Appendix C_Instrument English

V1

1. Is there more than one person age 18 or older living in this household?

Yes

No GO TO A1 on the next page

2. Including yourself, how many people age 18 or older live in this household?

3. The adult with the next birthday should complete this questionnaire. This way, across all households, HINTS will include responses from adults of all ages.

4. Please write the first name, nickname or initials of the adult with the next birthday. This is the person who should complete the questionnaire.

Si prefiere recibir la encuesta en español, por favor llame 1-888-738-6812

STATEMENT OF PRIVACY: Collection of this information is authorized by The Public Health Service Act, Sections 411 (42 USC 285 a) and 412 (42 USC 285a-1.a and 285a1.3). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private under the Privacy Act and will only be seen by people authorized to work on this project. The report summarizing the findings will not contain any names or identifying information. Identifying information will be destroyed when the project ends.

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN: Public reporting burden for this collection of information is estimated to average 30 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0538). Do not return the completed form to this address.

A: Looking For Health Information

A1. Have you ever looked for information about health or medical topics from any source?

Yes

No   GO TO A7 in the next column

A

X

2. The most recent time you looked for information about health or medical topics, where did you go first?

Mark only one.

Books

Brochures, pamphlets, etc.

Cancer organization

Family

Friend/Co-worker

Doctor or health care provider

Internet

Library

Magazines

Newspapers

Telephone information number

Complementary, alternative, or unconventional practitioner

Other-Specify

A3. Did you look or go anywhere else that time?

Yes

No

A4. The most recent time you looked for information about health or medical topics, who was it for?

Myself

Someone else

Both myself and someone else

A5. Have you ever looked for information about cancer from any source?

Yes

No    GO TO A7 in the next column

A6. Based on the results of your most recent search for information about cancer, how much do you agree or disagree with each of the following statements?

a. It took a lot of effort to get the information you needed
b. You felt frustrated during your search for the information
c. You were concerned about the quality of the information
d. The information you found was hard to understand

A7. Overall, how confident are you that you could get advice or information about cancer if you needed it?

Completely confident

Very confident

Somewhat confident

A little confident

Not confident at all

A8. In general, how much would you trust information about cancer from each of the following?

a. A doctor
b. Family or friends
c. Newspapers or magazines
d. Radio
e. Internet
f. Television
g. Government health agencies
h. Charitable organizations
i. Religious organizations and leaders

A9. Imagine that you had a strong need to get information about cancer. Where would you go first?

X

Mark only one.

Books

Brochures, pamphlets, etc.

Cancer organization

Family

Friend/Co-worker

Doctor or health care provider

Internet

Library

Magazines

Newspapers

Telephone information number

Complementary, alternative, or unconventional
practitioner

Other-Specify

A10. How much attention do you pay to information about cancer from each of the following sources?

a. In online newspapers
b. In print newspapers
c. In special health or medical magazines or newsletters
d. On the Internet
e. On the radio
f. On local television news programs
g. On national or cable television news programs

B: Using the Internet to Find Information

B1. Do you ever go on-line to access the Internet or World Wide Web, or to send and receive e-mail?

Yes

No   GO TO C1 on the next page

B2. When you use the Internet, do you access it through...

	Yes	No
a. A regular dial-up telephone line
b. Broadband such as DSL, cable or FiOS
c. A cellular network (i.e., phone, 3G/4G)
d. A wireless network (Wi-Fi)

B

3. Do you access the Internet any other way?

Yes – Specify

No

B4. In the past 12 months, have you used the Internet to look for information about cancer for yourself?

Yes

No

B5. Is there a specific Internet site you like to go to for information about cancer?

Yes

No   GO TO C1 on the next page

B6. Specify which Internet site you especially like as a source of information about cancer:

C: Your Health Care

C1. Not including psychiatrists and other mental health professionals, is there a particular doctor, nurse, or other health professional that you see most often?

Yes

No

C2. Do you have any of the following health insurance or health coverage plans:

	Yes	No
a. Insurance through a current or former employer or union (of you or another family member)
b. Insurance purchased directly from an insurance company (by you or another family member)
c. Medicare
d. Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability
e. TRICARE or other military health care
f. VA (including those who have ever used or enrolled for VA health care)
g. Indian Health Service

C

3. Do you have any other health care coverage plan for yourself (please do not include dental or vision plans)?

Yes-Specify

No

C4. About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.

Within past year
(anytime less than 12 months ago)

Within past 2 years
(1 year but less than 2 years ago)

Within past 5 years
(2 years but less than 5 years ago)

5 or more years ago

Don't know

Never

C5. In the past 12 months, not counting times you went to an emergency room, how many times did you go to a doctor, nurse, or other health professional to get care for yourself?

None   GO TO D1 on the next page

1 time

2 times

3 times

4 times

5-9 times

10 or more times

C6. The following questions are about your communication with all doctors, nurses, or other health professionals you saw during the past 12 months…

How often did they do each of the following:
	a. Give you the chance to ask all the health-related questions you had?
	b. Give the attention you needed to your feelings and emotions?
	c. Involve you in decisions about your health care as much as you wanted?
	d. Make sure you understood the things you needed to do to take care of your health?
	e. Explain things in a way you could understand?
	f. Spend enough time with you?
	g. Help you deal with feelings of uncertainty about your health or health care?

C7. In the past 12 months, how often did you feel you could rely on your doctors, nurses, or other health care professionals to take care of your health care needs?

Always

Usually

Sometimes

Never

C8. Overall, how would you rate the quality of health care you received in the past 12 months?

Excellent

Very good

Good

Fair

Poor

D: Medical Records

D1. As far as you know, do any of your doctors or other health care providers maintain your medical information in a computerized system?

Yes

No

D2. Please indicate how important each of the following statements is to you.

a. Doctors and other health care providers should be able to share your medical information with each other electronically
b. You should be able to get to your own medical information electronically

D3. Have you ever kept information from your health care provider because you were concerned about the privacy or security of your medical record?

Yes

No

E: Medical Research

E1. Clinical trials are research studies that involve people. They are designed to test the safety and effectiveness of new treatments and to compare new treatments with the standard care that people currently get. Have you ever heard of a clinical trial?

Yes

No

Don’t know

E2. Genetic tests that analyze your DNA, diet and lifestyle for potential health risks are currently being marketed by companies directly to consumers. Have you heard or read about these genetic tests?

Yes

No

E3. How much do you think health behaviors like diet, exercise and smoking determine whether or not a person will develop each of the following conditions? (Not at all, A little, Somewhat, Very / Don’t know)

a. Diabetes/High blood sugar
b. Obesity
c. Heart disease
d. High Blood Pressure/Hypertension
e. Cancer

E4. How much do you think genetics, that is characteristics passed from one generation to the next, determine whether or not a person will develop each of the following conditions? (Not at all, A little, Somewhat, Very / Don’t know)

a. Diabetes/High blood sugar
b. Obesity
c. Heart disease
d. High Blood Pressure/Hypertension
e. Cancer

E5. Has a doctor or other health professional ever told you that you had any of the following medical conditions:

	Yes	No
a. Diabetes or high blood sugar?
b. High blood pressure or hypertension?
c. A heart condition such as heart attack, angina, or congestive heart failure?
d. Chronic lung disease, asthma, emphysema, or chronic bronchitis?
e. Arthritis or rheumatism?
f. Depression or anxiety disorder?

F: Your Overall Health

F1. In general, would you say your health is...

Excellent,

Very good,

Good,

Fair, or

Poor?

F2. Overall, how confident are you about your ability to take good care of your health?

Completely confident

Very confident

Somewhat confident

A little confident

Not confident at all

F3. How much sleep do you usually get…

Hours

Minutes

a. On a weekday (e.g., workday or school day)?

b. On a weekend (e.g., non-work or non-school day)?

F4. About how tall are you without shoes?

Feet  and

Inches

F5. About how much do you weigh, in pounds, without shoes?

Pounds

F6. At any time in the past year, have you intentionally tried to…

lose weight,

maintain your weight,

gain weight, or

you haven’t really paid attention to your weight

F7. How much do you agree or disagree with this statement: Body weight is something basic about you that you can’t change very much?

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

F8. Over the past 2 weeks, how often have you been bothered by any of the following problems?

a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
c. Feeling nervous, anxious, or on edge
d. Not being able to stop or control worrying

F9. Is there anyone you can you count on to provide you with emotional support when you need it – such as talking over problems or helping you make difficult decisions?

Yes

No

F10. Do you have friends or family members that you talk to about your health?

Yes

No

F11. If you needed help with your daily chores is there someone who can help you?

Yes

No

G: Health and Nutrition

G1. When available, how often do you use menu information on calories in deciding what to order?

Always

Often

Sometimes

Rarely

Never   GO TO G3

G2. When available, how helpful do you find menu information on calories in deciding what to order?

Not at all helpful

A little helpful

Helpful

Very helpful

Extremely helpful

G3. How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals?

Always

Usually

Sometimes

Rarely

Never

G

1 cup of fruit could be:

• 1 small apple

• 1 large banana

• 1 large orange

• 8 large strawberries

• 1 medium pear

• 32 seedless grapes

• 1 cup (8 oz.) fruit juice

• ½ cup dried fruit

• 1 inch-thick wedge of watermelon

4. About how many cups of fruit (including 100% pure fruit juice) do you eat or drink each day?

None

½ cup or less

½ cup to 1 cup

1 to 2 cups

2 to 3 cups

3 to 4 cups

4 or more cups

G5. At any time in the past year, have you intentionally tried to . . .

INCREASE the amount of fruit or 100% fruit juice you eat or drink

MAINTAIN the same amount of fruit or 100%fruit juice you eat or drink, or

you haven’t really paid attention to the amount of fruit or 100% fruit juice you eat or drink each day

G 6. About how many cups of vegetables (including 100% pure vegetable juice) do you eat or drink each day?

None

½ cup or less

½ cup to 1 cup

1 to 2 cups

2 to 3 cups

3 to 4 cups

4 or more cups

G9. At any time in the past year, have you intentionally tried to . . .

INCREASE the amount of vegetables or 100% vegetable juice you eat or drink

MAINTAIN the same amount of vegetables or 100% vegetable juice you eat or drink, or

you haven’t really paid attention to the amount of vegetables or 100% vegetable juice you eat or drink each day

G10. Not counting any diet soda or pop, how much regular soda or pop do you usually drink in a typical week?

Every day

5-6 days a week

3-4 days a week

1-2 days a week

Less than 1 day a week

I don’t drink any regular soda or pop

G12. At any time in the past year have you intentionally tried to . . .

DECREASE the amount of regular soda or pop you usually drink a week,

MAINTAIN the same amount of regular soda or pop you usually drink a week, or

you haven’t really paid attention to amount of regular soda or pop you usually drink a week

H: Physical Activity and Exercise

H1. In a typical week, how many days do you do any physical activity or exercise of at least moderate intensity, such as brisk walking, bicycling at a regular pace, and swimming at a regular pace?

None   GO TO H3 in the next column

1 day per week

2 days per week

3 days per week

4 days per week

5 days per week

6 days per week

7 days per week

H2. On the days that you do any physical activity or exercise of at least moderate intensity, how long do you typically do these activities?

Write a number in one box below.

Minutes

Hours

H3. In a typical week, outside of your job or work around the house, how many days do you do leisure-time physical activities specifically designed to strengthen your muscles such as lifting weights or circuit training (do not include cardio exercise such as walking, biking, or swimming)?

None

1 day per week

2 days per week

3 days per week

4 days per week

5 days per week

6 days per week

7 days per week

H4. At any time in the past year, have you intentionally tried to. . .

INCREASE the amount of exercise you get in a typical week,

MAINTAIN the amount of exercise you get in a typical week, or

you haven’t really paid much attention to the amount of exercise you get

H5. People choose to start or continue exercising regularly for lots of reasons. How much do each of the following motivate you to start or continue exercising regularly?

a. Pressure from others
b. Concern over the way you look
c. Feeling guilty when you skip exercising
d. Getting enjoyment from exercise

H6. Over the past 30 days, in your leisure time, how many hours per day, on average, did you sit and watch TV or movies, surf the web, or play computer games? Do not include “active gaming” such as Wii.

Hours per day

I: Health and the Environment

I1. How much do you worry that each of the following will harm your health?

a. Outdoor air pollution
b. Indoor air pollution
c. Man-made chemicals in the water
d. Pesticides and other chemicals on food

I2. How much do you worry that each of the following will harm your health?

a. Radiation from cell phones
b. Radiation from medical imaging tests such as x-rays, mammography, radioactive dyes, etc
c. Chemicals in household items such as plastic containers, furniture, paint, etc
d. Chemicals in personal care products such as make-up, fragrances, hair products, etc

I3. How many times in the past 12 months have you used a tanning bed or booth?

0 times

1 to 2 times

3 to 10 times

11 to 24 times

25 or more times

I4. When you are outside for more than one hour on a warm, sunny day, how often do you wear sunscreen?

Never

Rarely

Sometimes

Often

Always

Don’t go out on sunny days   GO TO J1

I5. When you are outside for more than one hour on a warm, sunny day, how often do you ...

a. wear long pants?
b. wear a hat that shades your face, ears and neck?
c. wear a shirt with sleeves that cover your shoulders?
d. stay in the shade or under an umbrella?

J: Tobacco and Alcohol

J1. Have you smoked at least 100 cigarettes in your entire life?

Yes

No   GO TO J6 on the next page

J2. How often do you now smoke cigarettes?

Everyday

Some days

Not at all

J3. At any time in the past year, have you stopped smoking for one day or longer because you were trying to quit?

Yes

No

J4.   Are you seriously considering quitting smoking in the next six months?

Yes

No

J5. At any time in the past year, have you talked with your doctor or other health professional about having a test to check for lung cancer?

Yes

No

Don’t know

J6. How much do you agree or disagree with this statement: “Smoking behavior is something basic about you that you can’t change very much.”

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

J7. In your opinion, do you think that some types of cigarettes are less harmful to a person’s health than other types?

Yes

No

Don’t know

J8. In your opinion, do you think that some smokeless tobacco products, such as chewing tobacco, snus and snuff are less harmful to a person’s health than cigarettes?

Yes

No

Don’t know

J9. Compared to people who smoke every day, do you think people who smoke just some days have less or more risk of getting health problems in their lifetime?

Much less risk

Less risk

About the same risk

More risk

Much more risk

J10. New types of cigarettes are now available called electronic cigarettes (also known as e-cigarettes or personal vaporizers). These products deliver nicotine through a vapor. Compared to smoking cigarettes, would you say that electronic cigarettes are …

Much less harmful

Less harmful

Just as harmful

More harmful

Much more harmful

I’ve never heard of electronic cigarettes

J11. Do you believe that the United States Food and Drug Administration (FDA) regulates tobacco products in the U.S.?

Yes

No

Don’t know

J12. A drink of alcohol is 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 cocktail, or 1 shot of liquor.

During the past 30 days, how many days per week did you have at least one drink of any alcoholic beverage?

0 days   GO TO J16 on the next page

1 day

2 days

3 days

4 days

5 days

6 days

7 days

J13. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?

Drink(s)

K: Women and Cancer

K1. Are you male or female?

Male   GO TO L1 on the next page

Female

K2. Has a doctor ever told you that you could choose whether or not to have the Pap test?

Yes

No

K3. How long ago did you have your most recent Pap test to check for cervical cancer?

A year ago or less

More than 1, up to 2 years ago

More than 2, up to 3 years ago

More than 3, up to 5 years ago

More than 5 years ago

I have never had a Pap test

K4. If your doctor told you that getting a Pap test less often than you do now would give you the same health benefits, would you...

Agree to have Pap tests less often

Keep having Pap tests as often as you do now

K5. A mammogram is an x-ray of each breast to look for cancer.

Has a doctor ever told you that you could choose whether or not to have a mammogram?

Yes

No

K6. When did you have your most recent mammogram to check for breast cancer, if ever?

A year ago or less

More than 1, up to 2 years ago

More than 2, up to 3 years ago

More than 3, up to 5 years ago

More than 5 years ago

I have never had a mammogram

L: Screening for Cancer

L1. A vaccine to prevent HPV infection is available and is called the HPV shot, cervical cancer vaccine, GARDASIL®, or Cervarix®.

Has a doctor or other health care professional ever talked with you about the HPV shot or vaccine?

Yes

No

L2. Including yourself, is anyone in your immediate family between the ages of 9 and 27 years old?

Yes

No  GO TO L4

L3. In the last 12 months, has a doctor or health care professional recommended that you or someone in your immediate family get an HPV shot or vaccine?

Yes

No

Don’t know

L4. In your opinion, how successful is getting a Pap test on a regular basis at detecting cervical cancer in its earliest stages?

Not at all successful

A little successful

Pretty successful

Very successful

Don’t know

L5. In your opinion, how successful is receiving the HPV vaccine at preventing cervical cancer?

Not at all successful

A little successful

Pretty successful

Very successful

Don’t know

L6. There are a few different tests to check for colon cancer. These tests include:

A colonoscopy – For this test, a tube is inserted into your rectum and you are given medication that may make you feel sleepy. After the procedure, you need someone to drive you home.

A sigmoidoscopy – For this test, you are awake when the tube is inserted into your rectum. After the test you can drive yourself home.

A stool blood test – For this test, you collect a stool sample at home, and then provide it to a doctor or lab for testing.

Has a doctor ever told you that you could choose whether or not to have a test for colon cancer?

Yes

No

L7. Have you ever had a test to check for colon cancer?

Yes

No

L8. (Females go to M1 on the next page. Males continue with L8). The following questions are about discussions doctors or other health care professionals may have with their patients about the PSA test that is used to look for prostate cancer.

Have you ever had a PSA test?

Yes

No

L9. Would you prefer your doctor involve you in the decision about whether or not you should have the PSA test, or would you prefer the doctor decide for you?

I would like to be involved in the decision

I would rather the doctor decide

 

L10. Regardless of your preference, has a doctor ever discussed with you whether or not you should have the PSA test?

Yes

No  GO TO L12

L11. Did you have as much involvement as you wanted in the decision whether to have a PSA test?

Yes

No, I would have preferred more involvement

L12. Has a doctor or other health care professional ever told you that some doctors recommend the PSA test and others do not?

Yes

No

L13. Has a doctor or other health care professional ever told you that no one is sure if using the PSA test actually saves lives?

Yes

No

L14. Has a doctor or other health care professional ever told you that...

	Yes	No
a. The PSA test is not always accurate?
b. Some types of prostate cancer are slow-growing and need no treatment?
c. The results of the PSA test cannot tell the difference between slow-growing and fast-growing prostate cancer?
d. Treating any type of prostate cancer can lead to serious side-effects, such as problems with urination or having sex?

M: Your Cancer History

M1. Have you ever been diagnosed as having cancer?

Yes

No   GO TO N1 on page 20

M

X

2. What type of cancer did you have?

Mark all that apply.

Bladder cancer

Bone cancer

Breast cancer

Cervical cancer (cancer of the cervix)

Colon cancer

Endometrial cancer (cancer of the uterus)

Head and neck cancer

Hodgkin's lymphoma

Leukemia/Blood cancer

Liver cancer

Lung cancer

Melanoma

Non-Hodgkin lymphoma

Oral cancer

Ovarian cancer

Pancreatic cancer

Pharyngeal (throat) cancer

Prostate cancer

Rectal cancer

Renal (kidney) cancer

Skin cancer, non-melanoma

Stomach cancer

Other-Specify

M3. At what age were you first told that you had cancer?

Age

M4. Did you ever receive any treatment for your cancer?

Yes

No   GO TO M7 in the next column

M5. Which of the following cancer treatments have you ever received?

	Yes	No
a. Chemotherapy (IV or pills)
b. Radiation
c. Surgery
d. Other

M6. About how long ago did you receive your last cancer treatment?

Still receiving treatment    GO TO M9

Less than 1 year ago

1 year ago to less than 5 years ago

5 years ago to less than 10 years ago

10 or more years ago

M7. Did you ever receive a summary document from your doctor or other health care professional that listed all of the treatments you received for you cancer?

Yes

No   

M8. Have you ever received instructions from a doctor or other health care professional about where you should return or who you should see for routine cancer check-ups after completing your cancer treatment?

Yes

No

M9. Were you ever denied health insurance coverage because of your cancer?

Yes

No

M10. Looking back, since the time you were first diagnosed with cancer, how much of an impact has cancer and its treatment had on your financial situation?

No impact at all

A small impact

A moderate impact

A large impact

M11. Have you ever participated in a clinical trial for treatment of your cancer?

Yes

No

Not sure

M12. Has a doctor or other member of your medical team discussed clinical trials as a treatment option for your cancer?

Yes

No

If you have ever had a cancer diagnosis, please GO TO N7

N: Beliefs About Cancer

Think about cancer in general when answering the questions in this section.

N1. How likely are you to get cancer in your lifetime?

Very unlikely

Unlikely

Neither unlikely nor likely

Likely

Very likely

N2. Compared to other people your age, how likely are you to get cancer in your lifetime?

Much less likely

Less likely

About the same

More likely

Much more likely

N3. Select one answer that best represents your opinion about the statement: “I feel like I could easily get cancer in my lifetime.”

I feel very strongly that this will NOT happen

I feel somewhat strongly that this will NOT happen

I feel I am just as likely to get cancer as I am to not get cancer

I feel somewhat strongly that this WILL happen

I feel very strongly that this WILL happen

N5. How much to you agree or disagree with the statement: “I’d rather not know my chance of getting cancer.”

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

N7. How much do you agree or disagree with each of the following statements?

a. It seems like everything causes cancer
b. There’s not much you can do to lower your chances of getting cancer
c. There are so many different recommendations about preventing cancer, it's hard to know which ones to follow
d. Some cancers are slow growing and need no treatment
e. In adults, cancer is more common than heart disease
f. In women, breast cancer is more common than lung cancer

N8. As far as you know, who has a greater chance of getting cancer – a person with a 1 in 1,000 chance of getting cancer, or a person with a 1 in 100 chance?

1 in 1,000 is a greater chance of getting cancer

1 in 100 is a greater chance of getting cancer

N9. Have any of your family members ever had cancer?

Yes

No

Not sure

O: You and Your Household

O1. What is your age?

Years old

O

X

2. What is your current occupational status?

Mark only one.

Employed

Unemployed

Homemaker

Student

Retired

Disabled

Other-Specify

O3. Have you ever served on active duty in the U.S. Armed Forces, military Reserves or National Guard? Active duty does not include training in the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.

Yes, now on active duty

Yes, on active duty in the last 12 months but
not now

Yes, on active duty in the past, but not in the
last 12 months

No, training for Reserves or

National Guard only GO TO O5

No, never served in the military

O4. In the past 12 months, have you received some or all of your health care from a VA hospital or clinic?

Yes, all my health care

Yes, some of my health care

No, no VA health care received

O5. What is your marital status?

Married

Living as married

Divorced

Widowed

Separated

Single, never been married

O6. What is the highest grade or level of schooling you completed?

Less than 8 years

8 through 11 years

12 years or completed high school

Post high school training other than college
(vocational or technical)

Some college

College graduate

Postgraduate

O7. Were you born in the United States?

Yes   GO TO O10 in the next column

No

O8. In what year did you come to live in the United States?

Year

O9. How well do you speak English?

Very well

Well

Not well

Not at all

O

X

10. Are you Hispanic, Latino/a, or Spanish origin? One or more categories may be selected.

Mark one or more.

No, not of Hispanic, Latino/a, or Spanish origin

Yes, Mexican, Mexican American, Chicano/a

Yes, Puerto Rican

Yes, Cuban

Yes, another Hispanic, Latino/a, or Spanish origin

O

X

11. What is your race? One or more categories may be selected.

Mark one or more.

White

Black or African American

American Indian or Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

O12. Including yourself, how many people live in your household?

Number of people

O13. Including yourself, please mark the sex, and write in the age and month of birth for each adult 18 years of age or older living at this address.

Sex

Age

M onth Born

(01-12)

Adult 1

Male

Female

Adult 2

Male

Female

Adult 3

Male

Female

Adult 4

Male

Female

Adult 5

Male

Female

O14. How many children under the age of 18 live in your household?

Number of children under 18

O15. Do you currently rent or own your home?

Own

Rent

Occupied without paying monetary rent

O16. Does anyone in your family have a working cell phone?

Yes

No

O17. Is there at least one telephone inside your home that is currently working and is not a cell phone?

Yes

No

O18. Thinking about members of your family living in this household, what is your combined annual income, meaning the total pre-tax income from all sources earned in the past year?

$0 to $9,999

$10,000 to $14,999

$15,000 to $19,999

$20,000 to $34,999

$35,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $199,999

$200,000 or more

O19. Are you deaf or do you have serious difficulty hearing?

Yes

No

O20. Are you blind or do you have serious difficulty seeing, even when wearing glasses?

Yes

No

O21. Because of a physical, mental or emotional condition, do you have serious difficulty concentrating, remembering or making decisions?

Yes

No

O22. Do you have serious difficulty walking or climbing stairs?

Yes

No

O23. Do you have difficulty dressing or bathing?

Yes

No

O24. Because of a physical, mental or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

Yes

No

O25. Did you complete this survey all in one sitting, or did you do it in more than one sitting?

I completed the survey all in one sitting.

I completed the survey in more than one sitting.

O26. Did anyone help you complete this survey?

Yes

No

O27. About how long did it take you to complete the survey?

Write a number in one box below.

Minutes

Hours

O

X

28. At which of the following types of addresses does your household currently receive residential mail?

Mark all that apply.

A street address with a house or building number

An address with a rural route number

A U.S. post office box (P.O. Box)

A commercial mail box establishment (such as Mailboxes R Us, and Mailboxes Etc.)

Thank you!

P lease return this questionnaire in the postage-paid envelope at your earliest convenience.

If you have lost the envelope, mail the completed questionnaire to:

HINTS Study, TC 1046F

Westat

1600 Research Boulevard

Rockville, MD 20850

2