Attachment 4: NHIS 2011 Core
Page 1 of 5
2011 NHIS Questionnaire Family
Coverage
Document Version Date: 19-Jun-12
Question ID: COV.330_00.00 Instrument Variable Name: TELENUM QuestionnaireFileName: Family
QuestionText: What is the telephone number here?
* Enter the area code and the number, or enter "N" if no phone.
UniverseText: All families
SkipInstructions: <2000000000 - 9999999999, D, R> store in HPHONE1, GOTO CURWRK
<0-1999999999> GOTO ERR_TELENUM
<N> GOTO RH1LNGDY_1
Hard Edit: ERR_TELENUM
* Enter the entire telephone number.
* Please correct.
Question ID: COV.331_00.00 Instrument Variable Name: CURWRK QuestionnaireFileName: Family
QuestionText: ?[F1]
Is there at least one telephone INSIDE your home that is currently working and is not a cell phone?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with a phone
SkipInstructions: <1,Refused,Don't know> go to RNOSERV
<2> goto RH1LNGDY_1
Page 2 of 5
2011 NHIS Questionnaire Family
Coverage
Document Version Date: 19-Jun-12
Question ID: COV.332_00.00 Instrument Variable Name: RNOSERV QuestionnaireFileName: Family
QuestionText: Not including cell phones, have you or your family been without telephone service for one week or more DURING
THE PAST 12 MONTHS? Do not include interruptions of phone service due to weather or natural disasters.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: No phone in home that is working and not a cellular phone (or refused to provide or said don't know this
information)
SkipInstructions: <1> goto RH1LNGDY_1
<2, Refused, Don't know> goto TELCEL
Question ID: COV.333_01.00 Instrument Variable Name: RH1LNGDY_1 QuestionnaireFileName: Family
QuestionText: ?[F1]
Not including cell phones, how long were you or your family without telephone service in the PAST 12 MONTHS?
* Enter number for time without telephone service.
000 Less than 1 week
001-365 1-365
997 Refused
999 Don't know
UniverseText: Respondents with no phone or who have no working land-line phone or who have been without land-line
phone service for one week or more during the past 12 months.
SkipInstructions: <1-365> goto RH1LNGDY_2
<0,Refused, Don't know> goto TELCEL
Page 3 of 5
2011 NHIS Questionnaire Family
Coverage
Document Version Date: 19-Jun-12
Question ID: COV.333_02.00 Instrument Variable Name: RH1LNGDY_2 QuestionnaireFileName: Family
QuestionText: ?[F1]
* Enter time period for time without telephone service.
0 Less than 1 week
1 Day(s)
2 Week(s)
3 Months(s)
7 Refused
9 Don't know
UniverseText: Gave number at RH1LNGDY_1
SkipInstructions: <1> if RH1LNGDY_1 gt '7' goto ERR1_RH1LNGDY_2 else goto TELCEL
<2> if RH1LNGDY_1 gt '52' goto ERR2_RH1LNGDY_2 else goto TELCEL
<3> if RH1LNGDY_1 gt '12' goto ERR3_RH1LNGDY_2 else goto TELCEL
Hard Edit: ERR1_RH1LNGDY_2
* Days should be in the range 7-365.
* Please correct.
ERR2_RH1LNGDY_2
* Weeks should be in the range 1-52.
* Please correct.
ERR3_RH1LNGDY_2
* Months should be in the range 1-12.
* Please correct.
Page 4 of 5
2011 NHIS Questionnaire Family
Coverage
Document Version Date: 19-Jun-12
Question ID: COV.334_00.00 Instrument Variable Name: TELCEL QuestionnaireFileName: Family
QuestionText: Do you or anyone in your family have a working cell phone?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> goto WRKCEL
<2, Refused, Don't know> if CURWRK = '1' and RNOSERV = '1'
goto CELLOUT
elseif POS2 = '0'
goto hhc.NAME_FNAME
else
goto hhc.ADC
Question ID: COV.335_00.00 Instrument Variable Name: WRKCEL QuestionnaireFileName: Family
QuestionText: How many working cell phones do you or people in your family have?
01-10 1-10 phones
97 Refused
99 Don't know
UniverseText: Families with a working cell phone
SkipInstructions: <1-10, Refused, Don't know> if CURWRK = '1' and RNOSERV = '1'
goto CELLOUT
elseif CURWRK = '1' and RNOSERV = '2', 'Refused', or 'Don't know'
goto PHONEUSE
elseif POS2 = '0'
goto hhc.NAME_FNAME
else
goto hhc.ADC
Page 5 of 5
2011 NHIS Questionnaire Family
Coverage
Document Version Date: 19-Jun-12
Question ID: COV.336_00.00 Instrument Variable Name: CELLOUT QuestionnaireFileName: Family
QuestionText: During the most recent time you or your family were without telephone service, did you have a working cell phone?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Families with no cell phone, or Refused or Don't know whether they had working cell phone and have a
current working land-line that was out of service in the past 12 months, or who have a least one working cell
phone or Refused or Don't know number of working cell phones and have current working land-line that was
out of service in the past 12 months
SkipInstructions: <1, 2, Refused, Don't know> if TELCEL = '1'
goto PHONEUSE
elseif POS2 = '0'
goto hhc.NAME_FNAME
else
goto hhc.ADC
Question ID: COV.337_00.00 Instrument Variable Name: PHONEUSE QuestionnaireFileName: Family
QuestionText: Of all the telephone calls that you or your family receives, are…
*Read categories below.
1 All or almost all calls received on cell phones
2 Some received on cell phones and some on regular phones
3 Very few or none on cell phones
7 Refused
9 Don't know
UniverseText: Working cell phone and working land-line in family
SkipInstructions: <1-3, Refused, Don't know> if POS2 = '0'
goto hhc.NAME_FNAME
else
goto hhc.ADC
Page 1 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.010_01.00 Instrument Variable Name: NAME_FNAME QuestionnaireFileName: Household
Composition
QuestionText: [fill: What are the names of all the persons living or staying here?
Start with the name of the person, or one of the persons, who owns or rents this home.
/What is the name of the next person living or staying here?]
*Enter 999 if no more persons.
UniverseText: All persons
SkipInstructions: <999> if PCNT = 0, [goto ERR1_NAME_FNAME]
elseif POS2 or POS3 ne 0, [goto HHRESP]
else, [goto MISPERS_MCHILD]
<allow 20,R,D> if name on fake/false name list
[goto ERR2_NAME_FNAME];
else [goto NAME_MNAME]
Hard Edit: ERR1_NAME_FNAME
* 999 not allowed for the first person in the household.
* Please correct.
Soft Edit: ERR2_NAME_FNAME
* You are entering a possible fake/false name.
* Please correct.
* If this is a legitimate name, suppress this error message and continue. Otherwise, go back to the name field
and enter a legitimate name. To enter an alias, enter 'Ctrl D' or 'Ctrl R' for 'Don't Know' or 'Refused' at the name
field. Then, enter a matching identifier/alias at the next screen (ALIAS).
Question ID: HHC.010_02.00 Instrument Variable Name: NAME_MNAME QuestionnaireFileName: Household
Composition
QuestionText: * Enter Middle Name.
* Probe for middle name or middle initial if not reported.
* Press "ENTER" to skip to last name if no middle name.
UniverseText: First name is not blank
SkipInstructions: <allow 20, R,D, null> GOTO NAME_LNAME
Page 2 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.010_03.00 Instrument Variable Name: NAME_LNAME QuestionnaireFileName: Household
Composition
QuestionText: * If last name is the same as displayed, press "ENTER", otherwise, enter the new last name.
*Enter Last Name.
UniverseText: There is a name entered for 'first name'
SkipInstructions: <999> GOTO ERR1_NAME_FNAME
<allow 20, R,D> if name on fake/false name list
goto ERR2_NAME_LNAME
else if NAME_FNAME and NAME_LNAME ne D, R
Set ALIAS = NAME_FNAME< >NAME _LNAME,
goto USUALRES
else goto ALIAS
Hard Edit: ERR1_NAME_FNAME
* 999 is not allowed in the last name when there is a first name.
Soft Edit: ERR2_NAME_LNAME
* You are entering a possible fake/false name.
* Please correct.
* If this is a legitimate name, suppress this error message and continue. Otherwise, go back to the name field
and enter a legitimate name. To enter an alias, enter 'Ctrl D' or 'Ctrl R' for 'Don't Know' or 'Refused' at the name
field. Then, enter a matching identifier/alias at the next screen (ALIAS).
Question ID: HHC.015_00.00 Instrument Variable Name: ALIAS QuestionnaireFileName: Household
Composition
QuestionText: How shall I refer to [fill: you/this person] for the rest of the interview?
UniverseText: Persons who don't know or refused to give first or last name.
SkipInstructions: <allow 41> [goto USUALRES]
Page 3 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.020_00.00 Instrument Variable Name: USUALRES QuestionnaireFileName: Household
Composition
QuestionText: [fill: Do you/Does ALIAS] usually live here?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All non-deleted persons
SkipInstructions: <1> [goto NAME_FNAME]
<2,R,D> [goto ASKURE]
Question ID: HHC.030_00.00 Instrument Variable Name: ASKURE QuestionnaireFileName: Household
Composition
QuestionText: [fill1: Do you/Does ALIAS] have some other place where [fill2: he/she] usually lives?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: If the usual residence is not here, or 'don't know', or 'refused'.
SkipInstructions: <1> [goto NOLIST]
<2, R, D> [goto NAME_FNAME]
Question ID: HHC.035_00.00 Instrument Variable Name: NOLIST QuestionnaireFileName: Household
Composition
QuestionText: Since [fill1: you do/ALIAS does] not usually live here and [fill2: have/has] another residence elsewhere, [fill3:
you/he/she] will not be included in this interview.
* Enter <1> to continue to the next person.
1 To continue
UniverseText: Person living elsewhere
SkipInstructions: [goto NAME_FNAME]
Page 4 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.050_01.00 Instrument Variable Name: MISPERS_MCHILD QuestionnaireFileName: Household
Composition
QuestionText: I have listed living here ...
[fill roster]
Have I missed any babies or small children?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: After completing household roster
SkipInstructions: <1> empty out '999' in NAME_FNAME
empty out MISPERS_CHILD
empty out MISPERS_MLODGE
empty out MISPERS_MAWAY
empty out MISPERS_MELSE
[goto NAME_FNAME]
<2, R, D> goto MISPERS_MLODGE
Question ID: HHC.050_02.00 Instrument Variable Name: MISPERS_MLODGE QuestionnaireFileName: Household
Composition
QuestionText: * Read if necessary.
I have listed living here ...
[fill roster]
Have I missed any lodgers, boarders, or persons you employ who live here?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Not missing any children or R or D
SkipInstructions: <1> empty out '999' in NAME_FNAME
empty out MISPERS_CHILD
empty out MISPERS_MLODGE
empty out MISPERS_MAWAY
empty out MISPERS_MELSE
[goto NAME_FNAME]
<2,R,D> goto MISPERS_MAWAY
Page 5 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.050_03.00 Instrument Variable Name: MISPERS_MAWAY QuestionnaireFileName: Household
Composition
QuestionText: * Read if necessary.
I have listed living here...
[fill roster]
Have I missed anyone who USUALLY lives here, but is now away from home traveling or in a hospital?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: No 'lodgers' living here or R or D
SkipInstructions: <1> empty out '999' in NAME_FNAME
empty out MISPERS_CHILD
empty out MISPERS_MLODGE
empty out MISPERS_MAWAY
empty out MISPERS_MELSE
[goto NAME_FNAME]
<2,R,D> goto MISPERS_MELSE
Question ID: HHC.050_04.00 Instrument Variable Name: MISPERS_MELSE QuestionnaireFileName: Household
Composition
QuestionText: * Read if necessary.
I have listed living here...
[fill roster]
Have I missed anyone else staying here?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Nobody is away from home or R or D
SkipInstructions: <1> empty out '999' in NAME_FNAME
empty out MISPERS_CHILD
empty out MISPERS_MLODGE
empty out MISPERS_MAWAY
empty out MISPERS_MELSE
[goto NAME_FNAME]
<2,R,D> if PCNT = 0, goto EXIT
elseif PCNT = 1
store Yes (1) in LIVEAT, goto OTHLIV
else goto LIVEAT
Page 6 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.060_00.00 Instrument Variable Name: LIVEAT QuestionnaireFileName: Household
Composition
QuestionText: Do all the persons I have listed live AND eat together?
*Read names if necessary.
[fill roster]
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Person count is greater than one
SkipInstructions: <1,R,D> [goto OTHLIV]
<2> [goto XACCESS]
Question ID: HHC.070_00.00 Instrument Variable Name: XACCESS QuestionnaireFileName: Household
Composition
QuestionText: Do the people who do not live and eat here have direct access from the outside or through a common hallway to a
separate living quarters?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons don't eat and live together
SkipInstructions: <1> [goto TABX]
<2,R,D> [goto OTHLIV]
Page 7 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.090_00.00 Instrument Variable Name: OTHLIV QuestionnaireFileName: Household
Composition
QuestionText: Do members of any other household on the property live and eat with members of this household?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All
SkipInstructions: <1> [goto ERR_OTHLIV]
<2,R D> if PCNT = 1, [goto SEX]
else [goto HHRESP]
Hard Edit: ERR_OTHLIV
* All such persons should be included in this interview.
* Please correct by adding the additional person(s) to the household.
Question ID: HHC.100_00.00 Instrument Variable Name: HHRESP QuestionnaireFileName: Household
Composition
QuestionText: * Ask if necessary
With whom am I speaking?
* Enter the line number of the respondent. If more than one, enter the number of the one you consider to be the main
respondent.
UniverseText: All households with more than one nondeleted person in parent cases or more than one nondeleted person in
spawn cases and no household/family demographic respondent identified yet.
SkipInstructions: <1-25>
If deleted PX [goto ERR1_HHRESP]
elseif out of bound [goto ERR2_HHRESP]
elseif ADC = 1 [goto HHREF_A]
else [goto SEX]
Hard Edit: ERR1_HHRESP:
* Person was deleted from this household.
* Please correct.
ERR2_HHRESP:
*Invalid line number entered.
* Please correct.
Page 8 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.110_00.00 Instrument Variable Name: SEX QuestionnaireFileName: Household
Composition
QuestionText: * Ask if not apparent.
* If don’t know or refused enter your best guess.
[Are you/Is ALIAS] male or female?
1 Male
2 Female
UniverseText: All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions: <1,2> [goto AGEDOB_1]
Question ID: HHC.120_01.00 Instrument Variable Name: AGEDOB_1 QuestionnaireFileName: Household
Composition
QuestionText: 1 of 5
What is [fill: your/ALIAS's] age?
* Enter number for age.
01-120 Age in years
UniverseText: All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions: <001-120> [goto AGEDOB_2]
<R,D> [goto AGEDOB_3]
Question ID: HHC.120_02.00 Instrument Variable Name: AGEDOB_2 QuestionnaireFileName: Household
Composition
QuestionText: 2 of 5
* Enter number for age time period.
1 Days
2 Weeks
3 Months
4 Years
UniverseText: Valid age - number entered
SkipInstructions: <1-4> [goto AGEDOB_3]
Page 9 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.120_03.00 Instrument Variable Name: AGEDOB_3 QuestionnaireFileName: Household
Composition
QuestionText: 3 of 5
And what is [fill: your/ALIAS's] date of birth?
Please give month, day, and year for the date of birth.
* Enter month of birth.
01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
97 Refused
99 Don't know
UniverseText: All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions: <1-12,R,D> [goto AGEDOB_4]
Question ID: HHC.120_04.00 Instrument Variable Name: AGEDOB_4 QuestionnaireFileName: Household
Composition
QuestionText: 4 of 5
* Enter day of birth
01-31 Day of the month
UniverseText: All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions: <1-31,R,D>
Only allow valid days for month entered.
If days not valid, [goto ERR_AGEDOB_4]
ELSE [goto AGEDOB_5]
Hard Edit: ERR_AGEDOB_4
[fill1: AGEDOB_4] is not a valid day for [fill2: AGEDOB_3].
Page 10 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.120_05.00 Instrument Variable Name: AGEDOB_5 QuestionnaireFileName: Household
Composition
QuestionText: 5 of 5
* Enter year of birth.
1880-2030 Year of birth
9997 Refused
UniverseText: All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions: <1880 - 2030, R,D> [goto AGECAL]
Hard Edit: ERR1_AGEDOB_5
Future month invalid:<space>AGEDOB_3<space>AGEDOB_4<,><space> AGEDOB_5
ERR2_AGEDOB_5
Future day invalid:<space>AGEDOB_3<space>AGEDOB_4<,><space> AGEDOB_5
ERR3_AGEDOB_5
Invalid date:<space>AGEDOB_3<space>AGEDOB_4<,><space> AGEDOB_5
ERR4_AGEDOB_5
Future year invalid:<space>AGEDOB_3<space>AGEDOB_4<,><space> AGEDOB_5
Question ID: HHC.124_00.00 Instrument Variable Name: DOBVER QuestionnaireFileName: Household
Composition
QuestionText: There is a difference between the age the computer calculated from [fill: your/ALIAS's] date-of-birth and the age that
you gave me.
I recorded [fill: your/ALIAS's] date-of-birth as [AGEDOB_3] [AGEDOB_4], [AGEDOB _5]. Is that [fill:
your/ALIAS's] correct date-of-birth?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Age reported is not equal to age calculated from date of birth.
SkipInstructions: <1,R,D> [goto INTWKCK1]
<2> [goto AGEDOB_3]
Page 11 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.130_00.00 Instrument Variable Name: AGEPIC QuestionnaireFileName: Household
Composition
QuestionText: [fill1: Are you/Would you say ALIAS is] [fill2: less than 1 year old/AGE3 years old?]
1 AGE=AGE3 (or less than 1 years old)
2 AGE=AGE4
3 Neither is correct
7 Refused
9 Don't know
UniverseText: Able to narrow age to two options
SkipInstructions: <1,2> [goto INTWKCK1]
<3,R,D> if AGEDOB_1 = R, [goto AGEGES2]
elseif AGEDOB_1 = D, [goto AGEGES1_NUM]
Question ID: HHC.150_01.00 Instrument Variable Name: AGEGES1_NUM QuestionnaireFileName: Household
Composition
QuestionText: 1 of 2
What is your best guess of [fill: your/ALIAS's] age?
* If the respondent gives a range of ages, enter "C" to continue to the screen that will compute an age.
* If the respondent does not know the age, enter your best estimate of the person's age.
000-120 Age (number)
997 Refused
999 Don't know
C Compute from range
UniverseText: Age unknown and unable to narrow age down to two age choices and respondent did not refuse AGEDOB_1
SkipInstructions: <0-120> [goto AGEGES1_TP]
elseif outside range, [goto ERR_AGEGES1_NUM]
<C> [goto AGERNG_N1]
<R,D> [goto AGEGES2]
Hard Edit: ERR_AGEGES1_NUM
* Invalid entry.
* Please correct.
Page 12 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.150_02.00 Instrument Variable Name: AGEGES1_TP QuestionnaireFileName: Household
Composition
QuestionText: 2 of 2
* Enter time period for age guess.
3 Month(s)
4 Year(s)
UniverseText: Valid age number
SkipInstructions: <3, 4> If AGEDOB_5 = D, [goto YEARPIC]
else [goto INTWKCK1]
Question ID: HHC.152_00.00 Instrument Variable Name: AGEGES2 QuestionnaireFileName: Household
Composition
QuestionText: Certain sections of this interview depend on knowing if a person is 18 years old or older.
Could you please tell me if [fill: you are/ALIAS is] at least 18 years old?
1 Less than 18
2 18 or older
7 Refused
9 Don't know
UniverseText: (Age unknown and unable to narrow to two age choices and respondent refused or didn't know age at
AGEDOB_1) or (Refused to or did not guess age)
SkipInstructions: <1> [goto LESS18]
<2,R,D> [goto GREAT18]
Page 13 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.154_00.00 Instrument Variable Name: LESS18 QuestionnaireFileName: Household
Composition
QuestionText: * Enter your best estimate of [ALIAS's] age.
* Enter age "0" to 17
* Enter "0" if less than 1 year old.
000 Less than one year old
001 < 17 1 to 17 years of age
UniverseText: Person estimated less than eighteen years of age
SkipInstructions: <0-17> [goto AGEDOB_1, to collect information about next person in roster]
else, [goto INTWKCK1]
Question ID: HHC.156_00.00 Instrument Variable Name: GREAT18 QuestionnaireFileName: Household
Composition
QuestionText: * Enter your best estimate of [ALIAS’s] age.
* Enter age 18 or greater.
018-120 Age in years
UniverseText: Person estimated age (18 or older)
SkipInstructions: <18-120> [goto AGEDOB_1, to collect information about next person in roster]
else, [goto INTWKCK1]
Question ID: HHC.165_01.00 Instrument Variable Name: YEARPIC QuestionnaireFileName: Household
Composition
QuestionText: Would you say that [fill: you were/ALIAS was] born in:
1 Low guess for year born
2 High guess for year born
3 Neither is correct
7 Refused
9 Don't know
UniverseText: Person's age is known and birth year answered with 'don't know'
SkipInstructions: <1,2,3,R,D> [goto AGEDOB_1, to collect information about next person in roster]
else, [goto INTWKCK1]
Page 14 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.165_03.00 Instrument Variable Name: INTWKCK QuestionnaireFileName: Household
Composition
QuestionText: Was [ALIAS] born on or after [STARTDATE]?
1 Yes
2 No
UniverseText: Child's age = 0 and date of birth not known
SkipInstructions: <1> [goto ERR_INTWKCK]
then, [goto AGEDOB_1 to collect information about next person in roster]
else, [goto NATOR]
<2> [goto AGEDOB_1 to collect information about next person in roster]
else, [goto NATOR]
Question ID: HHC.170_00.00 Instrument Variable Name: NATOR QuestionnaireFileName: Household
Composition
QuestionText: (book) H1.
[fill1: Do you/Does ALIAS] consider [fill2: yourself/himself/herself] to be Hispanic or Latino?
* Read if necessary.
Puerto Rican
Cuban/Cuban American
Dominican (Republic)
Mexican
Mexican American
Central or South American
Other Latin American
Other Hispanic/Latino
Where did [your/ALIAS's] ancestors come from?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions: <1> [goto HISPAN]
<2,R,D> [goto NATOR for next person in roster]
else [goto RACE]
Page 15 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.180_01.00 Instrument Variable Name: HISPAN QuestionnaireFileName: Household
Composition
QuestionText: (book) H1
Please give me the number of the group that represents [fill: your/ ALIAS’s] Hispanic origin or ancestry.
You may choose up to five (5), if applicable.
* If a nonhispanic group is named, backup to previous screen and change the answer from "yes" to "no".
Enter all that apply, separate with commas.
01 Puerto Rican
02 Cuban/Cuban American
03 Dominican (Republic)
04 Mexican
05 Mexican American
06 Central or South American
07 Other Latin American
08 Other Hispanic/Latino/Spanish
97 Refused
99 Don't know
UniverseText: National origin was answered yes to being Hispanic or Latino
SkipInstructions: <1-6> [goto NATOR (for the next person)] else [goto RACE]
<7> [goto HIS_SP2]
<8> [goto HIS_SP3]
Question ID: HHC.190_00.00 Instrument Variable Name: HIS_SP2 QuestionnaireFileName: Household
Composition
QuestionText: * Probe for the country.
* If any of the following are mentioned, backup to previous screen and correct the entry.
Puerto Rican
Cuban/Cuban American
Dominican (Republic)
Mexican
Mexican American
Central or South American (REFER TO HELP SCREEN)
* (F1) For a list of Central or South American countries.
* Specify the other Latin American.
UniverseText: HISPAN answered from selection 7 for Hispanic origin.
SkipInstructions: <allow 30> [goto NATOR (for the next person)]
else [goto RACE]
Page 16 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.195_00.00 Instrument Variable Name: HIS_SP3 QuestionnaireFileName: Household
Composition
QuestionText: * Probe for the country.
* If any of the following are mentioned, backup to previous screen and correct the entry.
Puerto Rican
Cuban/Cuban American
Dominican (Republic)
Mexican
Mexican American
Central or South American (REFER TO HELP SCREEN)
* (F1) For a list of Central or South American countries.
* Specify the other Hispanic/Latino.
UniverseText: HISPAN answer from selection 8 (other Hispanic/Latino) origin
SkipInstructions: <allow 30> [goto NATOR (for the next person)]
else [goto RACE]
Page 17 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.200_01.00 Instrument Variable Name: RACE QuestionnaireFileName: Household
Composition
QuestionText: ( Book) H2
What race or races [fill1: Do you/Does ALIAS] consider [fill2: yourself/himself/herself] to be? Please select 1 or
more of these categories.
* Enter all that apply, separate with commas.
01 White
02 Black/African American
03 Indian (American)
04 Alaska Native
05 Native Hawaiian
06 Guamanian
07 Samoan
08 Other Pacific Islander
09 Asian Indian
10 Chinese
11 Filipino
12 Japanese
13 Korean
14 Vietnamese
15 Other Asian
16 Some other race
97 Refused
99 Don't know
UniverseText: All nondeleted persons in parent cases or all nondeleted persons being added in spawn cases.
SkipInstructions: <1-7, 9-14> If more than one selected, [goto MLTRAC, then goto RACE for next person in roster]
else [goto NOWAF_A]
<8> [goto RAC_SP1]
<15> [goto RAC_SP2]
<16> [goto RAC_SP3]
<R,D> [goto RACE, for the next person in roster]
else [goto NOWAF_A]
Page 18 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.210_00.00 Instrument Variable Name: RAC_SP1 QuestionnaireFileName: Household
Composition
QuestionText: * Specify the other pacific islander.
REM * If any of the following are mentioned, go back to RACE screen to correct.
* If the respondent’s answer could not be found, clear entry, type ‘ZZ’.
White Asian Indian
Black/African American Chinese
Indian (American) Filipino
Alaska Native Japanese
Native Hawaiian Korean
Guamanian Vietnamese
Samoan
* If the respondent's answer could not be found, type 'ZZ' to enable you to type an entry.
UniverseText: RACE= 8 (other Pacific Islander)
SkipInstructions: <allow 30> If more than one selected, [goto MLTRAC]
If 'ZZ' entered [goto RAC_SP1A]
then [goto RACE for next person on the roster]
else [goto NOWAF_A]
Question ID: HHC.212_00.00 Instrument Variable Name: RAC_SP2 QuestionnaireFileName: Household
Composition
QuestionText: * Specify the other Asian.
* If any of the following are mentioned, backup to previous item and correct the entry.
White Asian Indian
Black/African American Chinese
Indian (American) Filipino
Alaska Native Japanese
Native Hawaiian Korean
Guamanian Vietnamese
Samoan
* If the respondent's answer could not be found, type 'ZZ' to enable you to type an entry.
UniverseText: RACE = other Asian listed
SkipInstructions: <allow 30> If more than one selected [goto MLTRAC]
then [goto RACE] for next person on the roster
else [goto NOWAF_A]
Page 19 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.214_00.00 Instrument Variable Name: RAC_SP3 QuestionnaireFileName: Household
Composition
QuestionText: * Specify the other race.
* If any of the following are mentioned, backup to previous item and correct the entry.
White Asian Indian
Black/African American Chinese
Indian (American) Filipino
Alaska Native Japanese
Native Hawaiian Korean
Guamanian Vietnamese
Samoan
* If the respondent's answer could not be found, type 'ZZ' to enable you to type an entry.
UniverseText: RACE answered some other race.
SkipInstructions: <30 chars long> If more than one selected [goto MLTRAC] then [goto RACE] for next person on the roster
Else [goto NOWAF_A ]
Page 20 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.220_00.00 Instrument Variable Name: MLTRAC QuestionnaireFileName: Household
Composition
QuestionText: Which one of these groups, that is [Read Groups] would you say BEST represents [fill: your/ALIAS's] race?
01 White
02 Black/African American
03 Indian (American)
04 Alaska Native
05 Native Hawaiian
06 Guamanian
07 Samoan
08 Other Pacific Islander
09 Asian Indian
10 Chinese
11 Filipino
12 Japanese
13 Korean
14 Vietnamese
15 Other Asian
16 Other Race
97 Refused
99 Don't know
UniverseText: More than on race entered
SkipInstructions: <1-16,R,D> [goto NOWAF_A]
else, [goto ERR_MLTRAC]
Hard Edit: ERR_MLTRAC
* Select valid race group number.
* Please correct.
Page 21 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.230_01.00 Instrument Variable Name: NOWAF_A QuestionnaireFileName: Household
Composition
QuestionText: [fill: Is anyone in the household/Are you/Is ALIAS] now on full-time active duty with the Armed Forces?
[display eligible persons]
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: If household contains 1 or more persons 18-64 years old
SkipInstructions: If no person eq (18-64) years of age [goto EXIT]
< 2,R,D> if POS2 or POS3 ne 0, [goto ADC]
else [goto HHREF_A]
if NOWAF_A eq <1> and ADULTCNT eq <1> [goto EXIT]
else [goto NOWAF2_B]
Question ID: HHC.230_03.00 Instrument Variable Name: NOWAF2_B QuestionnaireFileName: Household
Composition
QuestionText: Who is this? (Anyone else)
* Enter line numbers as appropriate.
* Enter all that apply, separate with commas.
UniverseText: At least 1 person in the AF & more than 1 person eligible to be in the AF
SkipInstructions: <1-25> if all PX have HHSTAT = D or HHSTAT3 = A [goto EXIT]
elseif POS2 and POS3 ne 0 [goto ADC]
else [goto HHREF_A]
Invalid person # selected [goto ERR_NOWAF2_B]
Hard Edit: ERR_NOWAF2_B
* Invalid person number selected.
* Please correct.
Page 22 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.240_00.00 Instrument Variable Name: EXIT QuestionnaireFileName: Household
Composition
QuestionText: Not every household in our survey is asked all questions. I have all the information about your household that I
need at this time. Thank you for your assistance.
* Enter (1) to proceed.
1 Proceed
UniverseText: All persons are in the Armed Forces or everybody is either deleted or in the AF or All non-Armed Forces
persons are not Black, Hispanic or Asian and not marked for an interview
SkipInstructions: <1> [goto VISITCNT]
Question ID: HHC.250_01.00 Instrument Variable Name: HHREF_A QuestionnaireFileName: Household
Composition
QuestionText: * [fill: You have/ALIAS has] has been selected as the household reference person. Is this household member an
appropriate choice? Preferably a civilian adult?
[Display all non-deleted household members ge 14 years of age]
* Press shift F1 to see full roster information.
1 Yes
2 No
UniverseText: If more than one non-deleted person in the HH
SkipInstructions: <1> [goto RPREL]
<2> [goto HHREF_B]
Page 23 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.250_02.00 Instrument Variable Name: HHREF_B QuestionnaireFileName: Household
Composition
QuestionText: * Select another household member for the reference person.
* Enter the line number of the Household Reference person.
UniverseText: Selecting another Reference person
SkipInstructions: <1-25> GOTO RPREL
Soft Edit: ERR1_HHREF_B
* You have selected an Armed Forces person.
* Please select another person.
ERR2_HHREF_B
* You have selected a person less than 18 years old.
* Please select another person.
Page 24 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.260_00.00 Instrument Variable Name: RPREL QuestionnaireFileName: Household
Composition
QuestionText: (book) H3.
What is [fill1: your/ALIAS's] relationship to [fill2: Reference Person's name/you]
01 Household reference person
02 Spouse (husband/wife)
03 Unmarried Partner
04 Child (biological/adoptive/in-law/step/foster)
05 Child of partner
06 Grandchild
07 Parent (biological/adoptive/in-law/step/foster)
08 Brother/sister (biological/adoptive/in-law/step/foster)
09 Grandparent (Grandmother/Grandfather)
10 Aunt/Uncle
11 Niece/Nephew
12 Other relative
13 Housemate/roommate
14 Roomer/Boarder
15 Other nonrelative
16 Legal guardian
17 Ward
97 Refused
99 Don't know
Page 25 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
UniverseText: All where RPREL NE Reference Person
SkipInstructions: Loop through all non-deleted PX
<2, 3> if selected for more than one PX [goto ERR4_RPREL]
elseif AGE < 14 [goto ERR1_RPREL]
<4> [goto DEGREE1]
<5> if loop is completed and no PX has RPREL = 3 [goto ERR5_RPREL] endif
<6> if AGEDIFF < 25 [goto ERR2_RPREL] endif
<7> [goto DEGREE2]
<8> [goto DEGREE3]
<9> if AGEDIFF < 25 [goto ERR3_RPREL] endif
<10-17,R,D> end loop
if UNRELTAL > 1 [GOTO FAMNUM]
else [goto HHCHANGE]
Hard Edit: ERR1_RPREL:
*Spouse/partner must be 14 years old or older.
*Please correct.
ERR4_RPREL:
I have recorded that [fill 3] and [fill 2] are spouses or unmarried partners of [fill 6].
Which one is correct?
*First GOTO is for [fill 3]
*Second GOTO is for [fill 2]
Questions involved Value
Rprel: Relationship to Ref Person Spouse (husband/wife) or Unmarried Partner
Rprel: Relationship to Ref Person Spouse (husband/wife) or Unmarried Partner
***THE 1ST LINE HERE SHOULD REFER TO THIS PERSON: [fill 3]
***THE 2ND LINE HERE SHOULD REFER TO THIS PERSON: [fill 2]
ERR5_RPREL
I have recorded that [fill 2] is a child of a partner. However, no one in the family was picked as an unmarried
partner in order to have this response.
* Please correct .
Soft Edit: ERR2_RPREL
I have recorded [fill 6] is [AGE(HHREF_B)] years old and [fill:his/her] grandchild [fill 2] is [AGE(PX)] years
old.
Are these ages and relationships correct?
ERR3_RPREL
I have recorded [fill 6] is [AGE(HHREF_B)] years old and [fill:his/her] grandparent [fill 2] is [AGE(PX)]
years old.
Are these ages and relationships correct?
ERR6_RPREL
*Do not read this message to the respondent.
*The married couple [ALIAS(PX)] and [ALIAS(HHREF_B)] are both [SEX (PX)].
*Suppress message if correct.
*Otherwise, correct SEX of either person or choose different spouse.
*First GOTO is to change Relationship code of [fill 2]
*Second GOTO is to change SEX of spouse [fill 2]
*Third GOTO is to change SEX of Ref Person [fill 6]
Questions involved Value
RPREL: Relationship to Ref Person Spouse (husband/wife)
SEX SEX (PX)
SEX SEX (HHREF_B)
ERR7_RPREL
Page 26 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
*Age difference between spouses is greater than or equal to 30 years.
I have recorded [fill 6] is [AGE(HHREF_B)] years old and [fill: his/her] spouse [ALIAS(PX)] is [AGE(PX)]
years old. Are these ages and relationships correct?
*First GOTO is to change Relationship code of [fill 2]
*Second GOTO is to change AGE of spouse [fill 2]
*Third GOTO is to change AGE of Ref Person [fill 6]
Questions involved Value
RPREL: Relationship to Ref Person Spouse (husband/wife)
AGE AGE (PX)
AGE AGE (HHREF_B)
ERR9_RPREL
*Age difference between [fill 7] and child is only [AGEDIFF] years.
I have recorded [fill 6] is [AGE(HHREF_B)] years old and [fill:his/her] child [fill 2] is [AGE(PX)] years old.
Are these ages and relationships correct?
*First GOTO is to change Relationship code of [fill 2]
*Second GOTO is to change AGE of child [fill 2]
*Third GOTO is to change AGE of parent [fill 6]
Questions involved Value
RPREL: Relationship to Ref Person Child
AGE AGE (PX)
AGE AGE (HHREF_B)
Page 27 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
ERR10_RPREL
* Age difference between [fill 7] and child is greater than or equal to 50 years.
I have recorded [fill 6] is [AGE(HHREF_B)] years old and [fill:his/her] child [ALIAS(PX)] is [AGE(PX)]
years old. Are these ages and relationships correct?
*First GOTO is to change Relationship code of [fill 2]
*Second GOTO is to change AGE of child [fill 2]
*Third GOTO is to change AGE of parent [fill 6]
Questions involved Value
RPREL: Relationship to Ref Person Child
AGE AGE (PX)
AGE AGE (HHREF_B)
ERR12_RPREL
*Age difference between [fill 8] and child is only [AGEDIFF] years.
I have recorded [fill 6] is [AGE(HHREF_B)] years old and [fill:his/her] [fill 8] [fill 2] is [AGE(PX)] years old.
Are these ages and relationships correct?
*First GOTO is to change Relationship code of [fill 2]
*Second GOTO is to change AGE of parent [fill 2]
*Third GOTO is to change AGE of child [fill 6]
Questions involved Value
RPREL: Relationship to Ref Person Parent
AGE AGE (PX)
AGE AGE (HHREF_B)
ERR13_RPREL
* Age difference between [fill 8] and child is greater than or equal to 50 years.
I have recorded [fill 6] is [AGE(HHREF_B)] years old and [fill:his/her] [fill 8] [fill 2] is [AGE(PX)] years old.
Are these ages and relationships correct?
*First GOTO is to change Relationship code of [fill 2]
*Second GOTO is to change AGE of parent [fill 2]
*Third GOTO is to change AGE of child [fill 6]
Questions involved Value
RPREL: Relationship to Ref Person Parent
AGE AGE (PX)
AGE AGE (HHREF_B)
Page 28 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.270_00.00 Instrument Variable Name: DEGREE1 QuestionnaireFileName: Household
Composition
QuestionText: [fill1: Are you/Is ALIAS] [fill2: Reference Person's name's/your] biological (natural), adoptive, step, or foster [fill3:
son/daughter] or [fill4: son/daughter]-in-law?
1 Biological (natural) {son/daughter]
2 Adoptive {son/daughter}
3 Step {son/daughter]
4 Foster {son/daughter}
5 {son/daughter]-in-law
7 Refused
Refused
9 Don't know
UniverseText: RPREL=(4) child
SkipInstructions: <1> if AGEDIFF < 12 [goto ERR1_DEGREE1]
else [goto RPREL]
<2-5,R,D> [goto RPREL]
Hard Edit: ERR1_DEGREE1
*Age difference between [fill 6] and child is [AGEDIFF] years.
I have recorded [fill 7] is [AGE(HHREF_B)] years old and [fill:his/her] child [fill 2] is [AGE(PX)] years old.
Are these ages and relationships correct?
* Please correct relationship code or age.
*First GOTO is to change Relationship code of [fill 2]
*Second GOTO is to change AGE of child [fill 2]
*Third GOTO is to change AGE of parent [fill 7]
Questions involved Value
RPREL: Relationship to Ref Person Child
AGE AGE (PX)
AGE AGE(HHREF_B)
Soft Edit: ERR2_DEGREE1
*Age difference between [fill 6] and child is [AGEDIFF] years.
I have recorded [fill 7] is [AGE(HHREF_B)] years old and [fill:his/her] child [fill 2] is [AGE(PX)] years old.
Are these ages and relationships correct?
*First GOTO is to change Relationship code of [fill 2]
*Second GOTO is to change AGE of child [fill 2]
*Third GOTO is to change AGE of parent [fill 7]
Questions involved Value
RPREL: Relationship to Ref Person Child
AGE AGE (PX)
AGE AGE(HHREF_B)
Page 29 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.280_00.00 Instrument Variable Name: DEGREE2 QuestionnaireFileName: Household
Composition
QuestionText: [fill1: Are you/Is ALIAS] [fill2: Reference Person's name's/your] biological (natural), adoptive, step, or foster [fill3:
mother/father] or [fill4: mother/father]-in-law?
1 Biological (natural) {mother/father]
2 Adoptive {mother/father}
3 Step {mother/father]
4 Foster {mother/father}
5 {mother/father]-in-law
7 Refused
9 Don't know
UniverseText: RPREL=(7) parent
SkipInstructions: <1> if AGEDIFF <12 [goto ERR_DEGREE2]
elseif additional PX's remain [goto RPREL]
elseif UNRELTAL >1 [goto FAMNUM]
else [goto HHCHANGE]
<2-5,R,D> if additional PX's remain [goto RPREL]
elseif UNRELTAL >1 [goto FAMNUM]
else [goto HHCHANGE]
Hard Edit: ERR1_DEGREE2
*Age difference between [fill 2] and child is [AGEDIFF] years.
I have recorded [fill 7] is [AGE(HHREF_B)] years old and [fill:his/her] [fill 2] [fill 8] is [AGE(PX)] years old.
Are these ages and relationships correct?
* Please correct relationship code or age.
*First GOTO is to change Relationship code of [fill 8]
*Second GOTO is to change AGE of parent [fill 8]
*Third GOTO is to change AGE of child [fill 7]
Questions involved Value
RPREL: Relationship to Ref Person Parent
AGE AGE (PX)
AGE AGE(HHREF_B)
Soft Edit: ERR2_DEGREE2
*Age difference between [fill 2] and child is only [AGEDIFF] years.
I have recorded [fill 7] is [AGE(HHREF_B)] years old and [fill:his/her] [fill 2] [fill 8] is [AGE(PX)] years old.
Are these ages and relationships correct?
*First GOTO is to change Relationship code of [fill 8]
*Second GOTO is to change AGE of parent [fill 8]
*Third GOTO is to change AGE of child [fill 7]
Questions involved Value
RPREL: Relationship to Ref Person Parent
AGE AGE (PX)
AGE AGE (HHREF_B)
Page 30 of 30
2011 NHIS Questionnaire Household Composition
Household Composition
Document Version Date: 19-Jun-12
Question ID: HHC.290_01.00 Instrument Variable Name: DEGREE3 QuestionnaireFileName: Household
Composition
QuestionText: [fill1: Are you/Is ALIAS] [fill2: Reference Person's name's/your] full, half, adoptive, step, or foster [fill3:
brother/sister] or [fill4: brother/sister]-in-law?
1 Full {brother/sister}
2 Half {brother/sister}
3 Adopted {brother/sister}
4 Step {brother/sister]
5 Foster {brother/sister}
6 {brother/sister]-in-law
7 Refused
9 Don't know
UniverseText: All siblings
SkipInstructions: <1-6,R,D> [goto RPREL]
Page 1 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.100_00.000 Instrument Variable Name: HHCHANGE QuestionnaireFileName: Family
QuestionText: I have recorded that [your name is {fill fullname}, you are /fill ALIAS is] [fill sex], [fill age] years old, born on [fill
birthdate]. [His/Her] national origin is [fill Hispanic origin], and [his/her] race is [fill race]:
Is this information correct?
1 Yes, this information is correct
2 No, correction(s) needed/more corrections needed
UniverseText: All nondeleted family members
SkipInstructions: <1> if no additional PX remain
if SCREENIN = 0 and I_SCRN_STATUS = S [goto EXIT(HHC)]
else [goto FIDCC13]
<2> [goto CWHAT2]
Question ID: FID.110_00.000 Instrument Variable Name: CWHAT2 QuestionnaireFileName: Family
QuestionText: * Change(s) needed for [ALIAS].
* Enter each number that applies. If a wrong choice, type that choice again.
1 Name
2 Age or DOB
3 Sex
4 National origin
5 Race
UniverseText: HHCHANGE = 2 (No, not correct)
SkipInstructions: <1> [goto CHG_NAME_FNAME]
<2> [goto CHG_AGEDOB_1]
<3> [goto CHG_SEX]
<4> [goto CHG_NATOR]
<5> [goto CHG_RACE]
Page 2 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.245_00.000 Instrument Variable Name: HHCHANGE_1 QuestionnaireFileName: Family
QuestionText: I have recorded that {your name is/ALIAS is} {fill full name}, age is {fill age}, date of birth is {fill birthdate},
{his/her} national origin is {fill Hispanic origin}, and {his/her} {fill race} is:
Is this information correct?
UniverseText: All nondeleted family members with a change made to their demographic information
SkipInstructions: <1> if no additional PX remain
if SCREENIN = 0 and I_SCRN_STATUS = S, GOTO EXIT(HHC)
else GOTO FIDCC13
<2> GOTO ERR_HHCHANGE_1
Hard Edit: ERR_HHCHANGE_1
* Press enter to go back to change some demographic information or arrow down and press enter to change
your answer.
Default Goto should be CWHAT2
Question ID: FID.250_00.000 Instrument Variable Name: MARITAL QuestionnaireFileName: Family
QuestionText: * ASK OR VERIFY
[fill: Are you/Is ALIAS] now married, widowed, divorced, separated, never married, or living with a partner?
1 Married
2 Widowed
3 Divorced
4 Separated
5 Never Married
6 Living with partner
7 Refused
9 Don't know
UniverseText: All persons, 14 and older, who don't have a marital status yet
SkipInstructions: <1> [goto SPFLAG]
<2-5, R, D> [goto FIDCCI3]
<6> if LINTAL[FAMINT] = 1 [goto FIDCCI4]
else [goto COHAB1]
Page 3 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.260_00.000 Instrument Variable Name: SPOUS QuestionnaireFileName: Family
QuestionText: * ASK OR VERIFY
Is [fill: your/ALIAS's] spouse living in the household?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: A potential spouse lives in the unit.
SkipInstructions: <1> If SPOUS2[PX] = null [goto SPOUS2]
else [goto FIDCCI3]
<2,R,D> [goto FIDCCI3]
Page 4 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.270_00.000 Instrument Variable Name: SPOUS2 QuestionnaireFileName: Family
QuestionText: * Probe as necessary and enter the line number of the spouse.
[Display all possible spouse candidates]
01-25 Person # of spouse
UniverseText: Person has an unidentified spouse in the household.
SkipInstructions: Do not allow line number of the subject to be entered. If so [goto ERR_SPOUS2]
<1-25,R,D> [goto FIDCCI3]
Hard Edit: ERR1_SPOUS2
*Person can't be his or her own spouse.
*Please correct.
Soft Edit: ERR2_SPOUS2
*If [ALIAS (SPOUS2(PX)] is [ALIAS (PX)]’s spouse, [ALIAS (SPOUS2(PX))]’s RPREL value should be
‘02’.
*Correct relationship code at RPREL or change answer at SPOUS2.
*First GOTO is to change Relationship code of [ALIAS (SPOUS2(PX))]
*Second GOTO is to choose different spouse at SPOUS2
Questions involved Value
RPREL: Relationship to Ref Person RPREL(SPOUS2(PX))
SPOUS2 ALIAS (SPOUS2(PX))
ERR3_SPOUS2
*Do not read this message to the respondent.
*The married couple [ALIAS (SPOUS2(PX))] and [ALIAS (PX)] are both [SEX(PX)].
*Suppress message if correct.
*Otherwise, correct SEX of either person or choose different spouse.
*First GOTO is to choose different spouse at SPOUS2
*Second GOTO is to change SEX of spouse [ALIAS (SPOUS2(PX))]
*Third GOTO is to change SEX of [ALIAS(PX)]
Questions involved Value
SPOUS2 ALIAS (SPOUS2(PX))
SEX SEX (SPOUS2(PX))
SEX SEX (PX)
ERR4_SPOUS2
*Age difference between spouses is greater than or equal to 30 years.
I have recorded [ALIAS (PX)] is [AGE(PX)] years old and [fill: his/her] spouse [ALIAS(SPOUS2(PX))] is
[AGE(SPOUS2(PX))] years old. Are these ages and relationships correct?
*First GOTO is to choose different spouse at SPOUS2
*Second GOTO is to change AGE of spouse [ALIAS (SPOUS2(PX))]
*Third GOTO is to change AGE of [ALIAS(PX)]
Questions involved Value
SPOUS2 ALIAS (SPOUS2(PX))
AGE AGE (SPOUS2(PX))
AGE AGE (PX)
Page 5 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.280_00.000 Instrument Variable Name: COHAB1 QuestionnaireFileName: Family
QuestionText: [fill: Have you/Has ALIAS] ever been married?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Marital status is "living with a partner."
SkipInstructions: <1> [goto COHAB2]
<2,R,D> if COHAB3[PX] = null [goto COHAB3]
else [goto FIDCCI3]
Question ID: FID.290_00.000 Instrument Variable Name: COHAB2 QuestionnaireFileName: Family
QuestionText: What is [fill: your/ALIAS's] current legal marital status?
1 Married
2 Widowed
3 Divorced
4 Separated
7 Refused
9 Don't know
UniverseText: Person is currently cohabiting and has been married.
SkipInstructions: <1-4,R,D> If COHAB3[PX] = null [goto COHAB3]
else [goto FIDCCI3]
Page 6 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.300_00.000 Instrument Variable Name: COHAB3 QuestionnaireFileName: Family
QuestionText: * Probe as necessary and enter the line number of the cohabiting partner.
[Display all possible cohabitation candidates]
01-25 Person number
UniverseText: Cohabiting partner has yet to be identified.
SkipInstructions: If line number of the subject is entered [goto ERR_COHAB3]
<1-25,R,D> [goto FIDCCI3]
Hard Edit: ERR1_COHAB3
* Person can't be his or her own partner.
* Please correct.
Soft Edit: ERR2_COHAB3
*If [ALIAS (COHAB3(PX))] is [ALIAS (PX)]’s cohabiting partner, [ALIAS (COHAB3(PX))]’s RPREL
value should be ‘03’.
*Correct relationship code at RPREL or change answer at COHAB3.
*First GOTO is to change Relationship code of [ALIAS (COHAB3(PX))]
*Second GOTO is to choose different cohabiting partner at COHAB3
Questions involved Value
RPREL: Relationship to Ref Person RPREL(COHAB3 (PX))
COHAB3 ALIAS (COHAB3 (PX))
ERR3_COHAB3
*If [ALIAS (COHAB3(PX))] and [ALIAS (PX)] are cohabiting partners, it is not possible for both to have
RPREL codes equal to ‘04’ for ‘Child’. One of their RPREL codes should equal ‘12’ for ‘Other relative’.
*Correct relationship code at RPREL or change answer at COHAB3.
*First GOTO is to change Relationship code of [ALIAS (COHAB3(PX))]
*Second GOTO is to change Relationship code of [ALIAS (PX)]
*Third GOTO is to choose different cohabiting partner at COHAB3
Questions involved Value
RPREL: Relationship to Ref Person Child
RPREL: Relationship to Ref Person Child
COHAB3 ALIAS (COHAB3 (PX))
ERR4_ COHAB3
*Age difference between cohabiting partners is greater than or equal to 20 years.
I have recorded [ALIAS (PX)] is [AGE(PX)] years old and [fill: his/her] cohabiting partner
[ALIAS(COHAB3(PX))] is [AGE(COHAB3(PX))] years old. Are these ages and relationships correct?
*First GOTO is to choose different cohabiting partner at COHAB3
*Second GOTO is to change AGE of cohabiting partner [ALIAS (COHAB3(PX))]
*Third GOTO is to change AGE of [ALIAS(PX)]
Questions involved Value
COHAB3 ALIAS (COHAB3 (PX))
AGE AGE (COHAB3 (PX))
AGE AGE (PX)
Page 7 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.322_00.000 Instrument Variable Name: DEGREE4 QuestionnaireFileName: Family
QuestionText: I noted that [father's fullname] is the father of [child's fullname]. Is [child's fullname] his biological, adoptive, step,
foster, or [fill: son/daughter] in law?
1 Biological
2 Adoptive
3 Step
4 Foster
5 -in-law
7 Refused
9 Don't know
Page 8 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
UniverseText: When the reference person is the person in question's parent.
SkipInstructions: <1> if AGEDIFF <12 [goto ERR_DEGREE4]
if ERR_DEGREE4 = 1 [goto FIDCCI4B]
else reset DEGREE4 [goto DEGREE4] endif
else [goto FIDCCI4B]
<2-5,R,D> [goto FIDCCI4B]
Hard Edit: ERR2_DEGREE4
*Age difference between father and child is [AGEDIFF] years.
I have recorded [ALIAS (X2)] is [AGE(X2)] years old and his child [ALIAS(PX)] is [AGE(PX)] years old.
Are these ages and relationships correct?
* Please correct relationship code or age.
*First GOTO is to change Relationship code of [ALIAS(X2)]
*Second GOTO is to change Relationship code of [ALIAS(PX)]
*Third GOTO is to change AGE of father [ALIAS(X2)]
*Fourth GOTO is to change AGE of child [ALIAS(PX)]
Questions involved Value
RPREL: Relationship to Ref Person Spouse (husband) or Unmarried Partner
RPREL: Relationship to Ref Person Child or Child of Partner
AGE AGE (X2)
AGE AGE(PX)
Soft Edit: ERR1_DEGREE4
*Age difference between father and child is only [AGEDIFF] years.
I have recorded [ALIAS (X2)] is [AGE(X2)] years old and his child [ALIAS(PX)] is [AGE(PX)] years old.
Are these ages and relationships correct?
*First GOTO is to change Relationship code of [ALIAS(X2)]
*Second GOTO is to change Relationship code of [ALIAS(PX)]
*Third GOTO is to change AGE of father [ALIAS(X2)]
*Fourth GOTO is to change AGE of child [ALIAS(PX)]
Questions involved Value
RPREL: Relationship to Ref Person Spouse (husband) or Unmarried Partner
RPREL: Relationship to Ref Person Child or Child of Partner
AGE AGE (X2)
AGE AGE(PX)
If suppressed and additional persons remain, GOTO FIDCCI4
else GOTO FIDCCI4B, endif
ERR3_DEGREE4
*Age difference between father and child is greater than or equal to 50 years.
I have recorded [ALIAS (X2)] is [AGE(X2)] years old and his child [ALIAS(PX)] is [AGE(PX)] years old.
Are these ages and relationships correct?
*First GOTO is to change Relationship code of [ALIAS(X2)]
*Second GOTO is to change Relationship code of [ALIAS(PX)]
*Third GOTO is to change AGE of father [ALIAS(X2)]
*Fourth GOTO is to change AGE of child [ALIAS(PX)]
Questions involved Value
RPREL: Relationship to Ref Person Spouse (husband) or Unmarried Partner
RPREL: Relationship to Ref Person Child or Child of Partner
AGE AGE (X2)
AGE AGE(PX)
If suppressed and additional persons remain, GOTO FIDCCI4
else GOTO FIDCCI4B, endif
Page 9 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Page 10 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.324_00.000 Instrument Variable Name: DEGREE5 QuestionnaireFileName: Family
QuestionText: I noted that [mother's fullname] is the mother of [child's fullname]. Is [child's fullname] her biological, adoptive, step,
foster, or [fill: son/daughter] in law?
1 Biological
2 Adoptive
3 Step
4 Foster
5 -in-law
7 Refused
9 Don't know
Page 11 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
UniverseText: When the reference person is the person in question's parent.
SkipInstructions: <1> if AGEDIFF <12 [goto ERR_DEGREE5]
if yes, continue the interview [goto FIDCCI4B]
else, reset DEGREE5 [goto DEGREE5] endif
else [goto FIDCCI4B]
<2-5,R,D> [goto FIDCCI4B]
Hard Edit: ERR2_DEGREE5
*Age difference between mother and child is [AGEDIFF] years.
I have recorded [ALIAS (X2)] is [AGE(X2)] years old and her child [ALIAS(PX)] is [AGE(PX)] years old.
Are these ages and relationships correct?
* Please correct relationship code or age.
*First GOTO is to change Relationship code of [ALIAS(X2)]
*Second GOTO is to change Relationship code of [ALIAS(PX)]
*Third GOTO is to change AGE of mother [ALIAS(X2)]
*Fourth GOTO is to change AGE of child [ALIAS(PX)]
Questions involved Value
RPREL: Relationship to Ref Person Spouse (wife) or Unmarried Partner
RPREL: Relationship to Ref Person Child or Child of Partner
AGE AGE (X2)
AGE AGE(PX)
Soft Edit: ERR1_DEGREE5
*Age difference between mother and child is only [AGEDIFF] years.
I have recorded [ALIAS (X2)] is [AGE(X2)] years old and her child [ALIAS(PX)] is [AGE(PX)] years old.
Are these ages and relationships correct?
*First GOTO is to change Relationship code of [ALIAS(X2)]
*Second GOTO is to change Relationship code of [ALIAS(PX)]
*Third GOTO is to change AGE of mother [ALIAS(X2)]
*Fourth GOTO is to change AGE of child [ALIAS(PX)]
Questions involved Value
RPREL: Relationship to Ref Person Spouse (wife) or Unmarried Partner
RPREL: Relationship to Ref Person Child or Child of Partner
AGE AGE (X2)
AGE AGE(PX)
If suppressed and additional persons remain, GOTO FIDCCI4
else GOTO FIDCCI4B, endif
ERR3_DEGREE5
*Age difference between mother and child is greater than or equal to 50 years.
I have recorded [ALIAS (X2)] is [AGE(X2)] years old and her child [ALIAS(PX)] is [AGE(PX)] years old.
Are these ages and relationships correct?
*First GOTO is to change Relationship code of [ALIAS(X2)]
*Second GOTO is to change Relationship code of [ALIAS(PX)]
*Third GOTO is to change AGE of mother [ALIAS(X2)]
*Fourth GOTO is to change AGE of child [ALIAS(PX)]
Questions involved Value
RPREL: Relationship to Ref Person Spouse (wife) or Unmarried Partner
RPREL: Relationship to Ref Person Child or Child of Partner
AGE AGE (X2)
AGE AGE(PX)
If suppressed and additional persons remain, GOTO FIDCCI4
else GOTO FIDCCI4B, endif
Page 12 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.326_00.000 Instrument Variable Name: MOTHER QuestionnaireFileName: Family
QuestionText: * Ask or verify
Is [fill: your/ALIAS's] mother a household member? (Include biological (natural), adoptive, step, or foster mother or
mother-in-law)
* Enter the line number of the mother or mother-in-law.
If the mother or mother-in-law is not a household member, enter "0".
If the person has no parents present but has a legal guardian, enter "96".
* Choose mother over mother-in-law if both are present.
00 Mother not a household member
01-25 Person number of mother
96 Has legal guardian
97 Refused
99 Don't know
UniverseText: Potential mother in the Family, mother not already identified
SkipInstructions: <01-25> [goto MOTHERCK_A]
<0,R,D> [goto FIDCCI5]
<96> [goto GUARD]
Page 13 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.330_01.000 Instrument Variable Name: MOTHERCK_A QuestionnaireFileName: Family
QuestionText: [fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster mother or mother-in-law?
1 Biological mother
2 Adoptive mother
3 Step mother
4 Foster mother
5 Mother-in-law
7 Refused
9 Don't know
Page 14 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
UniverseText: Mother is in the immediate family.
SkipInstructions: <1> If AGEDIFF <12 [goto ERR_MOTHERCK_A]
if <1> [goto FIDCCI5]
elseif <2> [goto MOTHER]
elseif <3>, reset MOTHERCK_A [goto MOTHERCK_A]
else [goto FIDCCI5]
<2-5,R,D> [goto FIDCCI5]
Hard Edit: ERR2_MOTHERCK_A
*Age difference between mother and child is [AGEDIFF] years.
I have recorded [ALIAS (LNMOM[PX])] is [AGE(LNMOM[PX])] years old and her child [ALIAS(PX)] is
[AGE(PX)] years old. Are these ages and relationships correct?
* Please correct relationship code or age.
*First GOTO is to change code at MOTHER
*Second GOTO is to change AGE of mother [ALIAS (LNMOM[PX])]
*Third GOTO is to change AGE of child [ALIAS(PX)]
Questions involved Value
MOTHER ALIAS (MOTHER [PX])
AGE AGE(LNMOM[PX])
AGE AGE(PX)
Soft Edit: ERR1_MOTHERCK_A
*Age difference between mother and child is only [AGEDIFF] years.
I have recorded [ALIAS (LNMOM[PX])] is [AGE(LNMOM[PX])] years old and her child [ALIAS(PX)] is
[AGE(PX)] years old. Are these ages and relationships correct?
*First GOTO is to change code at MOTHER
*Second GOTO is to change AGE of mother [ALIAS (LNMOM[PX])]
*Third GOTO is to change AGE of child [ALIAS(PX)]
Questions involved Value
MOTHER ALIAS (MOTHER [PX])
AGE AGE(LNMOM[PX])
AGE AGE(PX)
if suppressed goto FIDCCI5
ERR3_MOTHERCK_A
*Age difference between mother and child is greater than or equal to 50 years.
I have recorded [ALIAS (LNMOM[PX])] is [AGE(LNMOM[PX])] years old and her child [ALIAS(PX)] is
[AGE(PX)] years old. Are these ages and relationships correct?
*First GOTO is to change code at MOTHER
*Second GOTO is to change AGE of mother [ALIAS (LNMOM[PX])]
*Third GOTO is to change AGE of child [ALIAS(PX)]
Questions involved Value
MOTHER ALIAS (MOTHER [PX])
AGE AGE(LNMOM[PX])
AGE AGE(PX)
if suppressed goto FIDCCI5
Page 15 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.330_02.000 Instrument Variable Name: MOM_CKFG QuestionnaireFileName: Family
QuestionText: [fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster mother or mother-in-law?
UniverseText: Mother is in the immediate family.
SkipInstructions: <1> If AGEDIFF <12 [goto ERR_MOTHERCK_A]
if <1> [goto FIDCCI5]
elseif <2> [goto MOTHER]
elseif <3>, reset MOTHERCK_A [goto MOTHERCK_A]
else [goto FIDCCI5]
<2-5,R,D> [goto FIDCCI5]
Question ID: FID.340_00.000 Instrument Variable Name: FATHER QuestionnaireFileName: Family
QuestionText: * Ask or verify
Is [fill: your/ALIAS's] father a household member? (Include biological (natural), adoptive, step, or foster father or
father-in-law).
* Enter the line number of the father or father-in-law.
* If the father is not a household member, enter '0'.
* If the person has no parents present but has a legal guardian, enter '96'.
* Choose father over father-in-law if both are present.
00 Father not in household
01-25 Person # of father
96 Has legal guardian
97 Refused
99 Don't know
UniverseText: Potential Father in Family, not already identified
SkipInstructions: <1-25> [goto FATHERCK_A]
<0,R,D> [goto FIDCCI4]
<96> [goto GUARD]
Page 16 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.350_01.000 Instrument Variable Name: FATHERCK_A QuestionnaireFileName: Family
QuestionText: [fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster father or father-in-law?
1 Biological father
2 Adoptive father
3 Step father
4 Foster father
5 Father-in-law
7 Refused
9 Don’t know
Page 17 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
UniverseText: Father is in the immediate family.
SkipInstructions: <1> If AGEDIFF <12 [goto ERR_FATHERCK_A]
if ERRFATHERCK_A = <1> [goto FIDCCI4]
elseif <2> [goto FATHER]
elseif <3> reset FATHERCK_A
[goto FATHERCK_A] endif
else [goto FIDCCI4]
<2-5,R,D> [goto FIDCCI4]
Hard Edit: ERR2_FATHERCK_A
*Age difference between father and child is [AGEDIFF] years.
I have recorded [ALIAS(LNDAD[PX])] is [AGE(LNDAD[PX])] years old and his child [ALIAS(PX)] is
[AGE(PX)] years old.
Are these ages and relationships correct?
* Please correct relationship code or age.
*First GOTO is to change code at FATHER
*Second GOTO is to change AGE of father [ALIAS (LNDAD[PX])]
*Third GOTO is to change AGE of child [ALIAS(PX)]
Questions involved Value
FATHER ALIAS(FATHER [PX])
AGE AGE(LNDAD[PX])
AGE AGE(PX)
Soft Edit: ERR1_FATHERCK_A
*Age difference between father and child is only [AGEDIFF] years.
I have recorded [ALIAS(LNDAD[PX])] is [AGE (LNDAD[PX])] years old and his child [ALIAS(PX)] is
[AGE(PX)] years old. Are these ages and relationships correct?
*First GOTO is to change code at FATHER
*Second GOTO is to change AGE of father [ALIAS (LNDAD[PX])]
*Third GOTO is to change AGE of child [ALIAS(PX)]
Questions involved Value
FATHER ALIAS(FATHER [PX])
AGE AGE(LNDAD[PX])
AGE AGE(PX)
if suppressed goto FIDCCI4
ERR3_FATHERCK_A
*Age difference between father and child is greater than or equal to 50 years.
I have recorded [ALIAS(LNDAD[PX])] is [AGE (LNDAD[PX])] years old and his child [ALIAS(PX)] is
[AGE(PX)] years old. Are these ages and relationships correct?
*First GOTO is to change code at FATHER
*Second GOTO is to change AGE of father [ALIAS (LNDAD[PX])]
*Third GOTO is to change AGE of child [ALIAS(PX)]
Questions involved Value
FATHER ALIAS(FATHER [PX])
AGE AGE(LNDAD[PX])
AGE AGE(PX)
if suppressed goto FIDCCI4
Page 18 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.350_02.000 Instrument Variable Name: DAD_CKFG QuestionnaireFileName: Family
QuestionText: [fill1: Are you/Is ALIAS] [fill2: ALIAS's/your] biological (natural), adoptive, step, or foster father or father-in-law?
UniverseText: Father has been identified
SkipInstructions: <1> If AGEDIFF <12 [goto ERR_FATHERCK_A]
if ERRFATHERCK_A = <1> [goto FIDCCI4]
elseif <2> [goto FATHER]
elseif <3> reset FATHERCK_A
[goto FATHERCK_A] endif
else [goto FIDCCI4]
<2-5,R,D> [goto FIDCCI4]
Question ID: FID.360_01.000 Instrument Variable Name: GUARD QuestionnaireFileName: Family
QuestionText: Who is [fill: your/ALIAS's ] legal guardian?
* Enter the line number of [fill1: your/ALIAS's] guardian.
* If the guardian is not a household member, enter '0'.
00 Guardian not a household member
01-25 Person # of guardian
97 Refused
99 Don't know
UniverseText: Mother or father was identified as legal guardian of child or, at the FIDCCI5 procedure, it's determined that the
child (AGE<14) has no mother or father in the family.
SkipInstructions: <0-25,R,D> [goto FIDCCI4]
Page 19 of 19
2011 NHIS Questionnaire Family
Family Identification
Document Version Date: 19-Jun-12
Question ID: FID.380_00.000 Instrument Variable Name: KNOW2 QuestionnaireFileName: Family
QuestionText: * Verify or ask
Who in the family would you say knows about the health of all the family members?
[Display all family members who not deleted and > 17 or emancipated minors.]
* Mark all that apply, separate with commas.
1 Yes, knows family members' health
2 No, does not know family member's health
7 Refused
9 Don't know
UniverseText: More than one adult
SkipInstructions: <1-25,R,D>
if SCSEL = 0 [goto FINTRO2]
else [goto KNOWSC2]
Question ID: FID.390_03.000 Instrument Variable Name: FINTRO2 QuestionnaireFileName: Family
QuestionText: * Enter line number(s) of family members listed that are currently present. Enter up to 10 numbers, separate with
commas.
[Display all family members who are not deleted and >17 or emancipated minors]
* If any persons listed are not present, say:
We would like to have all adult family members who are at home take part in the interview. Are (READ NAMES) at
home now?
* If yes, ask: Could they join us?
1 Present
2 Not present
UniverseText: All nondeleted persons >17 or emancipated minors
SkipInstructions: <96> [goto FCALLBK1]
if only one PX selected [goto HLTH_BEG]
else [goto FAMRESP]
Question ID: FID.390_04.000 Instrument Variable Name: FAMRESP QuestionnaireFileName: Family
QuestionText: * Ask if necessary: With whom am I speaking?
* Enter the line number of the person you consider to be the main respondent for this family's health questions.
01-25 Person # of Family Respondent
UniverseText: More than 1 adult present.
SkipInstructions: goto HLTH_BEG
Page 1 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.005_00.000 Instrument Variable Name: FLAPLYLM QuestionnaireFileName: Family
QuestionText: ? [F1]
[fill1: Are/Is]
* Read names
(fill roster of persons age 0-4)
limited in the kind or amount of play activities [fill2: they/he/she] can do because of a physical, mental, or emotional
problem?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with one or more persons less than 5 years of age
SkipInstructions: <1> [if only one child less than 5 years of age, store the person number in PLAPLYLM and goto
PLAPLYUN; else, goto PLAPLYLM]
<2,R,D> [goto FSPEDEIS]
Question ID: FHS.010_00.000 Instrument Variable Name: PLAPLYLM QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons less than five years of age and at least one is limited in play activities
SkipInstructions: goto PLAPLYUN
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 2 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.020_00.000 Instrument Variable Name: PLAPLYUN QuestionnaireFileName: Family
QuestionText: Is [fill: ALIAS] able to take part AT ALL in the usual kinds of play activities done by most children [fill: ALIAS]’s
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons less than 5 years of age who are limited in play activities
SkipInstructions: repeat this question for all persons listed at PLAPLYLM, then goto FSPEDEIS
Question ID: FHS.050_00.000 Instrument Variable Name: FSPEDEIS QuestionnaireFileName: Family
QuestionText: ? [F1]
[fill: Do you/Does/Do any of these family members,
* Read names
(fill roster of persons less than age 18)]
receive Special Educational or Early Intervention Services?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with one or more persons less than 18 years of age
SkipInstructions: <1> [if only one person less than 18 years of age, store the person number in PSPEDEIS and goto PSPEDEM;
else, goto PSPEDEIS]
<2,R,D> [goto FLAADL]
Page 3 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.060_00.000 Instrument Variable Name: PSPEDEIS QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons less than 18 years of age and at least one receives Special Educational
or Early Intervention Services
SkipInstructions: goto PSPEDEM
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Question ID: FHS.065_00.000 Instrument Variable Name: PSPEDEM QuestionnaireFileName: Family
QuestionText: [fill: Do you/Does ALIAS] receive these services because of an emotional
or behavioral problem?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who receive Special Educational or Early Intervention Services
SkipInstructions: repeat this question for all persons listed at PSPEDEIS, then goto FLAADL
Page 4 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.070_00.000 Instrument Variable Name: FLAADL QuestionnaireFileName: Family
QuestionText: ? [F1]
Because of a physical, mental, or emotional problem, [fill1: do you/does anyone in the family] need the help of other
persons with PERSONAL CARE NEEDS, such as eating, bathing, dressing, or getting around inside this home?
[fill2: Do not include family members age 2 and under.]
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with one or more persons 3 years of age or older
SkipInstructions: <1> [if a single-person family, store the person number in PLAADL and goto LABATH; else, goto PLAADL]
Question ID: FHS.080_00.000 Instrument Variable Name: PLAADL QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons 3 years of age or older and at least one needs the help of other persons
with personal care needs
SkipInstructions: goto LABATH
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 5 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.090_01.000 Instrument Variable Name: LABATH QuestionnaireFileName: Family
QuestionText: [fill: Do you/Does ALIAS] need the help of other persons with...
Bathing or showering?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons 3 years of age or older who need help with personal care needs
SkipInstructions: goto LADRESS
Question ID: FHS.090_02.000 Instrument Variable Name: LADRESS QuestionnaireFileName: Family
QuestionText: * Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Dressing?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons 3 years of age or older who need help with personal care needs
SkipInstructions: goto LAEAT
Page 6 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.090_03.000 Instrument Variable Name: LAEAT QuestionnaireFileName: Family
QuestionText: * Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Eating?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons 3 years of age or older who need help with personal care needs
SkipInstructions: goto LABED
Question ID: FHS.090_04.000 Instrument Variable Name: LABED QuestionnaireFileName: Family
QuestionText: * Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Getting in or out of bed or chairs?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons 3 years of age or older who need help with personal care needs
SkipInstructions: goto LATOILT
Page 7 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.090_05.000 Instrument Variable Name: LATOILT QuestionnaireFileName: Family
QuestionText: * Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Using the toilet, including getting to the toilet?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons 3 years of age or older who need help with personal care needs
SkipInstructions: goto LAHOME
Question ID: FHS.090_06.000 Instrument Variable Name: LAHOME QuestionnaireFileName: Family
QuestionText: * Read lead-in if necessary.
[fill: Do you/Does ALIAS] need the help of other persons with...
Getting around inside the home?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons 3 years of age or older who need help with personal care needs
SkipInstructions: goto LABATH for the next persons listed at PLAADL; else, goto FLAIADL
Page 8 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.150_00.000 Instrument Variable Name: FLAIADL QuestionnaireFileName: Family
QuestionText: ? [F1]
Because of a physical, mental, or emotional problem, do [fill: you/any of these family members
* Read names
(fill roster of persons age 18 or older)]
need the help of other persons in handling ROUTINE NEEDS, such as everyday household chores, doing necessary
business, shopping, or getting around for other purposes?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with one or more persons 18 years of age or older
SkipInstructions: <1> [if only one person 18 years of age or older, store the person number in PLAIADL and goto
FLAWKNOW; else, goto PLAIADL]
<2,R,D> [goto FLAWKNOW]
Question ID: FHS.160_00.000 Instrument Variable Name: PLAIADL QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons 18 years of age or older and at least one needs the help of other persons
in handling routine needs
SkipInstructions: goto FLAWKNOW
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 9 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.170_00.000 Instrument Variable Name: FLAWKNOW QuestionnaireFileName: Family
QuestionText: ? [F1]
Does a physical, mental, or emotional problem NOW keep [fill: you/any of these family members
* Read names
(fill roster of persons age 18 or older)]
from working at a job or business?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with one or more persons 18 years of age or older
SkipInstructions: <1> [if only one person 18 years of age or older, store the person number in PLAWKNOW and goto
FLAWALK; else, goto PLAWKNOW]
<2,R,D> [goto FLAWKLIM]
Question ID: FHS.180_00.000 Instrument Variable Name: PLAWKNOW QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons 18 years of age or older and at least one is unable to work due to a
physical, mental, or emotional problem
SkipInstructions: all persons selected goto FLAWALK; else, goto FLAWKLIM
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 10 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.190_00.000 Instrument Variable Name: FLAWKLIM QuestionnaireFileName: Family
QuestionText: ? [F1]
[fill: Are you limited in the kind OR amount of work you/ Is ALIAS limited in the kind OR amount of work he/she/
Are any of these family members,
* Read names
(fill roster of persons age 18 or older)]
limited in the kind OR amount of work they] can do because of a physical, mental or emotional problem?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with one or more persons 18 years of age or older not listed as being unable to work due to a
physical, mental, or emotional problem
SkipInstructions: <1> [if only one person 18 years of age or older not selected at PLAWKNOW, store person number in
PLAWKLIM and goto FLAWALK; else, goto PLAWKLIM]
<2,R,D> [goto FLAWALK]
Question ID: FHS.200_00.000 Instrument Variable Name: PLAWKLIM QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
0 Unable to work
1 Limited in work
2 Not limited in work
7 Refused
9 Don't know
UniverseText: All families with two or more persons 18 years of age or older able to work and at least one is limited in the
kind or amount of work he/she can do
SkipInstructions: goto FLAWALK
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 11 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.210_00.000 Instrument Variable Name: FLAWALK QuestionnaireFileName: Family
QuestionText: ? [F1]
Because of a health problem, [fill: do you/does anyone in the family]
have difficulty walking without using any special equipment?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PLAWALK and goto FLAREMEM; else, goto
PLAWALK]
<2,R,D> [goto FLAREMEM]
Question ID: FHS.220_00.000 Instrument Variable Name: PLAWALK QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one has difficulty walking without using special equipment
SkipInstructions: goto FLAREMEM
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 12 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.230_00.000 Instrument Variable Name: FLAREMEM QuestionnaireFileName: Family
QuestionText: ? [F1]
[fill1: Are you/Is anyone in the family] LIMITED IN ANY WAY because of difficulty remembering or because
[fill2: you/they] experience periods of confusion?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store person number in PLAREMEM and goto LAHCC; else, goto
PLAREMEM]
Question ID: FHS.240_00.000 Instrument Variable Name: PLAREMEM QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one is limited due to difficulty remembering or periods of
confusion
SkipInstructions: goto FLIMANY
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 13 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.250_00.000 Instrument Variable Name: FLIMANY QuestionnaireFileName: Family
QuestionText: ? [F1]
[fill: Are you/ Is ALIAS/ Are any family members
* Read names
(fill roster of applicable persons)]
LIMITED IN ANY WAY in any activities because of physical, mental or emotional problems?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with one or more family members not previously mentioned as having a limitation
SkipInstructions: <1> [if a one-person family or the respondent is the only person NOT previously mentioned as having a
limitation, store person number in PLIMANY and goto LAHCC; else goto PLIMANY]
<2,R,D> [goto LAHCC]
Question ID: FHS.260_00.000 Instrument Variable Name: PLIMANY QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who is this?
(Anyone else?)
0 Limitation previously mentioned
1 Yes, limited in some other way
2 Not limited in any way
7 Refused
9 Don't know
UniverseText: All families with two or more persons not previously mentioned as having a limitation
SkipInstructions: goto LAHCC
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 14 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.270_00.000 Instrument Variable Name: LAHCC QuestionnaireFileName: Family
QuestionText: (book) F1 ? [F1]
What conditions or health problems cause [fill: ALIAS]’s limitations?
* Enter all that apply, separate with commas.
* Do not probe except to clarify answer.
01 Vision/problem seeing
02 Hearing problem
03 Speech problem
04 Asthma/breathing problem
05 Birth defect
06 Injury
07 Intellectual disability, also known as mental retardation
08 Other developmental problem (for example, cerebral palsy)
09 Other mental, emotional or behavioral problem
10 Bone, joint, or muscle problem
11 Epilepsy or seizures
12 Learning disability
13 Attention Deficit/Hyperactivity Disorder (ADD/ADHD)
90 Other impairment/problem (Specify one)
91 Other impairment/problem (Specify one)
97 Refused
99 Don't know/not sure
UniverseText: All persons less than 18 years of age who have at least one reported limitation
SkipInstructions: <1-4,6-13> [goto appropriate follow-up questions: LHCL01N - LHCL04N, LHCL06N - LHCL13N]
<5> [fill "96" in LHCL05N and fill "6" in LHCL05T]
<90> [goto LAHCC_S1]
<91> [goto LAHCC_S2]
<R,D> [repeat this question for the next person less than 18 years of age with a reported limitation; if no more
persons less than 18 years of age with a reported limitation, goto LAHCA]
NOTE: This question and all appropriate follow-up questions are asked, in sequence, for each person less
than 18 years of age with a reported limitation. The instrument then proceeds to LAHCA.
Page 15 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.271_90.000 Instrument Variable Name: LAHCC_S1 QuestionnaireFileName: Family
QuestionText: * Read if necessary.
What is the other impairment or problem?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to at least one condition not listed at LAHCC
SkipInstructions: goto LHCL90N
Question ID: FHS.271_91.000 Instrument Variable Name: LAHCC_S2 QuestionnaireFileName: Family
QuestionText: * Read if necessary.
What is the other impairment or problem?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to at least one condition not listed at LAHCC
SkipInstructions: goto LHCL91N
Page 16 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.280_01.000 Instrument Variable Name: LHCL01N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a vision problem or problem seeing?
* Enter number for time with a vision problem or problem seeing.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to a vision problem or problem seeing
SkipInstructions: <1-95,D> [goto LHCL01T]
<96> [fill "6" in LHCL01T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL01T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 17 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.280_02.000 Instrument Variable Name: LHCL01T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with vision problem or problem seeing.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to a vision problem or problem seeing and 1-
95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL01T]
if (LHCL01T = 4 and LHCL01N > AGE) or (LHCL01T = 3 and LHCL01N > AGE in months) or (LHCL01T =
Hard Edit: ERR1_LHCL01T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL01T
* "6" not selectable.
Page 18 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.282_01.000 Instrument Variable Name: LHCL02N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a hearing problem?
* Enter number for time with a hearing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to a hearing problem
SkipInstructions: <1-95,D> [goto LHCL02T]
<96> [fill "6" in LHCL02T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL02T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 19 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.282_02.000 Instrument Variable Name: LHCL02T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with hearing problem.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to a hearing problem and 1-95, D was entered
for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL02T]
if (LHCL02T = 4 and LHCL02N > AGE) or (LHCL02T = 3 and LHCL02N > AGE in months) or (LHCL02T =
Hard Edit: ERR1_LHCL02T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL02T
* "6" not selectable.
Page 20 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.284_01.000 Instrument Variable Name: LHCL03N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a speech problem?
* Enter number for time with a speech problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to a speech problem
SkipInstructions: <1-95,D> [goto LHCL03T]
<96> [fill "6" in LHCL03T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL03T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 21 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.284_02.000 Instrument Variable Name: LHCL03T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with speech problem.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to a speech problem and 1-95, D was entered
for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL03T]
if (LHCL03T = 4 and LHCL03N > AGE) or (LHCL03T = 3 and LHCL03N > AGE in months) or (LHCL03T =
Hard Edit: ERR1_LHCL03T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL03T
* "6" not selectable.
Page 22 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.286_01.000 Instrument Variable Name: LHCL04N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had asthma or a breathing problem?
* Enter number for time with an asthma or breathing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to asthma/breathing problem
SkipInstructions: <1-95,D> [goto LHCL04T]
<96> [fill "6" in LHCL04T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL04T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 23 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.286_02.000 Instrument Variable Name: LHCL04T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with asthma or a breathing problem.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to asthma/breathing problem and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL04T]
if (LHCL04T = 4 and LHCL04N > AGE) or (LHCL04T = 3 and LHCL04N > AGE in months) or (LHCL04T =
Hard Edit: ERR1_LHCL04T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL04T
* "6" not selectable.
Page 24 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.288_01.000 Instrument Variable Name: LHCL06N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill1: have you/has ALIAS] had the injury that caused [fill2:your/his/her] limitation?
* Enter number for time with the injury.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to an injury
SkipInstructions: <1-95,D> [goto LHCL06T]
<96> [fill "6" in LHCL06T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL06T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 25 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.288_02.000 Instrument Variable Name: LHCL06T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with the injury that caused [fill: your/his/her] limitation.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to an injury and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL06T]
if (LHCL06T = 4 and LHCL06N > AGE) or (LHCL06T = 3 and LHCL06N > AGE in months) or (LHCL06T =
Hard Edit: ERR1_LHCL06T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL06T
* "6" not selectable.
Page 26 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.290_01.000 Instrument Variable Name: LHCL07N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had intellectual disability, also known as mental retardation?
* Enter number for time with intellectual disability/mental retardation.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to mental retardation
SkipInstructions: <1-95,D> [goto LHCL07T]
<96> [fill "6" in LHCL07T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL07T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 27 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.290_02.000 Instrument Variable Name: LHCL07T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with intellectual disability/mental retardation.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to mental retardation and 1-95, D was entered
for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL07T]
if (LHCL07T = 4 and LHCL07N > AGE) or (LHCL07T = 3 and LHCL07N > AGE in months) or (LHCL07T =
Hard Edit: ERR1_LHCL07T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL07T
* "6" not selectable.
Page 28 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.292_01.000 Instrument Variable Name: LHCL08N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a developmental problem (e.g. cerebral palsy)?
* Enter number for time with a developmental problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to some other developmental problem
SkipInstructions: <1-95,D> [goto LHCL08T]
<96> [fill "6" in LHCL08T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL08T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 29 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.292_02.000 Instrument Variable Name: LHCL08T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with developmental problem (e.g. cerebral palsy).
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to some other developmental problem and 1-
95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL08T]
if (LHCL08T = 4 and LHCL08N > AGE) or (LHCL08T = 3 and LHCL08N > AGE in months) or (LHCL08T =
Hard Edit: ERR1_LHCL08T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL08T
* "6" not selectable.
Page 30 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.294_01.000 Instrument Variable Name: LHCL09N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a mental, emotional, or behavioral problem?
* Enter number for time with a mental, emotional, or behavioral problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to a mental, emotional, or behavioral problem
SkipInstructions: <1-95,D> [goto LHCL09T]
<96> [fill "6" in LHCL09T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL09T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 31 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.294_02.000 Instrument Variable Name: LHCL09T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with mental, emotional, or behavioral problem.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to a mental, emotional, or behavioral problem
and 1-95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL09T]
if (LHCL09T = 4 and LHCL09N > AGE) or (LHCL09T = 3 and LHCL09N > AGE in months) or (LHCL09T =
Hard Edit: ERR1_LHCL09T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL09T
* "6" not selectable.
Page 32 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.296_01.000 Instrument Variable Name: LHCL10N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a bone, joint, or muscle problem?
* Enter number for time with a bone, joint, or muscle problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to a bone, joint, or muscle problem
SkipInstructions: <1-95,D> [goto LHCL10T]
<96> [fill "6" in LHCL10T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL10T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 33 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.296_02.000 Instrument Variable Name: LHCL10T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with bone, joint, or muscle problem.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to a bone, joint, or muscle problem and 1-95,
D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL10T]
if (LHCL10T = 4 and LHCL10N > AGE) or (LHCL10T = 3 and LHCL10N > AGE in months) or (LHCL10T =
Hard Edit: ERR1_LHCL10T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL10T
* "6" not selectable.
Page 34 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.298_01.000 Instrument Variable Name: LHCL11N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had epilepsy or seizures?
* Enter number for time with epilepsy or seizures.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to epilepsy or seizures
SkipInstructions: <1-95,D> [goto LHCL11T]
<96> [fill "6" in LHCL11T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL11T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 35 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.298_02.000 Instrument Variable Name: LHCL11T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with epilepsy or seizures.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to epilepsy or seizures and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL11T]
if (LHCL11T = 4 and LHCL11N > AGE) or (LHCL11T = 3 and LHCL11N > AGE in months) or (LHCL11T =
Hard Edit: ERR1_LHCL11T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL11T
* "6" not selectable.
Page 36 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.300_01.000 Instrument Variable Name: LHCL12N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a learning disability?
* Enter number for time with a learning disability.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to a learning disability
SkipInstructions: <1-95,D> [goto LHCL12T]
<96> [fill "6" in LHCL12T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL12T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 37 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.300_02.000 Instrument Variable Name: LHCL12T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with learning disability.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to a learning disability and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL12T]
if (LHCL12T = 4 and LHCL12N > AGE) or (LHCL12T = 3 and LHCL12N > AGE in months) or (LHCL12T =
Hard Edit: ERR1_LHCL12T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL12T
* "6" not selectable.
Page 38 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.302_01.000 Instrument Variable Name: LHCL13N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had attention deficit/hyperactivity disorder?
* Enter number for time with attention deficit/hyperactivity disorder.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to Attention Deficit/Hyperactivity Disorder
SkipInstructions: <1-95,D> [goto LHCL13T]
<96> [fill "6" in LHCL13T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL13T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 39 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.302_02.000 Instrument Variable Name: LHCL13T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with attention deficit/hyperactivity disorder.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to Attention Deficit/Hyperactivity Disorder
and 1-95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL13T]
if (LHCL13T = 4 and LHCL13N > AGE) or (LHCL13T = 3 and LHCL13N > AGE in months) or (LHCL13T =
Hard Edit: ERR1_LHCL13T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL13T
* "6" not selectable.
Page 40 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.304_01.000 Instrument Variable Name: LHCL90N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill1: have you/has ALIAS] had [fill2: problem in LAHCC_S1]?
* Enter number for time with [fill1: problem in LAHCC_S1]?
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to the problem entered at LAHCC_S1
SkipInstructions: <1-95,D> [goto LHCL90T]
<96> [fill "6" in LHCL90T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL90T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 41 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.304_02.000 Instrument Variable Name: LHCL90T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with [fill: problem in LAHCC_S1].
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to the problem entered at LAHCC_S1 and 1-
95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL90T]
if (LHCL90T = 4 and LHCL90N > AGE) or (LHCL90T = 3 and LHCL90N > AGE in months) or (LHCL90T =
Hard Edit: ERR1_LHCL90T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL90T
* "6" not selectable.
Page 42 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.306_01.000 Instrument Variable Name: LHCL91N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill1: have you/has ALIAS] had [fill2: problem in LAHCC_S2]?
* Enter number for time with [fill1: problem in LAHCC_S2].
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to the problem entered at LAHCC_S2
SkipInstructions: <1-95,D> [goto LHCL91T]
<96> [fill "6" in LHCL91T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
<R> [store "R" in LHCL91T and goto follow-up questions for next condition selected at LAHCC; if no more
conditions, goto LAHCC for next person less than 18 years of age with a reported limitation; if no more
persons, goto LAHCA]
Page 43 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.306_02.000 Instrument Variable Name: LHCL91T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with [fill: problem in LAHCC_S2].
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to the problem entered at LAHCC_S2 and 1-
95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCC; if no more conditions, goto
LAHCC for next person less than 18 years of age with a reported limitation; if no more persons, goto LAHCA]
<6> [goto ERR2_LHCL91T]
if (LHCL91T = 4 and LHCL91N > AGE) or (LHCL91T = 3 and LHCL91N > AGE in months) or (LHCL91T =
Hard Edit: ERR1_LHCL91T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHCL91T
* "6" not selectable.
Page 44 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.350_00.000 Instrument Variable Name: LAHCA QuestionnaireFileName: Family
QuestionText: (book) F2
What conditions or health problems cause [fill: your/ALIAS’s] limitations?
* Enter all that apply, separate with commas.
* Do not probe except to clarify answer.
01 Vision/problem seeing
02 Hearing problem
03 Arthritis/rheumatism
04 Back or neck problem
05 Fracture, bone/joint injury
06 Other injury
07 Heart problem
08 Stroke problem
09 Hypertension/high blood pressure
10 Diabetes
11 Lung/breathing problem(for example, asthma and emphysema)
12 Cancer
13 Birth defect
14 Intellectual disability, also known as mental retardation
15 Other developmental problem (for example cerebral palsy)
16 Senility
17 Depression/anxiety/emotional problem
18 Weight problem
19 Missing limbs (fingers, toes or digits), amputee
20 Kidney, bladder or renal problems
21 Circulation problems (including blood clots)
22 Benign tumors, cysts
23 Fibromyalgia, lupus
24 Osteoporosis, tendinitis
25 Epilepsy, seizures
26 Multiple Sclerosis (MS), Muscular Dystrophy (MD)
27 Polio(myelitis), paralysis, para/quadriplegia
28 Parkinson's disease, other tremors
29 Other nerve damage, including carpal tunnel syndrome
30 Hernia
31 Ulcer
32 Varicose veins, hemorrhoids
33 Thyroid problems, Grave's disease, gout
34 Knee problems (not arthritis (03), not joint injury(05))
35 Migraine headaches (not just headaches)
90 Other impairment/problem (Specify one)
91 Other impairment/problem (Specify one)
97 Refused
99 Don't know/not sure
Page 45 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
UniverseText: All persons 18 years of age or older who have at least one reported limitation
SkipInstructions: <1-12,14-35> [goto appropriate follow-up questions: LHAL01N - LHAL12N, LHAL14N - LHAL35N]
<13> [fill "96" in LHAL13N and fill "6" in LHAL13T]
<90> [goto LAHCA_S1]
<91> [goto LAHCA_S2]
<R,D> [repeat this question for the next person 18 years of age or older with a reported limitation; if no more
persons 18 years of age or older with a reported limitation, goto PHSTAT]
NOTE: This question and all appropriate follow-up questions are asked, in sequence, for each person 18 years
of age or older with a reported limitation. The instrument then proceeds to PHSTAT.
Question ID: FHS.351_90.000 Instrument Variable Name: LAHCA_S1 QuestionnaireFileName: Family
QuestionText: * Read if necessary.
What is the other impairment or problem?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to at least one condition not listed at LAHCC
SkipInstructions: goto LHAL90N
Question ID: FHS.351_91.000 Instrument Variable Name: LAHCA_S2 QuestionnaireFileName: Family
QuestionText: * Read if necessary.
What is the other impairment or problem?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age who have a limitation due to at least one condition not listed at LAHCC
SkipInstructions: goto LHAL91N
Page 46 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.360_01.000 Instrument Variable Name: LHAL01N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a vision problem or problem seeing?
* Enter number for time with a vision problem or problem seeing.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a vision problem or problem seeing
SkipInstructions: <1-95,D> [goto LHAL01T]
<96> [fill "6" in LHAL01T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL01T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.360_02.000 Instrument Variable Name: LHAL01T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with vision problem or problem seeing.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a vision problem or problem seeing and 1-
95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL01T]
Hard Edit: ERR1_LHAL01T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL01T
* "6" not selectable.
Page 47 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.362_01.000 Instrument Variable Name: LHAL02N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a hearing problem?
* Enter number for time with a hearing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a hearing problem
SkipInstructions: <1-95,D> [goto LHAL02T]
<96> [fill "6" in LHAL02T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL02T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.362_02.000 Instrument Variable Name: LHAL02T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with hearing problem.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a hearing problem and 1-95, D was entered
for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL02T]
Hard Edit: ERR1_LHAL02T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL02T
* "6" not selectable.
Page 48 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.364_01.000 Instrument Variable Name: LHAL03N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had arthritis or rheumatism?
* Enter number for time with arthritis or rheumatism.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to arthritis/rheumatism
SkipInstructions: <1-95,D> [goto LHAL03T]
<96> [fill "6" in LHAL03T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL03T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.364_02.000 Instrument Variable Name: LHAL03T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with arthritis or rheumatism.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to arthritis/rheumatism and 1-95, D was entered
for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL03T]
Hard Edit: ERR1_LHAL03T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL03T
* "6" not selectable.
Page 49 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.366_01.000 Instrument Variable Name: LHAL04N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a back or neck problem?
* Enter number for time with a back or neck problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a back or neck problem
SkipInstructions: <1-95,D> [goto LHAL04T]
<96> [fill "6" in LHAL04T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL04T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.366_02.000 Instrument Variable Name: LHAL04T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with back or neck problem.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a back or neck problem and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL04T]
Hard Edit: ERR1_LHAL04T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL04T
* "6" not selectable.
Page 50 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.368_01.000 Instrument Variable Name: LHAL05N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a fracture, bone, or joint injury?
* Enter number for time with a fracture, bone or joint injury.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a fracture or bone/joint injury
SkipInstructions: <1-95,D> [goto LHAL05T]
<96> [fill "6" in LHAL05T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL05T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.368_02.000 Instrument Variable Name: LHAL05T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with fracture, bone, or joint injury.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a fracture or bone/joint injury and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL05T]
Hard Edit: ERR1_LHAL05T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL05T
* "6" not selectable.
Page 51 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.370_01.000 Instrument Variable Name: LHAL06N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill1: have you/has ALIAS] had the other injury that caused [fill2: your/his/her] limitation?
* Enter number for time with the injury.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to some "other" injury
SkipInstructions: <1-95,D> [goto LHAL06T]
<96> [fill "6" in LHAL06T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL06T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.370_02.000 Instrument Variable Name: LHAL06T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with other injury that caused [fill: your/his/her] limitation.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to some "other" injury and 1-95, D was entered
for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL06T]
Hard Edit: ERR1_LHAL06T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL06T
* "6" not selectable.
Page 52 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.372_01.000 Instrument Variable Name: LHAL07N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a heart problem?
* Enter number for time with a heart problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a heart problem
SkipInstructions: <1-95,D> [goto LHAL07T]
<96> [fill "6" in LHAL07T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL07T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.372_02.000 Instrument Variable Name: LHAL07T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with heart problem.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a heart problem and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL07T]
Hard Edit: ERR1_LHAL07T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL07T
* "6" not selectable.
Page 53 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.374_01.000 Instrument Variable Name: LHAL08N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a stroke problem?
* Enter number for time with a stroke problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a stroke problem
SkipInstructions: <1-95,D> [goto LHAL08T]
<96> [fill "6" in LHAL08T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL08T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.374_02.000 Instrument Variable Name: LHAL08T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with stroke problem.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a stroke problem and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL08T]
Hard Edit: ERR1_LHAL08T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL08T
* "6" not selectable.
Page 54 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.376_01.000 Instrument Variable Name: LHAL09N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had hypertension or high blood pressure?
* Enter number for time with hypertension or high blood pressure.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to hypertension/high blood pressure
SkipInstructions: <1-95,D> [goto LHAL09T]
<96> [fill "6" in LHAL09T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL09T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.376_02.000 Instrument Variable Name: LHAL09T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with hypertension or high blood pressure.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to hypertension/high blood pressure and 1-95,
D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL09T]
Hard Edit: ERR1_LHAL09T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL09T
* "6" not selectable.
Page 55 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.378_01.000 Instrument Variable Name: LHAL10N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had diabetes?
* Enter number for time with diabetes.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to diabetes
SkipInstructions: <1-95,D> [goto LHAL10T]
<96> [fill "6" in LHAL10T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL10T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.378_02.000 Instrument Variable Name: LHAL10T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with diabetes.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to diabetes and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL10T]
Hard Edit: ERR1_LHAL10T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL10T
* "6" not selectable.
Page 56 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.380_01.000 Instrument Variable Name: LHAL11N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a lung problem or breathing problem (e.g., asthma and emphysema)?
* Enter number for time with a lung problem or breathing problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a lung/breathing problem
SkipInstructions: <1-95,D> [goto LHAL11T]
<96> [fill "6" in LHAL11T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL11T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.380_02.000 Instrument Variable Name: LHAL11T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with lung problem or breathing problem (e.g., asthma and emphysema).
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a lung/breathing problem and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL11T]
Hard Edit: ERR1_LHAL11T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL11T
* "6" not selectable.
Page 57 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.382_01.000 Instrument Variable Name: LHAL12N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had cancer?
* Enter number for time with cancer.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to cancer
SkipInstructions: <1-95,D> [goto LHAL12T]
<96> [fill "6" in LHAL12T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL12T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.382_02.000 Instrument Variable Name: LHAL12T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with cancer.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to cancer and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL12T]
Hard Edit: ERR1_LHAL12T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL12T
* "6" not selectable.
Page 58 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.384_01.000 Instrument Variable Name: LHAL14N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had intellectual disability, also known as mental retardation?
* Enter number for time with intellectual disability/mental retardation.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to mental retardation
SkipInstructions: <1-95,D> [goto LHAL14T]
<96> [fill "6" in LHAL14T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL14T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.384_02.000 Instrument Variable Name: LHAL14T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with intellectual disability/mental retardation.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to mental retardation and 1-95, D was entered
for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL14T]
Hard Edit: ERR1_LHAL14T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL14T
* "6" not selectable.
Page 59 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.386_01.000 Instrument Variable Name: LHAL15N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a developmental problem (e.g. cerebral palsy)?
* Enter number for time with a developmental problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to some other developmental problem
SkipInstructions: <1-95,D> [goto LHAL15T]
<96> [fill "6" in LHAL15T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL15T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.386_02.000 Instrument Variable Name: LHAL15T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with developmental problem (e.g. cerebral palsy).
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to some other developmental problem and 1-95,
D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL15T]
Hard Edit: ERR1_LHAL15T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL15T
* "6" not selectable.
Page 60 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.388_01.000 Instrument Variable Name: LHAL16N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had senility?
* Enter number for time with senility.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to senility
SkipInstructions: <1-95,D> [goto LHAL16T]
<96> [fill "6" in LHAL16T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL16T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.388_02.000 Instrument Variable Name: LHAL16T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with senility.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to senility and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL16T]
Hard Edit: ERR1_LHAL16T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL16T
* "6" not selectable.
Page 61 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.390_01.000 Instrument Variable Name: LHAL17N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had depression, anxiety, or an emotional problem?
* Enter number for time with depression, anxiety or an emotional problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to depression/anxiety/emotional problem
SkipInstructions: <1-95,D> [goto LHAL17T]
<96> [fill "6" in LHAL17T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL17T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.390_02.000 Instrument Variable Name: LHAL17T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with depression, anxiety, or an emotional problem.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to depression/anxiety/emotional problem and
1-95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL17T]
Hard Edit: ERR1_LHAL17T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL17T
* "6" not selectable.
Page 62 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.392_01.000 Instrument Variable Name: LHAL18N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a weight problem?
* Enter number for time with a weight problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a weight problem
SkipInstructions: <1-95,D> [goto LHAL18T]
<96> [fill "6" in LHAL18T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL18T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.392_02.000 Instrument Variable Name: LHAL18T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with weight problem.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a weight problem and 1-95, D was entered
for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL18T]
Hard Edit: ERR1_LHAL18T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL18T
* "6" not selectable.
Page 63 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.394_01.000 Instrument Variable Name: LHAL19N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a missing limb (finger, toe, or digit)?
* Enter number for time with a missing limb.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to missing limbs
SkipInstructions: <1-95,D> [goto LHAL19T]
<96> [fill "6" in LHAL19T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL19T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.394_02.000 Instrument Variable Name: LHAL19T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with missing limb (finger, toe, or digit).
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to missing limbs and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL19T]
Hard Edit: ERR1_LHAL19T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL19T
* "6" not selectable.
Page 64 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.396_01.000 Instrument Variable Name: LHAL20N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a kidney, bladder or renal problem?
* Enter number for time with a kidney, bladder or renal problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a kidney, bladder, or renal problem
SkipInstructions: <1-95,D> [goto LHAL20T]
<96> [fill "6" in LHAL20T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL20T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.396_02.000 Instrument Variable Name: LHAL20T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with kidney, bladder or renal problem.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a kidney, bladder, or renal problem and 1-95,
D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL20T]
Hard Edit: ERR1_LHAL20T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL20T
* "6" not selectable.
Page 65 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.398_01.000 Instrument Variable Name: LHAL21N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a circulation problem (including blood clots)?
* Enter number for time with a circulation problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to circulation problems
SkipInstructions: <1-95,D> [goto LHAL21T]
<96> [fill "6" in LHAL21T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL21T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.398_02.000 Instrument Variable Name: LHAL21T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with circulation problem (including blood clots).
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to circulation problems and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL21T]
Hard Edit: ERR1_LHAL21T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL21T
* "6" not selectable.
Page 66 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.400_01.000 Instrument Variable Name: LHAL22N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had benign tumors or cysts?
* Enter number for time with benign tumors or cysts.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to benign tumors or cysts
SkipInstructions: <1-95,D> [goto LHAL22T]
<96> [fill "6" in LHAL22T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL22T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.400_02.000 Instrument Variable Name: LHAL22T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with benign tumors or cysts.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to benign tumors or cysts and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL22T]
Hard Edit: ERR1_LHAL22T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL22T
* "6" not selectable.
Page 67 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.402_01.000 Instrument Variable Name: LHAL23N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had fibromyalgia or lupus?
* Enter number for time with fibromyalgia or lupus.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to fibromyalgia or lupus
SkipInstructions: <1-95,D> [goto LHAL23T]
<96> [fill "6" in LHAL23T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL23T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.402_02.000 Instrument Variable Name: LHAL23T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with fibromyalgia or lupus.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to fibromyalgia or lupus and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL23T]
Hard Edit: ERR1_LHAL23T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL23T
* "6" not selectable.
Page 68 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.404_01.000 Instrument Variable Name: LHAL24N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had osteoporosis or tendinitis?
* Enter number for time with osteoporosis or tendinitis.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to osteoporosis or tendinitis
SkipInstructions: <1-95,D> [goto LHAL24T]
<96> [fill "6" in LHAL24T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL24T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.404_02.000 Instrument Variable Name: LHAL24T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with osteoporosis or tendinitis.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to osteoporosis or tendinitis and 1-95, D was
entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL24T]
Hard Edit: ERR1_LHAL24T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL24T
* "6" not selectable.
Page 69 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.406_01.000 Instrument Variable Name: LHAL25N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had epilepsy or seizures?
* Enter number for time with epilepsy or seizures.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to epilepsy or seizures
SkipInstructions: <1-95,D> [goto LHAL25T]
<96> [fill "6" in LHAL25T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL25T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.406_02.000 Instrument Variable Name: LHAL25T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with epilepsy or seizures.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to epilepsy or seizures and 1-95, D was entered
for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL25T]
Hard Edit: ERR1_LHAL25T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL25T
* "6" not selectable.
Page 70 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.408_01.000 Instrument Variable Name: LHAL26N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had multiple sclerosis (MS) or muscular dystrophy (MD)?
* Enter number for time with multiple sclerosis (MS) or muscular dystrophy (MD)?
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to multiple sclerosis or muscular dystrophy
SkipInstructions: <1-95,D> [goto LHAL26T]
<96> [fill "6" in LHAL26T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL26T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.408_02.000 Instrument Variable Name: LHAL26T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with multiple sclerosis (MS) or muscular dystrophy (MD).
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to multiple sclerosis or muscular dystrophy
and 1-95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL26T]
Hard Edit: ERR1_LHAL26T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL26T
* "6" not selectable.
Page 71 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.410_01.000 Instrument Variable Name: LHAL27N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had polio(myelitis), paralysis or para/quadriplegia?
* Enter number for time with polio (myelitis) paralysis or para/quadriplegia.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to polio, paralysis, or para/quadriplegia
SkipInstructions: <1-95,D> [goto LHAL27T]
<96> [fill "6" in LHAL27T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL27T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.410_02.000 Instrument Variable Name: LHAL27T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with polio(myelitis), paralysis or para/quadriplegia.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to polio, paralysis, or para/quadriplegia and 1-
95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL27T]
Hard Edit: ERR1_LHAL27T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL27T
* "6" not selectable.
Page 72 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.412_01.000 Instrument Variable Name: LHAL28N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had Parkinson’s disease or tremors?
* Enter number for time with Parkinson's disease or tremors.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to Parkinson's disease or other tremors
SkipInstructions: <1-95,D> [goto LHAL28T]
<96> [fill "6" in LHAL28T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL28T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Question ID: FHS.412_02.000 Instrument Variable Name: LHAL28T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with Parkinson’s disease or tremors.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to Parkinson's disease or other tremors and 1-
95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL28T]
Hard Edit: ERR1_LHAL28T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL28T
* "6" not selectable.
Page 73 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.414_01.000 Instrument Variable Name: LHAL29N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had nerve damage (including carpal tunnel syndrome)?
* Enter number for time with nerve damage.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to other nerve damage, including carpal tunnel
syndrome
SkipInstructions: <1-95,D> [goto LHAL29T]
<96> [fill "6" in LHAL29T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL29T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Page 74 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.414_02.000 Instrument Variable Name: LHAL29T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with nerve damage (including carpal tunnel syndrome).
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to other nerve damage, including carpal tunnel
syndrome, and 1-95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL29T]
Hard Edit: ERR1_LHAL29T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL29T
* "6" not selectable.
Question ID: FHS.416_01.000 Instrument Variable Name: LHAL30N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a hernia?
* Enter number for time with a hernia.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a hernia
SkipInstructions: <1-95,D> [goto LHAL30T]
<96> [fill "6" in LHAL30T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL30T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Page 75 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.416_02.000 Instrument Variable Name: LHAL30T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with hernia.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to a hernia and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL30T]
Hard Edit: ERR1_LHAL30T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL30T
* "6" not selectable.
Question ID: FHS.418_01.000 Instrument Variable Name: LHAL31N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had an ulcer?
* Enter number for time with an ulcer.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to an ulcer
SkipInstructions: <1-95,D> [goto LHAL31T]
<96> [fill "6" in LHAL31T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL31T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Page 76 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.418_02.000 Instrument Variable Name: LHAL31T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with ulcer.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to an ulcer and 1-95, D was entered for the
"number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL31T]
Hard Edit: ERR1_LHAL31T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL31T
* "6" not selectable.
Question ID: FHS.420_01.000 Instrument Variable Name: LHAL32N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had varicose veins or hemorrhoids?
* Enter number for time with varicose veins or hemorrhoids.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to varicose veins or hemorrhoids
SkipInstructions: <1-95,D> [goto LHAL32T]
<96> [fill "6" in LHAL32T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL32T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Page 77 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.420_02.000 Instrument Variable Name: LHAL32T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with varicose veins or hemorrhoids.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to varicose veins or hemorrhoids and 1-95, D
was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL32T]
Hard Edit: ERR1_LHAL32T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL32T
* "6" not selectable.
Question ID: FHS.422_01.000 Instrument Variable Name: LHAL33N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a thyroid problem, Grave’s disease or gout?
* Enter number for time with a thyroid problem, Grave's disease or gout.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to thyroid problems, Grave's disease, or gout
SkipInstructions: <1-95,D> [goto LHAL33T]
<96> [fill "6" in LHAL33T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL33T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Page 78 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.422_02.000 Instrument Variable Name: LHAL33T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with thyroid problem, Grave’s disease or gout.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to thyroid problems, Grave's disease, or gout
and 1-95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL33T]
Hard Edit: ERR1_LHAL33T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL33T
* "6" not selectable.
Question ID: FHS.424_01.000 Instrument Variable Name: LHAL34N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had a knee problem?
* Enter number for time with a knee problem.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to knee problems
SkipInstructions: <1-95,D> [goto LHAL34T]
<96> [fill "6" in LHAL34T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL34T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Page 79 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.424_02.000 Instrument Variable Name: LHAL34T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with knee problem.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to knee problems and 1-95, D was entered for
the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL34T]
Hard Edit: ERR1_LHAL34T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL34T
* "6" not selectable.
Question ID: FHS.426_01.000 Instrument Variable Name: LHAL35N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill: have you/has ALIAS] had migraine headaches?
* Enter number for time with migraine headaches.
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to migraine headaches
SkipInstructions: <1-95,D> [goto LHAL35T]
<96> [fill "6" in LHAL35T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL35T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Page 80 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.426_02.000 Instrument Variable Name: LHAL35T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with migraine headaches.
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to migraine headaches and 1-95, D was entered
for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL35T]
Hard Edit: ERR1_LHAL35T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL35T
* "6" not selectable.
Question ID: FHS.450_01.000 Instrument Variable Name: LHAL90N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill1: have you/has ALIAS] had [fill2: LAHCA_S1]?
* Enter number for time with [fill1: LAHCA_S1].
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to the problem entered at LAHCA_S1
SkipInstructions: <1-95,D> [goto LHAL90T]
<96> [fill "6" in LHAL90T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL90T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Page 81 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.450_02.000 Instrument Variable Name: LHAL90T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with [fill: LAHCA_S1].
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to the problem entered at LAHCA_S1 and 1-
95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL90T]
Hard Edit: ERR1_LHAL90T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL90T
* "6" not selectable.
Question ID: FHS.452_01.000 Instrument Variable Name: LHAL91N QuestionnaireFileName: Family
QuestionText: 1 of 2
How long [fill1: have you/has ALIAS] had [fill2: LAHCA_S2]?
* Enter number for time with [fill1: LAHCA_S2].
* Enter '95' for 95 or more.
* Enter '96' if since birth.
01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to the problem entered at LAHCA_S2
SkipInstructions: <1-95,D> [goto LHAL91T]
<96> [fill "6" in LHAL91T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
<R> [store "R" in LHAL91T and goto follow-up questions for next condition selected at LAHCA; if no more
conditions, goto LAHCA for next person 18 years of age or older with a reported limitation; if no more
persons, goto PHSTAT]
Page 82 of 82
2011 NHIS Questionnaire Family
Family Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: FHS.452_02.000 Instrument Variable Name: LHAL91T QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for time with [fill: LAHCA_S2].
1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since birth
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who have a limitation due to the problem entered at LAHCA_S2 and 1-
95, D was entered for the "number" part of this two-part question
SkipInstructions: <1-4,R,D> [goto follow-up questions for next condition selected at LAHCA; if no more conditions, goto
LAHCA for next person 18 years of age or older with a reported limitation; if no more persons, goto PHSTAT]
<6> [goto ERR2_LHAL91T]
Hard Edit: ERR1_LHAL91T
* Time with condition cannot be greater than age. Please correct.
ERR2_LHAL91T
* "6" not selectable.
Question ID: FHS.500_00.000 Instrument Variable Name: PHSTAT QuestionnaireFileName: Family
QuestionText: Would you say [fill: your/ALIAS’s] health in general is excellent, very good, good, fair, or poor?
1 Excellent
2 Very good
3 Good
4 Fair
5 Poor
7 Refused
9 Don't know
UniverseText: All persons
SkipInstructions: repeat for all persons in the family, goto FINJ3M
Page 1 of 4
2011 NHIS Questionnaire Family
Family Food Security
Document Version Date: 19-Jun-12
Question ID: FFS.010_00.000 Instrument Variable Name: FSRUNOUT QuestionnaireFileName: Family
QuestionText: These next questions are about whether you were always able to afford the food you needed in the last 30 days. I'm
going to read you several statements that people have made about their food situation. For these statements, please
tell me whether the statement was often true, sometimes true, or never true for [fill 1: you/your family] in the last 30
days.
The first statement is "[fill 2: I/We] worried whether [fill 3: my/our] food would run out before [fill 4: I/we] got money
1 Often true
2 Sometimes true
3 Never true
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1-3,R,D> goto FSLAST
Question ID: FFS.020_00.000 Instrument Variable Name: FSLAST QuestionnaireFileName: Family
QuestionText: "The food that [fill 1: I/we] bought just didn't last, and [fill 1: I/we] didn't have money to get more." Was that often
true, sometimes true, or never true for [fill 2: you/your family] in the last 30 days?
1 Often true
2 Sometimes true
3 Never true
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1-3,R,D> goto FSBALANC
Page 2 of 4
2011 NHIS Questionnaire Family
Family Food Security
Document Version Date: 19-Jun-12
Question ID: FFS.030_00.000 Instrument Variable Name: FSBALANC QuestionnaireFileName: Family
QuestionText: "[fill 1: I/We] couldn't afford to eat balanced meals." Was that often true, sometimes true, or never true for [fill 2:
you/your family] in the last 30 days?
1 Often true
2 Sometimes true
3 Never true
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1,2> [goto FSSKIP]
<3,D,R> [if FSRUNOUT in(1,2) or FSLAST in(1,2), goto FSSKIP; else goto FINJ3M]
Question ID: FFS.040_00.000 Instrument Variable Name: FSSKIP QuestionnaireFileName: Family
QuestionText: In the last 30 days, did [fill 1: you/you or other adults in your family] ever cut the size of your meals or skip meals
because there wasn't enough money for food?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Families for whom it was often or sometimes true in the last 30 days that they worried that food would run out
before they got money to buy more, or that food that was bought didn't last and they didn't have money to get
more, or they couldn't afford to eat balanced meals
SkipInstructions: <1> [goto FSSKDAYS]
<2,R,D> [goto FSLESS]
Question ID: FFS.050_00.000 Instrument Variable Name: FSSKDAYS QuestionnaireFileName: Family
QuestionText: In the last 30 days, how many days did this happen?
01-30 Days
97 Refused
99 Don't know
UniverseText: Adults in the family cut the size of their meals or skipped meals in the last 30 days because there wasn't
enough money for food
SkipInstructions: <1-30,R,D> [goto FSLESS]
Page 3 of 4
2011 NHIS Questionnaire Family
Family Food Security
Document Version Date: 19-Jun-12
Question ID: FFS.060_00.000 Instrument Variable Name: FSLESS QuestionnaireFileName: Family
QuestionText: In the last 30 days, did you ever eat less than you felt you should because there wasn't enough money for food?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Families for whom it was often or sometimes true in the last 30 days that they worried that food would run out
before they got money to buy more, or that food that was bought didn't last and they didn't have money to get
more, or they couldn't afford to eat balanced meals
SkipInstructions: <1,2,R,D> [goto FSHUNGRY]
Question ID: FFS.070_00.000 Instrument Variable Name: FSHUNGRY QuestionnaireFileName: Family
QuestionText: In the last 30 days, were you ever hungry but didn't eat because there wasn't enough money for food?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Families for whom it was often or sometimes true in the last 30 days that they worried that food would run out
before they got money to buy more, or that food that was bought didn't last and they didn't have money to get
more, or they couldn't afford to eat balanced meals
SkipInstructions: <1,2,R,D> [goto FSWEIGHT]
Question ID: FFS.080_00.000 Instrument Variable Name: FSWEIGHT QuestionnaireFileName: Family
QuestionText: In the last 30 days, did you lose weight because there wasn't enough money for food?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Families for whom it was often or sometimes true in the last 30 days that they worried that food would run out
before they got money to buy more, or that food that was bought didn't last and they didn't have money to get
more, or they couldn't afford to eat balanced meals
SkipInstructions: <1> [goto FSNOTEAT]
<2,R,D> [if FSSKIP=1 or FSLESS=1 or FSHUNGRY=1, goto FSNOTEAT; else goto FINJ3M]
Page 4 of 4
2011 NHIS Questionnaire Family
Family Food Security
Document Version Date: 19-Jun-12
Question ID: FFS.090_00.000 Instrument Variable Name: FSNOTEAT QuestionnaireFileName: Family
QuestionText: In the last 30 days, did [fill 1: you/you or other adults in your family] ever not eat for a whole day because there
wasn't enough money for food?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families where adult(s) cut the size of meals or meals were skipped, ate less than they felt they should, were
hungry but didn't eat, or lost weight in the last 30 days because there wasn't enough money for food
SkipInstructions: <1> [goto FSNEDAYS]
<2,R,D> [goto FINJ3M]
Question ID: FFS.100_00.000 Instrument Variable Name: FSNEDAYS QuestionnaireFileName: Family
QuestionText: In the last 30 days, how many days did this happen?
01-30 Days
97 Refused
99 Don't know
UniverseText: All families where the adult(s) did not eat for a whole day, in the last 30 days, because there wasn't enough
money for food
SkipInstructions: <1-30,R,D> [goto FINJ3M]
Page 1 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.010_00.000 Instrument Variable Name: FINJ3M QuestionnaireFileName: Family
QuestionText: ? [F1]
The next set of questions is about INJURIES AND POISONINGS. People can be injured or poisoned unexpectedly,
accidentally or on purpose. They may have hurt themselves or others may have caused them to be hurt.
DURING THE PAST THREE MONTHS, that is since [fill1: (date 91 days before today's date)], [fill2: did you/did
you or anyone in your family] have an injury where any part of [fill3: your/the] body was hurt, for example, with a
[fill4: (random set of injury examples)]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in WFINJ3M and goto TFINJ3M; else, goto WFINJ3M]
Question ID: FIJ.012_00.000 Instrument Variable Name: WFINJ3M QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who was this?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one person was injured during the past 3 months
SkipInstructions: <R,D> [goto FPOI3M]
else, goto TFINJ3M
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 2 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.014_00.000 Instrument Variable Name: TFINJ3M QuestionnaireFileName: Family
QuestionText: ? [F1]
DURING THE PAST THREE MONTHS, how many different times [fill: were you/was ALIAS] injured?
01-91 1-91 times
97 Refused
99 Don't know
UniverseText: All persons injured during the past 3 months
SkipInstructions: <1-10,D> [goto MFINJ3M]
<R> [goto TFINJ3M for the next person with a reported injury episode; if no more persons with an injury
episode, goto FPOI3M]
<11-91> [goto ERR_TFINJ3M]
Soft Edit: ERR_TFINJ3M
* ^TFINJ3M is unusually high. Please verify.
<Suppress> [goto MFINJ3M]
<Close> [reset TFINJ3M for new entry]
<Goto> [reset TFINJ3M for new entry]
Question ID: FIJ.016_00.000 Instrument Variable Name: MFINJ3M QuestionnaireFileName: Family
QuestionText: ? [F1]
Did [fill1: you /ALIAS] talk to or see a medical professional about [fill2: any of these
injuries/this injury/your injury or injuries/his injury or injuries/her injury or injuries]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons with at least one or an unknown number of injury episodes during the past 3 months
SkipInstructions: <1> [if TFINJ3M eq 1, fill "1" in MTFINJ3M and goto IPDATEM; else, goto MTFINJ3M]
<2,R,D> [goto TFINJ3M for the next person with a reported injury episode; if no more persons with an injury
episode, goto FPOI3M]
Page 3 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.018_00.000 Instrument Variable Name: MTFINJ3M QuestionnaireFileName: Family
QuestionText: ? [F1]
Of [fill1: the ^TFINJ3M/all the] times that [fill2: you were/ALIAS was] injured, how many of
those times was the injury serious enough that a medical professional was consulted?
01-91 1-91 times
97 Refused
99 Don't know
UniverseText: All persons who consulted a medical professional for their injury episode(s)
SkipInstructions: <1-91> [If MTFINJ3M gt TFINJ3M, goto ERR1_MTFINJ3M; else, if MTFINJ3M gt 3 and TFINJ3M eq D, goto
ERR2_MTFINJ3M; else, goto IPDATEM]
<R,D> [goto TFINJ3M for the next person with a reported injury episode; if no more persons with an injury
episode, goto FPOI3M]
Hard Edit: ERR1_MTFINJ3M
[If (MTIFNJ3M gt TFINJ3M), display ERR1_MTFINJ3M]:
[^MTFINJ3M] is greater than the total number of times you said [you were/ALIAS was] injured, which is
[^TFINJ3M]. For this question, we are asking about the number of times [you were/ALIAS was] injured and a
medical professional was consulted. For example, if you were injured three different times but only sought
medical advice or treatment for one of those times, the answer would be one, even if you saw or talked to a
trained medical professional more than once about that injury event.
Goto
Close
Soft Edit: ERR2_MTFINJ3M
[If (TFINJ3M = 99 and MTFINJ3M gt 3), display ERR2_MTFINJ3M]:
^MTFINJ3M is an unusually high number of injuries for which a medical professional was consulted. Please
verify.
*Read if necessary.
For this question, we are asking about the number of times [you were/ALIAS was] injured and a medical
professional was consulted. For example, if you were injured three different times, but only sought medical
advice or treatment for one of those times, the answer would be one, even if you saw or talked to a trained
medical professional more than once about that injury event.
Suppress
Goto
Close
Page 4 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.020_00.000 Instrument Variable Name: FPOI3M QuestionnaireFileName: Family
QuestionText: ? [F1]
DURING THE PAST THREE MONTHS, that is since [fill1: (date 91 days before today's date)], [fill2: were you/
were you or anyone in your family] poisoned by swallowing or breathing in a harmful substance such as bleach,
carbon monoxide, or too many pills or drugs? Do not include food poisoning, sun poisoning, or poison ivy rashes.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if single-person family, store person number in WFPOI3M and goto TFPOI3M; else,
goto WFPOI3M]
<2,DK,R> [goto next section]
Question ID: FIJ.022_00.000 Instrument Variable Name: WFPOI3M QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who was this?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one person was poisoned during the past 3 months
SkipInstructions: <1-25> [All family members. Avoid duplicate; goto TFPOI3M]
<DK,R> [goto next section]
Page 5 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.024_00.000 Instrument Variable Name: TFPOI3M QuestionnaireFileName: Family
QuestionText: ? [F1]
DURING THE PAST THREE MONTHS, how many different times [fill: were you/was ALIAS] poisoned? Do not
include food poisoning, sun poisoning, or poison ivy rashes.
01-91 1-91 times
97 Refused
99 Don't know
UniverseText: All persons poisoned during the past 3 months
SkipInstructions: <01-10, DK> [goto MFPOI3M]
<R> [goto TFPOI3M for next person with reported poisoning; if
no more persons with a poisoning, goto next section]
<11-91> [goto ERR_TFPOI3M]
Soft Edit: ERR_TFPOI3M
[If TFPOI3M gt 10, display ERR_TFPOI3M]
* ^TFPOI3M is unusually high. Please verify.
<Suppress> [goto MFPOI3M]
<Close> [goto TFPOI3M for new entry]
<Goto> [goto TFPOI3M for new entry]
Question ID: FIJ.026_00.000 Instrument Variable Name: MFPOI3M QuestionnaireFileName: Family
QuestionText: ? [F1]
Did [fill1: you /ALIAS] talk to or see a medical professional about [fill2: any of these
poisonings/this poisoning/your poisoning or poisonings/his poisoning or poisonings/her poisoning or
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons with at least one or an unknown number of poisoning episodes during the past 3 months
SkipInstructions: <1> [if TFPOI3M eq 1, fill "1" in MTFPOI3M and goto IPDATEM; else goto MTFPOI3M]
<2,DK,R> [goto TFPOI3M for next person with reported poisoning; if no more persons with a poisoning,
goto next section]
Page 6 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.028_00.000 Instrument Variable Name: MTFPOI3M QuestionnaireFileName: Family
QuestionText: ? [F1]
Of [fill1: the ^TFPOI3M/all the] times that [fill2: you were/ALIAS was] poisoned, how many of
those times was the poisoning serious enough that a medical professional was consulted?
01-91 1-91 times
97 Refused
99 Don't know
UniverseText: All persons who consulted a medical professional for their poisoning episode(s)
SkipInstructions: <01-91> [If MTFPOI3M gt TFPOI3M, goto ERR1_MTFPOI3M; else, goto IPDATEM]
<DK, R> [goto TFPOI3M for next person with reported poisoning; if no more persons with a
poisoning, goto next section]
If ((MTFPOI3M gt TFPOI3M) or (TFPOI3M eq DK and MTFPOI3M gt 3)), display ERR_MTFPOI3M]:
Hard Edit: ERR1_MTFPOI3M
[If (MTFPOI3M gt TFPOI3M), display ERR1_MTFPOI3M]:
[^MTFPOI3M] is greater than the total number of times you said [you were/ALIAS was] poisoned, which is
[^TFPOI3M]. For this question, we are asking about the number of times [you were/ALIAS was] poisoned
and a medical professional was consulted. For example, if you were poisoned three different times but only
sought medical advice or treatment for one of those times, the answer would be one, even if you saw or talked
to a trained medical professional more than once about that poisoning event.
<Close> [goto MTFPOI3M for new entry]
<Goto> [goto TFPOI3M or MTFPOI3M for new entry]
Soft Edit: ERR2_MTFPOI3M
[If TFPOI3M = 99 and MTFPOI3M gt 3), display ERR2_MTFINJ3M]:
* ^MTFINJ3M is an unusually high number.
For this question, we are asking about the number of times [you were/ALIAS was]
poisoned and a medical professional was consulted. For example, if you were poisoned three different times
but only sought medical advice or treatment for one of those times, the answer would be one, even if you saw
or talked to a trained medical professional more than once about that poisoning event.
Suppress
Goto
Close
Page 7 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.050_01.000 Instrument Variable Name: IPDATEM QuestionnaireFileName: Family
QuestionText: 1 of 3
* Please hand the calendar card to the respondent.
{if only 1 injury/poisoning episode for the person}
When did [fill1: your/ALIAS’s] [fill2: injury/poisoning] happen for which a medical professional was consulted?
{first of multiple injury/poisoning episodes for the person}
Now I’m going to ask a few questions about the [fill3: ^MTFINJ3M/^MTFPOI3M] times [fill4: you were/ALIAS
was] [fill5: injured/poisoned] for which a medical professional was consulted. Starting with the most recent time,
when did this [fill2: injury/poisoning] happen?
{second plus of multiple injury/poisoning episodes for the person}
You just told me about [fill1: your/ALIAS’s] [fill6: (month, day of previous event)] [fill7:most recent/second most
recent/third most recent/fourth most recent][fill2: injury/poisoning]. What was the date of the [fill2:
injury/poisoning] before that for which a medical professional was consulted?
* Enter month.
01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
97 Refused
99 Don't know
UniverseText: All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions: <1-12> [goto IPDATED]
<R> [goto IPHOW]
<D> [goto IPDATENO]
Page 8 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.050_02.000 Instrument Variable Name: IPDATED QuestionnaireFileName: Family
QuestionText: 2 of 3
* Enter day.
01-31 1-31
97 Refused
99 Don't know
UniverseText: All injury/poisoning episodes where a valid month of episode was entered
SkipInstructions: <1-31> [goto IPDATEY]
<R> [goto IPHOW]
<D> [goto IPDATEMT]
Hard Edit: ERR_IPDATED
[fill1: IPDATED] is not a valid day for [fill2: IPDATEM ].
<Close> [reset IPDATED for new entry]
<Goto> [reset IPDATED for new entry]
Page 9 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.050_03.000 Instrument Variable Name: IPDATEY QuestionnaireFileName: Family
QuestionText: 3 of 3
* Enter year.
Year Year
9997 Refused
9999 Don't know
UniverseText: All injury/poisoning episodes where a valid day of episode was entered
SkipInstructions: if IPDATEM, IPDATED and IPDATEY result in a future date; goto ERR_IPDATEY; else, if IPDATEM,
IPDATED and IPDATEY result in a date prior to the start date of the 91 day reference period, goto
ERR1_IPDATEY; else, goto IPHOW
Hard Edit: ERR_IPDATEY
* Future date invalid.
* Please correct.
<Close> [reset IPDATED for new entry]
<Goto> [reset IPDATED for new entry]
Soft Edit: ERR1_IPDATEY
* The reported date, [^IPDATEM(text)^IPDATED(numeric)^IPDATEY(4-digit year)], falls outside the
reference period beginning [fill date used in FIJ.010].
*Please verify the date and make any corrections.
ERR2_IPDATEY
*The reported date, [^IPDATEM(text)^IPDATED(numeric)^IPDATEY(4-digit year)], falls outside the
reference period beginning [fill date used in FIJ.010]. NOTE: The start of the reference period falls in the
[beginning/middle/end] of [month used in FIJ.010].
*Please verify the date and make any corrections.
ERR3_IPDATEY
* The reported date, [^IPDATEM(text)^IPDATEY(4-digit year)], falls outside the reference period beginning
[fill date used in FIJ.010].
*Please verify the date and make any corrections.
Page 10 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.051_01.000 Instrument Variable Name: IPDATENO QuestionnaireFileName: Family
QuestionText: 1 of 2
Can you tell me approximately how long ago [fill1: your/ALIAS’s] [fill2: injury/poisoning] happened?
*Enter number for time since event.
001-096 1-96
997 Refused
999 Don't know
UniverseText: All injury/poisoning episodes where don't know was entered for month of episode
SkipInstructions: <1-91> [goto IPDATETP]
<R,D> [goto IPHOW]
Question ID: FIJ.051_02.000 Instrument Variable Name: IPDATETP QuestionnaireFileName: Family
QuestionText: 2 of 2
*Enter number for time period since event.
^IPDATENO…
1 Days
2 Weeks
3 Months
7 Refused
9 Don't know
UniverseText: All injury/poisoning episodes where don't know was entered for month of episode and 1-91 was entered for
the "number" part of this two-part question
SkipInstructions: goto IPHOW
Hard Edit: If IPDATENO GT 91 days (1) or
IPDATENO GT 13 weeks (2) or
IPDATENO GT 4 months (3) then goto ERR_IPDATETP
ERR_IPDATETP
default Blaise message for now "Out of range"
Soft Edit: ERR1_IPDATETP
*The approximate date falls outside the reference period beginning [fill date used in FIJ.010].
*Please verify and make any corrections.
Page 11 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.052_00.000 Instrument Variable Name: IPDATEMT QuestionnaireFileName: Family
QuestionText: (book) F3 ? [F1]
Was this in the beginning of [fill: ^IPDATEM (text)], the middle of [fill: ^IPDATEM (text)], or the end of [fill:
^IPDATEM (text)]?
1 Beginning
2 Middle
3 End
7 Refused
9 Don't know
UniverseText: All injury/poisoning episodes where don't know was entered for day of episode
SkipInstructions: goto IPHOW
Question ID: FIJ.060_00.000 Instrument Variable Name: IPHOW QuestionnaireFileName: Family
QuestionText: ? [F1]
[fill1: How did [fill2: your/ALIAS’s] [fill3: injury/poisoning] on [fill4: ^IPDATEM ^IPDATED (starting with
most recent if multiple)] happen?/How did this [fill3: injury/poisoning] happen?] Please describe fully the
circumstances or events leading to the [fill3: injury/poisoning], and any objects, substances, or other people
involved.
* Enter the verbatim response, probing for as much detail as possible, including specifically what the person was
doing at the time and all circumstances surrounding the event. Record all volunteered information.
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions: <verbatim> [if an injury episode, goto ICAUS; else, if a poisoning episode, goto PPCC]
<R> [if an injury episode, fill "R" in ICAUS and goto IJBODY; else, if a poisoning episode, goto PPCC]
<D> [if an injury episode, fill "D" in ICAUS and goto IJBODY; else, if a poisoning episode, goto PPCC]
Page 12 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.065_00.000 Instrument Variable Name: ICAUS QuestionnaireFileName: Family
QuestionText: ? [F1]
* Do not read.
* Enter the number which best describes the cause of the person’s injury from the list below.
01 In a motor vehicle
02 On a bike, scooter, skateboard, skates, skis, horse, etc.
03 Pedestrian who was struck by a vehicle such as a car or bicycle
04 In a boat, train, or plane
05 Fall
06 Burned or scalded by substances such as hot objects or liquids, fire, or chemicals
07 Other
97 Refused
99 Don't know
UniverseText: All injury episodes for which a medical professional was consulted and don't know or refused was not entered
at IPHOW
SkipInstructions: goto IJBODY
Page 13 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.070_00.000 Instrument Variable Name: IJBODY QuestionnaireFileName: Family
QuestionText: (book) F4
* Enter up to 4 responses, separate with commas.
* Ask or verify.
In this injury, what parts of [fill: your/ALIAS’s] body were hurt?
01 Ankle
02 Back
03 Buttocks
04 Chest
05 Ear
06 Elbow
07 Eye
08 Face
09 Finger/thumb
10 Foot
11 Forearm
12 Groin
13 Hand
14 Head (not face)
15 Hip
16 Jaw
17 Knee
18 Lower leg
19 Mouth
20 Neck
21 Nose
22 Shoulder
23 Stomach
24 Teeth
25 Thigh
26 Toe
27 Upper arm
28 Wrist
29 Other, specify
97 Refused
99 Don't know
UniverseText: All injury episodes for which a medical professional was consulted
SkipInstructions: <1-28> [goto IJTYPE1]
<29> [goto IJBODYOS]
<R,D> [goto IPEV]
Page 14 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.071_00.000 Instrument Variable Name: IJBODYOS QuestionnaireFileName: Family
QuestionText: *Read if necessary.
What other parts of the body were hurt?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All injury episodes where some "other" part of the body was hurt
SkipInstructions: goto IJTYPE1
Question ID: FIJ.072_00.000 Instrument Variable Name: IJTYPE1 QuestionnaireFileName: Family
QuestionText: (book) F5
*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill1: your/ALIAS’s] [fill2: first entry--^IJBODY (text) or ^IJBODYOS] hurt?
01 Broken bone or fracture
02 Sprain, strain, or twist
03 Cut
04 Scrape
05 Bruise
06 Burn
07 Insect bite
08 Animal bite
09 Other, specify
97 Refused
99 Don't know
UniverseText: All injury episodes where at least one part of the body was hurt
SkipInstructions: <1-8,D> [goto IJTYPE2 for next body part entered at IJBODY; if no more body parts, goto IPEV]
<9> [goto IJTYP1OS]
<R> [goto IPEV]
Page 15 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.073_00.000 Instrument Variable Name: IJTYP1OS QuestionnaireFileName: Family
QuestionText: ? [F1]
* Read if necessary.
How was [fill1: your/ALIAS’s] [fill2: first entry -- ^IJBODY (text) or ^IJBODYOS] hurt?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All injury episodes where the first body part was hurt in some "other" way
SkipInstructions: goto IJTYPE2 for next body part; if no more body parts, goto IPEV
Question ID: FIJ.074_00.000 Instrument Variable Name: IJTYPE2 QuestionnaireFileName: Family
QuestionText: (book) F5
*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill1: your/ALIAS’s] [fill2: second entry--^IJBODY (text) or ^IJBODYOS] hurt?
01 Broken bone or fracture
02 Sprain, strain, or twist
03 Cut
04 Scrape
05 Bruise
06 Burn
07 Insect bite
08 Animal bite
09 Other, specify
97 Refused
99 Don't know
UniverseText: All injury episodes where at least two body parts were hurt and the type of injury or don't know was entered
for the first body part at IJTYPE1
SkipInstructions: <1-8,D> [goto IJTYPE3 for next body part entered at IJBODY; if no more body parts, goto IPEV]
<9> [goto IJTYP2OS]
<R> [goto IPEV]
Page 16 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.075_00.000 Instrument Variable Name: IJTYP2OS QuestionnaireFileName: Family
QuestionText: * Read if necessary.
How else was [fill1: your/ALIAS’s] [fill2: second entry -- ^IJBODY (text) or ^IJBODYOS] hurt?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All injury episodes where the second body part was hurt in some "other" way
SkipInstructions: goto IJTYPE3 for next body part; if no more body parts, goto IPEV
Question ID: FIJ.076_00.000 Instrument Variable Name: IJTYPE3 QuestionnaireFileName: Family
QuestionText: (book) F5
*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill1: your/ALIAS’s] [fill2: third entry--^IJBODY (text) or ^IJBODYOS] hurt?
01 Broken bone or fracture
02 Sprain, strain, or twist
03 Cut
04 Scrape
05 Bruise
06 Burn
07 Insect bite
08 Animal bite
09 Other, specify
97 Refused
99 Don't know
UniverseText: All injury episodes where at least three body parts were hurt and type of injury or don't know was entered for
the second body part at IJTYPE2
SkipInstructions: <1-8,D> [goto IJTYPE4 for next body part entered at IJBODY; if no more body parts, goto IPEV]
<9> [goto IJTYP3OS]
<R> [goto IPEV]
Page 17 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.077_00.000 Instrument Variable Name: IJTYP3OS QuestionnaireFileName: Family
QuestionText: * Read if necessary.
How else was [fill1: your/ALIAS’s] [fill2: third entry -- ^IJBODY (text) or ^IJBODYOS] hurt?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All injury episodes where the third body part was hurt in some "other" way
SkipInstructions: goto IJTYPE4 for next body part; if no more body parts, goto IPEV
Question ID: FIJ.078_00.000 Instrument Variable Name: IJTYPE4 QuestionnaireFileName: Family
QuestionText: (book) F5
*Enter up to 2 responses, separate with a comma.
* Ask or verify.
In what way was [fill1: your/ALIAS’s] [fill2: fourth entry--^IJBODY (text) or ^IJBODYOS] hurt?
01 Broken bone or fracture
02 Sprain, strain, or twist
03 Cut
04 Scrape
05 Bruise
06 Burn
07 Insect bite
08 Animal bite
09 Other, specify
97 Refused
99 Don't know
UniverseText: All injury episodes where four body parts were hurt and type of injury or don't know was entered for the third
body part at IJTYPE3
SkipInstructions: <1-8,R,D> [goto IPEV]
<9> [goto IJTYP4OS]
Page 18 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.079_00.000 Instrument Variable Name: IJTYP4OS QuestionnaireFileName: Family
QuestionText: * Read if necessary.
How else was [fill1: your/ALIAS’s] [fill2: fourth entry -- ^IJBODY (text) or ^IJBODYOS] hurt?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All injury episodes where the fourth body part was hurt in some "other" way
SkipInstructions: if a poisoning episode, goto PPCC; else, goto IPEV
Question ID: FIJ.080_01.000 Instrument Variable Name: PPCC QuestionnaireFileName: Family
QuestionText: Did [fill: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this poisoning from..
A phone call to a poison control center?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All poisoning episodes for which a medical professional was consulted
SkipInstructions: <1,2,D> [goto IPEV]
<R> [goto IPHOSP]
Page 19 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.080_02.000 Instrument Variable Name: IPEV QuestionnaireFileName: Family
QuestionText: * Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
An emergency vehicle, such as an ambulance or fire truck
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions: <1,2,D> [goto IPER]
<R> [goto IPHOSP]
Question ID: FIJ.080_03.000 Instrument Variable Name: IPER QuestionnaireFileName: Family
QuestionText: * Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
A visit to an emergency room
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions: <1,2,D> [goto IPDO]
<R> [goto IPHOSP]
Page 20 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.080_04.000 Instrument Variable Name: IPDO QuestionnaireFileName: Family
QuestionText: ? [F1]
* Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
A visit to a doctor’s office or other health clinic
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions: <1,2,D> [goto IPPCHCP]
<R> [goto IPHOSP]
Question ID: FIJ.080_05.000 Instrument Variable Name: IPPCHCP QuestionnaireFileName: Family
QuestionText: ? [F1]
* Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
A phone call to a doctor, nurse, or other health care professional
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions: <1,2,D> [goto IPOTH]
<R> [goto IPHOSP]
Page 21 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.080_06.000 Instrument Variable Name: IPOTH QuestionnaireFileName: Family
QuestionText: * Read lead-in if necessary.
Did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
Any place else?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions: <1> [goto IPOTHOS]
if [MTFINJ3M= 01-91 and IPEV=2] goto IPVER
<2> [if poisoning and episode and PPCC eq 2 and IPEV eq 2 and IPER eq 2 and IPDO eq 2 and IPPCHCP eq
2, goto IPVER; else if an injury episode and IPEV eq 2 and IPER eq 2 and IPDO eq 2 and IPPCHCP eq 2,
goto IPVER; else goto IPHOSP]
<R,D> [goto IPHOSP]
Question ID: FIJ.081_00.000 Instrument Variable Name: IPOTHOS QuestionnaireFileName: Family
QuestionText: * Read lead-in if necessary.
Where else did [fill1: you/ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this [fill2:
injury/poisoning]?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All injury/poisoning episodes where medical advice, treatment, or follow-up care was received from some
"other" place
SkipInstructions: goto IPHOSP
Page 22 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.082_00.000 Instrument Variable Name: IPVER QuestionnaireFileName: Family
QuestionText: * Please verify.
[fill1: You/ALIAS] DID NOT receive any medical advice, treatment, or follow-up for this [fill2: injury/poisoning].
Is that correct?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All injury/poisoning episodes for which a medical professional was consulted, but no source of medical
advice, treatment, or follow-up care was selected
SkipInstructions: <1>[If the subject HAS more injury/poisoning episodes, then go to FIJ.050_1for that subject. If the subject
DOES NOT HAVE more injury/poisoning episodes, then go to FIJ.014/FIJ.024 for next person with an
injury/poisoning. If no more family members with an injury/poisoning, go to next section.]
<2> [if poisoning, goto PPCC for new entries; else if injury, goto IPEV for new entries]
Hard Edit: ERR_IPVER
Question ID: FIJ.090_00.000 Instrument Variable Name: IPHOSP QuestionnaireFileName: Family
QuestionText: ? [F1]
[fill1: Were you/Was ALIAS] hospitalized for at least one night as a result of this [fill2: injury/poisoning]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions: <1> [goto IPIHNO]
<2,R,D> [if an injury episode, goto IMTRAF; if a poisoning episode, goto PPOIS]
Page 23 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.091_00.000 Instrument Variable Name: IPIHNO QuestionnaireFileName: Family
QuestionText: ? [F1]
How many nights [fill: were you/was ALIAS] in the hospital?
* If still in hospital, ask how many nights up to today.
* Enter '95' for 95 or more nights.
01-94 1-94 nights
95 95+ nights
97 Refused
99 Don't know
UniverseText: All injury/poisoning episodes for which a medical professional was consulted and resulted in hospitalization
SkipInstructions: <1-60,R,D> [if ICAUS eq 1-3, goto IMTRAF; else, if ICAUS eq 4-7,R,D, goto IPWHAT; else, if ICAUS eq 5,
goto IFALL; if a poisoning episode, goto PPOIS]
<61-95> [goto ERR_IPIHNO]
Soft Edit: [if IPIHNO gt 60, display ERR_IPIHNO]
* ^IPIHNO is unusually high. Please verify.
Suppress
Goto
Close
<Supress> [if ICAUS eq 01 or 02 or 03, goto IMTRAF]
if ICAUS eq 04 or 06 or 07 or 97, or 99, goto IPWHAT]
if ICAUS eq 05, goto IFALL]]
<Close, Goto> [reset IPIHNO for new entry]
Question ID: FIJ.109_00.000 Instrument Variable Name: IMTRAF QuestionnaireFileName: Family
QuestionText: ? [F1]
* Ask or verify.
Did this accident occur on a public highway, street, or road?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All medically-consulted injury episodes that occurred while in a motor vehicle; on a bike, scooter,
skateboard, skates, skis, horse, etc.; or as a pedestrian who was struck by a vehicle such as a car or bicycle
SkipInstructions: goto IMVWHO
Page 24 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.110_00.000 Instrument Variable Name: IMVWHO QuestionnaireFileName: Family
QuestionText: *Read all categories.
* Ask or verify.
[fill: Were you/Was ALIAS] injured as:
* Read answer categories.
1 The driver of a motor vehicle
2 A passenger in a motor vehicle
3 A pedestrian
4 A bicycle rider or tricycle rider
5 The rider of a scooter, skateboard, skates, or other non-motorized vehicle
7 Refused
9 Don't know
UniverseText: All medically-consulted injury episodes that occurred while in a motor vehicle; on a bike, scooter,
skateboard, skates, skis, horse, etc.; or as a pedestrian who was struck by a vehicle such as a car or bicycle
SkipInstructions: <1,2> [goto IMVTYP]
<4,5> [goto IHELMT]
<3,R,D> [goto IPWHAT]
Question ID: FIJ.111_00.000 Instrument Variable Name: IMVTYP QuestionnaireFileName: Family
QuestionText: (book) F6 ? [F1]
* Ask or verify.
What type of vehicle [fill: were you/was ALIAS] in?
01 Passenger car
02 Passenger truck, such as a pickup truck, van, or SUV
03 Bus
04 Large commercial truck, such as a semi-truck, big rig, or 18 wheeler
05 Motorcycle (including mopeds and minibikes)
06 All terrain vehicle or ski/snow-mobile
07 Farm equipment (such as a tractor)
08 Industrial or construction vehicle
09 Other
97 Refused
99 Don't know
UniverseText: All medically-consulted injury episodes that occurred while a driver or passenger of a vehicle
SkipInstructions: <1,2,4> [goto ISBELT]
<5,6> [goto IHELMT]
<3,7,8,9,R,D> [goto IPWHAT]
Page 25 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.112_00.000 Instrument Variable Name: ISBELT QuestionnaireFileName: Family
QuestionText: ? [F1]
* Ask or verify.
[fill: Were you/Was ALIAS] restrained at the time of the accident?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All medically-consulted injury episodes that occurred while a driver or passenger of a car or truck
SkipInstructions: goto IPWHAT
Question ID: FIJ.113_00.000 Instrument Variable Name: IHELMT QuestionnaireFileName: Family
QuestionText: ? [F1]
* Ask or verify.
[fill: Were you/Was ALIAS] wearing a helmet at the time of the accident?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All medically-consulted injury episodes that occurred while riding a bicycle, tricycle, scooter, skateboard,
skates, or other nonmotorized vehicle; a motorcycle; or an all terrain vehicle or ski/snow-mobile
SkipInstructions: goto IPWHAT
Page 26 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.130_00.000 Instrument Variable Name: IFALL QuestionnaireFileName: Family
QuestionText: (book) F7
* Enter up to 2 responses, separate with a comma.
* Ask or verify.
How did [fill: you/ALIAS] fall? Anything else?
01 Stairs, steps, or escalator
02 Floor or level ground
03 Curb (including sidewalk)
04 Ladder or scaffolding
05 Playground equipment
06 Sports field, court, or rink
07 Building or other structure
08 Chair, bed, sofa, or other furniture
09 Bathtub, shower, toilet, or commode
10 Hole or other opening
11 Other
97 Refused
99 Don't know
UniverseText: All medically-consulted injury episodes that occurred due to a fall
SkipInstructions: goto IFALLWHY
Question ID: FIJ.131_00.000 Instrument Variable Name: IFALLWHY QuestionnaireFileName: Family
QuestionText: (book) F8
* Ask or verify.
What caused [fill: you/ALIAS] to fall?
1 Slipping or tripping
2 Jumping or diving
3 Bumping into an object or another person
4 Being shoved or pushed by another person
5 Losing balance or having dizziness (becoming faint or having a seizure)
6 Other
7 Refused
9 Don't know
UniverseText: All medically-consulted injury episodes that occurred due to a fall
SkipInstructions: goto IPWHAT
Page 27 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.140_00.000 Instrument Variable Name: PPOIS QuestionnaireFileName: Family
QuestionText: (book) F9 ? [F1]
* Ask or verify.
What did [fill: your/ALIAS’s] poisoning result from?
1 Swallowing a drug or medical substance mistakenly or in overdose
2 Swallowing or touching a harmful solid or liquid substance
3 Inhaling harmful gases or vapors
4 Eating a poisonous plant or other substance mistaken for food
5 Being bitten by a poisonous animal
6 Other, please specify
7 Refused
9 Don't know
UniverseText: All poisoning episodes for which a medical professional was consulted
SkipInstructions: <1-5,R,D> [goto IPWHAT]
<6> [goto PPOISOS]
Question ID: FIJ.141_00.000 Instrument Variable Name: PPOISOS QuestionnaireFileName: Family
QuestionText: * Read if necessary.
How did [fill: your/ALIAS’s] poisoning occur?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All medically-consulted poisoning episodes where the poisoning resulted from some "other" reason
SkipInstructions: goto IPWHAT
Page 28 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.150_00.000 Instrument Variable Name: IPWHAT QuestionnaireFileName: Family
QuestionText: (book) F10 ? [F1]
* Enter up to 2 responses, separate with a comma.
* Ask or verify.
What activity [fill1: were you/was ALIAS] involved in at the time of the [fill2: injury/poisoning]?
01 Driving or riding in a motor vehicle
02 Working at a paid job
03 Working around the house or yard
04 Attending school
05 Unpaid work (such as volunteer work)
06 Sports and exercise
07 Leisure activity (excluding sports)
08 Sleeping, resting, eating, or drinking
09 Cooking
10 Being cared for (hands-on care from other person)
11 Other, please specify
97 Refused
99 Don't know
UniverseText: All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions: <1-10,R,D> [goto IPWHER]
<11> [goto IPWHATOT]
Question ID: FIJ.151_00.000 Instrument Variable Name: IPWHATOT QuestionnaireFileName: Family
QuestionText: * Read if necessary.
What other activity [fill1: were you/was ALIAS] involved in at the time of the [fill2: injury/poisoning]?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All medically-consulted injury/poisoning episodes that occurred in some "other" place
SkipInstructions: goto IPWHER
Page 29 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.160_00.000 Instrument Variable Name: IPWHER QuestionnaireFileName: Family
QuestionText: (book) F11 ? [F1]
* Enter up to 2 responses, separate with a comma.
* Ask or verify.
Where [fill1: were you/was ALIAS] when the [fill2: injury/poisoning] happened?
01 Home (inside)
02 Home (outside)
03 School (not residential)
04 Child care center or preschool
05 Residential institution (excluding hospital)
06 Health care facility (including hospital)
07 Street or highway
08 Sidewalk
09 Parking lot
10 Sport facility, athletic field, or playground
11 Shopping center, restaurant, store, bank, gas station, or other place of business
12 Farm
13 Park or recreation area (include bike or jog path)
14 River, lake, stream, or ocean
15 Industrial or construction area
16 Other public building
17 Other
97 Refused
99 Don't know
UniverseText: All injury/poisoning episodes for which a medical professional was consulted
SkipInstructions: <01-17,R,DK> [If AGE lt 5 and person HAS more injury/poisoning episodes, goto IPDATEM
for that person; else if AGE lt 5 and person DOES NOT HAVE more
injury/poisoning episodes, goto TFINJ3M/TFPOI3M for next person with an
injury/poisoning; else if AGE lt 5 and no more family members with an
injury/poisoning, go to FPOI3M/next section;
Else [if AGE ge 13, goto IPEMP; else if AGE ge 5 and AGE le 12, goto IPSTU]
Page 30 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.170_00.000 Instrument Variable Name: IPEMP QuestionnaireFileName: Family
QuestionText: ? [F1]
At the time of this [fill1: injury/poisoning], [fill2: were you/was ALIAS] employed full-time, part-time, or not
1 Full-time
2 Part-time
3 Not employed
7 Refused
9 Don't know
UniverseText: All medically-consulted injury/poisoning episodes for persons 13 years of age or older
SkipInstructions: <1,2> [goto IPWKLS]
<3,R,D> [goto IPSTU]
Question ID: FIJ.171_00.000 Instrument Variable Name: IPWKLS QuestionnaireFileName: Family
QuestionText: As a result of this [fill1: injury/poisoning], how many days of work did [fill2: you/ALIAS] miss?
1 None
2 Less than one day
3 One to five days
4 Six or more days
7 Refused
9 Don't know
UniverseText: All medically-consulted injury/poisoning episodes for persons 13 years of age or older who were employed at
the time of the episode
SkipInstructions: goto IPSTU
Page 31 of 31
2011 NHIS Questionnaire Family
Injuries & Poisoning
Document Version Date: 19-Jun-12
Question ID: FIJ.180_00.000 Instrument Variable Name: IPSTU QuestionnaireFileName: Family
QuestionText: At the time of this [fill1: injury/poisoning], [fill2: were you/was ALIAS] a full-time student, part-time student or not
a student?
1 Full-time
2 Part-time
3 Not a student
7 Refused
9 Don't know
UniverseText: All medically-consulted injury/poisoning episodes for persons 5 years of age or older
SkipInstructions: <1,2> [goto IPSCLS]
<3,R,DK> [If person HAS more injury/poisoning episodes, goto IPDATEM for that person; else if person
DOES NOT HAVE more injury/poisoning episodes, goto TFINJ3M/TFPOI3M for next person with an
injury/poisoning; else if no more family members with an injury/poisoning, goto next section]
Question ID: FIJ.181_00.000 Instrument Variable Name: IPSCLS QuestionnaireFileName: Family
QuestionText: As a result of this [fill1: injury/poisoning], how many days of school did [fill2: you/ALIAS] miss?
1 None
2 Less than one day
3 One to five days
4 Six or more days
7 Refused
9 Don't know
UniverseText: All medically-consulted injury/poisoning episodes for persons 5 years of age or older who were students at
the time of the episode
SkipInstructions: <1-4,R,DK>[If person HAS more injury/poisoning episodes, goto IPDATEM for that person; else
if person DOES NOT HAVE more injury/poisoning episodes, goto
TFINJ3M/TFPOI3M for next person with an injury/poisoning; else if no more family
members with an injury/poisoning, goto next section]
Page 1 of 10
2011 NHIS Questionnaire Family
Family Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: FAU.010_00.00 Instrument Variable Name: FDMED12M QuestionnaireFileName: Family
QuestionText: ? [F1]
The following questions are about the use of health care. Do not include dental care.
DURING THE PAST 12 MONTHS, [fill: have you delayed seeking medical care/has medical care been delayed for
anyone in the family] because of worry about the cost?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PDMED12M and goto FNMED12M; else, goto
PDMED12M]
<2,R,D> [goto FNMED12M]
Question ID: FAU.020_00.00 Instrument Variable Name: PDMED12M QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
For which family member was medical care delayed?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one had medical care delayed due to worry about the cost
during the past 12 months
SkipInstructions: goto FNMED12M
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 2 of 10
2011 NHIS Questionnaire Family
Family Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: FAU.030_00.00 Instrument Variable Name: FNMED12M QuestionnaireFileName: Family
QuestionText: ? [F1]
DURING THE PAST 12 MONTHS, was there any time when [fill1: you/someone in the family] needed medical care,
but
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PNMED12M and goto FHOSPYR; else, goto
PNMED12M]
<2,R,D> [goto FHOSPYR]
Question ID: FAU.040_00.00 Instrument Variable Name: PNMED12M QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who didn't get needed care?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one didn't get medical care due to cost during the past 12
SkipInstructions: goto FHOSPYR
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 3 of 10
2011 NHIS Questionnaire Family
Family Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: FAU.050_00.00 Instrument Variable Name: FHOSPYR QuestionnaireFileName: Family
QuestionText: ?[F1]
[fill1: were you/Including all infants born in a hospital, has anyone in the family] been hospitalized OVERNIGHT in
the past 12 months? Do not include an overnight stay in the emergency room.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PHOSPYR and goto HOSPNO; else, goto
PHOSPYR]
Question ID: FAU.060_00.00 Instrument Variable Name: PHOSPYR QuestionnaireFileName: Family
QuestionText: *Ask or verify. Enter applicable line number(s), separate with commas.
Who was in a hospital overnight?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one was a patient overnight during the past 12 months
(excluding ER)
SkipInstructions: goto HOSPNO
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 4 of 10
2011 NHIS Questionnaire Family
Family Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: FAU.070_00.00 Instrument Variable Name: HOSPNO QuestionnaireFileName: Family
QuestionText: ? [F1]
How many different times did [fill: you/ALIAS] stay in any hospital overnight or longer DURING THE PAST 12
MONTHS?
001-365 1-365 times
997 Refused
999 Don't know
UniverseText: All persons who had an overnight hospital stay during the past 12 months (excluding ER)
SkipInstructions: <1-10> [goto HPNITE]
<11-365> [goto ERR_HOSPNO]
<R,D> [goto HPNITE]
Soft Edit: ERR_HOSPNO
* [fill: HOSPNO] is unusually high.
* Verify entry.
* Make corrections if necessary.
Question ID: FAU.110_00.00 Instrument Variable Name: HPNITE QuestionnaireFileName: Family
QuestionText: ? [F1]
Altogether how many nights [fill: were you/was ALIAS] in the hospital DURING THE PAST 12 MONTHS?
001-365 1-365 nights
997 Refused
999 Don't know
UniverseText: All persons who had an overnight hospital stay during the past 12 months (excluding ER)
SkipInstructions: <1-50,R,D> [goto next person selected at PHOSPYR; if no more persons, goto FHCM2W]
<51-365> [goto ERR1_HPNITE]
if HOSPNO gt HPNITE, goto ERR2_HPNITE
Soft Edit: ERR1_HPNITE
* [fill: HPNITE] is unusually high.
* Verify entry.
* Make corrections if necessary.
ERR2_HPNITE
* Do not read.
* [fill: HPNITE] night(s) is less than the total number of times in the hospital overnight.
* Please verify.
Note: If edit suppressed, store S in HPNITE_FLG
Page 5 of 10
2011 NHIS Questionnaire Family
Family Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: FAU.120_00.00 Instrument Variable Name: FHCHM2W QuestionnaireFileName: Family
QuestionText: ?[F1]
These next questions are about health care received DURING THE LAST 2 WEEKS. Include care from ALL types of
medical doctors, such as dermatologists, psychiatrists, ophthalmologists (AHF-thal-MOL-oh-jists), and general
practitioners. Also include care from OTHER health professionals such as nurses, physical therapists, and
chiropractors.
Do not include dental care. Do not include care while an overnight patient in a hospital.
DURING THE LAST 2 WEEKS, did [fill: you/anyone in the family] receive care
AT HOME from a nurse or other health care professional?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PHCHM2W and goto PHCHMN2W; else, goto
PHCHM2W]
<2,R,D> [goto FHCPH2W]
Question ID: FAU.130_00.00 Instrument Variable Name: PHCHM2W QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who received care at home?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one received care at home from a health care professional
during the past 2 weeks (excluding dental care)
SkipInstructions: goto PHCHMN2W
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 6 of 10
2011 NHIS Questionnaire Family
Family Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: FAU.140_00.00 Instrument Variable Name: PHCHMN2W QuestionnaireFileName: Family
QuestionText: How many home visits did [fill: you/ Alias] receive DURING THE LAST 2 WEEKS?
* Enter '50' for 50 or more visits.
01-50 1-50 home visits
97 Refused
99 Don't know
UniverseText: All persons who received care at home from a health care professional during the past 2 weeks (excluding
dental care)
SkipInstructions: <1-14,R,D> [repeat for all eligible persons, then goto FHCPH2W]
<15-50> [goto ERR_PHCPHMN2W]
Soft Edit: ERR_PHCHMN2W
* [fill: PHCHMN2W] is unusually high.
* Verify entry.
* DO NOT PROBE. Make corrections if necessary.
Question ID: FAU.150_00.00 Instrument Variable Name: FHCPH2W QuestionnaireFileName: Family
QuestionText: DURING THE LAST 2 WEEKS, did [fill: you/anyone in the family] get any medical advice or test results over the
PHONE from a doctor, nurse, or other health care professional?
Do not include phone calls to make appointments, for billing questions or for prescription refills.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PHCPH2W and goto PHCPHN2W; else, goto
PHCPH2W]
<2,R,D> [goto FHCDV2W]
Page 7 of 10
2011 NHIS Questionnaire Family
Family Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: FAU.160_00.00 Instrument Variable Name: PHCPH2W QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who was the phone call about?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one received medical advice or test results over the phone
during the past 2 weeks (excluding calls for appointments, billing questions, or prescription medicines)
SkipInstructions: goto PHCPHN2W
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Question ID: FAU.170_00.00 Instrument Variable Name: PHCPHN2W QuestionnaireFileName: Family
QuestionText: DURING THE LAST 2 WEEKS, how many telephone calls
[fill1: did you make?]
[fill2: were made about [fill: Alias]?
* Enter '50' for 50 or more phone calls.
01-50 1-50 calls
97 Refused
99 Don't know
UniverseText: All persons for whom medical advice or test results were received over the phone from a health care
professional during the past 2 weeks (excluding calls for appointments, billing questions, or prescription
SkipInstructions: <1-14,R,D> [repeat for all eligible persons, then goto FHCDV2W]
<15-50> [goto ERR_PHCPHN2W]
Soft Edit: ERR_PHCPHN2W
* [fill: PHCPHN2W] is unusually high.
* Verify that all calls were within the two week period.
* Make corrections if necessary.
Page 8 of 10
2011 NHIS Questionnaire Family
Family Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: FAU.180_00.00 Instrument Variable Name: FHCDV2W QuestionnaireFileName: Family
QuestionText: DURING THE LAST 2 WEEKS, did [fill1: you/anyone in the family] see a doctor or other health care professional at
a doctor's OFFICE, a clinic, an emergency room, or some other place?
[fill2: Do not include times during an overnight hospital stay.]
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PHCDV2W and goto PHCDVN2W; else, goto
PHCDV2W]
<2,R,D> [goto F10DVYR]
Question ID: FAU.190_00.00 Instrument Variable Name: PHCDV2W QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who received care?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one saw a health care professional in an office, clinic,
emergency room, or some other place during the past 2 weeks (excluding visits during overnight hospital
SkipInstructions: goto PHCDVN2W
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 9 of 10
2011 NHIS Questionnaire Family
Family Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: FAU.200_00.00 Instrument Variable Name: PHCDVN2W QuestionnaireFileName: Family
QuestionText: How many times did [fill: you/ Alias] visit a doctor or other health care professional DURING THE LAST 2
WEEKS?
01-50 1-50 times
97 Refused
99 Don't know
UniverseText: All persons who visited a health care professional during the past 2 weeks (excluding overnight hospital
SkipInstructions: <1-14,R,D> [repeat for all eligible persons, then goto F10DVYR]
<15-50> [goto ERR_PHCDVN2W]
Soft Edit: ERR_PHCDVN2W
* [fill: PHCDVN2W] is unusually high.
* Verify that all visits were within the two week reference period.
* Make corrections if necessary.
Question ID: FAU.210_00.00 Instrument Variable Name: F10DVYR QuestionnaireFileName: Family
QuestionText: DURING THE PAST 12 MONTHS did [fill: you/any member of the family] receive care from doctors or other health
care professionals 10 or more times? Do not include telephone calls.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in P10DVYR and goto FHICOV; else, goto
P10DVYR]
Page 10 of 10
2011 NHIS Questionnaire Family
Family Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: FAU.220_00.00 Instrument Variable Name: P10DVYR QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who received care 10 or more times?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one received care 10 or more times from a health care
professional during the past 12 months (excluding telephone calls)
SkipInstructions: goto FHICOV
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 1 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.050_00.000 Instrument Variable Name: FHICOV QuestionnaireFileName: Family
QuestionText: (book) F12 and (book) F14
The next questions are about health insurance. Include health insurance obtained through employment or purchased
directly as well as government programs like Medicare and Medicaid that provide Medical care or help pay medical
bills.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1,R,D> [goto HIKIND]
<2> [if AGE ge 65, goto MCAREPRB; else, goto MCAIDPRB]
Page 2 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.070_00.000 Instrument Variable Name: HIKIND QuestionnaireFileName: Family
QuestionText: (book) F12 and (book) F14 ? [F1]
What kind of health insurance or health care coverage [fill: do you/does ALIAS] have? INCLUDE those that pay for
only one type of service (nursing home care, accidents, or dental care). EXCLUDE private plans that only provide
extra cash while hospitalized.
* Enter all that apply, separate with commas.
01 Private health insurance
02 Medicare
03 Medi-Gap
04 Medicaid
05 SCHIP (CHIP/Children's Health Insurance Program)
06 Military health care (TRICARE/VA/CHAMP-VA)
07 Indian Health Service
08 State-sponsored health plan
09 Other government program
10 Single service plan (e.g., dental, vision, prescriptions)
11 No coverage of any type
97 Refused
99 Don't know
UniverseText: All persons in families where FHICOV= yes, don't know, or refused
SkipInstructions: <R,D> [goto HCSPFYR]
<1-10> [if AGE ge 65 and HIKIND ne 2, goto MCAREPRB; else, if HIKIND ne 10 goto SINCOV; else, goto
HICHANGE]
<11> [if HIKIND = 1-10, goto ERR_HIKIND; else, if AGE ge 65 goto MCAREPRB; else, goto MCAIDPRB]
Hard Edit: ERR_HIKIND:
* Cannot mark "No coverage of any kind" and another type.
* Please correct.
Question ID: FHI.072_00.000 Instrument Variable Name: MCAREPRB QuestionnaireFileName: Family
QuestionText: (book) F13
People covered by Medicare have a card that looks like this.
[fill: Are you/Is ALIAS] covered by Medicare?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons 65 years of age or older in families not covered by health insurance or Medicare was not selected
for those persons at HIKIND
SkipInstructions: if HIKIND ne 10, goto SINCOV; else, goto HICHANGE
Page 3 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.073_00.000 Instrument Variable Name: MCAIDPRB QuestionnaireFileName: Family
QuestionText: (book F14)
* Refer to flashcard F14 for state Medicaid names.
There is a program called Medicaid that pays for health care for persons in need. In this State it is also called (* fill
State name). [fill: Are you/Is ALIAS] covered by Medicaid?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons less than 65 years of age with no insurance coverage of any type
SkipInstructions: goto SINCOV
Question ID: FHI.074_00.000 Instrument Variable Name: SINCOV QuestionnaireFileName: Family
QuestionText: [fill: Do you/Does ALIAS] have any type of insurance that pays for only one type of service such as dental, vision, or
prescriptions?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons in families not covered by health insurance or single service plan was not selected for those
persons at HIKIND
SkipInstructions: goto HICHANGE
Page 4 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.075_00.000 Instrument Variable Name: HICHANGE QuestionnaireFileName: Family
QuestionText: I have recorded [fill1: you are/ALIAS is] [fill 2: covered by:
fill3: ^HIKIND] / not covered by health insurance.]
Is this correct?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons
SkipInstructions: <1,R,D> [repeat for all eligible persons, then goto MCPART]
<2> [goto ERR_HICHANGE]
Hard Edit: ERR_HICHANGE
*Press enter to go back to HIKIND and update coverage.
Question ID: FHI.090_00.000 Instrument Variable Name: MCPART QuestionnaireFileName: Family
QuestionText: {if subject ne respondent}:
Earlier I recorded that ALIAS is covered by Medicare. May I please see ALIAS’s Medicare card to determine the type
of coverage?
{if subject eq respondent}:
* Read if necessary.
What type of Medicare coverage do you have? Is it Part A - hospital insurance, Part B - medical insurance, or both?
* Fill in appropriate coverage type below.
1 Part A - Hospital only
2 Part B - Medical only
3 Both Part A and Part B
7 Refused
9 Don't know
UniverseText: All persons with Medicare
SkipInstructions: <1-3> [goto MCCARD]
<R,D> [prefill MCCARD with a "2" and goto MCCHOICE]
Page 5 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.092_00.000 Instrument Variable Name: MCCARD QuestionnaireFileName: Family
QuestionText: * Do not read. Was the type of coverage obtained from a Medicare card or some other form of documentation?
1 Yes
2 No
UniverseText: All persons with Part A Medicare coverage, Part B Medicare coverage, or both
SkipInstructions: if MCPART = 1, goto MCPARTD; else, goto MCCHOICE
Question ID: FHI.095_00.000 Instrument Variable Name: MCCHOICE QuestionnaireFileName: Family
QuestionText: ? [F1]
Medicare Advantage is the new name for Medicare Plus Choice plans. [fill: Are you/Is ALIAS] enrolled in a
Medicare Advantage plan?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for
Part B coverage
SkipInstructions: goto MCHMO
Question ID: FHI.100_00.000 Instrument Variable Name: MCHMO QuestionnaireFileName: Family
QuestionText: ? [F1]
[fill: Are you/Is ALIAS] under a Medicare managed care arrangement, such as an HMO, that is, a Health Maintenance
Organization? (With an HMO, you must generally receive care from HMO doctors, otherwise the expense is not
covered unless you were referred by the HMO or there was a medical emergency).
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for
Part B coverage
SkipInstructions: <1> [goto MCANAME]
<2,R,D> [if MCCHOICE=1, goto MCANAME; else if MCCHOICE=2,R,D, goto MCREF]
Page 6 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.112_00.000 Instrument Variable Name: MCANAME QuestionnaireFileName: Family
QuestionText: ? [F1]
What is the name of [fill 1: your/ALIAS’s] Medicare Advantage or Medicare HMO plan?
* Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons that had either a Medicare Advantage plan or a Medicare HMO plan
SkipInstructions: <allow 80,R,D> goto MCPREM
Question ID: FHI.113_00.000 Instrument Variable Name: MCPREM QuestionnaireFileName: Family
QuestionText: Besides [fill 1: your/ALIAS’s] Medicare Part B payment, [fill 2: are you/is ALIAS] paying a premium for [fill 3:
your/his/her] Medicare Advantage or Medicare HMO plan?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons that had either a Medicare Advantage plan or a Medicare HMO plan
SkipInstructions: <1,2,R,D> goto MCREF
Question ID: FHI.114_00.000 Instrument Variable Name: MCREF QuestionnaireFileName: Family
QuestionText: ? [F1]
Under [fill1: your/ALIAS's] Medicare plan, if [fill2: you need/he needs/she needs] to go to a different doctor or place
for special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for
Part B coverage
SkipInstructions: <1,2,R,D> goto MCPARTD
Page 7 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.118_00.000 Instrument Variable Name: MCPARTD QuestionnaireFileName: Family
QuestionText: [Fill 1: Are you/Is ALIAS] enrolled in Medicare Part D, also known as the Medicare Prescription Drug Plan?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons with Medicare
SkipInstructions: <1,2,7,9> [goto MCPART for next person with Medicare; else goto MACHMD]
Question ID: FHI.120_00.000 Instrument Variable Name: MACHMD QuestionnaireFileName: Family
QuestionText: (book F14) ? [F1]
* Refer to flashcard F14 for state Medicaid names.
The next questions are about Medicaid coverage. In this State it is also called (* fill State Name). [fill1: You
are/ALIAS is] listed as having Medicaid coverage. Can [fill2: you/ALIAS] go to ANY doctor who will accept
Medicaid or MUST [fill3: you/he/she] choose from a book or list of doctors or is a doctor assigned?
1 Any doctor
2 Select from book/list
3 Doctor is assigned
7 Refused
9 Don't know
UniverseText: All persons with Medicaid
SkipInstructions: <1,R,D> [goto MAPCMD]
<2> [goto MACHMD1]
<3> [goto MACHMD2]
Page 8 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.130_00.000 Instrument Variable Name: MACHMD1 QuestionnaireFileName: Family
QuestionText: * Ask or verify.
What is the name of the health plan that provided the book or list?
*Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons with Medicaid who must select a doctor from a book or list of doctors
SkipInstructions: goto MANAM
Question ID: FHI.131_00.000 Instrument Variable Name: MACHMD2 QuestionnaireFileName: Family
QuestionText: * Ask or verify.
What is the name of the health plan that assigned the doctor?
*Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons with Medicaid for whom a doctor is assigned
SkipInstructions: goto MANAM
Question ID: FHI.132_00.000 Instrument Variable Name: MANAM QuestionnaireFileName: Family
QuestionText: ? [F1]
* Do not read. Was the Health Plan name obtained from a Health Plan Card or something with the Health Plan name
on it?
1 Yes
2 No
UniverseText: All persons with Medicaid who must select a doctor from a book or list or for whom a doctor is assigned
SkipInstructions: goto MAPCMD
Page 9 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.140_00.000 Instrument Variable Name: MAPCMD QuestionnaireFileName: Family
QuestionText: [fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic
which [fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care
from a specialist [fill4: you were/he was/she was] referred to.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons with Medicaid
SkipInstructions: goto MAREF
Question ID: FHI.150_00.000 Instrument Variable Name: MAREF QuestionnaireFileName: Family
QuestionText: ? [F1]
Under [fill1: your/ALIAS's] Medicaid plan, if [fill2: you need/he needs/she needs] to go to a different doctor or place
for special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons with Medicaid
SkipInstructions: goto MACHMD for the next person with Medicaid; else, goto SSTYPE2
Page 10 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.156_00.000 Instrument Variable Name: SSTYPE2 QuestionnaireFileName: Family
QuestionText: (book) F15
* Enter all that apply, separate with commas.
You mentioned that [fill1: you have/ALIAS has] a single-service plan - that is, an insurance plan that provides one
specific type of coverage. What type of service or care does [fill2: your/ALIAS's] single service plan or plans pay
01 Accidents
02 AIDS care
03 Cancer treatment
04 Catastrophic care
05 Dental care
06 Disability insurance
07 Hospice care
08 Hospitalization only
09 Long-term care
10 Prescriptions
11 Vision care
12 Other (specify)
97 Refused
99 Don't know
UniverseText: All persons with single service plans
SkipInstructions: <1-11,R,D> [repeat for all eligible persons, then goto FHICCI6]
<12> [goto SSOTHER]
Question ID: FHI.157_00.000 Instrument Variable Name: SSOTHER QuestionnaireFileName: Family
QuestionText: * Other type of single-service plan
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons with an "other" single service plan
SkipInstructions: goto SSTYPE2 for the next person with a single service plan; else, goto FHICCI6
Page 11 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.158_00.000 Instrument Variable Name: FHICCI6 QuestionnaireFileName: Family
QuestionText: The next questions are about private health insurance plans [fill1: /including Medi-Gap]. These plans can be
obtained through work, purchased directly, or through a state or local government program or community program.
[fill2: We have the following persons listed as being covered by such plans:
* Read names.
(display roster of eligible persons)]
* Enter 1 to continue
1 Continue
UniverseText: All families with at least one person covered by private health insurance
SkipInstructions: goto HIPNAM1
Question ID: FHI.160_00.000 Instrument Variable Name: HIPNAM1 QuestionnaireFileName: Family
QuestionText: It is important that we record the complete and accurate name of each health insurance plan. What is the COMPLETE
name of the first plan?
Do NOT include plans that only provide extra cash while in the hospital or plans that pay for only one type of
service, such as nursing home care, accidents, or dental care.
* Read if necessary: Do you have your health plan card or something with the plan name on it?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All families with at least one person covered by private health insurance
SkipInstructions: <verbatim> [goto PCARD1]
<R,D> [prefill PCARD1 with a "2" and goto HIPNAM1B]
Page 12 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.160_01.000 Instrument Variable Name: PCARD1 QuestionnaireFileName: Family
QuestionText: * Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on
1 Yes
2 No
UniverseText: All private health insurance plans where the plan name was entered at HIPNAM1
SkipInstructions: goto HIPNAM1B
Question ID: FHI.170_00.000 Instrument Variable Name: HIPNAM1B QuestionnaireFileName: Family
QuestionText:
* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by this plan?
* Indicate each family member covered by this plan.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with a private health insurance plan and the plan name, refused, or don't know was entered at
HIPNAM1
SkipInstructions: <R,D> [if HIPNAM1= R or D, goto STNAME]
goto MORPLAN
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 13 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.171_00.000 Instrument Variable Name: MORPLAN QuestionnaireFileName: Family
QuestionText: * Ask if necessary
Are there any more private health insurance plans?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families where a private health insurance plan name was entered at HIPNAM1 or a person number was
entered at HIPNAM1B
SkipInstructions: <1> [goto HIPNAM2]
<2,R,D> [if no persons selected at HIPNAM1B, goto FHICCI8; else, if persons selected at HIPNAM1B, but
not all persons with HIKIND = 1 or 3 selected at HIPNAM1B, goto HIVER1]
Question ID: FHI.172_00.000 Instrument Variable Name: HIPNAM2 QuestionnaireFileName: Family
QuestionText: What is the name of the next plan?
*Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All families with a second private health insurance plan
SkipInstructions: <verbatim> [goto PCARD2]
<R,D> [prefill PCARD2 with a "2" and goto HIPNAM2B]
Question ID: FHI.172_01.000 Instrument Variable Name: PCARD2 QuestionnaireFileName: Family
QuestionText: * Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on
1 Yes
2 No
UniverseText: All private health insurance plans where the plan name was entered at HIPNAM2
SkipInstructions: goto HIPNAM2B
Page 14 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.173_00.000 Instrument Variable Name: HIPNAM2B QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by that plan?
* Indicate each family member covered by this plan.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with a second private health insurance plan and the plan name, refused, or don't know was entered
at HIPNAM2
SkipInstructions: <R,D> [if HIPNAM2 eq R or D and persons selected at HIPNAM1B, but not all persons with HIKIND eq 1 or
3 selected at HIPNAM1B, goto HIVER1; else, if HIPNAM2 eq R or D and persons selected at HIPNAM1B,
and all persons with HIKIND eq 1 or 3 selected at HIPNAM1B, goto FHICCI8; else, if HIPNAM2 eq R or D
and persons not selected at HIPNAM1B, goto FHICCI8; else, if a health plan name recorded in HIPNAM2,
goto MORPLAN2]
Question ID: FHI.174_00.000 Instrument Variable Name: MORPLAN2 QuestionnaireFileName: Family
QuestionText: * Ask if necessary
Are there any more private health insurance plans?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families where a private health insurance plan name was entered at HIPNAM2 or a person number was
entered at HIPNAM2B
SkipInstructions: <1> [goto HIPNAM3]
<2,R,D> [if persons selected at HIPNAM2B or HIPNAM1B, but not all persons with HIKIND eq 1 or 3
selected at HIPNAM2B or HIPNAM1B, goto HIVER1; else, goto FHICCI8]
Page 15 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.175_00.000 Instrument Variable Name: HIPNAM3 QuestionnaireFileName: Family
QuestionText: What is the name of the next plan?
*Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All families with a third private health insurance plan
SkipInstructions: <verbatim> [goto PCARD3]
<R,D> [prefill PCARD3 with a "2" and goto HIPNAM3B]
Question ID: FHI.175_01.000 Instrument Variable Name: PCARD3 QuestionnaireFileName: Family
QuestionText: * Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on
1 Yes
2 No
UniverseText: All private health insurance plans where the plan name was entered at HIPNAM3
SkipInstructions: goto HIPNAM3B
Page 16 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.176_00.000 Instrument Variable Name: HIPNAM3B QuestionnaireFileName: Family
QuestionText:
* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by that plan?
* Indicate each family member covered by this plan.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with a third private health insurance plan and the plan name, refused, or don't know was entered at
HIPNAM3
SkipInstructions: <R,D> [if HIPNAM3 eq R or D and persons selected at HIPNAM1B or HIPNAM2B, but not all persons with
HIKIND eq 1 or 3 selected at HIPNAM1B or HIPNAM2B, goto HIVER1; else, if HIPNAM3 eq R or D and
persons selected at HIPNAM1B or HIPNAM2B, and all persons with HIKIND eq 1 or 3 selected at
HIPNAM1B or HIPNAM2B, goto FHICCI8; else, if HIPNAM3 eq R or D and persons not selected at
HIPNAM1B and HIPNAM2B, goto FHICCI8; else, if the health plan name was entered at HIPNAM3, goto
MORPLAN3]
Question ID: FHI.177_00.000 Instrument Variable Name: MORPLAN3 QuestionnaireFileName: Family
QuestionText: * Ask if necessary
Are there any more private health insurance plans?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families where a private health insurance plan name was entered at HIPNAM3 or a person number was
entered at HIPNAM3B
SkipInstructions: <1> [goto HIPNAM4]
<2,R,D> [if persons selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, but not all persons with
HIKIND eq 1 or 3 selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, goto HIVER1; else, goto
Page 17 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.178_00.000 Instrument Variable Name: HIPNAM4 QuestionnaireFileName: Family
QuestionText: What is the name of the next plan?
*Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All families with a fourth private health insurance plan
SkipInstructions: <verbatim> [goto PCARD4]
<R,D> [prefill PCARD4 with a "2" and goto HIPNAM4B]
Question ID: FHI.178_01.000 Instrument Variable Name: PCARD4 QuestionnaireFileName: Family
QuestionText: * Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on
1 Yes
2 No
UniverseText: All private health insurance plans where the plan name was entered at HIPNAM4
SkipInstructions: goto HIPNAM4B
Page 18 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.179_00.000 Instrument Variable Name: HIPNAM4B QuestionnaireFileName: Family
QuestionText:
* Ask or verify. Enter all that apply, separate with commas.
Which family members are covered by that plan?
* Indicate each family member covered by this plan.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with a fourth private health insurance plan and the plan name, refused, or don't know was entered
at HIPNAM4
SkipInstructions: <R,D> [if HIPNAM4 eq R or D and persons selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, but not
all persons with HIKIND eq 1 or 3 selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, goto HIVER1;
else, goto FHICCI8]
goto FHICCI8
Question ID: FHI.180_00.000 Instrument Variable Name: HIVER1 QuestionnaireFileName: Family
QuestionText: ? [F1]
[fill1: You are/ALIAS is] listed as having private insurance but [fill2: were/was] not mentioned as being covered by
any of the plans we just discussed. [fill3: Are you/Is ALIAS] covered by private insurance?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons who have private health insurance coverage, but were not mentioned as being covered by any of
the reported plans
SkipInstructions: <1> [ goto HIVER2]
<2,R,D> [goto ERR_HIVER1]
Hard Edit: ERR_HIVER1
*Press ENTER to go back to HIKIND to update health insurance coverage.
Page 19 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.190_00.000 Instrument Variable Name: HIVER2 QuestionnaireFileName: Family
QuestionText: ? [F1]
* Enter all that apply, separate with commas.
Is [fill: your/ALIAS's] health insurance plan the same as one of those already mentioned?
1 1st plan mentioned (^HIPNAM1)
2 2nd plan mentioned (^HIPNAM2)
3 3rd plan mentioned (^HIPNAM3)
4 4th plan mentioned (^HIPNAM4)
5 Some other plan not already mentioned
7 Refused
9 Don't know
UniverseText: All persons for whom it was verified they have private health insurance coverage, but were not mentioned as
being covered by any of the reported plans
SkipInstructions: <1-4> [update responses for HIPNAM1B/HIPNAM2B/HIPNAM3B/HIPNAM4B and goto FHICCI8]
<5> [if 4 plans were reported, ignore this 5th plan and goto FHICCI8; else, goto HIPNAM2, or HIPNAM3, or
HIPNAM4 accordingly to enter information on this plan]
<R,D> [goto FHICCI8]
Question ID: FHI.190_01.000 Instrument Variable Name: HIVER2 QuestionnaireFileName:
QuestionText:
UniverseText:
SkipInstructions:
Question ID: FHI.190_02.000 Instrument Variable Name: HIVER2 QuestionnaireFileName:
QuestionText:
UniverseText:
SkipInstructions:
Page 20 of 48
2011 NHIS Questionnaire
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.190_03.000 Instrument Variable Name: HIVER2 QuestionnaireFileName:
QuestionText:
UniverseText:
SkipInstructions:
Question ID: FHI.190_04.000 Instrument Variable Name: HIVER2 QuestionnaireFileName:
QuestionText:
UniverseText:
SkipInstructions:
Question ID: FHI.190_05.000 Instrument Variable Name: HIVER2 QuestionnaireFileName:
QuestionText:
UniverseText:
SkipInstructions:
Page 21 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.195_01.000 Instrument Variable Name: FHICCI8 QuestionnaireFileName: Family
QuestionText: [fill1: Now I am going to ask some questions about the [fill2: plan/plans] you just told me about [fill3: /,starting
with [fill4: ^HIPNAM1/Plan1]]./Next I would like to ask you about [fill5:
^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 2/Plan 3/Plan 4]].
* Enter 1 to continue.
1 Continue
UniverseText: All families where a private health insurance plan was reported
SkipInstructions: goto FHI200
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
in a family. Information on up to 4 plans per family is collected.
Question ID: FHI.200_01.000 Instrument Variable Name: FHI200 QuestionnaireFileName: Family
QuestionText: ? [F1]
Health insurance plans are usually obtained in one person's name even if other family members are covered. That
person is called the policyholder. In whose name is this plan?
* Enter line number of family member (from list below) in whose name this plan is held.
* Enter 0 if the policyholder is not on the family roster."
00 Policyholder not on family roster
01-25 Two-digit person number
97 Refused
99 Don't know
UniverseText: All private health insurance plans
SkipInstructions: if <00> [ goto PRPOLH]
<01 to 25> [go to PRCOOH]
<R, D> [go to PLNWRK]
Page 22 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.202_01.010 Instrument Variable Name: PRPOLH QuestionnaireFileName: Family
QuestionText: How [fill1:are you/is ALIAS] related to the policyholder for [fill2: plan1/plan2/plan3/plan4]?
*Read if Necessary…
[fill3:You are/ALIAS is} the policyholder’s…
1 Child (including stepchildren)
2 Spouse
3 Former spouse
4 Some other relationship
7 Refused
9 Don't know
UniverseText: All persons on each plan where the policyholder is outside of the family roster
SkipInstructions: <1-4,R,D> [goto PLNWRK]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
in a family. Information on up to 4 plans per family is collected.
Question ID: FHI.204_01.010 Instrument Variable Name: PRCOOH QuestionnaireFileName: Family
QuestionText: Does this plan cover anyone who does not live here?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All private health insurance plans with policyholder on family roster
SkipInstructions: <1> [goto PRCTOH]
<2,R,D> [goto PLNWRK]
Page 23 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.205_01.010 Instrument Variable Name: PRCTOH QuestionnaireFileName: Family
QuestionText: How many people does this plan cover who live somewhere else?
01-30 01-30 persons
97 Refused
99 Don't know
UniverseText: All private health insurance plans with policyholder on family roster that cover someone outside the family
SkipInstructions: <1-30 > [goto PRRELOH]
<R,D> [goto PLNWRK]
Question ID: FHI.206_10.010 Instrument Variable Name: PRRELOH QuestionnaireFileName: Family
QuestionText: What [fill 1: is the relationship of this person/ are the relationships of these persons] to the policyholder?
*Read if Necessary: Children includes adult children.
*Enter all that apply, separate with commas.
1 Child (including stepchild)
2 Spouse
3 Former spouse
4 Some other relationship
7 Refused
9 Don't know
UniverseText: All private health insurance plans with policyholder on family roster that cover someone outside the family
SkipInstructions: <1 > [goto PRCNUM]
<2-4,R,D> [goto PLNWRK]
Page 24 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.207_01.010 Instrument Variable Name: PRCNUM QuestionnaireFileName: Family
QuestionText: How many children of the policyholder are covered who live elsewhere?
*Read if Necessary: Children includes adult children.
*If more than 10 children, enter '10'.
01-10 01-10 children
97 Refused
99 Don’t know
UniverseText: All private health insurance plans with policyholder on family roster that cover a child or children not on the
SkipInstructions: <01-10> if [PRCNUM > PRCTOH goto ERR1_PRCNUM]
else goto PRAGEOH
<R,D> [goto PLNWRK]
Hard Edit: if PRCNUM > PRCTOH
*Number of children, [fill 1], exceeds the total number who live elsewhere, [fill 2].
Question ID: FHI.208_01.010 Instrument Variable Name: PRAGEOH QuestionnaireFileName: Family
QuestionText: How old is {fill1: this child/the first child/ the next child}?
000-100 000-100 years
997 Refused
999 Don't know
UniverseText: All private health insurance plans with policyholder on family roster that cover one or more children not on
the roster
SkipInstructions: <000-100,R,D>if [AGE >= 50 years goto ERR1_PRAGEOH]
else if PRCNUM GE 2 [goto PRAGEOH up to 9 more times]
else [goto PLNWRK]
Soft Edit: If AGE >= 50 years
*Respondent said the child is [fill: PRAGEOH] years old. Please verify.
Page 25 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.210_01.000 Instrument Variable Name: PLNWRK QuestionnaireFileName: Family
QuestionText: (book) F16 ? [F1]
Which one of these categories best describes how this plan was obtained?
01 Through employer
02 Through union
03 Through workplace, but don't know if employer or union
04 Through workplace, self-employed or professional association
05 Purchased directly
06 Through a state/local government or community program
07 Other, specify
97 Refused
99 Don't know
UniverseText: All private health insurance plans
SkipInstructions: <1-6,R,D> [goto PLNPAY]
<7> [goto PLNWKSP]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
in a family. Information on up to 4 plans per family is collected.
Question ID: FHI.211_01.000 Instrument Variable Name: PLNWKSP QuestionnaireFileName: Family
QuestionText: *Read if necessary.
How was this plan obtained?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All private health insurance plans where the plan was obtained through an "other" source
SkipInstructions: goto PLNPAY
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
in a family. Information on up to 4 plans per family is collected.
Page 26 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.220_10.000 Instrument Variable Name: PLNPAY QuestionnaireFileName: Family
QuestionText: ? [F1]
* Enter all that apply, separate with commas.
Who pays for this health insurance plan?
* If government program is reported, probe for Medicare or Medicaid or SCHIP before entering code 7. If government
is the employer, enter code 2.
01 Self or family (living in the household)
02 Employer or union
03 Someone outside the household
04 Medicare
05 Medicaid
06 Children's Health Insurance Program (CHIP/SCHIP)
07 State or local government or community program
97 Refused
99 Don't know
UniverseText: All private health insurance plans
SkipInstructions: <1> [goto HICOSTN]
<2> [goto EMPPAY]
<3-7,D,R> [goto PLNMGD]
(if both 1 and 2 chosen, go to HICOSTN first and then EMPPAY)
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
Page 27 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.230_11.000 Instrument Variable Name: HICOSTN QuestionnaireFileName: Family
QuestionText: 1 of 2 ? [F1]
How much [fill1: do you/does your family] currently spend for health insurance premiums for [fill2:
^HIPNAM1/^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4]? Please include payroll
deductions for premiums.
*Enter dollar amount for premium payments.
00001-99995 $1-$99,995
99997 Refused
99999 Don't know
UniverseText: All private health insurance plans paid for by self or family
SkipInstructions: if gt 9999, [goto ERR_HICOSTN]
<1-9999> [goto HICOSTT]
<D> [store <D> in HICOSTT, goto EMPPAY if PLNPAY=2; else goto PLNMGD]
<R> [store <R> in HICOSTT, goto EMPPAY if PLNPAY=2; else goto PLNMGD]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
in a
Soft Edit: ERR_HICOSTN
* [fill # from HICOSTN] is unusually high. Please verify.
Make corrections if necessary.
Question ID: FHI.230_12.000 Instrument Variable Name: HICOSTT QuestionnaireFileName: Family
QuestionText: 2 of 2 ? [F1]
* Enter time period for premium payments.
01 Once a week
02 Once every 2 weeks
03 Once a month
04 Twice a month
05 Every 2 months
06 Quarterly (every 3 months)
07 Once a year
08 Twice a year
97 Refused
99 Don't know
UniverseText: All private health insurance plans with a valid response to HICOSTN
SkipInstructions: <1-8,R,D> if PLNPAY=2 [goto EMPPAY]; else [goto PLNMGD]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
in a
Page 28 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.235_01.010 Instrument Variable Name: EMPPAY QuestionnaireFileName: Family
QuestionText: Do you know how much the employer or union is paying for [fill1: plan1/plan2/plan3/plan4]?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: All private health insurance plans paid for by employer or union
SkipInstructions: <1> [goto EMPCOSTN] <2,R,D> [goto PLNMGD]
Question ID: FHI.237_01.010 Instrument Variable Name: EMPCOSTN QuestionnaireFileName: Family
QuestionText: 1 of 2
How much does the employer or union currently pay for health insurance premiums for [fill1: Plan 1/Plan 2/Plan
3/Plan 4]?
*Enter dollar amount for premium payments.
*Enter ‘ZZ’ to go to percentage format.
00001-99995 $1-$99,995
99997 Refused
99999 Don't know
UniverseText: All private health insurance plans where amount of premium employer/union pays is known
SkipInstructions: <1-99995> [goto EMPCOSTT]
<R> [store "R" in EMPCOSTT and goto PLNMGD] <D> [store "D" in EMPCOSTT and goto PLNMGD] <P>
[goto EMPCOSTP]
Soft Edit: ERR_EMPCOSTN
* [fill # from EMPCOSTN] is unusually high. Please verify.
Make corrections if necessary.
Page 29 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.237_02.020 Instrument Variable Name: EMPCOSTT QuestionnaireFileName: Family
QuestionText: 2 of 2
* Enter time period for premium payments.
01 Once a week
02 Once every 2 weeks
03 Once a month
04 Twice a month
05 Every 2 months
06 Quarterly (every 3 months)
07 Once a year
08 Twice a year
97 Refused
99 Don't know
UniverseText: All private health insurance plans with a valid response to EMPCOSTN
SkipInstructions: goto PLNMGD
Question ID: FHI.237_02.030 Instrument Variable Name: EMPCOSTP QuestionnaireFileName: Family
QuestionText: What percent of the premiums does the employer or union pay for [fill1: Plan 1/Plan 2/Plan 3/Plan 4]?
001-100 001-100 percent
997 Refused
999 Don’t know
UniverseText: All private health insurance plans paid for by employer or union where respondent wanted to report
percentage of premium paid
SkipInstructions: <1-100,R,D> [goto PLNMGD]
Page 30 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.240_01.000 Instrument Variable Name: PLNMGD QuestionnaireFileName: Family
QuestionText: ? [F1]
Is [fill: ^HIPNAM1/^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4] an HMO (Health
Maintenance Organization), an IPA (Individual Practice Association), a PPO (Preferred Provider Organization), a
POS (Point-Of-Service), fee-for-service, or indemnity or is it some other kind of plan?
1 HMO/IPA
2 PPO
3 POS
4 Fee-for-service/indemnity
5 Other
7 Refused
9 Don't know
UniverseText: All private health insurance plans
SkipInstructions: goto HDHP
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
in a family. Information on up to 4 plans per family is collected.
Question ID: FHI.241_01.000 Instrument Variable Name: HDHP QuestionnaireFileName: Family
QuestionText: ?[F1]
[If only one person covered by this plan:]
Is the annual deductible for medical care for this plan less than $1,200 or $1,200 or more? If there is a separate
deductible for prescription drugs, hospitalization, or out-of-network care, do not include those deductible amounts
here.
[If two or more persons in the family are covered by this plan:]
Is the family annual deductible for medical care for this plan less than $2,400 or $2,400 or more? If there is a separate
deductible for prescription drugs, hospitalization, or out-of-network care, do not include those deductible amounts
1 Less than [$1,200/$2,400]
2 [$1,200/$2,400] or more
7 Refused
9 Don't know
UniverseText: All private health insurance plans
SkipInstructions: 1,R,D [goto MGCHMD]
2 [goto HSAHRA]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
in a family. Information on up to 4 plans per family is collected.
Page 31 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.242_01.000 Instrument Variable Name: HSAHRA QuestionnaireFileName: Family
QuestionText: ?[F1]
With this plan, is there a special account or fund that can be used to pay for medical expenses? The accounts are
sometimes referred to as Health Savings Accounts (HSAs), Health Reimbursement Accounts (HRAs), Personal Care
accounts, Personal Medical funds, or Choice funds, and are different from Flexible Spending Accounts.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All high deductible private health plans
SkipInstructions: 1,2,R,D [goto MGCHMD]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
in a family. Information on up to 4 plans per family is collected.
Question ID: FHI.243_01.000 Instrument Variable Name: MGCHMD QuestionnaireFileName: Family
QuestionText: Under this plan, can [fill1:you/ALIAS/the family members with this plan] choose ANY doctor or MUST
[fill2:you/he/she/they] choose one from a specific group or list of doctors?
1 Any doctor
2 Select from group/list
7 Refused
9 Don't know
UniverseText: All private health insurance plans
SkipInstructions: <1> [goto MGPRMD]
<2> [goto MGPYMD]
<R,D> [goto MGPREF]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
in a family. Information on up to 4 plans per family is collected.
Page 32 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.244_01.000 Instrument Variable Name: MGPRMD QuestionnaireFileName: Family
QuestionText: [fill: Do you/Does ALIAS/Do the family members with this plan] have the option of choosing a doctor from a
preferred or select list at a lower cost?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All private health insurance plans where covered persons can choose any doctor
SkipInstructions: goto MGPREF
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
in a family. Information on up to 4 plans per family is collected.
Question ID: FHI.246_01.000 Instrument Variable Name: MGPYMD QuestionnaireFileName: Family
QuestionText: If [fill1: you select/ALIAS selects/the family members with this plan select] a doctor who is not in the plan, will
[fill2: ^HIPNAM1/^HIPNAM2/^HIPNAM3/^ HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4] pay for any or part of the
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All private health insurance plans where covered persons must select from a group or list of doctors
SkipInstructions: goto MGPREF
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
in a family. Information on up to 4 plans per family is collected.
Page 33 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.248_01.000 Instrument Variable Name: MGPREF QuestionnaireFileName: Family
QuestionText: ? [F1]
When [fill1: you need/ALIAS needs/the family members with this plan need] to go to a different doctor or place for
special care, [fill2: do you/does ALIAS/do they] need approval or a referral? Do not include emergency care.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All private health insurance plans
SkipInstructions: goto PCPREQ
Question ID: FHI.248_05.000 Instrument Variable Name: PCPREQ QuestionnaireFileName: Family
QuestionText: Does this plan REQUIRE [fill1: you/ALIAS/the family members with this plan] to have a primary care doctor or
group of doctors for all routine care?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Asked of all private health insurance plans
SkipInstructions: <1,2,R,D> [goto PRRXCOV]
Page 34 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.249_01.010 Instrument Variable Name: PRRXCOV QuestionnaireFileName: Family
QuestionText: Does [fill1: ^HIPNAM1/^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4] pay for any of the
costs for medicines prescribed by a doctor?
* Read if necessary: Does this plan have a drug benefit?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All private health insurance plans
SkipInstructions: goto PRDNCOV
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned
in a family. Information on up to 4 plans per family is collected.
Question ID: FHI.249_02.010 Instrument Variable Name: PRDNCOV QuestionnaireFileName: Family
QuestionText: Does [fill 1: ^HIPNAM1 or ^HIPNAM2, or ^HIPNAM3, or ^HIPNAM4 or Plan 1 or Plan 2 or Plan 3 or Plan 4] pay
for any of the costs for dental care?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All private health insurance plans
SkipInstructions: goto FHICCI8 for the next private health insurance plan; else, goto FCOVCONF
Page 35 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.249_03.000 Instrument Variable Name: FCOVCONF QuestionnaireFileName: Family
QuestionText: If [fill1: you/your family] had to buy a health plan on [fill 2: your/its] own with no help from [fill 3: your/an]
employer, how confident are you that [fill 1: you/your family] would be able to obtain affordable coverage Would
you say…
1 Very confident
2 Somewhat confident
3 Not too confident
4 Not confident at all
7 Refused
9 Don’t know
UniverseText: All families with an employer-based health plan
SkipInstructions: <1-4,R,D> goto STNAME1 or STNAME2 or STNAME3 or MILSPC or HILAST or HINOTYR
Question ID: FHI.250_00.000 Instrument Variable Name: STNAME1 QuestionnaireFileName: Family
QuestionText: Earlier I recorded that [fill: you are/ALIAS is] covered by the Children’s Health Insurance Program (CHIP/SCHIP).
What is the name of the plan?
* Read if necessary: Do you have a health plan card or something with the plan name on it?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons with SCHIP
SkipInstructions: goto STDOC1
Page 36 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.251_00.000 Instrument Variable Name: STDOC1 QuestionnaireFileName: Family
QuestionText: Under the [fill1:^STNAME1/SCHIP plan] can [fill2: you/ALIAS] go to ANY doctor who will accept this plan or
MUST [fill3: you/he/she] choose from a book or list of doctors or is the doctor assigned?
1 Any doctor
2 Select from book/list
3 Doctor is assigned
7 Refused
9 Don't know
UniverseText: All persons with SCHIP
SkipInstructions: goto STPCMD1
Question ID: FHI.252_00.000 Instrument Variable Name: STPCMD1 QuestionnaireFileName: Family
QuestionText: [fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic
which [fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care
from a specialist [fill4: you were/he was/she was] referred to.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons with SCHIP
SkipInstructions: goto STREF1
Question ID: FHI.253_00.000 Instrument Variable Name: STREF1 QuestionnaireFileName: Family
QuestionText: ? [F1]
Under [fill1: ^STNAME1/this SCHIP plan], if [fill2: you need/ALIAS needs] to go to a different doctor or place for
special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons with SCHIP
SkipInstructions: goto STNAME1 for the next person with SCHIP; else, goto STNAME2
Page 37 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.257_00.000 Instrument Variable Name: STNAME2 QuestionnaireFileName: Family
QuestionText: Earlier I recorded that [fill: you are/ALIAS is] covered by a state sponsored health plan. What is the name of the
plan?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons covered by a state sponsored health plan
SkipInstructions: goto STDOC2
Question ID: FHI.258_00.000 Instrument Variable Name: STDOC2 QuestionnaireFileName: Family
QuestionText: Under the [fill1:^STNAME2/state sponsored plan] can [fill2: you/ALIAS] go to ANY doctor who will accept this
plan or MUST [fill3: you/he/she] choose from a book or list of doctors or is the doctor assigned?
1 Any doctor
2 Select from book/list
3 Doctor is assigned
7 Refused
9 Don't know
UniverseText: All persons covered by a state sponsored health plan
SkipInstructions: goto STPCMD2
Question ID: FHI.259_00.000 Instrument Variable Name: STPCMD2 QuestionnaireFileName: Family
QuestionText: [fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic
which [fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care
from a specialist [fill4: you were/he was/she was] referred to.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons covered by a state sponsored health plan
SkipInstructions: goto STREF2
Page 38 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.260_00.000 Instrument Variable Name: STREF2 QuestionnaireFileName: Family
QuestionText: ? [F1]
Under [fill1:^STNAME2/this state sponsored plan], if [fill2: you need/ALIAS needs] to go to a different doctor or
place for special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons covered by a state sponsored health plan
SkipInstructions: goto STNAME2 for the next person with a state sponsored health plan; else, goto STNAME3
Question ID: FHI.264_00.000 Instrument Variable Name: STNAME3 QuestionnaireFileName: Family
QuestionText: Earlier I recorded that [fill: you are/ALIAS is] covered by an other government program. What is the name of the
plan?
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons covered by an "other" government plan
SkipInstructions: goto STDOC3
Question ID: FHI.265_00.000 Instrument Variable Name: STDOC3 QuestionnaireFileName: Family
QuestionText: Under the [fill1:^STNAME3/other government plan] can [fill2: you/ALIAS] go to ANY doctor who will accept this
plan or MUST [fill3:you/he/she] choose from a book or list of doctors or is the doctor assigned?
1 Any doctor
2 Select from book/list
3 Doctor is assigned
7 Refused
9 Don't know
UniverseText: All persons covered by an "other" government plan
SkipInstructions: goto STPCMD3
Page 39 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.266_00.000 Instrument Variable Name: STPCMD3 QuestionnaireFileName: Family
QuestionText: [fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic
which [fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care
from a specialist [fill4: you were/he was/she was] referred to.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons covered by an "other" government plan
SkipInstructions: goto STREF3
Question ID: FHI.267_00.000 Instrument Variable Name: STREF3 QuestionnaireFileName: Family
QuestionText: ? [F1]
Under [fill1:^ STNAME3/this other government plan], if [fill2: you need/ALIAS needs] to go to a different doctor or
place for special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons covered by an "other" government plan
SkipInstructions: goto STNAME3 for the next person with an "other" government plan; else, goto MILSPC
Page 40 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.270_00.000 Instrument Variable Name: MILSPC QuestionnaireFileName: Family
QuestionText: ? [F1]
* Enter all that apply, separate with commas.
Earlier I recorded that [fill1: you are/ALIAS is] covered by military health care. What types of military health care
[fill2: are you/is ALIAS] covered by?
1 TRICARE
2 VA
3 CHAMP-VA
4 Other military coverage (specify)
7 Refused
9 Don't know
UniverseText: All persons with military health care
SkipInstructions: <1> [goto MILMAN]
<2,3,R,D> [repeat question for next person with military health care; else, goto HILAST]
<4> [goto MILSPCOT]
Question ID: FHI.271_00.000 Instrument Variable Name: MILSPCOT QuestionnaireFileName: Family
QuestionText: * Other military coverage
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons with "other" military coverage
SkipInstructions: if MILSPC eq 1, goto MILMAN; else, goto MILSPC for the next person with military health care; else, goto
HILAST
Page 41 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.275_00.000 Instrument Variable Name: MILMAN QuestionnaireFileName: Family
QuestionText: ? [F1]
Is [fill: your/ALIAS's] TRICARE plan, TRICARE prime, TRICARE Extra, TRICARE Standard or TRICARE for Life?
1 TRICARE Prime
2 TRICARE Extra
3 TRICARE Standard
4 TRICARE for life
5 TRICARE other (specify)
7 Refused
9 Don't know
UniverseText: All persons with TRICARE coverage
SkipInstructions: <1-4,R,D> [goto MILSPC for the next person with military health care; else, goto HILAST]
<5> [goto MILMANOT]
Question ID: FHI.276_00.000 Instrument Variable Name: MILMANOT QuestionnaireFileName: Family
QuestionText: * Other type of TRICARE coverage
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons with "other" type of TRICARE coverage
SkipInstructions: goto MILSPC for the next person with military health care; else, goto HILAST
Page 42 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.280_00.000 Instrument Variable Name: HILAST QuestionnaireFileName: Family
QuestionText: (book) F17 ? [F1]
Not including Single Service Plans, about how long has it been since [fill: you/ALIAS] last had health care
1 6 months or less
2 More than 6 months, but not more than 1 year ago
3 More than 1 year, but not more than 3 years ago
4 More than 3 years
5 Never
7 Refused
9 Don't know
UniverseText: All persons without known health insurance or with only single service plans
SkipInstructions: goto HISTOP
Question ID: FHI.290_00.000 Instrument Variable Name: HISTOP QuestionnaireFileName: Family
QuestionText: (book) F18
[fill1: Which of these are reasons [fill2: you/ALIAS] stopped being covered?/Which of these are reasons [fill3:you
do/ALIAS does] not have health insurance?]
* Enter up to 5 reasons, separate with commas.
01 Person in family with health insurance lost job or changed employers
02 Got divorced or separated/death of spouse or parent
03 Became ineligible because of age/left school
04 Employer does not offer coverage/or not eligible for coverage
05 Cost is too high
06 Insurance company refused coverage
07 Medicaid/Medical plan stopped after pregnancy
08 Lost Medicaid/Medical plan because of new job or increase in income
09 Lost Medicaid (other)
10 Other (specify)
97 Refused
99 Don't know
UniverseText: All persons without known health insurance or with only single service plans
SkipInstructions: <1-9,R,D> [goto HCSPFYR]
<10> [goto HISTOPOT]
Page 43 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.291_00.000 Instrument Variable Name: HISTOPOT QuestionnaireFileName: Family
QuestionText: ? [F1]
* Other reason for not having coverage
Verbatim Verbatim response
7 Refused
9 Don't know
UniverseText: All persons without known health insurance and an "other" reason for stopping or not having coverage
SkipInstructions: goto HISTOP for the next person without known health insurance coverage or only single service plans; else,
goto HCSPFYR
Question ID: FHI.300_00.000 Instrument Variable Name: HINOTYR QuestionnaireFileName: Family
QuestionText: In the PAST 12 MONTHS, was there any time when [fill: you/ALIAS] did NOT have ANY health insurance or
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons with known health insurance coverage except single service plans
SkipInstructions: <1> [goto HINOTMYR] <2,R,D> [goto FHICHNG]
Question ID: FHI.310_00.000 Instrument Variable Name: HINOTMYR QuestionnaireFileName: Family
QuestionText: In the PAST 12 MONTHS, about how many months [fill: were you/was ALIAS] without coverage?
* If less than 1 month, enter '1'.
01-12 01-12 months
97 Refused
99 Don't know
UniverseText: All persons with known health insurance coverage, but did not have health insurance for some period of time
in the past 12 months
SkipInstructions: goto HINOTYR for the next person with known health insurance coverage, except single service plans; else,
goto HCSPFYR
Page 44 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.312_00.010 Instrument Variable Name: FHICHNG QuestionnaireFileName: Family
QuestionText: Did [fill1: you/ALIAS] have [fill2: type of health insurance coverage] for the past 12 months?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons who are currently insured who were continuously covered in the past year
SkipInstructions: <1,R,D> [goto HCSPFYR]
<2> [goto FHIKDB]
Page 45 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.315_00.010 Instrument Variable Name: FHIKDB QuestionnaireFileName: Family
QuestionText: (book) F12 and (book) F14
If person is currently uninsured:
{Think about the last time [fill1: you/ALIAS] had health insurance or health care coverage. What type did [fill1:
you/ALIAS] have?}
If person had a period without coverage in the past year:
{I recorded that [fill1: you/ALIAS] had a period without health insurance in the past year. What type of health
insurance or coverage did [fill1: you/ALIAS] have before this period?}
If person had a change in coverage type in the past year:
{What other types of health insurance or health care coverage did [fill1: you/ALIAS] have?}
*Enter all that apply, separate with commas.
01 Private health insurance
02 Medicare
03 Medi-Gap
04 Medicaid
05 SCHIP (CHIP/Children's Health Insurance Program)
06 Military health care (TRICARE/VA/CHAMP-VA)
07 Indian Health Service
08 State-sponsored health plan
09 Other government program
10 Single service plan (e.g., dental, vision, prescriptions)
11 No coverage of any type
97 Refused
99 Don't know
UniverseText: All persons except those with continuous coverage who are currently uninsured for more than 1 year with no
changes
SkipInstructions: <1> [goto PWRKB]
<2-11,R,D> [goto HCSPFYR]
Page 46 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.316_00.010 Instrument Variable Name: PWRKB QuestionnaireFileName: Family
QuestionText: Which one of these categories best describes how [fill1: your/ALIAS’s] private health insurance was obtained?
01 Through employer
02 Through union
03 Through workplace, but don't know if employer or union
04 Through workplace, self-employed or professional association
05 Purchased directly
06 Through a state/local government or community program
07 Other, specify
97 Refused
99 Don’t know
UniverseText: All persons who had private health insurance previously
SkipInstructions: <1-6,R,D> [goto HCSPFYR] <7> [goto PWRKBSP]
Question ID: FHI.317_00.010 Instrument Variable Name: PWRKBSP QuestionnaireFileName: Family
QuestionText: *Enter how private health insurance was obtained.
7 Refused
9 Don't know
Verbatim Verbatim response
UniverseText: All persons who had private health insurance obtained from other source previously
SkipInstructions: <Allow 75 characters> [goto HCSPFYR]
Page 47 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.320_00.000 Instrument Variable Name: HCSPFYR QuestionnaireFileName: Family
QuestionText: (book) F19
The next question is about money that [fill1: you have/your family has] spent out of pocket on medical care. We do
NOT want you to count health insurance premiums, over the counter drugs, or costs that you will be reimbursed for.
In the PAST 12 MONTHS, about how much did [fill2: you/your family] spend for medical care and dental care?
0 Zero
1 Less than $500
2 $500 - $1,999
3 $2,000 - $2,999
4 $3,000 - $4,999
5 $5,000 or more
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: goto MEDBILL
Question ID: FHI.325_00.010 Instrument Variable Name: MEDBILL QuestionnaireFileName: Family
QuestionText: In the past 12 months did [fill1: you/anyone in the family] have problems paying or were unable to pay any medical
bills? Include bills for doctors, dentists, hospitals, therapists, medication, equipment, nursing home or home care.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1,2,7,9> [goto MEDBPAY]
Page 48 of 48
2011 NHIS Questionnaire Family
Family Health Insurance
Document Version Date: 19-Jun-12
Question ID: FHI.327_00.010 Instrument Variable Name: MEDBPAY QuestionnaireFileName: Family
QuestionText: [fill 1: Do you/Does anyone in your family] currently have any medical bills that are being paid off over time? This
could include medical bills being paid off with a credit card, through personal loans, or bill paying arrangements
with hospitals or other providers. The bills can be from earlier years as well as this year.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1,2,7,9> if MEDBILL=2 [goto FSA]; else [goto MEDBNOP]
Question ID: FHI.327_00.020 Instrument Variable Name: MEDBNOP QuestionnaireFileName: Family
QuestionText: [fill 1: Do you/Does anyone in your family] currently have any medical bills that you are unable to pay at all?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families but those who said they don’t have problems paying their medical bills
SkipInstructions: <1,2,7,9> [goto FSA]
Question ID: FHI.330_00.000 Instrument Variable Name: FSA QuestionnaireFileName: Family
QuestionText: [fill 1: Do you/Does anyone in your family] have a Flexible Spending Account for health expenses? These accounts
are offered by some employers to allow employees to set aside pre-tax dollars of their own money for their use
throughout the year to reimburse themselves for their out-of-pocket expenses for health care. With this type of
account, any money remaining in the account at the end of the year, following a short grace period, is lost to the
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All Families
SkipInstructions: goto PLBORN
Page 1 of 27
2011 NHIS Questionnaire Family
Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.001_00.000 Instrument Variable Name: PLBORN QuestionnaireFileName: Family
QuestionText: [fill: Were you/Was ALIAS] born in the United States?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons
SkipInstructions: <1> [store "1" in CITIZEN and goto PLBORN1]
<2> [goto PLBORN2]
<R,D> [goto CITIZEN]
Page 2 of 27
2011 NHIS Questionnaire Family
Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.002_00.000 Instrument Variable Name: PLBORN1 QuestionnaireFileName: Family
QuestionText: In what state [fill: were you/was ALIAS] born?
01 Alabama
02 Alaska
03 Arizona
04 Arkansas
05 California
06 Colorado
07 Connecticut
08 Delaware
09 District of Columbia
10 Florida
11 Georgia
12 Hawaii
13 Idaho
14 Illinois
15 Indiana
16 Iowa
17 Kansas
18 Kentucky
19 Louisiana
20 Maine
21 Maryland
22 Massachusetts
23 Michigan
24 Minnesota
25 Mississippi
26 Missouri
27 Montana
28 Nebraska
29 Nevada
30 New Hampshire
31 New Jersey
32 New Mexico
33 New York
34 North Carolina
35 North Dakota
36 Ohio
37 Oklahoma
38 Oregon
39 Pennsylvania
40 Rhode Island
41 South Carolina
42 South Dakota
43 Tennessee
44 Texas
45 Utah
46 Vermont
47 Virginia
Page 3 of 27
2011 NHIS Questionnaire Family
Family Socio-Demographic
Document Version Date: 19-Jun-12
48 Washington
49 West Virginia
50 Wisconsin
51 Wyoming
57 United States (state unknown)
UniverseText: All persons born in the United States
SkipInstructions: <1-51,57> [goto HEADST]
Page 4 of 27
2011 NHIS Questionnaire Family
Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.003_00.000 Instrument Variable Name: PLBORN2 QuestionnaireFileName: Family
QuestionText: In what country [fill: were you/was ALIAS] born?
* Please record country of birth. If country not found, type "ZZ"
060 AMERICAN SAMOA
061 AM SAMOA
062 BAKER ISLAND
063 GUAM
064 HOWLAND ISLAND
065 JARVIS ISLAND
066 JOHNSTON ATOLL
067 KINGMAN REEF
068 MANUA ISLANDS
069 MIDWAY ISLANDS
070 NAVASSA ISLAND
071 NORTHERN MARIANAS
072 PALMYRA ATOLL
073 PUERTO RICO
074 ROTA
075 SAIPAN
076 SAND ISLAND
077 ST CROIX
078 ST JOHN
079 ST THOMAS
080 TINIAN
081 US OUTLYING AREA
082 US VIRGIN ISLANDS
083 USVI
084 VIRGIN ISLANDS
085 WAKE ISLAND
100 ABROAD
101 ABU DHABI
102 ADEN
103 AFGHANISTAN
104 AFRICA
105 ALBANIA
106 ALBERTA
107 ALGERIA
108 ALGIERS
109 ALSACE-LORRAINE
110 AMSTERDAM
111 ANEGADA
112 ANGOLA
113 ANGUILLA
114 ANGUILLA BWI
115 ANOJOUAN
116 ANTARCTICA
117 ANTIGUA
118 ANTIGUA & BARBUDA
119 ANTIGUA WI
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Family Socio-Demographic
Document Version Date: 19-Jun-12
120 ANTILLES
121 ARAB PALESTINE
122 ARABIA
123 ARGENTINA
124 ARMENIA
125 ARUBA
126 ARUBA DWI
127 ARUBA NETHERLANDS
128 ASCENSION ISLAND
129 ASIA
130 ASIA MINOR
131 ASSAM
132 AT SEA
133 AUSTRALIA
134 AUSTRIA
135 AUSTRIA-HUNGARY
136 AZERBAIJAN
137 AZORES ISLANDS
138 BAHAMAS
139 BAHAMAS UK
140 BAHRAIN
141 BAJA CAL
142 BAJA CAL SUR
143 BALBOA
144 BANGLADESH
145 BARBADOS
146 BARBUDA
147 BAVARIA
148 BELARUS
149 BELFAST
150 BELGIAN CONGO
151 BELGIUM
152 BELIZE
153 BENIN
154 BERLIN
155 BERMUDA
156 BESSARABIA
157 BHUTAN
158 BOHEMIA
159 BOLIVIA
160 BONAIRE
161 BORNEO
162 BOSNIA
163 BOSNIA & HERZEGOVINA
164 BOTSWANA
165 BRASIL
166 BRAZIL
167 BRAZZAVILLE
168 BREMEN
169 BRITAIN
170 BRITISH COLUMBIA
171 BRITISH EAST AFRICA
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172 BRITISH GUIANA
173 BRITISH GUYANA
174 BRITISH HONDURAS
175 BRITISH HONG KONG
176 BRITISH ISLES
177 BRITISH VI
178 BRITISH VIRGIN IS
179 BRITISH WEST INDIES
180 BRITISH WI
181 BRUNEI
182 BULGARIA
183 BURKINA FASO
184 BURMA
185 BURUNDI
186 BWI
187 BYELARUS
188 BYELORUSSIA
189 CAICOS ISLANDS
190 CAM PHA
191 CAM RANH
192 CAMBODIA
193 CAMEROON
194 CAN THO
195 CANADA
196 CANAL ZONE
197 CANARY ISLANDS
198 CANTON & ENDERBURY IS
199 CANTON ISLAND
200 CAPE VERDE
201 CARIBBEAN
202 CAYMAN ISLANDS
203 CENTRAL AFRICA
204 CENTRAL AFRICAN REP
205 CENTRAL AMERICA
206 CEYLON
207 CHAD
208 CHANNEL ISLANDS
209 CHIAPAS
210 CHIHUAHUA
211 CHILE
212 CHINA
213 CHINA HONG KONG
214 CHRISTMAS ISLAND
215 CHRISTMAS ISLAND, INDIAN OCEAN
216 COAHUILA
217 COLIMA
218 COLOMBIA
219 COMOROS
220 CONGO
221 COOK ISLANDS
222 CORAL SEA ISLANDS
223 CORK
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Family Socio-Demographic
Document Version Date: 19-Jun-12
224 CORSICA
225 COSTA RICA
226 COTE D'IVORIE
227 CRETE
228 CRIMEA
229 CRISTOBAL
230 CROATIA
231 CUBA
232 CURACAO
233 CYPRUS
234 CZ
235 CZECH REPUBLIC
236 CZECHOSLOVAKIA
237 DA LAT
238 DA NANG
239 DAKAR
240 DANZIG
241 DELHI
242 DEMO PEOPLE'S REP OF KOREA
243 DEMO REP OF CONGO
244 DENMARK
245 DISTRITO FEDERAL
246 DJIBOUTI
247 DOM REP
248 DOMINICA
249 DOMINICA BWI
250 DOMINICA WI
251 DOMINICAN REPUBLIC
252 DUBAI
253 DUBLIN
254 DURANGO
255 DUTCH EAST INDIES
256 DUTCH GUIANA
257 DUTCH INDONESIA
258 DUTCH NEW GUINEA
259 EAST PAKISTAN
260 EAST PRUSSIA
261 EASTER ISLAND
262 EASTERN AFRICA
263 ECUADOR
264 EGYPT
265 EIRE
266 EL SALVADOR
267 ENGLAND
268 EQUATORIAL GUINEA
269 ERITREA
270 ESPANA
271 ESTONIA
272 ETHIOPIA
273 EUROPA ISLAND
274 EUROPE
275 FALKLAND ISLANDS
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Family Socio-Demographic
Document Version Date: 19-Jun-12
276 FAROE ISLANDS
277 FEDERAL DISTRICT
278 FEDERAL REPUBLIC OF YUGOSLAVIA
279 FEDERATED STATES OF MICRONESIA
280 FIJI
281 FILIPINES
282 FINLAND
283 FOREIGN COUNTRY
284 FORMOSA
285 FRANCE
286 FRANKFURT
287 FRENCH GUIANA
288 FRENCH MOROCCO
289 FRENCH POLYNESIA
290 GABON
291 GALAPAGOS ISLANDS
292 GALWAY
293 GAMBIA
294 GAZA STRIP
295 GEORGIA
296 GERMANY
297 GHANA
298 GIA DINH
299 GIBRALTER
300 GLORIOSO ISLANDS
301 GOA
302 GRAND BAHAMA
303 GRAND CAYMAN
304 GRAND TURK
305 GREAT BRITAIN
306 GREAT COMORE
307 GREECE
308 GREENLAND
309 GRENADA
310 GUADALAJARA
311 GUADELOUPE
312 GUANAJUATO
313 GUATEMALA
314 GUERNSEY
315 GUERRERO
316 GUIANA
317 GUINEA
318 GUINEA-BISSAU
319 GUYANA
320 HA DONG
321 HAI PHONG
322 HAITI
323 HAMBURG
324 HANOI
325 HANOVER
326 HAVANA
327 HEARD & MCDONALD ISLANDS
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Family Socio-Demographic
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328 HERZEGOVINA
329 HESSE
330 HIDALGO
331 HIGH SEAS
332 HOLLAND
333 HONDURAS
334 HONG KONG
335 HUNGARY
336 HYDERABAD
337 ICELAND
338 INDIA
339 INDONESIA
340 INTERNATIONAL WATERS
341 IRAN
342 IRAQ
343 IRELAND
344 IRIAN JAYA
345 IRISH REPUBLIC
346 ISLE OF MAN
347 ISRAEL
348 ITALY
349 IVORY COAST
350 JALISCO
351 JAMAICA
352 JAN MEYAN
353 JAPAN
354 JAVA
355 JERSEY
356 JIBUTI
357 JORDAN
358 JUAN DE NOVA ISLAND
359 JUGOSLAVIA
360 KALININGRAD
361 KAMPUCHEA
362 KASHMIR
363 KAZAKHSTAN
364 KENYA
365 KHANH HUNG
366 KINSHASA
367 KIRIBATI
368 KOREA
369 KORO ISLAND
370 KUWAIT
371 KWAJALEIN
372 KWANTUNG
373 KYRGYZSTAN
374 LABRADOR
375 LABUAN
376 LAOS
377 LATAKIA
378 LATIN AMERICA
379 LATVIA
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Family Socio-Demographic
Document Version Date: 19-Jun-12
380 LEBANON
381 LEEWARD ISLANDS
382 LESOTHO
383 LIBERIA
384 LIBYA
385 LIECHTENSTEIN
386 LITHUANIA
387 LOAS
388 LONDONDERRY
389 LONG XUYEN
390 LORRAINE
391 LUBECK
392 LUXEMBOURG
393 MACAO
394 MACAU
395 MACEDONIA
396 MADAGASCAR
397 MADEIRA ISLANDS
398 MAINLAND CHINA
399 MAJORCA
400 MALAGASY REPUBLIC
401 MALAWI
402 MALAYSIA
403 MALDIVES
404 MALI
405 MALLORCA
406 MALTA
407 MACHURIA
408 MANICA
409 MANILA
410 MANITOBA
411 MARSHALL ISLANDS
412 MARTINIQUE
413 MAURITANIA
414 MAURITIUS
415 MAYOTTE ISLAND
416 MELANESIA
417 MEXICO
418 MICHOACAN
419 MICRONESIA
420 MIDDLE EAST
421 MOLDAVIA
422 MOLDOVA
423 MONACO
424 MONAGAS
425 MONGOLIA
426 MONTENEGRO
427 MONTSERRAT
428 MORELOS
429 MOROCCO
430 MOZAMBIQUE
431 MY THO
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Family Socio-Demographic
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432 N. IRELAND
433 NAM DINH
434 NAMIBIA
435 NAURU
436 NAYARIT
437 NEPAL
438 NETHERLANDS
439 NETH. ANTILLES
440 NETH. EAST INDIES
441 NEVIS ISLAND
442 NEW BRUNSWICK
443 NEW CALEDONIA
444 NEW GUINEA
445 NEW HEBRIDES
446 NEW SOUTH WALES
447 NEW ZEALAND
448 NEWFOUNDLAND
449 NHA TRANG
450 NICARAGUA
451 NIGER
452 NIGERIA
453 NIUE ISLAND
454 NORFOLK ISLAND
455 NORTH AFRICA
456 NORTH AMERICA
457 NORTH KOREA
458 NORTH VIETNAM
459 NORTHERN IRELAND
460 NORTHERN TERRITORY
461 NORWAY
462 NOVA SCOTIA
463 NUEVO LEON
464 OAXACA
465 OCEANIA
466 OKINAWA
467 OMAN
468 ONTARIO
469 OVERSEAS
470 PAKISTAN
471 PALAU
472 PALESTINE
473 PANAMA
474 PANAMA CANAL ZONE
475 PAPUA NEW GUINEA
476 PARACEL ISLANDS
477 PARAGUAY
478 PELAGOSA
479 PEOPLE'S REP. OF CHINA
480 PEOPLE'S REP. OF CONGO
481 PERSIA
482 PERU
483 PHAN THIET
Page 12 of 27
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Family Socio-Demographic
Document Version Date: 19-Jun-12
484 PHILIPPINES
485 PITCAIRN ISLAND
486 POLAND
487 POLYNESIA
488 PONAPE
489 PORTUGAL
490 PORTUGUESE INDIA
491 PRINCE EDWARD ISLAND
492 PRINCIPE ISLAND
494 PRUSSIA
495 PUEBLA
496 PUNJAB
497 PUNJAB, INDIA
498 PUNJAB, PAKISTAN
499 QATAR
500 QUANG LONG
501 QUEBEC
502 QUEENSLAND
503 QUERETARO
504 QUI NHON
505 RACH GIA
506 RAJASTHAN
507 RED CHINA
508 REPUBLIC OF CHINA
509 REPUBLIC OF CYPRUS
510 REPUBLIC OF IRELAND
511 REPUBLIC OF KOREA
512 REPUBLIC OF PANAMA
513 REP. OF PHILIPPINES
514 REP. OF SOUTH AFRICA
515 REPUBLICA DOMINICANA
516 REUNION ISLAND
517 RHODESIA
518 ROC
519 ROK
520 ROMANIA
521 ROTTERDAM
522 RUMANIA
523 RUSSIA
524 RUSSIAN FEDERATION
525 RWANDA
526 SAIGON
527 SALVADOR
528 SAMOA
529 SAN ANDRES
530 SAN LUIS POTOSI
531 SAN MARINO
532 SAN SALVADOR
533 SAO TOME ISLAND
534 SAO TOME & PRINCIPE
535 SARAWAK
536 SASKATCHEWAN
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Family Socio-Demographic
Document Version Date: 19-Jun-12
537 SAUDI ARABIA
538 SAXONY
539 SCOTLAND
540 SENEGAL
541 SEOUL
542 SERBIA
543 SEYCHELLES
544 SHANGHAI
545 SHARJAH
546 SIBERIA
547 SICILY
548 SIERRA LEONE
549 SIKKIM
550 SINALOA
551 SINGAPORE
552 SLAVONIA
553 SLOVAK REPUBLIC
554 SLOVAKIA
555 SLOVENIA
556 SOLOMAN ISLANDS
557 SOMALIA
558 SONORA
559 SOUTH AFRICA
560 SOUTH AMERICA
561 SOUTH AUSTRALIA
562 SOUTH KOREA
563 SOUTH VIETNAM
564 SOUTH WALES
565 SOUTH YEMEN
566 SOUTHEAST ASIA
567 SOUTHERN AFRICA
568 SOUTHERN RHODESIA
569 SOVIET UNION
570 SPAIN
571 SPRATLEY ISLANDS
572 SRI LANKA
573 ST BARTHELEMY
574 ST BARTS
575 ST CHRISTOPHER
576 ST CHRISTOPHER-NEVIS
577 ST EUSTATIUS
578 ST HELENA
579 ST KITTS
580 ST KITTS-NEVIS
581 ST LUCIA
582 ST MAARTEN
583 ST MARTIN
584 ST PIERRE & MIQUELON
585 ST VINCENT
586 ST VINCENT & THE GRENADINES
587 SUDAN
588 SUMATRA
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Family Socio-Demographic
Document Version Date: 19-Jun-12
589 SURINAM
590 SURINAME
591 SVALBARD
592 SWAZILAND
593 SWEDEN
594 SWITZERLAND
595 SYRIA
596 SYRIAN ARAB REP
597 TABASCO
598 TADZHIK
599 TAHITI
600 TAIWAN
601 TAIWAN ROC
602 TAJIKISTAN
603 TAMAULIPAS
604 TANGANYIKA
605 TANGIER
606 TANZANIA
607 TASMANIA
608 THAILAND
609 THANH HOA
610 THE GRENADINES
611 TIBET
612 TIJUANA
613 TLAXCALA
614 TOBAGO
615 TOGO
616 TOGOLAND
617 TOKELAU
618 TONGA
619 TORTOISE ISLANDS
620 TORTOLA
621 TRANSVAAL
622 TRANSYLVANIA
623 TRIESTE
624 TRINIDAD
625 TRINIDAD & TOBAGO
626 TRIPOLI
627 TROMELIN ISLAND
628 TRUK
629 TUNIS
630 TUNISIA
631 TURKEY
632 TURKMENISTAN
633 TURKS & CAICOS IS
634 TURK ISLANDS
635 TUVALU
636 TUY HOA
637 UGANDA
638 UK
639 UKRAINE
640 UKRAINIA
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Family Socio-Demographic
Document Version Date: 19-Jun-12
641 UNION ISLANDS
642 UNION OF SOUTH AFRICA
643 UNION OF SOVIET SOCIALIST REPUBLICS
644 UNITED ARAB EMIRATES
645 UNITED KINGDOM
646 UPPER VOLTA
647 URUGUAY
648 USSR
649 USBEKISTAN
650 VANCOUVER
651 VANUATU
652 VATICAN CITY
653 VENEZUELA
654 VERACRUZ
655 VICTORIA
656 VIETNAM
657 VINH LONG
658 VUNG TAU
659 WALES
660 WALLIS & FUTUNA ISLANDS
661 WEST AFRICA
662 WEST BANK
663 WEST BENGAL
664 WEST INDIES
665 WEST PAKISTAN
666 WESTERN AUSTRALIA
667 WESTERN SAHARA
668 WESTERN SAMOA
669 WHITE RUSSIA
670 WINDWARD ISLANDS
671 WINNIPEG
672 WURZBERG
673 YAP
674 YAR
675 YEMEN
676 YEMEN ARAB REPUBLIC
677 YEREVAN
678 YUCATAN
679 YUGOSLAVIA
680 YUKON TERRITORY
681 ZACATECAS
682 ZADAR
683 ZAIRE
684 ZAMBIA
685 ZANZIBAR
686 ZIMBABWE
687 ZURICH
688 ANDORRA
689 BRITISH INDIAN OCEAN TERRITORY
690 DEUTSCHLAND
691 FRENCH SOUTHERN AND ANTARCTIC LANDS
692 GRENADINES, THE
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Family Socio-Demographic
Document Version Date: 19-Jun-12
693 KOSOVO
694 MYANMAR
695 NORTHWEST TERRITORY
696 NUNAVUT TERRITORY
996 Country not listed
997 Refused
999 Don't know
UniverseText: All persons not born in the United States
SkipInstructions: <60-85> [store "2" in CITIZEN and goto USYR]
<100-696,996,R,D> [goto USYR]
Question ID: FSD.004_00.000 Instrument Variable Name: USYR QuestionnaireFileName: Family
QuestionText: * Read if necessary.
Earlier I recorded [fill1: your/ALIAS's] date of birth as [fill2: AGEDOB@3(text version) AGEDOB@4,
AGEDOB@5].
1880-Current Year 1880-Current Year
9997 Refused
9999 Don't know
UniverseText: All persons not born in the United States
SkipInstructions: <1880-Current Year> [if USYR lt AGEDOB@5, goto ERR2_USYR; else, goto CITIZEN]
<R,D> [goto USLONG]
NOTE: The "*Read if necessary…Earlier I recorded…" portion of this question is included for persons with
complete date of birth information.
Hard Edit: ERR1_USYR
*Future year invalid: [fill: USYR]. Please correct.
ERR2_USYR: * [fill year from USYR] is prior to the person's birth year.
*Please correct.
Page 17 of 27
2011 NHIS Questionnaire Family
Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.005_00.000 Instrument Variable Name: USLONG QuestionnaireFileName: Family
QuestionText: About how long [fill1: have you/has ALIAS] been in the United States?
* Read if necessary: Earlier I recorded that [fill2: you are/ALIAS is] [fill3: AGE] years old.
*Enter '95' for 95 or more years.
*If less than 1 year given as a response, code the answer as '0'.
00-94 00-94 years
95 95+ years
97 Refused
99 Don't know
UniverseText: All persons not born in the United States and refused or don't know was reported for USYR
SkipInstructions: <0-95> [if USLONG gt AGE, goto ERR_USLONG; else, goto CITIZEN]
<R,D> [goto CITIZEN]
Hard Edit: ERR_LONG: * In US longer than alive!
* Please correct.
Page 18 of 27
2011 NHIS Questionnaire Family
Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.006_00.000 Instrument Variable Name: CITIZEN QuestionnaireFileName: Family
QuestionText: (book) F20 ?[F1]
[fill: Are you/Is ALIAS] a CITIZEN of the United States?
1 Yes, born in one of the 50 United States or the District of Columbia
2 Yes, born in Puerto Rico, Guam, American Virgin Islands, or other U.S. territory
3 Yes, born abroad to American parent(s)
4 Yes, U.S. citizen by naturalization
5 No, not a citizen of the United States
7 Refused
9 Don't know
UniverseText: All persons not born in the United States or a United States territory
SkipInstructions: <1> [if PLBORN eq 2, goto ERR1_CITIZEN; else, if PLBORN eq R, goto ERR3_CITIZEN; else, goto
HEADST]
<2> [if (PLBORN eq 2 or PLBORN eq R), goto ERR2_CITIZEN; else, goto HEADST]
Hard Edit: ERR1_CITIZEN
*Already indicated birth outside the United States.
*Please correct.
ERR2_CITIZEN
*Already indicated birth outside United States territory.
*Please correct.
Soft Edit: ERR3_CITIZEN: Refused
Previously, you refused to say if [used/ALIAS] was born in the United States.
Would you like to change your answer to the question?
ERR4_CITIZEN: Don't Know
Previously, you didn't know if [you/ALIAS] were born in the United States.
Would you like to change your answer to the question?
Question ID: FSD.007_00.000 Instrument Variable Name: HEADST QuestionnaireFileName: Family
QuestionText: ?[F1]
Is [fill: ALIAS] now attending Head Start?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons less than 7 years of age
SkipInstructions: <1> [if no more persons less than 7 years of age, goto EDUC; else, repeat this question for the next eligible
person]
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Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.008_00.000 Instrument Variable Name: HEADSTEV QuestionnaireFileName: Family
QuestionText: Has [fill: ALIAS] ever attended Head Start?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons less than 18 years of age and not currently enrolled in Head Start
SkipInstructions: if no more persons less than 7 years of age, goto EDUC; else, goto HEADST for the next eligible person
Page 20 of 27
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Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.010_00.000 Instrument Variable Name: EDUC QuestionnaireFileName: Family
QuestionText: (book) F21 ?[F1]
What is the HIGHEST level of school [fill: you have/ALIAS has] completed or the highest degree [fill: you
have/ALIAS has] received? Please tell me the number from the card.
* Enter highest level of school completed.
00 Never attended/kindergarten only
01 1st grade
02 2nd grade
03 3rd grade
04 4th grade
05 5th grade
06 6th grade
07 7th grade
08 8th grade
09 9th grade
10 10th grade
11 11th grade
12 12th grade, no diploma
13 GED or equivalent
14 High School Graduate
15 Some college, no degree
16 Associate degree: occupational, technical, or vocational program
17 Associate degree: academic program
18 Bachelor's degree (Example: BA, AB, BS, BBA)
19 Master's degree (Example: MA, MS, MEng, MEd, MBA)
20 Professional School degree (Example: MD, DDS, DVM, JD)
21 Doctoral degree (Example: PhD, EdD)
96 Child under 5 years old
97 Refused
99 Don't know
UniverseText: All persons 5 years of age or older
SkipInstructions: repeat for all eligible persons, then goto ARMFVER
Page 21 of 27
2011 NHIS Questionnaire Family
Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.020_00.000 Instrument Variable Name: ARMFVER QuestionnaireFileName: Family
QuestionText: Earlier [fill1: you said/it was said] [fill2: you/alias] [fill3: were/was] on full-time active duty with the Armed Forces.
Is this correct?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with a person age 18 or older who were said to be on active duty in the armed forces in the HHC
section
SkipInstructions: <1> [goto ARMFFC] <2,R,D> [goto ARMFEV]
Question ID: FSD.021_00.000 Instrument Variable Name: ARMFEV QuestionnaireFileName: Family
QuestionText: [fill1: Have you/Has alias] ever served on active duty in the U.S. Armed Forces, military Reserves, or National
Guard?
*Read if necessary. Active duty does not include training for the Reserves or National Guard, but DOES include
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with a person age 18 or older who is not currently on active duty or said R,D to active duty
SkipInstructions: <1> [goto ARMFFC] <2,R,D> [goto DOINGLW]
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2011 NHIS Questionnaire Family
Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.022_00.000 Instrument Variable Name: ARMFFC QuestionnaireFileName: Family
QuestionText: Did [fill1: you/alias] ever serve in a foreign country during a time of armed conflict or on a humanitarian or peace-
keeping mission?
*Read if necessary. This would include National Guard or reserve or active duty monitoring or conducting peace
keeping operations in Bosnia Kosovo, in the Sinai between Egypt and Israel, or in response to the 2004 tsunami, or
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with a person age 18 or older who has ever served in the armed forces
SkipInstructions: <1,2,R,D> [goto ARMFTMP]
Question ID: FSD.023_00.000 Instrument Variable Name: ARMFTMP QuestionnaireFileName: Family
QuestionText: When did [fill1: you/alias] serve on ACTIVE DUTY in the U.S. Armed Forces?
*Enter all that apply, separate with commas.
*Enter all periods in which this person served. Enter the item even if the person served for just part of that period.
01 Sept 2001 or later
02 August 1990 to August 2001 (including Persian Gulf War)
03 September 1980 to July 1990
04 May 1975 to August 1980
05 Vietnam era (August 1964 to April 1975)
06 March 1961 to July 1964
07 February 1955 to February 1961
08 Korean War (July 1950 to January 1955)
09 January 1947 to June 1950
10 World War II (December 1941 to December 1946)
11 November 1941 or earlier
97 Refused
99 Don’t know
UniverseText: All families with a person age 18 or older who has ever served in the armed forces
SkipInstructions: <1,3-11,R,D> [goto DOINGLW] <2> [goto ARMFDS]
Hard Edit: If gray answer code is selected please display:
That selection is not valid at this time.
Please correct.
Page 23 of 27
2011 NHIS Questionnaire Family
Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.024_00.000 Instrument Variable Name: ARMFDS QuestionnaireFileName: Family
QuestionText: Did [fill1: you/alias] serve in the Persian Gulf during Operation Desert Shield or Operation Desert Storm between
August 1990 and April 1991?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with a person age 18 or older who served from August 1990 to August 2001
SkipInstructions: <1,2,R,D> [goto DOINGLW]
Question ID: FSD.050_00.000 Instrument Variable Name: DOINGLW QuestionnaireFileName: Family
QuestionText: (book) F22 ? [F1]
The next few questions are about employment status.
Which of the following [fill: were you/was ALIAS] doing last week?
* Read answer categories.
1 Working for pay at a job or business
2 With a job or business but not at work
3 Looking for work
4 Working, but not for pay, at a family-owned job or business
5 Not working at a job or business and not looking for work
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older
SkipInstructions: <1,4> [goto WRKHRS]
<2,5> [goto WHYNOWRK]
<3,R,D> [goto WRKLYR]
NOTE: A flashcard was added to this question in quarter 3 of 2005.
Page 24 of 27
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Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.060_00.000 Instrument Variable Name: WHYNOWRK QuestionnaireFileName: Family
QuestionText: ?[F1]
What is the main reason [fill1: you/ALIAS] did not [fill2: work last week/have a job or business last week]?
01 Taking care of house or family
02 Going to school
03 Retired
04 On a planned vacation from work
05 On family or maternity leave
06 Temporarily unable to work for health reasons
07 Have job/contract and off-season
08 On layoff
09 Disabled
10 Other
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who were either with a job or business but not at work, or not working at
a job or business and not looking for work
SkipInstructions: <1-3,8-10,R,D> [goto WRKLYR]
<4-7> [goto WRKHRS]
Question ID: FSD.070_00.000 Instrument Variable Name: WRKHRS1 QuestionnaireFileName: Family
QuestionText: ?[F1]
How many hours [fill: did you work LAST WEEK at ALL jobs or businesses/did ALIAS work LAST WEEK at
ALL jobs or businesses/do you USUALLY work at ALL jobs or businesses/does ALIAS USUALLY work at ALL
jobs or businesses]?
001-168 1-168 hours
997 Refused
999 Don't know
UniverseText: All persons 18 years of age or older who were working for pay at a job or business, or working, but not for
pay, at a job or business last week, or on a planned vacation from work, or on family or maternity leave, or
temporarily unable to work for health reasons, or have a job/contract and off-season
SkipInstructions: <1-34,R,D> [goto WRKFTALL]
<35-94> [goto WRKLYR]
<95-168> [goto ERR1_WRKHRS]
Soft Edit: * [Fill: WRKHRS] is an unusually high number.
* Please verify.
Page 25 of 27
2011 NHIS Questionnaire Family
Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.080_00.000 Instrument Variable Name: WRKFTALL QuestionnaireFileName: Family
QuestionText: ?[F1]
[fill: Do you/Does ALIAS] USUALLY work 35 hours or more per week in total at ALL jobs or businesses?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who worked less than 35 hours last week or did not know/refused to
answer how many hours they worked last week
SkipInstructions: [goto WRKLYR]
NOTE ON QUESTIONNAIRE FLOW: The instrument cycles through the appropriate questions from
DOINGLW to WRKFTALL for each eligible person, then proceeds to WRKLYR.
Question ID: FSD.100_00.000 Instrument Variable Name: WRKLYR QuestionnaireFileName: Family
QuestionText: ?[F1]
Did [fill1: you/ALIAS] work for pay at any time in [fill2: last calendar year in 4-digit format]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older
SkipInstructions: <1> [goto WRKMYR]
<2,R,D> [goto HIEMPOF]
Page 26 of 27
2011 NHIS Questionnaire Family
Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.110_00.000 Instrument Variable Name: WRKMYR QuestionnaireFileName: Family
QuestionText: How many months in [fill1: last calendar year in 4-digit format] did [fill2: you/ALIAS] have at least one job or
business?
01 1 month or less
02-12 2-12 months
97 Refused
99 Don't know
UniverseText: All persons 18 years of age or older who worked last year
SkipInstructions: goto ERNYR
Question ID: FSD.120_00.000 Instrument Variable Name: ERNYR QuestionnaireFileName: Family
QuestionText: ?[F1]
What is your best estimate of [fill1: your/ALIAS's] earnings before taxes and deductions from ALL jobs and
businesses in [fill2: last calendar year in 4-digit format]?
Include hourly wages, salaries, tips and commissions.
* Enter '999,995' if the reported income is greater than $999,995.
000001- 999994 $1-$999,994
999995 $999,995+
999997 Refused
999999 Don't know
UniverseText: All persons 18 years of age or older who worked last year
SkipInstructions: goto HIEMPOF
Page 27 of 27
2011 NHIS Questionnaire Family
Family Socio-Demographic
Document Version Date: 19-Jun-12
Question ID: FSD.130_00.000 Instrument Variable Name: HIEMPOF QuestionnaireFileName: Family
QuestionText: Regarding [fill1: your/ALIAS's] job or work last week, was health insurance offered to [fill2: you/ALIAS] through
[fill1: your/ALIAS's] workplace?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons 18 years of age or older who were working for pay at a job or business, or with a job or business,
but not at work, or working, but not for pay, at a family-owned job or business
SkipInstructions: goto INTROINC
NOTE ON QUESTIONNAIRE FLOW: The instrument cycles through the appropriate questions from
WRKLYR to HIEMPOF for each eligible person, then proceeds to INTROINC.
Page 1 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.010_00.000 Instrument Variable Name: FINCINT QuestionnaireFileName: Family
QuestionText: * Read the following.
The next questions are about [fill1: your total/your total family] income in [fill2: last calendar year in 4-digit format]
BEFORE TAXES.
Income is important in analyzing the health information we collect. For example, with this information, we can learn
whether persons in one income group use certain types of medical services more or less often than those in another
group. Please be assured that, like all other information you have provided, these answers will be kept strictly
confidential.
1 Enter 1 to continue
UniverseText: All families
SkipInstructions: goto FSAL
Question ID: FIN.030_00.000 Instrument Variable Name: FSAL QuestionnaireFileName: Family
QuestionText: ? [F1]
[fill1: Did you receive income in [fill2: last calendar year in 4-digit format] from wages and salaries?]
[fill3: When answering these questions, please remember that by "combined family income," I mean your income
PLUS the income of all family members living in this household (including cohabiting partners, and armed forces
members living at home).
Did any family members 18 and older, that is * Read names
(fill roster of people ge 18 years of age)
receive income in [fill2: last calendar year in 4-digit format] from...wages and salaries?]
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with one or more persons 18 years of age or older
SkipInstructions: <1> [if a single-person family, store the person number in PSAL and goto FSEINC; else, goto PSAL]
<2,R,D> [goto FSEINC]
Page 2 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.040_00.000 Instrument Variable Name: PSAL QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons 18 years of age or older and at least one received income from wages and
salaries in the last calendar year
SkipInstructions: goto FSEINC
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Question ID: FIN.050_00.000 Instrument Variable Name: FSEINC QuestionnaireFileName: Family
QuestionText: [fill1: Did you receive income in [fill2: last calendar year in 4-digit format] from self-employment including business
and farm income?/ Did ALIAS receive income in [fill2: last calendar year in 4-digit format] from self-employment
including business and farm income?/Did any family members 18 and older, that is
*Read names
(fill roster of people ge 18 years of age)
receive income in [fill2: last calendar year in 4-digit format] from...self-employment including business and farm
income?]
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with one or more persons 18 years of age or older
SkipInstructions: <1> [if a single-person family, store the person number in PSEINC and goto FSSRR; else, goto PSEINC]
<2,R,D> [goto FSSRR]
Page 3 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.060_00.000 Instrument Variable Name: PSEINC QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons 18 years of age or older and at least one received income from self-
employment in the last calendar year
SkipInstructions: goto FSSRR
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Question ID: FIN.070_00.000 Instrument Variable Name: FSSRR QuestionnaireFileName: Family
QuestionText: ? [F1]
Did [fill1: you/any family members living here] receive income in [fill2: last calendar year in 4-digit format] from
Social Security or Railroad Retirement?
* Read if necessary: Social Security checks are either automatically deposited in the bank or mailed to arrive on the
third of every month.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PSSRR and goto FSSRRD; else, goto PSSRR]
<2,R,D> [goto FPENS]
Page 4 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.080_00.000 Instrument Variable Name: PSSRR QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one received income from Social Security or Railroad
Retirement in the last calendar year
SkipInstructions: goto FSSRRD
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Question ID: FIN.082_00.000 Instrument Variable Name: FSSRRD QuestionnaireFileName: Family
QuestionText: Was [fill: your/any family member's *Read names
(fill roster of all persons selected at PSSRR and AGE LE 64)]
Social Security or Railroad Retirement income received as a disability benefit?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with persons less than 65 years of age who received Social Security or Railroad Retirement
income in the last calendar year
SkipInstructions: <1> [if only one person less than 65 years of age received Social Security or Railroad Retirement income, fill
the person number in PSSRRDB and goto PSSRRD; else, goto PSSRRDB]
<2,R,D> [goto FPENS]
Page 5 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.084_00.000 Instrument Variable Name: PSSRRDB QuestionnaireFileName: Family
QuestionText: *Ask or verify. Enter applicable line number(s), separate with commas.
Who received Social Security or Railroad Retirement as a disability benefit?
(Anyone else?)
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons less than 65 years of age who received income from Social Security or
Railroad Retirement in the last calendar year and at least one received the income as a disability benefit
SkipInstructions: goto PSSRRD
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Question ID: FIN.086_00.000 Instrument Variable Name: PSSRRD QuestionnaireFileName: Family
QuestionText: Did [fill1: you/ALIAS] receive this benefit because [fill2: you are/he is/she is] disabled?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons less than 65 years of age who received Social Security or Railroad Retirement income as a
disability benefit in the last calendar year
SkipInstructions: repeat for all eligible persons, then goto FPENS
Page 6 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.090_00.000 Instrument Variable Name: FPENS QuestionnaireFileName: Family
QuestionText: Did [fill1: you/any family members living here] receive income in [fill2: last calendar year in 4-digit format] from any
disability pension [fill3: other than Social Security or Railroad Retirement]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PPENS and goto FOPENS; else, goto PPENS]
<2,R,D> [goto FOPENS]
Question ID: FIN.100_00.000 Instrument Variable Name: PPENS QuestionnaireFileName: Family
QuestionText: *Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
*Indicate each family member with this income.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one received income from a disability pension (other than
Social Security or Railroad Retirement) in the last calendar year
SkipInstructions: goto FOPENS
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 7 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.102_00.000 Instrument Variable Name: FOPENS QuestionnaireFileName: Family
QuestionText: Did [fill1: you/any family members living here] receive income from any retirement or survivor pension other [fill2:
than Social Security or Railroad Retirement/than a disability pension/than Social Security, Railroad Retirement, or a
disability pension]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in POPENS and goto FSSI; else, goto POPENS]
<2,R,D> [goto FSSI]
Question ID: FIN.104_00.000 Instrument Variable Name: POPENS QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one received income from a retirement or survivor pension in
the last calendar year
SkipInstructions: goto FSSI
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 8 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.110_00.000 Instrument Variable Name: FSSI QuestionnaireFileName: Family
QuestionText: ? [F1]
Did [fill: you/any family members] receive Supplemental Security Income (SSI)?
* Read if necessary: Federal SSI checks are either automatically deposited in the bank or mailed to arrive on the first
of every month.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, fill the person number in PSSI and goto PSSID; else, goto PSSI]
<2,R,D> [goto FTANF]
Question ID: FIN.120_00.000 Instrument Variable Name: PSSI QuestionnaireFileName: Family
QuestionText: *Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family received this?
(Anyone else?)
*Indicate each family member with this income.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one received Supplemental Security Income (SSI) in the last
calendar year
SkipInstructions: goto PSSID
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 9 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.122_00.000 Instrument Variable Name: PSSID QuestionnaireFileName: Family
QuestionText: Did [fill1: you/ALIAS] receive SSI because [fill2: you have/he has/she has] a disability?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons who received SSI in the last calendar year
SkipInstructions: repeat for all eligible persons, then goto FTANF
Question ID: FIN.150_00.000 Instrument Variable Name: FTANF QuestionnaireFileName: Family
QuestionText: ? [F1]
At any time during [fill1: last calendar year in 4-digit format], even for one month, did [fill2: you/any family members
living here] receive any CASH assistance from a state or county welfare program, such as (* fill specific program
name)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PTANF and goto FOWBEN; else, goto PTANF]
<2,R,D> [goto FOWBEN]
Page 10 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.160_00.000 Instrument Variable Name: PTANF QuestionnaireFileName: Family
QuestionText: *Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family received this?
(Anyone else?)
*Indicate each family member with this income.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one received cash assistance from a state or county welfare
program in the last calendar year
SkipInstructions: goto FOWBEN
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Question ID: FIN.164_00.000 Instrument Variable Name: FOWBEN QuestionnaireFileName: Family
QuestionText: At any time during [fill1: last calendar year in 4-digit format], did [fill2: you/any family members living here] receive
any OTHER kind of welfare assistance such as help with getting a job, placement in education or job training
programs, or help with transportation or child care?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in POWBEN and goto FINTRST; else, goto
POWBEN]
Page 11 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.166_00.000 Instrument Variable Name: POWBEN QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one received income from some "other" kind of welfare
assistance in the last calendar year
SkipInstructions: goto FINTRST
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Question ID: FIN.170_00.000 Instrument Variable Name: FINTRST QuestionnaireFileName: Family
QuestionText: Did [fill: you/any family members living here] receive income from interest bearing checking accounts, savings
accounts, IRAs or certificates of deposit, money market funds, treasury notes, bonds, or any other investments that
earn interest?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PINTRST and goto FDIVD; else, goto PINTRST]
<2,R,D> [goto FDIVD]
Page 12 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.180_00.000 Instrument Variable Name: PINTRST QuestionnaireFileName: Family
QuestionText: *Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one received interest income in the last calendar year
SkipInstructions: goto FDIVD
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Question ID: FIN.190_00.000 Instrument Variable Name: FDIVD QuestionnaireFileName: Family
QuestionText: Did [fill: you/any family members living here] receive income from dividends from stocks or mutual funds, or net
rental income from property, royalties, estates or trusts?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PDIVD and goto FCHLDSP; else, goto PDIVD]
<2,R,D> [goto FCHLDSP]
Page 13 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.200_00.000 Instrument Variable Name: PDIVD QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s). Separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one received dividend or net rental income in the last
calendar year
SkipInstructions: goto FCHLDSP
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Question ID: FIN.210_00.000 Instrument Variable Name: FCHLDSP QuestionnaireFileName: Family
QuestionText: ? [F1]
Did [fill: you/any family members living here] receive income from child support?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PCHLDSP and goto FINCOT; else, goto
PCHLDSP]
Page 14 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.220_00.000 Instrument Variable Name: PCHLDSP QuestionnaireFileName: Family
QuestionText: *Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate which child in the family this is for. If that child is no longer residing with this family, enter line number of
custodial parent.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one received income from child support in the last calendar
SkipInstructions: goto FINCOT
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Question ID: FIN.230_00.000 Instrument Variable Name: FINCOT QuestionnaireFileName: Family
QuestionText: Did [fill: you/any family members living here] receive income from any other source such as alimony, contributions
from family/others, VA payments, Worker’s Compensation, or unemployment compensation?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PINCOT and goto FINCTOT; else, goto PINCOT]
<2,R,D> [goto FINCTOT]
Page 15 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.240_00.000 Instrument Variable Name: PINCOT QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who received this?
(Anyone else?)
* Indicate each family member with this income
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one received some "other" source of income in the last
calendar year
SkipInstructions: goto FINCTOT
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Question ID: FIN.250_00.000 Instrument Variable Name: FINCTOT QuestionnaireFileName: Family
QuestionText: [fill1: When answering this next question, please remember to include your income PLUS the income of all family
members living in this household.]
What is your best estimate of [fill2: your total income/the total income of all family members] from all sources, before
taxes, in [fill3: last calendar year in 4 digit format]?
* Enter ‘999,995’ if the reported income is greater than $999,995.
000000-999994 $0-$999,994
999995 $999,995+
999997 Refused
999999 Don't know
UniverseText: All families
SkipInstructions: <0-999> goto ERR1_FINCTOT
<250001-999995> goto ERR2_FINCTOT
if edit suppressed and INC_FLG = 1 and INCDISC =1 then goto FINCEDIT else goto HOUSEOWN
<1000-250000> if INC_FLG = 1 and INCDISC =1 then goto FINCEDIT else goto HOUSEOWN
<D,R> goto FINC50
Soft Edit: ERR1_FINCTOT:
* Do not read to the respondent.
* $[fill: FINCTOT] is unusually low. Make corrections if necessary.
ERR2_FINCTOT:
* Do not read to the respondent.
* $[fill: FINCTOT] is unusually high. Make corrections if necessary.
Page 16 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.255_00.000 Instrument Variable Name: FINC50 QuestionnaireFileName: Family
QuestionText: Was your total [fill: family] income from all sources less than $50,000 or $50,000 or more?
1 Less than $50,000
2 $50,000 or more
7 Refused
9 Don't know
UniverseText: Respondents who don't know or refuse their income
SkipInstructions: <1> [goto FINC35]
<2> [goto FINC100]
<R,D> [HOUSEOWN]
Question ID: FIN.260_00.000 Instrument Variable Name: FINC35 QuestionnaireFileName: Family
QuestionText: Was your total [fill: family] income from all sources less than $35,000 or $35,000 or more?
1 Less than $35,000
2 $35,000 or more
7 Refused
9 Don't know
UniverseText: The respondent answered Less than $50,000 in FINC50
SkipInstructions: <1> if PCNT <= '5', goto FINCPOV;
else goto HOUSEOWN
<2> if PCNT = '4', goto F200PV35;
elseif PCNT = '8', goto FINCPOV;
else goto HOUSEOWN
<R,D> goto HOUSEOWN
Page 17 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.261_00.000 Instrument Variable Name: F200PV35 QuestionnaireFileName: Family
QuestionText: Was your total family income from all sources less than [fill1: fill based on 200% poverty threshold] or [fill1: fill
based on 200% poverty threshold] or more?
1 Less than [$45,000]
2 [$45,000] or more
7 Refused
9 Don't Know
UniverseText: The respondent answered More than $35,000 and there are 4 persons in the family
SkipInstructions: <1,2,R,D> [goto HOUSEOWN]
Question ID: FIN.265_00.000 Instrument Variable Name: FINCPOV QuestionnaireFileName: Family
QuestionText: Was your total [fill1: family] income from all sources less than [fill2: fill based on poverty threshold] or [fill2: fill
based on poverty threshold] or more?
1 Less than [$10,500/$11,500/$13,000/$14,500/$17,000/$22,500/$27,000/$40,000]
2 [$10,500/$11,500/$13,000/$14,500/$17,000/$22,500/$27,000/$40,000] or more
7 Refused
9 Don't know
UniverseText: The respondent answered Less than $35,000 and there were 5 or fewer persons in the family or the respondent
answered $35,000 or More and there were 8 persons in the family
SkipInstructions: <1,R,D> goto HOUSEOWN
<2> if PCNT le ’2' [goto F200POV]
elseif PCNT gt ‘2’ [goto HOUSEOWN]
Question ID: FIN.268_00.000 Instrument Variable Name: F200POV QuestionnaireFileName: Family
QuestionText: Was your total [fill1: family/<blank>] income from all sources less than [fill2: fill based on 200% poverty threshold]
or [fill2: fill based on 200% poverty threshold] or more?
1 Less than [$21,000/$23,000/$26,000/$29,000]
2 [$21,000/$23,000/$26,000/$29,000] or more
7 Refused
9 Don't know
UniverseText: The respondent answered More than poverty threshold and there are 2 or fewer persons in the family
SkipInstructions: <1,2,R,D> [goto HOUSEOWN]
Page 18 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.270_00.000 Instrument Variable Name: FINC100 QuestionnaireFileName: Family
QuestionText: Was your total [fill: family] income from all sources less than $100,000 or $100,000 or more?
1 Less than $100,000
2 $100,000 or more
7 Refused
9 Don't know
UniverseText: The respondent answered More than $50,000 in FINC50
SkipInstructions: <1> [goto FINC75]
<2> [goto FINC150]
<R,D> [goto HOUSEOWN]
Question ID: FIN.272_00.000 Instrument Variable Name: FINC150 QuestionnaireFileName: Family
QuestionText: Was your total [fill: family] income from all sources less than $150,000 or $150,000 or more?
1 Less than $150,000
2 $150,000 or more
7 Refused
9 Don't know
UniverseText: The respondent answered $100,000 or more in FINC100
SkipInstructions: <1,2,R,D> [goto HOUSEOWN]
Question ID: FIN.275_00.000 Instrument Variable Name: FINC75 QuestionnaireFileName: Family
QuestionText: Was your total [fill: family] income from all sources less than $75,000 or $75,000 or more?
1 Less than $75,000
2 $75,000 or more
7 Refused
9 Don't know
UniverseText: The respondent answered Less than $100,000 in FINC100
SkipInstructions: <1> if PCNT = ‘6’, goto F200PV75;
else goto HOUSEOWN
<2> if PCNT = '8', goto F200PV75;
else goto HOUSEOWN
<R,D> goto HOUSEOWN
Page 19 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.276_00.000 Instrument Variable Name: F200PV75 QuestionnaireFileName: Family
QuestionText: Was your total family income from all sources less than [fill1: fill based on 200% poverty threshold] or [fill1: fill
based on 200% poverty threshold] or more?
1 Less than [$62,000/$80,000]
2 [$62,000/$80,000] or more
7 Refused
9 Don't know
UniverseText: The respondent answered Less than $75,000 and there are 6 persons in the family OR The respondent
answered $75,000 or More and there are 8 persons in the family
SkipInstructions: <1,2,R,D> [goto HOUSEOWN]
Question ID: FIN.280_00.000 Instrument Variable Name: HOUSEOWN QuestionnaireFileName: Family
QuestionText: Is this house/apartment owned or being bought, rented, or occupied by some other arrangement by you [fill: /or
someone in your family]?
1 Owned or being bought
2 Rented
3 Other arrangement
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1,3,R,D> [goto FSSAPL]
<2> [goto FGAH]
Question ID: FIN.282_00.000 Instrument Variable Name: FGAH QuestionnaireFileName: Family
QuestionText: ? [F1]
[fill: Are you/Is anyone in your family] paying lower rent because the Federal, State, or local government is paying
part of the cost?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families that rent their house/apartment
SkipInstructions: goto FSSAPL
Page 20 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.300_00.000 Instrument Variable Name: FSSAPL QuestionnaireFileName: Family
QuestionText: [fill: Have you EVER applied for Supplemental Security Income or SSI, even if the claim was denied?/Have any
family members living here EVER applied for Supplemental Security Income (SSI)? This includes people who
applied for benefits, even if the claim was denied.]
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [if a single-person family, store the person number in PSSAPL and goto FSDAPL; else, goto PSSAPL]
<2,R,D> [goto FSDAPL]
Question ID: FIN.310_00.000 Instrument Variable Name: PSSAPL QuestionnaireFileName: Family
QuestionText: *Ask or verify. Enter applicable line number(s), separate with a comma.
Who in the family applied for it?
(Anyone else?)
* Indicate each family member who applied for SSI benefits.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one applied for SSI
SkipInstructions: goto FSDAPL
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 21 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.330_00.000 Instrument Variable Name: FSDAPL QuestionnaireFileName: Family
QuestionText: [fill: Have you EVER APPLIED for disability benefits from Social Security even if the claim was denied?/Have any
family members living here EVER applied for disability benefits from Social Security? This includes people who
applied for benefits, even if the claim was denied.]
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All Families
SkipInstructions: <1> [if a single-person family, store the person number in PSDAPL and goto TANFMYR; else, goto
PSDAPL]
Question ID: FIN.340_00.000 Instrument Variable Name: PSDAPL QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family applied for it?
(Anyone else?)
* Indicate each family member who applied for Social Security Disability benefits.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons and at least one applied for Social Security Disability benefits
SkipInstructions: goto TANFMYR
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 22 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.350_00.000 Instrument Variable Name: TANFMYR QuestionnaireFileName: Family
QuestionText: ? [F1]
Earlier I recorded that [fill1: you/ALIAS] received cash assistance from programs such as welfare or public assistance
in [fill2: last calendar year in 4-digit format]. During [fill2: last calendar year in 4-digit format], about how many
months did [fill1: you/ALIAS] receive this assistance?
*Enter '1' if less than one month.
01-12 1-12 months
97 Refused
99 Don't know
UniverseText: All persons who received cash assistance from public assistance programs in the last calendar year
SkipInstructions: repeat for all eligible persons, then goto FSNAP
Question ID: FIN.360_00.000 Instrument Variable Name: FSNAP QuestionnaireFileName: Family
QuestionText: ?[F1]
At any time during [fill 1: last calendar year in 4-digit format], did [fill 2: you/any family members living here] receive
[fill 3: food stamp benefits/SNAPNAME or food stamp benefits]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families
SkipInstructions: <1> [goto FSNAPMYR]
<2, D, R> [Goto FINWIC to see if family falls into the universe for this question.]
Page 23 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.380_00.000 Instrument Variable Name: FSNAPMYR QuestionnaireFileName: Family
QuestionText: ?[F1]
During [fill 1: last year in 4 digit format], about how many months were [fill 2: food stamp benefits/SNAPNAME or
food stamp benefits] received?
* Enter "1" if less than 1 month
01-12 Months
97 Refused
99 Don't know
UniverseText: Family received food stamp/SNAP benefits in previous calendar year
SkipInstructions: Goto FINWIC to see if family fits into universe for this question.
Question ID: FIN.384_00.000 Instrument Variable Name: FINWIC QuestionnaireFileName: Family
QuestionText: ? [F1]
At any time during [fill1: last calendar year in 4-digit format] did [fill2: you/anyone in your family] receive benefits
from the WIC program, that is, the Women, Infants and Children program?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with females 12-55 years of age or children 0-5 years of age
SkipInstructions: <1> [if a single-person family, store the person number in PWIC and goto FMSSN; else, goto PWIC]
<2,R,D> [goto FMSSN]
Page 24 of 24
2011 NHIS Questionnaire Family
Family Income
Document Version Date: 19-Jun-12
Question ID: FIN.385_00.000 Instrument Variable Name: PWIC QuestionnaireFileName: Family
QuestionText: * Ask or verify. Enter applicable line number(s), separate with commas.
Who in the family received this?
(Anyone else?)
* Indicate family members who were authorized to receive WIC benefits.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All families with two or more persons who are female and between the ages of 12-55 or children between the
ages of 0-5, and at least one received WIC benefits in the last calendar year
SkipInstructions: goto FMSSN
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data
Page 1 of 2
2011 NHIS Questionnaire Family
Family Disability: Version 2
Document Version Date: 19-Jun-12
Question ID: FDB.020_00.000 Instrument Variable Name: P2DFHEAR QuestionnaireFileName: Family
QuestionText: With this next set of questions, we want to learn about people who have physical, mental, or emotional conditions
that cause serious difficulties with their daily activities. Though different, these questions may sound similar to ones
I asked earlier.
[fill 1: Are you/Is ALIAS] deaf or [fill 2: do you/does ALIAS] have serious difficulty hearing?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons age 1 or older and random number generator=2
SkipInstructions: <1,2,D,R> goto P2DFSEE
Question ID: FDB.040_00.000 Instrument Variable Name: P2DFSEE QuestionnaireFileName: Family
QuestionText: [fill 1: Are you/Is ALIAS] blind or [fill 2: do you/does ALIAS] have serious difficulty seeing even when wearing
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons age 1 or older
SkipInstructions: <1,2,D,R> if no more persons age 5 or older, goto next section;
else goto P2DFCON
Question ID: FDB.060_00.000 Instrument Variable Name: P2DFCON QuestionnaireFileName: Family
QuestionText: Because of a physical, mental, or emotional condition, [fill 1: do you/does ALIAS] have serious difficulty
concentrating, remembering, or making decisions?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons age 5 or older and random number generator=2
SkipInstructions: <1,2,D,R> goto P2DFWALK
Page 2 of 2
2011 NHIS Questionnaire Family
Family Disability: Version 2
Document Version Date: 19-Jun-12
Question ID: FDB.080_00.000 Instrument Variable Name: P2DFWALK QuestionnaireFileName: Family
QuestionText: [fill 1: Do you/Does ALIAS] have serious difficulty walking or climbing stairs?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons age 5 or older and random number generator=2
SkipInstructions: <1,2,D,R> goto P2DFDRES
Question ID: FDB.100_00.000 Instrument Variable Name: P2DFDRES QuestionnaireFileName: Family
QuestionText: [fill 1: Do you/Does ALIAS] have difficulty dressing or bathing?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons 5 or older
SkipInstructions: <1,2,D,R> if no more persons age 15 or older, goto next section;
else goto P2DFERR
Question ID: FDB.120_00.000 Instrument Variable Name: P2DFERR QuestionnaireFileName: Family
QuestionText: Because of a physical, mental, or emotional condition, [fill 1: do you/does ALIAS] have difficulty doing errands
alone such as visiting a doctor's office or shopping?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: All persons 15 or older
SkipInstructions: <1,2,D,R> if no more persons age 1 or older, goto next section;
else return to P2DFHEAR for next person age 1 or older
Page 1 of 9
2011 NHIS Questionnaire Sample Child
Child Identification
Document Version Date: 19-Jun-12
Question ID: CID.001_00.000 Instrument Variable Name: CURRES QuestionnaireFileName: Sample Child
QuestionText: * Enter the line number of the person to whom you are speaking.
01-25 Person number of the respondent for Sample Child
UniverseText: Sample child section not started or not completed
SkipInstructions: if CSTAT ne empty and CSTAT ne '2' THEN
if ASTAT = empty or ASTAT = '2' THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG ne '1' THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
goto back.OUTCOMEB1 procedure
endif
<01-25> if this is NOT an allowable line number
goto ERR_CURRES
elseif CURRES = a line number entered in KNOWSC2
store CURRES in CSPAVAIL and CSRESP
goto CSRELTIV
elseif KNOWSC2 = 'Don't know' or 'Refused' or empty (no line numbers in KNOWSC2)
goto KNOAVAIL
else
goto CSPAVAIL
endif
Hard Edit: ERR_CURRES
* You have selected a non-selectable person.
* Please correct.
Page 2 of 9
2011 NHIS Questionnaire Sample Child
Child Identification
Document Version Date: 19-Jun-12
Question ID: CID.010_00.000 Instrument Variable Name: CSPAVAIL QuestionnaireFileName: Sample Child
QuestionText: The next questions are about [fill1: ALIAS of Sample Child].
Is [fill2:KNOWSC2 names] available to answer some questions about [fill3: HISHER] health?
* Enter line number of available respondent from list or enter '96' if no one is available.
* If refused enter CTRL_R.
01-25 Person # of person available to answer questions about Sample Child
96 No person available
UniverseText: Someone identified as knowledgeable about child's health and knowledgeable person(s) not entered in
SkipInstructions: <01-25> if line number not equal one of the line numbers in KNOWSC2
goto child.cid.ERR_CSPAVAIL
else
store child.cid.CSPAVAIL in child.cid.CSRESP
goto child.cid.CSRELTIV
endif
<96> store child.cid.CSPAVAIL in child.cid.CSRESP
goto cbk.CCALLBK1
<R> store '4' in CSTAT(FAMINT)
if ASTAT = empty or ASTAT = '2' THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG ne '1' THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
Hard Edit: ERR_CSPAVAIL
* You have selected a non-selectable person.
* Please correct.
Page 3 of 9
2011 NHIS Questionnaire Sample Child
Child Identification
Document Version Date: 19-Jun-12
Question ID: CID.030_00.000 Instrument Variable Name: CSRELTIV QuestionnaireFileName: Sample Child
QuestionText: (book) C1
[fill1: The next questions are about [fill2: ALIAS of Sample Child].]
What is your relationship to [fill2: ALIAS of Sample Child]?
01 Parent (Biological, adoptive, or step)
02 Grandparent
03 Aunt/Uncle
04 Brother/Sister
05 Other relative
06 Legal guardian
07 Foster parent
08 Other non-relative
97 Refused
99 Don't know
UniverseText: Someone identified as knowledgeable about child's health
SkipInstructions: <1-8,R,D> If CSRESP = demographics.hhc.RELRESP_A
goto child.chs.BWGT_LB
elseif CSRESP = demographics.hhc.HHRESP
goto child.chs.BWGT_LB
else]
goto CSPVERF_S
endif]
Question ID: CID.040_00.000 Instrument Variable Name: CSPVERF_S QuestionnaireFileName: Sample Child
QuestionText: * Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s sex as [fill2: Sex of Sample Child]. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".
1 Yes
2 No
UniverseText: Respondent is not the person entered in HHRESP or RELRESP_A.
SkipInstructions: <1> goto CSPVERF_A
<2> goto NEWSEX
Page 4 of 9
2011 NHIS Questionnaire Sample Child
Child Identification
Document Version Date: 19-Jun-12
Question ID: CID.041_00.000 Instrument Variable Name: NEWSEX QuestionnaireFileName: Sample Child
QuestionText: * Ask if appropriate; otherwise, enter your best guess of the person's sex.
Is [fill: ALIAS of Sample Child] Male or Female?
1 Male
2 Female
UniverseText: Respondent said child's sex is not correct.
SkipInstructions: <1,2> store NEWSEX in SEX
goto ERR_NEWSEX
reset CSPVERF_S
goto CSPVERF_S
Hard Edit: ERR_NEWSEX
* The gender will now be changed to [fill: NEWSEX].
goto CSPVERF_S (as the default goto)
Question ID: CID.042_00.000 Instrument Variable Name: CSPVERF_A QuestionnaireFileName: Sample Child
QuestionText: * Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s age as [fill2: Age of Sample Child] old. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".
1 Yes
2 No
UniverseText: Respondent verified child's sex
SkipInstructions: <1> goto CSPVERF_D
<2> goto NEWAGE
Page 5 of 9
2011 NHIS Questionnaire Sample Child
Child Identification
Document Version Date: 19-Jun-12
Question ID: CID.043_00.000 Instrument Variable Name: NEWAGE QuestionnaireFileName: Sample Child
QuestionText: How old is [fill1: ALIAS of Sample Child]?
* If age given in months, weeks, or days, convert age to appropriate year. If less than one year old, enter "0".
000-120 Age in years
UniverseText: Respondent said child's age is not correct
SkipInstructions: <0-120, Refused, Don't know>
if NEWAGE = 'Refused' or NEWAGE = 'Don't know' or NEWAGE = AGE
reset CSPVERF_A
goto ERR_NEWAGE
else
store NEWAGE in AGE
goto NEWDOB_M
Hard Edit: ERR_NEWAGE
*Age of [fill1: ALIAS of Sample Child] remains [fill2: Age of Sample Child] years old.
goto CSPVERF_A (whether suppressed or not)
Question ID: CID.044_00.000 Instrument Variable Name: CSPVERF_D QuestionnaireFileName: Sample Child
QuestionText: * Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s birthday as [fill2: Birthday of Sample Child]. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".
1 Yes
2 No
UniverseText: Respondent verified child's sex
SkipInstructions: <1> if AGE of Sample Child ge '18'
goto CNO_MORE
else
goto child.chs.BWGT_LB
endif
<2> goto NEWDOB_M
Page 6 of 9
2011 NHIS Questionnaire Sample Child
Child Identification
Document Version Date: 19-Jun-12
Question ID: CID.046_01.000 Instrument Variable Name: NEWDOB_M QuestionnaireFileName: Sample Child
QuestionText: 1 of 3
What is [fill: ALIAS of Sample Child]'s birthday?
*Enter month of birth.
1 January
10 October
11 November
12 December
2 February
3 March
4 April
5 May
6 June
7 July
8 August
9 September
UniverseText: Respondent said child's date of birth is not correct or child's age is not correct
SkipInstructions: <01-12, Refused, Don't know> goto NEWDOB_D
Question ID: CID.046_02.000 Instrument Variable Name: NEWDOB_D QuestionnaireFileName: Sample Child
QuestionText: 2 of 3
* Enter day of birth.
01-31 Day of the month
UniverseText: Respondent said child's date of birth is not correct or child's age is not correct
SkipInstructions: <01-31,Refused,Don't know> goto NEWDOB_Y
If days not valid, goto ERR_NEWDOB_D
Hard Edit: ERR_NEWDOB_D
* [fill2: NEWDOB_D] is not a valid day for [fill3: NEWDOB_M].
* Please correct.
Page 7 of 9
2011 NHIS Questionnaire Sample Child
Child Identification
Document Version Date: 19-Jun-12
Question ID: CID.046_03.000 Instrument Variable Name: NEWDOB_Y QuestionnaireFileName: Sample Child
QuestionText: 3 of 3
* Enter year of birth.
1880-2020 Year of birth
Page 8 of 9
2011 NHIS Questionnaire Sample Child
Child Identification
Document Version Date: 19-Jun-12
UniverseText: Respondent said child's date of birth is not correct or child's age is not correct
SkipInstructions: <1880-2020, Refused, Don't know> if CSPVERF_A = '2' (No) then reset CSPVERF_A to empty
goto CSPVERF_A
elseif CSPVERF_D = '2' (No) then reset CSPVERF_D to empty
goto CSPVERF_D
endif
(if year GT current year) or (if year = current year and month GT current month) or (if year = current year and
month = current month and day GT current day)
goto ERR1_NEWDOB_Y
endif
(if birth month = '02' and birth day = '29' and this is not a leap year)
goto ERR2_NEWDOB_Y
endif
(if NEWDOB_M = 'Ref' or 'DK') or (if NEWDOB_D = 'Ref' or 'DK') or (if NEWDOB_Y = 'Ref' or 'DK')
goto ERR3_NEWDOB_Y
else
store NEWDOB_M in DOBM
store NEWDOB_D in DOBD
store NEWDOB_Y in DOBY
if CSPVERF_A = '2' (No) then reset CSPVERF_A to empty
goto CSPVERF_A
elseif CSPVERF_D = '2' (No) then reset CSPVERF_D to empty
goto CSPVERF_D
endif
endif
Calculate age from NEWDOB_M, NEWDOB_D, and NEWDOB_Y.
if age from NEWDOB items is ne AGE and age from NEWDOB items is valid
reset CSPVERF_A or CSPVERF_D
goto ERR4_NEWDOB_Y
endif
Hard Edit: ERR1_NEWDOB_Y
*Future date invalid: [fill2: <NEWDOB_M> <NEWDOB_D>, <NEWDOB_Y>]
*Please correct.
goto NEWDOB_M (whether suppressed or not)
ERR2_NEWDOB_Y
*Not a valid day: [fill2: <NEWDOB_M> <NEWDOB_D>, <NEWDOB_Y>]
*Please correct.
goto NEWDOB_M (whether suppressed or not)
ERR3_NEWDOB_Y
*DOB of [fill1: ALIAS of Sample Child] remains [fill3: <DOBM> <DOBD>, <DOBY>]
goto CSPVERF_A
ERR4_NEWDOB_Y
*Data mismatched. Please fix Age or Birthday.
Page 9 of 9
2011 NHIS Questionnaire Sample Child
Child Identification
Document Version Date: 19-Jun-12
goto CSPVERF_A (whether suppressed or not)
Page 1 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.010_01.000 Instrument Variable Name: BWGT_LB QuestionnaireFileName: Sample Child
QuestionText: What was [fill: S.C. name]'s birth weight?
* Enter 'M' to record metric measurements.
01-15 1-15 pounds
97 Refused
99 Don't know
M Metric
UniverseText: Sample children <18
SkipInstructions: <1-12> [goto BWGT_OZ]
<13-15> [goto ERR1_BWGT_LB]
<R,D> [goto CHGT_FT]
<M> [goto BWGT_GR]
[If NE <1-15, M, R, D> goto ERR2_BWGT_LB]
Hard Edit: ERR2_BWGT_LB
* Only "1-15" or "M" or "Don't know/Refused" allowed in this field.
* Please correct.
Soft Edit: ERR1_BWGT_LB
* [fill: BWGT_LB] is an unusually high number.
* Please verify.
Question ID: CHS.010_02.000 Instrument Variable Name: BWGT_OZ QuestionnaireFileName: Sample Child
QuestionText: * Enter ounces.
00-15 0-15 ounces
97 Refused
99 Don't know
Blank Blank
UniverseText: Sample children <18 who have a value entered for weight in pounds.
SkipInstructions: <0-15,R,D> [goto CHGT_FT]
[if BWGT_LB = <0-15, R, D> and BWGT_OZ = <empty> go to CHGT_FT]
Page 2 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.011_00.000 Instrument Variable Name: BWGT_GR QuestionnaireFileName: Sample Child
QuestionText: * Enter weight in grams.
0500 500 grams or less
0501-6899 501-6899 grams
6900 6900+ grams
9997 Refused
9999 Don't know
UniverseText: Sample children <18 whose birth weight will be entered in metric.
SkipInstructions: <500-5485,R,D> [goto CHGT_FT]
<5486-6900> [goto ERR_BWGT_GR]
Soft Edit: ERR_BWGT_GR
* [fill1: BWGT_GR] is an unusually high number (equal to [fill2] pounds, [fill3] ounces).
* Please verify.
Question ID: CHS.020_01.000 Instrument Variable Name: CHGT_FT QuestionnaireFileName: Sample Child
QuestionText: How tall is [fill: S.C. name] now (without shoes)?
* If the child's height is given in inches, press 'ENTER' at feet and enter the measure in inches (36 inches maximum).
* Enter 'M' to record metric measurements.
00-07 0-7 feet
97 Refused
99 Don't know
M Metric
UniverseText: Sample children 12+
SkipInstructions: <empty> [goto CHGT_IN]
<0-7> [goto CHGT_IN]
<R,D> [goto CWGT_LB]
<M> [goto CHGT_M]
[If NE <0-7, M, R, D> go to ERR_CHGT_FT]
Hard Edit: ERR_CHGT_FT
* Only "0-7" or "M" or "Don't know/Refused" allowed in this field.
* Please correct.
Page 3 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.020_02.000 Instrument Variable Name: CHGT_IN QuestionnaireFileName: Sample Child
QuestionText: * Enter inches.
00-36 0-36 inches
97 Refused
99 Don't know
UniverseText: Sample children 12+ whose height in feet is 0-7 or is left empty.
SkipInstructions: <0-36> [goto CWGT_LB]
[If both CHGT_FT and CHGT_IN are either <empty> or <0>, display ERR1_CHGT_IN]
[If CHGT_FT = <0-7> and CHGT_IN is GE <12> display ERR2_CHGT_IN]
Hard Edit: ERR1_CHGT_IN
* Must enter an answer in at least the inches item.
* Please correct.
ERR2_CHGT_IN
* Number of inches exceeds maximum allowed.
* Please correct.
Soft Edit: ERR3_CHGT_IN
* Please verify that the height was entered correctly. Probe only if necessary.
Question ID: CHS.021_01.000 Instrument Variable Name: CHGT_M QuestionnaireFileName: Sample Child
QuestionText: * Enter height in metric.
* If the child's height is given in centimeters, press 'ENTER' at meters and enter the measure in centimeters (241
centimeters maximum).
0-2 0-2 meters
7 Refused
9 Don't know
Blank Blank
UniverseText: Sample children 12+ whose current height will be entered in metric.
SkipInstructions: <0-2> [goto CHGT_CM]
<R,D> [goto CWGT_LB]
<empty> [go to CHGT_CM]
Page 4 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.021_02.000 Instrument Variable Name: CHGT_CM QuestionnaireFileName: Sample Child
QuestionText: * Enter centimeters.
000-241 0-241 centimeters
Blank Blank
UniverseText: Sample children 12+ whose weight will be entered in metric, and who entered "0-2" for height in meters or left
it empty.
SkipInstructions: <0-241> [goto CWGT_LB]
[if CHGT_M = <empty, 0> and CHGT_CM = <empty, 0> go to ERR1_CHGT_CM]
[if CHGT_M = 2 and CHGT_CM > 41 goto ERR2_CHGT_CM]
[if CHGT_M = 1 and CHGT_CM >141 goto ERR2_CHGT_CM]
Hard Edit: ERR1_CHGT_CM
* Must enter an answer at least in the centimeters item.
* Please correct.
ERR2_CHGT_CM
* Total height exceeds maximum allowed.
* Please correct.
Soft Edit: ERR3_CHGT_CM
* Please verify that the height was entered correctly. Probe only if necessary.
Question ID: CHS.022_00.000 Instrument Variable Name: CWGT_LB QuestionnaireFileName: Sample Child
QuestionText: How much does [fill: S.C. name] weigh now (without shoes)?
* Enter 'M' to record metric measurements.
* Enter '500' if 500 pounds or more.
001-500 1-500 pounds
997 Refused
999 Don't know
M Metric
UniverseText: Sample children 12+
SkipInstructions: <1-500,R,D> [if age ge <2> goto ADD_1, else, goto ADD1_2]
<M> [goto CWGT_KG]
[if = <501-999> goto ERR1_CWGT_LB]
[if NE <1-999, M, R, D> goto ERR2_CWGT_KG]
Hard Edit: ERR1_CWGT_LB
* Weight is out of range (1-500).
* Please correct.
Soft Edit: ERR2_CWGT_LB
* Please verify that the weight was entered correctly. Probe only if necessary.
Page 5 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.023_00.000 Instrument Variable Name: CWGT_KG QuestionnaireFileName: Sample Child
QuestionText: * Enter weight in kilograms.
002-226 2-226 kilograms
UniverseText: Sample children 12+ whose weight will be entered in metric.
SkipInstructions: <2-226> [if AGE ge <2> goto ADD_1; else goto ADD1_2]
[if CWGT_KG > 226 goto ERR_CWGT_KG]
Hard Edit: ERR1_CWGT_KG
* Weight is out of range (2-226).
* Please correct.
Soft Edit: ERR2_CWGT_KG
* Please verify that the weight was entered correctly. Probe only if necessary.
Question ID: CHS.031_02.000 Instrument Variable Name: ADD1_2 QuestionnaireFileName: Sample Child
QuestionText: Has a doctor or health professional ever told you that [fill: S.C. name] had…
an intellectual disability, also known as mental retardation?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <2
SkipInstructions: <1,2,R,D> [goto ADD1_3]
Page 6 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.031_03.000 Instrument Variable Name: ADD1_3 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <2
SkipInstructions: <1,2,R,D> [goto CONDL]
Question ID: CHS.032_01.000 Instrument Variable Name: ADD_1 QuestionnaireFileName: Sample Child
QuestionText: Has a doctor or health professional ever told you that [fill: S.C. name] had...
Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 2-17
SkipInstructions: <1,2,R,D> [go to ADD_2]
Page 7 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.032_02.000 Instrument Variable Name: ADD_2 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had….
an intellectual disability, also known as mental retardation?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 2-17
SkipInstructions: <1,2,R,D> [go to ADD_3]
Question ID: CHS.032_03.000 Instrument Variable Name: ADD_3 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 2-17
SkipInstructions: <1,2,R,D> [go to CONDL]
Page 8 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.060_00.000 Instrument Variable Name: CONDL QuestionnaireFileName: Sample Child
QuestionText: (book) C2 ?[F1]
Looking at this list, has a doctor or health professional ever told you that [fill: SC name] had any of these
conditions?
*Read if necessary.
Down syndrome
Cerebral palsy
Muscular dystrophy
Cystic fibrosis
Sickle cell anemia
Autism/Autism spectrum disorder
Diabetes
Arthritis
Congenital heart disease
Other heart condition
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [goto CONDL1] <2,R,D> [goto CPOX]
Page 9 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.061_00.000 Instrument Variable Name: CONDL1 QuestionnaireFileName: Sample Child
QuestionText: (book) C2 ?[F1]
Which ones?
* Enter all that apply, separate with commas.
01 Down syndrome
02 Cerebral palsy
03 Muscular dystrophy
04 Cystic fibrosis
05 Sickle cell anemia
06 Autism/Autism spectrum disorder
07 Diabetes
08 Arthritis
09 Congenital heart disease
10 Other heart condition
UniverseText: Sample children <18 and CONDL=1
SkipInstructions: <1-10,R,D> [go to CPOX]
[If <0> and <1-10> go to ERR_CONDL]
Question ID: CHS.070_00.000 Instrument Variable Name: CPOX QuestionnaireFileName: Sample Child
QuestionText: Has [fill: S.C. Name] EVER had chickenpox?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [go to CPOX12MO]
<2,R,D> [go to CASHMEV]
Page 10 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.072_00.000 Instrument Variable Name: CPOX12MO QuestionnaireFileName: Sample Child
QuestionText: Has [fill: S.C. name] had chickenpox DURING THE PAST 12 MONTHS?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 who have had chickenpox
SkipInstructions: <1,2,R,D> [goto CASHMEV]
Question ID: CHS.080_00.000 Instrument Variable Name: CASHMEV QuestionnaireFileName: Sample Child
QuestionText: Has a doctor or other health professional EVER told you that [fill: S.C. name] had asthma?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [go to CASSTILL]
<2,R,D> [if AGE LE 2 go to CCONDT1_1; if AGE >2 go to CCONDT_1]
Question ID: CHS.085_00.000 Instrument Variable Name: CASSTILL QuestionnaireFileName: Sample Child
QuestionText: Does [fill: S.C. name] still have asthma?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 and doctor has informed that child had asthma
SkipInstructions: <1,2,R,D> [go to CASHYR]
Page 11 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.090_00.000 Instrument Variable Name: CASHYR QuestionnaireFileName: Sample Child
QuestionText: The following questions are about [fill: S.C. name]'s asthma DURING THE PAST 12 MONTHS.
DURING THE PAST 12 MONTHS, has [fill: SC name] had an episode of asthma or an asthma attack?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 and doctor has informed that child had asthma
SkipInstructions: <1,2,R,D> [goto CASMERYR]
Question ID: CHS.100_00.000 Instrument Variable Name: CASMERYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, did [fill1: S.C. name] have to visit an emergency room or urgent care center
because of [fill2: his/her] asthma?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 and doctor has informed that child had asthma
SkipInstructions: <1,2,R,D> [if AGE LE 2 go to CCONDT1_1,
else go to CCONDT_1]
Question ID: CHS.111_01.000 Instrument Variable Name: CCONDT1_1 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Hay fever?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_2]
Page 12 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.111_02.000 Instrument Variable Name: CCONDT1_2 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of respiratory allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_3]
Question ID: CHS.111_03.000 Instrument Variable Name: CCONDT1_3 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of food or digestive allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_4]
Page 13 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.111_04.000 Instrument Variable Name: CCONDT1_4 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Eczema or any kind of skin allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_5]
Question ID: CHS.111_05.000 Instrument Variable Name: CCONDT1_5 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or repeated diarrhea or colitis?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_6]
Page 14 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.111_06.000 Instrument Variable Name: CCONDT1_6 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Anemia?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_8]
Question ID: CHS.111_08.000 Instrument Variable Name: CCONDT1_8 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Three or more ear infections?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_9]
Page 15 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.111_09.000 Instrument Variable Name: CCONDT1_9 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Seizures?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CHSTATYR]
Question ID: CHS.115_01.000 Instrument Variable Name: CCONDT_1 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Hay fever?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_2]
Page 16 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.115_02.000 Instrument Variable Name: CCONDT_2 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of respiratory allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_3]
Question ID: CHS.115_03.000 Instrument Variable Name: CCONDT_3 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of food or digestive allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_4]
Page 17 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.115_04.000 Instrument Variable Name: CCONDT_4 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Eczema or any kind of skin allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_5]
Question ID: CHS.115_05.000 Instrument Variable Name: CCONDT_5 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or repeated diarrhea or colitis?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_6]
Page 18 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.115_06.000 Instrument Variable Name: CCONDT_6 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Anemia?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_7]
Question ID: CHS.115_07.000 Instrument Variable Name: CCONDT_7 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or severe headaches, including migraines?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_8]
Page 19 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.115_08.000 Instrument Variable Name: CCONDT_8 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Three or more ear infections?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_9]
Question ID: CHS.115_09.000 Instrument Variable Name: CCONDT_9 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Seizures?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_10]
Page 20 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.115_10.000 Instrument Variable Name: CCONDT_10 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Stuttering or stammering?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CHSTATYR]
Question ID: CHS.210_00.000 Instrument Variable Name: CHSTATYR QuestionnaireFileName: Sample Child
QuestionText: Compared with 12 months ago, would you say [fill: S.C. name]'s health is now better, worse, or about the same?
1 Better
2 Worse
3 About the same
7 Refused
9 Don't know
UniverseText: Sample children < 18
SkipInstructions: <1-3,R,D> [if AGE le <4> goto CCOLD2W; else goto SCHDAYR]
Page 21 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.220_00.000 Instrument Variable Name: SCHDAYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, about how many days did [fill2: S.C. name] miss school because of illness or
injury?
000 None
001-240 1-240 days
996 Did not go to school
997 Refused
999 Don't know
UniverseText: Sample children 5-17
SkipInstructions: <0-99,996,R,D> [goto CCOLD2W]
<100-240> [go to ERR1_SCHDAYR]
<241-995> [goto ERR2_SCHDAYR]
Hard Edit: ERR2_SCHDAYR
* "241-995" days not allowed in this field.
* Please correct.
Soft Edit: ERR1_SCHDAYR
[fill4: SCHDAYR] is an unusually large number. Did [fill2: SC name] miss [fill: SCHDAYR] days of school
because of illness or injury?
* Please verify.
Question ID: CHS.230_00.000 Instrument Variable Name: CCOLD2W QuestionnaireFileName: Sample Child
QuestionText: These next questions are about [fill: SC name]'s recent health DURING THE LAST 2 WEEKS.
Did [fill: SC name] have a head cold or chest cold that started DURING THE LAST 2 WEEKS?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto CINTIL2W]
Page 22 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.240_00.000 Instrument Variable Name: CINTIL2W QuestionnaireFileName: Sample Child
QuestionText: Did [fill: SC name] have a stomach or intestinal illness with vomiting or diarrhea that started DURING THE LAST 2
WEEKS?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto CHEARST1]
Question ID: CHS.250_00.000 Instrument Variable Name: CHEARST1 QuestionnaireFileName: Sample Child
QuestionText: Which statement best describes [fill: SC name]'s hearing without a hearing aid: Excellent, good, a little trouble
hearing, moderate trouble, a lot of trouble, or is [fill: SC's name] deaf?
1 Excellent
2 Good
3 A little trouble hearing
4 Moderate trouble
5 A lot of trouble
6 Deaf
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1-6,R,D> [go to CVISION]
Question ID: CHS.260_00.000 Instrument Variable Name: CVISION QuestionnaireFileName: Sample Child
QuestionText: Does [fill1: S.C. name] have any trouble seeing [fill2: , even when wearing glasses or contact lenses]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [goto CBLIND]
<2,R,D> [goto IHSPEQ]
Page 23 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.270_00.000 Instrument Variable Name: CBLIND QuestionnaireFileName: Sample Child
QuestionText: Is [fill: S.C. name] blind or unable to see at all?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 having trouble seeing
SkipInstructions: <1,2,R,D> [goto IHSPEQ]
Question ID: CHS.290_00.000 Instrument Variable Name: IHSPEQ QuestionnaireFileName: Sample Child
QuestionText: Does [fill1: S.C. name] have any impairment or health problem that requires [fill2: him/her] to use special equipment,
such as a brace, a wheelchair, or a hearing aid (excluding ordinary eyeglasses or corrective shoes)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto IHMOB]
Question ID: CHS.300_00.000 Instrument Variable Name: IHMOB QuestionnaireFileName: Sample Child
QuestionText: Does [fill1: S.C. name] have an impairment or health problem that limits [fill2: his/her] ability to (crawl), walk, run, or
play?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [goto IHMOBYR]
<2,R,D> [goto PROBRX]
Page 24 of 28
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Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.310_00.000 Instrument Variable Name: IHMOBYR QuestionnaireFileName: Sample Child
QuestionText: Is this an impairment or health problem that has lasted, or is expected to last, 12 months or longer?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 that have limited ability to crawl, walk, run, or play
SkipInstructions: <1,2,R,D> [goto PROBRX]
Question ID: CHS.311_00.000 Instrument Variable Name: PROBRX QuestionnaireFileName: Sample Child
QuestionText: Does [fill1: S.C. name] NOW have a problem for which [fill2: he/she] has regularly taken prescription medication for
at least three months?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [if AGE LE <1> go to CUSUALPL;
if AGE GE <3> go to LEARND;
if AGE = <2> and SEX = <1> go to CMHAGM11_1;
if AGE = <2> and SEX = <2> go to CMHAGF11_1]
Question ID: CHS.312_00.000 Instrument Variable Name: LEARND QuestionnaireFileName: Sample Child
QuestionText: Has a representative from a school or a health professional ever told you that [fill: S.C. name] had a learning disability?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [if AGE > 3 go to CUSUALPL;
if AGE = 3 and SEX = 1 go to CMHAGM11_1;
if AGE = 3 and SEX = 2 go to CMHAGF11_1]
Page 25 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.321_01.000 Instrument Variable Name: CMHAGM11_1 QuestionnaireFileName: Sample Child
QuestionText: (book) C3
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has been uncooperative?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Male sample children 2-3
SkipInstructions: <0-2,R,D> [go to CMHAGM11_2]
Question ID: CHS.321_02.000 Instrument Variable Name: CMHAGM11_2 QuestionnaireFileName: Sample Child
QuestionText: (book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has trouble getting to sleep?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Male sample children 2-3
SkipInstructions: <0-2,R,D> [go to CMHAGM11_3]
Page 26 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.321_03.000 Instrument Variable Name: CMHAGM11_3 QuestionnaireFileName: Sample Child
QuestionText: (book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has speech problems?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Male sample children 2-3
SkipInstructions: <0-2,R,D> [go to CMHAGM11_4]
Question ID: CHS.321_04.000 Instrument Variable Name: CMHAGM11_4 QuestionnaireFileName: Sample Child
QuestionText: (book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has been unhappy, sad, or depressed?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Male sample children 2-3
SkipInstructions: <0-2,R,D> [go to CUSUALPL]
Page 27 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.361_01.000 Instrument Variable Name: CMHAGF11_1 QuestionnaireFileName: Sample Child
QuestionText: (book) C3
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has temper tantrums or a hot temper?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Female sample children 2-3
SkipInstructions: <0-2,R,D> [go to CMHAGF11_2]
Question ID: CHS.361_02.000 Instrument Variable Name: CMHAGF11_2 QuestionnaireFileName: Sample Child
QuestionText: (book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has speech problems?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Female sample children 2-3
SkipInstructions: <0-2,R,D> [go to CMHAGF11_3]
Page 28 of 28
2011 NHIS Questionnaire Sample Child
Child Health Status & Limitations
Document Version Date: 19-Jun-12
Question ID: CHS.361_03.000 Instrument Variable Name: CMHAGF11_3 QuestionnaireFileName: Sample Child
QuestionText: (book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has been nervous or high-strung?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Female sample children 2-3
SkipInstructions: <0-2,R,D> [go to CMHAGF11_4]
Question ID: CHS.361_04.000 Instrument Variable Name: CMHAGF11_4 QuestionnaireFileName: Sample Child
QuestionText: (book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has been unhappy, sad, or depressed?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Female sample children 2-3
SkipInstructions: <0-2,R,D> [go to CUSUALPL]
Page 1 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.020_00.00 Instrument Variable Name: CUSUALPL QuestionnaireFileName: Sample Child
QuestionText: The next questions are about health care.
Is there a place that [fill1: alias] USUALLY goes when [fill2: he/she] is sick or you need advice
about [fill3: his/her] health?
1 Yes
2 There is NO place
3 There is MORE THAN ONE place
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,3> [go to CPLKIND]
<2,R,D> [go to CHCPLKND]
Question ID: CAU.030_00.00 Instrument Variable Name: CPLKIND QuestionnaireFileName: Sample Child
QuestionText: [fill1: What kind of place is it / What kind of place does [fill2: alias] go to most often] - a clinic, doctor's office,
emergency room, or some other place?
1 Clinic or health center
2 Doctor's office or HMO
3 Hospital emergency room
4 Hospital outpatient department
5 Some other place
6 Doesn't go to one place most often
7 Refused
9 Don't know
UniverseText: Sample children <18 with one or more usual places to go when sick or need health advice
SkipInstructions: <1-5> [go to CHCPLROU]
<6,R,D> [go to CHCPLKND]
Page 2 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.035_00.00 Instrument Variable Name: CHCPLROU QuestionnaireFileName: Sample Child
QuestionText: Is that [fill1: CPLKIND/CAU.030] the same place [fill2: alias] USUALLY goes when [fill3: he/she] needs routine or
preventive care, such as a physical examination or (well baby/child) check-up?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 with one or more usual places to go when sick or need health advice who reported that
place as a clinic or health center, doctor's office or HMO, hospital emergency room, hospital outpatient
department, or some other place
SkipInstructions: <1> [go to CHCCHGYR]
<2,R,D> [go to CHCPLKND]
Question ID: CAU.037_00.00 Instrument Variable Name: CHCPLKND QuestionnaireFileName: Sample Child
QuestionText: What kind of place does [fill1: alias] USUALLY go to when [fill2: he/she] needs routine or preventive care, such as
a physical examination or (well baby/child) check-up?
0 Doesn't get preventive care anywhere
1 Clinic or health center
2 Doctor's office or HMO
3 Hospital emergency room
4 Hospital outpatient department
5 Some other place
6 Doesn't go to one place most often
7 Refused
9 Don't know
UniverseText: Sample children <18 who do not have a usual source of sick care; who Ref/NA/DK if have a usual source of
sick care; who have a usual source of sick care but does not go to one place most often; who have a usual
source of sick care but Ref/NA/DK what kind of place; who have a usual source of sick care, but it is not same
place as usual source of routine/preventive care; who have a usual source of sick care but Ref/NA/DK if it is
same place as usual source of routine/preventive care.
SkipInstructions: <0-6,R,D> if CUSUALPL=2 [goto CNOUSLPL]; else if CUSUALPL=,R,D [goto CPRVTRYR]; else [goto
CHCCHGYR]
Page 3 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.040_00.00 Instrument Variable Name: CHCCHGYR QuestionnaireFileName: Sample Child
QuestionText: At any time IN THE PAST 12 MONTHS did you CHANGE the place(s) to which [fill: alias] USUALLY goes for
health care?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 with one or more place to go when sick/need advice [or who reported same place as usual
source of routine/preventive care]
SkipInstructions: <1> [go to CHCCHGHI]
<2,R,D> [goto to CPRVTRYR]
Question ID: CAU.050_00.00 Instrument Variable Name: CHCCHGHI QuestionnaireFileName: Sample Child
QuestionText: Was this change for a reason related to health insurance?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 that have changed their usual place of health care in the past 12 months
SkipInstructions: <1,2,R,D> [goto CPRVTRYR]
Page 4 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.050_00.01 Instrument Variable Name: CNOUSLPL QuestionnaireFileName: Sample Child
QuestionText: Why doesn’t [fill: alias] have a usual source of medical care?
*Enter all that apply, separate with commas.
01 Doesn't need a doctor/Haven't had any problems
02 Doesn't like/trust/believe in doctors
03 Doesn't know where to go
04 Previous doctor is not available/moved
05 Too expensive/no insurance/cost
06 Speak a different language
07 No care available/Care too far away, not convenient
08 Put it off/Didn't get around to it
09 Other
97 Refused
99 Don’t know
UniverseText: Sample children <18 who don't have a usual place of care
SkipInstructions: <1-9,R,D>[goto CPRVTRYR]
Question ID: CAU.052_00.01 Instrument Variable Name: CPRVTRYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, did you have any trouble finding a general doctor or provider who would see
[fill: alias]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [goto CPRVTRFD ] <2,R,D> [goto CDRNANP]
Page 5 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.053_00.01 Instrument Variable Name: CPRVTRFD QuestionnaireFileName: Sample Child
QuestionText: Were you able to find a general doctor or provider who could see [fill: alias]?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children <18 who had trouble finding a provider in the last year
SkipInstructions: <1,2,R,D> [goto CDRNANP]
Question ID: CAU.055_00.01 Instrument Variable Name: CDRNANP QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they would not accept [fill:
alias] as a new patient?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D>[goto CDRNAI]
Question ID: CAU.056_00.01 Instrument Variable Name: CDRNAI QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they did not accept [fill: alias]'s
health care coverage?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D>[goto CHCDLYR_1]
Page 6 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.080_01.00 Instrument Variable Name: CHCDLYR1_1 QuestionnaireFileName: Sample Child
QuestionText:
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the
following reasons IN THE PAST 12 MONTHS...
You couldn't get through on the telephone.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto CHCDLYR1_2]
Question ID: CAU.080_02.00 Instrument Variable Name: CHCDLYR1_2 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the
following reasons IN THE PAST 12 MONTHS...
You couldn't get an appointment for [fill: alias] soon enough.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto CHCDLYR1_3]
Page 7 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.080_03.00 Instrument Variable Name: CHCDLYR1_3 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the
following reasons IN THE PAST 12 MONTHS...
Once you get there, [fill: alias] has to wait too long to see the doctor.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto CHCDLYR1_4]
Question ID: CAU.080_04.00 Instrument Variable Name: CHCDLYR1_4 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the
following reasons IN THE PAST 12 MONTHS...
The (clinic/doctor's office) wasn't open when you could get there.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto CHCDLYR1_5]
Page 8 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.080_05.00 Instrument Variable Name: CHCDLYR1_5 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the
following reasons IN THE PAST 12 MONTHS...
You didn’t have transportation.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [if AGE GE <2> goto CHCAFYR1_1; else goto CHCAFYR]
Question ID: CAU.130_00.00 Instrument Variable Name: CHCAFYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't
get it because you couldn't afford it...
Prescription medicines?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <2
SkipInstructions: <1,2,R,D> [goto CHCAFYRN]
Page 9 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.133_00.01 Instrument Variable Name: CHCAFYRN QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't
get it because you couldn't afford it...
To see a specialist?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <2
SkipInstructions: <1,2,R,D> [goto CHCAFYRF]
Question ID: CAU.133_00.02 Instrument Variable Name: CHCAFYRF QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't
get it because you couldn't afford it...
Follow-up care?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <2
SkipInstructions: <1,2,R,D> [if AGE <1 goto CHCSYR1_2; else goto CDENLONG]
Page 10 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.135_01.00 Instrument Variable Name: CHCAFYR1_1 QuestionnaireFileName: Sample Child
QuestionText:
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't
get it because you couldn't afford it...
Prescription medicines?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions: <1,2,R,D> [goto CHCAFYR1_2]
Question ID: CAU.135_02.00 Instrument Variable Name: CHCAFYR1_2 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't
get it because you couldn't afford it...
Mental health care or counseling?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions: <1,2,R,D> [goto CHCAFYR1_3]
Page 11 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.135_03.00 Instrument Variable Name: CHCAFYR1_3 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't
get it because you couldn't afford it...
Dental care (including check-ups)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions: <1,2,R,D> [goto CHCAFYR1_4]
Question ID: CAU.135_04.00 Instrument Variable Name: CHCAFYR1_4 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't
get it because you couldn't afford it...
Eyeglasses?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions: <1,2,R,D> [goto CHCAFYR1_5]
Page 12 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.135_05.01 Instrument Variable Name: CHCAFYR1_5 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't
get it because you couldn't afford it...
To see a specialist?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions: <1,2,R,D> [goto CHCAFYR1_6]
Question ID: CAU.135_06.01 Instrument Variable Name: CHCAFYR1_6 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't
get it because you couldn't afford it...
Follow-up care?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions: <1,2,R,D> [goto CDENLONG]
Page 13 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.160_00.00 Instrument Variable Name: CDENLONG QuestionnaireFileName: Sample Child
QuestionText: (book) C4
About how long has it been since [fill: alias] last saw a dentist? Include all types of dentists, such as orthodontists,
oral surgeons, and all other dental specialists, as well as dental hygienists.
0 Never
1 6 months or less
2 More than 6 months, but not more than 1 year ago
3 More than 1 year, but not more than 2 years ago
4 More than 2 years, but not more than 5 years ago
5 More than 5 years ago
7 Refused
9 Don't know
UniverseText: Sample children GE 1
SkipInstructions: <0-5,R,D> [if AGE GE <2> goto CHCSYR_1; else go to CHCSYR1_2]
Question ID: CAU.170_01.00 Instrument Variable Name: CHCSYR1_2 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has anyone in the family seen or talked to any of the following health care
providers about [fill2: alias]'s health?
An optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <2
SkipInstructions: <1,2,R,D> [goto CHCSYR1_3]
Page 14 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.170_02.00 Instrument Variable Name: CHCSYR1_3 QuestionnaireFileName: Sample Child
QuestionText: ?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, has anyone in the family seen or talked to any of the following health care
providers about [fill2: alias]'s health?
A foot doctor?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <2
SkipInstructions: <1,2,R,D> [goto CHCSYR1_5]
Question ID: CAU.170_03.00 Instrument Variable Name: CHCSYR1_5 QuestionnaireFileName: Sample Child
QuestionText: ?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, has anyone in the family seen or talked to any of the following health care
providers about [fill2: alias]'s health?
A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <2
SkipInstructions: <1,2,R,D> [goto CHCSYR1_6]
Page 15 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.170_04.00 Instrument Variable Name: CHCSYR1_6 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has anyone in the family seen or talked to any of the following health care
providers about [fill2: alias]'s health?
A nurse practitioner, physician assistant or midwife?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <2
SkipInstructions: <1,2,R,D> [goto CHCSYR8_1]
Question ID: CAU.175_01.00 Instrument Variable Name: CHCSYR_1 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care providers about
[fill2: alias]'s health?
A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions: <1,2,R,D> [goto CHCSYR_2]
Page 16 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.175_02.00 Instrument Variable Name: CHCSYR_2 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care providers about
[fill2: alias]'s health?
An optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions: <1,2,R,D> [goto CHCSYR_3]
Question ID: CAU.175_03.00 Instrument Variable Name: CHCSYR_3 QuestionnaireFileName: Sample Child
QuestionText: ?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care providers about
[fill2: alias]'s health?
A foot doctor?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions: <1,2,R,D> [goto CHCSYR_4]
Page 17 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.175_04.00 Instrument Variable Name: CHCSYR_4 QuestionnaireFileName: Sample Child
QuestionText: ?[F1]
Read if necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care providers about
[fill2: alias]'s health?
A chiropractor?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions: <1,2,R,D> [goto CHCSYR_5]
Question ID: CAU.175_05.00 Instrument Variable Name: CHCSYR_5 QuestionnaireFileName: Sample Child
QuestionText: ?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care providers about
[fill2: alias]'s health?
A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions: <1,2,R,D> [goto CHCSYR_6]
Page 18 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.175_06.00 Instrument Variable Name: CHCSYR_6 QuestionnaireFileName: Sample Child
QuestionText: ?[F1]
* Read if necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care providers about
[fill2: alias]'s health?
A nurse practitioner, physician assistant or midwife?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions: <1,2,R,D> [if SEX eq <2> and AGE GE 15 goto CHCSYR7; else goto CHCSYR8_1]
Question ID: CAU.230_00.00 Instrument Variable Name: CHCSYR7 QuestionnaireFileName: Sample Child
QuestionText: ?[F1]
DURING THE PAST 12 MONTHS, have you seen or talked to a doctor who specializes in women's health (an
obstetrician/gynecologist) about [fill2: alias]'s health?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 15 who are female
SkipInstructions: <1,2,R,D> [goto CHCSYR8_1]
Page 19 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.240_01.00 Instrument Variable Name: CHCSYR8_1 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, have you seen or talked to the following about [fill2: alias]'s health?
A medical doctor who specializes in a particular medical disease or problem (fill3:other than obstetrician/
gynecologist, psychiatrist or ophthalmologist? /fill4: other than psychiatrist or ophthalmologist)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto CHCSYR8_2]
Question ID: CAU.240_02.00 Instrument Variable Name: CHCSYR8_2 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to the following about [fill2: alias]'s health?
A general doctor who treats a variety of illnesses (a doctor in general practice, pediatrics, family medicine, or internal
medicine)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [goto CHCSYR10]
<2,R,D> [goto CHPEXYR]
Page 20 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.260_00.00 Instrument Variable Name: CHCSYR10 QuestionnaireFileName: Sample Child
QuestionText: Does that doctor treat children and adults (a doctor in general practice or family medicine)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 who have seen or talked to a general doctor during the past 12 months
SkipInstructions: <1,2,R,D> [goto CHCSYREM]
Question ID: CAU.265_00.00 Instrument Variable Name: CHCSYREM QuestionnaireFileName: Sample Child
QuestionText: Did you see or talk to this general doctor because of an emotional or behavioral problem that [fill1: alias] may have?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 who have seen a general doctor in the past 12 months
SkipInstructions: <1,2,R,D> [goto CHPEXYR]
Question ID: CAU.270_00.00 Instrument Variable Name: CHPEXYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, did [fill1: alias] receive a well-child check-up, that is a general check-up, when
[fill2: he/she] was not sick or injured?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto CHERNOYR]
Page 21 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.280_00.00 Instrument Variable Name: CHERNOYR QuestionnaireFileName: Sample Child
QuestionText: (book) C5
DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: alias] gone to a HOSPITAL EMERGENCY
ROOM about [fill2: his/her] health? (This includes emergency room visits that resulted in a hospital admission.)
00 None
01 1
02 2-3
03 4-5
04 6-7
05 8-9
06 10-12
07 13-15
08 16 or more
97 Refused
99 Don't know
UniverseText: Sample children <18
SkipInstructions: <0,R,D> [goto CHCHYR] <1-8> [goto CERVISND]
Question ID: CAU.281_00.01 Instrument Variable Name: CERVISND QuestionnaireFileName: Sample Child
QuestionText: Thinking about [fill: S.C. name]'s most recent emergency room visit, did [fill: he/she ] go to the emergency room either
at night or on the weekend?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 who had at least one ER visit in the past year
SkipInstructions: <1,2,R,D> [go to CERHOS]
Page 22 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.282_00.01 Instrument Variable Name: CERHOS QuestionnaireFileName: Sample Child
QuestionText: Did this emergency room visit result in a hospital admission?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 who had at least one ER visit in the past year
SkipInstructions: <1,R,D> [goto CHCHYR] < 2> [go to CERREAS1]
Question ID: CAU.283_01.01 Instrument Variable Name: CERREAS1 QuestionnaireFileName: Sample Child
QuestionText: Tell me which of these apply to [fill: alias]'s last emergency room visit?
… [fill: He/She] didn’t have another place to go
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions: <1,2,R,D> [goto CERREAS2]
Question ID: CAU.283_02.02 Instrument Variable Name: CERREAS2 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
… [fill: alias]'s doctor’s office or clinic was not open
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions: <1,2,R,D> [goto CERREAS3]
Page 23 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.283_03.03 Instrument Variable Name: CERREAS3 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
… [fill: alias]'s health provider advised that [fill: he/she] go
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions: <1,2,R,D> [goto CERREAS4]
Question ID: CAU.283_04.04 Instrument Variable Name: CERREAS4 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
… The problem was too serious for the doctor’s office or clinic
1 Yes
2 No
7 Refused
9 Don’t' know
UniverseText: Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions: <1,2,R,D> [goto CERREAS5]
Page 24 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.283_05.05 Instrument Variable Name: CERREAS5 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
… Only a hospital could help [fill: alias]
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions: <1,2,R,D> [goto CERREAS6]
Question ID: CAU.283_06.06 Instrument Variable Name: CERREAS6 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
… The emergency room is [fill: alias]'s closest provider
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions: <1,2,R,D> [goto CERREAS7]
Page 25 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.283_07.07 Instrument Variable Name: CERREAS7 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
…[fill: alias] gets most of [fill: his/her] care at the emergency room
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions: <1,2,R,D> [goto CERREAS8]
Question ID: CAU.283_08.08 Instrument Variable Name: CERREAS8 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
…[fill: alias] arrived by ambulance or other emergency vehicle
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions: <1,2,R,D> [goto CHCHYR]
Page 26 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.290_00.00 Instrument Variable Name: CHCHYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, did [fill1: alias] receive care AT HOME from a nurse or other health care
professional?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [goto CHCHMOYR]
<2,R,D> [goto CHCNOYR]
Question ID: CAU.300_00.00 Instrument Variable Name: CHCHMOYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, how many months did [fill: alias] receive care AT HOME from a health care
professional?
01-12 1-12 months
97 Refused
99 Don't know
UniverseText: Sample children <18 that have received home care from health professional during the past 12 months
SkipInstructions: <01-12,R,D> [goto CHCHNOYR]
Page 27 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.310_00.00 Instrument Variable Name: CHCHNOYR QuestionnaireFileName: Sample Child
QuestionText: (book) C6 ?[F1]
What was the total number of home visits received for [fill1: alias] during [fill2: that month/those months]?
01 1
02 2-3
03 4-5
04 6-7
05 8-9
06 10-12
07 13-15
08 16 or more
97 Refused
99 Don't know
UniverseText: Sample children <18 that have received home care from health professional during the past 12 months
SkipInstructions: <1-8,R,D> [goto CHCNOYR]
Question ID: CAU.320_00.00 Instrument Variable Name: CHCNOYR QuestionnaireFileName: Sample Child
QuestionText: (book) C5 ?[F1]
DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: alias] seen a doctor or other health care
professional about [fill2: his/her] health at A DOCTOR’S OFFICE, A CLINIC, OR SOME OTHER PLACE? Do not
include times [fill1: alias] was hospitalized overnight, visits to hospital emergency rooms, home visits, dental visits
or telephone calls.
00 None
01 1
02 2-3
03 4-5
04 6-7
05 8-9
06 10-12
07 13-15
08 16 or more
97 Refused
99 Don't know
UniverseText: Sample children <18
SkipInstructions: <0-8,R,D> [goto CSRGYR]
Page 28 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.330_00.00 Instrument Variable Name: CSRGYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS has [fill1: alias] had SURGERY or other surgical procedures either as an
inpatient or outpatient?
* Read if necessary.
This includes both major surgery and minor procedures such as setting bones or removing growths.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [goto CSRGNOYR]
<2,R,D> [goto CMDLONG]
Question ID: CAU.340_00.00 Instrument Variable Name: CSRGNOYR QuestionnaireFileName: Sample Child
QuestionText: Including any times you may have already told me about, HOW MANY DIFFERENT TIMES has [fill1: alias] had
surgery DURING THE PAST 12 MONTHS?
* Enter '95' for 95 or more times.
01-94 1-94 times
95 95+ times
97 Refused
99 Don't know
UniverseText: Sample children <18 that have undergone surgery during the past 12 months
SkipInstructions: <1-10,R,D> [goto CMDLONG]
<11-95> [goto ERR_CMDLONG]
Soft Edit: ERR_CMDLONG
[fill2: CSRGNOYR] is an unusually large number. Did [fill1: alias] have [fill2: CSRGNOYR] surgical
procedures?
Page 29 of 29
2011 NHIS Questionnaire Sample Child
Child Access to Health Care & Utilization
Document Version Date: 19-Jun-12
Question ID: CAU.345_00.00 Instrument Variable Name: CMDLONG QuestionnaireFileName: Sample Child
QuestionText: (book) C4
About how long has it been since anyone in the family last saw or talked to a doctor or other health care professional
about [fill1: alias]'s health? Include doctors seen while [fill2: he/she] was a patient in a hospital.
0 Never
1 6 months or less
2 More than 6 months, but not more than 1 year ago
3 More than 1 year, but not more than 2 years ago
4 More than 2 years, but not more than 5 years ago
5 More than 5 years ago
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <0-5, D, R> [if AGE=4-17 goto CMHCOPY; else goto CH1N1_1]
Page 1 of 4
2011 NHIS Questionnaire Sample Child
Child Mental Health Brief Questionnaire
Document Version Date: 19-Jun-12
Question ID: CMB.010_00.00 Instrument Variable Name: CMHCOPY QuestionnaireFileName: Sample Child
QuestionText: * The following statements are not to be read to the respondent. They are displayed and included here for legal
reasons.
* The next 6 items contained in CMHMF_1 through CMHDIFF are included in this survey with permission as
indicated below.
* The SDQ questions are copyrighted by Robert Goodman, Ph.D., FRCPSYCH, MRCP. State and local agencies
may use these questions without charge and without seeking separate permission provided the wording is not
modified, all the questions are retained, and Dr. Goodman's copyright is acknowledged.
* Enter 1 to Continue.
1 Enter 1 to continue
UniverseText: Sample children GE 4
SkipInstructions: <1> [goto CMHMF_1]
Question ID: CMB.020_01.00 Instrument Variable Name: CMHMF_1 QuestionnaireFileName: Sample Child
QuestionText: (book) C7
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,
SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...is generally well behaved, usually does what adults request.
0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions: <1-3,D,R> [goto CMHMF_2]
Page 2 of 4
2011 NHIS Questionnaire Sample Child
Child Mental Health Brief Questionnaire
Document Version Date: 19-Jun-12
Question ID: CMB.020_02.00 Instrument Variable Name: CMHMF_2 QuestionnaireFileName: Sample Child
QuestionText: (book) C7
* Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,
SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...has many worries, or often seems worried.
0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions: <1-3,D,R> [goto CMHMF_3]
Question ID: CMB.020_03.00 Instrument Variable Name: CMHMF_3 QuestionnaireFileName: Sample Child
QuestionText: (book) C7
* Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,
SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...is often unhappy, depressed or tearful.
0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions: <1-3,D,R> [goto CMHMF_4]
Page 3 of 4
2011 NHIS Questionnaire Sample Child
Child Mental Health Brief Questionnaire
Document Version Date: 19-Jun-12
Question ID: CMB.020_04.00 Instrument Variable Name: CMHMF_4 QuestionnaireFileName: Sample Child
QuestionText: (book) C7
* Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,
SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...gets along better with adults than with other [fill3: children/youth].
0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions: <1-3,D,R> [goto CMHMF_5]
Question ID: CMB.020_05.00 Instrument Variable Name: CMHMF_5 QuestionnaireFileName: Sample Child
QuestionText: (book) C7
* Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,
SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...has good attention span, sees chores or homework through to the end.
0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions: <1-3,D,R> [goto CMHDIFF]
Page 4 of 4
2011 NHIS Questionnaire Sample Child
Child Mental Health Brief Questionnaire
Document Version Date: 19-Jun-12
Question ID: CMB.030_00.00 Instrument Variable Name: CMHDIFF QuestionnaireFileName: Sample Child
QuestionText: (book) C8
Overall, do you think that [fill1: SC name] has difficulties in any of the following areas: emotions, concentration,
behavior, or being able to get along with other people?
1 No
2 Yes, minor difficulties
3 Yes, definite difficulties
4 Yes, severe difficulties
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions: <1-4,R,D> [goto next section]
Page 1 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.001_00.00 Instrument Variable Name: DIFF6M QuestionnaireFileName: Sample Child
QuestionText: Has [fill: SC name] had any difficulties with emotions, concentration, behavior, or getting along with others
DURING THE PAST 6 MONTHS?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17
SkipInstructions: <1> [goto DIFFINTF] <2,R,D> [if CMHDIFF (variable name in layouts is RSCL6) IN ('2',3','4') [goto
DIFFINTF]; else [goto PRESCP6M]
Question ID: CMS.005_00.00 Instrument Variable Name: DIFFINTF QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 6 MONTHS, did the difficulties interfere with or limit [fill1: SC name] being able to get along
in your family, in school, or in daily activities?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who have at least minor difficulties with emotions, concentration, behavior, or being
able to get along with others
SkipInstructions: <1> [goto DIFFDEG] <2,R,D> [goto DIFFLNG]
Question ID: CMS.007_00.00 Instrument Variable Name: DIFFDEG QuestionnaireFileName: Sample Child
QuestionText: How much did these difficulties interfere with [fill: S.C. name] being able to get along in your family, in school, or in
daily activities? Would you say...
*Read categories below.
1 A lot
2 Some
3 A little
7 Refused
9 Don't know
UniverseText: Sample children 4-17 whose difficulties interfere with child being able to get along in the family, school, or
daily activities
SkipInstructions: <1-3,R,D> [goto DIFFLNG]
Page 2 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.008_00.00 Instrument Variable Name: DIFFLNG QuestionnaireFileName: Sample Child
QuestionText: How long have these difficulties been present?
1 Less than a month
2 1-5 months
3 6 to 12 months
4 Over a year
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who have at least minor difficulties with emotions, concentration,
behavior, or being able to get along with others
SkipInstructions: <1-4,R,D> [goto PRESCP6M]
Question ID: CMS.010_00.00 Instrument Variable Name: PRESCP6M QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 6 MONTHS, was [fill1: S.C. name] prescribed medication or taking prescription medication for
difficulties with emotions, concentration, behavior, or being able to get along with others?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17
SkipInstructions: <1> [goto PRESHELP] <2,R,D> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [end]; else [goto NSDUH21]
Page 3 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.011_00.00 Instrument Variable Name: PRESHELP QuestionnaireFileName: Sample Child
QuestionText: During the past 6 months, how much has this prescription medication helped [fill: S.C. name]? Would you say…
*Read categories below.
1 Not at all
2 A little
3 Some
4 A lot
7 Refused
9 Don't know
UniverseText: Sample children 4-17 have taken prescription medicine in the past 6 mos
SkipInstructions: <1-4,R,D> [goto PMEDPED]
Question ID: CMS.012_01.00 Instrument Variable Name: PMEDPED QuestionnaireFileName: Sample Child
QuestionText: Who FIRST prescribed the medication? Was it
...A pediatrician or other family doctor?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who have been prescribed or have taken prescription medication in the past 6 months
SkipInstructions: <1> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto TRETHELP]; else [goto NSDUH21]; <2,R,D> [goto
PMEDPSY]
Page 4 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.012_02.00 Instrument Variable Name: PMEDPSY QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
Who FIRST prescribed the medication? Was it
...A psychiatrist, psychologist or other mental health professional?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who were prescribed medication in the past 6 months by someone other than a
pediatrician or other family doctor
SkipInstructions: <1> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto TRETHELP]; else [goto NSDUH21]; <2,R,D> [goto
PMEDNEU]
Question ID: CMS.012_03.00 Instrument Variable Name: PMEDNEU QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
Who FIRST prescribed the medication? Was it
...A neurologist?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who were prescribed medication in the past 6 months by someone other than a
pediatrician, psychiatrist/ or other family doctor
SkipInstructions: <1> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto TRETHELP]; else [goto NSDUH21]; <2,R,D> [goto
PMEDOTH]
Page 5 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.012_04.00 Instrument Variable Name: PMEDOTH QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
Who FIRST prescribed the medication? Was it
...Someone else?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who were prescribed medication in the past 6 months by someone other than a
pediatrician, family doctor, psychiatrist or neurologist
SkipInstructions: <1,2,R,D> if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto TRETHELP]; else [goto NSDUH21]
Question ID: CMS.014_00.00 Instrument Variable Name: NSDUH21 QuestionnaireFileName: Sample Child
QuestionText: Sometimes students get treatment or counseling through the school system for DIFFICULTIES WITH emotions,
concentration, behavior, or being able to get along with others.
DURING THE PAST 6 MONTHS, did [fill: S.C. name] receive any treatment or
counseling FROM A SCHOOL SOCIAL WORKER, SCHOOL PSYCHOLOGIST, SCHOOL NURSE, SCHOOL
COUNSELOR, SPECIAL ED TEACHER, OR SCHOOL SPEECH, OCCUPATIONAL OR PHYSICAL
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months
SkipInstructions: <1,2,R,D> [goto NSDUH3]
Page 6 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.015_00.00 Instrument Variable Name: NSDUH3 QuestionnaireFileName: Sample Child
QuestionText: At any time DURING THE PAST 6 MONTHS did [fill1: S.C. name] attend a school for students with difficulties with
emotions, concentration, behavior, or being able to get along with others?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months
SkipInstructions: <1> [go to NSDUH31 <2,R,D> [go to NSDUH4]
Question ID: CMS.015_00.01 Instrument Variable Name: NSDUH31 QuestionnaireFileName: Sample Child
QuestionText: Was it a day school or school where {S.C. name} stayed overnight or longer?
1 Day School
2 Overnight School
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with
emotions, concentration, behavior, or being able to get along in the past 6 months, and attend a special needs
school
SkipInstructions: <1> [goto NSDUH32] <2,R,D [got to NSDUH4]
Page 7 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.015_00.02 Instrument Variable Name: NSDUH32 QuestionnaireFileName: Sample Child
QuestionText: Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Special Ed teacher
2 Other school teacher
3 School counselor, psychologist, nurse or social worker
4 School speech, occupational or physical therapist
5 Other school official
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who participated in a special needs day school with program for these difficulties
SkipInstructions: <1-5,R,D> [goto NSDUH4];
Question ID: CMS.016_00.00 Instrument Variable Name: NSDUH4 QuestionnaireFileName: Sample Child
QuestionText: Regular schools sometimes provide programs for students with difficulties with emotions, concentration, behavior, or
being able to get along with others.
DURING THE PAST 6 MONTHS, did [fill1: S.C. name] participate in a school program that was just for students
with these kinds of difficulties?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months
SkipInstructions: <1> [goto NSDUH5] <2,R,D> if age 4-6 [goto TRETWHR1]; else [goto TRETWHR2]
Page 8 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.017_00.00 Instrument Variable Name: NSDUH5 QuestionnaireFileName: Sample Child
QuestionText: Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Special Ed teacher
2 Other school teacher
3 School counselor, psychologist, nurse or social worker
4 School speech, occupational or physical therapist
5 Other school official
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who participated in a school program for difficulties with emotions, concentration,
SkipInstructions: <1-5,R,D> age 4-6 [goto TRETWHR1]; else [goto TRETWHR2]
Question ID: CMS.020_01.00 Instrument Variable Name: TRETWHR1 QuestionnaireFileName: Sample Child
QuestionText: Now I’d like to ask about places other than {S.C.name}’s school where children and adolescents receive treatment or
counseling for difficulties with emotions, concentration, behavior, or being able to get along with others.
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
At daycare, child care, or play group?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-6 who had at least minor difficulties
SkipInstructions: <1> [goto TRETWHO1] <2,R,D> [goto TRETWHR2]
Page 9 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.020_02.00 Instrument Variable Name: TRETWHO1 QuestionnaireFileName: Sample Child
QuestionText: (book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Pediatrician or family doctor
2 Psychiatrist, psychologist, clinical social worker or psychiatric nurse
3 Speech, occupational or physical therapist
4 Religious or spiritual counselor or advisor
5 Probation of juvenile corrections officer or court counselor
6 Other
7 Refused
9 Don’t know
UniverseText: Sample children 4-6 who received counseling at daycare, child care, or play group
SkipInstructions: <1,3-6,R,D> [goto TRETWHR2] <2> [goto TRTMHP1]
Question ID: CMS.020_03.00 Instrument Variable Name: TRTMHP1 QuestionnaireFileName: Sample Child
QuestionText: You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or
psychiatric nurse. Who was this?
*Enter all that apply, separate with commas
1 Psychiatrist
2 Psychologist
3 Clinical social worker
4 Psychiatric nurse
7 Refused
9 Don't know
UniverseText: Sample children 4-6 who received counseling or treatment at daycare, child care, or play group from mental
health provider
SkipInstructions: <1-4,R,D> [goto TRETWHR2]
Page 10 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.021_01.00 Instrument Variable Name: TRETWHR2 QuestionnaireFileName: Sample Child
QuestionText: [fill2: Now I’d like to ask about places other than {S.C. name}’s school where children and adolescents receive
treatment or counseling for difficulties with emotions, concentration, behavior, or being able to get along with
others.]
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who had at least minor difficulties
SkipInstructions: <1> [goto TRETWHO2] <2,R,D> [goto TRETWHR3]
Question ID: CMS.021_02.00 Instrument Variable Name: TRETWHO2 QuestionnaireFileName: Sample Child
QuestionText: (book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Pediatrician or family doctor
2 Psychiatrist, psychologist, clinical social worker or psychiatric nurse
3 Speech, occupational or physical therapist
4 Religious or spiritual counselor or advisor
5 Probation or juvenile corrections officer or court counselor
6 Other
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling at an office, clinic or community center
SkipInstructions: <1,3-6,R,D> [goto TRETWHR3] <2> [goto TRTMHP2]
Page 11 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.021_03.00 Instrument Variable Name: TRTMHP2 QuestionnaireFileName: Sample Child
QuestionText: You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or
psychiatric nurse. Who was this?
*Enter all that apply, separate with commas
1 Psychiatrist
2 Psychologist
3 Clinical social worker
4 Psychiatric nurse
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling or treatment at an office, clinic or community center from mental
health provider
SkipInstructions: <1-4,R,D> [goto TRETWHR3]
Question ID: CMS.022_01.00 Instrument Variable Name: TRETWHR3 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
In your home, for example, from a visiting teacher or counselor?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who had at least minor difficulties
SkipInstructions: <1> [goto TRETWHO3] <2,R,D> [goto TRETWHR4]
Page 12 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.022_02.00 Instrument Variable Name: TRETWHO3 QuestionnaireFileName: Sample Child
QuestionText: (book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Pediatrician or family doctor
2 Psychiatrist, psychologist, clinical social worker or psychiatric nurse
3 Speech, occupational or physical therapist
4 Religious or spiritual counselor or advisor
5 Probation or juvenile corrections officer or court counselor
6 Other
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who received counseling at home from visiting teacher or counselor
SkipInstructions: <1,3-6,R,D> [goto TRETWHR4] <2> [goto TRTMHP3]
Question ID: CMS.022_03.00 Instrument Variable Name: TRTMHP3 QuestionnaireFileName: Sample Child
QuestionText: You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or
psychiatric nurse. Who was this?
*Enter all that apply, separate with commas
1 Psychiatrist
2 Psychologist
3 Clinical social worker
4 Psychiatric nurse
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who received counseling or treatment at home from mental health provider
SkipInstructions: <1-4,R,D> [goto TRETWHR4]
Page 13 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.023_01.00 Instrument Variable Name: TRETWHR4 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
In a hospital emergency room, crisis center, or emergency shelter?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who had at least minor difficulties
SkipInstructions: <1> [goto TRETWHO4] <2,R,D> [goto TRETWHR5]
Question ID: CMS.023_02.00 Instrument Variable Name: TRETWHO4 QuestionnaireFileName: Sample Child
QuestionText: (book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Pediatrician or family doctor
2 Psychiatrist, psychologist, clinical social worker or psychiatric nurse
3 Speech, occupational or physical therapist
4 Religious or spiritual counselor or advisor
5 Probation or juvenile corrections officer or court counselor
6 Other
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who received counseling at hospital/ER/crisis center/shelter
SkipInstructions: <1,3-6,R,D> [goto TRETWHR5] <2> [goto TRTMHP4]
Page 14 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.023_03.00 Instrument Variable Name: TRTMHP4 QuestionnaireFileName: Sample Child
QuestionText: You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or
psychiatric nurse. Who was this?
*Enter all that apply, separate with commas
1 Psychiatrist
2 Psychologist
3 Clinical social worker
4 Psychiatric nurse
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling or treatment at hospital/ER/crisis center/shelter from mental
health provider
SkipInstructions: <1-4,R,D> [goto TRETWHR5]
Question ID: CMS.024_01.00 Instrument Variable Name: TRETWHR5 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
At a day treatment program in a hospital or in your community?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who had at least minor difficulties
SkipInstructions: <1> [goto TRETWHO5] <2,R,D> [goto TRETWHR6]
Page 15 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.024_02.00 Instrument Variable Name: TRETWHO5 QuestionnaireFileName: Sample Child
QuestionText: (book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Pediatrician or family doctor
2 Psychiatrist, psychologist, clinical social worker or psychiatric nurse
3 Speech, occupational or physical therapist
4 Religious or spiritual counselor or advisor
5 Probation or juvenile corrections officer or court counselor
6 Other
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who received counseling at day treatment program in a hospital or community
SkipInstructions: <1,3-6,R,D> [goto TRETWHR6] <2> [goto TRTMHP5]
Question ID: CMS.024_03.00 Instrument Variable Name: TRTMHP5 QuestionnaireFileName: Sample Child
QuestionText: You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or
psychiatric nurse. Who was this?
*Enter all that apply, separate with commas
1 Psychiatrist
2 Psychologist
3 Clinical social worker
4 Psychiatric nurse
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling or treatment at day treatment program in a hospital or
community from mental health provider
SkipInstructions: <1-4,R,D> [goto TRETWHR6]
Page 16 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.025_01.00 Instrument Variable Name: TRETWHR6 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
Any other place?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who had at least minor difficulties
SkipInstructions: <1> [goto TRETWHO6] <2,R,D> [goto OVERNT6M]
Question ID: CMS.025_02.00 Instrument Variable Name: TRETWHO6 QuestionnaireFileName: Sample Child
QuestionText: (book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Pediatrician or family doctor
2 Psychiatrist, psychologist, clinical social worker or psychiatric nurse
3 Speech, occupational or physical therapist
4 Religious or spiritual counselor or advisor
5 Probation or juvenile corrections or court counselor
6 Other
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who received counseling at another place
SkipInstructions: <1,3-6,R,D> [goto OVERNT6M] <2> [goto TRTMHP6]
Page 17 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.025_03.00 Instrument Variable Name: TRTMHP6 QuestionnaireFileName: Sample Child
QuestionText: You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or
psychiatric nurse. Who was this?
*Enter all that apply, separate with commas
1 Psychiatrist
2 Psychologist
3 Clinical social worker
4 Psychiatric nurse
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who received counseling or treatment at another place from mental health provider
SkipInstructions: <1-4,R,D> [goto OVERNT6M]
Question ID: CMS.050_00.00 Instrument Variable Name: OVERNT6M QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 6 MONTHS, in addition to a school you may have told me about, did [fill: S.C. name] stay
overnight or longer in a hospital, any type of group home, any type of juvenile detention center, sometimes called
juvie, or juvenile hall, youth prison, training school or jail, foster care home, or another special type of center or
shelter to receive counseling or treatment for these difficulties?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months
SkipInstructions: <1> [goto OVERWHCH] <2,R,D> [goto SH1]
Page 18 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.060_00.00 Instrument Variable Name: OVERWHCH QuestionnaireFileName: Sample Child
QuestionText: Which ones?
*Read list if necessary.
*Enter all that apply, separate with commas.
01 Hospital
02 Residential treatment center
03 Foster care or therapeutic foster care home
04 In any type of juvenile detention center, sometimes called "juvie", prison, or jail
05 Group home
06 Homeless shelter
07 In another place
97 Refused
99 Don’t know
UniverseText: Sample children 4-17 who stayed overnight in a hospital or other overnight location for difficulties
SkipInstructions: <1-7,R,D> [goto SH1]
Question ID: CMS.070_00.00 Instrument Variable Name: SH1 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 6 MONTHS, did [fill1: S.C. name] take part in a self-help group for children and youth with
these difficulties?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months
SkipInstructions: <1,2,R,D> [goto SH2]
Page 19 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.080_00.00 Instrument Variable Name: SH2 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 6 MONTHS, did [fill1: S.C. name] use the Internet to seek treatment or counseling for these
difficulties?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months
SkipInstructions: <1,2,R,D> [goto CASEM6M]
Question ID: CMS.100_00.00 Instrument Variable Name: CASEM6M QuestionnaireFileName: Sample Child
QuestionText: Parents and caregivers sometimes get help from people sometimes called case managers or care coordinators who help
to find or organize treatment for children's difficulties with emotions, concentration, behavior, or being able to get
along with others.
*Read if necessary: This type of help is sometimes called care coordination or case management. People or agencies
that do this work might also help you develop a service plan, contact providers for you, and provide support to you
in getting the help your child or adolescent needs.
DURING THE PAST 6 MONTHS, did you or [fill1: S.C. name] receive this type of help from any individual or
agency?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months
SkipInstructions: <1> [goto CASEMWHO];
<2,R,D> IF PRESCP6M=1 or NSDUH21=1 or NSDUH3=1 or NSDUH4=1 or TRETWHR1=1 or
TRETWHR2=1 or TRETWHR3=1 or TRETWHR4=1 or TRETWHR5=1 or TRETWHR6=1 or OVERNT6M=1
or SH1=1 or SH2=1 or CASEM6M=1 [goto TRETHELP]; else [goto TRTNEED1]
Page 20 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.110_00.00 Instrument Variable Name: CASEMWHO QuestionnaireFileName: Sample Child
QuestionText: Who provides help arranging or coordinating [fill1: S.C. name]'s care?
*Enter the MAIN answer.
01 Child welfare/social services/family and child services agency
02 School or educational system
03 Mental health agency
04 Private mental health professional
05 Juvenile justice agency or court system
06 Private insurance service
07 Family or friend
08 Pediatrician or other family doctor
09 Family or youth advocacy groups
10 Other
97 Refused
99 Don't know
UniverseText: Sample children 4-17 who received help from case managers/care coordinators in the past 6 months
SkipInstructions: <1-10,R,D> [goto TRETHELP]
Question ID: CMS.115_00.00 Instrument Variable Name: TRETHELP QuestionnaireFileName: Sample Child
QuestionText: You told us that [S.C. child] has received treatment or counseling for difficulties with emotions, concentration,
behavior, or being able to get along with others. During the past 6 months, how much has this treatment or
counseling helped [S.C. child]? Would you say…
* Read answer categories below.
1 Not at all
2 A little
3 Some
4 A lot
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who received treatment in the past 6 months
SkipInstructions: <1-4,R,D> if CMHDIFF=2-4 and DIFF6M=1 [goto TRPAYPHI];
else [goto next section]
Page 21 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.120_01.00 Instrument Variable Name: TRPAYPHI QuestionnaireFileName: Sample Child
QuestionText: Next I'm going to read a list of ways that treatment and counseling get paid for. Please tell me who pays or paid for
[fill1: S.C. name]'s treatment or counseling during the past 6 months.
Private health insurance, such as insurance that comes with a job?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months and received some type of treatment or counseling in
the past 6 months
SkipInstructions: <1,2,R,D> [goto TRPAYSCH]
Question ID: CMS.120_02.00 Instrument Variable Name: TRPAYSCH QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.
School system?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months and received some type of treatment or counseling in
the past 6 months
SkipInstructions: <1,2,R,D> [goto TRPAYSLF]
Page 22 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.120_03.00 Instrument Variable Name: TRPAYSLF QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.
You or your family (sometimes called out of pocket or co-payment)?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months and received some type of treatment or counseling in
the past 6 months
SkipInstructions: <1,2,R,D> [goto TRPAYMED]
Question ID: CMS.120_04.00 Instrument Variable Name: TRPAYMED QuestionnaireFileName: Sample Child
QuestionText: (Book) F14
*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.
Medicaid?
*Read if necessary: In this State it is also called *(Refer to flashcard F14 for state Medicaid names).
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months and received some type of treatment or counseling in
the past 6 months
SkipInstructions: <1,2,R,D> [goto TRPAYCHP]
Page 23 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.120_05.00 Instrument Variable Name: TRPAYCHP QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.
[fill2: A state CHIP/SCHIP program?/ [STNAME1]]?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months and received some type of treatment or counseling in
the past 6 months
SkipInstructions: <1,2,R,D> [goto TRPAYMIL]
Question ID: CMS.120_06.00 Instrument Variable Name: TRPAYMIL QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.
Military health care?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months and received some type of treatment or counseling in
the past 6 months
SkipInstructions: <1,2,R,D> [goto TRPAYSHP]
Page 24 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.120_07.00 Instrument Variable Name: TRPAYSHP QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.
Some other state or county sponsored health plan, Medicare or other government program?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months and received some type of treatment or counseling in
the past 6 months
SkipInstructions: <1,2,R,D> [goto TRPAYIHS]
Question ID: CMS.120_09.00 Instrument Variable Name: TRPAYIHS QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.
Indian Health Service?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months and received some type of treatment or counseling in
the past 6 months
SkipInstructions: <1,2,R,D> [goto TRPAYOTH]
Page 25 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.120_10.00 Instrument Variable Name: TRPAYOTH QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.
Some other source?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months and received some type of treatment or counseling in
the past 6 months
SkipInstructions: <1,2,R,D> if TRPAYPHI=2,R,D and TRPAYSCH=2,R,D and TRPAYSLF=2,R,D and TRPAYMED=2,R,D
and TRPAYCHP=2,R,D and TRPAYMIL=2,R,D and TRPAYSHP=2,R,D and TRPAYIHS=2,R,D and
TRPAYOTH=2,R,D [goto TRETFREE];
else [goto TRTNEED1]
Question ID: CMS.120_12.00 Instrument Variable Name: TRETFREE QuestionnaireFileName: Sample Child
QuestionText: Was ALL OF THE treatment or counseling [fill1: S.C. name] RECEIVED during the past 6 months free?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who did not pay for treatment
SkipInstructions: <1,2,R,D>[goto TRTNEED1]
Page 26 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.150_00.00 Instrument Variable Name: TRTNEED1 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 6 MONTHS, did [fill1: S.C. name] need treatment or counseling for these difficulties but didn't
get it ?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,
behavior, or being able to get along in the past 6 months
SkipInstructions: <1> [goto NTRTCOST] <2,R,D> [goto next section]
Question ID: CMS.150_01.00 Instrument Variable Name: NTRTCOST QuestionnaireFileName: Sample Child
QuestionText: Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Help was too expensive?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months
SkipInstructions: <1,2,R,D> [goto NTRTLOC]
Page 27 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.150_02.00 Instrument Variable Name: NTRTLOC QuestionnaireFileName: Sample Child
QuestionText: *Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You didn't know where to go?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months
SkipInstructions: <1,2,R,D> [goto NTRTNEXP]
Question ID: CMS.150_03.00 Instrument Variable Name: NTRTNEXP QuestionnaireFileName: Sample Child
QuestionText: *Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You had a negative experience with professionals?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months
SkipInstructions: <1,2,R,D> [goto NTRTFEAR]
Page 28 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.150_04.00 Instrument Variable Name: NTRTFEAR QuestionnaireFileName: Sample Child
QuestionText: *Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You are afraid or you don't like professionals?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months
SkipInstructions: <1,2,R,D> [goto NTRTLOSE]
Question ID: CMS.150_05.00 Instrument Variable Name: NTRTLOSE QuestionnaireFileName: Sample Child
QuestionText: *Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You were afraid [fill1: S.C. name] would be taken from your home or that you would lose your parental rights or
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months
SkipInstructions: <1,2,R,D> [goto NTRTSAY]
Page 29 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.150_06.00 Instrument Variable Name: NTRTSAY QuestionnaireFileName: Sample Child
QuestionText: *Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You were afraid of what your family or friends would say?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months
SkipInstructions: <1,2,R,D> [goto NTRTWAIT]
Question ID: CMS.150_07.00 Instrument Variable Name: NTRTWAIT QuestionnaireFileName: Sample Child
QuestionText: *Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You had to wait a long time for an appointment?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months
SkipInstructions: <1,2,R,D> [goto NTRTTRAN]
Page 30 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.150_08.00 Instrument Variable Name: NTRTTRAN QuestionnaireFileName: Sample Child
QuestionText: *Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You had no way to get there?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months
SkipInstructions: <1,2,R,D> [goto NTRTINCV]
Question ID: CMS.150_09.00 Instrument Variable Name: NTRTINCV QuestionnaireFileName: Sample Child
QuestionText: *Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Services were too inconvenient to use?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months
SkipInstructions: <1,2,R,D> [goto NTRTFAR]
Page 31 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.150_10.00 Instrument Variable Name: NTRTFAR QuestionnaireFileName: Sample Child
QuestionText: *Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Services were too far away?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months
SkipInstructions: <1,2,R,D> [goto NTRTCHNO]
Question ID: CMS.150_11.00 Instrument Variable Name: NTRTCHNO QuestionnaireFileName: Sample Child
QuestionText: *Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
[fill1: S.C. name] did not want to go?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months
SkipInstructions: <1,2,R,D> [goto NTRTOTH]
Page 32 of 32
2011 NHIS Questionnaire Sample Child
Child Mental Health Services
Document Version Date: 19-Jun-12
Question ID: CMS.150_12.00 Instrument Variable Name: NTRTOTH QuestionnaireFileName: Sample Child
QuestionText: *Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Some other reason?
1 Yes
2 No
7 Refused
9 Don’t know
UniverseText: Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months
SkipInstructions: <1,2,R,D> [goto next section]
Page 1 of 3
2011 NHIS Questionnaire Sample Child
Child Influenza Immunization
Document Version Date: 19-Jun-12
Question ID: CFI.005_00.010 Instrument Variable Name: CH1N1_1 QuestionnaireFileName: Sample Child
QuestionText: During the past 12 months, several kinds of flu vaccines have been available. I will ask you about {S.C. name’s}
most recent flu vaccinations.
DURING THE PAST 12 MONTHS, has {SC name} had a flu vaccination? A flu vaccination is usually given in the
fall and protects against influenza for the flu season.
*Read if necessary: {fill: SC name}’s most recent flu vaccination could have been the new 2010-2011 flu vaccine
available starting last fall, or either of the two types available last season, one called “seasonal” and the other called
“H1N1” or “swine” flu vaccine.
UniverseText: Sample Child LE 17 years
SkipInstructions: <1> [goto CH1N1_2]
<2,R,D> [goto next section]
Question ID: CFI.005_00.020 Instrument Variable Name: CH1N1_2 QuestionnaireFileName: Sample Child
QuestionText: How many vaccinations has {S.C. name} received?
UniverseText: Sample Child LE 17 years who have had a flu vaccine dose
SkipInstructions: <1,2> [goto CH1N1_3M]
<R,D> [goto next section]
Question ID: CFI.005_00.030 Instrument Variable Name: CH1N1_3M QuestionnaireFileName: Sample Child
QuestionText: 1 of 2
During what month and year did {S.C. name} receive {fill: his/her} most recent flu vaccine?
UniverseText: Sample Child LE 17 who have had one or more vaccine doses
SkipInstructions: <1-12,D> [ goto CH1N1_4Y] <R> [goto CH1N1_5]
Page 2 of 3
2011 NHIS Questionnaire Sample Child
Child Influenza Immunization
Document Version Date: 19-Jun-12
Question ID: CFI.005_00.040 Instrument Variable Name: CH1N1_4Y QuestionnaireFileName: Sample Child
QuestionText: 2 of 2
*Enter year of most recent flu vaccine.
UniverseText: Sample Child LE 17 years who have had one or more vaccine doses and gave month/don't know month of
vaccine dose
SkipInstructions: <valid year,R,D> [goto CH1N1_5]
[If CH1N1_3M and CH1N1_4Y = a future date] goto ERR1_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to birth] goto ERR2_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to 12 months ago] goto ERR3_ CH1N1_4Y]
Hard Edit: ERR1_ CH1N1_4Y
*Future date invalid.
ERR2_ CH1N1_4Y
*Date before birth.
ERR3_ CH1N1_4Y
*Date before 12 months ago.
Question ID: CFI.005_00.050 Instrument Variable Name: CH1N1_5 QuestionnaireFileName: Sample Child
QuestionText: Was this a shot, or was it a vaccine sprayed in the nose?
*Read if necessary: The flu nasal spray is called FluMist(trademark).
UniverseText: Sample Child LE 17 years who have had one or more vaccine doses
SkipInstructions: <1-2,R,D> IF CH1N1_2=1 [goto next section]; else if CH1N1_2=2 [goto CH1N1_6M]
Question ID: CFI.005_00.060 Instrument Variable Name: CH1N1_6M QuestionnaireFileName: Sample Child
QuestionText: 1 of 2
During what month and year did {S.C. name} receive {fill: his/her} next most recent flu vaccine?
UniverseText: Sample Child LE 17 years who have had more than one vaccine doses
SkipInstructions: <1-12,D> [ goto CH1N1_7Y] <R> [goto CH1N1_8]
Page 3 of 3
2011 NHIS Questionnaire Sample Child
Child Influenza Immunization
Document Version Date: 19-Jun-12
Question ID: CFI.005_00.070 Instrument Variable Name: CH1N1_7Y QuestionnaireFileName: Sample Child
QuestionText: 2 of 2
*Enter year of next most recent flu vaccine.
UniverseText: Sample Child LE 17 years who have had more than one vaccine doses and gave month/don't know month of
vaccine dose
SkipInstructions: <valid year,R,D> [goto CH1N1_8]
[If CH1N1_6M and CH1N1_7Y = a future date] goto ERR1_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to birth] goto ERR2_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to 12 months ago] goto ERR3_ CH1N1_7Y]
Hard Edit: ERR1_ CH1N1_7Y
*Future date invalid.
ERR2_ CH1N1_7Y
*Date before birth.
ERR3_ CH1N1_7Y
*Date before 12 months ago.
Question ID: CFI.005_00.080 Instrument Variable Name: CH1N1_8 QuestionnaireFileName: Sample Child
QuestionText: Was this a shot, or was it a vaccine sprayed in the nose?
*Read if necessary: The flu nasal spray is called FluMist(trademark).
UniverseText: Sample Child LE 17 years who have more than one vaccine dose
SkipInstructions: <1-2,R,D> [goto next section]
Page 1 of 2
2011 NHIS Questionnaire Sample Child
Child Disability
Document Version Date: 19-Jun-12
Question ID: CDB.020_00.00 Instrument Variable Name: P2DCHEAR QuestionnaireFileName: Sample Child
QuestionText: With this next set of questions, we want to learn about people who have physical, mental, or emotional conditions
that cause serious difficulties with their daily activities. Though different, these questions may sound similar to ones
I asked earlier.
Is {S.C. name} deaf or does {S.C. name} have serious difficulty hearing?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 1-17 years and random number generator=1
SkipInstructions: <1,2,D,R> goto P2DCSEE
Question ID: CDB.040_00.00 Instrument Variable Name: P2DCSEE QuestionnaireFileName: Sample Child
QuestionText: Is {S.C. name} blind or does {S.C. name} have serious difficulty seeing even when wearing glasses?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 1-17 years and random number generator=1
SkipInstructions: <1,2,D,R> if AGE GE 5 goto P2DCCON;
else if AGE LE 4 goto SCSSN4
Question ID: CDB.060_00.00 Instrument Variable Name: P2DCCON QuestionnaireFileName: Sample Child
QuestionText: Because of a physical, mental, or emotional condition, does {S.C. name} have serious difficulty concentrating,
remembering, or making decisions?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 5-17 years and random number generator=1
SkipInstructions: <1,2,D,R> goto P2DCWALK
Page 2 of 2
2011 NHIS Questionnaire Sample Child
Child Disability
Document Version Date: 19-Jun-12
Question ID: CDB.080_00.00 Instrument Variable Name: P2DCWALK QuestionnaireFileName: Sample Child
QuestionText: Does {S.C. name} have serious difficulty walking or climbing stairs?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 5-17 years and random number generator=1
SkipInstructions: <1,2,D,R> goto P2DCDRES
Question ID: CDB.100_00.00 Instrument Variable Name: P2DCDRES QuestionnaireFileName: Sample Child
QuestionText: Does {S.C. name} have difficulty dressing or bathing?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 5-17 years and random number generator=1
SkipInstructions: <1,2,D,R> if AGE GE 15 goto P2DCERR,
else goto SCSSN4
Question ID: CDB.120_00.00 Instrument Variable Name: P2DCERR QuestionnaireFileName: Sample Child
QuestionText: Because of a physical, mental, or emotional condition, does {S.C. name} have difficulty doing errands alone such as
visiting a doctor's office or shopping?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 15-17 years and random number generator=1
SkipInstructions: <1,2,D,R> goto end of section
Section Name Adult Identification and Verification
Module 14
Instrument Variable SADULT
Question ID AID.005
Universe HHSTAT4 = 'S' and (ASTAT = empty or ASTAT = '2')
Universe-text This is the Sample Adult and (the Sample Adult section has not been started or
completed).
Question Text * The sample adult person is [fill: ALIAS of Sample Adult]. The next questions
must be answered by this person. Probe as necessary to determine the
availability of [fill: ALIAS of Sample Adult].
* If refused enter CTRL-R
Answer Codes 1. Available
2. Not Available
3. Physical or Mental condition prohibits responding
Refused
Question Type Pick One - answer list pane
Part
Field Pane Sample Adult Available
Fill Instructions
Special Instructions Do not allow "Don't Know" as an answer.
Display the description of the answer code entered in this question to the right of
the answer box in the field pane, e.g., if '1' is entered, display 'Available'; if
'Refused' is entered, display 'Refused'.
Skip Instructions <1> if Sample Adult = demographics.hhc.RELRESP_A
goto beginning of adult.asd
elseif Sample Adult = demographics.hhc.HHRESP
goto beginning of adult.asd
else
goto AIDVERF_S
endif
<2> goto callbk.ACALLBK1
<3> goto PROX1
<R> store '4' in ASTAT
if recontact.RCIFLAG ne '1'
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
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quSoftedits
Section Name Adult Identification and Verification
Module 14
Instrument Variable PROX1
Question ID AID.010
Universe SADULT = '3'
Universe-text The Sample Adult's physical or mental condition prohibits responding.
Question Text * Proxy interviews can be done for sample adults that have a mental or physical
condition that
prevents them from responding for themselves.
Is a family member or caregiver that is knowledgeable about [fill: ALIAS of
Sample Adult]'s health available?
Answer Codes 1. Yes
2. No
Question Type Yes/No
Part
Field Pane Proxy Available
Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Display the description of the answer code entered in this question to the right of
the answer box in the field pane, e.g., if '2' is entered, display 'No'.
Skip Instructions <1> goto PROX2
<2> goto PROX3
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Section Name Adult Identification and Verification
Module 14
Instrument Variable PROX2
Question ID AID.015
Universe PROX1 = '1'
Universe-text Knowledgeable proxy is available.
Question Text * Ask if necessary.
What is this person's relationship to [fill: ALIAS of Sample Adult]?
Answer Codes 1. Relative who lives in household
2. Relative who doesn't live in household
3. Other caregiver
4. Other
Question Type Pick One - answer list pane
Part
Field Pane Proxy's Relationship to Sample Adult
Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Skip Instructions <1-4> goto AIDVERF_S
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Tuesday, June 19, 2012 Page 3 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable PROX3
Question ID AID.020
Universe PROX1 = '2'
Universe-text Knowledgeable proxy is not available.
Question Text *Ask if necessary.
Can a callback with someone knowledgeable about [fill: ALIAS of Sample
Adult]'s health be arranged?
Answer Codes 1. Yes
2. No
Question Type Yes/No
Part
Field Pane Arrange Proxy Callback
Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Display the description of the answer code entered in this question to the right of
the answer box in the field pane, e.g., if '1' is entered, display 'Yes'.
Skip Instructions <1> goto callbk.ACALLBK1
<2> store '3' in ASTAT
if recontact.RCIFLAG ne '1'
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
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Section Name Adult Identification and Verification
Module 14
Instrument Variable SADATE
Question ID AID.025
Universe (SADULT = '1' (available)) or (SADULT = '3' (condition prohibits responding) and
PROX1 = '1' (yes) and PROX2 = response)
Universe-text Sample Adult section has been started with either the Sample Adult or a proxy.
Question Text
Answer Codes
Question Type Output Storage Variable
Part
Field Pane
Fill Instructions
Special Instructions Set only if SADATE = empty
If SADULT = '1' (available)
set SADATE = CDATE (current date) (now called ComputationDate)
elseif SADULT = '3' (condition prohibits responding) and PROX1 = '1' (yes) and
PROX2 = response
set SADATE = CDATE (current date) (now called ComputationDate)
endif
This is an output variable that should be in the format 'MMDDYYYY'.
Skip Instructions
Edit Name
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quSoftedits
Tuesday, June 19, 2012 Page 5 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable SATIME
Question ID AID.026
Universe (SADULT = '1' (available)) or (SADULT = '3' (condition prohibits responding) and
PROX1 = '1' (yes) and PROX2 = response)
Universe-text Sample Adult section has been started with either the Sample Adult or a proxy.
Question Text
Answer Codes
Question Type Output Storage Variable
Part
Field Pane
Fill Instructions
Special Instructions Set only if SATIME = empty
If SADULT = '1' (available)
set SATIME = current time
elseif SADULT = '3' (condition prohibits responding) and PROX1 = '1' (yes) and
PROX2 = response
set SATIME = current time
endif
This is an output variable that should be in the format 'HH:MM [ fill:a.m./p.m.]'.
Skip Instructions
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Section Name Adult Identification and Verification
Module 14
Instrument Variable AIDVERF_S
Question ID AID.030
Universe (RELRESP_A ne Sample Adult and HHRESP ne Sample Adult) or PROX1 = '1'
Universe-text Sample Adult is not the person entered in HHRESP or RELRESP_A. Or PROX1
= 'Yes'.
Question Text * Please verify the following information about the sample adult before
proceeding:
I have recorded your sex as [fill: Sex of Sample Adult]. Is this correct?
Answer Codes 1. Yes
2. No
Question Type Yes/No
Part
Field Pane Verified Adult's Sex
Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Display the description of the most recently updated sex to the right of the
answer box in the field pane, e.g., if '1' is the current answer, display 'Male'.
Skip Instructions <1> goto AIDVERF_A
<2> goto AIDSEX
Edit Name
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Tuesday, June 19, 2012 Page 7 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable AIDSEX
Question ID AID.040
Universe AIDVERF_S = '2' (No)
Universe-text Respondent said his/her sex is not correct.
Question Text * Ask if appropriate; otherwise, enter your best guess of the person's sex.
Are you Male or Female?
Answer Codes 1. Male
2. Female
Question Type Pick One - answer list pane
Part
Field Pane Adult's Revised Sex
Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Display the description of the sex for the answer entered in this question to the
right of the answer box in the field pane, e.g., if '2' is entered, display 'Female'.
Skip Instructions <1,2> store AIDSEX in SEX
goto ERR_AIDSEX
reset AIDVERF_S
goto AIDVERF_S
Edit Name ERR_AIDSEX
quHardedits ERR_AIDSEX
*The gender will now be changed to [fill: AIDSEX].
goto AIDVERF_S (as the default goto)
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Tuesday, June 19, 2012 Page 8 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable AIDVERF_A
Question ID AID.045
Universe AIDVERF_S = '1'
Universe-text Sample Adult said his/her sex is correct.
Question Text * Please verify the following information about the sample adult before
proceeding:
I have recorded your age as [fill: Age of Sample Adult] old. Is this correct?
Answer Codes 1. Yes
2. No
Question Type Yes/No
Part
Field Pane Verified Adult's Age
Fill Instructions If Sample Adult's age in AGE is > "0"
[fill: <AGE> years]
else
[fill: less than a year]
endif
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Display the most recently updated age in years to the right of the answer box in
the field pane, e.g., if the age is '32' display '32 years old'. For the case where
the age is '0' years, display 'less than a year old'. This last situation should
rarely, if ever, occur, but it is here just in case.
Skip Instructions <1> goto AIDVERF_D
<2> goto AIDAGE
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Tuesday, June 19, 2012 Page 9 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable AIDAGE
Question ID AID.050
Universe AIDVERF_A = '2' (No)
Universe-text Respondent said his/her age is not correct
Question Text How old are you?
Answer Codes
Question Type Integer
Part
Field Pane Adult's Revised Age
Fill Instructions
Special Instructions Hard code the phrase 'year(s) old' to the right of the answer box in the field
Skip Instructions <0-120, Refused, Don't know>
if AIDAGE = 'Refused' or AIDAGE = 'Don't know' or AIDAGE = AGE
reset AIDVERF_A
goto ERR_AIDAGE
else
store AIDAGE in AGE
goto AIDDOB_M
Edit Name ERR_AIDAGE
quHardedits
quSoftedits ERR_AIDAGE
*Age of [fill1: ALIAS of Sample Adult] remains [fill2: Age of Sample Adult] years
old.
Tuesday, June 19, 2012 Page 10 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable AIDVERF_D
Question ID AID.055
Universe AIDVERF_A = '1'
Universe-text Sample Adult said his/her age is correct.
Question Text * Please verify the following information about the sample adult before
proceeding:
I have recorded your birthday as [fill: Birthday of Sample Adult]. Is this correct?
Answer Codes 1. Yes
2. No
Question Type Yes/No
Part
Field Pane Verified Adult's Date of Birth
Fill Instructions [fill: <DOBM> <DOBD>, <DOBY>] = date of birth, where <DOBM> should be
filled with the name of the month, not the number. For any part of the birth
date that is "refused", "don't know", or otherwise "blank", put a "?" for that field.
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Display the Sample Adult's date of birth to the right of the answer box in the
field pane. For any part of the birth date that is "refused", "don't know", or
otherwise "blank", put a "?" for that field.
Skip Instructions <1> if AGE of Sample Adult le '17'
goto NO_MORE
else
goto beginning of adult.asd
endif
<2> goto AIDDOB_M
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Section Name Adult Identification and Verification
Module 14
Instrument Variable AIDDOB_M
Question ID AID.060_1
Universe AIDVERF_D = '2' (No) or AIDVERF_A = '2' (No)
Universe-text Respondent said his/her date of birth is not correct or his/her age is not correct
Question Text 1 of 3
What is your birthday?
*Enter month of birth.
Answer Codes 1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Adult's Revised Month of Birth
Fill Instructions
Special Instructions Display the name of the month for the answer entered in this question to the
right of the answer box in the field pane, e.g., if '10' is entered, display 'October'.
If 'Refused' or 'Don't know' is entered, do not display anything to the right of the
answer box.
Skip Instructions <01-12, Refused, Don't know> goto AIDDOB_D
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Tuesday, June 19, 2012 Page 12 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable AIDDOB_D
Question ID AID.060_2
Universe AIDVERF_D = '2' (No) or AIDVERF_A = '2' (No)
Universe-text Respondent said his/her date of birth is not correct or his/her age is not correct
Question Text 2 of 3
*Enter day of birth.
Answer Codes
Question Type Integer
Part
Field Pane Adult's Revised Day of Birth
Fill Instructions [fill2: AIDDOB_M] = month of birth, where <AIDDOB_M> should be filled with
the name of the month, not the number.
Special Instructions Only allow valid days for month entered.
Skip Instructions <01-31,Refused,Don't know> goto AIDDOB_Y
If days not valid, goto ERR_AIDDOB_D
Edit Name ERR_AIDDOB_D
quHardedits ERR_AIDDOB_D
*[fill1: AIDDOB_D] is not a valid day for [fill2: AIDDOB_M].
*Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 13 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable AIDDOB_Y
Question ID AID.060_3
Universe AIDVERF_D = '2' (No) or AIDVERF_A = '2' (No)
Universe-text Respondent said his/her date of birth is not correct or his/her age is not correct
Question Text 3 of 3
*Enter year of birth.
Answer Codes
Question Type Integer
Part
Field Pane Adult's Revised Year of Birth
Fill Instructions [fill1: <AIDDOB_M> <AIDDOB_D>, <AIDDOB_Y>] = date of birth, where
<AIDDOB_M> should be filled with the name of the month, not the number. For
any part of the birth date that is "refused", "don't know", or otherwise "blank", put
a "?" for that field.
[fill3: <DOBM> <DOBD>, <DOBY>] = date of birth, where <DOBM> should be
filled with the name of the month, not the number. For any part of the birth
date that is "refused", "don't know", or otherwise "blank", put a "?" for that field.
Special Instructions
Skip Instructions <1880-2020, Refused, Don't know> if AIDVERF_A = '2' (No) then reset
AIDVERF_A to empty
goto AIDVERF_A
elseif AIDVERF_D = '2' (No) then reset
AIDVERF_D to empty
goto AIDVERF_D
endif
(if year GT current year) or (if year = current year and month GT current month)
or (if year = current year and month = current month and day GT current day)
goto ERR1_AIDDOB_Y
endif
(if birth month = '02' and birth day = '29' and this is not a leap year)
goto ERR2_AIDDOB_Y
endif
(if AIDDOB_M = 'Ref' or 'DK') or (if AIDDOB_D = 'Re'f or 'DK') or (if AIDDOB_Y =
'Ref' or 'DK')
goto ERR3_AIDDOB_Y
else
store AIDDOB_M in DOBM
store AIDDOB_D in DOBD
store AIDDOB_Y in DOBY
if AIDVERF_A = '2' (No) then reset AIDVERF_A to empty
goto AIDVERF_A
elseif AIDVERF_D = '2' (No) then reset AIDVERF_D to empty
Tuesday, June 19, 2012 Page 14 of 26
goto AIDVERF_D
endif
endif
Calculate age from AIDDOB_M, AIDDOB_D, and AIDDOB_Y.
if age from AIDDOB items is ne AGE and age from AIDDOB items is valid
reset AIDVERF_A or AIDVERF_D.
goto ERR4_AIDDOB_Y
Edit Name ERR1_AIDDOB_Y;
ERR2_AIDDOB_Y;
quHardedits ERR1_AIDDOB_Y
*Future date invalid: [fill1: <AIDDOB_M> <AIDDOB_D>, <AIDDOB_Y>]
*Please correct.
goto AIDDOB_M (whether suppressed or not)
ERR2_AIDDOB_Y
*Not a valid day: [fill1: <AIDDOB_M> <AIDDOB_D>, <AIDDOB_Y>]
*Please correct.
goto AIDDOB_M (whether suppressed or not)
ERR3_AIDDOB_Y
*DOB of [fill2: ALIAS of Sample Adult] remains [fill3: <DOBM> <DOBD>,
<DOBY>]
goto AIDVERF_A (whether suppressed or not)
ERR4_AIDDOB_Y
* Data mismatched. Please fix Age or Birthday.
* If still cannot reconcile, enter 'Don't know' for year of birth.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 15 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable NO_MORE
Question ID AID.070
Universe [(ASTAT = empty or ASTAT = '2') and HHSTAT4 = 'S' and AGE le '17']
Universe-text Sample adult whose age is now less than or equal to 17
Question Text * [fill: ALIAS of Sample Adult] is no longer the sample adult for this family.
* You may need to ask additional questions before continuing with the rest of
the interview.
Answer Codes 1. Enter 1 to Continue
Question Type Enter 1 to Continue
Part
Field Pane This Person No Longer Sample Adult
Fill Instructions
Special Instructions
Skip Instructions Do not allow "Don't Know" or "Refused" as an answer.
<1> (Search and count the number of persons in the family 18+ years old.)
[if (age is now 14-17 inclusive) and (person is married or living with a
partner or there is no one over 17 years old in the family)]
store 'E' in HHSTAT4
store '0' in ASTAT
if recontact.RCIFLAG ne '1'
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
else
store empty in HHSTAT4
store '0' in ASTAT
if recontact.RCIFLAG ne '1'
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
endif
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Tuesday, June 19, 2012 Page 16 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable AAGECHG
Question ID AID.075
Universe HHSTAT4 = 'S' and ((AIDAGE ne empty and AIDAGE ne original age) OR
(AIDSEX ne empty and AIDSEX ne original sex))
Universe-text Person is SA and (there is a sex change or an age change)
Question Text * Because you changed the Sample Adult's sex and / or sex, you may need to
ask additional questions before continuing with the rest of the interview.
Answer Codes 1. Enter 1 to Continue
Question Type Enter 1 to Continue
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions
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Tuesday, June 19, 2012 Page 17 of 26
Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable WRKVER
Question ID ASD.050
Universe HHSTAT4 = S and DOINGLW = 1-5
Universe-text Sample adults 18+ who were working or not working last week
Question Text Earlier I recorded that in the last week you were
(Fill1: working for pay at a job or business.)
(Fill2: with a job or business but not at work.)
(Fill3: looking for work.)
(Fill4: working, but not for pay, at a family-owned job or business.)
(Fill5: not working at a job or business and not looking for work.)
Is that correct?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Verify last week's work activity
Fill Instructions Fill1: If DOINGLW = 1
Fill2: If DOINGLW = 2
Fill3: If DOINGLW = 3
Fill4: If DOINGLW = 4
Fill5: If DOINGLW = 5
Special Instructions Storage instructions: If WRKVER = 1 then
set DOINGLW2 = DOINGLW and WHYNOWK2 =
WHYNOWRK
elseif WRKVER = Refused or Don't know then
set DOINGLW2 = WRKVER
endif
Skip Instructions <1>if DOINGLW2 = 1,2,4 [goto WHOWRK]
else if DOINGLW2 = 3,5 [goto EVERWRK]
<2>go to WRKCOR
<R,D>go to EVERWRK
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Tuesday, June 19, 2012 Page 1 of 19
Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable WRKCOR
Question ID ASD.060
Universe HHSTAT4 = S and [(WRKVER = 2) or (SASEL ne FAMRESP and (DOINGLW =
Refused or Don't know))]
Universe-text Sample adults 18+ whose working status was incorrect or who were not the
Family Respondent and with an answer of D or R to DOINGLW.
Question Text (book) A1 ? [F1]
What is your correct working status?
* Read answer categories.
Answer Codes 1. Working for pay at a job or business
2. With a job or business but not at work
3. Looking for work
4. Working, but not for pay, at a family-owned job or business
5. Not working at a job or business and not looking for work
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Correct working status
Fill Instructions
Special Instructions Display the answer codes in the answer pane in bold black.
Storage instructions: set DOINGLW2 = WRKCOR
Skip Instructions <1,4> [goto to WHOWRK]
<2,5>[goto WHYNOWK2]
<3,R,D>[goto EVERWRK]
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable DOINGLW2
Question ID ASD.062
Universe HHSTAT4 = S and Sample Adult (L_NO) = FAMRESP and (DOINGLW =
Refused or Don't know)
Universe-text Sample Adults 18+ and also the family section respondent and said Refused or
Don't know to the working last week status question in the family section
Question Text Corrected Employment Status Last Week: (not displayed)
Answer Codes 1. Working for pay at a job or business
2. With a job or business but not at work
3. Looking for work
4. Working, but not for pay, at a family-owned job or business
5. Not working at a job or business and not looking for work
Refused
Don't know
Question Type Procedure
Part
Field Pane
Fill Instructions
Special Instructions Storage Instructions:
If (DOINGLW = Refused or Don't know) and Sample Adult (L_NO) = FAMRESP
then
set DOINGLW2 = DOINGLW
Skip Instructions if DOINGLW2 = Refused or Don't know then
[goto EVERWRK]
endif
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable WHYNOWK2
Question ID ASD.065
Universe HHSTAT4 = S and WRKCOR = 2,5
Universe-text Sample Adults 18+ whose corrected working status last week was not working at a
job or business and not looking for work or with a job or business but not at work
Question Text ? [F1]
(Fill1: What is the main reason you did not work last week?)
(Fill2: What is the main reason you did not have a job or business last week?)
Answer Codes 1. Taking care of house or family
2. Going to school
3. Retired
4. On a planned vacation from work
5. On family or maternity leave
6. Temporarily unable to work for health reasons
7. Have job/contract and off-season
8. On layoff
9. Disabled
10. Other
Refused
Don't know
Question Type Other
Part
Field Pane Reason not working last week
Fill Instructions Fill1: if WRKCOR = 2
Fill2: if WRKCOR = 5
Special Instructions
Skip Instructions <1-10,D,R> if WRKCOR = 2 then
[goto WHOWRK]
else [goto EVERWRK]
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable EVERWRK
Question ID ASD.066
Universe HHSTAT4 = S and DOINGLW2 = 3,5,Refused,or Don't know
Universe-text Sample adults 18+ who were NOT working at a job or business and not looking
for work or looking for work last week or didn't know or refused to provide their
employment status last week
Question Text Have you ever held a job or worked at a business?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Ever worked
Fill Instructions
Special Instructions
Skip Instructions <1> [goto WHOWRK]
<2,D,R> [goto next section]
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable WHOWRK
Question ID ASD.070
Universe HHSTAT4 = S and (DOINGLW2 = 1,2,4 or EVERWRK = 1)
Universe-text Sample adults 18+ who were working last week, or who were with a job or
business but not at work, or who were working but not for pay at a family-owned
job or business, or who have ever worked
Question Text ? [F1]
(Fill1:For whom did you work at your MAIN job or business? (Name of company,
business, organization or employer))
(Fill2: Thinking about the job you held the longest, for whom did you work?
(Name of company, business, organization or employer))
(Fill3: Thinking about the job you held most recently, for whom did you work?
(Name of company, business, organization or employer))
Answer Codes
Question Type Text
Part
Field Pane Whom did you work for
Fill Instructions Fill1: if DOINGLW2 = <1,2,4>
Fill2: if EVERWRK = 1 and (WHYNOWK2 = 3 or AGE ge 65)
Fill3: if EVERWRK = 1 and WHYNOWK2 ne 3 and AGE lt 65
Special Instructions
Skip Instructions <90 char long,D,R> [goto KINDIND]
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable KINDIND
Question ID ASD.080
Universe HHSTAT4 = S and (DOINGLW2 = 1,2,4 or EVERWRK = 1)
Universe-text Sample adults 18+ who were working last week, or who were with a job or
business but not at work, or who were working but not for pay at a family-owned
job or business, or who have ever worked
Question Text ? [F1]
What kind of business or industry was this? (For example: TV and radio mgt.,
retail shoe store, State Department of Labor)
Answer Codes
Question Type Text
Part
Field Pane What kind of business/industry
Fill Instructions
Special Instructions
Skip Instructions <90 char long,D,R> [goto KINDWRK]
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable KINDWRK
Question ID ASD.090
Universe HHSTAT4 = S and (DOINGLW2 = 1,2,4 or EVERWRK = 1)
Universe-text Sample adults 18+ who were working last week, or who were with a job or
business but not at work, or who were working but not for pay at a family-owned
job or business, or who have ever worked
Question Text ? [F1]
What kind of work were you doing? (For example: farming, mail clerk, computer
specialist.)
Answer Codes
Question Type Text
Part
Field Pane What kind of work
Fill Instructions
Special Instructions
Skip Instructions <90 char long,D,R> [goto IMPACT]
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable IMPACT
Question ID ASD.100
Universe HHSTAT4 = S and (DOINGLW2 = 1,2,4 or EVERWRK = 1)
Universe-text Sample adults 18+ who were working last week, or who were with a job or
business but not at work, or who were working but not for pay at a family-owned
job or business, or who have ever worked
Question Text ? [F1]
What were your most important activities on this job or business? (For example:
sells cars, keeps account books, operates printing press.)
Answer Codes
Question Type Text
Part
Field Pane Important activities
Fill Instructions
Special Instructions
Skip Instructions <90 char long,D,R> [goto WRKCAT]
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable WRKCAT
Question ID ASD.110
Universe HHSTAT4 = S and (DOINGLW2 = 1,2,4 or EVERWRK = 1)
Universe-text Sample adults 18+ who were working last week, or who were with a job or
business but not at work, or who were working but not for pay at a family-owned
job or business, or who have ever worked
Question Text (book) A2 ? [F1]
(Fill1: Looking at the card, which of these best describes your current job or work
situation?)
(Fill2: Looking at the card, which of these best describes the job you held for the
longest time?)
(Fill3: Looking at the card, which of these best describes the job you held most
recently?)
* Read answer choices if necessary.
Answer Codes 1. An employee of a PRIVATE company, business, or individual for wages,
salary, or commission
2. A FEDERAL government employee
3. A STATE government employee
4. A LOCAL government employee
5. Self-employed in OWN business, professional practice or farm
6. Working WITHOUT PAY in family-owned business or farm
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Class of worker
Fill Instructions Fill1: if DOINGLW2 = <1,2,4>
Fill2: if EVERWRK = 1 and (WHYNOWK2 = 3 or AGE ge 65)
Fill3: if EVERWRK = 1 and WHYNOWK2 ne 3 and AGE lt 65
Special Instructions
Skip Instructions <1-4,6,D,R>[goto LOCALLNO]
<5> [goto BUSINC]
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable BUSINC
Question ID ASD.112
Universe HHSTAT4 = S and WRKCAT = 5
Universe-text Sample adults 18+ who are self-employed
Question Text Is this business incorporated?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Incorporated business
Fill Instructions
Special Instructions
Skip Instructions <1,2,D,R> [goto LOCALLNO]
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable LOCALLNO
Question ID ASD.120
Universe HHSTAT4 = S and (DOINGLW2 = 1,2,4 or EVERWRK = 1)
Universe-text Sample adults 18+ who were working last week, or who were with a job or
business but not at work, or who were working but not for pay at a family-owned
job or business, or who have ever worked
Question Text (book) A3
Thinking about
(Fill1: this MAIN job or business)
(Fill2: your last week at the job you held the longest)
(Fill3: your last week at the job you held most recently)
how many people (Fill4:work/Fill5: worked) at this location?
* "People" includes both FULL- and PART-time employees; "location" refers to
the street address of the workplace.
Answer Codes 1. 1-9 employees
2. 10-24 employees
3. 25-49 employees
4. 50-99 employees
5. 100-249 employees
6. 250-499 employees
7. 500-999 employees
8. 1000 employees or more
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Number of employees
Fill Instructions Fill1: If [DOINGLW2 eq <1,2,4>]
Fill2: if [EVERWRK eq <1> and (WHYNOWK2 eq 03 or AGE ge 65)]
Fill3: if [EVERWRK eq <1> and WHYNOWK2 ne 03 and AGE lt 65]
Fill4: if [DOINGLW2 eq <1,2,4>
Fill5: if [EVERWRK eq 1]
Special Instructions
Skip Instructions <1-8, R,D>[goto WRKLONGN]
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable WRKLONGN
Question ID ASD.140_01
Universe HHSTAT4 = S and (DOINGLW2 = 1,2,4 or EVERWRK = 1)
Universe-text Sample adults 18+ who were working last week, or who were with a job or
business but not at work, or who were working but not for pay at a family-owned
job or business, or who have ever worked
Question Text ? [F1]
1 of 2
About how long
(Fill1: have you worked at this MAIN job or business?)
(Fill2: did you work at the job you held the longest?)
(Fill3: did you work at the job you held most recently?)
* Enter number.
Answer Codes 1-365
Refused
Don't know
Question Type Integer
Part
Field Pane Duration at this job: Number of units
Fill Instructions Fill1: If DOINGLW2 = <1,2,4>
Fill2: if EVERWRK = <1> and (WHYNOWK2 = 3 or AGE ge 65)
Fill3: if EVERWRK = <1> and WHYNOWK2 ne 3 and AGE lt 65
Special Instructions Store D,R in WRKLONGT
Skip Instructions <1-365> [goto WRKLONGT]
<D,R> if EVERWRK eq 1 and (WHYNOWK2 eq 03 or AGE GE 65)
[goto HOURPD] ;
Else if (EVERWRK eq 1 and WHYNOWK2 = 1,2,4-10, D,R," " and AGE lt
65) or (DOINGLW2 = 1,2,4)
[goto WRKLONGH]
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable WRKLONGT
Question ID ASD.140_02
Universe HHSTAT4 = S and (DOINGLW2 = 1,2,4 or EVERWRK = 1) and WRKLONGN ne
Refused or Don't know
Universe-text Sample adults 18+ (who were working last week, or who were with a job or
business but not at work, or who were working but not for pay at a family-owned
job or business, or who have ever worked) and who gave a number entry in
Question Text 2 of 2
* Enter time period.
Answer Codes 1. Days(s)
2. Week(s)
3. Month(s)
4. Year(s)
Question Type Pick One - answer list pane
Part
Field Pane Duration at this job: Time units
Fill Instructions
Special Instructions
Skip Instructions <4> if WRKLONGN gt AGE then [goto ERR_WRKLONGT]
<1-4> if EVERWRK = 1 and (WHYNOWK2 = 3 or AGE ge 65) then [goto
HOURPD]
else if (EVERWRK eq 1 and WHYNOWK2 = 1,2,4-10, D,R," " and AGE lt
Edit Name ERR_WRKLONGT
quHardedits ERR_WRKLONGT
* Number of years is greater than age.
* Please correct.
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Tuesday, June 19, 2012 Page 14 of 19
Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable WRKLONGH
Question ID ASD.146
Universe HHSTAT4 = S and (DOINGLW2 = 1,2,4 or (EVERWRK = 1 and WHYNOWK2 ne
3 and AGE lt 65))
Universe-text Sample adults 18+ (who were working last week, or who were with a job or
business but not at work, or who were working but not for pay at a family-owned
job or business,) or (who have ever worked and are not retired and are less than
65 years of age.)
Question Text ? [F1]
(Fill1: Is this MAIN job or business the job you have held for the longest?)
(Fill2: Was your most recently held job also the job you held the longest?)
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Longest job
Fill Instructions [Fill1: If DOINGLW2 eq 1,2,4, ]
[Fill2: if EVERWRK eq 1 and WHYNOWK2 ne 03 and AGE lt 65 ]
Special Instructions
Skip Instructions <1,2,R,D> [goto HOURPD]
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable HOURPD
Question ID ASD.150
Universe HHSTAT4 = S and (DOINGLW2 = 1,2,4 or EVERWRK = 1)
Universe-text Sample adults 18+ who were working last week, or who were with a job or
business but not at work, or who were working but not for pay at a family-owned
job or business, or who have ever worked
Question Text (Fill1: Are you paid by the hour at this MAIN job or business?)
(Fill2: Were you paid by the hour on the job you held the longest?)
(Fill3: Were you paid by the hour on the job you held most recently?)
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Paid by the hour
Fill Instructions Fill1: if DOINGLW2 = <1,2,4>
Fill2: if EVERWRK = 1 and (WHYNOWK2 = 3 or AGE ge 65)
Fill3: if EVERWRK = 1 and WHYNOWK2 ne 3 and AGE lt 65
Special Instructions
Skip Instructions <1,2,D,R> [goto PDSICK]
Edit Name
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable PDSICK
Question ID ASD.160
Universe HHSTAT4 = S and (DOINGLW2 = 1,2,4 or EVERWRK = 1)
Universe-text Sample adults 18+ who were working last week, or who were with a job or
business but not at work, or who were working but not for pay at a family-owned
job or business, or who have ever worked
Question Text (Fill1: Do you have paid sick leave on this MAIN job or business?
(Fill2: Did you ever have paid sick leave on the job you held the longest?
(Fill3: Did you ever have paid sick leave on the job you held most recently?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Paid sick leave
Fill Instructions Fill1: if DOINGLW2 = <1,2,4>
Fill2: if EVERWRK = 1 and (WHYNOWK2 = 3 or AGE ge 65)
Fill3: if EVERWRK = 1 and WHYNOWK2 ne 3 and AGE lt 65
Special Instructions
Skip Instructions <1,2,D,R>
if DOINGLW2 = 1,2,4 then [goto ONEJOB];
else if DOINGLW2=3,5 then [goto WRKLYR2];
else if DOINGLW2=D, R then [goto ADULT.ACN.HYPEV]
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Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable ONEJOB
Question ID ASD.170
Universe HHSTAT4 = S and DOINGLW2 = 1,2,4
Universe-text Sample adults 18+ who were working last week, or who were with a job or
business but not at work, or who were working but not for pay at a family-owned
job or business
Question Text Do you have more than one job or business?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane More than one job
Fill Instructions
Special Instructions
Skip Instructions : <1,2,D,R> [goto ADULT.ACN.HYPEV]
Edit Name
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Tuesday, June 19, 2012 Page 18 of 19
Section Name Adult Socio-Demographic Background
Module 15
Instrument Variable WRKLYR2
Question ID ASD.210_00.000
Universe HHSTAT4 =’S’ and AGE ge ‘18’ and (DOINGLW2 IN (’3’, ‘5’))
Universe-text Sample adults 18+ who were looking for work or who were not working at a job or
business AND who were not looking for work in the last week
Question Text ? [F1]
Although you did not work last week, did you have a job or business at any time
in the PAST 12 MONTHS?
Answer Codes 1. Yes
2. No
Refused
Don’t know
Question Type Yes/No
Part
Field Pane Worked past 12 months
Fill Instructions
Special Instructions
Skip Instructions <1,2,D,R> [goto ADULT.ACN.HYPEV]
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Section Name Adult Conditions
Module 16
Instrument Variable HYPEV
Question ID ACN.010
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Now I am going to ask you about certain medical conditions.
Have you EVER been told by a doctor or other health professional that you had
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Hypertension - ever
Fill Instructions
Special Instructions
Skip Instructions <1> [goto HYPDIFV]
<2,R,D> [goto CHDEV]
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Section Name Adult Conditions
Module 16
Instrument Variable HYPDIFV
Question ID ACN.020
Universe HHSTAT4 = 'S'and AGE GE 18 and HYPEV=1
Universe-text Sample adults 18+ who were told they had hypertension
Question Text Were you told on two or more DIFFERENT visits that you had hypertension, also
called high blood pressure?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Hypertension - 2+ visits
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to the previous question.
Skip Instructions <1,2,R,D> [goto CHDEV]
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Section Name Adult Conditions
Module 16
Instrument Variable CHDEV
Question ID ACN.031_01
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Have you EVER been told by a doctor or other health professional that you had
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Coronary heart disease -ever
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto ANGEV]
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Section Name Adult Conditions
Module 16
Instrument Variable ANGEV
Question ID ACN.031_02
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if necessary:
Have you EVER been told by a doctor or other health professional that you had
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Angina -ever
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto MIEV]
Edit Name
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Section Name Adult Conditions
Module 16
Instrument Variable MIEV
Question ID ACN.031_03
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if necessary:
Have you EVER been told by a doctor or other health professional that you had
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Heart attack - ever
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto HRTEV]
Edit Name
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Tuesday, June 19, 2012 Page 5 of 56
Section Name Adult Conditions
Module 16
Instrument Variable HRTEV
Question ID ACN.031_04
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
* Read if necessary:
Have you EVER been told by a doctor or other health professional that you had
...Any kind of heart condition or heart disease (other than the ones I just asked
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Heart condition/disease - ever
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto STREV]
Edit Name
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Tuesday, June 19, 2012 Page 6 of 56
Section Name Adult Conditions
Module 16
Instrument Variable STREV
Question ID ACN.031_05
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if necessary:
Have you EVER been told by a doctor or other health professional that you had
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Stroke - ever
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto EPHEV]
Edit Name
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Tuesday, June 19, 2012 Page 7 of 56
Section Name Adult Conditions
Module 16
Instrument Variable EPHEV
Question ID ACN.031_06
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if necessary:
Have you EVER been told by a doctor or other health professional that you had
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Emphysema - ever
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto AASMEV]
Edit Name
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Tuesday, June 19, 2012 Page 8 of 56
Section Name Adult Conditions
Module 16
Instrument Variable AASMEV
Question ID ACN.080
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
Have you EVER been told by a doctor or other health professional that you had
asthma?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Asthma - ever
Fill Instructions
Special Instructions
Skip Instructions <1> [goto AASSTILL]
<2,R,D> [goto ULCEV]
Edit Name
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Tuesday, June 19, 2012 Page 9 of 56
Section Name Adult Conditions
Module 16
Instrument Variable AASSTILL
Question ID ACN.085
Universe HHSTAT4 = 'S' and AGE GE 18 and AASMEV=1
Universe-text Sample adults 18+ who were ever told they have asthma
Question Text ? [F1]
Do you still have asthma?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Asthma - still
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to the previous question.
Skip Instructions <1,2,R,D> [go to AASMYR]
Edit Name
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Tuesday, June 19, 2012 Page 10 of 56
Section Name Adult Conditions
Module 16
Instrument Variable AASMYR
Question ID ACN.090
Universe HHSTAT4 = 'S' and AGE GE '18' and AASMEV='1'
Universe-text Sample adults 18+ who were ever told they had asthma
Question Text ? [F1]
DURING THE PAST 12 MONTHS, have you had an episode of asthma or an
asthma attack?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Asthma - past 12 months
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to AASMEV.
Skip Instructions <1, 2, R, D> [goto AASMERYR]
Edit Name
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Tuesday, June 19, 2012 Page 11 of 56
Section Name Adult Conditions
Module 16
Instrument Variable AASMERYR
Question ID ACN.100
Universe HHSTAT4 = 'S' and AGE GE 18 and AASMEV=1
Universe-text Sample adults 18+ with asthma episode/attack in past 12 months
Question Text ? [F1]
DURING THE PAST 12 MONTHS, have you had to visit an emergency room or
urgent care center because of asthma?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Asthma - ER past 12 months
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to the previous question.
Skip Instructions <1,2,R,D> [ goto ULCEV]
Edit Name
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Tuesday, June 19, 2012 Page 12 of 56
Section Name Adult Conditions
Module 16
Instrument Variable ULCEV
Question ID ACN.110
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Have you EVER been told by a doctor or other health professional that you had
...An ulcer
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Ulcer - ever
Fill Instructions
Special Instructions
Skip Instructions <1> [goto ULCYR]
<2,R,D>[goto CANEV]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 13 of 56
Section Name Adult Conditions
Module 16
Instrument Variable ULCYR
Question ID ACN.120
Universe HHSTAT4 = 'S' and AGE GE 18 and ULCEV=1
Universe-text Sample adults 18+ who were ever told they had an ulcer
Question Text DURING THE PAST 12 MONTHS have you had
... An ulcer?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Ulcer - past 12 months
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to the previous question.
Skip Instructions <1,2,R,D> [goto CANEV]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 14 of 56
Section Name Adult Conditions
Module 16
Instrument Variable CANEV
Question ID ACN.130
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Have you EVER been told by a doctor or other health professional that you had
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Cancer - ever
Fill Instructions
Special Instructions
Skip Instructions <1> [goto CANKIND]
<2,R,D> [goto DIBEV]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 15 of 56
Section Name Adult Conditions
Module 16
Instrument Variable CANKIND_1
Question ID ACN.140_1
Universe HHSTAT4 = 'S' and AGE GE 18 and CANEV=1
Universe-text Sample adults 18+ who were ever told they had cancer
Question Text What kind of cancer was it?
* Enter code for the first kind of cancer.
Answer Codes 1. Bladder
2. Blood
3. Bone
4. Brain
5. Breast
6. Cervix
7. Colon
8. Esophagus
9. Gallbladder
10. Kidney
11. Larynx-windpipe
12. Leukemia
13. Liver
14. Lung
15. Lymphoma
16. Melanoma
17. Mouth/tongue/lip
18. Ovary
19. Pancreas
20. Prostate
21. Rectum
22. Skin (non-melanoma )
23. Skin (don't know what kind)
24. Soft tissue (muscle or fat )
25. Stomach
26. Testis
27. Throat - pharynx
28. Thyroid
29. Uterus
30. Other
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Kind of cancer_1
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to the previous question.
Tuesday, June 19, 2012 Page 16 of 56
Skip Instructions <1-30,R,D>[goto CANAGE_1]
IF SEX=1 (MALE) and No. <6,18,29> selected goto ERR1_CANKIND_1
IF SEX=2 (FEMALE) and No. <20,26> selected goto ERR2_CANKIND_1
Edit Name ERR1_CANKIND_1,ERR2_CAN
KIND_1
quHardedits ERR1_CANKIND_1
* Code 6 or 18 or 29 is unavailable for males.
ERR2_CANKIND_1
* Code 20 or 26 is unavailable for females.
quSoftedits
Tuesday, June 19, 2012 Page 17 of 56
Section Name Adult Conditions
Module 16
Instrument Variable CANKIND_2
Question ID ACN.140_2
Universe HHSTAT4 = 'S' and AGE GE 18 and (CANAGE_1=1-100, D or (CANAGE_1=R
but CANKIND_1 ne R))
Universe-text Sample adults 18+ who either provided an age for one kind of cancer or didn't
know how old they were when first diagnosed with that kind of cancer or else
refused to provide an age but had not refused to answer CANKIND_1.
Question Text
* Enter code for the second kind of cancer.
* Enter '96' for no more.
Answer Codes 1. Bladder
2. Blood
3. Bone
4. Brain
5. Breast
6. Cervix
7. Colon
8. Esophagus
9. Gallbladder
10. Kidney
11. Larynx-windpipe
12. Leukemia
13. Liver
14. Lung
15. Lymphoma
16. Melanoma
17. Mouth/tongue/lip
18. Ovary
19. Pancreas
20. Prostate
21. Rectum
22. Skin (non-melanoma )
23. Skin (don't know what kind)
24. Soft tissue (muscle or fat )
25. Stomach
26. Testis
27. Throat - pharynx
28. Thyroid
29. Uterus
30. Other
96. No more
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Kind of cancer_2
Tuesday, June 19, 2012 Page 18 of 56
Fill Instructions
Special Instructions "Gray out" whatever option was selected in CANKIND_1 to indicate that that
option is now not available. Make sure that if this option is selected it triggers
the error message that this is an invalid option.
Indent this description to indicate that it is a "follow up" to CANEV.
Skip Instructions <1-30,R,D>[goto CANAGE_2]
<96> goto DIBEV
IF SEX=1 (MALE) and No. <6,18,29> selected goto ERR1_CANKIND_2
IF SEX=2 (FEMALE) and No. <20,26> selected goto ERR2_CANKIND_2
Edit Name ERR1_CANKIND_2,ERR2_CAN
KIND_2
quHardedits ERR1_CANKIND_2
* Code 6 or 18 or 29 is unavailable for males.
ERR2_CANKIND_2
* Code 20 or 26 is unavailable for females.
quSoftedits
Tuesday, June 19, 2012 Page 19 of 56
Section Name Adult Conditions
Module 16
Instrument Variable CANKIND_3
Question ID ACN.140_3
Universe HHSTAT4 = 'S' and AGE GE 18 and (CANAGE_2=1-100, D or (CANAGE_2=R
but CANKIND_2 ne R))
Universe-text Sample adults 18+ who either provided an age for a second kind of cancer or
didn't know how old they were when first diagnosed that kind of cancer or else
refused to provide an age but had not refused to answer CANKIND_2.
Question Text
* Enter code for the third kind of cancer.
* Enter '96' for no more.
Answer Codes 1. Bladder
2. Blood
3. Bone
4. Brain
5. Breast
6. Cervix
7. Colon
8. Esophagus
9. Gallbladder
10. Kidney
11. Larynx-windpipe
12. Leukemia
13. Liver
14. Lung
15. Lymphoma
16. Melanoma
17. Mouth/tongue/lip
18. Ovary
19. Pancreas
20. Prostate
21. Rectum
22. Skin (non-melanoma )
23. Skin (don't know what kind)
24. Soft tissue (muscle or fat )
25. Stomach
26. Testis
27. Throat - pharynx
28. Thyroid
29. Uterus
30. Other
96. No more
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Kind of cancer_3
Tuesday, June 19, 2012 Page 20 of 56
Fill Instructions
Special Instructions "Gray out" whatever options were selected in CANKIND_1 and CANKIND_2 to
indicate that those options are now not available. Make sure that if either of
these options are selected it triggers the error message that this is an invalid
option.
Skip Instructions <1-30,R,D>[goto CANAGE_3]
<96> [goto DIBEV]
IF SEX=1 (MALE) and No. <6,18,29> selected goto ERR1_CANKIND_3
IF SEX=2 (FEMALE) and No. <20,26> selected goto ERR2_CANKIND_3
Edit Name ERR1_CANKIND_3,ERR2_CAN
KIND_3
quHardedits ERR1_CANKIND_3
* Code 6 or 18 or 29 is unavailable for males.
ERR2_CANKIND_3
* Code 20 or 26 is unavailable for females.
quSoftedits
Tuesday, June 19, 2012 Page 21 of 56
Section Name Adult Conditions
Module 16
Instrument Variable CANKIND_4
Question ID ACN.140_4
Universe HHSTAT4 = 'S' and AGE GE 18 and (CANAGE_3=1-100, D or (CANAGE_3=R
but CANKIND_3 ne R))
Universe-text Sample adults 18+ who either provided an age for a third kind of cancer or
didn't know how old they were when first diagnosed that kind of cancer or else
refused to provide an age but had not refused to answer CANKIND_3
Question Text * Enter '95' if respondent offers more than 3 kinds of cancer.
* Enter '96' for no more.
Answer Codes 1. Bladder
2. Blood
3. Bone
4. Brain
5. Breast
6. Cervix
7. Colon
8. Esophagus
9. Gallbladder
10. Kidney
11. Larynx-windpipe
12. Leukemia
13. Liver
14. Lung
15. Lymphoma
16. Melanoma
17. Mouth/tongue/lip
18. Ovary
19. Pancreas
20. Prostate
21. Rectum
22. Skin (non-melanoma )
23. Skin (don't know what kind)
24. Soft tissue (muscle or fat )
25. Stomach
26. Testis
27. Throat - pharynx
28. Thyroid
29. Uterus
30. Other
95. More than 3 kinds of cancer
96. No more
Question Type Pick One - answer list pane
Part
Field Pane More than 3 kinds of cancer
Fill Instructions
Tuesday, June 19, 2012 Page 22 of 56
Special Instructions "Gray out" whatever options were selected in CANKIND_1, CANKIND_2 and
CANKIND_3 to indicate that those options were already chosen. The only valid
options for this question are 96 and 99.
Indent this description to indicate that it is a "follow up" to CANEV.
Skip Instructions <95,96> [goto DIBEV]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 23 of 56
Section Name Adult Conditions
Module 16
Instrument Variable CANAGE_1
Question ID ACN.150_1
Universe HHSTAT4 = 'S' and AGE GE 18 and CANKIND_1=1-30, D,R
Universe-text Sample adults 18+ who were ever told they had cancer
Question Text ? [F1]
How old were you when [Fill1: CANKIND_1 / Fill2: this cancer] was first
Answer Codes
Question Type Integer
Part
Field Pane Age_1
Fill Instructions Fill2: if (CANKIND_1 = D,R)
Fill1: if (CANKIND_1 NE D,R)
Fills to be used for CANKIND_1:
bladder cancer if CANKIND_1 = 1
blood cancer if CANKIND_1 = 2
bone cancer if CANKIND_1 = 3
brain cancer if CANKIND_1 = 4
breast cancer if CANKIND_1 = 5
cervical cancer if CANKIND_1 = 6
colon cancer if CANKIND_1 = 7
esophageal cancer if CANKIND_1 = 8
gallbladder cancer if CANKIND_1 = 9
kidney cancer if CANKIND_1 = 10
larynx-windpipe cancer if CANKIND_1 = 11
leukemia if CANKIND_1 = 12
liver cancer if CANKIND_1 = 13
lung cancer if CANKIND_1 = 14
lymphoma if CANKIND_1 = 15
melanoma if CANKIND_1 = 16
mouth/tongue/lip cancer if CANKIND_1 = 17
ovarian cancer if CANKIND_1 = 18
pancreatic cancer if CANKIND_1 = 19
prostate cancer if CANKIND_1 = 20
rectal cancer if CANKIND_1 = 21
skin (non-melanoma) cancer if CANKIND_1 = 22
skin (don't know what kind) cancer if CANKIND_1 = 23
soft tissue (muscle or fat) cancer if CANKIND_1 = 24
stomach cancer if CANKIND_1 = 25
testicular cancer if CANKIND_1 = 26
throat/pharynx cancer if CANKIND_1 = 27
thyroid cancer if CANKIND_1 = 28
uterine cancer if CANKIND_1 = 29other cancer if CANKIND_1 = 30
Special Instructions
Tuesday, June 19, 2012 Page 24 of 56
Skip Instructions diagnosed? <1-100, D> goto CANKIND_2
<R> and <R> at CANKIND_1[goto DIBEV]
<R> and CANKIND_1 NE <R> [goto CANKIND_2]
If number in CANAGE_1 greater than person years old (AGE) goto ERR_
CANAGE_1
Edit Name ERR_ CANAGE_1
quHardedits ERR_ CANAGE_1
* [Fill2: CANAGE_1] years old is older than age[fill3: AGE].
* Please correct.
quSoftedits
Section Name Adult Conditions
Module 16
Instrument Variable CANAGE_2
Question ID ACN.150_2
Universe HHSTAT4 = 'S' and AGE GE 18 and CANKIND_2 = 1-30,D,R
Universe-text Sample adults 18+ who were ever told they had cancer
Question Text ? [F1]
How old were you when [Fill1: CANKIND_2/Fill2: this cancer] was first diagnosed?
Answer Codes
Question Type Integer
Part
Field Pane Age_2
Fill Instructions Fill1: if (CANKIND_2 NE D,R)
Fill2: if (CANKIND_2 = D,R)
Special Instructions
Skip Instructions <1-100, D> goto CANKIND_3
<R> and <R> at CANKIND_2goto DIBEV]
<R> and CANKIND_2 NE <R> [goto CANKIND_3]
If number in CANAGE_2 greater than person years old (AGE) goto ERR_
CANAGE_2
Edit Name ERR_ CANAGE_2
quHardedits ERR_ CANAGE_2
* [Fill2: CANAGE_2] years old is older than your age[fill3: AGE].
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 25 of 56
Section Name Adult Conditions
Module 16
Instrument Variable CANAGE_3
Question ID ACN.150_3
Universe HHSTAT4 = 'S' and AGE GE 18 and CANKIND_3=1-30, D,R
Universe-text Sample adults 18+ who were ever told they had cancer
Question Text ? [F1]
How old were you when [Fill1: CANKIND_3/Fill2: this cancer ] was first
Answer Codes
Question Type Integer
Part
Field Pane Age_3
Fill Instructions Fill1: if (CANKIND_3 NE D,R)
Fill2: if (CANKIND_3 = D,R)
Special Instructions
Skip Instructions <1-100, D> goto CANKIND_4
<R> and <R> at CANKIND_3[goto DIBEV]
<R> and CANKIND_3 NE <R> [goto CANKIND_4]
If number in CANAGE_3 greater than person years old (AGE) goto ERR_
CANAGE_3
Edit Name ERR_ CANAGE_3
quHardedits ERR_ CANAGE_3
* [Fill2: CANAGE_3] years old is older than your age[fill3: AGE].
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 26 of 56
Section Name Adult Conditions
Module 16
Instrument Variable DIBEV
Question ID ACN.160
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
[Fill1:Other than during pregnancy, have you EVER been told by a doctor or
other health professional that you have diabetes or sugar diabetes?]/[Fill2:Have
you EVER been told by a doctor or other health professional that you have
diabetes or sugar diabetes?]
Answer Codes 1. Yes
2. No
3. Borderline
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Diabetes - ever
Fill Instructions Fill1: [If SEX=2 (female)]
Fill2: [if SEX ne 2]
Special Instructions ANSWER categories should appear vertically. If DIBEV=3 fill “1” in DIBPRE1
Skip Instructions <1> [goto DIBAGE]
<2,R,D> [goto DIBPRE1]
<3> [goto INSLN]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 27 of 56
Section Name Adult Conditions
Module 16
Instrument Variable DIBPRE1
Question ID ACN.165
Universe HHSTAT4 = 'S' and AGE GE 18 and DIBEV=2,R,D
Universe-text Sample adults 18+ who were never told they had diabetes, or who refused or
said don’t know to having been told they had diabetes
Question Text Have you EVER been told by a doctor or other health professional that you have
any of the following: prediabetes, impaired fasting glucose, impaired glucose
tolerance, borderline diabetes, or high blood sugar?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Pre-diabetic symptoms
Fill Instructions Fill1: [If SEX=2 (female)]
Fill2: [if SEX ne 2]
Special Instructions If DIBEV=3 fill 1 in DIBPRE1
Skip Instructions <1> [goto INSLN]
<2,R,D> [goto AHAYFYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 28 of 56
Section Name Adult Conditions
Module 16
Instrument Variable DIBAGE
Question ID ACN.170
Universe HHSTAT4 = 'S' and AGE GE 18 and DIBEV = 1
Universe-text Sample adults 18+ who were told they had diabetes or sugar diabetes (other
than during pregnancy)
Question Text ? [F1]
How old were you when a doctor or other health professional FIRST told you
that you had diabetes or sugar diabetes?
Answer Codes
Question Type Integer
Part
Field Pane Diabetes - age
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to the previous question.
Skip Instructions <1-100 R,D> [goto INSLN]
If number in DIBAGE greater than person years old (AGE) goto ERR_ DIBAGE
Edit Name
quHardedits ERR_ DIBAGE
* [Fill1: DIBAGE] years old is older than your age[fill2: AGE].
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 29 of 56
Section Name Adult Conditions
Module 16
Instrument Variable INSLN
Question ID ACN.180
Universe HHSTAT4 = 'S' and AGE GE 18 and DIBEV = 1 or DIBPRE1=1
Universe-text Sample adults 18+ who were told they had diabetes or sugar diabetes (other
than during pregnancy) or who were told they had prediabetes, impaired fasting
glucose, impaired glucose tolerance, borderline diabetes, or high blood sugar
Question Text Are you NOW taking insulin?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Insulin - now
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to DIBEV (ACN.160).
Skip Instructions <1,2,R,D> [goto DIBPILL]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 30 of 56
Section Name Adult Conditions
Module 16
Instrument Variable DIBPILL
Question ID ACN.190
Universe HHSTAT4 = 'S' and AGE GE 18 and DIBEV = 1 or DIBPRE1=1
Universe-text Sample adults 18+ who were told they had diabetes or sugar diabetes (other
than during pregnancy) or who were told they had pre-diabetes, impaired fasting
glucose, impaired glucose tolderance, borderline diabetes, or high blood sugar
Question Text Are you NOW taking diabetic pills to lower your blood sugar? These are
sometimes called oral agents or oral hypoglycemic agents.
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Diabetic pill
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to DIBEV (ACN.160).
Skip Instructions <1,2,R,D> [goto AHAYFYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 31 of 56
Section Name Adult Conditions
Module 16
Instrument Variable AHAYFYR
Question ID ACN.201_01
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text DURING THE PAST 12 MONTHS, have you been told by a doctor or other
health professional that you had
...Hay fever?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Hay fever
Fill Instructions
Special Instructions "Past 12 mo." as a heading for this question as well as ACN.201_02 -
ACN.201_05.
Skip Instructions <1,2,R,D> [goto SINYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 32 of 56
Section Name Adult Conditions
Module 16
Instrument Variable SINYR
Question ID ACN.201_02
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other
health professional that you had
...Sinusitis?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Sinusitis
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto CBRCHYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 33 of 56
Section Name Adult Conditions
Module 16
Instrument Variable CBRCHYR
Question ID ACN.201_03
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other
health professional that you had
...Chronic bronchitis?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Chronic bronchitis
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto KIDWKYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 34 of 56
Section Name Adult Conditions
Module 16
Instrument Variable KIDWKYR
Question ID ACN.201_04
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other
health professional that you had
......Weak or failing kidneys? - Do not include kidney stones, bladder infections or
incontinence.
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Weak/failing kidneys
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto LIVYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 35 of 56
Section Name Adult Conditions
Module 16
Instrument Variable LIVYR
Question ID ACN.201_05
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other
health professional that you had
...Any kind of liver condition?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Liver condition
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto JNTSYMP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 36 of 56
Section Name Adult Conditions
Module 16
Instrument Variable JNTSYMP
Question ID ACN.250
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text The next questions refer to your joints. Please do NOT include the back or neck.
DURING THE PAST 30 DAYS, have you had any symptoms of pain, aching, or
stiffness in or around a joint?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Joint pain - past 30 days
Fill Instructions
Special Instructions
Skip Instructions <1> [goto JMTHP]
<2,R,D> [goto ARTH]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 37 of 56
Section Name Adult Conditions
Module 16
Instrument Variable JMTHP
Question ID ACN.260
Universe HHSTAT4 = 'S' and AGE GE 18 and JNTSYMP=1
Universe-text Sample adults 18+ who had joint pain in the past 30 days
Question Text (book) A4
Which joints are affected?
* Enter all that apply, separate with commas.
Answer Codes 1. Shoulder-right
2. Shoulder-left
3. Elbow-right
4. Elbow-left
5. Hip-right
6. Hip-left
7. Wrist-right
8. Wrist-left
9. Knee-right
10. Knee-left
11. Ankle-right
12. Ankle-left
13. Toes-right
14. Toes-left
15. Fingers/thumb-right
16. Fingers/thumb-left
17. Other joint not listed
Don't know
Refused
Question Type Enter All That Apply
Part
Field Pane Joints affected
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to the previous question.
Skip Instructions <1-17,R,D> [goto JNTCHR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 38 of 56
Section Name Adult Conditions
Module 16
Instrument Variable JNTCHR
Question ID ACN.270
Universe HHSTAT4 = 'S' and AGE GE 18 and JNTSYMP=1
Universe-text Sample adults 18+ who had joint pain in the past 30 days
Question Text Did your joint symptoms FIRST begin more than 3 months ago?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Symptoms appear 3+ months
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to JNTSYMP (ACN.250).
Skip Instructions <1,2,R,D> [goto JNTHP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 39 of 56
Section Name Adult Conditions
Module 16
Instrument Variable JNTHP
Question ID ACN.280
Universe HHSTAT4 = 'S' and AGE GE 18 and JNTSYMP=1
Universe-text Sample adults 18+ who had joint pain in the past 30 days
Question Text Have you EVER seen a doctor or other health professional for these
joint symptoms?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Ever seen doctor/health professional
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to JNTSYMP (ACN.250).
Skip Instructions <1,2,R,D> [goto ARTH]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 40 of 56
Section Name Adult Conditions
Module 16
Instrument Variable ARTH
Question ID ACN.290
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
Have you EVER been told by a doctor or other health professional that you have
some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia (fy-bro-
my-AL-jee-uh)?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Arthritis - ever
Fill Instructions
Special Instructions
Skip Instructions (<1> or JNTSYMP eq <1>) [goto ARTHLMT];
else (<2,R,D> and JNTSYMP ne 1) [goto PAINECK]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 41 of 56
Section Name Adult Conditions
Module 16
Instrument Variable ARTHLMT
Question ID ACN.295
Universe HHSTAT4 = 'S' and AGE GE 18 and (JNTSYMP=1 or ARTH=1)
Universe-text Sample adults 18+ with joint pain or arthritis
Question Text ? [F1]
Are you now limited in any way in any of your usual activities because of arthritis
or joint symptoms?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Arthritis/joint symptoms - limitations
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to ARTH (ACN.290).
Skip Instructions <1,2,R,D> [goto PAINECK]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 42 of 56
Section Name Adult Conditions
Module 16
Instrument Variable PAINECK
Question ID ACN.300
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
The following questions are about pain you may have experienced in the
PAST THREE MONTHS. Please refer to pain that LASTED A WHOLE DAY OR
MORE. Do not report aches and pains that are fleeting or minor.
DURING THE PAST THREE MONTHS, did you have
... Neck pain?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Neck pain
Fill Instructions
Special Instructions "Past 3 months" as a heading for this question as well as ACN.310 - ACN.331_02
Skip Instructions <1,2,R,D> [goto PAINLB]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 43 of 56
Section Name Adult Conditions
Module 16
Instrument Variable PAINLB
Question ID ACN.310
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
* Read if necessary.
DURING THE PAST THREE MONTHS, did you have
... Low back pain?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Low back pain
Fill Instructions
Special Instructions
Skip Instructions <1> [goto PAINLEG]
<2,R,D> [goto PAINFACE]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 44 of 56
Section Name Adult Conditions
Module 16
Instrument Variable PAINLEG
Question ID ACN.320
Universe HHSTAT4 = 'S' and AGE GE 18 and PAINLB = 1
Universe-text Sample adults 18+ with low back pain in the past 3 months
Question Text ? [F1]
Did this pain spread down either leg to areas below the knees?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Pain down leg
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to the previous question.
Skip Instructions <1,2,R,D> [goto PAINFACE]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 45 of 56
Section Name Adult Conditions
Module 16
Instrument Variable PAINFACE
Question ID ACN.331_01
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text DURING THE PAST THREE MONTHS, did you have
... Facial ache or pain in the jaw muscles or the joint in front of the ear?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Jaw pain
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto AMIGR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 46 of 56
Section Name Adult Conditions
Module 16
Instrument Variable AMIGR
Question ID ACN.331_02
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if neccesary:
DURING THE PAST THREE MONTHS, did you have
...Severe headache or migraine?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Severe headache/migraine
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto ACOLD2W]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 47 of 56
Section Name Adult Conditions
Module 16
Instrument Variable ACOLD2W
Question ID ACN.350
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text These next questions are about your recent health DURING THE LAST 2
WEEKS.
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Head/chest cold past 2 weeks
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto AINTIL2W]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 48 of 56
Section Name Adult Conditions
Module 16
Instrument Variable AINTIL2W
Question ID ACN.360
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Did you have a stomach or intestinal illness with vomiting or diarrhea that
started DURING THE LAST TWO WEEKS?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Stomach problem - 2 weeks
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> if SEX=2 and age 18-49 [goto PREGNOW];
else <1,2,R,D> and ((SEX=1) or (SEX=2 and AGE>=50)) [goto HRAIDNOW]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 49 of 56
Section Name Adult Conditions
Module 16
Instrument Variable PREGNOW
Question ID ACN.370
Universe HHSTAT4 = 'S' and AGE 18-49 and SEX = 2
Universe-text Female sample adults 18-49 years of age
Question Text Are you currently pregnant?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Currently pregnant
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto HRAIDNOW]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 50 of 56
Section Name Adult Conditions
Module 16
Instrument Variable HRAIDNOW
Question ID ACN.400
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text These next questions are about your hearing, vision, and teeth.
Do you now use a hearing aid(s)?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Hearing aid - now
Fill Instructions
Special Instructions
Skip Instructions <1> [goto AHEARST1]
<2,R,D> [goto HRAIDEV]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 51 of 56
Section Name Adult Conditions
Module 16
Instrument Variable HRAIDEV
Question ID ACN.410
Universe HHSTAT4 = 'S' and AGE GE 18 and HRAIDNOW=2,R,D
Universe-text Sample adults 18+ who do not now use a hearing aid or REF/DK whether they
now use a hearing aid
Question Text Have you ever used a hearing aid(s) in the past?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Hearing aid - ever
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto AHEARST1]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 52 of 56
Section Name Adult Conditions
Module 16
Instrument Variable AHEARST1
Question ID ACN.420
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text WITHOUT the use of hearing aids or other listening devices, is your hearing
excellent, good, a little trouble hearing, moderate trouble, a lot of trouble, or
are you deaf?
Answer Codes 1. Excellent
2. Good
3. A little trouble hearing
4. Moderate trouble
5. A lot of trouble
6. Deaf
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Hearing status
Fill Instructions
Special Instructions
Skip Instructions <1-6,R,D> [goto AVISION]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 53 of 56
Section Name Adult Conditions
Module 16
Instrument Variable AVISION
Question ID ACN.430
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Do you have any trouble seeing, even when wearing glasses or contact lenses?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Trouble seeing
Fill Instructions
Special Instructions
Skip Instructions <1> [goto ABLIND]
<2,R,D> [goto LUPPRT]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 54 of 56
Section Name Adult Conditions
Module 16
Instrument Variable ABLIND
Question ID ACN.440
Universe HHSTAT4 = 'S' and AGE GE 18 and AVISION = 1
Universe-text Sample adults 18+ who have trouble seeing even when wearing glasses/contact
lenses
Question Text Are you blind or unable to see at all?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Blind
Fill Instructions
Special Instructions Indent this description to indicate that it is a "follow up" to the previous question.
Skip Instructions <1,2,R,D> [goto LUPPRT]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 55 of 56
Section Name Adult Conditions
Module 16
Instrument Variable LUPPRT
Question ID ACN.451
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Have you lost all of your upper and lower natural (permanent) teeth?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Lost all teeth
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto next section]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 56 of 56
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable WKDAYR
Question ID AHS.040
Universe HHSTAT4='S' and AGE ge '18' and (DOINGLW2 = '1' ,'2', '4' or WRKLYR2 = '1')
and (EVERWRK ne 'No', 'Refused', or 'Don't know')
Universe-text Sample adults 18+ who worked or had a job or business with or without pay in
the last week or who had a job or business in the past 12 months
Question Text During the PAST 12 MONTHS ABOUT how many days did you miss work at a
job or business because of illness or injury (do not include maternity leave)?
* Enter '0' for None.
Answer Codes
Question Type Integer
Part
Field Pane Work days missed
Fill Instructions
Special Instructions
Skip Instructions <0-366,R,D> [goto BEDDAYR]
<120-366> [goto ERR_WKDAYR]
Edit Name ERR_WKDAYR
quHardedits
quSoftedits ERR_WKDAYR
* [Fill: WKDAYR] is an unusually large number.
* Please verify.
Tuesday, June 19, 2012 Page 1 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable BEDDAYR
Question ID AHS.050
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN('997','999'))
Universe-text Sample adults 18+
Question Text During the PAST 12 MONTHS ABOUT how many days did illness or injury keep
you in bed more than half of the day (include days while an overnight patient in
a hospital)?
* Enter '0' for None.
Answer Codes
Question Type Integer
Part
Field Pane Days in bed
Fill Instructions
Special Instructions
Skip Instructions <0-366,R,D> [goto AHSTATYR]
<120-366> [goto ERR_BEDDAYR]
Edit Name ERR_BEDDAYR
quHardedits
quSoftedits ERR_BEDDAYR
* [Fill: BEDDAYR] is an unusually large number.
* Please verify.
Tuesday, June 19, 2012 Page 2 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHSTATYR
Question ID AHS.060
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Compared with 12 MONTHS AGO, would you say your health is better, worse, or
about the same?
Answer Codes 1. Better
2. Worse
3. About the same
Refused
Don’t know
Question Type Pick One - answer list pane
Part
Field Pane Health status
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1-3,R,D> [goto SPECEQ (AHS.070)]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 3 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable SPECEQ
Question ID AHS.070
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Do you now have any health problem that requires you to use special
equipment, such as a cane, a wheelchair, a special bed, or a special
Answer Codes 1. Yes
2. No
Refused
Don’t know
Question Type Yes/No
Part
Field Pane Special equipment
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1,2,R,D>[goto FLWALK_1]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 4 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable FLWALK_1
Question ID AHS.080
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text The next questions ask about difficulties you may have doing certain activities
because of a HEALTH PROBLEM. By "health problem" we mean any physical,
mental, or emotional problem or illness [Fill1:(not including pregnancy) ].
Answer Codes 1. Enter 1 to continue
Question Type Enter 1 to Continue
Part
Field Pane Continue
Fill Instructions Fill1: If SEX=2 (female), then display the following text: (not including
Special Instructions
Skip Instructions <1> [goto FLWALK]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 5 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable FLWALK
Question ID AHS.091_1
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A6
By yourself, and without using any special equipment, how difficult is it for you
to
Answer Codes 0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Refused
Don’t know
Question Type Repeating Series – Other
Part
Field Pane Walk a quarter of a mile
Fill Instructions
Special Instructions Answer name to the right. Blank line between Answer code 4 and Answer code 6.
Skip Instructions <0-4,6,R,D> [goto FLCLIMB]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 6 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable FLCLIMB
Question ID AHS.091_2
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you
to
Answer Codes 0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Refused
Don’t know
Question Type Repeating Series – Other
Part
Field Pane Walk up 10 steps
Fill Instructions
Special Instructions Answer name to the right. Blank line between Answer code 4 and Answer code 6.
Skip Instructions <0-4,6,R,D> [goto FLSTAND]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 7 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable FLSTAND
Question ID AHS.091_3
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you
to
Answer Codes 0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Refused
Don’t know
Question Type Repeating Series – Other
Part
Field Pane Stand for 2 hours
Fill Instructions
Special Instructions Answer name to the right. Blank line between Answer code 4 and Answer code 6.
Skip Instructions <0-4,6,R,D> [goto FLSIT]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 8 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable FLSIT
Question ID AHS.091_4
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you
to
Answer Codes 0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Refused
Don’t know
Question Type Repeating Series – Other
Part
Field Pane Sit for 2 hours
Fill Instructions
Special Instructions Answer name to the right. Blank line between Answer code 4 and Answer code 6.
Skip Instructions <0-4,6,R,D> [goto FLSTOOP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 9 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable FLSTOOP
Question ID AHS.091_5
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you
to
Answer Codes 0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Refused
Don’t know
Question Type Repeating Series – Other
Part
Field Pane Stoop, bend or kneel
Fill Instructions
Special Instructions Answer name to the right. Blank line between Answer code 4 and Answer code 6.
Skip Instructions <0-4,6,R,D> [goto FLREACH]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 10 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable FLREACH
Question ID AHS.091_6
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you
to
Answer Codes 0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Refused
Don’t know
Question Type Repeating Series – Other
Part
Field Pane Reach up overhead
Fill Instructions
Special Instructions Answer name to the right. Blank line between Answer code 4 and Answer code 6.
Skip Instructions <0-4,6,R,D> [goto FLGRASP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 11 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable FLGRASP
Question ID AHS.141_1
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you
to
Answer Codes 0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Refused
Don’t know
Question Type Repeating Series – Other
Part
Field Pane Grasp small objects
Fill Instructions
Special Instructions Answer name to the right. Blank line between Answer code 4 and Answer code 6.
Skip Instructions <0-4,6,R,D> [goto FLCARRY]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 12 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable FLCARRY
Question ID AHS.141_2
Universe HHSTAT4 = 'S'and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you
to
Answer Codes 0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Refused
Don’t know
Question Type Repeating Series – Other
Part
Field Pane Lift or carry 10 pounds
Fill Instructions
Special Instructions Answer name to the right. Blank line between Answer code 4 and Answer code 6.
Skip Instructions <0-4,6,R,D> [goto FLPUSH]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 13 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable FLPUSH
Question ID AHS.141_3
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you
to
Answer Codes 0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Refused
Don’t know
Question Type Repeating Series – Other
Part
Field Pane Push or pull large objects
Fill Instructions
Special Instructions Answer name to the right. Blank line between Answer code 4 and Answer code 6.
Skip Instructions <0-4,6,R,D> [goto FLSHOP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 14 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable FLSHOP
Question ID AHS.171_1
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you
to
Answer Codes 0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Refused
Don’t know
Question Type Repeating Series – Other
Part
Field Pane Go out to things
Fill Instructions
Special Instructions Answer name to the right. Blank line between Answer code 4 and Answer code 6.
Skip Instructions <0-4,6,R,D> [goto FLSOCL]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 15 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable FLSOCL
Question ID AHS.171_2
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you
to
...Participate in social activities such as visiting friends, attending clubs and
Answer Codes 0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Refused
Don’t know
Question Type Repeating Series – Other
Part
Field Pane Social activities
Fill Instructions
Special Instructions Answer name to the right. Blank line between Answer code 4 and Answer code 6.
Skip Instructions <0-4,6,R,D> [goto FLRELAX]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 16 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable FLRELAX
Question ID AHS.171_3
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you
to
...Do things to relax at home or for leisure (reading, watching TV, sewing,
Answer Codes 0. Not at all difficult
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Refused
Don’t know
Question Type Repeating Series – Other
Part
Field Pane Relax at home
Fill Instructions
Special Instructions Answer name to the right. Blank line between Answer code 4 and Answer code 6.
Skip Instructions <1-4 or FLWALK= 1-4 or FLCLIMB= 1-4 or FLSTAND= 1-4 or FLSIT= 1-4 or
FLSTOOP= 1-4 or FLREACH= 1-4 or FLGRASP= 1-4 or FLCARRY= 1-4 or
FLPUSH= 1-4 or FLSHOP= 1-4 or FLSOCL= 1-4>[goto AFLHCA]
Else goto SMKEV (next section)
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 17 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AFLHCA
Question ID AHS.200
Universe HHSTAT4 = 'S' and AGE GE 18 and (FLWALK= 1-4 or FLCLIMB= 1-4 or
FLSTAND= 1-4 or FLSIT= 1-4 or FLSTOOP= 1-4 or FLREACH= 1-4 or
FLGRASP= 1-4 or FLCARRY= 1-4 or FLPUSH= 1-4 or FLSHOP= 1-4 or
FLSOCL= 1-4 or FLRELAX = 1-4)
Universe-text Sample adults 18+ who, without using special equipment, have at least a little
difficulty walking a quarter mile; walking up 10 steps without resting;
standing/being on feet for about 2 hours; sitting for about 2 hours;
stooping/bending/kneeling; reaching up over head; using fingers to
grasp/handle small objects; lifting/carrying 10 pounds; pushing/pulling large
objects;going out for things (shopping/movies); participating in social activities;
Question Text (book) A7
What condition or health problem causes you to have difficulty with [fill1:
condition 1, condition 2 or condition 3 (as specified in AHS.091_1 through
AHS.171_3)][fill2: these activities]?
* Enter condition number for all that apply, separate with commas.
* Do not probe, except to clarify answer.
Answer Codes 1. Vision/problem seeing
2. Hearing problem
3. Arthritis/rheumatism
4. Back or neck problem
5. Fracture, bone/joint injury
6. Other injury
7. Heart problem
8. Stroke problem
9. Hypertension/high blood pressure
10. Diabetes
11. Lung/breathing problem (for example, asthma and emphysema)
12. Cancer
13. Birth defect
14. Intellectual disability also known as mental retardation
15. Other developmental problem (for example cerebral palsy)
16. Senility
17. Depression/anxiety/emotional problem
18. Weight problem
--------------------------------------------------------------------[*/On bottom of Flashcard only:
"Other impairment/problem" /*]
--------------------------------------------------------------------------------------------------- [*/ q4 or 2005
fix to add a divider line between 18 & 19 /*]
19. Missing limbs (fingers, toes or digits), amputee
20. Kidney, bladder or renal problems
21. Circulation problems (including blood clots)
22. Benign Tumors, cysts
23. Fibromyalgia, lupus
24. Osteoporosis, tendinitis
25. Epilepsy, seizures
26. Multiple Sclerosis (MS), Muscular Dystrophy (MD)
27. Polio(myelitis), paralysis, para/quadriplegia
28. Parkinson’s disease, other tremors
Tuesday, June 19, 2012 Page 18 of 95
or relaxing at home (reading/sewing). 29. Other nerve damage, including carpal tunnel syndrome
30. Hernia
31. Ulcer
32. Varicose veins, hemorrhoids
33. Thyroid problems, Grave’s disease, gout
34. Knee problems (not arthritis (03), not joint injury(05))
35. Migraine headaches (not just headaches)
90. Other impairment/problem (Specify one)
91. Other impairment/problem (Specify one)
Refused
Don’t know/not sure
Question Type Enter All That Apply
Part
Field Pane Condition numbers
Fill Instructions Fill1 = [if the number of conditions indicated in questions AHS.091_1 -
AHS.171_3 as having at least a little bit of difficulty (i.e. answers are 1-4) is less
than or equal to 3]
Fill2 = [if the number of conditions indicated in questions AHS.091_1 -
AHS.171_3 as having at least a little bit of difficulty (i.e. answers are 1-4) is
Special Instructions The fill to be applied in the question text for Fill 1 is conditional on how many
of the responses to questions AHS.091_1 through AHS.171_3 were either 1,2,3
or 4 (I.e. the respondent had a least a little difficulty carrying out the particular
activity/action). If only one of these questions has an answer that meets the
criteria (I.e. 1-4), then the question text is "What condition or health problem
causes you to have difficulty with [condition 1]?". If only 2 questions had answers
in the 1-4 range, the question text is "What condition or health problem causes
you to have difficulty with [condition 1] or [condition 2]?". If 3 questions had
such answers, use the question text provided.
Use the following phrases to fill in the question text when the conditions for Fill
1 apply:
FLWALK: walking a quarter of a mile
FLCLIMB: walking up 10 steps
FLSTAND: standing for 2 hours
FLSIT: sitting for 2 hours
FLSTOOP: stooping, bending or kneeling
FLREACH: reaching up overhead
FLGRASP: grasping or handling small objects
FLCARRY: lifting or carrying 10 pounds
FLPUSH: pushing or pulling large objects
FLSHOP: going out for things
FLSOCL: participating in social activities
FLRELAX: relaxing at home
Skip Instructions [1- 12, 14 - 35] goto the appropriate follow up question AHCL01N-AHCL12N,
AHCL14N-
AHCL35N], in numerical order
<13> store "96" in AHCL13N and "6" IN AHCL13T[goto SMKEV ]
<90> [goto AFLHCA_S1]
<91> [goto AFLHCA_S2]
Roster through all AFLHCA entries. Once exhausted goto SMKEV (next section)
Tuesday, June 19, 2012 Page 19 of 95
greater than 3] <D, R> [goto SMKEV (next section)]
Edit Name
quHardedits
quSoftedits
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AFLHCA_S1
Question ID AHS.201_90
Universe HHSTAT4 = 'S' and AGE GE 18 and 90 selected in AFLHCA
Universe-text Sample adults 18+ whose difficulties performing activities listed in FLWALK
through FLRELAX is due to at least one condition not listed in AFLHCA
Question Text * Enter other impairment/problem.
Answer Codes
Question Type Text
Part
Field Pane Specify
Fill Instructions
Special Instructions */ need to add Descriptor name to Form Pane in front of the answer box of:
Specify one (1) [ ] /* for either Q4 or 2005 fix
Skip Instructions <50 chars>[goto AHCL90N]
>ENTER< only with no description [goto ERR1_AFLHCA_S1]
Else goto the appropriate follow-up questions AHCL01N-AHCL12N, AHCL14N-
AHCL35N], in numerical order, as specified in AFLHCA
Edit Name ERR1_AFLHCA_S1
quHardedits $ You should enter something specific.
quSoftedits
Tuesday, June 19, 2012 Page 20 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AFLHCA_S2
Question ID AHS.201_91
Universe HHSTAT4 = 'S' and AGE GE 18 and 91 selected in AFLHCA
Universe-text Sample adults 18+ whose difficulty performing activities listed in FLWALK
through FLRELAX is due to more than one condition that is not listed in
Question Text * Enter other impairment/problem.
Answer Codes
Question Type Text
Part
Field Pane Specify
Fill Instructions
Special Instructions */ need to add Descriptor name to Form Pane in front of the answer box of:
Specify one (2) [ ] /* for either Q4 or 2005 fix
Skip Instructions <50 chars>[goto AHCL91N]
>ENTER< only with no description [goto ERR1_AFLHCA_S1]
*/ need to add Descriptor name to Form Pane in front of the answer box of:
Specify one (2) [ ] /* for either Q4 or 2005 fix
Edit Name ERR1_AFLHCA_S2
quHardedits $ You should enter something specific.
quSoftedits
Tuesday, June 19, 2012 Page 21 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL01N
Question ID AHS.300_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 1
Universe-text Sample adults 18+ who had difficulty due to a vision problem or problem seeing
Question Text 1 of 2
How long have you had a vision problem or problem seeing?
* Enter number for time with your vision problem or problem seeing..
* Enter '95' for 95 or more.
* Enter '96' if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL01T]
<R>[store "R" in AHCL01T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL01T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 22 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL01T
Question ID AHS.300_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL01N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with vision problem or problem seeing.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL01T
[if [AHCL01N = Number greater than person years old and AHCL01T= 4]] goto
ERR1_AHCL01T
Edit Name ERR1_AHCL01T,
ERR2_AHCL01T
quHardedits ERR1_AHCL01T
*Time with condition cannot be greater than age.
* Please correct.
ERR2_AHCL01T
* "6" not selectable.
quSoftedits
Tuesday, June 19, 2012 Page 23 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL02N
Question ID AHS.301_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 2
Universe-text Sample adults 18+ who had difficulty due to a hearing problem
Question Text 1 of 2
How long have you had a hearing problem?
* Enter number for time with a hearing problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL02T]
<R>[store "R" in AHCL02T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL02T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 24 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL02T
Question ID AHS.301_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL02N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with hearing problem.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL02T
[if [AHCL02N = Number greater than person years old and AHCL02T= 4]] goto
ERR1_AHCL02T
Edit Name ERR1_AHCL02T,
ERR2_AHCL02T
quHardedits ERR1_AHCL02T
* Time with condition cannot be greater than age.
* Please correct.
ERR2_AHCL02T
* "6" not selectable.
quSoftedits
Tuesday, June 19, 2012 Page 25 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL03N
Question ID AHS.302_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 3
Universe-text Sample adults 18+ who had difficulty due to arthritis or rheumatism
Question Text 1 of 2
How long have you had arthritis or rheumatism?
* Enter number for time with arthritis or rheumatism.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL03T]
<R>[store "R" in AHCL03T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL03T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 26 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL03T
Question ID AHS.302_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL03N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with arthritis or rheumatism.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL03T
[if [AHCL03N = Number greater than person years old and AHCL03T= 4]] goto
ERR1_AHCL03T
Edit Name ERR1_AHCL03T,
ERR2_AHCL03T
quHardedits ERR_AHCL03T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 27 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL04N
Question ID AHS.303_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 4
Universe-text Sample adults 18+ who had difficulty due to a back or neck problem
Question Text 1 of 2
How long have you had a back or neck problem?
* Enter number for time with back or neck problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL04T]
<R>[store "R" in AHCL04T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL04T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 28 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL04T
Question ID AHS.303_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL04N= 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with back or neck problem.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL04T
[if [AHCL04N = Number greater than person years old and AHCL04T= 4]] goto
ERR1_AHCL04T
Edit Name ERR1_AHCL04T,
ERR2_AHCL04T
quHardedits ERR_AHCL04T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 29 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL05N
Question ID AHS.304_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 5
Universe-text Sample adults 18+ who had difficulty due to a fracture, bone, or joint injury
Question Text 1 of 2
How long have you had a fracture, bone, or joint injury?
* Enter number for time with a fracture, bone, or joint injury.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL05T]
<R>[store "R" in AHCL05T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL05T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 30 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL05T
Question ID AHS.304_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL05N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with fracture, bone, or joint injury.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL05T
[if [AHCL05N = Number greater than person years old and AHCL05T= 4]] goto
ERR1_AHCL05T
Edit Name ERR1_AHCL05T,
ERR2_AHCL05T
quHardedits ERR_AHCL05T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 31 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL06N
Question ID AHS.305_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 6
Universe-text Sample adults 18+ who had difficulty due to an injury other than a fracture,
bone, or joint injury
Question Text 1 of 2
How long have you had the (fill: other) injury that caused your limitation?
* Enter number for time with injury that caused your limitation.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions Fill: [if condition 5 is selected at AFLHCA]
Special Instructions
Skip Instructions <1-95,D>[goto AHCL06T]
<R>[store "R" in AHCL06T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL06T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 32 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL06T
Question ID AHS.305_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL06N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with (fill: other) injury.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Integer
Part
Field Pane Time period
Fill Instructions Fill: [if condition 5 is selected at AFLHCA]
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL06T
[if [AHCL06N = Number greater than person years old and AHCL06T= 4]] goto
ERR1_AHCL06T
Edit Name ERR1_AHCL06T,
ERR2_AHCL06T
quHardedits ERR_AHCL06T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 33 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL07N
Question ID AHS.306_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 7
Universe-text Sample adults 18+ who had difficulty due to a heart problem
Question Text 1 of 2
How long have you had a heart problem?
* Enter number for time with a heart problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL07T]
<R>[store "R" in AHCL07T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL07T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 34 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL07T
Question ID AHS.306_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL07N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with heart problem.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Integer
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL07T
[if [AHCL07N = Number greater than person years old and AHCL07T= 4]] goto
ERR1_AHCL07T
Edit Name ERR1_AHCL07T,
ERR2_AHCL07T
quHardedits ERR_AHCL07T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 35 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL08N
Question ID AHS.307_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 8
Universe-text Sample adults 18+ who had difficulty due to a stroke problem
Question Text 1 of 2
How long have you had a stroke problem?
* Enter number for time with a stroke problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL08T]
<R>[store "R" in AHCL08T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL08T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 36 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL08T
Question ID AHS.307_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL08N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with stroke problem.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL08T
[if [AHCL08N = Number greater than person years old and AHCL08T= 4]] goto
ERR1_AHCL08T
Edit Name ERR1_AHCL08T,
ERR2_AHCL08T
quHardedits ERR_AHCL08T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 37 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL09N
Question ID AHS.308_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 9
Universe-text Sample adults 18+ who had difficulty due to hypertension or high blood pressure
Question Text 1 of 2
How long have you had hypertension or high blood pressure?
* Enter number for time with hypertension or high blood pressure.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL09T]
<R>[store "R" in AHCL09T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL09T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 38 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL09T
Question ID AHS.308_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL09N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with hypertension or high blood pressure.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL09T
[if [AHCL09N = Number greater than person years old and AHCL09T= 4]] goto
ERR1_AHCL09T
Edit Name ERR1_AHCL09T,
ERR2_AHCL09T
quHardedits ERR_AHCL09T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 39 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL10N
Question ID AHS.309_1
Universe HHSTAT4 = 'S'and AGE GE 18 and AFLHCA = 10
Universe-text Sample adults 18+ who had difficulty due to diabetes
Question Text 1 of 2
How long have you had diabetes?
* Enter number for time with diabetes.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL10T]
<R>[store "R" in AHCL10T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL10T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 40 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL10T
Question ID AHS.309_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL10N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with diabetes.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL10T
[if [AHCL10N = Number greater than person years old and AHCL10T= 4]] goto
ERR1_AHCL10T
Edit Name ERR1_AHCL10T,
ERR2_AHCL10T
quHardedits ERR_AHCL10T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 41 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL11N
Question ID AHS.310_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 11
Universe-text Sample adults 18+ who had difficulty due to a lung or breathing problem
Question Text 1 of 2
How long have you had a lung or breathing problem (e.g. asthma and
emphysema)?
* Enter number for time with a lung or breathing problem.
* Enter '95'' for 95 or more.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL11T]
<R>[store "R" in AHCL11T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL11T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 42 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL11T
Question ID AHS.310_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL11N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with lung or breathing problem (e.g. asthma and
emphysema).
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL11T
[if [AHCL11N = Number greater than person years old and AHCL11T= 4]] goto
ERR1_AHCL11T
Edit Name ERR1_AHCL11T,
ERR2_AHCL11T
quHardedits ERR_AHCL11T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 43 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL12N
Question ID AHS.311_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 12
Universe-text Sample adults 18+ who had difficulty due to cancer
Question Text 1 of 2
How long have you had cancer?
* Enter number for time with cancer.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL12T]
<R>[store "R" in AHCL12T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL12T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 44 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL12T
Question ID AHS.311_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL12N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with cancer.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL12T
[if [AHCL12N = Number greater than person years old and AHCL12T= 4]] goto
ERR1_AHCL12T
Edit Name ERR1_AHCL12T,
ERR2_AHCL12T
quHardedits ERR_AHCL12T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 45 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL13N
Question ID AHS.312_1
Universe
Universe-text
Question Text
Answer Codes
Question Type Other
Part
Field Pane
Fill Instructions
Special Instructions Storage variable for follow up to choice # 13 (birth defect) in AFLHCA
Skip Instructions
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 46 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL13T
Question ID AHS.312_2
Universe
Universe-text
Question Text
Answer Codes
Question Type Other
Part
Field Pane Time period
Fill Instructions
Special Instructions Storage variable for follow up to choice # 13 (birth defect) in AFLHCA
Skip Instructions
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 47 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL14N
Question ID AHS.313_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 14
Universe-text Sample adults 18+ who had difficulty due to mental retardation
Question Text 1 of 2
How long have you had intellectual disability, also known as mental
retardation?
* Enter number for time with intellectual disability/mental retardation.
* Enter '95'' for 95 or more.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL14T]
<R>[store "R" in AHCL14T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL14T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 48 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL14T
Question ID AHS.313_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL14N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with intellectual disability/mental retardation.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL14T
[if [AHCL14N = Number greater than person years old and AHCL14T= 4]] goto
ERR1_AHCL14T
Edit Name ERR1_AHCL14T,
ERR2_AHCL14T
quHardedits ERR_AHCL14T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 49 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL15N
Question ID AHS.314_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 15
Universe-text Sample adults 18+ who had difficulty due to a developmental problem
Question Text 1 of 2
How long have you had a developmental problem (e.g., cerebral palsy)?
* Enter number for time with a developmental problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL15T]
<R>[store "R" in AHCL15T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL15T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 50 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL15T
Question ID AHS.314_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL15N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with developmental problem.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL15T
[if [AHCL15N = Number greater than person years old and AHCL15T= 4]] goto
ERR1_AHCL15T
Edit Name ERR1_AHCL15T,
ERR2_AHCL15T
quHardedits ERR_AHCL15T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 51 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL16N
Question ID AHS.315_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 16
Universe-text Sample adults 18+ who had difficulty due to senility
Question Text 1 of 2
How long have you had senility?
* Enter number for time with senility.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL16T]
<R>[store "R" in AHCL16T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL16T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 52 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL16T
Question ID AHS.315_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL16N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with senility.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL16T
[if [AHCL16N = Number greater than person years old and AHCL16T= 4]] goto
ERR1_AHCL16T
Edit Name ERR1_AHCL16T,
ERR2_AHCL16T
quHardedits ERR_AHCL16T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 53 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL17N
Question ID AHS.316_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 17
Universe-text Sample adults 18+ who had difficulty due to depression, anxiety, or an
emotional problem
Question Text 1 of 2
How long have you had depression, anxiety, or an emotional problem?
* Enter number for time with depression, anxiety, or an emotional problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL17T]
<R>[store "R" in AHCL17T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL17T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 54 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL17T
Question ID AHS.316_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL17N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with depression, anxiety, or emotional problem.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL17T
[if [AHCL17N = Number greater than person years old and AHCL17T= 4]] goto
ERR1_AHCL17T
Edit Name ERR1_AHCL17T,
ERR2_AHCL17T
quHardedits ERR_AHCL17T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 55 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL18N
Question ID AHS.317_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 18
Universe-text Sample adults 18+ who had difficulty due to a weight problem
Question Text 1 of 2
How long have you had a weight problem?
* Enter number for time with a weight problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL18T]
<R>[store "R" in AHCL18T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL18T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 56 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL18T
Question ID AHS.317_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL18N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with weight problem.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL18T
[if [AHCL18N = Number greater than person years old and AHCL18T= 4]] goto
ERR1_AHCL18T
Edit Name ERR1_AHCL18T,
ERR2_AHCL18T
quHardedits ERR_AHCL18T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 57 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL19N
Question ID AHS.318_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 19
Universe-text Sample adults 18+ who had difficulty due to a missing limb
Question Text 1 of 2
How long have you had a missing limb (finger, toe, or digit)?
* Enter number for time with a missing limb.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL19T]
<R>[store "R" in AHCL19T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL19T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 58 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL19T
Question ID AHS.318_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL19N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with missing limb.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL19T
[if [AHCL19N = Number greater than person years old and AHCL19T= 4]] goto
ERR1_AHCL19T
Edit Name ERR1_AHCL19T,
ERR2_AHCL19T
quHardedits ERR_AHCL19T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 59 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL20N
Question ID AHS.319_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 20
Universe-text Sample adults 18+ who had difficulty due to a kidney, bladder or renal problem
Question Text 1 of 2
How long have you had a kidney, bladder or renal problem?
* Enter number for time with a kidney, bladder or renal problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL20T]
<R>[store "R" in AHCL20T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL20T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 60 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL20T
Question ID AHS.319_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL20N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with kidney, bladder or renal problem.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL20T
[if [AHCL20N = Number greater than person years old and AHCL20T= 4]] goto
ERR1_AHCL20T
Edit Name ERR1_AHCL20T,
ERR2_AHCL20T
quHardedits ERR_AHCL20T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 61 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL21N
Question ID AHS.320_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 21
Universe-text Sample adults 18+ who had difficulty due to a circulation problem
Question Text 1 of 2
How long have you had a circulation problem (including blood clots)?
* Enter number for time with a circulation problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL21T]
<R>[store "R" in AHCL21T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL21T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 62 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL21T
Question ID AHS.320_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL21N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with circulation problem.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL21T
[if [AHCL21N = Number greater than person years old and AHCL21T= 4]] goto
ERR1_AHCL21T
Edit Name ERR1_AHCL21T,
ERR2_AHCL21T
quHardedits ERR_AHCL21T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 63 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL22N
Question ID AHS.321_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 22
Universe-text Sample adults 18+ who had difficulty due to benign tumors or cysts
Question Text 1 of 2
How long have you had benign tumors or cysts?
* Enter number for time with benign tumors or cysts.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL22T]
<R>[store "R" in AHCL22T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL22T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 64 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL22T
Question ID AHS.321_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL22N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with benign tumors or cysts.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL22T
[if [AHCL22N = Number greater than person years old and AHCL22T= 4]] goto
ERR1_AHCL22T
Edit Name ERR1_AHCL22T,
ERR2_AHCL22T
quHardedits ERR_AHCL22T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 65 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL23N
Question ID AHS.322_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 23
Universe-text Sample adults 18+ who had difficulty due to fibromyalgia or lupus
Question Text 1 of 2
How long have you had fibromyalgia or lupus?
* Enter number for time with fibromyalgia or lupus.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL23T]
<R>[store "R" in AHCL23T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL23T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 66 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL23T
Question ID AHS.322_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL23N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with fibromyalgia or lupus.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL23T
[if [AHCL23N = Number greater than person years old and AHCL23T= 4]] goto
ERR1_AHCL23T
Edit Name ERR1_AHCL23T,
ERR2_AHCL23T
quHardedits ERR_AHCL23T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 67 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL24N
Question ID AHS.323_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 24
Universe-text Sample adults 18+ who had difficulty due to osteoporosis or tendinitis
Question Text 1 of 2
How long have you had osteoporosis or tendinitis?
* Enter number for time with osteoporosis or tendinitis.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL24T]
<R>[store "R" in AHCL24T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL24T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 68 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL24T
Question ID AHS.323_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL24N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with osteoporosis or tendinitis.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL24T
[if [AHCL24N = Number greater than person years old and AHCL24T= 4]] goto
ERR1_AHCL24T
Edit Name ERR1_AHCL24T,
ERR2_AHCL24T
quHardedits ERR_AHCL24T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 69 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL25N
Question ID AHS.324_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 25
Universe-text Sample adults 18+ who had difficulty due to epilepsy or seizures
Question Text 1 of 2
How long have you had epilepsy or seizures?
* Enter number for time with epilepsy or seizures.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL25T]
<R>[store "R" in AHCL25T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL25T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 70 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL25T
Question ID AHS.324_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL25N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with epilepsy or seizures.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL25T
[if [AHCL25N = Number greater than person years old and AHCL25T= 4]] goto
ERR1_AHCL25T
Edit Name ERR1_AHCL25T,
ERR2_AHCL25T
quHardedits ERR_AHCL25T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 71 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL26N
Question ID AHS.325_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 26
Universe-text Sample adults 18+ who had difficulty due to multiple sclerosis or muscular
Question Text 1 of 2
How long have you had multiple sclerosis (MS) or muscular dystrophy (MD)?
* Enter number for fime with multiple sclerosis (MS) or muscular dystrophy (MD).
* Enter '95'' for 95 or more.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL26T]
<R>[store "R" in AHCL26T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL26T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 72 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL26T
Question ID AHS.325_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL26N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with multiple sclerosis or muscular dystrophy.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL26T
[if [AHCL26N = Number greater than person years old and AHCL26T= 4]] goto
ERR1_AHCL26T
Edit Name ERR1_AHCL26T,
ERR2_AHCL26T
quHardedits ERR_AHCL26T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 73 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL27N
Question ID AHS.326_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 27
Universe-text Sample adults 18+ who had difficulty due to polio(myelitis), paralysis or
para/quadriplegia
Question Text 1 of 2
How long have you had polio(myelitis), paralysis or para/quadriplegia?
* Enter number for time with polio (myelitis), paralysis or para/quadriplegia.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL27T]
<R>[store "R" in AHCL27T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL27T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 74 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL27T
Question ID AHS.326_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL27N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with polio(myelitis), paralysis or para/quadriplegia.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL27T
[if [AHCL27N = Number greater than person years old and AHCL27T= 4]] goto
ERR1_AHCL27T
Edit Name ERR1_AHCL27T,
ERR2_AHCL27T
quHardedits ERR_AHCL27T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 75 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL28N
Question ID AHS.327_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 28
Universe-text Sample adults 18+ who had difficulty due to Parkinson's disease or tremors
Question Text 1 of 2
How long have you had Parkinson's disease or tremors?
* Enter number for time with Parkinson's disease or tremors.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL28T]
<R>[store "R" in AHCL28T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL28T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 76 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL28T
Question ID AHS.327_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL28N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with Parkinson's disease or tremors.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL28T
[if [AHCL28N = Number greater than person years old and AHCL28T= 4]] goto
ERR1_AHCL28T
Edit Name ERR1_AHCL28T,
ERR2_AHCL28T
quHardedits ERR_AHCL28T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 77 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL29N
Question ID AHS.328_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 29
Universe-text Sample adults 18+ who had difficulty due to nerve damage
Question Text 1 of 2
How long have you had nerve damage (including carpal tunnel syndrome)?
* Enter number for time with nerver damage (including carpal tunnel syndrome).
* Enter '95'' for 95 or more.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL29T]
<R>[store "R" in AHCL29T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL29T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 78 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL29T
Question ID AHS.328_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL29N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with nerve damage.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL29T
[if [AHCL29N = Number greater than person years old and AHCL29T= 4]] goto
ERR1_AHCL29T
Edit Name ERR1_AHCL29T,
ERR2_AHCL29T
quHardedits ERR_AHCL29T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 79 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL30N
Question ID AHS.329_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 30
Universe-text Sample adults 18+ who had difficulty due to a hernia
Question Text 1 of 2
How long have you had a hernia?
* Enter number for time with a hernia.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL30T]
<R>[store "R" in AHCL30T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL30T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 80 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL30T
Question ID AHS.329_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL30N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with hernia.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL30T
[if [AHCL30N = Number greater than person years old and AHCL30T= 4]] goto
ERR1_AHCL30T
Edit Name ERR1_AHCL30T,
ERR2_AHCL30T
quHardedits ERR_AHCL30T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 81 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL31N
Question ID AHS.330_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 31
Universe-text Sample adults 18+ who had difficulty due to an ulcer
Question Text 1 of 2
How long have you had an ulcer?
* Enter number for time with an ulcer.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL31T]
<R>[store "R" in AHCL31T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL31T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 82 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL31T
Question ID AHS.330_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL31N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with ulcer.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions Answer name to the right.
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL31T
[if [AHCL31N = Number greater than person years old and AHCL31T= 4]] goto
ERR1_AHCL31T
Edit Name ERR1_AHCL31T,
ERR2_AHCL31T
quHardedits ERR_AHCL31T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 83 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL32N
Question ID AHS.331_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 32
Universe-text Sample adults 18+ who had difficulty due to varicose veins or hemorrhoids
Question Text 1 of 2
How long have you had varicose veins or hemorrhoids?
* Enter number for time with varicose veins or hemorrhoids.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL32T]
<R>[store "R" in AHCL32T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL32T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 84 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL32T
Question ID AHS.331_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL32N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with varicose veins or hemorrhoids.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL32T
[if [AHCL32N = Number greater than person years old and AHCL32T= 4]] goto
ERR1_AHCL32T
Edit Name ERR1_AHCL32T,
ERR2_AHCL32T
quHardedits ERR_AHCL32T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 85 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL33N
Question ID AHS.332_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 33
Universe-text Sample adults 18+ who had difficulty due to a thyroid problem, Grave's disease
or gout
Question Text 1 of 2
How long have you had a thyroid problem, Grave's disease or gout?
* Enter number for time with a thyroid problem, Grave's disease or gout.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL33T]
<R>[store "R" in AHCL33T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL33T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 86 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL33T
Question ID AHS.332_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL33N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with thyroid problem, Grave's disease or gout.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL33T
[if [AHCL33N = Number greater than person years old and AHCL33T= 4]] goto
ERR1_AHCL33T
Edit Name ERR1_AHCL33T,
ERR2_AHCL33T
quHardedits ERR_AHCL33T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 87 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL34N
Question ID AHS.333_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 34
Universe-text Sample adults 18+ who had difficulty due to a knee problem
Question Text 1 of 2
How long have you had a knee problem?
* Enter number for time with a knee problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL34T]
<R>[store "R" in AHCL34T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL34T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 88 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL34T
Question ID AHS.333_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL34N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with knee problem.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL34T
[if [AHCL34N = Number greater than person years old and AHCL34T= 4]] goto
ERR1_AHCL34T
Edit Name ERR1_AHCL34T,
ERR2_AHCL34T
quHardedits ERR1_AHCL34T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 89 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL35N
Question ID AHS.334_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 35
Universe-text Sample adults 18+ who had difficulty due to migraine headaches
Question Text 1 of 2
How long have you had migraine headaches?
* Enter number for time with migraine headaches.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL35T]
<R>[store "R" in AHCL35T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL35T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 90 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL35T
Question ID AHS.334_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL35N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with migraine headaches.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL35T
[if [AHCL35N = Number greater than person years old and AHCL35T= 4]] goto
ERR1_AHCL35T
Edit Name ERR1_AHCL35T,
ERR2_AHCL35T
quHardedits ERR1_AHCL35T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 91 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL90N
Question ID AHS.335_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 90
Universe-text Sample adults 18+ who had difficulty due to {problem in AFLHCA90}
Question Text 1 of 2
How long have you had {problem in AFLHCA80}?
* Enter number for time with {problem in AFLHCA80}.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL90T]
<R>[store "R" in AHCL90T] [goto the next condition, in numerical order,
selected at AFLHCA (AHS.200). If this is the last condition selected, goto
SMKEV (next section)]
<96>[store "6" in AHCL90T] [goto the next condition, in numerical order,
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 92 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL90T
Question ID AHS.335_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL36N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with {problem in AFLHCA80}.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions
Skip Instructions <1- 4, R,D>[[if 91 selected in AFLHCA goto AFLHCA_S2]
Else goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL90T
[if [AHCL90N = Number greater than person years old and AHCL90T= 4]] goto
ERR1_AHCL90T
Edit Name ERR1_AHCL90T,
ERR2_AHCL90T
quHardedits ERR_AHCL90T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 93 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL91N
Question ID AHS.336_1
Universe HHSTAT4 = 'S' and AGE GE 18 and AFLHCA = 91
Universe-text Sample adults 18+ who had difficulty due to {problem in AFLHCA91}
Question Text 1 of 2
How long have you had {problem in AFLHCA81}?
* Enter number for time with {problem in AFLHCA81}.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.
Answer Codes
Question Type Integer
Part
Field Pane Number
Fill Instructions
Special Instructions
Skip Instructions <1-95,D>[goto AHCL36T]
<R>[store "R" in AHCL36T] [goto SMKEV (next section)]
<96>[store "6" in AHCL36T] [goto SMKEV (next section)]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 94 of 95
Section Name Adult Health Status and Limitation of
Module 17
Instrument Variable AHCL91T
Question ID AHS.336_2
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCL37N = 1-95, D
Universe-text Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part
question
Question Text 2 of 2
* Enter time period for time with {problem in AFLHCA81}.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Since birth
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Time period
Fill Instructions
Special Instructions
Skip Instructions <1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA
(AHS.200). If this is the last condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL37T
[if [AHCL91N = Number greater than person years old and AHCL91T= 4]] goto
ERR1_AHCL91T
Edit Name ERR1_AHCL91T,
ERR2_AHCL91T
quHardedits ERR_AHCL91T
* Time with condition cannot be greater than age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 95 of 95
Section Name Adult Health Behavior
Module 18
Instrument Variable SMKEV
Question ID AHB.010
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
These next questions are about cigarette smoking.
Have you smoked at least 100 cigarettes in your ENTIRE LIFE?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part A
Field Pane Ever smoked 100 cigarettes
Fill Instructions
Special Instructions
Skip Instructions <1>[goto SMKREG]
<2,D,R>[goto VIGNO]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 1 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable SMKREG
Question ID AHB.020
Universe HHSTAT4 = 'S' and AGE GE 18 and SMKEV = 1
Universe-text Sample adults 18+ who ever smoked 100 cigarettes
Question Text ? [F1]
How old were you when you FIRST started to smoke fairly regularly?
* Enter '6' if less than 6 years old.
* Enter '95' if 95 years old or older.
* Enter '96' if never smoked regularly.
Answer Codes
Question Type Integer
Part A
Field Pane Age started smoking
Fill Instructions
Special Instructions
Skip Instructions <6-95,96,R,D> [goto SMKNOW]
[If SMKREG gt AGE and SMKREG ne <96>, goto ERR_SMKREG
Edit Name ERR_SMKREG
quHardedits ERR_SMKREG
* Starting age exceeded current age.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 2 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable SMKNOW
Question ID AHB.030
Universe HHSTAT4 = 'S' and AGE GE 18 and SMKEV = 1
Universe-text Sample adults 18+ who ever smoked 100 cigarettes
Question Text ? [F1]
Do you NOW smoke cigarettes every day, some days or not at all?
Answer Codes 1. Every day
2. Some days
3. Not at all
Refused
Don't know
Question Type Pick One - answer list pane
Part A
Field Pane Now Smoke
Fill Instructions
Special Instructions Add answer name to the right of input.
Skip Instructions <1>[goto CIGSDA1]
<2>[goto CIGDAMO]
<3>[goto SMKQTNO]
<D,R>[goto VIGNO]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 3 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable SMKQTNO
Question ID AHB.040_1
Universe HHSTAT4 = 'S' and AGE GE 18 and SMKNOW= 3
Universe-text Sample adults 18+ who quit smoking
Question Text ? [F1]
1 of 2
How long has it been since you quit smoking cigarettes?
* Enter number for time since quit smoking.
* Enter '95' for 95 years old or older.
Answer Codes
Question Type Multi Part
Part A
Field Pane Number
Fill Instructions
Special Instructions "Time since quit smoking" as a header for this question and AHB.040_2
(SMKQTTP).
Skip Instructions <1-95> [goto SMKQTTP]
<D,R> [goto VIGNO]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 4 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable SMKQTTP
Question ID AHB.040_2
Universe HHSTAT4 = 'S' and AGE GE 18 and SMKQTNO = 1-95
Universe-text Sample adults 18+ who quit smoking
Question Text 2 of 2
* Enter time period for time since quit smoking.
Answer Codes 1. Days
2. Weeks
3. Months
4. Years
Refused
Don't know
Question Type Multi Part
Part A
Field Pane Time period
Fill Instructions
Special Instructions Flag when ERR2_SMKQTTP is triggered. Place answer box to the right of that
for AHB.040_1 (SMKQTNO). Show answer name on the right.
Skip Instructions <1-4> [goto VIGNO]
<4> [if SMKQTNO gt (AGE - <15>), goto ERR1_SMKQTTP
if (SMKREG + SMKQTNO gt AGE), goto ERR2_SMKQTTP.
Edit Name ERR1_SMKQTTP;
ERR1_SMKQTTP
quHardedits ERR2_SMKQTTP
* Age started ([Fill1: SMKREG]) + years since quit ([Fill2: SMKQTNO]) exceeds
current age ([Fill3: AGE]).
* Please correct.
quSoftedits ERR1_SMKQTTP
* Respondent quit smoking before age 15?
* Please verify.
Tuesday, June 19, 2012 Page 5 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable CIGSDA1
Question ID AHB.050
Universe HHSTAT4 = 'S' and AGE GE 18 and SMKNOW = 1
Universe-text Sample adults 18+ who are current every day smokers
Question Text ? [F1]
On the average, how many cigarettes do you now smoke a day?
* Enter '1' if less than 1 cigarette.
* Enter '95' if 95 or more cigarettes.
Answer Codes
Question Type Integer
Part A
Field Pane Average number of cigarettes daily
Fill Instructions
Special Instructions "Every day smokers" as a header.
Skip Instructions <1-95,D,R> [goto CIGQTYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 6 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable CIGDAMO
Question ID AHB.060
Universe HHSTAT4 = 'S' and AGE GE 18 and SMKNOW = 2
Universe-text Sample adults 18+ who are current some day smokers
Question Text ? [F1]
On how many of the PAST 30 DAYS did you smoke a cigarette?
*Enter '0' for None.
Answer Codes
Question Type Integer
Part A
Field Pane Number of days smoked
Fill Instructions
Special Instructions "Some day smokers - past 30 days" as a header for this question and AHB.070
Skip Instructions <0>[goto CIGQTYR]
<1-30,R,D> [goto CIGSDA2]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 7 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable CIGSDA2
Question ID AHB.070
Universe HHSTAT4 = 'S' and AGE GE 18 and [ CIGDAMO=1-30,D,R) ]
Universe-text Sample adults 18+ who are current some day smokers
Question Text ? [F1]
On the average, when you smoked during the PAST 30 DAYS, about how many
cigarettes did you smoke a day?
* Enter '1' if less than 1.
* Enter '95' if 95 or more cigarettes.
Answer Codes
Question Type Integer
Part A
Field Pane Average number of cigarettes on days smoked
Fill Instructions
Special Instructions Locate the Variable Description and answer box to the right of that for AHB.060
(CIGDAMO).
Skip Instructions <1-95,D,R> [goto CIGQTYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 8 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable CIGQTYR
Question ID AHB.080
Universe HHSTAT4 = 'S' and AGE GE 18 and SMKNOW = 1,2
Universe-text Sample adults 18+ who are every day or someday smokers
Question Text ? [F1]
During the PAST 12 MONTHS, have you stopped smoking for more than one
day BECAUSE YOU WERE TRYING TO QUIT SMOKING?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part A
Field Pane Tried to quit
Fill Instructions
Special Instructions
Skip Instructions <1,2,D,R> [goto VIGNO]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 9 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable VIGNO
Question ID AHB.090_1
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
1 of 2
The next questions are about physical activities (exercise, sports, physically
active hobbies...) that you may do in your LEISURE time.
How often do you do VIGOROUS leisure-time physical activities for AT LEAST
10 MINUTES that cause HEAVY sweating or LARGE increases in breathing or
heart rate?
* Read if necessary: How many times per day, per week, per month, or per year
do you do these activities?
* Enter number for vigorous leisure-time physical activities.
* Enter '0' for Never.
* Enter '996' if unable to do this type of activity.
Answer Codes
Question Type Multi Part
Part B
Field Pane How often - number
Fill Instructions
Special Instructions "Vigorous activities for at least 10 minutes" as a header for this question,
AHB.090_2, AHB.100_1 and AHB.100_2.
Skip Instructions <0,996,R,D>[goto MODNO]
<1-995>[goto VIGTP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 10 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable VIGTP
Question ID AHB.090_2
Universe HHSTAT4 = 'S' and AGE GE 18 and VIGNO = 1-995
Universe-text Sample adults 18+ who do vigorous activities
Question Text 2 of 2
* Enter time period for vigorous leisure-time physical activities.
Answer Codes 1. Day
2. Week
3. Month
4. Year
Question Type Multi Part
Part B
Field Pane How often - time period
Fill Instructions
Special Instructions Show answer name on the right. Do not allow "Refused" or "Don't know" answers.
Skip Instructions <1-4> goto VIGLNGNO
[if (VIGNO gt <4> and VIGTP eq <1>) or
(VIGNO gt <28> and VIGTP eq <2>) or
(VIGNO gt <31> and VIGTP eq <3>) or
(VIGNO gt <365> and VIGTP eq <4>) goto ERR1_VIGTP]
Edit Name ERR1_VIGTP
quHardedits
quSoftedits ERR1_VIGTP
* [Fill1: VIGNO] times per [Fill2: VIGTP] is unusually high.
* Please verify.
Tuesday, June 19, 2012 Page 11 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable VIGLNGNO
Question ID AHB.100_1
Universe HHSTAT4 = 'S' and AGE GE 18 AND VIGTP = 1 - 4
Universe-text Sample adults 18+ who do vigorous activities
Question Text ? [F1]
1 of 2
About how long do you do these vigorous leisure-time physical activities each
time?
Answer Codes
Question Type Multi Part
Part B
Field Pane How long - number
Fill Instructions
Special Instructions
Skip Instructions <1-995>[goto VIGLNGTP]
<D,R>[goto MODNO]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 12 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable VIGLNGTP
Question ID AHB.100_2
Universe HHSTAT4 = 'S' and AGE GE 18 and VIGLNGNO = 1- 995
Universe-text Sample adults 18+ who do vigorous activities
Question Text 2 of 2
* Enter time period for length of vigorous leisure-time physical activities.
Answer Codes 1. Minutes
2. Hours
Question Type Multi Part
Part B
Field Pane How long- time period
Fill Instructions Fill1: [if VIGLNGTP = 1]
Fill2: [if VIGLNGTP = 2]
Special Instructions Locate the Variable Description and answer box to the right of that for
AHB.100_1 (VIGLNGNO). Show answer name on the right. Do not allow
"Refused" or "Don't know" answers.
Skip Instructions <1,2>goto MODNO
if VIGLNGNO lt <10> and VIGLNGTP eq <1> goto ERR1_VIGLNGTP;
if (VIGLNGNO gt <90> and VIGLNGTP eq <1>) or if VIGLNGNO gt <2> and
VIGLNGTP eq <2> goto ERR2_VIGLNGTP
Edit Name ERR1_VIGLNGTP;
ERR2_VIGLNGTP;
quHardedits ERR1_VIGLNGTP
* Question asked for activities lasting at least 10 minutes.
* Please correct.
quSoftedits ERR2_VIGLNGTP
* [Fill1: VIGLNGNO] [fill2: VIGLNGTP] is unusually high.
* Please verify.
Tuesday, June 19, 2012 Page 13 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable MODNO
Question ID AHB.110_1
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
How often do you do LIGHT OR MODERATE LEISURE-TIME physical activities
for AT LEAST 10 MINUTES that cause ONLY LIGHT sweating or a SLIGHT to
MODERATE increase in breathing or heart rate?
* If necessary, prompt with: How many times per day, per week, per month, or per
year do you do these activities?
* Enter number of light or moderate leisure-time physical activities.
* Enter '0' for Never.
* Enter '996' if unable to do this type of activity.
Answer Codes
Question Type Multi Part
Part B
Field Pane How often - number
Fill Instructions
Special Instructions "Light or moderate activities for at least 10 minutes" as a header for this
question, AHB.110_2, AHB.120_1 and AHB.120_2.
Skip Instructions <1-995>[goto MODTP]
<0, 996, R,D>[goto STRNGNO]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 14 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable MODTP
Question ID AHB.110_2
Universe HHSTAT4 = 'S' and AGE GE 18 and MODNO = 1-995
Universe-text Sample adults 18+ who do light or moderate activities
Question Text 2 of 2
* Enter time period for light or moderate leisure-time physical activities
Answer Codes 1. Day
2. Week
3. Month
4. Year
Question Type Multi Part
Part B
Field Pane How often - time period
Fill Instructions
Special Instructions Locate the Variable Description and answer box to the right of that for
AHB.110_1 (MODNO). Show answer name on the right. Do not allow "Refused"
or "Don't know" answers.
Skip Instructions <1-4> goto MODLNGNO
[if (MODNO gt <4> and MODTP eq <1>) or
(MODNO gt <28> and MODTP eq <2>) or
(MODNO gt <31> and MODTP eq <3>) or
(MODNO gt <365> and MODTP eq <4>)] goto ERR_MODNO
Edit Name ERR_MODNO
quHardedits
quSoftedits ERR_MODNO
* [Fill1: MODNO] times per [fill2: MODTP] is unusually high.
* Please verify.
Tuesday, June 19, 2012 Page 15 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable MODLNGNO
Question ID AHB.120_1
Universe HHSTAT4 = 'S' and AGE GE 18 and MODTP = 1 - 4
Universe-text Sample adults 18+ who do light or moderate activities
Question Text ? [F1]
1 of 2
About how long do you do these light or moderate leisure-time physical
activities each time?
* Enter number for length of light or moderate leisure-time physical activities.
Answer Codes
Question Type Multi Part
Part B
Field Pane How long - number
Fill Instructions
Special Instructions
Skip Instructions <1-995>[goto MODLNGTP]
<D,R>[goto STRNGNO]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 16 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable MODLNGTP
Question ID AHB.120_2
Universe HHSTAT4 = 'S' and AGE GE 18 and MODLNGNO = 1 - 995
Universe-text Sample adults 18+ who do light or moderate activities
Question Text 2 of 2
* Enter time period for length of light or moderate leisure-time physical activities.
Answer Codes 1. Minutes
2. Hours
Question Type Multi Part
Part B
Field Pane How long - time period
Fill Instructions
Special Instructions Locate the Variable Description and answer box to the right of that for
AHB.120_1 (MODLNGNO). Show answer name on the right. Do not allow
"Refused" or "Don't know" answers.
Skip Instructions <1,2> goto STRNGNO
if MODLNGNO lt <10> and MODLNGTP eq <1> goto ERR1_MODLNGTP
if MODLNGNO gt <90> and MODLNGTP eq <1> or if MODLNGNO gt <2> and
MODLNGTP eq <2>goto ERR2_MODLNGTP
Edit Name ERR1_MODLNGTP,
ERR2_MODLNGTP
quHardedits ERR1_MODLNGTP
* Question asked for activities lasting at least 10 minutes.
* Please correct.
quSoftedits ERR2_MODLNGTP
* [Fill1: MODLNGNO] [Fill2: MODLNGTP] is unusually high.
* Please verify.
Tuesday, June 19, 2012 Page 17 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable STRNGNO
Question ID AHB.130_1
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
How often do you do LEISURE-TIME physical activities specifically designed to
STRENGTHEN your muscles such as lifting weights or doing calisthenics?
(Include all such activities even if you have mentioned them before.)
* Read if necessary: How many times per day, per week, per month, or per year
do you do these activities?
* Enter number for strengthening acativities.
* Enter '0' for Never.
* Enter '996' for Unable to do this type activity
Answer Codes
Question Type Multi Part
Part B
Field Pane Strengthening - number
Fill Instructions
Special Instructions "Strengthening activities" as a header for this question, and AHB.130_2.
Skip Instructions <1-995>[goto STRNGTP]
<0, 996,R,D>[goto ALC1YR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 18 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable STRNGTP
Question ID AHB.130_2
Universe HHSTAT4 = 'S' and AGE GE 18 and STRNGNO = 1-995
Universe-text Sample adults 18+ who do strengthening activities
Question Text 2 of 2
* Enter time period for strengthening activities
Answer Codes 1. Day
2. Week
3. Month
4. Year
Question Type Multi Part
Part B
Field Pane Time period
Fill Instructions
Special Instructions Locate the Variable Description and answer box to the right of that for
AHB.130_1 (STRNGNO). Show answer name on the right. Do not allow
"Refused" or "Don't know" answers
Skip Instructions <1-4> [goto ALC1YR]
[If (STRNGNO gt <4> & STRNGTP = <1>) or (STRNGNO gt <28> & STRNGTP =
<2>) or
(STRNGNO gt <31> & STRNGTP = <3>) or (STRNGNO gt <365> & STRNGTP
= <4>) goto ERR_STRNGTP]
Edit Name ERR_STRNGTP
quHardedits
quSoftedits ERR_STRNGTP
* [Fill1: STRNGNO] times per [Fill2: STRNGTP] is unusually high.
* Please verify.
Tuesday, June 19, 2012 Page 19 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable ALC1YR
Question ID AHB.140
Universe HHSTAT4 = 'S'and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
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?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part C
Field Pane Any ONE year 12 drinks
Fill Instructions
Special Instructions
Skip Instructions <1> [goto ALC12MNO]
<2,R,D> [goto ALCLIFE]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 20 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable ALCLIFE
Question ID AHB.150
Universe ASTATFLG=1 and AGE GE 18 and ALC1YR = 2, D, R
Universe-text Sample adults 18+ who have not had 12 drinks in any one year or don't know if
they did or refused to answer
Question Text ? [F1]
In your ENTIRE LIFE, have you had at least 12 drinks of any type of alcoholic
beverage?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part C
Field Pane Entire life 12 drinks
Fill Instructions
Special Instructions
Skip Instructions <1> [goto ALC12MNO]
<2,R,D> [goto AHGT_FT]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 21 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable ALC12MNO
Question ID AHB.160_1
Universe HHSTAT4 = 'S' and AGE GE 18 and (ALC1YR = 1 or ALCLIFE = 1)
Universe-text Sample adults 18+ who have had at least 12 drinks in any one year or at least
12 drinks in their entire life
Question Text ? [F1]
1 of 2
In the PAST YEAR, how often did you drink any type of alcoholic beverage?
* Read if necessary: "How many days per week, per month or per year did you
drink?"
* Enter number for how often alcohoilic berveages were consumed in the past
year.
*Enter '0' for Never.
Answer Codes
Question Type Multi Part
Part C
Field Pane How often - number
Fill Instructions
Special Instructions "Past year" as a header or this question, AHB.160_2, AHB.170, AHB.180_1 and
AHB.180_2.
Skip Instructions <1-365>[goto ALC12MTP]
<0,D,R>[goto AHGT_FT]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 22 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable ALC12MTP
Question ID AHB.160_2
Universe HHSTAT4 = 'S'1 and AGE GE 18 and ALC12MNO = 1 - 365
Universe-text Sample adults 18+ who drank at least once in the past year
Question Text 2 of 2
* Enter time period for how often alcoholic beverages were consumed in the
past year.
Answer Codes 1. Week
2. Month
3. Year
Question Type Multi Part
Part C
Field Pane How often - time period
Fill Instructions
Special Instructions Locate the Variable Description and answer box to the right of that for
AHB.160_1 (ALC12MNO). Show answer name on the right.
Skip Instructions <1-3> [goto ALCAMT]
[If (ALC12MNO gt <7> & ALC12MTP = <1>) or (ALC12MNO gt <31> &
ALC12MTP = <2>) or
(ALC12MNO gt <365> & ALC12MTP = <3>) goto ERR_ALC12MTP]
Edit Name ERR_ALC12MTP
quHardedits ERR_ALC12MTP
* [Fill1: ALC12MNO] days per [Fill2: ALC12MTP] exceeds number possible in
this time period.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 23 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable ALCAMT
Question ID AHB.170
Universe HHSTAT4 = 'S' and AGE GE 18 and ALC12MTP = 1-3
Universe-text Sample adults 18+ who have had at least 1 drink in the past year
Question Text ? [F1]
In the PAST YEAR, on those days that you drank alcoholic
beverages, on the average, how many drinks did you have?
* Enter '1' if less than 1 drink.
* Enter '95' if 95 or more drinks.
Answer Codes
Question Type Integer
Part C
Field Pane Average # of drinks/day
Fill Instructions
Special Instructions
Skip Instructions <1-95,D,R>[goto ALC5UPNO]
<10-95>[goto ERR_ALCAMT]
Edit Name ERR_ALCAMT
quHardedits
quSoftedits ERR_ALCAMT
* [Fill: ALCAMT] drinks is an unusually high number.
* Please verify.
* Do not probe
Tuesday, June 19, 2012 Page 24 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable ALC5UPNO
Question ID AHB.180_1
Universe HHSTAT4 = 'S' and AGE GE 18 and ALC12MNO = 1-365
Universe-text Sample adults 18+ who have had at least 1 drink in the past year
Question Text ? [F1]
1 of 2
In the PAST YEAR, on how many DAYS did you have 5 or more drinks of any
alcoholic beverage?
* Read if necessary:
How many days per week, per month or per year did you have 5 or more drinks in
a single day?
* Enter number of days.
* Enter '0' for Never/None.
Answer Codes
Question Type Multi Part
Part C
Field Pane Number
Fill Instructions
Special Instructions "Days with 5 or more drinks " as a header for this question and AHB.180_2.
Skip Instructions <1-365>[goto ALC5UPTP]
<0,R,D>[goto AHGT_FT]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 25 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable ALC5UPTP
Question ID AHB.180_2
Universe HHSTAT4 = 'S' and AGE GE 18 and ALC5UPNO = 1-365.
Universe-text Sample adults 18+ who have had 5+ drinks in one day at least once in the past
Question Text 2 of 2
* Enter time period for days per week, per month or per year.
Answer Codes 1. Week
2. Month
3. Year
Question Type Multi Part
Part C
Field Pane Time period
Fill Instructions
Special Instructions Locate the Variable Description and answer box to the right of that for
AHB.180_1 (ALC5UPNO). Show answer name on the right.
Skip Instructions <1-3>goto AHGT_FT
[If (ALC5UPNO gt <7> & ALC5UPTP = <1>) or
(ALC5UPNO gt <31> & ALC5UPTP = <2>) or
(ALC5UPNO gt <365> & ALC5UPTP = <3>) goto ERR1_ALC5UPTP
[if number of days drank in the past year (calculated from ALC12MNO and
ALC12MTP) lt number of days per year with 5 or more drinks (calculated from
ALC5UPNO and ALC5UPTP)] goto ERR2_ALC5UPTP]
Edit Name ERR1_ALC5UPTP;
ERR2_ALC5UPTP
quHardedits ERR1_ALC5UPTP
* [Fill1: ALC12MNO] days per [Fill2: ALC12MTP] exceeds number possible in
this time period.
* Please correct.
ERR2_ALC5UPTP
* Number of days had 5 or more drinks exceeds number of days drank.
* Please correct.
* Do not probe.
quSoftedits
Tuesday, June 19, 2012 Page 26 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable AHGT_FT
Question ID AHB.190_01
Universe HHSTAT4 = 'S'and AGE GE 18
Universe-text Sample adults 18+
Question Text How tall are you without shoes?
* Enter "M" to record metric measurements
Answer Codes
Question Type Integer
Part C
Field Pane Current height
Fill Instructions
Special Instructions "Current height" to the left. "feet" to the right.
Don't allow a '.' (a period) after a number. This is a 2 character field and will be
picked up in output
Skip Instructions <2-7> [goto AHGT_IN]
<R.D> [goto AWGT_LB]
<M> [goto AHGT_M]
[if AHGT_FT NE<2-7,R,D,M> goto ERR1_AHGT_FT]
[if AHGT_FT = <2,3> goto ERR2_AHGT_FT]
Edit Name ERR1_AHGT_FT;
ERR2_AHGT_FT
quHardedits ERR1_AHGT_FT
* Only 2-7, Don't Know/Refused or M allowed in this field.
* Please correct.
quSoftedits ERR2_AHGT_FT
* Respondent's height in feet is [fill: AHGT_FT]?
* Please verify.
Tuesday, June 19, 2012 Page 27 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable AHGT_IN
Question ID AHB.190_02
Universe HHSTAT4 = 'S' and AGE GE 18 and AHGT_FT = 2-7
Universe-text Sample adults 18+ who answered their height in feet
Question Text How tall are you without shoes?
* Enter '0' if exactly [fill1: AHGT_FT] feet tall.
Answer Codes
Question Type Integer
Part C
Field Pane Inches
Fill Instructions
Special Instructions Locate the Variable Description and answer box to the right of that for
AHB.190_01 (AHGT_FT). Show "inches" on the right.
If AHGT_FT = M, Refused, or Don’t know, do not calculate a value for AHTINCH
Create variable AHTINCH as follows: (AHGT_FT * 12) + AHGT_IN = AHTINCH
If AHGT_IN = Refused or Don’t know use ‘0’ for AHGT_IN when calculating
AHTINCH
If ERR2_AHGT_IN is displayed, set AHGT_FLG = ‘1’
If ERR2_AHGT_IN is closed or you goto another screen from it, leave
AHGT_FLG = ‘1’
If ERR2_AHGT_IN is suppressed, reset AHGT_FLG = ‘2’
Skip Instructions <empty> goto ERR_AHGT_IN
<0-11,R,D> if (SEX = ‘1’ and (AHTINCH lt ‘61’ or AHTINCH gt ‘75’)) or
(SEX = ‘2’ and (AHTINCH lt ‘56’ or AHTINCH gt ‘69’))
goto ERR2_AHGT_IN
else
goto AWGT_LB
Edit Name ERR1_AHGT_IN;
ERR2_AHGT_IN
quHardedits ERR1_AHGT_IN
* If [fill: AHGT_FT] feet exactly, enter "0"; otherwise enter number of inches.
quSoftedits ERR2_AHGT_IN
* Please verify that the height was entered correctly. Probe only if necessary.
Tuesday, June 19, 2012 Page 28 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable AHGT_M
Question ID AHB.190_03
Universe HHSTAT4 = 'S' and AGE GE 18 and AHGT_FT = M
Universe-text Sample adults 18+ who choose to give their height in metric measurements
Question Text How tall are you without shoes?
* Enter height in metric.
Answer Codes
Question Type Integer
Part C
Field Pane Current height
Fill Instructions
Special Instructions "meters" to the right.
Skip Instructions <empty> goto ERR_AHGT_M
<0-2> goto AHGT_CM
<R,D> goto AWGT_LB
Edit Name ERR_AHGT_M
quHardedits ERR_AHGT_M
* If height is being given in centimeters only, enter "0"; otherwise enter number
of meters.
quSoftedits
Tuesday, June 19, 2012 Page 29 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable AHGT_CM
Question ID AHB.190_04
Universe HHSTAT4 = 'S'and AGE GE 18 and AHGT_M = 0-2
Universe-text Sample adults 18+ who answered their height in meters
Question Text *Enter centimeters.
Answer Codes
Question Type Integer
Part C
Field Pane Centimeters
Fill Instructions
Special Instructions "centimeters" to the right.
If AHGT_M = Refused or Don’t know, do not calculate a value for AHTCM
Create variable AHTCM as follows: (AHGT_M * 100) + AHGT_CM = AHTCM
If AHGT_CM = Refused or Don’t know use ‘0’ for AHGT_CM when checking if
height exceeds maximum allowed, when checking if height is very small, or
when calculating AHTCM
If ERR3_AHGT_CM is displayed, set AHGT_FLG = ‘1’
If ERR3_AHGT_CM is closed or you goto another screen from it, leave
AHGT_FLG = ‘1’
If ERR3_AHGT_CM is suppressed, reset AHGT_FLG = ‘2’
Skip Instructions <empty> goto ERR2_AHGT_CM
<0-241,R,D> if (AHGT_M eq ‘2’ and AHGT_CM gt ‘41’) or (AHGT_M eq ‘1’ and
AHGT_CM gt ‘141’)
goto ERR1_AHGT_CM
elseif (SEX = ‘1’ and (AHTCM lt ‘156’ or AHTCM gt ‘192’)) or
(SEX = ‘2’ and (AHTCM lt ‘143’ or AHTCM gt ‘176’))
goto ERR3_AHGT_CM
else
goto AWGT_LB
Edit Name ERR1_AHGT_CM;
ERR2_AHGT_CM;
quHardedits ERR1_AHGT_CM
* Total height exceeds maximum allowed.
* Please correct.
ERR2_AHGT_CM
* If [fill: AHGT_M] meters exactly, enter "0"; otherwise enter number of
quSoftedits ERR3_AHGT_CM
* Please verify that the height was entered correctly. Probe only if necessary.
Tuesday, June 19, 2012 Page 30 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable AHTINCH
Question ID AHB.190_05
Universe
Universe-text
Question Text **OUT VARIABLE**
Answer Codes
Question Type Instrument Out Variable
Part C
Field Pane
Fill Instructions
Special Instructions If AHGT_FT = M, Refused or Don’t know, do not calculate a value for AHTINCH
Create variable AHTINCH as follows: (AHGT_FT * 12) + AHGT_IN = AHTINCH
If AHGT_IN = Refused or Don’t know, use ‘0’ for AHGT_IN when calculating
Skip Instructions
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 31 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable AHTCM
Question ID AHB.190_06
Universe
Universe-text
Question Text **OUT VARIABLE**
Answer Codes
Question Type Instrument Out Variable
Part C
Field Pane
Fill Instructions
Special Instructions If AHGT_M = Refused or Don’t know, do not calculate a value for AHTCM
Create variable AHTCM as follows: (AHGT_M * 100) + AHGT_CM = AHTCM
If AHGT_CM = Refused or Don’t know use ‘0’ for AHGT_CM when calculating
AHTCM
Skip Instructions
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 32 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable AHGT_FLG
Question ID AHB.190_07
Universe
Universe-text
Question Text **OUT VARIABLE**
Answer Codes blank,1,2
Question Type Instrument Out Variable
Part C
Field Pane
Fill Instructions
Special Instructions If ERR2_AHGT_IN or ERR3_AHGT_CM is displayed, set AHGT_FLG = ‘1’
If ERR2_AHGT_IN or ERR3_AHGT_CM is closed or you goto another screen
from it, leave AHGT_FLG = ‘1’
If ERR2_AHGT_IN or ERR3_AHGT_CM is suppressed, reset AHGT_FLG = ‘2’
Skip Instructions
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 33 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable AMETERS
Question ID AHB.190_08
Universe
Universe-text
Question Text **OUT VARIABLE**
Answer Codes
Question Type Instrument Out Variable
Part C
Field Pane
Fill Instructions
Special Instructions Create variable AMETERS as follows:
if AHTINCH ne ‘empty’
set AMETERS = AHTINCH/39.37008
elseif AHTCM ne ‘empty’
set AMETERS = AHTCM/100
Skip Instructions
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 34 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable AWGT_LB
Question ID AHB.200_01
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text How much do you weigh without shoes?
* Enter "M" to record metric measurements
* Enter '500' for 500 pounds or more
Answer Codes
Question Type Integer
Part C
Field Pane Current weight
Fill Instructions
Special Instructions "pounds" on the right.
If ERR2_AWGT_LB is displayed, set AWGT_FLG = ‘1’
If ERR2_AWGT_LB is closed or you goto another screen from it, leave
AWGT_FLG = ‘1’
If ERR2_AWGT_LB is suppressed, reset AWGT_FLG = ‘2’
Skip Instructions <50-500> if AWGT_LB lt ‘50’ or AWGT_LB gt ‘500’
goto ERR1_AWGT_LB
elseif ((SEX = ‘1’ and (AWGT_LB lt ’113’ or AWGT_LB gt ‘316’)) or
((SEX = ‘2’ and (AWGT_LB lt ’96’ or AWGT_LB gt ‘293’))
goto ERR2_AWGT_LB
elseif AHGT_FLG = ‘1’ and AWGT_FLG = ‘1’
goto SLEEP
else
calculate the BMI (Body Mass Index) - See BMI spec page
<R,D> goto SLEEP
<M> goto AWGT_KG
Edit Name ERR1_AWGT_LB;
ERR2_AWGT_LB
quHardedits ERR1_AWGT_LB
* Weight is out of range (50-500).
* Please correct.
quSoftedits ERR2_AWGT_LB
* Please verify that the weight was entered correctly. Probe only if necessary.
Tuesday, June 19, 2012 Page 35 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable AWGT_KG
Question ID AHB.200_02
Universe HHSTAT4 = 'S' and AGE GE 18 and AWGT_LB = M
Universe-text Sample adults 18+ who choose to give their weight in metric measurements
Question Text How much do you weigh without shoes?
* Enter weight in kilograms
Answer Codes <23-226>
Refused
Don't know
Question Type Integer
Part C
Field Pane Current weight
Fill Instructions
Special Instructions "kilograms" to the right.
If ERR2_AWGT_KG is displayed, set AWGT_FLG = ‘1’
If ERR2_AWGT_KG is closed or you goto another screen from it, leave
AWGT_FLG = ‘1’
If ERR2_AWGT_KG is suppressed, reset AWGT_FLG = ‘2’
Skip Instructions <23-226> if AWGT_KG lt ‘23’ or AWGT_KG gt ‘226’
goto ERR1_AWGT_KG
elseif ((SEX = ‘1’ and (AWGT_KG lt ’51’ or AWGT_KG gt ‘143’)) or
((SEX = ‘2’ and (AWGT_KG lt ’43’ or AWGT_KG gt ‘133’))
goto ERR2_AWGT_KG
elseif AHGT_FLG = ‘1’ and AWGT_FLG = ‘1’
goto SLEEP
else
calculate the BMI (Body Mass Index) - See BMI spec page
<R,D> goto SLEEP
Edit Name ERR1_AWGT_KG;
ERR2_AWGT_KG
quHardedits ERR1_AWGT_KG
*Weight is out of range (23-226).
* Please correct.
quSoftedits ERR2_AWGT_KG
* Please verify that the weight was entered correctly. Probe only if necessary.
Tuesday, June 19, 2012 Page 36 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable AWGT_FLG
Question ID AHB.200_03
Universe
Universe-text
Question Text **OUT VARIABLE**
Answer Codes blank,1,2
Question Type Instrument Out Variable
Part C
Field Pane
Fill Instructions
Special Instructions If ERR2_AWGT_LB or ERR2_AWGT_KG is displayed, set AWGT_FLG = ‘1’
If ERR2_AWGT_LB or ERR2_AWGT_KG is closed or you goto another screen
from it, leave AWGT_FLG = ‘1’
If ERR2_AWGT_LB or ERR2_AWGT_KG is suppressed, reset AWGT_FLG = ‘2’
Skip Instructions
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 37 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable AKG
Question ID AHB.200_04
Universe
Universe-text
Question Text **OUT VARIABLE**
Answer Codes
Question Type Instrument Out Variable
Part C
Field Pane
Fill Instructions
Special Instructions Create variable AKG as follows:
If AWGT_LB ne ‘M’, ‘Refused’, ‘Don’t know’, or ‘empty’
set AKG = AWGT_LB/2.20462
elseif AWGT_KG ne ‘Refused’, ‘Don’t know’, or ‘empty’
set AKG = AWGT_KG
Skip Instructions
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 38 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable ABMI
Question ID AHB.200_05
Universe
Universe-text
Question Text **OUT VARIABLE**
Answer Codes
Question Type Instrument Out Variable
Part C
Field Pane
Fill Instructions
Special Instructions Create variable ABMI as follows: (AKG/(AMETERS * AMETERS)) = ABMI
If ERR_ABMI is displayed, set ABMI_FLG = ‘1’
f ERR_ABMI is closed or you goto another screen from it, leave ABMI_FLG = ‘1’
Skip Instructions if (SEX = ‘1’ and (ABMI lt ‘18’ or ABMI gt ‘44’)) or
(SEX = ‘2’ and (ABMI lt ‘17’ or ABMI gt ‘49’))
goto ERR_ABMI
else
goto SLEEP
Edit Name ERR_ABMI
quHardedits
quSoftedits ERR_ABMI
* Please verify that the entries for height and weight were entered correctly.
Probe only if necessary.
Tuesday, June 19, 2012 Page 39 of 40
Section Name Adult Health Behavior
Module 18
Instrument Variable ABMI_FLG
Question ID AHB.200_06
Universe
Universe-text
Question Text **OUT VARIABLE**
Answer Codes blank,1,2
Question Type Instrument Out Variable
Part C
Field Pane
Fill Instructions
Special Instructions If ERR_ABMI is displayed, set ABMI_FLG = ‘1’
If ERR_ABMI is closed or you goto another screen from it, leave ABMI_FLG = ‘1’
Skip Instructions
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 40 of 40
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AUSUALPL
Question ID AAU.020
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
The next questions are about health care.
Is there a place that you USUALLY go to when you are sick or need advice
about your health?
Answer Codes 1. Yes
2. There is NO place
3. There is MORE THAN ONE place
Refused
Don't Know
Question Type Pick One - answer list pane
Part
Field Pane Usually go when sick
Fill Instructions
Special Instructions Answer on the right.
Skip Instructions <1,3> [go to APLKIND]
<2,R,D> [go to AHCPLKND]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 1 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable APLKIND
Question ID AAU.030
Universe HHSTAT4 = 'S' and AGE GE 18 and AUSUALPL =1,3
Universe-text Sample adults 18+ with 1+ usual place(s) to go when sick/need health advice
Question Text ? [F1]
[Fill1: What kind of place is it - a clinic, doctor's office, emergency room, or some
other place?
[Fill2: What kind of place do you go to most often - a clinic, doctor's office,
emergency room, or some other place?]
Answer Codes 1. Clinic or health center
2. Doctor's office or HMO
3. Hospital emergency room
4. Hospital outpatient department
5. Some other place
6. Doesn’t go to one place most often
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Go to most often
Fill Instructions Fill 1 = [If AUSUALPL (AAU.020) = 1]
Fill2 = [If AUSUALPL (AAU.020) = 3 ]
Special Instructions
Skip Instructions <1 - 5> [go to AHCPLROU]
<6,R,D> [go to AHCPLKND]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 2 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCPLROU
Question ID AAU.035
Universe HHSTAT4 = 'S' and AGE GE 18 and APLKIND =1-5
Universe-text Sample adults 18+ with 1+ usual place(s) to go when sick/need health advice
who reported place goes most often as a clinic or health center, doctor's office or
HMO, hospital emergency room, hospital outpatient department, or some other
Question Text ? [F1]
Is that {fill: place from (APLKIND)} the same place you USUALLY go when you
need routine or preventive care, such as a physical examination or check up?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part
Field Pane Routine/prev. care place
Fill Instructions
Special Instructions
Skip Instructions <1> [goto AHCCHGYR]
<2,R,D> [go to AHCPLKND]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 3 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCPLKND
Question ID AAU.037
Universe HHSTAT4 = 'S' and AGE GE 18, and [AUSUALPL = 2,D,R or
APLKIND = 6,D,R or AHCPLROU= 2,D,R]
Universe-text Sample Adults 18+ who do not have a usual source of sick care; who Ref/DK if
have a usual source of sick care; who have a usual source of sick care but do not
go to one place most often or Ref/DK what kind of place; who have a usual
source of sick care, but it is not same place as usual source of routine/preventive
care; who have a usual source of sick care but Ref/DK if it is same place as usual
source of routine/preventive care.
Question Text What kind of place do you USUALLY go to when you need routine or preventive
care, such as a physical examination or check-up?
Answer Codes 0. Doesn't get preventive care anywhere
1. Clinic or health center
2. Doctor's office or HMO
3. Hospital emergency room
4. Hospital outpatient department
5. Some other place
6. Doesn't go to one place most often
Refused
Don't Know
Question Type Pick One - answer list pane
Part
Field Pane Usually go for routine/prev. care
Fill Instructions
Special Instructions
Skip Instructions <0-6,R,D>
if AUSUALPL = 2 [goto ANOUSLPL];
else if AUSUALPL=R,D [goto APRVTRYR]
ELSE goto AHCCHGYR
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 4 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCCHGYR
Question ID AAU.040
Universe HHSTAT4=S and AGE GE 18 and [ (AUSUALPL = 1,3) OR AHCPLROU = 1 ]
Universe-text Sample adults 18+ with 1+ usual place(s) to go when sick/need health advice
[or who reported same place as usual source of routine/preventive care]
Question Text ? [F1]
At any time in the PAST 12 MONTHS did you CHANGE the place(s) to which
you USUALLY go for health care?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part
Field Pane Changed health care place
Fill Instructions
Special Instructions
Skip Instructions <1>[goto AHCCHGHI]
<2,R,D>[goto APRVTRYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 5 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCCHGHI
Question ID AAU.050
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCCHGYR = 1
Universe-text Sample adults 18+ with 1+ usual place(s) to go when sick/need health advice
who CHANGED their USUAL place for health care in past 12 months
Question Text Was this change for a reason related to health insurance?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part
Field Pane Change due to health ins.
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto APRVTRYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 6 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable ANOUSLPL
Question ID AAU.050_00.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and
AUSUALPL(e)='2'
Universe-text Sample adults 18+ without a usual place of care
Question Text Why don’t you have a usual source of medical care?
*Enter all that apply, separate with commas.
Answer Codes 1. Doesn’t need a doctor/Haven't had any problems
2. Doesn’t like/trust/believe in doctors
3. Doesn’t know where to go
4. Previous doctor is not available/moved
5. Too expensive/no insurance/cost
6. Speak a different language
7. No care available/Care too far away, not convenient
8. Put it off/Didn't get around to it
9.Other
Refused
Don't know
Question Type Enter all that apply
Part
Field Pane No usual source
Fill Instructions
Special Instructions
Skip Instructions <1-9,R,D>[goto APRVTRYR ]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 7 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable APRVTRYR
Question ID AAU.051_00.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text DURING THE PAST 12 MONTHS, did you have any trouble finding a general
doctor or provider who would see you?
Answer Codes 1 Yes
2 No
Refused
Don’t know
Question Type Yes/No
Part
Field Pane Trouble finding doctor
Fill Instructions
Special Instructions
Skip Instructions <1,>[goto APRVTRFD ]
<2,R,D>[goto ADRNANP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 8 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable APRVTRFD
Question ID AAU.053_00.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and
APRVTRYR(e)='1'
Universe-text Sample adults 18+ who had trouble finding a provider
Question Text Were you able to find a general doctor or provider who could see you?
Answer Codes 1 Yes
2 No
Refused
Don’t know
Question Type Yes/No
Part
Field Pane Able to find a doctor
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto ADRNANP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 9 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable ADRNANP
Question ID AAU.057_00.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that
they would not accept you as a new patient?
Answer Codes 1. Yes
2. No
Refused
Don’t know
Question Type Yes/No
Part
Field Pane Not accept as patient
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto ADRNAI]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 10 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable ADRNAI
Question ID AAU.059_00.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that
they did not accept your health care coverage?
Answer Codes 1. Yes
2. No
Refused
Don’t know
Question Type Yes/No
Part
Field Pane Not accept coverage
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto AHCDLY_1]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 11 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCDLY_1
Question ID AAU.061_1
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
There are many reasons people delay getting medical care.
Have you delayed getting care for any of the following reasons in the PAST 12
MONTHS?
...You couldn't get through on the telephone.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part
Field Pane Couldn't get through on phone
Fill Instructions
Special Instructions "Past 12 months" as a header for this question as well as AAU061_2 -
Skip Instructions <1,2,R,D>[goto AHCDLY_2]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 12 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCDLY_2
Question ID AAU.061_2
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
* Read if Necessary.
There are many reasons people delay getting medical care. Have you delayed
getting care for any of the following reasons in the PAST 12 MONTHS?
...You couldn't get an appointment soon enough.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part
Field Pane No appt. soon enough
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto AHCDLY_3]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 13 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCDLY_3
Question ID AAU.061_3
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
* Read if Necessary.
There are many reasons people delay getting medical care. Have you delayed
getting care for any of the following reasons in the PAST 12 MONTHS?
...Once you get there, you have to wait too long to see the doctor.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part
Field Pane Wait too long to see Dr.
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto AHCDLY_4]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 14 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCDLY_4
Question ID AAU.061_4
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
* Read if Necessary.
There are many reasons people delay getting medical care. Have you delayed
getting care for any of the following reasons in the PAST 12 MONTHS?
...The (clinic/doctor's) office wasn't open when you could get there.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part
Field Pane Clinic/office not open
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto AHCDLY_5]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 15 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCDLY_5
Question ID AAU.061_5
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
* Read if Necessary.
There are many reasons people delay getting medical care. Have you delayed
getting care for any of the following reasons in the PAST 12 MONTHS?
...You didn't have transportation.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part
Field Pane No transportation
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto AHCAFY_1]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 16 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCAFY_1
Question ID AAU.111_1
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
DURING THE PAST 12 MONTHS, was there any time when you needed any of
the following, but didn't get it because you couldn't afford it?
...Prescription medicines.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part
Field Pane Prescription medicines
Fill Instructions
Special Instructions "Past 12 mo. (needed but can't aford)" as a header for this question as well as
AAU.111_2 - AAU.111_4.
Indent all related Field Pane Descriptions under the heading.
Skip Instructions <1,2,R,D>[goto AHCAFY_2]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 17 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCAFY_2
Question ID AAU.111_2
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
* Read if Necessary.
DURING THE PAST 12 MONTHS, was there any time when you needed any of
the following, but didn't get it because you couldn't afford it?
...Mental health care or counseling.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part
Field Pane Mental health care/counselling
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto AHCAFY_3]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 18 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCAFY_3
Question ID AAU.111_3
Universe HHSTAT4 = 'S'and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
* Read if Necessary.
DURING THE PAST 12 MONTHS, was there any time when you needed any of
the following, but didn't get it because you couldn't afford it?
...Dental care (including check ups).
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part
Field Pane Dental care
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto AHCAFY_4]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 19 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCAFY_4
Question ID AAU.111_4
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
* Read if Necessary.
DURING THE PAST 12 MONTHS, was there any time when you needed any of
the following, but didn't get it because you couldn't afford it?
...Eyeglasses.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part
Field Pane Eyeglasses
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto AHCAFY_5]]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 20 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AHCAFY_5
Question ID AAU.111_5.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text *Read if necessary..
DURING THE PAST 12 MONTHS, was there any time when you needed any of
the following, but didn't get it because you couldn't afford it?
...To see a specialist.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto AHCAFY_6]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 21 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AHCAFY_6
Question ID AAU.111_6.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text *Read if necessary..
DURING THE PAST 12 MONTHS, was there any time when you needed any of
the following, but didn't get it because you couldn't afford it?
...Follow-up care.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto AWORPAY]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 22 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AWORPAY
Question ID AAU.113_00.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text If you get sick or have an accident, how worried are you that you will be able to
pay your medical bills? Are you very worried, somewhat worried, or not at all
Answer Codes 1. Very worried
2. Somewhat worried
3. Not at all worried
Refused
Don’t know
Question Type Pick One - answer list pane
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1-3,R,D>[goto AHICOMP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 23 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AHICOMP
Question ID AAU.113_00.020
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text In regard to your health insurance or health care coverage, how does it compare
to a year ago? Is it better, worse, or about the same?
Answer Codes 1. Better
2. Worse
3. About the same
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,3,R,D>[goto ARXPR_1]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 24 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable ARXPR_1
Question ID AAU.127_01.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text The following questions concern the use of prescription medication DURING
THE PAST 12 MONTHS, are any of the following true for you?
…You skipped medication doses to save money
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto ARXPR_2]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 25 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable ARXPR_2
Question ID AAU.127_02.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text *Read if necessary..
The following questions concern the use of prescription medication DURING
THE PAST 12 MONTHS, are any of the following true for you?
…you took less medicine to save money
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto ARXPR_3]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 26 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable ARXPR_3
Question ID AAU.127_03.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text *Read if necessary.
The following questions concern the use of prescription medication DURING
THE PAST 12 MONTHS, are any of the following true for you?
…You delayed filling a prescription to save money
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto ARXPR_4]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 27 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable ARXPR_4
Question ID AAU.127_04.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text *Read if necessary..
The following questions concern the use of prescription medication DURING
THE PAST 12 MONTHS, are any of the following true for you?
…You asked your doctor for a lower cost medication to save money.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto ARXPR_5]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 28 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable ARXPR_5
Question ID AAU.127_05.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text *Read if necessary..
The following questions concern the use of prescription medication DURING
THE PAST 12 MONTHS, are any of the following true for you?
…You bought prescription drugs from another country to save money.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto ARXPR_6]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 29 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable ARXPR_6
Question ID AAU.127_06.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text *Read if necessary..
The following questions concern the use of prescription medication DURING
THE PAST 12 MONTHS, are any of the following true for you?
…You used alternative therapies to save money.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[goto ADENLONG]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 30 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable ADENLONG
Question ID AAU.135
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A8
About how long has it been since you last saw a dentist? Include all types of
dentists, such as orthodontists, oral surgeons, and all other dental specialists, as
well as dental hygienists.
Answer Codes 0. Never
1. 6 months or less
2. More than 6 months, but not more than 1 year ago
3. More than 1 year, but not more than 2 years ago
4. More than 2 years, but not more than 5 years ago
5. More than 5 years ago
Refused
Don't Know
Question Type Pick One - answer list pane
Part
Field Pane Last saw dentist
Fill Instructions
Special Instructions Answer on the right.
Skip Instructions <0-5,R,D>[ goto AHCSY1_1]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 31 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCSY1_1
Question ID AAU.141_1
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text DURING THE PAST 12 MONTHS have you seen or talked to any of the
following health care providers about your own health?
...A mental health professional such as a psychiatrist, psychologist, psychiatric
nurse, or clinical social worker.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part C
Field Pane Mental heallth professional
Fill Instructions
Special Instructions "Past 12 mo. (seen/talked to)" as a header for this question as well as
AAU.141_2 - AAU.230.
Indent all related Field Pane Descriptions under the heading.
Skip Instructions <1,2,R,D>[ goto AHCSY1_2]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 32 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCSY1_2
Question ID AAU.141_2
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if Necessary.
DURING THE PAST 12 MONTHS have you seen or talked to any of the
following health care providers about your own health?
...An optometrist, ophthalmologist (AHF-thal-MOL-oh-jist), or eye doctor
(someone who prescribes eyeglasses).
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part C
Field Pane Eye doctor
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[ goto AHCSY1_3]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 33 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCSY1_3
Question ID AAU.141_3
Universe HHSTAT4 = 'S'and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if Necessary.
DURING THE PAST 12 MONTHS have you seen or talked to any of the
following health care providers about your own health?
...A foot doctor.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part C
Field Pane Foot doctor
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[ goto AHCSY1_4]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 34 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCSY1_4
Question ID AAU.141_4
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if Necessary.
DURING THE PAST 12 MONTHS have you seen or talked to any of the
following health care providers about your own health?
...A chiropractor.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part C
Field Pane Chiropractor
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[ goto AHCSY1_5]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 35 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCSY1_5
Question ID AAU.141_5
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1}
* Read if Necessary.
DURING THE PAST 12 MONTHS have you seen or talked to any of the
following health care providers about your own health?
...A physical therapist, speech therapist, respiratory therapist, audiologist, or
occupational therapist.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part C
Field Pane Physical/speech/resp. therapist
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D>[ goto AHCSY1_6]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 36 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCSY1_6
Question ID AAU.141_6
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1}
* Read if Necessary.
DURING THE PAST 12 MONTHS have you seen or talked to any of the
following health care providers about your own health?
{Fill1: ...A nurse practitioner, physician assistant, or midwife.
Or Filll2: ...A nurse practitioner or physician assistant.}
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part C
Field Pane Nurse prac./phys. asst./midwife
Fill Instructions fill1: If SEX=2 Fill1: ...A nurse practitioner, physician assistant, or midwife”
Else if SEX=1 Fill2: ...A nurse practitioner or physician assistant.
Special Instructions
Skip Instructions <1,2,R,D>[if SEX=1goto AHCSY8_8;
else if SEX=2 goto AHCSYR7]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 37 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCSYR7
Question ID AAU.200
Universe HHSTAT4 = 'S' and AGE GE 18 and SEX = 2
Universe-text Sample adults 18+ who are female
Question Text ? [F1}
* Read if Necessary.
DURING THE PAST 12 MONTHS have you seen or talked to any of the
following health care providers about your own health?
...A doctor who specializes in women's health (an obstetrician/gynecologist).
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part C
Field Pane OB/GYN
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [go to AHCSY8_ 8]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 38 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCSY8_8
Question ID AAU.211_1
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if Necessary.
DURING THE PAST 12 MONTHS have you seen or talked to any of the
following health care providers about your own health?
...A medical doctor who specializes in a particular medical disease or problem
(other than obstetrician/gynecologist, psychiatrist, or ophthalmologist (AHF-thal-
MOL-oh-jist)).
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part C
Field Pane Specialist doctor
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [go to AHCSY8_ 9]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 39 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCSY8_ 9
Question ID AAU.211_2
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text * Read if Necessary.
DURING THE PAST 12 MONTHS have you seen or talked to any of the
following health care providers about your own health?
...A general doctor who treats a variety of illnesses (a doctor in general practice,
family medicine, or internal medicine)?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part C
Field Pane General doctor
Fill Instructions
Special Instructions
Skip Instructions <1> [goto AHCSYR10]
<2,R,D> [goto AHERNOYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 40 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCSYR10
Question ID AAU.230
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCSY8_9=1
Universe-text Sample adults 18+ who have seen or talked to a general doctor during the past
12 months
Question Text Does that doctor treat children and adults (a doctor in general practice or family
medicine)?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part C
Field Pane Doctor treats children and adults
Fill Instructions
Special Instructions Indent to indicate that this is a follow on from the previous question.
Skip Instructions <1,2,R,D> [go to AHERNOYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 41 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHERNOYR
Question ID AAU.240
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A9 ? [F1]
DURING THE PAST 12 MONTHS, HOW MANY TIMES have you gone to a
HOSPITAL EMERGENCY ROOM about your own health (This includes
emergency room visits that resulted in a hospital admission.)?
Answer Codes 0. None
1. 1
2. 2-3
3. 4-5
4. 6-7
5. 8-9
6. 10-12
7. 13-15
8. 16 or more
Refused
Don't Know
Question Type Pick One - answer list pane
Part C
Field Pane Number of times in ER
Fill Instructions
Special Instructions "Past 12 months as a header for this question as well as AAU.250 - AAU.280.
Indent all related Field Pane Descriptions under the heading.
Skip Instructions <0,R,D> [go to AHCHYR]
<1-8> [goto AERVISND]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 42 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AERVISND
Question ID AAU.243_00.010
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and ('01'
<=AHERNOYR<='08')
Universe-text Sample adults 18+ who had at least one ER visit in the past year
Question Text Thinking about your most recent emergency room visit, did you go to the
emergency room either at night or on the weekend?
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [go to AERHOS]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 43 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AERHOS
Question ID AAU.245_00.010
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and ('01'
<=AHERNOYR<='08')
Universe-text Sample adults 18+ who had at least one ER visit in the past year
Question Text Did this emergency room visit result in a hospital admission?
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,R,D> [goto AHCHYR]
< 2> [go to AERREAS1]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 44 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AERREAS1
Question ID AAU.248_01.010
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and AERHOS
(e)='2'
Universe-text Sample adults 18+ who had at least one ER visit in the past year and the last
visit did not result in a hospital admission
Question Text Tell me which of these apply to your last emergency room visit?
… You didn't have another place to go
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto AERREAS2]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 45 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AERREAS2
Question ID AAU.248_02.020
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and AERHOS
(e)='2'
Universe-text Sample adults 18+ who had at least one ER visit in the past year and the last
visit did not result in a hospital admission
Question Text *Read if necessary..
Tell me which of these apply to your last emergency room visit?
… Your doctor’s office or clinic was not open
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto AERREAS3]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 46 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AERREAS3
Question ID AAU.248_03.030
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and AERHOS
(e)='2'
Universe-text Sample adults 18+ who had at least one ER visit in the past year and the last
visit did not result in a hospital admission
Question Text *Read if necessary..
Tell me which of these apply to your last emergency room visit?
… Your health provider advised you to go
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto AERREAS4]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 47 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AERREAS4
Question ID AAU.248_04.040
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and AERHOS
(e)='2'
Universe-text Sample adults 18+ who had at least one ER visit in the past year and the last
visit did not result in a hospital admission
Question Text *Read if necessary..
Tell me which of these apply to your last emergency room visit?
… The problem was too serious for the doctor’s office or clinic
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto AERREAS5]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 48 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AERREAS5
Question ID AAU.248_05.050
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and AERHOS
(e)='2'
Universe-text Sample adults 18+ who had at least one ER visit in the past year and the last
visit did not result in a hospital admission
Question Text *Read if necessary..
Tell me which of these apply to your last emergency room visit?
… Only a hospital could help you
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto AERREAS6]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 49 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AERREAS6
Question ID AAU.248_06.060
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and AERHOS
(e)='2'
Universe-text Sample adults 18+ who had at least one ER visit in the past year and the last
visit did not result in a hospital admission
Question Text *Read if necessary..
Tell me which of these apply to your last emergency room visit?
… the emergency room is your closest provider
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto AERREAS7]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 50 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AERREAS7
Question ID AAU.248_07.070
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and AERHOS
(e)='2'
Universe-text Sample adults 18+ who had at least one ER visit in the past year and the last
visit did not result in a hospital admission
Question Text *Read if necessary..
Tell me which of these apply to your last emergency room visit?
…you get most of your care at the emergency room
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto AERREAS8]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 51 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AERREAS8
Question ID AAU.248_08.080
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and AERHOS
(e)='2'
Universe-text Sample adults 18+ who had at least one ER visit in the past year and the last
visit did not result in a hospital admission
Question Text *Read if necessary..
Tell me which of these apply to your last emergency room visit?
…you arrived by ambulance or other emergency vehicle
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto AHCHYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 52 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCHYR
Question ID AAU.250
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text ? [F1]
DURING THE PAST 12 MONTHS, did you receive care AT HOME from a nurse
or other health care professional?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part C
Field Pane Home care - nurse/hlth. prof.
Fill Instructions
Special Instructions
Skip Instructions <1>[goto AHCHMOYR]
<2,R,D>[goto AHCNOYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 53 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCHMOYR
Question ID AAU.260
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCHYR = 1
Universe-text Sample adults 18+ who received home care from a health professional during
the past 12 months
Question Text ? [F1]
During how many of the PAST 12 MONTHS did you receive care AT HOME
from a health care professional?
Answer Codes
Question Type Integer
Part C
Field Pane Number of months
Fill Instructions
Special Instructions Indent to indicate that this is a follow up from the previous question.
Skip Instructions <1-12,R,D>[goto AHCHNOYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 54 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCHNOYR
Question ID AAU.270
Universe HHSTAT4 = 'S' and AGE GE 18 and AHCHYR = 1
Universe-text Sample adults 18+ who received home care from a health professional during
the past 12 months
Question Text (book) A10
What was the total number of home visits received during {Fill1: that
month/Fill2: those months}?
Answer Codes 1. 1
2. 2-3
3. 4-5
4. 6-7
5. 8-9
6. 10-12
7. 13-15
8. 16 or more
Refused
Don't Know
Question Type Pick One - answer list pane
Part C
Field Pane Number of visits
Fill Instructions Fill1: if [AHCHMOYR = 1]
Fill2: if [AHCHMOYR NE 1]
Special Instructions Indent to indicate that this is a follow up from AAU.270.
Skip Instructions <1-8,R,D>[goto AHCNOYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 55 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHCNOYR
Question ID AAU.280
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A9 ? [F1]
DURING THE PAST 12 MONTHS, HOW MANY TIMES have you seen a doctor
or other health care professional about your own health at a DOCTOR’S
OFFICE, A CLINIC, OR SOME OTHER PLACE? Do not include times you were
hospitalized overnight, visits to hospital emergency rooms, home visits, dental
visits, or telephone calls.
Answer Codes 0. None
1. 1
2. 2-3
3. 4-5
4. 6-7
5. 8-9
6. 10-12
7. 13-15
8. 16 or more
Refused
Don't Know
Question Type Pick One - answer list pane
Part C
Field Pane Number of office visits
Fill Instructions
Special Instructions
Skip Instructions <0-8,R,D>[goto ASRGYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 56 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable ASRGYR
Question ID AAU.290
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text DURING THE PAST 12 MONTHS, have you had SURGERY or other surgical
procedures either as an inpatient or outpatient?
* Read if necessary: This includes both major surgery and minor procedures such
as setting bones or removing growths.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part C
Field Pane Surgery/surgical procedures
Fill Instructions
Special Instructions "Past 12 months as a header for this question as well as AAU.300 and AAU.305.
Skip Instructions <1>[goto ASRGNOYR]
<2,R,D> [goto AMDLONG].
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 57 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable ASRGNOYR
Question ID AAU.300
Universe HHSTAT4 = 'S' and AGE GE 18 and ASRGYR = 1
Universe-text Sample adults 18+ who had surgery or surgical procedures during past 12 months
Question Text Including any times you may have already told me about, HOW MANY
DIFFERENT TIMES have you had surgery during the PAST 12 MONTHS?
* Enter "95" for 95 or more times.
Answer Codes
Question Type Integer
Part C
Field Pane Number of surgeries
Fill Instructions
Special Instructions Indent to indicate that this is a follow up to the previous question.
Skip Instructions <1-95,R,D> [goto AMDLONG].
<11-95>[goto ERR_ASGYR]
Edit Name ERR_ASGYR
quHardedits
quSoftedits * {ASRGYR} is an unusually large number.
* Please verify.
Tuesday, June 19, 2012 Page 58 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AMDLONG
Question ID AAU.305
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text (book) A8 ? [F1]
About how long has it been since you last saw or talked to a doctor or other
health care professional about your own health? Include doctors seen while a
patient in a hospital.
Answer Codes 0. Never
1. 6 months or less
2. More than 6 months but not more than 1 year ago
3. More than 1 year, but not more than 2 years ago
4. More than 2 years, but not more than 5 years ago
5. More than 5 years ago
Refused
Don't Know
Question Type Pick One - answer list pane
Part C
Field Pane Last saw/talked with doctor/hlth. prof.
Fill Instructions
Special Instructions Answer name on the right.
Skip Instructions <0,R,D> [goto HIT1A]
<1-5> [goto AVISLAST]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 59 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AVISLAST
Question ID AAU.306_00.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and
AMDLONGR(e) IN('1','2','3','4','5')
Universe-text Sample adults 18+ who have ever seen/talked to a doctor
Question Text Thinking about your last visit for any type of medical care, where did you go?
*Read categories if necessary.
Answer Codes 1. Clinic or health center
2. Doctor's office or HMO
3. Hospital emergency room
4. Hospital outpatient department
5. Urgent care center
6. Some other place
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,4,6> [goto ALASTTYP]
<3,5> [goto AWAITRMN]
<R,D> [goto HIT1A]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 60 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable ALASTTYP
Question ID AAU.306_00.020
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and
AVISLAST(e) IN('1','2','4','6')
Universe-text Sample adults 18+ who visited a clinic, doctor’s office/HMO, hospital outpatient
department or someplace else (not ER or urgent care center) on their last visit
Question Text Did you see a general doctor, a specialist, or someone else?
Answer Codes 1. General doctor
2. Specialist
3. Someone else
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1-3,R,D> [goto AVISAPTN]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 61 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AVISAPTN
Question ID AAU.307_01.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and
AVISLAST(e) IN('1','2','4','6')
Universe-text Sample adults 18+ who visited a clinic, doctor’s office/HMO, hospital outpatient
department or someplace else (not ER or urgent care center) on their last visit
Question Text 1 of 2
For this visit, how long did you have to wait between the time you made the
appointment and the day you actually saw the doctor or other health
professional?
*Enter ‘0’ for same day , walk-in appointment , or no appointment made.
Answer Codes
Question Type Integer
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <0,R> [goto AWAITRMN]
<1-96,D> [goto AVISAPTT]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 62 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AVISAPTT
Question ID AAU.307_02.020
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and ('01'<=
AVISAPTN(e)<='96','99')
Universe-text Sample adults 18+ who visited a clinic, doctor’s office/HMO, hospital outpatient
department or someplace else and gave a number or answered DK for length of
time to make an appointment
Question Text 2 of 2
*Enter time period for appointment wait time.
Answer Codes 1. Days
2. Weeks
3. Months
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1-3,R,D> [goto AWAITRMN]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 63 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AWAITRMN
Question ID AAU.308_01.010
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and
AVISLAST(e) IN('1','2','3','4','5','6')
Universe-text Sample adults 18+ who had a place of last medical visit
Question Text 1 of 2
How long did you have to wait in the waiting room before you saw a doctor or
other health professional for this visit?
*Enter ‘0’ for no wait time.
*Enter number for time in waiting room.
Answer Codes
Question Type Integer
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <0,R> [goto HIT1A]
<1-96,D> [goto AWAITRMT]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 64 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AWAITRMT
Question ID AAU.308_02.020
Universe HHSTAT4='S' and (AGE GE '018' and AGE not IN ('997','999')) and ('01'<=
AWAITRMN(e)<='96','99')
Universe-text Sample adults 18+ who had a place of last medical visit and did not refuse
number portion of waiting room time
Question Text 2 of 2
*Enter time period for time in waiting room.
Answer Codes 1. Minutes
2. Hours
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane
Fill Instructions
Special Instructions If AWAITRMN gt 8 and AWAITRMT=2 (more than 8 hours), please have soft edit
"Verify wait time was longer than 8 hours"
Skip Instructions <1,2,R,D> [goto HIT1A]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 65 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable HIT1A
Question ID AAU.309_00.010
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text DURING THE PAST 12 MONTHS, have you ever used computers for any of the
following
…Look up health information on the Internet.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto HIT2A]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 66 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable HIT2A
Question ID AAU.309_00.020
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text *Read if necessary..
DURING THE PAST 12 MONTHS, have you ever used computers for any of the
following
…Fill a prescription.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto HIT3A]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 67 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable HIT3A
Question ID AAU.309_00.030
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text *Read if necessary..
DURING THE PAST 12 MONTHS, have you ever used computers for any of the
following
…Schedule an appointment with a health care provider.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto HIT4A]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 68 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable HIT4A
Question ID AAU.309_00.040
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text *Read if necessary..
DURING THE PAST 12 MONTHS, have you ever used computers for any of the
following
…Communicate with a health care provider by email.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto HIT5A]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 69 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable HIT5A
Question ID AAU.309_00.050
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text *Read if necessary..
DURING THE PAST 12 MONTHS, have you ever used computers for any of the
following
…Use online chat groups to learn about health topics.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto SHTFLUYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 70 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SHTFLUYR
Question ID AAU.310
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text During the past 12 months, several kinds of flu vaccines have been available. I
will ask you about your most recent flu vaccination.
DURING THE PAST 12 MONTHS, have you had a flu shot? A flu shot is usually
given in the fall and protects against influenza for the flu season.
* Read if necessary: A flu shot is injected in the arm. Do not include an
influenza vaccine sprayed in the nose.
*Read if necessary: Your most recent flu vaccination could have been the new
2010-2011 flu vaccine available starting last fall, or either of the two types
available last season, one called “seasonal” and the other called “H1N1” or
“swine” flu vaccine.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part D
Field Pane Flu shot - past 12 mo.
Fill Instructions
Special Instructions
Skip Instructions <1> [goto ASHFLU_M]
<2,R,D> [ goto SPRFLUYR ]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 71 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable ASHFLU_M
Question ID AAU.312_1
Universe HHSTAT4 = 'S' and AGE GE 18 and SHTFLUYR=1
Universe-text Sample adults 18+ who have had a flu shot
Question Text 1 of 2
During what month and year did you receive your most recent flu shot?
Answer Codes 1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
Refused
Don't Know
Question Type Pick One - answer list pane
Part D
Field Pane Flu shot-month
Fill Instructions
Special Instructions
Skip Instructions <1-12,D> [ goto ASHFLU_Y] <R> [goto SPRFLUYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 72 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable ASHFLU_Y
Question ID AAU.312_2
Universe HHSTAT4 = 'S' and AGE GE 18 and ASHFLU_M=1-12,D
Universe-text Sample adults 18+ who gave a month for their last flu shot or who didn’t know
the month
Question Text 2 of 2
*Enter year of most recent flu shot.
Answer Codes
Question Type Integer
Part D
Field Pane Flu shot-year
Fill Instructions
Special Instructions
Skip Instructions <valid year,R,D> [goto SPRFLUYR]
[If ASHFLU_M and ASHFLU_Y = a future date [goto ERR1_ASHFLU_Y]
[If ASHFLU_M and ASHFLU_Y = a date prior to birth [goto ERR2_ASHFLU_Y ]
[If ASHFLU_M and ASHFLU_Y = a date before 12 months ago [goto
ERR3_ASHFLU_Y ]
*/ OLD INSTRUCTIONS BEFORE 10/25/04
<1880-2030,R,D> [goto SPRFLUYR]
[If ASHFLU_M and ASHFLU_Y = a future date] goto ERR1_ASHFLU_Y
[If ASHFLU_M and ASHFLU_Y = a date prior to birth] goto ERR2_ASHFLU_Y
Edit Name ERR1_ASHFLU_Y;
ERR2_ASHFLU_Y;
quHardedits ERR1_ASHFLU_Y
*Future date invalid
ERR2_ASHFLU_Y
*Date before birth
ERR3_ASHFLU_Y
*Date more than 12 months ago
quSoftedits
Tuesday, June 19, 2012 Page 73 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SPRFLUYR
Question ID AAU.315
Universe HHSTAT4 = 'S' and Sample adults 18+
Universe-text Sample adults 18+
Question Text DURING THE PAST 12 MONTHS, have you had a flu vaccine sprayed in your
nose by a doctor or other health professional? A health professional may have
let you spray it. This vaccine is usually given in the fall and protects against
influenza for the flu season.
* Read if necessary: This influenza vaccine is called FluMist (trademark).
*Read if necessary: Your most recent flu vaccination could have been the new
2010-2011 flu vaccine available starting last fall, or either of the two types
available last season, one called “seasonal” and the other called “H1N1” or
“swine” flu vaccine.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part D
Field Pane Flu spray - past 12 mo.
Fill Instructions
Special Instructions
Skip Instructions <1> [goto ASPFLU_M]
[if SHTFLUYR =1 and SPRFLUYR=1] goto ERR1_SPRFLUYR
[if AGE GE 50] goto ERR2_SPRFLUYR
<2,D,R> [goto SHTPNUYR]
*/ OLD SPECS- DON'T USE - <1,2,D,R> [ goto SHTPNUYR ] /*
Edit Name ERR1_SPRFLUYR ;
ERR2_SPRFLUYR
quHardedits
quSoftedits ERR1_SPRFLUYR
*Respondent says they have received both a flu shot and flu nasal
vaccine.
*Please verify.
ERR2_SPRFLUYR
*Respondent says they have received a nasal vaccine to PREVENT the flu, not
Tuesday, June 19, 2012 Page 74 of 121
to TREAT symptoms of the flu.
*Please verify.
Section Name Health Care Access and Utilization
Module 19
Instrument Variable ASPFLU_M
Question ID AAU.318_1
Universe HHSTAT4 = 'S' and AGE GE 18 and SPRFLUYR=1
Universe-text Sample adults 18+ who have had a flu nasal vaccine
Question Text 1 of 2
During what month and year did you receive your most recent flu nasal spray?
Answer Codes 1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
Refused
Don't Know
Question Type Pick One - answer list pane
Part D
Field Pane Flu spray - past 12 mo.
Fill Instructions
Special Instructions
Skip Instructions <1-12,D> [ goto ASPFLU_Y]
<R> [goto SHTPNUYR]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 75 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable ASPFLU_Y
Question ID AAU.318_2
Universe HHSTAT4 = 'S' and AGE GE 18 and ASPFLU_M=1-12,D
Universe-text Sample adults 18+ who gave a month for their flu nasal vaccine or who didn’t
know the month
Question Text 2 of 2
*Enter year of most recent flu nasal spray.
Answer Codes
Question Type Integer
Part D
Field Pane Flu spray-year
Fill Instructions
Special Instructions
Skip Instructions <valid year, R, D> [goto SHTPNUYR]
[If ASPFLU_M and ASPFLU_Y = a future date] goto ERR1_ASPFLU_Y
[If ASPFLU_M and ASPFLU_Y = a date prior to birth] goto ERR2_ASPFLU_Y
[If ASPFLU_M and ASPFLU_Y = a date before 12 months ago] goto
ERR3_ASPFLU_Y
*/ OLD INSTRUCTIONS BEFORE 10/25/04
<1880-2030,R,D> [goto SHTPNUYR]
[If ASPFLU_M and ASPFLU_Y = a future date] goto ERR1_ASPFLU_Y
[If ASPFLU_M and ASPFLU_Y = a date prior to birth] goto ERR2_ASPFLU_Y
/*
Edit Name ERR1_ASPFLU_Y;
ERR2_ASPFLU_Y;
quHardedits ERR1_ASPFLU_Y
*Future date invalid
ERR2_ASPFLU_Y
*Date before birth
ERR3_ASPFLU_Y
*Date more than 12 months ago
quSoftedits
Tuesday, June 19, 2012 Page 76 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SHTPNUYR
Question ID AAU.320
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Have you EVER had a pneumonia shot?
This shot is usually given only once or twice in a person's lifetime and is
different from the flu shot. It is also called the pneumococcal vaccine.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part D
Field Pane Pneumonia shot - ever
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto APOX]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 77 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable APOX
Question ID AAU.330
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Have you EVER had chickenpox?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part D
Field Pane Chickenpox - ever
Fill Instructions
Special Instructions
Skip Instructions <1> [goto APOX12MO]
<2,R,D> [goto AHEP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 78 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable APOX12MO
Question ID AAU.340
Universe HHSTAT4 = 'S' and AGE GE 18 and APOX=1
Universe-text Sample adults 18+ who have ever had chickenpox
Question Text Have you had chickenpox in the PAST 12 MONTHS?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part D
Field Pane Chickenpox - past 12 mo.
Fill Instructions
Special Instructions Indent to indicate that this is a follow up to the previous question.
Skip Instructions <1,2,R,D> [goto AHEP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 79 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHEP
Question ID AAU.350
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Have you EVER had hepatitis?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part D
Field Pane Hepatitis - ever
Fill Instructions
Special Instructions
Skip Instructions <1> [goto SHTHEPB]
<2,R,D> [goto AHEPLIV]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 80 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable AHEPLIV
Question ID AAU.360
Universe HHSTAT4 = 'S' and AGE GE 18 and AHEP =2,D,R
Universe-text Sample adults 18+ who have never had hepatitis; Ref/DK if ever had hepatitis
Question Text Have you ever lived with someone who had hepatitis?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part D
Field Pane Lived w/ someone w/ hepatitis
Fill Instructions
Special Instructions Indent to indicate that this is a follow up to the previous question.
Skip Instructions <1,2,R,D> [goto SHTHEPB]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 81 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SHTHEPB
Question ID AAU.370
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Have you EVER received the hepatitis B vaccine?
* Read if necessary: This is given in three separate doses and has been
available since 1991. It is recommended for newborn infants, adolescents, and
people such as health care workers, who may be exposed to the hepatitis B virus.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part D
Field Pane Hepatitis B vaccine - ever
Fill Instructions
Special Instructions
Skip Instructions <1> [goto SHEPDOS]
<2,R,D> [goto SHTHEPA]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 82 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SHEPDOS
Question ID AAU.380
Universe HHSTAT4 = 'S' and AGE GE 18 and SHTHEPB = 1
Universe-text Sample adults 18+ who have ever received the Hepatitis B vaccine
Question Text Did you receive at least 3 doses of the hepatitis B vaccine, or less than 3 doses?
Answer Codes 1. Received at least 3 doses
2. Received less than 3 doses
Refused
Don't Know
Question Type Pick One - answer list pane
Part D
Field Pane Hepatitis B vaccine - # of doses
Fill Instructions
Special Instructions Indent to indicate that this is a follow up to the previous question.
Answer name on the right.
Skip Instructions <1,2,R,D> [goto SHTHEPA]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 83 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SHTHEPA
Question ID AAU.390.010
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text The hepatitis A vaccine is given as a two dose series routinely to some children
starting at 1 year of age, and to some adults and people who travel outside the
United States. Although it can be given as a combination vaccine with hepatitis
B, it is different from the hepatitis B shot, and has only been available since
1995. Have you ever received the hepatitis A vaccine?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part D
Field Pane Had Hep A vaccine
Fill Instructions
Special Instructions
Skip Instructions <1> goto SHEPANUM
<2,R,D> if AGE GE 50 goto SHINGLES
else goto SHTTD
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 84 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SHEPANUM
Question ID AAU.400.010
Universe HHSTAT4 = 'S' and AGE GE 18 and SHTHEPA=1
Universe-text Sample adults 18+ who have had a hepatitis A vaccine
Question Text How many hepatitis A shots did you receive?
*Enter '96' if all shots were received
Answer Codes
Question Type Integer
Part D
Field Pane Number of Hep A shots
Fill Instructions
Special Instructions
Skip Instructions <1-95,96,R,D> if AGE GE 50 goto SHINGLES
elseif AGE LT 50 goto SHTTD
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 85 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SHINGLES
Question ID AAU.410.010
Universe HHSTAT4 = 'S' and AGE GE 50
Universe-text Sample adults 50+
Question Text Shingles is an outbreak of a rash or blisters on the skin that may be associated
with severe pain. The pain is generally on one side of the body or face.
Shingles is caused by the chicken pox virus. A vaccine for shingles has been
available since May 2006. Have you ever had the Zoster (ZOSS-ter) or Shingles
vaccine, also called Zostavax®?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part D
Field Pane Had shingles vaccine
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> goto SHTTD
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 86 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SHTTD
Question ID AAU.420.010
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Have you received a tetanus shot in the past 10 years?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part D
Field Pane Had tetanus shot, past 10 years
Fill Instructions
Special Instructions
Skip Instructions <1> goto SHTTD05
<2,R,D> and AGE >64 [goto LIVEV]
Else if <2,R,D> and AGE<65 [goto HPVHRD]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 87 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SHTTD05
Question ID AAU.430.010
Universe HHSTAT4 = 'S' and AGE GE 18 and SHTTD=1
Universe-text Sample adults 18+ who have had a tetanus shot in the past 10 years
Question Text Was your most recent tetanus shot given in 2005 or later?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Part D
Field Pane Tetanus shot in 2005+
Fill Instructions
Special Instructions
Skip Instructions <1,R> if AGE le 64 [goto SHTTDAP]
elseif AGE gt 64 [goto LIVEV]
<2,D> if AGE le 64 goto HPVHRD
elseif AGE gt 64 goto LIVEV
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 88 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SHTTDAP
Question ID AAU.440.010
Universe HHSTAT4 = 'S' and AGE 18-64 and SHTTD05=1,R
Universe-text Sample adults <65 who have had a tetanus shot in 2005 or beyond or refused to
say if they had a tetanus shot in 2005 or beyond
Question Text There are currently two types of tetanus shots available today. One is the Td or
tetanus-diphtheria vaccine and the other is called Tdap or Adacel (trademark).
They are similar except the Tdap shot also includes a pertussis (per-TUH-sis) or
whooping cough vaccine. Thinking back to your most recent tetanus shot, did
the doctor tell you the vaccine included the pertussis or whooping cough
vaccine? The shot is often called Tdap or ADACEL (trademark).
Answer Codes 1. Yes-included pertussis
2. No-did not include pertussis
3. Doctor did not say
Refused
Don't Know
Question Type Pick One - answer list pane
Part D
Field Pane Combo tetanus/pertussis shot
Fill Instructions
Special Instructions
Skip Instructions <1-3,R,D> [goto HPVHRD]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 89 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable HPVHRD
Question ID AAU.442.010
Universe HHSTAT4 = 'S' and AGE LE 64
Universe-text Sample adults LE 64
Question Text Have you ever heard of HPV? HPV stands for human papillomavirus (pap-uh-
LOW-muh-vi-rus).
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Ever heard of HPV
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto SHHPVHD1]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 90 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SHHPVHD1
Question ID AAU.444.010
Universe HHSTAT4 = 'S' and AGE LE 64
Universe-text Sample adults age LE 64
Question Text Two vaccines, or shots, to prevent HPV infection are available in the United
States. Both vaccines prevent cervical cancer and one also prevents genital
warts. The two HPV vaccines are sometimes called CERVARIX® or GARDASIL®.
Before this survey, have you ever heard of HPV vaccines or shots?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Heard about HPV vaccine
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto SHTHPV1]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 91 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SHTHPV1
Question ID AAU.446.010
Universe HHSTAT4 = 'S' and AGE LE 64
Universe-text Sample adults age LE 64
Question Text Have you ever received an HPV shot or vaccine?
Answer Codes 1. Yes
2. No
3. Doctor refused when asked
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane Had HPV shot
Fill Instructions
Special Instructions
Skip Instructions <1> [goto SHHPVDOS]
<2,3,R,D> [goto LIVEV]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 92 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable SHHPVDOS
Question ID AAU.448.010
Universe HHSTAT4 = 'S' and AGE LE 64 and SHTHPV1=1
Universe-text Sample adults age LE 64 who have had an HPV shot
Question Text How many HPV shots did you receive?
* Enter '50' if 50 or more shots
* Enter '96' for all shots
Answer Codes
Question Type Integer
Part
Field Pane Number of shots
Fill Instructions
Special Instructions Allow 1-50,96, Refused, Don't know
Skip Instructions <1-50,96,R,D> [goto LIVEV]
<51-95> [goto ERR_SHHPVDOS]
Edit Name ERR_SHHPVDOS
quHardedits ERR_SHHPVDOS
* Shots should be in the range 1-50 or 96 for all shots.
* Please correct.
quSoftedits
Tuesday, June 19, 2012 Page 93 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable LIVEV
Question ID AAU.450.010
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Has a doctor or other health professional ever told you that you had any kind of
chronic, or long-term liver condition?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Ever had liver problems
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> goto TRAVEL
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 94 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable TRAVEL
Question ID AAU.460.010
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Have you ever traveled outside of the United States to countries other than
Europe, Japan, Australia, New Zealand or Canada, since 1995?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part D
Field Pane Traveled since 1995-selected countries
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto WRKHLTH]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 95 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable WRKHLTH
Question ID AAU.465.010
Universe HHSTAT4 = 'S' and AGE GE 18
Universe-text Sample adults 18+
Question Text Do you currently volunteer or work in a hospital, medical clinic, doctor’s office,
dentist’s office, nursing home or some other health-care facility? This includes
part-time and unpaid work in a health care facility as well as professional nursing
care provided in the home.
*Read if necessary: This includes non-health care professionals, such as
administrative staff, who work in a health-care facility.
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part D
Field Pane Work
Fill Instructions
Special Instructions
Skip Instructions <1> [goto WRKDIR]
<2,R,D> [goto APSBPCHK]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 96 of 121
Section Name Health Care Access and Utilization
Module 19
Instrument Variable WRKDIR
Question ID AAU.470.010
Universe HHSTAT4 = 'S' and AGE GE 18 and WRKHLTH=1
Universe-text Sample adults 18+ who work or volunteer in a health-care setting
Question Text Do you provide direct patient care as part of your routine work? By direct patient
care we MEAN PHYSICAL OR HANDS ON CONTACT WITH PATIENTS.
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part D
Field Pane Direct care
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto APSBPCHK]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 97 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable APSBPCHK
Question ID AAU.500_00.010
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text DURING THE PAST 12 MONTHS, have you had your blood pressure checked by
a doctor, nurse, or other health professional?
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto APSCHCHK]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 98 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable APSCHCHK
Question ID AAU.510_00.010
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text DURING THE PAST 12 MONTHS, have you had your blood cholesterol checked
by a doctor, nurse, or other health professional?
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto APSBSCHK]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 99 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable APSBSCHK
Question ID AAU.520_00.010
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text Have you had a fasting test for high blood sugar or diabetes DURING THE PAST
12 MONTHS?
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> and SEX=1 and AGE GE 40 [goto APSCOL]
If <1,2,R,D> and SEX=1 and AGE < 40 [goto APSDIET]
Else <1,2,R,D> and SEX=2 [goto APSPAP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 100 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable APSPAP
Question ID AAU.530_00.010
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and SEX='2'
Universe-text Female sample adults 18+
Question Text Have you had a Pap smear or Pap test DURING THE PAST 12 MONTHS?
*Read if necessary.
A Pap smear or Pap test is a routine test for women in which the doctor
examines the cervix, takes a cell sample from the cervix with a small stick or
brush, and sends it to the lab.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> if AGE GE 30 [goto APSMAM];
else <1,2,R,D and AGE<30 [goto APSDIET]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 101 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable APSMAM
Question ID AAU.540_00.010
Universe HHSTAT4 = 'S' and (AGE GE '030' and AGE not IN ('997','999')) and SEX='2'
Universe-text Female sample adults 30+
Question Text Have you had a Mammogram DURING THE PAST 12 MONTHS?
*Read if necessary.
A mammogram is an x-ray of each breast to look for breast cancer.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> if AGE GE 40 [gotoAPSCOL];
else <1,2,R,D and AGE<40> [goto APSDIET]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 102 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable APSCOL
Question ID AAU.550_00.010
Universe HHSTAT4 = 'S' and (AGE GE '040' and AGE not IN ('997','999'))
Universe-text Sample adults 40+
Question Text DURING THE PAST 12 MONTHS, have you had any test done for colon cancer?
*Read if necessary.
Colon cancer tests include blood stool tests, colonoscopy and sigmoidoscopy.
A blood stool test is a test that may use a special kit at home to determine
whether the stool contains blood.
A sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the
rectum to view the colon for signs of cancer or other health problems.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto APSDIET]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 103 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable APSDIET
Question ID AAU.560_00.010
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text DURING THE PAST 12 MONTHS, has a doctor or other health professional
talked to you about your diet?
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> if SMKNOW in ('1','2') [goto APSSMKC];
else if (40<=AGE<=65) [goto LTCFAM];
else [goto AINDINS]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 104 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable APSSMKC
Question ID AAU.570_00.010
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and
SMKNOW(e) IN('1','2')
Universe-text Sample adults 18+ currently who smoke every day or some days
Question Text DURING THE PAST 12 MONTHS, has a doctor or other health professional
talked to you about your smoking?
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> if (40<=AGE<=65) [goto LTCFAM];
else [goto AINDINS]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 105 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable LTCFAM
Question ID AAU.580_00.010
Universe HHSTAT4 = 'S' and ('040' <=AGE <= '065' and AGE not IN ('997','999'))
Universe-text Sample adults Sample adults 40-65
Question Text Do you have a parent, spouse, sibling, or adult child who has needed help for at
least a year with everyday needs like bathing, dressing or eating due to a long
term condition?
*Read if necessary.
Due to a chronic illness or disability.
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto LTCHELP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 106 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable LTCHELP
Question ID AAU.582_00.010
Universe HHSTAT4 = 'S' and ('040' <=AGE <= '065' and AGE not IN ('997','999'))
Universe-text Sample adults Sample adults 40-65
Question Text How likely is it that you may someday need help with daily activities like
bathing, dressing, eating, or using the toilet due to a long term condition?
Would you say…
Answer Codes 1. Very likely
2. Somewhat likely
3. Somewhat unlikely
4. Very unlikely
Refused
Don’t know
Question Type Pick One - answer list pane
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1-4,R,D> [goto LTCWHO]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 107 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable LTCWHO
Question ID AAU.584_00.010
Universe HHSTAT4 = 'S' and ('040' <=AGE <= '065' and AGE not IN ('997','999'))
Universe-text Sample adults Sample adults 40-65
Question Text If you needed such help, who would provide this help?
*Enter all that apply, separate with commas.
Answer Codes 1. My family
2. Someone I hire
3. Home health care organization
4. Nursing home/assisted living
5. Other
Refused
Don’t know
Question Type Enter all that apply
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1-5,R,D> [goto LTCPRCH]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 108 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable LTCPRCH
Question ID AAU.586_00.010
Universe HHSTAT4 = 'S' and ('040' <=AGE <= '065' and AGE not IN ('997','999'))
Universe-text Sample adults Sample adults 40-65
Question Text Health Care Reform establishes a voluntary, government-run insurance program
to pay for help with everyday needs like bathing, dressing or eating. People will
be able to enroll, and pay a monthly premium. Once they need care they
would receive an average of $50 each day. Would you be interested in
Answer Codes 1.Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,D> [goto LTCPAY]
<2,R> [goto AINDINS]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 109 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable LTCPAY
Question ID AAU.588_00.010
Universe HHSTAT4 = 'S' and ('040' <=AGE <= '065' and AGE not IN ('997','999')) and
LTCPRCH(e) IN('1','9')
Universe-text Sample adults 40-65 who would be interested in purchasing long-term care
insurance or don’t know if they are interested
Question Text How much would you be willing to pay per month NOW to receive this benefit
later in life?
Answer Codes 1.$1-$24 per month
2.$25-$49 per month
3.$50-$74 per month
4.$75-$99 per month
5.$100-$124 per month
6.$125 per month or more
7. Nothing/Not interested in the program
Refused
Don't know
Question Type Pick One - answer list pane
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1-7,R> [goto AINDINS]
<D> [goto LTC100M]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 110 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable LTC100M
Question ID AAU.590_00.010
Universe HHSTAT4 = 'S' and ('040' <=AGE <= '065' and AGE not IN ('997','999')) and
LTCPAY(e)='99'
Universe-text Sample adults 40-65 who don’t know how much they would be willing to pay per
month for long-term care insurance
Question Text How likely would it be for you to pay $100 per month for this insurance? Would
you say…
*Read categories below.
Answer Codes 1. Very likely
2. Somewhat likely
3. Somewhat unlikely
4. Very unlikely
Refused
Don’t know
Question Type Pick One - answer list pane
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1-4,R,D> [goto AINDINS]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 111 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AINDINS
Question ID AAU.600_00.010
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999'))
Universe-text Sample adults 18+
Question Text DURING THE PAST 3 YEARS, did you try to purchase health insurance directly,
that is, not through any employer, union, or government program?
Answer Codes 1. Yes
2. No
Refused
Don’t know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1> [goto AINDPRCH>
<2,R,D> [goto next section]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 112 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AINDPRCH
Question ID AAU.600_00.020
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and
Universe-text Sample adults 18+ who tried to purchase health insurance directly in the past 3
Question Text Was a plan purchased?
Answer Codes 1. Yes
2. No
Refused
Don’t know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1> [goto AINDWHO]
<2> [goto AINDNOT]
<R,D> [goto next section]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 113 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AINDWHO
Question ID AAU.600_00.030
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and
AINDPRCH(e)='1'
Universe-text Sample adults 18+ who purchased health insurance directly in the past 3 years
Question Text Was this plan for yourself, someone else in your family, or both?
Answer Codes 1. Self
2. Someone else in family
3. Both
Refused
Don’t know
Question Type Pick One - answer list pane
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1-3,R,D> [goto AINDDIF1]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 114 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AINDDIF1
Question ID AAU.600_00.040
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and
AINDPRCH(e)='1'
Universe-text Sample adults 18+ who purchased health insurance directly in the past 3 years
Question Text How difficult was it to find a plan with the type of coverage you needed? Would
you say…
*Read categories below.
Answer Codes 1. Very difficult
2. Somewhat difficult
3. Not at all difficult
Refused
Don’t know
Question Type Pick One - answer list pane
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1-3,R,D> [goto AINDDIF2]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 115 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AINDDIF2
Question ID AAU.600_00.050
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and
AINDPRCH(e)='1'
Universe-text Sample adults 18+ who purchased health insurance directly in the past 3 years
Question Text How difficult was it to find a plan you could afford? Would you say…
*Read categories below.
Answer Codes 1. Very difficult
2. Somewhat difficult
3. Not at all difficult
Refused
Don’t know
Question Type Pick One - answer list pane
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1-3,R,D> [goto AINDENY1]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 116 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AINDENY1
Question ID AAU.600_01.060
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and
AINDPRCH(e)='1'
Universe-text Sample adults 18+ who purchased health insurance directly in the past 3 years
Question Text Did any company turn you down when you tried to buy coverage on your own ?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto AINDENY2]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 117 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AINDENY2
Question ID AAU.600_02.060
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and
AINDPRCH(e)='1'
Universe-text Sample adults 18+ who purchased health insurance directly in the past 3 years
Question Text Did any company charge a higher price because of {fill 1: your/your family’s/you
or your family’s} health?
Answer Codes 1. Yes
2. No
Refused
Don’t know
Question Type Yes/No
Part
Field Pane
Fill Instructions Fill 1: If AINDWHO='1', then fill "your",
Else if AINDWHO='2', then fill "your family's",
Else if AINDWHO='3','D','R', then fill "you or your family's"
Special Instructions
Skip Instructions <1,2,R,D> [goto AINDENY3]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 118 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AINDENY3
Question ID AAU.600_03.060
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and
AINDPRCH(e)='1'
Universe-text Sample adults 18+ who purchased health insurance directly in the past 3 years
Question Text Did any company exclude a specific health problem from the coverage?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1,2,R,D> [goto next section]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 119 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AINDNOT
Question ID AAU.601_00.070
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and
AINDPRCH(e)='2'
Universe-text Sample adults 18+ who tried but did not purchase health insurance directly in
the past 3 years
Question Text Why did you not buy the plan?
*Enter all that apply, separate with commas.
Answer Codes 1. Turned down
2. Cost
3. Pre-existing condition
4. Got health insurance from other source
5.Other reason (specify)
Refused
Don’t know
Question Type Enter all that apply
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <1-4,R,D> [goto next section]
<5> [goto AINDNTSP]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 120 of 121
Section Name Adult Access to Health Care & Utilization
Module 19
Instrument Variable AINDNTSP
Question ID AAU.601_00.080
Universe HHSTAT4 = 'S' and (AGE GE '018' and AGE not IN ('997','999')) and
AINDNOT(e)='5'
Universe-text Sample adults 18+ who had other reason plan was not purchased
Question Text *Specify other reason plan was not obtained.
Answer Codes
Question Type Verbatim
Part
Field Pane
Fill Instructions
Special Instructions
Skip Instructions <allow 75,R,D> [goto next section]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 121 of 121
Insert ACASI Supplement Here
Section Name Adult Identification and Verification
Module 14
Instrument Variable LNKINTRO
Question ID AID.082
Universe HHSTAT4 = 'S'
Universe-text Sample Adults 18+
Question Text ?[F1]
Finally, we would like the last four digits of your Social Security Number [Fill:].
This information will help us link your survey data with health-related records of
other government agencies, and allow us to conduct additional research without
taking up your time with more questions. The National Center for Health
Statistics uses this information for research purposes only. Providing this
information is voluntary. Federal laws authorize us to ask for this information
and require us to keep it strictly private. There will be no effect on your benefits
if you do not provide this information.
* Read if necessary: The specific federal laws are the Public Health Service Act
(Title 42, United States Code, Section 242K) and the Confidential Information
Protection and Statistical Efficiency Act (Title V of Public Law 107-347).
* Enter '1' to continue.
Answer Codes
Question Type Enter 1 to Continue
Part
Field Pane Linkage intro
Fill Instructions Fill: If sample adult has Medicare (HIKIND=2 or HIKIND=3 or MCAREPRB=1),
then
fill ", and the last four numbers and any letters of your Medicare number"
Special Instructions QUESTION SHOULD APPEAR AT THE END OF THE SAMPLE ADULT CORE
AND SUPPLEMENT QUESTIONS.
Skip Instructions <1,D> [goto SASSN4]
<R> [goto SARLINK]
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 18 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable SASSN4
Question ID AID.085
Universe HHSTAT4 = S and (LNKINTRO= '1' or LNKINTRO = 'don't know'
Universe-text Sample adults 18+ who answered "Enter 1 to continue" or "don’t know" at
LNKINTRO
Question Text ?[F1]
What are the last four digits of your Social Security Number?
* Read if necessary: Providing this information is voluntary. Federal laws
authorize us to ask for this information and require us to keep it strictly private
(Public Health Service Act, which is Title 42, United States Code, Section 242K;
and the Confidential Information Protection and Statistical Efficiency Act,
which is Title V of Public Law 107-347).
* Enter 'N' if no Social Security Number.
Answer Codes
Question Type Integer
Part
Field Pane SSN
Fill Instructions
Special Instructions Allow 4 digits. QUESTION SHOULD APPEAR AT THE END OF THE SAMPLE
ADULT CORE AND SUPPLEMENT QUESTIONS.
NOTE: THIS QUESTION ACTUALLY APPEARS AT THE END OF THE SAMPLE
ADULT QUESTIONS INCLUDING ANY SUPPLEMENT QUESTIONS IN THE
INSTRUMENT. THIS IS LOCATED HERE BECAUSE NCHS WANTED THE
OUTPUT DATA TO CONTAIN THIS INFORMATION HERE.---T.M.
Skip Instructions <0001-9999> if SCSSN4=SASSN4 goto ERR2_SASSN4;
else goto SASSNRP4
<0-999> goto ERR_SASSN4
<0000> goto ERR3_SASSN4
<N,R,D> if HIKIND=2 or HIKIND = 3 or MCAREPRB=1
goto SAMCNO4
else
goto SARLINK
Edit Name ERR_SASSN4, ERR2_SASSN4,
ERR3_SASSN4
quHardedits ERR_SASSN4
* You must enter all four of the last four digits of the Social Security Number.
*Please correct.
ERR3_SASSN4
Tuesday, June 19, 2012 Page 19 of 26
* The last 4 digits of a SSN may be between 0001-9999.
* Please correct.
* For a respondent who does not want to provide the SSN, enter 'Ctrl D' or 'Ctrl R'
for 'Don't Know' or 'Refused.'
quSoftedits ERR2_SASSN4
*The last four digits of [fill: ALIAS of Sample Adult]'s Social Security Number
are the same as the last four digits of [SC name]'s Social Security Number.
Please verify.
*First goto change Sample Adult's SSN at SASSN4
Section Name Adult Identification and Verification
Module 14
Instrument Variable SASSNRP4
Question ID AID.090
Universe HHSTAT4 = S and ('0000' <= SASSN4 <='9999')
Universe-text Sample adult reported the last four digits of the SSN at SASSN4
Question Text * Enter how the last four digits of the Social Security Number were reported.
Answer Codes 1. From memory
2. From records
Question Type Pick One - answer list pane
Part
Field Pane SSN memory or records
Fill Instructions
Special Instructions Do not allow Refused or Don't know
QUESTION SHOULD APPEAR AT THE END OF THE SAMPLE ADULT CORE
AND SUPPLEMENT QUESTIONS.
Skip Instructions <1,2> goto SASSNTL4
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 20 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable SASSNTL4
Question ID AID.095
Universe HHSTAT4 = S and (SASSNRP4 = 1 or 2)
Universe-text Recorded how last four digits of the sample adult’s SSN were reported
Question Text * Select one category below to indicate reporting of the last four digits of the
Social Security Number.
Answer Codes 1. In person
2. Telephone
Question Type Pick One - answer list pane
Part
Field Pane SSN in person or phone
Fill Instructions
Special Instructions Do not allow Refused or Don't know
QUESTION SHOULD APPEAR AT THE END OF THE SAMPLE ADULT CORE
AND SUPPLEMENT QUESTIONS.
NOTE: THIS IS LOCATED HERE BECAUSE NCHS WANTED THE OUTPUT
DATA TO CONTAIN THIS INFORMATION HERE.---T.M.
Skip Instructions <1,2> if HIKIND= 2 or HIKIND = 3 or MCAREPRB=1
goto SAMCNO4
else
goto beginning of Recontact or Back section
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 21 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable SAMCNO4
Question ID AID.100_1
Universe HHSTAT4 = S and (LNKINTRO = 1 or LNKINTRO = don't kow) and (HIKIND = 2
or HIKIND = 3 or MCAREPRB = 1)
Universe-text Sample adult has Medicare
Question Text ? [F1]
1 of 2
May I please see your Medicare card to record the last four numbers and any
letters of the Health Insurance Claim Number?
* Read if necessary: Providing this information is voluntary. Federal laws
authorize us to ask for this information and require us to keep it strictly private
(Public Health Service Act, which is Title 42, United States Code, Section 242K;
and the Confidential Information Protection and Statistical Efficiency Act,
which is Title V of Public Law 107-347).
* Reports from memory are acceptable if the Medicare card (or some other form
of documentation) is not available.
* Enter the last four numbers.
Answer Codes
Question Type Integer
Part
Field Pane Medicare number
Fill Instructions
Special Instructions Allow 4 digits. QUESTION SHOULD APPEAR AT THE END OF THE SAMPLE
ADULT CORE AND SUPPLEMENT QUESTIONS.
If SAMCNO4 = 'Refused'
set SAMCNO4_FLG = 'R'
elseif SAMCNO4 = 'Don't know'
set SAMCNO4_FLG = 'D'
else
set SAMCNO4_FLG = empty
endif
Skip Instructions <0000-9999> goto SAMCLET
<0-999> goto ERR_SAMCNO4
<R,D> goto SARLINK
Edit Name ERR_SAMCNO4
quHardedits ERR_SAMCNO4
* You must enter all four of the last four numbers of the Medicare number.
Tuesday, June 19, 2012 Page 22 of 26
* Please correct.
quSoftedits
Section Name Adult Identification and Verification
Module 14
Instrument Variable SAMCLET
Question ID AID.100_2
Universe HHSTAT4 = S and SAMCNO4 = 0000 - 9999
Universe-text Sample adult has Medicare and reported the last four numbers of the Medicare
number
Question Text 2 of 2
*Enter the letters that appear after the claim number.
Answer Codes empty, A - Z, AA - ZZ
Question Type Text
Part
Field Pane Letters
Fill Instructions
Special Instructions Allow up to 2 letters and allow 'empty'. QUESTION SHOULD APPEAR AT THE
END OF THE SAMPLE ADULT CORE AND SUPPLEMENT QUESTIONS.
Skip Instructions <Allow 2, 'Refused', 'Don't know'> if SASSN4 = 0000-9999
goto beginning of Recontact or Back
section
elseif SASSN4 = 'N','Refused','Don't know'
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 23 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable SAMCNO4_FLG
Question ID AID.100_3
Universe
Universe-text
Question Text
Answer Codes
Question Type **Instrument variable**
Part
Field Pane
Fill Instructions
Special Instructions If SAMCNO4 = 'Refused'
set SAMCNO4_FLG = 'R'
elseif SAMCNO4 = 'Don't know'
set SAMCNO4_FLG = 'D'
else
set SAMCNO4_FLG = empty
endif
Skip Instructions
Edit Name
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 24 of 26
Section Name Adult Identification and Verification
Module 14
Instrument Variable SARLINK
Question ID AID.105
Universe HHSTAT4 = S and (LNKINTRO=refused or SAMCNO4=refused or
SAMCNO4=don't know or SASSN4=no SSN or SASSN4=refused or
SASSN4=don't know)
Universe-text Version 2 and Sample Adult answered refused at LNKINTRO, or answered
refused or don't know at SAMCNO4 or answered no SSN or refused or don't know
at SASSN4
Question Text ?[F1]
May we try to link your survey data without [Fill:]?
* Read if necessary:
Any data obtained will be kept strictly private as required by law (Public Health
Service Act, which is Title 42, United States Code, Section 242K; and the
Confidential Information Protection y Statistical Efficiency Act, which is Title V
of Public Law 107-347).
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Part
Field Pane Permission to link
Fill Instructions IF LNKINTRO = RF OR ((SASSN4 = 'N' OR SASSN4 = RF OR SASSN4 = DK)
AND (SAMCNO4 = RF OR SAMCNO4 = DK)) THEN
If ((Medicare IN FHI.ITYPE.ITYPE[SASEL].HIKIND) OR (Medigap IN
FHI.ITYPE.ITYPE[SASEL].HIKIND) OR
(FHI.ITYPE.ITYPE[SASEL].MCAREPRB=Yes)) THEN
Fill := 'Medicare and Social Security numbers'
else
Fill := 'a Social Security Number'
Endif
ELSEIF (SAMCNO4 = RF OR SAMCNO4 = DK) THEN
Fill := 'a Medicare number'
ELSEIF (SASSN4 = RF OR SASSN4 = DK or SASSN4 = 'N') THEN
Fill := 'a Social Security Number'
ENDIF
Special Instructions QUESTION SHOULD APPEAR AT THE END OF THE SAMPLE ADULT CORE
AND SUPPLEMENT QUESTIONS.
Skip Instructions goto beginning of Recontact or Back section
Edit Name
Tuesday, June 19, 2012 Page 25 of 26
quHardedits
quSoftedits
Tuesday, June 19, 2012 Page 26 of 26
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |