3 Reach U.S. Study Booklet

REACH U.S. Household Member Interview
The Centers for Disease Control and Prevention is conducting a study regarding health issues
in your area. 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 stop at any time. The booklet takes about 15 minutes
and your answers will be confidential. There are no risks or benefits to you for participating. If
you would like to participate, please answer the questions in this booklet using a pen with blue
or black ink. When you are finished, please return your booklet to us in the enclosed envelope.

Instructions for Completing the Booklet
This booklet contains several types of questions. Each question should be answered only
about yourself, not anyone else in your household.


For some questions, you answer the question by marking a box, like this:
 Yes
2
No
1



For some questions, you answer the question by filling in one number per box, like this:

0 9


NUMBER OF DAYS

You will sometimes be instructed to skip one or more questions. In this example, if your
choice is 'No', you skip to question 10; otherwise, you continue to the next question.
Yes
2  No
1

Go To 10

2

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

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

2
3
4
5
1

Yes
2
No
1

Excellent
Very good
Good
Fair
Poor

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.

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? If none, enter 0.

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
1

NUMBER OF DAYS
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? If none,
enter 0.

8. About how much do you weigh without
shoes? Answer in pounds or kilograms.
POUNDS
OR

NUMBER OF DAYS

KILOGRAMS

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? If none, enter 0.

9. About how tall are you without shoes?
Answer in feet and inches or centimeters.
FEET AND
OR

NUMBER OF DAYS

CENTIMETERS

5. Do you have any kind of health care
coverage, including health insurance,
prepaid plans such as HMOs, or
government plans such as Medicare?
Yes
2
No
1

3

INCHES

10. Are you currently . . .? Mark only one.

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?

Employed for wages
Go To 11
2
Self-employed
Go To 11
3
Out of work for more than
Go To 14
1 year
4
Out of work for less than
Go To 14
1 year
5
A Homemaker
Go To 15
6
A Student
Go To 15
7
Retired
Go To 14
8
Unable to work
Go To 15
1

HOURS
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?

2
1

11. When you are at work, which of the
following best describes what you do?
Mark only one. If you have more than one
job, please include all jobs in your answer.

Yes
No

Section B

Mostly sitting or standing
2
Mostly walking
3
Mostly heavy labor or physically
demanding work
1

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.

12. At your main job or business, how are
you generally paid for the work you do?
If you are paid in more than one way at
your main job, please mark “paid some
other way”.

2
3
4
1

Paid
Paid
Paid
Paid

17. Now thinking about the moderate
activities you do 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?

by salary
by the hour
by the job/task
some other way

1

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

2

2
3
4

Paid
Paid
Paid
Paid

Go To 16

by salary
by the hour
by the job/task
some other way

Yes
No

Go To 20

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

14. Thinking about the last time you
worked, at your main job or business,
how were you generally paid for the
work you do?
1

DAYS PER WEEK

4

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

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?

DAYS PER WEEK

MINUTES PER DAY

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?

20. Now thinking about the vigorous
activities you do 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?

2
1

Yes
No

MINUTES PER DAY

Go To Section C

Section C
These next questions are about the foods you usually eat or drink. Include all foods you eat,
both at home and away from home. Enter a number in the "number of times" box and then mark if it
is times per day, per week, per month or per year. If never, enter "0".
Per
Day
NUMBER OF TIMES

23. How often do you drink fruit juices such
as orange, grapefruit, or tomato?. . . . . . . . . . . . . . . .
24. Not counting juice, how often do you
eat fruit?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25. How often do you eat green salad? . . . . . . . . . . . . . .
26. How often do you eat potatoes not including
French fries, fried potatoes, or potato chips?. . . . . .
27. How often do you eat carrots? . . . . . . . . . . . . . . . . . .
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.). . . . . . . . . . . .

5

▼

Per
Week

Per
Month

Per
Year

▼
▼
Mark only one.

▼

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

33. About how many times in the past 12
months have you seen a doctor, nurse,
or other health professional for your
diabetes? If never, enter "0".

Section D
The next questions are about diabetes.

NUMBER OF TIMES
29. Have you ever been told by a doctor
that you have diabetes?
1

Yes

If you are male
If you are female

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"? If never, enter "0".

go to 31.
go to 30.

No
Go To Section E on page 7
3
No, pre-diabetes or borderline
diabetes
Go To Section E on page 7
2

NUMBER OF TIMES

30. Was this only when you were pregnant?

2
1

Yes
No

OR
98 Mark here if you have never heard of
an "A one C" test.

Go To Section E on page 7

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. If never,
enter "0".
NUMBER OF TIMES

Per
Day

Per
Week

▼

▼
▼
▼
Mark only one.

1

2

Per
Month

3

35. About how many times in the past 12
months has a health professional
checked your feet for any sores or
irritations? If never, enter "0".
NUMBER OF TIMES
OR
555
Mark here if your feet have been
amputated.

Per
Year

4

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.

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. If never,
enter "0".
NUMBER OF TIMES

Per
Day

▼
1

Per
Week

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
1

Per
Per
Month Year

▼
▼
▼
Mark only one.
2

3

4

OR
555
Mark here if your feet have been
amputated.
6

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

2
1

Section F
The next questions are about blood
cholesterol.

Yes
No

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

Section E
The next questions are about high blood
pressure.

2
1

38. Have you ever been told by a doctor,
nurse, or other health professional that
you have high blood pressure?
Yes
No
Go To Section F
3
Told borderline or
pre-hypertensive
Go To Section F

1

2

3

4

2

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

2

Go To Section G on page 8

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

1

1

Yes
No

Yes
No

Within the past year
(anytime less than 12 months ago)
Within the past 2 years
(1 year but less than 2 years ago)
Within the past 5 years
(2 years but less than 5 years ago)
5 or more years ago

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

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

1
2

a. changing your eating habits?
1
Yes
2
No
b. cutting down on salt?
1
Yes
2
No
3
Do not use salt
c. reducing alcohol use?
1
Yes
2
No
3
Do not drink
d. exercising?
1
Yes
2
No

7

Yes
No

46. Which of the following do you think is a
symptom of a stroke?

Section G
The next questions are about cardiovascular
disease.

Yes

▼
a. sudden confusion or
trouble speaking. . . . . . 1

44. Has a doctor, nurse, or other health
professional ever told you that you had
any of the following?
Yes

No

a. a heart attack, also ▼ ▼
called a myocardial
2
infarction . . . . . . . . . . 1
b. angina or coronary
heart disease. . . . . . . 1
c. a stroke. . . . . . . . . . . . 1

b. sudden numbness or
weakness of face, arm,
or leg, especially on
one side. . . . . . . . . . . . .

Not
sure

c. sudden trouble seeing
in one or both eyes. . . .

▼

d. sudden chest pain or
discomfort . . . . . . . . . . .

77

2

77

2

77

f. severe headache with
no known cause . . . . . .

Yes

No

Not
sure

▼
a. pain or discomfort
in the jaw, neck,
or back. . . . . . . . . . . . 1

▼

▼

b. feeling weak,
lightheaded,
or faint . . . . . . . . . . . .
c. chest pain or
discomfort . . . . . . . . .
d. sudden trouble
seeing in one or
both eyes. . . . . . . . . .
e. pain or discomfort
in the arms or
shoulder. . . . . . . . . . .
f. shortness of
breath. . . . . . . . . . . . .

2

3
4
5
1

2

2

77

1

2

77

1

2

77

1

2

77

1

2

77

▼

▼
77

1

2

77

1

2

77

1

2

77

2

77

2

77

1

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

77

1

Not
sure

2

e. sudden trouble walking,
dizziness, or loss of
balance. . . . . . . . . . . . . . 1

45. Which of the following do you think is a
symptom of a heart attack?

No

8

Take them to the hospital
Tell them to call their doctor
Call 911
Call their spouse or a family member
Do something else

52. 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?

Section H
The next questions are about vaccines.

2
1

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

2
1

2

Yes
No

2

3

4

5

3

4

5

Within the past year
(anytime less than 12 months ago)
Within the past 2 years
(1 year but less than 2 years ago)
Within the past 3 years
(2 years but less than 3 years ago)
Within the past 5 years
(3 years but less than 5 years ago)
5 or more years ago

Yes
No

Go To 56

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

Go To 52

51. How long has it been since you had
your last mammogram?
1

2

2

50. A mammogram is an x-ray of each
breast to look for breast cancer. Have
you ever had a mammogram?
Yes
No

1

The next questions are about breast and
cervical cancer. Only women should answer
these questions. If you are male, go to
Section J on page 10.

2

1

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

Section I

1

Go To 54

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

Yes
No

49. 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
No

Within the past year
(anytime less than 12 months ago)
Within the past 2 years
(1 year but less than 2 years ago)
Within the past 3 years
(2 years but less than 3 years ago)
Within the past 5 years
(3 years but less than 5 years ago)
5 or more years ago

1

2

3

4

5

Within the past year
(anytime less than 12 months ago)
Within the past 2 years
(1 year but less than 2 years ago)
Within the past 3 years
(2 years but less than 3 years ago)
Within the past 5 years
(3 years but less than 5 years ago)
5 or more years ago

56. Have you had a hysterectomy? A
hysterectomy is an operation to remove
the uterus (womb).

2
1

9

Yes
No

If you are 18-49 years old
go to 57.
If you are 50 years old or older
go to
Section J.

Section K
The next questions are about hepatitis.

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

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

2
1

Yes
2
No
Go To Section J
3
Doctor refused when
asked
Go To Section J
4
No, never heard about it/ Never offered
to you
Go To Section J
1

2
3
1

5
4

NUMBER OF SHOTS

Section J

1

2

59. Have you smoked at least 100 cigarettes
(5 packs) in your entire life?
Yes
No

3

Go To Section K

4

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

2
3
1

Everyday
Some days
Not at all

5
6

2

8
7

Go To Section K

61. During the past 12 months, have you
stopped smoking for one day or longer
because you were trying to quit
smoking?
1

Your doctor’s office/lab
In the hospital (as an overnight patient)
At a clinic (other than your doctor's
office)
In a community screening program
Other site (such as blood bank, military
installation, mobile clinic, prison or jail,
emergency room, etc.)

64. Why were you tested for hepatitis B?
Mark all that apply.

The next questions are about cigarette
smoking.

2

Go To 65

63. Where were you tested for hepatitis B?
Mark all that apply.

58. How many HPV shots did you receive?

1

Yes
No

Yes
No
10

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

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

2
1

Yes
No

71. Why were you tested for hepatitis C?
Mark all that apply.
1

3

Go To 69

2

66. How long ago did you first learn you
had hepatitis B? Answer in years or
months.

4

5

OR
MONTHS AGO

Yes
No

1
2

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

2
1

2

2
3

5
4

Go To 76

OR
MONTHS AGO
74. Are you currently seeing a doctor for
your hepatitis C?

Go To 72

2
1

70. Where were you tested for hepatitis C?
Mark all that apply.
1

Yes
No

YEARS AGO

Yes
No

Yes
No

73. How long ago did you first learn you had
hepatitis C? Answer in years or months.

69. Have you ever had a blood test for
hepatitis C?
1

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

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

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

2

6
7

YEARS AGO

1

Yes
No

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

Your doctor’s office/lab
In the hospital (as an overnight patient)
At a clinic (other than your doctor's
office)
In a community screening program
Other site (such as blood bank, military
installation, mobile clinic, prison or jail,
emergency room, etc.)

1
2

11

Yes
No

76. This question is about behaviors or
events related to hepatitis. Please mark
all that apply to you.
1

2

3

4

5

6

7

8

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

 ou received a blood transfusion before
Y
1992
You ever received a blood transfusion
outside of the U.S.
Your mother had hepatitis B before you
were born
You ever had sex with a person who
had hepatitis
You are a man and you have had sex
with other men, even just one time
You have taken street drugs by needle,
even just one time
At least one of the above is true but
you do not want to specify which one
None of the above

1

2

3

4

5

6

82. Are you Hispanic or Latino?
1
2

Section L

2
3
4
1

77. Were you born in the United States?

2

Yes
No

78. Are you male or female?

2
1

Yes
No

83. Which one or more of the following
would you say is your race?
Mark all that apply.

The next questions are about you and your
household.

1

Never attended school or only attended
kindergarten
Grades 1 through 8
(Elementary)
Grades 9 through 11
(Some high school)
Grade 12 or GED
(High school graduate)
College 1 year to 3 years
(Some college or technical school)
College 4 years or more
(College graduate)

Male
Female

5

6

White
Go To 86
Black or African American
Go To 86
Asian
Go To 84
Native Hawaiian or
Other Pacific Islander
Go To 85
American Indian or
Go To 86
Alaska Native
Some other race
(specify here)

79. What is your age?
YEARS OLD
80. How many adults, age 18 or older, live in
this household? Please include yourself.
Do not include adult family members who
are currently living elsewhere, college
students away at school, or anyone in a
prison, mental hospital, or nursing home.
NUMBER OF ADULTS
12

Go To 86

84. Are you …? Mark all that apply.

2
3
4
5
6
7
8
9
10
1

87. What type of telephone service does your
household have? Mark all that apply.
1
Cell phone
2
Regular phone
3
No phone service

Cambodian
Chinese
Filipino
Laotian
Thai
Vietnamese
Hmong
Korean
Asian Indian
Other Asian (specify here)

Section M
These next questions are about your daily life.
88. Do
1
2
3

If you are Native Hawaiian or other Pacific
Islander
go to 85.
If you are not Native Hawaiian or other Pacific
go to 86.
Islander

you own or rent your home?
Own
Rent
Other Arrangement (such as group home
or staying with friends or family without
Go To 90
paying rent)

89. How often in the past 12 months would
you say you were worried or stressed
about having enough money to pay your
rent/mortgage?
1
Always
2
Usually
3
Sometimes
4
Rarely
5
Never
6
Not Applicable (Do not pay rent/
mortgage)

85. Are you …? Mark all that apply.
1
Native Hawaiian
2
Chamorro or Guamanian
3
Samoan
4
Tongan
5
Marshallese
6
Other Pacific Islander (specify here)

86. What is the main language that you
speak at home? Mark only one.
1
English
2
Spanish
3
Haitian Creole
4
Vietnamese
5
Khmer
6
Chinese (Cantonese or Mandarin)
7
Korean
8
Other (specify here)

90. How often in the past 12 months would
you say you were worried or stressed
about having enough money to buy
nutritious meals?
1
Always
2
Usually
3
Sometimes
4
Rarely
5
Never
6
Not Applicable (Do not buy food)

13

91. Is your annual household income
from all sources . . . ?
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
92. Have you ever heard of a program in
your area called [PROGRAM NAME]?

2
1

Yes
No

14

Thank you very much for your time and cooperation. Please place your
completed booklet in the envelope marked confidential, then place all
completed booklets for your household in the pre-paid return envelope
and mail back to:
CENTERS FOR DISEASE CONTROL AND PREVENTION
C/O NATIONAL OPINION RESEARCH CENTER
1 NORTH STATE STREET, 16TH FLOOR
CHICAGO, IL 60602
If you have misplaced the pre-paid return envelope, please call
1-877-375-5964 for a replacement.
If you have questions about your rights as a study participant,
you may call the NORC Institutional Review Board Administrator toll
free, at 866-309-0542.

15