1-AID Update

Page 1 of 6

2007 NHIS Questionnaire - Sample Adult

Adult Identification

Document Version Date: 12-Jul-06

Question ID: AID.005_00.000 Instrument Variable Name: SADULT QuestionnaireFileName: Sample Adult

QuestionText: * The sample adult person is [fill: Sample Adult name]. The next questions must be answered by this person. Probe as

necessary to determine the availability of [fill: Sample Adult name].

If refused enter CTRL-R

1 Available

2 Not available

3 Physical or mental condition prohibits responding

7 Refused

UniverseText: Sample adult section has not been started or completed

SkipInstructions: <1> [if Sample Adult = demographics.hhc.RELRESP_A]

[goto beginning of adult.asd]

[elseif Sample Adult = demographics.hhc.HHRESP]

[goto beginning of adult.asd]

[else]

[goto AIDVERF_S]

[endif]

<2> [goto callbk.ACALLBK1]

<3> [goto PROX1]

<R> [store <4> in ASTAT]

[if recontact.RCIFLAG <> 1]

[goto recontact.RCI_BEGIN procedure]

[else]

[goto back.OUTCOMEB1 procedure]

[endif]

Question ID: AID.010_00.000 Instrument Variable Name: PROX1 QuestionnaireFileName: Sample Adult

QuestionText: * Proxy interviews can be done for sample adults that have a mental or physical condition that prevents them from

responding for themselves.

Is a family member or caregiver that is knowledgeable about [fill: Sample Adult name]'s health available?

1 Yes

2 No

UniverseText: The Sample adult's physical or mental condition prohibits responding

SkipInstructions: <1> [goto PROX2]

<2> [goto PROX3]

Page 2 of 6

2007 NHIS Questionnaire - Sample Adult

Adult Identification

Document Version Date: 12-Jul-06

Question ID: AID.015_00.000 Instrument Variable Name: PROX2 QuestionnaireFileName: Sample Adult

QuestionText: * Ask if necessary.

What is this person's relationship to [fill: Sample Adult name]?

1 Relative who lives in household

2 Relative who doesn't live in household

3 Other caregiver

4 Other

7 Refused

9 Don't know

UniverseText: Knowledgeable proxy is available

SkipInstructions: <1-4> [goto AIDVERF_S]

Question ID: AID.020_00.000 Instrument Variable Name: PROX3 QuestionnaireFileName: Sample Adult

QuestionText: *Ask if necessary.

Can a callback with someone knowledgeable about [fill: Sample Adult name]'s health be arranged?

1 Yes

2 No

UniverseText: Knowledgeable proxy is not available

SkipInstructions: <1> [goto callbk.ACALLBK1]

<2> [store <3> in ASTAT]

[if recontact.RCIFLAG <> 1]

[goto recontact.RCI_BEGIN procedure]

[else]

[goto back.OUTCOMEB1 procedure]

[endif]

Question ID: AID.030_00.000 Instrument Variable Name: AIDVERF_S QuestionnaireFileName: Sample Adult

QuestionText: * Please verify the following information about the sample adult before proceeding:

I have recorded your sex as [fill: Sex of Sample Adult]. Is this correct?

*If respondent "refuses" or says "don't know", enter "1" for "yes".

1 Yes

2 No

UniverseText: Sample adult is not the person entered in HHRESP or RELRESP_A Or PROX1 = 'Yes'

SkipInstructions: <1> [goto AIDVERF_A]

<2> [goto AIDSEX]

Page 3 of 6

2007 NHIS Questionnaire - Sample Adult

Adult Identification

Document Version Date: 12-Jul-06

Question ID: AID.040_00.000 Instrument Variable Name: AIDSEX QuestionnaireFileName: Sample Adult

QuestionText: * Ask if appropriate; otherwise, enter your best guess of the person's sex.

Are you Male or Female?

1 Male

2 Female

UniverseText: Respondent said his/her sex is not correct

SkipInstructions: <1,2> [store AIDSEX in SEX]

[goto ERR_AIDSEX]

[reset AIDVERF_S]

[goto AIDVERF_S]

Question ID: AID.045_00.000 Instrument Variable Name: AIDVERF_A QuestionnaireFileName: Sample Adult

QuestionText: * Please verify the following information about the sample adult before proceeding:

I have recorded your age as [fill: Age of Sample Adult] old. Is this correct?

*If respondent "refuses" or says "don't know", enter "1" for "yes".

1 Yes

2 No

UniverseText: Sample adult said his/her sex is correct

SkipInstructions: <1> [goto AIDVERF_D]

<2> [goto AIDAGE]

Question ID: AID.050_00.000 Instrument Variable Name: AIDAGE QuestionnaireFileName: Sample Adult

QuestionText: How old are you?

000-120 Age in years

997 Refused

999 Don't know

UniverseText: Respondent said his/her age is not correct

SkipInstructions: <0-120, Refused, Don't know>

[if AIDAGE = Refused or AIDAGE = Don't know or AIDAGE = AGE]

[reset AIDVERF_A]

[goto ERR_AIDAGE]

[else]

[store AIDAGE in AGE]

[goto AIDDOB_M]

Page 4 of 6

2007 NHIS Questionnaire - Sample Adult

Adult Identification

Document Version Date: 12-Jul-06

Question ID: AID.055_00.000 Instrument Variable Name: AIDVERF_D QuestionnaireFileName: Sample Adult

QuestionText: * Please verify the following information about the sample adult before proceeding:

I have recorded your birthday as [fill: Birthday of Sample Adult]. Is this correct?

*If respondent "refuses" or says "don't know", enter "1" for "yes".

1 Yes

2 No

UniverseText: Sample adult said his/her age is correct

SkipInstructions: Do not allow "Don't Know" or "Refused" as an answer.

<1> [if AGE of Sample Adult le <17>]

[goto NO_MORE]

[else]

[goto beginning of adult.asd]

[endif]

<2> [goto AIDDOB_M]

Question ID: AID.060_01.000 Instrument Variable Name: AIDDOB_M QuestionnaireFileName: Sample Adult

QuestionText: 1 of 3

What is your birthday?

*Enter month of birth.

01 January

02 February

03 March

04 April

05 May

06 June

07 July

08 August

09 September

10 October

11 November

12 December

97 Refused

99 Don't know

UniverseText: Respondent said his/her date of birth is not correct or his/her age is not correct

SkipInstructions: <01-12, Refused, Don't know> [goto AIDDOB_D]

Page 5 of 6

2007 NHIS Questionnaire - Sample Adult

Adult Identification

Document Version Date: 12-Jul-06

Question ID: AID.060_02.000 Instrument Variable Name: AIDDOB_D QuestionnaireFileName: Sample Adult

QuestionText: 2 of 3

*Enter day of birth.

01-31 Day of the month

97 Refused

99 Don't know

UniverseText: Respondent said his/her date of birth is not correct or his/her age is not correct

SkipInstructions: <01-31,Refused,Don't know> [goto AIDDOB_Y]

If days not valid, goto ERR_AIDDOB_D

Question ID: AID.060_03.000 Instrument Variable Name: AIDDOB_Y QuestionnaireFileName: Sample Adult

QuestionText: 3 of 3

*Enter year of birth.

1880-2020 Year of Birth

UniverseText: Respondent said his/her date of birth is not correct or his/her age is not correct

SkipInstructions: <1880-2020, Refused, Don't know> if AIDVERF_A = No then reset AIDVERF_A to empty

goto AIDVERF_A

elseif AIDVERF_D = No then reset AIDVERF_D to empty

goto AIDVERF_D

endif

(if year GT current year) or (if year = current year and month GT current month) or (if year = current year and month

= current month and day GT current day)

goto ERR1_AIDDOB_Y

endif

(if birth month = <02> and birth day = <29> and this is not a leap year)

goto ERR2_AIDDOB_Y

endif

(if AIDDOB_M = Ref or DK) or (if AIDDOB_D = Ref or DK) or (if AIDDOB_Y = Ref or DK)

goto ERR3_AIDDOB_Y

else

store AIDDOB_M in DOBM

store AIDDOB_D in DOBD

store AIDDOB_Y in DOBY

if AIDVERF_A = No then reset AIDVERF_A to empty

goto AIDVERF_A

elseif AIDVERF_D = No then reset AIDVERF_D to empty

goto AIDVERF_D

endif

endif

Calculate age from AIDDOB_M, AIDDOB_D, and AIDDOB_Y.

if age from AIDDOB items is ne AGE and age from AIDDOB items is valid

reset AIDVERF_A or AIDVERF_D.

goto ERR4_AIDDOB_Y

endif

Page 6 of 6

2007 NHIS Questionnaire - Sample Adult

Adult Identification

Document Version Date: 12-Jul-06

Split sample 1. Linkage permission question prior to questions for SSN and

Medicare number: sample adult

Question ID AID.081

Question Text Finally, we would like to link your survey data with health-related records of other

government agencies. This will allow us to conduct additional research without taking up

your time with more questions. Any data obtained will be kept strictly private as

required by law. May we try to link your survey data with other health-related records?

* Read if necessary: The specific federal laws are the Public Health Service Act (Title 42, United States Code, Section 242K) and the Confidential Information Protection and Statistical Efficiency Act (Title V of Public Law 107-347).

Answer Codes 1. Yes

2. No

Refused

Don’t know

Skip Instructions <1> [goto AID.085]

<2,R,D> [goto beginning of Recontact or Back section]

Question ID AID.085

Question Text

To help us link your survey data with vital statistics and health-related records of other

government agencies, we would like the last four digits of your Social Security Number.

The National Center for Health Statistics uses this information for research purposes only.

Providing this information is voluntary. Federal laws authorize us to ask for this information and require us to keep it strictly private. There will be no effect on your benefits if you do not provide this information.

* Read if necessary: The specific federal laws are the Public

Health Service Act (Title 42, United States Code, Section 242K) and the Confidential Information Protection and Statistical Efficiency Act (Title V of Public Law 107-347).

What are the last four digits of your Social Security Number?

• Enter 'N' if no Social Security Number.

Question ID AID.090

Question Text * Enter how the last four digits of the Social Security Number were reported.

Answer Codes 1. From memory

2. From records

Question ID AID.095

Question Text * Select one category below to indicate reporting of the last four digits of the Social

Security Number.

Answer Codes 1. In person

2. Telephone

Question ID AID.100_1

Question Text

Earlier I recorded that you are covered by Medicare. To help us link your survey data with

Medicare records of the Centers for Medicare and Medicaid Services, we would like the last

four numbers and any letters of your Health Insurance Claim Number. The National

Center for Health Statistics uses this information for research purposes only. Providing

this information is voluntary. Federal laws authorize us to ask for this information and require us to keep it strictly private. There will be no effect on your benefits if you do not provide this information.

May I please see your Medicare card to record the last four numbers and any letters of the

Health Insurance Claim Number?

* Read if necessary: The specific federal laws are the Public Health Service Act (Title 42, United States Code, Section 242K) and the Confidential Information Protection and Statistical Efficiency Act (Title V of Public Law 107-347).

* Reports from memory are acceptable if the Medicare card (or some other form of

documentation) is not available.

* Enter the last four numbers.

Question ID AID.100_2

Question Text

*Enter the letters that appear after the claim number.

SkipInstructions: <1,2> goto beginning of Recontact or Back section

Split sample 2. Linkage permission question after questions for SSN and

Medicare number: sample adult

Question ID AID.082

Question Text Finally, we would like the last four digits of your Social Security Number [if sample adult has Medicare: , and the last four numbers and any letters of your Medicare number]. This information will help us link your survey data with health-related records of other government agencies, and allow us to conduct additional research without taking up your time with more questions. The National Center for Health Statistics uses this information for research purposes only. Providing this information is voluntary. Federal laws authorize us to ask for this information and require us to keep it strictly private. There will be no effect on your benefits if you do not provide this

information.

* Read if necessary. The specific federal laws are the Public Health Service Act (Title 42, United States Code, Section 242K) and the Confidential Information Protection and Statistical Efficiency Act (Title V of Public Law 107-347).

* Enter '1' to continue.

Question ID AID.085

Question Text What are the last four digits of your Social Security Number? (if sample adult has Medicare: May I please see your Medicare card to record the last four numbers and any letters of the

Health Insurance Claim Number?)

Skip Instructions SSN given, go to AID.090

SSN/Medicare # refused or don’t know, go to AID.105

Question ID AID.090

Question Text * Enter how the last four digits of the Social Security Number were reported.

Answer Codes 1. From memory

2. From records

Question ID AID.095

Question Text * Select one category below to indicate reporting of the last four digits of the Social

Security Number.

Answer Codes 1. In person

2. Telephone

Skip Instructions Go to beginning of Recontact, or Back section

Question ID AID.105

Question Text May we try to link your survey data without your Social Security (and Medicare) number(s):]?

Read if necessary: Any data obtained will be kept strictly private as required by law (Public Health Service Act, which is Title 42, United States Code, Section 242K; and the Confidential Information Protection and Statistical Efficiency Act, which is Title V of Public Law 107-347).

Answer Codes 1. Yes

2. No

Refused

Don’t know

Skip Instructions Go to beginning of Recontact, or Back section