Chronic Fatigue Surveillance
Georgia Survey of CFS
First Follow-up Detailed Telephone Questionnaire
Participant's ID Number I___I___I___I___I___I___I___I___I
ZIP Code I___I___I___I___I___I
Interview Date:_____________________ Start Time: I__I__I : I__I__I |
1A. Hello, my name is [INTERVIEWER NAME]. (May I please speak to /Am I speaking to) (<NAME>/ the <SEX> living in this household who is about <AGE> years old)?
BOX A
AGE to be calculated on Baseline DOB; or if DOB is missing, on other CATI preloads or screener age +2 years. IF R IS ON LINE, GO TO INTRODUCTION . IF R COMES TO PHONE, REPEAT Q1A. IF R IS NOT AVAILABLE, SET CALLBACK. IF NO SUCH RESPONDENT, SKIP TO CLOSING 1. IF RESPONDENT HAS MOVED, GO TO CLOSING 2.
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INTRODUCTION:
I am calling for the Centers for Disease Control and Prevention, or CDC. We interviewed you by telephone [LAST INTERVIEW MO/ LAST INTERVIEW YR] for a research study of fatiguing illness in Georgia. Now, we would like to conduct a follow-up interview with you. The questions are similar to those we asked you last year, and your answers may help find ways to treat and prevent these illnesses. You may have received a letter in the mail describing our study.
Before we begin, I need to be sure that you have the following information. This interview will take about 20 minutes of your time. Because we are also studying causes of illness, I will ask you about your health and life experiences, including traumatic events that may have happened to you. Your name and your answers to our questions will be kept private to the extent permitted by law. Only staff that has been allowed by the CDC to do this research will know your personal information. CDC is allowed by a law called the Public Health Service Act to do a lot of public health activities, including this research study. This law allows us to ask about many things, including your health. Still, completing this interview is your choice. You may choose not to answer any question for any reason and you can stop at any time. Whether you complete this interview or not will in no way affect any health benefits that you expect to get. To evaluate my performance, my supervisor may record and listen as I ask the questions. We may contact you again about participating in further research.
If you have any questions about your rights in this study, I can give you the number for the CDC Director for Science. If you have any other questions about this research study, you can call Dr. Jim Jones at the CDC. I can give you his number as well.
INTERVIEWER: DO YOU VERIFY THAT YOU HAVE READ THE INFORMED CONSENT IN ITS ENTIRETY TO THE PARTICIPANT?
YES 1 GO TO BOX A
NO 2 GO BACK TO BEGINNING OF INTRODUCTION
BOX A
IF BASELINE INTERVIEW SEX IS REFUSED OR DK, GO TO Q2A.
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2. Based on our conversation in [LAST INTERVIEW MO/LAST INTERVIEW YR], my records show that you are (female/male). Is that correct?
YES 1 SKIP TO BOX B
NO 2
DON’T KNOW 8 SKIP TO BOX B
REFUSED 7 SKIP TO BOX B
2A. Are you male or female?
MALE 1
FEMALE 2
BOX B
IF BASELINE ETHNICITY IS REFUSED OR DK, GO TO Q3B. OTHERWISE, GO TO Q3.
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3. My records show that you are (Hispanic or Latino /not Hispanic and not Latino). Is that correct?
YES 1 SKIP TO BOX C
NO 2
DON’T KNOW 8 SKIP TO Q3B
REFUSED 7 SKIP TO BOX C
3A. Okay, I will correct my records to show that you are (Hispanic or Latino /not Hispanic and not Latino).
HISPANIC OR LATINO 1 SKIP TO BOX C
NOT HISPANIC AND NOT LATINO 2 SKIP TO BOX C
3B. Do you consider yourself to be Hispanic or Latino?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
BOX C
IF BASELINE RACE IS REFUSED OR DK, GO TO Q4A.
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4. My records show that you are (RACE). Is that correct?
YES 1 SKIP TO BOX D
NO 2
DON’T KNOW 8 SKIP TO BOX D
REFUSED 7 SKIP TO BOX D
4A. What race do you consider yourself to be? Please note that you may choose more than one option. (CODE ALL THAT ARE MENTIONED.)
White 1
Black or African-American 2
Asian 3
American Indian or Alaskan Native 4
Native Hawaiian or Other Pacific Islander 5
OTHER (SPECIFY) 95
DON’T KNOW 98
REFUSED 97
BOX D
IF DOB IS COMPLETE, GO TO Q5. IF DOB IS INCOMPLETE, GO TO Q5A.
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According to our records, your birth date is [RESPONDENT’S DATE OF BIRTH]. Is this correct?
YES 1 GO TO BOX E
NO 2
DON'T KNOW 8 SKIP TO Q5 B
REFUSED 7 SKIP TO Q5 B
5A. What is your date of birth?
___ ___/___ ___ /___ ___ ___ ___ GO TO BOX E
MONTH DAY YEAR
DON’T KNOW 98 GO TO Q5B
REFUSED 97 GO TO Q5B
5B. How old are you?
I___I___I
ENTER AGE:________ GO TO BOX E
DON’T KNOW 98 GO TO Q5C
REFUSED 97 GO TO Q5C
5C. Are you age 18 to 59?
YES 1
NO 2
DON’T KNOW 8 FILL OUT PROBLEM SHEET
REFUSED 7 FILL OUT PROBLEM SHEET
BOX E
IF THE RESPONDENT REFUSES DOB AND AGE, FILL OUT A PROBLEM SHEET FOR CASE REVIEW.
IF AGE IS DIFFERENT FROM BASELINE BY MORE THAN TWO YEARS, GO TO Q5D. THIS ASSUMES THAT THE INCORRECT RESPONDENT HAS BEEN CONTACTED. OTHERWISE SKIP TO Q6.
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5D. Is there a (male/female) in the house who is about [AGE] years old?
YES 1
NO 2 SKIP TO CLOSING 1
DON'T KNOW 8 SKIP TO CLOSING 1
REFUSED 7 SKIP TO CLOSING 1
5E. May I speak with (him/her)?
YES 1 GO TO INTRO
NO 2 SET CALLBACK
DON'T KNOW 8 SET CALLBACK
REFUSED 7 SET CALLBACK
CLOSING 1 My information may be incorrect. I need to go back to my records to confirm I have contacted the correct person. If I need to contact you again, when would be the best time to reach you?
Thank you for your time.
CLOSING 2 I am trying to reach [SUBJECT] about a research study that (he/she) participated in in (2004/2005). May I please have (his/her) telephone number?
FATIGUE STATUS
6. Have you suffered from severe fatigue, extreme tiredness, or exhaustion within the last month?
YES 1
NO 2 GO TO Q18
DON'T KNOW 8 GO TO Q18
REFUSED 7 GO TO Q18
7. Have you suffered from this severe fatigue, extreme tiredness, or exhaustion for one month or longer?
YES 1
NO 2 GO TO Q18
DON'T KNOW 8 GO TO Q18
REFUSED 7 GO TO Q18
8. When you are fatigued, tired, or exhausted does rest make this fatigue, tiredness, or exhaustion a lot better? Would you say…
PROBE Can you count on rest to make your fatigue, tiredness, or exhaustion a lot better...
All of the time 1
Most of the time 2
Some of the time 3
A little of the time 4
Hardly ever 5
DON’T KNOW 8
REFUSED 7
9. How often do you suffer from this fatigue, tiredness, or exhaustion? Would you say…
most of the time 1
sometimes 2
rarely 3
DON’T KNOW 8
REFUSED 7
10. Has this severe fatigue, extreme tiredness, or exhaustion substantially limited your ability to do your usual job or occupation?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
NOT APPLICABLE 6
11. Has this severe fatigue, extreme tiredness, or exhaustion substantially limited your ability to do your usual educational activities?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
NOT APPLICABLE 6
12. Has this severe fatigue, extreme tiredness, or exhaustion substantially limited your social activities?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
13. Has this severe fatigue, extreme tiredness, or exhaustion substantially limited your leisure or recreational activities?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
14. When this fatigue, tiredness, or exhaustion began, would you say that it came on all of a sudden, or slowly over time?
ALL OF A SUDDEN 1
SLOWLY OVER TIME 2
DON’T KNOW 8
REFUSED 7
15. In what year did this fatigue, tiredness, or exhaustion begin?
IF RESPONDENT CANNOT REMEMBER THE YEAR, PROBE: If you cannot remember the specific year, please estimate to the best of your ability.
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW 8 SKIP TO Q15B
REFUSED 7 SKIP TO Q15B
15A. And now I need to know the month this fatigue began.
IF RESPONDENT CANNOT REMEMBER THE MONTH, PROBE: If you cannot remember the specific month, please estimate to the best of your ability.
ENTER MONTH: __ __ IF MONTH = 1-12, GO TO Q16
DON’T KNOW 98 IF Q15 = 2006 OR 2007, GO TO Q15B. OTHERWISE SKIP TO Q16
REFUSED 97 IF Q15 = 2006 OR 2007, GO TO Q15B. OTHERWISE SKIP TO Q16
15B. How long ago did this fatigue, tiredness, or exhaustion begin?
ENTER NUMBER FOR WEEKS, MONTHS OR YEARS________
SELECT TIME PERIOD ________
WEEK(S) 1 SKIP TO Q16
MONTH(S) 2 SKIP TO Q16
YEAR(S) 3 SKIP TO Q16
DON’T KNOW -1 GO TO Q15C
REFUSED -2 GO TO Q15C
15C. Have you had this fatigue for six months or longer?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
16. Have you ever gone to a doctor because of your fatigue?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
17. Has a doctor ever diagnosed you with the illness called chronic fatigue syndrome?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
HEALTH PERCEPTIONS
18. I’d like to ask you some general questions about your health.
Would you say that in general your health is excellent, very good, good, fair, or poor?
EXCELLENT 1
VERY GOOD 2
GOOD 3
FAIR 4
POOR 5
DON’T KNOW 8
REFUSED 7
19. 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?
NUMBER OF DAYS: ___ ____
DON'T KNOW -1
REFUSED -2
20. 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?
NUMBER OF DAYS: ___ ____
DON'T KNOW -1
REFUSED -2
21. 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, school or recreation?
NUMBER OF DAYS: ___ ____
DON'T KNOW -1
REFUSED -2
22. Compared to other adults your age would you say your health is much better, better, the same, worse, or much worse?
MUCH BETTER 1
BETTER 2
THE SAME 3
WORSE 4
MUCH WORSE 5
DON’T KNOW 8
REFUSED 7
23. How would you rate your overall quality of life at the present time? Would you say excellent, very good, good, fair, or poor?
EXCELLENT 1
VERY GOOD 2
GOOD 3
FAIR 4
POOR 5
DON’T KNOW 8
REFUSED 7
24. In general, how satisfied are you with your life? Would you say very satisfied, satisfied, dissatisfied, or very dissatisfied?
VERY SATISFIED 1
SATISFIED 2
DISSATISFIED 3
VERY DISSATISFIED 4
DON’T KNOW 8
REFUSED 7
25. I am going to ask you about persistent symptoms that you may have experienced in the past month. By persistent, we mean that it bothers or bothered you a lot of the time.
INTERVIEWER PROBE: Whatever “bother” or “a lot of the time” means to you.
25A. During the past month, have you had persistent <SYMPTOM>?
YES 1
NO 2 GO TO NEXT SYMPTOM
DON’T KNOW 8 GO TO NEXT SYMPTOM
REFUSED 7 GO TO NEXT SYMPTOM
25B. Have you been bothered by persistent <SYMPTOM> for 1 month or longer?
YES 1
NO 2 GO TO NEXT SYMPTOM
DON’T KNOW 8 GO TO NEXT SYMPTOM
REFUSED 7 GO TO NEXT SYMPTOM
25C. Have you been bothered by persistent <SYMPTOM> for 6 months or longer?
YES 1
NO 2 GO TO NEXT SYMPTOM
DON’T KNOW 8 GO TO NEXT SYMPTOM
REFUSED 7 GO TO NEXT SYMPTOM
25D. FOR SYMPTOMS 2-10 ONLY: In what year did the <SYMPTOM> begin?
VALID YEARS: DOB - PRESENT
ENTER YEAR: __ __ __ __
DON’T KNOW 8
REFUSED 7
<SYMPTOM>
NOTE: ALTHOUGH NOT ASKED IN THIS SECTION (INCLUDED IN EARLIER SECTION), EXTREME TIREDNESS OR EXHAUSTION IS CONSIDERED SYMPTOM NUMBER 1.
2. unusual fatigue or exhaustion for more than a day, following physical or mental effort
3. unrefreshing sleep
4. forgetfulness or memory problems
5. problems with thinking or concentrating
6. pain in your joints
7. pain in your muscles
8. severe headaches
9. swollen glands in your neck or under your arms
10. sore throat
11. problems falling asleep at night
12. problems staying asleep through the night
13. depression
14. diarrhea
15. nausea
16. stomach or abdominal pain
17. sinus or nasal problems
18. fever
19. shortness of breath
20. your eyes being extremely sensitive to light
BOX F
IF RESPONDENT HAS REPORTED HAVING MORE THAN ONE SYMPTOM (INCLUDING FATIGUE IN Q15A AND Q15B AND Q15C) LASTING SIX MONTHS OR LONGER, GO TO Q26. OTHERWISE, SKIP TO Q27.
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26. Of the symptoms you have reported having for 6 months or more, that is…
<INTERVIEWER READ LIST OF SYMPTOMS REPORTED FOR DURATION OF 6 MONTHS OR LONGER, INCLUDING SEVERE FATIGUE, TIREDNESS, OR EXHAUSTION (Q8)>
Which one bothers you the most right now?
RECORD SYMPTOM #: |___|___|
USE STANDARD PROBE IF RESPONDENT HAS TROUBLE PICKING JUST ONE SYMPTOM. REREAD STEM
“If you could be cured of just one of these symptoms, which one would it be?
ASSIGNMENT OF SAMPLE TYPE (BASED ON FATIGUE STATUS AND SYMPTOMS ONLY)
IF FATIGUED FOR AT LEAST ONE MONTH OR LONGER (Q7=1) AND HAS HAD AT LEAST ONE UNWELLNESS SYMPTOM OR FATIGUE FOR SIX MONTHS OR LONGER ((Q15 AND Q15A AND Q15B AND Q15C INDICATE FATIGUE FOR SIX MONTHS OR LONGER)) OR Q25C=1 FOR SYMPTOMS 1, 2, 3, 4, 5, 6, 7, 8, OR 9) THEN RESPONDENT IS CHRONIC UNWELL, FATIGUED (CUF)
ELSE IF RESPONDENT HAS ONE OR MORE UNWELLNESS SYMPTOMS FOR SIX MONTHS OR LONGER (SORE THROAT, SWOLLEN GLANDS, FATIGUE FOLLOWING PHYSICAL/MENTAL EFFORT, PAIN IN JOINTS, PAIN IN MUSCLES, SEVERE HEADACHES, FORGETFULNESS OR MEMORY PROBLEMS, UNREFRESHING SLEEP), THEN RESPONDENT IS CHRONIC UNWELL, NOT FATIGUED (CU)
ELSE IF FATIGUED FOR ONE MONTH OR LONGER (Q7=1) THEN RESPONDENT IS PROLONGED UNWELL, FATIGUED (PUF)
ELSE IF RESPONDENT HAS ONE OR MORE UNWELLNESS SYMPTOMS FOR ONE MONTH OR LONGER, THEN RESPONDENT IS PROLONGED UNWELL, NOT FATIGUED (PU)
ELSE RESPONDENT IS WELL (WL)
27. How tall are you?
|___|___| FEET |___|___| INCHES
DON’T KNOW 8
REFUSED 7
28. Some people may consider the next question to be very sensitive. We are asking it because combinations of weight and height can affect a person’s health. How much do you weigh in pounds? Please be as accurate as possible.
_____ POUNDS
DON’T KNOW 8
REFUSED 7
EXCLUSIONARY MEDICAL CONDITIONS
I am now going to ask you about your medical history. I will ask you questions about conditions for which you have been diagnosed. Some of these questions may be perceived as sensitive, so I want to remind you that your responses are completely voluntary. If I ask you a question you don’t want to answer, let me know and I’ll go to the next question.
BOX G
IF RESPONDENT IS FEMALE, ASK Q29, OTHERWISE SKIP TO Q30.
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29. Have you been pregnant at any time during the past twelve months?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
30. Have you had surgery during the past twelve months?
YES 1 GO TO Q30A
NO 2 SKIP TO Q31
DON’T KNOW 8 SKIP TO Q31
REFUSED 7 SKIP TO Q31
UP TO THREE SURGERIES CAN BE REPORTED IN CATI
30A. What kind of surgery did you have?
SPECIFY: __________________________________
30B. What illness or condition prompted your surgery?
SPECIFY: ____________________________
30C. When did you have this surgery?
|___|___| / 20 |___|___|
MONTH YEAR
31. Have you ever been diagnosed with or treated by a doctor for a heart attack?
YES 1 GO TO Q31A
NO 2 SKIP TO Q32
DON’T KNOW 8 SKIP TO Q32
REFUSED 7 SKIP TO Q32
SPECIFY: ____________________________
32. Have you ever been diagnosed with or treated by a doctor for heart disease, including heart failure?
YES 1 GO TO Q32A
NO 2 SKIP TO Q33
DON’T KNOW 8 SKIP TO Q33
REFUSED 7 SKIP TO Q33
SPECIFY: ____________________________
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
YES 1 GO TO Q33A
NO 2 SKIP TO Q34
DON’T KNOW 8 SKIP TO Q34
REFUSED 7 SKIP TO Q34
SPECIFY: ____________________________
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
34. Have you ever been diagnosed or treated by a doctor for cancer?
YES 1 GO TOQ34A
NO 2 SKIP TO Q35
DON’T KNOW 8 SKIP TO Q35
REFUSED 7 SKIP TO Q35
DO NOT READ LIST.
DISPLAY CANCER PICKLIST:
1=BASAL CELL CANCER
2=BREAST CANCER
3=CERVICAL CANCER
4=COLON CANCER
5=LYMPHOMA
6=LEUKEMIA
7=LUNG CANCER
8=OVARIAN CANCER
9=PROSTATE CANCER
10=SKIN CANCER
11=THYROID CANCER
12=UTERINE CANCER
95 = OTHER (SPECIFY: ____________________________)
97 = REFUSED
98 = DON'T KNOW
SPECIFY: ____________________________
35. Have you ever been diagnosed or treated by a doctor for hepatitis?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
36. Have you ever been diagnosed with or treated by a doctor for HIV or AIDS?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
37. Are there any other conditions or illnesses that I have not asked about for which you were diagnosed or treated by a doctor?
YES (SPECIFY) 1 GO TO Q37A
NO 2 SKIP TO Q38
DON’T KNOW 8 SKIP TO Q38
REFUSED 7 SKIP TO Q38
UP TO FIVE CONDITIONS CAN BE RECORDED IN CATI.
37A. What treatment were you given for [CONDITION]?
SPECIFY: ____________________________
37B. Do you currently have [CONDITION]?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
37C. In what year was your (CONDITION) cured or controlled?
ENTER YEAR: __ __ __ __
DON’T KNOW F9 (-1)
REFUSED F10 (-2)
EXCLUSIONARY PSYCHIATRIC CONDITIONS
Now I want to ask you some specific questions about conditions you may have or have had.
38. Have you ever received a formal diagnosis of bipolar disorder or schizophrenia by a doctor, psychologist or other health care professional?
YES, BIPOLAR DISORDER 1
YES, SCHIZOPHRENIA 2
YES, BOTH 3
NO, NEITHER 4
DON’T KNOW 8
REFUSED 7
39. In the last five years, have you received a formal diagnosis of anorexia nervosa or bulimia by a doctor, psychologist or other health care professional?
YES, ANOREXIA NERVOSA 1
YES, BULIMIA NERVOSA 2
YES, BOTH 3
NO, NEITHER 4
DON’T KNOW 8
REFUSED 7
40. In the last two years, have you received a formal diagnosis of alcohol abuse or dependence or substance abuse or dependence by a doctor, psychologist or other health care professional?
YES, ALCOHOL ABUSE OR DEPENDENCE 1
YES, DRUG ABUSE OR DEPENDENCE 2
YES, BOTH 3
NO, NEITHER 4
DON’T KNOW 8
REFUSED 7
41. During the past 12 months, have you had a period when you were feeling depressed or down most of the day, nearly every day?
YES 1
NO 2 SKIP TO Q42
DON’T KNOW 8 SKIP TO Q42
REFUSED 7 SKIP TO Q42
41A. How long did it last? _____________________
42. During the past 12 months, have you had a time when you lost interest or pleasure in things you usually enjoyed?
YES 1
NO 2 GO TO BOX K
DON’T KNOW 8 GO TO BOX K
REFUSED 7 GO TO BOX K
42A. How long did it last? _____________________ GO TO BOX K
BOX K
IF Q41 OR Q42 = 1, GO TO Q43
OTHERWISE SKIP TO Q46
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43. Now I’m going to ask you about the last month. In the last month has there been a period of time when you were feeling depressed or down most of the day, nearly every day?
YES 1
NO 2 SKIP TO Q44
DON’T KNOW 8 SKIP TO Q44
REFUSED 7 SKIP TO Q44
43A. How long did it last? _____________________
44. In the past month has there been a period of time when you lost interest or pleasure in things you usually enjoyed?
YES 1
NO 2 SKIP TO BOX L
DON’T KNOW 8 SKIP TO BOX L
REFUSED 7 SKIP TO BOX L
44A. How long did it last? ____________________
BOX L
IF Q41A, Q42A, Q43A, OR Q44A IS 2 WEEKS OR LONGER, GO TO Q45.
OTHERWISE SKIP TO Q46.
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45. During the past 12 months, have you received a formal diagnosis of depression by a doctor, psychologist or other health care professional?
YES 1
NO 2 SKIP TO Q46
DON’T KNOW 8 SKIP TO Q46
REFUSED 7 SKIP TO Q46
45A. What treatment were you given? ________________________________________________
46. During the past 12 months, have you had a panic attack, when you suddenly felt frightened or anxious or suddenly developed a lot of symptoms such as accelerated heart rate, sweating, trembling, shaking, chills, hot flushes, shortness of breath or feeling of choking?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
47. During the past 12 months, were you afraid of going out of the house alone, being in crowds, standing in a line or traveling on buses or trains?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
48. During the past 12 months, is there anything that you have been afraid to do or felt uncomfortable doing in front of other people, like speaking, eating or writing?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
49. During the past 12 months, have there been any other things that you have been especially afraid of, like flying, seeing blood, getting a shot, heights, closed places, or certain kinds of animals or insects?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
50. Now I'm going to ask about the past six months. In the last six months, have you been particularly nervous--that is, worried excessively--and anxious about several things?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
BOX M
IF Q46=1 OR Q47=1 OR Q48=1 OR Q49=1 OR Q50=1 THEN ASK Q51. OTHERWISE, SKIP TO Q52.
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51. Now I'm going to ask again about the past 12 months. During the past 12 months, have you received a formal diagnosis of panic disorder, agoraphobia, social phobia, specific phobia or generalized anxiety disorder by a doctor, psychologist or other health care professional?
YES 1
NO 2 SKIP TO Q52
DON’T KNOW 8 SKIP TO Q52
REFUSED 7 SKIP TO Q52
51A. What treatment were you given? _________________________________________
52. Sometimes things happen to people that are extremely upsetting - things like being in a life threatening situation like a major disaster, very serious accident or fire, being physically assaulted or raped, seeing another person killed or dead, or badly hurt, or hearing about something horrible that has happened to someone you are close to.
During the past 12 months, have any of these kinds of things happened to you?
YES 1
NO 2 SKIP TO Q53
DON’T KNOW 8 SKIP TO Q53
REFUSED 7 SKIP TO Q53
52A. Sometimes these things keep coming back in nightmares, flashbacks, or thoughts that you can’t get rid of. During the past 12 months, has that happened to you?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
52B. What about being very upset when you were in a situation that reminded you of one of these terrible things?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
BOX N
IF Q52A OR Q52B=1 (YES), GO TO Q52C. OTHERWISE, SKIP TO Q53.
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52C. How long did these problems last?
52D. During the past 12 months, have you received a formal diagnosis of posttraumatic stress disorder by a doctor, psychologist or other health care professional?
YES 1
NO 2
DON’T KNOW 8
REFUSED 7
52E. What treatment were you given?
____________________________________________
PERCEIVED STRESS
Now I’m going to ask you about your feelings and thoughts during the last 12-months. In each case, please indicate how often you felt or thought a certain way.
53. During the last 12 months, how often have you felt that you were unable to control the important things in your life? Would you say…
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
54. During the last 12 months, how often have you felt confident about your ability to handle your personal problems? Would you say…
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
55. During the last 12 months, how often have you felt that things were going your way? (Would you say…)
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
56. During the last 12 months, how often have you felt difficulties were piling up so high that you could not overcome them? (Would you say…)
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
SOCIOECONOMIC STATUS DURING CHILDHOOD
57. For most of your childhood, did your family own their home?
YES 1
NO 2
DON'T KNOW 8
REFUSED 7
58. How much education did your mother have? Please choose one answer.
Didn't go to high school 1
Some high school 2
High school graduate or GED 3
Some college or technical school 4
4 year college degree graduate or higher 5
DON'T KNOW 8
REFUSED 7
59. How much education did your father have? Please choose one answer.
Didn't go to high school 1
Some high school 2
High school graduate or GED 3
Some college or technical school 4
4 year college degree graduate or higher 5
DON'T KNOW 8
REFUSED 7
60. How old was your mother when you were born?
ENTER AGE: ___ ___
DON'T KNOW -1 GO TO Q60A
REFUSED -2 GO TO Q60A
60A. If you don’t know the exact age, would you say it was between:
15 to 19 1
20 to 30 2
31 to 40 3
or 41 to 50 4
DON'T KNOW 8
REFUSED 7
DEMOGRAPHICS
61. The next question is about health insurance. Are you covered by any type of health insurance?
YES 1
NO 2 SKIP TO Q62
DON'T KNOW 8 SKIP TO Q62
REFUSED 7 SKIP TO Q62
61A. What type of health insurance do you have? Please note that you may choose more than one option. Health insurance provided by an employer – either yours or someone else's such as your spouse's, Medicare, Medicaid, or another type of insurance?
HEALTH INSURANCE PROVIDED BY
AN EMPLOYER – EITHER YOURS OR SOMEONE
ELSE’S, SUCH AS YOUR SPOUSE’S 1
MEDICARE 2
MEDICAID 3
ANOTHER TYPE OF INSURANCE
(SPECIFY: ___________) 95
DON'T KNOW 98
REFUSED 97
62. Are you currently married, not married but living with a partner, separated, divorced, widowed, or have you never been married?
MARRIED 1
NOT MARRIED BUT LIVING WITH PARTNER 2
SEPARATED 3
DIVORCED 4
WIDOWED 5
NEVER BEEN MARRIED 6
OTHER 96
DON'T KNOW 98
REFUSED 97
63. What was the last grade or year of school you completed?
No formal schooling 01
First through eighth grade 02
Some high school 03
High school graduate 04
Trade\technical\vocational
after high school 05
Some college 06
Two-year college graduate 07
Four-year college graduate 08
Postgraduate 09
Other (SPECIFY _______________) 10
DON'T KNOW 98
REFUSED 97
64. Which of the following categories best describes your household's income before taxes in 2006? READ LIST.
$10,000 or less 01
$10,001 to $20,000 02
$20,001 to $30,000 03
$30,001 to $40,000 04
$40,001 to $50,000 05
$50,001 to $60,000 06
$60,001 to $70,000 07
$70,001 or more 08
DON'T KNOW 98
REFUSED 97
CONTACT INFORMATION
65. According to my records, your telephone number is [NUMBER]. Is that correct?
YES 1 GO TO Q65B
NO 2 GO TO Q65A
DON’T KNOW 8 GO TO Q65B
REFUSED 7 GO TO Q65B
65A. May I please have your correct phone number?
PHONE: ( ) - __________
DON’T KNOW 8
REFUSED 7
65B. Under what name is this phone listed?
LISTED UNDER:
DON’T KNOW 8
REFUSED 7
66. RESPONDENTS WILL BE ASKED TO CONFIRM CONTACT INFORMATION IF IT WAS OBTAINED IN THE BASELINE INTERVIEW.
IF POSSIBLY ELIGIBLE FOR CLINIC, BUT REQUIRES REVIEW:
“Thank you for this information. We may want to get in touch with you again in the future for further participation in this study. The study will include the completion of medical history interviews, a physical examination and routine laboratory tests and a mental health interview, all at no cost to you.
I’d like to get some information now that will help us contact you.
CONFIRM NAME. IF BASELINE NAME IS INCOMPLETE, ASK: "What is your name?”
IF ELIGIBLE FOR CLINIC:
“Thank you for this information. We would like to get in touch with you again in the future for further participation in this study. The study will include the completion of medical history interviews, a physical examination and routine laboratory tests and mental health interview, all at no cost to you.
I’d like to get some information now that will help us contact you.
CONFIRM NAME. IF BASELINE NAME IS INCOMPLETE, ASK: "What is your name?”
CONFIRM SPELLING. IF RESPONDENT REFUSES: Just your first name will do.
Title (Ms, Mr. Mrs.):
First Name:
Middle Initial:
Last Name:
Suffix (e.g., Jr., Sr., II):
67. What are the last four digits of your social security number?
|_ _|_ _|_ _|_ _|
68. What is your address?
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
69. What is the name of your employer?
EMPLOYER NAME:
69A. What is your employer's address?
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
69B. What is your phone number at work?
(____)_____-__________
EXTENSION: _______
DON’T KNOW 8
REFUSED 7
70. Is there another number where you can usually be reached?
YES 1
NO 2 GO TO Q72
DON’T KNOW 8 GO TO Q72
REFUSED 7 GO TO Q72
70A. What is that phone number?
(____)_____-__________
EXTENSION: _______
DON’T KNOW 8
REFUSED 7
70B. And where is that? (neighbor, other) ________________
DON’T KNOW 8
REFUSED 7
72. May I have your email address?
___________________________________________________________
DON’T KNOW 8
REFUSED 7
73. In case we have trouble reaching you, we would like to have the names of two of your close relatives or friends who do not live with you and who would know how to get in touch with you. We will not contact these people for any other reason. IF RESPONDENT HAS NO RELATIVES OR FRIENDS, PROBE: Then who else would be most likely to know how to reach you?
RESPONDENT AGREES 1
RESPONDENT REFUSES 7 SKIP TO Q74
RESPONDENT DOESN’T KNOW ANYONE
TO CONTACT 8 SKIP TO Q74
73A. First Relative/Friend
First Name:
Last Name:
What is <NAME’s> relationship to you?______________________
Street Address:
City:
State: Zip Code:
Phone Number(____)_____-__________
Under what name is this phone listed?_______________________
73B. Second Relative/Friend
First Name:
Last Name:
What is <NAME’s> relationship to you?______________________
Street Address:
City:
State: Zip Code:
Phone Number(____)_____-__________
Under what name is this phone listed?_______________________
You may also be eligible for other studies of fatiguing illness in the future. May we contact you again about these other studies? Telling us now that we may contact you does not obligate you to participate in these studies. You are only giving us permission to contact you and invite you to participate.
74. May we contact you again for future studies?
YES 1
NO 2 GO TO REFUSAL SCREENS TO RECORD REASON FOR REFUSAL
CLOSING: These are all the questions I have. If you have any questions about your rights in this study, you may call the CDC Deputy Director for Science toll-free at 1-800-584-8814. Please be prepared to leave a message and your call will be returned.
If you have any other questions about this research study, or if you think that you have been injured in this study, please call Dr. Jim Jones at the CDC. Dr. Jones’ number is: 1-404-639-1412 . Please note that this may be a toll call.
END TIME: I__I__I : I__I__I
| File Type | application/msword |
| File Title | Computer-Assisted Telephone Interview, Detailed Questionnaire |
| Author | MartinezE |
| Last Modified By | Rebecca Devlin |
| File Modified | 2007-04-10 |
| File Created | 2007-04-10 |