NHANES Questionnaires and MEC Data Collection Forms

Questionnaires and

MEC Data Collection Forms

OMB No. 0920-0237 (expires December 31, 2011)

Assurance of Confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347). By law, every employee as well as every agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

NOTICE-Public reporting burden of this collection of information is estimated to average 3 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS E-11, Atlanta, GA 30333. ATTN: PRA (0920-0278).

Questionnaire TABLE OF CONTENTS

Sections	pags
SCREENER QUESTIONNAIRE …………………………………………………………………..	4
SCREENER MODULE #1 (SCQ)…………………………………………………………………………..	5
FAMILY RELATIONSHIP QUESTIONNAIRE ……………………………………………….	21
SCREENER MODULE #2 (SFQ)…………………………………………………………………………...	22
SAMPLE PERSON QUESTIONNAIRE………………………………………………………….	34
RESPONDENT SELECTION (RIQ)………………………………………………………………………..	35
INTRODUCTION AND VERIFICATION (IVQ)…………………………………………………………….	40
EARLY CHILDHOOD (ECQ)………………………………………………………………………………..	43
HOSPITAL UTILIZATION AND ACCESS TO CARE (HUQ)………………………………………..	46
IMMUNIZATION (IMQ)………………………………………………………………………………………	50
PHYSICAL FUNCTIONING (PFQ)………………………………………………………………………	52
MEDICAL CONDITIONS (MCQ)…………………………………………………………………………	57
KIDNEY CONDITIONS (KIQ)…………………………………………………………………………….	68
DIABETES (DIQ)……………………………………………………………………………………………..	69
BLOOD PRESSURE (BPQ)…………………………………………………………………………………	76
CARDIOVASCULAR DISEASE (CDQ)…………………………………………………………………….	81
OSTEOPOROSIS (OSQ)……………………………………………………………………………………	83
RESPIRATORY HEALTH AND DISEASE (RDQ)………………………………………………………...	89
AUDIOMETRY (AUQ)………………………………………………………………………………………..	93
Dermatology (DEQ)…………………………………………………………………………………….	97
ORAL HEALTH (OHQ)………………………………………………………………………………………	100
PHYSICAL ACTIVITY AND PHYSICAL FITNESS (PAQ)……………………………………………….	104
SLEEP DISORDERS (SLQ)…………………………………………………………………………………	112
Diet behavior &nutrition (DBQ)…………………………………………………………………	113
WEIGHT HISTORY (WHQ)………………………………………………………………………………….	129
SMOKING AND TOBACCO USE (SMQ)………………………………………………………………….	140
Coded occupation (OCQ)……………………………………………………………………………..	146
ACCULTURATION (ACQ)…………………………………………………………………………………..	155
Arthritis (ARQ)…………………………………………………………………………………………..	156
Dietary screener module (DTQ)…………………………………………………………………..	169
Demographics (DMQ)…………………………………………………………………………………...	194
Health insurance (HIQ)………………………………………………………………………………..	207
Dietary supplements and antacids (DSQ)…………………………………………………….	211
mailing address (MAQ)…………………………………………………………………….................	247
Post interview………………………………………………………………………………………….	250
FAMILY QUESTIONNAIRE………………………………………………………………………….	251
Demographics (DMQ)…………………………………………………………………………………...	252
HOUSING CHARACTERISTICS (HOQ)…………………………………………………………………..	256
SMOKING (SMQ)…………………………………………………………………………………………….	258
CONSUMER BEHAVIOR (CBQ)……………………………………………………………………………	260
Income (INQ)……………………………………………………............................................................	267
Food Security (FSQ)……………………………………………………………………………………	282
TRACKING AND TRACING (TTQ)…………………………………………………………………………	289
MEC QUESTIONNAIRE - CAPI……………………………………………………………………	292
RESPONDENT SELECTION (RIQ)………………………………………………………………………..	293
Volatile Toxicant (VTQ)……………………………………………………………………………….	295
PESTICIDE USE (PUQ)……………………………………………………………………………………..	300
Dietary screener module (DTQ)…………………………………………………………………..	301
CURRENT HEALTH STATUS (HSQ)……………………………………………………………………...	326
DEPRESSION SCREEN (DPQ)…………………………………………………………………………….	330
TOBACCO (SMQ)……………………………………………………………………………………………	334
ALCOHOL USE (ALQ)……………………………………………………………………………………….	340
REPRODUCTIVE HEALTH (RHQ)…………………………………………………………………………	342
KIDNEY CONDITIONS (KIQ)……………………………………………………………………………….	361
BOWEL HEALTH (BHQ)…………………………………………………………………………………….	364
PHYSICAL ACTIVITY AND PHYSICAL FITNESS (PAQ)……………………………………………….	368
WEIGHT HISTORY (WHQ)………………………………………………………………………………….	375
MEC Interview Critical Data Items (CDI)………………………………………………………..	380
MEC QUESTIONNAIRE – ACASI………………………………………………………………...	381
Introduction…………………………………………………………………………………………..…	382
Food security (FSQ)……………………………………………………………………………………	383
SMOKING (SMQ)…………………………………………………………………………………………….	385
ALCOHOL use (ALQ)……………………………………………………………………………………….	397
DRUG USE (DUQ)…………………………………………………………………………………………...	399
SEXUAL BEHAVIOR (SXQ)………………………………………………………………………………...	414
Reactions to race (RRQ)……………………………………………………………………………..	449
SPECIAL FOLLOW-UP QUESTIONNAIRES…………………………………………………	454
FLEXIBLE CONSUMER BEHAVIOR SURVEY PHONE FOLLOW-UP MODULE (CBQ) …………..	455
HANES Hepatitis C Follow-Up Questionnaire (HCQ)………………………………………..	486
MEC dATA COLLECTION fORMS……………………………………………………...………	491

SCREENER QUESTIONNAIRE

SCREENER MODULE #1 (SCQ)

SCQ_INTRO010 Hello, I’m {INTERVIEWER’S NAME} and we are conducting a survey for the ”U.S. Public Health Service” may need to be changed to Centers for Disease Control and Prevention (CDC)

SHOW ID CARD.

A letter was sent to you recently explaining a survey which is called the National Health and Nutrition Examination Survey and is about your family’s health.

IF RESIDENT DOES NOT REMEMBER LETTER, HAND NEW COPY.

All the information that you give us is voluntary and will be kept in the strictest confidence. Your name will not be attached to any of your answers without your specific permission.

SCQ_INTRO020 -- Omitted

SCQ.025 -- Omitted

SCQ.027 INTERVIEWER: IS THIS A DORMITORY ROOM?

YES 1

NO 2

DK 9

RF 7

SCQ_CHECK030 -- Omitted

SCQ.040 -- Omitted

SCQ_CHECK050 – Omitted

SCQ.060 -- Omitted

SCQ.070 I would like to verify your address. Please give me your complete address.

{#} {DIRECTION} {STREET NAME} {STREET/ROAD/AVENUE} {DIRECTION} {#}

{PO BOX} {RURAL ROUTE #} {RURAL ROUTE BOX} {CITY} {STATE} { ZIP}

NO (WRONG ADDRESS) 1 (SCQ_END5)

YES (CORRECTIONS) 2 (SCQ.080)

YES 3 (SCQ.090)

SCQ.080 PRESENT “ADDRESS UPDATE SCREEN”. REVIEW THE ADDRESS FIELDS AND MAKE CHANGES AS NECESSARY, THEN GO TO SCQ.090.

PROGRAMMER SPECS: If “YES (CORRECTIONS)” is selected and none of the address fields are modified, auto-backcode the response to “YES” and go to SCQ.090. The field for state may not be updated.

SCQ.090 To begin, how many people live in this household? Please do not include anyone who usually lives somewhere else.

________

NUMBER

DK 99

RF 77

SCQ.100 – 180. Disallow DK and RF in "FIRST" name field. Entry in this field should be a unique identifier for the person.

PROGRAMMER SPECS: After entry, upon exiting the screen, post information entered on this screen on line one of the HH composition matrix in the “name” field.

SCQ.101 Display question text above matrix with cursor in the cell labeled “gender”.

SCQ.101 ASK IF NOT OBVIOUS.

Is {NAME} male or female?

MALE 1

FEMALE 2

DK 9

RF 7

PROGRAMMER SPEC: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.

SCQ_CHECK110 If SCQ.090 = “1”, go to SCQ.145; ELSE, GO TO SCQ.130.

SCQ.120 -- Omitted.

SCQ.130 - 180 Display HH composition matrix: name and gender fields. After a name has been entered, post the name on the matrix and display the text of the gender question above the matrix with the cursor residing on the appropriate cell within the matrix.

SCQ.145 Dynamic display of HH composition matrix: first, middle, last name, and gender. If total # of people enumerated on the HH roster =1, display “person”; else display “people.”

SCQ.145 I have {TOTAL # OF PERSONS ENUMERATED} {person/people} living here --

[READ NAMES LISTED BELOW.]

SCQ.150 – 181. The sweep questions should be displayed on a single screen as appears on the example below. A "yes" response to the sweep question brings up a screen for entry of name(s) and gender. Upon exiting the name/gender screen, the cursor should return to the screen of sweep questions with the cursor residing on the next line (question) that requires an answer. If all the questions have been answered, go to SCQ.190.

SCQ.150, 160, 170, 180.

Have I missed . . .

SCQ.150 . . . any babies or small children?

SCQ.160 . . . any lodgers, boarders, or persons in your employ who live here?

SCQ.170 . . . anyone who usually lives here but is now away from home?

SCQ.180 . . . anyone else living or staying here?

YES 1 (SCQ.150N, 160N, 170N, 180N)

NO 2 (SCQ.160, 170, 180, 190)

DK 9 (SCQ.160, 170, 180, 190)

RF 7 (SCQ.160, 170, 180, 190)

SCQ.150N (What are their names?)

PROBE: Is (he/she) a “Junior”, “Senior”, “the 3rd” or something like that? (What is that?)

PROBE: Any others?

FIRST MIDDLE LAST SUFFIX

PROGRAMMER SPECS: After entry in SCQ.150 the cursor should move to the gender cell (SCQ.151) and display the gender question. Do not allow exit from the matrix unless all gender cells are filled. After exiting from the name/gender screen, the next question would be SCQ.160.

SCQ.151 Display question text above matrix with cursor in the cell labeled “gender”.

SCQ.151 ASK IF NOT OBVIOUS.

Is {NAME} male or female?

MALE 1

FEMALE 2

DK 9

RF 7

PROGRAMMER SPEC: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.

SCQ.160N (What are their names?)

PROBE: Any others?

FIRST MIDDLE LAST SUFFIX

DK 9

RF 7

PROGRAMMER SPECS: After entry in SCQ.160 the cursor should move to the gender cell (SCQ.161) and display the gender question. Do not allow exit from the matrix unless all gender cells are filled. After exiting from the name/gender screen, the next question would be SCQ.170.

SCQ.161 Display question text above matrix with cursor in the cell labeled “gender”.

SCQ.161 ASK IF NOT OBVIOUS:

Is {NAME} male or female?

MALE 1

FEMALE 2

DK 9

RF 7

PROGRAMMER SPEC: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.

SCQ.170N (What are their names?)

PROBE: Any others?

FIRST MIDDLE LAST SUFFIX

DK 9

RF 7

PROGRAMMER SPECS: After entry in SCQ.170 the cursor should move to the gender cell (SCQ.171) and display the gender question. Do not allow exit from the matrix unless all gender cells are filled. After exiting from the name/gender screen, the next question would be SCQ.180.

SCQ.171 Display question text above matrix with cursor in the cell labeled “gender”.

SCQ.171 ASK IF NOT OBVIOUS:

Is {NAME} male or female?

MALE 1

FEMALE 2

DK 9

RF 7

PROGRAMMER SPEC: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.

SCQ.180N (What are their names?)

PROBE: Any others?

FIRST MIDDLE LAST SUFFIX

DK 9

RF 7

PROGRAMMER SPECS: After entry in SCQ.180 the cursor should move to the gender cell (SCQ.181) and display the gender question. Do not allow exit from the matrix unless all gender cells are filled. After exiting from the name/gender screen, the next question would be SCQ.190.

SCQ.181 Display question text above matrix with cursor in the cell labeled “gender”.

SCQ.181 ASK IF NOT OBVIOUS:

Is {NAME} male or female?

MALE 1

FEMALE 2

DK 9

RF 7

PROGRAMMER SPEC: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.

SCQ.190 [VERIFY HOUSEHOLD MEMBERS BY READING NAMES LISTED BELOW.]

PROGRAMMER SPECS: The application should allow the interviewer to add or delete names or rows from the HH composition matrix, as necessary, based on respondent’s confirmation of the persons who have been enumerated.

SCQ_CHECK191 APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR HISPANICS, BLACKS, WHITE/OTHER NON-LOW INCOME OR WHITE/OTHER LOW INCOME, GO TO SCQ.430.

OTHERWISE, CONTINUE.

SCQ_CHECK193 IF SCQ.027 = YES (1), CODE SCQ.195 AS DORM ROOM (3) AND SKIP TO SCQ.220.

SCQ.195 Do {you/any of the persons in this household} have a home anywhere else?

STUDENTS LIVING AWAY AT SCHOOL ARE CONSIDERED TO HAVE A HOME SOMEWHERE ELSE.

YES 1 (SCQ.200)

NO 2 (SCQ.220)

DK 9 (SCQ.210)

RF 7 (SCQ.210)

SCQ.200 Display question text above HH composition matrix.

SCQ.200 (Who is that?)

SELECT MEMBERS WITH HOME ELSEWHERE.

PROBE: Anyone else?

PROGRAMMER SPECS: The cursor should reside in the column “Other Home”. The default fill for this column should be “NO”. However, the default can be toggled to “YES” by moving the cursor to the “Other Home” cell associated with the person who has a second residence, and selecting “YES”. If none of the “Other Home” cells have been set to “YES”, auto-backcode the response to SCQ.195 to “NO” and proceed to SCQ.220.

SCQ.210 Display question text above HH composition matrix, replacing SCQ.200.

SCQ.210 Where {do you/does {NAME}} usually live and sleep; here or somewhere else?

HERE 1

SOMEWHERE ELSE 2

DK 9

RF 7

PROGRAMMER SPECS: If “1”, “9”, OR “7” leave person on HH composition matrix; else, if “2” and this is a single person household, or if all household members are "2", the household is “ineligible” and the screener is terminated after the collection of the telephone number (SCQ.430); else if “2” and the household is more than a single person household, set a flag to indicate this person’s permanent residence was somewhere else. The flag is an indication that on all future displays of the HH composition matrix, this person (and all person-level data) will not be displayed.

In the event that the person being flagged as “living elsewhere” is the reference person, identify a new reference person as the next person who appears on the enumeration table and “living here.”

SCQ.220 Are {you/any of the persons in this household} now on full-time active duty with the Armed Forces of the United States?

YES 1 (SCQ.230)

NO 2 (SCQ.242)

DK 9 (SCQ.242)

RF 7 (SCQ.242)

PROGRAMMER SPECS: If coded “1” and this is a single person household, or if all household members are "1", the household is “ineligible” and the screener is terminated after the collection of the telephone number (SCQ.430); else, if the household is more than a single person household, the skips should be followed as specified above.

SCQ.230 Display question text above HH composition matrix.

SCQ.230 (Who is that?)

SELECT ACTIVE MILITARY MEMBERS.

PROBE: Anyone else?

PROGRAMMER SPECS: The cursor should reside in the column “ACTIVE MIL”. The default for this column should be “NO”. However, when on this question, the default can be toggled to “YES” by moving the cursor to the “ACTIVE MIL” cell associated with the person identified and selecting “YES”. If none of the “ACTIVE MIL” cells have been set to “YES”, auto-backcode the response to SCQ.220 to “NO” and go to SCQ.242.

SCQ.240 Display question text above HH composition matrix, replacing SCQ.230.

SCQ.240 Where {do you/does {NAME}} usually live and sleep; here or some where else?

HERE 1

SOMEWHERE ELSE 2

DK 9

RF 7

PROGRAMMER SPECS: If “1”, “9”, OR “7” leave person on HH composition matrix; Do not flag for sampling.

If “2”, set a flag to indicate person’s permanent residence was somewhere else. The flag is an indication that on all future displays of the HH composition matrix, this person (and all person-level data) will not be displayed.

In the event that the person being flagged as “living elsewhere” is the reference person, identify a new reference person as the next person who appears on the enumeration table and “living here”.

SCQ.242 THESE ARE THE MEMBERS OF THE DU WHO HAVE BEEN LISTED AS HH MEMBERS.

{NAME GENDER}

SCQ_CHECK245 APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR HISPANICS, BLACKS, WHITE/OTHER NON-LOW INCOME OR WHITE/OTHER LOW INCOME, GO TO SCQ.430.

OTHERWISE, CONTINUE.

SCQ.260 – 303 Fill “NAME” with the components of the “name” cell that uniquely identifies the person; at a minimum this is “first” name.

SCQ.260 Display question text above the matrix.

Change to NCHS-HIS Model:

[Do you/Does NAME] consider [yourself/himself/herself] to be Hispanic or Latino?

READ IF NECESSARY: Where do your ancestors come from?

Puerto Rican

Cuban/Cuban American

Dominican (Republic)

Mexican/Mexican American

Central/South American

Other Latin American

Other Hispanic or Latino

YES 1

NO 2

DK 9

RF 7

Help Screen: A help screen will be placed at this question. The help screen will list all countries associated with Hispanic or Latino origin or ancestry. This help screen will be a duplicate of the one NCHS proposed for the DMQ section of the SP Questionnaire.

PROGRAMMER SPECS: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.

SCQ.265 WARNING: REVIEW ETHNICITY FOR EACH PERSON! SAMPLING ALGORITHM WILL BE APPLIED.

{NAME ETHNICITY}

PROGRAMMER SPECS: Display name and ethnicity as determined at SCQ.260 for each enumerated person. Interviewer may back-up to correct.

SCQ.270 Display SCQ.270 above the matrix.

SCQ.270 SHOW CARD 2

What race do you consider {yourself/NAME} to be? Please select one or more.

CHECK ALL THAT APPLY.

AMERICAN INDIAN OR ALASKAN NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR PACIFIC ISLANDER 4

WHITE 5

OTHER 6

DK 9

RF 7

PROGRAMMER SPECS:

Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.

SCQ.275 WARNING! REVIEW RACE FOR EACH PERSON! SAMPLING ALGORITHM WILL BE APPLIED.

{NAME RACE}

PROGRAMMER SPECS: Display name and race(s) as determined at SCQ.270 for each enumerated person. Interviewer may back-up to correct.

SCQ.280 – omitted

SCQ_CHECK285 APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR HISPANICS, BLACKS, WHITE/OTHER NON-LOW INCOME OR WHITE/OTHER LOW INCOME, GO TO SCQ.430.

OTHERWISE, CONTINUE.

SCQ.290 Display question text above the matrix with cursor residing in the first DOB cell on the matrix.

SCQ.290 What is {your/{NAME}’s} birthdate?

____ ____ ____

MM DD YYYY (SCQ.291)

DK 9 (SCQ.292)

RF 7 (SCQ.292)

PROGRAMMER SPECS: If date of birth is specified, calculate age and post in the “age” cell for the appropriate person with the cursor residing in that cell and SCQ.291 displayed above the matrix; else go to SCQ.292. Fill DK and RF as follows:

DK RF

MM 999 777

DD 999 777

YYYY 9999 7777

SCQ.291 Display question text above the matrix with cursor residing in appropriate “age” cell on the matrix.

SCQ.291 So {you are/{NAME} is} {AGE AS CALCULATED FROM DOB}?

IF NECESSARY, RE-ENTER CORRECT AGE. (SCQ.301)

PROGRAMMER SPECS: If age is re-entered by the interviewer, the application should adjust DOB.

SCQ.292 Display question text above the matrix with cursor residing in appropriate “age” cell on the matrix.

SCQ.292 About how old {are you/is {NAME}}?

_____

AGE (SCQ.301)

DK 999 (SCQ.300)

RF 777 (SCQ.300)

IF AGE IS LESS THAN 12 MONTHS, ENTER “0”.

PROGRAMMER SPEC: Post the age collected in SCQ.292 to the “age” cell in the matrix.

SCQ.300 Age ranges will change

Display question text above the matrix with cursor residing in appropriate “age” cell on the matrix. Display the following age ranges: for Sampled Race/Ethnicity = Whites/Others, use “less than 1 year old, 1 - 2, 3 - 5, 6 - 11, 12 - 15, 16 - 19, 20 - 29, 30 - 39, 40 - 49, 50 - 59, 60 - 69, 70 - 79, or 80 years or older”; for Sampled Race/Ethnicity = Hispanic or Black, use "less than 1 year old, 1-2, 3-5, 6-11, 12-15, 16-19, 20-39, 40-59, 60 years or older".

SCQ.300 Would you say {you are/{NAME} is}...

{{AGE RANGES FOR SAMPLED RACE/ETHNICITY = BLACK OR HISPANIC}/{AGE RANGES FOR SAMPLED RACE/ETHNICITY = WHITES/OTHERS; DK/RF RACE/ETHNICITY}}

DK 9999

RF 7777

PROGRAMMER SPEC: Provide a soft range edit check the first time a DK or RF is entered. Accept the second entry.

SCQ.301 WARNING: REVIEW AGE FOR EACH PERSON! SAMPLING ALGORITHM WILL BE APPLIED.

{NAME AGE}

PROGRAMMER SPECS: Display name and age as determined at SCQ.291, SCQ.292, or SCQ.300 for each enumerated person. Interviewer may back-up to correct.

SCQ_CHECK303 APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR HISPANICS, BLACKS, WHITE/OTHER NON-LOW INCOME OR WHITE/OTHER LOW INCOME, GO TO SCQ.430.

OTHERWISE, CONTINUE.

SCQ_CHECK313 If the reference person is not eligible to be the reference person based on where s/he usually lives, identification of a new reference person is required. Re-apply the reference person edit logic to identify the reference person as the first person on the enumeration table who is > 18 years old; else, if no one on the enumeration table is age 18 or older, identify the reference person as the oldest person in the household for whom this is the primary residence.

APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR HISPANICS, BLACKS, WHITE/OTHER NON-LOW INCOME OR WHITE/OTHER LOW INCOME, GO TO SCQ.430.

OTHERWISE, CONTINUE.

SCQ_CHECK315 IF SAMPLING MESSAGE FOR LOW INCOME SET, CONTINUE.

OTHERWISE, GO TO SCQ_CHECK355.

SCQ_CHECK320 IF SCQ.027 = YES (1), GO TO SCQ_CHECK355.

OTHERWISE, CONTINUE.

SCQ_CHECK325 IF ALL HOUSEHOLD MEMBER'S SAMPLED RACE/ETHNICITY = HISPANIC (1) OR BLACK (2), GO TO SCQ_CHECK355.

IF ANY HOUSEHOLD MEMBER'S SAMPLED RACE/ETHNICITY = WHITE/OTHER (3) AND ONE OR MORE PERSON'S IN THE HOUSEHOLD COULD MEET THE LOW INCOME SAMPLING CRITERIA AND THOSE PERSONS ARE NOT ALL ACTIVE MILITARY, CONTINUE.

OTHERWISE, GO TO SCQ_CHECK355.

SCQ_CHECK330 IF ALL HOUSEHOLD MEMBERS WHO WOULD MEET THE LOW INCOME SAMPLING CRITERIA ARE ALREADY SAMPLED BASED ON GENDER, ETHNICITY, RACE, AGE,OR ARE ACTIVE MILITARY, GO TO SCQ_CHECK355.

OTHERWISE, CONTINUE.

SCQ.340 Please think for a moment about the various sources from which the members of this household received income during the last 12 months, that is from {CURRENT MONTH} {LAST YEAR IN 4-DIGITS} to {LAST MONTH} {CURRENT YEAR IN 4-DIGITS}. Thinking about all the sources of income, please tell me whether the total income received by the members of this household during the last 12 months was more or less than {DISPLAY EXACT THRESHOLD DOLLAR AMOUNT FOR # OF PEOPLE LIVING IN HOUSEHOLD}.

IF INCOME EQUAL TO {DISPLAY EXACT THRESHOLD DOLLAR AMOUNT FOR # OF PEOPLE LIVING IN HOUSEHOLD}, CODE 'LESS'.

MORE 1 (SCQ_CHECK355)

LESS 2 (SCQ_CHECK355)

DK 9

RF 7

SCQ_CHECK345 IF ANY CHILDREN IN HOUSEHOLD <6 YEARS OLD, CONTINUE.

OTHERWISE, GO TO SCQ_CHECK 355.

SCQ_CHECK347 IF ANY MALES IN HOUSEHOLD >= 18 YEARS OLD, GO TO SCQ_CHECK355.

OTHERWISE, TREAT HOUSEHOLD AS LOW INCOME FOR PURPOSES OF SAMPLING.

SCQ_CHECK355 IF ANY INDIVIDUAL MEETS THE SPECIFIED SAMPLING CRITERIA BASED ON GENDER, ETHNICITY, RACE, AGE, STATUS, OR INCOME LEVEL AND IS NOT ON ACTIVE MILITARY STATUS, GO TO SCQ.370.

IF SAMPLING FOR ALL PARTICIPANTS IS INCONCLUSIVE DUE TO CONFIRMED MISSING DATA (DK/RF) IN THE CRITICAL SAMPLING VARIABLES, GO TO SCQ.430, THEN TERMINATE THE SCREENER WITH AN ASSIGNED STATUS OF “INCOMPLETE”.

OTHERWISE, GO TO SCQ.430.

SCQ.370 THIS HOUSEHOLD HAS ELIGIBLE SURVEY PARTICIPANTS.

THE ELIGIBLE PERSON(S) SAMPLED IN THIS HOUSEHOLD ARE:

{UNIQUE NAMES, GENDERS, AGES OF SAMPLED PERSONS}

PROGRAMMER SPECS: Since the sampling algorithm has been run for the last time, back-up is not allowed beyond this check.

SCQ.420 Is {REFERENCE PERSON}’s mailing address the same as {his/her} street address?

YES 1 (SCQ.430)

NO 2 (SCQ.425)

DK 9 (SCQ.430)

RF 7 (SCQ.430)

SCQ.425 Please give me {REFERENCE PERSON}'s complete mailing address.

{#} {DIRECTION} {STREET NAME} {STREET/ROAD/AVENUE} {DIRECTION} {#}

{PO BOX} {RURAL ROUTE #} {RURAL ROUTE BOX} {CITY} {STATE} { ZIP}

PROGRAMMER SPECS: Display the complete address of the household as collected in SCQ.070 or SCQ.080 and allow updates in all fields. If updates are made, store this address as the mailing address. If no updates are made, reset SCQ.420 to “NO” and continue to SCQ.430.

SCQ.430 Please give me your home telephone number in case my office wants to check my work.

( ) - ______ - __________ - __________

HOME TELEPHONE NUMBER (SCQ.440)

NO HOME TELEPHONE 2 (SCQ.460)

DK 9 (SCQ.460)

RF 7 (SCQ.460)

PROGRAMMER SPECS: Fill DK and RF as follows:

DK RF

Area code 999 777

Exchange 999 777

Number 9999 7777

Extension 9999 7777

The field for "extension" should be allowed to be blank.

SCQ.440 In whose name is the telephone listed?

________ ________

FIRST LAST (END_CHECK)

UNLISTED 1 (END_CHECK)

NOT ON LIST 2 (SCQ.445)

DK 9 (END_CHECK)

RF 7 (END_CHECK)

SCQ.445 [In whose name is the telephone listed?]

________ ________

FIRST LAST (END_CHECK)

SCQ.460 Is there another number where you can be reached?

( ) - ______ - __________ - __________

OTHER TELEPHONE NUMBER (SCQ.461)

NO 2 (END_CHECK)

DK 9 (END_CHECK)

RF 7 (END_CHECK)

PROGRAMMER SPECS: Fill DK and RF as follows:

DK RF

Area code 999 777

Exchange 999 777

Number 9999 7777

Extension 9999 7777

The field for "extension" should be allowed to be blank.

SCQ.461 Where is that telephone located?

WORK 1

RELATIVE’S HOME 2

NEIGHBOR’S HOME 3

CELL PHONE 4

OTHER 5

DK 9

RF 7

END_CHECK If this is an ineligible household, go to SCQ_END1; else

If this is an eligible household, go to SCQ_END2; else

If this is a break-off, go to SCQ_END3, then require entry of disposition; else

If missing critical sampling data, go to SCQ_END4; else

If SCQ.070 (address verification) is “NO (WRONG ADDRESS)", go to SCQ_END5.

SCQ_END1 Thank you.

SCQ_END2 Thank you. This household has eligible survey participants.

[READ NAMES LISTED BELOW.]

{UNIQUE NAMES, GENDERS, AGES OF SAMPLE PERSONS}

[IF APPROPRIATE, EXPLAIN PARTICIPATION IN STUDY TO RESPONDENT.]

PROGRAMMER SPECS: After exiting from this screen, launch module 2 of the screener, collecting relationship information.

SCQ_END3 Thank you.

PROGRAMMER SPECS: After exiting from this screen, present the list of dispositions and do not allow exit from the application without entry of a disposition.

SCQ_END4 Thank you.

[EXPLAIN TO RESPONDENT THAT YOU WILL NEED TO RETURN TO THE HOUSEHOLD TO COLLECT CRITICAL INFORMATION THAT WAS NOT PROVIDED THIS TIME.]

SCQ_END5 Thank you.

LOCATE CORRECT ADDRESS AND RESTART SCREENER.

FAMILY RELATIONSHIP QUESTIONNAIRE

SCREENER MODULE #2 (SFQ)

TO BE ADMINISTERED TO ALL ELIGIBLE HOUSEHOLDS

BOX 1

CHECK ITEM SFQ.001:

IF ONLY 1 PERSON HOUSEHOLD, CODE PERSON AS "REFERENCE PERSON", CODE RELATIONSHIP AS "SELF", ASSIGN FAMILY #1 TO PERSON AND GO TO END OF SECTION.

OTHERWISE, CONTINUE.

BOX 2

CHECK ITEM SFQ.004:

CODE FIRST PERSON LISTED ON H.H. MATRIX WHOSE AGE IS > 18 AND IS NOT FLAGGED AS LIVING "SOMEWHERE ELSE" AS "REFERENCE PERSON", HEAD OF FAMILY #1 AND RELATIONSHIP AS "SELF".

BOX 3

LOOP 1:

ASK SFQ.010 – SFQ.040 AS APPROPRIATE FOR EACH PERSON {P} LISTED BELOW REFERENCE PERSON ON THE HOUSEHOLD MATRIX.

SFQ.010 {The next questions are about family relationships.}

What is {PERSON'S) relationship to {REFERENCE PERSON}?

HAND CARD SFQ1

SPOUSE (HUSBAND/WIFE) 01

UNMARRIED PARTNER 02

CHILD (BIOLOGICAL/ADOPTIVE/IN-LAW/

STEP/FOSTER) 03

CHILD OF PARTNER 04

GRANDCHILD 05

PARENT (BIOLOGICAL/ADOPTIVE/

IN-LAW/STEP/FOSTER) 06

BROTHER/SISTER (BIOLOGICAL/

ADOPTIVE/IN-LAW/STEP/FOSTER) 07

GRANDMOTHER/GRANDFATHER 08

AUNT/UNCLE 09

NIECE/NEPHEW 10

OTHER RELATIVE 11

HOUSEMATE/ROOMMATE 12

ROOMER/BOARDER 13

OTHER NONRELATIVE 14

LEGAL GUARDIAN 15

WARD 16

REFUSED 77

DON'T KNOW 99

BOX 4

CHECK ITEM SFQ.015:

RELATIONSHIP CODES FROM SFQ.010. NOTE RP ON MATRIX MAY HAVE MULTIPLE RELATIONSHIP CODES.

"RP" = REFERENCE PERSON

"P" = PERSON = MEMBERS OF HOUSEHOLD

n IF CODE 1 (SPOUSE), CHECK GENDER OF BOTH {RP} AND {P} AND CODE {RP} AS HUSBAND OR WIFE OF {P} DEPENDING ON GENDER
AND {P} AS HUSBAND OR WIFE OF {RP} DEPENDING ON GENDER.

n IF CODE 2 (UNMARRIED PARTNER), CHECK GENDER OF BOTH {RP} AND
{P} AND CODE {RP} AS UNMARRIED MALE OR FEMALE PARTNER OF {P}
DEPENDING ON GENDER AND {P} AS UNMARRIED MALE OR FEMALE PARTNER OF {RP} DEPENDING ON GENDER.

n IF CODE 3 (CHILD), CHECK GENDER OF {P} AND {RP} AND CODE {RP} AS MOTHER OR FATHER OF {P} DEPENDING ON GENDER AND {P} AS SON OR DAUGHTER OF {RP} DEPENDING ON GENDER.

n IF CODE 4 (CHILD OF PARTNER), CODE {RP} AS PARTNER OF CHILD'S
PARENT AND CODE {P} AS CHILD OF PARTNER.

n IF CODE 5 (GRANDCHILD), CODE {RP} AS GRANDPARENT OF {P} AND
{P} AS GRANDCHILD OF {RP}.

n IF CODE 6 (PARENT), CHECK GENDER OF BOTH {RP} AND {P} AND
CODE {RP} AS SON OR DAUGHTER OF {P} DEPENDING ON GENDER AND CODE {P} AS MOTHER OR FATHER OF {RP} DEPENDING ON GENDER.

n IF CODE 7 (BROTHER/SISTER), CHECK GENDER OF BOTH {RP} AND {P}
AND CODE {RP} AS BROTHER/SISTER OF {P} DEPENDING ON GENDER
AND {P} AS BROTHER/SISTER OF {RP} DEPENDING ON GENDER.

n IF CODE 8 (GRANDPARENT), CODE {RP} AS GRANDCHILD OF {RP} AND
{P} AS GRANDPARENT OF {P}.

n IF CODE 9 (AUNT/UNCLE), CODE {RP} AS NIECE/NEPHEW OF {P} AND
{P} AS AUNT/UNCLE OF {RP}.

n IF CODE 10 (NIECE/NEPHEW), CODE {RP} AS AUNT/UNCLE OF {P} AND
{P} AS NIECE/NEPHEW OF {RP}.

n IF CODE 11 (OTHER RELATIVE), CODE {RP} AS OTHER RELATIVE OF {P}
AND {P} AS OTHER RELATIVE OF {RP}.

n IF CODE 12 (HOUSEMATE/ROOMMATE), CODE {RP} AS HOUSEMATE/
ROOMMATE OF {P} AND {P} AS HOUSEMATE/ROOMMATE OF {RP}.

n IF CODE 13 (ROOMER/BOARDER), CODE {RP} AS OTHER NONRELATIVE
OF {P} AND {P} AS ROOMER/BOARDER OF {RP}.

n IF CODE 14 (OTHER NONRELATIVE), CODE {RP} AS OTHER
NONRELATIVE OF {P} AND {P} AS OTHER NONRELATIVE OF {RP}.

n IF CODE 15 (LEGAL GUARDIAN), CODE {RP} AS WARD OF {P} AND {P} AS
LEGAL GUARDIAN OF {RP}.

n IF CODE 16 (WARD), CODE {RP} AS LEGAL GUARDIAN OF {P} AND {P} AS
WARD OF {RP}.

n IF CODE 77 OR CODE 99, CODE {RP} AS OTHER RELATIVE OF {P} AND
{P} AS OTHER RELATIVE OF {RP}.

BOX 5

CHECK ITEM SFQ.017:

IF {P} RELATIONSHIP IN SFQ.010 = CHILD (CODE 3), CONTINUE.

OTHERWISE, SKIP TO BOX 6.

SFQ.020 Is {PERSON}, {REFERENCE PERSON'S} biological (natural), adoptive, step, foster {son/daughter} or (son/daughter)-in-law?

BIOLOGICAL (NATURAL) {SON/
DAUGHTER} 1

ADOPTIVE {SON/DAUGHTER} 2

STEP {SON/DAUGHTER} 3

FOSTER {SON/DAUGHTER} 4

{SON/DAUGHTER}-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 6

CHECK ITEM SFQ.025:

IF {P} RELATIONSHIP IN SFQ.010 = PARENT (CODE 6), CONTINUE.

OTHERWISE, GO TO BOX 7.

SFQ.030 Is {PERSON}, {REFERENCE PERSON'S} biological (natural), adoptive, step, or foster parent or {mother/father}-in-law?

BIOLOGICAL (NATURAL) PARENT 1

ADOPTIVE PARENT 2

STEP PARENT 3

FOSTER PARENT 4

{MOTHER/FATHER}-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 7

CHECK ITEM SFQ.035:

IF {P} RELATIONSHIP IN SFQ.010 = BROTHER/SISTER (CODE 7), CONTINUE.

OTHERWISE, GO TO BOX 8.

SFQ.040 Is {PERSON}, {REFERENCE PERSON'S} full, half, adoptive, step, or foster {brother/sister} or {brother/sister}-in-law?

FULL {BROTHER/SISTER} 1

HALF {BROTHER/SISTER} 2

ADOPTED {BROTHER/SISTER} 3

STEP {BROTHER/SISTER} 4

FOSTER {BROTHER/SISTER} 5

{BROTHER/SISTER}-IN-LAW 6

REFUSED 7

DON'T KNOW 9

BOX 8

END LOOP 1:

ASK SFQ.010 – SFQ.040 AS APPROPRIATE FOR NEXT PERSON {P} LISTED BELOW REFERENCE PERSON ON THE HOUSEHOLD MATRIX.

IF NO NEXT PERSON, GO TO BOX 9.

BOX 9

CHECK ITEM SFQ.043:

IF ALL PERSONS IN HOUSEHOLD ARE RELATED (HAVE RELATIONSHIP CODES ASSOCIATED WITH CODES 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15, 16, 77 OR 99 IN SFQ.010 OR SFQ.070), GO TO BOX 20.

OTHERWISE, CONTINUE WITH BOX 10.

BOX 10

CHECK ITEM SFQ.045:

CODE FIRST PERSON REMAINING UNRELATED TO REFERENCE PERSON AND HEADS OF ADDITIONAL FAMILIES AND WHOSE AGE IS >18 AS HEAD OF NEXT FAMILY {H OF F} AS APPROPRIATE (#2, 3, 4, ETC.), AND GO TO BOX 11.

IF NO PERSONS AGE > 18, CODE OLDEST PERSON FROM THIS GROUP AS HEAD OF FAMILY.

BOX 11

CHECK ITEM SFQ.047:

IF MORE THAN ONE PERSON CODED AS UNRELATED, CONTINUE WITH BOX 12.

OTHERWISE, GO TO BOX 20.

BOX 12

LOOP 2:

ASK SFQ.050 – SFQ.100 FOR FIRST (NEXT) HEAD OF FAMILY.

SFQ.050 Now I would like to talk about those persons in the household who are not related to {REFERENCE PERSON/REFERENCE PERSON OR HEADS OF FAMILY}. That is {LIST ALL PERSONS IN HOUSEHOLD NOT RELATED TO {REFERENCE PERSON/REFERENCE PERSON OR HEADS OF FAMILY}.

DISPLAY NAME OF REFERENCE PERSON IF THIS IS THE FIRST TIME THIS QUESTION IS ASKED. DISPLAY NAMES OF REFERENCE PERSON AND ALL HEADS OF ADDITIONAL FAMILIES IF THIS IS NOT THE FIRST TIME QUESTION IS ASKED.

Is {HEAD OF FAMILY #2, 3, 4, ETC} related to anyone in the household?

YES 1

NO 2 (BOX 19)

REFUSED 7

DON'T KNOW 9

SFQ.060 Who is {HEAD OF FAMILY #2, 3, 4, ETC. FROM BOX 10} related to? {DISPLAY LIST OF NAMES OF ALL PERSONS WHO ARE NOT REFERENCE PERSON, OR HEAD OF FAMILY AND WHO ARE NOT RELATED TO ANYONE ELSE IN HOUSEHOLD (DO NOT HAVE RELATIONSHIP CODE = CODE 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15 OR 16)}.

SELECT NAMES OF PERSONS RELATED TO {REFERENCE PERSON OR HEAD(S) OF FAMILY}.

BOX 13

EMBEDDED LOOP 2A:

ASK SFQ.070 – SFQ.100 FOR EACH PERSON SELECTED IN SFQ.060.

SFQ.070 What is {PERSON'S} relationship to {HEAD OF FAMILY}.

HAND CARD SFQ1

SPOUSE (HUSBAND/WIFE) 01

UNMARRIED PARTNER 02

CHILD (BIOLOGICAL/ADOPTIVE/IN-LAW/

STEP/FOSTER) 03

CHILD OF PARTNER 04

GRANDCHILD 05

PARENT (BIOLOGICAL/ADOPTIVE/

IN-LAW/STEP/FOSTER) 06

BROTHER/SISTER (BIOLOGICAL/

ADOPTIVE/IN-LAW/STEP/FOSTER) 07

GRANDMOTHER/GRANDFATHER 08

AUNT/UNCLE 09

NIECE/NEPHEW 10

OTHER RELATIVE 11

HOUSEMATE/ROOMMATE 12

ROOMER/BOARDER 13

OTHER NONRELATIVE 14

LEGAL GUARDIAN 15

WARD 16

REFUSED 77

DON'T KNOW 99

BOX 14

CHECK ITEM SFQ.073:

RELATIONSHIP CODES FROM SFQ.070. NOTE H OF F ON MATRIX MAY HAVE MULTIPLE RELATIONSHIP CODES.

"H OF F" = HEAD OF FAMILY IN SFQ.060 AS DEFINED I BOX 10.

"P" = OTHER PERSONS SELECTED IN SFQ.060.

n IF CODE 1 (SPOUSE), CHECK GENDER OF BOTH {H OF F} AND {P} AND
CODE {H OF F} AS HUSBAND OR WIFE OF {P} DEPENDING ON GENDER
AND {P} AS HUSBAND OR WIFE OF {H OF F} DEPENDING ON GENDER.

n IF CODE 2 (UNMARRIED PARTNER), CHECK GENDER OF BOTH {H OF F}
AND {P} DEPENDING ON GENDER AND CODE {H OF F} AS UNMARRIED
MALE OR FEMALE PARTNER OF {P} AND {P} AS UNMARRIED MALE OR FEMALE PARTNER OF {H OF F} DEPENDING ON GENDER.

n IF CODE 3 (CHILD), CHECK GENDER OF {P} AND {H OF F} AND CODE
{H OF F} AS MOTHER OR FATHER OF {P} DEPENDING ON GENDER AND {P} AS SON OR DAUGHTER OF {H OF F} DEPENDING ON GENDER.

n IF CODE 4 (CHILD OF PARTNER), CODE {H OF F} AS PARTNER OF
CHILD'S PARENT AND CODE {P} AS CHILD OF PARTNER.

n IF CODE 5 (GRANDCHILD), CODE {H OF F} AS GRANDPARENT OF {P}
AND {P} AS GRANDCHILD OF {H OF F}.

n IF CODE 6 (PARENT), CHECK GENDER OF BOTH {H OF F} AND {P} AND
CODE {H OF F} AS SON OR DAUGHTER OF {P} DEPENDING ON GENDER AND CODE {P} AS MOTHER OR FATHER OF {H OF F} DEPENDING ON GENDER.

n IF CODE 7 (BROTHER/SISTER), CHECK GENDER OF BOTH {H OF F} AND
{P} AND CODE {H OF F} AS BROTHER/SISTER OF {P} DEPENDING ON
GENDER AND {P} AS BROTHER/SISTER OF {H OF F} DEPENDING ON GENDER.

n IF CODE 8 (GRANDPARENT), CODE {H OF F} AS GRANDCHILD OF{RP}
AND {P} AS GRANDPARENT OF {P}.

n IF CODE 9 (AUNT/UNCLE), CODE {H OF F} AS NIECE/NEPHEW OF {P}
AND {P} AS AUNT/UNCLE OF {H OF F}.

n IF CODE 10 (NIECE/NEPHEW), CODE {H OF F} AS AUNT/UNCLE OF {P}
AND {P} AS NIECE/NEPHEW OF {H OF F}.

n IF CODE 11 (OTHER RELATIVE), CODE {H OF F} AS OTHER RELATIVE OF
{P} AND {P} AS OTHER RELATIVE OF {H OF F}.

n IF CODE 12 (HOUSEMATE/ROOMMATE), CODE {H OF F} AS HOUSEMATE/
ROOMMATE OF {P} AND {P} AS HOUSEMATE/ROOMMATE OF {H OF F}.

n IF CODE 13 (ROOMER/BOARDER), CODE {H OF F} AS
OTHER NONRELATIVE OF {P} AND {P} AS ROOMER/BOARDER OF {H OF F}.

n IF CODE 14 (OTHER NONRELATIVE), CODE {H OF F} AS OTHER
NONRELATIVE OF {P} AND {P} AS OTHER NONRELATIVE OF {H OF F}.

n IF CODE 15 (LEGAL GUARDIAN), CODE {H OF F} AS WARD OF {P} AND
{P} AS LEGAL GUARDIAN OF {H OF F}.

n IF CODE 16 (WARD), CODE {H OF F} AS LEGAL GUARDIAN OF {P} AND
{P} AS WARD OF {H OF F}.

n IF CODE 77 OR CODE 99, CODE {H OF F} AS OTHER RELATIVE OF {P}
AND {P} AS OTHER RELATIVE OF {H OF F}.

BOX 15

CHECK ITEM SFQ.075:

IF {P} RELATIONSHIP IN SFQ.070 = CHILD (CODE 3), CONTINUE.

OTHERWISE, SKIP TO BOX 16.

SFQ.080 Is {PERSON}, {HEAD OF FAMILY'S} biological (natural), adoptive, step, foster {son/daughter} or (son/daughter)-in-law?

BIOLOGICAL (NATURAL) {SON/
DAUGHTER} 1

ADOPTIVE {SON/DAUGHTER} 2

STEP {SON/DAUGHTER} 3

FOSTER {SON/DAUGHTER} 4

{SON/DAUGHTER}-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 16

CHECK ITEM SFQ.085:

IF {P} RELATIONSHIP IN SFQ.070 = PARENT (CODE 6), CONTINUE.

OTHERWISE, GO TO BOX 17.

SFQ.090 Is {PERSON}, {HEAD OF FAMILY'S} biological (natural), adoptive, step, or foster parent or {mother/father}-in-law?

BIOLOGICAL (NATURAL) PARENT 1

ADOPTIVE PARENT 2

STEP PARENT 3

FOSTER PARENT 4

{MOTHER/FATHER}-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 17

CHECK ITEM SFQ.095:

IF {P} RELATIONSHIP IN SFQ.010 = BROTHER/SISTER (CODE 7), CONTINUE.

OTHERWISE, GO TO BOX 18.

SFQ.100 Is {PERSON}, {HEAD OF FAMILY'S} full, half, adoptive, step, or foster {brother/sister} or {brother/sister}-in-law?

FULL {BROTHER/SISTER} 1

HALF {BROTHER/SISTER} 2

ADOPTED {BROTHER/SISTER} 3

STEP {BROTHER/SISTER} 4

FOSTER {BROTHER/SISTER} 5

{BROTHER/SISTER}-IN-LAW 6

REFUSED 7

DON'T KNOW 9

BOX 18

END EMBEDDED LOOP 2A:

ASK SFQ.070 – SFQ.100 AS APPROPRIATE FOR NEXT PERSON SELECTED AS RELATED TO HEAD OF FAMILY IN SFQ.060.

IF NO NEXT PERSON, GO TO BOX 19.

BOX 19

END LOOP 2:

IF MORE THAN 1 PERSON REMAINS UNRELATED TO THE REFERENCE PERSON OR THE HEAD OF ADDITION FAMILY:

n DESIGNATE NEXT HEAD OF FAMILY AS INSTRUCTED IN BOX 10.

n ASK SFQ.050 – SFQ.100 FOR NEXT HEAD OF FAMILY AND PERSONS
WHO REMAIN AS UNRELATED.

IF NO NEXT PERSONS GO TO BOX 20.

BOX 20

CHECK ITEM SFQ.105:

n IF REFERENCE PERSON IS MARRIED (CODED AS HUSBAND/WIFE) OR
LIVING WITH A PARTNER (CODED AS UNMARRIED PARTNER).

AND

n REFERENCE PERSON HAS A C

HILD OR THE PARTNER HAS A CHILD CONTINUE

OTHERWISE GO TO BOX 23.

BOX 21

LOOP 3:

ASK SFQ.110 FOR EACH PERSON (CHILD OF REFERENCE PERSON AND CHILD OF PARTNER – RELATIONSHIP CODE 3 OR 4).

SFQ.110 I recorded that {NAME OF MOTHER/FATHER OF CHILD – THIS IS SPOUSE OR PARTNER OF REFERENCE PERSON} is the {father/mother} of {NAME OF CHILD – THIS IS CHILD OF REFERENCE PERSON AND SPOUSE OR REFERENCE PERSON AND PARTNER OR CHILD OF PARTNER}. Is {NAME OF CHILD} {his/her} biological, adoptive, step, foster child or (son or daughter)-in-law?

BIOLOGICAL CHILD 1

ADOPTIVE CHILD 2

STEP CHILD 3

FOSTER CHILD 4

(SON/DAUGHTER)-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 22

END LOOP 3:

ASK SFQ.110 FOR NEXT PERSON (CHILD OR CHILD OF PARTNER).

IF NO NEXT PERSON, CONTINUE WITH BOX 23.

BOX 23

CHECK ITEM 115:

CHECK RELATIONSHIPS. IF ALL HOUSEHOLD MEMBERS HAVE MOTHER, FATHER, AND SPOUSE OR PARTNER IDENTIFIED, GO TO BOX 31.

OTHERWISE, IF ANY OF THESE RELATIONSHIPS FOR EACH PERSON IS NOT ALREADY IDENTIFIED, CONTINUE.

BOX 24

LOOP 4:

ASK SFQ.120 – SFQ.200 AS APPROPRIATE FOR EACH PERSON WHO DOES NOT HAVE A MOTHER AND FATHER AND SPOUSE OR PARTNER IDENTIFIED IN HOUSEHOLD.

BOX 25

CHECK ITEM SFQ.117:

IF PERSON'S MOTHER HAS NOT BEEN IDENTIFIED, AND THERE ARE FEMALES IN THE HOUSEHOLD WHO ARE > 11 YEARS OLDER THAN PERSON, CONTINUE OTHERWISE, GO TO BOX 27.

SFQ.120 Is {PERSON'S} mother a household member? [Include mother-in-law].

IF OBVIOUS, VERIFY ONLY.

CHOOSE MOTHER OVER MOTHER-IN-LAW IF BOTH PRESENT.

YES – MOTHER IN HOUSEHOLD 1

NO – MOTHER NOT IN HOUSEHOLD 2 (BOX 27)

LEGAL GUARDIAN IN HOUSEHOLD 3

REFUSED 7 (BOX 27)

DON'T KNOW 9 (BOX 27)

SFQ.130 Who is that?

[SELECT PERSON FROM HOUSEHOLD MATRIX.

BOX 26

CHECK ITEM SFQ.135:

IF LEGAL GUARDIAN CODED IN SFQ.120, GO TO BOX 27.

OTHERWISE, CONTINUE.

SFQ.140 Is {NAME OF MOTHER IN SFQ.130}, {PERSON'S} biological [natural], adoptive, step, or foster mother or mother-in-law?

BIOLOGICAL MOTHER 1

ADOPTIVE MOTHER 2

STEP MOTHER 3

FOSTER MOTHER 4

MOTHER-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 27

CHECK ITEM SFQ.145:

IF PERSON'S FATHER HAS NOT BEEN IDENTIFIED, AND THERE ARE MALES IN THE HOUSEHOLD WHO ARE > 11 YEARS OLDER THAN PERSON.

OTHERWISE, GO TO BOX 29A.

SFQ.150 Is {PERSON'S} father a household member? [Include father-in-law].

IF OBVIOUS, VERIFY ONLY.

CHOOSE FATHER OVER FATHER-IN-LAW IF BOTH PRESENT.

YES – FATHER IN HOUSEHOLD 1

NO – FATHER NOT IN HOUSEHOLD 2 (BOX 29)

LEGAL GUARDIAN IN HOUSEHOLD 3

REFUSED 7 (BOX 29)

DON'T KNOW 9 (BOX 29)

SFQ.160 Who is that?

[SELECT PERSON FROM HOUSEHOLD MATRIX.

BOX 28

CHECK ITEM SFQ.165:

IF LEGAL GUARDIAN CODED IN SFQ.150, GO TO BOX 29A.

OTHERWISE, CONTINUE.

SFQ.170 Is {NAME OF FATHER IN SFQ.160}, {PERSON'S} biological (natural), adoptive, step, or foster father or father-in-law?

BIOLOGICAL FATHER 1

ADOPTIVE FATHER 2

STEP FATHER 3

FOSTER FATHER 4

FATHER-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 29A

CHECK ITEM SFQ.175:

IF PERSON'S AGE >= 14 AND SPOUSE OR UNMARRIED PARTNER HAS NOT BEEN IDENTIFIED, CONTINUE.

OTHERWISE, GO TO BOX 30.

SFQ.180 Is {PERSON'S NAME} now married, widowed, divorced, separated, never married or living with a partner?

MARRIED 1

WIDOWED 2 (BOX 30)

DIVORCED 3 (BOX 30)

SEPARATED 4 (BOX 30)

NEVER MARRIED 5 (BOX 30)

LIVING WITH PARTNER 6

REFUSED 7 (BOX 30)

DON'T KNOW 9 (BOX 30)

BOX 29B

CHECK ITEM SFQ.185:

IF THERE ARE PERSONS IN THE HOUSEHOLD WHO ARE > = 14 YEARS OLD, CONTINUE.

OTHERWISE, GO TO BOX 30.

SFQ.190 Is {PERSON'S} {spouse/partner} living in the household?

YES 1

NO 2 (BOX 30)

REFUSED 7 (BOX 30)

DON'T KNOW 9 (BOX 30)

SFQ.200 Who is that?

DISPLAY LIST OF ALL NONDELETED HOUSEHOLD MEMBERS WHO ARE 14 YEARS OLD OR OLDER.

BOX 30

END LOOP 4:

ASK SFQ.120 – SFQ.200 FOR NEXT PERSON.

IF NO NEXT PERSON, GO TO BOX 31.

BOX 31

CHECK ITEM SFQ.205:

n APPLY NHANES AND CPS FAMILY DEFINITIONS.

n IF MORE THAN 1 NHANES FAMILY, CONTINUE.

n IF ONLY 1 NHANES FAMILY, GO TO SFQ.210. DO NOT REASK SCQ.430 –
SCQ.461.

OTHERWISE, GO TO SFQ.210.

BOX 32

LOOP 5:

ASK MODULE 1 – SCQ.420 – SCQ.461 FOR EACH ADDITIONAL NHANES FAMILY.

NOTE: THE SUBJECT OF QUESTIONS SHOULD BE EACH ADDITIONAL HEAD OF NHANES FAMILY

DO NOT REASK SCQ.430 – SCQ.461 OF THE FIRST NHANES FAMILY.

SFQ.210 Thank you. That completes the questions about family relationships.

END OF SECTION

SAMPLE PERSON QUESTIONNAIRE

RESPONDENT SELECTION

NOTE: THIS IS ADMINISTRATIVE INFORMATION ENTERED BY THE INTERVIEWER NOT

QUESTIONS ASKED OF THE PARTICIPANT

RIQ.010 SELECT RESPONDENT FOR THE SP QUESTIONNAIRE FOR {SP NAME}.

CAPI INSTRUCTION:

DISPLAY FAMILY ROSTER AND 'SOMEONE OUTSIDE FAMILY' AS OPTION.

BOX 1

CHECK ITEM RIQ.015:

 IF SP IS SELECTED AS RESPONDENT AND SP AGE IS <=

15, GO TO RIQ.020.

 IF SP IS SELECTED AS RESPONDENT AND SP AGE IS >=

16, GO TO RIQ.080.

 IF SP IS NOT SELECTED AS RESPONDENT AND SP AGE

IS <= 15, GO TO BOX 2.

 IF SP IS NOT SELECTED AS RESPONDENT AND SP AGE

IS >= 16, GO TO RIQ.030.

RIQ.020 INTERVIEW SHOULD BE CONDUCTED WITH A PROXY BECAUSE SP IS UNDER 16 YEARS OLD.

ENTER ONE OPTION.

SP IS AN INDEPENDENT MINOR 1 (RIQ.080)

PERSON SELECTED AS

RESPONDENT IN ERROR 2 (RIQ.010)

SP AGE ENTERED IN ERROR -- SP IS

AGE 16+ 3 (RIQ.080)

RIQ.030 WHY IS INTERVIEW BEING CONDUCTED WITH A PROXY?

SP HAS COGNITIVE PROBLEMS 1

SP HAS PHYSICAL PROBLEMS (SPECIFY)… 2

OTHER (SPECIFY) 3

BOX 2

CHECK ITEM RIQ.031:

IF 'SOMEONE OUTSIDE THE FAMILY' SELECTED AS RESPONDENT, CONTINUE.

OTHERWISE, GO TO RIQ.080.

RIQ.040 WHY IS INTERVIEW BEING CONDUCTED WITH SOMEONE OUTSIDE THE

HOUSEHOLD?

RIQ.050 ENTER RESPONDENT NAME.

FIRST NAME LAST NAME

RIQ.060 ENTER RESPONDENT'S PHONE NUMBER.

ENTER '00' IN AREA CODE IF NO PHONE.

|___|___|___| |___|___|___| - |___|___|___|___|

AREA CODE ENTER PHONE NUMBER

RIQ.070 DESCRIBE RESPONDENT'S RELATIONSHIP TO SP.

RIQ.080 HAS RESPONDENT SIGNED A HOUSEHOLD INTERVIEW CONSENT FORM?

CAPI INSTRUCTION:

IF 'NO' (CODE 2), DISPLAY THE FOLLOWING MESSAGE: "EACH RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE MUST SIGN A HOUSEHOLD INTERVIEW CONSENT FORM BEFORE THE INTERVIEW CAN BE ADMINISTERED" AND RETURN TO RIQ.080.

NOTE: IF INTERPRETER USED, RESPONDENT MUST SIGN FORM.

YES 1

NO 2

RIQ.090 INTERPRETER USED FOR THIS INTERVIEW?

YES 1

NO 2 (END OF SECTION)

RIQ.100 CODE TYPE OF INTERPRETER.

LIVING IN HOUSEHOLD 1

NEIGHBORHOOD/FRIEND 2 (RIQ.120)

PAID INTERPRETER 3 (RIQ.120)

RIQ.110 SELECT NAME OF INTERPRETER FROM HOUSEHOLD ROSTER.

{DISPLAY NAMES OF HOUSEHOLD MEMBERS}

BOX 3

CHECK ITEM RIQ.115:

GO TO RIQ.140.

RIQ.120 ENTER NAME OF INTERPRETER.

FIRST NAME LAST NAME

BOX 4

CHECK ITEM RIQ.125:

IF INTERPRETER IS NEIGHBOR OR FRIEND (CODE 2 IN RIQ.100), CONTINUE.

OTHERWISE, GO TO RIQ.140.

RIQ.130 ENTER PHONE NUMBER OF INTERPRETER.

ENTER '00' IN AREA CODE IF NO PHONE.

|___|___|___| |___|___|___| - |___|___|___|___|

REFUSED 7

DON'T KNOW 9

RIQ.140 LANGUAGE OF INTERVIEW.

CHINESE 1

FRENCH 2

GERMAN 3

ITALIAN 4

JAPANESE 5

RUSSIAN 6

OTHER (SPECIFY) 7

DON'T KNOW 9

END OF SECTION

INTRODUCTION AND VERIFICATION (IVQ)

DMQ.010 [You have been chosen to participate in the National Health and Nutrition Examination Survey conducted by the U.S. Public Health Service. All the information that you give us will be kept in the strictest of confidence. Your name will not be attached to any of your answers without your specific permission. HAND RESPONDENT THE ADVANCE LETTER.] I would like to begin the health interview by verifying some information about {you/SP}.

VERIFY OR ASK DATE OF BIRTH AND AGE.

CAPI INSTRUCTION:

DISPLAY DATE OF BIRTH AND SP AGE FROM SCREENER.

IF AGE OR ALL OR PART OF DATE OF BIRTH NOT AVAILABLE, FILL CORRESPONDING FIELDS WITH 'DK' OR 'REF' AS APPROPRIATE.

IF AGE IS A RANGE, DISPLAY THE RANGE FOR AGE.

IF AGE IS LESS THAN 1 YEAR, DISPLAY AGE IN MONTHS.

IF AGE IS CHANGED, DISPLAY MESSAGE TO CORRECT DOB.

IF DOB IS CHANGED, RECALCULATE AGE.

{ |___|___|___|___|___|___|___|___| } { |___|___|___| }

DATE OF BIRTH (MONTH, DAY, YEAR) AGE

REFUSED 77777777

DON'T KNOW 99999999

DMQ.020 VERIFY GENDER.

CAPI INSTRUCTION:

DISPLAY SP GENDER FROM SCREENER. IF GENDER NOT AVAILABLE, DISPLAY DK OR REF AS APPROPRIATE.

{ |___| }

GENDER

BOX 1

CHECK ITEM DMQ.025:

RUN SAMPLING ALGORITHM. IF PERSON NO LONGER IN THE SAMPLE DUE TO UPDATED AGE OR GENDER INFORMATION, CONTINUE.

OTHERWISE, GO TO BOX 4.

DMQ.030 Thank you for your participation in the study. Our scientific, random selection process indicates that {you/SP} {have/has} not been selected for the next part of the study.

BOX 2

CHECK ITEM DMQ.035:

GO TO END OF INTERVIEW.

DMQ.040 What is {your/SP's} full name, including middle name?

What is your first name?

VERIFY SPELLING

USE F1 FOR HELP RECORDING FIRST NAME

|___|___|___|___|

ENTER PREFIX (MS, MR, MRS, DR)

REFUSED 7777

DON'T KNOW 9999

ENTER FIRST NAME

REFUSED 7

DON'T KNOW 9

DMQ.050 What is {your/SP's} middle name?

VERIFY SPELLING

USE F1 FOR HELP RECORDING MIDDLE NAME(S)

IF NO MIDDLE NAME, MARK CHECK BOX

ENTER MIDDLE NAME #1

REFUSED 7

DON'T KNOW 9

ENTER MIDDLE NAME #2

REFUSED 7

DON'T KNOW 9

DMQ.060 What is {your/SP's} last name?

VERIFY SPELLING

USE F1 FOR HELP RECORDING LAST NAME(S)

ENTER LAST NAME #1

REFUSED 7

DON'T KNOW 9

ENTER LAST NAME #2

REFUSED 7

DON'T KNOW 9

DMQ.070 {Do you/Does SP} have a suffix? [What is it?]

ENTER SUFFIX (JR, SR, III)

or

NO 2

REFUSED 7

DON'T KNOW 9

EARLY CHILDHOOD

ECQ.010 First I have some questions about {SP NAME's} birth.

How old was {SP NAME's} biological mother when {s/he} was born?

|___|___|

ENTER AGE IN YEARS

CAPI INSTRUCTION:

HARD EDIT 10-59, SOFT EDIT <13

REFUSED 77

DON'T KNOW 99

ECQ.020 Did {SP NAME's} biological mother smoke at any time while she was pregnant with {him/her}?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

ECQ.071/ How much did {SP NAME} weigh at birth?

L/O/K/M

IF ANSWER GIVEN IN POUNDS ONLY, PROBE FOR OUNCES.

IF ANSWER GIVEN IN EXACT POUNDS, ENTER NUMBER OF POUNDS AND 0 OUNCES.

|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 3-13, HARD EDIT 0-20

AND

|___|___|

ENTER NUMBER OF OUNCES

CAPI INSTRUCTION:

HARD EDIT 0-15, NO SOFT EDIT

OR

|___|___|___|

ENTER NUMBER IN KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 1.5-6, HARD EDIT 0-9

OR

|___|___|___|

ENTER NUMBER IN GRAMS

CAPI INSTRUCTION:

SOFT EDIT 1,500-6,000, HARD EDIT 0-9,000

OR

REFUSED 7777

DON’T KNOW 9999

BOX 1

CHECK ITEM ECQ.075:

IF REFUSED (CODE 7) OR DON'T KNOW (CODE 9), CONTINUE.

OTHERWISE, GO TO BOX 2.

ECQ.080 Did {SP NAME} weigh . . .

more than 5-1/2 lbs. (2500 g), or 1

less than 5-1/2 lbs. (2500 g)? 2 (BOX 2)

REFUSED 7 (BOX 2)

DON'T KNOW 9 (BOX 2)

ECQ.090 Did {SP NAME} weigh . . .

more than 9 lbs. (4100 g), or 1

less than 9 lbs. (4100 g)? 2

REFUSED 7

DON'T KNOW 9

BOX 2

CHECK ITEM ECQ.095:

IF SP AGE = 2-15 YEARS, CONTINUE.

OTHERWISE, GO TO End of Section.

WHQ.030e Do you consider {SP} now to be . . .

overweight, 1

underweight, or 2

about the right weight? 3

REFUSED 7

DON’T KNOW 9

MCQ.080e Has a doctor or health professional ever told you that {SP} was overweight?

YES 1

NO 2 (End of Section)

REFUSED 7 (End of Section)

DON’T KNOW 9 (End of Section)

ECQ.150 Are you now doing anything to help {SP} control {his/her} weight?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HOSPITAL UTILIZATION AND ACCESS TO CARE

HUQ.010 {First/Next} I have some general questions about {your/SP's} health.

Would you say {your/SP's} health in general is . . .

CAPI INSTRUCTION:

DISPLAY "FIRST" IF SP AGE IS >= 16 YEARS.

excellent, 1

very good, 2

good, 3

fair, or 4

poor? 5

REFUSED 7

DON'T KNOW 9

BOX 1

CHECK ITEM HUQ.015:

IF SP AGE >= 1, CONTINUE.

OTHERWISE, GO TO HUQ.030.

HUQ.020 Compared with 12 months ago, would you say {your/SP's} health is now . . .

better, 1

worse, or 2

about the same? 3

REFUSED 7

DON'T KNOW 9

HUQ.030 Is there a place that {you/SP} usually {go/goes} when {you are/he/she is} sick or {you/s/he} need{s} advice about {your/his/her} health?

CAPI INSTRUCTION:

IF SP AGE < 12, DISPLAY "YOU" IN THE FOURTH DISPLAY AND DON'T DISPLAY THE "S" IN THE FIFTH DISPLAY.

YES 1

THERE IS NO PLACE 2 (HUQ.050)

THERE IS MORE THAN ONE PLACE 3

REFUSED 7 (HUQ.050)

DON'T KNOW 9 (HUQ.050)

HUQ.040 What kind of place {do you/does SP} go to most often: is it a clinic, doctor's office, emergency room, or some other place?

CLINIC OR HEALTH CENTER 1

DOCTOR'S OFFICE OR HMO 2

HOSPITAL EMERGENCY ROOM 3

HOSPITAL OUTPATIENT DEPARTMENT 4

SOME OTHER PLACE 5

REFUSED 7

DON'T KNOW 9

HUQ.050 {During the past 12 months, how/How} many times {have you/has SP} seen a doctor or other health care professional about {your/his/her} health at a doctor's office, a clinic, hospital emergency room, at home or some other place? Do not include times {you were/s/he was} hospitalized overnight.

CAPI INSTRUCTION:

DISPLAY "12 MONTHS" ONLY IF SP'S AGE IS >= 1.

NONE 0

1 1 (HUQ.071)

2 TO 3 2 (HUQ.071)

4 TO 9 3 (HUQ.071)

10 TO 12 4 (HUQ.071)

13 OR MORE 5 (HUQ.071)

REFUSED 7 (HUQ.071)

DON'T KNOW 9 (HUQ.071)

CAPI INSTRUCTION:

ELIMINATE CURRENT HELP.

ADD NEW HELP 1 FOR 07. INCLUDE: PHYSICIAN’S, OSTEOPATHS, DOCTOR’S ASSISTANTS, NURSE PRACTITIONERS, NURSES, LAB TECHNICIANS AND TECHNICIANS WHO ADMINISTER SHOTS (I.E., ALLERGY SHOTS), PARAMEDICS, MEDICS AND PHYSICAL THERAPISTS WHO WORK WITH OR IN A DOCTOR’S OFFICE. DO NOT INCLUDE: DENTISTS, ORAL SURGEONS, CHIROPRACTORS, CHEROPODISTS, PODIATRISTS, NATURAPATHS, CHRISTIAN SCIENCE HEALERS, OPTICIANS, OPTOMETRISTS AND PSYCHOLOGISTS OR SOCIAL WORKERS.

HUQ.060 About how long has it been since {you/SP} last saw or talked to a doctor or other health care professional about {your/his/her} health? Include doctors seen while {you were} {he/she was} a patient in a hospital. Has it been . . .

6 months or less, 1

more than 6 months, but not more than

1 year ago, 2

more than 1 year, but not more than

3 years ago, 3

more than 3 years, or 4

never? 5

REFUSED 7

DON'T KNOW 9

HUQ.071 {During the past 12 months, were you/{Was/was} SP} a patient in a hospital overnight? Do not include an overnight stay in the emergency room.

CAPI INSTRUCTION:

DISPLAY "12 MONTHS" ONLY IF SP'S AGE IS >= 1.

DISPLAY "WAS SP" WITH LEADING CAPS, IF SP'S AGE IS <1.

YES 1

NO 2 (BOX 2)

REFUSED 7 (BOX 2)

DON'T KNOW 9 (BOX 2)

CAPI INSTRUCTION:

ELIMINATE CURRENT HELP. ADD NEW HELP.

HELP SCREEN:

Overnight Stay in a Hospital: A person is admitted to a hospital and spends at least one night in the hospital. Note that a person can be “admitted” to a hospital without staying overnight. Do not count as “overnight” when a person is admitted and discharged on the same day. Do not include visits outpatient clinics or stays for non-medical reasons, such as staying with a family member.

Emergency Room: Do not include urgent care centers, which are not part of a hospital, or outpatient clinics.

HUQ.080 How many different times did {you/SP} stay in any hospital overnight or longer {during the past 12 months}? (Do not count total number of nights, just total number of hospital admissions for stays which lasted 1 or more nights.)

CAPI INSTRUCTION:

DISPLAY "12 MONTHS" ONLY IF SP'S AGE IS >= 1.

HARD EDIT: 1-366.

SOFT EDIT: 1-6.

|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

CAPI INSTRUCTION:

ELIMINATE CURRENT HELP.

BOX 1A

OMITTED

BOX 2

CHECK ITEM 085:

IF SP AGE >= 4, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

HUQ.090 During the past 12 months, that is since {DISPLAY CURRENT MONTH} of {DISPLAY LAST YEAR}, {have you/has SP} seen or talked to a mental health professional such as a psychologist, psychiatrist, psychiatric nurse or clinical social worker about {your/his/her} health?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

IMMUNIZATION

BOX 0

CHECK ITEM IMQ.005:

IF SP AGE >= 2, CONTINUE.

OTHERWISE, GO TO IMQ.020.

BOX 1

OMITTED

IMQ.011 Hepatitis (Hep-a-ti-tis) A vaccine is given as a two dose series to some children older than 2 years and also to some adults, especially people who travel outside the United States. It has only been available since 1995. {Have you/Has SP} ever received the hepatitis A vaccine?

INTERVIEWER INSTRUCTION: A COMBINATION HEPATITIS A AND HEPATITIS B VACCINE SHOULD BE COUNTED AS THE A VACCINE FOR THE PURPOSE OF THIS QUESTION. CODE 'YES AT LEAST 2 DOSES' IF RESPONDENT ANSWERS 3 OR 4 DOSES WERE RECEIVED. CODE 'LESS THAN 2 DOSES' ONLY IF MENTIONED BY RESPONDENT

YES AT LEAST 2 DOSES 1

LESS THAN 2 DOSES 2

NO DOSES 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

REMOVE CURRENT HELP.

IMQ.020 Hepatitis (Hep-a-ti-tis) B vaccine is given in three separate doses and has been recommended for all newborn infants since 1991. In 1995, it was recommended that adolescents be given the vaccine. Persons who may be exposed to other people’s blood, such as health care workers, also may have received the vaccine. {Have you/Has SP} ever received the 3-dose series of the hepatitis B vaccine?

INTERVIEWER INSTRUCTION: A COMBINATION HEPATITIS A AND HEPATITIS B VACCINE SHOULD BE COUNTED AS THE B VACCINE FOR THE PURPOSE OF THIS QUESTION. CODE 'YES AT LEAST 3 DOSES' IF RESPONDENT ANSWERS 4 DOSES WERE RECEIVED. CODE 'LESS THAN 3 DOSES' ONLY IF MENTIONED BY RESPONDENT

YES AT LEAST 3 DOSES 1

LESS THAN 3 DOSES 2

NO DOSES 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

REMOVE CURRENT HELP.

BOX 2

CHECK ITEM IMQ.035:

IF SP = FEMALE AND AGE IS >= 9 AND <= 59, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

IMQ.040 Human Papillomavirus (HPV) vaccine is given to prevent cervical cancer in girls and women. It is given in 3 separate doses over 6 months and has been recommended for girls and women since June, 2006. {Have you/Has SP} ever received one or more doses of the HPV vaccine? (The brand name for the vaccine is Gardasil.)

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

IMQ.045 How many doses {have you/has SP} received?

1 DOSE 1

2 DOSES 2

3 DOSES 3

REFUSED 7

DON'T KNOW 9

P

NHANES 2009

HYSICAL FUNCTIONING

BOX 1A

CHECK ITEM PFQ.001:

IF AGE OF SP IS >= 20, GO TO PFQ.049

OTHERWISE, CONTINUE.

PFQ.020 {Do you/Does SP} have an impairment or health problem that limits {your/his/her} ability to {walk, run or play} {walk or run}?

CAPI INSTRUCTION:

IF CHILD'S AGE = 5-15, DISPLAY "WALK, RUN OR PLAY". IF SP'S AGE = 16-19, DISPLAY "WALK OR RUN".

Yes 1

No 2 (BOX 1BB)

Refused 7 (BOX 1BB)

DON'T know 9 (BOX 1BB)

PFQ.030 Is this an impairment or health problem that has lasted, or is expected to last 12 months or longer?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1BB

CHECK ITEM PFQ.035A:

IF SP AGE <= 17, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

PFQ.041 Does {SP} receive Special Education or Early Intervention Services?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1C

CHECK ITEM PFQ.045:

GO TO END OF SECTION.

PFQ.049 The next set of questions is about limitations caused by any long-term physical, mental or emotional problem or illness. Please do not include temporary conditions, such as a cold [or pregnancy].

Does a physical, mental or emotional problem now keep {you/SP} from working at a job or business?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PFQ.051 {Are you/Is SP} limited in the kind or amount of work {you/s/he} can do because of a physical, mental or emotional problem?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PFQ.054 Because of a health problem, {do you/does SP} have difficulty walking without using any special equipment?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PFQ.057 {Are you/Is SP} limited in any way because of difficulty remembering or because {you/s/he} experience{s} periods of confusion?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1D

CHECK ITEM PFQ.058:

IF 'YES' (CODE 1) IN PFQ.049, PFQ.051, PFQ.054, OR PFQ.057, GO TO PFQ.061.

OTHERWISE, CONTINUE.

PFQ.059 {Are you/Is SP} limited in any way in any activity because of a physical, mental or emotional problem?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1E

CHECK ITEM PFQ.059A:

IF SP AGE IS <=59 AND 'NO' (CODE 2) ENTERED IN PFQ.049, PFQ.057 AND PFQ.059, GO TO PFQ.090.

OTHERWISE, CONTINUE.

PFQ.061 a-r

The next questions ask about difficulties {you/SP} may have doing certain activities because of a health problem. By "health problem" we mean any long-term physical, mental or emotional problem or illness {not including pregnancy}.

By {yourself/himself/herself} and without using any special equipment, how much difficulty {do you/does SP} have . . .

HAND CARD PFQ1

DO NOT INCLUDE TEMPORARY CONDITIONS LIKE PREGNANCY OR BROKEN LIMBS.

CAPI INSTRUCTION:

IF PFQ.054 = '1' (YES), DO NOT DISPLAY 'B' OR 'C'.

IF SP FEMALE, DISPLAY 'NOT INCLUDING PREGNANCY'.

RESPONSES: NO DIFFICULTY = 1, SOME DIFFICULTY = 2, MUCH DIFFICULTY = 3,

UNABLE TO DO = 4, DO NOT DO THIS ACTIVITY = 5, REFUSED = 7, DON'T KNOW = 9.

a. managing {your/his/her} money [such as keeping track of

{your/his/her} expenses or paying bills]? ____

b. walking for a quarter of a mile [that is about 2 or 3 blocks]? ____

c. walking up 10 steps without resting? ____

d. stooping, crouching, or kneeling? ____

e. lifting or carrying something as heavy as 10 pounds [like a

sack of potatoes or rice]? ____

f. doing chores around the house [like vacuuming, sweeping,

dusting, or straightening up]? ____

g. preparing {your/his/her} own meals? ____

h. walking from one room to another on the same level? ____

i. standing up from an armless straight chair? ____

j. getting in or out of bed? ____

k. eating, like holding a fork, cutting food or drinking from a glass? ____

l. dressing {yourself/himself/herself}, including tying shoes,

working zippers, and doing buttons? ____

m. standing or being on {your/his/her} feet for about 2 hours? ____

n. sitting for about 2 hours? ____

o. reaching up over {your/his/her} head? ____

p. using {your/his/her} fingers to grasp or handle small objects? ____

q. going out to things like shopping, movies, or sporting events? ____

r. participating in social activities [visiting friends, attending

clubs or meetings or going to parties]? ____

s. doing things to relax at home or for leisure [reading, watching

TV, sewing, listening to music]? ____

t. pushing or pulling large objects like a living room chair? ____

BOX 1F

CHECK ITEM PFQ.066A:

IF 'SOME DIFFICULTY' (CODE 2), 'MUCH DIFFICULTY' (CODE 3), OR 'UNABLE TO DO' (CODE 4) IN PFQ.061 A THROUGH T, CONTINUE.

OTHERWISE, GO TO PFQ.090.

PFQ.063 What condition or health problem causes {you/SP} to have difficulty with or need help with {NAME OF UP TO 3 ACTIVITIES/these activities}?

HAND CARD PFQ2

ENTER ALL THAT APPLY UP TO 5 BUT DO NOT PROBE.

DO NOT ENTER 'OLD AGE' AS CONDITION -- IF OLD AGE IS REPORTED, PROBE FOR ANY OTHER CONDITION.

CAPI INSTRUCTION:

IF THE TOTAL NUMBER OF ITEMS CODED 'SOME DIFFICULTY' (CODE 2), 'MUCH DIFFICULTY' (CODE 3), OR 'UNABLE TO DO' (CODE 4) IN PFQ.061 A THROUGH T <=3, DISPLAY EACH ITEM NAME IN THE TEXT OF QUESTION. IF MORE THAN 3 ITEMS ARE CODED IN THIS MANNER DISPLAY "THESE ACTIVITIES" IN THE TEXT OF QUESTION.

ARTHRITIS/RHEUMATISM 10

BACK OR NECK PROBLEM 11

BIRTH DEFECT 12

CANCER 13

DEPRESSION/ANXIETY/EMOTIONAL

PROBLEM 14

OTHER DEVELOPMENTAL PROBLEM

(SUCH AS CEREBRAL PALSY) 15

DIABETES 16

FRACTURES, BONE/JOINT INJURY 17

HEARING PROBLEM 18

HEART PROBLEM 19

HYPERTENSION/HIGH BLOOD

PRESSURE 20

LUNG/BREATHING PROBLEM 21

MENTAL RETARDATION 22

OTHER INJURY 23

SENILITY 24

STROKE PROBLEM 25

VISION/PROBLEM SEEING 26

WEIGHT PROBLEM 27

OTHER IMPAIRMENT/PROBLEM 28

REFUSED 77

DON'T KNOW 99

PFQ.090 {Do you/Does SP} now have any health problem that requires {you/him/her} to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

MEDICAL CONDITIONS

MCQ.010 Has a doctor or other health professional ever told {you/SP} that {you have/s/he/SP has} asthma (az-ma)?

CAPI INSTRUCTION:

IF SP AGE >= 12, DISPLAY SP NAME AND "S/HE":

IF SP AGE < 12, DISPLAY "YOU" AND SP NAME.

HELP SCREEN:

Asthma: Asthma is a condition that affects your airways that carry air in and out of your lungs. It causes symptoms like wheezing (a whistling sound when you breathe), coughing, chest tightness, and trouble breathing,

INTERVIEWER: DO NOT ACCEPT SELF-DIAGNOSED OR DIAGNOSED BY A PERSON WHO IS NOT A DOCTOR OR OTHER HEALTH PROFESSIONAL.

YES 1

NO 2 (MCQ.053)

REFUSED 7 (MCQ.053)

DON'T KNOW 9 (MCQ.053)

MCQ.025 How old {were you/was SP} when {you were/s/he was} first told {you/he/she} had asthma (az-ma)?

IF LESS THAN 1 YEAR, ENTER 1

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY "WERE YOU" AND "YOU WERE".

IF SP AGE = 12-15, DISPLAY "WAS {SP}" AND "S/HE WAS".

IF SP AGE < 12, DISPLAY "WAS {SP}" AND "YOU WERE".

|___|___|___|

ENTER AGE IN YEARS

CAPI INSTRUCTION:

HARD EDIT: 1-120

REFUSED 777

DON'T KNOW 999

MCQ.035 {Do you/Does SP} still have asthma (az-ma)?

YES 1

NO 2 (MCQ.053)

REFUSED 7 (MCQ.053)

DON'T KNOW 9 (MCQ.053)

MCQ.040 During the past 12 months, {have you/has SP} had an episode of asthma (az-ma) or an asthma attack?

HELP SCREEN:

Episode/attack: When your asthma symptoms become worse than usual it is called an asthma episode or attack.

YES 1

NO 2 (MCQ.051)

REFUSED 7 (MCQ.051)

DON'T KNOW 9 (MCQ.051)

MCQ.050 [During the past 12 months], {have you/has SP} had to visit an emergency room or urgent care center because of asthma (az-ma)?

HELP SCREEN:

Emergency Room: An emergency care facility at a hospital that is open 24 hours a day. No appointments are necessary. Emergency care may be administered by a physician, nurse, paramedic, physician extender, or other health provider.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

MCQ.051 During the past 3 months, {have you/has SP} taken medication prescribed by a doctor or other health professionals for asthma?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

MCQ.053 During the past 3 months, {have you/has SP} been on treatment for anemia (a-nee-me-a), sometimes called "tired blood" or "low blood"? [Include diet, iron pills, iron shots, transfusions as treatment.]

HELP SCREEN:

Anemia: Anemia (uh-NEE-me-eh) is a condition in which a person’s blood has a lower than normal number of red blood cells (RBCs).

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2

CHECK ITEM MCQ.055:

IF SP AGE < 2, GO TO END OF SECTION.

IF SP AGE 2-15, GO TO BOX 3.

IF SP AGE 16+, CONTINUE.

OTHERWISE, CONTINUE.

MCQ.070 {Have you/Has SP} ever been told by a doctor or other health care professional that {you/s/he} had psoriasis (sore-eye-asis)?

Help Screen: Psoriasis is a skin disease that causes itchy or sore patches of thick, red skin with white or silvery scales. You usually get them on your elbows, knees, scalp, back, face, palms and feet, but they can show up on other parts of your body. It sometimes runs in families.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

MCQ.080 Has a doctor or other health professional ever told {you/SP} that {you were/s/he/SP was} overweight?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2A

OMITTED

BOX 3

CHECK ITEM MCQ.085:

IF SP'S AGE >= 6, CONTINUE.

OTHERWISE, GO TO MCQ.140.

MCQ.082 Has a doctor or other health professional ever told {you/SP} that {you have/s/he/SP has} celiac (sele-ak) disease, also called sprue (sproo)?

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY "YOU" AND "YOU HAVE".

IF SP AGE = 12-15, DISPLAY "SP" AND "S/HE HAS".

IF SP AGE < 12, DISPLAY "YOU" AND "SP HAS".

Help Screen: Celiac disease is a digestive disease where the individual can’t tolerate a protein called gluten, found in wheat, rye, and barley.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

MCQ.086 {Are you/Is SP} on a gluten-free diet?

Help Screen: A gluten-free diet means not eating foods that contain wheat, rye, and barley.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

MCQ.092 {Have you/Has SP} ever received a blood transfusion?

YES 1

NO 2 (MCQ.140)

REFUSED 7 (MCQ.140)

DON'T KNOW 9 (MCQ.140)

MCQ.093 In what year did {you/SP} receive {your/his/her} first transfusion?

|___|___|___|___|

ENTER 4-DIGIT YEAR

CAPI INSTRUCTION:

HARD EDIT: 1900-2006

REFUSED 7777

DON’T KNOW 9999

BOX 4

OMITTED

BOX 6

OMITTED

MCQ.140 {Do you/Does SP} have trouble seeing, even when wearing glasses or contact lenses, if {you/he/she} wear{s} them?

HELP SCREEN:

Glasses: Includes prescription eyeglasses as well as nonprescription reading glasses purchased at drug stores or variety stores. Do not include safety glasses, which are worn for protection only. Do not include non prescription sunglasses or glasses or contact lenses worn for cosmetic purposes.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 7

CHECK ITEM MCQ.145:

IF SP'S AGE 6-19, CONTINUE.

IF SP'S AGE >= 20, GO TO MCQ.160.

OTHERWISE, GO TO END OF SECTION.

BOX 7A

CHECK ITEM MCQ.146:

IF SP AGE 8-11 AND SP IS FEMALE, CONTINUE.

OTHERWISE, GO TO MCQ.300b.

MCQ.149 Have {SP's} periods or menstrual (men-stral) cycles started yet?

YES 1 (MCQ.300b)

NO 2 (MCQ.300b)

REFUSED 7 (MCQ.300b)

DON'T KNOW 9 (MCQ.300b)

BOX 8

OMITTED

BOX 8A

OMITTED

MCQ.160 Has a doctor or other health professional ever told {you/SP} that {you/s/he} . . . CAPI INSTRUCTION: TEXT OF QUESTION SHOULD BE OPTIONAL AFTER FIRST ITEM IS READ.	MCQ.170 {Do you/Does SP} still . . . ?	MCQ.180 How old {were you/was SP} when {you were/s/he was} first told {you/s/he} . . .	MCQ.191 Which type of arthritis was it?
a. had arthritis (ar-thry-tis)? YES 1 NO 2 (n) REFUSED 7 (n) DON'T KNOW 9 (n)		had arthritis? |___|___|___| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999	RHEUMATOID ARTHRITIS 1 OSTEOARTHRITIS 2 PSORIATIC ARTHRITIS 3 OTHER 4 REFUSED 7 DON'T KNOW 9
n. had gout? YES 1 NO 2 (b) REFUSED 7 (b) DON'T KNOW 9 (b)		had gout? |___|___|___| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999
b. had congestive heart failure? YES 1 NO 2 (c) REFUSED 7 (c) DON'T KNOW 9 (c)		had congestive heart failure? |___|___|___| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999
c. had coronary (kor-o-nare-ee) heart disease? YES 1 NO 2 (d) REFUSED 7 (d) DON'T KNOW 9 (d)		had coronary heart disease? |___|___|___| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999
d. had angina (an-gī-na), also called angina pectoris? YES 1 NO 2 (e) REFUSED 7 (e) DON'T KNOW 9 (e)		had angina, also called agina pectoris? |___|___|___| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999

e. had a heart attack (also called myocardial infarction (my-O-car-dee-al in-fark-shun))? YES 1 NO 2 (f) REFUSED 7 (f) DON'T KNOW 9 (f)		had a heart attack (also called myocardial infarction)? |___|___|___| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999
f. had a stroke? YES 1 NO 2 (g) REFUSED 7 (g) DON'T KNOW 9 (g)		had a stroke? |___|___|___| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999
g. had emphysema (emph-phi-see-ma)? YES 1 NO 2 (m) REFUSED 7 (m) DON'T KNOW 9 (m)		had emphysema? |___|___|___| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999
m. had a thyroid (thigh-roid) problem? YES 1 NO 2 (k) REFUSED 7 (k) DON'T KNOW 9 (k)	have a thyroid problem? YES 1 NO 2 REFUSED 7 DON'T KNOW 9	had a thyroid problem? |___|___|___| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999
k. had chronic bronchitis? YES 1 NO 2 (l) REFUSED 7 (l) DON'T KNOW 9 (l)	have chronic bronchitis? YES 1 NO 2 REFUSED 7 DON'T KNOW 9	had chronic bronchitis? |___|___|___| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999
l. had any kind of liver condition? YES 1 NO 2 (MCQ.220) REFUSED 7 (MCQ.220) DON'T KNOW 9 (MCQ.220)	have this liver condition? YES 1 NO 2 REFUSED 7 DON'T KNOW 9	had this liver condition? |___|___|___| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999

HELP SCREENS FOR MCQ.160

MCQ160a

Arthritis: Is joint inflammation characterized by stiffness, swelling, redness, heat, or pain in the joint. Common types of arthritis are rheumatoid arthritis and osteoarthritis

MCQ.191

Rheumatoid Arthritis: A common type of arthritis. If one knee or hand has rheumatoid arthritis, usually the other does too. This disease often occurs in more than one joint and can affect any joint in the body. People with this disease may feel sick and tired, and they sometimes get fevers.

Osteoarthritis: This is the most common type of arthritis. Osteoarthritis primarily affects cartilage, which is the tissue that cushions the ends of bones within the joint. Frequently affects the spine and the weight-bearing joints (the knees and hips).

Arthritis: A condition affecting the bone and muscle. The inflammation of a joint. Common types of arthritis are rheumatoid arthritis and osteoarthritis.

MCQ160n

Gout: Gout is one of the most painful forms of arthritis. It occurs when too much uric acid builds up in the body. For many people, the first attack of gout occurs in the big toe. Often, the attack wakes a person from sleep.

MCQ160b

Congestive Heart Failure: Heart failure is a condition where the heart cannot pump enough blood throughout the body. Blood and fluid to "back up" into the lungs which causes shortness of breath. The heart failure causes a buildup of fluid in the feet, ankles, and legs. Do not count heart murmurs, dropped or skipped heart beats, chest pain or heart attacks.

MCQ160c

Coronary Heart Disease: Occurs when the arteries that supply blood to the heart muscle become hardened and narrowed due to buildup of a material called plaque (plak). The buildup of plaque is known as atherosclerosis (ATH-er-o-skler-O-sis). This can lead to angina or a heart attack.

INTERVIEWER: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR CORONARY HEART DISEASE.

MCQ160d

Angina (Angina Pectoris): (AN-ji-na or an-JI-na). Angina is chest pain or discomfort that occurs when the heart does not get enough blood.

INTERVIEWER: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR ANGINA.

MCQ160e

Heart Attack (Myocardial Infarction): A heart attack happens when a blood clot develops at the site of plaque in a coronary artery and suddenly cuts off most or all blood supply to that part of the heart muscle. Common symptoms include crushing lower chest pain that may radiate to the jaw or arms. The chest pain may be associated with nausea, sweating, and shortness of breath.

MCQ160f

Stroke: A stroke occurs when the blood supply to part of the brain is suddenly interrupted or when a blood vessel in the brain bursts. The symptoms of a stroke include sudden numbness or weakness, especially on one side of the body; sudden confusion or trouble speaking or understanding speech; sudden trouble seeing in one or both eyes; sudden trouble with walking, dizziness, or loss of balance or coordination; or sudden severe headache with no known cause.

MCQ160g

Emphysema: Emphysema is a lung disease in which the alveoli (tiny air sacs) become damaged and less air goes in and out. It is frequently due to smoking. The main symptom is shortness of breath.

MCQ160m

Thyroid Problem: Include hyperthyroidism (overactive thyroid); hypothyroidism (underactive thyroid); Graves disease (a thyroid eye disease); Hashimoto's thyroditis (inflamed thyroid); thyroid cancer; thyroid nodule (lump growing in thyroid); and postpartum thyroiditis (a thyroid disease that occurs after delivery).

MCQ160k

Chronic (Bronchitis): is characterized by a productive cough that produces sputum for three months or more in at least two consecutive years.

MCQ.220 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had cancer or a malignancy (ma-lig-nan-see) of any kind?

HELP SCREEN:

Cancer: An abnormal uncontrolled growth of tissue that has potential to spread to distant sites of the body, also known as a malignant tumor.

Malignancy: A tumor or growth that is cancerous. (see Cancer)

YES 1

NO 2 (MCQ.300a)

REFUSED 7 (MCQ.300a)

DON'T KNOW 9 (MCQ.300a)

MCQ.230 What kind of cancer was it?

ENTER UP TO 3 KINDS. IF RESPONDENT OFFERS MORE THAN 3, ENTER 66 AS THE 4TH RESPONSE.

CAPI INSTRUCTIONS:

ALLOW UP TO 3 ENTRIES.

ALLOW 'MORE THAN 3 KINDS (CODE 66) ONLY AS 4TH ENTRY.

(        ) (        ) (        ) (        )

BLADDER 10 BLOOD 11 BONE 12 BRAIN 13 BREAST 14 CERVIX (CERVICAL) 15 COLON 16 ESOPHAGUS (ESOPHAGEAL) 17 GALLBLADDER 18 KIDNEY 19 LARYNX/WINDPIPE 20

LEUKEMIA 21 LIVER 22 LUNG 23 LYMPHOMA/HODGKINS' DISEASE 24 MELANOMA 25 MOUTH/TONGUE/LIP 26 NERVOUS SYSTEM 27 OVARY (OVARIAN) 28 PANCREAS (PANCREATIC) 29 PROSTATE 30 RECTUM (RECTAL) 31

SKIN (NON-MELANOMA) 32 SKIN (DON'T KNOW WHAT KIND) 33 SOFT TISSUE (MUSCLE OR FAT) 34 STOMACH 35 TESTIS (TESTICULAR) 36 THYROID 37 UTERUS (UTERINE) 38 OTHER 39 MORE THAN 3 KINDS 66 REFUSED 77 DON'T KNOW 99

BOX 9

LOOP 1:

ASK MCQ.240 FOR EACH TYPE OF CANCER (CODES 10-39 AND CODE 99) ENTERED IN MCQ.230.

MCQ.240 How old {were you/was SP} when {TYPE OF CANCER/cancer} was first diagnosed?

CAPI INSTRUCTIONS:

DISPLAY TYPE OF CANCER (CODE 10-39) ENTERED IN MCQ.230.

DISPLAY "CANCER " IF DON'T KNOW ENTERED IN MCQ.230.

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

BOX 9A

END LOOP 1:

ASK MCQ.240 FOR NEXT TYPE OF CANCER (CODES 10-39 AND CODE 99) ENTERED IN MCQ.230.

IF NO NEXT TYPE, CONTINUE WITH MCQ.300a.

BOX 10

OMITTED

BOX 10A

CHECK ITEM MCQ.248:

IF SP AGE >= 20, CONTINUE.

OTHERWISE, GO TO MCQ.300b.

KIDNEY CONDITIONS

KIQ.022 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had weak or failing kidneys? Do not include kidney stones, bladder (bladd-er) infections, or incontinence (in‑kon‑ti‑nens).

YES 1

NO 2 (KIQ.026)

REFUSED 7 (KIQ.026)

DON'T KNOW 9 (KIQ.026)

KIQ.025 In the past 12 months, {have you/has SP} received dialysis (either hemodialysis (heemo-di-al-i-sis) or peritoneal dialysis (pare-i-ton-nee-al di-al-i-sis))?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

KIQ.026 {Have you/Has SP} ever had kidney stones?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

KIQ.028 How many times {have you/has SP} passed a kidney stone?

|___|___|

ENTER NUMBER OF TIMES

SOFT EDIT 1-12

NEVER 1

REFUSED 77

DON'T KNOW 99

DIABETES

DIQ.010 {Other than during pregnancy, {have you/has SP}/{Have you/Has SP}} ever been told by a doctor or other health professional that {you have/{he/she/SP} has} diabetes or sugar diabetes?

CAPI INSTRUCTION:

IF SP AGE < 15, DISPLAY "HAS SP" FOR THE FIRST DISPLAY AND "SP HAS" FOR THE SECOND DISPLAY.

IF SP IS FEMALE AND AGE >= 20, DISPLAY "OTHER THAN DURING PREGNANCY, {HAVE YOU/HAS SP}".

YES 1

NO 2 (BOX 4)

BORDERLINE OR PREDIABETES 3 (BOX 4)

REFUSED 7 (BOX 4)

DON'T KNOW 9 (BOX 4)

DIQ.040 G/Q

How old {was SP/were you} when a doctor or other health professional first told {you/him/her} that {you/he/she} had diabetes or sugar diabetes?

|___|___|

ENTER AGE IN YEARS

LESS THAN 1 YEAR 666

REFUSED 777

DON'T KNOW 999

BOX 4

CHECK ITEM DIQ.159:

IF AGE < 12 OR DIQ.010 = 1 (YES) GO TO DIQ.050.

IF AGE >= 12 AND DIQ.010 = 3, GO TO DIQ.170.

OTHERWISE, CONTINUE.

DIQ.160 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/SP has} any of the following: prediabetes, impaired fasting glucose, impaired glucose tolerance, borderline diabetes or that {your/her/his} blood sugar is higher than normal but not high enough to be called diabetes or sugar diabetes?

CAPI INSTRUCTION:

HELP SCREEN: PREDIABETES, IMPAIRED FASTING GLUCOSE, IMPAIRED GLUCOSE TOLERANCE, OR BORDERLINE DIABETES OCCURS WHEN BLOOD SUGAR (GLUCOSE) LEVELS ARE HIGHER THAN NORMAL BUT NOT HIGH ENOUGH TO BE DIABETES.

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HAND CARD DIQ1

Prediabetes

Impaired fasting glucose

Impaired glucose tolerance

Borderline diabetes

DIQ.170 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/s/he has} health conditions or a medical or family history that increases {your/his/her} risk for diabetes?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

DIQ.180 {Have you/Has SP} had a blood test for high blood sugar or diabetes within the past three years?

INTERVIEWER INSTRUCTION: DO NOT INCLUDE URINE TESTS

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

DIQ.050 {Is SP/Are you} now taking insulin?

YES 1

NO 2 (BOX 0)

REFUSED 7 (BOX 0)

DON'T KNOW 9 (BOX 0)

DIQ.060 G/Q/U

For how long {have you/has SP} been taking insulin?

|___|___|___|

ENTER NUMBER (OF MONTHS OR YEARS)

LESS THAN 1 MONTH 666

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MONTHS 1

YEARS 2

BOX 0

CHECK ITEM DIQ.065:

IF DIQ.010 = 1 (YES) OR DIQ.160 = 1 (YES) OR DIQ.010 = 3, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

DIQ.070 {Is SP/Are you} now taking diabetic pills to lower {{his/her}/your} blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 8

CHECK ITEM DIQ.229:

IF DIQ.010 = 3 OR DIQ.160 = 1 (YES), GO TO END OF SECTION.

OTHERWISE, CONTINUE.

DIQ.230 When was the last time {you/SP} saw a diabetes nurse educator or dietitian or nutritionist for {your/his/her} diabetes? Do not include doctors or other health professionals.

INTERVIEWER INSTRUCTION: IF RESPONDENT ANSWERS “TODAY” OR A PERIOD LESS THAN A MONTH, CODE 1 – THE 0-12 MONTH CATEGORY.

CAPI INSTRUCTION:

HELP SCREEN: A diabetes nurse educator is a nurse who teaches people with diabetes and who is knowledgeable about the day-to-day aspects of diabetes self-care, such as, use of diabetes medications, checking and controlling blood glucose levels, managing weight through diet and physical activity, and maintaining a healthy pregnancy if diabetes is present.

1 YEAR AGO OR LESS 1

MORE THAN 1 YEAR AGO BUT NO MORE
THAN 2 YEARS AGO 2

MORE THAN 2 YEARS AGO BUT NO MORE
THAN 5 YEARS AGO 3

MORE THAN 5 YEARS AGO 4

NEVER 5

REFUSED 7

DON’T KNOW 9

DIQ.240 Is there one doctor or other health professional {you usually see/SP usually sees} for {your/his/her} diabetes? Do not include specialists to whom {you have/SP has} been referred such as diabetes educators, dieticians or foot and eye doctors.

CAPI INSTRUCTION:

HELP SCREEN: A diabetes nurse educator is a nurse who teaches people with diabetes and who is knowledgeable about the day-to-day aspects of diabetes self-care, such as, use of diabetes medications, checking and controlling blood glucose levels, managing weight though diet and physical activity, and maintaining a healthy pregnancy if diabetes is present.

YES 1

NO 2 (DIQ.260)

REFUSED 7 (DIQ.260)

DON’T KNOW 9 (DIQ.260)

DIQ.250 How many times {have you/has SP} seen this doctor or other health professional in the past 12 months?

|___|___|___|

ENTER NUMBER OF TIMES

CAPI INSTRUCTION:

HARD EDIT: DO NOT ALLOW 0.

NONE 2

REFUSED 7777

DON'T KNOW 9999

BOX 9

CHECK ITEM DIQ.369:

IF DIQ.250 = 2 (NONE), CONTINUE.

OTHERWISE, GO TO BOX 10.

DIQ.370 INTERVIEWER: YOU HAVE ENTERED “NONE” FOR THE NUMBER OF TIMES IN THE PAST 12 MONTHS THAT THE SP HAS SEEN THEIR USUAL DOCTOR OR OTHER HEALTH PROFESSIONAL. THIS IS AN UNLIKELY RESPONSE. IS THIS CORRECT?

YES 1

NO 2 (DIQ.250)

BOX 10

CHECK ITEM DIQ.379:

IF DIQ.250 = 100 OR MORE, CONTINUE.

OTHERWISE, GO TO DIQ.260.

DIQ.380 INTERVIEWER: YOU HAVE ENTERED A VALUE THAT IS OUTSIDE THE EXPECTED RANGE FOR THE NUMBER OF TIMES IN THE PAST 12 MONTHS THAT THE SP HAS SEEN THEIR USUAL DOCTOR OR OTHER HEALTH PROFESSIONAL. THIS IS AN UNLIKELY RESPONSE. IS THIS CORRECT?

YES 1

NO 2 (DIQ.250)

DIQ.260 G/Q/U

How often {do you check your/does SP check his/her} blood for glucose or sugar? Include times when checked by a family member or friend, but do not include times when checked by a doctor or other health professional.

INTERVIEWER INSTRUCTION: DO NOT INCLUDE URINE TESTS.

|___|___|___|

ENTER NUMBER OF TIMES

CAPI INSTRUCTION: SOFT EDIT 7 OR MORE PER DAY

SOFT EDIT 30 OR MORE PER WEEK.

NEVER 2

UNABLE TO DO ACTIVITY (BLIND) 3

REFUSED 7777

DON'T KNOW 9999

ENTER UNIT

PER DAY 1

PER WEEK 2

PER MONTH 3

PER YEAR 4

BOX 10A

CHECK ITEM DIQ.295:

IF AGE <12, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

DIQ.341 G/Q

During the past 12 months, about how many times has a doctor or other health professional checked {your/SP’s} feet for any sores or irritations?

|___|___|___|

ENTER NUMBER OF TIMES

CAPI INSTRUCTION:

HARD EDIT: DO NOT ALLOW 0.

NONE 2

BOTH FEET AMPUTATED 3 (DIQ.360)

REFUSED 7777

DON'T KNOW/not sure 9999

DIQ.350 G/Q/U

How often {do you check your feet/does SP check (his/her) feet} for sores or irritations? Include times when checked by a family member or friend, but do not include times when checked by a doctor or other health professional.

|___|___|___|

ENTER NUMBER OF TIMES

NONE 2

REFUSED 7777

DON'T KNOW 9999

ENTER UNIT

PER DAY 1

PER WEEK 2

PER MONTH 3

PER YEAR 4

DIQ.360 When was the last time {you/SP} had an eye exam in which the pupils were dilated? This would have made {you/SP} temporarily sensitive to bright light.

LESS THAN 1 MONTH 1

1-12 MONTHS 2

13-24 MONTHS 3

GREATER THAN 2 YEARS 4

NEVER 5

REFUSED 7

DON'T KNOW 9

DIQ.080 Has a doctor ever told {you/SP} that diabetes has affected {your/his/her} eyes or that {you/s/he} had retinopathy (ret-in-op-ath-ee)?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BLOOD PRESSURE

BPQ.020 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had hypertension (hy-per-ten-shun), also called high blood pressure?

IF HIGH BLOOD PRESSURE ONLY DURING PREGNANCY, CODE NO.

INTERVIEWER INSTRUCTION: IF SP SAYS “HIGH NORMAL BLOOD PRESSURE”, “BORDERLINE HYPERTENSION” OR “PREHYPERTENSION” CODE NO.

YES 1

NO 2 (BPQ.057)

REFUSED 7 (BPQ.057)

DON'T KNOW 9 (BPQ.057)

HELP SCREEN:

Hypertension (High Blood Pressure): A repeatedly increased blood pressure with the first number 140 or higher and the second number 90 or higher.

BPQ.030 {Were you/Was SP} told on 2 or more different visits that {you/s/he} had hypertension (hy-per-ten-shun), also called high blood pressure?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BPQ.035 How old {were you/was SP} when {you were/he/she was} first told that {you/he/she} had hypertension or high blood pressure?

|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

BPQ.040a Because of {your/SP’s} (high blood pressure/hypertension) (hy-per-ten-shun), {have you/has s/he} ever been told to take prescribed medicine?

YES 1

NO 2 (BPQ.057)

REFUSED 7 (BPQ.057)

DON’T KNOW 9 (BPQ.057)

HELP SCREEN:

Prescribed Medicine: Prescribed medicines are those ordered by a doctor or other health provider through a written or verbal prescription for a pharmacist to fill. Prescription medicines can also be given by a medical provider directly to a patient to take home, such as free samples.

BOX 1A

OMITTED

BOX 1B

OMITTED

BPQ.050a {Are you/Is SP} now taking a prescribed medicine?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BPQ.057 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/s/he has} high normal blood pressure, prehypertension or borderline hypertension?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HAND CARD BPQ1

High normal blood pressure

Prehypertension

Borderline hypertension

CAPI INSTRUCTION:

HELP SCREEN:

High normal blood pressure or borderline hypertension is defined as having a blood pressure reading of 120 to 139 for the first reading and the second reading of 80 to 89 millimeters. People with blood pressures that are high normal blood pressure or borderline hypertension also called prehypertension.

BPQ.056 {Did you/Did SP} take {your/his/her} blood pressure at home during the last 12 months?

YES 1

NO 2 (BPQ.059)

REFUSED 7 (BPQ.059)

DON'T KNOW 9 (BPQ.059)

BPQ.058 How often {did you check your/did SP check his/her} blood pressure at home during the last 12 months? (You can tell me the number of times per day, per week, per month, or per year.)

Q/U

|___|___|___|

ENTER NUMBER OF TIMES

CAPI INSTRUCTION:

SOFT EDIT 10 OR MORE PER DAY

SOFT EDIT 50 OR MORE PER WEEK

SOFT EDIT 200 OR MORE PER MONTH

REFUSED 7777

DON'T KNOW 9999

ENTER UNIT

PER DAY 1

PER WEEK 2

PER MONTH 3

PER YEAR 4

BPQ.059 Did a doctor or other health professional tell {you/SP} to take {your/his/her} blood pressure at home?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2

CHECK ITEM BPQ.055:

IF SP AGE >= 20, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

BPQ.060 {Have you/Has SP} ever had {your/his/her} blood cholesterol checked?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

CAPI INSTRUCTION:

IF DIQ.320 = 3 (NEVER HAD CHOLESTEROL TEST) AND BPQ.060 = 1 (YES), DISPLAY THE FOLLOWING MESSAGE: “YOU HAVE CODED THAT SP HAS HAD THEIR BLOOD CHOLESTEROL CHECKED. EARLIER ON DIQ SP REPORTED NEVER HAVING A CHOLESTEROL TEST – RECONCILE RESPONSE WITH SP AND CHANGE RESPONSE TO ONE OF THE QUESTIONS BELOW (BPQ.060).” DISPLAY RESPONSES TO BOTH – WITH LABELS. DIQ.320 – NEVER HAD CHOLESTEROL TEST, BPQ.060 – HAS HAD CHOLESTEROL CHECKED. HIGHLIGHT MUST BE ON DIQ.320.

BPQ.070 About how long has it been since {you/SP} last had {your/his/her} blood cholesterol checked? Has it been…

less than 1 year ago, 1

1 year but less than 2 years ago, 2

2 years but less than 5 years ago, or 3

5 years or more? 4

REFUSED 7

DON'T KNOW 9

BPQ.080 {Have you/Has SP} ever been told by a doctor or other health professional that {your/his/her} blood cholesterol level was high?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

HELP SCREEN:

Cholesterol: Cholesterol is a type of fat in the bloodstream and is measured with a blood test, usually done in the morning before you’ve eaten. High levels of cholesterol is a major risk factor for heart disease, which leads to heart attack.

BPQ.090 To lower {your/his/her} blood cholesterol, {have you/has SP} ever been told by a doctor or other health professional . . .

RESPONSES: YES = 1, NO = 2, REFUSED = 7, DON'T KNOW = 9.

a. to eat fewer high fat or high cholesterol foods? ____

b. to control {your/his/her} weight or lose weight? ____

c. to increase {your/his/her} physical activity or exercise? ____

d. to take prescribed medicine? ____

HELP SCREEN:

Prescribed Medicine: Prescribed medicines are those ordered by a doctor or other health provider through a written or verbal prescription for a pharmacist to fill. Prescription medicines can also be given by a medical provider directly to a patient to take home, such as free samples.

BOX 3

CHECK ITEM BPQ.095:

IF 'YES' (CODE 1) TO BPQ.090A, B, C OR D, CONTINUE WITH BPQ.100.

OTHERWISE, GO TO END OF SECTION.

BPQ.100 {Are you/Is SP} now following this advice to {DISPLAY ACTIVITY}?

CAPI INSTRUCTIONS:

DISPLAY EACH ACTIVITY CODED AS 'YES' (CODE 1) IN BPQ.090 A-D.

RESPONSES: YES = 1, NO = 2, REFUSED = 7, DON'T KNOW = 9.

a. eat fewer high fat or high cholesterol foods? ____

b. control {your/his/her} weight or lose weight? ____

c. increase {your/his/her} physical activity or exercise? ____

d. take prescribed medicine? ____

HELP SCREEN:

Prescribed Medicine: Prescribed medicines are those ordered by a doctor or other health provider through a written or verbal prescription for a pharmacist to fill. Prescription medicines can also be given by a medical provider directly to a patient to take home, such as free samples.

BOX 5

OMITTED

BOX 6

OMITTED

BOX 7

OMITTED

BOX 8

OMITTED

BOX 9

OMITTED

CARDIOVASCULAR disease

CDQ.001 {Have you/Has SP} ever had any pain or discomfort in {your/her/his} chest?

YES 1

NO 2 (CDQ.010)

REFUSED 7 (CDQ.010)

DON'T KNOW 9 (CDQ.010)

CDQ.002 {Do you/Does she/Does he} get it when {you/she/he} {walk/walks} uphill or {hurry/hurries}?

YES 1

NO 2 (CDQ.008)

NEVER WALKS UPHILL OR HURRIES 3

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.003 {Do you/Does she/Does he} get it when {you/she/he} {walk/walks} at an ordinary pace on level ground?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1

CHECK ITEM CDQ.003A:

IF 'YES' (CODE '1') IN CDQ.002 OR CDQ.003, CONTINUE.

OTHERWISE, GO TO CDQ.008.

CDQ.004 What {do you/does she/does he} do if {you/she/he} get it while {you/she/he} are walking? {Do you/Does she/Does he} stop or slow down, or continue at the same pace?

CODE "STOP OR SLOW DOWN" IF SP CARRIES ON AFTER TAKING NITROGLYCERINE.

STOP OR SLOW DOWN 1

CONTINUE AT THE SAME PACE 2 (CDQ.008)

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.005 If {you/she/he} {stand/stands} still, what happens to it? Is the pain or discomfort relieved or not relieved?

RELIEVED 1

NOT RELIEVED 2 (CDQ.008)

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.006 How soon is the pain relieved? Would you say . . .

10 minutes or less or 1

more than 10 minutes? 2 (CDQ.008)

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.009 Please look at this card and show me where the pain or discomfort is located.

CODE ALL THAT APPLY.

PROBE FOR ADDITIONAL AREAS.

HAND CARD CDQ1

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

REFUSED 77

DON'T KNOW 99

CDQ.008 Have {you/she/he} ever had a severe pain across the front of {your/her/his} chest lasting for half an hour or more?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CDQ.010 {Have you/Has SP} had shortness of breath either when hurrying on the level or walking up a slight hill?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2

OMITTED

OSTEOPOROSIS

OSQ.010 a/b/c	Has a doctor ever told {you/SP} that {you/SP} had broken or fractured {your/his/her} . . .		OSQ.020	How many times {have you/has SP} broken or fractured {your/his/her} {hip/wrist/spine}?
	a. hip? YES 1 NO 2 (b) REFUSED 7 (b) DON'T KNOW 9 (b)			|___|___| ENTER NUMBER OF TIMES CAPI INSTRUCTION: HARD EDIT: 1-33. REFUSED 77 DON'T KNOW 99
	b. wrist? YES 1 DO NOT NO 2 (c) INCLUDE REFUSED 7 (c) FOREARM OR DON'T KNOW 9 (c) HAND			|___|___| ENTER NUMBER OF TIMES CAPI INSTRUCTION: HARD EDIT: 1-33. REFUSED 77 DON'T KNOW 99
	c. spine? YES 1 NO 2 (BOX 1) REFUSED 7 (BOX 1) DON'T KNOW 9 (BOX 1)			|___|___| ENTER NUMBER OF TIMES CAPI INSTRUCTION: HARD EDIT: 1-33. REFUSED 77 DON'T KNOW 99

BOX 1

CHECK ITEM OSQ.025:

IF 'YES' (CODE 1) IN OSQ.010 a, b, OR c, CONTINUE WITH LOOP 1.

OTHERWISE, GO TO OSQ.080.

LOOP 1:

ASK OSQ.030 - OSQ.051 FOR EACH TYPE AND EACH INCIDENT OF FRACTURE. (EXAMPLE: HOW OLD WERE YOU WHEN YOU FRACTURED YOUR HIP THE FIRST TIME?)

OSQ.030 a/b/c

How old {were you/was SP} when {you/s/he} fractured {your/his/her} {hip/wrist/spine} {the {1st/2nd/10th or more recent time . . .} time}?

CAPI INSTRUCTION:

IF ONLY BROKE HIP, WRIST OR SPINE 1 TIME, DO NOT DISPLAY "THE {1ST/2ND . . .} TIME".

IF 10TH TIME, DISPLAY {10TH OR MOST RECENT TIME}.

|___|___|___| (BOX 2)

ENTER AGE IN YEARS

CAPI INSTRUCTION: HARD EDIT: 1-120.

REFUSED 777

DON'T KNOW 999

OSQ.040 {Were you/Was SP} . . .

a/b/c

under 50 years old, or 1

50 years old or older? 2

REFUSED 7 (BOX 3)

DON'T KNOW 9 (BOX 3)

BOX 2

CHECK ITEM OSQ.045:

IF AGE IS >= 50 IN OSQ.030 OR OSQ.040, CONTINUE.

OTHERWISE, GO TO BOX 3.

OSQ.051 Did that fracture occur as a result of . . .

a fall from standing height or less, for
example, tripped, slipped, fell out of bed 4

a hard fall, such as falling off a ladder or
step stool, down stairs, or 5

a car accident or other severe trauma? 6

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

HELP SCREEN SHOULD READ: Additional examples for “a fall from standing height or less” include leg gave way, was dizzy, fell bending over, fell out of a chair. Additional examples for “a hard fall” include being forcibly knocked down by another person or bicycle.

BOX 3

END LOOP1:

• ASK OSQ.030 - OSQ.051 FOR NEXT INCIDENT OF FRACTURE.

• IF NO NEXT INCIDENT, CONTINUE.

OSQ.080 Has a doctor ever told {you/SP} that {you/s/he} had broken or fractured any other bone after {you were/s/he was} 20 years of age?

YES 1

NO 2 (OSQ.060)

REFUSED 7 (OSQ.060)

DON'T KNOW 9 (OSQ.060)

OSQ.090 Was this fracture the result of severe trauma such as a car accident, being struck by a vehicle, a physical attack, or a hard fall such as falling off a ladder or down stairs?

YES 1 (OSQ.120)

NO 2

REFUSED 7 (OSQ.120)

DON'T KNOW 9 (OSQ.120)

CAPI INSTRUCTION:

HELP SCREEN SHOULD READ:

Do not include a fall from standing height or less, for example, tripped, slipped, fell out of bed, leg gave way, was dizzy, fell bending over, or fell out of a chair.

Additional examples for “a hard fall” include being knocked down by another person or bicycle.

OSQ.100 Please look at this card and tell me where the fracture occurred.

HAND CARD OSQ 1

HEAD/FACE 10

UPPER ARM (HUMERUS) 11

LOWER ARM BETWEEN WRIST AND

ELBOW (DO NOT INCLUDE WRIST) 12

ELBOW 13

HAND 14

FINGERS 15

SHOULDER 16

COLLAR BONE 17

RIBS (EITHER SIDE) 18

PELVIS (NOT HIP) 19

UPPER LEG (THIGH EXCLUDING HIP) 20

LOWER LEG (BETWEEN ANKLE AND

KNEE) 21

KNEE (PATELLA) 22

ANKLE 23

HEEL 24

FOOT 25

TOES 26

OTHER (DO NOT SPECIFY) 27

REFUSED 77

DON'T KNOW 99

OSQ.110 How old {were you/was SP} when {you/SP} fractured {your/his/her} (fracture site selected in OSQ.100) for the first time after age 20?

|___|___|___|

ENTER AGE IN YEARS

CAPI INSTRUCTION: HARD EDIT: 20-120.

REFUSED 777

DON'T KNOW 999

OSQ.120 Has a doctor ever told {you/SP} that {you/s/he} had broken or fractured any other bones after {you were/s/he was} 20 years of age?

YES 1

NO 2 (OSQ.060)

REFUSED 7 (OSQ.060)

DON'T KNOW 9 (OSQ.060)

BOX 4

CHECK ITEM OSQ.129:

IF OSQ120 = 1 (YES), CONTINUE WITH LOOP 2. OTHERWISE, GO TO OSQ.060.

LOOP 2:

ASK OSQ.090 – OSQ.120 FOR NEXT INCIDENT OF FRACTURE. IF NO NEXT INCIDENT, CONTINUE.

OSQ.060 Has a doctor ever told {you/SP} that {you/s/he} had osteoporosis, sometimes called thin or brittle bones?

YES 1

NO 2 (OSQ.130)

REFUSED 7 (OSQ.130)

DON'T KNOW 9 (OSQ.130)

OSQ.070 {Were you/Was SP} ever treated for osteoporosis?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OSQ.130 {Have you/has SP} ever taken any prednisone or cortisone pills nearly every day for a month or longer? [Prednisone and cortisone are types of steroids.]

YES 1

NO 2 (OSQ.150)

REFUSED 7 (OSQ.150)

DON'T KNOW 9 (OSQ.150)

OSQ.140 Q/U

Please think about {your/SP's} use of prednisone or cortisone during {your/his/her} lifetime. For how long did {you/s/he} use prednisone or cortisone nearly every day? Do not count the months or years when {you were/s/he was} not taking the medicine.

|___|___|

ENTER NUMBER

CAPI INSTRUCTION: SOFT EDIT: 19 OR HIGHER.

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MONTH 1

YEAR 2

REFUSED 7

DON’T KNOW 9

OSQ.150 Including living and deceased, were either of {your/SP's} biological parents ever told by a health professional that they had osteoporosis or brittle bones?

YES 1

NO 2 (OSQ.170)

REFUSED 7 (OSQ.170)

DON'T KNOW 9 (OSQ.170)

OSQ.160 Which biological [blood] parent?

CODE ALL THAT APPLY

MOTHER 1

FATHER 2

REFUSED 7

DON'T KNOW 9

OSQ.170 Did {your/SP's} biological mother ever fracture her hip?

YES 1

NO 2 (OSQ.200)

REFUSED 7 (OSQ.200)

DON'T KNOW 9 (OSQ.200)

OSQ.180 About how old was she when she fractured her hip (the first time)?

|___|___|___| (OSQ.200)

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

OSQ.190 Was she. . .

under 50 years old, or 1

50 years old or older? 2

REFUSED 7

DON'T KNOW 9

OSQ.200 Did {your/SP's} biological father ever fracture his hip?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

OSQ.210 About how old was he when he fractured his hip (the first time)?

|___|___|___| (END OF SECTION)

ENTER AGE IN YEARS

CAPI INSTRUCTION: HARD EDIT: 20-120.

REFUSED 777

DON'T KNOW 999

OSQ.220 Was he . . .

under 50 years old, or 1

50 years old or older? 2

REFUSED 7

DON'T KNOW 9

RESPIRATORY HEALTH AND DISEASE

BOX 1

CHECK ITEM RDQ.005A:

IF SP AGE < 40, GO TO RDQ.070.

OTHERWISE, CONTINUE

RDQ.031 {Do you/Does SP} usually cough on most days for 3 consecutive months or more during the year?

YES 1

NO 2 (RDQ.050)

REFUSED 7 (RDQ.050)

DON'T KNOW 9 (RDQ.050)

RDQ.040 For how many years {have you/has SP} had this cough?

IF LESS THAN 1 YEAR, ENTER 1

|___|___|___|

ENTER NUMBER OF YEARS

REFUSED 777

DON'T KNOW 999

RDQ.050 {Do you/Does SP} bring up phlegm on most days for 3 consecutive months or more during the year?

YES 1

NO 2 (RDQ.070)

REFUSED 7 (RDQ.070)

DON'T KNOW 9 (RDQ.070)

RDQ.060 For how many years {have you/has SP} had trouble with phlegm (flem)?

IF LESS THAN 1 YEAR, ENTER 1

|___|___|

ENTER NUMBER OF YEARS

REFUSED 777

DON'T KNOW 999

RDQ.070 In the past 12 months, {have you/has SP} had wheezing or whistling in {your/his/her} chest?

YES 1

NO 2 (RDQ.140)

REFUSED 7 (RDQ.140)

DON'T KNOW 9 (RDQ.140)

RDQ.080 [In the past 12 months], how many attacks of wheezing or whistling {have you/has SP} had?

IF 12 OR MORE EPISODES, ENTER 12

CAPI INSTRUCTION:

HARD EDIT: RANGE EQUALS 1 TO 12.

|___|___|

ENTER NUMBER OF EPISODES

REFUSED 77

DON'T KNOW 99

RDQ.090 [In the past 12 months], how often, on average, has {your/SP's} sleep been disturbed because of wheezing? Would you say this happens . . .

never, 0

1 or more nights per week, or 1

less than 1 night per week? 2

REFUSED 7

DON’T KNOW 9

RDQ.100 [In the past 12 months], has {your/SP's} chest sounded wheezy during or after exercise or physical activity?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 3

OMITTED

RDQ.120 [In the past 12 months], how many times {have you/has SP} gone to the doctor's office or the hospital emergency room for one or more of these attacks of wheezing or whistling?

IF NEVER, ENTER 0

|___|___|

ENTER NUMBER

CAPI INSTRUCTION:

SOFT EDIT: IF RESPONSE >20, THEN DISPLAY “UNLIKELY RESPONSE. PLEASE VERIFY. (RDQ.150).”

HARD EDIT: CHECK: RDQ.120 – RANGE ERROR, THE VALID RANGE IS 0-50.

REFUSED 77

DON'T KNOW 99

RDQ.134 [In the past 12 months], {have you/has SP} taken any medication, prescribed by a doctor, for wheezing or whistling?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

RDQ.135 During the past 12 months, how much did {you/SP} limit {your/his/her} usual activities due to wheezing or whistling? Would you say…

not at all, 1

a little, 2

a fair amount, 3

a moderate amount, or 4

a lot? 5

REFUSED 7

DON'T KNOW 9

BOX 4

CHECK ITEM RDQ.136:

IF SP AGE = 6-69 YEARS, CONTINUE.

OTHERWISE, GO TO RDQ.140.

RDQ.137 During the past 12 months, how many days of work or school did {you/SP} miss due to wheezing or whistling?

NONE 0

1 TO 7 1

8 TO 30 2

31 PLUS 3

REFUSED 7

DON'T KNOW 9

RDQ.140 [In the past 12 months], {have you/has SP} had a dry cough at night not counting a cough associated with a cold or chest infection lasting 14 days or more?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AGQ.030 During the past 12 months, {have you/has SP} had an episode of hay fever?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUDIOMETRY

AUQ.131 These next questions are about {your/SP’s} hearing.

Which statement best describes {your/SP’s} hearing (without a hearing aid)? Would you say {your/his/her} hearing is excellent, good, that {you have/s/he has} a little trouble, moderate trouble, a lot of trouble, or {are you/is s/he} deaf?

EXCELLENT 1

GOOD 2

A LITTLE TROUBLE 3

MODERATE HEARING TROUBLE 4

A LOT OF TROUBLE 5

DEAF 6

REFUSED 7

DON’T KNOW 9

BOX 1

CHECK ITEM AUQ.135:

IF SP AGE >= 12 AND AGE <= 19, GO TO AUQ.136.

OTHERWISE, CONTINUE.

BOX 2

CHECK ITEM AUQ.249:

IF AGE 70+, GO TO AUQ.141.

OTHERWISE, GO TO END OF SECTION.

AUQ.136 {Have you/Has SP} ever had 3 or more ear infections?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.138 {Have you/Has SP} ever had a tube placed in {your/his/her} ear to drain the fluid from {your/his/her} ear?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.141 When was the last time {you had/SP had} {your/his/her} hearing tested?

READ CATEGORIES IF NECESSARY

LESS THAN A YEAR AGO 1

1 YEAR TO 4 YEARS AGO 2

5 TO 9 YEARS AGO 3

TEN OR MORE YEARS AGO 4

NEVER 5

REFUSED 7

DON’T KNOW 9

AUQ.150 {Have you/Has SP} ever worn a hearing aid?

YES 1

NO 2 (AUQ.185)

REFUSED 7 (AUQ.185)

DON'T KNOW 9 (AUQ.185)

AUQ.171 In the past 12 months, {have you/has SP} worn a hearing aid at least 5 hours a week?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.185 {Have you/Has SP} ever used assistive listening devices (ALDs), such as FM systems, closed-captioned television, or amplified telephone (or relay services)?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.191 In the past 12 months, {have you/has SP} been bothered by ringing, roaring, or buzzing in {your/his/her} ears or head that lasts for 5 minutes or more?

YES 1

NO 2 (AUQ.211)

REFUSED 7 (AUQ.211)

DON'T KNOW 9 (AUQ.211)

AUQ.250 How long {have you/has SP} been bothered by this ringing, roaring, or buzzing in {your/his/her} ears or head?

READ CATEGORIES IF NECESSARY

LESS THAN THREE MONTHS 1

THREE MONTHS TO A YEAR 2

1 TO 4 YEARS 3

5 TO 9 YEARS 4

TEN OR MORE YEARS 5

REFUSED 7

DON’T KNOW 9

AUQ.260 {Are you/Is SP} bothered by ringing, roaring, or buzzing in {your/his/her} ears or head only after listening to loud sounds or loud music?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.270 {Are you/Is SP} bothered by ringing, roaring, or buzzing in {your/his/her} ears or head when going to sleep?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.280 How much of a problem is this ringing, roaring, or buzzing in {your/his/her} ears or head?

No problem 1

A small problem 2

A moderate problem 3

A big problem 4

A very big problem 5

REFUSED 7

DON’T KNOW 9

AUQ.211 {Have you/Has SP} ever used firearms for target shooting, hunting, or for any other purposes?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.290 {Have you/Has SP} ever had a job where {you were/s/he was} exposed to loud noise for 5 or more hours a week? By loud noise I mean noise so loud that {you/s/he} had to speak in a raised voice to be heard.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.231 Outside of a job, {have you/has SP} ever been exposed to steady loud noise or music for 5 or more hours a week? This is noise so loud that {you have/s/he has} to raise {your/his/her} voice to be heard. Examples are noise from power tools, lawn mowers, farm machinery, cars, trucks, motorcycles, or loud music.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.241 How often {do you/does SP} wear hearing protection devices (ear plugs, ear muffs) when exposed to loud sounds or noise? (Include both job and off work exposures.)

Most of the time 1

Sometimes 2

Rarely/seldom 3

Never 4

REFUSED 7

DON’T KNOW 9

DERMATOLOGY

DEQ.031 Next are some general questions about {your/SP’s} skin.

If after several months of not being in the sun, {you/SP} then went out in the sun without sunscreen or protective clothing for a half hour, which one of these would happen to {your/his/her} skin?

HAND CARD DEQ1

GET A SEVERE SUNBURN WITH

BLISTERS 1

A SEVERE SUNBURN FOR A FEW DAYS

WITH PEELING 2

MILDLY BURNED WITH SOME TANNING 3

TURNING DARKER WITHOUT A

SUNBURN 4

NOTHING WOULD HAPPEN IN HALF AN

HOUR 5

OTHER 6

REFUSED 7

DON'T KNOW 9

DEQ.034 a/c/d

When {you go/SP goes} outside on a very sunny day, for more than one hour, how often {do you/does SP} . . .

HAND CARD DEQ2

a. Stay in the shade? Would you say . . .

always, 1

most of the time, 2

sometimes, 3

rarely, or 4

never? 5

DON'T GO OUT IN THE SUN 6 (DEQ.038)

REFUSED 7

DON'T KNOW 9

c. Wear a long sleeved shirt? Would you say . . .

always, 1

most of the time, 2

sometimes, 3

rarely, or 4

never? 5

REFUSED 7

DON'T KNOW 9

d. Use sunscreen? Would you say . . .

always, 1

most of the time, 2

sometimes, 3

rarely, or 4

never? 5 (DEQ.038)

REFUSED 7 (DEQ.038)

DON'T KNOW 9 (DEQ.038)

DEQ.038 G/Q

How many times in the past year {have you/has SP} had a sunburn?

|___|___|___|

ENTER NUMBER OF TIMES

NEVER 000

REFUSED 777

DON'T KNOW 999

CAPI INSTRUCTION:

BUILD HARD EDITS AS 1-365.

DEQ.120 G/Q/U

The next questions ask about the time you spent outdoors during the past 30 days. By outdoors, I mean outside and not under any shade.

How much time did you usually spend outdoors between 9 in the morning and 5 in the afternoon on the days that you worked or went to school?

PROBE IF NEEDED: I am only interested in the amount of time you spent outdoors between 9 in the morning and 5 in the afternoon.

1. ENTER AMOUNT OF TIME (IN MINUTES OR HOURS)

2. NO TIME SPENT OUTDOORS

3. DOES NOT WORK OR GO TO SCHOOL

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

HARD EDIT: The value entered cannot exceed 8 hours or 480 minutes.

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

DEQ.125 G/Q/U

During the past 30 days, how much time did you usually spend outdoors between 9 in the morning and 5 in the afternoon on the days when you were not working or going to school?

1. ENTER AMOUNT OF TIME (IN MINUTES OR HOURS)

2. NO TIME SPENT OUTDOORS

3. AT WORK OR AT SCHOOL 9 to 5 SEVEN DAYS A WEEK

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

HARD EDIT: The value entered cannot exceed 8 hours or 480 minutes.

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

Oral health

OHQ.800 The next questions will ask about the condition of {your/SP’s} teeth and some factors related to gum health.

{Have you/Has SP} lost all of {your/his/her} upper and lower natural (permanent) teeth?

YES 1 (END OF SECTION)

NO 2

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

OHQ.805 Has the doctor or dentist ever told {you/SP} that {you/he/she} must always take antibiotics (such as penicillin) before {you get/ he/she gets} a dental check up or dental care?

HELP SCREEN:

Antibiotics: Antibiotics (penicillin, amoxicillin, erythromycin and so on) cure disease by killing or injuring bacteria. Today, over 100 different antibiotics are available to doctors to cure minor discomforts as well as life-threatening infections.

YES 1 (OHQ.835)

NO 2

REFUSED 7 (OHQ.835)

DON'T KNOW 9 (OHQ.835)

OHQ.810 {Do you/Does SP} have an artificial heart valve?

HELP SCREEN:

Artificial heart valve: An artificial heart valve is a device which is implanted into the heart to replace a defective or malfunctioning valve.

YES 1 (OHQ.835)

NO 2

REFUSED 7 (OHQ.835)

DON'T KNOW 9 (OHQ.835)

OHQ.815 { Have you/Has SP} had heart disease since birth?

INTERVIEWER INSTRUCTION: IF SP SAYS “MITRAL VALVE PROLAPSE” OR “MVP” CODE “NO”.

YES 1 (OHQ.835)

NO 2

REFUSED 7 (OHQ.835)

DON'T KNOW 9 (OHQ.835)

OHQ.820 {Have you/Has SP} had a bacterial infection of the heart, also called bacterial endocarditis (back-t-ear-e-l in-dough-card-eye-t-us)?

HELP SCREEN:

Bacterial Endocarditis: Endocarditis is an inflammation of the inner layer of the heart, the endocardium.

YES 1 (OHQ.835)

NO 2

REFUSED 7 (OHQ.835)

DON'T KNOW 9 (OHQ.835)

OHQ.825 Has a doctor ever told {you/SP} that {you have/he/she has} rheumatic fever?

HELP SCREEN: Rheumatic fever: Rheumatic fever is a disease that affects the joints, skin, heart, blood vessels, and brain. It is a systemic immune disease that may develop after an infection with streptococcus bacteria, such as strep throat and scarlet fever.

YES 1 (OHQ.835)

NO 2

REFUSED 7 (OHQ.835)

DON'T KNOW 9 (OHQ.835)

OHQ.830 Has a doctor ever told {you/SP} that {you have/she/he has} a hip, bone or other joint replacement?

HELP SCREEN: Hip bone or joint replacement: Surgery to replace all or part of the hip joint or other joint with an artificial device that re-establishes normal joint motion.

CAPI INSTRUCTION: IF 'YES' (CODE 1) IN OHQ.800 – OHQ.830, THE SP IS NOT ELIGIBLE FOR THE MEC ORAL HEALTH EXAMINATION.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.835 Gum disease is a common problem with the mouth. People with gum disease might have swollen gums, receding gums, sore or infected gums or loose teeth. {Do you/Does SP} think {you/s/he} might have gum disease?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.845 Overall, how would {you/SP} rate the health of {your/his/her} teeth and gums?

EXCELLENT 1

VERY GOOD 2

GOOD, 3

FAIR 4

POOR 5

REFUSED 7

DON’T KNOW 9

OHQ.850 {Have you/Has SP} ever had treatment for gum disease such as scaling and root planing, sometimes called deep cleaning?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.855 {Have you/Has SP} ever had any teeth become loose on their own, without an injury?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.860 {Have you/Has SP} ever been told by a dental professional that {you/s/he} lost bone around {your/his/her} teeth?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.865 During the past three months, {have you/has SP} noticed a tooth that doesn’t look right?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.870 Aside from brushing {your/his/her} teeth with a toothbrush, in the last seven days, how many days did {you/SP} use dental floss or any other device to clean between {your/his/her} teeth?

HARD EDIT 0-7.

|___|

ENTER number of DAYS

REFUSED 77

DON'T KNOW 99

OHQ.875 Aside from brushing {your/his/her} teeth with a toothbrush, in the last seven days, how many days did {you/SP} use mouthwash or other dental rinse product that {you use/s/he uses} to treat dental disease or dental problems?

HARD EDIT 0-7.

|___|

ENTER number of DAYS

REFUSED 77

DON'T KNOW 99

physical activity AND PHYSICAL FITNESS

BOX 1

CHECK ITEM PAQ.700:

IF SP AGE 2-11, CONTINUE.

IF SP AGE <2 OR SP 12-15, GO TO NEXT SECTION.

IF SP AGE 16+, GO TO PAQ.605.

PAQ.706 Now I'd like to ask you some questions about {SP's} activities.

During the past 7 days, on how many days was {SP} physically active for a total of at least 60 minutes per day? Add up all the time {SP} spent in any kind of physical activity that increased {his/her} heart rate and made {him/her} breathe hard some of the time.

0 days 0

1 day 1

2 days 2

3 days 3

4 days 4

5 days 5

6 days 6

7 days 7

REFUSED 77

DON’T KNOW 99

PAQ.710 Now I will ask you about TV watching and computer use.

Over the past 30 days, on average how many hours per day did {SP} sit and watch TV or videos? Would you say . . .

less than 1 hour, 0

1 hour, 1

2 hours, 2

3 hours, 3

4 hours, or 4

5 hours or more, or 5

none, {SP} does not watch TV or
videos 8

REFUSED 77

DON'T KNOW 99

PAQ.715 Over the past 30 days, on average how many hours per day did {SP} use a computer or play computer games outside of school? Would you say . . .

less than 1 hour, 0

1 hour, 1

2 hours, 2

3 hours, 3

4 hours, or 4

5 hours or more, or 5

{SP} does not use a computer
outside of school 8

REFUSED 77

DON'T KNOW 99

BOX 2

CHECK ITEM PAQ.720:

IF SP AGE 2-11, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

PAQ.605 Next I am going to ask you about the time {you spend/SP spends} doing different types of physical activity in a typical week.

Think first about the time {you spend/SP spends} doing work. Think of work as the things that {you have/SP has} to do such as paid or unpaid work, household chores, and yard work.

Does {your/SP’s} work involve vigorous-intensity activity that causes large increases in breathing or heart rate like carrying or lifting heavy loads, digging or construction work for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.620)

REFUSED 7 (PAQ.620)

DON'T KNOW 9 (PAQ.620)

PAQ.610 In a typical week, on how many days {do you/does SP} do vigorous-intensity activities as part of your work?

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: 1-7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.620)

DON'T KNOW 99 (PAQ.620)

PAQ.615 How much time {do you/does SP} spend doing vigorous-intensity activities at work on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when you do vigorous-intensity activities during your work.

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

SOFT EDIT: >4 HOURS. SOFT EDIT WORDING: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING VIGOROUS-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

SOFT EDIT: >4 HOURS.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

PAQ.620 Does {your/SP’s} work involve moderate-intensity activity that causes small increases in breathing or heart rate such as brisk walking or carrying light loads for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.635)

REFUSED 7 (PAQ.635)

DON'T KNOW 9 (PAQ.635)

PAQ.625 In a typical week, on how many days {do you/does SP} do moderate-intensity activities as part of {your/his/her} work?

PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: 1-7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.635)

DON'T KNOW 99 (PAQ.635)

PAQ.630 How much time {do you/does SP} spend doing moderate-intensity activities at work on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when you do moderate-intensity activities during your work.

PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.

SOFT EDIT: >4 HOURS. SOFT EDIT WORDING: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING MODERATE-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

SOFT EDIT: >4 HOURS.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

PAQ.635 The next questions exclude the physical activity of work that you have already mentioned. Now I would like to ask you about the usual way {you travel/SP travels} to and from places. For example to work, for shopping, to school.

{Do you/Does SP} walk or use a bicycle for at least 10 minutes continuously to get to and from places?

YES 1

NO 2 (PAQ.650)

REFUSED 7 (PAQ.650)

DON'T KNOW 9 (PAQ.650)

PAQ.640 In a typical week, on how many days {do you/does SP} walk or bicycle for at least 10 minutes continuously to get to and from places?

HARD EDIT: 1-7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.650)

DON'T KNOW 99 (PAQ.650)

PAQ.645 How much time {do you/does SP} spend walking or bicycling for travel on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when you walk or bicycle for travel.

SOFT EDIT: >4 HOURS. SOFT EDIT WORDING: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS WALKING OR BICYCLING TO GET TO AND FROM PLACES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

SOFT EDIT: >4 HOURS.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

PAQ.650 The next questions exclude the work and transportation activities that you have already mentioned. Now I would like to ask you about sports, fitness and recreational activities.

{Do you/Does SP} do any vigorous-intensity sports, fitness, or recreational activities that cause large increases in breathing or heart rate like running or basketball for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.665)

REFUSED 7 (PAQ.665)

DON'T KNOW 9 (PAQ.665)

PAQ.655 In a typical week, on how many days {do you/does SP} do vigorous-intensity sports, fitness or recreational activities?

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: 1-7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.665)

DON'T KNOW 99 (PAQ.665)

PAQ.660 Q/U

How much time {do you/does SP} spend doing vigorous–intensity sports, fitness or recreational activities on a typical day?

PROBE IF NEEDED: Think about a typical day when you do vigorous-intensity sports, fitness or recreational activities.

SOFT EDIT: >4 HOURS. SOFT EDIT WORDING: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING VIGOROUS-INTENSITY RECREATIONAL ACTIVITIES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

SOFT EDIT: >4 HOURS.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

PAQ.665 {Do you/Does SP} do any moderate-intensity sports, fitness, or recreational activities that cause a small increase in breathing or heart rate such as brisk walking, bicycling, swimming, or golf for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.680)

REFUSED 7 (PAQ.680)

DON'T KNOW 9 (PAQ.680)

PAQ.670 In a typical week, on how many days {do you/does SP} do moderate-intensity sports, fitness or recreational activities?

PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: 1-7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.680)

DON'T KNOW 99 (PAQ.680)

PAQ.675 Q/U

How much time {do you/does SP} spend doing moderate-intensity sports, fitness or recreational activities on a typical day?

PROBE IF NEEDED: Think about a typical day when you do moderate-intensity sports, fitness or recreational activities.

PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.

SOFT EDIT: >4 HOURS. SOFT EDIT WORDING: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING MODERATE-INTENSITY RECREATIONAL ACTIVITIES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

SOFT EDIT: >4 HOURS.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

PAQ.680 Q/U

The following question is about sitting at work, at home, getting to and from places, or with friends, including time spent sitting at a desk, traveling in a car or bus, reading, playing cards, watching television, or using a computer. Do not include time spent sleeping. How much time {do you/does SP} usually spend sitting on a typical day?

SOFT EDIT: >17 HOURS.

HARD EDIT: >24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

PAQ.685 During the past 12 months, when {you thought/SP thought} or {were/was} informed air quality was bad, {did you/did SP} do anything differently?

YES 1

NO 2 (END OF SECTION)

SP NEVER THOUGHT/NOT INFORMED
BAD AIR QUALITY 3 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

PAQ.690 Which of these {did you/did SP} do differently?

INTERVIEWER: CODE ALL THAT APPLY.

HAND CARD 07PAQ1

WORE A MASK 10

SPENT LESS TIME OUTDOORS 11

AVOIDED ROADS THAT HAVE HEAVY
TRAFFIC 12

DID LESS STRENUOUS ACTIVITIES 13

TOOK MEDICATION 14

CLOSED WINDOWS OF YOUR HOUSE 15

DROVE MY CAR LESS 16

CANCELED OUTDOOR ACTIVITIES 17

EXERCISED INDOORS INSTEAD OF
OUTSIDE 18

USED BUSES, TRAINS, OR SUBWAYS 19

OTHER (SPECIFY) 71

REFUSED 77

DON’T KNOW 99

SLEEP DISORDERS

SLQ.010 The next set of questions is about {your/SP’s} sleeping habits.

H/M

How much sleep {do you/does SP} usually get at night on weekdays or workdays?

INTERVIEWER INSTRUCTION: IF RESPONDENT SLEEPS FOR ONLY VERY SHORT PERIODS OF TIME, ASK HIM/HER TO ESTIMATE ON AVERAGE THE TOTAL NUMBER OF HOURS THAT THEY GENERALLY SLEEP AT NIGHT.

|___|___|

ENTER HOURS

CAPI INSTRUCTION: HARD EDIT: HOURS MUST EQUAL 0-24.

REFUSED 777

DON'T KNOW 999

SLQ.050 {Have you/Has SP} ever told a doctor or other health professional that {you have/s/he has} trouble sleeping?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SLQ.060 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/s/he has} a sleep disorder?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DIET BEHAVIOR and NUTRITION

BOX 1

CHECK ITEM DBQ.005:

IF SP AGE <= 6, CONTINUE.

OTHERWISE, GO TO BOX 2.

DBQ.010 Now I'm going to ask you some general questions about {SP's} eating habits.

Was {SP} ever breastfed or fed breastmilk?

YES 1

NO 2 (DBQ.041)

REFUSED 7 (DBQ.041)

DON'T KNOW 9 (DBQ.041)

DBQ.030 G/Q/U

How old was {SP} when {he/she} completely stopped breastfeeding or being fed breastmilk?

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

STILL BREASTFEEDING 6666

REFUSED 7777

DON'T KNOW 9999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

DBQ.041 G/Q/U

How old was {SP} when {he/she} was first fed formula?

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

NEVER 2 (DBQ.055)

REFUSED 7777

DON'T KNOW 9999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

DBQ.050 G/Q/U

How old was {SP} when {he/she} completely stopped drinking formula?

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

STILL DRINKING FORMULA 6666

REFUSED 7777

DON'T KNOW 9999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

DBQ.055 G/Q/U

This next question is about the first thing that {SP} was given other than breast milk or formula. Please include juice, cow’s milk, sugar water, baby food, or anything else that {SP} might have been given, even water. How old was {SP} when {he/she} was first fed anything other than breast milk or formula?

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

INTERVIEWER INSTRUCTION:

DO NOT COUNT MEDICATIONS, VITAMIN DROPS, OR SMALL AMOUNT OF WATER THAT USED FOR ORAL HYGIENE PURPOSES.

|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

NEVER 2 (BOX 2)

REFUSED 777 (BOX 2)

DON'T KNOW 999 (BOX 2)

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

DBQ.061 G/Q/U

How old was {SP} when {he/she} was first fed milk?

INCLUDE LACTAID AS MILK

DO NOT INCLUDE BREASTMILK OR FORMULA

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

NEVER 2 (BOX 2)

REFUSED 7777

DON'T KNOW 9999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

DBQ.073 What type of milk was {SP} first fed? Was it . . .

CODE ALL THAT APPLY

whole or regular, 10

2% fat or reduced-fat milk, 11

1% fat or low-fat milk (includes 0.5% fat

milk or “low-fat milk” not further specified), 12

fat-free, skim or nonfat milk, 13

soy milk, or 14

another type? 30

REFUSED 77

DON'T KNOW 99

BOX 2

CHECK ITEM DBQ.085:

IF SP AGE >= 16, CONTINUE.

IF SP AGE <16 BUT >= 1, GO TO DBQ.197.

OTHERWISE, GO TO FSQ.651.

DBQ.700 Next I have some questions about {your/SP’s} eating habits.

In general, how healthy is {your/his/her} overall diet? Would you say . . .

excellent, 1

very good, 2

good, 3

fair, or 4

poor? 5

REFUSED 7

DON'T KNOW 9

BOX 3

OMITTED

BOX 4

OMITTED

DBQ.197 {Next I have some questions about {SP’s} eating habits.}

{First/Next}, I’m going to ask a few questions about milk products. Do not include their use in cooking.

In the past 30 days, how often did {you/SP} have milk to drink or on {your/his/her} cereal? Please include chocolate and other flavored milks as well as hot cocoa made with milk. Do not count small amounts of milk added to coffee or tea. Would you say . . .

HAND CARD DBQ1

CAPI INSTRUCTION:

THIS SHOULD NOT BE A GATE QUESTION ANYMORE.

CAPI DISPLAY INSTRUCTIONS: IF SP AGE 7-15 YEARS OLD, DISPLAY “{Next I have some questions about {SP’s} eating habits.} First, I’m going to ask about milk products. Do not include their use in cooking. IF SP AGE <= 6 OR => 16 YEARS OLD. DISPLAY “Next I’m going to ask a few questions about milk products. Do not include their use in cooking.”

never, 0 (BOX 6)

rarely – less than once a week, 1

sometimes – once a week or more, but

less than once a day, or 2

often – once a day or more? 3

VARIED 4

REFUSED 7 (BOX 6)

DON'T KNOW 9 (BOX 6)

DBQ.223 What type of milk was it? Was it usually . . .

IF RESPONDENT CANNOT PROVIDE USUAL TYPE, CODE ALL THAT APPLY

whole or regular, 10

2% fat or reduced-fat milk, 11

1% fat or low-fat milk (includes 0.5% fat

milk or “low-fat milk” not further specified), 12

fat-free, skim or nonfat milk, 13

soy milk, or 14

another type? 30

REFUSED 77

DON'T KNOW 99

BOX 6

CHECK ITEM DBQ.225:

IF SP AGE >= 20, CONTINUE.

OTHERWISE, GO TO BOX 9.

DBQ.229 The next question is about regular milk use.

A regular milk drinker is someone who uses any type of milk at least 5 times a week. Using this definition, which statement best describes {you/SP}?

HAND CARD DBQ2

{I've/He's/She's} been a regular milk

drinker for most or all of {my/his/her}

life, including {my/his/her} childhood; 1

{I've/He's/She's} never been a regular

milk drinker; 2 (BOX 8A)

{My/His/Her} milk drinking has varied over

{my/his/her} life – sometimes {I've/he's/

she's} been a regular milk drinker and

sometimes {I have/he has/she has} not

been a regular milk drinker 3

REFUSED 7 (BOX 8A)

DON'T KNOW 9 (BOX 8A)

DBQ.235 a/b/c

Now, I’m going to ask you how often {you/SP} drank milk at different times in {your/his/her} life.

How often did {you/SP} drink any type of milk, including milk added to cereal, when {you were/s/he was} . . .

HAND CARD DBQ3

IF NECESSARY, PROBE FOR USUAL OR MOST COMMON AMOUNT FOR THIS TIME PERIOD

CAPI INSTRUCTION:

THESE (A-C) SHOULD NOT BE GATE QUESTIONS ANYMORE.

a. a child between the ages of 5 and 12 years old? Would you say. . .

never, 0

rarely – less than once a week, 1

sometimes – once a week or more, but

less than once a day, or 2

often – once a day or more? 3

VARIED 4

REFUSED 7

DON'T KNOW 9

b. a teenager between the ages of 13 and 17 years old? Would you say . . .

never, 0

rarely – less than once a week, 1

sometimes – once a week or more, but

less than once a day, or 2

often – once a day or more? 3

VARIED 4

REFUSED 7

DON'T KNOW 9

c. a young adult between the ages of 18 and 35 years old? Would you say . . .

never, 0

rarely – less than once a week, 1

sometimes – once a week or more, but

less than once a day, or 2

often – once a day or more? 3

VARIED 4

REFUSED 7

DON'T KNOW 9

BOX 8A

CHECK ITEM DBQ.265A:

IF SP AGE >= 60, CONTINUE.

OTHERWISE, GO TO BOX 15.

DBQ.301 The next questions are about meals provided by community or government programs.

In the past 12 months, did {you/SP} receive any meals delivered to {your/his/her} home from community programs, “Meals on Wheels”, or any other programs?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

DBQ.330 In the past 12 months, did {you/SP} go to a community program or senior center to eat prepared meals?

INCLUDE ADULT DAY CARE

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 8B

CHECK ITEM DBQ.335:

GO TO BOX 15.

BOX 9

CHECK ITEM DBQ.355:

IF SP AGE 4-19, CONTINUE.

OTHERWISE, GO TO BOX 14.

DBQ.360 During the school year, {do you/does SP} attend a kindergarten, grade school, junior or high school?

INTERVIEWER INSTRUCTION: ENTER ‘NO’ IF THE SP IS HOME SCHOOLED.

YES 1

NO 2 (BOX 14)

REFUSED 7 (BOX 14)

DON'T KNOW 9 (BOX 14)

DBQ.370 Does {your/SP's} school serve school lunches? These are complete lunches that cost the same every day.

YES 1

NO 2 (DBQ.400)

REFUSED 7 (DBQ.400)

DON'T KNOW 9 (DBQ.400)

DBQ.381 G/Q

During the school year, about how many times a week {do you/does SP} usually get a complete school lunch?

|___|

ENTER NUMBER OF TIMES

NONE 2 (DBQ.400)

REFUSED 7 (DBQ.400)

DON'T KNOW 9 (DBQ.400)

DBQ.390 {Do you/Does SP} get these lunches free, at a reduced price, or {do you/does he/she} pay full price?

FREE 1

REDUCED PRICE 2

FULL PRICE 3

REFUSED 7

DON'T KNOW 9

DBQ.400 Does {your/SP's} school serve a complete breakfast that costs the same every day?

YES 1

NO 2 (BOX 9A)

REFUSED 7 (BOX 9A)

DON'T KNOW 9 (BOX 9A)

DBQ.411 G/Q

During the school year, about how many times a week {do you/does SP} usually get a complete breakfast at school?

|___|

ENTER NUMBER OF TIMES

NONE 2 (BOX 9A)

REFUSED 7 (BOX 9A)

DON'T KNOW 9 (BOX 9A)

DBQ.421 {Do you/Does SP} get these breakfasts free, at a reduced price, or {do you/does he/she} pay full price?

FREE 1

REDUCED PRICE 2

FULL PRICE 3

REFUSED 7

DON'T KNOW 9

BOX 9A

CHECK ITEM DBQ.422:

IF DBQ.390 = CODE 1 OR CODE 2 OR DBQ.421 = CODE 1 OR CODE 2, CONTINUE.

OTHERWISE, GO TO BOX 14.

DBQ.424 {Do you/Does SP} get a free or reduced price meal at any summer program {you/he/she} attends?

YES 1

NO 2

DID NOT ATTEND SUMMER PROGRAM 3

REFUSED 7

DON’T KNOW 9

BOX 10

OMITTED

BOX 10A

OMITTED

BOX 11

OMITTED

BOX 14

CHECK ITEM DBQ.710:

IF SP AGE > 11, GO TO BOX 15.

ELSE, IF SP AGE 6-11, GO TO FSQ.675,

OTHERWISE, CONTINUE.

FSQ.651 Next are a few questions about the WIC program.

Did {SP} receive benefits from WIC, that is, the Women, Infants, and Children program, in the past 12 months?

YES 1 (FSQ.673)

NO 2 (BOX 14a)

REFUSED 7 (BOX 14a)

DON'T KNOW 9 (BOX 14a)

BOX 14a

CHECK ITEM DBQ.710a:

IF SP AGE < 1, GO TO FSQ.690.

OTHERWISE, GO TO FSQ.675.

FSQ.673 Is {SP} now receiving benefits from the WIC program?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 14b

CHECK ITEM DBQ.710b:

IF SP AGE =1 or < 1, GO TO FSQ.685.

OTHERWISE, CONTINUE.

FSQ.675 {Next are a few questions about the WIC program, that is, the Women, Infants, and Children program}

Did {SP} receive benefits from WIC when {he/she} was less than one year old?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

DISPLAY INTRODUCTION IF SP AGE IS 6-11.

BOX 14c

CHECK ITEM DBQ.710c:

IF SP AGE = 1, GO TO BOX 14d.

IF SP AGE = 2-5, and (FSQ651 = 1 or FSQ.673 = 1),

GO TO BOX 14d.

OTHERWISE, CONTINUE.

FSQ.680 Did {SP} receive benefits from WIC when {he/she} {was/is} between the ages of 1 to {SP AGE} years old?

CAPI INSTRUCTION:

If SP age = 2 or 3, DISPLAY the current age of the SP in years;

If SP age >3, DISPLAY “4”.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 14d

CHECK ITEM DBQ.710d:

IF SP AGE = 1 and FSQ651 in (2, 7, 9) and FSQ.675 in (2, 7, 9),

GO TO FSQ.690.

SP AGE 2-5 and FSQ651 in (2, 7, 9) and FSQ.675 in (2, 7, 9) and FSQ.680

in (2, 7, 9), GO TO FSQ.690.

SP AGE = 6-11 and FSQ.675 in (2, 7, 9) and FSQ.680 in (2, 7, 9),

GO TO FSQ.690.

OTHERWISE, CONTINUE.

FSQ.685 How long {did SP receive/has SP been receiving} benefits from the WIC program?

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

|__|__|

ENTER NUMBER (OF MONTHS OR YEARS)

REFUSED 77

DON'T KNOW 99

ENTER UNIT

MONTHS 1

YEARS 2

REFUSED 7

DON'T KNOW 9

FSQ.690 Did {SP’s} mother receive benefits from WIC, while she was pregnant with {SP}?

YES 1

NO 2 (BOX 15)

REFUSED 7 (BOX 15)

DON'T KNOW 9 (BOX 15)

FSQ.695 What month of the pregnancy did {SP’s} mother begin to receive WIC benefits?

|__|__|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

BOX 15

CHECK ITEM DBQ.715:

IF SP AGE < 1 GO TO END OF SECTION.

IF SP AGE 12-15 GO TO DBQ.915.

OTHERWISE, CONTINUE.

BOX 12

OMITTED

BOX 13

OMITTED

DBQ.895 Next I’m going to ask you about meals. By meal, I mean breakfast, lunch and dinner. During the past 7 days, how many meals {did you/did SP} get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines?

{Please do not include meals provided as part of the school lunch or school breakfast./Please do not include meals provided as part of the community programs you reported earlier.}

CAPI INSTRUCTION:

IF DBQ381G = 1 OR DBQ.411G = 1, DISPLAY {Please do not include meals provided as part of the school lunch or school breakfast.}

IF DBQ.301 = 1 OR DBQ.330 = 1, DISPLAY {Please do not include meals provided as part of the community programs you reported earlier.}

SOFT EDIT: DISPLAY A MESSAGE FOR ENTRY LARGER THAN “21.” – “Unusually large number entered – Please verify – this is more than 3 meals per day, each day during the past 7 days.”

|___|___|

ENTER NUMBER

NONE 2 (DBQ.905)

REFUSED 7 (DBQ.905)

DON'T KNOW 9 (DBQ.905)

DBQ.900 How many of those meals {did you/did SP} get from a fast-food or pizza place?

|___|___|

ENTER NUMBER

NONE 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION: HARD EDIT

NUMBER OF MEALS ENTERED IN DBQ.900 MUST BE EQUAL TO OR LESS THAN NUMBER ENTERED IN DBQ.895. IF NOT, DISPLAY THE FOLLOWING:

“THE NUMBER OF MEALS FROM A FAST FOOD OR PIZZA PLACE CANNOT BE GREATER THAN NUMBER OF MEALS PREPARED AWAY FROM HOME.”

DBQ.905 Some grocery stores sell “ready to eat” foods such as salads, soups, chicken, sandwiches and cooked vegetables in their salad bars and deli counters.

During the past 30 days, how often did {you/SP} eat “ready to eat” foods from the grocery store? Please do not include sliced meat or cheese you buy for sandwiches and frozen or canned foods.

|___|___|

ENTER NUMBER OF TIMES (PER DAY, WEEK, OR MONTH)

NEVER 0

REFUSED 7

DON’T KNOW 9

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

DBQ.910 During the past 30 days, how often did you {SP} eat frozen meals or frozen pizzas? Here are some examples of frozen meals and frozen pizzas.

HAND CARD DBQ4

|___|___|

ENTER NUMBER OF TIMES (PER DAY, WEEK, OR MONTH)

NEVER 0

REFUSED 7

DON’T KNOW 9

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

DBQ.915 {Do you/Does SP} consider {yourself/himself/herself} to be a vegetarian?

CAPI INSTRUCTION:

PARENT SHOULD BE ASKED THIS QUESTION ABOUT CHILD WHO IS AGE 1-11. “Do you consider ________ to be”

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.920 {Do you/Does SP} have any food allergies?

YES 1

NO 2 (BOX 15a)

REFUSED 7 (BOX 15a)

DON'T KNOW 9 (BOX 15a)

HELP SCREEN:

Food Allergy: A reaction causing a skin rash, hives, difficulty breathing, wheezing, or itching of the eyes, mouth, throat or skin.

DBQ.925 What foods {are you/is SP} allergic to?

HAND CARD DBQ5

[CODE ALL THAT APPLY]

WHEAT 10

COW’S MILK 11

EGGS 12

FISH 13

SHELLFISH (SHRIMP, CRAB, OR

LOBSTER) 14

CORN 15

PEANUT 16

OTHER NUTS 17

SOY PRODUCTS 18

OTHER 19

REFUSED 7

DON'T KNOW 9

BOX 15a

CHECK ITEM DBQ.715a:

IF SP AGE < 16, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

DBQ.930 {Are you/Is SP} the person who does most of the planning or preparing of meals in {your/SP’s} family?

INTERVIEWER INSTRUCTION: IF SP ANSWERS “SOMETIMES” OR “50/50”, ENTER YES

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.935 {Do you/Does SP} share in the planning or preparing of meals with someone else?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.940 {Are you/Is SP} the person who does most of the shopping for food in {your/SP’s} family?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.945 {Do you/Does SP} share in the shopping for food with someone else?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

END OF SECTION

WEIGHT HISTORY

WHQ.010 G/F/I/M/C

These next questions ask about {your/SP's} height and weight at different times in {your/his/her} life.

How tall {are you/is SP} without shoes?

ENTER HEIGHT IN FEET AND INCHES OR METERS AND CENTIMETERS

|___|___|

ENTER NUMBER OF FEET

AND

|___|___|

ENTER NUMBER OF INCHES

OR

|___|___|

ENTER NUMBER OF METERS

AND

|___|___|___|

ENTER NUMBER OF CENTIMETERS

OR

REFUSED 7777

DON’T KNOW 9999

WHQ.025/ L/K

How much {do you/does SP} weigh without clothes or shoes? [If {you are/she is} currently pregnant, how much did {you/she} weigh before your pregnancy?]

RECORD CURRENT WEIGHT

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you are/she is} currently pregnant . . .] ONLY IF SP IS FEMALE AND AGE IS 16 THROUGH 59.

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

OR

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

OR

REFUSED 777

DON’T KNOW 999

WHQ.030 {Do you/Does SP} consider {your/his/her}self now to be . . . [If {you are/she is} currently pregnant, what did {you/she} consider {your/her}self to be before {you were/she was} pregnant?]

overweight, 1

underweight, or 2

about the right weight? 3

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you are/she is} currently pregnant…] ONLY IF SP IS FEMALE AND AGE IS 16 THROUGH 59.

WHQ.040 Would {you/SP} like to weigh . . .

more, 1

less, or 2

stay about the same? 3 (WHQ.053)

REFUSED 7 (WHQ.053)

DON’T KNOW 9 (WHQ.053)

WHQ.045/ L/K

How much {would you/would SP} like to weigh?

ENTER WEIGHT IN POUNDS OR KILOGRAMS

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

OR

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777

DON’T KNOW 99999

WHQ.053/ L/K

How much did {you/SP} weigh a year ago? [If {you were/she was} pregnant a year ago, how much did {you/she} weigh before your pregnancy?]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you were/she was} pregnant . . .] ONLY IF SP IS FEMALE AND SP AGE IS 17 THROUGH 60.

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

OR

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

OR

REFUSED 777

DON’T KNOW 999

BOX 1

CHECK ITEM WHQ.055:

IF WEIGHT IN WHQ.053/L/K IS 10 POUNDS, 4.55 KILOGRAMS, OR MORE THAN WEIGHT IN WHQ.025/L/K (E.G., WHQ.053/L/K = 150 LBS AND WHQ.025/L/K = 135 LBS), CONTINUE.

OTHERWISE, GO TO WHQ.070.

WHQ.061 Was the change between {your/SP's} current weight and {your/his/her} weight a year ago because you tried to lose weight?

YES 1 (WHQ.089/OS)

NO 2

REFUSED 7

DON'T KNOW 9

WHQ.070 During the past 12 months, {have you/has SP} tried to lose weight?

YES 1

NO 2 (WHQ.090)

REFUSED 7 (WHQ.090)

DON’T KNOW 9 (WHQ.090)

WHQ.089/ OS

How did {you/SP} try to lose weight?

HAND CARD WHQ1

CODE ALL THAT APPLY

ATE LESS FOOD (AMOUNT) 100

SWITCHED TO FOODS WITH LOWER

CALORIES 110

ATE LESS FAT 120

ATE FEWER CARBOHYDRATES 125

EXERCISED 130

SKIPPED MEALS 140

ATE “DIET” FOODS OR PRODUCTS 150

USED A LIQUID DIET FORMULA SUCH

AS SLIMFAST OR OPTIFAST 160

JOINED A WEIGHT LOSS PROGRAM

SUCH AS WEIGHT WATCHERS, JENNY

CRAIG, TOPS, OR OVEREATERS

ANONYMOUS 170

FOLLOWED A SPECIAL DIET SUCH AS

DR. ATKINS, SOUTH BEACH, OTHER

HIGH PROTEIN OR LOW

CARBOHYDRATE DIET, CABBAGE

SOUP DIET, ORNISH, NUTRISYSTEM,

BODY-FOR-LIFE 300

TOOK DIET PILLS PRESCRIBED BY A

DOCTOR 310

TOOK OTHER PILLS, MEDICINES, HERBS,

OR SUPPLEMENTS NOT NEEDING A

PRESCRIPTION 320

STARTED TO SMOKE OR BEGAN TO

SMOKE AGAIN 325

TOOK LAXATIVES OR VOMITED 330

DRANK A LOT OF WATER 340

ATE MORE FRUITS, VEGETABLES,

SALADS 350

ATE LESS SUGAR, CANDY, SWEETS 360

CHANGED EATING HABITS (DIDN’T EAT

LATE AT NIGHT, ATE SEVERAL SMALL

MEALS A DAY) 370

ATE LESS JUNK FOOD OR FAST FOOD 380

OTHER (SPECIFY) 400

REFUSED 777

DON’T KNOW 999

WHQ.270 In the past 12 months, {did you/did SP} seek help from a personal trainer, dietitian, nutritionist, doctor or other health professional to lose weight?

YES 1

NO 2 (BOX 2A)

REFUSED 7 (BOX 2A)

DON’T KNOW 9 (BOX 2A)

WHQ.281 Was that a . . .

CODE ALL THAT APPLY.

personal trainer, 1

dietitian, 2

nutritionist, 3

doctor, or 4

other health professional? 5

REFUSED 7

DON’T KNOW 9

BOX 2A

CHECK ITEM WHQ.185:

IF WHQ.061 = CODE 1 OR WHQ.070 = CODE 1, GO TO WHQ.220/L/K.

WHQ.090 During the past 12 months, {have you/has SP} done anything to keep from gaining weight?

YES 1

NO 2 (WHQ.210)

REFUSED 7 (WHQ.210)

DON’T KNOW 9 (WHQ.210)

WHQ.104/ What did {you/SP} do to keep from gaining weight?

OS

CODE ALL THAT APPLY.

HAND CARD WHQ1

ATE LESS FOOD (AMOUNT) 100

SWITCHED TO FOODS WITH LOWER

CALORIES 110

ATE LESS FAT 120

ATE FEWER CARBOHYDRATES 125

EXERCISED 130

SKIPPED MEALS 140

ATE “DIET” FOODS OR PRODUCTS 150

USED A LIQUID DIET FORMULA SUCH

AS SLIMFAST OR OPTIFAST 160

JOINED A WEIGHT LOSS PROGRAM

SUCH AS WEIGHT WATCHERS, JENNY

CRAIG, TOPS, OR OVEREATERS

ANONYMOUS 170

FOLLOWED A SPECIAL DIET SUCH AS

DR. ATKINS, SOUTH BEACH, OTHER

HIGH PROTEIN OR LOW

CARBOHYDRATE DIET, CABBAGE

SOUP DIET, ORNISH, NUTRISYSTEM,

BODY-FOR-LIFE 300

TOOK DIET PILLS PRESCRIBED BY A

DOCTOR 310

TOOK OTHER PILLS, MEDICINES, HERBS,

OR SUPPLEMENTS NOT NEEDING A

PRESCRIPTION 320

STARTED TO SMOKE OR BEGAN TO

SMOKE AGAIN 325

TOOK LAXATIVES OR VOMITED 330

DRANK A LOT OF WATER 340

ATE MORE FRUITS, VEGETABLES,

SALADS 350

ATE LESS SUGAR, CANDY, SWEETS 360

CHANGED EATING HABITS (DIDN’T EAT

LATE AT NIGHT, ATE SEVERAL SMALL

MEALS A DAY) 370

ATE LESS JUNK FOOD OR FAST FOOD 380

OTHER (SPECIFY) 400

REFUSED 777

DON’T KNOW 999

WHQ.210 {Have you/Has SP} ever tried to lose weight?

YES 1

NO 2 (BOX 2)

REFUSED 7 (BOX 2)

DON’T KNOW 9 (BOX 2

WHQ.220/ L/K

How much weight {did you/did SP} lose in {your/his/her} most successful attempt ever to lose weight?

ENTER WEIGHT IN POUNDS OR KILOGRAMS

HELP SCREEN: This question refers only to deliberate attempts to lose weight; it does not refer to weight loss because of illness, side effects of medication, stress, or other unintended causes.

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT OVER 100 POUNDS

OR

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT OVER 45 KILOGRAMS

OR

REFUSED 777

DON’T KNOW 999

BOX 2

CHECK ITEM WHQ.105:

IF SP AGE >= 36, CONTINUE.

OTHERWISE, GO TO BOX 3.

WHQ.111/ L/K

How much did {you/SP} weigh 10 years ago? [If you don't know {your/his/her} exact weight, please make your best guess.] [If {you were/she was} pregnant, how much did {you/she} weigh before {your/her} pregnancy?]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you were/she was} . . .] ONLY IF SP IS FEMALE AND AGE IS LESS THAN OR EQUAL TO 69.

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

OR

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

OR

REFUSED 77777

DON’T KNOW 99999

BOX 3

CHECK ITEM WHQ.115A:

IF SP AGE >= 27, CONTINUE.

OTHERWISE, GO TO WHQ.147/L/K.

WHQ.121/ L/K

How much did {you/SP} weigh at age 25? [If you don't know {your/his/her} exact weight, please make your best guess.] [If {you were/she was} pregnant, how much did {you/she} weigh before your pregnancy?]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you were/she was} . . .] ONLY IF SP IS FEMALE.

|___|___|___|

ENTER NUMBER OF POUNDS

OR

|___|___|___|

ENTER NUMBER OF KILOGRAMS

OR

REFUSED 77777

DON’T KNOW 99999

BOX 3A

CHECK ITEM WHQ.125:

IF SP AGE >= 50, CONTINUE.

OTHERWISE, GO TO WHQ.147/L/K.

WHQ.130/ F/I/M/C

How tall {were you/was SP} at age 25? [If you don't know {your/his/her} exact height, please make your best guess.]

ENTER HEIGHT IN FEET AND INCHES OR METERS AND CENTIMETERS

|___|___|

ENTER NUMBER OF FEET

CAPI INSTRUCTION: HARD EDIT 2-8

AND

|___|___|

ENTER NUMBER OF INCHES

CAPI INSTRUCTION: HARD EDIT 0-11

OR

|___|___|

ENTER NUMBER OF METERS

CAPI INSTRUCTION: HARD EDIT 0-3

AND

|___|___|___|

ENTER NUMBER OF CENTIMETERS

CAPI INSTRUCTION: HARD EDIT 0-99

OR

REFUSED 7777

DON’T KNOW 9999

BOX 4

OMITTED

WHQ.147/ L/K

What is the most {you have/SP has} ever weighed? [Do not include any times when {you were/she was} pregnant.]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE {Do not include . . .} ONLY IF SP IS FEMALE.

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

OR

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

OR

REFUSED 777 (END OF SECTION)

DON’T KNOW 999 (END OF SECTION)

WHQ.150 How old {were you/was SP} then? [If you don't know {your/his/her} exact age, please make your best guess.]

|___|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

BOX 5

OMITTED

S

NHANES 2007

MOKING AND TOBACCO USE

These next questions are about cigarette smoking.

SMQ.020 {Have you/Has SP} smoked at least 100 cigarettes in {your/his/her} entire life?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

SMQ.030 How old {were you/was SP} when {you/s/he} first started to smoke cigarettes fairly regularly?

G/Q

|___|___|___|

ENTER AGE IN YEARS

NEVER SMOKED CIGARETTES

REGULARLY 666

REFUSED 77777

DON'T KNOW 99999

SMQ.040 {Do you/Does SP} now smoke cigarettes . . .

every day, 1 (SMQ.077)

some days, or 2 (SMQ.641)

not at all? 3 (SMQ.050Q/U)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

SMQ.050 How long has it been since {you/SP} quit smoking cigarettes?

Q/U

|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777

DON'T KNOW 99999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

BOX 1A

CHECK ITEM SMQ.053:

IF SMQ.050Q/U >= 1 YEAR (365 DAYS, 52 WEEKS, 12 MONTHS, OR 1 YEAR), CONTINUE.

OTHERWISE, GO TO END.

SMQ.055 How old {were you/was SP} when {you/s/he} last smoked cigarettes {fairly regularly}?

CAPI INSTRUCTION:

DISPLAY "FAIRLY REGULARLY" EXCEPT WHEN SMQ.030G/Q = 666 (NEVER SMOKED CIGARETTES REGULARLY).

|___|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

SMQ.057 At that time, about how many cigarettes did {you/SP} usually smoke per day?

1 PACK EQUALS 20 CIGARETTES

IF LESS THAN 1 PER DAY, ENTER 1

IF 95 OR MORE PER DAY, ENTER 95

|___|___|___|

ENTER NUMBER OF CIGARETTES (PER DAY)

REFUSED 7777

DON'T KNOW 9999

BOX 1B

CHECK ITEM SMQ.060:

GO TO END.

SMQ.077 How soon after {you/SP} wake{s} up {do you/does s/he} smoke? Would you say . . .

within 5 minutes, 1

from 6 to 30 minutes, 2

from more than 30 minutes to 1 hour, or 3

more than 1 hour? 4

REFUSED 7

DON'T KNOW 9

SMQ.641 During the past 30 days, on how many days did {you/SP} smoke cigarettes?

|___|___|

ENTER NUMBER OF DAYS

REFUSED 7777

DON'T KNOW 9999

CAPI INSTRUCTION:

ALLOW '0' AS AN ENTRY. IF '0' DK OR RF ENTERED, SKIP TO QUESTION SMQ.093.

SMQ.650 During the past 30 days, on the days that {you/SP} smoked, how many cigarettes did {you/s/he} smoke per day?

1 PACK EQUALS 20 CIGARETTES

IF LESS THAN 1 PER DAY, ENTER 1

IF 95 OR MORE PER DAY, ENTER 95

|___|___|___|

ENTER NUMBER OF CIGARETTES (PER DAY)

REFUSED 7777

DON'T KNOW 9999

SMQ.093 May I please see the pack for the brand of cigarettes {you usually smoke/SP usually smokes}.

TO OBTAIN ACCURATE PRODUCT INFORMATION, IT IS IMPORTANT THAT YOU SEE THE CIGARETTE PACK.

PACK SEEN 1

PACK NOT SEEN 2 (SMQ.100k)

REFUSED 7 (SMQ.100k)

SMQ.310 ENTER THE UNIVERSAL PRODUCT CODE FROM THE CIGARETTE PACK. UPC MUST CONTAIN 8 OR 12 DIGITS.

SELECT ONE OPTION.

ENTERING 8 DIGIT UPC 1

ENTERING 12 DIGIT UPC 2 (SMQ.330)

UNABLE TO READ CODE-PACK DAMAGED 3 (SMQ.100k)

SMQ.320 ENTER THE 8 DIGIT UPC CODE.

|___|___|___|___|___|___|___|___|

CAPI INSTRUCTION:

DOUBLE ENTRY IS REQUIRED. IF ENTRIES DO NOT MATCH, DISPLAY THE FOLLOWING MESSAGE: ENTRIES DO NOT MATCH. HIGHLIGHT THE ENTRY THAT SHOULD BE CORRECTED AND PRESS ‘ENTER’ TO CHANGE.

BOX 2B

CHECK ITEM SMQ.329:

GO TO END.

SMQ.330 ENTER THE 12 DIGIT UPC CODE.

|___|___|___|___|___|___|___|___|___|___|___|___|

CAPI INSTRUCTION:

DOUBLE ENTRY IS REQUIRED. IF ENTRIES DO NOT MATCH, DISPLAY THE FOLLOWING MESSAGE: ENTRIES DO NOT MATCH. HIGHLIGHT THE ENTRY THAT SHOULD BE CORRECTED AND PRESS ‘ENTER’ TO CHANGE.

BOX 3

CHECK ITEM SMQ.096A:

IF INVALID CODE OR CODE NOT ON FILE, GO TO SMQ.099.

OTHERWISE, CONTINUE.

SMQ.098 YOU HAVE SELECTED

{DISPLAY BRAND ASSOCIATED WITH CODE}

CORRECT 1 (END OF SECTION)

NOT CORRECT 2 (SMQ.100k)

CAPI INSTRUCTION:

DISPLAY BRAND NAME WITH ALL QUALIFIERS – NAME, SIZE (REGULAR, KING, 100, 120), FILTERED/NONFILTERED, MENTHOLATED/NONMENTHOLATED, OTHER QUALIFIERS (DELUXE, HARD PACK, LIGHTS, ETC.)

SMQ.099 CODE NOT ON FILE – PRESS ‘ENTER’ TO CONTINUE

SMQ.100k What brand of cigarettes {do you/does SP} usually smoke?

CAPI INSTRUCTION:

FOLLOW THE BASIC FORMAT FOR DIETARY SUPPLEMENT LOOKUP. ONLY ALLOW INTERVIEWER TO ENTER 1 BRAND OF CIGARETTES OR 'NO USUAL BRAND'. ALLOW ENTRY OF DON'T KNOW AND REFUSED.

REFER TO PRODUCT LABEL IF AVAILABLE.

ENTER BRAND NAME OF CIGARETTE.

IF NO USUAL BRAND, TYPE ‘NO USUAL BRAND’.

SMQ.111 PRESS BS TO START THE LOOKUP.

SELECT PRODUCT FROM

LIST OR TYPE

'NO USUAL BRAND.'

IF PRODUCT NOT ON LIST.

PRESS BS TO

DELETE ENTRY.

TYPE '**'.

PRESS ENTER TO SELECT.

CAPI INSTRUCTION:

Display CAPI cigarette product list. Interviewer should be able to select one product name from list OR 'NO USUAL BRAND'. In addition, interviewer should be able TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN SMQ.100k BY TYPING IN '**'.

BOX 4A

CHECK ITEM SMQ.112:

IF '** PRODUCT NOT ON LIST' SELECTED AT SMQ.111, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

SMQ.110a ASK IF NECESSARY:

IS THE CIGARETTE PRODUCT FILTERED OR NON-FILTERED?

ENTER '1' FOR FILTERED

ENTER '0' FOR NON-FILTERED

CAPI INSTRUCTION:

'1' AND '0' SHOULD BE THE ONLY CODES ACCEPTED BY CAPI.

FILTERED 1

NON-FILTERED 0

SMQ.110b ASK IF NECESSARY:

IS THE CIGARETTE PRODUCT MENTHOLATED OR NON-MENTHOLATED?

ENTER '1' FOR MENTHOLATED

ENTER '0' FOR NON-MENTHOLATED

CAPI INSTRUCTION:

'1' AND '0' SHOULD BE THE ONLY CODES ACCEPTED BY CAPI.

MENTHOLATED 1

NON-MENTHOLATED 0

REFUSED 7

DON'T KNOW 9

SMQ.110h ASK IF NECESSARY:

WHAT IS THE CIGARETTE PRODUCT SIZE?

CAPI INSTRUCTION:

THIS ITEM IS STORED IN SMQ.110f IN THE DATA BASE.

REGULARS 1

KINGS 2

100S 3

120S 4

REFUSED 77

DON'T KNOW 99

SMQ.110g REFER TO PRODUCT LABEL, IF AVAILABLE – ASK IF NECESSARY.

WHAT ARE THE OTHER NAME BRAND QUALIFIERS FOR THE CIGARETTE PRODUCT?

CAPI INSTRUCTION:

SHOULD BE A 'CODE ALL THAT APPLY' EXCEPT IF "REF", "DK" OR "NONE" SELECTED. NO OTHER RESPONSE OPTION SHOULD BE ALLOWED. THE "OTHER SPECIFY" RESPONSE SHOULD REQUIRE A TEXT ENTRY.

DELUXE 10

HARD PACK 11

LIGHTS 12

MILDS 13

SLIMS 14

SPECIALS 15

SUPER 16

ULTRA LIGHTS 17

OTHER (SPECIFY) 18

NONE 19

REF 77

DK 99

OCCUPATION

OCQ.152 In this part of the survey I will ask you questions about {your/SP's} work experience.

Which of the following {were you/was SP} doing last week . . .

working at a job or business, 1 (OCQ.180)

with a job or business but not at work, 2 (OCQ.210)

looking for work, or 3 (OCQ.385G/Q)

not working at a job or business? 4 (OCQ.380)

REFUSED 7 (OCQ.385G/Q)

DON'T KNOW 9 (OCQ.385G/Q)

OCQ.180 How many hours did {you/SP} work last week at all jobs or businesses?

|___|___|___|

ENTER NUMBER OF HOURS

CAPI INSTRUCTION:

HARD EDIT 1-168.

REFUSED 77777

DON'T KNOW 99999

BOX 1

CHECK ITEM OCQ.200:

IF HOURS IN OCQ.180 <= 34, OR REFUSED (CODE 777), OR DON'T KNOW (CODE 999), CONTINUE.

OTHERWISE, GO TO OCQ.220.

OCQ.210 {Do you/Does SP} usually work 35 hours or more per week in total at all jobs or businesses?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OCQ.220 For whom did {you/SP} work at {your/his/her} main job or business? (What is the name of the company, business, organization or employer?)

IF MORE THAN 1 JOB, PROBE FOR MAIN JOB.

ENTER NAME OF EMPLOYER

REFUSED 7---77

DON'T KNOW 9---99

OCQ.230 What kind of business or industry is this? (For example: a TV or radio station, retail shoe store, state labor department, farm.)

ENTER NAME OF BUSINESS OR INDUSTRY

REFUSED 7---77

DON'T KNOW 9---99

OCQ.240 What kind of work {were you/was SP} doing? (For example: farming, mail clerk, computer specialist.)

ENTER NAME OF OCCUPATION

REFUSED 7---77

DON'T KNOW 9---99

OCQ.250 What were {your/SP's} most important activities on this job? (For example: sells cars, keeps account books, operates printing press.)

ENTER NAME OF DUTIES

REFUSED 7---77

DON'T KNOW 9---99

OCQ.260 Looking at the card, which of these best describes this job or work situation?

ASK IF NOT CLEAR.

HAND CARD OCQ1

AN EMPLOYEE OF A PRIVATE COMPANY,

BUSINESS, OR INDIVIDUAL FOR WAGES,

SALARY, OR COMMISSION 1

A FEDERAL GOVERNMENT EMPLOYEE 2

A STATE GOVERNMENT EMPLOYEE 3

A LOCAL GOVERNMENT EMPLOYEE 4

SELF-EMPLOYED IN OWN BUSINESS,

PROFESSIONAL PRACTICE OR FARM 5

WORKING WITHOUT PAY IN FAMILY

BUSINESS OR FARM 6

REFUSED 77

DON'T KNOW 99

OCQ.265 Which of the following best describes the hours {you/SP} usually {work/works} at {your/his/her} main job or business?

INTERVIEWER INSTRUCTION: IF THE RESPONDENT SAYS "FLEXTIME", ETC., PROBE TO DETERMINE WHETHER THE SHIFT THAT IS WORKED ACTUALLY FALLS IN A DAY, EVENING, NIGHT, OR ROTATING SHIFT CATEGORY BEFORE CODING IT AS "ANOTHER SCHEDULE."

HELP AVAILABLE:

Standard Shift Definitions are:

A regular daytime schedule: this is work anytime between 6am and 6pm.

A regular evening shift: this is work anytime between 2pm and midnight.

A regular night shift: this is work anytime between 9pm and 8am.

A rotating shift: a work shift that changes periodically from days to evenings or nights.

Another schedule includes: a split shift (consisting of two distinct work periods each day), an irregular schedule arranged by the employer, or any other schedule. 

A regular daytime schedule 1

A regular evening shift 2

A regular night shift 3

A rotating shift 4

Another schedule 5

REFUSED 7

DON’T KNOW 9

OCQ.270 About how long {have you/has SP} worked for {EMPLOYER} as a(n) {OCCUPATION}?

Q/U

CAPI INSTRUCTIONS:

DISPLAY AS LEFT HEADER "EMPLOYER:" AND EMPLOYER FROM OCQ.220.

DISPLAY AS LEFT HEADER "OCCUPATION:" AND OCCUPATION FROM OCQ.240.

IF OCQ.220 AND/OR OCQ.240 ARE DK/RF, DISPLAY “AT YOUR MAIN JOB.” IF PROXY, DISPLAY {HIS/HER MAIN JOB}.

DO NOT ALLOW MORE THAN THE SP’S AGE, OR >90 DAYS OR >104 WEEKS OR GREATER THAN 48 MONTHS OR GREATER THAN 60 YEARS.

|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 777777

DON'T KNOW 999999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

OCQ.290G/Q

At this job or business, that is at {EMPLOYER} as a(n) {OCCUPATION}, how many hours per day can {you/SP} smell the smoke from other people's cigarettes, cigars, and/or pipes?

CAPI INSTRUCTIONS:

DISPLAY AS LEFT HEADER "EMPLOYER:" AND EMPLOYER FROM OCQ.220.

DISPLAY AS LEFT HEADER "OCCUPATION:" AND OCCUPATION FROM OCQ.240.

IF OCQ.220 AND/OR OCQ.240 ARE DK/RF, DISPLAY “AT YOUR MAIN JOB.”

HARD EDIT 0-24.

|___|___|

ENTER NUMBER OF HOURS

NEVER 66

REFUSED 7777

DON'T KNOW 9999

BOX 3

CHECK ITEM OCQ.370:

GO TO OCQ.392G/Q.

OCQ.380 What is the main reason {you/SP} did not work last week?

TAKING CARE OF HOUSE OR FAMILY 1

GOING TO SCHOOL 2

RETIRED 3

UNABLE TO WORK FOR HEALTH

REASONS 4

ON LAYOFF 5

DISABLED 6

OTHER 7

REFUSED 77

DON'T KNOW 99

OCQ.385 G/Q

Thinking of all the paid jobs {you/SP} ever had, what kind of work {were you/was s/he} doing the longest? (For example, electrical engineer, stock clerk, typist, farmer.)

CAPI INSTRUCTION:

IF CURRENT OCCUPATION HAS BEEN ENTERED IN OCQ.240, DISPLAY AS LEFT HEADER "CURRENT OCCUPATION: {OCQ.240}".

ENTER OCCUPATION

or

ARMED FORCES 3 (OCQ.393)

NEVER WORKED 4 (END OF SECTION)

REFUSED 7 (OCQ.393)

DON'T KNOW 9 (OCQ.393)

OCQ.389 What kind of business or industry {did you/did SP} work in for the longest period of time as a (DISPLAY LONGEST OCCUPATION AS “LONGEST OCCUPATION” {OCQ385Q})? (For example, a TV or radio station, retail shoe store, state labor department, farm.)

(OCQ.393)

ENTER DESCRIPTION FOR KIND OF BUSINESS/INDUSTRY

REFUSED 7---77 (OCQ.393)

DON'T KNOW 9---99 (OCQ.393)

OCQ.392 G/Q

Thinking of all the paid jobs {you/SP} ever had, what kind of work {were you/was s/he} doing the longest? (For example, electrical engineer, stock clerk, typist, farmer.)

CAPI INSTRUCTION:

IF CURRENT OCCUPATION HAS BEEN ENTERED IN OCQ.240, DISPLAY AS LEFT HEADER "CURRENT OCCUPATION: {OCQ.240}".

ENTER OCCUPATION

or

SAME AS CURRENT OCCUPATION 2 (BOX 6)

ARMED FORCES 3 (OCQ.393)

REFUSED 7 (OCQ.393)

DON'T KNOW 9 (OCQ.393)

OCQ.394 What kind of business or industry {did you/did SP} work in for the longest period of time as a (DISPLAY LONGEST OCCUPATION AS “LONGEST OCCUPATION” {OCQ392Q})? (For example, a TV or radio station, retail shoe store, state labor department, farm.)

ENTER DESCRIPTION FOR KIND OF BUSINESS/INDUSTRY

REFUSED 7---77

DON'T KNOW 9---99

OCQ.393 What were {your/SP's} most important activities on this job or business? (For example: sells cars, keeps account books, operates printing press.)

ENTER NAME OF DUTIES

REFUSED 7---77

DON'T KNOW 9---99

OCQ.395 About how long did {you/SP} work at that job or business?

Q/U

CAPI INSTRUCTION:

DISPLAY "LONGEST OCCUPATION: {OCQ.385G/Q or OCQ.392G/Q}" AS LEFT HEADER.

DO NOT ALLOW LESS THAN SP’S AGE OR <90 DAYS OR <104 WEEKS OR <48 MONTHS OR <60 YEARS.

|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777

DON'T KNOW 99999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

BOX 4

OMITTED

BOX 4A

OMITTED

BOX 5A

OMITTED

BOX 5B

OMITTED

BOX 6

CHECK ITEM OCQ.500:

IF SP AGE >= 16 AND < 80, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

OCQ.510 The next questions ask about being exposed to dust in {your/SPs} work.

Being exposed to dust means that {you/SP} breathed in the dust or had dust on {your/his/her} clothes, skin or hair.

INTERVIEWER INSTRUCTION: DO NOT COUNT TEMPORARY ONE-TIME EXPOSURES THAT MIGHT HAVE HAPPENED.

In any job, {have you/has SP} ever been exposed to dust from rock, sand, concrete, coal, asbestos, silica or soil?

YES 1

NO 2 (OCQ.530)

REFUSED 7 (OCQ.530)

DON'T KNOW 9 (OCQ.530)

OCQ.520 Please give me the total number of years for all jobs where this has happened.

INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS MORE THAN ONE JOB, THEY SHOULD ADD ALL YEARS TOGETHER.

IF LESS THAN 1 YEAR, ENTER 0

|___|___|___|

ENTER NUMBER OF YEARS

REFUSED 777

DON'T KNOW 999

CAPI INSTRUCTION:

HARD EDIT – NUMBER ENTERED CANNOT EQUAL OR BE MORE THAN SP AGE.

OCQ.530 In any job, {have you/has SP} ever been exposed to dust from baking flours, grains, wood, cotton, plants or animals?

YES 1

NO 2 (OCQ.550)

REFUSED 7 (OCQ.550)

DON'T KNOW 9 (OCQ.550)

OCQ.540 Please give me the total number of years for all jobs where this has happened.

INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS MORE THAN ONE JOB, THEY SHOULD ADD ALL YEARS TOGETHER.

IF LESS THAN 1 YEAR, ENTER 0

|___|___|___|

ENTER NUMBER OF YEARS

REFUSED 777

DON'T KNOW 999

CAPI INSTRUCTION:

HARD EDIT – NUMBER ENTERED CANNOT EQUAL OR BE MORE THAN SP AGE.

OCQ.550 The next questions ask about being exposed to fumes in {your/SPs} work.

Being exposed to fumes means that {you/SP} breathed in fumes or had a lasting smell on {your/his/her} clothes, skin or hair.

INTERVIEWER INSTRUCTION: DO NOT COUNT TEMPORARY ONE-TIME EXPOSURES THAT MIGHT HAVE HAPPENED.

In any job, {have you/has SP} ever been exposed to exhaust fumes from trucks, buses, heavy machinery, or diesel engines?

YES 1

NO 2 (OCQ.570)

REFUSED 7 (OCQ.570)

DON'T KNOW 9 (OCQ.570)

OCQ.560 Please give me the total number of years for all jobs where this has happened.

INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS MORE THAN ONE JOB, THEY SHOULD ADD ALL YEARS TOGETHER.

IF LESS THAN 1 YEAR, ENTER 0

|___|___|___|

ENTER NUMBER OF YEARS

REFUSED 777

DON'T KNOW 999

CAPI INSTRUCTION:

HARD EDIT – NUMBER ENTERED CANNOT EQUAL OR BE MORE THAN SP AGE.

OCQ.570 In any job, {have you/has SP} ever been exposed to any other gases, vapors or fumes?

Examples are vapors from paints, cleaning products, glues, solvents, and acids; or welding/soldering fumes.

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

OCQ.580 Please give me the total number of years for all jobs where this has happened.

INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS MORE THAN ONE JOB, THEY SHOULD ADD ALL YEARS TOGETHER.

IF LESS THAN 1 YEAR, ENTER 0

|___|___|___|

ENTER NUMBER OF YEARS

REFUSED 777

DON'T KNOW 999

CAPI INSTRUCTION:

HARD EDIT – NUMBER ENTERED CANNOT EQUAL OR BE MORE THAN SP AGE.

ACCULTURATION

BOX 1

CHECK ITEM ACQ.005:

IF SP CODED HISPANIC IN SCREENER, GO TO ACQ.041.

OTHERWISE, CONTINUE.

ACQ.011 Now I'm going to ask you about language use.

What language(s) {do you/does SP} usually speak at home?

CODE ALL THAT APPLY

ENGLISH 1

SPANISH 8

OTHER 9

REFUSED 77

DON'T KNOW 99

BOX 2

CHECK ITEM ACQ.015:

GO TO END OF SECTION.

ACQ.041 Now I’m going to ask you about language use.

What language(s) {do you/does SP} usually speak at home?

HAND CARD ACQ1

ONLY SPANISH, 1

MORE SPANISH THAN ENGLISH, 2

BOTH EQUALLY, 3

MORE ENGLISH THAN SPANISH, OR 4

ONLY ENGLISH 5

REFUSED 7

DON'T KNOW 9

Arthritis Questionnaire

ARQ.010 These next questions are about pain in the back, neck or hip area that {you/SP} may have had.

Please look at this hand card.

HAND CARD ARQ1

{Have you/Has SP} ever had pain, aching or stiffness in any of these locations almost every day for at least 6 weeks in a row? Include pain even if it was mild.

[INTERVIEWER INSTRUCTIONS: PAIN OF ANY DEGREE (MILD, MODERATE, SEVERE) SHOULD BE INCLUDED WHEN ANSWERING THIS QUESTION. ALSO INCLUDE PAIN THAT THE RESPONDENT TREATED BY THEMSELVES, AND DID NOT SEE A DOCTOR.]

HELP SCREEN:

This question asks whether there was one time when the respondent ever had a single period of pain lasting for six weeks. To answer “yes” to this question, pain must have been present on almost all days for six weeks.

Please include all degrees of pain, whether it was mild, moderate or severe. The pain does not have to last very long on any particular day, but had to be definitely present on almost all of those days.

Many people with chronic pain are “used to” having pain and may want to answer this question referring only to the more severe pain that they have. This is not correct. We want to collect data on all degrees of pain no matter how severe it is.

Pain should be included whether a person saw a doctor or other medical person for it, or if they just treated it themselves.

YES 1

NO 2 (ARQ.110)

REFUSED 7 (ARQ.110)

DON'T KNOW 9 (ARQ.110)

ARQ.020 Please show me in which locations {you have/SP has} had this pain, aching or stiffness on almost everyday for at least 6 weeks in a row.

HAND CARD ARQ1

HELP SCREEN:

This question is designed to ask about pain in the bones, joints and muscles that is located in these specific areas. Do not include pain that happened in these areas because of other reasons. For example location 7 asks about pain in the rib cage area. Do not include chest pain due to heart or lung problems, stomach problems or heartburn.

CODE ALL THAT APPLY.

NECK 1

UPPER BACK 2

MID BACK 3

LOW BACK 4

BUTTOCKS 5

HIPS 6

RIB CAGE 7

REFUSED 777

DON’T KNOW 999

BOX 1

CHECK ITEM ARQ.200:

IF CODE 1-7 IN ARQ.020, CONTINUE.

OTHERWISE, SKIP TO ARQ.110.

BOX 2

CHECK ITEM ARQ.205:

ASK ARQ.021 THROUGH ARQ.027 FOR EACH CODE 1 THROUGH 7 IN ARQ.020.

ARQ.021 Which specifically did {you/SP} have in {your/his/her} {DISPLAY RESPONSE (CODE 1-7) FROM ARQ.020}? Was it…

HAND CARD ARQ2

CODE ALL THAT APPLY.

pain, 1

aching, and/or 2

stiffness? 3

REFUSED 7

DON’T KNOW 9

ARQ.022 How old {were you/was SP} when {you/s/he} first had {DISPLAY RESPONSE (CODE 1-7) FROM ARQ.020} pain, aching or stiffness?

HARD EDIT: AGE MUST BE ≤ SP’S CURRENT AGE.

|___|___|___|

ENTER AGE IN YEARS 1

REFUSED 7777

DON’T KNOW 9999

ARQ.023 G/Q

How old {were you/was SP} when {you/s/he} last had {DISPLAY RESPONSE (CODE 1-7) FROM ARQ.020} pain, aching, or stiffness?

HARD EDIT: AGE MUST BE ≤ SP’S CURRENT AGE.

|___|___|___|

ENTER AGE IN YEARS 1

CURRENTLY HAS 2

HAD LESS THAN 1 YEAR AGO BUT

NOT NOW 3

REFUSED 7777

DON’T KNOW 9999

ARQ.024 Was there one time when {you/SP} had pain, aching or stiffness in {your/his/her} {DISPLAY RESPONSE (CODE 1-7) FROM ARQ.020} on almost every day for 3 or more months in a row?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

ARQ.025 How long did it take for {your/SP’s} {DISPLAY RESPONSE (CODE 1-7) FROM ARQ.020} pain, aching or stiffness to fully develop? Was it…

HELP SCREEN:

The question is designed to ask how long it took the pain to reach its full intensity or severity. Not everyone will have a constant pain pattern. For some people, pain will go up and down.

For these persons code the category that best reflects the time from when the pain first started until it reached its peak.

Most respondents with pain due to an injury will say it started suddenly or in a single day.

suddenly, within an hour, 1

in a single day, 2

over 1 to 3 weeks, 3

from a month up to a year, or 4

over a year or more? 5

REFUSED 7

DON'T KNOW 9

BOX 2A

CHECK ITEM ARQ.225:

IF ARQ.023 = CODE 2, SKIP TO ARQ.027.

OTHERWISE, CONTINUE.

ARQ.026 How often did {you/SP} get {DISPLAY RESPONSE (CODE 1-7) FROM ARQ.020} pain, aching or stiffness? Did {you/SP} have it . . .

HELP SCREEN:

The question is designed to ask whether the pain was limited to one single episode, whether it was recurrent (it comes and goes) or whether it is constant. People with constant pain may have pain that goes up and down in intensity, but it never goes away completely for a month or more.

just one time, then it went away, 1 (BOX 3)

more than once, but it would always come

back within a month, or 2 (BOX 3)

more than once, but it would go away for

over a month? 3 (BOX 3)

REFUSED 7 (BOX 3)

DON'T KNOW 9 (BOX 3)

ARQ.027 How often {do you/does SP} get {DISPLAY RESPONSE (CODE 1-7) FROM ARQ.020} pain, aching or stiffness? {Do you/Does SP} have it…

HELP SCREEN:

The question is designed to ask whether the pain is recurrent (it comes and goes) or whether it is constant. People with constant pain may have pain that goes up and down in intensity, but it never goes away completely for a month or more.

more than once, but it comes back within a
month, 1

more than once, but it goes away for over
a month at a time, or 2

all the time - it varies but never completely
goes away? 3

REFUSED 7

DON'T KNOW 9

BOX 3

CHECK ITEM ARQ.210:

CYCLE THROUGH QUESTIONS ARQ.021 THROUGH ARQ.027 FOR NEXT LOCATION (CODE 1-7) IN ARQ.020.

IF NO NEXT LOCATION, GO TO BOX 3A.

BOX 3A

CHECK ITEM ARQ.230:

IF ARQ.020 = CODE 1-5, GO TO ARQ.030.

IF ARQ.020 = CODE 6-7 ONLY, GO TO ARQ.110.

CAPI FILL INSTRUCTIONS FOR ARQ.030, ARQ.034, ARQ.040, ARQ.050, AND ARQ.077:

DISPLAY ALL CATEGORIES 1-5 MENTIONED IN ARQ.020.

SPECIAL INSTRUCTIONS:

IF ARQ.020 = 1, DISPLAY “NECK”.

IF ARQ.020 = 2, 3, OR 4, DISPLAY “BACK”.

IF ARQ.020 = 5, DISPLAY “BUTTOCKS”.

ARQ.030 For {your/SP’s} {back/{or} neck/{or} buttocks} pain, aching or stiffness, {have you/has s/he} ever taken any of the following medicines?	ARQ.034 How much did this medicine help to relieve {your/SP’s} {back/{or} neck/{or} buttocks} pain, aching or stiffness? Would you say it relieved… HAND CARD ARQ3
a. Ibuprofen (eye-byu-proh-fen), Motrin, or Advil Y ES 1 NO 2 (ARQ.030b) REFUSED 7 (ARQ.030b) DON’T KNOW 9 (ARQ.030b)	none of the pain, 0 some of the pain, 1 most of the pain, or 2 all of the pain? 3 REFUSED 7 DON'T KNOW 9
b. Aleve, Naprosyn (na-proh-sen), Anaprox (an-a-proks), Naproxyn (na-prox-sen) Y ES 1 NO 2 (ARQ.030c) REFUSED 7 (ARQ.030c) DON’T KNOW 9 (ARQ.030c)	none of the pain, 0 some of the pain, 1 most of the pain, or 2 all of the pain? 3 REFUSED 7 DON'T KNOW 9
c. Indocin (in-doh-sen), Indomethacin (in-doh-meth-a-sen) Y ES 1 NO 2 (ARQ.030d) REFUSED 7 (ARQ.030d) DON’T KNOW 9 (ARQ.030d)	none of the pain, 0 some of the pain, 1 most of the pain, or 2 all of the pain? 3 REFUSED 7 DON'T KNOW 9
d. Celebrex, Vioxx Y ES 1 NO 2 (ARQ.030e) REFUSED 7 (ARQ.030e) DON’T KNOW 9 (ARQ.030e)	none of the pain, 0 some of the pain, 1 most of the pain, or 2 all of the pain? 3 REFUSED 7 DON'T KNOW 9
e. Aspirin, Bufferin, Ecotrin, or Vanquish (Please do not count acetaminophen (a-see-ta-mi-no-fen), Tylenol or only 1 aspirin pill a day.) Y ES 1 NO 2 (ARQ.040) REFUSED 7 (ARQ.040) DON’T KNOW 9 (ARQ.040)	none of the pain, 0 some of the pain, 1 most of the pain, or 2 all of the pain? 3 REFUSED 7 DON'T KNOW 9

ARQ.034a-e HELP SCREEN:

If the SP says the medicine helped with pain in one location but not others, code the response based on the area where the medicine helped with the pain. If the medicine helped one area more than another, code the response based on the location where the medicine helped the most.

CAPI FILL INSTRUCTIONS:

IF ANY ARQ.023 = CODE 2 (CURRENTLY HAS) FOR CATEGORIES 1-5 AT ARQ.020, USE CURRENT TENSE. IF ALL ARQ.023 = CODE 1, DK OR REF FOR CATEGORIES 1-5 AT ARQ.020, USE PAST TENSE.

ARQ.040 The next question is just about stiffness in {your/SP’s} {back/{or} neck/{or} buttocks}.

If {you/he/she} {don’t/doesn’t/didn’t} take any medicine, when {you/he/she} {wake/wakes/woke} up from sleep how long {do/does/did} {you/he/she} have stiffness? Would you say…

HELP SCREEN:

Stiffness may occur with or without pain; however, this question asks only about stiffness and not about any pain the respondent may have had.

Stiffness is the feeling of being inflexible and hard to bend.

This question refers to limited movement of the spine, neck or back—either inability or difficulty in fully bending or moving the back or neck.

less than 10 minutes, 1

10 to 30 minutes, 2

31 to 60 minutes, 3

more than 1 but less than 4 hours, or 4

more than 4 hours? 5

DON’T HAVE MORNING STIFFNESS 6

REFUSED 7

DON’T KNOW 9

ARQ.050 Next are questions about pain, aching or stiffness in {your/SP’s} {back/{or} neck/{or} buttocks} {you/he/she} usually {has/have/had} if {you/he/she} {don’t/doesn’t/didn’t} take medication.

If {you/SP} {is/are/was/were} not taking any medicine, and not working or exercising, what usually {happens/happened} to the pain, aching or stiffness over the course of the day? {Does/Did} it increase, decrease or stay the same?

INTERVIEWER INSTRUCTIONS: DO NOT COUNT DAYS WHERE RESPONDENT IS DOING PROLONGED SITTING, STANDING, OR HEAVY EXERCISE.

INCREASES 1

DECREASES 2

STAYS THE SAME 3

IT VARIES, NO PATTERN 4

REFUSED 7

DON'T KNOW 9

ARQ.060 If {you/SP} {don’t/doesn’t/didn’t} take medicine, what usually {happens/happened} to the pain, aching or stiffness over the time that {you/he/she} {sleep/sleeps/slept} or {rest/rests/rested}? {Does/Did} it increase, decrease or stay the same?

HELP SCREEN:

Rest means lying down or recumbent—for example, lying down on a bed, recliner, etc. Prolonged sitting does not count as rest.

INCREASES 1

DECREASES 2

STAYS THE SAME 3

IT VARIES, NO PATTERN 4

DOESN’T HAVE REST OR SLEEP PAIN 5

REFUSED 7

DON'T KNOW 9

ARQ.070 If {you/SP} {don’t/doesn’t/didn’t} take any medicine, {do/does/did} {you/he/she} often wake up from sleep because of pain, aching or stiffness?

YES 1 (ARQ.073)

NO 2 (ARQ.080)

REFUSED 7 (ARQ.080)

DON'T KNOW 9 (ARQ.080)

ARQ.073 If {you/SP} {don’t/doesn’t/didn’t} take any medicine {does/did} {your/his/her} pain, aching or stiffness often wake {you/him/her} up after {you/s/he} {have/has/had} been sleeping for 4 or more hours?

INTERVIEWER INSTRUCTION: CODE 3 IF THE RESPONDENT SLEEPS LESS THAN 4 HOURS AT A TIME.

YES 1 (ARQ.080)

NO 2 (ARQ.080)

SLEEPS LESS THAN 4 HOURS 3 (ARQ.077)

REFUSED 7 (ARQ.080)

DON'T KNOW 9 (ARQ.080)

ARQ.077 Was it {your/SP’s} {back/{or} neck/{or} buttocks} pain, aching or stiffness that kept {you/him/her} from sleeping more than 4 hours at a time?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

ARQ.080 {Does/Did} {your/SP’s} pain, aching or stiffness usually get better when {you/he/she} {do/does/did} either walking or stretching for a half hour?

INTERVIEWER INSTRUCTIONS:

IF RESPONDENT STATES THEY DO NOT DO SUCH EXERCISE BECAUSE OF PAIN, CODE ”DOES NOT DO THESE ACTIVITIES.”

YES 1

NO 2

DOES NOT DO THESE ACTIVITIES 3

REFUSED 7

DON'T KNOW 9

BOX 5

CHECK ITEM ARQ.220:

IF ARQ.020 = CODE 5 (BUTTOCKS), CONTINUE.

OTHERWISE, GO TO ARQ.110.

ARQ.100 Does/Did the pain, aching or stiffness in {your/SP’s} buttocks ever switch from one side to the other?

HELP SCREEN:

Code “yes” only if the buttock pain that was present on one side completely went away and then the person had buttock pain on the other side.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

ARQ.110 Please look at this hand card. Besides injuries or fractures, {have you/has SP} ever had pain that is just in one of these two areas every day for at least two weeks?

INTERVIEWER INSTRUCTION:

CODE “NO” IF THE FOOT PAIN IS ANYWHERE OTHER THAN IN JUST THESE TWO SPECIFIC AREAS.

THE ANSWER SHOULD BE “YES”EVEN IF PAIN HAPPENS IN JUST ONE FOOT.

HAND CARD ARQ4

HELP SCREEN:

Code “no” if the pain is widespread, or in the whole foot rather than in just one of the local areas marked in the diagrams. For example, if there is painful swelling of the whole foot, a painful problem on the skin, or nerve pain, code “no.”

YES 1 (ARQ.112)

NO 2 (ARQ.125a)

REFUSED 7 (ARQ.125a)

DON'T KNOW 9 (ARQ.125a)

ARQ.112 Looking at this diagram, where was the pain located?

HAND CARD ARQ4

CODE ALL THAT APPLY.

LOCATION A 1

LOCATION B 2

REFUSED 7 (ARQ.125a)

DON'T KNOW 9 (ARQ.125a)

ARQ.115 What was the cause of this pain?

HELP SCREEN:

Heel spurs are bone spurs that occur underneath the heel bone. They can only be seen on x-rays.

Plantar fasciitis (plant-are fash-ee- eye-t-us) is painful inflammation underneath the heel.

Tendons are the tough cords of tissue that attach muscles to bones. They help your muscles move your bones. Tendonitis means inflammation of a tendon. It causes pain and tenderness near a joint. Depending on where it happens, it may have a special name. Achilles tendonitis (a-kill-ease ten- done-eye-t-us) is a tendonitis that occurs at the back of the heel.

CODE ALL THAT APPLY.

HEEL SPURS 1

PLANTAR FASCIITIS 2

ACHILLES TENDONITIS 3

OTHER TENDONITIS 4

INJURY, SPRAIN OR STRAIN 5

FRACTURE 6

INFECTIONS 7

CALLOUSES 8

BLISTERS OR SKIN RASH 9

GOUT 10

BUNIONS 11

CORNS 12

SWELLING 13

NERVE PAIN 14

OTHER (SPECIFY) 91

REFUSED 77

DON’T KNOW 99

ARQ.125 Has a doctor or other health professional ever told {you/SP} that {you/s/he}… CAPI INSTRUCTION: TEXT OF QUESTION SHOULD BE OPTIONAL AFTER THE FIRST ITEM IS READ.	ARQ.130 Did {you/SP} have pain and sensitivity to light in just one eye at a time, and for which {you/s/he} used eye drops prescribed by an eye doctor?	ARQ.135 At the time the doctor told {you/SP} that {you/s/he} had…
a. had iritis (eye-right-us)? Y ES 1 NO 2 (ARQ.125b) REFUSED 7 (ARQ.125b) DON’T KNOW 9 (ARQ.125b)	YES 1 NO 2 REFUSED 7 DON’T KNOW 9
b. had uveitis (you-vee-eye-t-us)? Y ES 1 NO 2 (ARQ.125c) REFUSED 7 (ARQ.125c) DON’T KNOW 9 (ARQ.125c)	YES 1 NO 2 REFUSED 7 DON’T KNOW 9
c. had ulcerative colitis (ulcer-a-tive co-light-us)? Y ES 1 NO 2 (ARQ.125d) REFUSED 7 (ARQ.125d) DON’T KNOW 9 (ARQ.125d)		ulcerative colitis (ulcer-a-tive co-light-us), did {you/SP} have a colonoscopy (co-low-nas-co-pee)? YES 1 NO 2 REFUSED 7 DON’T KNOW 9
d. had Crohn’s (crow-n-z) disease? Y ES 1 NO 2 (ARQ.125e) REFUSED 7 (ARQ.125e) DON’T KNOW 9 (ARQ.125e)		Crohn’s (crow-n-z) disease, did {you/SP} have a colonoscopy (co-low-nas-co-pee)? YES 1 NO 2 REFUSED 7 DON’T KNOW 9
e. had ankylosing spondylitis (ank-eh-low-s-ing spawn-d-light-us)? YES 1 NO 2 REFUSED 7 DON’T KNOW 9

HELP SCREENS FOR ARQ.125a TO ARQ.125e

ARQ.125a and 125b

Iritis and Uveitis are similar eye conditions. They are not eye infections (conjunctivitis) and they are not allergies. Rather, they are a sterile inflammation of the iris and surrounding areas in the eye which can cause permanent eye damage if not medically treated. Iritis and Uveitis should not be confused with glaucoma, which is a different disease altogether. Iritis and uveitis are usually treated by eye doctors with prescription cortisone eye drops.

ARQ.130a

Sensitivity to light means that it hurts to look at bright light, for example, ordinary daylight.

Iritis is very painful and it hurts to look at bright light because the iris cannot close properly, so light is always let into the eye.

If the respondent says they took prescription eye drops for an eye infection or for glaucoma, do not count this. Iritis is usually treated by eye doctors with prescription cortisone eye drops.

ARQ.130b

Sensitivity to light means that it hurts to look at bright light, for example, ordinary daylight.

Uveitis is very painful and it hurts to look at bright light because the iris cannot close properly, so light is always let into the eye.

If the respondent says they took prescription eye drops for an eye infection or for glaucoma, do not count this. Uveitis is usually treated by eye doctors with prescription cortisone eye drops.

ARQ.125c and 125d

Ulcerative Colitis and Crohn’s Disease are both inflammatory diseases of the large intestine or colon. They both cause abdominal pain, cramping and diarrhea and also sometimes fever. Ulcerative Colitis causes bloody diarrhea because there is a large amount of bleeding from ulcers that develop in the large intestine. Do not confuse this with bleeding from hemorrhoids. In Ulcerative Colitis and Crohn’s Disease, patients often have to wake up at night to go have a bowel movement.

These two diseases are not the same as diarrhea that is caused by infections or food poisioning and they are not the same as Irritable Bowel Syndrome or IBS, which is a different intestinal cramping problem that sometimes causes diarrhea and is a much more common condition among adults.

Ulcerative Colitis and Crohn’s are treated by doctors with special prescription anti-inflammatory drugs that need to be carefully monitored for side effects.

ARQ.135c and 135d

Colonoscopy: an examination of the inside of the large intestine or colon. First the colon must be cleaned out with laxatives and enemas, and then the doctor inserts an instrument called a colonoscope through the rectum. This is a small flexible tube with a camera attached. It is advanced to look at the entire length of the colon or large intestine. Photographs of the inside of the intestines can be taken and tissue samples may be also taken with tiny scissors inserted through the scope.

ARQ.125e

Ankylosing spondylitis (ank-eh-low-s-ing spawn-d-light-us) is a type of arthritis of the spine. It is an immune disease that causes pain and stiffness in the spine and in the pelvis. These problems often start in adolescence or early adulthood. Over time, ankylosing spondylitis can fuse the spine together, limiting movement. The disease is more common and more severe in men, and often runs in families. People who have the HLA-B27 marker are more likely to have ankylosing spondylitis.

DIETARY SCREENER MODULE (DTQ)

2-11 – Household

12+ – MEC

DTQ.010 G/Q/U

These questions are about the different kinds of foods {you/SP} ate or drank during the past month, that is, the past 30 days. When answering, please include meals and snacks eaten at home, at work or school, in restaurants, and anyplace else.

During the past month, how often did {you/SP} eat hot or cold cereals? You can tell me per day, per week or per month.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.030)

REFUSED 777 (DTQ.030)

DON'T KNOW 999 (DTQ.030)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.015.

DTQ.015 You said (DISPLAY NUMBER FROM DTQ.010) times per (DISPLAY UNIT FROM DTQ.010). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.010)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.020 During the past month, what kinds of cereal did {you/SP} usually eat?

ENTER FIRST FEW LETTERS OF CEREAL NAME TO START THE LOOKUP.

SELECT CEREAL FROM LIST. IF CEREAL NOT ON LIST, PRESS BS TO DELETE THE ENTRY AND TYPE ** TO ENTER CEREAL NAME.

CAPI INSTRUCTION:

DISPLAY CEREAL LIST. INTERVIEWER SHOULD BE ABLE TO SELECT CEREAL FROM LIST OR PRESS BS TO DELETE ENTRY AND TYPE ** TO ENTER NAME OF CEREAL.

NEW BOX 0

CHECK ITEM DTQ.300:

IF THIS IS THE FIRSTENTRY, CONTINUE.

OTHERWISE, GO TO DTQ.030.

DTQ.025 IS THERE ANOTHER CEREAL SP USUALLY EATS?

OR ASK IF NECESSARY (Is there another cereal {you/SP} usually eat(s)?)

YES 1 (RETURN TO DTQ.020)

NO 2 (DTQ.030)

DTQ.030 G/Q/U

(During the past month), how often did {you/SP} have milk {either to drink or on cereal}? Do not include soy milk or small amounts of milk in coffee or tea. (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTION:

INCLUDE: skim, no-fat, low-fat, whole milk, buttermilk, and lactose-free milk. Also INCLUDE chocolate or other flavored milks.

DO NOT INCLUDE: cream.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.040)

REFUSED 777 (DTQ.040)

DON'T KNOW 999 (DTQ.040)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF DTQ.010 >= 1, DISPLAY PHRASE {“either to drink or on cereal”}.

CAPI INSTRUCTION:

IF RESPONSE > 2 AND UNIT = 1 (DAY), ELIMINATE >2 AND UNIT = 1 FOR HOUSEHOLD QUESTIONNAIRE SECTION (SPs 2-11 YEARS OLD)

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.035.

DTQ.035 You said (DISPLAY NUMBER FROM DTQ.030) times per (DISPLAY UNIT FROM DTQ.030). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.030)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.040 G/Q/U

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 INSTRUCTION:

INCLUDE: MANZANITA AND PEÑAFIEL SODAS.

DO NOT INCLUDE: DIET OR SUGAR-FREE FRUIT DRINKS. DO NOT INCLUDE JUICES OR TEA IN CANS.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.050)

REFUSED 777 (DTQ.050)

DON'T KNOW 999 (DTQ.050)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 2 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.045.

DTQ.045 You said (DISPLAY NUMBER FROM DTQ.040) times per (DISPLAY UNIT FROM DTQ.040). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.040)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.050 G/Q/U

(During the past month), how often did {you/SP} drink 100% pure fruit juice such as orange, mango, apple, grape and pineapple juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTION:

INCLUDE: ONLY 100% PURE JUICES.

DO NOT INCLUDE: FRUIT-FLAVORED DRINKS WITH ADDED SUGAR, LIKE CRANBERRY COCKTAIL, HI-C, LEMONADE, KOOL-AID, GATORADE, TAMPICO, AND SUNNY DELIGHT.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (BOX 1)

REFUSED 777 (BOX 1)

DON'T KNOW 999 (BOX 1)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), ELIMINATE > 1 AND UNIT = 1 FOR HOUSEHOLD QUESTIONNAIRES (SPs 2-11 YEARS OLD)

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.055.

DTQ.055 You said (DISPLAY NUMBER FROM DTQ.050) times per (DISPLAY UNIT FROM DTQ.050). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.050)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

NEW BOX 1

CHECK ITEM DTQ.305:

IF SP AGE 2-11 YEARS OLD, SKIP TO DTQ.070.

OTHERWISE, CONTINUE.

DTQ.060 G/Q/U

(During the past month), how often did {you/SP} drink coffee or tea that had sugar or honey added to it? Include coffee and tea you sweetened yourself and presweetened tea and coffee drinks such as Arizona Iced Tea and Frappuccino. Do not include artificially sweetened coffee or diet tea. (You can tell me per day, per week or per month.)

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.070)

REFUSED 777 (DTQ.070)

DON'T KNOW 999 (DTQ.070)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.065.

DTQ.065 You said (DISPLAY NUMBER FROM DTQ.060) times per (DISPLAY UNIT FROM DTQ.060). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.060)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.070 G/Q/U

(During the past month), how often did {you/SP} drink sweetened fruit drinks, sports or energy drinks, such as Kool-aid, lemonade, Hi-C, cranberry drink, Gatorade, 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.)

INTERVIEWER INSTRUCTION:

INCLUDE: DRINKS WITH ADDED SUGAR, TAMPICO, SUNNY DELIGHT, AND TWISTER.

DO NOT INCLUDE: 100% FRUIT JUICES OR SODA, YOGURT DRINKS, CARBONATED WATER OR FRUIT-FLAVORED TEAS.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.080)

REFUSED 777 (DTQ.080)

DON'T KNOW 999 (DTQ.080)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), ELIMINATE > 1 AND UNIT = 1 FOR HOUSEHOLD QUESTIONNAIRES (SPs 2-11 YEARS OLD)

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.075.

DTQ.075 You said (DISPLAY NUMBER FROM DTQ.070) times per (DISPLAY UNIT FROM DTQ.070). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.070)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.080 G/Q/U

(During the past month), how often did {you/SP} eat fruit? Include fresh, frozen or canned fruit. Do not include juices. (You can tell me per day, per week or per month.)

Interviewer Instructions:

Do not include: dried fruits.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.090)

REFUSED 777 (DTQ.090)

DON'T KNOW 999 (DTQ.090)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.085.

DTQ.085 You said (DISPLAY NUMBER FROM DTQ.080) times per (DISPLAY UNIT FROM DTQ.080). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.080)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.090 G/Q/U

(During the past month), how often did {you/SP} eat a green leafy or lettuce salad, with or without other vegetables? (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: SPINACH SALADS.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.100)

REFUSED 777 (DTQ.100)

DON'T KNOW 999 (DTQ.100)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.095.

DTQ.095 You said (DISPLAY NUMBER FROM DTQ.090) times per (DISPLAY UNIT FROM DTQ.090). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.090)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.100 G/Q/U

(During the past month), how often did {you/SP} eat any kind of fried potatoes, including french fries, home fries, or hash brown potatoes? (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

DO NOT INCLUDE: POTATO CHIPS.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.110)

REFUSED 777 (DTQ.110)

DON'T KNOW 999 (DTQ.110)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.105.

DTQ.105 You said (DISPLAY NUMBER FROM DTQ.100) times per (DISPLAY UNIT FROM DTQ.100). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.100)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.110 G/Q/U

(During the past month), how often did {you/SP} eat any other kind of potatoes, such as baked, boiled, mashed potatoes, sweet potatoes, or potato salad? (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: ALL TYPES OF POTATOES EXCEPT FRIED. INCLUDE POTATOES AU GRATIN, SCALLOPED POTATOES.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.120)

REFUSED 777 (DTQ.120)

DON'T KNOW 999 (DTQ.120)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.115.

DTQ.115 You said (DISPLAY NUMBER FROM DTQ.110) times per (DISPLAY UNIT FROM DTQ.110). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.110)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.120 G/Q/U

(During the past month), how often did {you/SP} eat refried beans, baked beans, beans in soup, pork and beans or any other type of cooked dried beans? Do not include green beans. (You can tell me per day, per week or per month.)

Interviewer Instructions:

INCLUDE: SOYBEANS, KIDNEY, PINTO, GARBANZO, LENTILS, BLACK, BLACK-EYED PEAS, COW PEAS, AND LIMA BEANS.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.210)

REFUSED 777 (DTQ.210)

DON'T KNOW 999 (DTQ.210)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.125.

DTQ.125 You said (DISPLAY NUMBER FROM DTQ.120) times per (DISPLAY UNIT FROM DTQ.120). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.120)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.210 G/Q/U

(During the past month), how often did {you/SP} eat brown rice or other cooked whole grains, such as bulgur, cracked wheat, or millet? Do not include white rice. (You can tell me per day, per week or per month.)

HELP SCREEN:

Brown rice is a type of whole grain. It is brown in color and takes longer to cook than white rice. It contains almost all of the rice grain and is not as processed as white rice. Compared to white rice it also contains more fiber and more of some vitamins and minerals that are lost during the processing of rice.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.130)

REFUSED 777 (DTQ.130)

DON'T KNOW 999 (DTQ.130)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.215.

DTQ.215 You said (DISPLAY NUMBER FROM DTQ.210) times per (DISPLAY UNIT FROM DTQ.210). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.210)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.130 G/Q/U

(During the past month), not including what you just told me about (lettuce salads, potatoes, cooked dried beans), how often did {you/SP} eat other vegetables? (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

DO NOT INCLUDE: RICE

EXAMPLES OF OTHER VEGETABLES INCLUDE: TOMATOES, GREEN BEANS, CARROTS, CORN, CABBAGE, BEAN SPROUTS, COLLARD GREENS, AND BROCCOLI. INCLUDE ANY FORM OF THE VEGETABLE (RAW, COOKED, CANNED, OR FROZEN).

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.150)

REFUSED 777 (DTQ.150)

DON'T KNOW 999 (DTQ.150)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 2 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.135.

DTQ.135 You said (DISPLAY NUMBER FROM DTQ.130) times per (DISPLAY UNIT FROM DTQ.130). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.130)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.150 G/Q/U

(During the past month), how often did {you/SP} have Mexican-type salsa made with tomato? (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: ALL TOMATO-BASED SALSAS.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.140)

REFUSED 777 (DTQ.140)

DON'T KNOW 999 (DTQ.140)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.155.

DTQ.155 You said (DISPLAY NUMBER FROM DTQ.150) times per (DISPLAY UNIT FROM DTQ.150). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.150)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.140 G/Q/U

During the past month, how often did {you/SP} eat pizza? Include frozen pizza, fast food pizza, and homemade pizza. You can tell me per day, per week or per month.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.160)

REFUSED 777 (DTQ.160)

DON'T KNOW 999 (DTQ.160)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.145.

DTQ.145 You said (DISPLAY NUMBER FROM DTQ.140) times per (DISPLAY UNIT FROM DTQ.140). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.140)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.160 G/Q/U

(During the past month), how often did {you/SP} have tomato sauces such as with spaghetti or noodles or mixed into foods such as lasagna? {Please do not count tomato sauce on pizza.} (You can tell me per day, per week or per month.)

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.190)

REFUSED 777 (DTQ.190)

DON'T KNOW 999 (DTQ.190)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF DTQ.140 >= 1, DISPLAY “Please do not count tomato sauce on pizza.”

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.165.

DTQ.165 You said (DISPLAY NUMBER FROM DTQ.160) times per (DISPLAY UNIT FROM DTQ.160). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.160)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.190 G/Q/U

(During the past month), how often did {you/SP} eat any kind of cheese? Include cheese as a snack, cheese on burgers, sandwiches, and cheese in foods such as lasagna, quesadillas, or casseroles. {Please do not count cheese on pizza.} (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: MACARONI AND CHEESE, ENCHILADAS.

DO NOT INCLUDE: CREAM CHEESE OR CHEESES MADE FROM NON-DAIRY FOODS, SUCH AS SOY OR RICE, OR CHEESE ON PIZZA.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.170)

REFUSED 777 (DTQ.170)

DON'T KNOW 999 (DTQ.170)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF DTQ.140 >= 1, DISPLAY “Please do not count cheese on pizza.”

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.195.

DTQ.195 You said (DISPLAY NUMBER FROM DTQ.190) times per (DISPLAY UNIT FROM DTQ.190). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.190)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.170 G/Q/U

Please look at this card, during the past month, how often did {you/SP} eat red meat, such as beef, pork, ham, or sausage? Do not include chicken, turkey or seafood. (You can tell me per day, per week or per month.)

HAND CARD DTQ1

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.180)

REFUSED 777 (DTQ.180)

DON'T KNOW 999 (DTQ.180)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.175.

DTQ.175 You said (DISPLAY NUMBER FROM DTQ.170) times per (DISPLAY UNIT FROM DTQ.170). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.170)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.180 G/Q/U

Please look at this card, (during the past month), how often did {you/SP} eat processed meat, such as bacon, lunch meats, or hot dogs? (You can tell me per day, per week or per month.)

HAND CARD DTQ2

INTERVIEWER INSTRUCTIONS:

INCLUDE: PROCESSED POULTRY AND RED MEAT.

DO NOT INCLUDE: CANNED TUNA FISH OR CHICKEN NUGGETS.

HELP SCREEN:

processed meat: Meats (usually red meats, but not always) preserved by smoking, curing, or salting, or by the addition of preservatives. Examples include: ham, bacon, pastrami, salami, sausages, bratwursts, frankfurters, hot dogs, or spam.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.200)

REFUSED 777 (DTQ.200)

DON'T KNOW 999 (DTQ.200)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.185.

DTQ.185 You said (DISPLAY NUMBER FROM DTQ.180) times per (DISPLAY UNIT FROM DTQ.180). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.180)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.200 G/Q/U

(During the past month), how often did {you/SP} eat whole grain bread including toast, rolls and in sandwiches? Whole grain breads include whole wheat, rye, oatmeal and pumpernickel. Do not include white bread. (You can tell me per day, per week or per month.)

HAND CARD DTQ3

INTERVIEWER INSTRUCTIONS:

INCLUDE: CRACKED WHEAT, MULTI-GRAIN, BRAN BREADS, WHOLE GRAIN WHITE BREAD.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.220)

REFUSED 777 (DTQ.220)

DON'T KNOW 999 (DTQ.220)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.205.

DTQ.205 You said (DISPLAY NUMBER FROM DTQ.200) times per (DISPLAY UNIT FROM DTQ.200). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.200)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.220 G/Q/U

During the past month, how often did {you/SP} eat chocolate or any other types of candy? Do not include sugar-free candy. You can tell me per day, per week or per month.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.230)

REFUSED 777 (DTQ.230)

DON'T KNOW 999 (DTQ.230)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.225.

DTQ.225 You said (DISPLAY NUMBER FROM DTQ.220) times per (DISPLAY UNIT FROM DTQ.220). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.220)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.230 G/Q/U

(During the past month), how often did {you/SP} eat doughnuts, sweet rolls, Danish, muffins, (pan dulce) or pop-tarts? Do not include sugar-free items. (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: LOW-FAT KINDS.

DO NOT INCLUDE: PANCAKES, WAFFLES, FRENCH TOAST, CAKE, ICE CREAM AND OTHER FROZEN DESSERTS OR CANDY.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.240)

REFUSED 777 (DTQ.240)

DON'T KNOW 999 (DTQ.240)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.235.

DTQ.235 You said (DISPLAY NUMBER FROM DTQ.230) times per (DISPLAY UNIT FROM DTQ.230). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.230)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.240 G/Q/U

(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.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: LOW-FAT KINDS, TWINKIES AND HOSTESS CUPCAKES.

DO NOT INCLUDE: ICE CREAM AND OTHER FROZEN DESSERTS OR CANDY.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.250)

REFUSED 777 (DTQ.250)

DON'T KNOW 999 (DTQ.250)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.245.

DTQ.245 You said (DISPLAY NUMBER FROM DTQ.240) times per (DISPLAY UNIT FROM DTQ.240). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.240)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.250 G/Q/U

(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.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: LOW-FAT KINDS. ALSO INCLUDE FROZEN YOGURT AND SHERBET.

DO NOT INCLUDE: NON-DAIRY FROZEN DESSERTS, SUCH AS SORBET, SNO-CONES.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.260)

REFUSED 777 (DTQ.260)

DON'T KNOW 999 (DTQ.260)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.255.

DTQ.255 You said (DISPLAY NUMBER FROM DTQ.250) times per (DISPLAY UNIT FROM DTQ.250). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.250)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.260 G/Q/U

(During the past month), how often did {you/SP} eat popcorn? (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: LOW-FAT POPCORN.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (END OF SECTION)

REFUSED 777 (END OF SECTION)

DON'T KNOW 999 (END OF SECTION)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.265.

DTQ.265 You said (DISPLAY NUMBER FROM DTQ.260) times per (DISPLAY UNIT FROM DTQ.260). Is that correct?

YES 1 (END OF SECTION)

NO 2 (RETURN TO DTQ.260)

REFUSED 777 (END OF SECTION)

DON’T KNOW 999 (END OF SECTION)

D

EMOGRAPHICS INFORMATION

D

EMOGRAPHICS INFORMATION – DMQ – SP

Target Group: SPs Birth +

BOX 1A

CHECK ITEM DMQ.030:

IF SP AGE >= 6, CONTINUE.

OTHERWISE, GO TO DMQ.061.

DMQ.141 What is the highest grade or level of school {you have/SP has} completed or the highest degree {you have/s/he has} received?

HAND CARD DMQ1

READ HAND CARD CATEGORIES IF NECESSARY.

Enter highest level of school.

NEVER ATTENDED/KINDERGARTEN

ONLY 0 (BOX 1B)

1ST GRADE 1

2ND GRADE 2

3RD GRADE 3

4TH GRADE 4

5TH GRADE 5

6TH GRADE 6

7TH GRADE 7

8TH GRADE 8

9TH GRADE 9

10TH GRADE 10

11TH GRADE 11

12TH GRADE, NO DIPLOMA 12

HIGH SCHOOL GRADUATE 13

GED OR EQUIVALENT 14

SOME COLLEGE, NO DEGREE 15

ASSOCIATE DEGREE: OCCUPATIONAL,

TECHNICAL, OR VOCATIONAL

PROGRAM 16

ASSOCIATE DEGREE: ACADEMIC

PROGRAM 17

BACHELOR’S DEGREE (EXAMPLE: BA,

AB, BS, BBA) 18

MASTER’S DEGREE (EXAMPLE: MA,

MS, MEng, MEd, MBA) 19

PROFESSIONAL SCHOOL DEGREE

(EXAMPLE: MD, DDS, DVM, JD) 20

DOCTORAL DEGREE (EXAMPLE:

PhD, EdD) 21

REFUSED 77

DON’T KNOW 99

BOX 1AA

CHECK ITEM DMQ.035:

IF SP AGE <= 19, CONTINUE

OTHERWISE, GO TO DMQ.051.

DMQ.037 {Are you/Is SP} now . . .

going to school, 1

on vacation from school (between

grades), or 2

neither? 3

REFUSED 7

DON’T KNOW 9

BOX 1B

CHECK ITEM DMQ.040:

IF SP AGE >= 17, CONTINUE.

OTHERWISE, GO TO DMQ.061.

DMQ.051 Did {you/SP} ever serve in the Armed Forces of the United States?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DMQ.061 {Do you/Does SP} usually go by another first name besides {DISPLAY FIRST NAME FROM DMQ-SPIV.040}?

CAPI INSTRUCTION:

DISPLAY "FIRST NAME:" AND FIRST NAME FROM DMQ-SPIV.040 AS LEFT HEADER.

YES 1

NO 2 (BOX 1BB)

REFUSED 7 (BOX 1BB)

DON'T KNOW 9 (BOX 1BB)

DMQ.071 What is this other first name?

VERIFY SPELLING

____________________________________

ENTER NAME

REFUSED 7

DON'T KNOW 9

BOX 1BB

CHECK ITEM DMQ.073a:

IF AGE >= 14, CONTINUE.

OTHERWISE, GO TO BOX 1D.

DMQ.380 {Are you/Is SP} now married, widowed, divorced, separated, never married or living with a partner?

MARRIED 1

WIDOWED 2

DIVORCED 3

SEPARATED 4

NEVER MARRIED 5 (BOX 1D)

LIVING WITH PARTNER 6

REFUSED 7

DON'T KNOW 9

BOX 1C

CHECK ITEM DMQ.075A:

IF SP IS MALE OR CODED AS 'NEVER MARRIED' IN DMQ.380, GO TO BOX 1D.

OTHERWISE, CONTINUE.

DMQ.081 {Do you/Does SP} have a maiden name?

ASK IF NOT KNOWN

YES 1

NO 2 (BOX 1D)

REFUSED 7 (BOX 1D)

DON'T KNOW 9 (BOX 1D)

DMQ.090 What is {your/SP's} maiden name?

G/Q

VERIFY SPELLING

CAPI INSTRUCTION:

DISPLAY "LAST NAME:" AND SP'S CURRENT LAST NAME FROM DMQ-SPIV.060 AS LEFT HEADER.

____________________________________

ENTER MAIDEN NAME 1

SAME AS CURRENT LAST NAME 2

REFUSED 7

DON'T KNOW 9

BOX 1D

CHECK ITEM DMQ.094:

IF SP AGE >= 16, CONTINUE.

OTHERWISE, GO TO DMQ.107.

DMQ.101 What is {your/SP's} father's last name?

G/Q

VERIFY SPELLING

CAPI INSTRUCTION:

DISPLAY "LAST NAME:" AND SP'S CURRENT LAST NAME FROM DMQ-SPIV.060 AS LEFT HEADER.

IF MAIDEN NAME ENTERED IN DMQ.090G/Q, AND MAIDEN NAME IS DIFFERENT FROM CURRENT LAST NAME, ALSO DISPLAY "MAIDEN NAME:" AND MAIDEN NAME FROM DMQ.090G/Q AS LEFT HEADER.

CAPI INSTRUCTION:

HARD EDIT: IF SP MALE, DO NOT ALLOW RESPONSE 3.

____________________________________

ENTER NAME 1

SAME AS CURRENT LAST NAME 2

SAME AS MAIDEN NAME 3

REFUSED 7

DON'T KNOW 9

DMQ.107 In what country {were you/was SP} born?

UNITED STATES 1 (DMQ.130)

OTHER COUNTRY 2

REFUSED 7 (BOX 3)

DON'T KNOW 9 (BOX 3)

DMQ.112 SELECT COUNTRY OF BIRTH

ARGENTINA 1 (DMQ.160 M/Y)

BELIZE 2 (DMQ.160 M/Y)

BOLIVIA 3 (DMQ.160 M/Y)

BRAZIL 4 (DMQ.160 M/Y)

CHILE 5 (DMQ.160 M/Y)

COLOMBIA 6 (DMQ.160 M/Y)

COSTA RICA 7 (DMQ.160 M/Y)

CUBA 8 (DMQ.160 M/Y)

DOMINICAN REPUBLIC 9 (DMQ.160 M/Y)

ECUADOR 10 (DMQ.160 M/Y)

EL SALVADOR 11 (DMQ.160 M/Y)

GUATEMALA 12 (DMQ.160 M/Y)

HONDURAS 13 (DMQ.160 M/Y)

MEXICO 14 (DMQ.160 M/Y)

NICARAGUA 15 (DMQ.160 M/Y)

PANAMA 16 (DMQ.160 M/Y)

PARAGUAY 17 (DMQ.160 M/Y)

PERU 18 (DMQ.160 M/Y)

PHILIPPINES 19 (DMQ.160 M/Y)

PUERTO RICO 20 (DMQ.160 M/Y)

SPAIN 21 (DMQ.160 M/Y)

URUGUAY 22 (DMQ.160 M/Y)

VENEZUELA 23 (DMQ.160 M/Y)

OTHER COUNTRY (CAPI INSTRUCTION:

DO NOT SPECIFY) 40 (DMQ.160 M/Y)

DMQ.130 In what state {were you/was SP} born?

ENTER 2 LETTER STATE ABBREVIATION TO START THE LOOKUP.

SELECT STATE FROM CAPI STATE LIST.

PRESS ENTER TO ACCEPT SELECTION.

CAPI INSTRUCTION:

DISPLAY FIPS STATE LIST. INTERVIEWER ONLY SHOULD BE ABLE TO SELECT 1 STATE FROM LIST. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. THE STATE LOOKUP IN THE SP AND FAMILY QUESTIONNAIRES SHOULD WORK EXACTLY THE SAME.

BOX 3

CHECK ITEM DMQ.150:

GO TO DMQ.241.

DMQ.160 In what month and year did {you/SP} come to the United States to stay?

M/Y

|___|___|

ENTER MONTH NUMBER

REFUSED 7777

DON'T KNOW 9999

|___|___|___|___|

ENTER 4-DIGIT YEAR

REFUSED 777777

DON'T KNOW 999999

DMQ.170 {Are you/Is SP} a citizen of the United States?

[Information about citizenship is being collected by the Centers for Disease Control and Prevention to perform health related research. Providing this information is voluntary and is collected under the authority of the Public Health Service Act. There will be no effect on pending immigration or citizenship petitions.]

HAND CARD DMQ2

YES, BORN IN UNITED STATES 1

YES, BORN IN PUERTO RICO, GUAM,

AMERICAN VIRGIN ISLANDS, OR

OTHER U.S. TERRITORY 2

YES, BORN ABROAD TO AMERICAN

PARENTS 3

YES, U.S. CITIZEN BY NATURALIZATION 4

NO, NOT A CITIZEN OF THE UNITED

STATES 5

REFUSED 7

DON'T KNOW 9

DMQ.241 {Do you/Does SP} consider {yourself/himself/herself} to be Hispanic or Latino?

READ IF NECESSARY: Where {do your/do his/do her} ancestors come from?

Puerto Rican

Cuban/Cuban American

Dominican Republic

Mexican/Mexican American

Central/South American

Other Latin American

Other Hispanic or Latino

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

SPANISH, HISPANIC OR LATINO PEOPLE MAY BE OF ANY RACE. LISTED BELOW ARE HISPANIC OR LATINO CATEGORIES/COUNTRIES.

MEXICAN

PUERTO RICAN

CUBAN

DOMINICAN REPUBLIC

CENTRAL AMERICAN:

COSTA RICAN

GUATEMALAN

HONDURAN

NICARAGUAN

PANAMANIAN

SALVADORAN

OTHER CENTRAL AMERICAN

SOUTH AMERICAN:

ARGENTINEAN

BOLIVIAN

CHILEAN

COLOMBIAN

ECUADORIAN

PARAGUAYAN

PERUVIAN

URUGUAYAN

VENEZUELAN

OTHER SOUTH AMERICAN

OTHER HISPANIC OR LATINO:

SPANIARD

SPANISH

SPANISH AMERICAN

BOX 3F

OMITTED

BOX 3G

OMITTED

BOX 3H

OMITTED

BOX 3I

CHECK ITEM DMQ.242:

IF YES (CODE 1) IN DMQ.241 AND YES IN SCQ.260 GO TO DMQ.252.

IF NO (CODE 2) IN DMQ.241 AND NO IN SCQ.260

GO TO DMQ.262.

OTHERWISE, GO TO BOX 3J.

BOX 3J

CHECK ITEM DMQ.249:

IF YES (CODE 1) OR DK IN DMQ.241 AND NO (CODE 2) IN SCQ.260, DISPLAY SOFT EDIT MESSAGE “WARNING – SCREENER ETHNICITY IS NOT HISPANIC – SP MAY BE DESAMPLED. HAND CARD DMQ4 TO RESPONDENT AND READ CATEGORIES.

BOX 3K

CHECK ITEM DMQ.254:

IF NO (CODE 2) OR DK IN DMQ.241 AND YES (CODE 1) IN SCQ.260, DISPLAY SOFT EDIT MESSAGE “WARNING – SCREENER ETHNICITY IS HISPANIC – SP MAY BE DESAMPLED. HAND CARD DMQ4 TO RESPONDENT AND READ CATEGORIES.

DMQ.252 Please give me the number of the group that represents {your/SP's} Hispanic/Latino origin or ancestry. Please select 1 or more of these categories.

PROBE: Where do you/your ancestors come from?

HAND CARD DMQ4

SELECT 1 OR MORE

MEXICAN 10

PUERTO RICAN 11

CUBAN 12

DOMINICAN REPUBLIC 13

CENTRAL AMERICAN:

COSTA RICAN 14

GUATEMALAN 15

HONDURAN 16

NICARAGUAN 17

PANAMANIAN 18

SALVADORAN 19

OTHER CENTRAL AMERICAN 20

SOUTH AMERICAN:

ARGENTINEAN 21

BOLIVIAN 22

CHILEAN 23

COLOMBIAN 24

ECUADORIAN 25

PARAGUAYAN 26

PERUVIAN 27

URUGUAYAN 28

VENEZUELAN 29

OTHER SOUTH AMERICAN 30

OTHER HISPANIC OR LATINO:

FILIPINO 31

SPANIARD 32

SPANISH 33

SPANISH AMERICAN 34

HISPANO/HISPANA 35

HISPANIC/LATINO 36

OTHER HISPANIC/LATINO (SPECIFY) 40

REFUSED 77

DON'T KNOW 99

BOX 3L

CHECK ITEM DMQ.255:

IF ‘OTHER SPECIFY’ (CODE 40) IN DMQ.252, DISPLAY SOFT ERROR MESSAGE “PLEASE REVIEW THE LIST AND SELECT RESPONSE FROM LIST BEFORE TYPING. THE LIST IS MEANT TO INCLUDE ALL CATEGORIES” AND CAPI SHOULD RETURN TO DMQ.252.

DMQ.262 What race {do you/does SP} consider {yourself/himself/herself} to be? Please select 1 or more of these categories.

HAND CARD DMQ5

SELECT 1 OR MORE

WHITE 110 (DMQ.281a)

BLACK/AFRICAN AMERICAN 111 (DMQ.281a)

INDIAN (AMERICAN) 112 (DMQ.281a)

ALASKA NATIVE 113 (DMQ.281a)

NATIVE HAWAIIAN 114 (DMQ.281a)

GUAMANIAN 115 (DMQ.281a)

SAMOAN 116 (DMQ.281a)

OTHER PACIFIC ISLANDER (SPECIFY) 117 (DMQ.281a)

ASIAN INDIAN (INCLUDES PERSONS OF
INDIA, PAKISTAN, CEYLON, AND
SRI LANKA) 118 (DMQ.281a)

CHINESE 119 (DMQ.281a)

FILIPINO (FROM PHILIPPINES) 120 (DMQ.281a)

JAPANESE 121 (DMQ.281a)

KOREAN 122 (DMQ.281a)

VIETNAMESE 123 (DMQ.281a)

OTHER ASIAN 124 (DMQ.265)

SOME OTHER RACE 125 (DMQ.266)

REFUSED 777 (DMQ.281a)

DON’T KNOW 999 (DMQ.281a)

CAPI INSTRUCTION:

THE WORDS “INDIA”, “PAKISTAN”, “CEYLON”, AND “SRI LANKA” SHOULD APPEAR IN BLUE.

DMQ.265 CODE SP ANSWER TO OTHER ASIAN.

INTERVIEWER INSTRUCTION: READ CATEGORIES IF NECESSARY.

HMONG 1 (DMQ.281a)

LAOTIAN 2 (DMQ.281a)

CAMBODIAN 4 (DMQ.281a)

TAIWANESE 5 (DMQ.281a)

THAI (FROM THAILAND) 6 (DMQ.281a)

OTHER (SPECIFY) 40 (DMQ.281a)

DMQ.266 CODE SP ANSWER TO ‘OTHER RACE’.

MEXICAN 10

PUERTO RICAN 11

CUBAN 12

DOMINICAN REPUBLIC 13

CENTRAL AMERICAN:

COSTA RICAN 14

GUATEMALAN 15

HONDURAN 16

NICARAGUAN 17

PANAMANIAN 18

SALVADORAN 19

OTHER CENTRAL AMERICAN 20

SOUTH AMERICAN:

ARGENTINEAN 21

BOLIVIAN 22

CHILEAN 23

COLOMBIAN 24

ECUADORIAN 25

PARAGUAYAN 26

PERUVIAN 27

URUGUAYAN 28

VENEZUELAN 29

OTHER SOUTH AMERICAN 30

OTHER HISPANIC OR LATINO:

SPANIARD 32

SPANISH 33

SPANISH AMERICAN 34

HISPANO/HISPANA 35

HISPANIC/LATINO 36

OTHER (SPECIFY) 40

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF CODE 10 THROUGH 36, CHECK DMQ.241. IF “NO” (CODE 2) IN DMQ.241, DISPLAY THE FOLLOWING HARD ERROR MESSAGE. RESPONDENT CODED AS NOT HISPANIC IN PREVIOUS QUESTION “{DO YOU/DOES SP} CONSIDER {YOURSELF/HIMSELF/HERSELF} HISPANIC/LATINO – BACK UP TO CORRECT PREVIOUS QUESTION OR CORRECT ENTRY AT THIS QUESTION.

BOX 3M

CHECK ITEM DMQ.268:

IF ‘OTHER SPECIFY’ (CODE 40) IN DMQ.266, DISPLAY SOFT ERROR MESSAGE – “PLEASE REVIEW THE LIST AND SELECT RESPONSE FROM LIST BEFORE TYPING. THE LIST IS MEANT TO INCLUDE ALL CATEGORIES.” AND CAPI SHOULD RETURN TO QUESTION DMQ.266.

DMQ.281a

The National Center for Health Statistics will conduct statistical research by combining {your/his/her} survey data with vital, health, nutrition and other related records. {Your/SP’s} social security number is used only for these purposes and the Center will not release it to anyone, including any government agency, for any other reason. Providing this information is voluntary and is collected under the authority of Section 306 of the Public Health Service Act. There will be no effect on {your/his/her} benefits if you do not provide it.

INTERVIEWER INSTRUCTION—ONLY READ IF ASKED. [Public Health Service Act is title 42, United States Code, section 242k.]

What is {your/SP's} Social Security Number?

INTERVIEWER INSTRUCTION:

IF RESPONDENT CANNOT RECALL FROM MEMORY ASK {HIM/HER} TO GET CARD AT THIS TIME.

IF RESPONDENT IS RELUCTANT OR NEEDS MORE INFORMATION, PRESS F1 TO ACCESS THE HELP SCREEN AND FOLLOW THE SCRIPT.

ENTER SOCIAL SECURITY NUMBER 1 (DMQ281b)

DOES NOT HAVE SOCIAL SECURITY NUMBER 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

CAPI INSTRUCTION:

IF SP REFUSES (CODE 7), DISPLAY THE FOLLOWING SOFT ERROR MESSAGE:

I understand your concern. The National Center for Health Statistics has never had a breach of confidentiality in the 40 years we have been conducting this study. I do not have access to this information after I type it. Once I complete the interview all the information is sent to a secure facility. No one takes it home on a computer, no one works on it at home and only one or two people have access to the file to use it for our health research.

HELP TEXT - IF R IS RELUCTANT TO GIVE NUMBER OR IF R ASKS IF THEY MUST GIVE NUMBER –

It is extremely useful to have this information to be able to link to health records such as death certificates and Medicare records in the future. Many years in the future the information you give me can be used to see how health habits and diet at one point in your life influence how healthy you are in the future.

DMQ281b/c

CAPI INSTRUCTION:

REQUIRE DOUBLE ENTRY OF SOCIAL SECURITY NUMBER.

|___|___|___| |___|___| |___|___|___|___|

ENTER SOCIAL SECURITY NUMBER

or

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

DMQ.300 INTERVIEWER: SELECT CATEGORY FOR REPORTING OF SOCIAL SECURITY NUMBER

SELF REPORTED FROM MEMORY 1

SELF REPORTED FROM RECORDS 2

PROXY REPORTED FROM MEMORY 3

PROXY REPORTED FROM RECORDS 4

HEALTH INSURANCE

HIQ.011 The next questions are about health insurance.

Include health insurance obtained through employment or purchased directly as well as government programs like Medicare and Medicaid that provide medical care or help pay medical bills.

{Are you/Is SP} covered by health insurance or some other kind of health care plan?

YES 1

NO 2 (BOX 12)

REFUSED 7 (BOX 12)

DON'T KNOW 9 (BOX 12)

HIQ.031 What kind of health insurance or health care coverage {do you/does SP} have? Include those that pay for only one type of service (nursing home care, accidents, or dental care). Exclude private plans that only provide extra cash while hospitalized. If {you have/s/he has} more than one kind of health insurance, tell me all plans that {you have/s/he has}.

CODE ALL THAT APPLY

HAND CARD HIQ1

CAPI INSTRUCTION:

DO NOT ALLOW MORE THAN ONE ANSWER WHEN 40 (NO COVERAGE OF ANY TYPE) IS CODED.

PRIVATE HEALTH INSURANCE 14

MEDICARE 15

MEDI-GAP 16

MEDICAID ({DISPLAY STATE PLAN NAME}) 17

SCHIP (CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM) 18

MILITARY HEALTH CARE (TRICARE/VA/CHAMP-VA) 19

INDIAN HEALTH SERVICE 20

STATE-SPONSORED HEALTH PLAN ({DISPLAY STATE

PLAN NAME}) 21

OTHER GOVERNMENT PROGRAM 22

SINGLE SERVICE PLAN (E.G., DENTAL, VISION,

PRESCRIPTIONS) 23

NO COVERAGE OF ANY TYPE 40

REFUSED 77

DON'T KNOW 99

BOX 2

OMITTED

BOX 3

OMITTED

BOX 4

OMITTED

BOX 5

OMITTED

BOX 10

OMITTED

BOX 11

OMITTED

BOX 12

CHECK ITEM HIQ.065:

• IF AGE => 65 AND HIQ.031 = CODE 14 OR CODE 16-99 OR HIQ.031 IS EMPTY, GO TO HIQ.260.

• IF AGE = BIRTH+ AND HIQ.031 = CODE 15, GO TO HIQ.500.

• OTHERWISE, CONTINUE.

BOX 13

CHECK ITEM HIQ.259:

IF AGE < 65 AND (HIQ.011 = 1 (YES) AND HIQ.031 NOT = 40 (NO COVERAGE), GO TO HIQ.270.

IF AGE < 65 AND (HIQ.011 = 2, 7, OR 9 OR HIQ.031 = 40), GO TO END OF SECTION.

HIQ.260 {Do you/Does SP} have Medicare? This is a health insurance program that virtually all persons 65 and older are eligible for. A card is automatically mailed to you shortly before your 65th birthday, it looks like this.

SHOW HAND CARD HIQ2 OF MEDICARE CARD

YES 1

NO 2 (BOX 14)

REFUSED 7 (BOX 14)

DON’T KNOW 9 (BOX 14)

HIQ.500 May I please see {your/SP's} Medicare card to determine the type of coverage and to record the Health Insurance Claim Number?

This number is needed to allow Medicare records of the Center for Medicare and Medicaid Services to be easily and accurately located and identified for statistical or research purposes. We may also need to link it with other records in order to re-contact {you/SP}. Except for these purposes, the Department of Health and Human Services will not release {your/his/her} Health Insurance Claim Number to anyone, including any other government agency. Providing the Health Insurance Claim Number is voluntary and collected under the authority of the Public Health Service Act. Whether the number is given or not, there will be no effect on {your/his/her} benefits. This number will be held in strict confidence. [The Public Health Service Act is Title 42, United States Code, Section 242K.]

CAPI INSTRUCTION:

REQUIRE DOUBLE ENTRY OF NUMBER.

ALLOW UP TO 11 CHARACTERS (LETTERS OR NUMBERS)

|___|___|___|___|___|___|___|___|___|___|___|

ENTER CLAIM NUMBER

REFUSED 777777777 (BOX 14)

DON'T KNOW 999999999 (BOX 14)

HIQ.105 INTERVIEWER: ENTER 1 RESPONSE

CARD AVAILABLE 1

CARD NOT AVAILABLE 2 (BOX 14)

BOX 14

CHECK ITEM HIQ.269:

IF (HIQ.011 = 1 AND HIQ.031 NOT = 40) OR HIQ.260 = 1, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

BOX 6

OMITTED

BOX 7

OMITTED

BOX 8

OMITTED

BOX 9

OMITTED

HIQ.270 {Does this plan/Do any of these plans} cover any part of the cost of prescriptions?

CAPI INSTRUCTION:

IF HIQ.031 = 15 or HIQ.260 = 1, DISPLAY: [If you are enrolled in Medicare Part D, also known as the Medicare Prescription Drug Plan, you have some prescription drug coverage.]

Yes 1

No 2

Refused 7

Don't know 9

HIQ.210 In the past 12 months, was there any time when {you/SP} did not have any health insurance coverage?

Yes 1

No 2

Refused 7

Don't know 9

DIETARY SUPPLEMENTS AND PRESCRIPTION MEDICATION

DSQ.012 The next questions are about {your/SP's} use of dietary supplements, nonprescription antacids, and prescription medications during the past 30 days.

{Have you/Has SP} used or taken any vitamins, minerals, herbals or other dietary supplements in the past 30 days? Include prescription and non-prescription supplements.

This card lists some examples of different types of dietary supplements.

HAND CARD DSQ1a

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

RXQ.021 {Have you/Has SP} used or taken any nonprescription antacids in the past 30 days?

HAND CARD DSQ1b

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 0

OMITTED

RXQ.032 In the past 30 days, {have you/has SP} used or taken medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. [Do not include prescription vitamins or minerals you may have already told me about.]

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1

CHECK ITEM DSQ.035A:

IF 'YES' (CODE 1) IN DSQ.012, RXQ.021, OR RXQ.032, CONTINUE.

OTHERWISE, GO TO BOX 14A.

DSQ.042 May I please see the containers for all the {vitamins, minerals, herbals, and other dietary supplements}, {and} {nonprescription antacids} {and} {prescription medicines} that {you/SP} used or took in the past 30 days?

PRESS ENTER TO CONTINUE

CAPI INSTRUCTION:

DISPLAY {vitamins, minerals, herbals and other dietary supplements,} only if DSQ.012 = yes (1), {nonprescription antacids.} only if RXQ.021 = yes (1), {prescription medicines,} only if RXQ.032 = yes (1), and the word {“and”} only before the last product type if there is more than one product type.

BOX 1A

CHECK ITEM DSQ.045:

IF 'YES' (CODE 1) IN DSQ.012, CONTINUE WITH DSQ.047.

OTHERWISE, GO TO BOX 6.

DSQ.047 I will start with the vitamins, minerals, herbals and other dietary supplements. Please show me any {you have/SP has} taken in the past 30 days.

CHECK PRODUCT LABEL OR ASK PRODUCT NAME.

IS THIS PRODUCT ON THE LIST BELOW?

YES 1

NO 2 (DSQ.052)

DON’T KNOW 9 (DSQ.052)

SINGLE ELEMENTS

VITAMIN A 10

VITAMIN B6 12

VITAMIN B12 13

VITAMIN C (WITH OR WITHOUT ROSE HIPS) 14

VITAMIN D 15

VITAMIN E 16

CALCIUM 18

CHROMIUM (CHROMIUM PICOLINATE) 19

FOLATE (FOLIC ACID) 20

IRON (FERROUS XXXATE) 21

MAGNESIUM 27

POTASSIUM 28

SELENIUM 29

ZINC (ZINC GLUCONATE) 40

MULTI ELEMENTS

VITAMINS A & D 50

CALCIUM & VITAMIN D 51

CALCIUM & MAGNESIUM 52

DSQ.049 WHICH PRODUCT IS IT?

ENTER 1 PRODUCT CODE

VITAMIN A 10

VITAMIN B6 12

VITAMIN B12 13

VITAMIN C (WITH OR WITHOUT ROSE HIPS) 14

VITAMIN D 15

VITAMIN E 16

CALCIUM 18

CHROMIUM (CHROMIUM PICOLINATE) 19

FOLATE (FOLIC ACID) 20

IRON (FERROUS XXXATE) 21

MAGNESIUM 27

POTASSIUM 28

SELENIUM 29

ZINC (ZINC GLUCONATE) 40

VITAMINS A & D 50

CALCIUM & VITAMIN D 51

CALCIUM & MAGNESIUM 52

REFUSED 77 (DSQ.052)

DON’T KNOW 99 (DSQ.052)

BOX 1B

CHECK ITEM DSQ.059:

GO TO DSQ.071.

DSQ.052 REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF DIETARY SUPPLEMENTS USED. ENTER FULL NAME OF SUPPLEMENT, INCLUDING BRAND.

ENTER SUPPLEMENT NAME

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF DON'T KNOW OR REFUSAL, THEN GO TO BOX 6.

SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.

TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.

DSQ.060s PRESS BS TO START THE LOOKUP.

SELECT SUPPLEMENT FROM LIST.

IF SUPPLEMENT NOT

ON LIST – PRESS BS

TO DELETE ENTRY.

TYPE '**'

PRESS ENTER TO SELECT.

CAPI INSTRUCTION:

DISPLAY CAPI VITAMIN PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN DSQ.052 BY TYPING IN "**".

THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION TEXT ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.

INTERVIEWER SHOULD BE ABLE TO ACCEPT THE KEYED NAME AS A NEW PRODUCT NAME. AFTER ENTRY, INTERVIEWER SHOULD RETURN TO THE DATA BASE LIST. IF NO MORE ENTRIES, INTERVIEWERS SHOULD HAVE A WAY OF MOVING INTO LOOP 1.

ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:

DRUG TYPE {3}

GENERIC NAME {60}

THERAPEUTIC CLASS CODE {6}

GENERIC FLAG {1}

THERE IS NO NEED TO DISPLAY THIS INFORMATION.

BOX 2

CHECK ITEM DSQ.061:

IF PRODUCT IS SELECTED FROM THE LOOKUP AND THE PRODUCT NAME IS GREATER THAN THE LOOKUP DISPLAY FIELD, CONTINUE WITH DSQ.057.

OTHERWISE, GO TO DSQ.071.

DSQ.057 YOU HAVE SELECTED

{DISPLAY FULL VARIABLE NAME}

IS THIS CORRECT?

YES 1

NO 2 (CAPI INSTRUCTION)

CAPI INSTRUCTION:

DISPLAY SCREEN DSQ.060s – ENTRY FIELD SHOULD BE BLANK. AT DSQ.060s, INTERVIEWER SHOULD PRESS THE ‘BACKSPACE’ KEY TO START THE LOOKUP AGAIN AND SELECT ANOTHER PRODUCT.

DSQ.071 INTERVIEWER: ENTER 1 RESPONSE

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

CONTAINER SEEN 1

CONTAINER NOT SEEN 2

BOX 2A

CHECK ITEM DSQ.074:

• IF PRODUCT WAS SELECTED FROM SPECIAL PRODUCT LIST (YES, CODE 1 IN DSQ.047) AND CONTAINER SEEN, CONTINUE.

• IF PRODUCT WAS NOT SELECTED FROM SPECIAL PRODUCT LIST (NO, CODE 2 IN DSQ.047) AND CONTAINER SEEN, GO TO DSQ.077.

• OTHERWISE (IF CONTAINER NOT SEEN), GO TO DSQ.096.

DSQ.066 SELECT STRENGTH FOR {ELEMENT}

a/b/aO/bO

IF STRENGTH NOT ON FRONT OR UNCLEAR, TURN CONTAINER AROUND AND GET STRENGTH FROM FACTS BOX.

PRESS BS TO START LOOKUP.

PRESS ENTER TO SELECT.

CAPI INSTRUCTION:

• {ELEMENT} = DISPLAY PRODUCT ELEMENT SELECTED IN DSQ.049. IF PRODUCT SELECTED HAS MORE THAN 1 ELEMENT (EXAMPLE = ), STRENGTH QUESTION SHOULD APPEAR FOR EACH ELEMENT.

• IF “OTHER” STRENGTH IS SELECTED, GET OTHER SPECIFY AND INTERVIEWER INSTRUCTION SHOULD READ “ENTER SUPPLEMENT STRENGTH”.

• ALL OF THE STRENGTH QUESTION AND INSTRUCTION SHOULD APPEAR WHEN STRENGTH LOOKUP LIST IS DISPLAYED (NO SCROLLING). THIS MAY MEAN PRINTING ALL WORDS ON THE SCREEN FLUSH LEFT IN MULTIPLE LINES.

BOX 3

OMITTED

DSQ.077 WHAT IS THE FORM OF THIS PRODUCT?

OS

CAPSULES 1

TABLETS 2

CHEWABLE TABLETS 3

PILLS 4

CAPLETS 5

SOFT GELS 6

GEL CAPS 7

VEGICAPS 8

PACKAGE/PACKETS 9

LIQUID 10

POWDER 11

WAFERS 12

CHEWS/GUMMIES 13

DOTS 14

GRANULES 15

LOZENGES/COUGH DROPS 16

GEL 17

OTHER FORM (SPECIFY) 91

REFUSED 77

DON’T KNOW 99

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

BOX 3A

CHECK ITEM DSQ.079:

IF PRODUCT NOT SELECTED FROM SPECIAL PRODUCT LIST (NO, CODE 2 IN DSQ.047), CONTINUE.

OTHERWISE, GO TO DSQ.096.

DSQ.081 ENTER MANUFACTURER/DISTRIBUTOR/STORE BRAND NAME.

ENTER AS MUCH INFORMATION AS POSSIBLE.

ENTER MANUFACTURER/DISTRIBUTOR/STORE BRAND NAME

REFUSED 7 (DSQ.088)

DON'T KNOW 9 (DSQ.088)

CAPI INSTRUCTION:

FOLLOW THE BASIC FORMAT FOR THE DIETARY SUPPLEMENT LOOKUP. ONLY ALLOW ENTRY OF 1 MANUFACTURER. DISPLAY PRODUCT NAME AS A LEFT HEADER.

DSQ.084 PRESS BS TO START THE LOOKUP.

SELECT MANUFACTURER

FROM LIST.

IF MANUFACTURER NOT

ON LIST – PRESS BS

TO DELETE ENTRY

TYPE '**'.

PRESS ENTER TO SELECT.

CAPI INSTRUCTION:

DISPLAY MANUFACTURER LIST. INTERVIEWER SHOULD BE ABLE TO SELECT ONLY 1 MANUFACTURER OR THE '**' OPTION. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. IF MANUFACTURER IS SELECTED FROM THE LOOKUP LIST, AUTOMATICALLY FILL IN THE CITY AND STATE INFORMATION (DSQ.088).

DISPLAY PRODUCT NAME AS LEFT HEADER.

BOX 4

CHECK ITEM DSQ.085:

IF MANUFACTURER SELECTED FROM LOOKUP, GO TO DSQ.096.

OTHERWISE, CONTINUE.

DSQ.088b ENTER CITY NAME.

ENTER AS MUCH INFORMATION AS POSSIBLE.

ENTER CITY

REFUSED 7

DON’T KNOW 9

DSQ.088c ENTER STATE NAME.

ENTER 2-LETTER

STATE ABBREVIATION.

PRESS ENTER TO

SELECT STATE FROM LIST.

ENTER STATE

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS A LEFT HEADER.

AN ENTRY MUST BE MADE IN ALL DSQ.081 AND DSQ.087 FIELDS (MANUFACTURER INFO). IF THE MANUFACTURER INFO IS DON'T KNOW OR REFUSED, THEN SET THE NO MANUFACTURER INFORMATION VARIABLE.

DSQ.096 For how long {have/has} {you/SP} been taking {PRODUCT NAME} or a similar type of product?

Q/U

CAPI INSTRUCTION:

RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 777

DON'T KNOW 999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

DSQ.103 In the past {30 DAYS/NUMBER AND UNIT}, on how many days did {you/SP} take {PRODUCT NAME}?

CAPI INSTRUCTION:

• {30 DAYS/NUMBER AND UNIT} = IF NUMBER AND UNIT ENTERED IN DSQ.096 >= 30 DAYS, OR REFUSED (CODE 7), OR DON’T KNOW (CODE 9), DISPLAY “30 DAYS” IN TEXT OF QUESTION. IF NUMBER AND UNIT ENTERED IN DSQ.096 IS < 30 DAYS, DISPLAY ACTUAL NUMBER AND UNIT ENTERED IN DSQ.096 IN TEXT OF QUESTION.

• {PRODUCT NAME} = PRODUCT SELECTED AT DSQ.049 OR PRODUCT ENTERED IN DSQ.052.

|___|___|

ENTER NUMBER OF DAYS FROM 1-30

REFUSED 777

DON'T KNOW 999

DSQ.123 On the days that {you/SP} took {PRODUCT NAME}, how much did {you/SP} usually take on a single day?

Q/U/OS

CAPI INSTRUCTION:

RESPONSE FIELD SHOULD ALLOW FOR 3 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW 0 OR 1 ENTRIES TO THE LEFT OF THE DECIMAL AND 0, 1 OR 2 ENTRIES TO THE RIGHT OF THE DECIMAL.

|___|___|___|

ENTER NUMBER

REFUSED 7777 (DSQ.124)

DON'T KNOW 9999 (DSQ.124)

|___|___|

ENTER UNIT/FORM

TABLETS/CAPSULES/PILLS/CAPLETS/
SOFTGELS/GEL CAPS/VEGICAPS/
CHEWABLE TABLETS 1 (07BOX NEW 4A)

DROPPERS 2 (07BOX NEW 4A)

DROPS 3 (07BOX NEW 4A)

INJECTIONS/SHOTS 5 (07BOX NEW 4A)

LOZENGES/COUGH DROPS 6 (07BOX NEW 4A)

MILLILITERS 7 (07BOX NEW 4A)

TABLESPOONS 11 (07BOX NEW 4A)

TEASPOONS 12 (07BOX NEW 4A)

WAFERS 13 (07BOX NEW 4A)

CANS 15 (07BOX NEW 4A)

GRAMS 16 (07BOX NEW 4A)

DOTS 17 (07BOX NEW 4A)

CUPS 18 (07BOX NEW 4A)

SPRAYS/SQUIRTS 19 (07BOX NEW 4A)

CHEWS/GUMMIES 20 (07BOX NEW 4A)

SCOOPS 21 (07BOX NEW 4A)

CAPFULS 23 (07BOX NEW 4A)

OUNCES 27 (07BOX NEW 4A)

PACKAGES/PACKETS 28 (CONTINUE)

VIALS 29 (07BOX NEW 4A)

GUMBALLS 30 (07BOX NEW 4A)

OTHER FORM (SPECIFY) 91 (07BOX NEW 4A)

REFUSED 77 (07BOX NEW 4A)

DON’T KNOW 99 (07BOX NEW 4A)

CAPI INSTRUCTION:

• IF FORM CODE 1 THROUGH 8 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 1 AND SKIP TO 07BOX NEW 4A.

• IF FORM CODE 12 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 13 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.

• IF FORM CODE 13 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 20 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.

• IF FORM CODE 14 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 17 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.

• IF FORM CODE 16 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 6 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.

• IF FORM CODE 9 IN DSQ.077, DISPLAY THE UNIT CODES 1, 6, 7, 11, 12, 13, 15, 16, 17, 18, 20, 21, 23, 27, 28, 30, 91, 77, 99 FOR DSQ.123U.

• IF FORM CODE 10, 17 IN DSQ.077, DISPLAY THE UNIT CODES 2, 3, 5, 7, 11, 12, 15, 18, 19, 23, 27, 29, 91, 77, 99 FOR DSQ.123U.

• IF FORM CODE 11, 15 IN DSQ.077, DISPLAY THE UNIT CODES 11, 12, 15, 16, 18, 21, 23, 27, 28, 91, 77, 99 FOR DSQ.123U.

• IF FORM CODE 91, 77, 99 IN DSQ.077, DISPLAY ENTIRE PICK LIST FOR DSQ.123U.

• IF CONTAINER NOT SEEN (CODE 2 IN DSQ.071), DISPLAY ENTIRE PICK LIST FOR DSQ.123U.

DSQ.125 {Did you/Does SP} take an entire packet of {PRODUCT NAME} each time?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

07BOX NEW 4A

CHECK ITEM DSQ.105:

IF PRODUCT NOT SEEN IN DSQ.071 (CODE 2) AND DSQ.123 = 7, 11, 12, 15, 16, 18, 21, 23 OR 27, CONTINUE.

OTHERWISE, SKIP TO DSQ.124.

DSQ.110 Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 77

DON'T KNOW 99

DSQ.124 HAND CARD DSQ2

Looking at this card, what is the reason {you take/SP takes} {PRODUCT NAME}?

(Did {you/SP NAME} decide to take it for reasons of your own or did a doctor or other health provider tell you to take it?)

DECIDED TO TAKE IT FOR REASONS
OF MY OWN 1

A DOCTOR OR OTHER HEALTH
PROVIDER TOLD ME TO 2

REFUSED 7 (DSQ.127)

DON’T KNOW 9 (DSQ.127)

DSQ.128 {For what reason or reasons {do you/does SP} take {PRODUCT NAME}?}

{For what reason or reasons did the doctor or other health professional tell {you/SP} to take {PRODUCT}?}

HAND CARD DSQ3

CODE ALL THAT APPLY.

FOR GOOD BOWEL/COLON HEALTH 10

FOR PROSTATE HEALTH 11

FOR MENTAL HEALTH 12

TO PREVENT HEALTH PROBLEMS 13

TO IMPROVE MY OVERALL HEALTH 14

FOR TEETH, PREVENT CAVITIES 15

TO SUPPLEMENT MY DIET (BECAUSE
I DON’T GET ENOUGH FROM FOOD) 16

TO MAINTAIN HEALTH (TO STAY
HEALTHY) 17

TO PREVENT COLDS, BOOST IMMUNE
SYSTEM 18

FOR HEART HEALTH, CHOLESTEROL 19

FOR EYE HEALTH 20

FOR HEALTHY JOINTS, ARTHRITIS 21

FOR SKIN HEALTH, DRY SKIN 22

FOR WEIGHT LOSS 23

FOR BONE HEALTH, BUILD STRONG
BONES, OSTEOPOROSIS 24

TO GET MORE ENERGY 25

FOR PREGNANCY 26

FOR ANEMIA, SUCH AS LOW IRON 27

OTHER SPECIFY 91

REFUSED 77

DON’T KNOW 99

CAPI INSTRUCTION:

IF CODE 1 IN DSQ.124, DISPLAY For what reason or reasons {do you/does SP} take {PRODUCT NAME}?

IF CODE 2 IN DSQ.124, DISPLAY For what reason or reasons did the doctor or other health professional tell {you/SP} to take {PRODUCT}?

DSQ.127 ARE THERE ANY OTHER VITAMINS, MINERALS, HERBALS OR DIETARY SUPPLEMENTS?

YES 1

NO 2

BOX 5

CHECK ITEM DSQ.129:

ASK DSQ.127 FOR NEXT VITAMIN (CODE 1 IN DSQ.127). IF NO NEXT VITAMIN (CODE 2 IN DSQ.127), CONTINUE WITH DSQ.131.

DSQ.131 REVIEW TOTAL NUMBER OF DIETARY SUPPLEMENTS AND THEIR NAMES WITH RESPONDENT.

I have listed {TOTAL NUMBER} vitamin(s), mineral(s), herbals or dietary supplement(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME (STRENGTH)}

PRESS ENTER TO CONTINUE

CAPI INSTRUCTION:

DISPLAY LIST OF ALL VITAMIN AND MINERAL NAMES AND STRENGTHS SELECTED AT DSQ.060 AND ENTERED AT DSQ.052. CALCULATE TOTAL NUMBER OF ALL VITAMINS AND MINERALS SELECTED AT DSQ.060 AND ENTERED AT DSQ.052. DISPLAY NUMBER ON SCREEN.

BOX 6

CHECK ITEM DSQ.133:

IF 'YES' (CODE 1) IN RXQ.021, CONTINUE.

OTHERWISE, GO TO BOX 10A.

RXQ.141 Now I would like to ask you some questions about {your/SP's} use of nonprescription antacids in the past 30 days.

[First I will record some information about an antacid, then I will ask you some questions about it.]

REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF NONPRESCRIPTION ANTACIDS USED. ENTER FULL BRAND NAME OF ANTACID.

ENTER ANTACID NAME

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF DON'T KNOW OR REFUSED, THEN GO TO BOX 10A.

SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.

[TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.

RXQ.150s PRESS BS TO START THE LOOKUP.

SELECT ANTACID

FROM LIST.

IF ANTACID NOT

ON LIST – PRESS BS

TO DELETE ENTRY.

TYPE '**'.

PRESS ENTER TO SELECT.

CAPI INSTRUCTION:

DISPLAY CAPI ANTACID PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN RXQ.141 BY TYPING IN "**". THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.

INTERVIEWER SHOULD BE ABLE TO ACCEPT THE KEYED NAME AS A NEW PRODUCT NAME AN UNLIMITED NUMBER OF TIMES. AFTER ENTRY, INTERVIEWER SHOULD RETURN TO THE DATA BASE LIST. IF NO MORE ENTRIES, INTERVIEWERS SHOULD HAVE A WAY OF MOVING INTO LOOP 2.

ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:

DRUG TYPE {3}

GENERIC NAME {60}

THERAPEUTIC CLASS CODE {6}

GENERIC FLAG {1}

THERE IS NO NEED TO DISPLAY THIS INFORMATION.

BOX 7

OMITTED

RXQ.180 For how long {have/has} {you/SP} been using or taking {PRODUCT NAME}?

CAPI INSTRUCTION:

RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 777

DON'T KNOW 999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

RXQ.191 In the past {30 DAYS/NUMBER AND UNIT}, on how many days did {you/SP} take {PRODUCT NAME}?

CAPI INSTRUCTION:

• {30 DAYS/NUMBER AND UNIT} = IF NUMBER AND UNIT ENTERED IN RXQ.180 >= 30 DAYS, OR REFUSED (CODE 7), OR DON’T KNOW (CODE 9), DISPLAY “30 DAYS” IN TEXT OF QUESTION. IF NUMBER AND UNIT ENTERED IN RXQ.180 IS < 30 DAYS, DISPLAY ACTUAL NUMBER AND UNIT ENTERED IN DSQ.096 IN TEXT OF QUESTION.

• {PRODUCT NAME} = PRODUCT SELECTED AT DSQ.049 OR PRODUCT ENTERED IN DSQ.052.

|___|___|

ENTER NUMBER OF DAYS FROM 1-30

REFUSED 7777

DON'T KNOW 9999

RXQ.195 Q/U/OS

On those days that you used or took {PRODUCT NAME}, how much did {you/SP} usually take on a single day?

CAPI INSTRUCTION:

RESPONSE FIELD SHOULD ALLOW FOR 3 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW 0 OR 1 ENTRIES TO THE LEFT OF THE DECIMAL AND 0, 1 OR 2 ENTRIES TO THE RIGHT OF THE DECIMAL.

OPTIONS MUST BE IN ORDER SPECIFIED – APPROVED BY DRG (NCHS)

|___|___|___|

ENTER NUMBER

REFUSED 7777 (RXQ.216)

DON'T KNOW 9999 (RXQ.216)

ENTER UNIT/FORM

TABLETS/CAPSULES/PILLS/CAPLETS/
SOFTGELS/GEL CAPS/VEGICAPS/
CHEWABLE TABLETS 1 (07BOX NEW 8)

DROPPERS 2 (07BOX NEW 8)

DROPS 3 (07BOX NEW 8)

INJECTIONS/SHOTS 5 (07BOX NEW 8)

LOZENGES/COUGH DROPS 6 (07BOX NEW 8)

MILLILITERS 7 (07BOX NEW 8)

TABLESPOONS 11 (07BOX NEW 8)

TEASPOONS 12 (07BOX NEW 8)

WAFERS 13 (07BOX NEW 8)

CANS 15 (07BOX NEW 8)

GRAMS 16 (07BOX NEW 8)

DOTS 17 (07BOX NEW 8)

CUPS 18 (07BOX NEW 8)

SPRAYS/SQUIRTS 19 (07BOX NEW 8)

CHEWS/GUMMIES 20 (07BOX NEW 8)

SCOOPS 21 (07BOX NEW 8)

CAPFULS 23 (07BOX NEW 8)

OUNCES 27 (07BOX NEW 8)

PACKAGES/PACKETS 28 (CONTINUE)

VIALS 29 (07BOX NEW 8)

GUMBALLS 30 (07BOX NEW 8)

OTHER FORM (SPECIFY) 91 (07BOX NEW 8)

REFUSED 77 (07BOX NEW 8)

DON’T KNOW 99 (07BOX NEW 8)

RXQ.200 {Do you/Does SP{ take an entire packet each time?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

07BOX NEW 8

CHECK ITEM RXQ.205:

IF RXQ.195U IS 7, 11, 12, 15, 16, 18, 21, 23, OR 27, CONTINUE.

OTHERWISE, SKIP TO RXQ.215a.

DSQ.110 Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 77

DON'T KNOW 99

RXQ.215a Did you take {PRODUCT NAME} as an antacid, as a calcium supplement, or both?

ANTACID 1

CALCIUM SUPPLEMENT 2

BOTH 3

NEITHER 4

REFUSED 7

DON'T KNOW 9

RXQ.216 CHECK CONTAINERS. ARE THERE ANY OTHER NONPRESCRIPTION ANTACIDS?

OR ASK RESPONDENT:

[Are there any other nonprescription antacids that {you/SP} used in the past 30 days?]

YES 1

NO 2

BOX 9

CHECK ITEM RXQ.219:

ASK RXQ.141 FOR NEXT ANTACID (CODE 1 IN RXQ.216). IF NO NEXT ANTACID, (CODE 2 IN RXQ.216), CONTINUE WITH RXQ.221.

RXQ.221 REVIEW TOTAL NUMBER OF ANTACIDS AND THEIR NAMES WITH RESPONDENT.

I have listed {TOTAL NUMBER} nonprescription antacid(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}

PRESS ENTER TO CONTINUE

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL ANTACIDS SELECTED AT RXQ.150 AND ENTERED AT RXQ.141. CALCULATE TOTAL NUMBER OF ALL ANTACIDS SELECTED AT RXQ.150 AND ENTERED AT RXQ.141. DISPLAY NUMBER ON SCREEN.

BOX 15

OMITTED

BOX 16

OMITTED

BOX 16A

OMITTED

BOX 10A

CHECK ITEM DSQ.225:

IF 'YES' (CODE 1) IN RXQ.032, CONTINUE.

OTHERWISE, GO TO BOX 14A.

RXQ.231 Now I would like to talk about prescription medication {you have/SP has} used in the past 30 days. Again, these are products prescribed by a health professional such as a doctor or dentist.

[First I will record some information about the medication, then I will ask you some questions about it.]

REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF PRESCRIPTION MEDICATIONS USED.

ENTER MEDICATION NAME

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF DON'T KNOW OR REFUSED, THEN GO TO RXQ.439.

SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.

TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.

RXQ.240s PRESS BS TO START THE LOOKUP.

SELECT MEDICATION

FROM LIST.

IF MEDICATION NOT

ON LIST – PRESS BS

TO DELETE ENTRY.

TYPE '**'.

PRESS ENTER TO SELECT

CAPI INSTRUCTION:

DISPLAY CAPI MEDICATION PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN RXQ.231 BY TYPING IN "**". THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.

INTERVIEWER SHOULD BE ABLE TO ACCEPT THE KEYED NAME AS A NEW PRODUCT NAME AN UNLIMITED NUMBER OF TIMES. AFTER ENTRY, INTERVIEWER SHOULD RETURN TO THE DATA BASE LIST. IF NO MORE ENTRIES, INTERVIEWERS SHOULD HAVE A WAY OF MOVING INTO LOOP 3.

ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:

DRUG TYPE {3}

GENERIC NAME {60}

THERAPEUTIC CLASS CODE {6}

GENERIC FLAG {1}

THERE IS NO NEED TO DISPLAY THIS INFORMATION.

BOX 10B

CHECK ITEM RXQ.243:

IF PRODUCT IS SELECTED FROM THE LOOKUP AND THE PRODUCT HAS AN ‘OTC’ DESIGNATION, CONTINUE WITH RXQ.245.

OTHERWISE, GO TO RXQ.250.

RXQ.245 YOU HAVE SELECTED

{DISPLAY FULL PRODUCT VARIABLE NAME}.

YOU HAVE SELECTED THIS PRODUCT IN AN ‘OVER THE COUNTER’ FORM. IS THIS CORRECT?

YES 1

NO 2

CAPI INSTRUCTION:

DISPLAY SCREEN RXQ.240s – ENTRY FIELD SHOULD BE BLANK. INTERVIEWER SHOULD PRESS THE ‘BACKSPACE’ KEY TO START THE LOOKUP AGAIN AND SELECT ANOTHER PRODUCT.

BOX 11

OMITTED

RXQ.250 INTERVIEWER: ENTER 1 RESPONSE

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS A LEFT HEADER.

CONTAINER SEEN 1

CONTAINER NOT SEEN 2

RXQ.260 For how long {have/has} {you/SP} been using or taking {PRODUCT NAME}?

Q/U

CAPI INSTRUCTION:

RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 777

DON'T KNOW 999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

BOX 13

OMITTED

RXQ.290 What is the main reason for which (you use/SP uses) {PRODUCT NAME}?

REFUSED 7

DON'T KNOW 9

RXQ.291 INTERVIEWER INSTRUCTION: ASK IF NECESSARY

IS SP TAKING MEDICATION FOR ASTHMA, BREATHING PROBLEMS, EMPHYSEMA OR RELATED CONDITION?

YES 1

NO 2

REFUSED 77

DON’T KNOW 99

RXQ.294 CHECK CONTAINERS. ARE THERE ANY OTHER PRESCRIPTION MEDICATIONS?

OR ASK RESPONDENT:

[Are there any other prescription medications that {you/SP} used in the past 30 days?]

YES 1

NO 2

REFUSED 77

DON’T KNOW 99

BOX 14

CHECK ITEM RXQ.294A:

ASK RXQ.231 - RXQ.294 FOR NEXT MEDICATION (CODE 1 IN RXQ.294). IF NO NEXT MEDICATION (CODE 2 IN RXQ.294), CONTINUE WITH RXQ.295.

RXQ.295 REVIEW TOTAL NUMBER OF PRESCRIBED MEDICATIONS AND THEIR NAMES WITH RESPONDENT.

I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}

PRESS ENTER TO CONTINUE

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231. CALCULATE TOTAL NUMBER OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231. DISPLAY NUMBER ON SCREEN.

07BOX NEW13A

CHECK ITEM RXQ.400:

1. IF PRODUCT SELECTED FROM LOOKUP AND CLASS CODE = 125, 131, 243, 296 OR 298, CONTINUE.

2. IF PRODUCT NOT SELECTED FROM LIST AND RXQ.291 = ASTHMA OR BREATHING DIFFICULTY (CODE 1), CONTINUE.

3. OTHERWISE, SKIP TO RXQ.439.

RXQ.403 Now I would like to ask you a few additional questions about {PRODUCTS SPECIFIED IN 07BOX NEW13A – CLASS CODE 125, 131, 243, 296 OR 298 AND PRODUCTS NOT SELECTED FROM LIST WITH CODE 1 IN RXQ.291.

07BOX NEW13AA

CHECK ITEM RXQ.406:

ASK RXQ.409 – RXQ.433 FOR EACH MEDICATION THAT MEETS SPECIFICATION IN 07BOX NEW13A #1 OR #2.

RXQ.409 Have you used {PRODUCT NAME} every day or nearly every day for a month or longer?

YES 1

NO 2 (07BOX NEW14A)

REFUSED 7 (07BOX NEW14A)

DON’T KNOW 9 (07BOX NEW14A)

RXQ.413 During the past 3 months, how many months did you use this medication every day or nearly every day?

HAND CARD DSQ4

less than 1 month 1

1 month but less than 2 months 2

2 months but less than 3 months 3

3 months 4

REFUSED 7

DON’T KNOW 9

BOX 13B

CHECK ITEM RXQ.415:

CHECK RXQ.250. IF CONTAINER NOT SEEN (CODE 2), GO TO RXQ.424.

OTHERWISE, CONTINUE

RXQ.418 ENTER DRUG STRENGTH FROM LABEL

|___|___|

ENTER NUMBER: EXAMPLE – 20, 50, ETC.

IF NO EXACT MATCH, SELECT ‘OTHER SPECIFY’

SELECT UNIT: EXAMPLE – 0.042 mg/inhalation

RXQ.421 INTERVIEWER: RECORD FORM FROM PRODUCT CONTAINER.

CAPSULES 1

TABLETS 2

CHEWABLE TABLETS 3

PILLS 4

CAPLETS 5

SOFT GELS 6

GEL CAPS 7

VEGICAPS 8

PACKAGE/PACKETS 9

LIQUID 10

POWDER 11

WAFERS 12

CHEWS 13

DOTS 14

GRANULES 15

LOZENGES 16

GEL 17

INHALER 18

NEBULIZER 19

INJECTION 20

DISCUS 21

REFUSED 77

DON’T KNOW 99

SKIP TO RXQ.427

RXQ.424 Please look at this card and tell me in what form is this product?

HAND CARD DSQ5

CAPSULES 1 TABLETS 2 CHEWABLE TABLETS 3 PILLS 4 CAPLETS 5 SOFT GELS 6 GEL CAPS 7 VEGICAPS 8 PACKAGE/PACKETS 9 LIQUID 10 POWDER 11 WAFERS 12 CHEWS 13 DOTS 14 GRANULES 15 LOZENGES 16 GEL 17

INHALER 18 NEBULIZER 19 INJECTION 20 DISCUS 21 REFUSED 77 DON’T KNOW 99

HELP SCREEN:

Nebulizer: A device to give a medicine as a fine mist into the nose.

An inhaler or metered dose inhaler (MDI): A device used to deliver allergy and asthma medicines to the lungs. It is a small L-shaped device, which you put into their mouth to get the medication directly into their lungs.

Discus: It is a dry powder inhaler. It has a dose counter. Dry powder inhalers deliver a powdered form of medicine directly to the lungs.

RXQ.427 On the days that {you/SP NAME} took this medication, how many times did you usually take it in a single day?

CAPI INSTRUCTION:

|___|___|___|

NUMBER OF TIMES

REFUSED 77

DON’T KNOW 99

RXQ.430 How much did you take each time you took it?

Q/U/OS

|___|___|___|

ENTER NUMBER

|___|___|

ENTER UNIT

CAPSULES 1

TABLETS 2

CHEWABLE TABLETS 3

PILLS 4

CAPLETS 5

SOFT GELS 6

GEL CAPS 7

VEGICAPS 8

PACKAGE/PACKETS 9

WAFERS 10

CHEWS 11

DOTS 12

LOZENGES 13

DROPS 14

TEASPOONS 15

TABLESPOONS 16

MILLILITERS 17

SCOOPS 18

PUFFS 19

DOSES 20

VIALS 21

INJECTIONS 22

OTHER (SPECIFY) 23

REFUSED 77

DON’T KNOW 99

CAPI INSTRUCTION FOR UNIT – CHECK RXQ.421 OR RXQ.424 (FORM):

• IF FORM CODE 1 THROUGH 9 OR 12, 13, 14, 15, OR 16 IN RXQ.421 OR RXQ.424, CODE THE SAME FORM FOR UNIT AND SKIP TO RXQ.433.

• IF CODE 10 IN RXQ.421 OR RXQ.424, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
  DROPS 14
  TEASPOONS 15
  TABLESPOONS 16
  MILLILITERS 17

OTHER (SPECIFY) 22

• IF CODE 11 IN RXQ.421 OR RXQ.424, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
  TEASPOONS 15
  TABLESPOONS 16
  SCOOPS 18

OTHER (SPECIFY) 22

• IF CODE 17, 20, OR 21 IN RXQ.421 OR RXQ.424, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:

OTHER (SPECIFY) 22

• IF CODE 18 IN RXQ.421 OR RXQ.424, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
  PUFFS 19
  DOSES 20

OTHER (SPECIFY) 22

• IF CODE 19 IN RXQ.421 OR RXQ.424, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
  VIALS 21

OTHER (SPECIFY) 22

• IF DK/REF (CODE 77 OR CODE 99), DISPLAY ENTIRE PICK LIST.

RXQ.433 So you took {NUMBER/UNIT} each time you took it, correct?

CORRECT 1

INCORRECT 2 (RETURN TO

RXQ.430 Q/U/OS)

CAPI INSTRUCTION:

DISPLAY NUMBER AND UNIT FROM RXQ.430 Q/U/OS.

07BOX NEW14A

CHECK ITEM RXQ.436:

ASK RXQ.409 – RXQ.433 FOR NEXT MEDICATION (FROM BOX 13AA).
IF NO NEXT MEDICATION, CONTINUE.

RXQ.439 During the past 3 months, have you used/taken {any/any other similar} products for asthma or breathing difficulties every day or nearly every day. This card lists some examples.

HAND CARD DSQ6

YES 1

NO 2 (BOX 18)

REFUSED 77 (BOX 18)

DON’T KNOW 99 (BOX 18)

CAPI INSTRUCTION:

DISPLAY “ANY” IF THERE HAS BEEN NO ASTHMA MEDICATION ENTERED (NO CLASS CODE 125, 131, 243, 296 OR 298 SELECTED FROM LOOKUP OR CODE 2 IN RXQ.291).

DISPLAY “ANY OTHER” IF CLASS CODE 125, 131, 243, 296 OR 298 ENTERED FROM LOOKUP OR CODE 1 IN RXQ.291.

RXQ.442 May I please see all the containers for these medications.

REFER TO PRODUCT LABEL OR ASK THE RESPONDENT FOR NAME(S) OF PRODUCTS.

PRESS ENTER TO CONTINUE.

RXQ.446 ENTER MEDICATION NAME.

BOX 14B

CHECK ITEM RXQ.445:

ASK RXQ.231 THROUGH – RXQ.487 FOR EACH MEDICATION.

RXQ.448 PRESS BS TO START THE LOOKUP.

SELECT MEDICATION

FROM LIST.

IF MEDICATION NOT

ON LIST – PRESS BS

TO DELETE ENTRY.

TYPE '**'.

PRESS ENTER TO SELECT

CAPI INSTRUCTION:

DISPLAY CAPI MEDICATION PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN RXQ.231 BY TYPING IN "**". THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.

INTERVIEWER SHOULD BE ABLE TO ACCEPT THE KEYED NAME AS A NEW PRODUCT NAME AN UNLIMITED NUMBER OF TIMES. AFTER ENTRY, INTERVIEWER SHOULD RETURN TO THE DATA BASE LIST. IF NO MORE ENTRIES, INTERVIEWERS SHOULD HAVE A WAY OF MOVING INTO LOOP 3.

ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:

DRUG TYPE {3}

GENERIC NAME {60}

THERAPEUTIC CLASS CODE {6}

GENERIC FLAG {1}

THERE IS NO NEED TO DISPLAY THIS INFORMATION.

BOX 15

CHECK ITEM RXQ.451:

IF PRODUCT IS SELECTED FROM THE LOOKUP AND THE PRODUCT HAS AN ‘OTC’ DESIGNATION, CONTINUE WITH RXQ.454.

OTHERWISE, GO TO RXQ.457.

RXQ.454 YOU HAVE SELECTED

{DISPLAY FULL PRODUCT VARIABLE NAME}.

YOU HAVE SELECTED THIS PRODUCT IN AN ‘OVER THE COUNTER’ FORM. IS THIS CORRECT?

YES 1

NO 2 DISPLAY HARD ERROR

CAPI INSTRUCTION:

DISPLAY SCREEN RXQ.448 – ENTRY FIELD SHOULD BE BLANK. INTERVIEWER SHOULD PRESS THE ‘BACKSPACE’ KEY TO START THE LOOKUP AGAIN AND SELECT ANOTHER PRODUCT.

RXQ.457 INTERVIEWER: ENTER 1 RESPONSE

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS A LEFT HEADER.

CONTAINER SEEN 1

CONTAINER NOT SEEN 2

RXQ.460 For how long {have/has} {you/SP} been using or taking {PRODUCT NAME}?

Q/U

CAPI INSTRUCTION:

RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 777

DON'T KNOW 999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

RXQ.463 What is the main reason for which (you use/SP uses) {PRODUCT NAME}?

ENTER TEXT

REFUSED 7

DON’T KNOW 9

RXQ.466 Have you used {PRODUCT NAME} every day or nearly every day for a month or longer?

YES 1

NO 2 (RXQ.490)

REFUSED 7 (RXQ.490)

DON’T KNOW 9 (RXQ.490)

RXQ.470 During the past 3 months, how many months did you use this medication every day or nearly every day?

HAND CARD DSQ7

less than 1 month 1

1 month but less than 2 months 2

2 months but less than 3 months 3

3 months 4

REFUSED 7

DON’T KNOW 9

BOX 16

CHECK ITEM RXQ.472:

CHECK RXQ.457. IF CONTAINER NOT SEEN (CODE 2), GO TO RXQ.478.

OTHERWISE, CONTINUE

RXQ.473 ENTER DRUG STRENGTH FROM LABEL

|___|___|

ENTER NUMBER: EXAMPLE – 20, 50, ETC.

IF NO EXACT MATCH, SELECT ‘OTHER SPECIFY’

SELECT UNIT: EXAMPLE – 0.042 mg/inhalation

RXQ.475 INTERVIEWER: RECORD FORM FROM PRODUCT CONTAINER.

CAPSULES 1

TABLETS 2

CHEWABLE TABLETS 3

PILLS 4

CAPLETS 5

SOFT GELS 6

GEL CAPS 7

VEGICAPS 8

PACKAGE/PACKETS 9

LIQUID 10

POWDER 11

WAFERS 12

CHEWS 13

DOTS 14

GRANULES 15

LOZENGES 16

GEL 17

INHALER 18

NEBULIZER 19

INJECTION 20

DISCUS 21

REFUSED 77

DON’T KNOW 99

SKIP TO RXQ.481

RXQ.478 Please look at this card and tell me in what form is this product?

HAND CARD DSQ8

CAPSULES 1

TABLETS 2

CHEWABLE TABLETS 3

PILLS 4

CAPLETS 5

SOFT GELS 6

GEL CAPS 7

VEGICAPS 8

PACKAGE/PACKETS 9

LIQUID 10

POWDER 11

WAFERS 12

CHEWS 13

DOTS 14

GRANULES 15

LOZENGES 16

GEL 17

INHALER 18

NEBULIZER 19

INJECTION 20

DISCUS 21

REFUSED 77

DON’T KNOW 99

RXQ.481 On the days that you took this medication, how many times did you usually take it in a single day?

CAPI INSTRUCTION:

|___|___|___|

NUMBER OF TIMES

REFUSED 77

DON’T KNOW 99

RXQ.484 How much did you take each time you took it?

Q/U/OS

|___|___|___|

ENTER NUMBER

|___|___|

ENTER UNIT

CAPSULES 1

TABLETS 2

CHEWABLE TABLETS 3

PILLS 4

CAPLETS 5

SOFT GELS 6

GEL CAPS 7

VEGICAPS 8

PACKAGE/PACKETS 9

WAFERS 10

CHEWS 11

DOTS 12

LOZENGES 13

DROPS 14

TEASPOONS 15

TABLESPOONS 16

MILLILITERS 17

SCOOPS 18

PUFFS 19

DOSES 20

VIALS 21

INJECTIONS 22

OTHER (SPECIFY) 23

REFUSED 77

DON’T KNOW 99

CAPI INSTRUCTION FOR UNIT – CHECK RXQ.475 OR RXQ.478 (FORM):

• IF FORM CODE 1 THROUGH 9 OR 12, 13, 14, 15, OR 16 IN RXQ.475 OR RXQ.478, CODE THE SAME FORM FOR UNIT AND SKIP TO RXQ.487.

• IF CODE 10 IN RXQ.475 OR RXQ.478, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
  DROPS 14
  TEASPOONS 15
  TABLESPOONS 16
  MILLILITERS 17

OTHER (SPECIFY) 22

• IF CODE 11 IN RXQ.485 OR RXQ.478, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
  TEASPOONS 15
  TABLESPOONS 16
  SCOOPS 18

OTHER (SPECIFY) 22

• IF CODE 17, 20, OR 21 IN RXQ.475 OR RXQ.478, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:

OTHER (SPECIFY) 22

• IF CODE 18 IN RXQ.475 OR RXQ.478, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
  PUFFS 19
  DOSES 20

OTHER (SPECIFY) 22

• IF CODE 19 IN RXQ.475 OR RXQ.578, DISPLAY THE FOLLOWING PICK LIST FOR UNIT:
  VILES 21

OTHER (SPECIFY) 22

• IF DK/REF (CODE 77 OR CODE 99), DISPLAY ENTIRE PICK LIST.

RXQ.487 So {you/SP} took {NUMBER/UNIT} each time {you/he/she} took it, correct?

CORRECT 1

INCORRECT 2 (RETURN TO

RXQ.430 Q/U/OS)

CAPI INSTRUCTION:

DISPLAY NUMBER AND UNIT FROM RXQ.430 Q/U/OS.

RXQ.490 CHECK CONTAINERS. ARE THERE ANY OTHER PRESCRIPTION MEDICATIONS?

OR ASK RESPONDENT:

[During the past 3 months, were there any other products that {you/SP} used for asthma or breathing problems every day or nearly every day?]

YES 1

NO 2

REFUSED 77

DON’T KNOW 99

BOX 17

CHECK ITEM RXQ.493:

ASK RXQ.448 – RXQ.490 FOR NEXT PRODUCT.

IF NO NEXT PRODUCT, CONTINUE WITH BOX 18.

BOX 18

CHECK ITEM DSQ.332:

IF PROXY INTERVIEW IN RPQ, CONTINUE.

IF NOT PROXY INTERVIEW IN RPQ, GO TO DSQ.335.

DSQ.334 INTERVIEWER OBSERVATION: WAS SP PRESENT FOR ALL OR PART OF INTERVIEW?

YES 1

NO 2

DSQ.335 PRESS F10 TO EXIT BLAISE.

mailing address

MAQ.005 Processing Extended SP Questionnaire. Please Wait.

MAQ.020 The Centers for Disease Control and Prevention may wish to contact {you/SP} again. Please give me {your/SP's} complete mailing address.

CRITICAL INFORMATION – CHECK CAREFULLY.

USE PEN OR PRESS 'TAB' KEY TO MOVE TO THE NEXT ENTRY FIELD.

TAP 'NEXT' BUTTON OR PRESS 'ENTER' KEY WHEN FINISHED VERIFYING ADDRESS.

CAPI INSTRUCTION:

DISPLAY THE SCREENER MAILING ADDRESS INFORMATION. ENTRY SHOULD APPEAR IN ALL CAPS – AS IT DOES IN IVQ.

________ ________ ____________________________ __________ ________ _________

STREET # DIR PRE STREET NAME ST/RD/AVE DIR POST APT/LOT #

________ ________ ________ ______________________________ ________ ________

PO BOX # RR # RR BOX CITY STATE ZIP

MAQ.040 I have recorded . . .

{DISPLAY ADDRESS ENTERED IN MAQ.020 IN UPPER CASE}

Is that correct?

YES 1 (MAQ.100)

NO 2

MAQ.060 ENTER CORRECTED MAILING ADDRESS INFORMATION.

PROBE FOR MAILING ADDRESS CORRECTIONS, IF NECESSARY.

USE PEN OR PRESS 'TAB' KEY TO MOVE TO THE NEXT ENTRY FIELD.

TAP 'NEXT' BUTTON OR PRESS 'ENTER' KEY WHEN CORRECTIONS COMPLETED.

{DISPLAY ALL ADDRESS FIELDS AND INFORMATION ENTERED IN MAQ.020 IN UPPER CASE. ALLOW CORRECTIONS.}

MAQ.080 I now have {your/SP's} mailing address as . . .

{DISPLAY CORRECTED ADDRESS FROM MAQ.060 IN UPPER CASE}

Is that correct?

YES 1

NO 2

BOX 2

CHECK ITEM MAQ.090:

IF 'NO' IN MAQ.080, RETURN TO MAQ.060. DISPLAY CORRECTED ADDRESS INFORMATION IN MAQ.060. (CONTACT KAY IF THERE ARE PROBLEMS DOING THIS.)

OTHERWISE, CONTINUE.

BOX 3

CHECK ITEM MAQ.095:

CHECK TELEPHONE NUMBER LISTED IN SCREENER (SCQ.430). IF NO HOME TELEPHONE (CODE 2), REF (CODE 9), OR DK (CODE 7), CONTINUE.

OTHERWISE, GO TO MAQ.130.

MAQ.100 Please give me your home telephone number in case my office wants to check my work.

CAPI INSTRUCTION:

ONLY ALLOW 10 DIGIT PHONE NUMBER. DISPLAY HARD RANGE CHECK MESSAGE IF NOT 10 DIGITS.

|__|__|__|__|__|__|__|__|__|__|

NO HOME TELEPHONE 2 (MAQ.110)

REFUSED 7 (MAQ.110)

DON’T KNOW 9 (MAQ.110)

MAQ.110 Is there another number where you can be reached?

CAPI INSTRUCTION:

ONLY ALLOW 10 DIGIT PHONE NUMBER. DISPLAY HARD RANGE ERROR IF NOT 10 DIGITS.

|__|__|__|__|__|__|__|__|__|__|

NO 2 (MAQ.130)

REFUSED 7 (MAQ.130)

DON’T KNOW 9 (MAQ.130)

MAQ.120 Where is that phone located?

WORK 1

RELATIVE’S HOME 2

NEIGHBOR’S HOME 3

MOBILE PHONE 4

OTHER 5

REFUSED 7

DON’T KNOW 9

MAQ.130 This is the end of the health interview. Thank you very much for your cooperation.

POST INTERVIEW

BOX 1

CHECK ITEM DUST:

IF SP AGE = 1 TO 5, CONTINUE.

OTHERWISE, GO TO APPTCONT.

DUSTCONT PERFORM THE DUST MODULE AT THIS TIME?

YES 1 (LAUNCH DUST MODULE)

NO 2

APPTCONT PERFORM THE APPOINTMENT MODULE AT THIS TIME?

YES 1

NO 2

FAMILY QUESTIONNAIRE

DEMOGRAPHIC BACKGROUND/OCCUPATION

BOX 1A

RULES FOR ADMINISTERING THE DEMOGRAPHIC AND OCCUPATION SECTION OF THE FAMILY QUESTIONNAIRE:

• A CPS FAMILY INCLUDES INDIVIDUALS AND GROUPS OF INDIVIDUALS WHO ARE 16+ AND RELATED BY BIRTH, MARRIAGE OR ADOPTION. STEP CHILDREN, PARENTS OR SIBLINGS ARE INCLUDED. IT ALSO INCLUDES UNMARRIED PARTNERS IF THEY HAVE A BIOLOGICAL OR ADOPTIVE CHILD IN COMMON. IT DOES NOT INCLUDE UNMARRIED PARTNERS WHO DO NOT HAVE A CHILD IN COMMON, FOSTER PARENTS OR FOSTER CHILDREN. NOTE: A CPS FAMILY CAN BE ONE INDIVIDUAL.

BOX 1

LOOP 1:

ASK DMQ.106 – DMQ.141 AS APPROPRIATE FOR NON-SP HEAD OF CPS FAMILY AND NON-SP SPOUSE (RELATIONSHIP OF "MARRIED" IN THE SCREENER) OF HEAD OF CPS FAMILY.

• FIRST ASK DMQ.106, 130, AND 141 FOR NON-SP HEAD OF CPS FAMILY.

• NEXT, ASK DMQ.141 FOR NON-SP SPOUSE OF HEAD OF CPS FAMILY.

• EACH TARGET PERSON SHOULD BE ASKED THIS SECTION ONCE.

• IF NO NON-SP HEAD OF CPS FAMILY AND NON-SP SPOUSE, GO TO
  END OF SECTION.

DMQ.107 In what country {were you/was NON-SP Head} born?

UNITED STATES 1 (DMQ.130)

OTHER COUNTRY 2

REFUSED 7 (BOX 2)

DON'T KNOW 9 (BOX 2)

DMQ.112 SELECT COUNTRY OF BIRTH

ARGENTINA 1 (DMQ.141)

BELIZE 2 (DMQ.141)

BOLIVIA 3 (DMQ.141)

BRAZIL 4 (DMQ.141)

CHILE 5 (DMQ.141)

COLOMBIA 6 (DMQ.141)

COSTA RICA 7 (DMQ.141)

CUBA 8 (DMQ.141)

DOMINICAN REPUBLIC 9 (DMQ.141)

ECUADOR 10 (DMQ.141)

EL SALVADOR 11 (DMQ.141)

GUATEMALA 12 (DMQ.141)

HONDURAS 13 (DMQ.141)

MEXICO 14 (DMQ.141)

NICARAGUA 15 (DMQ.141)

PANAMA 16 (DMQ.141)

PARAGUAY 17 (DMQ.141)

PERU 18 (DMQ.141)

PHILIPPINES 19 (DMQ.141)

PUERTO RICO 20 (DMQ.141)

SPAIN 21 (DMQ.141)

URUGUAY 22 (DMQ.141)

VENEZUELA 23 (DMQ.141)

OTHER COUNTRY (CAPI INSTRUCTION:

DO NOT SPECIFY) 40 (DMQ.141)

BOX 2

CHECK ITEM DMQ.120:

IF ANY CODE OTHER THAN 'UNITED STATES', SKIP TO DMQ.141.

DMQ.130 In what state {were you/was NON-SP HEAD} born?

ENTER 2 LETTER STATE ABBREVIATION TO START THE LOOKUP.

SELECT STATE FROM CAPI STATE LIST.

PRESS ENTER TO ACCEPT SELECTION.

CAPI INSTRUCTION:

DISPLAY FIPS STATE LIST. INTERVIEWER SHOULD ONLY BE ABLE TO SELECT 1 STATE FROM THE LIST. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. THE STATE LOOKUP IN THE SP AND FAMILY QUESTIONNAIRES SHOULD WORK EXACTLY THE SAME.

DMQ.141 What is the highest grade or level of school {you have/NON-SP HEAD/NON-SP SPOUSE has} completed or the highest degree {you have/he/she has} received?

HAND CARD DMQ1

READ HAND CARD CATEGORIES IF NECESSARY

Enter highest level of school.

NEVER ATTENDED/KINDERGARTEN

ONLY 0

1ST GRADE 1

2ND GRADE 2

3RD GRADE 3

4TH GRADE 4

5TH GRADE 5

6TH GRADE 6

7TH GRADE 7

8TH GRADE 8

9TH GRADE 9

10TH GRADE 10

11TH GRADE 11

12TH GRADE, NO DIPLOMA 12

HIGH SCHOOL GRADUATE 13

GED OR EQUIVALENT 14

SOME COLLEGE, NO DEGREE 15

ASSOCIATE DEGREE: OCCUPATIONAL,

TECHNICAL, OR VOCATIONAL

PROGRAM 16

ASSOCIATE DEGREE: ACADEMIC

PROGRAM 17

BACHELOR’S DEGREE (EXAMPLE: BA,

AB, BS, BBA) 18

MASTER’S DEGREE (EXAMPLE: MA,

MS, MEng, MEd, MBA) 19

PROFESSIONAL SCHOOL DEGREE

(EXAMPLE: MD, DDS, DVM, JD) 20

DOCTORAL DEGREE (EXAMPLE:

PhD, EdD) 21

REFUSED 77

DON’T KNOW 99

BOX 3

END LOOP 1:

• ASK DMQ.106-141 FOR NEXT TARGET PERSON (NON-SP HEAD)

• ASK DMQ.141 FOR NEXT TARGET PERSON (NON-SP SPOUSE –
  RELATIONSHIP OF "MARRIED" IN THE SCREENER).

IF NO NEXT PERSON, GO TO BOX 4.

BOX 4

LOOP 2:

ASK OCQ.150-OCQ.380 FOR NON-SP HEAD IF AGE >= 16 AND NON-SP SPOUSE (RELATIONSHIP OF 'MARRIED' IN THE SCREENER) OF HEAD IF NON-SP SPOUSE AGE >= 16.

OCQ.150 The next questions are about {your/NON-SP HEAD'S/NON-SP SPOUSE'S} current job or business. Which of the following {were you/was} {NON-SP HEAD/NON-SP SPOUSE} doing last week . . .

working at a job or business, 1 (Box 7)

with a job or business but not at work, 2 (Box 7)

looking for work, or 3 (Box 7)

not working at a job or business? 4

REFUSED 7 (Box 7)

DON'T KNOW 9 (Box 7)

OCQ.380 What is the main reason {you/NON-SP HEAD/NON-SP SPOUSE} did not work last week?

TAKING CARE OF HOUSE OR FAMILY 1

GOING TO SCHOOL 2

RETIRED 3

UNABLE TO WORK FOR HEALTH

REASONS 4

ON LAYOFF 5

DISABLED 6

OTHER 7

REFUSED 77

DON'T KNOW 99

BOX 7

END LOOP 2:

ASK OCQ.150 FOR NEXT TARGET PERSON (NON-SP HEAD OR NON-SP SPOUSE - RELATIONSHIP OF "MARRIED" IN THE SCREENER).
IF NO NEXT PERSON, GO TO END OF SECTION.

housing characteristics

HOQ.040 I'd like to ask you a few questions about your home.

When was this home originally built?

READ CATEGORIES IF NECESSARY.

1990 TO PRESENT, 1

1978 TO 1989, 2

1960 TO 1977, 3

1950 TO 1959, 4

1940 TO 1949, OR 5

BEFORE 1940? 6

REFUSED 77

DON'T KNOW 99

HOQ.050 How many rooms are in this home? Count the kitchen but not the bathroom.

|___|___|

ENTER NUMBER OF ROOMS

REFUSED 777777

DON'T KNOW 999999

HOQ.060 How long {have you/has your family} lived at this address?

G/Q/U

|___|___|___|

ENTER NUMBER (OF MONTHS OR YEARS)

LESS THAN ONE MONTH 666 (HOQ.065)

REFUSED 777777 (HOQ.065)

DON'T KNOW 999999 (HOQ.065)

ENTER UNIT

MONTHS 1

YEARS 2

HOQ.065 Is this home owned, being bought, rented, or occupied by some other arrangement by {you/you or someone else in your family}?

OWNED OR BEING BOUGHT 1

RENTED 2

OTHER ARRANGEMENT 3

REFUSED 7

DON'T KNOW 9

HOQ.070 What is the source of tap water in this home? Is it a private or public water company, a private or public well, or something else?

PRIVATE/PUBLIC WATER COMPANY 1

PRIVATE/PUBLIC WELL 2

SOMETHING ELSE 3

REFUSED 7

DON'T KNOW 9

HOQ.080 Are any of the water treatment devices listed on this card used in your home?

HAND CARD HOQ1

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

HOQ.083 Which of these water treatment devices are now used in your home?

HAND CARD HOQ1

CODE ALL THAT APPLY

BRITA OR OTHER PITCHER

WATER FILTER 1

CERAMIC OR CHARCOAL FILTER 2

WATER SOFTENER 3

AERATOR 4

REVERSE OSMOSIS 5

REFUSED 7

DON'T KNOW 9

SMOKING

SMQ.410 I would now like to ask you a few questions about smoking.

Does anyone who lives here smoke cigarettes, cigars, or pipes anywhere inside this home?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

SMQ.420 Who smokes?

PROBE: Anyone else?

CAPI INSTRUCTION:

DISPLAY HOUSEHOLD ROSTER

SELECT NAMES FROM HOUSEHOLD ROSTER

SELECT 1

REFUSED 7

DON'T KNOW 9

BOX 1

LOOP 1:

ASK SMQ.430 FOR EACH PERSON SELECTED FROM HOUSEHOLD ROSTER AS SMOKING INSIDE THE HOME.

SMQ.430 How many cigarettes per day {do you/does PERSON} usually smoke anywhere inside the home?

1 PACK EQUALS 20 CIGARETTES

IF NONE, ENTER 0

IF LESS THAN 1 PER DAY, ENTER 1

|___|___|___|

ENTER NUMBER OF CIGARETTES

REFUSED 777777

DON'T KNOW 999999

BOX 2

END LOOP 1:

ASK SMQ.430 FOR EACH PERSON SELECTED FROM HOUSEHOLD ROSTER AS SMOKING INSIDE THE HOME.

IF NO NEXT PERSON, GO TO END OF SECTION.

consumer behavior

BOX NEW 1A

NEW CHECK ITEM:

IF ONE PERSON FAMILY, GO TO CBQ.020.

OTHERWISE, CONTINUE.

CBQ.010 Is anyone in this family on any kind of diet, either to lose weight or for some other health-related reason?

HELP SCREEN:

Examples of special diets include diet for weight loss, low carbohydrate, high protein, Atkins, to lower cholesterol, gluten-free, low sodium, diabetic diet, etc.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CBQ.020 The next questions ask how often {your family has/you have} certain types of food available at home.

How often {does your family/do you} have fruits available at home? This includes fresh, dried, canned and frozen fruits. Would you say always, most of the time, sometimes, rarely, or never?

HAND CARD CBQ1

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

REFUSED 7

DON'T KNOW 9

CBQ.030 How often {does your family/do you} have any of these dark green vegetables available at home? This includes fresh, dried, canned, and frozen vegetables. [Would you say always, most of the time, sometimes, rarely, or never?]

HAND CARD CBQ2 and HAND CARD CBQ3.

INTERVIEWER INSTRUCTION: DO NOT INCLUDE ICEBERG, BUTTERHEAD, BOSTON, AND MANOA LETTUCE

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

REFUSED 7

DON'T KNOW 9

CBQ.040 How often {does your family/do you} have salty snacks such as chips and crackers available at home? Do not include nuts. [Would you say always, most of the time, sometimes, rarely, or never?]

HAND CARD CBQ3

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

REFUSED 7

DON'T KNOW 9

CBQ.050 How often {does your family/do you} have 1% fat, skim or fat-free milk available at home? Please do not include 2% milk. [Would you say always, most of the time, sometimes, rarely, or never?]

HAND CARD CBQ3

INTERVIEWER INSTRUCTION: DO NOT INCLUDE SOY MILK

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

REFUSED 7

DON'T KNOW 9

CBQ.060 How often {does your family/do you} have soft drinks, fruit-flavored drinks, or fruit punch available at home? Please do not include diet drinks, 100 percent juice or sports drinks. [Would you say always, most of the time, sometimes, rarely, or never?]

HAND CARD CBQ3

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

REFUSED 7

DON'T KNOW 9

CBQ.070 Q/U

The next questions are about how much money {your family spends/you spend} on food. First I’ll ask you about money spent at supermarkets or grocery stores. Then we will talk about money spent at other types of stores.

During the past 30 days, how much money {did your family/did you} spend at supermarkets or grocery stores? Please include purchases made with food stamps. (You can tell me per week or per month.)

INTERVIEWER: ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

$ |___|___|___|___|___|___|___|___|___|

NO MONEY SPENT 0 (CBQ.100)

REFUSED 7 (CBQ.100)

DON'T KNOW 9 (CBQ.100)

ENTER UNIT

WEEK 1

MONTH 2

REFUSED 7

DON'T KNOW 9

CBQ.080 Was any of this money spent on nonfood items such as cleaning or paper products, pet food, cigarettes or alcoholic beverages?

YES 1

NO 2 (CBQ.100)

REFUSED 7 (CBQ.100)

DON'T KNOW 9 (CBQ.100)

CBQ.090 Q/U

About how much money was spent on nonfood items? (You can tell me per week or per month.)

$ |___|___|___|___|___|___|___|___|___|

HARD EDIT: AMOUNT CANNOT BE MORE THAN
THE AMOUNT ENTERED ON CBQ.070.

REFUSED 7

DON'T KNOW 9

ENTER UNIT

WEEK 1

MONTH 2

REFUSED 7

DON'T KNOW 9

CBQ.100 During the past 30 days, {did your family/did you} spend money on food at stores other than grocery stores? Here are some examples of stores where you might buy food. Please do not include stores that you have already told me about.

HAND CARD CBQ4

YES 1

NO 2 (CBQ.120)

REFUSED 7 (CBQ.120)

DON'T KNOW 9 (CBQ.120)

CBQ.110 Q/U

About how much money {did your family/did you} spend on food at these types of stores? (Please do not include any stores you have already told me about.) (You can tell me per week or per month.)

INTERVIEWER: ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

HAND CARD CBQ4

$ |___|___|___|___|___|___|___|___|___|

REFUSED 7

DON'T KNOW 9

ENTER UNIT

WEEK 1

MONTH 2

REFUSED 7

DON'T KNOW 9

CBQ.120 Q/U

During the past 30 days, how much money {did your family/did you} spend on eating out? Please include money spent in cafeterias at work or at school or on vending machines, for all family members. (You can tell me per week or per month.)

INTERVIEWER INSTRUCTION: IF RESPONDENT KNOWS ONLY AMOUNT FOR SELF, CODE DK.

INTERVIEWER: ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

$ |___|___|___|___|___|___|___|___|___|

REFUSED 7

DON'T KNOW 9

ENTER UNIT

WEEK 1

MONTH 2

REFUSED 7

DON'T KNOW 9

CBQ.130 Q/U

During the past 30 days, how much money {did your family/did you} spend on food carried out or delivered? Please do not include money you have already told me about. (You can tell me per week or per month.)

INTERVIEWER INSTRUCTION: IF RESPONDENT KNOWS ONLY AMOUNT FOR SELF, CODE DK.

INTERVIEWER: ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

$ |___|___|___|___|___|___|___|___|___|

REFUSED 7

DON'T KNOW 9

ENTER UNIT

WEEK 1

MONTH 2

REFUSED 7

DON'T KNOW 9

CBQ.140 How often {do you/do you or someone else} do the major food shopping for {yourself/your family}? Please do not include times when {you buy/someone buys} only a few items.

Would you say…

CAPI INSTRUCTIONS:

IF FAMILY IS COMPRISED OF ONLY ONE ADULT SP, SELECT FIRST PREFILLS FOR THE THREE ALTERNATIVE PHRASINGS.

more than once a week, 1

once a week, 2

once every two weeks, or 3

once a month or less? 4

RARELY MAKE ANY MAJOR SHOPPING

TRIPS, ONLY SMALL TRIPS 5

RARELY SHOP FOR FOOD 6

REFUSED 7

DON'T KNOW 9

CBQ.150 How much time does it usually take to get to the grocery store for food shopping?

Q/U

INTERVIEWER INSTRUCTION: IF MORE THAN ONE STORE SAY: Please tell me about the one you go to most often.

INTERVIEWER INSTRUCTION: IF MORE THAN ONE PERSON DOES THE FOOD SHOPPING SAY: Please tell me about the one who does most of the shopping.

INTERVIEWER INSTRUCTION: THE AMOUNT OF TIME RECORDED HERE REFERS TO A “ONE-WAY” TRIP.

|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

CBQ.160 During the past 7 days, how many times did {you or someone else in your family/you} cook food for dinner or supper at home?

HELP SCREEN:

This includes time spent putting the ingredients together to cook a meal. Do not include heating up leftovers.

CAPI INSTRUCTIONS:

SOFT EDIT: 1-7.

|___|___|

ENTER NUMBER

NEVER 0 (BOX 1B)

REFUSED 77

DON'T KNOW 99

CBQ.170 How much time do {you or someone else in your family/do you} usually spend on cooking dinner or supper

Q/U and cleaning up after the cooking? Please do not include time spent eating.

|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

BOX 1B

CHECK ITEM CBQ.175:

IF ONLY 1 PERSON IN FAMILY, GO TO END OF SECTION.

CBQ.180 During the past 7 days, how many meals did all or most of your family sit down and eat together at home?

|___|___|

ENTER NUMBER

NEVER 0 (END OF SECTION)

REFUSED 777 (END OF SECTION)

DON'T KNOW 999 (END OF SECTION)

CAPI INSTRUCTIONS:

SOFT EDIT: 0-21.

MESSAGE: VERIFY FAMILY EATS AT HOME MORE THAN 3 MEALS PER DAY.

CBQ.190 How many of these meals were cooked at home?

|___|___|

ENTER NUMBER

REFUSED 777

DON'T KNOW 999

INCOME

Definitions for Testers:

• NHANES FAMILY: Everyone related to each other by blood, marriage or a marriage-like relationship including partners and foster children.

• FAMILY: Individuals and groups of individuals who are related by birth, marriage or adoption. step children, parents or siblings are included. It also includes unmarried partners if they have a biological or adoptive child in common. It does not include unmarried partners who do not have a child in common, foster parents or foster children. Note: Individuals living alone or with other unrelated individuals are referred to as “unrelated individuals”.

INQ.020 The next questions are about {your/your combined family} income. When answering these questions, please remember that by {"income/combined family income"}, I mean {your income/your income plus the income of {NAMES OF OTHER NHANES FAMILY MEMBERS} for {LAST CALENDAR YEAR}. Did {you/you and OTHER NHANES FAMILY MEMBERS 16+} receive income in {LAST CALENDAR YEAR} from wages and salaries?

[Did {you/you or OTHER FAMILY MEMBERS 16+} get paid for work in {LAST CALENDAR YEAR}.]

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

INQ.012 Did {you/you or any family members 16 and older} receive income in {LAST CALENDAR YEAR} from self-employment including business and farm income?

[Self-employment means you worked for yourself.]

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1B

OMITTED

BOX 1C

OMITTED

INQ.030 When answering the next questions about different kinds of income members of your family might have received in {LAST CALENDAR YEAR}, please consider that we also want to know about family members less than 16 years old. Did {you/you or any family members living here, that is: you or NAME(S) OF OTHER NHANES FAMILY MEMBERS} receive income in {LAST CALENDAR YEAR} from Social Security or Railroad Retirement?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1D

OMITTED

BOX 1E

OMITTED

INQ.060 Did {you/you or any family members living here} receive any disability pension [other than Social Security or Railroad Retirement] in {LAST CALENDAR YEAR}?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2A

OMITTED

INQ.080 Did {you/you or any family members living here} receive retirement or survivor pension [other than Social Security or Railroad Retirement or disability pension] in {LAST CALENDAR YEAR}?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2B

OMITTED

INQ.090 Did {you/you or any family members living here} receive Supplemental Security Income [SSI] in {LAST CALENDAR YEAR}?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2C

OMITTED

BOX 3A

OMITTED

INQ.132 Did {you/you or any family members living here} receive any cash assistance from a state or county welfare program such as {DISPLAY SPECIFIC STATE PROGRAMS} in {LAST CALENDAR YEAR}?

CAPI INSTRUCTION:

DISPLAY FULL NAMES OF ALL STATE PROGRAMS FOR STATE IN WHICH INTERVIEW IS BEING CONDUCTED. NAMES FOR EACH STATE WILL BE SENT TO PROGRAMMING IN A SEPARATE FILE.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 3AA

OMITTED

BOX 3B

OMITTED

INQ.140 Did {you/you or any family members living here} receive interest from savings or other bank accounts or income from dividends received from stocks or mutual funds or net rental income from property, royalties, estates, or trusts in {LAST CALENDAR YEAR}?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 3C

OMITTED

INQ.150 Did {you/you or any family members living here} receive income in {LAST CALENDAR YEAR} from child support, alimony, contributions from family or others, VA payments, worker's compensation, or unemployment compensation?

INTERVIEWER INSTRUCTION: CONTRIBUTIONS INCLUDE GIFTS.

INTERVIEWER INSTRUCTION: IF RESPONDENT IS A COLLEGE STUDENT LIVING AWAY FROM THEIR FAMILY PLEASE ADD “INCLUDING MONEY RECEIVED FROM FAMILY FOR COLLEGE TUITION, BOOKS AND LIVING EXPENSES”

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 3D

OMITTED

BOX 4A

OMITTED

BOX 4C

OMITTED

BOX 4B

OMITTED

BOX 5

OMITTED

BOX 7

ASK INQ.200 – 230 FOR EACH FAMILY IN THE HOUSEHOLD.

FOR THE PURPOSE OF ADMINISTERING THE QUESTIONS ABOUT TOTAL INCOME:

 A FAMILY INCLUDES INDIVIDUALS AND GROUPS OF INDIVIDUALS WHO ARE RELATED BY BIRTH, MARRIAGE OR ADOPTION. STEP CHILDREN, PARENTS OR SIBLINGS ARE INCLUDED. IT ALSO INCLUDES UNMARRIED PARTNERS IF THEY HAVE A BIOLOGICAL OR ADOPTIVE CHILD IN COMMON. IT DOES NOT INCLUDE UNMARRIED PARTNERS WHO DO NOT HAVE A CHILD IN COMMON, FOSTER PARENTS OR FOSTER CHILDREN. NOTE: INDIVIDUALS LIVING ALONG OR WITH OTHER UNRELATED INDIVIDUALS ARE REFERRED TO AS “UNRELATED INDIVIDUALS”.

 TOTAL INCOME IS ADMINISTERED FOR EACH FAMILY AND THEN FOR THE ENTIRE HOUSEHOLD.

INQ.200 Now I am going to ask about the total income for {you/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} in {LAST CALENDAR YEAR}, including income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Can you tell me that amount before taxes?

CAPI INSTRUCTIONS:

 DISPLAY "YOU" IF ONLY 1 PERSON IN THE FAMILY.

 DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.

$ |___|___|___|___|___|___|___|___|___| (GO TO INQ.235)

REFUSED 7777777777 (INQ.220)

DON'T KNOW 9999999999 (INQ.220)

CAPI INSTRUCTION:

 REQUIRE DOUBLE ENTRY OF INCOME.

 SCREEN SHOULD READ:

“INCOME FOR {NAMES OF FAMILY MEMBERS} HAS BEEN RECORDED AS {INCOME ENTERED IN INQ.200} DOUBLE ENTRY OF INCOME REQUIRED.”

 IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.

BOX 5A

OMITTED

INQ.220 You may not be able to give us an exact figure for {your/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} income, but can you tell me if this income in {LAST CALENDAR YEAR} was . . .

PROBE: Income is important in using the health information we collect.  For example, it helps us to learn whether persons in one income group use certain types of medical services or have certain health conditions more or less often than those in another income group.

CAPI INSTRUCTIONS:

 DISPLAY "YOUR" IF ONLY 1 PERSON IN THE FAMILY.

 DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.

$20,000 or more, or 1

less than $20,000? 2

REFUSED 7 (BOX 8)

DON'T KNOW 9 (BOX 8)

INQ.230 a/b

Of these income groups, can you tell me which letter best represents {your/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} income in {LAST CALENDAR YEAR}?

HAND CARD {INQ1 AND INQ2}

ENTER LETTER(S) CORRESPONDING TO TOTAL COMBINED FAMILY INCOME.

CAPI INSTRUCTIONS:

 DISPLAY "YOUR" IF ONLY 1 PERSON IN THE FAMILY.

 DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.

 IF $20,000 OR MORE, DISPLAY HAND CARD INQ1.

 IF LESS THAN $20,000, DISPLAY HAND CARD INQ2.

|___|___|

A B C D E F G H

I J K L M N O P

Q R S T U V W X

Y Z AA BB CC DD EE FF

GG HH II JJ KK LL MM NN

OO PP QQ RR SS TT UU VV WW

REFUSED 77

DON'T KNOW 99

BOX 6

OMITTED

INQ.235 What is the total income received last month, {LAST CALENDAR MONTH & CURRENT CALENDAR YEAR} by {you/NAMES OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS}} before taxes?

[Please include income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth.]

[INTERVIEWER INSTRUCTION: IF SP DOES NOT KNOW INCOME OF OTHER FAMILY MEMBERS, ENTER DON’T KNOW.]

CAPI INSTRUCTION:

 REQUIRE DOUBLE ENTRY OF INCOME.

 SCREEN SHOULD READ:

“LAST MONTH’S INCOME FOR {NAMES OF FAMILY MEMBERS} HAS BEEN RECORDED AS {INCOME ENTERED IN INQ.200} DOUBLE ENTRY OF INCOME REQUIRED.”

• IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.

• FOR THE CALENDAR FILL: IF CURRENT MONTH IS JANUARY THE PAST CALENDAR YEAR WILL BE SHOWN

$ |___|___|___|___|___|___|___|___|___| (BOX NEW 7A)

REFUSED 7

DON'T KNOW 9

INQ.238 You may not be able to give us an exact figure, but can you tell me if the income for {you/NAMES OF OTHER FAMILY/your family} in {LAST CALENDAR YEAR} was . . .

{185% or less of monthly poverty

level}, or 1

more than {185% monthly poverty level}? 2 (BOX NEW 7A)

REFUSED 7

DON'T KNOW 9

PROBE: (That would be {12 times 185% monthly poverty level}} per year.)

CAPI INSTRUCTION:

• Fill 185% of the monthly poverty level based on family size:

For family size of 1, fill ($1511 round to nearest 100s = $1,500)

For each additional family member, fill {[$1511+(524* # of additional person)] round to nearest 100s}

• Fill 185% of the annual poverty level based on family size in the PROBE:

For family size of 1, fill [($1511*12) round to nearest 100s] = $18,100)

For each additional member, fill {[$1511+(524* # of additional person)]*12 round to nearest 100s}

Persons in Family	185% monthly poverty level		185% annual poverty level
	Raw Number1	Rounded to nearest 100s2	Raw Number3	Rounded to nearest 100s4
1	1511	1500	18132	18100
2	2035	2000	24420	24400
3	2559	2600	30708	30700
4	3083	3100	36996	37000
5	3607	3600	43284	43300
6	4131	4100	49572	49600
7	4655	4700	55860	55900
8	5179	5200	62148	62100

¹: $1,511 for family size of 1, thereafter, adding $524 for each additional person.

²: These are the numbers to be used in the response category fills.

³: Multiply by 12 to the raw number of the 185% monthly poverty level.

⁴: These are the numbers to be used in the probe fills

INQ.241 Was it more or less than {130% monthly poverty level}?

130% or less than monthly poverty level 1

More than 130% of monthly poverty level 2

REFUSED 7

DON'T KNOW 9

PROBE: {That would be 12 times 130% annual poverty level per year.}

CAPI INSTRUCTION:

• Fill 130% of the monthly poverty level based on family size:

For family size of 1, fill ($1062 round to nearest 100s = $1,100)

For each additional family member, fill {[$1062+(368* # of additional person)] round to nearest 100s}

• Fill 130% of the annual poverty level based on family size in the PROBE:

For family size of 1, fill [($1062*12) round to nearest 100s] = $12,700)

For each additional member, fill {[$1062+(368* # of additional person)]*12 round to nearest 100s}

Persons in Family	130% monthly poverty level		130% annual poverty level
	Raw Number1	Rounded to nearest 100s2	Raw Number3	Rounded to nearest 100s4
1	1062	1100	12744	12700
2	1430	1400	17160	17200
3	1798	1800	21576	21600
4	2166	2200	25992	26000
5	2534	2500	30408	30400
6	2902	2900	34824	34800
7	3270	3300	39240	39200
8	3638	3600	43656	43700

¹: $1,062 for family size of 1, thereafter, adding $368 for each additional person.

²: These are the numbers to be used in the text of question and response category fills.

³: Multiply 12 to the raw number of the 130% monthly poverty level.

⁴: These are the numbers to be used in the probe fills

BOX NEW 7A

CHECK ITEM INQ.242:

IF FAMILY ANNUAL INCOME (INQ200) EQUAL OR LESS THAN {200% POVERTY LEVEL}, CONTINUE;

OTHERWISE, GO TO BOX 8.

CALCULATE 200% OF THE ANNUAL POVERTY LEVEL BASED ON FAMILY SIZE: $19,600 FOR FAMILY SIZE OF 1, THEREAFTER, ADDING $6,800 FOR EACH ADDITIONAL PERSON

INQ.244 Do {you/NAMES OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} have more than $5,000 in savings at this time? Please include money in your checking accounts.

INTERVIEWER INSTRUCTION: INCLUDE CASH, SAVINGS OR CHECKING ACCOUNTS, STOCKS, BONDS, MUTUAL FUNDS, RETIREMENT FUNDS (SUCH AS PENSIONS, IRAS, 401KS, ETC), AND CERTIFICATES OF DEPOSIT.

CAPI INSTRUCTION:

DISPLAY “you” for single-person family; DISPLAY “the members of your family” for multi-persons family.

YES 1 (BOX 9)

NO 2

REFUSED 7 (BOX 9)

DON'T KNOW 9 (BOX 9)

INQ.247 Which letter on this card best represents the total savings or cash assets at this time for {you/NAMES OF OTHER FAMILY/your family}?

HAND CARD INQ3

|___| ENTER LETTER

REFUSED 7

DON'T KNOW 9

A: Less than $500

B: $501- $1000

C: $1001-$2000

D: $2001-$3000

E: $3001-$4000

F: $4001-$5000

BOX 8

END LOOP 2:

ASK INQ.200 – INQ.247 FOR NEXT FAMILY.

IF NO NEXT FAMILY, CONTINUE.

BOX 9

CHECK ITEM INQ.240:

IF THERE IS MORE THAN ONE NHANES FAMILY IN THE HOUSEHOLD, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

INQ.250 Now I am going to ask you about the total household income for the persons we have talked about plus {NAMES OF ALL OTHER PERSONS IN ADDITIONAL NHANES FAMILIES} in {LAST CALENDAR YEAR}, including income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Can you tell me that amount before taxes?

$ |___|___|___|___|___|___|___|___|___| (GO TO END OF SECTION)

REFUSED 7777777777 (INQ.260)

DON'T KNOW 9999999999 (INQ.260)

CAPI INSTRUCTION:

 REQUIRE DOUBLE ENTRY OF INCOME.

 SCREEN SHOULD READ:

“INCOME FOR YOUR HOUSEHOLD HAS BEEN RECORDED AS {INCOME ENTERED IN INQ.250} DOUBLE ENTRY OF INCOME REQUIRED.”

 IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.

INQ.260 You may not be able to give us an exact figure for your total household income, but can you tell me if this income in {LAST CALENDAR YEAR} was . . .

PROBE: Income is important in analyzing the health information we collect. For example, this information helps us to learn whether persons in one income group use certain types of medical services or have certain conditions more or less often than those in another group.

$20,000 or more, or 1

less than $20,000? 2

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

INQ.270

Of these income groups, can you tell me which letter best represents your total household income in {LAST CALENDAR YEAR}?

HAND CARD {INQ1 AND INQ2}

ENTER LETTER(S) CORRESPONDING TO TOTAL COMBINED HOUSEHOLD INCOME.

|___|___|

A B C D E F G H

I J K L M N O P

Q R S T U V W X

Y Z AA BB CC DD EE FF

GG HH II JJ KK LL MM NN

OO PP QQ RR SS TT UU VV WW

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF $20,000 OR MORE, DISPLAY HAND CARD INQ1.

IF LESS THAN $20,000, DISPLAY HAND CARD INQ2.

END OF SECTION

INQ1

U. $20,000 - $20,999

V. $21,000 - $21,999

W. $22,000 - $22,999

X. $23,000 - $23,999

Y. $24,000 - $24,999

Z. $25,000 - $25,999

AA. $26,000 - $26,999

BB. $27,000 - $27,999

CC. $28,000 - $28,999

DD. $29,000 - $29,999

EE. $30,000 - $30,999

FF. $31,000 - $31,999

GG. $32,000 - $32,999

HH. $33,000 - $33,999

II. $34,000 - $34,999

JJ. $35,000 - $39,999

KK. $40,000 - $44,999

LL. $45,000 - $49,999

MM. $50,000 - $54,999

NN. $55,000 - $59,999

OO. $60,000 - $64,999

PP. $65,000 - $69,999

QQ. $70,000 - $74,999

RR. $75,000 - $79,999

SS. $80,000 - $84,999

TT. $85,000 - $89,999

UU. $90,000 - $94,999

VV. $95,000 - $99,999

WW. $100,000 and over

INQ2

A. Less than $1,000

B. $1,000 - $1,999

C. $2,000 - $2,999

D. $3,000 - $3,999

E. $4,000 - $4,999

F. $5,000 - $5,999

G. $6,000 - $6,999

H. $7,000 - $7,999

I. $8,000 - $8,999

J. $9,000 - $9,999

K. $10,000 - $10,999

L. $11,000 - $11,999

M. $12,000 - $12,999

N. $13,000 - $13,999

O. $14,000 - $14,999

P. $15,000 - $15,999

Q. $16,000 - $16,999

R. $17,000 - $17,999

S. $18,000 - $18,999

T. $19,000 - $19,999

INQ3

A. Less than $500

B. $501 - $1000

C. $1001 - $2000

D. $2001 - $3000

E. $3001 - $4000

F. $4001 - $5000

FOOD SECURITY

(CAPI DISPLAY INSTRUCTIONS FOR {YOU/YOUR HOUSEHOLD}:

IF ONLY ONE PERSON IN HOUSEHOLD, DISPLAY “YOU”.

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “YOUR HOUSEHOLD.”

CAPI DISPLAY INSTRUCTIONS FOR {I/WE}, {MY/OUR}:

IF ONLY ONE PERSON IN HOUSEHOLD, DISPLAY “I” AND “MY”.

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “WE” AND “OUR”.)

FSQ.032 First, I am going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for {you/your household} in the last 12 months, that is since {DISPLAY CURRENT MONTH AND LAST YEAR}.

RESPONSES TO FSQ032A, B, AND C: OFTEN TRUE = 1, SOMETIMES TRUE = 2, NEVER TRUE = 3, REFUSED = 7, DON'T KNOW = 9

a. {I/we} worried whether {my/our} food would run out before {I/we} got money

to buy more. ____

b. The food that {I/we} bought just didn't last, and {I/we} didn't have enough

money to get more food. ____

c. {I/we} couldn't afford to eat balanced meals. ____

BOX 2

IF RESPONSE TO FSQ032 A, B, OR C, IS 1 OR 2 (AFFIRMATIVE), CONTINUE WITH ADULT QUESTIONS FSQ.041 – 081.

OTHERWISE, GO TO BOX 4A

FSQ.041 In the last 12 months, since last { DISPLAY CURRENT MONTH AND LAST YEAR }, did {you/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 (FSQ.061)

REFUSED 7 (FSQ.061)

DON'T KNOW 9 (FSQ.061)

FSQ.052 How often did this happen?

Almost every month, 1

some months but not every month, or 2

only 1 or 2 months? 3

REFUSED 7

DON'T KNOW 9

FSQ.061 In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

FSQ.071 [In the last 12 months], were you ever hungry but didn't eat because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

FSQ.081 [In the last 12 months], did you lose weight because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 5

IF RESPONSE TO ONE OR MORE OF FSQ.041, 061, 071, OR 081 IS 1 (YES),

CONTINUE.

OTHERWISE GO TO BOX 4A

FSQ.092 [In the last 12 months], did {you/you or other adults in your household} ever not eat for a whole day because there wasn't enough money for food?

YES 1

NO 2 (BOX 4A)

REFUSED 7 (BOX 4A)

DON'T KNOW 9 (BOX 4A)

FSQ.102 How often did this happen?

Almost every month, 1

some months but not every month, or 2

in only 1 or 2 months? 3

REFUSED 7

DON'T KNOW 9

BOX 4A

CHECK ITEM FSQ.085A:

IF THERE IS AT LEAST 1 CHILD IN THE HOUSEHOLD WHO IS <=

17 (OR IN THE AGE RANGE THAT INCLUDES OR IS LESS THAN

THE ONE THAT INCLUDES 17), CONTINUE.

OTHERWISE, GO TO FSQ.151.

DISPLAY INSTRUCTIONS FOR {NAME/THE CHILDREN}:

IF ONLY ONE CHILD IN THE HOUSEHOLD AGED <=17, DISPLAY CHILD’S NAME.

IF MORE THAN ONE CHILD IN HOUSEHOLD AGED <=17, DISPLAY “THE CHILDREN”.

FSQ032 The next questions are about children living in the household who are under 18 years old.

I am going to read you several statements that people have made about their children’s food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for {your child / the children in your household who are under 18 years old} in the last 12 months, that is since {DISPLAY CURRENT MONTH AND LAST YEAR}.

d. (I/we) relied on only a few kinds of low-cost foods to feed {CHILD’s NAME / the children} because there wasn’t enough money for food.

e. (I/we) couldn't feed {(CHILD’s NAME/the children} a balanced meal, because there wasn’t enough money for food.

f. {CHILD’s NAME was/the children were} not eating enough because there wasn't enough money for food.

NEW BOX

CHECK ITEM FSQ.NEW:

IF RESPONSE TO FSQ.032D, E, or F, IS 1 OR 2 (AFFIRMATIVE), CONTINUE

OTHERWISE, GO TO FSQ.151.

FSQ.111 In the last 12 months, since {DISPLAY CURRENT MONTH AND LAST YEAR } did you ever cut the size of {child’s name /any of the children's} meals because there wasn't enough money for food?

CAPI INSTRUCTION: IF ONLY 1 CHILD IN HOUSEHOLD IS <=17, DISPLAY CHILD’S NAME.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

FSQ.121 [In the last 12 months], did {CHILD'S NAME/any of the children} ever skip meals because there wasn't enough money for food?

CAPI INSTRUCTION: IF ONLY 1 CHILD IN HOUSEHOLD IS <=17, DISPLAY CHILD’S NAME.

YES 1

NO 2 (FSQ.141)

REFUSED 7 (FSQ.141)

DON'T KNOW 9 (FSQ.141)

FSQ.132 How often did this happen?

Almost every month, 1

some months but not every month, or 2

only 1 or 2 months? 3

REFUSED 7

DON'T KNOW…………………………….. 9

FSQ.141 In the last 12 months, {was child’s name/were any of the children} ever hungry, but there wasn’t enough money for food?

CAPI INSTRUCTION: IF ONLY 1 CHILD IN HOUSEHOLD IS <=17, DISPLAY CHILD’S NAME.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

FSQ.146 [In the last 12 months], did {child’s name/any of the children} ever not eat for a whole day because there wasn't enough money for food?

CAPI INSTRUCTION: IF ONLY 1 CHILD IN HOUSEHOLD IS <=17, DISPLAY CHILD’S NAME.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

FSQ.151 [In the last 12 months], did {you/you or any member of your household} ever get emergency food from a church, a food pantry, or a food bank, or eat in a soup kitchen?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 6

CHECK ITEM FSQ.155B:

IF THE HOUSEHOLD INCLUDES:

**A CHILD AGED 6 YEARS OR UNDER, OR IN AN AGE RANGE THAT INCLUDES AGE 6 AND UNDER

OR

** A FEMALE BETWEEN AGES 12 AND 59, OR IN AN AGE RANGE THAT INCLUDES ANY AGES BETWEEN 12 AND 59) CONTINUE

OTHERWISE, GO TO FSQ.165.

FSQ.162 [In the last 12 months], did {you/you or any member of your household} receive benefits from the WIC program, that is, the Women, Infants and Children program?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

FSQ.165 The next questions are about the Food Stamp Program. Food stamps are usually provided on an electronic debit card {or EBT card} {called the {{STATE NAME FOR EBT CARD}} card in {{STATE}}}.

CAPI INSTRUCTIONS:

INSERT “OR EBT CARD” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD AND STATE NAME IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SEND FILE WITH EBT STATE CARD NAMES TO PROGRAMMING

Have {you/you or anyone in your household} ever received Food Stamp benefits?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

FSQ.171 In the last 12 months, did {you/you or any member of your household} receive Food Stamp benefits?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

FSQ.225 On what date did {you/your household} last receive food stamp benefits?

M/D/Y

|___|___| - |___|___| - |___|___| (FSQ.235)

MONTH DAY YEAR

INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.

CAPI INSTRUCTION:

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

REFUSED 7

DON'T KNOW 9

FSQ.230 {Do you/Does any member of your household} currently receive Food Stamp benefits?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

FSQ.235 How much did {you/your household} receive in food stamp benefits the last time you got them?

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON'T KNOW 99999

TRACKING AND TRACING (TTQ)

BOX 1

LOOP 1:

ASK TTQ.010 - TTQ.040 FOR 2 CONTACT PERSONS.

TTQ.005 The United States Public Health Service may wish to contact you again to obtain additional health related information. Please give me the names, addresses, and telephone numbers of 2 relatives or friends who would know where you could be reached in case we have trouble reaching you. (Please give me the names of persons not currently living in the household.)

PRESS F6 IF RESPONDENT REFUSES {ALL/SECOND} CONTACT INFORMATION

PRESS F5 IF RESPONDENT DOESN'T KNOW {ANY/SECOND} CONTACT INFORMATION

PRESS ENTER TO ADD {FIRST/SECOND} CONTACT INFORMATION

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

TTQ.010 REFERRING TO PERSON {1/2}

VERIFY SPELLING.

ENTER FIRST NAME

REFUSED 7

DON'T KNOW 9

PROBE FOR MIDDLE NAME IF NOT REPORTED

ENTER "NMN" FOR NO MIDDLE NAME

ENTER MIDDLE NAME

REFUSED 7

DON'T KNOW 9

ENTER LAST NAME

REFUSED 7

DON'T KNOW 9

TTQ.020 REFERRING TO PERSON {1/2}

What is this person's address? [If there is more than one address, please give us the address used most often.]

ENCOURAGE RESPONDENT TO USE PHONE BOOK OR OTHER DOCUMENTATION IF AVAILABLE.

______________________ ___________________________ _____________________

ENTER STREET NUMBER ENTER STREET NAME ENTER APARTMENT NUMBER

REFUSED 7 REFUSED 7 REFUSED 7

DON'T KNOW 9 DON'T KNOW 9 DON'T KNOW 9

_____________________ |____|____| |___|____|____|____|____|

ENTER TOWN OR ENTER 2 LETTER ENTER POSTAL CODE

CITY NAME STATE ABBREVIATION TO OR ZIPCODE

TO START THE LOOKUP.

SELECT STATE FROM CAPI STATE LIST.

PRESS ENTER TO ACCEPT SELECTION.

REFUSED 7 REFUSED 77 REFUSED 77777

DON'T KNOW 9 DON'T KNOW 99 DON'T KNOW 99999

CAPI INSTRUCTION:

DISPLAY FIPS STATE LIST. INTERVIEWER SHOULD ONLY BE ABLE TO SELECT 1 STATE FROM THE LIST. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. THE STATE LOOKUP IN THE SP AND FAMILY QUESTIONNAIRES SHOULD WORK EXACTLY THE SAME.

TTQ.030 REFERRING TO PERSON {1/2}

What is this person's telephone number, beginning with the area code?

REPEAT AREA CODE

REPEAT PHONE NUMBER

REPEAT EXTENSION

|___|___|___| |___|___|___| - |___|___|___|___| |___|___|____|____|

ENTER AREA CODE ENTER TELEPHONE NUMBER ENTER EXTENSION

NO PHONE 666 (TTQ.040) REFUSED 7777777 REFUSED 7777

REFUSED 777 (TTQ.040) DON'T KNOW 9999999 DON'T KNOW 9999

DON'T KNOW 999 (TTQ.040)

TTQ.040 REFERRING TO PERSON {1/2}

What is the relationship of this contact person to you?

SPOUSE/EX-SPOUSE NOT LIVING IN HH 1

UNMARRIED PARTNER NOT LIVING IN HH 2

CHILD 3

GRANDCHILD 4

PARENT (MOTHER OR FATHER) 5

BROTHER OR SISTER 6

GRANDPARENT 7

OTHER RELATIVE 8

LEGAL GUARDIAN 9

FRIEND 10

CO-WORKER 11

NEIGHBOR 12

OTHER 13

REFUSED 77

DON'T KNOW 99

BOX 2

END LOOP 1:

ASK TTQ.010 - TTQ.040 FOR SECOND CONTACT PERSON.

IF SECOND CONTACT PERSON INFORMATION COLLECTED, GO TO TTQ.050.

TTQ.050 This is the end of the Family Interview. Thank you very much for your cooperation.

MEC QUESTIONNAIRE - CAPI

RESPONDENT SELECTION SECTION

RIQ.005 INTERVIEWER: MARK MAIN RESPONDENT. SPECIFY RELATIONSHIP OF RESPONDENT TO SP IF OTHER THAN SP.

SP 1 (RIQ.090)

MOTHER 2

FATHER 3

SPOUSE 4

SISTER OR BROTHER 5

CHILD 6

GRANDPARENT 7

LEGAL GUARDIAN 8

OTHER (SPECIFY) 9

RIQ.030 WHY IS INTERVIEW BEING CONDUCTED WITH A PROXY?

SP HAS COGNITIVE PROBLEMS 1

SP HAS PHYSICAL PROBLEMS

(SPECIFY) 2

OTHER (SPECIFY) 3

RIQ.038 INTERVIEWER: WAS SP PRESENT IN THE ROOM DURING ANY PART OF THE INTERVIEW?

YES 1

NO 2

RIQ.090 INTERPRETER USED FOR THIS INTERVIEW?

YES 1

NO 2 (END OF SECTION)

RIQ.100 CODE TYPE OF INTERPRETER.

RELATIVE 1

NEIGHBOR OR FRIEND 2

PAID INTERPRETER 3

RIQ.140 LANGUAGE OF INTERVIEW.

CHINESE 1

FRENCH 2

GERMAN 3

ITALIAN 4

JAPANESE 5

RUSSIAN 6

VIETNAMESE 8

SPANISH 9

OTHER (SPECIFY) 10

BOX 1

CHECK ITEM RIQ.149:

• IF SP 8-11 YEARS AND INTERVIEW DONE WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), DISPLAY THE FOLLOWING INTRODUCTORY TEXT: “During this interview, I will be asking you questions about your health and weight. Your answers will be kept private. Do you have any questions before we begin?”

• IF SP 12 YEARS OR OLDER AND INTERVIEW DONE WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), DISPLAY THE FOLLOWING INTRODUCTORY TEXT: “During this interview, I will be asking you questions about your home, diet ,current health status and other health behaviors. Remember, all of your responses to these questions will be kept strictly confidential. Do you have any questions before we begin?”

• OTHERWISE, DISPLAY THE FOLLOWING INTRODUCTORY TEXT: ”During this interview, I will be asking you questions about {SP}'s current health status, and on other health behaviors.”

Volatile Toxicant

The VOC section is applicable for only those SPs that are subsampled into VOC. To determine if a particular SP is subsampled into VOC, check the mec_sp_subsample. If the SP in question has a record for subsample 1, they are subsampled for VOC and so should get the VOC section

VTQ.210_ First, I would like to ask you a few questions about {your/SP's} home.

VTQ.210 Does {your/her/his} home have an attached garage?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.220 Is the source of water for {your/her/his} home from a private well?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.200a {Do you/Does she/Does he} store paints or fuels inside {your/her/his} home? Include {your/her/his} basement {and attached garage}.

CAPI INSTRUCTION:

IF SP HAS AN ATTACHED GARAGE (CODED ‘1’ IN VTQ.210), DISPLAY {and attached garage}.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.230a {Do you/Does she/Does he} use toilet bowl deodorizers inside {your/her/his} home?

HELP SCREEN SHOULD READ: Some toilet bowl deodorizers clip onto the toilet rim, others, such as deodorant blocks and gels, are placed inside the tank or hang inside the wall of the tank. Brand names include Bully, 2000 Flushes, Vanish, X-14, Ty-D-Bol, Toilet Duck, Clorox, Lime-A-Way, and Sno Bol.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.230b {Do you/Does she/Does he} use moth balls or crystals inside {your/her/his} home?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.240_ Now I am going to ask you a few questions about {your/SP’s} activities over the last three days. This means today, yesterday, or the day before yesterday.

VTQ.240a In the last three days, did {you/she/he} pump gas into a car or other motor vehicle {yourself/herself/himself}?

YES 1

NO 2 (VTQ.250a)

REFUSED 7 (VTQ.250a)

DON'T KNOW 9 (VTQ.250a)

VTQ.240b How long ago, in hours, did {you/she/he} pump gas into a car?

HARD EDIT: Range - 1 – 72

|___|___|

HOURS

REFUSED 777

DON'T KNOW 999

VTQ.250a In the last three days, did {you/she/he} spend any time at a swimming pool, in a hot tub, or in a steam room?

YES 1

NO 2 (VTQ.260a)

REFUSED 7 (VTQ.260a)

DON'T KNOW 9 (VTQ.260a)

VTQ.250b How long ago, in hours, has it been since {you/she/he} spent time in a swimming pool, in a hot tub, or in a steam room?

HARD EDIT: Range - 1 – 72

|___|___|

HOURS

REFUSED 777

DON'T KNOW 999

VTQ.260a In the last three days, did {you/she/he} visit a dry cleaning shop or wear clothes that had been dry-cleaned within the last week?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.260b In the last three days, did {you/she/he} spend 10 or more minutes near a person who was smoking a cigarette, cigar, or pipe?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.270a In the last three days, did {you/she/he} take a hot shower or bath for five minutes or longer?

YES 1

NO 2 (VTQ.280a)

REFUSED 7 (VTQ.280a)

DON'T KNOW 9 (VTQ.280a)

VTQ.270b How long ago, in hours, has it been since {your/SP’s} last shower or hot bath?

HARD EDIT: Range - 1 – 72

|___|___|

HOURS

REFUSED 777

DON'T KNOW 999

VTQ.280a In the last three days, did {you/she/he} breathe fumes from any of the following:

Paints?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.280b [In the last three days, did {you/she/he} breathe fumes from any of the following:]

Degreasing cleaners?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.280c [In the last three days, did {you/she/he} breathe fumes from any of the following:]

Diesel fuel or kerosene?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.280d [In the last three days, did {you/she/he} breathe fumes from any of the following:]

Paint thinner, brush cleaner, or furniture stripper?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.280e [In the last three days, did {you/she/he} breathe fumes from any of the following:]

Drycleaning fluid or spot remover?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.280f [In the last three days, did {you/she/he} breathe fumes from any of the following:]

Fingernail polish or fingernail polish remover?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.280g [In the last three days, did {you/she/he} breathe fumes from any of the following:]

Glues or adhesives used for hobbies or crafts?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PESTICIDE USE

PUQ.100 In the past 7 days, were any chemical products used in {your/his/her} home to control fleas, roaches, ants, termites, or other insects?

CAPI INSTRUCTION:

IF SP 8-17 YEARS, DISPLAY THE FOLLOWING INTERVIEWER INSTRUCTION: "THIS ITEM IS COLLECTED VIA PROXY FOR SPS 8-17. LOOK UP THE PROXY RESPONSE IN THE PUQ REPORT AND ENTER IT IN PUQ.100"

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PUQ.110 In the past 7 days, were any chemical products used in {your/his/her} lawn or garden to kill weeds?

CODE ‘NO’ IF THE RESPONDENT SAYS S/HE DOES NOT HAVE A LAWN OR GARDEN.

CAPI INSTRUCTION:

IF SP 8-17 YEARS, DISPLAY THE FOLLOWING INTERVIEWER INSTRUCTION: "THIS ITEM IS COLLECTED VIA PROXY FOR SPS 8-17. LOOK UP THE PROXY RESPONSE IN THE PUQ REPORT AND ENTER IT IN PUQ.110."

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DIETARY SCREENER MODULE (DTQ)

2-11 – Household

12+ – MEC

DTQ.010 G/Q/U

These questions are about the different kinds of foods {you/SP} ate or drank during the past month, that is, the past 30 days. When answering, please include meals and snacks eaten at home, at work or school, in restaurants, and anyplace else.

During the past month, how often did {you/SP} eat hot or cold cereals? You can tell me per day, per week or per month.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.030)

REFUSED 777 (DTQ.030)

DON'T KNOW 999 (DTQ.030)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.015.

DTQ.015 You said (DISPLAY NUMBER FROM DTQ.010) times per (DISPLAY UNIT FROM DTQ.010). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.010)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.020 During the past month, what kinds of cereal did {you/SP} usually eat?

ENTER FIRST FEW LETTERS OF CEREAL NAME TO START THE LOOKUP.

SELECT CEREAL FROM LIST. IF CEREAL NOT ON LIST, PRESS BS TO DELETE THE ENTRY AND TYPE ** TO ENTER CEREAL NAME.

CAPI INSTRUCTION:

DISPLAY CEREAL LIST. INTERVIEWER SHOULD BE ABLE TO SELECT CEREAL FROM LIST OR PRESS BS TO DELETE ENTRY AND TYPE ** TO ENTER NAME OF CEREAL.

NEW BOX 0

CHECK ITEM DTQ.300:

IF THIS IS THE FIRSTENTRY, CONTINUE.

OTHERWISE, GO TO DTQ.030.

DTQ.025 IS THERE ANOTHER CEREAL SP USUALLY EATS?

OR ASK IF NECESSARY (Is there another cereal {you/SP} usually eat(s)?)

YES 1 (RETURN TO DTQ.020)

NO 2 (DTQ.030)

DTQ.030 G/Q/U

(During the past month), how often did {you/SP} have milk {either to drink or on cereal}? Do not include soy milk or small amounts of milk in coffee or tea. (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTION:

INCLUDE: skim, no-fat, low-fat, whole milk, buttermilk, and lactose-free milk. Also INCLUDE chocolate or other flavored milks.

DO NOT INCLUDE: cream.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.040)

REFUSED 777 (DTQ.040)

DON'T KNOW 999 (DTQ.040)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF DTQ.010 >= 1, DISPLAY PHRASE {“either to drink or on cereal”}.

CAPI INSTRUCTION:

IF RESPONSE > 2 AND UNIT = 1 (DAY), ELIMINATE >2 AND UNIT = 1 FOR HOUSEHOLD QUESTIONNAIRE SECTION (SPs 2-11 YEARS OLD)

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.035.

DTQ.035 You said (DISPLAY NUMBER FROM DTQ.030) times per (DISPLAY UNIT FROM DTQ.030). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.030)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.040 G/Q/U

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 INSTRUCTION:

INCLUDE: MANZANITA AND PEÑAFIEL SODAS.

DO NOT INCLUDE: DIET OR SUGAR-FREE FRUIT DRINKS. DO NOT INCLUDE JUICES OR TEA IN CANS.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.050)

REFUSED 777 (DTQ.050)

DON'T KNOW 999 (DTQ.050)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 2 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.045.

DTQ.045 You said (DISPLAY NUMBER FROM DTQ.040) times per (DISPLAY UNIT FROM DTQ.040). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.040)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.050 G/Q/U

(During the past month), how often did {you/SP} drink 100% pure fruit juice such as orange, mango, apple, grape and pineapple juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTION:

INCLUDE: ONLY 100% PURE JUICES.

DO NOT INCLUDE: FRUIT-FLAVORED DRINKS WITH ADDED SUGAR, LIKE CRANBERRY COCKTAIL, HI-C, LEMONADE, KOOL-AID, GATORADE, TAMPICO, AND SUNNY DELIGHT.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (BOX 1)

REFUSED 777 (BOX 1)

DON'T KNOW 999 (BOX 1)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), ELIMINATE > 1 AND UNIT = 1 FOR HOUSEHOLD QUESTIONNAIRES (SPs 2-11 YEARS OLD)

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.055.

DTQ.055 You said (DISPLAY NUMBER FROM DTQ.050) times per (DISPLAY UNIT FROM DTQ.050). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.050)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

NEW BOX 1

CHECK ITEM DTQ.305:

IF SP AGE 2-11 YEARS OLD, SKIP TO DTQ.070.

OTHERWISE, CONTINUE.

DTQ.060 G/Q/U

(During the past month), how often did {you/SP} drink coffee or tea that had sugar or honey added to it? Include coffee and tea you sweetened yourself and presweetened tea and coffee drinks such as Arizona Iced Tea and Frappuccino. Do not include artificially sweetened coffee or diet tea. (You can tell me per day, per week or per month.)

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.070)

REFUSED 777 (DTQ.070)

DON'T KNOW 999 (DTQ.070)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.065.

DTQ.065 You said (DISPLAY NUMBER FROM DTQ.060) times per (DISPLAY UNIT FROM DTQ.060). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.060)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.070 G/Q/U

(During the past month), how often did {you/SP} drink sweetened fruit drinks, sports or energy drinks, such as Kool-aid, lemonade, Hi-C, cranberry drink, Gatorade, 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.)

INTERVIEWER INSTRUCTION:

INCLUDE: DRINKS WITH ADDED SUGAR, TAMPICO, SUNNY DELIGHT, AND TWISTER.

DO NOT INCLUDE: 100% FRUIT JUICES OR SODA, YOGURT DRINKS, CARBONATED WATER OR FRUIT-FLAVORED TEAS.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.080)

REFUSED 777 (DTQ.080)

DON'T KNOW 999 (DTQ.080)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), ELIMINATE > 1 AND UNIT = 1 FOR HOUSEHOLD QUESTIONNAIRES (SPs 2-11 YEARS OLD)

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.075.

DTQ.075 You said (DISPLAY NUMBER FROM DTQ.070) times per (DISPLAY UNIT FROM DTQ.070). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.070)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.080 G/Q/U

(During the past month), how often did {you/SP} eat fruit? Include fresh, frozen or canned fruit. Do not include juices. (You can tell me per day, per week or per month.)

Interviewer Instructions:

Do not include: dried fruits.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.090)

REFUSED 777 (DTQ.090)

DON'T KNOW 999 (DTQ.090)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.085.

DTQ.085 You said (DISPLAY NUMBER FROM DTQ.080) times per (DISPLAY UNIT FROM DTQ.080). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.080)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.090 G/Q/U

(During the past month), how often did {you/SP} eat a green leafy or lettuce salad, with or without other vegetables? (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: SPINACH SALADS.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.100)

REFUSED 777 (DTQ.100)

DON'T KNOW 999 (DTQ.100)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.095.

DTQ.095 You said (DISPLAY NUMBER FROM DTQ.090) times per (DISPLAY UNIT FROM DTQ.090). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.090)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.100 G/Q/U

(During the past month), how often did {you/SP} eat any kind of fried potatoes, including french fries, home fries, or hash brown potatoes? (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

DO NOT INCLUDE: POTATO CHIPS.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.110)

REFUSED 777 (DTQ.110)

DON'T KNOW 999 (DTQ.110)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.105.

DTQ.105 You said (DISPLAY NUMBER FROM DTQ.100) times per (DISPLAY UNIT FROM DTQ.100). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.100)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.110 G/Q/U

(During the past month), how often did {you/SP} eat any other kind of potatoes, such as baked, boiled, mashed potatoes, sweet potatoes, or potato salad? (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: ALL TYPES OF POTATOES EXCEPT FRIED. INCLUDE POTATOES AU GRATIN, SCALLOPED POTATOES.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.120)

REFUSED 777 (DTQ.120)

DON'T KNOW 999 (DTQ.120)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.115.

DTQ.115 You said (DISPLAY NUMBER FROM DTQ.110) times per (DISPLAY UNIT FROM DTQ.110). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.110)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.120 G/Q/U

(During the past month), how often did {you/SP} eat refried beans, baked beans, beans in soup, pork and beans or any other type of cooked dried beans? Do not include green beans. (You can tell me per day, per week or per month.)

Interviewer Instructions:

INCLUDE: SOYBEANS, KIDNEY, PINTO, GARBANZO, LENTILS, BLACK, BLACK-EYED PEAS, COW PEAS, AND LIMA BEANS.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.210)

REFUSED 777 (DTQ.210)

DON'T KNOW 999 (DTQ.210)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.125.

DTQ.125 You said (DISPLAY NUMBER FROM DTQ.120) times per (DISPLAY UNIT FROM DTQ.120). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.120)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.210 G/Q/U

(During the past month), how often did {you/SP} eat brown rice or other cooked whole grains, such as bulgur, cracked wheat, or millet? Do not include white rice. (You can tell me per day, per week or per month.)

HELP SCREEN:

Brown rice is a type of whole grain. It is brown in color and takes longer to cook than white rice. It contains almost all of the rice grain and is not as processed as white rice. Compared to white rice it also contains more fiber and more of some vitamins and minerals that are lost during the processing of rice.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.130)

REFUSED 777 (DTQ.130)

DON'T KNOW 999 (DTQ.130)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.215.

DTQ.215 You said (DISPLAY NUMBER FROM DTQ.210) times per (DISPLAY UNIT FROM DTQ.210). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.210)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.130 G/Q/U

(During the past month), not including what you just told me about (lettuce salads, potatoes, cooked dried beans), how often did {you/SP} eat other vegetables? (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

DO NOT INCLUDE: RICE

EXAMPLES OF OTHER VEGETABLES INCLUDE: TOMATOES, GREEN BEANS, CARROTS, CORN, CABBAGE, BEAN SPROUTS, COLLARD GREENS, AND BROCCOLI. INCLUDE ANY FORM OF THE VEGETABLE (RAW, COOKED, CANNED, OR FROZEN).

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.150)

REFUSED 777 (DTQ.150)

DON'T KNOW 999 (DTQ.150)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 2 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.135.

DTQ.135 You said (DISPLAY NUMBER FROM DTQ.130) times per (DISPLAY UNIT FROM DTQ.130). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.130)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.150 G/Q/U

(During the past month), how often did {you/SP} have Mexican-type salsa made with tomato? (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: ALL TOMATO-BASED SALSAS.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.140)

REFUSED 777 (DTQ.140)

DON'T KNOW 999 (DTQ.140)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.155.

DTQ.155 You said (DISPLAY NUMBER FROM DTQ.150) times per (DISPLAY UNIT FROM DTQ.150). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.150)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.140 G/Q/U

During the past month, how often did {you/SP} eat pizza? Include frozen pizza, fast food pizza, and homemade pizza. You can tell me per day, per week or per month.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.160)

REFUSED 777 (DTQ.160)

DON'T KNOW 999 (DTQ.160)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.145.

DTQ.145 You said (DISPLAY NUMBER FROM DTQ.140) times per (DISPLAY UNIT FROM DTQ.140). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.140)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.160 G/Q/U

(During the past month), how often did {you/SP} have tomato sauces such as with spaghetti or noodles or mixed into foods such as lasagna? {Please do not count tomato sauce on pizza.} (You can tell me per day, per week or per month.)

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.190)

REFUSED 777 (DTQ.190)

DON'T KNOW 999 (DTQ.190)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF DTQ.140 >= 1, DISPLAY “Please do not count tomato sauce on pizza.”

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.165.

DTQ.165 You said (DISPLAY NUMBER FROM DTQ.160) times per (DISPLAY UNIT FROM DTQ.160). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.160)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.190 G/Q/U

(During the past month), how often did {you/SP} eat any kind of cheese? Include cheese as a snack, cheese on burgers, sandwiches, and cheese in foods such as lasagna, quesadillas, or casseroles. {Please do not count cheese on pizza.} (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: MACARONI AND CHEESE, ENCHILADAS.

DO NOT INCLUDE: CREAM CHEESE OR CHEESES MADE FROM NON-DAIRY FOODS, SUCH AS SOY OR RICE, OR CHEESE ON PIZZA.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.170)

REFUSED 777 (DTQ.170)

DON'T KNOW 999 (DTQ.170)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF DTQ.140 >= 1, DISPLAY “Please do not count cheese on pizza.”

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.195.

DTQ.195 You said (DISPLAY NUMBER FROM DTQ.190) times per (DISPLAY UNIT FROM DTQ.190). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.190)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.170 G/Q/U

Please look at this card, during the past month, how often did {you/SP} eat red meat, such as beef, pork, ham, or sausage? Do not include chicken, turkey or seafood. (You can tell me per day, per week or per month.)

HAND CARD DTQ1

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.180)

REFUSED 777 (DTQ.180)

DON'T KNOW 999 (DTQ.180)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.175.

DTQ.175 You said (DISPLAY NUMBER FROM DTQ.170) times per (DISPLAY UNIT FROM DTQ.170). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.170)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.180 G/Q/U

Please look at this card, (during the past month), how often did {you/SP} eat processed meat, such as bacon, lunch meats, or hot dogs? (You can tell me per day, per week or per month.)

HAND CARD DTQ2

INTERVIEWER INSTRUCTIONS:

INCLUDE: PROCESSED POULTRY AND RED MEAT.

DO NOT INCLUDE: CANNED TUNA FISH OR CHICKEN NUGGETS.

HELP SCREEN:

processed meat: Meats (usually red meats, but not always) preserved by smoking, curing, or salting, or by the addition of preservatives. Examples include: ham, bacon, pastrami, salami, sausages, bratwursts, frankfurters, hot dogs, or spam.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.200)

REFUSED 777 (DTQ.200)

DON'T KNOW 999 (DTQ.200)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.185.

DTQ.185 You said (DISPLAY NUMBER FROM DTQ.180) times per (DISPLAY UNIT FROM DTQ.180). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.180)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.200 G/Q/U

(During the past month), how often did {you/SP} eat whole grain bread including toast, rolls and in sandwiches? Whole grain breads include whole wheat, rye, oatmeal and pumpernickel. Do not include white bread. (You can tell me per day, per week or per month.)

HAND CARD DTQ3

INTERVIEWER INSTRUCTIONS:

INCLUDE: CRACKED WHEAT, MULTI-GRAIN, BRAN BREADS, WHOLE GRAIN WHITE BREAD.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.220)

REFUSED 777 (DTQ.220)

DON'T KNOW 999 (DTQ.220)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.205.

DTQ.205 You said (DISPLAY NUMBER FROM DTQ.200) times per (DISPLAY UNIT FROM DTQ.200). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.200)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.220 G/Q/U

During the past month, how often did {you/SP} eat chocolate or any other types of candy? Do not include sugar-free candy. You can tell me per day, per week or per month.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.230)

REFUSED 777 (DTQ.230)

DON'T KNOW 999 (DTQ.230)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.225.

DTQ.225 You said (DISPLAY NUMBER FROM DTQ.220) times per (DISPLAY UNIT FROM DTQ.220). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.220)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.230 G/Q/U

(During the past month), how often did {you/SP} eat doughnuts, sweet rolls, Danish, muffins, (pan dulce) or pop-tarts? Do not include sugar-free items. (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: LOW-FAT KINDS.

DO NOT INCLUDE: PANCAKES, WAFFLES, FRENCH TOAST, CAKE, ICE CREAM AND OTHER FROZEN DESSERTS OR CANDY.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.240)

REFUSED 777 (DTQ.240)

DON'T KNOW 999 (DTQ.240)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.235.

DTQ.235 You said (DISPLAY NUMBER FROM DTQ.230) times per (DISPLAY UNIT FROM DTQ.230). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.230)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.240 G/Q/U

(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.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: LOW-FAT KINDS, TWINKIES AND HOSTESS CUPCAKES.

DO NOT INCLUDE: ICE CREAM AND OTHER FROZEN DESSERTS OR CANDY.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.250)

REFUSED 777 (DTQ.250)

DON'T KNOW 999 (DTQ.250)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.245.

DTQ.245 You said (DISPLAY NUMBER FROM DTQ.240) times per (DISPLAY UNIT FROM DTQ.240). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.240)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.250 G/Q/U

(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.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: LOW-FAT KINDS. ALSO INCLUDE FROZEN YOGURT AND SHERBET.

DO NOT INCLUDE: NON-DAIRY FROZEN DESSERTS, SUCH AS SORBET, SNO-CONES.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (DTQ.260)

REFUSED 777 (DTQ.260)

DON'T KNOW 999 (DTQ.260)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.255.

DTQ.255 You said (DISPLAY NUMBER FROM DTQ.250) times per (DISPLAY UNIT FROM DTQ.250). Is that correct?

YES 1 (CONTINUE)

NO 2 (RETURN TO DTQ.250)

REFUSED 777 (CONTINUE)

DON’T KNOW 999 (CONTINUE)

DTQ.260 G/Q/U

(During the past month), how often did {you/SP} eat popcorn? (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: LOW-FAT POPCORN.

|___|___|___|

ENTER quantity IN DAYS, WEEKS, or MONTHS

NEVER 0 (END OF SECTION)

REFUSED 777 (END OF SECTION)

DON'T KNOW 999 (END OF SECTION)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RESPONSE > 1 AND UNIT = 1 (DAY), OR

IF RESPONSE > 14 AND UNIT = 2 (WEEK), OR

IF RESPONSE > 60 AND UNIT = 3 (MONTH),

THEN DISPLAY QUESTION DTQ.265.

DTQ.265 You said (DISPLAY NUMBER FROM DTQ.260) times per (DISPLAY UNIT FROM DTQ.260). Is that correct?

YES 1 (END OF SECTION)

NO 2 (RETURN TO DTQ.260)

REFUSED 777 (END OF SECTION)

DON’T KNOW 999 (END OF SECTION)

CURRENT HEALTH STATUS

HUQ.010 Next, I have some general questions about {your/SP's} health.

Would you say {your/SP's} health in general is . . .

excellent, 1

very good, 2

good, 3

fair, or 4

poor? 5

REFUSED 7

DON'T KNOW 9

HSQ.470 The next questions are about {your/SP's} recent health during the 30 days outlined on the calendar.

Thinking about {your/SP's} physical health, which includes physical illness and injury, for how many days during the past 30 days was {your/his/her} physical health not good?

HAND CARD HSQ1

CAPI INSTRUCTION:

HARD EDIT VALUES: 0-30.

|___|___|

ENTER # OF DAYS

REFUSED 77

DON'T KNOW 99

HSQ.480 Now thinking about {your/SP's} mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was {your/his/her} mental health not good?

CAPI INSTRUCTION:

HARD EDIT VALUES: 0-30.

|___|___|

ENTER # OF DAYS

REFUSED 77

DON'T KNOW 99

HSQ.490 During the past 30 days, for about how many days did poor physical or mental health keep {you/SP} from doing {your/his/her} usual activities, such as self-care, work, school or recreation?

CAPI INSTRUCTION:

HARD EDIT VALUES: 0-30.

|___|___|

ENTER # OF DAYS

REFUSED 77

DON'T KNOW 99

HSQ.493 During the past 30 days, for about how many days did pain make it hard for {you/SP} to do {your/his/her} usual activities, such as self-care, work, or recreation?

CAPI INSTRUCTION:

HARD EDIT VALUES: 0-30.

|___|___|

ENTER # OF DAYS

REFUSED 77

DON'T KNOW 99

HSQ.496 During the past 30 days, for about how many days {have you/has SP} felt worried, tense, or anxious?

CAPI INSTRUCTION:

HARD EDIT VALUES: 0-30.

|___|___|

ENTER # OF DAYS

REFUSED 77

DON'T KNOW 99

HSQ.500 Did {you/SP} have a head cold or chest cold that started during those 30 days?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HSQ.510 Did {you/SP} have a stomach or intestinal illness with vomiting or diarrhea that started during those 30 days?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HSQ.520 Did {you/SP} have flu, pneumonia, or ear infections that started during those 30 days?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1

CHECK ITEM HSQ.560:

IF SP 16 YEARS OR OLDER, CONTINUE WITH HSQ.571.

OTHERWISE, GO TO END OF SECTION.

HSQ.571 During the past 12 months, that is, since {DISPLAY CURRENT MONTH, DISPLAY LAST YEAR}, {have you/has SP} donated blood?

YES 1

NO 2 (HSQ.590)

REFUSED 7 (HSQ.590)

DON'T KNOW 9 (HSQ.590)

HSQ.580 How long ago was {your/SP's} last blood donation?

IF LESS THAN ONE MONTH, ENTER '1'.

CAPI INSTRUCTION:

HARD EDIT VALUES: 1-12.

|___|___|

ENTER # OF MONTHS

REFUSED 77

DON'T KNOW 99

HSQ.590 Except for tests {you/SP} may have had as part of blood donations, {have you/has he/has she} ever had {your/his/her} blood tested for the AIDS virus infection?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DEPRESSION SCREEN

BOX 1

CHECK ITEM DPQ.001:

• IF INTERVIEW DONE ONLY WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), CONTINUE.

• OTHERWISE, GO TO NEXT SECTION.

DPQ.010 Over the last 2 weeks, how often have you been bothered by the following problems:

little interest or pleasure in doing things? Would you say . . .

HANDCARD DPQ1

Not at all, 0

several days, 1

more than half the days, or 2

nearly every day? 3

REFUSED 7

DON’T KNOW 9

DPQ.020 [Over the last 2 weeks, how often have you been bothered by the following problems:]

feeling down, depressed, or hopeless?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.030 [Over the last 2 weeks, how often have you been bothered by the following problems:]

trouble falling or staying asleep, or sleeping too much?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.040 [Over the last 2 weeks, how often have you been bothered by the following problems:]

feeling tired or having little energy?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.050 [Over the last 2 weeks, how often have you been bothered by the following problems:]

poor appetite or overeating?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.060 [Over the last 2 weeks, how often have you been bothered by the following problems:]

feeling bad about yourself – or that you are a failure or have let yourself or your family down?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.070 [Over the last 2 weeks, how often have you been bothered by the following problems:]

trouble concentrating on things, such as reading the newspaper or watching TV?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.080 [Over the last 2 weeks, how often have you been bothered by the following problems:]

moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.090 Over the last 2 weeks, how often have you been bothered by the following problem:

Thoughts that you would be better off dead or of hurting yourself in some way?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

BOX 2

CHECK ITEM DPQ.095:

• IF RESPONSE TO ANY OF QUESTIONS DPQ.010 – DPQ.090 = 1, 2, OR 3, GO TO DPQ.100.

• OTHERWISE, GO TO NEXT SECTION.

DPQ.100 How difficult have these problems made it for you to do your work, take care of things at home, or get along with people?

Not at all difficult, 0

Somewhat difficult, 1

Very difficult, 2

Extremely difficult? 3

REFUSED 7

DON’T KNOW 9

TOBACCO

SMQ.680 The following questions ask about use of tobacco or nicotine products in the past 5 days.

During the past 5 days, did {you/he/she} use any product containing nicotine including cigarettes, pipes, cigars, chewing tobacco, snuff, nicotine patches, nicotine gum, or any other product containing nicotine?

VERBAL INSTRUCTIONS TO SP:

Please select yes, no.

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

SMQ.690 Which of these products did {you/he/she} use? (CHECK ALL THAT APPLY)

VERBAL INSTRUCTIONS TO SP:

Please select all that you used.

Cigarettes 1

Pipes 2

Cigars 3

Chewing tobacco 4

Snuff 5

Nicotine patches, gum, or other nicotine

product 6

REFUSED 77

DON’T KNOW 99

BOX 2

CHECK ITEM SMQ.700:

IF ‘CIGARETTES’ (CODE 1) IN SMQ.690, GO TO SMQ.710.

IF ‘PIPES’ (CODE 2) IN SMQ.690, GO TO SMQ.740.

IF ‘CIGARS’ (CODE 3) IN SMQ.690, GO TO SMQ.770.

IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.

IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.

IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.

IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.710.

SMQ.710 During the past 5 days (including today), on how many days did {you/he/she} smoke cigarettes?

VERBAL INSTRUCTIONS TO SP:

Please enter a number.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.720 During the past 5 days, on the days {you/he/she} smoked, how many cigarettes did {you/he/she} smoke each day?

IF R SAYS 95 OR MORE CIGARETTES PER DAY, ENTER 95.

VERBAL INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|

ENTER NUMBER OF CIGARETTES

REFUSED 777

DON'T KNOW 999

SMQ.725 When did {you/he/she} smoke {your/his/her} last cigarette? Was it . . .

today, 1

yesterday, or 2

3 to 5 days ago? 3

REFUSED 7

DON'T KNOW 9

BOX 3

CHECK ITEM SMQ.730:

IF ‘PIPES’ (CODE 2) IN SMQ.690, GO TO SMQ.740.

IF ‘CIGARS’ (CODE 3) IN SMQ.690, GO TO SMQ.770.

IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.

IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.

IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.

IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.740.

SMQ.740 During the past 5 days (including today), on how many days did {you/he/she} smoke a pipe?

VERBAL INSTRUCTIONS TO SP:

Please enter a number.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.750 During the past 5 days, on the days {you/he/she} smoked a pipe, how many pipes did {you/he/she} smoke each day?

IF R SAYS LESS THAN 1 PIPE PER DAY, ENTER 1.

VERBAL INSTRUCTIONS TO SP:

Please enter a number.

|___|___|

ENTER NUMBER OF PIPES

REFUSED 77

DON'T KNOW 99

SMQ.755 When did {you/he/she} smoke {your/his/her} last pipe? Was it . . .

today, 1

yesterday, or 2

3 to 5 days ago? 3

REFUSED 7

DON'T KNOW 9

BOX 4

CHECK ITEM SMQ.760:

IF ‘CIGARS’ (CODE 3) IN SMQ.690, GO TO SMQ.770.

IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.

IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.

IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.

IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.770.

SMQ.770 During the past 5 days (including today), on how many days did {you/he/she} smoke cigars?

VERBAL INSTRUCTIONS TO SP:

Please enter a number.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.780 During the past 5 days, on the days {you/he/she} smoked cigars, how many cigars did {you/he/she} smoke each day?

IF R SAYS LESS THAN 1 CIGAR PER DAY, ENTER 1.

VERBAL INSTRUCTIONS TO SP:

Please enter a number.

|___|___|

ENTER NUMBER OF CIGARS

REFUSED 77

DON'T KNOW 99

SMQ.785 When did {you/he/she} smoke {your/his/her} last cigar? Was it . . .

today, 1

yesterday, or 2

3 to 5 days ago? 3

REFUSED 7

DON'T KNOW 9

BOX 5

CHECK ITEM SMQ.790:

IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.

IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.

IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.

IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.800.

SMQ.800 During the past 5 days (including today), on how many days did {you/he/she} use chewing tobacco, such as Redman, Levi Garrett or Beechnut?

VERBAL INSTRUCTIONS TO SP:

Please enter a number.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.815 When did {you/he/she} last use chewing tobacco? Was it . . .

today, 1

yesterday, or 2

3 to 5 days ago? 3

REFUSED 7

DON'T KNOW 9

BOX 5A

CHECK ITEM SMQ.816:

IF ‘SNUFF’ (CODE 5) IN SMQ.690, GO TO SMQ.817.

IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.

IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.817.

SMQ.817 During the past 5 days (including today), on how many days did {you/he/she} use snuff, such as Skoal, Skoal Bandits, or Copenhagen?

VERBAL INSTRUCTIONS TO SP:

Please enter a number.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.819 When did {you/he/she} last use snuff? Was it . . .

today, 1

yesterday, or 2

3 to 5 days ago? 3

REFUSED 7

DON'T KNOW 9

BOX 6

CHECK ITEM SMQ.820:

IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.

IF ‘REFUSED’ (CODE 77) OR ‘DON’T KNOW’ (CODE 99) IN SMQ.690, GO TO SMQ.830.

OTHERWISE, GO TO END OF SECTION.

SMQ.830 During the past 5 days (including today), on how many days did {you/he/she} use any product containing nicotine to help {you/him/her} stop smoking? Include nicotine patches, gum, or any other product containing nicotine.

VERBAL INSTRUCTIONS TO SP:

Please enter a number.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.840 When did {you/he/she} last use a product containing nicotine? Was it . .

today, 1

yesterday, or 2

3 to 5 days ago? 3

REFUSED 7

DON'T KNOW 9

A

NHANES 2005

LCOHOL USE

ALQ.101 The next questions are about drinking alcoholic beverages. Included are liquor (such as whiskey or gin), beer, wine, wine coolers, and any other type of alcoholic beverage.

In any one year, {have you/has SP} had at least 12 drinks of any type of alcoholic beverage? By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and half ounces of liquor.

YES 1 (ALQ.120)

NO 2

REFUSED 7

DON'T KNOW 9

ALQ.110 In {your/SP’s} entire life, {have you/has he/has she} had at least 12 drinks of any type of alcoholic beverage?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

ALQ.120 Q/U

In the past 12 months, how often did {you/SP} drink any type of alcoholic beverage?

PROBE: How many days per week, per month, or per year did {you/SP} drink?

ENTER '0' FOR NEVER.

|___|___|___|

ENTER QUANTITY

REFUSED 777

DON'T KNOW 999

ENTER UNIT

WEEK 1

MONTH 2

YEAR 3

REFUSED 7

DON'T KNOW 9

BOX 1

CHECK ITEM ALQ.125:

IF SP DIDN'T DRINK (CODED '0') IN ALQ.120, GO TO ALQ.150.

OTHERWISE, CONTINUE WITH ALQ.130.

ALQ.130 In the past 12 months, on those days that {you/SP} drank alcoholic beverages, on the average, how many drinks did {you/he/she} have?

IF LESS THAN 1 DRINK, ENTER '1'.

IF 95 DRINKS OR MORE, ENTER '95'.

|___|___|___|

ENTER # OF DRINKS

REFUSED 777

DON'T KNOW 999

ALQ.140 Q/U

In the past 12 months, on how many days did {you/SP} have 5 or more drinks of any alcoholic beverage?

PROBE: How many days per week, per month, or per year did {you/SP} have 5 or more drinks in a single day?

ENTER '0' FOR NONE.

|___|___|___|

ENTER QUANTITY

REFUSED 777

DON'T KNOW 999

ENTER UNIT

WEEK 1

MONTH 2

YEAR 3

REFUSED 7

DON'T KNOW 9

ALQ.150 Was there ever a time or times in {your/SP's} life when {you/he/she} drank 5 or more drinks of any kind of alcoholic beverage almost every day?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

R

NHANES 2007

EPRODUCTIVE HEALTH

RHQ.010 The next series of questions are about {your/SP's} reproductive history. I will begin by asking some questions about {your/SP's} period or menstrual cycle.

How old {were you/was SP} when {you/she} had {your/her} first menstrual period?

CODE "0" IF HAVEN'T STARTED YET.

CAPI INSTRUCTION:

SOFT EDIT VALUES: 8-25 YEARS.

HARD EDIT VALUES: AGE OF 1^ST PERIOD CANNOT BE GREATER THAN CURRENT AGE.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

BOX 1

CHECK ITEM RHQ.015:

• IF PERIODS HAVEN'T STARTED (CODED '0'), GO TO END OF SECTION.

• IF PERIODS HAVE STARTED AND SP REPORTS AGE (CODED '1' - '76') IN RHQ.010, OR IF SP REFUSES AGE (CODED '77') IN RHQ.010, GO TO RHQ.031.

• OTHERWISE, CONTINUE WITH RHQ.020.

RHQ.020 {Were you/Was SP} . . .

younger than 10, 1

10 to 12, 2

13 to 15, or 3

16 or older? 4

REFUSED 7

DON'T KNOW 9

RHQ.031 {Have you/Has SP} had at least one menstrual period in the past 12 months? (Please do not include bleedings caused by medical conditions, hormone therapy, or surgeries.)

SOFT EDIT: Display edit when age of SP is greater than or equal to 60 and RHQ.031 is coded yes.

Error message:  "It is unlikely that SPs aged 60 years or older will still be menstruating.  Please verify." 

YES 1 (RHQ.131)

NO 2

REFUSED 7 (RHQ.060)

DON'T KNOW 9 (RHQ.060)

RHQ.042 What is the reason that {you have/SP has} not had a period in the past 12 months?

PREGNANCY 1 (RHQ.143)

BREAST FEEDING 2 (RHQ.143)

MENOPAUSE/HYSTERECTOMY 7

MEDICAL CONDITIONS/TREATMENTS 8

OTHER 9

REFUSED 77

DON'T KNOW 99

RHQ.060 About how old {were you/was SP} when {you/she} had {your/her} last menstrual period?

SOFT EDIT: Display edit when RHQ.060 is greater than 59.

Error message: "It is unlikely that an SP will have her last menstrual period after age 59.  Please verify."

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

BOX 2

CHECK ITEM RHQ.065:

• IF SP DOESN'T KNOW AGE AT LAST MENSTRUAL PERIOD (CODED '99') IN RHQ.060, CONTINUE WITH RHQ.070.

• OTHERWISE, GO TO RHQ.131.

RHQ.070 {Were you/Was SP} . . .

younger than 30, 1

30 to 34, 2

35 to 39, 3

40 to 44, 4

45 to 49, 5

50 to 54, or 6

55 or older? 7

REFUSED 77

DON'T KNOW 99

RHQ.131 The next questions are about {your/SP's} pregnancy history.

{Have you/Has SP} ever been pregnant? Please include (current pregnancy,) live births, miscarriages, stillbirths, tubal pregnancies and abortions.

MARK IF KNOWN. OTHERWISE ASK.

YES 1

NO 2 (BOX 12)

REFUSED 7 (BOX 12)

DON'T KNOW 9 (BOX 12)

BOX 6

CHECK ITEM RHQ.135C:

• IF SP HAD PERIOD IN PAST 12 MONTHS (CODED '1' IN RHQ.031) OR SP HAS NOT EXPERIENCED MENOPAUSE/HYSTERECTOMY (NOT CODED 7 IN RHQ.042), CONTINUE WITH RHQ.143.

• OTHERWISE, GO TO RHQ.160.

RHQ.143 {Are you/Is SP} pregnant now?

MARK IF KNOWN. OTHERWISE ASK.

YES 1

NO 2 (RHQ.160)

REFUSED 7 (RHQ.160)

DON'T KNOW 9 (RHQ.160)

RHQ.152 Which month of pregnancy {are you/is she} in?

|___|___|

ENTER NUMBER OF MONTHS

REFUSED 77

DON'T KNOW 99

RHQ.160 How many times {have you/has SP} been pregnant? ({Again, be/Be} sure to count all {your/her} pregnancies including (current pregnancy,) live births, miscarriages, stillbirths, tubal pregnancies, or abortions.)

|___|___|

ENTER NUMBER OF PREGNANCIES

REFUSED 77

DON'T KNOW 99

RHQ.162 During {any/your/SP’s} pregnancy, {were you/was SP} ever told by a doctor or other health professional that {you/she} had diabetes, sugar diabetes or gestational diabetes? Please do not include diabetes that {you/SP} may have known about before the pregnancy.

CAPI INSTRUCTION:

IF RHQ.160 = 1, DISPLAY {your/SP’s}. OTHERWISE, DISPLAY {any}.

HELP SCREEN SHOULD READ: Gestational diabetes is a form of diabetes or high blood sugar found in pregnant women.

YES 1

NO 2 (BOX 7)

BORDERLINE 3 (BOX 7)

REFUSED 7 (BOX 7)

DON'T KNOW 9 (BOX 7)

RHQ.163 How old {were you/was SP} when {you were/she was} first told {you/she} had diabetes during a pregnancy?

SOFT EDIT: IF RHQ.143 = 1 AND RHQ.160 = 1, THEN RHQ.163 must be equal to the age of the SP or the age of the SP minus 1.

Error message: “It is unlikely you were first told you had diabetes at that age since this is your first pregnancy. Please verify.”

HARD EDIT: RHQ.163 must be equal to or less than age of SP.

Error message: "Age cannot be greater than age of SP."

SOFT EDIT: RHQ.163 must be equal to or greater than 12.

Error message: "Unlikely age. Please verify."

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

BOX 7

CHECK ITEM RHQ.165:

• IF SP ONLY HAD ONE PREGNANCY (CODED '1') IN RHQ.160 AND CURRENTLY PREGNANT (CODED '1') IN RHQ.143, SKIP TO RHQ.395.

• OTHERWISE CONTINUE WITH RHQ.166.

RHQ.166 How many vaginal deliveries {have you/has SP} had? {Please count stillbirths as well as live births}

COUNT THE NUMBER OF DELIVERIES, NOT THE NUMBER OF LIVE-BORN CHILDREN. FOR EXAMPLE, IF SP DELIVERED TWINS OR HAD ANY OTHER MULTIPLE BIRTH, COUNT AS A SINGLE DELIVERY.

HARD EDIT: RHQ.166 must be equal to or less than RHQ.160.

Error message: "Number of vaginal deliveries cannot be greater than the number of pregnancies."

SOFT EDIT: IF RHQ.143 = 1, THEN RHQ.166 must be equal to or less than RHQ.160 minus 1.

Error message: "Since you are currently pregnant, it is unlikely that the number of vaginal deliveries is equal to or greater than the number of your pregnancies. Please verify."

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

BOX 7A

CHECK ITEM RHQ.168:

• IF NUMBER OF PREGNANCIES IN RHQ.160 EQUALS THE NUMBER OF VAGINAL DELIVERIES IN RHQ.166, SKIP TO RHQ.172.

• IF SP CURRENTLY PREGNANT (CODED '1') IN RHQ.143 AND THE NUMBER OF VAGINAL DELIVERIES IN RHQ.166 EQUALS THE NUMBER OF PREGNANCIES IN RHQ.160 MINUS 1, SKIP TO RHQ.172.

• OTHERWISE, CONTINUE WITH RHQ.169.

RHQ.169 How many cesarean deliveries {have you/has SP} had? (Cesarean deliveries are also known as C-sections.) (Please count stillbirths as well as live births.)

COUNT THE NUMBER OF DELIVERIES, NOT THE NUMBER OF LIVE-BORN CHILDREN. FOR EXAMPLE, IF SP DELIVERED TWINS OR HAD ANY OTHER MULTIPLE BIRTH, COUNT AS A SINGLE DELIVERY.

SOFT EDIT: Sum of RHQ166 and RHQ.169 must be equal to or less than RHQ160.

Error message: "It is unlikely that the number of deliveries (vaginal and cesarean deliveries combined) is greater than the number of pregnancies. Please verify.”

SOFT EDIT: If currently pregnant (coded '1' in RHQ143) then the sum of RHQ166 and RHQ169 should be less than or equal to RHQ160 minus 1.

Error Message: "Since SP is currently pregnant, it is unlikely that the number of vaginal and cesarean deliveries is equal to or greater than the number of pregnancies. Please verify."

HARD EDIT: RHQ.169 must be equal to or less than RHQ.160.

Error message: “Number of cesarean deliveries cannot be greater than the number of pregnancies.”

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

BOX 7B

CHECK ITEM RHQ.170A:

• IF THE NUMBER OF DELIVERIES IN RHQ.166 AND RHQ.169 EQUALS ZERO, GO TO BOX 12.

• OTHERWISE, CONTINUE WITH RHQ.172.

RHQ.172 {Did {your/SP's} delivery/Did any of {your/SP's} deliveries} result in a baby that weighed 9 pounds (4082 g) or more at birth? (Please count stillbirths as well as live births.)

CAPI INSTRUCTION:

IF SP HAD ONE DELIVERY (SUM OF RHQ.166 AND RHQ.169 = 1), DISPLAY {YOUR DELIVERY}.

IF SP HAD MORE THAN ONE DELIVERY (SUM OF RHQ.166 AND RHQ.169 > 1), DISPLAY {ANY OF YOUR DELIVERIES}.

YES 1

NO 2 (RHQ.171)

REFUSED 7 (RHQ.171)

DON'T KNOW 9 (RHQ.171)

RHQ.173 How old {were you/was SP} when {you/she} delivered a baby that weighed 9 pounds or more? (Please count stillbirths as well as live births.)

[IF MORE THAN 1 BABY WEIGHED 9 POUNDS OR MORE RECORD AGE FOR FIRST ONE]

HARD EDIT: RHQ.173 must be equal to or less than age of SP.

Error message: "Age cannot be greater than age of SP."

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

RHQ.171 How many of {your/her} deliveries resulted {Did {your/her} delivery result} in a live birth?

CAPI INSTRUCTION:

IF SP HAD ONE DELIVERY (SUM OF RHQ.166 AND RHQ.169 = 1), REPLACE {How many of {your/her} deliveries resulted} WITH {Did {your/her} delivery result}.

FOR SINGLE DELIVERIES:

Yes = 1

No = 0

COUNT THE NUMBER OF TOTAL DELIVERIES, NOT NUMBER OF LIVE-BORN CHILDREN. FOR EXAMPLE, IF SP HAD TWINS OR OTHER MULTIPLE BIRTH, COUNT AS A SINGLE DELIVERY.

|___|___|

ENTER NUMBER OF DELIVERIES

REFUSED 77

DON'T KNOW 99

BOX 8

CHECK ITEM RHQ.175:

• IF SP HAD NO DELIVERIES THAT RESULTED IN A LIVE BIRTH (CODED '0') IN RHQ.171, GO TO BOX 12.

• IF SP HAD ONE DELIVERY THAT RESULTED IN A LIVE BIRTH (CODED '1') IN RHQ.171, GO TO BOX 8A.

• OTHERWISE, CONTINUE WITH RHQ.180.

RHQ.180 How old {were you/was SP} at the time of {your/her} first live birth?

CAPI INSTRUCTION:

HARD EDIT: RHQ.180 must be equal to or less than age of SP.

Error message: "Age of SP at first delivery cannot be greater than age of SP."

|___|___| (RHQ.190)

ENTER AGE IN YEARS

REFUSED 77 (RHQ.190)

DON'T KNOW 99 (RHQ.190)

BOX 8A

CHECK ITEM RHQ.176:

• IF SP HAD ONE DELIVERY (SUM OF RHQ.166 AND RHQ.169 = 1) AND SP HAD ONE DELIVERY THAT RESULTED IN A LIVE BIRTH (CODED ‘1’) IN RHQ.171 AND SP DELIVERED ONE BABY THAT WEIGHTED 9 POUNDS OR MORE (CODED ‘1’) IN RHQ.172 AND THE DIFFERENCE BETWEEN RHQ.173 AND CURRENT AGE IS ZERO OR 1, GO TO RHQ.197.

• IF SP HAD ONE DELIVERY (SUM OF RHQ.166 AND RHQ.169 = 1) AND SP HAD ONE DELIVERY THAT RESULTED IN A LIVE BIRTH (CODED ‘1’) IN RHQ.171 AND SP DELIVERED ONE BABY THAT WEIGHTED 9 POUNDS OR MORE (CODED ‘1’) IN RHQ.172 AND THE DIFFERENCE BETWEEN RHQ.173 AND CURRENT AGE IS GREATER THAN 1, GO TO RHQ.205.

• OTHERWISE, CONTINUE WITH RHQ.190.

RHQ.190 How old {were you/was SP} at the time of {your/her} {last} live birth?

CAPI INSTRUCTION:

IF SP HAD MORE THAN 1 LIVE BIRTH (CODED >= 2) IN RHQ.171, DISPLAY {LAST}.

HARD EDIT: RHQ190 must be equal to or less than age of SP.

Error message: "Age of SP at last delivery cannot be greater than age of SP."

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

BOX 9

CHECK ITEM RHQ.195:

• IF DIFFERENCE BETWEEN AGE AT TIME OF LAST DELIVERY IN RHQ.190 AND CURRENT AGE IS ZERO OR 1, CONTINUE.

• OTHERWISE, GO TO RHQ.205.

RHQ.197 How many months ago did {you/SP} have {your/her} baby?

|___|___|___|

ENTER NUMBER OF MONTHS

REFUSED 777

DON'T KNOW 999

RHQ.200 {Are you/Is SP} now breast feeding a child?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

RHQ.205 Did {you/SP} breast feed {{your/her} child/any of {your/her} children} for at least one month?

CAPI INSTRUCTION:

IF SP HAD ONE LIVE BIRTH (CODED '1') IN RHQ.171, DISPLAY {YOUR/HER CHILD}.

IF SP HAD MORE THAN ONE LIVE BIRTH (CODED > 1) IN RHQ.171, DISPLAY {ANY OF YOUR/HER CHILDREN}.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 12

CHECK ITEM RHQ.275A:

• IF SP < 20 YEARS OLD, GO TO RHQ.420.

• IF SP CURRENTLY PREGNANT (CODED '1') IN RHQ.143, GO TO RHQ.395.

• IF SP HAD PERIOD IN PAST 12 MONTHS (CODED '1' IN RHQ.031), GO TO RHQ.282.

• OTHERWISE, CONTINUE WITH RHQ.282.

RHQ.282 {Have you/Has SP} had a hysterectomy, including a partial hysterectomy, that is, surgery to remove {your/her} uterus or womb?

MARK IF KNOWN. OTHERWISE ASK.

YES 1

NO 2 (RHQ.305)

REFUSED 7 (RHQ.305)

DON'T KNOW 9 (RHQ.305)

RHQ.291 How old {were you/was SP} when {you/she} had {your/her} (hysterectomy/uterus removed/womb removed)?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

RHQ.305 {Have you/Has SP} had both of {your/her} ovaries removed (either when {you/she} had {your/her} uterus removed or at another time)?

YES 1

NO 2 (RHQ.395)

REFUSED 7 (RHQ.395)

DON'T KNOW 9 (RHQ.395)

RHQ.332 How old {were you/was SP} when {you/she} had {your/her} ovaries removed or last ovary removed if removed at different times?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

RHQ.395 {Do you/Does SP} experience bulging or something falling out that {you/she} can see or feel in the vaginal area?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

RHQ.420 Now I am going to ask you about {your/SP's} birth control history.

{Have you/Has SP} ever taken birth control pills for any reason?

YES 1

NO 2 (RHQ.510)

REFUSED 7 (RHQ.510)

DON'T KNOW 9 (RHQ.510)

BOX 18

CHECK ITEM RHQ.435B:

• IF SP < 20 YEARS OLD AND IF SP IS NOT PREGNANT (CODED ‘2’, ‘7’, ‘9’ OR MISSING IN RHQ.143), CONTINUE WITH RHQ.442.

• IF SP >= 20 YEARS OLD AND IF SP IS NOT PREGNANT (CODED ‘2’, ‘7’, ‘9’ OR MISSING IN RHQ.143) AND IF SP HAS NOT HAD HYSTERECTOMY (CODED ‘2’, ‘7’, ‘9’ OR MISSING IN RHQ.282) AND IF SP HAS NOT HAD BOTH HER OVARIES REMOVED (CODED ‘2’, ‘7’, ‘9’ IN RHQ.305) AND IF SP IS NOT MENOPAUSAL (CODED ‘1’, ‘2’, ‘8’, ‘9’, ‘77’, ‘99’ OR MISSING IN RHQ.042), CONTINUE WITH RHQ.442.

• OTHERWISE, GO TO RHQ.460.

RHQ.442 {Are you/Is SP} taking birth control pills now?

YES 1

NO 2

REFUSED 7 (RHQ.510)

DON'T KNOW 9 (RHQ.510)

RHQ.460 Q/U

Not counting any time when {you/SP} stopped taking them, for how long altogether {have you taken/did you take/has she taken/did she take} birth control pills?

CODE "1" FOR LESS THAN ONE MONTH.

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

ENTER UNIT

MONTHS 1

YEARS 2

REFUSED 7

DON'T KNOW 9

RHQ.510 {Have you/Has SP} ever used Depo-Provera or injectables to prevent pregnancy?

YES 1

NO 2 (BOX 20)

REFUSED 7 (BOX 20)

DON'T KNOW 9 (BOX 20)

BOX 19

CHECK ITEM RHQ.519:

• IF SP < 20 YEARS OLD AND IF SP IS NOT PREGNANT (CODED ‘2’, ‘7’, ‘9’ OR MISSING IN RHQ.143), CONTINUE WITH RHQ.520.

• IF SP >= 20 YEARS OLD AND IF SP IS NOT PREGNANT (CODED ‘2’, ‘7’, ‘9’ OR MISSING IN RHQ.143) AND IF SP HAS NOT HAD HYSTERECTOMY (CODED ‘2’, ‘7’, ‘9’ OR MISSING IN RHQ.282) AND IF SP HAS NOT HAD BOTH HER OVARIES REMOVED (CODED ‘2’, ‘7’, ‘9’ IN RHQ.305) AND IF SP IS NOT MENOPAUSAL (CODED ‘1’, ‘2’, ‘8’, ‘9’, ‘77’, ‘99’ OR MISSING IN RHQ.042), CONTINUE WITH RHQ.520.

• OTHERWISE, GO TO BOX 20.

RHQ.520 {Are you/Is SP} now using Depo-Provera or injectables to prevent pregnancy?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 20

CHECK ITEM RHQ.535:

• IF SP 20 YEARS OF AGE OR OLDER, CONTINUE WITH RHQ.540.

• OTHERWISE, SKIP TO BOX 24.

RHQ.540 {Have you/Has SP} ever used female hormones such as estrogen and progesterone? Please include any forms of female hormones, such as pills, cream, patch, and injectables, but do not include birth control methods or use for infertility.

YES 1

NO 2 (BOX 24)

REFUSED 7 (BOX 24)

DON'T KNOW 9 (BOX 24)

RHQ.541 Which forms of female hormones {have you/has SP} used?

CODE ALL THAT APPLY

PILLS 10

PATCHES 11

CREAM/SUPPOSITORY/INJECTION 12

REFUSED 77

DON'T KNOW 99

BOX 21

CHECK ITEM RHQ.552:

IF SP USED FEMALE HORMONE PILLS (CODE '10') IN RHQ.541, CONTINUE WITH RHQ.554.

OTHERWISE, GO TO BOX 22.

RHQ.554 {Have you/Has SP} ever taken female hormone pills containing estrogen only (like Premarin)? (Do not include birth control pills.)

YES 1

NO 2 (RHQ.562)

REFUSED 7 (RHQ.562)

DON'T KNOW 9 (RHQ.562)

RHQ.558 {Are you/Is SP} taking pills containing estrogen only now?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

RHQ.560 Q/U

Not counting any time when {you/SP} stopped taking them, for how long altogether {have you taken/did you take/has she taken/did she take} pills containing estrogen only?

CODE "1" FOR LESS THAN 1 MONTH

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

ENTER UNIT

MONTHS 1

YEARS 2

REFUSED 7

DON'T KNOW 9

RHQ.562 {Have you/Has SP} taken female hormone pills containing progestin only (like Provera)? (Do not include birth control pills.)

YES 1

NO 2 (RHQ.570)

REFUSED 7 (RHQ.570)

DON'T KNOW 9 (RHQ.570)

RHQ.566 {Are you/Is SP} taking pills containing progestin only now?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

RHQ.568 Q/U

Not counting any time when {you/SP} stopped taking them, for how long altogether {have you taken/did you take/has she taken/did she take} pills containing progestin only?

CODE "1" FOR LESS THAN 1 MONTH

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

ENTER UNIT

MONTHS 1

YEARS 2

REFUSED 7

DON'T KNOW 9

RHQ.570 {Have you/Has SP} taken female hormone pills containing both estrogen and progestin (like Prempro, Premphase)? (Do not include birth control pills.)

YES 1

NO 2 (BOX 22)

REFUSED 7 (BOX 22)

DON'T KNOW 9 (BOX 22)

RHQ.574 {Are you/Is SP} taking pills containing both estrogen and progestin now?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

RHQ.576 Q/U

Not counting any time when {you/SP} stopped taking them, for how long altogether {have you taken/did you take/has she taken/did she take} pills containing both estrogen and progestin?

CODE "1" FOR LESS THAN 1 MONTH

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

ENTER UNIT

MONTHS 1

YEARS 2

REFUSED 7

DON'T KNOW 9

BOX 22

CHECK ITEM RHQ.578:

IF SP USED PATCHES (CODE '11') IN RHQ.541, CONTINUE WITH RHQ.580.

OTHERWISE, GO TO BOX 24.

RHQ.580 {Have you/Has SP} ever used female hormone patches containing estrogen only?

YES 1

NO 2 (RHQ.596)

REFUSED 7 (RHQ.596)

DON'T KNOW 9 (RHQ.596)

RHQ.584 {Are you/Is SP} using patches containing estrogen only now?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

RHQ.586 Q/U

Not counting any time when {you/SP} stopped using them, for how long altogether {have you used/did you use/has she used/did she use} patches containing estrogen only?

CODE "1" FOR LESS THAN 1 MONTH

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

ENTER UNIT

MONTHS 1

YEARS 2

REFUSED 7

DON'T KNOW 9

RHQ.596 {Have you/Has SP} used female hormone patches containing both estrogen and progestin?

YES 1

NO 2 (BOX 24)

REFUSED 7 (BOX 24)

DON'T KNOW 9 (BOX 24)

RHQ.600 {Are you/Is SP} using patches containing both estrogen and progestin now?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

RHQ.602 Q/U

Not counting any time when {you/SP} stopped using them, for how long altogether {have you used/did you use/has she used/did she use} patches containing both estrogen and progestin?

CODE "1" FOR LESS THAN 1 MONTH

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

ENTER UNIT

MONTHS 1

YEARS 2

REFUSED 7

DON'T KNOW 9

BOX 24

CHECK ITEM RHQ.640A:

• IF SP CURRENTLY PREGNANT (CODED '1') IN RHQ.143, CONTINUE WITH FSQ.652.

• IF RHQ.190 IS FILLED AND THE AGE DIFFERENCE BETWEEN SP'S CURRENT AGE AND AGE IN RHQ.190 IS ZERO, 1, OR 2, CONTINUE WITH FSQ.652 ELSE IF RHQ190 IS EMPTY AND RHQ.173 IS FILLED AND THE AGE DIFFERENCE BETWEEN SP'S CURRENT AGE AND AGE IN RHQ.173 IS ZERO, 1, OR 2, CONTINUE WITH FSQ.652

• OTHERWISE, GO TO END OF SECTION.

FSQ.652 These next questions are about participation in programs for women with young children.

Did {you/SP} personally receive benefits from WIC, that is, the Women, Infants, and Children Program, in the past 12 months?

YES 1

NO 2 (GO TO END OF SECTION)

REFUSED 7 (GO TO END OF SECTION)

DON'T KNOW 9 (GO TO END OF SECTION)

BOX 26

CHECK ITEM RHQ.641:

• IF CODED ‘1-12’ IN RHQ.197, CONTINUE WITH FSQ.661.

• IF SP CURRENTLY PREGNANT (CODED '1') IN RHQ.143, CONTINUE WITH FSQ.661.

• OTHERWISE, GO TO END OF SECTION.

FSQ.661 {Are you/Is SP} now receiving benefits from the WIC Program?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

FSQ.671 Q/U

Thinking about {your/SP’s} {pregnancy/recent pregnancy/most recent pregnancy/most recent pregnancies}, how long {did you receive/have you been receiving/did she receive/has she been receiving} benefits from the WIC Program?

PROBE: We want to know about benefits meant just for {you/SP} that {you/SP} received for {your/her} {current pregnancy/child/last child/last child and during {your/her} current pregnancy}.

CAPI INSTRUCTION:

IF RHQ.143 = 1 AND RHQ.160 = 1, DISPLAY {PREGNANCY}.

IF RHQ.143 = 1 AND RHQ.160 DOES NOT EQUAL 1 AND RHQ.190 IS FILLED AND THE DIFFERENCE BETWEEN AGE AT TIME OF LAST DELIVERY IN RHQ.190 AND CURRENT AGE IS GREATER THAN 1, DISPLAY {PREGNANCY}.

IF RHQ.143 = 1 AND RHQ.160 DOES NOT EQUAL 1 AND RHQ.190 IS EMPTY AND RHQ.173 IS FILLED AND THE DIFFERENCE BETWEEN RHQ.173 AND CURRENT AGE IS GREATER THAN 1, DISPLAY {PREGNANCY}.

IF RHQ.197 = 1 - 12 AND RHQ.143 DOES NOT EQUAL 1 AND RHQ.160 = 1, DISPLAY {RECENT PREGNANCY}.

IF RHQ.197 = 1 - 12 AND RHQ.143 DOES NOT EQUAL 1 AND RHQ.160 IS GREATER THAN 1, DISPLAY {MOST RECENT PREGNANCY}.

OTHERWISE, DISPLAY {MOST RECENT PREGNANCIES}.

IF SP CURRENTLY RECEIVING WIC BENEFITS (CODED '1') IN FSQ.661, DISPLAY {HAVE YOU BEEN RECEIVING/HAS SHE BEEN RECEIVING}.

OTHERWISE, DISPLAY {DID YOU RECEIVE/DID SHE RECEIVE}.

IF RHQ.143 = 1 AND RHQ.160 = 1, DISPLAY {CURRENT PREGNANCY}.

IF RHQ.143 = 1 AND RHQ.160 DOES NOT EQUAL 1 AND RHQ.190 IS FILLED AND THE DIFFERENCE BETWEEN AGE AT TIME OF LAST DELIVERY IN RHQ.190 AND CURRENT AGE IS GREATER THAN 1, DISPLAY {CURRENT PREGNANCY}.

IF RHQ.143 = 1 AND RHQ.160 DOES NOT EQUAL 1 AND RHQ.190 IS EMPTY AND RHQ.173 IS FILLED AND THE DIFFERENCE BETWEEN RHQ.173 AND CURRENT AGE IS GREATER THAN 1, DISPLAY {CURRENT PREGNANCY}.

IF RHQ.197 = 1 - 12 AND RHQ.143 DOES NOT EQUAL 1 AND RHQ.160 = 1, DISPLAY {CHILD}.

IF RHQ.197 = 1 - 12 AND RHQ.143 DOES NOT EQUAL 1 AND RHQ.160 IS GREATER THAN 1, DISPLAY {LAST CHILD}.

OTHERWISE, DISPLAY {LAST CHILD AND DURING {YOUR/HER} CURRENT PREGNANCY}.

SOFT EDIT: FSQ.671 must be equal to or less than 24 months or 2 years.

Error message: Unlikely response. Please verify.

|___|___|

ENTER QUANTITY

REFUSED 77

DON'T KNOW 99

ENTER UNIT

MONTHS 1

YEARS 2

REFUSED 7

DON'T KNOW 9

KIDNEY CONDITIONS

KIQ.005 Many people have leakage of urine. The next few questions ask about urine leakage.

How often {do you/does SP} have urinary leakage? Would {you/s/he} say . . .

CAPI INSTRUCTION:

HELP SCREEN: Other terms for urinary leakage are not being able to hold your urine until you can reach a toilet, not being able to control your bladder, loss of urine control.

never, 1 (KIQ.042)

less than once a month, 2

a few times a month, 3

a few times a week, or 4

every day and/or night? 5

REFUSED 7 (KIQ.042)

DON’T KNOW 9 (KIQ.042)

KIQ.010 How much urine {do you/does SP} lose each time? Would {you/s/he} say . . .

drops, 1

small splashes, or 2

more? 3

REFUSED 7

DON’T KNOW 9

KIQ.042 During the past 12 months, {have you/has SP} leaked or lost control of even a small amount of urine with an activity like coughing, lifting or exercise?

YES 1

NO 2 (KIQ.044)

REFUSED 7 (KIQ.044)

DON’T KNOW 9 (KIQ.044)

KIQ.430 How frequently does this occur? Would {you/s/he} say this occurs . . .

less than once a month, 1

a few times a month, 2

a few times a week, or 3

every day and/or night? 4

REFUSED 7

DON’T KNOW 9

KIQ.044 During the past 12 months, {have you/has SP} leaked or lost control of even a small amount of urine with an urge or pressure to urinate and {you/s/he} couldn’t get to the toilet fast enough?

YES 1

NO 2 (KIQ.046)

REFUSED 7 (KIQ.046)

DON’T KNOW 9 (KIQ.046)

KIQ.450 How frequently does this occur? Would {you/s/he} say this occurs. . .

less than once a month, 1

a few times a month, 2

a few times a week, or 3

every day and/or night? 4

REFUSED 7

DON’T KNOW 9

KIQ.046 During the past 12 months, {have you/has SP} leaked or lost control of even a small amount of urine without an activity like coughing, lifting, or exercise, or an urge to urinate?

YES 1

NO 2 (BOX 1)

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

KIQ.470 How frequently does this occur? Would {you/s/he} say this occurs . . .

less than once a month, 1

a few times a month, 2

a few times a week, or 3

every day and/or night? 4

REFUSED 7

DON’T KNOW 9

BOX 1

CHECK ITEM KIQ.048A:

• IF 'YES' (CODED '1') IN KIQ.042 OR KIQ.044 OR KIQ.046, CONTINUE WITH KIQ.050.

• OTHERWISE, GO TO KIQ.480.

KIQ.050 During the past 12 months, how much did {your/her/his} leakage of urine bother {you/her/him}? Please select one of the following choices:

not at all, 1

only a little, 2

somewhat, 3

very much, or 4

greatly? 5

REFUSED 7

DON'T KNOW 9

KIQ.052 During the past 12 months, how much did {your/his/her} leakage of urine affect {your/his/her} day-to-day activities? (Please select one of the following choices:)

not at all, 1

only a little, 2

somewhat, 3

very much, or 4

greatly? 5

REFUSED 7

DON'T KNOW 9

KIQ.480 During the past 30 days, how many times per night did {you/SP} most typically get up to urinate, from the time {you/s/he} went to bed at night until the time {you/he/she} got up in the morning. Would {you/s/he} say . . .

0, 0

1, 1

2, 2

3, 3

4, 4

5 or more? 5

REFUSED 77

DON'T KNOW 99

BOWEL health

BOX 1

CHECK ITEM BHQ.005:

• IF INTERVIEW DONE ONLY WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), CONTINUE WITH BHQ.010.

• OTHERWISE, GO TO NEXT SECTION.

BHQ.010 Next, we’d like to talk to you about bowel health. We’ll start with accidental bowel leakage. There are four types of bowel leakage that can happen: leakage (passing) of gas, leakage of mucus, leakage of liquid stool, and leakage of solid stool. We will ask you about leakage of each of these one at a time.

How often during the past 30 days have you had any amount of accidental bowel leakage that consisted of gas? Would you say . . .

HAND CARD BHQ1

CAPI INSTRUCTION:

HELP SCREEN SHOULD READ: The bowel is another name for the intestines. Other names for the bowel include guts or innards. Accidental bowel leakage is leaking from the bowel or intestines that can’t be controlled. Leakage of gas is also called passing gas, passing wind, or farting.

2 or more times a day, 1

once a day, 2

2 or more times a week, 3

once a week, 4

1-3 times a month, or 5

never? 6

REFUSED 77

DON'T KNOW 99

BHQ.020 How often during the past 30 days have you had any amount of accidental bowel leakage that consisted of mucus?

HAND CARD BHQ1

CAPI INSTRUCTION:

HELP SCREEN SHOULD READ: Mucus is a thick, jelly-like substance made by the intestines that helps coat and protect the lining of the intestine. Mucus also helps stool pass through the large intestine and rectum more easily.

2 OR MORE TIMES A DAY 1

ONCE A DAY 2

2 OR MORE TIMES A WEEK 3

ONCE A WEEK 4

1-3 TIMES A MONTH 5

NEVER 6

REFUSED 77

DON'T KNOW 99

BHQ.030 How often during the past 30 days have you had any amount of accidental bowel leakage that consisted of liquid stool?

HAND CARD BHQ1

CAPI INSTRUCTION:

HELP SCREEN SHOULD READ: Stool is also called a bowel movement, BM, or poop.

2 OR MORE TIMES A DAY 1

ONCE A DAY 2

2 OR MORE TIMES A WEEK 3

ONCE A WEEK 4

1-3 TIMES A MONTH 5

NEVER 6

REFUSED 77

DON'T KNOW 99

BHQ.040 How often during the past 30 days have you had any amount of accidental bowel leakage that consisted of solid stool?

HAND CARD BHQ1

2 OR MORE TIMES A DAY 1

ONCE A DAY 2

2 OR MORE TIMES A WEEK 3

ONCE A WEEK 4

1-3 TIMES A MONTH 5

NEVER 6

REFUSED 77

DON'T KNOW 99

BHQ.050 How often do you usually have bowel movements?

Q/U

PROBE: How many times per day or per week do you usually have a bowel movement?

|___|___|

ENTER NUMBER OF TIMES (PER DAY OR PER WEEK)

REFUSED 77

DON'T KNOW 99

ENTER UNIT

DAY 1

WEEK 2

REFUSED 7

DON’T KNOW 9

BHQ.060 Please look at this card and tell me the number that corresponds to your usual or most common stool type.

HAND CARD BHQ2

TYPE 1 (SEPARATE HARD LUMPS, LIKE
NUTS) 1

TYPE 2 (SAUSAGE-LIKE, BUT LUMPY) 2

TYPE 3 (LIKE A SAUSAGE BUT WITH
CRACKS IN THE SURFACE) 3

TYPE 4 (LIKE A SAUSAGE OR SNAKE,
SMOOTH AND SOFT) 4

TYPE 5 (SOFT BLOBS WITH CLEAR-CUT
EDGES) 5

TYPE 6 (FLUFFY PIECES WITH RAGGED
EDGES, A MUSHY STOOL) 6

TYPE 7 (WATERY, NO SOLID PIECES) 7

REFUSED 77

DON'T KNOW 99

BHQ.070 During the past 12 months, how often have you had an urgent need to empty your bowels that makes you rush to the toilet? Would you say…

HAND CARD BHQ3

always, 1

most of the time, 2

sometimes, 3

rarely, or 4

never? 5

REFUSED 77

DON'T KNOW 99

BHQ.080 During the past 12 months, how often have you been constipated? Would you say…

HAND CARD BHQ3

always 1

most of the time 2

sometimes 3

rarely 4

never 5

REFUSED 77

DON'T KNOW 99

BHQ.090 During the past 12 months, how often have you had diarrhea? Would you say…

HAND CARD BHQ3

always 1

most of the time 2

sometimes 3

rarely 4

never 5

REFUSED 77

DON'T KNOW 99

BHQ.100 In the past 30 days, did you take any laxatives or stool softeners, such as Ex-Lax, Metamucil or Fiberall, to help move your bowels?

Yes 1

NO 2 (End of section)

REFUSED 77 (End of section)

DON'T KNOW 99 (End of section)

BHQ.110 How many times have you taken laxatives or stool softeners in the past 30 days? Would you say…

most days, 1

1-3 times a week, 2

2-3 times a month, or 3

once a month? 4

REFUSED 77

DON'T KNOW 99

physical activity AND PHYSICAL FITNESS

PAQ.605 Next I am going to ask you about the time {you spend/SP spends} doing different types of physical activity in a typical week.

Think first about the time {you spend/SP spends} doing work. Think of work as the things that {you have/SP has} to do such as paid or unpaid work, household chores, and yard work.

Does {your/SP’s} work involve vigorous-intensity activity that causes large increases in breathing or heart rate like carrying or lifting heavy loads, digging or construction work for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.620)

REFUSED 7 (PAQ.620)

DON’T KNOW 9 (PAQ.620)

PAQ.610 In a typical week, on how many days {do you/does SP} do vigorous-intensity activities as part of {your/his/her} work?

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: Less than 1 day or more than 7 days

Error Message: The number of days should be between 1 and 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.620)

DON’T KNOW 99 (PAQ.620)

PAQ.615 How much time {do you/does SP} spend doing vigorous–intensity activities at work on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when you do vigorous-intensity activities during your work.

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

SOFT EDIT: >4 hours.

Error Message: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING VIGOROUS-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: Less than 10 minutes or 24 hours or more.

Error Message: The time should be 10 minutes or more, but less than 24 hours.

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

REFUSED 777

DON’T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON’T KNOW 9

PAQ.620 Does {your/SP’s} work involve moderate-intensity activity that causes small increases in breathing or heart rate such as brisk walking or carrying light loads for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.635)

REFUSED 7 (PAQ.635)

DON’T KNOW 9 (PAQ.635)

PAQ.625 In a typical week, on how many days {do you/does SP} do moderate-intensity activities as part of {your/his/her} work?

PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: Less than 1 day or more than 7 days

Error Message: The number of days should be between 1 and 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.635)

DON’T KNOW 99 (PAQ.635)

PAQ.630 How much time {do you/does SP} spend doing moderate-intensity activities at work on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when you do moderate-intensity activities during your work.

PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.

SOFT EDIT: >4 hours.

Error Message: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING MODERATE-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: Less than 10 minutes or 24 hours or more.

Error Message: The time should be 10 minutes or more, but less than 24 hours.

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

REFUSED 777

DON’T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON’T KNOW 9

PAQ.635 The next questions exclude the physical activities at work that you have already mentioned. Now I would like to ask you about the usual way {you travel/SP travels} to and from places. For example to school, for shopping, to work.

{Do you/Does SP} walk or use a bicycle for at least 10 minutes continuously to get to and from places?

YES 1

NO 2 (PAQ.650)

REFUSED 7 (PAQ.650)

DON’T KNOW 9 (PAQ.650)

PAQ.640 In a typical week, on how many days {do you/does SP} walk or bicycle for at least 10 minutes continuously to get to and from places?

HARD EDIT: Less than 1 day or more than 7 days

Error Message: The number of days should be between 1 and 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.650)

DON’T KNOW 99 (PAQ.650)

PAQ.645 How much time {do you/does SP} spend walking or bicycling for travel on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when you walk or bicycle for travel.

SOFT EDIT: >4 hours.

Error Message: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS WALKING OR BICYCLING TO GET TO AND FROM PLACES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: Less than 10 minutes or 24 hours or more.

Error Message: The time should be 10 minutes or more, but less than 24 hours.

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

REFUSED 777

DON’T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON’T KNOW 9

PAQ.650 The next questions exclude the work and transport activities that you have already mentioned. Now I would like to ask you about sports, fitness and recreational activities.

{Do you/Does SP} do any vigorous-intensity sports, fitness, or recreational activities that cause large increases in breathing or heart rate like running or basketball for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.665)

REFUSED 7 (PAQ.665)

DON’T KNOW 9 (PAQ.665)

PAQ.655 In a typical week, on how many days {do you/does SP} do vigorous-intensity sports, fitness or recreational activities?

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: Less than 1 day or more than 7 days

Error Message: The number of days should be between 1 and 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.665)

DON’T KNOW 99 (PAQ.665)

PAQ.660 Q/U

How much time {do you/does SP} spend doing vigorous-intensity sports, fitness or recreational activities on a typical day?

PROBE IF NEEDED: Think about a typical day when you do vigorous-intensity sports, fitness or recreational activities.

SOFT EDIT: >4 hours.

Error Message: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING VIGOROUS-INTENSITY RECREATIONAL ACTIVITIES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: Less than 10 minutes or 24 hours or more.

Error Message: The time should be 10 minutes or more, but less than 24 hours.

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

REFUSED 777

DON’T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON’T KNOW 9

PAQ.665 {Do you/Does SP} do any moderate-intensity sports, fitness, or recreational activities that cause a small increase in breathing or heart rate such as brisk walking, bicycling, swimming, or volleyball for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.680Q)

REFUSED 7 (PAQ.680Q)

DON’T KNOW 9 (PAQ.680Q)

PAQ.670 In a typical week, on how many days {do you/does SP} do moderate-intensity sports, fitness or recreational activities?

PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: Less than 1 day or more than 7 days

Error Message: The number of days should be between 1 and 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.680Q)

DON’T KNOW 99 (PAQ.680Q)

PAQ.675 Q/U

How much time {do you/does SP} spend doing moderate–intensity sports, fitness or recreational activities on a typical day?

PROBE IF NEEDED: Think about a typical day when you do moderate-intensity sports, fitness or recreational activities.

PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.

SOFT EDIT: >4 hours.

Error Message: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING MODERATE-INTENSITY RECREATIONAL ACTIVITIES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: Less than 10 minutes or 24 hours or more.

Error Message: The time should be 10 minutes or more, but less than 24 hours.

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

REFUSED 777

DON’T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON’T KNOW 9

PAQ.680 Q/U

The following question is about sitting at school, at home, getting to and from places, or with friends including time spent sitting at a desk, traveling in a car or bus, reading, playing cards, watching television, or using a computer. Do not include time spent sleeping.

How much time {do you/does SP} usually spend sitting on a typical day?

SOFT EDIT: 18 hours or more.

Error Message: Please verify times of 18 hours or more.

HARD EDIT: 24 hours or more.

Error Message: The time should be less than 24 hours.

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

REFUSED 777

DON’T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON’T KNOW 9

WEIGHT HISTORY

BOX 1

CHECK ITEM WHQ.499:

• IF INTERVIEW DONE ONLY WITH SURVEY PARTICIPANT (CODED ‘1’) IN RIQ.005 AND NO INTERPRETER USED (RIQ.090 CODED ‘2’), CONTINUE WITH WHQ.030c.

• IF INTERVIEW DONE WITH SURVEY PARTICIPANT (CODED ‘1’) IN RIQ.005 AND INTERPRETER USED (RIQ.090 CODED ‘1’), AND PAID INTERPRETER (CODED ‘3’) IN RIQ.100, CONTINUE WITH WHQ.030c.

• OTHERWISE, GO TO NEXT SECTION.

WHQ.030c Do you consider yourself now to be . . .

fat or overweight, 1

too thin, or 2

about the right weight? 3

REFUSED 7

DON’T KNOW 9

WHQ.500 Which of the following are you trying to do about your weight:

lose weight, 1

gain weight, 2 (WHQ.520)

stay the same weight, or. 3 (WHQ.520)

not trying to do anything about your weight? 4 (WHQ.520)

REFUSED 7 (WHQ.520)

DON’T KNOW 9 (WHQ.520)

WHQ.511 Why are you trying to lose weight? (Check all that apply)

HAND CARD WHQ1 [CATEGORIES 22, 23, AND 24 APPEAR ON INTERVIEWER’S SCREEN ONLY]

I WANT TO LOOK BETTER 10

I WANT TO BE HEALTHIER 11

I WANT TO BE BETTER AT SPORTS AND

OTHER PHYSICAL ACTIVITIES 12

I GET TEASED ABOUT MY WEIGHT 13

I THINK MY CLOTHES WILL FIT BETTER 14

I THINK BOYS WILL LIKE ME BETTER 15

I THINK GIRLS WILL LIKE ME BETTER 16

MY FRIENDS ARE TRYING TO LOSE

WEIGHT 17

SOMEONE IN MY FAMILY IS TRYING TO

LOSE WEIGHT 18

MY MOTHER OR FATHER WANTS ME

TO LOSE WEIGHT 19

MY TEACHER OR COACH WANTS

ME TO LOSE WEIGHT 20

A DOCTOR, NURSE, OR OTHER HEALTH

PROFESSIONAL WANTS ME TO LOSE

WEIGHT 21
I DON’T WANT TO BE FAT 22

I WANT TO BE SKINNY 23

I WANT TO FEEL GOOD/BETTER ABOUT

MYSELF 24

OTHER (SPECIFY) 30

REFUSED 77

DON’T KNOW 99

WHQ.520 In the past year, how often have you tried to lose weight? Would you say . . .

never, 1 (BOX 2)

sometimes, or 2

a lot? 3

REFUSED 7

DON’T KNOW 9

WHQ.530 In the past year, how often have you been on a diet to lose weight? Would you say . . .

never, 1

sometimes, or 2

a lot? 3

REFUSED 7

DON’T KNOW 9

WHQ.540 In the past year, how often have you gone without eating for a day or more (starved) to lose weight? Would you say . . .

never, 1

sometimes, or 2

a lot? 3

REFUSED 7

DON’T KNOW 9

WHQ.550 In the past year, how often have you cut back on what you ate to lose weight? Would you say . . .

never, 1

sometimes, or 2

a lot? 3

REFUSED 7

DON’T KNOW 9

WHQ.560 In the past year, how often have you skipped meals to lose weight? Would you say . . .

never, 1

sometimes, or 2

a lot? 3

REFUSED 7

DON’T KNOW 9

WHQ.570 In the past year, how often have you exercised to lose weight? Would you say . . .

never, 1

sometimes, or 2

a lot? 3

REFUSED 7

DON’T KNOW 9

WHQ.580 In the past year, how often have you eaten less sweets or fatty foods to lose weight? Would you say . . .

never, 1

sometimes, or 2

a lot? 3

REFUSED 7

DON’T KNOW 9

BOX 2

CHECK ITEM WHQ.709:

• IF SP AGE >= 12, CONTINUE.

• OTHERWISE, GO TO END OF SECTION.

DBQ.895 G/Q

Next, I’m going to ask you about meals. By meal, I mean breakfast, lunch and dinner. During the past 7 days, how many meals did you get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines? Please do not include meals provided as part of the school lunch or school breakfast.

SOFT EDIT VALUES: 0-21

Error message: “Please verify that you ate more than 3 meals prepared away from home every day during the past 7 days.”

|___|___|

ENTER NUMBER

NONE 2 (DBQ.905)

REFUSED 77 (DBQ.905)

DON'T KNOW 99 (DBQ.905)

DBQ.900 How many of those meals did you get from a fast-food or pizza place?

G/Q

HARD EDIT: “DBQ.900 must be equal to or less than DBQ.895.”

Error message: "The number of meals from a fast-food or pizza place cannot be greater than the total number of meals you had that were prepared away from home. Could I have another answer please?"

|___|___|

ENTER NUMBER

NONE 2

REFUSED 77

DON'T KNOW 99

DBQ.905 G/Q/U

Some grocery stores sell “ready to eat” foods such as salads, soups, chicken, sandwiches and cooked vegetables in their salad bars and deli counters.

During the past 30 days, how often did you buy “ready to eat” foods at the grocery store? Please do not count frozen or canned foods.

|___|___|

ENTER NUMBER OF TIMES (PER DAY, WEEK, OR MONTH)

NEVER 2

REFUSED 77

DON’T KNOW 99

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

DBQ.910 G/Q/U

During the past 30 days, how often did you eat frozen meals or frozen pizzas? Here are some examples of frozen meals and frozen pizzas.

HAND CARD WHQ2

|___|___|

ENTER OF TIMES (PER DAY, WEEK, OR MONTH)

NEVER 2

REFUSED 77

DON’T KNOW 99

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

MEC Interview Critical Data Items

Verify Street Address

SCQ.070 I would like to verify {your/SP’s} address. Please give me {your/SP’s} complete address.

SCQ.420 Is {your/SP’s} mailing address the same as {your/SP’s} street address?

Validation Form Q7 Did {you/he/she} live at this address on {SCREENER DISPOSITION DATE}?

Verify Mailing Address

In case we have to contact {you/SP} again, please give me {your/his/her} complete mailing address.

Verify Phone Numbers

Please give me {your/SP’s} home telephone number.

Is there another number where {you/SP} can be reached? Where is that phone

located?

Verify SSN

DMQ.280a We also need {your/SP’s} Social Security Number. The Department of Health and Human Services will use {your/his/her} Social Security Number to conduct health-related research by linking {your/his/her} survey data with vital statistics and other records, such as health registries. We may also use it if we need to recontact {you/him/her} or {your/his/her} family. Except for these purposes, the Department will not release {your/his/her} SSN to anyone, including any government agency. Providing this information is voluntary and is collected under the authority of the Public Health Service Act. There will be no effect on {your/his/her} benefits if you do not provide it. [Public Health Service Act is title 42, United States Code, section 242k.]

DMQ.280b What is {your/SP’s} Social Security Number?

MEC QUESTIONNAIRE – ACASI

I

Note: The following is the method for coding response categories Refused and Don’t Know in ACASI.

1. These categories are not on the screen when the question is read.

2. If a question isn’t answered the following screen appears:

“You did not answer the previous question.

1. Did you mean to answer………………………….QUESTION REPEATED

2. would you prefer not to answer the question…..REFUSED RESPONSE CODED

3. or don’t you know the answer?..........................DON’T KNOW RESPONSE CODED

ntroduction

FOOD SECURITY

BOX 1

CHECK ITEM FSQ.699:

• IF ANY OF ITEMS FSQ.032a – FSQ.032f FROM THE HOUSEHOLD INTERVIEW ARE CODED ‘1’, ‘2’, ‘7’, OR ‘9’, CONTINUE WITH FSQ.700.

• OTHERWISE, GO TO END OF SECTION.

FSQ.700_ The next questions are about the food situation in your home during the last 30 days.

FSQ.700 In the last 30 days, was the size of your meals cut because your family didn’t have enough money for food?

INSTRUCTIONS TO SP:

Please select one of the following choices.

A lot 1

Sometimes 2

Never 3

REFUSED 77

DON’T KNOW 99

FSQ.710 In the last 30 days, did you eat less than you thought you should because your family didn’t have enough money for food?

INSTRUCTIONS TO SP:

Please select one of the following choices.

A lot 1

Sometimes 2

Never 3

REFUSED 77

DON’T KNOW 99

FSQ.720 In the last 30 days, were you hungry but didn’t eat because your family didn’t have enough food?

INSTRUCTIONS TO SP:

Please select one of the following choices.

A lot 1

Sometimes 2

Never 3

REFUSED 77

DON’T KNOW 99

FSQ.730 In the last 30 days, did you skip a meal because your family didn’t have enough money for food?

INSTRUCTIONS TO SP:

Please select one of the following choices.

A lot 1

Sometimes 2

Never 3

REFUSED 77

DON’T KNOW 99

New BOX 1

IF (FSQ700 OR FSQ710 OR FSQ720 OR FSQ730= 1 OR 2), CONTINUE; OTHERWISE, GO TO THE END OF THE SECTION.

FSQ.740 In the last 30 days, did you not eat for a whole day because your family didn’t have enough money for food?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Sometimes 1

Once or twice 2

Never 3

REFUSED 77

DON’T KNOW 99

TOBACCO

SMQ.620_ The following questions are about cigarette smoking and other tobacco use.

SMQ.620 Have you ever tried cigarette smoking, even 1 or 2 puffs?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (SMQ.680)

REFUSED 7 (SMQ.680)

DON'T KNOW 9 (SMQ.680)

SMQ.630 How old were you when you smoked a whole cigarette for the first time?

SMQ.630a

INSTRUCTIONS TO SP:

Please enter an age or select zero for never smoked a whole cigarette.

CAPI INSTRUCTION:

COMBINATION CONTROL: Number Pad: Enter Age

ACCEPTABLE VALUES: 0, 6-20 years, Refused, Don’t Know.

If R enters 0, store 55 for "Never smoked a whole cigarette.”

If R enters 1-5, store 6 years.

HARD EDIT: If SMQ.630 > RIAAGEYR then ERROR

Error message: "Your response is older than your recorded age. Please press the “Back” button, press “Clear,” and try again."

|___|___|

ENTER AGE

AGE 1-20

NEVER SMOKED A WHOLE CIGARETTE 55 (SMQ.680)

REFUSED 77 (SMQ.680)

DON'T KNOW 99 (SMQ.680)

SMQ.640 During the past 30 days, on how many days did you smoke cigarettes?

INSTRUCTIONS TO SP:

Please enter a number or enter zero if none.

CAPI INSTRUCTION:

ACCEPTABLE VALUES: 0-30, Refused, Don’t Know

HARD EDIT: If SMQ.640 > 30 then ERROR

Error message: "Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again."

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (SMQ.670)

DON'T KNOW 99 (SMQ.670)

BOX 1A

CHECK ITEM SMQ.645:

IF 'NONE' (CODE '00'), 'REFUSED' (CODE '77'), OR 'DON'T KNOW' (CODE '99') IN SMQ.640, GO TO SMQ.670.

OTHERWISE, CONTINUE WITH SMQ.650.

SMQ.650 During the past 30 days, on the days that you smoked, how many cigarettes did you smoke per day?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTION:

If R says 95 or more cigarettes per day, store 95.

ACCEPTABLE VALUES: 1-95, Refused, Don’t Know

HARD EDIT: If SMQ.650 = 0 then ERROR

Error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER NUMBER OF CIGARETTES

MORE THAN 1 PACK OF CIGARETTES 95

REFUSED 777

DON'T KNOW 999

SMQ.077 How soon after you wake up do you smoke? Would you say . . .

Within 5 minutes 1

From 6 to 30 minutes 2

From more than 30 minutes to one hour 3

More than one hour 4

REFUSED 7

DON'T KNOW 9

SMQ.660 During the past 30 days, on the days that you smoked, which brand of cigarettes did you usually smoke?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Marlboro 1

Camel 2

Newport 3

Kool 4

Winston 5

Benson and Hedges 6

Salem 7

Other 8

REFUSED 77 (SMQ.670)

DON'T KNOW 99 (SMQ.670)

BOX 1B

CHECK ITEM SMQ.662:

IF NEWPORT, KOOL, OR SALEM BRAND (CODED '3', '4', OR '7') REPORTED IN SMQ.660, GO TO SMQ.666.

OTHERWISE, CONTINUE WITH SMQ.664.

SMQ.664 {Were/Was} the {BRAND REPORTED IN SMQ.660/brand of} cigarettes menthol or non-menthol?

M/C/W/B/O

INSTRUCTIONS TO SP:

Please select . . .

CAPI INSTRUCTION:

If SMQ.660 = 8, DISPLAY {Was/brand of} otherwise DISPLAY {Were/BRAND REPORTED IN SMQ.660}

Store result in appropriate field based on SMQ.660: 1:SMQ.664M, 2:SMQ.664C, 5:SMQ.664W, 6:SMQ.664B, 8:SMQ.664O.

Menthol 1

Non-menthol 2

REFUSED 7

DON'T KNOW 9

SMQ.666 {Were/Was} the {BRAND REPORTED IN SMQ.660/brand of} cigarettes regular, lights, or ultralights?

M/C/N/K/

W/B/S/O INSTRUCTIONS TO SP:

Please select . . .

CAPI INSTRUCTION:

If SMQ.660 = 8, DISPLAY {Was/brand of} otherwise DISPLAY {Were/BRAND REPORTED IN SMQ.660}

Store result in appropriate field based on SMQ.660: 1:SMQ.666M, 2:SMQ.666C, 3:SMQ.666N, 4:SMQ.666K, 5:SMQ.666W, 6:SMQ.666B, 7:SMQ.666S, 8:SMQ.666O.

Regular 1

Lights 2

Ultralights 3

REFUSED 7

DON'T KNOW 9

SMQ.670 During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SMQ.680_ The following questions ask about use of tobacco or nicotine products in the past 5 days.

SMQ.680 During the past 5 days, did you use any product containing nicotine including cigarettes, pipes, cigars, chewing tobacco, snuff, nicotine patches, nicotine gum, or any other product containing nicotine?

INSTRUCTIONS TO SP:

Please select . . .

CAPI INSTRUCTIONS:

If SMQ.620 = 2 or SMQ.640 = 0 then do not display {“cigarettes, “}

Recording Note: 2 wave files needed one with and one without the word cigarettes.

Yes 1

No 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

SMQ.690 Which of these products did you use? (CHECK ALL THAT APPLY)

INSTRUCTIONS TO SP:

Please select all that you used.

CAPI INSTRUCTIONS:

If SMQ.620 = 2 or SMQ.640 = 0 then do not display code 1: Cigarettes

Cigarettes 1

Pipes 2

Cigars 3

Chewing tobacco 4

Snuff 5

Nicotine patches, gum, or other

nicotine product 6

REFUSED 77 (END OF SECTION)

DON’T KNOW 99 (END OF SECTION)

BOX 2

CHECK ITEM SMQ.700:

IF ‘CIGARETTES’ (CODE 1) IN SMQ.690, GO TO SMQ.710.

IF ‘PIPES’ (CODE 2) IN SMQ.690, GO TO SMQ.740.

IF ‘CIGARS’ (CODE 3) IN SMQ.690, GO TO SMQ.770.

IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.

IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.

IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.

SMQ.710 During the past 5 days, including today, on how many days did you smoke cigarettes?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: If SMQ.710 < 1 or SMQ.710 > 5 then ERROR

Error message: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.720 During the past 5 days, on the days you smoked, how many cigarettes did you smoke each day?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTION:

If R says 95 or more cigarettes per day, store 95.

HARD EDIT: If SMQ.720 = 0 then ERROR

Error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER NUMBER OF CIGARETTES

MORE THAN 1 PACK OF CIGARETTES 95

REFUSED 777

DON'T KNOW 999

SMQ.725 When did you smoke your last cigarette? Was it . . .

Today 1

Yesterday 2

3 to 5 days ago 3

REFUSED 7

DON'T KNOW 9

BOX 3

CHECK ITEM SMQ.730:

IF ‘PIPES’ (CODE 2) IN SMQ.690, GO TO SMQ.740.

IF ‘CIGARS’ (CODE 3) IN SMQ.690, GO TO SMQ.770.

IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.

IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.

IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.

SMQ.740 During the past 5 days, including today, on how many days did you smoke a pipe?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: If SMQ.740 < 1 or SMQ.740 > 5 then ERROR

Error message: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.750 During the past 5 days, on the days you smoked a pipe, how many pipes did you smoke each day?

IF R SAYS LESS THAN 1 PIPE PER DAY, ENTER 1.

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

If R says less than 1 pipe per day, store 1.

If R says >59 pipes per day, store 59.

|___|___|

ENTER NUMBER OF PIPES

59 OR MORE PIPES 59

REFUSED 77

DON'T KNOW 99

SMQ.755 When did you smoke your last pipe? Was it . . .

Today 1

Yesterday 2

3 to 5 days ago 3

REFUSED 7

DON'T KNOW 9

BOX 4

CHECK ITEM SMQ.760:

IF ‘CIGARS’ (CODE 3) IN SMQ.690, GO TO SMQ.770.

IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.

IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.

IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.

SMQ.770 During the past 5 days, including today, on how many days did you smoke cigars?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: If SMQ.770 < 1 or SMQ.770 > 5 then ERROR

Error message: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.780 During the past 5 days, on the days you smoked cigars, how many cigars did you smoke each day?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

If R says less than 1 cigar per day, store 1.

If R says >59 cigars per day, store 59.

|___|___|

ENTER NUMBER OF CIGARS

59 OR MORE CIGARS 59

REFUSED 77

DON'T KNOW 99

SMQ.785 When did you smoke your last cigar? Was it . . .

Today 1

Yesterday 2

3 to 5 days ago 3

REFUSED 7

DON'T KNOW 9

BOX 5

CHECK ITEM SMQ.790:

IF ‘CHEW’ (CODE 4) IN SMQ.690, GO TO SMQ.800.

IF 'SNUFF' (CODE 5) IN SMQ.690, GO TO SMQ.817.

IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.

SMQ.800 During the past 5 days, including today, on how many days did you use chewing tobacco, such as Redman, Levi Garrett or Beechnut?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: If SMQ.800 < 1 or SMQ.800 > 5 then ERROR

Error message: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.815 When did you last use chewing tobacco? Was it . . .

Today 1

Yesterday 2

3 to 5 days ago 3

REFUSED 7

DON'T KNOW 9

BOX 5A

CHECK ITEM SMQ.816:

IF ‘SNUFF’ (CODE 5) IN SMQ.690, GO TO SMQ.817.

IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.

SMQ.817 During the past 5 days, including today, on how many days did you use snuff, such as Skoal, Skoal Bandits, or Copenhagen?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: If SMQ.817 < 1 or SMQ.817 > 5 then ERROR

Error message: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.819 When did you last use snuff? Was it . . .

Today 1

Yesterday 2

3 to 5 days ago 3

REFUSED 7

DON'T KNOW 9

BOX 6

CHECK ITEM SMQ.820:

IF ‘NICOTINE PRODUCT’ (CODE 6) IN SMQ.690, GO TO SMQ.830.

OTHERWISE, GO TO END OF SECTION.

SMQ.830 During the past 5 days, including today, on how many days did you use any product containing nicotine to help you stop smoking? Include nicotine patches, gum, or any other product containing nicotine.

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

If SMQ.830 < 1 or SMQ.830 > 5 then ERROR

Error message: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.840 When did you last use a product containing nicotine? Was it . .

Today 1

Yesterday 2

3 to 5 days ago 3

REFUSED 7

DON'T KNOW 9

ALCOHOL use

ALQ.010_ The following questions ask about alcohol use. This includes beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. This does not include drinking a few sips of wine for religious purposes.

ALQ.010 How old were you when you had your first drink of alcohol, other than a few sips?

INSTRUCTIONS TO SP:

Please select one of the following choices.

HARD EDIT: If (RIAAGEYR < 17 and ALQ.010 = 7) OR (RIAAGEYR < 15 and ALQ.010 in (6, 7)) OR (RIAAGEYR < 13 and ALQ.010 in (5, 6, 7)) then ERROR

Error message: “Your response is older than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

I have never had a drink of alcohol other
than a few sips 1 (END OF SECTION)

8 years old or younger 2

9 or 10 years old 3

11 or 12 years old 4

13 or 14 years old 5

15 or 16 years old 6

17 years old or older 7

REFUSED 77

DON'T KNOW 99

ALQ.022 During your life, on how many days have you had at least one drink of alcohol?

INSTRUCTIONS TO SP:

Please select one of the following choices.

1 or 2 days 2

3 to 9 days 3

10 to 19 days 4

20 to 39 days 5

40 to 99 days 6

100 or more days 7

REFUSED 77

DON'T KNOW 99

ALQ.031 During the past 30 days, on how many days did you have at least one drink of alcohol?

INSTRUCTIONS TO SP:

Please select one of the following choices.

HARD EDIT: If (ALQ.022 = 2 and ALQ.031 in (3,4,5,6,7)) or (ALQ.022 =3 and ALQ.031 in (5,6,7)) or (ALQ.022 = 4 and ALQ.031 in (6,7)) then ERROR

Error message: “Your response is not consistent with your lifetime use. Please press the “Back” button, press “Clear,” and try again.”

0 days 1 (END OF SECTION)

1 or 2 days 2

3 to 5 days 3

6 to 9 days 4

10 to 19 days 5

20 to 29 days 6

All 30 days 7

REFUSED 77

DON'T KNOW 99

ALQ.041 During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours?

INSTRUCTIONS TO SP:

Please select one of the following choices.

HARD EDIT: If (ALQ.031= 2 and ALQ.041 in (4,5,6,7)) or (ALQ.031=3 and ALQ.041 in (5,6,7)) or (ALQ.031 = 4 and ALQ.041 in (6,7)) or (ALQ.031 = 5 and ALQ.041 = 7) then ERROR

Error message: “Your response is not consistent with your use in the past 30 days. Please press the “Back” button, press “Clear,” and try again.”

0 days 1

1 day 2

2 days 3

3 to 5 days 4

6 to 9 days 5

10 to 19 days 6

20 or more days 7

REFUSED 77

DON'T KNOW 99

DRUG USE

DUQ.200_ The following questions ask about use of drugs not prescribed by a doctor. Please remember that your answers to these questions are strictly confidential.

The first questions are about marijuana and hashish. Marijuana is also called pot or grass. Marijuana is usually smoked, either in cigarettes, called joints, or in a pipe. It is sometimes cooked in food. Hashish is a form of marijuana that is also called “hash.” It is usually smoked in a pipe. Another form of hashish is hash oil.

BOX 1a

CHECK ITEM DUQ.201:

• IF 60 – 69 YEARS GO TO DUQ.240

• ELSE CONTINUE

DUQ.200 Have you ever, even once, used marijuana or hashish?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.240)

REFUSED 7 (DUQ.240)

DON'T KNOW 9 (DUQ.240)

DUQ.210 How old were you the first time you used marijuana or hashish?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: DUQ.210 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

DUQ.new1 Have you ever smoked marijuana or hashish at least once a month for more than one year?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.220G)

REFUSED 7 (DUQ.220G)

DON'T KNOW 9 (DUQ.220G)

DUQ.new2 How old were you when you started smoking marijuana or hashish regularly at least once a month for one year?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: DUQ.new2 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

DUQ.new3 How long has it been since you last smoked marijuana or hashish regularly at least once a month for one year?

INSTRUCTIONS TO SP: Please enter the number of days, weeks, months, or years, then select the unit of time.

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

REFUSED 7

DON'T KNOW 9

DUQ.new4 During the time that you smoked marijuana or hashish, how often would you usually use it?

INSTRUCTIONS TO SP:

Please select . . .

Once per month……………..……………………………1

2-3 times per month……………………………………...2

4-8 times per month (about 1-2 times per week)……..3

9-24 times per month (about 3-6 times per week)……4

25-30 times per month (one or more times per day)…5

REFUSED …………. 7

DON'T KNOW 9

DUQ.new5 During the time that you smoked marijuana or hashish, how many joints or pipes would you usually smoke in a day?

INSTRUCTIONS TO SP:

Please select . . .

1 per day………………………………………… 1

2 per day………………………………………… 2

3-5 per day……………………………………… 3

Six or more per day……………………………… 4

REFUSED …………. 7

DON'T KNOW 9

DUQ.220 How long has it been since you last used marijuana or hashish?

G/Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

CAPI INSTRUCTIONS:

If SP Ref/DK then store 7/9 in DUQ.220G and DUQ.220U, 7/9-fill in DUQ.220Q

If a value is entered in Quantity and Unit store Quantity in DUQ.220Q, Unit in DUQ.220U and 1 in DUQ.220G

HARD EDIT: Response must be equal to or less than current age minus DUQ.210.

Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

REFUSED 7

DON'T KNOW 9

BOX 1

CHECK ITEM DUQ.225:

• IF SP USED MARIJUANA WITHIN THE PAST MONTH (CODED 1-30 DAYS, OR 1-4 WEEKS, OR 1 MONTH IN DUQ.220), CONTINUE WITH DUQ.230.

• OTHERWISE, GO TO DUQ.240.

DUQ.230 During the past 30 days, on how many days did you use marijuana or hashish?

INSTRUCTIONS TO SP:

Please enter a number.

HARD EDIT VALUES: 1-30.

If DUQ.230 = 0, display error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

If DUQ.230 > 30, display error message: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER A NUMBER

REFUSED 77

DON'T KNOW 99

DUQ.240 Have you ever used cocaine, crack cocaine, heroin, or methamphetamine?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.370)

REFUSED 7 (DUQ.370)

DON'T KNOW 9 (DUQ.370)

DUQ.250_ The following questions are about cocaine, including all the different forms of cocaine such as powder, ‘crack’, ‘free base’, and coca paste.

DUQ.250 Have you ever, even once, used cocaine, in any form?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.290)

REFUSED 7 (DUQ.290)

DON'T KNOW 9 (DUQ.290)

BOX 2a

CHECK ITEM DUQ.255:

• IF 60 – 69 YEARS GO TO DUQ.290_

• ELSE CONTINUE

DUQ.260 How old were you the first time you used cocaine, in any form?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: DUQ.260 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

DUQ.270 How long has it been since you last used cocaine, in any form?

G/Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select unit of time.

CAPI INSTRUCTIONS:

If SP Ref/DK then store 7/9 in DUQ.270G and DUQ.270U, 7/9-fill in DUQ.270Q

If a value is entered in Quantity and Unit store Quantity in DUQ.270Q, Unit in DUQ.270U and 1 in DUQ.270G

HARD EDIT: Response must be equal to or less than current age minus DUQ.260.

Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

REFUSED 7

DON'T KNOW 9

DUQ.272 During your life, altogether how many times have you used cocaine, in any form?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Once 1

2-5 times 2

6-19 times 3

20-49 times 4

50-99 times 5

100 times or more 6

REFUSED 77

DON’T KNOW 99

BOX 2

CHECK ITEM DUQ.275:

• IF SP USED COCAINE WITHIN THE PAST MONTH (CODED 1-30 DAYS, OR 1-4 WEEKS, OR 1 MONTH IN DUQ.270), CONTINUE WITH DUQ.280.

• OTHERWISE, GO TO DUQ.290.

DUQ.280 During the past 30 days, on how many days did you use cocaine, in any form?

INSTRUCTIONS TO SP:

Please enter a number

HARD EDIT VALUES: 1-30.

If DUQ.280 = 0, display error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

If DUQ.280 > 30, display error message: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER A NUMBER

REFUSED 77

DON'T KNOW 99

DUQ.290_ The following questions are about heroin.

DUQ.290 Have you ever, even once, used heroin?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.330)

REFUSED 7 (DUQ.330)

DON'T KNOW 9 (DUQ.330)

BOX 3a

CHECK ITEM DUQ.295:

• IF SP 60-69 YEARS GO TO DUQ.330_

• OTHERWISE, CONTINUE.

DUQ.300 How old were you the first time you used heroin?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: DUQ.300 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

DUQ.310 How long has it been since you last used heroin?

G/Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

CAPI INSTRUCTIONS:

If SP Ref/DK then store 7/9 in DUQ.310G and DUQ.310U, 7/9-fill in DUQ.310Q

If a value is entered in Quantity and Unit store Quantity in DUQ.310Q, Unit in DUQ.310U and 1 in DUQ.310G

HARD EDIT: Response must be equal to or less than current age minus DUQ.300.

Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

REFUSED 7

DON'T KNOW 9

BOX 3

CHECK ITEM DUQ.315:

• IF SP USED HEROIN WITHIN THE PAST MONTH (CODED 1-30 DAYS, OR 1-4 WEEKS, OR 1 MONTH IN DUQ.310), CONTINUE WITH DUQ.320.

• OTHERWISE, GO TO DUQ.330.

DUQ.320 During the past 30 days, on how many days did you use heroin?

INSTRUCTIONS TO SP:

Please enter a number.

HARD EDIT VALUES: 1-30.

If DUQ.320 = 0, display error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

If DUQ.320 > 30, display error message: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER A NUMBER

REFUSED 77

DON'T KNOW 99

DUQ.330_ The following questions are about methamphetamine, also known as crank, crystal, ice or speed.

DUQ.330 Have you ever, even once, used methamphetamine?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.370)

REFUSED 7 (DUQ.370)

DON'T KNOW 9 (DUQ.370)

BOX 4a

CHECK ITEM DUQ.335:

• IF SP 60-69 YEARS GO TO DUQ.370_

• OTHERWISE, CONTINUE.

DUQ.340 How old were you the first time you used methamphetamine?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: DUQ.340 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

DUQ.350 How long has it been since you last used methamphetamine?

G/Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

CAPI INSTRUCTIONS:

If SP Ref/DK then store 7/9 in DUQ.350G and DUQ.350U, 7/9-fill in DUQ.350Q

If a value is entered in Quantity and Unit store Quantity in DUQ.350Q, Unit in DUQ.350U and 1 in DUQ.350G

HARD EDIT: Response must be equal to or less than current age minus DUQ.340.

Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

REFUSED 7

DON'T KNOW 9

DUQ.352 During your life, altogether how many times have you used methamphetamine?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Once 1

2-5 times 2

6-19 times 3

20-49 times 4

50-99 times 5

100 times or more 6

REFUSED 77

DON’T KNOW 99

BOX 4

CHECK ITEM DUQ.355:

• IF SP USED METHAMPHETAMINE WITHIN THE PAST MONTH (CODED 1-30 DAYS, OR 1-4 WEEKS, OR 1 MONTH IN DUQ.350), CONTINUE WITH DUQ.360.

• OTHERWISE, GO TO DUQ.370.

DUQ.360 During the past 30 days, on how many days did you use methamphetamine?

INSTRUCTIONS TO SP:

Please enter a number.

HARD EDIT VALUES: 1-30.

If DUQ.360 = 0, display error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

If DUQ.360 > 30, display error message: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER A NUMBER

REFUSED 77

DON'T KNOW 99

DUQ.370_ The following questions are about the different ways that certain drugs can be used.

DUQ.370 Have you ever, even once, used a needle to inject a drug not prescribed by a doctor?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (BOX 5)

REFUSED 7 (BOX 5)

DON'T KNOW 9 (BOX 5)

DUQ.380 Which of the following drugs have you injected using a needle?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select all the drugs that you injected.

CAPI INSTRUCTION:

SHOW ALL FIVE ITEMS ON SINGLE ACASI SCREEN

Cocaine 1

Heroin 2

Methamphetamine 3

Steroids 4

Any other drugs 5

REFUSED 7

DON'T KNOW 9

DUQ.390 How old were you when you first used a needle to inject any drug not prescribed by a doctor?

(Target 12-69)

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: DUQ.390 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

DUQ.400 How long ago has it been since you last used a needle to inject a drug not prescribed by a doctor?

G/Q/U

(Target 12-69) INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

CAPI INSTRUCTIONS:

If SP Ref/DK then store 7/9 in DUQ.400G and DUQ.400U, 7/9-fill in DUQ.400Q

If a value is entered in Quantity and Unit store Quantity in DUQ.400Q, Unit in DUQ.400U and 1 in DUQ.400G

HARD EDIT: Response must be equal to or less than current age minus DUQ.390.

Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 7777

DON'T KNOW 9999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

REFUSED 7

DON'T KNOW 9

DUQ.410 During your life, altogether how many times have you injected drugs not prescribed by a doctor?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select one of the following choices.

Once 1 (DUQ.430)

2-5 times 2

6-19 times 3

20-49 times 4

50-99 times 5

100 times or more 6

REFUSED 77

DON’T KNOW 99

DUQ.420 Think about the period of your life when you injected drugs the most often. How often did you inject then?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select one of the following choices.

More than once a day 1

About once a day 2

At least once a week but not every day 3

At least once a month but not every week 4

Less than once a month 5

REFUSED 7

DON’T KNOW 9

BOX 5

CHECK ITEM DUQ.426:

• IF SP 60-69 YEARS, GO TO END OF SECTION.

• IF SP HAS USED MARIJUANA (CODED ‘1’) IN DUQ.200 OR SP HAS USED COCAINE, HEROIN, OR METHAMPHETAMINE (CODED ‘1’) IN DUQ.240, OR SP HAS INJECTED ANY DRUG NOT PRESCRIBED BY A DOCTOR (CODED ‘1’) IN DUQ.370, GO TO DUQ.430.

• OTHERWISE, GO TO END OF SECTION.

DUQ.430 Have you ever been in a drug treatment or drug rehabilitation program?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SEXUAL BEHAVIOR – (SXQ)

Target Group: Female SPs 14-69 (Audio-CASI)

SXQ.615_ The next set of questions is about your sexual history. By sex, we mean vaginal, oral, or anal sex. Please remember that your answers are strictly confidential.

BOX 1B

CHECK ITEM SXQ.773:

• IF SP AGE GREATER THAN 17, GO TO SXQ.700.

• OTHERWISE, CONTINUE.

SXQ.615 Have you ever had any kind of sex?

(Target 14-17)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (BOX 11)

REFUSED 7 (BOX 11)

DON'T KNOW 9 (BOX 11)

SXQ.700 Have you ever had vaginal sex, also called sexual intercourse, with a man? This means a man’s penis in your vagina.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.703 Have you ever performed oral sex on a man? This means putting your mouth on a man’s penis or genitals.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.706 Have you ever had anal sex? This means contact between a man’s penis and your anus or butt.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.709 Have you ever had any kind of sex with a woman? By sex, we mean sexual contact with another woman’s vagina or genitals.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 1A

CHECK ITEM SXQ.762:

• IF SP 60-69 YEARS AND SXQ.703 OR SXQ.709 = 1 AND SXQ.700 = 2 AND SXQ.706 = 2, GO TO END OF SECTION.

• IF SXQ.700, SXQ.706, AND SXQ.709 NOT EQUAL TO ‘1’ AND SXQ.703 = 1, GO TO BOX 4.

• IF SXQ.700, SXQ.703, SXQ.706, AND SXQ.709 NOT EQUAL TO ‘1’, GO TO BOX 11.

• OTHERWISE, CONTINUE.

SXQ.618 (Target 14-69)

How old were you the first time you had any kind of sex, including {vaginal, anal, or oral / vaginal or anal / vaginal or oral / anal or oral / vaginal / anal / oral}?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF SXQ.700 AND SXQ.703 = 1 AND SXQ.706 NOT EQUAL TO ‘1’, DISPLAY {vaginal or oral}.

IF SXQ.700 AND SXQ.709 = 1 AND SXQ.706 NOT EQUAL TO ‘1’, DISPLAY {vaginal or oral}.

IF SXQ.700 AND SXQ.706 = 1 AND SXQ.703 AND SXQ.709 NOT EQUAL TO ‘1’, DISPLAY {vaginal or anal}.

IF SXQ.703 AND SXQ.706 = 1 AND SXQ.700 NOT EQUAL TO ‘1’, DISPLAY {anal or oral}.

IF SXQ.706 AND SXQ.709 = 1 AND SXQ.700 NOT EQUAL TO ‘1’, DISPLAY {anal or oral}.

IF SXQ.700 = 1 AND SXQ.703, SXQ.706, AND SXQ.709 NOT EQUAL TO ‘1’, DISPLAY {vaginal}.

IF SXQ.706 = 1 AND SXQ.700, SXQ.703, AND SXQ.709 NOT EQUAL TO ‘1’, DISPLAY {anal}.

IF SXQ.709 = 1 AND SXQ.700, AND SXQ.706 NOT EQUAL TO ‘1’, DISPLAY {oral}.

OTHERWISE, DISPLAY {vaginal, anal, or oral}.

HARD EDIT VALUES: 0-69

Error message: “Your response cannot exceed 69 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.618 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 1

CHECK ITEM SXQ.701:

• IF SXQ.703 = 1 AND SXQ.700 AND SXQ.706 NOT EQUAL TO ‘1’, GO TO BOX 3.

• IF SXQ.700 = 1 AND SXQ.703 AND SXQ.706 NOT EQUAL TO ‘1’, GO TO BOX 3.

• IF SXQ.709 = 1 AND SXQ.700, SXQ.703, AND SXQ.706 NOT EQUAL TO ‘1’, GO TO BOX 3.

• OTHERWISE, CONTINUE.

SXQ.712 In your lifetime, with how many men have you had any kind of sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.712 must be greater than 0.

Error message: “Your response is not consistent with your previous responses about male sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 2

CHECK ITEM SXQ.715:

• IF SP 60-69 YEARS, GO TO END OF SECTION.

• OTHERWISE, GO TO SXQ.718

SXQ.718 In the past 12 months, with how many men have you had any kind of sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.718 must be equal to or less than SXQ.712.

Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 3

CHECK ITEM SXQ.721:

• IF SXQ.700 = 1, GO TO SXQ.724.

• OTHERWISE, GO TO BOX 4.

SXQ.724 In your lifetime, with how many men have you had vaginal sex? Vaginal sex means a man’s penis in your vagina.

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.724 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about male vaginal sex partners. Please press the “Back” button, press “Clear,” and try again."

HARD EDIT: SXQ.724 must be equal to or less than SXQ.712.

Error message: "Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.727 In the past 12 months, with how many men have you had vaginal sex? Vaginal sex means a man’s penis in your vagina.

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.727 must be equal to or less than SXQ.724.

Error message: “Your response is greater than your lifetime number of male vaginal sex partners. Please press the “Back” button, press “Clear”, and try again.”

BOX 4

CHECK ITEM SXQ.730:

• IF SXQ.703 = 1, GO TO SXQ.621.

• OTHERWISE, GO TO BOX 6.

SXQ.621 How old were you when you first performed oral sex on a man? Performing oral sex means your mouth on a man’s penis or genitals.

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.621 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

SXQ.624 In your lifetime, on how many men have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.624 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about male oral sex partners. Please press the “Back” button, press “Clear,” and try again."

SXQ.627 In the past 12 months, on how many men have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.627 must be equal to or less than SXQ.624.

Error message: “Your response is greater than your lifetime number of male oral sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 5

CHECK ITEM SXQ.765:

• IF SP HAD ONLY 1 LIFETIME ORAL SEX PARTNER (CODED ‘1’) IN SXQ.624, GO TO BOX 6.

• OTHERWISE CONTINUE.

SXQ.630 How long has it been since the last time you performed oral sex on a new male partner? A new sexual partner is someone that you had never had sex with before.

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777

DON'T KNOW 99999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

HARD EDIT: Response must be equal to or less than current age minus SXQ.621.

Error message: “Your response is earlier than your response to the age when you first performed oral sex on a man. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.630 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 6

CHECK ITEM SXQ.733:

• IF SXQ.709 = 1, GO TO SXQ.736.

• OTHERWISE, GO TO BOX 7.

SXQ.736 In your lifetime with how many women have you had sex? By sex, we mean sexual contact with another woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.736 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about sex with a female partner. Please press the “Back” button, press “Clear,” and try again."

SXQ.739 In the past 12 months, with how many women have you had sex? By sex, we mean sexual contact with another woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.739 must be equal to or less than SXQ.736.

Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear”, and try again.”

SXQ.741 Have you ever performed oral sex on a woman? Performing oral sex means your mouth on a woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (BOX 7A)

REFUSED 7 (BOX 7A)

DON'T KNOW 9 (BOX 7A)

SXQ.633 How old were you when you first performed oral sex on a woman? Performing oral sex means your mouth on a woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.633 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

SXQ.636 In your lifetime, on how many women have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.636 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about female oral sex partners. Please press the “Back” button, press “Clear,” and try again."

SXQ.639 In the past 12 months, on how many women have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.639 must be equal to or less than SXQ.636.

Error message: “Your response is greater than your lifetime number of female oral sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 6B

CHECK ITEM SXQ.768:

• IF SP HAD ONLY 1 LIFETIME ORAL SEX PARTNER (CODED ‘1’) IN SXQ.636, GO TO BOX 7A.

• OTHERWISE, CONTINUE.

SXQ.642 How long has it been since the last time you performed oral sex on a new female partner? A new sexual partner is someone that you had never had sex with before.

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777

DON'T KNOW 99999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

HARD EDIT: Response must be equal to or less than current age minus SXQ.633.

Error message: “Your response is earlier than your response to the age when you first performed oral sex on a woman. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.642 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 7A

CHECK ITEM SXQ.744:

• IF SP DID NOT HAVE A PARTNER IN PAST 12 MONTHS (SXQ.718, SXQ.727, SXQ.627, SXQ.639, AND SXQ.739 CODED ‘0000’ OR MISSING), GO TO SXQ.260.

• IF SXQ.709 = 1 AND SXQ.700, SXQ.703, OR SXQ.706 = 1, THEN DISPLAY “The next set of questions is about all of your partners, males and females.”, THEN GO TO BOX 7.

• OTHERWISE, GO TO BOX 7.

BOX 7

CHECK ITEM SXQ.747:

• IF SP HAD ORAL SEX PARTNER IN PAST 12 MONTHS (SXQ.627 OR SXQ.639 GREATER THAN ‘0000’), THEN GO TO SXQ.645.

• OTHERWISE, GO TO BOX 7B.

SXQ.645 When you performed oral sex in the past 12 months, how often would you use protection, like a condom or dental dam?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 1

Rarely 2

Usually 3

Always 4

Unsure 5

REFUSED 7

DON'T KNOW 9

BOX 7B

CHECK ITEM SXQ.771:

• IF SXQ.718, SXQ.727, OR SXQ.739 GREATER THAN ‘0000’, GO TO SXQ.648.

• OTHERWISE, GO TO BOX 9.

SXQ.648 In the past 12 months, did you have any kind of sex with a person that you never had sex with before?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 8A

CHECK ITEM SXQ.859:

• IF SXQ.700 OR SXQ.706 = 1, THEN CONTINUE.

• OTHERWISE, GO TO BOX 9,

SXQ.610 In the past 12 months, about how many times have you had {vaginal or anal/vaginal/anal} sex?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 0

Once 1

2-11 times 2

12-51 times 3

52-103 times 4

104-364 times 5

365 times or more 6

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTON:

IF SXQ.700 = 1 AND SXQ.706 = 2, DISPLAY {vaginal}.

IF SXQ.700 = 2 AND SXQ.706 = 1, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal or anal}.

BOX 8

CHECK ITEM SXQ.245:

• IF SP DID NOT HAVE VAGINAL OR ANAL SEX (CODED ‘0’) IN SXQ.610, GO TO BOX 9.

• OTHERWISE, CONTINUE WITH SXQ.250.

SXQ.250 In the past 12 months, about how often have you had {vaginal or anal/vaginal/anal} sex without using a condom?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 1

Less than half of the time 2

About half of the time 3

Not always, but more than half of the time 4

Always 5

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTON:

IF SXQ.700 = 1 AND SXQ.706 = 2, DISPLAY {vaginal}.

IF SXQ.700 = 2 AND SXQ.706 = 1, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal or anal}.

BOX 9

CHECK ITEM SXQ.750:

• IF SP 14-29 YEARS AND IF SP HAD PARTNER IN PAST 12 MONTHS (SXQ.718, SXQ.727, SXQ.627, SXQ.639, OR SXQ.739 GREATER THAN ‘0000’), GO TO SXQ.651.

• OTHERWISE, GO TO SXQ.260.

SXQ.651 Of the persons you had any kind of sex with in the past 12 months, how many were five or more years older than you?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT FOR FEMALES: SXQ.651 must be equal to or less than (sum of SXQ.718 and SXQ.739 and SXQ.627 and SXQ.727 and SXQ.639)

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

SXQ.654 Of the persons you had any kind of sex with in the past 12 months, how many were five or more years younger than you?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT FOR FEMALES: SXQ.654 must be equal to or less than (sum of SXQ.718 and SXQ.739 and SXQ.627 and SXQ.727 and SXQ.639)

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT (combined) for SXQ.651 and SXQ.654

HARD EDIT FOR FEMALES: (sum of SXQ.651 and SXQ.654) must be equal to or less than (sum of SXQ.718 and SXQ.739 and SXQ.627 and SXQ.727 and SXQ.639)

Error message: "Your responses to the last two questions are not consistent with your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again."

SXQ.260 Has a doctor or other health care professional ever told you that you had genital herpes?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.265 Has a doctor or other health care professional ever told you that you had genital warts?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.753 Has a doctor or other health care professional ever told you that you had human papillomavirus or HPV?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.270 In the past 12 months, has a doctor or other health care professional told you that you had gonorrhea, sometimes called GC or clap?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.272 In the past 12 months, has a doctor or other health care professional told you that you had chlamydia?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 11

CHECK ITEM SXQ.756:

• IF SP 18-59 YEARS, GO TO SXQ.294.

• OTHERWISE, GO TO END OF SECTION.

SXQ.294 Do you think of yourself as . . .

Heterosexual or straight (attracted to men) 1

Homosexual or lesbian (attracted to women) 2

Bisexual (attracted to men and women) 3

Something else 4

Not sure 5

REFUSED 7

DON'T KNOW 9

SEXUAL BEHAVIOR – (SXQ)

Target Group: Male SPs 14-69 (Audio-CASI)

SXQ.615_ The next set of questions is about your sexual history. By sex, we mean vaginal, oral, or anal sex.

Please remember that your answers are strictly confidential.

BOX 1B

CHECK ITEM SXQ.873:

• IF SP AGE GREATER THAN 17, GO TO SXQ.800.

• OTHERWISE, CONTINUE.

SXQ.615 Have you ever had any kind of sex?

(Target 14-17)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (BOX 8)

REFUSED 7 (BOX 8)

DON'T KNOW 9 (BOX 8)

SXQ.800 Have you ever had vaginal sex, also called sexual intercourse, with a woman? This means your penis in a woman’s vagina.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.803 Have you ever performed oral sex on a woman? This means putting your mouth on a woman’s vagina or genitals.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.806 Have you ever had anal sex with a woman? Anal sex means contact between your penis and a woman’s anus or butt.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.809 Have you ever had any kind of sex with a man, including oral or anal?

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 1A

CHECK ITEM SXQ.862:

• IF SXQ.803 = 1 AND SXQ.800, SXQ.806, AND SXQ.809 NOT EQUAL TO ‘1’, GO TO BOX 4.

• IF SXQ.800, SXQ.803, SXQ.806, AND SXQ.809 NOT EQUAL TO ‘1’, GO TO BOX 8.

• OTHERWISE, CONTINUE.

SXQ.618 (Target 14-69)

How old were you the first time you had any kind of sex, including {vaginal, anal, or oral / vaginal or anal / vaginal or oral / anal or oral / vaginal / anal / oral}?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF SXQ.800 AND SXQ.803 = 1 AND SXQ.806 AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal or oral}.

IF SXQ.800 AND SXQ.806 = 1 AND SXQ.803 AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal or anal}.

IF SXQ.809 = 1 AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal or oral}.

IF SXQ.803 AND SXQ.806 = 1 AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal or oral}.

IF SXQ.800 = 1 AND SXQ.803, SXQ.806, AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal}.

IF SXQ.806 = 1 AND SXQ.800, SXQ.803, AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal, anal, or oral}.

HARD EDIT VALUES: 0-69

Error message: “Your response cannot exceed 69 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.618 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 1

CHECK ITEM SXQ.801:

• IF SXQ.803=1 AND SXQ.800 AND SXQ.806 NOT EQUAL TO ‘1’, GO TO BOX 3.

• IF SXQ.800=1 AND SXQ.803 AND SXQ.806 NOT EQUAL TO ‘1’, GO TO BOX 3.

• IF SXQ.809=1 AND SXQ.800, SXQ.803, AND SXQ.806 NOT EQUAL TO ‘1’, GO TO BOX 3.

• OTHERWISE, CONTINUE.

SXQ.812 In your lifetime, with how many women have you had any kind of sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.812 must be greater than zero.

Error message: “Your response is not consistent with your previous responses about female sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 2

CHECK ITEM SXQ.815:

• IF SP 60-69 YEARS AND SXQ.809 = 1, GO TO SXQ.410.

• IF SP 60-69 YEARS AND SXQ.809 NOT EQUAL TO 1, GO TO END OF SECTION.

• OTHERWISE, CONTINUE WITH SXQ.818.

SXQ.818 In the past 12 months, with how many women have you had any kind of sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.818 must be equal to or less than SXQ.812.

Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 3

CHECK ITEM SXQ.821:

• IF SXQ.800 = 1, GO TO SXQ.824.

• OTHERWISE, GO TO BOX 4.

SXQ.824 In your lifetime, with how many women have you had vaginal sex? Vaginal sex means your penis in a woman’s vagina.

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.824 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about female vaginal sex partners. Please press the “Back” button, press “Clear,” and try again."

HARD EDIT: SXQ.824 must be equal to or less than SXQ.812.

Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.827 In the past 12 months, with how many women have you had vaginal sex? Vaginal sex means your penis in a woman’s vagina.

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.827 must be equal to or less than SXQ.824.

Error message: “Your response is greater than your lifetime number of female vaginal sex partners. Please press the “Back” button, press “Clear”, and try again.”

BOX 4

CHECK ITEM SXQ.830:

• IF SXQ.803 = 1, GO TO SXQ.633.

• OTHERWISE, GO TO BOX 5.

SXQ.633 How old were you when you first performed oral sex on a woman? Performing oral sex means your mouth on a woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.633 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

SXQ.636 In your lifetime, on how many women have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.636 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about female oral sex partners. Please press the “Back” button, press “Clear,” and try again."

SXQ.639 In the past 12 months, on how many women have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.639 must be equal to or less than SXQ.636.

Error message: “Your response is greater than your lifetime number of female oral sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 4B

CHECK ITEM SXQ.868:

• IF SP HAD ONLY 1 LIFETIME ORAL SEX PARTNER (CODED ‘1’) IN SXQ.636, GO TO BOX 5.

• OTHERWISE CONTINUE.

SXQ.642 How long has it been since the last time you performed oral sex on a new female partner? A new sexual partner is someone that you had never had sex with before.

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777

DON'T KNOW 99999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

HARD EDIT: Response must be equal to or less than current age minus SXQ.633.

Error message: “Your response is earlier than your response to the age when you first performed oral sex on a woman. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.642 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 5

CHECK ITEM SXQ.833:

• IF SXQ.809 = 1, GO TO SXQ.410.

• OTHERWISE, GO TO BOX 9.

SXQ.410 In your lifetime, with how many men have you had anal or oral sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.410 must be greater than zero.

Error message: “Your response is not consistent with your previous responses about male sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 2

CHECK ITEM SXQ.815:

• IF SP IS 60-69 YEARS, GO TO SXQ.836.

• OTHERWISE, CONTINUE WITH SXQ.550.

SXQ.550 In the past 12 months, with how many men have you had anal or oral sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.450 must be equal to or less than SXQ.410.

Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.836 In your lifetime, with how many men have you had anal sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

BOX 6

CHECK ITEM SXQ.839:

• IF SP IS 60-69 YEARS, GO TO SXQ.853.

• IF SP HAD NO ANAL SEX PARTNERS (CODED ‘0000’ IN SXQ.836), GO TO SXQ.853.

• OTHERWISE, CONTINUE WITH SXQ.841.

SXQ.841 In the past 12 months, with how many men have you had anal sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.841 must be equal to or less than SXQ.836.

Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.853 Have you ever performed oral sex on a man? Performing oral sex means your mouth on a man’s penis or genitals.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 7

CHECK ITEM SXQ.847:

• IF SP NEVER HAD ORAL MALE PARTNER (CODED ‘2’, ‘7’, OR ‘9’) IN SXQ.853 AND SP IS 60-69 YEARS, GO TO END OF SECTION.

• IF SP NEVER HAD ORAL MALE PARTNER (CODED ‘2’, ‘7’, OR ‘9’) IN SXQ.853 AND SP IS 14-59 YEARS, GO TO BOX 9A.

• OTHERWISE, CONTINUE WITH SXQ.621.

SXQ.621 How old were you when you first performed oral sex on a man? Performing oral sex means your mouth on a man’s penis or genitals.

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-69

Error message: “Your response cannot exceed 69 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.621 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

SXQ.624 In your lifetime, on how many men have you performed oral sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.624 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about male oral sex partners. Please press the “Back” button, press “Clear,” and try again."

BOX 8

CHECK ITEM SXQ.850:

• IF SP 60-69 YEARS, GO TO END OF SECTION.

• IF SP 14-17 YEARS AND SXQ.615 = 2, 7, OR 9, GO TO SXQ.280.

• IF SXQ.800, SXQ.803, SXQ.806, AND SXQ.809 = 2, 7, OR 9, GO TO SXQ.280.

• OTHERWISE, CONTINUE WITH SXQ.627.

SXQ.627 In the past 12 months, on how many men have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.627 must be equal to or less than SXQ.624.

Error message: “Your response is greater than your lifetime number of male oral sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 8B

CHECK ITEM SXQ.865:

• IF SP HAD ONLY 1 LIFETIME MALE ORAL SEX PARTNER (CODED ‘1’) IN SXQ.624, GO TO BOX 9A.

• OTHERWISE CONTINUE.

SXQ.630 How long has it been since the last time you performed oral sex on a new male partner? A new sexual partner is someone that you had never had sex with before.

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777

DON'T KNOW 99999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

HARD EDIT: Response must be equal to or less than current age minus SXQ.621.

Error message: “Your response is earlier than your response to the age when you first performed oral sex on a man. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.630 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 9A

CHECK ITEM SXQ.844:

• IF SP DID NOT HAVE A PARTNER IN PAST 12 MONTHS (SXQ.627, SXQ.639, SXQ.818, SXQ.827, AND SXQ.841 CODED ‘0000’ OR MISSING), GO TO SXQ.260.

• IF SXQ.809 = 1 AND SXQ.800, SXQ.803, OR SXQ.806 = 1, THEN DISPLAY “The next set of questions is about all of your partners, males and females.”, THEN GO TO BOX 9.

• OTHERWISE, GO TO BOX 9.

BOX 9

CHECK ITEM SXQ.845:

• IF SP HAD ORAL SEX PARTNER IN PAST 12 MONTHS (SXQ.627 OR SXQ.639 GREATER THAN ‘0000’), GO TO SXQ.645.

• OTHERWISE, GO TO BOX 9B.

SXQ.645 When you performed oral sex in the past 12 months, how often would you use protection, like a condom or dental dam?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 1

Rarely 2

Usually 3

Always 4

Unsure 5

REFUSED 7

DON'T KNOW 9

BOX 9B

CHECK ITEM SXQ.871:

• IF SXQ.818, SXQ.841, OR SXQ.827 GREATER THAN ‘0000’, GO TO SXQ.648.

• OTHERWISE, GO TO BOX 11.

SXQ.648 In the past 12 months, did you have any kind of sex with a person that you never had sex with before?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 10A

CHECK ITEM SXQ.859:

• IF SXQ.800, SXQ.806, AND SXQ.809 NOT EQUAL TO ‘1’, GO TO BOX 11.

• OTHERWISE, GO TO SXQ.610.

SXQ.610 In the past 12 months, about how many times have you had {vaginal or anal/vaginal/anal} sex?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 0

Once 1

2-11 times 2

12-51 times 3

52-103 times 4

104-364 times 5

365 times or more 6

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF SXQ.800 = 1 AND SXQ.806 AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal}.

IF SXQ.806 = 1 AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal}.

IF SXQ.836 GREATER THAN ‘0000’ AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal or anal}.

BOX 10

CHECK ITEM SXQ.245:

• IF SP DID NOT HAVE VAGINAL OR ANAL SEX (CODED ‘0’) IN SXQ.610, GO TO BOX 11.

• OTHERWISE, CONTINUE WITH SXQ.250.

SXQ.250 In the past 12 months, about how often have you had {vaginal or anal/vaginal/anal} sex without using a condom?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 1

Less than half of the time 2

About half of the time 3

Not always, but more than half of the time 4

Always 5

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTON:

IF SXQ.800 = 1 AND SXQ.806 AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal}.

IF SXQ.806 = 1 AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal or anal}.

BOX 11

CHECK ITEM SXQ.856:

• IF SP 14-29 YEARS AND IF SP HAD PARTNER IN PAST 12 MONTHS (SXQ.627, SXQ.639, SXQ.818, SXQ.827, OR SXQ.841 GREATER THAN ‘0000’), GO TO SXQ.651.

• OTHERWISE, GO TO SXQ.260.

SXQ.651 Of the persons you had any kind of sex with in the past 12 months, how many were five or more years older than you?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT FOR MALES: SXQ.651 must be equal to or less than (sum of SXQ.818 and SXQ.841 and SXQ.627 and SXQ.639 and SXQ.827)

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

SXQ.654 Of the persons you had any kind of sex with in the past 12 months, how many were five or more years younger than you?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT FOR MALES: SXQ.654 must be equal to or less than (sum of SXQ.818 and SXQ.841 and SXQ.627 and SXQ.639 and SXQ.827).

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT (combined) for SXQ.651 and SXQ.654

HARD EDIT FOR MALES: (sum of SXQ.651 and SXQ.654) must be equal to or less than (sum of SXQ.818 and SXQ.841 and SXQ.627 and SXQ.639 and SXQ.827).

Error message: "Your responses to the last two questions are not consistent with your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again."

SXQ.260 Has a doctor or other health care professional ever told you that you had genital herpes?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.265 Has a doctor or other health care professional ever told you that you had genital warts?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.270 In the past 12 months, has a doctor or other health care professional told you that you had gonorrhea, sometimes called GC or clap?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.272 In the past 12 months, has a doctor or other health care professional told you that you had chlamydia?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.280 Are you circumcised or uncircumcised?

INSTRUCTIONS TO SP:

Please select . . .

CAPI INSTRUCTIONS:

Display the sketches below each selection. Sketch should display by default.

ACASI FIGURE SXQ1 – CLINICAL SKETCH OF CIRCUMCISED PENIS

ACASI FIGURE SXQ2 – CLINICAL SKETCH OF UNCIRCUMCISED PENIS

Circumcised 1

Uncircumcised 2

REFUSED 7

DON'T KNOW 9

BOX 12

CHECK ITEM SXQ.285:

• IF SP 18-59 YEARS, CONTINUE WITH SXQ.292.

• OTHERWISE, GO TO END OF SECTION.

SXQ.292 Do you think of yourself as . . .

Heterosexual or straight (attracted to women) 1

Homosexual or gay (attracted to men) 2

Bisexual (attracted to men and women) 3

Something else 4

Not sure 5

REFUSED 7

DON'T KNOW 9

Reactions to Race

"This next set of questions asks about your health and how other people identify you and treat you. Please remember that your answers to these questions are strictly confidential."

RRQ.010 How do other people usually see you in this country?

Would you say . . . .

White 1

Black or African American 2

Asian Indian 3

Asian 4

Native Hawaiian or Other Pacific Islander 5

American Indian or Alaska Native 6

Hispanic or Latino 7

Some Other Group 8

REFUSED 77

DON'T KNOW 99

RRQ.020 Do you consider yourself Hispanic or Latino?

Yes............................................................... 1 (RRQ040)

No................................................................. 2 REFUSED..................................................... 7

DON'T KNOW............................................... 9

RRQ.030 What race do you consider yourself to be?

White........................................................... 1

Black or African American ........................ 2

Asian Indian............................................. 3

Asian................................................................... 4

Native Hawaiian or Other Pacific Islander 5

American Indian or Alaska Native........... . 6

Some Other Race .................................... 7

REFUSED

DON'T KNOW

RRQ.040 How often do you think about {being Hispanic or Latino/ being RACE REPORTED IN RRQ030/your race or ethnicity}?

Would you say . . .

Never 1

Once A Year 2

Once A Month 3

Once A Week 4

Once A Day 5

Once An Hour 6

Constantly 7

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF RACE020 = 1, DISPLAY {being Hispanic or Latino}.

IF RACE030 = 1, 2, 3, 4, 5, OR 6, DISPLAY {being RACE REPORTED IN RACE030}. OTHERWISE, DISPLAY {your race or ethnicity}.

RRQ.050 Within the past 12 months, have you seen a doctor or other health care professional at a doctor's office, clinic or emergency room OR stayed in the hospital?

Yes ………………..1

No …………………2 (RRQ.070)

RRQ.060 Within the past 12 months, when seeking health care do you feel your experiences were worse than, the same as, or better than people of other races?

Worse Than Other Races or Ethnicities 1

The Same As Other Races or Ethnicities 2

Better Than Other Races or Ethnicities 3

REFUSED 7

DON'T KNOW 9

RRQ.070 Have you worked at a job anytime in the past year?

Yes ……………….1

No ………………...2 (RRQ090)

RRQ.080 Within the past 12 months at work, do you feel you were treated worse than, the same as, or better than people of other races?

Worse Than Other Races or Ethnicities 1

The Same As Other Races or Ethnicities 2

Better Than Other Races or Ethnicities 3

REFUSED 7

DON'T KNOW 9

RRQ.090 Within the past 30 days, have you experienced any physical symptoms, for example a headache, an upset stomach, tensing of your muscles, or a pounding heart, as a result of how you were treated because {you are Hispanic or Latino/ you are RACE REPORTED IN RRQ030/of your race or ethnicity}?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RRQ020 = 1, DISPLAY {you are Hispanic or Latino}.

IF RRQ030 = 1, 2, 3, 4, 5, OR 6, DISPLAY {you are RACE REPORTED IN RRQ030}. OTHERWISE, DISPLAY {of your race or ethnicity}.

RRQ.100. Within the past 30 days, have you felt emotionally upset, for example angry, sad, or frustrated, as a result of how you were treated because {you are Hispanic or Latino/ you are RACE REPORTED IN RRQ030/of your race or ethnicity}?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF RRQ020 = 1, DISPLAY {you are Hispanic or Latino}.

IF RRQ030 = 1, 2, 3, 4, 5, OR 6, DISPLAY {you are RACE REPORTED IN RRQ030}. OTHERWISE, DISPLAY {of your race or ethnicity}.

SPECIAL FOLLOW-UP QUESTIONNAIRES

Flexible Consumer Behavior Survey Phone Follow-up

CBQ.502 You will need the green hand card booklet that is in the same bag as the food measuring guides {you used for your/we used for SP’s} dietary phone interview. I’ll wait while you locate it.

Do you have it?

Yes 1 (CBQ.505)

No, 2

REFUSED 7

DON'T KNOW 9

CBQ.503 Let’s go ahead with the interview anyway. Do you have a cereal box, can or package of food with a food label on the back or the side that you can use for this interview? I’ll wait while you locate it.

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

CBQ.505 {Great. I’ll tell you when you will need it.} For the first few questions, please answer yes or no.

In the past 12 months, did you buy food from fast food or pizza places?

CAPI INSTRUCTION:

If CBQ.503=”2”, “7”, OR “9”, REPLACE TEXT IN THE BRACES WITH THE FOLLOWING:

“Ok, let’s go ahead with the interview.”

Yes 1

No 2 [CBQ.550]

REFUSED 7

DON'T KNOW 9

CBQ.510 I’m going to read several reasons why you might buy food from fast food or pizza places instead of cooking at home.

First, do you buy food from fast food or pizza places because it is cheaper than cooking at home?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

CBQ.515 Do you buy food from fast food or pizza places because the foods there are more nutritious than foods cooked at home?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

CBQ.520 Do you buy food from fast food or pizza places because the foods there taste better than foods cooked at home?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

CBQ.525 Do you buy food from fast food or pizza places because it is more convenient than cooking at home?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

CBQ.530 Do you eat at fast food or pizza places instead of cooking at home to socialize with family and friends?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

CBQ.535 The last time when you ate out or bought food at a fast-food or pizza place, did you see nutrition or health information about any foods on the menu?

YES 1

NO 2 (CBQ.545)

REFUSED 7 (CBQ.545)

DON'T KNOW 9 (CBQ.545)

CBQ.540 Did you use the information in deciding which foods to buy?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CBQ.545 {Please open your hand card booklet and turn to hand card 1 to answer the next question.}

If nutrition or health information were readily available in fast food or pizza places, would you use it often, sometimes, rarely, or never, in deciding what to order?

[HAND CARD #1]

CAPI INSTRUCTION: Do NOT display the text in braces if CBQ.502=”2”.

OFTEN 1

SOMETIMES 2

RARELY 3

NEVER 4

REFUSED 7

DON'T KNOW 9

CBQ.550 In the past 12 months, did you eat at a restaurant with waiter or waitress service?

Yes 1

No 2 [CBQ.595]

REFUSED 7

DON'T KNOW 9

CBQ.555 I’m going to read several reasons why you might eat at a restaurant with a waiter or waitress instead of cooking at home.

First, do you eat at a restaurant with a waiter or waitress because it is cheaper than cooking at home?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

CBQ.560 Do you eat at a restaurant [with a waiter or waitress] because the foods there are more nutritious than foods cooked at home?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

CBQ.565 Do you eat at a restaurant [with a waiter or waitress] because the foods there taste better than foods cooked at home?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

CBQ.570 Do you eat at a restaurant [with a waiter or waitress] because it is more convenient than cooking at home?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

CBQ.575 Do you eat at a restaurant [with a waiter or waitress] instead of cooking at home to socialize with family and friends?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

CBQ.580 The last time you ate at a restaurant with a waiter or waitress, did you see nutrition or health information about any foods on the menu?

YES 1

NO 2 (CBQ.590)

REFUSED 7 (CBQ.590)

DON'T KNOW 9 (CBQ.590)

CBQ.585 Did you use the information in deciding which foods to buy?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CBQ.590 {Please look at hand card 1 [again].}

If nutrition or health information were readily available in restaurants with a waiter or waitress, would you use it often, sometimes, rarely, or never, in deciding what to order?

[HAND CARD #1]

CAPI INSTRUCTION: Do NOT display the text in braces if CBQ.502=”2”.

OFTEN 1

SOMETIMES 2

RARELY 3

NEVER 4

REFUSED 7

DON'T KNOW 9

CBQ.595 Next I’m going to ask a few questions about the nutritional guidelines recommended for Americans by the federal government.

Have you heard of My Pyramid?

YES 1 (CBQ.605)

NO 2

REFUSED 7

DON'T KNOW 9

CBQ.600 Have you heard of the Food Pyramid or the Food Guide Pyramid?

YES 1 (CBQ.610)

NO 2 (DBQ.890)

REFUSED 7 (DBQ.890)

DON’T KNOW 9 (DBQ.890)

CBQ.605 Have you looked up the My Pyramid plan for a {man/woman/person} your age on the internet?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

CBQ.610 Have you tried to follow the {My Pyramid Plan/Pyramid plan} recommended for you?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

IF CBQ595 = Yes THEN DISPLAY "My Pyramid/Plan Mi Pirámide". ELSE DISPLAY "Pyramid plan/plan de la Pirámide de Alimentos"

BOX 2

CHECK ITEM CBQ.615:

CBQ.620-CBQ.645 ONLY APPLY TO RESPODENT WHO IS A SP.

IF RESPONDENT IS A SP, CONTINUE.

OTHERWISE, GO TO DBQ.890.

CBQ.620 Let us talk about the amounts from different food groups that a person should eat each day.

How many cups of milk would you say a {man/woman} of your age and physical activity should drink each day for good health?

|___|___|.|___|

ENTER NUMBER OF CUPS

REFUSED 77

DON'T KNOW 99

CBQ.625 How many cups of fruits would you say a {man/woman} of your age and physical activity should eat each day for good health?

|___|___|.|___|

ENTER NUMBER OF CUPS

REFUSED 77

DON'T KNOW 99

CBQ.630 How many cups of vegetables, including dark green, orange, starchy, and other vegetables, would you say a {man/woman} of your age and physical activity should eat each day for good health?

|___|___|.|___|

ENTER NUMBER OF CUPS

REFUSED 77

DON'T KNOW 99

CBQ.635 How many ounces of meat and beans would you say a {man/woman} of your age and physical activity should eat each day for good health?

|___|___|.|___|

ENTER NUMBER OF OUNCES

REFUSED 77

DON'T KNOW 99

CBQ.637 How many ounces of grains would you say a {man/woman} of your age and physical activity should eat each day for good health?

HELP SCREEN:

Any food made from wheat, rice, oats, cornmeal, barley or another cereal grain is a grain product. Bread, pasta, oatmeal, breakfast cereals, tortillas, and grits are examples of grain products.

|___|___|.|___|

ENTER NUMBER OF OUNCES

REFUSED 77

DON'T KNOW 99

CBQ.640 How many ounces of “whole grains” would you say a {man/woman} of your age and physical activity should eat each day for good health?

INTERVIEWER INSTRUCTION:

If the respondent does not know what “whole grains” means, code “66”.

Use help screen to provide answers to the respondent if he/she wants to know what “whole grains” means. However, do NOT change the original “66” code even if the respondent gives an answer after you had explained “whole grains”.

HELP SCREEN:

Whole grains contain the entire grain kernel -- the bran, germ, and endosperm. Examples include: whole-wheat flour, whole-wheat bread, whole-wheat cereal flakes, bulgur (cracked wheat), oatmeal, whole cornmeal, and brown rice.

|___|___|.|___|

ENTER NUMBER OF OUNCES

DON'T KNOW WHAT IS “WHOLE GRAIN” 66

REFUSED 77

DON'T KNOW 99

CBQ.645 {Please turn to hand card 2.}

About how many calories do you think a {man/woman} of your age and physical activity needs to consume a day to maintain your current weight?

[HAND CARD #2]

CAPI INSTRUCTION: Do NOT display the text in braces if CBQ.502=”2”.

A. Less than 500 calories 1

B. 500-1000 calories 2

C. 1001-1500 calories 3

D. 1501-2000 calories 4

E. 2001-2500 calories 5

F. 2501-3000 calories 6

G. More than 3000 calories 7

REFUSED 77

DON'T KNOW 99

DBQ.890 {Turn to hand card 3.}

Would you say you strongly agree, somewhat agree, neither agree nor disagree, somewhat disagree, or strongly disagree with the following statement: “Some people are born to be fat and some thin; there is not much you can do to change this”?

[HAND CARD #3]

CAPI INSTRUCTION: Do NOT display the text in braces if CBQ.502=”2”.

STRONGLY AGREE 1

SOMEWHAT AGREE 2

NEITHER AGREE NOR DISAGREE 3

SOMEWHAT DISAGREE 4

STRONGLY DISAGREE 5

REFUSED 7

DON'T KNOW 9

BOX 3

CHECK ITEM CBQ.650:

CBQ.655 ONLY APPLY TO RESPODENT WHO IS A SP.

IF RESPONDENT IS A SP, CONTINUE.

OTHERWISE, GO TO CBQ.660.

CBQ.655 Would you say you strongly agree, somewhat agree, neither agree nor disagree, somewhat disagree, or strongly disagree with the following statement: “There is no reason for me to make changes to the things I eat”?

[HAND CARD #3]

STRONGLY AGREE 1

SOMEWHAT AGREE 2

NEITHER AGREE NOR DISAGREE 3

SOMEWHAT DISAGREE 4

STRONGLY DISAGREE 5

REFUSED 7

DON'T KNOW 9

CBQ.660 {For the next set of questions, please use hand card 4.}

When you buy food from a grocery store or supermarket, how important is “price”?

Would you say very important, somewhat important, not too important, or not at all important?

[HAND CARD #4]

CAPI INSTRUCTION: Do NOT display the text in braces if CBQ.502=”2”.

VERY IMPORTANT 1

SOMEWHAT IMPORTANT 2

NOT TOO IMPORTANT 3

NOT AT ALL IMPORTANT 4

NEVER BUY FROM A GROCERY STORE OR SUPERMARKET 5 (DBQ.700)

REFUSED 7

DON'T KNOW 9

CBQ.665 How about “nutrition”? When you buy food from a grocery store or supermarket, how important is “nutrition”?

[Would you say very important, somewhat important, not too important, or not at all important?]

[HAND CARD #4]

VERY IMPORTANT 1

SOMEWHAT IMPORTANT 2

NOT TOO IMPORTANT 3

NOT AT ALL IMPORTANT 4

REFUSED 7

DON'T KNOW 9

CBQ.670 How about “taste”?

[When you buy food from a grocery store or supermarket, how important is “taste”?]

[Would you say very important, somewhat important, not too important, or not at all important?]

[HAND CARD #4]

VERY IMPORTANT 1

SOMEWHAT IMPORTANT 2

NOT TOO IMPORTANT 3

NOT AT ALL IMPORTANT 4

REFUSED 7

DON'T KNOW 9

CBQ.675 How about “how easy the food is to prepare”?

[When you buy food from a grocery store or supermarket, how important is “how easy the food is to prepare”?]

[Would you say very important, somewhat important, not too important, or not at all important?]

[HAND CARD #4]

VERY IMPORTANT 1

SOMEWHAT IMPORTANT 2

NOT TOO IMPORTANT 3

NOT AT ALL IMPORTANT 4

REFUSED 7

DON'T KNOW 9

CBQ.680 How about “how well the food keeps after it’s bought”?

[When you buy food from a grocery store or supermarket, how important is “how well the food keeps after it’s bought [in other words, how soon it spoils]”?]

[Would you say very important, somewhat important, not too important, or not at all important?]

[HAND CARD #4]

VERY IMPORTANT 1

SOMEWHAT IMPORTANT 2

NOT TOO IMPORTANT 3

NOT AT ALL IMPORTANT 4

REFUSED 7

DON'T KNOW 9

CBQ.700 {Now turn the page to use hand card 5.}

Many food packages contain an expiration date such as “use by” or “sell by”. How often do you use the expiration date when deciding to buy a food product?

Would you say always, most of the time, sometimes, rarely, or never?

[HAND CARD #5]

CAPI INSTRUCTION: Do NOT display the text in braces if CBQ.502=”2”.

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

NEVER SEEN 6

REFUSED 7

DON'T KNOW 9

DBQ.780 Some food packages contain health claims about the benefits of nutrients or foods {like the examples on hand card 6}. How often do you use this kind of health claim when deciding to buy a food product?

Using hand card 7, would you say always, most of the time, sometimes, rarely, or never?

[HAND CARDS #6 & #7]

CAPI INSTRUCTIONS:

IF CBQ.502=2, 7, or 9, REPLACE TEXT IN THE BRACES WITH THE FOLLOWING:

‘For example, "Diets low in sodium may reduce the risk of high blood pressure”, or “Diets rich in calcium may reduce your risk of osteoporosis” ’

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

NEVER SEEN 6

REFUSED 7

DON'T KNOW 9

DBQ.750 {For the next few questions you’ll use hand card 9 to respond, but first please look at hand card 8 which shows an example of the food label.

The "Nutrition Facts panel" of a food label is everything on this page except the list of ingredients in pink. How often do you use the Nutrition Facts panel when deciding to buy a food product?}

Would you say always, most of the time, sometimes, rarely, or never?

[HAND CARDS #8 & #9]

CAPI INSTRUCTIONS:

IF CBQ.502=1, DISPLAY DBQ.750 AS SHOWN ABOVE.

ELSE IF CBQ.503=1, REPLACE TEXT IN THE BRACES WITH THE FOLLOWING:

“Next, we have some questions about food labels. On your (cereal box, can, food package, etc.) please look for the food label that is usually on the back or the side of the package. A food label has two parts, a Nutrition Facts panel and a list of ingredients. The "Nutrition Facts panel" of a food label lists the amount of calories, fat, fiber, carbohydrates and some other nutritional information.

How often do you use the Nutrition Facts panel when deciding to buy a food product?”

ELSE IF CBQ.503=2, 7, OR 9, REPLACE TEXT IN THE BRACES WITH THE FOLLOWING:

“Next, we have some questions about food labels. A food label usually is on the back or the side of the food package. It has two parts, a Nutrition Facts panel and a list of ingredients. The "Nutrition Facts panel" of a food label lists the amount of calories, fat, fiber, carbohydrates and some other nutritional information.

How often do you use the Nutrition Facts panel when deciding to buy a food product?”

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

NEVER SEEN 6

REFUSED 7

DON'T KNOW 9

DBQ.760 How about the list of ingredients? [HAND CARD #8]

How often do you use the list of ingredients on a food label, {such as the part colored in pink on hand card 8,} when deciding to buy a food product?

Would you say always, most of the time, sometimes, rarely, or never?

[HAND CARD #9]

CAPI INSTRUCTION: Do NOT display the text in braces if CBQ.502=”2”.

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

NEVER SEEN 6

REFUSED 7

DON'T KNOW 9

DBQ.770 How about the information on the serving size? [HAND CARD #8]

[How often do you use information on the serving size on a food label, {such as the part colored in green on hand card 8,} when deciding to buy a food product?]

[Would you say always, most of the time, sometimes, rarely, or never?]

[HAND CARD #9]

CAPI INSTRUCTION: Do NOT display the text in braces if CBQ.502=”2”.

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

NEVER SEEN 6

REFUSED 7

DON'T KNOW 9

CBQ.685 How about the information on the percent daily value? [HAND CARD #8]

[How often do you use information on the percent daily value on a food label, {such as the part colored in blue on hand card 8,} when deciding to buy a food product?]

[Would you say always, most of the time, sometimes, rarely, or never?]

[HAND CARD #9]

CAPI INSTRUCTION: Do NOT display the text in braces if CBQ.502=”2”.

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

NEVER SEEN 6

REFUSED 7

DON'T KNOW 9

BOX 5

CHECK ITEM CBQ. 707new:

IF (DBQ.750 = 1-3) OR (DBQ.760 = 1-3) OR (DBQ.770 = 1-3) OR (DBQ.780 = 1-3), OR (CBQ.685 = 1-3), CONTINUE;

ELSE IF (DBQ.750 = 6-9) AND (DBQ.760 = 6-9) AND (DBQ.770 = 6-9) AND (DBQ.780 = 6-9), AND (CBQ.685 = 6-9), GO TO CBQ.695;

OTHERWISE, GO TO CBQ.697.

CBQ.710 Now think about the types of food products you buy using food labels.

How often do you look for nutrition information on the food label when you buy snack items like chips, popcorn, or pretzels?

Would you say always, most of the time, sometimes, rarely, or never?

[HAND CARD #9]

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

NEVER BUY THESE ITEMS 6

REFUSED 7

DON'T KNOW 9

CBQ.715 How about when you buy “breakfast cereals”?

[How often do you look for nutrition information on the food label when you buy breakfast cereals?] [Would you say always, most of the time, sometimes, rarely, or never?]

[HAND CARD #9]

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

NEVER BUY THESE ITEMS 6

REFUSED 7

DON'T KNOW 9

CBQ.720 How about when you buy “salad dressings”?

[How often do you look for nutrition information on the food label when you buy salad dressings?]

[Would you say always, most of the time, sometimes, rarely, or never?]

[HAND CARD #9]

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

NEVER BUY THESE ITEMS 6

REFUSED 7

DON'T KNOW 9

CBQ.725 How about when you buy “raw meat, poultry, or fish”?

[How often do you look for nutrition information on the food label when you buy raw meat, poultry, or fish?]

[Would you say always, most of the time, sometimes, rarely, or never?]

[HAND CARD #9]

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

NEVER BUY THESE ITEMS 6

REFUSED 7

DON'T KNOW 9

CBQ.730 How about when you buy “processed meat products like hot dogs or bologna”?

[How often do you look for nutrition information on the food label when you buy processed meat products like hot dogs or bologna?]

[Would you say always, most of the time, sometimes, rarely, or never?]

[HAND CARD #9]

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

NEVER BUY THESE ITEMS 6

REFUSED 7

DON'T KNOW 9

CBQ.735 How about when you buy “bread”?

[How often do you look for nutrition information on the food label when you buy bread?]

[Would you say always, most of the time, sometimes, rarely, or never?]

[HAND CARD #9]

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

NEVER BUY THIS ITEM 6

REFUSED 7

DON'T KNOW 9

CBQ.737 {What is the reason or reasons that you check the food label when deciding to buy a food product? There are some examples on hand card 10. You may give more than one answer.}

[HAND CARD #10]

CAPI INSTRUCTIONS:

IF CBQ.502=1, DISPLAY CBQ.737 AS SHOWN ABOVE.

ELSE IF CBQ.502=2, 7, OR 9 –

1. REPLACE TEXT IN THE BRACES WITH THE FOLLOWING:

“For this next question you may give more than one answer. What is the reason or reasons that you check the food label when deciding to buy a food product? I will read you some examples.”

2. DISPLAY ALL THE RESPONSE CATEGORIES IN LOWER CASE

CODE ALL THAT APPLY.

TO WATCH MY WEIGHT AND/OR LOSE WEIGHT 10

A FAMILY MEMBER IS TRYING TO WATCH WEIGHT AND/OR LOSE WEIGHT 11

TO WATCH FOR DIABETES, HIGH TRIGLYCERIDES, HIGH CHOLESTEROL, HIGH BLOOD PRESSURE OR OTHER HEALTH CONDITIONS 12

A FAMILY MEMBER HAS A HEALTH CONDITION

(FOR EXAMPLE, DIABETES, HIGH TRIGLYCERIDES, HIGH CHOLESTEROL, HIGH BLOOD PRESSURE, ETC) 13

I AM ALLERGIC TO CERTAIN FOOD(S) 14

MY FAMILY MEMBER(S) HAS FOOD ALLERGIES 15

TO AVOID CERTAIN INGREDIENTS

(SUCH AS MSG, HIGH FRUCTOSE CORN SYRUP, COLOR DYES, ARTIFICIAL PRESERVATIVES, OR HYDROGENATED OILS, ETC) 16

TO INCREASE CERTAIN NUTRIENTS IN MY/FAMILY’S DIET

(SUCH AS FIBER, CALCIUM, ETC) 17

TO COMPARE WHICH BRAND/FOOD IS BETTER/HEALTHIER 18

TO MAKE BETTER/HEALTHIER CHOICES FOR ME AND MY FAMILY 19

OTHER SPECIFY________________ 91

REFUSED 77

DON’T KNOW 99

BOX new.

CHECK ITEM CBQ.new1:

GO TO CBQ.695.

CBQ.697 {What is the reason or reasons that you rarely or never check the food label when deciding to buy a food product? There are some examples on hand card 11. You may give more than one answer.}

[HAND CARD #11]

CAPI INSTRUCTIONS:

IF CBQ.502=1, DISPLAY CBQ.697 AS SHOWN ABOVE.

ELSE IF CBQ.502=2, 7, OR 9 –

1. REPLACE TEXT IN THE BRACES WITH THE FOLLOWING:

“For this next question you may give more than one answer. What is the reason or reasons that you rarely or never check the food label when deciding to buy a food product? I will read you some examples.”

2. DISPLAY ALL THE RESPONSE CATEGORIES IN LOWER CASE

CODE ALL THAT APPLY.

I DON'T HAVE THE TIME 10

THE PRINT IS TOO SMALL FOR ME TO READ 11

I’M SATISFIED WITH MY HEALTH SO THERE IS NO NEED FOR ME TO CHECK 12

I HAVE A GOOD DIET SO THERE IS NO NEED TO CHECK LABELS 13

I USUALLY BUY FOODS THAT I'M USED TO, SO I DON’T FEEL THAT I NEED TO CHECK LABELS 14

I BUY WHAT I OR MY FAMILY LIKE, I DON’T CARE ABOUT THE LABELS 15

I DON’T THINK THE FOOD LABELS ARE IMPORTANT TO ME 16

I WON’T KNOW WHAT TO LOOK FOR EVEN IF I READ THE LABELS 17

I CAN’T READ ENGLISH THAT WELL 18

OTHER SPECIFY________________ 91

REFUSED 77

DON’T KNOW 99

CBQ.695 {Now turn to hand card 12.} Again, for this next question you may give more than one answer.

Now think about the “serving size” on a food label. What does serving size mean to you? Serving size is…

CODE ALL THAT APPLY

[HAND CARD #12]

CAPI INSTRUCTION:

1. Do NOT display the text in braces if CBQ.502=”2”.

2. IF (DBQ.750 = 6-9) AND (DBQ.760 = 6-9) AND (DBQ.770 = 6-9) AND (DBQ.780 = 6-9), AND (CBQ.685 = 6-9), Do NOT display the word “Again,” in the introduction sentence.

The amount of this food that people should eat 1

The amount of this food that people usually eat 2

Something that makes it easier to compare foods 3

REFUSED 7

DON'T KNOW 9

CBQ.741 In the past 30 days, did you buy any food that had the word ‘organic’ on the package?

INTERVIEWER INSTRUCTION:

Include foods bought at the organic section in a store, or food stands labeled organic.

YES 1

NO 2 (CBQ.825)

DO NOT SHOP FOR FOOD 3 (CBQ.825)

REFUSED 7 (CBQ.825)

DON'T KNOW 9 (CBQ.825)

CBQ.790 In the past 30 days, when you bought fruits, how often did you buy organic fruits?

{Using hand card 13}

Would you say always, most of the time, sometimes, rarely, or never?

[HAND CARD #13]

CAPI INSTRUCTION: Do NOT display the text in braces if CBQ.502=”2”.

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

DO NOT SHOP FOR FRUIT 6

REFUSED 7

DON'T KNOW 9

CBQ.795 How about organic vegetables?

[In the past 30 days,] when you bought vegetables, how often did you buy organic vegetables? Would you say always, most of the time, sometimes, rarely, or never?

[HAND CARD #13]

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

DO NOT SHOP FOR VEGETABLES 6

REFUSED 7

DON'T KNOW 9

CBQ.800 How about organic milk and other dairy products?

[In the past 30 days,] [when you bought milk and other dairy products, how often did you buy organic milk and other dairy products? Would you say always, most of the time, sometimes, rarely, or never?]

[HAND CARD #13]

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

DO NOT SHOP FOR MILK OR DAIRY PRODUCTS 6

REFUSED 7

DON'T KNOW 9

CBQ.805 How about organic eggs?

[In the past 30 days,] [when you bought eggs, how often did you buy organic eggs? Would you say always, most of the time, sometimes, rarely, or never?]

[HAND CARD #13]

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

DO NOT SHOP FOR EGGS 6

REFUSED 7

DON'T KNOW 9

CBQ.810 How about organic baby foods?

[In the past 30 days,] [when you bought baby foods, how often did you buy organic baby foods? Would you say always, most of the time, sometimes, rarely, or never?]

[HAND CARD #13]

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

DO NOT SHOP FOR BABY FOODS 6

REFUSED 7

DON'T KNOW 9

CBQ.815 How about organic poultry, such as chicken or turkey?

[In the past 30 days,] [when you bought poultry, such as chicken or turkey, how often did you buy organic poultry? Would you say always, most of the time, sometimes, rarely, or never?]

[HAND CARD #13]

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

DO NOT SHOP FOR POULTRY 6

REFUSED 7

DON'T KNOW 9

CBQ.820 How about organic meats?

[In the past 30 days,] [when you bought meats, how often did you buy organic meats? Would you say always, most of the time, sometimes, rarely, or never?]

[HAND CARD #13]

INTERVIEWER INSTRUCTION: Do not include seafood.

ALWAYS 1

MOST OF THE TIME 2

SOMETIMES 3

RARELY 4

NEVER 5

DO NOT SHOP FOR MEATS 6

REFUSED 7

DON'T KNOW 9

CBQ.825 {Now, please look at hand card 14.  This is a picture of the USDA Organic seal.  Have you ever seen this seal on a food product?}

[HAND CARD #14]

CAPI INSTRUCTIONS:

IF CBQ.502=2, 7, or 9, REPLACE TEXT IN THE BRACES WITH THE FOLLOWING:

‘Have you ever seen the “USDA ORGANIC” seal on a food product? ’

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 6.

CHECK ITEM CBQ.750:

CBQ.755, DBQ.930-DBQ.945, CBQ.760-CBQ.780 ONLY APPLY TO NON-SP PROXY.

IF RESPONDENT IS A SP, GO TO CBQ.785.

OTHERWISE, CONTINUE.

CBQ.755 What is your relation with {SP}?

Mother of SP 1

Father of SP 2

Grandparent of SP 3

Child care provider, Caretaker 4

Other Relative 5

Friend, Non Relative 6

REFUSED 7

DON'T KNOW 9

DBQ.930 Are you the person who does most of the planning or preparing of meals in your family?

INTERVIEWER INSTRUCTION: IF SP ANSWERS “SOMETIMES” OR “50/50”, ENTER YES

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.935 Do you share in the planning or preparing of meals with someone else?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.940 Are you the person who does most of the shopping for food in your family?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.945 Do you share in the shopping for food with someone else?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CBQ.760 How old are you?

|___|___| Years

Enter AGE

REFUSED 77

DON'T KNOW 99

CBQ.765 Which of the following best describe your highest education level?

Less than high school 1

High school diploma (including GED), or 2

More than high school 3

REFUSED 7

DON'T KNOW 9

CBQ.770 WHAT IS THE GENDER OF THE RESPONDENT?

[Interviewer Instruction: this is a question for the interviewer to complete by selecting the appropriate option. No need to read the question to the SP]

MALE 1

FEMALE 2

CBQ.785 THE INTERVIEW WAS COMPLETED IN:

INTERVIEWER INSTRUCTION:

This is a question for the interviewer to complete by selecting the appropriate option. Do not read the question to the SP.

ENGLISH 1

SPANISH 2

ENGLISH AND SPANISH 3

OTHER 4

HANES Hepatitis C Follow-Up Questionnaire

Telephone survey script and questionnaire:

I am calling from the NHANES program. You participated in our examination survey in _____,<month/year>, and on ______ <date> you were mailed a letter with your hepatitis C test result. Explain what report this is. Participants get preliminary results at the time of the examination, early reports of abnormal labs (liver function tests) and letters reporting other possible infection...Hepatitis B.

64180. Did you receive a letter in the mail with your Hepatitis C test results?

1. Yes

2. No –> <verify address, describe letter and fact sheet, if absolutely no recall, resend letter, follow-up in two months> (if participant has questions about hepatitis C, transfer call to Dr. Kathryn Porter (ext. 4441) or Dr. Geraldine McQuillan (ext. 4371). End interview

I would like to ask you some questions about what you know about hepatitis C and any follow-up you may have taken since getting the letter. The interview will take about 20 minutes. All information you provide is strictly confidential, and your participation is voluntary. Information will be used by the Centers for Disease Control and Prevention to help people with hepatitis C.

May we proceed with the interview?

If "yes", go to 2). If not - set up an appointment for a better time, or note the reason for the refusal.

2) There are many types of hepatitis. Before receiving the letter with your test result, had you heard of hepatitis C?

1. Yes

2. No

3. Heard of hepatitis, but not specifically hepatitis C

7. Refused

9. Don’t know

3) Was the test result in our letter the first time you were told you had hepatitis C?

1. Yes [skip to 6]

2. No

7. Refused [skip to 6]

9. Don’t know [skip to 6]

4) For about how long have you known that you had hepatitis C? Would you say..

1. One year

2. 2 to 5 years

3. More than 5 years

7. Refused

9. Don’t know

5) Why were you first tested for hepatitis C? Was it because:

1. You donated blood?

2. You had other blood tests done for a routine physical that showed you might have liver disease?

3. You were sick with symptoms like fatigue, nausea, stomach pain, yellowing of the eyes or skin (known as jaundice)?

4. You were exposed to blood while on the job?

5. You or your doctor thought you were at risk of having Hepatitis C?

6. You had an other reason?

7. Refused

9. Don’t know

Now I’m going to ask you some questions about what you have done since finding out that you have hepatitis C.

6. Did you see a doctor or other health professional about your Hepatitis C test result? (If tested before NHANES, question refers to first test; otherwise refers to NHANES test)

1. Yes [skip to 8]

2. No

7. Refused

9. Don’t know

7. Do you have an appointment to see a doctor or other health care professional about your hepatitis C test result?

1. Yes [skip to 15]

2. No [skip to 15]

7. Refused [skip to 15]

9. Don’t know [skip to 15]

8) When you saw a doctor or other health professional about your hepatitis C test results, did you have other blood tests to check how your liver is working?

1. Yes

2. No

7. Refused

9. Don’t know

9. Which of the following statements describes most closely what your doctor told you about your hepatitis C test result? (Read each statement and check only one)

1. You have hepatitis C and need regular medical follow-up.

2. You tested positive for hepatitis C, but you do not need to do anything or worry about it. [skip to 15]

3. You really don’t have hepatitis C because a follow-up test showed that the positive test result was in error. (End interview)

4. Other

7. Refused

9. Don’t know

10) Did you have a liver biopsy (procedure to get a small piece of your liver through a needle)?

1. Yes

2. No

7. Refused

9. Don’t know

11) Did your doctor or health care professional tell you that your hepatitis C should be treated with medication such as Interferon and Ribavirin?

1. Yes

2. No (skip to 14)

7. Refused (skip to 14)

9. Don’t know (skip to 14)

12) Did you get treated with these medicines?

1. Yes (skip to 14)

2. No

7. Refused (skip to 14)

9. Don’t know (skip to 14)

13) Why did you not get treated? (Chose all that apply) Was it because ..

1. The side effects to the treatment are unpleasant.

2. The treatment shots must be self injected.

3. The treatment is too expensive,

4. There is a hope of better treatment in the future.

5. Or is there some other reason?

14) Did your doctor or health care professional tell you to avoid or limit alcoholic beverages because of your hepatitis C?

1. Yes

2. No

7. Refused

9. Don’t know

We would like to know what you have learned about hepatitis C. Please tell me if you believe the following statements are true or false, or if you don’t know whether they are true or false.

15) If someone is infected with hepatitis C virus, they will most likely carry the virus all their lives.

1. True

2. False

7. Refused

9. Don't know

16) Infection with the hepatitis C virus can cause the liver to stop working.

1. True

2. False

7. Refused

9. Don't know

17) Someone with hepatitis C can look and feel fine.

1. True

2. False

7. Refused

9. Don't know

18) You can get hepatitis C by getting a blood transfusion from an infected donor.

1. True

2. False

7. Refused

9. Don't know

19) You can get hepatitis C by shaking hands with someone who has hepatitis C.

1. True

2. False

7. Refused

9. Don't know

20) You can get hepatitis C by kissing someone who has hepatitis C.

1. True

2. False

7. Refused

9. Don't know

21) You can get hepatitis C by having sex with someone who has hepatitis C.

1. True

2. False

7. Refused

9. Don't know

22) You can get hepatitis C by being born to a woman who had hepatitis C when she gave birth.

1. True

2. False

7. Refused

9. Don't know

23) You can get hepatitis C by being stuck with a needle or sharp instrument that has hepatitis C infected blood on it.

1. True

2. False

7. Refused

9. Don't know

24) You can get hepatitis C by working with someone who has hepatitis C.

1. True

2. False

7. Refused

9. Don't know

25) You can get hepatitis C by injecting illegal drugs, even if only a few times.

1. True

2. False

7. Refused

9. Don't know

End Interview

Thank you for your time. We want to emphasize that everything you have told us will be held strictly confidential. We appreciate your participation in the National Health and Nutrition Examination Survey.

MEC DATA COLLECTION FORMS

MEC Data Collection Forms

Anthropometry

Arthritis physical measures

Dual X-ray absorptiometry

Bone Mineral Density

Dietary Interview

Audiometry

Oral Health

Physician Examination

Blood Pressure Measurement

Spirometry / Exhaled Nitric Oxide (ENO) Measurement

Venipuncture

Second venipuncture

*No data collection forms for urine

ANTHROPOMETRY NHANES 2009-20010 (All ages)

Target Age Groups: Anthropometry Measurements and Questions

Birth+	2mo+	2yr+	4yr+	8yr+
Weight	Weight	Weight	Weight	Weight
Recumbent length	Recumbent length	Recumbent length (through 47 mo.)
Head circumference	Head circumference (through 6 mo.)
		Standing height	Standing height	Standing height
	Upper arm length	Upper arm length	Upper arm length	Upper arm length
	Mid-upper arm circumference	Mid-upper arm circumference	Mid-upper arm circumference	Mid-upper arm circumference
		Waist circumference	Waist circumference	Waist circumference
				Upper leg length
	Triceps skinfolds	Triceps skinfolds	Triceps skinfolds	Triceps skinfolds
	Subscapular skinfold	Subscapular skinfold	Subscapular skinfold	Subscapular skinfold
Would you like to know your height and weight?	Would you like to know your height and weight?	Would you like to know your height and weight?	Would you like to know your height and weight?	Would you like to know your height and weight?

ANTHROPOMETRY COMPONENT DATA COLLECTION (cont’d)

AMPUTATION QUESTIONS: Information is recorded during the body measurement examination for all ages. Questions may be asked if the information is not obvious to the examiner. The responses are used to interpret body measurement results, particularly the body weight data.

Are there any amputations? Recorder codes YES/NO

IF YES to the amputation question, continue with information on the site(s) of the amputation(s):

Amputation of the Upper Right Extremity? YES/NO/COULD NOT OBTAIN

IF YES: Code if the amputation is ABOVE ELBOW/BELOW ELBOW

Amputation of the Upper Left Extremity? YES/NO/COULD NOT OBTAIN

IF YES: Code if the amputation is ABOVE ELBOW/BELOW ELBOW

Amputation of the Lower Right Extremity? YES/NO/COULD NOT

IF YES: Code if the amputation is ABOVE KNEE/BELOW KNEE

Amputation of the Lower Left Extremity? YES/NO/COULD NOT OBTAIN

IF YES: Code if the amputation is ABOVE KNEE/BELOW KNEE

ARTHRITIS EXAMINATION (Adults 20-69 years)

Three assessments will be integrated into the anthropometry examination to assess spine flexibility. The assessments are:

1) Occiput-to-wall distance to assess cervical (neck) region spine flexibility

2) Chest circumferences (inflated and deflated chest circumferences) to assess thoracic (chest) region flexibility

3) Modified Schober Test to assess lower spine flexibility.

Bone Mineral Density (DXA) (Ages 8+ years)

Additional Safety/Exclusion Questions for Proximal Femur (hip) and Lumbar Spine Scans:

1. Do you have a lumbar spine fusion? 1=Yes (Exclude from spine,

but not from femur scan)

2=No

2. Have you ever fractured your hip, had a hip replacement, or do you have a pin in your

hip? 1=Yes

2=No

If yes, ask:

3. Was it your right hip, left hip, or both hips? 1=Right

2=Left

3=Both (Exclude from femur,

but not from spine scan)

Bone Mineral Content (BMC) and Bone Mineral Density (BMD):

Proximal Femur:

Area cm²

Bone Mineral Content grams

Bone Mineral Density (grams/cm²)

Values for each of the variables listed above will be given for the following regions:

Femoral neck

Trochanter

Intertrochanter

Ward’s triangle

Total femur

Lumbar spine:

Area cm²

Bone Mineral Content grams

Bone Mineral Density grams/cm²

Values for each of the variables listed above will be given for lumbar spine vertebrae L1 – L4 and the total spine

DIETARY INTERVIEW (all ages)

24-Hour Dietary Recall Interview

Information will be obtained on all foods and beverages that were consumed during a 24-hour time period (midnight to midnight). The information that is obtained for foods and beverages includes the following:

1. Time of day -Time when the food was eaten

2. Meal name code - The name of the eating occasion is selected from a list of options.

3. Meal place - Whether the meal was eaten at home.

4. Food item name - The name of the food is either typed in or selected from a list of food item names.

5. Food item description - Detailed description of the food including information about commercial product name (if applicable), preparation method, and major recipe ingredients.

6. Fat added in preparation - A preparation fat probe is asked for certain foods. The type of fat used during food preparation is specified as well.

7. Amount of food eaten - The amount of food consumed by the respondent.

8. Food source - The place where the food was obtained is selected from a list of options

24-Hour Dietary Recall Interview Scripts - In-Person Interview:

A. Introduction script

First, we’ll make a list of the foods you/SP ate and drank yesterday, Monday. It may help you remember what you/SP ate by thinking about where you/he/she were, who you/he/she were with, or what you/he/she were doing, like working, eating out, or watching television.

Please tell me everything you/SP had to eat and drink all day yesterday, Monday, from midnight to midnight. Include everything you/he/she had at home and away, even snacks, coffee, soft drinks, water, and alcoholic beverages. I’ll ask you for specific details and amounts of the foods in a few minutes. At this time, just tell me what you/SP had.

B. Forgotten food probes script

Your answers are important, so we’d like this list to be as complete as possible.

In addition to the foods you have/SP has already told me about, did you have any coffee, tea, soft drinks, milk or juice?

Beer, wine, cocktails or other drinks?

Cookies, candy, ice cream or other sweets?

Chips, crackers, popcorn, pretzels, nuts, or other snack foods?

Fruits, vegetables, or cheese?

Bread, rolls or tortillas?

Anything else?

C. Food detail probes script

Now we’re going to fill in your list with more detail. When I ask how much {you/SP} ate, you can tell me the amount by using the models on the table and in the racks.

You may use the grid for rectangular or square shapes and the circles for circular or round shapes. Use the wedge for wedge shaped foods.

You can use the thickness bars to show me the thickness of a food and the bean bags and mounds to describe the amounts of solid foods.

When you use the cups, bowls, and glasses, please show me which line best describes the portion {you/SP/he/she} ate or drank. When you use any of the spoons, please tell me the quantity in LEVEL spoonfuls.

24-Hour Dietary Recall Interview Scripts - Telephone Interview:

A. Greeting script

Hello, Mr./Mrs. {SP/Proxy}, my name is {interviewer’s name}. I am calling for the National Health and Nutrition Examination Survey to conduct {your/SP’s} second dietary interview over the telephone.

You will need the food measuring guides that we gave you during your MEC visit. I’ll wait while you locate them.

Do you have them? Yes/No/Needs to reschedule

If yes, go to next question.

If no:

Let’s go ahead with the interview today anyway. Do you have a ruler or some measuring cups and measuring spoons in your home that you can use for this interview?

If SP needs to reschedule:

We can schedule another appointment for the interview. Is there a time that will be convenient? Enter date/ Enter time/ Verify contact phone

If SP is not willing to reschedule:

We cannot ask everyone in the country to be in our study. You are special because you have been chosen to participate. No one else can take your place. We hope that you will help us with this interview. It will only take about 20 minutes, you will receive $30 for participating, and it is such an important part of the health survey.

If SP still says no:

Thank you for your time.

B. Introduction script

First, we’ll make a list of the foods you/SP ate and drank yesterday, Monday. It may help you remember what you/SP ate by thinking about where you/he/she were, who you/he/she were with, or what you/he/she were doing, like working, eating out, or watching television.

Please tell me everything you/SP had to eat and drink all day yesterday, Monday, from midnight to midnight. Include everything you/he/she had at home and away, even snacks, coffee, soft drinks, water, and alcoholic beverages. I’ll ask you for specific details and amounts of the foods in a few minutes. At this time, just tell me what you/SP had.

C. Follow-up probing script

Your answers are important, so we’d like this list to be as complete as possible. Here are some foods people often forget.

In addition to the foods you have/SP has already told me about, did you have any coffee, tea, soft drinks, milk or juice?

Beer, wine, cocktails or other drinks?

Cookies, candy, ice cream or other sweets?

Chips, crackers, popcorn, pretzels, nuts, or other snack foods?

Fruits, vegetables, or cheese?

Bread, rolls or tortillas?

Anything else?

D. Food detail probes script

When I ask how much {you/SP} ate, you can tell me the amount by using the drawings in the Food Model Booklet, the measuring cups and spoons, the ruler, and any of your own dishes and glasses. Feel free to check the labels on any food packages during the interview.

Post-dietary Recall Questions

NHANES III

REC.155 Was the amount of food that {you/NAME} ate yesterday much more than usual, usual, or much less than usual?

MUCH MORE THAN USUAL 1

USUAL 2

MUCH LESS THAN USUAL 3

REFUSED 7

DON’T KNOW 9

CSFII

REC.265 When you drink tap water, what is the main source of the tap water? Is the city water supply (community water supply); a well or rain cistern; a spring; or something else?

COMMUNITY WATER 1

A WELL OR RAIN CISTERN 2

A SPRING 3

NEVER DRINK TAP WATER 4

REFUSED 7

DON’T KNOW 9

OTHER (SPECIFY) 91

[RECORD Drinking fountain AS COMMUNITY WATER SUPPLY.]

NHANES III

REC.325 Now I'll be asking some questions about {your/NAME's} use of table salt.

What type of salt {do you/does NAME} usually add to {your/his/her} food at the table? Would you say it is ordinary or seasoned salt, lite salt, or a salt substitute?

ORDINARY, SEA, SEASONED, OR OTHER FLAVORED SALT

[includes regular iodized salt,

sea salt and seasoning salts

made with regular salt] 1

LITE SALT 2

SALT SUBSTITUTE 3

NONE 4 (REC.335)

REFUSED 7 (REC.335)

DON'T KNOW 9 (REC.335)

NHANES III

REC.330 How often {do you/does NAME} add {REC325 ANSWER} to {your/his/her} food at the table? Is it rarely, occasionally, or very often?

RARELY, 1

OCCASIONALLY 2

VERY OFTEN 3

REFUSED 7

DON'T KNOW 9

CSFII

REC.335 How often is ordinary salt or seasoned salt added in cooking or preparing foods in your household? Is it never, rarely, occasionally, or very often?

NEVER 1

RARELY 2

OCCASIONALLY 3

VERY OFTEN 4

REFUSED 7

DON'T KNOW 9

[THIS QUESTION APPLIES ONLY TO USE OF ORDINARY SALT OR SEASONED SALT AND NOT TO LITE SALT OR SALT SUBSTITUTES.]

CSFII

REC.340 {Are you/Is NAME} currently on any kind of diet, either to lose weight or for some other health-related reason?

YES 1

NO 2 (Box 1)

REFUSED 7 (Box 1)

DON’T KNOW 9 (Box 1)

CSFII

REC.345 What kind of diet {are you/is NAME} on?

[READ AS NEEDED: Is it a weight loss or low calorie diet; low fat or cholesterol diet; low salt or sodium diet; diabetic diet; or another type of diet?]

WEIGHT LOSS OR LOW CALORIE DIET 1

LOW FAT OR CHOLESTEROL DIET 2

LOW SALT OR SODIUM DIET 3

SUGAR FREE OR LOW SUGAR DIET 4

LOW FIBER DIET 5

HIGH FIBER DIET 6

DIABETIC DIET 7

LOW CARBOHYDRATE DIET 8

HIGH PROTEIN DIET 9

WEIGHT GAIN DIET 10

OTHER 91

(SPECIFY) ___________

REFUSED 77

DON’T KNOW 99

BOX 1

IF SP < 1 YEAR OLD, GO TO BOX 2.

OTHERWISE, CONTINUE.

NHANES 1999

DRQ.361 Please look at this list of fish. During the past 30 days, did you eat any types of fish listed on this card? Include any foods that had fish in them such as sandwiches, soups, or salads.

YES 1

NO 2 (DRQ.380)

REFUSED 7 (DRQ.380)

DON’T KNOW 9 (DRQ.380)

NHANES 1999

DRQ. 370 During the past 30 days, which types of fish did you eat and how many times did you eat them?

Type listed: breaded fish products, tuna (canned or fresh), bass, catfish, cod, flatfish, haddock, mackerel, perch, pike, pollock, porgy, salmon, sardines, sea bass, shark, swordfish, trout, walleye, other type of fish and unknown type of fish.

Interviewer instruction:

Check each type of shellfish the SP reports eating, and then ask and record the number of times each type was eaten.

NHANES 1999

DRQ.380 Please look at this list of shellfish. During the past 30 days, did you eat any types of shellfish listed on this card? Include any foods that had shellfish in them such as sandwiches, soups, or salads.

YES 1

NO 2 (Box 2)

REFUSED 7 (Box 2)

DON’T KNOW 9 (Box 2)

NHANES 1999

DRQ. 390 During the past 30 days, which types of shellfish did you eat and how many times did you eat them?

Type listed: clams, crab, crayfish (crawfish), lobster, mussels, oysters, scallops, shrimp, other shellfish (for example, octopus, squid) and unknown type of shellfish.

Interviewer instruction:

Check each type of shellfish the SP reports eating, and then ask and record the number of times each type was eaten.

BOX 2

If the response to FSQ.030 'A', 'B', 'C', 'D' or 'E' is ' often true'

(code 1), 'sometimes true' (code 2), ' refuse' (code 7), ‘don’t know' (code 9), continue with Box 3.

Otherwise, go to Box 5.

BOX 3

If SP 16 years or older, continue;

If SP less than 12 years old, go to the second FSQ.401 listed.

Otherwise, go to the end of the section.

Individual Food Security Questions for NHANES participants 16 and older.

FSQ.401 The next questions are about whether you were always able to afford enough food in the last 30 days.

In the last 30 days, did you ever cut the size of your meals because there wasn't enough money for food?

Yes …………………..1

No ……………………2 (FSQ.421)

Refused ……….……...7 (FSQ.421)

Don’t Know ………… 9 (FSQ.421)

FSQ.new1 Did that happen often, sometimes or just once or twice?

Often 1

Sometimes 2

Once or Twice 3

Refused 7

Don’t Know…………....9

FSQ.421 In the last 30 days, did you ever eat less than you felt you should because there wasn't enough money for food?

Yes …………………..1

No …………………..….2 (FSQ.431)

Refused ………………..7 (FSQ.431)

Don’t Know ……………9 (FSQ.431)

FSQ.new2 Did that happen often, sometimes or just once or twice?

Often 1

Sometimes 2

Once or Twice 3

Refused 7

Don’t Know……….......9

FSQ.431 In the last 30 days, were you ever hungry but didn't eat because you couldn't afford enough food?

Yes …………………..1

No ……………………2 (FSQ.411)

Refused …………….....7 (FSQ.411)

Don’t Know ……………9 (FSQ.411)

FSQ.new3 Did that happen often, sometimes or just once or twice?

Often 1

Sometimes 2

Once or Twice 3

Refused 7

Don’t Know………..9

FSQ.411 In the last 30 days, did you ever skip meals because there wasn't enough money for food?

Yes …………………..1

No ………………… …2 (FSQ.440)

Refused ………… …...7 (FSQ.440)

Don’t Know ………… 9 (FSQ.440)

FSQ.new4 Did that happen often, sometimes or just once or twice?

Often 1

Sometimes 2

Once or Twice 3

Refused 7

Don’t Know……….......9

FSQ.440 In the last 30 days, did you lose weight because you didn't have enough money for food?

Yes …………………..1

No ……………………2 (Box A)

Refused ………… …...7 (Box A)

Don’t Know ……… …9 (Box A)

FSQ.new5 Did that happen often, sometimes or just once or twice?

Often 1

Sometimes 2

Once or Twice 3

Refused 7

Don’t Know….....……..9

BOX A

IF (FSQ401 OR FSQ411 OR FSQ421 OR FSQ431 OR FSQ440=1), CONTINUE; OTHERWISE, GO TO THE END OF THE SECTION.

FSQ.451 In the last 30 days, did you ever not eat for a whole day because there wasn't enough money for food?

Yes …………………..1

No ……………………2 (End of Section)

Refused ………… …...7 (End of Section)

Don’t Know …… ……9 (End of Section)

FSQ.new6 Did that happen often, sometimes or just once or twice?

Often 1

Sometimes 2

Once or Twice 3

Refused 7

Don’t Know……….......9

BOX 4

Go to the end of the section.

Individual NHANES Food Security Questions for participants ages 0-11.

FSQ.401 The next questions are about whether you were always able to afford enough food for (NAME) in the last 30 days.

In the last 30 days, did you ever cut the size of (NAME’s) meals because there wasn't enough money for food?

Yes …………………..1

No ……………………2 (FSQ.421)

Refused ………… ….. .7 (FSQ.421)

Don’t Know …… … …9 (FSQ.421)

FSQ.new1 Did that happen often, sometimes or just once or twice?

Often 1

Sometimes 2

Once or Twice 3

Refused 7

Don’t Know…….....…..9

FSQ.421 In the last 30 days, did (NAME) ever eat less than you felt (he/she) should because there wasn't enough money for food?

Yes …………………..1

No ……………………2 (FSQ.491)

Refused ……………. ..7 (FSQ.491)

Don’t Know ……… …9 (FSQ.491)

FSQ.new2 Did that happen often, sometimes or just once or twice?

Often 1

Sometimes 2

Once or Twice 3

Refused 7

Don’t Know…… ……9

FSQ.491 In the last 30 days, was (NAME) ever hungry but you just couldn't afford more food?

Yes …………………..1

No ……………………2 (FSQ.501)

Refused …… ………...7 (FSQ.501)

Don’t Know …………9 (FSQ.501)

FSQ.new3 Did that happen often, sometimes or just once or twice?

Often 1

Sometimes 2

Once or Twice 3

Refused 7

Don’t Know….....……..9

FSQ.501 In the last 30 days, did (NAME) ever skip a meal because there wasn't enough money for food?

Yes …………………..1

No ……………………2 (Box B)

Refused ………… …...7 (Box B)

Don’t Know …… ……9 (Box B)

FSQ.new4 Did that happen often, sometimes or just once or twice?

Often 1

Sometimes 2

Once or Twice 3

Refused 7

Don’t Know….........…..9

BOX B

IF (FSQ421 OR FSQ401 OR FSQ491 OR FSQ501= 1), CONTINUE; OTHERWISE, GO TO THE END OF THE SECTION.

USDA-FNS

FSQ.521 In the last 30 days, did (NAME) ever not eat for a whole day because there wasn't enough money for food?

Yes …………………..1

No ……………………2 (End of Section)

Refused ………… …...7 (End of Section)

Don’t Know … ………9 (End of Section)

FSQ.new5 Did that happen often, sometimes or just once or twice?

Often 1

Sometimes 2

Once or Twice 3

Refused 7

Don’t Know………. .9

BOX 5

IF SP 1-11 YEARS OLD, CONTINUE.

OTHERWISE, GO TO THE END OF THE SECTION.

HSQ.500 The next questions are about {your/SP's} recent health during the 30 days outlined on the calendar.

Did {you/SP} have a head cold or chest cold that started during those 30 days?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HSQ.510 Did {you/SP} have a stomach or intestinal illness with vomiting or diarrhea that started during those 30 days?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HSQ.520 Did {you/SP} have flu, pneumonia, or ear infections that started during those 30 days?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 6

IF SP 6-7 YEARS OLD, CONTINUE.

OTHERWISE, GO TO THE END OF THE SECTION.

PUQ.100 In the past 7 days, were any chemical products used in {your/his/her} home to control fleas, roaches, ants, termites, or other insects?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PUQ.110 In the past 7 days, were any chemical products used in {your/his/her} lawn or garden to kill weeds?

CODE ‘NO’ IF THE RESPONDENT SAYS S/HE DOES NOT HAVE A LAWN OR GARDEN.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DIETARY SUPPLEMENTS (all ages)

24-Hour Dietary Supplements Recall Interview

Information will be obtained on all vitamins, minerals, herbals and other dietary supplements that were consumed during a 24-hour time period (midnight to midnight). The information that is obtained for dietary supplements includes the following:

1. Verifying that dietary supplement(s) reported during the Dietary Supplement Section in the Household Interview was also taken during the 24-Hour time period. – Dietary supplement information is collected during the SP Household Interview. The interviewer will first ask if the supplements reported during the Household Interview were also taken during the 24-Hour time period.

2. Dietary supplement Name – The name of any new/additional dietary supplements are typed and selected from a list of dietary supplement names.

3. Amount of dietary supplement taken – The amount of dietary supplement consumed by the respondent during the 24-Hour time period.

24-Hour Dietary Supplement Recall Interview Scripts – In-Person Interview:

1. Script for respondents that reported taking a dietary supplement or antacid during the Dietary Supplements Section in the Household Interview:

The next questions are about {your/SPs} use of dietary supplements, vitamins, minerals and herbals all day yesterday, {day}, between midnight and midnight. This includes prescription and over the counter dietary supplements.

During the interview in your home {you/SP reported taking} {supplement}.

Did {you/SP} take this supplement yesterday {day}. (between midnight and midnight)?

Was {supplement} a {form}?

You said {you/SP} took ___, is that correct? Was that a liquid or powder?

Between midnight and midnight, how much did {you/SP} take?

It was also reported {you/SP} took {supplement}.

All day yesterday, {day}, between midnight and midnight, did {you/SP} take any other vitamins, minerals, herbals or other dietary supplements? Include any prescription and over the counter dietary supplements.

What is the name of the supplement {you/SP} took?

Between midnight and midnight, how much did {you/SP} take?

Any others?

The next questions are about {your/SPs} use of non-prescription antacids.

During the interview in your home {you/SP reported taking} {antacid}.

Did {you/SP} take this antacid yesterday (between midnight and midnight )?

Between midnight and midnight how much did {you/SP} take?

It was also reported {you/SP} took {antacid}.

All day yesterday, {day}, between midnight and midnight did {you/SP} take any other antacids?

What is the name of the antacid {you/SP} took?

Between midnight and midnight how much did {you/SP} take?

Any others?

2. Script for respondents that did not report taking a dietary supplement or antacid during the Dietary Supplement Section in the Household Interview:

The next questions are about {your/SPs} use of dietary supplements, including prescription and over the counter supplements. All day yesterday, {day}, between midnight and midnight did {you/SP} take any vitamins, minerals, herbals or other dietary supplements?

What is the name of the supplement {you/SP} took?

Between midnight and midnight how much did {you/SP} take?

Any others?

The next questions are about {your/SPs} use of non-prescription antacids All day yesterday, {day}, between midnight and midnight did {you/SP} take any antacids?

What is the name of the antacid {you/SP} took?

Between midnight and midnight how much did {you/SP} take?

Any others?

24-Hour Dietary Supplement Recall Interview Scripts – Telephone Interview:

Same as above, except respondent is asked to get their dietary supplements and read from the container the name of any new supplements they have taken since the 24-hour dietary supplement recall in-person interview.

1. Script for respondents that reported taking a dietary supplement or antacid during the Dietary Supplements Section in the Household Interview or during the 24-hour dietary supplement recall in-person interview:

The next questions are about {your/SPs} use of dietary supplements, vitamins, minerals and herbals all day yesterday, {day}, between midnight and midnight. This includes prescription and over the counter dietary supplements.

During the interview in your home and our exam center {you/SP reported taking} {supplement}.

Did {you/SP} take this supplement yesterday {day} (between midnight and midnight)?

Was {supplement} a {form}?

You said {you/SP} took ___, is that correct? Was that a liquid or powder?

Between midnight and midnight, how much did {you/SP} take?

It was also reported {you/SP} took {supplement}.

All day yesterday, {day}, between midnight and midnight, did {you/SP} take any other vitamins, minerals, herbals or other dietary supplements? Include any prescription and over the counter dietary supplements.

Can you please locate the containers for all the dietary supplements {you/SP}took?

I will wait while you get them.

Can you please read to me all the words on the front label?

What is the name of the supplement {you/SP} took?

Between midnight and midnight, how much did {you/SP} take?

Any others?

The next questions are about {your/SPs} use of non-prescription antacids.

During the interview in your home and our exam center {you/SP reported taking} {antacid}.

Did {you/SP} take this antacid yesterday (between midnight and midnight )?

Between midnight and midnight how much did {you/SP} take?

It was also reported {you/SP} took {antacid}.

All day yesterday, {day}, between midnight and midnight did {you/SP} take any other antacids?

What is the name of the antacid {you/SP} took?

Between midnight and midnight how much did {you/SP} take?

Any others?

2. Script for respondents that did not report taking a dietary supplement or antacid during the Dietary Supplement Section in the Household Interview or the 24-hour dietary supplement recall in-person interview :

The next questions are about {your/SPs} use of dietary supplements, including prescription and over the counter supplements. All day yesterday, {day}, between midnight and midnight did {you/SP} take any vitamins, minerals, herbals or other dietary supplements?

Can you please locate the containers for all the dietary supplements {you/SP}took?

I will wait while you get them.

Can you please read to me all the words on the front label?

What is the name of the supplement {you/SP} took?

Between midnight and midnight how much did {you/SP} take?

Any others?

The next questions are about {your/SPs} use of non-prescription antacids All day yesterday, {day}, between midnight and midnight did {you/SP} take any antacids?

What is the name of the antacid {you/SP} took?

Between midnight and midnight how much did {you/SP} take?

Any others?

Probes

3. Probes for collecting dietary supplement names

Multivitamin and/or Multimineral:

• What is the brand name?

• Did it also include minerals like iron, zinc, or calcium?

• Iron only

• Was it a special type?(silver, women’s, men’s, prenatal, liquid)

Single / double nutrient:

• What is the brand name?

• How much (ingredient name) was in it?(or what was the strength of X)

Other supplement type:

• Please describe the label name or type of supplement

• What is the brand name?

4. Probes for collecting antacid names

What is the brand name? Was it extra strength, regular strength, ultra, maximum strength?

5. Probes for collecting the quantity the respondent took – UNIT

Was it a tablet, capsule, pill, caplet, softgel, or something else?

AUDIOMETRY (12-19 and 70 and older)

Tech. No. _____________ SP No. _____________

Otoscope No. _________ Tympanometer No. _________ Audiometer No. __________

A. CONDITIONS AFFECTING TEST RESULTS
1. Do you now have a tube in your right or left ear? (If yes indicate affected ear(s))	 No
	 Yes, Right ear
	 Yes, Left ear
	 Yes, Both ears
	 Refused
	 Don’t Know
2. Have you had a cold, sinus problem or earache in the past 24 hours?	 Yes (2b)
	 No (3)
	 Refused (3)
	 Don’t Know (3)
2b. Which have you had? (mark all that apply)	 Cold
	 Sinus problem
	 Earache, right ear
	 Earache, left ear
	 Earache, both
	 Refused
	 Don’t Know
3. Have you been exposed to loud noise or listened to music with headphones in the past 24 hours?	 Yes (3b)
	 No (4)
	 Refused (4)
	 Don’t Know (4)
3b. How many hours ago did the noise or music end?	|__|__| # hours
	 Refused
	 Don’t Know
4. Do you hear better in one ear or the other?	 Yes, right ear
	 Yes, left ear
	 No/Don’t Know
	 Refused

B. OTOSCOPY EXAM
Right Ear	 Normal
	 Excessive cerumen*
	 Impacted cerumen*
	 Other abnormality (comment)
	 Collapsing ear canal
Left Ear	 Normal
	 Excessive cerumen*
	 Impacted cerumen*
	 Other abnormality (comment)
	 Collapsing ear canal
RESULTS OF OTOSCOPY	 Test complete
	 Test partially complete
	 Test not done

REASONS TEST INCOMPLETE OR NOT DONE

		 Safety exclusion
		 Physical limitation
		 SP refusal
		 SP ill/emergency
		 Out of time
		 Equipment failure
		 Communication problem
		 Other (specify): ________

* TYMPANOMETRY will not be done on ears with cerumen blockage. Cerumen blockage does not exclude an SP from audiometry.

C. TYMPANOMETRY**

Right Ear	 Obtained
	 Not obtained
Left Ear	 Obtained
	 Not obtained

RESULTS OF TYMPANOMETRY

 Test complete

		 Test partially complete
		 Test not done

REASONS TEST INCOMPLETE OR NOT DONE

 Safety exclusion

		 Physical limitation
		 SP refusal
		 SP ill/emergency
		 Out of time
		 Equipment failure

		 Communication problem
		 Other (specify): _________________________ _________________________

** Tympanometry will not be done on ears with cerumen blockage found in otoscopy.

D. PURE TONE AUDIOMETRY ***
START HERE IF SP NUMBER ODD OR SP HEARS BETTER IN LEFT EAR			START HERE IF SP NUMBER EVEN OR SP HEARS BETTER IN RIGHT EAR
AIR CONDUCTION-LEFT EAR			AIR CONDUCTION-RIGHT EAR
Hearing Level (dB)	Frequency (Hz)	Hearing Level with Masking on R(dB)	Hearing Level (dB)	Frequency (Hz)	Hearing Level with Masking on L(dB)
	1000			1000
	2000			2000
	3000			3000
	4000			4000
	6000			6000
	8000			8000
	1000			1000
	500			500
RESULTS OF AUDIOMETRY				 Test complete
				 Test partially complete
				 Test not done
REASONS TEST INCOMPLETE OR NOT DONE				 Safety exclusion
				 Physical limitation
				 SP refusal
				 SP ill/emergency
				 Out of time
				 Equipment failure
				 Communication problem
				 Other (specify):______
*** Audiometry will not be done on SP's with flat tympanogram.

ORAL HEALTH (ages 3-19 years and 30 years and older)

Questions:

OHQ.800 {Have you/Has SP} lost all of {your/his/her} upper and lower natural (permanent) teeth?

YES 1 (END OF SECTION)

NO 2

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

OHQ.805 Has the doctor or dentist ever told {you/SP} that {you/he/she} must always take antibiotics (such as penicillin) before {you get/ he/she gets} a dental check up or dental care?

HELP SCREEN:

Antibiotics: Antibiotics (penicillin, amoxicillin, erythromycin and so on) cure disease by killing or injuring bacteria. Today, over 100 different antibiotics are available to doctors to cure minor discomforts as well as life-threatening infections.

YES 1 (BOX 1)

NO 2

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

OHQ.810 {Do you/Does SP} have an artificial heart valve?

HELP SCREEN:

Artificial heart valve: An artificial heart valve is a device which is implanted into the heart to replace a defective or malfunctioning valve.

YES 1 (BOX 1)

NO 2

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

OHQ.815 {Have you/Has SP} had heart disease since birth?

INTERVIEWER INSTRUCTION: IF SP SAYS “MITRAL VALVE PROLAPSE” OR “MVP” CODE NO

YES 1 (BOX 1)

NO 2

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

OHQ.820 {Have you/Has SP} had a bacterial infection of the heart, also called bacterial endocarditis?

HELP SCREEN:

Bacterial Endocarditis: Endocarditis is an inflammation of the inner layer of the heart, the endocardium.

YES 1 (BOX 1)

NO 2

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

OHQ.825 Has a doctor ever told {you/SP} that {you have/he/she has} rheumatic fever?

HELP SCREEN: Rheumatic fever: Rheumatic fever is a disease that affects the joints, skin, heart, blood vessels, and brain. It is a systemic immune disease that may develop after an infection with streptococcus bacteria, such as strep throat and scarlet fever.

YES 1 (BOX 1)

NO 2

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

OHQ.830 Has a doctor ever told {you/SP} that {you have/she/he has} a hip, bone or other joint replacement?

HELP SCREEN: Hip bone or joint replacement: Surgery to replace all or part of the hip joint or other joint with an artificial device that re-establishes normal joint motion.

CAPI INSTRUCTION: IF 'YES' (CODE 1) IN OHQ.800 – OHQ.830, THE SP IS NOT ELIGIBLE FOR THE MEC ORAL HEALTH EXAMINATION.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

Oral Health Examination

3-19 years	6-19 years	30 years and older
Tooth count		Tooth count
Basic Screening Exam (BSE)
	Dental Fluorosis
		Periodontal Exam
Report of Findings		Report of Findings

PHYSICIAN EXAMINATION (all ages)

Blood Pressure (ages 8 years and older)*

*Note half sample of blood pressures from participants 16 and older will be taken by a NHANES health technician beginning in 2007. This will result in more observers taking the blood pressure measurements and more time for the physician to add the new Growth and Development module to his/her duties.

Have you had any of the following in the past 30 minutes? (food, coffee, alcohol, cigarettes) Check all that apply:

Arm selected Right/left/Could not obtain

Cuff size selected Infant/Child/Adult/Large Arm/Thigh

Heart Rate/Pulse Beats per minute

Pulse type

Radial/Brachial

Maximum Inflation Level mm Hg

Systolic Blood Pressure (Readings 1,2,3) mm Hg

Diastolic Blood Pressure (Readings 1,2,3) mm Hg

e)

Average Blood Pressure mm Hg (mean of last 2 measurements will be used)

SPIROMETRY (ages 6 and older)

M

EC EXAMINATION SPIROMETRY EXCLUSIONS QUESTIONNAIRE –SPQ

Target Ages 6-15 years

SPQ.020 Does SURVEY PARTICIPANT now have a painful ear infection?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.030 Has SURVEY PARTICIPANT ever had eye surgery?

YES 1

NO 2 (SPQ.040)

REFUSED 7 (SPQ.040)

DON'T KNOW 9 (SPQ.040)

SPQ.035 Was the eye surgery in the last three months?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.040 Has SURVEY PARTICIPANT ever had open chest or abdominal surgery?

YES 1

NO 2 (SPQ.050)

REFUSED 7 (SPQ.050)

DON'T KNOW 9 (SPQ.050)

SPQ.045 Was the open chest or abdominal surgery in the last three months?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.050 Does SURVEY PARTICIPANT or anyone in {his/her} household now have tuberculosis?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.065a Has a doctor or other health professional ever told SURVEY PARTICIPANT that SURVEY PARTICIPANT had an aneurysm?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.065b Has a doctor or other health professional ever told SURVEY PARTICIPANT that SURVEY PARTICIPANT had a collapsed lung?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.110 Does SURVEY PARTICIPANT currently have a breathing problem that requires {you/SURVEY PARTICIPANT} to use supplemental oxygen during the day?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.120 Does SURVEY PARTICIPANT now have any pain or physical problem that may prevent {him/her} from taking a deep breath and exhaling forcefully?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.155 In the past month has SURVEY PARTICIPANT coughed up blood?

YES 1 (Exclude)

NO 2 (End)

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

M

EC EXAMINATION SPIROMETRY EXCLUSIONS QUESTIONNAIRE –SPQ

Target Ages 16-79 Years

SPQ.030 {Have you/Has SURVEY PARTICIPANT} ever had eye surgery?

YES 1

NO 2 (SPQ.040)

REFUSED 7 (SPQ.040)

DON'T KNOW 9 (SPQ.040)

SPQ.035 Was this surgery in the last three months?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.040 {Have you/Has SURVEY PARTICIPANT} ever had open chest or abdominal surgery?

YES 1

NO 2 (SPQ.050)

REFUSED 7 (SPQ.050)

DON'T KNOW 9 (SPQ.050)

SPQ.045 Was this surgery in the last three months?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.050 {Do you/Does SURVEY PARTICIPANT} or anyone in {your/his/her} household now have tuberculosis?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ065a Has a doctor or other health professional ever told {you/ SURVEY PARTICIPANT} that {you/SURVEY PARTICIPANT} has an aneurysm?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.065b Has a doctor or other health professional ever told {you/SURVEY PARTICIPANT} that {you/SURVEY PARTICIPANT} had a collapsed lung?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.065c Has a doctor or other health professional ever told {you/ SURVEY PARTICIPANT} that {you/SURVEY PARTICIPANT} had a detached retina?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.065d Has a doctor or other health professional ever told {you/SURVEY PARTICIPANT} that {you/SURVEY PARTICIPANT} had a stroke?

YES 1 (SPQ.075)

NO 2

REFUSED 7

DON'T KNOW 9

SPQ.165e Has a doctor or other health professional ever told {you/ SURVEY PARTICIPANT} that {you/SURVEY PARTICIPANT} had a heart attack?

YES 1 (SPQ.085)

NO 2 (SPQ110)

REFUSED 7 (SPQ110)

DON'T KNOW 9 (SPQ110)

SPQ.075 Did this stroke happen in the last three months?

YES 1 (Exclude)

NO 2 (SPQ165e)

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.085 Did this heart attack happen in the last three months?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.110 {Do you/Does SURVEY PARTICIPANT} currently have a breathing problem that requires {you/SURVEY PARTICIPANT to use supplemental oxygen during the day?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.120 {Do you/Does SURVEY PARTICIPANT} now have any pain or physical problem that may prevent {you/SURVEY PARTICIPANT} from taking a deep breath and exhaling forcefully?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ.155 In the past month {have you/has SURVEY PARTICIPANT} coughed up blood?

YES 1 (Exclude)

NO 2 (End)

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

Spirometry :Bronchodilator Exclusion Criteria

Physician’s Exam Post Spirometry

Target Ages 6-79 years

SPABPPLS: Blood pressure and pulse

PHYSICIAN OBSERVATION: VERIFY THAT PULSE, BLOOD PRESSURE AND DROPPED HEART BEATS ARE WITH ACCEPTABLE LIMITS SET BY GUIDELINES. IF NOT, CHECK EXCLUDE, OTHERWISE CHECK REVIEW AND CONTINUE.

EXCLUDE 1 (Exclude)

REVIEWED 2

SPAPREG: Currently Pregnant

POSITIVE URINARY HCG TEST, OR IF UNABLE TO OBTAIN BASED ON SELF-REPORT OF PREGNANCY. IF EITHER POSITIVE CHECK EXCLUDE, OTHERWISE CHECK REVIEW AND CONTINUE.

EXCLUDE 1 (Exclude)

REVIEWED 2

RHQ200: (For females 12-59 years) Are you/Is SURVEY PARTICIPANT} now breastfeeding a child?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ195: (For youths 6-15 years): Does your child have a congenital heart defect?).

EXCLUDE 1 (Exclude)

REVIEWED 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ200: Has a doctor now diagnosed or treated {you/your child} for a rapid heart beat?

EXCLUDE 1 (Exclude)

REVIEWED 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQMEDA - - SPQMEAZ: Drug Review : MARK ALL THAT APPLY.

These are the drugs {you reported/you reported your child taking} in the household interview on {_INTERVIEW DATA} [READ LIST BELOW]. Please tell me additional drugs {you are/your child is} now taking. Allow up to 26 new drugs.

SPQMEDA - - SPQMEDH: Codes for drug review

Codes:

1=Potassium lowering drugs

2=Potassium raising drugs

3=Tricyclic antidepressant

4=Anti-convulsants

5=Bronchodilators

7=Antiarrhythmics

13=MAO Inhibitors

19=No new drugs

SPQ210 {Do you/Does your child} have epilepsy?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ230 {Have you/Has your child} ever had an adverse reaction to albuterol? [Albuterol is inhaled medication used to treat asthma and other breathing problems. Product brand names are Proventil, Ventolin, Combivent and Accunneb].

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ240 Has the survey participant inhaled a long acting beta 2 agonist bronchodilator within the last 12 hours?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

SPQ240 Has the survey participant inhaled a short- acting beta 2 agonist bronchodilator within the last 12 hours?

YES 1 (Exclude)

NO 2

REFUSED 7 (Exclude)

DON'T KNOW 9 (Exclude)

List of Anti-Arrhythmics That Exclude Participants from Bronchodilator Testing:

Amiodarone (Cordarone)

Bretylium (Bretylol)

Bretylol (Bretylium)

Cardioquin (Quinidine, Quinalan, Quinidex, Quinaglute)

Cordarone (Amiodarone)

Disopyramide (Norpace)

Dofetilide

Enkaid (Encainide)

Ethmozine (Moricizine)

Flecanide (Tambocor)

Ibutilide

Lidocaine (Xylocaine, Xylocard)

Mexiletine (Mexitil) Mexitil (Mexilitine)

Moricizine (Ethmozine)

Norpace (Disopyramide)

Procainamide (Pronestyl, Procan SR)

Procan SP (Procainamide, Pronestyl)

Pronestyl (Procan SP, Procainamide)

Propafenone (Rhythmol)

Rhythmol (Propafenone)

Tambocore (Flecainide)

Tocainide (Tonocard)

Tonocard (Tocainide)

Quinaglute (Cardioquin, Quinidine, Quinora, Quinalan, Quinidex)

Quinidine (Quinora, Quinalan, Cardioquin, Quinidex, Quinaglute)

Quinalan (Quinora, Cardioquin, Quinidex, Quinaglute, Quinidine)

Quinora (Quinidine, Quinalan, Cardioquin, Quinidex, Quinaglute)

Xylocaine (Lidocaine, Xylocard)

Xylocard (Lidocaine, Xylocaine)

List of MAO Inhibitors that Exclude Participants from Bronchodilator Testing:

Isocarboxazid (Marplan)

Phenelzine Sulfate (Nardil)

Tranylcypromine Sulfate (Parnate)

Phenelzine Sulfate

TranylcypromineSulfate

EXHALED NITRIC OXIDE (ENO) MEASUREMENT (Ages 6-79)

ENO PRECONDITIONS

BOX 1

CHECK ITEM ENQ.005:

IF SP 6-15 GO TO ENQ.020.

ENQ.010 Within the last hour {have you/has SURVEY PARTICIPANT} smoked a cigarette, cigar, pipe, or used any other tobacco product?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

ENQ.020 [Within the last hour}]{have you/Has SURVEY PARTICIPANT} exercised strenuously?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

ENQ.030 [Within the last hour}]{have you/Has SURVEY PARTICIPANT} had anything to eat or drink?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

ENQ.040 Within the last three hours {have you/has SURVEY PARTICIPANT} eaten beets, broccoli, cabbage, celery, lettuce, spinach or radishes?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

ENQ.050 Within the last three hours {have you/has SURVEY PARTICIPANT} eaten bacon, ham, hot dogs or smoked fish?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

ENQ.060 Within the last two days have you/has SURVEY PARTICIPANT} used any of the following oral or inhaled steroids?

(HANDCARD)

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

ENO results will not be reported to participants. Several factors are known to markedly influence ENO levels. In addition, the ENO level cannot be clinically interpreted in participants who are current smokers or have a history of recent upper respiratory infection. (References are available upon request).

==========================

Questions for PSA Analysis (ages 40 and older)

KIQ.01115 {Do you/does SP} have an infection or inflammation of the prostate gland at the present time?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

KIQ.01185 {Have you/Has SP} had a rectal exam in the last 7 days?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

KIQ.01190 {Have you/Has SP} had a prostate biopsy in the last 4 weeks?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

KIQ.01195 {Have you/Has SP} had a cystoscopy in the last 4 weeks? (Cystoscopy is an internal examination of the prostate and bladder using a flexible tube-like instrument with a lens inserted through the penis.)

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

KIQ.01200 {Have you/Has SP} ever been told by a doctor or health professional that {you/he} had prostate cancer?

YES 1

NO 2 [end of section]

REFUSED 7 [end of section]

DON’T KNOW 9 [end of section]

KIQ.01220 How old {were you/was SP} when {you were/he was} first told that {you/he} had prostate cancer?

AGE _____ (YEARS)

REFUSED 7

DON’T KNOW 9

KIQ.01240 {Have you/Has SP} ever had surgery on {your/his} prostate?

YES 1

NO 2 [Go to KIQ.01300]

REFUSED 7 [Go to KIQ.01300]

DON’T KNOW 9 [Go to KIQ.01300]

KIQ.01280 Was the surgery for cancer of the prostate gland?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

KIQ.01300 {Have you/Has SP} ever had radiation treatments for prostate cancer?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

KIQ.01310 {Have you/Has SP} ever taken prescribed medicines for prostate cancer?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

==================

HPV swab collection (ages 14-59 years)

The physician will explain the HPV swab collection after discussing the tests for sexually transmitted diseases and HIV, and getting the password the participant will use to obtain his or her results.

==================

Phlebotomy (venipuncture 1, Trutol administration, venipuncture 2)

VENIPUNCTURE 1 (ages 1 year and older)

SP ID______________ Tech ID_______________

Pre venipuncture questions (Q1-Q5 only asked during morning session: Q4-Q5 of those 12 and older)

Q1. When did you last have anything at all to eat or drink other than water?

HH:MM (AM PM NOON) MMDDYY

Q2. Have you had coffee, tea, soda, alcoholic beverages, gum, breath mints, cough drops or vitamins since [TIME/DATE IN Q3]?

YES (probe and edit response in Q3)

NO

Q3. You have not had anything to drink, other than water, since [TIME/DATE IN Q3]. Is this correct?

YES

NO (probe and edit response in Q3)

Q4. Are you now taking insulin?

Yes(OGTT will not be conducted)

No

Refused

Don’t knowDIQ050 (yes, no, refused, don’t know)

Q5. Are you now taking diabetic pills to lower your blood sugar?

Yes(OGTT will not be conducted)

No

Refused

Don’t know

Q6. Do you have hemophilia? SEQ010 (yes, no, refused, don’t know)

Yes(Venipuncture and OGTT will not be conducted)

No

Refused

Don’t know

Q7. Have you received cancer chemotherapy in the past four weeks? SEQ020 (yes, no, refused, don’t know)

Yes(Venipuncture and OGTT will not be conducted)

No

Refused

Don’t know

Pregnancy Status

Positive (OGTT will not be conducted if SP reports pregnancy at home

interview or has a positive pregnancy test prior to first venipuncture)

Negative

RESULTS OF FIRST VENIPUNCTURE

Test complete

Test partially complete

Test not done

REASONS TEST INCOMPLETE OR NOT DONE

Safety exclusion

Pregnancy

Physical limitation

SP refusal

SP ill/emergency

Out of time

Equipment failure

Communication problem

Trutol Administration (12 and older morning session only)

SP ID______________ Tech ID_______________

Please drink this solution within 10 minutes

Timer 10

Start ____

Stop _____

Total ____

Amount of Trutol drank

 All

 Some

None

RESULTS OF Trutol Administration

Test complete

Test partially complete

Test not done

REASONS TEST INCOMPLETE OR NOT DONE

Solution not consumed within 10 minutes

Physical limitation

SP refusal

SP ill/emergency

Out of time

Equipment failure???

Communication problem

VENIPUNCTURE 2 (ages 12 year and older if Trutol administered)

SP ID______________ Tech ID_______________

OGTT tubes

 2 ml grey Obtained all

Phlebotomy tubes not collected

 of 3 4 ml lavender Obtained all

 of 4 15 ml red

 of 2 10 ml red

RESULTS OF SECOND VENIPUNCURE

Test complete

Test partially complete

Test not done

REASONS TEST INCOMPLETE OR NOT DONE

Solution not consumed within 10 minutes

Physical limitation

SP refusal

SP ill/emergency

Out of time

Equipment failure

Communication problem

Q-3