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

Check-In Survey
Please fill out this survey. Any information you share about
your attitudes, beliefs, and behaviors will be private. No one
outside of the research team will know what you write. There
are no right or wrong answers to these questions.
Read the instructions for each question carefully and let us
know if you have any questions.
Thank you very much for your help.

OMB# 0910-0497

 Exp. 10/31/2020
RIHSC #

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to

average 15 minutes per response to complete the Check-In Survey (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.

Unique ID:____________

PERSONALITY & VALUES

INSTRUCTIONS: For each question, fill in one bubble to indicate the answer you select.
Please fill in your selected responses like this:

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1. How much do you agree with each of the
following statements?
Please fill in one bubble for each row below.

Strongly
Disagree
Disagree

Neither
Agree or
Disagree

Agree

Strongly
Agree

a.

I care about the responsible use of our natural
resources, like wood, water, and food.

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b.

When I’m with other people my age, it is
important for me to show pride in my Native
culture.

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c.

I spend a lot of time finding ways to feel
connected to the larger Native community.

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d.

I am a religious person.

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e.

I am always fighting to be in control of my life.

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f.

I am tougher than most people.

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g.

I use my clothes to express my identity.

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h.

I go out of my way to support local music and
artists.

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i.

I feel like I have to work hard than other people
my age to achieve my goals.

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j.

I care about being fashionable.

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k.

I believe family is one of the most important
things in life.

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l.

I like making decisions quickly, without
spending too much time thinking over them.

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m.

Ensuring that I live a long and healthy life is a
top priority for me.

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n.

I care about keeping my body free from toxins
and unhealthy substances.

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o.

I consider myself spiritual.

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p.

I feel like other people sometimes hold me
back from reaching my goals.

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q.

I have to regularly avoid physical danger
around me.

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1

Unique ID:____________

(CONTINUED) 1. How much do you agree with
each of the following statements?
Please fill in one bubble for each row below.

Strongly
Disagree

Disagree

Neither
Agree or
Disagree

Agree

Strongly
Agree

r.

I think it is more important to live in the
moment than to think about the future.

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s.

I care about having a good reputation.

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t.

I enjoy things that some teens would describe
as weird.

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u.

I try to always follow the rules.

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v.

I want to be a good student at school.

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w.

I like to join clubs and other after school
opportunities.

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x.

I care a lot about what other people think of
me.

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y.

I am a social person with lots of friends.

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z.

I make it a priority to spend time in nature.

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aa. I like being the center of attention.

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bb. Following tradition is important to me.

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2. Choose the phrase that best describes you by filling in one bubble for each row.

a.

b.

c.

d.

e.

f.

g.

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Up for anything

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Low key

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Center of attention

OR

OR

OR

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OR

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OR

Street smart

Studier

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Plan it out

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The carefree one

OR

OR

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Picks & chooses what to do

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Outgoing

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Lay low

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Book smart

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Partier

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Wing it

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The responsible one

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Unique ID:____________

3. In an average week, on how many nights do you go out to have fun?

Nights:

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0

1

2

3

4

5

6

7

4. Please tell us if you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree with
the following statements:
How much do you agree with each of the
following statements?

Strongly
Disagree
Disagree

Neither
Agree or
Disagree

Agree

Strongly
Agree

a.

I would like to explore strange places.

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b.

I like to do frightening things.

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c.

I like new and exciting experiences, even if
I have to break the rules.

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d.

I prefer friends who are exciting and
unpredictable.

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3

Unique ID:____________

5) RANK THE 3 PEOPLE THAT

Rank #1:

WOULD BEST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE BEST FIT.

Rank #2:

6) RANK THE 3 PEOPLE THAT
WOULD LEAST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE WORST
FIT.

Rank #3:

Rank #1:
Rank #2:
Rank #3:

1

2

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Unique ID:____________

7) RANK THE 3 PEOPLE THAT
WOULD BEST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE BEST FIT.

Rank #1:

8) RANK THE 3 PEOPLE THAT
WOULD LEAST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE WORST
FIT.

Rank #2:
Rank #3:

Rank #1:
Rank #2:
Rank #3:

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70

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Unique ID:____________

HEALTH & WELLNESS

9. For the following questions, please fill in YES or NO for each row:
Have you EVER…
Tried smoking cigars, cigarillos, or little cigars, such as Black and Milds, Swisher
Sweets, Dutch Masters, White Owl, or Phillies Blunts, even one or two puffs?

a.

b. Tried smoking tobacco from a hookah or waterpipe, even one or two puffs?
Tried smokeless tobacco, such as snus pouches, moist snuff, dip, spit, or chewing
tobacco?

c.

10. How old were you when you first tried
cigarette smoking, even one or two puffs?

Yes

No

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11. For the following questions, please fill in YES or
NO for each row:

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I have never tried cigarette smoking,
not even one or two puffs

During the PAST 30 DAYS, have
you personally …

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8 years old or younger

a.

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9 or 10 years old

b.

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11 or 12 years old

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13 or 14 years old

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15 or 16 years old

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17 years old or older

Yes

No

Smoked cigars, cigarillos, or
little cigars?

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Smoked tobacco from a
hookah or waterpipe?

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c. Used smokeless tobacco?

12. For the following questions, please fill in ONE bubble in each row.
How many of your best friends:

None

A Few

Some

Most

All

a.

Smoke cigarettes

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b.

Smoke cigars, cigarillos, or little cigars

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c.

Use electronic cigarettes, e-cigarettes,
vape pens, or hookah pens

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d.

Smoke tobacco from a hookah or waterpipe

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e.

Use smokeless tobacco

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PAGE 7 FOR NON-ALASKA FGs ONLY
Unique ID:____________

13. For the following questions, please fill in ONE bubble in each row.
How likely is someone to become addicted to:

Very
Unlikely
Unlikely

Neutral

Likely

Very
LIkely

a.

Cigarettes

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b.

Cigars, cigarillos, or little cigars

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c.

Electronic cigarettes, e-cigarettes, vape
pens, or hookah pens

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d.

Hookah or waterpipe

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e.

Smokeless tobacco

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14. For the following questions, please fill in ONE bubble in each row.
How much do you think people harm themselves
when they:

No
Harm

Little
Harm

Neutral

Some
Harm

A lot of
Harm

a.

Smoke cigarettes

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b.

Smoke cigars, cigarillos, or little cigars

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c.

Use electronic cigarettes, e-cigarettes,
vape pens, or hookah pens

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d.

Smoke tobacco from a hookah or
waterpipe

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e.

Use smokeless tobacco

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15. Not including yourself, does anyone who lives with
you now do any of the following?

(Fill in the bubbles for ALL that apply)

16a. Have you ever used tobacco for ceremonial
prayer or traditional reasons?

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Yes

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No one who lives with me now uses any form of
tobacco

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No

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Smoke cigarettes

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Don’t Know/Not sure

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Smoke cigars, cigarillos, or little cigars

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Smoke tobacco from a waterpipe or hookah

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I never use tobacco this way

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Use smokeless tobacco

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Daily

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Use any other form of tobacco

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Weekly

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Monthly

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A few times a year or less

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16b. How often do you use tobacco for ceremonial
prayer or traditional reasons?

PAGE 7 FOR ALASKA FGs ONLY
Unique ID:____________

13. For the following questions, please fill in ONE bubble in each row.
How likely is someone to become addicted to:

Very
Unlikely
Unlikely

Neutral

Likely

Very
LIkely

a.

Cigarettes

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b.

Cigars, cigarillos, or little cigars

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c.

Electronic cigarettes, e-cigarettes, vape
pens, or hookah pens

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d.

Hookah or waterpipe

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e.

Smokeless tobacco

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14. For the following questions, please fill in ONE bubble in each row.
How much do you think people harm themselves
when they:

No
Harm

Little
Harm

Neutral

Some
Harm

A lot of
Harm

a.

Smoke cigarettes

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b.

Smoke cigars, cigarillos, or little cigars

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c.

Use electronic cigarettes, e-cigarettes,
vape pens, or hookah pens

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d.

Smoke tobacco from a hookah or
waterpipe

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e.

Use smokeless tobacco

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15. Not including yourself, does anyone who lives with
you now do any of the following?

(Fill in the bubbles for ALL that apply)

16. Have you ever used iqmik, even one time?

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Yes

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No one who lives with me now uses any form of
tobacco

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No

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Smoke cigarettes

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Don’t Know/Not sure

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Smoke cigars, cigarillos, or little cigars

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Smoke tobacco from a waterpipe or hookah

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Use smokeless tobacco

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Use any other form of tobacco

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Unique ID:____________

MEDIA USE & INTERESTS
17. For each social media platform below, please answer the questions about what you have done in the
PAST 7 DAYS:
a. Have you done this in the past 7 days on FACEBOOK?

Yes

No

Consumed content (e.g., Watched a video, clicked on an article, or clicked through
photo albums, viewed your home page, scrolled through your newsfeed)

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Created or interacted with content (e.g., Posted, shared a post, liked a post,
commented on a post)

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Yes

No

Consumed content (e.g., Watched a video, clicked out to an article, scrolled through
feed)

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Created or interacted with content (e.g., Liked, commented on, shared or reposted a
post)

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Yes

No

Consumed content (e.g., Read tweets, looked through a Twitter profile, clicked out to an
article or video)

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Created content (e.g., Tweeted, liked, commented, shared or re-tweeted)

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Yes

No

Consumed content (e.g., Watched a video, scrolled through a page, clicked on an
article, looked at images)

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Created content (e.g., Liked, commented, posted, reblogged)

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Yes

No

Consumed content (e.g., Watched a story)

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Created content (e.g., Posted a Snap story, sent a Snap to someone else)

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Yes

No

Consumed content (e.g., Viewed a pinboard, bookmarked an idea or product)

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Created content (e.g., Made a pinboard, pinned an idea or product, upload an idea or
product)

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b. Have you done this in the past 7 days on INSTAGRAM?

c. Have you done this in the past 7 days on TWITTER?

d. Have you done this in the past 7 days on TUMBLR?

e. Have you done this in the past 7 days on SNAPCHAT?

f. Have you done this in the past 7 days on PINTEREST?

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Unique ID:____________

18. Which of these influencers or accounts do you follow on social media? (e.g., Instagram, Twitter,
Facebook, Snapchat, etc.,) (Fill in the bubbles for ALL that apply)

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Gigi & Bella Hadid

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Roman Atwood

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Kendall and Kylie Jenner

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Dude perfect

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Zendaya

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NuggetNoggin

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Shawn Mendes

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Outlaw

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Baby Ariel

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Logan Paul

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Connor Franta

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Casey Nestat

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King Bach

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Smosh

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Amanda Steele

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Funny or Die

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Justin Bieber

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Boonk Gang

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Hailey Baldwin

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Charlamagne Tha God

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Jaden Smith

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DJ Akademiks

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Brooklyn Beckham

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Cardi B

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Bryan Stars

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King Imprint

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Eugenia Cooney

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A Tribe Called Red

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Social Repose

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PewDiePie

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Andy Biersack

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Onision

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Ryan Upchurch

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Live2Thrill

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Redneck Nation

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Mudjug1

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Ride Channel

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Other: _______________

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Maxwell Ren

Other: _______________

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Markiplier

Other: _______________

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Unique ID:____________

19. Which of the following music artists, if any, would you say you listen to regularly?

(Fill in the bubbles for ALL that apply)

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21 Savage

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Shawn Mendes

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P!nk

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Big and Rich

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Slipknot

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Portugal. The Man

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Black Veil Brides

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Taylor Swift

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A Tribe Called Red

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Camila Cabello

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The Chainsmokers

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Sam Hunt

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Cardi B

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Chance the Rapper

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Trippie Redd

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Coldplay

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Zayn Malik

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Alessia Cara

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Demi Lovato

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Lorde

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Julia Michaels

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Ed Sheeran

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Adele

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Miguel

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Florida Georgia Line

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Beyonce

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Dua Lipa

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Justin Bieber

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Selena Gomez

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Charlie Puth

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Kelsea Ballerini

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Ariana Grande

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Thomas Rhett

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Khalid

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Logic

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Twenty One Pilots

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Imagine Dragons

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Post Malone

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Kendrick Lamar

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Drake

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Fifth Harmony

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Miley Cyrus

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Blackbear

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The Weeknd

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Other:_______________

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Cold War Kids

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Maroon 5

Other:_______________

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Kodak Black

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Migos

Other:_______________

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Sam Smith

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Niall Horan

10

Unique ID:____________

20. Which of the following types of events, if any, would you say you regularly attend?
(Fill in the bubbles for ALL that apply)

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Art exhibits

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Football games

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Comic conventions

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Auto races

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High school band
performances

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Mixed martial arts/
wrestling events

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Baseball games

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High school dances

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Academic/Quiz Event

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Basketball games

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Monster truck rallies

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Student Government/
Model UN

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Cheerleading
competitions

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Mudding competitions

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Car/truck show

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Church events

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Rap battles

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Political Rally/event

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Community service
events

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Rodeos/Bull Riding

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Fashion Show

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Concerts or music
festivals – country

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Science fairs

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Fundraiser/Charity Event

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Concerts or music
festivals – hip hop

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Skateboarding
competitions

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Film Festival

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Concerts or music
festivals – pop

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Soccer games

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Theatre/Musical

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Concerts or music
festivals – rock

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Talent showcases

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Other: _______________

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Concerts or music
festivals – other

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Video game
tournaments

Other: _______________

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Dance clubs

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Video game
tournaments

Other: _______________

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Farmers markets

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Snowboarding
competitions

21. In the PAST 12 MONTHS have you participated in a cultural or traditional Native event?

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Yes

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No

HOMETOWN ENVIRONMENT

22. Please describe where you CURRENTLY live:

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I currently live on a reservation

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I do not currently live on a reservation

23. Please write in the 5-digit zip code where you CURRENTLY live: __ __ __ __ __

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