Form Survey EVALI Survey

Attachment 2. EVALI Survey

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2019 LUNG INJURY RESPONSE

UNDERSTANDING VAPING PRACTICES IN THE UNITED STATES

Form Approved

OMB Control No.:0920-XXXX

Expiration date: XX/XX/XXXX

Public reporting burden of this collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX.

Assurance of Confidentiality:  The voluntarily provided information obtained in this survey that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Are you 18 years or older? [If Yes] Continue survey [If No] End survey Do you live in State (to be determined) [If Yes] Continue survey [If No] End survey	Yes No Yes No
Have you used nicotine-containing vaping products in the past 3 months? [If Yes] Continue survey [If No] End survey	Yes No
In the past year, have you been diagnosed with lung injury associated with your use of vaping or dabbing products or e-cigarettes? [If Yes] End survey [If No] Continue survey	Yes No
Remember: Your participation in this survey is voluntary and you can decline to answer any question at any time.
In the past 3 months, have you vaped or dabbed marijuana or THC (the psychoactive compound in marijuana) at least five times? This includes items you’ve purchased at a store, bought off the street, or that were given to you by someone. [If Yes] Continue survey [If No] End survey	Yes No
The next few questions are about your use of THC vaping products in the past 3 months Remember: Your participation in this survey is voluntary and you can decline to answer any question at any time. The voluntarily provided information obtained in this survey that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution.
Which THC substance(s) did you use in an e-cigarette, vaping device, vaporizer, or dab rig in the past 3 months? (Select all that apply)	Marijuana herb (flower or leaves) THC oils Butane hash oil THC concentrate (e.g., wax, badder/budder, crumble, shatter, pull and snap) THC powder form (e.g., dry sift) Other (Specify)
[If Yes to THC oils or Butane hash oil] In what form did you use these THC-containing products? (Select all that apply)	Pre-filled cartridge or pod Liquid or oil used to fill a cartridge or tank Other (Specify)
How many different brands of THC-containing products did you vape or dab in the past 3 months?	(Enter whole number)
Did you use flavored THC-containing products in the past 3 months?	Yes No
Where did you obtain these THC-containing products? (Select all that apply)	Medical dispensary Recreational dispensary (retail cannabis/marijuana shop) Vape shop Pop-up shop Convenience store/gas station Family or friend Illicit dealer Online Other (Specify)
What type of device(s) did you use to vape or dab THC-containing products in the past 3 months? (Select all that apply)	Disposable e-cigarette or vape E-cigarette or vape with prefilled cartridges E-cigarette or vape with a tank that you refill with liquids (including sub-ohm, mod or modifiable systems) E-cigarette or vape with prefilled or refillable “pods” or pod cartridges (e.g. JUUL, Suorin) Dab rig Vaporizer (for dry herbs, etc.) Other (Specify)
What brand of THC-containing cartridge(s) were used with device(s)? (Select all that apply)	Rove Dank Vapes Golden Gorilla Smart Cart Other (Specify)
Approximately how frequently did you vape THC-containing products in the past 3 months?	Monthly or less A few days per month Number of days: (enter number of days in a month) A few days per week Number of days: (enter number of days in a week) Daily
Within a day, on average how many times did you vape THC-containing products in the past 3 months?	(Enter number of times)
How long have you been vaping or dabbing THC-containing products?	< 3 months 3-6 months 7-12 months >1 year
Have you vaped any THC-containing products in the last 30 days?	Yes No
The next few questions are about your use of nicotine-containing products in the past 3 months Remember: Your participation in this survey is voluntary and you can decline to answer any question at any time.
Have you used any nicotine-containing vaping products in the past 3 months? If NO skip to next section	Yes No
In the past 3 months, how many different brands of nicotine-containing products did you vape in the past 3 months?	(enter whole number) _______________
Did you use flavored nicotine-containing products in the past 3 months?	Yes No
In what form did you use nicotine-containing products in the past 3 months? (Select all that apply)	Pre-filled cartridge or pod Liquid or oil used to fill a cartridge or tank Other (Specify)
Where did you obtain the nicotine-containing product you vaped? (Select all that apply)	Medical dispensary Recreational dispensary (retail cannabis/marijuana shop) Vape shop Pop-up shop Convenience store/gas station Family or friend Illicit dealer Online Other (Specify)
In the past 3 months, what type of device(s) did you vape nicotine? (Select all that apply)	Disposable e-cigarette or vape E-cigarette or vape with prefilled cartridges E-cigarette or vape with a tank that you refill with liquids (including sub-ohm, mod or modifiable systems) E-cigarette or vape with prefilled or refillable pods or pod cartridges (e.g. JUUL, Suorin) Other (Specify)
Approximately how frequently did you vape nicotine-containing products in the past 3 months?	Monthly or less A few days per month Number of days: (enter number of days in a month) A few days per week Number of days: (enter number of days in a week) Daily
Within a day, how many times did you vape nicotine-containing products on average in the past 3 months?	(Enter number of times within a day)
How long have you been vaping nicotine-containing products?	< 3 months 3-6 months 7-12 months >1 year
Have you used nicotine-containing products in the last 30 days?	Yes No
The next few questions are about your use of other substances Remember: Your participation in this survey is voluntary and you can decline to answer any question at any time.
Have you used any of the following substances in the past 3 months? (Select all that apply)	Cigarettes Cigars Hookah Chewing tobacco Marijuana (i.e., not used with an e-cigarette, vaping device, or dab rig) Synthetic marijuana (e.g., K2, spice) CBD Other (Specify)
[If selected cigarettes] About how many cigarettes did you smoke per day in the past 3 months?	<1 cigarette a day Quarter of a pack of cigarettes Half a pack of cigarettes More than half but less than a pack of cigarettes A pack of cigarettes More than a pack of cigarettes
[If selected cigarettes] For how long have you smoked cigarettes?	<1 year 1-2 years 3-5 years 6-8 years >8 years
[If selected marijuana] In the past 3 months, how did you most frequently use marijuana? (Select all that apply) Remember: Your participation in this survey is voluntary and you can decline to answer any question at any time.	Smoked it (i.e., joint, pipe, or blunt) Ate it (i.e., in brownies, cakes, cookies, or candy) Drank it (i.e., in tea, cola, or alcohol) Used it some other way (Specify) Do not know/not sure
[If selected marijuana] When you used marijuana during the past 3 months, was it for (Select all that apply) Remember: Your participation in this survey is voluntary and you can decline to answer any question at any time.	Medical reasons (recommended by a doctor or other health professional) Non-medical (recreational) reasons (to have fun or fit in or for the feeling or experience the marijuana causes) Other (Specify)
[If selected marijuana] How often did you smoke marijuana in the past 3 months?	Monthly or less A few days per month Number of days: (enter number of days in a month) A few days per week Number of days: (enter number of days in a week) Daily
Within a day, on average how many times did you smoke marijuana in the past 3 months?	(Enter number of times within a day)
Have you used any other substances or flavors in e-cigarettes and/or vaping devices in the past 3 months? (select all that apply) Remember: Your participation in this survey is voluntary and you can decline to answer any question at any time.	Cannabidiol (CBD) Synthetic marijuana (such as K2, spice) Flavors alone (without substances such as nicotine, THC, CBD) Other substances (Specify)
You have reached the end of the survey. Thank you for your time.

Understanding Vaping Practices in the U.S.

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