Form Assigned NHANES 2007-2008 Attachment 16 (Questionnaires)
National Health and Nutrition Examination Survey (NHANES)
Updated_NHANES 2007-2008 Attachment 16 (Questionnaires)
National Health and Nutrition Examination Survey (NHANES) - Telephone interview (FCBS)
OMB: 0920-0237
Attachment 16
Questionnaire TABLE OF CONTENTS
FAMILY RELATIONSHIP QUESTIONNAIRE 18
SAMPLE PERSON QUESTIONNAIRE 31
INTRODUCTION AND VERIFICATION (IVQ) 35
HOSPITAL UTILIZATION AND ACCESS TO CARE (HUQ) 45
CARDIOVASCULAR DISEASE (CDQ) 90
RESPIRATORY HEALTH AND DISEASE (RDQ) 99
PHYSICAL ACTIVITY AND PHYSICAL FITNESS (PAQ) 124
DIET BEHAVIOR and NUTRITION - DBQ 131
SMOKING AND TOBACCO USE (SMQ) 159
DEMOGRAPHICS INFORMATION – DMQ – SP 178
DIETARY SUPPLEMENTS AND PRESCRIPTION MEDICATION – DSQ 192
DEMOGRAPHIC BACKGROUND/OCCUPATION – DMQ - fam 230
HOUSING CHARACTERISTICS – HOQ 235
TRACKING AND TRACING (TTQ) 268
RESPONDENT SELECTION (RIQ) 272
CURRENT HEALTH STATUS (HSQ) 274
physical activity AND PHYSICAL FITNESS (paq) 313
SPECIAL FOLLOW-UP QUESTIONNAIRES 362
Flexible Consumer Behavior Survey (FCBS) Module 363
SCQ_INTRO010 Hello, I’m {INTERVIEWER’S NAME} and we are conducting a survey for the ”U.S. Public Health Service” may need to be changed to Centers for Disease Control and Prevention (CDC)
SHOW ID CARD.
A letter was sent to you recently explaining a survey which is called the National Health and Nutrition Examination Survey and is about your family’s health.
IF RESIDENT DOES NOT REMEMBER LETTER, HAND NEW COPY.
All the information that you give us is voluntary and will be kept in the strictest confidence. Your name will not be attached to any of your answers without your specific permission.
SCQ_INTRO020 -- Omitted
SCQ.025 -- Omitted
SCQ.027 INTERVIEWER: IS THIS A DORMITORY ROOM?
YES 1
NO 2
DK 9
RF 7
SCQ_CHECK030 -- Omitted
SCQ.040 -- Omitted
SCQ_CHECK050 – Omitted
SCQ.060 -- Omitted
SCQ.070 I would like to verify your address. Please give me your complete address.
{#} {DIRECTION} {STREET NAME} {STREET/ROAD/AVENUE} {DIRECTION} {#}
{PO BOX} {RURAL ROUTE #} {RURAL ROUTE BOX} {CITY} {STATE} { ZIP}
NO (WRONG ADDRESS) 1 (SCQ_END5)
YES (CORRECTIONS) 2 (SCQ.080)
YES 3 (SCQ.090)
SCQ.080 PRESENT “ADDRESS UPDATE SCREEN”. REVIEW THE ADDRESS FIELDS AND MAKE CHANGES AS NECESSARY, THEN GO TO SCQ.090.
PROGRAMMER SPECS: If “YES (CORRECTIONS)” is selected and none of the address fields are modified, auto-backcode the response to “YES” and go to SCQ.090. The field for state may not be updated.
SCQ.090 To begin, how many people live in this household? Please do not include anyone who usually lives somewhere else.
________
NUMBER
DK 99
RF 77
SCQ.100 – 180. Disallow DK and RF in "FIRST" name field. Entry in this field should be a unique identifier for the person.
PROGRAMMER SPECS: After entry, upon exiting the screen, post information entered on this screen on line one of the HH composition matrix in the “name” field.
SCQ.101 Display question text above matrix with cursor in the cell labeled “gender”.
SCQ.101 ASK IF NOT OBVIOUS.
Is {NAME} male or female?
MALE 1
FEMALE 2
DK 9
RF 7
PROGRAMMER SPEC: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.
SCQ_CHECK110 If SCQ.090 = “1”, go to SCQ.145; ELSE, GO TO SCQ.130.
SCQ.120 -- Omitted.
SCQ.130 - 180 Display HH composition matrix: name and gender fields. After a name has been entered, post the name on the matrix and display the text of the gender question above the matrix with the cursor residing on the appropriate cell within the matrix.
SCQ.145 Dynamic display of HH composition matrix: first, middle, last name, and gender. If total # of people enumerated on the HH roster =1, display “person”; else display “people.”
SCQ.145 I have {TOTAL # OF PERSONS ENUMERATED} {person/people} living here --
[READ NAMES LISTED BELOW.]
SCQ.150 – 181. The sweep questions should be displayed on a single screen as appears on the example below. A "yes" response to the sweep question brings up a screen for entry of name(s) and gender. Upon exiting the name/gender screen, the cursor should return to the screen of sweep questions with the cursor residing on the next line (question) that requires an answer. If all the questions have been answered, go to SCQ.190.
SCQ.150, 160, 170, 180.
Have I missed . . .
SCQ.150 . . . any babies or small children?
SCQ.160 . . . any lodgers, boarders, or persons in your employ who live here?
SCQ.170 . . . anyone who usually lives here but is now away from home?
SCQ.180 . . . anyone else living or staying here?
YES 1 (SCQ.150N, 160N, 170N, 180N)
NO 2 (SCQ.160, 170, 180, 190)
DK 9 (SCQ.160, 170, 180, 190)
RF 7 (SCQ.160, 170, 180, 190)
SCQ.150N (What are their names?)
PROBE: Is (he/she) a “Junior”, “Senior”, “the 3rd” or something like that? (What is that?)
PROBE: Any others?
FIRST MIDDLE LAST SUFFIX
PROGRAMMER SPECS: After entry in SCQ.150 the cursor should move to the gender cell (SCQ.151) and display the gender question. Do not allow exit from the matrix unless all gender cells are filled. After exiting from the name/gender screen, the next question would be SCQ.160.
SCQ.151 Display question text above matrix with cursor in the cell labeled “gender”.
SCQ.151 ASK IF NOT OBVIOUS.
Is {NAME} male or female?
MALE 1
FEMALE 2
DK 9
RF 7
PROGRAMMER SPEC: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.
SCQ.160N (What are their names?)
PROBE: Any others?
FIRST MIDDLE LAST SUFFIX
DK 9
RF 7
PROGRAMMER SPECS: After entry in SCQ.160 the cursor should move to the gender cell (SCQ.161) and display the gender question. Do not allow exit from the matrix unless all gender cells are filled. After exiting from the name/gender screen, the next question would be SCQ.170.
SCQ.161 Display question text above matrix with cursor in the cell labeled “gender”.
SCQ.161 ASK IF NOT OBVIOUS:
Is {NAME} male or female?
MALE 1
FEMALE 2
DK 9
RF 7
PROGRAMMER SPEC: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.
SCQ.170N (What are their names?)
PROBE: Any others?
FIRST MIDDLE LAST SUFFIX
DK 9
RF 7
PROGRAMMER SPECS: After entry in SCQ.170 the cursor should move to the gender cell (SCQ.171) and display the gender question. Do not allow exit from the matrix unless all gender cells are filled. After exiting from the name/gender screen, the next question would be SCQ.180.
SCQ.171 Display question text above matrix with cursor in the cell labeled “gender”.
SCQ.171 ASK IF NOT OBVIOUS:
Is {NAME} male or female?
MALE 1
FEMALE 2
DK 9
RF 7
PROGRAMMER SPEC: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.
SCQ.180N (What are their names?)
PROBE: Any others?
FIRST MIDDLE LAST SUFFIX
DK 9
RF 7
PROGRAMMER SPECS: After entry in SCQ.180 the cursor should move to the gender cell (SCQ.181) and display the gender question. Do not allow exit from the matrix unless all gender cells are filled. After exiting from the name/gender screen, the next question would be SCQ.190.
SCQ.181 Display question text above matrix with cursor in the cell labeled “gender”.
SCQ.181 ASK IF NOT OBVIOUS:
Is {NAME} male or female?
MALE 1
FEMALE 2
DK 9
RF 7
PROGRAMMER SPEC: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.
SCQ.190 [VERIFY HOUSEHOLD MEMBERS BY READING NAMES LISTED BELOW.]
PROGRAMMER SPECS: The application should allow the interviewer to add or delete names or rows from the HH composition matrix, as necessary, based on respondent’s confirmation of the persons who have been enumerated.
SCQ_CHECK191 APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR HISPANICS, BLACKS, WHITE/OTHER NON-LOW INCOME OR WHITE/OTHER LOW INCOME, GO TO SCQ.430.
OTHERWISE, CONTINUE.
SCQ_CHECK193 IF SCQ.027 = YES (1), CODE SCQ.195 AS DORM ROOM (3) AND SKIP TO SCQ.220.
SCQ.195 Do {you/any of the persons in this household} have a home anywhere else?
STUDENTS LIVING AWAY AT SCHOOL ARE CONSIDERED TO HAVE A HOME SOMEWHERE ELSE.
YES 1 (SCQ.200)
NO 2 (SCQ.220)
DK 9 (SCQ.210)
RF 7 (SCQ.210)
SCQ.200 Display question text above HH composition matrix.
SCQ.200 (Who is that?)
SELECT MEMBERS WITH HOME ELSEWHERE.
PROBE: Anyone else?
PROGRAMMER SPECS: The cursor should reside in the column “Other Home”. The default fill for this column should be “NO”. However, the default can be toggled to “YES” by moving the cursor to the “Other Home” cell associated with the person who has a second residence, and selecting “YES”. If none of the “Other Home” cells have been set to “YES”, auto-backcode the response to SCQ.195 to “NO” and proceed to SCQ.220.
SCQ.210 Display question text above HH composition matrix, replacing SCQ.200.
SCQ.210 Where {do you/does {NAME}} usually live and sleep; here or somewhere else?
HERE 1
SOMEWHERE ELSE 2
DK 9
RF 7
PROGRAMMER SPECS: If “1”, “9”, OR “7” leave person on HH composition matrix; else, if “2” and this is a single person household, or if all household members are "2", the household is “ineligible” and the screener is terminated after the collection of the telephone number (SCQ.430); else if “2” and the household is more than a single person household, set a flag to indicate this person’s permanent residence was somewhere else. The flag is an indication that on all future displays of the HH composition matrix, this person (and all person-level data) will not be displayed.
In the event that the person being flagged as “living elsewhere” is the reference person, identify a new reference person as the next person who appears on the enumeration table and “living here.”
SCQ.220 Are {you/any of the persons in this household} now on full-time active duty with the Armed Forces of the United States?
YES 1 (SCQ.230)
NO 2 (SCQ.242)
DK 9 (SCQ.242)
RF 7 (SCQ.242)
PROGRAMMER SPECS: If coded “1” and this is a single person household, or if all household members are "1", the household is “ineligible” and the screener is terminated after the collection of the telephone number (SCQ.430); else, if the household is more than a single person household, the skips should be followed as specified above.
SCQ.230 Display question text above HH composition matrix.
SCQ.230 (Who is that?)
SELECT ACTIVE MILITARY MEMBERS.
PROBE: Anyone else?
PROGRAMMER SPECS: The cursor should reside in the column “ACTIVE MIL”. The default for this column should be “NO”. However, when on this question, the default can be toggled to “YES” by moving the cursor to the “ACTIVE MIL” cell associated with the person identified and selecting “YES”. If none of the “ACTIVE MIL” cells have been set to “YES”, auto-backcode the response to SCQ.220 to “NO” and go to SCQ.242.
SCQ.240 Display question text above HH composition matrix, replacing SCQ.230.
SCQ.240 Where {do you/does {NAME}} usually live and sleep; here or some where else?
HERE 1
SOMEWHERE ELSE 2
DK 9
RF 7
PROGRAMMER SPECS: If “1”, “9”, OR “7” leave person on HH composition matrix; Do not flag for sampling.
If “2”, set a flag to indicate person’s permanent residence was somewhere else. The flag is an indication that on all future displays of the HH composition matrix, this person (and all person-level data) will not be displayed.
In the event that the person being flagged as “living elsewhere” is the reference person, identify a new reference person as the next person who appears on the enumeration table and “living here”.
SCQ.242 THESE ARE THE MEMBERS OF THE DU WHO HAVE BEEN LISTED AS HH MEMBERS.
{NAME GENDER}
SCQ_CHECK245 APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR HISPANICS, BLACKS, WHITE/OTHER NON-LOW INCOME OR WHITE/OTHER LOW INCOME, GO TO SCQ.430.
OTHERWISE, CONTINUE.
SCQ.260 – 303 Fill “NAME” with the components of the “name” cell that uniquely identifies the person; at a minimum this is “first” name.
SCQ.260 Display question text above the matrix.
Change to NCHS-HIS Model:
[Do you/Does NAME] consider [yourself/himself/herself] to be Hispanic or Latino?
READ IF NECESSARY: Where do your ancestors come from?
Puerto Rican
Cuban/Cuban American
Dominican (Republic)
Mexican/Mexican American
Central/South American
Other Latin American
Other Hispanic or Latino
YES 1
NO 2
DK 9
RF 7
Help Screen: A help screen will be placed at this question. The help screen will list all countries associated with Hispanic or Latino origin or ancestry. This help screen will be a duplicate of the one NCHS proposed for the DMQ section of the SP Questionnaire.
PROGRAMMER SPECS: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.
SCQ.265 WARNING: REVIEW ETHNICITY FOR EACH PERSON! SAMPLING ALGORITHM WILL BE APPLIED.
{NAME ETHNICITY}
PROGRAMMER SPECS: Display name and ethnicity as determined at SCQ.260 for each enumerated person. Interviewer may back-up to correct.
SCQ.270 Display SCQ.270 above the matrix.
SCQ.270 SHOW CARD 2
What race do you consider {yourself/NAME} to be? Please select one or more.
CHECK ALL THAT APPLY.
AMERICAN INDIAN OR ALASKAN NATIVE 1
ASIAN 2
BLACK OR AFRICAN AMERICAN 3
NATIVE HAWAIIAN OR PACIFIC ISLANDER 4
WHITE 5
OTHER 6
DK 9
RF 7
PROGRAMMER SPECS:
Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.
SCQ.275 WARNING! REVIEW RACE FOR EACH PERSON! SAMPLING ALGORITHM WILL BE APPLIED.
{NAME RACE}
PROGRAMMER SPECS: Display name and race(s) as determined at SCQ.270 for each enumerated person. Interviewer may back-up to correct.
SCQ.280 – omitted
SCQ_CHECK285 APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR HISPANICS, BLACKS, WHITE/OTHER NON-LOW INCOME OR WHITE/OTHER LOW INCOME, GO TO SCQ.430.
OTHERWISE, CONTINUE.
SCQ.290 Display question text above the matrix with cursor residing in the first DOB cell on the matrix.
SCQ.290 What is {your/{NAME}’s} birthdate?
____ ____ ____
MM DD YYYY (SCQ.291)
DK 9 (SCQ.292)
RF 7 (SCQ.292)
PROGRAMMER SPECS: If date of birth is specified, calculate age and post in the “age” cell for the appropriate person with the cursor residing in that cell and SCQ.291 displayed above the matrix; else go to SCQ.292. Fill DK and RF as follows:
DK RF
MM 999 777
DD 999 777
YYYY 9999 7777
SCQ.291 Display question text above the matrix with cursor residing in appropriate “age” cell on the matrix.
SCQ.291 So {you are/{NAME} is} {AGE AS CALCULATED FROM DOB}?
IF NECESSARY, RE-ENTER CORRECT AGE. (SCQ.301)
PROGRAMMER SPECS: If age is re-entered by the interviewer, the application should adjust DOB.
SCQ.292 Display question text above the matrix with cursor residing in appropriate “age” cell on the matrix.
SCQ.292 About how old {are you/is {NAME}}?
_____
AGE (SCQ.301)
DK 999 (SCQ.300)
RF 777 (SCQ.300)
IF AGE IS LESS THAN 12 MONTHS, ENTER “0”.
PROGRAMMER SPEC: Post the age collected in SCQ.292 to the “age” cell in the matrix.
SCQ.300
Age ranges will change |
Display question text above the matrix with cursor residing in appropriate “age” cell on the matrix. Display the following age ranges: for Sampled Race/Ethnicity = Whites/Others, use “less than 1 year old, 1 - 2, 3 - 5, 6 - 11, 12 - 15, 16 - 19, 20 - 29, 30 - 39, 40 - 49, 50 - 59, 60 - 69, 70 - 79, or 80 years or older”; for Sampled Race/Ethnicity = Hispanic or Black, use "less than 1 year old, 1-2, 3-5, 6-11, 12-15, 16-19, 20-39, 40-59, 60 years or older". |
SCQ.300 Would you say {you are/{NAME} is}...
{{AGE RANGES FOR SAMPLED RACE/ETHNICITY = BLACK OR HISPANIC}/{AGE RANGES FOR SAMPLED RACE/ETHNICITY = WHITES/OTHERS; DK/RF RACE/ETHNICITY}}
DK 9999
RF 7777
PROGRAMMER SPEC: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.
SCQ.301 WARNING: REVIEW AGE FOR EACH PERSON! SAMPLING ALGORITHM WILL BE APPLIED.
{NAME AGE}
PROGRAMMER SPECS: Display name and age as determined at SCQ.291, SCQ.292, or SCQ.300 for each enumerated person. Interviewer may back-up to correct.
SCQ_CHECK303 APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR HISPANICS, BLACKS, WHITE/OTHER NON-LOW INCOME OR WHITE/OTHER LOW INCOME, GO TO SCQ.430.
OTHERWISE, CONTINUE.
SCQ_CHECK313 If the reference person is not eligible to be the reference person based on where s/he usually lives, identification of a new reference person is required. Re-apply the reference person edit logic to identify the reference person as the first person on the enumeration table who is > 18 years old; else, if no one on the enumeration table is age 18 or older, identify the reference person as the oldest person in the household for whom this is the primary residence.
APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR HISPANICS, BLACKS, WHITE/OTHER NON-LOW INCOME OR WHITE/OTHER LOW INCOME, GO TO SCQ.430.
OTHERWISE, CONTINUE.
SCQ_CHECK315 IF SAMPLING MESSAGE FOR LOW INCOME SET, CONTINUE.
OTHERWISE, GO TO SCQ_CHECK355.
SCQ_CHECK320 IF SCQ.027 = YES (1), GO TO SCQ_CHECK355.
OTHERWISE, CONTINUE.
SCQ_CHECK325 IF ALL HOUSEHOLD MEMBER'S SAMPLED RACE/ETHNICITY = HISPANIC (1) OR BLACK (2), GO TO SCQ_CHECK355.
IF ANY HOUSEHOLD MEMBER'S SAMPLED RACE/ETHNICITY = WHITE/OTHER (3) AND ONE OR MORE PERSON'S IN THE HOUSEHOLD COULD MEET THE LOW INCOME SAMPLING CRITERIA AND THOSE PERSONS ARE NOT ALL ACTIVE MILITARY, CONTINUE.
OTHERWISE, GO TO SCQ_CHECK355.
SCQ_CHECK330 IF ALL HOUSEHOLD MEMBERS WHO WOULD MEET THE LOW INCOME SAMPLING CRITERIA ARE ALREADY SAMPLED BASED ON GENDER, ETHNICITY, RACE, AGE,OR ARE ACTIVE MILITARY, GO TO SCQ_CHECK355.
OTHERWISE, CONTINUE.
SCQ.340 Please think for a moment about the various sources from which the members of this household received income during the last 12 months, that is from {CURRENT MONTH} {LAST YEAR IN 4-DIGITS} to {LAST MONTH} {CURRENT YEAR IN 4-DIGITS}. Thinking about all the sources of income, please tell me whether the total income received by the members of this household during the last 12 months was more or less than {DISPLAY EXACT THRESHOLD DOLLAR AMOUNT FOR # OF PEOPLE LIVING IN HOUSEHOLD}.
IF INCOME EQUAL TO {DISPLAY EXACT THRESHOLD DOLLAR AMOUNT FOR # OF PEOPLE LIVING IN HOUSEHOLD}, CODE 'LESS'.
MORE 1 (SCQ_CHECK355)
LESS 2 (SCQ_CHECK355)
DK 9
RF 7
SCQ_CHECK345 IF ANY CHILDREN IN HOUSEHOLD <6 YEARS OLD, CONTINUE.
OTHERWISE, GO TO SCQ_CHECK 355.
SCQ_CHECK347 IF ANY MALES IN HOUSEHOLD >= 18 YEARS OLD, GO TO SCQ_CHECK355.
OTHERWISE, TREAT HOUSEHOLD AS LOW INCOME FOR PURPOSES OF SAMPLING.
SCQ_CHECK355 IF ANY INDIVIDUAL MEETS THE SPECIFIED SAMPLING CRITERIA BASED ON GENDER, ETHNICITY, RACE, AGE, STATUS, OR INCOME LEVEL AND IS NOT ON ACTIVE MILITARY STATUS, GO TO SCQ.370.
IF SAMPLING FOR ALL PARTICIPANTS IS INCONCLUSIVE DUE TO CONFIRMED MISSING DATA (DK/RF) IN THE CRITICAL SAMPLING VARIABLES, GO TO SCQ.430, THEN TERMINATE THE SCREENER WITH AN ASSIGNED STATUS OF “INCOMPLETE”.
OTHERWISE, GO TO SCQ.430.
SCQ.370 THIS HOUSEHOLD HAS ELIGIBLE SURVEY PARTICIPANTS.
THE ELIGIBLE PERSON(S) SAMPLED IN THIS HOUSEHOLD ARE:
{UNIQUE NAMES, GENDERS, AGES OF SAMPLED PERSONS}
PROGRAMMER SPECS: Since the sampling algorithm has been run for the last time, back-up is not allowed beyond this check.
SCQ.420 Is {REFERENCE PERSON}’s mailing address the same as {his/her} street address?
YES 1 (SCQ.430)
NO 2 (SCQ.425)
DK 9 (SCQ.430)
RF 7 (SCQ.430)
SCQ.425 Please give me {REFERENCE PERSON}'s complete mailing address.
{#} {DIRECTION} {STREET NAME} {STREET/ROAD/AVENUE} {DIRECTION} {#}
{PO BOX} {RURAL ROUTE #} {RURAL ROUTE BOX} {CITY} {STATE} { ZIP}
PROGRAMMER SPECS: Display the complete address of the household as collected in SCQ.070 or SCQ.080 and allow updates in all fields. If updates are made, store this address as the mailing address. If no updates are made, reset SCQ.420 to “NO” and continue to SCQ.430.
SCQ.430 Please give me your home telephone number in case my office wants to check my work.
( ) - ______ - __________ - __________
HOME TELEPHONE NUMBER (SCQ.440)
NO HOME TELEPHONE 2 (SCQ.460)
DK 9 (SCQ.460)
RF 7 (SCQ.460)
PROGRAMMER SPECS: Fill DK and RF as follows:
DK RF
Area code 999 777
Exchange 999 777
Number 9999 7777
Extension 9999 7777
The field for "extension" should be allowed to be blank.
SCQ.440 In whose name is the telephone listed?
________ ________
FIRST LAST (END_CHECK)
UNLISTED 1 (END_CHECK)
NOT ON LIST 2 (SCQ.445)
DK 9 (END_CHECK)
RF 7 (END_CHECK)
SCQ.445 [In whose name is the telephone listed?]
________ ________
FIRST LAST (END_CHECK)
SCQ.460 Is there another number where you can be reached?
( ) - ______ - __________ - __________
OTHER TELEPHONE NUMBER (SCQ.461)
NO 2 (END_CHECK)
DK 9 (END_CHECK)
RF 7 (END_CHECK)
PROGRAMMER SPECS: Fill DK and RF as follows:
DK RF
Area code 999 777
Exchange 999 777
Number 9999 7777
Extension 9999 7777
The field for "extension" should be allowed to be blank.
SCQ.461 Where is that telephone located?
WORK 1
RELATIVE’S HOME 2
NEIGHBOR’S HOME 3
CELL PHONE 4
OTHER 5
DK 9
RF 7
END_CHECK If this is an ineligible household, go to SCQ_END1; else
If this is an eligible household, go to SCQ_END2; else
If this is a break-off, go to SCQ_END3, then require entry of disposition; else
If missing critical sampling data, go to SCQ_END4; else
If SCQ.070 (address verification) is “NO (WRONG ADDRESS)", go to SCQ_END5.
SCQ_END1 Thank you.
SCQ_END2 Thank you. This household has eligible survey participants.
[READ NAMES LISTED BELOW.]
{UNIQUE NAMES, GENDERS, AGES OF SAMPLE PERSONS}
[IF APPROPRIATE, EXPLAIN PARTICIPATION IN STUDY TO RESPONDENT.]
PROGRAMMER SPECS: After exiting from this screen, launch module 2 of the screener, collecting relationship information.
SCQ_END3 Thank you.
PROGRAMMER SPECS: After exiting from this screen, present the list of dispositions and do not allow exit from the application without entry of a disposition.
SCQ_END4 Thank you.
[EXPLAIN TO RESPONDENT THAT YOU WILL NEED TO RETURN TO THE HOUSEHOLD TO COLLECT CRITICAL INFORMATION THAT WAS NOT PROVIDED THIS TIME.]
SCQ_END5 Thank you.
LOCATE CORRECT ADDRESS AND RESTART SCREENER.
SCREENER MODULE #2 (SFQ)
TO BE ADMINISTERED TO ALL ELIGIBLE HOUSEHOLDS
BOX 1
CHECK ITEM SFQ.001:
IF ONLY 1 PERSON HOUSEHOLD, CODE PERSON AS "REFERENCE PERSON", CODE RELATIONSHIP AS "SELF", ASSIGN FAMILY #1 TO PERSON AND GO TO END OF SECTION.
OTHERWISE, CONTINUE.
BOX 2
CHECK ITEM SFQ.004:
CODE FIRST PERSON LISTED ON H.H. MATRIX WHOSE AGE IS > 18 AND IS NOT FLAGGED AS LIVING "SOMEWHERE ELSE" AS "REFERENCE PERSON", HEAD OF FAMILY #1 AND RELATIONSHIP AS "SELF".
BOX 3
LOOP 1:
ASK SFQ.010 – SFQ.040 AS APPROPRIATE FOR EACH PERSON {P} LISTED BELOW REFERENCE PERSON ON THE HOUSEHOLD MATRIX.
SFQ.010 {The next questions are about family relationships.}
What is {PERSON'S) relationship to {REFERENCE PERSON}?
HAND CARD SFQ1
SPOUSE (HUSBAND/WIFE) 01
UNMARRIED PARTNER 02
CHILD (BIOLOGICAL/ADOPTIVE/IN-LAW/
STEP/FOSTER) 03
CHILD OF PARTNER 04
GRANDCHILD 05
PARENT (BIOLOGICAL/ADOPTIVE/
IN-LAW/STEP/FOSTER) 06
BROTHER/SISTER (BIOLOGICAL/
ADOPTIVE/IN-LAW/STEP/FOSTER) 07
GRANDMOTHER/GRANDFATHER 08
AUNT/UNCLE 09
NIECE/NEPHEW 10
OTHER RELATIVE 11
HOUSEMATE/ROOMMATE 12
ROOMER/BOARDER 13
OTHER NONRELATIVE 14
LEGAL GUARDIAN 15
WARD 16
REFUSED 77
DON'T KNOW 99
BOX 4
CHECK ITEM SFQ.015:
RELATIONSHIP CODES FROM SFQ.010. NOTE RP ON MATRIX MAY HAVE MULTIPLE RELATIONSHIP CODES.
"RP" = REFERENCE PERSON
"P" = PERSON = MEMBERS OF HOUSEHOLD
n IF
CODE 1 (SPOUSE), CHECK GENDER OF BOTH {RP}
AND {P}
AND CODE {RP}
AS HUSBAND OR WIFE OF {P}
DEPENDING ON GENDER
AND {P}
AS HUSBAND OR WIFE OF {RP}
DEPENDING ON GENDER.
n IF
CODE 2 (UNMARRIED PARTNER), CHECK GENDER OF BOTH {RP}
AND
{P}
AND CODE {RP} AS
UNMARRIED MALE OR FEMALE PARTNER OF {P}
DEPENDING ON GENDER AND {P}
AS UNMARRIED MALE OR FEMALE PARTNER OF {RP}
DEPENDING ON GENDER.
n IF CODE 3 (CHILD), CHECK GENDER OF {P} AND {RP} AND CODE {RP} AS MOTHER OR FATHER OF {P} DEPENDING ON GENDER AND {P} AS SON OR DAUGHTER OF {RP} DEPENDING ON GENDER.
n IF
CODE 4 (CHILD OF PARTNER), CODE {RP}
AS PARTNER OF
CHILD'S
PARENT AND CODE {P}
AS CHILD OF PARTNER.
n IF
CODE 5 (GRANDCHILD), CODE {RP}
AS GRANDPARENT OF {P}
AND
{P}
AS GRANDCHILD OF {RP}.
n IF
CODE 6 (PARENT), CHECK GENDER OF BOTH {RP}
AND {P}
AND
CODE {RP}
AS SON OR DAUGHTER OF {P}
DEPENDING ON GENDER
AND CODE {P}
AS MOTHER OR FATHER OF {RP}
DEPENDING ON
GENDER.
n IF
CODE 7 (BROTHER/SISTER), CHECK GENDER OF BOTH {RP}
AND {P}
AND CODE {RP}
AS BROTHER/SISTER OF {P}
DEPENDING ON GENDER
AND {P}
AS BROTHER/SISTER OF {RP}
DEPENDING ON
GENDER.
n IF
CODE 8 (GRANDPARENT), CODE {RP}
AS GRANDCHILD OF {RP}
AND
{P}
AS GRANDPARENT OF {P}.
n IF
CODE 9 (AUNT/UNCLE), CODE {RP}
AS NIECE/NEPHEW OF {P}
AND
{P}
AS AUNT/UNCLE OF {RP}.
n IF
CODE 10 (NIECE/NEPHEW), CODE {RP}
AS AUNT/UNCLE OF {P}
AND
{P}
AS NIECE/NEPHEW OF {RP}.
n IF
CODE 11 (OTHER RELATIVE), CODE {RP}
AS OTHER RELATIVE OF {P}
AND {P}
AS OTHER RELATIVE OF {RP}.
n IF
CODE 12 (HOUSEMATE/ROOMMATE), CODE {RP}
AS HOUSEMATE/
ROOMMATE OF {P}
AND {P}
AS HOUSEMATE/ROOMMATE OF
{RP}.
n IF
CODE 13 (ROOMER/BOARDER), CODE {RP}
AS OTHER NONRELATIVE
OF {P}
AND {P}
AS ROOMER/BOARDER OF {RP}.
n IF
CODE 14 (OTHER NONRELATIVE), CODE {RP}
AS OTHER
NONRELATIVE OF {P}
AND {P}
AS OTHER NONRELATIVE OF {RP}.
n IF
CODE 15 (LEGAL GUARDIAN), CODE {RP}
AS WARD OF {P}
AND {P}
AS
LEGAL GUARDIAN OF {RP}.
n IF
CODE 16 (WARD), CODE {RP}
AS LEGAL GUARDIAN OF {P}
AND {P}
AS
WARD OF {RP}.
n IF
CODE 77 OR CODE 99, CODE {RP}
AS OTHER RELATIVE OF {P}
AND
{P}
AS OTHER RELATIVE OF {RP}.
BOX 5
CHECK ITEM SFQ.017:
IF {P} RELATIONSHIP IN SFQ.010 = CHILD (CODE 3), CONTINUE.
OTHERWISE, SKIP TO BOX 6.
SFQ.020 Is {PERSON}, {REFERENCE PERSON'S} biological (natural), adoptive, step, foster {son/daughter} or (son/daughter)-in-law?
BIOLOGICAL (NATURAL) {SON/
DAUGHTER} 1
ADOPTIVE {SON/DAUGHTER} 2
STEP {SON/DAUGHTER} 3
FOSTER {SON/DAUGHTER} 4
{SON/DAUGHTER}-IN-LAW 5
REFUSED 7
DON'T KNOW 9
BOX 6
CHECK ITEM SFQ.025:
IF {P} RELATIONSHIP IN SFQ.010 = PARENT (CODE 6), CONTINUE.
OTHERWISE, GO TO BOX 7.
SFQ.030 Is {PERSON}, {REFERENCE PERSON'S} biological (natural), adoptive, step, or foster parent or {mother/father}-in-law?
BIOLOGICAL (NATURAL) PARENT 1
ADOPTIVE PARENT 2
STEP PARENT 3
FOSTER PARENT 4
{MOTHER/FATHER}-IN-LAW 5
REFUSED 7
DON'T KNOW 9
BOX 7
CHECK ITEM SFQ.035:
IF {P} RELATIONSHIP IN SFQ.010 = BROTHER/SISTER (CODE 7), CONTINUE.
OTHERWISE, GO TO BOX 8.
SFQ.040 Is {PERSON}, {REFERENCE PERSON'S} full, half, adoptive, step, or foster {brother/sister} or {brother/sister}-in-law?
FULL {BROTHER/SISTER} 1
HALF {BROTHER/SISTER} 2
ADOPTED {BROTHER/SISTER} 3
STEP {BROTHER/SISTER} 4
FOSTER {BROTHER/SISTER} 5
{BROTHER/SISTER}-IN-LAW 6
REFUSED 7
DON'T KNOW 9
BOX 8
END LOOP 1:
ASK SFQ.010 – SFQ.040 AS APPROPRIATE FOR NEXT PERSON {P} LISTED BELOW REFERENCE PERSON ON THE HOUSEHOLD MATRIX.
IF NO NEXT PERSON, GO TO BOX 9.
BOX 9
CHECK ITEM SFQ.043:
IF ALL PERSONS IN HOUSEHOLD ARE RELATED (HAVE RELATIONSHIP CODES ASSOCIATED WITH CODES 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15, 16, 77 OR 99 IN SFQ.010 OR SFQ.070), GO TO BOX 20.
OTHERWISE, CONTINUE WITH BOX 10.
BOX 10
CHECK ITEM SFQ.045:
CODE FIRST PERSON REMAINING UNRELATED TO REFERENCE PERSON AND HEADS OF ADDITIONAL FAMILIES AND WHOSE AGE IS >18 AS HEAD OF NEXT FAMILY {H OF F} AS APPROPRIATE (#2, 3, 4, ETC.), AND GO TO BOX 11.
IF NO PERSONS AGE > 18, CODE OLDEST PERSON FROM THIS GROUP AS HEAD OF FAMILY.
BOX 11
CHECK ITEM SFQ.047:
IF MORE THAN ONE PERSON CODED AS UNRELATED, CONTINUE WITH BOX 12.
OTHERWISE, GO TO BOX 20.
BOX 12
LOOP 2:
ASK SFQ.050 – SFQ.100 FOR FIRST (NEXT) HEAD OF FAMILY.
SFQ.050 Now I would like to talk about those persons in the household who are not related to {REFERENCE PERSON/REFERENCE PERSON OR HEADS OF FAMILY}. That is {LIST ALL PERSONS IN HOUSEHOLD NOT RELATED TO {REFERENCE PERSON/REFERENCE PERSON OR HEADS OF FAMILY}.
DISPLAY NAME OF REFERENCE PERSON IF THIS IS THE FIRST TIME THIS QUESTION IS ASKED. DISPLAY NAMES OF REFERENCE PERSON AND ALL HEADS OF ADDITIONAL FAMILIES IF THIS IS NOT THE FIRST TIME QUESTION IS ASKED.
Is {HEAD OF FAMILY #2, 3, 4, ETC} related to anyone in the household?
YES 1
NO 2 (BOX 19)
REFUSED 7
DON'T KNOW 9
SFQ.060 Who is {HEAD OF FAMILY #2, 3, 4, ETC. FROM BOX 10} related to? {DISPLAY LIST OF NAMES OF ALL PERSONS WHO ARE NOT REFERENCE PERSON, OR HEAD OF FAMILY AND WHO ARE NOT RELATED TO ANYONE ELSE IN HOUSEHOLD (DO NOT HAVE RELATIONSHIP CODE = CODE 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15 OR 16)}.
SELECT NAMES OF PERSONS RELATED TO {REFERENCE PERSON OR HEAD(S) OF FAMILY}.
BOX 13
EMBEDDED LOOP 2A:
ASK SFQ.070 – SFQ.100 FOR EACH PERSON SELECTED IN SFQ.060.
SFQ.070 What is {PERSON'S} relationship to {HEAD OF FAMILY}.
HAND CARD SFQ1
SPOUSE (HUSBAND/WIFE) 01
UNMARRIED PARTNER 02
CHILD (BIOLOGICAL/ADOPTIVE/IN-LAW/
STEP/FOSTER) 03
CHILD OF PARTNER 04
GRANDCHILD 05
PARENT (BIOLOGICAL/ADOPTIVE/
IN-LAW/STEP/FOSTER) 06
BROTHER/SISTER (BIOLOGICAL/
ADOPTIVE/IN-LAW/STEP/FOSTER) 07
GRANDMOTHER/GRANDFATHER 08
AUNT/UNCLE 09
NIECE/NEPHEW 10
OTHER RELATIVE 11
HOUSEMATE/ROOMMATE 12
ROOMER/BOARDER 13
OTHER NONRELATIVE 14
LEGAL GUARDIAN 15
WARD 16
REFUSED 77
DON'T KNOW 99
BOX 14
CHECK ITEM SFQ.073:
RELATIONSHIP CODES FROM SFQ.070. NOTE H OF F ON MATRIX MAY HAVE MULTIPLE RELATIONSHIP CODES.
"H OF F" = HEAD OF FAMILY IN SFQ.060 AS DEFINED I BOX 10.
"P" = OTHER PERSONS SELECTED IN SFQ.060.
n IF
CODE 1 (SPOUSE), CHECK GENDER OF BOTH {H
OF F} AND {P}
AND
CODE {H
OF F} AS HUSBAND OR
WIFE OF {P} DEPENDING ON GENDER
AND {P} AS HUSBAND OR WIFE OF
{H OF F} DEPENDING
ON GENDER.
n IF
CODE 2 (UNMARRIED PARTNER), CHECK GENDER OF BOTH {H
OF F}
AND
{P}
DEPENDING ON GENDER AND CODE {H
OF F} AS UNMARRIED
MALE OR FEMALE PARTNER OF {P}
AND {P}
AS UNMARRIED MALE OR FEMALE PARTNER OF {H
OF F} DEPENDING ON
GENDER.
n IF
CODE 3 (CHILD), CHECK GENDER OF {P}
AND {H OF F}
AND CODE
{H
OF F} AS MOTHER OR
FATHER OF {P}
DEPENDING ON GENDER AND {P}
AS SON OR DAUGHTER OF {H
OF F} DEPENDING ON
GENDER.
n IF
CODE 4 (CHILD OF PARTNER), CODE {H
OF F} AS PARTNER OF
CHILD'S PARENT AND CODE {P}
AS CHILD OF PARTNER.
n IF
CODE 5 (GRANDCHILD), CODE {H
OF F} AS
GRANDPARENT OF {P}
AND {P}
AS GRANDCHILD OF {H
OF F}.
n IF
CODE 6 (PARENT), CHECK GENDER OF BOTH {H
OF F} AND {P}
AND
CODE {H
OF F} AS SON OR
DAUGHTER OF {P}
DEPENDING ON GENDER AND CODE {P}
AS MOTHER OR FATHER OF {H
OF F} DEPENDING ON
GENDER.
n IF
CODE 7 (BROTHER/SISTER), CHECK GENDER OF BOTH {H
OF F} AND
{P}
AND CODE {H OF F}
AS BROTHER/SISTER OF {P}
DEPENDING ON
GENDER AND {P}
AS BROTHER/SISTER OF {H
OF F} DEPENDING ON
GENDER.
n IF
CODE 8 (GRANDPARENT), CODE {H
OF F} AS GRANDCHILD
OF{RP}
AND {P}
AS GRANDPARENT OF {P}.
n IF
CODE 9 (AUNT/UNCLE), CODE {H
OF F} AS
NIECE/NEPHEW OF {P}
AND {P}
AS AUNT/UNCLE OF {H
OF F}.
n IF
CODE 10 (NIECE/NEPHEW), CODE {H
OF F} AS AUNT/UNCLE
OF {P}
AND {P}
AS NIECE/NEPHEW OF {H
OF F}.
n IF
CODE 11 (OTHER RELATIVE), CODE {H
OF F} AS OTHER
RELATIVE OF
{P}
AND {P}
AS OTHER RELATIVE OF {H
OF F}.
n IF
CODE 12 (HOUSEMATE/ROOMMATE), CODE {H
OF F} AS
HOUSEMATE/
ROOMMATE OF {P}
AND {P}
AS HOUSEMATE/ROOMMATE OF {H
OF F}.
n IF
CODE 13 (ROOMER/BOARDER), CODE {H
OF F} AS
OTHER
NONRELATIVE OF {P}
AND {P}
AS ROOMER/BOARDER OF {H
OF F}.
n IF
CODE 14 (OTHER NONRELATIVE), CODE {H
OF F} AS OTHER
NONRELATIVE OF {P}
AND {P} AS OTHER
NONRELATIVE OF {H OF
F}.
n IF
CODE 15 (LEGAL GUARDIAN), CODE {H
OF F} AS WARD OF
{P}
AND
{P}
AS LEGAL GUARDIAN OF {H
OF F}.
n IF
CODE 16 (WARD), CODE {H
OF F} AS LEGAL
GUARDIAN OF {P}
AND
{P}
AS WARD OF {H OF F}.
n IF
CODE 77 OR CODE 99, CODE {H
OF F} AS OTHER
RELATIVE OF {P}
AND {P}
AS OTHER RELATIVE OF {H
OF F}.
BOX 15
CHECK ITEM SFQ.075:
IF {P} RELATIONSHIP IN SFQ.070 = CHILD (CODE 3), CONTINUE.
OTHERWISE, SKIP TO BOX 16.
SFQ.080 Is {PERSON}, {HEAD OF FAMILY'S} biological (natural), adoptive, step, foster {son/daughter} or (son/daughter)-in-law?
BIOLOGICAL (NATURAL) {SON/
DAUGHTER} 1
ADOPTIVE {SON/DAUGHTER} 2
STEP {SON/DAUGHTER} 3
FOSTER {SON/DAUGHTER} 4
{SON/DAUGHTER}-IN-LAW 5
REFUSED 7
DON'T KNOW 9
BOX 16
CHECK ITEM SFQ.085:
IF {P} RELATIONSHIP IN SFQ.070 = PARENT (CODE 6), CONTINUE.
OTHERWISE, GO TO BOX 17.
SFQ.090 Is {PERSON}, {HEAD OF FAMILY'S} biological (natural), adoptive, step, or foster parent or {mother/father}-in-law?
BIOLOGICAL (NATURAL) PARENT 1
ADOPTIVE PARENT 2
STEP PARENT 3
FOSTER PARENT 4
{MOTHER/FATHER}-IN-LAW 5
REFUSED 7
DON'T KNOW 9
BOX 17
CHECK ITEM SFQ.095:
IF {P} RELATIONSHIP IN SFQ.010 = BROTHER/SISTER (CODE 7), CONTINUE.
OTHERWISE, GO TO BOX 18.
SFQ.100 Is {PERSON}, {HEAD OF FAMILY'S} full, half, adoptive, step, or foster {brother/sister} or {brother/sister}-in-law?
FULL {BROTHER/SISTER} 1
HALF {BROTHER/SISTER} 2
ADOPTED {BROTHER/SISTER} 3
STEP {BROTHER/SISTER} 4
FOSTER {BROTHER/SISTER} 5
{BROTHER/SISTER}-IN-LAW 6
REFUSED 7
DON'T KNOW 9
BOX 18
END EMBEDDED LOOP 2A:
ASK SFQ.070 – SFQ.100 AS APPROPRIATE FOR NEXT PERSON SELECTED AS RELATED TO HEAD OF FAMILY IN SFQ.060.
IF NO NEXT PERSON, GO TO BOX 19.
BOX 19
END LOOP 2:
IF MORE THAN 1 PERSON REMAINS UNRELATED TO THE REFERENCE PERSON OR THE HEAD OF ADDITION FAMILY:
n DESIGNATE NEXT HEAD OF FAMILY AS INSTRUCTED IN BOX 10.
n ASK
SFQ.050 – SFQ.100 FOR NEXT HEAD OF FAMILY AND PERSONS
WHO
REMAIN AS UNRELATED.
IF NO NEXT PERSONS GO TO BOX 20.
BOX 20
CHECK ITEM SFQ.105:
n IF
REFERENCE PERSON IS MARRIED (CODED AS HUSBAND/WIFE) OR
LIVING
WITH A PARTNER (CODED AS UNMARRIED PARTNER).
AND
n REFERENCE PERSON HAS A C
HILD OR THE PARTNER HAS A CHILD CONTINUE
OTHERWISE GO TO BOX 23.
BOX 21
LOOP 3:
ASK SFQ.110 FOR EACH PERSON (CHILD OF REFERENCE PERSON AND CHILD OF PARTNER – RELATIONSHIP CODE 3 OR 4).
SFQ.110 I recorded that {NAME OF MOTHER/FATHER OF CHILD – THIS IS SPOUSE OR PARTNER OF REFERENCE PERSON} is the {father/mother} of {NAME OF CHILD – THIS IS CHILD OF REFERENCE PERSON AND SPOUSE OR REFERENCE PERSON AND PARTNER OR CHILD OF PARTNER}. Is {NAME OF CHILD} {his/her} biological, adoptive, step, foster child or (son or daughter)-in-law?
BIOLOGICAL CHILD 1
ADOPTIVE CHILD 2
STEP CHILD 3
FOSTER CHILD 4
(SON/DAUGHTER)-IN-LAW 5
REFUSED 7
DON'T KNOW 9
BOX 22
END LOOP 3:
ASK SFQ.110 FOR NEXT PERSON (CHILD OR CHILD OF PARTNER).
IF NO NEXT PERSON, CONTINUE WITH BOX 23.
BOX 23
CHECK ITEM 115:
CHECK RELATIONSHIPS. IF ALL HOUSEHOLD MEMBERS HAVE MOTHER, FATHER, AND SPOUSE OR PARTNER IDENTIFIED, GO TO BOX 31.
OTHERWISE, IF ANY OF THESE RELATIONSHIPS FOR EACH PERSON IS NOT ALREADY IDENTIFIED, CONTINUE.
BOX 24
LOOP 4:
ASK SFQ.120 – SFQ.200 AS APPROPRIATE FOR EACH PERSON WHO DOES NOT HAVE A MOTHER AND FATHER AND SPOUSE OR PARTNER IDENTIFIED IN HOUSEHOLD.
BOX 25
CHECK ITEM SFQ.117:
IF PERSON'S MOTHER HAS NOT BEEN IDENTIFIED, AND THERE ARE FEMALES IN THE HOUSEHOLD WHO ARE > 11 YEARS OLDER THAN PERSON, CONTINUE OTHERWISE, GO TO BOX 27.
SFQ.120 Is {PERSON'S} mother a household member? [Include mother-in-law].
IF OBVIOUS, VERIFY ONLY.
CHOOSE MOTHER OVER MOTHER-IN-LAW IF BOTH PRESENT.
YES – MOTHER IN HOUSEHOLD 1
NO – MOTHER NOT IN HOUSEHOLD 2 (BOX 27)
LEGAL GUARDIAN IN HOUSEHOLD 3
REFUSED 7 (BOX 27)
DON'T KNOW 9 (BOX 27)
SFQ.130 Who is that?
[SELECT PERSON FROM HOUSEHOLD MATRIX.
BOX 26
CHECK ITEM SFQ.135:
IF LEGAL GUARDIAN CODED IN SFQ.120, GO TO BOX 27.
OTHERWISE, CONTINUE.
SFQ.140 Is {NAME OF MOTHER IN SFQ.130}, {PERSON'S} biological [natural], adoptive, step, or foster mother or mother-in-law?
BIOLOGICAL MOTHER 1
ADOPTIVE MOTHER 2
STEP MOTHER 3
FOSTER MOTHER 4
MOTHER-IN-LAW 5
REFUSED 7
DON'T KNOW 9
BOX 27
CHECK ITEM SFQ.145:
IF PERSON'S FATHER HAS NOT BEEN IDENTIFIED, AND THERE ARE MALES IN THE HOUSEHOLD WHO ARE > 11 YEARS OLDER THAN PERSON.
OTHERWISE, GO TO BOX 29A.
SFQ.150 Is {PERSON'S} father a household member? [Include father-in-law].
IF OBVIOUS, VERIFY ONLY.
CHOOSE FATHER OVER FATHER-IN-LAW IF BOTH PRESENT.
YES – FATHER IN HOUSEHOLD 1
NO – FATHER NOT IN HOUSEHOLD 2 (BOX 29)
LEGAL GUARDIAN IN HOUSEHOLD 3
REFUSED 7 (BOX 29)
DON'T KNOW 9 (BOX 29)
SFQ.160 Who is that?
[SELECT PERSON FROM HOUSEHOLD MATRIX.
BOX 28
CHECK ITEM SFQ.165:
IF LEGAL GUARDIAN CODED IN SFQ.150, GO TO BOX 29A.
OTHERWISE, CONTINUE.
SFQ.170 Is {NAME OF FATHER IN SFQ.160}, {PERSON'S} biological (natural), adoptive, step, or foster father or father-in-law?
BIOLOGICAL FATHER 1
ADOPTIVE FATHER 2
STEP FATHER 3
FOSTER FATHER 4
FATHER-IN-LAW 5
REFUSED 7
DON'T KNOW 9
BOX 29A
CHECK ITEM SFQ.175:
IF PERSON'S AGE >= 14 AND SPOUSE OR UNMARRIED PARTNER HAS NOT BEEN IDENTIFIED, CONTINUE.
OTHERWISE, GO TO BOX 30.
SFQ.180 Is {PERSON'S NAME} now married, widowed, divorced, separated, never married or living with a partner?
MARRIED 1
WIDOWED 2 (BOX 30)
DIVORCED 3 (BOX 30)
SEPARATED 4 (BOX 30)
NEVER MARRIED 5 (BOX 30)
LIVING WITH PARTNER 6
REFUSED 7 (BOX 30)
DON'T KNOW 9 (BOX 30)
BOX 29B
CHECK ITEM SFQ.185:
IF THERE ARE PERSONS IN THE HOUSEHOLD WHO ARE > = 14 YEARS OLD, CONTINUE.
OTHERWISE, GO TO BOX 30.
SFQ.190 Is {PERSON'S} {spouse/partner} living in the household?
YES 1
NO 2 (BOX 30)
REFUSED 7 (BOX 30)
DON'T KNOW 9 (BOX 30)
SFQ.200 Who is that?
DISPLAY LIST OF ALL NONDELETED HOUSEHOLD MEMBERS WHO ARE 14 YEARS OLD OR OLDER.
BOX 30
END LOOP 4:
ASK SFQ.120 – SFQ.200 FOR NEXT PERSON.
IF NO NEXT PERSON, GO TO BOX 31.
BOX 31
CHECK ITEM SFQ.205:
n APPLY NHANES AND CPS FAMILY DEFINITIONS.
n IF MORE THAN 1 NHANES FAMILY, CONTINUE.
n IF
ONLY 1 NHANES FAMILY, GO TO SFQ.210. DO NOT
REASK SCQ.430 –
SCQ.461.
OTHERWISE, GO TO SFQ.210.
BOX 32
LOOP 5:
ASK MODULE 1 – SCQ.420 – SCQ.461 FOR EACH ADDITIONAL NHANES FAMILY.
NOTE: THE SUBJECT OF QUESTIONS SHOULD BE EACH ADDITIONAL HEAD OF NHANES FAMILY
DO NOT REASK SCQ.430 – SCQ.461 OF THE FIRST NHANES FAMILY.
SFQ.210 Thank you. That completes the questions about family relationships.
END OF SECTION
RESPONDENT SELECTION (RIQ)
NOTE: THIS IS ADMINISTRATIVE INFORMATION ENTERED BY THE INTERVIEWER NOT QUESTIONS ASKED OF THE PARTICIPANT
RIQ.010 SELECT RESPONDENT FOR THE SP QUESTIONNAIRE FOR {SP NAME}.
CAPI INSTRUCTION:
DISPLAY FAMILY ROSTER AND 'SOMEONE OUTSIDE FAMILY' AS OPTION.
BOX
1
CHECK
ITEM RIQ.015:
IF
SP IS SELECTED AS RESPONDENT AND SP AGE IS <=
15,
GO TO RIQ.020.
IF
SP IS SELECTED AS RESPONDENT AND SP AGE IS >=
16,
GO TO RIQ.080.
IF
SP IS NOT
SELECTED AS RESPONDENT AND SP AGE
IS
<= 15, GO TO BOX 2.
IF
SP IS NOT
SELECTED AS RESPONDENT AND SP AGE
IS
>= 16, GO TO RIQ.030.
RIQ.020 INTERVIEW SHOULD BE CONDUCTED WITH A PROXY BECAUSE SP IS UNDER 16 YEARS OLD.
ENTER ONE OPTION.
SP IS AN INDEPENDENT MINOR 1 (RIQ.080)
PERSON SELECTED AS
RESPONDENT IN ERROR 2 (RIQ.010)
SP AGE ENTERED IN ERROR -- SP IS
AGE 16+ 3 (RIQ.080)
RIQ.030 WHY IS INTERVIEW BEING CONDUCTED WITH A PROXY?
SP HAS COGNITIVE PROBLEMS 1
SP HAS PHYSICAL PROBLEMS
(SPECIFY) 2
OTHER
(SPECIFY) 3
BOX
2
CHECK
ITEM RIQ.031:
IF
'SOMEONE OUTSIDE THE FAMILY' SELECTED AS RESPONDENT, CONTINUE.
OTHERWISE,
GO TO RIQ.080.
IQ.040 WHY IS INTERVIEW BEING CONDUCTED WITH SOMEONE OUTSIDE THE HOUSEHOLD?
RIQ.050 ENTER RESPONDENT NAME.
FIRST NAME LAST NAME
RIQ.060 ENTER RESPONDENT'S PHONE NUMBER.
ENTER '00' IN AREA CODE IF NO PHONE.
|___|___|___| |___|___|___| - |___|___|___|___|
AREA CODE ENTER PHONE NUMBER
RIQ.070 DESCRIBE RESPONDENT'S RELATIONSHIP TO SP.
RIQ.080 HAS RESPONDENT SIGNED A HOUSEHOLD INTERVIEW CONSENT FORM?
CAPI INSTRUCTION:
IF 'NO' (CODE 2), DISPLAY THE FOLLOWING MESSAGE: "EACH RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE MUST SIGN A HOUSEHOLD INTERVIEW CONSENT FORM BEFORE THE INTERVIEW CAN BE ADMINISTERED" AND RETURN TO RIQ.080.
NOTE: IF INTERPRETER USED, RESPONDENT MUST SIGN FORM.
YES 1
NO 2
RIQ.090 INTERPRETER USED FOR THIS INTERVIEW?
YES 1
NO 2 (END OF SECTION)
RIQ.100 CODE TYPE OF INTERPRETER.
LIVING IN HOUSEHOLD 1
NEIGHBORHOOD/FRIEND 2 (RIQ.120)
PAID INTERPRETER 3 (RIQ.120)
RIQ.110 SELECT NAME OF INTERPRETER FROM HOUSEHOLD ROSTER.
{DISPLAY NAMES OF HOUSEHOLD MEMBERS}
BOX
3
CHECK
ITEM RIQ.115:
GO
TO RIQ.140.
RIQ.120 ENTER NAME OF INTERPRETER.
FIRST NAME LAST NAME
BOX
4
CHECK
ITEM RIQ.125:
IF
INTERPRETER IS NEIGHBOR OR FRIEND (CODE 2 IN RIQ.100), CONTINUE.
OTHERWISE,
GO TO RIQ.140.
RIQ.130 ENTER PHONE NUMBER OF INTERPRETER.
ENTER '00' IN AREA CODE IF NO PHONE.
|___|___|___| |___|___|___| - |___|___|___|___|
REFUSED 7
DON'T KNOW 9
RIQ.140 LANGUAGE OF INTERVIEW.
CHINESE 1
FRENCH 2
GERMAN 3
ITALIAN 4
JAPANESE 5
RUSSIAN 6
OTHER (SPECIFY) 7
DON'T KNOW 9
END OF SECTION
INTRODUCTION AND VERIFICATION (IVQ)
DMQ.010 [You have been chosen to participate in the National Health and Nutrition Examination Survey conducted by the U.S. Public Health Service. All the information that you give us will be kept in the strictest of confidence. Your name will not be attached to any of your answers without your specific permission. HAND RESPONDENT THE ADVANCE LETTER.] I would like to begin the health interview by verifying some information about {you/SP}.
VERIFY OR ASK DATE OF BIRTH AND AGE.
CAPI INSTRUCTION:
DISPLAY DATE OF BIRTH AND SP AGE FROM SCREENER.
IF AGE OR ALL OR PART OF DATE OF BIRTH NOT AVAILABLE, FILL CORRESPONDING FIELDS WITH 'DK' OR 'REF' AS APPROPRIATE.
IF AGE IS A RANGE, DISPLAY THE RANGE FOR AGE.
IF AGE IS LESS THAN 1 YEAR, DISPLAY AGE IN MONTHS.
IF AGE IS CHANGED, DISPLAY MESSAGE TO CORRECT DOB.
IF DOB IS CHANGED, RECALCULATE AGE.
{ |___|___|___|___|___|___|___|___| } { |___|___|___| }
DATE OF BIRTH (MONTH, DAY, YEAR) AGE
REFUSED 77777777
DON'T KNOW 99999999
DMQ.020 VERIFY GENDER.
CAPI INSTRUCTION:
DISPLAY SP GENDER FROM SCREENER. IF GENDER NOT AVAILABLE, DISPLAY DK OR REF AS APPROPRIATE.
{ |___| }
GENDER
BOX 1
CHECK ITEM DMQ.025:
RUN SAMPLING ALGORITHM. IF PERSON NO LONGER IN THE SAMPLE DUE TO UPDATED AGE OR GENDER INFORMATION, CONTINUE.
OTHERWISE, GO TO BOX 4.
DMQ.030 Thank you for your participation in the study. Our scientific, random selection process indicates that {you/SP} {have/has} not been selected for the next part of the study.
BOX 2
CHECK ITEM DMQ.035:
GO TO END OF INTERVIEW.
DMQ.040 What is {your/SP's} full name, including middle name?
What is your first name?
VERIFY SPELLING
USE F1 FOR HELP RECORDING FIRST NAME
|___|___|___|___|
ENTER PREFIX (MS, MR, MRS, DR)
REFUSED 7777
DON'T KNOW 9999
ENTER FIRST NAME
REFUSED 7
DON'T KNOW 9
DMQ.050 What is {your/SP's} middle name?
VERIFY SPELLING
USE F1 FOR HELP RECORDING MIDDLE NAME(S)
IF NO MIDDLE NAME, MARK CHECK BOX
ENTER MIDDLE NAME #1
REFUSED 7
DON'T KNOW 9
ENTER MIDDLE NAME #2
REFUSED 7
DON'T KNOW 9
DMQ.060 What is {your/SP's} last name?
VERIFY SPELLING
USE F1 FOR HELP RECORDING LAST NAME(S)
ENTER LAST NAME #1
REFUSED 7
DON'T KNOW 9
ENTER LAST NAME #2
REFUSED 7
DON'T KNOW 9
DMQ.070 {Do you/Does SP} have a suffix? [What is it?]
ENTER SUFFIX (JR, SR, III)
or
NO 2
REFUSED 7
DON'T KNOW 9
ECQ.010 First I have some questions about {SP NAME's} birth.
How old was {SP NAME's} biological mother when {s/he} was born?
|___|___|
ENTER AGE IN YEARS
CAPI INSTRUCTION:
HARD EDIT 10-59, SOFT EDIT <13
REFUSED 77
DON'T KNOW 99
ECQ.020 Did {SP NAME's} biological mother smoke at any time while she was pregnant with {him/her}?
YES 1
NO 2 (ECQ.060)
REFUSED 7 (ECQ.060)
DON’T KNOW 9 (ECQ.060)
ECQ.030 At any time during the pregnancy, did {SP NAME's} biological mother quit or refrain from smoking for the rest of the pregnancy?
YES 1
NO 2 (ECQ.060)
REFUSED 7 (ECQ.060)
DON’T KNOW 9 (ECQ.060)
ECQ.040 About what month of the pregnancy did {SP NAME's} biological mother stop smoking?
USE ROUNDING RULE IF NECESSARY.
FIRST MONTH 1
SECOND MONTH 2
THIRD MONTH 3
FOURTH MONTH 4
FIFTH MONTH 5
SIXTH MONTH 6
SEVENTH MONTH 7
EIGHTH MONTH 8
NINTH MONTH 9
REFUSED 77
DON’T KNOW 99
ECQ.060 Did {SP NAME} receive any newborn care in an intensive care unit, premature nursery, or any other type of special care facility?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
ECQ.071/ How much did {SP NAME} weigh at birth?
L/O/K/M
IF ANSWER GIVEN IN POUNDS ONLY, PROBE FOR OUNCES.
IF ANSWER GIVEN IN EXACT POUNDS, ENTER NUMBER OF POUNDS AND 0 OUNCES.
|___|___|
ENTER NUMBER OF POUNDS
CAPI INSTRUCTION:
SOFT EDIT 3-13, HARD EDIT 0-20
AND
|___|___|
ENTER NUMBER OF OUNCES
CAPI INSTRUCTION:
HARD EDIT 0-15, NO SOFT EDIT
OR
|___|___|___|
ENTER NUMBER IN KILOGRAMS
CAPI INSTRUCTION:
SOFT EDIT 1.5-6, HARD EDIT 0-9
OR
|___|___|___|
ENTER NUMBER IN GRAMS
CAPI INSTRUCTION:
SOFT EDIT 1,500-6,000, HARD EDIT 0-9,000
OR
REFUSED 7777
DON’T KNOW 9999
-
BOX 1
CHECK ITEM ECQ.075:
IF REFUSED (CODE 7) OR DON'T KNOW (CODE 9), CONTINUE.
OTHERWISE, GO TO BOX 2.
ECQ.080 Did {SP NAME} weigh . . .
more than 5-1/2 lbs. (2500 g), or 1
less than 5-1/2 lbs. (2500 g)? 2 (BOX 2)
REFUSED 7 (BOX 2)
DON'T KNOW 9 (BOX 2)
ECQ.090 Did {SP NAME} weigh . . .
more than 9 lbs. (4100 g), or 1
less than 9 lbs. (4100 g)? 2
REFUSED 7
DON'T KNOW 9
-
BOX 2
CHECK ITEM ECQ.095:
IF SP AGE = 2-15 YEARS, CONTINUE.
OTHERWISE, GO TO BOX 4.
HIQ.011 The next questions are about health insurance.
Include health insurance obtained through employment or purchased directly as well as government programs like Medicare and Medicaid that provide medical care or help pay medical bills.
{Are you/Is SP} covered by health insurance or some other kind of health care plan?
YES 1
NO 2 (BOX 12)
REFUSED 7 (BOX 12)
DON'T KNOW 9 (BOX 12)
HIQ.031 What kind of health insurance or health care coverage {do you/does SP} have? Include those that pay for only one type of service (nursing home care, accidents, or dental care). Exclude private plans that only provide extra cash while hospitalized. If {you have/s/he has} more than one kind of health insurance, tell me all plans that {you have/s/he has}.
CODE ALL THAT APPLY
HAND CARD HIQ1
CAPI INSTRUCTION:
DO NOT ALLOW MORE THAN ONE ANSWER WHEN 40 (NO COVERAGE OF ANY TYPE) IS CODED.
PRIVATE HEALTH INSURANCE 14
MEDICARE 15
MEDI-GAP 16
MEDICAID ({DISPLAY STATE PLAN NAME}) 17
SCHIP (CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM) 18
MILITARY HEALTH CARE (TRICARE/VA/CHAMP-VA) 19
INDIAN HEALTH SERVICE 20
STATE-SPONSORED HEALTH PLAN ({DISPLAY STATE
PLAN NAME}) 21
OTHER GOVERNMENT PROGRAM 22
SINGLE SERVICE PLAN (E.G., DENTAL, VISION,
PRESCRIPTIONS) 23
NO COVERAGE OF ANY TYPE 40
REFUSED 77
DON'T KNOW 99
-
BOX 2
OMITTED
-
BOX 3
OMITTED
-
BOX 4
OMITTED
-
BOX 5
OMITTED
-
BOX 10
OMITTED
-
BOX 11
OMITTED
-
BOX 12
IF AGE => 65 AND HIQ.031 = CODE 14 OR CODE 16-99 OR HIQ.031 IS EMPTY, GO TO HIQ.260.
IF AGE => 65 AND HIQ.031 = CODE 15, GO TO HIQ.500.
OTHERWISE, CONTINUE.
-
BOX 13
IF AGE < 65 AND (HIQ.011 = 1 (YES) AND HIQ.031 NOT = 40 (NO COVERAGE), GO TO HIQ.270.
IF AGE < 65 AND (HIQ.011 = 2, 7, OR 9 OR HIQ.031 = 40), GO TO END OF SECTION.
HIQ.260 {Do you/Does SP} have Medicare? This is a health insurance program that virtually all persons 65 and older are eligible for. A card is automatically mailed to you shortly before your 65th birthday, it looks like this.
SHOW HAND CARD HIQ2 OF MEDICARE CARD
YES 1
NO 2 (BOX 14)
REFUSED 7 (BOX 14)
DON’T KNOW 9 (BOX 14)
HIQ.500 May I please see {your/SP's} Medicare card to determine the type of coverage and to record the Health Insurance Claim Number?
This number is needed to allow Medicare records of the Center for Medicare and Medicaid Services to be easily and accurately located and identified for statistical or research purposes. We may also need to link it with other records in order to re-contact {you/SP}. Except for these purposes, the Department of Health and Human Services will not release {your/his/her} Health Insurance Claim Number to anyone, including any other government agency. Providing the Health Insurance Claim Number is voluntary and collected under the authority of the Public Health Service Act. Whether the number is given or not, there will be no effect on {your/his/her} benefits. This number will be held in strict confidence. [The Public Health Service Act is Title 42, United States Code, Section 242K.]
CAPI INSTRUCTION:
REQUIRE DOUBLE ENTRY OF NUMBER.
ALLOW UP TO 11 CHARACTERS (LETTERS OR NUMBERS)
|___|___|___|___|___|___|___|___|___|___|___|
ENTER CLAIM NUMBER
REFUSED 777777777 (BOX 14)
DON'T KNOW 999999999 (BOX 14)
HIQ.105 INTERVIEWER: ENTER 1 RESPONSE
CARD AVAILABLE 1
CARD NOT AVAILABLE 2 (BOX 14)
-
BOX 14
IF (HIQ.011 = 1 AND HIQ.031 NOT = 40) OR HIQ.260 = 1, CONTINUE.
OTHERWISE, GO TO END OF SECTION.
-
BOX 6
OMITTED
-
BOX 7
OMITTED
-
BOX 8
OMITTED
-
BOX 9
OMITTED
HIQ.270 {Does this plan/Do any of these plans} cover any part of the cost of prescriptions?
CAPI INSTRUCTION:
IF HIQ.031 = 15 or HIQ.260 = 1, DISPLAY: [If you are enrolled in Medicare Part D, also known as the Medicare Prescription Drug Plan, you have some prescription drug coverage.]
Yes 1
No 2
Refused 7
Don't know 9
HIQ.210 In the past 12 months, was there any time when {you/SP} did not have any health insurance coverage?
Yes 1
No 2
Refused 7
Don't know 9
HOSPITAL UTILIZATION AND
ACCESS TO CARE (HUQ)
HUQ.010 {First/Next} I have some general questions about {your/SP's} health.
Would you say {your/SP's} health in general is . . .
CAPI INSTRUCTION:
DISPLAY "FIRST" IF SP AGE IS >= 16 YEARS.
excellent, 1
very good, 2
good, 3
fair, or 4
poor? 5
REFUSED 7
DON'T KNOW 9
BOX 1
IF SP AGE >= 1, CONTINUE.
OTHERWISE, GO TO HUQ.030.
HUQ.020 Compared with 12 months ago, would you say {your/SP's} health is now . . .
better, 1
worse, or 2
about the same? 3
REFUSED 7
DON'T KNOW 9
HUQ.030 Is there a place that {you/SP} usually {go/goes} when {you are/he/she is} sick or {you/s/he} need{s} advice about {your/his/her} health?
CAPI INSTRUCTION:
IF SP AGE < 12, DISPLAY "YOU" IN THE FOURTH DISPLAY AND DON'T DISPLAY THE "S" IN THE FIFTH DISPLAY.
YES 1
THERE IS NO PLACE 2 (HUQ.050)
THERE IS MORE THAN ONE PLACE 3
REFUSED 7 (HUQ.050)
DON'T KNOW 9 (HUQ.050)
HUQ.040 What kind of place {do you/does SP} go to most often: is it a clinic, doctor's office, emergency room, or some other place?
CLINIC OR HEALTH CENTER 1
DOCTOR'S OFFICE OR HMO 2
HOSPITAL EMERGENCY ROOM 3
HOSPITAL OUTPATIENT DEPARTMENT 4
SOME OTHER PLACE 5
REFUSED 7
DON'T KNOW 9
HUQ.050 {During the past 12 months, how/How} many times {have you/has SP} seen a doctor or other health care professional about {your/his/her} health at a doctor's office, a clinic, hospital emergency room, at home or some other place? Do not include times {you were/s/he was} hospitalized overnight.
CAPI INSTRUCTION:
DISPLAY "12 MONTHS" ONLY IF SP'S AGE IS >= 1.
NONE 0
1 1 (HUQ.071)
2 TO 3 2 (HUQ.071)
4 TO 9 3 (HUQ.071)
10 TO 12 4 (HUQ.071)
13 OR MORE 5 (HUQ.071)
REFUSED 7 (HUQ.071)
DON'T KNOW 9 (HUQ.071)
HUQ.060 About how long has it been since {you/SP} last saw or talked to a doctor or other health care professional about {your/his/her} health? Include doctors seen while {you were} {he/she was} a patient in a hospital. Has it been . . .
6 months or less, 1
more than 6 months, but not more than
1 year ago, 2
more than 1 year, but not more than
3 years ago, 3
more than 3 years, or 4
never? 5
REFUSED 7
DON'T KNOW 9
HUQ.071 {During the past 12 months, were you/{Was/was} SP} a patient in a hospital overnight? Do not include an overnight stay in the emergency room.
CAPI INSTRUCTION:
DISPLAY "12 MONTHS" ONLY IF SP'S AGE IS >= 1.
DISPLAY "WAS SP" WITH LEADING CAPS, IF SP'S AGE IS <1.
YES 1
NO 2 (BOX 2)
REFUSED 7 (BOX 2)
DON'T KNOW 9 (BOX 2)
HUQ.080 How many different times did {you/SP} stay in any hospital overnight or longer {during the past 12 months}? (Do not count total number of nights, just total number of hospital admissions for stays which lasted 1 or more nights.)
CAPI INSTRUCTION:
DISPLAY "12 MONTHS" ONLY IF SP'S AGE IS >= 1.
HARD EDIT: 1-366.
SOFT EDIT: 1-6.
|___|___|___|
ENTER NUMBER
REFUSED 77777
DON'T KNOW 99999
BOX 1A
OMITTED
BOX 2
IF SP AGE >= 4, CONTINUE.
OTHERWISE, GO TO END OF SECTION.
HUQ.090 During the past 12 months, that is since {DISPLAY CURRENT MONTH} of {DISPLAY LAST YEAR}, {have you/has SP} seen or talked to a mental health professional such as a psychologist, psychiatrist, psychiatric nurse or clinical social worker about {your/his/her} health?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
BOX 0
CHECK ITEM IMQ.005:
IF SP AGE >= 2, CONTINUE.
OTHERWISE, GO TO IMQ.020.
BOX 1
OMITTED
IMQ.011 Hepatitis (Hep-a-ti-tis) A vaccine is given as a two dose series to some children older than 2 years and also to some adults, especially people who travel outside the United States. It has only been available since 1995. {Have you/Has SP} ever received hepatitis A vaccine?
CODE 'LESS THAN 2 DOSES' ONLY IF MENTIONED BY RESPONDENT
YES AT LEAST 2 DOSES 1
LESS THAN 2 DOSES 2
NO DOSES 3
REFUSED 7
DON'T KNOW 9
IMQ.020 Hepatitis (Hep-a-ti-tis) B vaccine is given in three separate doses and has been recommended for all newborn infants since 1991. In 1995, it was recommended that adolescents be given the vaccine. Persons who may be exposed to other people’s blood, such as health care workers, also may have received the vaccine. {Have you/Has SP} ever received the 3-dose series of the hepatitis B vaccine?
CODE 'LESS THAN 3 DOSES' ONLY IF MENTIONED BY RESPONDENT
YES AT LEAST 3 DOSES 1
LESS THAN 3 DOSES 2
NO DOSES 3
REFUSED 7
DON'T KNOW 9
BOX 2
CHECK ITEM IMQ.035:
IF SP = FEMALE AND AGE IS >= 9 AND <= 59, CONTINUE.
OTHERWISE, GO TO END OF SECTION.
IMQ.040 Human Papillomavirus (HPV) vaccine is given to prevent cervical cancer in girls and women. It is given in 3 separate doses over 6 months and has been recommended for girls and women since June, 2006. {Have you/Has SP} ever received one or more doses of the HPV vaccine? (The brand name for the vaccine is Gardasi.)
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
IMQ.045 How many doses {have you/has SP} received?
1 1
2 2
3 3
REFUSED 7
DON'T KNOW 9
MCQ.010 Has a doctor or other health professional ever told {you/SP} that {you have/s/he/SP has} asthma (az-ma)?
CAPI INSTRUCTION:
IF SP AGE >= 12, DISPLAY SP NAME AND "S/HE":
IF SP AGE < 12, DISPLAY "YOU" AND SP NAME.
HELP SCREEN:
Asthma: Asthma is a condition that affects your airways.that carry air in and out of your lungs. It causes symptoms like wheezing (a whistling sound when you breathe), coughing, chest tightness, and trouble breathing,
INTERVIEWER: DO NOT ACCEPT SELF-DIAGNOSED OR DIAGNOSED BY A PERSON WHO IS NOT A DOCTOR OR OTHER HEALTH PROFESSIONAL.
YES 1
NO 2 (MCQ.053)
REFUSED 7 (MCQ.053)
DON'T KNOW 9 (MCQ.053)
MCQ.025 How old {were you/was SP} when {you were/s/he was} first told {he/she} had asthma (az-ma)?
IF LESS THAN 1 YEAR, ENTER 1
CAPI INSTRUCTION:
IF SP AGE >= 16, DISPLAY "WERE YOU" AND "YOU WERE".
IF SP AGE = 12-15, DISPLAY "WAS {SP}" AND "S/HE WAS".
IF SP AGE < 12, DISPLAY "WAS {SP}" AND "YOU WERE".
|___|___|___|
ENTER AGE IN YEARS
CAPI INSTRUCTION:
HARD EDIT: 1-120
REFUSED 777
DON'T KNOW 999
MCQ.035 {Do you/Does SP} still have asthma (az-ma)?
YES 1
NO 2 (MCQ.053)
REFUSED 7 (MCQ.053)
DON'T KNOW 9 (MCQ.053)
MCQ.040 During the past 12 months, {have you/has SP} had an episode of asthma (az-ma) or an asthma attack?
HELP SCREEN:
Episode/attack: When your asthma symptoms become worse than usual it is called an asthma episode or attack.
YES 1
NO 2 (MCQ.053)
REFUSED 7 (MCQ.053)
DON'T KNOW 9 (MCQ.053)
MCQ.050 [During the past 12 months], {have you/has SP} had to visit an emergency room or urgent care center because of asthma (az-ma)?
HELP SCREEN:
Emergency Room: An emergency care facility at a hospital that is open 24 hours a day. No appointments are necessary. Emergency care may be administered by a physician, nurse, paramedic, physician extender, or other health provider. Do not include urgent care centers, which are not part of a hospital, or outpatient clinics.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
MCQ.051 During the past 3 months, {have you/has SP} taken medication prescribed by a doctor or other health professionals for asthma?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
MCQ.053 During the past 3 months, {have you/has SP} been on treatment for anemia (a-nee-me-a), sometimes called "tired blood" or "low blood"? [Include diet, iron pills, iron shots, transfusions as treatment.]
HELP SCREEN:
Anemia: Anemia (uh-NEE-me-eh) is a condition in which a person’s blood has a lower than normal number of red blood cells (RBCs).
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 2
IF SP AGE < 2, GO TO END OF SECTION.
IF SP AGE 2-15, GO TO BOX 3.
IF SP AGE 16+, CONTINUE.
OTHERWISE, CONTINUE.
MCQ.080 Has a doctor or other health professional ever told {you/SP} that {you were/s/he/SP was} overweight?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 2A
OMITTED
-
BOX 3
IF SP'S AGE >= 6, CONTINUE.
OTHERWISE, GO TO MCQ.140.
MCQ.092 {Have you/Has SP} ever received a blood transfusion?
YES 1
NO 2 (MCQ.140)
REFUSED 7 (MCQ.140)
DON'T KNOW 9 (MCQ.140)
MCQ.093 In what year did {you/SP} receive {your/his/her} first transfusion?
|___|___|___|___|
ENTER 4-DIGIT YEAR
CAPI INSTRUCTION:
HARD EDIT: 1900-2006
REFUSED 7777
DON’T KNOW 9999
-
BOX 4
OMITTED
-
BOX 6
OMITTED
MCQ.140 {Do you/Does SP} have trouble seeing, even when wearing glasses or contact lenses, if {you/he/she} wear{s} them?
HELP SCREEN:
Glasses: Includes prescription eyeglasses as well as nonprescription reading glasses purchased at drug stores or variety stores. Do not include safety glasses, which are worn for protection only. Do not include non prescription sunglasses or glasses or contact lenses worn for cosmetic purposes.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 7
IF SP'S AGE 6-19, CONTINUE.
IF SP'S AGE >= 20, GO TO MCQ.160.
OTHERWISE, GO TO END OF SECTION.
-
BOX 7A
IF SP AGE 8-11 AND SP IS FEMALE, CONTINUE.
OTHERWISE, GO TO MCQ.150.
MCQ.149 Have {SP's} periods or menstrual (men-stral) cycles started yet?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
MCQ.150 |
During the past 12 months, that is, since {DISPLAY CURRENT MONTH} of {DISPLAY LAST YEAR}, about how many days did {you/SP} miss school because of an illness or injury? |
IF NONE, ENTER 0
HELP SCREEN:
Injury: INTERVIEWER: INJURY IS DEFINED BY THE RESPONDENT.
|___|___|___|
ENTER NUMBER OF DAYS
DID NOT GO TO SCHOOL 666
REFUSED 777
DON'T KNOW 999
-
BOX 8
OMITTED
-
07New Box 1
IF SP AGE >= 16, GO TO MCQ.245.
OTHERWISE, GO TO MCQ.300b.
MCQ.160
CAPI INSTRUCTION: |
MCQ.170 |
MCQ.180 |
MCQ.190 |
a. had arthritis (ar-thry-tis)?
YES 1 NO 2 (b) REFUSED 7 (b) DON'T KNOW 9 (b)
|
|
had arthritis? |___|___|___| ENTER AGE IN YEARS
REFUSED 777 DON'T KNOW 999
|
RHEUMATOID ARTHRITIS 1 OSTEOARTHRITIS 2 OTHER 3 REFUSED 7 DON'T KNOW 9
|
n. had gout?
YES 1 NO 2 REFUSED 7 DON'T KNOW 9
|
|
had gout? |___|___|___| ENTER AGE IN YEARS
REFUSED 777 DON'T KNOW 999
|
|
b. had congestive heart failure?
YES 1 NO 2 (c) REFUSED 7 (c) DON'T KNOW 9 (c)
|
|
had congestive heart failure? |___|___|___| ENTER AGE IN YEARS
REFUSED 777 DON'T KNOW 999
|
|
c. had coronary (kor-o-nare-ee) heart disease?
NO 2 (d) REFUSED 7 (d) DON'T KNOW 9 (d)
|
|
had coronary heart disease? |___|___|___| ENTER AGE IN YEARS
REFUSED 777 DON'T KNOW 999
|
|
d. had angina (an-gī-na), also called angina pectoris?
YES 1 NO 2 (e) REFUSED 7 (e) DON'T KNOW 9 (e)
|
|
had angina, also called agina pectoris? |___|___|___| ENTER AGE IN YEARS
REFUSED 777 DON'T KNOW 999
|
|
e. had a heart attack (also called myocardial infarction (my-O-car-dee-al in-fark-shun))?
NO 2 (f) REFUSED 7 (f) DON'T KNOW 9 (f)
|
|
had a heart attack (also called myocardial infarction)? |___|___|___| ENTER AGE IN YEARS
REFUSED 777 DON'T KNOW 999
|
|
f. had a stroke?
YES 1 NO 2 (g) REFUSED 7 (g) DON'T KNOW 9 (g)
|
|
had a stroke? |___|___|___| ENTER AGE IN YEARS
REFUSED 777 DON'T KNOW 999
|
|
g. had emphysema (emph-phi-see-ma)?
NO 2 (m) REFUSED 7 (m) DON'T KNOW 9 (m)
|
|
had emphysema? |___|___|___| ENTER AGE IN YEARS
REFUSED 777 DON'T KNOW 999
|
|
m. had a thyroid (thigh-roid) problem?
NO 2 (k) REFUSED 7 (k) DON'T KNOW 9 (k)
|
have a thyroid problem? YES 1 NO 2 REFUSED 7 DON'T KNOW 9
|
had a thyroid problem? |___|___|___| ENTER AGE IN YEARS
REFUSED 777 DON'T KNOW 999
|
|
k. had chronic bronchitis?
NO 2 (l) REFUSED 7 (l) DON'T KNOW 9 (l)
|
have chronic bronchitis? YES 1 NO 2 REFUSED 7 DON'T KNOW 9
|
had chronic bronchitis? |___|___|___| ENTER AGE IN YEARS
REFUSED 777 DON'T KNOW 999
|
|
l. had any kind of liver condition?
NO 2 (MCQ.220) REFUSED 7 (MCQ.220) DON'T KNOW 9 (MCQ.220)
|
have this liver condition? YES 1 NO 2 REFUSED 7 DON'T KNOW 9
|
had this liver condition? |___|___|___| ENTER AGE IN YEARS
REFUSED 777 DON'T KNOW 999
|
|
HELP SCREENS FOR MCQ.160
MCQ160a
Arthritis: Is joint inflammation characterized by stiffness, swelling, redness, heat, or pain in the joint. Common types of arthritis are rheumatoid arthritis and osteoarthritis
MCQ160n
Gout: Gout is one of the most painful forms of arthritis. It occurs when too much uric acid builds up in the body. For many people, the first attack of gout occurs in the big toe. Often, the attack wakes a person from sleep.
MCQ160b
Congestive Heart Failure: Heart failure is a condition where the heart cannot pump enough blood throughout the body. Blood and fluid to "back up" into the lungs which causes shortness of breath. The heart failure causes a buildup of fluid in the feet, ankles, and legs. Do not count heart murmurs, dropped or skipped heart beats, chest pain or heart attacks.
MCQ160c
Coronary Heart Disease: Occurs when the arteries that supply blood to the heart muscle become hardened and narrowed due to buildup of a material called plaque (plak). The buildup of plaque is known as atherosclerosis (ATH-er-o-skler-O-sis). This can lead to angina or a heart attack.
INTERVIEWER: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR CORONARY HEART DISEASE.
MCQ160d
Angina (Angina Pectoris): (AN-ji-na or an-JI-na). Angina is chest pain or discomfort that occurs when the heart does not get enough blood.
INTERVIEWER: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR ANGINA.
MCQ160e
Heart Attack (Myocardial Infarction): A heart attack happens when a blood clot develops at the site of plaque in a coronary artery and suddenly cuts off most or all blood supply to that part of the heart muscle. Common symptoms include crushing lower chest pain that may radiate to the jaw or arms. The chest pain may be associated with nausea, sweating, and shortness of breath.
MCQ160f
Stroke: A stroke occurs when the blood supply to part of the brain is suddenly interrupted or when a blood vessel in the brain bursts. The symptoms of a stroke include sudden numbness or weakness, especially on one side of the body; sudden confusion or trouble speaking or understanding speech; sudden trouble seeing in one or both eyes; sudden trouble with walking, dizziness, or loss of balance or coordination; or sudden severe headache with no known cause.
MCQ160g
Emphysema: Emphysema is a lung disease in which the alveoli (tiny air sacs) become damaged and less air goes in and out. It is frequently due to smoking. The main symptom is shortness of breath.
MCQ160m
Thyroid Problem: Include hyperthyroidism (overactive thyroid); hypothyroidism (underactive thyroid); Graves disease (a thyroid eye disease); Hashimoto's thyroditis (inflamed thyroid); thyroid cancer; thyroid nodule (lump growing in thyroid); and postpartum thyroiditis (a thyroid disease that occurs after delivery).
MCQ160k
Chronic (Bronchitis): is characterized by a productive cough that produces sputum for three months or more in at least two consecutive years.
MCQ.220 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had cancer or a malignancy (ma-lig-nan-see) of any kind?
HELP SCREEN:
Cancer: An abnormal uncontrolled growth of tissue that has potential to spread to distant sites of the body, also known as a malignant tumor.
Malignancy: A tumor or growth that is cancerous.
YES 1
NO 2 (MCQ.245)
REFUSED 7 (MCQ.245)
DON'T KNOW 9 (MCQ.245)
MCQ.230 What kind of cancer was it?
ENTER UP TO 3 KINDS. IF RESPONDENT OFFERS MORE THAN 3, ENTER 66 AS THE 4TH RESPONSE.
CAPI INSTRUCTIONS:
ALLOW UP TO 3 ENTRIES.
ALLOW 'MORE THAN 3 KINDS (CODE 66) ONLY AS 4TH ENTRY.
( ) ( ) ( ) ( )
BLADDER 10 BLOOD 11 BONE 12 BRAIN 13 BREAST 14 CERVIX (CERVICAL) 15 COLON 16 ESOPHAGUS (ESOPHAGEAL) 17 GALLBLADDER 18 KIDNEY 19 LARYNX/WINDPIPE 20
|
LEUKEMIA 21 LIVER 22 LUNG 23 LYMPHOMA/HODGKINS' DISEASE 24 MELANOMA 25 MOUTH/TONGUE/LIP 26 NERVOUS SYSTEM 27 OVARY (OVARIAN) 28 PANCREAS (PANCREATIC) 29 PROSTATE 30 RECTUM (RECTAL) 31
|
SKIN (NON-MELANOMA) 32 SKIN (DON'T KNOW WHAT KIND) 33 SOFT TISSUE (MUSCLE OR FAT) 34 STOMACH 35 TESTIS (TESTICULAR) 36 THYROID 37 UTERUS (UTERINE) 38 OTHER 39 MORE THAN 3 KINDS 66 REFUSED 77 DON'T KNOW 99
|
-
BOX 9
LOOP 1:
ASK MCQ.240 FOR EACH TYPE OF CANCER (CODES 10-39 AND CODE 99) ENTERED IN MCQ.230.
MCQ.240 How old {were you/was SP} when {TYPE OF CANCER/cancer} was first diagnosed?
CAPI INSTRUCTIONS:
DISPLAY TYPE OF CANCER (CODE 10-39) ENTERED IN MCQ.230.
DISPLAY "CANCER " IF DON'T KNOW ENTERED IN MCQ.230.
|___|___|___|
ENTER AGE IN YEARS
REFUSED 777
DON'T KNOW 999
-
BOX 9A
END LOOP 1:
ASK MCQ.240 FOR NEXT TYPE OF CANCER (CODES 10-39 AND CODE 99) ENTERED IN MCQ.230.
IF NO NEXT TYPE, CONTINUE WITH MCQ.245.
MCQ.245 |
During the past 12 months, that is since {DISPLAY CURRENT MONTH} of last year, about how many days did {you/SP} miss work at a job or business because of an illness or injury {do not include maternity leave}? |
CAPI INSTRUCTION:
DISPLAY "DO NOT INCLUDE MATERNITY LEAVE" ONLY IF SP IS FEMALE.
|___|___|___|
ENTER NUMBER OF DAYS
DOES NOT WORK 666
REFUSED 777
DON'T KNOW 999
HELP SCREEN:
Job: Work (Working) for pay, tips or in exchange for meals, living quarters, or supplies provided in place of pay.
-
BOX 10
OMITTED
-
07New Box
IF SP AGE >= 20, CONTINUE.
OTHERWISE, GO TO MCQ.300b.
MCQ.300 |
Including living and deceased, were any of {SP’s/your} close biological that is, blood relatives including father, mother, sisters or brothers, ever told by a health professional that they had . . . |
CAPI INSTRUCTION:
TEXT OF QUESTION SHOULD BE OPTIONAL, “[ ]’S, AFTER FIRST TIME.
a. a heart attack or angina (an-gī-na) before the age of 50?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
b. asthma (az-ma)?
CAPI INSTRUCTION:
IF SP AGE 6-19, DISPLAY: Including living and deceased, were any of {SP’s/your} close biological that is, blood relatives including father, mother, sisters or brothers, ever told by a health professional that they had . . .
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
07New Box 3
IF SP AGE 6-19, GO TO END OF SECTION.
OTHERWISE, CONTINUE.
c. diabetes?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 11
IF SP IS MALE AGE >= 40, CONTINUE.
OTHERWISE, GO TO END OF SECTION
MCQ.265 Including living and deceased, were any of {SP's/your} biological that is, blood relatives including grandfathers, fathers, brothers, ever told by a health professional that they had prostate (pros-state) cancer?
YES 1
NO 2 (MCQ.310)
REFUSED 7 (MCQ.310)
DON'T KNOW 9 (MCQ.310)
MCQ.268 Which biological [blood] family members?
CODE ALL THAT APPLY.
FATHER 1
MOTHER’S FATHER 2
FATHER’S FATHER 3
BROTHER 4
REFUSED 7
DON'T KNOW 9
MCQ.310 {Have you/Has SP} ever had a blood test that {your/his} doctor told {you/him} was being used to check for prostate (pros-state) cancer, called PSA, or Prostate Specific Antigen (An-ti-jen)?
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
MCQ.320 How old {were you/was SP} when {you/he} first had {your/his} PSA test?
|___|___|___|
ENTER AGE IN YEARS
CAPI INSTRUCTION:
HARD EDIT: 1-120
REFUSED 777
DON'T KNOW 999
MCQ.330 |
How long ago was {your/his} last PSA test? |
|___|___|___|
ENTER NUMBER
CAPI INSTRUCTION:
HARD EDITS: 0-366.
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 777
DON'T KNOW 999
MCQ.340 How many PSA tests {have you/has SP} had in the last 5 years?
|___|___|
ENTER NUMBER
CAPI INSTRUCTION:
SOFT EDIT: 0-20
REFUSED 777
DON'T KNOW 999
MCQ.350 Has a doctor or other health care professional ever told {you/SP} that {your/his} PSA test was not normal?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
KIQ.022 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had weak or failing kidneys? Do not include kidney stones, bladder (bladd-er) infections, or incontinence (in‑kon‑ti‑nens).
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
KIQ.025 In the past 12 months, {have you/has SP} received dialysis (either hemodialysis (heemo-di-al-i-sis) or peritoneal dialysis (pare-i-ton-nee-al di-al-i-sis))?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
KIQ.026 {Have you/Has SP} ever had kidney stones?
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
KIQ.028 How many times {have you/has SP} passed a kidney stone?
|___|___|
ENTER NUMBER OF TIMES
SOFT EDIT 1-12
NEVER 1
REFUSED 77
DON'T KNOW 99
-
BOX 1A
CHECK ITEM PFQ.001:
IF AGE OF SP IS >= 20, GO TO PFQ.049
OTHERWISE, CONTINUE WITH BOX 1B.
-
BOX 1B
CHECK ITEM PFQ.002:
IF SP <= 4, CONTINUE.
OTHERWISE, GO TO PFQ.020.
PFQ.010 The next set of questions is about limitations caused by any long-term physical, mental or emotional problem or illness. Please do not include temporary conditions, such as a cold.
Is {SP} limited in the kind or amount of play activities {he/she} can do because of a physical, mental or emotional problem?
YES 1
NO 2 (PFQ.020)
REFUSED 7 (PFQ.020)
DON'T KNOW 9 (PFQ.020)
PFQ.015 Is {SP} able to take part at all in the usual kinds of play activities done by most children {his/her} age?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
PFQ.020 {Do you/Does SP} have an impairment or health problem that limits {your/his/her} ability to {crawl, walk or play} {walk, run or play} {walk or run}?
CAPI INSTRUCTION:
IF CHILD'S AGE = 1-4, DISPLAY "CRAWL, WALK OR PLAY". IF CHILD'S AGE = 5-15, DISPLAY "WALK, RUN OR PLAY". IF SP'S AGE = 16-19, DISPLAY "WALK OR RUN".
Yes 1
No 2 (BOX 1BB)
Refused 7 (BOX 1BB)
DON'T know 9 (BOX 1BB)
PFQ.030 Is this an impairment or health problem that has lasted, or is expected to last 12 months or longer?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 1BB
CHECK ITEM PFQ.035A:
IF SP AGE <= 17, CONTINUE.
OTHERWISE, GO TO END OF SECTION.
PFQ.041 Does {SP} receive Special Education or Early Intervention Services?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 1C
CHECK ITEM PFQ.045:
GO TO END OF SECTION.
PFQ.049 The next set of questions is about limitations caused by any long-term physical, mental or emotional problem or illness. Please do not include temporary conditions, such as a cold [or pregnancy].
Does a physical, mental or emotional problem now keep {you/SP} from working at a job or business?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
PFQ.051 {Are you/Is SP} limited in the kind or amount of work {you/s/he} can do because of a physical, mental or emotional problem?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
PFQ.054 Because of a health problem, {do you/does SP} have difficulty walking without using any special equipment?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
PFQ.057 {Are you/Is SP} limited in any way because of difficulty remembering or because {you/s/he} experience{s} periods of confusion?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 1D
CHECK ITEM PFQ.058:
IF 'YES' (CODE 1) IN PFQ.049, PFQ.051, PFQ.054, OR PFQ.057, GO TO PFQ.061.
OTHERWISE, CONTINUE.
PFQ.059 {Are you/Is SP} limited in any way in any activity because of a physical, mental or emotional problem?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 1E
CHECK ITEM PFQ.059A:
IF SP AGE IS <=59 AND 'NO' (CODE 2) ENTERED IN PFQ.049, PFQ.057 AND PFQ.059, GO TO PFQ.090.
OTHERWISE, CONTINUE.
PFQ.061 |
The next questions ask about difficulties {you/SP} may have doing certain activities because of a health problem. By "health problem" we mean any long-term physical, mental or emotional problem or illness {not including pregnancy}. |
By {yourself/himself/herself} and without using any special equipment, how much difficulty {do you/does SP} have . . .
HAND CARD PFQ1
DO NOT INCLUDE TEMPORARY CONDITIONS LIKE PREGNANCY OR BROKEN LIMBS.
CAPI INSTRUCTION:
IF PFQ.054 = '1' (YES), DO NOT DISPLAY 'B' OR 'C'.
IF SP FEMALE, DISPLAY 'NOT INCLUDING PREGNANCY'.
RESPONSES: NO DIFFICULTY = 1, SOME DIFFICULTY = 2, MUCH DIFFICULTY = 3,
UNABLE TO DO = 4, DO NOT DO THIS ACTIVITY = 5, REFUSED = 7, DON'T KNOW = 9.
a. managing {your/his/her} money [such as keeping track of
{your/his/her} expenses or paying bills]? ____
b. walking for a quarter of a mile [that is about 2 or 3 blocks]? ____
c. walking up 10 steps without resting? ____
d. stooping, crouching, or kneeling? ____
e. lifting or carrying something as heavy as 10 pounds [like a
sack of potatoes or rice]? ____
f. doing chores around the house [like vacuuming, sweeping,
dusting, or straightening up]? ____
g. preparing {your/his/her} own meals? ____
h. walking from one room to another on the same level? ____
i. standing up from an armless straight chair? ____
j. getting in or out of bed? ____
k. eating, like holding a fork, cutting food or drinking from a glass? ____
l. dressing {yourself/himself/herself}, including tying shoes,
working zippers, and doing buttons? ____
m. standing or being on {your/his/her} feet for about 2 hours? ____
n. sitting for about 2 hours? ____
o. reaching up over {your/his/her} head? ____
p. using {your/his/her} fingers to grasp or handle small objects? ____
q. going out to things like shopping, movies, or sporting events? ____
r. participating in social activities [visiting friends, attending
clubs or meetings or going to parties]? ____
s. doing things to relax at home or for leisure [reading, watching
TV, sewing, listening to music]? ____
t. pushing or pulling large objects like a living room chair? ____
-
BOX 1F
CHECK ITEM PFQ.066A:
IF 'SOME DIFFICULTY' (CODE 2), 'MUCH DIFFICULTY' (CODE 3), OR 'UNABLE TO DO' (CODE 4) IN PFQ.061 A THROUGH T, CONTINUE.
OTHERWISE, GO TO PFQ.090.
PFQ.063 What condition or health problem causes {you/SP} to have difficulty with or need help with {NAME OF UP TO 3 ACTIVITIES/these activities}?
HAND CARD PFQ2
ENTER ALL THAT APPLY UP TO 5 BUT DO NOT PROBE.
DO NOT ENTER 'OLD AGE' AS CONDITION -- IF OLD AGE IS REPORTED, PROBE FOR ANY OTHER CONDITION.
CAPI INSTRUCTION:
IF THE TOTAL NUMBER OF ITEMS CODED 'SOME DIFFICULTY' (CODE 2), 'MUCH DIFFICULTY' (CODE 3), OR 'UNABLE TO DO' (CODE 4) IN PFQ.061 A THROUGH T <=3, DISPLAY EACH ITEM NAME IN THE TEXT OF QUESTION. IF MORE THAN 3 ITEMS ARE CODED IN THIS MANNER DISPLAY "THESE ACTIVITIES" IN THE TEXT OF QUESTION.
ARTHRITIS/RHEUMATISM 10
BACK OR NECK PROBLEM 11
BIRTH DEFECT 12
CANCER 13
DEPRESSION/ANXIETY/EMOTIONAL
PROBLEM 14
OTHER DEVELOPMENTAL PROBLEM
(SUCH AS CEREBRAL PALSY) 15
DIABETES 16
FRACTURES, BONE/JOINT INJURY 17
HEARING PROBLEM 18
HEART PROBLEM 19
HYPERTENSION/HIGH BLOOD
PRESSURE 20
LUNG/BREATHING PROBLEM 21
MENTAL RETARDATION 22
OTHER INJURY 23
SENILITY 24
STROKE PROBLEM 25
VISION/PROBLEM SEEING 26
WEIGHT PROBLEM 27
OTHER IMPAIRMENT/PROBLEM 28
REFUSED 77
DON'T KNOW 99
-
BOX 2
CHECK ITEM PFQ.068A:
IF CODE 10-11 OR 13-28 IN PFQ.063, CONTINUE WITH LOOP 1.
OTHERWISE, GO TO PFQ.090.
LOOP 1:
ASK QUESTION PFQ.069 FOR EACH CONDITION MENTIONED IN PFQ.063 (CONDITION: 10-11 OR 13-28).
PFQ.069 |
How long {have you/has SP}
had {CONDITION 10-11 or 13-28}? |
IF CODE 28 IN PFQ.063, THE FILL SHOULD BE {THE OTHER CONDITION YOU MENTIONED}.
|___|___|___|
ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)
SINCE BIRTH 666
REFUSED 777
DON'T KNOW 999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
-
BOX 3
END LOOP 1:
CYCLE ON NEXT CONDITION.
IF NO NEXT CONDITION, GO TO PFQ.090.
PFQ.090 {Do you/Does SP} now have any health problem that requires {you/him/her} to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
DIQ.010 {Other than during pregnancy, {have you/has SP}/{Have you/Has SP}} ever been told by a doctor or other health professional that {you have/{he/she/SP} has} diabetes or sugar diabetes?
CAPI INSTRUCTION:
IF SP AGE < 15, DISPLAY "HAS SP" FOR THE FIRST DISPLAY AND "SP HAS" FOR THE SECOND DISPLAY.
IF SP IS FEMALE AND AGE >= 20, DISPLAY "OTHER THAN DURING PREGNANCY, {HAVE YOU/HAS SP}".
YES 1
NO 2 (BOX 4)
BORDERLINE OR PREDIABETES 3 (BOX 4)
REFUSED 7 (BOX 4)
DON'T KNOW 9 (BOX 4)
|
|
|___|___|
ENTER AGE IN YEARS
LESS THAN 1 YEAR 666
REFUSED 777
DON'T KNOW 999
BOX 6
CHECK ITEM DIQ.219:
IF AGE AT SCREENING MINUS AGE RECORDED AT DIQ.040 > 2, GO TO BOX 4.
OTHERWISE, CONTINUE.
DIQ.220 Was {your/his/her} diabetes diagnosed …
3 months ago or less, 1
More than 3 months ago but not
more
than 6 months ago, 2
More than 6 months ago but not
more
than 9 months ago, 3
More than 9 months ago but not
more
than 12 months ago, or 4
More than 12 months ago? 5
REFUSED 7
DON’T KNOW 9
BOX 4
CHECK ITEM DIQ.159:
IF AGE < 12, GO TO DIQ.050.
IF AGE >= 12 AND DIQ.010 = 1 (YES), GO TO DIQ.190.
IF AGE >= 12 AND DIQ.010 = 3, GO TO DIQ.170.
OTHERWISE, CONTINUE.
DIQ.160 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/SP has} any of the following: prediabetes, impaired fasting glucose, impaired glucose tolerance, borderline diabetes or that {your/her/his} blood sugar is higher than normal but not high enough to be called diabetes or sugar diabetes?
CAPI INSTRUCTION:
HELP SCREEN: PREDIABETES, IMPAIRED FASTING GLUCOSE, IMPAIRED GLUCOSE TOLERANCE, OR BORDERLINE DIABETES OCCURS WHEN BLOOD SUGAR (GLUCOSE) LEVELS ARE HIGHER THAN NORMAL BUT NOT HIGH ENOUGH TO BE DIABETES.
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
HAND CARD DIQ1
Prediabetes
Impaired fasting glucose
Impaired glucose tolerance
Borderline diabetes
DIQ.170 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/s/he has} health conditions or a medical or family history that increases {your/his/her} risk for diabetes?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
DIQ.180 {Have you/Has SP} had a blood test for high blood sugar or diabetes within the past three years?
INTERVIEWER INSTRUCTION: DO NOT INCLUDE URINE TESTS
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
BOX 4A
OMITTED
DIQ.190 To lower {your/his/her} risk for certain diseases, during the past 12 months {have you/has s/he} ever been told by a doctor or health professional to:
CAPI INSTRUCTION:
HELP SCREEN: CONTROLLING YOUR WEIGHT MIGHT BE RECOMMENDED TO HELP PREVENT HIGH BLOOD PRESSURE, DIABETES, HIGH CHOLESTEROL AND OTHER CONDITIONS.
RESPONSES: YES = 1, NO = 2, REFUSED = 7, DON’T KNOW = 9
a. control {your/his/her} weight or lose weight? ____
b. increase {your/his/her} physical activity or exercise? ____
c. reduce the amount of fat or calories in {your/his/her} diet? ____
DIQ.200 To lower {your/his/her} risk for certain diseases, {are you/is s/he} now doing any of the following:
CAPI INSTRUCTION:
HELP SCREEN: CONTROLLING YOUR WEIGHT MIGHT BE RECOMMENDED TO HELP PREVENT HIGH BLOOD PRESSURE, DIABETES, HIGH CHOLESTEROL AND OTHER CONDITIONS.
RESPONSES: YES = 1, NO = 2, REFUSED = 7, DON’T KNOW = 9
a. controlling {your/his/her} weight or losing weight? ____
b. increasing {your/his/her} physical activity or exercise? ____
c. reducing the amount of fat or calories in {your/his/her} diet? ____
BOX 5
OMITTED
DIQ.050 {Is SP/Are you} now taking insulin?
YES 1
NO 2 (BOX 0)
REFUSED 7 (BOX 0)
DON'T KNOW 9 (BOX 0)
|
|
ENTER NUMBER (OF MONTHS OR YEARS)
LESS THAN 1 MONTH 666
REFUSED 777
DON'T KNOW 999
ENTER UNIT
MONTHS 1
YEARS 2
BOX 0
CHECK ITEM DIQ.065:
IF DIQ.010 = 1 (YES) OR DIQ.160 = 1 (YES), CONTINUE.
OTHERWISE, GO TO END OF SECTION.
DIQ.070 {Is SP/Are you} now taking diabetic pills to lower {{his/her}/your} blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
BOX 1
OMITTED
BOX 8
CHECK ITEM DIQ.229:
IF DIQ.160 = 1 (YES), GO TO END OF SECTION.
OTHERWISE, CONTINUE.
DIQ.230 When was the last time {you/SP} saw a diabetes nurse educator or dietitian or nutritionist for {your/his/her} diabetes? Do not include doctors or other health professionals.
INTERVIEWER INSTRUCTION: IF RESPONDENT ANSWERS “TODAY” OR A PERIOD LESS THAN A MONTH, CODE 1 – THE 0-12 MONTH CATEGORY.
CAPI INSTRUCTION:
HELP SCREEN: A diabetes nurse educator is a nurse who teaches people with diabetes and who is knowledgeable about the day-to-day aspects of diabetes self-care, such as, use of diabetes medications, checking and controlling blood glucose levels, managing weight though diet and physical activity, and maintaining a healthy pregnancy if diabetes is present.
1 YEAR AGO OR LESS 1
MORE THAN 1 YEAR AGO BUT NO
MORE
THAN 2 YEARS AGO 2
MORE THAN 2 YEARS AGO BUT NO
MORE
THAN 5 YEARS AGO 3
MORE THAN 5 YEARS AGO 4
NEVER 5
REFUSED 7
DON’T KNOW 9
DIQ.240 Is there one doctor or other health professional {you usually see/SP usually sees} for {your/his/her} diabetes? Do not include specialists to whom {you have/SP has} been referred such as diabetes educators, dieticians or foot and eye doctors.
CAPI INSTRUCTION:
HELP SCREEN: A diabetes nurse educator is a nurse who teaches people with diabetes and who is knowledgeable about the day-to-day aspects of diabetes self-care, such as, use of diabetes medications, checking and controlling blood glucose levels, managing weight though diet and physical activity, and maintaining a healthy pregnancy if diabetes is present.
YES 1
NO 2 (DIQ.260)
REFUSED 7 (DIQ.260)
DON’T KNOW 9 (DIQ.260)
DIQ.250 How many times {have you/has SP} seen this doctor or other health professional in the past 12 months?
|___|___|___|
ENTER NUMBER OF TIMES
CAPI INSTRUCTION:
HARD EDIT: DO NOT ALLOW 0.
NONE 2
REFUSED 7777
DON'T KNOW 9999
BOX 9
CHECK ITEM DIQ.369:
IF DIQ.250 = 2 (NONE), CONTINUE.
OTHERWISE, GO TO BOX 10.
DIQ.370 INTERVIEWER: YOU HAVE ENTERED “NONE” FOR THE NUMBER OF TIMES IN THE PAST 12 MONTHS THAT THE SP HAS SEEN THEIR USUAL DOCTOR OR OTHER HEALTH PROFESSIONAL. THIS IS AN UNLIKELY RESPONSE. IS THIS CORRECT?
YES 1
NO 2 (DIQ.250)
BOX 10
CHECK ITEM DIQ.379:
IF DIQ.250 = 100 OR MORE, CONTINUE.
OTHERWISE, GO TO DIQ.260.
DIQ.380 INTERVIEWER: YOU HAVE ENTERED A VALUE THAT IS OUTSIDE THE EXPECTED RANGE FOR THE NUMBER OF TIMES IN THE PAST 12 MONTHS THAT THE SP HAS SEEN THEIR USUAL DOCTOR OR OTHER HEALTH PROFESSIONAL. THIS IS AN UNLIKELY RESPONSE. IS THIS CORRECT?
YES 1
NO 2 (DIQ.250)
BOX 2
OMITTED
|
|
INTERVIEWER INSTRUCTION: DO NOT INCLUDE URINE TESTS.
|___|___|___|
ENTER NUMBER OF TIMES
CAPI INSTRUCTION: SOFT EDIT 30 OR MORE PER WEEK.
NEVER 2
UNABLE TO DO ACTIVITY (BLIND) 3
REFUSED 7777
DON'T KNOW 9999
ENTER UNIT
PER DAY 1
PER WEEK 2
PER MONTH 3
PER YEAR 4
|
|
|___|___|___|
ENTER NUMBER OF TIMES
CAPI INSTRUCTION: SOFT EDIT MORE THAN 13 TIMES.
NOT TESTED IN LAST 12 MONTHS 2 (DIQ.300)
NEVER HEARD OF A ONE C TEST 3 (DIQ.300)
DON’T KNOW HOW MANY TIMES 4
REFUSED 7777
DIQ.280 What was {your/SP’s} last “A one C” level?
CAPI INSTRUCTION:
SOFT EDIT FOR ANY NUMBER LESS THAN 5 OR MORE THAN 14.
|___|___| . |___|
ENTER VALUE
REFUSED 777
DON'T KNOW 999
DIQ.290 What does {your/SP’s} doctor or other health professional say {your/his/her} “A one C” level should be? (Pick the lowest level recommended by your health care professional.)
HAND CARD DIQ2
6 OR LESS 1
7 OR LESS 2
8 OR LESS 3
9 OR LESS 4
10 OR LESS 5
PROVIDER DID NOT SPECIFY GOAL 6
REFUSED 77
DON'T KNOW 99
BOX 10A
CHECK ITEM DIQ.295:
IF AGE <12, GO TO END OF SECTION.
OTHERWISE, CONTINUE.
|
|
CAPI INSTRUCTION:
SYSTOLIC VALUE HARD EDIT: 48-300, SOFT EDIT 80-200. DIASTOLIC VALUE HARD EDIT: 0-300, SOFT EDIT 0-150.
|___|___|___| OVER |___|___|___|
SYSTOLIC DIASTOLIC
ENTER VALUES
CAPI INSTRUCTION:
HARD EDIT 0-300. SOFT EDIT 80-200.
REFUSED 7777
DON'T KNOW 9999
|
|
CAPI INSTRUCTION:
SYSTOLIC VALUE HARD EDIT: 48-300, SOFT EDIT 80-200. DIASTOLIC VALUE HARD EDIT: 0-300, SOFT EDIT 0-150.
|___|___|___| OVER |___|___|___|
SYSTOLIC DIASTOLIC
ENTER VALUES
INTERVIEWER INSTRUCTION. IF RANGE
GIVEN, RECORD UPPER VALUE OF RANGE.
CAPI INSTRUCTION:
HARD EDIT 0-300. SOFT EDIT 0-150.
PROVIDER DID NOT SPECIFY GOAL 2
REFUSED 7777
DON'T KNOW 9999
|
|
|___|___|___|
ENTER VALUE
CAPI INSTRUCTION:
HARD EDIT: ALLOW 25-350. SOFT EDIT ALLOW 40-250.
NEVER HEARD OF LDL 2 (DIQ.335)
NEVER HAD CHOLESTEROL TEST 3 (DIQ.335)
REFUSED 7777
DON'T KNOW 9999
|
|
|___|___|___|
ENTER VALUE. INTERVIEWER INSTRUCTION: IF RANGE GIVEN,
RECORD UPPER VALUE OF RANGE.
CAPI INSTRUCTION:
HARD EDIT 25-350. SOFT EDIT 40-250.
PROVIDER DID NOT SPECIFY GOAL 2
REFUSED 7777
DON'T KNOW 9999
DIQ.335 INTERVIEWER INSTRUCTION ONLY:
DOES THE SP HAVE BOTH FEET AMPUTATED?
YES 1 (DIQ.360)
NO 2
|
|
|___|___|___|
ENTER NUMBER OF TIMES
CAPI INSTRUCTION:
HARD EDIT: DO NOT ALLOW 0.
NONE 2
REFUSED 7777
DON'T KNOW/not sure 9999
|
|
|___|___|___|
ENTER NUMBER OF TIMES
NONE 2
REFUSED 7777
DON'T KNOW 9999
ENTER UNIT
PER DAY 1
PER WEEK 2
PER MONTH 3
PER YEAR 4
DIQ.360 When was the last time {you/SP} had an eye exam in which the pupils were dilated? This would have made {you/SP} temporarily sensitive to bright light.
LESS THAN 1 MONTH 1
1-12 MONTHS 2
13-24 MONTHS 3
GREATER THAN 2 YEARS 4
NEVER 5
REFUSED 7
DON'T KNOW 9
DIQ.080 Has a doctor ever told {you/SP} that diabetes has affected {your/his/her} eyes or that {you/s/he} had retinopathy (ret-in-op-ath-ee)?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
BPQ.020 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had hypertension (hy-per-ten-shun), also called high blood pressure?
[IF HIGH BLOOD PRESSURE ONLY DURING PREGNANCY, CODE NO.]
INTERVIEWER INSTRUCTION: IF SP SAYS “HIGH NORMAL BLOOD PRESSURE”, “BORDERLINE HYPERTENSION” OR “PREHYPERTENSION” CODE NO.
YES 1
NO 2 (BPQ.052)
REFUSED 7 (BPQ.052)
DON'T KNOW 9 (BPQ.052)
HELP SCREEN:
Hypertension (High Blood Pressure): A repeatedly increased blood pressure with the first number 140 or higher and the second number 90 or higher.
BPQ.030 {Were you/Was SP} told on 2 or more different visits that {you/s/he} had hypertension (hy-per-ten-shun), also called high blood pressure?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
BPQ.035 How old {were you/was SP} when {you were/he/she was} first told that {you/he/she} had hypertension or high blood pressure?
|___|___|
ENTER AGE IN YEARS
LESS THAN 1 YEAR 666
REFUSED 777
DON'T KNOW 999
BPQ.040a Because of {your/SP’s} (high blood pressure/hypertension) (hy-per-ten-shun), {have you/has s/he} ever been told to take prescribed medicine?
YES 1
NO 2 (BPQ.052)
REFUSED 7 (BPQ.052)
DON’T KNOW 9 (BPQ.052)
HELP SCREEN:
Prescribed Medicine: Prescribed medicines are those ordered by a doctor or other health provider through a written or verbal prescription for a pharmacist to fill. Prescription medicines can also be given by a medical provider directly to a patient to take home, such as free samples.
-
BOX 1A
OMITTED
-
BOX 1B
OMITTED
BPQ.050a {Are you/Is SP} now taking a prescribed medicine?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
BPQ.052 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/SP has} prehypertension?
HELP SCREEN:
Prehypertension is defined as having a blood pressure reading of 120 to 139 for the first reading and the second reading of 80 to 89 millimeters.
YES 1 (BOX 2)
NO 2
REFUSED 7
DON'T KNOW 9
BPQ.057 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/SP has} high normal blood pressure or borderline hypertension?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
HAND CARD BPQ1
High normal blood pressure
Borderline hypertension
CAPI INSTRUCTION:
HELP SCREEN:
High normal blood pressure or borderline hypertension is defined as having a blood pressure reading of 120 to 139 for the first reading and the second reading of 80 to 89 millimeters. People with blood pressures that are high normal blood pressure or borderline hypertension also called prehypertension.
-
BOX 2
CHECK ITEM BPQ.055:
IF SP AGE >= 20, CONTINUE.
OTHERWISE, GO TO END OF SECTION.
BPQ.060 {Have you/Has SP} ever had {your/his/her} blood cholesterol checked?
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
CAPI INSTRUCTION:
IF DIQ.320 = 3 (NEVER HAD CHOLESTEROL TEST) AND BPQ.060 = 1 (NO), DISPLAY THE FOLLOWING MESSAGE: “YOU HAVE CODED THAT SP HAS HAD THEIR BLOOD CHOLESTEROL CHECKED. EARLIER ON DIQ SP REPORTED NEVER HAVING A CHOLESTEROL TEST – RECONCILE RESPONSE WITH SP AND CHANGE RESPONSE TO ONE OF THE QUESTIONS BELOW (BPQ.060).” DISPLAY RESPONSES TO BOTH – WITH LABELS. DIQ.320 – NEVER HAD CHOLESTEROL TEST, BPQ.060 – HAS HAD CHOLESTEROL CHECKED. HIGHLIGHT MUST BE ON DIQ.320.
BPQ.070 About how long has it been since {you/SP} last had {your/his/her} blood cholesterol checked? Has it been...
less than 1 year ago, 1
1 year but less than 2 years ago, 2
2 years but less than 5 years ago, or 3
5 years or more? 4
REFUSED 7
DON'T KNOW 9
BPQ.080 {Have you/Has SP} ever been told by a doctor or other health professional that {your/his/her} blood cholesterol level was high?
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
HELP SCREEN:
Cholesterol: Cholesterol is a type of fat in the bloodstream and is measured with a blood test, usually done in the morning before you’ve eaten. High levels of cholesterol is a major risk factor for heart disease, which leads to heart attack.
BPQ.090 To lower {your/his/her} blood cholesterol, {have you/has SP} ever been told by a doctor or other health professional . . .
RESPONSES: YES = 1, NO = 2, REFUSED = 7, DON'T KNOW = 9.
a. to eat fewer high fat or high cholesterol foods? ____
b. to control {your/his/her} weight or lose weight? ____
c. to increase {your/his/her} physical activity or exercise? ____
d. to take prescribed medicine? ____
HELP SCREEN:
Prescribed Medicine: Prescribed medicines are those ordered by a doctor or other health provider through a written or verbal prescription for a pharmacist to fill. Prescription medicines can also be given by a medical provider directly to a patient to take home, such as free samples.
-
BOX 3
CHECK ITEM BPQ.095:
IF 'YES' (CODE 1) TO BPQ.090A, B, C OR D, CONTINUE WITH BPQ.100.
OTHERWISE, GO TO END OF SECTION.
BPQ.100 {Are you/Is SP} now following this advice to {DISPLAY ACTIVITY}?
CAPI INSTRUCTIONS:
DISPLAY EACH ACTIVITY CODED AS 'YES' (CODE 1) IN BPQ.090 A-D.
RESPONSES: YES = 1, NO = 2, REFUSED = 7, DON'T KNOW = 9.
a. eat fewer high fat or high cholesterol foods? ____
b. control {your/his/her} weight or lose weight? ____
c. increase {your/his/her} physical activity or exercise? ____
d. take prescribed medicine? ____
HELP SCREEN:
Prescribed Medicine: Prescribed medicines are those ordered by a doctor or other health provider through a written or verbal prescription for a pharmacist to fill. Prescription medicines can also be given by a medical provider directly to a patient to take home, such as free samples.
-
BOX 5
OMITTED
-
BOX 6
OMITTED
-
BOX 7
OMITTED
-
BOX 8
OMITTED
-
BOX 9
OMITTED
CDQ.001 {Have you/Has SP} ever had any pain or discomfort in {your/her/his} chest?
YES 1
NO 2 (CDQ.010)
REFUSED 7 (CDQ.010)
DON'T KNOW 9 (CDQ.010)
CDQ.002 {Do you/Does she/Does he} get it when {you/she/he} {walk/walks} uphill or {hurry/hurries}?
YES 1
NO 2 (CDQ.008)
NEVER WALKS UPHILL OR HURRIES 3
REFUSED 7 (CDQ.008)
DON'T KNOW 9 (CDQ.008)
CDQ.003 {Do you/Does she/Does he} get it when {you/she/he} {walk/walks} at an ordinary pace on level ground?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 1
CHECK ITEM CDQ.003A:
IF 'YES' (CODE '1') IN CDQ.002 OR CDQ.003, CONTINUE.
OTHERWISE, GO TO CDQ.008.
CDQ.004 What {do you/does she/does he} do if {you/she/he} get it while {you/she/he} are walking? {Do you/Does she/Does he} stop or slow down, or continue at the same pace?
CODE "STOP OR SLOW DOWN" IF SP CARRIES ON AFTER TAKING NITROGLYCERINE.
STOP OR SLOW DOWN 1
CONTINUE AT THE SAME PACE 2 (CDQ.008)
REFUSED 7 (CDQ.008)
DON'T KNOW 9 (CDQ.008)
CDQ.005 If {you/she/he} {stand/stands} still, what happens to it? Is the pain or discomfort relieved or not relieved?
RELIEVED 1
NOT RELIEVED 2 (CDQ.008)
REFUSED 7 (CDQ.008)
DON'T KNOW 9 (CDQ.008)
CDQ.006 How soon is the pain relieved? Would you say . . .
10 minutes or less or 1
more than 10 minutes? 2 (CDQ.008)
REFUSED 7 (CDQ.008)
DON'T KNOW 9 (CDQ.008)
CDQ.009 Please look at this card and show me where the pain or discomfort is located.
CODE ALL THAT APPLY.
PROBE FOR ADDITIONAL AREAS.
HAND CARD CDQ1
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
REFUSED 77
DON'T KNOW 99
CDQ.008 Have {you/she/he} ever had a severe pain across the front of {your/her/his} chest lasting for half an hour or more?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
CDQ.010 {Have you/Has SP} had shortness of breath either when hurrying on the level or walking up a slight hill?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
OSQ.010 |
Has a doctor ever told {you/SP} that {you/SP} had broken or fractured {your/his/her} . . . |
|
OSQ.020 |
How many times {have you/has SP} broken or fractured {your/his/her} {hip/wrist/spine}? |
|
|
|
|
|
|
a. hip? YES 1 NO 2 (b) REFUSED 7 (b) DON'T KNOW 9 (b)
|
|
|___|___| ENTER NUMBER OF TIMES
CAPI INSTRUCTION: HARD EDIT: 1-33.
REFUSED 77 DON'T KNOW 99
|
|
|
b. wrist? YES 1 DO NOT NO 2 (c) INCLUDE REFUSED 7 (c) FOREARM OR DON'T KNOW 9 (c) HAND |
|
|___|___| ENTER NUMBER OF TIMES
CAPI INSTRUCTION: HARD EDIT: 1-33.
REFUSED 77 DON'T KNOW 99
|
|
|
c. spine? YES 1 NO 2 (BOX 1) REFUSED 7 (BOX 1) DON'T KNOW 9 (BOX 1)
|
|
|___|___| ENTER NUMBER OF TIMES
CAPI INSTRUCTION: HARD EDIT: 1-33.
REFUSED 77 DON'T KNOW 99
|
|
-
BOX 1
CHECK ITEM OSQ.025:
IF 'YES' (CODE 1) IN OSQ.010 a, b, OR c, CONTINUE WITH LOOP 1.
OTHERWISE, GO TO OSQ.080.
LOOP 1:
ASK OSQ.030 - OSQ.051 FOR EACH TYPE AND EACH INCIDENT OF FRACTURE. (EXAMPLE: HOW OLD WERE YOU WHEN YOU FRACTURED YOUR HIP THE FIRST TIME?)
|
|
CAPI INSTRUCTION:
IF ONLY BROKE HIP, WRIST OR SPINE 1 TIME, DO NOT DISPLAY "THE {1ST/2ND . . .} TIME".
IF 10TH TIME, DISPLAY {10TH OR MOST RECENT TIME}.
|___|___|___| (BOX 2)
ENTER AGE IN YEARS
CAPI INSTRUCTION: HARD EDIT: 1-120.
REFUSED 777
DON'T KNOW 999
OSQ.040 {Were you/Was SP} . . .
a/b/c
under 50 years old, or 1
50 years old or older? 2
REFUSED 7 (BOX 3)
DON'T KNOW 9 (BOX 3)
-
BOX 2
CHECK ITEM OSQ.045:
IF AGE IS >= 50 IN OSQ.030 OR OSQ.040, CONTINUE.
OTHERWISE, GO TO BOX 3.
OSQ.051 Did that fracture occur as a result of . . .
a
fall from standing
height or less,
for
example, tripped, slipped, fell out of bed 4
a
hard fall, such as
falling off a ladder or
step stool, down stairs, or 5
a car accident or other severe trauma? 6
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION:
HELP SCREEN SHOULD READ: Additional examples for “a fall from standing height or less” include leg gave way, was dizzy, fell bending over, fell out of a chair. Additional examples for “a hard fall” include being forcibly knocked down by another person or bicycle.
-
BOX 3
END LOOP1:
ASK OSQ.030 - OSQ.051 FOR NEXT INCIDENT OF FRACTURE.
IF NO NEXT INCIDENT, CONTINUE.
OSQ.080 Has a doctor ever told {you/SP} that {you/s/he} had broken or fractured any other bone after {you were/s/he was} 20 years of age?
YES 1
NO 2 (OSQ.060)
REFUSED 7 (OSQ.060)
DON'T KNOW 9 (OSQ.060)
OSQ.090 Was this fracture the result of severe trauma such as a car accident, being struck by a vehicle, a physical attack, or a hard fall such as falling off a ladder or down stairs?
YES 1 (OSQ.120)
NO 2
REFUSED 7 (OSQ.120)
DON'T KNOW 9 (OSQ.120)
CAPI INSTRUCTION:
HELP SCREEN SHOULD READ:
Do not include a fall from standing height or less, for example, tripped, slipped, fell out of bed, leg gave way, was dizzy, fell bending over, or fell out of a chair.
Additional examples for “a hard fall” include being knocked down by another person or bicycle.
OSQ.100 Please look at this card and tell me where the fracture occurred.
HAND CARD OSQ 1
HEAD/FACE 10
UPPER ARM (HUMERUS) 11
LOWER ARM BETWEEN WRIST AND
ELBOW (DO NOT INCLUDE WRIST) 12
ELBOW 13
HAND 14
FINGERS 15
SHOULDER 16
COLLAR BONE 17
RIBS (EITHER SIDE) 18
PELVIS (NOT HIP) 19
UPPER LEG (THIGH EXCLUDING HIP) 20
LOWER LEG (BETWEEN ANKLE AND
KNEE) 21
KNEE (PATELLA) 22
ANKLE 23
HEEL 24
FOOT 25
TOES 26
OTHER (DO NOT SPECIFY) 27
REFUSED 77
DON'T KNOW 99
OSQ.110 How old {were you/was SP} when {you/SP} fractured {your/his/her} (fracture site selected in OSQ.100) for the first time after age 20?
|___|___|___|
ENTER AGE IN YEARS
CAPI INSTRUCTION: HARD EDIT: 20-120.
REFUSED 777
DON'T KNOW 999
OSQ.120 Has a doctor ever told {you/SP} that {you/s/he} had broken or fractured any other bones after {you were/s/he was} 20 years of age?
YES 1
NO 2 (OSQ.060)
REFUSED 7 (OSQ.060)
DON'T KNOW 9 (OSQ.060)
-
BOX 4
CHECK ITEM OSQ.129:
IF OSQ120 = 1 (YES), CONTINUE WITH LOOP 2. OTHERWISE, GO TO OSQ.060.
LOOP 2:
ASK OSQ.090 – OSQ.120 FOR NEXT INCIDENT OF FRACTURE. IF NO NEXT INCIDENT, CONTINUE.
OSQ.060 Has a doctor ever told {you/SP} that {you/s/he} had osteoporosis, sometimes called thin or brittle bones?
YES 1
NO 2 (OSQ.130)
REFUSED 7 (OSQ.130)
DON'T KNOW 9 (OSQ.130)
OSQ.070 {Were you/Was SP} ever treated for osteoporosis?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
OSQ.130 {Have you/has SP} ever taken any prednisone or cortisone pills nearly every day for a month or longer? [Prednisone and cortisone are types of steroids.]
YES 1
NO 2 (OSQ.150)
REFUSED 7 (OSQ.150)
DON'T KNOW 9 (OSQ.150)
|
|
|___|___|
ENTER NUMBER
CAPI INSTRUCTION: SOFT EDIT: 19 OR HIGHER.
REFUSED 777
DON'T KNOW 999
ENTER UNIT
MONTH 1
YEAR 2
REFUSED 7
DON’T KNOW 9
OSQ.150 Including living and deceased, were either of {your/SP's} biological parents ever told by a health professional that they had osteoporosis or brittle bones?
YES 1
NO 2 (OSQ.170)
REFUSED 7 (OSQ.170)
DON'T KNOW 9 (OSQ.170)
OSQ.160 Which biological [blood] parent?
CODE ALL THAT APPLY
MOTHER 1
FATHER 2
REFUSED 7
DON'T KNOW 9
OSQ.170 Did {your/SP's} biological mother ever fracture her hip?
YES 1
NO 2 (OSQ.200)
REFUSED 7 (OSQ.200)
DON'T KNOW 9 (OSQ.200)
OSQ.180 About how old was she when she fractured her hip (the first time)?
|___|___|___| (OSQ.200)
ENTER AGE IN YEARS
REFUSED 777
DON'T KNOW 999
OSQ.190 Was she. . .
under 50 years old, or 1
50 years old or older? 2
REFUSED 7
DON'T KNOW 9
OSQ.200 Did {your/SP's} biological father ever fracture his hip?
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
OSQ.210 About how old was he when he fractured his hip (the first time)?
|___|___|___| (END OF SECTION)
ENTER AGE IN YEARS
CAPI INSTRUCTION: HARD EDIT: 20-120.
REFUSED 777
DON'T KNOW 999
OSQ.220 Was he . . .
under 50 years old, or 1
50 years old or older? 2
REFUSED 7
DON'T KNOW 9
RESPIRATORY HEALTH AND DISEASE (RDQ)
-
BOX 1
IF SP AGE < 40, GO TO RDQ.070.
OTHERWISE, CONTINUE
RDQ.031 {Do you/Does SP} usually cough on most days for 3 consecutive months or more during the year?
YES 1
NO 2 (RDQ.050)
REFUSED 7 (RDQ.050)
DON'T KNOW 9 (RDQ.050)
RDQ.040 For how many years {have you/has SP} had this cough?
IF LESS THAN 1 YEAR, ENTER 1
|___|___|___|
ENTER NUMBER OF YEARS
REFUSED 777
DON'T KNOW 999
RDQ.050 {Do you/Does SP} bring up phlegm on most days for 3 consecutive months or more during the year?
YES 1
NO 2 (RDQ.070)
REFUSED 7 (RDQ.070)
DON'T KNOW 9 (RDQ.070)
RDQ.060 For how many years, {have you/has SP} had trouble with phlegm (flem)?
IF LESS THAN 1 YEAR, ENTER 1
|___|___|
ENTER NUMBER OF YEARS
REFUSED 777
DON'T KNOW 999
RDQ.070 In the past 12 months {have you/has SP} had wheezing or whistling in {your/his/her} chest?
YES 1
NO 2 (RDQ.140)
REFUSED 7 (RDQ.140)
DON'T KNOW 9 (RDQ.140)
RDQ.080 [In the past 12 months], how many attacks of wheezing or whistling {have you/has SP} had?
IF 12 OR MORE EPISODES, ENTER 12
CAPI INSTRUCTION:
HARD EDIT: RANGE EQUALS 1 TO 12.
|___|___|
ENTER NUMBER OF EPISODES
REFUSED 77
DON'T KNOW 99
RDQ.090 [In the past 12 months], how often, on average, has {your/SP's} sleep been disturbed because of wheezing? Would you say this happens . . .
never, 0
1 or more nights per week, or 1
less than 1 night per week? 2
REFUSED 7
DON’T KNOW 9
RDQ.100 [In the past 12 months], has {your/SP's} chest sounded wheezy during or after exercise or physical activity?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 3
OMITTED
RDQ.120 [In the past 12 months], how many times {have you/has SP} gone to the doctor's office or the hospital emergency room for one or more of these attacks of wheezing or whistling?
IF NEVER, ENTER 0
|___|___|
ENTER NUMBER
CAPI INSTRUCTION:
SOFT EDIT: IF RESPONSE >20, THEN DISPLAY “UNLIKELY RESPONSE. PLEASE VERIFY. (RDQ.150).”
HARD EDIT: CHECK: RDQ.120 – RANGE ERROR, THE VALID RANGE IS 0-50.
REFUSED 77
DON'T KNOW 99
RDQ.134 [In the past 12 months], {have you/has SP} taken any medication, prescribed by a doctor, for wheezing or whistling?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
RDQ.135 During the past 12 months, how much did {you/SP} limit {your/his/her} usual activities due to wheezing or whistling? Would you say…
not at all, 1
a little, 2
a fair amount, 3
a moderate amount, or 4
a lot? 5
REFUSED 7
DON'T KNOW 9
-
BOX 4
IF SP AGE = 6-69 YEARS, CONTINUE.
OTHERWISE, GO TO RDQ.140.
RDQ.137 During the past 12 months, how many days of work or school did {you/SP} miss due to wheezing or whistling?
NONE 0
1 TO 7 1
8 TO 30 2
31 PLUS 3
REFUSED 7
DON'T KNOW 9
RDQ.140 [In the past 12 months], {have you/has SP} had a dry cough at night not counting a cough associated with a cold or chest infection lasting 14 days or more?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
AGQ.030 During the past 12 months, {have you/has SP} had an episode of hay fever?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
BOX 1
OMITTED
VIQ.010 Next I have some questions about {your/SP’s} ability to see.
With both eyes open, can {you/he/she} see light?
YES 1 (VIQ.031)
NO 2
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION:
IF VIQ.010 = 2 AND MCQ.140 = 1, DISPLAY THE FOLLOWING MESSAGE: “YOU HAVE CODED THAT SP CANNOT SEE LIGHT – PLEASE VERIFY BY REENTERING THE RESPONSE.” CAPI SHOULD DISPLAY VIQ.010 AGAIN WITH BLANK ENTRY.
IF VIQ.010 = 2 AND MCQ.140 = 2, DISPLAY THE FOLLOWING MESSAGE: “YOU HAVE CODED THAT SP CANNOT SEE LIGHT. EARLIER SP REPORTED NO TROUBLE SEEING. RECONCILE RESPONSES WITH SP AND CHANGE RESPONSE TO ONE OF THE QUESTIONS BELOW.” DISPLAY RESPONSES TO BOTH – WITH LABELS. MCQ.140 – TROUBLE SEEING, VIQ.010 – SEE LIGHT, HIGHLIGHT MUST BE ON VIQ.010.
VIQ.017 {Are you/Is SP} blind in both eyes?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION:
IF VIQ.010 = 2 (NO) AND VIQ.017 = 2 (NO), DISPLAY THE FOLLOWING MESSAGE: “YOU HAVE CODED THAT SP IS NOT BLIND. EARLIER SP REPORTED THAT HE/SHE CANNOT SEE LIGHT. RECONCILE RESPONSES WITH SP AND CHANGE RESPONSE TO ONE QUESTION BELOW:” DISPLAY RESPONSES TO BOTH VIQ.010 AND VIQ.017 WITH LABELS. PLACE HIGHLIGHT ON VIQ.010.
BOX 1A
CHECK ITEM VIQ.024:
IF VIQ.017 = 1, GO TO VIQ.071.
OTHERWISE, CONTINUE.
BOX 1A
OMITTED
BOX 2
OMITTED
VIQ.031 At the present time, would you say {your/SP's} eyesight, with glasses or contact lenses if {you/s/he} wear them, is . . .
excellent, 1
good, 2
fair, 3
poor, or 4
very poor? 5
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION:
IF VIQ.010 = 2 AND VIQ.031 = 1 (EXCELLENT vision), DISPLAY THE FOLLOWING MESSAGE: “YOU HAVE CODED THAT SP CANNOT SEE LIGHT. SP REPORTED EXCELLENT VISION. RECONCILE RESPONSES WITH SP AND CHANGE RESPONSE TO ONE OF THE QUESTIONS BELOW.”
DISPLAY RESPONSES TO ALL – WITH LABELS.
VIQ.010 – CAN’T SEE LIGHT
VIQ.031 = 1 (EXCELLENT vision)
HIGHLIGHT MUST BE ON VIQ.010.
VIQ.041 How much of the time {do you/does SP} worry about {your/his/her} eyesight? Would you say . . .
none of the time, 0
a little of the time, 1
some of the time, 2
most of the time, or 3
all of the time? 4
REFUSED 7
DON'T KNOW 9
BOX 3
CHECK ITEM VIQ.049:
IF SP AGE < 20, GO TO END OF SECTION.
OTHERWISE, CONTINUE.
VIQ.051 The next questions are about how much difficulty, if any, {you have/SP has} doing certain activities, such as reading ordinary newsprint or going down steps. If {you/s/he} usually wear{s} glasses or contact lenses to do these activities, please rate {your/his/her} ability to do them while wearing {your/his/her} glasses or contacts.
How much difficulty {do you/does SP} have . . .
HAND CARD VIQ1.
READ CATEGORIES TO RESPONDENT IF NECESSARY.
RESPONSES: NO DIFFICULTY = 1, A LITTLE DIFFICULTY = 2, MODERATE DIFFICULTY = 3, EXTREME DIFFICULTY = 4, UNABLE TO DO BECAUSE OF EYESIGHT = 5, DOES NOT DO THIS FOR OTHER REASONS = 6, REFUSED = 7, DON'T KNOW = 9.
a. reading ordinary print in newspapers? _____
b. doing
work or hobbies that require {you/him/her} to
see well up
close such as cooking, sewing, fixing things
around the house,
or using hand tools? _____
c. going
down steps, stairs, or curbs in dim light
or at night? _____
d. noticing
objects off to the side while {you are/s/he is}
walking? _____
e. finding something on a crowded shelf? _____
VIQ.056 How much difficulty {do you/does SP} have driving during the daytime in familiar places?
HAND CARD VIQ2
NO DIFFICULTY 1
A LITTLE DIFFICULTY 2
MODERATE DIFFICULTY 3
EXTREME DIFFICULTY 4
UNABLE TO DO BECAUSE OF
EYESIGHT 5
DOES NOT DO THIS FOR OTHER
REASONS 6
NEVER DROVE 7
REFUSED 77
DON'T KNOW 99
CAPI INSTRUCTION:
IF VIQ.010 = 2 AND VIQ.056 = 1 (NO DIFFICULTY), DISPLAY THE FOLLOWING MESSAGE: “YOU HAVE REPORTED THAT SP CANNOT SEE LIGHT. SP REPORTED NO DIFFICULTY DRIVING. RECONCILE RESPONSES WITH SP AND CHANGE RESPONSE TO ONE OF THE QUESTIONS BELOW.”
DISPLAY RESPONSES TO ALL – WITH LABELS.
VIQ.010 – CAN’T SEE LIGHT
VIQ.056 = 1 (NO DIFFICULTY),
HIGHLIGHT MUST BE ON VIQ.010.
VIQ.061 How limited {are you/is SP} in how long {you/s/he} can work or do other daily activities such as housework, child care, school, or community activities because of {your/his/her} vision? Would you say {you are/s/he is} limited . . .
none of the time, 0
a little of the time, 1
some of the time, 2
most of the time, or 3
all of the time? 4
REFUSED 7
DON'T KNOW 9
VIQ.071 {Have you/Has SP} ever had a cataract operation?
YES 1
NO 2 (BOX 4)
REFUSED 7 (BOX 4)
DON'T KNOW 9 (BOX 4)
VIQ.081 Was the operation in {your/SPs} right eye, left eye, or both eyes?
RIGHT EYE 1
LEFT EYE 2
BOTH 3
REFUSED 7
DON'T KNOW 9
BOX 4
CHECK ITEM VIQ.089:
IF SP AGE < 40, GO TO END OF SECTION.
OTHERWISE, CONTINUE.
VIQ.090 {Have you/Has SP} ever been told by an eye doctor that {you have/s/he has} glaucoma (gla-cO-ma), sometimes called high pressure in {your/his/her} eyes?
HELP SCREEN:
An eye doctor is a person who specializes in the study of the eye. An ophthalmologist specializes in the structure, function, and diseases of the eye. An optometrist specializes in the examining the eye for defects and faults of refraction and prescribing correctional lenses or exercises.
YES 1
NO 2 (VIQ.310)
REFUSED 7 (VIQ.310)
DON'T KNOW 9 (VIQ.310)
VIQ.100 Was the glaucoma (gla-cO-ma) in {your/his/her} right eye, left eye, or both eyes?
RIGHT EYE 1
LEFT EYE 2
BOTH 3
REFUSED 7
DON'T KNOW 9
VIQ.310 {Have you/Has SP} ever been told by an eye doctor that {you have/s/he has} age-related macular (mac‑ū‑lar) degeneration?
HELP SCREEN:
An eye doctor is a person who specializes in the study of the eye. An ophthalmologist specializes in the structure, function, and diseases of the eye. An optometrist specializes in the examining the eye for defects and faults of refraction and prescribing correctional lenses or exercises.
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
VIQ.320 Was the age-related macular (mac‑ū‑lar) degeneration in {your/his/her} right eye, left eye, or both eyes?
RIGHT EYE 1
LEFT EYE 2
BOTH 3
REFUSED 7
DON'T KNOW 9
AUQ.131 These next questions are about {your/SP’s} hearing.
Which statement best describes {your/SP’s} hearing (without a hearing aid)? Would you say {your/his/her} hearing is excellent, good, that {you have/s/he has} a little trouble, moderate trouble, a lot of trouble, or {are you/is s/he} deaf?
EXCELLENT 1
GOOD 2
A LITTLE TROUBLE 3
MODERATE HEARING TROUBLE 4
A LOT OF TROUBLE 5
DEAF 6
REFUSED 7
DON’T KNOW 9
BOX 1
IF SP AGE >= 12 AND AGE <= 19, GO TO AUQ.136.
OTHERWISE, CONTINUE.
BOX 2
IF AGE 70+, GO TO AUQ.141.
OTHERWISE, GO TO END OF SECTION.
AUQ.136 {Have you/Has SP} ever had 3 or more ear infections?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
AUQ.138 {Have you/Has SP} ever had a tube placed in {your/his/her} ear to drain the fluid from {your/his/her} ear?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
AUQ.141 When was the last time {you had/SP had} {your/his/her} hearing tested?
READ CATEGORIES IF NECESSARY
LESS THAN A YEAR AGO 1
1 YEAR TO 4 YEARS AGO 2
5 TO 9 YEARS AGO 3
TEN OR MORE YEARS AGO 4
NEVER 5
REFUSED 7
DON’T KNOW 9
AUQ.150 {Have you/Has SP} ever worn a hearing aid?
YES 1
NO 2 (AUQ.185)
REFUSED 7 (AUQ.185)
DON'T KNOW 9 (AUQ.185)
AUQ.171 In the past 12 months, {have you/has SP} worn a hearing aid at least 5 hours a week?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
AUQ.185 {Have you/Has SP} ever used assistive listening devices (ALDs), such as FM systems, closed-captioned television, or amplified telephone (or relay services)?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
07BOX 3
IF SP AGE >= 70, GO TO END OF SECTION.
OTHERWISE, CONTINUE.
AUQ.191 In the past 12 months, {have you/has SP} been bothered by ringing, roaring, or buzzing in {your/his/her} ears or head that lasts for 5 minutes or more?
YES 1
NO 2 (AUQ.211)
REFUSED 7 (AUQ.211)
DON'T KNOW 9 (AUQ.211)
AUQ.250 How long {have you/has SP} been bothered by this ringing, roaring, or buzzing in {your/his/her} ears or head?
READ CATEGORIES IF NECESSARY
LESS THAN THREE MONTHS 1
THREE MONTHS TO A YEAR 2
1 TO 4 YEARS 3
5 TO 9 YEARS 4
TEN OR MORE YEARS 5
REFUSED 7
DON’T KNOW 9
AUQ.260 {Are you/Is SP} bothered by ringing, roaring, or buzzing in {your/his/her} ears or head only after listening to loud sounds or loud music?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
AUQ.270 {Are you/Is SP} bothered by ringing, roaring, or buzzing in {your/his/her} ears or head when going to sleep?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
AUQ.280 How much of a problem is this ringing, roaring, or buzzing in {your/his/her} ears or head?
No problem 1
A small problem 2
A moderate problem 3
A big problem 4
A very big problem 5
REFUSED 7
DON’T KNOW 9
AUQ.211 {Have you/Has SP} ever used firearms for target shooting, hunting, or for any other purposes?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
AUQ.290 {Have you/Has SP} ever had a job where {you were/s/he was} exposed to loud noise for 5 or more hours a week? By loud noise I mean noise so loud that {you/s/he} had to speak in a raised voice to be heard.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
AUQ.231 Outside of a job, {have you/has SP} ever been exposed to steady loud noise or music for 5 or more hours a week? This is noise so loud that {you have/s/he has} to raise {your/his/her} voice to be heard. Examples are noise from power tools, lawn mowers, farm machinery, cars, trucks, motorcycles, or loud music.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
AUQ.241 How often {do you/does SP} wear hearing protection devices (ear plugs, ear muffs) when exposed to loud sounds or noise? (Include both job and off work exposures.)
Most of the time 1
Sometimes 2
Rarely/seldom 3
Never 4
REFUSED 7
DON’T KNOW 9
OHQ.011 Now I have some questions about the condition of your teeth and gums.
How would you describe the condition of {your/SP’s} teeth? Would you say . . .
excellent, 11
very good, 12
good, 13
fair, or 14
poor? 15
REFUSED 7
DON’T KNOW 9
OHQ.620 How often during the last year {have you/has SP} had painful aching anywhere in {your/his/her} mouth? Would you say . . .
HAND CARD OHQ1
Very often, 1
Fairly often, 2
Occasionally, 3
Hardly ever, or 4
Never? 5
REFUSED 7
DON'T KNOW 9
OHQ.630 How often during the last year {have you/has SP} felt that life in general was less satisfying because of problems with {your/his/her} teeth, mouth or dentures?
HAND CARD OHQ1
VERY OFTEN, 1
FAIRLY OFTEN, 2
OCCASIONALLY, 3
HARDLY EVER, OR 4
NEVER? 5
REFUSED 7
DON'T KNOW 9
OHQ.640 How often during the last year {have you/has SP} had difficulty doing {your/his/her} usual jobs or attending school because of problems with {your/his/her} teeth, mouth or dentures?
HAND CARD OHQ1
VERY OFTEN, 1
FAIRLY OFTEN, 2
OCCASIONALLY, 3
HARDLY EVER, OR 4
NEVER? 5
REFUSED 7
DON'T KNOW 9
OHQ.650 How often during the last year {has your/has SP’s} sense of taste been affected by problems with {your/his/her} teeth, mouth or dentures?
HAND CARD OHQ1
VERY OFTEN, 1
FAIRLY OFTEN, 2
OCCASIONALLY, 3
HARDLY EVER, OR 4
NEVER? 5
REFUSED 7
DON'T KNOW 9
OHQ.660 How often during the last year {have you/has SP} avoided particular foods because of problems with {your/his/her} teeth, mouth or dentures?
HAND CARD OHQ1
VERY OFTEN, 1
FAIRLY OFTEN, 2
OCCASIONALLY, 3
HARDLY EVER, OR 4
NEVER? 5
REFUSED 7
DON'T KNOW 9
OHQ.670 How often during the last year {have you/has SP} found it uncomfortable to eat any food because of problems with {your/his/her} teeth, mouth or dentures?
HAND CARD OHQ1
VERY OFTEN, 1
FAIRLY OFTEN, 2
OCCASIONALLY, 3
HARDLY EVER, OR 4
NEVER? 5
REFUSED 7
DON'T KNOW 9
OHQ.680 How often during the last year {have you/has SP} been self-conscious or embarrassed because of {your/his/her} teeth, mouth or dentures?
HAND CARD OHQ1
VERY OFTEN, 1
FAIRLY OFTEN, 2
OCCASIONALLY, 3
HARDLY EVER, OR 4
NEVER? 5
REFUSED 7
DON'T KNOW 9
SLQ.010 The next set of questions is about your sleeping habits.
H/M
How much sleep {do you/does SP} usually get at night on weekdays or workdays?
|___|___|
ENTER HOURS
CAPI INSTRUCTION: HARD EDIT: HOURS MUST EQUAL 0-24.
REFUSED 777
DON'T KNOW 999
SLQ.021G How long does it usually take {you/SP} to fall asleep at bedtime?
ENTER MINUTES 1-59 1
ONE HOUR OR MORE 2 (SLQ.030)
REFUSED 777 (SLQ.030)
DON'T KNOW 999 (SLQ.030)
CAPI INSTRUCTION:
GATE QUESTION.
SLQ.021M How long does it usually take {you/SP} to fall asleep at bedtime?
|___|___|
ENTER MINUTES 1-59
CAPI INSTRUCTION:
HARD EDIT: MINUTES MUST EQUAL 0-59.
SLQ.030 In the past 12 months, how often did {you/SP} snore while {you were/s/he was} sleeping?
Never 0
Rarely (1-2 nights/week) 1
Occasionally (3-4 nights/week) 2
Frequently (5 or more nights/week) 3
REFUSED 7
DON’T KNOW 9
SLQ.040 In the past 12 months, how often did {you/SP} snort, gasp, or stop breathing while {you were/s/he was} asleep?
Never 0
Rarely (1-2 nights/week) 1
Occasionally (3-4 nights/week) 2
Frequently (5 or more nights/week) 3
REFUSED 7
DON’T KNOW 9
SLQ.050 {Have you/Has SP} ever told a doctor or other health professional that {you have/s/he has} trouble sleeping?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
SLQ.060 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/s/he has} a sleep disorder?
YES 1
NO 2 (SLQ.080)
REFUSED 7 (SLQ.080)
DON'T KNOW 9 (SLQ.080)
SLQ.070 What was the sleep disorder?
CODE ALL THAT APPLY.
SLEEP APNEA 1
INSOMNIA 2
RESTLESS LEGS 3
OTHER 4
REFUSED 7
DON’T KNOW 9
SLQ.080 This next set of questions is about {your/SP’s} sleeping habits in the past month.
In the past month, how often did {you/SP} have trouble falling asleep?
HAND CARD SLQ1
NEVER 0
RARELY – 1 TIME A MONTH 1
SOMETIMES – 2-4 TIMES A MONTH 2
OFTEN – 5-15 TIMES A MONTH 3
ALMOST ALWAYS – 16-30
TIMES A
MONTH 4
REFUSED 7
DON’T KNOW 9
SLQ.090 [In the past month, how often did {you/SP}] wake up during the night and had trouble getting back to sleep?
HAND CARD SLQ1
NEVER 0
RARELY – 1 TIME A MONTH 1
SOMETIMES – 2-4 TIMES A MONTH 2
OFTEN – 5-15 TIMES A MONTH 3
ALMOST ALWAYS – 16-30
TIMES A
MONTH 4
REFUSED 7
DON’T KNOW 9
SLQ.100 [In the past month, how often did {you/SP}] wake up too early in the morning and {were/was} unable to get back to sleep?
HAND CARD SLQ1
NEVER 0
RARELY – 1 TIME A MONTH 1
SOMETIMES – 2-4 TIMES A MONTH 2
OFTEN – 5-15 TIMES A MONTH 3
ALMOST ALWAYS – 16-30
TIMES A
MONTH 4
REFUSED 7
DON’T KNOW 9
SLQ.110 [In the past month, how often did {you/SP}] feel unrested during the day, no matter how many hours of sleep {you have/s/he has} had?
HAND CARD SLQ1
NEVER 0
RARELY – 1 TIME A MONTH 1
SOMETIMES – 2-4 TIMES A MONTH 2
OFTEN – 5-15 TIMES A MONTH 3
ALMOST ALWAYS – 16-30
TIMES A
MONTH 4
REFUSED 7
DON’T KNOW 9
SLQ.120 [In the past month, how often did {you/SP}] feel excessively or overly sleepy during the day?
HAND CARD SLQ1
NEVER 0
RARELY – 1 TIME A MONTH 1
SOMETIMES – 2-4 TIMES A MONTH 2
OFTEN – 5-15 TIMES A MONTH 3
ALMOST ALWAYS – 16-30
TIMES A
MONTH 4
REFUSED 7
DON’T KNOW 9
SLQ.130 [In the past month, how often did {you/SP}] not get enough sleep?
HAND CARD SLQ1
NEVER 0
RARELY – 1 TIME A MONTH 1
SOMETIMES – 2-4 TIMES A MONTH 2
OFTEN – 5-15 TIMES A MONTH 3
ALMOST ALWAYS – 16-30
TIMES A
MONTH 4
REFUSED 7
DON’T KNOW 9
SLQ.140 [In the past month, how often did {you/SP}] take sleeping pills or other medication to help {you/him/her} sleep?
HAND CARD SLQ1
NEVER 0
RARELY – 1 TIME A MONTH 1
SOMETIMES – 2-4 TIMES A MONTH 2
OFTEN – 5-15 TIMES A MONTH 3
ALMOST ALWAYS – 16-30
TIMES A
MONTH 4
REFUSED 7
DON’T KNOW 9
SLQ.150 [In the past month, how often did {you/SP}] have leg jerks while trying to sleep?
HAND CARD SLQ1
NEVER 0
RARELY – 1 TIME A MONTH 1
SOMETIMES – 2-4 TIMES A MONTH 2
OFTEN – 5-15 TIMES A MONTH 3
ALMOST ALWAYS – 16-30
TIMES A
MONTH 4
REFUSED 7
DON’T KNOW 9
SLQ.160 [In the past month, how often did {you/SP}] have leg cramps while trying to sleep?
HAND CARD SLQ1
NEVER 0
RARELY – 1 TIME A MONTH 1
SOMETIMES – 2-4 TIMES A MONTH 2
OFTEN – 5-15 TIMES A MONTH 3
ALMOST ALWAYS – 16-30
TIMES A
MONTH 4
REFUSED 7
DON’T KNOW 9
SLQ.170 The purpose of this next set of questions is to find out if {you generally have/SP generally has} difficulty carrying out certain activities because {you are/s/he is} too sleepy or tired. When the words “sleepy” or “tired” are used, it means the feeling that {you/s/he} can’t keep {your/his/her} eyes open, {your/his/her} head is droopy, that {you/s/he} want to “nod off” or that {you feel/s/he feels} the urge to take a nap. The words do not refer to the tired or fatigued feeling {you/she} may have after {you have/s/he has} exercised.
{Do you/Does SP} have difficulty concentrating on the things {you do/s/he does} because {you feel/s/he feels} sleepy or tired?
HAND CARD SLQ2
DON’T DO THIS ACTIVITY
FOR OTHER
REASONS 1
NO DIFFICULTY 2
YES, A LITTLE DIFFICULTY 3
YES, MODERATE DIFFICULTY 4
YES, EXTREME DIFFICULTY 5
REFUSED 7
DON’T KNOW 9
SLQ.180 {Do you/Does SP} generally have difficulty remembering things, because {you are/s/he is} sleepy or tired?
HAND CARD SLQ2
DON’T DO THIS ACTIVITY
FOR OTHER
REASONS 1
NO DIFFICULTY 2
YES, A LITTLE DIFFICULTY 3
YES, MODERATE DIFFICULTY 4
YES, EXTREME DIFFICULTY 5
REFUSED 7
DON’T KNOW 9
SLQ.190 {Do you/Does SP} have difficulty finishing a meal because {you become/s/he becomes} sleepy or tired?
HAND CARD SLQ2
DON’T DO THIS ACTIVITY
FOR OTHER
REASONS 1
NO DIFFICULTY 2
YES, A LITTLE DIFFICULTY 3
YES, MODERATE DIFFICULTY 4
YES, EXTREME DIFFICULTY 5
REFUSED 7
DON’T KNOW 9
SLQ.200 {Do you/Does SP} have difficulty working on a hobby, for example, sewing, collecting, gardening, because {you are/s/he is} sleepy or tired?
HAND CARD SLQ2
DON’T DO THIS ACTIVITY
FOR OTHER
REASONS 1
NO DIFFICULTY 2
YES, A LITTLE DIFFICULTY 3
YES, MODERATE DIFFICULTY 4
YES, EXTREME DIFFICULTY 5
REFUSED 7
DON’T KNOW 9
SLQ.210 {Do you/Does SP} have difficulty getting things done because {you are/s/he is} too sleepy or tired to drive or take public transportation?
HAND CARD SLQ2
DON’T DO THIS ACTIVITY
FOR OTHER
REASONS 1
NO DIFFICULTY 2
YES, A LITTLE DIFFICULTY 3
YES, MODERATE DIFFICULTY 4
YES, EXTREME DIFFICULTY 5
REFUSED 7
DON’T KNOW 9
SLQ.220 {Do you/Does SP} have difficulty taking care of financial affairs and doing paperwork (for example, paying bills or keeping financial records) because {you are/s/he is} sleepy or tired?
HAND CARD SLQ2
CAPI INSTRUCTION:
DISPLAY IF AGE 16-19: “{Do you/Does s/he} have difficulty doing homework or paperwork, for example paying bills or keeping financial records, because {you are/s/he is} sleepy or tired?”
DON’T DO THIS ACTIVITY
FOR OTHER
REASONS 1
NO DIFFICULTY 2
YES, A LITTLE DIFFICULTY 3
YES, MODERATE DIFFICULTY 4
YES, EXTREME DIFFICULTY 5
REFUSED 7
DON’T KNOW 9
SLQ.230 {Do you/Does SP} have difficulty performing employed or volunteer work because {you are/s/he is} sleepy or tired?
HAND CARD SLQ2
CAPI INSTRUCTION:
DISPLAY IF SP AGE 16-19: “{Do you/Does SP} have difficulty performing employed or volunteer work or attending school because {you are/s/he is} sleepy or tired?”
DON’T DO THIS ACTIVITY
FOR OTHER
REASONS 1
NO DIFFICULTY 2
YES, A LITTLE DIFFICULTY 3
YES, MODERATE DIFFICULTY 4
YES, EXTREME DIFFICULTY 5
REFUSED 7
DON’T KNOW 9
SLQ.240 {Do you/Does SP} have difficulty maintaining a telephone conversation because {you become/s/he becomes} sleepy or tired?
HAND CARD SLQ2
DON’T DO THIS ACTIVITY
FOR OTHER
REASONS 1
NO DIFFICULTY 2
YES, A LITTLE DIFFICULTY 3
YES, MODERATE DIFFICULTY 4
YES, EXTREME DIFFICULTY 5
REFUSED 7
DON’T KNOW 9
PHYSICAL ACTIVITY AND PHYSICAL FITNESS (PAQ)
PAQ.605 Next I am going to ask you about the time {you spend/SP spends} doing different types of physical activity in a typical week. Please answer these questions even if {you do not consider yourself/SP does not consider himself/herself} to be a physically active person.
Think first about the time {you spend/SP spends} doing work. Think of work as the things that {you have/SP has} to do such as paid or unpaid work, studying or training, household chores, and yard work. In answering the following questions, ‘vigorous-intensity activities’ are activities that require hard physical effort and cause large increases in breathing or heart rate, and ‘moderate-intensity activities’ are activities that require moderate physical effort and cause small increases in breathing or heart rate.
Does {your/SP’s} work involve vigorous-intensity activity that causes large increases in breathing or heart rate like carrying or lifting heavy loads, digging or construction work for at least 10 minutes continuously?
YES 1
NO 2 (PAQ.620)
REFUSED 7 (PAQ.620)
DON'T KNOW 9 (PAQ.620)
PAQ.610 In a typical week, on how many days {do you/does SP} do vigorous-intensity activities as part of your work?
HARD EDIT: 1-7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 777 (PAQ.620)
DON'T KNOW 999 (PAQ.620)
PAQ615 How much time {do you/does SP} spend doing vigorous-intensity activities at work on a typical day?
Q/U
SOFT EDIT: >11 HOURS.
HARD EDIT: >24 HOURS.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
REFUSED 7777
DON'T KNOW 9999
ENTER UNIT
MINUTES 1
HOURS 2
REFUSED 7
DON'T KNOW 9
PAQ.620 Does {your/SP’s} work involve moderate-intensity activity that causes small increases in breathing or heart rate such as brisk walking or carrying light loads for at least 10 minutes continuously?
YES 1
NO 2 (PAQ.635)
REFUSED 7 (PAQ.635)
DON'T KNOW 9 (PAQ.635)
PAQ.625 In a typical week, on how many days {do you/does SP} do moderate-intensity activities as part of {your/his/her} work?
HARD EDIT: 1-7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 777 (PAQ.635)
DON'T KNOW 999 (PAQ.635)
PAQ.630 How much time {do you/does SP} spend doing moderate-intensity activities at work on a typical day?
Q/U
SOFT EDIT: >11 HOURS.
HARD EDIT: >24 HOURS.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
REFUSED 7777
DON'T KNOW 9999
ENTER UNIT
MINUTES 1
HOURS 2
REFUSED 7
DON'T KNOW 9
PAQ.635 The next questions exclude the physical activity of work that you have already mentioned. Now I would like to ask you about the usual way {you travel/SP travels} to and from places. For example to work, for shopping, to school.
{Do you/Does SP} walk or use a bicycle for at least 10 minutes continuously to get to and from places?
YES 1
NO 2 (PAQ.650)
REFUSED 7 (PAQ.650)
DON'T KNOW 9 (PAQ.650)
PAQ.640 In a typical week, on how many days {do you/does SP} walk or bicycle for at least 10 minutes continuously to get to and from places?
HARD EDIT: 1-7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 777 (PAQ.650)
DON'T KNOW 999 (PAQ.650)
PAQ.645 How much time {do you/does SP} spend walking or bicycling for travel on a typical day?
Q/U
SOFT EDIT: >11 HOURS.
HARD EDIT: >24 HOURS.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
REFUSED 7777
DON'T KNOW 9999
ENTER UNIT
MINUTES 1
HOURS 2
REFUSED 7
DON'T KNOW 9
PAQ.650 The next questions exclude the work and transport activities that you have already mentioned. Now I would like to ask you about sports, fitness and recreational activities.
{Do you/Does SP} do any vigorous-intensity sports, fitness, or recreational activities that cause large increases in breathing or heart rate like running or basketball for at least 10 minutes continuously?
YES 1
NO 2 (PAQ.665)
REFUSED 7 (PAQ.665)
DON'T KNOW 9 (PAQ.665)
PAQ.655 In a typical week, on how many days {do you/does SP} do vigorous-intensity sports, fitness or recreational activities?
HARD EDIT: 1-7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 777 (PAQ.665)
DON'T KNOW 999 (PAQ.665)
PAQ.660 |
How much time {do you/does SP} spend doing vigorous–intensity sports, fitness or recreational activities on a typical day? |
SOFT EDIT: >11 HOURS.
HARD EDIT: >24 HOURS.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
REFUSED 7777
DON'T KNOW 9999
ENTER UNIT
MINUTES 1
HOURS 2
REFUSED 7
DON'T KNOW 9
PAQ.665 {Do you/Does SP} do any moderate-intensity sports, fitness, or recreational activities that cause a small increase in breathing or heart rate such as brisk walking, bicycling, swimming, or golf for at least 10 minutes continuously?
YES 1
NO 2 (PAQ.680)
REFUSED 7 (PAQ.680)
DON'T KNOW 9 (PAQ.680)
PAQ.670 In a typical week, on how many days {do you/does SP} do moderate-intensity sports, fitness or recreational activities?
HARD EDIT: 1-7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 777 (PAQ.680)
DON'T KNOW 999 (PAQ.680)
PAQ.675 |
How much time {do you/does SP} spend doing moderate-intensity sports, fitness or recreational activities on a typical day? |
SOFT EDIT: >11 HOURS.
HARD EDIT: >24 HOURS.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
REFUSED 7777
DON'T KNOW 9999
ENTER UNIT
MINUTES 1
HOURS 2
REFUSED 7
DON'T KNOW 9
PAQ.680 |
The following question is about sitting or reclining at work, at home, or at school. Include time spent sitting at a desk, sitting with friends, traveling in a car, bus, or train, reading, playing cards, watching television, or using a computer. Do not include time spent sleeping. How much time {do you/does SP} usually spend sitting or reclining on a typical day? |
SOFT EDIT: >11 HOURS.
HARD EDIT: >24 HOURS.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
REFUSED 7777
DON'T KNOW 9999
ENTER UNIT
MINUTES 1
HOURS 2
REFUSED 7
DON'T KNOW 9
PAQ.685 During the past 12 months, when {you thought/SP thought} or were (informed) air quality was bad, {did you/did SP} do anything differently?
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON’T KNOW 9 (END OF SECTION)
PAQ.690 Which of these {did you/did SP} do differently?
INTERVIEWER: CODE ALL THAT APPLY.
HAND CARD 07PAQ1
WORE A MASK 10
SPENT LESS TIME OUTDOORS 11
AVOIDED ROADS THAT HAVE HEAVY
TRAFFIC 12
DID LESS STRENUOUS ACTIVITIES 13
TOOK MEDICATION 14
CLOSED WINDOWS OF YOUR HOUSE 15
DROVE MY CAR LESS 16
CANCELED OUTDOOR ACTIVITIES 17
EXERCISED INDOORS INSTEAD OF
OUTSIDE 18
USED BUSES, TRAINS, OR SUBWAYS 19
NONE OF ABOVE 20
OTHER (SPECIFY) 71
REFUSED 77
DON’T KNOW 99
DIET BEHAVIOR and NUTRITION - DBQ
Target Group: SPs Birth + (Questions grouped by age categories)
-
BOX 1
CHECK ITEM DBQ.005:
IF SP AGE <= 6, CONTINUE.
OTHERWISE, GO TO BOX 2.
DBQ.010 Now I'm going to ask you some general questions about {SP's} eating habits.
Was {SP} ever breastfed or fed breastmilk?
YES 1
NO 2 (DBQ.040)
REFUSED 7 (DBQ.040)
DON'T KNOW 9 (DBQ.040)
DBQ.020 |
How old was {SP} when {he/she} was first fed something other than breastmilk or water? |
INCLUDE FORMULA, JUICE, SOLID FOODS
|___|___|___|
ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS
NEVER 2 (BOX 2)
REFUSED 777 (BOX 2)
DON'T KNOW 999 (BOX 2)
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
DBQ.030 |
How old was {SP} when {he/she} completely stopped breastfeeding or being fed breastmilk? |
|___|___|___|___|
ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS
STILL BREASTFEEDING 6666
REFUSED 7777
DON'T KNOW 9999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
DBQ.040 |
How old was {SP} when {he/she} was first fed formula on a daily basis? |
INCLUDE CHILDREN RECEIVING FORMULA AND THOSE RECEIVING FORMULA AND BREASTMILK AT THE SAME TIME
|___|___|___|___|
ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS
NEVER ON A DAILY BASIS 2 (DBQ.060)
REFUSED 7777
DON'T KNOW 9999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
DBQ.050 |
How old was {SP} when {he/she} completely stopped drinking formula? |
|___|___|___|___|
ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS
STILL DRINKING FORMULA 6666
REFUSED 7777
DON'T KNOW 9999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
DBQ.060 |
How old was {SP} when {he/she} was first fed milk on a daily basis? |
INCLUDE LACTAID AS MILK
DO NOT INCLUDE BREASTMILK OR FORMULA
|___|___|___|___|
ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS
NEVER ON A DAILY BASIS 2 (DBQ.080)
REFUSED 7777
DON'T KNOW 9999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
DBQ.072 What type of milk was {SP} first fed on a daily basis? Was it . . .
CODE ALL THAT APPLY
whole or regular, 10
2% fat or reduced-fat milk, 11
1% fat or low-fat milk (includes 0.5% fat
milk or “low-fat milk” not further specified), 12
fat-free, skim or nonfat milk, or 13
another type? 30
REFUSED 77
DON'T KNOW 99
DBQ.080 |
How old was {SP} when {he/she} started eating solid foods [such as strained foods like baby food or any other non-liquid foods] on a daily basis? |
|___|___|___|___|
ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS
NEVER ON A DAILY BASIS 2
REFUSED 7777
DON’T KNOW 9999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
-
BOX 2
CHECK ITEM DBQ.085:
IF SP AGE >= 16, CONTINUE.
IF SP AGE <16 BUT >= 1, GO TO DBQ.197.
OTHERWISE, GO TO FSQ.651.
DBQ.700 Next I have some questions about {your/SP’s} eating habits.
In general, how healthy is {your/his/her} overall diet? Would you say . . .
excellent, 1
very good, 2
good, 3
fair, or 4
poor? 5
REFUSED 7
DON'T KNOW 9
-
BOX 3
OMITTED
-
BOX 4
OMITTED
DBQ.197 {Next I have some questions about {SP’s} eating habits.}
{First/Next} I’m going to ask a few questions about milk products. Do not include their use in cooking.
In the past 30 days, how often did {you/SP} have milk to drink or on {your/his/her} cereal? Please include chocolate and other flavored milks as well as hot cocoa made with milk. Do not count small amounts of milk added to coffee or tea. Would you say . . .
HAND CARD DBQ1
CAPI INSTRUCTION:
THIS SHOULD NOT BE A GATE QUESTION ANYMORE.
CAPI DISPLAY INSTRUCTIONS: IF SP AGE 7-15 YEARS OLD, DISPLAY “{Next I have some questions about {SP’s} eating habits.} First, I’m going to ask about milk products. Do not include their use in cooking. IF SP AGE <= 6 OR => 16 YEARS OLD. DISPLAY “Next I’m going to ask a few questions about milk products. Do not include their use in cooking.”
never, 0 (BOX 6)
rarely – less than once a week, 1
sometimes – once a week or more, but
less than once a day, or 2
often – once a day or more? 3
VARIED 4
REFUSED 7 (BOX 6)
DON'T KNOW 9 (BOX 6)
DBQ.222 What type of milk was it? Was it usually . . .
IF RESPONDENT CANNOT PROVIDE USUAL TYPE, CODE ALL THAT APPLY
whole or regular, 10
2% fat or reduced-fat milk, 11
1% fat or low-fat milk (includes 0.5% fat
milk or “low-fat milk” not further specified), 12
fat-free, skim or nonfat milk, or 13
another type? 30
REFUSED 77
DON'T KNOW 99
-
BOX 6
CHECK ITEM DBQ.225:
IF SP AGE >= 20, CONTINUE.
OTHERWISE, GO TO BOX 9.
DBQ.229 The next question is about regular milk use.
A regular milk drinker is someone who uses any type of milk at least 5 times a week. Using this definition, which statement best describes {you/SP}?
HAND CARD DBQ2
{I've/He's/She's} been a regular milk
drinker for most or all of {my/his/her}
life, including {my/his/her} childhood; 1
{I've/He's/She's} never been a regular
milk drinker; 2 (BOX 8A)
{My/His/Her} milk drinking has varied over
{my/his/her} life – sometimes {I've/he's/
she's} been a regular milk drinker and
sometimes {I have/he has/she has} not
been a regular milk drinker 3
REFUSED 7 (BOX 8A)
DON'T KNOW 9 (BOX 8A)
DBQ.235 |
Now, I’m going to ask you how often {you/SP} drank milk at different times in {your/his/her} life. |
How often did {you/SP} drink any type of milk, including milk added to cereal, when {you were/s/he was} . . .
HAND CARD DBQ3
IF NECESSARY, PROBE FOR USUAL OR MOST COMMON AMOUNT FOR THIS TIME PERIOD
CAPI INSTRUCTION:
THESE (A-C) SHOULD NOT BE GATE QUESTIONS ANYMORE.
a. a child between the ages of 5 and 12 years old? Would you say. . .
never, 0
rarely – less than once a week, 1
sometimes – once a week or more, but
less than once a day, or 2
often – once a day or more? 3
VARIED 4
REFUSED 7
DON'T KNOW 9
b. a teenager between the
ages of 13 and 17 years old? Would you
say . . .
never, 0
rarely – less than once a week, 1
sometimes – once a week or more, but
less than once a day, or 2
often – once a day or more? 3
VARIED 4
REFUSED 7
DON'T KNOW 9
c. a young adult between the
ages of 18 and 35 years old? Would
you say . . .
never, 0
rarely – less than once a week, 1
sometimes – once a week or more, but
less than once a day, or 2
often – once a day or more? 3
VARIED 4
REFUSED 7
DON'T KNOW 9
-
BOX 8A
CHECK ITEM DBQ.265A:
IF SP AGE >= 60, CONTINUE.
OTHERWISE, GO TO BOX 15.
DBQ.301 The next questions are about meals provided by community or government programs.
In the past 12 months, did {you/SP} receive any meals delivered to {your/his/her} home from community programs, “Meals on Wheels”, or any other programs?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
DBQ.330 In the past 12 months, did {you/SP} go to a community program or senior center to eat prepared meals?
INCLUDE ADULT DAY CARE
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
-
BOX 8B
CHECK ITEM DBQ.335:
GO TO BOX 15.
-
BOX 9
CHECK ITEM DBQ.355:
IF SP AGE 4-19, CONTINUE.
OTHERWISE, GO TO BOX 14.
DBQ.360 During the school year, {do you/does SP} attend a kindergarten, grade school, junior or high school?
YES 1
NO 2 (BOX 14)
REFUSED 7 (BOX 14)
DON'T KNOW 9 (BOX 14)
DBQ.370 Does {your/SP's} school serve school lunches? These are complete lunches that cost the same every day.
YES 1
NO 2 (DBQ.400)
REFUSED 7 (DBQ.400)
DON'T KNOW 9 (DBQ.400)
DBQ.381 |
During the school year, about how many times a week {do you/does SP} usually get a complete school lunch? |
|___|
ENTER NUMBER OF TIMES
NONE 2 (DBQ.400)
REFUSED 7 (DBQ.400)
DON'T KNOW 9 (DBQ.400)
DBQ.390 {Do you/Does SP} get these lunches free, at a reduced price, or {do you/does he/she} pay full price?
FREE 1
REDUCED PRICE 2
FULL PRICE 3
REFUSED 7
DON'T KNOW 9
DBQ.400 Does {your/SP's} school serve a complete breakfast that costs the same every day?
YES 1
NO 2 (BOX 9A)
REFUSED 7 (BOX 9A)
DON'T KNOW 9 (BOX 9A)
DBQ.411 |
During the school year, about how many times a week {do you/does SP} usually get a complete breakfast at school? |
|___|
ENTER NUMBER OF TIMES
NONE 2 (BOX 9A)
REFUSED 7 (BOX 9A)
DON'T KNOW 9 (BOX 9A)
DBQ.421 {Do you/Does SP} get these breakfasts free, at a reduced price, or {do you/does he/she} pay full price?
FREE 1
REDUCED PRICE 2
FULL PRICE 3
REFUSED 7
DON'T KNOW 9
-
BOX 9A
CHECK ITEM DBQ.422:
IF DBQ.390 = CODE 1 OR CODE 2 OR DBQ.421 = CODE 1 OR CODE 2, CONTINUE.
OTHERWISE, GO TO BOX 14.
DBQ.424 {Do you/Does SP} get a free or reduced price meal at any summer program {you/he/she} attends?
YES 1
NO 2
DID NOT ATTEND SUMMER PROGRAM 3
REFUSED 7
DON’T KNOW 9
-
BOX 10
OMITTED
-
BOX 10A
OMITTED
-
BOX 11
OMITTED
-
BOX 14
CHECK ITEM DBQ.710:
IF SP AGE > 11, GO TO BOX 15.
ELSE, IF SP AGE 6-11, GO TO FSQ.675,
OTHERWISE, CONTINUE.
FSQ.651 Next are a few questions about the WIC program.
Did {SP} receive benefits from WIC, that is, the Women, Infants, and Children program, in the past 12 months?
YES 1 (FSQ.673)
NO 2 (BOX 14a)
REFUSED 7 (BOX 14a)
DON'T KNOW 9 (BOX 14a)
-
BOX 14a
CHECK ITEM DBQ.710a:
IF SP AGE < 1, GO TO FSQ.690.
OTHERWISE, GO TO FSQ.675.
FSQ.673 Is {SP} now receiving benefits from the WIC program?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 14b
CHECK ITEM DBQ.710b:
IF SP AGE =1 or < 1, GO TO FSQ.685.
OTHERWISE, CONTINUE.
{Next are a few questions about the WIC program, that is, the Women, Infants, and Children program}
FSQ.675 Did {SP} receive benefits from WIC when {he/she} was less than one year old?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION:
DISPLAY INTRODUCTION IF SP AGE IS 6-11.
-
BOX 14c
CHECK ITEM DBQ.710c:
IF SP AGE = 1, GO TO BOX 14d.
IF SP AGE = 2-5, and (FSQ651 = 1 or FSQ.673 = 1), GO TO BOX 14d.
OTHERWISE, CONTINUE.
FSQ.680 Did {SP} receive benefits from WIC when {he/she} {was/is} between the ages of 1 to {SP AGE} years old?
CAPI INSTRUCTION:
If SP age = 2 or 3, DISPLAY the current age of the SP in years;
If SP age >3, DISPLAY “4”.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 14d
CHECK ITEM DBQ.710d:
IF SP AGE = 1 and
FSQ651 in (2, 7, 9) and FSQ.675 in (2, 7, 9), GO TO FSQ.690.
SP AGE 2-5 and
FSQ651 in (2, 7, 9) and FSQ.675 in (2, 7, 9) and FSQ.680 in (2, 7, 9), GO TO FSQ.690.
SP AGE = 6-11 and
FSQ.675 in (2, 7, 9) and FSQ.680 in (2, 7, 9), GO TO FSQ.690.
OTHERWISE, CONTINUE.
FSQ.685 How long {did SP receive/has SP been receiving} benefits from the WIC program?
|__|__|
ENTER NUMBER (OF MONTHS OR YEARS)
REFUSED 77
DON'T KNOW 99
ENTER UNIT
MONTHS 1
YEARS 2
REFUSED 7
DON'T KNOW 9
FSQ.690 Did {SP’s} mother receive benefits from WIC, while she was pregnant with {SP}?
YES 1
NO 2 (BOX 15)
REFUSED 7 (BOX 15)
DON'T KNOW 9 (BOX 15)
FSQ.695 What month of the pregnancy did {SP’s} mother begin to receive WIC benefits?
|__|__|
ENTER NUMBER
REFUSED 77
DON'T KNOW 99
-
BOX 15
CHECK ITEM DBQ.715:
IF SP AGE < 1 GO TO END OF SECTION.
IF SP AGE 12-15 GO TO DBQ.915.
OTHERWISE, CONTINUE.
|
|
-
BOX 12
OMITTED
-
BOX 13
OMITTED
DBQ.895 Next I’m going to ask you about meals. By meal, I mean breakfast, lunch and dinner. During the past 7 days, how many meals {did you/did SP} get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines?
{Please do not include meals provided as part of the school lunch or school breakfast./Please do not include meals provided as part of the community programs you reported earlier.}
CAPI INSTRUCTION:
IF DBQ381G = 1 OR DBQ.411G = 1, DISPLAY {Please do not include meals provided as part of the school lunch or school breakfast.}
IF DBQ.301 = 1 OR DBQ.330 = 1, DISPLAY {Please do not include meals provided as part of the community programs you reported earlier.}
|___|___|
ENTER NUMBER
NONE 2 (DBQ.905)
REFUSED 7 (DBQ.905)
DON'T KNOW 9 (DBQ.905)
DBQ.900 How many of those meals {did you/did SP} get from a fast-food or pizza place?
|___|___|
ENTER NUMBER
NONE 2
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION: HARD EDIT
NUMBER OF MEALS ENTERED IN DBQ.900 MUST BE EQUAL TO OR LESS THAN NUMBER ENTERED IN DBQ.895. IF NOT, DISPLAY THE FOLLOWING:
“THE NUMBER OF MEALS FROM A FAST FOOD OR PIZZA PLACE CANNOT BE GREATER THAN NUMBER OF MEALS PREPARED AWAY FROM HOME.”
DBQ.905 Some grocery stores sell “ready to eat” foods such as salads, soups, chicken, sandwiches and cooked vegetables in their salad bars and deli counters.
During the past 30 days, how often did {you/SP} buy “ready to eat” foods at the grocery store? Please do not count frozen or canned foods.
|___|___|
ENTER NUMBER OF TIMES (PER DAY, WEEK, OR MONTH)
NEVER 0
REFUSED 7
DON’T KNOW 9
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
REFUSED 7
DON'T KNOW 9
DBQ.910 During the past 30 days, how often did you {SP} eat frozen meals or frozen pizzas? Here are some examples of frozen meals and frozen pizzas.
HAND CARD DBQ4
|___|___|
ENTER OF TIMES (PER DAY, WEEK, OR MONTH)
NEVER 0
REFUSED 7
DON’T KNOW 9
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
REFUSED 7
DON'T KNOW 9
DBQ.915 {Do you/Does SP} consider {yourself/himself/herself} to be a vegetarian?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
DBQ.920 {Do you/Does SP} have any food allergies?
YES 1
NO 2 (BOX 15a)
REFUSED 7 (BOX 15a)
DON'T KNOW 9 (BOX 15a)
HELP SCREEN:
Food Allergy: A reaction causing a skin rash, hives, difficulty breathing, wheezing, or itching of the eyes, mouth, throat or skin.
DBQ.925 What foods {are you/is SP} allergic to?
HAND CARD DBQ5
[CODE ALL THAT APPLY]
Wheat 10
Cow’s Milk 11
Eggs 12
Fish 13
Shellfish (shrimp, crab, or lobster) 14
Corn 15
Peanut 16
Other Nuts 17
Soy Products 18
Other 19
REFUSED 7
DON'T KNOW 9
-
BOX 15a
CHECK ITEM DBQ.715a:
IF SP AGE < 16, GO TO END OF SECTION.
OTHERWISE, CONTINUE.
DBQ.930 Are you the person who does most of the planning or preparing of meals in your family?
INTERVIEWER INSTRUCTION: IF SP ANSWERS “SOMETIMES” OR “50/50”, ENTER YES
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
DBQ.935 Do you share in the planning or preparing of meals with someone else?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
DBQ.940 Are you the person who does most of the shopping for food in your family?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
DBQ.945 Do you share in the shopping for food with someone else?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
END OF SECTION |
WHQ.010 |
These next questions ask about {your/SP's} height and weight at different times in {your/his/her} life. |
How tall {are you/is SP} without shoes?
ENTER HEIGHT IN FEET AND INCHES OR METERS AND CENTIMETERS
|___|___|
ENTER NUMBER OF FEET
AND
|___|___|
ENTER NUMBER OF INCHES
OR
|___|___|
ENTER NUMBER OF METERS
AND
|___|___|___|
ENTER NUMBER OF CENTIMETERS
OR
REFUSED 7777
DON’T KNOW 9999
WHQ.025/ |
How much {do you/does SP} weigh without clothes or shoes? [If {you are/she is} currently pregnant, how much did {you/she} weigh before your pregnancy?] |
RECORD CURRENT WEIGHT
ENTER WEIGHT IN POUNDS OR KILOGRAMS
CAPI INSTRUCTION:
DISPLAY OPTIONAL SENTENCE [If {you are/she is} currently pregnant . . .] ONLY IF SP IS FEMALE AND AGE IS 16 THROUGH 59.
|___|___|___|
ENTER NUMBER OF POUNDS
CAPI INSTRUCTION:
SOFT EDIT 75-500, HARD EDIT 50-750
OR
|___|___|___|
ENTER NUMBER OF KILOGRAMS
CAPI INSTRUCTION:
SOFT EDIT 34-225, HARD EDIT 23-338
OR
REFUSED 777
DON’T KNOW 999
WHQ.030 {Do you/Does SP} consider {your/his/her}self now to be . . . [If {you are/she is} currently pregnant, what did {you/she} consider {your/her}self to be before {you were/she was} pregnant?]
overweight, 1
underweight, or 2
about the right weight? 3
REFUSED 7
DON’T KNOW 9
CAPI INSTRUCTION:
DISPLAY OPTIONAL SENTENCE [If {you are/she is} currently pregnant…] ONLY IF SP IS FEMALE AND AGE IS 16 THROUGH 59.
WHQ.040 Would {you/SP} like to weigh . . .
more, 1
less, or 2
stay about the same? 3 (WHQ.053)
REFUSED 7 (WHQ.053)
DON’T KNOW 9 (WHQ.053)
WHQ.045/ |
How much {would you/would SP} like to weigh? |
ENTER WEIGHT IN POUNDS OR KILOGRAMS
|___|___|___|
ENTER NUMBER OF POUNDS
CAPI INSTRUCTION:
SOFT EDIT 75-500, HARD EDIT 50-750
OR
|___|___|___|
ENTER NUMBER OF KILOGRAMS
CAPI INSTRUCTION:
SOFT EDIT 34-225, HARD EDIT 23-338
REFUSED 77777
DON’T KNOW 99999
WHQ.053/ |
How much did {you/SP} weigh a year ago? [If {you were/she was} pregnant a year ago, how much did {you/she} weigh before your pregnancy?] |
ENTER WEIGHT IN POUNDS OR KILOGRAMS
CAPI INSTRUCTION:
DISPLAY OPTIONAL SENTENCE [If {you were/she was} pregnant . . .] ONLY IF SP IS FEMALE AND SP AGE IS 17 THROUGH 60.
|___|___|___|
ENTER NUMBER OF POUNDS
CAPI INSTRUCTION:
SOFT EDIT 75-500, HARD EDIT 50-750
OR
|___|___|___|
ENTER NUMBER OF KILOGRAMS
CAPI INSTRUCTION:
SOFT EDIT 34-225, HARD EDIT 23-338
OR
REFUSED 777
DON’T KNOW 999
-
BOX 1
IF WEIGHT IN WHQ.053/L/K IS 10 POUNDS, 4.55 KILOGRAMS, OR MORE THAN WEIGHT IN WHQ.025/L/K (E.G., WHQ.053/L/K = 150 LBS AND WHQ.025/L/K = 135 LBS), CONTINUE.
OTHERWISE, GO TO WHQ.070.
WHQ.061 Was the change between {your/SP's} current weight and {your/his/her} weight a year ago because you tried to lose weight?
YES 1 (WHQ.088/OS)
NO 2
REFUSED 7
DON'T KNOW 9
WHQ.070 During the past 12 months, {have you/has SP} tried to lose weight?
YES 1
NO 2 (WHQ.090)
REFUSED 7 (WHQ.090)
DON’T KNOW 9 (WHQ.090)
WHQ.088/ |
How did {you/SP} try to lose weight? |
HAND CARD WHQ1
CODE ALL THAT APPLY
ATE LESS FOOD (AMOUNT) 100
SWITCHED TO FOODS WITH LOWER
CALORIES 110
ATE LESS FAT 120
ATE FEWER CARBOHYDRATES 125
EXERCISED 130
SKIPPED MEALS 140
ATE “DIET” FOODS OR PRODUCTS 150
USED A LIQUID DIET FORMULA SUCH
AS SLIMFAST OR OPTIFAST 160
JOINED A WEIGHT LOSS PROGRAM
SUCH AS WEIGHT WATCHERS, JENNY
CRAIG, TOPS, OR OVEREATERS
ANONYMOUS 170
FOLLOWED A SPECIAL DIET SUCH AS
DR. ATKINS, OTHER HIGH PROTEIN OR
LOW CARBOHYDRATE DIET, ZONE,
GRAPEFRUIT, PRITIKIN 300
TOOK DIET PILLS PRESCRIBED BY A
DOCTOR 310
TOOK OTHER PILLS, MEDICINES, HERBS,
OR SUPPLEMENTS NOT NEEDING A
PRESCRIPTION 320
STARTED TO SMOKE OR BEGAN TO
SMOKE AGAIN 325
TOOK LAXATIVES OR VOMITED 330
DRANK A LOT OF WATER 340
OTHER (SPECIFY) 400
REFUSED 777
DON’T KNOW 999
WHQ.270 In the past 12 months, {did you/did SP} seek help from a personal trainer, dietitian, nutritionist, doctor or other health professional to lose weight?
YES 1
NO 2 (BOX 2A)
REFUSED 7 (BOX 2A)
DON’T KNOW 9 (BOX 2A)
WHQ.280 Was that a . . .
CODE ALL THAT APPLY.
personal trainer, 1
dietitian, 2
nutritionist, 3
doctor, or 4
other health professional? 5
REFUSED 7
DON’T KNOW 9
-
BOX 2A
IF WHQ.061 = CODE 1 OR WHQ.070 = CODE 1, GO TO WHQ.220/L/K.
WHQ.090 During the past 12 months, {have you/has SP} done anything to keep from gaining weight?
YES 1
NO 2 (WHQ.210)
REFUSED 7 (WHQ.210)
DON’T KNOW 9 (WHQ.210)
WHQ.103/ What did {you/SP} do to keep from gaining weight?
OS
CODE ALL THAT APPLY.
HAND CARD WHQ1
ATE LESS FOOD (AMOUNT) 100
SWITCHED TO FOODS WITH LOWER
CALORIES 110
ATE LESS FAT 120
ATE FEWER CARBOHYDRATES 125
EXERCISED 130
SKIPPED MEALS 140
ATE “DIET” FOODS OR PRODUCTS 150
USED A LIQUID DIET FORMULA SUCH
AS SLIMFAST OR OPTIFAST 160
JOINED A WEIGHT LOSS PROGRAM
SUCH AS WEIGHT WATCHERS, JENNY
CRAIG, TOPS, OR OVEREATERS
ANONYMOUS 170
FOLLOWED A SPECIAL DIET SUCH AS
DR. ATKINS, OTHER HIGH PROTEIN OR
LOW CARBOHYDRATE DIET, ZONE,
GRAPEFRUIT, PRITIKIN 300
TOOK DIET PILLS PRESCRIBED BY A
DOCTOR 310
TOOK OTHER PILLS, MEDICINES, HERBS,
OR SUPPLEMENTS NOT NEEDING A
PRESCRIPTION 320
STARTED TO SMOKE OR BEGAN TO
SMOKE AGAIN 325
TOOK LAXATIVES OR VOMITED 330
DRANK A LOT OF WATER 340
OTHER (SPECIFY) 400
REFUSED 777
DON’T KNOW 999
WHQ.210 {Have you/Has SP} ever tried to lose weight?
YES 1
NO 2 (BOX 2)
REFUSED 7 (BOX 2)
DON’T KNOW 9 (BOX 2
WHQ.220/ |
How much weight {did you/did SP} lose in {your/his/her} most successful attempt ever to lose weight? |
ENTER WEIGHT IN POUNDS OR KILOGRAMS
HELP SCREEN: This question refers only to deliberate attempts to lose weight; it does not refer to weight loss because of illness, side effects of medication, stress, or other unintended causes.
|___|___|___|
ENTER NUMBER OF POUNDS
CAPI INSTRUCTION:
SOFT EDIT OVER 100 POUNDS
OR
|___|___|___|
ENTER NUMBER OF KILOGRAMS
CAPI INSTRUCTION:
SOFT EDIT OVER 45 KILOGRAMS
OR
REFUSED 777
DON’T KNOW 999
-
BOX 2
IF SP AGE >= 36, CONTINUE.
OTHERWISE, GO TO BOX 3.
WHQ.111/ |
How much did {you/SP} weigh 10 years ago? [If you don't know {your/his/her} exact weight, please make your best guess.] [If {you were/she was} pregnant, how much did {you/she} weigh before {your/her} pregnancy?] |
ENTER WEIGHT IN POUNDS OR KILOGRAMS
CAPI INSTRUCTION:
DISPLAY OPTIONAL SENTENCE [If {you were/she was} . . .] ONLY IF SP IS FEMALE AND AGE IS LESS THAN OR EQUAL TO 69.
|___|___|___|
ENTER NUMBER OF POUNDS
CAPI INSTRUCTION:
SOFT EDIT 75-500, HARD EDIT 50-750
OR
|___|___|___|
ENTER NUMBER OF KILOGRAMS
CAPI INSTRUCTION:
SOFT EDIT 34-225, HARD EDIT 23-338
OR
REFUSED 77777
DON’T KNOW 99999
-
BOX 3
IF SP AGE >= 27, CONTINUE.
OTHERWISE, GO TO WHQ.147/L/K.
WHQ.121/ |
How much did {you/SP} weigh at age 25? [If you don't know {your/his/her} exact weight, please make your best guess.] [If {you were/she was} pregnant, how much did {you/she} weigh before your pregnancy?] |
ENTER WEIGHT IN POUNDS OR KILOGRAMS
CAPI INSTRUCTION:
DISPLAY OPTIONAL SENTENCE [If {you were/she was} . . .] ONLY IF SP IS FEMALE.
|___|___|___|
ENTER NUMBER OF POUNDS
OR
|___|___|___|
ENTER NUMBER OF KILOGRAMS
OR
REFUSED 77777
DON’T KNOW 99999
-
BOX 3A
IF SP AGE >= 50, CONTINUE.
OTHERWISE, GO TO WHQ.147/L/K.
WHQ.130/ |
How tall {were you/was SP} at age 25? [If you don't know {your/his/her} exact height, please make your best guess.] |
ENTER HEIGHT IN FEET AND INCHES OR METERS AND CENTIMETERS
|___|___|
ENTER NUMBER OF FEET
CAPI INSTRUCTION: HARD EDIT 2-8
AND
|___|___|
ENTER NUMBER OF INCHES
CAPI INSTRUCTION: HARD EDIT 0-11
OR
|___|___|
ENTER NUMBER OF METERS
CAPI INSTRUCTION: HARD EDIT 0-3
AND
|___|___|___|
ENTER NUMBER OF CENTIMETERS
CAPI INSTRUCTION: HARD EDIT 0-99
OR
REFUSED 7777
DON’T KNOW 9999
-
BOX 4
OMITTED
WHQ.147/ |
What is the most {you have/SP has} ever weighed? [Do not include any times when {you were/she was} pregnant.] |
ENTER WEIGHT IN POUNDS OR KILOGRAMS
CAPI INSTRUCTION:
DISPLAY OPTIONAL SENTENCE {Do not include . . .} ONLY IF SP IS FEMALE.
|___|___|___|
ENTER NUMBER OF POUNDS
CAPI INSTRUCTION:
SOFT EDIT 75-500, HARD EDIT 50-750
OR
|___|___|___|
ENTER NUMBER OF KILOGRAMS
CAPI INSTRUCTION:
SOFT EDIT 34-225, HARD EDIT 23-338
OR
REFUSED 777 (END OF SECTION)
DON’T KNOW 999 (END OF SECTION)
WHQ.150 How old {were you/was SP} then? [If you don't know {your/his/her} exact age, please make your best guess.]
|___|___|___|
ENTER AGE IN YEARS
REFUSED 77777
DON'T KNOW 99999
-
BOX 5
OMITTED
These next questions are about cigarette smoking.
SMQ.020 {Have you/Has SP} smoked at least 100 cigarettes in {your/his/her} entire life?
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
SMQ.030 How old {were you/was SP} when {you/s/he} first started to smoke cigarettes fairly regularly?
G/Q
|___|___|___|
ENTER AGE IN YEARS
NEVER SMOKED CIGARETTES
REGULARLY 666
REFUSED 77777
DON'T KNOW 99999
SMQ.040 {Do you/Does SP} now smoke cigarettes . . .
every day, 1 (SMQ.077)
some days, or 2 (SMQ.641)
not at all? 3 (SMQ.050Q/U)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
SMQ.050 How long has it been since {you/SP} quit smoking cigarettes?
Q/U
|___|___|___|
ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)
REFUSED 77777
DON'T KNOW 99999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
-
BOX 1A
IF SMQ.050Q/U >= 1 YEAR (365 DAYS, 52 WEEKS, 12 MONTHS, OR 1 YEAR), CONTINUE.
OTHERWISE, GO TO END.
SMQ.055 How old {were you/was SP} when {you/s/he} last smoked cigarettes {fairly regularly}?
CAPI INSTRUCTION:
DISPLAY "FAIRLY REGULARLY" EXCEPT WHEN SMQ.030G/Q = 666 (NEVER SMOKED CIGARETTES REGULARLY).
|___|___|___|
ENTER AGE IN YEARS
REFUSED 77777
DON'T KNOW 99999
SMQ.057 At that time, about how many cigarettes did {you/SP} usually smoke per day?
1 PACK EQUALS 20 CIGARETTES
IF LESS THAN 1 PER DAY, ENTER 1
IF 95 OR MORE PER DAY, ENTER 95
|___|___|___|
ENTER NUMBER OF CIGARETTES (PER DAY)
REFUSED 7777
DON'T KNOW 9999
-
BOX 1B
GO TO END.
SMQ.077 How soon after {you/SP} wake{s} up {do you/does s/he} smoke? Would you say . . .
within 5 minutes, 1
from 6 to 30 minutes, 2
from more than 30 minutes to 1 hour, or 3
more than 1 hour? 4
REFUSED 7
DON'T KNOW 9
SMQ.641 During the past 30 days, on how many days did {you/SP} smoke cigarettes?
|___|___|
ENTER NUMBER OF DAYS
REFUSED 7777
DON'T KNOW 9999
CAPI INSTRUCTION:
ALLOW '0' AS AN ENTRY. IF '0' DK OR RF ENTERED, SKIP TO QUESTION SMQ.093.
SMQ.650 During the past 30 days, on the days that {you/SP} smoked, how many cigarettes did {you/s/he} smoke per day?
1 PACK EQUALS 20 CIGARETTES
IF LESS THAN 1 PER DAY, ENTER 1
IF 95 OR MORE PER DAY, ENTER 95
|___|___|___|
ENTER NUMBER OF CIGARETTES (PER DAY)
REFUSED 7777
DON'T KNOW 9999
SMQ.093 May I please see the pack for the brand of cigarettes {you usually smoke/SP usually smokes}.
TO OBTAIN ACCURATE PRODUCT INFORMATION, IT IS IMPORTANT THAT YOU SEE THE CIGARETTE PACK.
PACK SEEN 1
PACK NOT SEEN 2 (SMQ.100k)
REFUSED 7 (SMQ.100k)
SMQ.310 ENTER THE UNIVERSAL PRODUCT CODE FROM THE CIGARETTE PACK. UPC MUST CONTAIN 8 OR 12 DIGITS.
SELECT ONE OPTION.
ENTERING 8 DIGIT UPC 1
ENTERING 12 DIGIT UPC 2 (SMQ.330)
UNABLE TO READ CODE-PACK DAMAGED 3 (SMQ.100k)
SMQ.320 ENTER THE 8 DIGIT UPC CODE.
|___|___|___|___|___|___|___|___|
CAPI INSTRUCTION:
DOUBLE ENTRY IS REQUIRED. IF ENTRIES DO NOT MATCH, DISPLAY THE FOLLOWING MESSAGE: ENTRIES DO NOT MATCH. HIGHLIGHT THE ENTRY THAT SHOULD BE CORRECTED AND PRESS ‘ENTER’ TO CHANGE.
-
BOX 2B
GO TO END.
SMQ.330 ENTER THE 12 DIGIT UPC CODE.
|___|___|___|___|___|___|___|___|___|___|___|___|
CAPI INSTRUCTION:
DOUBLE ENTRY IS REQUIRED. IF ENTRIES DO NOT MATCH, DISPLAY THE FOLLOWING MESSAGE: ENTRIES DO NOT MATCH. HIGHLIGHT THE ENTRY THAT SHOULD BE CORRECTED AND PRESS ‘ENTER’ TO CHANGE.
-
BOX 3
IF INVALID CODE OR CODE NOT ON FILE, GO TO SMQ.099.
OTHERWISE, CONTINUE.
SMQ.098 YOU HAVE SELECTED
{DISPLAY BRAND ASSOCIATED WITH CODE}
CORRECT 1 (END OF SECTION)
NOT CORRECT 2 (SMQ.100k)
CAPI INSTRUCTION:
DISPLAY BRAND NAME WITH ALL QUALIFIERS – NAME, SIZE (REGULAR, KING, 100, 120), FILTERED/NONFILTERED, MENTHOLATED/NONMENTHOLATED, OTHER QUALIFIERS (DELUXE, HARD PACK, LIGHTS, ETC.)
SMQ.099 CODE NOT ON FILE – PRESS ‘ENTER’ TO CONTINUE
SMQ.100k What brand of cigarettes {do you/does SP} usually smoke?
CAPI INSTRUCTION:
FOLLOW THE BASIC FORMAT FOR DIETARY SUPPLEMENT LOOKUP. ONLY ALLOW INTERVIEWER TO ENTER 1 BRAND OF CIGARETTES OR 'NO USUAL BRAND'. ALLOW ENTRY OF DON'T KNOW AND REFUSED.
REFER TO PRODUCT LABEL IF AVAILABLE.
ENTER BRAND NAME OF CIGARETTE.
IF NO USUAL BRAND, TYPE ‘NO USUAL BRAND’.
SMQ.111 PRESS BS TO START THE LOOKUP.
SELECT PRODUCT FROM
LIST OR TYPE
'NO USUAL BRAND.'
IF PRODUCT NOT ON LIST.
PRESS BS TO
DELETE ENTRY.
TYPE '**'.
PRESS ENTER TO SELECT.
CAPI INSTRUCTION:
Display CAPI cigarette product list. Interviewer should be able to select one product name from list OR 'NO USUAL BRAND'. In addition, interviewer should be able TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN SMQ.100k BY TYPING IN '**'.
-
BOX 4A
IF '** PRODUCT NOT ON LIST' SELECTED AT SMQ.111, CONTINUE.
OTHERWISE, GO TO END OF SECTION.
SMQ.110a ASK IF NECESSARY:
IS THE CIGARETTE PRODUCT FILTERED OR NON-FILTERED?
ENTER '1' FOR FILTERED
ENTER '0' FOR NON-FILTERED
CAPI INSTRUCTION:
'1' AND '0' SHOULD BE THE ONLY CODES ACCEPTED BY CAPI.
FILTERED 1
NON-FILTERED 0
SMQ.110b ASK IF NECESSARY:
IS THE CIGARETTE PRODUCT MENTHOLATED OR NON-MENTHOLATED?
ENTER '1' FOR MENTHOLATED
ENTER '0' FOR NON-MENTHOLATED
CAPI INSTRUCTION:
'1' AND '0' SHOULD BE THE ONLY CODES ACCEPTED BY CAPI.
MENTHOLATED 1
NON-MENTHOLATED 0
REFUSED 7
DON'T KNOW 9
SMQ.110h ASK IF NECESSARY:
WHAT IS THE CIGARETTE PRODUCT SIZE?
CAPI INSTRUCTION:
THIS ITEM IS STORED IN SMQ.110f IN THE DATA BASE.
REGULARS 1
KINGS 2
100S 3
120S 4
REFUSED 77
DON'T KNOW 99
SMQ.110g REFER TO PRODUCT LABEL, IF AVAILABLE – ASK IF NECESSARY.
WHAT ARE THE OTHER NAME BRAND QUALIFIERS FOR THE CIGARETTE PRODUCT?
CAPI INSTRUCTION:
SHOULD BE A 'CODE ALL THAT APPLY' EXCEPT IF "REF", "DK" OR "NONE" SELECTED. NO OTHER RESPONSE OPTION SHOULD BE ALLOWED. THE "OTHER SPECIFY" RESPONSE SHOULD REQUIRE A TEXT ENTRY.
DELUXE 10
HARD PACK 11
LIGHTS 12
MILDS 13
SLIMS 14
SPECIALS 15
SUPER 16
ULTRA LIGHTS 17
OTHER (SPECIFY) 18
NONE 19
REF 77
DK 99
Target Group: SPs >= 40
SSQ.011 Now I would like to ask a few questions about {your/SP's} friends and family.
Can {you/SP} count on anyone to provide {you/him/her} with emotional support such as talking over problems or helping {you/him/her} make a difficult decision?
YES 1
NO 2 (SSQ.044)
SP DOESN'T NEED HELP 3 (SSQ.044)
REFUSED 7 (SSQ.044)
DON'T KNOW 9 (SSQ.044)
SSQ.021 In the last 12 months, who was most helpful in providing {you/SP} with emotional support?
CODE ALL THAT APPLY
SPOUSE 10
DAUGHTER 11
SON 12
SISTER/BROTHER 13
PARENT 14
OTHER RELATIVE 15
NEIGHBORS 16
CO-WORKERS 17
CHURCH MEMBERS 18
CLUB MEMBERS 19
PROFESSIONALS 20
FRIENDS 21
OTHER 22
NO ONE 23
REFUSED 77
DON'T KNOW 99
SSQ.031 [In the last 12 months], could {you/SP} have used more emotional support than {you/s/he} received?
YES 1
NO 2 (SSQ.044)
REFUSED 7 (SSQ.044)
DON'T KNOW 9 (SSQ.044)
SSQ.041 Would you say that {you/SP} could have used . . .
a lot more, 1
some, or 2
a little more emotional support? 3
REFUSED 7
DON'T KNOW 9
|
|
|___|___|___|
ENTER NUMBER OF TIMES (PER DAY, WEEK, MONTH OR YEAR)
NEVER 2
REFUSED 777
DON’T KNOW 999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEAR 4
REFUSED 7
DON’T KNOW 9
SSQ.051 If {you/SP} need{s} some extra help financially, could {you/s/he} count on anyone to help {you/him/her}; for example, by paying any bills, housing costs, hospital visits, or providing {you/him/her} with food or clothes?
YES 1
NO 2
OFFERED HELP BUT WOULDN'T
ACCEPT IT 3
REFUSED 7
DON'T KNOW 9
SSQ.061 In general, how many close friends {do you/does SP} have?
PROBE: By "close friends" I mean relatives or non-relatives that {you s/he} feel{s} at ease with, can talk to about private matters, and can call on for help.
INTERVIEWER INSTRUCTION: ENTER ‘50’ FOR RESPONSES OF 50 OR MORE.
|___|___|
ENTER NUMBER OF CLOSE FRIENDS
REFUSED 777
DON'T KNOW 999
Target Group: SPs 16+
OCQ.152 In this part of the survey I will ask you questions about {your/SP's} work experience.
Which of the following {were you/was SP} doing last week . . .
working at a job or business, 1 (OCQ.180)
with a job or business but not at work, 2 (OCQ.210)
looking for work, or 3 (OCQ.385G/Q)
not working at a job or business? 4 (OCQ.380)
REFUSED 7 (OCQ.385G/Q)
DON'T KNOW 9 (OCQ.385G/Q)
OCQ.180 How many hours did {you/SP} work last week at all jobs or businesses?
|___|___|___|
ENTER NUMBER OF HOURS
CAPI INSTRUCTION:
HARD EDIT 1-168.
REFUSED 77777
DON'T KNOW 99999
-
BOX 1
CHECK ITEM OCQ.200:
IF HOURS IN OCQ.180 <= 34, OR REFUSED (CODE 777), OR DON'T KNOW (CODE 999), CONTINUE.
OTHERWISE, GO TO OCQ.220.
OCQ.210 {Do you/Does SP} usually work 35 hours or more per week in total at all jobs or businesses?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
OCQ.220 For whom did {you/SP} work at {your/his/her} main job or business? (What is the name of the company, business, organization or employer?)
IF MORE THAN 1 JOB, PROBE FOR MAIN JOB.
ENTER NAME OF EMPLOYER
REFUSED 7---77
DON'T KNOW 9---99
OCQ.230 What kind of business or industry is this? (For example: a TV or radio station, retail shoe store, state labor department, farm.)
ENTER NAME OF BUSINESS OR INDUSTRY
REFUSED 7---77
DON'T KNOW 9---99
OCQ.240 What kind of work {were you/was SP} doing? (For example: farming, mail clerk, computer specialist.)
ENTER NAME OF OCCUPATION
REFUSED 7---77
DON'T KNOW 9---99
OCQ.250 What were {your/SP's} most important activities on this job? (For example: sells cars, keeps account books, operates printing press.)
ENTER NAME OF DUTIES
REFUSED 7---77
DON'T KNOW 9---99
OCQ.260 Looking at the card, which of these best describes this job or work situation?
ASK IF NOT CLEAR.
HAND CARD OCQ1
AN EMPLOYEE OF A PRIVATE COMPANY,
BUSINESS, OR INDIVIDUAL FOR WAGES,
SALARY, OR COMMISSION 1
A FEDERAL GOVERNMENT EMPLOYEE 2
A STATE GOVERNMENT EMPLOYEE 3
A LOCAL GOVERNMENT EMPLOYEE 4
SELF-EMPLOYED IN OWN BUSINESS,
PROFESSIONAL PRACTICE OR FARM 5
WORKING WITHOUT PAY IN FAMILY
BUSINESS OR FARM 6
REFUSED 77
DON'T KNOW 99
OCQ.265 Which of the following best describes the hours {you/SP} usually {work/works} at {your/his/her} main job or business?
INTERVIEWER INSTRUCTION: IF THE RESPONDENT SAYS "FLEXTIME", ETC., PROBE TO DETERMINE WHETHER THE SHIFT THAT IS WORKED ACTUALLY FALLS IN A DAY, EVENING, NIGHT, OR ROTATING SHIFT CATEGORY BEFORE CODING IT AS "ANOTHER SCHEDULE."
HELP AVAILABLE:
Standard Shift Definitions are:
A regular daytime schedule: this is work anytime between 6am and 6pm.
A regular evening shift: this is work anytime between 2pm and midnight.
A regular night shift: this is work anytime between 9pm and 8am.
A rotating shift: a work shift that changes periodically from days to evenings or nights.
Another schedule includes: a split shift (consisting of two distinct work periods each day), an irregular schedule arranged by the employer, or any other schedule.
A regular daytime schedule 1
A regular evening shift 2
A regular night shift 3
A rotating shift 4
Another schedule 5
REFUSED 7
DON’T KNOW 9
OCQ.270 About how long {have you/has SP} worked for {EMPLOYER} as a(n) {OCCUPATION}?
Q/U
CAPI INSTRUCTIONS:
DISPLAY AS LEFT HEADER "EMPLOYER:" AND EMPLOYER FROM OCQ.220.
DISPLAY AS LEFT HEADER "OCCUPATION:" AND OCCUPATION FROM OCQ.240.
IF OCQ.220 AND/OR OCQ.240 ARE DK/RF, DISPLAY “AT YOUR MAIN JOB.” IF PROXY, DISPLAY {HIS/HER MAIN JOB}.
DO NOT ALLOW MORE THAN THE SP’S AGE, OR >90 DAYS OR >104 WEEKS OR GREATER THAN 48 MONTHS OR GREATER THAN 60 YEARS.
|___|___|___|
ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)
REFUSED 777777
DON'T KNOW 999999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
OCQ.290G/Q |
The next questions are about conditions {you/SP} may experience at {EMPLOYER} as a(n) {OCCUPATION}. |
At this job or business, how many hours per day can {you/SP} smell the smoke from other people's cigarettes, cigars, and/or pipes?
CAPI INSTRUCTIONS:
DISPLAY AS LEFT HEADER "EMPLOYER:" AND EMPLOYER FROM OCQ.220.
DISPLAY AS LEFT HEADER "OCCUPATION:" AND OCCUPATION FROM OCQ.240.
IF OCQ.220 AND/OR OCQ.240 ARE DK/RF, DISPLAY “AT YOUR MAIN JOB.”
HARD EDIT 0-24.
|___|___|
ENTER NUMBER OF HOURS
NEVER 66
REFUSED 7777
DON'T KNOW 9999
-
BOX 3
CHECK ITEM OCQ.370:
GO TO OCQ.392G/Q.
OCQ.380 What is the main reason {you/SP} did not work last week?
TAKING CARE OF HOUSE OR FAMILY 1
GOING TO SCHOOL 2
RETIRED 3
UNABLE TO WORK FOR HEALTH
REASONS 4
ON LAYOFF 5
DISABLED 6
OTHER 7
REFUSED 77
DON'T KNOW 99
OCQ.385 |
Thinking of all the paid jobs {you/SP} ever had, what kind of work {were you/was s/he} doing the longest? (For example, electrical engineer, stock clerk, typist, farmer.) |
CAPI INSTRUCTION:
IF CURRENT OCCUPATION HAS BEEN ENTERED IN OCQ.240, DISPLAY AS LEFT HEADER "CURRENT OCCUPATION: {OCQ.240}".
ENTER OCCUPATION
or
ARMED FORCES 3 (OCQ.393)
NEVER WORKED 4 (END OF SECTION)
REFUSED 7 (OCQ.393)
DON'T KNOW 9 (OCQ.393)
OCQ.389 What kind of business or industry {did you/did SP} work in for the longest period of time as a (DISPLAY LONGEST OCCUPATION AS “LONGEST OCCUPATION” {OCQ385Q})? (For example, a TV or radio station, retail shoe store, state labor department, farm.)
(OCQ.393)
ENTER DESCRIPTION FOR KIND OF BUSINESS/INDUSTRY
REFUSED 7---77 (OCQ.393)
DON'T KNOW 9---99 (OCQ.393)
OCQ.392 |
Thinking of all the paid jobs {you/SP} ever had, what kind of work {were you/was s/he} doing the longest? (For example, electrical engineer, stock clerk, typist, farmer.) |
CAPI INSTRUCTION:
IF CURRENT OCCUPATION HAS BEEN ENTERED IN OCQ.240, DISPLAY AS LEFT HEADER "CURRENT OCCUPATION: {OCQ.240}".
ENTER OCCUPATION
or
SAME AS CURRENT OCCUPATION 2 (BOX 6)
ARMED FORCES 3 (OCQ.393)
REFUSED 7 (OCQ.393)
DON'T KNOW 9 (OCQ.393)
OCQ.394 What kind of business or industry {did you/did SP} work in for the longest period of time as a (DISPLAY LONGEST OCCUPATION AS “LONGEST OCCUPATION” {OCQ392Q})? (For example, a TV or radio station, retail shoe store, state labor department, farm.)
ENTER DESCRIPTION FOR KIND OF BUSINESS/INDUSTRY
REFUSED 7---77
DON'T KNOW 9---99
OCQ.393 What were {your/SP's} most important activities on this job or business? (For example: sells cars, keeps account books, operates printing press.)
ENTER NAME OF DUTIES
REFUSED 7---77
DON'T KNOW 9---99
OCQ.395 About how long did {you/SP} work at that job or business?
Q/U
CAPI INSTRUCTION:
DISPLAY "LONGEST OCCUPATION: {OCQ.385G/Q or OCQ.392G/Q}" AS LEFT HEADER.
DO NOT ALLOW LESS THAN SP’S AGE OR <90 DAYS OR <104 WEEKS OR <48 MONTHS OR <60 YEARS.
|___|___|___|
ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)
REFUSED 77777
DON'T KNOW 99999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
-
BOX 4
OMITTED
-
BOX 4A
OMITTED
-
BOX 5A
OMITTED
-
BOX 5B
OMITTED
-
BOX 6
CHECK ITEM OCQ.500:
IF SP AGE >= 16 AND < 80, CONTINUE.
OTHERWISE, GO TO END OF SECTION.
OCQ.510 The next questions ask about being exposed to dust in {your/SPs} work.
Being exposed to dust means that {you/SP} breathed in the dust or had dust on {your/his/her} clothes, skin or hair.
INTERVIEWER INSTRUCTION: DO NOT COUNT TEMPORARY ONE-TIME EXPOSURES THAT MIGHT HAVE HAPPENED.
In any job, {have you/has SP} ever been exposed to dust from rock, sand, concrete, coal, asbestos, silica or soil?
YES 1
NO 2 (OCQ.530)
REFUSED 7 (OCQ.530)
DON'T KNOW 9 (OCQ.530)
OCQ.520 Please give me the total number of years for all jobs where this has happened.
INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS MORE THAN ONE JOB, THEY SHOULD ADD ALL YEARS TOGETHER.
IF LESS THAN 1 YEAR, ENTER 0
|___|___|___|
ENTER NUMBER OF YEARS
REFUSED 777
DON'T KNOW 999
OCQ.530 In any job, {have you/has SP} ever been exposed to dust from baking flours, grains, wood, cotton, plants or animals?
YES 1
NO 2 (OCQ.550)
REFUSED 7 (OCQ.550)
DON'T KNOW 9 (OCQ.550)
OCQ.540 Please give me the total number of years for all jobs where this has happened.
INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS MORE THAN ONE JOB, THEY SHOULD ADD ALL YEARS TOGETHER.
IF LESS THAN 1 YEAR, ENTER 0
|___|___|___|
ENTER NUMBER OF YEARS
REFUSED 777
DON'T KNOW 999
OCQ.550 The next questions ask about being exposed to fumes in {your/SPs} work.
Being exposed to fumes means that {you/SP} breathed in fumes or had a lasting smell on {your/his/her} clothes, skin or hair.
INTERVIEWER INSTRUCTION: DO NOT COUNT TEMPORARY ONE-TIME EXPOSURES THAT MIGHT HAVE HAPPENED.
In any job, {have you/has SP} ever been exposed to exhaust fumes from trucks, buses, heavy machinery, or diesel engines?
YES 1
NO 2 (OCQ.570)
REFUSED 7 (OCQ.570)
DON'T KNOW 9 (OCQ.570)
OCQ.560 Please give me the total number of years for all jobs where this has happened.
INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS MORE THAN ONE JOB, THEY SHOULD ADD ALL YEARS TOGETHER.
IF LESS THAN 1 YEAR, ENTER 0
|___|___|___|
ENTER NUMBER OF YEARS
REFUSED 777
DON'T KNOW 999
OCQ.570 In any job, {have you/has SP} ever been exposed to any other gases, vapors or fumes?
Examples are vapors from paints, cleaning products, glues, solvents, and acids; or welding/soldering fumes.
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
OCQ.580 Please give me the total number of years for all jobs where this has happened.
INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS MORE THAN ONE JOB, THEY SHOULD ADD ALL YEARS TOGETHER.
IF LESS THAN 1 YEAR, ENTER 0
|___|___|___|
ENTER NUMBER OF YEARS
REFUSED 777
DON'T KNOW 999
DEMOGRAPHICS INFORMATION – DMQ – SP
Target Group: SPs Birth +
-
BOX 1A
CHECK ITEM DMQ.030:
IF SP AGE >= 6, CONTINUE.
OTHERWISE, GO TO DMQ.061.
DMQ.141 What is the highest grade or level of school {you have/SP has} completed or the highest degree {you have/s/he has} received?
HAND CARD DMQ1
READ HAND CARD CATEGORIES IF NECESSARY.
Enter highest level of school.
NEVER ATTENDED/KINDERGARTEN
ONLY 0 (BOX 1B)
1ST GRADE 1
2ND GRADE 2
3RD GRADE 3
4TH GRADE 4
5TH GRADE 5
6TH GRADE 6
7TH GRADE 7
8TH GRADE 8
9TH GRADE 9
10TH GRADE 10
11TH GRADE 11
12TH GRADE, NO DIPLOMA 12
HIGH SCHOOL GRADUATE 13
GED OR EQUIVALENT 14
SOME COLLEGE, NO DEGREE 15
ASSOCIATE DEGREE: OCCUPATIONAL,
TECHNICAL, OR VOCATIONAL
PROGRAM 16
ASSOCIATE DEGREE: ACADEMIC
PROGRAM 17
BACHELOR’S DEGREE (EXAMPLE: BA,
AB, BS, BBA) 18
MASTER’S DEGREE (EXAMPLE: MA,
MS, MEng, MEd, MBA) 19
PROFESSIONAL SCHOOL DEGREE
(EXAMPLE: MD, DDS, DVM, JD) 20
DOCTORAL DEGREE (EXAMPLE:
PhD, EdD) 21
REFUSED 77
DON’T KNOW 99
-
BOX 1AA
CHECK ITEM DMQ.035:
IF SP AGE <= 19, CONTINUE
OTHERWISE, GO TO DMQ.051.
DMQ.037 {Are you/Is SP} now . . .
going to school, 1
on vacation from school (between
grades), or 2
neither? 3
REFUSED 7
DON’T KNOW 9
-
BOX 1B
CHECK ITEM DMQ.040:
IF SP AGE >= 17, CONTINUE.
OTHERWISE, GO TO DMQ.061.
DMQ.051 Did {you/SP} ever serve in the Armed Forces of the United States?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
DMQ.061 {Do you/Does SP} usually go by another first name besides {DISPLAY FIRST NAME FROM DMQ.040}?
CAPI INSTRUCTION:
DISPLAY "FIRST NAME:" AND FIRST NAME FROM DMQ.040 AS LEFT HEADER.
YES 1
NO 2 (BOX 1BB)
REFUSED 7 (BOX 1BB)
DON'T KNOW 9 (BOX 1BB)
DMQ.071 What is this other first name?
VERIFY SPELLING
____________________________________
ENTER NAME
REFUSED 7
DON'T KNOW 9
-
BOX 1BB
CHECK ITEM DMQ.073a:
IF AGE >= 14, CONTINUE.
OTHERWISE, GO TO BOX 1D.
DMQ.380 {Are you/Is SP} now married, widowed, divorced, separated, never married or living with a partner?
MARRIED 1
WIDOWED 2
DIVORCED 3
SEPARATED 4
NEVER MARRIED 5 (BOX 1D)
LIVING WITH PARTNER 6
REFUSED 7
DON'T KNOW 9
-
BOX 1C
CHECK ITEM DMQ.075A:
IF SP IS MALE OR CODED AS 'NEVER MARRIED' IN DMQ.380, GO TO
BOX 1D.OTHERWISE, CONTINUE.
DMQ.081 {Do you/Does SP} have a maiden name?
ASK IF NOT KNOWN
YES 1
NO 2 (BOX 1D)
REFUSED 7 (BOX 1D)
DON'T KNOW 9 (BOX 1D)
DMQ.090 What is {your/SP's} maiden name?
G/Q
VERIFY SPELLING
CAPI INSTRUCTION:
DISPLAY "LAST NAME:" AND SP'S CURRENT LAST NAME FROM DMQ.060 AS LEFT HEADER.
____________________________________
ENTER MAIDEN NAME
or
SAME AS CURRENT LAST NAME 2
REFUSED 7
DON'T KNOW 9
-
BOX 1D
CHECK ITEM DMQ.094:
IF SP AGE >= 16, CONTINUE.
OTHERWISE, GO TO DMQ.106.
DMQ.101 What is {your/SP's} father's last name?
G/Q
VERIFY SPELLING
CAPI INSTRUCTION:
DISPLAY "LAST NAME:" AND SP'S CURRENT LAST NAME FROM DMQ.060 AS LEFT HEADER.
IF MAIDEN NAME ENTERED IN DMQ.090G/Q, AND MAIDEN NAME IS DIFFERENT FROM CURRENT LAST NAME, ALSO DISPLAY "MAIDEN NAME:" AND MAIDEN NAME FROM DMQ.090G/Q AS LEFT HEADER.
CAPI INSTRUCTION:
HARD EDIT: IF SP MALE, DO NOT ALLOW RESPONSE 3.
____________________________________
ENTER NAME
or
SAME AS CURRENT LAST NAME 2
SAME AS MAIDEN NAME 3
REFUSED 7
DON'T KNOW 9
DMQ.107 In what country {were you/was SP} born?
UNITED STATES 1 (DMQ.130)
OTHER COUNTRY 2
REFUSED 7 (BOX 3)
DON'T KNOW 9 (BOX 3)
DMQ.112 SELECT COUNTRY OF BIRTH
ARGENTINA 1 (DMQ.160 M/Y)
BELIZE 2 (DMQ.160 M/Y)
BOLIVIA 3 (DMQ.160 M/Y)
BRAZIL 4 (DMQ.160 M/Y)
CHILE 5 (DMQ.160 M/Y)
COLOMBIA 6 (DMQ.160 M/Y)
COSTA RICA 7 (DMQ.160 M/Y)
CUBA 8 (DMQ.160 M/Y)
DOMINICAN REPUBLIC 9 (DMQ.160 M/Y)
ECUADOR 10 (DMQ.160 M/Y)
EL SALVADOR 11 (DMQ.160 M/Y)
GUATEMALA 12 (DMQ.160 M/Y)
HONDURAS 13 (DMQ.160 M/Y)
MEXICO 14 (DMQ.160 M/Y)
NICARAGUA 15 (DMQ.160 M/Y)
PANAMA 16 (DMQ.160 M/Y)
PARAGUAY 17 (DMQ.160 M/Y)
PERU 18 (DMQ.160 M/Y)
PHILIPPINES 19 (DMQ.160 M/Y)
PUERTO RICO 20 (DMQ.160 M/Y)
SPAIN 21 (DMQ.160 M/Y)
URUGUAY 22 (DMQ.160 M/Y)
VENEZUELA 23 (DMQ.160 M/Y)
OTHER COUNTRY (CAPI INSTRUCTION:
DO NOT SPECIFY) 40 (DMQ.160 M/Y)
DMQ.130 In what state {were you/was SP} born?
ENTER 2 LETTER STATE ABBREVIATION TO START THE LOOKUP.
SELECT STATE FROM CAPI STATE LIST.
PRESS ENTER TO ACCEPT SELECTION.
CAPI INSTRUCTION:
DISPLAY FIPS STATE LIST. INTERVIEWER ONLY SHOULD BE ABLE TO SELECT 1 STATE FROM LIST. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. THE STATE LOOKUP IN THE SP AND FAMILY QUESTIONNAIRES SHOULD WORK EXACTLY THE SAME.
-
BOX 3
CHECK ITEM DMQ.150:
GO TO DMQ.241.
DMQ.160 In what month and year did {you/SP} come to the United States to stay?
M/Y
|___|___|
ENTER MONTH NUMBER
REFUSED 7777
DON'T KNOW 9999
|___|___|___|___|
ENTER 4-DIGIT YEAR
REFUSED 777777
DON'T KNOW 999999
DMQ.170 {Are you/Is SP} a citizen of the United States?
[Information about citizenship is being collected by the U.S. Public Health Service to perform health related research. Providing this information is voluntary and is collected under the authority of the Public Health Service Act. There will be no effect on pending immigration or citizenship petitions.]
HAND CARD DMQ2
YES, BORN IN UNITED STATES 1
YES, BORN IN PUERTO RICO, GUAM,
AMERICAN VIRGIN ISLANDS, OR
OTHER U.S. TERRITORY 2
YES, BORN ABROAD TO AMERICAN
PARENTS 3
YES, U.S. CITIZEN BY NATURALIZATION 4
NO, NOT A CITIZEN OF THE UNITED
STATES 5
REFUSED 7
DON'T KNOW 9
DMQ.241 {Do you/Does SP} consider {yourself/himself/herself} to be Hispanic or Latino?
READ IF NECESSARY: Where do your ancestors come from?
Puerto Rican
Cuban/Cuban American
Dominican Republic
Mexican/Mexican American
Central/South American
Other Latin American
Other Hispanic or Latino
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
HELP SCREEN:
SPANISH, HISPANIC OR LATINO PEOPLE MAY BE OF ANY RACE. LISTED BELOW ARE HISPANIC OR LATINO CATEGORIES/COUNTRIES.
Mexican
Puerto Rican
Cuban
Dominican Republic
Central American:
Costa Rican
Guatemalan
Honduran
Nicaraguan
Panamanian
Salvadoran
Other Central American
South American:
Argentinean
Bolivian
Chilean
Colombian
Ecuadorian
Paraguayan
Peruvian
Uruguayan
Venezuelan
Other South American
Other Hispanic or Latino:
Spaniard
Spanish
Spanish American
-
BOX 3F
CHECK ITEM DMQ.244:
IF YES (CODE 1) IN DMQ.241, GO TO DMQ.252.
IF DON'T KNOW (CODE 9) OR REF (CODE 7) IN DMQ.241.
OR
*IF NO (CODE 2) IN DMQ.241, CONTINUE TO BOX 3G.
-
BOX 3G
CHECK ITEM DMQ.246:
IF NO (CODE 2) IN 07SCQ.New260 (07 SCREENER QUESTIONNAIRE), GO TO DMQ.261.
IF HISPANIC OR LATINO IN 07SCQ.New260 (07 SCREENER QUESTIONNAIRE), DISPLAY SOFT EDIT ONCE THEN GO TO BOX 3H.
OTHERWISE, GO TO DMQ.261.
CAPI INSTRUCTION:
DISPLAY SOFT EDIT MESSAGE –
"SCREENER ETHNICITY: HISPANIC OR LATINO.
INTERVIEWER: GIVE RESPONDENT HAND CARD DMQ4 AND READ CATEGORIES."
-
BOX 3H
CHECK ITEM DMQ.248:
IF YES (CODE 1) IN DMQ.241, CONTINUE.
OTHERWISE, GO TO DMQ.261.
DMQ.252 Please give me the number of the group that represents {your/SP's} Hispanic origin or ancestry. Please select 1 or more of these categories.
HAND CARD DMQ4
SELECT 1 OR MORE
Mexican 1
Puerto Rican 2
Cuban 3
Dominican Republic 4
Central American:
Costa Rican 5
Guatemalan 6
Honduran 7
Nicaraguan 8
Panamanian 9
Salvadoran 10
Other Central American 11
South American:
Argentinean 12
Bolivian 13
Chilean 14
Colombian 15
Ecuadorian 16
Paraguayan 17
Peruvian 18
Uruguayan 19
Venezuelan 20
Other South American 21
Other Hispanic or Latino:
Spaniard 22
Spanish 23
Spanish American 24
OTHER (SPECIFY) 40
REFUSED 77
DON'T KNOW 99
DMQ.261 What race {do you/does SP} consider {yourself/himself/herself} to be? Please select 1 or more of these categories.
HAND CARD DMQ5
SELECT 1 OR MORE
WHITE 1 (BOX 4)
BLACK/AFRICAN AMERICAN 2 (BOX 4)
INDIAN (AMERICAN) 3 (BOX 4)
ALASKA NATIVE 4 (BOX 4)
NATIVE HAWAIIAN 5 (BOX 4)
GUAMANIAN 6 (BOX 4)
SAMOAN 7 (BOX 4)
OTHER PACIFIC ISLANDER (SPECIFY) 8 (BOX 4)
ASIAN INDIAN (INCLUDES PERSONS
OF
INDIA, PAKISTAN, CEYLON, AND
SRI LANKA) 9 (BOX 4)
CHINESE 10 (BOX 4)
FILIPINO (FROM PHILIPPINES) 11 (BOX 4)
JAPANESE 12 (BOX 4)
KOREAN 13 (BOX 4)
VIETNAMESE 14 (BOX 4)
OTHER ASIAN 15 (DMQ.264)
SOME OTHER RACE 16 (DMQ.267)
REFUSED 77 (BOX 4)
DON’T KNOW 99 (BOX 4)
CAPI INSTRUCTION:
THE WORDS “INDIA”, “PAKISTAN”, “CEYLON”, AND “SRI LANKA” SHOULD APPEAR IN BLUE.
DMQ.264 CODE SP ANSWER TO OTHER ASIAN.
HMONG 1 (BOX 4)
LAOTIAN 2 (BOX 4)
CAMBODIAN 4 (BOX 4)
TAIWANESE 5 (BOX 4)
OTHER (SPECIFY) 40 (BOX 4)
DMQ.267 CODE SP ANSWER TO ‘OTHER RACE’.
Mexican 1
Puerto Rican 2
Cuban 3
Dominican Republic 4
Central American:
Costa Rican 5
Guatemalan 6
Honduran 7
Nicaraguan 8
Panamanian 9
Salvadoran 10
Other Central American 11
South American:
Argentinean 12
Bolivian 13
Chilean 14
Colombian 15
Ecuadorian 16
Paraguayan 17
Peruvian 18
Uruguayan 19
Venezuelan 20
Other South American 21
Other Hispanic or Latino:
Spaniard 22
Spanish 23
Spanish American 24
OTHER SPECIFY 40
REFUSED 77
DON'T KNOW 99
CAPI INSTRUCTION:
CHECK DMQ.241. IF “NO” (CODE 2) IN DMQ.241, DISPLAY THE FOLLOWING HARD ERROR MESSAGE. RESPONDENT CODED AS NOT HISPANIC IN PREVIOUS QUESTION “DO YOU CONSIDER YOURSELF HISPANIC/LATINO – BACK UP TO CORRECT PREVIOUS QUESTION OR CORRECT ENTRY AT THIS QUESTION.
-
BOX 4
CHECK ITEM DMQ.270:
IF MORE THAN 1 ENTRY IN DMQ.261, CONTINUE.
OTHERWISE, GO TO DMQ.281.
DMQ.275 |
Which one of these groups, that is {DISPLAY RESPONSES CODED IN DMQ.260 WITH CORRESPONDING CODES}, would you say best represents {your/SP's} race? |
|___|___|
ENTER RACE CODE
CANNOT CHOOSE 1 RACE 66
REFUSED 7777
DON'T KNOW 9999
DMQ.281a |
The Department of Health and Human Services will conduct statistical research by combining {your/his/her} survey data with vital, health, nutrition and other related records. Your social security number is used only for these purposes and the Department will not release it to anyone, including any government agency, for any other reason. Providing this information is voluntary and is collected under the authority of Section 306 of the Public Health Service Act. There will be no effect on {your/his/her} benefits if you do not provide it. |
INTERVIEWER INSTRUCTION—ONLY READ IF ASKED. [Public Health Service Act is title 42, United States Code, section 242k.]
What is {your/SP's} Social Security Number?
INTERVIEWER INSTRUCTION:
IF RESPONDENT CANNOT RECALL FROM MEMORY ASK {HIM/HER} TO GET CARD AT THIS TIME.
IF RESPONDENT IS RELUCTANT OR NEEDS MORE INFORMATION, PRESS F1 TO ACCESS THE HELP SCREEN AND FOLLOW THE SCRIPT.
ENTER SOCIAL SECURITY NUMBER 1 (DMQ281b)
DOES NOT HAVE SOCIAL SECURITY NUMBER 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
CAPI INSTRUCTION:
IF SP REFUSES (CODE 7), DISPLAY THE FOLLOWING SOFT ERROR MESSAGE:
TEXT TO BE SUPPLIED LATER AND WILL BE WRITTEN BY NCHS/WESTAT.
DMQ281b/c
CAPI INSTRUCTION:
REQUIRE DOUBLE ENTRY OF SOCIAL SECURITY NUMBER.
|___|___|___| |___|___| |___|___|___|___|
ENTER SOCIAL SECURITY NUMBER
or
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
CAPI INSTRUCTION:
IF SP REFUSES (CODE 7), DISPLAY THE FOLLOWING SOFT ERROR MESSAGE:
TEXT TO BE SUPPLIED LATER AND WILL BE WRITTEN BY NCHS/WESTAT.
NEW HELP SCREEN TO ADDRESS RESPONDENTS WHO ARE RELUCTANT OR WHO NEED MORE INFORMATION WILL BE WRITTEN BY NCHS/WESTAT.
DMQ.300 INTERVIEWER: SELECT CATEGORY FOR REPORTING OF SOCIAL SECURITY NUMBER
SELF REPORTED FROM MEMORY 1
SELF REPORTED FROM RECORDS 2
PROXY REPORTED FROM MEMORY 3
PROXY REPORTED FROM RECORDS 4
NEW HELP SCREEN TO ADDRESS REFUSALS AND SPs WHO NEED MORE INFORMATION TO FOLLOW – FROM NCHS.
-
BOX 1
CHECK ITEM ACQ.005:
IF SP CODED HISPANIC IN SCREENER, GO TO ACQ.041.
OTHERWISE, CONTINUE.
ACQ.011 Now I'm going to ask you about language use.
What language(s) {do you/does SP} usually speak at home?
CODE ALL THAT APPLY
ENGLISH 1
SPANISH 8
OTHER 9
REFUSED 77
DON'T KNOW 99
-
BOX 2
CHECK ITEM ACQ.015:
GO TO END OF SECTION.
ACQ.041 Now I’m going to ask you about language use.
What language(s) {do you/does SP} usually speak at home?
HAND CARD ACQ1
ONLY SPANISH, 1
MORE SPANISH THAN ENGLISH, 2
BOTH EQUALLY, 3
MORE ENGLISH THAN SPANISH, OR 4
ONLY ENGLISH 5
REFUSED 7
DON'T KNOW 9
DIETARY SUPPLEMENTS AND PRESCRIPTION MEDICATION – DSQ
Target Group: SPs Birth +
DSQ.012 The next questions are about {your/SP's} use of dietary supplements, nonprescription antacids, and prescription medications during the past 30 days.
{Have you/Has SP} used or taken any vitamins, minerals, herbals or other dietary supplements in the past 30 days? Include prescription and non-prescription supplements.
This card lists some examples of different types of dietary supplements.
HAND CARD DSQ1a
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
RXQ.021 {Have you/Has SP} used or taken any nonprescription antacids in the past 30 days?
HAND CARD DSQ1b
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 0
OMITTED
RXQ.032 In the past 30 days, {have you/has SP} used or taken medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. [Do not include prescription vitamins or minerals you may have already told me about.]
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 1
CHECK ITEM DSQ.035A:
IF 'YES' (CODE 1) IN DSQ.012, RXQ.021, OR RXQ.032, CONTINUE.
OTHERWISE, GO TO BOX 14A.
DSQ.042 May I please see the containers for all the {vitamins, minerals, herbals, and other dietary supplements}, {and} {nonprescription antacids} {and} {prescription medicines} that {you/SP} used or took in the past 30 days?
PRESS ENTER TO CONTINUE
CAPI INSTRUCTION:
DISPLAY {vitamins, minerals, herbals and other dietary supplements,} only if DSQ.012 = yes (1), {nonprescription antacids.} only if RXQ.021 = yes (1), {prescription medicines,} only if RXQ.032 = yes (1), and the word {“and”} only before the last product type if there is more than one product type.
-
BOX 1A
CHECK ITEM DSQ.045:
IF 'YES' (CODE 1) IN DSQ.012, CONTINUE WITH DSQ.047.
OTHERWISE, GO TO BOX 6.
DSQ.047 I will start with the vitamins, minerals, herbals and other dietary supplements. Please show me any {you have/SP has} taken in the past 30 days.
CHECK PRODUCT LABEL OR ASK PRODUCT NAME.
IS THIS PRODUCT ON THE LIST BELOW?
YES 1
NO 2 (DSQ.052)
DON’T KNOW 9 (DSQ.052)
SINGLE ELEMENTS
VITAMIN A 10
VITAMIN B6 12
VITAMIN B12 13
VITAMIN C (WITH OR WITHOUT ROSE HIPS) 14
VITAMIN D 15
VITAMIN E 16
CALCIUM 18
CHROMIUM (CHROMIUM PICOLINATE) 19
FOLATE (FOLIC ACID) 20
IRON (FERROUS XXXATE) 21
MAGNESIUM 27
POTASSIUM 28
SELENIUM 29
ZINC (ZINC GLUCONATE) 40
MULTI ELEMENTS
VITAMINS A & D 50
CALCIUM & VITAMIN D 51
CALCIUM & MAGNESIUM 52
DSQ.049 WHICH PRODUCT IS IT?
ENTER 1 PRODUCT CODE
VITAMIN A 10
VITAMIN B6 12
VITAMIN B12 13
VITAMIN C (WITH OR WITHOUT ROSE HIPS) 14
VITAMIN D 15
VITAMIN E 16
CALCIUM 18
CHROMIUM (CHROMIUM PICOLINATE) 19
FOLATE (FOLIC ACID) 20
IRON (FERROUS XXXATE) 21
MAGNESIUM 27
POTASSIUM 28
SELENIUM 29
ZINC (ZINC GLUCONATE) 40
VITAMINS A & D 50
CALCIUM & VITAMIN D 51
CALCIUM & MAGNESIUM 52
REFUSED 77 (DSQ.052)
DON’T KNOW 99 (DSQ.052)
-
BOX 1B
CHECK ITEM DSQ.059:
GO TO DSQ.071.
DSQ.052 REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF DIETARY SUPPLEMENTS USED. ENTER FULL NAME OF SUPPLEMENT, INCLUDING BRAND.
ENTER SUPPLEMENT NAME
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION:
IF DON'T KNOW OR REFUSAL, THEN GO TO BOX 6.
SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.
TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.
DSQ.060s PRESS BS TO START THE LOOKUP.
SELECT SUPPLEMENT FROM LIST.
IF SUPPLEMENT NOT
ON LIST – PRESS BS
TO DELETE ENTRY.
TYPE '**'
PRESS ENTER TO SELECT.
CAPI INSTRUCTION:
DISPLAY CAPI VITAMIN PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN DSQ.052 BY TYPING IN "**".
THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION TEXT ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.
INTERVIEWER SHOULD BE ABLE TO ACCEPT THE KEYED NAME AS A NEW PRODUCT NAME. AFTER ENTRY, INTERVIEWER SHOULD RETURN TO THE DATA BASE LIST. IF NO MORE ENTRIES, INTERVIEWERS SHOULD HAVE A WAY OF MOVING INTO LOOP 1.
ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:
DRUG TYPE {3}
GENERIC NAME {60}
THERAPEUTIC CLASS CODE {6}
GENERIC FLAG {1}
THERE IS NO NEED TO DISPLAY THIS INFORMATION.
-
BOX 2
CHECK ITEM DSQ.061:
IF PRODUCT IS SELECTED FROM THE LOOKUP AND THE PRODUCT NAME IS GREATER THAN THE LOOKUP DISPLAY FIELD, CONTINUE WITH DSQ.057.
OTHERWISE, GO TO DSQ.071.
DSQ.057 YOU HAVE SELECTED
{DISPLAY FULL VARIABLE NAME}
IS THIS CORRECT?
YES 1
NO 2 (CAPI INSTRUCTION)
CAPI INSTRUCTION:
DISPLAY SCREEN DSQ.060s – ENTRY FIELD SHOULD BE BLANK. AT DSQ.060s, INTERVIEWER SHOULD PRESS THE ‘BACKSPACE’ KEY TO START THE LOOKUP AGAIN AND SELECT ANOTHER PRODUCT.
DSQ.071 INTERVIEWER: ENTER 1 RESPONSE
CAPI INSTRUCTION:
DISPLAY PRODUCT NAME AS LEFT HEADER.
CONTAINER SEEN 1
CONTAINER NOT SEEN 2
-
BOX 2A
CHECK ITEM DSQ.074:
IF PRODUCT WAS SELECTED FROM SPECIAL PRODUCT LIST (YES, CODE 1 IN DSQ.047) AND CONTAINER SEEN, CONTINUE.
IF PRODUCT WAS NOT SELECTED FROM SPECIAL PRODUCT LIST (NO, CODE 2 IN DSQ.047) AND CONTAINER SEEN, GO TO DSQ.077.
OTHERWISE (IF CONTAINER NOT SEEN), GO TO DSQ.096.
DSQ.066 SELECT STRENGTH FOR {ELEMENT}
a/b/aO/bO
IF STRENGTH NOT ON FRONT OR UNCLEAR, TURN CONTAINER AROUND AND GET STRENGTH FROM FACTS BOX.
PRESS BS TO START LOOKUP.
PRESS ENTER TO SELECT.
CAPI INSTRUCTION:
{ELEMENT} = DISPLAY PRODUCT ELEMENT SELECTED IN DSQ.049. IF PRODUCT SELECTED HAS MORE THAN 1 ELEMENT (EXAMPLE = ), STRENGTH QUESTION SHOULD APPEAR FOR EACH ELEMENT.
IF “OTHER” STRENGTH IS SELECTED, GET OTHER SPECIFY AND INTERVIEWER INSTRUCTION SHOULD READ “ENTER SUPPLEMENT STRENGTH”.
ALL OF THE STRENGTH QUESTION AND INSTRUCTION SHOULD APPEAR WHEN STRENGTH LOOKUP LIST IS DISPLAYED (NO SCROLLING). THIS MAY MEAN PRINTING ALL WORDS ON THE SCREEN FLUSH LEFT IN MULTIPLE LINES.
-
BOX 3
OMITTED
DSQ.077 WHAT IS THE FORM OF THIS PRODUCT?
OS
CAPSULES 1
TABLETS 2
CHEWABLE TABLETS 3
PILLS 4
CAPLETS 5
SOFT GELS 6
GEL CAPS 7
VEGICAPS 8
PACKAGE/PACKETS 9
LIQUID 10
POWDER 11
WAFERS 12
CHEWS/GUMMIES 13
DOTS 14
GRANULES 15
LOZENGES/COUGH DROPS 16
GEL 17
OTHER FORM (SPECIFY) 91
REFUSED 77
DON’T KNOW 99
CAPI INSTRUCTION:
DISPLAY PRODUCT NAME AS LEFT HEADER.
-
BOX 3A
CHECK ITEM DSQ.079:
IF PRODUCT NOT SELECTED FROM SPECIAL PRODUCT LIST (NO, CODE 2 IN DSQ.047), CONTINUE.
OTHERWISE, GO TO DSQ.096.
DSQ.081 ENTER MANUFACTURER/DISTRIBUTOR/STORE BRAND NAME.
ENTER AS MUCH INFORMATION AS POSSIBLE.
ENTER MANUFACTURER/DISTRIBUTOR/STORE BRAND NAME
REFUSED 7 (DSQ.088)
DON'T KNOW 9 (DSQ.088)
CAPI INSTRUCTION:
FOLLOW THE BASIC FORMAT FOR THE DIETARY SUPPLEMENT LOOKUP. ONLY ALLOW ENTRY OF 1 MANUFACTURER. DISPLAY PRODUCT NAME AS A LEFT HEADER.
DSQ.084 PRESS BS TO START THE LOOKUP.
SELECT MANUFACTURER
FROM LIST.
IF MANUFACTURER NOT
ON LIST – PRESS BS
TO DELETE ENTRY
TYPE '**'.
PRESS ENTER TO SELECT.
CAPI INSTRUCTION:
DISPLAY MANUFACTURER LIST. INTERVIEWER SHOULD BE ABLE TO SELECT ONLY 1 MANUFACTURER OR THE '**' OPTION. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. IF MANUFACTURER IS SELECTED FROM THE LOOKUP LIST, AUTOMATICALLY FILL IN THE CITY AND STATE INFORMATION (DSQ.088).
DISPLAY PRODUCT NAME AS LEFT HEADER.
-
BOX 4
CHECK ITEM DSQ.085:
IF MANUFACTURER SELECTED FROM LOOKUP, GO TO DSQ.096.
OTHERWISE, CONTINUE.
DSQ.088b ENTER CITY NAME.
ENTER AS MUCH INFORMATION AS POSSIBLE.
ENTER CITY
REFUSED 7
DON’T KNOW 9
DSQ.088c ENTER STATE NAME.
ENTER 2-LETTER
STATE ABBREVIATION.
PRESS ENTER TO
SELECT STATE FROM LIST.
ENTER STATE
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION:
DISPLAY PRODUCT NAME AS A LEFT HEADER.
AN ENTRY MUST BE MADE IN ALL DSQ.081 AND DSQ.087 FIELDS (MANUFACTURER INFO). IF THE MANUFACTURER INFO IS DON'T KNOW OR REFUSED, THEN SET THE NO MANUFACTURER INFORMATION VARIABLE.
DSQ.096 For how long {have/has} {you/SP} been taking {PRODUCT NAME} or a similar type of product?
Q/U
CAPI INSTRUCTION:
RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.
|___|___|___|___|
ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)
REFUSED 777
DON'T KNOW 999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
DSQ.103 In the past {30 DAYS/NUMBER AND UNIT}, on how many days did {you/SP} take {PRODUCT NAME}?
CAPI INSTRUCTION:
{30 DAYS/NUMBER AND UNIT} = IF NUMBER AND UNIT ENTERED IN DSQ.096 >= 30 DAYS, OR REFUSED (CODE 7), OR DON’T KNOW (CODE 9), DISPLAY “30 DAYS” IN TEXT OF QUESTION. IF NUMBER AND UNIT ENTERED IN DSQ.096 IS < 30 DAYS, DISPLAY ACTUAL NUMBER AND UNIT ENTERED IN DSQ.096 IN TEXT OF QUESTION.
{PRODUCT NAME} = PRODUCT SELECTED AT DSQ.049 OR PRODUCT ENTERED IN DSQ.052.
|___|___|
ENTER NUMBER OF DAYS FROM 1-30
REFUSED 777
DON'T KNOW 999
DSQ.123 On the days that {you/SP} took {PRODUCT NAME}, how much did {you/SP} usually take on a single day?
Q/U/OS
CAPI INSTRUCTION:
RESPONSE FIELD SHOULD ALLOW FOR 3 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW 0 OR 1 ENTRIES TO THE LEFT OF THE DECIMAL AND 0, 1 OR 2 ENTRIES TO THE RIGHT OF THE DECIMAL.
|___|___|___|
ENTER NUMBER
REFUSED 7777 (DSQ.126a)
DON'T KNOW 9999 (DSQ.126a)
|___|___|
ENTER UNIT/FORM
TABLETS/CAPSULES/PILLS/CAPLETS/
SOFTGELS/GEL
CAPS/VEGICAPS/
CHEWABLE TABLETS 1 (07BOX NEW 4A)
DROPPERS 2 (07BOX NEW 4A)
DROPS 3 (07BOX NEW 4A)
INJECTIONS/SHOTS 5 (07BOX NEW 4A)
LOZENGES/COUGH DROPS 6 (07BOX NEW 4A)
MILLILITERS 7 (07BOX NEW 4A)
TABLESPOONS 11 (07BOX NEW 4A)
TEASPOONS 12 (07BOX NEW 4A)
WAFERS 13 (07BOX NEW 4A)
CANS 15 (07BOX NEW 4A)
GRAMS 16 (07BOX NEW 4A)
DOTS 17 (07BOX NEW 4A)
CUPS 18 (07BOX NEW 4A)
SPRAYS/SQUIRTS 19 (07BOX NEW 4A)
CHEWS/GUMMIES 20 (07BOX NEW 4A)
SCOOPS 21 (07BOX NEW 4A)
CAPFULS 23 (07BOX NEW 4A)
OUNCES 27 (07BOX NEW 4A)
PACKAGES/PACKETS 28 (CONTINUE)
VIALS 29 (07BOX NEW 4A)
GUMBALLS 30 (07BOX NEW 4A)
OTHER FORM (SPECIFY) 91 (07BOX NEW 4A)
REFUSED 77 (07BOX NEW 4A)
DON’T KNOW 99 (07BOX NEW 4A)
CAPI INSTRUCTION:
IF FORM CODE 1 THROUGH 8 IN DSQ.077, PREFILL AND DISPLAY THE UNIT CODE 1 FOR DSQ.123U.
IF FORM CODE 12 IN DSQ.077, PREFILL AND DISPLAY THE UNIT CODE 13 FOR DSQ.123U.
IF FORM CODE 13 IN DSQ.077, PREFILL AND DISPLAY THE UNIT CODE 20 FOR DSQ.123U.
IF FORM CODE 14 IN DSQ.077, PREFILL AND DISPLAY THE UNIT CODE 17 FOR DSQ.123U.
IF FORM CODE 16 IN DSQ.077, PREFILL AND DISPLAY THE UNIT CODE 6 FOR DSQ.123U.
IF FORM CODE 9 IN DSQ.077, DISPLAY THE UNIT CODES 1, 6, 7, 11, 12, 13, 15, 16, 17, 18, 20, 21, 23, 27, 28, 30, 91, 77, 99 FOR DSQ.123U.
IF FORM CODE 10, 17 IN DSQ.077, DISPLAY THE UNIT CODES 2, 3, 5, 7, 11, 12, 15, 18, 19, 23, 27, 29, 91, 77, 99 FOR DSQ.123U.
IF FORM CODE 11, 15 IN DSQ.077, DISPLAY THE UNIT CODES 11, 12, 15, 16, 18, 21, 23, 27, 28, 91, 77, 99 FOR DSQ.123U.
IF FORM CODE 91, 77, 99 IN DSQ.077, DISPLAY ENTIRE PICK LIST FOR DSQ.123U.
IF CONTAINER NOT SEEN (CODE 2 IN DSQ.071), DISPLAY ENTIRE PICK LIST FOR DSQ.123U.
DSQ.125 {Did you/Does SP} take an entire packet of {PRODUCT NAME} each time?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
07BOX NEW 4A
CHECK ITEM DSQ.105:
IF PRODUCT NOT SEEN IN DSQ.071 (CODE 2) AND DSQ.123 = 7, 11, 12, 15, 16, 18, 21, 23 OR 27, CONTINUE.
OTHERWISE, SKIP TO DSQ.124.
DSQ.110 Was that a liquid or powder?
LIQUID 1
POWDER 2
REFUSED 77
DON'T KNOW 99
DSQ.124 HAND CARD 2
Looking at this card, what is the reason {you take/SP takes} {PRODUCT NAME}?
(Did you decide to take it for reasons of your own or did a doctor or other health provider tell you to take it?)
DECIDED TO TAKE IT FOR REASONS
OF MY OWN 1
A DOCTOR OR OTHER HEALTH
PROVIDER TOLD ME TO 2
REFUSED 7 (DSQ.127)
DON’T KNOW 9 (DSQ.127)
DSQ.128 {For what reason or reasons {do you/does SP} take {PRODUCT NAME}?}
{For what reason or reasons did the doctor or other health professional tell {you/SP} to take {PRODUCT}?}
HAND CARD 3
CODE ALL THAT APPLY.
FOR GOOD BOWEL/COLON HEALTH 1
FOR PROSTATE HEALTH 2
FOR MENTAL HEALTH 3
TO PREVENT HEALTH PROBLEMS 4
TO IMPROVE MY OVERALL HEALTH 5
FOR TEETH, PREVENT CAVITIES 6
TO SUPPLEMENT MY DIET (BECAUSE
I DON’T GET ENOUGH FROM FOOD) 7
TO MAINTAIN HEALTH (TO STAY
HEALTHY) 8
TO PREVENT COLDS, BOOST IMMUNE
SYSTEM 9
FOR HEART HEALTH, CHOLESTEROL 10
FOR EYE HEALTH 11
FOR HEALTHY JOINTS, ARTHRITIS 12
FOR SKIN HEALTH, DRY SKIN 13
FOR WEIGHT LOSS 14
FOR BONE HEALTH, BUILD STRONG
BONES, OSTEOPOROSIS 15
TO GET MORE ENERGY 16
FOR PREGNANCY 17
FOR ANEMIA, SUCH AS LOW IRON 18
OTHER SPECIFY 91
REFUSED 77
DON’T KNOW 99
CAPI INSTRUCTION:
IF CODE 1 IN DSQ.124, DISPLAY For what reason or reasons {do you/does SP} take {PRODUCT NAME}?
IF CODE 2 IN DSQ.124, DISPLAY For what reason or reasons did the doctor or other health professional tell {you/SP} to take {PRODUCT}?
DSQ.127 ARE THERE ANY OTHER VITAMINS, MINERALS, HERBALS OR DIETARY SUPPLEMENTS?
YES 1
NO 2
-
BOX 5
CHECK ITEM DSQ.129:
ASK DSQ.127 FOR NEXT VITAMIN (CODE 1 IN DSQ.127). IF NO NEXT VITAMIN (CODE 2 IN DSQ.127), CONTINUE WITH DSQ.131.
DSQ.131 REVIEW TOTAL NUMBER OF DIETARY SUPPLEMENTS AND THEIR NAMES WITH RESPONDENT.
I have listed {TOTAL NUMBER} vitamin(s), mineral(s), herbals or dietary supplement(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME (STRENGTH)}
PRESS ENTER TO CONTINUE
CAPI INSTRUCTION:
DISPLAY LIST OF ALL VITAMIN AND MINERAL NAMES AND STRENGTHS SELECTED AT DSQ.060 AND ENTERED AT DSQ.052. CALCULATE TOTAL NUMBER OF ALL VITAMINS AND MINERALS SELECTED AT DSQ.060 AND ENTERED AT DSQ.052. DISPLAY NUMBER ON SCREEN.
-
BOX 6
CHECK ITEM DSQ.133:
IF 'YES' (CODE 1) IN RXQ.021, CONTINUE.
OTHERWISE, GO TO BOX 10A.
RXQ.141 Now I would like to ask you some questions about {your/SP's} use of nonprescription antacids in the past 30 days.
[First I will record some information about an antacid, then I will ask you some questions about it.]
REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF NONPRESCRIPTION ANTACIDS USED. ENTER FULL BRAND NAME OF ANTACID.
ENTER ANTACID NAME
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION:
IF DON'T KNOW OR REFUSED, THEN GO TO BOX 10A.
SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.
[TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.
RXQ.150s PRESS BS TO START THE LOOKUP.
SELECT ANTACID
FROM LIST.
IF ANTACID NOT
ON LIST – PRESS BS
TO DELETE ENTRY.
TYPE '**'.
PRESS ENTER TO SELECT.
CAPI INSTRUCTION:
DISPLAY CAPI ANTACID PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN RXQ.141 BY TYPING IN "**". THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.
INTERVIEWER SHOULD BE ABLE TO ACCEPT THE KEYED NAME AS A NEW PRODUCT NAME AN UNLIMITED NUMBER OF TIMES. AFTER ENTRY, INTERVIEWER SHOULD RETURN TO THE DATA BASE LIST. IF NO MORE ENTRIES, INTERVIEWERS SHOULD HAVE A WAY OF MOVING INTO LOOP 2.
ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:
DRUG TYPE {3}
GENERIC NAME {60}
THERAPEUTIC CLASS CODE {6}
GENERIC FLAG {1}
THERE IS NO NEED TO DISPLAY THIS INFORMATION.
-
BOX 7
OMITTED
RXQ.180 For how long {have/has} {you/SP} been using or taking {PRODUCT NAME}?
CAPI INSTRUCTION:
RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.
|___|___|___|___|
ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)
REFUSED 777
DON'T KNOW 999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
RXQ.191 In the past {30 DAYS/NUMBER AND UNIT}, on how many days did {you/SP} take {PRODUCT NAME}?
CAPI INSTRUCTION:
{30 DAYS/NUMBER AND UNIT} = IF NUMBER AND UNIT ENTERED IN DSQ.096 >= 30 DAYS, OR REFUSED (CODE 7), OR DON’T KNOW (CODE 9), DISPLAY “30 DAYS” IN TEXT OF QUESTION. IF NUMBER AND UNIT ENTERED IN DSQ.096 IS < 30 DAYS, DISPLAY ACTUAL NUMBER AND UNIT ENTERED IN DSQ.096 IN TEXT OF QUESTION.
{PRODUCT NAME} = PRODUCT SELECTED AT DSQ.049 OR PRODUCT ENTERED IN DSQ.052.
|___|___|
ENTER NUMBER OF DAYS FROM 1-30
REFUSED 7777
DON'T KNOW 9999
RXQ.195 |
On those days that you used or took {PRODUCT NAME}, how much did {you/SP} usually take on a single day? |
CAPI INSTRUCTION:
RESPONSE FIELD SHOULD ALLOW FOR 3 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW 0 OR 1 ENTRIES TO THE LEFT OF THE DECIMAL AND 0, 1 OR 2 ENTRIES TO THE RIGHT OF THE DECIMAL.
OPTIONS MUST BE IN ORDER SPECIFIED – APPROVED BY DRG (NCHS)
|___|___|___|
ENTER NUMBER
REFUSED 7777 (RXQ.216)
DON'T KNOW 9999 (RXQ.216)
ENTER UNIT/FORM
TABLETS/CAPSULES/PILLS/CAPLETS/
SOFTGELS/GEL
CAPS/VEGICAPS/
CHEWABLE TABLETS 1 (07BOX NEW 8)
DROPPERS 2 (07BOX NEW 8)
DROPS 3 (07BOX NEW 8)
INJECTIONS/SHOTS 5 (07BOX NEW 8)
LOZENGES 6 (07BOX NEW 8)
MILLILITERS 7 (07BOX NEW 8)
TABLESPOONS 11 (07BOX NEW 8)
TEASPOONS 12 (07BOX NEW 8)
WAFERS 13 (07BOX NEW 8)
CANS 15 (07BOX NEW 8)
GRAMS 16 (07BOX NEW 8)
DOTS 17 (07BOX NEW 8)
CUPS 18 (07BOX NEW 8)
SPRAYS/SQUIRTS 19 (07BOX NEW 8)
CHEWS 20 (07BOX NEW 8)
SCOOPS 21 (07BOX NEW 8)
CAPFULS 23 (07BOX NEW 8)
OUNCES 27 (07BOX NEW 8)
PACKAGES/PACKETS 28 (CONTINUE)
VIALS 29 (07BOX NEW 8)
GUMBALLS 30 (07BOX NEW 8)
OTHER FORM (SPECIFY) 91 (07BOX NEW 8)
REFUSED 77 (07BOX NEW 8)
DON’T KNOW 99 (07BOX NEW 8)
RXQ.200 {Do you/Does SP{ take an entire packet each time?
Q/U/OS
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
07BOX NEW 8
CHECK ITEM RXQ.205:
IF RXQ.195U IS 7, 11, 12, 15, 16, 18, 21, 23, OR 27, CONTINUE.
OTHERWISE, SKIP TO RXQ.215a.
DSQ.110 Was that a liquid or powder?
LIQUID 1
POWDER 2
REFUSED 77
DON'T KNOW 99
RXQ.215a Did you take {PRODUCT NAME} as an antacid, as a calcium supplement, or both?
ANTACID 1
CALCIUM SUPPLEMENT 2
BOTH 3
NEITHER 4
REFUSED 7
DON'T KNOW 9
RXQ.216 CHECK CONTAINERS. ARE THERE ANY OTHER NONPRESCRIPTION ANTACIDS?
OR ASK RESPONDENT:
[Are there any other nonprescription antacids that {you/SP} used in the past 30 days?]
YES 1
NO 2
-
BOX 9
CHECK ITEM RXQ.219:
ASK RXQ.216 FOR NEXT ANTACID (CODE 1 IN RXQ.216). IF NO NEXT ANTACID, (CODE 2 IN RXQ.216), CONTINUE WITH RXQ.221.
RXQ.221 REVIEW TOTAL NUMBER OF ANTACIDS AND THEIR NAMES WITH RESPONDENT.
I have listed {TOTAL NUMBER} nonprescription antacid(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}
PRESS ENTER TO CONTINUE
CAPI INSTRUCTION:
DISPLAY NAMES OF ALL ANTACIDS SELECTED AT RXQ.150 AND ENTERED AT RXQ.141. CALCULATE TOTAL NUMBER OF ALL ANTACIDS SELECTED AT RXQ.150 AND ENTERED AT RXQ.141. DISPLAY NUMBER ON SCREEN.
-
BOX 15
OMITTED
-
BOX 16
OMITTED
-
BOX 16A
OMITTED
-
BOX 10A
CHECK ITEM DSQ.225:
IF 'YES' (CODE 1) IN RXQ.032, CONTINUE.
OTHERWISE, GO TO BOX 14A.
RXQ.231 Now I would like to talk about prescription medication {you have/SP has} used in the past 30 days. Again, these are products prescribed by a health professional such as a doctor or dentist.
[First I will record some information about the medication, then I will ask you some questions about it.]
REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF PRESCRIPTION MEDICATIONS USED.
ENTER MEDICATION NAME
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION:
IF DON'T KNOW OR REFUSED, THEN GO TO BOX 18.
SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.
TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.
RXQ.240s PRESS BS TO START THE LOOKUP.
SELECT MEDICATION
FROM LIST.
IF MEDICATION NOT
ON LIST – PRESS BS
TO DELETE ENTRY.
TYPE '**'.
PRESS ENTER TO SELECT
CAPI INSTRUCTION:
DISPLAY CAPI MEDICATION PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN RXQ.231 BY TYPING IN "**". THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.
INTERVIEWER SHOULD BE ABLE TO ACCEPT THE KEYED NAME AS A NEW PRODUCT NAME AN UNLIMITED NUMBER OF TIMES. AFTER ENTRY, INTERVIEWER SHOULD RETURN TO THE DATA BASE LIST. IF NO MORE ENTRIES, INTERVIEWERS SHOULD HAVE A WAY OF MOVING INTO LOOP 3.
ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:
DRUG TYPE {3}
GENERIC NAME {60}
THERAPEUTIC CLASS CODE {6}
GENERIC FLAG {1}
THERE IS NO NEED TO DISPLAY THIS INFORMATION.
-
BOX 10B
CHECK ITEM RXQ.243:
IF PRODUCT IS SELECTED FROM THE LOOKUP AND THE PRODUCT HAS AN ‘OTC’ DESIGNATION, CONTINUE WITH RXQ.245.
OTHERWISE, GO TO RXQ.250.
RXQ.245 YOU HAVE SELECTED
{DISPLAY FULL PRODUCT VARIABLE NAME}.
YOU HAVE SELECTED THIS PRODUCT IN AN ‘OVER THE COUNTER’ FORM. IS THIS CORRECT?
YES 1
NO 2 DISPLAY HARD ERROR
CAPI INSTRUCTION:
DISPLAY SCREEN RXQ.240s – ENTRY FIELD SHOULD BE BLANK. INTERVIEWER SHOULD PRESS THE ‘BACKSPACE’ KEY TO START THE LOOKUP AGAIN AND SELECT ANOTHER PRODUCT.
-
BOX 11
OMITTED
RXQ.250 INTERVIEWER: ENTER 1 RESPONSE
CAPI INSTRUCTION:
DISPLAY PRODUCT NAME AS A LEFT HEADER.
CONTAINER SEEN 1
CONTAINER NOT SEEN 2
RXQ.260 For how long {have/has} {you/SP} been using or taking {PRODUCT NAME}?
Q/U
CAPI INSTRUCTION:
RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.
|___|___|___|___|
ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)
REFUSED 777
DON'T KNOW 999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
-
BOX 13
OMITTED
RXQ.290 What is the main reason for which (you use/SP uses) {PRODUCT NAME}?
RXQ.291 INTERVIEWER INSTRUCTION: ASK IF NECESSARY
IS SP TAKING MEDICATION FOR ASTHMA, BREATHING PROBLEMS, EMPHYSEMA OR RELATED CONDITION?
YES 1
NO 2
REFUSED 77
DON’T KNOW 99
RXQ.294 CHECK CONTAINERS. ARE THERE ANY OTHER PRESCRIPTION MEDICATIONS?
OR ASK RESPONDENT:
[Are there any other prescription medications that {you/SP} used in the past 30 days?]
YES 1
NO 2
REFUSED 77
DON’T KNOW 99
-
BOX 14
CHECK ITEM RXQ.294A:
ASK RXQ.250 - RXQ.294 FOR NEXT MEDICATION (CODE 1 IN RXQ.294). IF NO NEXT MEDICATION (CODE 2 IN RXQ.294), CONTINUE WITH RXQ.295.
RXQ.295 REVIEW TOTAL NUMBER OF PRESCRIBED MEDICATIONS AND THEIR NAMES WITH RESPONDENT.
I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}
PRESS ENTER TO CONTINUE
CAPI INSTRUCTION:
DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231. CALCULATE TOTAL NUMBER OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231. DISPLAY NUMBER ON SCREEN.
-
07BOX NEW13A
CHECK ITEM RXQ.370:
1. IF PRODUCT SELECTED FROM LOOKUP AND CLASS CODE = 125, 131 OR 296, CONTINUE.
2. IF PRODUCT NOT SELECTED FROM LIST AND RXQ.291 = ASTHMA OR BREATHING DIFFICULTY (CODE 1), CONTINUE.
3. OTHERWISE, SKIP TO RXQ.450.
RXQ.372 Now I would like to ask you a few additional questions about {PRODUCTS SPECIFIED IN 07BOX NEW13A – CLASS CODE 125, 131 OR 296 AND PRODUCTS NOT SELECTED FROM LIST WITH CODE 1 IN RXQ.291.
-
07BOX NEW13AA
CHECK ITEM RXQ.374:
ASK RXQ.376 – RXQ.440 FOR EACH MEDICATION THAT MEETS SPECIFICATION IN 07BOX NEW13A #1 OR #2.
RXQ.376 Have you used {PRODUCT NAME} every day or nearly every day for a month or longer?
YES 1
NO 2 (07BOX NEW14A)
REFUSED 7 (07BOX NEW14A)
DON’T KNOW 9 (07BOX NEW14A)
RXQ.378 During the past 3 months, how many months did you use this medication every day or nearly every day?
HAND CARD 4
1 month or less 1
More than 1 month but less than 2 months 2
More than 2 months but less than 3 months 3
3 months or more 4
REFUSED 7
DON’T KNOW 9
-
BOX 13B
CHECK ITEM RXQ.410:
CHECK RXQ.250. IF CONTAINER NOT SEEN (CODE 2), GO TO RXQ.425.
OTHERWISE, CONTINUE
RXQ.415 ENTER DRUG STRENGTH FROM LABEL NCHS??
REFUSED 77
DON’T KNOW 99
RXQ.420 INTERVIEWER: RECORD FORM FROM PRODUCT CONTAINER.
CAPSULES 1
TABLETS 2
CHEWABLE TABLETS 3
PILLS 4
CAPLETS 5
SOFT GELS 6
GEL CAPS 7
VEGICAPS 8
PACKAGE/PACKETS 9
LIQUID 10
POWDER 11
WAFERS 12
CHEWS 13
DOTS 14
GRANULES 15
LOZENGES 16
GEL 17
INHALER 18
NEBULIZER 19
INJECTION 20
DISCUS 21
REFUSED 77
DON’T KNOW 99
SKIP TO RXQ.430
|
RXQ.425 Please look at this card and tell me in what form is this product?
HAND CARD 5
-
CAPSULES 1
TABLETS 2
CHEWABLE TABLETS 3
PILLS 4
CAPLETS 5
SOFT GELS 6
GEL CAPS 7
VEGICAPS 8
PACKAGE/PACKETS 9
LIQUID 10
POWDER 11
WAFERS 12
CHEWS 13
DOTS 14
GRANULES 15
LOZENGES 16
GEL 17
INHALER 18
NEBULIZER 19
INJECTION 20
DISCUS 21
REFUSED 77
DON’T KNOW 99
RXQ.430 On the days that you took this medication, how many times did you usually take it in a single day?
CAPI INSTRUCTION:
|___|___|___|
NUMBER OF TIMES
REFUSED 77
DON’T KNOW 99
RXQ.435 How much did you take each time you took it?
Q/U/OS
|___|___|___|
ENTER NUMBER
|___|___|
ENTER UNIT
CAPSULES 1
TABLETS 2
CHEWABLE TABLETS 3
PILLS 4
CAPLETS 5
SOFT GELS 6
GEL CAPS 7
VEGICAPS 8
PACKAGE/PACKETS 9
WAFERS 10
CHEWS 11
DOTS 12
LOZENGES 13
DROPS 14
TEASPOONS 15
TABLESPOONS 16
MILLILITERS 17
SCOOPS 18
PUFFS 19
DOSES 20
VIALS 21
INJECTIONS 22
OTHER (SPECIFY) 23
REFUSED 77
DON’T KNOW 99
CAPI INSTRUCTION FOR UNIT – CHECK RXQ.420 OR RXQ.425 (FORM):
IF FORM CODE 1 THROUGH 9 OR 12, 13, 14, 15, OR 16 IN RXQ.420 OR RXQ.425, PREFILL AND DISPLAY THE SAME FORM FOR UNIT.
IF CODE 10 IN RXQ.420 OR RXQ.425, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
DROPS 14
TEASPOONS 15
TABLESPOONS 16
MILLILITERS 17
OTHER (SPECIFY) 22
IF CODE 11 IN RXQ.420 OR RXQ.425, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
TEASPOONS 15
TABLESPOONS 16
SCOOPS 18
OTHER (SPECIFY) 22
IF CODE 17, 20, OR 21 IN RXQ.420 OR RXQ.425, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
OTHER (SPECIFY) 22
IF CODE 18 IN RXQ.420 OR RXQ.425, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
PUFFS 19
DOSES 20
OTHER (SPECIFY) 22
IF CODE 19 IN RXQ.420 OR RXQ.425, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
VIALS 21
OTHER (SPECIFY) 22
IF DK/REF (CODE 77 OR CODE 99), DISPLAY ENTIRE PICK LIST.
RXQ.440 So you took {NUMBER/UNIT} each time you took it, correct?
CORRECT 1
INCORRECT 2 (RETURN TO
RXQ.435 Q/U/OS)
CAPI INSTRUCTION:
DISPLAY NUMBER AND UNIT FROM RXQ.435 Q/U/OS.
-
07BOX NEW14A
CHECK ITEM RXQ.445:
ASK RXQ.376 – RXQ.440 FOR NEXT MEDICATION (FROM BOX 13AA).
IF NO NEXT MEDICATION, CONTINUE.
RXQ.450 During the past 3 months, have you used/taken {any/any other similar} products for asthma or breathing difficulties every day or nearly every day. This card lists some examples.
HAND CARD 6
YES 1
NO 2 (BOX 18)
REFUSED 77 (BOX 18)
DON’T KNOW 99 (BOX 18)
CAPI INSTRUCTION:
DISPLAY “ANY” IF THERE HAS BEEN NO ASTHMA MEDICATION ENTERED (NO CLASS CODE 125, 131 OR 296 SELECTED FROM LOOKUP OR CODE 2 IN RXQ.291).
DISPLAY “ANY OTHER” IF CLASS CODE 125, 131 OR 296 ENTERED FROM LOOKUP OR CODE 1 IN RXQ.291.
RXQ.455 May I please see all the containers for these medications.
REFER TO PRODUCT LABEL OR ASK THE RESPONDENT FOR NAME(S) OF PRODUCTS.
-
BOX 14B
CHECK ITEM RXQ.380:
ASK RXQ.381 THROUGH – RXQ.392 FOR EACH MEDICATION.
RXQ.381 PRESS BS TO START THE LOOKUP.
SELECT MEDICATION
FROM LIST.
IF MEDICATION NOT
ON LIST – PRESS BS
TO DELETE ENTRY.
TYPE '**'.
PRESS ENTER TO SELECT
CAPI INSTRUCTION:
DISPLAY CAPI MEDICATION PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN RXQ.231 BY TYPING IN "**". THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.
INTERVIEWER SHOULD BE ABLE TO ACCEPT THE KEYED NAME AS A NEW PRODUCT NAME AN UNLIMITED NUMBER OF TIMES. AFTER ENTRY, INTERVIEWER SHOULD RETURN TO THE DATA BASE LIST. IF NO MORE ENTRIES, INTERVIEWERS SHOULD HAVE A WAY OF MOVING INTO LOOP 3.
ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:
DRUG TYPE {3}
GENERIC NAME {60}
THERAPEUTIC CLASS CODE {6}
GENERIC FLAG {1}
THERE IS NO NEED TO DISPLAY THIS INFORMATION.
-
BOX 15
CHECK ITEM RXQ.243:
IF PRODUCT IS SELECTED FROM THE LOOKUP AND THE PRODUCT HAS AN ‘OTC’ DESIGNATION, CONTINUE WITH RXQ.382.
OTHERWISE, GO TO RXQ.383.
RXQ.382 YOU HAVE SELECTED
{DISPLAY FULL PRODUCT VARIABLE NAME}.
YOU HAVE SELECTED THIS PRODUCT IN AN ‘OVER THE COUNTER’ FORM. IS THIS CORRECT?
YES 1
NO 2 DISPLAY HARD ERROR
CAPI INSTRUCTION:
DISPLAY SCREEN RXQ.381 – ENTRY FIELD SHOULD BE BLANK. INTERVIEWER SHOULD PRESS THE ‘BACKSPACE’ KEY TO START THE LOOKUP AGAIN AND SELECT ANOTHER PRODUCT.
RXQ.383 INTERVIEWER: ENTER 1 RESPONSE
CAPI INSTRUCTION:
DISPLAY PRODUCT NAME AS A LEFT HEADER.
CONTAINER SEEN 1
CONTAINER NOT SEEN 2
RXQ.384 For how long {have/has} {you/SP} been using or taking {PRODUCT NAME}?
Q/U
CAPI INSTRUCTION:
RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.
|___|___|___|___|
ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)
REFUSED 777
DON'T KNOW 999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
RXQ.385 What is the main reason for which (you use/SP uses) {PRODUCT NAME}?
ENTER TEXT
RXQ.386 Have you used {PRODUCT NAME} every day or nearly every day for a month or longer?
YES 1
NO 2 (07BOX NEW17)
REFUSED 7 (07BOX NEW17)
DON’T KNOW 9 (07BOX NEW17)
RXQ.387 During the past 3 months, how many months did you use this medication every day or nearly every day?
HAND CARD 7
1 month or less 1
More than 1 month but less than 2 months 2
More than 2 months but less than 3 months 3
3 months or more 4
REFUSED 7
DON’T KNOW 9
-
BOX 16
CHECK ITEM RXQ.410:
CHECK RXQ.383. IF CONTAINER NOT SEEN (CODE 2), GO TO RXQ.389.
OTHERWISE, CONTINUE
RXQ.388 INTERVIEWER: RECORD FORM FROM PRODUCT CONTAINER.
CAPSULES 1
TABLETS 2
CHEWABLE TABLETS 3
PILLS 4
CAPLETS 5
SOFT GELS 6
GEL CAPS 7
VEGICAPS 8
PACKAGE/PACKETS 9
LIQUID 10
POWDER 11
WAFERS 12
CHEWS 13
DOTS 14
GRANULES 15
LOZENGES 16
GEL 17
INHALER 18
NEBULIZER 19
INJECTION 20
DISCUS 21
REFUSED 77
DON’T KNOW 99
SKIP TO RXQ.390
|
RXQ.389 Please look at this card and tell me in what form is this product?
HAND CARD 8
CAPSULES 1
TABLETS 2
CHEWABLE TABLETS 3
PILLS 4
CAPLETS 5
SOFT GELS 6
GEL CAPS 7
VEGICAPS 8
PACKAGE/PACKETS 9
LIQUID 10
POWDER 11
WAFERS 12
CHEWS 13
DOTS 14
GRANULES 15
LOZENGES 16
GEL 17
INHALER 18
NEBULIZER 19
INJECTION 20
DISCUS 21
REFUSED 77
DON’T KNOW 99
RXQ.390 On the days that you took this medication, how many times did you usually take it in a single day?
CAPI INSTRUCTION:
|___|___|___|
NUMBER OF TIMES
REFUSED 77
DON’T KNOW 99
RXQ.391 How much did you take each time you took it?
Q/U/OS
|___|___|___|
ENTER NUMBER
|___|___|
ENTER UNIT
CAPSULES 1
TABLETS 2
CHEWABLE TABLETS 3
PILLS 4
CAPLETS 5
SOFT GELS 6
GEL CAPS 7
VEGICAPS 8
PACKAGE/PACKETS 9
WAFERS 10
CHEWS 11
DOTS 12
LOZENGES 13
DROPS 14
TEASPOONS 15
TABLESPOONS 16
MILLILITERS 17
SCOOPS 18
PUFFS 19
DOSES 20
VIALS 21
INJECTIONS 22
OTHER (SPECIFY) 23
REFUSED 77
DON’T KNOW 99
CAPI INSTRUCTION FOR UNIT – CHECK RXQ.388 OR RXQ.389 (FORM):
IF FORM CODE 1 THROUGH 9 OR 12, 13, 14, 15, OR 16 IN RXQ.388 OR RXQ.389, PREFILL AND DISPLAY THE SAME FORM FOR UNIT (FORM CODE 1 THROUGH 13 ON UNIT LIST).
IF CODE 10 IN RXQ.388 OR RXQ.389, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
DROPS 14
TEASPOONS 15
TABLESPOONS 16
MILLILITERS 17
OTHER (SPECIFY) 22
IF CODE 11 IN RXQ.388 OR RXQ.389, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
TEASPOONS 15
TABLESPOONS 16
SCOOPS 18
OTHER (SPECIFY) 22
IF CODE 17, 20, OR 21 IN RXQ.388 OR RXQ.389, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
OTHER (SPECIFY) 22
IF CODE 18 IN RXQ.388 OR RXQ.389, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
PUFFS 19
DOSES 20
OTHER (SPECIFY) 22
IF CODE 19 IN RXQ.388 OR RXQ.389, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
VILES 21
OTHER (SPECIFY) 22
IF DK/REF (CODE 77 OR CODE 99), DISPLAY ENTIRE PICK LIST.
RXQ.392 So you took {NUMBER/UNIT} each time you took it, correct?
CORRECT 1
INCORRECT 2 (RETURN TO
RXQ.435 Q/U/OS)
CAPI INSTRUCTION:
DISPLAY NUMBER AND UNIT FROM RXQ.435 Q/U/OS.
RXQ.393 CHECK CONTAINERS. ARE THERE ANY OTHER PRESCRIPTION MEDICATIONS?
OR ASK RESPONDENT:
[During the past 3 months, were there any other products that {you/SP} used for asthma or breathing problems every day or nearly every day?]
YES 1
NO 2
REFUSED 77
DON’T KNOW 99
-
BOX 17
CHECK ITEM RXQ.395:
ASK RXQ.381 – RXQ.393 FOR NEXT PRODUCT.
IF NO NEXT PRODUCT, CONTINUE WITH BOX 18.
-
BOX 18
CHECK ITEM DSQ.332:
IF PROXY INTERVIEW IN RPQ, CONTINUE.
IF NOT PROXY INTERVIEW IN RPQ, GO TO DSQ.335.
DSQ.334 INTERVIEWER OBSERVATION: WAS SP PRESENT FOR ALL OR PART OF INTERVIEW?
YES 1
NO 2
DSQ.335 PRESS F10 TO EXIT BLAISE.
DEMOGRAPHIC BACKGROUND/OCCUPATION – DMQ - fam
Target Group: Head of CPS Family (Non-SP)
Head of CPS Family Spouse (Non-SP)
-
BOX 1A
RULES FOR ADMINISTERING THE DEMOGRAPHIC AND OCCUPATION SECTION OF THE FAMILY QUESTIONNAIRE:
A CPS FAMILY INCLUDES INDIVIDUALS AND GROUPS OF INDIVIDUALS WHO ARE 16+ AND RELATED BY BIRTH, MARRIAGE OR ADOPTION. STEP CHILDREN, PARENTS OR SIBLINGS ARE INCLUDED. IT ALSO INCLUDES UNMARRIED PARTNERS IF THEY HAVE A BIOLOGICAL OR ADOPTIVE CHILD IN COMMON. IT DOES NOT INCLUDE UNMARRIED PARTNERS WHO DO NOT HAVE A CHILD IN COMMON, FOSTER PARENTS OR FOSTER CHILDREN. NOTE: A CPS FAMILY CAN BE ONE INDIVIDUAL.
-
BOX 1
LOOP 1:
ASK DMQ.106 – DMQ.141 AS APPROPRIATE FOR NON-SP HEAD OF CPS FAMILY AND NON-SP SPOUSE (RELATIONSHIP OF "MARRIED" IN THE SCREENER) OF HEAD OF CPS FAMILY.
FIRST ASK DMQ.106, 130, AND 141 FOR NON-SP HEAD OF CPS FAMILY.
NEXT, ASK DMQ.141 FOR NON-SP SPOUSE OF HEAD OF CPS FAMILY.
EACH TARGET PERSON SHOULD BE ASKED THIS SECTION ONCE.
IF NO NON-SP HEAD OF CPS FAMILY AND NON-SP SPOUSE, GO TO
END OF SECTION.
DMQ.107 In what country {were you/was NON-SP Head} born?
UNITED STATES 1 (DMQ.130)
OTHER COUNTRY 2
REFUSED 7
DON'T KNOW 9
DMQ.112 SELECT COUNTRY OF BIRTH
ARGENTINA 1 (DMQ.141)
BELIZE 2 (DMQ.141)
BOLIVIA 3 (DMQ.141)
BRAZIL 4 (DMQ.141)
CHILE 5 (DMQ.141)
COLOMBIA 6 (DMQ.141)
COSTA RICA 7 (DMQ.141)
CUBA 8 (DMQ.141)
DOMINICAN REPUBLIC 9 (DMQ.141)
ECUADOR 10 (DMQ.141)
EL SALVADOR 11 (DMQ.141)
GUATEMALA 12 (DMQ.141)
HONDURAS 13 (DMQ.141)
MEXICO 14 (DMQ.141)
NICARAGUA 15 (DMQ.141)
PANAMA 16 (DMQ.141)
PARAGUAY 17 (DMQ.141)
PERU 18 (DMQ.141)
PHILIPPINES 19 (DMQ.141)
PUERTO RICO 20 (DMQ.141)
SPAIN 21 (DMQ.141)
URUGUAY 22 (DMQ.141)
VENEZUELA 23 (DMQ.141)
OTHER COUNTRY (CAPI INSTRUCTION:
DO NOT SPECIFY) 40 (DMQ.141)
-
BOX 2
CHECK ITEM DMQ.120:
IF ANY CODE OTHER THAN 'UNITED STATES', SKIP TO DMQ.141.
DMQ.130 In what state {were you/was NON-SP HEAD} born?
ENTER 2 LETTER STATE ABBREVIATION TO START THE LOOKUP.
SELECT STATE FROM CAPI STATE LIST.
PRESS ENTER TO ACCEPT SELECTION.
CAPI INSTRUCTION:
DISPLAY FIPS STATE LIST. INTERVIEWER SHOULD ONLY BE ABLE TO SELECT 1 STATE FROM THE LIST. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. THE STATE LOOKUP IN THE SP AND FAMILY QUESTIONNAIRES SHOULD WORK EXACTLY THE SAME.
DMQ.141 What is the highest grade or level of school {you have/NON-SP HEAD/NON-SP SPOUSE has} completed or the highest degree {you have/he/she has} received?
HAND CARD DMQ1
READ HAND CARD CATEGORIES IF NECESSARY
Enter highest level of school.
NEVER ATTENDED/KINDERGARTEN
ONLY 0
1ST GRADE 1
2ND GRADE 2
3RD GRADE 3
4TH GRADE 4
5TH GRADE 5
6TH GRADE 6
7TH GRADE 7
8TH GRADE 8
9TH GRADE 9
10TH GRADE 10
11TH GRADE 11
12TH GRADE, NO DIPLOMA 12
HIGH SCHOOL GRADUATE 13
GED OR EQUIVALENT 14
SOME COLLEGE, NO DEGREE 15
ASSOCIATE DEGREE: OCCUPATIONAL,
TECHNICAL, OR VOCATIONAL
PROGRAM 16
ASSOCIATE DEGREE: ACADEMIC
PROGRAM 17
BACHELOR’S DEGREE (EXAMPLE: BA,
AB, BS, BBA) 18
MASTER’S DEGREE (EXAMPLE: MA,
MS, MEng, MEd, MBA) 19
PROFESSIONAL SCHOOL DEGREE
(EXAMPLE: MD, DDS, DVM, JD) 20
DOCTORAL DEGREE (EXAMPLE:
PhD, EdD) 21
REFUSED 77
DON’T KNOW 99
-
BOX 3
END LOOP 1:
ASK DMQ.106-141 FOR NEXT TARGET PERSON (NON-SP HEAD)
ASK DMQ.141 FOR NEXT TARGET PERSON (NON-SP SPOUSE –
RELATIONSHIP OF "MARRIED" IN THE SCREENER).
IF NO NEXT PERSON, GO TO BOX 4.
-
BOX 4
LOOP 2:
ASK OCQ.150 - OCQ.380 FOR NON-SP HEAD IF AGE >= 16 AND NON-SP SPOUSE (RELATIONSHIP OF 'MARRIED' IN THE SCREENER) OF HEAD IF NON-SP SPOUSE AGE >= 16.
OCQ.150 The next questions are about {your/NON-SP HEAD'S/NON-SP SPOUSE'S} current job or business. Which of the following {were you/was} {NON-SP HEAD/NON-SP SPOUSE} doing last week . . .
working at a job or business, 1 (OCQ.261)
with a job or business but not at work, 2
looking for work, or 3
not working at a job or business? 4 (OCQ.380)
REFUSED 7
DON'T KNOW 9
OCQ.160 Did {you/NON-SP HEAD/NON-SP SPOUSE} do any work at a job or business at all last week (include unpaid work in a family farm or business)?
YES 1
NO 2
REFUSED 7 (OCQ.380)
DON'T KNOW 9 (OCQ.380)
-
BOX 5
CHECK ITEM DMQ.170:
IF OCQ.150 IS CODED '2', CONTINUE.
OTHERWISE, GO TO BOX 7.
OCQ.261 Looking at the card, which of these best describes this job or work situation?
ASK IF NOT CLEAR
HAND CARD DMQ2
AN EMPLOYEE OF A PRIVATE COMPANY,
BUSINESS, OR INDIVIDUAL FOR WAGES,
SALARY, OR COMMISSION 1
A FEDERAL GOVERNMENT EMPLOYEE 2
A STATE GOVERNMENT EMPLOYEE 3
A LOCAL GOVERNMENT EMPLOYEE 4
SELF-EMPLOYED IN OWN BUSINESS,
PROFESSIONAL PRACTICE OR FARM 5
WORKING WITHOUT PAY IN FAMILY
BUSINESS OR FARM 6
REFUSED 7
DON'T KNOW 9
-
BOX 6
CHECK ITEM DMQ.270:
GO TO BOX 7.
OCQ.380 What is the main reason {you/NON-SP HEAD/NON-SP SPOUSE} did not work last week?
TAKING CARE OF HOUSE OR FAMILY 1
GOING TO SCHOOL 2
RETIRED 3
UNABLE TO WORK FOR HEALTH
REASONS 4
ON LAYOFF 5
DISABLED 6
OTHER 7
REFUSED 77
DON'T KNOW 99
-
BOX 7
END LOOP 2:
ASK OCQ.150 - OCQ.380 FOR NEXT TARGET PERSON (NON-SP HEAD OR NON-SP SPOUSE - RELATIONSHIP OF "MARRIED" IN THE SCREENER).
IF NO NEXT PERSON, GO TO END OF SECTION.
Target Group: SPs Family
HOQ.040 I'd like to ask you a few questions about your home.
When was this home originally built?
READ CATEGORIES IF NECESSARY.
1990 TO PRESENT, 1
1978 TO 1989, 2
1960 TO 1977, 3
1950 TO 1959, 4
1940 TO 1949, OR 5
BEFORE 1940? 6
REFUSED 77
DON'T KNOW 99
HOQ.050 How many rooms are in this home? Count the kitchen but not the bathroom.
|___|___|
ENTER NUMBER OF ROOMS
REFUSED 777777
DON'T KNOW 999999
HOQ.060 How long {have you/has your family} lived at this address?
G/Q/U
|___|___|___|
ENTER NUMBER (OF MONTHS OR YEARS)
LESS THAN ONE MONTH 666 (HOQ.065)
REFUSED 777777 (HOQ.065)
DON'T KNOW 999999 (HOQ.065)
ENTER UNIT
MONTHS 1
YEARS 2
HOQ.065 Is this home owned, being bought, rented, or occupied by some other arrangement by {you/you or someone else in your family}?
OWNED OR BEING BOUGHT 1
RENTED 2
OTHER ARRANGEMENT 3
REFUSED 7
DON'T KNOW 9
HOQ.070 What is the source of tap water in this home? Is it a private or public water company, a private or public well, or something else?
PRIVATE/PUBLIC WATER COMPANY 1
PRIVATE/PUBLIC WELL 2
SOMETHING ELSE 3
REFUSED 7
DON'T KNOW 9
HOQ.080 Are any of the water treatment devices listed on this card used in your home?
HAND CARD HOQ1
YES 1
NO 2 (HOQ.230)
REFUSED 7 (HOQ.230)
DON'T KNOW 9 (HOQ.230)
HOQ.083 Which of these water treatment devices are now used in your home?
HAND CARD HOQ1
CODE ALL THAT APPLY
BRITA OR OTHER PITCHER
WATER FILTER 1
CERAMIC OR CHARCOAL FILTER 2
WATER SOFTENER 3
AERATOR 4
REVERSE OSMOSIS 5
REFUSED 7
DON'T KNOW 9
SMQ.410 I would now like to ask you a few questions about smoking.
Does anyone who lives here smoke cigarettes, cigars, or pipes anywhere inside this home?
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
SMQ.420 Who smokes?
PROBE: Anyone else?
CAPI INSTRUCTION:
DISPLAY HOUSEHOLD ROSTER
SELECT NAMES FROM HOUSEHOLD ROSTER
SELECT 1
REFUSED 7
DON'T KNOW 9
-
BOX 1
LOOP 1:
ASK SMQ.430 FOR EACH PERSON SELECTED FROM HOUSEHOLD ROSTER AS SMOKING INSIDE THE HOME.
SMQ.430 How many cigarettes per day {do you/does PERSON} usually smoke anywhere inside the home?
1 PACK EQUALS 20 CIGARETTES
IF NONE, ENTER 0
IF LESS THAN 1 PER DAY, ENTER 1
|___|___|___|
ENTER NUMBER OF CIGARETTES
REFUSED 777777
DON'T KNOW 999999
-
BOX 2
END LOOP 1:
ASK SMQ.430 FOR EACH PERSON SELECTED FROM HOUSEHOLD ROSTER AS SMOKING INSIDE THE HOME.
IF NO NEXT PERSON, GO TO END OF SECTION.
Target Group: Family Questionnaire
CBQ.010 {Is anyone in this family/Are you} on any kind of diet, either to lose weight or for some other health-related reason?
HELP SCREEN:
Examples of special diets include diet for weight loss, low carbohydrate, high protein, Atkins, to lower cholesterol, gluten-free, low sodium, diabetic diet, etc.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
CBQ.020 The next questions ask how often {your family has/you have} certain types of food available at home.
How often {does your family/do you} have fruits available at home? This includes fresh, dried, canned and frozen fruits. Would you say always, most of the time, sometimes, rarely, or never?
HAND CARD CBQ1
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
REFUSED 7
DON'T KNOW 9
CBQ.030 How often {does your family/do you} have any of these dark green vegetables available at home? This includes fresh, dried, canned, and frozen vegetables. [Would you say always, most of the time, sometimes, rarely, or never?]
HAND CARD CBQ2 and HAND CARD CBQ3.
INTERVIEWER INSTRUCTION: DO NOT INCLUDE ICEBERG, BUTTERHEAD, BOSTON, AND MANOA LETTUCE
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
REFUSED 7
DON'T KNOW 9
CBQ.040 How often {does your family/do you} have salty snacks such as chips and crackers available at home? Do not include nuts. [Would you say always, most of the time, sometimes, rarely, or never?]
HAND CARD CBQ3
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
REFUSED 7
DON'T KNOW 9
CBQ.050 How often {does your family/do you} have 1% fat, skim or fat-free milk available at home? Please do not include 2% milk. [Would you say always, most of the time, sometimes, rarely, or never?]
HAND CARD CBQ3
INTERVIEWER INSTRUCTION: DO NOT INCLUDE SOY MILK
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
REFUSED 7
DON'T KNOW 9
CBQ.060 How often {does your family/do you} have soft drinks, fruit-flavored drinks, or fruit punch available at home? Please do not include diet drinks or 100 percent juice. [Would you say always, most of the time, sometimes, rarely, or never?]
HAND CARD CBQ3
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
REFUSED 7
DON'T KNOW 9
CBQ.070 |
The next questions are about how much money {your family spends/you spend} on food. First I’ll ask you about money spent at supermarkets or grocery stores. Then we will talk about money spent at other types of stores. |
During the past 30 days, how much money {did your family/did you} spend at supermarkets or grocery stores? Please include purchases made with food stamps. (You can tell me per week or per month.)
$ |___|___|___|___|___|___|___|___|___|
REFUSED 7 (CBQ.100)
DON'T KNOW 9 (CBQ.100)
ENTER UNIT
WEEK 1
MONTH 2
REFUSED 7
DON'T KNOW 9
CBQ.080 Was any of this money spent on nonfood items such as cleaning or paper products, pet food, cigarettes or alcoholic beverages?
YES 1
NO 2 (CBQ.100)
REFUSED 7 (CBQ.100)
DON'T KNOW 9 (CBQ.100)
CBQ.090 |
About how much money was spent on nonfood items? (You can tell me per week or per month.) |
$ |___|___|___|___|___|___|___|___|___|
REFUSED 7
DON'T KNOW 9
ENTER UNIT
WEEK 1
MONTH 2
REFUSED 7
DON'T KNOW 9
CBQ.100 During the past 30 days, {did your family/did you} spend money on food at stores other than grocery stores? Here are some examples of stores where you might buy food. Please do not include stores that you have already told me about.
HAND CARD CBQ4
YES 1
NO 2 (CBQ.120)
DON'T KNOW 9 (CBQ.120)
CBQ.110 |
About how much money {did your family/did you} spend on food at these types of stores? (Please do not include any stores you have already told me about.) (You can tell me per week or per month.) |
HAND CARD CBQ4
$ |___|___|___|___|___|___|___|___|___|
REFUSED 7
DON'T KNOW 9
ENTER UNIT
WEEK 1
MONTH 2
REFUSED 7
DON'T KNOW 9
CBQ.120 |
During the past 30 days, how much money {did your family/did you} spend on eating out? Please include money spent in cafeterias at work or at school or on vending machines, for all family members. (You can tell me per week or per month.) |
INTERVIEWER INSTRUCTION: IF RESPONDENT KNOWS ONLY AMOUNT FOR SELF, CODE DK.
$ |___|___|___|___|___|___|___|___|___|
REFUSED 7
DON'T KNOW 9
ENTER UNIT
WEEK 1
MONTH 2
REFUSED 7
DON'T KNOW 9
CBQ.130 |
During the past 30 days, how much money {did your family/did you} spend on food carried out or delivered? Please do not include money you have already told me about. (You can tell me per week or per month.) |
INTERVIEWER INSTRUCTION: IF RESPONDENT KNOWS ONLY AMOUNT FOR SELF, CODE DK.
$ |___|___|___|___|___|___|___|___|___|
REFUSED 7
DON'T KNOW 9
ENTER UNIT
WEEK 1
MONTH 2
REFUSED 7
DON'T KNOW 9
CBQ.140 How often {do you/does someone} do the major food shopping for {yourself/your family}? Please do not include times when {you buy/someone buys} only a few items.
Would you say…
CAPI INSTRUCTIONS:
IF FAMILY IS COMPRISED OF ONLY ONE ADULT SP, SELECT FIRST PREFILLS FOR THE THREE ALTERNATIVE PHRASINGS.
more than once a week, 1
once a week, 2
once every two weeks, or 3
once a month or less? 4
RARELY MAKE ANY MAJOR SHOPPING
TRIPS, ONLY SMALL TRIPS 5
RARELY SHOP FOR FOOD 6
REFUSED 7
DON'T KNOW 9
CBQ.150 How much time does it usually take you to get to the grocery store for food shopping?
H/M
INTERVIEWER INSTRUCTION: IF MORE THAN ONE STORE SAY: Please tell me about the one you go to most often.
INTERVIEWER INSTRUCTION: THE AMOUNT OF TIME RECORDED HERE REFERS TO A “ONE-WAY” TRIP.
|___|___|
HOURS
and
|___|___|
MINUTES
REFUSED 777
DON'T KNOW 999
CBQ.160 During the past 7 days, how many times did {you or someone else in your family/you} cook food for dinner or supper at home?
HELP SCREEN:
This includes time spent putting the ingredients together to cook a meal. Do not include heating up leftovers.
CAPI INSTRUCTIONS:
SOFT EDIT: 1-7.
|___|___|
ENTER NUMBER
NEVER 0
REFUSED 77
DON'T KNOW 99
CBQ.170 How much time do {you or someone else in your family/do you} usually spend on cooking dinner or supper and cleaning up after the cooking? Please do not include time spent eating.
|___|
HOURS
and
|___|___|
MINUTES
REFUSED 777
DON'T KNOW 999
-
BOX 1
CHECK ITEM CBQ.175:
IF ONLY 1 PERSON IN FAMILY, GO TO END OF SECTION.
CBQ.180 During the past 7 days, how many meals did all or most of your family sit down and eat together at home?
|___|___|
ENTER NUMBER
NEVER 0 (END OF SECTION)
REFUSED 777 (END OF SECTION)
DON'T KNOW 999 (END OF SECTION)
CBQ.190 How many of these meals were cooked at home?
|___|___|
ENTER NUMBER
REFUSED 777
DON'T KNOW 999
Target Group: SP, Family, Household
RULES FOR ADMINISTRATION
FOR THE PURPOSE OF ADMINISTERING THE INCOME SECTION:
A FAMILY INCLUDES INDIVIDUALS AND GROUPS OF INDIVIDUALS WHO ARE RELATED BY BIRTH, MARRIAGE OR ADOPTION. STEP CHILDREN, PARENTS OR SIBLINGS ARE INCLUDED. IT ALSO INCLUDES UNMARRIED PARTNERS IF THEY HAVE A BIOLOGICAL OR ADOPTIVE CHILD IN COMMON. IT DOES NOT INCLUDE UNMARRIED PARTNERS WHO DO NOT HAVE A CHILD IN COMMON, FOSTER PARENTS OR FOSTER CHILDREN. NOTE: INDIVIDUALS LIVING ALONE OR WITH OTHER UNRELATED INDIVIDUALS ARE REFERRED TO AS “UNRELATED INDIVIDUALS”
ONE INCOME SECTION IS ADMINISTERED FOR EACH FAMILY AND FOR EACH UNRELATED INDIVIDUAL.
TOTAL HOUSEHOLD INCOME QUESTIONS ARE ASKED FOR EVERY FAMILY QUESTIONNAIRE COMPLETED WITHIN A HOUSEHOLD (SEE UNNUMBERED BOX)
INQ.020 The next questions are about {your/your combined family} income. When answering these questions, please remember that by {"income/combined family income"}, I mean {your income/your income plus the income of {NAMES OF OTHER NHANES FAMILY MEMBERS} for {LAST CALENDAR YEAR}. Did {you/you or OTHER FAMILY MEMBERS 16+} receive income in {LAST CALENDAR YEAR} from wages and salaries?
[Did {you/you or OTHER FAMILY MEMBERS 16+} get paid for work in {LAST CALENDAR YEAR}.]
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
INQ.012 Did {you/you or any family members 16 and older} receive income in {LAST CALENDAR YEAR} from self-employment including business and farm income?
[Self-employment means you worked for yourself.]
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 1B
OMITTED
-
BOX 1C
OMITTED
INQ.030 When answering the next questions about different kinds of income members of your family might have received in {LAST CALENDAR YEAR}, please consider that we also want to know about family members less than 16 years old. Did {you/you or any family members living here, that is: you or NAME(S) OF OTHER FAMILY MEMBERS} receive income in {LAST CALENDAR YEAR} from Social Security or Railroad Retirement?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 1D
OMITTED
-
BOX 1E
OMITTED
INQ.060 Did {you/you or any family members living here} receive any disability pension [other than Social Security or Railroad Retirement] in {LAST CALENDAR YEAR}?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 2A
OMITTED
INQ.080 Did {you/you or any family members living here} receive retirement or survivor pension [other than Social Security or Railroad Retirement or disability pension] in {LAST CALENDAR YEAR}?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 2B
OMITTED
INQ.090 Did {you/you or any family members living here} receive Supplemental Security Income [SSI] in {LAST CALENDAR YEAR}?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 2C
OMITTED
-
BOX 3A
OMITTED
INQ.132 Did {you/you or any family members living here} receive any cash assistance from a state or county welfare program such as {DISPLAY SPECIFIC STATE PROGRAMS} in {LAST CALENDAR YEAR}?
CAPI INSTRUCTION:
DISPLAY FULL NAMES OF ALL STATE PROGRAMS FOR STATE IN WHICH INTERVIEW IS BEING CONDUCTED. NAMES FOR EACH STATE WILL BE SENT TO PROGRAMMING IN A SEPARATE FILE.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 3AA
OMITTED
-
BOX 3B
OMITTED
INQ.140 Did {you/you or any family members living here} receive interest from savings or other bank accounts or income from dividends received from stocks or mutual funds or net rental income from property, royalties, estates, or trusts in {LAST CALENDAR YEAR}?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 3C
OMITTED
INQ.150 Did {you/you or any family members living here} receive income in {LAST CALENDAR YEAR} from child support, alimony, contributions from family or others, VA payments, worker's compensation, or unemployment compensation?
INTERVIEWER INSTRUCTION: CONTRIBUTIONS INCLUDE GIFTS.
INTERVIEWER INSTRUCTION: IF RESPONDENT IS A COLLEGE STUDENT LIVING AWAY FROM THEIR FAMILY PLEASE ADD “INCLUDING MONEY RECEIVED FROM FAMILY FOR COLLEGE TUITION, BOOKS AND LIVING EXPENSES”
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 3D
OMITTED
-
BOX 4A
OMITTED
-
BOX 4C
OMITTED
-
BOX 4B
OMITTED
-
BOX 5
OMITTED
-
BOX 7
ASK INQ.200 – 230 FOR EACH FAMILY IN THE HOUSEHOLD.
-
FOR THE PURPOSE OF ADMINISTERING THE QUESTIONS ABOUT TOTAL INCOME:
A FAMILY INCLUDES INDIVIDUALS AND GROUPS OF INDIVIDUALS WHO ARE RELATED BY BIRTH, MARRIAGE OR ADOPTION. STEP CHILDREN, PARENTS OR SIBLINGS ARE INCLUDED. IT ALSO INCLUDES UNMARRIED PARTNERS IF THEY HAVE A BIOLOGICAL OR ADOPTIVE CHILD IN COMMON. IT DOES NOT INCLUDE UNMARRIED PARTNERS WHO DO NOT HAVE A CHILD IN COMMON, FOSTER PARENTS OR FOSTER CHILDREN. NOTE: INDIVIDUALS LIVING ALONG OR WITH OTHER UNRELATED INDIVIDUALS ARE REFERRED TO AS “UNRELATED INDIVIDUALS”.
TOTAL INCOME IS ADMINISTERED FOR THE FAMILY AND FOR THE ENTIRE HOUSEHOLD.
INQ.200 Now I am going to ask about the total income for {you/NAME(S) OF FAMILY MEMBERS} in {LAST CALENDAR YEAR}, including income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Can you tell me that amount before taxes?
CAPI INSTRUCTIONS:
DISPLAY "YOU" IF ONLY 1 PERSON IN THE FAMILY.
DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.
$ |___|___|___|___|___|___|___|___|___| (GO TO BOX 8A)
REFUSED 7777777777 (INQ.220)
DON'T KNOW 9999999999 (INQ.220)
CAPI INSTRUCTION:
REQUIRE DOUBLE ENTRY OF INCOME.
SCREEN SHOULD READ:
“INCOME FOR {NAMES OF FAMILY MEMBERS} HAS BEEN RECORDED AS {INCOME ENTERED IN INQ.200} DOUBLE ENTRY OF INCOME REQUIRED.”
IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.
-
BOX 5A
OMITTED
INQ.220 You may not be able to give us an exact figure for {your/NAME(S) OF FAMILY MEMBERS} income, but can you tell me if this income in {LAST CALENDAR YEAR} was . . .
PROBE: Income is important in using the health information we collect. For example, it helps us to learn whether persons in one income group use certain types of medical services or have certain health conditions more or less often than those in another income group.
CAPI INSTRUCTIONS:
DISPLAY "YOUR" IF ONLY 1 PERSON IN THE FAMILY.
DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.
$20,000 or more, or 1
less than $20,000? 2
REFUSED 7 (BOX 8)
DON'T KNOW 9 (BOX 8)
INQ.230 |
Of these income groups, can you tell me which letter best represents {your/NAME(S) OF FIRST/NEXT FAMILY MEMBERS} income in {LAST CALENDAR YEAR}? |
HAND CARD {INQ1 AND INQ2}
ENTER LETTER(S) CORRESPONDING TO TOTAL COMBINED FAMILY INCOME.
CAPI INSTRUCTIONS:
DISPLAY "YOUR" IF ONLY 1 PERSON IN THE FAMILY.
DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.
IF $20,000 OR MORE, DISPLAY HAND CARD INQ1.
IF LESS THAN $20,000, DISPLAY HAND CARD INQ2.
|___|___|
-
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
AA
BB
CC
DD
EE
FF
GG
HH
II
JJ
KK
LL
MM
NN
OO
PP
QQ
RR
SS
TT
UU
VV
WW
REFUSED 77
DON'T KNOW 99
-
BOX 6
OMITTED
INQ.235 What is the total income received last month, {LAST CALENDAR MONTH & CURRENT CALENDAR YEAR} by {you/all members of your family}} before taxes?
[Please include income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth.]
[INTERVIEWER INSTRUCTION: IF SP DOES NOT KNOW INCOME OF OTHER FAMILY MEMBERS, ENTER DON’T KNOW.]
CAPI INSTRUCTION:
REQUIRE DOUBLE ENTRY OF INCOME.
SCREEN SHOULD READ:
“LAST MONTH’S INCOME FOR {NAMES OF FAMILY MEMBERS} HAS BEEN RECORDED AS {INCOME ENTERED IN INQ.200} DOUBLE ENTRY OF INCOME REQUIRED.”
IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.
FOR THE CALENDAR FILL: IF CURRENT MONTH IS JANUARY THE PAST CALENDAR YEAR WILL BE SHOWN
$ |___|___|___|___|___|___|___|___|___| (INQ.244)
REFUSED 7
DON'T KNOW 9
INQ.238 You may not be able to give us an exact figure, but can you tell me if {your/your family} income in {LAST CALENDAR MONTH & CURRENT CALENDAR YEAR} was . . .
{185% or less of monthly poverty
level}, or 1 (INQ.244)
more than {185% monthly poverty level}? 2
REFUSED 7
DON'T KNOW 9
PROBE: (That would be {12 times 185% monthly poverty level}} per year.)
CAPI INSTRUCTION:
Fill 185% of the monthly poverty level based on family size:
For family size of 1, fill ($1511 round to nearest 100s = $1,500)
For each additional family member, fill {[$1511+(524* # of additional person)] round to nearest 100s}
Fill 185% of the annual poverty level based on family size in the PROBE:
For family size of 1, fill [($1511*12) round to nearest 100s] = $18,100)
For each additional member, fill {[$1511+(524* # of additional person)]*12 round to nearest 100s}
Persons in Family |
185% monthly poverty level |
185% annual poverty level |
||
Raw Number1 |
Rounded to nearest 100s2 |
Raw Number3 |
Rounded to nearest 100s4 |
|
1 |
1511 |
1500 |
18132 |
18100 |
2 |
2035 |
2000 |
24420 |
24400 |
3 |
2559 |
2600 |
30708 |
30700 |
4 |
3083 |
3100 |
36996 |
37000 |
5 |
3607 |
3600 |
43284 |
43300 |
6 |
4131 |
4100 |
49572 |
49600 |
7 |
4655 |
4700 |
55860 |
55900 |
8 |
5179 |
5200 |
62148 |
62100 |
1: $1,511 for family size of 1, thereafter, adding $524 for each additional person.
2: These are the numbers to be used in the response category fills.
3: Multiply by 12 to the raw number of the 185% monthly poverty level.
4: These are the numbers to be used in the probe fills
INQ.241 Was it more or less than {130% monthly poverty level}?
130% or less than monthly poverty level 1
More than 130% of monthly poverty level 2
REFUSED 7
DON'T KNOW 9
PROBE: {That would be 12 times 130% annual poverty level per year.}
CAPI INSTRUCTION:
Fill 130% of the monthly poverty level based on family size:
For family size of 1, fill ($1062 round to nearest 100s = $1,100)
For each additional family member, fill {[$1062+(368* # of additional person)] round to nearest 100s}
Fill 130% of the annual poverty level based on family size in the PROBE:
For family size of 1, fill [($1062*12) round to nearest 100s] = $12,700)
For each additional member, fill {[$1062+(368* # of additional person)]*12 round to nearest 100s}
Persons in Family |
130% monthly poverty level |
130% annual poverty level |
||
Raw Number1 |
Rounded to nearest 100s2 |
Raw Number3 |
Rounded to nearest 100s4 |
|
1 |
1062 |
1100 |
12744 |
12700 |
2 |
1430 |
1400 |
17160 |
17200 |
3 |
1798 |
1800 |
21576 |
21600 |
4 |
2166 |
2200 |
25992 |
26000 |
5 |
2534 |
2500 |
30408 |
30400 |
6 |
2902 |
2900 |
34824 |
34800 |
7 |
3270 |
3300 |
39240 |
39200 |
8 |
3638 |
3600 |
43656 |
43700 |
1: $1,062 for family size of 1, thereafter, adding $368 for each additional person.
2: These are the numbers to be used in the text of question and response category fills.
3: Multiply 12 to the raw number of the 130% monthly poverty level.
4: These are the numbers to be used in the probe fills
-
BOX NEW 7A
CHECK ITEM INQ.242:
IF FAMILY ANNUAL INCOME (INQ200) EQUAL OR LESS THAN {200% POVERTY LEVEL}, CONTINUE;
OTHERWISE, GO TO BOX 8.
CALCULATE 200% OF THE ANNUAL POVERTY LEVEL BASED ON FAMILY SIZE: $19,600 FOR FAMILY SIZE OF 1, THEREAFTER, ADDING $6,800 FOR EACH ADDITIONAL PERSON
INQ.244 Do {you/the members of your family} have more than $5,000 in savings at this time? Please include money in your checking accounts.
INTERVIEWER INSTRUCTION: INCLUDE CASH, SAVINGS OR CHECKING ACCOUNTS, STOCKS, BONDS, MUTUAL FUNDS, RETIREMENT FUNDS (SUCH AS PENSIONS, IRAS, 401KS, ETC), AND CERTIFICATES OF DEPOSIT.
CAPI INSTRUCTION:
DISPLAY “you” for single-person family; DISPLAY “the members of your family” for multi-persons family.
YES 1 (END OF SECTION)
NO 2
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
INQ.247 Which letter on this card best represents {your/your family’s} total savings or cash assets at this time?
HAND CARD 3
|___| ENTER LETTER
REFUSED 7
DON'T KNOW 9
A: Less than $500
B: $501- $1000
C: $1001-$2000
D: $2001-$3000
E: $3001-$4000
F: $4001-$5000
-
BOX 8
END LOOP 2:
ASK INQ.200 – INQ.230 FOR NEXT FAMILY.
IF NO NEXT FAMILY, CONTINUE.
-
BOX 9
CHECK ITEM INQ.240:
IF THERE IS MORE THAN ONE FAMILY IN THE HOUSEHOLD, CONTINUE.
OTHERWISE, GO TO END OF SECTION.
INQ.250 Now I am going to ask you about the total household income for the persons we have talked about plus NAMES OF ALL OTHER PERSONS IN ADDITIONAL FAMILIES (MEMBERS OF FAMILIES WHO ARE NOT INCLUDED IN THIS QUESTIONNAIRE) in {LAST CALENDAR YEAR}, including income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Can you tell me that amount before taxes?
$ |___|___|___|___|___|___|___|___|___| (GO TO END OF SECTION)
REFUSED 7777777777 (INQ.260)
DON'T KNOW 9999999999 (INQ.260)
CAPI INSTRUCTION:
REQUIRE DOUBLE ENTRY OF INCOME.
SCREEN SHOULD READ:
“INCOME FOR YOUR HOUSEHOLD HAS BEEN RECORDED AS {INCOME ENTERED IN INQ.250} DOUBLE ENTRY OF INCOME REQUIRED.”
IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.
INQ.260 You may not be able to give us an exact figure for your total household income, but can you tell me if this income in {LAST CALENDAR YEAR} was . . .
PROBE: Income is important in analyzing the health information we collect. For example, this information helps us to learn whether persons in one income group use certain types of medical services or have certain conditions more or less often than those in another group.
$20,000 or more, or 1
less than $20,000? 2
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
INQ.270 |
Of these income groups, can you tell me which letter best represents your total household income in {LAST CALENDAR YEAR}? |
HAND CARD {INQ1 AND INQ2}
ENTER LETTER(S) CORRESPONDING TO TOTAL COMBINED HOUSEHOLD INCOME.
|___|___|
-
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
AA
BB
CC
DD
EE
FF
GG
HH
II
JJ
KK
LL
MM
NN
OO
PP
QQ
RR
SS
TT
UU
VV
WW
REFUSED 77
DON'T KNOW 99
CAPI INSTRUCTION:
IF $20,000 OR MORE, DISPLAY HAND CARD INQ1.
IF LESS THAN $20,000, DISPLAY HAND CARD INQ2.
END OF SECTION
INQ1
U. $20,000 - $20,999
V. $21,000 - $21,999
W. $22,000 - $22,999
X. $23,000 - $23,999
Y. $24,000 - $24,999
Z. $25,000 - $25,999
AA. $26,000 - $26,999
BB. $27,000 - $27,999
CC. $28,000 - $28,999
DD. $29,000 - $29,999
EE. $30,000 - $30,999
FF. $31,000 - $31,999
GG. $32,000 - $32,999
HH. $33,000 - $33,999
II. $34,000 - $34,999
JJ. $35,000 - $39,999
KK. $40,000 - $44,999
LL. $45,000 - $49,999
MM. $50,000 - $54,999
NN. $55,000 - $59,999
OO. $60,000 - $64,999
PP. $65,000 - $69,999
QQ. $70,000 - $74,999
RR. $75,000 - $79,999
SS. $80,000 - $84,999
TT. $85,000 - $89,999
UU. $90,000 - $94,999
VV. $95,000 - $99,999
WW. $100,000 and over
INQ2
A. Less than $1,000
B. $1,000 - $1,999
C. $2,000 - $2,999
D. $3,000 - $3,999
E. $4,000 - $4,999
F. $5,000 - $5,999
G. $6,000 - $6,999
H. $7,000 - $7,999
I. $8,000 - $8,999
J. $9,000 - $9,999
K. $10,000 - $10,999
L. $11,000 - $11,999
M. $12,000 - $12,999
N. $13,000 - $13,999
O. $14,000 - $14,999
P. $15,000 - $15,999
Q. $16,000 - $16,999
R. $17,000 - $17,999
S. $18,000 - $18,999
T. $19,000 - $19,999
INQ3
A. Less than $500
B. $501 - $1000
C. $1001 - $2000
D. $2001 - $3000
E. $3001 - $4000
F. $4001 - $5000
Target Group: Household
-
BOX 0
CHECK ITEM FSQ.005:
IF THIS IS THE FIRST NHANES FAMILY IN THE HOUSEHOLD, CONTINUE.
OTHERWISE, GO TO END OF SECTION.
BOX 1
OMITTED
-
BOX 1A
OMITTED
FSQ.032 Now I am going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for {you/your household} in the last 12 months, that is since last {DISPLAY CURRENT MONTH}.
CAPI INSTRUCTION:
CHECK SCREENER: ASK D AND E ONLY IF THERE IS AT LEAST 1 CHILD IN THE HOUSEHOLD WHO IS <= 17 (OR IN THE AGE RANGE THAT INCLUDES OR IS LESS THAN THE ONE THAT INCLUDES 17).
DISPLAY INSTRUCTIONS FOR {YOU/YOUR HOUSEHOLD}:
IF ONLY ONE PERSON IN HOUSEHOLD, DISPLAY “YOU”.
IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “YOUR HOUSEHOLD”.
DISPLAY INSTRUCTIONS FOR {I/WE}, {MY/OUR} AND {I WAS/WE WERE}:
IF ONLY ONE PERSON IN HOUSEHOLD, DISPLAY “I” AND “MY”.
IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “WE” AND “OUR”.
DISPLAY INSTRUCTIONS FOR {NAME/THE CHILDREN}:
IF ONLY ONE CHILD IN THE HOUSEHOLD AGE <=17, DISPLAY CHILD’S NAME.
IF MORE THAN ONE CHILD IN HOUSEHOLD AGE <=17, DISPLAY “THE CHILDREN”.
RESPONSES: OFTEN TRUE = 1, SOMETIMES TRUE = 2, NEVER TRUE = 3, REFUSED = 7, DON'T KNOW = 9
a. {I/we}
worried whether {my/our} food would run out
before {I/we} got
money to buy more. ____
b. the
food that {I/we} bought just didn't last, and {I/we}
didn't
have money to get more. ____
c. {I/we} couldn't afford to eat balanced meals. ____
d. (I/we)
relied on only a few kinds of low-cost foods to
feed {NAME/the
children} because (I was/we were)
running out of money to buy
food. ____
e. (I/we)
couldn't feed {NAME/the children} a balanced
meal, because
(I/we) couldn't afford that. ____
BOX 2
CHECK ITEM FSQ.038B:
IF THE RESPONSE TO FSQ.032 'A', 'B', 'C', 'D' OR 'E' IS 'OFTEN TRUE' (CODE 1) OR 'SOMETIMES TRUE' (CODE 2), CONTINUE.
OTHERWISE, GO TO FSQ.151.
BOX 3
CHECK ITEM FSQ.039A:
IF THERE IS AT LEAST 1 CHILD IN THE HOUSEHOLD WHO IS <= 17 (OR IN THE AGE RANGE THAT INCLUDES OR IS LESS THAN THE ONE THAT INCLUDES 17), CONTINUE WITH ITEM F.
OTHERWISE, GO TO FSQ.041.
f. {NAME
was/the children were} not eating enough
because (I/we) just
couldn't afford enough food. ____
FSQ.041 In the last 12 months, since last {DISPLAY CURRENT MONTH}, did {you/you or other adults in your household} ever cut the size of your meals or skip meals because there wasn't enough money for food?
YES 1
NO 2 (FSQ.061)
REFUSED 7 (FSQ.061)
DON'T KNOW 9 (FSQ.061)
FSQ.052 How often did this happen?
Almost every month, 1
some months but not every month, or 2
in only 1 or 2 months? 3
REFUSED 7
DON'T KNOW 9
FSQ.061 In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money to buy food?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
FSQ.071 [In the last 12 months], were you ever hungry but didn't eat because you couldn't afford enough food?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
FSQ.081 [In the last 12 months], did you lose weight because you didn't have enough money for food?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
BOX 5
CHECK ITEM FSQ.086A:
IF FSQ.032F IS OFTEN TRUE (CODE 1) OR SOMETIMES TRUE (CODE 2), OR IF 'YES' (CODE 1) IN FSQ.041, FSQ.061, FSQ.071, OR FSQ.081, CONTINUE.
OTHERWISE, GO TO FSQ.151.
FSQ.092 [In the last 12 months], did {you/you or other adults in your household} ever not eat for a whole day because there wasn't enough money for food?
YES 1
NO 2 (BOX 4A)
REFUSED 7 (BOX 4A)
DON'T KNOW 9 (BOX 4A)
FSQ.102 How often did this happen?
Almost every month, 1
some months but not every month, or 2
in only 1 or 2 months? 3
REFUSED 7
DON'T KNOW 9
BOX 4A
CHECK ITEM FSQ.085A:
IF THERE IS AT LEAST 1 CHILD IN THE HOUSEHOLD WHO IS <= 17 (OR IN THE AGE RANGE THAT INCLUDES OR IS LESS THAN THE ONE THAT INCLUDES 17), CONTINUE.
OTHERWISE, GO TO FSQ.151.
FSQ.111 The next questions are about children living in the household who are under 18 years old.
In the last 12 months, since {DISPLAY CURRENT MONTH} of last year, did you ever cut the size of {CHILD'S NAME's/any of the children's} meals because there wasn't enough money for food?
CAPI INSTRUCTION:
IF ONLY 1 CHILD IN HOUSEHOLD IS <= 17, DISPLAY CHILD'S NAME.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
FSQ.121 [In the last 12 months], did {CHILD'S NAME/any of the children} ever skip meals because there wasn't enough money for food?
CAPI INSTRUCTION:
IF ONLY 1 CHILD IN HOUSEHOLD <= 17, DISPLAY CHILD'S NAME.
YES 1
NO 2 (FSQ.141)
REFUSED 7 (FSQ.141)
DON'T KNOW 9 (FSQ.141)
FSQ.132 How often did this happen?
Almost every month, 1
some months but not every month, or 2
in only 1 or 2 months? 3
REFUSED 7
DON'T KNOW 9
FSQ.141 In the last 12 months, {was CHILD'S NAME/were the children} ever hungry but you just couldn't afford more food?
CAPI INSTRUCTION:
IF ONLY 1 CHILD IN HOUSEHOLD IS <= 17, DISPLAY CHILD'S NAME.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
FSQ.146 [In the last 12 months], did {CHILD'S NAME/any of the children} ever not eat for a whole day because there wasn't enough money for food?
CAPI INSTRUCTION:
IF ONLY 1 CHILD IN HOUSEHOLD IS <= 17, DISPLAY CHILD'S NAME.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
FSQ.151 In the last 12 months, did {you/you or any member of your household} ever get emergency food from a church, a food pantry, or a food bank, or eat in a soup kitchen?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 6
CHECK ITEM FSQ.155B:
IF THERE IS AT LEAST 1 CHILD IN THE HOUSEHOLD WHO IS <=5 (OR IN THE AGE RANGE THAT INCLUDES OR IS LESS THAN THE ONE THAT INCLUDES 5) OR THERE IS A FEMALE IN THE HOUSEHOLD WHO IS BETWEEN 12 AND 59 (OR IN THE AGE RANGE THAT INCLUDES OR IS GREATER THAN THE ONE THAT INCLUDES 12 AND IN THE AGE RANGE THAT INCLUDES OR IS LESS THAN THE ONE THAT INCLUDES 59), CONTINUE.
OTHERWISE, GO TO FSQ.165.
FSQ.162 [In the last 12 months], did {you/you or any member of your household} receive benefits from the WIC program, that is, the Women, Infants and Children program?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
FSQ.165 The next questions are about the Food Stamp Program. Food stamps are usually provided on an electronic debit card, EBT card, also called the {State FSP name} in {state name}.
CAPI INSTRUCTION:
INCLUDE FOOD STAMP PROGRAM NAME AND THE STATE THE STAND IS IN THE INTRODUCTORY SENTENCE.
Have {you/you or anyone in your household} ever received Food Stamp benefits?
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
FSQ.171 [In the last 12 months], did {you/you or any member of your household} receive Food Stamp benefits?
YES 1
NO 2 (END)
REFUSED 7 (END)
DON'T KNOW 9 (END)
FSQ.225 On what date did {you/your household} last receive food stamp benefits?
M/D/Y
|___|___| - |___|___| - |___|___| (FSQ.235)
MONTH DAY YEAR
INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.
CAPI INSTRUCTION:
SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.
REFUSED 7
DON'T KNOW 9
FSQ.230 {Do you/Does any member of your household} currently receive Food Stamp benefits?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
FSQ.235 How much did {you/your household} receive in food stamp benefits the last time you got them?
|___|___|___|___|
ENTER DOLLAR AMOUNT
REFUSED 77777
DON'T KNOW 99999
-
BOX 1
LOOP 1:
ASK TTQ.010 - TTQ.040 FOR 2 CONTACT PERSONS.
TTQ.005 The United States Public Health Service may wish to contact you again to obtain additional health related information. Please give me the names, addresses, and telephone numbers of 2 relatives or friends who would know where you could be reached in case we have trouble reaching you. (Please give me the names of persons not currently living in the household.)
PRESS F6 IF RESPONDENT REFUSES {ALL/SECOND} CONTACT INFORMATION
PRESS F5 IF RESPONDENT DOESN'T KNOW {ANY/SECOND} CONTACT INFORMATION
PRESS ENTER TO ADD {FIRST/SECOND} CONTACT INFORMATION
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
TTQ.010 REFERRING TO PERSON {1/2}
VERIFY SPELLING.
ENTER FIRST NAME
REFUSED 7
DON'T KNOW 9
PROBE FOR MIDDLE NAME IF NOT REPORTED
ENTER "NMN" FOR NO MIDDLE NAME
ENTER MIDDLE NAME
REFUSED 7
DON'T KNOW 9
ENTER LAST NAME
REFUSED 7
DON'T KNOW 9
TTQ.020 REFERRING TO PERSON {1/2}
What is this person's address? [If there is more than one address, please give us the address used most often.]
ENCOURAGE RESPONDENT TO USE PHONE BOOK OR OTHER DOCUMENTATION IF AVAILABLE.
______________________ ___________________________ _____________________
ENTER STREET NUMBER ENTER STREET NAME ENTER APARTMENT NUMBER
REFUSED 7 REFUSED 7 REFUSED 7
DON'T KNOW 9 DON'T KNOW 9 DON'T KNOW 9
_____________________ |____|____| |___|____|____|____|____|
ENTER TOWN OR ENTER 2 LETTER ENTER POSTAL CODE
CITY NAME STATE ABBREVIATION TO OR ZIPCODE
TO START THE LOOKUP.
SELECT STATE FROM CAPI STATE LIST.
PRESS ENTER TO ACCEPT SELECTION.
REFUSED 7 REFUSED 77 REFUSED 77777
DON'T KNOW 9 DON'T KNOW 99 DON'T KNOW 99999
CAPI INSTRUCTION:
DISPLAY FIPS STATE LIST. INTERVIEWER SHOULD ONLY BE ABLE TO SELECT 1 STATE FROM THE LIST. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. THE STATE LOOKUP IN THE SP AND FAMILY QUESTIONNAIRES SHOULD WORK EXACTLY THE SAME.
TTQ.030 REFERRING TO PERSON {1/2}
What is this person's telephone number, beginning with the area code?
REPEAT AREA CODE
REPEAT PHONE NUMBER
REPEAT EXTENSION
|___|___|___| |___|___|___| - |___|___|___|___| |___|___|____|____|
ENTER AREA CODE ENTER TELEPHONE NUMBER ENTER EXTENSION
NO PHONE 666 (TTQ.040) REFUSED 7777777 REFUSED 7777
REFUSED 777 (TTQ.040) DON'T KNOW 9999999 DON'T KNOW 9999
DON'T KNOW 999 (TTQ.040)
TTQ.040 REFERRING TO PERSON {1/2}
What is the relationship of this contact person to you?
SPOUSE/EX-SPOUSE NOT LIVING IN HH 1
UNMARRIED PARTNER NOT LIVING IN HH 2
CHILD 3
GRANDCHILD 4
PARENT (MOTHER OR FATHER) 5
BROTHER OR SISTER 6
GRANDPARENT 7
OTHER RELATIVE 8
LEGAL GUARDIAN 9
FRIEND 10
CO-WORKER 11
NEIGHBOR 12
OTHER 13
REFUSED 77
DON'T KNOW 99
-
BOX 2
END LOOP 1:
ASK TTQ.010 - TTQ.040 FOR SECOND CONTACT PERSON.
IF SECOND CONTACT PERSON INFORMATION COLLECTED, GO TO TTQ.050.
TTQ.050 This is the end of the Family Interview. Thank you very much for your cooperation.
PRESS F10 TO SAVE AND EXIT FOR
RIQ.005 INTERVIEWER: MARK MAIN RESPONDENT. SPECIFY RELATIONSHIP OF RESPONDENT TO SP IF OTHER THAN SP.
SP 1 (RIQ.090)
MOTHER 2
FATHER 3
SPOUSE 4
SISTER OR BROTHER 5
CHILD 6
GRANDPARENT 7
LEGAL GUARDIAN 8
OTHER (SPECIFY) 9
RIQ.030 WHY IS INTERVIEW BEING CONDUCTED WITH A PROXY?
SP HAS COGNITIVE PROBLEMS 1
SP HAS PHYSICAL PROBLEMS
(SPECIFY) 2
OTHER (SPECIFY) 3
RIQ.038 INTERVIEWER: WAS SP PRESENT IN THE ROOM DURING ANY PART OF THE INTERVIEW?
YES 1
NO 2
RIQ.090 INTERPRETER USED FOR THIS INTERVIEW?
YES 1
NO 2 (END OF SECTION)
RIQ.100 CODE TYPE OF INTERPRETER.
RELATIVE 1
NEIGHBOR OR FRIEND 2
PAID INTERPRETER 3
RIQ.140 LANGUAGE OF INTERVIEW.
CHINESE 1
FRENCH 2
GERMAN 3
ITALIAN 4
JAPANESE 5
RUSSIAN 6
VIETNAMESE 8
SPANISH 9
OTHER (SPECIFY) 10
BOX 1
CHECK ITEM RIQ.149:
IF SP 8-11 YEARS AND INTERVIEW DONE WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), DISPLAY THE FOLLOWING INTRODUCTORY TEXT: “During this interview, I will be asking you questions about your health and weight. Your answers will be kept private. Do you have any questions before we begin?”
IF SP 12 YEARS OR OLDER AND INTERVIEW DONE WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), DISPLAY THE FOLLOWING INTRODUCTORY TEXT: “During this interview, I will be asking you questions on your current health status, and on other health behaviors. Remember, all of your responses to these questions will be kept strictly confidential. Do you have any questions before we begin?”
OTHERWISE, DISPLAY THE FOLLOWING INTRODUCTORY TEXT: ”During this interview, I will be asking you questions about {SP}'s current health status, and on other health behaviors.”
HUQ.010 {First/Next} I have some general questions about {your/SP's} health.
Would you say {your/SP's} health in general is . . .
CAPI INSTRUCTION:
DISPLAY "FIRST" IF SP AGE IS >= 16 YEARS.
excellent, 1
very good, 2
good, 3
fair, or 4
poor? 5
REFUSED 7
DON'T KNOW 9
HSQ.470 The next questions are about {your/SP's} recent health during the 30 days outlined on the calendar.
Thinking about {your/SP's} physical health, which includes physical illness and injury, for how many days during the past 30 days was {your/his/her} physical health not good?
HAND CARD HSQ1
CAPI INSTRUCTION:
HARD EDIT VALUES: 0-30.
|___|___|
ENTER # OF DAYS
REFUSED 77
DON'T KNOW 99
HSQ.480 Now thinking about {your/SP's} mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was {your/his/her} mental health not good?
CAPI INSTRUCTION:
HARD EDIT VALUES: 0-30.
|___|___|
ENTER # OF DAYS
REFUSED 77
DON'T KNOW 99
HSQ.490 During the past 30 days, for about how many days did poor physical or mental health keep {you/SP} from doing {your/his/her} usual activities, such as self-care, work, school or recreation?
CAPI INSTRUCTION:
HARD EDIT VALUES: 0-30.
|___|___|
ENTER # OF DAYS
REFUSED 77
DON'T KNOW 99
HSQ.493 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?
CAPI INSTRUCTION:
HARD EDIT VALUES: 0-30.
|___|___|
ENTER # OF DAYS
REFUSED 77
DON'T KNOW 99
HSQ.496 During the past 30 days, for about how many days have you felt worried, tense, or anxious?
CAPI INSTRUCTION:
HARD EDIT VALUES: 0-30.
|___|___|
ENTER # OF DAYS
REFUSED 77
DON'T KNOW 99
HSQ.500 Did {you/SP} have a head cold or chest cold that started during those 30 days?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
HSQ.510 Did {you/SP} have a stomach or intestinal illness with vomiting or diarrhea that started during those 30 days?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
HSQ.520 Did {you/SP} have flu, pneumonia, or ear infections that started during those 30 days?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 1
CHECK ITEM HSQ.560:
IF SP 16 YEARS OR OLDER, CONTINUE WITH HSQ.571.
OTHERWISE, GO TO END OF SECTION.
HSQ.571 During the past 12 months, that is, since {DISPLAY CURRENT MONTH, DISPLAY LAST YEAR}, {have you/has SP} donated blood?
YES 1
NO 2 (HSQ.590)
REFUSED 7 (HSQ.590)
DON'T KNOW 9 (HSQ.590)
HSQ.580 How long ago was {your/SP's} last blood donation?
IF LESS THAN ONE MONTH, ENTER '1'.
CAPI INSTRUCTION:
HARD EDIT VALUES: 1-12.
|___|___|
ENTER # OF MONTHS
REFUSED 77
DON'T KNOW 99
HSQ.590 Except for tests {you/SP} may have had as part of blood donations, {have you/has he/has she} ever had {your/his/her} blood tested for the AIDS virus infection?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
05BOX 1
CHECK ITEM 05DPQ.001:
IF INTERVIEW DONE ONLY WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), CONTINUE.
OTHERWISE, GO TO NEXT SECTION.
05DPQ.010 Over the last 2 weeks, how often have you been bothered by the following problems:
little interest or pleasure in doing things? Would you say . . .
HANDCARD DPQ1
Not at all, 0
several days, 1
more than half the days, or 2
nearly every day? 3
REFUSED 7
DON’T KNOW 9
05DPQ.020 [Over the last 2 weeks, how often have you been bothered by the following problems:]
feeling down, depressed, or hopeless?
HANDCARD DPQ1
NOT AT ALL 0
SEVERAL DAYS 1
MORE THAN HALF THE DAYS 2
NEARLY EVERY DAY 3
REFUSED 7
DON’T KNOW 9
05DPQ.030 [Over the last 2 weeks, how often have you been bothered by the following problems:]
trouble falling or staying asleep, or sleeping too much?
HANDCARD DPQ1
NOT AT ALL 0
SEVERAL DAYS 1
MORE THAN HALF THE DAYS 2
NEARLY EVERY DAY 3
REFUSED 7
DON’T KNOW 9
05DPQ.040 [Over the last 2 weeks, how often have you been bothered by the following problems:]
feeling tired or having little energy?
HANDCARD DPQ1
NOT AT ALL 0
SEVERAL DAYS 1
MORE THAN HALF THE DAYS 2
NEARLY EVERY DAY 3
REFUSED 7
DON’T KNOW 9
05DPQ.050 [Over the last 2 weeks, how often have you been bothered by the following problems:]
poor appetite or overeating?
HANDCARD DPQ1
NOT AT ALL 0
SEVERAL DAYS 1
MORE THAN HALF THE DAYS 2
NEARLY EVERY DAY 3
REFUSED 7
DON’T KNOW 9
05DPQ.060 [Over the last 2 weeks, how often have you been bothered by the following problems:]
feeling bad about yourself – or that you are a failure or have let yourself or your family down?
HANDCARD DPQ1
NOT AT ALL 0
SEVERAL DAYS 1
MORE THAN HALF THE DAYS 2
NEARLY EVERY DAY 3
REFUSED 7
DON’T KNOW 9
05DPQ.070 [Over the last 2 weeks, how often have you been bothered by the following problems:]
trouble concentrating on things, such as reading the newspaper or watching TV?
HANDCARD DPQ1
NOT AT ALL 0
SEVERAL DAYS 1
MORE THAN HALF THE DAYS 2
NEARLY EVERY DAY 3
REFUSED 7
DON’T KNOW 9
05DPQ.080 [Over the last 2 weeks, how often have you been bothered by the following problems:]
moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?
HANDCARD DPQ1
NOT AT ALL 0
SEVERAL DAYS 1
MORE THAN HALF THE DAYS 2
NEARLY EVERY DAY 3
REFUSED 7
DON’T KNOW 9
05DPQ.090 Over the last 2 weeks, how often have you been bothered by the following problem:
Thoughts that you would be better off dead or of hurting yourself in some way?
INTERVIEWER INSTRUCTION: IF DPQ.090 CODED 1, 2, OR 3, PLEASE COMPLETE MENTAL HEALTH OBSERVATION FOR PHYSICIAN REVIEW AT CONCLUSION OF INTERVIEW.
NOT AT ALL 0
SEVERAL DAYS 1
MORE THAN HALF THE DAYS 2
NEARLY EVERY DAY 3
REFUSED 7
DON’T KNOW 9
05BOX 2
CHECK ITEM 05DPQ.095:
IF RESPONSE TO ANY OF QUESTIONS 05DPQ.010 – 05DPQ.090 = 1, 2, OR 3, GO TO 05DPQ.100.
OTHERWISE, GO TO NEXT SECTION.
05DPQ.100 How difficult have these problems made it for you to do your work, take care of things at home, or get along with people?
Not at all difficult, 0
Somewhat difficult, 1
Very difficult, 2
Extremely difficult? 3
REFUSED 7
DON’T KNOW 9
SMQ.680 The following questions ask about use of tobacco or nicotine products in the past 5 days.
During the past 5 days, did {you/he/she} use any product containing nicotine including cigarettes, pipes, cigars, chewing tobacco, snuff, nicotine patches, nicotine gum, or any other product containing nicotine?
VERBAL INSTRUCTIONS TO SP:
Please select yes, no.
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON’T KNOW 9 (END OF SECTION)
SMQ.690 Which of these products did {you/he/she} use? (CHECK ALL THAT APPLY)
VERBAL INSTRUCTIONS TO SP:
Please select all that you used.
Cigarettes 1
Pipes 2
Cigars 3
Chewing tobacco 4
Snuff 5
Nicotine patches, gum, or other nicotine
product 6
REFUSED 77
DON’T KNOW 99
BOX 2
CHECK ITEM SMQ.700:
IF ‘CIGARETTES’ (CODE 1) IN SMQ.690, GO TO SMQ.710.
IF ‘PIPES’ (CODE 2) IN SMQ.690, GO TO SMQ.740.
IF ‘CIGARS’ (CODE 3) IN SMQ.690, GO TO SMQ.770.
IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.
IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.
IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.
IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.710.
SMQ.710 During the past 5 days (including today), on how many days did {you/he/she} smoke cigarettes?
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON'T KNOW 9
SMQ.720 During the past 5 days, on the days {you/he/she} smoked, how many cigarettes did {you/he/she} smoke each day?
IF R SAYS 95 OR MORE CIGARETTES PER DAY, ENTER 95.
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|___|___|
ENTER NUMBER OF CIGARETTES
REFUSED 777
DON'T KNOW 999
SMQ.725 When did {you/he/she} smoke {your/his/her} last cigarette? Was it . . .
today, 1
yesterday, or 2
3 to 5 days ago? 3
REFUSED 7
DON'T KNOW 9
BOX 3
CHECK ITEM SMQ.730:
IF ‘PIPES’ (CODE 2) IN SMQ.690, GO TO SMQ.740.
IF ‘CIGARS’ (CODE 3) IN SMQ.690, GO TO SMQ.770.
IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.
IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.
IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.
IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.740.
SMQ.740 During the past 5 days (including today), on how many days did {you/he/she} smoke a pipe?
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON'T KNOW 9
SMQ.750 During the past 5 days, on the days {you/he/she} smoked a pipe, how many pipes did {you/he/she} smoke each day?
IF R SAYS LESS THAN 1 PIPE PER DAY, ENTER 1.
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|___|
ENTER NUMBER OF PIPES
REFUSED 77
DON'T KNOW 99
SMQ.755 When did {you/he/she} smoke {your/his/her} last pipe? Was it . . .
today, 1
yesterday, or 2
3 to 5 days ago? 3
REFUSED 7
DON'T KNOW 9
BOX 4
CHECK ITEM SMQ.760:
IF ‘CIGARS’ (CODE 3) IN SMQ.690, GO TO SMQ.770.
IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.
IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.
IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.
IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.770.
SMQ.770 During the past 5 days (including today), on how many days did {you/he/she} smoke cigars?
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON'T KNOW 9
SMQ.780 During the past 5 days, on the days {you/he/she} smoked cigars, how many cigars did {you/he/she} smoke each day?
IF R SAYS LESS THAN 1 CIGAR PER DAY, ENTER 1.
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|___|
ENTER NUMBER OF CIGARS
REFUSED 77
DON'T KNOW 99
SMQ.785 When did {you/he/she} smoke {your/his/her} last cigar? Was it . . .
today, 1
yesterday, or 2
3 to 5 days ago? 3
REFUSED 7
DON'T KNOW 9
BOX 5
CHECK ITEM SMQ.790:
IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.
IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.
IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.
IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.800.
SMQ.800 During the past 5 days (including today), on how many days did {you/he/she} use chewing tobacco, such as Redman, Levi Garrett or Beechnut?
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON'T KNOW 9
SMQ.815 When did {you/he/she} last use chewing tobacco? Was it . . .
today, 1
yesterday, or 2
3 to 5 days ago? 3
REFUSED 7
DON'T KNOW 9
BOX 5A
CHECK ITEM SMQ.816:
IF ‘SNUFF’ (CODE 5) IN SMQ.690, GO TO SMQ.817.
IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.
IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.817.
SMQ.817 During the past 5 days (including today), on how many days did {you/he/she} use snuff, such as Skoal, Skoal Bandits, or Copenhagen?
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON'T KNOW 9
SMQ.819 When did {you/he/she} last use snuff? Was it . . .
today, 1
yesterday, or 2
3 to 5 days ago? 3
REFUSED 7
DON'T KNOW 9
BOX 6
CHECK ITEM SMQ.820:
IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.
IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.830.
OTHERWISE, GO TO END OF SECTION.
SMQ.830 During the past 5 days (including today), on how many days did {you/he/she} use any product containing nicotine to help {you/him/her} stop smoking? Include nicotine patches, gum, or any other product containing nicotine.
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON'T KNOW 9
SMQ.840 When did {you/he/she} last use a product containing nicotine? Was it . .
today, 1
yesterday, or 2
3 to 5 days ago? 3
REFUSED 7
DON'T KNOW 9
RHQ.010 The next series of questions are about {your/SP's} reproductive history. I will begin by asking some questions about {your/SP's} period or menstrual cycle.
How old {were you/was SP} when {you/she} had {your/her} first menstrual period?
CODE "0" IF HAVEN'T STARTED YET.
CAPI INSTRUCTION:
SOFT EDIT VALUES: 8-25 YEARS.
HARD EDIT VALUES: AGE OF 1ST PERIOD CANNOT BE GREATER THAN CURRENT AGE.
|___|___|
ENTER AGE IN YEARS
REFUSED 77
DON'T KNOW 99
-
BOX 1
CHECK ITEM RHQ.015:
IF PERIODS HAVEN'T STARTED (CODED '0'), GO TO END OF SECTION.
IF PERIODS HAVE STARTED AND SP REPORTS AGE (CODED '1' - '76') IN RHQ.010, OR IF SP REFUSES AGE (CODED '77') IN RHQ.010, GO TO RHQ.031.
OTHERWISE, CONTINUE WITH RHQ.020.
RHQ.020 {Were you/Was SP} . . .
younger than 10, 1
10 to 12, 2
13 to 15, or 3
16 or older? 4
REFUSED 7
DON'T KNOW 9
RHQ.031 {Have you/Has SP} had at least one menstrual period in the past 12 months? (Please do not include bleedings caused by medical conditions, hormone therapy, or surgeries.)
SOFT EDIT: Display edit when age of SP is greater than or equal to 60 and RHQ.031 is coded yes.
Error message: "It is unlikely that SPs aged 60 years or older will still be menstruating. Please verify."
YES 1 (RHQ.131)
NO 2
REFUSED 7 (RHQ.060)
DON'T KNOW 9 (RHQ.060)
RHQ.042 What is the reason that {you have/SP has} not had a period in the past 12 months?
PREGNANCY 1 (RHQ.143)
BREAST FEEDING 2 (RHQ.143)
MENOPAUSE/HYSTERECTOMY 7
MEDICAL CONDITIONS/TREATMENTS 8
OTHER 9
REFUSED 77
DON'T KNOW 99
RHQ.060 About how old {were you/was SP} when {you/she} had {your/her} last menstrual period?
SOFT EDIT: Display edit when RHQ.060 is greater than 59.
Error message: "It is unlikely that an SP will have her last menstrual period after age 59. Please verify."
|___|___|
ENTER AGE IN YEARS
REFUSED 77
DON'T KNOW 99
-
BOX 2
CHECK ITEM RHQ.065:
IF SP DOESN'T KNOW AGE AT LAST MENSTRUAL PERIOD (CODED '99') IN RHQ.060, CONTINUE WITH RHQ.070.
OTHERWISE, GO TO RHQ.131.
RHQ.070 {Were you/Was SP} . . .
younger than 30, 1
30 to 34, 2
35 to 39, 3
40 to 44, 4
45 to 49, 5
50 to 54, or 6
55 or older? 7
REFUSED 77
DON'T KNOW 99
RHQ.131 The next questions are about {your/SP's} pregnancy history.
{Have you/Has SP} ever been pregnant? Please include (current pregnancy,) live births, miscarriages, stillbirths, tubal pregnancies and abortions.
MARK IF KNOWN. OTHERWISE ASK.
YES 1
NO 2 (BOX 12)
REFUSED 7 (BOX 12)
DON'T KNOW 9 (BOX 12)
-
BOX 6
CHECK ITEM RHQ.135C:
IF SP HAD PERIOD IN PAST 12 MONTHS (CODED '1' IN RHQ.031) OR SP HAS NOT EXPERIENCED MENOPAUSE/HYSTERECTOMY (NOT CODED 7 IN RHQ.042), CONTINUE WITH RHQ.143.
OTHERWISE, GO TO RHQ.160.
RHQ.143 {Are you/Is SP} pregnant now?
MARK IF KNOWN. OTHERWISE ASK.
YES 1
NO 2 (RHQ.160)
REFUSED 7 (RHQ.160)
DON'T KNOW 9 (RHQ.160)
RHQ.152 Which month of pregnancy {are you/is she} in?
|___|___|
ENTER NUMBER OF MONTHS
REFUSED 77
DON'T KNOW 99
RHQ.160 How many times {have you/has SP} been pregnant? ({Again, be/Be} sure to count all {your/her} pregnancies including (current pregnancy,) live births, miscarriages, stillbirths, tubal pregnancies, or abortions.)
|___|___|
ENTER NUMBER OF PREGNANCIES
REFUSED 77
DON'T KNOW 99
RHQ.162 During any pregnancy, were you ever told by a doctor or other health professional that you had diabetes, sugar diabetes or gestational diabetes? Please do not include diabetes that you may have known about before the pregnancy.
HELP SCREEN SHOULD READ: Gestational diabetes is a form of diabetes or high blood sugar found in pregnant women.
YES 1
NO 2 (BOX 7)
BORDERLINE 3 (BOX 7)
REFUSED 7 (BOX 7)
DON'T KNOW 9 (BOX 7)
RHQ.163 How old were you when you were first told you had diabetes during a pregnancy?
HARD EDIT: RHQ.163 must be equal to or less than age of SP.
Error message: "Age cannot be greater than age of SP."
|___|___|
ENTER AGE IN YEARS
REFUSED 77
DON'T KNOW 99
-
BOX 7
CHECK ITEM RHQ.165:
IF SP ONLY HAD ONE PREGNANCY (CODED '1') IN RHQ.160 AND CURRENTLY PREGNANT (CODED '1') IN RHQ.143, SKIP TO RHQ.395.
OTHERWISE CONTINUE WITH RHQ.166.
RHQ.166 How many vaginal deliveries {have you/has SP} had? {Please count stillbirths as well as live births}
COUNT THE NUMBER OF DELIVERIES, NOT THE NUMBER OF LIVE-BORN CHILDREN. FOR EXAMPLE, IF SP DELIVERED TWINS OR HAD ANY OTHER MULTIPLE BIRTH, COUNT AS A SINGLE DELIVERY.
HARD EDIT: RHQ.166 must be equal to or less than RHQ.160.
Error message: "Number of vaginal deliveries cannot be greater than the number of pregnancies."
|___|___|
ENTER NUMBER
REFUSED 77
DON'T KNOW 99
-
BOX 7A
CHECK ITEM RHQ.168:
IF NUMBER OF PREGNANCIES IN RHQ.160 EQUALS THE NUMBER OF VAGINAL DELIVERIES IN RHQ.166, SKIP TO RHQ.172.
OTHERWISE, CONTINUE WITH RHQ.169.
RHQ.169 How many cesarean deliveries {have you/has SP} had? (Cesarean deliveries are also known as C-sections.) (Please count stillbirths as well as live births.)
COUNT THE NUMBER OF DELIVERIES, NOT THE NUMBER OF LIVE-BORN CHILDREN. FOR EXAMPLE, IF SP DELIVERED TWINS OR HAD ANY OTHER MULTIPLE BIRTH, COUNT AS A SINGLE DELIVERY.
SOFT EDIT: Sum of RHQ166 and RHQ.169 must be equal to or less than RHQ160.
Error message: "It is unlikely that the number of deliveries (vaginal and cesarean deliveries combined) is greater than the number of pregnancies. Please verify.”
HARD EDIT: RHQ.169 must be equal to or less than RHQ.160.
Error message: “Number of cesarean deliveries cannot be greater than the number of pregnancies.”
|___|___|
ENTER NUMBER
REFUSED 77
DON'T KNOW 99
RHQ.172 {Did {your/SP's} delivery/Did any of {your/SP's} deliveries} result in a baby that weighed 9 pounds (4082 g) or more at birth? (Please count stillbirths as well as live births.)
CAPI INSTRUCTION:
IF SP HAD ONE DELIVERY (SUM OF RHQ.166 AND RHQ.169 = 1), DISPLAY {YOUR DELIVERY}.
IF SP HAD MORE THAN ONE DELIVERY (SUM OF RHQ.166 AND RHQ.169 > 1), DISPLAY {ANY OF YOUR DELIVERIES}.
YES 1
NO 2 (RHQ.171)
REFUSED 7 (RHQ.171)
DON'T KNOW 9 (RHQ.171)
RHQ.173 How old were you when you delivered a baby that weighed 9 pounds or more? (Please count stillbirths as well as live births.)
[IF MORE THAN 1 BABY WEIGHED 9 POUNDS OR MORE RECORD AGE FOR FIRST ONE]
HARD EDIT: RHQ.173 must be equal to or less than age of SP.
Error message: "Age cannot be greater than age of SP."
|___|___|
ENTER AGE IN YEARS
REFUSED 77
DON'T KNOW 99
-
BOX 7B
CHECK ITEM RHQ.170A:
IF THE NUMBER OF DELIVERIES IN RHQ.166 AND RHQ.169 EQUALS ZERO, GO TO BOX 12.
OTHERWISE, CONTINUE WITH RHQ.171.
RHQ.171 How many of {your/her} deliveries resulted {Did {your/her} delivery result} in a live birth?
CAPI INSTRUCTION:
IF SP HAD ONE DELIVERY (SUM OF RHQ.166 AND RHQ.169 = 1), REPLACE {How many of {your/her} deliveries resulted} WITH {Did {your/her} delivery result}.
FOR SINGLE DELIVERIES:
Yes = 1
No = 0
COUNT THE NUMBER OF TOTAL DELIVERIES, NOT NUMBER OF LIVE-BORN CHILDREN. FOR EXAMPLE, IF SP HAD TWINS OR OTHER MULTIPLE BIRTH, COUNT AS A SINGLE DELIVERY.
|___|___|
ENTER NUMBER OF DELIVERIES
REFUSED 77
DON'T KNOW 99
-
BOX 8
CHECK ITEM RHQ.175:
IF SP HAD NO DELIVERIES THAT RESULTED IN A LIVE BIRTH (CODED '0') IN RHQ.171, GO TO BOX 12.
IF SP HAD ONE DELIVERY THAT RESULTED IN A LIVE BIRTH (CODED '1') IN RHQ.171, GO TO RHQ.190.
OTHERWISE, CONTINUE WITH RHQ.180.
RHQ.180 How old {were you/was SP} at the time of {your/her} first live birth?
CAPI INSTRUCTION:
HARD EDIT: RHQ.180 must be equal to or less than age of SP.
Error message: "Age of SP at first delivery cannot be greater than age of SP."
|___|___|
ENTER AGE IN YEARS
REFUSED 77
DON'T KNOW 99
RHQ.190 How old {were you/was SP} at the time of {your/her} {last} live birth?
CAPI INSTRUCTION:
IF SP HAD MORE THAN 1 LIVE BIRTH (CODED >= 2) IN RHQ.171, DISPLAY {LAST}.
HARD EDIT: RHQ190 must be equal to or less than age of SP.
Error message: "Age of SP at last delivery cannot be greater than age of SP."
|___|___|
ENTER AGE IN YEARS
REFUSED 77
DON'T KNOW 99
-
BOX 9
CHECK ITEM RHQ.195:
IF DIFFERENCE BETWEEN AGE AT TIME OF LAST DELIVERY IN RHQ.190 AND CURRENT AGE IS ZERO OR 1, CONTINUE.
OTHERWISE, GO TO RHQ.205.
RHQ.197 How many months ago did you have your baby?
|___|___|___|
ENTER NUMBER OF MONTHS
REFUSED 777
DON'T KNOW 999
RHQ.200 {Are you/Is SP} now breast feeding a child?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
RHQ.205 Did {you/SP} breast feed any of {your/her} children for at least one month?
CAPI INSTRUCTION:
IF SP HAD ONE LIVE BIRTH (CODED '1') IN RHQ.171, DISPLAY {YOUR CHILD}.
IF SP HAD MORE THAN ONE LIVE BIRTH (CODED > 1) IN RHQ.171, DISPLAY {ANY OF YOUR CHILDREN}.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 12
CHECK ITEM RHQ.275A:
IF SP < 20 YEARS OLD, GO TO RHQ.420.
IF SP CURRENTLY PREGNANT (CODED '1') IN RHQ.143, GO TO RHQ.395.
IF SP HAD PERIOD IN PAST 12 MONTHS (CODED '1' IN RHQ.031), GO TO RHQ.282.
OTHERWISE, CONTINUE WITH RHQ.282.
RHQ.282 {Have you/Has SP} had a hysterectomy, including a partial hysterectomy, that is, surgery to remove {your/her} uterus or womb?
MARK IF KNOWN. OTHERWISE ASK.
YES 1
NO 2 (RHQ.300)
REFUSED 7 (RHQ.300)
DON'T KNOW 9 (RHQ.300)
RHQ.291 How old {were you/was SP} when {you/she} had {your/her} (hysterectomy/uterus removed/womb removed)?
|___|___|___|
ENTER AGE IN YEARS
REFUSED 777
DON'T KNOW 999
RHQ.305 {Have you/Has SP} had both of {your/her} ovaries removed (either when {you/she} had {your/her} uterus removed or at another time)?
YES 1
NO 2 (RHQ.395)
REFUSED 7 (RHQ.395)
DON'T KNOW 9 (RHQ.395)
RHQ.332 How old {were you/was SP} when {you/she} had {your/her} ovaries removed or last ovary removed if removed at different times?
|___|___|___|
ENTER AGE IN YEARS
REFUSED 777
DON'T KNOW 999
RHQ.395 {Do you/Does SP} experience bulging or something falling out that {you/she} can see or feel in the vaginal area?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
RHQ.420 Now I am going to ask you about {your/SP's} birth control history.
{Have you/Has SP} ever taken birth control pills for any reason?
YES 1
NO 2 (RHQ.510)
REFUSED 7 (RHQ.510)
DON'T KNOW 9 (RHQ.510)
-
BOX 18
CHECK ITEM RHQ.435B:
IF SP < 20 YEARS OLD AND IF SP IS NOT PREGNANT (CODED ‘2’, ‘7’, ‘9’ OR MISSING IN RHQ.143), CONTINUE WITH RHQ.442.
IF SP >= 20 YEARS OLD AND IF SP IS NOT PREGNANT (CODED ‘2’, ‘7’, ‘9’ OR MISSING IN RHQ.143) AND IF SP HAS NOT HAD HYSTERECTOMY (CODED ‘2’, ‘7’, ‘9’ OR MISSING IN RHQ.282) AND IF SP HAS NOT HAD BOTH HER OVARIES REMOVED (CODED ‘2’, ‘7’, ‘9’ IN RHQ.305) AND IF SP IS NOT MENOPAUSAL (CODED ‘1’, ‘2’, ‘8’, ‘9’, ‘77’, ‘99’ OR MISSING IN RHQ.042), CONTINUE WITH RHQ.442.
OTHERWISE, GO TO RHQ.460.
RHQ.442 {Are you/Is SP} taking birth control pills now?
YES 1
NO 2
REFUSED 7 (RHQ.510)
DON'T KNOW 9 (RHQ.510)
RHQ.460 |
Not counting any time when {you/SP} stopped taking them, for how long altogether {have you taken/did you take/has she taken/did she take} birth control pills? |
CODE "1" FOR LESS THAN ONE MONTH.
|___|___|
ENTER NUMBER
REFUSED 77
DON'T KNOW 99
ENTER UNIT
MONTHS 1
YEARS 2
REFUSED 7
DON'T KNOW 9
RHQ.510 {Have you/Has SP} ever used Depo-Provera or injectables to prevent pregnancy?
YES 1
NO 2 (BOX 20)
REFUSED 7 (BOX 20)
DON'T KNOW 9 (BOX 20)
-
BOX 19
CHECK ITEM RHQ.519:
IF SP < 20 YEARS OLD AND IF SP IS NOT PREGNANT (CODED ‘2’, ‘7’, ‘9’ OR MISSING IN RHQ.143), CONTINUE WITH RHQ.520.
IF SP >= 20 YEARS OLD AND IF SP IS NOT PREGNANT (CODED ‘2’, ‘7’, ‘9’ OR MISSING IN RHQ.143) AND IF SP HAS NOT HAD HYSTERECTOMY (CODED ‘2’, ‘7’, ‘9’ OR MISSING IN RHQ.282) AND IF SP HAS NOT HAD BOTH HER OVARIES REMOVED (CODED ‘2’, ‘7’, ‘9’ IN RHQ.305) AND IF SP IS NOT MENOPAUSAL (CODED ‘1’, ‘2’, ‘8’, ‘9’, ‘77’, ‘99’ OR MISSING IN RHQ.042), CONTINUE WITH RHQ.520.
OTHERWISE, GO TO BOX 20.
RHQ.520 {Are you/Is SP} now using Depo-Provera or injectables to prevent pregnancy?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 20
CHECK ITEM RHQ.535:
IF SP 20 YEARS OF AGE OR OLDER, CONTINUE WITH RHQ.540.
OTHERWISE, SKIP TO BOX 24.
RHQ.540 {Have you/Has SP} ever used female hormones such as estrogen and progesterone? Please include any forms of female hormones, such as pills, cream, patch, and injectables, but do not include birth control methods or use for infertility.
YES 1
NO 2 (BOX 24)
REFUSED 7 (BOX 24)
DON'T KNOW 9 (BOX 24)
RHQ.541 Which forms of female hormones {have you/has SP} used?
CODE ALL THAT APPLY
PILLS 10
PATCHES 11
CREAM/SUPPOSITORY/INJECTION 12
REFUSED 77
DON'T KNOW 99
-
BOX 21
CHECK ITEM RHQ.552:
IF SP USED FEMALE HORMONE PILLS (CODE '10') IN RHQ.541, CONTINUE WITH RHQ.554.
OTHERWISE, GO TO BOX 22.
RHQ.554 {Have you/Has SP} ever taken female hormone pills containing estrogen only (like Premarin)? (Do not include birth control pills.)
YES 1
NO 2 (RHQ.562)
REFUSED 7 (RHQ.562)
DON'T KNOW 9 (RHQ.562)
RHQ.558 {Are you/Is SP} taking pills containing estrogen only now?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
RHQ.560 |
Not counting any time when {you/SP} stopped taking them, for how long altogether {have you taken/did you take/has she taken/did she take} pills containing estrogen only? |
CODE "1" FOR LESS THAN 1 MONTH
|___|___|
ENTER NUMBER
REFUSED 77
DON'T KNOW 99
ENTER UNIT
MONTHS 1
YEARS 2
REFUSED 7
DON'T KNOW 9
RHQ.562 {Have you/Has SP} taken female hormone pills containing progestin only (like Provera)? (Do not include birth control pills.)
YES 1
NO 2 (RHQ.570)
REFUSED 7 (RHQ.570)
DON'T KNOW 9 (RHQ.570)
RHQ.566 {Are you/Is SP} taking pills containing progestin only now?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
RHQ.568 |
Not counting any time when {you/SP} stopped taking them, for how long altogether {have you taken/did you take/has she taken/did she take} pills containing progestin only? |
CODE "1" FOR LESS THAN 1 MONTH
|___|___|
ENTER NUMBER
REFUSED 77
DON'T KNOW 99
ENTER UNIT
MONTHS 1
YEARS 2
REFUSED 7
DON'T KNOW 9
RHQ.570 {Have you/Has SP} taken female hormone pills containing both estrogen and progestin (like Prempro, Premphase)? (Do not include birth control pills.)
YES 1
NO 2 (BOX 22)
REFUSED 7 (BOX 22)
DON'T KNOW 9 (BOX 22)
RHQ.574 {Are you/Is SP} taking pills containing both estrogen and progestin now?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
RHQ.576 |
Not counting any time when {you/SP} stopped taking them, for how long altogether {have you taken/did you take/has she taken/did she take} pills containing both estrogen and progestin? |
CODE "1" FOR LESS THAN 1 MONTH
|___|___|
ENTER NUMBER
REFUSED 77
DON'T KNOW 99
ENTER UNIT
MONTHS 1
YEARS 2
REFUSED 7
DON'T KNOW 9
-
BOX 22
CHECK ITEM RHQ.578:
IF SP USED PATCHES (CODE '11') IN RHQ.541, CONTINUE WITH RHQ.580.
OTHERWISE, GO TO BOX 24.
RHQ.580 {Have you/Has SP} ever used female hormone patches containing estrogen only?
YES 1
NO 2 (RHQ.596)
REFUSED 7 (RHQ.596)
DON'T KNOW 9 (RHQ.596)
RHQ.584 {Are you/Is SP} using patches containing estrogen only now?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
RHQ.586 |
Not counting any time when {you/SP} stopped using them, for how long altogether {have you used/did you use/has she used/did she use} patches containing estrogen only? |
CODE "1" FOR LESS THAN 1 MONTH
|___|___|
ENTER NUMBER
REFUSED 77
DON'T KNOW 99
ENTER UNIT
MONTHS 1
YEARS 2
REFUSED 7
DON'T KNOW 9
RHQ.596 {Have you/Has SP} used female hormone patches containing both estrogen and progestin?
YES 1
NO 2 (BOX 24)
REFUSED 7 (BOX 24)
DON'T KNOW 9 (BOX 24)
RHQ.600 {Are you/Is SP} using patches containing both estrogen and progestin now?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
RHQ.602 |
Not counting any time when {you/SP} stopped using them, for how long altogether {have you used/did you use/has she used/did she use} patches containing both estrogen and progestin? |
CODE "1" FOR LESS THAN 1 MONTH
|___|___|
ENTER NUMBER
REFUSED 77
DON'T KNOW 99
ENTER UNIT
MONTHS 1
YEARS 2
REFUSED 7
DON'T KNOW 9
-
BOX 24
CHECK ITEM RHQ.640A:
IF SP CURRENTLY PREGNANT (CODED '1') IN RHQ.143, CONTINUE WITH FSQ.652.
IF THE AGE DIFFERENCE BETWEEN SP's CURRENT AGE AND AGE AT LAST LIVE BIRTH IN RHQ.190 IS ZERO, 1, OR 2, CONTINUE WITH FSQ.652.
OTHERWISE, GO TO END OF SECTION.
FSQ.652 These next questions are about participation in programs for women with young children.
Did {you/SP} personally receive benefits from WIC, that is, the Women, Infants, and Children Program, in the past 12 months?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
-
BOX 26
CHECK ITEM RHQ.640A:
IF CODED ‘1-12’ IN RHQ.197, CONTINUE WITH FSQ.661.
OTHERWISE, GO TO END OF SECTION.
FSQ.661 {Are you/Is SP} now receiving benefits from the WIC Program?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
FSQ.671 |
How long {did you receive/have you been receiving/did she receive/has she been receiving} benefits from the WIC Program? |
CAPI INSTRUCTION:
IF SP CURRENTLY RECEIVING WIC BENEFITS (CODED '1') IN FSQ.661, DISPLAY {HAVE YOU BEEN RECEIVING/HAS SHE BEEN RECEIVING}.
OTHERWISE, DISPLAY {DID YOU RECEIVE/DID SHE RECEIVE}.
|___|___|
ENTER QUANTITY
REFUSED 77
DON'T KNOW 99
ENTER UNIT
MONTHS 1
YEARS 2
REFUSED 7
DON'T KNOW 9
ALQ.101 The next questions are about drinking alcoholic beverages. Included are liquor (such as whiskey or gin), beer, wine, wine coolers, and any other type of alcoholic beverage.
In any one year, {have you/has SP} had at least 12 drinks of any type of alcoholic beverage? By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and half ounces of liquor.
YES 1 (ALQ.120)
NO 2
REFUSED 7
DON'T KNOW 9
ALQ.110 In {your/SP’s} entire life, {have you/has he/has she} had at least 12 drinks of any type of alcoholic beverage?
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
ALQ.120 |
In the past 12 months, how often did {you/SP} drink any type of alcoholic beverage? |
PROBE: How many days per week, per month, or per year did {you/SP} drink?
ENTER '0' FOR NEVER.
|___|___|___|
ENTER QUANTITY
REFUSED 777
DON'T KNOW 999
ENTER UNIT
WEEK 1
MONTH 2
YEAR 3
REFUSED 7
DON'T KNOW 9
-
BOX 1
CHECK ITEM ALQ.125:
IF SP DIDN'T DRINK (CODED '0') IN ALQ.120, GO TO ALQ.150.
OTHERWISE, CONTINUE WITH ALQ.130.
ALQ.130 In the past 12 months, on those days that {you/SP} drank alcoholic beverages, on the average, how many drinks did {you/he/she} have?
IF LESS THAN 1 DRINK, ENTER '1'.
IF 95 DRINKS OR MORE, ENTER '95'.
|___|___|___|
ENTER # OF DRINKS
REFUSED 777
DON'T KNOW 999
ALQ.140 |
In the past 12 months, on how many days did {you/SP} have 5 or more drinks of any alcoholic beverage? |
PROBE: How many days per week, per month, or per year did {you/SP} have 5 or more drinks in a single day?
ENTER '0' FOR NONE.
|___|___|___|
ENTER QUANTITY
REFUSED 777
DON'T KNOW 999
ENTER UNIT
WEEK 1
MONTH 2
YEAR 3
REFUSED 7
DON'T KNOW 9
ALQ.150 Was there ever a time or times in {your/SP's} life when {you/he/she} drank 5 or more drinks of any kind of alcoholic beverage almost every day?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
05KIQ.005 Many people have leakage of urine. The next few questions ask about urine leakage.
How often {do you/does SP} have urinary leakage? Would {you/s/he} say . . .
never, 1 (KIQ.042)
less than once a month, 2
a few times a month, 3
a few times a week, or 4
every day and/or night? 5
REFUSED 7 (KIQ.042)
DON’T KNOW 9 (KIQ.042)
05KIQ.010 How much urine {do you/does SP} lose each time? Would {you/s/he} say . . .
drops, 1
small splashes, or 2
more? 3
REFUSED 7
DON’T KNOW 9
KIQ.042 During the past 12 months, {have you/has SP} leaked or lost control of even a small amount of urine with an activity like coughing, lifting or exercise?
YES 1
NO 2 (KIQ.044)
REFUSED 7 (KIQ.044)
DON’T KNOW 9 (KIQ.044)
05KIQ.430 How frequently does this occur? Would {you/s/he} say this occurs . . .
less than once a month, 1
a few times a month, 2
a few times a week, or 3
every day and/or night? 4
REFUSED 7
DON’T KNOW 9
KIQ.044 During the past 12 months, {have you/has SP} leaked or lost control of even a small amount of urine with an urge or pressure to urinate and {you/s/he} couldn’t get to the toilet fast enough?
YES 1
NO 2 (KIQ.046)
REFUSED 7 (KIQ.046)
DON’T KNOW 9 (KIQ.046)
05KIQ.450 How frequently does this occur? Would {you/s/he} say this occurs. . .
less than once a month, 1
a few times a month, 2
a few times a week, or 3
every day and/or night? 4
REFUSED 7
DON’T KNOW 9
KIQ.046 During the past 12 months, {have you/has SP} leaked or lost control of even a small amount of urine without an activity like coughing, lifting, or exercise, or an urge to urinate?
YES 1
NO 2 (05BOX 1)
REFUSED 7 (05BOX 1)
DON'T KNOW 9 (05BOX 1)
05KIQ.470 How frequently does this occur? Would {you/s/he} say this occurs . . .
less than once a month, 1
a few times a month, 2
a few times a week, or 3
every day and/or night? 4
REFUSED 7
DON’T KNOW 9
05BOX 1
CHECK ITEM KIQ.048A:
IF 'YES' (CODED '1') IN KIQ.042 OR KIQ.044 OR KIQ.046, CONTINUE WITH KIQ.050.
OTHERWISE, GO TO 05KIQ.480.
KIQ.050 During the past 12 months, how much did {your/her/his} leakage of urine bother {you/her/him}? Please select one of the following choices:
not at all, 1
only a little, 2
somewhat, 3
very much, or 4
greatly? 5
REFUSED 7
DON'T KNOW 9
KIQ.052 During the past 12 months, how much did {your/his/her} leakage of urine affect {your/his/her} day-to-day activities? Please select one of the following choices:
not at all, 1
only a little, 2
somewhat, 3
very much, or 4
greatly? 5
REFUSED 7
DON'T KNOW 9
05KIQ.480 During the past 30 days, how many times per night did {you/SP} most typically get up to urinate, from the time {you/s/he} went to bed at night until the time {you/he/she} got up in the morning. Would {you/s/he} say . . .
0, 1
1, 2
2, 3
3, 4
4, 5
5 or more? 6
REFUSED 7
DON'T KNOW 9
05BOX 2
CHECK ITEM KIQ.070:
IF SP FEMALE, GO TO END OF SECTION.
IF SP MALE AGE 20-39, GO TO 05KIQ.490.
OTHERWISE, CONTINUE WITH KIQ.080.
KIQ.080 {Do you/Does SP} usually have trouble starting to urinate (pass water)?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
KIQ.100 After urinating (passing water), does {your/his} bladder feel empty?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
05KIQ.490 The next set of questions is about men’s health including urinary and prostate problems. The prostate is a gland located just below the bladder.
{Have you/Has SP} ever been told by a doctor or health professional that {you have/he has} any disease of the prostate? This includes an enlarged prostate.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
05BOX 3
CHECK ITEM KIQ.170:
IF SP AGE IS 20-39, GO TO END OF SECTION.
OTHERWISE, CONTINUE WITH KIQ.120.
KIQ.120 {Have you/Has SP} ever been told by a doctor or health professional that {you/he} had an enlarged prostate gland?
YES 1
NO 2 (KIQ.360)
REFUSED 7 (KIQ.360)
DON'T KNOW 9 (KIQ.360)
KIQ.140 Was it a benign enlargement – that is, not cancerous, also called benign prostatic hypertrophy?
YES 1
NO 2 (KIQ.180)
REFUSED 7 (KIQ.180)
DON'T KNOW 9 (KIQ.180)
KIQ.160 How old {were you/was SP} when {you were/he was} first told that {you/he} had benign enlargement of the prostate gland?
|___|___|___|
ENTER AGE IN YEARS
REFUSED 777
DON'T KNOW 999
05BOX 4
CHECK ITEM KIQ.230:
GO TO KIQ.360.
KIQ.180 Was the enlargement due to cancer?
YES 1
NO 2
REFUSED 7
KIQ.360 {Have you/Has SP} ever had a rectal examination to check for prostate cancer? A rectal examination is usually done by a doctor who inserts a finger in the rectum to check for problems.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
05BOX 1
CHECK ITEM BHQ.005:
IF INTERVIEW DONE ONLY WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), CONTINUE WITH 05BHQ.010.
OTHERWISE, GO TO NEXT SECTION.
05BHQ.010 Next, we’d like to talk to you about bowel health. We’ll start with accidental bowel leakage. There are four types of bowel leakage that can happen: leakage (passing) of gas, leakage of mucus, leakage of liquid stool, and leakage of solid stool. We will ask you about leakage of each of these one at a time.
How often during the past 30 days have you had any amount of accidental bowel leakage that consisted of gas? Would you say . . .
HAND CARD BHQ1
CAPI INSTRUCTION:
HELP SCREEN SHOULD READ: The bowel is another name for the intestines. Other names for the bowel include guts or innards. Accidental bowel leakage is leaking from the bowel or intestines that can’t be controlled. Leakage of gas is also called passing gas, passing wind, or farting.
2 or more times a day, 1
once a day, 2
2 or more times a week, 3
once a week, 4
1-3 times a month, or 5
never? 6
REFUSED 77
DON'T KNOW 99
05BHQ.020 How often during the past 30 days have you had any amount of accidental bowel leakage that consisted of mucus?
HAND CARD BHQ1
CAPI INSTRUCTION:
HELP SCREEN SHOULD READ: Mucus is a thick, jelly-like substance made by the intestines that helps coat and protect the lining of the intestine. Mucus also helps stool pass through the large intestine and rectum more easily.
2 OR MORE TIMES A DAY 1
ONCE A DAY 2
2 OR MORE TIMES A WEEK 3
ONCE A WEEK 4
1-3 TIMES A MONTH 5
NEVER 6
REFUSED 77
DON'T KNOW 99
05BHQ.030 How often during the past 30 days have you had any amount of accidental bowel leakage that consisted of liquid stool?
HAND CARD BHQ1
CAPI INSTRUCTION:
HELP SCREEN SHOULD READ: Stool is also called a bowel movement, BM, or poop.
2 OR MORE TIMES A DAY 1
ONCE A DAY 2
2 OR MORE TIMES A WEEK 3
ONCE A WEEK 4
1-3 TIMES A MONTH 5
NEVER 6
REFUSED 77
DON'T KNOW 99
05BHQ.040 How often during the past 30 days have you had any amount of accidental bowel leakage that consisted of solid stool?
HAND CARD BHQ1
2 OR MORE TIMES A DAY 1
ONCE A DAY 2
2 OR MORE TIMES A WEEK 3
ONCE A WEEK 4
1-3 TIMES A MONTH 5
NEVER 6
REFUSED 77
DON'T KNOW 99
05BHQ.050 How often do you usually have bowel movements?
Q/U
PROBE: How many times per day or per week do you usually have a bowel movement?
|___|___|
ENTER NUMBER OF TIMES (PER DAY OR PER WEEK)
REFUSED 77
DON'T KNOW 99
ENTER UNIT
DAY 1
WEEK 2
REFUSED 7
DON’T KNOW 9
05BHQ.060 Please look at this card and tell me the number that corresponds to your usual or most common stool type.
HAND CARD BHQ2
TYPE
1 (SEPARATE HARD LUMPS, LIKE
NUTS) 1
TYPE 2 (SAUSAGE-LIKE, BUT LUMPY) 2
TYPE
3 (LIKE A SAUSAGE BUT WITH
CRACKS IN THE SURFACE) 3
TYPE
4 (LIKE A SAUSAGE OR SNAKE,
SMOOTH AND SOFT) 4
TYPE
5 (SOFT BLOBS WITH CLEAR-CUT
EDGES) 5
TYPE
6 (FLUFFY PIECES WITH RAGGED
EDGES, A MUSHY STOOL) 6
TYPE 7 (WATERY, NO SOLID PIECES) 7
REFUSED 77
DON'T KNOW 99
physical activity AND PHYSICAL FITNESS (paq)
PAQ.605 Next I am going to ask you about the time you spend doing different types of physical activity in a typical week. Please answer these questions even if you do not consider yourself to be a physically active person.
Think first about the time you spend doing work. Think of work as the things that you have to do such as paid or unpaid work, studying or training, household chores, and yard work. In answering the following questions ‘vigorous-intensity activities’ are activities that require hard physical effort and cause large increases in breathing or heart rate, ‘moderate-intensity activities’ are activities that require moderate physical effort and cause small increases in breathing or heart rate.
Does your work involve vigorous-intensity activity that causes large increases in breathing or heart rate like carrying or lifting heavy loads, digging or construction work for at least 10 minutes continuously?
YES 1
NO 2 (PAQ.620)
REFUSED 7 (PAQ.620)
DON’T KNOW 9 (PAQ.620)
PAQ.610 In a typical week, on how many days do you do vigorous-intensity activities as part of your work?
HARD EDIT: Less than 1 day or more than 7 days
Error Message: The number of days should be between 1 and 7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 77 (PAQ.620)
DON’T KNOW 99 (PAQ.620)
PAQ.615 How much time do you spend doing vigorous–intensity activities at work on a typical day?
Q/U
SOFT EDIT: 12 hours or more.
Error Message: Please verify times of 12 hours or more.
HARD EDIT: Less than 10 minutes or 24 hours or more.
Error Message: The time should be 10 minutes or more, but less than 24 hours.
|___|___|___|
ENTER NUMBER (OF MINUTES OR HOURS)
REFUSED 777
DON’T KNOW 999
ENTER UNIT
MINUTES 1
HOURS 2
REFUSED 7
DON’T KNOW 9
PAQ.620 Does your work involve moderate-intensity activity that causes small increases in breathing or heart rate such as brisk walking or carrying light loads for at least 10 minutes continuously?
YES 1
NO 2 (PAQ.635)
REFUSED 7 (PAQ.635)
DON’T KNOW 9 (PAQ.635)
PAQ.625 In a typical week, on how many days do you do moderate-intensity activities as part of your work?
HARD EDIT: Less than 1 day or more than 7 days
Error Message: The number of days should be between 1 and 7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 77 (PAQ.635)
DON’T KNOW 99 (PAQ.635)
PAQ.630 How much time do you spend doing moderate-intensity activities at work on a typical day?
Q/U
SOFT EDIT: 12 hours or more.
Error Message: Please verify times of 12 hours or more.
HARD EDIT: Less than 10 minutes or 24 hours or more.
Error Message: The time should be 10 minutes or more, but less than 24 hours.
|___|___|___|
ENTER NUMBER (OF MINUTES OR HOURS)
REFUSED 777
DON’T KNOW 999
ENTER UNIT
MINUTES 1
HOURS 2
REFUSED 7
DON’T KNOW 9
PAQ.635 The next questions exclude the physical activity of work that you have already mentioned. Now I would like to ask you about the usual way you travel to and from places. For example to school, for shopping, to work.
Do you walk or use a bicycle for a least 10 minutes continuously to get to and from places?
YES 1
NO 2 (PAQ.650)
REFUSED 7 (PAQ.650)
DON’T KNOW 9 (PAQ.650)
PAQ.640 In a typical week, on how many days do you walk or bicycle for at least 10 minutes continuously to get to and from places?
HARD EDIT: Less than 1 day or more than 7 days
Error Message: The number of days should be between 1 and 7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 77 (PAQ.650)
DON’T KNOW 99 (PAQ.650)
PAQ.645 How much time do you spend walking or bicycling for travel on a typical day?
Q/U
SOFT EDIT: 12 hours or more.
Error Message: Please verify times of 12 hours or more.
HARD EDIT: Less than 10 minutes or 24 hours or more.
Error Message: The time should be 10 minutes or more, but less than 24 hours.
|___|___|___|
ENTER NUMBER (OF MINUTES OR HOURS)
REFUSED 777
DON’T KNOW 999
ENTER UNIT
MINUTES 1
HOURS 2
REFUSED 7
DON’T KNOW 9
PAQ.650 The next questions exclude the work and transport activities that you have already mentioned. Now I would like to ask you about sports, fitness and recreational activities.
Do you do any vigorous-intensity sports, fitness, or recreational activities that cause large increases in breathing or heart rate like running or basketball for at least 10 minutes continuously?
YES 1
NO 2 (PAQ.665)
REFUSED 7 (PAQ.665)
DON’T KNOW 9 (PAQ.665)
PAQ.655 In a typical week, on how many days do you do vigorous-intensity sports, fitness or recreational activities?
HARD EDIT: Less than 1 day or more than 7 days
Error Message: The number of days should be between 1 and 7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 77 (PAQ.665)
DON’T KNOW 99 (PAQ.665)
PAQ.660 |
How much time do you spend doing vigorous – intensity sports, fitness or recreational activities on a typical day? |
SOFT EDIT: 12 hours or more.
Error Message: Please verify times of 12 hours or more.
HARD EDIT: Less than 10 minutes or 24 hours or more.
Error Message: The time should be 10 minutes or more, but less than 24 hours.
|___|___|___|
ENTER NUMBER (OF MINUTES OR HOURS)
REFUSED 777
DON’T KNOW 999
ENTER UNIT
MINUTES 1
HOURS 2
REFUSED 7
DON’T KNOW 9
PAQ.665 Do you do any moderate-intensity sports, fitness, or recreational activities that cause a small increase in breathing or heart rate like such as brisk walking, bicycling, swimming, or volleyball for at least 10 minutes continuously?
YES 1
NO 2 (PAQ.680Q)
REFUSED 7 (PAQ.680Q)
DON’T KNOW 9 (PAQ.680Q)
PAQ.670 In a typical week, on how many days do you do moderate-intensity sports, fitness or recreational activities?
HARD EDIT: Less than 1 day or more than 7 days
Error Message: The number of days should be between 1 and 7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 77 (PAQ.680Q)
DON’T KNOW 99 (PAQ.680Q)
PAQ.675 |
How much time do you spend doing moderate –intensity sports, fitness or recreational activities on a typical day? |
SOFT EDIT: 12 hours or more.
Error Message: Please verify times of 12 hours or more.
HARD EDIT: Less than 10 minutes or 24 hours or more.
Error Message: The time should be 10 minutes or more, but less than 24 hours.
|___|___|___|
ENTER NUMBER (OF MINUTES OR HOURS)
REFUSED 777
DON’T KNOW 999
ENTER UNIT
MINUTES 1
HOURS 2
REFUSED 7
DON’T KNOW 9
PAQ.680 |
The following question is about sitting or reclining at school, at home, at work, getting to and from places, or with friends including time spent sitting at a desk, sitting with friends, traveling in car, bus, train, reading, playing cards or watching television, but do not include time spent sleeping. |
How much time do you usually spend sitting or reclining on a typical day?
SOFT EDIT: 12 hours or more.
Error Message: Please verify times of 12 hours or more.
HARD EDIT: 24 hours or more.
Error Message: The time should be less than 24 hours.
|___|___|___|
ENTER NUMBER (OF MINUTES OR HOURS)
REFUSED 777
DON’T KNOW 999
ENTER UNIT
MINUTES 1
HOURS 2
REFUSED 7
DON’T KNOW 9
BOX 1
CHECK ITEM WHQ.499:
IF INTERVIEW DONE ONLY WITH SURVEY PARTICIPANT (CODED ‘1’) IN RIQ.005), CONTINUE WITH WHQ.030c.
OTHERWISE, GO TO NEXT SECTION.
WHQ.030c Do you consider yourself now to be . . .
fat or overweight, 1
too thin, or 2
about the right weight? 3
REFUSED 7
DON’T KNOW 9
WHQ.500 Which of the following are you trying to do about your weight:
lose weight, 1
gain weight, 2 (WHQ.520)
stay the same weight, or. 3 (WHQ.520)
not trying to do anything about your weight? 4 (WHQ.520)
REFUSED 7 (WHQ.520)
DON’T KNOW 9 (WHQ.520)
WHQ.511 Why are you trying to lose weight? (Check all that apply)
HAND CARD WHQ1 [CATEGORIES 22, 23, AND 24 APPEAR ON INTERVIEWER’S SCREEN ONLY]
I WANT TO LOOK BETTER 10
I WANT TO BE HEALTHIER 11
I WANT TO BE BETTER AT SPORTS AND
OTHER PHYSICAL ACTIVITIES 12
I GET TEASED ABOUT MY WEIGHT 13
I THINK MY CLOTHES WILL FIT BETTER 14
I THINK BOYS WILL LIKE ME BETTER 15
I THINK GIRLS WILL LIKE ME BETTER 16
MY FRIENDS ARE TRYING TO LOSE
WEIGHT 17
SOMEONE IN MY FAMILY IS TRYING TO
LOSE WEIGHT 18
MY MOTHER OR FATHER WANTS ME
TO LOSE WEIGHT 19
MY TEACHER OR COACH WANTS
ME TO LOSE WEIGHT 20
A DOCTOR, NURSE, OR OTHER HEALTH
PROFESSIONAL WANTS ME TO LOSE
WEIGHT 21
I
DON’T WANT TO BE FAT 22
I WANT TO BE SKINNY 23
I WANT TO FEEL GOOD/BETTER ABOUT
MYSELF 24
OTHER (SPECIFY) 30
REFUSED 77
DON’T KNOW 99
WHQ.520 In the past year, how often have you tried to lose weight? Would you say . . .
never, 1 (BOX 2)
sometimes, or 2
a lot? 3
REFUSED 7
DON’T KNOW 9
WHQ.530 In the past year, how often have you been on a diet to lose weight? Would you say . . .
never, 1
sometimes, or 2
a lot? 3
REFUSED 7
DON’T KNOW 9
WHQ.540 In the past year, how often have you starved (not eaten) for a day or more to lose weight? Would you say . . .
never, 1
sometimes, or 2
a lot? 3
REFUSED 7
DON’T KNOW 9
WHQ.550 In the past year, how often have you cut back on what you ate to lose weight? Would you say . . .
never, 1
sometimes, or 2
a lot? 3
REFUSED 7
DON’T KNOW 9
WHQ.560 In the past year, how often have you skipped meals to lose weight? Would you say . . .
never, 1
sometimes, or 2
a lot? 3
REFUSED 7
DON’T KNOW 9
WHQ.570 In the past year, how often have you exercised to lose weight? Would you say . . .
never, 1
sometimes, or 2
a lot? 3
REFUSED 7
DON’T KNOW 9
WHQ.580 In the past year, how often have you eaten less sweets or fatty foods to lose weight? Would you say . . .
never, 1
sometimes, or 2
a lot? 3
REFUSED 7
DON’T KNOW 9
-
BOX 2
CHECK ITEM WHQ.709:
IF SP AGE >= 12, CONTINUE.
OTHERWISE, GO TO END OF SECTION.
DBQ.092 |
Next, I’m going to ask you about meals. By meal, I mean breakfast, lunch and dinner. During the past 7 days, how many meals did you get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines? Please do not include meals provided as part of the school lunch or school breakfast. |
|___|___|
ENTER NUMBER PER WEEK
NEVER 2 (DBQ.905)
REFUSED 77 (DBQ.905)
DON'T KNOW 99 (DBQ.905)
DBQ.900 How many of those meals did you get from a fast-food or pizza place?
|___|___|
ENTER NUMBER PER WEEK
NEVER 2
REFUSED 77
DON'T KNOW 99
DBQ.905 Some grocery stores sell “ready to eat” foods such as salads, soups, chicken, sandwiches and cooked vegetables in their salad bars and deli counters.
During the past 30 days, how often did you buy “ready to eat” foods at the grocery store? Please do not count frozen or canned foods.
|___|___|
ENTER NUMBER OF TIMES (PER DAY, WEEK, OR MONTH)
NEVER 0
REFUSED 77
DON’T KNOW 99
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
REFUSED 7
DON'T KNOW 9
DBQ.910 During the past 30 days, how often did you eat frozen meals or frozen pizzas? Here are some examples of frozen meals and frozen pizzas.
HAND CARD WHQ2
|___|___|
ENTER OF TIMES (PER DAY, WEEK, OR MONTH)
NEVER 0
REFUSED 77
DON’T KNOW 99
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
REFUSED 7
DON'T KNOW 9
PESTICIDE USE (PUQ)
PUQ.new1 In the past 7 days, were any chemical products used in your (his, her) home to control fleas, roaches, ants, termites, or other insectsPUQ.new2
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
PUQ.new2 In the past 7 days, were any chemical products used in your (his, her) lawn or garden to kill weeds?
INTERVIEWER INSTRUCTION. If the respondent says so not have a lawn or a garden –code ‘NO’.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
SMOKING (SMQ)
SMQ.620 The following questions are about cigarette smoking and other tobacco use.
Have you ever tried cigarette smoking, even 1 or 2 puffs?
VERBAL INSTRUCTIONS TO SP:
Please select Yes, No.
YES 1
NO 2 (SMQ.680)
REFUSED 7 (SMQ.680)
DON'T KNOW 9 (SMQ.680)
SMQ.630 How old were you when you smoked a whole cigarette for the first time?
IF R SAYS LESS THAN 6 YEARS, ENTER 6 YEARS.
VERBAL INSTRUCTIONS TO SP:
Please enter an age or select Never smoked a whole cigarette.
CAPI INSTRUCTION:
ACCEPTABLE VALUES: 6-19 YEARS.
|___|___|
ENTER AGE
NEVER SMOKED A WHOLE CIGARETTE 666 (SMQ.680)
REFUSED 777 (SMQ.680)
DON'T KNOW 999 (SMQ.680)
SMQ.640 During the past 30 days, on how many days did you smoke cigarettes?
VERBAL INSTRUCTIONS TO SP:
Please enter a number or enter zero if none.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 77
DON'T KNOW 99
BOX 1A
CHECK ITEM SMQ.645:
IF 'NONE' (CODE '00'), 'REFUSED' (CODE '77'), OR 'DON'T KNOW' (CODE '99') IN SMQ.640, GO TO SMQ.670.
OTHERWISE, CONTINUE WITH SMQ.650.
SMQ.650 During the past 30 days, on the days that you smoked, how many cigarettes did you smoke per day?
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|___|
ENTER NUMBER OF CIGARETTES
MORE THAN 1 PACK OF CIGARETTES 66
REFUSED 77
DON'T KNOW 99
SMQ.077 How soon after you wake up do you smoke? Would you say . . .
within 5 minutes, 1
from 6 to 30 minutes, 2
from more than 30 minutes to one hour, or 3
more than one hour? 4
REFUSED 7
DON'T KNOW 9
SMQ.660 During the past 30 days, on the days that you smoked, which brand of cigarettes did you usually smoke?
VERBAL INSTRUCTIONS TO SP:
Please select one of the following choices: Marlboro, Camel, Newport, Kool, Winston, Benson and Hedges, Salem, Some other brand.
Marlboro, 1
Camel, 2
Newport, 3
Kool, 4
Winston, 5
Benson and Hedges, 6
Salem, 7
Other 8
REFUSED 77
DON'T KNOW 99
BOX 1B
CHECK ITEM SMQ.662:
IF NEWPORT, KOOL, OR SALEM BRAND (CODED '3', '4', OR '7') REPORTED IN SMQ.660, GO TO SMQ.666.
OTHERWISE, CONTINUE WITH SMQ.664.
SMQ.664 {Were/Was} the {BRAND REPORTED IN SMQ.660} cigarettes menthol or non-menthol?
VERBAL INSTRUCTIONS TO SP:
Please select menthol, non-menthol.
CAPI INSTRUCTION:
IF SMQ.660 = 8, DISPLAY {WAS} {BRAND OF}.
MENTHOL 1
NON-MENTHOL 2
REFUSED 7
DON'T KNOW 9
SMQ.666 {Were/Was} the {BRAND REPORTED IN SMQ.660} cigarettes regulars, lights, or ultra-lights?
VERBAL INSTRUCTIONS TO SP:
Please select regulars, lights, ultra-lights.
CAPI INSTRUCTION:
IF SMQ.660 = 8, DISPLAY {WAS} {BRAND OF}.
REGULARS 1
LIGHTS 2
ULTRA-LIGHTS 3
REFUSED 7
DON'T KNOW 9
SMQ.670 During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
VERBAL INSTRUCTIONS TO SP:
Please select Yes, No.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
SMQ.680 The following questions ask about use of tobacco or nicotine products in the past 5 days.
During the past 5 days, did you use any product containing nicotine including cigarettes, pipes, cigars, chewing tobacco, snuff, nicotine patches, nicotine gum, or any other product containing nicotine?
VERBAL INSTRUCTIONS TO SP:
Please select Yes, No.
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON’T KNOW 9 (END OF SECTION)
SMQ.690 Which of these products did you use? (CHECK ALL THAT APPLY)
VERBAL INSTRUCTIONS TO SP:
Please select all that you used.
Cigarettes 1
Pipes 2
Cigars 3
Chewing tobacco 4
Snuff 5
Nicotine patches, gum, or other
nicotine product 6
REFUSED 77
DON’T KNOW 99
BOX 2
CHECK ITEM SMQ.700:
IF ‘CIGARETTES’ (CODE 1) IN SMQ.690, GO TO SMQ.710.
IF ‘PIPES’ (CODE 2) IN SMQ.690, GO TO SMQ.740.
IF ‘CIGARS’ (CODE 3) IN SMQ.690, GO TO SMQ.770.
IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.
IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.
IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.
IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.710.
SMQ.710 During the past 5 days (including today), on how many days did you smoke cigarettes?
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON'T KNOW 9
SMQ.720 During the past 5 days, on the days you smoked, how many cigarettes did you smoke each day?
IF R SAYS 95 OR MORE CIGARETTES PER DAY, ENTER 95.
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|___|___|
ENTER NUMBER OF CIGARETTES
REFUSED 777
DON'T KNOW 999
SMQ.725 When did you smoke your last cigarette? Was it . . .
today, 1
yesterday, or 2
3 to 5 days ago? 3
REFUSED 7
DON'T KNOW 9
BOX 3
CHECK ITEM SMQ.730:
IF ‘PIPES’ (CODE 2) IN SMQ.690, GO TO SMQ.740.
IF ‘CIGARS’ (CODE 3) IN SMQ.690, GO TO SMQ.770.
IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.
IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.
IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.
IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.740.
SMQ.740 During the past 5 days (including today), on how many days did you smoke a pipe?
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON'T KNOW 9
SMQ.750 During the past 5 days, on the days you smoked a pipe, how many pipes did you smoke each day?
IF R SAYS LESS THAN 1 PIPE PER DAY, ENTER 1.
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|___|
ENTER NUMBER OF PIPES
REFUSED 77
DON'T KNOW 99
SMQ.755 When did you smoke your last pipe? Was it . . .
today, 1
yesterday, or 2
3 to 5 days ago? 3
REFUSED 7
DON'T KNOW 9
BOX 4
CHECK ITEM SMQ.760:
IF ‘CIGARS’ (CODE 3) IN SMQ.690, GO TO SMQ.770.
IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.
IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.
IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.
IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.770.
SMQ.770 During the past 5 days (including today), on how many days did you smoke cigars?
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON'T KNOW 9
SMQ.780 During the past 5 days, on the days you smoked cigars, how many cigars did you smoke each day?
IF R SAYS LESS THAN 1 CIGAR PER DAY, ENTER 1.
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|___|
ENTER NUMBER OF CIGARS
REFUSED 77
DON'T KNOW 99
SMQ.785 When did you smoke your last cigar? Was it . . .
today, 1
yesterday, or 2
3 to 5 days ago? 3
REFUSED 7
DON'T KNOW 9
BOX 5
CHECK ITEM SMQ.790:
IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.
IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.
IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.
IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.800.
SMQ.800 During the past 5 days (including today), on how many days did you use chewing tobacco, such as Redman, Levi Garrett or Beechnut?
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON'T KNOW 9
SMQ.815 When did you last use chewing tobacco? Was it . . .
today, 1
yesterday, or 2
3 to 5 days ago? 3
REFUSED 7
DON'T KNOW 9
BOX 5A
CHECK ITEM SMQ.816:
IF ‘SNUFF’ (CODE 5) IN SMQ.690, GO TO SMQ.817.
IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.
IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.817.
SMQ.817 During the past 5 days (including today), on how many days did you use snuff, such as Skoal, Skoal Bandits, or Copenhagen?
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON'T KNOW 9
SMQ.819 When did you last use snuff? Was it . . .
today, 1
yesterday, or 2
3 to 5 days ago? 3
REFUSED 7
DON'T KNOW 9
BOX 6
CHECK ITEM SMQ.820:
IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.
IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.830.
OTHERWISE, GO TO END OF SECTION.
SMQ.830 During the past 5 days (including today), on how many days did you use any product containing nicotine to help you stop smoking? Include nicotine patches, gum, or any other product containing nicotine.
VERBAL INSTRUCTIONS TO SP:
Please enter a number.
|___|
ENTER NUMBER OF DAYS
REFUSED 7
DON'T KNOW 9
SMQ.840 When did you last use a product containing nicotine? Was it . .
today, 1
yesterday, or 2
3 to 5 days ago? 3
REFUSED 7
(Audio-CASI)
ALQ.010_ The following questions ask about alcohol use. This includes beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. This does not include drinking a few sips of wine for religious purposes.
ALQ.010 How old were you when you had your first drink of alcohol, other than a few sips?
INSTRUCTIONS TO SP:
Please select one of the following choices.
HARD EDIT: If (RIAAGEYR < 17 and ALQ.010 = 7) OR (RIAAGEYR < 15 and ALQ.010 in (6, 7)) OR (RIAAGEYR < 13 and ALQ.010 in (5, 6, 7)) then ERROR
Error message: “Your response is older than your recorded age. Please press the “Back” button, press “Clear,” and try again.”
I have never had a drink of
alcohol other
than a few sips 1 (END OF SECTION)
8 years old or younger 2
9 or 10 years old 3
11 or 12 years old 4
13 or 14 years old 5
15 or 16 years old 6
17 years old or older 7
REFUSED 77
DON'T KNOW 99
ALQ.022 During your life, on how many days have you had at least one drink of alcohol?
INSTRUCTIONS TO SP:
Please select one of the following choices.
1 or 2 days 2
3 to 9 days 3
10 to 19 days 4
20 to 39 days 5
40 to 99 days 6
100 or more days 7
REFUSED 77
DON'T KNOW 99
ALQ.031 During the past 30 days, on how many days did you have at least one drink of alcohol?
INSTRUCTIONS TO SP:
Please select one of the following choices.
HARD EDIT: If (ALQ.022 = 2 and ALQ.031 in (3,4,5,6,7)) or (ALQ.022 =3 and ALQ.031 in (5,6,7)) or (ALQ.022 = 4 and ALQ.031 in (6,7)) then ERROR
Error message: “Your response is not consistent with your lifetime use. Please press the “Back” button, press “Clear,” and try again.”
0 days 1 (END OF SECTION)
1 or 2 days 2
3 to 5 days 3
6 to 9 days 4
10 to 19 days 5
20 to 29 days 6
All 30 days 7
REFUSED 77
DON'T KNOW 99
ALQ.041 During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours?
INSTRUCTIONS TO SP:
Please select one of the following choices.
HARD EDIT: If (ALQ.031= 2 and ALQ.041 in (4,5,6,7)) or (ALQ.031=3 and ALQ.041 in (5,6,7)) or (ALQ.031 = 4 and ALQ.041 in (6,7)) or (ALQ.031 = 5 and ALQ.041 = 7) then ERROR
Error message: “Your response is not consistent with your use in the past 30 days. Please press the “Back” button, press “Clear,” and try again.”
0 days 1
1 day 2
2 days 3
3 to 5 days 4
6 to 9 days 5
10 to 19 days 6
20 or more days 7
REFUSED 77
DON'T KNOW 99
Target Group: SPs 12-69 (Audio-CASI)
05DUQ.200_ The following questions ask about use of drugs not prescribed by a doctor. Please remember that your answers to these questions are strictly confidential.
The first questions are about marijuana and hashish. Marijuana is also called pot or grass. Marijuana is usually smoked, either in cigarettes, called joints, or in a pipe. It is sometimes cooked in food. Hashish is a form of marijuana that is also called “hash.” It is usually smoked in a pipe. Another form of hashish is hash oil.
07BOX NEW1
CHECK ITEM 07DUQ.NEWBOXITEM1:
IF 60 – 69 YEARS GO TO 05DUQ.240
ELSE CONTINUE
05DUQ.200 Have you ever, even once, used marijuana or hashish?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2 (05DUQ.240)
REFUSED 7 (05DUQ.240)
DON'T KNOW 9 (05DUQ.240)
05DUQ.210 How old were you the first time you used marijuana or hashish?
INSTRUCTIONS TO SP:
Please enter an age.
|___|___|
ENTER AGE IN YEARS
REFUSED 77
DON'T KNOW 99
HARD EDIT VALUES: 0-59
Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”
HARD EDIT: 05DUQ.210 must be equal to or less than current age.
Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”
05DUQ.220 How long has it been since you last used marijuana or hashish?
G/Q/U
INSTRUCTIONS TO SP:
Please enter the number of days, weeks, months, or years, then select the unit of time.
CAPI INSTRUCTIONS:
If SP Ref/DK then store 7/9 in DUQ.220G and DUQ.220U, 7/9-fill in DUQ.220Q
If a value is entered in Quantity and Unit store Quantity in DUQ.220Q, Unit in DUQ.220U and 1 in DUQ.220G
HARD EDIT: Response must be equal to or less than current age minus DUQ.210.
Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”
|___|___|___|
ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS
REFUSED 777
DON'T KNOW 999
ENTER UNIT
Days 1
Weeks 2
Months 3
Years 4
REFUSED 7
DON'T KNOW 9
05BOX 1
CHECK ITEM 05DUQ.225:
IF SP USED MARIJUANA WITHIN THE PAST MONTH (CODED 1-30 DAYS, OR 1-4 WEEKS, OR 1 MONTH IN 05DUQ.220), CONTINUE WITH 05DUQ.230.
OTHERWISE, GO TO 05DUQ.240.
05DUQ.230 During the past 30 days, on how many days did you use marijuana or hashish?
INSTRUCTIONS TO SP:
Please enter a number.
HARD EDIT VALUES: 1-30.
If DUQ.230 = 0, display error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.
If DUQ.230 > 30, display error message: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”
|___|___|
ENTER A NUMBER
REFUSED 77
DON'T KNOW 99
(Ages 14-69)
05DUQ.240 Have you ever used cocaine, crack cocaine, heroin, or methamphetamine?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2 (05DUQ.370)
REFUSED 7 (05DUQ.370)
DON'T KNOW 9 (05DUQ.370)
(Ages 14-69)
05DUQ.250_ The following questions are about cocaine, including all the different forms of cocaine such as powder, ‘crack’, ‘free base’, and coca paste.
05DUQ.250 Have you ever, even once, used cocaine, in any form?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2 (05DUQ.290)
REFUSED 7 (05DUQ.290)
DON'T KNOW 9 (05DUQ.290)
07BOX NEW2
CHECK ITEM 07DUQ.NEWBOXITEM2:
IF 60 – 69 YEARS GO TO 05DUQ.290
ELSE CONTINUE
05DUQ.260 How old were you the first time you used cocaine, in any form?
INSTRUCTIONS TO SP:
Please enter an age.
|___|___|
ENTER AGE IN YEARS
REFUSED 77
DON'T KNOW 99
HARD EDIT VALUES: 0-59
Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”
HARD EDIT: 05DUQ.260 must be equal to or less than current age.
Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”
05DUQ.270 How long has it been since you last used cocaine, in any form?
G/Q/U
INSTRUCTIONS TO SP:
Please enter the number of days, weeks, months, or years, then select unit of time.
CAPI INSTRUCTIONS:
If SP Ref/DK then store 7/9 in DUQ.270G and DUQ.270U, 7/9-fill in DUQ.270Q
If a value is entered in Quantity and Unit store Quantity in DUQ.270Q, Unit in DUQ.270U and 1 in DUQ.270G
HARD EDIT: Response must be equal to or less than current age minus DUQ.260.
Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”
|___|___|___|
ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS
REFUSED 777
DON'T KNOW 999
ENTER UNIT
Days 1
Weeks 2
Months 3
Years 4
REFUSED 7
DON'T KNOW 9
05DUQ.272 During your life, altogether how many times have you used cocaine, in any form?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Once 1
2-5 times 2
6-19 times 3
20-49 times 4
50-99 times 5
100 times or more 6
REFUSED 77
DON’T KNOW 99
05BOX 2
CHECK ITEM 05DUQ.275:
IF SP USED COCAINE WITHIN THE PAST MONTH (CODED 1-30 DAYS, OR 1-4 WEEKS, OR 1 MONTH IN 05DUQ.270), CONTINUE WITH 05DUQ.280.
OTHERWISE, GO TO 05DUQ.290.
05DUQ.280 During the past 30 days, on how many days did you use cocaine, in any form?
INSTRUCTIONS TO SP:
Please enter a number
HARD EDIT VALUES: 1-30.
If DUQ.280 = 0, display error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.
If DUQ.280 > 30, display error message: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”
|___|___|
ENTER A NUMBER
REFUSED 77
DON'T KNOW 99
(Ages 14-69)
05DUQ.290_ The following questions are about heroin.
05DUQ.290 Have you ever, even once, used heroin?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2 (05DUQ.330)
REFUSED 7 (05DUQ.330)
DON'T KNOW 9 (05DUQ.330)
07NEWBOX3
CHECK ITEM 07NEWBOX3:
IF 05DUQ.290=1 AND SP 60-69 YEARS GO TO 05DUQ.330
OTHERWISE, CONTINUE.
05DUQ.300 How old were you the first time you used heroin?
INSTRUCTIONS TO SP:
Please enter an age.
|___|___|
ENTER AGE IN YEARS
REFUSED 77
DON'T KNOW 99
HARD EDIT VALUES: 0-59
Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”
HARD EDIT: 05DUQ.300 must be equal to or less than current age.
Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”
05DUQ.310 How long has it been since you last used heroin?
G/Q/U
INSTRUCTIONS TO SP:
Please enter the number of days, weeks, months, or years, then select the unit of time.
CAPI INSTRUCTIONS:
If SP Ref/DK then store 7/9 in DUQ.310G and DUQ.310U, 7/9-fill in DUQ.310Q
If a value is entered in Quantity and Unit store Quantity in DUQ.310Q, Unit in DUQ.310U and 1 in DUQ.310G
HARD EDIT: Response must be equal to or less than current age minus DUQ.300.
Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”
|___|___|___|
ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS
REFUSED 777
DON'T KNOW 999
ENTER UNIT
Days 1
Weeks 2
Months 3
Years 4
REFUSED 7
DON'T KNOW 9
05BOX 3
CHECK ITEM 05DUQ.315:
IF SP USED HEROIN WITHIN THE PAST MONTH (CODED 1-30 DAYS, OR 1-4 WEEKS, OR 1 MONTH IN 05DUQ.310), CONTINUE WITH 05DUQ.320.
OTHERWISE, GO TO 05DUQ.330.
05DUQ.320 During the past 30 days, on how many days did you use heroin?
INSTRUCTIONS TO SP:
Please enter a number.
HARD EDIT VALUES: 1-30.
If DUQ.320 = 0, display error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.
If DUQ.320 > 30, display error message: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”
|___|___|
ENTER A NUMBER
REFUSED 77
DON'T KNOW 99
05DUQ.330_ The following questions are about methamphetamine, also known as crank, crystal, ice or speed.
(Ages 14-69)
05DUQ.330 Have you ever, even once, used methamphetamine?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2 (05DUQ.370)
REFUSED 7 (05DUQ.370)
DON'T KNOW 9 (05DUQ.370)
07NEWBOX4
CHECK ITEM 07NEWBOX4:
IF 05DUQ.330=1 AND SP 60-69 YEARS GO TO 05DUQ.370
OTHERWISE, CONTINUE.
05DUQ.340 How old were you the first time you used methamphetamine?
INSTRUCTIONS TO SP:
Please enter an age.
|___|___|
ENTER AGE IN YEARS
REFUSED 77
DON'T KNOW 99
HARD EDIT VALUES: 0-59
Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”
HARD EDIT: 05DUQ.340 must be equal to or less than current age.
Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”
05DUQ.350 How long has it been since you last used methamphetamine?
G/Q/U
INSTRUCTIONS TO SP:
Please enter the number of days, weeks, months, or years, then select the unit of time.
CAPI INSTRUCTIONS:
If SP Ref/DK then store 7/9 in DUQ.350G and DUQ.350U, 7/9-fill in DUQ.350Q
If a value is entered in Quantity and Unit store Quantity in DUQ.350Q, Unit in DUQ.350U and 1 in DUQ.350G
HARD EDIT: Response must be equal to or less than current age minus DUQ.340.
Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”
|___|___|___|
ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS
REFUSED 777
DON'T KNOW 999
ENTER UNIT
Days 1
Weeks 2
Months 3
Years 4
REFUSED 7
DON'T KNOW 9
05DUQ.352 During your life, altogether how many times have you used methamphetamine?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Once 1
2-5 times 2
6-19 times 3
20-49 times 4
50-99 times 5
100 times or more 6
REFUSED 77
DON’T KNOW 99
05BOX 4
CHECK ITEM 05DUQ.355:
IF SP USED METHAMPHETAMINE WITHIN THE PAST MONTH (CODED 1-30 DAYS, OR 1-4 WEEKS, OR 1 MONTH IN 05DUQ.350), CONTINUE WITH 05DUQ.360.
OTHERWISE, GO TO 05DUQ.370.
05DUQ.360 During the past 30 days, on how many days did you use methamphetamine?
INSTRUCTIONS TO SP:
Please enter a number.
HARD EDIT VALUES: 1-30.
If DUQ.360 = 0, display error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.
If DUQ.360 > 30, display error message: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”
|___|___|
ENTER A NUMBER
REFUSED 77
DON'T KNOW 99
(Ages 14-69)
05DUQ.370_ The following questions are about the different ways that certain drugs can be used.
05DUQ.370 Have you ever, even once, used a needle to inject a drug not prescribed by a doctor?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2 (05BOX 5)
REFUSED 7 (05BOX 5)
DON'T KNOW 9 (05BOX 5)
(Ages 14-69)
05DUQ.380 Which of the following drugs have you injected using a needle?
INSTRUCTIONS TO SP:
Please select all the drugs that you injected.
CAPI INSTRUCTION:
SHOW ALL FIVE ITEMS ON SINGLE ACASI SCREEN
HARD EDIT: AT LEAST ONE ITEM IN 05DUQ.380 MUST BE SELECTED.
Error message: “Earlier you reported using a needle to inject drugs not prescribed by a doctor. Which of these drugs did you inject?”
Cocaine 1
Heroin 2
Methamphetamine 3
Steroids 4
Any other drugs 5
REFUSED 7
DON'T KNOW 9
(Ages 14-69)
05DUQ.390 How old were you when you first used a needle to inject any drug not prescribed by a doctor?
INSTRUCTIONS TO SP:
Please enter an age.
|___|___|
ENTER AGE IN YEARS
REFUSED 77
DON'T KNOW 99
HARD EDIT VALUES: 0-59
Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”
HARD EDIT: 05DUQ.390 must be equal to or less than current age.
Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”
(Ages 14-69)
05DUQ.400 How long ago has it been since you last used a needle to inject a drug not prescribed by a doctor?
G/Q/U
INSTRUCTIONS TO SP:
Please enter the number of days, weeks, months, or years, then select the unit of time.
CAPI INSTRUCTIONS:
If SP Ref/DK then store 7/9 in DUQ.400G and DUQ.400U, 7/9-fill in DUQ.400Q
If a value is entered in Quantity and Unit store Quantity in DUQ.400Q, Unit in DUQ.400U and 1 in DUQ.400G
HARD EDIT: Response must be equal to or less than current age minus DUQ.390.
Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”
|___|___|___|
ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS
REFUSED 777
DON'T KNOW 999
ENTER UNIT
Days 1
Weeks 2
Months 3
Years 4
REFUSED 7
DON'T KNOW 9
(Ages 14-69)
05DUQ.410 During your life, altogether how many times have you injected drugs not prescribed by a doctor?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Once 1 (05DUQ.430)
2-5 times 2
6-19 times 3
20-49 times 4
50-99 times 5
100 times or more 6
REFUSED 77
DON’T KNOW 99
(Ages 14-69)
05DUQ.420 Think about the period of your life when you injected drugs the most often. How often did you inject then?
INSTRUCTIONS TO SP:
Please select one of the following choices.
More than once a day 1
About once a day 2
At least once a week but not every day 3
At least once a month but not every week 4
Less than once a month 5
REFUSED 7
DON’T KNOW 9
05BOX 5
CHECK ITEM 05DUQ.425:
IF SP 60-69 YEARS END
IF SP HAS USED MARIJUANA (CODED ‘1’) IN 05DUQ.200 OR SP HAS USED COCAINE, HEROIN, OR METHAMPHETAMINE (CODED ‘1’) IN 05DUQ.240, OR SP HAS INJECTED ANY DRUG NOT PRESCRIBED BY A DOCTOR (CODED ‘1’) IN 05DUQ.370, GO TO 05DUQ.430.
OTHERWISE, GO TO END OF SECTION.
05DUQ.430 Have you ever been in a drug treatment or drug rehabilitation program?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
Target Group: SPs 14-69 (Audio-CASI)
SXQ.021_ The next set of questions is about your sexual behavior. By sex, we mean vaginal, anal, or oral sex. Please remember that your answers are strictly confidential.
SXQ.021 Have you ever had vaginal, anal, or oral sex?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2 (BOX 11)
REFUSED 7 (BOX 11)
DON'T KNOW 9 (BOX 11)
SXQ.031 When you first had vaginal, anal, or oral sex, how old were you?
INSTRUCTIONS TO SP:
Please enter an age.
|___|___|
ENTER AGE IN YEARS
REFUSED 77
DON'T KNOW 99
HARD EDIT VALUES: 0-59
Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”
HARD EDIT: SXQ.031 must be equal to or less than current age.
Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”
05BOX 3
CHECK ITEM SXQ.090:
IF SP MALE, GO TO SXQ.171.
OTHERWISE, CONTINUE WITH SXQ.101.
SXQ.101 In your lifetime, with how many men have you had vaginal, anal, or oral sex?
VERBAL INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
05BOX 4
CHECK ITEM SXQ.110:
IF SP 60-69 YEARS, END
IF SP NEVER HAD MALE PARTNER (CODED '0000') IN SXQ.101, GO TO SXQ.130.
OTHERWISE, CONTINUE WITH 05SXQ.350.
05SXQ.350 With how many of these men have you had only oral sex?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
HARD EDIT: 05SXQ.350 must be equal to or less than SXQ.101.
Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear”, and try again.”
SXQ.130 In your lifetime, with how many women have you had sex?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
05BOX 5
CHECK ITEM 05SXQ.370:
IF SP FEMALE, GO TO 05BOX 9.
OTHERWISE, CONTINUE WITH SXQ.171.
SXQ.171 In your lifetime, with how many women have you had vaginal, anal, or oral sex?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
05BOX 7
CHECK ITEM 05SXQ.390:
IF SP 60-69 YEARS, GO TO SXQ.410 .
IF SP NEVER HAD FEMALE PARTNER (CODED '0000') IN SXQ.171, GO TO 05SXQ.410.
OTHERWISE, CONTINUE WITH 05SXQ.400.
05SXQ.400 With how many of these women have you had only oral sex?
VERBAL INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
HARD EDIT: 05SXQ.400 must be equal to or less than SXQ.171.
Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear”, and try again.”
05SXQ.410 In your lifetime, with how many men have you had anal or oral sex?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
05BOX 8
CHECK ITEM SXQ.210:
IF SP NEVER HAD MALE PARTNER (CODED '0000') IN 05SXQ.410 AND SP IS 60-69 YEARS, END.
IF SP NEVER HAD MALE PARTNER (CODED '0000') IN 05SXQ.410, GO TO 05BOX 9.
OTHERWISE, CONTINUE WITH 05SXQ.430.
05SXQ.430 With how many of these men have you had only oral sex?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
HARD EDIT: 05SXQ.430 must be equal to or less than SXQ.410.
Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear”, and try again.”
05BOX 9
CHECK ITEM SXQ.230:
IF SP IS 60-69 YEARS, END .
IF SP IS MALE, GO TO 05BOX 16.
IF SP IS FEMALE AND HAD NO MALE PARTNER (CODED ‘0000’) IN SXQ.101, GO TO 05BOX 14.
OTHERWISE, CONTINUE WITH 05SXQ.450.
05SXQ.450 In the past 12 months, with how many men have you had vaginal, anal, or oral sex?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
HARD EDIT: 05SXQ.450 must be equal to or less than SXQ.101.
Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”
05BOX 14
CHECK ITEM 05SXQ.460:
IF SP DID NOT HAVE ANY MALE PARTNER (CODED '0000') IN 05SXQ.450, GO TO 05BOX 15.
OTHERWISE, CONTINUE WITH 05SXQ.470.
05SXQ.470 With how many of these men have you had only oral sex?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
HARD EDIT: 05SXQ.470 must be equal to or less than 05SXQ.450.
Error message: “Your response is greater than your number of male partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”
05BOX 15
CHECK ITEM 05SXQ.480:
IF SP DID NOT HAVE ANY FEMALE PARTNER (CODED ‘0000’) IN SXQ.130, GO TO 05BOX 16.
OTHERWISE, CONTINUE WITH 05SXQ.490.
05SXQ.490 In the past 12 months, with how many females have you had sex?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
HARD EDIT: 05SXQ.490 must be equal to or less than SXQ.130.
Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear,” and try again.”
05BOX 16
CHECK ITEM 05SXQ.500:
IF SP IS FEMALE, GO TO 05BOX 20.
IF SP IS MALE, AND NEVER HAD FEMALE PARTNER (CODED ‘0000’) IN SXQ.171, GO TO 05BOX 18.
OTHERWISE CONTINUE WITH 05SXQ.510.
05SXQ.510 In the past 12 months, with how many women have you had vaginal, anal, or oral sex?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
HARD EDIT: 05SXQ.510 must be equal to or less than SXQ.171.
Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear,” and try again.”
05BOX 17
CHECK ITEM 05SXQ.520:
IF SP HAD NO FEMALE PARTNER (CODED '0000') IN 05SXQ.510, GO TO 05BOX 18.
OTHERWISE, CONTINUE WITH 05SXQ.530.
05SXQ.530 With how many of these females have you had only oral sex?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
HARD EDIT: 05SXQ.530 must be equal to or less than 05SXQ.510.
Error message: “Your response is greater than your number of female partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”
05BOX 18
CHECK ITEM 05SXQ.540:
IF SP NEVER HAD MALE PARTNER (CODED ‘0000’) IN 05SXQ.410, GO TO 05BOX 20.
OTHERWISE, GO TO 05SXQ.550.
05SXQ.550 In the past 12 months, with how many men have you had anal or oral sex?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
HARD EDIT: 05SXQ.550 must be equal to or less than 05SXQ.410.
Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”
05BOX 19
CHECK ITEM 05SXQ.560:
IF SP HAD NO MALE PARTNER (CODED ‘0000’) IN 05SXQ.550, GO TO 05BOX 20.
05SXQ.570 With how many of these men have you had only oral sex?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
HARD EDIT: 05SXQ.570 must be equal to or less than 05SXQ.550.
Error message: “Your response is greater than your number of male partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”
05BOX 20
CHECK ITEM 05SXQ.580:
IF SP HAD NO PARTNER IN PAST 12 MONTHS (CODED ‘0000’ IN 05SXQ.450 AND 05SXQ.490 FOR FEMALES, OR CODED ‘0000’ IN 05SXQ.510 AND 05SXQ.550 FOR MALES), GO TO SXQ.260.
OTHERWISE, CONTINUE WITH 05SXQ.590.
05SXQ.590 Of the persons you had sex with in the past 12 months, how many were five or more years older than you?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
HARD EDIT FOR FEMALES: 05SXQ.590 must be equal to or less than (sum of 05SXQ.450 and 05SXQ.490)
HARD EDIT FOR MALES: 05SXQ.590 must be equal to or less than (sum of 05SXQ.510 and 05SXQ.550)
Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”
05SXQ.600 Of the persons you had sex with in the past 12 months, how many were five or more years younger than you?
INSTRUCTIONS TO SP:
Please enter a number or enter zero for none.
|___|___|___|___|
ENTER NUMBER
REFUSED 7777
DON'T KNOW 9999
HARD EDIT FOR FEMALES: 05SXQ.600 must be equal to or less than (sum of 05SXQ.450 and 05SXQ.490)
HARD EDIT FOR MALES: 05SXQ.600 must be equal to or less than (sum of 05SXQ.510 and 05SXQ.550)
Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”
HARD EDIT (combined) for 05SXQ.590 and 05SXQ.600
HARD EDIT FOR FEMALES: (sum of 05SXQ.590 and 05SXQ.600) must be equal to or less than (sum of 05SXQ.450 and 05SXQ.490)
HARD EDIT FOR MALES: (sum of 05SXQ.590 and 05SXQ.600) must be equal to or less than (sum of SXQ.510 and SXQ.550)
Error message: "Your responses to the last two questions are inconsistent with your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again."
05SXQ.610 In the past 12 months, about how many times have you had vaginal or anal sex?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Never 0
Once 1
2-11 times 2
12-51 times 3
52-103 times 4
104-364 times 5
365 times or more 6
REFUSED 77
DON'T KNOW 99
05BOX 10
CHECK ITEM SXQ.245:
IF SP DID NOT HAVE VAGINAL OR ANAL SEX (CODED ‘0’) IN 05SXQ.610, GO TO SXQ.260.
OTHERWISE, CONTINUE WITH SXQ.250.
SXQ.250 In the past 12 months, about how often have you had vaginal or anal sex without using a condom?
INSTRUCTIONS TO SP:
Please select one of the following choices.
Never 1
Less than half of the time 2
About half of the time 3
Not always, but more than half of the time 4
Always 5
REFUSED 7
DON'T KNOW 9
SXQ.260 Has a doctor or other health care professional ever told you that you had genital herpes?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
SXQ.265 Has a doctor or other health care professional ever told you that you had genital warts?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
SXQ.270 In the past 12 months, has a doctor or other health care professional told you that you had gonorrhea, sometimes called GC or clap?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
SXQ.272 In the past 12 months, has a doctor or other health care professional told you that you had chlamydia?
INSTRUCTIONS TO SP:
Please select . . .
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
BOX 11
CHECK ITEM SXQ.275:
IF SP MALE, CONTINUE WITH SXQ.280.
IF SP FEMALE 18-59 YEARS, GO TO SXQ.294.
IF SP FEMALE 14-17 YEARS, GO TO END OF SECTION.
SXQ.280 Are you circumcised or uncircumcised?
INSTRUCTIONS TO SP:
Please select . . .
CAPI INSTRUCTIONS:
Display the sketches below each selection. Sketch should display by default.
ACASI FIGURE SXQ1 – CLINICAL SKETCH OF CIRCUMCISED PENIS
ACASI FIGURE SXQ2 – CLINICAL SKETCH OF UNCIRCUMCISED PENIS
Circumcised 1
Uncircumcised 2
REFUSED 7
DON'T KNOW 9
BOX 12
CHECK ITEM SXQ.285:
IF SP AGE 18-59 YEARS, CONTINUE WITH SXQ.292.
OTHERWISE, GO TO END OF SECTION.
SXQ.292 Do you think of yourself as . . .
Heterosexual or straight (attracted to women) 1
Homosexual or gay (attracted to men) 2
Bisexual (attracted to men and women) 3
Something else 4
Not sure 5
REFUSED 7
DON'T KNOW 9
BOX 17
CHECK ITEM SXQ.293:
END OF SECTION
SXQ.294 Do you think of yourself as . . .
Heterosexual or straight (attracted to men) 1
Homosexual or gay (attracted to women) 2
Bisexual (attracted to men and women) 3
Something else 4
Not sure 5
REFUSED 7
DON'T KNOW 9
SPECIAL FOLLOW-UP QUESTIONNAIRES
Flexible Consumer Behavior Survey (FCBS) Module
Phone Follow Up Questionnaire
-
Box 1, Ages 1-11 years
INSTRUCTIONS for CBQ.new20:
LIST ALL SP’s IN HOUSEHOLD IN DESCENDING ORDER FOR AGE AND LIST ADULTS AGES >=16 IN GREEN, 0-15 YEARS IN RED, AND “NON-SP” IN BLUE.
THIS IS A QUESTION FOR THE INTERVIEWER TO COMPLETE BY SELECTING THE APPROPRIATE OPTION. NO NEED TO READ THE QUESTION TO THE RESPONDENT.
IF “NON-SP” WAS SELECTED, THE “NAME” FIELD WILL BE ACTIVE FOR INTERVIEWER TO ENTER THE NAME.
CBQ.new20 Who is the proxy?
□ SP 1 Name
□ SP 2 Name
□ SP 3 Name
□ Non-SP (Name: ___________Relationship to SP: ______)
-
Box 2, Ages 1-11 years
IF THE PROXY IS AN SP, LINK THEIR CBQ PFU DATA TO ALL SP‘s 1-15 YEARS IN THE FAMILY AND GO TO END, OTHERWISE CONTINUE WITH CBQ.new21
CBQ.new21 Who is the person who does most of the planning or preparing of meals in your family?
□ SP 1 Name
□ SP 2 Name
□ SP 3 Name
□ Non-SP (Name: ___________Relationship to SP: ______)
CBQ.new22 {Do you/Does he/she} share in the planning or preparing of meals with someone else?
□ No
□ SP 1 Name
□ SP 2 Name
□ SP 3 Name
□ Non-SP (Name: ___________Relationship to SP: ______)
CBQ.new23 Who is the person who does most of the shopping for food in your household?
□ SP 1 Name
□ SP 2 Name
□ SP 3 Name
□ Non-SP (Name: ___________Relationship to SP: ______)
CBQ.new24 {Do you/Does he/she} share in the shopping for food with someone else?
□ No
□ SP 1 Name
□ SP 2 Name
□ SP 3 Name
□ Non-SP (Name: ___________Relationship to SP: ______)
-
Box 5, Ages 12-15 years
INSTRUCTIONS for CBQ.new25 (screen 6):
LIST ALL SP’s IN HOUSEHOLD IN DESCENDING ORDER FOR AGE AND LIST ADULTS AGES >=16 IN GREEN, 0-15 YEARS IN RED, AND “NON-SP” IN BLUE.
THIS IS A QUESTION FOR THE INTERVIEWER TO COMPLETE BY SELECTING THE APPROPRIATE OPTION. NO NEED TO READ THE QUESTION TO THE RESPONDENT.
IF “NON-SP” WAS SELECTED, THE “NAME” FIELD WILL BE ACTIVE FOR INTERVIEWER TO ENTER THE NAME.
CBQ.new25 WHO COMPLETED THE INTERVIEW?
□ SP 1 Name
□ SP 2 Name
□ SP 3 Name
□ Non-SP (Name: ___________Relationship to SP: ______)
-
Box 6, Ages 12-15 years
IF DAY 2 DIETARY INTERVIEW WAS COMPLETED BY AN ADULT SP, LINK THE PROXY’S CBQ PFU DATA TO ALL SP‘s 1-15 YEARS IN THE FAMILY AND GO TO END, OTHERWISE CONTINUE WITH CBQ.new21
CBQ.new21 Who is the person who does most of the planning or preparing of meals in your family?
□ SP 1 Name
□ SP 2 Name
□ SP 3 Name
□ Non-SP (Name: ___________Relationship to SP: ______)
CBQ.new22 {Do you/Does he/she} share in the planning or preparing of meals with someone else?
□ No
□ SP 1 Name
□ SP 2 Name
□ SP 3 Name
□ Non-SP (Name: ___________Relationship to SP: ______)
CBQ.new23 Who is the person who does most of the shopping for food in your household?
□ SP 1 Name
□ SP 2 Name
□ SP 3 Name
□ Non-SP (Name: ___________Relationship to SP: ______)
CBQ.new24 {Do you/Does he/she} share in the shopping for food with someone else?
□ No
□ SP 1 Name
□ SP 2 Name
□ SP 3 Name
□ Non-SP (Name: ___________Relationship to SP: ______)
-
Box 7, Ages 12-15 years
ISIS WILL FOLLOW THE PROTOCOL TO SELECT APPROPORATE PROXY AND DISPLAY
“Is {Proxy} home now? May I speak with him/her?”
If proxy not home, schedule appointment for a later time.
OTHERWISE, CONTINUE
CBQ.new26 In the past 12 months, did you buy food from fast food or pizza places?
Yes 1
No 2 [CBQ.new35]
REFUSED 7
DON'T KNOW 9
CBQ.new27 I’m going to read several reasons why you might buy food from fast food or pizza places instead of cooking at home.
First, do you buy food from fast food or pizza places because it is cheaper than cooking at home?
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
CBQ.new28 [Next], do you buy food from fast food or pizza places because the foods there are more nutritious than foods cooked at home?
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
CBQ.new29 [Next], do you buy food from fast food or pizza places because the foods there taste better than foods cooked at home?
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
CBQ.new30 [Next], do you buy food from fast food or pizza places because it is more convenient than cooking at home?
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
CBQ.new31 [Next], do you eat at fast food or pizza places instead of cooking at home to socialize with family and friends?
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
CBQ.new32 The last time when you ate out or bought food at a fast-food or pizza place, did you see nutrition or health information about any foods on the menu?
YES 1
NO 2 (CBQ.new34)
REFUSED 7 (CBQ.new34)
DON'T KNOW 9 (CBQ.new34)
CBQ.new33 Did you use the information in deciding which foods to buy?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
CBQ.new34 If nutrition or health information was readily available in fast food or pizza places, would you use it often, sometimes, rarely, or never, in deciding what to order?
[HAND CARD CBQ.new34]
OFTEN 1
SOMETIMES 2
RARELY 3
NEVER 4
REFUSED 7
DON'T KNOW 9
CBQ.new35 In the past 12 months, did you eat at a restaurant with waiter or waitress service?
Yes 1
No 2 [CBQ.new44]
REFUSED 7
DON'T KNOW 9
CBQ.new36 I’m going to read several reasons why you might eat at a restaurant with a waiter or waitress instead of cooking at home.
First, do you eat at a restaurant with a waiter or waitress because it is cheaper than cooking at home?
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
CBQ.new37 [Next], do you eat at a restaurant (with a waiter or waitress) because the foods there are more nutritious than foods cooked at home?
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
CBQ.new38 [Next], do you eat at a restaurant (with a waiter or waitress) because the foods there taste better than foods cooked at home?
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
CBQ.new39 [Next], do you eat at a restaurant (with a waiter or waitress) because it is more convenient than cooking at home?
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
CBQ.new40 [Next], do you eat at a restaurant (with a waiter or waitress) instead of cooking at home to socialize with family and friends?
Yes 1
No 2
REFUSED 7
DON'T KNOW 9
CBQ.new41 The last time you ate at a restaurant with a waiter or waitress, did you see nutrition or health information about any foods on the menu?
YES 1
NO 2 (CBQ.new43)
REFUSED 7 (CBQ.new43)
DON'T KNOW 9 (CBQ.new43)
CBQ.new42 Did you use the information in deciding which foods to buy?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
CBQ.new43 If nutrition information were readily available in restaurants with a waiter or waitress, would you use it often, sometimes, rarely, or never, in deciding what to order?
[HAND CARD CBQ.new34]
OFTEN 1
SOMETIMES 2
RARELY 3
NEVER 4
REFUSED 7
DON'T KNOW 9
CBQ.new44 Have you heard of MyPyramid?
YES 1 (CBQ.new46)
NO 2
REFUSED 7
DON'T KNOW 9
CBQ.new45 Have you heard of the Food Pyramid or the Food Guide Pyramid?
YES 1 (CBQ.new47)
NO 2 (CBQ.new53)
REFUSED 7 (CBQ.new53)
DON’T KNOW 9 (CBQ.new53)
CBQ.new46 Have you looked up the MyPyramid plan for a {man/woman} your age on the internet?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
CBQ.new47 Have you tried to follow the (MyPyramid Plan/Pyramid plan) recommended for you?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
-
Box 9
If CBQ.new44 is YES, Continue
If CBQ.new45 is YES, Go To CBQ.new53
CBQ.new48 Let us talk about the amounts from different food groups that a person should eat each day. How many cups of milk would you say a {man/woman} of your age and physical activity should eat each day for good health?
|___|___|.|___|
ENTER NUMBER OF CUPS
REFUSED 77
DON'T KNOW 99
CBQ.new49 How many cups of fruits would you say a {man/woman} of your age and physical activity should eat each day for good health?
|___|___|.|___|
ENTER NUMBER OF CUPS
REFUSED 77
DON'T KNOW 99
CBQ.new50 How many cups of vegetables, including dark green, orange, starchy, and other vegetables, would you say a {man/woman} of your age and physical activity should eat each day for good health?
|___|___|.|___|
ENTER NUMBER OF CUPS
REFUSED 77
DON'T KNOW 99
CBQ.new51 How many ounces of meat and beans would you say a {man/woman} of your age and physical activity should eat each day for good health?
|___|___|.|___|
ENTER NUMBER OF OUNCES
REFUSED 77
DON'T KNOW 99
CBQ.new52 How many ounces of “whole grains”, would you say a {man/woman} of your age and physical activity should eat each day for good health?
|___|___|.|___|
ENTER NUMBER OF OUNCES
REFUSED 77
DON'T KNOW 99
CBQ.new53 About how many calories do you think a {man/woman} of your age and physical activity needs to consume a day to maintain your current weight?
[HAND CARD CBQ.new53]
Less than 500 calories 1
500-1000 calories 2
1001-1500 calories 3
1501-2000 calories 4
2001-2500 calories 5
2501-3000 calories 6
More than 3000 calories 7
REFUSED 77
DON'T KNOW 99
DBQ.890 Would you say you strongly agree, somewhat agree, neither agree nor disagree, somewhat disagree, or strongly disagree with the following statement: “Some people are born to be fat and some thin; there is not much you can do to change this”?
[HAND CARD DBQ.890]
STRONGLY AGREE 1
SOMEWHAT AGREE 2
NEITHER AGREE NOR DISAGREE 3
SOMEWHAT DISAGREE 4
STRONGLY DISAGREE 5
REFUSED 7
DON'T KNOW 9
CBQ.new54 Would you say you strongly agree, somewhat agree, neither agree nor disagree, somewhat disagree, or strongly disagree with the following statement: “There is no reason for me to make changes to the things I eat”?
[HAND CARD DBQ.890]
STRONGLY AGREE 1
SOMEWHAT AGREE 2
NEITHER AGREE NOR DISAGREE 3
SOMEWHAT DISAGREE 4
STRONGLY DISAGREE 5
REFUSED 7
DON'T KNOW 9
CBQ.new55 When you buy food from a grocery store or supermarket, how important is “price”?
Would you say very important, somewhat important, not too important, or not at all important?
[HAND CARD CBQ.new55]
VERY IMPORTANT 1
SOMEWHAT IMPORTANT 2
NOT TOO IMPORTANT 3
NOT AT ALL IMPORTANT 4
NEVER BUY FROM A GROCERY STORE OR SUPERMARKET 5 (DBQ.750)
REFUSED 7
DON'T KNOW 9
CBQ.new56 When you buy food from a grocery store or supermarket, how important is “nutrition”? [Would you say very important, somewhat important, not too important, or not at all important?]
[HAND CARD CBQ.new55]
VERY IMPORTANT 1
SOMEWHAT IMPORTANT 2
NOT TOO IMPORTANT 3
NOT AT ALL IMPORTANT 4
REFUSED 7
DON'T KNOW 9
CBQ.new57 When you buy food from a grocery store or supermarket, how important is “taste”? [Would you say very important, somewhat important, not too important, or not at all important?]
[HAND CARD CBQ.new55]
VERY IMPORTANT 1
SOMEWHAT IMPORTANT 2
NOT TOO IMPORTANT 3
NOT AT ALL IMPORTANT 4
REFUSED 7
DON'T KNOW 9
CBQ.new58 When you buy food from a grocery store or supermarket, how important is “how easy the food is to prepare”? [Would you say very important, somewhat important, not too important, or not at all important?]
[HAND CARD CBQ.new55]
VERY IMPORTANT 1
SOMEWHAT IMPORTANT 2
NOT TOO IMPORTANT 3
NOT AT ALL IMPORTANT 4
REFUSED 7
DON'T KNOW 9
CBQ.new59 When you buy food from a grocery store or supermarket, how important is “how well the food keeps after it’s bought”? [Would you say very important, somewhat important, not too important, or not at all important?]
[HAND CARD CBQ.new55]
VERY IMPORTANT 1
SOMEWHAT IMPORTANT 2
NOT TOO IMPORTANT 3
NOT AT ALL IMPORTANT 4
REFUSED 7
DON'T KNOW 9
DBQ.750 Please look at handcard number XX which shows an example of the food label. [HANDCARD DBQ.new750A]
This part of the food label is called the “Nutrition Facts” panel. How often do you use the Nutrition Facts panel when deciding to buy a food product?
Would you say always, most of the time, sometimes, rarely, or never?
[HAND CARD DBQ.750]
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5 (DBQ.780)
NEVER SEEN 6 (DBQ.780)
REFUSED 7
DON'T KNOW 9
DBQ.760 How about the list of ingredients? [HAND CARD DBQ.new750A]
[How often do you use the list of ingredients when deciding to buy a food product? Would you say always, most of the time, sometimes, rarely, or never?]
[HAND CARD DBQ.750]
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
NEVER SEEN 6
REFUSED 7
DON'T KNOW 9
DBQ.770 How about the information on the size of a serving? [HAND CARD DBQ.new750A]
[How often do you use information on the size of a serving when deciding to buy a food product? Would you say always, most of the time, sometimes, rarely, or never?]
[HAND CARD DBQ.750]
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
NEVER SEEN 6
REFUSED 7
DON'T KNOW 9
CBQ.new60 How about the information on the percent daily value? [HAND CARD DBQ.new750A]
[How often do you use information on the percent daily value when deciding to buy a food product? Would you say always, most of the time, sometimes, rarely, or never?]
[HAND CARD DBQ.750]
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
REFUSED 7
DON'T KNOW 9
DBQ.780 Some food packages contain health claims about the benefits of nutrients or foods like the examples on this card. [HAND CARD DBQ.780] How often do you use this kind of health claim when deciding to buy a product?
Would you say always, most of the time, sometimes, rarely, or never?
[HANDCARD DBQ.750]
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
NEVER SEEN 6
REFUSED 7
DON'T KNOW 9
.
CBQ.new61 Now think about the “serving size” on this label. What does serving size mean to you? Please include all meanings that apply. Serving size is…
CODE ALL THAT APPLY
CAPI INSTRUCTION: IF ONLY ONE RESPONSE IS GIVEN, SHOW SCREEN DISPLAYING, “Anything else?”
[HAND CARD CBQ.new61]
The amount of this food that people should eat 1
The amount of this food that people usually eat 2
Something that makes it easier to compare foods 3
REFUSED 7
DON'T KNOW 9
CBQ.new62 Many food packages contain an expiration date such as “use by” or “sell by”. How often do you use the expiration date when deciding to buy a product?
Would you say always, most of the time, sometimes, rarely, or never?
[HAND CARDDBQ.750]
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
NEVER SEEN 6
REFUSED 7
DON'T KNOW 9
-
BOX P2
CHECK ITEM DBQ. 789New:
IF (DBQ.750 = 1-4) OR (DBQ.760 = 1-4) OR (DBQ.770 = 1-4) OR (DBQ.780 = 1-4), OR (CBQ.new60 = 1-4), CONTINUE;
OTHERWISE, GO TO CBQ.new69.
CBQ.new63 Now think about the types of food products you buy using food labels.
How often do you look for nutrition information on the food label when you buy snack items like chips, popcorn, or pretzels?
Would you say always, most of the time, sometimes, rarely, or never?
[HAND CARD DBQ.750]
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
NEVER BUY THESE ITEMS 6
REFUSED 7
DON'T KNOW 9
CBQ.new64 How often do you look for nutrition information on the food label when you buy breakfast cereals?
[Would you say always, most of the time, sometimes, rarely, or never?]
[HAND CARD DBQ.750]
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
NEVER BUY THESE ITEMS 6
REFUSED 7
DON'T KNOW 9
CBQ.new65 How often do you look for nutrition information on the food label when you buy salad dressings?
[Would you say always, most of the time, sometimes, rarely, or never?]
[HAND CARD DBQ.750]
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
NEVER BUY THESE ITEMS 6
REFUSED 7
DON'T KNOW 9
CBQ.new66 How often do you look for nutrition information on the food label when you buy raw meat, poultry, or fish? [Would you say always, most of the time, sometimes, rarely, or never?]
[HAND CARD DBQ.750]
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
NEVER BUY THESE ITEMS 6
REFUSED 7
DON'T KNOW 9
CBQ.new67 How often do you look for nutrition information on the food label when you buy processed meat products like hot dogs or bologna? [Would you say always, most of the time, sometimes, rarely, or never?]
[HAND CARD DBQ.750]
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
NEVER BUY THESE ITEMS 6
REFUSED 7
DON'T KNOW 9
CBQ.new68 How often do you look for nutrition information on the food label when you buy bread? [Would you say always, most of the time, sometimes, rarely, or never?]
[HAND CARD DBQ.750]
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
NEVER 5
NEVER BUY THIS ITEM 6
REFUSED 7
DON'T KNOW 9
CBQ.new69 In the past 30 days, did you buy any food that was labeled ‘organic’?
[HAND CARD CBQ.new69 (QP42)]
HELP SCREEN
YES 1
NO 2 (Box 6)
DO NOT SHOP FOR FOOD 3 (Box 6)
REFUSED 7 (Box 6)
DON'T KNOW 9 (Box 6)
CBQ.new70 How often do you buy organic food?
Would you say always, most of the time, sometimes, or rarely?
[HAND CARD CBQ.new69 (QP42)]
ALWAYS 1
MOST OF THE TIME 2
SOMETIMES 3
RARELY 4
REFUSED 7
DON'T KNOW 9
-
BOX 6.
CHECK ITEM CBQ.newXX:
CBQ.NEW71, DBQ.NEW7-10, CBQ.NEW72 - CBQ.NEW74 ONLY APPLY TO NON-SP PROXY:
IF SP IS 16+ YEARS, GO TO CBQ.new75.
OTHERWISE, CONTINUE.
CBQ.new71 What is your relation with {SP}?
Mother of SP 1
Father of SP 2
Grandparent of SP 3
Child care provider, Caretaker 4
Other Relative 5
Friend, Non Relative 6
REFUSED 7
DON'T KNOW 9
DBQ.new7 Are you the person who does most of the planning or preparing of meals in your household?
INTERVIEWER INSTRUCTION: IF SP ANSWERS “SOMETIMES” OR “50/50”, ENTER YES
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
DBQ.new8 Do you share in the planning or preparing of meals with someone else?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
DBQ.new9 Are you the person who does most of the shopping for food in your household?
CAPI INSTRUCTION: IF YES, ENTER “DO YOU” IN CBQ.new14; IF NO, DON’T KNOW, OR MISSING, ENTER “DOES SOMEONE” IN CBQ.new14
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
DBQ.new10 Do you share in the shopping for food with someone else?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
CBQ.new72 What is the gender of the respondent?
[Interviewer Instruction: this is a question for the interviewer to complete by selecting the appropriate option. No need to read the question to the SP]
MALE 1
FEMALE 2
CBQ.new73 How old are you?
|___|___| Years
Enter AGE
REFUSED 77
DON'T KNOW 99
CBQ.new74 Which of the following best describe your highest education level?
Less than high school 1
High school diploma (including GED), or 2
More than high school 3
REFUSED 7
DON'T KNOW 9
CBQ.new75 The interview was completed in:
INTERVIEWER INSTRUCTION:
This is a question for the interviewer to complete by selecting the appropriate option. Do not read the question to the SP.
ENGLISH 1
SPANISH 2
ENGLISH AND SPANISH 3
OTHER
End Interview--Thank you for your time. We want to emphasize that everything you have told us will be held strictly confidential. We appreciate your participation in the National Health and Nutrition Examination Survey.
HANES Hepatitis C Follow-Up Questionnaire
Telephone survey script and questionnaire:
I am calling from the NHANES program. You participated in our examination survey in _____,<month/year>, and on ______ <date> you were mailed a letter with your hepatitis C test result. Explain what report this is. Participants get preliminary results at the time of the examination, early reports of abnormal labs (liver function tests) and letters reporting other possible infection...Hepatitis B.
Did you receive a letter in the mail with your Hepatitis C test results?
1. Yes
2. No –> <verify address, describe letter and fact sheet, if absolutely no recall, resend letter, follow-up in two months> (if participant has questions about hepatitis C, transfer call to Dr. Kathryn Porter (ext. 4441) or Dr. Geraldine McQuillan (ext. 4371). End interview
I would like to ask you some questions about what you know about hepatitis C and any follow-up you may have taken since getting the letter. The interview will take about 20 minutes. All information you provide is strictly confidential, and your participation is voluntary. Information will be used by the Centers for Disease Control and Prevention to help people with hepatitis C.
May we proceed with the interview?
If "yes", go to 2). If not - set up an appointment for a better time, or note the reason for the refusal.
2) There are many types of hepatitis. Before receiving the letter with your test result, had you heard of hepatitis C?
1. Yes
2. No
3. Heard of hepatitis, but not specifically hepatitis C
7. Refused
9. Don’t know
3) Was the test result in our letter the first time you were told you had hepatitis C?
1. Yes [skip to 6]
2. No
7. Refused [skip to 6]
9. Don’t know [skip to 6]
4) For about how long have you known that you had hepatitis C? Would you say..
1. One year
2. 2 to 5 years
3. More than 5 years
7. Refused
9. Don’t know
5) Why were you first tested for hepatitis C? Was it because:
1. You donated blood?
2. You had other blood tests done for a routine physical that showed you might have liver disease?
3. You were sick with symptoms like fatigue, nausea, stomach pain, yellowing of the eyes or skin (known as jaundice)?
4. You were exposed to blood while on the job?
5. You or your doctor thought you were at risk of having Hepatitis C?
6. You had an other reason?
7. Refused
9. Don’t know
Now I’m going to ask you some questions about what you have done since finding out that you have hepatitis C.
Did you see a doctor or other health professional about your Hepatitis C test result? (If tested before NHANES, question refers to first test; otherwise refers to NHANES test)
1. Yes [skip to 8]
2. No
7. Refused
9. Don’t know
Do you have an appointment to see a doctor or other health care professional about your hepatitis C test result?
1. Yes [skip to 15]
2. No [skip to 15]
7. Refused [skip to 15]
9. Don’t know [skip to 15]
8) When you saw a doctor or other health professional about your hepatitis C test results, did you have other blood tests to check how your liver is working?
1. Yes
2. No
7. Refused
9. Don’t know
Which of the following statements describes most closely what your doctor told you about your hepatitis C test result? (Read each statement and check only one)
1. You have hepatitis C and need regular medical follow-up.
2. You tested positive for hepatitis C, but you do not need to do anything or worry about it. [skip to 15]
3. You really don’t have hepatitis C because a follow-up test showed that the positive test result was in error. (End interview)
4. Other
7. Refused
9. Don’t know
10) Did you have a liver biopsy (procedure to get a small piece of your liver through a needle)?
1. Yes
2. No
7. Refused
9. Don’t know
11) Did your doctor or health care professional tell you that your hepatitis C should be treated with medication such as Interferon and Ribavirin?
1. Yes
2. No (skip to 14)
7. Refused (skip to 14)
9. Don’t know (skip to 14)
12) Did you get treated with these medicines?
1. Yes (skip to 14)
2. No
7. Refused (skip to 14)
9. Don’t know (skip to 14)
13) Why did you not get treated? (Chose all that apply) Was it because ..
1. The side effects to the treatment are unpleasant.
2. The treatment shots must be self injected.
3. The treatment is too expensive,
4. There is a hope of better treatment in the future.
5. Or is there some other reason?
14) Did your doctor or health care professional tell you to avoid or limit alcoholic beverages because of your hepatitis C?
1. Yes
2. No
7. Refused
9. Don’t know
We would like to know what you have learned about hepatitis C. Please tell me if you believe the following statements are true or false, or if you don’t know whether they are true or false.
15) If someone is infected with hepatitis C virus, they will most likely carry the virus all their lives.
1. True
2. False
7. Refused
9. Don't know
16) Infection with the hepatitis C virus can cause the liver to stop working.
1. True
2. False
7. Refused
9. Don't know
17) Someone with hepatitis C can look and feel fine.
1. True
2. False
7. Refused
9. Don't know
18) You can get hepatitis C by getting a blood transfusion from an infected donor.
1. True
2. False
7. Refused
9. Don't know
19) You can get hepatitis C by shaking hands with someone who has hepatitis C.
1. True
2. False
7. Refused
9. Don't know
20) You can get hepatitis C by kissing someone who has hepatitis C.
1. True
2. False
7. Refused
9. Don't know
21) You can get hepatitis C by having sex with someone who has hepatitis C.
1. True
2. False
7. Refused
9. Don't know
22) You can get hepatitis C by being born to a woman who had hepatitis C when she gave birth.
1. True
2. False
7. Refused
9. Don't know
23) You can get hepatitis C by being stuck with a needle or sharp instrument that has hepatitis C infected blood on it.
1. True
2. False
7. Refused
9. Don't know
24) You can get hepatitis C by working with someone who has hepatitis C.
1. True
2. False
7. Refused
9. Don't know
25) You can get hepatitis C by injecting illegal drugs, even if only a few times.
1. True
2. False
7. Refused
9. Don't know
End Interview
Thank you for your time. We want to emphasize that everything you have told us will be held strictly confidential. We appreciate your participation in the National Health and Nutrition Examination Survey.
N
SP
ID Label
What are the main reasons you agreed to have the Mobile Examination Center (MEC) exam?
civic duty
money
health exam
travel expenses
curiosity
other (specify)___________________________________________
What were the main barriers to getting to the MEC?
time commitment
child care
scheduling
transportation
mistrust of government
not enough information
other (specify)___________________________________________
| File Type | application/msword |
| File Title | TABLE OF CONTENTS |
| Author | Vicki Burt |
| Last Modified By | Vicki Burt |
| File Modified | 2006-11-22 |
| File Created | 2006-09-06 |
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