Outcome Baseline in Person
Food and Drug Administration's Research and Evaluation Survey for the Public Education Campaign on Tobacco among LGBT (RESPECT)
Attachment 1_BaselineWebSurvey
Outcome Baseline in Person
OMB: 0910-0808
Attachment 1: lgbt young adult Baseline Instrument
Form Approved
OMB No. 0910-0808
Exp. Date 01/31/2019
Research and Evaluation Survey for the Public Education Campaign on Tobacco among Lesbian Gay Bisexual Transgender (LGBT) (RESPECT)
Subjects
for Questionnaire:
Section
AA: Informed Consent
Section A: Demographic Items
Section B: Tobacco Use Behavior
Section C: Tobacco Use Intentions and Self-Efficacy
Section D: Cessation (Intention, Behavior, Motivation)
Section E: Attitudes, Beliefs & Risk Perceptions, Social Norm
Section F: Media Use and Awareness
Section G: Environment
Section H: LGBT Identity and Community
Notes: LGBT stands for Lesbian Gay Bisexual Transgender
The “Prefer not to answer” option will be available for all questions; however, it will not be visible on the screen. Rather respondents will have the option of continuing to the next question without answering the current question. If they do, they will be prompted to answer the question they skipped, but can continue without answering the question.
WID [IF INTERCEPT] Our records indicate that a XX PREFILL AGE year old named XX PREFILL NAME answered some questions for this study. Are you XX PREFILL NAME?
1. Yes
2. No
PROGRAMMER: FILL DATA FROM SCREENER IN THIS QUESTION.
[IF WID=2] Thank you, but you are not eligible to take this survey.
Section AA: Informed consent
AA1. [THE INFORMED CONSENT TEXT WILL BE INSERTED HERE.]
Section A: Demographic Items
The first part of the survey asks you some general questions about yourself.
A1. What is your date of birth? (mm-yyyy)?
A2. Are you Hispanic, Latino/a, or of Spanish origin? Check all that apply.
1 No, not of Hispanic, Latino/a, or Spanish origin
2 Yes, Mexican American, Chicano/a
3 Yes, Puerto Rican
4 Yes, Cuban
5 Yes, another Hispanic, Latino/a, or Spanish origin
9 Prefer not to answer
A3. What race or races do you consider yourself to be? (You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER or YOU MAY SKIP THIS QUESTION)
-
Yes
No
Prefer Not to AnswerA3_1. American Indian or Alaska Native
1
2
9
A3_2. Asian
1
2
9
A3_3. Black or African American
1
2
9
A3_4. Native Hawaiian or Other Pacific Islander
1
2
9
A3_5. White
1
2
9
A3_6. Other
1
2
9
A3_7. Prefer not to answer
A4. Which best describes your current job or paid employment status?
1 Work full-time at least 35 hours per week
2 Work part-time 15 to 34 hours per week
3 Work part-time less than 15 hours per week
4 I don't currently work for pay
5 Don’t know
9 Prefer not to answer
A5. What is the highest grade or level of school you have completed?
1 Less than high school
2 Some high school, no diploma
3 GED
4 High school graduate—diploma
5 Some college but no degree
6 Associate degree—occupational/vocational
7 Associate degree—academic program
8 Bachelor’s degree (ex: BA, AB, BS)
9 Master’s degree (ex: MA, MS, MEng, Med, MSW)
10 Professional school degree (ex: MD, DDS, DVM, JD)
11 Doctorate degree (ex: PhD, EdD)
12 Don’t know
99 Prefer not to answer
A6. Are you currently enrolled in a degree program?
1 Yes
2 No
3 Don’t know
9 Prefer not to answer
A7. Which of the following categories best describes your total household income in the past 12 months?
This is the total income before taxes of all persons in your household combined. Please include money from jobs, relatives, pensions, dividends, interest, social security payments or retirement benefits, net income from business, farm or rent, and any other money received by household members.
1 Less than $10,000
2 $10,000 to $14,999
3 $15,000 to $24,999
4 $25,000 to $34,999
5 $35,000 to $49,999
6 $50,000 to $74,999
7 $75,000 to $99,999
8 $100,000 to $149,999
9 $150,000 to $199,999
10 $200,000 or more
11 Don’t know
99 Prefer not to answer
Section B: Tobacco Use Behavior
The next section asks about your experiences with tobacco products.
Cigarette Use
B1. Have you ever tried cigarette smoking, even one or two puffs?
1 Yes
2 No
9 Prefer not to answer
B2. [IF B1=1 or 9] During the past 30 days, on how many days did you smoke cigarettes?
|_|_| days [RANGE: 0-30, 99]
[PN: IF RESPONDENT DOESN’T ANSWER 0-30, FILL WITH 99]
B3. [IF B2=1 to 30] During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?
1 Fewer than 5 cigarettes
2 5-9 cigarettes
3 10 cigarettes (1/2 a pack)
4 11-19 cigarettes (more than 1/2 pack but less than 1 pack)
5 20 cigarettes (1 pack)
6 30 cigarettes (1 ½ packs)
7 40 cigarettes (2 packs)
8 More than 40 cigarettes (more than 2 packs)
9 Prefer not to answer
B4. [IF B2=1 to 30] On the days that you smoke, how soon after you wake up do you have your first cigarette? Would you say…
1 Within 5 minutes
2 6-30 minutes
3 31-60 minutes
4 After 60 minutes
9 Prefer not to answer
B5. [IF B2=1 to 30] Do you consider yourself a smoker?
1 Yes
2 No
9 Prefer not to answer
B6. [IF B2=1 to 30] Do you consider yourself a social smoker?
1 Yes
2 No
9 Prefer not to answer
B7. [IF B1=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
B8. [IF B1=1 AND B2=0 OR 99] About how long has it been since you last smoked cigarettes?
1 More than 30 days ago but within the past 3 months
2 More than 3 months ago but within the past 12 months
3 More than 12 months ago but within the past 3 years
4 More than 3 years ago
9 Prefer not to answer
B9. Have you ever used smokeless tobacco, such as chewing tobacco, snuff, snus (rhymes with goose) or dip, such as Copenhagen, Skoal, Grizzly, Kodiak, and Red Seal even just a small amount?
1 Yes
2 No
9 Prefer not to answer
B10. [IF B9=1] During the past 30 days, on how many days did you use chewing tobacco, snuff, snus or dip?
1 0 days
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days or
7 All 30 days
9 Prefer not to answer
B11. Have you ever smoked cigars, cigarillos, or little cigars such as Swisher Sweets, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s, even one or two puffs?
1 Yes
2 No
9 Prefer not to answer
[IF B11=1, ASK B12]
B12. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars such as Swisher Sweets, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s?
1 0 days
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days or
7 All 30 days
9 Prefer not to answer
B13. Have you ever tried smoking tobacco out of a water pipe (also called “hookah”)?
1 Yes
2 No
9 Prefer not to answer
[IF B13=1, ASK B14]
B14. During the past 30 days, on how many days did you smoke tobacco out of a water pipe (also called “hookah”)?
1 0 days
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days or
7 All 30 days
9 Prefer not to answer
B
15. These
are examples of electronic nicotine products: e-cigarettes,
e-cigars, e-hookahs, epipes, vape pens, hookah pens and personal
vaporizers. These products are battery-powered, use nicotine fluid
rather than tobacco leaves, and produce vapor instead of smoke. Some
common brands include Fin, NJOY, Blu, e-Go and Vuse. Have you ever
tried these products, even once or twice?
1 Yes
2 No
9 Prefer not to answer
B16. [IF B15=1] During the past 30 days, on how many days did you use electronic nicotine products, such as “e-cigarettes”, “e-cigs”, “vapor pens”, or “e-hookahs”?
1 0 days
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days or
7 All 30 days
9 Prefer not to answer
B17. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?
1 0 days
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days
7 All 30 days
9 Prefer not to answer
Section C: Tobacco Use Intentions and Self-Efficacy
C1. [IF B1=2] Thinking about the future…
|
|
|
|
|
|
|
C1_1. |
Do you think that you will try a cigarette soon? |
1 |
2 |
3 |
4 |
9 |
C1_2. |
Do you think you will smoke a cigarette at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_3. |
If one of your best friends were to offer you a cigarette, would you smoke it? |
1 |
2 |
3 |
4 |
9 |
C2. How sure are you that, if you really wanted to, you could avoid smoking cigarettes if…
[RANDOMIZE C2_1-C2_5]
|
|
|
|
|
|
|
|
C2_1. You are at a party, bar or club? |
1 |
2 |
3 |
4 |
5 |
9 |
|
C2_2. You are in a place where most people are smoking? |
1 |
2 |
3 |
4 |
5 |
9 |
|
C2_3. Someone you know offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
|
C2_4. Someone you want to get to know offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
|
C2_5. Someone offers it to take a break? |
1 |
2 |
3 |
4 |
5 |
9 |
|
Section D: Cessation (Intention, Behavior, Motivation)
Cigarette Use
D1. [IF B2=1-30] How much do you want to stop smoking for good? Would you say…?
1 Not at all
2 A little
3 Somewhat
4 A lot
9 Prefer not to answer
D2. [IF B2=1-30] How much do you think your health would improve if you were to stop smoking for good?
1 Not at all
2 A little
3 Somewhat
4 A lot
9 Prefer not to answer
D3. [IF B2=1-30] How worried are you that smoking will damage your health in the future?
1 Not at all worried
2 A little worried
3 Somewhat worried
4 Very worried
9 Prefer not to answer
D4. [IF B2=1-30] How worried are you that smoking will damage your physical appearance or attractiveness?
1 Not at all worried
2 A little worried
3 Somewhat worried
4 Very worried
9 Prefer not to answer
[Ask ALL]
Section E: Attitudes, Beliefs & Risk Perceptions, Social Norms
The next set of questions asks for your opinions on cigarette use and other tobacco products.
Attitude
E1. How much do you agree or disagree with the following statements about people who are tobacco-free?
[RANDOMIZE ALL ROWS]
|
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree |
Agree |
Strongly Agree |
|
E1_1. |
People who are tobacco-free are confident. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_2. |
People who are tobacco-free are trendsetting. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_3. |
People who are tobacco-free are happy. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_4. |
People who are tobacco-free are judgmental. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_5. |
People who are tobacco-free are attractive. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_6. |
People who are tobacco-free are basic. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_7. |
People who are tobacco-free are boring. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_8. |
People who are tobacco-free are predictable. |
1 |
2 |
3 |
4 |
5 |
9 |
E2. Smoking cigarettes is… (pick one)
[RANDOMIZE E2_1-E2_2]
E2_1. |
Bad |
|
|
|
|
|
|
|
Good |
E2_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
E3A. [IF B1= 2 OR B2= 0 AND B9=2 OR B10= 1 AND B11= 2 OR B12= 1 AND B13= 2 OR B14= 1 AND B15= 2 OR B16= 1]
How much do you agree or disagree with the following statements?
[RANDOMIZE E3A_1-E3A_5]
|
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree |
Agree |
Strongly Agree |
|
E3A_1. |
I am proud to live tobacco-free. |
1 |
2 |
3 |
4 |
5 |
9 |
E3A_2. |
Living tobacco-free is important to me. |
1 |
2 |
3 |
4 |
5 |
9 |
E3A_3. |
Tobacco use is harmful to the LGBT community. |
1 |
2 |
3 |
4 |
5 |
9 |
E3A_4. |
Being tobacco free when I go out makes me feel excluded. |
1 |
2 |
3 |
4 |
5 |
9 |
E3A_5. |
Using tobacco makes life harder. |
1 |
2 |
3 |
4 |
5 |
9 |
E3B. [IF B2 NE 0 OR B10 NE 1 OR B12 NE 1 OR B14 NE 1 OR B16 NE 1]
How much do you agree or disagree with the following statements?
[RANDOMIZE E3B_1-E3B_7]
|
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree |
Agree |
Strongly Agree |
|
E3B_1. |
I would be proud to live tobacco-free. |
1 |
2 |
3 |
4 |
5 |
9 |
E3B_2. |
Living tobacco-free is important to me. |
1 |
2 |
3 |
4 |
5 |
9 |
E3B_3. |
If I lived tobacco-free I would be proud to tell other people. |
1 |
2 |
3 |
4 |
5 |
9 |
E3B_4. |
Using tobacco interferes with my life. |
1 |
2 |
3 |
4 |
5 |
9 |
E3B_5. |
Tobacco use is harmful to the LGBT community. |
1 |
2 |
3 |
4 |
5 |
9 |
E3B_6. |
If I was tobacco free I would feel excluded when I go out. |
1 |
2 |
3 |
4 |
5 |
9 |
E3B_7. |
Using tobacco makes life harder. |
1 |
2 |
3 |
4 |
5 |
9 |
E4. How much do you agree or disagree with the following statements? If I smoke cigarettes every day, I will…
[RANDOMIZE ROWS]
|
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree |
Agree |
Strongly Agree |
|
E4_1. |
Shorten my life |
1 |
2 |
3 |
4 |
5 |
9 |
E4_2. |
Be able to stop smoking when I want to |
1 |
2 |
3 |
4 |
5 |
9 |
E4_3. |
Damage my immune system |
1 |
2 |
3 |
4 |
5 |
9 |
E4_4. |
Turn off potential partners |
1 |
2 |
3 |
4 |
5 |
9 |
E4_5. |
Damage my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E4_6. |
Damage my skin |
1 |
2 |
3 |
4 |
5 |
9 |
E4_7. |
Develop lung cancer |
1 |
2 |
3 |
4 |
5 |
9 |
Social Norms
E5. How many of your four closest friends…
|
|
0 None |
1 One |
2 Two |
3 Three |
4 Four |
9 |
E5_1. |
Smoke cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
E5_2. |
Use a hookah or water pipe to smoke tobacco? |
0 |
1 |
2 |
3 |
4 |
9 |
E5_3. |
Use electronic nicotine products such as “e-cigarettes”, “e-cigs”, “vapor pens”, or “e-hookahs”?
Common
brands are Blu, Njoy, Logic, Fin, Swisher, 21st
Century Smoke, Vuse, Markten, V2 |
0 |
1 |
2 |
3 |
4 |
9 |
E6. How many LGBT people who are your age...
|
|
None |
A few |
Some |
Most |
All |
|
E6_1. |
Smoke cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
E6_2. |
Use a hookah or water pipe to smoke tobacco? |
0 |
1 |
2 |
3 |
4 |
9 |
E6_3. |
Use electronic nicotine products such as “e-cigarettes”, “e-cigs”, “vapor pens”, or “e-hookahs”?
Common
brands are Blu, Njoy, Logic, Fin, Swisher, 21st
Century Smoke, Vuse, Markten, V2 |
0 |
1 |
2 |
3 |
4 |
9 |
E7. How do LGBT people your age feel about cigarette smoking? Would you say most LGBT people your age...
2 Strongly disapprove
3 Somewhat disapprove
4 Neither approve nor disapprove
4 Somewhat approve
4 Strongly approve
9 Prefer not to answer
E8. Compared to 3 months ago, people my age at LGBT bars, clubs and events are smoking...
1 More often
2 Less often
3 About the same
4 Not sure
9 Prefer not to answer
Perceived Approval
E9. How much do you agree or disagree with the following statements?
[RANDOMIZE E9_1-E9_3]
|
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree |
Agree |
Strongly Agree |
|
E9_1. |
According to my friends, it is very important for me to not smoke cigarettes. |
1 |
2 |
3 |
4 |
5 |
9 |
E9_2. |
According to most people who hang out where I hang out, it is very important for me to not smoke cigarettes. |
1 |
2 |
3 |
4 |
5 |
9 |
E9_3. |
According to people my age in LGBT communities it is very important for me to not smoke cigarettes. |
1 |
2 |
3 |
4 |
5 |
9 |
E10. How much do you agree or disagree with the following statements? If I only smoke cigarettes on some days (for example, smoking only when I go out), I will…
[RANDOMIZE ROWS]
|
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree |
Agree |
Strongly Agree |
|
E10_1. |
Shorten my life |
1 |
2 |
3 |
4 |
5 |
9 |
E10_2. |
Be able to stop smoking when I want to |
1 |
2 |
3 |
4 |
5 |
9 |
E10_3. |
Damage my immune system |
1 |
2 |
3 |
4 |
5 |
9 |
E10_4. |
Turn off potential partners |
1 |
2 |
3 |
4 |
5 |
9 |
E10_5. |
Damage my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E10_6. |
Damage my skin |
1 |
2 |
3 |
4 |
5 |
9 |
E10_7. |
Develop lung cancer |
1 |
2 |
3 |
4 |
5 |
9 |
APPROVAL OF SMOKING
E11. This next set of questions asks about how willing or unwilling you are to do things with people who smoke cigarettes. Would you:
|
|
Definitely Yes |
Probably Yes |
Probably Not |
Definitely Not |
|
E11_1. |
Go to a bar, club, party, concert or event where people are smoking cigarettes? |
1 |
2 |
3 |
4 |
9 |
E11_2. |
Hang out with someone who smokes cigarettes? |
1 |
2 |
3 |
4 |
9 |
E11_3. |
Dance with someone who smokes cigarettes? |
1 |
2 |
3 |
4 |
9 |
E11_4. |
Kiss someone who smokes cigarettes? |
1 |
2 |
3 |
4 |
9 |
E11_5. |
Date someone who smokes cigarettes? |
1 |
2 |
3 |
4 |
9 |
E12. How much do you agree or disagree with the following statements about smoking cigarettes?
|
|
|
|
|
|
|
|
E12_1. |
It is safe for me to smoke for only a year or two, as long as I quit after that. |
1 |
2 |
3 |
4 |
5 |
9 |
E12_2. |
If I started to smoke occasionally I would not become addicted. |
1 |
2 |
3 |
4 |
5 |
9 |
E12_3. |
Smoking cigarettes helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
E12_4. |
Cigarette ingredients are harmful. |
1 |
2 |
3 |
4 |
5 |
9 |
E12_5. |
Cigarette ingredients are dangerous. |
1 |
2 |
3 |
4 |
5 |
9 |
E12_6. |
Smoking is a way to show my identity to others. |
1 |
2 |
3 |
4 |
5 |
9 |
E12_7. |
Smoking cigarettes can help keep your weight down. |
1 |
2 |
3 |
4 |
5 |
9 |
E12_8. |
Smoking can cause damage to nearly every part of your body. |
1 |
2 |
3 |
4 |
5 |
9 |
E12_9. |
Smoking weakens your immune system. |
1 |
2 |
3 |
4 |
5 |
9 |
Section F: Media Use and Awareness
Next, we’d like to ask you about your use of TV and other media.
F1. How often do you…
|
Several times a day |
About Once a Day |
3-5 days a week |
1-2 days a week |
Every few weeks |
Less often |
Never |
Prefer Not to Answer |
F1_1. Watch TV shows or movies on any platform including a TV set, a computer, laptop or tablet, a smartphone or an iPod or MP3 player? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_2. Watch videos on YouTube? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_3. Listen to streaming radio? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2. Thinking about the social networking sites you use. About how often do you visit or use…
[RANDOMIZE ALL]
|
Several times a day |
About Once a Day |
3-5 days a week |
1-2 days a week |
Every few weeks |
Less often |
Never |
Prefer Not to Answer |
F2_1. Facebook |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_2. Instagram |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_3. Twitter |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_4. Tumblr |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_5. Snapchat |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3. Thinking about the following websites. About how often do you visit or use…
[RANDOMIZE ALL]
|
Several times a day |
About Once a Day |
3-5 days a week |
1-2 days a week |
Every few weeks |
Less often |
Never |
Prefer Not to Answer |
F3_1. Queerty http://www.queerty.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_2. Logo TV http://www.logotv.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_3. Out http://www.out.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_4. Autostraddle http://www.autostraddle.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_5. After Ellen http://www.afterellen.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_6. Gay.com http://www.gay.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F4. How often do you go to concerts, live shows, or other events at a store, local stage, community center, or music venue?
1 Once a week or more often
2 One or two times a month
3 Once every two or three months
4 One or two times a year
5 I do not attend concerts, live shows, or other events
9 Prefer not to answer
F5. In the past 30 days, on how many days did you go to an LGBT party, night, bar, club, or event?
1 0 days
2 1-3 days
3 4-6 days
4 7 or more days
5 Don’t remember how many days
9 Prefer not to answer
F6. How many LGBT celebrities, athletes, musicians, or artists do you follow on social media (e.g. Laverne Cox, Tegan & Sara, Ruby Rose, Angel Haze)?
1 0
2 1-2
3 3-4
4 5 or more
9 Prefer not to answer
Section G: Environment
The next section asks some questions about your household and peers.
G1. Other than you, has anyone who lives with you used any of the following during the past 30 days…? Check all that apply.
1 cigarettes
2 cigars, cigarillos, or little cigars such as Swisher Sweets, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s
3 tobacco out of a water pipe (also called “hookah”)
4 No, no one who lives with me has used any form of tobacco during the past 30 days
9 Prefer not to answer
G2. How often do you attend church or religious services? Would you say…
1 Never
2 Less than once a month
3 About once a month
4 About 2 or 3 times a month
5 Once a week
6 More than once a week
9 Prefer not to answer
Please tell us if you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree with the following statements.
G3. I would like to explore strange places. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree
4 Agree
5 Strongly Agree
9 Prefer not to answer
G4. I like to do frightening things. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree
4 Agree
5 Strongly Agree
9 Prefer not to answer
G5. I like new and exciting experiences, even if I have to break the rules. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree
4 Agree
5 Strongly Agree
9 Prefer not to answer
G6. I prefer friends who are exciting and unpredictable. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree
4 Agree
5 Strongly Agree
9 Prefer not to answer
G7. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
_____ Number of days (1-30)
2 None
3 Don’t know
9 Prefer not to answer
G8. In the last month, how often have you
|
|
|
|
|
|
|
|
G8_1. |
Felt that you were unable to control the important things in your life. |
1 |
2 |
3 |
4 |
5 |
9 |
G8_2. |
Felt confident about your ability to handle your personal problems. |
1 |
2 |
3 |
4 |
5 |
9 |
G8_3. |
Felt that things were going your way. |
1 |
2 |
3 |
4 |
5 |
9 |
G8_4. |
Felt difficulties were piling up so high that you could not overcome them. |
1 |
2 |
3 |
4 |
5 |
9 |
Section H: LGBT Identity and Community
Discrimination
H1. Have you ever experienced discrimination, been prevented from doing something, or been hassled or made to feel inferior in any of the following seven situations because of your sexual identity (lesbian, gay, bisexual, transgender)?
|
|
1 Yes |
2 No |
9 Prefer not to answer |
H1_1. |
In your family |
1 |
2 |
9 |
H1_2. |
At school |
1 |
2 |
9 |
H1_3. |
Getting a job |
1 |
2 |
9 |
H1_4. |
At work |
1 |
2 |
9 |
H1_5. |
At home |
1 |
2 |
9 |
H1_6. |
Getting medical care |
1 |
2 |
9 |
H1_7 |
On the street or in a public setting |
1 |
2 |
9 |
LGBT Community Involvement
H2_1. Have you ever attended an LGBT pride event?
1 Yes
2 No
9 Prefer not to answer
H2_2. [IF H2_1= 1] Have you attended an LGBT pride event in the past 12 months?
1 Yes
2 No
9 Prefer not to answer
LGBT Identity Development
H3. For each of the following questions, please mark the response that best
indicates your current experience as an LGBT person. Please be as honest as possible: Indicate how you really feel now, not how you think you should feel. There is no need to think too much about any one question. Answer each question according to your initial reaction and then move on to the next.
|
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree (Neutral) |
Agree |
Strongly Agree |
|
H3_1. |
I am glad to be an LGBT person. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_2. |
My sexual identity is an insignificant part of who I am. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_3. |
I’m proud to be part of the LGBT community. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_4. |
My sexual identity is a central part of my identity. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_5. |
To understand who I am as a person, you have to know that I’m LGBT. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_6. |
Being an LGBT person is a very important aspect of my life. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_7. |
I believe being LGBT is an important part of me. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_8. |
I am proud to be LGBT. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_9. |
I feel part of the LGBT community. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_10. |
I feel accepted by the LGBT community. |
1 |
2 |
3 |
4 |
5 |
9 |
WEBTH Within 2 business days, we will send an email containing information about how to access and redeem your digital gift card. This information must be sent via email to the email address you supplied before starting this survey.
RECON Thank you for your responses! We will be conducting additional rounds of this survey. The next round will take place in about 6 months. Your participation in these next rounds is really important so that we can measure what has changed over time. When we contact you again via email or text message in the future, you will be able to decide if you want to take part in the survey at that time, and you can change your mind at any point.
NEXT
Thank you for taking time to complete this survey. You may close this window now.
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 30 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
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Pamela Rao* |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |
© 2024 OMB.report | Privacy Policy