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| File Title | Attachment 2 |
| Author | lee |
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| File Modified | 2011-01-14 |
| File Created | 2026-10-04 |
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Attachment 1
CHIS 2011 Cancer Control Module (CCM) and Demographic Core Questionnaire Items
CALIFORNIA HEALTH INTERVIEW SURVEY 2011
OMB No. 0925-0598
Expires: 02-28-2011
Public reporting burden for this collection of information is estimated to vary from 2 to 23 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 Dr., MSC 7974, Bethesda, MD 20892-7974, Attn: PRA (0925-0598). Do not return the completed form to this address.
TABLE OF CONTENTS
MODULE A – CANCER SCREENING 3
MODULE B – WOMEN’S HEALTH 15
MODULE C – HUMAN PAPILOMAVIRUS 17
MODULE E – FAMILY HISTORY OF CANCER 20
MODULE G – DEMOGRAPHICS, PART I 23
MODULE H – DEMOGRAPHICS, PART II 31
MODULE I – EMPLOYMENT, INCOME AND POVERTY 43
MODULE J – DEMOGRAPHICS, PART III AND CLOSING 53
MODULE K – GENERAL HEALTH, HEALTH-RELATED QUALITY OF LIFE,
AND SEXUAL HEALTH 57
MODULE L – EPILEPSY 62
MODULE M – MEDICAL HOME 63
MODULE A – CANCER SCREENING
PROGRAMMING NOTE QA11_A1:
IF (AGE < 40 OR AGE IS UNKNOWN), GO TO PROGRAMMING NOTE QA11_A19;
ELSE CONTINUE WITH QA11_A1
QA11_A1 A stool or fecal blood test is done at home to check for colon cancer. You send your stool sample to the doctor’s office or lab for testing. Have you ever done a stool or fecal blood test?
[IF NEEDED, SAY: “Do not include over-the-counter test kits from a drugstore or pharmacy.”]
[IF NEEDED, SAY: “Do not include tests done at the doctor’s office.”]
YES 1
NO 2 [GO TO QA11_A4]
REFUSED -7 [GO TO QA11_A4]
DON'T KNOW -8 [GO TO QA11_A4]
QA11_A2 When did you do your most recent blood test using a home kit to check for colon cancer?
A YEAR AGO OR LESS 1
MORE THAN 1 YEAR AGO UP TO
2 YEARS AGO 2
MORE THAN 2 YEARS AGO UP TO
5 YEARS AGO 3
MORE THAN 5 YEARS AGO 4
REFUSED -7
DON'T KNOW -8
QA11_A3 What was the main reason you had your most recent stool blood test using a home kit? Was it…
Part of a routine physical exam, 1
Because of a problem, or 2
Some other reason? 3
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A4:
IF QA11_A2 = 1 (MOST RECENT FOBT A YEAR AGO OR LESS), THEN CONTINUE WITH QA11_A4;
ELSE CONTINUE WITH QA11_A6
QA11_A4 How much did you pay for your most recent stool blood test using a home kit—was it none, some or all of the cost?
NONE OF THE COST 1 [GO TO QA11_A5]
SOME OF THE COST 2 [GO TO QA11_A5]
ALL OF THE COST 3
REFUSED -7
DON'T KNOW -8
QA11_A5 Was the test provided through a special low-cost program?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA11_A6 A sigmoidoscopy and a colonoscopy are both tests that examine the bowel by inserting a tube in the rectum. The difference is that during a sigmoidoscopy, you are awake and can drive yourself home after the test; however, during a colonoscopy, you may feel sleepy and you need someone to drive you home. Have you ever had a colonoscopy?
YES 1
NO 2 [GO TO QA11_A11]
REFUSED -7 [GO TO QA11_A11]
DON'T KNOW -8 [GO TO QA11_A11]
QA11_A7 When did you have your most recent colonoscopy to check for colon cancer?
A YEAR AGO OR LESS 1
MORE THAN 1 UP TO 5 YEARS AGO 2
MORE THAN 5 UP TO 10 YEARS AGO 3
MORE THAN 10 YEARS AGO 4
REFUSED -7
DON'T KNOW -8
QA11_A8 What was the main reason you had your most recent colonoscopy? Was it…
Part of a routine physical exam, 1
Because of a problem, or 2
Some other reason? 3
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A10:
IF QA11_A7= 1 (MOST RECENT COLONOSCOPY A YEAR AGO OR LESS), THEN CONTINUE WITH QA11_A9;
ELSE CONTINUE WITH QA11_A11
QA11_A9 How much did you pay for your most recent colonoscopy—was it none, some or all of the cost?
NONE OF THE COST 1 [GO TO QA11_A10]
SOME OF THE COST 2 [GO TO QA11_A10]
ALL OF THE COST 3
REFUSED -7
DON'T KNOW -8
QA11_A10 Was the colonoscopy provided through a special low-cost program?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA11_A11 Have you ever had a sigmoidoscopy?
YES 1
NO 2 [GO TO QA11_A16]
REFUSED -7 [GO TO QA11_A16]
DON'T KNOW -8 [GO TO QA11_A16]
QA11_A12 When did you have your most recent sigmoidoscopy to check for colon cancer?
A YEAR AGO OR LESS 1
MORE THAN 1 UP TO 5 YEARS AGO 2
MORE THAN 5 UP TO 10 YEARS AGO 3
MORE THAN 10 YEARS AGO 4
REFUSED -7
DON'T KNOW -8
QA11_A13 What was the main reason you had your most recent sigmoidoscopy? Was it…
Part of a routine physical exam, 1
Because of a problem, or 2
Some other reason? 3
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A14:
IF QA11_A12 = 1 (MOST RECENT SIGMOIDOSCOPY A YEAR AGO OR LESS), THEN CONTINUE WITH QA11_A14;
ELSE CONTINUE WITH QA11_A16
QA11_A14 How much did you pay for your most recent sigmoidoscopy—was it none, some or all of the cost?
NONE OF THE COST 1 [GO TO QA11_A15]
SOME OF THE COST 2 [GO TO QA11_A15]
ALL OF THE COST 3
REFUSED -7
DON'T KNOW -8
QA11_A15 Was the sigmoidoscopy provided through a special low-cost program?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA11_A16 In the past 5 years, has a doctor recommended that you have a sigmoidoscopy,
colonoscopy, or stool blood test?
YES 1
NO 2
DID NOT GO TO A DOCTOR
IN PAST 5 YEARS 92
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A17:
IF QA11_A1 = 2 (NEVER HAD FOBT) AND QA11_A6 = 2 (NEVER HAD COLONOSCOPY) AND QA11_A11 = 2 (NEVER HAD SIGMOIDOSCOPY) CONTINUE WITH QA11_A17 AND DISPLAY "never had";
ELSE IF QA11_A1 ≠ 1 (MOST RECENT FOBT OVER 1 YEAR AGO) AND QA11_A7 ≠ 1, 2, OR 3 (MOST RECENT COLONOSCOPY OVER 10 YEARS AGO) AND QA11_A812 ≠ 1 OR 2 (MOST RECENT SIGMOIDOSCOPY OVER 5 YEARS AGO) CONTINUE WITH QA11_A17 AND DISPLAY "not had" AND "recently";
ELSE GO TO PROGRAMMING NOTE QA11_A18
QA11_A17 What is the ONE most important reason why you have {never had/not had} one of these exams {recently}?
NO REASON/NEVER THOUGHT ABOUT IT 1
DIDN'T KNOW I NEEDED
THIS TYPE OF TEST 2
DOCTOR DIDN'T TELL ME I NEEDED IT 3
HAVEN'T HAD ANY PROBLEMS 4
PUT IT OFF/LAZINESS 5
TOO EXPENSIVE/NO INSURANCE/COST 6
TOO PAINFUL, UNPLEASANT, OR
EMBARRASSING 7
HAD ANOTHER TYPE OF
COLORECTAL EXAM 8
DON'T HAVE A DOCTOR 9
OTHER 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A18:
IF FEMALE GO TO QA11_A20;
ELSE CONTINUE WITH QA11_A18
QA11_A18 Have you ever heard of a PSA or "prostate-specific antigen" test to detect prostate cancer? A PSA test is a blood test to detect prostate cancer.
YES 1
NO 2 [GO TO PN QA11_A44]
REFUSED -7 [GO TO PN QA11_A44]
DON'T KNOW -8 [GO TO PN QA11_A44]
QA11_A19 Have you ever had a PSA test?
[IF NEEDED, SAY: “A PSA test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.”]
YES 1
NO 2 [GO TO QA11_A24]
REFUSED -7 [GO TO QA11_A24]
DON'T KNOW -8 [GO TO QA11_A24]
QA11_A20 When did you have your most recent PSA test?
A YEAR AGO OR LESS 1
MORE THAN 1 UP TO 2 YEARS AGO 2
MORE THAN 2 UP TO 3 YEARS AGO 3
MORE THAN 3 UP TO 5 YEARS AGO 4
MORE THAN 5 YEARS AGO 5
REFUSED -7
DON'T KNOW -8
QA11_A21 What was the main reason you had this PSA test – was it part of a routine physical exam, because of a problem, or some other reason?
Part of a routine physical exam, 1
Because of a problem, OR 2
Some other reason? 3
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A22:
IF QA11_A20 = 1 (MOST RECENT PSA TEST A YEAR AGO OR LESS), THEN CONTINUE WITH QA11_A22;
ELSE CONTINUE WITH QA11_A24
QA11_A22 How much did you pay for your most recent PSA test—was it none, some or all of the cost?
NONE OF THE COST 1 [GO TO QA11_A23]
SOME OF THE COST 2 [GO TO QA11_A23]
ALL OF THE COST 3
REFUSED -7
DON'T KNOW -8
QA11_A23 Was the PSA test provided through a special low-cost program?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A24:
IF QA11_A19 = 1 DISPLAY “before you had the PSA test, did” AND “it”;
ELSE DISPLAY “Did” AND “the PSA test”
QA11_A24 {Before you had the PSA test, did/Did} a doctor ever talk with you about the advantages and disadvantages of having {it/the PSA test}?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A25:
IF QA11_A19 = 1 DISPLAY “before you had the PSA test” AND “it”;
ELSE DISPLAY “Did” AND “the PSA test”
QA11_A25 {Before you had the PSA test, did/Did} a doctor ever tell you that some doctors recommend having {it/the PSA test} and others do not?
YES 1
NO 2
REFUSED -7
DON’T KNOW -8
QA11_A26 Did a doctor or other health professional ever recommend that you have a PSA test?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A27:
IF MALE OR AGE < 30, GO TO PROGRAMMING NOTE QA11_A44;
ELSE CONTINUE WITH QA11_A27 (INCLUDING WOMEN WITH AGE UNKNOWN)
QA11_A27 In the past 12 months, has a doctor examined your breasts for lumps?
[IF NEEDED, SAY: “This is when a doctor touches your breasts to check for bumps, cysts, or abnormal growth.”]
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA11_A28 Have you ever had a mammogram?
[IF NEEDED, SAY: "A mammogram is an x-ray taken of each breast separately by a machine that flattens or squeezes each breast."]
YES 1
NO 2 [READ DEFINITION, IF STILL
NO, GO TO QA11_A42]
REFUSED -7 [GO TO PN QA11_A44]
DON'T KNOW -8 [GO TO PN QA11_A44]
QA11_A29 How many mammograms have you had in the last 6 years? Your best estimate is fine.
_____ MAMMOGRAMS
NONE 0 [GO TO QA11_A42]
REFUSED -7
DON'T KNOW -8
QA11_A30 How long ago did you have your most recent mammogram?
A YEAR AGO OR LESS 1
MORE THAN 1 UP TO 2 YEARS AGO 2
MORE THAN 2 UP TO 3 YEARS AGO 3
MORE THAN 3 UP TO 5 YEARS AGO 4
MORE THAN 5 YEARS AGO 5
REFUSED -7 [GO TO PN QA11_A44]
DON'T KNOW -8 [GO TO PN QA11_A44]
QA11_A31 Was your most recent mammogram recommended by a doctor?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A32:
IF QA11_A30 = 3, 4, OR 5 (MAMMOGRAM MORE THAN 2 YEARS AGO), THEN GO TO QA11_A35;
ELSE CONTINUE WITH QA11_A32
QA11_A32 Tell me the main reason you had a mammogram. Was it…
[IF NEEDED, SAY: "The main reason is the most important reason.”]
Part of a routine exam, 1
Because of a specific breast problem, 2
A follow-up to a previously identified
breast problem, or 3
Due to family history? 4
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A33:
IF QA11_A30 = 1 (MOST RECENT MAMMOGRAM A YEAR AGO OR LESS), THEN CONTINUE WITH QA11_A33;
ELSE CONTINUE WITH QA11_A35
QA11_A33 How much did you pay for your most recent mammogram—was it none, some or all of the cost?
NONE OF THE COST 1 [GO TO QA11_A34]
SOME OF THE COST 2 [GO TO QA11_A34]
ALL OF THE COST 3
REFUSED -7
DON'T KNOW -8
QA11_A34 Was the mammogram provided through a special low-cost program?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA11_A35 Have you ever had a mammogram where the results were not normal?
YES 1
NO 2 [GO TO QA11_A42]
REFUSED -7 [GO TO QA11_A42]
DON'T KNOW -8 [GO TO QA11_A42]
QA11_A36 Have you ever had an operation to remove a lump from your breast?
YES 1
NO 2 [GO TO QA11_A40]
DON’T KNOW -7 [GO TO QA11_A40]
REFUSED -8 [GO TO QA11_A40]
QA11_A37 Did the lump turn out to be cancer?
YES 1 [GO TO QA11_A39]
NO 2
REFUSED -7
DON'T KNOW -8
QA11_A38 How many operations have you had to remove a lump that wasn’t cancer?
______ NUMBER OF OPERATIONS [GO TO QA11_A40]
REFUSED -7 [GO TO QA11_A40]
DON'T KNOW -8 [GO TO QA11_A40]
QA11_A39 Tell me how you first found out about your breast cancer. Was it by…
Finding it yourself by accident, 1
Finding it yourself during a
self breast examination, 2
Your husband or partner finding it, 3
Your doctor finding it during a routine
breast exam, 4
Finding it by a mammogram, or 5
Some other way? (SPECIFY:_____________) 6
DON’T KNOW -7
REFUSED -8
QA11_A40 Did you have any other tests and/or surgery when your mammogram was not normal?
YES 1
NO 2 [GO TO QA11_A42]
DON’T KNOW -7 [GO TO QA11_A42]
REFUSED -8 [GO TO QA11_A42]
QA11_A41 What additional tests and/or surgery did you have?
[CODE ALL THAT APPLY]
[IF NEEDED, SAY: “Any others?”]
NO TESTS/NO SURGERY 1
MASTECTOMY (SURGERY TO
REMOVE BREAST) 2
LUMPECTOMY (SURGERY TO
REMOVE LUMP) 3
NEEDLE BIOPSY 4
ULTRASOUND TEST 5
ANOTHER MAMMOGRAM 6
CLINICAL BREAST EXAM 7
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A42:
IF QA11_A28 = 2 OR QA11_A29 = 0 OR QA11_A30 = 3, 4, OR 5, CONTINUE WITH QA11_A42;
ELSE GO TO PROGRAMMING NOTE QA11_A43;
QA11_A42 In the past 2 years, has a doctor recommended that you have a mammogram?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A43:
IF QA11_A42 = 1 (YES, DOCTOR RECOMMENDED A MAMMOGRAM) AND (QA11_A28 = 2 OR QA11_A29 = 0 OR QA11_A30 = 3, 4, OR 5), CONTINUE WITH QA11_A43;
IF QA11_A30 = 3, 4, 5, OR -8 (MOST RECENT MAMMOGRAM > 2 YEARS AGO or DK),
DISPLAY “NOT had a mammogram in the past 2 years”;
IF QA11_A28 = 2 (NEVER HAD MAMMOGRAM), DISPLAY “NEVER had a mammogram”;
ELSE GO TO PROGRAMMING NOTE QA11_A44;
QA11_A43 What is the ONE most important reason why you have {NEVER had a mammogram/NOT had a mammogram in the past 2 years}?
NO REASON/NEVER THOUGHT ABOUT IT 1
DIDN'T KNOW I NEEDED THIS TYPE OF TEST 2
DOCTOR DIDN'T TELL ME I NEEDED IT 3
HAVEN'T HAD ANY PROBLEMS 4
PUT IT OFF/LAZINESS 5
TOO EXPENSIVE/NO INSURANCE/COST 6
TOO PAINFUL, UNPLEASANT,
EMBARRASSING 7
TOO YOUNG 8
DON'T HAVE A DOCTOR 9
OTHER 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_A44:
IF AGE < 40, THEN GO TO NEXT SECTION;
ELSE CONTINUE WITH QA11_A44
QA11_A44 In the last 12 months, did you have a CAT scan or CT scan? During this test, you are lying down and moved through a donut shaped x-ray machine while holding your breath.
YES 1
NO 2 [GO TO NEXT SECTION]
REFUSED -7 [GO TO NEXT SECTION]
DON'T KNOW -8 [GO TO NEXT SECTION]
QA11_A45 Were any of the CAT scans you had in the last 12 months done of your chest area?
YES 1
NO 2 [GO TO NEXT SECTION]
SEVERAL AREAS OF UPPER BODY REGION....3
REFUSED -7 [GO TO NEXT SECTION]
DON'T KNOW -8 [GO TO NEXT SECTION]
QA11_A46 Were any of the CAT scans of your chest area done to check for lung cancer, rather than for some other reason?
YES, TO CHECK FOR LUNG CANCER 1
NO, FOR SOME OTHER REASON 2
REFUSED -7
DON'T KNOW -8
MODULE B – WOMEN’S HEALTH
PROGRAMMING NOTE QA11_B1:
IF MALE OR AGE < 18, GO NEXT SECTION;
IF AGE > 39 THEN CONTINUE WITH QA11_B1;
ELSE GO TO PROGRAMMING NOTE QA11_B5
QA11_B1 Have you ever taken hormone replacement therapy or HRT for menopausal symptoms?
YES 1
NO 2 [GO TO PN QA11_B5]
REFUSED -7 [GO TO PN QA11_B5]
DON’T KNOW -8 [GO TO PN QA11_B5]
QA11_B2 Are you currently taking hormone replacement therapy?
[IF NEEDED, SAY: “This is a pill, patch or treatment that gives women more of the female hormone, estrogen.”]
YES 1 [GO TO QA11_B4]
NO 2
REFUSED -7 [GO TO QA11_B4]
DON'T KNOW -8 [GO TO QA11_B4]
QA11_B3 About how long ago did you stop using Hormone Replacement Therapy – was it…
2 years ago or less, 1
More than 2 years up to 5 years ago, or 2
More than 5 years ago? 3
REFUSED -7
DON’T KNOW -8
QA11_B4 Some women go on and off hormone replacement therapy. Altogether, how long have you taken HRT?
A YEAR OR LESS 1
MORE THAN 1 UP TO 2 YEARS 2
MORE THAN 2 UP TO 4 YEARS 3
MORE THAN 4 UP TO 8 YEARS 4
MORE THAN 8 YEARS AGO 5
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_B5:
IF AGE > 44 CONTINUE WITH QA11_B5;
ELSE GO TO NEXT SECTION
QA11_B5 INTRO Are you taking any of the following medications?
QA11_B5 Tamoxifen or Nolvadex?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA11_B6 Raloxifene or Evista?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
MODULE C – HUMAN PAPILOMAVIRUS
PROGRAMMING NOTE QA11_C1:
IF AGE < 18 GO TO NEXT SECTION;
ELSE IF AGE < 65, THEN CONTINUE WITH QA11_C1;
ELSE GO TO QA11_C5
QA11_C1 Have you ever heard of HPV? HPV stands for human papillomavirus (pap-uh-LOW-muh-vi-rus).
YES 1
NO 2 [GO TO QA11_C4]
REFUSED -7 [GO TO QA11_C4]
DON’T KNOW -8 [GO TO QA11_C4]
QA11_C2 These next questions are about HPV. Your best guess is fine.
Do you think HPV can cause cervical cancer?
YES 1
NO 2
REFUSED -7
DON’T KNOW -8
QA11_C3 Do you think HPV can go away on its own without treatment?
YES 1
NO 2
REFUSED -7
DON’T KNOW -8
QA11_C4 A vaccine to prevent HPV infection is available and is called the HPV shot, cervical cancer vaccine, GARDASIL®, or Cervarix®. Before this survey, have you ever heard of the HPV shot or cervical cancer vaccine?
YES 1
NO 2
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_C5:
IF FEMALE AND AGE < 36 THEN CONTINUE WITH QA11_C5;
ELSE GO TO NEXT SECTION
QA11_C5 Have you ever received the HPV shot or cervical cancer vaccine?
YES 1
NO 2 [GO TO QA11_C7]
REFUSED -7 [GO TO QA11_C7]
DON’T KNOW -8 [GO TO QA11_C7]
QA11_C6 How many HPV shots did you receive?
1-2 SHOTS 1
3-50 SHOTS 2 [GO TO NEXT SECTION]
“ALL SHOTS” 3 [GO TO NEXT SECTION]
REFUSED -7 [GO TO NEXT SECTION]
DON’T KNOW -8 [GO TO NEXT SECTION]
QA11_C7 Do you plan to receive HPV shots in the next 12 months?
YES 1 [GO TO NEXT SECTION]
NO 2
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_C8:
IF QA11_C6 = 1 (RECEIVED 1-2 DOSES OF HPV VACCINE) AND QA11_C7 = 2, -7, OR -8 (DO NOT PLAN TO RECEIVE ANY MORE SHOTS, REF, OR DK), THEN CONTINUE WITH QA11_C8;
ELSE GO QA11_C9
QA11_C8 What is the main reason you do not plan to receive more HPV shots in the next 12 months?
DON’T NEED ANOTHER DOSE/
HAVE COMPLETED THE SERIES 1 [GO TO QA11_C10]
DOCTOR DIDN’T RECOMMEND IT 2 [GO TO NEXT SECTION]
TOO EXPENSIVE/
INSURANCE DOESN’T COVER 3 [GO TO QA11_C11]
TOO TIME-CONSUMING TO GO TO
AN APPOINTMENT TO GET ANOTHER DOSE 4 [GO TO QA11_C10]
HAD SIDE EFFECTS FROM AN EARLIER DOSE/
WORRIED ABOUT SAFETY 5 [GO TO QA11_C10]
OTHER 6 [GO TO QA11_C10]
QA11_C9 What is the main reason you will not receive HPV shots in the next 12 months?
DOES NOT NEED VACCINE 1
NOT SEXUALLY ACTIVE 2
TOO EXPENSIVE 3 [GO TO QA11_C11]
TOO OLD FOR VACCINE 4
DOCTOR DIDN’T RECOMMEND IT 5 [GO TO NEXT SECTION]
WORRIED ABOUT SAFETY OF VACCINE 6
DON’T KNOW WHERE TO GET VACCINE 7
MY SPOUSE/FAMILY MEMBER IS
AGAINST IT 8
DON’T KNOW ENOUGH ABOUT VACCINE 9
HAVE HPV/CERVICAL DYSPLASIA/
CERVICAL CANCER 10
VACCINE WAS NOT AVAILABLE AT
MY DOCTOR/CLINIC 11
OTHER 91
REFUSED -7
DON’T KNOW -8
QA11_C10 Is cost a reason that you do not plan to receive HPV shots in the next 12 months?
YES 1
NO 2
REFUSED -7
DON’T KNOW -8
QA11_C11 Has a doctor or other health care professional ever recommended that you receive HPV shots?
YES 1
NO 2
REFUSED -7
DON’T KNOW -8
MODULE E – FAMILY HISTORY OF CANCER
PROGRAMMING NOTE QA11_E1:
IF AGE < 18, THEN GO TO NEXT SECTION;
ELSE CONTINUE WITH QA11_E1
QA11_E1 Now I’m going to ask about your family’s history of cancer. By family we mean only your blood relatives. Did your biological father or mother, full brothers or sisters, or biological sons or daughters ever have cancer of any kind?
[IF NEEDED, SAY: “Do not include family members related through marriage such as a stepfather or stepsister, or family members who were adopted.”]
YES 1
NO 2 [GO TO NEXT SECTION]
REFUSED -7 [GO TO NEXT SECTION]
DON’T KNOW -8 [GO TO NEXT SECTION]
QA11_E2 What kind of cancer or cancers were these?
[CODE ALL THAT APPLY]
[PROBE: “Any others?”]
BLADDER 1
BLOOD 2
BONE 3
BRAIN 4
BREAST 5
CERVIX 6
COLON 7
ESOPHAGUS 8
GALLBLADDER 9
KIDNEY 10
LARYNX-WINDPIPE 11
LEUKEMIA 12
LIVER 13
LUNG 14
LYMPHOMA 15
MOUTH/TONGUE/LIP 16
OVARY 17
PANCREAS 18
PROSTATE 19
RECTUM 20
SKIN 21
SOFT TISSUE (MUSCLE OR FAT) 24
STOMACH 25
TESTIS 26
THROAT-PHARYNX 27
THYROID 28
UTERUS 29
OTHER 91
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_E3:
IF QA11_E2 = 21 (SKIN CANCER) THEN CONTINUE WITH QA11_E3;
ELSE SKIP TO PROGRAMMING NOTE QA11_E4
QA11_E3 Was the skin cancer you mentioned non-melanoma, melanoma, or an unknown type?
[CODE ALL THAT APPLY]
[PROBE: “Any others?”]
Non-melanoma 1
Melanoma 2
Unknown type 3
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_E4:
IF FEMALE AND QA11_E2 = 5 (BREAST CANCER), THEN CONTINUE WITH QA11_E4;
ELSE SKIP TO PROGRAMMING NOTE QA11_E7
QA11_E4 Was your mother ever diagnosed with breast cancer?
YES 1
NO 2
REFUSED -7
DON’T KNOW -8
QA11_E5 Do you have any sisters who have ever been diagnosed with breast cancer?
YES 1
NO 2 [GO TO PN QA11_E7]
REFUSED -7 [GO TO PN QA11_E7]
DON’T KNOW -8 [GO TO PN QA11_E7]
QA11_E6 How many sisters have been diagnosed with breast cancer?
________ NUMBER OF SISTERS WITH BREAST CANCER
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_E7:
IF QA11_E2 = 7 (COLON CANCER) OR 20 (RECTAL CANCER), THEN CONTINUE WITH QA11_E7;
ELSE SKIP TO NEXT SECTION
QA11_E7 Who was diagnosed with colon or rectal cancer?
[IF NEEDED, SAY: “Do NOT include STEP or HALF brothers and sisters.”]
[CODE ALL THAT APPLY]
[PROBE: “Any others?”]
Mother 1
Father 2
Full brother 3
Full sister 4
Biological son 5
Biological daughter 6
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_E8:
IF QA11_E7 = (3, 4, 5, OR 6) THEN CONTINUE WITH QA11_E8
IF QA11_E7 = 3, THEN DISPLAY “brothers”;
IF QA11_E7 = 4, THEN DISPLAY “sisters”;
IF QA11_E7 = 5, THEN DISPLAY “sons”;
IF QA11_E7= 6, THEN DISPLAY “daughters”;
ELSE SKIP TO NEXT SECTION
QA11_E8 How many {brothers/sisters/sons/daughters} were diagnosed with colon or rectal cancer?
________ NUMBER OF FAMILY MEMBERS WITH COLON OR RECTAL CANCER
REFUSED -7
DON’T KNOW -8
MODULE G – DEMOGRAPHICS, PART I
QA11_G1 What is your date of birth?
MONTH _______
1. JANUARY 7. JULY
2. FEBRUARY 8. AUGUST
3. MARCH 9. SEPTEMBER
4. APRIL 10. OCTOBER
5. MAY 11. NOVEMBER
6. JUNE 12. DECEMBER
DAY _______ YEAR ______
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE FOR QA11_G2:
IF QA11_G1 = -7 OR -8, CONTINUE WITH QA11_G2;
ELSE GO TO QA11_G5
QA11_G2 What month and year were you born?
MONTH _______
1. JANUARY 7. JULY
2. FEBRUARY 8. AUGUST
3. MARCH 9. SEPTEMBER
4. APRIL 10. OCTOBER
5. MAY 11. NOVEMBER
6. JUNE 12. DECEMBER
YEAR ______
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE FOR QA11_G3:
IF QA11_G2 = -7 OR -8 THEN CONTINUE WITH QA11_G3;
ELSE GO TO QA11_G5
QA11_G3 What is your age, please?
_____YEARS OF AGE [GO TO QA11_G5]
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE FOR QA11_G4:
IF QA11_G3 = -7 OR -8 THEN CONTINUE WITH QA11_G4;
ELSE GO TO QA11_G5
QA11_G4 Are you between 18 and 29, between 30 and 39, between 40 and 44, between 45 and 49, between 50 and 64, or 65 or older?
BETWEEN 18 AND 29 1
BETWEEN 30 AND 39 2
BETWEEN 40 AND 44 3
BETWEEN 45 AND 49 4
BETWEEN 50 AND 64 5
65 OR OLDER 6
REFUSED -7
DON'T KNOW -8
QA11_G5 Are you male or female?
MALE 1
FEMALE 2
REFUSED -7
DON'T KNOW -8
Ethnicity
QA11_G6 Are you Latino or Hispanic?
YES 1
NO 2 [GO TO QA11_G8]
REFUSED -7 [GO TO QA11_G8]
DON'T KNOW -8 [GO TO QA11_G8]
QA11_G7 And what is your Latino or Hispanic ancestry or origin? Such as Mexican, Salvadoran, Cuban, Honduran -- and if you have more than one, tell me all of them.
[IF NECESSARY, GIVE MORE EXAMPLES]
[CODE ALL THAT APPLY]
MEXICAN/MEXICAN AMERICAN/CHICANO 1
SALVADORAN 4
GUATEMALAN 5
COSTA RICAN 6
HONDURAN 7
NICARAGUAN 8
PANAMANIAN 9
PUERTO RICAN 10
CUBAN 11
SPANISH-AMERICAN (FROM SPAIN) 12
OTHER LATINO (SPECIFY: ____________) 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_G8:
IF QA11_G6 = 1 (YES, LATINO/HISPANIC) DISPLAY “You said you are Latino or Hispanic. Also,”;
IF MORE THAN ONE RACE GIVEN AFTER ENTERING RESPONSES FOR QA11_G8 CONTINUE WITH PROGRAMMING NOTE QA11_G9;
ELSE FOLLOW SKIPS AS INDICATED FOR SINGLE RESPONSES
Race
QA11_G8 {You said you are Latino or Hispanic. Also,} please tell me which one or more of the following you would use to describe yourself. Would you describe yourself as Native Hawaiian, Other Pacific Islander, American Indian, Alaska Native, Asian, Black, African American, or White?
[IF R SAYS “NATIVE AMERICAN” CODE AS “4”]
[IF R GIVES ANOTHER RESPONSE YOU MUST SPECIFY WHAT IT IS]
[CODE ALL THAT APPLY]
WHITE 1 [GO TO PN QA11_G16]
BLACK OR AFRICAN AMERICAN 2 [GO TO PN QA11_G16]
ASIAN 3 [GO TO PN QA11_G12]
AMERICAN INDIAN OR ALASKA NATIVE 4 [GO TO PN QA11_G9]
OTHER PACIFIC ISLANDER 5 [GO TO PN QA11_G13]
NATIVE HAWAIIAN 6 [GO TO PN QA11_G16]
OTHER (SPECIFY: _________________) 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE FOR QA11_G9:
IF QA11_G8 = 4 (AMERICAN INDIAN OR ALASKA NATIVE), CONTINUE WITH QA11_G9;
ELSE GO TO PROGRAMMING NOTE QA11_G12;
QA11_G9 You said American Indian or Alaska Native - and what is your tribal heritage? If you have more than one tribe, tell me all of them.
[CODE ALL THAT APPLY]
APACHE 1
BLACKFOOT/BLACKFEET 2
CHEROKEE 3
CHOCTAW 4
MEXICAN AMERICAN INDIAN 5
NAVAJO 6
POMO 7
PUEBLO 8
SIOUX 9
YAQUI 10
OTHER TRIBE (SPECIFY):_____________ 91
REFUSED -7
DON'T KNOW -8
QA11_G10 Are you an enrolled member in a federally or state recognized tribe?
YES 1
NO 2 [GO TO QA11_G12]
REFUSED -7 [GO TO QA11_G12]
DON'T KNOW -8 [GO TO QA11_G12]
QA11_G11 Which tribe are you enrolled in?
APACHE
MESCALERO APACHE, NM 1
APACHE (NOT SPECIFIED) 2
OTHER APACHE [Ask for spelling] (SPECIFY): 3
BLACKFEET
BLACKFOOT/BLACKFEET 4
CHEROKEE
WESTERN CHEROKEE 5
CHEROKEE (NOT SPECIFIED) 6
OTHER CHEROKEE [Ask for spelling] (SPECIFY) 7
CHOCTAW
CHOCTAW OKLAHOMA 8
CHOCTAW (NOT SPECIFIED) 9
OTHER CHOCTAW [Ask for spelling] (SPECIFY): 10
NAVAJO
NAVAJO (NOT SPECIFIED) 11
POMO
HOPLAND BAND, HOPLAND RANCHERIA 12
SHERWOOD VALLEY RANCHERIA 13
POMO (NOT SPECIFIED) 14
OTHER POMO [Ask for spelling] (SPECIFY): 15
PUEBLO
HOPI 16
YSLETA DEL SUR PUEBLO OF TEXAS 17
PUEBLO (NOT SPECIFIED) 18
OTHER PUEBLO [Ask for spelling] (SPECIFY): 19
SIOUX
OGLALA/PINE RIDGE SIOUX 20
SIOUX (NOT SPECIFIED) 21
OTHER SIOUX [Ask for spelling] (SPECIFY): 22
YAQUI
PASCUA YAQUI TRIBE OF ARIZONA 23
YAQUI (NOT SPECIFIED) 24
OTHER YAQUI [Ask for spelling] (SPECIFY): 25
OTHER
OTHER [Ask for spelling] (SPECIFY: _______) 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_G12:
IF QA11_G8 = 3 (ASIAN) CONTINUE WITH QA11_G12;
ELSE GO TO PROGRAMMING NOTE QA11_G13;
QA11_G12 You said Asian, and what specific ethnic group are you, such as Chinese, Filipino, Vietnamese? If you are more than one, tell me all of them.
[CODE ALL THAT APPLY]
BANGLADESHI 1
BURMESE 2
CAMBODIAN 3
CHINESE 4
FILIPINO 5
HMONG 6
INDIAN (INDIA) 7
INDONESIAN 8
JAPANESE 9
KOREAN 10
LAOTIAN 11
MALAYSIAN 12
PAKISTANI 13
SRI LANKAN 14
TAIWANESE 15
THAI 16
VIETNAMESE 17
OTHER ASIAN (SPECIFY): _________________ 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_G13:
IF QA11_G8 = 5 (OTHER PACIFIC ISLANDER), CONTINUE WITH QA11_G13;
ELSE GO TO PROGRAMMING NOTE QA11_G14;
QA11_G13 You said you are Pacific Islander. What specific ethnic group are you, such as Samoan, Tongan, or Guamanian? If you are more than one, tell me all of them.
[CODE ALL THAT APPLY]
SAMOAN/AMERICAN SAMOAN 1
GUAMANIAN 2
TONGAN 3
FIJIAN 4
OTHER PACIFIC ISLANDER (SPECIFY): _______ 91
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE FOR QA11_G14:
IF QA11_G6 = 1 (LATINO) AND [QA11_G8 = 6 (NATIVE HAWAIIAN) OR QA11_G8 = 5 (OTHER PACIFIC ISLANDER) OR QA11_G8 = 4 (AMERICAN INDIAN OR ALASKA NATIVE) OR QA11_G8 = 3 (ASIAN) OR QA11_G8 = 2 (BLACK/AFRICAN AMERICAN) OR QA11_G8 = 1 (WHITE) OR QA11_G8 = 91 (OTHER)], CONTINUE WITH QA11_G14;
ELSE IF THERE WERE MULTIPLE RESPONSES TO QA11_G8, QA11_G12, OR QA11_G13 (NOT COUNTING -7 OR -8), CONTINUE WITH QA11_G14;
ELSE SKIP TO QA11_G16;
QA11_G14 You said that you are: {INSERT MULTIPLE RESPONSES QA11_G7, QA11_G8, QA11_G12 AND QA11_G13}.
Do you identify with any one race in particular?
YES 1
NO 2 [GO TO QA11_G16]
REFUSED -7 [GO TO QA11_G16]
DON'T KNOW - 8 [GO TO QA11_G16]
PROGRAMMING NOTE FOR QA11_G15:
IF QA11_G6 = 1 (YES, LATINO) AND QA11_G7 ≠ -7 or -8, DO NOT DISPLAY QA11_G15 = 14 (LATINO);
IF QA11_G8 = 1 (YES, OTHER PACIFIC ISLANDER) AND QA11_G13 = 1 to 4 OR 91, DO NOT DISPLAY QA11_G15 = 17 (OTHER PACIFIC ISLANDER);
IF QA11_G8 = 3 AND QA11_G12 = 1 TO 17 OR 91, DO NOT DISPLAY QA11_G15 = 19 (ASIAN);
QA11_G15 Which do you most identify with?
[IF R UNABLE TO CHOOSE ONE, OFFER “BOTH/ALL/MULTIRACIAL”]
MEXICAN/MEXICANO 1
MEXICAN AMERICAN 2
CHICANO 3
SALVADORAN 4
GUATEMALAN 5
COSTA RICAN 6
HONDURAN 7
NICARAGUAN 8
PANAMANIAN 9
PUERTO RICAN 10
CUBAN 11
SPANISH-AMERICAN (FROM SPAIN) 12
LATINO, OTHER SPECIFY 13
LATINO 14
NATIVE HAWAIIAN 16
OTHER PACIFIC ISLANDER 17
AMERICAN INDIAN OR ALASKA NATIVE 18
ASIAN 19
BLACK OR AFRICAN AMERICAN 20
WHITE 21
RACE, OTHER SPECIFY 22
BANGLADESHI 30
BURMESE 31
CAMBODIAN 32
CHINESE 33
FILIPINO 34
HMONG 35
INDIAN (INDIA) 36
INDONESIAN 37
JAPANESE 38
KOREAN 39
LAOTIAN 40
MALAYSIAN 41
PAKISTANI 42
SRI LANKAN 43
TAIWANESE 44
THAI 45
VIETNAMESE 46
ASIAN, OTHER SPECIFY 49
SAMOAN/AMERICAN SAMOAN 50
GUAMANIAN 51
TONGAN 52
FIJIAN 53
PACIFIC ISLANDER, OTHER SPECIFY 55
BOTH/ALL/MULTIRACIAL 90
NONE OF THESE 95
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE FOR QA11_G16:
IF AGE < 18, THEN GO TO NEXT SECTION;
ELSE CONTINUE WITH QA11_G16;
QA11_G16 Are you now married, living with a partner in a marriage-like relationship, widowed, divorced, separated, or never married?
[IF R MENTIONS MORE THAN ONE, CODE THE LOWEST NUMBER THAT APPLIES]
MARRIED 1
LIVING WITH PARTNER 2
WIDOWED 3
DIVORCED 4
SEPARATED 5
NEVER MARRIED 6
REFUSED -7
DON'T KNOW -8
MODULE H – DEMOGRAPHICS, PART II
PROGRAMMING NOTE FOR QA11_H1:
IF AGE < 18, GO TO QA11_H4;
ELSE CONTINUE WITH QA11_H1
QA11_H1 Now a few more questions about you.
In what country were you born?
[SELECT FROM MOST LIKELY COUNTRIES]
UNITED STATES… 1
AMERICAN SAMOA 2
CANADA 3
CHINA 4
EL SALVADOR 5
ENGLAND 6
FRANCE 7
GERMANY 8
GUAM 9
GUATEMALA 10
HUNGARY 11
INDIA 12
IRAN 13
IRELAND 14
ITALY 15
JAPAN 16
KOREA 17
MEXICO 18
PHILIPPINES 19
POLAND 20
PORTUGAL 21
PUERTO RICO 22
RUSSIA 23
TAIWAN 24
VIETNAM 25
VIRGIN ISLANDS 26
OTHER (SPECIFY):_______________ 91
REFUSED -7
DON'T KNOW -8
QA11_H2 In what country was your mother born?
[SELECT FROM MOST LIKELY COUNTRIES]
[FOR RESPONDENTS WHO WERE ADOPTED, QUESTION REFERS
TO ADOPTIVE PARENTS]
UNITED STATES… 1
AMERICAN SAMOA 2
CANADA 3
CHINA 4
EL SALVADOR 5
ENGLAND 6
FRANCE 7
GERMANY 8
GUAM 9
GUATEMALA 10
HUNGARY 11
INDIA 12
IRAN 13
IRELAND 14
ITALY 15
JAPAN 16
KOREA 17
MEXICO 18
PHILIPPINES 19
POLAND 20
PORTUGAL 21
PUERTO RICO 22
RUSSIA 23
TAIWAN 24
VIETNAM 25
VIRGIN ISLANDS 26
OTHER (SPECIFY):_______________ 91
REFUSED -7
DON'T KNOW -8
QA11_H3 In what country was your father born?
[SELECT FROM MOST LIKELY COUNTRIES]
[FOR RESPONDENTS WHO WERE ADOPTED, QUESTION REFERS
TO ADOPTIVE PARENTS]
UNITED STATES… 1
AMERICAN SAMOA 2
CANADA 3
CHINA 4
EL SALVADOR 5
ENGLAND 6
FRANCE 7
GERMANY 8
GUAM 9
GUATEMALA 10
HUNGARY 11
INDIA 12
IRAN 13
IRELAND 14
ITALY 15
JAPAN 16
KOREA 17
MEXICO 18
PHILIPPINES 19
POLAND 20
PORTUGAL 21
PUERTO RICO 22
RUSSIA 23
TAIWAN 24
VIETNAM 25
VIRGIN ISLANDS 26
OTHER (SPECIFY):_______________ 91
REFUSED -7
DON'T KNOW -8
Language Spoken at Home
QA11_H4 What languages do you speak at home?
[CODE ALL THAT APPLY. ALSO PROBE, "Any others?"]
ENGLISH 1
SPANISH 2
CANTONESE 3
VIETNAMESE 4
TAGALOG 5
MANDARIN 6
KOREAN 7
ASIAN INDIAN LANGUAGES 8
RUSSIAN 9
OTHER 1 (SPECIFY: ____________) 91
OTHER 2 (SPECIFY:____________) 92
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_H5 AND QA11_H6:
IF AGE < 18, GO TO QA11_H32;
ELSE IF INTERVIEW NOT CONDUCTED IN ENGLISH, CONTINUE WITH QA11_H5;
ELSE IF INTERVIEW CONDUCTED IN ENGLISH AND QA11_H4 > 1 (SPEAKS LANGUAGE OTHER THAN ENGLISH AT HOME), CONTINUE WITH QA11_H5 AND DISPLAY: “Since you speak a language other than English at home, we are interested in the languages you use in other situations”;
ELSE IF QA11_H4 = 1 ONLY (ENGLISH IS ONLY LANGUAGE SPOKEN AT HOME), GO TO QA11_H8
QA11_H5 {Since you speak a language other than English at home, we are interested in the languages you use in other situations.} What language do you speak with your friends?
oNLY ENGLISH 1
Both ENGLISH AND OTHER LANGUAGE(s) 2
oNLY OTHER lANGUAGE(s) 3
REFUSED -7
DON’T KNOW -8
QA11_H6 In what languages are the TV shows, radio stations, or newspapers that you usually watch, listen
or read?
oNLY ENGLISH 1
Both ENGLISH AND OTHER LANGUAGE(s) 2
oNLY OTHER lANGUAGE(s) 3
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_H7:
IF INTERVIEW CONDUCTED IN ENGLISH AND QA11_H4 > 1 (SPEAKS LANGUAGE OTHER THAN ENGLISH AT HOME), CONTINUE WITH QA11_H7 AND DISPLAY: “Since you speak a language other than English at home, we are interested in your own opinion of how well you speak English” AND DROP RESPONSE CATEGORY “Not at all?”;
ELSE IF INTERVIEW NOT CONDUCTED IN ENGLISH, CONTINUE WITH QA11_H7;
ELSE GO TO PROGRAMMING NOTE QA11_H8
QA11_H7 {Since you speak a language other than English at home, we are interested in your own opinion of how well you speak English.} Would you say you speak English…
Very well, 1
Well, 2
Not well, or 3
Not at all? 4
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_H8:
IF QA11_H1 = 1 (USA) OR 2 (AMERICAN SAMOA) OR 9 (GUAM) OR 22 (PUERTO RICO) OR 26 (VIRGIN ISLANDS), GO TO QA11_H11;
ELSE CONTINUE WITH QA11_H8;
Citizenship and Immigration
QA11_H8 The next questions are about citizenship and immigration.
Are you a citizen of the United States?
YES 1 [GO TO QA11_H10]
NO 2
APPLICATION PENDING 3
REFUSED -7
DON'T KNOW -8
QA11_H9 Are you a permanent resident with a green card? Your answers are confidential and will not be reported to Immigration Services.
[IF NEEDED SAY, “People usually call this a "Green Card" but the color can also be pink, blue, or white."]
YES 1
NO 2
APPLICATION PENDING 3
REFUSED -7
DON'T KNOW -8
QA11_H10 About how many years have you lived in the United States?
[FOR LESS THAN A YEAR, ENTER 1 YEAR]
_____ NUMBER OF YEARS
_____ YEAR (FIRST CAME TO LIVE IN U.S.)
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_H11:
IF QA11_G16 =1 (MARRIED) CONTINUE WITH QA11_H11;
IF QA11_G16 = 2 (LIVING WITH PARTNER), GO TO QA11_H12;
ELSE GO TO PROGRAMMING NOTE QA11_H13;
QA11_H11 Is your spouse also living in your household?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA11_H12 May I have your {spouse/partner}’s first name and age?
[ENTER SPOUSE’S/PARTNER’S NAME, AGE, AND SEX]
SPOUSE/PARTNER NAME ________________________________
SPOUSE/PARTNER AGE __________________________________
SPOUSE/PARTNER SEX __________________________________
PROGRAMMING NOTE QA11_H13:
IF AGE < 30 OR QA11_G4 = 1 (AGE 18-29) AND QA11_G16 = 1 (MARRIED) AND QA11_H11 =1 (SPOUSE LIVING IN HH) AND 3 OR MORE ADULTS LIVE IN HH, CONTINUE WITH QA11_H13;
IF AGE < 30 OR QA11_G4 =1 (AGE 18-29) AND QA11_G16 = 2 (LIVING WITH PARTNER) AND 3 OR MORE ADULTS LIVING IN HH, CONTINUE WITH QA11_H13;
IF AGE < 30 OR QA11_G4 =1 (AGE 18-29) AND QA11_G16 = 3, 4, 5, 6, –7, OR -8 (WIDOWED, DIVORCED, SEPARATED, NEVER MARRIED, REF, OR DK) AND 2 OR MORE ADULTS LIVING IN HH, CONTINUE WITH QA11_H13;
ELSE GO TO QA11_H14;
QA11_H13 Are you now living with either of your parents?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_H14;
IF COMPLETED CHILD 1ST INTERVIEW, SKIP TO QA11_H20;
ELSE CONTINUE WITH QA11_H14;
Child and Teen Selection
QA11_H14 Are there any children under the age of 18 living in the household, including babies?
YES 1
NO 2 [GO TO QA11_H22]
REFUSED -7 [GO TO QA11_H22]
DON'T KNOW -8 [GO TO QA11_H22]
QA11_H15 Please tell me only the first names and ages of all the children under 18, including babies, who normally live in your household.
[INTERVIEWER NOTE: PROBE,“Is there anyone else?” ALSO, ENTER AGE OF 0 (ZERO), IF LESS THAN 1 YEAR OLD]
CHILD
FIRST NAME
AGE
M/F
1
2
3
4
5
QA11_H16 Is (CHILD) …
0 To 11 years old 1 [CODE AS CHILD]
12 To 17 years old 2 [CODE AS TEEN]
REFUSED -7 [CODE AS TEEN]
DON'T KNOW -8 [CODE AS TEEN]
QA11_H17 I have recorded {number} {child/children} under 18 in the household. Have I missed any children under 18 who usually live here but are temporarily away?
NO ONE MISSED -- ROSTER IS CORRECT 1
RETURN TO ROSTER 2 [BACK TO QA11_H15]
PROGRAMMING NOTE QA11_H18:
IF ANY PEOPLE IN HH UNDER 18, ASK ABOUT EACH PERSON UNDER 18
QA11_H18 Are you the parent or legal guardian of {PERSON NAME/AGE/SEX}?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_H19:
IF ANY PEOPLE IN HH UNDER AGE 18 AND [QA11_H11 = 1 OR QA11_G16 = 2], ASK QA11_H19 ABOUT THE SPOUSE/PARTNER AND EACH PERSON UNDER 18;
ELSE SKIP TO QA11_H20;
QA11_H19 Is (NAME/AGE/SEX) the parent or legal guardian of (PERSON NAME/AGE/SEX}?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_H20:
IF QA11_H14 = 1 (YES, CHILDREN UNDER 18 IN HH) AND ANY CHILDREN IN QA11_H15 ARE AGE 13 OR LESS, CONTINUE WITH QA11_H20;
ELSE GO TO QA11_H22;
IF ANY CHILD IN ROSTER QA11_H15 < 14 AND ≥ 14 DISPLAY “for any children under age 14”;
IF QA11_G16 = 1 (MARRIED) AND QA11_G11 =1 (SPOUSE LIVING IN HH), DISPLAY “you or your spouse”;
IF QA11_G16 = 2 (LIVING WITH PARTNER), DISPLAY “you or your partner”;
ELSE DISPLAY “you”
QA11_H20 In the past month, did you use any paid childcare {for any children under age 14} while {you or your spouse/partner/you} worked, were in school, or looked for work?
[IF NEEDED, SAY: “This includes Head Start, day care centers, before- or after-school care programs, and any baby-sitting arrangements.”]
YES 1
NO 2 [GO TO QA11_H22]
REFUSED -7 [GO TO QA11_H22]
DON'T KNOW -8 [GO TO QA11_H22]
QA11_H21 In the past month, how much did you pay for all child care arrangements and programs?
[IF NEEDED, SAY: “If it is easier for you, you can tell me what you paid in a typical week last month. You or any other adult in your household.”]
$_______________ AMOUNT LAST MONTH [HR: 0-8,000]
$_______________ AMOUNT IN TYPICAL WEEK [HR: 0-3,000]
NO PAYMENT IN LAST MONTH OR WEEK 3
REFUSED -7
DON'T KNOW -8
QA11_H22 What is the highest grade of education you have completed and received credit for?
NO FORMAL EDUCATION 30
GRADE SCHOOL
1ST GRADE 1
2ND GRADE 2
3RD GRADE 3
4TH GRADE 4
5TH GRADE 5
6TH GRADE 6
7TH GRADE 7
8TH GRADE 8
HIGH SCHOOL OR EQUIVALENT
9TH GRADE 9
10TH GRADE 10
11TH GRADE 11
12TH GRAD 12
4-YEAR COLLEGE OR UNIVERSITY
1ST YEAR (FRESHMAN) 13
2ND YEAR (SOPHOMORE) 14
3RD YEAR (JUNIOR) 15
4TH YEAR (SENIOR) (BA/BS) 16
5TH YEAR 17
GRADUATE OR PROFESSIONAL SCHOOL
1ST YEAR GRAD OR PROF SCHOOL 18
2ND YEAR GRAD OR PROF SCHOOL (MA/MS) 19
3RD YEAR GRAD OR PROF SCHOOL 20
MORE THAN 3 YEARS GRAD OR
PROF SCHOOL (PhD) 21
2-YEAR JUNIOR OR COMMUNITY COLLEGE
1ST YEAR 22
2ND YEAR (AA/AS) 23
VOCATIONAL, BUSINESS, OR TRADE SCHOOL
1ST YEAR 24
2ND YEAR 25
MORE THAN 2 YEARS 26
REFUSED -7
DON'T KNOW (OUT OF RANGE) -8
QA11_H23 Which of the following were you doing last week?
Working at a job or business 1 [GO TO QA11_H27]
With a job or business but not at work 2
Looking for work 3
Not working at a job or business 4
REFUSED -7 [GO TO QA11_H27]
DON'T KNOW -8 [GO TO QA11_H27]
QA11_H24 What is the main reason you did not work last week?
[IF NEEDED SAY, “Main reason is the most important reason.”]
TAKING CARE OF HOUSE OR FAMILY 1
ON PLANNED VACATION 2
COULDN'T FIND A JOB 3
GOING TO SCHOOL/STUDENT 4
RETIRED 5 [GO TO PN QA11_H26]
DISABLED 6 [GO TO PN QA11_H26]
UNABLE TO WORK TEMPORARILY 7
ON LAYOFF OR STRIKE 8
ON FAMILY OR MATERNITY LEAVE 9
OFF SEASON 10
OTHER 91
REFUSED -7
DON'T KNOW -8
QA11_H25 Do you usually work?
YES 1
NO 2
LOOKING FOR WORK 3
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_H26;
IF AGE = -7 OR -8 OR AGE < 65 AND QA11_H25 = 2 (NO) CONTINUE WITH QA11_H26;
IF AGE = -7 OR -8 OR AGE < 65 AND QA11_H24 = 5 (RETIRED) or 6 (DISABLED) CONTINUE
WITH QA11_H26;
ELSE GO TO PROGRAMMING NOTE QA11_H27;
QA11_H26 Are you receiving Social Security Disability Insurance or SSDI?
YES 1 [GO TO PN QA11_H28]
NO 2 [GO TO PN QA11_H28]
REFUSED -7 [GO TO PN QA11_H28]
DON'T KNOW -8 [GO TO PN QA11_H28]
PROGRAMMING NOTE QA11_H27:
ELSE IF (QA11_H23 = 1, 2, -7, OR -8) OR (QA11_H25 = 1), CONTINUE WITH QA11_H27;
ELSE GO TO PROGRAMMING NOTE QA11_H28;
QA11_H27 On your main job, are you employed by a private company, the government, or are you self-employed, or are you working without pay in a family business or farm?
[IF NEEDED SAY, “Where did you work most hours?”]
PRIVATE COMPANY,
NON-PROFIT ORGANIZATION, FOUNDATION 1
GOVERNMENT 2
SELF-EMPLOYED 3
FAMILY BUSINESS OR FARM 4
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_H28;
IF QA11_ G16 = 1 (MARRIED), CONTINUE WITH QA11_H28;
ELSE GO TO NEXT SECTION;
QA11_H28 Which of the following was your spouse doing last week?
Working at a job or business 1 [GO TO QA11_H30]
With a job or business but not at work 2 [GO TO QA11_H30]
Looking for work 3
Not working at a job/business 4
REFUSED -7
DON'T KNOW -8
QA11_H29 Does your spouse usually work?
YES 1
NO 2 [GO TO NEXT SECTION]
LOOKING FOR WORK 3 [GO TO NEXT SECTION]
REFUSED -7 [GO TO NEXT SECTION]
DON'T KNOW -8 [GO TO NEXT SECTION]
QA11_H30 On your spouse’s main job, is he/she employed by a private company, the government, or is he/she self-employed, or is he/she working without pay in a family business or farm?
[IF NEEDED SAY, “Where did he/she work most hours?”]
PRIVATE COMPANY,
NON-PROFIT ORGANIZATION, FOUNDATION 1
GOVERNMENT 2
SELF-EMPLOYED 3
FAMILY BUSINESS OR FARM 4
REFUSED -7
DON'T KNOW -8
QA11_H31 Do you own or rent your home?
OWN 1
RENT 2
OTHER ARRANGEMENT 3
REFUSED -7
DON’T KNOW -8
QT11_H32 Did you attend school last week?
YES 1 [GO TO QT11_H34]
NO 2
ON VACATION 3
HOME SCHOOLED 4 [GO TO NEXT SECTION]
REFUSED -7
DON’T KNOW -8
QT11_H33 Did you attend school during the last school year?
YES 1
NO 2 [GO TO NEXT SECTION]
HOME SCHOOLED LAST YEAR 3 [GO TO NEXT SECTION]
REFUSED -7 [GO TO NEXT SECTION]
DON’T KNOW -8 [GO TO NEXT SECTION]
of School
QT11_H34 What is the name of the school you go to or last attended?
[IF NEEDED, ASK: “Is that an elementary, middle, junior high, or high school?”]
[RECORD VERBATIM]
NAME OF SCHOOL __________________________________
REFUSED -7
DON’T KNOW -8
____TYPE OF SCHOOL
TEEN NOT IN SCHOOL 0
ELEMENTARY 1
INTERMEDIATE 2
JUNIOR HIGH 3
MIDDLE SCHOOL 4
HIGH SCHOOL 5
SENIOR HIGH SCHOOL 6
CONTINUATION 7
CHARTER SCHOOL 8
OTHER (SPECIFY:____________) 91
REFUSED -7
DON’T KNOW -8
MODULE I – EMPLOYMENT, INCOME AND POVERTY
PROGRAMMING NOTE QA11_I1:
IF AGE < 18, GO TO NEXT SECTION;
ELSE IF QA11_H23 = 1 (WORKING AT JOB OR BUSINESS) OR 2 (WITH A JOB OR BUISNESS BUT NOT AT WORK) OR QA11_H25 = 1 (R USUALLY WORKS) CONTINUE WITH QA11_I1;
ELSE GO TO PROGRAMMING NOTE QA11_I5
QA11_I1 The next questions are about your employment.
How many hours per week do you usually work at all jobs or businesses?
[IF WORKS > 95 HOURS, ENTER 95. IF DOES NOT WORK, ENTER 0 (ZERO).]
_____ HOURS [HR: 0-95]
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_I2
IF QA11_I1 = 0 (NO HOURS WORKED), GO TO PROGRAMMING NOTE QA11_I5;
ELSE CONTINUE WITH QA11_I2 AND
IF QA11_H27 = 1 (PRIVATE COMPANY), DISPLAY “employed by a private company”;
IF QA11_H27 = 2 (GOVERNMENT), CODE QA11_I2 AS “GOVERNMENT” AND GO TO QA11_I3;
IF QA1_H27 = 3 (SELF-EMPLOYED), DISPLAY “self-employed”;
IF QA11_H27 = 4 (FAMILY BUSINESS OR FARM), DISPLAY “working without pay in a family business or farm”
QA11_I2 Earlier, you told me that on your main job, you are {employed by a private company/self-employed/ working without pay in a family business or farm}. What kind of business or industry is this?
[IF NEEDED, SAY: “What do they make or do at this business?”]
[ENTER DESCRIPTION]
_________________________ (BUSINESS OR INDUSTRY)
REFUSED -7
DON'T KNOW -8
QA11_I3 How long have you worked at your main job?
[IF NEEDED, SAY: “That is, for your current employer.”]
_____ MONTHS [HR: 0-12]
_____ YEARS [HR: 0-50]
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_I4:
IF QA11_H27 = 2 (GOVERNMENT EMPLOYEE), CODE QA11_I4 = 5 AND GO TO QA11_I5;
IF QA11_H27 = 3 (SELF-EMPLOYED), CONTINUE WITH QA11_I4 AND DISPLAY "Including yourself, about" AND “you”;
ELSE CONTINUE WITH QA11_I4 AND DISPLAY "About" AND “your employer”;
QA11_I4 {Including yourself, about/About} how many people are employed by {your employer/you} at all locations?
[IF NEEDED SAY, “Your best guess is fine.”]
1-2 1
3-9 2
10-24 3
25-50 4
51-100 5
101-200 6
201-999 7
1,000 OR MORE 8
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_I5:
QA11_H23 = 1 (WORKING AT JOB OR BUSINESS) OR 2 (WITH JOB OR BUSINESS BUT NOT AT WORK)] OR QA11_H25 = 1 (USUALLY WORKS), CONTINUE WITH QA11_I5;
ELSE SKIP TO PROGRAMMING NOTE QA11_I6
Income Last Month
QA11_I5 What is your best estimate of all your earnings last month before taxes and other deductions from all jobs and businesses, including hourly wages, salaries, tips and commissions?
[IF AMOUNT GREATER THAN $999,995, ENTER "999,995"]
$_____________ AMOUNT
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_I6;
IF QA11_H28 = [1 (SPOUSE WORKING AT JOB OR BUSINESS) OR 2 (SPOUSE WITH JOB OR BUSINESS BUT NOT AT WORK)] OR QA11_H29 = 1 (SPOUSE USUALLY WORKS), CONTINUE WITH QA11_I6 AND:
IF QA11_H23 ≠ 1 OR 2 (R NOT AT A JOB OR BUSINESS LAST WEEK, DID NOT WORK,
AND DOES NOT HAVE A JOB) AND QA11_H25 ≠ 1 (R DOES NOT USUALLY WORK),
DISPLAY “The next question is about your spouse’s employment.”
IF AR GENDER AND SPOUSE GENDER ARE BOTH KNOWN AND AR GENDER ≠ SP
GENDER THEN:
IF QA11_G5 = 1 (MALE) DISPLAY “wife”;
ELSE IF QA11_G5 = 2 (FEMALE) DISPLAY “husband”;
ELSE DISPLAY “spouse”;
ELSE SKIP TO QA11_I8
QA11_I6 {The next question is about your spouse’s employment.}
How many hours per week does your {husband/wife/spouse} usually work at all jobs or businesses?
[IF WORKS > 95 HOURS, ENTER 95. IF DOES NOT WORK, ENTER 0 (ZERO).]
_____ HOURS [HR: 0-95]
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_I7;
IF QA11_I6 > 0 CONTINUE WITH QA11_I7;
ELSE GO TO QA11_I8;
QA11_I7 What is your best estimate of all your spouse’s earnings last month before taxes and other deductions from all jobs and businesses, including hourly wages, salaries, tips and commissions?
[IF AMOUNT GREATER THAN $999,995, ENTER "999,995"]
$_______________ AMOUNT
REFUSED -7
DON'T KNOW -8
Income
QA11_I8 What is your best estimate of your household’s total annual income from all sources before taxes in 2010?
[IF NEEDED SAY, “Include money from jobs, social security, retirement income, unemployment payments, public assistance and so forth. Also include income from interest, dividends, net income from business, farm, or rent and any other money income.”]
[IF AMOUNT GREATER THAN $999,995, ENTER "999,995"]
$_______________ AMOUNT
REFUSED -7 [GO TO QA11_I10]
DON'T KNOW -8 [GO TO QA11_I10]
QA11_I9 I have entered that your annual household income is (AMOUNT). Is that correct?
YES 1 [GO TO QA11_I16]
NO 2 [GO BACK TO QA11_I8]
PROGAMMING NOTE QA11_I10:
IF QA11_I8 = -7 OR -8, CONTINUE WITH QA11_I10;
ELSE GO TO PROGRAMMING NOTE QA11_I16
QA11_I10 We don’t need to know exactly, but could you tell me if your household’s annual income from all sources before taxes is more than $20,000 per year or is it less?
MORE 1 [GO TO QA11_I12]
EQUAL TO $20K OR LESS 2
REFUSED -7 [GO TO QA11_I16]
DON'T KNOW -8 [GO TO QA11_I16]
QA11_I11 Is it …
$5,000 or less, or 1 [GO TO QA11_I16]
$5,001 to $10,000, or 2 [GO TO QA11_I16]
$10,001 to $15,000, or 3 [GO TO QA11_I16]
$15,001 to 20,000? 4 [GO TO QA11_I16]
REFUSED -7 [GO TO QA11_I16]
DON'T KNOW -8 [GO TO QA11_I16]
QA11_I12 Is it more or less than $70,000 per year?
MORE 1 [GO TO QA11_I14]
EQUAL TO $70K OR LESS 2
REFUSED -7 [GO TO QA11_I16]
DON'T KNOW -8 [GO TO QA11_I16]
QA11_I13 Is it …
$20,001 to $30,000, 1 [GO TO QA11_I16]
$30,001 to $40,000, 2 [GO TO QA11_I16]
$40,001 to $50,000, 3 [GO TO QA11_I16]
$50,001 to $60,000, or 4 [GO TO QA11_I16]
$60,001 to $70,000? 5 [GO TO QA11_I16]
REFUSED -7 [GO TO QA11_I16]
DON'T KNOW -8 [GO TO QA11_I16]
QA11_I14 Is it more or less than $135,000 per year?
MORE 1 [GO TO QA11_I16]
EQUAL TO $135K OR LESS 2
REFUSED -7 [GO TO QA11_I16]
DON'T KNOW -8 [GO TO QA11_I16]
QA11_I15 Is it …
$70,001 to $80,000, 1
$80,001 to $90,000, 2
$90,001 to $100,000, or 3
$100,001 to $135,000? 4
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_I16:
IF R IS ONLY MEMBER OF HH, GO TO PROGRAMMING NOTE QA11_I18;
ELSE CONTINUE WITH QA11_I16;
Number of persons supported
QA11_I16 Including yourself, how many people living in your household are supported by your total household income?
_____ NUMBER OF PEOPLE
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_I17:
QA11_I17 MUST BE LESS THAN QA11_I16
IF NO CHILDREN UNDER 18 IN HH (AS DETERMINED FROM CHILD ENUMERATION QUESTIONS) OR TOTAL NUMBER OF PEOPLE LIVING IN HH (AS DETERMINED BY ADULT PLUS CHILD ENUMERATION) = QA11_I16, GO TO PROGRAMMING NOTE QA11_I18;
ELSE CONTINUE WITH QA11_I17
QA11_I17 How many of these {INSERT NUMBER FROM QA11_I16} people are children under the age of 18?
_____ NUMBER OF CHILDREN (UNDER AGE 18)
REFUSED -7
DON'T KNOW -8
Poverty level test
PROGRAMMING NOTE QA11_I18:
OBTAIN THE FEDERAL POVERTY 100%, 130% 200%, AND 300% LEVEL CUTOFF POINTS FROM THE 2008 FEDERAL POVERTY GUIDELINE USING THE TOTAL HOUSEHOLD SIZE AND NUMBER OF CHILDREN FROM QA11_I16 AND QA11_I17 RESPECTIVELY.
(THE 200% AND 300% VALUES WERE DERIVED BY MULTIPLYING THE CENSUS POVERTY 2008 THRESHOLD "SIZE OF FAMILY UNIT" BY "RELATED CHILDREN UNDER 18 YEARS" TABLE AMOUNTS BY 2 AND 3, RESPECTIVELY, THEN ROUNDING TO THE NEAREST 100 DOLLARS. REFER TO SPECIFICATIONS ADDENDUM “Poverty Level 2008” DOCUMENT FOR THE TABLE OF VALUES. THE 100% POVERTY CUTOFF VALUE WILL BE STORED IN CATI VARIABLE POVRT100, THE 200% POVERTY CUTOFF VALUE WILL BE STORED IN CATI VARIABLE POVRT200 AND THE 300% VALUE IN CATI VARIABLE POVRT300).
IF EITHER QA11_I16 OR QA11_I17 IS MISSING, USE THE TOTAL NUMBER OF ADULTS ENUMERATED IN THE SCREENER (GIVEN BY CATI VARIABLE RADLTCNT) AND THE TOTAL NUMBER OF CHILDREN ENUMERATED AT QA11_H15 OF THE ADULT INTERVIEW (GIVEN BY CATI VARIABLE KIDCNT) INSTEAD.
ASCERTAIN IF THE HOUSEHOLD INCOME IS...
1) AT OR BELOW 100% FPL
2) ABOVE 100% FPL BUT AT OR BELOW 200% FPL
3) ABOVE 200% FPL BUT AT OR BELOW 300% FPL
4) ABOVE 300% FPL
5) UNKNOWN BECAUSE HOUSEHOLD INCOME WAS NOT GIVEN
IF QA11_I8= -7 OR -8 (REF/DK) AND IF THE HOUSEHOLD'S 100% CUTOFF VALUE FALLS WITHIN A RESPONSE FROM QA11_I11, QA11_I13, OR QA11_I15 OR QA11_I10 = -7 OR QA11_I12 = -7 OR QA11_I14 = -7, ASK QA11_I18 USING POVRT100 (THE 100% FPL CUTOFF DISPLAY AMOUNT);
ELSE GO TO PROGRAMMING NOTE QA11_I19
QA11_I18 I need to ask just one or two more questions about income.
Was your total annual household income before taxes less than or more than ${POVRT100}?
EQUAL TO OR LESS 1 [GO TO QA11_I22]
MORE 2
REFUSED -7 [GO TO QA11_I22]
DON'T KNOW -8 [GO TO QA11_I22]
PROGRAMMING NOTE QA11_I19:
IF QA11_I8 = -7 OR -8 (REF/DK) AND IF THE HOUSEHOLD'S 200% CUTOFF VALUE FALLS WITHIN A RESPONSE FROM QA11_I11, QA11_I13, OR QA11_I15 OR IF QA11_I10 = -7 OR QA11_I12 = -7 OR QA11_I14= -7, CONTINUE WITH QA11_I19 USING POVRT200 (200% POVERTY CUTOFF DISPLAY AMOUNT);
ELSE GO TO PROGRAMMING NOTE QA11_I21
QA11_I19 {I need to ask just one or two more questions about income} Was your total annual household income before taxes less than or more than ${POVRT200}?
EQUAL TO OR LESS 1
MORE 2 [GO TO QA11_I21]
REFUSED -7 [GO TO QA11_I22]
DON'T KNOW -8 [GO TO QA11_I22]
PROGRAMMING NOTE QA11_I20:
IF QA11_I19 = 1 (≤ 200% FPL), CONTINUE WITH QA11_I20 USING POVRT130 (130% POVERTY CUTOFF DISPLAY AMOUNT);
ELSE SKIP TO QA11_I21
QA11_I20 {I need to ask just one or two more questions about income} Was your total annual household income before taxes less than or more than ${POVRT130}?
EQUAL TO OR LESS 1 [GO TO QA11_I22]
MORE 2 [GO TO QA11_I22]
REFUSED -7 [GO TO QA11_I22]
DON'T KNOW -8 [GO TO QA11_I22]
PROGRAMMING NOTE QA11_I21:
IF QA11_I8 = -7 OR –8 (REF/DK) AND IF THE HOUSEHOLD'S 300% CUTOFF VALUE FALLS WITHIN A RESPONSE FROM QA11_I11, QA11_I13, OR QA11_I15 OR IF QA11_I10 = -7 OR QA11_I12= -7 OR QA11_I14 = -7, CONTINUE WITH QA11_I21 USING POVRT300 (300% POVERTY CUTOFF DISPLAY AMOUNT);
IF NEITHER QA11_I18 OR QA11_I19 WAS ASKED, DISPLAY “I need to ask just one or two more questions about income. Was your total annual household income before taxes”;
ELSE DISPLAY “Was it”;
ELSE GO TO QA11_I22;
QA11_I21 {I need to ask just one or two more questions about income} Was your total annual household income before taxes less than or more than ${POVRT300}?
EQUAL TO OR LESS 1
MORE 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_I22;
IF POVERTY < 3 (HH Income ≤ 200% FPL) OR 5 (HH INCOME NOT KNOWN), CONTINUE WITH QA11_I22;
ELSE GO TO NEXT SECTION
QA11_I22 These next questions are about the food eaten in your household in the last 12 months and whether you were able to afford food.
I'm going to read two statements that people have made about their food situation. For each,
please tell me whether the statement describes something that was often true, sometimes
true, or never true for you and your household in the last 12 months. The first statement is:
"The food that (I/we) bought just didn't last, and (I/we) didn't have money to get more."
Was that often true, sometimes true, or never true for you and your household in the last 12 months?
OFTEN TRUE 1
SOMETIMES TRUE 2
NEVER TRUE 3
REFUSED -7
DON'T KNOW -8
QA11_I23 The second statement is:
"(I/We) couldn't afford to eat balanced meals."
Was that often true, sometimes true, or never true for you and your household in the last 12 months?
OFTEN TRUE 1
SOMETIMES TRUE 2
NEVER TRUE 3
REFUSED -7
DON'T KNOW -8
QA11_I24 Please tell me yes or no. In the last 12 months, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?
YES 1
NO 2 [GO TO QA11_I26]
REFUSED -7 [GO TO QA11_I26]
DON'T KNOW -8 [GO TO QA11_I26]
QA11_I25 How often did this happen -- almost every month, some months but not every month, or only in 1 or 2 months?
ALMOST EVERY MONTH 1
SOME MONTHS BUT NOT EVERY MONTH 2
ONLY IN 1 OR 2 MONTHS 3
REFUSED -7
DON'T KNOW -8
QA11_I26 In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money to buy food?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA11_I27 In the last 12 months, were you ever hungry but didn't eat because you couldn't afford enough food?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
MODULE J – DEMOGRAPHICS, PART III AND CLOSING
County of Residence
PROGRAMMING NOTE QA11_J1;
IF AGE < 18, GO TO NEXT SECTION;
ELSE CONTINUE WITH QA11_J1
QA11 _J1 Just a few final questions and then we are done.
To be sure we are covering the entire state, what county do you live in?
ALAMEDA 1
ALPINE 2
AMADOR 3
BUTTE 4
CALAVERAS 5
COLUSA 6
CONTRA COSTA 7
DEL NORTE 8
EL DORADO 9
FRESNO 10
GLENN 11
HUMBOLDT 12
IMPERIAL 13
INYO 14
KERN 15
KINGS 16
LAKE 17
LASSEN 18
LOS ANGELES 19
MADERA 20
MARIN 21
MARIPOSA 22
MENDOCINO 23
MERCED 24
MODOC 25
MONO 26
MONTEREY 27
NAPA 28
NEVADA 29
ORANGE 30
PLACER 31
PLUMAS 32
RIVERSIDE 33
SACRAMENTO 34
SAN BENITO 35
SAN BERNARDINO 36
SAN DIEGO 37
SAN FRANCISCO 38
SAN JOAQUIN 39
SAN LUIS OBISPO 40
SAN MATEO 41
SANTA BARBARA 42
SANTA CLARA 43
SANTA CRUZ 44
SHASTA 45
SIERRA 46
SISKIYOU 47
SOLANO 48
SONOMA 49
STANISLAUS 50
SUTTER 51
TEHAMA 52
TRINITY 53
TULARE 54
TUOLUMNE 55
VENTURA 56
YOLO 57
YUBA 58
REFUSED -7
DON'T KNOW -8
Address confirmation, cross streets, zip code
PROGRAMMING NOTE QA11_J2:
IF ADVANCE LETTER SENT, CONTINUE WITH QA11_J2;
IF R’S ADDRESS IS A P.O. BOX, GO TO QA11_J3
ELSE GO TO QA11_J3;
QA11_J2 Your phone number was randomly selected for this study by a computer. We were able to match an address to your phone number to send a letter to your home explaining the purpose of this study. To help us better understand the environment you live in and how it may affect your health, we would like to confirm your address. This information will be kept confidential and will be destroyed after the entire survey has been completed.
Do you now live at {R’s address and street}?
YES 1 [GO TO QA11_J6]
NO 2
REFUSED -7
DON'T KNOW -8
QA11_J3 What is your zip code?
_________ (ZIP CODE)
REFUSED -7
DON'T KNOW -8
QA11_J4 To help us better understand the environment you live in and how it may affect your health, please tell me the address where you live. This information will be kept confidential and will be destroyed after the entire survey has been completed.
___________ HOUSE ADDRESS NUMBER
________ NAME OF STREET (VERIFY SPELLING) [GO TO QA11_J6]
________ STREET TYPE
________ APT. NO
REFUSED -7
DON'T KNOW -8
QA11_J5 Can you tell me just the name of the street you live on?
________ NAME OF STREET
REFUSED -7 [GO TO CLOSE1]
DON'T KNOW -8 [GO TO CLOSE1]
QA11_J6 And what is the name of the street down the corner from you that crosses your street?
________ NAME OF CROSS-STREET
REFUSED -7
DON'T KNOW -8l phone use
QA11_J7 Do you have a working cell phone?
[IF NEEDED, SAY: “I’m not going to ask you for the number.”]
YES 1
NO 2
SHARES CELL PHONE 3
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_J8:
IF QA11_J7 = 1 (YES) OR 3 (SHARES CELL PHONE), CONTINUE WITH QA11_J8;
ELSE SKIP TO QA11_J9;
QA11_J8 Of all the telephone calls that you receive, are...
All or almost all calls received on a cell phone 1
Some on cell phones & some on regular phones 2
Very few or none on cell phones 3
REFUSED -7
DON'T KNOW -8
Follow-up Survey Permission
QA11_J9 Finally, do you think you would be willing to do a follow-up to this survey some time in the future?
YES 1
MAYBE/PROBABLY YES 2
DEFINITELY NOT 3
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE CLOSE1 and CLOSE2:
IF ALL INTERVIEWS FOR HOUSEHOLD COMPLETE, SKIP TO CLOSE2;
ELSE CONTINUE WITH CLOSE1;
CLOSE1 Let me check to see if there is anyone else.
[GO TO HHSELECT]
CLOSE2 Thank you, I really appreciate your time and cooperation. You have helped with a very important health survey. If you have any questions about the study, please contact Dr. E. Richard Brown, the Principal Investigator. Dr. Brown can be reached toll-free at 1-866-275-2447. Thank you, and good-bye.
MODULE K – GENERAL HEALTH, HEALTH-RELATED QUALITY OF LIFE, AND SEXUAL HEALTH
Height and Weight
QA11_K1 These next questions are about your health.
Would you say that in general your health is excellent, very good, good, fair, or poor?
EXCELLENT 1
VERY GOOD 2
GOOD 3
FAIR 4
POOR 5
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_K2:
IF AGE < 18, CONTINUE WITH QA11_K2;
ELSE GO TO QA11_K4;
QA11_K2 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?
______ NUMBER OF DAYS
REFUSED -7
DON’T KNOW -8
QA11_K3 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?
______ NUMBER OF DAYS
REFUSED -7
DON’T KNOW -8
QA11_K4 These next questions are about your height and weight.
How tall are you without shoes?
[IF NEEDED SAY, “About how tall?”]
_____ FEET _____ INCHES
_____ METERS _____ CENTIMETERS
FEET/INCHES 1
METERS/CENTIMETERS 2
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_K5:
IF AGE < 18, GO TO QA11_K11;
ELSE IF QA11_G5 = 2 (FEMALE) and AGE < 50, DISPLAY "When not pregnant, how";
ELSE DISPLAY "How";
QA11_K5 {When not pregnant, how/How} much do you weigh without shoes?
[IF NEEDED SAY, “About how much?”]
_____ POUNDS
_____ KILOGRAMS
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_K6:
IF AGE > 70 OR QA11_G4 = 6 (65 OR OLDER) OR ENUM.AGE > 70 OR IF AGE IS UNKNOWN, GO TO QA11_K11;
ELSE CONTINUE WITH QA11_K6;
Sexual Partners, Sexual Orientation
QA11_K6 We are asking a few questions about people’s sexual experiences. All answers will be kept private.
In the past 12 months, how many sexual partners have you had?
_______ NUMBER OF SEXUAL PARTNERS [GO TO QA11_K8]
REFUSED -7 [GO TO QA11_K8]
DON'T KNOW -8
QA11_K7 Can you give me your best guess?
[IF R PROVIDES EXACT NUMBER, ENTER AS GIVEN. OTHERWISE CODE INTO CATEGORIES PROVIDED]
___ NUMBER OF PARTNERS
1 PARTNER 1
2-3 PARTNERS 2
4-5 PARTNERS 3
6-10 PARTNERS 4
MORE THAN 10 PARTNERS 5
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_K8:
IF QA11_K6 = 0 (NO SEXUAL PARTNERS IN LAST 12 MONTHS) OR QA11_K7=0, GO TO PROGRAMMING NOTE QA11_K9;
ELSE CONTINUE WITH QA11_K8;
IF QA11_K6 OR QA11_K7 = 1 (ONE PARTNER IN LAST 12 MONTHS), DISPLAY “Is that partner male or female”’
ELSE DISPLAY “In the past 12 months, have your sexual partners been male, female, or both male and female”
QA11_K8 {Is that partner male or female/In the past 12 months, have your sexual partners been male, female, or both male and female}?
MALE 1
FEMALE 2
BOTH MALE AND FEMALE 3
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_K9:
IF QA11_G5 = 1 (MALE), DISPLAY “Gay” in question and “Gay” IN HELP SCREEN;
ELSE IF QA11_G5 =2 (FEMALE), DISPLAY “Gay, Lesbian” in question and “Gay and Lesbian” IN HELP SCREEN
QA11_K9 Do you think of yourself as straight or heterosexual, as gay {lesbian} or homosexual, or bisexual?
[IF NEEDED SAY, “Straight or Heterosexual people have sex with, or are primarily attracted to people of the opposite sex, Gay {and Lesbian} people have sex with or are primarily attracted to people of the same sex, and Bisexuals have sex with or are attracted to people of both sexes.”]
STRAIGHT OR HETEROSEXUAL 1
GAY, LESBIAN, OR HOMOSEXUAL 2
BISEXUAL 3
NOT SEXUAL/ CELIBATE/ NONE 4
OTHER (SPECIFY)______________ 5
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_K10:
IF [QA11_H5 = 1 (MALE) AND QA11_K8 = 1 (MALE)] OR [QA11_G5 = 2 (FEMALE) AND QA11_K8 = 2 (FEMALE)] OR [QA11_K8 = 3, -7, OR -8] OR [IF QA11_K9 ≠ 1] CONTINUE WITH QA11_K10;
ELSE GO TO QA11_K11
QA11_K10 Are you legally registered as a domestic partner or legally married in California with someone of the same sex?
[ONLY INCLUDE SAME SEX MARRAIGES PERFORMED IN CALIFORNIA.]
[IF NEEDED, SAY: “Which one of these applies to you?”]
YES (DOMESTIC PARTNER) 4
YES (MARRIED IN CALIFORNIA) 5
NO 6
REFUSED -7
DON'T KNOW -8
QA11_K11 Is there a place that you usually go to when you are sick or need advice about your health?
[CIRCLE "3" OR "4" ONLY IF VOLUNTEERED. DO NOT PROBE.]
YES 1
NO 2 [GO TO QA11_K13]
DOCTOR/MY DOCTOR 3
KAISER 4
MORE THAN ONE PLACE 5
REFUSED -7 [GO TO QA11_K13]
DON'T KNOW -8 [GO TO QA11_K13]
PROGRAMMING NOTE QA11_K12:
IF QA11_K11 = 1 (YES) OR 5 (MORE THAN ONE PLACE) DISPLAY "What kind of place do you go to most often--a medical";
ELSE IF QA11_K11 = 3 (DOCTOR/MY DOCTOR), DISPLAY "Is your doctor in a private";
ELSE IF QA11_K11 = 4 (KAISER) CIRCLE “1” FOR QA11_K12 AND GO TO QA11_K13
QA11_K12 {What kind of place do you go to most often—a medical/Is your doctor in a private} doctor's office, a clinic or hospital clinic, an emergency room, or some other place?
DOCTOR'S OFFICE/KAISER/OTHER HMO 1
CLINIC/HEALTH CENTER/HOSPITAL CLINIC 2
EMERGENCY ROOM 3
SOME OTHER PLACE (SPECIFY:_________) 91
NO ONE PLACE 92
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_K13:
IF CHILD OR TEEN SELECTED OR SPOUSE IN HH, DISPLAY “Now, I’d like to ask about the health care YOU receive”;
ELSE BEGIN QUESTION WITH “During the past 12 months, how many times have you seen a medical doctor”
QA11_K13 {Now, I’d like to ask about the health care you receive.} During the past 12 months, how many times have you seen a medical doctor}?
_____ TIMES [HR: 0-365]
REFUSED -7
DON'T KNOW -8
MODULE L – EPILEPSY
PROGRAMMING NOTE QA11_L1:
IF AGE < 18, CONTINUE WITH QA11_L1;
ELSE GO TO NEXT SECTION;
QA11_L1 Has a doctor ever told you that you have seizure disorder or epilepsy?
[INTERVIEWER NOTE: IF R REPORTS THEIR MOTHER/FATHER/GUARDIAN TOLD THEM THEY HAVE SEIZURES OR EPILEPSY, CODE AS 1]
YES........................................................................ 1
NO.......................................................................... 2
REFUSED............................................................. -7
DON’T KNOW..................................................... -8
QA11_L2 Are you now taking any medicine to control your seizure disorder or epilepsy?
YES........................................................................ 1
NO.......................................................................... 2
REFUSED............................................................. -7
DON'T KNOW..................................................... -8
QA11_L3 How many seizures of any type have you had in the last three months?
[INTERVIEWER NOTE: IF R REPORTS ONLY HAVING “AURAS” AND NO SEIZURES, INSTRUCT R TO DISREGARD AURAS. IF R NORMALLY COUNTS “AURAS” AS SEIZURES, ACCEPT THE RESPONSE]
NO SEIZURE....................................................... 1
ONE SEISURE..................................................... 2
MORE THAN ONE SEISURE............................ 3
REFUSED........................................................... -7
DON'T KNOW.................................................... -8
MODULE M – MEDICAL HOME
PROGRAMMING NOTE QA11_M1:
IF R HAS ASTHMA THEN CONTINUE WITH QA11_M1;
ELSE GO TO PROGRAMMING NOTE QA11_M3
QA11_M1 Have your doctors or other medical providers worked with you to develop a plan so that you know how to take care of your asthma?
YES 1
NO 2 [GO TO PN QA11_M3]
REFUSED -7 [GO TO PN QA11_M3]
DON'T KNOW -8 [GO TO PN QA11_M3]
QA11_M2 Do you have a written or printed copy of this plan?
[IF NEEDED, SAY: “This can be an electronic or hard copy.”]
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_M3:
IF AGE < 18 GO TO QA11_M7;
ELSE IF R HAS DIABETES THEN CONTINUE WITH QA11_M3;
ELSE GO TO PROGRAMMING NOTE QA11_M5
QA11_M3 Have your doctors or other medical providers worked with you to develop a plan so that you know how to take care of your diabetes?
YES 1
NO 2 [GO TO PN QA11_M5]
REFUSED -7 [GO TO PN QA11_M5]
DON'T KNOW -8 [GO TO PN QA11_M5]
QA11_M4 Do you have a written or printed copy of this plan?
[IF NEEDED, SAY: “This can be an electronic or hard copy.”]
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_M5:
IF R HAS HEART DISEASE THEN CONTINUE WITH QA11_M5;
ELSE GO TO QA11_M7
QA11_M5 Have your doctors or other medical providers worked with you to develop a plan so that you know how to take care of your heart disease?
YES 1
NO 2 [GO TO QA11_M7]
REFUSED -7 [GO TO QA11_M7]
DON'T KNOW -8 [GO TO QA11_M7]
QA11_M6 Do you have a written or printed copy of this plan?
[IF NEEDED, SAY: “This can be an electronic or hard copy.”]
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA11_M7 The next topics are about health insurance and health care.
Is there a place that you usually go to when you are sick or need advice about your health?
[CODE "3" OR "4" ONLY IF VOLUNTEERED. DO NOT PROBE.]
YES 1
NO 2 [GO TO NEXT SECTION]
DOCTOR/MY DOCTOR 3
KAISER 4
MORE THAN ONE PLACE 5
REFUSED -7 [GO TO NEXT SECTION]
DON'T KNOW -8 [GO TO NEXT SECTION]
PROGRAMMING NOTE QA11_M8:
IF QA11_M7 = 1 OR 5 (HAS A USUAL SOURCE OF CARE) THEN DISPLAY "What kind of place do you go to most often--a medical";
ELSE IF QA11_M7 = 3 (DOCTOR/MY DOCTOR), THEN DISPLAY "Is your doctor in a private";
ELSE IF QA11_M7 = 4 (KAISER), THEN CODE “1” FOR QA11_M8 AND GO TO QA11_M9
QA11_M8 {What kind of place do you go to most often—a medical/Is your doctor in a private} doctor's office, a clinic or hospital clinic, an emergency room, or some other place?
DOCTOR'S OFFICE/KAISER/OTHER HMO 1
CLINIC/HEALTH CENTER/HOSPITAL CLINIC 2
EMERGENCY ROOM 3
SOME OTHER PLACE (SPECIFY:_________) 91
NO ONE PLACE 92
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_M9:
IF QA11_M7 = 1, 3, 4, OR 5 (HAVE A USUAL SOURCE OF CARE) AND ASTHMA, DIABETES, OR HEART DISEASE, THEN CONTINUE WITH QA11_M9;
ELSE GO TO QA11_M10
QA11_M9 Do you have a personal doctor or medical provider who is your main provider?
[IF NEEDED, SAY: “This can be a general doctor, a specialist doctor, a physician assistant, a nurse, or other health provider.”]
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
PROGRAMMING NOTE QA11_M10:
IF R HAS ASTHMA, DIABETES, OR HEART DISEASE AND SAW A DOCTOR IN THE PAST 12 MONTHS, THEN CONTINUE WITH QA11_M10;
ELSE GO TO PROGRAMMING NOTE QA11_M12
QA11_M10 During the past 12 months, did you phone or e-mail the doctor’s office with a medical question?
YES 1
NO 2 [GO TO PN QA11_M12]
REFUSED -7 [GO TO PN QA11_M12]
DON'T KNOW -8 [GO TO PN QA11_M12]
QA11_M11 How often did you get an answer as soon as you needed it? Would you say…
Never, 1
Sometimes, 2
Usually, or 3
Always? 4
REFUSED -7
DON’T KNOW -8
PROGRAMMING NOTE QA11_M12:
IF QA11_M7 = 1, 3, 4, OR 5 (HAS A USUAL SOURCE OF CARE) AND QA11_M9 = 1 (HAS A PERSONAL DOCTOR/MEDICAL PROVIDER) AND HAS ASTHMA, DIABETES OR HAS HEART DISEASE, THEN CONTINUE WITH QA11_M12;
ELSE GO TO NEXT SECTION
QA11_M12 Is there anyone at your doctor’s office or clinic who helps coordinate your care with other doctors or services such as tests or treatments?
YES 1
NO 2
REFUSED -7
DON'T KNOW -8
QA11_M13 How often does your medical provider listen carefully to you? Would you say…
Never, 1
Sometimes, 2
Usually, or 3
Always? 4
REFUSED -7
DON’T KNOW -8
QA11_M14 How often does your medical provider make sure you understand how to take care of your health? Would you say…
Never, 1
Sometimes, 2
Usually, or 3
Always? 4
REFUSED -7
DON’T KNOW -8
QA11_M15 When you need care right away, how often can you to get an appointment to see your medical provider within two days? Would you say…
Never, 1
Sometimes, 2
Usually, or 3
Always? 4
DIDN’T NEED CARE RIGHT AWAY 5
REFUSED -7
DON’T KNOW -8