Form 1 Survey
California Health Interview Survey 2007
Attachment 2[3][1]
California Health Interview Survey 2007
OMB: 0925-0578
Attachment 2
CHIS 2007 Cancer Control Module (CCM) and Demographic Core Questionnaire Items
CALIFORNIA HEALTH INTERVIEW SURVEY 2007
OMB No. 0925-XXXX
Expires: XX-XX-200X
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH Project Clearance Branch, 6705 Rockledge Dr., MSC 7974, Bethesda, MD 20892-7974, Attn: PRA (0925-XXXX). Do not return the completed form to this address.
TABLE OF CONTENTS
ADULT QUESTIONNAIRE
MODULE B – CANCER DIAGNOSIS 11
MODULE C – COMMON MEDICATIONS 13
MODULE D – WOMEN’S HEALTH, HPV 14
MODULE F – FAMILY HISTORY OF CARDIOVASCULAR DISEASE AND DIABETES 19
EMPLOYMENT, INCOME, AND POVERTY STATUS 59
ADOLESCENT QUESTIONNAIRE
MODULE A – CANCER SCREENING
PROGRAMMING NOTE QA07_D1
IF AAGE < 40 OR [AA2A = 1 (BETWEEN 18 AND 29) OR 2 (BETWEEN 30 AND 39)] OR ENUM.AGE < 40 OR AGE IS UNKNOWN, GO TO QA07_D25;
ELSE CONTINUE WITH QA07_D1
QA07_A1 Have you ever had a Sigmoidoscopy or Colonoscopy? These are exams in which a health care professional inserts a tube into the rectum to look for signs of cancer or other problems.
[IF NEEDED, SAY: "For a Sigmoidoscopy a flexible tube is inserted into the rectum to look for problems. A Colonoscopy is similar, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home. ”]
YES 1
NO 2 [GO TO QA07_D8]
REFUSED -7 [GO TO QA07_D8]
DON'T KNOW -8 [GO TO QA07_D8]
QA07_A2 How long ago did you have your most recent exam?
A YEAR AGO OR LESS 1
MORE THAN 1 YEAR AGO UP TO
2 YEARS AGO 2
MORE THAN 2 YEARS AGO UP TO
3 YEARS AGO 3
MORE THAN 3 YEARS AGO UP TO
5 YEARS AGO 4
MORE THAN 5 YEARS AGO UP TO
10 YEARS AGO 5
MORE THAN 10 YEARS AGO 6
REFUSED -7
DON'T KNOW -8
QA07_A3 Did you have this exam…
As part of a routine physical exam
or screening test, 1
Because of a specific problem, or 2
As a follow-up to an earlier test
or screening exam? 3
REFUSED -7
DON'T KNOW -8
QA07_A4 Was this MOST RECENT exam a sigmoidoscopy, colonoscopy, or something else?
[IF NEEDED, SAY: "For a SIGMOIDOSCOPY, a flexible tube is inserted into the rectum to look for problems. A COLONOSCOPY is SIMILAR, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy, and told to have someone else drive you home]
SigmoidoscopY 1
Colonoscopy 2
Something else 3
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_D8:
IF [QA07_D1 = 2 (NEVER HAD SIGMOIDOSCOPY OR COLONOSCOPY)], CONTINUE WITH QA07_D8 AND DISPLAY "NEVER had";
ELSE IF QA07_D5 = 0 (NONE IN LAST 10 YEARS) OR QA07_D2 = 6 (MOST RECENT OVER 10 YEARS AGO), CONTINUE WITH QA07_D8 AND DISPLAY "NOT had" AND "in the last 10 years";
ELSE GO TO QA07_D9
QA07_A5 During the past 12 months has a doctor or other health professional recommended that you have a sigmoidoscopy or colonoscopy?
YES 1
NO 2
DID NOT GO TO DOCTOR IN
PAST 12 MONTHS 92
REFUSED -7
DON'T KNOW -8
QA07_A6 What is the ONE most important reason why you have {NEVER had/NOT had} one of these exams {in the last 10 years}?
NO REASON/NEVER THOUGHT ABOUT IT 1
DIDN'T KNOW I NEEDED THIS TYPE OF TEST 2
DOCTOR DIDN'T TELL ME I NEEDED IT 3 [GO TO QA07_D10]
HAVEN'T HAD ANY PROBLEMS 4
PUT IT OFF/LAZINESS 5
TOO EXPENSIVE/NO INSURANCE/COST 6
TOO PAINFUL, UNPLEASANT, OR
EMBARRASSING 7
HAD ANOTHER TYPE OF COLORECTAL EXAM 8
DON'T HAVE A DOCTOR 9
OTHER 91
REFUSED -7
DON'T KNOW -8
QA07_A7 The following questions are about the blood stool or occult blood test, a test to determine whether you have blood in your stool or bowel movement. The blood stool test can be done at home using a kit. You smear a small amount of stool on cards at home and send the cards back to the doctor or lab.
Have you ever done a blood stool test, using a HOME test kit?
YES 1
NO 2 [GO TO QA07_D16]
REFUSED -7 [GO TO QA07_D17]
DON'T KNOW -8 [GO TO QA07_D17]
QA07_A8 How long ago did you do your most recent HOME blood stool test?
A YEAR AGO OR LESS 1
MORE THAN 1 YEAR AGO UP TO
2 YEARS AGO 2
MORE THAN 2 YEARS AGO UP TO
3 YEARS AGO 3
MORE THAN 3 YEARS AGO UP TO
5 YEARS AGO 4
MORE THAN 5 YEARS AGO 5
REFUSED -7
DON'T KNOW -8
QA07_A9 Did you take this test…
As part of a routine physical exam
or screening test, 1
Because of a specific problem, or 2
As a follow-up to an earlier test
or screening exam? 3
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_D16:
IF QA07_D10 = 2 (NEVER HAD HOME STOOL TEST), CONTINUE WITH QA07_D16 AND DISPLAY "NEVER had";
ELSE IF QA07_D11 > 1 (NONE IN PAST YEAR), CONTINUE WITH QA07_D16 AND DISPLAY "NOT had" and "in the past year";
ELSE GO TO QA07_D17
QA07_A10 What is the most important reason you have {NEVER had /NOT had} a HOME blood stool test {in the past year}?
NO REASON/NEVER THOUGHT ABOUT IT 1
DIDN'T NEED/DIDN'T KNOW I NEEDED
THIS TYPE OF TEST 2
DOCTOR DIDN'T TELL ME I NEEDED IT 3 [GO TO PN QA07_D18]
HAVEN'T HAD ANY PROBLEMS 4
PUT IT OFF/LAZINESS 5
TOO EXPENSIVE/NO INSURANCE/COST 6
TOO PAINFUL, UNPLEASANT, EMBARRASSING 7
HAD ANOTHER TYPE OF COLORECTAL EXAM 8
DON'T HAVE A DOCTOR 9
OTHER 91
REFUSED -7
DON'T KNOW -8
QA07_A11 In the past 12 months, has a doctor or other health professional recommended that you have a home blood stool test?
YES 1
NO 2
DID NOT GO TO DOCTOR
IN PAST 12 MONTHS 92
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_D18:
IF FEMALE GO TO PN QA07_D25;
IF MALE AND [AGE < 40 OR BETWEEN 18 AND 29 OR BETWEEN 30 AND 39 OR ENUM.AGE < 45 OR IF AGE IS UNKNOWN], GO TO QA07_D25;
ELSE CONTINUE WITH QA07_D18
QA07_A12 Have you ever HEARD OF a PSA or "prostate-specific antigen" test to detect prostate cancer? A PSA test is a blood test to detect prostate cancer.
YES 1
NO 2 [GO TO QA07_D25]
REFUSED -7 [GO TO QA07_D25]
DON'T KNOW -8 [GO TO QA07_D25]
QA07_A13 Have you ever HAD a PSA test?
YES 1
NO 2 [GO TO QA07_D25]
REFUSED -7 [GO TO QA07_D25]
DON'T KNOW -8 [GO TO QA07_D25]
QA07_A14 How long ago did you have your most recent PSA test?
A YEAR AGO OR LESS 1
MORE THAN 1 YEAR AGO UP TO
2 YEARS AGO 2
MORE THAN 2 YEARS AGO UP TO
3 YEARS AGO 3
MORE THAN 3 YEARS AGO UP TO
5 YEARS AGO 4
MORE THAN 5 YEARS AGO 5
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_D34:
IF QA07_D32 = 8, SET QA07_D34 = 1 AND GO TO PROGRAMMING NOTE QA07_D35;
ELSE CONTINUE WITH QA07_D34
QA07_A15 Have you had a hysterectomy?
[IF NEEDED, SAY: "A hysterectomy is when the uterus or womb is removed, not just
having your tubes tied to prevent pregnancy."]
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_D35:
IF QA07_D32 = 8 (HYSTERECTOMY), DISPLAY "You said that you had a hysterectomy. Were your ovaries removed?";
ELSE IF QA07_D34 = 1 (YES, HAD A HYSTERECTOMY), DISPLAY "Were your ovaries removed?";
ELSE DISPLAY "Have you had an operation to have your ovaries removed?"
QA07_A16 {You said that you had a hysterectomy. Were your ovaries removed?/Were your ovaries removed?/Have you had an operation to have your ovaries removed?}
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_D26:
IF MALE, GO TOQA07_E1; IF FEMALE CONTINUE WITH QA07_D26
QA07_A17 Have you ever had a Pap smear test to check for cervical cancer?
[IF NEEDED, SAY: "A pap smear is a routine cancer test for women in which the doctor examines the cervix during a gynecological exam, and takes a cell sample from the cervix with a small stick or brush and sends it to the lab. This is not a test for detecting sexually transmitted diseases."]
YES 1
NO 2 [GO TO QA07_D32]
REFUSED -7 [GO TO QA07_D33]
DON'T KNOW -8 [GO TO QA07_D33]
QA07_A18 How many Pap smear tests have you had in the last 6 years?
_____ PAP SMEARS [HR: 0-99]
NONE 0
REFUSED -7
DON'T KNOW -8
QA07_A19 How long ago did you have your most recent Pap smear test?
A YEAR AGO OR LESS 1 [GO TO PN QA07_A23]
MORE THAN 1 UP TO 2 YEARS AGO 2 [GO TO PN QA07_A23]
MORE THAN 2 UP TO 3 YEARS AGO 3
MORE THAN 3 UP TO 5 YEARS AGO 4
MORE THAN 5 YEARS AGO 5
REFUSED -7 [GO TO PN QA07_A23]
DON'T KNOW -8 [GO TO PN QA07_A23]
IF AD4 = 1 (Ever had a Pap test) and AD12= 2, -7, or -8 (Did not have a hysterectomy)
CONTINUE WITH QA07_A20;
QA07_A20 Have you ever had a Pap smear test where the results were NOT normal?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_A21 What is the ONE most important reason why you have {NEVER had a Pap smear/NOT had a Pap smear in the last 3 years}?
NO REASON/NEVER THOUGHT ABOUT IT 1
DIDN'T KNOW I NEEDED THIS TYPE OF TEST 2
DOCTOR DIDN'T TELL ME I NEEDED IT 3 [GO TO PN QA07_D34]
HAVEN'T HAD ANY PROBLEMS 4
PUT IT OFF/LAZINESS 5
TOO EXPENSIVE/NO INSURANCE/COST 6
TOO PAINFUL, UNPLEASANT,
OR EMBARRASSING 7
HYSTERECTOMY 8
DON'T HAVE A DOCTOR 9
OTHER 91
REFUSED -7
DON'T KNOW -8
QA07_A22 In the past year, has a doctor or other health professional recommended that you have a Pap smear?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_A23 Have you ever had a mammogram?
[IF NEEDED, SAY: "A mammogram is an x-ray taken of each breast
separately by a machine that flattens or squeezes each breast."]
YES 1
NO 2
[READ DEFINITION, IF STILL NO, GO TO PN QA07_E24]
REFUSED -7 [GO TO PN QA07_E27]
DON'T KNOW -8 [GO TO PN QA07_E27]
PROGRAMMING NOTE QA07_D36:
IF AAGE < 30 OR AA2A = 1 (BETWEEN 18 AND 29) OR ENUM.AGE < 30, GO TO NEXT SECTION;
ELSE IF RESPONDENT REPORTED HAVING A MAMMOGRAM, CONTINUE WITH QA07_D37
QA07_A24 How many mammograms have you had in the last 6 years? Your best estimate is fine.
_____ MAMMOGRAMS [HR: 0-99]
REFUSED -7
DON'T KNOW -8
QA07_A25 How long ago did you have your most recent mammogram?
A YEAR AGO OR LESS 1
MORE THAN 1 UP TO 2 YEARS AGO 2
MORE THAN 2 UP TO 3 YEARS AGO 3 [GO TO QA07_4]
MORE THAN 3 UP TO 5 YEARS AGO 4 [GO TO QA07_E24]
MORE THAN 5 YEARS AGO 5 [GO TO QA07_E24]
REFUSED 7 [GO TO PN QA07_E27]
DON'T KNOW -8 [GO TO PN QA07_E27]
PROGRAMMING NOTE QA07_D44:
IF RESPONDENT NEVER HAD A MAMMOGRAM, CONTINUE WITH QA07_D44 AND DISPLAY "NEVER had a mammogram";
ELSE IF RESPONDENT’S MOST RECENT MAMMOGRAM MORE THAN 2 YEARS AGO OR DK, CONTINUE WITH QA07_D44 AND DISPLAY "NOT had a mammogram in the past 2 years";
ELSE GO TO QA07_D45
QA07_A26 What is the ONE most important reason why you have {NEVER had a mammogram/NOT had a mammogram in the past 2 years}?
NO REASON/NEVER THOUGHT ABOUT IT 1
DIDN'T KNOW I NEEDED THIS TYPE OF TEST 2
DOCTOR DIDN'T TELL ME I NEEDED IT 3 [GO TO NEXT SECTION]
HAVEN'T HAD ANY PROBLEMS 4
PUT IT OFF/LAZINESS 5
TOO EXPENSIVE/NO INSURANCE/COST 6
TOO PAINFUL, UNPLEASANT,
EMBARRASSING 7
TOO YOUNG 8
DON'T HAVE A DOCTOR 9
OTHER 91
REFUSED -7
DON'T KNOW -8
QA07_A27 In the past 12 months, has a doctor or other health professional recommended that you have a mammogram?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_E13:
IF AAGE < 30 OR QA07_A4 = 1 (BETWEEN 18 AND 29) OR ENUM.AGE < 30, GO TO QAO5_F1;
ELSE CONTINUE WITH QA07_E13 (INCLUDE WOMEN WITH AGE UNKNOWN)
Mammography
QA07_A28 In the past 12 months, has a doctor examined your breasts for lumps?
AF37 |
[IF NEEDED, SAY: “This is when a doctor touches your breasts to check for
bumps, cysts, or abnormal growth.”]
YES 1
NO 2
REFUSED -7
DON’T KNOW -8
MODULE B – CANCER DIAGNOSIS
PROGRAMMING NOTE QA07_B1
IF QA07_A20 =1 (BREAST CANCER) DISPLAY “Besides the breast cancer you told me about”
Cancer history
QA07_B1 {Besides the breast cancer you told me about,} Has a doctor ever told you that you had a cancer of any kind?
YES 1
NO 2
REFUSED -7 [GO TO PN QA07_B7]
DON'T KNOW -8
PROGRAMMING NOTE QA07_B2:
ACCEPT ONLY FIRST SIX RESPONSES
QA07_B2 What kind of cancer was it?
[CODE ALL THAT APPLY. CTRL-P TO EXIT]
[PROBE: "Any others?"]
BLADDER 1
BLOOD 2
BONE 3
BRAIN 4
BREAST 5
CERVIX 6
COLON 7
ESOPHAGUS 8
GALLBLADDER 9
KIDNEY 10
LARYNX-WINDPIPE 11
LEUKEMIA 12
LIVER 13
LUNG 14
LYMPHOMA 15
MOUTH/TONGUE/LIP 16
OVARY 17
PANCREAS 18
PROSTATE 19
RECTUM 20
SKIN 21
SOFT TISSUE (MUSCLE OR FAT) 24
STOMACH 25
TESTIS 26
THROAT-PHARYNX 27
THYROID 28
UTERUS 29
OTHER 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_B3:
IF QA07_A40=1 (LUMP REMOVED WAS CANCEROUS) OR E2 = 5 (YES HAD BREAST CANCER), CONTINUE WITH QA07_E3;
ELSE GO TO PROGRAMMING NOTE QA07_A7
QA07_B3 Tell me how you first found out about your breast cancer. Was it by…
Finding it yourself by accident 1
Finding it yourself during a
self breast examination 2
Your husband or partner finding it 3
Your doctor finding it during
a routine breast exam 4
Finding it by a mammogram 5
Or Some other way?
(IF OTHER, SPECIFY):_____________ 91
REFUSED -7
DON'T KNOW -8
QA07_B4 Was your breast cancer diagnosed at an early or late stage?
EARLY STAGE (STAGE 1 OR 2) 1
LATE STAGE (STAGE 3 OR 4) 2
REFUSED -7
DON'T KNOW -8
IF QA07_E1 = 2 (NOT DIAGNOSED WITH CANCER) AND QA07_D40 NE 1 (LUMP REMOVED NOT CANCEROUS) GO TO NEXT SECTION;
ELSE IF QA07_E1 = 1 (DIAGNOSED WITH CANCER) AND QA07_E2 = 21 (HAD SKIN CANCER), CONTINUE WITH QA07_E7;
ELSE GO TO QA07_E8
QA07_B5 Was the skin cancer you mentioned non-melanoma, melanoma, or an unknown type?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
NON-MELANOMA 1
MELANOMA 2
UNKNOWN TYPE 3
REFUSED -7
DON'T KNOW -8
QA07_B6 How old were you when cancer was first diagnosed?
_____ AGE IN YEARS [HR: 1 THRU AAGE OR (105 IF AAGE = -7)]
REFUSED -7
DON'T KNOW -8
MODULE C – COMMON MEDICATIONS
QA07_C1 INTRO Do you now take any of the following types of medications regularly, that is, at least 3 times a week?
QA07_C1 Aspirin, Bayer, Bufferin, or Excedrin?
[NOTE TO INTERVIEWER: DO NOT INCLUDE TYLENOL]
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_C2 Advil, Ibuprofen, Motrin, or Nuprin.
[NOTE TO INTERVIEWER: DO NOT INCLUDE TYLENOL]
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_C3 Aleve, Naprosyn, Naproxen, or Celebrex?
[NOTE TO INTERVIEWER: DO NOT INCLUDE TYLENOL]
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_C28
IF (QA07_C25 = 1 OR QA07_C26 = 1 OR QA07_C27 =1) CONTINUE WITH QA07_C28;
ELSE GO TO QA07_C29
QA07_C4 Have you taken any of these kinds of medications regularly for the last 3 months?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
MODULE D – WOMEN’S HEALTH, HPV
QA07_D27_INTRO Are
you currently taking any of the following medications?
PROGRAMMING NOTE QA07_D27
IF AGE>44 CONTINUE WITH QA07_D27
ELSE GO TO QA07_D28
QA07_D27 Hormone replacement therapy?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_D28 Tamoxifen or Molvadex?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_D29
IF AGE>44 CONTINUE WITH QA07_D29
ELSE GO TO QA07_D30
QA07_D29 Raloxifen or Evista?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_D30
IF AGE<55 CONTINUE WITH QA07_D30
ELSE GO TO QA05_F1
QA07_D30 Birth control pills, the patch, or birth control shots?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_D31;
IF QA07_A5 = 1 (MALE) OR AGE>65, GO NEXT SECTION;
ELSE CONTINUE QA07_D31.
QA07_D31 Have you ever heard of HPV? HPV stands for Human Papillomavirus.
YES 1
NO 2 [GO TO QA07_D39]
DON’T KNOW -7 [GO TO QA07_D39]
REFUSED -8 [GO TO QA07_D39]
QA07_D32 Where did you heard about HPV?
A doctor, nurse or other health care professional 1
Family or friends 2
Newspaper or magazine 3
Saw an ad on television 4
Television news 5
Internet 6
Other 7
DON’T KNOW -7
REFUSED -8
QA07_D33 Do you think HPV can cause cervical cancer?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_D34 Do you think HPV can be sexually transmitted?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_D35 Do you think HPV infection is rare?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_D36 Do you think HPV usually goes away on its own?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_D37 Do you think HPV causes AIDS?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_D38 Do you think you can have an HPV infection and not know it?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
PROGRAMMING NOTE HPV VACCINE SECTION;
IF SC13A = FEMALE CHILD IN HOUSEHOLD AGE>8, CONTINUE QA07_D39.
IF QA07_A5 = 2 (FEMALE) AND AGE<65, CONTINUE QA07_D39.
QA07_D39 Have you ever heard of a vaccine or shot to prevent cervical cancer?
YES 1
NO 2 [SKIP TO D40]
DON’T KNOW -7 [SKIP TO D40]
REFUSED -8 [SKIP TO D40]
IF QA07_A5 = 2 (FEMALE) AND AGE<65, CONTINUE QA07_D39a.
IF SC13A = FEMALE CHILD IN HOUSEHOLD AGE>8 AND QA07_A5=1, SKIP TO QA07_D39b.
QA07_D39a
Have you ever received the HPV vaccine or shot?
YES 1 [SKIP TO NEXT SECTION]
NO 2 [GO TO D40]
DON’T KNOW -7 [SKIP TO NEXT SECTION]
REFUSED -8 [SKIP TO NEXT SECTION]
QA07_D39b Has your daughter ever received the HPV vaccine or shots?
YES 1 [SKIP TO NEXT SECTION]
NO 2 [GO TO PN D40]
DON’T KNOW -7[SKIP TO NEXT SECTION]
REFUSED -8[SKIP TO NEXT SECTION]
QA07_D39 Have you ever heard of a vaccine or shot to prevent cervical cancer?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
IF SC13A = FEMALE CHILD IN HOUSEHOLD AGE>8
SKIP TO QA07_D42.
QA07_D40 A vaccine, or shot that protects against HPV, a virus that can cause cervical cancer, was recently approved for girls and women ages 9 to 26. Would you be interested in getting the vaccine?
YES 1 [GO TO QA07_D44]
NO 2 [GO TO QA07_D41]
NOT SURE 3 [GO TO QA07_D41]
DON’T KNOW -7 [GO TO QA07_D41]
REFUSED -8 [GO TO QA07_D41]
QA07_D41 What is the MAIN reason you would NOT want to get the vaccine?
Does not need vaccine 1 [SKIP TO NEXT SECTION]
Not sexually active 2 [SKIP TO NEXT SECTION]
Too expensive 3 [GO TO QA07_D45]
Too young for vaccine 4 [SKIP TO NEXT SECTION]
Doctor didn’t recommend it 5 [SKIP TO NEXT SECTION]
Worried about safety of vaccine 6 [SKIP TO NEXT SECTION]
Don’t know where to get vaccine 7 [SKIP TO NEXT SECTION]
My spouse/family member is against it 8 [SKIP TO NEXT SECTION]
Other 9 [SKIP TO NEXT SECTION]
DON’T KNOW -7 [SKIP TO NEXT SECTION]
REFUSED -8 [SKIP TO NEXT SECTION]
QA07_D42 A vaccine, or shot that protects against HPV, a virus that can cause cervical cancer was recently approved for girls and women ages 9 to 26. If your daughter’s doctor recommended that she get the HPV vaccine, would you let her get it?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_D43 What is the MAIN reason you would NOT want your daughter to get the vaccine?
Does not need vaccine 1 [SKIP TO NEXT SECTION]
Not sexually active 2 [SKIP TO NEXT SECTION]
Too expensive 3 [GO TO QA07_D45]
Too young for vaccine 4 [SKIP TO NEXT SECTION]
Doctor didn’t recommend it 5 [SKIP TO NEXT SECTION]
Worried about safety of vaccine 6 [SKIP TO NEXT SECTION]
Don’t know where to get vaccine 7 [SKIP TO NEXT SECTION]
My spouse/family member is against it 8 [SKIP TO NEXT SECTION]
Other 9 [SKIP TO NEXT SECTION]
DON’T KNOW -7 [SKIP TO NEXT SECTION]
REFUSED -8 [SKIP TO NEXT SECTION]
QA07_D44. It is anticipated that the cost of the vaccine required to prevent HPV infection will be $360 total for the series of three shots. Would you get this vaccine if you had to pay all of this cost?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_D45 If all or most of the costs were covered, would you get the vaccine?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
MODULE E – SUN EXPOSURE
QA07_E1 These next questions are about the time you spend in the sun.
When you go outside on a very sunny day for MORE than one hour, how often do you wear any kind of hat that shades your face, ears and neck from the sun?
Would you say always, sometimes or never?
ALWAYS 1
SOMETIMES 2
NEVER 3
NEVER GO OUT IN THE SUN FOR MORE THAN
1 HOUR/NEVER GO OUT IN THE SUN 4
REFUSED -7
DON'T KNOW -8
QA07_E2 And how often do you stay in the shade?
ALWAYS 1
SOMETIMES 2
NEVER 3
NEVER GO OUT IN THE SUN FOR MORE THAN
1 HOUR/NEVER GO OUT IN THE SUN 4
REFUSED -7
DON'T KNOW -8
QA07_E3 And how often do you use sunscreen of SPF 15 or greater?
ALWAYS 1
SOMETIMES 2
NEVER 3
NEVER GO OUT IN THE SUN FOR MORE THAN
1 HOUR/NEVER GO OUT IN THE SUN 4
REFUSED -7
DON'T KNOW -8
QA07_E4 How many times in the past year have you had a sunburn?
ENTER TIMES: _____ [HR: 0-365]
REFUSED -7
DON'T KNOW -8
QA07_E5 How many times in the past year have you used indoor tanning devices?
ENTER TIMES: _____ [HR: 0-365]
REFUSED -7
DON'T KNOW -8
MODULE F – FAMILY HISTORY OF CARDIOVASCULAR DISEASE AND DIABETES
cer history
QA07_F1 These next questions ask about your family history of coronary heart disease, stroke and diabetes. By family we mean only your blood relatives, including half brothers and sisters.
First, has your father or mother, or have any of your brothers, sisters, sons, or daughters ever had coronary heart disease, stroke, or diabetes?
[IF NEEDED, SAY: "We want you to include information about both living and deceased blood relatives. Do not include family members related through marriage such as a stepfather or stepsister, or family members who were adopted."]
YES 1
GO
TO PN QA07_F25
REFUSED -7
DON'T KNOW -8
QA07_F2 Which of your parents, bothers and sisters or sons and daughters have been diagnosed with coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
MOTHER 1
FATHER 2
BROTHER(S) 3
SISTER(S) 4
SON(S)…………………………………………………. 5
DAUGHTER(S) 6
REFUSED -7
DON'T KNOW -8
QA07_F3 Did your mother have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F4 {Were any of these diagnoses before age 60?} Was her diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F5 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F6 Did your father have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F7 {Were any of these diagnoses before age 60?} Was his diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F8 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F9 How many of your brothers had coronary heart disease, stroke, or diabetes
_____ NUMBER OF BROTHERS
REFUSED -7
DON'T KNOW -8
[REPEAT FOR EACH BOTHER]
QA07_F10 {Did he have coronary heart disease, stroke, or diabetes? Thinking about the (youngest/next youngest) of your brothers who had disease did he have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F11 {Were any of these diagnoses before age 60?} Was his diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F12 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F13 How many of your sisters had coronary heart disease, stroke, or diabetes?
_____ NUMBER OF SISTERS
REFUSED -7
DON'T KNOW -8
[REPEAT FOR SISTER]
QA07_F14 {Did she have coronary heart disease, stroke, or diabetes? Thinking about the (youngest/next youngest) of your sisters who had disease did she have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F15 {Were any of these diagnoses before age 60?} Was her diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F16 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F17 How many of your daughters had coronary heart disease, stroke, or diabetes?
_____ NUMBER OF DAUGHTERS
REFUSED -7
DON'T KNOW -8
[REPEAT FOR DAUGHTER]
QA07_F18 {Did she have coronary heart disease, stroke, or diabetes? } Thinking about the (youngest/next youngest) of your daughters who had disease, did she have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F19 {Were any of these diagnoses before age 60?} Was her diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F20 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F21 How many of your sons had coronary heart disease, stroke, or diabetes?
_____ NUMBER OF SONS
REFUSED -7
DON'T KNOW -8
[REPEAT FOR SON]
QA07_F22 {Did he have coronary heart disease, stroke, or diabetes? } Thinking about the (youngest/next youngest) of your sons who had disease, did he have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F23 {Were any of these diagnoses before age 60?} Was his diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F24 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F25 Have any of your parents’ brothers or sisters, that is, your uncles or aunts, ever had coronary heart disease, stroke, or diabetes?
GO
TO PN QA07_F42
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F26 How many of your mother’s sisters had coronary heart disease, stroke, or diabetes?
_____ NUMBER OF MOTHER’S SISTERS
REFUSED -7
DON'T KNOW -8
[REPEAT FOR EACH AUNT]
QA07_F27 {Did she have coronary heart disease, stroke, or diabetes? } Thinking about the (youngest/next youngest) of your mother’s sisters who had disease, did she have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F28 {Were any of these diagnoses before age 60?} Was her diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F29 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F30 How many of your mother’s brothers had coronary heart disease, stroke, or diabetes?
_____ NUMBER OF MOTHER’S BROTHERS
REFUSED -7
DON'T KNOW -8
[REPEAT FOR EACH UNCLE]
QA07_F31 {Did he have coronary heart disease, stroke, or diabetes? } Thinking about the (youngest/next youngest) of your mother’s brothers who had disease, did he have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F32 {Were any of these diagnoses before age 60?} Was his diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F33 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F34 How many of your father’s sisters had coronary heart disease, stroke, or diabetes?
_____ NUMBER OF FATHER’S SISTERS
REFUSED -7
DON'T KNOW -8
[REPEAT FOR EACH AUNT]
QA07_F35 {Did she have coronary heart disease, stroke, or diabetes? } Thinking about the (youngest/next youngest) of your mother’s sisters who had disease, did she have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F36 {Were any of these diagnoses before age 60?} Was her diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F37 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F38 How many of your father’s brothers had coronary heart disease, stroke, or diabetes?
_____ NUMBER OF FATHER’S BROTHERS
REFUSED -7
DON'T KNOW -8
[REPEAT FOR EACH UNCLE]
QA07_F39 {Did he have coronary heart disease, stroke, or diabetes? } Thinking about the (youngest/next youngest) of your mother’s brothers who had disease, did he have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F40 {Were any of these diagnoses before age 60?} Was his diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F41 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F42 Have any of your grandparents ever had coronary heart disease, stroke, or diabetes?
End
section F ]]QA07_F30
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F43 Did your mother’s mother have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F44 {Were any of these diagnoses before age 60?} Was her diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F45 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F46 Did your mother’s father have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F47 {Were any of these diagnoses before age 60?} Was his diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F48 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F49 Now tell me about your father’s mother. Did your father’s mother have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F50 {Were any of these diagnoses before age 60?} Was her diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F51 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F52 Did your father’s father have coronary heart disease, stroke, or diabetes?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
QA07_F53 {Were any of these diagnoses before age 60?} Was his diagnosis before age 60?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_F54 Which of these diseases were diagnosed before age 60?
[CODE ALL THAT APPLY. CTRL-P TO EXIT.]
[PROBE: "Any others?"]
CORONARY HEART DISEASE 1
STROKE 2
DIABETES 3
REFUSED -7
DON'T KNOW -8
MODULE G – EPILEPSY
QA07_G1 Have you ever been told by a doctor that you have a seizure disorder or epilepsy?
YES 1
NO 2 [GO TO NEXT SECTION]
REFUSED -7 [GO TO NEXT SECTION]
DON'T KNOW -8 [GO TO NEXT SECTION]
QA07_G2 Are you currently taking any medicine to control your seizure disorder or epilepsy?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_G3 How many seizures of any type have you had in the last three months?
NONE 1
ONE 2
MORE THAN ONE 3
NO LONGER HAVE EPILEPSY
OR SEIZURE DISORDER 4 [GO TO NEXT SECTION]
REFUSED -7
DON'T KNOW -8
Instructions to interviewer: If the respondent mentions and counts "auras" as
seizures, accept the response. If a respondent indicates that he/she has had
nothing more than an aura and is unsure about counting the aura(s), do NOT
count auras as seizures.
QA07_G4 In the past year, have you seen a neurologist or epilepsy specialist for your epilepsy
or seizure disorder?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA07_G5 During the past month, to what extent has epilepsy or its treatment interfered with
your normal activities like working, school, or socializing with family or friends? Would you say (read list)
NOT AT ALL 1
SLIGHTLY 2
MODERATELY 3
QUITE A BIT 4
EXTREMELY 5
REFUSED -7
DON'T KNOW -8
QA07_G6 Please state whether you agree or disagree with each of the following statements regarding epilepsy.
I believe people with epilepsy can do anything I can do.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G7 I believe people with epilepsy are able to cope with everyday life.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G8 I believe people with epilepsy cannot have as good a quality of life.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G9 I believe people with epilepsy can be as successful at work as others.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G10 I believe people with epilepsy can work 40 hours per week.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G11 I believe there are work activities people with epilepsy can’t do safely.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G12 I expect as much from people with epilepsy as from others.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G13 I believe people with epilepsy can lead normal lives.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G14 I would be nervous around a person with epilepsy because they might have a seizure.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G15 I would not date a person with epilepsy.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G16 I would not want my child to date a person with epilepsy.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G17 I would be uncomfortable being around a person with epilepsy.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G18 I would not want to work with someone who had epilepsy.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G19 I would be afraid to be alone with someone with epilepsy.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G20 I would avoid a person with epilepsy who has frequent seizures.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
QA07_G20 I would be embarrassed if someone in the family had epilepsy.
AGREE 1
DISAGREE 2
REFUSED -7
DON'T KNOW -8
MODULE H – DISCRIMINATION
QA07_H1 These next questions are about events that happen to you in your day-to-day life.
About how often in your day-to-day life are you treated with less courtesy than other people-Would you say almost everyday, at least once a week, a few times a month, a few times a year, less than once a year?
ALMOST EVERYDAY 1
AT LEAST ONCE A WEEK 2
A FEW TIMES A MONTH 3
A FEW TIMES A YEAR 4
LESS THAN ONCE A YEAR 5
NEVER 6
DON’T KNOW -7
REFUSED -8
QA07_H2 About how often in your day-to-day life are you treated with less respect than other people-Would you say almost everyday, at least once a week, a few times a month, a few times a year, less than once a year?
ALMOST EVERYDAY 1
AT LEAST ONCE A WEEK 2
A FEW TIMES A MONTH 3
A FEW TIMES A YEAR 4
LESS THAN ONCE A YEAR 5
NEVER 6
DON’T KNOW -7
REFUSED -8
QA07_H3 About how often in your day-to-day life do you receive poorer service than other people at restaurants or stores?
ALMOST EVERYDAY 1
AT LEAST ONCE A WEEK 2
A FEW TIMES A MONTH 3
A FEW TIMES A YEAR 4
LESS THAN ONCE A YEAR 5
NEVER 6
DON’T KNOW -7
REFUSED -8
QA07_H4 About how often in your day-to-day life do people act as if they think you are not smart?
ALMOST EVERYDAY 1
AT LEAST ONCE A WEEK 2
A FEW TIMES A MONTH 3
A FEW TIMES A YEAR 4
LESS THAN ONCE A YEAR 5
NEVER 6
DON’T KNOW -7
REFUSED -8
QA07_H5 About how often in your day-to-day life do people act as if they are afraid of you?
ALMOST EVERYDAY 1
AT LEAST ONCE A WEEK 2
A FEW TIMES A MONTH 3
A FEW TIMES A YEAR 4
LESS THAN ONCE A YEAR 5
NEVER 6
DON’T KNOW -7
REFUSED -8
QA07_H6 About how often in your day-to-day life do people act as if they think you are dishonest?
ALMOST EVERYDAY 1
AT LEAST ONCE A WEEK 2
A FEW TIMES A MONTH 3
A FEW TIMES A YEAR 4
LESS THAN ONCE A YEAR 5
NEVER 6
DON’T KNOW -7
REFUSED -8
QA07_H7 About how often in your day-to-day life do people act as if you are not as good as they are?
ALMOST EVERYDAY 1
AT LEAST ONCE A WEEK 2
A FEW TIMES A MONTH 3
A FEW TIMES A YEAR 4
LESS THAN ONCE A YEAR 5
NEVER 6
DON’T KNOW -7
REFUSED -8
QA07_H8 About how often in your day-to-day life are you called names or insulted?
ALMOST EVERYDAY 1
AT LEAST ONCE A WEEK 2
A FEW TIMES A MONTH 3
A FEW TIMES A YEAR 4
LESS THAN ONCE A YEAR 5
NEVER 6
DON’T KNOW -7
REFUSED -8
QA07_H9 About how often in your day-to-day life are you threatened or harassed?
ALMOST EVERYDAY 1
AT LEAST ONCE A WEEK 2
A FEW TIMES A MONTH 3
A FEW TIMES A YEAR 4
LESS THAN ONCE A YEAR 5
NEVER 6
DON’T KNOW -7
REFUSED -8
QA07_H10 What do you think was the main reason for this/these experience(s)? Would you say…?
YOUR ANCESTRY/NATIONAL ORIGIN/ETHNICITY 1
YOUR GENDER OR SEX 2
YOUR RACE 3
YOUR AGE 4
YOUR HEIGHT 5
YOUR SKIN COLOR 6
YOUR SEXUAL ORIENTATION 7
YOUR WEIGHT 8
YOUR INCOME OR EDUCATIONAL LEVEL 9
OTHER (SPECIFY);____________________ 91
DON’T KNOW -7
REFUSED -8
QA07_H11 How often do people dislike you because you are [race/ethnic group] -- often, sometimes, rarely or never?
OFTEN 1
SOMETIMES 2
RARELY 3
NEVER 4
DON’T KNOW -7
REFUSED -8
QA07_H12 How often do people treat you unfairly because you are [race/ethnic group] -- often, sometimes, rarely or never?
OFTEN 1
SOMETIMES 2
RARELY 3
NEVER 4
DON’T KNOW -7
REFUSED -8
QA07_H13 How often have you seen friends treated unfairly because they are [race/ethnic group] -- often, sometimes, rarely or never?
OFTEN 1
SOMETIMES 2
RARELY 3
NEVER 4
DON’T KNOW -7
REFUSED -8
QA07_H14 If you feel you have been treated unfairly, do you usually:
ACCEPT IT AS A FACT OF LIFE 1
TRY TO DO SOMETHING ABOUT IT 2
DON’T KNOW -7
REFUSED -8
QA07_H15 If you have been treated unfairly, do you usually:
TALK TO OTHER PEOPLE ABOUT IT 1
KEEP IT TO YOURSELF 2
DON’T KNOW -7
REFUSED -8
QA07_H16 Have you ever experienced discrimination, been prevented from doing something, or been hassled or made to feel inferior in any of the following situations because of your race, ethnicity, or color?
At school?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_H17 How many times did this happen?
ONCE 1
TWO OR THREE TIMES 2
FOUR OR MORE TIMES 3
DON’T KNOW -7
REFUSED -8
QA07_H18 Getting hired or getting a job?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_H19 How many times did this happen?
ONCE 1
TWO OR THREE TIMES 2
FOUR OR MORE TIMES 3
DON’T KNOW -7
REFUSED -8
QA07_H20. At work?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_H21 How many times did this happen?
ONCE 1
TWO OR THREE TIMES 2
FOUR OR MORE TIMES 3
DON’T KNOW -7
REFUSED -8
QA07_H22 Getting housing?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_H23 How many times did this happen?
ONCE 1
TWO OR THREE TIMES 2
FOUR OR MORE TIMES 3
DON’T KNOW -7
REFUSED -8
QA07_H24 Getting medical care?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_H25 How many times did this happen?
ONCE 1
TWO OR THREE TIMES 2
FOUR OR MORE TIMES 3
DON’T KNOW -7
REFUSED -8
QA07_H26 Getting service in a store or restaurant?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_H27 How many times did this happen?
ONCE 1
TWO OR THREE TIMES 2
FOUR OR MORE TIMES 3
DON’T KNOW -7
REFUSED -8
QA07_H28 Getting credit, bank loans, or a mortgage?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_H29 How many times did this happen?
ONCE 1
TWO OR THREE TIMES 2
FOUR OR MORE TIMES 3
DON’T KNOW -7
REFUSED -8
QA07_H30 On the street or in a public setting?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_H31 How many times did this happen?
ONCE 1
TWO OR THREE TIMES 2
FOUR OR MORE TIMES 3
DON’T KNOW -7
REFUSED -8
QA07_H32 From the police or in the courts?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QA07_H33 How many times did this happen?
ONCE 1
TWO OR THREE TIMES 2
FOUR OR MORE TIMES 3
DON’T KNOW -7
REFUSED -8
DEMOGRAPHICS
Age
PROGRAMMING NOTE QA07_1.1:
SET AADATE = CURRENT DATE (YYYYMMDD)
QA07_1.1 What is your date of birth?
MONTH _____ DAY _____ YEAR _____ [GO TO QA07_1.5]
[RANGE: 1-12] [RANGE: 1-31] [RANGE: 1898-1985]
REFUSED -7
DON'T KNOW -8
1. JANUARY 7. JULY
2. FEBRUARY 8. AUGUST
3. MARCH 9. SEPTEMBER
4. APRIL 10. OCTOBER
5. MAY 11. NOVEMBER
6. JUNE 12. DECEMBER
PROGRAMMING NOTE QA07_1.2:
IF QA07_1.1 = -7 OR –8 (REF/DK), CONTINUE WITH QA07_1.2;
ELSE GO TO QA07_1.5
QA07_1.2 What month and year were you born?
MONTH _____ YEAR _____ [GO TO QA07_1.5]
[RANGE: 1-12] [RANGE: 1898-1985]
REFUSED -7
DON'T KNOW -8
1. JANUARY 7. JULY
2. FEBRUARY 8. AUGUST
3. MARCH 9. SEPTEMBER
4. APRIL 10. OCTOBER
5. MAY 11. NOVEMBER
6. JUNE 12. DECEMBER
PROGRAMMING NOTE QA07_1.3:
IF QA07_1.1 = -7 OR -8 (REF/DK) THEN CONTINUE WITH QA07_1.3;
ELSE GO TO QA07_1.5
QA07_1.3 What is your age, please?
_____YEARS OF AGE [GO TO QA07_1.5]
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_1.4:
IF QA07_1.2 = -7 OR -8 (REF/DK) THEN CONTINUE WITH QA07_1.4;
ELSE GO TO QA07_1.5
QA07_1.4 Are you between 18 and 29, between 30 and 39, between 40 and 44, between 45 and 49, between 50 and 64, or 65 or older?
BETWEEN 18 AND 29 1 …………………………..1
BETWEEN 30 AND 39 2 …………………………..2
BETWEEN 40 AND 44 3
BETWEEN 45 AND 49 4
BETWEEN 50 AND 64 5
65 OR OLDER 6
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_1.5:
CALCULATE VALUE OF AAGE BASED ON QA07_1.1, QA07_1.2, OR QA07_1.3 TO USE IN ALL AGE-RELATED QUESTIONS;
IF QA07_1.1, QA07_1.2, OR QA07_1.3 = -7 OR -8 (REF/DK), THEN USE QA07_1.4;
ELSE USE ENUM.AGE
Gender
QA07_1.5 Are you male or female?
MALE 1
FEMALE 2
REFUSED -7
DON'T KNOW -8
Ethnicity
QA07_1.6 Are you Latino or Hispanic?
YES 1
NO ……………………….. 2
REFUSED -7 [GO TO PN QA07_1.8]
DON'T KNOW -8
QA07_1.7 And what is your Latino or Hispanic ancestry or origin? Such as Mexican, Salvadoran, Cuban, Honduran-- and if you have more than one, tell me all of them.
[IF NECESSARY, GIVE MORE EXAMPLES]
[CODE ALL THAT APPLY.]
MEXICAN/MEXICANO .1
MEXICAN AMERICAN .2
CHICANO………………… .3
SALVADORAN ……………………………………4
GUATEMALAN …………………………………...5
COSTA RICAN …………………………………….6
HONDURAN ……………………………………….7
NICARAGUAN …………………………………….8
PANAMANIAN ……………………………………9
PUERTO RICAN ………………………………….10
CUBAN ……………………………………………11
SPANISH-AMERICAN (FROM SPAIN) 12
OTHER LATINO (SPECIFY): ___________ 91
REFUSED …………………………………………-7
DON'T KNOW …………………………………….-8
PROGRAMMING NOTE QA07_1.8:
IF QA07_1.5 = 1 (YES), DISPLAY “You said you are Latino or Hispanic. Also…”
IF MORE THAN ONE RACE GIVEN, AFTER ENTERING RESPONSES FOR QA07_1.8, CONTINUE WITH PROGRAMMING NOTE QA07_1.9;
ELSE FOLLOW GOS AS INDICATED FOR SINGLE RESPONSES
Race
QA07_1.8 {You said you are Latino or Hispanic. Also} please tell me which one or more of the following you would use to describe yourself. Would you describe yourself as Native Hawaiian, Other Pacific Islander, American Indian, Alaska Native, Asian, Black, African American, or White?
[IF R GIVES ANOTHER RESPONSE YOU MUST SPECIFY WHAT IT IS]
[CODE ALL THAT APPLY.]
IF ONLY ONE RACE…
WHITE 1 [GO TO QA07_1.15]
BLACK OR AFRICAN AMERICAN 2 [GO TO QA07_1.15]
ASIAN 3 [GO TO QA07_1.12]
AMERICAN INDIAN OR ALASKA NATIVE 4 [GO TO QA07_1.9]
OTHER PACIFIC ISLANDER 5 [GO TO QA07_1.13]
NATIVE HAWAIIAN 6 [GO TO QA07_1.15]
OTHER (SPECIFY): _____________ 91 [GO TO QA07_1.15]
REFUSED -7 [GO TO QA07_1.15]
DON'T KNOW -8 [GO TO QA07_1.15]
PROGRAMMING NOTE QA07_1.9:
IF QA07_1.8 = 4 (AMERICAN INDIAN OR ALASKA NATIVE) AND [QA07_1.8 = 2 (NATIVE HAWAIIAN) OR QA07_1.8 =5 (OTHER PACIFIC ISLANDER) OR QA07_1.8 = 3 (ASIAN) OR QA07_1.8= 2 (BLACK OR AFRICAN AMERICAN)
OR QA07_1.8= 1 (WHITE) OR QA07_1.8= 91 (OTHER (Specify))], CONTINUE WITH QA07_1.9;
ELSE GO TO PROGRAMMING NOTE QA07_1.13
QA07_1.9 You said, American Indian or Alaska Native, and what is your tribal heritage? If you have more than one tribe, tell me all of them.
[CODE ALL THAT APPLY.]
APACHE 1
BLACKFOOT/BLACKFEET 2
CHEROKEE 3
CHOCTAW 4
MEXICAN AMERICAN INDIAN 5
NAVAJO 6
POMO 7
PUEBLO 8
SIOUX 9
YAQUI 10
OTHER TRIBE [Ask for spelling] (SPECIFY):__ 91
REFUSED -7
DON'T KNOW -8
QA07_1.10 Are you an enrolled member in a federally or state recognized tribe?
YES 1
NO 2 [GO TO PN QA07_1.12]
REFUSED -7 [GO TO PN QA07_1.12]
DON'T KNOW -8 [GO TO PN QA07_1.12]
QA07_1.11 Which tribe are you enrolled in?
APACHE
MESCALERO APACHE, NM 1
APACHE (NOT SPECIFIED) 2
OTHER APACHE [Ask for spelling] (SPECIFY): 3
BLACKFEET
BLACKFOOT/BLACKFEET 4
CHEROKEE
WESTERN CHEROKEE 5
CHEROKEE (NOT SPECIFIED) 6
OTHER CHEROKEE [Ask for spelling] (SPECIFY) 7
CHOCTAW
CHOCTAW OKLAHOMA 8
CHOCTAW (NOT SPECIFIED) 9
OTHER CHOCTAW [Ask for spelling] (SPECIFY): 10
NAVAJO
NAVAJO (NOT SPECIFIED) 11
POMO
HOPLAND BAND, HOPLAND RANCHERIA 12
SHERWOOD VALLEY RANCHERIA 13
POMO (NOT SPECIFIED) 14
OTHER POMO [Ask for spelling] (SPECIFY): 15
PUEBLO
HOPI 16
YSLETA DEL SUR PUEBLO OF TEXAS 17
PUEBLO (NOT SPECIFIED) 18
OTHER PUEBLO [Ask for spelling] (SPECIFY): 19
SIOUX
OGLALA/PINE RIDGE SIOUX 20
SIOUX (NOT SPECIFIED) 21
OTHER SIOUX [Ask for spelling] (SPECIFY): 22
YAQUI
PASCUA YAQUI TRIBE OF ARIZONA 23
YAQUI (NOT SPECIFIED) 24
OTHER YAQUI [Ask for spelling] (SPECIFY): 25
OTHER
OTHER [Ask for spelling] (SPECIFY): 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_1.12:
IF QA07_1.8= 3 (ASIAN) AND [QA07_1.8= 6 (NATIVE HAWAIIAN) OR QA07_1.8= 5 (OTHER PACIFIC ISLANDER) OR QA07_1.8 = 4 (AMERICAN INDIAN OR ALASKA NATIVE) OR QA07_1.8 = 2 (BLACK OR AFRICAN AMERICAN) OR QA07_1.8 = 1 (WHITE) OR QA07_1.8 = 91 (OTHER (Specify))], CONTINUE WITH QA07_1.11;
ELSE GO TO PROGRAMMING NOTE QA07_1.13
QA07_1.12 You said Asian, and what specific ethnic group are you, such as Chinese, Filipino, Vietnamese? If you are more than one, tell me all of them.
[CODE ALL THAT APPLY.]
BANGLADESHI 1
BURMESE 2
CAMBODIAN 3
CHINESE 4
FILIPINO 5
HMONG 6
INDIAN (INDIA) 7
INDONESIAN 8
JAPANESE 9
KOREAN 10
LAOTIAN 11
MALAYSIAN 12
PAKISTANI 13
SRI LANKAN 14
TAIWANESE 15
THAI 16
VIETNAMESE 17
OTHER ASIAN (SPECIFY): 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_1.13:
IF QA07_1.8 = 5 (OTHER PACIFIC ISLANDER), CONTINUE WITH QA07_1.13;
ELSE GO TO PROGRAMMING NOTE QA07_1.14
QA07_1.13 You said you are Pacific Islander. What specific ethnic group are you, such as Samoan, Tongan, or Guamanian? If you are more than one, tell me all of them.
[CODE ALL THAT APPLY.]
SAMOAN/AMERICAN SAMOAN 1
GUAMANIAN 2
TONGAN 3
FIJIAN 4
OTHER PACIFIC ISLANDER (SPECIFY): 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_1.14:
IF QA07_1.5 = YES (LATINO) AND [QA07_1.8 = 6 (NATIVE HAWAIIAN) OR QA07_1.8 = 5 (OTHER PACIFIC ISLANDER) OR QA07_1.8 = 4 (AMERICAN INDIAN OR ALASKA NATIVE) OR QA07_1.8 = 3 (ASIAN) OR QA07_1.8 = 2 (BLACK OR AFRICAN AMERICAN) OR QA07_1.8 = 1 (WHITE) OR QA07_1.8 = 91 (OTHER)], CONTINUE WITH QA07_1.14;
ELSE IF MULTIPLE RESPONSES TO QA07_1.8 OR QA07_1.12 OR QA07_1.12 [NOT COUNTING -7 OR -8 (REF/DK)] CONTINUE WITH QA07_1.14;
ELSE GO TO QA07_1.15
[NOTE: FOR QA07_1.14 RESPONSES, INCLUDE "Specify" RESPONSE FOR 91 (OTHER LATINO); IF QA07_1.7 = -7 (REFUSE), INSERT “Latino”]
IF QA07_1.6 = 1 (YES, LATINO) AND ANY OF QA07_1.7 = 1 THRU 12, DO NOT DISPLAY QA07_1.14 = 14 (LATINO).
IF QA07_1.8 = 5 (OTHER PACIFIC ISLANDER) AND QA07_1.12 = 1 THRU 4, DO NOT DISPLAY QA07_1.14 = 17 (OTHER PACIFIC ISLANDER).
IF QA07_1.8= 3 AND ANY OF QA07_1.12 = 1 THRU 17, DO NOT SAY QA07_1.14 = 19 (ASIAN)
QA07_1.14 You said that you are: [INSERT MULTIPLE RESPONSES FROM AA5, AA5A, AA5E AND AA5E1].
Of these, which do you most identify with?
[IF R UNABLE TO CHOOSE ONE, OFFER OPTION “BOTH/ALL/MULTIRACIAL”]
MEXICAN/MEXICANO 1
MEXICAN AMERICAN 2
CHICANO 3
SALVADORAN 4
GUATEMALAN 5
COSTA RICAN 6
HONDURAN 7
NICARAGUAN 8
PANAMANIAN 9
PUERTO RICAN 10
CUBAN 11
SPANISH-AMERICAN (FROM SPAIN) 12
LATINO, OTHER SPECIFY 13
LATINO 14
NATIVE HAWAIIAN 16
OTHER PACIFIC ISLANDER 17
AMERICAN INDIAN OR ALASKA NATIVE 18
ASIAN 19
BLACK OR AFRICAN AMERICAN 20
WHITE 21
RACE, OTHER SPECIFY 22
BANGLADESHI 30
BURMESE 31
CAMBODIAN 32
CHINESE 33
FILIPINO 34
HMONG 35
INDIAN (INDIA) 36
INDONESIAN 37
JAPANESE 38
KOREAN 39
LAOTIAN 40
MALAYSIAN 41
PAKISTANI 42
SRI LANKAN 43
TAIWANESE 44
THAI 45
VIETNAMESE 46
ASIAN, OTHER SPECIFY 49
SAMOAN/AMERICAN SAMOAN 50
GUAMANIAN 51
TONGAN 52
FIJIAN 53
PACIFIC ISLANDER, OTHER SPECIFY 55
BOTH/ALL/MULTIRACIAL 90
NONE OF THESE 95
REFUSED -7
DON'T KNOW -8
Marital status
QA07_1.15 Are you now married, living with a partner in a marriage-like relationship, widowed, divorced, separated, or never married?
[IF R MENTIONS MORE THAN ONE, CODE THE LOWEST NUMBER THAT APPLIES]
MARRIED 1
LIVING WITH PARTNER 2
WIDOWED 3
DIVORCED 4
SEPARATED 5
NEVER MARRIED 6
REFUSED -7
DON'T KNOW -8
QA07_1.16 What is the highest grade of education you have completed and received credit for?
Educational attainment
NO FORMAL EDUCATION 30
GRADE SCHOOL
1ST GRADE 1
2ND GRADE 2
3RD GRADE 3
4TH GRADE………………………………………..4
5TH GRADE………………………………………..5
6TH GRADE 6 (Primaria)
7TH GRADE 7
8TH GRADE 8
HIGH SCHOOL OR EQUIVALENT
9TH GRADE 9 (Secundaria)
10TH GRADE 10
11TH GRADE 11
12TH GRAD 12 (Preparatoria)
4-YEAR COLLEGE OR UNIVERSITY
1ST YEAR (FRESHMAN) 13
2ND YEAR (SOPHOMORE) 14
3RD YEAR (JUNIOR) 15
4TH YEAR (SENIOR) (BA/BS) 16
5TH YEAR 17
GRADUATE OR PROFESSIONAL SCHOOL
1ST YEAR GRAD OR PROF SCHOOL 18
2ND YEAR GRAD OR PROF SCHOOL (MA/MS) 19
3RD YEAR GRAD OR PROF SCHOOL 20
MORE THAN 3 YEARS GRAD OR
PROF SCHOOL (PhD) 21
2-YEAR JUNIOR OR COMMUNITY COLLEGE
1ST YEAR 22
2ND YEAR (AA/AS) 23
VOCATIONAL, BUSINESS, OR TRADE SCHOOL
1ST YEAR 24
2ND YEAR 25
MORE THAN 2 YEARS 26
REFUSED -7
DON'T KNOW (OUT OF RANGE) -8
QA07_1.17 In what country were you born?
Country of birth
[SELECT FROM MOST LIKELY COUNTRIES]
UNITED STATES… 1
AMERICAN SAMOA 2
CANADA 3
CHINA 4
EL SALVADOR 5
ENGLAND 6
FRANCE 7
GERMANY 8
GUAM 9
GUATEMALA 10
HUNGARY 11
INDIA 12
IRAN 13
IRELAND 14
ITALY 15
JAPAN 16
KOREA 17
MEXICO 18
PHILIPPINES 19
POLAND 20
PORTUGAL 21
PUERTO RICO 22
RUSSIA 23
TAIWAN 24
VIETNAM 25
VIRGIN ISLANDS 26
OTHER (SPECIFY):_____________________ 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_1.18:
IF QA07_1.17 NE 1 (NOT BORN IN US), GO TO QA07_1.20
ELSE IF QA07_1.17 = 1 (BORN IN US) CONTINUE WITH QA07_1.18
QA07_1.18 In what country was your mother born?
Mother’s/Father’s country of birth
[SELECT FROM MOST LIKELY COUNTRIES]
[FOR RESPONDENTS WHO WERE ADOPTED, QUESTION REFERS TO ADOPTIVE PARENTS]
UNITED STATES… 1
AMERICAN SAMOA 2
CANADA 3
CHINA 4
EL SALVADOR 5
ENGLAND 6
FRANCE 7
GERMANY 8
GUAM 9
GUATEMALA 10
HUNGARY 11
INDIA 12
IRAN 13
IRELAND 14
ITALY 15
JAPAN 16
KOREA 17
MEXICO 18
PHILIPPINES 19
POLAND 20
PORTUGAL 21
PUERTO RICO 22
RUSSIA 23
TAIWAN 24
VIETNAM 25
VIRGIN ISLANDS 26
OTHER (SPECIFY):_____________________ 91
REFUSED -7
DON'T KNOW -8
QA07_1.19 In what country was your father born?
[SELECT FROM MOST LIKELY COUNTRIES]
[FOR RESPONDENTS WHO WERE ADOPTED, QUESTION REFERS TO ADOPTIVE PARENTS]
UNITED STATES… 1
AMERICAN SAMOA 2
CANADA 3
CHINA 4
EL SALVADOR 5
ENGLAND 6
FRANCE 7
GERMANY 8
GUAM 9
GUATEMALA 10
HUNGARY 11
INDIA 12
IRAN 13
IRELAND 14
ITALY 15
JAPAN 16
KOREA 17
MEXICO 18
PHILIPPINES 19
POLAND 20
PORTUGAL 21
PUERTO RICO 22
RUSSIA 23
TAIWAN …………………………………………..24
VIETNAM 25
VIRGIN ISLANDS 26
OTHER (SPECIFY):_____________________ 91
REFUSED -7
DON'T KNOW -8
QA07_1.20 What languages do you speak at home?
Language(s) spoken at home
[CODE ALL THAT APPLY.]
[PROBE: "Any others?"]
ENGLISH 1
SPANISH 2
CANTONESE 3
VIETNAMESE 4
TAGALOG 5
MANDARIN 6
KOREAN 7
ASIAN INDIAN LANGUAGES 8
RUSSIAN 9
OTHER1 (SPECIFY): 91
OTHER2 (SPECIFY): 92
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA07_1.21:
IF INTERVIEW NOT CONDUCTED IN ENGLISH, CONTINUE WITH QA07_1.21
IF INTERVIEW CONDUCTED IN ENGLISH AND R SPEAKS LANGUAGE OTHER THAN ENGLISH AT HOME), CONTINUE WITH QA07_1.21 AND DISPLAY: “Since you speak a language other than English at home, we are interested in your own opinion of how well you speak English…” AND DROP RESPONSE CATEGORY “NOT AT ALL”;
ELSE IF QA07_1.20 = 1 ONLY (ENGLISH IS ONLY LANGUAGE SPOKEN AT HOME), GO TO PN QA07_1.22
QA07_1.21 {Since you speak a language other than English at home, we are interested in your own opinion of how well you speak English} Would you say you speak English …
English proficiency
Very well 1
Well 2
Not well or 3
Not at all? 4
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_1.22:
IF QA07_1.17 = 1 (USA) OR 2 (AMERICAN SAMOA) OR 9 (GUAM) OR 22 (PUERTO RICO) OR 26 (VIRGIN ISLANDS), GO TO PROGRAMMING NOTE QA07_1.25;
ELSE CONTINUE WITH QA07_1.22
Citizenship-Immigration status
QA07_1.22 The next questions are about citizenship and immigration. Your answers are confidential and will not be reported to the INS.
Are you a citizen of the United States?
YES 1 [GO TO PN QA07_A1.25]
NO 2
APPLICATION PENDING 3
REFUSED -7
DON'T KNOW -8
QA07_1.23 Are you a permanent resident with a green card?
IF NEEDED, SAY: "People usually
call this a "Green Card"
but the color can also be
pink, blue, or white."
YES 1
NO 2
APPLICATION PENDING 3
REFUSED -7
DON'T KNOW -8
QA07_1.24 About how many years have you lived in the United States?
[FOR LESS THAN A YEAR, ENTER 1 YEAR]
_____ (NUMBER OF YEARS)
_____ YEAR (FIRST CAME TO LIVE IN U.S.)
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_1.25:
IF AAGE > 70 OR QA07_1.4 = 6 (65 OR OLDER) OR ENUM.AGE > 70 OR IF AGE IS UNKNOWN,
GO TO PROGRAMMING NOTE QA07_1.28;
ELSE CONTINUE WITH QA07_1.25
Sexual orientation
QA07_1.25 We are asking a few questions about people’s sexual experiences. All answers will be kept private.
In the past 12 months, how many sexual partners have you had?
_______ NUMBER OF SEXUAL PARTNERS [GO TO PN QA07_1.27]
REFUSED -7 [GO TO PN QA07_1.28]
DON’T KNOW -8
QA07_1.26 Can you give me your best guess?
[IF R PROVIDES EXACT NUMBER, ENTER AS GIVEN.
OTHERWISE CODE INTO CATEGORIES PROVIDED]
_________ PARTNERS
1 PARTNER 1
2-3 PARTNERS 2
4-5 PARTNERS 3
6-10 PARTNERS 4
MORE THAN 10 PARTNERS 5
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA07_1.27:
IF QA07_1.25 = 0 (NO SEXUAL PARTNERS IN LAST 12 MONTHS), GO TO PROGRAMMING NOTE QA07_1.29;
ELSE CONTINUE WITH QA07_1.27
IF QA07_1.24 OR QA07_1.25 = 1 (ONE PARTNER IN LAST 12 MONTHS), DISPLAY “Is that partner male or female?”
QA07_1.27 {Is that partner male or female?} In the past 12 months, have your sexual partners been male, female, or both male and female?
MALE 1
FEMALE 2
BOTH MALE AND FEMALE 3
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA07_1.28:
IF QA07_1.5=1 (MALE), DISPLAY “Gay” in question and “Gay” in Help Screen,
ELSE IF QA07_1.5=2 (FEMALE), DISPLAY “Gay, Lesbian” in question and “Gay and Lesbian” in Help Screen
IF AAGE > 70 OR QA07_1.4 = 6 (65 OR OLDER) OR ENUM.AGE > 70 OR IF AGE IS UNKNOWN,
Read “The next question is about sexual orientation. All answers will be kept private.” and continue with QA07_1.28
QA07_1.28 Do you think of yourself as straight or heterosexual, as gay {, lesbian} or homosexual, or bisexual?
[IF NEEDED, SAY:
“Straight or Heterosexual people have sex with,
or are
primarily attracted to people of the opposite sex,
Gay {and
Lesbian} people have sex with or are primarily
attracted to
people of the same sex, and Bisexuals have sex with or
are
attracted to people of both sexes”.]
STRAIGHT OR HETEROSEXUAL 1
GAY, LESBIAN, OR HOMOSEXUAL 2
BISEXUAL 3
NOT SEXUAL/ CELIBATE/ NONE 4
OTHER (SPECIFY): 5
REFUSED -7
DON’T KNOW -8
County of residence
QA07_1.29 To be sure we are covering the entire state, what county do you live in?
ALAMEDA 1
ALPINE 2
AMADOR 3
BUTTE 4
CALAVERAS 5
COLUSA 6
CONTRA COSTA 7
DEL NORTE 8
EL DORADO 9
FRESNO 10
GLENN 11
HUMBOLDT 12
IMPERIAL 13
INYO 14
KERN 15
KINGS 16
LAKE 17
LASSEN 18
LOS ANGELES 19
MADERA 20
MARIN 21
MARIPOSA 22
MENOCINO 23
MERCED 24
MODOC 25
MONO 26
MONTEREY 27
NAPA 28
NEVADA 29
ORANGE 30
PLACER 31
PLUMAS 32
RIVERSIDE 33
SACRAMENTO 34
SAN BENITO 35
SAN BERNARDINO 36
SAN DIEGO 37
SAN FRANCISCO 38
SAN JOAQUIN 39
SAN LUIS OBISPO 40
SAN MATEO 41
SANTA BARBARA 42
SANTA CLARA 43
SANTA CRUZ 44
SHASTA 45
SIERRA 46
SISKIYOU 47
SOLANO 48
SONOMA 49
STANISLAUS 50
SUTTER 51
TEHAMA 52
TRINITY 53
TULARE 54
TUOLUMNE 55
VENTURA 56
YOLO 57
YUBA 58
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_1.30:
IF ADVANCE LETTER SENT, ASK QA07_1.30;
ELSE GO TO QA07_1.31
Geographic location
QA07_1.30 Your phone number was randomly selected for this study by a computer. We were able to match an address to your phone number to send a letter to your home explaining the purpose of this study.
To help us better understand the environment you live in and how it may affect your health, can you confirm your address? Your street address will not be given out to researchers or any other organization and, like your telephone number, will be protected and kept confidential.
Is your current address {R’s address and street}?
YES 1 [GO TO NEXT SECTION]
NO………………………………………………….2
REFUSED…………………………………………-7
DON'T KNOW -8
QA07_1.31 What is your zip code?
_______(ZIP CODE)
REFUSED -7
DON'T KNOW -8
QA07_1.32 To help us better understand the environment you live in and how it may affect your health, can you tell me your address? Your street address will not be given out to researchers or any other organization and, like your telephone number, will be protected and kept confidential.
___________ (HOUSE ADDRESS NUMBER)
_______________________(NAME OF STREET, VERIFY SPELLING)
NO 2
REFUSED -7
DON'T KNOW……………. -8
QA07_1.33 Can you tell me just the name of the street you live on?
____________________________(NAME OF STREET)
REFUSED -7 [GO TO NEXT SECTION]
DON'T KNOW -8 [GO TO NEXT SECTION]
QA07_1.34 And what is the name of the street down the corner from you that crosses your street?
____________________________(NAME OF CROSS-STREET)
REFUSED -7
DON'T KNOW -8
Follow-up survey permission
QA07_A1.35 Do you think you would be willing to do a follow-up to this survey some time in the future?
YES 1
MAYBE/PROBABLY YES 2
DEFINITELY NOT 3
REFUSED -7
DON'T KNOW -8
EMPLOYMENT, INCOME, AND POVERTY STATUS
Employment status
QA07_12.1 Which of the following were you doing last week?
Working at a job or business 1 [GO TO QA07_12.3]
With a job or business but not at work 2
Looking for work or 3 [GO TO QA07_12.9]
Not working at a job or business? 4
REFUSED -7 [GO TO QA07_12.3]
DON'T KNOW -8 [GO TO QA07_12.3]
QA07_12.2 What is the main reason you did not work last week?
[IF NEEDED, SAY: “Main reason is the most important reason.”
KEEPING HOUSE/CARING FOR CHILDREN
OR OTHERS 1 [GO TO QA07_12.9]
VACATION OR LEAVE 2
COULDN'T FIND A JOB 3
GOING
TO SCHOOL/STUDENT 4
RETIRED 5 [GO TO QA07_12.9]
PHYSICAL DISABILITY 6
UNABLE TO WORK 7
ON LAYOFF OR STRIKE 8
OTHER 91
REFUSED -7
DON'T KNOW -8
QA07_12.3 How many hours per week do you usually work at all jobs or businesses?
[IF WORKS > 95 HOURS, ENTER 95. IF DOES NOT WORK, ENTER 0 (ZERO).]
_____ HOURS [HR: 0-95]
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_12.4
IF QA07_12.1 = 3 (LOOKING FOR WORK) OR QA07_12.2 = 3 (COULDN’T FIND A JOB) OR QA07_12.3 = 0 (NO HOURS WORKED), GO TO QA07_12
QA07_12.4 On your main job, are you employed by a private company, the government, or are you self-employed, or are you working without pay in a family business or farm?
[IF NEEDED, SAY: “Where did you work most hours?”]
PRIVATE COMPANY, NON-PROFIT
ORGANIZATION, FOUNDATION 1
GOVERNMENT 2
SELF-EMPLOYED 3
FAMILY BUSINESS OR FARM 4
REFUSED -7
DON'T KNOW -8
QA07_12.5 What kind of business or industry is this?
Occupation and industry
[IF NEEDED, SAY: “What do they make or do at this business?”]
[INTERVIEWER: ENTER DESCRIPTION]
_________________________ (BUSINESS OR INDUSTRY)
REFUSED -7
DON'T KNOW -8
QA07_12.6 What is the main kind of work you do?
[MAIN JOB = WHERE WORKS MOST HOURS.]
[INTERVIEWER: ENTER DESCRIPTION]
___________________________ (OCCUPATION)
REFUSED -7
DON'T KNOW -8
QA07_12.7 How long have you worked at your main job?
Time on current job
[IF NEEDED, SAY: “That is, for your current employer?”]
_____ MONTHS [HR: 0-12]
_____ YEARS [HR: 0-50]
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_12.8:
IF QA07_12.4 = 2 (GOVERNMENT EMPLOYEE), GO TO QA07_12.10;
IF QA07_12.4 = 3 OR 4 (SELF-EMPLOYED/FAMILY FARM), CONTINUE WITH QA07_12.8 AND DISPLAY "Including yourself, about";
ELSE CONTINUE WITH QA07_12.8 AND DISPLAY "About"
Firm size
QA07_12.8 {Including yourself, about / About} how many people are employed by {your employer/you} at all locations?
[IF NEEDED SAY: “Your best guess is fine.”]
FEWER
THAN 10 1
10-50 2
51-99 3
100-999 4 [GO TO QA07_12.10]
1,000 OR MORE 5
REFUSED -7
DON'T KNOW -8
QA07_12.9 Did you work at any time in the last month?
YES 1
NO 2
[GO TO PN
REFUSED -7 QA07_12.12]
DON'T KNOW -8
QA07_12.10 What is your best estimate of all your earnings last month before taxes and other deductions from all jobs and businesses, including hourly wages, salaries, tips and commissions?
Earnings, last month
[IF AMOUNT GREATER THAN $999,995, ENTER "999,995"]
$_____________ AMOUNT
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_12.12
IF RESPONDENT MARRIED AND LIVING WITH SPOUSE, CONTINUE WITH QA07_12.12 AND DISPLAY “spouse’s”;
ELSE IF RESPONDENT LIVING WITH PARTNER, CONTINUE WITH QA07_12 AND DISPLAY “partner’s”;
ELSE GO TO QA07_12.13
QA07_12.12 What is your best estimate of all your spouse’s earnings last month before taxes and other deductions from all jobs and businesses, including hourly wages, salaries, tips and commissions?
[IF AMOUNT GREATER THAN $999,995, ENTER "999,995"]
$_______________ AMOUNT
REFUSED -7
DON'T KNOW -8
Annual household income
QA07_12.13 What is your best estimate of your household’s total annual income from all sources before taxes in 2002?
[IF NEEDED SAY, “Include money from jobs, social security, retirement income, unemployment payments, public assistance and so forth. Also include income from interest, dividends, net income from business, farm, or rent and any other money income.”]
[IF AMOUNT GREATER THAN $999,995, ENTER "999,995"]
$_______________ AMOUNT
REFUSED -7
DON'T KNOW -8
QA07_12.14 I have entered that your annual household income is (AMOUNT). Is that correct?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGAMMING NOTE QA07_12.15:
IF QA07_12.13= -7 or -8 CONTINUE WITH QA07_12.15;
ELSE GO TO PROGRAMMING NOTE QA07_12.21
QA07_12.15 We don’t need to know exactly, but could you tell me if your household’s annual income from all sources before taxes is more than $20,000 per year or is it less?
MORE 1 [GO TO QA07_12.17]
EQUAL
TO $20K OR LESS 2
REFUSED -7 [GO TO PN DON'T KNOW………………………………………-8 QA07_12.21]
QA07_12.16 Is it …
$5,000 or less, or 1
$5,001 to $10,000, or 2
$10,001 to $15,000, or 3 [GO TO PN QA07_12.21]
$15,001 to 20,000? 4
REFUSED -7
DON'T KNOW -8
QA07_12.17 Is it more or less than $70,000 per year?
MORE 1 [GO TO QA07_12.19]
EQUAL
TO $70K OR LESS 2
REFUSED -7 [GO TO PN
DON'T KNOW -8 QA07_12.21]
QA07_12.18 Is it …
$20,001 to $30,000, 1
$30,001 to $40,000, 2
$40,001 to $50,000, 3
$50,001 to $60,000, or 4 [GO TO PN QA07_12.21]
$60,001 to $70,000? 5
REFUSED -7
DON'T KNOW -8
QA07_12.19 Is it more or less than $135,000 per year?
MORE 1 [GO TO PN QA07_12.21]
EQUAL TO $135K OR LESS 2
REFUSED -7
[GO TO PN
DON'T KNOW -8 QA07_12.21]
QA07_12.20 Is it …
$70,001 to $80,000, 1
$80,001 to $90,000, 2
$90,001 to $100,000, or 3
$100,001 to $135,000? 4
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_12.21:
IF R IS ONLY MEMBER OF HH, GO TO PROGRAMMING NOTE QA07_12.22;
ELSE CONTINUE WITH QA07_12.21
Number of people supported by income
QA07_12.21 Including yourself, how many people living in your household are supported by your total household income?
_____ NUMBER OF PEOPLE [HR: 1-20]
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_12.22:
QA07_12.22 MUST BE LESS THAN QA07_12.21
IF NO CHILDREN UNDER 18 IN HH (AS DETERMINED FROM CHILD ENUMERATION QUESTIONS) OR TOTAL NUMBER OF PEOPLE LIVING IN HH (AS DETERMINED BY ADULT PLUS CHILD ENUMERATION) = QA07_12.21, GO TO PROGRAMMING NOTE QA07_12.23;
ELSE CONTINUE WITH QA07_12.22
QA07_12.22 How many of these {INSERT NUMBER FROM AK18} people are children under the age of 18?
_____ NUMBER OF CHILDREN (UNDER AGE 18)
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_12.23: OBTAIN THE FEDERAL POVERTY 100%, 200%, AND 300% LEVEL CUTOFF POINTS FROM THE 2002 FEDERAL POVERTY GUIDELINE USING THE TOTAL HOUSEHOLD SIZE AND NUMBER OF CHILDREN FROM QA07_12.21 AND QA07_12.22 RESPECTIVELY. BASE.POVRT130POVRT200 BASE.POVRT100 BASE.POVRT200 SCRN.RADLTCNT SCRN.KIDCNT (THE 200% AND 300% VALUES WERE DERIVED BY MULTIPLYING THE CENSUS POVERTY 2002 THRESHOLD "SIZE OF FAMILY UNIT" BY "RELATED CHILDREN UNDER 18 YEARS" TABLE AMOUNTS BY 2 AND 3, RESPECTIVELY, THEN ROUNDING TO THE NEAREST 100 DOLLARS. REFER TO SPECIFICATIONS ADDENDUM xxx FOR THE TABLE OF VALUES. THE 100% POVERTY CUTOFF VALUE WILL BE STORED IN CATI VARIABLE POVRT100, THE 200% POVERTY CUTOFF VALUE WILL BE STORED IN CATI VARIABLE POVRT200 AND THE 300% VALUE IN CATI VARIABLE POVRT300). IF EITHER QA07_12.21 OR QA07_12.22 IS MISSING, USE THE TOTAL NUMBER OF ADULTS ENUMERATED IN THE SCREENER (GIVEN BY CATI VARIABLE RADLTCNT) AND THE TOTAL NUMBER OF CHILDREN ENUMERATED IN OTHER SECTION OF THE ADULT INTERVIEW (GIVEN BY CATI VARIABLE KIDCNT) INSTEAD. ASCERTAIN IF THE HOUSEHOLD INCOME IS ...
IF QA07_12.13= -7 OR -8 (REF/DK) AND IF THE HOUSEHOLD'S 100% CUTOFF VALUE FALLS WITHIN A RESPONSE FROM QA07_12.16, QA07_12.18, OR QA07_12.20 OR QA07_12.15= -7 OR QA07_12.17= -7 OR QA07_12.19= -7, ASK QA07_12.23 USING POVRT100 (THE 100% FPL CUTOFF DISPLAY AMOUNT); ELSE GO TO PROGRAMMING NOTE QA07_12.24 |
QA07_12.23 I need to ask just one last, very specific question about income. Was your total annual household income before taxes less than or more than ${POVRT100}?
EQUAL TO OR LESS 1 [GO TO NEXT SECTION]
MORE 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_12.24: IF QA07_12.13= -7 OR -8 (REF/DK) AND IF THE HOUSEHOLD'S 200% CUTOFF VALUE FALLS WITHIN A RESPONSE FROM QA07_12.16, QA07_12.18, OR QA07_12.20 OR IF QA07_12.15 = -7 OR QA07_12.17 = -7 OR QA07_12.19 = -7, CONTINUE WITH QA07_12.24 USING POVRT200 (200% POVERTY CUTOFF DISPLAY AMOUNT); ELSE GO TO PROGRAMMING NOTE QA07_12.26 |
QA07_12.24 {I need to ask just one last, very specific question about income.} Was your total annual household income before taxes less than or more than ${POVRT200}?
EQUAL TO OR LESS 1 [GO TO NEXT SECTION]
MORE 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_12.25: IF QA07_12.13 = -7 OR –8 (REF/DK) AND IF THE HOUSEHOLD'S 300% CUTOFF VALUE FALLS WITHIN A RESPONSE FROM QA07_12.16, QA07_12.18, OR QA07_12.20 OR IF QA07_12.15 = -7 OR QA07_12.17 = -7 OR QA07_12.19 = -7, CONTINUE WITH QA07_12.26 USING POVRT300 (300% POVERTY CUTOFF DISPLAY AMOUNT); ELSE GO TO NEXT SECTION |
QA07_12.25 {I need to ask just one last, very specific question about income.} Was your total annual household income before taxes less than or more than ${POVRT130}?
EQUAL TO OR LESS 1 [GO TO NEXT SECTION]
MORE 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA07_12.26: IF QA07_12.13 = -7 OR –8 (REF/DK) AND IF THE HOUSEHOLD'S 300% CUTOFF VALUE FALLS WITHIN A RESPONSE FROM QA07_12.16, QA07_12.18, OR QA07_12.20 OR IF QA07_12.15 = -7 OR QA07_12.17 = -7 OR QA07_12.19 = -7, CONTINUE WITH QA07_12.26 USING POVRT300 (300% POVERTY CUTOFF DISPLAY AMOUNT); ELSE GO TO NEXT SECTION |
QA07_12.26 {I need to ask just one last, very specific question about income.} Was your total annual household income before taxes less than or more than ${POVRT300}?
EQUAL TO OR LESS 1
MORE 2
REFUSED -7
DON'T KNOW -8
Adolescent Questionnaire
MODULE A – SUN EXPOSURE
QT07_A1 These next questions are about the time you spend in the sun.
When you go outside on a very sunny day for MORE than one hour, how often do you wear any kind of hat that shades your face, ears and neck from the sun?
Would you say always, sometimes or never?
ALWAYS 1
SOMETIMES 2
NEVER 3
NEVER GO OUT IN THE SUN FOR MORE THAN
1 HOUR/NEVER GO OUT IN THE SUN 4
REFUSED -7
DON'T KNOW -8
QT07_A2 And how often do you use sunscreen of SPF 15 or greater?
ALWAYS 1
SOMETIMES 2
NEVER 3
NEVER GO OUT IN THE SUN FOR MORE THAN
1 HOUR/NEVER GO OUT IN THE SUN 4
REFUSED -7
DON'T KNOW -8
QT07_A3 How many times in the past year have you had a sunburn?
ENTER TIMES: _____ [HR: 0-365]
REFUSED -7
DON'T KNOW -8
QT07_A4 How many times in the past year have you used indoor tanning devices?
ENTER TIMES: _____ [HR: 0-365]
REFUSED -7
DON'T KNOW -8
MODULE B–HPV
PROGRAMMING NOTEQT07_B1;
IF TA07_A5 = 1 (MALE), GO NEXT SECTION;
ELSE CONTINUE QT07_B1.
QT07_B1 Have you ever heard of HPV? HPV stands for Human Papillomavirus.
YES 1
NO 2 [GO TO QT07_B3]
DON’T KNOW -7 [GO TO QT07_B3]
REFUSED -8 [GO TO QT07_B3]
QT07_B2 Where did you heard about HPV?
A doctor, nurse or other health care professional 1
Family 2
Friends 3
Newspaper or magazine 4
Saw an ad on television 5
Television news 6
Internet 7
School 8
Other 9
DON’T KNOW -7
REFUSED -8
QT07_B3 Have you ever heard of a vaccine or shot to prevent cervical cancer?
YES 1
NO 2
DON’T KNOW -7
REFUSED -8
QT07_B3a. Have you ever received the HPV vaccine or shots?
YES 1 [SKIP TO NEXT SECTION]
NO 2
DON’T KNOW -7
REFUSED -8
QT07_B4 A vaccine, or shot that protects against HPV, a virus that can cause cervical cancer, was recently approved for girls and women ages 9 to 26. Would you be interested in getting the vaccine?
YES 1
NO 2
NOT SURE 3
DON’T KNOW -7
REFUSED -8
DEMOGRAPHICS
PROGRAMMING NOTE QT07_1.1:
SET TADATE = CURRENT DATE (YYYYMMDD)
Age
QT07_1.1 What is your date of birth?
TA1 |
_____ MONTH _____ DAY _____ YEAR [GO TO QT07_1.4]
[HR: 1-12] [HR: 1-31] [SR: 1985-1991]
REFUSED -7
DON'T KNOW -8
1. JANUARY 7. JULY
2. FEBRUARY 8. AUGUST
3. MARCH 9. SEPTEMBER
4. APRIL 10. OCTOBER
5. MAY 11. NOVEMBER
6. JUNE 12. DECEMBER
PROGRAMMING NOTE QT07_1.2:
IF QT07_1.1 = -7 OR –8 (REF/DK), CONTINUE WITH QT07_1.2;
ELSE GO TO QT07_1.4
QT07_1.2 What month and year were you born?
TA1A |
_____ MONTH _____ YEAR [GO TO QT07_1.4]
[HR: 1-12] [SR: 1985-1991]
REFUSED -7
DON'T KNOW -8
1. JANUARY 7. JULY
2. FEBRUARY 8. AUGUST
3. MARCH 9. SEPTEMBER
4. APRIL 10. OCTOBER
5. MAY 11. NOVEMBER
6. JUNE 12. DECEMBER
PROGRAMMING NOTE QT07_1.3:
IF QT07_1.2 = -7 OR –8 (REF/DK), CONTINUE WITH QT07_1.3;
ELSE GO TO QT07_1.4
QT07_1.3 How old are you?
TA2 |
______________ [SR: 12-17]
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QT07_1.4:
CALCULATE VALUE OF TEENAGE BASED ON QT07_1.1, QT07_1.2, OR QT07_1.3;
IF QT07_1.1 AND QT07_1.3 ARE NOT KNOWN, USE CHILD ROSTER AGE (ENUM.AGE);
IF TEENAGE <> BETWEEN 12 AND 17, THEN TERMINATE INTERVIEW AND CODE INELIGIBLE (IT)
Gender
QT07_1.4 Are you male or female?
TA3 |
MALE 1
FEMALE 2
REFUSED -7 [END INTERVIEW AND
DON”T KNOW -8 CODE INELIGIBLE.]
Education
QT07_1.5 Did you attend school last week?
TA4 |
YES 1 [GO TO QT07_1.6]
NO 2
ON VACATION 3
HOME SCHOOLED 4 [GO TO QT07_1.6]
REFUSED -7 [GO TO QT07_1.6]
DON’T KNOW -8 [GO TO QT07_1.6]
QT07_1.5A Did you attend school during the last school year?
TA4C |
YES 1
NO 2
REFUSED -7
DON’T KNOW -8
QT07_1.6 What is the name of the school you go to or last attended?
TA4B |
[RECORD VERBATIM]
(NAME OF SCHOOL)
REFUSED -7
DON’T KNOW -8
QT07_1.7 Not including any allowance you may get, have you worked for pay in the past 12 months?
TA5 |
[IF NEEDED, SAY: Include babysitting, yard work, pet care and any other odd jobs you were paid for.]
[NOTE: ENTER ZERO IF RESPONDENT DID NOT WORK DURING THE SCHOOL YEAR. IF WORK FOR PAY INTERMITTENLY, ENTER 95]
YES 1
NO 2 [GO TO QT05_B1]
REFUSED -7 [GO TO QT05_B1]
DON’T KNOW -8 [GO TO QT05_B1]
Employment
QT07_1.8 How many hours do you spend working for pay in a typical week during the school year?
TA5A |
[IF NEEDED, SAY: A typical week is a usual week. Pick the most recent school year.]
_____ NUMBER OF HOURS [HR: 0-60]
REFUSED -7
DON’T KNOW -8
So we can be sure we have included all races and ethnic groups in California, I need to ask a few questions about you.
Race/Ethnicity
QT07_2.1 Are you Latino or Hispanic?
TI1 |
[IF NEEDED, SAY: Such as Mexican, Central or South American?]
YES 1
NO 2 [GO TO QT07_2.3]
REFUSED -7 [GO TO QT07_2.3]
DON’T KNOW -8 [GO TO QT07_2.3]
QT07_2.2 And what is your Latino or Hispanic ancestry or origin? Such as Mexican, Salvadoran, Cuban, Honduran -- and if you have more than one, tell me all of them.
TI1A |
[IF NEEDED, GIVE MORE EXAMPLES]
[CODE ALL THAT APPLY]
MEXICAN/MEXICANO 1
MEXICAN AMERICAN 2
CHICANO 3
SALVADORAN 4
GUATEMALAN 5
COSTA RICAN 6
HONDURAN 7
NICARAGUAN 8
PANAMANIAN 9
PUERTO RICAN 10
CUBAN 11
SPANISH-AMERICAN (FROM SPAIN 12
OTHER LATINO (SPECIFY): __________________ 91
REFUSED -7
DON’T KNOW –8
PROGRAMMING NOTE QT07_2.3:
IF QT07_2.1=1 (YES), CATI DISPLAY “You said you are Latino or Hispanic. Also…”
IF MORE THAN ONE RACE GIVEN, AFTER ENTERING RESPONSES FOR QT07_2.3, CONTINUE WITH PROGRAMMING NOTE QT07_2.4;
ELSE GO TO SKIPS AS INDICATED FOR SINGLE RESPONSES.
QT07_2.3 {You said you are Latino or Hispanic. Also}, Please tell me which one or more of the following you would use to describe yourself: Would you describe yourself as Native Hawaiian, Other Pacific Islander, American Indian, Alaska Native, Asian, Black, African American, or White?
TI2 |
[IF R GIVES AN “OTHER” RESPONSE YOU MUST SPECIFY WHAT IT IS]
[CODE ALL THAT APPLY]
W
HITE
1 [GO
TO QT07_2.10]
BLACK OR AFRICAN AMERICAN 2 [GO TO QT07_2.10] IF
ASIAN 3 [GO TO QT07_2.7] ONLY
AMERICAN INDIAN, ALASKA NATIVE 4 [GO TO QT07_2.4] ONE
OTHER PACIFIC ISLANDER 5 [GO TO QT07_2.8] RACE
NATIVE HAWAIIAN 6 [GO TO QT07_2.10]
OTHER (SPECIFY): _________________ 91 [GO TO QT05_ K10]
REFUSED -7 [GO TO QT07_2.10]
DON’T KNOW -8 [GO TO QT07_2.10]
PROGRAMMING NOTE QT07_2.4:
IF QT05_ K3 = 4 (AMERICAN INDIAN, ALASKA NATIVE) CONTINUE WITH QT07_2.4;
ELSE GO TO PROGRAMMING NOTE AT QT07_2.7.
QT07_2.4 You said, American Indian or Alaska Native, and what is your tribal heritage? If you have more than one tribe, tell me all of them.
TI2A |
[CODE ALL THAT APPLY]
APACHE 1
BLACKFEET 2
CHEROKEE 3
CHOCTAW 4
MEXICAN AMERICAN 5
NAVAJO 6
POMO 7
PUEBLO 8
SIOUX 9
YAQUI 10
OTHER TRIBE [Ask for spelling] (SPECIFY):________________ 91
REFUSED -7
DON'T KNOW -8
QT07_2.5 Are you an enrolled member in a federally or state recognized tribe?
TI2B |
YES 1
NO 2 [GO TO PN QT07_2.7]
REFUSED -7 [GO TO PN QT07_2.7]
DON’T KNOW -8 [GO TO PN QT07_2.7]
QT07_2.6 Which tribe are you enrolled in?
TI2C |
APACHE
MESCALERO APACHE, NM 1
APACHE (NOT SPECIFIED) 2
OTHER APACHE [Ask for spelling] (SPECIFY) 3
BLACKFEET
BLACKFOOT/BLACKFEET 4
CHEROKEE
WESTERN CHEROKEE 5
CHEROKEE (NOT SPECIFIED) 6
OTHER CHEROKEE [Ask for spelling] (SPECIFY) 7
CHOCTAW
CHOCTAW OKLAHOMA 8
CHOCTAW (NOT SPECIFIED 9
OTHER CHOCTAW [Ask for spelling] (SPECIFY): 10
NAVAJO
NAVAJO (NOT SPECIFIED 11
POMO
HOPLAND BAND, HOPLAND RANCHERIA 12
SHERWOOD VALLEY RANCHERIA 13
POMO (NOT SPECIFIED) 14
OTHER POMO [Ask for spelling] (SPECIFY) 15
PUEBLO
HOPI 16
YSLETA DEL SUR PUEBLO OF TEXAS 17
PUEBLO (NOT SPECIFIED 18
OTHER PUEBLO [Ask for spelling] (SPECIFY): 19
SIOUX
OGLALA/PINE RIDGE SIOUX 20
SIOUX (NOT SPECIFIED) 21
OTHER SIOUX [Ask for spelling] (SPECIFY): 22
YAQUI
PASCUA YAQUI TRIBE OF ARIZONA 23
YAQUI (NOT SPECIFIED 24
OTHER YAQUI [Ask for spelling] (SPECIFY): 25
OTHER
OTHER [Ask for spelling] (SPECIFY): ________________________ 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QT07_2.7:
IF QT07_2.3 = 3 (ASIAN) CONTINUE WITH QT07_2.7;
ELSE GO TO PROGRAMMING NOTE QT07_2.8.
QT07_2.7 You said Asian, and what specific ethnic group are you, such as Chinese, Filipino, Vietnamese? If you are more than one, tell me all of them.
TI2D |
[CODE ALL THAT APPLY]
BANGLADESHI 1
BURMESE 2
CAMBODIAN 3
CHINESE 4
FILIPINO 5
HMONG 6
INDIAN (INDIA) 7
INDONESIAN 8
JAPANESE 9
KOREAN 10
LAOTIAN 11
MALAYSIAN 12
PAKISTANI 13
SRI LANKAN 14
TAIWANESE 15
THAI 16
VIETNAMESE 17
OTHER ASIAN (SPECIFY): _________________ 91
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QT07_2.8:
IF QT07_2.3 = 5 (PACIFIC ISLANDER) CONTINUE WITH QT07_2.8;
ELSE GO TO PROGRAMMING NOTE QT07_2.9.
QT07_2.8 You said you are Pacific Islander. What specific ethnic group are you, such as Samoan, Tongan, or Guamanian? If you are more than one, tell me all of them.
TI2D1 |
[CODE ALL THAT APPLY]
SAMOAN/AMERICAN SAMOAN 1
GUAMANIAN 2
TONGAN 3
FIJIAN 4
OTHER PACIFIC ISLANDER (SPECIFY): 91
_______________________
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QT07_2.9
IF QT07_2.1 = 1 (YES, LATINO) AND [QT07_2.3 = 6 (NATIVE HAWAIIAN) OR 5 (OTHER PACIFIC ISLANDER) OR 4 (AMERICAN INDIAN OR ALASKA NATIVE) OR 3 (ASIAN) OR 2 (BLACK OR AFRICAN AMERICAN) OR 1 (WHITE) OR 91 (OTHER (Specify))], CONTINUE WITH QT07_2.9;
ELSE IF MULTIPLE RESPONSES TO QT07_2.3 OR QT07_2.7 OR QT07_2.8 [NOT COUNTING -7 OR -8 (REF/DK)], CONTINUE WITH QT07_2.9; ELSE GO TO QT07_2.10.
FOR QT07_2.2 RESPONSES, INCLUDE "Specify" RESPONSE FOR 91 (OTHER LATINO); IF QT07_2.1 = -7 (REFUSE), INSERT "Latino".
QT07_2.9 You said that you are {DISPLAY RESPONSES FROM QT07_2.2, QT07_2.3, QT05_1.14, QT07_2.8}. Of these, which do you MOST identify with?
TI2E |
[IF R IS UNABLE TO CHOOSE ONE, OFFER OPTION “BOTH/ALL/MULTIRACIAL”]
MEXICAN/MEXICANO 1
MEXICAN AMERICAN 2
CHICANO 3
SALVADORAN 4
GUATEMALAN 5
COSTA RICAN…………………………………………………..6
HONDURAN 7
NICARAGUAN 8
PANAMANIAN 9
PUERTO RICAN 10
CUBAN 11
SPANISH-AMERICAN (FROM SPAIN) 12
LATINO, OTHER SPECIFY 13
LATINO 14
NATIVE HAWAIIAN 16
OTHER PACIFIC ISLANDER 17
AMERICAN INDIAN OR ALASKA NATIVE 18
ASIAN 19
BLACK OR AFRICAN AMERICAN 20
WHITE 21
RACE, OTHER SPECIFY 22
BANGLADESHI 30
BURMESE 31
CAMBODIAN 32
CHINESE 33
FILIPINO 34
HMONG 35
INDIAN (INDIA) 36
INDONESIAN 37
JAPANESE 38
KOREAN 39
LAOTIAN 40
MALAYSIAN 41
PAKISTANI 42
SRI LANKAN 43
TAIWANESE 44
THAI 45
VIETNAMESE 46
ASIAN, OTHER SPECIFY 49
SAMOAN/AMERICAN SAMOAN 50
GUAMANIAN 51
TONGAN 52
FIJIAN 53
PACIFIC ISLANDER, OTHER SPECIFY 55
BOTH/ALL/MULTIRACIAL 90
NONE OF THESE 95
REFUSED -7
DON'T KNOW -8
County of Birth, Citizenship, Immigration Status
QT07_2.10 In what country were you born?
TI3 |
UNITED STATES 1
AMERICAN SAMOA 2
CANADA 3
CHINA 4
EL SALVADOR 5
ENGLAND 6
FRANCE 7
GERMANY 8
GUAM 9
GUATEMALA 10
HUNGARY 11
INDIA 12
IRAN 13
IRELAND 14
ITALY 15
JAPAN 16
KOREA 17
MEXICO 18
PHILIPPINES 19
POLAND 20
PORTUGAL 21
PUERTO RICO 22
RUSSIA 23
TAIWAN 24
VIETNAM 25
VIRGIN ISLANDS 26
OTHER (SPECIFY):_____________________ 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QT07_2.11:
IF QT07_2.10 = 1, 2, 9, 22, or 26 (BORN IN USA or US TERRITORY), GO TO QT07_2.14;
ELSE, CONTINUE WITH QT07_2.11
QT07_2.11 Are you a citizen of the United States?
TI4 |
YES 1 [GO TO QT07_2.13]
NO 2
APPLICATION PENDING 3
REFUSED -7
DON’T KNOW -8
QT07_2.12 Are you a permanent resident with a green card?
TI5 |
[IF NEEDED SAY: “People usually call this a “Green Card” but the color can also be pink, blue or white.”]
YES 1
NO 2
APPLICATION PENDING 3
REFUSED -7
DON’T KNOW -8
QT07_2.13 About how many years have you lived in the United States?
TI6 |
[FOR LESS THAN A YEAR, ENTER 1 YEAR]
_____ NUMBER OF YEARS [HR: 0-17]
{OR}
_____ YEAR FIRST CAME TO LIVE IN U.S. HR: 1982-2000]
REFUSED -7
DON’T KNOW -8
Languages Spoken at Home
QT07_2.14 What languages do you speak at home?
TI7 |
[CODE ALL THAT APPLY]
[PROBE: “Any others?”]
ENGLISH 1
SPANISH 2
CANTONESE 3
VIETNAMESE 4
TAGALOG 5
MANDARIN 6
KOREAN 7
ASIAN INDIAN LANGUAGES 8
RUSSIAN 9
OTHER1 (SPECIFY): ___________ 91
OTHER2 (SPECIFY): ___________ 92
REFUSED -7
DON’T KNOW -8
| File Type | application/msword |
| File Title | Attachment 2 |
| Author | lee |
| Last Modified By | curriem |
| File Modified | 2007-01-25 |
| File Created | 2007-01-25 |
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