Outcome Screener in Person

IRB 13819

Attachment 3: CROSS-SECTIONAL (INTERCEPT AND SOCIAL MEDIA ) SCREENERs

[THESE SPECIFICATIONS SCREEN NEW PARTICIPANTS FOR ELIGIBILITY FOR THE STUDY. THE FIRST SECTION INCLUDES THE INTERCEPT SCREENER, WHICH IS ADMINISTERED TO NEW POTENTIAL STUDY MEMBERS IN PERSON. THE SECOND INCLUDES THE SOCIAL MEDIA SCREENER, WHICH IS ADMINISTERED ON THE WEB.]

Form Approved
OMB No. 0910-0808
Exp. Date 01/31/2019

Research and Evaluation Survey for the Public Education Campaign on Tobacco among LGBT (RESPECT)

Programming conventions and specifications notes

• Abbreviations used include ‘R’ for ‘respondent’ and ‘PNTA’ for ‘prefer not to answer’

• Prefer Not To Answer/Don’t Know/Refused/None of these are not allowed in combination with other responses

• Variable names and section headings are not displayed on screen

• Response options should not be labeled with numbers.

• A back button will not be offered to respondents.

• Bolding conveys emphasis while capital letters convey instructions for programmers or interviewers.

• Questionnaire will include a progress bar.

• All items are required

• “Next” buttons will be displayed on every survey screen as appropriate.

• All images should be arranged in such a way that focus on usability and layout. Images should be aligned and of similar sizes as one another.

Intercept Screener for In-Person Respondents

AA1. INTERVIEWER, SELECT MARKET AND BAR

PROGRAMMER: DISPLAY MARKETS

1. New York-Newark-Jersey City, NY/NJ/PA

2. LA-Long Beach-Anaheim, CA

3. Chicago-Naperville-Elgin, IL/IN, WI

4. San Francisco-Oakland-Hayward, CA

5. Dallas-Fort Worth-Arlington, TX

6. Boston-Cambridge-Newton, MA/NH

7. Miami-Fort Lauderdale-West Palm Beach, FL

8. Washington-Arlington-Alexandria, DC/VA/MD/WV

9. Atlanta- Sandy Springs-Roswell, GA

10. Phoenix-Mesa-Scottsdale, AZ

11. Seattle-Tacoma-Bellevue, WA

12. Detroit-Warren-Dearborn, MI

13. San Diego-Carlsbad, CA

14. Minneapolis-St. Paul-Bloomington, MN/WI

15. Denver-Aurora-Lakewood, CO

16. Portland-Vancouver-Hillsboro, OR/WA

17. Tampa-St. Petersburg-Clearwater, FL

18. Austin-Round Rock, TX

19. St. Louis, MO/IL

20. San Antonio-New Braunfels, TX

21. Providence-Warwick, RI/MA

22. Virginia Beach – Norfolk – Newport News, VA/NC

23. Pittsburgh, PA

24. Sacramento – Roseville – Arden – Arcade, CA

25. Charlotte, NC

ASK: All intercept interviewers

_________________________________________________________________________

AA2. PROGRAMMER: DISPLAY BARS

[GPS COORDINATES CAPTURED AT THIS SCREEN FOR AUTHENTICATION PURPOSES.]

ASK: All intercept interviewers

_________________________________________________________________________

AA3. PROGRAMMER: Insert Intercept Screener Consent (First half of Attachment 5)

ASK: All intercept respondents

_________________________________________________________________________

C0S. [IF INTERCEPT AND AA3=2(NO)] Thank you for your consideration. Please give the tablet back to the interviewer. INTERVIEWER: ENTER A PASSWORD TO CONTINUE.

EXIT

ASK: Intercept respondents who select No to informed consent

_________________________________________________________________________

Section A: Demographic Items

The first part of the survey asks you some general questions about yourself.

A1. What is the 5-digit zip code where you currently live?

__ __ __ __ __ (5-digit, numeric responses only)

ASK: All intercept respondents

_________________________________________________________________________

A2.

What is your date of birth?

Month Year

Please confirm your date of birth.

Month Year

PROGRAMMER: CALCULATE MINIMUM AGE. FOR EXAMPLE, IF MONTH IS CURRENT MONTH AND R CAN BE EITHER 17 OR 18 BASED ON DATE, CALCULATE 17. INCLUDE DROP DOWN MENUS FOR MONTH AND YEAR. THE RANGE OF YEARS SHOULD INCLUDE 1985 TO 2005. BIRTHDAY ENTRIES SHOULD MATCH. IF ENTRIES DON’T MATCH, DISPLAY ERROR MESSAGE.

ASK: All intercept respondents

_________________________________________________________________________A3. What is your current gender identity?

1 Male

2 Female

3 Trans male/Trans man

4 Trans female/Trans woman

5 Genderqueer/Gender non-conforming

6 Different identity (please state)______________________

9 Prefer not to answer

ASK: All intercept respondents

_________________________________________________________________________

A4. What sex were you assigned at birth, on your original birth certificate?

1 Female

2 Male

9 Prefer not to answer

ASK: All intercept respondents

_________________________________________________________________________

A5. [IF A3=1 OR 3] Which of the following best represents how you think of yourself?

1 Gay – GO TO A9

2 Straight, that is, not gay – GO TO A9

3 Bisexual – GO TO A9

4 Something else – GO TO A7

5 I don’t know the answer – GO TO A8

9 Prefer not to answer – GO TO A9

ASK: All male or trans male intercept respondents

_________________________________________________________________________

A6. [IF A3=2 OR 4 OR 5 OR 6 OR 9] Which of the following best represents how you think of yourself?

1 Lesbian or gay – GO TO A9

2 Straight, that is, not lesbian or gay – GO TO A9

3 Bisexual - GO TO A9

4 Something else – GO TO A7

5 I don’t know the answer – GO TO A8

9 Prefer not to answer – GO TO A9

ASK: All female or trans female intercept respondents

________________________________________________________________________________________________________

A7. [IF A5=4 OR A6=4] What do you mean by something else?

1 You are not straight, but identify with another label such as queer, trisexual, omnisexual, or pansexual – GO TO A9

2 You are transgender, transsexual, or gender variant - GO TO A9

3 You have not figured out or are in the process of figuring out your sexuality - GO TO A9

4 You do not think of yourself as having sexuality - GO TO A9

5 You do not use labels to identify yourself - GO TO A9

6 You mean something else (please state) _____________- GO TO A9

9 Prefer not to answer - GO TO A9

ASK: All intercept respondents who report ‘something else’ in A5 OR A6

________________________________________________________________________________________________________

A8. [IF A5=9 OR A6=9] What do you mean by don’t know?

1 You don’t understand the words

2 You understand the words, but you have not figured out or are in the process of figuring out your sexuality

3 You mean something else

9 Prefer not to answer

ASK: All intercept respondents who report ‘don’t know’ in A5 OR A6

________________________________________________________________________________________________________

A10. Have you ever tried cigarette smoking, even one or two puffs?

1 Yes

2 No

9 Prefer not to answer

ASK: All intercept respondents

________________________________________________________________________________________________________

A11. [IF A10=1] About how many cigarettes have you smoked in your entire life? Your best guess is fine.

1 1 or more puffs but never a whole cigarette

2 1 cigarette

3 2 to 5 cigarettes

4 6 to 15 cigarettes (about 1/2 a pack total)

5 16 to 25 cigarettes (about 1 pack total)

6 26 to 99 cigarettes (more than 1 pack, but less than 5 packs)

7 100 or more cigarettes (5 or more packs)

9 Prefer not to answer

ASK: Intercept respondents who have ever tried cigarette smoking according to A10

________________________________________________________________________________________________________

A12. [IF A10=1] During the past 30 days, on how many days did you smoke cigarettes?

|_|_| days [RANGE: 0-30, 99]

ASK: Intercept respondents who have ever tried cigarette smoking according to A10

________________________________________________________________________________________________________

A12a. To show that you are paying attention, please respond to this item by marking “Disagree”.

1 Strongly Agree

2 Agree

3 Neither Agree nor Disagree

4 Disagree

5 Strongly Disagree

ASK: All respondents

________________________________________________________________

A13. Have you ever received money or gift cards from a company for sharing your opinions about LGBT health in a discussion group, interview, or survey?

1 Yes, within the past 9 months

2 Yes, more than 9 months ago

3 No

4 I’m not sure

ASK: All intercept respondents

_________________________________________________________________________

A14. How old are you?

______________________ Age (Range: 15 – 60)

ASK: All intercept respondents

_________________________________________________________________________

PROGRAMMER: CALCULATE AGE BASED ON DOB IN A2. IF BIRTH MONTH = CURRENT MONTH, THEN USE FIRST DAY OF MONTH AS BIRTH DAY.

________________________________________________________________________________________________________

PROGRAMMER: SET ELIGFLAG. IF [A1= VALID AND A2= 18 to 24-years-old] AND [A3= 3 to 5 OR A5= 1 or 3 OR A6= 1 or 3 OR A7= 1 or 2 OR 6] AND IF AGE CALCULATED FROM A2 = AGE IN A14 OR AGE IN A14-1 THEN ELIGFLAG=1. ELSE ELIGFLAG=2.

___________________________________________________________

INELGBL_intercept Thank you for your responses. We have no further questions at this time. The interviewer will now give you $10 for answering these questions.

Please give the tablet back to the interviewer.

INTERVIEWER: ENTER A PASSWORD TO CONTINUE

PROGRAMMER: DISPLAY DISPOSITION SUCH AS INELIGIBLE AGE, INELIGIBLE NOT LOCAL, INELIGIBLE OTHER. INELIGIBLE AGE SHOULD BE USED FOR ALL OUT OF RANGE AGES, INCLUDING THOSE YOUNGER THAN 18

Response has been recorded.

ASK: Respondents who are ineligible for the main study based on their responses to the screener

_________________________________________________________________________

ELGBL_ContactInfo Based on your answers to our questions, you meet our criteria to complete our web survey for a $20 digital gift card. We would like to collect your contact information and want to keep it secure. Please hand the tablet back to the interviewer. They will open another questionnaire and hand it right back.

Please give the tablet back to the interviewer.

INTERVIEWER: ENTER A PASSWORD TO CONTINUE

PROGRAMMER: DISPLAY DISPOSITION SUCH AS COMPLETE AND ELIGIBLE

Response has been recorded.

INTERVIEWER: RETURN TABLET TO RESPONDENT

ASK: Eligible respondents

________________________________________________________________________________________________________

B1. Congratulations!  Based on your answers to our questions, you are eligible to complete our survey for a $20 electronic gift card.  Please provide your first name, email address, and cell phone number so that we can send you a link to the web survey that you will complete on your own. You can choose whether you want to receive the link via email or text message. If you complete the survey within 48 hours of receiving the link you will receive an added $5 for a total of $25.  We will only use this information to contact you about the survey.

 

First name. ______________

Primary Email address ______________

Confirm Email address______________________

Cell phone number ___-____-____

Confirm phone number______________________

PROGRAMMER: VALIDATE EMAIL ADDRESS AND CELL PHONE NUMBER FOR CORRECT FORMAT. EMAIL ADDRESS IS REQUIRED TO MOVE FORWARD.

ASK: Eligible respondents

________________________________________________________________________________________________________

B2. The survey can be taken on a computer, tablet or on the web on a smart phone, like an iPhone or an Android. To make sure this invitation is easy for you to find, can we send you both a text and an email with the survey link?

1 Yes, send both a text and an email

2 No, just send an email

ASK: Eligible respondents

________________________________________________________________________________________________________

B3. Within the next few days, if you have not previously been invited, we will send you a text message and/or an email with a link to the web survey that you will complete on your own. Only one entry is allowed per participant.

If you complete the survey within 48 hours of receiving the link you will receive an added $5 for a total of $25.

The interviewer will now give you $10 for answering these questions.

OMB No: 0910-0808 Expiration Date: 01/31/2019

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

ASK: Eligible respondents

_________________________________________________________________________

LAST Please give the tablet back to the interviewer.

ASK: Eligible respondents

_________________________________________________________________________

PASS INTERVIEWER: ENTER A PASSWORD TO CONTINUE.

PROGRAMMER: THIS SCREEN CANNOT MOVE FORWARD UNTIL PASSWORD IS ENTERED.

PASSWORD IS EXIT

Response has been recorded.

ASK: Eligible respondents

_________________________________________________________________________

Inelig_dupe Thank you for your responses. Our records indicate that we already have your email address or cell phone number on file. Thank you for completing the follow-up survey if you already have. If not, you will receive a reminder email or text message with the survey link to complete and receive your $10.

ASK: Respondents who have a duplicate email address to one previously collected

_________________________________________________________________________

Web Screener for Social Media Respondents

CAPTCHA. PROGRAMMER: INSERT CAPTCHA ON SCREEN SUCH AS THE IMAGE BELOW

ASK: All respondents recruited from social media

_________________________________________________________________

AA3. PROGRAMMER: Insert Social Media Consent (Second half of Attachment 5)

ASK: All respondents recruited from social media

________________________________________________________________________________________________________REFSCRN. [IF SOCIAL MEDIA AND AA3 [SCREENER CONSENT] = NO]

Thank you for your time.

ASK: Respondents who are recruited from social media and who refuse informed consent

________________________________________________________________________________________________________

A0. The first part of the survey asks you some general questions about yourself.

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

PROGRAMMER: PLEASE ONLY ALLOW ALPHA CHARACTERS IN THE OTHER SPECIFY FIELD. NUMBERS AND SPECIAL CHARACTERS SHOULD NOT BE ALLOWED.

ASK: All respondents

________________________________________________________________________________________________________

A1. What is the 5-digit zip code where you currently live?

__ __ __ __ __ (5-digit, numeric responses only)

ASK: All respondents

_________________________________________________________________________

A2.

What is your date of birth?

Month Year

Please confirm your date of birth.

Month Year

PROGRAMMER: CALCULATE MINIMUM AGE. FOR EXAMPLE, IF MONTH IS CURRENT MONTH AND R CAN BE EITHER 17 OR 18 BASED ON DATE, CALCULATE 17. INCLUDE DROP DOWN MENUS FOR MONTH AND YEAR. THE RANGE OF YEARS SHOULD INCLUDE 1985 TO 2005. BIRTHDAY ENTRIES SHOULD MATCH. IF ENTRIES DON’T MATCH, DISPLAY ERROR MESSAGE.

ASK: All respondents

_________________________________________________________________________

A3. What is your current gender identity?

1 Male

2 Female

3 Trans male/Trans man

4 Trans female/Trans woman

5 Genderqueer/Gender non-conforming

6 Different identity (please state) ___________________

9 Prefer not to answer

ASK: All respondents

_________________________________________________________________________

A4. What sex were you assigned at birth, on your original birth certificate?

1 Female

2 Male

9 Prefer not to answer

ASK: All respondents

_________________________________________________________________________

A5. [IF A3=1 OR 3] Which of the following best represents how you think of yourself?

1 Gay – GO TO A9

2 Straight, that is, not gay – GO TO A9

3 Bisexual – GO TO A9

4 Something else – GO TO A7

5 I don’t know the answer – GO TO A8

9 Prefer not to answer – GO TO A9

ASK: All male or trans male new cohort respondents

_________________________________________________________________________

A6. [IF A3=2 OR 4 OR 5 OR 6 OR 9] Which of the following best represents how you think of yourself?

1 Lesbian or gay – GO TO A9

2 Straight, that is, not lesbian or gay – GO TO A9

3 Bisexual - GO TO A9

4 Something else – GO TO A7

5 I don’t know the answer – GO TO A8

9 Prefer not to answer – GO TO A9

ASK: All female or trans female new cohort respondents

________________________________________________________________________________________________________

A7. [IF A5=4 OR A6=4] What do you mean by something else?

1 You are not straight, but identify with another label such as queer, trisexual, omnisexual, or pansexual – GO TO A9

2 You are transgender, transsexual, or gender variant - GO TO A9

3 You have not figured out or are in the process of figuring out your sexuality - GO TO A9

4 You do not think of yourself as having sexuality - GO TO A9

5 You do not use labels to identify yourself - GO TO A9

6 You mean something else (please state) ___________ - GO TO A9

9 Prefer not to answer - GO TO A9

ASK: All new cohort respondents who report ‘something else’ in A5 OR A6

________________________________________________________________________________________________________

A8. [IF A5=9 OR A6=9] What do you mean by don’t know?

1 You don’t understand the words

2 You understand the words, but you have not figured out or are in the process of figuring out your sexuality

3 You mean something else

9 Prefer not to answer

ASK: All respondents who report ‘don’t know’ in A5 OR A6

________________________________________________________________________________________________________

A10. Have you ever tried cigarette smoking, even one or two puffs?

1 Yes

2 No

9 Prefer not to answer

ASK: All respondents

________________________________________________________________________________________________________

A11. [IF A10=1] About how many cigarettes have you smoked in your entire life? Your best guess is fine.

1 1 or more puffs but never a whole cigarette

2 1 cigarette

3 2 to 5 cigarettes

4 6 to 15 cigarettes (about 1/2 a pack total)

5 16 to 25 cigarettes (about 1 pack total)

6 26 to 99 cigarettes (more than 1 pack, but less than 5 packs)

7 100 or more cigarettes (5 or more packs)

9 Prefer not to answer

ASK: Respondents who have ever tried cigarette smoking according to A10

________________________________________________________________________________________________________

A12. [IF A10=1] During the past 30 days, on how many days did you smoke cigarettes? Enter 99 for ‘Don’t Know’

|_|_| days [RANGE: 0-30, 99]

ASK: Respondents who have ever tried cigarette smoking according to A10

________________________________________________________________________________________________________

A12a. To show that you are paying attention, please respond to this item by marking “Disagree”.

1 Strongly Agree

2 Agree

3 Neither Agree nor Disagree

4 Disagree

5 Strongly Disagree

ASK: All respondents

_________________________________________________________________

A13. Have you ever received money or gift cards from a company for sharing your opinions about LGBT health in a discussion group, interview, or survey?

1 Yes, within the past 9 months

2 Yes, more than 9 months ago

3 No

4 I’m not sure

ASK: All respondents

________________________________________________________________________

A14. How old are you?

______________________ Age (Range: 15 – 60)

ASK: All intercept respondents

________________________________________________________________________

PROGRAMMER: If [A1= valid AND A2= 18 to 24-years-old] AND [A3= 3 to 5 OR A5= 1 or 3 OR A6= 1 or 3 OR A7= 1 or 2 or 6] AND A12a =2 AND IF AGE CALCULATED FROM A2 = AGE IN A14 OR AGE IN A14-1 THEN ELIGFLAG=1. Else ELIGFLAG=2.

________________________________________________________________________

SMINELIG Thank you for your responses. We have no further questions at this time. Your responses have been recorded.

NEXT

ASK: Respondents who are not eligible for the main study based on their responses to the screener

________________________________________________________________________

SMEML Based on your answers, you may be eligible to complete our web survey for a $20 electronic gift card. Please provide your first name, email address and cell phone number. If you are eligible we will use this information to send you your $20 electronic gift card after you complete the full survey.

First name. ______________

Primary Email address: ______________

Confirm Email address________________

Cell phone number ___-____-____

Confirm Cell Phone Number ______-_______-_________

PROGRAMMER: EMAIL ADDRESS WILL BE A REQUIRED FIELD, BUT CELL PHONE NUMBER IS OPTIONAL

To make sure this invitation is easy for you to find, can we send you both a text and an email with the survey link?

1 Yes, send both a text and an email

2 No, just send an email

ASK: Eligible respondents

________________________________________________________________________

CONF Thank you, we will verify your eligibility to continue with the survey now.

NEXT

ASK: Eligible respondents

________________________________________________________________________

SMELIG Congratulations!  You are eligible and are invited to complete our web survey for a $20 electronic gift card. Please click Next to continue to the survey.

NEXT

ASK: Eligible respondents

________________________________________________________________________

SMINEDUPE Thank you for your responses. Our records indicate that we already have your email address on file. Thank you for completing the follow-up survey if you already have. If not, you may have received a reminder email with the survey link.

Check your spam, junk or clutter folder(s) if you don’t see our email in your email inbox. The study team is available to assist you at respect@rti.org if you are unable to locate the message in your inbox, junk, or clutter folders.

ASK: Respondents who submit an email address that is already in the system

_________________________________________________________________

OMB No: 0910-0808 Expiration Date: 01/31/2019

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

ASK: All respondents

_________________________________________________________________________

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