Caregiver Survey

rForm Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Caregiver Survey

Public reporting burden of this collection of information is estimated to average 18 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)

Caregiver Survey

INTERVIEWER SHOULD ONLY READ STATEMENTS IN lower case.

INSTRUCTIONS TO INTERVIEWERS ARE IN UPPER CASE

PA_INTRO_cy.

[PHYSICAL ACTIVITY]

Let’s begin by talking about the biking and walking that [TEXTFILL IF {S.C} AGE<12 “{S.C} did with or without you,” ELSE “you did”] this past week either for transportation or leisure. 

{SELECT NEXT TO CONTINUE}

PA_01_cy. During the past week, on how many days did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] walk or bicycle [TEXTFILL IF {S.C} AGE<12”, with or without you,”] for at least 10 minutes continuously to get to and from places?

___ DAYS [RANGE 0 -7] [IF PA_01_CY=0, GO TO PA_11_cy, ELSE CONTINUE]

__-1. DON’T KNOW/NOT SURE [GO TO PA_11_cy]

__-2. REFUSED [GO TO PA_11_cy]

PA_02_cy. Thinking about the last five week days, on a typical week day how much time did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] spend walking or bicycling for travel? For example, to go to a friend’s house or school.

IF NEEDED, PROBE SAYING: How much time did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] spend walking or biking for travel on Wednesday?”)

_ _ Hours {RANGE 0 – 24}

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

[HARD CHECK TEXT: BOTH NUMBER OF AMOUNT AND UNIT (MINUTES AND/OR HOURS) MUST BE REPORTED, UNLESS DK/RF]

[ASK PA_02_CONF_cy IF (PA_02_cy SUM OF hours AND (MINUTES/60)>4 hours) or ask PA_02_conf_cy IF (PA_02_cy SUM OF hours AND (MINUTES/60)<10 minutes) ]

PA_02_CONF_cy. IN A NEUTRAL TONE, ASK: You said {FILL HOURS NUMBER FROM PA_03_cy} (hours) and {FILL MINUTES NUMBER FROM PA_02_cy } (minutes), 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]

PA_03_cy. Thinking about a typical day over the past weekend, how much time did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] spend walking or bicycling for travel? (For example, to go to a friend’s house or school.)

IF NEEDED, PROBE SAYING: (“How much time in total did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] spend walking or biking for travel on Saturday?”)

_ _ Hours {RANGE 0 – 24}

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

[HARD CHECK TEXT: BOTH NUMBER OF AMOUNT AND UNIT (MINUTES AND/OR HOURS) MUST BE REPORTED, UNLESS DK/RF]

[ASK PA_03_CONF_cy IF (PA_03_cy SUM OF hours AND (MINUTES/60)>4 hours) or ask PA_03_conf_cy IF (PA_03_cy SUM OF hours AND (MINUTES/60)<10 minutes) ]

PA_03_CONF_cy. IN A NEUTRAL TONE, ASK: You said {FILL HOURS NUMBER FROM PA_03_y} (hours) and {FILL MINUTES NUMBER FROM PA_03_cy } (minutes), 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]

PA_04_cy. (Thinking about the past week,) not counting any walking that you already mentioned, on how many days did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] walk or bike for at least 10 minutes continuously for leisure?

IF NEEDED, SAY: (Think about only the walking that [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] did for at least 10 minutes at a time.)

_____ Days per week {RANGE 0 – 7}

-1. DON’T KNOW/NOT SURE

-2. REFUSED

PA_05_cy. (Thinking about the past week,) on a typical weekday, how much time did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] spend walking or biking for leisure?

IF NEEDED, PROBE SAYING: (“How much time in total did you spend walking on Wednesday?”)

___ ___ Hours per day {RANGE 0 – 24}

___ ___ Minutes per day {RANGE 0 – 60}

-1. DON’T KNOW/NOT SURE

-2. REFUSED

[ASK PA_05_CONF_y IF (PA_05_y SUM OF hours AND (MINUTES/60)>3 hours)]

PA_05_CONF_y. IN A NEUTRAL TONE, ASK: You said {FILL HOURS NUMBER FROM PA_05_y} (hours) and {FILL MINUTES NUMBER FROM PA_05_y } (minutes), 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]

PA_06_cy. Thinking about a typical day over the past weekend, how much time did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] spend walking or biking for leisure?

IF NEEDED, PROBE SAYING: (“How much time in total did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] spend walking on Saturday?”)

___ ___ Hours per day {RANGE 0 – 24}

___ ___ Minutes per day {RANGE 0 – 60}

-1. DON’T KNOW/NOT SURE

-2. REFUSED

[ASK PA_06_CONF_cy IF (PA_06_cy SUM OF hours AND (MINUTES/60)>3 hours)]

PA_06_CONF_cy. IN A NEUTRAL TONE, ASK: You said {FILL HOURS NUMBER FROM PA_06_cy} (hours) and {FILL MINUTES NUMBER FROM PA_06_cy} (minutes), 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]

PA_07_cy. During the past week, how many days did you or any family member take {S.C.} on any kind of outing, such as to the park, library, zoo, shopping, church, restaurants, or family gatherings?

RECORD NUMBER OF DAYS

___ DAYS [RANGE 0 – 7]

__-1. DON’T KNOW/NOT SURE

__-2. REFUSED

PA_08_ cy. Now, let’s turn to other activities that [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] you did this past week, besides the walking and biking we already talked about.  For these questions think about all the other activities [TEXTFILL IF {S.C} AGE<12 “{S.C} does” ELSE “you do”] that increase [TEXTFILL IF {S.C} AGE<12 “his/her” ELSE “your"] heart-rate or make [TEXTFILL IF {S.C} AGE<12 “him/her” ELSE “your"] breathe harder.

(During the past week,) on how many days [TEXTFILL IF {S.C} AGE<12 “did {S.C}” ELSE “did you”] do these sports, fitness or recreational activities?

___ DAYS {RANGE 0 – 7}

__-1. DON’T KNOW/NOT SURE

__-2. REFUSED

PA_09_ cy. (Thinking about the past week,) on a typical weekday, how much time did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] spend doing these other sports, fitness or recreational activities?

___ ___ Hours per day {RANGE 0 – 24}

___ ___ Minutes per day {RANGE 0 – 60}

-1. DON’T KNOW/NOT SURE

-2. REFUSED

PA_10_ cy. Thinking about a typical day over the past weekend, how much time did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] spend doing these other sports, fitness or recreational activities?

___ ___ Hours per day {RANGE 0 – 24}

___ ___ Minutes per day {RANGE 0 – 60}

-1. DON’T KNOW/NOT SURE

-2. REFUSED

PA_11_ cy. (During the past week,) on how many weekend days [TEXTFILL IF {S.C} AGE<12 “did {S.C}” ELSE “did you”] do these sports, fitness or recreational activities?

IF NEEDED, SAY: (The weekend refers to the days Saturday and Sunday.)

___ DAYS {RANGE 0 – 2}

__-1. DON’T KNOW/NOT SURE

__-2. REFUSED

PA_12_ cy. [ASK IF {S.C.} AGE >4, ELSE SKIP TO ASK]. (During the past week,) on how many days did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] play active video games such as Wii Sports, Wii Fit, Xbox 360, Xbox Kinect, Playstation 3, or Dance, Dance Revolution?

IF NEEDED, PROBE SAYING: (“How much time in total did you spend playing active video games on Wednesday?”)

___ DAYS {RANGE 0 – 7} [IF PA_12_cy=0, GO TO PA_14_cy; ELSE CONTINUE]

__-1. DON’T KNOW/NOT SURE {GO TO PA_14_cy}

__-2. REFUSED {GO TO PA_13_cy}

PA_13_ cy. On average, for how long did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] play these active video games on a typical day?

___ ___ Hours per day {RANGE 0 – 24}

___ ___ Minutes per day {RANGE 0 – 60}

-1. DON’T KNOW/NOT SURE

-2. REFUSED

PA_14_cy. The following questions are about the total time [TEXTFILL IF {S.C} AGE<12 “{S.C} spends” ELSE “you spend”] sitting anywhere, such as at school, [TEXTFILL IF {S.C} AGE<6 “at day care,”] [TEXTFILL IF {S.C} AGE>14 “at work,”] home, getting to and from places, or with friends, including time spent sitting at a desk, traveling in a car or bus, reading, playing cards, watching television, or using a computer. Do not include time spent sleeping.

(Thinking about the past week,) on a typical weekday how much time [TEXTFILL IF {S.C} AGE<12 “did {S.C}” ELSE “did you”] spend sitting?

IF NEEDED, PROBE SAYING: (“How much time in total [TEXTFILL IF {S.C} AGE<12 “did {S.C}” ELSE “did you”] spend sitting on Wednesday?”)

_ _ HOURS {RANGE 0 – 24}

_ _ MINUTES {RANGE 0 – 60}

1 NONE
-1 DON’T KNOW / NOT SURE
-2 REFUSED

[ASK PA_14_CONF_cy IF (PA_14_cy SUM OF hours AND (MINUTES/60)>17 hours)]

PA_14_CONF_cy. IN A NEUTRAL TONE, ASK: You said {FILL HOURS NUMBER FROM PA_14_cy } (hours) and {FILL MINUTES NUMBER FROM PA_14_cy } (minutes), 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]

PA_15_cy. Thinking about this past weekend, how much time [TEXTFILL IF {S.C} AGE<12 “did {S.C}” ELSE “did you”] usually spend sitting?

IF NEEDED, PROBE SAYING: (“How much time in total did you spend sitting on Saturday?”)

_ _ HOURS {RANGE 0 – 24}

_ _ MINUTES {RANGE 0 – 60}

1 NONE
-1 DON’T KNOW / NOT SURE
-2 REFUSED

[ASK PA_15_CONF_cy IF (PA_15_cy SUM OF hours AND (MINUTES/60)>17 hours)]

PA_15_CONF_cy. IN A NEUTRAL TONE, ASK: You said {FILL HOURS NUMBER FROM PA_15_cy } (hours) and {FILL MINUTES NUMBER FROM PA_15_cy } (minutes), 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]

PA_16_cy. Now I will ask you first about [TEXTFILL IF {S.C} AGE<12 “{S.C’s}” ELSE “your”] TV watching and then about computer use.

(Thinking about the past week,) on a typical weekday, how much time [TEXTFILL IF {S.C} AGE<12 “did {S.C}” ELSE “did you”] sit and watch TV or videos?

IF NEEDED, PROBE SAYING: (“How much time in total did you spend sitting on Wednesday?”)

_ _ HOURS {RANGE 0 – 24}

_ _ MINUTES {RANGE 0 – 60}

1. [TEXTFILL IF {S.C} AGE<12 “{S.C} does” ELSE “I do”] not watch TV or videos

-1 DON’T KNOW / NOT SURE
-2 REFUSED

PA_17_cy. (Thinking about the past week,) on a typical weekday, how much time [TEXTFILL IF {S.C} AGE<12 “did {S.C}” ELSE “did you”] use a computer or play computer games outside of [TEXTFILL IF {S.C} AGE>14 “work or”] school [TEXTFILL IF {S.C} AGE<6 “or day care”]. Include Playstation, Nintendo DS, other portable video games, or iPad. Would you say . . .

IF THE SP WATCHES T.V. OR VIDEO AT THE SAME TIME AS WORKING ON THE COMPUTER, ONLY COUNT THIS TIME AS WATCHING T.V. OR VIDEO.

IF NEEDED, PROBE SAYING: (“How much time in total [TEXTFILL IF {S.C} AGE<12 “did {S.C}” ELSE “did you”] spend sitting on Wednesday?”)

_ _ HOURS {RANGE 0 – 24}

_ _ MINUTES {RANGE 0 – 60}

1. I do not watch TV or videos

-1 DON’T KNOW / NOT SURE
-2 REFUSED

PA_18_cy. Let’s talk now about your neighborhood and community. Please tell me if the following places and things are available in your neighborhood, even if [TEXTFILL IF {S.C} AGE<12 “{S.C} does” ELSE “you do”] not actually use them.

PA_18a_cy . Sidewalks or walking paths?

IF NEEDED, SAY: Do those exist in your neighborhood?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

PA_18b_cy . A park or playground area?

IF NEEDED, SAY: Do those exist in your neighborhood?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

PA_18c_cy . A recreation center, community center, or boys’ or girls’ club?

IF NEEDED, SAY: Do those exist in your neighborhood?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

PA_19_cy. How often do you feel [TEXTFILL IF {S.C} AGE<12 “{S.C} is”] safe in your community or neighborhood? Would you say….

1. Always

2. Usually

3. Sometimes

4. Never

-1 DON’T KNOW / NOT SURE
-2 REFUSED

N_INTRO_cy.

[NUTRITION]

Now I have some questions about [TEXTFILL IF {S.C} AGE<12 “{S.C.’s}” ELSE “your”] eating habits.

These questions are about the different kinds of foods [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] ate or drank during the past month, that is, since [FILL IN WITH DAY 30 DAYS AGO]. When answering, please include meals and snacks eaten [TEXTFILL IF {S.C} AGE<12 “by {S.C}” ELSE “by you”] at home, at [TEXTFILL IF {S.C} AGE>14 “at work,”] school, [TEXTFILL IF {S.C} AGE<6 “at day care,”] in restaurants, and anyplace else. Keep in mind there are no right or wrong answers. Your best guess is fine.

N_01_cy. During the past month, how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] eat hot or cold cereals? You can tell me per day, per week or per month.

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

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
4 never {SKIP TO n_03_cy}
-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_cy_CONF IF (N_01_ cy TIMES PER DAY >1 OR TIMES PER WEEK > 14 OR TIMES PER MONTH >60)]

N_01_ cy _CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_01_ cy} and {fill unit from N_01_ cy }, 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_02_cy. During the past month, what kinds of cereal did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] usually eat?

ENTER FIRST FEW LETTERS OF CEREAL NAME TO START THE LOOKUP. SELECT CEREAL FROM LIST. IF CEREAL NOT ON LIST, PRESS BS TO DELETE THE ENTRY AND TYPE ** TO ENTER CEREAL NAME.

___________________________________RECORD CEREAL NAME

CAPI INSTRUCTION: DISPLAY CEREAL LIST. INTERVIEWER SHOULD BE ABLE TO SELECT CEREAL FROM LIST OR PRESS BS TO DELETE ENTRY AND TYPE ** TO ENTER NAME OF CEREAL.

N_03_cy (During the past month), since [FILL IN DATE 30 DAYS AGO) how often did {S.C.} have milk {TEXT FILL IF N_01_cy is not NEVER, “either to drink or on cereal”}? (You can tell me per day, per week or per month.)

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

HELP POP-UP:

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

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

D o Include Do not Include

Buttermilk Chocolate Milk Cream

Lactose-free Milk Low-fat Milk

No-fat Milk Other Flavored Milks

Skim Milk Whole Milk

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
4 never {GO TO N_04_cy)
-1 DON’T KNOW / NOT SURE {GO TO N_04_cy)
-2 REFUSED {GO TO N_04_cy)

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

[ASK N_03_cy_CONF IF (N_03_ cy Times per day > 2 or TIMES PER WEEK > 14 OR TIMES PER MONTH >60)]

N_03_ cy _CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_03_ cy} and {fill unit from N_03_ cy }, 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_03a_cy. What type of milk was it?

IF RESPONDENT CANNOT PROVIDE USUAL TYPE, CODE ALL THAT APPLY.

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

[ALLOW MULTIPLE SELECTIONS]

N_03b_cy . IF NEEDED SAY: (Was the milk [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] usually drank flavored?)

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_cy. During the past month, how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] drink regular soda, or pop that contained sugar? Do not include diet soda. (You can tell me per day, per week or per month.)

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

IF NEEDED, SAY: (Keep in mind there are no right or wrong answers. Your best guess is fine.)

HELP POP-UP:

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC TYPE OF 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

Manzanita Penafiel sodas Diet Fruit Drinks Juices in Cans

Sugar-free Fruit Drinks Tea in Cans

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
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_cy_CONF IF (N_04_cy TIMES PER DAY >2 OR TIMES PER WEEK > 14 OR TIMES PER MONTH >60)]

N_04_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_04_ cy} and {fill unit from N_04_cy }, 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_05_cy. (During the past month), since (POPULATE WITH DATE 30 DAYS AGO) how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] drink 100% pure fruit juice such as orange, mango, apple, grape and pineapple juices? Do not include fruit-flavored drinks with added sugar or fruit juice [TEXTFILL IF {S.C} AGE<12 “{S.C}/you” ELSE “you”] made at home and added sugar to. (You can tell me per day, per week or per month.)

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

IF NEEDED, SAY: (Keep in mind there are no right or wrong answers. Your best guess is fine.)

HELP POP-UP:

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC TYPE OF 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

100% Pure Juices Fruit-flavored Drinks with Added Sugar

Cranberry Cocktail Gatorade

Hi-C Kool-Aid

Lemonade Sunny Delight

Tampico

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
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_cy_CONF IF (N_05_cy Times per day > 2 or TIMES PER WEEK > 14 OR TIMES PER MONTH >60)]

N_05_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_05_ cy} and {fill unit from N_05_cy }, 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_06_cy. Now we are going to ask about fruit-flavored drinks with added sugar. (During the past month), how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] drink sweetened fruit drinks, sports or energy drinks, such as Kool-aid, lemonade, Hi-C, cranberry drink, Gatorade, Red Bull or Vitamin Water? Include fruit juices you made at home and added sugar to. Do not include diet drinks or artificially sweetened drinks. (You can tell me per day, per week or per month.)

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

IF NEEDED, SAY: (Keep in mind there are no right or wrong answers. Your best guess is fine.)

HELP POP-UP:

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC TYPE OF 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

Drinks with Added Sugar 100% fruit juices Carbonated Water

Tampico Sunny Delight Fruit-Flavored teas Soda

Twister Yogurt drinks

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
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_06_cy_CONF IF (N_06_cy Times per day > 2 or TIMES PER WEEK > 14 OR TIMES PER MONTH >60)]

N_06_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_06_ cy} and {fill unit from N_06_cy }, 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_07_cy (During the past month), how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] eat fruit? Include fresh, frozen or canned fruit. Do not include juices. (You can tell me per day, per week or per month.)

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

IF NEEDED, SAY: (Keep in mind there are no right or wrong answers. Your best guess is fine.)

HELP POP-UP:

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

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

D o Include Do not Include

Apples Applesauce Dried Fruits

Bananas Berries

Fruit Salad Grapes

Mangos Melon

Oranges Papayas

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
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_07_cy_CONF IF (N_07_cy TIMES PER DAY>1 TIMES PER WEEK > 14 OR TIMES PER MONTH >60)]

N_07_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_07_ cy} and {fill unit from N_07_cy }, 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_cy. (During the past month), how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] eat a green leafy or lettuce salad, with or without other vegetables? (You can tell me per day, per week or per month.)

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

IF NEEDED, SAY:

• (Include spinach salads)

• (Keep in mind there are no right or wrong answers. Your best guess is fine.)

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
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_08_cy_CONF IF (N_08_cy TIMES PER DAY>1 TIMES PER WEEK > 14 OR TIMES PER MONTH >60)]

N_08_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_08_ cy} and {fill unit from N_08_cy }, 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_09_y (During the past month), how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] eat any kind of fried potatoes, including french fries, home fries, or hash brown potatoes? (You can tell me per day, per week or per month.)

1 _ _ Times per day [RANGE 0 – 15]
2 _ _ Times per week [RANGE 0 – 105]
3 _ _ Times per month [RANGE 0 - 450]
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_09_y_CONF IF (N_09_y TIMES PER DAY>1 TIMES PER WEEK > 14 OR TIMES PER MONTH >60)]

N_09_y_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_09_ y} and {fill unit from N_09_y}, 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_10_cy. (During the past month), how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] eat potatoes such as baked, boiled, mashed potatoes, sweet potatoes, or potato salad? (You can tell me per day, per week or per month.)

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

IF NEEDED, SAY: (Keep in mind there are no right or wrong answers. Your best guess is fine.)

HELP POP-UP:

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

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

D o Include Do not Include

Potatoes au Gratin Scalloped Potatoes Fried Potatoes

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
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_10_cy_CONF IF (N_10_cy TIMES PER DAY>1 TIMES PER WEEK > 14 OR TIMES PER MONTH >60)]

N_10_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_10_ cy} and {fill unit from N_10_cy }, 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_cy. (During the past month), how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] eat refried beans, baked beans, beans in soup, pork and beans or any other type of cooked beans? Do not include green beans. (You can tell me per day, per week or per month.)

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

IF NEEDED, SAY: (Keep in mind there are no right or wrong answers. Your best guess is fine.)

HELP POP-UP:

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

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

D o Include Do not Include

Black Beans Black-Eyed Peas

Cow Peas Garbanzo

Kidney Lentils

Lima Beans Pinto Beans

Soybeans

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
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_11_cy_CONF IF (N_11_cy TIMES PER DAY>1 TIMES PER WEEK > 14 OR TIMES PER MONTH >60)]

N_11_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_11_ cy} and {fill unit from N_11_cy }, 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_12_cy. (During the past month), not including what you just told me about (lettuce salads, potatoes, cooked dried beans), how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] eat other vegetables? (You can tell me per day, per week or per month.)

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

IF NEEDED, SAY: (Keep in mind there are no right or wrong answers. Your best guess is fine.)

HELP POP-UP:

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

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

IF NEEDED, SAY: (Include any form of the vegetable including raw, cooked, canned, or frozen.)

D o Include Do not Include

Bean Sprouts Broccoli

Cabbage Carrots

Collard Greens Corn

Green Beans Tomatoes

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
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_12_cy_CONF IF (N_12_cy TIMES PER DAY>2 TIMES PER WEEK > 14 OR TIMES PER MONTH >60)]

N_12_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_12_ cy} and {fill unit from N_12_cy }, 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_cy. During the past month, (that is since [FILL IN DATE 30 DAYS AGO],) how many times per day, week or month, did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “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: (Keep in mind there are no right or wrong answers. Your best guess is fine.)

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]

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_cy_CONF IF (N_13_cy TIMES PER DAY>8 TIMES PER WEEK > 14 OR TIMES PER MONTH >60)]

N_13_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_13_ cy} and {fill unit from N_13_cy}, 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_14_cy. 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_15_cy. 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_16_cy. How often do you have fat-free or low-fat (1%) milk at home?  (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_17_cy. How often do you have regular soda, soft drinks, or pop that contain sugar at home? Do not include diet soda. (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_18_cy. How often do you have fruit-flavored drinks with added sugar at home, such sports or energy drinks, such as Kool-aid, lemonade, Hi-C, cranberry drink, Gatorade, Red Bull or Vitamin Water or homemade fruit juices with added sugar? Do not include diet drinks or artificially sweetened drinks. (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_19_cy. Thinking now about eating fruits and vegetables, please say if you strongly agree, somewhat agree, somewhat disagree or strongly disagree with each statement.

N_19a_cy . I regularly eat more fruits and 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_19b_cy. [TEXTFILL IF AGE>12, {S.C.} ELSE “I”] would be healthier if [TEXTFILL IF AGE>12, he/she ELSE “I”] ate more fruits and 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_19c_cy. [TEXT FILL IF {S.C.} AGE<12, “{S.C.} has” ELSE “I have”] friends or family members who encourage [TEXT FILL IF {S.C.} AGE<12, “him/her” ELSE “me”] to eat more fruits and 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_19d1_cy. [ASK IF AGE>11, ELSE SKIP] 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_19d2_cy. [ASK IF AGE<12, ELSE SKIP] People in my household prepare meals and snacks with fruits and vegetables for me. (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_19e1_y. [ASK IF AGE>11, ELSE SKIP] I prepare fruits and vegetables for my meals and snacks. (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_19e2_cy. [ASK IF AGE<12, ELSE SKIP] I do not know how to prepare good tasting meals and snacks with fruits and 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_19f_cy. [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “I”] would rather eat sweets or high fat snacks than eat fruits and 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_19g_cy. [TEXTFILL IF {S.C} AGE<12 “{S.C} does” ELSE “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_19h_cy [TEXTFILL IF {S.C} AGE<12 “{S.C} does” ELSE “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_20_cy. And our last question about food is about whole meals. By meal, I mean breakfast, lunch and dinner. During the past 7 days, how many meals did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] eat 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

CG_INTRO_cy. [IF {S.C.} AGE<12, SKIP TO H_INTRO_cy, ELSE CONTINUE]

[SMOKING]

Now, let’s turn to a few questions about smoking.

CG_01_cy. Have you ever tried cigarette smoking, even one or two puffs?

1. YES

2. NO {Go to H_INTRO_Cy}

-1 DON’T KNOW / NOT SURE

-2 REFUSED

CG_02_cy. During the past 30 days, on how many days did you smoke cigarettes?

READ ANSWER CATEGORIES ONLY IF NEEDED

1. 0 days {GO TO H_INTRO_cy }

2. 1 or 2 days

3. 3 to 5 days

4. 6 to 9 days

5. 10 to 19 days

6. 20 to 29 days

7. All 30 days

-1 DON’T KNOW / NOT SURE

-2 REFUSED

CG_03_cy. During the past 30 days, how did you usually get your own cigarettes?

READ ANSWER CATEGORIES ONLY IF NEEDED

IF NEEDED, PROBE FOR SINGLE BEST ANSWER THAT MATCHES RESPONSE OPTIONS

1. I did not smoke cigarettes during the past 30 days

2. I bought them in a store such as a convenience store, supermarket, discount store, or gas station

3. I bought them from a vending machine

4. I gave someone else money to buy them for me

5. I borrowed (or bummed) them from someone else

6. A person 18 years old or older gave them to me

7. I took them from a store or family member

8. I got them some other way

-1 DON’T KNOW / NOT SURE

-2 REFUSED

CG_04_cy. During the past 12 months, did you ever try to quit smoking cigarettes?

1. Yes

2. No

3. I did not smoke during the past 12 months

-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_INTRO_cy

[HEALTH AND HEALTH CARE ACCESS]

Our final questions are about [TEXTFILL IF {S.C} AGE<12 “{S.C.'s}” ELSE “your”] health care and health.

H_01_cy. To begin, is there a place that [TEXTFILL IF {S.C} AGE<12 “{S.C} usually goes when he/she is” ELSE “you usually go when you are”] sick or you need advice about [TEXTFILL IF {S.C} AGE<12 “his/her” ELSE “your"]health?

1 YES

2 THERE IS NO PLACE {GO TO 35C}

3 THERE IS MORE THAN ONE PLACE

-1. DON’T KNOW/NOT SURE {GO TO 35C}

-2. REFUSED {GO TO 35C}

H_01a_cy. {TEXT FILL IF H_01_cy=3, “What kind of place [TEXTFILL IF {S.C} AGE<12 “does {S.C}” ELSE “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_02c_cy }

-1. DON’T KNOW/NOT SURE {GO TO H_02c_cy }

-2. REFUSED {GO TO H_02c_cy }

H_01b_cy. Is that {fill: H_01a_cy } the same place [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] usually [TEXTFILL IF {S.C} AGE<12 “goes” ELSE “go”] when [TEXTFILL IF “he/she needs” AGE<12 “{S.C}” ELSE “you need”] routine or preventive care, such as a physical examination or [IF {S.C.} AGE>12, “(well baby/child)”] check up?

1 YES {GO TO H_02_cy}

2 NO {GO TO H_02c_cy }

-1. DON’T KNOW/NOT SURE {GO TO H_02c_cy }

-2. REFUSED {GO TO H_02c_cy }

H_01c_cy. What kind of place [TEXTFILL IF {S.C} AGE<12 “Does {S.C}” ELSE “Do you”] usually go to when [TEXTFILL IF “he/she needs” AGE<12 “{S.C}” ELSE “you need”]routine or preventive care, such as a physical examination or[IF {S.C.} AGE>12, “(well baby/child)”] 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_cy =2 (THERE IS NO PLACE USUALLY GOES WHEN SICK) AND H_01c_cy =(1 or 7) (NO USUAL PLACE FOR PREVENTIVE CARE), GO TO H_01d_cy, ELSE GO TO H_02_cy }

H_01d_cy. Why [IF {S.C.} AGE> 12, “doesn’t {S.C.}” ELSE “don’t you”] have a usual source of medical care? [IF {S.C.} AGE<11, “(My parents and or I feel….”]

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_02_cy. During the past 12 months did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] see a doctor, nurse, or other health care professional for any kind of medical care, including sick-child care, well-child check-ups, physical exams, and hospitalizations?

1. YES

2. NO {SKIP TO H_04_cy }

-1. DON’T KNOW/NOT SURE {SKIP TO H_04_cy }

-2. REFUSED {SKIP TO H_04_cy }

H_03_cy. During the past 12 months how many times did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] see a doctor, nurse, or other health care provider for preventive medical care such as a physical exam or well-child checkup?

_____TIMES

-1. DON’T KNOW/NOT SURE

-2. REFUSED

H_04_cy. Mental health professionals include psychiatrists, psychologists, psychiatric nurses, and clinical social workers. During the past 12 months, [TEXTFILL IF {S.C} AGE<12 “has {S.C}” ELSE “have you”] received any treatment or counseling from a mental health professional in or outside of [IF AGE>12, “day-care or”] school?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_05_cy. Now I am going to read you a list of health problems, concerns or conditions [TEXTFILL IF {S.C.} AGE>12, “that may affect {S.C.’s} behavior, learning, or growth”]. For each condition, please tell me if a doctor or other health care provider ever told you [TEXTFILL IF AGE<11, “or your parents”] that [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] had the condition, even if [TEXTFILL IF {S.C} AGE<12 “he/she doesn’t” ELSE “you don’t"] have the condition now.

INTERVIEWER INSTRUCTION: IF THE RESPONDENT HAS NEVER HEARD OF THE MEDICAL CONDITION OR DOES NOT KNOW WHAT THE CONDITION IS, THEN A DOCTOR OR OTHER HEALTH CARE PROVIDER PROBABLY HAS NOT TOLD THE RESPONDENT THAT S/HE. HAS THE CONDITION. IF A DOCTOR OR OTHER HEALTH CARE PROVIDER HAS NOT TOLD THE RESPONDENT THAT S/HE HAS THE CONDITION, BUT THE RESPONDENT INSISTS THAT S/HE HAS THE CONDITION, WE STILL NEED TO CODE THE ANSWER AS “NO.”

{SELECT NEXT TO CONTINUE}

H_05a_cy. Has a doctor or other health care provider ever told you [TEXTFILL IF AGE<11, “or your parents”] that [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] had depression?

IF NEEDED, SAY: (Depression is an illness that involves the body, mood, and thoughts. It is marked by persistent sadness or an anxious or empty mood. It affects how a person feels, and the way a person eats, sleeps, and functions.)

1 YES

2 NO

-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_05b_cy. Has a doctor or other health care provider ever told you [TEXTFILL IF AGE<11, “or your parents”] that [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] had anxiety problems?

IF NEEDED, SAY: (Anxiety is a feeling of constant worrying. Children with severe anxiety problems may be diagnosed as having anxiety disorders. Anxiety disorders include panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and phobias.)

1 YES

2 NO

-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_05c_cy Has a doctor or other health care provider ever told you [TEXTFILL IF AGE<11, “or your parents”] that[TEXTFILL IF {S.C} AGE<12 “{S.C} has” ELSE “you had”] diabetes?

IF NEEDED, SAY: (Diabetes is a disease in which the body does not properly make or use insulin.)

1 YES

2 NO

-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_05d_cy. Has a doctor or other health care provider ever told you [TEXTFILL IF AGE<11, “or your parents”] that [TEXTFILL IF {S.C} AGE<12 “{S.C} was” ELSE “you were”] overweight?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_05e_cy [TEXTFILL IF {S.C} AGE<12 “Does {S.C}” ELSE “Do you”]have an impairment or health problem that limits [TEXTFILL IF {S.C} AGE<12 “his/her” ELSE “your"] ability to walk, run, or play?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_05f_cy. [TEXTFILL IF {S.C} AGE<12 “Is {S.C}” ELSE “Are you”] limited in any way in any activity because of a physical, mental or emotional problem?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE

-2 REFUSED

Demographics

We are going to begin with a couple of questions about [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”].

{SELECT NEXT TO CONTINUE}

D_01_cy [TEXTFILL IF {S.C} AGE<12 “Is {S.C}” ELSE “Are you”] Hispanic or Latino?

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

D_02_cy. What [TEXTFILL, IF {S.C.} AGE>12, “do you consider to be {SP’s}” ELSE “do you consider to be your”] race? I am going to read a list. You can select one or more options from the list.

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_03. (In the last question), I asked you to [TEXTFILL IF {S.C} AGE<12 “identify {S.C.’s}” ELSE “self-identify your”] race. Now, I want to find out how other people usually classify [TEXTFILL IF {S.C} AGE<12 “{S.C.}” ELSE “you”] in this country.

Would you say (other people this country usually classify [TEXTFILL IF {S.C} AGE<12 “{S.C.}” ELSE “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 [TEXTFILL IF {S.C} AGE<12 “{S.C.}” ELSE “you”] in this country, which might be different from how you classify [TEXTFILL IF {S.C} AGE<12 “{S.C.}” ELSE “yourself”].‖

ONLY ONE SELECTION ALLOWED.

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

transition. “Thank you for your participation in this very important survey. We have completed the survey portion of the study and now we will take some physical measurements of [TEXTFILL IF {S.C} AGE<12 “{S.C.}” ELSE “you”].

{SELECT NEXT TO CONTINUE}

46