Form 1 CHIS-CCM Module 2009

Attachment 1
CHIS 2009 Cancer Control Module (CCM) and
Demographic Core Questionnaire Items

CHIS 2009 OMB Questionnaire 1

CALIFORNIA HEALTH INTERVIEW SURVEY 2009
OMB No. XXXX-XXXX
Expires: XX-XX-20XX
Public reporting burden for this collection of information is estimated to vary from 2 to 23 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to: NIH Project Clearance Branch, 6705 Rockledge Dr., MSC 7974, Bethesda, MD 20892-7974,
Attn: PRA (XXXX-XXXX). Do not return the completed form to this address.

TABLE OF CONTENTS
ADULT QUESTIONNAIRE
MODULE A – CANCER SCREENING ...................................................................................................... 1
MODULE D – WOMEN’S HEALTH........................................................................................................ 13
MODULE F – HEALTH BEHAVIORS (CANCER PREVENTION)....................................................... 17
MODULE G – FAMILY HISTORY OF CANCER................................................................................... 23
MODULE I – VA TOPICS......................................................................................................................... 27
MODULE J – DISCRIMINATION............................................................................................................ 29
MODULE K – DEMOGRAPHICS, PART I.............................................................................................. 39
MODULE L – DEMOGRAPHICS, PART II............................................................................................. 48
MODULE M – EMPLOYMENT, INCOME AND POVERTY ................................................................ 59
MODULE N – DEMOGRAPHIC, PART III AND CLOSING ................................................................. 67
MODULE O – GENERAL HEALTH, DISABILITY, AND SEXUAL HEALTH ................................... 70

CHIS 2009 OMB Questionnaire 2

MODULE A – CANCER SCREENING
PROGRAMMING NOTE QA09_A1
IF AAGE < 40 OR [AA2A = 1 (BETWEEN 18 AND 29) OR 2 (BETWEEN 30 AND 39)] OR ENUM.AGE <
40 OR AGE IS UNKNOWN, GO TO NEXT SECTION;
ELSE CONTINUE WITH QA09_A1
QA09_A1

A stool or fecal blood test is done at home to check for colon cancer. You send your stool sample
to the doctor’s office or lab for testing. Have you ever done a stool or fecal blood test?
[INTERVIEWER NOTE: IF NEEDED, SAY: “Do not include over-the-counter test kits from a
drugstore or pharmacy.”]
YES...........................................................................1
NO ............................................................................2 [GO TO QA09_A4]
REFUSED .............................................................. -7 [GO TO QA09_A4]
DON'T KNOW ....................................................... -8 [GO TO QA09_A4]

QA09_A2

When did you do your most recent blood test using a home kit to check for colon cancer?
A YEAR AGO OR LESS .........................................1
MORE THAN 1 YEAR AGO UP TO
2 YEARS AGO ........................................................2
MORE THAN 2 YEARS AGO UP TO
5 YEARS AGO ........................................................3
MORE THAN 5 YEARS AGO................................4
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_A3

What was the main reason you had your most recent stool blood test using a home kit? Was it…
Part of a routine physical exam, ...............................1
Because of a problem, OR ........................................2
Some other reason?...................................................3
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_A4

A sigmoidoscopy and a colonoscopy are both tests that examine the bowel by inserting a tube in
the rectum. The difference is that during a sigmoidoscopy, you are awake and can drive yourself
home after the test; however, during a colonoscopy, you may feel sleepy and you need someone to
drive you home. Have you ever had a colonoscopy?
YES...........................................................................1
NO ............................................................................2 [GO TO QA09_A7]
REFUSED .............................................................. -7 [GO TO QA09_A7]
DON'T KNOW ....................................................... -8 [GO TO QA09_A7]

CHIS 2009 OMB Questionnaire

1

CHIS 2009 OMB Questionnaire 2

QA09_A5

When did you have your most recent colonoscopy to check for colon cancer?
A YEAR AGO OR LESS .........................................1
MORE THAN 1 UP TO 5 YEARS AGO ................2
MORE THAN 5 UP TO 10 YEARS AGO ..............3
MORE THAN 10 YEARS AGO..............................4
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_A6

What was the main reason you had your most recent colonoscopy? Was it…
Part of a routine physical exam, ...............................1
Because of a problem, OR ........................................2
Some other reason?...................................................3
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_A7

Have you ever had a sigmoidoscopy?
YES...........................................................................1
NO ............................................................................2 [GO TO QA09_A11]
REFUSED .............................................................. -7 [GO TO QA09_A11]
DON'T KNOW ....................................................... -8 [GO TO QA09_A11]

QA09_A8

When did you have your most recent sigmoidoscopy to check for colon cancer?
A YEAR AGO OR LESS .........................................1
MORE THAN 1 UP TO 5 YEARS AGO ................2
MORE THAN 5 UP TO 10 YEARS AGO ..............3
MORE THAN 10 YEARS AGO..............................4
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_A9

What was the main reason you had your most recent sigmoidoscopy? Was it…
Part of a routine physical exam, ...............................1
Because of a problem, OR ........................................2
Some other reason?...................................................3
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 3

QA09_A11

During the past 5 years, has a doctor recommended that you have a sigmoidoscopy,
colonoscopy, or blood stool test?
YES...........................................................................1
NO ............................................................................2
DID NOT GO TO A DOCTOR
IN PAST 5 YEARS ................................................92
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_A12:
IF QA09_A4 = 2 (NEVER HAD COLONOSCOPY) AND QA09_A7 = 2 (NEVER HAD SIGMOIDOSCOPY),
CONTINUE WITH QA09_A12 AND DISPLAY "never had";
ELSE IF QA09_A5 = 4 (MOST RECENT COLONOSCOPY OVER 10 YEARS AGO) OR QA09_A8 = 6 (MOST
RECENT SIGMOIDOSCOPY OVER 10 YEARS AGO), CONTINUE WITH QA09_D8 AND DISPLAY "not
had" AND "in the last 10 years";
ELSE GO TO NEXT SECTION
QA09_A12

What is the ONE most important reason why you have {never had/not had} one of these exams
{in the last 10 years}?
NO REASON/NEVER THOUGHT ABOUT IT .....1
DIDN'T KNOW I NEEDED
THIS TYPE OF TEST..............................................2
DOCTOR DIDN'T TELL ME I NEEDED IT ..........3
HAVEN'T HAD ANY PROBLEMS........................4
PUT IT OFF/LAZINESS..........................................5
TOO EXPENSIVE/NO INSURANCE/COST .........6
TOO PAINFUL, UNPLEASANT, OR
EMBARRASSING...................................................7
HAD ANOTHER TYPE OF
COLORECTAL EXAM ...........................................8
DON'T HAVE A DOCTOR .....................................9
OTHER...................................................................91
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_A13:
IF FEMALE GO TO QA09_A22;
IF MALE AND (AGE < 40 OR BETWEEN 18 AND 29 OR BETWEEN 30 AND 39 OR ENUM.AGE < 45 OR IF
AGE IS UNKNOWN), GO TO QA09_A22;
ELSE CONTINUE WITH QA09_A13
QA09_A13

Have you ever heard of a PSA or "prostate-specific antigen" test to detect prostate cancer? A
PSA test is a blood test to detect prostate cancer.
YES...........................................................................1
NO ............................................................................2 [GO TO QA09_A22]
REFUSED .............................................................. -7 [GO TO QA09_A22]
DON'T KNOW ....................................................... -8 [GO TO QA09_A22]

CHIS 2009 OMB Questionnaire 4

QA09_A14

Have you ever had a PSA test?
[INTERVIEWER NOTE: IF NEEDED, SAY: “A PSA test is a blood test to detect prostate
cancer. It is also called a prostate-specific antigen test.”]
YES...........................................................................1
NO ............................................................................2 [GO TO QA09_A19]
REFUSED .............................................................. -7 [GO TO QA09_A19]
DON'T KNOW ....................................................... -8 [GO TO QA09_A19]

QA09_A15

When did you have your most recent PSA test?
A YEAR AGO OR LESS .........................................1
MORE THAN 1 YEAR AGO UP TO
2 YEARS AGO ........................................................2
MORE THAN 2 YEARS AGO UP TO
3 YEARS AGO ........................................................3
MORE THAN 3 YEARS AGO UP TO
5 YEARS AGO ........................................................4
MORE THAN 5 YEARS AGO................................5
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_A16

What was the main reason you had this PSA test – was it part of a routine exam, because of a
problem, or some other reason?
Part of a routine physical exam, ...............................1
Because of a problem, OR ........................................2
Some other reason?...................................................3
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_A19

[{Before you had the PSA test}], did a doctor ever talk with you about the advantages and
disadvantages of [{it}/the PSA test]?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_A20

[{Before you had the PSA test}], did a doctor ever tell you that some doctors recommend
[{it}/the PSA test] and others do not?
YES...........................................................................1
NO ............................................................................2 [GO TO QA09_A22]
REFUSED .............................................................. -7 [GO TO QA09_A22]
DON'T KNOW ....................................................... -8 [GO TO QA09_A22]

CHIS 2009 OMB Questionnaire 5

QA09_A21

Did a doctor or other health professional ever recommend that you have a PSA test?

YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 6

PROGRAMMING NOTE QA09_A28:
IF MALE GO TO NEXT SECTION;
ELSE IF 18≤AAGE < 30, GO TO NEXT SECTION;
ELSE CONTINUE WITH QA09_A28 (INCLUDING WOMEN WITH AGE UNKNOWN)
QA09_A28

In the past 12 months, has a doctor examined your breasts for lumps?
[INTERVIEWER NOTE: IF NEEDED, SAY: “This is when a doctor touches your breasts to
check for bumps, cysts, or abnormal growth.”]
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_A29

Have you ever had a mammogram?
[INTERVIEWER NOTE: IF NEEDED, SAY: "A mammogram is an x-ray taken of each breast
separately by a machine that flattens or squeezes each breast." IF DEFINITION WAS NOT READ
AND RESPONDENT ANSWERS “NO”, READ DEFINITION BEFORE CODING]
YES...........................................................................1
NO ............................................................................2 [GO TO QA09_A39]
REFUSED .............................................................. -7 [GO TO NEXT SECT]
DON'T KNOW ....................................................... -8 [GO TO NEXT SECT]

QA09_A30

How many mammograms have you had in the last 6 years? Your best estimate is fine.
_____ MAMMOGRAMS
NO ............................................................................0 [GO TO QA09_A39]
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_A31

How long ago did you have your most recent mammogram?
A YEAR AGO OR LESS .........................................1
MORE THAN 1 UP TO 2 YEARS AGO ................2
MORE THAN 2 UP TO 3 YEARS AGO ................3
MORE THAN 3 UP TO 5 YEARS AGO ................3
MORE THAN 5 YEARS AGO................................3
REFUSED ................................................................7 [GO TO NEXT SECT]
DON'T KNOW ....................................................... -8 [GO TO NEXT SECT]

QA09_A32

Was your most recent mammogram recommended by a doctor?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 7

QA09_A33

Tell me the main reason you had a mammogram. Was it…
[INTERVIEWER NOTE: IF NEEDED, SAY: "The main reason is the most important reason.”]
Part of a routine exam,..............................................1
Because of a specific breast problem,.......................2
A follow-up to a previously identified
breast problem, .........................................................3
Or due to family history?..........................................4
REFUSED ................................................................7
DON'T KNOW ....................................................... -8

QA09_A34

Have you ever had a mammogram where the results were not normal?
YES...........................................................................1
NO ............................................................................2 [GO TO QA09_A41]
REFUSED .............................................................. -7 [GO TO QA09_A41]
DON'T KNOW ....................................................... -8 [GO TO QA09_A41]

QA09_A35

Have you ever had an operation to remove a lump from your breast?
YES...........................................................................1
NO ............................................................................2 [GO TO QA09_A39]
DON’T KNOW ...................................................... -7 [GO TO QA09_A39]
REFUSED .............................................................. -8 [GO TO QA09_A39]

QA09_A36

Did the lump turn out to be cancer?
YES...........................................................................1 [GO TO QA09_A38]
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_A37

How many operations have you had to remove a lump that wasn’t cancer?
______ NUMBER OF OPERATIONS

[GO TO QA09_A39]

REFUSED .............................................................. -7 [GO TO QA09_A39]
DON'T KNOW ....................................................... -8 [GO TO QA09_A39]
QA09_A38

Tell me how you first found out about your breast cancer. Was it by…
Finding it yourself by accident .......................................... 1
Finding it yourself during a self breast examination ......... 2
Your husband or partner finding it .................................... 3
Your doctor finding it during a routine breast exam ......... 4
Finding it by a mammogram.............................................. 5
Or some other way? (IF OTHER, SPECIFY):_____ ........ 6
DON’T KNOW ................................................................ -7
REFUSED ........................................................................ -8

CHIS 2009 OMB Questionnaire 8

QA09_A39

Did you have any other tests and/or surgery when your mammogram was not normal?
YES...........................................................................1
NO ............................................................................2 [GO TO QA09_A41]
DON’T KNOW ...................................................... -7 [GO TO QA09_A41]
REFUSED .............................................................. -8 [GO TO QA09_A41]

QA09_A40

What additional tests and/or surgery did you have?
[INTERVIEWER NOTE: CODE ALL THAT APPLY. IF NEEDED, SAY: “Any others?”]
NO TESTS/NO SURGERY .....................................1
MASTECTOMY (SURGERY TO
REMOVE BREAST)................................................2
LUMPECTOMY (SURGERY TO
REMOVE LUMP)....................................................3
NEEDLE BIOPSY ...................................................4
ULTRASOUND TEST.............................................5
ANOTHER MAMMOGRAM..................................6
CLINICAL BREAST EXAM...................................7
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_A41:
IF QA09_A29=2 OR QA09_A30 = 0 OR QA09_A31 > 2 years, CONTINUE WITH QA09_A41;
ELSE GO TO PROGRAMMING NOTE QA09_A42;
QA09_A41

In the past 2 years, has a doctor recommended that you have a mammogram?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_A42:
IF QA09_A41 = 1 (YES, DOCTOR RECOMMENDED A MAMMOGRAM) AND (QA09_A29=2 OR
QA09_A30 = 0 OR QA09_A31 > 2 years), CONTINUE WITH QA09_A42;
IF QA09_A31 = 3, 4, 5, -8 (MOST RECENT MAMMOGRAM > 2 YEARS or DK), DISPLAY
“NOT had a mammogram in the past 2 years”; IF QA09_A29 = 2 (NEVER HAD MAMMOGRAM), DISPLAY
“NEVER had a mammogram”;
ELSE GO TO NEXT SECTION;
QA09_A42

What is the ONE most important reason why you have {NEVER had a mammogram/NOT had
a mammogram in the past 2 years}?
NO REASON/NEVER THOUGHT ABOUT IT....... 1
DIDN'T KNOW I NEEDED THIS TYPE OF TEST 2
DOCTOR DIDN'T TELL ME I NEEDED IT ........... 3
HAVEN'T HAD ANY PROBLEMS ......................... 4
PUT IT OFF/LAZINESS ........................................... 5

CHIS 2009 OMB Questionnaire 9

TOO EXPENSIVE/NO INSURANCE/COST........... 6
TOO PAINFUL, UNPLEASANT,
EMBARRASSING .................................................... 7
TOO YOUNG ............................................................ 8
DON'T HAVE A DOCTOR....................................... 9
OTHER .................................................................... 91
REFUSED ................................................................. -7
DON'T KNOW ......................................................... -8

CHIS 2009 OMB Questionnaire 10

CHIS 2009 OMB Questionnaire 11

CHIS 2009 OMB Questionnaire 12

MODULE D – WOMEN’S HEALTH
PROGRAMMING NOTE QA09_D1:
IF MALE, GO NEXT SECTION; ELSE CONTINUE QA09_D1;
QA09_D1

These next questions are about women's health.
How old were you when your periods or menstrual cycles started?
[INTERVIEWER NOTE: IF NEVER STARTED MENSTRUAL CYCLE, ENTER 96]
_____ AGE
NEVER STARTED MENSTRUAL CYCLE.........96
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_D2

Do you still have periods or menstrual cycles?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_D3

[GO TO QA09_D4]
[GO TO QA09_D4]
[GO TO QA09_D4]

When did you have your last period or menstrual cycle?
_____ AGE
_____ MONTHS
_____ YEARS
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_D4

Have you ever given birth to a live born infant?
[INTERVIEWER NOTE: IF NEEDED, SAY: “A live born infant is an infnt born alive.”]
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON’T KNOW ...................................................... -8

QA09_D5

[GO TO NEXT SECTION]
[GO TO NEXT SECTION]
[GO TO NEXT SECTION]

How old were you when your first child was born?
______ YEARS OLD ...............................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

[GO TO QA09_D7]
[GO TO QA09_D7]

CHIS 2009 OMB Questionnaire 13

QA09_D6

In what year was your first child born?
_____ YEAR
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_D2
IF AGE>44 CONTINUE WITH QA09_D2;
ELSE GO TO QA09_D3;

QA09_D10 INTRO
QA09_D10

Are you taking any of the following medications?

Hormone replacement therapy?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_D11

Tamoxifen or Molvadex?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 14

PROGRAMMING NOTE QA09_D12
IF AGE>44 CONTINUE WITH QA09_D12;
ELSE GO TO QA09_D13;
QA09_D12

Raloxifen or Evista?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_D13
IF AGE<55 CONTINUE WITH QA09_D13;
ELSE GO TO SECTION E;
QA09_D13

Birth control pills, the patch, or birth control shots?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_D14

Have you ever taken HRT?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON’T KNOW ...................................................... -8

QA09_D15

[GO TO SECTION E]
[GO TO SECTION E]
[GO TO SECTION E]

About how long ago did you stop using Hormone Replacement Therapy – was it 2 years ago or
less, more than 2 years ago, up to 5 years ago, or more than 5 years ago?
LESS THAN 2 YEARS AGO ..................................1
MORE THAN 2 YEARS UP TO 5 YEARS AGO ..2
MORE THAN 5 YEARS AGO................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_D16

Some women go on and off hormone replacement therapy. Altogether, how long have you taken
HRT?
A YEAR AGO OR LESS .........................................1
MORE THAN 1 UP TO 2 YEARS ..........................2
MORE THAN 2 UP TO 4 YEARS ..........................3
MORE THAN 4 UP TO 8 YEARS ..........................4
MORE THAN 8 YEARS AGO................................5
REFUSED .............................................................. -7
DON’T KNOW ...................................................... -8

CHIS 2009 OMB Questionnaire 15

CHIS 2009 OMB Questionnaire 16

MODULE F – HEALTH BEHAVIORS (CANCER PREVENTION)
Moderate and Vigorous Physical Activity
QA09_F7

The next questions are about walking for transportation. I will ask you separately about walking for
relaxation or exercise.
During the past 7 days, did you walk to get some place that took you at least 10 minutes?
YES...........................................................................1
NO ............................................................................2
UNABLE TO WALK...............................................3
REFUSED .............................................................. -7
DON’T KNOW ...................................................... -8

[GO TO QA09_F10]
[GO TO QA09_F10]
[GO TO QA09_F10]
[GO TO QA09_F10]

CHIS 2009 OMB Questionnaire 17

QA09_F8

In the past 7 days, how many times did you do that?
[IF NEEDED, SAY: “Walk for at least 10 minutes to get some place.”]
______ TIMES PER WEEK
REFUSED ..................................................................-7 [GO TO QA09_F10]
DON’T KNOW ..........................................................-8 [GO TO QA09_F10]

QA09_F9

{How long did that walk take? / On average, how long did those walks take?}
______ MINUTES
REFUSED ..................................................................-7
DON’T KNOW ..........................................................-8

QA09_F10

Sometimes you may walk for fun, relaxation, exercise, or to walk the dog. During the past 7 days
did you walk for at least 10 minutes for any of these reasons? {Please do not include walking for
transportation.}
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON’T KNOW ...................................................... -8

QA09_F11

[GO TO QA09_F13]
[GO TO QA09_F13]
[GO TO QA09_F13]

In the past 7 days, how many times did you do that?
[IF NEEDED, SAY: “Walk for at least 10 minutes to get some place.”]
______ TIMES PER WEEK

[IF 0, GO TO QA09_F13]

REFUSED ..................................................................-7 [GO TO QA09_F13]
DON’T KNOW ..........................................................-8 [GO TO QA09_F13]
QA09_F12

{How long did that walk take? / On average, how long did those walks take}?
______ MINUTES
REFUSED ..................................................................-7
DON’T KNOW ..........................................................-8

QA09_F13

Now, I am going to ask about various health behaviors.
Altogether, have you smoked at least 100 or more cigarettes in your entire lifetime?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON’T KNOW ...................................................... -8

[GO TO NEXT SECTION]

CHIS 2009 OMB Questionnaire 18

QA09_F14

Do you now smoke cigarettes every day, some days, or not at all?
EVERY DAY ...........................................................1
SOME DAYS ...........................................................2
NOT AT ALL...........................................................3
REFUSED .............................................................. -7
DON’T KNOW ...................................................... -8

[GO TO QA09_F16]
[GO TO NEXT SECTION]
[GO TO NEXT SECTION]

PROGRAMMING NOTE QA09_F13
IF QA09_F14 = 1 DISPLAY “On the average” and “do” and “now”;
IF QA09_F14 = 3 DISPLAY “Thinking back over the years you have smoked regularly, about” and “did” and
“usually”;
QA09_F15

(On the average/Thinking back over the years you have smoked regularly, about) how many
cigarettes (do/did) you (now/usually) smoke a day?
[INTERVIEWER NOTE: IF R SAYS, A “PACK”, CODE AS 20 CIGARETTES]
_____ NUMBER OF CIGARETTES.........................

[GO TO QA09_F17]

REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

[GO TO QA09_F17]
[GO TO QA09_F17]

PROGRAMMING NOTE QA09_F16
IF QA09_F14 = 2 (SMOKE SOME DAYS), CONTINUE WITH QA09_F16;
ELSE CONTINUE WITH QA09_F17;
QA09_F16

In the past 30 days, when you smoked, how many cigarettes did you smoke per day?
[INTERVIEWER NOTE: IF NEEDED SAY, “On the days you smoked.” AND IF R SAYS, A
“PACK”, CODE THIS AS 20 CIGARETTES]
_____ NUMBER OF CIGARETTES
REFUSED ......................................................... -7
DON'T KNOW .................................................. -8

QA09_F17

About how many years [have you/did you] smoke[d/] cigarettes regularly?
_____ NUMBER OF YEARS
REFUSED ......................................................... -7
DON'T KNOW .................................................. -8

PROGRAMMING NOTE QA09_F27
IF AGE ≥ 12, CONTINUE WITH QA09_F27;

CHIS 2009 OMB Questionnaire 19

QA09_F27

During the past 12 months, how many times have you had a sunburn?
[INTERVIEWER NOTE:IF NECESSARY SAY, “By ‘sunburn’ we mean even a small part of your
skin turning red or hurting for 12 hours or more]
______NUMBER OF SUNBURNS
REFUSED ......................................................... -7
DON’T KNOW ...................................................... -8

A09_F29

During the past 12 months, how many times have you used any of the following indoor tanning
devices – a sunlamp, sunbed or tanning booth? Do NOT include times you have gotten a spray-on
tan.
______NUMBER OF TIMES
REFUSED ......................................................... -7
DON’T KNOW ................................................. -8

CHIS 2009 OMB Questionnaire 20

PROGRAMMING NOTE QA09_F30
Asked of all adults
QA09_F40

During the past month, how often did {you/SP} drink regular soda or pop that contains sugar? Do
not include diet soda. (You can tell me per day, per week or per month).
[INTERVIEWER NOTE: IF NEEDED SAY, “Do not include canned or bottled juices or teas. Your
best guess is fine.”]
__________TIMES
PER DAY .................................................................1
PER WEEK ..............................................................2
PER MONTH ...........................................................3
REFUSED ............................................................ - 7
DON’T KNOW ..................................................... - 8

QA09_F42

(During the past month), how often did you drink coffee or tea that had sugar or honey added to it?
Include coffee and tea you sweetened yourself and presweetened tea and coffee such as Arizona
Iced Tea or Frappuccino. Do not include artificially sweetened or diet coffee and diet tea. (You
can tell me per day, per week or per month.)
__________TIMES
PER DAY .................................................................1
PER WEEK ..............................................................2
PER MONTH ...........................................................3
REFUSED ............................................................ - 7
DON’T KNOW ..................................................... - 8

QA09_F37

(During the past month), how often did you drink sweetened fruit drinks, sports or energy drinks,
such as Kool-aid, lemonade, Hi-C, cranberry drink, Gatorade, and Red Bull, or vitamin water?
Include fruit juices you made at home and added sugar to. Do not include diet drinks or artificially
sweetened drinks. (You can tell me per day, per week or per month.)
[IF NEEDED, SAY: “Do not include yogurt drinks or mineral water.”]
__________TIMES
PER DAY .................................................................1
PER WEEK ..............................................................2
PER MONTH ...........................................................3
REFUSED ............................................................ - 7
DON’T KNOW ..................................................... - 8

QA09_F38

(During the past month), how often did {you/SP} eat cookies, cake, pie or brownies? Do not
include sugar-free kinds. (You can tell me per day, per week or per month.)
[IF NEEDED, SAY: “Include ANY sweet pastries.” “Do not include sugar-free kinds..”]
__________TIMES

CHIS 2009 OMB Questionnaire 21

PER DAY .................................................................1
PER WEEK ..............................................................2
PER MONTH ...........................................................3
REFUSED ............................................................ - 7
DON’T KNOW ..................................................... - 8
QA09_F39

(During the past month), how often did {you/SP} eat ice cream or other frozen desserts? Do
not include sugar-free kinds. (You can tell me per day, per week or per month.)
[IF NEEDED, SAY: “Do not include sugar-free kinds. Your best guess is fine.” ]
[IF STRONGLY NEEDED, SAY: “Other examples are frozen yogurt and popsicles.”]
__________TIMES
PER DAY .................................................................1
PER WEEK ..............................................................2
PER MONTH ...........................................................3
REFUSED ............................................................ - 7
DON’T KNOW ................................................ - 8

QA09_F41

Now think about the past week. In the past 7 days, how many times did you eat fast food? Include
fast food meals eaten at work, at home, or at fast-food restaurants, carryout or drive through.
[INTERVIEWER NOTE: IF NEEDED SAY, “Such as food you get at McDonald’s, KFC, Panda
Express or Taco Bell.”]
__________# OF TIMES IN PAST 7 DAYS
REFUSED .............................................................. -7
DON’T KNOW ...................................................... -8

CHIS 2009 OMB Questionnaire 22

MODULE G – FAMILY HISTORY OF CANCER
QA09_G1

What about your family? By family we mean only your blood relatives. Did your biological father
or mother, full brother or sisters, or biological sons or daughters ever have cancer of any kind?
[IF NEEDED, SAY: “Do not include family members related through marriage such as a
stepfather or stepsister, or family members who were adopted.”]
YES......................................................................1
NO .......................................................................2
REFUSED ......................................................... -7
DON’T KNOW ................................................. -8

QA09_G2

What kind of cancer or cancers were these?
[CODE ALL THAT APPLY]
[PROBE: “Any others?”]
BLADDER....................................................................... 1
BLOOD ............................................................................ 2
BONE............................................................................... 3
BRAIN ............................................................................. 4
BREAST .......................................................................... 5
CERVIX........................................................................... 6
COLON ............................................................................ 7
ESOPHAGUS .................................................................. 8
GALLBLADDER ............................................................ 9
KIDNEY ........................................................................ 10
LARYNX-WINDPIPE................................................... 11
LEUKEMIA ................................................................... 12
LIVER ............................................................................ 13
LUNG............................................................................. 14
LYMPHOMA................................................................. 15
MOUTH/TONGUE/LIP................................................. 16
OVARY.......................................................................... 17
PANCREAS................................................................... 18
PROSTATE.................................................................... 19
RECTUM ....................................................................... 20
SKIN .............................................................................. 21
SOFT TISSUE (MUSCLE OR FAT)............................. 24
STOMACH .................................................................... 25
TESTIS........................................................................... 26
THROAT-PHARYNX ................................................... 27
THYROID...................................................................... 28
UTERUS ........................................................................ 29
OTHER .......................................................................... 91
REFUSED .......................................................................-7
DON'T KNOW................................................................-8

CHIS 2009 OMB Questionnaire 23

PROGRAMMING NOTE QA09_G3
IF QA09_G2 = 21, THEN CONTINUE WITH QA09_G3;
ELSE SKIP TO PN QA09_G4;
QA09_G3

Was the skin cancer you mentioned non-melanoma, melanoma, or an unknown type?
[CODE ALL THAT APPLY]
Non-melanoma ....................................................1
Melanoma ............................................................2
Unknown type......................................................3
REFUSED ......................................................... -7
DON’T KNOW ................................................. -8

PROGRAMMING NOTE QA09_G4
IF QA09_G2 = 5, THEN CONTINUE WITH QA09_G4;
ELSE SKIP TO PN QA09_G7;
QA09_G4

Was your mother ever diagnosed with breast cancer?
YES......................................................................1
NO .......................................................................2
REFUSED ......................................................... -7
DON’T KNOW ................................................. -8

QA09_G5

Do you have any sisters who have ever been diagnosed with breast cancer?
YES......................................................................1
NO .......................................................................2 [GO TO PN QA09_G7]
REFUSED ......................................................... -7 [GO TO PN QA09_G7]
DON’T KNOW ................................................. -8 [GO TO PN QA09_G7]

QA09_G6

How many?
________ NUMBER OF SISTERS WITH BREAST CANCER
REFUSED ......................................................... -7
DON’T KNOW ................................................. -8

CHIS 2009 OMB Questionnaire 24

PROGRAMMING NOTE QA09_G7
IF QA09_G2 = (7 OR 20), THEN CONTINUE WITH QA09_G7;
ELSE SKIP TO NEXT SECTION;
QA09_G7

Who was diagnosed with colon or rectal cancer?
[CODE ALL THAT APPLY]
Mother .................................................................1
Father ...................................................................2
Full brother ..........................................................3
Full sister .............................................................4
Biological son ......................................................5
Biological daughter..............................................6
REFUSED ......................................................... -7
DON’T KNOW ................................................. -8

PROGRAMMING NOTE QA09_G8
IF QA09_G7 = (3, 4, 5, or 6), THEN CONTINUE WITH QA09_G8;
ELSE SKIP TO NEXT SECTION;
QA09_G8

How many?
________ NUMBER OF FAMILY MEMBER WITH COLON OR RECTAL CANCER
REFUSED ......................................................... -7
DON’T KNOW ................................................-8

CHIS 2009 OMB Questionnaire 25

CHIS 2009 OMB Questionnaire 26

MODULE I – VA TOPICS
QA09_I1

Did you ever serve on active duty in the Armed Forces of the United States?
YES.................................................................... 1
NO ..................................................................... 2 [GO TO NEXT SECTION]
REFUSED ........................................................-7 [GO TO NEXT SECTION]
DON'T KNOW .................................................-8 [GO TO NEXT SECTION]

QA09_I2

When did you serve?
FROM ________ TO ________
OR
[CHECK ALL THAT APPLY]
World War II (Sept 1940 to July 1947) ............. 1
Korean War (June 1950 to Jan 1955) ................ 2
Vietnam War (Aug 1964 to April 1975)............ 3
Gulf War/Operation
Desert Storm (1990 to 1991) ............................. 4
Afghanistan/Operation
Enduring Freedom (2001 to present)................. 5
Iraq War/Operation
Iraqi Freedom (2003 to present) ........................ 6
REFUSED ........................................................-7
DON'T KNOW .................................................-8

QA09_I3

Are you eligible to receive care at Veterans Health Administration hospitals or clinics?
YES.................................................................... 1
NO ..................................................................... 2
REFUSED ........................................................-7
DON’T KNOW ................................................-8

QA09_I4

Have you ever received care from a Veterans Health Administration hospital or clinic?
YES.................................................................... 1
NO ..................................................................... 2 [GO TO QA09_I7]
REFUSED ........................................................-7 [GO TO QA09_I7]
DON'T KNOW .................................................-8 [GO TO QA09_I7]

QA09_I5

Is the Veterans Health Administration your main source for your health care needs?
YES.................................................................... 1
NO ..................................................................... 2 [GO TO QA09_I7]
REFUSED ........................................................-7 [GO TO QA09_I7]
DON'T KNOW .................................................-8 [GO TO QA09_I7]

CHIS 2009 OMB Questionnaire 27

QA09_I6

In the past 2 years, have you also received health care from a non-Veterans Health Administration
facility?
YES.................................................................... 1
NO ..................................................................... 2
REFUSED ........................................................-7
DON'T KNOW .................................................-8

[GO TO QA09_I8]
[GO TO NEXT SECTION]
[GO TO NEXT SECTION]
[GO TO NEXT SECTION]

PROGRAMMING NOTE QA09_I7:
IF QA09_I4 = 2, DISPLAY “you have never used the Veterans Health Administration”;
IF QA09_I5 = 2, DISPLAY “the Veterans Health Administration is not your main source of health care”;
QA09_I7

What is the one main reason that {you have never used the Veterans Health Administration}/{the
Veterans Health Administration is not your main source of health care}?
Use other sources for health care....................... 1
Did not need any health care ............................. 2
Not aware of VA benefits .................................. 3
Not entitled or eligible for
VA health care benefits ..................................... 4
VA care is inconvenient..................................... 5
Other Specify___________ ............................... 6
REFUSED ........................................................-7
DON'T KNOW .................................................-8

PROGRAMMING NOTE QA09_I8:
ASK if QA09_I4 = 1 AND QA09_I6 = 1;
ELSE SKIP TO NEXT SECTION;
QA09_I8

Please tell me which one of the following statements best describes how you get your medical care:
You get all your medical care through the VA.. 1
You get most of your medical care through
the VA, but sometimes get health care outside the VA ........................................................ 2
You only use the VA as a back-up .................... 3
You use the VA for disability or
specific services only......................................... 4
You no longer use the VA for medical care ...... 5
Other Specify ______________ ........................ 6
REFUSED ........................................................-7
DON'T KNOW .................................................-8

CHIS 2009 OMB Questionnaire 28

MODULE J – DISCRIMINATION
PROGRAMMING NOTE QA09_J1 INTRO:
IF CASE NOT SELECTED, SKIP TO NEXT SECTION;
QA09_J1 INTRO
These next questions ask about situations where you were treated unfairly in your day-to-day life.
You can skip any of these questions. The information you provide is confidential.
PROGRAMMING NOTE QA09_J1:
ASK ITEMS QA09_J2 TO QA09_J8 IN RANDOM ORDER
QA09_J1

In the past 12 months, how often have you been treated with less respect than other people? Would
you say…
Never .......................................................................................... 1
Rarely.......................................................................................... 2
Sometimes .................................................................................. 3
Often? ......................................................................................... 4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J2

In the past 12 months, how often have you been treated unfairly at restaurants or stores? Would you
say…
Never .......................................................................................... 1
Rarely.......................................................................................... 2
Sometimes .................................................................................. 3
Often? ......................................................................................... 4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J3

In the past 12 months, how often have people criticized your accent or the way you speak? Would
you say…
Never .......................................................................................... 1
Rarely.......................................................................................... 2
Sometimes .................................................................................. 3
Often? ......................................................................................... 4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

CHIS 2009 OMB Questionnaire 29

QA09_J4

[In the past 12 months,]
…how often have people acted as if they think you are not smart?
[IF NEEDED, READ “Would you say…” AND THE RESPONSES CATEGORIES:]
NEVER....................................................................................... 1
RARELY .................................................................................... 2
SOMETIMES ............................................................................. 3
OFTEN ....................................................................................... 4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J5

[In the past 12 months,]
…how often have people acted as if they are afraid of you?
[IF NEEDED, READ “Would you say…” AND THE RESPONSES CATEGORIES:]
NEVER....................................................................................... 1
RARELY .................................................................................... 2
SOMETIMES ............................................................................. 3
OFTEN ....................................................................................... 4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J6

[In the past 12 months,]
…how often have people acted as if they think you are dishonest?
[IF NEEDED, READ “Would you say…” AND THE RESPONSES CATEGORIES:]
NEVER....................................................................................... 1
RARELY .................................................................................... 2
SOMETIMES ............................................................................. 3
OFTEN ....................................................................................... 4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J7

[In the past 12 months,]
…how often have people acted as if they’re better than you are?
[IF NEEDED, READ “Would you say…” AND THE RESPONSES CATEGORIES:]
NEVER....................................................................................... 1
RARELY .................................................................................... 2
SOMETIMES ............................................................................. 3
OFTEN ....................................................................................... 4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

CHIS 2009 OMB Questionnaire 30

QA09_J8

[In the past 12 months,]
…how often have you been threatened or harassed?
[IF NEEDED, READ “Would you say…” AND THE RESPONSES CATEGORIES:]
NEVER....................................................................................... 1
RARELY .................................................................................... 2
SOMETIMES ............................................................................. 3
OFTEN ....................................................................................... 4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

PROGRAMMING NOTE QA09_J9A:
IF ALL RESPONSES TO QA09_J1 - QA09_J8 =1 (NEVER), THEN SKIP TO PN QA09_J11;
ELSE CONTINUE WITH QA09_ J9A;
QA09_J9A Now, I’m going to ask you why you may have been treated unfairly.
YES

NO

REF

DK

1. In the past 12 months, were you treated unfairly
because of your ancestry or national origin?

[ ]

[ ]

[ ]

[ ]

2. In the past 12 months, were you treated unfairly
because of your gender or sex?

[ ]

[ ]

[ ]

[ ]

3. [In the past 12 months, were you treated unfairly]
..Because of your race or skin color?

[ ]

[ ]

[ ]

[ ]

4. [In the past 12 months, were you treated unfairly]
..Because of your age?

[ ]

[ ]

[ ]

[ ]

5. [In the past 12 months, were you treated unfairly]
..Because of the way you speak English?

[ ]

[ ]

[ ]

[ ]

6. [In the past 12 months, were you treated unfairly]
...Because of some other reason?

[ ]

[ ]

[ ]

[ ]

PROGRAMMING NOTE QA09_J9A_OV:
IF QA09_J9A = 1 (YES TO SOME OTHER REASON), THEN CONTINUE;
ELSE GO TO PN QA09_ J9B;
QA09_J9A_OV
[If YES TO “some other reason”, ASK:]
What was that reason?
OTHER (SPECIFY) ____________________

CHIS 2009 OMB Questionnaire 31

PROGRAMMING NOTE QA09_J9B:
IF MORE THAN ONE RESPONSE IN QA09_J9A, CONTINUE WITH QA09_J9B AND ONLY DISPLAY
“YES” RESPONSES AS CATEGORIES;
ELSE GO TO QA09_ J10;
QA09_J9B
Which of these do you think is the main reason why you were treated unfairly? Was it because of...
[IF NEEDED, “In the past 12 months…”]
{Your ancestry or national origin} ............................................. 1
{{or because of} Your gender or sex}........................................ 2
{{or because of } Your race or skin color} ................................ 3
{{or because of } Your age}....................................................... 4
{{or because of } The way you speak English} ......................... 5
{or because of } Some other reason (Specified):{__________} 6
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8
QA09_J10

In the past 12 months, how stressful have these experiences of unfair treatment usually been for
you? Would you say...
Not at all stressful ....................................................................... 1
A little stressful........................................................................... 2
Somewhat stressful ..................................................................... 3
Extremely stressful ..................................................................... 4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J11

Now, think about your entire lifetime.
Over your entire lifetime, how often have you been treated unfairly at school? Would you say…
Never .......................................................................................... 1
Rarely.......................................................................................... 2
Sometimes .................................................................................. 3
Often ..........................................................................................4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J12

Over your entire lifetime, how often have you been treated unfairly at work? Would you say…
Never .......................................................................................... 1
Rarely.......................................................................................... 2
Sometimes .................................................................................. 3
Often ..........................................................................................4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

CHIS 2009 OMB Questionnaire 32

QA09_J13

[Over your entire lifetime,]
…how often have you been treated unfairly when getting medical care?
[IF NEEDED, READ “Would you say…” AND THE RESPONSES CATEGORIES:]
NEVER....................................................................................... 1
RARELY .................................................................................... 2
SOMETIMES ............................................................................. 3
OFTEN ....................................................................................... 4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J14

[Over your entire lifetime,]
…how often would you say you have been treated unfairly or been discriminated against by the
police and the courts?
[IF NEEDED, READ “Would you say…” AND THE RESPONSES CATEGORIES:]
NEVER....................................................................................... 1
RARELY .................................................................................... 2
SOMETIMES ............................................................................. 3
OFTEN ......................................................................................4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J15

[Over your entire lifetime,]
…how often would you say you have been treated unfairly or been discriminated against in other
situations?
[IF NEEDED, READ “Would you say…” AND THE RESPONSES CATEGORIES:]
NEVER....................................................................................... 1
RARELY .................................................................................... 2
SOMETIMES ............................................................................. 3
OFTEN ....................................................................................... 4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

PROGRAMMING NOTE QA09_J15_OV:
IF QA09_J15 = 3 OR 4 (SOMETIMES OR OFTEN), THEN CONTINUE WITH QA09_J15_OV;
ELSE GO TO QA09_ J16A;
QA09_J15_OV And where did that happen?
OTHER (SPECIFY): ____________________

CHIS 2009 OMB Questionnaire 33

PROGRAMMING NOTE QA09_J16a:
IF (QA09_J11-QA09_J15 = 1 (NEVER) AND AT LEAST 1 RESPONSE IN QA09_J1 - QA09_J8 ≠ 1, SKIP
TO QA09_JINTRO2;
ELSE IF ALL RESPONSES TO QA09_J11-QA09_J15 = 1 (NEVER) AND ALL RESPONSES TO QA09_J1
- QA09_J8= 1 (NEVER), SKIP TO QA09_INTROJ25;
ELSE CONTINUE WITH QA09_J16A;
QA09_ J16A

Now, I’m going to ask you why you may have been treated unfairly.
YES

N
O

REF

DK

1. Over your entire lifetime, were you treated unfairly
because of your ancestry or national origin

[ ]

[
]

[ ]

[ ]

2. Over your entire lifetime, were you treated unfairly
because of your gender or sex

[ ]

[
]

[ ]

[ ]

[ ]

[
]

[ ]

[ ]

[ ]

[
]

[ ]

[ ]

[ ]

[
]

[ ]

[ ]

[ ]

[
]

[ ]

[ ]

3. [Over your entire lifetime, were you treated
unfairly]
…Because of your race or skin color
4. [Over your entire lifetime, were you treated
unfairly]
…Because of your age
5. [Over your entire lifetime, were you treated
unfairly]
…Because of the way you speak English
6. [Over your entire lifetime, were you treated
unfairly]
…Because of some other reason

PROGRAMMING NOTE QA09_J16A_OV-a:
IF QA09_J16A_6 (YES TO SOME OTHER REASON), THEN CONTINUE WITH QA09_J16A_OV;
ELSE SKIP TO PN QA09_J16B-a;
QA09_J16A_OV
What was that reason?
OTHER (SPECIFY) ____________________

CHIS 2009 OMB Questionnaire 34

PROGRAMMING NOTE QA09_J16B:
IF MORE THAN ONE RESPONSE IN QA09_J16A, CONTINUE WITH QA09_J16B AND ONLY
DISPLAY “YES” RESPONSES AS CATEGORIES.
ELSE SKIP TO QA09_ J17;
QA09_J16B

Which of these do you think is the main reason why you were treated unfairly, over your entire
lifetime? Was it because of...
[IF NEEDED, “Over your entire lifetime…”]
{Your ancestry or national origin} ............................................. 1
{{or because of} Your gender or sex}........................................ 2
{{or because of} Your race or skin color} ................................. 3
{{or because of} Your age}........................................................ 4
{{or because of} The way you speak English} .......................... 5
{or because of} OTHER REASON (Specified):{___________} 6
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J17

Over your entire lifetime, how stressful have these experiences of unfair treatment usually been for
you? Would you say…
Not at all stressful, ...................................................................... 1
A little stressful,.......................................................................... 2
Somewhat stressful, or................................................................ 3
Extremely stressful ..................................................................... 4
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_JINTRO2
The next questions ask about how you have usually responded when you were treated unfairly over
your entire lifetime.
QA09_J18

Did you work harder to prove them wrong?
[IF NEEDED, SAY: “Over your entire lifetime, have you usually reacted that way when you
were treated unfairly?”]
YES............................................................................................. 1
NO .............................................................................................. 2
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

CHIS 2009 OMB Questionnaire 35

QA09_J19

Did you get angry or get into an argument or physical fight?
[IF NEEDED, SAY: “Over your entire lifetime, have you usually reacted that way when you
were treated unfairly?”]
YES............................................................................................. 1
NO .............................................................................................. 2
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J20

Did you talk to someone about how you were feeling?
[IF NEEDED, SAY: “Over your entire lifetime, have you usually reacted that way when you
were treated unfairly?”]
YES............................................................................................. 1
NO .............................................................................................. 2
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J21

Did you pray or meditate about the situation?
[IF NEEDED, SAY: “Over your entire lifetime, have you usually reacted that way when you
were treated unfairly?”]
YES............................................................................................. 1
NO .............................................................................................. 2
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J22

Did you take drastic steps, such as filling a grievance or a lawsuit, quitting your job, moving away?
[IF NEEDED, SAY: “Over your entire lifetime, have you usually reacted that way when you
were treated unfairly?”]
YES............................................................................................. 1
NO .............................................................................................. 2
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

QA09_J23

Did you accept it as a fact of life?
[IF NEEDED, SAY: “Over your entire lifetime, have you usually reacted that way when you
were treated unfairly?”]
YES............................................................................................. 1
NO .............................................................................................. 2
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

CHIS 2009 OMB Questionnaire 36

QA09_J24

Did you do something else about it?
[IF NEEDED, SAY: “Over your entire lifetime, have you usually reacted that way when you
were treated unfairly?”]
YES............................................................................................. 1
NO .............................................................................................. 2
DON’T KNOW .........................................................................-7
REFUSED .................................................................................-8

PROGRAMMING NOTE QA09_J24_OV;
IF QA09_J24 = 1 (YES), THEN CONTINUE WITH QA09_J24_OV;
ELSE SKIP TO PN QA09_J25INTRO;
QA09_J4_OV
And what was that?:________________
QA09_J25INTRO
Finally, I would like to ask about your background—that is, your race or ethnicity—to find out how
you think of yourself.
PROGRAMMING NOTE QA09_J25:
IF QA09_K6 = 1 (LATINO/HISPANIC) AND [QA09_K8 = 1 (WHITE), 91 (OTHER) -7/-8 (REF/DK)]
IF QA09_K5 = 1 OR -7 (MALE OR REFUSED), DISPLAY "Latino";
IF QA09_K5 = 2 (FEMALE), DISPLAY "Latina";
IF QA09_K6 = 1 (LATINO/HISPANIC) AND [QA09_K8 =2 (BLACK/AFRICAN AMERICAN), 3
(ASIAN), 4 (OTHER PACIFIC ISLANDER), OR 6 (NATIVE HAWAIIN)], DISPLAY “Multiracial”
ELSE IF QA09_K6 = 1 (LATINO/HISPANIC) AND QA09_K8 = 4 (AMERICAN INDIAN OR ALASKA
NATIVE), DISPLAY "American Indian";
IF QA09_K6 = 2 (NOT LATINO/HISPANIC),
AND IF QA09_K8 = 1 (WHITE), DISPLAY "White";
AND IF QA09_K8 = 2 (BLACK/AFRICAN AMERICAN, DISPLAY "African American";
AND IF QA09_K8 = 3 (ASIAN), DISPLAY "Asian";
AND IF QA09_K8 = 4 (AMER INDIAN/ALASKA NATIVE), DISPLAY "American Indian";
AND IF QA09_K8 = 5 (OTHER PACIFIC ISLANDER), DISPLAY "Pacific Islander";
AND IF QA09_K8 = 6 (NATIVE HAWAIIAN), DISPLAY "Native Hawaiian";
AND IF QA09_K8 IS MORE THAN ONE RACE (EXCLUDING NATIVE AMERICAN), DISPLAY
“Multiracial”

CHIS 2009 OMB Questionnaire 37

QA09_J25

Do you think of yourself as {FILL FROM PREVIOUS RACE/ETHNICITY ITEMS}, or is there
some other term that you think better describes you?
WHITE ....................................................................................... 1
LATINO ..................................................................................... 2
HISPANIC.................................................................................. 3
BLACK....................................................................................... 4
AFRICAN AMERICAN ............................................................ 5
AMERICAN INDIAN................................................................ 6
ASIAN ........................................................................................ 7
NATIVE HAWAIIAN................................................................ 8
PACIFIC ISLANDER ................................................................ 9
MULTIRACIAL...................................................................... 10
OTHER (SPECIFY):_________________ ............................. 91

PROGRAMMING NOTE DMRESRC1:
IF AT LEAST ONE RESPONSE TO QA09_J1-QA09_J8 OR QA09_J11 – QA09_J15 ≠ 1 (NEVER),
CONTINUE WITH DMRESRC1;
ELSE SKIP TO NEXT SECTION;
DMRESRC1 [IF THE RESPONDENT IS UPSET ABOUT DISCUSSION OF DISCRIMINATION, THEN
ASK:]
We have a toll-free hotline if you’d like to talk to someone about your experiences of unfair
treatment. Would you like the toll-free number?
[IF YES: 800-784-2433]
[IF RESPONDENT ASKS ABOUT REPORTING DISCRIMINATION:]
We have a toll-free number you can call to learn more about reporting acts of discrimination.
[IF YES: 866-442-2529]

CHIS 2009 OMB Questionnaire 38

MODULE K – DEMOGRAPHICS, PART I
QA09_K1

What is your date of birth?
MONTH _______
1.
2.
3.
4.
5.
6.

JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE

DAY _______

7.
8.
9.
10.
11.
12.

JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER

YEAR ______

REFUSED..................................................................-7
DON'T KNOW ..........................................................-8
PROGRAMMING NOTE FOR QA09_K2:
IF QA09_K1 = -7 OR –8 THEN CONTINUE WITH QA09_K2;
ELSE GO TO QA09_K5
QA09_K2

What month and year were you born?
MONTH _______
1.
2.
3.
4.
5.
6.

JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE

7. JULY
8. AUGUST
9. SEPTEMBER
10. OCTOBER
11. NOVEMBER
12. DECEMBER

YEAR ______
REFUSED..................................................................-7
DON'T KNOW ..........................................................-8
PROGRAMMING NOTE FOR QA09_K3:
IF QA09_K2 = -7 OR -8 THEN CONTINUE WITH QA09_K3;
ELSE GO TO QA09_K5
QA09_K3

What is your age, please?
_____YEARS OF AGE
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 39

PROGRAMMING NOTE FOR QA09_K4:
IF QA09_K3 = -7 OR -8 THEN CONTINUE WITH QA09_K4;
ELSE GO TO QA09_K5
QA09_K4

Are you between 18 and 29, between 30 and 39, between 40 and 44, between 45 and 49, between
50 and 64, or 65 or older?
BETWEEN 18 AND 29 ...........................................1
BETWEEN 30 AND 39 ...........................................2
BETWEEN 40 AND 44 ...........................................3
BETWEEN 45 AND 49 ...........................................4
BETWEEN 50 AND 64 ...........................................5
65 OR OLDER .........................................................6
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE:
CALCULATE VALUE OF AGE (AAGE) BASED ON QA09_K1, QA09_K2, OR QA09_K3 TO USE IN ALL
AGE-RELATED QUESTIONS;
IF QA09_K1, QA09_K2, OR QA09_K3 = -7 OR -8 THEN USE QA09_K4;
ELSE USE ENUM.AGE (FROM SCREENER SEGMENT OF INTERVIEW);
Gender
QA09_K5
Are you male or female?
MALE.......................................................................1
FEMALE ..................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8
Ethnicity
QA09_K6

Are you Latino or Hispanic?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

[GO TO QA09_K8]

CHIS 2009 OMB Questionnaire 40

QA09_K7

And what is your Latino or Hispanic ancestry or origin? Such as Mexican, Salvadoran, Cuban,
Honduran -- and if you have more than one, tell me all of them.
[INTERVIEWER NOTE: CODE ALL THAT APPLY. IF NECESSARY, GIVE MORE EXAMPLES.]
MEXICAN/MEXICANO .........................................1
MEXICAN AMERICAN .........................................2
CHICANO ................................................................3
SALVADORAN.......................................................4
GUATEMALAN ......................................................5
COSTA RICAN........................................................6
HONDURAN ...........................................................7
NICARAGUAN .......................................................8
PANAMANIAN.......................................................9
PUERTO RICAN ...................................................10
CUBAN ..................................................................11
SPANISH-AMERICAN (FROM SPAIN) .............12
OTHER LATINO (SPECIFY): ____________ .....91
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE FOR QA09_K8:
IF QA09_K6 = 1 (YES, LATINO/HISPANIC), DISPLAY “You said you are Latino or Hispanic. Also…”
Race
QA09_K8
{You said you are Latino or Hispanic. Also} please tell me which one or more of the following you
would use to describe yourself. Would you describe yourself as Native Hawaiian, Other Pacific
Islander, American Indian, Alaska Native, Asian, Black, African American, or White?
[INTERVIEWER NOTE: IF R GIVES ANOTHER RESPONSE, SPECIFY. CODE ALL THAT
APPLY]
WHITE .....................................................................1
BLACK OR AFRICAN AMERICAN .....................2
ASIAN ......................................................................3
AMERICAN INDIAN OR ALASKA NATIVE ......4
OTHER PACIFIC ISLANDER................................5
NATIVE HAWAIIAN .............................................6
OTHER (SPECIFY): _________________ ...........91
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 41

PROGRAMMING NOTE FOR QA09_K9:
IF QA09_K8 = 4 (AMERICAN INDIAN OR ALASKA NATIVE), CONTINUE WITH QA09_K9;
ELSE GO TO PROGRAMMING NOTE QA09_K12;
QA09_K9

You said American Indian or Alaska Native - and what is your tribal heritage? If you have more
than one tribe, tell me all of them.
[INTERVIEWER NOTE: CODE ALL THAT APPLY]
APACHE ...................................................................1
BLACKFOOT/BLACKFEET ...................................2
CHEROKEE..............................................................3
CHOCTAW ...............................................................4
MEXICAN AMERICAN INDIAN ...........................5
NAVAJO ...................................................................6
POMO........................................................................7
PUEBLO....................................................................8
SIOUX .......................................................................9
YAQUI .....................................................................10
OTHER TRIBE (SPECIFY):_____________..........91
REFUSED ................................................................ -7
DON'T KNOW ......................................................... -8

CHIS 2009 OMB Questionnaire 42

QA09_K10

Are you an enrolled member in a federally or state recognized tribe?
YES............................................................................1
NO .............................................................................2
REFUSED ................................................................ -7
DON'T KNOW ......................................................... -8

QA09_K11

[GO TO QA09_K12]
[GO TO QA09_K12]
[GO TO QA09_K12]

Which tribe are you enrolled in?
APACHE
MESCALERO APACHE, NM.............................................1
APACHE (NOT SPECIFIC) ................................................2
OTHER APACHE (SPECIFY):__________________ .......3
BLACKFEET
BLACKFOOT/BLACKFEET ..............................................4
CHEROKEE
WESTERN CHEROKEE .....................................................5
CHEROKEE (NOT SPECIFIC)...........................................6
OTHER CHEROKEE (SPECIFY):_________________....7
CHOCTAW
CHOCTAW OKLAHOMA..................................................8
CHOCTAW (NOT SPECIFIC) ............................................9
OTHER CHOCTAW (SPECIFY):__________________ ..10
NAVAJO
NAVAJO (NOT SPECIFIC) ...............................................11
POMO
HOPLAND BAND, HOPLAND RANCHERIA ................12
SHERWOOD VALLEY RANCHERIA .............................13
POMO (NOT SPECIFIC)....................................................14
OTHER POMO (SPECIFY):__________________...........15
PUEBLO
HOPI....................................................................................16
YSLETA DEL SUR PUEBLO OF TEXAS........................17
PUEBLO (NOT SPECIFIC)................................................18
OTHER PUEBLO (SPECIFY):_________________.........19
SIOUX
OGLALA/PINE RIDGE SIOUX ........................................20
SIOUX (NOT SPECIFIC) ...................................................21
OTHER SIOUX (SPECIFY):_________________ ............22
YAQUI
PASCUA YAQUI TRIBE OF ARIZONA..........................23
YAQUI (NOT SPECIFIC) ..................................................24
OTHER YAQUI (SPECIFY):_________________ ...........25
OTHER
OTHER (SPECIFY):__________________ .......................91
REFUSED ........................................................................... -7
DON'T KNOW.................................................................... -8

CHIS 2009 OMB Questionnaire 43

PROGRAMMING NOTE FOR QA09_K12:
IF QA09_K8= 3 (ASIAN) CONTINUE WITH QA09_K12;
ELSE GO TO PROGRAMMING NOTE QA09_K13;
QA09_K12

You said Asian, and what specific ethnic group are you, such as Chinese, Filipino, Vietnamese? If
you are more than one, tell me all of them.
[INTERVIEWER NOTE: CODE ALL THAT APPLY]
BANGLADESHI.......................................................1
BURMESE ................................................................2
CAMBODIAN...........................................................3
CHINESE ..................................................................4
FILIPINO...................................................................5
HMONG ....................................................................6
INDIAN (INDIA) ......................................................7
INDONESIAN...........................................................8
JAPANESE................................................................9
KOREAN..................................................................10
LAOTIAN ................................................................11
MALAYSIAN ..........................................................12
PAKISTANI .............................................................13
SRI LANKAN ..........................................................14
TAIWANESE...........................................................15
THAI.........................................................................16
VIETNAMESE.........................................................17
OTHER ASIAN (SPECIFY): _________________ 91
REFUSED ................................................................ -7
DON'T KNOW ......................................................... -8

PROGRAMMING NOTE FOR QA09_K13:
IF QA09_K8= 5 (OTHER PACIFIC ISLANDER), CONTINUE WITH QA09_K13;
ELSE GO TO PROGRAMMING NOTE QA09_K15;
QA09_K13

You said you are Pacific Islander. What specific ethnic group are you, such as Samoan, Tongan, or
Guamanian? If you are more than one, tell me all of them.
[INTERVIEWER NOTE: CODE ALL THAT APPLY]
SAMOAN/AMERICAN SAMOAN .........................1
GUAMANIAN ..........................................................2
TONGAN ..................................................................3
FIJIAN .......................................................................4
OTHER PACIFIC ISLANDER (SPECIFY): _______
REFUSED ................................................................ -7
DON'T KNOW ......................................................... -8

91

CHIS 2009 OMB Questionnaire 44

PROGRAMMING NOTE FOR QA09_K14:
IF QA09_K6 = 1 (LATINO) AND [QA09_K8 = 6 (NATIVE HAWAIIAN) OR QA09_K8= 5 (OTHER PACIFIC
ISLANDER) OR QA09_K8= 4 (AMERICAN INDIAN OR ALASKA NATIVE) OR QA09_K8= 3 (ASIAN) OR
QA09_K8= 2 (BLACK/AFRICAN AMERICAN) OR QA09_K8= 1 (WHITE) OR QA09_K8 = 91 (OTHER)],
CONTINUE WITH QA09_K14;
ELSE IF THERE WERE MULTIPLE RESPONSES TO QA09_K8, QA09_K12, OR QA09_K13 (NOT
COUNTING -7 OR -8) CONTINUE WITH QA09_K14;
ELSE SKIP TO QA09_K15;
QA09_K14
AA5E1].

You said that you are: [INSERT MULTIPLE RESPONSES FROM AA5, AA5A, AA5E AND
Do you identify with any one race in particular?
YES............................................................................1
NO .............................................................................2
REFUSED ................................................................ -7
DON'T KNOW .........................................................- 8

[GO TO QA09_K16]
[GO TO QA09_K16]
[GO TO QA09_K16]

CHIS 2009 OMB Questionnaire 45

PROGRAMMING NOTE FOR QA09_K15: IF QA09_K6 = 1 (YES, LATINO) AND QA09_K7 ≠ -7 or -8, DO
NOT DISPLAY QA09_K15 = 14 (LATINO); IF QA09_K8 = 1 (YES, OTHER PACIFIC ISLANDER) AND
QA09_K12 = 1 to 5, DO NOT DISPLAY QA09_K15 = 17 (OTHER PACIFIC ISLANDER);
IF QA09_K8 = 3 AND QA09_K12 = 1 to 18ANY OF AA5E1 THROUGH AA5E18 = 1, DO NOT DISPLAY
QA09_K15 = 19 (ASIAN);
QA09_K15

Which do you most identify with?
[INTERVIEWER NOTE: IF R UNABLE TO CHOOSE ONE, OFFER
“BOTH/ALL/MULTIRACIAL”]
MEXICAN/MEXICANO ............................................................1
MEXICAN AMERICAN.............................................................2
CHICANO ...................................................................................3
SALVADORAN..........................................................................4
GUATEMALAN .........................................................................5
COSTA RICAN...........................................................................6
HONDURAN ..............................................................................7
NICARAGUAN...........................................................................8
PANAMANIAN ..........................................................................9
PUERTO RICAN .......................................................................10
CUBAN ......................................................................................11
SPANISH-AMERICAN (FROM SPAIN) ..................................12
LATINO, OTHER SPECIFY .....................................................13
LATINO .....................................................................................14
NATIVE HAWAIIAN................................................................16
OTHER PACIFIC ISLANDER ..................................................17
AMERICAN INDIAN OR ALASKA NATIVE.........................18
ASIAN ........................................................................................19
BLACK OR AFRICAN AMERICAN........................................20
WHITE .......................................................................................21
RACE, OTHER SPECIFY..........................................................22
BANGLADESHI ........................................................................30
BURMESE .................................................................................31
CAMBODIAN............................................................................32
CHINESE ...................................................................................33
FILIPINO....................................................................................34
HMONG .....................................................................................35
INDIAN (INDIA) .......................................................................36
INDONESIAN............................................................................37
JAPANESE.................................................................................38
KOREAN....................................................................................39
LAOTIAN...................................................................................40
MALAYSIAN ............................................................................41
PAKISTANI ...............................................................................42
SRI LANKAN ............................................................................43
TAIWANESE .............................................................................44
THAI...........................................................................................45
VIETNAMESE...........................................................................46
ASIAN, OTHER SPECIFY ........................................................49
SAMOAN/AMERICAN SAMOAN...........................................50
GUAMANIAN ...........................................................................51
TONGAN ...................................................................................52
FIJIAN ........................................................................................53
PACIFIC ISLANDER, OTHER SPECIFY ................................55
BOTH/ALL/MULTIRACIAL ....................................................90
NONE OF THESE......................................................................95
REFUSED .................................................................................. -7
DON'T KNOW ........................................................................... -8

CHIS 2009 OMB Questionnaire

46

QA09_K16

Are you now married, living with a partner in a marriage-like relationship, widowed, divorced,
separated, or never married?
[INTERVIEWER NOTE: IF R MENTIONS MORE THAN ONE, CODE THE LOWEST NUMBER
THAT APPLIES]
MARRIED.................................................................1
LIVING WITH PARTNER.......................................2
WIDOWED ...............................................................3
DIVORCED...............................................................4
SEPARATED ............................................................5
NEVER MARRIED ..................................................6
REFUSED ................................................................ -7
DON'T KNOW ......................................................... -8

CHIS 2009 OMB Questionnaire 47

MODULE L – DEMOGRAPHICS, PART II
QA09_L1

Now a few more questions about you.
In what country were you born?
UNITED STATES…................................................1
AMERICAN SAMOA .............................................2
CANADA .................................................................3
CHINA .....................................................................4
EL SALVADOR.......................................................5
ENGLAND...............................................................6
FRANCE ..................................................................7
GERMANY ..............................................................8
GUAM ......................................................................9
GUATEMALA.......................................................10
HUNGARY ............................................................11
INDIA.....................................................................12
IRAN ......................................................................13
IRELAND...............................................................14
ITALY ....................................................................15
JAPAN....................................................................16
KOREA ..................................................................17
MEXICO ................................................................18
PHILIPPINES.........................................................19
POLAND ................................................................20
PORTUGAL...........................................................21
PUERTO RICO ......................................................22
RUSSIA ..................................................................23
TAIWAN ................................................................24
VIETNAM..............................................................25
VIRGIN ISLANDS ................................................26
OTHER (SPECIFY):_______________ ................91
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 48

PROGRAMMING NOTE QA07_G2;
IF QA07_G1 NE 1 (NOT BORN IN US), GO TO QA07_G4;
ELSE IF QA07_G1 = 1, -7, -8 (BORN IN US, DON’T KNOW, REFUSED) CONTINUE WITH QA07_G2;

QA09_L2

In what country was your mother born?
[INTERVIEWER NOTE: FOR RESPONDENTS WHO WERE ADOPTED, QUESTION REFERS

TO
ADOPTIVE PARENTS]
UNITED STATES…................................................1
AMERICAN SAMOA .............................................2
CANADA .................................................................3
CHINA .....................................................................4
EL SALVADOR.......................................................5
ENGLAND...............................................................6
FRANCE ..................................................................7
GERMANY ..............................................................8
GUAM ......................................................................9
GUATEMALA.......................................................10
HUNGARY ............................................................11
INDIA.....................................................................12
IRAN ......................................................................13
IRELAND...............................................................14
ITALY ....................................................................15
JAPAN....................................................................16
KOREA ..................................................................17
MEXICO ................................................................18
PHILIPPINES.........................................................19
POLAND ................................................................20
PORTUGAL...........................................................21
PUERTO RICO ......................................................22
RUSSIA ..................................................................23
TAIWAN ................................................................24
VIETNAM..............................................................25
VIRGIN ISLANDS ................................................26
OTHER (SPECIFY):_______________ ................91
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 49

QA09_L3

In what country was your father born?
[INTERVIEWER NOTE: FOR RESPONDENTS WHO WERE ADOPTED, QUESTION REFERS
TO ADOPTIVE PARENTS]

UNITED STATES…................................................1
AMERICAN SAMOA .............................................2
CANADA .................................................................3
CHINA .....................................................................4
EL SALVADOR.......................................................5
ENGLAND...............................................................6
FRANCE ..................................................................7
GERMANY ..............................................................8
GUAM ......................................................................9
GUATEMALA.......................................................10
HUNGARY ............................................................11
INDIA.....................................................................12
IRAN ......................................................................13
IRELAND...............................................................14
ITALY ....................................................................15
JAPAN....................................................................16
KOREA ..................................................................17
MEXICO ................................................................18
PHILIPPINES.........................................................19
POLAND ................................................................20
PORTUGAL...........................................................21
PUERTO RICO ......................................................22
RUSSIA ..................................................................23
TAIWAN ................................................................24
VIETNAM..............................................................25
VIRGIN ISLANDS ................................................26
OTHER (SPECIFY):_______________ ................91
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8
Language Spoken at Home
QA09_L4
What languages do you speak at home?
[INTERVIEWER NOTE: CODE ALL THAT APPLY. ALSO PROBE, "Any others?"]
ENGLISH .................................................................1
SPANISH..................................................................2
CANTONESE ..........................................................3
VIETNAMESE.........................................................4
TAGALOG...............................................................5
MANDARIN ............................................................6
KOREAN..................................................................7
ASIAN INDIAN LANGUAGES .............................8
RUSSIAN .................................................................9
OTHER 1 (SPECIFY): ____________ ..................91
OTHER 2 (SPECIFY) :____________ ..................92
REFUSED .............................................................. -7
DON’T KNOW ...................................................... -8

CHIS 2009 OMB Questionnaire 50

PROGRAMMING NOTE QA09_L5A and QA09_L5B;
IF INTERVIEW NOT CONDUCTED IN ENGLISH, CONTINUE WITH QA09_L5A;
IF INTERVIEW CONDUCTED IN ENGLISH AND QA09_L5 >1 (SPEAKS LANGUAGE OTHER THAN
ENGLISH AT HOME), CONTINUE WITH QA09_L5A AND DISPLAY: “Since you speak a language other than
English at home, we are interested in the languages you use in other situations ” AND DROP RESPONSE
CATEGORY “NOT AT ALL”;
REPLACE OTHER LANGUAGE FOR QA09_L5A and QA09_L5B WITH LANGUAGE PROVIDED IN
QA09_L4
OR INTERVIEW LANGUAGE;
ELSE IF QA09_L4 = 1 ONLY (ENGLISH IS ONLY LANGUAGE SPOKEN AT HOME), GO TO QA09_L7;
Additional Language Use
QA09_L5A
What language do you speak with your friends?
ONLY ENGLISH .....................................................1
BOTH ENGLISH AND OTHER LANGUAGE(S) .2
ONLY OTHER LANGUAGE(S).............................3
REFUSED .............................................................. -7
DON’T KNOW ...................................................... -8
QA09_L5B

In what languages are the TV shows, radio stations, or newspapers that you usually watch, listen or
read?
ONLY ENGLISH .....................................................1
BOTH ENGLISH AND OTHER LANGUAGE(S) .2
ONLY OTHER LANGUAGE(S).............................3
REFUSED .............................................................. -7
DON’T KNOW ...................................................... -8

PROGRAMMING NOTE QA09_L6:
IF INTERVIEW CONDUCTED IN ENGLISH AND QA09_L4 >1 (SPEAKS LANGUAGE OTHER THAN
ENGLISH AT HOME), CONTINUE WITH QA09_L6 AND DISPLAY: “Since you speak a language other than
English at home, we are interested in your own opinion of how well you speak English…” AND DROP
RESPONSE CATEGORY “NOT AT ALL”;
ELSE IF QA09_L4 = 1 ONLY (ENGLISH IS ONLY LANGUAGE SPOKEN AT HOME), GO TO QA09_L7;
QA09_L6

{Since you speak a language other than English at home, we are interested in your own opinion of
how well you speak English} Would you say you speak English …
Very well ..................................................................1
Well ..........................................................................2
Not well ....................................................................3
Not at all ...................................................................4
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 51

PROGRAMMING NOTE QA09_L7:
IF QA09_L1 = 1 (USA) OR 2 (AMERICAN SAMOA) OR 9 (GUAM) OR 22 (PUERTO RICO) OR 26 (VIRGIN
ISLANDS), GO TO QA09_L11;
ELSE CONTINUE WITH QA09_L7;
Citizenship and Immigration
QA09_L7
The next questions are about citizenship and immigration.
Are you a citizen of the United States?
YES...........................................................................1
NO ............................................................................2
APPLICATION PENDING......................................3
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8
QA09_L8

[GO TO QA09_L9]

Are you a permanent resident with a green card? Your answers are confidential and will not be
reported to Immigration Services.
[INTERVIEWER NOTE: IF NEEDED SAY, “People usually call this a "Green Card" but the color
can also be pink, blue, or white."]
YES...........................................................................1
NO ............................................................................2
APPLICATION PENDING......................................3
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_L9

About how many years have you lived in the United States?
[INTERVIEWER NOTE: FOR LESS THAN A YEAR, ENTER 1 YEAR]
_____ NUMBER OF YEARS
_____ YEAR (FIRST CAME TO LIVE IN U.S.)
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_L11:
IF QA09_K16 =1 (MARRIED) CONTINUE WITH QA09_L11;
IF QA09_K16 = 2 (LIVING WITH PARTNER), GO TO QA09_L12;
ELSE GO TO PROGRAMMING NOTE QA09_L13;
QA09_L11

Is your spouse also living in your household?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 52

QA09_L12

May I have your {spouse/partner}’s first name and age?
[INTERVIEWER NOTE: ENTER SPOUSE’S/PARTNER’S NAME, AGE, AND SEX]
SPOUSE/PARTNER NAME ________________________________
SPOUSE/PARTNER AGE __________________________________
SPOUSE/PARTNER SEX __________________________________

PROGRAMMING NOTE QA09_L13:
IF AAGE<30 OR QA09_K4 = 1 (AGE 18-29) AND QA09_K16 = 1 (MARRIED) AND QA09_L11 =1 (SPOUSE
LIVING IN HH) AND 3 OR MORE ADULTS LIVE IN HH, CONTINUE WITH QA09_L13;
IF AAGE<30 OR QA09_K4 =1 (AGE 18-29) AND QA09_K16 =2 (LIVING WITH PARTNER) AND 3 OR
MORE ADULTS LIVING IN HH, CONTINUE WITH QA09_L13;
IF AAGE<30 OR QA09_K4 =1 (AGE 18-29) AND QA09_K16 = 3, 4, 5, 6, OR –7, -8 (WIDOWED, DIVORCED,
SEPARATED, NEVER MARRIED, REF, DK) AND 2 OR MORE ADULTS LIVING IN HH, CONTINUE WITH
QA09_L13;
ELSE GO TO QA09_L14;
QA09_L13

Are you now living with either of your parents?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_L14;
IF COMPLETED CHILD 1ST INTERVIEW, SKIP TO QA09_L15;
ELSE CONTINUE WITH QA09_L14;
Child and Teen Selection
QA09_L14
Are there any children under the age of 18 living in the household, including babies?
YES...........................................................................1
NO ...........................................................................2
REFUSED ............................................................. -7
DON'T KNOW ...................................................... -8
QA09_L15

[GO TO QA09_L21]
[GO TO QA09_L21]
[GO TO QA09_L21]

Please tell me only the first names and ages of all the children under 18, including babies, who
normally live in your household.
[INTERVIEWER NOTE: PROBE,“Is there anyone else?” ALSO, ENTER AGE OF 0 (ZERO), IF
LESS THAN 1 YEAR OLD]
CHILD
1
2
3
4
5

FIRST NAME

AGE

M/F

CHIS 2009 OMB Questionnaire 53

QA09_L16

Is (CHILD) …
0 To 11 years old .....................................................1
12 To 17 years old ....................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_L17

[CODE AS CHILD]
[CODE AS TEEN]
[CODE AS TEEN]
[CODE AS TEEN]

I have recorded {number} {child/children} under 18 in the household. Have I missed any children
under 18 who usually live here but are temporarily away?
NO ONE MISSED -- ROSTER IS CORRECT........1
RETURN TO ROSTER............................................2

[BACK TO QA09_L15]

PROGRAMMING NOTE QA09_L18: IF ANY PEOPLE IN HH UNDER 18, ASK ABOUT EACH PERSON <
18;
QA09_L18

Are you the parent or legal guardian of {PERSON NAME/AGE/SEX}?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_L18A:
IF ANY PEOPLE IN HH UNDER AGE 18 AND [AH44=1 OR AH43=2], ASK QA09_L18A ABOUT THE
SPOUSE/PARTNER AND EACH PERSON UNDER 18; ELSE SKIP TO QA09_L19;
QA09_L18A

Is (NAME/AGE/SEX) the parent or legal guardian of (PERSON NAME/AGE/SEX}?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 54

PROGRAMMING NOTE QA09_L19:
IF QA09_L14 = 1 (YES, CHILDREN UNDER 18 IN HH) AND ANY CHILDREN IN QA09_L15 ARE AGE 13
OR LESS, CONTINUE WITH QA09_L19;ELSE GO TO QA09_L21
IF ANY CHILD IN ROSTER QA09_L15 < 14 AND >= 14 display “for any children under age 13”;
IF QA09_K16 = 1 (MARRIED) AN D QA09_L11 =1 (SPOUSE LIVING IN HH), DISPLAY “you or your
spouse”;
IF QA09_K16 = 2 (LIVING WITH PARTNER), DISPLAY “you or your partner”; ELSE DISPLAY “you”;
Paid Child Care, Cost
QA09_L19 In the past month, did you use any paid childcare {for any children under age 13} while {you or
your spouse/partner/ you} worked, were in school, or looked for work?
[INTERVIEWER NOTE: IF NEEDED SAY, “This includes Head Start, day care centers, before- or
after-school care programs, and any baby-sitting arrangements.”]
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8
QA09_L20

[GO TO QA09_L21]
[GO TO QA09_L21]
[GO TO QA09_L21]

In the past month, how much did you pay for all child care arrangements and programs?
[INTERVIEWER NOTE: IF NEEDED SAY, “If it is easier for you, you can tell me what you paid
in a typical week last month." OR “You or any other adult in your household.”]
$_______________ AMOUNT LAST MONTH
$_______________ AMOUNT IN TYPICAL WEEK

NO PAYMENT IN LAST MONTH OR WEEK .....3
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8
Educational Attainment

CHIS 2009 OMB Questionnaire 55

QA09_L21

What is the highest grade of education you have completed and received credit for?
NO FORMAL EDUCATION........................................30
GRADE SCHOOL
1ST GRADE .....................................................................1
2ND GRADE ....................................................................2
3RD GRADE.....................................................................3
4TH GRADE.....................................................................4
5TH GRADE.....................................................................5
6TH GRADE.....................................................................6
7TH GRADE.....................................................................7
8TH GRADE.....................................................................8
HIGH SCHOOL OR EQUIVALENT
9TH GRADE.....................................................................9
10TH GRADE.................................................................10
11TH GRADE.................................................................11
12TH GRAD ...................................................................12
4-YEAR COLLEGE OR UNIVERSITY
1ST YEAR (FRESHMAN) .............................................13
2ND YEAR (SOPHOMORE) .........................................14
3RD YEAR (JUNIOR)....................................................15
4TH YEAR (SENIOR) (BA/BS) ....................................16
5TH YEAR......................................................................17
GRADUATE OR PROFESSIONAL SCHOOL
1ST YEAR GRAD OR PROF SCHOOL........................18
2ND YEAR GRAD OR PROF SCHOOL (MA/MS)......19
3RD YEAR GRAD OR PROF SCHOOL.......................20
MORE THAN 3 YEARS GRAD OR
PROF SCHOOL (PhD) ...................................................21
2-YEAR JUNIOR OR COMMUNITY COLLEGE
1ST YEAR ......................................................................22
2ND YEAR (AA/AS)......................................................23
VOCATIONAL, BUSINESS, OR TRADE SCHOOL
1ST YEAR ......................................................................24
2ND YEAR .....................................................................25
MORE THAN 2 YEARS ................................................26
REFUSED ....................................................................... -7
DON'T KNOW (OUT OF RANGE) ............................... -8

CHIS 2009 OMB Questionnaire 56

QA09_L22

Which of the following were you doing last week?
Working at a job or business ....................................1
With a job or business but not at work ....................2
Looking for work......................................................3
Not working at a job or business ..............................4
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_L23

[GO TO QA09_L26]

[GO TO QA09_L26]
[GO TO QA09_L26]

What is the main reason you did not work last week?
[INTERVIEWER NOTE: IF NEEDED SAY, “Main reason is the most important reason.”]
TAKING CARE OF HOUSE OR FAMILY ............1
ON PLANNED VACATION ...................................2
COULDN'T FIND A JOB ........................................3
GOING TO SCHOOL/STUDENT...........................4
RETIRED .................................................................5
DISABLED ..............................................................6
UNABLE TO WORK TEMPORARILY .................7
ON LAYOFF OR STRIKE ......................................8
ON FAMILY OR MATERNITY LEAVE ...............9
OFF SEASON ........................................................10
OTHER...................................................................91
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_L24

[GO TO QA09_L25]
[GO TO QA09_L25]

Do you usually work?
YES...........................................................................1
NO ............................................................................2
LOOKING FOR WORK ..........................................3
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_L25;
IF AAGE = -7 OR –8 OR AAGE < 65 AND QA09_L24 = 2 (NO) CONTINUE WITH QA09_L25;
IF AAGE = -7 OR -8 OR AAGE<65 AND QA09_L23 = 5 (RETIRED) or 6 (DISABLED) CONTINUE
WITH QA09_L25;
ELSE GO TO PROGRAMMING NOTE QA09_L27;
QA09_L25

Are you receiving Social Security Disability Insurance or SSDI?
YES........................................................................1
NO .........................................................................2
REFUSED ........................................................... -7
DON'T KNOW .................................................... -8

[GO TO QA09_L27]
[GO TO QA09_L27]
[GO TO QA09_L27]
[GO TO QA09_L27]

CHIS 2009 OMB Questionnaire 57

PROGRAMMING NOTE QA09_L26:
ELSE IF QA09_L22 = 1, 2, -7, -8 OR QA09_L24 = 1, CONTINUE WITH QA09_L26;
ELSE GO TO PROGRAMMING NOTE QA09_L27;
QA09_L26

On your main job, are you employed by a private company, the government, or are you selfemployed, or are you working without pay in a family business or farm?

[INTERVIEWER NOTE: IF NEEDED SAY, “Where did you work most hours?”]
PRIVATE COMPANY,
NON-PROFIT ORGANIZATION,FOUNDATION 1
GOVERNMENT ......................................................2
SELF-EMPLOYED..................................................3
FAMILY BUSINESS OR FARM ............................4
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8
PROGRAMMING NOTE QA09_L27;
IF QA09_ K16 = 1 (MARRIED), CONTINUE WITH QA09_L27;
ELSE GO TO NEXT SECTION;
QA09_L27

Which of the following was your spouse doing last week?
Working at a job or business ....................................1
With a job or business but not at work .....................2
Looking for work......................................................3
Not working at a job/business...................................4
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_L28

[GO TO QA09_L29]
[GO TO QA09_L29]

Does your spouse usually work?
YES...........................................................................1
NO ..................................................................... 2
[NEXT SECTION]
LOOKING FOR WORK ....................................... 3
[NEXT SECTION]
REFUSED ............................................................-7
[NEXT SECTION]
DON'T KNOW .....................................................-8
[NEXT SECTION]

QA09_L29

On your spouse’s main job, is he/she employed by a private company, the government, or is he/she
self-employed, or is he/she working without pay in a family business or farm?
[INTERVIEWER NOTE: IF NEEDED SAY, “Where did he/she work most hours?”]
PRIVATE COMPANY,
NON-PROFIT ORGANIZATION, FOUNDATION1
GOVERNMENT ......................................................2
SELF-EMPLOYED..................................................3
FAMILY BUSINESS OR FARM ............................4
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 58

MODULE M – EMPLOYMENT, INCOME AND POVERTY
PROGRAMMING NOTE QA09_M1:
IF QA09_L22 = 1 (WORKING AT JOB OR BUSINESS) OR QA09_L24 = 1 (R USUALLY WORKS)
CONTINUE WITH QA09_M1;
ELSE GO TO PROGRAMMING NOTE QA09_M5;
QA09_M1

This is about the work you do.
How many hours per week do you usually work at all jobs or businesses?
[INTERVIEWER NOTE: IF WORKS > 95 HOURS, ENTER 95. IF DOES NOT WORK, ENTER 0
(ZERO).]
_____ HOURS
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_M2

How long have you worked at your main job?
[INTERVIEWER NOTE: IF NEEDED SAY, “That is, for your current employer?”]
____ AMOUNT OF TIME
_____ MONTHS .....................................................1
_____ YEARS .......................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_M3:
IF QA09_L26 = 2 (GOVERNMENT EMPLOYEE), CODE QA09_M3 = 5 AND GO TO QA09_M4;
IF QA09_L26 = 3 (SELF-EMPLOYED), CONTINUE WITH QA09_M3 AND DISPLAY "Including yourself,
about"; ELSE CONTINUE WITH QA09_M3 AND DISPLAY "About";
QA09_M3

{Including yourself, about / About} how many people are employed by {your employer/you} at all
locations?
[INTERVIEWER NOTE: IF NEEDED SAY, “Your best guess is fine.”]
FEWER THAN 10....................................................1
10-50.........................................................................2
51-99.........................................................................3
100-999.....................................................................4
1,000 OR MORE ......................................................5
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 59

PROGRAMMING NOTE QA09_M4:
QA09_L22 = 1 (WORKING AT JOB OR BUSINESS) OR 2 (WITH JOB OR BUSINESS BUT NOT AT WORK)]
OR QA09_L24 = 1 (USUALLY WORKS), CONTINUE WITH QA09_M3
ELSE SKIP TO QA09_M5
Income Last Month
QA09_M4
What is your best estimate of all your earnings last month before taxes and other deductions from
all jobs and businesses, including hourly wages, salaries, tips and commissions?
[INTERVIEWER NOTE: IF AMOUNT GREATER THAN $999,995, ENTER "999,995"]
$_____________ AMOUNT
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8
PROGRAMMING NOTE QA09_M5;
IF QA09_L27= 1 (SPOUSE WORKING AT JOB OR BUSINESS) OR 2 (SPOUSE WITH JOB OR BUSINESS
BUT NOT AT WORK), CONTINUE WITH QA09_M5 AND:
IF QA09_L22 NE 1 OR 2 (R NOT AT A JOB OR BUSINESS LAST WEEK, DID NOT WORK, AND
DOES NOT HAVE A JOB)] AND QA09_L24 NE 1 ( R DOES NOT USUALLY WORK), DISPLAY “The next
question is about your spouse’s employment.”
ELSE SKIP TO QA09_M7;
QA09_M5

How many hours per week do your {husband/wife/spouse} usually work at all jobs or businesses?
[INTERVIEWER NOTE: IF WORKS > 95 HOURS, ENTER 95. IF DOES NOT WORK, ENTER 0
(ZERO).]
_____ HOURS
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_M6;
IF QA09_M5 > 0 CONTINUE WITH QA09_M6;
ELSE GO TO QA09_M7;
QA09_M6

What is your best estimate of all your spouse’s earnings last month before taxes and other
deductions from all jobs and businesses, including hourly wages, salaries, tips and commissions?
[INTERVIEWER NOTE: IF AMOUNT GREATER THAN $999,995, ENTER "999,995"]
$_______________ AMOUNT
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire

60

Annual Household Income
QA09_M7
What is your best estimate of your household’s total annual income from all sources before taxes in
2006?
[IF NEEDED SAY,“Include money from jobs, social security, retirement income, unemployment
payments, public assistance and so forth. Also include income from interest, dividends, net income
from business, farm, or rent and any other money income.” IF AMOUNT GREATER THAN
$999,995, ENTER "999,995"]
$_______________ AMOUNT
REFUSED ........................................................... -7
DON'T KNOW ....................................................... -8
QA09_M8

[GO TO QA09_M9]
[GO TO QA09_M9]

I have entered that your annual household income is (AMOUNT). Is that correct?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

[GO TO QA09_M15]
[GO BACK TO QA09_M7]
[GO TO QA09_M15]
[GO TO QA09_M15]

PROGAMMING NOTE QA09_M15:
IF QA09_M7 = -7 or -8 CONTINUE WITH QA09_M9;
ELSE GO TO PROGRAMMING NOTE QA09_M15;
QA09_M9

QA09_M10

QA09_M11

We don’t need to know exactly, but could you tell me if your household’s annual income from all
sources before taxes is more than $20,000 per year or is it less?
MORE.......................................................................1
EQUAL TO $20K OR LESS....................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

[GO TO QA09_M11]

$5,000 or less, or.......................................................1
$5,001 to $10,000, or................................................2
$10,001 to $15,000, or..............................................3
$15,001 to 20,000? ...................................................4
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

[GO TO QA09_M15]
[GO TO QA09_M15]
[GO TO QA09_M15]
[GO TO QA09_M15]
[GO TO QA09_M15]
[GO TO QA09_M15]

[GO TO QA09_M15]
[GO TO QA09_M15]

Is it …

Is it more or less than $70,000 per year?
MORE.......................................................................1
EQUAL TO $70K OR LESS....................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire

[GO TO QA09_M13]
[GO TO QA09_M15]
[GO TO QA09_M15]

61

QA09_M12

Is it …
$20,001 to $30,000, ..................................................1
$30,001 to $40,000, ..................................................2
$40,001 to $50,000, ..................................................3
$50,001 to $60,000, or..............................................4
$60,001 to $70,000? .................................................5
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_M13

Is it more or less than $135,000 per year?
MORE.......................................................................1
EQUAL TO $135K OR LESS..................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_M14

[GO TO QA09_M15]
[GO TO QA09_M15]
[GO TO QA09_M15]
[GO TO QA09_M15]
[GO TO QA09_M15]
[GO TO QA09_M15]
[GO TO QA09_M15]

[GO TO QA09_M15]
[GO TO QA09_M15]
[GO TO QA09_M15]

Is it …
$70,001 to $80,000, ..................................................1
$80,001 to $90,000, ..................................................2
$90,001 to $100,000, or............................................3
$100,001 to $135,000? .............................................4
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_M15:
IF R IS ONLY MEMBER OF HH, GO TO PROGRAMMING NOTE QA09_M17;
ELSE CONTINUE WITH QA09 N5;
Number of persons supported
QA09_M15
Including yourself, how many people living in your household are supported by your total
household income?
_____ NUMBER OF PEOPLE
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire

62

PROGRAMMING NOTE QA09_M16:
QA09_M16 MUST BE LESS THAN QA09_M15
IF NO CHILDREN UNDER 18 IN HH (AS DETERMINED FROM CHILD ENUMERATION QUESTIONS) OR
TOTAL NUMBER OF PEOPLE LIVING IN HH (AS DETERMINED BY ADULT PLUS CHILD
ENUMERATION) = QA09_M16;GO TO PROGRAMMING NOTE QA09_M17;
ELSE CONTINUE WITH QA09_M16;
QA09_M16

How many of these {INSERT NUMBER FROM QA09_M15} people are children under the age
of 18?
_____ NUMBER OF CHILDREN (UNDER AGE 18)
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

Poverty level test
PROGRAMMING NOTE QA09_M17:
OBTAIN THE FEDERAL POVERTY 100%, 130% 200%, AND 300% LEVEL CUTOFF POINTS FROM THE
2006 FEDERAL POVERTY GUIDELINE USING THE TOTAL HOUSEHOLD SIZE AND NUMBER OF
CHILDREN FROM QA09_M15 AND QA09_M16 RESPECTIVELY.
(THE 200% AND 300% VALUES WERE DERIVED BY MULTIPLYING THE CENSUS POVERTY 2006
THRESHOLD "SIZE OF FAMILY UNIT" BY "RELATED CHILDREN UNDER 18 YEARS" TABLE
AMOUNTS BY 2 AND 3, RESPECTIVELY, THEN ROUNDING TO THE NEAREST 100 DOLLARS. REFER
TO SPECIFICATIONS ADDENDUM “Poverty Level 2006” DOCUMENT FOR THE TABLE OF VALUES.
THE 100% POVERTY CUTOFF VALUE WILL BE STORED IN CATI VARIABLE POVRT100, THE 200%
POVERTY CUTOFF VALUE WILL BE STORED IN CATI VARIABLE POVRT200 AND THE 300% VALUE
IN CATI VARIABLE POVRT300).
IF EITHER QA09_M15 OR QA09_M16 IS MISSING, USE THE TOTAL NUMBER OF ADULTS
ENUMERATED IN THE SCREENER (GIVEN BY CATI VARIABLE RADLTCNT) AND THE TOTAL
NUMBER OF CHILDREN ENUMERATED AT QA09_L15 OF THE ADULT INTERVIEW (GIVEN BY CATI
VARIABLE KIDCNT) INSTEAD.
ASCERTAIN IF THE HOUSEHOLD INCOME IS...
1) AT OR BELOW 100% FPL
2) ABOVE 100% FPL BUT AT OR BELOW 200% FPL
3) ABOVE 200% FPL BUT AT OR BELOW 300% FPL
4) ABOVE 300% FPL
5) UNKNOWN BECAUSE HOUSEHOLD INCOME WAS NOT GIVEN.
IF QA09_M7= -7 OR -8 (REF/DK) AND IF THE HOUSEHOLD'S 100% CUTOFF VALUE FALLS WITHIN A
RESPONSE FROM QA09_M10, QA09_M12, OR QA09_M14 OR QA09_M9 = -7 OR QA09_M11 = -7 OR
QA09_M13 = -7, ASK QA09_M17 USING POVRT100 (THE 100% FPL CUTOFF DISPLAY AMOUNT);
ELSE GO TO PROGRAMMING NOTE QA09_M20

CHIS 2009 OMB Questionnaire

63

QA09_M17

I need to ask just one or two more questions about income.
Was your total annual household income before taxes less than or more than ${POVRT100}?
EQUAL TO OR LESS .............................................1
[GO TO QA09_M21]
MORE.......................................................................2
REFUSED ........................................................... -7
[GO TO QA09_M21]
DON'T KNOW .................................................... -8
[GO TO QA09_M21]

PROGRAMMING NOTE QA09_M18:
IF QA09_M7 = -7 OR -8 (REF/DK) AND IF THE HOUSEHOLD'S 200% CUTOFF VALUE FALLS WITHIN
A RESPONSE FROM QA09_M10, QA09_M12, OR QA09_M14 OR IF QA09_M9 = -7 OR QA09_M11 = -7
OR QA09_M13= -7, CONTINUE WITH QA09_M18 USING POVRT200 (200% POVERTY CUTOFF
DISPLAY AMOUNT); ELSE GO TO PROGRAMMING NOTE QA09_M21;
QA09_M18

{I need to ask just one or two more questions about income} Was your total annual household
income before taxes less than or more than ${POVRT200}?
EQUAL TO OR LESS .............................................1
MORE....................................................................2
[GO TO QA09_M20]
REFUSED ........................................................... -7
[GO TO QA09_M21]
DON'T KNOW .................................................... -8
[GO TO QA09_M21]

PROGRAMMING NOTE QA09_M19:
IF QA09_M18 = 1 (YES), CONTINUE WITH QA09_M19 USING POVRT130 (130% POVERTY CUTOFF
DISPLAY AMOUNT);
ELSE SKIP TO QA09_M20
QA09_M19

{I need to ask just one or two more questions about income} Was your total annual household
income before taxes less than or more than ${POVRT130}?
EQUAL TO OR LESS ..........................................1
MORE....................................................................2
REFUSED ........................................................... -7
DON'T KNOW ..................................................... -8

[GO TO QA09_M21]
[GO TO QA09_M21]
[GO TO QA09_M21]
[GO TO QA09_M21]

PROGRAMMING NOTE QA09_M20:
IF QA09_M7 = -7 OR –8 (REF/DK) AND IF THE HOUSEHOLD'S 300% CUTOFF VALUE FALLS WITHIN
A RESPONSE FROM QA09_M10, QA09_M12, OR QA09_M14 OR IF QA09_M9 = -7 OR QA09_M11= -7 OR
QA09_M13 = -7, CONTINUE WITH QA09_M20 USING POVRT300 (300% POVERTY CUTOFF DISPLAY
AMOUNT) AND IF NEITHER QA09_M17 OR QA09_M18 WAS ASKED, DISPLAY “I need to ask just one or
two more questions about income. Was your total annual household income before taxes”; ELSE DISPLAY “Was
it”; ELSE GO TO QA09_M21;
QA09_M20

{I need to ask just one or two more questions about income} Was your total annual household
income before taxes less than or more than ${POVRT300}?
EQUAL TO OR LESS .............................................1
MORE....................................................................2
[GO TO QA09_M21]
REFUSED ........................................................... -7
[GO TO QA09_M21]
DON'T KNOW .................................................... -8
[GO TO QA09_M21]

CHIS 2009 OMB Questionnaire 64

PROGRAMMING NOTE QA09_M21;
IF POVERTY < 3 (HH Income <= 200% FPL) OR 5 (HH INCOME NOT KNOWN), CONTINUE WITH
QA09_M21;
ELSE GO TO QA09_N1;
QA09_M21

These next questions are about the food eaten in your household in the last 12 months and
whether you were able to afford food.
I'm going to read two statements that people have made about their food situation. For each,
please tell me whether the statement describes something that was often true, sometimes
true, or never true for you and your household in the last 12 months. The first statement is:
"The food that (I/we) bought just didn't last, and (I/we) didn't have money to get more."
Was that often true, sometimes true, or never true for you and your household in the last 12
months?
OFTEN TRUE..........................................................1
SOMETIMES TRUE................................................2
NEVER TRUE .........................................................3
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_M22

The second statement is:
"(I/We) couldn't afford to eat balanced meals."
Was that often true, sometimes true, or never true for you and your household in the last 12
months?
OFTEN TRUE..........................................................1
SOMETIMES TRUE................................................2
NEVER TRUE .........................................................3
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_M23

Please tell me yes or no. In the last 12 months, since {DATE 12 MONTHS AGO}, did you or
other adults in your household ever cut the size of your meals or skip meals because there wasn't
enough money for food?
YES...........................................................................1
NO ............................................................................2
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

QA09_M24

[GO TO QA09_M25]
[GO TO QA09_M25]
[GO TO QA09_M25]

How often did this happen -- almost every month, some months but not every month, or only in 1
or 2 months?
ALMOST EVERY MONTH....................................1
SOME MONTHS BUT NOT EVERY MONTH .....2
ONLY IN 1 OR 2 MONTHS....................................3
REFUSED .............................................................. -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 65

Hunger
QA09_M25

In the last 12 months, did you ever eat less than you felt you should because there wasn't
enough money to buy food?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

QA09_M26

In the last 12 months, since {DATE 12 MONTHS AGO}, were you ever hungry but didn't
eat because you couldn't afford enough food?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 66

MODULE N – DEMOGRAPHIC, PART III AND CLOSING
County of Residence
QA09 _N1

Just a few final questions and then we are done.
To be sure we are covering the entire state, what county do you live in?
ALAMEDA ..................................................................................... 1
ALPINE.......................................................................................... 2
AMADOR....................................................................................... 3
BUTTE........................................................................................... 4
CALAVERAS................................................................................. 5
COLUSA........................................................................................ 6
CONTRA COSTA.......................................................................... 7
DEL NORTE.................................................................................. 8
EL DORADO ................................................................................. 9
FRESNO ..................................................................................... 10
GLENN ........................................................................................ 11
HUMBOLDT ................................................................................ 12
IMPERIAL.................................................................................... 13
INYO............................................................................................ 14
KERN .......................................................................................... 15
KINGS ......................................................................................... 16
LAKE ........................................................................................... 17
LASSEN ...................................................................................... 18
LOS ANGELES ........................................................................... 19
MADERA ..................................................................................... 20
MARIN......................................................................................... 21
MARIPOSA ................................................................................. 22
MENDOCINO .............................................................................. 23
MERCED..................................................................................... 24
MODOC....................................................................................... 25
MONO ......................................................................................... 26
MONTEREY ................................................................................ 27
NAPA........................................................................................... 28
NEVADA...................................................................................... 29
ORANGE..................................................................................... 30
PLACER ...................................................................................... 31
PLUMAS...................................................................................... 32
RIVERSIDE ................................................................................. 33
SACRAMENTO ........................................................................... 34
SAN BENITO............................................................................... 35
SAN BERNARDINO .................................................................... 36
SAN DIEGO ................................................................................ 37
SAN FRANCISCO....................................................................... 38
SAN JOAQUIN ............................................................................ 39
SAN LUIS OBISPO ..................................................................... 40
SAN MATEO ............................................................................... 41
SANTA BARBARA ...................................................................... 42
SANTA CLARA ........................................................................... 43
SANTA CRUZ ............................................................................. 44
SHASTA ...................................................................................... 45
SIERRA ....................................................................................... 46
SISKIYOU ................................................................................... 47
SOLANO ..................................................................................... 48
SONOMA .................................................................................... 49
STANISLAUS .............................................................................. 50
SUTTER ...................................................................................... 51
TEHAMA ..................................................................................... 52
TRINITY ...................................................................................... 53
TULARE ...................................................................................... 54
TUOLUMNE ................................................................................ 55
VENTURA ................................................................................... 56
YOLO .......................................................................................... 57
YUBA........................................................................................... 58
REFUSED ....................................................................................-7
DON'T KNOW ..............................................................................-8

Address confirmation, cross streets, zip code

CHIS 2009 OMB Questionnaire 67

PROGRAMMING NOTE QA09_N2:
IF ADVANCE LETTER SENT, ASK QA09_N2;
IF R’S ADDRESS IS A P.O. BOX, GO TO QA09_N3
ELSE GO TO QA09_N3;
QA09_N2

Your phone number was randomly selected for this study by a computer. We were able to
match an address to your phone number to send a letter to your home explaining the purpose
of this study. To help us better understand the environment you live in and how it may affect
your health, we would like to confirm your address. This information will be kept confidential
and will be destroyed after the entire survey has been completed.
Do you now live at {R’s address and street}?
YES .......................................................................... 1
NO............................................................................ 2
REFUSED ............................................................... -7
DON'T KNOW ......................................................... -8

QA09_N3

[GO TO QA09_N6]

What is your zip code?
_________ (ZIP CODE)
REFUSED ............................................................... -7
DON'T KNOW ......................................................... -8

QA09_N4

To help us better understand the environment you live in and how it may affect your health,
please tell me the address where you live. This information will be kept confidential and will
be destroyed after the entire survey has been completed.
________ HOUSE ADDRESS NUMBER
________ NAME OF STREET

[GO TO QA09_N6]

NO............................................................................ 2
REFUSED ............................................................... -7
DON'T KNOW ......................................................... -8
QA09_N5

Can you tell me just the name of the street you live on?
________ NAME OF STREET
REFUSED ............................................................... -7
DON'T KNOW ......................................................... -8

QA09_N6

[GO TO CLOSE1]
[GO TO CLOSE1]

And what is the name of the street down the corner from you that crosses your street?
________ NAME OF CROSS STREET
REFUSED ............................................................... -7
DON'T KNOW ......................................................... -8

Cell phone use

CHIS 2009 OMB Questionnaire 68

QA09_N6A

Do you have a working cell phone?
YES .......................................................................... 1
NO............................................................................ 2
SHARES CELL PHONE .......................................... 3
REFUSED ............................................................... -7
DON'T KNOW ......................................................... -8

PROGRAMMING NOTE QA09_N6B:
IF QA09_N6B = 1 (YES) OR 3 (SHARES CELL PHONE, CONTINUE WITH QA09_N6B;
ELSE SKIP TO QA09_N7;
QA09_N6B

Of all the telephone calls that you receive, are...
All or almost all calls received on a cell phone ........ 1
Some on cell phones & some on regular phones .... 2
Very few or none on cell phones.............................. 3
REFUSED ............................................................... -7
DON'T KNOW ......................................................... -8

Follow-up Survey Permission
QA09_N7

Finally, do you think you would be willing to do a follow-up to this survey some time in the
future?
YES .......................................................................... 1
MAYBE/PROBABLY YES........................................ 2
DEFINITELY NOT.................................................... 3
REFUSED ............................................................... -7
DON'T KNOW ......................................................... -8

PROGRAMMING NOTE CLOSE1 and CLOSE2:
IF ALL INTERVIEWS FOR HOUSEHOLD COMPLETE, SKIP TO CLOSE2;
ELSE CONTINUE WITH CLOSE1;
CLOSE1

Let me check to see if there is anyone else.
[INTERVIEWER NOTE: GO TO HHSELECT]

CLOSE2

Thank you, I really appreciate your time and cooperation. You have helped with a very
important health survey. If you have any questions about the study, please contact Dr. E.
Richard Brown, the Principal Investigator. Dr. Brown can be reached toll-free at 1-866-2752447. Thank you, and good-bye.

CHIS 2009 OMB Questionnaire 69

MODULE O – GENERAL HEALTH, DISABILITY, AND SEXUAL HEALTH
Height and Weight
QA09_O1
These next questions are about your height and weight.
How tall are you without shoes?
[INTERVIEWER NOTE: IF NEEDED SAY, “About how tall?”]
_____ FEET _____ INCHES
_____ METERS _____ CENTIMETERS
FEET/INCHES .........................................................1
METERS/CENTIMETERS ......................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8
PROGRAMMING NOTE QA09_O2:
IF QA09_A5 = 2 (FEMALE) and AAGE<50, DISPLAY "When not pregnant, how";ELSE DISPLAY "How";
QA09_O2

{When not pregnant, how/How} much do you weigh without shoes?
[INTERVIEWER NOTE: IF NEEDED SAY, “About how much?”]
_____ POUNDS
_____ KILOGRAMS
POUNDS ..................................................................1
KILOGRAMS...........................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

PROGRAMMING NOTE QA09_O3:
IF AAGE = 18, GO TO QA09_O4;
QA09_O3

How much did you weigh at age 18?
[INTERVIEWER NOTE: IF NEEDED SAY, “About how much?”]
_____ POUNDS
_____ KILOGRAMS
POUNDS ..................................................................1
KILOGRAMS...........................................................2
REFUSED............................................................... -7
DON’T KNOW....................................... -8Disability

CHIS 2009 OMB Questionnaire 70

QA09_O4

Are you blind or deaf, or do you have a severe vision or hearing problem?
YES...........................................................................1
NO......................................................................... 2 [GO TO QA09_O6]
REFUSED............................................................ -7 [GO TO QA09_O6]
DON'T KNOW .................................................... -8 [GO TO QA09_O6]

QA09_O5

Are you legally blind?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

QA09_O6

Do you have a condition that substantially limits one or more basic physical activities such as
walking, climbing stairs, reaching, lifting, or carrying?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW....................................................... -8

QA09_O7

Because of a physical, mental, or emotional condition lasting 6 months or more, do you
have any of the following:
Any difficulty learning, remembering, or concentrating?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

QA09_O8

Any difficulty dressing, bathing, or getting around inside the home?
[INTERVIEWER NOTE: IF NEEDED SAY, “Because of a physical, mental, or emotional
condition.”]
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

QA09_O9

Any difficulty going outside the home alone to shop or visit a doctor’s office?
[INTERVIEWER NOTE: IF NEEDED SAY, “Because of a physical, mental, or emotional
condition.”]
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 71

PROGRAMMING NOTE QA09_O10:
IF AAGE > 64 GO TO QA09_O12;
QA09_O10

Any difficulty working at a job or business?
[INTERVIEWER NOTE: IF NEEDED SAY, “Because of a physical, mental, or emotional
condition.”]
YES...........................................................................1
NO........................................................................... 2
REFUSED..............................................................-7
DON'T KNOW ......................................................-8

QA09_O11

[GO TO QA09_O12]
[GO TO QA09_O12]
[GO TO QA09_O12]

Do you have a physical or mental condition that has kept you from working for at least a
year?
[INTERVIEWER NOTE: IF NEEDED SAY, “Current condition”]
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_O12:
IF AAGE > 70 OR QA09_A4 = 6 (65 OR OLDER) OR ENUM.AGE > 70 OR IF AGE IS UNKNOWN, GO
TO NEXT SECTION;
ELSE CONTINUE WITH QA09_O12;
Sexual Partners, Sexual Orientation
QA09_O12
We are asking a few questions about people’s sexual experiences. All answers will be kept
private.
In the past 12 months, how many sexual partners have you had?
_______ NUMBER OF SEXUAL PARTNERS

[GO TO QA09_O14]

REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

[GO TO QA09_O14]

CHIS 2009 OMB Questionnaire 72

QA09_O13

Can you give me your best guess?
[INTERVIEWER NOTE: IF R PROVIDES EXACT NUMBER, ENTER AS GIVEN.
OTHERWISE CODE INTO CATEGORIES PROVIDED]
___ NUMBER OF PARTNERS
1 PARTNER .............................................................1
2-3 PARTNERS........................................................2
4-5 PARTNERS........................................................3
6-10 PARTNERS......................................................4
MORE THAN 10 PARTNERS ................................5
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

PROGRAMMING NOTE QA09_O14:
IF QA09_O12 = 0 (NO SEXUAL PARTNERS IN LAST 12 MONTHS) OR QA09_O13=0, GO TO
PROGRAMMING NOTE QA09_O15; ELSE CONTINUE WITH QA09_O14;
IF QA09_O12 OR QA09_O13 = 1 (ONE PARTNER IN LAST 12 MONTHS), DISPLAY “Is that partner
male or female?”
QA09_O14

{Is that partner male or female?} In the past 12 months, have your sexual partners been male,
female, or both male and female?
MALE .......................................................................1
FEMALE ..................................................................2
BOTH MALE AND FEMALE.................................3
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

PROGRAMMING NOTE QA09_O15:
IF QA09_A5 = 1 (MALE), DISPLAY “Gay” in question and “Gay” in Help Screen,
ELSE IF QA09_A5 =2 (FEMALE), DISPLAY “Gay, Lesbian” in question and “Gay and Lesbian” in Help
Screen
QA09_O15

Do you think of yourself as straight or heterosexual, as gay {,lesbian} or homosexual, or
bisexual?
[INTERVIEWER NOTE: IF NEEDED SAY, “Straight or Heterosexual people have sex with,
or are primarily attracted to people of the opposite sex, Gay {and Lesbian} people have sex
with or are primarily attracted to people of the same sex, and Bisexuals have sex with or are
attracted to people of both sexes.”]
STRAIGHT OR HETEROSEXUAL........................1
GAY, LESBIAN, OR HOMOSEXUAL ..................2
BISEXUAL...............................................................3
NOT SEXUAL/ CELIBATE/ NONE.......................4
OTHER (SPECIFY)______________......................5
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

CHIS 2009 OMB Questionnaire 73

HIV testing, Other STI Testing
QA09_O16
Have you ever been tested for HIV, the virus that causes AIDS?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8
PROGRAMMING NOTE QA09_O17:
IF QA09_O12 =0 OR QA09_O13=0 (NO SEXUAL PARTNERS LAST 12 MONTHS) GO TO
PROGRAMMING NOTE QA09_E1;
ELSE CONTINUE WITH QA09_O17;
QA09_O17

Now thinking about other sexually transmitted diseases besides HIV—In the past 12 months,
have you been tested for a sexually transmitted disease?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

PROGRAMMING NOTE QA09_O18:
IF FEMALE OR AAGE>50, GO TO QA09_E1;
ELSE CONTINUE WITH QA09_O18;
Infertility, Male Response
QA09_O18
Have you and a partner ever tried for more than 12 months to get pregnant but were not able
to?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON'T KNOW ....................................................... -8

CHIS 2009 OMB Questionnaire 74

MODULE P: Medical Home
ASKED OF ALL RESPONDENTS
QA09_P1

The next topics are about health insurance and health care.
Is there a place that you usually go to when you are sick or need advice about your health?
[INTERVIEWER NOTE: CIRCLE "3" OR "4" ONLY IF VOLUNTEERED. DO NOT
PROBE.]
YES...........................................................................1
NO.............................................................................2
DOCTOR/MY DOCTOR .........................................3
KAISER ....................................................................4
MORE THAN ONE PLACE ....................................5
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

[SKIP NEXT QUESTION]

[SKIP NEXT QUESTION]
[SKIP NEXT QUESTION]

PROGRAMMING NOTE Question QA09_P2:
ASKED OF RESPONDENTS WHO HAVE A PLACE TO GO WHEN SICK OR NEED ADVICE;
IF QUESTION QA09_P1 = 1 (YES) OR 5 (MORE THAN ONE PLACE) OR -7 (REF) OR -8 (DK), SAY
"What kind of place do you go to most often--a medical";
ELSE IF QA09_P1 = 3 (DOCTOR/MY DOCTOR), SAY "Is your doctor in a private";
ELSE IF QA09_P1 = 4 (KAISER) SELECT ANSER CHOICE “1” FOR QUESTION QA09_P2;
QA09_P2

{What kind of place do you go to most often—a medical/Is your doctor in a private} doctor's
office, a clinic or hospital clinic, an emergency room, or some other place?
DOCTOR'S OFFICE/KAISER/OTHER HMO ........1
CLINIC/HEALTH CENTER/HOSPITAL CLINIC.2
EMERGENCY ROOM.............................................3
VETERANS HEALTH CARE SYSTEM (VA).......4
SOME OTHER PLACE (SPECIFY):_________....91
NO ONE PLACE.....................................................92
REFUSED............................................................... -7
DON’T KNOW........................................................-8

ASK OF RESPONDENTS WHO HAVE A PLACE THEY USUALLY GO WHEN SICK OR NEED
ADVICE ABOUT THEIR HEALTH. [QUESTION QA09_P1 = 1, 3, 4, 5]
QA09_P3

Do you have a personal doctor or medical provider you see or talk to where you get your
care? This can be a general doctor, a specialist doctor, a physician assistant, a nurse, or other
health provider.
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

[SKIP NEXT QUESTION]
[SKIP NEXT QUESTION]
[SKIP NEXT QUESTION]

CHIS 2009 OMB Questionnaire 75

QA09_P4

In the last 12 months, how often did this medical provider seem to know the important
information about your medical history?
NEVER .....................................................................1
SOMETIMES ...........................................................2
OFTEN .....................................................................3
ALWAYS .................................................................4
REFUSED............................................................... -7
DON’T KNOW.........................................................8

PROGRAMMING NOTE QA09_P5 TO QA09_P6:
ASKED OF RESPONDENTS WHO HAVE A USUAL SOURCE OF CARE AND QA09_P3 = 1
QA09_P5

How often did your doctor seem informed and up-to-date about care you got from other
specialists? Would you say Always, Almost Always, Usually, Sometimes, Almost Never, or
Never?
NEVER .....................................................................1
ALMOST NEVER....................................................2
SOMETIMES ...........................................................3
USUALLY................................................................4
ALMOST ALWAYS................................................5
ALWAYS .................................................................6
NO OTHER SPECIALIST/DOES NOT APPLY.....7
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

QA09_P6

[SKIP NEXT QUESTION]
[SKIP NEXT QUESTION]
[SKIP NEXT QUESTION]

Is there anyone at your doctor’s office or clinic who helps coordinate your care with other
doctors and other health services such as tests or treatments?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

PROGRAMMING NOTE QA09_P7 TO QA09_P13:
ASKED OF RESPONDENTS WHO HAVE ASTHMA, DIABETES, HEART DISEASE, OR CANCER
AND HAD A DOCTOR VISIT IN THE PAST 12 MONTHS
QA09_P7

In the last 12 months, did you phone or e-mail the doctor’s office with a medical question?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

[SKIP NEXT QUESTION]
[SKIP NEXT QUESTION]
[SKIP NEXT QUESTION]

CHIS 2009 OMB Questionnaire 76

QA09_P8

If yes, when you phoned or e-mailed the doctor’s office, how often did you get an answer to
your medical question as soon as you needed it? Would you say Always, Almost Always,
Usually, Sometimes, Almost Never, or Never?
NEVER .....................................................................1
ALMOST NEVER....................................................2
SOMETIMES ...........................................................3
USUALLY................................................................4
ALMOST ALWAYS................................................5
ALWAYS .................................................................6
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

QA09_P9

In the past 12 months, how often were you able to get a referral to a specialist that you needed
to see for your {asthma/diabetes/heart disease/cancer}?
[Interviewer Note: Read all health conditions that apply to Respondent]
NEVER .....................................................................1
ALMOST NEVER....................................................2
SOMETIMES ...........................................................3
USUALLY................................................................4
ALMOST ALWAYS................................................5
ALWAYS .................................................................6
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

QA09_P10

In the past 12 months, how often did you get the care you, your doctor or other health
provider believed necessary for your {asthma/diabetes/heart disease/cancer}?
[Interviewer Note: Read all health conditions that apply to Respondent]
NEVER .....................................................................1
ALMOST NEVER....................................................2
SOMETIMES ...........................................................3
USUALLY................................................................4
ALMOST ALWAYS................................................5
ALWAYS .................................................................6
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

CHIS 2009 OMB Questionnaire 77

QA09_P11

In the past 12 months, how often did you get each person involved in your care to
communicate with each other about care for your [asthma/diabetes/heart disease/cancer]?
[Interviewer Note: Read all health conditions that apply to Respondent]
NEVER .....................................................................1
ALMOST NEVER....................................................2
SOMETIMES ...........................................................3
USUALLY................................................................4
ALMOST ALWAYS................................................5
ALWAYS .................................................................6
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

QA09_P12

In the past 12 months, how often did you get your doctor, nurse, or other health professionals
to discuss with you choices or options for your treatment?
NEVER .....................................................................1
ALMOST NEVER....................................................2
SOMETIMES ...........................................................3
USUALLY................................................................4
ALMOST ALWAYS................................................5
ALWAYS .................................................................6
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

QA09_P13

In the past 12 months, how often did you get your doctor, nurse, or other health professionals
to give you complete and accurate information about your medical tests?
NEVER .....................................................................1
ALMOST NEVER....................................................2
SOMETIMES ...........................................................3
USUALLY................................................................4
ALMOST ALWAYS................................................5
ALWAYS .................................................................6
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

CHIS 2009 OMB Questionnaire 78

PROGRAMMING NOTE QA09_P14 TO QA09_P16:
ASK IF R REPORTED ASTHMA OR DIABETES OR HEART DISEASE OR CANCER AND HAVE A
USUAL SOURCE OF CARE
QA09_P14

Have your doctors or nurses worked with you to develop a plan so that you know how to take
care of your [asthma/diabetes/heart disease/cancer]?
[Interviewer Note: Read all health conditions that apply to Respondent]
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

QA09_P15

[SKIP NEXT QUESTION]
[SKIP NEXT QUESTION]
[SKIP NEXT QUESTION]

Do you have a copy of this plan in writing?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

QA09_P16

Have your doctors or nurses worked with you to set personal goals for your
[asthma/diabetes/heart disease/cancer] treatment?
[Interviewer Note: Read all health conditions that apply to Respondent]
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

PROGRAMMING NOTE FOR QA09_P17 TO QA09_18:
ASKED ONLY IF R HAS REPORTED HAVING BEEN DIAGNOSED WITH CURRENT ASTHMA
QA09_P17

During the past 12 months, have you had to visit a hospital emergency room or urgent care
clinic because of your asthma?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

QA09_P18

During the past 12 months, were you admitted to the hospital overnight or longer for your
asthma?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

CHIS 2009 OMB Questionnaire 79

PROGRAMMING NOTE FOR QA09_P19 TO QA09_20:
ASKED ONLY IF R HAS REPORTED HAVING BEEN DIAGNOSED WITH DIABETES
QA09_P19

During the past 12 months, have you had to visit a hospital emergency room or urgent care
clinic because of your diabetes?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

QA09_P20

During the past 12 months, were you admitted to the hospital overnight or longer for your
diabetes?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

PROGRAMMING NOTE FOR QA09_P21 TO QA09_22:
ASKED ONLY IF R HAS REPORTED HAVING BEEN DIAGNOSED WITH HEART DISEASE
QA09_P21

During the past 12 months, have you had to visit a hospital emergency room or urgent care
clinic because of your heart disease?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

QA09_P22

During the past 12 months, were you admitted to the hospital overnight or longer for your
heart disease?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

PROGRAMMING NOTE FOR QA09_P23:
ASKED ONLY IF QA09_P19 =1 AND R IS ALSO DIAGNOSED WITH DIABETES/HEART DISEASE
(ONE, BOTH, OR ALL)
QA09_P23

When you visited the hospital ER or urgent care clinic for your asthma, was it also for your
[diabetes/heart disease/diabetes and heart disease]?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

CHIS 2009 OMB Questionnaire 80

PROGRAMMING NOTE FOR QA09_P24:
ASKED ONLY IF QA09_P20 =1 AND R IS ALSO DIAGNOSED WITH DIABETES/HEART DISEASE
(ONE, BOTH, OR ALL)
QA09_P24

When you stayed overnight or longer in the hospital for your asthma, was it also for your
{(diabetes),(heart disease),(diabetes and heart disease)}?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

PROGRAMMING NOTE FOR QA09_P25:
ASKED ONLY IF R HAS REPORTED HAVING GOING TO THE ER OR URGENT CARE CLINIC FOR
ASTHMA, DIABETES, HEART DISEASE (ONE, BOTH, OR ALL)
QA09_P25

Did you visit a hospital emergency room for your [asthma/diabetes/heart disease] because you
were unable to see your doctor?
[Interviewer Note: Read all health conditions that apply to Respondent]
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

PROGRAMMING NOTE FOR QA09_P26:
ASK OF ALL ADULT RESPONDENTS
QA09_P26

During the past 12 months, did you either delay or not get a medicine that a doctor prescribed
for you
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

[SKIP TO QA09_P30]
[SKIP TO QA09_P30]
[SKIP TO QA09_P30]

PROGRAMMING NOTE QA09_P27:
ASK IF R REPORTED ASTHMA OR DIABETES OR HEART DISEASE OR CANCER ANDQA)9_P26 =
1; ELSE CONTINUE WITH QA09_P28;
QA09_P27

Was this prescription for your [asthma/diabetes/heart disease/cancer]?
[Interviewer Note: Read all health conditions that apply to Respondent]
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

CHIS 2009 OMB Questionnaire 81

PROGRAMMING NOTE QA09_P28:
ASK OF ALL Rs WHO REPORT DELAYING OR NOT GETTING PRESCRIPTION
QA09_P28

Was the cost of the prescription or the payment you had to make a reason why you delayed or
did not get the prescription?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

QA09_P29

Were problems with your insurance plan or lack of insurance coverage a reason why you
delayed or did not get the prescription?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

PROGRAMMING NOTE QA09_P30:
ASKED OF ALL RESPONDENTS
QA09_P30

During the past 12 months, did you delay or not get any other medical care you felt you
needed—such as seeing a doctor, a specialist or other health professional?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

[SKIP TO QA09_P34]
[SKIP TO QA09_P34]
[SKIP TO QA09_P34]

PROGRAMMING NOTE QA09_P31:
ASK IF RESPONDENT REPORTED ASTHMA OR DIABETES OR HEART DISEASE OR CANCER
AND REPORTED DELAYING OR NOT GETTING MEDICAL CARE IN PAST 12 MONTHS;
ELSE CONTINUE WITH QA09_P32
QA09_P31

Was this medical care for your [asthma/diabetes/heart disease/cancer]?
[Interviewer Note: Read all health conditions that apply to Respondent]
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

CHIS 2009 OMB Questionnaire 82

QA09_P32

Was the cost of the care or the payment you had to make a reason why you delayed or did not
get the medical care you felt you needed?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

QA09_P33

Was lack of insurance coverage or problems with your insurance plan a reason why you
delayed or did not get the medical care you felt you needed?
YES...........................................................................1
NO.............................................................................2
REFUSED............................................................... -7
DON’T KNOW....................................................... -8

PROGRAMMING NOTE QA09_P34:
ASK IF R REPORTED ASTHMA OR DIABETES OR HEART DISEASE OR CANCER AND HAS A
USUAL SOURCE OF CARE
QA09_P34

In the last 12 months, how often did your doctor listen carefully to you? Was it never,
sometimes, usually, or always?
NEVER .....................................................................1
SOMETIMES ...........................................................2
OFTEN .....................................................................3
ALWAYS .................................................................4
REFUSED............................................................... -7
DON’T KNOW.........................................................8

QA09_P35

Do you feel comfortable asking your doctor questions?
YES...........................................................................1
NO.............................................................................2
NO REGULAR DOCTOR AT PLACE OF CARE..3
OTHER SPECIFY_________________ ..................4
REFUSED............................................................... -7
DON’T KNOW.........................................................8

QA09_P35

How confident are you that you can control and manage your health problems? Would you
say you are very confident, somewhat confident, not too confident, or not at all confident?
VERY CONFIDENT................................................1
SOMEWHAT CONFIDENT....................................2
NOT TOO CONFIDENT .........................................3
NOT AT ALL CONFIDENT ...................................4
REFUSED............................................................... -7
DON’T KNOW.........................................................8

CHIS 2009 OMB Questionnaire 83