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)
AA1. INTERVIEWER, SELECT MARKET AND BAR
PROGRAMMER: DISPLAY MARKETS
AA2. PROGRAMMER: DISPLAY BARS
[GPS COORDINATES CAPTURED AT THIS SCREEN FOR AUTHENTICATION PURPOSES.]
AA2a. PROGRAMMER: DISPLAY BAR ID
AA3.
[INFORMED CONSENT TEXT WILL BE DISPLAYED HERE.]
BEGIN TIME STAMP
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)
A2. What is your age?
___________ (Range: 15 to 80]
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
A4. What sex were you assigned at birth, on your original birth certificate?
1 Female
2 Male
9 Prefer not to answer
[If A3= 1 or 3 (male or trans male) display A5, ELSE display A6]
A5. Which of the following best represents how you think of yourself?
1 Gay
2 Straight, that is, not gay
3 Bisexual
4 Something else
5 I don’t know the answer
9 Prefer not to answer
[If A5= 4, go to A7, if A5= 5 go to A8, else go to A9]
A6. Which of the following best represents how you think of yourself?
1 Lesbian or gay
2 Straight, that is, not lesbian or gay
3 Bisexual
4 Something else
5 I don’t know the answer
9 Prefer not to answer
[If A6= 4, go to A7, if A6= 5 go to A8, else go to A9]
A7. What do you mean by something else?
1 You are not straight, but identify with another label such as queer, trisexual, omnisexual, or pansexual
2 You are transgender, transsexual, or gender variant
3 You have not figured out or are in the process of figuring out your sexuality
4 You do not think of yourself as having sexuality
5 You do not use labels to identify yourself
6 You mean something else (Please state)
9 Prefer not to answer
[All Skip to A9]
A8. 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
A9. Have you attended a LGBT pride event in the past 12 months?
1 Yes
2 No
9 Prefer not to answer
A10. Have you ever tried cigarette smoking, even one or two puffs?
1 Yes
2 No
9 Prefer not to answer
A11. 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
A12. During the past 30 days, on how many days did you smoke cigarettes?
|_|_| days [RANGE: 0-30, 99]
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
Eligibility Criteria
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] THEN ELIGFLAG=1. ELSE ELIGFLAG=2.
In-Person Respondent not eligible due to survey responses
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
[DISPLAY DISPOSITION]
Response has been recorded.
Eligible In-Person Respondents
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
[DISPLAY DISPOSITION]
Response has been recorded.
INTERVIEWER: RETURN TABLET TO RESPONDENT
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.
B2. The survey can be taken on a computer, tablet or on the web on a smart phone, like an iPhone or an Android. How would you prefer to receive the survey link?
1 via email
2 via SMS text message on your smartphone and email
B3. Within the next few days, if you have not previously been invited, we will send you an email or text message 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
LAST Please give the tablet back to the interviewer.
PASS INTERVIEWER: ENTER A PASSWORD TO CONTINUE.
PROGRAMMER: THIS SCREEN CANNOT MOVE FORWARD UNTIL PASSWORD IS ENTERED.
PASSWORD IS EXIT
Response has been recorded.
In-Person Respondent not eligible due to duplicate email address or cell phone number
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 incentive.
AA3. [INFORMED CONSENT TEXT WILL BE DISPLAYED HERE.]
BEGIN TIME STAMP
The first part of the survey asks you some general questions about yourself.
A0. How did you find out about this survey?
1 Facebook ad/Sponsored NewsFeed story
2 Twitter ad/Promoted Tweet
3 Someone sent it to me on Facebook
4 Someone sent it to me on Twitter
5 Someone sent it to me in another way
6 Another way (Specify)
9 Prefer not to answer
A1. What is the 5-digit zip code where you currently live?
__ __ __ __ __ (5-digit, numeric responses only)
A2. What is your age?
___________ (Range: 15 to 80]
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
A4. What sex were you assigned at birth, on your original birth certificate?
1 Female
2 Male
9 Prefer not to answer
[If A3= 1 or 3 (male or trans male) display A5, ELSE display A6]
A5. Which of the following best represents how you think of yourself?
1 Gay
2 Straight, that is, not gay
3 Bisexual
4 Something else
5 I don’t know the answer
9 Prefer not to answer
[If A5= 4, go to A7, if A5= 5 go to A8, else go to A9]
A6. Which of the following best represents how you think of yourself?
1 Lesbian or gay
2 Straight, that is, not lesbian or gay
3 Bisexual
4 Something else
5 I don’t know the answer
9 Prefer not to answer
[If A6= 4, go to A7, if A6= 5 go to A8, else go to A9]
A7. What do you mean by something else?
1 You are not straight, but identify with another label such as queer, trisexual, omnisexual, or pansexual
2 You are transgender, transsexual, or gender variant
3 You have not figured out or are in the process of figuring out your sexuality
4 You do not think of yourself as having sexuality
5 You do not use labels to identify yourself
6 You mean something else (Please state)
9 Prefer not to answer
[All Skip to A9]
A8. 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
A9. Have you attended a LGBT pride event in the past 12 months?
1 Yes
2 No
9 Prefer not to answer
A10. Have you ever tried cigarette smoking, even one or two puffs?
1 Yes
2 No
9 Prefer not to answer
A11. 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
A12. During the past 30 days, on how many days did you smoke cigarettes?
|_|_| days [RANGE: 0-30, 99]
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
Eligibility Criteria
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] THEN ELIGFLAG=1. Else ELIGFLAG=2.
Social Media Respondent not eligible due to survey responses
Thank you for your responses. We have no further questions at this time. Your responses have been recorded.
Eligible Social Media Respondents
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 incentive 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 NOTE: EMAIL ADDRESS WILL BE A REQUIRED FIELD, BUT CELL PHONE NUMBER IS OPTIONAL]
How would you prefer to be contacted?
1 Via email
2 Via SMS text message on your smartphone and email
CONF. Thank you, we will verify your eligibility to continue with the survey now.
Email Address is Eligible.
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.
Ineligible due to duplicate email address
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 will receive a reminder email with the survey link to complete and receive your incentive.
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
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jamie Guillory |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |