Developing Strategic Concepts Designed to Prevent AI/AN Youth Tobacco Use

Screener

We are looking for teens to take part in an upcoming discussion group. If you
are selected and agree to take part, you will receive $25 as a thank you for
participating. Your parent, or an adult that drives you will receive $25. Please
answer a few personal questions on the following pages to see if you qualify.
We will let you know in the next few days if you were selected. If so, you will
be asked to attend a 90 minute discussion group nearby.
There are no right or wrong answers, and only the researchers will know how
you answer these questions, so please be honest in your responses. You
don’t have to answer any question you don’t want to answer.

OMB# 0910-0497
Exp. 10/31/2020
RIHSC #

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First Name:

Last Name:

Cell Phone:

Home Phone:

Email:

4. Do you think that you will smoke a
cigarette soon?

1. How old are you?
a. 11 years old or younger

a. Definitely yes

b. 12 years old

b. Probably yes

c. 13 years old

c. Probably not

d. 14 years old

d. Definitely not

e. 15 years old
f. 16 years old
g. 17 years old

5. Do you think that you will smoke a
cigarette in the next year?

h. 18 years old or older

a. Definitely yes
b. Probably yes

[Not visible to participant] Recruiter:

c. Probably not

If Q1 = 11 yrs. old or younger (a) OR 18 yrs. or
older participant is NOT ELIGIBLE

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

d. Definitely not

a. Yes

[Not visible to
participant]
Recruiter:

b. No

If Q2 = No (b)
AND

3. About how many cigarettes have you
smoked in your entire life? A pack usually
has 20 cigarettes in it.

6. If one of your best friends were to offer
you a cigarette, would you smoke it?
a. Definitely yes
b. Probably yes
c. Probably not

If Q4, Q5, Q6, Q9,
AND Q10 = Definitely
not (d), participant is 

NOT ELIGIBLE

d. Definitely not

a. I have never smoked cigarettes, even one or two
puffs

7. During the past 30 days, on how many
days did you smoke cigarettes?

b. 1 or more puffs but never a whole cigarette

a. 0 days

c. 1 cigarette

b. 1 or 2 days

d. 2 to 10 cigarettes (about ½ pack total)

c. 3 to 5 days

e. 11 to 20 cigarettes (about ½ pack to 1 pack)

d. 6 to 9 days

f. 21 to 50 cigarettes (more than 1 pack but less than
3 packs)

e. 10 to 19 days
f. 20 to 29 days

g. 51 to 99 cigarettes (more than 2 ½ packs but less
than 5 packs)

g. All 30 days

h. 100 or more cigarettes (5 packs or more)
[Not visible to participant] Recruiter:
[Not visible to participant] Recruiter:

If Q7 = All 30 days (g) participant is NOT
ELIGIBLE

If Q3 = 100 cigarettes or more (h) participant
is NOT ELIGIBLE

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8. Have you ever tried smoking electronic
cigarettes, e-cigarettes, vape pens, or
hookah pens, such as Fin, NJOY, JUUL,
Blu, e-Go, or Vuse, even one or two
puffs?

12. What is your sex?
a. Female
b. Male

a. Yes
b. No

13. What race or races do you consider yourself
to be? 

(You can circle more than one)

9. Do you think you will smoke an
electronic cigarette, e-cigarette, vape pen,
or hookah pen soon?

a. American Indian
b. Alaska Native

a. Definitely yes

c. Asian

b. Probably yes
c. Probably not

d. Black or African American

d. Definitely not

e. Native Hawaiian or Other Pacific Islander
f. White

10. Do you think you will smoke an
electronic cigarette, e-cigarette, vape pen,
or hookah pen in the next year?

g. Other

a. Definitely yes

14a. Are you currently an enrolled member of a
Native tribe or village?

b. Probably yes
c. Probably not

a. Yes

d. Definitely not

b. No

11. During the past 30 days, on how many
days did you use an electronic cigarette, ecigarette, vape pen, or hookah pen?

14b. If yes, in which tribes(s) or village(s) are
you a member of?

a. 0 days
b. 1 or 2 days

c. 3 to 5 days

————————————————————
—————————————————————————

d. 6 to 9 days
e. 10 to 19 days
f. 20 to 29 days

[Not visible to participant] Recruiter:

g. All 30 days

If Q13 = American Indian or Alaska Native is not
selected (c-g) 

OR 

If Q14a = No (b) 

OR
If Q14b = blank (no written response) or a non-valid
tribe or village name is provided, participant is NOT
ELIGIBLE

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Contact Information for Parent/Guardian Permission Only (For 12 and 13 year olds)
Parent/Guardian First & Last Name:

Cell Phone:

Home Phone:

Email:

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