ATTACHMENT 3b
Family Member Interview
REACH US
Evaluation
(English-Language)
Form Approved
OMB No. 0920-XXXX
Exp. Date XX/XX/XXXX
[IF SCREENER RESPONDENT IS SAMPLED FOR DETAILED INTERVIEW AND NO BREAK OCCURS BETWEEN SCREENER AND DETAILED INTERVIEW, SKIP TO CONSENT1.]
Hello, my name is [INTERVIEWER NAME]. I’m calling on behalf of the Centers for Disease Control and Prevention. We’re conducting a study of [TARGET RACE] regarding health issues in your area. This is a research study. Taking part is up to you. You don’t have to answer any question you don’t want to, and you can end the interview at any time. The interview takes about 15 minutes and any information you give me will be confidential. There are no risks or benefits to you for participating. In order to evaluate my performance, my supervisor may record and listen as I ask the questions. The recordings will be destroyed when the data collection for the study is completed. Would you like to participate? I’d like to continue now unless you have any questions.
IF RESPONDENT REFUSES TO CONTINUE, EXIT THE INTERVIEW AND CODE THE CASE AS A REFUSAL.
1. Would you say that in general your health is:
(PLEASE READ ALL)
1. Excellent
2. Very good
3. Good
4. Fair or
5. Poor
9. REF 7. DK
Public reporting of this collection of information is estimated to average 15 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 CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)
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?
(INTERVIEWER: ENTER “0" FOR NONE. RANGE 0-30, 77, 99)
NUMBER OF DAYS |___|___|
99. REF 77. DK
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?
(INTERVIEWER: ENTER “0" FOR NONE. RANGE 0-30, 77, 99)
NUMBER OF DAYS |___|___| [IF 2 and 3 = “0" GO TO 5]
99. REF 77. DK
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?
(INTERVIEWER: ENTER “0" FOR NONE. RANGE 0-30, 77, 99)
NUMBER OF DAYS |___|___|
99. REF 77. DK
5.
5.a. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?
1, YES
2. NO
9. REF 7. DK
5.b. Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?
1, YES
2. NO
9. REF 7. DK
6. About how long has it been since you last visited a doctor for a routine checkup?
(READ ONLY IF NECESSARY. INTERVIEWER: “A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.”)
1. Within the past year (anytime less than 12 months ago)
2. Within the past 2 years (1 year but less than 2 years ago)
3. Within the past 5 years (2 years but less than 5 years ago)
4. 5 or more years ago
5. Never
9. REF 7. DK
7. Have you ever been told by a doctor that you have diabetes?
(READ IF NECESSARY: Diabetes is a disease in which blood glucose levels are above normal. The pancreas does not make enough insulin or does not use it properly to enable the body to use glucose for energy. This causes sugar to build up in your blood, which can lead to further health complications.)
IF RESPONDENT SAYS PRE-DIABETES OR BORDERLINE DIABETES, USE RESPONSE CHOICE 3.
1. YES [GO TO 7a]
2. NO [GO TO 11]
3. NO, PRE-DIABETES OR BORDERLINE DIABETES [GO TO 11]
9. REF 7.DK [BOTH GO TO 11]
7.a. INTERVIEWER: IF FEMALE, ASK
Was this only when you were pregnant?
1. YES GO TO 8
2. NO GO TO 8
3. MALE GO TO 8
9. REF 7. DK [BOTH GO TO 8]
8. A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?
INTERVIEWER:ENTER “00" FOR NONE. RANGE 0-77, 99.
ENTER “76" FOR “76 OR MORE”
98 Never heard of “A one C” test
NUMBER OF TIMES |___|___|
99. REF 77. DK
9. About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
INTERVIEWER:ENTER “00" FOR NONE. RANGE 0-77, 99.
ENTER “76" FOR “76 OR MORE”
NUMBER OF TIMES |___|___|
99.REF 77.DK
10. When was the last time you had an eye exam in which your pupils were dilated? This would have made you temporarily sensitive to bright light.
READ ONLY IF NECESSARY
1. Within the past month (anytime less than 1 month ago)
2. Within the past year (1 month but less than 12 months ago)
3. Within the past 2 years (1 year but less than 2 years ago)
4. 2 or more years ago
5. Never
9. REF 7. DK
11. Are you currently . . .?
PLEASE READ ALL
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. Homemaker
6. Student
7. Retired, or
8. Unable to work
77. DK 99. REF
INTERVIEWER: If Q11=1 (employed for wages) or 2 (self-employed) then continue. Otherwise, go to Q12.2.
12.
12.1 When you are at work, which of the following best describes what you do? Would you say
If respondent has multiple jobs, include all jobs.
Please read:
1. Mostly sitting or standing
2. Mostly walking
3. Mostly heavy labor or physically demanding work
7. DK 9. REF
12.2 At your job or business, how are (were) you generally paid for the work you do. Would you say you are (were)… (DO NOT ASK IF THE ANSWER TO Q11 IS 5, 6, 8)
1. Salaried
2. Paid by the hour
3. Paid some other way
7. DK 9. REF
12.3 About how many hours per week do (did) you usually work at all your jobs or businesses?
_____ Hours (HR: 0-95); (If does not work, enter 0)
7. DK 9. REF
The next few questions are about exercise, recreation, or physical activities other than your regular job duties.
We are interested in two types of physical activity – vigorous and moderate. Vigorous activities cause large increases in breathing or heart rate while moderate activities cause small increases in breathing or heart rate.
12.2 Now thinking about the moderate activities you do [fill in “when you are not working” if “employed” or “self-employed”] in a usual week, do you do moderate activities for at least 10 minutes at a time, such as brisk walking, bicycling, vacuuming, gardening, or anything else that causes some increase in breathing or heart rate?
1. YES 2. NO º GO TO 12.5
9. REF 7. DK [BOTH GO TO 12.5]
12.3 How many days per week do you do moderate activities for at least 10 minutes at a time?
DAYS PER WEEK |___|___| RANGE 1-7, 77, 88, 99
99. REF 77. DK 88. Do not do any moderate physical activity for at least 10 minutes at a time
12.4 On days when you do moderate activities for at least 10 minutes at a time, how much total time do you spend doing these activities?
HOURS _|___|___| RANGE 0-10, 77, 99
MINUTES |___|___|___| RANGE 0-600, 7777, 9999
9999. REF 7777. DK [BOTH GO TO 12.5]
12.5 Now thinking about the vigorous activities you do [fill in “when you are not working” if “employed” or “self-employed”] in a usual week, do you do vigorous activities for at least 10 minutes at a time, such as running, aerobics, heavy yard work, or anything else that causes large increase in breathing or heart rate?
1. YES 2. NO º GO TO Q.20
9. REF 7. DK [BOTH GO TO Q.20]
12.6 How many days per week do you do these vigorous activities for at least 10 minutes at a time?
DAYS PER WEEK |___|___| RANGE 1-7, 77, 88, 99
99. REF 77. DK 88. Do not do any vigorous physical activity for at least 10 minutes at a time
12.7 On days when you do vigorous activities for at least 10 minutes at a time, how much total time do you spend doing these activities?
HOURS _|___|___| RANGE 0-10, 77, 99
MINUTES |___|___|___| RANGE 0-600, 7777, 9999
9999. REF 7777. DK
20. Have you smoked at least 100 cigarettes in your entire life?
INTERVIEWER: 5 PACKS = 100 CIGARETTES
1. YES 2. NO º GO TO 24
9. REF 7. DK
21. Do you now smoke cigarettes everyday, some days, or not at all?
1. EVERYDAY
2. SOME DAYS
3. NOT AT ALL º GO TO 24
9. REF 7. DK
22. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
1. YES 2. NO º GO TO 24
9. REF 7. DK
These next questions are about the foods you usually eat or drink. Please tell me how often you eat or drink each one, for example, twice a week, three times a month, and so forth. Remember, I am only interested in the foods you eat. Include all foods you eat, both at home and away from home.
24a. How often do you drink fruit juices such as orange, grapefruit, or tomato?
READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”
INTERVIEWER: ENTER “555" FOR “NEVER” º GO TO 25a
NUMBER OF TIMES: |___|___|___| RANGE 1-365, 555, 777, 999
999.REF 777. DK [BOTH GO TO 25a]
24b. FRUIT JUICE MODE
1. PER DAY
2. PER WEEK
3. PER MONTH
4. PER YEAR
REF DK
SKIP TO 24c IF NUMBER/PERIOD > 3 TIMES PER DAY OR
> 21 TIMES PER WEEK OR
> 90 TIMES PER MONTH OR
> 1095 TIMES PER YEAR OR
ELSE, SKIP TO 25a.
24c. Just to confirm that I entered it correctly, I have [NUMBER/PERIOD]. Is that correct?
1. YES [SKIP TO 25a]
2. NO [SKIP BACK TO 24a]
25a. Not counting juice, how often do you eat fruit?
READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”
INTERVIEWER: ENTER “555" FOR “NEVER” º GO TO 26a
NUMBER OF TIMES: |___|___|___| RANGE 1-365, 555, 777, 999
999.REF 777. DK [BOTH GO TO 26a]
25b. FRUIT MODE
1. PER DAY
2. PER WEEK
3. PER MONTH
4. PER YEAR
REF DK
SKIP TO 25c IF NUMBER/PERIOD > 3 TIMES PER DAY OR
> 21 TIMES PER WEEK OR
> 90 TIMES PER MONTH OR
> 1095 TIMES PER YEAR OR
ELSE, SKIP TO 26a.
25c. Just to confirm that I entered it correctly, I have [NUMBER/PERIOD]. Is that correct?
1. YES [SKIP TO 26a]
2. NO [SKIP BACK TO 25a]
26a. How often do you eat green salad?
READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”
INTERVIEWER: ENTER “555" FOR “NEVER” º GO TO 27a
NUMBER OF TIMES: |___|___|___| RANGE 1-365, 555, 777, 999
999.REF 777. DK [BOTH GO TO 27a]
26b. GREEN SALAD MODE
1. PER DAY
2. PER WEEK
3. PER MONTH
4. PER YEAR
REF DK
SKIP TO 26c IF NUMBER/PERIOD > 2 TIMES PER DAY OR
> 14 TIMES PER WEEK OR
> 60 TIMES PER MONTH OR
> 730 TIMES PER YEAR OR
ELSE, SKIP TO 27a.
26c. Just to confirm that I entered it correctly, I have [NUMBER/PERIOD]. Is that correct?
1. YES [SKIP TO 27a]
2. NO [SKIP BACK TO 26a]
27a. How often do you eat potatoes not including French fries, fried potatoes, or potato chips?
READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”
INTERVIEWER: ENTER “555" FOR “NEVER” º GO TO 28a
NUMBER OF TIMES: |___|___|___| RANGE 1-365, 555, 777, 999
999.REF 777. DK [BOTH GO TO 28a]
27b. POTATOES MODE
1. PER DAY
2. PER WEEK
3. PER MONTH
4. PER YEAR
REF DK
SKIP TO 27c IF NUMBER/PERIOD > 1 TIMES PER DAY OR
> 7 TIMES PER WEEK OR
> 30 TIMES PER MONTH OR
> 365 TIMES PER YEAR OR
ELSE, SKIP TO 28a.
27c. Just to confirm that I entered it correctly, I have [NUMBER/PERIOD]. Is that correct?
1. YES [SKIP TO 28a]
2. NO [SKIP BACK TO 27a]
28a. How often do you eat carrots?
READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”
INTERVIEWER: ENTER “555" FOR “NEVER” º GO TO 29a
NUMBER OF TIMES: |___|___|___| RANGE 1-365, 555, 777, 999
999.REF 777. DK [BOTH GO TO 29a]
28b. CARROTS MODE
1. PER DAY
2. PER WEEK
3. PER MONTH
4. PER YEAR
REF DK
SKIP TO 28c IF NUMBER/PERIOD > 1 TIMES PER DAY OR
> 7 TIMES PER WEEK OR
> 30 TIMES PER MONTH OR
> 365 TIMES PER YEAR OR
ELSE, SKIP TO 29a.
28c. Just to confirm that I entered it correctly, I have [NUMBER/PERIOD]. Is that correct?
1. YES [SKIP TO 29a]
2. NO [SKIP BACK TO 28a]
29a. Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?
READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”
INTERVIEWER: ENTER “555" FOR “NEVER” º GO TO 30
NUMBER OF TIMES: |___|___|___| RANGE 1-365, 555, 777, 999
999.REF 777. DK [BOTH GO TO 30]
29b. VEGETABLES MODE
1. PER DAY
2. PER WEEK
3. PER MONTH
4. PER YEAR
REF DK
SKIP TO 29c IF NUMBER/PERIOD > 2 TIMES PER DAY OR
> 14 TIMES PER WEEK OR
> 60 TIMES PER MONTH OR
> 730 TIMES PER YEAR OR
ELSE, SKIP TO 30.
29c. Just to confirm that I entered it correctly, I have [NUMBER/PERIOD]. Is that correct?
1. YES [SKIP TO 30]
2. NO [SKIP BACK TO 29a]
30. Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
If “yes” and respondent is female, ask: “Was this only when you were pregnant?”
1. YES
2. Yes, but female told only during pregnancy (go to Q33)
3. NO (go to Q33)
4. Told borderline high or pre-hypertensive (go to Q33)
9. REF 7. DK [BOTH GO TO 32]
31. Are you currently taking medicine for your high blood pressure?
1. YES
2. NO
9. REF 7. DK
32. Are you now doing any of the following to help lower or control your high blood pressure?
32a. (Are you) changing your eating habits (to help lower or control your high blood pressure)?
1. YES 2. NO
9. REF 7. DK
32b. (Are you) cutting down on salt (to help lower or control your high blood pressure)?
1. YES 2. NO 3. DO NOT USE SALT
9. REF 7. DK
32c. (Are you) reducing alcohol use (to help lower or control your high blood pressure)?
1. YES 2. NO
9. REF 7. DK
32d. (Are you) exercising (to help lower or control your high blood pressure)?
1. YES 2. NO
9. REF 7. DK
33.
33a. Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?
1. YES 2. NO GO TO 34
9. REF 7. DK [Both Go to 34]
33b. About how long has it been since you last had your blood cholesterol checked?
Read only if necessary:
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 5 years (2 years but less than 5 years ago)
5 or more years ago
9. REF 7. DK
33c. Have you ever been told by a doctor or other health professional that your blood cholesterol is high?
1. YES 2. NO
9. REF 7. DK
Now I would like to ask you some questions about cardiovascular disease.
34. Has a doctor, nurse, or other health professional EVER told you that you had any of the following? For each, tell me “Yes”, “No” or your’re “Not sure.”
34a. (Ever told) you had a heart attack, also called a myocardial infarction?
1. YES 2. NO
9. REF 7. DK
34b. (Ever told) you had angina or coronary heart disease?
1. YES 2. NO
9. REF 7. DK
34c. (Ever told) you had a stroke?
1. YES 2. NO
9. REF 7. DK
35. To lower your risk of developing heart disease or stroke, are you –
35a. Eating fewer high fat or high cholesterol foods?
1. YES 2. NO
9. REF 7. DK
35b. Eating more fruits and vegetables?
1. YES 2. NO
9. REF 7. DK
35a. More physically active?
1. YES 2. NO
9. REF 7. DK
Interviewer: IF RESPONDENT IS THE SAME PERSON WHO ANSWERED THE SCREENER QUESTIONS, THEN SAY:
I know we collected some of this information earlier, but I just need to confirm this information here.
What is your age? |___|___|___| CODE AGE IN YEARS. RANGE 18-120, 777, 999
999. REF 777. DK
IF 35 <= AGE <= 120, THEN GO TO Q36. ELSE, IF 18 <= AGE <= 34, SKIP TO Q37.
IF AGE = 777, 999, BUT AGE WAS GIVEN IN THE SCREENER, USE SCREENER AGE TO DETERMINE SKIP.
36.
36.a Do you take aspirin daily or every other day?
1. YES [GO TO 36.c]
2. NO
9. REF 7. DK
36.b Do you have a health problem or condition that makes taking aspirin unsafe for you?
If “yes”, ask “Is this a stomach condition?” Code upset stomach as stomach problems.
YES, NOT STOMACH RELATED [GO TO Q37]
YES, STOMACH PROBLESM [GO TO Q37]
NO [GO TO Q37]
9. REF 7. DK [BOTH GO TO Q37]
36.c Why do you take aspirin? . . .To relieve pain
1. YES 2. NO
9. REF 7. DK
36.d ( Why do you take aspirin?) . . .To reduce the chance of a heart attack
1. YES 2. NO
9. REF 7. DK
36.e ( Why do you take aspirin?) . . .To reduce the chance of a stroke
1. YES 2. NO
9. REF 7. DK
9. REF 7. DK/NOT SURE
37. A flu shot is an influenza vaccine injected into your arm. During the past 12 months, have you had a flu shot?
1. YES 2. NO
9. REF 7. DK
38. A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person´s lifetime and is different from the flu shot. Have you ever had a pneumonia shot?
1. YES 2. NO
9. REF 7. DK
INDICATE GENDER OF RESPONDENT
ASK ONLY IF NECESSARY: “Just to confirm, are you male or female?”
1. MALE [GO TO Q44]
2. FEMALE
9. REF [GO TO Q44]
READ QUESTIONS 39 THROUGH 43 FOR FEMALES ONLY.
The next questions are about breast and cervical cancer.
39. A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
1. YES 2. NO [GO TO 41]
9. REF 7. DK [BOTH GO TO 41]
40. How long has it been since you had your last mammogram?
READ ONLY IF NECESSARY
1. Within the past year (anytime less than 12 months ago)
2. Within the past 2 years (1 year but less than 2 years ago)
3. Within the past 3 years (2 years but less than 3 years ago)
4. Within the past 5 years (3 years but less than 5 years ago)
5. 5 or more years ago
9. REF 7. DK
41. A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear?
1. YES 2. NO [GO TO 44]
9. REF 7. DK [BOTH GO TO 44]
42. How long has it been since you had your last Pap test?
READ ONLY IF NECESSARY
1. Within the past year (anytime less than 12 months ago)
2. Within the past 2 years (1 year but less than 2 years ago)
3. Within the past 3 years (2 years but less than 3 years ago)
4. Within the past 5 years (3 years but less than 5 years ago)
5. 5 or more years ago
9. REF 7. DK
43. Have you had a hysterectomy?
READ ONLY IF NECESSARY: A hysterectomy is an operation to remove the uterus (womb).
1. YES 2. NO
9. REF 7. DK
44. What is the highest grade or year of school you completed?
READ LIST ONLY IF NECESSARY
1. Never attended school or only attended kindergarten
2. Grades 1 through 8 (Elementary)
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. REF
45. Are you Hispanic or Latino?
1. YES 2. NO
9. REF 7. DK
46. What one or more of the following would you say is your race?
PLEASE READ ALL
MARK ALL THAT APPLY
1. White
2. Black or African American
3. Asian
4. Native Hawaiian or Other Pacific Islander
5. American Indian or Alaska Native or
6. Some other race [specify] ________________
8. No additional choices
9. REF 7. DK
IF MORE THAN ONE RESPONSE TO Q46, CONTINUE. OTHERWISE GO TO Q48.
47. Which one of these groups would you say best represents your race?
READ IF NECESSARY
1. White
2. Black or African American
3. Asian (GO TO 47a.)
4. Native Hawaiian or Other Pacific Islander
5. American Indian or Alaska Native
6. Other [specify] _______________
9. REF 7. DK
47a. Are you …? (If answered “Asian” in Q47)
PLEASE READ:
1. Vietnamese
2. Cambodian
3. Chinese
4. Japanese
5. Korean
6. Filipino
7. Asian Indian
8. Other Asian
99. REF 77. DK
48. What is the main language do you speak at home (ONLY ASK IN SELECTED COMMUNITIES)?
English
Spanish
Vietnamese
Khmer
Chinese
Others (specify) ________________
49. Are you…?
PLEASE READ:
1 Married
2 Divorced
3 Widowed
4 Separated
5 Never married, or
6 A member of an unmarried couple
9 REFUSED
50. Do you own or rent your home?
1. Own
2. Rent
3. Other arrangement [GO TO Q52]
7. DK [GO TO Q52]
9. REF [GO TO Q52]
51. In the last 12 months, were you ever concerned about having enough money to pay your rent/mortgage? Would you say you were concerned often, sometimes, or never in the last 12 months?
1. Often
2. Sometimes
3. Never
7. DK 9. REF
52. In the last 12 months, were you ever concerned about being able to afford to eat nutritious meals? Would you say you were concerned often, sometimes, or never in the last 12 months?
1. Often
2. Sometimes
3. Never
7. DK 9. REF
53. How often do you get the social and emotional support you need?
PLEASE READ
Always
Usually
Sometimes
Rarely
Never
9. REF 7. DK
54. In general, how satisfied are you with your life?
PLEASE READ
Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
9. REF 7. DK
55. Have you ever heard of a program in your area called [PROGRAM NAME]?
1. Yes
2. No
9. REF 7. DK
56. Is your annual household income from all sources. . .
IF RESPONDENT REFUSES AT ANY INCOME LEVEL, CODE ‘99’ (REFUSED)
READ ONLY IF NECESSARY:
04 Less than $25,000 If “no,” ask 05; if “yes,” ask 03
($20,000 to less than $25,000)
03 Less than $20,000 If “no,” code 04; if “yes,” ask 02
($15,000 to less than $20,000)
02 Less than $15,000 If “no,” code 03; if “yes,” ask 01
($10,000 to less than $15,000)
01 Less than $10,000 If “no,” code 02
05 Less than $35,000 If “no,” ask 06
($25,000 to less than $35,000)
06 Less than $50,000 If “no,” ask 07
($35,000 to less than $50,000)
07 Less than $75,000 If “no,” code 08
($50,000 to less than $75,000)
08 $75,000 or more
77 Don’t know / Not sure
99 Refused
57. Did you vote in the last presidential election? (the November 2008 election between XXX and XXX)
1. YES
2. NO
7. DON’T KNOW/NOT SURE
9. REFUSED
58. About how much do you weigh without shoes?
INTERVIEWER: ROUND FRACTIONS UP
|___|___|___| WEIGHT IN POUNDS. RANGE 1-500, 777, 999
777 Don’t know / Not sure
999 Refused
59. About how tall are you without shoes?
INTERVIEWER: ROUND FRACTIONS DOWN
a. FEET |___|___| RANGE 0-8, 77, 99 [77 UK, 99 REF]
b. INCHES |___|___| RANGE 0-72, 77, 99 [77 UK, 99 REF]
CLOSING STATEMENT:
Those are all the questions I have. I’d like to thank you on behalf of the Centers for Disease Control and Prevention for the time and effort you’ve spent answering these questions. If you have any questions about this survey, you may call my supervisor toll-free at 1-800-xxx-xxxx. If you have questions about your rights as a survey participant, or if you feel that you have been harmed in any way by taking part in this study, please contact the office of CDC’s Human research Protection Office at 1-800-584-8814. Leave a message with your name, phone number, and refer to CDC protocol #5337, and someone will call you back. Thanks again.
Modules that may be used in selected communities
HEART ATTACK AND STROKE MODULE
Now I would like to ask you about your knowledge of the signs and symptoms of a heart attack and stroke.
1. Which of the following do you think is a symptom of a heart attack? For each, tell me yes, no, or you’re not sure.
1.1 (Do you think) pain or discomfort in the jaw, neck, or back (are symptoms of a heart attack?)
1. YES 2. NO
9. REF 7. DK/NOT SURE
1.2 (Do you think) feeling weak, lightheaded, or faint (are symptoms of a heart attack?)
1. YES 2. NO
9. REF 7. DK/NOT SURE
1.3 (Do you think) chest pain or discomfort (are symptoms of a heart attack?)
1. YES 2. NO
9. REF 7. DK/NOT SURE
1.4 (Do you think) sudden trouble seeing in one or both eyes (is a symptom of a heart attack?)
1. YES 2. NO
9. REF 7. DK/NOT SURE
1.5 (Do you think) pain or discomfort in the arms or shoulder (are symptoms of a heart attack?)
1. YES 2. NO
9. REF 7. DK/NOT SURE
1.6 (Do you think) shortness of breath (is a symptom of a heart attack?)
1. YES 2. NO
9. REF 7. DK/NOT SURE
2. Which of the following do you think is a symptom of a stroke? For each, tell me yes, no, or you’re not sure.
2.1 (Do you think) sudden confusion or trouble speaking (are symptoms of a stroke?)
1. YES 2. NO
9. REF 7. DK/NOT SURE
2.2 (Do you think) sudden numbness or weakness of face, arm, or leg, especially on one side, (are symptoms of a stroke?)
1. YES 2. NO
9. REF 7. DK/NOT SURE
2.3 (Do you think) sudden trouble seeing in one or both eyes (is a symptom of a stroke?)
1. YES 2. NO
9. REF 7. DK/NOT SURE
2.4 (Do you think) sudden chest pain or discomfort (are symptoms of a stroke?)
1. YES 2. NO
9. REF 7. DK/NOT SURE
2.5 (Do you think) sudden trouble walking, dizziness, or loss of balance (are symptoms of a stroke?)
1. YES 2. NO
9. REF 7. DK/NOT SURE
2.6 (Do you think) severe headache with no known cause (is a symptom of a stroke?)
1. YES 2. NO
9. REF 7. DK/NOT SURE
3. If you thought someone was having a heart attack or a stroke, what is the first thing you would do:
PLEASE READ ALL
1. Take them to the hospital
2. Tell them to call their doctor
3. Call 911
4. Call their spouse or a family member, or
5. Do something else
WEIGHT CONTROL MODULE
1. Are you now trying to lose weight?
1 Yes [Go to Q3]
2 No
7 Don’t know / Not sure
9 Refused
2. Are you now trying to maintain your current weight, that is, to keep from gaining weight?
1 Yes
2 No [Go to Q5]
7 Don’t know / Not sure [Go to Q5]
9 Refused [Go to Q5]
3. Are you eating either fewer calories or less fat to —
lose weight? [If “Yes” to Q1]
keep from gaining weight? [If “Yes” to Q2]
Probe for which:
1 Yes, fewer calories
2 Yes, less fat
3 Yes, fewer calories and less fat
4 No
7 Don’t know / Not sure
9 Refused
4. Are you using physical activity or exercise to —
lose weight? [If “Yes” to Q1]
keep from gaining weight? [If “Yes” to Q2]
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
5. In the past 12 months, has a doctor, nurse or other health professional given you advice about your weight?
Probe for which:
1 Yes, lose weight
2 Yes, gain weight
3 Yes, maintain current weight
4 No
7 Don’t know / Not sure
9 Refused
HEPATITIS B MODULE
INTERVIEWER: THE FOLLOWING 5 QUESTIONS ARE RELATED TO HEPATITIS B AND HEPATITIS B VACCINE. IF THE RESPONDENT’S ANSWERS REFER TO ‘HEPATITIS,” CODE THE ANSWERS AS FOR “HEPATITIS B.”
1. Have you ever had a blood test for hepatitis B?
1. YES
2. NO
7. DON’T KNOW/NOT SURE
9. REFUSED
2. Have you ever been told by a doctor, nurse, or other health professional that you have hepatitis B? Please choose one of the following answers: Yes, I have hepatitis B; Yes, I had hepatitis B but I do not have the infection now, or No, I have never had hepatitis B.
1. Yes, I have hepatitis B
2. Yes, I had hepatitis B but I do not have the infection now
3. No, I have never had hepatitis B
7. DON’T KNOW/NOT SURE
9. REFUSED
3. Has a doctor, nurse or other health professional ever discussed hepatitis B with you?
1. YES
2. NO
7. DON’T KNOW/NOT SURE
9. REFUSED
4. Are people who have hepatitis B at risk for liver cancer? Would you say yes or no?
1. YES
2. NO
7. DON’T KNOW/NOT SURE
9. REFUSED
5. Have you EVER received the hepatitis B vaccine? The hepatitis B vaccine is completed after the third shot is given.
1. YES
2. NO
7. DON’T KNOW/NOT SURE
9. REFUSED
| File Type | application/msword |
| File Title | REACH US |
| Author | ycl1 |
| Last Modified By | arp5 |
| File Modified | 2008-02-29 |
| File Created | 2008-02-29 |