Form 2 Household Member Interview for Telephone Interviewing

ATTACHMENT 2b

Household Member Interview

Household Member Interview for Telephone Interviewing

Form Approved

OMB No. 0920-0805

Exp. Date 02/29/2012

IF SCREENER RESPONDENT IS SAMPLED FOR DETAILED INTERVIEW AND NO BREAK OCCURS BETWEEN SCREENER AND DETAILED INTERVIEW, SKIP TO CONSENT1.

INTRO

Hello, my name is [INTERVIEWER NAME]. I’m calling on behalf of the Centers for Disease Control and Prevention [IF COMMUNITY =12 FILL "for the Inter-Tribal Council of Michigan"]. We’re conducting a study regarding health issues in [IF ENGLISH FILL LOCALITY1. ELSE IF SPANISH FILL LOCALITY1_SP. ELSE IF HAITIAN CREOLE FILL LOCALITY1_HC.]. This is a research study. Taking part is up to you. You don’t have to answer any question you don’t want to, and you can end the interview at any time. The interview takes about 15 minutes and any information you give me will be kept secure and private. There are no risks or benefits to you for participating. In order to evaluate my performance, my supervisor may record and listen as I ask the questions. The recordings will be destroyed when the data collection for the study is completed. Would you like to participate? I’d like to continue now unless you have any questions.

READ IF NECESSARY: We are collecting data to better understand health related behaviors and diseases that may affect adults in your neighborhood. Researchers are trying to understand the health issues specific to your neighborhood, so programs can better fit the needs of the people living there. NORC is conducting this survey for the Centers for Disease Control and Prevention (CDC).

IF RESPONDENT REFUSES TO CONTINUE, EXIT THE INTERVIEW AND CODE THE CASE AS A REFUSAL.

1. CONTINUE

99. REFUSE

INTERVIEWER: READ ONLY IF RESPONDENT ASKS TO CONTACT THE IRB

If you want to know more about your rights as a study participant you may call the NORC Institutional Review Board Administrator, toll free, at 866-309-0542.

Thanks again.

IF SCREENER RESPONDENT IS SAMPLED FOR DETAILED INTERVIEW AND NO BREAK OCCURS BETWEEN SCREENER AND DETAILED INTERVIEW, SKIP TO CONSENT1.

USER SHALL NOT BE ABLE TO BACK UP FROM INTRO.

Do not go to INTRO/CONSENT1 on callback if INTRO/CONSENT1=1 from a previous call.

CONSENT 1

Before we begin, this is a research study. Taking part is up to you. You don’t have to answer any question you don’t want to, and you can end the interview at any time. The interview takes about 15 minutes and any information you give me will be kept secure and private. There are no risks or benefits to you for participating. In order to evaluate my performance, my supervisor may record and listen as I ask the questions. The recordings will be destroyed when the data collection for the study is completed. Would you like to participate? I’d like to continue now unless you have any questions.

IF RESPONDENT REFUSES TO CONTINUE, EXIT THE INTERVIEW AND CODE THE CASE AS A REFUSAL.

1. CONTINUE

99. REFUSE

INTERVIEWER: READ ONLY IF RESPONDENT ASKS TO CONTACT THE IRB

If you want to know more about your rights as a study participant you may call the NORC Institutional Review Board Administrator, toll free, at 866-309-0542.

GENHLTH

1. Would you say that in general your health is:

PLEASE READ:

1. Excellent
2. Very good
3. Good
4. Fair, or
5. Poor
77. DON’T KNOW
99. REFUSE

PHYSHLTH

2. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

INTERVIEWER: ENTER “00” FOR NONE.

|___|___| NUMBER OF DAYS
77. DON’T KNOW
99. REFUSE

RANGE 0-30, 77, 99

MENTHLTH

3. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

INTERVIEWER: ENTER “00” FOR NONE.

|___|___| NUMBER OF DAYS

77. DON’T KNOW

99. REFUSE

RANGE 0-30, 77, 99

IF PHYSHLTH and MENTHLTH = “00” GO TO HLTHPLAN

POORHLTH

4. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

INTERVIEWER: ENTER “00” FOR NONE

|___|___| NUMBER OF DAYS

77. DON’T KNOW

99. REFUSE

RANGE 0-30, 77, 99

HLTHPLAN

5. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?

1. YES

2. NO

77. DON’T KNOW

99. REFUSE

MEDCOST

6. Was there a time in the past 12 months when you needed to see a doctor, but could not because of cost?

1. YES

2. NO

77. DON’T KNOW

99. REFUSE

CHECKUP

7. 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.

1. Within the past year (anytime less than 12 months ago)

2. Within the past 2 years (1 year but less than 2 years ago)

3. Within the past 5 years (2 years but less than 5 years ago)

4. 5 or more years ago

5. Never

77. DON’T KNOW

99. REFUSE

WEIGHT

8. About how much do you weigh without shoes?

INTERVIEWER: ROUND FRACTIONS UP
ENTER 0 IF RESPONDENT ANSWERS IN KILOGRAMS AT WEIGHT

|___|___|___| WEIGHT IN POUNDS

777. DON’T KNOW

999. REFUSE

WEIGHT: SKIP TO WEIGHT_KILO IF WEIGHT = 0.

WEIGHT_KILO

8A. |___|___|___| KILOGRAMS

777. DON’T KNOW

999. REFUSE

IF WEIGHT_KILO = 0:

DISPLAY ERROR MESSAGE: “Weight cannot be 0 in both pounds and kilograms.”

GO TO WEIGHT

If WEIGHT<>0 and (WEIGHT<75 or WEIGHT>500), GO TO WGTCONF.

If WEIGHT_KILO <>blank and (WEIGHT_KILO<34 or WEIGHT_KIL0>227), GO TO WGTCONF.

WGTCONF

Just to confirm that I entered it correctly, I have [IF WEIGHT<>0 FILL, "[WEIGHT] pounds", ELSE IF WEIGHT=0 FILL "[WEIGHT_KILO] kilograms"]. Is that correct?

1. YES [GO TO HEIGHTF]

2. NO [GO TO WEIGHT]

HEIGHT

9. About how tall are you without shoes?

INTERVIEWER: ROUND FRACTIONS DOWN
ENTER 0 IF RESPONDENT ANSWERS IN CENTIMETERS AT HEIGHTF AND HEIGHTIN

HEIGHTF

a. FEET |___|___|
77. DON’T KNOW
99. REFUSE

HEIGHTIN

b. INCHES |___|___|
77. DON’T KNOW
99. REFUSE

HEIGHTF RANGE 0-8, 77, 99

HEIGHTIN RANGE 0-96, 77, 99

SKIP TO HEIGHTCENT IF HEIGHTF AND HEIGHTIN = 0.

HEIGHTCENT

9A. CENTIMETERS |___|___|___|

777. DON’T KNOW

999. REFUSE

RANGE 0-244, 777, 999

IF HEIGHTCENT = 0:

DISPLAY ERROR MESSAGE: “Height cannot be 0 in feet, inches and centimeters.”

GO TO HEIGHTF

If HEIGHTF<>0 AND (HEIGHTF<3 OR HEIGHTF>7), GO TO HGTCONF.

IF HEIGHTIN<>0 AND (HEIGHTIN<36 OR HEIGHTIN>84), GO TO HGTCONF.

IF HEIGHTCENT<>blank AND (HEIGHTCENT<91 OR HEIGHTCENT>213), GO TO HGTCONF.

HGTCONF

Just to confirm that I entered it correctly, I have

[IF HEIGHTF<>0 AND (HEIGHTF<3 OR HEIGHTF>7 FILL, "[HEIGHTF] feet tall",

ELSE IF HEIGHTIN<>0 AND (HEIGHTIN<36 OR HEIGHTIN>84) FILL "[HEIGHTIN] inches tall"]

ELSE IF HEIGHTCENT<>blank AND (HEIGHTCENT<91 OR HEIGHTCENT>213) FILL "[HEIGHTCENT] centimeters tall"].

1. YES [GO TO EMPLOY]

2. NO [GO TO HEIGHTF]

EMPLOY

10. Are you currently . . .?

PLEASE READ ALL

1. Employed for wages [GO TO JOBACTIV]

2. Self-employed [GO TO JOBACTIV]

3. Out of work for more than 1 year [GO TO EMPLOY5]4. Out of work for less than 1 year [GO TO EMPLOY5]5. Homemaker [GO TO EMPLOY6]6. Student [GO TO EMPLOY6]

7. Retired, or [GO TO EMPLOY5]

8. Unable to work [GO TO EMPLOY6]

77. DON’T KNOW

99. REFUSE

JOBACTIV

11. When you are at work, which of the following best describes what you do? Would you say…
INTERVIEWER: IF RESPONDENT HAS MULTIPLE JOBS, INCLUDE ALL JOBS.

1. Mostly sitting or standing

2. Mostly walking

3. Mostly heavy labor or physically demanding work

77. DON’T KNOW

99. REFUSE

EMPLOY3

12. At your main job or business, how are you generally paid for the work you do? Are you:

INTERVIEWER NOTE: IF PAID IN MULTIPLE WAYS AT THEIR MAIN JOB, SELECT OPTION 4 (PAID SOME OTHER WAY).

1. Paid by salary

2. Paid by the hour

3. Paid by the job/task (e.g. commission, piecework)

4. Paid some other way

77. DON’T KNOW

99. REFUSE

EMPLOY4

13. About how many hours do you work per week at all of your jobs and businesses combined?

INTERVIEWER: ENTER "96" FOR "96 OR MORE".

|___|___| Hours

97. DON’T KNOW

98. DOES NOT WORK

99. REFUSE

INTERVIEWER: ENTER "96" FOR "96 OR MORE".

RANGE 1-97, 99

ANY RESPONSE SKIPS TO EXERANY.

EMPLOY5

14. Thinking about the last time you worked, at your main job or business, how were you generally paid for the work you do? Were you:

1. Paid by salary

2. Paid by the hour

3. Paid by the job/task (e.g. commission, piecework)

4. Paid some other way

77. DON’T KNOW

99. REFUSE

EMPLOY6

15. Thinking about the last time you worked, about how many hours did you work per week at all of your jobs and businesses combined?

|___|___| Hours

97. DON’T KNOW

98. DOES NOT WORK

99. REFUSE

RANGE 1-99

EXERANY

16. During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

1. YES
2. NO
77. DON’T KNOW
99. REFUSE

ACTVE_INTRO

We are interested in two types of physical activity – vigorous and moderate. Vigorous activities cause large increases in breathing or heart rate while moderate activities cause small increases in breathing or heart rate.

MODEXER

17. Now thinking about the moderate activities you do [IF EMPLOY =1 OR 2 THEN FILL :"when you are not working"] in a usual week, do you do moderate activities for at least 10 minutes at a time, such as brisk walking, bicycling, vacuuming, gardening, or anything else that causes some increase in breathing or heart rate?

1. YES

2. NO [GO TO VIGEXER]

77. DON’T KNOW [GO TO VIGEXER]

99. REFUSE [GO TO VIGEXER]

MODEXDAY

18. How many days per week do you do these moderate activities for at least 10 minutes at a time?

DAYS PER WEEK |___|___|

77. DON’T KNOW

99. REFUSE

RANGE 1-7, 77, 99

IF MODEXDAY IS 77, OR 99, GO TO MODEXTM

MODEXTM

19. On days when you do moderate activities for at least 10 minutes at a time, how much total time per day do you spend doing these activities?

INTERVIEWER: ENTER RESPONSE AS GIVEN BY THE R. IF THEY RESPOND IN MINUTES (SUCH AS 90 MINUTES) ENTER 90 MINUTES, NOT 1 HOUR AND 30 MINUTES.

MODEXTM_HRS

HOURS |___|___|

77. DON’T KNOW [GO TO VIGEXER, FILL MODEXTM_MIN=7777]

99. REFUSE [GO TO VIGEXER, FILL MODEXTM_MIN=9999]

HOURS RANGE 0-10, 77, 99

MODEXTM_MIN

MINUTES |___|___|___|

7777. DON’T KNOW [GO TO VIGEXER]

9999. REFUSE [GO TO VIGEXER]

MINUTES RANGE 0-600, 7777, 9999

IF (MODEXTM_HRS > 2) OR (MODEXTM_MIN > 120) OR (MODEXTM_HRS=2 AND MODEXTM_MIN>0) GO TO MODEXCONF

MODEXCONF

19A. Just to confirm that I entered it correctly, I have [MODEXTM HOURS /MODEXTM MINUTES]. Is that correct?

1. YES [GO TO VIGEXER]

2. NO [GO TO MODEXTM]

VIGEXER

20. Now thinking about the vigorous activities you do [IF EMPLOY =1 OR 2 THEN FILL "when you are not working"] in a usual week, do you do vigorous activities for at least 10 minutes at a time, such as running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate?

1. YES

2. NO [GO TO FOOD_INTRO]

77. DON’T KNOW [GO TO FOOD_INTRO]

99. REFUSE [GO TO FOOD_INTRO]

VIGEXDAY

21. How many days per week do you do these vigorous activities for at least 10 minutes at a time?

DAYS PER WEEK |___|___|

77. DON’T KNOW

99. REFUSE

RANGE 1-7, 77, 99

IF VIGEXDAY IS NOT 77, OR 99, GO TO VIGEXTM

VIGEXTM

22. On days when you do vigorous activities for at least 10 minutes at a time, how much total time per day do you spend doing these activities?

INTERVIEWER: ENTER RESPONSE AS GIVEN BY THE R. IF THEY RESPOND IN MINUTES (SUCH AS 90 MINUTES) ENTER 90 MINUTES, NOT 1 HOUR AND 30 MINUTES.

VIGEXTM_HRS

HOURS |___|___|

77. DON’T KNOW [GO TO FOOD_INTRO, FILL VIGEXTM_MIN=7777]

99. REFUSE [GO TO FOOD_INTRO, FILL VIGEXTM_MIN=9999]

HOURS RANGE 0-10, 77, 99

MINUTES |___|___|___|

77. DON’T KNOW [GO TO FOOD_INTRO]

99. REFUSE [GO TO FOOD_INTRO]

MINUTES RANGE 0-600, 7777, 9999

IF (VIGEXTM_HRS > 2) OR (VIGEXTM_MIN > 120) OR (VIGEXTM_HRS=2 AND VIGEXTM_MIN>0) GO TO VIGEXCONF GO TO VIGEXCONF

VIGEXCONF

22A. Just to confirm that I entered it correctly, I have [VIGEXCONF HOURS / VIGEXCONF MINUTES]. Is that correct?

1. YES [GO TO FOOD_INTRO]

2. NO [GO TO VIGEXTM]

HOURS RANGE 0-10, 77, 99

MINUTES RANGE 0-600, 7777, 9999

FOOD_INTRO

These next questions are about the foods you usually eat or drink. Please tell me how often you eat or drink each one, for example, twice a week, three times a month, and so forth.

Remember, I am only interested in the foods you eat. Include all foods you eat, both at home and away from home.

FRUITJU

23. How often do you drink fruit juices such as orange, grapefruit, or tomato?

READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”

INTERVIEWER: ENTER “000” FOR “NEVER”. CONFIRM ENTRY WITH RESPONDENT

NUMBER OF TIMES |___|___|___|___|

7777. DON’T KNOW [GO TO FRUIT, FILL FRUITJU2 = 77]

9999. REFUSE [GO TO FRUIT, FILL FRUITJU2 = 99]

IF FRUITJU = 000 GO TO FRUIT

FRUITJU2

23A. FRUIT JUICE MODE

1. PER DAY

2. PER WEEK

3. PER MONTH

4. PER YEAR

77. DON’T KNOW

99. REFUSE

IF [FRUITJU NUMBER OF TIMES / FRUITJU2 MODE]

> 3 TIMES PER DAY OR

> 21 TIMES PER WEEK OR

> 90 TIMES PER MONTH OR

> 1095 TIMES PER YEAR

GO TO FRUITJUCONF

ELSE, GO TO FRUIT

FRUITJUCONF

23B. Just to confirm that I entered it correctly, I have [FRUITJU NUMBER OF TIMES / FRUITJU2 MODE]. Is that correct?

1. YES [GO TO FRUIT]

2. NO [GO TO FRUITJU]

FRUIT

24. Not counting juice, how often do you eat fruit?

READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”

INTERVIEWER: ENTER “000” FOR “NEVER”. CONFIRM ENTRY WITH RESPONDENT.

NUMBER OF TIMES |___|___|___|___|

7777. DON’T KNOW [GO TO GREENSAL, FILL FRUIT2 = 77]

9999. REFUSE [GO TO GREENSAL, FILL FRUIT2 = 99]

IF FRUIT = 000 GO TO GREENSAL

FRUIT2

24A. FRUIT MODE

1. PER DAY

2. PER WEEK

3. PER MONTH

4. PER YEAR

77. DON’T KNOW

99. REFUSE

IF [FRUIT NUMBER OF TIMES / FRUIT2 MODE]

> 3 TIMES PER DAY OR

> 21 TIMES PER WEEK OR

> 90 TIMES PER MONTH OR

> 1095 TIMES PER YEAR

GO TO FRUITCONF

ELSE, GO TO GREENSAL

FRUITCONF

24B. Just to confirm that I entered it correctly, I have [FRUIT NUMBER OF TIMES / FRUIT2 MODE]. Is that correct?

1. YES [GO TO GREENSAL]

2. NO [GO TO FRUIT]

GREENSAL

25. How often do you eat green salad?

READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”

INTERVIEWER: ENTER “000” FOR “NEVER”. CONFIRM ENTRY WITH RESPONDENT.

NUMBER OF TIMES |___|___|___|___|

7777. DON’T KNOW [GO TO POTATO, FILL GREENSAL2 = 77]

9999. REFUSE [GO TO POTATO, FILL GREENSAL2 = 99]

IF GREENSAL = 000 GO TO POTATO

GREENSAL2

25A. GREEN SALAD MODE

1. PER DAY

2. PER WEEK

3. PER MONTH

4. PER YEAR

77. DON’T KNOW

99. REFUSE

IF [GREENSAL NUMBER OF TIMES / GREENSAL2 MODE]> 2 TIMES PER DAY OR

> 14 TIMES PER WEEK OR

> 60 TIMES PER MONTH OR

> 730 TIMES PER YEAR

GO TO GREENSALCONF

ELSE, GO TO POTATO

GREENSALCONF

25B. Just to confirm that I entered it correctly, I have [GREENSAL NUMBER OF TIMES / GREENSAL2 MODE]. Is that correct?

1. YES [GO TO POTATO]

2. NO [GO TO GREENSAL]

POTATO

26. How often do you eat potatoes not including French fries, fried potatoes, or potato chips?

READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”

INTERVIEWER: ENTER “000” FOR “NEVER”. CONFIRM ENTRY WITH RESPONDENT.

NUMBER OF TIMES |___|___|___|___|

7777. DON’T KNOW [GO TO CARROTS, FILL POTATO2 = 77]

9999. REFUSE [GO TO CARROTS, FILL POTATO2 = 99]

IF POTATO = 000 GO TO CARROTS

POTATO2

26A. POTATO MODE

1. PER DAY

2. PER WEEK

3. PER MONTH

4. PER YEAR

77. DON’T KNOW

99. REFUSE

IF [POTATO NUMBER OF TIMES / POTATO2 MODE]

> 1 TIMES PER DAY OR

> 7 TIMES PER WEEK OR

> 30 TIMES PER MONTH OR

> 365 TIMES PER YEAR

GO TO POTATOCONF

ELSE, GO TO CARROTS

POTATOCONF

26B. Just to confirm that I entered it correctly, I have [POTATO NUMBER OF TIMES / POTATO2 MODE]. Is that correct?

1. YES [GO TO CARROTS]

2. NO [GO TO POTATO]

CARROTS

27. How often do you eat carrots?

READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”

INTERVIEWER: ENTER “000” FOR “NEVER”. CONFIRM ENTRY WITH RESPONDENT.

NUMBER OF TIMES |___|___|___|___|

7777. DON’T KNOW [GO TO VEGETABL, FILL CARROTS2 = 77]

9999. REFUSE [GO TO VEGETABL, FILL CARROTS2 = 99]

IF CARROTS = 000 GO TO VEGETABL

CARROTS2

27A. CARROTS MODE

1. PER DAY

2. PER WEEK

3. PER MONTH

4. PER YEAR

77. DON’T KNOW

99. REFUSE

IF [CARROTS NUMBER OF TIMES / CARROTS2 MODE]> 1 TIMES PER DAY OR

> 7 TIMES PER WEEK OR

> 30 TIMES PER MONTH OR

> 365 TIMES PER YEAR

GO TO CARROTSCONF

ELSE, GO TO VEGETABL

CARROTSCONF

27B. Just to confirm that I entered it correctly, I have [CARROTS NUMBER OF TIMES / CARROTS2 MODE]. Is that correct?

1. YES [GO TO VEGETABL]

2. NO [GO TO CARROTS]

VEGETABL

28. Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat? (Example: A serving of vegetables at both lunch and dinner would be two servings.)

READ ONLY IF NECESSARY: “Please respond in terms of times per day, per week, per month or per year.”

INTERVIEWER: ENTER “000” FOR “NEVER”. CONFIRM ENTRY WITH RESPONDENT.

NUMBER OF TIMES |___|___|___|___|

7777. DON’T KNOW [GO TO SEX, FILL VEGETABL2 = 77]

9999. REFUSE [GO TO SEX, FILL VEGETABL2 = 99]

IF VEGETABL = 000 GO TO SEX

VEGETABL2

28A. VEGETABLES MODE

1. PER DAY

2. PER WEEK

3. PER MONTH

4. PER YEAR

77. DON’T KNOW

99. REFUSE

IF [VEGETABL NUMBER OF TIMES / VEGETABL2 MODE]

> 2 TIMES PER DAY OR

> 14 TIMES PER WEEK OR

> 60 TIMES PER MONTH OR

> 730 TIMES PER YEAR

GO TO VEGETABLCONF

ELSE, GO TO SEX

VEGETABLCONF

28B. Just to confirm that I entered it correctly, I have [VEGETABL NUMBER OF TIMES / VEGETABL2 MODE]. Is that correct?

1. YES [GO TO SEX]

2. NO [GO TO VEGETABL]

SEX

29. ASK ONLY IF NECESSARY: Just to confirm, are you male or female?

1. MALE

2. FEMALE

77. DON’T KNOW

99. REFUSE

IF SEX = 77, 99, BUT GENDER_X WAS GIVEN IN THE SCREENER, USE GENDER_X TO DETERMINE SKIP. IF [GENDER = 77 OR 99] AND [SEX = 77 OR 99] THEN SET 'SEX_UNKNOWN' = 1

DIAB_INTRO

The next questions are about diabetes.

DIABETES

30. Have you ever been told by a doctor that you have diabetes?

1. YES [IF GENDER=FEMALE GO TO DIABPREG; ELSE GO TO BLDSUGAR AND FILL DIABPREG=3]

2. NO [GO TO BPHIGH]

3. NO, PRE-DIABETES OR BORDERLINE DIABETES [GO TO BPHIGH]

77. DON’T KNOW [GO TO BPHIGH]

99. REFUSE [GO TO BPHIGH]

DIABPREG

30A. Was this only when you were pregnant?

1. YES [GO TO BPHIGH]

2. NO

3. MALE

77. DON’T KNOW

99. REFUSE

BLDSUGAR

31. About how often do you check your blood for glucose or sugar? Include times when checked by a family member or friend, but do not include times when checked by a health professional.

1. |___|___| TIMES PER DAY

2. |___|___| TIMES PER WEEK

3. |___|___| TIMES PER MONTH

4. |___|___| TIMES PER YEAR

888. NEVER

777. DON’T KNOW

999. REFUSE

FEETCHK2

32. About how often do you check your feet for any sores or irritations? Include times when checked by a family member or friend, but do not include times when checked by a health professional.

1. |___|___| TIMES PER DAY

2. |___|___| TIMES PER WEEK

3. |___|___| TIMES PER MONTH

4. |___|___| TIMES PER YEAR

555. NO FEET

888. NEVER

777. DON’T KNOW

999. REFUSE

DOCTDIAB

33. About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?

INTERVIEWER: ENTER “00” FOR NONE AND “76” FOR “76 OR MORE”

|___|___| NUMBER OF TIMES

00. NONE

77. DON’T KNOW

99. REFUSE

RANGE 0 – 77, 99

CHKHEMO

34. A test for “A one C” measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for “A one C”?

INTERVIEWER: ENTER “00” FOR NONE AND “76” FOR “76 OR MORE”

|___|___| NUMBER OF TIMES

77. DON’T KNOW

98. NEVER HEARD OF “A ONE C” TEST [GO TO FEETCHK]

99. REFUSE

RANGE 0 – 77, 98, 99

IF FEETCHK2 = 555 (NO FEET) GO TO EYEEXAM

IF CHKHEMO > 24 GO TO CHKHEMOCONF,, ELSE GO TO FEETCHK

CHKHEMOCONF 34A. Just to confirm that I entered it correctly, I have [CHKHEMO NUMBER] times. Is that correct?

1. YES [IF FEETCHK2 = 555 (NO FEET) GO TO EYEEXAM; ELSE GO TO FEETCHK]

2. NO [GO TO CHKHEMO]

FEETCHK

35. About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?

INTERVIEWER: ENTER “00” FOR NONE AND ENTER “76” FOR “76 OR MORE”

|___|___| NUMBER OF TIMES

77. DON’T KNOW

99. REFUSE

RANGE 0 – 77, 99

IF FEETCHK > 24 GO TO FEETCHKCONF,, ELSE GO TO EYEEXAM

FEETCHKCONF,35A. Just to confirm that I entered it correctly, I have [FEETCHK NUMBER] times. Is that correct?

1. YES [GO TO EYEEXAM]

2. NO [GO TO FEETCHK]

EYEEXAM

36. When was the last time you had an eye exam in which your pupils were dilated? This would have made you temporarily sensitive to bright light.

READ IF NECESSARY:

1. Within the past month (anytime less than 1 month ago)

2. Within the past year (1 month but less than 12 months ago)

3. Within the past 2 years (1 year but less than 2 years ago)

4. 2 or more years ago

5. Never

77. DON’T KNOW

99. REFUSE

DIABEDU

37. Have you ever taken a course or class in how to manage your diabetes yourself?

1. YES

2. NO

77. DON’T KNOW

99. REFUSE

BPHIGH

38. The next few questions are about high blood pressure. Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?

1. YES [GO TO BPMEDS]

2. NO [GO TO CHOLES_INTRO]

3. TOLD BORDERLINE OR PRE-HYPERTENSIVE [GO TO CHOLES_INTRO]

77. DON’T KNOW [GO TO CHOLES_INTRO]

99. REFUSE [GO TO CHOLES_INTRO]

BPMEDS

39. Are you currently taking medicine for your high blood pressure?

1. YES

2. NO

77. DON’T KNOW

99. REFUSE

HIBPYOU

40. Are you now doing any of the following to help lower or control your high blood pressure?

BPEATHBT

40A. (Are you) changing your eating habits (to help lower or control your high blood pressure)?

1. YES

2. NO

77. DON’T KNOW

99. REFUSE

BPSALT

40B. (Are you) cutting down on salt (to help lower or control your high blood pressure)?

1. YES

2. NO

3. DO NOT USE SALT

77. DON’T KNOW

99. REFUSE

BPALCHOL

40C. (Are you) reducing alcohol use (to help lower or control your high blood pressure)?

1. YES

2. NO

3. DO NOT DRINK

77. DON’T KNOW

99. REFUSE

BPEXER

40D. (Are you) exercising (to help lower or control your high blood pressure)?

1. YES

2. NO

77. DON’T KNOW

99. REFUSE

CHOLES_INTRO

The next few questions are about blood cholesterol.

CHOLESCHK

41. Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?

1. YES

2. NO [GO TO CVD_INTRO]

77. DON’T KNOW [GO TO CVD_INTRO]

99. REFUSE [GO TO CVD_INTRO]

CHOLESLAST

42. About how long has it been since you last had your blood cholesterol checked?

READ ONLY IF NECESSARY:

1. 1. Within the past year (anytime less than 12 months ago)

2. 2. Within the past 2 years (1 year but less than 2 years ago)

3. 3. Within the past 5 years (2 years but less than 5 years ago)

4. 4. 5 or more years ago

77. DON’T KNOW

99. REFUSE

CHOLESHI

43. Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol is high?

1. YES

2. NO

77. DON’T KNOW

99. REFUSE

CVD_INTRO

Now I would like to ask you some questions about cardiovascular disease.

CVDDRTLD

44. Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me “Yes”, “No” or you’re “Not sure.”

CVDINFAR

44A. (Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me "Yes", "No" or you’re "Not sure.")

(Ever told) you had a heart attack, also called a myocardial infarction?

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

CVDCORHD

44B. (Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me "Yes", "No" or you’re "Not sure.")

(Ever told) you had angina or coronary heart disease?

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

CVDSTROK

44C. (Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me "Yes", "No" or you’re "Not sure.")

(Ever told) you had a stroke?

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

HEART_INTRO

Now I would like to ask you about your knowledge of the signs and symptoms of a heart attack and stroke.

HASYMP

45. Which of the following do you think is a symptom of a heart attack? For each, tell me “Yes”, “No” or you’re “Not sure.”

HASYMP1

45A. (Which of the following do you think is a symptom of a heart attack? For each, tell me "Yes", "No", or you're "Not sure.")

(Do you think) pain or discomfort in the jaw, neck, or back (are symptoms of a heart attack?)

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

HASYMP2

45B. (Which of the following do you think is a symptom of a heart attack? For each, tell me "Yes", "No", or you're "Not sure.")

(Do you think) feeling weak, lightheaded, or faint (are symptoms of a heart attack?)

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

HASYMP3

45C. (Which of the following do you think is a symptom of a heart attack? For each, tell me "Yes", "No", or you're "Not sure.")

(Do you think) chest pain or discomfort (are symptoms of a heart attack?)

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

HASYMP4

45D. (Which of the following do you think is a symptom of a heart attack? For each, tell me "Yes", "No", or you're "Not sure.")

(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a heart attack?)

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

HASYMP5

45E. (Which of the following do you think is a symptom of a heart attack? For each, tell me "Yes", "No", or you're "Not sure.")

(Do you think) pain or discomfort in the arms or shoulder (are symptoms of a heart attack?)

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

HASYMP6

45F. (Which of the following do you think is a symptom of a heart attack? For each, tell me "Yes", "No", or you're "Not sure.")

(Do you think) shortness of breath (is a symptom of a heart attack?)

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

STRKSYMP

46. Which of the following do you think is a symptom of a stroke? For each, tell me “Yes”, “No” or you’re “Not sure.”

STRSYMP1

46A. (Which of the following do you think is a symptom of a stroke? For each, tell me "Yes", "No", or you're "Not sure.")

(Do you think) sudden confusion or trouble speaking (are symptoms of a stroke?)

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

STRSYMP2

46B. (Which of the following do you think is a symptom of a stroke? For each, tell me "Yes", "No", or you're "Not sure.")

(Do you think) sudden numbness or weakness of face, arm, or leg, especially on one side, (are symptoms of a stroke?)

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

STRSYMP3

46C. (Which of the following do you think is a symptom of a stroke? For each, tell me "Yes", "No", or you're "Not sure.")

(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a stroke?)

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

STRSYMP4

46D. (Which of the following do you think is a symptom of a stroke? For each, tell me "Yes", "No", or you're "Not sure.")

(Do you think) sudden chest pain or discomfort (are symptoms of a stroke?)

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

STRSYMP5

46E. (Which of the following do you think is a symptom of a stroke? For each, tell me "Yes", "No", or you're "Not sure.")

(Do you think) sudden trouble walking, dizziness, or loss of balance (are symptoms of a stroke?)

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

STRSYMP6

46F. (Which of the following do you think is a symptom of a stroke? For each, tell me "Yes", "No", or you're "Not sure.")

(Do you think) severe headache with no known cause (is a symptom of a stroke?)

1. YES

2. NO

77. DON’T KNOW/NOT SURE

99. REFUSE

FIRSTAID

47. If you thought someone was having a heart attack or a stroke, what is the first thing you would do:

PLEASE READ ALL:

1. Take them to the hospital

2. Tell them to call their doctor

3. Call 911

4. Call their spouse or a family member, or

5. Do something else

77. DON’T KNOW

99. REFUSE

AGE

48. For the following questions, I'll need to know your age. How old are you?

|___|___|___| CODE AGE IN YEARS

777. DK

999. REF

IF AGE = 777, 999, BUT AGE WAS GIVEN IN THE SCREENER, FILL WITH SCREENER AGECAT RANGE PROVIDED.

RANGE 18 – 120, 777, 999

FLUSHOT

49. A flu shot is an influenza vaccine injected into your arm. During the past 12 months, have you had a flu shot?

1. YES

2. NO

77. DON’T KNOW

99. REFUSE

PNEUMVAC

50. A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person’s lifetime and is different from the flu shot. Have you ever had a pneumonia shot?

1. YES
2. NO
77. DON’T KNOW
99. REFUSE

BCC_INTRO

The next questions are about breast and cervical cancer.

QUESTIONS BCC_INTRO THROUGH HPVNUM FOR FEMALES ONLY

IF GENDER <> FEMALE SKIP TO SMOKE100

HADMAM

51. A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?

1. YES

2. NO [GO TO PROFEXAM]

77. DON’T KNOW [GO TO PROFEXAM]

99. REFUSE [GO TO PROFEXAM]

HOWLONG

52. How long has it been since you had your last mammogram?

READ ONLY IF NECESSARY:

1. Within the past year (anytime less than 12 months ago)

2. Within the past 2 years (1 year but less than 2 years ago)

3. Within the past 3 years (2 years but less than 3 years ago)

4. Within the past 5 years (3 years but less than 5 years ago)

5. 5 or more years ago

77. DON’T KNOW

99. REFUSE

PROFEXAM

53. A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you ever had a clinical breast exam?

1. YES

2. NO [GO TO HADPAP]

77. DON’T KNOW [GO TO HADPAP]

99. REFUSE [GO TO HADPAP]

LENGEXAM

54. How long has it been since your last breast exam?

READ ONLY IF NECESSARY:

1. Within the past year (anytime less than 12 months ago)

2. Within the past 2 years (1 year but less than 2 years ago)

3. Within the past 3 years (2 years but less than 3 years ago)

4. Within the past 5 years (3 years but less than 5 years ago)

5. 5 or more years ago

77. DON’T KNOW

99. REFUSE

HADPAP

55. A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?

1. YES

2. NO [GO TO HADHYST]

77. DON’T KNOW [GO TO HADHYST]

99. REFUSE [GO TO HADHYST]

LASTPAP

56. How long has it been since you had your last Pap test?

READ ONLY IF NECESSARY:

1. Within the past year (anytime less than 12 months ago)

2. Within the past 2 years (1 year but less than 2 years ago)

3. Within the past 3 years (2 years but less than 3 years ago)

4. Within the past 5 years (3 years but less than 5 years ago)

5. 5 or more years ago

77. DON’T KNOW

99. REFUSE

HADHYST

57. Have you had a hysterectomy?

READ ONLY IF NECESSARY: A hysterectomy is an operation to remove the uterus (womb).

INTERVIEWER: IF R HAD PARTIAL HYSTERECTOMY CODE AS “YES”

1. YES

2. NO

77. DON’T KNOW

99. REFUSE

HPVSHOT

58. A vaccine to prevent the human papilloma virus or HPV infection is available and is called cervical cancer or genital warts vaccine, HPV shot, GARDASIL or CERVARIX®. Have you ever had the HPV vaccination?

1. YES

2. NO [GO TO SMOKE100]

3. DOCTOR REFUSED WHEN ASKED [GO TO SMOKE100]

4. NO, NEVER HEARD ABOUT IT / NEVER OFFERED TO YOU [GO TO SMOKE100]

77. DON’T KNOW [GO TO SMOKE100]

99. REFUSE [GO TO SMOKE100]

HPVNUM

59. How many HPV shots did you receive?

|___|___| NUMBER OF SHOTS

03. ALL SHOTS

77. DON’T KNOW

99. REFUSE

RANGE 1 – 3, 77, 99

SMOKE100

60. The next questions are about cigarette smoking. Have you smoked at least 100 cigarettes in your entire life?

INTERVIEWER: 5 PACKS = 100 CIGARETTES

1. YES

2. NO [GO TO HEPBTEST]

77. DON’T KNOW [GO TO HEPBTEST]

99. REFUSE [GO TO HEPBTEST]

SMOKEDAY

61. Do you now smoke cigarettes everyday, some days, or not at all?

1. EVERYDAY

2. SOME DAYS

3. NOT AT ALL [GO TO HEPBTEST]

77. DON’T KNOW [GO TO HEPBTEST]

99. REFUSE [GO TO HEPBTEST]

SMOKEQUIT

62. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

1. YES
2. NO
77. DON’T KNOW
99. REFUSE

HEPBTEST

63. Have you ever had a blood test for hepatitis B?

1. YES
2. NO [GO TO HEPBTOLD]
77. DON’T KNOW [GO TO HEPBTOLD]
99. REFUSE [GO TO HEPBTOLD]

HEPBWHERE

64. Where were you tested for hepatitis B?

MARK ALL THAT APPLY

1. Your doctor’s office/lab
2. In the hospital (as an overnight patient)
3. At a clinic (other than your doctor’s office)
4. In a community screening program

5. Other site (such blood bank, military installation, prison or jail, mobile clinic, emergency room, etc)
77. DON’T KNOW
99. REFUSE

HEPBWHY

65. Why were you tested for hepatitis B?

MARK ALL THAT APPLY

1. You had symptoms (such as yellow eyes, abdominal pain, etc)
2. You had an abnormal lab test
3. You or someone else was concerned you might be at risk of having hepatitis B
4. You were pregnant and testing was part of your care
5. You were donating blood
6. You were in a special screening program

7. Doctor ordered the test

8. Other reason
77. DON’T KNOW
99. REFUSE

DISPLAY OPTION 4 IF SEX = 2 ; ELSE IF SEX = 1, 77 OR 99 OPTION 4 SHOULD NOT APPEAR.

HEPBTOLD

66. Have you ever been told by a medical doctor, nurse, or other health professional that you have hepatitis B?

1. YES
2. NO [GO TO HEPCTEST]
77. DON’T KNOW [GO TO HEPCTEST]
99. REFUSE [GO TO HEPCTEST]

HEPBAGO_Y

67. How long ago did you first learn you had hepatitis B?

ANSWER IN YEARS OR MONTHS

|___|___| YEARS

HEPBAGO_M

|___|___| MONTHS
77. DON’T KNOW
99. REFUSE

HEPBDOC

68. Are you currently seeing a doctor for your hepatitis B?

1. YES
2. NO
77. DON’T KNOW
99. REFUSE

HEPBMED

69. Have you ever taken any medications such as pills or shots prescribed by a doctor for hepatitis B?

1. YES
2. NO
77. DON’T KNOW
99. REFUSE

HEPCTEST

70. Have you ever had a blood test for hepatitis C?

1. YES
2. NO [GO TO HEPCTOLD]
77. DON’T KNOW [GO TO HEPCTOLD]
99. REFUSE [GO TO HEPCTOLD]

HEPCWHERE

71. Where were you tested for hepatitis C?

MARK ALL THAT APPLY

1. Your doctor’s office/lab
2. In the hospital (as an overnight patient)
3. At a clinic (other than your doctor’s office)

4. In a community screening program
5. Other site (such blood bank, military installation, prison or jail, mobile clinic, emergency room, etc)
77. DON’T KNOW
99. REFUSE

HEPCWHY

72. Why were you tested for hepatitis C?

MARK ALL THAT APPLY

1. You had symptoms (such as yellow eyes, abdominal pain, etc)
2. You had an abnormal lab test
3. You or someone else was concerned you might be at risk of having hepatitis C
4. You were pregnant and testing was part of your care
5. You were donating blood
6. Doctor ordered the test

7. Other reason
77. DON’T KNOW
99. REFUSE

DISPLAY OPTION 4 IF SEX = 2 ; ELSE IF SEX = 1, 77 OR 99 OPTION 4 SHOULD NOT APPEAR.

HEPCTOLD

73. Have you ever been told by a medical doctor, nurse, or other health professional that you have hepatitis C?

1. YES
2. NO [GO TO DEMOG_INTRO]
77. DON’T KNOW [GO TO DEMOG_INTRO]
99. REFUSE [GO TO DEMOG_INTRO]

HEPCAGO_Y

74. How long ago did you first learn you had hepatitis C?

|___|___| YEARS

HEPCAGO_M

|___|___| MONTHS
77. DON’T KNOW
99. REFUSE

HEPCDOC

75. Are you currently seeing a doctor for your hepatitis C?

1. YES
2. NO
77. DON’T KNOW
99. REFUSE

HEPCMED

76. Have you ever taken any medications such as pills or shots prescribed by a doctor for hepatitis C?

1. YES
2. NO
77. DON’T KNOW
99. REFUSE

HEPBEHV

The next question is about behaviors or events related to hepatitis. I will read you a list and then you can tell me which ones apply to you.

INTERVIEWER: READ ALL. MARK ALL THAT APPLY

1. You received a blood transfusion before 1992

2. You ever received a blood transfusion outside of the U.S.

3. Your mother had hepatitis B before you were born

4. You ever had sex with a person who had hepatitis

5. You have had sex with other men, even just one time [DISPLAY ONLY IF RESPONDENT IS MALE AND COMMUNITY IS <>2]

6. You have taken street drugs by needle, even just one time

7. At least one of the above is true but you do not want to specify which one

8. None of the above

77. DON’T KNOW

99. REFUSED

DEMOG_INTRO

Thank you for your responses thus far. The next few questions are about you and your household.

BORN

77. Were you born in the United States?

1. YES
2. NO
77. DON’T KNOW
99. REFUSE

ASK ONLY IF ASKHEP=1.

IF ASKHEP=0 SKIP TO EDUCA.

EDUCA

78. What is the highest grade or year of school you completed?

READ LIST ONLY IF NECESSARY:

1. Never attended school or only attended kindergarten

2. Grades 1 through 8 (Elementary)

3. Grades 9 through 11 (Some high school)

4. Grade 12 or GED (High school graduate)

5. College 1 year to 3 years (Some college or technical school)

6. College 4 years or more (College graduate)

99. REFUSE

HISPANIC

79. Are you Hispanic or Latino?

(HISPANIC OR LATINO INCLUDES MEXICAN, MEXICAN-AMERICAN, CENTRAL AMERICAN, SOUTH AMERICAN OR PUERTO RICAN, CUBAN, OR OTHER SPANISH-CARIBBEAN.)

1. YES

2. NO

77. DON’T KNOW

99. REFUSE

IF HISPANIC = 77, 99, BUT ETHNICITY WAS GIVEN IN THE SCREENER, USE SCREENER ETHNICITY.

RACE

80. We collected some of this information earlier, but I just need to confirm this information here. Which one or more of the following would you say is your race?

PLEASE READ ALL.

MARK ALL THAT APPLY.

1. White

2. Black or African American [IF COMMUNITY=17, THEN DISPLAY 'Haitian or Haitian American']

3. Asian [GO TO ASIAN]

4. Native Hawaiian or Other Pacific Islander

5. American Indian or Alaska Native, or

6. Some other race [GO TO RACEOTH]

77. DON’T KNOW

99. REFUSE

IF RACE = 3, GO TO ASIAN

IF RACE = 1, 4, 5, 77, 99 GO TO HMLANG

IF RACE = 77, 99 BUT RACE_X WAS GIVEN IN THE SCREENER, USE SCREENER RACE.

RACEOTH

80A. Other – specify: __________

GO TO HMLANG

ASIAN

82. Are you …?

PLEASE READ ALL

MARK ALL THAT APPLY

1. Cambodian

2. Chinese

3. Filipino

4. Laotian

5. Thai

6. Vietnamese

7. Hmong

8. Korean

9. Asian Indian

10. Other Asian [GO TO ASIANOTH]

77. DON'T KNOW

99. REFUSED

RESPONSE OPTIONS HERE ARE DYNAMIC. INCLUDE ASIAN SUB-GROUPS APPROPRIATE FOR COMMUNITY BASED ON GRANTEE FEEDBACK. RESPONSE “10. OTHER ASIAN” WILL ALWAYS BE DISPLAYED.

Ask ASIAN only if RACE=3. Do not ask ASIAN if RACE is not 3 regardless of screener race.

ASIANOTH

82A. Other – specify: __________

HMLANG

83. What is the main language that you speak at home?

READ ONLY IF NECESSARY:

1. 1. ENGLISH

2. 2. SPANISH

3. 3. HAITIAN CREOLE

4. 4. VIETNAMESE

5. 5. KHMER

6. 6. CHINESE (CANTONESE OR MANDARIN)

7. 7. KOREAN

8. 8. OTHER [GO TO HMLANGOTH]

RESPONSE OPTIONS HERE ARE DYNAMIC. INCLUDE LANGUAGES APPROPRIATE FOR COMMUNITY BASED ON GRANTEE FEEDBACK. RESPONSE “1. ENGLISH”, “8. OTHER” AND INTERVIEW LANGUAGE WILL ALWAYS BE DISPLAYED.

HMLANGOTH

83A. Other – specify: __________

[ASK ONLY IF MODE = CAPI]

PHONE

What type of telephone service does your household have?

PLEASE READ ALL

MARK ALL THAT APPLY

1. Cell phone

2. Regular phone

3. No phone service

77. DON'T KNOW

99. REFUSED

DAILY_INTRO

These next questions are about your daily life.

HOME

84. Do you own or rent your home?

INTERVIEWER NOTE: “OTHER ARRANGEMENT” MAY INCLUDE GROUP HOME OR STAYING WITH FRIENDS OR FAMILY WITHOUT PAYING RENT.

PLEASE READ:

1. Own

2. Rent

3. Other arrangement [GO TO MEALS]

77. DON’T KNOW [GO TO MEALS]

99. REFUSE [GO TO MEALS]

HOUSING

85. How often in the past 12 months would you say you were worried or stressed about having enough money to pay your [IF HOME=1, FILL "MORTGAGE". ELSE IF HOME=2, FILL "RENT".]? Would you say you were worried or stressed---

1. Always
2. Usually
3. Sometimes
4. Rarely
5. Never
6. NOT APPLICABLE
77. DON’T KNOW
99. REFUSED

MEALS

86. How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say you were worried or stressed---

1. Always
2. Usually
3. Sometimes
4. Rarely
5. Never
6. NOT APPLICABLE
77. DON’T KNOW
99. REFUSED

CHCGROCER_MIN

How long does it take you to get to your usual grocery store?

MINUTES |___|___|___|

777. DON’T KNOW

999. REFUSE

MINUTES RANGE 0-600, 777, 999

INTERVIEWER: ENTER RESPONSE AS GIVEN BY THE R. IF THEY RESPOND IN MINUTES (SUCH AS 90 MINUTES) ENTER 90 MINUTES, NOT 1 HOUR AND 30 MINUTES.

CHCGROCER_HRS

HOURS |___|___|

77. DON’T KNOW

99. REFUSE

HOURS RANGE 0-10, 77, 99

IF (CHCGROCER_HRS > 3 except 77 and 99) OR (CHCGROCER_MIN > 180 except 777 and 999) OR (CHCGROCER_HRS=3 AND CHCGROCER_MIN>0) GO TO CHCGROCER_CONF

CHCGROCER_CONF

Just to confirm that I entered it correctly, I have [CHCGROCER_HRS] hours / [CHCGROCER_MIN] minutes. Is that correct?

1. YES

2. NO

CHCFRTVEG

In your neighborhood, how often can you easily find a variety of good quality, affordable, fresh fruits and vegetables that you want? Would you say…

1. Always

2. Often

3. Sometimes

4. Seldom

5. Never

77. DON’T KNOW
99. REFUSED

CHCQUALITY

How would you rate the quality of the fresh fruits and vegetables where you shop-very high quality, somewhat high quality, not of high quality or would you say that fresh fruits and vegetables are not available?

1. Very High

2. Somewhat High

3. Not High Quality

4. Not Available

77. DON’T KNOW
99. REFUSED

CHCFASTFD

How often do you eat any food, including meals and snacks, from a fast food restaurant, like McDonald's, Taco Bell, Kentucky Fried Chicken or another similar type of place-4 or more times per week, 1-3 times per week, less than once a week but more than once a month, less than once a month or never?

1. 4+ times per week

2. 1-3 times per week

3. Less than once a week/More than once a month

4. Less than once a month

5. Never

77. DON’T KNOW
99. REFUSED

INCOME

87. Is your annual household income from all sources. . .

VARIABLE INCOME2 WILL BE CODED BASED ON CASCADE.

INCOMEA

87A. (Is your annual household income from all sources. . .?)

Less than $25,000?

1. YES [GO TO INCOMEB]
2. NO [GO TO INCOMEE]
77. DON’T KNOW [CODE INCOME2 77, GO TO HEARDPROG]
99. REFUSED [CODE INCOME2 99, GO TO HEARDPROG]

INCOMEB

87B. (Is your annual household income from all sources. . .?)

Less than $20,000?

1. YES [GO TO INCOMEC]
2. NO [CODE INCOME2 04, GO TO HEARDPROG]
77. DON’T KNOW [CODE INCOME2 10, GO TO HEARDPROG]
99. REFUSED [CODE INCOME2 10, GO TO HEARDPROG]

INCOMEC

87C. (Is your annual household income from all sources. . .?)

Less than $15,000?

1. YES [GO TO INCOMED]
2. NO [CODE INCOME2 03, GO TO HEARDPROG]
77. DON’T KNOW [CODE INCOME2 11, GO TO HEARDPROG]
99. REFUSED [CODE INCOME2 11, GO TO HEARDPROG]

INCOMED

87D. (Is your annual household income from all sources. . .?)

Less than $10,000?

1. YES [CODE INCOME2 01, GO TO HEARDPROG]
2. NO [CODE INCOME2 02, GO TO HEARDPROG]
77. DON’T KNOW [CODE INCOME2 11, GO TO HEARDPROG]
99. REFUSED [CODE INCOME2 11, GO TO HEARDPROG]

INCOMEE

87E. (Is your annual household income from all sources. . .?)

Less than $35,000?

1. YES [CODE INCOME2 05, GO TO HEARDPROG]
2. NO [GO TO INCOMEF]
77. DON’T KNOW [CODE INCOME2 12, GO TO HEARDPROG]
99. REFUSED [CODE INCOME2 12, GO TO HEARDPROG]

INCOMEF

87F. (Is your annual household income from all sources. . .?)

Less than $50,000?

1. YES [CODE INCOME2 06, GO TO HEARDPROG]
2. NO [GO TO INCOMEG]
77. DON’T KNOW [CODE INCOME2 13, GO TO HEARDPROG]
99. REFUSED [CODE INCOME2 13, GO TO HEARDPROG]

INCOMEG

87G. (Is your annual household income from all sources. . .?)

Less than $75,000?

1. YES [CODE INCOME2 07, GO TO HEARDPROG]
2. NO [CODE INCOME2 08, GO TO HEARDPROG]
77. DON’T KNOW [CODE INCOME2 14, GO TO HEARDPROG]
99. REFUSED [CODE INCOME2 14, GO TO HEARDPROG]

INCOME2

CALCULATE VARIABLE INCOME2 BASED ON RESPONSES TO INCOME SERIES.

1. Less than $10,000

2. $10,000 to less than $15,000

3. $15,000 to less than $20,000

4. $20,000 to less than $25,000

5. $25,000 to less than $35,000

6. $35,000 to less than $50,000

7. $50,000 to less than $75,000

8. $75,000 or more

9. Less than 25,000

10. Less than 20,000

11. Less than 15,000

12. More than 25,000

13. More than 35,000

14. More than 50,000

77. Don't know

99. Refused

HEARDPROG

88. Have you ever heard of a program in your area called [PROGRAM NAME]?

1. YES

2. NO

77. NOT SURE

99. REFUSED

SKIP PROGNAME IF COMMUNITY=28

GO TO AC_INCENT IF (INCENTIVE_GRP >0 OR <> NULL AND IF ALL ELIGIBLE MEMBERS HAVE COMPLETED THE QUESTIONNAIRES

ELSE GO TO CLOSING OR CLOSING_HHM AS APPROPRIATE.

CLOSING STATEMENT:

READ IF THERE ARE MULTIPLE HH MEMBERS AND NOT ALL ARE COMPLETE.

CLOSING_HHM

Those are all the questions I have for you. There is another person in your household eligible for this survey that I’d like to speak with in a moment, but first I’d like to thank you on behalf of the Centers for Disease Control and Prevention for the time and effort you’ve spent answering these questions.

If you have any questions about this survey, you may call my supervisor toll-free at 1- 877-375-5964. [IF COMMUNITY <>28 DISPLAY "If you would like more information about health behaviors in your area call [INSERT GRANTEE CONTACT INFORMATION]."] If you want to know more about your rights as a study participant you may call the NORC Institutional Review Board Administrator, toll free, at 866-309-0542.
Thanks again.

1. Continue with roster [RETURN TO ROSTER TABLE ]

1. EXIT [GO TO UE]

CLOSING

Those are all the questions I have. I'd like to thank you on behalf of the Centers for Disease Control and Prevention for the time and effort you’ve spent answering these questions. [IF INCENT_GRP <> ?? AND INCENT_GRP>0, FILL We will send you $[INCENT_GRP] as a token of our appreciation.]

If you have any questions about this survey, you may call my supervisor toll-free at 1- 877-375-5964. If you would like more information about health behaviors in your area call [INSERT GRANTEE CONTACT INFORMATION]. If you want to know more about your rights as a study participant you may call the NORC Institutional Review Board Administrator, toll free, at 866-309-0542.

Thanks again.

NORC REACH U.S. Final Data User’s Manual and Methodology Report: Phase 2 38