Questionnaire

Attachment 1 – Questions to be evaluated OMB #0920-0222; Expiration Date: 06/30/2015

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[ASK FEMALE RESPONDENTS 21+ YEARS OLD AND OLDER; ELSE GO TO Q #6]

The following questions are about women's health.

1.Question ID: NAF.130_00.000 Variable Name: PAPHAD1

Have you EVER HAD had a pap smear test?

1 Yes (Go to Question 2)

2 NO (Go to Question 5)

7 Refused (Go to next section)

9 Don't know (Go to next section)

*Read if necessary.

A Pap smear 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.

2.Question ID: NAF.168_00.000 Instrument Variable Name: HPVPAP

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 for cervical cancer screening?

1 Yes, I had an HPV test with the Pap test (Go to Q3)

2 Yes, I had an HPV test but not with the Pap test (Go to Q3)

3 NO (Go to Q4)

7 Refused (Go to Q3)

9 Don't know (Go to Q3)

3.Question ID: NAF.170_00.000 Instrument Variable Name: PAPREA2

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 Part of a routine exam (Go to Q4)

2 Because of a problem (Go to Q4)

3 Other reason (Go to Q4)

7 Refused (Go to Q4)

9 Don't know (Go to Q4)

4. Question ID: NAF.180_00.000 Instrument Variable Name: PAPABN3

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 (Go to next section)

2 Yes, HPV test not normal (Go to next section)

3 Yes, both were not normal (Go to next section)

4 NO (Go to next section)

7 Refused (Go to next section)

9 Don’t know/not sure (Go to next section)

5. Question ID: NAF.210_00.000 Instrument Variable Name: PAPNOT2

What is the most important reason you have NOT had a Pap or HPV test?

01 No reason/never thought about it (Go to next section)

02 Didn’t know I needed it (Go to next section)

03 Doctor didn't order it/didn't say I needed it (Go to next section)

04 Haven't had any problems (Go to next section)

05 Put it off/didn't get around to it (Go to next section)

06 Too expensive/no insurance/cost (Go to next section)

07 Too painful, unpleasant, or embarrassing (Go to next section)

08 Had hysterectomy (Go to next section)

09 Don't have doctor (Go to next section)

10 Had HPV vaccine, so don’t need screening (Go to next section)

111 Other (Go to next section)

97 Refused (Go to next section)

99 Don't know (Go to next section)

[ASK MALE AND FEMALE RESPONDENTS 40> YEARS OF AGE]

Chest x-ray/CT scan lung cancer screening questions

The next set of questions are about tests of your chest area. These questions ask about chest x-rays and CT scans, but not mammograms.

6.Question ID: NAF.423_01.000 Instrument Variable Name: CHESTX

In the last 12 months, did you have a chest x-ray?

1 Yes (Go to Q7)

2 No (Go to Q8)

7 Refused (Go to Q8)

9 Don't know (Go to Q8)

7.Question ID: NAF.423_02.000 Instrument Variable Name: CHESTREA

Were any of the chest x-rays you had in the last 12 months done to check for lung cancer, rather than for some other reason?

1 Yes, to check for lung cancer (Go to Q8)

2 No, for some other reason (Go to Q8)

7 Refused (Go to Q8)

9 Don't know (Go to Q8)

The following questions are about CT scans, also called CAT scans. During this test, you are lying down and moved through a donut shaped x-ray machine while holding your breath.

8.Question ID: NAF.423_03.000 Instrument Variable Name: CATEVER

Have you EVER HAD a CT or CAT scan?

1 Yes (Go to Q9)

2 No (End interview)

7 Refused (End interview)

9 Don't know (End interview)

9.Question ID: NAF.423_04.000 Instrument Variable Name: CATCHST1

Were any of the CT or CAT scans you had done of your chest area?

1 Yes (Go to Q10)

2 No (End interview)

3 Several areas of upper body region (End interview)

7 Refused (End interview)

9 Don't know

The next questions are only about CT or CAT scans to check or screen for lung cancer. Do not include any CT or CAT scans of your chest area that were NOT done to check or screen for lung cancer.

10.Question ID: NAF.423_05.000 Instrument Variable Name: CATLUNG1

Were any of the CT or CAT scans done to check or screen for lung cancer, rather than for some other reason?

1 Yes, to check or screen for lung cancer (Go to Q11)

2 No, for some other reason (End interview)

7 Refused (End interview)

9 Don't know (End interview)

11.Question ID: NAF.423_06.000 Instrument Variable Name: CATWHEN

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

1 A year ago or less (Go to Q12)

2 More than 1 year but not more than 2 years (Go to Q12)

3 More than 2 years but not more than 3 years (Go to Q12)

4 More than 3 years but not more than 5 years (Go to Q12)

5 Over 5 years ago (Go to Q12)

7 Refused (Go to Q12)

9 Don’t know (Go to Q12)

12.Question ID: NAF.423_07.000 Instrument Variable Name: CATNUM

How many CT or CAT scans to check or screen for lung cancer have you had in the LAST 3 YEARS?

*Enter '0' for none.

*Enter '95' for 95 or more CT scans.

00 None (Go to Q13)

01-94 1-94 (Go to Q13)

95 95+ (Go to Q13)

97 Refused (Go to Q13)

99 Don't know (Go to Q13)

13.Question ID: NAF.423_08.000 Instrument Variable Name: CATNEXT

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

01 Less than a year from now (End interview)

02 One year from now (End interview)

03 More than one year from now (End interview)

04 When doctor recommends it (End interview)

05 Never (End interview)

97 Refused (End interview)

99 Don't know (End interview)

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