Youth Screener and Consent for Online Outcome Survey

aTTACHMENT 3: WEB SCREENER survey

Form Approved

OMB No. 0910-0788

Exp. Date 05/31/2018

Evaluation of the Fresh Empire Campaign on Tobacco- Web Screener (EFECT-S)

Subjects for Questionnaire:

Section S: Study Screener

THIS QUESTIONNAIRE IS INTENDED FOR SOCIAL MEDIA RESPONDENTS ON THE WEB.

PROGRAMMER NOTES: THE WEB INSTRUMENT WILL BE OPTIMIZED FOR MOBILE

[IF WEB] PROGRAMMER NOTE: UPON ARRIVING AT THE WEBSITE, PLEASE PRESENT A POPUP THAT REQUESTS THE RESPONDENT’S AGE.

WORDING: Welcome! To provide the best browsing experience, please enter your date of birth.

CHECK FOR VALID DATE AND ONLY ALLOW 2-DIGIT MONTH AND DAY AND 4 DIGIT YEAR. ALLOW ALL AGES TO PROCEED.

WELCOME This survey contains questions about you and your friends. It should take less than 5 minutes to complete. Please take your time and answer each question. Thank you!

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WECON We would like to ask you some questions about yourself and your friends. Your participation is voluntary. You can quit the survey at any time. No absolute guarantees can be made because of the technology used for electronic surveys like these, but we are taking extensive precautions to protect the confidentiality of your data.

There are no physical risks to you from participating in this survey. It is possible that some questions might make you mildly uncomfortable, depending on your responses.

There are no direct benefits to you from answering our questions. However, you will be contributing to important research related to tobacco use among youth.

[IF AGE < 15] If you meet our criteria to participate in the study, you will be invited to provide your email address or mobile number and a parent or legal guardian’s first name and phone number so that we can get their permission for you to participate in our study. Your answers will not be shared with your parent or guardian. Once we receive your parent or guardian’s permission, we will email or text you a link to invite you to take a 40-minute survey online. You can decide whether or not you want to take the survey. If you decide to take the survey, you will receive a $25 virtual gift card upon completion. We may contact you again to invite you to participate in one additional survey in six months.

[IF AGE IS 15 TO 17] If you meet our criteria to participate in the study, you will be invited to take part in our web survey. Your answers will not be shared with your parent or guardian. This is a 40-minute survey online. You can decide whether or not you want to take the survey. If you decide to take the survey, you will receive a $25 virtual gift card upon completion. We may contact you again to invite you to participate in one additional survey in six months.

[IF AGE IS 18 AND OLDER] If you meet our criteria to participate in the study, you will be invited to take part in our web survey. This is a 40-minute survey online. You can decide whether or not you want to take the survey. If you decide to take the survey, you will receive a $25 virtual gift card upon completion. We may contact you again to invite you to participate in one additional survey in six months.

Please check the appropriate box below.

[IF YOUNGER THAN 15]

I understand that I will be answering some questions about myself, and if I meet the criteria will need to provide my email or mobile number and my parents’ first name and phone number to get their permission for me to be in the study.

[IF 15 OR OLDER]

I understand that I will be answering some questions about myself, and if I meet the criteria I will be invited to participate in a 40 minute survey for $25.

__Agree – GO TO S0

__Disagree – GO TO REF

If you have any questions about the survey, please contact our research team at efectsurvey@rti.org or call 800-845-6708.

REF Thank you for your interest in the study. You do not qualify to participate.

S0. [IF WEB] How did you find out about this survey?

1. Facebook ad/Sponsored NewsFeed story

2. Instagram/Sponsored post on Instagram

3. Someone sent it to me on Facebook

4. Someone sent it to me on Instagram

5. Someone sent it to me in another way

6. Another way (Specify)

9. Prefer not to answer

S2. What is your gender?

₁ Female

₂ Male

₃ Other (Please specify _______________)

₉ Prefer not to answer

S3. Are you of Hispanic, Latino/a, or Spanish origin? Select all that apply.

₁ No, not of Hispanic, Latino, Latina, or Spanish origin

₂ Yes, Mexican, Mexican American, Chicano or Chicana

₃ Yes, Puerto Rican

₄ Yes, Cuban

₅ Yes, Another Hispanic, Latino/a or Spanish origin

₉ Prefer not to answer

S4. What race or races do you consider yourself to be? Select all that apply.

₁ American Indian or Alaska Native

₂ Asian

₃ Black or African American

₄ Native Hawaiian or Other Pacific Islander

₅ White

₆ Other (specify)

₉ Prefer not to answer

S5a. Rank the three people that would BEST FIT in your main group of friends, starting with the best fit. Click on the picture to make a selection.

S5b. Rank the three people that would LEAST FIT in your main group of friends, starting with the worst fit. Click on the picture to make a selection.

S6a. Rank the three people that would BEST FIT in your main group of friends, starting with the best fit. Click on the picture to make a selection.

S6b. Rank the three people that would LEAST FIT in your main group of friends, starting with the worst fit. Click on the picture to make a selection.

S7. [IF WEB] What is your zip code?

_______________________ NUMERIC 5 DIGIT ENTRY REQUIRED. LEADING 0 ALLOWED.

□ Don’t Know

□ Prefer Not to Answer

______

VALIDATE ZIP. IF NOT VALID – INCLUDING MISSING - SKIP TO S9.

S7a. What is your date of birth?

MM/DD/YYYY

PROGRAMMER: PLEASE PROGRAM AS A DROP DOWN BOX FOR EACH FIELD. THE RANGE OF YEARS SHOULD BE FROM 1950-2010.

PROGRAMMER NOTE: WEB RESPONDENTS DOB AT FIRST QUESTION SHOULD MATCH S7A. IF MISMATCH, MAKE INELIGIBLE.

A HIP HOP SCORE OF 4 OR HIGHER IS ELIGIBLE

4 through 12 is eligible. Otherwise, not eligible.

IF AGE = 13-17 THEN GO TO S8. IF AGE NE 13-17 THEN GO TO S9.

S9. [IF NOT ELIGIBLE] That was the last question. Unfortunately, you do not qualify for the study. Thank you for your time and responses.

S8. What is your first name?

S10_2. [IF ELIGIBLE AND AGE = 15-17] You are eligible to take part in an online study conducted by the U.S. Food and Drug Administration (FDA). This survey will take about 40 minutes to complete. The survey will ask questions about tobacco use, media use, illegal behaviors, opinions about tobacco, and experiences at home and at school. Everyone who completes the online study will receive a $25 gift card by email.

Note: You can participate only once and are eligible to receive only one gift card.

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SKIP TO S10A.

S10. [IF ELIGIBLE AND AGE = 13 OR 14] You are eligible to take part in an online study conducted by the U.S. Food and Drug Administration (FDA). This survey will take about 40 minutes to complete. The survey will ask questions about tobacco use, media use, illegal behaviors, opinions about tobacco, and experiences at home and at school. Everyone who completes the online study will receive a $25 gift card by email.

Note: You can participate only once and are eligible to receive only one gift card.

We need your parent’s/guardian’s permission for you to take the survey. Your answers will not be shared with your parent/guardian. They will be kept private.

Please provide the information below. If your parent/guardian gives their permission for you to take the survey, we will send the survey link to you.

Parent/Guardian Name ___________________

Phone Number __________________________

S10a. [IF ELIGIBLE AND AGE=15-17] Press FINISH on the next screen to be directed to the survey. In case you don’t finish the survey today or in case we need to reach you, please enter your email address. We will only use this address to contact you about the study.

Email address:___________________

Verify Email address:________________

Note: You can participate only once and are eligible to receive only one gift card.

S11. [IF AGE=13 OR 14] The survey can be taken on a computer, tablet or on the web on a smart phone, like an iPhone or an Android. How do you prefer to take the survey?

□ Laptop/Desktop Computer

□ Tablet

□ Cell Phone

S12. [IF AGE=13 OR 14] Thanks! Please provide your contact information so that we can send you the survey. We will try to send it by email or text, depending on which way you prefer. Just in case, please provide both your email and cell phone number. We will only use this information to contact you about the survey.

Your email address ______________________

□I don’t have an email address

Your cell phone number (xxx-xxx-xxxx) ___-___-_____

□I don’t have a cell phone

S13. [IF DON’T HAVE EMAIL ADDRESS AND IF AGE=13 OR 14]

Can you please provide the email address of someone in your family? We can email the survey to them and ask them to share it with you.

Family member’s email address____________________

□ Don’t Know Family Member’s email address

S14. [IF NO CELL PHONE AND IF AGE=13 OR 14]

Can you please provide the cell phone number of someone in your family who will share their phone with you?

Family member’s cell phone number (xxx-xxx-xxxx) ___-___-_____

□ Don’t Know Family Member’s cell phone number

S14a. [IF NO PHONE, EMAIL, FAMILY EMAIL OR FAMILY PHONE AND IF AGE=13 OR 14] To be able to take the next survey, you need to provide contact information. Please provide an email address or a cell phone number below.

Email_________________

Cell Phone (xxx-xxx-xxxx) ___-___-_____

□I don’t have/know this information

S14b. [IF S14a=I DON’T HAVE INFO AND AGE=13 OR 14] Thank you for your responses. That was the last question.

S15. [IF AGE=13 OR 14] Thank you for your responses! Please be on the look-out for an email or text message with a link to the survey in the next few days. Everyone who completes the survey will receive a $25 virtual Gift Card.

Note: You can participate only once and are eligible to receive only one gift card.

S16. PROGRAMMER: IF R IS 15-17 AND ELIGIBLE, ROUTE TO THE BEGINNING OF THE MAIN INSTRUMENT.

CREATE AND STORE CREDENTIALS TO BE SENT TO THEM VIA EMAIL/TEXT IF THEY BREAKOFF OR LOSE THEIR CONNECTION.

Thank you for your time.

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 5 minutes per response to complete the web screener (the time estimated to read, review, respond). Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov

HEND. You may now close your browser or navigate away from this page.