Attachment P: Proposed ACASI questions
(including sexual identity questions)
for 5,000 case field test to be tested following full NHIS
Note to reviewers: The “Green Arrow Key” refers to the Enter key. A green arrow sticker is placed on the Enter key. The “Red Circle Key” refers to the Space Bar. A red circle sticker is placed on the Space Bar. Finally, the “Blue Arrow Key” is the Tab key. A blue arrow sticker is placed on the Tab key.
INSTRUCTIONS AND PRACTICE SESSION QUESTIONS
ACASINTR. READ TO RESPONDENT: Now I will ask you to do an important part of this interview on your own, using the computer and headphones. You will hear questions through the headphones and see them on the computer screen.
FR INSTRUCTION: TURN COMPUTER AND HAND HEADPHONES/EARBUDS TO RESPONDENT
Before you start, you will go through a short practice session. Let me first show you the keys you will use. The practice session that follows will go through what each key does also.
FR INSTRUCTION: WHEN THE RESPONDENT IS READY, ASK THEM TO PRESS “1” TO CONTINUE.
ACIHEAD. First I want to make sure you can hear me. I will ask you questions at this level. If you want to change the level of my voice, use the knob that the interviewer showed you. If you have difficulty, ask the interviewer for help. When you are comfortable with the volume, press the Green Arrow Key once.
ACIINTR1. We want you to be able to answer the remaining questions in complete privacy. The first questions are for practice. When you are ready to go to the next screen, press the Green Arrow Key.
ACIINTR2. You can read the questions on the computer screen and hear them read through the headphones. If you would like to just see the questions on the screen without sound, you can turn off the voice using the knob on the cord. Now press the Green Arrow Key.
ACIDLIC. After you hear or read this question, press the Red Circle Key until the circle is on the answer you want, then press the Green Arrow Key.
Do you have a driver’s license?
Yes
No
ACINUM. Other questions will ask you to type in a number instead of choosing a number from a list.
In the past 30 days, on how many days did you watch TV? Type in the number of days you watched TV, then press the Green Arrow Key.
If you did not watch TV, press 0.
________________ [RANGE: 0 - 30]
ACIDOAGAIN. You can tell the computer to repeat a question by pressing the Red Circle Key until you are at the question again. Try this now. Then press the Red Circle Key to pick your answer, then press the Green Arrow Key. How many times did you listen to this screen>
One time
Two or more times
ACIBACK. If you want to change or see your answer to a previous question, you can back up using the Blue Arrow Key. Each time you press this key, the computer will go back one question. Press the Green Arrow Key to continue. Pressing the Green Arrow Key will always take you to the next question even if you don’t pick an answer.
ACIDKREF. If you cannot answer a question because you do not know the answer or do not want to answer you have that choice. Press the Red Circle Key until you have the answer you want, then press the Green Arrow Key to get to the next question. Try that now.
How many stars are there in the sky?
I don’t know the answer
I don’t want to answer
ACISTART. If you have any questions, ask your interviewer now. If not, press 7 and then [ENTER] to begin the questions.
ACASI QUESTIONS TO BE TESTED
These questions are about you and your life.
How often do you use a computer?
Never or almost never
Some days
Most days
Every day
I don’t know the answer
I don’t want to answer
In general, how satisfied are you with the health care you received in the past 12 months?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
I haven’t had health care in the past 12 months
I don’t know the answer
I don’t want to answer
How tall are you without shoes? First, type the number of feet, and then press the Green Arrow Key. Then, type the number of inches and press the Green Arrow Key again.
Feet: __________[RANGE: 1-10]
Inches: __________[RANGE: 0-11]
I don’t know the answer
I don’t want to answer
How much do you weigh without shoes? Type in the number of pounds and then press the Green Arrow Key.
Number of pounds: __________[RANGE: 50-999]
I don’t know the answer
I don’t want to answer
When you were 6 years old, who did you live with most of the time?
My mother only
My father only
Both my mother and father
I did not live with either parent
I don’t know the answer
I don’t want to answer
When you were 16 years old, who did you live with most of the time?
My mother only
My father only
Both my mother and father
I did not live with either parent
I don’t know the answer
I don’t want to answer
Where any of your grandparents born in the United States?
Yes (Go to 7a)
No (Go to 8)
I don’t know the answer
I don’t want to answer
7a. How many of your grandparents were born in this country?
One
Two
Three
Four
I don’t know the answer
I don’t want to answer
8a. For men: Do you think of yourself as
Gay
Straight, that is, not gay
Bisexual
Something else
I don’t know the answer
[If “Something else” is selected]
By something else, do you mean that…
You are not straight, but identify with another label such as queer, trisexual, omnisexual or pan-sexual
You are transgender, transsexual or gender variant
You have not figured out or are in the process of figuring out your sexuality
You do not think of yourself as having sexuality
You do not use labels to identify yourself
You made a mistake and did not mean to pick this answer
You mean something else
[If “You mean something else” is selected]
What do you mean by something else? Please type in your answer and then press the Green Arrow Key.
[If “I don’t know the answer” is selected]
By Don’t Know, do you mean that…
You don’t understand the words
You understand the words, but you have not figured out or are in the process of figuring out your sexuality
You mean something else
[If “You mean something else” is selected]
What do you mean by something else? Please type in your answer and then press the Green Arrow Key.
[If no answer is selected]
You did not enter an answer for the question. That is because you:
Made a mistake and would like to have another chance
Are not sure how to answer
Do not want to answer
8b. For women: Do you think of yourself as
Lesbian or Gay
Straight, that is, not gay
Bisexual
Something Else
I don’t know the answer
[If “Something else” is selected]
By something else, do you mean that…
You are not straight, but identify with another label such as queer, trisexual, omnisexual or pan-sexual
You are transgender, transsexual or gender variant
You have not figured out or are in the process of figuring out your sexuality
You do not think of yourself as having sexuality
You do not use labels to identify yourself
You made a mistake and did not mean to pick this answer
You mean something else
[If “You mean something else” is selected]
What do you mean by something else? Please type in your answer and then press the Green Arrow Key.
[If “I don’t know the answer” is selected]
By Don’t Know, do you mean that…
You don’t understand the words
You understand the words, but you have not figured out or are in the process of figuring out your sexuality
You mean something else
[If “You mean something else” is selected]
What do you mean by something else? Please type in your answer and then press the Green Arrow Key.
[If no answer is selected]
You did not enter an answer for the question. That is because you:
Made a mistake and would like to have another chance
Are not sure how to answer
Do not want to answer
The next questions ask how concerned you are right now about financial matters.
9. How concerned are you right now about not having enough money for retirement? Are you…
Very worried
Moderately worried
Not too worried
Not worried at all
I don’t know the answer
I don’t want to answer
How concerned are you right now about not being able to pay medical costs of a serious illness or accident? Are you…
Very worried
Moderately worried
Not too worried
Not worried at all
I don’t know the answer
I don’t want to answer
How concerned are you right now about not being able to maintain the standard of living you enjoy? Are you…
Very worried
Moderately worried
Not too worried
Not worried at all
I don’t know the answer
I don’t want to answer
How concerned are you right now about not being able to pay medical costs for normal healthcare? Are you…
Very worried
Moderately worried
Not too worried
Not worried at all
I don’t know the answer
I don’t want to answer
How concerned are you right now about not having enough money to pay for your children's college? Are you…
Very worried
Moderately worried
Not too worried
Not worried at all
This does not apply to me
I don’t know the answer
I don’t want to answer
How concerned are you right now about not having enough to pay your normal monthly bills? Are you…
Very worried
Moderately worried
Not too worried
Not worried at all
I don’t know the answer
I don’t want to answer
How concerned are you right now about not being able to pay your rent, mortgage, or other housing costs? Are you…
Very worried
Moderately worried
Not too worried
Not worried at all
I don’t know the answer
I don’t want to answer
How concerned are you right now about not being able to make the minimum payments on your credit cards? Are you…
Very worried
Moderately worried
Not too worried
Not worried at all
I don’t have credit cards
I don’t know the answer
I don’t want to answer
On average, how many hours of sleep do you get in a 24-hour period?
Four hours or less
Five hours
Six hours
Seven hours
Eight hours
Nine hours
Ten hours or more
I don’t know the answer
I don’t want to answer
In the past week, how often did you have trouble falling asleep?
I didn’t have trouble falling asleep in the past week
One time
Two times
Three times
Four times
Five times
Six times
Seven or more times
I don’t know the answer
I don’t want to answer
In the past week, how many times did you have trouble staying asleep?
I didn’t have trouble staying asleep in the past week
One time
Two times
Three times
Four times
Five times
Six times
Seven or more times
I don’t know the answer
I don’t want to answer
In the past week, how many times did you take medication to help you fall asleep or stay asleep?
I did not take medication to help me sleep in the past week
One time
Two times
Three times
Four times
Five times
Six times
Seven or more times
I don’t know the answer
I don’t want to answer
In the past week, on how many days did you wake up feeling well rested?
I never felt rested
One time
Two times
Three times
Four times
Five times
Six times
Seven or more times
I don’t know
I don’t want to answer
Now I am going to ask you some questions about feelings you may have experienced over the PAST 30 DAYS.
DURING THE PAST 30 DAYS, how often did you feel
... So sad that nothing could cheer you up?
ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
I don’t know the answer
I don’t want to answer
During the PAST 30 DAYS, how often did you feel
... Nervous?
ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
I don’t know the answer
I don’t want to answer
During the PAST 30 DAYS, how often did you feel
... Restless or fidgety?
ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
I don’t know the answer
I don’t want to answer
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
I don’t know the answer
I don’t want to answer
During the PAST 30 DAYS, how often did you feel
...That everything was an effort?
ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
I don’t know the answer
I don’t want to answer
During the PAST 30 DAYS, how often did you feel
...Worthless?
ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
I don’t know the answer
I don’t want to answer
Universe statement: Sample adults 18+ who at least some of the time have felt sad, nervous, restless or fidgety, hopeless, that everything was an effort, or worthless, in the past 30 days.
We just talked about a number of feelings you had during the past 30 days. Altogether, how much did these feelings interfere with your life or activities: a lot, some, a little, or not at all?
A lot
Some
A little
Not at all
I don’t know the answer
I don’t want to answer
The next question is about the test for HIV, the virus that causes AIDS. Except for tests you may have had as part of blood donations, have you ever been tested for HIV?
Yes
No
I don’t know the answer
I don’t want to answer
These next questions are about drinking alcoholic beverages. Included are liquor such as whiskey or gin, beer, wine, wine coolers, and any other type of alcoholic beverage.
In any one year, have you had at least 12 drinks of any type of alcoholic beverage?
Yes (Go to Q32)
No (Go to Q31)
I don’t know the answer
I don’t want to answer
In your entire life, have you had at least 12 drinks of any type of alcoholic beverage?
Yes
No
I don’t know the answer
I don’t want to answer
In the past year, how many days did you drink any type of alcoholic beverage?
Enter number of days you drank any alcoholic beverage in the past year then press the Green Arrow Key.
Press 0 for no days.
________________number of days drank any alcoholic beverage in the past year
I don’t know the answer
I don’t want to answer
In the past year, on those days that you drank alcoholic beverages, on the average, how many drinks did you have?
Enter number of drinks per day and then press the Green Arrow Key.
___________drinks per day
I don’t know the answer
I don’t want to answer
In the past year, on how many days did you have 5 or more drinks of any alcoholic beverage?
Enter number of days you drank 5 or more drinks then press the Green Arrow Key.
Press 0 for no days.
___________number of days you drank 5 or more drinks
I don’t know the answer
I don’t want to answer
| File Type | application/msword |
| Author | Centers for Disease Control & Prevention |
| Last Modified By | CDC User |
| File Modified | 2012-02-13 |
| File Created | 2012-02-13 |