Additional Optional Survey Modules on Demographics, QOL,

Attachment G. Additional Modules

1. Demographics

2. Health Related Quality of Life

3. Stress

4. Intention to Change

5. Knowledge and Beliefs

G1. Demographics Module

Questions 1, 2, 3, 6, 7, 8, 13, and 14 are from the 2004 CDC Behavioral Risk Factor Surveillance System Survey (BRFSS). The BRFSS is a telephone based survey.

Questions 4, 5, 9, and 10 are also from the 2004 BRFSS with some slight modifications to fit a personal interview or self-administered survey format.

Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Questionnaire. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2004].

This last section asks a few questions about yourself and your household.

1. What is your age?

_______ Years

2. Are you Hispanic or Latino?

_____1. Yes

_____2. No

_____3. Don’t know / Not sure

3. Which one or more of the following would you say is your race?

_____1. American Indian or Alaska Native

_____2. Asian

_____3. Black or African American

_____4. Hispanic or Latino

_____5. Native Hawaiian or Other Pacific Islander

_____6. White

4. What is your marital status?

_____1. Married

_____2. Divorced

_____3. Widowed

_____4. Separated

_____5. Never married

_____6. A member of an unmarried couple

5. What is your sex?

(In an interview situation, instructions will be given to the interviewer not to ask this question but to simply record the answer)

_____1. Male (Skip to question 7)

_____2. Female (If respondent is 45 years old or older, instructions

will be given to go to question 7)

6. To your knowledge, are you now pregnant?

_____1. Yes

_____2. No

_____3. Don’t know / Not sure

7. How many children less than 18 years of age live in your household?

­_________ Number of children

8. What is the highest grade or year of school you completed?

_____1. Never attended school or only attended kindergarten

_____2. Grades 1 through 8 (Elementary school)

_____3. Grades 9 through 11 (Some high school)

_____4. Grade 12 or GED (High school graduate)

_____5. College 1 year to 3 years (Some college or technical school)

_____6. College 4 years or more (College graduate)

9. What is your current employment status? Are you currently ……

_____1. Employed for wages

_____2. Self-employed

_____3. Out of work for more than 1 year

_____4. Out of work for less than 1 year

_____5. A Homemaker

_____6. A Student

_____7. Retired

_____8. Unable to work

10. What is your annual household income from all sources? Would you say it is …

_____1. Less than $10,000

_____2. $10,000 to less than $15,000

_____3. $15,000 to less than $20,000

_____4. $20,000 to less than $25,000

_____5. $25,000 to less than $35,000

_____6. $35,000 to less than $50,000

_____7. $50,000 to less than $75,000

_____8. $75,000 or more

_____9. Don’t know / Not sure

11. How long have you lived at your current residence?

________ years

________ Don’t know / Not sure

12. When was your house built?

________ year (example: 1965)

________ Don’t know / Not sure

13. Have you smoked at least 100 cigarettes in your entire life?

Note: 5 packs = 100 cigarettes

_____ 1. Yes

_____ 2. No

_____ 3. Not sure / Don’t know

14. Do you now smoke cigarettes every day, some days, or not at all?

_____1. Everyday

_____2. Some days

_____3. Not al all

15. What is your current address? [Ask if don’t know]

Street Address ______________________________________ Apt # ________

City _______________________ State __________ Zip Code______________

G2. Health Related Quality of Life Module

CDC’s health related quality of life measures includes four core questions, and ten additional questions about health-related quality of life. These questions ask about recent pain, depression, anxiety, sleeplessness, vitality, and the cause, duration, and severity of a current activity limitation an individual may have in his or her life. Since 1993, the four core Healthy Days measures have been part of the state based BRFSS's full sample. Also starting in 2000, the Healthy Days Measures were added to the examination component of the National Health and Nutrition Examination Survey (NHANES).

We have elected to include in the Health Related Quality of Life Module, the four core questions, one question on activity limitations, and the healthy days symptoms measure. We selected to use only one question on activity limitation after consulting with David Moriarty, a CDC subject matter expert on the HRQOL measures (770-488-5455/[email protected]),

Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Health-Related Quality of Life. http://www.cdc.gov/hrqol/

This section asks you to respond to a few general questions about your health.

Core 4 questions

1. Would you say that in general your health is:

_____1. Excellent

_____2. Very good

_____3. Good

_____4. Fair

_____5. Poor

2. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

days

(If none, enter zero on the line.)

3. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

days

(If none, enter zero on the line.)

4. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

days

(If none, enter zero on the line.)

Activity Limitations Module

5. Are you LIMITED in any way in any activities because of any impairment or health problem?

_____1. Yes

_____2. No

Healthy Days Symptoms Module

6. During the past 30 days, for about how many days did PAIN make it hard for you to do your usual activities, such as self-care, work, or recreation?

days

(If none, enter zero on the line.)

7. During the past 30 days, for about how many days have you felt SAD, BLUE, or DEPRESSED?

days

(If none, enter zero on the line.)

8. During the past 30 days, for about how many days have you felt WORRIED, TENSE, or ANXIOUS?

days

(If none, enter zero on the line.)

9. During the past 30 days, for about how many days have you felt you did NOT get ENOUGH REST OR SLEEP?

days

(If none, enter zero on the line.)

10. During the past 30 days, for about how many days have you felt VERY HEALTHY AND FULL OF ENERGY?

days

(If none, enter zero on the line.)

G3. Stress Module

Perceived Stress Scale – 10 Item and 4 item scale (4 item scale is suggested for telephone and where there are time limitations. 4 item scale is noted with asterisks.)

Source:

Cohen, S., Kamarck, T., Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385-396.

Chen, Sheldon and Gail M. Williamson. (1988). “Perceived Stress in a Probability Sample of the United States.” In S. Spacepan & S. Oskamp (Eds.), The Social Psychology of Health. Newbury Park, CA: Sage.

John D. and Catherine T. MacArthur
Research Network on Socioeconomic Status and Health http://www.macses.ucsf.edu/Research/Psychosocial/notebook/PSS10.html

[Instructions if self-administered]. The questions in this section ask you about your feelings and thoughts during the past 6 months. For each statement, please circle the number which best corresponds to how often you felt or thought a certain way.

[Instructions if interviewer-administered]. The next set of questions are about some of your feelings and thoughts during the past 6 months. For each statement that I read, please indicate how often you felt or thought a certain way. For example, did you “never feel that way”, “almost never” feel that way, “sometimes” feel that way, “fairly often” feel that way, or did you “very often” feel that way.

10-item scale

In the past 6 months, how often have you ……	Never	Almost Never	Sometimes	Fairly Often	Very Often
Been upset because of something that happened unexpectedly?	1	2	3	4	5
Felt that you were unable to control the important things in your life?*	1	2	3	4	5
Felt nervous and “stressed”?	1	2	3	4	5
Felt confident about your ability to handle your personal problems?*	1	2	3	4	5
Felt that things were going your way?*	1	2	3	4	5
Found that you could not cope with all the things that you had to do?	1	2	3	4	5
Been able to control irritations in your life?	1	2	3	4	5
Felt that you were on top of things?	1	2	3	4	5
Been angered because of things that were outside of your control?	1	2	3	4	5
Felt difficulties were piling up so high that you could not overcome them?*	1	2	3	4	5

4-item scale

In the past 6 months, how often have you ……	Never	Almost Never	Sometimes	Fairly Often	Very Often
1. Felt that you were unable to control the important things in your life?	1	2	3	4	5
2. Felt confident about your ability to handle your personal problems?	1	2	3	4	5
3. Felt that things were going your way?	1	2	3	4	5
4. Felt difficulties were piling up so high that you could not overcome them?	1	2	3	4	5

G4. Intention to Change Module

[Instructions if self-adminstered]. For the following statement, please indicate with a check () whether you “Agree” or “Don’t agree” with the statement.

[Instructions if interviewer-adminstered]. Please let me know whether you “Agree” or “Don’t agree” with the following statement.

Filter question

I am aware of contaminants in my community.

1. _____Agree

2. _____Don’t agree [Stop, skip to next section]

[Additional instructions if self-adminstered]. The following set of statements might describe different behaviors in regard to the contaminants in your community. Please indicate with a check () which one of the following statements best describes your behavior in regard to the contaminants in your community.

[Additional instructions if interviewer-adminstered]. I am now going read to you a set of statements that might describe different behaviors in regard to the contaminants in your community. Please let me know which one of these statements best describes your behavior in regard to these contaminants.

Select the statement that best describes your behavior in regard to the contaminants in your community (check only one statement)
	I do not plan to change anything I do in order to reduce my or members of my household’s potential exposure.
	I plan to do something different in the next six months in order to reduce potential exposure.
	I have recently started taking steps to limit potential exposure.
	I have taken the recommended actions to limit potential exposure to contaminants in my community.
	Changing my behavior to limit or reduce potential exposure to contaminants in my community has become routine.

G5. Knowledge and Belief Module

[Instructions if self-administered]. Here are a few statements about some types of environmental hazards that communities such as yours might experience. Please indicate how much you feel each of the following is a problem in your community. 1 means “a very big problem,” 2 means “somewhat of a problem,” 3 means “somewhat not a problem,” and 4 means “not at all a problem.” For each statement, circle the number that best represents how you feel. If you “don’t know” circle 5 and if the statement is “not applicable” circle 6.

[Instructions if interviewer-administered]. I am going to read a few statements about some types of environmental hazards that communities such as yours might experience. Please tell me how much you feel each of the following are a problem in your community. Are any one of these environmental hazards “a very big problem,” “somewhat of a problem,” “somewhat not a problem,” or “not at all a problem” in your community? Or, would you say you “don’t know” or it is “not applicable.” [Hand respondent correct response card]

	A very big problem	Somewhat of a problem	Somewhat not a problem	Not at all a problem	Don’t know	Not Applicable
1. Indoor air quality	1	2	3	4	5	6
2. Outdoor air quality	1	2	3	4	5	6
3. Safety of water for drinking	1	2	3	4	5	6
4. Safety of water for recreational use (such as fishing, swimming, canoeing, boating)	1	2	3	4	5	6
5. Safety of food grown locally	1	2	3	4	5	6
6. Safety of fish caught locally	1	2	3	4	5	6
7. Environmental hazards in your home	1	2	3	4	5	6
8. Environmental hazards in your workplace	1	2	3	4	5	6
9. Environmental hazards in local schools	1	2	3	4	5	6
10. Environmental hazards in recreational areas such as playgrounds and parks	1	2	3	4	5	6

Example of Respondent Card for Interviewer Administered:

Response Choices

1. A very big problem

2. Somewhat of a problem

3. Somewhat not a problem

4. Not at all a problem

5. Don’t know

6. Not Applicable

[Instructions if self-administered]. These next set of statements are about environmental hazards in general and in your community. Please indicate how strongly you agree or disagree with each statement. 1 means “strongly agree,” 2 means “agree somewhat,” 3 means “disagree somewhat,” and 4 means “strongly disagree.” For each statement, circle the number that best represents how you feel. If you “don’t know” circle 5.

[Instructions if interviewer-administered]. I am next going to read you a few statements about environmental hazards in general and in your community. Please tell me how strongly you agree or disagree with each statement. That is, do you “strongly agree,” “agree somewhat,” “disagree somewhat,” or “strongly disagree” with the statement about environmental hazards. Or would you say you “don’t know.” [Hand respondent correct response card]

	Strongly Agree	Agree Somewhat	Disagree Somewhat	Strongly Disagree	Don’t know
1. An environmental hazard can only make you sick if you are exposed	1	2	3	4	5
2. It may take years of exposure to an environmental hazard to become sick	1	2	3	4	5
3. My family and I are at risk because of environmental hazards in our area	1	2	3	4	5
4. You can get cancer from exposure to environmental hazards	1	2	3	4	5
5. Environmental hazards can cause serious health problems	1	2	3	4	5

[Instructions if self-administered]. These statements are also about contaminants in general and in your community. Using the same response categories as before, please tell me how strongly you agree or disagree with each statement. Again, 1 means “a very big problem,” 2 means “somewhat of a problem,” 3 means “somewhat not a problem,” and 4 means “not at all a problem.” For each statement, circle the number that best represents how you feel.

[Instructions if interviewer-administered]. I am next going to read you a few statements about contaminants in general and in your community. Please tell me how strongly you agree or disagree with each statement. That is, do you “strongly agree,” “agree somewhat,” “disagree somewhat,” or “strongly disagree” with the statement about environmental hazards. [Hand respondent correct response card]

	Strongly Agree	Agree Somewhat	Disagree Somewhat	Strongly Disagree
1. I know where site contaminants are located in my community	1	2	3	4
2. I know the ways in which the contaminants could get in my body	1	2	3	4
3. I know how exposure to contaminants could effect my health	1	2	3	4
4. I know what actions I can take to keep me and my family safe	1	2	3	4