Cancer Control - Questionniare

Attachment 1- 2015 NHIS Cancer Control Supplement

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 55 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 06/30/2015

NHIS 2015 Cognitive Testing of Cancer Control Supplement Items

Physical Activity

*The next questions are for sample adults 18+ years.

The next questions are about where you live and walking near where you live

Q1 Would you call where you live rural? (that is, in the country)

1. Yes

2. No

Refused

Don’t know

Q2 How often are there people walking within sight of your home? Would you say:

1. Throughout the day

2. Every day

3. Every 2-3 days

4. About once a week

5. Less than once a week

Refused

Don’t know

Q3 How far away from your home is the nearest road, path or trail where you can walk?

0. At my home/ Zero distance

_________Number of feet/miles/meters/kilometers away?

Refused

Don’t know

Q4 How often does the weather make you less likely to walk? (If needed state “ We mean any kind of bad weather that makes you less likely to walk, such as hot, cold, rainy, snowy, and windy) Would you say:

1. Always

2. Most of the time

3. Some of the time

4. A little of the time

5. Never

Refused

Don’t know

Q5 For each of the following, tell me whether it is true or not true

5a. Where you live there are roads, paths or trails where you can walk

1. True 2. Not true Refused Don’t know

5b. Where you live there are shops, stores, or markets within walking distance

1. True 2. Not true Refused Don’t know

5c. (Where you live) There are bus or transit stops within walking distance of where I live.

1. True 2. Not true Refused Don’t know

5d. (Where you live) There are places like movies, libraries, or churches within walking distance

1. True 2. Not true Refused Don’t know

5e. (Where you live) There are places to walk near where you live that help you relax, clear your mind, and reduce stress

1. True 2. Not true Refused Don’t know

5f. (Where you live) Most of the streets have sidewalks

1. True 2. Not true Refused Don’t know

5g. (Where you live) Traffic makes it unsafe to walk

1. True 2. Not true Refused Don’t know

5h. (Where you live) Crime makes it unsafe to walk

1. True 2. Not true Refused Don’t know

5j. (Where you live) Dogs or other animals make it dangerous to walk

1. True 2. Not true Refused Don’t know

Tobacco

*The next questions are for sample adults 18+ years.

Q5k Smokeless tobacco products are placed in the mouth or nose and can include chewing tobacco, snuff, dip, snus (snoose), or dissolvable tobacco.

Have you ever used smokeless tobacco products EVEN ONE TIME?

*Read if necessary: Do not include nicotine replacement therapy products (patch, gum, lozenge, spray), which are considered smoking cessation treatments.)

1. Yes

2. No

Refused

Don’t know

<1> [goto Q5l]; else [goto Q5o]

Q5l Do you NOW use smokeless tobacco products every day, some days, or not at all?

1. Every day

2. Some days

3. Not at all

Refused

Don’t know

<2,R,D> [goto Q5m]; else [goto Q5o]

Q5m On how many of the PAST 30 DAYS have you used chewing tobacco, snuff, dip, snus, or dissolvable tobacco?

______

Refused

Don’t know

<01-30> [goto Q5n]; else [goto Q5o]

Q5n During the past 30 days, what brand of smokeless tobacco product did you use MOST OFTEN?

1. Beech-Nut 2. Camel Snus 3. Cope 4. Copenhagen 5. Cougar 6. Grizzly 7. Hawken 8. Husky 9. Kayak 10. Kodiak 11. Levi Garrett 12. Longhorn 13. Marlboro Snus 14. Red Man 15. Red Seal 16. Rooster 17. Silver Creek 18. Skoal 19. Taylor's Pride 20. Timber Wolf 21. Brand not on list__________________________ Refused Don't know

Q5o Have you ever smoked a regular cigar, cigarillo, or little filtered cigar EVEN ONE TIME?

1. Yes

2. No

Refused

Don’t know

<1> [goto Q5p]; else [goto next applicable section]

Q5p Have you smoked at least 50 regular cigar, cigarillo, or little filtered cigar in your entire life?

1. Yes

2. No

Refused

Don’t know

<1,2,R,D> [goto Q5q]

Q5q Do you now smoke regular cigars, cigarillos, or little filtered cigars every day, some days, or not at all?

1. Every day

2. Some days

3. Not at all

Refused

Don’t know

<2,R,D> [goto Q5r]; else [goto next applicable section]

Q5r On how many of the PAST 30 DAYS have you smoked a regular cigar, cigarillo, or little filtered

cigar?

______

Refused

Don’t know

Sun Protection / Indoor Tanning

Q6 DURING THE PAST 12 MONTHS, has a physician or other health care provider talked to you about reducing your exposure to the sun or indoor tanning devices such as sunlamps, sunbeds, or tanning booths to reduce the risk for skin cancer?

1. Yes

2. No

Refused

Don’t know

Q7 Have you EVER used an indoor tanning device such as a sunlamp, sunbed, or tanning booth? Do NOT include times you have gotten a spray-on tan.

1. Yes

2. No

Refused

Don’t know

<1> [goto next question] <2,R,D> [goto Q10]

Q7 DURING THE PAST 12 MONTHS, where did you use an indoor tanning device such as a sunlamp, sunbed, or tanning booth? Please SELECT ALL that apply:

1. A tanning salon

2. A fitness center such as a gym or health club, recreation center, yoga/pilates or dance studio

3. A beauty facility such as a hair or nail salon, barber shop, or a spa center

4. A residential common area, such as the gym or lobby of an apartment complex or college dorm

5. Your home or someone else’s home

6. Another location

Refused

Don’t Know

Q9 How old were you THE FIRST TIME you used an indoor tanning device such as a sunlamp, sunbed, or tanning booth? Do NOT include times you have gotten a spray-on tan.

______01-84 years old

85. 85 years or older

Refused

Don’t know

Q10 DURING THE PAST 12 MONTHS, have you had a problem (such as a rash or burn) caused by using an indoor tanning device such as a sunlamp, sunbed, or tanning booth? Do NOT include problems you have experienced from getting a spray-on tan. *Read if necessary: By “sunburn” we mean even a small part of your skin turns red or hurts for 12 hours or more. Please select all that apply.

1. Got a sunburn

2. Got a rash

3. Got a skin infection

4. Experienced another problem

5. I have not had any problems from indoor tanning

Refused

Don’t know

Q11 DURING THE PAST 12 MONTHS, have you:

Used SELF-APPLIED sunless tanning products, including creams, lotions, sprays, mists, or towelettes, also known as self-tanning or fake tanning?

1. Yes

2. No

Refused

Don’t know

Q12 Gotten a spray-on or mist tan AT A TANNING SALON or other business?

1. Yes

2. No

Refused

Don’t know

Breast Cancer

*These questions are for females 40+ years who have ever had a mammogram.

Q13 How much did you pay for this mammogram. Was it NONE, PART, or ALL of the cost?

1. None of the cost

2. Part of the cost

3. All of the cost

Refused

Don’t know

Q14 As a result of your MOST RECENT mammogram, were you informed that your mammogram showed that you have dense breast tissue?

1. Yes

2. No

Refused

Don’t know

<1> [goto Q15]; else [goto Q18]

Q15 After your MOST RECENT mammogram, were you advised to have more tests because your breasts are dense?

1. Yes

2. No

Refused

Don’t know

<1> [goto Q16]; else [goto Q18]

Q16 What tests were recommended?

1. Ultrasound

2. Breast MRI

3. Additional mammogram(s)

4. Biopsy

5. Other

Refused

Don’t know

Q17 Which tests did you actually have?

1. Ultrasound

2. Breast MRI

3. Additional mammogram(s)

4. Biopsy

5. Did not receive additional tests

6. Other

Refused

Don’t know

Q18 After your MOST RECENT mammogram, were you advised to have more tests for another reason?

1. Yes

2. No

Refused

Don’t know

<1> [goto Q19]; else [goto Q22]

Q19 Why were these tests recommended?

1. Because my mammogram was abnormal

2. Because of another breast problem

3. Because of another reason

Refused

Don’t know

Q20 Which tests were recommended?

1. Ultrasound

2. Breast MRI

3. Additional mammogram(s)

4. Biopsy

5. Other

Refused

Don’t know

Q21 Which tests did you actually have?

1. Ultrasound

2. Breast MRI

3. Additional mammogram(s)

4. Biopsy

*5. Other [May need additional answer here no tests performed]

Refused

Don’t know

Q22 Did a doctor EVER talk with you about the advantages of mammograms?

1. Yes

2. No

Refused

Don’t know

Q23 Did a doctor EVER talk with you about the disadvantages of mammograms?

1. Yes

2. No

Refused

Don’t know

Cervical Cancer

*These questions are for women 18+ years who have ever had a Pap smear test.

Q24 An HPV test is sometimes given with the Pap test for cervical cancer screening. Did you have an HPV test with your most recent Pap?

1. Yes

2. No

Refused

Don’t know

Q25 How much did you pay out of pocket for this Pap or HPV test - Was it NONE, PART, or ALL of the cost?

1. None of the cost

2. Part of the cost

3. All of the cost

Refused

Don’t know

Q26 What was the MAIN reason you had this Pap or HPV test-was it part of a routine exam, because of a problem, or some other reason?

1. Routine exam

2. Because of a problem

3. Some other reason

Refused

Don’t know

Q27 Have you had a Pap or HPV test in the LAST 3 YEARS where the results were NOT normal?

Pre-coded answers:

1. Yes, Pap test not normal

2. Yes, HPV test not normal

3. Yes, both were not normal

NO

Refused

Don’t know/not sure

*Next question is for women 18+ who have never had a Pap/HPV test or have not had one in the past 5 years.

Q28 What is the most important reason you have NEVER had a Pap or HPV test/NOT had a Pap or HPV test in the LAST 5 YEARS?

1. No reason/never thought about it

2. Didn't need it/didn't know I needed this type of test

3. Doctor didn't order it/didn't say I needed it

4. Haven't had any problems

5. Put it off/didn't get around to it

6. Too expensive/no insurance/cost

7. Too painful, unpleasant, or embarrassing

8. Had hysterectomy

9. Don't have doctor

10. Had an HPV DNA test

11. Had HPV vaccine

12. Other

Refused

Don't know

Q29 The last time you were told you should be tested for cervical cancer, which test did your doctor or other health professional recommend? [RESPONSES SHOULD ALL BE READ ALOUD and check one:]

1. Pap test

2. HPV test

3. Both tests

4. My doctor did not recommend a test to check for cervical cancer

5. My doctor left the choice to me

Refused

Don’t know

<1-3> [goto Q30]; else [goto next applicable section]

Q30 When the doctor recommended you have [FILL FROM PREVIOUS QUESTION], how often did the

doctor say you should be tested?

1. Every 6 months

2. Every year

3. Every 3 years

4. Every 5 years

5. Something else

Refused

Don’t know

Lung Cancer

*These questions are for sample adults 40+ years.

Q31 A CT scan of your chest area is a test during which you are lying down and moved through a donut shaped x-ray machine while holding your breath. It is a new type of test to check or screen for lung cancer.

1. Before today, have you EVER HEARD of a CT scan of your chest area to check or screen for lung cancer?

1. Yes

2. No

Refused

Don’t know

<1> [goto Q32]; else [goto next applicable section]

Q32 Have you ever discussed getting a CT scan of your chest area to check or screen for lung cancer with your doctor or other health professional?

1. Yes

2. No

Refused

Don’t know

<1> [goto Q33]; else [goto Q36]

Q33 Did the doctor or other health professional EVER talk with you about the advantages of lung cancer CT screening?

1. Yes

2. No

Refused

Don’t know

Q34 Did the doctor or other health professional EVER talk with you about the disadvantages of lung cancer CT screening?

1 Yes

2 No

Refused

Don't know

<1> [goto Q35]; else [goto Q36]

Q35 What possible harms did you and the doctor discuss? Check all that apply.

1. False-alarms because CT scan can find spots that are not lung cancer and do not need treatment

2. Follow-up tests that are needed to find out if lung spots are cancer or not may have complications

3. CT scans sometimes find slow-growing cancers that may never have caused problems

4. Radiation exposure over time

5. Other

Refused

Don’t know

Q36 Have you EVER HAD a CT scan of your chest area to check or screen for lung cancer?

1. Yes

2. No

Refused

Don’t know

<1> [goto Q37]; else [goto next applicable section]

Q37 When did you have your MOST RECENT CT scan of your chest area to check or screen for lung cancer?

1. A year ago or less

2. More than 1 year but not more than 2 years

3. More than 2 years but not more than 3 years

4. More than 3 years but not more than 5 years

5. Over 5 years ago

Refused

Don’t know

<1,2,3> [goto Q38]; else [goto Q39]

Q38 How many CT scans of your chest area have you had in the LAST 3 YEARS?

*Enter '0' for none. *Enter '95' for 95 or more CT scans.

None

_____1-94

95+

Refused

Don't know

Q39 Who first raised the idea of getting a CT scan of your chest area to check or screen for lung cancer? Was it you, or was it a health care provider?

1. You

2. Health care provider

Refused

Don't know

*Alternative to #39

Q39A Was your CT scan part of a plan to be checked or screened for lung cancer regularly, even if there is no reason to think you have lung cancer?

1. Yes

2. No

Refused

Don’t know

Q40 Before you had a CT scan to check or screen for lung cancer, did a doctor EVER tell you that the best way to prevent lung cancer is to stop smoking if a current smoker (or do not restart if an ex- smoker)?

1. Yes

2. No

Refused

Don’t know

Q41 When do you expect to have your next CT scan of your chest area to check or screen for lung cancer?

1. Less than a year from now

2. One year from now

3. More than one year from now

4. When doctor recommends it

5. Never

Refused

Don't know

Prostate Cancer

Q43 Have you ever discussed getting a PSA test with your doctor or other health professional?

1. Yes

2. No

Refused

Don’t know

<1> [goto Q44]; else [goto Q45]

Q44. Who first raised the idea of getting a PSA test? Was it you, or your doctor or other health professional?

1. You

2. Your health care provider

Refused

Don’t know

Q45 Did your doctor or other health professional ask how you felt about PSA testing?

1. Yes

2. No

Refused

Don’t know

*Next question is for males 40+ years who have ever had a PSA test; question version depends on answer to Q43.

Q46 Which of the following best describes the decision to have the PSA test done/not have the PSA test done? (Question about the test not being done would be for men who replied that yes they have had a discussion with their doctor but no they have not the test)

Please read:

1. You made the decision

2. Your doctor/nurse/ other health professional made the decision

3. Your doctor/nurse/ other health professional and you made the decision together

4. Your spouse/significant other/family member made the decision

Do not read:

You don‘t know who made the decision

Refused

Don’t know

Q47 Has a doctor or other health professional ever told you that...

The PSA test is not always accurate?

1. Yes

2. No

Refused

Don’t know

Some types of prostate cancer are slow-growing and need no treatment? [Also test: Prostate cancer usually does not grow or cause health problems in men who have it?]

1. Yes

2. No

Refused

Don’t know

Treating any type of prostate cancer can lead to serious side-effects, such as problems with urination or having sex?

1. Yes

2. No

Refused

Don’t know

No one is sure if using the PSA test actually saves lives?

1. Yes

2. No

Refused

Don’t know

The PSA test can help some men avoid death from prostate cancer

1. Yes

2. No

Refused

Don’t know

Colorectal cancer

*The next questions are for sample adults age 40+ years.

Q48 Have you ever discussed getting a test to check for colon cancer with your doctor or other health professional?

1. Yes

2. No

Refused

Don’t know

Q49 The blood stool or occult blood test, or (fecal) immunochemical or FIT test, are tests to determine whether you have blood in your stool or bowel movement. These tests can be done to the doctor or lab. Has your doctor or other health professional EVER told you about these tests to check for colon cancer?

1. Yes

2. No

Refused

Don’t know

<1> [goto Q50]; else if had a colonsoscopy in the past 10 years, [goto Q53]; else [goto next applicable section]

Q50 Did your doctor or other health professional say that these tests are a good way to check for colon cancer?

1. Yes

2. No

Refused

Don’t know

Alternative to Item Q50:

Q51 Did your doctor or other health professional describe the ADVANTAGES of the blood stool or FIT test as an option to check for colon cancer?

1. Yes

2. No

Refused

Don’t know

Q52 Did your doctor or other health professional describe the DISADVANTAGES of the blood stool or FIT test as an option to check for colon cancer?

1. Yes

2. No

Refused

Don’t know

*This next question is for adults who have had a colonoscopy in the past 10 years.

Q53 How much did you pay for your most recent colonoscopy? Was it all, part, or none of the cost?

1.All of the cost

2. Part of the cost

3. None of the cost

Refused

Don’t know

Genetic testing

The following questions refer to "genetic counseling for cancer risk." Genetic counseling involves a discussion with a specially trained health care provider about your family history of cancer and its impact on your cancer risk.

Q54 Has a doctor or health professional ever recommended or referred you to get genetic counseling because of your family history of cancer?

1. Yes

2. No

Refused

Don’t know

Q55 Have you ever received genetic counseling for cancer risk?

1. Yes

2. No

Refused

Don’t know

<1> [goto Q56]; else [goto Q57]

Q56 Please think about your MOST RECENT genetic counseling session for cancer risk. Which kind of cancer was it for?

Breast cancer?

1. Yes

2. No

Refused

Don’t know

Ovarian cancer?

1. Yes

2. No

Refused

Don’t know

Colon or rectal cancer?

1. Yes

2. No

Refused

Don’t know

Another type of cancer?

1. Yes

2. No

Refused

Don’t know

<1> [goto specify question]; else [goto Q57]

*Specify other cancer for which received genetic counseling

_______

Refused

Don’t know

Q57 Compared to the average {man/woman} your age, would you say that you are more likely to get colon or rectal cancer, less likely, or about as likely? *Read if necessary. For a colon or rectal cancer survivor, this means getting colon or rectal cancer again in the future.

1. More likely to get colon or rectal cancer

2. Less likely

3. About as likely

Don't know

Refuse

Q58 Compared to the average woman your age, would you say that you are more likely to get breast

cancer, less likely, or about as likely? *Read if necessary. For a breast cancer survivor, this means getting breast cancer again in the future.

1. More likely to get breast cancer

2. Less likely

3. About as likely

Don't know

Refuse

Q59 Compared to the average woman your age, would you say that you are more likely to get ovarian cancer, less likely, or about as likely? *Read if necessary. For an ovarian cancer survivor, this means getting ovarian cancer again in the future.

1. More likely to get ovarian cancer

2. Less likely

3. About as likely

Don't know

Refuse

Family History

Second Degree Relatives –

Reason: To better assess issues related to breast-ovarian syndrome

Q60. The next few questions are about the number of your second-degree relatives who have been diagnosed with breast or ovarian cancer.

How many of your grandparents, aunts, uncles, nieces, nephews, or grandchildren have ever been diagnosed with breast cancer?

* Interviewer read: Do not include great grandparents, great aunts or uncles, cousins, or step- relatives

*Report number of second-degree relatives who have been diagnosed with breast cancer

­­­­________

Q61. How many of them were diagnosed with breast cancer before the age of 50?

*Report number of second-degree relatives who have ever been diagnosed with breast cancer under age 50

________

Q62. How many of your grandmothers, aunts, nieces, or granddaughters have ever been diagnosed with ovarian cancer?

* Interviewer read: Do not include great grandparents, great aunts, cousins, or step- relatives

*Report number of second-degree relatives who have been diagnosed with ovarian cancer

________