Developing Brand & Creative Concepts Designed to Prevent AI/AN Youth Tobacco Use

Screener
G+G Advertising, an American Indian communications company, and Rescue Agency, a health
communications & research company, are working with the U.S. Food & Drug Administration
(FDA) to hold discussion groups with teens to get their opinions on teen culture and future
commercials. If you qualify and participate in the discussion group, you will get $25.
To see if you qualify for the discussion group, we would like you to answer a few questions on
the following pages. The screening survey asks basic questions about yourself and about
tobacco. There are no right or wrong answers, and only the researchers will know how you
answer these questions, so please be honest. We will try our best to keep your information
private. Still, your information could be shared by accident or as a result of hacking. Your
participation is voluntary you can stop at any time. There is no direct benefit to you for
participating in the screening survey.
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.
If you have any questions about the discussion group, you may contact the project staff through
Samantha Jacobs of Rescue at 619-231-7555 ext 153 or sjacobs@rescueagency.com.
[Not visible to participant]
Recruiter:

Do you assent to participate in this short screening survey?
Yes, I agree to participate in this short survey

If selected: “No, I do not want
to participate in this short
survey.” then participant is
NOT ELIGIBLE.

IF YES, CONTINUE ON NEXT PAGE
No, I do not want to participate in this short survey

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 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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First Name:

Last Name:

Cell Phone:

Home Phone:

Email:

1. How old are you?
a. 12 years old or younger
b. 13 years old
c. 14 years old

[Not visible to participant]
Recruiter:
If Q1 = 11 yrs. old or younger (a)
OR 18 yrs. or older participant is
NOT ELIGIBLE

4. Do you think that you
will smoke a cigarette in
the next year?
a. Definitely Yes

d. 15 years old

b. Probably Yes

e. 16 years old

c. Probably Not

f. 17 years old

d. Definitely Not

g. 18 years old or older
2. Have you ever tried cigarette
smoking, even one or two puffs?
a. Yes
b. No
3. About how many cigarettes have
you smoked in your entire life? A pack
usually has 20 cigarettes in it.
a.

[Not visible to participant]
Recruiter:

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

If Q2 = No (b)

a. Definitely Yes

AND

b. Probably Yes

If Q4, Q5, Q6 = Definitely not (d),
participant is NOT ELIGIBLE

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

I have never smoked cigarettes, even
one or two puffs

b. 1 or more puffs but never a whole
cigarette

a. Definitely Yes

c. 1 cigarette

b. Probably Yes

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

c. Probably Not

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

d. Definitely Not

f. 21 to 50 cigarettes (more than 1 pack
but less than 3 packs)
g. 51 to 99 cigarettes (more than 2½
packs but less than 5 packs)
h. 100 or more cigarettes (5 packs or
more)
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[Not visible to participant]
Recruiter:
If Q3 = 100 cigarettes or more (h)
participant is NOT ELIGIBLE

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CONTINUE ON NEXT PAGE

7. What is your sex?
a. Female
b. Male
8. What of the following do you
consider yourself to be?

(You can circle more than one
answer)
a.

Native American /
American Indian

b. Alaska Native
c.

Asian

[Not visible to participant] Recruiter:
If Q8 = American Indian or Alaska Native is not
selected (c-h)
AND
If Q9 = No (b) AND blank (no written response) or a
non-valid tribe or village name is provided
OR

d. Black or African American
e. Native Hawaiian or Other
Pacific Islander
f.

If Q10 = No (b) AND blank (no written response) or a
non-valid tribe or village name is provided, participant
is NOT ELIGIBLE

White

g. Hispanic
9. Are you, yourself, a member
of a tribe or village?
a. Yes
b. No
If YES, write in which tribe or
village:
___________________________

10. Is your parent / caregiver a
member of a tribe or village?
a. Yes
b. No
If YES, write in which tribe or
village:
___________________________

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Contact Information for Parent/Guardian Permission Only
Parent/Guardian First & Last Name:

Cell Phone:

Home Phone:

Email:

Please fill out your availability:
Please circle the times you think you are available for each day listed (select ALL possible times
that apply). If you qualify for participation, we will confirm your availability again.
Thursday _______:

Evening

Friday

Evening

_______:

Saturday _______:

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Morning

Afternoon

3

Evening