Attach 6 Subject Contact Materials

Attachment 6
CHIS 2011 Subject Contact Materials
6A: Survey Advance Letter
6B: Telephone Introduction and Consent/Assent Scripts
6C: Screener Refusal Conversion Letter
6D: Extended Interview Refusal Conversion Letter
6E: Permission Refusal Conversion Letter

Dear Current Resident,
Your household has been selected for this year’s California Health Survey. This
important telephone survey is your opportunity to have your voice heard on health issues.
This survey helps California learn about the health of its people and the problems they
have getting health care. The results may help the people and families in your
community.
Your household is very special because you are part of a scientific sample representing
many other households like yours. Since 2001, more than 275,000 Californians have
talked to us about many different health topics.
We will be calling sometime in the next two weeks and one adult in your household will be
selected for the interview. If you have teenagers (ages 12-17), we will ask to interview one
with permission from a parent. Participation is voluntary and confidential. Your answers
will be combined with other participants and used only for statistical reporting.
Please take a moment to take our call. We are not selling anything or asking for money.
If we call at an inconvenient time, you can suggest a better time for us to call back. To
thank you in advance for taking our call and hearing about this survey, we are enclosing
a $2 bill. This small gift is for you to keep whether or not you decide to participate (this
money is not from State or local taxes).
Thank you for your help.
Sincerely,

Dr. E. Richard Brown
Director, UCLA Center for Health Policy Research
Note:

If you have questions about the California Health Survey, you can call toll-free 1888-941-2950 or visit our website at www.californiahealthsurvey.org

Major funders of this survey include the California Department of Health Care Services, California Department of
Public Health, First 5 California, Office of the Patient Advocate, The California Endowment, and the National Cancer
Institute.
Relevant to Privacy Act Information, the legislative authority for this survey is 42 USC 285.

10960 Wilshire Boulevard, Suite 1550 Los Angeles, CA 90024
Attachment 6A – Page 1

CALIFORNIA HEALTH INTERVIEW SURVEY

RESPONDENT CONSENT SCRIPT

Attachment 6B – Page 2

Verbal Consent Obtaining Process:
Verbal Consent and Assent Scripts for the California Health Interview Survey
1) Consent Script read to the adult respondent for RDD cases and bias study cases with telephone
recruitment
2) Consent Script read to the adult proxy for the selected frail elderly interview
3) Consent Script read to the adult respondent, who is the parent/guardian for the selected child
interview
4) Consent Script read to the adult proxy if different from the parent/guardian for the selected
child interview;
5) Consent Script read to parent/guardian giving permission to interview their adolescent;
6) Consent Script read to the selected adolescent respondent;
7) Consent Script read to the screener respondent for the cell phone component; and
8) Consent script read to the respondent if eligible (at least 18, telephone is not business use only, and
respondent has no landline) for the cell phone component.
9) Consent script read to the adult respondent selected for staging (English only)

Attachment 6B – Page 3

1) Consent Script read to the adult respondent for RDD cases:
"Hello, my name is {interviewer name}. I am calling for the University of California at Los Angeles.
We are doing a scientific study about health that may help improve services in your community.
Your telephone number was chosen at random to be in the California Health Survey.
“This interview is voluntary and confidential. You can skip any question, and you can stop at any
time.
"The interview takes about 30 minutes on average, but may be as short as 20 minutes. There are
questions about your health, diet and exercise, sexual behaviors, violence, suicide, emotional health
and treatment for mental health problems, and your healthcare and insurance. I will also ask you
about where you live.
“Do you have any questions about this?
[PROGRAMMING NOTE: ANSWER QUESTIONS AND PROCEED.]
"The University has very strict safeguards to protect your confidentiality. We are also certified by the
National Institutes of Health to protect your privacy. We may not be able to keep confidential any
thoughts to harm yourself and if you tell us that you have had thoughts of suicide we may provide
you with a referral to someone who can help.

We make every effort to protect your identity. If you provide your address, it will be kept in a
secure data center for research to better understand how health is related to where people
live. Other information that could identify you, like your name and telephone number will be erased
after the study is completed. Your other answers will be combined with the answers of other
participants and shared with researchers to better understand the health of Californians. Your
address, if you provide it, will be erased after conversion into latitude and longitude for research
purposes.
If you want, I can give you the name and toll-free telephone number of the persons at UCLA in
charge of the study. Would you like this information now, or can we begin the interview?"
[PROGRAMMING NOTES: IF REQUESTS INFORMATION ABOUT PRIVACY SAFEGUARDS]
Your name and telephone number will be removed from your answers and erased after the study is
completed. The survey responses will be kept in a secure data center, and your responses will only be
used to produce aggregate numbers.
IF REQUESTS INFORMATION ABOUT NIH CERTIFICATE OF CONFIDENTIALITY:
With a Certificate of Confidentiality, the researchers cannot be forced to disclose information that
may identify you, even by a court subpoena, in any federal, state, or local civil, criminal,
administrative, legislative, or other proceedings. The researchers will use the Certificate to resist
any demands for information that would identify you, except for those from personnel of the United
States Government for information that would be used for auditing or evaluation of federally funded
projects.
A Certificate of Confidentiality does not prevent you or a member of your family from voluntarily
releasing information about yourself or your involvement in this research. If an insurer, employer, or
other person obtains your written consent to receive research information, then the researchers may

Attachment 6B – Page 4

not use the Certificate to withhold that information."
A Certificate of Confidentiality does not prevent the researchers from disclosing voluntarily, without
your consent, information that would identify you as a participant in the research project if you
disclose information about harming yourself or others."]
“Would you like this information now or can we begin the interview?"
[PROGRAMMING NOTES:
IF REQUESTED:
1. WANTS STUDY INFORMATION: Please contact Dr. E. Richard Brown if you have any questions
about the study. Dr. Brown can be reached toll-free at 1-866-275-2447.
2. WANTS INFORMATION ABOUT RIGHTS OF RESEARCH SUBJECTS OR THE NIH
CERTIFICATION FOR PROTECTION OF PERSONAL INFORMATION: Please contact the Office
for the Protection of Research Subjects at (310) 825-8714.]
3. BOTH: Provide both contact numbers.
4. BEGIN INTERVIEW – THANK AND CONTINUE
5. DON'T BEGIN INTERVIEW: Ask, "If another time is more convenient, we can schedule at a better
time."]
Read to the adult respondent for quality control methodological research audio recording:
"We are randomly tape-recording some interviews for quality control purposes. The
tapes are kept strictly confidential, and your identity will not be disclosed. The tapes will
be destroyed at the completion of the project. May I have your permission to tape this
interview?
"I need to confirm that you gave your permission to participate and to be recorded. Is that
correct?"
2) Consent Script read to the adult proxy for the selected frail elderly interview:
"Hello, my name is {interviewer name}. I am calling for the University of California at Los Angeles.
We are doing a scientific study about health and health care that may help improve services in your
community. Your telephone number was chosen at random to be in the California Health Survey.
"{Now} I'd like to ask you some questions about {selected respondent}. When we called several
weeks ago, we were told that {Adult's first name} was too ill to participate in the interview.
1) Is {he/she} able to participate in the interview at this time?
1. YES................................................ [ASK TO SPEAK WITH SELECTED ADULT]
2. NO.................................................. [PROCEED]
2) "Because information about all older adults is important to us, I'd like to ask you some
questions about {frail elderly adult’s first name}. Are you the person in the household who is
the most knowledgeable about the health and health care of {Adult's first name}?"
1. YES................................................ [RESPONDENT IS MKA; GO TO 3]
2. NO.................................................. [GO TO 2a]

Attachment 6B – Page 5

2a) “What is the first name of the person in the household who is most knowledgeable about the
health and health care of {Adult's first name}?”
3) "What is (your/MKA’s) relationship to {frail adult elderly's first name}?"
1. Spouse or domestic partner
2. Adult son or daughter
3. Custodial parent
4. Adult brother or sister
5. Adult grandchild
6. Other adult relative
4) “Does {Adult's first name} have an agent named by an advance health care directive?
1. YES................................................ [GO TO 4a]
2. NO.................................................. [GO TO 5]
4a) “Are you or (MKA) that agent?”
1. YES, RESPONDENT IS AGENT... [IF R IS MKA, GO TO PROXY CONSENT SCRIPT;
ELSE GO TO 7]
2. YES, MKA IS AGENT…………… [ASK TO SPEAK WITH MKA, THEN GO TO PROXY
CONSENT SCRIPT]
3. NO.................................................. [GO TO 4b]
4b) “Does that agent live in this household?”
1. YES................................................ [GO TO 4c]
2. NO.................................................. [GO TO 5]
4c) “California law requires that I get that person’s permission before I can interview you about
{adult's first name}? What is his or her first name?”
ASK TO SPEAK WITH AGENT. IF AGENT COMES TO PHONE, GO TO 7.
5) “Does {frail adult elderly's first name} have a conservator or guardian having the
authority to make health care decisions for (him/her)?
1. YES................................................ [GO TO 5a]
2. NO.................................................. [GO TO PN 6]
5a) “Are you or (MKA) that conservator or guardian?”
1. YES, RESPONDENT IS AGENT... [IF R IS MKA, GO TO PROXY CONSENT SCRIPT;
ELSE GO TO 7]
2. YES, MKA IS AGENT………………[ASK TO SPEAK WITH MKA, THEN GO TO
PROXY CONSENT SCRIPT]
3. NO.................................................. [GO TO 5b]
5b) “Does that conservator or guardian live in this household?”
1. YES................................................ [GO TO 5c]
2. NO.................................................. [GO TO PN 6]
5c) “California law requires that I get that person’s permission before I can interview you about
[ADULT]. What is his or her first name?”

Attachment 6B – Page 6

ASK TO SPEAK WITH CONSERVATOR/GUARDIAN. IF PERSON COMES TO PHONE, GO
TO 7.
PN 6: IF MKA IS SPOUSE OR DOMESTIC PARTNER (Q3=1), ASK TO SPEAK WITH MKA IF
NOT ALREADY DOING SO AND GO TO PROXY CONSENT SCRIPT. ELSE ASK 6A AND 6B
AS APPROPRIATE FOR EACH RELATIONSHIP IN Q3 WITH A LOWER NUMBER THAN
THAT OF THE MKA UNTIL 6A=1. IF 6A NE 1 FOR ALL ELIGIBLE RELATIONSHIPS, AFTER
LAST ELIGIBLE RELATIONSHIP, ASK TO SPEAK WITH MKA IF NOT ALREADY DOING
SO AND GO TO PROXY CONSENT SCRIPT.
6a) “Does (ADULT) have a(n) (RELATIONSHIP) living in this household?”
1. YES................................................ [GO TO 6b]
2. NO.................................................. [GO TO PN 6]
6b) “California law requires that I get that person’s permission before I can interview you about
[ADULT]. What is his or her first name?”
ASK TO SPEAK WITH RELATIVE. IF PERSON COMES TO PHONE, GO TO 7.
7) May we have your permission to ask (MKA) about the health and health care of (ADULT)?
1. YES................................................ [ASK FOR MKA, THEN GO TO PROXY CONSENT
SCRIPT]
2. NO.................................................. [THANK AND END]
Continuation of consent script read to the adult proxy for the selected frail elderly interview:
"Again, I am calling for the University of California at Los Angeles. We are doing a scientific study
about health that may help improve services in your community. {Frail adult elderly's first name}’s
telephone number was chosen at random to be in the California Health Survey."
[IF THE ANSWER IS YES, THE INTERVIEW PROCEEDS AS FOLLOWS.]
“This interview is voluntary and confidential. You can skip any question, and you can stop at any
time.
The interview will take about 20 minutes. Specifically, I will ask about health, health care, and
{his/her/his or her} health insurance coverage. I will also ask you about where {he/she} lives.
“Do you have any questions about this?
[PROGRAMMING NOTES: ANSWER QUESTIONS AND PROCEED.]

"The University has very strict safeguards to protect your confidentiality. We have also obtained a
certification from the National Institutes of Health to protect your privacy.
We make every effort to protect {frail adult elderly's first name}’s identity. If you provide {frail adult
elderly’s first name} address, it will be kept in a secure data center for research to better understand
how health is related to where people live.
Other information that could identify {frail adult elderly’s first name}, like {his/her} name and
telephone number will be erased after the study is completed. Your other answers will be combined

Attachment 6B – Page 7

with the answers of other participants and shared with researchers to better understand the health of
Californians. {Frail adult elderly's first name}’s address, if you provide it, will be erased after
conversion into latitude and longitude for research purposes.

Do you have any questions about this?
[PROGRAMMING NOTES: IF REQUESTS INFORMATION ABOUT PRIVACY SAFEGUARDS:
Your name and telephone number will be removed from your answers and erased after the study is
completed. The survey responses will be kept in a secure data center, and your responses will only be
used to produce aggregate numbers.
IF REQUESTS INFORMATION ABOUT NIH CERTIFICATE OF CONFIDENTIALITY:
With a Certificate of Confidentiality, the researchers cannot be forced to disclose information that
may identify you, even by a court subpoena, in any federal, state, or local civil, criminal,
administrative, legislative, or other proceedings. The researchers will use the Certificate to resist
any demands for information that would identify you, except for those from personnel of the United
States Government for information that would be used for auditing or evaluation of Federally funded
projects.
A Certificate of Confidentiality does not prevent you or a member of your family from voluntarily
releasing information about yourself or your involvement in this research. If an insurer, employer, or
other person obtains your written consent to receive research information, then the researchers may
not use the Certificate to withhold that information."]
“If you want, I can give you the name and toll-free telephone number of the persons at UCLA in
charge of the study. Would you like this information now or can we begin the interview?"
[PROGRAMMING NOTES:
IF REQUESTED:
1. WANTS STUDY INFORMATION: Please contact Dr. E. Richard Brown if you have any questions
about the study. Dr. Brown can be reached toll-free at 1-866-275-2447.
2. WANTS INFORMATION ABOUT RIGHTS OF RESEARCH SUBJECTS OR THE NIH
CERTIFICATION FOR PROTECTION OF PERSONAL INFORMATION: Please contact the Office
for the Protection of Research Subjects at (310) 825-8714.]
3. BOTH: Provide both contact numbers.
4. BEGIN INTERVIEW – THANK AND CONTINUE
5. DON'T BEGIN INTERVIEW: Ask "If another time is more convenient, we can schedule at a better
time."]
[IF THE RESPONDENT IS NOT THE MOST KNOWLEDGEABLE ADULT, THE FOLLOWING
QUESTIONS ARE ASKED:]
"Who is the person in the household who is most knowledgeable about the health and healthcare of
{frail elderly adult’s first name}?"
3) Consent Script read to the adult respondent, who is the parent/guardian for the selected
child interview:
"Now I'd like to ask you some questions about {child's first name}, who was also selected
for this study. Specifically, I will ask about health, diet, exercise, and health care.
Attachment 6B – Page 8

"Are you the parent or legal guardian of {child's first name}?
[IF THE ANSWER IS YES, THE INTERVIEW PROCEEDS AS FOLLOWS.]
Are you the person in the household who is most knowledgeable about the health and
health care of {child's first name}?
[IF THE ANSWER IS YES, THE INTERVIEW PROCEEDS AS FOLLOWS.]
"Again, your participation in this section of the interview is voluntary and confidential and takes about
15 minutes. Your answers will be combined with the answers of other participants and shared with
researchers to better understand the health of Californians. You can skip any question, and you can
stop at any time.
"Do you have any questions about this?"
[IF THE ANSWER IS NO, THE FOLLOWING QUESTIONS ARE ASKED:]
"Who is the person in the household who is most knowledgeable about the health and healthcare of
{child's first name}? What is {most knowledgeable adult's first name} relationship to {child's first
name}?
“May we have your permission to ask {most knowledgeable adult's name} about the health and health
care of your child?”
4) Consent Script read to the adult proxy if different from the parent/guardian for the selected
child interview:
"Hello, my name is {interviewer name}. I am calling for the University of California at Los Angeles.
We are doing a scientific study about health that may help improve services for adults and children in
your community. Your number was chosen at random to be in the California Health Survey.
"{Child's first name} has been selected for the study. {Adult respondent's first name} told us that you
were the person in the household that is most knowledgeable about the health and health care of
{child's name}.
"I’d like to ask you some questions about {child’s first name}. Specifically, I will ask about health,
diet, exercise, and health care.
"Your participation in this interview is voluntary and confidential, and the child survey takes about 15
minutes. You can skip any question, and you can stop at any time.
"Do you have any questions about this?
[PROGRAMMING NOTE: ANSWER QUESTIONS AND PROCEED.]
"The University has very strict safeguards to protect your confidentiality. We have also obtained a
certificate from the National Institutes of Health to protect your privacy.

Attachment 6B – Page 9

We make every effort to protect {child’s first name} identity. If you provide your address, it
will be kept in a secure data center for research to better understand how health is related to
where people live. Other information that could identify {child’s first name}, like your
{Child’s first name}’s name and telephone number will be erased after the study is completed. Your
address, if you provide it, will be erased after conversion into latitude and longitude for research
purposes.
[PROGRAMMING NOTES: IF REQUESTS INFORMATION ABOUT PRIVACY SAFEGUARDS:
Your name and telephone number will be removed from your answers and erased after the study is
completed. The survey responses will be kept in a secure data center, and your responses will only be
used to produce aggregate numbers.
IF REQUESTS INFORMATION ABOUT NIH CERTIFICATE OF CONFIDENTIALITY:
With a Certificate of Confidentiality, the researchers cannot be forced to disclose information that
may identify you, even by a court subpoena, in any federal, state, or local civil, criminal,
administrative, legislative, or other proceedings. The researchers will use the Certificate to resist
any demands for information that would identify you, except for those from personnel of the United
States Government for information that would be used for auditing or evaluation of Federally funded
projects.
A Certificate of Confidentiality does not prevent you or a member of your family from voluntarily
releasing information about yourself or your involvement in this research. If an insurer, employer, or
other person obtains your written consent to receive research information, then the researchers may
not use the Certificate to withhold that information."]
“If you want, I can give you the name and toll-free telephone number of the persons at UCLA in
charge of the study. Would you like this information now or can we begin the interview?"
[PROGRAMMING NOTES:
IF REQUESTED:
1. WANTS STUDY INFORMATION: Please contact Dr. E. Richard Brown if you have any questions
about the study. Dr. Brown can be reached toll-free at 1-866-275-2447.
2. WANTS INFORMATION ABOUT RIGHTS OF RESEARCH SUBJECTS OR THE NIH
CERTIFICATION FOR PROTECTION OF PERSONAL INFORMATION: Please contact the Office
for the Protection of Research Subjects at (310) 825-8714.]
3. BOTH: Provide both contact numbers.
4. BEGIN INTERVIEW – THANK AND CONTINUE
5. DON'T BEGIN INTERVIEW: Ask "If another time is more convenient, we can schedule at a better
time."]
5) Consent Script read to parent/guardian giving permission to interview their adolescent:
"{Adolescent’s first name} has {also} been selected for the study. Are you the parent or legal
guardian who can give permission for us to speak with {adolescent’s first name}?
"Because this interview is voluntary, I will need to ask {adolescent’s first name} if {he/she} is willing
to do it. However, I need to obtain your consent to talk to {adolescent’s first name} because {he/she}
is under the age of 18.

Attachment 6B – Page 10

"I will ask questions about health and health behaviors, such as food, exercise, tobacco, and alcohol
and drug use. There are also questions about sexual behavior. Children and teens have heard about
many of these topics in the classroom as important health issues.
"All the information is strictly confidential and will not be released to anyone, even you.
{Adolescent’s first name} can skip any question and can stop the interview at any time.
{adolescent’s first name}’s answers will be combined with the answers of other participants and
shared with researchers to better understand the health of Californians. The phone interview takes
about 15 minutes.
We make every effort to protect {adolescent’s first name}’s information.
Your teen’s name and telephone number will be erased after the study is completed. Your teen’s
answers will be combined with answers of other participants and shared with researchers to better
understand the health of Californians. Your address, if you provide it, will be erased after conversion
into latitude and longitude for research purposes.
"Also, we believe that young people tend to feel more comfortable doing the interview when their
parents are not in the same room listening. Do you have any questions?
[PROGRAMMING NOTE: ANSWER QUESTIONS AND PROCEED.]
"May I have your permission to speak with and interview {adolescent’s first name}?
"If you’d like more information, I can give you the name and toll-free telephone number of the
persons at UCLA in charge of the survey.”
[PROGRAMMING NOTES:
IF REQUESTED:
1. WANTS STUDY INFORMATION: Please contact Dr. E. Richard Brown if you have any questions
about the study. Dr. Brown can be reached toll-free at 1-866-275-2447.
2. WANTS INFORMATION ABOUT RIGHTS OF RESEARCH SUBJECTS OR THE NIH
CERTIFICATION FOR PROTECTION OF PERSONAL INFORMATION: Please contact the Office
for the Protection of Research Subjects at (310) 825-8714.]
3. BOTH: Provide both contact numbers.

4. READ VERBAL ASSENT SCRIPT TO ADOLESCENT
5. DON'T BEGIN INTERVIEW: Ask "If another time is more convenient, we can schedule at
a better time."]
6) Consent Script read to the selected adolescent respondent:
"Hello, my name is {interviewer name}. I am calling for the University of California at Los Angeles.
We are doing a scientific study about health that may help improve services in your community.
"You were chosen at random to be in the California Health survey.
This interview is completely voluntary and confidential. You can skip any question, and you can
stop at any time.
"The interview takes about 15 minutes. There are questions about diet and exercise and about
tobacco, alcohol, and drugs, even if you don't use any of these. There are also some questions about

Attachment 6B – Page 11

sexual behavior. Remember, there are no right or wrong answers in a survey like this. Answer the
questions based on what you really do, think, and feel.
Do you have any questions about this?
[ANSWER QUESTIONS AND PROCEED.]

"The University has very strict safeguards to protect your confidentiality. We have also obtained a
certificate from the National Institutes of Health to protect your privacy.

We make every effort to protect your identity. If your parent or guardian provided an
address, it will be kept in a secure data center for research to better understand how
health is related to where people live.
Other information that could identify you, like your name and telephone number will be erased after
the study is completed. Your other answers will be combined with the answers of other participants
and shared with researchers to better understand the health of Californians.
Do you have any questions about this?"
[PROGRAMMING NOTES: IF REQUESTS INFORMATION ABOUT PRIVACY SAFEGUARDS:
Your name and telephone number will be removed from your answers and erased after the study is
completed. The survey responses will be kept in a secure data center, and your responses will only be
used to produce aggregate numbers.
IF REQUESTS INFORMATION ABOUT NIH CERTIFICATE OF CONFIDENTIALITY:
With a Certificate of Confidentiality, the researchers cannot be forced to disclose information that
may identify you, even by a court subpoena, in any federal, state, or local civil, criminal,
administrative, legislative, or other proceedings. The researchers will use the Certificate to resist
any demands for information that would identify you, except for those from personnel of the United
States Government for information that would be used for auditing or evaluation of Federally funded
projects.
A Certificate of Confidentiality does not prevent you or a member of your family from voluntarily
releasing information about yourself or your involvement in this research. If an insurer, employer, or
other person obtains your written consent to receive research information, then the researchers may
not use the Certificate to withhold that information."]
"If you want, I can give you the name and toll-free telephone number of the persons at UCLA in
charge of the study. Would you like this information now or can we begin the interview?"
[PROGRAMMING NOTES:
IF REQUESTED:
1. WANTS STUDY INFORMATION: Please contact Dr. E. Richard Brown if you have any questions
about the study. Dr. Brown can be reached toll-free at 1-866-275-2447.
2. WANTS INFORMATION ABOUT RIGHTS OF RESEARCH SUBJECTS OR THE NIH
CERTIFICATION FOR PROTECTION OF PERSONAL INFORMATION: Please contact the Office
for the Protection of Research Subjects at (310) 825-8714.]
3. BOTH: Provide both contact numbers.

Attachment 6B – Page 12

"Are you in a private enough place so you can answer these questions freely?"
[PROGRAMMING NOTES:
1. BEGIN INTERVIEW – THANK AND CONTINUE
2. DON'T BEGIN INTERVIEW: Ask "If another time is more convenient, we can schedule at a better
time."]
7) Consent Script read to the screener respondent for the cell phone component
"Hello, my name is {INTERVIEWER NAME}. I am calling for the University of California. We
are doing a scientific study about health in California. If you are currently driving a car or doing any
activity that requires your full attention, I need to call you back at a later time. [PROGRAMMING
NOTE: IF TRUE, END CALL IMMEDIATELY AND SET APPOINTMENT]. In this part of the
study, we are trying to reach people who use cellular service for their primary telephone. It will take
about 2 minutes to see if you qualify for the study. We will send you $5 to thank you for answering
these questions.”
Are you at least 18 years old?
1. YES................................................ [CONTINUE]]
2. NO.................................................. [THANK and END]
Are you a California resident?
1. YES................................................ [CONTINUE]]
2. NO.................................................. [THANK and END]
I would like to ask if you have any regular, landline telephone numbers in your home?
1. YES................................................... [CONTINUE]
2. NO.......................................................[CONTINUE]
Is this telephone number also used for business purposes?
1. YES................................................ [GO TO END]
2. NO.................................................. [CONTINUE]
Including yourself, how many adults AGE 18 AND OLDER, currently live in this household?
_____ NUMBER OF ADULTS
Do any of the adults share this cell phone number?
1. YES............................. [USE MODIFIED LAST-BIRTHDAY SELECTION METHOD]
2. NO............................... [GO TO EXTENDED INTERVIEW]
[PROGRAMMING NOTE: IF ANOTHER MEMBER OF THE HOUSEHOLD IS SELECTED]
Please tell me just the first name and age of the other adult in this household.
NAME ____________________ AGE____[GO TO PROGRAMMING NOTE: IF SCREENER
COMPLETED]
END and THANK RESPONDENT

Attachment 6B – Page 13

[PROGRAMMING NOTE: IF INELIGIBLE]
“Thank you. These are all the questions I have. Because you are not a cell-phone only user, you are
not eligible to participate in this survey. If you can provide me with your name and mailing address,
we would be happy to send you $5 to thank you for your time.
[PROGRAMMING NOTE: IF REFUSE TO PARTICIPATE]
“If you can provide me with your name and mailing address, we would be happy to send you $5 to
compensate you for your time and costs in taking this call.”
8) Consent script read to the respondent if eligible (at least 18, telephone is not business use only,
and respondent has no landline) for the cell phone component:
[PROGRAMMING NOTE: IF PERSON COMPLETING SCREENER IS SELECTED] “You have
been selected to participate in this interview. Please tell me just your first name and age.
NAME ____________________ AGE _____
"Again, I am calling for the University of California at Los Angeles. This is a scientific study about
health that may help improve services in your community. Your telephone number was chosen at
random to be in the California Health Survey. Some people are concerned about the privacy of
conversations on cell phones. If you would prefer, I would be happy to call you back on a landline
phone to conduct this interview at a time that is convenient for you. [PROGRAMMING NOTE: IF
YES GO TO APPOINTMENT SCREEN].
[PROGRAMMING NOTE: IF PERSON SHARING CELL PHONE WITH PERSON
COMPLETING SCREENER IS SELECTED]
"Hello, my name is {INTERVIEWER NAME}. I am calling for the University of California. We
are doing a scientific study about health in California. This part of the study has to do with people
who only use cell phones. If you are currently driving a car or doing any activity that requires your
full attention, I need to call you back at a later time. [PROGRAMMING NOTE: IF TRUE, END
CALL IMMEDIATELY AND SET APPOINTMENT]. Some of the numbers we are calling are for
cell phones. Some people are concerned about the privacy of conversations on cell phones. If you
would prefer, I would be happy to call you back on a landline phone to conduct this interview at a
time that is convenient for you. [PROGRAMMING NOTE: IF YES GO TO APPOINTMENT
SCREEN].
[FOR ALL EXTENDED INTERVIEWS]
“This interview is voluntary and confidential. You can skip any question, and you can stop at any
time.
"The interview takes about 30 minutes on average, but may be as short as 20 minutes. There are
questions about your health, diet and exercise, sexual behaviors, violence, suicide, emotional health
and treatment for mental health problems, and your healthcare and insurance. I will also ask about
where you live. We will send you $25 to thank you for your help with this survey.
"Do you have any questions about this?"

Attachment 6B – Page 14

[PROGRAMMING NOTE: ANSWER QUESTIONS AND PROCEED.]
"The University has very strict safeguards to protect your confidentiality. We have obtained a
certificate from the National Institutes of Health to protect your privacy. We may not be able to
keep confidential any thoughts to harm yourself and if you tell us that you have had thoughts of
suicide we may provide you with a referral to someone who can help.
We make every effort to protect your identity. If you provide your address, it will be kept in a secure
data center for research to better understand how health is related to where people live.
Other information that could identify you, like your name and telephone number will be erased after
the study is completed. Your other answers will be combined with the answers of other participants
and shared with researchers to better understand the health of Californians. Your address, if you
provide it, will be erased after conversion into latitude and longitude for research purposes.
If you want, I can give you the name and toll-free telephone number of the persons at UCLA in
charge of the study.
[PROGRAMMING NOTES: IF REQUESTS INFORMATION ABOUT PRIVACY SAFEGUARDS]:
Your name and telephone number will be removed from your answers and erased after the study is
completed. The survey responses will be kept in a secure data center, and your responses will only
be used to produce aggregate numbers.
IF REQUESTS INFORMATION ABOUT NIH CERTIFICATE OF CONFIDENTIALITY:
With a Certificate of Confidentiality, the researchers cannot be forced to disclose information that
may identify you, even by a court subpoena, in any federal, state, or local civil, criminal,
administrative, legislative, or other proceedings. The researchers will use the Certificate to resist
any demands for information that would identify you, except for those from personnel of the United
States Government for information that would be used for auditing or evaluation of Federally
funded projects.
A Certificate of Confidentiality does not prevent you or a member of your family from voluntarily
releasing information about yourself or your involvement in this research. If an insurer, employer,
or other person obtains your written consent to receive research information, then the researchers
may not use the Certificate to withhold that information."
A Certificate of Confidentiality does not prevent the researchers from disclosing voluntarily,
without your consent, information that would identify you as a participant in the research project if
you disclose information about harming yourself or others."]
"Would you like this information now or can we begin the interview?"
[PROGRAMMING NOTES:
IF REQUESTED:
1. WANTS STUDY INFORMATION: Please contact Dr. E. Richard Brown if you have any
questions about the study. Dr. Brown can be reached toll-free at 1-866-275-2447.
2. WANTS INFORMATION ABOUT RIGHTS OF RESEARCH SUBJECTS OR THE NIH
CERTIFICATION FOR PROTECTION OF PERSONAL INFORMATION: Please contact the Office
for the Protection of Research Subjects at (310) 825-8714.]
3. BOTH: Provide both contact numbers.
4. BEGIN INTERVIEW – THANK AND CONTINUE

Attachment 6B – Page 15

5. DON'T BEGIN INTERVIEW: Ask, "If another time is more convenient, we can schedule at a
better time."]
9) Consent Script read to the adult respondent selected for staging (English only):
"Hello, my name is {interviewer name}. I am calling for the University of California at Los Angeles.
We are doing a scientific study about health that may help improve services in your community.
Your telephone number was chosen at random to be in the California Health Survey.
“This interview is voluntary and confidential. You can skip any question, and you can stop at any
time.
"The interview takes about 30 minutes on average, but may be as short as 20 minutes. There are
questions about your health, diet and exercise, sexual behaviors, violence, suicide, emotional health
and treatment for mental health problems, and your healthcare and insurance. I will also ask you
about where you live. We will send you $25 to thank you for your help with this survey.
“Do you have any questions about this?
[PROGRAMMING NOTE: ANSWER QUESTIONS AND PROCEED.]
"The University has very strict safeguards to protect your confidentiality. We are also certified by the
National Institutes of Health to protect your privacy. We may not be able to keep confidential any
thoughts to harm yourself and if you tell us that you have had thoughts of suicide we may provide
you with a referral to someone who can help.

We make every effort to protect your identity. If you provide your address, it will be kept in a
secure data center for research to better understand how health is related to where people
live. Other information that could identify you, like your name and telephone number will be erased
after the study is completed. Your other answers will be combined with the answers of other
participants and shared with researchers to better understand the health of Californians. Your
address, if you provide it, will be erased after conversion into latitude and longitude for research
purposes.
If you want, I can give you the name and toll-free telephone number of the persons at UCLA in
charge of the study. Would you like this information now, or can we begin the interview?"
[PROGRAMMING NOTES: IF REQUESTS INFORMATION ABOUT PRIVACY SAFEGUARDS]
Your name and telephone number will be removed from your answers and erased after the study is
completed. The survey responses will be kept in a secure data center, and your responses will only be
used to produce aggregate numbers.
IF REQUESTS INFORMATION ABOUT NIH CERTIFICATE OF CONFIDENTIALITY:
With a Certificate of Confidentiality, the researchers cannot be forced to disclose information that
may identify you, even by a court subpoena, in any federal, state, or local civil, criminal,
administrative, legislative, or other proceedings. The researchers will use the Certificate to resist
any demands for information that would identify you, except for those from personnel of the United
States Government for information that would be used for auditing or evaluation of Federally funded
projects.

Attachment 6B – Page 16

A Certificate of Confidentiality does not prevent you or a member of your family from voluntarily
releasing information about yourself or your involvement in this research. If an insurer, employer, or
other person obtains your written consent to receive research information, then the researchers may
not use the Certificate to withhold that information."
A Certificate of Confidentiality does not prevent the researchers from disclosing voluntarily, without
your consent, information that would identify you as a participant in the research project if you
disclose information about harming yourself or others."]
“Would you like this information now or can we begin the interview?"
[PROGRAMMING NOTES:
IF REQUESTED:
1. WANTS STUDY INFORMATION: Please contact Dr. E. Richard Brown if you have any questions
about the study. Dr. Brown can be reached toll-free at 1-866-275-2447.
2. WANTS INFORMATION ABOUT RIGHTS OF RESEARCH SUBJECTS OR THE NIH
CERTIFICATION FOR PROTECTION OF PERSONAL INFORMATION: Please contact the Office
for the Protection of Research Subjects at (310) 825-8714.]
3. BOTH: Provide both contact numbers.
4. BEGIN INTERVIEW – THANK AND CONTINUE
5. DON'T BEGIN INTERVIEW: Ask, "If another time is more convenient, we can schedule at a better
time."]
Read to the adult respondent for quality control methodological research audio recording:
"We are randomly tape-recording some interviews for quality control purposes. The
tapes are kept strictly confidential, and your identity will not be disclosed. The tapes will
be destroyed at the completion of the project. May I have your permission to tape this
interview?

"I need to confirm that you gave your permission to participate and to be recorded. Is that
correct?"

Attachment 6B – Page 17

Dear Current Resident,
Your household has been selected for this year’s California Health Survey.
This telephone survey is an important opportunity to have your voice heard on
health care issues.
This research helps California learn about the health of its people and the
problems they have getting health care. The results may be used to help the
people and families in your community.
We recently called your home, but it was not a good time for anyone to speak
with us. We know your time is valuable. However, we encourage you to take
just a few minutes to talk to our interviewer when we call again.
Your household is part of a scientific sample representing many other
households like yours. Please take a moment to take our call. If we happen to
call at an inconvenient time, you can suggest a time that is better for you.
If you have any questions, you may call toll free at 1-888-941-2950.
Sincerely,

Dr. E. Richard Brown
Director, UCLA Center for Health Policy Research
Note: If you want to read more about this survey, you can visit our website at
www.californiahealthsurvey.org
Major funders of this survey include the California Department of Health Care Services, California Department of
Public Health, First 5 California, Office of the Patient Advocate, The California Endowment, and the National
Cancer Institute.
Relevant to Privacy Act Information, the legislative authority for this survey is 42 USC 285.

10960 Wilshire Boulevard, Suite 1550 Los Angeles, CA 90024

Attachment 6C – Page 18

Dear Current Resident,
We recently talked on the telephone with someone in your home who has been
selected to be part of the California Health Survey. I do not know that person’s
name because this is a confidential survey and names cannot be released.
The person we talked to chose not to do the interview or not to finish it. We
respect that decision since the interview is voluntary. However, I kindly ask
him or her to please reconsider.
You are part of a scientific sample representing many others like yourself. You
are important in making a complete picture of the people of California. The
results may be used to improve health care and help your community.
One of our interviewers from [data collection vendor information will be
available in October], the survey firm making the telephone calls, will call
again. I want to give the selected person one more opportunity to be part of
this important survey. If necessary, our interviewer can make an appointment
for a more convenient time.
Please take a moment to talk with us. If you have any questions, you may call
toll free at 1-888-941-2950.
Sincerely,

Dr. E. Richard Brown
Director, UCLA Center for Health Policy Research
Note: If you want to read more about this survey, you can visit our website at
www.californiahealthsurvey.org

Major funders of this survey include the California Department of Health Care Services, California Department of
Public Health, First 5 California, Office of the Patient Advocate, The California Endowment, and the National
Cancer Institute.
Relevant to Privacy Act Information, the legislative authority for this survey is 42 USC 285.

10960 Wilshire Boulevard, Suite 1550 Los Angeles, CA 90024
Attachment 6D – Page 19

Dear Parent or Guardian,
We recently did a telephone interview with an adult in your household. I want
to thank that person for his or her time. We also selected one teenager
between age 12 and 17 to be interviewed. However, the parent or guardian did
not give us permission to interview their teenager. We respect that decision
and will not speak with anyone under 18 years old without permission.
I want to ask the parent or guardian to please reconsider. Our survey results
may help to improve the health of young people in your community. Your
teenager is important. She or he is part of a scientific sample representing
many other similar young people.
One of our interviewers from [data collection vendor information will be
available in October], the survey firm making the telephone calls, will call
again. We will again ask for permission to interview the selected teenager.
This voluntary interview only takes about 15 minutes. We can make an
appointment for a convenient time to do it.
If we still cannot get permission, or the selected teenager does not want to do
it, tell the interviewer when we call. We will not call or write again.
If you have any questions, you may call toll-free at 1-888-941-2950.
Yours truly,

Dr. E. Richard Brown
Director, UCLA Center for Health Policy Research
Note: If you want to read more about this survey, you can visit our website at
www.californiahealthsurvey.org
Major funders of this survey include the California Department of Health Care Services, California Department of
Public Health, First 5 California, Office of the Patient Advocate, The California Endowment, and the National
Cancer Institute.
Relevant to Privacy Act Information, the legislative authority for this survey is 42 USC 285.

10960 Wilshire Boulevard, Suite 1550 Los Angeles, CA 90024
Attachment 6E – Page 20