1 Survey

OMB # 0925-XXXX
Expiration Date: XX/XX/XXXX

HINTS 2007
HEALTH INFORMATION NATIONAL TRENDS SURVEY 2007

SCREENER
June 2007
Annotated
NATIONAL CANCER INSTITUTE (NCI)
The Privacy Act requires us to tell you that we are authorized to collect this
information by Section 411.285a, 42 USC. You do not have to provide the
information requested. However, the information you provide will help the
National Cancer Institute’s ongoing efforts to promote good health and
prevent disease. There are no penalties should you choose not to participate in
this study.
Public reporting burden for this collection of information is estimated to
average 5 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 Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to
this address.

CONTACT PROCEDURES

CNT1100.
Autodial
PHONE: {Display phone number}
DO YOU WANT TO . . .
DIAL THIS PHONE NUMBER ..................................
ENTER ANOTHER PHONE NUMBER .....................
DO NOT DIAL..........................................................
CNT2000.
IntroAutodial

RESIDENTIAL

Hello, this is {INTERVIEWER NAME} and I'm calling for the U.S. Department of Health
and Human Services for a national study on people’s needs for health information.
OR
Hello, this is {INTERVIEWER NAME} and I'm calling for the U.S. Department of Health
and Human Services for a national health study.
OR
Hello, this is {INTERVIEWER NAME} and I’m calling for the U.S. Department of Health
and Human Services. I’m following up on questionnaires mailed to your home for a
national health study.

Am I speaking to someone who lives in this household and is at least {18} years old?
YES.........................................................................
NO ..........................................................................
PROBABLE BUSINESS...........................................
ANSWERING MACHINE..........................................
RETRY AUTODIALER .............................................
NONWORKING, DISCON., CHANGED ....................
GO TO RESULT......................................................

CNT2200.
HHMember18Plus

1
2
3

1
2
3
4
5
6
7

(CNT2300)
(CNT2400)
(CNT2300)
(RST3020)
(CNT1100)
(Code result)
(Code result)

Hello, this is {INTERVIEWER NAME} and I'm calling for the U.S. Department of Health
and Human Services for a national study on people’s needs for health information.
OR
Hello, this is {INTERVIEWER NAME} and I’m calling for the U.S. Department of Health
and Human Services for a national health study.
OR
Hello, this is {INTERVIEWER NAME} and I’m calling for the U.S. Department of Health
and Human Services. I’m following up on questionnaires mailed to your home for a
national health study.
Am I speaking to someone who lives in this household and is at least {18} years old?

YES.........................................................................
NO ..........................................................................
GO TO RESULT ......................................................

HINTS 2007, Draft Screening Instrument, National Cancer Institute (NCI)

1

1
2 (CNT2400)
3 (Code result)

Page 1

CNT2300. (CNT2100)
HHAdultPhoneUse

Is this phone number for . . .
home use, ...............................................................
home and business use, or ......................................
business use only? ..................................................
GO TO RESULT ......................................................

CNT2400.
HHAdultAvailable

1
2
3
4

(BRD1150)
(BRD1150)
(RST7100)
(Code result)

May I speak with a household member who is at least {18} years old?
[IF NEEDED: Household members include people who think of this household as their
primary place of residence. It includes persons who usually stay in the household but are
temporarily away on business, vacation, in a hospital, or living at school in a dorm,
fraternity or sorority.]
AVAILABLE.............................................................
NOT AVAILABLE.....................................................
THERE ARE NONE .................................................
GO TO RESULT ......................................................

CNT2500.
HHHeadUnderAge

[IF RESPONDENT IS A CHILD, ASK FOR AN OLDER HOUSEHOLD MEMBER.]
NO ONE LIVING IN HH IS {18} OR
OLDER....................................................................
THERE ARE HH MEMBERS {18} OR
OLDER....................................................................
GO TO RESULT ......................................................

CNT4080. (CNT2080)
HelloContinuingCall

1 (CNT2200)
2 (Code result as callback)
3
4 (Code result)

1 (RST9040)
2 (CNT2400)
3 (Code result)

May I speak to {NAME}?
My name is {INTERVIEWER NAME}, and I'm calling for the U.S. Department of Health
and Human Services for a national study on people’s needs for health information.
OR
My name is {INTERVIEWER NAME} and I’m calling for the U.S. Department of Health and
Human Services for a national health study.
OR
My name is {INTERVIEWER NAME} and I’m calling for the U.S. Department of Health and
Human Services. I’m following up on questionnaires mailed to your home for a national
health study.
AVAILABLE.............................................................
NOT AVAILABLE ....................................................
GO TO RESULT ......................................................

HINTS 2007, Draft Screening Instrument, National Cancer Institute (NCI)

2

1
2 (Code result callback)
3 (Code result)

Page 2

CNT4090. (CNT2090)
IntroExtended

[Hello], My name is {INTERVIEWER NAME} and I'm calling for the U.S. Department of
Health and Human Services for a national study on people’s needs for health information
and we need your participation .
OR
[Hello], My name is {INTERVIEWER NAME} and I’m calling for the U.S. Department of
Health and Human Services for a national health study.
OR
[Hello], My name is {INTERVIEWER NAME} and I’m calling for the U.S. Department of
Health and Human Services. I’m following up on questionnaires mailed to your home for a
national health study.
The interview will take about 25-30 minutes depending on your answers, but your
participation is voluntary and you can refuse to answer any questions or withdraw from the
study at any time. All information obtained will be kept confidential to the extent the law
allows. If you want, we can do part of the interview and finish it at another time.
[GO TO EXTENDED INTERVIEW]

BIRTHDAY METHOD

BRD1150.
SCQHE4Intro

BRD1200.
SCQHE4Number
OfAdults

I have some questions to see who in your household may be eligible to participate in this
study.

Including yourself, how many people aged 18 or older currently live in this
household?
[IF NEEDED: Include people who usually stay in this household, but are temporarily away
on business, vacation, or in the hospital. Do not include persons who are away on full-time
active military duty with the armed forces, students living away from home in their own
apartment, or any other family member who may be in a nursing home or other institution.]
|__|__|

[0 to 25]

HINTS 2007, Draft Screening Instrument, National Cancer Institute (NCI)

3

Page 3

BRD2000.
Select one respondent using modified Rizzo method:
IF BRD1200 = 1, select the screener respondent as the subject
THEN GOTO BRD2210
ELSE IF BRD1200 = 2, run respondent algorithm, then
IF the screener respondent is selected as the subject
THEN GOTO BRD2210
ELSE IF the non-screener respondent is selected as the subject THEN GOTO BRD2410
ELSE IF BRD1200 = 3, run respondent algorithm, then
IF the screener respondent is selected as the subject
THEN GOTO BRD2210
ELSE IF the older household member is selected as subject
THEN GOTO BRD2510
ELSE IF the younger household member is selected as subject
THEN GOTO BRD2610
ELSE IF BRD1200 > 3, then
IF the screener respondent is selected as the subject
THEN GOTO BRD2210
ELSE, GOTO BRD3000
BRD2210.
SCQHE9Name
SelectedPerson

May I please have your first name?
[IF NEEDED: I only need something to refer to you. Could you please give me your initials
or something else that would allow me to identify you?.]
[ENTER NAME]
_______________________

BRD2220.
SCQHEYourGender

[1 to 20 characters]

IF NOT OBVIOUS, ASK: [Are you male or female?]
MALE ......................................................................
FEMALE..................................................................

BRD2230.
SCQHEYourAge

1
2

May I please have your age?
|__|__| .....................................................................

HINTS 2007, Draft Screening Instrument, National Cancer Institute (NCI)

4

[18 to 130] (APQ1200)

Page 4

BRD2410.
SCQHE9AName
OtherAdult

The computer has randomly determined that the other adult in this household should
participate in the rest of the interview. I would like to get the first name of this person so I
can ask him or her to participate in the study. May I please have the first name of the other
adult?
[IF NEEDED: I only need something to refer to (him/her). Could you please give me
(his/her) initials or something else that would allow me to identify (him/her)?]
_______________________

BRD2510.
SCQHE5Name
OlderHousem

[1 to 20 characters]
(BRD3200)

The computer has randomly determined that one of the adults in the household other than
yourself should participate in the rest of the interview. To help us select this person, may I
please have the first name of the older of these two adults?
[IF NEEDED: I only need something to refer to (him/her). Could you please give me
(his/her) initials or something else that would allow me to identify (him/her)?]
[ENTER NAME]
[IF R DOESN'T KNOW WHO IS OLDEST, RECORD A DK RESPONSE.]
_______________________

BRD2610.
SCQHE5Name
YoungerHous

[1 to 20 characters]
(BRD3200)

The computer has randomly determined that one of the adults in the household other than
yourself should participate in the rest of the interview. To help us select this person, may I
please have the first name of the younger of these two adults?
[IF NEEDED: I only need something to refer to (him/her). Could you please give me
(his/her) initials or something else that would allow me to identify (him/her)?]
[ENTER NAME]
[IF R DOESN'T KNOW WHO IS YOUNGEST, RECORD A DK RESPONSE.]
_______________________

BRD3000.
SCQHE6Know
Birthdays

[1 to 20 characters]
(BRD3200)

The computer has randomly determined that one of the {NUMBER} adults other than
yourself should participate in the rest of the interview. To help us select this person, do
you know who has had the most recent birthday among these adults?
YES.........................................................................
NO ..........................................................................

HINTS 2007, Draft Screening Instrument, National Cancer Institute (NCI)

5

1 (BRD3100)
2 (ENM2100)

Page 5

BRD3100.
SCQHE7Name
RecentBirthday

Other than yourself then, may I please have the first name of the adult who has
most recent birthday?

had the

[IF NEEDED: I only need something to refer to (him/her). Could you please give me
(his/her) initials or something else that would allow me to identify (him/her)?]
_______________________
BRD3200.
SCQHEPersonGender

[1 to 20 characters]

Is {NAME/this person} male or female?
MALE ......................................................................
FEMALE..................................................................

BRD3300.
SCQHEPersonAge

1
2

May I please have {NAME/this person}’s age?
|__|__|__| ................................................................

[18 to 130] (APQ1200)

HOUSEHOLD ENUMERATION
ENM2100.
SCQNameHHM(N)

So that the computer can choose someone to interview, may I please have the first names
and ages of the {Number} adults currently living in this household. Please do not include
yourself.
[IF NEEDED: Include people who usually stay in this household, but are temporarily away
on business, vacation, or in the hospital. Do not include persons who are away on full-time
active military duty with the armed forces, students living away from home in their own
apartment, or any other family member who may be in a nursing home or other institution.]
[IF NEEDED: I only need something to refer to (him/her). Could you please give me
(his/her) initials or something else that would allow me to identify (him/her)?]
_______________________

ENM2200.
SCQAskAge(N)

[1 to 25 characters]

May I please have {NAME/this person}’s age?
|__|__|__| ................................................................

ENM2250.
SCQGender(N)

[18 to 130]

[CODE GENDER. IF NOT OBVIOUS, ASK:
Is {NAME/this person} male or female?]
MALE ......................................................................
FEMALE..................................................................

HINTS 2007, Draft Screening Instrument, National Cancer Institute (NCI)

6

1
2

Page 6

ENM3000.
SCQAnyoneElse

We have listed {NUMBER} household member{s} other than yourself who {is/are} 18 or
older.
Have we missed anyone else 18 or older who usually lives here but is temporarily away?
For example, away on business, vacation, in a hospital, or living away at school in a dorm,
fraternity, or sorority?
NO ONE WAS MISSED ...........................................
SOMEONE WAS MISSED .......................................

1
2

SAMPLING

SMP2010.
Randomly select one household member.
GOTO APQ1200.

ADDITIONAL PHONE QUESTIONS

APQ1200.
AddPhones

Because we are conducting this study by phone, and people with more telephone
numbers have more chances of being in the study, I have some questions about the
telephone numbers in your household.
Besides the number I called, do you have other telephone numbers in your household not
including cell phones?
YES.........................................................................
NO ..........................................................................

APQ1300.
PhoneUse

1
2 (APQ1700)

Including computer and fax phone numbers, how many of these additional phone
numbers are for home use?
[IF NEEDED: Do not include cell phones.].
|__|__| .....................................................................
REFUSED ...............................................................
DON'T KNOW..........................................................

HINTS 2007, Draft Screening Instrument, National Cancer Institute (NCI)

7

[0 to 19]
-7 (BOX MLS2100)
-8 (BOX MLS2100)

Page 7

APQ1305.
If APQ1300 = 0, GOTO BOX MLS2100.
Else if APQ1300 = 1, GOTO APQ1400.
Else, GOTO APQ1500
APQ1400.
Phon1Fax

Is this additional phone number used for a computer or fax machine?
YES.........................................................................
NO ..........................................................................

APQ1500.
Phon2Fax

1 (APQ1600)
2 (BOX MLS2100)

Of these {NUMBER} additional home use phone numbers, how many are used for a
computer or fax machine?
|__|__| .....................................................................
REFUSED ...............................................................
DON'T KNOW..........................................................

[0 to 19] (BOX APQ1505)
-7 (BOX MLS2100)
-8 (BOX MLS2100)

APQ1505.
If APQ1500 = 0, GOTO BOX MLS2100.
Else if APQ1500 = 1, GOTO APQ1600.
Else, GOTO APQ1800
APQ1600.
Phon1Talk

Some households have telephone numbers that are used both for talking and for
computer or fax. Is this number ever answered for talking?
YES.........................................................................
NO ..........................................................................

APQ1700.
PhonFax

Do you have any additional phone numbers for computers or fax machines?
YES.........................................................................
NO ..........................................................................

APQ1800.
Phon2Talk

1 (APQ1900)
2 (BOX MLS2100)

1 (APQ1800)
2 (BOX MLS2100)

Some households have telephone numbers that are used both for talking and for
computer or fax. How many of these {NUMBER} computer or fax numbers are ever
answered for talking?
|__|__| .....................................................................
REFUSED ...............................................................
DON'T KNOW..........................................................

[0 to 19]
-7 (BOX MLS2100)
-8 (BOX MLS2100)

APQ1805.
If APQ1800 = 0, GOTO BOX MLS2100.
Else if APQ1800 = 1, GOTO APQ1900.
Else, GOTO APQ2000

HINTS 2007, Draft Screening Instrument, National Cancer Institute (NCI)

8

Page 8

APQ1900.
PhonFax1Use

Is this computer or fax number answered for …
personal calls,..........................................................
business calls, or .....................................................
both?.......................................................................

APQ2000.
PhonFax2Use

1 (BOX MLS2100)
2 (BOX MLS2100)
3 (BOX MLS2100)

Of these {NUMBER} phone numbers that are answered, how many are answered
for non-business related calls?
|__|__| .....................................................................

[0 to 19]

MANIPLUS

MLS2100.
Screener is complete.

Create extended record, then
If Screener Respondent = Selected person, GOTO CNT4090
Else, GOTO CNT4080.

RESULT CODING

RST3020.
ReadMsg2

[PLEASE READ
MACHINE.]

THE

FOLLOWING

MESSAGE

INTO

THE

ANSWERING

This is {INTERVIEWER NAME} calling for the U.S. Department of Health and Human
Services for a national study on people’s needs for health information. It is very important
that we speak with you. We will call back within the next day or two, or you can call us at
1-888-314-1133. Thank you.
OR
This is {INTERVIEWER NAME} calling for the U.S. Department of Health and Human
Services for a national health study. It is very important that we speak with you. We will
call back within the next day or two, or you can call us at 1-888-314-1133. Thank you.
OR
This is {INTERVIEWER NAME} calling for the U.S. Department of Health and Human
Services. I’m following up on questionnaires mailed to your home for a national health
study. It is very important that we speak with you. We will call back within the next day or
two, or you can call us at 1-888-314-1133. Thank you.
CONTINUE..............................................................

HINTS 2007, Draft Screening Instrument, National Cancer Institute (NCI)

9

1 (END)

Page 9

RST7100.
NR_Thanks

Thank you, but we are only interviewing in private residences. Good-bye.
CONTINUE..............................................................

RST9040.
In_Thanks

1 (END)

These are all the questions I have for you at this time. Thank you very much for your
cooperation. Good-bye.
CONTINUE..............................................................

HINTS 2007, Draft Screening Instrument, National Cancer Institute (NCI)

10

1 (End)

Page 10