Form Approved
OMB No. 0910-0753
Exp. Date XX/XX/XXXX
Evaluation of the Public Education Campaign on Teen Tobacco-Media Tracking (ExPECTT-MT)
Study Screener (Email invitation to pre-selected parents from existing panel)
Greetings!
We have a new survey and your participation is requested. The survey is meant for children (males/females) ages 13-17. If [he/she] qualifies and completes, your Global Test Market account will be credited with the Market Points stated in the invitation.
Best Regards –
Global Test Market Team
Study Introduction
Thank you for agreeing to take part in this survey. The survey will take approximately 30 minutes to complete. You will be asked various questions about your experiences with tobacco products, media use, as well as questions about your background. Even if you do not use tobacco products, the information you provide will still be very important.
Your responses will be keptprivate to the fullest extent allowed by law, and neither your name nor other personal information will be associated with your responses. The data collected for this study will be combined with that of all participants before it is analyzed. At the end of the survey, a link will take you to the GMI website to collect your MarketPoints.
If you have any questions about this study, you can call Jane Allen, at 1-800-334-8571 extension 25115 or send email to jallen@rti.org. If you have any questions about your rights as a study participant, you can call RTI's Human Research Protections Office at 1-866-214-2043 or send email to orpe@rti.org.
I have read and understand this information, and the study purpose and process are clear to me.
Yes, I agree to participate in this study
No, I do not wish to participate in this study
S1. How old are you?
1 11 years old or younger (GO TO CLOSING TEXT)
2 12 years old (GO TO CLOSING TEXT)
3 13 years old (GO TO A1)
4 14 years old (GO TO A1)
5 15 years old (GO TO A1)
6 16 years old (GO TO A1)
7 17 years old (GO TO A1)
8 18 years old or older (GO TO CLOSING TEXT)
9 Prefer not to answer (GO TO CLOSING TEXT)
CLOSING TEXT “You do not qualify for this survey, which is for children ages 13 to 17. Thank you very much for your response.“
C1. Are you male or female?
1 Female
2 Male
9 Prefer not to answer
C2. Are you Hispanic, Latino/a, or of Spanish origin?
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
C3. What race or races do you consider yourself to be? Please select 1 or more of these categories.
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1 |
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C3_1. White |
1 |
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C3_2. Black or African American |
1 |
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C3_3. American Indian or Alaska Native |
1 |
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C3_4. Asian Indian |
1 |
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C3_5. Chinese |
1 |
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C3_6. Filipino |
1 |
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C3_7. Japanese |
1 |
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C3_8. Korean |
1 |
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C3_9. Vietnamese |
1 |
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C3_10. Native Hawaiian |
1 |
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C3_11. Guamanian or Chamorro |
1 |
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C3_12. Samoan |
1 |
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C3_13. Other Asian |
1 |
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C3_14. Other Pacific Islander |
1 |
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OMB No: 0910-0753 Expiration Date: xx/xx/xxxx
Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 2 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 |
| File Title | [Insert Title of Information Collection] |
| Author | jcapezzu |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |