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pdfAppendix B1: List of Potential Questionnaire Items
The instrument for each cycle of data collection will draw from this list of potential questionnaire items. Each instrument will be
designed to take no longer than 30 minutes to complete. Each final data collection instrument will be submitted to OMB for review and
approval prior to going to the field.
Construct
Question
Response Options
Affective
Forecasting
If I did not [insert exercise/diet/screening intention here from
Strongly disagree; Moderately disagree;
prior question] in [the specified intention time frame], I would feel Neither agree nor disagree; Moderately agree;
regret.
Strongly agree
Affective
Forecasting
Strongly disagree; Moderately disagree;
If I did not get screened forspecific type of cancer [in time frame
Neither agree nor disagree; Moderately agree;
specified in corresponding intentions question], I would feel regret.
Strongly agree
Affective
Forecasting
Sometimes people can feel like something is both good and bad at
the same time. Please indicate below how you would feel/felt
about {getting/having cancer/Getting cance (or getting cancer
again) would be/Having cancer was: The best thing to happen in
my life 2. Getting cancer was the worst thing to happen in my life.
Alcohol
A drink of alcohol is 1 can or bottle of beer, 1 glass of wine, 1 can or
bottle of wine cooler, 1 cocktail, or 1 shot of liquor. During the past
30 days, how many days per week did you have at least one drink
of any alcoholic beverage?
Alcohol
During the past 30 days, on the days when you drank, about how
many drinks did you drink on the average?
Alcohol
In the past 12 months have you tried to reduce your intake of
alcoholic beverages?
Ambiguity
aversion
If experts had conflicting opinions about a medical test or
treatment, I would still be willing to try it.
Attention to health Have you heard inconsistent or differing advice from the media
information
(e.g., television, newspapers) about [mammograms/ PSA]?
7-point likert scale anchored by Strongly
Disagree Strongly Agree
Strongly disagree; Disagree; Agree; Strongly
agree
yes; no
I have paid no attention, I have paid a little
Attention to health How closely have you followed the debate about [mammography in
attention, I have paid a lot of attention, I did not
information
women under the age of 50/ PSA testing]?
know there was a debate
I have paid no attention, I have paid a little
Attention to health How closely have you followed the debate about mammography in
attention, I have paid a lot of attention, I did not
information
women under the age of 50?
know there was a debate
Attention to health How has the debate affected how you understand
information
recommendations about mammography?
I am more confused, No change in my
understanding, I am less confused
Attention to health How has the debate affected how you understand
information
recommendations about PSA testing?
I am more confused, No change in my
understanding, I am less confused
Attention to health How much attention do you pay to information about health or
information
medical topics in general magazines?
None to A lot
Attention to health How much attention do you pay to information about health or
information
medical topics in online newspapers?
None to A lot
Page 1
Construct
Question
Response Options
Attention to health How much attention do you pay to information about health or
information
medical topics in print newspapers?
None to A lot
How much attention do you pay to information about health or
Attention to health
medical topics in special health or medical magazines or
information
newsletters magazines?
None to A lot
Attention to health How much attention do you pay to information about health or
information
medical topics on the Internet?
Attention to health How much attention do you pay to information about health or
information
medical topics on the radio?
Attention to health
I am upset when experts disagree about mammograms
information
strongly disagree – strongly agree
Attention to health
I am upset when experts disagree about PSA testing
information
strongly disagree – strongly agree
Some cable and national television news programs include special
Attention to health segments of their newscasts that focus on health issues. About how
0 - 30
often have you watched such cable or national health segments in
information
the past 30 days?
Some local television news programs include special segments of
Attention to health
their newscasts that focus on health issues. About how often have
information
you watched such local health segments in the past 30 days?
0 - 30
Some people notice information about health on the Internet, even
Attention to health when they are not trying to find out about a health concern they
Yes; No; Refused; Don't know;
have or someone in the family has. Have you read such health
information
information on the Internet in the past 12 months?
Some people notice information about health on the Internet, even
Attention to health when they are not trying to find out about a health concern they
Yes; No; Refused; Don't know;
have or someone in the family has. Have you read such health
information
information on the Internet in the past 30 days?
Autonomy Support
I am able to be open with my health care practitioners about my
health
Strongly Disagree; Moderately Disagree;
Slightly Disagree; Neutral; Slightly Agree;
Moderately Agree; Strongly Agree
Autonomy Support
I dont feel very good about the way my health care practitioners
talk to me about my health.
Strongly Disagree; Moderately Disagree;
Slightly Disagree; Neutral; Slightly Agree;
Moderately Agree; Strongly Agree
Autonomy Support I feel a lot of trust in my health care practitioners.
Strongly Disagree; Moderately Disagree;
Slightly Disagree; Neutral; Slightly Agree;
Moderately Agree; Strongly Agree
Autonomy Support I feel able to share my feelings with my health care practitioners.
Strongly Disagree; Moderately Disagree;
Slightly Disagree; Neutral; Slightly Agree;
Moderately Agree; Strongly Agree
Page 2
Construct
Question
Response Options
Autonomy Support
Strongly Disagree; Moderately Disagree;
I feel my health care practitioners understand how I see things with
Slightly Disagree; Neutral; Slightly Agree;
respect to my health.
Moderately Agree; Strongly Agree
Autonomy Support
I feel that my health care practitioners accept me whether I follow
their recommendations or not.
Strongly Disagree; Moderately Disagree;
Slightly Disagree; Neutral; Slightly Agree;
Moderately Agree; Strongly Agree
Autonomy Support I feel that my health care practitioners care about me as a person.
Strongly Disagree; Moderately Disagree;
Slightly Disagree; Neutral; Slightly Agree;
Moderately Agree; Strongly Agree
Autonomy Support
I feel that my health care practitioners have provided me choices
and options about my health.
Strongly Disagree; Moderately Disagree;
Slightly Disagree; Neutral; Slightly Agree;
Moderately Agree; Strongly Agree
Autonomy Support
My health care practitioners answer my questions related to my
health fully and carefully.
Strongly Disagree; Moderately Disagree;
Slightly Disagree; Neutral; Slightly Agree;
Moderately Agree; Strongly Agree
Autonomy Support
My health care practitioners convey confidence in my ability to
make changes regarding my health.
Strongly Disagree; Moderately Disagree;
Slightly Disagree; Neutral; Slightly Agree;
Moderately Agree; Strongly Agree
Autonomy Support My health care practitioners encourage me to ask questions.
Strongly Disagree; Moderately Disagree;
Slightly Disagree; Neutral; Slightly Agree;
Moderately Agree; Strongly Agree
Autonomy Support My health care practitioners handle my emotions very well.
Strongly Disagree; Moderately Disagree;
Slightly Disagree; Neutral; Slightly Agree;
Moderately Agree; Strongly Agree
My health care practitioners have made sure I really understand
Autonomy Support my health risk behaviors and the benefits of changing these
behaviors without pressuring me to do so.
Strongly Disagree; Moderately Disagree;
Slightly Disagree; Neutral; Slightly Agree;
Moderately Agree; Strongly Agree
Autonomy Support
Strongly Disagree; Moderately Disagree;
My health care practitioners listen to how I would like to do things
Slightly Disagree; Neutral; Slightly Agree;
regarding my health.
Moderately Agree; Strongly Agree
Autonomy Support
Strongly Disagree; Moderately Disagree;
My health care practitioners try to understand how I see my health
Slightly Disagree; Neutral; Slightly Agree;
before suggesting any changes.
Moderately Agree; Strongly Agree
Avoidance
Are there any other reasons why you avoid seeing your doctor?
Yes; No; Refused; Don't know;
Avoidance
I avoid seeing my doctor because I fear I may have a serious illness.
Strongly agree; Somewhat agree; Somewhat
disagree; Strongly disagree;
Avoidance
I avoid seeing my doctor because it makes me think about dying.
Strongly agree; Somewhat agree; Somewhat
disagree; Strongly disagree;
Avoidance
I avoid seeing my doctor because of financial concerns
Strongly disagree; somewhat disagree;
somewhat agree; strongly agree
Avoidance
I don’t want to know my risk for getting cancer if there is little I can
do to lower my risk
Page 3
Construct
Avoidance
Avoidance
Avoidance
Question
Response Options
Extremely not like me, Somewhat not like me,
I would not want to know if I had a cancer that was difficult to treat Uncertain, Somewhat like me, Extremely like
me
Extremely not like me; Somewhat not like me;
Uncertain; Somewhat like me; Extremely like
I’d rather not know my chances of getting cancer.
me
Extremely not like me; Somewhat not like me;
Uncertain; Somewhat like me; Extremely like
If I had cancer, I wouldn’t want to know.
me
Avoidance
Some people avoid visiting their doctor even when they suspect
True; Not true;
they should. Would you say this is true for you, or not true for you?
Avoidance
Some people who are concerned they may have cancer avoid
visiting their doctor even when they should. Would you say this is
true for you, or not true for you?
True; Not true;
Behavior change
How often in the past 12 months have you tried to decrease the
amount of fat in your diet?
Number of times
Behavior change
How often in the past 12 months have you tried to increase the
amount of physical activity or exercise you get?
Number of times
Behavior change
How often in the past 12 months have you tried to increase your
fruit and vegetable intake?
Number of times
Behavior change
How often in the past 12 months have you tried to reduce the
number of sugar-sweetened beverages you consume?
Number of times
Behavior change
How successful do you feel you were in your attempts to decrease
the amount of fat in your diet?
1-5 where 1= not at all successful and 5= very
successful
Behavior change
How successful do you feel you were in your attempts to increase
the amount of physical activity or exercise you get?
1-5 where 1= not at all successful and 5= very
successful
Behavior change
How successful do you feel you were in your attempts to increase
your fruit and vegetable intake?
1-5 where 1= not at all successful and 5= very
successful
Behavior change
How successful do you feel you were in your attempts to manage
your weight in the past 12 months?
1-5 where 1= not at all successful and 5= very
successful
Behavior change
How successful would you rate your attempts to reduce the
number of sugar-sweetened beverages you consume?
1-5 where 1= not at all successful and 5= very
successful
Behavior Change
In the past 12 months, have you tried to get more sleep or improve
y/n
the quality of your sleep?
Behavior Change
In the past 12 months, have you tried to quit smoking?
y/n
Behavior Change
In the past 12 months, have you tried to reduce your stress level?
Y/N
Bodily Pain
During the past 4 weeks, how much did bodily pain interfere with
your work, including work outside the home and housework?
Not at all; A little bit; Moderately; Quite a bit;
Extremely
Bodily Pain
How much bodily pain have you had during the past 4 weeks?
Bracing
None; Very Mild; Mild; Moderate; Severe; Very
Severe
Extremely not like me; Somewhat not like me;
The closer I get to hearing important news, the more I imagine the
Uncertain; Somewhat like me; Extremely like
worst will happen.
me
Page 4
Construct
Question
Response Options
Breast cancer
[If had a mammogram]: Before you had the mammogram, did you
and a doctor talk about it? [if not had a mammogram]: Did you
and a doctor talk about mammograms?
Breast cancer
A mammogram is an x-ray of each breast to look for breast cancer.
During the past 12 months, did a doctor, nurse, or other health
professional advise you to get a mammogram?
Breast cancer
A mammogram is an x-ray of each breast to look for breast cancer.
Have you ever had a mammogram?
Breast cancer
A mammogram is an x-ray of each breast to look for cancer. When
did you have your most recent mammogram to check for breast
cancer, if ever?
Breast cancer
Before you had the mammogram, did you and a doctor or other
health care professional talk about it?
Breast cancer
Compared to the average woman your age, would you say that you More likely to get breast cancer; Less likely;
are more likely to get breast cancer, less likely, or about as likely? About as likely; Don't know; Refused;
Breast cancer
Breast cancer
Has a doctor ever asked you whether or not you wanted to have a
mammogram?
Has a doctor ever told you that no one is sure if routinely
recommending mammograms for women in their 40s actually
saves lives?
Yes; No; DON’T KNOW/DON’T REMEMBER
Yes; No
Yes; No; Dont know
Breast cancer
Has a doctor ever told you that some doctors routinely recommend
Yes; No; Dont know
mammograms for women in their 40s and others do not?
Breast cancer
Has a doctor ever told you that… a. Mammograms for women in
their 40s are not always accurate? b. Some types of breast cancer
are slow-growing and need no treatment?
Breast cancer
Has your doctor ever told you that experts disagree about whether
recommending mammograms for women in their 40s actually
Yes; No; Dont know
saves lives?
Breast cancer
Have at least one of these biopsies had atypical hyperplasia?
Breast cancer
Have you and a doctor or other health care professional talked
about mammograms?
Breast cancer
Have you thought about getting a mammogram?
Breast cancer
How likely do you think it is that you will develop breast cancer in
the future?
Breast cancer
How long before your most recent mammogram was the last one?
Breast cancer
How many breast biopsies have you had?
Open ended
Breast cancer
How many of your first degree relatives (parents, siblings,
children) have had breast cancer?
Open ended
Breast cancer
How often do you worry about getting breast cancer?
Page 5
Yes; No; Not sure
No;Yes
Construct
Question
Response Options
Breast cancer
In general, once women start having mammograms, about how
often should they have them?
More often than once a year; Every 1 to < 2
years; Every 3 to < 5 years; Only when there is
a problem; Other (specify); Don't know;
Refused; Not ascertained; When doctor/health
provider recommends; Depends on age; Every
5 to < 10 years; Every 10 years
Breast cancer
Is there any particular reason why you haven't had a mammogram?
Free text (see on-line HINTS codebook for full
list of responses)
Breast cancer
When did you and a doctor or other health care professional talk
about your mammogram, if ever?
Breast cancer
When did you have your most recent mammogram to check for
breast cancer?
A year ago or less; More than 1 but not more
than 2 years ago; More than 2 but not more
than 5 years ago; Over 5 years ago; Refused;
Don't know;
Breast cancer
When do you expect to have your next mammogram?
A year or less from now; More than 1 but not
more than 2 years from now; Over 5 years
from now; Refused; Don't know; When
doctor/health provider recommends; More
than 2 but not more than 5 years from now;
Breast cancer
Would you say that you plan to get a mammogram, you don't plan
to get one, or you're undecided?
You plan to get one; You don't plan to get one;
Refused; Don't know; You're undecided;
During the last 30 days how often did you use any of these places
to be physically active?
During the last 30 days how often did you use any of this
Built Environment
equipment to be physically active?
How safe from crime do you feel while you are walking or riding
Built Environment
your bike in your community
Built Environment
Built Environment
How safe from traffic do you feel while you are walking or riding
your bike in your community?
number of times
number of times
Extremely safe, quite safe, slightly safe, or not
at all safe
Extremely safe, quite safe, slightly safe, or not
at all safe
Built Environment I often walk to places near my home
(yes/no)
There are many destinations (for example, a store, a workplace, a
Built Environment place of worship) to go within easy walking distance from my
home.
(strongly agree, agree, disagree, strongly
disagree)
Built Environment
There are many places to be physically active in my community not (strongly agree, agree, disagree, strongly
including streets for walking or jogging.
disagree)
Built Environment There is equipment available for physical activity in my community
strongly agree, agree, disagree, strongly
disagree
Cancer
perceptions
[Colon/Lung/Skin] cancer is most often caused by a person's
behavior or lifestyle.
Agree; Disagree; Refused; Don't know;
Cancer
perceptions
Getting checked regularly for [colon/lung/skin] cancer increases
the chances of finding cancer when it's easy to treat.
Agree; Disagree; Refused; Don't know;
Cancer
perceptions
How much do you agree or disagree with the following statements?
Cancer is most often caused by a person's behavior or lifestyle.
Cancer
perceptions
How much do you agree or disagree with the following statements?
When I think of cancer, I automatically think of death.
Page 6
Construct
Question
Response Options
Cancer
perceptions
How often do you think about other people with cancer as: …being
on a “journey” that has a beginning, ups and downs along the way,
1 (never) to 5 (frequently)
and a destination? …having a “weight” that they carry … being in
a “battle” or “fight” with an opponent
Cancer
perceptions
How often do you think about your experience with cancer as
(please rate each one): … a “journey” that has a beginning, ups and
1 (never) to 5 (frequently)
downs along the way, and a destination? …a “weight” that you
carry … a “battle” or “fight" with an opponent?
Cancer
perceptions
It seems like almost everything causes [colon/lung/skin] cancer.
Cancer
perceptions
People with cancer have often talked about their experience in
different ways. When you think about people who have had breast
1[not at all] 2[slightly], 3[somewhat],
cancer, how much do you think each of these phrases describes
4[moderately], 5very much])
them? A) a cancer patient B) a cancer warrior C) a person who has
had cancer D) a cancer victim E) a cancer survivor
Cancer
perceptions
People with cancer have often talked about their experience in
different ways. When you think about people who have had lung
1[not at all] 2[slightly], 3[somewhat],
cancer, how much do you think each of these phrases describes
4[moderately], 5very much])
them? A) a cancer patient B) a cancer warrior C) a person who has
had cancer D) a cancer victim E) a cancer survivor
Cancer
perceptions
People with cancer have often talked about their experience in
different ways. When you think about yourself in relation to your
cancer, how much do you think each of these phrases describes
1[not at all] 2[slightly], 3[somewhat],
you? … a “journey” that has a beginning, ups and downs along the 4[moderately], 5very much])
way, and a destination? …a “weight” that you carry … a “battle” or
“fight" with an opponent?
Cancer
perceptions
People with cancer have often talked about their experience in
different ways. When you think about yourself in relation to your
cancer, how much do you think each of these phrases describes
you? A) a cancer patient B) a cancer warrior C) a person who has
had cancer D) a cancer victim E) a cancer survivor
Cancer
perceptions
Physical activity or exercise can help lower your chances of getting
which type of cancer?
Cancer
perceptions
Since being treated for cancer, I find it harder to multi-task (that is,
1 (strongly agree); 5 (strongly disagree)
to do two or more things at the same time).
Cancer
perceptions
Since being treated for cancer, I find it harder to think through all
of the alternatives before acting.
Cancer
perceptions
Cancer
perceptions
Since being treated for cancer, I find that I am good at resisting
temptation
Since being treated for cancer, I find that I have trouble
concentrating
Cancer
perceptions
There's not much you can do to lower your chances of getting
[colon/lung/skin cancer].
Page 7
Agree; Disagree; Refused; Don't know;
1[not at all]; 2; 3;4;[very much])
1 (strongly agree) to 5 (strong disagree)
1 (strongly agree); 5 (strongly disagree)
1 (strongly agree); 5 (strongly disagree)
Agree; Disagree; Refused; Don't know; Agree;
Disagree; Refused; Don't know;
Construct
Question
Response Options
Cancer
perceptions
When you think about people who have cancer, how much does
each of these phrases describe them? A) a cancer victim B) a
1 (not at all) to 5 (very much)
cancer patient C) a person who had cancer D) a cancer survivor E)
a cancer warrior
Cancer
perceptions
When you think about yourself in relation to your cancer, how
much does each of these phrases describe you? A) a cancer victim
1[not at all]; 2; 3;4;[very much])
B) a cancer patient C) a person who had cancer D) a cancer
survivor E) a cancer warrior
Cancer
perceptions
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree with the following statements or do you
have no opinion: It seems like everything causes cancer.
Cancer
perceptions
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree with the following statements or do you
have no opinion: There are so many different recommendations
about preventing cancer, it's hard to know which ones to follow.
Cancer
perceptions
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree with the following statements or do you
have no opinion: There's not much you can do to lower your
chances of getting cancer.
Cancer
perceptions
Cancer related
knowledge
You said you should get tested for cancer. What kinds of tests do
you have in mind?
Free text (see on-line HINTS codebook for full
list of responses)
Have you ever heard of "chemobrain"
Yes; no
Cancer related
knowledge
Have you ever heard or read somewhere that some people can
experience memory or other cognitive problems after completing
chemotherapy for cancer treatment?
Yes; Unsure; No
Cancer related
knowledge
Have you ever heard or read somewhere that some people can
experience memory or other cognitive problems after completing
chemotherapy for cancer?
Yes/Unsure/No
Cancer related
knowledge
How likely is it that someone will experience significant memory or
other cognitive problems after chemotherapy for cancer cognitive Very likely, Somewhat likely, Somewhat
problems like concentration or multi-tasking that could interfere
unlikely, Very Unlikely, not at all
with work, for example?
Cancer related
knowledge
I’m going to list some symptoms that may or may not be warning
signs for cancer. For each one can you tell me the extent to which
you think that it is a warning sign for cancer: An unexplained lump
Definitely not a warning sign; Probably not a
or swelling; Persistent unexplained pain; Unexplained bleeding; a
warning sign; Probably is a warning sign;
persistent cough or hoarseness; a change in bowel or bladder
Definitely is a warning sign; Refused; Missing
habits; a persistent difficulty in swallowing; a change in the
appearance of a mole; a sore that does not heal; unexplained night
sweats; unexplained weight loss; unexplained tiredness.
Cancer related
knowledge
People being treated for cancer may have trouble concentrating or
remembering things.
Page 8
Construct
Question
Response Options
Cancer Risk
Perceptions
{Cancer/Lung Cancer/Skin Cancer/Breast Cancer/Cervical
Cancer/Prostate Cancer} in the United States is:
very rare; moderately rare; slightly rare;
neither rare nor common; slightly common;
moderately common; very common
Cancer Risk
Perceptions
Compared to cancer, how likely are you to {get heart disease/get
diabetes/have a stroke/be in a serious car crash}?
much less likely than cancer1]; less likely than
cancer2]; about the same as cancer3]; more
likely than cancer4]; much more likely than
cancer5]
Cancer Risk
Perceptions
Compared with other {men/women] your age, how likely are you
to get {cancer/lung cancer/skin cancer/breast cancer/ cervical
cancer/prostate cancer} in your lifetime?
much less likely1]; less likely2]; about the
same3]; more likley4]; much more likely5]
Cancer Risk
Perceptions
Do you think that being a particular race or ethnicity increases a
person's chances of getting cancer a lot, a little, or not at all or do
you have no opinion?
A lot; A little; Refused; Don't know; No
opinion; Not at all;
Cancer Risk
Perceptions
Do you think that being hit in the breast increases a person's
chances of getting cancer a lot, a little, or not at all or do you have
no opinion?
A lot; Don't know; No opinion; Not at all; A
little;
Cancer Risk
Perceptions
Do you think that drinking a lot of alcoholic beverages increases a
person's chances of getting cancer a lot, a little, or not at all or do
you have no opinion?
A lot; No opinion; Refused; Not at all; A little;
Don't know;
Cancer Risk
Perceptions
Do you think that eating a high fat diet increases a person's chances
of getting cancer a lot, a little, or not at all or do you have no
opinion?
Cancer Risk
Perceptions
Do you think that exposure to the sun increases a person's chances
of getting cancer a lot, a little, or not at all or do you have no
opinion?
Cancer Risk
Perceptions
Do you think that having a family history of cancer increases a
person's chances of getting cancer a lot, a little, or not at all or do
you have no opinion?
Cancer Risk
Perceptions
Do you think that having many sexual partners increases a person's
A lot; A little; Not at all; Refused; Don't know;
chances of getting cancer a lot, a little, or not at all or do you have
No opinion;
no opinion?
Cancer Risk
Perceptions
Do you think that not eating many fruits and vegetables increases a
A lot; Not at all; Don't know; No opinion; A
person's chances of getting cancer a lot, a little, or not at all or do
little;
you have no opinion?
Cancer Risk
Perceptions
Do you think that not eating much fiber increases a person's
chances of getting cancer a lot, a little, or not at all or do you have
no opinion?
A lot; A little; Refused; Don't know; No
opinion; Not at all;
Cancer Risk
Perceptions
Do you think that not getting much exercise increases a person's
chances of getting cancer a lot, a little, or not at all or do you have
no opinion?
A lot; Not at all; Don't know; No opinion; A
little;
Cancer Risk
Perceptions
Do you think that pesticides or food additives increase a person's
chances of getting cancer a lot, a little, or not at all or do you have
no opinion?
Page 9
A lot; No opinion; A little; Not at all; Refused;
Don't know;
Construct
Question
Response Options
Cancer Risk
Perceptions
Do you think that pollution increases a person's chances of getting A lot; A little; Not at all; No opinion; Don't
cancer a lot, a little, or not at all or do you have no opinion?
know;
Cancer Risk
Perceptions
Do you think that radon increases a person's chances of getting
cancer a lot, a little, or not at all or do you have no opinion?
Cancer Risk
Perceptions
Do you think that smoking increases a person's chances of getting
cancer a lot, a little, or not at all or do you have no opinion?
Cancer Risk
Perceptions
Do you think that stress increases a person's chances of getting
cancer a lot, a little, or not at all or do you have no opinion?
Cancer Risk
Perceptions
How likely are you to get {cancer/lung cancer/ skin cancer/ breast very unlikely (1); unlikely (2); neither unlikely
cancer/ cervical cancer/ prostate cancer} in your lifetime?
nor likely (3); likely (4); very likely (5)
Cancer Risk
Perceptions
How likely are you to get colon/lung/skin cancer compared to the
average person your age?
More likely to get cancer; Less likely; About as
likely; Refused; Don't know; Rarely or never;
Sometimes; Often; All the time; Refused;
Don't know;
Cancer Risk
Perceptions
How likely do you think it is that you will develop cancer in the
future?
Very low; Somewhat low; Moderate;
Somewhat high; Very high; Don't know;
Cancer Risk
Perceptions
How likely is it that the average {male/female} cigarette smoker
your age will develop lung cancer in {his/her} lifetime?
very unlikely (1); unlikely (2); neither unlikely
nor likely (3); likely (4); very likely (5)
Cancer Risk
Perceptions
How likely is it that the average {man/woman} your age will
very unlikely (1); unlikely (2); neither unlikely
develop {cancer/ lung cancer/ skin cancer/ breast cancer/ cervical
nor likely (3); likely (4); very likely (5)
cancer/ prostate cancer} in {his/her} lifetime?
Cancer Risk
Perceptions
How often do you worry about getting cancer?
Rarely or never; Sometimes; Often; All the
time;
Cancer Risk
Perceptions
How will your chances of getting cancer change as you get older?
My chance will...
go up a lot as I get older; go up a little as I get
older; not change as I get older; go down a little
as I get older; go down a lot as I get older
Cancer Screening
Knowledge
How often do you think [PSA/mammogram/colonoscopy] could
suggest [Prostate cancer/breast cancer/colon cancer] when there
is none present?
All the time; Most of the time; Some of the time;
A little of the time; It never makes a mistake
Cancer Screening
Knowledge
How often do you thinkPSA/mammogram/colonoscopy] could
suggest there is noProstate cancer/breast cancer/colon cancer]
when there is cancer present?
All the time; Most of the time; Some of the time;
A little of the time; It never makes a mistake
Cancer
survivorship
Cancer
survivorship
A lot; A little; Refused; Don't know; No
opinion; Not at all;
A lot; A little; Not at all; No opinion; Don't
know; Refused;
Are you currently receiving cancer treatment?
At what age were you first told that you had cancer?
Cancer
survivorship
Did any doctor, nurse, or other health professoinal EVER give you a
Yes; No; Dont know/Not sure
written summary of all the cancer treatments that you received?
Cancer
survivorship
Did you participate in a clinical trial as part of your cancer
treatment?
Cancer
survivorship
Has a doctor, nurse, or other health professional EVER given you a
summary of all the cancer treatments that you received that was
Yes; No; Dont know/Not sure
accessible on the Internet?
Page 10
Yes; No; Dont know/Not sure
Construct
Question
Response Options
Cancer
survivorship
Has any doctor or other health care professional ever discussed
with you what late or long-term side effects of cancer treatment
you may experience over time?
Cancer
survivorship
Have you EVER received instructions from a doctor, nurse, or other
health professional about where you should return or who you
Yes; No; Dont know/Not sure
should see for routine cancer check-ups after completing your
treatment for cancer?
Cancer
survivorship
How would you rate your follow-up care doctors knowledge of how
cancer and the medical treatments you received for cancer have
Poor; Fair; Good; Very good; Excellent
affected your quality of life?
Cancer
survivorship
How would you rate your follow-up care doctors knowledge of
your medical history?
Poor; Fair; Good; Very good; Excellent
Cancer
survivorship
How would you rate your follow-up care doctors knowledge of
your responsibilities at home, work, or school?
Poor; Fair; Good; Very good; Excellent
I am confident I can manage my cancer
SA, A, D, SD
I am confident in my ability to understand cancer materials
SA, A, D, SD
I was able to actively participate in decisions about my treatment
SA, A, D, SD
Cancer
survivorship
In the last 12 months, how often did your follow-up care doctor
give you clear instructions about what to do if your symptoms or
side effects got worse or came back?
Never; Sometimes; Usually; Always
Cancer
survivorship
In the last 12 months, did your follow-up care doctor or someone
from your doctors office or clinic give you the help you wanted to
make changes in your habits or lifestyle that would improve your
health or prevent illness?
I didnt want help with this; Yes, definitely; Yes,
somewhat; No
Cancer
survivorship
In the last 12 months, did your follow-up care doctor or someone
from your doctors office or clinic talk with you about how much or Yes, definitely; Yes, somewhat; No
what kind of exercise you get?
Cancer
survivorship
In the last 12 months, did your follow-up care doctor or someone
from your doctors office or clinic talk with you about how much or Yes, defnitely; Yes, somewhat; No
what kinds of foods you eat?
Cancer
survivorship
In the last 12 months, did your follow-up care doctor or someone
from your doctors office or clinic talk with you about specific things Yes, definitely; Yes, somewhat; No
you could do to improve your health or prevent illness?
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
In the last 12 months, did your follow-up care doctor or someone
from your doctors office or clinic talk with you about your
smoking?
In the last 12 months, did your follow-up care doctor order any
medical tests to check for signs of cancer or other medical
problems?
Yes, discussed in detail; Yes, discussed
somewhat; No, did not discuss
Yes, definitely; Yes, somewhat; No
Yes; No
In the last 12 months, how often did your follow-up care doctor
give you the help you wanted to take care of the symptoms or side Never; Sometimes; Usually; Always
effects that were bothering you?
Page 11
Construct
Question
Response Options
In the last 12 months, how often did your follow-up care doctor
seem informed and up-to-date about the care you received from
any other doctors or health professionals you saw for cancerrelated issues or problems?
I didnt see any other doctor/health
professional for cancer-related issues in the
last 12 months
Cancer
survivorship
In the last 12 months, how were the decisions about how to treat
your symtoms or side effects made?
I made the decisions with little or no input
from my doctor; I made the decisions after
seriously considering my doctors opinion; My
doctor and I made the decision together; My
doctor made the decision after seriously
considering my opinion; My doctor made the
decisions with little or no input from me.
Cancer
survivorship
In the last 12 months, in your opinion, how often did your followup care doctor, the nurses, and staff at your follow-up care doctors Never; Sometimes; Usually; Always
office or clinic seem to work well together as a team?
Cancer
survivorship
In the last 12 months, were you bothered by any symptoms or
treatment-related side effects?
Cancer
survivorship
In the last 12 months, when you received any medical tests ordered
by your follow-up care doctor, how often did you get the tests
Never; Sometimes; Usually; Always
results in a timely manner?
Cancer
survivorship
In the last 12 months, when you received any medical tests ordered
by your follow-up care doctor, how often did your doctor or
Never; Somtimes; Usually; Always
someone from your doctors office or clinic explain the test results
in a way you could understand.
Cancer
survivorship
In the past 12 months, did you discuss any of these symptoms or
side effects with your follow-up care doctor?
Cancer
survivorship
In the past 2 years, when your cancer-related follow up care
doctor(s) ordered any medical tests, how often was the need for or
Never; Sometimes; Usually; Always
purpose of these tests explained to you in a way you would
understand?
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Yes; No
Yes; No
It is easy for me to ask my doctor questions
SA, A, D, SD
It is easy for me to get information about my cancer
SA, A, D, SD
Cancer
survivorship
Were these instructions written down or printed on paper for you?
(NOTE: This item is asked in relationship to "Have you EVER
Yes; No; Dont know/Not sure
received instructions . . . about where you should return or who
you should see . . . after completing treatment for your cancer)
Cancer
survivorship
Were you EVER denied health insurance or life insurance coverage
Yes; No; Dont know/Not sure
because of your cancer?
Cancer
survivorship
What type of doctor provides the majority of your health care?
Cancer
survivorship
Which of the following cancer treatments have you ever received?
Page 12
Cancer Surgeon; Family Practitioner; General
Surgeon; Gynecologic Oncologist; Internist;
Plastic Surgeon, Reconstructive Surgeon;
Medical Oncologist; Radiation Oncologist;
Urologist; Other; Dont know/Not sure
Construct
Question
Response Options
Cancer
survivorship
My level of involvement was less than what I
Which of the following options best describes your level of
wanted; My level of involvement was just right;
involvement in making the decisions about how your symptoms or
My level of involvement was more than what I
side-effects should be treated?
wanted
Cancer
survivorship
With your most recent diagnosis of cancer, did you have health
insurance that paid for all or part of your cancer treatment?
Caregiver
Preparedness
There are situations where people provide regular care or
assistance to a family member or friend who is elderly or has a longterm illness or disability. During the past month, did you provide
any such care or assistance to a family member or friend who is 60
years of age or older?
Cervical Cancer
A vaccine to prevent HPV infection is available and is called the
cervical cancer vaccine or HPV shot. Before today, have you ever
heard of the cervical cancer vaccine or HPV shot?
Cervical Cancer
A vaccine to prevent HPV infection is available and is called the
HPV shot, cervical cancer vaccine, GARDASIL®, or Cervarix®. Has a
doctor or other health care professional ever talked with you about
the HPV shot or vaccine?
Cervical Cancer
A vaccine to prevent the human papillomavirus or HPV infection is
recommended for girls ages 11-12 and is called the cervical cancer Yes; No; Not sure/It depends; Refused; Don't
know;
vaccine, HPV shot, or GARDASIL. If you had a daughter that age,
would you have her get it?
Cervical Cancer
Before you had the Pap test, did you and a doctor or other health
care professional talk about it?
Cervical Cancer
Do you plan to get another dose of the HPV vaccine for your
daughter (son?) in the next 12 months?
yes; no; dont know
Cervical Cancer
Do you think HPV can cause abnormal Pap smears?
Yes; No; Refused; Don't know;
Cervical Cancer
Do you think HPV can cause cervical cancer?
Cervical Cancer
Do you think HPV can go away on its own, without treatment?
Yes; No; Refused; Don't know;
Cervical Cancer
Do you think women who get the cervical cancer vaccine or HPV
shot should continue to get screened for cervical cancer with the
Pap test?
Yes; No; Refused; Don't know;
Cervical Cancer
Do you think you can get HPV through sexual contact?
Yes; No; Refused; Don't know;
Cervical Cancer
Has a doctor or other health care professional ever recommended
that [YOU OR YOUR CHILD/DAUGHTER/SON] receive HPV shots?
Yes; No; Don't know;
Cervical Cancer
Have you ever been told by a health care provider that you had a
human papillomavirus or HPV infection?
Yes; No; Refused; Don't know;
Cervical Cancer
Cervical Cancer
Have you ever been treated for genital warts?
Have you ever had a Pap smear or Pap test?
Yes; No; Refused; Don't know;
Yes; No; Refused; Don't know;
Cervical Cancer
Have you ever heard of HPV? HPV stands for Human
Papillomavirus. It is not HIV, HSV, or herpes.
Yes; No;
Page 13
Yes; No; Dont know/Not sure
Yes; No; Refused; Don't know;
Construct
Cervical Cancer
Question
How long ago did you have your most recent Pap test to check for
cervical cancer?
Response Options
Cervical Cancer
How many HPV doses or shots did your daughter (son?) receive?
1 dose; 2 doses; 3 doses; dont know; refuse
Cervical Cancer
The HPV vaccine has recently been recommended for boys to
prevent genital warts. Now thinking about your SON.. Do you plan
to get the HPV vaccine for your him?
Yes; no; dont know
Cervical Cancer
What is the main reason you would not let your daughter get the
cervical cancer vaccine?
[open ended]
Cervical Cancer
What was the main reason that you had this Pap test?
Routine annual Pap test or part of routine
physical exam; Last Pap test was not normal;
A specific problem; Never had one and thought
you should; Pregnancy/Followup to birth;
Other; Refused; Don't know;
Cervical Cancer
When did you and a doctor or other health care professional talk
about your Pap test, if ever?
When did you have your most recent Pap test?
1 year ago or less; More than 1 but not more
than 3 years ago; More than 3 but not more
than 5 years ago; More than 5 years ago;
Refused; Don't know;
Cervical Cancer
When do you expect to have your next Pap test?
A year or less from now; More than 1 but not
more than 3 years from now; More than 3 but
not more than 5 years from now; Over 5 years
from now; Not planning to have another; If I
have symptoms; When doctor/health care
provider recommends; Refu
Cervical Cancer
When was your last Pap Screen? Guidelines based on
recommendations from the U.S. Preventive Services Task Force,
2005.
Had Pap Screen within last 3 yrs; Had Pap
Screen more than 3 yrs ago; Never had Pap
Screen; Refused; Don't Know;
Cervical Cancer
Would you agree to have Pap smears every three years if your
health care provider recommended it?
Yes; No; Refused; Don't know;
Chemical
Exposures
Do you feel that inhaling toner from copy machines and/or printers
located in your immediate work environment can lead to
Yes; No
respiratory diseases and/or cancers?
Cervical Cancer
Chemical
Exposures
Chemical
Exposures
Do you feel that you have adequate ventilation while using
household cleaning products?
Yes; No
Do you worry that chemicals in plastics cause cancer?
Yes; No
Chemical
Exposures
How many times a week do you eat food that was heated/cooked in Daily; 1-2 times per week; 3-4 times per week;
a plastic container?
greater than 4 times per week
Chemical
Exposures
Gas: from underground pipes serving the
neighborhood; Gas: bottled, tank, or LP 3;
Electricity; Fuel oil, kerosene, etc; Coal or coke;
Wood; Solar energy; Other fuel (Specify:
____________________); No fuel used
Which fuels are used for heating this (house/apartment)?
Page 14
Construct
Question
Response Options
Clinical trial
Clinical trials are research studies that involve people. They are
designed to test the safety and effectiveness of new treatments and
Yes, No, Refuse, Dont Know
to compare new treatments with the standard care that people
currently get. Have you ever heard of a clinical trial?
Clinical trial
Clinical trials are research studies that involve people. They are
designed to test how well new treatments work, what effects they
have on the people who take them, and to compare new treatments Yes, No, Refuse, Dont Know
with the care that is currently offered to people. Have you ever
heard of a clinical trial?
Clinical trial
Clinical trials are research studies with people that test how well
new medical treatments work compared to the standard care
people get now. Have you ever heard of a clinical trial?
Yes, No, Refuse, Dont Know
• Doctor, nurse or other medical professional
• Family member or friend
• Internet
• Organization such as NCI/ACS
• Newspaper, television news or the radio
• Entertainment media such as a fictional TV
program, movie or book
• Other source
Clinical trial
From what source did you hear about a clinical trial?
Clinical trial
Has a doctor or other member of the medical team discussed
clinical trials as a treatment option for your cancer?
Yes/No
Clinical trial
Have you ever looked for information about clinical trials for your
type of cancer?
Yes/No
Clinical trial
Have you ever looked for information about clinical trials?
Clinical trial
Clinical trial
Clinical trial
Clinical trial
Have you participated in a clinical trial for treatment of your
cancer?
Have you participated in a clinical trial?
If I were diagnosed with a life-threatening condition, my friends
and family members would encourage me to enroll in a clinical
trial?
Yes/No
Yes/No
Yes, No, Refuse, Dont Know
• Strongly agree
• Agree
• Neither agree nor disagree
• Disagree
• Strongly disagree
• asked my doctor, nurse or other member of
my medical team
• looked on the internet
• talked with friends, family members, or other
people who are not members of your medical
team
• contacted an organization such as NCI/ACS
• Other
If so, where did you look?
Page 15
Construct
Clinical trial
Clinical trial
Question
Response Options
If you chose to enroll in a clinical trial, what would be the primary
reason for that decision?
If you have participated in a clinical trial for treatment of your
cancer, what were the reasons?
(select only 1 response)
• doctor recommended
• to help others who will be diagnosed with the
condition in the future
• to advance understanding of cancer
prevention
• to understand cancer prevention
• to receive ‘state of the art’ care
• to increase my chances of improvement
• because the current treatment stopped
working
• to be monitored closely
• other reason
• doctor recommended
• to help others who will be diagnosed with the
condition in the future
• to advance understanding of cancer
prevention
• to understand cancer prevention
• to receive ‘state of the art’ care
• to increase my chances of improvement
• because the current treatment stopped
working
• to be monitored closely
• other reason
• Very likely
• Likely
• Neither likely nor unlikely
• Unlikely
• Very unlikely
Clinical trial
If you were diagnosed with a life-threatening medical condition,
how likely is it you would participate in a clinical trial offered for
that condition?
Colorectal cancer
[If respond yes to having had a test to look for CRC]: Before you
had the test, did you and a doctor talk about the different tests that
are used to look for colorectal cancer?;; If responded no: Did you
Yes; No; Dont know/Dont remember
and a doctor talk about the different tests that are used to look for
colorectal cancer?
Colorectal cancer
A sigmoidoscopy and a colonoscopy are both tests that examine the
bowel by inserting a tube in the rectum. Have you ever had either a
colonoscopy or a sigmoidoscopy?
Colorectal cancer
At what age are people supposed to start doing home stool blood
tests?
Colorectal cancer
Before you had the test, did you and a doctor or other health care
professional talk about the different tests that are used to look for
colorectal cancer?
Colorectal cancer
Did a doctor, nurse, or other health professional ever advise you to
Yes; No; Don't know; Refused;
get a colonoscopy?
Page 16
_______age; Don't know; Refused; When a
doctor/health provider says to
Construct
Colorectal cancer
Colorectal cancer
Colorectal cancer
Question
Did the {doctor, nurse, or other health professional} describe any
other test?
Did the {doctor, nurse, or other health professional} describe
colonoscopy?
Did the {the doctor, nurse, or other health professional} describe
sigmoidoscopy?
Response Options
Yes; No; Don't Know;
Colorectal cancer
Do you believe the stool blood test, colonoscopy, and
sigmoidoscopy are about equally effective in finding colon cancer,
or are some tests more effective than others?
Colorectal cancer
During the past 12 months, did a doctor, nurse, or other health
professional advise you to do a stool blood test using a home test
kit?
Yes; Don't know; No;
Colorectal cancer
Has a doctor ever asked you which test you preferred to have?
Yes;No
Colorectal cancer
Has a doctor, nurse or other health professional ever advised you
to get a test to check for colon cancer?
Yes; No; Don't know;
Colorectal cancer
Have you and a doctor or other health care professional talked
about any of the different tests that are used to look for colorectal
cancer?
Colorectal cancer
Have you ever done a stool blood test using a home kit?
Colorectal cancer
Colorectal cancer
Have you ever had a colonoscopy?
Have you ever had a sigmoidoscopy?
Have you ever had a test to check for colon cancer? These tests
include:
Yes; No;
Yes; No; Refused; Don't know;
Colorectal cancer
Have you ever heard of a fecal occult or stool blood test?
Yes; No; Refused; Don't know;
Colorectal cancer
Have you ever heard of a sigmoidoscopy or colonoscopy?
Yes; No; Refused; Don't know;
Colorectal cancer
Have you thought about doing {a/another} home stool blood test?
Yes; No; Refused; Don't know;
Colorectal cancer
Colorectal cancer
Colorectal cancer
Have you thought about getting {a/another} {sigmoidoscopy or
colonoscopy?}
How likely do you think it is that you will develop colon cancer in
the future?
Yes; No; Refused; Don't know;
Colorectal cancer
In general, once people start having sigmoidoscopy or colonoscopy Free text (see on-line HINTS codebook for full
exams, about how often should they have them?
list of responses)
Colorectal cancer
The following questions are about discussions doctors may have
with patients about tests that are used to look for colorectal cancer: Yes; No; DON’T KNOW/DON’T REMEMBER
Have you ever had a test to look for colorectal cancer?
Colorectal cancer
What was the main reason you did your most recent stool blood
test using a home kit?
Colorectal cancer
Colorectal cancer
Colorectal cancer
Free text (see on-line HINTS codebook for full
list of responses)
Free text (see on-line HINTS codebook for full
What was the main reason you had your most recent colonoscopy?
list of responses)
A year ago or less; More than 1 but not more
When did you do your most recent stool blood test using a home kit than 2 years ago; More than 2 but not more
to check for colon cancer?
than 5 years ago; Over 5 years ago; Don't
know;
A year ago or less; More than 1 but not more
than 5 years ago; More than 5 but not more
When did you have your most recent colonoscopy to check for
colon cancer?
than 10 years ago; Over 10 years ago; Don't
know;
Page 17
Construct
Question
Response Options
A year ago or less; More than 1 but not more
than 5 years ago; More than 5 but not more
than 10 years ago; Over 10 years ago; Don't
know;
Colorectal cancer
When did you have your most recent sigmoidoscopy to check for
colon cancer?
Colorectal cancer
When was your last Endoscopy?
Had Sig/Col in past 5/10 yrs; No Sig/Col in
past 5/10 yrs ago; Never had Endoscopy;
Refused; Don't Know;
Colorectal cancer
When was your last Home Stool Blood Test?
Had home fobt within last 1 yr; Had home fobt
more than 1 yr ago; Never had home fobt;
Refused; Don't know;
Colorectal cancer
When would you say the risk of colon cancer is the highest, when
Under 40 years old; Refused; Between 40 and
you're under 40 years old, between 40 and 60 years old, or over 60
60 years old; Over 60 years old; Don't know;
years old?
Colorectal cancer
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree, or do you have no opinion with the
following statements: Getting checked for colon cancer is too
expensive.
Colorectal cancer
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree, or do you have no opinion with the
following statements: You are afraid of finding colon cancer if you
were checked.
Comorbidity
Please tell us whether a doctor or other health care professional
has ever told you that you had any of the following medical
conditions
Consideration of
future
consequences
Consideration of
future
consequences
Consideration of
future
consequences
Consideration of
future
consequences
Consideration of
future
consequences
Demographics
Demographics
Demographics
Demographics
Demographics
Demographics
Demographics
Demographics
I act now to avoid problems in the future
I focus on the present, thinking that I will take care of future
problems when they happen.
I only focus on the present, figuring that I will take care of future
problems when they happen.
I only focus on the present, thinking that I will take care of future
problems when they happen
I take action now to avoid problems in the future.
Heart attack; angina; CHF; stroke; HBP; chronic
lung disease; diabetes; kidney disease; liver
disease; osteoperosis; arthritis; Crohns disease;
HIV or AIDS; dementia; ulcers; thyroid disease;
blood clots
Extremely not like me, Somewhat not like me,
Uncertain, Somewhat like me, Extremely like
me
Extremely not like me, Somewhat not like me,
Uncertain, Somewhat like me, Extremely like
me
Extremely not like me, Somewhat not like me,
Uncertain, Somewhat like me, Extremely like
me
Extremely not like me, Somewhat not like me,
Uncertain, Somewhat like me, Extremely like
me
Extremely not like me, Somewhat not like me,
Uncertain, Somewhat like me, Extremely like
me
Are any of the children in your household female?
Yes; No;
Are any of the children under the age of 18 in your household
female?
Are you a citizen of the United States?
Are you a permanent resident with a green card / permanent
residence authorization?
Are you currently pregnant?
Are you Hispanic or Latino?
Are you male or female?
Did anyone help you complete this survey?
Yes; No
Yes; No; Refused; Don't know;
Male; Female;
Yes; No;
Page 18
Construct
Question
Response Options
Own; Rent; Occupied without paying
monetary rent; Refused; Don't know;
Demographics
Do you currently rent or own your home?
Demographics
Have you ever served on active duty in the United States Armed
Forces, either in the regular military or in a National Guard or
military reserve unit? Active duty does not include training for the 1 = Yes, 2 = No
Reserves or National Guard, but DOES include activation, for
example, for the Persian Gulf War.
Demographics
How comfortable do you feel speaking English?
Demographics
How many adults age 18 or older live in this household?
Demographics
How many children under the age of 18 live in your household?
Demographics
In general, would you describe your own political views as...
Demographics
In the past 12 months, have you received some or all of your health 1 = Yes, all of my health care; 2=Yes, some of
care from VA hospital or clinic?
my health care; No, No VA health care received
Demographics
In what year did you come to live in the United States?
Demographics
Including yourself, how many people live in your household?
Demographics
Thinking about members of your family living in this household,
what is your combined annual income, meaning the total pre-tax
income from all sources earned in the past year?
Demographics
Were you born in the United States?
Demographics
What is the highest grade or level of schooling you completed?
Demographics
What is the highest level of school you completed?
Less than High School; High School Graduate;
Some College; College Graduate;
Demographics
What is your {combined} annual household income?
< $25,000; $25,000 to < $35,000; $35,000 to <
$50,000; $50,000 to < $75,000; >= $75,000;
Refused; Don't know;
Demographics
What is your age?
18-34; 35-49; 50-64; 65-74; 75+; 45+, exact
age unknown;
Demographics
What is your current occupational status?
Employed; Unemployed; Homemaker;
Student; Retired; Unable to work/disabled;
Other; Refused; Don't know;
Demographics
What is your marital status?
Married; Living with a partner; Divorced;
Widowed; Separated; Never been married;
Not Ascertained;
Demographics
Which one or more of the following would you say is your race?
American Indian/Alaska Native; Asian;
Black/African American; Native
Hawaiian/Other Pacific Islander; White
Depression
During the past 30 days, how often did you feel hopeless?
All of the time; Most of the time; Some of the
time; A little of the time; None of the time;
Refused; Don't know;
1 Very Conservative, 2 Conservative, 3
Moderate, 4 Liberal, 5 Very liberal, 9
DK/Refused
Yes; No;
Page 19
Construct
Question
Response Options
All of the time; Most of the time; Some of the
time; A little of the time; None of the time;
Refused; Don't know;
Depression
During the past 30 days, how often did you feel nervous?
Depression
All of the time; Most of the time; Some of the
During the past 30 days, how often did you feel restless or fidgety? time; A little of the time; None of the time;
Refused; Don't know;
Depression
All of the time; Most of the time; Some of the
During the past 30 days, how often did you feel so sad that nothing
time; A little of the time; None of the time;
could cheer you up?
Refused; Don't know;
Depression
All of the time; Most of the time; Some of the
During the past 30 days, how often did you feel that everything was
time; A little of the time; None of the time;
an effort?
Refused; Don't know;
Depression
During the past 30 days, how often did you feel worthless?
Depression
The last few questions were about a number of feelings you had
during the past 30 days. Altogether, how much did these feelings
interfere with your life or activities?
Dietary
Assessment
During the past month, how often did you drink 100 pure fruit juice
such as orange, mango, apple, grape and pineapple juices? Do not
Enter number of times per day, week, month
include fruit-flavored drinks with added sugar or fruit juice you
(e.g., 3 times/week)
made at home and added sugar to. (You can tell me per day, per
week or per month.)
Dietary
Assessment
During the past month, how often did you drink coffee or tea that
had sugar or honey added to it? Include coffee and tea you
sweetened yourself and presweetened tea and coffee drinks such
as Arizona Iced Tea and Frappuccino. Do not include artificially
sweetened sodas.
Number of times per day, week, or month
Dietary
Assessment
During the past month, how often did you drink regular soda or
pop that contains sugar? Do not include diet soda.
Number of times per day, per week, per month
Dietary
Assessment
During the past month, how often did you drink sweetened fruit
drinks, sports or energy drinks, such as Kool-aid, lemonade, Hi-C,
cranberry drink, Gatorade, Red Bull or Vitamin Water? Include fruit Number of times per day, week, or month
juices you made at home and added sugar to. Do not include
artificially sweetened sodas.
Dietary
Assessment
During the past month, how often did you eat a green leafy or
lettuce salad, with or without other vegetables?
Dietary
Assessment
During the past month, how often did you eat any kind of fried
potatoes, including French fries, home fires, or hash brown
potatoes? Do not include potato chips.
Dietary
Assessment
During the past month, how often did you eat any other kind of
potatoes, such as baked, boiled, mashed potatoes, sweet potatoes,
or potato salad?
Page 20
All of the time; Most of the time; Some of the
time; A little of the time; None of the time;
Refused; Don't know;
Enter number of times per day, week, or month
(e.g., 2 times per week
Enter number of times per day, week, month
(e.g., 3 times/week)
Construct
Question
Response Options
Dietary
Assessment
During the past month, how often did you eat fruit? Include fresh,
frozen or canned fruit. Do not include juices.
Dietary
Assessment
During the past month, how often did you eat refried beans, baked
beans, beans in soup, pork and beans or any other type of cooked Number of times per day, week, or month
dried beans? Do not include green beans.
Dietary
Assessment
During the past month, how often did you eat vegetables, including
lettuce salads, potatoes (not fried), and all other vegetables? Do not
include fried potatoes or potato chips.
Dietary
Assessment
During the past month, not including what you just told me about
(lettuce salads, potatoes, cooked dried beans), how often did you
eat other vegetables? (You can tell me per day, per week or per
month.)
Dietary
Assessment
Dietary
Assessment
Dietary
Assessment
Endocrine
Disruptors
Endocrine
Disruptors
How many servings of fruits do you usually eat or drink each day?
How many servings of vegetables do you usually eat or drink each
day?
Enter number of times per day, week, month
(e.g., 3 times/week)
Free text (see on-line HINTS codebook for full
list of responses)
Free text (see on-line HINTS codebook for full
list of responses)
When available, how often do you use menu information on
calories in deciding what to order?
Do you know what endocrine disruptors are?
Yes/No
Do you think endocrine disruptors are assoicated with cancer?
Yes; No
Environment and
Cancer
Do you think the environment is related to human health? Do you
think environmental exposures are assoicated with cancer?
Yes; No
Environment and
Cancer
Environment and
Cancer
Environmental
Exposure Risk
Perception
What proportion of cancers are attributable/related to the
environment?
Unknown
When you hear the term environment what do you think of?
All non-genetic factors; Air, water, food, and
soil pullutants
Compared to other {men/women} my age, I am {more/less} likely
to come into contact with harmful substances in the environment.
men/women; more/less
Environmental
Exposure Risk
Perception
How much does _____ negatively affect health
1. Air pollution
2. Pesticides
3. Car exhaust
4. Diesel particles (from buses, trains, cargo ships, trucks, etc)
5. Mercury
6. Lead
7. Nano materials
8. Cell phone use
9. Chemicals from plastics
10. Ozone
11. Flame retardants
12. Hazardous waste
13. lack of exercise,
14. low fruit and vegetable consumption,
15. sun exposure,
16. dietary fat intake,
17. obesity,
18. genes
Page 21
Very little – Very much for:
Construct
Environmental
Exposure Risk
Perception
Question
Response Options
How worried are you about coming in contact with ____?
Not at all – Extremely for: 1. Air pollution
2. Pesticides
3. Car exhaust
4. Diesel particles (from buses, trains, cargo
ships, trucks, etc)
5. Mercury
6. Lead
7. Nano materials
8. Cell phone use
9. Chemicals from plastics
10. Ozone
11. Flame retardants
12. Hazardous waste
Have you ever looked for information about _____?
1. Outdoor air pollution and asthma
2. Indoor air pollution and asthma
3. Chemicals in the environment and cancer
4. Harmful substances in your household
5. Harmful substances in your personal care products
6. Chemicals in plastics
Environmental
7. Cell phone use and human health
Yes/No for:
health information
8. Proximity to power lines and human health
seeking
9. Exposure to lead and human health
10. Nanomaterials and human health
11. Environmental exposures to pregnant mothers and child health
12. Ozone and human health
13. Global climate change and human health
14. Mold in the home
15. Proximity to a nuclear power plant and human health
Environmental
Did you feel that you received helpful information? Why? Why not? Open Ended
Health Knowledge
Environmental
Have you heard that environmental exposures may lead to adverse
Yes; No
Health Knowledge health outcomes?
Environmental
Have you talked with your physician, nurse, or healthcare
Health Knowledge professional about environmental exposures and health?
Yes; No
Environmental
If so, which health condition have you head about?
Health Knowledge
Open Ended
Environmental
If so, which topics?
Health Knowledge
Open Ended
Environmental
When you hear of the term environment, what do you think of?
Health Knowledge
Open Ended
Environmental
When you hear the term environmental health what do you think
Health Knowledge of?
Open Ended
Environmental
Do you find it difficult to know what action to take given all
Health Perception information and recommendations?
Yes; No
Page 22
Construct
Question
Response Options
Environmental
Do you think that public health experts seem to disagree on what
Health Perception exposures are harmful to human health?
Yes; No
Would you say that harmful environmental exposures are most
Environmental
often the result of personal behavior? Or the result of conditions
Health Perception
outside the person’s control?
Personal Behavior; Outside the persons control
Environmental
Health Seeking
Behavior
Environmental
Health Seeking
Behavior
Environmental
Health Seeking
Behavior
Environmental
Health Seeking
Behavior
Environmental
Health Seeking
Behavior
Environmental
Health Seeking
Behavior
Environmental
Health Seeking
Behavior
Have you been looking for environmental health information
recently?
Yes; No
Have you ever talked to your physician about environmental
exposures and its potential impact on your health?
Yes/No
If so, what topic area?
Open Ended
What type of information would stimulate you to take action to
reduce or remove an environmental exposure from your life?
Open Ended
What type of information would stimulate you to take action?
Open Ended
Where do you go for trusted environmental health information?
Open Ended
Who do you talk with about environmental health information?
Open Ended
Exposure to
Before being contacted for this study had you ever heard of Cancer
support Resources Control of America?
Exposure to
Before being contacted for this study had you ever heard of the 1support Resources 800-4-Cancer information number?
Exposure to
Before being contacted for this study had you ever heard of the 1support Resources 800-ACS-2345 cancer information number?
Exposure to
Before being contacted for this study had you ever heard of the
support Resources CDC or the Centers for Disease Control and Prevention?
Exposure to
Before being contacted for this study had you ever heard of the
support Resources National Cancer Institute?
Yes; No; Refused; Don't know;
Exposure to
Before being contacted for this study had you ever heard of the
support Resources National Cancer Institute's Cancer Information Service?
Exposure to
Before being contacted for this study, had you ever heard of the
support Resources American Cancer Society?
Yes; Don't know; No;
Exposure to
Have you ever heard of 2-1-1- Information and Referral Search?
support Resources
Yes; No; Dont know; refuse
Exposure to
Have you ever used 2-1-1- Information and Referral Search?
support Resources
Yes; No; Dont know; refuse
Exposures in the
home
Exposures in the
home
Broiling, smoking, grilling or frying outside the house?
Yes; No
Chain saw or other gasoline equipment?
Yes; No
Page 23
Construct
Question
Response Options
Exposures in the
home
Did you bring home any items from the cleaners that were drycleaned during the past week?
Yes; No
Exposures in the
home
Did you go to the dry cleaners during the past week?
Yes; No
Exposures in the
home
Did you use or were you near somebody else who used cleaning
solutions (including household cleaners and chemicals)?
Yes; No
Exposures in the
home
Do you actively refrain from using insecticides, herbicides, and
fungicides in your home? If so, why?
Yes; If yes explain why; No
Do you allow people to wear shoes in your home? If so, why?
Yes; If yes explain why; No
Do you live in the center of town or on the edge of town?
Center of town; Town Edge
Do you live near farm fields or orchards?
Yes; No
Do you live on a farm?
Yes; No
Exposures in the
home
Exposures in the
home
Exposures in the
home
Exposures in the
home
Exposures in the
home
Do you try to avoid _____? If Yes, why?
1. Wearing shoes in the house
2. Eating foods that are not organic
3. Using pesticides in the house
4. Using pesticides outside your home (on your lawn or garden)
5. Plastic containers that have BPA
6. Re-heating food in plastic containers
7. Personal care products that have phthalates, parabens, and
fragrances
Yes/No for:
Exposures in the
home
Do you use BPA free containers for storing food and beverages? If
so, why?
Yes; If yes explain why; No
Exposures in the
home
Do you use certain personal care products that are free of
phthalates, parabens, and fragrances? If so, why?
Yes; If yes explain why; No
Exposures in the
home
During the last 48 hours (the study period) did you or anyone else A garage attached to your home; A detached
park a car or other motor vehicle in:
garage; A carport attached to your home?
Exposures in the
home
During the last 48 hours (the study period) did you or anyone else A garage attached to your home; A detached
start a car or other motor vehicle in:
garage; A carport attached to your home?
Exposures in the
home
During the last 48 hours (the study period) have you operated or
been near diesel engines, (e.g. bus terminal, truck stop)?
Yes; No
Exposures in the
home
During the last 48 hours (the study period) was there any diesel
vehicles parked around the house?
Yes; No
Dusting?
Yes; No
Gardening?
Yes; No
Gasoline lawn mower?
Yes; No
Exposures in the
home
Glues and adhesives, such as contact cement, super glues, and
aerosol adhesives that contain chemical solvents?)
Yes; No
Exposures in the
home
How successful do you feel you have been in using BPA-free
containers for storing food and beverages?
Unsuccesful - Very Succesful
Exposures in the
home
Exposures in the
home
Exposures in the
home
Page 24
Construct
Question
Response Options
Exposures in the
home
How successful do you feel you have been in using personal care
products that are free of phthalates, parabens, and fragrances?
Unsuccesful - Very Succesful
Exposures in the
home
If so, how often?
Never; Occasionally; Frequently
Exposures in the
home
In or around your home, lawn, or garden, do you (or someone else)
Yes; No
use fungicides to kill mold, mildew, or rot?
Exposures in the
home
In or around your home, lawn, or garden, do you (or someone else)
Yes; No
use herbicides to kill weeds or plants?
Exposures in the
home
In or around your home, lawn, or garden, do you (or someone else)
use insecticides to kill bugs such as ants, roaches, mites or other
Yes; No
pests? Include any used on pets.
Exposures in the
home
In the last year has your home suffered water damage?
Exposures in the
home
In the past year has there been a major renovation to this house or
apartment, such as adding a room, putting up or taking down a
Open Ended
wall, replacing windows, or refinishing floors? When was the last
one?
Exposures in the
home
In the past year were new carpets or rugs installed?
Exposures in the
home
In the past year, was the inside of this house or apartment painted?
Open Ended
When was the last time? On how many rooms?
Exposures in the
home
Exposures in the
home
Exposures in the
home
Exposures in the
home
Exposures in the
home
Yes; No
Yes; No
Metal working/welding?
Yes; No
Paints or solvents (paint thinners and removers, typewriter
corrective fluids)?
Yes; No
Pesticides sprayed?
Yes; No
Sander and/or saw?
Yes; No
Sweeping indoors?
Yes; No
Exposures in the
home
The following questions are about things that you may have used
or may have been used by someone near you in the last 48 hours.
Enter all that applies, if Yes, write for how long.
Open Ended
Exposures in the
home
Vacuuming?
Yes; No
Exposures in the
home
Within the last six months were rugs, drapes or furniture
professionally cleaned? Inside the house? When? What items?
Open Ended
Exposures in the
home
Woodworking?
Yes; No
Family History
Do you have any first-degree relatives (mother, father, sibling,
grandparent) who have cancer?
Yes- please speciify; No
Family History
Do you have any first-degree relatives (mother, father, sibling, or
child) who have been diagnosed with cancer in their lifetime?
Yes- please speciify; No
Family History
From which of the following sources have you read or heard
anything about the importance of knowing your family history?
Newspaper; Magazine; Radio; Health
professional; Family member; Social Media;
Friend; Television; Internet; Other; Have not
heard of such test; Not sure
Page 25
Construct
Question
Response Options
Family History
Have you changed your lifestyle (i.e. diet, exercise, smoking or
preventive screening) as a result of someone in your family being
diagnosed with cancer
Family History
Have you changed your lifestyle (i.e. diet, exercise, smoking or
preventive screening) to help reduce your risk of a cancer that runs Yes; No; Not yet but I plan to in the future
in your family?
Family History
Have you ever actively collected health information from your
relatives for purposes of developing family history?
Family History
Have you ever actively collected health information from your
Yes; No
relatives for purposes of documenting your familys health history?
Family History
Have you shared the family history information you collected with Yes; No; Not yet, but I plan to in the future; I
a health professional?
have not collected Family History
Family History
In the past year, have you read or heard about the importance of
knowing your family’s health history
Yes; No
Family History
In the past year, have you read or heard about the importance of
knowing your family’s health history for your own health?
Yes; No
Food Safety and
Applied Nutrition
Food Safety and
Applied Nutrition
Food Safety and
Applied Nutrition
Food Safety and
Applied Nutrition
All cancers can be avoided by using dietary supplements such as
herbal supplements
Strongly agree -- Strongly disagree
All cancers can be avoided through what one eats and drinks
Strongly agree -- Strongly disagree
All cancers can be cured in the same ways
Strongly agree -- Strongly disagree
All cancers can be prevented in the same ways
Strongly agree -- Strongly disagree
Food Safety and
Applied Nutrition
All cancers can be treated by using dietary supplements such as
herbal supplements instead of drugs or surgery
Strongly agree -- Strongly disagree
All cancers can be treated in the same ways
Strongly agree -- Strongly disagree
All cancers have the same causes
Strongly agree -- Strongly disagree
Food Safety and
Applied Nutrition
Food Safety and
Applied Nutrition
Food Safety and
Applied Nutrition
Yes; No
a single type of cancer
□ a few or some types of cancer
If an herbal supplement product says on its package that it "may
□ all cancers
produce anticarcinogenic effects in the body," it means the product
□ one or more diseases other than cancer
may reduce the risk of:
(please specify below:_________)
Food Safety and
Applied Nutrition
If an herbal supplement product says on its package that it "may
reduce the risk of certain cancers," it means the product may
reduce the risk of:
Food Safety and
Applied Nutrition
If you hear or read that an herbal supplement product "may
produce anticarcinogenic effects in the body," do you think this
supplement may do each of the following things:
Food Security
How often in the past 12 months would you say you were worried
or stressed about having enough money to buy nutritious meals?
Page 26
a single type of cancer
□ a few or some types of cancer
□ all cancers
□ one or more diseases other than cancer
(please specify below:_________)
reduce the risk of cancer(s)
treat cancer(s)
completely prevent cancer(s)
cure cancer(s)
Construct
Question
Response Options
Food Security
These next questions are about the food eaten in your household in
the last 12 months and whether you were able to afford the food
you need. Please read the following statements and indicate
whether the statement was OFTEN, SOMETIMES, or NEVER true for
you: The food that we bought just didn't last, and we didn't have
Often true, sometimes true, never true, dont
money to get more; We couldn't afford to eat balanced meals;
know
Members of our household had to cut the size of our meals or skip
meals because there wasn't enough money for food; Members of
our household ate less than they felt they should because there
wasn't enough money to buy food; Members of our household were
hungry but didn't eat because we couldn't afford enough food.
Genomics
Genetic tests that analyze your DNA and lifestyle for potential
health risks are currently being marketed by companies directly to Yes; No
consumers. Have you heard or read about these genetic tests?
Have you ever had a genetic test that analyzes your DNA and
lifestyle for potential health risks?
No; Yes, I ordered the test directly from the
company, but I discussed the results with my
health care provider; Yes, I ordered the test
directly from the company and did not discuss
the results with my health care provider
Genomics
Have you ever had a genetic test that analyzes your DNA for
potential health information?
No; Yes, I ordered the test directly from the
company, but I discussed the results with my
health care provider; Yes, I ordered the test
directly from the company and did not discuss
the results with my health care provider; Yes,
my health care provider ordered the test.
Genomics
No; Yes, I ordered the test directly from the
company, but I discussed the results with my
Have you ever had a genetic test that analyzes your DNA, diet, and
health care provider; Yes, I ordered the test
lifestyle for potential health risks?
directly from the company and did not discuss
the results with my health care provider
Genomics
Have you ever had a genetic test?
Genomics
Have you heard or read about any genetic tests?
Genomics
If you had a genetic test, to whom did you communicate the
results?
Genomics
Yes; No; Refused; Don't know;
Page 27
Health professional; Family member; Friend;
Other; Did not have this type of test; Did not
communicate the results
Construct
Question
Response Options
Genomics
Paternity testing: to determine if a man is the
father of a child Ancestry testing: to determine
the background or geographic/ethnic origin of
an individual’s ancestors DNA testing for
disease risk/disease susceptibility Testing for
genetic influence on medication effectiveness
and side effects DNA fingerprinting: to
distinguish between or match individuals using
Some companies are offering genetic tests that you can order
hair, blood, or other biological material Cystic
directly (such as purchasing in store or by mail, phone, or the
Fibrosis (CF) carrier testing: to determine if a
Internet) without the help of a healthcare provider. Which of the
person is at risk of having a child with cystic
following type(s) of genetic tests are you aware that you can order
fibrosis BRCA 1&2 testing: to determine if a
directly?
person has more than an average chance of
developing breast cancer Nutrigenomic testing:
to recommend diet & lifestyle changes to lower
the risk of developing common disease Lynch
syndrome testing: to determine if a person has
more than an average chance of developing
colon cancer Other (please specify) None of the
above
Genomics
Which of the following type(s) of genetic tests have you heard or
read about?
Paternity testing: to determine if a man is the
father of a child; Ancestry testing: to determine
the background or geographic/ethnic origin of
an individual’s ancestors; DNA fingerprinting:
to distinguish between or match individuals
using hair, bl
Genomics
Which of the following type(s) of genetic tests have you heard or
read about?
Paternity testing; to determine if a man is the
father of a child; Ancestry testing: to determine
the background/ethnic origin of an individuals
ancestors; Disease risk: to determine if an
individual might be at a higher or lower risk for
developing a disease; Pharmacogenetic testing:
to determine the genetic influence on
medication effectiveness and side effects;
Carrier status; to learn if an individual carries a
gene for an inherited disease
Health Behavior
How likely is it that you will tan indoors within the next 12
months? Would you say...
Very likely, somewhat likely, not very likely,
not at all likely
Health Care
About how long has it been since you last visited a doctor for a
routine checkup? A routine checkup is a general physical exam, not
an exam for a specific injury, illness, or condition.
Page 28
Construct
Question
Response Options
Insurance through a current or former
employer or union (of you or another family
member); Medicare; Medicaid, Medical
Assistance, or any kind of governmentassistance plan for those with low incomes or a
disability; TRICARE or other military health
care; VA (including those who have ever used
or enrolled for VA health care); Indian Health
Service
Health Care
Do you have any of the following healthcare coverage options:
Health Care
Do you have any other health care coverage option?
Health Care
During the past 12 months, did you use any complementary,
alternative, or uncoventional therapies such as herbal supplements,
Yes; No; Refused; Don't know;
acupuncture, chiropractic, homeopathy, meditation, yoga, or Tai
Chi?
Health Care
None; 1 Time; 2 Times; 3 Times; 4 Times; 5During the past 12 months, not counting times you went to an
emergency room, how many times did you go to a doctor, nurse, or 9 Times; 10 Or more times; Refused; Don't
know;
other health professional to get care for yourself?
Health Care
If you had a symptom that you thought might be a sign of cancer
1-7 (1 = Not confident at all; 7 = Very
how confident are you that you could get help from a doctor, nurse
Confident)
or other healthcare professional?
Health Care
If you noticed a change in bowel or bladder habits how soon would
Within 1 month; After 1-3 months; After more
you contact a doctor, nurse or other healthcare professional to
than 3 months; Never
make an appointment to discuss it?
Health Care
If you noticed a change in the appearance of a mole how soon
Within 1 month; After 1-3 months; After more
would you contact a doctor, nurse or other healthcare professional
than 3 months; Never
to make an appointment to discuss it?
Health Care
If you noticed a cough or hoarseness how soon would you contact a
Within 1 month; After 1-3 months; After more
doctor, nurse or other healthcare professional to make an
than 3 months; Never
appointment to discuss it?
Health Care
If you noticed a lump or swelling how soon would you contact a
doctor, nurse or other healthcare professional to make an
appointment to discuss it?
Within 1 month; After 1-3 months; After more
than 3 months; Never
Health Care
If you use "non-traditional" forms of treatment, how often do you
tell your primary cancer physician about these "non-traditional"
treatments?
1 Never, 2 Seldom, 3 Sometimes, 4 Often, 5
Always, 9 DK/Refused
Health Care
In the last 6 months, how often did your personal doctor listen
carefully to you
never; almost never;sometimes; usually; almost
always; always
Health Care
In the past 12 months, how often did you feel you received health
care that led to the best possible result for your situation?
Always; Usually; Sometimes; Never
Health Care
In the past 12 months, how often did you feel you received the
health care services you needed when you needed them?
Always; Usually; Sometimes; Never
Health Care
In the past 12 months, how often did you feel you received the
health care services you needed?
Always; Usually; Sometimes; Never
Health Care
In the past 12 months, how often did you feel you received the right
Always; Usually; Sometimes; Never
tests or procedures for your health care needs?
Page 29
Construct
Question
Response Options
Health Care
Not including psychiatrists and other mental health professionals,
is there a particular doctor, nurse, or other health professional that Yes; No; Refused; Don't know;
you see most often?
Health Care
To what extent do you use "non-traditional" treatments for your
cancer?
1 Never, 2 Seldom, 3 Sometimes, 4 Often, 5
Always, 9 DK/Refused
Health Care
What kind of health professional do you see most often? Do you
see a doctor, nurse, or some other health professional?
Doctor; Nurse; COMPLEMENTARY,
ALTERNATIVE, OR UNCONVENTIONAL
PRACTITIONER; NURSE PRACTITIONER;
PHYSICIAN'S ASSISTANT; Some other health
professional? (Please specify); Refused; Don't
know;
Health Care
Would you be willing to participate in a clinical trial?
Yes, No, Dont Know
Based on the results of your most recent search for information
Health information about health or medical topics, how much do you agree or disagree
seeking
with the following statements? It took a lot of effort to get the
information you needed.
Based on the results of your most recent search for information
Health information about health or medical topics, how much do you agree or disagree
with the following statements? The information you found was
seeking
hard to understand.
Based on the results of your most recent search for information
Health information about health or medical topics, how much do you agree or disagree
with the following statements? You felt frustrated during your
seeking
search for the information.
Based on the results of your most recent search for information
Health information about health or medical topics, how much do you agree or disagree
with the following statements? You were concerned about the
seeking
quality of the information.
Based on the results of your search for information on cancer from
Health information all sources, how much do you agree or disagree with the following
seeking
statements? It took a lot of effort to get the information you
needed.
Based on the results of your search for information on cancer from
Health information all sources, how much do you agree or disagree with the following
seeking
statements? The information you found was too hard to
understand.
Based on the results of your search for information on cancer from
Health information all sources, how much do you agree or disagree with the following
seeking
statements? You felt frustrated during your search for the
information.
Based on the results of your search for information on cancer from
Health information all sources, how much do you agree or disagree with the following
seeking
statements? You were concerned about the quality of the
information.
Page 30
Construct
Question
Response Options
Health information Did you look or go anywhere else [for information about health or
seeking
medical topics]?
Health information Have you ever looked for information about cancer from any
seeking
source?
Yes; No; Refused; Don't know;
Health information Have you ever looked for information about health or medical
seeking
topics from any source?
Yes; No; Refused; Don't know;
Health information Have you ever visited an Internet web site to learn specifically
seeking
about cancer?
Yes; No; Don't know;
Health information
How many days since you looked for cancer info?
seeking
Health information Imagine that you had a strong need to get information about
seeking
cancer. Where would you go first?
Free text (see on-line HINTS codebook for full
list of responses)
Health information Imagine that you had a strong need to get information about health
seeking
or medical topics. Where would you go first?
Health information In the past 12 months, have you done the following things while
seeking
using the Internet? Looked for health or medical information?
In the past 12 months, have you done the following things while
Health information
using the Internet? Looked for information about protecting
seeking
yourself from the sun?
Yes; No; Refused; Don't know;
Health information In the past 12 months, have you done the following things while
Yes; No; Refused;
seeking
using the Internet? Looked for information about quitting smoking?
In the past 12 months, have you usedIn the past 12 months, have
Health information
you used the Internet to look for health or medical information for
seeking
yourself?
Health information Is there a specific Internet site you like to go to for health or
seeking
medical information?
Health information Not including your doctor or other health care provider, has
seeking
someone else ever looked for information about cancer for you?
Yes; No; Refused; Don't know;
Health information Overall, how confident are you that you could get advice or
seeking
information about cancer if you needed it?
Health information Overall, how confident are you that you could get health-related
seeking
advice or information if you needed it?
Completely confident; Very confident;
Somewhat confident; A little confident; Not
confident at all;
Health information Specify which Internet site you especially like as a source of health
seeking
or medical information:
Health information The most recent time you looked for cancer information, where did Free text (see on-line HINTS codebook for full
seeking
you go first?
list of responses)
Health information The most recent time you looked for information about health or
seeking
medical topics, was it for yourself, someone else, or both?
Page 31
Construct
Question
Response Options
Health information The most recent time you looked for information about health or
seeking
medical topics, where did you go first?
Free text (see on-line HINTS codebook for full
list of responses)
Health information
Time since last sought cancer information
seeking
In the last month; 1+ to 6 months ago; 6+
months to 1 year ago; 1+ to 5 years ago; More
than 5 years ago;
Health information
Were you looking for information on a specific cancer?
seeking
Yes; No;
Health information Were you looking for information on causes of cancer or risk
seeking
factors for cancer?
Yes; No;
Health information
Were you looking for information on coping with cancer?
seeking
Yes; No;
Health information Were you looking for information on paying for medical care or
seeking
insurance?
Yes; No;
Health information
Were you looking for information on where to get medical care?
seeking
Yes; No;
Health information
Were you looking for other information related to cancer?
seeking
Yes; No;
Health information
Were your looking for information on cancer organizations?
seeking
Yes; No;
Health information When you need health or medical information, do you usually get it
seeking
from…
Health information
Who was that? [that looked for information about cancer for you]
seeking
Spouse; Information specialist (e.g., librarian);
Other (specify); Don't know; Refused; Cancer
organizations; Co-worker; Friend; Other
family member;
Health Information As far as you know, do your healthcare providers maintain your
Technology
medical information in a portable, electronic format?
Yes; No; Refused; Don't know;
Health Information How important is it to you that your healthcare providers are able
Technology
to share your medical information with each other electronically?
Health Information How important would it be for you to get your own medical
Technology
information electronically?
In the past 12 months, have you done the following things while
Health Information
using the Internet? Kept track of personal health information, such
Technology
as care received, test results, or upcoming medical appointments?
Health Information Scientists doing research should be able to review my medical
Technology
information if the information cannot be linked to me personally.
Health literacy
How confident are you filling out medical forms by yourself?
Never; Occasionally; Sometimes; Often; Always
Health literacy
How often do you need to have someone help you read and
understand health information?
all of the time; most of the time; some of the
time; a little of the time; none of the time
Page 32
Construct
Question
Response Options
Health literacy
If you are allowed to eat 60 g of carbohydrates as a snack, how
much ice cream could you have?
Health literacy
If you eat the entire container, how many calories will you eat?
Health literacy
If you usually eat 2500 calories in a day, what percentage of your
daily value of calories will you be eating if you eat one serving?
Health literacy
Strongly agree; Somewhat agree; Somewhat
My doctor/health care provider talks to me about my health using
disagree; Strongly disagree; NA (no usual
language that is easy to understand.
doctor or health care provider)
Health literacy
Strongly agree; Somewhat agree; Somewhat
My doctor/health care provider talks to me about my health using
disagree; Strongly disagree; NA (no usual
words that are easy to understand.
doctor or health care provider)
Health literacy
Pretend that you are allergic to the following substances: penicillin,
peanuts, latex gloves, and bee stings. 5. Is it safe for you to eat this
ice cream? 6. (Ask only if the patient responds no to question 5):
Why not?
Health literacy
Your doctor advises you to reduce the amount of saturated fat in
your diet. You usually have 42 g of saturated fat each day, which
includes 1 serving of ice cream. If you stop eating ice cream, how
many grams of saturated fat would you be consuming each day?
Health SelfEfficacy
Completely confident; Very confident;
Overall, how confident are you about your ability to take good care
Somewhat confident; A little confident; Not
of your health?
confident at all;
Health SelfEfficacy
Overall, how confident are you that you could get advice or
information about health or medical topics if you needed it?
Health status
About how much do you weigh, in pounds, without shoes?
Health status
About how tall are you without shoes?
Health status
At what age did you have your first child?
Open ended (restricted to plausible values for
age)
Health status
At what age did you have your first menstrual period?
Open ended
Health status
At what age were you diagnosed with cancer?
Health status
Did you ever receive any treatment for your cancer?
Yes; No; Don't know;
Health status
During the past 4 weeks, how much did physical health problems
limit your usual physical activities (such as walking or climbing
stairs)?
not at all; very little; somewhat; quite a lot;
could not do physical activities
Health status
Have any of your family members ever had cancer?
Yes; No; Has no family; Refused; Don't know;
Health status
Have you ever been diagnosed as having cancer?
Yes; No; Refused; Don't know;
Health status
Have you had a hysterectomy?
Yes; No; Refused; Don't know;
Health status
How long ago did you finish your most recent treatment?
Still in Treatment; During the past year; 1+ to
2 years ago; 2+ to 3 years ago; 3+ to 4 years
ago; 4+ to 5 years ago; Over 5 years ago;
Health status
In general, would you say your health is…poor, fair, good, very
good, or excellent?
Page 33
Construct
Question
Response Options
excellent; very good; good; fair; poor; very
poor;
Health status
Overall, how would you rate your health in the past 4 weeks?
Health status
Right now do you feel you are...overweight, slightly overweight,
underweight, slightly underweight, or just about the right weight
for you?
Health status
Time since diagnosed with cancer
Health status
What type of cancer did you have?
Free text (see on-line HINTS codebook for full
list of responses)
Health status
What type of cancer have you received treatment for?
A mutating cancer; Abdominal cancer;
Abdominal mass; Adenocarcinoma;
Adenocarcinoma in epithelial lining of
abdominal wall, brain cancer; Adrenocortical
cancer, multiple myeloma; Adrenocortical
carcinoma; Anal cancer, brain cancer;
Angiosarco
Implicit theories
1-6; 1= Strongly agree; 2= Moderately agree;
I think your body weight is something basic about you that you cant
3= Slightly agree; 4= Slightly disagree; 5=
change very much.
Moderately disagree; 6= Strongly disagree
Implicit theories
1-6; 1= Strongly agree; 2= Moderately agree;
I think your cancer risk is something basic about you that you cant
3= Slightly agree; 4= Slightly disagree; 5=
change very much.
Moderately disagree; 6= Strongly disagree
Implicit theories
I think your health is something basic about you that you cant
change very much.
1-6; 1= Strongly agree; 2= Moderately agree;
3= Slightly agree; 4= Slightly disagree; 5=
Moderately disagree; 6= Strongly disagree
Implicit theories
I think your smoking behavior is something basic about you that
you cant change very much.
1-6; 1= Strongly agree; 2= Moderately agree;
3= Slightly agree; 4= Slightly disagree; 5=
Moderately disagree; 6= Strongly disagree
Information
Seeking
I heard about it on television;I heard about it
on the radio;I read about it in a print
magazine;I read about it on the Internet;A
How did you hear about the cancer risk assessment tool you used?
family member or friend told me about it;My
healthcare provider told me about it;I dont
remember;Other
Information
Seeking
There are tools available on the Internet that allow you to estimate
your risk of developing cancer. Have you ever used one of these
Yes;No;Dont know
risk calculators to learn about your cancer risk?
Information
Seeking
There are tools available on the Internet that can tell you about
your chances of getting cancer based on your answers to medical
questions. Have you EVER used one of these tools to learn about
your cancer risk?
Yes;No;Dont know
Have you ever heard about the recall of any of the following
medical products: gel-filled teethers, automated external
defribrillators, stents, pacemakers, or infant apnea monitors?
Yes; No; Refused; Don't know;
How easy or hard was it to find the information you were looking
for?
Very easy; Easy; Neither easy nor hard; Hard;
Very hard; Don’t Know; Refused;
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
Page 34
Construct
Question
Response Options
InformationSeeking about
Medical Products
and Foods
How much do you agree or disagree with the following
statements... Advertisements for commonly used medical products Strongly agree; Agree; Neither agree nor
(such as inhalers, glucose test kits, and contact lenses) do not give disagree; Disagree; Strongly disagree; Don’t
enough information about the possible benefits and positive effects Know; Refused;
of using these products.
InformationSeeking about
Medical Products
and Foods
How much do you agree or disagree with the following
statements... Advertisements for commonly used medical products Strongly agree; Agree; Neither agree nor
such as inhalers, glucose test kits, and contact lenses give enough
disagree; Disagree; Strongly disagree; Don’t
information about the possible risks and negative effects of using Know; Refused;
these products.
InformationSeeking about
Medical Products
and Foods
How much do you agree or disagree with the following
statements... Advertisements for over-the-counter drugs do not
give enough information about the possible risks and negative
effects of using the drug.
InformationSeeking about
Medical Products
and Foods
How much do you agree or disagree with the following
Strongly agree; Agree; Neither agree nor
statements... Advertisements for over-the-counter drugs give
disagree; Disagree; Strongly disagree; Don’t
enough information about benefits and positive effects of using the
Know; Refused;
drug.
InformationSeeking about
Medical Products
and Foods
How much do you agree or disagree with the following
Strongly agree; Agree; Neither agree nor
statements... Advertisements for prescription drugs do not give
disagree; Disagree; Strongly disagree; Don’t
enough information about the possible benefits and positive effects
Know; Refused;
of using the medication.
InformationSeeking about
Medical Products
and Foods
How much do you agree or disagree with the following
statements... Advertisements for prescription drugs give enough
information about the possible risks and negative effects of using
the drug.
Strongly agree; Agree; Neither agree nor
disagree; Disagree; Strongly disagree; Don’t
Know; Refused;
How much do you agree or disagree with the following
statements... Over-the-counter drugs are safer than prescription
drugs.
Strongly agree; Agree; Neither agree nor
disagree; Disagree; Strongly disagree; Don’t
Know; Refused;
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
Strongly agree; Agree; Neither agree nor
disagree; Disagree; Strongly disagree; Don’t
Know; Refused;
How much do you agree or disagree with the following
Strongly agree; Agree; Neither agree nor
statements... Over-the-counter drugs are weaker than prescription disagree; Disagree; Strongly disagree; Don’t
drugs.
Know; Refused;
Strongly agree; Agree; Neither agree nor
How much do you agree or disagree with the following statements:
disagree; Disagree; Strongly disagree; Don’t
I can easily find information about the foods I eat.
Know; Refused;
Strongly agree; Agree; Neither agree nor
How much do you agree or disagree with the following statements:
disagree; Disagree; Strongly disagree; Don’t
I can easily find information about the risks of the drugs I use.
Know; Refused;
How much do you agree or disagree with the following statements: Strongly agree; Agree; Neither agree nor
The information I get about the benefits of the drugs I use is clear disagree; Disagree; Strongly disagree; Don’t
and understandable.
Know; Refused;
Strongly agree; Agree; Neither agree nor
How much do you agree or disagree with the following statements:
disagree; Disagree; Strongly disagree; Don’t
I can easily find information about the benefits of the drugs I use.
Know; Refused;
Page 35
Construct
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
Question
Response Options
How much do you agree or disagree with the following statements: Strongly agree; Agree; Neither agree nor
The information I get about drug benefits is not helpful for making disagree; Disagree; Strongly disagree; Don’t
drug decisions.
Know; Refused;
How much do you agree or disagree with the following statements: Strongly agree; Agree; Neither agree nor
The information I get about drug risks is not helpful for making
disagree; Disagree; Strongly disagree; Don’t
drug decisions.
Know; Refused;
How much do you agree or disagree with the following statements: Strongly agree; Agree; Neither agree nor
The information I get about the foods I eat is clear and
disagree; Disagree; Strongly disagree; Don’t
understandable.
Know; Refused;
How much do you agree or disagree with the following statements: Strongly agree; Agree; Neither agree nor
The information I get about the foods I eat is not helpful for making disagree; Disagree; Strongly disagree; Don’t
food choices.
Know; Refused;
How much do you agree or disagree with the following statements: Strongly agree; Agree; Neither agree nor
The information I get about the risks of the drugs I use is clear and disagree; Disagree; Strongly disagree; Don’t
understantble.
Know; Refused;
How much do you agree or disagree with the following
statements… Advertisements for prescription drugs give enough
information about the possible risks and negative effects of using
the drug.
Strongly agree; Agree; Neither agree nor
disagree; Disagree; Strongly disagree; Don’t
Know; Refused;
How much do you agree with the following statement: The Drug
Facts label is easy to understand.
Strongly agree; Agree; Neither agree nor
disagree; Disagree; Strongly disagree; Don’t
Know; Refused;
How much do you agree with the following statement: The
information leaflet for prescription drugs is easy to understand.
Strongly agree; Agree; Neither agree nor
disagree; Disagree; Strongly disagree; Don’t
Know; Refused;
How much do you agree with the following statement: The
information leaflets that come with the medical products I use in
my home are easy to understand.
Strongly agree; Agree; Neither agree nor
disagree; Disagree; Strongly disagree; Don’t
Know; Refused;
In the past six months, did you visit the Food & Drug
Administration’s website (www.fda.gov)?
Yes; No; Refused; Don't know;
InformationSeeking about
Medical Products
and Foods
In the past year, how frequently did you read the information
leaflet that comes with the medical products that you use in your
home? [probe: these include such items as contact lenses, blood
pressure cuffs, glucose test kits, and pregnancy test kits]
Always; Often; Sometimes; Rarely; Never; Don’t
Know; Refused;
InformationSeeking about
Medical Products
and Foods
In the past year, the first time you use a home medical product such
as contact lenses, blood pressure cuffs, glucose test kits, and
pregnancy test kits, how frequently did you read the information
leaflet that came with it?
InformationSeeking about
Medical Products
and Foods
On your most recent visit, did you find the information you were
looking for?
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
Page 36
Yes; No; Refused; Don't know;
Construct
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
Question
Response Options
The information I get about drug benefits does not usually help me
make decisions about whether or not to start taking a drug.
The information I get about drug risks does not usually help me
make decisions about whether or not to start taking a drug.
What would you do if a drug you used had to be recalled? Would
you:
What would you do if a medical product recall affected you?
Have it removed/stopped using it; Contact my
doctor; Contact the manufacturer; Have it
replaced/Find a substitute; Keep using it/Keep
it; Make no change; Other (please specify)
___________; Unsure/Don’t know; Refused;
When you buy drugs your doctor prescribes, how frequently do
you read the information leaflet that comes with the drugs?
Strongly agree; Agree; Neither agree nor
disagree; Disagree; Strongly disagree; Don’t
Know; Refused;
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
When you purchase over-the-counter drugs for the first time, how Always; Often; Sometimes; Rarely; Never; Don’t
frequently do you read the Drug Facts label?
Know; Refused;
Insurance status
Do you have any kind of health care coverage, including health
insurance, prepaid plans such as HMOs, or government plans such
as Medicare?
Internal Process
Data
About how long did it take you to complete the survey?
Internal Process
Data
At which of the following types of addresses does your household
currently receive residential mail?
Internal Process
Data
Internal Process
Data
Why haven’t you visited the FDA’s website?
Yes; No; Refused; Don't know;
Did anyone help you complete this survey?
Did you complete this survey in one sitting or did you do it in more
than one sitting?
Internal Process
Data
Please mark the gender and write the age of each adult 18 years of
age or older livign at this address.
Lung cancer
A low-dose helical CT is a test to check for lung cancer. During the
past 12 months, did a doctor, nurse, or other health professional
Yes; No; Dont know; refuse
advise you to get a low-dose helical CT?
Lung cancer
Compared to the average person your age, would you say that you More likely to get lung cancer; Less likely;
are more likely to get lung cancer, less likely, or about as likely?
About as likely; Refused; Don't know;
Lung cancer
During the past 12 months, did you have a low-dose helical CT test
yes; no; Dont know; refused
to check for lung cancer
Lung cancer
Have you heard of any tests to find lung cancer before the cancer
creates noticeable problems?
Page 37
Yes; No; Refused; Don't know;
Construct
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Question
How likely do you think it is that you will develop lung cancer in
the future?
Response Options
How often do you worry about getting lung cancer?
Overall, how many people who develop lung cancer do you think
are cured?
Overall, how many people who develop lung cancer do you think
survive at least 5 years?
Sometimes people can feel like something is both good and bad at
7-point scale with anchors: The worst thing to
the same time. Please indicate below how you would feel/felt about
happen in my life (1); Neither good nor bad4];
getting/having lung cancer 1. Getting lung cancer would be: 2.
The best thing to happen in my life7]
Having lung cancer was the worst thing to happen in my life.
What [lung] tests have you heard of?
MRI; Other;
What are some things that people can do to reduce their chances of
Stay away from second-hand smoke;
getting lung cancer?
What are the common symptoms of lung cancer?
Bronchitis; Chest pain; Coughing; Depression;
Difficulty breathing/shortness of
breath/wheezing; Excessive phlegm/mucus;
Fatigue/tiredness; Loss of appetite;
Pneumonia; Spitting up blood; Swelling of
neck and/or face; Weakness; Weight loss
Lung cancer
Who advised you to have the low-dose helical CT to check for lung
cancer?
I asked my health provider about a low-dose
helical CT scan and he/she ordered it for me;
My health provider recommended a low-dose
helical CT scan; I obtained a low-dose helical
CT scan without involving my health provider.)
Lung cancer
Would you say you agree or disagree with the following
statements? It seems like almost everything causes lung cancer.
Lung cancer
Would you say you agree or disagree with the following
statements? Lung cancer develops over a period of several years.
Lung cancer
Would you say you agree or disagree with the following
statements? Lung cancer is most often caused by a person's
behavior or lifestyle.
Lung cancer
Would you say you agree or disagree with the following
statements? People with lung cancer would have pain or other
symptoms prior to being diagnosed.
Lung cancer
Would you say you agree or disagree with the following
statements? There are so many different recommendations about
preventing lung cancer that it's hard to know which ones to follow.
Lung cancer
Would you say you agree or disagree with the following
statements? There are ways to slow down or disrupt the
development of lung cancer.
Lung cancer
Would you say you agree or disagree with the following
statements? There's not much you can do to lower your chances of
getting lung cancer.
Lung cancer
Page 38
Construct
Question
Response Options
Lung cancer
Would you say you agree or disagree with the following
statements? You are reluctant to get checked for lung cancer
because you fear you may have it.
Lung cancer
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree or you have no opinion with the
statement: Whether a person gets lung cancer depends more on
genes than anything else.
Lung cancer
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree or you have no opinion with the
statement: Whether a person gets lung cancer depends more on
genes than anything else.
Strongly disagree; Disagree; Agree; Strongly
agree
Thinking about the past 12 months, how much conflicting or
Media exposure to contradictory information have you heard from the media
contradictory
(including television, radio, newspapers, magazines and the
health information Internet) about each of the following cancer screening tests?
Prostate-specific antigen test
Not at all; A little; Some; A lot
Thinking about the past 12 months, how much conflicting or
Media exposure to contradictory information have you heard from the media
(including television, radio, newspapers, magazines and the
contradictory
health information Internet) about each of the following cancer screening tests?
Mammography
Not at all; A little; Some; A lot
Mental Models of
Cancer
[Breast cancer/ prostate cancer] can be in your body for many
years without causing problems
agree – disagree
Mental Models of
Cancer
[Breast cancer/ prostate cancer] is treatable if found early enough almost never – almost always
Mental Models of
Cancer
[Women/ men] die from other causes with [breast cancer/
prostate cancer] they never knew they had in their body
never – often
Mental Models of
Cancer
Mental Models of
Cancer
Breast cancer can be in your body for many years without causing
problems
agree – disagree
Breast cancer is treatable if found early enough
almost never – almost always
Do all [breast cancers/ prostate cancers] need to be treated (by
surgery, chemotherapy, radiation, or other methods) as soon as
they are found?
never – always
Mental Models of
Cancer
Mental Models of
Cancer
Mental Models of
Cancer
Mental Models of
Cancer
Mental Models of
Cancer
Mental Models of
Cancer
Do all breast cancers need to be treated (by surgery,
chemotherapy, radiation, or other methods) as soon as they are
found?
How often does {breast/ prostate} cancer lead to death when it is
treated?
never – always
almost never – almost always
How often does {breast/ prostate} cancer lead to death?
almost never – almost always
How often does breast cancer lead to death when it is treated?
almost never – almost always
If a trusted healthcare provider told you that you had [breast
cancer/ prostate cancer] that would probably never hurt you, how very unlikely – very likely
likely would you be to seek treatment anyway?
Page 39
Construct
Question
Response Options
Mental Models of
Cancer
If a trusted healthcare provider told you that you had breast cancer
that would probably never hurt you, how likely would you be to
very unlikely – very likely
seek treatment anyway?
Mental Models of
Cancer
If you had [breast cancer/ prostate cancer] and didn’t know about
it, how likely would it be to cause you harm?
Mental Models of
Cancer
If you had breast cancer and didn’t know about it, how likely would
very unlikely – very likely
it be to cause you harm?
Mental Models of
Cancer
Women die from other causes with breast cancer they never knew
never – often
they had in their body
Mental Models of
Screening
How good is [mammography/ PSA] at separating women who have
very bad – very good
breast cancer from women who don’t have breast cancer?
Mental Models of
Screening
How likely are you personally to benefit from [mammography/
PSA]?
very unlikely – very likely
Mental Models of
Screening
How many {men/ women} do you need to screen to prevent one
death from {prostate/ breast} cancer?
open
Mental Models of
Screening
How many women do you need to screen to prevent one death
from breast cancer?
open
Mental Models of
Screening
Imagine a [woman/ man] has [breast/ prostate] cancer. What
percent of the time will a [mammogram/ PSA] correctly show a
positive result (true positive)?
open ended
Mental Models of
Screening
Imagine a {man/woman} does not have {prostate/breast cancer}.
What percent of the time will a {PSA/ mammogram} incorrectly
show a positive result (false positive)?
open
Mental Models of
Screening
Imagine over the course of your life that you had 30
{mammograms/ PSAs}. How many of those 30 would you be
willing to have be false positives (indicating high risk for cancer
when you do not have cancer) before you stopped having
{mammograms/ PSAa}? *Note that 30 may not be an appropriate
number for PSA*
open
Mental Models of
Screening
Imagine over the course of your life that you had 30 mammograms.
How many of those 30 would you be willing to have be false
open
positives (indicating high risk for cancer when you do not have
cancer) before you stopped having mammograms?
Mental Models of
Screening
What do [mammograms/ PSAs] test for:
your risk for cancer; whether you have cancer;
whether you have pre-cancer; none of the
above
Mental Models of
Screening
What is the level of false positives (being told your {mammogram/
PSA} places you at high risk for {breast/ prostate} cancer when you
do not actually have {breast/ prostate} cancer) you would put up
with?
I would put up with any amount of false
positives in order to ensure that I detect cancer
if I have it – I would not put up with any
amount of false positives
Mental Models of
Screening
What percent of the time does a [man/woman] receiving a positive
open
result on a [PSA/mammogram] get a cancer diagnosis?
Page 40
very unlikely – very likely
Construct
Question
Response Options
Mental Models of
Screening
Which is more common, being told your {PSA/mammogram}
results indicate you are at high risk for cancer when you do not
false positive is much more common – true
actually have cancer (false positive), or being told your
positive is much more positive
{PSA/mammogram} results indicate you are at high risk for cancer
when you do in fact have cancer?
Numeracy
How often do you find numerical information to be useful?
Imagine that we flip a fair coin 1,000 times. What is your best guess
Numeracy (Health) about how many times the coin would come up heads in 1,000
Open ended
flips? __ times out of 1000.
In ACME Publishing Sweepstakes, the chance of winning a car is 1
Numeracy (Health) in 1,000. What percent of tickets to ACME Publishing Sweepstakes
win a car?
In general, how easy or hard do you find it to understand medical
statistics?
In general, I depend on numbers and statistics to help me make
Numeracy (Health)
decisions about my health.
Numeracy (Health)
open ended
Very easy; Easy; Hard; Very hard;
Numeracy (Health)
In general, I feel uncomfortable with health information that has a
lot of numbers and statistics.
Numeracy (Health)
When I am looking for information about health, I prefer to a) read
Read stories; review statistics
stories; b) review statistics
Numeracy (Health)
When people tell you the chance of something happening do you
prefer they use words or numbers?
Numeracy (Health)
Which of the following numbers represents the biggest risk of
getting a disease? 1 in 100, 1 in 1,000, 1 in 10
1 in 100; 1 in 1,000; 1 in 10;
Nutrition
Are you concerned about the safety of consuming fish containing
mercury such as tuna?
Yes; No
Nutrition
Are you concerned about the safety of consuming foods such as
beef, chicken, or milkl that were raised on feed containing growth
hormone?
Yes; No
Nutrition
Are you concerned about the safety of eating foods containing
preservatives, pesticides, and other chemicals that are added to
foods?
Are you concerned that artifical sweetners may increase your
cancer risk?
Do you believe that organic foods are healthier than conventional
foods sold in grocery stores?
Does your local store have a variety of healthy food options (fresh
fruits and vegetables)?
food label use
Nutrition
How far to the closest grocery store from home?
Nutrition
How many servings of fruits and vegetables do you think the
average adult should eat each day for good health?
Nutrition
How often do you consume organic foods?
Nutrition
Nutrition
Nutrition
Nutrition
Yes; No
Yes; No
Yes; No
Yes; No
often; sometimes; rarely; never
Open Ended
Daily; 1-2 times per week; 3-4 times per week;
greater than 4 times per week
Page 41
Construct
Nutrition
Nutrition
Nutrition
Question
Response Options
How often do you consume products that contain artifical
sweetners such as Phenylalanine (Equal, NutraSweet, Sweet N
Low) and/or Sucralose (Splenda)?
Never, Ocassionally; Frequently
How often do you use menu information on calories in deciding
1-5 scale; 1= never; 5= always
what to order?
How useful do you find the menu information on calories posted in
1-5 scale; 1= not at all useful; 5= very useful
restaurants?
Nutrition
Id like you to think about the labels on many food products that list
ingredients and provide nutrition and other information. When you
often; sometimes; rarely; never
buy a product for the first time, how often do you read this
information?
Nutrition
lt is easy to purchase fresh fruits and vegetables in my community.
Nutrition
Sunlight helps the body produce Vitamin D naturally. Would you
say you strongly agree, somewhat agree, somewhat disagree, or
strongly disagree?
Nutrition
The costs of fruits and vegetables are affordable.
Nutrition
Nutrition
Nutrition
Occupational
Exposures
Occupational
Exposures
Occupational
Exposures
Patient Activation
(strongly agree, agree, disagree, strongly
disagree)
(strongly agree, agree, disagree, strongly
disagree)
(strongly agree, agree, disagree, strongly
The produce in my community is of high quality.
disagree)
There is a large selection of fresh fruits and vegetables in my
(strongly agree, agree, disagree, strongly
community.
disagree)
To what extent do you believe that obesity is caused by overeating A lot; Some; A little; Not at all; Refused;
?
Don't Know;
Do you work night shifts on a regular basis?
Yes; No
Were you ever exposed to the following chemicals at work?
[List of chemicals]
What type of job do you have?
Open Ended
Do you always, usually, sometimes or never bring with you to your always; usually; sometimes; never; refused;
doctor visits a list of questions or concerns you want to cover?
dont know
Do you always, usually, sometimes or never make sure you
understand the results of any medical test or procedure? (An
Patient Activation
example would be an x-ray, blood tests, or EKG for heart
conditions)
always; usually; sometimes; never; refused;
dont know
Patient Activation
Do you always, usually, sometimes or never read information about always; usually; sometimes; never; refused;
a new prescription, such as side effects and precautions?
dont know
Patient Activation
Do you always, usually, sometimes or never take a list of all your
prescribed medicines to your doctor visits.
always; usually; sometimes; never; not
applicable; refused; dont know
Patient Activation
Have you ever asked your doctor questions about any treatment,
test or prescription that he or she has recommended?
yes; no; doesnt apply
Have you ever brought a friend or a relative to a doctors
Patient Activation appointment so that they could help ask questions, understand, or yes; no; doesnt apply
remember what the doctor was telling you?
Patient Activation
Have you ever called to check on the results of a medical test you
had done?
Patient Activation
Have you ever checked the medication that a pharmacist gave you
yes; no; doesnt apply
with the prescription your doctor wrote?
Page 42
yes; no; doesnt apply
Construct
Question
Have you ever consulted with your doctor about the hospital you
Patient Activation
go to?
Response Options
yes; no; doesnt apply
Have you ever talked to a surgeon about the details of surgery, such
yes; no; doesnt apply
Patient Activation as exactly what they will be doing, how long it will take and the
recovery process?
Patient Activation I do what I can to get checked for cancer
Patient Activation
Please tell me how confident you are that you can identify when it
is necessary for you to get medical care.
Taking an active role in my own health care is the most important
factor in determining my health and ability to function. OR When
Patient Activation
all is said and done, I am the person who is responsible for
managing my health condition
very confident; confident; somewhat confident;
not at all confident; refused; dont know
disagree strongly; disagree; agree; agree
strongly; not applicable
The following always, usually, sometimes or never happens: Before
always; usually; sometimes; never; not
Patient Activation I go to a new doctor, I find out as much as I can about his or her
applicable; refused; dont know
qualifications.
Patient Activation
The following always, usually, sometimes or never happens: I ask always; usually; sometimes; never; not
my doctor to explain a test, treatment, or procedure to me in detail. applicable; refused; dont know
Patient satisfaction
During the past 12 months, how often did doctors or other health
providers give you good advice or treatment?
Always; Usually; Sometimes; Never
In the past 12 months, how often did you feel you could rely on
Patient satisfaction your doctors, nurses, or other health care professionals to take care Always; Usually; Sometimes; Never;
of your health care needs?
Patient satisfaction
Overall, how satisfied were you with your care in the last three
months
very satisfied; somewhat satisfied; somewhat
dissatisfied; very dissatisfied
Patient satisfaction
Overall, how would you rate the care you got in the last 6 months
from the doctors and nurses ni your personal doctors office?
very poor; poor; fair; good; very good;
excellent
Patient satisfaction
Overall, how would you rate the quality of health care you received
in the last 12 months?
Patient satisfaction
Patient-provider
communication
Patient-provider
communication
Patient-provider
communication
Overall, how would you rate the quality of your care in the last
three months
Did you discuss your use of unconventional therapies with any of
your doctors?
Poor; Fair; Good; Very Good; Excellent
Yes; No; Refused; Don't know;
During the past 12 months, how often did doctors, nurses, or other
health professionals give you the chance to ask all the healthrelated questions you had.
From the following five options, please mark the one that best
describes your preference for how medical decisions about your
health care should be made.
Page 43
I would prefer to make the decisions with little
or no input from my doctor; I would prefer to
make the decisions after seriously considering
my doctors opinion; I would prefer that my
doctor and I make the decisions together; I
would prefer my doctor to make the decisions
after seriously considering my opinion; I would
prefer my doctor to make the decisions with
little or no input from me.
Construct
Question
Response Options
Patient-provider
communication
How often did doctors, nurses, or other health professionals give
the attention you needed to your feelings and emotions?
Patient-provider
communication
How often did doctors, nurses, or other health professionals help
you deal with feelings of uncertainty about your health or health
care?
Patient-provider
communication
How often did doctors, nurses, or other health professionals make
sure you understood the things you needed to do to take care of
your health?
Patient-provider
communication
How often did the health professional you see most often involve
you in decisions about your health care as much as you wanted?
Always; Sometimes; Don't know; Refused;
Never; Usually;
Patient-provider
communication
In the past 12 months when you talked with a health care
professional, how interested were they in hearing about the
information you found on-line?
Very interested; Somewhat interested; A little
interested; Not at all interested;
Patient-provider
communication
In the past 12 months, have you talked to a doctor, nurse, or other
health professional about any kind of health information you have Yes; No;
gotten from the Internet?
Patient-provider
communication
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during the
past 12 months. How often did they do each of the following?
Spend enough time with you?
Always; Usually; Sometimes; Never
Patient-provider
communication
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during the
past 12 months. How often did they do each of the following?
Explain things in a way you could understand?
Always; Usually; Sometimes; Never
Patient-provider
communication
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during the
past 12 months. How often did they do each of the following?
Give the attention you needed to your feelings and emotions?
Always; Usually; Sometimes; Never
Patient-provider
communication
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during the
Always; Usually; Sometimes; Never
past 12 months. How often did they do each of the following?
Give you the chance to ask all the health-related questions you had?
Patient-provider
communication
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during the
past 12 months. How often did they do each of the following?
Help you deal with feelings of uncertainty about your health or
health care?
Page 44
Always; Usually; Sometimes; Never
Construct
Question
Response Options
Patient-provider
communication
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during the
past 12 months. How often did they do each of the following?
Involve you in decisions about your health care as much as you
wanted?
Always; Usually; Sometimes; Never
Patient-provider
communication
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during the
past 12 months. How often did they do each of the following?
Listen carefully to you?
Always; Usually; Sometimes; Never
Patient-provider
communication
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during the
past 12 months. How often did they do each of the following?
Always; Usually; Sometimes; Never
Make sure you understood the things you needed to do to take care
of your health?
Patient-provider
communication
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during the
past 12 months. How often did they do each of the following?
Show respect for what you had to say?
Always; Usually; Sometimes; Never
Were you involved in decisions about your care as much as you
wanted?
Yes, definitely; Yes, somewhat; no
Were you told of your diagnosis in a sensitive manner?
Yes, definitely; Yes, somewhat; no
Patient-provider
communication
Patient-provider
communication
Perceived
Discrimination
Perceived
Discrimination
Perceived
Discrimination
Perceived
Discrimination
Perceived
Discrimination
Perceived
Discrimination
Perceived
Discrimination
Never; once; two or three times; four or more
times
Never; once; two or three times; four or more
times
Never; once; two or three times; four or more
times
never; once; two or three times; four or more
times
Never; once; two or three times; four or more
times
Never; once; two or three times; four or more
times
Never; once; two or three times; four or more
times
At work?
From the police or in the courts?
Getting credit, bank loans, or a mortgage
Getting hired or getting a job?
Getting housing?
Getting medical care
Getting service in a store or restaurant
Perceived
Discrimination
How often have you experienced discrimination, been prevented
from doing something, or been hassled or made to feel inferior in
any of the following situations: At school?
never; once; two or three times; four or more
times;
Perceived
Discrimination
On the street or in a public setting?
Never; once; two or three times; four or more
times
Perceived
vulnerability
Compared to the average person your age, would you say that you More likely to get colon cancer; Less likely;
are more likely to get colon cancer, less likely, or about as likely?
About as likely; Refused; Don't know;
Perceived
vulnerability
Feelings of risk
1=Agree strongly; 2=Agree mildly; 3=Disagree
mildly; 4=Disagree Strongly
Page 45
Construct
Question
Response Options
Personal
Behaviors
Have you ever refused or discontinued treatment recommended by
your doctor/dentist based on information you obtained from the
yes; no
internet?
Physical Activity
Are you currently trying to gain weight, lose weight, maintain your
current weight, or none of these?
Physical Activity
As far as you know, does physical activity or exercise increase the Increases chances of cancer; Decreases
chances of getting some types of cancer, decrease the chances of
chances of cancer; Makes no difference;
getting some types of cancer, or does it not make much difference? Refused; Don't know;
Physical Activity
Do you feel safe exercising outdoors in your own
neighborhood/community?
Physical Activity
Do you have access (within a reasonable distance) to a health club,
Yes; No
gym, and/or fitness facility?
Physical Activity
Have you tried to lose any weight in the past 12 months?
Physical Activity
How many days in a typical week do you exercise at least at a
moderate level, making you breathe somewhat harder than
normal?
Physical Activity
None; Less than 30 Minutes; 30 Minutes to
How many minutes per week of physical activity or exercise of at
less than 1 Hour; 1 Hour to less than 1.5 Hours;
least moderate intensity are recommended for the average adult to
1.5 Hours to less than 2 Hours; 2 Hours to less
stay healthy?
than 2.5 Hours; Over 2.5 Hours;
Physical Activity
How often do you do leisure-time physical activities specifically
designed to strengthen your muscles such as lifting weights or
doing calisthenics?
Physical Activity
In a typical week, how many days do you do any physical activity or
exercise of at least moderate intensity, such as brisk walking,
bicycling at a regular pace, and swimming at a regular pace?
Physical Activity
In a typical week, how many days do you do leisure-time physical
activities specifically designed to strengthen your muscles such as
lifting weights or doing calisthenics?
Physical Activity
None; Less than 30 Minutes; 30 Minutes to
On the days that you do any physical activity or exercise of at least
less than 1 Hour; 1 Hour to less than 1.5 Hours;
moderate intensity, how long are you typically doing these
1.5 Hours to less than 2 Hours; 2 Hours to less
activities?
than 2.5 Hours; Over 2.5 Hours;
Physical Activity
Over the past 30 days, on average how many hours per day did you
sit and watch TV/movies or use a computer game console? Do not
include “active gaming” such as Wii.
Physical Activity
Over the past 30 days, on average how many hours per day did you
Number, in hours
sit and watch TV/movies or use computer/game console?
Physical Activity
There are so many different messages about whether being
overweight is harmful to one's health it is hard to know what
weight one should maintain to be healthy.
Physical Activity
To what extent do you believe that obesity is caused by not
exercising?
Page 46
Yes; No
Yes; No; Refused; Don't know;
# of times per day/week/month/year
A lot; Some; A little; Not at all; Refused;
Don't Know;
Construct
Question
Response Options
Physical Activity
To what extent do you believe that obesity is inherited? Would you
say… a lot, some, a little, or not at all?
Physical Activity
What activities do you typically do to strengthen your muscles?
Pluralistic
ignorance
Pluralistic
ignorance
How worried are you that your smoking will lead to lung cancer?
Not at all worried; Very worried
How worried do you think other smokers are that their smoking
will lead to lung cancer?
Not at all worried; Very worried
Prostate Cancer
Before you had the PSA test, did you and a doctor or other health
care professional talk about the test?
Prostate Cancer
Did you and a doctor or other health care professional talk about
the PSA test?
Prostate Cancer
During the past 12 months, did a doctor, nurse, or other health
professional advise you to get a PSA test?
Prostate Cancer
Prostate Cancer
Yes; No; Don't know; Had blood test, but dk if
checked psa;
Has a doctor ever asked you whether or not you wanted to have the
Yes;No
PSA test?
Has a doctor ever told you that some doctors recommend the PSA
Yes; No; DON’T KNOW
test and others do not?
Prostate Cancer
Has a doctor ever told you that… a. The PSA test is not always
accurate? b. Some types of prostate cancer are slow-growing and
need no treatment? c. The results of the PSA test cannot tell the
Yes;No;Dont Know
difference between slow-growing and fast-growing prostate
cancer? d. Treating any type of prostate cancer can lead to serious
side effects, such as problems with urination or having sex?
Prostate Cancer
Has a doctor or other health care professional ever told you that no
one is sure if using the PSA test actually saves lives?
Prostate Cancer
Has a doctor or other health care professional ever told you that
some doctors recommend the PSA test and others do not?
Prostate Cancer
Has a health care provider such as a doctor or nurse ever talked to
Yes; No; Don't know;
you about a PSA test?
Prostate Cancer
Have you ever had a PSA test?
Yes; No; Had blood test, but don't know if
checked psa; Refused; Don't know;
Prostate Cancer
Have you ever heard of a PSA or prostate-specific antigen test?
Yes; No; Not ascertained; Don't know;
Prostate Cancer
How likely do you think it is that you will develop prostate cancer
in the future?
Prostate Cancer
How long before your most recent PSA test was the last one?
Prostate Cancer
If Had PSA: Before you had the PSA test, did you and a doctor talk
about the test? If No PSA: Did you and a doctor talk about the PSA
test?
Prostate Cancer
The following questions are about discussions doctors or other
health care professionals may have with their patients about the
PSA test that is used to look for prostate cancer. Have you ever had
a PSA test?
Page 47
Yes; No; DON’T KNOW/DON’T REMEMBER
Construct
Question
Response Options
A year ago or less; More than 1 but not more
than 2 years ago; More than 2 but not more
than 5 years ago; Over 5 years ago; Don't
know;
Prostate Cancer
When did you have your most recent PSA test?
Prostate Cancer
When, if ever, did you and a doctor or other health care
professional talk about the PSA test?
Quality of Life
How likely is it that going through a serious illness will one day
lead to positive outcomes for a person?
very unlikely; somewhat unlikely; somewhat
likely; very likely
Quality of Life
How much do you agree or disagree with this statement: People
who have survived a serious illness tend to be more self-reliant
than people who have not.
strongly disagree; disagree; agree; strongly
agree
Radiation
Did the doctor that ordered the test discuss radiation risks of the
test with you?
Yes; No
Radiation
Do you worry that radiation from cell phones causes cancer?
Yes; No
Radiation
Have you had a CT scan, x-ray, or other medical test using radiation
Yes; No
in the last year?
Radiation
How many hours a day do you use your cell phone?
Less than one hour; one hour; two hours; three
hours; four hours; greater than four hours
Religiosity and
Spirituality
In general, how would you describe your religious or spiritual
beliefs?
1 Very Conservative, 2 Conservative, 3
Moderate, 4 Liberal, 5 Very liberal, 9
DK/Refused
Secondhand
Smoke
At this job or business, that is at {EMPLOYER} as a(n)
{OCCUPATION}, how many hours per day can {you/SP} smell the
smoke from other people’s cigarettes, cigars, and/or pipes?
Open Ended
Secondhand
Smoke
Secondhand
Smoke
Does your place of work have an official policy that restricts
smoking in any way?
During the PAST TWO WEEKS, has anyone smoked in the area in
which you work?
Secondhand
Smoke
How many cigarettes per day {do you/does PERSON} usually
smoke anywhere inside the home?
Open Ended
Secondhand
Smoke
Which of these best describes your place of works smoking policy
for INDOOR PUBLIC OR COMMON AREAS, such as lobbies, rest
rooms, and lunch rooms?
(1) Not allowed in ANY public areas (2)
Allowed in SOME public areas (3) Allowed in
ALL public areas
Secondhand
Smoke
Which of these best describes your place of works smoking policy
for WORK AREAS?
(1) Not allowed in ANY work areas (2) Allowed
in SOME work areas (3) Allowed in ALL work
areas
Secondhand
Smoke
Which statement best describes the rules about smoking inside
your home?
(No one is allowed to smoke anywhere inside
your house/ Smoking is allowed in some places
or at some times inside your house / Smoking
is permitted anywhere inside your house)
Self-affirmation
I feel a sense of choice in my decision making about health
Self-affirmation
I feel controlled in making decisions about health
Self-affirmation
When I feel threatened or anxious by people or events I find myself
disagree completely; agree completely
thinking about my values
Page 48
Yes/No
Yes/No
not at all1]; slightly2]; somewhat3];
moderately4]; extremely5]
not at all1]; slightly2]; somewhat3];
moderately4]; extremely5]
Construct
Question
Response Options
Self-affirmation
When I feel threatened or anxious by people or events I find myself
disagree completely;agree completely
thinking about the people who are important to me
Self-affirmation
When I feel threatened or anxious I find myself thinking about my
core values.
disagree completely; agree completely
Self-affirmation
When I feel threatened or anxious I find myself thinking about the
people who are important to me.
disagree completely;agree completely
Skin cancer
How likely do you think it is that you will develop skin cancer in the
future?
Skin cancer
How often do you worry about getting skin cancer?
Abnormal growths; Blisters; Blotches;
Lesions; Mole/change in mole; Pigment
discoloration; Rash; Redness of skin; Other
(specify);
Skin cancer
What are the common symptoms of skin cancer?
Sleep Quality
On the average, how many hours of sleep do you get in a 24-hour
period? Think about the time you actually spend sleeping or
napping, not just the amount of sleep you think you should get?
Social Support
Are you currently married or living with a partner?
Yes; No
Social Support
Can you count on anyone to provide you with emotional support
(talking over problems or helping you make a difficult decision)?
Yes; No
Social Support
Do you have as much contact as you would like with someone you
feel close to, someone in whom you can trust and confide in?
Yes; No
Social Support
Is there someone available to whom you can count on to listen to
you when you need to talk?
None to All the Time
Social Support
Is there someone avaliable to help with daily chores?
Yes; No
Social Support
Social Support
Is there someone avaliable to you to give you good advice about a
problem?
Is there someone avaliable to you who shows you love and
affection?
Yes; No
Yes; No
Sun Safety
Are you in favor or against restricting children under the age of 18 Strongly in favor, somewhat in favor,
to have access to tanning beds and booths?
somewhat against, strongly against
Sun Safety
How many times in the past 12 months have you used a tanning
bed or booth?
Sun Safety
How often do you stay in the shade or under an umbrella?
Sun Safety
How often do you wear a hat?
Always; Often; Sometimes; Rarely; Never;
Refused; Does not go out on sunny day;
Sun Safety
How often do you wear a shirt with sleeves that cover your
shoulders?
Always; Often; Sometimes; Rarely; Never;
Don't know; Does not go out on sunny day;
Sun Safety
When you are outside for more than one hour on a warm sunny
day, how often do you wear sunscreen?
Sun Safety
When you go outside for more than 1 hour on a warm, sunny day,
how often do you wear long pants?
Page 49
0 times; 1 to 2 times; 3 to 10 times; 11 to 24
times; 25 times or more; Don't know;
Construct
Sun Safety
Question
Response Options
When you go outside for more than 1 hour on a warm, sunny day,
how often do you wear sunscreen?
Tobacco Use
About how long has it been since you completely quit smoking
cigarettes?
Less than 1 month ago; 1 month to less than 3
months ago; 3 months to less than 6 months
ago; 6 months to less than 1 year ago; 1 year
to less than 5 years ago; 5 years to less than 15
years ago; 15 or more years ago;
Tobacco Use
Are you seriously considering quitting smoking within the next 6
months?
Yes; No; Refused; Don't know;
Tobacco Use
Around this time 12 months ago, were you smoking cigarettes. . .
Tobacco Use
As far as you know, what is it about some cigarettes that might
make them safer or less harmful? (less
tar/nicotine/additives/genetically modified tobacco/other)
Tobacco Use
At this job or business, that is at {EMPLOYER} as a(n)
{OCCUPATION}, how many hours per day can {you/SP} smell the
smoke from other people’s cigarettes, cigars, and/or pipes?
Tobacco Use
Before being contacted for this survey, had you ever heard of 1-800Yes; No; Refused; Don't know;
QUIT-NOW?
Tobacco Use
Cigarette advertising increases the chance that a child starts
smoking. (strongly agree, agree, disagree, strongly disagree)
Tobacco Use
Cigarette advertising that increases the chance that children will
start smoking should be prohibited, whether or not it was meant to
target children. (strongly agree, agree, disagree, strongly disagree)
Tobacco Use
Cigarette packages often use colors to distinguish the type of
cigarette. Please rank the following colors (1-4) in terms of the
harmfulness of the cigarette, with 1 being the safest and 4 being the
least safe. (silver, gold, red, green, do not know, same harm)
Tobacco Use
Cigarettes with added flavorings like cherry, chocolate, lime, and
mint should be prohibited. (strongly agree, agree, disagree,
strongly disagree)
Tobacco Use
Do you believe that any government agency regulates tobacco
products in the U.S.? Y/N
Tobacco Use
Do you believe that some cigarettes are less harmful than others?
Tobacco Use
Do you know of any law that came into effect (time frame)
regarding federal government regulation of cigarettes and other
tobacco products? (Y/N)
Tobacco Use
Do you now smoke cigarettes...
Tobacco Use
Do you now use {FILL} every day, some days, or not at all?
Tobacco Use
Do you think it is possible for government regulations to change
cigarettes to make them less harmful? (Y/N)
Tobacco Use
Do you think the FDA controls the amount of nicotine in cigarettes?
Page 50
Open Ended
Yes; No; Don't know;
Not at all;
Construct
Question
Response Options
Tobacco Use
Do you think the FDA tests cigarette ingredients for safety?
Tobacco Use
Do you think there are any tobacco products that are safe?
Tobacco Use
During the past 12 months, have you tried to quit smoking
completely?
Tobacco Use
Government regulation of cigarettes will make cigarettes safer.
(strongly agree, agree, disagree, strongly disagree)
Tobacco Use
Have you ever called a telephone quit line?
Yes; No;
Tobacco Use
Have you ever smoked cigarettes every day for at least 6 months?
Yes; No;
Tobacco Use
Have you ever stopped smoking for one day or longer because you
Yes; No;
were trying to quit smoking?
Tobacco Use
Tobacco Use
Yes; No; Refused; Don't know;
Have you ever used a website or online program to help you quit
smoking?
Have you heard about a nicotine vaccine that helps people quit
smoking? (Y/N)
Tobacco Use
Have you heard about medications to help people stop smoking
such as Nicotine Replacement Therapies like nicotine gum or the
patch, or pills such as Zyban or Chantix? (Y/N)
Tobacco Use
Have you smoked at least 100 cigarettes in your entire life?
Tobacco Use
How did you find out about this? (television, newspaper, magazine,
internet, radio, friend or family member, coworker,
doctor/healthcare professional, partner/spouse, children, other
(specify))
Tobacco Use
How did you hear about {other specified product}?
Tobacco Use
How did you hear about Accord?
Yes; No;
Free text (see on-line HINTS codebook for full
list of responses)
In a newspaper; In a magazine; On television;
Other (specify);
From a doctor or health care provider; From
family or friends; In a newspaper; In a
magazine; On the radio; On the internet; On
television; Saw it in a store; Other (specify);
Not ascertained; Refused; Don't know;
Tobacco Use
How did you hear about Eclipse?
Tobacco Use
How good or bad would it be if the average {male/female} cigarette
smoker developed lung cancer in the future? (very bad, slightly
bad, neither bad nor good, slightly good, very good)
Tobacco Use
How good or bad would it be if you developed lung cancer in the
future? (very bad, slightly bad, neither bad nor good, slightly good,
very good)
Tobacco Use
How good or bad would it be if you developed lung cancer in the
future? (very bad, slightly bad, neither bad nor good, slightly good,
very good)
Tobacco Use
How likely do you think it is that the average {male/female}
cigarette smoker will develop lung cancer in the future?
Page 51
Construct
Tobacco Use
Question
How likely do you think it is that you will develop lung cancer in
the future?
Response Options
Tobacco Use
How likely would you be to call a smoking cessation telephone quit Very likely; Somewhat likely; Somewhat
line in the future, for any reason?
unlikely; Very unlikely;
Tobacco Use
How many cigarettes per day {do you/does PERSON} usually
smoke anywhere inside the home?
Tobacco Use
How many times during the past 12 months have you stopped
smoking for one day or longer because you were trying to quit
smoking?
Tobacco Use
How much less harmful? (a lot less harmful, somewhat less
harmful, a little less harmful)
How often do you now smoke cigarettes...
Tobacco Use
How old were you when you first started smoking regularly?
Tobacco Use
How old were you when you started smoking?
Tobacco Use
If a new cigarette advertised as less harmful than current cigarettes
was available, how important would each of the following qualities
be for you in considering whether to completely switch to such a
product? [using a scale of 1 to 5 where 1 is not at all important and
5 is extremely important]: harm reduction/taste/price/ability to
easily inhale/looks like ordinary cigarette/satisfies desire for
tobacco/helps me manage moods/produces less secondhand
smoke
Tobacco Use
If a new cigarette were advertised as less harmful than current
cigarettes, how interested would you be in trying it?
Tobacco Use
If a new smokeless tobacco product advertised as less harmful than
current cigarettes was available, how important would each of the
following qualities be for you in considering whether to switch to
such a product? Extent of harm reduction/taste/price/no need to
spit/dissolves in mouth/satisfies desire for tobacco/helps manage
moods
Tobacco Use
If a new smokeless tobacco product that didn’t require spitting
were advertised as less harmful than current cigarettes, how
interested would you be in trying it?
Tobacco Use
If a new spitless, smokeless tobacco product were developed that
was scientifically proven to be less harmful than ordinary
cigarettes, how likely would you be to try it? Would you say very
likely, somewhat likely, not very likely, or not at all likely?
Tobacco Use
If more than never, may probe to ask where they saw this
information?
Tobacco Use
If plan to quit: Have you set a firm quit date? (Y/N)
Tobacco Use
Page 52
Open Ended
Open ended (restricted to plausible values for
age)
Construct
Question
Response Options
Tobacco Use
If the government were to ban the use of menthol in cigarettes,
how might this affect your smoking? Would you switch to a nonmenthol brand or would you try to quit smoking? (switch to a nonmenthol brand, try to stop smoking, both switch to a non-menthol
brand and try to quit smoking, not applicable, refused, don't know)
Tobacco Use
If Yes: Do you believe that if this agency regulates tobacco products
before they can be sold to consumers, this makes tobacco products
less harmful? Y/N
Tobacco Use
If Yes: Which government agency or agencies regulate(s) tobacco
products? (Choose all the apply: Centers for Disease Control, Food
and Drug Administration, Surgeon General, National Institutes for
Health…)
Tobacco Use
In the last 12 months, about how often have you seen or heard a
news story related to smoking, tobacco, or tobacco companies that
might have been on TV, radio, magazines, or in the newspapers?
(never, rarely, sometimes, often, very often)
Tobacco Use
In the last 12 months, have you noticed cigarettes or tobacco
products being advertised in any of the following places (Y/N:
internet, email, television, radio, cinema/movie theater before or
after the film/movie; posters or billboards; newspapers or
magazines; shop/store windows or inside shops/stores where you
buy tobacco; where else open ended).
Tobacco Use
In the last 30 days, have the warning labels stopped you from
having a cigarette when you were about to smoke one? (1, never;
2, once; 3, a few times; 4, many times)
Tobacco Use
In the last 30 days, have you made an effort to avoid looking at or
thinking about the warning labels (by covering the warnings up, by
keeping the pack out of sight, by using a cigarette case or some
other pack, by not buying packs with particular labels- (yes,no to
each of the above))
Tobacco Use
In the last 30 days, have you noticed advertising or information
about the dangers of smoking or encouraged quitting on cigarette
packages? (Y/N)
Tobacco Use
In the last 30 days, how often, if at all, have you noticed the
warning labels on cigarette packages or cigarette advertisements?
(1, never; 2, rarely; 3, sometimes; 4, often; 5, very often)
Tobacco Use
In the last 30 days, how often, if at all, have you read or looked
closely at the warning labels on cigarette packages or cigarette
advertisements? (1, never; 2, rarely; 3, sometimes; 4, often; 5, very
often)
Page 53
Construct
Question
Response Options
Tobacco Use
In the last 30 days, to what extent have the warning labels led you
to think about quitting smoking? (1, never; 2, once; 3, a few times;
4, many times)
Tobacco Use
In the last 30 days, to what extent have the warning labels made
you think about the health risks of smoking? (1, never; 2, once; 3, a
few times; 4, many times)
Tobacco Use
In the past 12 months have you quit or tried to quit smoking?
Tobacco Use
In the past 12 months, did any doctor, dentist, nurse or other health Yes; No; Has not smoked in the past 12
professional suggest that you call or use a telephone helpline or
months; Did not see health care provider in
quit line to help you quit smoking?
last 12 months; Don't know;
Tobacco Use
In the past 6 months, how often, if at all, have you noticed
advertising or information that talks about the dangers of smoking,
or encourages quitting? (never, rarely, sometimes, often, very
often)
Tobacco Use
Is the main reason you now smoke this type of cigarette because it
is a way to reduce the health risks of smoking, to try to quit
smoking, because of the taste, or for some other reason?
Tobacco Use
Is the main reason you now smoke ultra light, light, medium, or
some other type of cigarette because it is a way to reduce the
Free text (see on-line HINTS codebook for full
health risks of smoking, to try to quit smoking, because of the taste, list of responses)
or for some other reason?
Tobacco Use
Menthol cigarettes should be prohibited just like other flavored
cigarettes. (strongly agree, agree, disagree, strongly disagree)
Tobacco Use
Menthol flavoring in cigarettes should be banned.(strongly agree,
agree, disagree, strongly disagree)
Tobacco Use
New types of cigarettes are now available that are supposed to be
less harmful than ordinary cigarettes. Have you heard of such
products? Y/N
Tobacco Use
New types of smokeless tobacco products are now available that
are put in the mouth but don’t involve chewing or spitting. Some
come in teabag-like pouches and some come in the form of a
lozenge or tablet. Have you heard of any products like this? Y/N
Tobacco Use
New types of tobacco products are now available that come in
teabag-like pouches that are put in the mouth, under the lip. They
do not involve chewing, spitting, or smoking. Have you heard of any
products like this? (yes/no)
Tobacco Use
Next are some questions about new types of tobacco products that
have been recently introduced. Have you ever heard of a tobacco
product called Eclipse?
Tobacco Use
Now I'd like you to compare these new tobacco products to
ordinary cigarettes. In your opinion, are these new products more
harmful, less harmful, or as harmful to the user as ordinary
cigarettes? (more harmful/less/as)
Page 54
Construct
Question
Response Options
Tobacco Use
On balance, how did the news stories you saw or heard portray
smoking? Were they: all pro-smoking; mostly pro-smoking; equally
pro- and anti-smoking; mostly anti-smoking; all anti-smoking?
Tobacco Use
On how many of the past 30 days, did you smoke a cigarette?
Tobacco Use
On the average, how many cigarettes do you now smoke a day?
None; 1-9; 10-19; 20-29; 30-39; 40+;
Tobacco Use
On the average, when you smoked during the past 30 days, about
how many cigarettes did you smoke a day?
0; 1; 2; 3; 4; 5; 6; 8; 10; 12; 15; 20;
Refused; Don't know;
Tobacco Use
extremely unfavorable1]; somewhat
Overall, how favorable or unfavorable do you feel toward cigarette
unfavorable2]; neutral3]; somewhat
smoking?
favorable4]; extremely favorable5]
Tobacco Use
The federal government should restrict what is in cigarettes.
(strongly agree, agree, disagree, strongly disagree)
Tobacco Use
The government has no business telling tobacco companies what
they can and cannot do. (strongly agree, agree, disagree, strongly
disagree)
Tobacco Use
The government should put larger warning labels covering half of
the front of a pack of cigarettes to discourage people from smoking.
(strongly agree, agree, disagree, strongly disagree)
Tobacco Use
The government should reduce the amount of nicotine in cigarettes
so that kids who experiment with smoking do not become addicted
(strongly agree, agree, disagree, strongly disagree)
Tobacco Use
The government should reduce the amount of nicotine in cigarettes
to help smokers quit. (strongly agree, agree, disagree, strongly
disagree)
Tobacco Use
Tobacco companies have also recently introduced new types of
smokeless tobacco products. Have you ever tried one of these
products?
Tobacco Use
Tobacco companies have also recently introduced new types of
smokeless tobacco products. These have names like Arriva, Exalt,
and Revel. Have you ever tried one of these products?
Tobacco Use
Tobacco companies have recently introduced new types of
cigarettes that are claimed to have fewer harmful chemicals or
carcinogens. Have you ever tried one of these products?
Page 55
Construct
Question
Response Options
Tobacco Use
Tobacco companies have recently introduced new types of
cigarettes that are claimed to have fewer harmful chemicals or
carcinogens. These have names like Eclipse, Accord, Advance, and
Omni. Have you ever tried one of these products?
Tobacco Use
What do you remember about the law or the changes about
tobacco?
Tobacco Use
What is the main reason you {use/tried or used} {FILL}?
Instead of quitting, as a way to reduce health
risks; As a way of cutting down the number of
cigarettes/other cigarettes smoked; To help
you quit smoking; Because of the taste;
Because lower costs/cheaper than
cigarettes/other cigarettes/other ty
Tobacco Use
What other new types of tobacco products have you heard of?
Omni; Exalt; Stonewall;
Tobacco Use
When it comes to this government agency's ability to regulate
cigarettes, this agency is: not at all qualified to very qualified (5
point likert scale)
Tobacco Use
When you last smoked every day, how many cigarettes did you
usually smoke each day?
Free text (see on-line HINTS codebook for full
list of responses)
Tobacco Use
Which new product have you tried? (First Response)
Eclipse; Marlboro ultrasmooth; Quest;
Smokeless tobacco, mint scented cigarette,
macdonal twist, spirit, digraham,;
Tobacco Use
Tobacco Use
Which statement best describes the rules about smoking inside
your home?
Within the last 30 days, on how many days did you use tobacco
from a waterpipe (hookah)?
Tobacco Use
Would you say that smoking from a waterpipe (hookah, shisha,
narghile, goza) is more harmful or less harmful than smoking
regular cigarettes? (much more harmful to much less harmful, five
response categories).
Tobacco Use
Would you say that you plan to quit smoking, you don't plan to quit,
or you're undecided?
Page 56
[Number of times in 30 days]
Construct
Question
Response Options
Tobacco Use
Would you say the average smoker has about the same lung cancer
risk as a non-smoker, a little higher lung cancer risk than a nonsmoker, twice the non-smoker's risk, 5 times the non-smoker's risk
or 10 or more times the non-smoker's risk?
Tobacco Use
Would you say you have about the same lung cancer risk as a nonsmoker, a little higher lung cancer risk than a non-smoker, twice
the non-smoker's risk, 5 times the non-smoker's risk, or 10 or more
times the non-smoker's risk?
Tobacco Use
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree or you have no opinion with the
statement: Exercise can undo most of the effects of smoking.
Tobacco Use
You said you have heard of {FILL WITH LIST OF ITEMS
MENTIONED IN TU-18A-Jii}. Have you ever tried {this product/any
of these products}?
Tobacco:
Behavioral
Tradeoff
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree or you have no opinion with the
statement: Exercise can undo most of the effects of smoking.
Tobacco:
Behavioral
Tradeoff
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree or you have no opinion with the
statement: There's no risk of getting cancer if someone only
smokes a few years.
Tobacco:
Behavioral
Tradeoff
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree or you have no opinion with the
statement: Vitamins can undo most of the effects of smoking.
Tobacco: Cessation
Before being contacted for this survey, had you ever heard of 1-800QUIT-NOW?
Before being contacted for this survey, had you ever heard of
Tobacco: Cessation telephone quit lines such as a toll-free number to call for help in
quitting smoking?
Tobacco: Cessation
Have you ever called a telephone quit line to help you or someone
else quit smoking?
Tobacco: Cessation
Have you ever used a website or online program to help you or
someone else quit smoking?
Tobacco: Implicit
Theories
Y/N
I think your smoking behavior is something basic about you that
you can't change very much"
Tobacco:
Intentions
How interested are you in switching to a smokeless tobacco
product?
Tobacco:
Intentions
How likely would you be to switch to a smokeless tobacco product
instead of trying to quit smoking?
Page 57
Very Interested/Somewhat Interested/ Not
Interested/ Refused/ Don't know
Construct
Tobacco:
Pluralistic
Ignorance
Question
Response Options
How worried are you that your smoking will lead to lung cancer?
Tobacco:
Pluralistic
Ignorance
How worried do you think other smokers are that their smoking
will lead to lung cancer
Tobacco: Product
Packaging
To what extent does the color of the cigarette pack give you
information on the harmfulness of the cigarette?
not at all, a little, somewhat, a lot
A type of device known as a waterpipe (also known as hookah,
narghile, shisha, and goza) contains a smoke chamber, a bowl, a
Tobacco: Products pipe and a hose. Specially made tobacco is heated, and the smoke Y/N (if no, skips next 3 items)
passes through water and is then drawn through a rubber hose to a
mouthpiece. Have you heard of any devices like this?
Do you believe that cigarettes sold in packages labeled as "smooth" much more harmful to much less harmful, five
response categories, I have never heard of
Tobacco: Products are (LESS HARMFUL, EQUALLY HARMFUL, or MORE HARMFUL)
smooth cigarettes
than cigarettes without those labels?
Do you believe that menthol cigarettes are (LESS HARMFUL,
Tobacco: Products EQUALLY HARMFUL, or MORE HARMFUL) than non-menthol
cigarettes?
Tobacco: Products
much more harmful to much less harmful, five
response categories, I have never heard of
menthol cigarettes
Have you ever heard of dissolvable tobacco products, such as Ariva,
Yes/No (if no, skips next 3 items)
Stonewall, or Camel orbs, ticks, or strips?
Tobacco: Products Have you ever used a waterpipe to smoke tobacco?
Y/N
Tobacco: Products Have you ever used an electronic cigarette?
y/n
Tobacco: Products
Have you ever used dissolvable tobacco products, such as Ariva,
Stonewall, or Camel orbs, ticks, or strips?
New types of cigarettes are now available called electronic
cigarettes (also known as e-cigarettes or personal vaporizers).
Tobacco: Products These products deliver nicotine through a vapor. Have you heard
of any products like this?
Tobacco: Products
What type of cigarette do you now smoke most often -- a regular,
light, ultra light or some other type?
Tobacco: Products Where did you hear about electronic cigarettes?
Tobacco: Products
Would you say that e-cigarettes are more addictive or less
addictive than smoking regular cigarettes?
Y/N
Y/N (if no, skips next 4 items)
regular, light, ultra light, some other type,
*don't know
radio, television, newspaper, magazine…
much more addictive to much less addictive
five response categories
Would you say that smoking from a waterpipe (hookah, shisha,
Tobacco: Products narghile, Goza) is more addictive or less addictive than smoking
regular cigarettes?
much more addictive to much less addictive,
five response categories
Would you say that smoking from a waterpipe (hookah, shisha,
Tobacco: Products narghile, goza) is more harmful or less harmful than smoking
regular cigarettes?
much more harmful to much less harmful, five
response categories
Page 58
Construct
Question
Response Options
Would you say that using dissolvable tobacco products, such as
much more addictive to much less addictive
Tobacco: Products Ariva, Stonewall, or Camel orbs, ticks, or strips is more addictive or
five response categories
less addictive than smoking regular cigarettes?
Would you say that using dissolvable tobacco products, such as
Tobacco: Products Ariva, Stonewall, or Camel orbs, ticks, or strips is more harmful or
less harmful than smoking regular cigarettes?
much more harmful to much less harmful, five
response categories
Would you say that using electronic cigarettes is more harmful or
less harmful than smoking regular cigarettes?
much more harmful to much less harmful, five
response categories
Tobacco:
Regulation
Tobacco:
Regulation
Do you believe that government regulation of cigarettes make
cigarettes safer.
Yes/No
Do you believe that government regulation of cigarettes will…
make cigarettes less harmful; have no effect,
make cigarettes more harmful
Tobacco:
Regulation
Do you believe that some cigarettes are less harmful than others
because of government regulation?
Yes/No
Tobacco:
Regulation
Do you believe that the government regulates tobacco products in
the U.S.?
Yes/No (skip)
Tobacco:
Regulation
For persons who quit smoking during the past six months: To what
extent did cigarette warnings on cigarette packages or cigarette
advertisements influence your decision to quit smoking?
not at all, at little, some, a lot, don’t know/not
applicable
Tobacco:
Regulation
Government regulation of cigarettes make cigarettes less harmful.
strongly agree, agree, disagree, strongly
disagree
Tobacco:
Regulation
In the past 30 days, have the warning labels stopped you from
having a cigarette when you were about to smoke one?
never; once; a few times; many times
Tobacco:
Regulation
In the past 30 days, have you made an effort to avoid looking at or
thinking about the warning labels?
Check all that apply:
by covering the warnings up
by keeping the pack out of sight
by using a cigarette case or some other pack
by not buying packs with particular labels
Tobacco:
Regulation
In the past 30 days, have you noticed information about the
dangers of smoking on cigarette packages?
Yes/No
Tobacco:
Regulation
In the past 30 days, have you noticed messages that have
encouraged quitting on cigarette packages?
Yes/No (if no, skip next 7 cigarette warning
labels items)
Tobacco:
Regulation
In the past 30 days, how often have the warning labels on cigarette
never, rarely, sometimes, often, don’t know/not
packages or cigarette advertisements made you think about
applicable
quitting smoking?
Tobacco: Products
never; rarely; sometimes; often; very often
Tobacco:
Regulation
Tobacco:
Regulation
In the past 30 days, how often have you noticed the warning labels Alternate: every time I saw a package or
on cigarette packages or cigarette advertisements?
advertisement; almost every time I saw a
package or advertisement; sometimes…
rarely… I never noticed the warning labels
In the past 30 days, how often have you noticed the warning labels I did not see a smokeless tobacco product
on smokeless tobacco packages or smokeless tobacco
during the past 30 days, Never, Rarely,
advertisements?
Sometimes, Most of the time, Always
Page 59
Construct
Question
Response Options
Tobacco:
Regulation
In the past 30 days, how often have you read or looked closely at
the warning labels on cigarette packages or cigarette
advertisements?
Tobacco:
Regulation
In the past 30 days, to what extent did warning labels on smokeless Not at all, A little, Somewhat, A lot, I did not see
tobacco packages or smokeless tobacco advertisements make you a warning label on a smokeless tobacco
think about the health risks of smokeless tobacco?
product in the past 30 days
Tobacco:
Regulation
In the past 30 days, to what extent have warning labels on cigarette Not at all, A little, Somewhat, A lot, I did not see
packages or cigarette advertisements made you think about the
a warning label on a smokeless tobacco
health risks of smoking?
product in the past 30 days
Tobacco:
Regulation
Is tobacco safer now than it was 5 years ago?
Tobacco: Risk
Perception
Assuming you continue to smoke the same number of cigarettes
and same type of cigarette that you currently do every day, what is
your risk of getting (lung) cancer {in the next 10 years/ in the next
25 years/in your lifetime}?
Tobacco: Risk
Perception
Based on what you know or believe, does smoking cigarettes cause:
(list specific diseases - head and neck cancer, lung cancer, cervical
Check List?
cancer, bladder cancer, heart disease, stroke, Pneumonia,
Pancreatic Cancer….)?
Tobacco: Risk
Perception
Compared to other {men/women} your age who smoke the same
number of cigarettes and same type of cigarette as you do, how
likely are you to get lung cancer in your lifetime?
1=5 point scale with 1=very unlikely
Tobacco: Risk
Perception
Compared with other {men/women} your age, how likely are you
to get lung cancer in your lifetime?
1=5 point scale with 1=very unlikely
Tobacco: Risk
Perception
Do you believe that some cigarettes are less harmful than others?
Tobacco: Risk
Perception
Do you believe that some smokeless tobacco products, such as
chewing tobacco, snus, and snuff, are less harmful than cigarettes?
Tobacco: Risk
Perception
How likely are you to get lung cancer in your lifetime?
1-5 point scale with 1= very unlikely
Tobacco: Risk
Perception
How likely is it that the average {man/woman} cigarette smoker
your age will get lung cancer in {his/her} lifetime?
1=5 point scale with 1=very unlikely
Tobacco: Risk
Perception
How long do you think someone has to smoke before it harms their
Less than a year, 1 year, 5 years, 10 years, 20
health?
years or more
Tobacco: Risk
Perception
How much do you think people risk harming themselves when they
No risk, Slight risk, Moderate risk, Great risk
smoke cigarettes every day but less than a pack per day?
Tobacco: Risk
Perception
Tobacco: Risk
Perception
never; rarely; sometimes; often; very often
(don't know, not applicable)
strongly agree, agree, disagree, strongly
disagree
How much do you think people risk harming themselves when they
smoke cigarettes some days but not everyday?
No risk, Slight risk, Moderate risk, Great risk
How much do you think people risk harming themselves when they
use smokeless tobacco everyday?
No risk, Slight risk, Moderate risk, Great risk
Page 60
Construct
Question
Response Options
Tobacco: Risk
Perception
How much do you think people risk harming themselves when they
No risk, Slight risk, Moderate risk, Great risk
use smokeless tobacco some days but not everyday?
Tobacco: Risk
Perception
How worried are you about getting lung cancer?
(1) not at all to (5) extremely
Tobacco: Risk
Perception
If a new cigarette were advertised as less harmful than current
cigarettes, how interested would you be in trying it?
Very Interested/Somewhat Interested/ Not
Interested/ Refused/ Don't know
Tobacco: Risk
Perception
If a new electronic cigarette product were advertised as less
harmful than current cigarettes, how interested would you be in
trying it?
Very Interested/Somewhat Interested/ Not
Interested/ Refused/ Don't know
Tobacco: Risk
Perception
If a new smokeless tobacco product were advertised as less
harmful than current cigarettes, how interested would you be in
trying it?
Very Interested/Somewhat Interested/ Not
Interested/ Refused/ Don't know
Tobacco: Risk
Perception
If you continue to smoke the same number of cigarettes and same
type of cigarette that you currently do every day {for the next 10
Response Options would be either a percentage
years/ for the next 25 years/ for the rest of your life}, how likely do or Likert scale.
you think you are to get a disease due to your smoking?
Tobacco: Risk
Perception
Tobacco: Risk
Perception
In the past 30 days, how often have you thought about the harmful
chemicals in tobacco products?
Never, Rarely, Sometimes, Often, Very Often
very rare, moderately rare, slightly rare,
neither rare or common, slightly common,
moderately common, very common
Lung Cancer in the United States is:
Trust and Mistrust How much would you trust information about cancer from cable
Items
and national television news programs?
A lot; Some; A little; Not at all; Refused; Don't
know;
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
How much would you trust information about cancer from local
television news programs?
How much would you trust information about cancer in general
magazines?
How much would you trust information about cancer in online
newspapers?
How much would you trust information about cancer in print
newspapers?
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
Trust and Mistrust How much would you trust information about cancer in special
Items
health or medical magazines or newsletters?
A lot; Some; A little; Not at all; Refused; Don't
know;
Trust and Mistrust How much would you trust information about health or medical
Items
topics from cable and national television news programs?
Not at all to A lot
Trust and Mistrust How much would you trust information about health or medical
Items
topics from local television news programs?
Not at all to A lot
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
How much would you trust information about health or medical
topics in general magazines?
How much would you trust information about health or medical
topics in magazines?
How much would you trust information about health or medical
topics in newspapers?
How much would you trust information about health or medical
topics in online newspapers?
Page 61
Not at all to A lot
Not at all to A lot
Not at all to A lot
Not at all to A lot
Construct
Question
Trust and Mistrust How much would you trust information about health or medical
Items
topics in print newspapers?
Response Options
Not at all to A lot
Trust and Mistrust How much would you trust information about health or medical
Items
topics in special health or medical magazines or newsletters?
Not at all to A lot
Trust and Mistrust How much would you trust the information about cancer from a
Items
doctor or other health professional?
A lot; Some; A little; Not at all; Refused; Don't
know;
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused;
Don't know;
A lot; Some; A little; Not at all; Refused;
Don't know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
How much would you trust the information about cancer from
family or friends?
How much would you trust the information about cancer from
magazines?
How much would you trust the information about cancer from
newspapers?
How much would you trust the information about cancer from
television?
How much would you trust the information about cancer from the
Internet?
How much would you trust the information about cancer from the
radio?
Trust and Mistrust In general, how much would you trust information about health or A lot; Some; A little; Not at all; Refused;
Items
medical topics from family or friends?
Don't know;
Trust and Mistrust In general, how much would you trust information about health or A lot; Some; A little; Not at all; Refused;
Items
medical topics in newspapers or magazines?
Don't know;
Trust and Mistrust In general, how much would you trust information about health or A lot; Some; A little; Not at all; Refused;
Items
medical topics on television?
Don't know;
Trust and Mistrust In general, how much would you trust information about health or A lot; Some; A little; Not at all; Refused;
Items
medical topics on the Internet?
Don't know;
Trust and Mistrust In general, how much would you trust information about health or A lot; Some; A little; Not at all; Refused;
Items
medical topics on the radio?
Don't know;
In general, how much would you trust information about health or
A lot; Some; A little; Not at all; Refused;
Trust and Mistrust
medical topics from a doctor or other health care professional?
Don't know;
Items
Would you say a lot, some, a little, or not at all?
Trust and Mistrust In general, how much would you trust information about health or A lot; Some; A little; Not at all; Refused;
Items
medical topics from charitable organizations?
Don't know;
Trust and Mistrust In general, how much would you trust information about health or A lot; Some; A little; Not at all; Refused;
Items
medical topics from government health agencies?
Don't know;
Trust and Mistrust In general, how much would you trust information about health or A lot; Some; A little; Not at all; Refused;
Items
medical topics from religious organizations and leaders?
Don't know;
Trust and Mistrust In general, I think that the information I give doctors is safely
Items
guarded when the information is stored in an electronic format.
Strongly Agree-Strongly Disagree
Trust and Mistrust In general, I think that the information I give doctors is safely
Items
guarded when the information is stored on paper
Strongly Agree-Strongly Disagree
Trust and Mistrust In general, I think that the information I give doctors is safely
Items
guarded.
Strongly Agree-Strongly Disagree
Page 62
Construct
Question
Response Options
Below are some ways people use the Internet. Some people have
done these things, but other people have not. Please tell us
whether or not you have done each of these things while using the
Internet in the past 12 months.
'Looked for information about quitting smoking?;
Bought medicine or vitamins on-line?;
Participated in an on-line support group for people with a similar
health ; or medical issue?;
Used e-mail or the Internet to communicate with a doctor or a
doctor's office?;
YES/NO
Use of Technology Used a website to help you with your diet, weight, or physical
activity?;
Looked for a healthcare provider?;
Downloaded to a mobile device, such as an MP3 player, cell phone, ;
tablet computer, or electronic book device?;
Visited a "social networking" site, such as "Facebook" or
"LinkedIn"? ;
Wrote in an online diary or "blog" (i.e., Web log)? ;
Kept track of personal health information, such as care received, ;
test results, or upcoming medical appointments? ;
Looked for health or medical information for someone else?
Use of Technology
Do you ever go on-line to access the Internet or World Wide Web,
or to send and receive e-mail?
Yes; No; Refused; Don't know;
Use of Technology
Do you ever use your cell phones hands free device to minimize
radiation exposure?
Yes/No
Use of Technology Do you or anyone in your household have cable or satellite TV?
Yes; No; Refused; Don't know;
Use of Technology Do you use the Internet from home?
Yes; No; Refused; Don't know;
Use of Technology Does anyone in your family have a working cellular phone?
Yes; No;
Use of Technology
During a typical weekend, about how many hours do you use the
Internet for personal reasons?
Use of Technology Have you done anything else health-related on the Internet?
Use of Technology
Have you ever posted comments, queries or information about
health or medical matters in an online discussion or a listserv?
Yes/No
VERY CONCERNED, SOMEWHAT CONCERNED,
NOT CONCERNED
VERY CONCERNED, SOMEWHAT CONCERNED,
Use of Technology How concerned are you with the security of your medical records?
NOT CONCERNED
Use of Technology How concerned are you with the privacy of your medical records?
Use of Technology
How interested would you be in having your health care provider VERY INTERESTED, SOMEWHAT INTERESTED,
communicate with you about health matters using text messaging? NOT AT ALL INTERESTED
I want my health care provider to use a computerized medical
Use of Technology record to store and manage my health information despite any
concerns I might have about privacy and security.
Page 63
STRONGLY AGREE, AGREE, DISAGREE,
STRONGLY DISAGREE
Construct
Question
Response Options
I want my health care providers to use a computer to share my
Use of Technology health information with other health care providers treating me
despite any concerns I might have about privacy and security.
STRONGLY AGREE, AGREE, DISAGREE,
STRONGLY DISAGREE
If medical information about appointments and other
health/medical matters could be shared with you via text
Use of Technology
messaging, how concerned are you that an unauthorized person
could intercept that information while it is being sent?
VERY CONCERNED, SOMEWHAT CONCERNED,
NOT CONCERNED
If medical information about you is sent from one of your health
Use of Technology care providers to another by fax, how concerned are you that an
unauthorized person would see it?
VERY CONCERNED, SOMEWHAT CONCERNED,
NOT CONCERNED
If medical information about you is sent from one of your health
care providers to another electronically, how concerned are you
Use of Technology that an unauthorized person would see it? (Electronically means
from computer to computer, instead of by telephone, mail, or fax
machine.)
VERY CONCERNED, SOMEWHAT CONCERNED,
NOT CONCERNED
If your health care provider could communicate with you about
health matters via text messaging, how concerned are you that an VERY CONCERNED, SOMEWHAT CONCERNED,
Use of Technology
unauthorized person would see it on your cell phone; for example, NOT CONCERNED
if your cell phone is stolen or lost?
In the past 12 months, have you done the following things while
Use of Technology using the Internet: Downloaded to a portable device, such as an
iPod, cell phone, or PDA?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Looked for health or medical information for
yourself?
Use of Technology
In the past 12 months, have you done the following things while
using the Internet? Bought medicine or vitamins on-line?
Yes; No; Refused; Don't know;
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Done anything else health-related on the
Internet? (SPECIFY)
Use of Technology
In the past 12 months, have you done the following things while
using the Internet? Looked for a healthcare provider?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Looked for health or medical information for
someone else?
Use of Technology
Yes; No; Refused; Don't know;
In the past 12 months, have you done the following things while
Yes; No; Refused;
using the Internet? Looked for information about diet or nutrition?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Looked for information about physical activity
or exercise?
Page 64
Yes; No; Refused; Don't know;
Construct
Question
Response Options
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Participated in an on-line support group for
people with a similar health or medical issue?
Yes; No; Refused;
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Used a website to help you with your diet,
weight, or physical activity?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Used e-mail or the Internet to communicate
with a doctor or a doctor's office?
Yes; No; Refused;
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Visited a "social networking" site, such as
MySpace or Second Life?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Wrote in an online diary or "blog" (i.e., Web
log)?
Use of Technology
In the past 12 months, how often did you use the Internet to look
for health or medical information [for yourself (or) someone else]?
Use of Technology
In the past 12 months, how often have you used the Internet to look
for advice or information about cancer?
Use of Technology
Is there at least one telephone inside your home that is currently
working and is not a cell phone?
Use of Technology
On a typical weekday, about how many hours do you use the
Internet for personal reasons?
Over the past year, have you withheld information from a health
Use of Technology care provider because you were concerned about the privacy of
your medical record?
Yes; No;
Yes/No
Please tell me if you ever use the internet to do any of the following
things. Do you ever use the internet to … Participate in an online
Yes/No (Dont know)
Use of Technology
discussion or a listserv that helps people with personal issues or
health problems
Please tell me if you ever use the internet to do any of the following
Use of Technology things. Do you ever use the internet to…Create or work on your
Yes/No
own online journal or blog
Please tell me if you ever use the internet to do any of the following
Use of Technology things. Do you ever use the internet to…Look for information on
Yes/No
Wikipedia
Please tell me if you ever use the internet to do any of the following
Use of Technology things. Do you ever use the internet to…Read someone else’s online Yes/No
journal or blog
Please tell me if you ever use the internet to do any of the following
Yes/No
Use of Technology things. Do you ever use the internet to…Use a social networking
site like MySpace or Facebook
Page 65
Construct
Question
Response Options
Please tell me if you ever use the internet to do any of the following
things. Do you ever use the internet to…Use Twitter or another
Use of Technology
Yes/No
service to share updates about yourself or to see updates about
others
There are many different activities related to health and medical
issues a person might do on the internet. I’m going to read a list of
things you may or may not have ever done online related to health
and medical issues. Just tell me if you happened to do these things.
a. Signed up to receive updates about health or medical issues
b. Read someone else's commentary or experience about health or
medical issues on an online news group, website or blog
c. Listened to a podcast about health or medical issues
Use of Technology f. Consulted rankings or reviews online of doctors or other
providers
g. Consulted rankings or reviews online of hospitals or other
medical facilities
h. Posted a review online of a doctor
i. Posted a review online of a hospital
j. Shared photos, videos or audio files online about health or
medical issues
k. Tagged or categorized online content about health or medical
issues
Yes/No for
Thinking about what you have done on social networking sites like
Use of Technology Facebook and MySpace, have you followed your friends’ or
Yes/No
relatives’ personal health experiences or updates on the site?
Thinking about what you have done on social networking sites like
Use of Technology Facebook and MySpace, have you gotten any health information on Yes/No
the sites?
Thinking about what you have done on social networking sites like
Use of Technology Facebook and MySpace, have you started or joined a health-related Yes/No
group on a social networking site?
Use of Technology
When purchasing a cell phone, do you consider how much
radiation it emits as part of your purchase decision?
Use of Technology
When was the last time you used the Internet to look for
information about health or medical care?
Use of Technology
When you use the Internet at home, do you mainly access it
through...
When you use the Internet at home, do you mainly access it
Use of Technology through…a wireless device such as a PDA, telephone modem, DSL
modem, cable or satellite modem, some other way (SPECIFY)?
Page 66
Yes/No
Do not use the Internet at home
A regular ‘dial-up’ telephone line; Broadband
(such as DSL, cable, FiOS); Mobile wireless
broadband (such as a 4G network); Something
else (specify)
Free text (see on-line HINTS codebook for full
list of responses)
Construct
Use of Technology
Question
Response Options
When you use the Internet, do you mainly access it through a
telephone modem or some other way?
Free text (see on-line HINTS codebook for full
list of responses)
Use of Technology Where do you go to use the Internet?
Use of Technology Where do you use the Internet?
Use of Technology
Which of the following, if any, are the reasons you do not access the
Internet? Because it costs too much.
Use of Technology
Which of the following, if any, are the reasons you do not access the
Internet? Because it is too complicated to use.
Use of Technology
Which of the following, if any, are the reasons you do not access the
Internet? Because you are not interested.
Use of Technology
Which of the following, if any, are the reasons you do not access the
Internet? Because you do not think it is useful.
Values/Aspiration
I will be physically healthy
s
1-5; 1= not at all important; 2= a little
important; 3= moderately important; 4= very
important; 5= extremely important
Values/Aspiration
My image will be one others find appealing.
s
1-5; 1= not at all important; 2= a little
important; 3= moderately important; 4= very
important; 5= extremely important
Values/Aspiration
My physical appearance will be one others find appealing
s
1-5; 1= not at all important; 2= a little
important; 3= moderately important; 4= very
important; 5= extremely important
Water Source
Are you concerned there may be chemicals in the water you drink
that may be harmful to you?
Yes; No
Water Source
How often do you use plastic water bottles?
1-2 times per week; 2-4 times per week; 4-6
times per week; greater than 6 times per week
Water Source
What is your primary source of drinking water?
Bottles; well; tap; other (please specify)
Weight Stigma
Concerns
Being overweight will influence how people will act with me.
Strongly Disagree; Disagree, Somewhat
Disagree, Neither Agree nor Disagree;
Somewhat Agree; Agree; Strongly Agree
Weight Stigma
Concerns
I am afraid that other people will reject me because of my weight.
Strongly Disagree; Disagree, Somewhat
Disagree, Neither Agree nor Disagree;
Somewhat Agree; Agree; Strongly Agree
Weight Stigma
Concerns
Strongly Disagree; Disagree, Somewhat
I am concerned that I will not be treated fairly by others because of
Disagree, Neither Agree nor Disagree;
my weight.
Somewhat Agree; Agree; Strongly Agree
Weight Stigma
Concerns
Most people will not judge me on the basis of my weight.
Strongly Disagree; Disagree, Somewhat
Disagree, Neither Agree nor Disagree;
Somewhat Agree; Agree; Strongly Agree
Weight Stigma
Concerns
Stereotypes about people who are heavyweight will affect me
personally.
Strongly Disagree; Disagree, Somewhat
Disagree, Neither Agree nor Disagree;
Somewhat Agree; Agree; Strongly Agree
Page 67
Construct
Question
Response Options
Strongly Disagree; Disagree, Somewhat
Disagree, Neither Agree nor Disagree;
Somewhat Agree; Agree; Strongly Agree
Weight Stigma
Concerns
Weight Stigma Concerns
Weight Stigma
Concerns
Strongly Disagree; Disagree, Somewhat
When interacting with people, I am concerned that their opinion of
Disagree, Neither Agree nor Disagree;
me will be based on my weight.
Somewhat Agree; Agree; Strongly Agree
Weight/Weight
Loss
In your efforts to manage your weight, which of the following
strategies have you used (check all that apply):
Worry
How much has worry about cancer affected your daily life?
Worry
How much has worry about getting cancer caused you to change
your behavior?
Worry
How worried are you about getting cancer?
Worry
I feel I will get cancer.
strongly disagree1]; disagree2]; Neither
disagree nor agree3]; agree4]; strongly agree5]
Worry
I feel very vulnerable to cancer.
strongly disagree1]; disagree2]; Neither
disagree nor agree3]; agree4]; strongly agree5]
Page 68
Change eating behaviors; Change physical
activity behaviors; Use pills or supplements;
Purchase exercise equipment
not at all1]; slightly2]; somewhat3];
moderately4]; extremely5]
not at all1]; slightly2]; somewhat3];
moderately4]; extremely5]
not at all1]; slightly2]; somewhat3];
moderately4]; extremely5]
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 2011-04-22 |