Form 1 HINTS 4 Attachment A, B, & E

Questionnaire Cognitive Interviewing and Pretesting (NCI)

#9_Attachs A B and E-- Instrument Protocol Screener_updated

#9 Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 1 Instrument

OMB: 0925-0589

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0925-0589 can be found here:

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Health Information National Trends Survey 4 (HINTS 4)

Cognitive Testing of Cycle 1 Instrument

Generic Sub-study under “Questionnaire Cognitive Interviewing and

Pretesting,” (OMB No. 0925-0589-09; Expiration Date: 5/31/2011)

Attachment A: HINTS 4 Questionnaire Content (Cycle 1)

Attachment B: Interview Protocol Overlaid with Questionnaire Content and Alternative Questions for Cycle 1

Attachment E: Screening Questionnaire

ATTACHMENT A: HINTS 4 PROPOSED QUESTIONNAIRE CONTENT – CYCLE 1

OMB #: 0925-0589-09

Expiry Date: 5/31/2011

Public reporting burden for this collection of information is estimated to average 1.5 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0589-06). Do not return the completed form to this address.

START HERE:

How many adults age 18 or older live in this household?

Each adult (age 18 or older) living in your household should fill out one questionnaire. Please be sure that each adult has an opportunity to fill out a questionnaire. This is very important to the success of the study.

OR – Next Birthday method

If only one adult lives in this household, then that person should complete this questionnaire. If more than one adult lives here, then the adult with the next birthday should complete this questionnaire.

OR – Hagan Collier method

In order for the study to accurately represent all adults in America, we are asking households to have the person fitting the rule shown below complete this questionnaire. Following this rule is very important to the success of the study. Thank you for your cooperation.”

WHO SHOULD COMPLETE THIS QUESTIONNAIRE: (only one will display per questionnaire)

Version 1: The oldest adult male in the household should complete this questionnaire. If no males live here, then the oldest adult female in the household should complete this questionnaire.
Version 2: The oldest adult female in the household should complete this questionnaire. If no females live here, then the oldest adult male in the household should complete this questionnaire.
Version 3: The youngest adult male in the household should complete this questionnaire. If no males live here, then the youngest adult female in the household should complete this questionnaire.
Version 4: The youngest adult female in the household should complete this questionnaire. If no females live here, then the youngest adult male in the household should complete this questionnaire.

If more questionnaires are needed, please call 1-888-xxx-xxxx

If you would like Spanish questionnaires, please call 1-888-xxx-xxxx

Not all questions will apply to you – sometimes you will see instructions following your answer to a question that direct you to skip to a question farther in the questionnaire.

1. Have you ever looked for information about health or medical topics from any source?

Yes
No  Skip to 6

2. The most recent time you looked for information about health or medical topics, where did you go first?

Books
Brochures, pamphlets, etc.
Cancer organization
Family
Friend/co-Worker
Doctor or health care provider
Internet
Library
Magazines
Newspapers
Telephone information number
Complementary, alternative, or unconventional practitioner
Other (Specify:) _____________

3. Did you look or go anywhere else?

Yes
No

4. The most recent time you looked for information about health or medical topics who was it for...

Myself
Someone else
Both myself and someone else

5. Based on the results of your most recent search for information about health or medical topics, how much do you agree or disagree with each of the following statements?

		Strongly Agree	Somewhat Agree	Somewhat Disagree	Strongly Disagree
a.	It took a lot of effort to get the information you needed.	___	___	___	___
b.	You felt frustrated during your search for the information.	___	___	___	___
c.	You were concerned about the quality of the information.	___	___	___	___
d.	The information you found was hard to understand.	___	___	___	___

6. Overall, how confident are you that you could get advice or information about health or medical topics if you needed it?

Completely confident
Very confident
Somewhat confident
A little confident
Not confident at all

7. In general, how much would you trust information about health or medical topics from each of the following?

		A lot	Some	A little	Not at all
a.	A doctor	___	___	___	___
b.	Family or friends	___	___	___	___
c.	Newspapers or magazines	___	___	___	___
d.	Radio	___	___	___	___
e.	The internet	___	___	___	___
f.	Television	___	___	___	___
g.	Government health agencies	___	___	___	___
h.	Charitable organizations	___	___	___	___
i.	Religious organizations and leaders	___	___	___	___

8. Imagine that you had a strong need to get information about health or medical topics. Where would you go first?

9. Have you ever looked for information about cancer from any source?

Yes
No

10. The most recent time you looked for cancer information, where did you go first?

11. The most recent time you looked for information about cancer who was it for…

Myself
Someone else
Both myself and someone else

12. Do you ever go on-line to access the Internet or World Wide Web, or to send and receive e-mail?

Yes  Skip to 14
No

13. Which of the following, if any, are the reasons you do not access the Internet?

__ Because you are not interested.

__ Because it costs too much.

__ Because it is too complicated to use.

__ Because you do not think it is useful.

Go to question 21

14. Where do you use the Internet?

__ Home
__ Work
__ School
__ Public Library
__ Community Center
__ Someone else's house
__ Some other place

15. When you use the Internet at home, do you mainly access it through...

__ Do not use the Internet at home
__ A regular ‘dial-up’ telephone line
__ A DSL Line (Digital Subscriber Line)
__ A cable modem
__ Something else

16. In the past 12 months, have you used the Internet to look for health or medical information for yourself?

Yes
No

17. Is there a specific Internet site you like to go to for health or medical information?

Yes

No  Skip to 19

18. Specify which Internet site you especially like as a source of health or medical information:

__________________________________________________________________________________

19. Below are some ways people use the Internet. Some people have done these things, but other people have not. Please tell us whether or not you have done each of these things while using the Internet in the past 12 months.

		Yes	No
a.	Looked for information about quitting smoking?	___	___
b.	Bought medicine or vitamins on-line?	___	___
c.	Participated in an on-line support group for people with a similar health or medical issue?	___	___
d.	Used e-mail or the Internet to communicate with a doctor or a doctor's office?	___	___
e.	Used a website to help you with your diet, weight, or physical activity?	___	___
f.	Looked for a healthcare provider?	___	___
g.	Downloaded to a portable device, such as an iPod, cell phone, or PDA?	___	___
h.	Visited a "social networking" site, such as "Facebook" or "LinkedIn"?	___	___
I	Wrote in an online diary or "blog" (i.e., Web log)?	___	___
j.	Kept track of personal health information, such as care received, test results, or upcoming medical appointments?	___	___
k.	Looked for health or medical information for someone else?	___	___

20. Have you done anything else health-related on the Internet?

Yes (Specify:) ___________________________

21. Not including psychiatrists and other mental health professionals, is there a particular doctor, nurse, or other health professional that you see most often?

Yes
No

22. Do you have any of the following healthcare coverage options:

		Yes	No
a.	Insurance through a current or former employer or union (of you or another family member)	___	___
b.	Medicare	___	___
c.	Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability	___	___
d.	TRICARE or other military health care	___	___
e.	VA (including those who have ever used or enrolled for VA health care)	___	___
f.	Indian Health Service	___	___

23. Do you have any other health care coverage option?

Yes (Specify): ___________________
No

24. About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.

Within past year (anytime less than 12 months ago)
Within past 2 years (1 year but less than 2 years ago)
Within past 5 years (2 years but less than 5 years ago)
5 or more years ago
Don't Know
Never

25. In the past 12 months, not counting times you went to an emergency room, how many times did you go to a doctor, nurse, or other health professional to get care for yourself?

None  Skip to 31

1 Time
2 Times
3 Times
4 Times
5-9 Times
10 or More Times

26. In the past 12 months, how often did you feel you could rely on your doctors, nurses, or other health care professionals to take care of your health care needs?

Always
Usually
Sometimes
Never

27. Overall, how would you rate the quality of health care you received in the past 12 months?

Excellent
Very Good
Good
Fair
Poor

28. The following questions are about your communication with all doctors, nurses, or other health professionals you saw during the past 12 months. How often did they do each of the following?

		Always	Usually	Sometimes	Never
a.	Give you the chance to ask all the health-related questions you had	___	___	___	___
b.	Listen carefully to you	___	___	___	___
c.	Give the attention you needed to your feelings and emotions	___	___	___	___
d.	Involve you in decisions about your health care as much as you wanted	___	___	___	___
e.	Make sure you understood the things you needed to do to take care of your health	___	___	___	___
f.	Explain things in a way you could understand	___	___	___	___
g.	Spend enough time with you	___	___	___	___
h.	Show respect for what you had to say	___	___	___	___
i.	Help you deal with feelings of uncertainty about your health or health care	___	___	___	___

29. In the past 12 months, have you talked to a doctor, nurse, or other health professional about any kind of health information you have gotten from the Internet?

Yes
No  Skip to 31

30. In the past 12 months when you talked with a health care professional, how interested were they in hearing about the information you found on-line?

Very interested
Somewhat interested
A little interested
Not at all interested

31. Overall, how confident are you about your ability to take good care of your health?

Completely confident
Very confident

Somewhat confident
A little confident
Not confident at all

The next two questions ask about fruits and vegetables. The following boxes provide some examples of how much counts as 1 cup.

1 cup of fruit could be:

1 small apple

1 large banana

1 large orange

8 large strawberries

1 medium pear

2 large plums

32 seedless grapes

1 cup (8 oz.) of 100% juice

½ cup of dried fruit

1 small wedge of watermelon (1 inch thick)

1 cup of vegetables could be:

3 broccoli spears, 5 in. long

1 cup of cooked leafy greens

2 cups of lettuce or raw greens

12 baby carrots

1 medium potato

1 large sweet potato

1 large ear of corn

1 large raw tomato

2 large celery stalks

1 cup of cooked beans

32. About how many cups of fruit (including 100% pure fruit juice) do you eat or drink each day?

None
1/2 cup or less

1/2 to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 cups or more

33. About how many cups of vegetables (including 100% vegetable juice) do you eat or drink each day?

None
1/2 cup or less

1/2 to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 cups or more

34. In a typical week, how many days do you do any physical activity or exercise of at least moderate intensity, such as brisk walking, bicycling at a regular pace, swimming at a regular pace, and heavy gardening?

None
1 day per week
2 days per week
3 days per week
4 days per week
5 days per week
6 days per week
7 days per week

35. On the days that you do any physical activity or exercise of at least moderate intensity, how long are you typically doing these activities?

Hours : minutes
|__|__|: |__|__|

36. About how tall are you without shoes?

|__|__|.|__|__|
feet . inches

37. About how much do you weigh, in pounds, without shoes?

|__|__|__|Lbs.

38. When you are outside during the summer on a warm sunny day, how often do you wear sunscreen?

Always
Often
Sometimes
Rarely
Never
Do not go out on sunny day

39. Have you smoked at least 100 cigarettes in your entire life?

Yes
No  Skip to 41

40. How often do you now smoke cigarettes...

Everyday
Some days
Not at all

41. A drink of alcohol is 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 cocktail, or 1 shot of liquor. During the past 30 days, how many days per week did you have at least one drink of any alcoholic beverage?

0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

42. During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?

|__|__| number of days

43. Are you male or female?

Male  Skip to 48
Female

44. Have you ever had a Pap smear or Pap test?

Yes
No

45. When did you have your most recent Pap test?

A year ago or less
More than 1 but not more than 3 years ago
More than 3 but not more than 5 years ago
More than 5 years ago

46. A mammogram is an x-ray of each breast to look for breast cancer. During the past 12 months, did a doctor, nurse, or other health professional advise you to get a mammogram?

Yes
No

47. When did you have your most recent mammogram to check for breast cancer?

A year ago or less
More than 1 but not more than 2 years ago
More than 2 but not more than 5 years ago
Over 5 years ago

48. Has a health care provider such as a doctor or nurse ever talked to you about a HPV vaccine or shot?

Yes
No

49. Did a doctor, nurse, or other health professional ever advise you to get a sigmoidoscopy?

Yes
No

50. Did a doctor, nurse, or other health professional ever advise you to get a colonoscopy?

Yes
No

51. During the past 12 months, did a doctor, nurse, or other health professional advise you to do a stool blood test using a home test kit?

Yes
No

52. Have you ever had a procedure or test to check for colorectal cancer?

Yes
No

53. When did you have your last procedure or test to check for colorectal cancer?

A year ago or less
More than 1 but not more than 2 years ago
More than 2 but not more than 5 years ago
Over 5 years ago

54. A Prostate-Specific Antigen test, also called a PSA test, is a blood test used to check men for prostate cancer. Has a health care provider such as a doctor or nurse ever talked to you about a PSA test?

Yes
No

T his section contains several questions about cancer. For each, try to think about cancer in general when answering.

55. How likely do you think it is that you will develop cancer in the future?

Very low
Somewhat low
Moderate
Somewhat high
Very high

56. How often do you worry about getting cancer?

Rarely or never
Sometimes
Often
All the time

57. How much do you agree or disagree with each of the following statements?

		Strongly Agree	Somewhat Agree	Somewhat Disagree	Strongly Disagree
a.	It seems like everything causes cancer	___	___	___	___
b.	There’s not much you can do to lower your chances of getting cancer.	___	___	___	___
c.	There are so many different recommendations about preventing cancer, it's hard to know which ones to follow.	___	___	___	___

58. Have you ever been diagnosed as having cancer?

Yes
No  Skip to 64

59. What type of cancer did you have?

Bladder cancer
Bone cancer
Breast cancer
Cervical cancer (cancer of the cervix)
Colon cancer
Endometrial cancer (cancer of the uterus)
Head and neck cancer
Hodgkin's lymphoma
Leukemia/blood cancer
Liver cancer
Lung cancer
Melanoma
Non-Hodgkin lymphoma

Oral cancer

Ovarian cancer

Pancreatic cancer

Pharyngeal (throat) cancer

Prostate cancer

Rectal cancer

Renal (kidney) cancer

Skin cancer, other

Stomach cancer

Other (Specify): ___________

60. At what age were you first told that you had cancer?

[ENTER AGE.]
|__|__|__|

61. Did you ever receive any treatment for your cancer?

Yes
No  Skip to 64

62. Which of the following cancer treatments have you ever received?

		Yes	No
a.	Chemotherapy (pills)	___	___
b.	Chemotherapy (intravenous)	___	___
c.	Radiation	___	___
d.	Surgery	___	___
e.	Other	___	___

63. How long ago did you finish your most recent treatment?

[ENTER MONTHS] [ENTER YEARS]

|__|__| |__|__|

I am still in treatment

64. Have any of your family members ever had cancer?

Yes
No
No Family

65. In general, would you say your health is...

Excellent
Very Good
Good
Fair
Poor

66. How often did you feel each of the following during the past 30 days?

		All of the time	Most of the time	Some of the time	A little of the time	None of the time
a.	So sad that nothing could cheer you up	___	___	___	___	___
b.	Nervous	___	___	___	___	___
c.	Restless or fidgety	___	___	___	___	___
d.	Hopeless	___	___	___	___	___
e.	That everything was an effort	___	___	___	___	___
f.	Worthless	___	___	___	___	___

67. In the past six months, did you visit the Food & Drug Administration’s website (www.fda.gov)?

Yes  Skip to 69
No

68. Why haven’t you visited the FDA’s website?

I don’t own a computer (no Internet access)
No reason to visit the site
I prefer other sites
Didn’t know about FDA site
I don’t trust government websites (general answer)
I don’t trust the FDA
It’s too hard to find information on the FDA website
Other (please specify):_______

69. On your most recent visit, did you find the information you were looking for?

Yes
No

70. How easy or hard was it to find the information you were looking for?

Very easy
Easy
Neither easy nor hard
Hard
Very hard

71. How much do you agree or disagree with the following statements:

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	I can easily find information about the foods I eat.	___	___	___	___	___
b.	The information I get about the foods I eat is clear and understandable.	___	___	___	___	___
c.	The information I get about the foods I eat is not helpful for making food choices.	___	___	___	___	___

72. The next set of questions asks for your opinion about the information you get about the benefits of the drugs you use.

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	I can easily find information about the benefits of the drugs I use.	___	___	___	___	___
b.	The information I get about the benefits of the drugs I use is clear and understandable.	___	___	___	___	___
c.	The information I get about drug benefits is not helpful for making drug decisions.	___	___	___	___	___

73. The next set of questions asks for your opinion about the information you get about the risks of the drugs you use.

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	I can easily find information about the risks of the drugs I use.	___	___	___	___	___
b.	The information I get about the risks of the drugs I use is clear and understandable.	___	___	___	___	___
c.	The information I get about drug risks is not helpful for making drug decisions.	___	___	___	___	___

INFORMATION LEAFLET

74. When you buy drugs your doctor prescribes, how frequently do you read the information leaflet that comes with the drugs?

Always
Often
Sometimes
Rarely
Never

75. How much do you agree or disagree with the following statement:

The information leaflet for prescription drugs is easy to understand.

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

76. In the past year, how frequently did you read the information leaflet that comes with the medical products that you use in your home such items as contact lenses, blood pressure cuffs, glucose test kits, and pregnancy test kits?

Always
Often
Sometimes
Rarely
Never

77. How much do you agree or disagree with the following statement:

The information leaflets that come with the medical products I use in my home are easy to understand.

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

ADVERTISEMENTS

78. The following questions ask about advertisements for prescription drugs.

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	Advertisements for prescription drugs do not give enough information about the possible benefits and positive effects of using the medication.	___	___	___	___	___
b.	Advertisements for prescription drugs give enough information about the possible risks and negative effects of using the drug.	___	___	___	___	___

79. The following questions ask about advertisements for over the counter drugs.

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	Advertisements for over-the-counter drugs give enough information about benefits and positive effects of using the drug.	___	___	___	___	___
b.	Advertisements for over-the-counter drugs do not give enough information about the possible risks and negative effects of using the drug.	___	___	___	___	___

80. The following questions ask about advertisements for commonly used medical products such as inhalers, glucose test kites and contact lenses.

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	Advertisements for commonly used medical products do not give enough information about the possible benefits and positive effects of using these products.	___	___	___	___	___
b.	Advertisements for commonly used medical products give enough information about the possible risks and negative effects of using these products.	___	___	___	___	___

DRUG FACTS LABEL

81. When you purchase over-the-counter drugs for the first time, how frequently do you read the Drug Facts label?

Always
Often
Sometimes
Rarely
Never

82. How much do you agree with the following statement:

The Drug Facts label is easy to understand.

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Don’t Know
Refused

RECALLS

83. What would you do if a drug you used had to be recalled? Would you:

Stop taking it at once
Keep using the drug/Pay no attention to the recall
Contact the manufacturer
Go on the manufacturer’s website
Contact your doctor/nurse/other medical professional
Talk to my pharmacist
Be on my guard/keep using it
Unsure
Other (please specify:) _________________

84. What would you do if a medical product recall affected you?

Have it removed/stopped using it
Contact my doctor
Contact the manufacturer
Have it replaced/Find a substitute
Keep using it/Keep it
Make no change
Other (please specify:) _____________
Unsure

85. Have you ever heard about the recall of any of the following medical products: gel-filled teethers, automated external defibrillators, stents, pacemakers, or infant apnea monitors?

Yes
No

86. How much do you agree or disagree with the following statements...

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	Over-the-counter drugs are safer than prescription drugs.	___	___	___	___	___
b.	Over-the-counter drugs are weaker than prescription drugs.	___	___	___	___	___

87. In general, I think that the information I give doctors is safely guarded.

Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree

88. Clinical trials are research studies that involve people. They are designed to test the safety and effectiveness of new treatments and to compare new treatments with the standard care that people currently get. Have you ever heard of a clinical trial?

Yes
No

89. As far as you know, do your healthcare providers maintain your medical information in a portable, electronic format?

Yes
No

90. Please indicate how important each of the following statements is to you.

		Very Important	Somewhat Important	Not at all Important
a.	Health care providers should be able to share your medical information with each other electronically	___	___	___
b.	You should be able to get to your own medical information electronically	___	___	___

91. Please indicate how much you agree or disagree with the following statement.

Scientists doing research should be able to review my medical information if the information cannot be linked to me personally.

Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree

92. Does anyone in your family have a working cellular phone?

Yes
No

93. Is there at least one telephone inside your home that is currently working and is not a cell phone?

Yes
No

94. What is your age?

[ENTER AGE.]
|__|__|__|

95. What is your current occupational status?

Employed
Unemployed
Homemaker
Student
Retired
Disabled
Other (Specify:) ______________

96. Have you ever served on active duty in the U.S. Armed Forces, military Reserves or National Guard? Active duty does not include training in the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf war.

Yes, now on active duty

Yes on active duty in the last 12 months but not now

Yes on active duty in the past, but not in the last 12 months

No, training for Reserves or National Guard only

No, never served in the military

97. What is your marital status?

Married
Living as Married
Divorced
Widowed
Separated
Single, Never Been Married

98. What is the highest grade or level of schooling you completed?

Less Than 8 Years
8 Through 11 Years
12 Years or Completed High School
Post High School Training Other Than College (Vocational or Technical)
Some College
College Graduate
Postgraduate

99. Were you born in the United States?

Yes  Skip to 103
No

100. Are you a citizen of the United States?

Yes  Skip to 102
No
Application Pending

101. Are you a permanent resident with a green card / permanent residence authorization?

Yes
No
Application Pending

102. In what year did you come to live in the United States?

[ENTER YEAR]
|__|__|__|__|

103. How comfortable do you feel speaking English?

Completely comfortable
Very comfortable
Somewhat comfortable
A little comfortable
Not at all comfortable

104. Are you Hispanic or Latino?

Yes
No

105. Which one or more of the following would you say is your race? MARK ALL THAT APPLY.

American Indian / Alaska Native
Asian
Black / African American
Native Hawaiian / Other Pacific Islander

White

106. Including yourself, how many people live in your household?

[ENTER NUMBER.]
|__|__|

107. How many children under the age of 18 live in your household?

[ENTER NUMBER.]
|__|__|

108. Please mark the gender and write in the age of each adult 18 years of age or older living at this address.

	Gender	Age
1	Male Female
2	Male Female
3	Male Female
4	Male Female
5	Male Female

109. Thinking about members of your family living in this household, what is your combined annual income, meaning the total pre-tax income from all sources earned in the past year?

$0 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $199,999
$200,000 or more

110. Do you currently rent or own your home?

Own
Rent
Occupied Without Paying Monetary Rent

ATTACHMENT B: CYCLE 1 INTERVIEW PROTOCOL OVERLAID WITH QUESTIONNAIRE

Date:_____ Time:_____ Interviewer:______ Respondent ID:_______

REVIEW CONSENT FORM FIRST.

OMB #: 0925-0589-09

Expiry Date: 5/31/2011

START OF INTERVIEW

Today we are interested in learning about your reaction to a questionnaire we’re developing for a survey called the Health Information National Trends Survey or HINTS. I will hand you the questionnaire in a minute, but first I want to explain how we’d like you to complete the questionnaire.

So that I can tell where you are in the document, I’d like you to read or skim the questionnaire aloud as you work through it. If there is something you wouldn’t read if you were doing this at home, then don’t read it now. If there is something that you would only skim if you were doing this at home, then skim it now. It’s important for me to know what you would pay attention to and what you wouldn’t. It is not important that you read well, nor do I care if you read quickly or slowly. Really, all I need to know is what you read on the form, what you skim and what you choose to skip as you work through the questionnaire answering the questions.

As you are completing the questionnaire, I’d also like you to think aloud as you’re coming up with your answer. That is, I’d like you to say aloud what you’re thinking about as you decide what your answer is.

Let’s do an example. Here are a couple of questions from another survey (Hand printed copy to respondent). I’ll read the first one aloud and answer aloud first, and then you can give it a try with the second one.

(INTERVIEWER Q) Overall, do you think the nation's public schools are teaching students the skills they will need to be competitive in the workplace? Yes / No

Now you give it a try.

(RESPONDENT Q) Do you think the federal government should play a major role, a minor role, or no role at all in making policy decisions for schools?

Great, that’s how I’d like you to work through the questionnaire. Occasionally I might interrupt and ask a question or two about what you meant, or how you interpreted something. My goal is simply to get information about how people understand and think about the questions on the form.

There are no right or wrong answers. This is just how we go about checking the questions to see if they work the way we want them to. Hearing your thoughts helps us figure out how to improve the questions moving forward.

Do you have any questions?

There are a couple more things I want to mention before we get started. As I said, there is no right or wrong answers. And you don’t have to answer anything that you don’t want to. And of course, your participation is voluntary and you may stop at any time.

Do you have any questions before we get started?

Okay, as we discussed a few minutes ago, I’m going to turn the recorder on.

(TURN ON RECORDER, STATE DATE AND TIME AND INTERVIEW ID NUMBER)

Remember to read or skim aloud as you move through the questionnaire so I can keep up with you. Also, try to say aloud what you’re thinking about as you come up with your answers. Let’s get started.

CP: Before we get started, I meant to ask who in your household you think would complete this questionnaire if it was mailed to your house. Why (you/that person)?

Thanks, we can get started now.

HAND RESPONDENT THE QUESTIONNAIRE

ONCE THE RESPONDENT BEGINS THE QUESTIONNAIRE NOTE IF THEY HAVE ANY TROUBLE NAVIGATING THROUGH THE QUESTIONNAIRE, ANY QUESTIONS THEY APPEAR TO PAUSE AT, OR IF THEY FLIP BACK AND FORTH BETWEEN PAGES.

TAKE NOTES ON: 1. NAVIGATION

2. INSTRUCTIONS

3. ATTENTION

4. WHAT IS FILLED IN

5. ACCURACY OF INFORMATION PROVIDED

6. GET A TIMING ON TIME TO COMPLETE

FOLLOW-UP ON THESE SITUATIONS AS THEY OCCUR:

Respondent voices uncertainty or questions something about a question, instructions or anything else on the form
Respondent’s facial expression, body language or mannerisms suggest confusion, sensitivity, etc.

GENERAL PROBES:

I noticed you (describe what you’re reacting to, such as “hesitate”) right there. Tell me what you were thinking.
To get respondents to elaborate more on their answer: Can you tell me more about that?
Respondent asks you a question about a term or phrase:
- Okay, what do you think that means in this question/context?
- How would you interpret that in order to answer the question?

REMAINDER OF PROTOCOL EMBEDDED WITHIN QUESTIONNAIRE (highlighted by green text).

COGNITIVE PROBES START WITH “CP”.

START HERE:

How many adults age 18 or older live in this household?

Each adult (age 18 or older) living in your household should fill out one questionnaire. Please be sure that each adult has an opportunity to fill out a questionnaire. This is very important to the success of the study.

OR – Next Birthday method

If only one adult lives in this household, then that person should complete this questionnaire. If more than one adult lives here, then the adult with the next birthday should complete this questionnaire.

OR – Hagan Collier method

In order for the study to accurately represent all adults in America, we are asking households to have the person fitting the rule shown below complete this questionnaire. Following this rule is very important to the success of the study. Thank you for your cooperation.”

WHO SHOULD COMPLETE THIS QUESTIONNAIRE: (only one will display per questionnaire)

Version 1: The oldest adult male in the household should complete this questionnaire. If no males live here, then the oldest adult female in the household should complete this questionnaire.
Version 2: The oldest adult female in the household should complete this questionnaire. If no females live here, then the oldest adult male in the household should complete this questionnaire.
Version 3: The youngest adult male in the household should complete this questionnaire. If no males live here, then the youngest adult female in the household should complete this questionnaire.
Version 4: The youngest adult female in the household should complete this questionnaire. If no females live here, then the youngest adult male in the household should complete this questionnaire.

If more questionnaires are needed, please call 1-888-xxx-xxxx

If you would like Spanish questionnaires, please call 1-888-xxx-xxxx

Not all questions will apply to you – sometimes you will see instructions following your answer to a question that direct you to skip to a question farther in the questionnaire.

CP: IF READ/SKIM THIS PAGE -- Before turning the page, in your opinion, tell me what you think the most important pieces of information are on this page?

CP IF NEEDED: Take a look at the second bullet. Tell me what you think it’s saying, in your own words.

CP: Do you think after having read this (first page/bullet) that (person identified earlier) would fill out this questionnaire, or would someone else? Talk a little more about that.

START OF HINTS 4 CYCLE 1 CONTENT

1. Have you ever looked for information about health or medical topics from any source?

Yes
No  Skip to 6

CP: What are you thinking of as “health or medical topics”?

2. The most recent time you looked for information about health or medical topics, where did you go first?

CP: Tell me a little about how you selected (ANSWER)? IF NEEDED: What do you think this question is trying to get at?

3. Did you look or go anywhere else?

Yes
No

4. The most recent time you looked for information about health or medical topics who was it for? (C34)

Myself
Someone else
Both myself and someone else

5. Based on the results of your most recent search for information about health or medical topics, how much do you agree or disagree with each of the following statements?

		Strongly Agree	Somewhat Agree	Somewhat Disagree	Strongly Disagree
a.	It took a lot of effort to get the information you needed.	___	___	___	___
b.	You felt frustrated during your search for the information.	___	___	___	___
c.	You were concerned about the quality of the information.	___	___	___	___
d.	The information you found was hard to understand.	___	___	___	___

6. Overall, how confident are you that you could get advice or information about health or medical topics if you needed it? (RC31)

Completely confident
Very confident
Somewhat confident
A little confident
Not confident at all

7. In general, how much would you trust information about health or medical topics from each of the following? (RC131)

		A lot	Some	A little	Not at all
a.	A doctor	___	___	___	___
b.	Family or friends	___	___	___	___
c.	Newspapers or magazines	___	___	___	___
d.	Radio	___	___	___	___
e.	The internet	___	___	___	___
f.	Television	___	___	___	___
g.	Government health agencies	___	___	___	___
h.	Charitable organizations	___	___	___	___
i.	Religious organizations and leaders	___	___	___	___

8. Imagine that you had a strong need to get information about health or medical topics. Where would you go first? (RC102)

9. Have you ever looked for information about cancer from any source? (C27)

Yes
No

10. The most recent time you looked for cancer information, where did you go first? (C33)

11. The most recent time you looked for information about cancer who was it for? (C35B)

Myself
Someone else
Both myself and someone else

12. Do you ever go on-line to access the Internet or World Wide Web, or to send and receive e-mail? (C54)

Yes  Skip to 14
No

13. Which of the following, if any, are the reasons you do not access the Internet?

__ Because you are not interested. (RC152)

__ Because it costs too much. (RC150)

__ Because it is too complicated to use. (RC151)

__ Because you do not think it is useful. (RC153)

Go to question 21 on page ??

14. Where do you use the Internet? (RC149)

__ Home
__ Work
__ School
__ Public Library
__ Community Center
__ Someone else's house
__ Some other place

15. When you use the Internet at home, do you mainly access it through... (C59)

__ Do not use the Internet at home
__ A regular ‘dial-up’ telephone line
__ A DSL Line (Digital Subscriber Line)
__ A cable modem
__ Something else

16. In the past 12 months, have you looked for health or medical information for yourself? (C57)

Yes
No

17. Is there a specific Internet site you like to go to for health or medical information? (RC105?)

Yes

No  Skip to 19

18. Specify which Internet site you especially like as a source of health or medical information (RC104?)

__________________________________________________________________________________

		Yes	No
a.	Looked for information about quitting smoking? (RC103)	___	___
b.	Bought medicine or vitamins on-line? (RC139)	___	___
c.	Participated in an on-line support group for people with a similar health or medical issue? (RC142)	___	___
d.	Used e-mail or the Internet to communicate with a doctor or a doctor's office? (RC144)	___	___
e.	Used a website to help you with your diet, weight, or physical activity? (RC143)	___	___
f.	Looked for a healthcare provider? (RC?58)	___	___
g.	Downloaded to a portable device, such as an iPod, cell phone, or PDA? (RC138)	___	___
h.	Visited a "social networking" site, such as "Facebook" or "LinkedIn"? (RC145?)	___	___
I	Wrote in an online diary or "blog" (i.e., Web log)? (RC146)	___	___
j.	Kept track of personal health information, such as care received, test results, or upcoming medical appointments? (RC157)	___	___
k.	Looked for health or medical information for someone else? (RC141)	___	___

CP: What were you thinking of at letter I?

20. Have you done anything else health-related on the Internet? (RC140)

Yes (Specify:) ___________________________

CP: IF YES: Can you say more about that?

CP: IF NO: In reading this question, what do you think counts as doing anything “health-related” on the internet?

ALTERNATIVE VERSIONS FOR 19 and 20: HALF WILL GET THE ABOVE, THE OTHER HALF WILL GET THE BELOW

19. In the last 12 months, have you used the Internet for any of the following reasons?

		Yes	No
a.	Looked for information about quitting smoking? (RC103)	___	___
b.	Bought medicine or vitamins on-line? (RC139)	___	___
c.	Participated in an on-line support group for people with a similar health or medical issue? (RC142)	___	___
d.	Used e-mail or the Internet to communicate with a doctor or a doctor's office? (RC144)	___	___
e.	Used a website to help you with your diet, weight, or physical activity? (RC143)	___	___
f.	Looked for a healthcare provider? (RC?58)	___	___
g.	Downloaded to a portable device, such as an iPod, cell phone, or PDA? (RC138)	___	___
h.	Visited a "social networking" site, such as "Facebook" or "LinkedIn"? (RC145?)	___	___
I	Wrote in an online diary or "blog" (i.e., Web log)? (RC146)	___	___
j.	Kept track of personal health information, such as care received, test results, or upcoming medical appointments? (RC157)	___	___
k.	Looked for health or medical information for someone else? (RC141)	___	___

CP: What were you thinking of at letter I?

20. Have you done anything else health-related on the Internet? (RC140)

Yes (Specify:) ___________________________

CP: IF YES: Can you say more about that?

CP: IF NO: In reading this question, what do you think counts as doing anything “health-related” on the internet?

------

21. Not including psychiatrists and other mental health professionals, is there a particular doctor, nurse, or other health professional that you see most often? (C26)

Yes
No

22. Do you have any of the following healthcare coverage options: (C48)

		Yes	No
a.	Insurance through a current or former employer or union (of you or another family member)	___	___
b.	Medicare	___	___
c.	Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability	___	___
d.	TRICARE or other military health care	___	___
e.	VA (including those who have ever used or enrolled for VA health care)	___	___
f.	Indian Health Service	___	___

CP: NOTE HOW COMPLETE THE YES/NO BOXES ACROSS ITEMS

23. Do you have any other health care coverage option?

Yes (Specify): ___________________
No

CP: IF YES: Can you say more about that?

CP: IF NO: In reading this question, what do you think counts as “health care coverage option”?

24. About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition. (C47D)

Within past year (anytime less than 12 months ago)
Within past 2 years (1 year but less than 2 years ago)
Within past 5 years (2 years but less than 5 years ago)
5 or more years ago
Don't Know
Never

25. In the past 12 months, not counting times you went to an emergency room, how many times did you go to a doctor, nurse, or other health professional to get care for yourself? (C25)

None  Skip to 31

1 Time
2 Times
3 Times
4 Times
5-9 Times
10 or More Times

IF TIME ALLOWS - CP: Can you tell me a little about how you came up with (ANSWER)?

CP: IF SAID NONE – CHECK IF Q24=1. IF SO, ASK: So tell me a little more about what you think this question is asking (see if excluding routine exams).

26. In the past 12 months, how often did you feel you could rely on your doctors, nurses, or other health care professionals to take care of your health care needs? (C49)

Always
Usually
Sometimes
Never

27. Overall, how would you rate the quality of health care you received in the past 12 months? (C50)

Excellent
Very Good
Good
Fair
Poor

28. The following questions are about your communication with all doctors, nurses, or other health professionals you saw during the past 12 months. How often did they do each of the following?

		Always	Usually	Sometimes	Never
a.	Give you the chance to ask all the health-related questions you had (RC121)	___	___	___	___
b.	Listen carefully to you (RC120)	___	___	___	___
c.	Give the attention you needed to your feelings and emotions (RC122)	___	___	___	___
d.	Involve you in decisions about your health care as much as you wanted (RC125)	___	___	___	___
e.	Make sure you understood the things you needed to do to take care of your health (RC126)	___	___	___	___
f.	Explain things in a way you could understand (RC123)	___	___	___	___
g.	Spend enough time with you (RC128)	___	___	___	___
h.	Show respect for what you had to say (RC127)	___	___	___	___
i.	Help you deal with feelings of uncertainty about your health or health care (RC124)	___	___	___	___

CP: AS NEEDED, FOLLOW UP ON C, D, I.

ALTERNATIVE TO Q28: HALF GET THE ABOVE, HALF GET THE BELOW

28. In the last 12 months, when talking with your doctors, nurses or other health professionals, how often did they . . .

		Always	Usually	Sometimes	Never
a.	Give you the chance to ask all the health-related questions you had ?	___	___	___	___
b.	Listen carefully to you ?	___	___	___	___
c.	Give the attention you needed to your feelings and emotions ?	___	___	___	___
d.	Involve you in decisions about your health care as much as you wanted ?	___	___	___	___
e.	Make sure you understood the things you needed to do to take care of your health?	___	___	___	___
f.	Explain things in a way you could understand?	___	___	___	___
g.	Spend enough time with you ?	___	___	___	___
h.	Show respect for what you had to say?	___	___	___	___
i.	Help you deal with feelings of uncertainty about your health or health care?	___	___	___	___

CP: AS NEEDED, FOLLOW UP ON C, D, I.

___

29. In the past 12 months, have you talked to a doctor, nurse, or other health professional about any kind of health information you have gotten from the Internet? (RC130)

Yes
No  Skip to 31

30. In the past 12 months when you talked with a health care professional, how interested were they in hearing about the information you found on-line? (RC129)

Very interested
Somewhat interested
A little interested
Not at all interested

31. Overall, how confident are you about your ability to take good care of your health? (C38)

Completely confident
Very confident

Somewhat confident
A little confident
Not confident at all

The next two questions ask about fruits and vegetables. The following boxes provide some examples of how much counts as 1 cup.

1 cup of fruit could be:

1 small apple

1 large banana

1 large orange

8 large strawberries

1 medium pear

2 large plums

32 seedless grapes

1 cup (8 oz.) of 100% juice

½ cup of dried fruit

1 small wedge of watermelon (1 inch thick)

1 cup of vegetables could be:

3 broccoli spears, 5 in. long

1 cup of cooked leafy greens

2 cups of lettuce or raw greens

12 baby carrots

1 medium potato

1 large sweet potato

1 large ear of corn

1 large raw tomato

2 large celery stalks

1 cup of cooked beans

32. About how many cups of fruit (including 100% pure fruit juice) do you eat or drink each day? (C72)

None
1/2 cup or less

1/2 to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 cups or more

CP: Tell me how you came up with (ANSWER)? IF NEEDED: What are the fruits that you typically eat? Is there anything that you didn’t “count” in this question?

33. About how many cups of vegetables (including 100% vegetable juice) do you eat or drink each day? (C73)

None
1/2 cup or less

1/2 to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 cups or more

CP: Tell me how you came up with (ANSWER)? IF NEEDED: What are the vegetables that you typically eat? Is there anything that you didn’t “count” in this question?

None
1 day per week
2 days per week
3 days per week
4 days per week
5 days per week
6 days per week
7 days per week

ALTERNATIVE VERSIONS FOR COGNITIVE TESTING: HALF THE RESPONDENTS WILL SEE THE ABOVE, THE OTHER HALF WILL SEE THE VERSIONS BELOW

34. How many days in a typical week do you do any exercise that makes you breath somewhat harder than normal?

None
1 day per week
2 days per week
3 days per week
4 days per week
5 days per week
6 days per week
7 days per week

35. On the days that you do any physical activity or exercise of at least moderate intensity, how long are you typically doing these activities? (C71)

Hours : minutes
|__|__|: |__|__|

36. About how tall are you without shoes? (C40)

|__|__|.|__|__|
feet . inches

37. About how much do you weigh, in pounds, without shoes? (C39)

|__|__|__|Lbs.

38. When you are outside during the summer on a warm sunny day, how often do you wear sunscreen? (C74)

Always
Often
Sometimes
Rarely
Never
Do not go out on sunny day

39. Have you smoked at least 100 cigarettes in your entire life? (C75)

Yes
No  Skip to 41

40. How often do you now smoke cigarettes... (C76)

Everyday
Some days
Not at all

0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

42. During the past 30 days, for about how many days have you felt you did not get enough rest or sleep? (C47C)

|__|__| number of days

43. Are you male or female? (C3)

Male  Skip to 48
Female

44. Have you ever had a Pap smear or Pap test? (C60)

Yes
No

45. When did you have your most recent Pap test? (C61)

A year ago or less
More than 1 but not more than 3 years ago
More than 3 but not more than 5 years ago
More than 5 years ago

IF TIME ALLOWS - CP: Tell me how you decided your answer should be (ANSWER)

46. A mammogram is an x-ray of each breast to look for breast cancer. During the past 12 months, did a doctor, nurse, or other health professional advise you to get a mammogram? (C62)

Yes
No

CP: In your own words, what is this question asking? IF NEEDED: What does “advise you to get a mammogram” mean in this question?

47. When did you have your most recent mammogram to check for breast cancer? (C63)

A year ago or less
More than 1 but not more than 2 years ago
More than 2 but not more than 5 years ago
Over 5 years ago

48. Has a health care provider such as a doctor or nurse ever talked to you about a HPV vaccine or shot?

Yes
No

CP: IF NO: We’re interested in understanding what terms we might want to provide a little more information about. So with that in mind, can you tell me whether you have you ever heard of that term “HPV vaccine”?

CP: IF YES: We’re interested in understanding whether we using the best terms to describe some of the health procedures. So with that in mind, can you tell me whether your health care provider used the term “HPV vaccine” with you, or a more general description? What are some of the words he/she used, if you can recall?

49. Did a doctor, nurse, or other health professional ever advise you to get a sigmoidoscopy? (C?)

Yes
No

CP: IF YES: We’re interested in understanding whether we using the best terms to describe some of the health procedures. So with that in mind, can you tell me whether your health care provider used the term “sigmoidoscopy” with you, or a more general description? What are some of the words he/she used, if you can recall?

50. Did a doctor, nurse, or other health professional ever advise you to get a colonoscopy? (C?)

Yes
No

CP: IF YES: We’re interested in understanding whether we using the best terms to describe some of the health procedures. So with that in mind, can you tell me whether your health care provider used the term “colonoscopy” with you, or a more general description? What are some of the words he/she used, if you can recall?

51. During the past 12 months, did a doctor, nurse, or other health professional advise you to do a stool blood test using a home test kit?

Yes
No

CP: IF NEEDED: In your own words, in questions 49 – 51 how do you interpret the words “ did a doctor, nurse, or other health professional advise you to…”?

52. Have you ever had a procedure or test to check for colorectal cancer? (C63B)

Yes
No

53. When did you have your last procedure or test to check for colorectal cancer? (C63C)

A year ago or less
More than 1 but not more than 2 years ago
More than 2 but not more than 5 years ago
Over 5 years ago

CP: Can you tell me the name of the procedures you’ve had to check for colorectal cancer, or describe the procedure(s) in general?

54. (Only males should answer this.) A Prostate-Specific Antigen test, also called a PSA test, is a blood test used to check men for prostate cancer. Has a health care provider such as a doctor or nurse ever talked to you about a PSA test?

Yes
No

T his section contains several questions about cancer. For each, try to think about cancer in general when answering.

55. How likely do you think it is that you will develop cancer in the future?

Very low
Somewhat low
Moderate
Somewhat high
Very high

56. How often do you worry about getting cancer?

Rarely or never
Sometimes
Often
All the time

57. How much do you agree or disagree with each of the following statements?

		Strongly Agree	Somewhat Agree	Somewhat Disagree	Strongly Disagree
a.	It seems like everything causes cancer	___	___	___	___
b.	There’s not much you can do to lower your chances of getting cancer.	___	___	___	___
c.	There are so many different recommendations about preventing cancer, it's hard to know which ones to follow.	___	___	___	___

CP – Tell me a little about what you were thinking about in answering these questions? IF NEEDED – Were you thinking about any particular form of cancer, cancer in general, or something else?

58. Have you ever been diagnosed as having cancer?

Yes
No  Skip to 64

59. What type of cancer did you have?

Oral cancer

Ovarian cancer

Pancreatic cancer

Pharyngeal (throat) cancer

Prostate cancer

Rectal cancer

Renal (kidney) cancer

Skin cancer, other

Stomach cancer

Other (Specify): ___________

60. At what age were you first told that you had cancer?

[ENTER AGE.]
|__|__|__|

61. Did you ever receive any treatment for your cancer?

Yes
No  Skip to 64

62. Which of the following cancer treatments have you ever received?

		Yes	No
a.	Chemotherapy (pills)	___	___
b.	Chemotherapy (intravenous)	___	___
c.	Radiation	___	___
d.	Surgery	___	___
e.	Other	___	___

CP: IF YES TO OTHER: Tell me a little more about the cancer treatment you marked as “other”?

63. How long ago did you finish your most recent treatment?

[ENTER MONTHS] [ENTER YEARS]

|__|__| |__|__|

I am still in treatment

64. Have any of your family members ever had cancer?

Yes
No
No Family

65. In general, would you say your health is...

Excellent
Very Good
Good
Fair
Poor

66. How often did you feel each of the following during the past 30 days?

		All of the time	Most of the time	Some of the time	A little of the time	None of the time
a.	So sad that nothing could cheer you up	___	___	___	___	___
b.	Nervous	___	___	___	___	___
c.	Restless or fidgety	___	___	___	___	___
d.	Hopeless	___	___	___	___	___
e.	That everything was an effort	___	___	___	___	___
f.	Worthless	___	___	___	___	___

67. In the past six months, did you visit the Food & Drug Administration’s website (www.fda.gov)?

Yes  Skip to 69
No

68. Why haven’t you visited the FDA’s website?

SKIP TO Q71

don’t own a computer (no Internet access)
No reason to visit the site
I prefer other sites
Didn’t know about FDA site
I don’t trust government websites (general answer)
I don’t trust the FDA
It’s too hard to find information on the FDA website
Other (please specify):_______

CP: IF SELECT FIRST – Tell me something about that first category you selected.

CP: IF ONLY SELECT ONE ANSWER (OTHER THAN FIRST): How did you decide that (ANSWER)? Were there any others that apply to you?

69. On your most recent visit, did you find the information you were looking for?

Yes
No

70. How easy or hard was it to find the information you were looking for?

Very easy
Easy
Neither easy nor hard
Hard
Very hard

71. How much do you agree or disagree with the following statements:

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	I can easily find information about the foods I eat.	___	___	___	___	___
b.	The information I get about the foods I eat is clear and understandable.	___	___	___	___	___
c.	The information I get about the foods I eat is not helpful for making food choices.	___	___	___	___	___

72. The next set of questions asks for your opinion about the information you get about the benefits of the drugs you use.

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	I can easily find information about the benefits of the drugs I use.	___	___	___	___	___
b.	The information I get about the benefits of the drugs I use is clear and understandable.	___	___	___	___	___
c.	The information I get about drug benefits is not helpful for making drug decisions.	___	___	___	___	___

73. The next set of questions asks for your opinion about the information you get about the risks of the drugs you use.

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	I can easily find information about the risks of the drugs I use.	___	___	___	___	___
b.	The information I get about the risks of the drugs I use is clear and understandable.	___	___	___	___	___
c.	The information I get about drug risks is not helpful for making drug decisions.	___	___	___	___	___

76. When you buy drugs your doctor prescribes, how frequently do you read the information leaflet that comes with the drugs?

Always
Often
Sometimes
Rarely
Never

CP: Tell me what you think this question is asking about? IF NEEDED: What do you think of as the information leaflet?

75. How much do you agree or disagree with the following statement:

The information leaflet for prescription drugs is easy to understand.

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

Always
Often
Sometimes
Rarely
Never

CP: Tell me what you think this question is asking about? IF NEEDED: What do you think of as medical products that you use in your home?

77. How much do you agree or disagree with the following statement:

The information leaflets that come with the medical products I use in my home are easy to understand.

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

78. The following questions ask about advertisements for prescription drugs.

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	Advertisements for prescription drugs do not give enough information about the possible benefits and positive effects of using the medication.	___	___	___	___	___
b.	Advertisements for prescription drugs give enough information about the possible risks and negative effects of using the drug.	___	___	___	___	___

79. The following questions ask about advertisements for over the counter drugs.

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	Advertisements for over-the-counter drugs give enough information about benefits and positive effects of using the drug.	___	___	___	___	___
b.	Advertisements for over-the-counter drugs do not give enough information about the possible risks and negative effects of using the drug.	___	___	___	___	___

CP: Tell me in your own words what (a) is asking about? COG INT – NOTICE IF READ (a) as “do not give enough information” or as printed?

80. The following questions ask about advertisements for commonly used medical products such as inhalers, glucose test kites and contact lenses.

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	Advertisements for commonly used medical products do not give enough information about the possible benefits and positive effects of using these products.	___	___	___	___	___
b.	Advertisements for commonly used medical products give enough information about the possible risks and negative effects of using these products.	___	___	___	___	___

81. When you purchase over-the-counter drugs for the first time, how frequently do you read the Drug Facts label?

Always
Often
Sometimes
Rarely
Never
CP: Tell me what you think this question is asking about? IF NEEDED: What do you think of as Drug Facts Label?

82. How much do you agree with the following statement:

The Drug Facts label is easy to understand.

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

83. What would you do if a drug you used had to be recalled? Would you:

CP: Tell me how you decided (ANSWER)

CP: IF ONLY ONE: Do any others on this list apply to you?

84. What would you do if a medical product recall affected you?

Have it removed/stopped using it
Contact my doctor
Contact the manufacturer
Have it replaced/Find a substitute
Keep using it/Keep it
Make no change
Other (please specify:) _____________
Unsure
CP: Tell me how you decided (ANSWER)

CP: IF ONLY ONE: Do any others on this list apply to you?

85. Have you ever heard about the recall of any of the following medical products: gel-filled teethers, automated external defibrillators, stents, pacemakers, or infant apnea monitors?

Yes
No

86. How much do you agree or disagree with the following statements...

		Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
a.	Over-the-counter drugs are safer than prescription drugs.	___	___	___	___	___
b.	Over-the-counter drugs are weaker than prescription drugs.	___	___	___	___	___

CP: NOTE IF A TRANSITION IS NEEDED HERE

87. In general, I think that the information I give doctors is safely guarded.

Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree

Yes
No

CP: In your own words, what is this question asking about?

89. As far as you know, do your healthcare providers maintain your medical information in a portable, electronic format?

Yes
No

CP: In your own words, what is this question asking about?

90. Please indicate how important each of the following statements is to you.

		Very Important	Somewhat Important	Not at all Important
a.	Health care providers should be able to share your medical information with each other electronically	___	___	___
b.	You should be able to get to your own medical information electronically	___	___	___

CP: In your own words, what is (a) asking about? IF NEEDED: What do you think of as “share your medical information”?

91. Please indicate how much you agree or disagree with the following statement.

Scientists doing research should be able to review my medical information if the information cannot be linked to me personally.

Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree

CP: In your own words, what is (a) asking about?

92. Does anyone in your family have a working cellular phone?

Yes
No

93. Is there at least one telephone inside your home that is currently working and is not a cell phone?

Yes
No

94. What is your age?

|__|__|__|

95. What is your current occupational status?

Employed
Unemployed
Homemaker
Student
Retired
Disabled
Other (Specify:) ______________

Yes, now on active duty

Yes on active duty in the last 12 months but not now

Yes on active duty in the past, but not in the last 12 months

No, training for Reserves or National Guard only

No, never served in the military

97. What is your marital status?

Married
Living as Married
Divorced
Widowed
Separated
Single, Never Been Married

98. What is the highest grade or level of schooling you completed?

Less Than 8 Years
8 Through 11 Years
12 Years or Completed High School
Post High School Training Other Than College (Vocational or Technical)
Some College
College Graduate
Postgraduate

99. Were you born in the United States?

Yes  Skip to 103
No

100. Are you a citizen of the United States?

Yes  Skip to 102
No
Application Pending

101. Are you a permanent resident with a green card / permanent residence authorization?

Yes
No
Application Pending

102. In what year did you come to live in the United States?

[ENTER YEAR]
|__|__|__|__|

103. How comfortable do you feel speaking English?

Completely comfortable
Very comfortable
Somewhat comfortable
A little comfortable
Not at all comfortable

104. Are you Hispanic or Latino?

Yes
No

105. Which one or more of the following would you say is your race? MARK ALL THAT APPLY.

American Indian / Alaska Native
Asian
Black / African American
Native Hawaiian / Other Pacific Islander

White

106. Including yourself, how many people live in your household?

[ENTER NUMBER.]
|__|__|

107. How many children under the age of 18 live in your household?

[ENTER NUMBER.]
|__|__|

108. Please mark the gender and write in the age of each adult 18 years of age or older living at this address.

	Gender	Age
1	Male Female
2	Male Female
3	Male Female
4	Male Female
5	Male Female

109. Thinking about members of your family living in this household, what is your combined annual income, meaning the total pre-tax income from all sources earned in the past year?

$0 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $199,999
$200,000 or more

110. Do you currently rent or own your home?

Own
Rent
Occupied Without Paying Monetary Rent

END INTERVIEW.

ASK – DO YOU HAVE ANY QUESTIONS, OR DO YOU HAVE ANY OTHER GENERAL COMMENTS?

THANK RESPONDENT AND PROVIDE INCENTIVE ALONG WITH RECEIPT

INTRO

Screener for the Health Information National Trends Survey

OMB #: 0925-0589-09

Expiry Date: 5/31/2011

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0589-06). Do not return the completed form to this address.

NAME____________________________ PHONE__________________________

RESPONDENT Number ____________________

Hello, my name is (NAME) and I’m calling from Westat, a research company in Rockville. May I speak with (NAME)?

(reintroduce yourself if needed)

Thank you for your interest in the Health Information National Trends Survey (HINTS). I would like to tell you a little bit about the study and then I’ll ask you a few questions to see if you are eligible to take part.

We’re looking for people to participate in a session that can last about an hour and a half. In that session you would meet with a Westat researcher who would ask you some questions from a survey that we’re developing about how people look for and use health-related information. We need men and women over the age of 18 to take part in the interviews. All the interviews are being conducted at Westat, in Rockville MD, and everyone who participates will receive $50 in appreciation for their time.

If you are open to it, I would like to ask you a few questions to see if you’re eligible to participate.

IF NEEDED: Westat, a research company in Rockville, Maryland is conducting survey research for the U.S. Department of Health and Human Services to test questions for an upcoming national survey – we’d like to get your opinion on whether the questions are easy to understand and answer.

Q1. As I said, these interviews will take place at Westat’s headquarters, located on Research Boulevard in Rockville, Maryland. Are you within driving or commuting distance of our location?

PROVIDE MORE INFO IF NEEDED: Rt 28 off of 270. 1600 RESEARCH; NEAR THE CORNER OF RESEARCH AND GUDE DRIVE; AT ROCKVILLE METRO STATION - END OF RED LINE - 63 OR 54 BUS STOPS IN FRONT OF 1600; ETC.

Yes
No – TERMINATE AND THANK (“Based on the study design, our interviews are going to be conducted at Westat, so it looks like we can’t include you at this time.”)

Q2. ASK ONLY IF NOT OBVIOUS: Are you male or female?

Male
Female

Q3. Which of the following age categories are you in?

Under 18 – TERMINATE AND THANK (“Based on the requirements of this study, it looks like we can’t include you at this time. It is possible we will be calling you in the future for other studies.”)
18 – 29
30 – 44
45 – 54
55 – 64
65 and older

INTERVIEWER: RECRUIT A MIX OF AGES.

Q4. Are you of Hispanic or Latino Origin?

INTERVIEWER: RECRUIT NO MORE THAN 2 HISPANIC RESPONDENTS FOR EACH ENGLISH LANGUAGE GROUP

Q5. What race do you consider yourself? MARK ALL THAT APPLY.

White
Black or African American
Asian or Pacific Islander
American Indian or Alaska Native
Other? ______________________

INTERVIEWER: RECRUIT SOME NON-WHITE RESPONDENTS.

Q6. What is the highest level of education you have completed?

11^th grade or less
12 years of school, no diploma
GED or high school graduate (diploma)
Some college or technical school
College or technical school graduate
Post-graduate

INTERVIEWER: RECRUIT A MIX OF RESPONDENTS FROM EACH EDUCATION GROUP.

Q7. Have you ever been told by a doctor that you have any of the following health conditions?

Asthma?
Diabetes?
Any type of cancer?
Heart disease?
High cholesterol?

INTERVIEWER: RECRUIT UP TO 10 ENGLISH SPEAKING RESPONDENTS OR 5 SPANISH SPEAKING RESPONDENTS FROM GROUP C.

Q8. When was the last time you participated in this type of interview session?

a. 6 months ago or less –THANK AND TERMINATE (“Based on the requirements of this study, it looks like we can’t include you at this time. It is possible we will be calling you in the future for other studies.)

b. More than 6 months but less than a year

c. More than a year ago

Q9. Do you now or have you ever worked for Westat?

Yes – THANK AND TERMINATE
No

Q10. Have you ever worked for US Department of Health and Human Services or any of its agencies?

Yes – What agency is/was that? IF NCI, THANK AND TERMINATE
No

Q11. Have you ever heard of the Health Information National Trends Survey?

a. Yes – Ask where they have heard of it? [Find out if they are a researcher that uses/used

HINTS data. If they are, TERMINATE AND THANK (“Based on the

requirements of this study, it looks like we can’t include you at this time. It is possible we will be calling you in the future for other studies.”)]

b. No

Q12. What is your zip code? ______________________

INTERVIEWER – INSERT A TABLE WITH THE RECRUITING CATEGORIES SO YOU CAN FILL IT OUT AS YOU TALK TO PEOPLE.

Requirement	Status

Adult Requirements
2 or 3 of these adults should have only a HS degree or GED
2 or 3 should be African American or other minority
2 or 3 should be 44 or younger
2 or 3 should be over the age of 44

If response to Q8 = B (i.e., they have done a cognitive interview from 6 months to a year ago), then read Closing #2

Otherwise read Closing #1

Closing #1

You are eligible to help with this research project. Just to give you a little more information, we’ll be asking people about how they get information about health and their thoughts about health-related topics. Please note, we will not share your personal information with anyone not involved in this study. Are you interested in participating?

YES — Thank you so much for your willingness to help us. If you are selected as a participant you will receive $50 cash upon completion of the interview. If you are chosen as a participant, I will call you back within two business days to set up a time for you to meet with someone from the study team.

NO — Thank you for taking the time to talk with me today and have a great (day/evening).

Closing #2

Thank you for answering those questions. We will contact you within the next week to indicate if you are eligible to help with this research project.

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Author	mcbride_b
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