CASA Online Screener
Dr. David Strong and Dr. John Pierce, Professors in the Department of Family Medicine and Public Health are conducting a research study to find out more about cigarette packaging.  This study is funded by the National Institute of Health (NIH).  

In order to determine study eligibility, you are asked to first complete the 5 minute screening survey below or call us directly at 1-844-534-2272 to complete the questions with a staff member over the telephone.  In this screener, you will be asked to provide information regarding the use of cigarettes.  These questions take less than five minutes to answer and you will not be compensated for completing the questions.

If you are eligible for the research study, research staff may contact you via telephone or email to ask whether you would like to participate.  If you enroll in the study, you would be asked to schedule an in-person visit at the UCSD Moores Cancer Center in La Jolla or Cal State San Marcos.  Questionnaires and assessments would be completed online (using a unique personalized link) and be asked to give three saliva samples at all three clinic visits.  The study also includes using the Kinect XBox to video record reactions to cigarette packs.  If you complete all assessments, you would receive up to $400 in compensation for your time and participation.  We will also cover the cost of parking.

If you have questions or research-related problems, you may reach the program manager at 1-844-534-2272 or email us at casastudy@ucsd.edu.  You may call the Human Research Protections Program Office at 858-657-5100 for more information about this or to inquire about your rights as a research subject, or to report research related problems.


Sign in to Google to save your progress. Learn more
1. What is your email address?
2. Please provide your cell phone number where we can reach you:
3. What is your current age?
4. Do you have a text messaging plan with unlimited messages on your cell phone?
5. How many cigarettes do you smoke per day?
6. What brand and variant of cigarettes do you smoke?
Example: Marlboro Red
7. Do you have any plans to quit smoking in the next 30 days?
8. Would you be willing to commit to purchasing your cigarettes from a protected study website using your credit/debit card for 4 months?
9. Would you be willing to have your cigarettes delivered to you every 2 weeks for 4 months?
10. Will you be living in San Diego for the next 12 months?
11. Please provide your first name only if you would like to receive a call from the study staff:
12. Where would you prefer to be seen for study visits?
13. How did you hear about us?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy