Developing Brand & Creative 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.

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to
average 7 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
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Unique ID:____________

1. Have you EVER tried any of the following tobacco products?
Please fill in YES or NO for each row.

Yes

No

a.

Cigars, cigarillos, or little cigars (like Black and Milds, Swisher Sweets, or Dutch
Masters), even one or two puffs

○

○

b.

Hookah or waterpipe, even one or two puffs

○

○

c.

Smokeless tobacco, such as dip, spit, or chewing tobacco (like Redman, Levi
Garrett, Beechnut, Skoal, and Copenhagen)

○

○

d.

Electronic cigarettes, e-cigarettes, mods, personal vaporizers, vape pens, or
hookah pens (like Suorin, Vuse, Blu, JUUL, Logic, NJOY, and eGo), even one or
two puffs

○

○

2. Do you think you will smoke an electronic
cigarette, e-cigarette, mod, personal vaporizer,
vape pen, or hookah pen IN THE NEXT YEAR?

3. Do you think you will smoke an electronic
cigarette, e-cigarette, mod, personal vaporizer,
vape pen, or hookah pen SOON?

○

Definitely Yes

○

Definitely Yes

○

Probably Yes

○

Probably Yes

○

Probably Not

○

Probably Not

○

Definitely Not

○

Definitely Not

4. If ONE OF YOUR BEST FRIENDS were to offer
you an electronic cigarette, e-cigarette, mod,
personal vaporizer, vape pen, or hookah pen,
would you smoke it?

5. During the PAST 30 DAYS, have
you used any of the following
products, even one or two times?

Yes

No

Please fill in YES or NO for each
row.

○

Definitely Yes

○

Probably Yes

a.

Cigarettes

○

○

○

Probably Not

b.

Cigars, cigarillos, or little cigars

○

○

○

Definitely Not

c.

Hookah or a water pipe

○

○

d.

Smokeless tobacco, such as
dip, spit, or chewing tobacco

○

○

e.

Electronic cigarettes,
e-cigarettes, mods, personal
vaporizers, vape pens, or
hookah pens

○

○

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Unique ID:____________

6. In the PAST TWO YEARS…

Yes

No

○

○

7. Have you EVER been taught
about Native customs,
traditions, or language
through any resources in
your school or community?

Please fill in YES or NO for each row.
a.

Have YOU participated in a cultural or
traditional Native event?

Has YOUR PARENT/CAREGIVER
b. participated in a cultural or traditional Native
event?

○

○

Have YOU visited a place within your
community that offers activities or programs
for Natives?

○

○

c.

8. How much do you agree with each of the
following statements?
Please fill ONE bubble for each row.

○

Yes

○

No

○

Don’t Know/Not sure

Strongly
Disagree

Disagree

Neither
Agree or
Disagree

Agree

Strongly
Agree

a.

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

○

○

○

○

○

b.

It is important to me to feel connected to the larger
Native community.

○

○

○

○

○

c.

Knowing my traditions is important to me.

○

○

○

○

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9. Do you live…?

10. Please describe where you CURRENTLY live:

○

In an urban or city area

○

I live most of the time on a reservation

○

In a suburban area next to a city

○

I live some of the time on a reservation

○

In a small town or rural area

○

I do not currently live on a reservation

○

Don’t Know/Not sure

○

Don’t Know/Not sure

Q10 FOR
NON-ALASKA
FGs ONLY

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

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