23 survey

The Hispanic Community Health Study/ Study of Latinos (HCHS/SOL)(NHLBI)

Personal Information_11-21-08

Clinic Questionaires

OMB: 0925-0584

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ID NUMBER:








FORM CODE: PIE

VERSION: A 7/02/07

Contact

Occasion



SEQ #




OMB#: 0925-0584

Exp. XX/XXXX




Public reporting burden for this collection of information is estimated to average 09 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0584). Do not return the completed form to this address.


H

OMB#: 0925-0584

Exp. XX/XXXX

CHS/SOL Personal Information Questionnaire



ID NUMBER:










FORM CODE: PIE

VERSION: A 11/21/08


Contact

Occasion



SEQ #





Acrostic:












Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Enter the answer given by the participant for each response. The special value, "Q", is allowed for cases where the response 'Don’t know/refused' is not listed as an option. Use location codes at end for coding place of birth.


A. Demographics

1. Gender: Male 1 Female 2


2. Date of Birth: //19

Month Day Year


3. Marital Status: (Mark only one)

Single 1

Married 2

Separated 3

Divorced 4

Widow(er) 5

Living with a partner 6


4. In what country or territory were you born? (Select location code from list)


5. Which of the following best describes your Hispanic/Latino heritage? (Mark only one)

Dominican or Dominican descent 0

Central American or Central American descent 1

Cuban or Cuban descent 2

Mexican or Mexican descent 3

Puerto - Rican or Puerto Rican descent 4

South American or South American descent 5

More than one heritage 6

Other 7

If other, please specify: __________________


6. In addition to being of Hispanic/Latino heritage, which of the following categories would you use to describe yourself? (Mark only one)

American Indian or Alaskan Native 1

Asian 2

Native Hawaiian or Other Pacific Islander 3

Black or African – American 4

White 5

More than one race 6

Unknown or Not reported 7

IF RESPONSE TO QUESTION 4 IS U.S. BORN (63), GO TO QUESTION 11


B. Residential History

7. From the time that you FIRST moved to the U.S. to today, about how many years have you lived in the mainland U.S. (50 states + DC)? (Round to the nearest full year)

Number of years


8. When you are in the United States, do you live in the same state all year?

No 0

Yes 1


9. Except for short vacations, do you return to your native country for part of each year?

No 0 GO TO QUESTION 11

Yes 1


10. How many months per year? Months per year



C. Parents/Grandparents

11. Where was your mother born? (Select location code from list)


12. Where was your maternal grandmother born? (Select location code from list)


13. Where was your maternal grandfather born? (Select location code from list)


14. Where was your father born? (Select location code from list)


15. Where was your paternal grandmother born? (Select location code from list)


16. Where was your paternal grandfather born? (Select location code from list)


D. Education

17. How many years of schooling in total have you completed?

Years


If response to Question 17 equals “0” GO TO QUESTION 22


18. In what country or territory was your highest level of education completed? (Select location code from list)


19. What was the highest grade/level of education achieved? If exact level is not listed, mark the closest equivalent. (Mark only one)

Elementary/primary school (includes grades 1 – 5) 1

Middle school/junior high (includes grades 6 – 8) 2

High School/preparatory school 3

Trade school/vocational school 4

University/college 5

Other 6

If other, please specify:_________________________


20. Have you received any diplomas, certificates or degrees from your schooling?

No 0 GO TO QUESTION 22

Yes 1


21. What types of diploma, certificate, or degree did you receive? If exact diploma, certificate, or degree is not listed, mark the closest equivalent.

No Yes

a. High School diploma or equivalent (includes GED) 0 1

b. Trade school/vocational school certificate 0 1

c. Associate degree (i.e. AA, AS) 0 1

d. Bachelor’s degree (i.e. BA, AB, BS) 0 1

e. Master’s degree (i.e. MA, MS, MEd, MSW, MBA) 0 1

f. Professional degree (i.e. MD, DDS, DVM, LLB, JD) 0 1

g. Doctorate degree (i.e. PhD, EdD) 0 1

h. Other 0 1

If other, please specify:_________________________


22. What was the highest grade/level of education achieved by your father? (Mark only one)

No schooling 1

Elementary/primary school (includes grades 1 – 5) 2

Middle school/junior high (includes grades 6 – 8) 3

High School/preparatory school 4

Trade school/vocational school 5

University/college 6

Other 7

If other, please specify:_________________________


23. What was the highest grade/level of education achieved by your mother? (Mark only one)

No schooling 1

Elementary/primary school (includes grades 1 – 5) 2

Middle school/junior high (includes grades 6 – 8) 3

High School/preparatory school 4

Trade school/vocational school 5

University/college 6

Other 7

If other, please specify:_________________________


Location Codes for Question 4, 11, 12, 13, 14, 15, 16, and 18


  1. Afghanistan

  2. Anguilla

  3. Antigua and Barbuda

  4. Argentina

  5. Aruba

  6. Australia

  7. Austria

  8. Bangladesh

  9. Belgium

  10. Belize

  11. Bolivia

  12. Brazil

  13. Canada

  14. Chile

  15. China

  16. Colombia

  17. Costa Rica

  18. Cuba

  19. Czech Republic

  20. Denmark

  21. Dominican Republic

  22. Ecuador

  23. El Salvador

  24. Finland

  25. France

  26. Germany

  27. Great Britain

  28. Greece

  29. Guam

  30. Guatemala

  31. Haiti

  32. Holland

  33. Honduras

  34. Hungary

  35. India

  36. Indonesia

  37. Iran

  38. Iraq

  39. Ireland

  40. Israel

  41. Italy

  42. Japan

  43. Korea

  44. Lebanon

  45. Malaya

  46. Mexico

  47. New Zealand

  48. Nicaragua

  49. Norway

  50. Pakistan

  51. Panama

  52. Paraguay

  53. Peru

  54. Philippines

  55. Poland

  56. Portugal

  57. Puerto Rico

  58. Russia

  59. South Africa

  60. Spain

  61. Sweden

  62. Switzerland

  63. United States

  64. Uruguay

  65. Venezuela

  66. Virgin Islands

  67. Other

99 Unknown/refused



Personal Information Form (PIE) Page 0 of 4

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Last Modified ByCSCC
File Modified2008-12-03
File Created2008-12-03

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