Adult Targeted Survey

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Adult Targeted Surveillance Survey

Public reporting burden of this collection of information is estimated to average 28 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

Adult Targeted Surveillance Survey

[INTERVIEWER SHOULD ONLY READ STATEMENTS IN lower case.]

[INSTRUCTIONS TO INTERVIEWERS ARE IN UPPER CASE[

[INTRODUCTION]

Intro. I’d like to start by finding out about you and the people in your household.

{SELECT NEXT}

INTRO_1. What is your age?

_ _ {RANGE 0 – 99}

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[ASK INTRO_1_CONF IF (INTRO_1<18), ELSE GO TO INTRO_2]

INTRO_1_CONF. IN A NEUTRAL TONE, ASK: You said that you were {fill number from INTRO_1 } years old, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if no, DK or RF, go back TO INTRO_1, IF YES go to age_inelig]

Age_inelig. Unfortunately this survey can only be administered to an adult resident of the household who is 18 years or older. Those are all the questions that I have for you today. Thank you.

END INTERVIEW AND SUBMIT A PROBLEM SHEET AND

[END]

INTRO_2 if necessary, say: (For survey purposes, I need to confirm, are you male or female?)

1 MALE
2 FEMALE

INTRO_3 Are you currently ….?

IF NEEDED, SAY: (Please choose the category that describes your current situation the best.)

1 Married
2 Divorced
3 Widowed
4 Separated
5 Never married, or

6 A member of an unmarried couple

-1 DON’T KNOW
-2 REFUSED

INTRO_4 How many children less than 18 years of age live in your household?

_ _ Number of children {range 0 – 20}

-1 DON’T KNOW
-2 REFUSED

INTRO_5. What is the highest grade or year of school you completed?

Read only if necessary:

1 Never attended school or only attended kindergarten

2 Grades 1 through 8 (Elementary)

3 Grades 9 through 11 (Some high school)

4 Grade 12 or GED (High school graduate)

5 College 1 year to 3 years (Some college or technical school)

6 College 4 years or more (College graduate)

-1 DON’T KNOW / NOT SURE

-2 REFUSED

INTRO_6. Are you currently….?

IF NEEDED, SAY: (Which one of these would you say is your main status now?)

1 Employed for wages
2 Self-employed
3 Out of work for more than 1 year
4 Out of work for less than 1 year
5 A Homemaker
6 A Student
7 Retired

8 Unable to work

-1 DON’T KNOW

-2 REFUSED

INTRO_7. What is your annual household income from all sources -

If respondentHESITATES OR refuses at income level, code REFUSED

_________ {RANGE: 0-1,000,000}

[IF INTRO_7=-1 (dk) OR -2 (rf), GO TO INTRO_7_04, ELSE GO TO P_INTRO]

INTRO_7_04 – (What is your annual household income from all sources?) Is it less than $25,000?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[If INTRO_7_04=“no,” ask 05; if “yes,” ask INTRO_7_03; if -1 or -2, skip to p_intro]

INTRO_7_03 - – (What is your annual household income from all sources?) Is it less than $20,000

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[If INTRO_7_03=“no,” go to p_intro; if “yes,” ask INTRO_7_02; if -1 or -2, skip to p_intro]

INTRO_7_02 - – (What is your annual household income from all sources?) Is it less than $15,000

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[If INTRO_7_02=“no,” go to p_intro; if “yes,” ask INTRO_7_01; if -1 or -2, skip to p_intro]

INTRO_7_01 - – (What is your annual household income from all sources?) Is it less than $10,000

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[After presenting INTRO_7_01, go to p_intro]

INTRO_7_05 - – (What is your annual household income from all sources?) Is it less than $35,000

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF INTRO_7_05=YES, go to p_intro; If “no,” ask INTRO_7_06; if -1 or -2, skip to p_intro]

INTRO_7_06 - – (What is your annual household income from all sources?) Is it less than $50,000

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF INTRO_7_06=YES, go to p_intro; If “no,” ask INTRO_7_07; if -1 or -2, skip to p_intro]

INTRO_7_07 - – (What is your annual household income from all sources?) Is it less than $75,000

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[After presenting 07, go to p_intro]

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[PHYSICAL ACTIVITY]

P_INTRO. Now, I am going to ask you a few questions about your physical activity habits. For these questions, think about the exercise, recreation, or physical activities you perform{TEXT FILL IF INTRO_6=1, 2 (EMPLOYED) “, other than your regular job duties.”}

{SELECT NEXT}

PA00. During the past month, {TEXT FILL IF INTRO_6=1, 2 (EMPLOYED) “, other than your regular job,”} did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

1 YES

2 NO {GO TO PA04}

-1 DON’T KNOW
-2 REFUSED

PA01. What type of physical activity or exercise did you spend the most time doing during the past month?

If the respondent’s activity is not included in the Coding List, choose the option listed as “Other “.

Housework may be included as a physical activity or exercise spent and can be coded as “Other”.

01 ACTIVE GAMING DEVICES (WII FIT, DANCE DANCE REVOLUTION)

02 AEROBICS VIDEO OR CLASS

03 BACKPACKING

04 BADMINTON

05 BASKETBALL

06 BICYCLING MACHINE EXERCISE

07 BICYCLING

08 BOATING (CANOEING, ROWING, KAYAKING, SAILING FOR PLEASURE OR CAMPING)

09 BOWLING

10 BOXING

11 CALISTHENICS

12 CANOEING/ROWING IN COMPETITION

13 CARPENTRY

14 DANCING-BALLET, BALLROOM, LATIN, HIP HOP, ETC

15 ELLIPTICAL/EFX MACHINE EXERCISE

16 FISHING FROM RIVER BANK OR BOAT

17 FRISBEE

18 GARDENING (SPADING, WEEDING, DIGGING, FILLING)

19 GOLF (WITH MOTORIZED CART)

20 GOLF (WITHOUT MOTORIZED CART)

21 HANDBALL

22 HIKING – CROSS-COUNTRY

23 HOCKEY

24 HORSEBACK RIDING

25 HUNTING LARGE GAME – DEER, ELK

26 HUNTING SMALL GAME – QUAIL

27 INLINE SKATING

28 JOGGING

29 LACROSSE

30 MOUNTAIN CLIMBING

31 MOWING LAWN

32 PADDLEBALL

33 PAINTING/PAPERING HOUSE

34 PILATES

35 RACQUETBALL

36 RAKING LAWN

37 RUNNING

38 ROCK CLIMBING

39 ROPE SKIPPING

40 ROWING MACHINE EXERCISE

41 RUGBY

42 SCUBA DIVING

43 SKATEBOARDING

44 SKATING – ICE OR ROLLER

45 SLEDDING, TOBOGGANING

46 SNORKELING

47 SNOW BLOWING

48 SNOW SHOVELING BY HAND

49 SNOW SKIING

50 SNOWSHOEING

51 SOCCER

52 SOFTBALL/BASEBALL

53 SQUASH

54 STAIR CLIMBING/STAIR MASTER

55 STREAM FISHING IN WADERS

56 SURFING

57 SWIMMING

58 SWIMMING IN LAPS

59 TABLE TENNIS

60 TAI CHI

61 TENNIS

62 TOUCH FOOTBALL

63 VOLLEYBALL

64 WALKING

66 WATERSKIING

67 WEIGHT LIFTING

68 WRESTLING

69 YOGA

70 OTHER

-1 DON’T KNOW / NOT SURE [GO TO PA04]
-2 REFUSED [GO TO PA04]

[IF PA01=70, PRESENT PA01_OTH; ELSE GO TO PA02]

PAO1_OTH. PLEASE SPECIFY “OTHER” _____________ [ACCEPT UP TO 500 CHARACTERS]

PA02. How many times per week or per month did you take part in this activity during the past month?

IF NEEDED, ASK: “Is that __ times per week or __ times per month?”

____Times per week ____Times per month{ Never
-1 DON’T KNOW / NOT SURE
-2 REFUSED

{HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF}

[ASK PA02_CONF IF (Times per week > 5) OR (Times per month >15)]

PA02_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from PA02} times per {fill unit from PA02}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if yes, continue; IF no, DK or RF, go back]

pa03. And when you took part in this activity, for how many minutes or hours did you usually keep at it?

IF NEEDED, ASK: “Is that ___ hours or __ minutes?”

_ _ Hours {RANGE 0 – 24} _ _ minutes {RANGE 0 – 60}
-1 DON’T KNOW / NOT SURE
-2 REFUSED

{ALLOW ENTRIES IN BOTH HOURS AND/OR MINUTES}

{HARD CHECK TEXT: PLEASE MAKE SURE THAT YOU HAVE ENTERED BOTH A NUMERICAL AMOUNT IN THE TEXT FIELD FOR HOURS THAT IS LESS THAN 24 AND/OR AN AMOUNT LESS THAN 60 IN THE MINUTES TEXT FIELD.

ALSO VERIFY THAT YOU HAVE SELECTED A REPORTING PERIOD, BY HOUR AND/OR BY MINUTES}

[ASK PA03_CONF IF (PA03 SUM OF hours AND (MINUTES/60)>=2 hours)]

PA03_CONF. IN A NEUTRAL TONE, ASK: You said {FILL HOURS NUMBER FROM PA03} hours and {FILL MINUTES NUMBER FROM PA03}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if yes, continue; IF no, DK or RF, go back]

pa05. In a typical week, how many days do you walk or cycle for at least 30 minutes? Include walking or cycling for leisure, transportation or for exercise.

1. None {go to pa04}

2. _1 day

3. _2 days

4. _3 days

5. _4 days

6. _5 days

7. _6 days

8. _7 days

-1__DON’T KNOW/NOT SURE

-2__REFUSED

pa05a [SKIP IF PA05=1]. What is the main reason that you walk or bicycle? Is it for leisure, transportation or exercise?

__1. LEISURE

__2. TRANSPORTATION

__3. EXERCISE

__-1. DON’T KNOW/NOT SURE

__-2. REFUSED

pa04. Now, I would like to talk about your neighborhood as a place for walking and cycling.

In thinking about your neighborhood as a place to walk and bicycle, please tell me if you strongly agree, somewhat agree, somewhat disagree or strongly disagree with the following statements.

{SELECT NEXT}

pa04a. There are sidewalks on most of the streets in my neighborhood. Would you say….

1 Strongly agree

2 Somewhat agree

3 Somewhat Disagree

4 Strongly Disagree

5 THERE ARE NO SIDEWALKS IN MY NEIGHBORHOOD

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if Pa04a=5 (no Sidewalks in neighborhood), then skip to PA04c]

pa04b. The sidewalks in my neighborhood are well maintained (paved, even, and not a lot of cracks). Would you say….

1 Strongly agree

2 Somewhat agree

3 Somewhat disagree

4 Strongly disagree

5 THERE ARE NO SIDEWALKS IN MY NEIGHBORHOOD

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if Pa04a=5 or PA04b=5 (no Sidewalks in neighborhood), then skip to PA04c]

pa04d. When I am walking on a sidewalk in my neighborhood, there are parked cars between and me and the road. (Would you say….

READ OPTIONS IF NEEDED

1 STRONGLY AGREE

2 SOMEWHAT AGREE

3 SOMEWHAT DISAGREE

4 STRONGLY DISAGREE

5 THERE ARE NO SIDEWALKS IN MY NEIGHBORHOOD

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if Pa04a=5 or PA04b=5 or pa04d=5 (no Sidewalks in neighborhood), then skip to PA04c]

PA04e. There is a grass ordirt strip that separates the streets from the sidewalks in my neighborhood. (Would you say….

READ OPTIONS IF NEEDED

1 STRONGLY AGREE

2 SOMEWHAT AGREE

3 SOMEWHAT DISAGREE

4 STRONGLY DISAGREE

5 THERE ARE NO SIDEWALKS IN MY NEIGHBORHOOD

-1 DON’T KNOW / NOT SURE
-2 REFUSED

pa04c. There are bicycle or pedestrian trails in or near my neighborhood that are easy to get to. (Would you say….

READ OPTIONS IF NEEDED

1 STRONGLY AGREE

2 SOMEWHAT AGREE

3 SOMEWHAT DISAGREE

4 STRONGLY DISAGREE

-1 DON’T KNOW / NOT SURE
-2 REFUSED

pa06. Besides what you already told me about the sidewalks and trails in your neighborhood, why don’t you walk or cycle more often in your neighborhood?

ACCEPT ALL ANSWERS AND PROBE UNTIL R INDICATES NO OTHERS APPLY: Any others?

{ALLOW MULTIPLE RESPONSES}

1 Weather
2 Lack of time
3 Nowhere to go
4 No sidewalks
5 Too much traffic
6 Medical conditions
7 Lack of energy / motivation
8 Exercise elsewhere
9 Safety (crime)

10 I WALK OR CYCLE AS MUCH AS I WANT TO
11 Other
-1 Don't know / Not sure
-2 REFUSED

[NUTRITION]

N_INTRO. Now I’d like to ask you about foods and drinks you have recently eaten.

Let’s start by talking about the fruits and vegetables you ate or drank during the past 30 days.

Please think about all forms of fruits and vegetables including cooked or raw, fresh, frozen or canned. Please think about all meals, snacks, and food consumed at home and away from home. I will be asking how often you ate or drank each one: for example, once a day, twice a week, three times a month, and so forth.

{SELECT NEXT}

N_05. During the past month, that is since {FILL IN DATE 30 DAYS AGO}, how often did you drink sweetened fruit drinks, such as Kool-aid, cranberry juice cocktail, and lemonade, including fruit drinks you made at home and added sugar to?

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If says less than once per month, put “0” times per month.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Fruit drinks are sweetened beverages that often contain some fruit juice or flavoring.)

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC DRINK, SAY YES IF IT IS ON THE ‘DO INCLUDE’ LIST AND NO IF IT IS ON THE ‘DO NOT INCLUDE’ LIST. IF THE SPECIFIC DRINK IS NOT IN ANY LIST, RE-READ QUESTION.

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

D o Include Do not Include

Sweetened Fruit Drinks mixed with Alcohol 100% Fruit Juice Energy drinks

Coffee Drinks Sports drinks

Sweet Tea

1 _ _ Times per day
2 _ _ Times per week
3 _ _ Times per month
4 never
-1 DON’T KNOW / NOT SURE
-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_05_CONF. IF (Times per day > 2) OR (times per week>14 or <3) or (Times per month >60 OR <14)]

N_05_CONF. IN A NEUTRAL TONE, ASK: You said you drink sweetened fruit drinks {fill number from N_05} times per {fill unit from N_05}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if yes, continue; IF no, DK or RF, go back]

N_01. During the past month, (that is since {FILL IN DATE30 DAYS AGO},) how many times per day, week or month did you drink 100% PURE fruit juices that were not fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to.

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If says less than once per month, put “0” times per month.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Only include 100% Pure Fruit Juices, 100% Pure Juice from Concentrate and 100% Juice Blends. Do not include Vegetable Juices or Fruit Juices with added sugar. Some examples, but not all, of what to include and what not to include are listed below.)

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC DRINK, SAY YES IF IT IS ON THE ‘DO INCLUDE’ LIST AND NO IF IT IS ON THE ‘DO NOT INCLUDE’ LIST. IF THE SPECIFIC DRINK IS NOT IN ANY LIST, RE-READ QUESTION.

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

D o Include Do not Include

Apple Grape Cranberry Cocktail Gatorade

Grapefruit Mango Fruitopia Hi-C

Orange-Pineapple Orange-Tangerine Kool-Aid Lemonade

Papaya Pineapple Power-Ade Snapple

Sunny Delight Tampico

V8 Yogurt Drinks

1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
4 never
-1 DON’T KNOW / NOT SURE
-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_01_CONF. IF (Times per day > 2) OR (times per week>14 or <3) or (Times per month >60 OR <14)]

N_01_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_01} times per {fill unit from N_01}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if yes, continue, no, DK or RF, go back]

N_02. During the past month,(that is since [FILL IN DAY 30 DAYS AGO],) not counting juice or sweetened fruit drinks, how many times per day, week, or month did you eat fruit, including fresh, frozen, or canned fruit?

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If says less than once per month, put “0” times per month.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Include cut up fresh, frozen, or canned fruit. Do not include dried fruit in ready-to-eat cereals. Do not include fruit jams and similar products. Some examples, but not all, of what to include and what not to include are listed below.)

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC DRINK, SAY YES IF IT IS ON THE ‘DO INCLUDE’ LIST AND NO IF IT IS ON THE ‘DO NOT INCLUDE’ LIST. IF THE SPECIFIC DRINK IS NOT IN ANY LIST, RE-READ QUESTION.

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

D o Include Do not Include

Apples Applesauce Akee Fruit Jam Jelly

Bananas Blueberries Bread Fruit Fruit added to Cereal

Cantaloupe Carambola Figs Fruit added to Jell-o

Genip Grape fruit Grapes Fruit added to Yogurt

Fruit salad Longans Lychees Fruit Preserves

Mangos Musk Melon Oranges

Papaya Pomegranates Rambutan

Sea Grapes Soursop Star Fruit

Strawberries Sugar Apple Tamarind

Watermelon

1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
4 never
-1 DON’T KNOW / NOT SURE
-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_02_CONF. IF (Times per day > 4) OR (times per week>18 or <6) or (Times per month >60 OR <21)]

N_02_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_02} times per {fill unit from N_02}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if yes, continue; IF no, DK or RF, go back]

N_13 During the past month, (that is since [FILL IN DAY 30 DAYS AGO]) how many times per day, week, or month did you eat cooked or canned beans, such as refried, baked, black, garbanzo beans, beans in soup, soybeans, edamame, tofu or lentils. Do not include long green beans.

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If respondent responds less than once per month, put “0” times per month.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Include round or oval beans, soybeans, and bean burgers. Do not include long green beans. Some examples, but not all, of what to include and what not to include are listed below.)

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC DRINK, SAY YES IF IT IS ON THE ‘DO INCLUDE’ LIST AND NO IF IT IS ON THE ‘DO NOT INCLUDE’ LIST. IF THE SPECIFIC DRINK IS NOT IN ANY LIST, RE-READ QUESTION.

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

D o Include Do not Include

Black-eyed Peas Cow Peas Broad Beans Pole Beans

Edamame Falafel String Beans Winged Beans

Garden Burgers Hummus

Lentils Lima beans

Kidney Beans Navy Beans

Pinto Beans Soy Beans

Split Peas Tempeh

Tofu Veggie Burgers

White beans

1 _ Per day
2 _ _Per week
3 _ _Per month

4 NEVER

-1 DON’T KNOW / NOT SURE

-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_13_CONF. IF (Times per day > 4) OR (times per week>18 or <6) or (Times per month >60 OR <21)]

N_13_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_13} times per {fill unit from N_13}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if yes, continue; no, DK or RF, go back]

N_14 During the past month, (that is since [FILL IN DAY 30 DAYS AGO],) how many times per day, week, or month did you eat dark green vegetables, for example, broccoli or dark leafy greens including romaine, chard, collard greens or spinach?

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If respondent responds less than once per month, put “0” times per month.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Include all raw leafy green salads and cooked greens, but do not include iceberg lettuce. Some examples, but not all, of what to include and what not to include are listed below.)

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC DRINK, SAY YES IF IT IS ON THE ‘DO INCLUDE’ LIST AND NO IF IT IS ON THE ‘DO NOT INCLUDE’ LIST. IF THE SPECIFIC DRINK IS NOT IN ANY LIST, RE-READ QUESTION.

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

D o Include Do not Include

Arugula Bok Choy Iceburg Lettuce

Choys Collard Greens

Dandelions Kale

Komatsuna Mesclun

Mustard Greens Romaine Lettuce

Spinach Turnip greens

Watercress

1 _ Per day
2 _ _Per week
3 _ _Per month

4 NEVER

-1 DON’T KNOW / NOT SURE

-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_14_CONF. IF (Times per day > 4) OR (times per week>18 or <6) or (Times per month >60 OR <21)]

N_14_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_14} times per {fill unit from N_14}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if yes, continue; IF no, DK or RF, go back]

N_15 During the past month, (that is since [FILL IN DAY 30 DAYS AGO],) how many times per day, week, or month did you eat orange-colored vegetables such as sweet potatoes, pumpkin, winter squash, or carrots?

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If respondent responds less than once per month, put “0” times per month.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Include all forms of carrots and winter squash and all forms of sweet potatoes. Also include all forms of pumpkin, but do not include grain-based dessert-type food containing pumpkin. Some examples, but not all, of what to include and what not to include are listed below.)

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC DRINK, SAY YES IF IT IS ON THE ‘DO INCLUDE’ LIST AND NO IF IT IS ON THE ‘DO NOT INCLUDE’ LIST. IF THE SPECIFIC DRINK IS NOT IN ANY LIST, RE-READ QUESTION.

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

D o Include Do not Include

Acorn Squash Autumn Cup Squash Pumpkin Bars Pumpkin Bread

Baby-cut Carrots Baked Sweet Potato Pumpkin Cake

Banana Squash Buttercup Squash

Butternut Squash Carrot-Slaw

Delicata Squash Hubbard Squash

Kabocha Squash Long Carrots

Mashed Sweet Potato (mashed, casserole, pie)

Pumpkin Pumpkin Soup

Pumpkin Pie Spaghetti Squash

Sweet Potatoes Fries

1 _ Per day
2 _ _Per week
3 _ _Per month

4 NEVER

-1 DON’T KNOW / NOT SURE

-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_15_CONF. IF (Times per day > 4) OR (times per week>18 or <6) or (Times per month >60 OR <21)]

N_15_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_15} times per {fill unit from N_15}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if yes, continue; if no, DK or RF, go back]

N_16 Not counting what you just told me about (dark green vegetables and orange-colored vegetables), during the past month, (that is since [FILL IN DAY 30 DAYS AGO],) about how many times per day, week, or month did you eat other vegetables, such as tomatoes, tomato juice or V-8 juice, corn, eggplant, peas, lettuce, cabbage, and white potatoes that are not fried such as baked or mashed potatoes?

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If SAYS less than once per month, put “0” times per month.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Include any form of vegetable (raw, cooked, canned, or frozen) not listed in the examples above. Do not include products consumed usually as condiments. Do not include rice or other grains. Some examples, but not all, of what to include and what not to include are listed below.)

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC DRINK, SAY YES IF IT IS ON THE ‘DO INCLUDE’ LIST AND NO IF IT IS ON THE ‘DO NOT INCLUDE’ LIST. IF THE SPECIFIC DRINK IS NOT IN ANY LIST, RE-READ QUESTION.

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST

D o Include Do NOT Include

American-style cole-slaw Avocado Catsup Chutney

Bean Sprouts Beets Fried potatoes Ketchup

Broad Beans Cabbage Relish Salsa

Cauliflower Corn

Cucumber Daikon

Jicama Mushrooms

Okra Onions

Oriental cucumber Peas

Peppers (red, green, yellow, orange)

Pole-beans Snap Peas

Snow Peas String Beans

Tomatoes Tomato Juice

Wax-beans

1 _ Per day
2 _ _Per week
3 _ _Per month

4 NEVER

-1 DON’T KNOW / NOT SURE

-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_16_CONF. IF (Times per day > 4) OR (times per week>18 or <6) or (Times per month >60 OR <21)]

N_16_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_16} times per {fill unit from N_16}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if yes, continue; if no, DK or RF, go back]

N_11 Thinking now about buying, preparing, and eating fruits and vegetables, please say if you strongly agree, somewhat agree, somewhat disagree or strongly disagree with each statement.

{SELECT NEXT}

N_11a There is a wide variety of fruits and vegetables where I shop. (Would you say….

1 Strongly Agree

2 Somewhat Agree

3 Somewhat Disagree

4 Strongly Disagree

-1 DON’T KNOW/NOT SURE

-2 REFUSED

N_11b The fruits and vegetables where I shop are at good prices. (Would you say….

1 Strongly Agree

2 Somewhat Agree

3 Somewhat Disagree

4 Strongly Disagree

-1 DON’T KNOW/NOT SURE

-2 REFUSED

N_11c The fruits and vegetables where I shop are of good quality. (Would you say….

1 Strongly Agree

2 Somewhat Agree

3 Somewhat Disagree

4 Strongly Disagree

-1 DON’T KNOW/NOT SURE

-2 REFUSED

N_11d Fruits and vegetables take too much time to prepare. (Would you say….

READ OPTIONS IF NEEDED

1 STRONGLY AGREE

2 SOMEWHAT AGREE

3 SOMEWHAT DISAGREE

4 STRONGLY DISAGREE

-1 DON’T KNOW/NOT SURE

-2 REFUSED

N_11e I do not like the taste of fruits. (Would you say….

READ OPTIONS IF NEEDED

1 STRONGLY AGREE

2 SOMEWHAT AGREE

3 SOMEWHAT DISAGREE

4 STRONGLY DISAGREE

-1 DON’T KNOW/NOT SURE

-2 REFUSED

N_11f I do not like the taste of vegetables. (Would you say….

READ OPTIONS IF NEEDED

1 STRONGLY AGREE

2 SOMEWHAT AGREE

3 SOMEWHAT DISAGREE

4 STRONGLY DISAGREE

-1 DON’T KNOW/NOT SURE

-2 REFUSED

N_17 Now, let’s talk about non-fruit drinks that you may have recently drunk.

During the past month, (that is since [FILL IN DAY 30 DAYS AGO],) how many times per day, week or month did you drink milk as a beverage that was not in coffee and not in cereal. In your answer, please include chocolate milk and hot chocolate.

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If says less than once per month, put “0” times per month.

IF NEEDED, SAY: (We want to know about your what you drank in general. We know it may be hard to remember, so your best estimate is fine.)

1 _ _ Per day
2 _ _ Per week
3 _ _ Per month

4 NEVER

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_17_CONF. IF (Times per day > 3) OR (times per week>21 or <6) or (Times per month >90 OR <28)]

N_17_CONF. IN A NEUTRAL TONE, ASK: You said you drink milk as a beverage {fill number from N_17} times per {fill unit from N_17}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if yes, continue; no, DK or RF, go back]

N_17a . [SKIP IF N_17 = 0] What kind of milk did you usually drink?

IF RESPONDENT INDICATES A FLAVORED MILK, SUCH AS “CHOCOLATE MILK,” PROBE FOR A BEST GUESS THAT FITS ANSWER OPTIONS BEFORE CODING AS OTHER

Read answer options only if necessary:

__ 1. Whole milk

____ 2. 2% fat milk

____ 3. 1% fat milk

____ 4. Skim, nonfat, or ½% fat milk

____ 5. Soy milk

____ 6. Rice milk

___ 7. Raw, unpasteurized milk

____ 8. Other

-1 DON’T KNOW / NOT SURE
-2 REFUSED

N_17b . [SKIP IF N_17 = 0] IF NECESSARY SAY: (Was the [FILL FROM N17a] you drank with flavoring?)

if respondent gave a response such as “chocolate milk” in the previous question select yes and continue, else ask question

1. Yes

2 No

-1 DON’T KNOW / NOT SURE
-2 REFUSED

N_04.

During the past 30 days, (that is since [FILL IN DAY 30 DAYS AGO],) how often did you drink regular soda or pop that contains sugar, not including diet soda or diet pop?

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If says less than once per month, put “0” times per month.

IF NEEDED, SAY: (Please include regular soda that was mixed with alcohol.)

IF NEEDED, SAY: (We are interested in hearing about your what you drank in general. We know it may be hard to remember, so your best estimate is fine.)

1 _ _ Times per day
2 _ _ Times per week
3 _ _ Times per month

4 NEVER
-1 DON’T KNOW / NOT SURE
-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_04_CONF. IF (Times per day > 2) OR (times per week>14) or (Times per month >30]

N_04_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_04} times per {fill unit from N_04}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if yes, continue; if no, DK or RF, go back]

N_03 During the past month, (that is since [FILL IN DATE30 DAYS AGO],) how many times per day, week or month, did you drink water? Include tap, bottled, and unflavored sparkling water.

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If says less than once per month, put “0” times per month.

IF NEEDED, SAY: (We are interested in hearing about your what you drank in general. We know it may be hard to remember, so your best estimate is fine.)

1 _ _ Times per day
2 _ _ Times per week
3 _ _ Times per month

4 NEVER
-1 DON’T KNOW / NOT SURE
-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_03_CONF. IF (Times per day > 8) OR (times per week>56 or <10) or (Times per month >240 OR <14)]

N_03_CONF. IN A NEUTRAL TONE, ASK: You said you drink water {fill number from N_03} times per {fill unit from N_03}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if yes, continue: IF no, DK or RF, go back]

N_08. Now, let’s talk about what foods you keep at home.

How often do you have fruits available at home? This includes fresh, dried, canned and frozen fruits. Would you say . . . ?

1. Always

2. Most of the time

3. Sometimes

4. Rarely or never

-1 DON’T KNOW/ NOT SURE

-2 REFUSED

N_09. How often do you have vegetables available at home? This includes fresh, dried, canned, and frozen vegetables. Would you say . . . ?

1. Always

2. Most of the time

3. Sometimes

4. Rarely or never

-1 DON’T KNOW/ NOT SURE

-2 REFUSED

N_06. During the past 7 days, how many meals did you get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines?

____ Number

-1 DON’T KNOW/ NOT SURE
-2 REFUSED

N_12 Our last question in this section is, are you currently on any kind of diet, either to lose weight or for some other health reason?

1. YES

_ 2. NO

-1 DON’T KNOW/ NOT SURE
-2 REFUSED

N_12a. [SKIP IF N_12=2, -1 or -2] What kind of diet are you on?

ACCEPT ALL ANSWER AND PROBE UNTIL R INDICATES NO OTHERS APPLY: Any others?

[ALLOW MORE THAN ONE ANSWER]

__ 1. Weight loss or low calorie diet

__ 2. Low fat or cholesterol diet

__ 3. Low salt or sodium diet

__ 4. Sugar free or low sugar diet

_ 5. Low fiber diet

__ 6. High fiber diet

__ 7. Diabetic diet

__ 8. Low carbohydrate diet

__ 9. High protein diet

__ 10. Weight gain diet

__ 11. Other

-1 DON’T KNOW/ NOT SURE
-2 REFUSED

[CIGARETTES]

C_INTRO. Now, I’d like to ask you some questions about smoking.

{SELECT NEXT}

CG01. To begin, have you smoked at least 100 cigarettes in your entire life?

IF NEEDED, SAY: (5 packs = 100 cigarettes)

1. Yes

2. No [Go to CG05]

-1 DON’T KNOW / NOT SURE

-2 REFUSED

CG02. Do you now smoke cigarettes every day, some days, or not at all?

1. Every day [Go to CG05]

2. Some days

3. Not at all

-1 - DON’T KNOW / NOT SURE

-2 - REFUSED

CG03. How long has it been since you last smoked a cigarette, even one or two puffs?

READ ANSWER CATEGORIES ONLY IF NEEDED

1. Within the past month (less than 1 month ago)

2. Within the past 3 months (1 month but less than 3 months ago)

3. Within the past 6 months (3 months but less than 6 months ago)

4. Within the past year (6 months but less than 1 year ago)

5. Within the past 5 years (1 year but less than 5 years ago)

6. Within the past 10 years (5 years but less than 10 years ago)

07. 10 years or more

-1. DON’T KNOW / NOT SURE

-2. REFUSED

CG05. Not counting decks, porches, or garages, inside your home, is smoking …?

1. Always allowed

2. Allowed only at some times or in some places

3. Never allowed

4. Family does not have a smoking policy

-1 DON’T KNOW/NOT SURE

-2 REFUSED

CG06. During the past 7 days, that is, since last {TODAY‟S DAY OF WEEK},{IF=INTRO_6 = 1,2 FILL=”not counting times while you were at work,”} on how many days did you breathe the smoke from someone else who was smoking in an indoor public place?

IF NEEDED, SAY: (Examples of indoor public places are the indoor areas of stores, restaurants, bars, casinos, clubs, and sports arenas.)

____ NUMBER OF DAYS {RANGE 0 – 7}

-1 DON’T KNOW
-2 REFUSED

{HARD CHECK TEXT: CANNOT ENTER MORE THAN 7 AS VALID RESPONSE}

CG07. At workplaces, do you think smoking indoors should be…?

1. Always allowed

2. Allowed only at some times or in some places

3. Never allowed

-1. DON’T KNOW/NOT SURE

-2. REFUSED

CG08. Would you favor a policy that bans smoking in all areas of multi-unit housing, including personal living spaces, such as balconies and patios?

1. YES

_2. NO

-1. DON’T KNOW/NOT SURE

-2. REFUSED

[HEALTH]

H_INTRO. Now, I’d like to ask you a few questions about your health and health care.

{SELECT NEXT}

H_01. To begin, is there a place that you usually go to when you are sick or need advice about your health?

1 YES

2 THERE IS NO PLACE {GO TO H_01c}

3 THERE IS MORE THAN ONE PLACE

-1. DON’T KNOW/NOT SURE {GO TO H_01c}

-2. REFUSED {GO TO H_01c}

H_01a. {TEXT FILL IF H_01=3, “What kind of place do you go to most often” ELSE “What kind of place”} is it - 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 {GO TO H_01c}

-1. DON’T KNOW/NOT SURE {GO TO H_01c}

-2. REFUSED {GO TO H_01c}

H_01b. Is that {fill: H_01a)} the same place you usually go when you need routine or preventive care, such as a physical examination or check up?

1 YES {GO TO H_17}

2 NO {GO TO H_01c}

-1. DON’T KNOW/NOT SURE {GO TO H_01c}

-2. REFUSED {GO TO H_01c}

H_01c. What kind of place do you usually go to when you need routine or preventive care, such as a physical examination or check-up?

Read answer options only if necessary:

1 Doesn't get preventive care anywhere

2 Clinic or health center

3 Doctor's office or HMO

4 Hospital emergency room

5 Hospital outpatient department

6 SOME OTHER PLACE

7 DOESN'T GO TO ONE PLACE MOST OFTEN

-1. DON’T KNOW/NOT SURE

-2. REFUSED

{IF H_01=2 (THERE IS NO PLACE USUALLY GOES WHEN SICK) AND H_01c=(1 or 7OR ) (NO USUAL PLACE FOR PREVENTIVE CARE), GO TO H_01d, ELSE GO TO H_17}

H_01d. Why don’t you have a usual source of medical care?

cHOOSE ALL THAT APPLY

ACCEPT ALL ANSWER AND PROBE UNTIL R INDICATES NO OTHERS APPLY: Any others?

Read answer options only if necessary:

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

-1. DON’T KNOW/NOT SURE

-2. REFUSED

{ALLOW MULTIPLE SELECTIONS}

H_17 About how long has it been since you last visited a doctor for a routine checkup?

READ ONLY IF NECESSARY: (A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.)

Read answer options only if necessary:

1 Within past year (anytime less than 12 months ago)
2 Within past 2 years (1 year but less than 2 years ago)
3 Within past 5 years (2 years but less than 5 years ago)
4 5 or more years ago

5 NEVER
-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_02. Has a doctor or other health professional ever advised you to reduce sodium or salt intake?

           

1. Yes

2. No

-1. Don’t know/not sure

-2. REFUSED

H_03. Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?

READ ONLY IF NECESSARY: (By "other health professional" we mean a nurse practitioner, a physician‘s assistant, or some other licensed health professional.)

1 Yes {IF H_03=1 & INTRO_2=2, go to H_03a}
2 No [Go to H_08 ]
3 Told borderline high or pre-hypertensive [Go to H_08 ]
-1 DON’T KNOW / NOT SURE [Go to H_08]
-2 REFUSED [Go to H_08]

H_03a. Was this only when you were pregnant?

1 Yes [Go to H_08]
2 No [Go to H_05]

H_05. Are you exercising (to help lower or control your high blood pressure)?

1 Yes
2 No
-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_06. Are you currently taking medicine for your high blood pressure?

1 Yes
2 No
-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_07. Are you cutting down on salt (to help lower or control your high blood pressure)?

1 Yes
2 No
3 Do not use salt
-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_08. Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?

1 Yes
2 No {Go to H_18}
-1 DON’T KNOW / NOT SURE {Go to H_18}
-2 REFUSED {Go to H_18}

H_09. About how long has it been since you last had your blood cholesterol checked?

Read answer options only if necessary:

1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 5 years (2 years but less than 5 years ago)
4 5 or more years ago

-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_10. Have you ever been told by a doctor, nurse or other health professional that your blood cholesterol is high?

1 Yes
2 No
-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_05. Are you exercising to help lower your cholesterol?

1 Yes
2 No
-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_06. Are you currently taking medicine to lower your cholesterol?

1 Yes
2 No
-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_18. Thinking about your overall physical health, which includes physical illness and injury, for how many days during the past 30 days, (that is since [FILL IN DATE30 DAYS AGO],) was your physical health not good?

_ _ Number of days {RANGE 0 – 30}

-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_18a. [skip if h_18=0] During the past 30 days, (that is since [FILL IN DATE30 DAYS AGO],) for about how many days did physical health keep you from doing your usual activities, such as self-care, work, or recreation?

_ _ Number of days {Range 0 – 30}

-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_19. Now, turning to your mental health, have you ever been told by a doctor or other health professional that you had depression?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_20. Have you ever been told by a doctor or other health professional that you had anxiety?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE

-2 REFUSED

HF_01 How often in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage? Would you say you were worried or stressed---

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

6 I DO NOT OWN OR RENT A HOME/APARTMENT

-1 DON’T KNOW / NOT SURE

-2 REFUSED

HF_02 And how often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say you were worried or stressed ….

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

6 NOT APPLICABLE

-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_13 Are you now taking medicine or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem?

1. YES

2. NO

-1. DON’T KNOW / NOT SURE

-2. REFUSED

H_11. Now, in thinking about your overall mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days, (that is since [FILL IN DATE30 DAYS AGO],) was your mental health not good?

_ _ Number of days {Range 0 – 30}

-1 DON’T KNOW / NOT SURE

-2 REFUSED

{HARD CHECK TEXT: CANNOT ENTER MORE THAN 30 AS VALID RESPONSE}

H12. During the past 30 days, (that is since [FILL IN DATE30 DAYS AGO],) for about how many days did poor mental health keep you from doing your usual activities, such as self-care, work, or recreation?

_ _ Number of days {Range 0 – 30}

-1 DON’T KNOW / NOT SURE

-2 REFUSED

{HARD CHECK TEXT: CANNOT ENTER MORE THAN 30 AS VALID RESPONSE}

H19. How often do you get the social and emotional support you need?

IF NEEDED , SAY: “Please include support from any source.”

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

-1 DON’T KNOW / NOT SURE

-2 REFUSED

[DEMOGRAPHICS]

D_INTRO. We are almost done. The last questions are about you.

{SELECT NEXT}

D_01. Are you Hispanic or Latino?

1 YES
2 NO
-1 DON’T KNOW / NOT SURE
-2 REFUSED

D_02 What is your race? I am going to read a list. You can select one or more options from the list. Do you consider yourself…

RECORD ALL ANSWERS GIVEN BY RESPONDENT, BUT DO NOT PROBE FURTHER. *OPTION #6, “OTHER,” MAY BE USED AS A RECORDING OPTION FOR NON-CONFORMING RESPONSES. OPTION #6 SHOULD NOT BE PRESENTED AS A RESPONSE OPTION.

{ONE OR MORE CATEGORIES MAY BE SELECTED}

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Other Pacific Islander

*6. OTHER

D_09. (In the last question), I asked you to self-identify your race. Now, I want to find out how other people usually classify you in this country.

Would you say (other people this country usually classify you as): White, Black or African American, Hispanic or Latino, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, or some other group?

IF NEEDED, SAY: We want to know how other people usually classify you in this country, which might be different from how you classify yourself.‖

ONLY ONE SELECTION ALLOWED.

IF NEEDED, SAY: “How do other people usually classify you in this country?”

1 WHITE

2 BLACK OR AFRICAN AMERICAN

3 HISPANIC OR LATINO

4 ASIAN

5 NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

6 AMERICAN INDIAN OR ALASKA NATIVE

7 SOME OTHER GROUP

-1 DON’T KNOW / NOT SURE

-2 REFUSED

D_10. How often do you think about your race? Would you say never, once a year, once a

month, once a week, once a day, once an hour, or constantly?

1 NEVER

2 ONCE A YEAR

3 ONCE A MONTH

4 ONCE A WEEK

5 ONCE A DAY

6 ONCE AN HOUR

7 CONSTANTLY

-1 DON’T KNOW / NOT SURE

-2 REFUSED

D_06. {ASK IF INTRO_1<=50 & INTRO_2=2 (LESS THAN 50 YEARS OLD AND IS FEMALE), ELSE GO TO D_07}

To your knowledge, are you now pregnant?

1 YES
2 NO
-1 DON’T KNOW / NOT SURE
-2 REFUSED

D_07. About how much do you weigh without shoes?

RECORD WEIGHT IN EITHER POUNDS OR KILOGRAMS

IF NEEDED, CLARIFY: Is that ___ pounds or ___ kilograms?

PROBE FOR CLOSEST WHOLE NUMBER IF NEEDED

_ _ _ _ WEIGHT (POUNDS) {RANGE 1 – 800 }

_ _ _ _ WEIGHT (KILOGRAMS) {RANGE 1 – 800 }
-1 DON’T KNOW / NOT SURE
-2REFUSED

{HARD CHECK: WEIGHT MUST EITHER BE NON-ZERO FOR POUNDS OR KILOGRAMS, UNLESS DK/RF}

{HARD CHECK TEXT: VERIFY WEIGHT WITH RESPONDENT, IF GREATER THAN UPPER BOUND RECORD UPPER BOUND AND MAKE NOTE}

D_08. About how tall are you without shoes?

Record height in either feet and inches or in meters and centimeters

IF HEIGHT IS REPORTED IN AN EXACT FOOT INCREMENT ENTER 0 FOR INCHES

IF HEIGHT IS REPORTED IN CENTIMETERS ONLY ENTER 0 FOR METERS

PROBE FOR CLOSEST WHOLE NUMBER FOR FEET AND INCHES IF NEEDED

__ FEET {RANGE 2 – 9 }

__INCHES {RANGE 0 – 11}

__METERS {0 – 2 }

__CENTIMETERS {RANGE 0 - 275 }

-1 DON’T KNOW /NOT SURE
-2 REFUSED

{ALLOW ENTRIES TO BE MADE IN FEET AND INCHES -OR- METERS AND/OR CENTIMERS}

{HARD CHECK TEXT: VERIFY THAT YOU HAVE ENTERED A HEIGHT IN BOTH FEET AND INCHES, OR THAT YOU HAVE ENTERED A HEIGHT IN METERS AND/OR CENTIMETERS.}

[PRESENT D08_CONF IF (FEET + (INCHES/12))>9 OR (FEET + (INCHES/12))<2 OR (METERS+(CENTIMETERS/100))>2.7 OR (METERS+(CENTIMETERS/100))<.6]

D_08_CONF. IN A NEUTRAL TONE, ASK: You said {fill first number from D_08} {fill first unit from D_08} and {fill second number from D_08} {fill second unit from D_08}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if yes, continue; no, DK or RF, go back]

transition. “Thank you for your participation in this very important survey. Before we end, I’d like to quickly share with you information about other study opportunities.”

{SELECT NEXT TO CONTINUE}

6