Attachment 3 - Data elements for the survey instrument

Data elements for the survey instrument
A. Introduction
1. Race/ethnicity
2. Gender
3. Language spoken
4. Age
B. Conditions
1. General health
a. Pregnancy
b. Height
c. Weight
d. Self-assessment of weight
e. Doctor assessment of weight
2. High blood pressure
3. Asthma
4. Diabetes
5. Other health
a. Series of health conditions
6. Cancer
7. Cholesterol
8. Hearing
9. Vision
10. Dental
11. Physical and Developmental problems
C. Access to Care
1. Reasons for not seeking care
2. Severity of condition
3. Barriers to treatment
4. Does condition still persist
D. Routine Care
1. Routine health visits
2. Emergency visits
3. Hospital stays
4. Hospital emergency room
5. Influenza vaccine
6. Pneumonia shot
7. Physicals and routine check-ups (adolescent/adult)
a. When/where
b. Tests performed
c. Health inquiry by health professional
8. Physicals and routine checkups (child-proxy)
a. When/where
b. Tests performed

c. Health inquiry by health professional
9. Lead screening
E. Conditions follow-up
1. High blood pressure (asked of respondents who indicated condition in section
B)
2. Asthma (asked of respondents who indicated condition in section B)
3. Diabetes (asked of respondents who indicated condition in section B)
F. Cancer Screening
1. Pap smears (asked only of females 18+)
2. Mammograms (asked only of females 18+)
3. Colonoscopy/ Sigmoidoscopy exam (asked only of males 50+)
4. Blood stool or occult blood test (asked only of males and females 50+)
G. Health Center Services
1. Visits to specific health center
2. Reasons health center is not regular facility
3. Facility for routine care
4. Services performed at facility
5. Referrals
6. Preventative care
7. Satisfaction with services
H. Substance Use
1. Tobacco use
2. Illicit drug use
3. Alcohol use
4. Drug treatment / counseling
I. Prescription Medication
1. Barriers to obtaining medications
2. Delays in obtaining medications
3. Getting prescriptions filled
J. Dental
1. Recent visits
2. Reasons for visits
3. Barriers to obtaining dental care
4. Delays in obtaining dental care
5. Satisfaction with services
6. Condition of respondents teeth/gums
K. Mental Health
1. Feeling/mood during the past 30 days
2. Feeling/mood during the past 12 months (adolescent/adult)
3. Feeling/mood during the past 6 months (child-proxy)
4. Barriers to obtaining mental health care
5. Delays in obtaining mental health care
6. Treatment / counseling

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Prenatal Care / Family Planning (Females aged 15-49)
1. Pregnancy history
2. Pregnancy during the past 12 months
3. Prenatal care
4. Family planning services
5. Satisfaction with services

M. Occupational Health (All respondents 15+)
1. Work-related injuries / illnesses in the past 12 months
2. Description of each illness and medical care received
3. Barriers to obtaining health care
N. HIV Testing
1. History of HIV testing
2. Risk factors of HIV
O. Living Arrangements
1. Type of shelter
2. Without regular housing/where you sleep
3. Currently with regular housing
P. Health Insurance
1. Health insurance coverage
2. Medicare/ Medicaid
3. Private health insurance
Q. Income and Assets
1. Family members supported by family income
2. Total annual earnings
2. Public assistance
3. Get enough food to eat
R. Demographics
1. Born in U.S.
2. Length of time living in U.S.
3. Education
4. Number of times moved in past 12 months
5. Marital status
6. Veterans questions
7. Employment status
8. Farm work / past 24 months