CHECK: Please enter a number between 1 and 99.
PROGRAMMER NOTE: IF R LEAVES PBB10 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB10
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB10a
PBB10a. How soon after you wake up do you usually have your first regular cigar,
cigarillo, or little filtered cigar?
1
2
3
4
Within 5 minutes
From 6 to 30 minutes
From more than 30 minutes to 1 hour
After more than 1 hour
PROGRAMMER NOTE: IF R LEAVES PBB10a BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB10a
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB11
PBB11. Are you planning to stop smoking regular cigars, cigarillos, or little filtered
cigars within the next 30 days?
1
2
Yes
No
PROGRAMMER NOTE: IF R LEAVES PBB11 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB11
8
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO CHECK BOX 4
CHECK BOX 4: BASED ON SURVEY INITIATION CODE:
R CLASSIFIED AS “SMOKELESS USER” (EVERY DAY OR SOME DAYS), GO TO
PB12INTRO
R NOT CLASSIFIED AS “SMOKELESS USER”, GO TO PBB20INTRO
SMOKELESS TOBACCO
PBB12INTRO: [IF PBB6 OR PBB11 NE BLANK, FILL: Now/ELSE, FILL: First] we’d
like to ask you about smokeless tobacco products. Smokeless tobacco products are
placed in the mouth or nose and can include chewing tobacco, snuff, dip, snus
(snoose), or dissolvable tobacco.
Some examples of these product brands are Skoal, Copenhagen, Grizzly, Levi
Garrett, and Red Man.
PROGRAMMER NOTE: INSERT BANNER—“SMOKELESS TOBACCO”— AT THE TOP OF SCREENS
SHOWING QUESTIONS PBB12INTRO THROUGH PBB19
PBB12. Have you used smokeless tobacco at least 20 times in your entire life?
1
2
YES
NO
CHECK BOX 5: BASED ON SURVEY INITIATION CODE:
R CLASSIFIED AS “EVERY DAY” SMOKELESS USER, GO TO PBB12a. PBB13 AND PBB14 ARE
FOR NON-DAILY SMOKELESS USERS.
R CLASSIFIED AS “SOME DAY” SMOKELESS USER”, GO TO PBB13
PBB12a. On the average, about how many times do you now use smokeless tobacco a day?
____ Number of times GO TO PBB15
PBB13. On how many of the past 30 days did you use smokeless tobacco?
____ Number of days (RANGE 0-30)
RANGE CHECK: Please enter a number between 1 and 30.
PROGRAMMER NOTE: IF R LEAVES PBB13 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB13
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB14
9
PBB14. On the average, on days when you used smokeless tobacco during the past
30 days, about how many times did you use a day?
____ Number of times
PROGRAMMER NOTE: IF R LEAVES PBB14 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB14
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB15
PBB15. What brand of smokeless tobacco do you usually use? Please select one.
1
2
3
4
5
6
Copenhagen
Skoal
Red Man
Grizzly
Kodiak
Some other brand (Please specify: ________________)
PROGRAMMER NOTE: IF R LEAVES PBB15 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB15
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB16
PBB16. Do you usually use smokeless tobacco that is in a pouch?
1
2
Yes
No
PROGRAMMER NOTE: IF R LEAVES PBB16 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB16
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB18
PBB18.
1
2
3
4
How soon after you wake up do you usually use smokeless tobacco?
Within 5 minutes
From 6 to 30 minutes
From more than 30 minutes to 1 hour
After more than 1 hour
PROGRAMMER NOTE: IF R LEAVES PBB18 BLANK, ASK:
10
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB18
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB19
PBB19. Are you planning to stop using smokeless tobacco within the next 30 days?
1
2
Yes
No
PROGRAMMER NOTE: IF R LEAVES PBB19 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB19
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB20INTRO
OTHER TOBACCO PRODUCTS
PBB20INTRO: The next questions are about electronic cigarettes or e-cigarettes.
You may also know them as vape-pens, hookah-pens, e-hookahs, or evaporizers. Some look like cigarettes, and others look like pens or small
pipes. These are battery-powered, usually contain liquid nicotine, and
produce vapor instead of smoke.
PROGRAMMER NOTE: INSERT BANNER—“OTHER TOBACCO PRODUCTS”— AT THE TOP OF SCREEN
FOR QUESTION PBB20.
PBB20I1. Have you EVER used an e-cigarette EVEN ONE TIME?
1
2
Yes
No GO TO PBB20
PBB20I2. Do you now use e-cigarettes every day, some days, or not at all?
1
2
3
Every day
Some days
Not at all
PBB20I3. On how many of the past 30 days, did you use e-cigarettes?
____ Number of days (RANGE 0-30)
RANGE CHECK: Please enter a number between 0 and 30.
11
PBB20. Do you now use any of the following tobacco products? Answer “Yes” or
“No” for each.
a. Pipe
b. Water pipe (or Hookah)
c. Other tobacco products not already mentioned (SPECIFY IF YES)
YES
NO
1
2
1
2
1
2
PROGRAMMER NOTE: IF R LEAVES ANY ITEM IN PBB20 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB20
-2
CONTINUE CODE BLANK ITEM AS -2 (REFUSED ) AND CONTINUE TO CHECK BOX 6
CHECK BOX 6: BASED ON SURVEY INITIATION CODE:
- IF PARTICIPANT IS CLASSIFIED AS ONLY ONE OF THE FOLLOWING--SMOKER OR CIGAR
SMOKER OR SMOKELESS USER CONTINUE TO PBB21
- IF PARTICIPANT IS CLASSIFIED AS A DUAL OR POLY TOBACCO USER (CLASSIFIED AS AT
LEAST 2 OF THE 3 TYPES OF TOBACCO USERS) GO TO PBB22.
PBB21. Do you consider yourself a [CHOOSE THE TOBACCO PRODUCT PARTICIPANT IS
CLASSIFIED AS USING: smoker/regular cigar, cigarillo, or little filtered cigar
smoker/smokeless tobacco user]?
1
2
Yes
No GO TO PBC1
PROGRAMMER NOTE: IF R LEAVES PBB21 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB21
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBC1
PBB22. You said you [CHOOSE WHICH OF THE FOLLOWING 3 PRODUCTS PARTICIPANT
IS CLASSIFIED AS USING: smoke cigarettes/”and” smoke regular cigars,
cigarillos, or little filtered cigars/”and” use smokeless tobacco products].
Do you consider yourself primarily a [CHOOSE WHICH OF THE FOLLOWING 3
PRODUCTS PARTICIPANT IS CLASSIFIED AS USING: cigarette smoker, regular
cigar, cigarillo, or little filtered cigar smoker, or smokeless tobacco user]?
Please select one.
[PROGRAMMER: DISPLAY ONLY OPTIONS THAT APPLY TO R, PLUS “NONE OF
THESE”]
1
2
Cigarette smoker
Regular cigar, cigarillo, or little filtered cigar smoker
12
3
4
Smokeless tobacco user
None of these
PROGRAMMER NOTE: IF R LEAVES PBB22 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB22
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBC1
C. COMPUTER METHODOLOGY QUESTIONS
PBC1. The last questions are about your use of computers. In the past 30 days,
have you used any of the following computing devices? Please include
devices you may have used at home, work, school, or a library. Answer
“Yes” or “No” for each.
a.
b.
c.
d.
Smart Phone or Cell Phone (Examples: iPhone or
Android)
Tablet (Examples: iPad, iPad Mini, Galaxy, Nexus)
E-Reader (Examples: Kindle or Nook)
Laptop or Desktop Computer
YES
NO
1
2
1
2
1
2
1
2
PROGRAMMER NOTE: IF R LEAVES ANY ITEM IN PBC1 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBC1
-2
CONTINUE CODE BLANK ITEM AS -2 (REFUSED ) AND CONTINUE TO CHECK BOX
7
CHECK BOX 7: IF “NO” TO ALL IN PBC1 (items a-d) GO TO PBC6. ELSE, CONTINUE.
PBC2. In the past 30 days, how often did you use a computing device, such as a
computer, tablet, e-reader or a smart phone? Would you say…
1
2
3
4
5
Every day
A few times per week
Once a week GO TO PBC4
Once a month GO TO PBC4
Never GO TO PBC4
PBC3. On an average day, how many hours do you use a computing device, such as
a computer, tablet, e-reader, or smart phone? Would you say…
13
1
2
3
4
Less than 1 hour per day
Between 1-5 hours per day
Between 5-8 hours per day
More than 8 hours per day
PROGRAMMER NOTE: IF R LEAVES PBC3 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBC3
-2
CONTINUE CODE AS -2 (REFUSED ) AND CONTINUE TO PBC4
PBC4. The next question is about your use of Apps. An App is a small specialized
program downloaded onto a mobile device. Apps may be used to do things
like play games or music, go to social media sites like Twitter or Facebook,
or get directions.
In the past 30 days, how often have you used Apps? Would you say…
1
2
3
4
5
Every day
A few times per week
Once a week
Once a month
Never GO TO PBC6
PBC5. Do you use Apps to…(Answer “Yes” or “No” for each.)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Download or play music files
Play games
Check the weather
Get news
Send or receive email
Access social networking sites
Watch a movie
Use online classified ads
Make a phone or video call
Shop online
Get directions or maps
2
Other 1
YES
NO
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
PBC6. How comfortable do you feel using a computer? Would you say…
1
2
3
4
Very comfortable
Comfortable
Uncomfortable
Very uncomfortable
14
PROGRAMMER NOTE: IF R LEAVES PBC6 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBC6
-2
CONTINUE CODE AS -2 (REFUSED ) AND CONTINUE TO PB_END
PBEND: So that we can confirm we have an active email address on file for you,
please enter your best email address in the blank below. Once you enter your
address and complete this survey, you will receive a confirmation email from
tcs@rti.org to verify your email address and provide the link to the panel website
for future surveys. We recommend that you keep this email for future reference.
[Collect 1 email address – with checks for acceptable email address]
No email address
1
PROGRAMMER NOTE: IF R LEAVES PBEND BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
-2
RETURN TO QUESTION RETURN TO PBEND
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PB_END2
PBEND2: Thank you for completing this first survey. Again, we look forward to
your participation in the TCS survey panel.
As a reminder, RTI International may send you one or more messages in
approximately one week, thanking you for your participation in the panel. This
could take the form of a brief email, text message, and/or automated phone call.
This message will also serve as a confirmation that all information collected during
your enrollment was entered correctly. If you have any questions, please feel free
to visit the TCS panel website (https://tcs.rti.org), call our project helpline (1800-613-0326), or send an email to tcs@rti.org.
Paperwork Reduction Act Statement: The public reporting burden for this information
collection has been estimated to average 10 minutes per response to complete the survey
questions. Send comments regarding this burden estimate or any other aspects of this
information collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov.
15
| File Type | application/pdf |
| File Modified | 2016-08-10 |
| File Created | 2016-07-25 |