Moderation in SPSS
2 016 Behavioral Risk Factor Surveillance System Questionnaire October 14, 2015 2 Behavioral Risk Factor Surveillance System 2016 Questionnaire Table of Contents Table of Contents ........................................................................................................................................ 2 Interviewer’s Script ..................................................................................................................................... 3 Landline .................................................................................................................................................... 3 Cell Phone ................................................................................................................................................ 7 Core Sections ............................................................................................................................................ 10 Section 1: Health Status ....................................................................................................................... 10 Section 2: Healthy Days — Health -Related Quality of Life .................................................................. 10 Section 3: Health Care Access ............................................................................................................. 11 Section 4: Exercise ............................................................................................................................... 12 Section 5: Inadequate Sleep ................................................................................................................ 13 Section 6: Chronic Health Conditions ................................................................................................... 13 Section 7: Oral Health........................................................................................................................... 16 Section 8: Demographics ...................................................................................................................... 16 Section 9: Tobacco Use........................................................................................................................ 24 Section 10: E-Cigarettes ......................................................................................................................... 26 Section 11: Alcohol Consumption ........................................................................................................... 26 Section 12: Immunization ....................................................................................................................... 27 Section 13: Falls ..................................................................................................................................... 28 Section 14: Seatbelt Use ........................................................................................................................ 29 Section 15: Drinking and Driving ............................................................................................................ 29 Section 16: Breast and Cervical Cancer Screening ............................................................................... 30 Section 17: Prostate Cancer Screening ................................................................................................. 31 Section 18: Colorectal Cancer Screening ............................................................................................... 33 Section 19: HIV/AIDS ............................................................................................................................. 34 Optional Modules ...................................................................................................................................... 36 Module 1: Pre -Diabetes ......................................................................................................................... 36 Module 2: Diabetes ................................................................................................................................ 36 Module 3: Healt hy Days (Symptoms) .................................................................................................... 39 Module 4: Health Care Access .............................................................................................................. 39 Module 5: Health Literacy ...................................................................................................................... 42 Module 6: C aregiver .............................................................................................................................. 46 Module 7: Cognitive Decline ................................................................................................................. 46 Module 8: Sugar Sweetened Beverages .............................................................................................. 49 Module 9: Menu Labeling ..................................................................................................................... 50 Module 10: Marijuana Use ...................................................................................................................... 50 Module 11 Sleep Disorder ..................................................................................................................... 51 Module 12: Adult Asthma History ........................................................................................................... 52 Module 13: Influenza .............................................................................................................................. 55 Module 14: Adult Human Papillomavirus (HPV) ..................................................................................... 56 Module 15: Shingles ............................................................................................................................... 56 Module 16: Excess Sun Exposure .......................................................................................................... 57 Module 17: Cancer Survivorship ............................................................................................................ 57 Module 18: Clinical Breast Exam for Women’s Health ........................................................................... 62 Module 19: Prostate Cancer Screening Decision Making ...................................................................... 62 Module 20: Industry and Occupation ...................................................................................................... 63 Module 21: Sexual Orientation and Gender Identity .............................................................................. 64 Module 22: Random Child Selection ...................................................................................................... 65 Module 23: Childhood Asthma Prevalence ............................................................................................ 68 Module 24: Emotional Support and Life Satisfaction .............................................................................. 69 Module 25: Disability ............................................................................................................................... 69 3 Interviewer’s Script Landline Form Approved OMB No. 0920 -1061 Exp. Date 3/31/2018 Public reporting burden of this collection of information is estimated to average 27 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 -1061) .
NOTE: Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the aver age time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Carol Pierannunzi at [email protected] . HELLO, I am calling for the (health department) . My name is (name) . We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices. Is this (phone number) ? If "No” Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time. STOP Is this a private residence? READ ONLY IF NECESSARY: “By private residence, we mean someplace like a house or apartment.” Yes [Go to state of residence] No [Go to college housing] 4 No, business phone only If “No, business phone only”. Thank you very much but we are only interviewing persons on residential phones lines at this time.
STOP College Housing Do you live in college housing? READ ONLY IF NECESSARY: “By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.” Yes [Go to state of residence] No If "No”, Thank you very much, but we are only interviewing persons who live in a private r esidence or college housing at this time. STOP State of Residence Do you currently live in ____(state)____? Yes [ Go to Cell(ular) Phone ] No If “No” Thank you very much, but we are only interviewing persons who live in the state of ______at this time. STOP NOTE: Items in parentheses at any place in the questions or response DO NOT need to be read. 5 Cell(ular) Phone Is this a cell(ular) telephone? INTERVIEWER NOTE : Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home -based phone services). Read only if necessary: “ By cell(ular) telephone we mean a telephone that is mobile and usable outside of your neighborhood.” If “Yes” Thank you very much, but we are only interviewing by land line telephones and for private residences or college housing. STOP No CAT I NOTE : IF (College Housing = Yes) continue; otherwise go to Adult Random Selection Adult Are you 18 years of age or older? 1 Yes, respondent is male [Go to Page 6] 2 Yes, respondent is female [Go to Page 6] 3 No If "No”, Thank you very much, but we are only interviewing persons aged 18 or older at this time. STOP Adult Random Selection I need to randomly select one adult who lives in your household to be interviewed. Excluding adults living away from home such as students away at college, how many members of your household, including yourself, are 18 years of age or older? __ Number of adults If "1," Are you the adult? If "yes," Then you are the person I need to speak with. Enter 1 man or 1 woman below (Ask gender if necessary). Go to page 6. If "no," Is the adult a man or a woman? Enter 1 man or 1 woman below. May I speak with [fill in (him/her) from previous question]? Go to "correct respondent" on the next page. 6 How many of these adults are men and how many are women?
__ Number of men CAT I NOTE: CATI program to subtract number of men from number of adults provided So the number of adult women in the household is __ Number of women is that correct?
The person in your household that I need to speak with is . If "you," go to page # 10 (correct page) .
To the correct respondent: HELLO, I am calling for the (health department) . My name is (name) . We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about your health and health practic es.
7 Cell Phone Form Approved OMB No. 0920 -1061 Exp. Date 3/31/2018 Public reporting burden of this collection of information is estimated to average 27 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 -1061) .
NOTE: Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the aver age time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Carol Pierannunzi at [email protected] . HELLO, I am calling for the (health department). My name is (name) . We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices. Is this a safe time to talk with you? Yes [Go to phone] No If "No”, Thank you very much. We will call you back at a more convenient time. ([Set up appointment if possible]) STOP Phone Is this (phone number) ?
Yes [Go to cell(ular) phone] No [Confirm phone number] If "No”, Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time. STOP 8 Cell(ular) Phone Is this a cell(ular) telephone? READ ONLY IF NECESSARY: “By cell(ular) telephone, we mean a telephon e that is mobile and usable outside of your neighborhood.” Yes [Go to adult] No If "No”, Thank you very much, but we are only interviewing cell telephones at this time. STOP Adult Are you 18 years of age or older? 1 Yes, respondent is male [Go to Private Residence] 2 Yes, respondent is female [Go to Private Residence] 3 No If "No”, Thank you very much, but we are only interviewing persons aged 18 or older at this time. STOP Private Residence Do you live in a private residence?
READ ONLY IF NECESSARY: “By private residence, we mean someplace like a house or apartment.” Yes [Go to state of residence] No [Go to college housing] College Housing Do you live in college housing? READ ONLY IF NECESSARY: “By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.” Yes [Go to state of residence] No If "No”, Thank you very much, but we are only interviewing persons who live in a private residence or college housing at this time. STOP 9 State of Residence Do you currently live in ____(state)____? Yes [Go to landline] No [Go to state] State In what state do you currently live?
ENTER FIPS STATE Landline Do you also have a landline telephone in your home that is used to make and receive calls? READ ONLY IF NECESSARY: “By landline telephone, we mean a “regular” telephone in your home that is used for making or receiving calls.” Please include landline phones used for both business and personal use.” Interviewer Note: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services.). Yes No If College Housing = “Yes”, do not ask Number of adults Questions, go to Core. NUMADULT How many members of your household, including yourself, are 18 years of age or older?
__ Number of adults (Note: If college housing = ”yes” then number of adults is set to 1.) NOTE: Items in parentheses at any place in the questions or response DO NOT need to be read. 10 Core Sections I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will be confidential. If you have any questions about the survey, please call (give appropriate state telephone number). Section 1: Health Status 1.1 Would you say that in general your health is — (90) Please read:
1 Excellent 2 Very good 3 Good 4 Fair Or 5 Poor Do not read:
7 Don’t know / Not sure 9 Refused Section 2 : Healthy Days — Health -Related Quality of Life 2.1 Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? (91– 92 _ _ Number of days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused 11 2.2 Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
(93– 94) _ _ Number of days 8 8 None [If Q2.1 and Q2.2 = 88 (None), go to next section ] 7 7 Don’t know / Not sure 9 9 Refused 2.3 During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self -care, work, or r ecreation?
(95- 96) _ _ Number of days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused Section 3: Health Care Access 3.1 Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, government plans such as Medicare, or Indian Health Service? (97) 1 Yes [If using Health Care Access (HCA) Module go to Module 4 , Q 1, else continue] 2 No 7 Don’t know / Not sure 9 Refused 3. 2 Do you have one person you think of as your personal doctor or health care provider?
If “No,” ask: “Is there more than one, or is there no person who you think of as your personal doctor or health care provider?” (98) 1 Yes, only one 2 More than one 3 No 7 Don’t know / Not sure 9 Refused 12 3.3 Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?
(99) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused CAT I NOTE : If using HCA Module, go to Module 4, Q3, else continue .
3. 4 About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition. (100) 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 5 years (2 years but less than 5 years ago) 4 5 or more years ago 7 Don’t know / Not sure 8 Never 9 Refused CAT I NOTE : If using HCA Module and Q3.1 = 1 go to Module 4 , Question 4a or if using HCA Module and Q3.1 = 2, 7, or 9 go to Module 4 , Question 4b, or if not using HCA Module go to next section. Section 4: Exercise 4.1 During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise? (101) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 13 Section 5: Inadequate Sleep 5.1 On average, how many hours of sleep do you get in a 24- hour period? INTERVIEWER NOTE: Enter hours of sleep in whole numbers, rounding 30 minutes (1/2 hour) or more up to the next whole hour and dropping 29 or fewer minutes. (102- 103) _ _ Number of hours [01- 24] 7 7 Don’t know / Not sure 9 9 Refused Section 6: Chronic Health Conditions Has a doctor, nurse, or other health professional EVER told you that you had any of the following? For each, tell me “Yes,” “No,” or you’re “Not sure.” 6 .1 (Ever told) you that you had a heart attack also called a myocardial infarction?
(104) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 6 .2 (Ever told) you had angina or coronary heart disease? (105) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 6 .3 (Ever told) you had a stroke? (106) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 6 .4 (Ever told) you had asthma? (107) 1 Yes 2 No [Go to Q 6.6] 7 Don’t know / Not sure [Go to Q 6.6] 9 Refused [Go to Q 6.6] 14 6.5 Do you still have asthma?
(108) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 6.6 (Ever told) you had skin cancer? ( 109) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 6 .7 (Ever told) you had any other types of cancer? (110) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 6 .8 (Ever told) you have chronic obstructive pulmonary disease (COPD), emphysema or chronic bronchitis? (111) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 6 .9 (Ever told) you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia? (112) 1 Yes 2 No 7 Don’t know / Not sur e 9 Refused INTERVIEWER NOTE: Arthritis diagnoses include: • rheumatism, polymyalgia rheumatica • osteoarthritis (not osteoporosis) • tendonitis, bursitis, bunion, tennis elbow • carpal tunnel syndrome, tarsal tunnel syndrome • joint infection, Reiter’s syndrome • ankylosing spondylitis; spondylosis • rotator cuff syndrome 15 • connective tissue disease, scleroderma, polymyositis, Raynaud’s syndrome • vasculitis (giant cell arteritis, Henoch- Schonlein purpura, W egener’s granulomatosis, polyarteritis nodosa) 6 .10 (Ever told) you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)? (113) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 6 .11 (Ever told) you have kidney disease? Do NOT include kidney stones, bladder infection or incontinence. INTERVIEWER NOTE: Incontinence is not being able to control urine flow. (114) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 6 .1 2 (Ever told) you have diabetes? (115) If “Yes” and respondent is female, ask: “Was this only when you were pregnant?” If respondent says pre- diabetes or borderline diabetes, use response code 4. 1 Yes 2 Yes, but female told only during pregnancy 3 No 4 No, pre- diabetes or borderline diabetes 7 Don’t know / Not sure 9 Refused CAT I NOTE : If Q6.1 2 = 1 (Yes), go to next question . If any other response to Q6.1 2, go to Pre - Diabetes Optional Module (if used). Otherwise, go to next section. (116- 117 ) 6 .1 3 How old were you when you were told you have diabetes? _ _ Code age in years [97 = 97 and older] 9 8 Don‘t know / Not sure 9 9 Refused 16 CAT I NOTE : Go to Diabetes Optional Module (if used). Otherwise, go to next section. Section 7 : Oral Health 7.1 How long has it been since you last visited a dentist or a dental clinic for any reason?
Include visits to dental specialists, such as orthodontists. (118) Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 5 years (2 years but less than 5 years ago) 4 5 or more years ago Do not read: 7 Don’t know / Not sure 8 Never 9 Refused 7.2 How many of your permanent teeth have been removed because of tooth decay or gum disease? Include teeth lost to infection, but do not include teeth lost for other reasons, such as injury or orthodontics. N OTE : If wisdom teeth are removed because of tooth decay or gum disease, they should be included in the count for lost teeth. (119) 1 1 to 5 2 6 or more but not all 3 All 8 None 7 Don’t know / Not sure 9 Refused Section 8: Demographics 8.1 Are you … (120) 1 Male 2 Female 9 Refused Note: This may be populated from information derived from screening, household enumeration. However, interviewer should not make judgement on sex of respondent. 17 8.2 What is your age? (121- 122 ) _ _ Code age in years 0 7 Don’t know / Not sure 0 9 Refused 8 .3 Are you Hispanic, Latino/a, or Spanish origin? (1 23-126) If yes, ask: Are you… INTERVIEWER NOTE: One or more categories may be selected. 1 Mexican, Mexican American, Chicano/a 2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino/a, or Spanish origin Do not read:
5 No 7 Don’t know / Not sure 9 Refused 8 .4 Which one or more of the following would you say is your r ace? (127- 154 ) INTERVIEWER NOTE: Select all that apply. INTERVIEWER NOTE: 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 18 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read:
60 Other 88 No additional choices 77 Don’t know / Not sure 99 Refused CAT I NOTE : If more than one response to Q 8.4 ; continue. Otherwise, go to Q 8.6 .
8 .5 Which one of these groups would you say best represents your race? INTERVIEWER NOTE: If 40 (Asian) or 5 0 (Pacific Islander) is selected read and code subcategory underneath major heading. (155-156) 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander 19 Do not read:
60 Other 77 Don’t know / Not sure 99 Refused 8 .6 Are you…?
(157) Please read:
1 Married 2 Divorced 3 Widowed 4 Separated 5 Never married Or 6 A member of an unmarried couple Do not read:
9 Refused 8.7 What is the highest grade or year of school you completed? (158) Read only if necessary: 1 Never attended school or only attended kindergarten 2 Grades 1 through 8 (Elementary) 3 Grades 9 through 11 (Some high school) 4 Grade 12 or GED (High school graduate) 5 College 1 year to 3 years (Some college or technical school) 6 College 4 years or more (College graduate) Do not read: 9 Refused 8. 8 Do you own or rent your home? (159) 1 Own 2 Rent 3 Other arrangement 7 Don’t know / Not sure 9 Refused INTERVIEWER NOTE: “Other arrangement” may include group home, staying with friends or family without paying rent. NOTE : Home is defined as the place where you live most of the time/the majority of the year. NOTE: Items in parentheses at any place in the questions or response DO NOT need to be read. 20 INTERVIEWER NOTE: We ask this question in order to compare health indicators among people with different housing situations. 8 .9 In what county do you currently live? (160- 162) _ _ _ ANSI County Code (formerly FIPS county code) 7 7 7 Don’t know / Not sure 9 9 9 Refused 8 .1 0 What is the ZIP Code where you currently live? (1 63-167) _ _ _ _ _ ZIP Code 7 7 7 7 7 Don’t know / Not sure 9 9 9 9 9 Refused CATI NOTE: If cell(ular) telephone interview skip to 8 .14 (QSTVER GE 20) 8 .1 1 Do you have more than one telephone number in your household? Do not include cell phones or numbers that are only used by a computer or fax machine. (168) 1 Yes 2 No [Go to Q 8.1 3] 7 Don’t know / Not sure [Go to Q 8.1 3] 9 Refused [Go to Q 8.1 3] 8 .1 2 How many of these telephone numbers are residential numbers?
(169) _ Residential telephone numbers [6 = 6 or more] 7 Don’t know / Not sure 9 Refused 8 .1 3 Do you have a cell phone for personal use? Please include cell phones used for both business and personal use. (170) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 21 8.14 Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit? INTERVIEWER NOTE: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War .
(1 71) 1 Yes 2 No Do not read:
7 Don’t know / Not sure 9 Refused 8 .1 5 Are you currently…? INTERVIEWER NOTE: If more than one, select the category which best describes you. (172) Please read: 1 Employed for wages 2 Self-employed 3 Out of work for 1 year or more 4 Out of work for less than 1 year 5 A Homemaker 6 A Student 7 Retired Or 8 Unable to work Do not read:
9 Refused 8 .1 6 How many children less than 18 years of age live in your household? (1 73- 17 4) _ _ Number of children 8 8 None 9 9 Refused 8 .1 7 Is your annual household income from all sources — 22 (1 75-1 76 ) If respondent refuses at ANY income level, code ‘99’ (Refused) Read only if necessa ry:
0 4 Less than $25,000 If “no,” ask 05; if “yes,” ask 03 ($20,000 to less than $25,000) 0 3 Less than $20,000 If “no,” code 04; if “yes,” ask 02 ($15,000 to less than $20,000) 0 2 Less than $15,000 If “no,” code 03; if “yes,” ask 01 ($10,000 to less than $15,000) 0 1 Less than $10,000 If “no,” code 02 0 5 Less than $35,000 If “no,” ask 06 ($25,000 to less than $35,000) 0 6 Less than $50,000 If “no,” ask 07 ($35,000 to less than $50,000) 0 7 Less than $75,000 If “no,” code 08 ($50,000 to less than $75,000) 0 8 $75,000 or more Do not read:
7 7 Don’t know / Not sure 9 9 Refused 8 .18 Have you used the internet in the past 30 days? (1 77) 1 Yes 2 No 7 Don’t know/Not sure 9 Refused 8 .19 About how much do you weigh without shoes? (1 78- 181 ) NOTE : If respondent answers in metrics, put “9” in column 1 78. Round fractions up 23 _ _ _ _ Weight (pounds/kilograms) 7 7 7 7 Don’t know / Not sure 9 9 9 9 Refused 8 .2 0 About how tall are you without shoes? (1 82- 185) NOTE: If respondent answers in metrics, put “9” in column 1 82. Round fractions down _ _ / _ _ Height (f t / inches/meters/centimeters) 7 7/ 7 7 Don’t know / Not sure 9 9/ 9 9 Refused If male, go to 8 .22, if female respondent is 45 years old or older, go to Q 8.2 2 8 .2 1 To your knowledge, are you now pregnant? (1 86) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused The following questions are about health problems or impairments you may have. Some people who are deaf or have serious difficulty hearing may or may not use equipment to communicate by phone. 8 .2 2 Are you deaf or do you have serious difficulty hearing? (187) 1 Yes 2 No 7 Don’t know / Not Sure 9 Refused 8 .2 3 Are you blind or do you have serious difficulty seeing, even when wearing glasses? ( 188) 1 Yes 2 No 7 Don’t know / Not Sure 24 9 Refused 8 .2 4 Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions ? (189) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 8 .2 5 Do you have serious difficulty walking or climbing stairs ? (1 90) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 8 .2 6 Do you have difficulty dressing or bathing? (1 91) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 8 .2 7 Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? (192) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused Section 9 : Tobacco Use 9.1 Have you smoked at least 100 cigarettes in your entire life? (1 93) INTERVIEWER NOTE: “For cigarettes, do not include: electronic cigarettes (e- cigarettes, NJOY, Bluetip), herbal cigarettes, cigars, cigarillos, little cigars, pipes, bidis, kreteks, water pipes (hookahs ) or marijuana.” NOTE: 5 packs = 100 cigarettes 1 Yes 2 No [Go to Q 9.5] 7 Don’t know / Not sure [Go to Q 9.5] 9 Refused [Go to Q 9.5] 25 9.2 Do you now smoke cigarettes every day, some days, or not at all? (1 94) 1 Every day 2 Some days 3 Not at all [Go to Q 9.4] 7 Don’t know / Not sure [Go to Q 9.5] 9 Refused [Go to Q 9.5] 9 .3 During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking? (1 95) 1 Yes [Go to Q 9.5] 2 No [Go to Q 9.5] 7 Don’t know / Not sure [Go to Q 9.5] 9 Refused [Go to Q 9.5] 9 .4 How long has it been since you last smoked a cigarette, even one or two puffs? (196- 197) 0 1 Within the past month (less than 1 month ago) 0 2 Within the past 3 months (1 month but less than 3 months ago) 0 3 Within the past 6 months (3 months but less than 6 months ago) 0 4 Within the past year (6 months but less than 1 year ago) 0 5 Within the past 5 years (1 year but less than 5 years ago) 0 6 Within the past 10 years (5 years but less than 10 years ago) 0 7 10 years or more 0 8 Never smoked regularly 7 7 Don’t know / Not sure 9 9 Refused 9 .5 Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all? Snus (rhymes with ‘goose’) NOTE: Snus (Swed ish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum. (1 98) 1 Every day 2 Some days 3 Not at all Do not read:
7 Don’t know / Not sure 9 Refused 26 Section 10: E-Cigarettes Read if necessary: E lectronic cigarettes (e- cigarettes) and other electronic “vaping” products include electronic hookahs (e- hookahs), vape pens, e- cigars, and others. These products are battery -powered and usually contain nicotine and flavors such as fruit, mint, or candy. 10.1 Have you ever used an e- cigarette or other electronic “vaping” product, even just one time, in your entire life? (1 99) 1 Yes 2 No [Go to next section] 7 Do t know / Not Sure 9 Refused [Go to next section ] 10.2 Do you now use e -cigarettes or other electronic “vaping” products every day, some days, or not at all? (200 ) 1 Every day 2 Some days 3 Not at all 7 Don’t know / Not 9 Refused Section 11: Alcohol Consumption 11.1 During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor? ( 201- 203) 1 _ _ Days per week 2 _ _ Days in past 30 days 8 8 8 No drinks in past 30 days [Go to next section] 7 7 7 Don’t know / Not sure [Go to next section] 9 9 9 Refused [Go to next section] 11.2 One drink is equivalent to a 12- ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average? (204- 205) 27 NOTE: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.
_ _ Number of drinks 7 7 Don’t know / Not sure 9 9 Refused 11.3 Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI X = 5 for men, X = 4 for women] or more drinks on an occasion?
( 206- 207) _ _ Number of times 8 8 None 7 7 Don’t know / Not sure 9 9 Refused 11. 4 During the past 30 days, what is the largest number of drinks you had on any occasion? ( 208- 209) _ _ Number of drinks 7 7 Don’t know / Not sure 9 9 Refused Section 1 2: Immunization Now I will ask you questions about the flu vaccine. There are two ways to get the flu vaccine, one is a shot in the arm and the other is a spray, mist, or drop in the nose called FluMist™. 12.1 During the past 12 months, have you had either a flu shot or a flu vaccine that was sprayed in your nose?
(210) Read if necessary: A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot. 1 Yes 2 No [Go to Q1 2.3] 7 Don’t know / Not sure [Go to Q1 2.3] 9 Refused [Go to Q1 2.3] 1 2.2 During what month and year did you receive your most recent flu shot injected into your arm or flu vaccine that was sprayed in your nose? (211- 216) _ _ / _ _ _ _ Month / Year 7 7 / 7 7 7 7 Don’t know / Not sure 9 9 / 9 9 9 9 Refused 28 12.3 A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person’s lifetime and is different from the flu shot. Have you ever had a pneumonia s hot?
(2 17) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 12.4. Since 2005, have you had a tetanus shot? (218) If ye s, ask: “Was this Tdap, the tetanus shot that also has pertussis or whooping cough vaccine?” 1 Yes, received Tdap 2 Yes, received tetanus shot, but not Tdap 3 Yes, received tetanus shot but not sure what type 4 N o, did not receive any tetanus since 2005 7 Don’t know/Not sure 9 Refused Section 13: Falls If respondent is 45 years or older continue, otherwise go to next section. The next questions ask about recent falls. By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level. 13.1 In the past 12 months, how many times have you fallen? (2 19– 220) _ _ Number of times [76 = 76 or more] 8 8 None [Go to next section] 7 7 Don’t know / Not sure [Go to next section] 9 9 Refused [Go to next section] 13.2 [Fill in “Did this fall (from Q 13.1) cause an injury?”]. If only one fall from Q 13.1 and response is “Yes” (caused an injury); code 01. If response is “No,” code 88 . 29 How many of these falls caused an injury? By an injury, we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor. (221– 222) _ _ Number of falls [76 = 76 or more] 8 8 None 7 7 Don’t know / Not sure 9 9 Refused Section 1 4: Seatbelt Use 14.1 How often do you use seat belts when you drive or ride in a car ? Would you say — (2 23) Please read:
1 Always 2 Nearly always 3 Sometimes 4 Seldom 5 Never Do not read: 7 Don’t know / Not sure 8 Never drive or ride in a car 9 Refused CATI note: If Q1 4.1 = 8 (Never drive or ride in a car), go to Section 1 6; o therwise continue. Section 1 5: Drinking and Driving CATI note: If Q11.1 = 888 (No drinks in the past 30 days); go to next section. 15.1 During the past 30 days, how many times have you driven when you’ve had perhaps too much to drink? (2 24- 225 ) _ _ Number of times 8 8 None 7 7 Don’t know / Not sure 9 9 Refused 30 Section 16: Breast and Cervical Cancer Screening CATI NOTE: If male go to the next section. The next questions are about breast and cervical cancer. 16.1 A mammogram is an x -ray of each breast to look for breast cancer. Have you ever had a mammogram? (2 26) 1 Yes 2 No [Go to Q 16.3] 7 Don’t know / Not sure [Go to Q 16.3] 9 Refused [Go to Q 16.3] 16.2 How long has it been sinc e you had your last mammogram? (2 27) 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago 7 Don’t know / Not sure 9 Refused 16.3 A Pap test is a test for cancer of the cervix. Have you ever had a Pap test? (228) 1 Yes 2 No [Go to Q 16.5] 7 Don’t know / Not sure [Go to Q 16.5] 9 Refused [Go to Q 16.5] 16.4 How long has it been since you had your last Pap test? (2 29) 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago 7 Don’t know / Not sure 9 Refused Now, I would like to ask you about the Human Papillomavirus (Pap·uh·loh·muh virus) or HPV test .
31 16.5 An HPV test is sometimes given with the Pap test for cervical cancer screening. Have you ever had an HPV test? (2 30) 1 Yes 2 No [Go to Q 16.7] 7 Don’t know/Not sure [Go to Q 16.7] 9 Refused [Go to Q 16.7] 16.6 How long has it been since you had your last HPV test? (2 31) 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago 7 Don’t know / Not sure 9 Refused CAT I NOTE : If response to Core Q8 .21 = 1 (is pregnant); then go to next section. 16.7 Have you had a hysterectomy? (2 32) Read only if necessary: A hysterectomy is an operation to remove the uterus (womb). 1 Yes 2 No 7 Don’t know / Not sure 9 Refused Section 1 7: Prostate Cancer Screening CATI note: If respondent is <39 years of age, or is female, go to next section. Now, I will ask you some questions about prostate cancer screening. 1 7.1 A Prostate-Specific Antigen test, also called a PSA test, is a blood test used to check men for prostate cancer. Has a doctor, nurse, or other health professional EVER talked with you about the advantages of the PSA test? (2 33) 1 Yes 2 No 7 Don’t Know / Not sure 9 Refused 32 17.2 Has a doctor, nurse, or other health professional EVER talked with you about the disadvantages of the PSA test? (2 34) 1 Yes 2 No 7 Don’t Know / Not sure 9 Refused 1 7.3 Has a doctor, nurse, or other health professional EVE R recommended that you have a PSA test? (2 35) 1 Yes 2 No 7 Don’t Know / Not sure 9 Refused 1 7.4. Have you EVER HAD a PSA test? (2 36) 1 Yes 2 No [Go to next section] 7 Don’t Know / Not sure [Go to next section] 9 Refused [Go to next section] 1 7.5. How long has it been since you had your last PSA test? (2 37) Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years) 3 Within the past 3 years (2 years but less than 3 years) 4 Within the past 5 years (3 years but less than 5 years) 5 5 or more years ago Do not read:
7 Don’t know / Not sure 9 Refused 1 7.6. What was the MAIN reason you had this PSA test – was it …? (238) Please read:
1 Part of a routine exam 2 Because of a prostate problem 3 Because of a family history of prostate cancer 4 Because you were told you had prostate cancer 5 Some other reason 33 Do not read: 7 Don’t know / Not sure 9 Refused Section 18: Colorectal Cancer Screening CATI note: If respondent is < 49 years of age, go to next section. The next questions are about colorectal cancer screening. 1 8.1 A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit? (2 39) 1 Yes 2 No [Go to Q 18.3] 7 Don't know / Not sure [Go to Q1 8.3] 9 Refused [Go to Q1 8.3] 1 8.2 How long has it been since you had your l ast blood stool test using a home kit? (2 40) Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago Do not read:
7 Don't know / Not sure 9 Refused 1 8.3 Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems. Have you ever had either of these exams? ( 2 41) 1 Yes 2 No [Go to next section] 7 Don’t know / Not sure [Go to next section] 9 Refused [Go to next section] 34 18.4 For a SIGMOIDOSCOPY, a flexible tube is inserted into the rectum to look for problems. A COLONOSCOPY is similar, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test. W as your MOST RECENT exam a sigmoidoscopy or a colonoscopy?
(2 42) 1 Sigmoidoscopy 2 Colonoscopy 7 Don’t know / Not sure 9 Refused 1 8.5 How long has it been since you had your last sigmoidoscopy or colonoscopy? (2 43) Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 Within the past 10 years (5 years but less than 10 years ago) 6 10 or more years ago Do not read:
7 Don't know / Not sure 9 Refused Section 1 9: HIV/AIDS The next few questions are about the national health problem of HIV, the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don’t have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had. 1 9.1 Not counting tests you may have had as part of blood donation, have you ever been tested for HIV? Include testing fluid from your mouth. (2 44) 1 Yes 2 No [Go to Q 19.3 ] 7 Don’t know / Not sure [Go to Q 19.3 ] 9 Refused [Go to Q 19.3 ] 1 9.2 Not including blood donations, in what month and year was your last HIV test? ( 2 45- 250 ) 35 NOTE: If response is before January 1985, code “Don’t know.” CATI INSTRUCTION: If the respondent remembers the year but cannot remember the month, code the first two digits 77 and the last four digits for the year. _ _ /_ _ _ _ Code month and year 7 7/ 7 7 7 7 Don’t know / Not sure 9 9/ 9 9 9 9 Refused / No t sure 1 9.3 I am going to read you a list. When I am done, please tell me if any of the situations apply to you. You do not need to tell me which one. (2 51) You have used intravenous drugs in the past year. You have been treated for a sexually transmitted or venereal disease in the past year. You have given or received money or drugs in exchange for sex in the past year. You had anal sex without a condom in the past year. You had four or more sex partners in the past year. Do any of these situations apply to you? 1 Yes 2 No 7 Don’t know / Not sure 9 Refused Closing Statement or Transition to Modules and/or State -Added Questions Closing statement Please read:
That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation. Or Transition to modules and/or state -added questions Please read: Finally, I have just a few questions left about some other health topics. 36 Optional Modules Module 1: Pre-Diabetes NOTE: Only asked of those not responding “Yes” (code = 1) to Core Q 6.12 (Diabetes awareness question). 1. Have you had a test for high blood sugar or diabetes within the past three years? (3 00) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused CATI note: If Core Q 6.12 = 4 (No, pre -diabetes or borderline diabetes); answer Q2 “Yes” (code = 1). 2 Have you ever been told by a doctor or other health professional that you have pre- diabetes or borderline diabetes? If “Yes” and respondent is female, ask: “Was this onl y when you were pregnant?” (3 01) 1 Yes 2 Yes, during pregnancy 3 No 7 Don’t know / Not sure 9 Refused Module 2: Diabetes CATI note: To be asked following Core Q 6.13; if response to Q6.12 is "Yes" (code = 1) 1. Are you now taking insulin? (3 02) 1 Yes 2 No 9 Refused 37 2. About how often do you check your blood for glucose or sugar? Include times when checked by a family member or friend, but do NOT include times when checked by a health professional. (3 03- 305 ) 1 _ _ Times per day 2 _ _ Times per week 3 _ _ Times per month 4 _ _ Times per year 8 8 8 Never 7 7 7 Don’t know / Not sure 9 9 9 Refused Interviewer Note : If the respondent uses a continuous glucose monitoring system (a sensor inserted under the skin to check glucose levels continuously), fill in ‘98 times per day.’ 3 . About how often do you check your feet for any sores or irritations? Include times when checked by a family member or friend, but do NOT include times when checked by a health professional. (3 06- 30 8) 1 _ _ Times per day 2 _ _ Times per week 3 _ _ Times per month 4 _ _ Times per year 5 5 5 No feet 8 8 8 Never 7 7 7 Don’t know / Not sure 9 9 9 Refused 4 . About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes? ( 3 09-3 1 0) _ _ Number of times [7 6 = 76 or more] 8 8 None 7 7 Don’t know / Not sure 9 9 Refused 5 . A test for "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for "A one C"? (3 11-3 1 2) _ _ Number of times [76 = 76 or more] 8 8 None 9 8 Never heard of “A one C” test 7 7 Don’t know / Not sure 9 9 Refused CATI note: If Q 3 = 555 (No feet), go to Q 7.
38 6. About how many times in the past 12 months has a health professional checked your feet for any sores or irritations? ( 3 13-3 1 4) _ _ Number of times [76 = 76 or more] 8 8 None 7 7 Don’t know / Not sure 9 9 Refused 7 . When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light. ( 3 15) Read only if necessary: 1 Within the past month (anytime less than 1 month ago) 2 Within the past year (1 month but less than 12 months ago) 3 Within the past 2 years (1 year but less than 2 years ago) 4 2 or more years ago Do not read: 7 Don’t know / Not sure 8 Never 9 Refused 8 . Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
(3 16) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 9 . Have you ever taken a course or class in how to manage your diabetes yourself? ( 3 17) 1 Yes 2 No 7 Don't know / Not sure 9 Refused 39 Module 3: Healthy Days (Symptoms) The next few questions are about health- related problems or symptoms.
1. During the past 30 days, for about how many days did pain make it hard for you to do your usual activities, such as self -care, work, or recreation? (3 18-3 1 9) _ _ Number of days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused 2. During the past 30 days, for about how many days have you felt sad, blue, or depressed? (3 20- 32 1) _ _ Number of days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused 3. During the past 30 days, for about how many days have you felt worried, tense, or anxious? (3 22-3 2 3) _ _ Number of days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused 4. During the past 30 days, for about how many days have you felt very healthy and full of energy? (3 24-3 2 5) _ _ Number of days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused Module 4: Health Care Access 1 . Do you have Medicare? (3 26) 1 Yes 2 No 7 Don’t know/Not sure 9 Refused 40 Note: Medicare is a coverage plan for people age 65 or over and for certain disabled people.
2. What is the primary source of your health care coverage? Is it… (3 27- 328 ) Please Read 01 A plan purchased through an employer or union (includes plans purchased through another person's employer) 02 A plan that you or another family member buys on your own 03 Medicare 04 Medicaid or other state program 05 TRICARE (formerly CHAMPUS), VA, or Military 06 Alaska Native, Indian Health Service, Tribal Health Services Or 07 Some other source 08 None (no coverage) Do not read:
77 Don't know/Not sure 99 Refused INTERVIEWER NOTE: If the respondent indicates that they purchased health insurance through the Health Insurance Marketplace (name of state Marketplace), ask if it was a private health insurance plan purchased on their own or by a family member (private) or if they received Medicaid (state plan)? If purchased on their ow n (or by a family member), select 02, if Medicaid select 04. CATI NOTE: G o to Core Q3.2. 3 . Other than cost, there are many other reasons people delay getting needed medical care. Have you delayed getting needed medical care for any of the following reasons in the past 12 months? Select the most important reason. (3 29) Please read 1 You couldn’t get through on the telephone. 2 You couldn’t get an appointment soon enough. 3 Once you got there, you had to wait too long to see the doctor .
4 The (clinic/doctor’s) office wasn’t open when you got there. 5 You didn’t have transportation. Do not read:
6 Other ____________ ( specify) (330-3 54 ) 8 No, I did not delay getting medical care/did not need medical care 7 Don’t know/Not sure 9 Refused 41 CATI NOTE: G o to Core Q3.4. CATI NOTE: If Q3.1 = 1 (Yes) continue, else go to Q4b .
4a. In the PAST 12 MONTHS was there any time when you did NOT have ANY health insurance or coverage? (3 55) 1 Yes [Go to Q5] 2 No [Go to Q5] 7 Don’t know/Not sure [Go to Q5] 9 Refused [Go to Q5] CATI Note: If Q3.1 = 2, 7, or 9 continue, else go to next question (Q5). 4b . About how long has it been since you last had health care coverage? (3 56) 1 6 months or less 2 More than 6 months, but not more than 1 year ago 3 More than 1 year, but not more than 3 years ago 4 More than 3 years 5 Never 7 Don’t know/Not sure 9 Refused 5 . How many times have you been to a doctor, nurse, or other health professional in the past 12 months? (3 57- 358 ) _ _ Number of times 8 8 None 7 7 Don’t know/Not sure 9 9 Refused 6 . Not including over the counter (OTC) medications, was there a time in the past 12 months when you did not take your medication as prescribed because of cost? (3 59) 1 Yes 2 No Do not read:
3 No medication was prescribed 7 Don’t know/Not sure 9 Refused 42 7. In general, how satisfied are you with the health care you received? W ould you say — Please read: ( 360 ) 1 Very satisfied 2 Somewhat satisfied 3 Not at all satisfied Do not read : 8 Not applicable 7 Don’t know/Not sure 9 Refused 8 . Do you currently have any health care bills that are being paid off over time? (3 61) INTERVIEWER NOTE: This could include medical bills being paid off with a credit card, through personal loans, or bill paying arrangements with hospitals or other providers. The bills can be from earlier years as well as this year. INTERVIEWER NOTE: Health care bills can include medical, dental, physical therapy and/or chiropractic cost. 1 Yes 2 No 7 Don’t know/Not sure 9 Refused CATI NOTE: Go to Core Section 4. Module 5: Health Literacy 1. How difficult is it for you to get advice or information about health or medical topics if you need it? Would you say it is … (362) Please read 1. Very easy 2. Somewhat easy 3. Somewhat difficult 4. Very difficult 5. I don’t look for health information Do not read 7. Don’t know/not sure 9. Refused 43 INTERVIEWER NOTE: Respondent can answer based on any source of health or medical advice or information. If the respondent asks what is meant by advice or information, interviewer re -reads the question to the respondent. If the respondent still doesn’t understand, interviewer can say, “You can think about any source of health or medical advice or information.” 2. How difficult is it for you to understand information that doctors, nurses and other health professionals tell you? Would you say it is … (363) Please read 1. Very easy 2. Somewhat easy 3. Somewhat difficult 4. Very difficult Do not read 7. Don’t know/not sure 9. R efused 3. You can find written information about health on the Internet, in newspapers and magazines, and in brochures in the doctor’s office and clinic. In general, how difficult is it for you to understand written health information? Would you say it is … (364) Please read 1. Very easy 2. Somewhat easy 3. Somewhat difficult 4. Very difficult 5. I don’t pay attention to written health information Do not read 7. Don’t know/not sure 9. Refused Module 6: Caregiver People may provide regular care or assistance to a friend or family member who has a health problem or disability. 1. During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability? (365) 44 INTERVIEWER INSTRUCTIONS: If caregiving recipient has died in the past 30 days, say “I’m so sorry to hear of your loss.” and code 8. 1. Yes 2. No [Go to Question 9] 7 Don’t know/Not sure [Go to Question 9] 8 Caregiving recipient died in past 30 days [Go to next module] 9 Refused [Go to Question 9] 2. What is his or her relationship to you ?
INTERVIEWER NOTE: If more than one person, say: “Please refer to the person to whom you are giving the most care.” (366- 367) 01 Mother 02 Father 03 Mother -in -law 04 Father -in -law 05 Child 06 Husband 07 Wife 08 Live in partner 09 Brother or brother -in -law 10 Sister or sister -in -law 11 Grandmother 12 Grandfather 13 Grandchild 14 Other relative 15 Non-relative/Family friend 77 Don’t know/Not sure 99 Refused 3. For how long have you provided care for that person? Would you say… (368) 1 Less than 30 days 2 1 month to less than 6 months 3 6 months to less than 2 years 4 2 years to less than 5 years 5 More than 5 years 45 7 Don’t Know/ Not Sure 9 Refused 4. In an average week, how many hours do you provide care or assistance? Would you say… (369) 1 Up to 8 hours per week 2 9 to 19 hours per week 3 20 to 39 hours per week 4 40 hours or more 7 Don’t know/Not sure 9 Refused 5. What is the main health problem, long- term illness, or disability that the person you care for has? (370- 371) IF NECESSARY: Please tell me which one of these conditions would you say is the major problem? [DO NOT READ: RECORD ONE RESPONSE] 1 Arthritis/Rheumatism 2 Asthma 3 Cancer 4 Chronic respiratory conditions such as Emphysema or COPD 5 Dementia or other Cognitive Impairment Disorders 6 Developmental Disabilities such as Autism, Down’s Syndrome, and Spina Bifida 7 Diabetes 8 Heart Disease, Hypertension, Stroke 9 Human Immunodeficiency Virus Infection (HIV) 10 Mental Illnesses, such as Anxiety, Depression, or Schizophrenia 11 Other organ failure or diseases such as kidney or liver problems 12 Substance Abuse or Addiction Disorders 13 Injuries, including broken bones 14 Old age/infirmity/frailty 15 Other 77 Don’t know/Not sure 99 Refused 6. In the past 30 days, did you provide care for this person by… (372) Managing personal care such as giving medications, feeding, dressing, or bathing? 1 Yes 2 No 7 Don’t Know /Not Sure 9 Refused 46 7. In the past 30 days, did you provide care for this person by… (373) Managing household tasks such as cleaning, managing money, or preparing meals? 1 Yes 2 No 7 Don’t Know /Not Sure 9 Refused 8. Of the following support services, which one do YOU most need, that you are not currently getting? (374) [INTERVIEWER NOTE: IF RESPONDENT ASKS WHAT RESPITE CARE IS]: Respite care means short -term or long -term breaks for people who provide care. [READ OPTIONS 1 – 6] 1 Classes about giving care, such as giving medications 2 Help in getting access to services 3 Support groups 4 Individual counseling to help cope with giving care 5 Respite care 6 You don’t need any of these support services [DO NOT READ] 7 Don’t Know /Not Sure 9 Refused [If Q1 = 1 or 8, GO TO NEXT MODULE] 9. In the next 2 years, do you expect to provide care or assistance to a friend or family member who has a health problem or disability? (375) 1 Yes 2 No 7 Don’t know/Not sure 9 Refused Module 7: Cognitive Decline CAT I N OTE : If respondent is 45 years of age or older continue, else go to next module 47 Introduction: The next few questions ask about difficulties in thinking or remembering that can make a big difference in everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you recently met, which is normal. This refers to confusion or memory loss that is happening more often or getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would normally know. We want to know how these difficulties impact you. 48 1. During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse? (376) 1 Yes 2 No [Go to next module] 7 Don't know [Go to Q2] 9 Refused [Go to next module] 2. During the past 12 months, as a result of confusion or memory loss , how often have you given up day-to -day household activities or chores you used to do, such as cooking, cleaning, taking medications, driving, or paying bills? (377) Please read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don't know 9 Refused 3. As a result of confusion or memory loss, how often do you need assistance with these day -to -day activities? (378) Please read: 1 Always 2 Usually 3 Sometimes 4 Rarely [Go to Q5] 5 Never [Go to Q5] 7 Don't know [Go to Q5] 9 Refused [Go to Q5] CATI NOTE: If Q3 = 1, 2, or 3, continue. If Q3 = 4 ,5, 7, or 9 go to Q5. 4. When you need help with these day -to -day activities, how often are you able to get the help that you need? (3 79) Please read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 49 7 Don't know 9 Refused 5. During the past 12 months, how often has confusion or memory loss i nterfered with your ability to work, volunteer, or engage in social activities outside the home? (380) Please read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don't know 9 Refused 6. Have you or anyone else discussed your confusion or memory loss with a health care professional? (3 81) 1 Yes 2 No 7 Don't know 9 Refused Module 8: Sugar Sweetened Beverages Now I would like to ask you som e questions about sugary beverages. 1 . During the past 30 days, how often did you drink regular soda or pop that contains sugar? Do not include diet soda or diet pop. (382-384) Please read: You can answer times per day, week, or month; for example, twice a day, once a week, and so forth. 1 _ _ Times per day 2 _ _ Times per week 3 _ _ Times per month Do not read:
8 8 8 None 7 7 7 Don’t know / Not sure 9 9 9 Refused 50 2. During the past 30 days, how often did you drink sugar -sweetened fruit drinks (such as Kool -A id and lemonade), sweet tea, and sports or energy drinks (such as Gatorade and Red Bull)? Do not include 100% fruit juice, diet drinks, or artificially sweetened drinks. Please read: You can answer times per day, week, or month: for example, twice a day, once a week, and so forth. (385-387 ) 1 _ _ Times per day 2 _ _ Times per week 3 _ _ Times per month Do not read:
8 8 8 None 7 7 7 Don’t know / Not sure 9 9 9 Refused Module 9: Menu Labeling 1 . The next question is about eating out at fast food and chain restaurants. W hen calorie information is available in the restaurant, how often does this information help you decide what to order? (388- 389) Please read: 01 Always 02 Most of the time 03 About half the time 04 Sometimes 05 Never Do not read: 06 Never noticed or never looked for calorie information 08 Usually cannot find calorie information 55 Do not eat at fast food or chain restaurants 77 Don’t know / Not sure 99 Refused 51 Module 10: Marijuana Use 1. During the past 30 days, on how many days did you use marijuana or hashish? (390- 39 1) _ _ 01 -30 Number of Days 8 8. None [Go to next module] 7 7. Don’t know/not sure [Go to next module] 9 9 . Refused [Go to next module ] 2. During the past 30 days, how did you use marijuana? Please tell me all that apply. Did you…. [INTERVIEWER NOTE: Use clarification in parentheses only if needed. Please slowly read all modes in succession ] 1 Smoke it? (for example: in a joint, bong, pipe, or blunt) (392- 397) 2 Eat it? (for example, in brownies, cakes, cookies, or candy) 3 Drink it? (for example, in tea, cola, alcohol) 4 Vaporize it ? (fo r example in an e -cigarette -like vaporizer) 5 Dab it? (for example using butane hash oil, wax or concentrates) or 6 Was it used in some other way? 7 Don’t know/Not sure 9 Refused Module 11: Sleep Disorder I would like to ask you a few questions about your sleep patterns. 1. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much? (398 -399) __ __ 01 -14 days 8 8 None 7 7 Don’t know/Not sure 9 9 Refused 52 2. Over the last 2 weeks, how many days did you unintentionally fall asleep during the day? (400 -401 ) __ __ 01 -14 days 8 8 None 7 7 Don’t know/Not sure 9 9 Refused 3. Have you ever been told that you snore loudly? (402 ) 1 Yes 2 No 7 Don’t know/Not sure 9 Refused 4. Has anyone ever observed that you stop breathing during your sleep? (403 ) INTERVIEWER NOTE: Also enter “yes” if respondent mentions having a machine or CPAP that records that breathing sometimes stops during the night. 1 Yes 2 No 7 Don’t know/Not sure 9 Refused Module 12: Adult Asthma History CAT I NOTE : If "Yes" to Core Q 6.4; continue. Otherwise, go to next module. Previously you said you were told by a doctor, nurse or other health professional that you had asthma. 1. How old were you when you were first told by a doctor, nurse, or other health professional that you had asthma? ( 404- 405) _ _ Age in years 11 or older [96 = 96 and older] 9 7 Age 10 or younger 9 8 Don’t know / Not sure 9 9 Refused 53 CAT I NOTE : If "Yes" to Core Q 6.5, continue. Otherwise, go to next module. 2. During the past 12 months, have you had an episode of asthma or an asthma attack? (4 06) 1 Yes 2 No [Go to Q5 ] 7 Don’t know / Not sure [Go to Q5] 9 Refused [Go to Q5] 3. During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma?
(407- 408) _ _ Number of visits [87 = 87 or more] 8 8 None 9 8 Don’t know / Not sure 9 9 Refused 4. [If one or more visits to Q3, fill in “Besides those emergency room or urgent care center visits,”] During the past 12 months, how many times did you see a doctor, nurse or other health professional for urgent treatment of worsening asthma symptoms? ( 409- 41 0) _ _ Number of visits [87 = 87 or more] 8 8 None 9 8 Don’t know / Not sure 9 9 Refused 5. During the past 12 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma? (411- 412) _ _ Number of visits [87 = 87 or more] 8 8 None 9 8 Don’t know / Not sure 9 9 Refused 6. During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma? (413- 415) _ _ _ Number of days 8 8 8 None 7 7 7 Don’t know / Not sure 9 9 9 Refused 54 7. Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness and phlegm production when you don’t have a cold or respiratory infection. During the past 30 days, how often did you have any symptoms of asthma? Would you say — ( 416) NOTE: Phlegm (‘flem’) Please read: 8 Not at any time [Go to Q9] 1 Less than once a week 2 Once or twice a week 3 More than 2 times a week, but not every day 4 Every day, but not all the time Or 5 Every day, all the time Do not read:
7 Don’t know / Not sure 9 Refused 8. During the past 30 days, how many days did symptoms of asthma mak e it difficult for you to stay asleep? Would you say — (417) Please read:
8 None 1 One or two 2 Three to four 3 Five 4 Six to ten Or 5 More than ten Do not read: 7 Don’t know / Not sure 9 Refused 9. During the past 30 days, how many days did you take a prescription asthma medication to PREVENT an asthma attack from occurring? (418) Please read: 8 Never 1 1 to 14 days 2 15 to 24 days 3 25 to 30 days Do not read: 55 7 Don’t know / Not sure 9 Refused 10. During the past 30 days, how often did you use a prescription asthma inhaler DURING AN ASTHMA ATTACK to stop it? (419) INTERVIEWER INSTRUCTION: How often (number of times) does NOT equal number of puffs. Two to three puffs are usually taken each time the inhaler is used. Read only if necessary: 8 Never (include no attack in past 30 days) 1 1 to 4 times (in the past 30 days) 2 5 to 14 times (in the past 30 days) 3 15 to 29 times (in the past 30 days) 4 30 to 59 times (in the past 30 days) 5 60 to 99 times (in the past 30 days) 6 100 or more times (in the past 30 days) Do not read:
7 Don’t know / Not sure 9 Refused Module 13: Influenza CATI Note: If Q1 2.1 = 1 (Yes) then continue, else go to next module. Earlier, you told me you had received an influenza vaccination in the past 12 months. Please read only if necessary: At what kind of place did you get your last flu shot/vaccine? (420- 421) 0 1 A doctor’s office or health maintenance organization (HMO) 0 2 A health department 0 3 Another type of clinic or health center (Example: a community health center) 0 4 A senior, recreation, or community center 0 5 A store (Examples: supermarket, drug store) 0 6 A hospital (Example: inpatient) 0 7 An emergency room 56 0 8 Workplace 0 9 Some other kind of place 1 0 Received vaccination in Canada/Mexico (Volunteered – Do not read) 1 1 A school 7 7 Don’t know / Not sure ( Probe: “How would you describe the place where you went to get your most recent flu vaccine?” Do not read: 9 9 Refused Module 14: Adult Human Papillomavirus (HPV ) CATI note: To be asked of respondents between the ages of 18 and 49 years; otherwise, go to next module. NOTE: Human Papillomavirus (Human P ap·uh·loh·muh virus); Gardasil (Gar·duh· seel); Cervarix (Sir·var· icks) 1. A vaccine to prevent the human papillomavirus or HPV infection is available and is called the cervical cancer or genital warts vaccine, HPV shot, [Fill: if female “GARDASIL or CERVARIX”; if male “ or GARDASIL”]. Have you EVER had an HPV vaccination? ( 422) 1 Yes 2 No [Go to next module] 3 Doctor refused when asked [Go to next module] 7 Don’t know / Not sure [Go to next module] 9 Refused [Go to next module] 2. How many HPV shots did you receive?
(423- 424) _ _ Number of shots 0 3 All shots 7 7 Don’t know / Not sure 9 9 Refused Module 15: S hingles CATI NOTE: If respondent is ˃ 49 years of age go to next module .
1. Shingles is caused by the chicken pox virus. It is an outbreak of rash or blisters on the skin that may be associated with severe pain. A vaccine for shingles has been available since May 2006; it is called Zostavax ®, the zoster vaccine, or the shingles vaccine. Have you had this vaccine? (425) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 57 Module 16: Excess Sun Exposure 1. In the past 12 months, how many times did you have a red OR painful sunburn that lasted a day or more?
(426) 8 Zero 1 One 2 Two 3 Three 4 Four 5 Five or more 7 Don’t know / Not sure 9 Refused Module 1 7: Cancer Survivorship CATI note: If Core Q6.6 or Q6.7 = 1 (Yes) or Q17 .6 = 4 (Because you were told you had prostate cancer) continue, else go to next module. You’ve told us that you have had cancer. I would like to ask you a few more questions about your cancer. 1. How many different types of cancer have you had? (427) 1 Only one 2 Two 3 Three or more 7 Don’t know / Not sure [Go to next mo dule] 9 Refused [Go to next module] 2. At what age were you told that you had cancer? (428- 429) _ _ Code age in years [97 = 97 and older] 9 8 Don’t know / Not sure 9 9 Refused CATI note: If Q1= 2 (Two) or 3 (Three or more), ask: “At what age were you first diagnosed with cancer?” INTERVIEWER NOTE: This question refers to the first time they were told about their first cancer. 58 CATI note: If Core Q6.6 = 1 (Yes) and Q1 = 1 (Only one): ask “W as it “Melanoma” or “other skin cancer”? then c ode 21 if “Melanoma” or 22 if “other skin cancer” CATI note: If Core Q16.6 = 4 (Because you were told you had Prostate Cancer) and Q1 = 1 (Only one) then code 19. 3. What type of cancer was it?
(430- 431) If Q1 = 2 (Two) or 3 (Three or more), ask: “W ith your most recent diagnoses of cancer, what type of cancer was it?” INTERVIEWER NOTE: Please read list only if respondent needs prompting for cancer type (i.e., name of cancer) [1 -30]: Breast 0 1 Breast cancer Female reproduct ive (Gynecologic) 0 2 Cervical cancer (cancer of the cervix) 0 3 Endometrial cancer (cancer of the uterus) 0 4 Ovarian cancer (cancer of the ovary) Head/Neck 0 5 Head and neck cancer 0 6 Oral cancer 0 7 Pharyngeal (throat) cancer 0 8 Thyroid 0 9 Larynx Gastrointestinal 1 0 Colon (intestine) cancer 1 1 Esophageal (esophagus) 1 2 Liver cancer 1 3 Pancreatic (pancreas) cancer 1 4 Rectal (rectum) cancer 1 5 Stomach Leukemia/Lymphoma (lymph n odes and bone marrow) 1 6 Hodgkin's Lymphoma (Hodgkin’s disease) 1 7 Leukemia (blood) cancer 1 8 Non-Hodgkin’s Lymphoma Male reproductive 1 9 Prostate cancer 2 0 Testicular cancer Skin 2 1 Melanoma 2 2 Other skin cancer 59 Thoracic 2 3 Heart 2 4 Lung Urinary cancer: 2 5 Bladder cancer 2 6 Renal (kidney) cancer Others 2 7 Bone 2 8 Brain 2 9 Neuroblastoma 3 0 Other Do not read:
7 7 Don’t know / Not sure 9 9 Refused 4. Are you currently receiving treatment for cancer? By treatment, we mean surgery, radiation therapy, chemotherapy, or chemotherapy pills. (432) 1 Yes [Go to next module] 2 No, I’ve completed treatment 3 No, I’ve refused treatment [Go to next mo dule] 4 No, I haven’t started treatment [Go to next module] 7 Don’t know / Not sure [Go to next module] 9 Refused [Go to next module] 5. What type of doctor provides the majority of your health care? (433- 434) INTERVIEWER NOTE: If the respondent requests clarification of this question, say: “We want to know which type of doctor you see most often for illness or regular health care (Examples: annual exams and/or physicals, treatment of colds, etc.).” 60 Please read [1- 10]:
0 1 Cancer Surgeon 0 2 Family Practitioner 0 3 General Surgeon 0 4 Gynecologic Oncologist 0 5 General Practitioner, Internist 0 6 Plastic Surgeon, Reconstructive Surgeon 0 7 Medical Oncologist 0 8 Radiation Oncologist 0 9 Urologist 1 0 Other Do not read: 7 7 Don’t know / Not sure 9 9 Refused 6. Did any doctor, nurse, or other health professional EVER give you a written summary of all the cancer treatments that you received? (435) Read only if necessary: “By ‘other healthcare professional’, we mean a nurse practitioner, a physician’s assistant, social worker, or some other licensed professional.” 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 7. Have you EV ER received instructions from a doctor, nurse, or other health professional about where you should return or who you should see for routine cancer check-ups after completing your treatment for cancer?
(436) 1 Yes 2 No [Go to Q9] 7 Don’t know / Not sure [Go to Q9] 9 Refused [Go to Q9] 8. Were these instructions written down or printed on paper for you? (437) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 61 9. With your most recent diagnosis of cancer, did you have health insurance that paid for all or part of your cancer treatment?
(438) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused INTERVIEWER NOTE: “Health insurance” also includes Medicare, Medicaid, or other types of state health programs. 10. Were you EVER denied health insurance or life insurance coverage because of your cancer?
(439) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 11. Did you participate in a clinical trial as part of your cancer treatment? (440) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused 12. Do you currently have physical pain caused by your cancer or cancer treatment?
(441) 1 Yes 2 No [Go to next module] 7 Don’t know / Not sure [Go to next module] 9 Refused [Go to next module] 13. Is your pain currently under control? (442) Please read: 1 Yes, with medication (or treatment) 2 Yes, without medication (or treatment) 3 No, with medication (or treatment) 4 No, without medication (or treatment) Do not read:
62 7 Don’t know / Not sure 9 Refused Module 1 8: Clinical Breast Exam for Women’s Health CATI NOTE: If respondent is male, go to the next section. 1. A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you ever had a clinical breast exam? (443) 1 Yes 2 No [Go to next module] 7 Don’t know / Not sure [Go to next module] 9 Refused [Go to next mo dule] 2. How long has it been since your last breast exam? (444) 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago 7 Don’t know / Not sure 9 Refused Module 1 9: Prostate Cancer Screening Decision Making CAT I NOTE : If core section Q1 7, question 4 = 1 (has had a PSA test) continue, el se go to next module. 1. Which one of the following best describes the decision to have the PSA test done? (445) Please read :
1 You made the decision alone [Go to next module] 2 Your doctor, nurse, or health care provider made the decision alone [Go to next module] 3 You and one or more other persons made the decision together 4 You don’t remember how the decision was made [Go to next module] Do not read: 9 Refused 63 2. Who made the decision with you? (Mark all that apply) (446- 449) 1 Doctor/nurse /health care provider 2 Spouse/significant other 3 Other family member 4 Friend/non- relative 8 No additional choices 7 Don’t know / Not sure 9 Refused Module 20: Industry and Occupation If Core Q8.15 = 1 or 4 (Employed for wages or out of work for less than 1 year) or 2 (Self- employed), continue else go to next module. Now I am going to ask you about your work. If Core Q8. 15 = 1 (Employed for wages) or 2 (Self- employed) ask, 1 . What kind of work do you do? For example, registered nurse, janitor, cashier, auto mechanic. INTERVIEWER NOTE: If respondent is unclear, ask “What is your job title?” INTERVIEWER NOTE: If respondent has more than one job then ask, “What is your main job?” [Record answer] _________________________________ (450-549) 99 Refused Or If Core Q8. 15 = 4 (Out of work for less than 1 year) ask, What kind of work did you do? For example, registered nurse, janitor, cashier, auto mechanic. INTERVIEWER NOTE: If respondent is unclear, ask “What was your job title?” INTERVIEWER NOTE: If respondent has more than one job then ask, “What was your main job?” [Record answer] _________________________________ 99 Refused 64 If Core Q8. 15 = 1 (Employed for wages) or 2 (Self- employed) ask, 2. What kind of business or industry do you work in? For example, hospital, elementary school, clothing manufacturing, restaurant. [Record answer] _________________________________ (550-649) 99 Refused Or If Core Q8. 15 = 4 (Out of work for less than 1 year) ask, What kind of business or industry did you work in? For example, hospital, elementary school, clothing manufacturing, restaurant. [Record answer] _________________________________ 99 Refused Module 2 1: Sexual Orientation and Gender Identity The next two questions are about sexual orientation and gender identity. INTERVIEWER NOTE: We ask this question in order to better understand the health and health care needs of people with different sexual orientations. INTERVIEWER NOTE: Please say the number before the text response. Respondent can answer with either the number or the text/word. 1. Do you consider y ourself to be: (6 50) Please read: 1 Straight 2 Lesbian or gay 3 Bisexual Do not read:
4 Other 7 Don’t know/Not sure 9 Refused 65 2. Do you consider yourself to be transgender? ( 651) If yes, ask “Do you consider yourself to be 1. male -to -female, 2. female- to-male, or 3. gender non- conforming?
INTERVIEWER NOTE: Please say the number before the “yes” text response. Respondent can answer with either the number or the text/word. 1 Yes, Transgender, male- to-female 2 Yes, Transgender, female to male 3 Yes, Transgender, gender nonconforming 4 No 7 Don’t know/not sure 9 Refused INTERVIEWER NOTE: If asked about definition of transgender: Some people describe themselves as transgender when they experience a different gender identity from their sex at birth. For example, a person born into a male body, but who feels female or lives as a woman would be transgender. Some transgender people c hange their physical appearance so that it matches their internal gender identity. Some transgender people take hormones and some have surgery. A transgender person may be of any sexual orientation – straight, gay, lesbian, or bisexual. INTERVIEWER NOTE: If asked about definition of gender non -conforming : Some people think of themselves as gender non -conforming when they do not identify only as a man or only as a woman. Module 22: Random Child Selection CAT I NOTE : If Core Q 8.1 6 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module. If Core Q 8.1 6 = 1, Interviewer please read: “ Previously, you indicated there was one child age 17 or younger in your household. I would like to ask you some questions about that child.” [Go to Q1] If Core Q 8.1 6 is >1 and Core Q 8.1 6 does not equal 88 or 99, Interviewer please read: “Previously, you indicated there were [number] children age 17 or younger in your household. Think about those [number] children in order of their birth, from oldest to youngest. The oldest child is the first child and the youngest child is the last. Please include children with the same birth date, including twins, in the order of their birth.” 66 CATI INSTRUCTION: RANDOMLY SELECT ONE OF THE CHILDREN. This is the “Xth” child.
Please substitute “Xth” child’s number in all questions below. INTERVIEWER PLEASE READ: I have some additional questions about one specific child. The child I will be referring to is the “Xth” [C AT I:
please fill in correct number] child in your household. All following questions about children will be about the “Xth” [CATI: please fill in] child. 1. What is the birth month and year of the “ Xth” child? (6 52-6 5 7) _ _ /_ _ _ _ Code month and year 7 7/ 7 7 7 7 Don’t know / Not sure 9 9/ 9 9 9 9 Refused CATI INSTRUCTION: Calculate the child’s age in months (CHLDAGE1=0 to 216) and also in years (CHLDAGE2=0 to 17) based on the interview date and the birth month and year using a value of 1 5 for the birth day. If the selected child is < 12 months old enter the calculated months in CHLDAGE1 and 0 in CHLDAGE2. If the child is > 12 months enter the calculated months in CHLDAGE1 and set CHLDAGE2=Truncate (CHLDAGE1/12). 2. Is the child a boy or a girl? (6 58) 1 Boy 2 Girl 9 Refused 3. Is the child Hispanic, Latino/a, or Spanish origin? (659- 662) If yes, ask: Are they… INTERVIEWER NOTE: One or more categories may be selected 1 Mexican, Mexican American, Chicano/a 2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino/a, or Spanish origin Do not read:
5 No 7 Don’t know / Not sure 9 Refused 67 4. Which one or more of the following would you say is the race of the child? (6 63- 692) (Select all that apply) INTERVIEWER NOTE: If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read :
60 Other 88 No additional choices 77 Don’t know / Not sure 99 Refused 5. Which one of these groups would you say best represents the child’s race? (6 93- 694) INTERVIEWER NOTE: If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. 10 White 20 Black or African American 68 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 77 Don’t know / Not sure 99 Refused 6. How are you related to the child? (6 95) Please read:
1 Parent (include biologic, step, or adoptive parent) 2 Grandparent 3 Foster parent or guardian 4 Sibling (include biologic, step, and adoptive sibling) 5 Other relative 6 Not related in any way Do not read:
7 Don’t know / Not sure 9 Refused Module 23: Childhood Asthma Prevalence CAT I NOTE : If response to Core Q 8.1 6 = 88 (None) or 99 (Refused), go to next module. The next two questions are about the “Xth” [CATI: please fill in correct number] child. 69 1. Has a doctor, nurse or other health professional EVER said that the child has asthma? ( 696) 1 Yes 2 No [Go to next module] 7 Don’t know / Not sure [Go to next module] 9 Refused [Go to next module] 2. Does the child still have asthma? (697) 1 Yes 2 No 7 Don’t know / Not sure 9 Refused Module 24: Emotional Support and Life Satisfaction 1. How often do you get the social and emotional support you need? INTERVIEWER NOTE: If asked, say “please include support from any s ource.” (698) Please read:
1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never Do not read:
7 Don't know / Not sure 9 Refused 2. In general, how satisfied are you with your life? (699) Please read:
1 Very satisfied 2 Satisfied 3 Dissatisfied 4 Very dissatisfied 70 Do not read:
7 Don't know / Not sure 9 Refused Module 25: Disability 1. Are you limited in any way in any activities because of physical, mental, or emotional problems? (700) 1 Yes 2 No 7 Don’t know / Not Sure 9 Refused 2 . Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone? (7 01) NOTE: Include occasional use or use in certain circumstances. 1 Yes 2 No 7 Don’t know / Not Sure 9 Refused 71 Asthma Call-Back Permission Script We would like to call you again within the next 2 weeks to talk in more detail about (your/your child’s) experiences with asthma. The information will be used to help develop and improve the asthma programs in < ST AT E >. The information you gave us today and any you give us in the future will be kept confidential.
If you agree to this, we will keep your first name or initials and phone number on file, separate from the answers collected today. Even if you agree now, you or others may refuse to participate in the future. Would it be okay if we called you back to ask additional asthma- related questions at a later time?
(702) 1 Yes 2 No Can I please have either (your/yo ur child’s) first name or initials, so we will know who to ask for when we call back?
____________________ Enter first name or initials. Asthma Call-Back Selection Which person in the household was selected as the focus of the asthma call -back? (703) 1 Adult 2 Child
