Parent Screener--Main: Baseline & Follow-up 2 Replenishment

Expectt 3: baseline WEB Screener Specifications for Programming

ExPECTT 3 Baseline Web Screening Application Specifications

Document Format:

Each question is represented by a table (see template below) and each web screen is separated by a *** line.

Table Template:

VARIABLE NAME
ASK	Universe Receiving Question
Question Text Yes No
NEXT	Logic to next items.
POP UP	Explanation and text of any pop ups that respondents might receive on this screen.

*************************************************************************************

LANG
ASK	ALL
Thank you for your interest in the Health and Media Study being conducted for the U.S. Food and Drug Administration (FDA). Would you like to complete this in English or Spanish? [SPANISH TEXT OF SAME TEXT ABOVE] 1 English/Inglés 2 Spanish/Espańol
NEXT	IF LANG = SPANISH, SHOW SCREENER IN SPANISH AND GO TO INSTRUCTIONS IF LANG = ENGLISH, SHOW SCREENER IN ENGLISH AND GO TO INSTRUCTIONS
POP UP	NA

INSTRUCTIONS
ASK	ALL
The U.S. Food and Drug Administration (FDA) is conducting the Health and Media Study across the United States. Your address was randomly chosen along with approximately 300,000 other addresses nationwide. We ask that an adult member of your household (18 or older) answer these questions to determine if any household members are selected to complete the study. If anyone is selected, they will be provided with a unique link to begin an online survey. If they complete the survey before [END DATE] they will receive $25 [IF TODAY IS BEFORE EARLY BIRD DATE] and a bonus $5 if they complete it on or before [EARLY BIRD DATE]. (Note that parental permission is required before anyone under the age of 18 can participate.)  Also, please understand that federal law keeps your answers confidential, your participation is voluntary, and you can refuse to answer any question. If you have questions about the study, call the project helpline at 1-866-800-9177. If you have questions about your rights as a study participant, call Advarra’s institutional review board (IRB) toll-free at 877-992-4724. [SCNR_ASSENT] Please indicate whether you are willing to answer a few questions to see if you or another household member are eligible to participate in the study. 1. Yes, I am willing to answer questions 2. No, I do not want to participate ASK: All respondents [EXIT_1] [IF SCNR_ASSENT = 2] Thank you for your time. ASK: Ask respondents who do not provide consent To continue, if you are 18 years old or older and a resident of this household, please enter the participant code from the letter you received and click NEXT. Participant Code: ____________ OMB No:0910-XXX Exp: XX/XX/XXXX
NEXT	IF RETURNING AFTER COMPLETED SCREENER: IF INSTRUCTIONS = NEXT, THEN CAI START IF RETURNING AFTER INCOMPLETE SCREENER AFTER MORE THAN ONE HOUR: IF INSTRUCTIONS = NEXT, THEN IDENTIFY SR1
POP UP	NA

SR AGE
ASK	ALL
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] First, to verify, are you 18 years old or older? 1 Yes 2 No
NEXT	IF SR AGE = YES, THEN SR RESIDE IF SR AGE = NO, THEN THANK YOU
POP UP	NA

SR RESIDE
ASK	ALL
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Do you live at: [FILL ADDRESS]? 1 Yes 2 No
NEXT	IF SR RESIDE = YES, THEN OCCUPANCY IF SR RESIDE = NO, THEN THANK YOU
POP UP	IF NO: Just to confirm, you answered in the previous question that you do not currently live at [ADDRESS FILL]? Is this correct? 1 Yes 2 No

OCCUPANCYALL
ASK	IF SR RESIDE = YES
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] The first few questions are about people who live or stay in this home. Please do not include anyone who is living somewhere else for more than 2 months, such as a college student living away, someone in the Armed Forces on deployment, or anyone who is visiting temporarily. Including you, how many total people live or stay at this address? _______ # of people at the address (including yourself) (RANGE 0-20)
NEXT	IF OCCUPANCYALL = 0, THEN POP UP IF OCCUPANCYALL > 0, THEN OCCUPANCY
POP UP	You indicated no one lives or stays at [ADDRESS FILL]? Is that correct? Yes No (IF YES, GO TO THANK YOU. IF NO, THEN OCCUPANCYALL)

OCCUPANCY
ASK	IF OCCUPANCYALL > 0
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Including you, how many of these people are adults 18 years old or older who live or stay at this address? _______ # of people 18 years old or older (including yourself) (RANGE 0-20)
NEXT	IF OCCUPANCY = 0, THEN POP UP IF OCCUPANCY > 0, THEN ADULTS
POP UP	You indicated no adult age 18 years old or older lives or stays at [ADDRESS FILL]? Is that correct? Yes No (IF YES, GO TO THANK YOU. IF NO, THEN OCCUPANCY)

ADULTS
ASK	IF OCCUPANCY > 0
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Including you, how many adults living or staying in this home are age 18-24?
NEXT	ADULTS2
POP UP	NA

ADULTS2
ASK	IF OCCUPANCY > 0
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Including you, how many adults living or staying in this home are age 25-34?
NEXT	ADULTS3
POP UP	NA

ADULTS3
ASK	IF OCCUPANCY > 0
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Including you, how many adults living or staying in this home are age 35-54?
NEXT	ADULTS4
POP UP	NA

ADULTS4
ASK	IF OCCUPANCY > 0
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Including you, how many adults living or staying in this home are age 55-64?
NEXT	ADULTS5
POP UP	NA

ADULTS5
ASK	IF OCCUPANCY > 0
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Including you, how many adults living or staying in this home are age 65 or older?
NEXT	CHILDRENHH
POP UP	NA

CHILDRENHH
ASK	ALL
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] How many total children age 17 or younger live or stay in this home? ____ total number of children
NEXT	CHILDREN1
POP UP	NA

CHECKPOINT: Compare number of total HH members (OCCUPANCYALL), number of adults (OCCUPANCY), and number of children (CHILDRENHH) reported. If there are inconsistencies, check on total numbers here.

You reported that there were X people in this household: X adults and X children. Is this correct?

Yes

No

IF NO – Which of these statements is not true? Select all that apply.

There are X people in this household

There are X adults in this household

There are X children in this household

ASK incorrect/”not true” questions again.

CHILDREN1
ASK	IF CHILDRENHH>0
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] How many children living or staying in this home are age 0-5?
NEXT	CHILDREN2
POP UP	NA

CHILDREN2
ASK	IF CHILDRENHH>0
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] How many children living or staying in this home are age 6-10?
NEXT	CHILDREN3
POP UP	NA

CHILDREN3
ASK	IF CHILDRENHH>0
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] How many children living or staying in this home are age 11-17?
NEXT	EDUCATION1
POP UP	NA

EDUCATION1
ASK	ALL
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] We’d like to know about the highest level of education of the adults 18 years or older in your household. Including you, how many adults 18 years old and older living or staying in this home have an Associates, Bachelor’s, graduate or professional degree? _______ # of adults (including yourself) (RANGE 0-20)
NEXT	EDUCATION2
POP UP	Provide a check if the # of adults is greater than the total number of adults

EDUCATION2
ASK	ALL
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] We’d like to know about the highest level of education of the adults 18 years or older in your household. Including you, how many adults 18 years old and older living or staying in this home attended some college but do not have a degree? _______ # of adults (including yourself) (RANGE 0-20)
NEXT	EDUCATION3
POP UP	Provide a check if the # of adults is greater than the total number of adults

EDUCATION3
ASK	ALL
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] We’d like to know about the highest level of education of the adults 18 years or older in your household. Including you, how many adults 18 years old and older living or staying in this home have a high school diploma or GED or less? _______ # of adults (including yourself) (RANGE 0-20)
NEXT	RACE
POP UP	Provide a check if the # of adults is greater than the total number of adults. Add up all adults reported in education questions. This number should = the total number of adults in the HH.

RACE

ASK

ALL

[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK]

Is anyone living or staying in this home……

	Yes	No
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White

NEXT

HOME LANG

POP UP

NA

HOME LANG
ASK	ALL
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Which best describes the language spoken in your home? English only Mostly English Mostly Spanish Mostly another language
NEXT	INCOME
POP UP	NA

INCOME
ASK	ALL
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Which of the following categories best describes the total income of your household from all sources in the past year? Less than $10,000 $10,000 to under $30,000 $30,000 to under $50,000 $50,000 to under $70,000 $70,000 to under $110,000 $110,000 or more
NEXT	HOME
POP UP	NA

HOME
ASK	ALL
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] These next questions are about your home. Is this home…. Owned by you or someone in your household Rented Occupied without payment of rent
NEXT	INTERNET
POP UP	NA

INTERNET
ASK	ALL
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] At this house, apartment, or mobile home, do you or any member of your household have access to the Internet? Yes, by paying a cell phone company or Internet service provider Yes, without paying a cell phone company or Internet service provider No access to the Internet at this household
NEXT	BENEFITS
POP UP	NA

BENEFITS
ASK	ALL
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] In the past 12 months, did you or any member of this household receive benefits from the Food Stamp Program or SNAP (the Supplemental Nutrition Assistance Program)? Do NOT include WIC, the School Lunch Program, or assistance from food banks. Yes No
NEXT	SMOKING
POP UP	NA

SMOKING
ASK	ALL
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] The next question is about cigarette smoking. Do any of the adults (18 or older) living or staying in this home currently smoke cigarettes? Yes No
NEXT	VERIFY ROSTER DATA
POP UP	NA

VERIFY ROSTER DATA
ASK
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Let’s confirm the people who live here. These are the people listed as living in this household. 1 adult / X adults 18-24 years old 1 adult / X adults 25-34 years old 1 adult / X adults 35-54 years old 1 adult / X adults 55-64 years old 1 adult / X adults 65 or older 1 child / X children 0-5 years old 1 child / X children 6-10 years old 1 child / X children 11-17 years old LIST AGE GROUP EACH AGE GROUP HAS AN EDIT FUNCTION BUTTON AND ALL MEMBERS HAVE A DELETE BUTTON. Add Member button. (If any household member is missing, please click the Add Member button.) If this information is correct and there are no other household members, please click the Submit button. [SUBMIT]
NEXT	ENGLISH: IF EDIT FUNCTION SELECTED, THEN EDIT ROSTER OPTION IF DELETE FUNCTION SELECTED, THEN “Are you sure you want to delete this household member?” IF VERIFY ROSTER DATA = SUBMIT, THEN RESPONDENT SELECTION IF VERIFY ROSTER DATA = Add Member+, THEN PERSON # AGE
POP UP	NA

NAME
ASK	IF HH MEMBERS are 11-17 YEARS OLD
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Can you please tell us the name or nickname and current age of the X child(ren) who is/are 11-17 years old? PROGRAMMER: LIST RESPONSE OPTIONS THAT MATCH THE NUMBER OF CHILDREN REPORTED NAME1: AGE1: NAME2: AGE2: NAME3: AGE3: NAME4: AGE4: NAME5: AGE5:
NEXT	SELECT HH MEMBERS BASED ON NUMBER OF 11-17 YEAR OLDS.
POP UP	NA

RESPONDENT SELECTION
ASK	IF VERIFY ROSTER DATA = YES
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] [IF ONE OR TWO SELECTED] Congratulations! The following people from this household have been selected to participate in the study. NAME1 and AGE1 NAME2 and AGE2 [IF NO ONE SELECTED] Thank you for answering these questions. No one in your household was selected for the study. Have a great day!
NEXT	IF RESPONDENT SELECTION = NEXT, THEN YOUTHR1
POP UP	NA

YOUTHR1
ASK	IF RESPONDENT SELECTION = YOUTH R
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] [IF ONE OR TWO YOUTH R SELECTED] Because the person/people selected to participate in the Health and Media Study is/are younger than 18 years old, a parent or guardian must first provide permission. INTERVIEW A: [NAME] [AGE] Are you the parent or guardian of [NAME1]? Parent Guardian Not the parent or guardian [IF TWO YOUTH SELECTED] INTERVIEW B: [NAME] [AGE] Are you the parent or guardian of [NAME2]? Parent Guardian I am not the parent or guardian of this youth
NEXT	IF ONE YOUTH R SELECTED AND YOUTHR1a = YES, THEN YOUTHR3 – SR IS PARENT IF ONE YOUTH R SELECTED AND YOUTHR1a = NO, THEN YOUTHR2 SR – NOT PARENT IF TWO YOUTH R SELECTED AND YOUTHR1a = YES AND YOUTHR1b = YES, THEN YOUTHR3 – SR IS PARENT IF TWO YOUTH R SELECTED AND YOUTHR1a = YES AND YOUTHR1b = NO, THEN YOUTHR4 – SR PARENT/NOT PARENT IF TWO YOUTH R SELECTED AND YOUTHR1a = NO AND YOUTHR1b = YES, THEN YOUTHR4 – SR PARENT/NOT PARENT IF TWO YOUTH R SELECTED AND YOUTHR1a = NO AND YOUTHR1b = NO, THEN YOUTHR2 – SR NOT PARENT
POP UP	NA

YOUTHR2 – SR NOT PARENT
ASK	IF (ONE YOUTH R SELECTED AND YOUTHR1a = NO) OR (TWO YOUTH R SELECTED AND YOUTHR1a = NO AND YOUTHR1b = NO)
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] [IF (ONE YOUTH R SELECTED AND YOUTHR1a = NO) OR (TWO YOUTH R SELECTED AND YOUTHR1a = NO AND YOUTHR1b = NO) Before [NAME1 AND NAME2] can begin the survey a parent or guardian must first provide permission. Is [NAME1’s] or [NAME2’s] parent or guardian available right now to provide permission in this survey? Yes No
NEXT	YOUTHR2 – SR NOT PARENT = NO, THEN YOUTHR2A – SR NOT PARENT, REQUEST CONTACT INFO YOUTHR2 – SR NOT PARENT = YES, THEN YOUTHR2 – PASS1
POP UP	NA

YOUTHR2 – PASS1
ASK	IF YOUTHR2=YES
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Please pass your device to the parent or guardian of [NAME1] or [NAME 2] and press Next when they are ready. Next
NEXT	YOUTHR2 – PASS2
POP UP	NA

YOUTHR2 – PASS2
ASK	IF YOUTHR2=YES
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Hello. The U.S. Food and Drug Administration (FDA) is conducting the Health and Media Study across the United States. Your address was randomly chosen along with approximately 300,000 other addresses nationwide. Please understand that federal law keeps your answers confidential, your participation is voluntary, and you can refuse to answer any question. If you have questions about the study, call the project helpline at 1-866-800-9177. If you have questions about your rights as a study participant, call Advarra’s institutional review board (IRB) toll-free at 877-992-4724. Based on the people in this household, we have selected the following person / people to participate in the study. NAME 1 AGE 1 NAME 2 AGE 2 Are you the parent or guardian of NAME 1 AGE 1? Yes No Are you the parent or guardian or NAME 2 AGE 2? Yes No
NEXT	Go to parental permission Need to repeat the logic above IF ONE YOUTH R SELECTED AND YOUTHR1a = YES, THEN YOUTHR3 – SR IS PARENT IF ONE YOUTH R SELECTED AND YOUTHR1a = NO, THEN YOUTHR2 SR – NOT PARENT IF TWO YOUTH R SELECTED AND YOUTHR1a = YES AND YOUTHR1b = YES, THEN YOUTHR3 – SR IS PARENT IF TWO YOUTH R SELECTED AND YOUTHR1a = YES AND YOUTHR1b = NO, THEN YOUTHR4 – SR PARENT/NOT PARENT IF TWO YOUTH R SELECTED AND YOUTHR1a = NO AND YOUTHR1b = YES, THEN YOUTHR4 – SR PARENT/NOT PARENT IF TWO YOUTH R SELECTED AND YOUTHR1a = NO AND YOUTHR1b = NO, THEN YOUTHR2 – SR NOT PARENT
Hard check	If YOUTHR2 – PASS2=NO: Please ask the parent or guardian of [NAME1/AGE1 OR NAME2/AGE2] to complete the rest of the survey. If the parent or guardian of this child is unavailable, please go back to the previous question and correct your responses.
POP UP	NA

YOUTHR2 – CONTACT
ASK	IF YOUTHR2=NO
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] We would like to contact the parent or guardian of [Name1] or [Name2] to get permission for the survey. Can you please provide their name and phone number and email address? As a reminder, we will provide everyone who participates by [DATE] with a $25 gift card. Yes No – I do not wish to provide their information
NEXT	IF YES - CONTACT3 IF NO – CONTACT2
POP UP	NA

YOUTHR2 – CONTACT2
ASK	IF YOUTHR2- CONTACT1=NO
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Participation in this study is important and we would like to invite NAME1 and NAME2 to take part. We will send a letter to your house with more details. Can you also please invite the parent or guardian of NAME1 and NAME2 to call us at 866-800-9177? Thank you.
NEXT	Go to THANK YOU
	Set status as selected youth no parental permission no contact info
POP UP	NA

YOUTHR2 – CONTACT3
ASK	IF YOUTHR2 CONTACT=YES
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Thank you. Please fill in the information below. Name Phone Number Email Is this person the parent or guardian of NAME 1? Yes/No Is this person the parent or guardian of NAME 2? Yes/No We will contact this person to provide permission for NAME 1 (and NAME 2) to participate in the study. Thank you for your help.
NEXT	THANK YOU if yes to both children. If no to one child, go to CONTACT4
POP UP	NA

YOUTHR2 – CONTACT4
ASK	IF YOUTHR2 CONTACT3a OR CONTACT3b = NO
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Thank you. We would like to contact the parents or guardians of both selected participants. Please enter the contact information for the other parent or guardian below. Name Phone Number Email Is this person the parent or guardian of NAME 1? Yes/No Is this person the parent or guardian of NAME 2? Yes/No We will contact this person to provide permission for NAME 1 (and NAME 2) to participate in the study. Thank you for your help.
NEXT	THANK YOU
POP UP	NA

YOUTHR3 – SR IS PARENT
ASK	IF (ONE YOUTH R SELECTED AND YOUTHR1a = YES) OR (TWO YOUTH R SELECTED AND YOUTHR1a = YES AND YOUTHR1b = YES)
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Before [CHILD NAME] age [AGE] [IF TWO SELECTED: and [CHILD NAME] age [AGE] [can participate in this study, which asks about tobacco, alcohol, and drug use or non-use and other health related issues, we need to get your permission. [INSERT PARENTAL PERMISSION] Do you agree to let CHILD1 AGE1 participate in the Health and Media Study? Yes No Do you agree to let CHILD2 AGE2 participate in the Health and Media Study? Yes No INSERT INCENTIVE CONTACT INFORMATION
NEXT	YOUTHR3 – SR IS PARENT = NEXT, THEN YOUTHR3A – SR IS PARENT, CONTACT INFO
POP UP	NA

YOUTHR3 – SR IS PARENT2
ASK	SR IS PARENT = permission and incentive contact information is provided
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Thank you. Your child can start the interview now, or he/she can begin at another time that is convenient for them. We will email you and your child a unique link for them to access the survey online. You can use this link to start the survey at another time, or to reenter the survey after beginning it. Please provide these email addresses, even if your child plans to complete the survey today. Your email address Name1 (Age AGE)’s email address Name2 (Age AGE)’s email address
NEXT	PASS4
POP UP	NA

Checkpoint: have we received parental permission for Name 1?

Have we received parental permission for Name 2? If so, enable continuation to youth assent.

YOUTHR3 – PASS4
ASK	SR IS PARENT = permission and incentive contact information is provided
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Thank you. Your child can start the interview now, or he/she can begin at another time that is convenient for them. We will email you and your child a link to access the survey. You can use this link to start the survey at another time, or to reenter the survey after beginning it. Please provide these email addresses, even if your child plans to complete the survey today. Your email address Name1 (Age AGE)’s email address Name2 (Age AGE)’s email address
NEXT	PASS5
POP UP	NA

YOUTHR3 – PASS5
ASK	CONSENTEDCHILDREN = 1
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Thank you. Is your child NAME1 AGE available to complete the survey now? The survey should take about 30 minutes to complete. Yes – please pass this device to your child and allow them to complete the study in private. Please press Next when they are ready. No
NEXT	If PASS5=Yes go to YOUTH SURVEY LINK IF PASS5=No go to LINKS
POP UP	NA

YOUTHR3 – PASS5_CHILD2
ASK	CONSENTEDCHILDREN = 2
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Thank you. We would like one of your children to complete the survey today, if possible. Is NAME1 AGE1 or NAME2 AGE2 available to complete the survey now? The survey should take about 30 minutes to complete. Yes, NAME1 AGE1 is available now Yes, NAME2 AGE2 is available now No neither child is available now
NEXT	If PASS5=1,2 go to YOUTHR3 – PASS6_CHILD2 IF PASS5=3 go to LINKS
POP UP	NA

YOUTHR3 – PASS6_CHILD2
ASK	YOUTHR3 – PASS5_CHILD2 = 1, 2
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] Please pass this device to [FILL1] and allow them to complete the study in private. Please press Next when they are ready. We will email a survey link to [FILL2] within the next [X] days to complete the survey at their convenience. As a reminder, we will provide everyone who participates by [DATE] with a $25 gift card.
	FILL 1: IF YOUTHR3- PASS5_CHILD2 = 1, FILL NAME1 AGE1 ELSE FILL NAME2 AGE2 FILL2: IF YOUTHR3- PASS5_CHILD2 = 1, FILL NAME2 AGE2 ELSE FILL NAME1 AGE1
NEXT
POP UP	NA

YOUTH SURVEY LINK
ASK	PASS5 NE YES
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] INSERT LINK TO YOUTH SURVEY
NEXT	Move into main instrument
POP UP	NA

LINKS
ASK	YOUTHR3 – PASS5_CHILD2=3
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 866-800-9177 [/LINK] We will email a survey link to [FILL1] within the next [X] days to complete the survey at their convenience. As a reminder, we will provide everyone who participates by [DATE] with a $25 gift card. Thank you.
	FILL1: IF CONSENTEDCHILDREN=1, FILL NAME1, AGE1 ELSE FILL “NAME1 AGE1 and NAME2 AGE2”
NEXT	NA
POP UP	NA

THANK YOU
ASK	IF (IDENTIFY SR1 = NO) OR (IDENTIFY SR2 = NO) OR (OCCUPANCY = NO) OR (TOTAL SDU MEMBERS = 0 POP UP = 0) OR (MEMBERS 12 OR OLDER = 0 POP UP = 0) OR (RESPONDENT SELECTION = BLANK) OR (SR PHONE1 = NO) OR (SR PHONE2 = NEXT) OR (YOUTHR2A – SR NOT PARENT, REQUEST CONTACT INFO = NO AND NO OTHER RESPONDENT SELECTED) OR (SR PHONE = NEXT AND NO OTHER RESPONDENT SELECTED) OR (YOUTHR3A – SR IS PARENT, CONTACT INFO = NO AND NO OTHER RESPONDENT SELECTED) OR (YOUTHR3A – SR IS PARENT, PARENT PHONE = NEXT AND NO OTHER RESPONDENT SELECTED) OR (CAI START, ADULT = NO)
[LINK] FAQ [/LINK] [PHONE ICON] [LINK] 800-848-4079 [/LINK] [IF IDENTIFY SR1 = NO OR IDENTIFY SR2 = NO] An adult resident at this address must complete these questions. Thank you for your time. [TOTAL SDU MEMBERS = 0 POP UP = 0 OR MEMBERS 12 OR OLDER = 0 POP UP = 0] Thank you for your time. [OCCUPANCY = NO] Thank you for your time. This household is not eligible to participate in this study. [RESPONDENT SELECTION = BLANK] No one in your household has been selected for an interview. Thank you for your time.
NEXT	NA
POP UP	NA

OMB No: [FILL NUMBER] Expiration Date: [FILL DATE]

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.

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