Attachment 1: ACASI questions to be tested following full NHIS
Note to reviewers: These instructions will change as Census develops the ACASI programming strategy. For example, [ENTER} may actually be the ENTER key with a green dot or label.
INSTRUCTIONS AND PRACTICE SESSION QUESTIONS
READ TO RESPONDENT: Now I will ask you to do an important part of this interview on your own, using the computer and headphones. You will hear questions through the headphones and see them on the computer screen. Before you start, we’ll go through a short practice session. Let me first show you the keys you will use. The practice session that follows will go through what each key does also.
MOVE COMPUTER SO RESPONDENT CAN SEE THE KEYBOARD AND POINT OUT THE
FOLLOWING: WHERE THE QUESTIONS WILL APPEAR, each key that will be used. (next question, previous question, change your answer, skip the question, if you don’t know the answer, ENTER, WHERE THE NUMERIC KEYS ARE LOCATED)
These headphones will allow you to listen to the interview questions.
HAND HEADPHONES TO RESPONDENT.
You can adjust the volume here [DEMONSTRATE VOLUME ADJUSTMENT ON THE HEADPHONE
CORD].
Please put on your headphones. When you are ready, let me know.
MOVE COMPUTER SO RESPONDENT CAN USE IT. ONCE RESPONDENT HAS HEADPHONES ON, PRESS “1" AND [ENTER] SO R CAN BEGIN PRACTICE SESSION.
HeadPhone- First I want to make sure you can hear me. I will ask you questions at this level. If you want to change the level of my voice, use the knob that the interviewer showed you. If you have difficulty, ask the interviewer for help. When you are comfortable with the volume, press the [ENTER]* key on the right side of the keyboard.
INTRO1- We want you to be able to answer the remaining questions in complete privacy. The first questions are for practice. When you are ready to go to the next screen, press the large [ENTER] key.
INTRO2- You can read the questions on the computer screen and hear them read through the headphones. If you would like to just see the questions on the screen without sound, you can turn off the voice using the knob on the cord. Now press the large [ENTER] key on the right side of the keyboard to move to the next screen.
DLIC After you hear or read this question, touch the [CIRCLE] key until the circle is on the answer you want, then press [ENTER}.
Do you have a driver’s license?
Yes
No
NUMBER Other questions will ask you to type in a number instead of choosing a number from a list.
In the past 30 days, on how many days did you watch TV? Type in the number of days you watched TV. If you are happy with your answer, press the [ENTER].
________________ [RANGE: 0 - 30]
If you want to change or see your answer to a previous question, you can back up using the [BB] key. Each time you press the [BB] key, the computer will go back one question.
Press [ENTER] to continue.
DOAGAIN- You can tell the computer to repeat a question by pressing [??]. Try this now.
How many times did you listen to this screen?
1 One time.
2 Two or more times
LIST-The next type of question asks you to pick an answer from a list.
How many days are in a week? Touch the [CIRCLE] key until the answer you want is circled, then push [ENTER]. If you need to back up, >>>>
One
Two
Three
Four
Five
Six
Seven
Eight
DKREF- If you cannot answer a question because you do not know the answer or do not want to answer you have that choice. Touch the [CIRCLE] until you have the answer you want, then push [ENTER] to get to the next question. Try that now.
How many stars are there in the sky?
I don’t know the answer
I don’t want to answer
If you have any questions, ask your interviewer now. If not, press 7 and then [ENTER] to begin the questions.
ACASI QUESTIONS TO BE TESTED
These questions are about you and your life.
How often do you use a computer?
Never or almost never
Some days
Most days
Every day
I don’t know
I don’t want to answer
In general, how satisfied are you with the health care you received in the past 12 months?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
I haven’t had health care in the past 12 months
I don’t know
I don’t want to answer
How tall are you without shoes? First, please [CIRCLE] the number of feet, then press [Enter].
one foot tall
two feet tall
three fee tall
four feet tall
five feet tall
six feet tall
seven feet tall
eight feet tall
nine feet tall
ten feet tall
I don’t know the answer
I don’t want to answer
Now please [CIRCLE] number of inches and then press [Enter].
no inches
one inch
two inches
three inches
four inches
five inches
six inches
seven inches
eight inches
nine inches
ten inches
eleven inches
twelve inches
I don’t know the answer
I don’t want to answer
How much do you weigh without shoes? Type in the number of pounds and then push [ENTER].
________Number of pounds
I don’t know the answer
I don’t want to answer
When you were 6 years old, who did you live with most of the time?
My mother only
My father only
Both my mother and father
I did not live with either parent
I don’t know
I don’t want to answer
When you were 16 years old, who did you live with most of the time?
My mother only
My father only
Both my mother and father
I did not live with either parent
I don’t know
I don’t want to answer
Where any of your grandparents born in the United States?
Yes (Go to 7a)
No (Go to 8)
I don’t know
I don’t want to answer
7a. How many of your grandparents were born in this country?
1
2
3
4
I don’t know
I don’t want to answer
8a. For men: Do you think of yourself as
Gay
straight, that is, not gay
bisexual
something else
I don’t know
[If something else is selected]
By something else, do you mean that…
You are not straight, but identify with another label such as queer, trisexual, omnisexual or pan-sexual
You are transgender, transsexual or gender variant
You have not figured out or are in the process of figuring out your sexuality
You do not think of yourself as having sexuality
You do not use labels to identify yourself
You made a mistake and did not mean to pick this answer
You mean something else
You don’t know
You don’t want to answer
8b. For women: Do you think of yourself as
Lesbian or Gay
Straight, that is, not gay
Bisexual
Something Else
I don’t know
[If something else is selected]
By something else, do you mean that…
You are not straight, but identify with another label such as queer, trisexual, omnisexual or pan-sexual
You are transgender, transsexual or gender variant
You have not figured out or are in the process of figuring out your sexuality
You do not think of yourself as having sexuality
You do not use labels to identify yourself
You made a mistake and did not mean to pick this answer
You mean something else
You don’t know
You don’t want to answer
The next questions ask how concerned you are right now about financial matters.
How concerned are you right now about not having enough money for retirement? Are you
very worried
moderately worried
not too worried
not worried at all
I don’t know the answer
I don’t want to answer
How concerned are you right now about not being able to pay medical costs of a serious illness or accident? Are you
very worried
moderately worried
not too worried
not worried at all
I don’t know the answer
I don’t want to answer
How concerned are you right now about not being able to maintain the standard of living you enjoy? Are you
very worried
moderately worried
not too worried
not worried at all
I don’t know the answer
I don’t want to answer
How concerned are you right now about not being able to pay medical costs for normal healthcare? Are you
very worried
moderately worried
not too worried
not worried at all
I don’t know the answer
I don’t want to answer
How concerned are you right now about not having enough money to pay for your children's college? Are you
very worried
moderately worried
not too worried
not worried at all
I don’t know the answer
I don’t want to answer
How concerned are you right now about not having enough to pay your normal monthly bills? Are you
very worried
moderately worried
not too worried
not worried at all
I don’t know the answer
I don’t want to answer
How concerned are you right now about not being able to pay your rent, mortgage, or other housing costs? Are you
very worried
moderately worried
not too worried
not worried at all
I don’t know the answer
I don’t want to answer
How concerned are you right now about not being able to make the minimum payments on your credit cards? Are you
very worried
moderately worried
not too worried
not worried at all
I don’t know the answer
I don’t want to answer
On average, how many hours of sleep do you get in a 24-hour period?
one hour or less
two hours
three hours
four hours
five hours
six hours
seven hours
eight hours
nine hours
ten hours
eleven hours
twelve or more hours
I don’t know
I don’t want to answer
In the past week, how often did you have trouble falling asleep?
I didn’t have trouble falling asleep in the past week
One time
two times
three times
four times
five times
six times
seven or more times
I don’t know
I don’t want to answer
In the past week, how many times did you have trouble staying asleep?
I didn’t have trouble staying asleep in the past week
One time
two times
three times
four times
five times
six times
seven or more times
I don’t know
I don’t want to answer
In the past week, how many times did you take medication to help you fall asleep or stay asleep?
I did not take medication to help me sleep in the past week
one time
two times
three times
four times
five times
six times
seven or more times
I don’t know
I don’t want to answer
In the past week, on how many days did you wake up feeling well rested?
I never woke up feeling rested last week
One time
two times
three times
four times
five times
six times
seven or more times
I don’t know
I don’t want to answer
Now I am going to ask you some questions about feelings you may have experienced over the PAST 30 DAYS.
DURING THE PAST 30 DAYS, how often did you feel
... So sad that nothing could cheer you up?
ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
I don’t know
I don’t want to answer
During the PAST 30 DAYS, how often did you feel
... Nervous?
ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
I don’t know
I don’t want to answer
During the PAST 30 DAYS, how often did you feel
... Restless or fidgety?
ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
I don’t know
I don’t want to answer
During the PAST 30 DAYS, how often did you feel
... Hopeless?
ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
I don’t know
I don’t want to answer
During the PAST 30 DAYS, how often did you feel
...That everything was an effort?
ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
I don’t know
I don’t want to answer
During the PAST 30 DAYS, how often did you feel
...Worthless?
ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
I don’t know
I don’t want to answer
Universe statement: Sample adults 18+ who at least some of the time have felt sad, nervous, restless or fidgety, hopeless, that everything was an effort, or worthless, in the past 30 days
We just talked about a number of feelings you had during the PAST 30 DAYS. Altogether, how MUCH did these feelings interfere with your life or activities: a lot, some, a little, or not at all?
A lot
Some
A little
Not at all
I don’t know
I don’t want to answer
The next question is about the test for HIV (the virus that causes AIDS). Except for tests you may have had as part of blood donations, have you ever been tested for HIV?
Yes
No
I don’t know
I don’t want to answer
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?
Yes (Go to Q32)
No (Go to Q31)
I don’t know
I don’t want to answer
In your ENTIRE LIFE, have you had at least 12 drinks of any type of alcoholic beverage?
Yes
No
I don’t know
I don’t want to answer
In the PAST YEAR, how many days did you drink any type of alcoholic beverage?
________________number of days drank any alcoholic beverage in the past year
I don’t know
I don’t want to answer
In the PAST YEAR, on those days that you drank alcoholic beverages, on the average, how many drinks did you have?
___________drinks per day
I don’t know
I don’t want to answer
In the PAST YEAR, on how many DAYS did you have 5 or more drinks of any alcoholic beverage?
___________number of days you drank 5 or more drinks
I don’t know
I don’t want to answer
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Centers for Disease Control & Prevention |
| File Modified | 0000-00-00 |
| File Created | 2021-02-03 |