Form no number no number BRFSS Stand Alone

10-04-2010 Draft

Revised final questions for the Gulf oil spill surveillance survey

10-04-2010

Demographic characteristic 9 questions	Response set
1. What is your gender? (BRFSS)	Male Female
2. What is your age? (BRFSS)	_ _ Code age in years 0 7 Don’t know / Not sure 0 9 Refused
3. Are you Hispanic or Latino? (BRFSS)	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
4. Which one of these groups would you say best represents your race? (OMB stnd)	1. American Indian or Alaska Native 2. Asian 3. Black or African American 4. Native Hawaiian or Other Pacific Islander 5. White Do not read: 7 Don’t know / Not sure 9 Refused
5. What is your employment status? (BRFSS)	Please read: 1 Employed for wages 2 Self-employed 3 Out of work for more than 1 year 4 Out of work for less than 1 year 5 A Homemaker 6 A Student 7 Retired 8 Unable to work Do not read: 9 Refused
[if employed] 6. What type of industry are you currently employed in? (new)	01. Fishing, agriculture, forestry, hunting. 02. Oil and gas extraction, mining. 03. Construction 04. Manufacturing 05. Wholesale or retail trade 06. Hotels, restaurants, recreation, arts, and entertainment 07. Healthcare, social assistance 08. Real estate, rental, and leasing 09. other 99 Refused
7. What is your current marital status? (BRFSS)	Please read: 1 Married 2 Divorced 3 Widowed 4 Separated 5 Never married 6 A member of an unmarried couple Do not read: 9 Refused
8. How many children less than 18 years of age live in your household? (BRFSS)	_ _ Number of children 88 None 99 refused
9. What County/Parish do you live in? (new)	--
10. What is your zip code? (new)	--

General health 2 questions	Response set
11. How would you rate your general health? BRFSS	1 Excellent 2 Very good 3 Good 4 Fair 5 Poor Do not read: 7 Don’t know / Not sure 9 Refused
12. How would you rate your physical health? (modified BRFSS)	1 Excellent 2 Very good 3 Good 4 Fair 5 Poor Do not read: 7 Don’t know / Not sure 9 Refused
13. How would you rate your mental health? (modified BRFSS)	1 Excellent 2 Very good 3 Good 4 Fair 5 Poor Do not read: 7 Don’t know / Not sure 9 Refused

Risk behaviors 7 questions	Response set
14. During the past 30 days, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise? BRFSS	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
15. During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage? BRFSS	101-199 days per week 201-299 days per month 777 don’t know 888 no drink in past 30 days 999 refused
16. Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 or more drinks for men or 4 or more drinks for women on an occasion? BRFSS	1-76 number of times 88 none 77 don’t know/not sure 99 refused
17. One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average? [A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.] BRFSS	1-76 number of times 88 none 77 don’t know/not sure 99 refused
18. Have you smoked at least 100 cigarettes in your entire life? [Note: 5 packs = 100 cigarettes] BRFSS	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
19. Do you now smoke cigarettes every day, some days, or not at all? BRFSS	1. every day 2. some days 3. not at all 7. don’ t know/ not sure 9. refused
20. In the past 30 days, have you increased your level of prescription or non-prescription medication use without the advice of a doctor or other health care professional? (new)	1 Yes No 7 Don’t know / Not sure 9 Refused

Chronic conditions 7 questions	Response set
21. Has a doctor, nurse, or other health professional EVER told you that you had a heart attack, also called a myocardial infarction? (BRFSS)	1 Yes No 7 Don’t know / Not sure 9 Refused
22. Has a doctor, nurse, or other health professional EVER told you that you had angina or coronary heart disease? (BRFSS)	1 Yes No 7 Don’t know / Not sure 9 Refused
23. Has a doctor, nurse, or other health professional EVER told you that you had a stroke? (BRFSS)	1 Yes No 7 Don’t know / Not sure 9 Refused
24. Have you ever been told by a doctor, nurse, or other health professional that you had asthma? (BRFSS)	1 Yes No 7 Don’t know / Not sure 9 Refused
[if yes] 25. Do you still have asthma? (BRFSS)	1 Yes No 7 Don’t know / Not sure 9 Refused
26. Have you ever been told by a doctor that you have diabetes? If “Yes” and respondent is female, ask: “Was this only when you were pregnant?” If respondent says pre-diabetes or borderline diabetes, use response code 4. (BRFSS)	1 Yes Yes, but female told only during pregnancy No No, pre-diabetes or borderline diabetes 7 Don’t know / Not sure 9 Refused
27. Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia? (BRFSS)	1 Yes No 7 Don’t know / Not sure 9 Refused

Quality of life 2 questions	Response set
28. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? (BRFSS)	_ _ Number of days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
29. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? (BRFSS)	_ _ Number of days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused

Disability 3 questions	Response set
30. Do you have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone? Include occasional use or use in certain circumstances. (BRFSS)	1 Yes No 7 Don’t know / Not sure 9 Refused
31. During the past 30 days, for about how many days did a mental health condition or emotional problem keep you from doing your work or other usual activities? (modified BRFSS)	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
32. During the past 30 days, for about how many days did a physical health condition keep you from doing your work or other usual activities? (modified BRFSS)	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused

Healthcare access 2 questions	Response set
33. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare? (BRFSS)	1 Yes 2. No 7 Don’t know / Not sure 9 Refused
34. [if yes] Does your health care plan include mental health coverage? (new)	1 Yes 2. No 7 Don’t know / Not sure 9 Refused

Life satisfaction and social support 2 questions	Response set
35. In general, how satisfied are you with your life? (BRFSS)	Please read: 1 Very satisfied 2. Satisfied 3. Dissatisfied 4. Very dissatisfied Do not read: 7 Don’t know / Not sure 9 Refused
36. How often do you get the social and emotional support you need? BRFSS	1 Always 2. Usually 3. Sometimes 4. Rarely 5 Never Do not read: 7 Don’t know / Not sure 9 Refused

Resiliency/Coping 5 questions (from Pearlin & Schooler standardized psych scale)	Response set
How strongly do you agree or disagree that:
37. I have little control over the things that happen to me.	Please read: 1 Strongly Disagree 2. Disagree 3. Neither Agree nor Disagree 4. Agree 5 Strongly Agree Do not read: 6 Refused
38. What happens to me in the future mostly depends on me.	Please read: 1 Strongly Disagree 2. Disagree 3. Neither Agree nor Disagree 4. Agree 5 Strongly Agree Do not read: 6 Refused
39. I can do just about anything I really set my mind to do.	Please read: 1 Strongly Disagree 2. Disagree 3. Neither Agree nor Disagree 4. Agree 5 Strongly Agree Do not read: 6 Refused
40. I am confident in my ability to handle unexpected problems.	Please read: 1 Strongly Disagree 2. Disagree 3. Neither Agree nor Disagree 4. Agree 5 Strongly Agree Do not read: 6 Refused
41. When I need suggestions about how to deal with a personal problem, I know there is someone I can turn to.	Please read: 1 Strongly Disagree 2. Disagree 3. Neither Agree nor Disagree 4. Agree 5 Strongly Agree Do not read: 6 Refused

Social context 2 questions	Response set
42. How often would you say you are worried or stressed about having enough money to pay your rent/mortgage? Would you say you are worried or stressed--- (modified BRFSS)	Please read: 1 Always 2. Usually 3. Sometimes 4. Rarely 5 Never Do not read: 8 Not applicable 7 Don’t know / Not sure 9 Refused
43. How often would you say you are worried or stressed about having enough money to buy nutritious meals? Would you say you are worried or stressed--- (modified BRFSS)	Please read: 1 Always 2. Usually 3. Sometimes 4. Rarely 5 Never Do not read: 8 Not applicable 7 Don’t know / Not sure 9 Refused

Child question 1 question	Response set
44.During the past 30 days, have any of the children in your household experienced any of the following difficulties: (Alabama CASPER)	1. No children 2. Been very sad or depressed 3. Felt nervous or afraid 4. Problems sleeping 5 Problems getting along with other children 7 Don’t know/ not sure 9 Refused

Anxiety and Depression questions (addresses anxiety and depression diagnoses)	Response set
45. Has a doctor or other healthcare provider EVER told you that you had an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder)? (BRFSS)	1 Yes 2. No 7 Don’t know / Not sure 9 Refused
46. Has a doctor or other healthcare provider EVER told you that you had a depressive disorder (including depression, major depression, dysthymia, or minor depression)? (BRFSS)	1 Yes 2 No 7 Don’t know / Not sure 9 Refused

Depression (PHQ-8) 8 questions (standardized psych scale and BRFSS)	Response set
Now, I am going to ask you some questions about your mood. When answering these questions, please think about how many days each of the following has occurred in the past 2 weeks.
47. Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
48. Over the last 2 weeks, how many days have you felt down, depressed or hopeless?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
49. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
50. Over the last 2 weeks, how many days have you felt tired or had little energy?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
51. Over the last 2 weeks, how many days have you had a poor appetite or eaten too much?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
52. Over the last 2 weeks, how many days have you felt bad about yourself or that you were a failure or had let yourself or your family down?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
53.Over the last 2 weeks, how many days have you had trouble concentrating on things, such as reading the newspaper or watching the TV?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
54. Over the last 2 weeks, how many days have you moved or spoken so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you were moving around a lot more than usual?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused

Anxiety (GAD-7) 7 questions (standardized psych scale)	Response set
Now, I am going to ask you some questions about your mood. When answering these questions, please think about how many days each of the following has occurred in the past 2 weeks.
55. Over the last 2 weeks, how many days have you been nervous, anxious, or on edge?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
56. Over the last 2 weeks, how many days have you not been able to stop or control worrying?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
57. Over the last 2 weeks, how many days have you worried too much about different things?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
58. Over the last 2 weeks, how many days have you had trouble relaxing?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
59. Over the last 2 weeks, how many days have you been so restless that it was hard to sit still?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
60. Over the last 2 weeks, how many days have you been easily annoyed or irritable?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused
61. Over the last 2 weeks, how many days have you felt afraid as if something awful might happen?	_ _ 01-14 days 8 8 None 7 7 Don’t know / Not sure 9 9 Refused

Mental Health Treatment 4 questions	Response set
62. Have you EVER received any sort of counseling for problems with your emotions, nerves, or mental health? (BRFSS)	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
63. If YES, how many times in the past year have you received counseling for problems with your emotions, nerves, or mental health? (new)	1 ___ 7 Don’t know / Not sure 9 Refused
64. Were you EVER prescribed medication for problems with your emotions, nerves, or mental health? (BRFSS)	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
65. If YES, when was the last time that you were prescribed medication for problems with your emotions, nerves, or mental health? (new)	Within the past month (anytime less than 1 month ago) Within the past year (1 month but less than 12 months ago) Within the past 2 years (1 year but less than 2 years ago) 2 or more years ago

Transition: The next few questions deal with intimate partner violence and suicide. We realize that these topics are quite personal and can be difficult to think and talk about, but we would appreciate it if you would try to answer these questions to the best of your ability

Suicide Thoughts & Behavior 3 Questions	Response set
The next three questions deal with thoughts of suicide.  We wish to remind you that you don't have to answer any questions you don't want to.
66. At any time in the past 12 months, did you seriously think about trying to kill yourself? (SAMHSA NSDUH)	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
67. At any time in the past 12 months, did you make any plans to kill yourself? (SAMHSA NSDUH)	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
68. At any time in the past 12 months, did you try to kill yourself? (SAMHSA NSDUH)	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
Closing Statement: We are finished with the suicide questions now. Some respondents have been interested in receiving the names and numbers of organizations that can provide them with help during difficult times. If you like, I can give you a number of an organization in your area. If respondent affirms interest in receiving number---> The number is.. (give number of suicide prevention center matched for geographic proximity with respondent's area code) If respondent does not affirm interest in receiving number---> I understand you're not interested in contacting such an organization. Please remember that such organizations exist. If you ever need it, help is available and you can find numbers in the phone book or by calling information.

Intimate partner violence 3 Questions	Response set
The next questions are about different types of violence in relationships with an intimate partner. By an intimate partner I mean any current or former spouse, boyfriend, or girlfriend. Someone you were dating, or romantically or sexually intimate with would also be considered an intimate partner. This information will help us to better understand the problem of violence in relationships. This is a sensitive topic. Some people may feel uncomfortable with these questions. At the end of this section, I will give you phone numbers of organizations that can provide information and referral for these issues. Please keep in mind that if you are not in a safe place you can ask me to skip any question you do not want to answer.
69. Are you in a safe place to answer these questions? (BRFSS)	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
70. At any time in the past 12 months has an intimate partner hit, slapped, pushed, kicked, or hurt you in any way? (BRFSS)	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
71. At any time in the past 12 months has an intimate partner put you down, humiliated you or tried to control what you can do? (modified BRFSS)	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
Closing Statement: We realize that this topic may bring up past experiences that some people may wish to talk about. If you or someone you know would like to talk to a trained counselor, there is a toll-free and confidential intimate partner violence telephone hotline you can call. The number is 1- 800-799-SAFE (7233). Would you like me to repeat the number?

Gulf oil spill awareness 1 question	Response set
72. Are you aware of the Gulf oil spill that occurred in the Gulf of Mexico on April 20, 2010? (new)	1 Yes 2 No 7 Don’t know / Not sure 9 Refused

Environmental 2 questions	Response set
73. Did you have direct contact with the oil from the Gulf oil spill? (Alabama CASPER)	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
74. If so, in what way? (Alabama CASPER)	1. Skin 2. Inhalation (e.g. breathing it in) 3. Ingestion (e.g. swallowing) 4. Other 7. Don’t know/Not sure 9. Refused

Employment status 7 questions	Response set
75. What was your employment status before the Gulf oil spill? (modified BRFSS)	Please read: 1 Employed for wages 2 Self-employed 3 Out of work for more than 1 year 4 Out of work for less than 1 year 5 A Homemaker 6 A Student 7 Retired 8 Unable to work Do not read: 9 Refused
76. What type of industry were you employed in? (new)	01. Fishing, agriculture, forestry, hunting. 02. Oil and gas extraction, mining. 03. Construction 04. Manufacturing 05. Wholesale or retail trade 06. Hotels, restaurants, recreation, arts, and entertainment 07. Healthcare, social assistance 08. Real estate, rental, and leasing 09. other 99 Refused
77. Including yourself, how many people in your household lost their job due to the Gulf oil spill? (new)	1-9,10+ 77 Don’t know/ Not sure 88 none 99 Refused
78. Did you participate in the Gulf oil spill cleanup activities? (Alabama CASPER)	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
79. [If yes] Were you a volunteer or did you get paid? (new)	1. Volunteer 2. Paid 7. Don’t know/Not sure 9. Refused
80.[If yes] What type of cleanup activities did you participate in? (check all that apply) (new)	01.Beach/marsh cleanup 02.Birds/wildlife cleanup 03. Boom deployment/recovery / Off-shore skimming 04. Decontamination / Waste stream management 05. At the well-head / Controlled burning 06. Administrative / logistical / medical personnel 07. Other 77. Don’t know/Not sure 99 Refused

Income 2 questions	Response set
81. What was your estimated household income in 2010? (BRFSS)	0 4 Less than $25,000 ($20,000 to less than $25,000) 0 3 Less than $20,000 ($15,000 to less than $20,000) 0 2 Less than $15,000 ($10,000 to less than $15,000) 0 1 Less than $10,000 0 5 Less than $35,000 ($25,000 to less than $35,000) 0 6 Less than $50,000 ($35,000 to less than $50,000) 0 7 Less than $75,000 ($50,000 to less than $75,000) 0 8 $75,000 or more Do not read: 7 7 Don’t know / Not sure 9 9 Refused
82. How did the Gulf oil spill affect your household income? (Alabama CASPER)	1 decreased 2 increased 3 no change 7 Don’t know / Not sure 9 Refused

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