Att 2 - Cognitive testing interview guide

Attachment 2. Cognitive testing interview guide and A-CASI instrument

OMB #0920-0222, Expiration Date: 03/31/2013

Public reporting burden for this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222). The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used only for statistical purposes 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 the 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).

Cognitive Interviewing Protocol

Introduction to the Cognitive Interview:

Next, we are going to go back through the questionnaire and talk about how you interpreted these questions. I am interested in knowing how you understood certain questions, interpreted certain words, and whether any of them were difficult to answer.

Do have any (more) questions? (If no questions) OK, let’s begin.

FAMILY STATUS

Q1. What are the names of all family members living in your home? (Please give first names only.)

DEMOGRAPHICS

Q2. How old are you?

_________ age in years

Refused to answer

Don’t know

Q3. What was your sex at birth?

1 Male

2 Female

3 Intersex/ambiguous

7 Refused to answer

9 Don't know

Q4. Do you consider yourself to be male, female, or transgender?

1 Male

2 Female

3 Transgender

7 Refused to answer

9 Don't know

Q5. Do you consider yourself to be Hispanic or Latino?

1. Yes

2. No

7 Refused

9 Don’t know

Q5 Help screen:

Puerto Rican

Cuban/Cuban American

Dominican (Republic)

Mexican

Mexican American

Central or South American

Other Latin American

Other Hispanic Latino

Q6. Please tell us the groups that represent your Hispanic origin or ancestry. You may choose up to five (5), if applicable.

01 Puerto Rican

02 Cuban/Cuban American

03 Dominican (Republic)

04 Mexican

05 Mexican American

06 Central or South American

07 Other Latin American

08 Other Hispanic/Latino/Spanish

97 Refused

99 Don't know

Q7. What race or races do you consider yourself to be? Please select 1 or more of these categories.

01 White

02 Black/African American

03 Indian (American)

04 Alaska Native

05 Native Hawaiian

06 Guamanian

07 Samoan

08 Other Pacific Islander

09 Asian Indian

10 Chinese

11 Filipino

12 Japanese

13 Korean

14 Vietnamese

15 Other Asian

16 Some other race

97 Refused

99 Don't know

If [Q3= 1] or [Q3=2 and Q4 = 1 or 3] or [Q3=3 and Q4=1] ask Q8a.

Q8a. Do you currently consider yourself to be:

Heterosexual or "Straight"…………….……......  1

Homosexual or Gay ……………………………  2

Bisexual………………………………………..  3

Other……………………………………………  4

Refused to answer…………………..………….  7

Don’t know................……………………….….  9

Question Q8a Help:

A heterosexual or straight man is someone who sees himself as forming intimate or loving relationships with women. He may also think of himself as being attracted to, or primarily attracted to, women. He may also engage in sexual behaviors with women.

A homosexual or gay man is someone who sees himself as forming intimate or loving relationships with other men. He may also think of himself as being attracted to, or primarily attracted to, men. He may also engage in sexual behavior with other men. He might also form political, social, or cultural connections with a community of other homosexual men.

A bisexual man is someone who sees himself as forming intimate or loving relationships with either men or women. He may also think of himself as being attracted to both men and women, and he may also engage in sexual behavior with either men, women, or with both men and women.

If [Q3= 2] or [Q3=1 and Q4 = 2 or 3] or [Q3 and Q4=2] ask Q8b.

Q8b. Do you currently consider yourself to be:

Heterosexual or "Straight"…………….……...... 1

Homosexual or lesbian.…………..……………. 2

Bisexual……………………………………….. 3

Other…………………………………………… 4

Refused to answer…………………..…………. 7

Don’t know................……………………….…. 9

Question Q8b Help:

A heterosexual or straight woman is someone who sees herself as forming intimate or loving relationships with men. She may also think of herself as being attracted to, or primarily attracted to, men. She may also engage in sexual behavior with men.

A homosexual or lesbian woman is someone who sees herself as forming intimate or loving relationships with women. She may also think of herself as being attracted to, or primarily attracted to, women and she may engage in sexual behavior with women. She might also form political, social, or cultural connections with a community of other lesbians.

A bisexual woman is someone who sees herself as forming intimate or loving relationships with either men or women. She may also think of herself as being attracted to both men and women, and she may also engage in sexual behavior with either men or women.

Q9. Are you now married, widowed, divorced, separated, never married, or living with a partner?

1 Married

2 Widowed

3 Divorced

4 Separated

5 Never Married

6 Living with a partner

7 Refused

9 Don’t know

Q10. What is your correct working status?

1 Working for pay at a job or business

2 With a job or business but not at work

3 Looking for work

4 Working, but not for pay, at a family-owned job or business

5 Not working at a job or business and not looking for work

7 Refused

9 Don't know

Q11. What is the HIGHEST level of school you have completed or the highest degree you have received?

00 Never attended/Kindergarten only

01 1^st grade

02 2^nd grade

03 3^rd grade

04 4^th grade

05 5^th grade

06 6^th grade

07 7^th grade

08 8^th grade

09 9^th grade

10 10^th grade

11 11^th grade

12 12^th grade, no diploma

13 GED or equivalent

14 High School Graduate

15 Some college, no degree

16 Associate degree: occupational, technical, or vocational program

17 Associate degree: academic program

18 Bachelor’s degree (Example: BA, AB, BS, BBA)

19 Master’s degree (Example: MA, MS, MEng, MEd, MBA)

20 Professional School degree (Example: MD, DDS, DVM, JD)

21 Doctoral degree (Example: PhD, EdD)

97 Refused

99 Don’t know

FAMILY INCOME QUESTIONS

Q11intro (FINCINT)

The next questions are about [fill1: your total/your total family] income in [fill2: last calendar year in 4-digit format] BEFORE TAXES. Income is important in analyzing the health information we collect. For example, with this information, we can learn whether persons in one income group use certain types of medical services more or less often than those in another group. Please be assured that, like all other information you have provided, these answers will be kept strictly confidential.

1 Enter 1 to Continue

fill1: If one person family, fill [your total]; else, fill: [your total family]

goto FINCTOT

Q12 (FINCTOT) [fill1: When answering this next question, please remember to include your income PLUS the income of all family members living in this household.]

What is your best estimate of [fill2: your total income/the total income of all family members] from all sources, before taxes, in [fill3: last calendar year in 4 digit format]?

000000-999994 $0-$999,994

999995 $999,995+

999997 Refused

999999 Don’t know

fill1: If more than one person in the family, fill this text.

fill2: If one person in the family, fill: [your total income]; else, fill: [the total income of all family members]

<0-999995> goto HOUSEOWN

<999997,999999> goto FINC50

Q13 (FINC50) Was your total [fill: family] income from all sources less than $50,000 or $50,000 or more?

1 Less than $50,000

2 $50,000 or more

7 Refused

9 Don't know

fill: If more than one person in the family, fill: [family]

<1> [goto FINC35]

<2> [goto FINC100]

<7,9> [HOUSEOWN]

Q14 (FINC35) Was your total [fill: family] income from all sources less than $35,000 or $35,000 or more?

1 Less than $35,000

2 $35,000 or more

7 Refused

9 Don't know

fill: If more than one person in the family, fill: [family]

<1> if family size <= 5, goto FINCPOV; else goto HOUSEOWN

<2> if family size = 4, goto F200PV35; elseif family size = 8, goto FINCPOV; else goto HOUSEOWN

<7,9> goto HOUSEOWN

Q15 (F200PV35) Was your total family income from all sources less than [fill1: fill based on 200% poverty threshold] or [fill1: fill based on 200% poverty threshold] or more?

1 Less than [fill1: fill based on 200% poverty threshold]

2 [fill1: fill based on 200% poverty threshold] or more

7 Refused

9 Don't know

fill1: fill 200% poverty threshold value based on family size

Use the following thresholds based on family size: 4 persons: $45,000

<1,2,7,9> [goto HOUSEOWN]

Q16 (FINCPOV) Was your total [fill1: family] income from all sources less than [fill2: fill based on

poverty threshold] or [fill2: fill based on poverty threshold] or more?

1 Less than [fill2: fill based on poverty threshold]

2 [fill2: fill based on poverty threshold] or more

7 Refused

9 Don't know

fill1: If more than one person in the family, fill: [family]

fill2: Fill poverty threshold value. Use the following family size criteria to determine the amount to be filled in the question:

$11,500 (1 person family)

$14,500 (2 person family)

$17,000 (3 person family)

$22,500 (4 person family)

$27,000 (5 person family)

$31,000 (6 person family)

$36,000 (7 person family)

$40,000 (8 person family)

$48,000 (9 or more person family)

<1,7,9> goto HOUSEOWN

<2> if family size <= 2 [goto F200POV]; elseif family size > 2 [goto HOUSEOWN]

Q17 (F200POV) Was your total [fill1: family] income from all sources less than [fill2: fill based on 200% poverty threshold] or [fill2: fill based on 200% poverty threshold] or more?

1 Less than [fill2: fill based on poverty threshold]?

2 [fill2: fill based on poverty threshold] or more

7 Refused

9 Don't know

fill1: If more than one person in the family, fill: [family]

fill2: Fill poverty threshold value based on family size:

1 person: $23,000

2 persons: $29,000

<1,2,7,9> [goto HOUSEOWN]

Q18 (FINC100) Was your total [fill: family] income from all sources less than $100,000 or $100,000 or more?

1 Less than $100,000

2 $100,000 or more

7 Refused

9 Don't know

fill: If more than one person in the family, fill: [family]

<1> [goto FINC75]

<2> [goto FINC150]

<7,9> [goto HOUSEOWN]

Q19 (FINC150) Was your total [fill: family] income from all sources less than $150,000 or $150,000 or more?

1 Less than $150,000

2 $150,000 or more

7 Refused

9 Don't know

fill: If 2 or more persons in the family, fill "family"; else leave blank

<1,2,7,9> [goto HOUSEOWN]

Q20 (FINC75) Was your total [fill: family] income from all sources less than $75,000 or $75,000 or more?

1 Less than $75,000

2 $75,000 or more

7 Refused

9 Don't know

fill: If more than one person in the family, fill: [family]

<1> if family size = 6, goto F200PV75; else goto HOUSEOWN

<2> if family size = 8, goto F200PV75; else goto HOUSEOWN

<7,9> goto HOUSEOWN

Q21 (F200PV75) Was your total [fill1: family] income from all sources less than [fill2: fill based on 200% poverty threshold] or [fill2: fill based on 200% poverty threshold] or more?

1 Less than [fill2: fill based on poverty threshold]

2 [fill2: fill based on poverty threshold] or more

7 Refused

9 Don't know

fill1: If more than one person in the family, fill: [family]

fill2: Fill 200% poverty threshold value based on family size:

6 persons: $62,000

8 persons: $80,000

<1,2,7,9> [goto HOUSEOWN]

Q22 (HOUSEOWN) Is this house/apartment owned or being bought, rented, or occupied by some other arrangement by you [fill: or someone in your family]?

1 Owned or being bought

2 Rented

3 Other arrangement

7 Refused

9 Don’t know

fill1: If family members > 1, fill: [or someone in your family?]

ALCOHOL QUESTIONS

Q23 (ALC1YR) These 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 had at least 12 drinks of any type of alcoholic beverage?

1 Yes

2 No

7 Refused

9 Don't know

<1> [goto ALC12MNO]

<2,7,9> [goto ALCLIFE]

Help Screen:

Include as alcohol all types of beer (including stout, ale, malt liquor, or light beer, but does not include alcohol-free beer), wine (including port, sherry, sangria wine coolers, and champagne), and liquor (including brandy, liqueurs, scotch, whiskeys, tequila and gin.)

Q24 (ALCLIFE) In your ENTIRE LIFE, have you had at least 12 drinks of any type of alcoholic beverage?

1 Yes

2 No

7 Refused

9 Don't know

<1> [goto ALC12MNO]

<2,7,9> [goto LNKINTRO]

Help Screen:

Include as alcohol all types of beer (including stout, ale, malt liquor, or light beer, but does not include alcohol-free beer), wine (including port, sherry, sangria wine coolers, and champagne), and liquor (including brandy, liqueurs, scotch, whiskeys, tequila and gin.)

Q25 (ALC12MNO. 1 of 2)

In the PAST YEAR, how often did you drink any type of alcoholic beverage?

*Enter '0' for Never.

000-365 Days per week, month, or year

997 Refused

999 Don’t know

<1-365> [goto ALC12MTP]

<0,997,999> [goto LNKINTRO]

Help Screen:

Include as alcohol all types of beer (including stout, ale, malt liquor, or light beer, but does not include alcohol-free beer), wine (including port, sherry, sangria wine coolers, and champagne), and liquor (including brandy, liqueurs, scotch, whiskeys, tequila and gin.)

ALC12MTP. 2 of 2

* Enter time period for how often alcoholic beverages were consumed in the past year.

1 Week

2 Month

3 Year

<1-3> [goto ALCAMT]

[If (ALC12MNO gt <7> & ALC12MTP = <1>) or (ALC12MNO gt <31> & ALC12MTP = <2>) or

(ALC12MNO gt <365> & ALC12MTP = <3>) goto ERR_ALC12MTP]

Hard Edits:

ERR_ALC12MTP:

* [Fill1: ALC12MNO] days per [Fill2: ALC12MTP] exceeds number possible in this time period.

* Please correct.

Q26 (ALCAMT) In the PAST YEAR, on those days that you drank alcoholic beverages, on the average, how many drinks did you have?

* Enter '1' if less than 1 drink.

* Enter '95' if 95 or more drinks.

01-95 Drinks

97 Refused

99 Don’t know

<1-95,D,R>[goto ALC5UPNO]

<10-95>[goto ERR_ALCAMT]

Soft Edits:

ERR_ALCAMT

* [Fill: ALCAMT] drinks is an unusually high number.

* Please verify.

Help Screen:

Include as alcohol all types of beer (including stout, ale, malt liquor, or light beer, but does not include alcohol-free beer), wine (including port, sherry, sangria wine coolers, and champagne), and liquor (including brandy, liqueurs, scotch, whiskeys, tequila and gin.)

Q27 (ALC5UPNO. 1 of 2)

In the PAST YEAR, on how many DAYS did you have 5 or more drinks of any alcoholic beverage?

* Enter '0' for Never/None.

000-365 Days per week, month, or year

997 Refused

999 Don’t know

<1-365> [goto ALC5UPTP]

<0,997,999> [goto LNKINTRO]

Help Screen:

Include as alcohol all types of beer (including stout, ale, malt liquor, or light beer, but does not include alcohol-free beer), wine (including port, sherry, sangria wine coolers, and champagne), and liquor (including brandy, liqueurs, scotch, whiskeys, tequila and gin.)

ALC5UPTP. 2 of 2

1 Week

2 Month

3 Year

<1-3> [goto LNKINTRO]

[If (ALC5UPNO gt <7> & ALC5UPTP = <1>) or (ALC5UPNO gt <31> & ALC5UPTP = <2>) or

(ALC5UPNO gt <365> & ALC5UPTP = <3>) goto ERR1_ALC5UPTP

[If number of days drank in the past year (calculated from ALC12MNO and ALC12MTP) lt number of days per year with 5 or more drinks (calculated from ALC5UPNO and ALC5UPTP)] goto ERR2_ALC5UPTP]

Hard Edit:

ERR1_ALC5UPTP:

* [Fill1: ALC12MNO] days per [Fill2: ALC12MTP] exceeds number possible in this time period.

* Please correct.

ERR2_ALC5UPTP:

* Number of days had 5 or more drinks exceeds number of days drank.

* Please correct.

Q28 (ALC5N2HR. 1 of 2)

In the PAST 30 DAYS, on how many DAYS did you have 5 or more drinks of any alcoholic beverage in a TWO HOUR PERIOD?

* Enter '0' for Never/None.

00 Never/None

01-30 1-30 days

97 Refused

99 Don't know

<1-30>[goto ALC5T2HR]

<0,97,99>[goto LNKINTRO]

Help Screen:

Include as alcohol all types of beer (including stout, ale, malt liquor, or light beer, but does not include alcohol-free beer), wine (including port, sherry, sangria wine coolers, and champagne), and liquor (including brandy, liqueurs, scotch, whiskey, tequila and gin).

ALC5T2HR. 2 of 2

1 Week

2 Month

7 Refused

9 Don’t know

<1-2,R,D>[goto LNKINTRO]

[If (ALC5N2HR gt <7> & ALC5T2HR = <1>) or (ALC5N2HR gt <30> & ALC5T2HR = <2>) goto ERR1_ALC5T2HR]

Hard Edits:

ERR1_ALC5T2HR:

* [Fill1: ALC5N2HR] days per [Fill2: ALC5T2HR] exceeds number possible in this time period.

* Please correct.

RECORD LINKAGE QUESTIONS

Q29intro (LNKINTRO) Finally, we would like the last four digits of your Social Security Number. This information will help us link your survey data with health-related records of other government agencies, and allow us to conduct additional research without taking up your time with more questions. The National Center for Health Statistics uses this information for research purposes only. Providing this information is voluntary. Federal laws authorize us to ask for this information and require us to keep it strictly private. There will be no effect on your benefits if you do not provide this information.

Enter ‘1’ to continue.

7 Refused

9 Don’t know

Help Screen:

NHIS data have been linked with health-related records of government agencies such as the Centers for Medicare and Medicaid Services and the Social Security Administration. NHIS data have also been linked with death certificate data stored in the National Death Index (NDI). The NDI is a database of death certificate information provided to NCHS by State offices.

All personal identifying information is removed from the linked data files.

These are some examples of possible research studies using NHIS data together with health-related records of other government agencies or the NDI:

• Predicting the number of disabled persons in the U.S. based on health conditions

reported in the NHIS.

• Predicting the costs of Medicare based on health conditions reported in the NHIS.

• Studying the risk of certain diseases for persons with and without health insurance.

• Studying the health characteristics of people who retire early.

• Calculating how long a person in the U.S. might live, based on his or her education, income, or race and ethnicity.

Providing this information is voluntary. Federal laws authorize us to ask for this information and require us to keep it strictly private. The specific federal laws are the Public Health Service Act ( Title 42, United States Code, Section 242K) and the Confidential Information Protection and Statistical Efficiency Act (Title V of Public Law 107-347).

Q29 (SASSN4) What are the last four digits of your Social Security Number?

* Enter 'N' if no Social Security Number.

Refused

Don’t know

<0-999> goto ERR_SASSN4

<0000> goto ERR3_SASSN4

<N,R,D> goto SARLINK

Hard Edits:

ERR_SASSN4:

* You must enter all four of the last four digits of the Social Security Number.

*Please correct.

ERR3_SASSN4:

* The last 4 digits of a SSN may be between 0001-9999.

* Please correct.

Help Screen:

NHIS data have been linked with health-related records of government agencies such as the Centers for Medicare and Medicaid Services and the Social Security Administration. NHIS data have also been linked with death certificate data stored in the National Death Index (NDI). The NDI is a database of death certificate information provided to NCHS by State offices.

All personal identifying information is removed from the linked data files.

These are some examples of possible research studies using NHIS data together with health-related records of other government agencies or the NDI:

• Predicting the number of disabled persons in the U.S. based on health conditions

reported in the NHIS.

• Predicting the costs of Medicare based on health conditions reported in the NHIS.

• Studying the risk of certain diseases for persons with and without health insurance.

• Studying the health characteristics of people who retire early.

• Calculating how long a person in the U.S. might live, based on his or her education, income, or race and ethnicity.

Providing this information is voluntary. Federal laws authorize us to ask for this information and require us to keep it strictly private. The specific federal laws are the Public Health Service Act ( Title 42, United States Code, Section 242K) and the Confidential Information Protection and Statistical Efficiency Act (Title V of Public Law 107-347).

Q30 (SARLINK) May we try to link your survey data without a Social Security Number?

1 Yes

2 No

7 Refused

9 Don't know

Help Screen:

NHIS data have been linked with health-related records of government agencies such as the Centers for Medicare and Medicaid Services and the Social Security Administration. NHIS data have also been linked with death certificate data stored in the National Death Index (NDI). The NDI is a database of death certificate information provided to NCHS by State offices.

All personal identifying information is removed from the linked data files.

These are some examples of possible research studies using NHIS data together with health-related records of other government agencies or the NDI:

• Predicting the number of disabled persons in the U.S. based on health conditions

reported in the NHIS.

• Predicting the costs of Medicare based on health conditions reported in the NHIS.

• Studying the risk of certain diseases for persons with and without health insurance.

• Studying the health characteristics of people who retire early.

• Calculating how long a person in the U.S. might live, based on his or her education, income, or race and ethnicity.

Any data obtained will be kept strictly private as required by law (Public Health Service Act, which is Title 42, United States Code, Section 242K; and the Confidential Information Protection and Statistical Efficiency Act, which is Title V of Public Law 107-347).

35