Attachment 13d
National Youth Fitness Survey Questionnaires
and Data Collection Forms
OMB No. 0920-0237
Exp. Date Nov. 30, 2012
Assurance of Confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347). By law, every employee as well as every agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.
NOTICE-Public reporting burden of this collection of information is estimated to average 2.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333. ATTN: PRA (0920-0237).
Questionnaire TABLE OF CONTENTS
Sections
|
pagEs |
SCREENER QUESTIONNAIRE ………………………………………………………………….. |
3 |
SCREENER MODULE #1 (SCQ)………………………………………………………………………….. |
4 |
FAMILY RELATIONSHIP QUESTIONNAIRE ………………………………………………. |
21 |
SCREENER MODULE #2 (SFQ)…………………………………………………………………………... |
22 |
SAMPLE PERSON QUESTIONNAIRE…………………………………………………………. |
37 |
RESPONDENT SELECTION (RIQ)……………………………………………………………………….. |
38 |
EARLY CHILDHOOD (ECQ)……………………………………………………………………………….. |
43 |
HOSPITAL UTILIZATION AND ACCESS TO CARE (HUQ)……………………………………………. |
45 |
PHYSICAL FUNCTIONING (PFQ)………………………………………………………………………… |
46 |
MEDICAL CONDITIONS (MCQ)…………………………………………………………………………… |
48 |
DIABETES (DIQ)…………………………………………………………………………………………….. |
50 |
RESPIRATORY HEALTH AND DISEASE (RDQ)………………………………………………………... |
52 |
PHYSICAL ACTIVITY AND PHYSICAL FITNESS (PAQ) (3-11 years)……………………………. |
53 |
PHYSICAL ACTIVITY AND PHYSICAL FITNESS (PAQ)(12-15 years)……………………………. |
59 |
Diet behavior &nutrition (DBQ)………………………………………………………………… |
72 |
ACCULTURATION (ACQ)………………………………………………………………………………….. |
75 |
Demographics (DMQ)…………………………………………………………………………………... |
79 |
Health insurance (HIQ)……………………………………………………………………………….. |
88 |
Dietary supplements and antacids (DSQ)……………………………………………………. |
90 |
mailing address (MAQ)……………………………………………………………………................. |
121 |
FAMILY QUESTIONNAIRE…………………………………………………………………………. |
124 |
Demographics (DMQ)…………………………………………………………………………………... |
125 |
Income (INQ)……………………………………………………............................................................ |
128 |
MEC Data Collection Forms…………………………………………………………...… |
133 |
SCREENER QUESTIONNAIRE
NYFS SCREENER MODULE
Household enumeration questions
SCQ_INTR Hello, I’m {INTERVIEWER’S NAME} and we are conducting a survey for the Centers for Disease Control and Prevention (CDC).
SHOW ID CARD.
A letter was sent to you recently explaining a survey which is called the National Health and Nutrition Examination Survey and is about your family’s health.
IF RESIDENT DOES NOT REMEMBER LETTER, HAND NEW COPY.
All the information that you give us is voluntary and will be kept in the strictest confidence. Your name will not be attached to any of your answers without your specific permission.
HELP SCREEN:
Information will be collected under authority of Section 306 of the Public Health Service Act (42 USC 242k) with a guarantee of strict confidence. Federal law (Section 308(d) of the Public Health Service Act (42 USC 242m), the Privacy Act of 1974 (5 USC 552a) and the Confidential Information Protection Act http://aspe.hhs.gov/datacncl/privacy/titleV.pdf,) forbids us to release any information that identifies you or your family to anyone, for any purpose, without your consent. These laws carry stiff fines (up to $250,000) and a jail term if we violate your privacy. Public reporting burden for this collection of information is estimated to average 6.7 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0237).
SCQ.070a I would like to verify your address. Please give me your complete address.
{#} {DIRECTION} {STREET NAME} {STREET/ROAD/AVENUE} {DIRECTION} {#}
{PO BOX} {RURAL ROUTE #} {RURAL ROUTE BOX} {CITY} {STATE} { ZIP}
NO (WRONG ADDRESS) 1 (SCQ_END5)
YES (CORRECTIONS) 2 (SCQ.070b)
YES 3 (SCQ.090)
SCQ.070b I would like to verify your address. Please give me your complete address.
{ADDITIONAL ADDRESS LINE}
{#} {DIRECTION} {STREET NAME} {STREET/ROAD/AVENUE} {DIRECTION}
{UNIT/APT/BLDG} {UNIT #} {PO BOX} {RURAL ROUTE #} {RURAL ROUTE BOX}
{CITY} {STATE} { ZIP}-{ZIP-4}
CAPI INSTRUCTIONS: DISPLAY THE ADDRESS COLUMNS LISTED ABOVE AND ALLOW THE INTERVIEWER TO MAKE CORRECTIONS AS NEEDED. ONCE THE INTERVIEWER IS DONE, SHE WILL PRESS THE NEXT KEY TO CONTINUE.
THE FIELD FOR STATE MAY NOT BE UPDATED.
IF SCQ.070A = 2 AND NONE OF THE ADDRESS FIELDS ARE MODIFIED, AUTO-BACKCODE THE RESPONSE TO SCQ.070A = 3 (YES) AND GO TO SCQ.090.
SCQ.090 To begin, how many people live in this household? Please do not include anyone who usually lives somewhere else.
________
NUMBER
DK 99
RF 77
SCQ.130 What are the names of all of the persons living here? Start with the name of the person, or one of the persons, who owns or rents this home. (Please remember not to include anyone who usually lives somewhere else.)
PROBE: Any others?
______ _______
FIRST MIDDLE LAST SUFFIX GENDER
DK 9
RF 7
CAPI INSTRUCTIONS: WHEN THE FOCUS IS ON THE “GENDER” FIELD, DISPLAY:
ASK IF NOT OBVIOUS:
Is {NAME} male or female?
MALE 1
FEMALE 2
DK 9
RF 7
CAPI INSTRUCTIONS:
HARD EDIT: IF FOCUS IS SHIFTED FROM THE “GENDER” FIELD AND NO ENTRY HAS BEEN MADE FOR GENDER, DISPLAY THE FOLLOWING HARD EDIT:
“REQUIRED VALUE MISSING FOR GENDER IN ROW {ROW IN WHICH GENDER IS MISSING}. PLEASE ENTER A VALUE.”
SOFT EDIT: THE FIRST TIME DK OR RF IS ENTERED FOR GENDER, DISPLAY THE FOLLOWING:
“A MISSING VALUE HERE MAY RESULT IN INCONCLUSIVE SAMPLING. PLEASE RE-ENTER THE VALUE TO CONFIRM.”
ACCEPT THE SECOND ENTRY.
ENSURE THAT EACH NAME (COMBINATION OF FIRST, MIDDLE, LAST, SUFFIX) IS UNIQUE WITHIN THE HOUSEHOLD. IF A DUPLICATE NAME IS ENTERED, DISPLAY THE FOLLOWING HARD EDIT, “NAMES MUST BE UNIQUE. PERSONS # AND # HAVE IDENTICAL NAMES RECORDED. CORRECT THE ERROR TO CONTINUE.”
SCQ.145 I have {TOTAL # OF PERSONS ENUMERATED} {person/people} living here --
[READ NAMES LISTED BELOW.]
______ _______
FIRST MIDDLE LAST SUFFIX GENDER
SCQ.150
Have I missed . . .
SCQ.150 . . . any babies or small children?
SCQ.160 . . . any lodgers, boarders, or persons in your employ who live here?
SCQ.170 . . . anyone who usually lives here but is now away from home?
SCQ.180 . . . anyone else living or staying here?
YES 1 (SCQ.150N, 160N, 170N, 180N)
NO 2 (SCQ.190)
DK 9 (SCQ.190)
RF 7 (SCQ.190)
CAPI INSTRUCTIONS: THE SWEEP QUESTIONS (SCQ.150, 160, 170 AND 180) SHOULD BE DISPLAYED ON A SINGLE SCREEN. A "YES" RESPONSE TO A SWEEP QUESTION BRINGS UP THE HOUSEHOLD COMPOSITION MATRIX. BY CLICKING ON THE “INSERT ROW” BUTTON ON THIS SCREEN, A NEW ROW APPEARS FOR ENTRY OF NAME AND GENDER.
UPON EXITING THE NAME/GENDER SCREEN, THE CURSOR SHOULD RETURN TO THE SCREEN OF SWEEP QUESTIONS WITH THE CURSOR RESIDING ON THE NEXT LINE (QUESTION) THAT REQUIRES AN ANSWER.
IF ALL THE QUESTIONS HAVE BEEN ANSWERED, GO TO SCQ.190.
SCQ.150N [Have I missed any babies or small children?] (What are their names?)
PROBE: Is (he/she) a “Junior”, “Senior”, “the 3rd” or something like that? (What is that?)
PROBE: Any others?
______ _______
FIRST MIDDLE LAST SUFFIX GENDER
DK 9
RF 7
CAPI INSTRUCTIONS: IF THE FOCUS IS ON THE GENDER FIELD, DISPLAY:
ASK IF NOT OBVIOUS:
Is {NAME} male or female?
MALE 1
FEMALE 2
DK 9
RF 7
SCQ.160N [Have I missed any lodgers, boarders, or persons in your employ who live here?] (What are their names?)
PROBE: Any others?
______ _______
FIRST MIDDLE LAST SUFFIX GENDER
DK 9
RF 7
CAPI INSTRUCTIONS: IF THE FOCUS IS ON THE GENDER FIELD, DISPLAY:
ASK IF NOT OBVIOUS:
Is {NAME} male or female?
MALE 1
FEMALE 2
DK 9
RF 7
SCQ.170N [Have I missed anyone who usually lives here but is now away from home?] (What are their names?)
PROBE: Any others?
______ _______
FIRST MIDDLE LAST SUFFIX GENDER
DK 9
RF 7
CAPI INSTRUCTIONS: IF THE FOCUS IS ON THE GENDER FIELD, DISPLAY:
ASK IF NOT OBVIOUS:
Is {NAME} male or female?
MALE 1
FEMALE 2
DK 9
RF 7
SCQ.180N [Have I missed anyone else living or staying here?] (What are their names?)
PROBE: Any others?
______ _______
FIRST MIDDLE LAST SUFFIX GENDER
DK 9
RF 7
CAPI INSTRUCTIONS: IF THE FOCUS IS ON THE GENDER FIELD, DISPLAY:
ASK IF NOT OBVIOUS:
Is {NAME} male or female?
MALE 1
FEMALE 2
DK 9
RF 7
SCQ.190 [VERIFY HOUSEHOLD MEMBERS BY READING NAMES LISTED BELOW.]
______ _______
FIRST MIDDLE LAST SUFFIX GENDER
CAPI INSTRUCTIONS: THE APPLICATION SHOULD ALLOW THE INTERVIEWER TO ADD OR DELETE NAMES OR ROWS FROM THE HH COMPOSITION MATRIX, AS NECESSARY, BASED ON RESPONDENT’S CONFIRMATION OF THE PERSONS WHO HAVE BEEN ENUMERATED.
BOX 1
CHECK ITEM SCQ.191:
APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR GENDER GO TO SCQ.430; ELSE
GO TO BOX 2.
SCQ.195 Do {you/any of the persons in this household} have a home anywhere else?
STUDENTS LIVING AWAY AT SCHOOL ARE CONSIDERED TO HAVE A HOME SOMEWHERE ELSE.
YES 1 (SCQ.200)
NO 2 (SCQ.290)
SCQ.200 (Who is that?)
SELECT MEMBERS WITH HOME ELSEWHERE.
Name Other Home
CAPI INSTRUCTIONS: DISPLAY FIRST AND LAST NAMES OF ALL PERSONS LISTED ON THE HOUSEHOLD COMPOSITION MATRIX.
PROBE: Anyone else?
CAPI INSTRUCTIONS: THE DEFAULT FILL FOR THE “OTHER HOME” COLUMN IS “NO”. HOWEVER, THE DEFAULT CAN BE TOGGLED TO “YES” BY MOVING THE CURSOR TO THE “OTHER HOME” CELL ASSOCIATED WITH THE PERSON WHO HAS A SECOND RESIDENCE, AND SELECTING “YES”.
IF NONE OF THE “OTHER HOME” CELLS HAVE BEEN SET TO “YES”, DISPLAY THE FOLLOWING BOX:
“. You did NOT select any HH member living in another place.
Button 1: Go back and select a person
Button 2: No
one living elsewhere
”
IF BUTTON #1 IS SELECTED, RETURN TO SCQ.200. IF BUTTON #2 IS SELECTED, AUTO-BACKCODE THE RESPONSE TO SCQ.195 TO “NO” AND PROCEED TO SCQ.220.
SCQ.210 Where {do you/does {NAME}} usually live and sleep; here or somewhere else?
Name Live Here
CAPI INSTRUCTIONS: DISPLAY “NAME” AND “LIVE HERE” COLUMNS. THE ANSWER CATEGORIES FOR THE LIVE HERE COLUMN ARE “HERE” (1), “SOMEWHERE ELSE” (2), “DK” (9), AND “RF” (7)
HERE 1
SOMEWHERE ELSE 2
DK 9
RF 7
CAPI INSTRUCTIONS: IF “1”, “9”, OR “7” IS SELECTED, LEAVE THE PERSON ON THE HH COMPOSITION MATRIX; ELSE
IF “2” IS SELECTED AND THIS IS A SINGLE PERSON HOUSEHOLD, OR IF “2” HAS BEEN SELECTED FOR ALL HOUSEHOLD MEMBERS, THE HOUSEHOLD IS “INELIGIBLE” AND THE SCREENER IS TERMINATED AFTER THE COLLECTION OF THE TELEPHONE NUMBER (SCQ.430); ELSE
IF “2” IS SELECTED FOR AT LEAST ONE PERSON AND THE HOUSEHOLD IS MORE THAN A SINGLE PERSON HOUSEHOLD AND “2” HAS NOT BEEN SELECTED FOR ALL MEMBERS OF THE HH, SET A FLAG TO INDICATE THIS PERSON’S PERMANENT RESIDENCE WAS SOMEWHERE ELSE.
THE FLAG IS AN INDICATION THAT ON ALL FUTURE DISPLAYS OF THE HH COMPOSITION MATRIX, THIS PERSON (AND ALL PERSON-LEVEL DATA) WILL NOT BE DISPLAYED.
IF THE REFERENCE PERSON IS NOT ELIGIBLE TO BE THE REFERENCE PERSON BASED ON WHERE S/HE USUALLY LIVES, IDENTIFICATION OF A NEW REFERENCE PERSON IS REQUIRED. RE-APPLY THE REFERENCE PERSON EDIT LOGIC TO IDENTIFY THE REFERENCE PERSON AS THE FIRST PERSON ON THE ENUMEARATION TABLE WHO IS > 18 YEARS OLD; ELSE
IF NO ONE ON THE ENUMBERATION TABLE IS AGE 18 OR OLDER, IDENTIFY THE REFERENCE PERSON AS THE OLDEST PERSON IN THE HOUSEHOLD FOR WHOM THIS IS THE PRIMARY RESIDENCE.
SCQ.250 THESE ARE THE MEMBERS OF THE DU WHO HAVE BEEN LISTED AS HH MEMBERS.
{NAME GENDER}
BOX 3A
CHECK ITEM SCQ.256:
ASK SCQ.290 THROUGH SCQ.301 FOR EACH PERSON ON HH ROSTER.
SCQ.290 What is {your/{NAME}’s} birthdate?
____ ____ ____
MM DD YYYY (SCQ.291)
DK 9 (SCQ.292)
RF 7 (SCQ.292)
CAPI INSTRUCTIONS: IF DATE OF BIRTH IS SPECIFIED, CALCULATE AGE AND POST IN THE “AGE” CELL FOR THE APPROPRIATE PERSON WITH THE CURSOR RESIDING IN THAT CELL AND SCQ.291 DISPLAYED ABOVE THE HH COMPOSITION MATRIX; ELSE
GO TO SCQ.292.
SCQ.291 So {you are/{NAME} is} {AGE AS CALCULATED FROM DOB}?
IF NECESSARY, RE-ENTER CORRECT AGE.
CAPI INSTRUCTIONS: IF AGE IS RE-ENTERED BY THE INTERVIEWER, THE APPLICATION SHOULD ADJUST DOB YEAR IF VALID VALUES FOR DOB MONTH AND DAY EXIST. IF DOB MONTH, DAY AND YEAR ARE RF OR DK, DO NOT BACK-FILL THE DOB YEAR BASED ON THE ENTERED AGE.
SCQ.292 How old {are you/is {NAME}}?
IF AGE IS LESS THAN 12 MONTHS, ENTER 0.
_____
AGE (SCQ.301)
DK 999 (SCQ.300)
RF 777 (SCQ.300)
SCQ.300 About how old {are you/is {NAME}}?
DISPLAY AGE RANGES
DK 9999
RF 7777
CAPI INSTRUCTIONS: DISPLAY QUESTION TEXT ABOVE THE HH COMPOSITION MATRIX WITH THE CURSOR RESIDING IN THE “AGE RANGE” CELL ON THE MATRIX.
AGE RANGES TO BE COMPLETED LATER
DISPLAY THE FOLLOWING SOFT EDIT THE FIRST TIME A DK OR RF IS ENTERED. ACCEPT THE SECOND ENTRY.
“A missing value here may result in inconclusive sampling. Please re-enter the value to confirm.”
ACCEPT THE SECOND ENTRY.
SCQ.301 WARNING: REVIEW AGE FOR EACH PERSON! SAMPLING ALGORITHM WILL BE APPLIED.
{NAME AGE RANGE}
CAPI INSTRUCTIONS: DISPLAY NAME AND AGE AS DETERMINED AT SCQ291, SCQ292, OR SCQ300 FOR EACH ENUMERATED PERSON. INTERVIEWER MAY BACK-UP TO CORRECT.
BOX 5
CHECK ITEM SCQ.303:
APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS ELIGIBLE FOR THE STUDY BASED ON SAMPLING MESSAGES FOR AGE AND GENDER, GO TO SCQ.430; ELSE
CONTINUE.
SCQ.260 [Do you/Does NAME] consider [yourself/himself/herself] to be Hispanic or Latino?
READ IF NECESSARY: Where do {your/his/her} ancestors come from?
Puerto Rican
Cuban/Cuban American
Dominican (Republic)
Mexican/Mexican American
Central/South American
Other Latin American
Other Hispanic or Latino
YES 1
NO 2
DK 9
RF 7
HELP SCREEN:
SPANISH, HISPANIC OR LATINO PEOPLE MAY BE OF ANY RACE. LISTED BELOW ARE HISPANIC OR LATINO CATEGORIES/COUNTRIES.
MEXICAN
PUERTO RICAN
CUBAN
DOMINICAN REPUBLIC
CENTRAL AMERICAN:
COSTA RICAN
GUATEMALAN
HONDURAN
NICARAGUAN
PANAMANIAN
SALVADORAN
OTHER CENTRAL AMERICAN
SOUTH AMERICAN:
ARGENTINEAN
BOLIVIAN
CHILEAN
COLOMBIAN
ECUADORIAN
PARAGUAYAN
PERUVIAN
URUGUAYAN
VENEZUELAN
OTHER SOUTH AMERICAN
OTHER HISPANIC OR LATINO:
SPANIARD
SPANISH
SPANISH AMERICAN
BOX 3B
CHECK ITEM SCQ.265:
CYCLE THROUGH SCQ.270 FOR EACH PERSON LISTED ON HH ROSTER.
SCQ.270 HAND CARD #1
Please look at the categories on this card. What race or races do you consider {yourself/NAME} to be? Please select one or more.
CHECK ALL THAT APPLY.
AMERICAN INDIAN OR ALASKAN NATIVE 1
ASIAN 2
BLACK OR AFRICAN AMERICAN 3
NATIVE HAWAIIAN OR PACIFIC ISLANDER 4
WHITE 5
OTHER 6
DK 9
RF 7
BOX 3C
CHECK ITEM SCQ.270A:
ASK FOR NEXT PERSON. IF NO NEXT PERSON, CONTINUE WITH BOX 3D.
BOX 3D
CHECK ITEM SCQ.270B:
CYCLE THROUGH BOX 3E THROUGH SCQ.280 FOR EACH PERSON ON HH ROSTER.
BOX 3E
CHECK ITEM SCQ.270C:
CHECK SCQ.260 FOR EACH PERSON. IF PERSON LISTED AS NOT HISPANIC (CODE 2), CONTINUE.
OTHERWISE, SKIP TO BOX 3H.
BOX 3F
CHECK ITEM SCQ.270D:
CHECK SCQ.270 – IF ANY PERSON’S RACE = CODE 6 (OTHER) AND DOES NOT = CODE 2 OR CODE 3 (ASIAN OR BLACK), CONTINUE.
OTHERWISE, SKIP TO BOX 3H.
BOX 3G
CHECK ITEM SCQ.270E:
ASK QUESTION SCQ.280 FOR EACH PERSON ON HH ROSTER WHO MEET THE CRITERIA SPECIFIED IN BOXES 3E AND 3F (CODE 2 IN SCQ.260 AND CODE 6 ALONE OR WITH CODE 1, 4 OR 5 IN SCQ.270.
SCQ.280
Do any of the groups on this card represent {your/NAME’s} national origin or ancestry?
HAND CARD #2
YES 1 (CONTINUE WITH CAPI
INSTRUCTION SCQ.282)
NO 2 (BOX 3H)
SCQ.282
CAPI INSTRUCTION: ADD CODE #2 (ASIAN) AS RACE IN SCQ.270.
BOX 3H
CHECK ITEM SCQ.282A:
CYCLE THROUGH BOX 3D – SCQ.280 FOR NEXT PERSON. IF NO NEXT PERSON, CONTINUE.
SCQ.370 THIS HOUSEHOLD HAS ELIGIBLE SURVEY PARTICIPANTS.
THE ELIGIBLE PERSON(S) SAMPLED IN THIS HOUSEHOLD ARE:
{UNIQUE NAMES, GENDERS, AGES OF SAMPLED PERSONS}
CAPI INSTRUCTIONS: SINCE THE SAMPLING ALGORITHM HAS BEEN RUN FOR THE LAST TIME, BACK-UP IS NOT ALLOWED AFTER THIS SCREEN.
SCQ.420 Is {REFERENCE PERSON}’s mailing address the same as {his/her} street address?
SFQ.220
YES 1 (SCQ.430)
NO 2 (SCQ.425)
DK 9 (SCQ.430)
RF 7 (SCQ.430)
SCQ.425 Please give me {REFERENCE PERSON}'s complete mailing address.
SFQ.225
{#} {DIRECTION} {STREET NAME} {STREET/ROAD/AVENUE} {DIRECTION} {#}
{PO BOX} {RURAL ROUTE #} {RURAL ROUTE BOX} {CITY} {STATE} { ZIP}
CAPI INSTRUCTIONS: DISPLAY THE COMPLETE ADDRESS OF THE HOUSEHOLD AS COLLECTED IN SCQ070 OR SCQ080 AND ALLOW UPDATES IN ALL FIELDS. IF UPDATES ARE MADE, STORE THIS ADDRESS AS THE MAILING ADDRESS. IF NO UPDATES ARE MADE, RESET SCQ.420 TO “NO” AND CONTINUE TO SCQ.430.
SCQ.430 Please give me your home telephone number in case my office wants to check my work.
SFQ.230
( ) - ______ - __________ - __________
HOME TELEPHONE NUMBER (SCQ.440a)
NO HOME TELEPHONE 2 (SCQ.460)
DK 9 (SCQ.460)
RF 7 (SCQ.460)
CAPI INSTRUCTIONS: THE FIELD FOR "EXTENSION" IS ALLOWED TO BE BLANK.
SCQ.440a In whose name is the telephone listed?
SFQ.240a
INTERVIEWER INSTRUCTION: SELECT NAME FOR TELEPHONE LISTING FROM HOUSEHOLD ROSTER.
________ ________
FIRST LAST (BOX 13)
UNLISTED 1 (BOX 13)
NOT ON LIST 2 (SCQ440b)
DK 9 (BOX 13)
RF 7 (BOX 13)
SCQ.440b [In whose name is the telephone listed?]
SFQ.240b
INTERVIEWER INSTRUCTION: ENTER NAME.
Name ________ ________
{FIRST} {LAST} (BOX 13)
CAPI INSTRUCTIONS: THE DEFAULT FILL FOR THE “NAME” FIELD SHOULD BE THE FIRST, LAST, AND SUFFIX NAME OF THE REFERENCE PERSON. HOWEVER, MOVING THE FOCUS OF THE CURSOR OVER THE “NAME” FILL PRODUCES A LIST DISPLAYING THE FIRST AND LAST NAMES OF ALL HH MEMBERS ON THE HH COMPOSITION MATRIX AND THE OPTIONS OF “UNLISTED”, AND “NOT ON LIST”.
SCQ.460 Is there another number where you can be reached?
( ) - ______ - __________ - __________
OTHER TELEPHONE NUMBER (SCQ461)
NO 2 (BOX 13)
DK 9 (BOX 13)
RF 7 (BOX 13)
CAPI INSTRUCTIONS: THE FIELD FOR "EXTENSION" IS ALLOWED TO BE BLANK.
SCQ.461 Where is that telephone located?
WORK 1
RELATIVE’S HOME 2
NEIGHBOR’S HOME 3
CELL PHONE 4
OTHER 5
DK 9
RF 7
BOX 13
CHECK ITEM SCQ.465:
IF THIS IS AN INELIGIBLE HOUSEHOLD, GO TO SCQ_END1; ELSE
IF THIS IS AN ELIGIBLE HOUSEHOLD, GO TO SCQ_END2; ELSE
IF THIS IS A BREAK-OF, GO TO SCQ_END3 AND REQUIRE ENTRY OF DISPOSITION; ELSE
IF MISSING CRITICAL SAMPLING DATA, GO TO SCQ_END4; ELSE
IF SCQ.070 (ADDRESS VERIFICATION) IS “NO (WRONG ADDRESS)”; GO TO SCQ_END 5.
SCQ_END1 Thank you.
BOX 14
CHECK ITEM SCQ.???:
GO TO INTERPRETER MODULE – INT_END1.
SCQ_END2 Thank you. This household has eligible survey participants.
[READ NAMES LISTED BELOW.]
{UNIQUE NAMES, GENDERS, AGES OF SAMPLE PERSONS}
[IF APPROPRIATE, EXPLAIN PARTICIPATION IN STUDY TO RESPONDENT.]
SCQCONT PERFORM THE RELATIONSHIP INTERVIEW AT THIS TIME?
YES 1 SCQ_MODULE 2)
NO 2 (SCQ_END2b)
CAPI INSTRUCTIONS: IF CODED “YES” (1), UPON LEAVING THIS SCREEN, LAUNCH MODULE 2 OF THE SCREENER, COLLECTING RELATIONSHIP INFORMATION.
RIQ.010 SELECT RESPONDENT FOR THE SCREENER MODULE 1 – HOUSEHOLD COMPOSITION.
Respondent
{FIRST NAME} {LAST NAME}
CAPI INSTRUCTIONS: WHEN THE FOCUS OF THE CURSOR IS ON THE “RESPONDENT” FIELD, THE ANSWER CHOICES SHOULD BE A LIST THAT DISPLAYS FIRST AND LAST NAMES OF ALL HH MEMBERS ON THE HH COMPOSITION MATRIX.
MDUREMIN REMINDER: PLEASE COMPLETE THE MISSED-DU PROCEDURE.
CAPI INSTRUCTION: DISPLAY IF CASE SELECTED FOR MDU PROCEDURE.
BOX 15
CHECK ITEM SCQ.???:
GO TO INTERPRETER MODULE – INT_END1.
SCQ_END3 Thank you.
SCQEND3 PROGRAMMER SPEC: AFTER EXITING FROM THIS SCREEN, PRESENT THE LIST OF DISPOSITIONS AND DO NOT ALLOW EXIT FROM THE APPLICATION WITHOUT ENTRY OF A DISPOSITION.
SCQ_END4 Thank you.
[EXPLAIN TO RESPONDENT THAT YOU WILL NEED TO RETURN TO THE HOUSEHOLD TO COLLECT CRITICAL INFORMATION THAT WAS NOT PROVIDED THIS TIME.]
SCQ_END5 Thank you.
LOCATE CORRECT ADDRESS AND RESTART SCREENER.
FAMILY RELATIONSHIP QUESTIONNAIRE
NYFS SCREENER MODULE
RELATIONSHIP questions
TO BE ADMINISTERED TO ALL ELIGIBLE HOUSEHOLDS
BOX 1
CHECK ITEM SFQ.001:
IF ONLY 1 PERSON HOUSEHOLD, CODE PERSON AS "REFERENCE PERSON", CODE RELATIONSHIP AS "SELF", ASSIGN FAMILY #1 TO PERSON AND GO TO END OF SECTION.
OTHERWISE, CONTINUE.
BOX 2
CHECK ITEM SFQ.004:
CODE FIRST PERSON LISTED ON H.H. MATRIX WHOSE AGE IS > 18 AND IS NOT FLAGGED AS LIVING "SOMEWHERE ELSE" AS "REFERENCE PERSON", HEAD OF FAMILY #1 AND RELATIONSHIP AS "SELF".
BOX 3
LOOP 1:
ASK NEW BOX 3A – SFQ.040 AS APPROPRIATE FOR EACH PERSON {P} LISTED BELOW REFERENCE PERSON ON THE HOUSEHOLD MATRIX.
NEW BOX 3A
CHECK ITEM SFQ.005:
CHECK GENDER OF {PERSON} FROM SCREENER. IF {PERSON} IS MALE, DISPLAY SFQ.006. IF FEMALE, DISPLAY SFQ.007.
SFQ.000 {The next questions are about family relationships.}
SFQ.006 What is {PERSON'S} relationship to {REFERENCE PERSON}?
HAND CARD SFQ1
CAPI DESIGN = RADIO BUTTONS
RELATED HUSBAND 01 PARTNER 02
SON (BIOLOGICAL, SON-IN-LAW, SON OF PARTNER 04 GRANDSON 05 FATHER 06 BROTHER 07 GRANDFATHER 08 UNCLE 09 NEPHEW 10 OTHER RELATIVE 11 |
NOT RELATED HOUSEMATE/ROOMMATE 12 ROOMER/BOARDER 13 OTHER/NON RELATED 14
LEGAL GUARDIAN 15 WARD 16
REFUSED 77 DON’T KNOW 99 |
CAPI INSTRUCTIONS: IF CODE 1 AND {PERSON} IS <16 YEARS OLD, DISPLAY THE FOLLOWING BOX:
{PERSON} is listed as being under 16 years old. Are you sure {PERSON} should be coded as {HUSBAND/WIFE}?
Button 1: No, change relationship
Button 2: Yes, continue
IF BUTTON #1 IS SELECTED, RETURN TO SFQ.006/007. IF BUTTON #2 IS SELECTED, CONTINUE WITH BOX 5.
SFQ.007 {The next questions are about family relationships.}
What is {PERSON'S} relationship to {REFERENCE PERSON}?
HAND CARD SFQ2
CAPI DESIGN = RADIO BUTTONS
RELATED WIFE 01 PARTNER 02
DAUGHTER (BIOLOGICAL, DAUGHTER OF PARTNER 04 GRANDDAUGHTER 05 MOTHER 06 SISTER 07 GRANDMOTHER 08 AUNT 09 NIECE 10 OTHER RELATIVE 11 |
NOT RELATED HOUSEMATE/ROOMMATE 12 ROOMER/BOARDER 13 OTHER/NON RELATED 14
LEGAL GUARDIAN 15 WARD 16
REFUSED 77 DON’T KNOW 99 |
CAPI INSTRUCTIONS: IF CODE 1 AND {PERSON} IS <16 YEARS OLD, DISPLAY THE FOLLOWING BOX:
{PERSON} is listed as being under 16 years old. Are you sure {PERSON} should be coded as {HUSBAND/WIFE}?
Button 1: No, change relationship
Button 2: Yes, continue
IF BUTTON #1 IS SELECTED, RETURN TO SFQ.006/007. IF BUTTON #2 IS SELECTED, CONTINUE WITH BOX 5.
BOX 5
CHECK ITEM SFQ.017:
IF {P} RELATIONSHIP IN SFQ.006 or SFQ.007 = SON OR DAUGHTER (CODE 3), CONTINUE.
OTHERWISE, SKIP TO BOX 6.
SFQ.020 Is {PERSON}, {REFERENCE PERSON'S} biological (natural), adoptive, step, foster {son/daughter} or (son/daughter)-in-law?
BIOLOGICAL (NATURAL) {SON/
DAUGHTER} 1
ADOPTIVE {SON/DAUGHTER} 2
STEP {SON/DAUGHTER} 3
FOSTER {SON/DAUGHTER} 4
{SON/DAUGHTER}-IN-LAW 5
REFUSED 7
DON'T KNOW 9
BOX 6
CHECK ITEM SFQ.025:
IF {P} RELATIONSHIP IN SFQ.006 or SFQ.007 = FATHER OR MOTHER (CODE 6), CONTINUE.
OTHERWISE, GO TO BOX 7.
SFQ.030 Is {PERSON}, {REFERENCE PERSON'S} biological (natural), adoptive, step, or foster parent or {mother/father}-in-law?
BIOLOGICAL (NATURAL) PARENT 1
ADOPTIVE PARENT 2
STEP PARENT 3
FOSTER PARENT 4
{MOTHER/FATHER}-IN-LAW 5
REFUSED 7
DON'T KNOW 9
BOX 7
CHECK ITEM SFQ.035:
IF {P} RELATIONSHIP IN SFQ. 006 or SFQ.007 = BROTHER OR SISTER (CODE 7), CONTINUE.
OTHERWISE, GO TO BOX 8.
SFQ.100 Is {PERSON}, {REFERENCE PERSON'S} full, half, adoptive, step, or foster {brother/sister} or {brother/sister}-in-law?
FULL {BROTHER/SISTER} 1
HALF {BROTHER/SISTER} 2
ADOPTED {BROTHER/SISTER} 3
STEP {BROTHER/SISTER} 4
FOSTER {BROTHER/SISTER} 5
{BROTHER/SISTER}-IN-LAW 6
REFUSED 7
DON'T KNOW 9
BOX 8
END LOOP 1:
ASK NEW BOX 3A – SFQ.040 AS APPROPRIATE FOR NEXT PERSON {P} LISTED BELOW REFERENCE PERSON OR NEXT PERSON RELATED TO HEAD OF FAMILY ON THE HOUSEHOLD MATRIX.
IF NO NEXT PERSON, GO TO BOX 9.
BOX 9
CHECK ITEM SFQ.043:
IF ALL PERSONS IN HOUSEHOLD ARE RELATED (HAVE RELATIONSHIP CODES ASSOCIATED WITH CODES 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15, 16, 77 OR 99 IN SFQ.006 OR SFQ.007), GO TO BOX 20.
OTHERWISE, CONTINUE WITH BOX 10.
BOX 10
CHECK ITEM SFQ.045:
CODE FIRST PERSON REMAINING UNRELATED TO REFERENCE PERSON AND HEADS OF ADDITIONAL FAMILIES AND WHOSE AGE IS >18 AS HEAD OF NEXT FAMILY {H OF F} AS APPROPRIATE (#2, 3, 4, ETC.), AND GO TO BOX 11.
IF NO PERSONS AGE > 18, CODE OLDEST PERSON FROM THIS GROUP AS HEAD OF FAMILY.
BOX 11
CHECK ITEM SFQ.047:
IF MORE THAN ONE PERSON CODED AS UNRELATED, CONTINUE WITH SFQ.050.
OTHERWISE, GO TO BOX 20.
SFQ.050 Now I would like to talk about those persons in the household who are not related to {REFERENCE PERSON/REFERENCE PERSON OR HEADS OF FAMILY}. That is {LIST ALL PERSONS IN HOUSEHOLD NOT RELATED TO {REFERENCE PERSON/REFERENCE PERSON OR HEADS OF FAMILY}.
DISPLAY NAME OF REFERENCE PERSON IF THIS IS THE FIRST TIME THIS QUESTION IS ASKED. DISPLAY NAMES OF REFERENCE PERSON AND ALL HEADS OF ADDITIONAL FAMILIES IF THIS IS NOT THE FIRST TIME QUESTION IS ASKED.
Is {HEAD OF FAMILY #2, 3, 4, ETC} related to anyone in the household?
YES 1
NO 2 (BOX 19)
REFUSED 7
DON'T KNOW 9
SFQ.060 Who is {HEAD OF FAMILY #2, 3, 4, ETC. FROM BOX 10} related to? {DISPLAY LIST OF NAMES OF ALL PERSONS WHO ARE NOT REFERENCE PERSON, OR HEAD OF FAMILY AND WHO ARE NOT RELATED TO ANYONE ELSE IN HOUSEHOLD (DO NOT HAVE RELATIONSHIP CODE = CODE 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15 OR 16)}.
SELECT NAMES OF PERSONS RELATED TO {REFERENCE PERSON OR HEAD(S) OF FAMILY}.
BOX 13
EMBEDDED LOOP 2A:
ASK NEW BOX 3A THROUGH SFQ.040 FOR EACH PERSON SELECTED IN SFQ.060.
BOX 18
END EMBEDDED LOOP 2A:
ASK NEW BOX 3A THROUGH SFQ.040 AS APPROPRIATE FOR NEXT PERSON SELECTED AS RELATED TO HEAD OF FAMILY IN SFQ.060.
IF NO NEXT PERSON, GO TO BOX 19.
BOX 19
END LOOP 2:
IF MORE THAN 1 PERSON REMAINS UNRELATED TO THE REFERENCE PERSON OR THE HEAD OF ADDITION FAMILY:
DESIGNATE NEXT HEAD OF FAMILY AS INSTRUCTED IN BOX 10.
ASK NEW BOX 3A THROUGH SFQ.040 FOR NEXT HEAD OF FAMILY AND PERSONS WHO REMAIN AS UNRELATED.
IF NO NEXT PERSONS GO TO BOX 20.
BOX 20
CHECK ITEM SFQ.105:
IF
REFERENCE PERSON OR HEAD OF FAMILY IS MARRIED (CODED AS 01 IN SFQ.006
OR SFQ.007) OR
LIVING WITH A PARTNER (CODED AS UNMARRIED
PARTNER IN SFQ.006 OR SFQ.007).
AND
REFERENCE PERSON OR HEAD OF FAMILY HAS A CHILD OR THE PARTNER HAS A CHILD (CODED AS 03 OR 04 IN SFQ.006 OR SFQ.007), CONTINUE.
OTHERWISE GO TO BOX 23.
BOX 21
LOOP 3:
ASK SFQ.110 FOR EACH PERSON (CHILD OF REFERENCE PERSON AND CHILD OF PARTNER – RELATIONSHIP CODE 3 OR 4).
SFQ.110 I recorded that {NAME OF MOTHER/FATHER OF CHILD – THIS IS SPOUSE OR PARTNER OF REFERENCE PERSON} is the {father/mother} of {NAME OF CHILD – THIS IS CHILD OF REFERENCE PERSON AND SPOUSE OR REFERENCE PERSON AND PARTNER OR CHILD OF PARTNER}. Is {NAME OF CHILD} {his/her} biological, adoptive, step, foster child, (son or daughter)-in-law or a non relative of {NAME OF MOTHER/FATHER}?
BIOLOGICAL CHILD 1
ADOPTIVE CHILD 2
STEP CHILD 3
FOSTER CHILD 4
(SON/DAUGHTER)-IN-LAW 5
NON RELATIVE 6
REFUSED 7
DON'T KNOW 9
BOX 22
END LOOP 3:
ASK SFQ.110 FOR NEXT PERSON (CHILD OR CHILD OF PARTNER).
IF NO NEXT PERSON, CONTINUE WITH BOX 23.
BOX 23
CHECK ITEM 115:
CHECK RELATIONSHIPS. IF ALL HOUSEHOLD MEMBERS HAVE MOTHER, FATHER, AND SPOUSE OR PARTNER IDENTIFIED, GO TO BOX 31.
OTHERWISE, IF ANY OF THESE RELATIONSHIPS FOR EACH PERSON IS NOT ALREADY IDENTIFIED, CONTINUE.
BOX 24
LOOP 4:
ASK SFQ.120 – SFQ.200 AS APPROPRIATE FOR EACH PERSON WHO DOES NOT HAVE A MOTHER AND FATHER AND SPOUSE OR PARTNER IDENTIFIED IN HOUSEHOLD.
BOX 25
CHECK ITEM SFQ.117:
IF PERSON'S MOTHER HAS NOT BEEN IDENTIFIED, AND THERE ARE FEMALES IN THE HOUSEHOLD WHO ARE > 13 YEARS OLDER THAN PERSON, CONTINUE OTHERWISE, GO TO BOX 27.
SFQ.120 Is {PERSON'S} mother a household member? [Include mother-in-law].
IF OBVIOUS, VERIFY ONLY.
CHOOSE MOTHER OVER MOTHER-IN-LAW IF BOTH PRESENT.
YES – MOTHER IN HOUSEHOLD 1
NO – MOTHER NOT IN HOUSEHOLD 2 (BOX 27)
LEGAL GUARDIAN IN HOUSEHOLD 3
REFUSED 7 (BOX 27)
DON'T KNOW 9 (BOX 27)
SFQ.130 Who is that?
[SELECT PERSON FROM HOUSEHOLD MATRIX.
BOX 26
CHECK ITEM SFQ.135:
IF LEGAL GUARDIAN CODED IN SFQ.120, GO TO BOX 27.
OTHERWISE, CONTINUE.
SFQ.140 Is {NAME OF MOTHER IN SFQ.130}, {PERSON'S} biological [natural], adoptive, step, or foster mother or mother-in-law?
BIOLOGICAL MOTHER 1
ADOPTIVE MOTHER 2
STEP MOTHER 3
FOSTER MOTHER 4
MOTHER-IN-LAW 5
REFUSED 7
DON'T KNOW 9
BOX 27
CHECK ITEM SFQ.145:
IF PERSON'S FATHER HAS NOT BEEN IDENTIFIED, AND THERE ARE MALES IN THE HOUSEHOLD WHO ARE > 13 YEARS OLDER THAN PERSON.
OTHERWISE, GO TO BOX 29A.
SFQ.150 Is {PERSON'S} father a household member? [Include father-in-law].
IF OBVIOUS, VERIFY ONLY.
CHOOSE FATHER OVER FATHER-IN-LAW IF BOTH PRESENT.
YES – FATHER IN HOUSEHOLD 1
NO – FATHER NOT IN HOUSEHOLD 2 (BOX 29)
LEGAL GUARDIAN IN HOUSEHOLD 3
REFUSED 7 (BOX 29)
DON'T KNOW 9 (BOX 29)
SFQ.160 Who is that?
[SELECT PERSON FROM HOUSEHOLD MATRIX.
BOX 28
CHECK ITEM SFQ.165:
IF LEGAL GUARDIAN CODED IN SFQ.150, GO TO BOX 29A.
OTHERWISE, CONTINUE.
SFQ.170 Is {NAME OF FATHER IN SFQ.160}, {PERSON'S} biological (natural), adoptive, step, or foster father or father-in-law?
BIOLOGICAL FATHER 1
ADOPTIVE FATHER 2
STEP FATHER 3
FOSTER FATHER 4
FATHER-IN-LAW 5
REFUSED 7
DON'T KNOW 9
BOX 29A
CHECK ITEM SFQ.175:
IF PERSON'S AGE >= 16 AND SPOUSE OR UNMARRIED PARTNER HAS NOT BEEN IDENTIFIED, CONTINUE.
OTHERWISE, GO TO BOX 30.
SFQ.180 Is {PERSON'S NAME} now married, widowed, divorced, separated, never married or living with a partner?
MARRIED 1
WIDOWED 2 (BOX 30)
DIVORCED 3 (BOX 30)
SEPARATED 4 (BOX 30)
NEVER MARRIED 5 (BOX 30)
LIVING WITH PARTNER 6
REFUSED 7 (BOX 30)
DON'T KNOW 9 (BOX 30)
BOX 29B
CHECK ITEM SFQ.185:
IF THERE ARE PERSONS IN THE HOUSEHOLD WHO ARE > = 14 YEARS OLD, CONTINUE.
OTHERWISE, GO TO BOX 30.
SFQ.190 Is {PERSON'S} {spouse/partner} living in the household?
YES 1
NO 2 (BOX 30)
REFUSED 7 (BOX 30)
DON'T KNOW 9 (BOX 30)
SFQ.200 Who is that?
DISPLAY LIST OF ALL NONDELETED HOUSEHOLD MEMBERS WHO ARE 14 YEARS OLD OR OLDER.
BOX 30
END LOOP 4:
ASK SFQ.120 – SFQ.200 FOR NEXT PERSON.
IF NO NEXT PERSON, GO TO BOX 31.
BOX 31
CHECK ITEM SFQ.205:
APPLY NHANES AND CPS FAMILY DEFINITIONS.
IF MORE THAN 1 NHANES FAMILY, CONTINUE.
IF
ONLY 1 NHANES FAMILY, GO TO SFQ.210. DO NOT REASK SCQ.430 –
SCQ.461.
OTHERWISE, GO TO SFQ.210.
BOX 32
LOOP 5:
ASK MODULE 1 – SCQ.420 – SCQ.440b FOR EACH ADDITIONAL NHANES FAMILY.
NOTE: THE SUBJECT OF QUESTIONS SHOULD BE EACH ADDITIONAL HEAD OF NHANES FAMILY AND NUMBERED SFQ.220, SFQ.225, SFQ.230 AND SFQ.240a.
DO NOT REASK SCQ.430 – SCQ.461 OF THE FIRST NHANES FAMILY.
SFQEND Thank you. That completes the questions about family relationships.
RIQ.010 SELECT RESPONDENT FOR THE SCREENER MODULE II – HOUSEHOLD RELATIONSHIPS.
Respondent
{FIRST NAME} {LAST NAME}
CAPI INSTRUCTIONS: WHEN THE FOCUS OF THE CURSOR IS ON THE “RESPONDENT” FIELD, THE ANSWER CHOICES SHOULD BE A LIST THAT DISPLAYS FIRST AND LAST NAMES OF ALL HH MEMBERS ON THE HH COMPOSITION MATRIX.
INT.001 WAS AN INTERPRETER USED FOR INTERVIEW?
YES 1
NO 2 (GO TO THE END
OF THE SECTION)
BOX #1
CHECK ITEM INT.001A:
IF THIS IS SCREENER, SKIP TO INT.003.
OTHERWISE, IF THIS IS RELATIONSHIP MODULE, CONTINUE WITH BOX 2.
BOX #2
CHECK ITEM INT.001B:
IF SCREENER AND RELATIONSHIP COMPLETED DURING SAME SESSION (SCQ_END 2a = YES), SKIP TO INT.003.
OTHERWISE, CONTINUE.
INT.002 IS THIS THE SAME INTERPRETER THAT WAS USED FOR THE SCREENER?
YES 1 {CODE INTERPRETER
SCREENER INFORMATION
AND SKIP TO END OF SECTION)}
NO 2 (CONTINUE)
INT.003 LANGUAGE USED FOR INTERVIEW
AMERICAN SIGN LANGUAGE 1 (SKIP TO INT.005)
CHINESE (CANTONESE) 2 (SKIP TO INT.005)
CHINESE (MANDARIN) 3 (SKIP TO INT.005)
FRENCH 4 (SKIP TO INT.005)
GERMAN 5 (SKIP TO INT.005)
ITALIAN 6 (SKIP TO INT.005)
JAPANESE 7 (SKIP TO INT.005)
KOREAN 8 (SKIP TO INT.005)
RUSSIAN 9 (SKIP TO INT.005)
SPANISH (READER) 10 (SKIP TO INT.005)
VIETNAMESE 11 (SKIP TO INT.005)
OTHER SPECIFY 99
INT.004 ENTER LANGUAGE USED FOR INTERVIEW
_________________________________
INT.005 HOW WAS INTERPRETER OBTAINED
ARRANGED BY FIELD OFFICE 1
RECRUITED DURING VISIT/APPOINTMENT 2 (INT.007)
INT.006 SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME
{DROP DOWN LIST SHOULD HAVE ALL NAMES FROM EVM AND AN “OTHER SPECIFY” TO ALLOW FOR THOSE NAMES THAT HAVE NOT BEEN TRANSFERRED TO INTERVIEWER PENTOP}
BOX #3
CHECK ITEM INT.006A:
IF OTHER (SELECTED IN INT.006) GO TO INT.009.
OTHERWISE, GO TO SFQMISDU.
INT.007 SELECT INTERPRETER SOURCE
RELATIVE LIVING IN HOUSEHOLD 1
NON-RELATIVE LIVING IN HOUSEHOLD 2
NEIGHBOR, RELATIVE OR FRIEND –
NOT IN
HOUSEHOLD 3 (SKIP TO INT.009)
INT.008 SELECT NAME OF INTERPRETER FROM HOUSEHOLD ROSTER.
{DISPLAY CAPI PULL DOWN LIST FROM HH ROSTER}
BOX #4
CHECK ITEM INT.008A:
GO TO END OF SECTION.
INT.009 ENTER NAME OF INTERPRETER
______________________________________
INT.010 ENTER PHONE # OF INTERPRETER
___ -___ ____
INT.011 ENTER AGE RANGE OF INTERPRETER
{AGE RANGE CAN BE A PULL DOWN LIST}
RANGES = 18-29
30-59
60+
INT.012 ENTER GENDER OF INTERPRETER
MALE 1
FEMALE 2
SFQMISDU REMINDER: PLEASE COMPLETE THE MISSED-DU PROCEDURE.
CAPI INSTRUCTION: DISPLAY IF CASE SELECTED FOR MDU PROCEDURE.
NHANES NYFS
RIQ.010 SELECT RESPONDENT FOR THE SP QUESTIONNAIRE FOR {SP NAME}.
CAPI INSTRUCTION:
DISPLAY FAMILY ROSTER AND 'SOMEONE OUTSIDE FAMILY' AS OPTION.
BOX 1
CHECK ITEM *11RIQ.015:
IF SP IS SELECTED AS RESPONDENT AND SP AGE IS <= 15, GO
TO
*11RIQ.020.
IF SP IS SELECTED AS RESPONDENT AND SP AGE IS >= 16, GO
TO
RIQ.080.
IF SP IS NOT
SELECTED AS RESPONDENT AND SP AGE IS <= 15, GO TO
BOX 2.
IF SP IS NOT
SELECTED AS RESPONDENT AND SP AGE IS >= 16, GO TO
RIQ.030.
*11RIQ.020 INTERVIEW SHOULD BE CONDUCTED WITH A PROXY BECAUSE SP IS UNDER 16 YEARS OLD.
ENTER ONE OPTION.
SP IS AN EMANCIPATED MINOR 1 (BOX 3)
PERSON SELECTED AS
RESPONDENT IN ERROR 2 (RIQ.010)
SP AGE ENTERED IN ERROR -- SP IS
AGE 16+ 3 (RIQ.080)
RIQ.030 WHY IS INTERVIEW BEING CONDUCTED WITH A PROXY?
SP HAS COGNITIVE PROBLEMS 1
SP HAS PHYSICAL PROBLEMS
(SPECIFY) 2
OTHER (SPECIFY) 3
*11RIQ.035 DO YOU HAVE SUPERVISOR PERMISSION TO CONDUCT INTERVIEW WITH A PROXY?
YES 1
NO 2 (RIQ.010)
BOX 2
CHECK ITEM RIQ.031:
IF 'SOMEONE OUTSIDE THE FAMILY' SELECTED AS RESPONDENT, CONTINUE.
OTHERWISE, GO TO RIQ.080.
RIQ.040 WHY IS INTERVIEW BEING CONDUCTED WITH SOMEONE OUTSIDE THE HOUSEHOLD?
RIQ.050 ENTER RESPONDENT NAME.
FIRST NAME LAST NAME
RIQ.060 ENTER RESPONDENT'S PHONE NUMBER.
ENTER '00' IN AREA CODE IF NO PHONE.
|___|___|___| |___|___|___| - |___|___|___|___|
AREA CODE ENTER PHONE NUMBER
RIQ.070 DESCRIBE RESPONDENT'S RELATIONSHIP TO SP.
BOX 3
CHECK ITEM *11RIQ.072:
IF SP SELECTED AS RESPONDENT IS <12 YEARS OLD, CONTINUE.
OTHERWISE, GO TO RIQ.080.
*11RIQ.074 EMANCIPATED MINOR MUST BE AT LEAST 12 YEARS OLD.
PRESS ‘ENTER’ TO SELECT ANOTHER RESPONDENT.
CAPI INSTRUCTION:
WHEN ‘ENTER’ IS PRESSED, CAPI SHOULD RETURN TO RIQ.010.
RIQ.080 HAS RESPONDENT SIGNED A HOUSEHOLD INTERVIEW CONSENT FORM?
CAPI INSTRUCTION:
IF 'NO' (CODE 2), DISPLAY THE FOLLOWING MESSAGE: "EACH RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE MUST SIGN A HOUSEHOLD INTERVIEW CONSENT FORM BEFORE THE INTERVIEW CAN BE ADMINISTERED" AND RETURN TO RIQ.080.
NOTE: IF INTERPRETER USED, RESPONDENT MUST SIGN FORM.
YES 1
NO 2
INT.001 WAS AN INTERPRETER USED FOR INTERVIEW?
YES 1
NO 2 (GO TO THE END
OF THE SECTION)
INT.003 LANGUAGE USED FOR INTERVIEW
AMERICAN SIGN LANGUAGE 1 (INT.013)
CHINESE (CANTONESE) 2 (INT.013)
CHINESE (MANDARIN) 3 (INT.013)
FRENCH 4 (INT.013)
GERMAN 5 (INT.013)
ITALIAN 6 (INT.013)
JAPANESE 7 (INT.013)
KOREAN 8 (INT.013)
RUSSIAN 9 (INT.013)
SPANISH (READER) 10 (INT.013)
VIETNAMESE 11 (INT.013)
OTHER SPECIFY 99
INT.004 ENTER LANGUAGE USED FOR INTERVIEW
_________________________________
INT.013 {DISPLAY INTERPRETER NAMES FROM ALL PREVIOUS INTERVIEWS: SCREENER, RELATIONSHIP, SP, FAMILY QUESTIONNAIRE}
ENTER INTERPRETER NAME INFO
SAME INTERPRETER USED IN OTHER
INTERVIEW FOR
HOUSEHOLD 1 (INT.014)
NEW INTERPRETER 2 (INT.005)
INT.014 {DISPLAY LIST OF INTERPRETER NAMES FROM SCREENER, RELATIONSHIP, SP AND/OR FAMILY QUESTIONNAIRES}
{INCLUDE “OTHER” AS A SELECTION}
SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME
BOX 4
CHECK ITEM INT.014a:
IF ‘OTHER’ SELECTED IN INT.014, GO TO INT.005.
OTHERWISE, CODE INTERPRETER INFO FROM PREVIOUS INTERVIEW AND GO TO END OF SECTION.
INT.005 HOW WAS INTERPRETER OBTAINED
ARRANGED BY FIELD OFFICE 1
RECRUITED DURING VISIT/APPOINTMENT 2 (INT.007)
INT.006 SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME
{DROP DOWN LIST SHOULD HAVE ALL NAMES FROM EVM AND AN “OTHER SPECIFY” TO ALLOW FOR THOSE NAMES THAT HAVE NOT BEEN TRANSFERRED TO INTERVIEWER PENTOP}
BOX 6
CHECK ITEM INT.006A:
IF OTHER (SELECTED IN INT.006), GO TO INT.009.
OTHERWISE, GO TO END OF SECTION.
INT.007 SELECT INTERPRETER SOURCE
RELATIVE LIVING IN HOUSEHOLD 1
NON-RELATIVE LIVING IN HOUSEHOLD 2
NEIGHBOR, RELATIVE OR FRIEND –
NOT IN
HOUSEHOLD 3 (SKIP TO INT.009)
INT.008 SELECT NAME OF INTERPRETER FROM HOUSEHOLD ROSTER.
{DISPLAY CAPI PULL DOWN LIST FROM HH ROSTER}
BOX 7
CHECK ITEM INT.008A:
GO TO END OF SECTION.
INT.009 ENTER NAME OF INTERPRETER
______________________________________
INT.010 ENTER PHONE # OF INTERPRETER
___ -___ ____
INT.011 ENTER AGE RANGE OF INTERPRETER
{AGE RANGE CAN BE A PULL DOWN LIST}
RANGES = 18-29
30-59
60+
INT.012 ENTER GENDER OF INTERPRETER
MALE 1
FEMALE 2
E
NHANES NYFS
Target Group: 3 to 15 Years
First I have some questions about {SP NAME's} birth.
ECQ.020 Did {SP NAME's} biological mother smoke at any time while she was pregnant with {him/her}?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
ECQ.071/ How much did {SP NAME} weigh at birth?
L/O/K/M
IF ANSWER GIVEN IN POUNDS ONLY, PROBE FOR OUNCES.
IF ANSWER GIVEN IN EXACT POUNDS, ENTER NUMBER OF POUNDS AND 0 OUNCES.
|___|___|
ENTER NUMBER OF POUNDS
CAPI INSTRUCTION:
SOFT EDIT 3-13, HARD EDIT 0-20
AND
|___|___|
ENTER NUMBER OF OUNCES
CAPI INSTRUCTION:
HARD EDIT 0-15, NO SOFT EDIT
OR
|___|___|___|
ENTER NUMBER IN KILOGRAMS
CAPI INSTRUCTION:
SOFT EDIT 1.5-6, HARD EDIT 0-9
OR
|___|___|___|
ENTER NUMBER IN GRAMS
CAPI INSTRUCTION:
SOFT EDIT 1,500-6,000, HARD EDIT 0-9,000
OR
REFUSED 7777
DON’T KNOW 9999
|
WHQ.030e Do you consider {SP} now to be . . .
overweight, 1
underweight, or 2
about the right weight? 3
REFUSED 7
DON’T KNOW 9
MCQ.080e Has a doctor or health professional ever told you that {SP} was overweight?
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON’T KNOW 9 (END OF SECTION)
HELP SCREEN:
Doctor: The term refers to both medical doctors (M.D.s) and osteopathic physicians (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Other Health (Care) Professional: A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, lab technicians, and technicians who administer shots (i.e., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.
ECQ.150 Are you now doing anything to help {SP} control {his/her} weight?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
H
NHANES NYFS
Target
Group: 3 to 15 years
HUQ.010 Next I have some general questions about {SP's} health.
Would you say {SP's} health in general is . . .
excellent, 1
very good, 2
good, 3
fair, or 4
poor? 5
REFUSED 7
DON'T KNOW 9
HUQ.030 Is there a place that {SP} usually goes when {he/she is} sick or you need advice about {his/her} health?
YES 1
THERE IS NO PLACE 2 (End of Section)
THERE IS MORE THAN ONE PLACE 3
REFUSED 7 (End of Section)
DON'T KNOW 9 (End of Section)
HELP SCREEN:
Usual Place: Include walk-in clinic, doctor's office, clinic, health center, Health Maintenance Organization or HMO, hospital emergency room or outpatient clinic, or a military health care facility.
HUQ.040 What kind of place does {SP} go to most often: is it a clinic, doctor's office, emergency room, or some other place?
CLINIC OR HEALTH CENTER 1
DOCTOR'S OFFICE OR HMO 2
HOSPITAL EMERGENCY ROOM 3
HOSPITAL OUTPATIENT DEPARTMENT 4
SOME OTHER PLACE 5
REFUSED 7
DON'T KNOW 9
P
Target Group: 3 to 15 years
PFQ.020 Does {SP} have an impairment or health problem that limits {his/her} ability to walk, run or play?
Yes 1
No 2 (PFQ.New1)
Refused 7 (PFQ.New1)
DON'T know 9 (PFQ.New1)
PFQ.030 Is this an impairment or health problem that has lasted, or is expected to last 12 months or longer?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
PFQ.New1 {Do you/Does SP} have any impairment or health problem that requires {you/him/her} to use special equipment, such as a brace, a wheelchair, or a hearing aid (excluding ordinary eyeglasses or corrective shoes)?
YES....................................................................... 1
NO......................................................................... 2 (PFQ.041)
REFUSED............................................................ 7 (PFQ.041)
DON'T KNOW...................................................... 9 (PFQ.041)
PFQ.New2 What special equipment {do you/does he/does she} use?
BRACE................................................................. 1
WHEELCHAIR.................................................... 2
HEARING AID..................................................... 3
OTHER (SPECIFY)............................................. 4
REFUSED............................................................ 7
DON'T KNOW...................................................... 9
PFQ.041 Does {SP} receive Special Education or Early Intervention Services?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
HELP SCREEN:
Special Education: Teaching designed to meet the needs of a child with special needs and/or disabilities. It is paid for by the public school system and may take place at a regular school, a special school, a private school, at home, or at a hospital.
Early Intervention Services: Services designed to meet the needs of very young children with special needs and/or disabilities. They may include but are not limited to: medical and social services, parental counseling, and therapy. They may be provided at the child's home, a medical center, a day care center, or other place. They are provided by the state or school system at no cost to the parent.
M
Target Group: 3 to 15years
MCQ.010 The following questions are about different medical conditions.
Has a doctor or other health professional ever told {you/SP} that {s/he/SP has} asthma (az-ma)?
CAPI INSTRUCTION:
IF SP AGE = 12-15, DISPLAY "SP" AND “S/HE HAS”.
IF SP AGE < 12, DISPLAY “YOU” AND “SP HAS”.
INTERVIEWER: DO NOT ACCEPT SELF-DIAGNOSED OR DIAGNOSED BY A PERSON WHO IS NOT A DOCTOR OR OTHER HEALTH PROFESSIONAL.
YES 1
NO 2 (MCQ.140)
REFUSED 7 (MCQ.140)
DON'T KNOW 9 (MCQ.140)
HELP SCREEN:
Asthma: Is a disease of the airways that carry air in and out of your lungs. It causes wheezing or whistling sounds when you breathe and can make you short of breath.
MCQ.035 Does {SP} still have asthma (az-ma)?
YES 1
NO 2 (MCQ.140)
REFUSED 7 (MCQ.140)
DON'T KNOW 9 (MCQ.140)
MCQ.040 During the past 12 months, has {SP} had an episode of asthma (az-ma) or an asthma attack?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
HELP SCREEN:
Episode/attack: When your asthma symptoms become worse than usual it is called an asthma episode or attack.
MCQ.051 During the past 3 months, has {SP} taken medication prescribed by a doctor or other health professionals for asthma?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
MCQ.140 {Does SP} have trouble seeing, even when wearing glasses or contact lenses, if {he/she} wear{s} them?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
HELP SCREEN:
Glasses: Includes prescription eyeglasses as well as nonprescription reading glasses purchased at drug stores or variety stores. Do not include safety glasses, which are worn for protection only. Do not include nonprescription sunglasses or glasses or contact lenses worn for cosmetic purposes.
BOX 7A
CHECK ITEM MCQ.146: IF SP AGE 8-15 AND SP IS FEMALE, CONTINUE. OTHERWISE, GO TO END OF SECTION
|
MCQ.149 Have {SP's} periods or menstrual (men-stral) cycles started yet?
YES 1 (MCQ.next)
NO 2
REFUSED 7
DON'T KNOW 9
MCQ.next How old was {SP} when she had {her} first menstrual period?
_______________Years
Hard edits: maximum of 15 and age of onset must be less than or equal to current age
Soft edit: if age less than 7
D
NHANES NYFS
Target Group: Ages 3-15
DIQ.010 {Other than during pregnancy, {have you/has SP}/{Have you/Has SP}} ever been told by a doctor or other health professional that {you have/{s/he/SP} has} diabetes or sugar diabetes?
CAPI INSTRUCTION:
IF SP AGE >= 16, DISPLAY "HAVE YOU" AND "YOU HAVE"
IF SP AGE 12-15, DISPLAY "HAS {SP}" AND "S/HE HAS"
IF SP AGE <12, DISPLAY "HAVE YOU" AND "{SP} HAS"
YES 1
NO 2 (BOX 4)
BORDERLINE OR PREDIABETES 3 (BOX 4)
REFUSED 7 (BOX 4)
DON'T KNOW 9 (BOX 4)
DIQ.040 |
How old {was SP/were you} when a doctor or other health professional first told {you/him/her} that {you/s/he} had diabetes or sugar diabetes? |
CAPI INSTRUCTION:
IF SP AGE 12-15, DISPLAY "WAS {SP}" AND "HIM/HER" AND "S/HE"
IF SP AGE <12, DISPLAY "WAS {SP}" AND "YOU" AND "S/HE"
|___|___|
ENTER AGE IN YEARS
LESS THAN 1 YEAR 2
REFUSED 777
DON'T KNOW 999
BOX 4
CHECK ITEM DIQ.159:
IF AGE < 12 OR DIQ.010 = 1 (YES) GO TO DIQ.050.
IF AGE >= 12 AND DIQ.010 = 3, GO TO DIQ.050.
OTHERWISE, CONTINUE.
DIQ.160 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/SP has} any of the following: prediabetes, impaired fasting glucose, impaired glucose tolerance, borderline diabetes or that {your/her/his} blood sugar is higher than normal but not high enough to be called diabetes or sugar diabetes?
HAND CARD DIQ1
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
HELP SCREEN: PREDIABETES, IMPAIRED FASTING GLUCOSE, IMPAIRED GLUCOSE TOLERANCE, OR BORDERLINE DIABETES OCCURS WHEN BLOOD SUGAR (GLUCOSE) LEVELS ARE HIGHER THAN NORMAL BUT NOT HIGH ENOUGH TO BE DIABETES.
DIQ.050 {Is SP/Are you} now taking insulin?
YES 1
NO 2 (BOX 0)
REFUSED 7 (BOX 0)
DON'T KNOW 9 (BOX 0)
HELP SCREEN:
Insulin: A chemical used in the treatment of diabetes. Typically, insulin is administered with a syringe by the patient.
BOX 0
CHECK ITEM DIQ.065:
IF DIQ.010 = 1 (YES) OR DIQ.160 = 1 (YES) OR DIQ.010 = 3, CONTINUE.
OTHERWISE, GO TO END OF SECTION.
DIQ.070 {Is SP/Are you} now taking diabetic pills to lower {{his/her}/your} blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
R
NHANES NYFS
Target Group: 3 to 15 years
RDQ.100 [In the past 12 months], has {SP's} chest sounded wheezy during or after exercise or physical activity?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
HELP SCREEN:
Wheezing: To breathe with difficulty, producing a hoarse whistling sound.
RDQ.135 During the past 12 months, how much did {SP} limit {his/her} usual activities due to wheezing or whistling? Would you say…
not at all, 1
a little, 2
a fair amount, 3
a moderate amount, or 4
a lot? 5
REFUSED 7
DON'T KNOW 9
HELP SCREEN:
Wheezing: To breathe with difficulty, producing a hoarse whistling sound.
P
NHANES NYFS
Target Group: SPs 3-15
CAPI INSTRUCTION: FOR PAQ SECTION ONLY, USE ‘YOU’ FILLS FOR SPs 12-15 YEARS OLD.
BOX 1
CHECK ITEM PAQ.702: 3-11 YEAR OLD SPS, SKIP TO PAQ.706. 12-15 YEAR OLD SPS, CONTINUE.
|
PAQ.703 INTERVIEWER: ASK TO SEE IF {SP} IS AVAILABLE TO ANSWER PAQ QUESTIONS {HIMSELF/HERSELF}.
SPEAKING TO {SP} 1
{SP} NOT AVAILABLE 2 (END OF SECTION)
PAQ.706 I'd like to ask you some questions about {your/SP’s} activities.
During the past 7 days, on how many days {were you/was SP} physically active for a total of at least 60 minutes per day? Add up all the time {you/he/she} spent in any kind of physical activity that increased {your/his/her} heart rate and made {you/him/her} breathe hard some of the time.
0 days 0
1 day 1
2 days 2
3 days 3
4 days 4
5 days 5
6 days 6
7 days 7
REFUSED 77
DON’T KNOW 99
BOX 2
CHECK ITEM PAQ.707: IF SP AGE 3-11, GO TO PAQ.710. IF SP AGE 12-15, CONTINUE.
|
PAQ.605 Next I am going to ask you about the time {you spend/SP spends} doing different types of physical activity in a typical week.
Think first about the time {you spend/he spends/she spends} doing work. Think of work as the things that {you have/he has/she has} to do such as paid or unpaid work, household chores, and yard work.
Does {your/SP’s} work involve vigorous-intensity activity that causes large increases in breathing or heart rate like carrying or lifting heavy loads, digging or construction work for at least 10 minutes continuously?
YES 1
NO 2 (PAQ.620)
REFUSED 7 (PAQ.620)
DON’T KNOW 9 (PAQ.620)
PAQ.610 In a typical week, on how many days {do you/does SP} do vigorous-intensity activities as part of {your/his/her} work?
PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.
HARD EDIT: LESS THAN 1 DAY OR MORE THAN 7 DAYS.
ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 77 (PAQ.620)
DON’T KNOW 99 (PAQ.620)
PAQ.615 How much time {do you/does SP} spend doing vigorous–intensity activities at work on a typical day?
Q/U
PROBE IF NEEDED: Think about a typical day when {you do/he does/she does} vigorous-intensity activities during {your/his/her} work.
PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.
SOFT EDIT: >4 HOURS.
ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING VIGOROUS-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.
HARD EDIT: LESS THAN 10 MINUTES OR 24 HOURS OR MORE.
ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
REFUSED 7777 (PAQ.620)
DON'T KNOW 9999 (PAQ.620)
|___|
ENTER UNIT
MINUTES 1
HOURS 2
PAQ.620 Does {your/SP’s} work involve moderate-intensity activity that causes small increases in breathing or heart rate such as brisk walking or carrying light loads for at least 10 minutes continuously?
YES 1
NO 2 (PAQ.635)
REFUSED 7 (PAQ.635)
DON’T KNOW 9 (PAQ.635)
PAQ.625 In a typical week, on how many days {do you/does SP} do moderate-intensity activities as part of {your/his/her} work?
PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.
HARD EDIT: LESS THAN 1 DAY OR MORE THAN 7 DAYS.
ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 77 (PAQ.635)
DON’T KNOW 99 (PAQ.635)
PAQ.630 How much time {do you/does SP} spend doing moderate-intensity activities at work on a typical day?
Q/U
PROBE IF NEEDED: Think about a typical day when {you do/he does/she does} moderate-intensity activities during your work.
PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.
SOFT EDIT: >4 HOURS.
ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING MODERATE-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.
HARD EDIT: LESS THAN 10 MINUTES OR 24 HOURS OR MORE.
ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
REFUSED 7777 (PAQ.635)
DON'T KNOW 9999 (PAQ.635)
|___|
ENTER UNIT
MINUTES 1
HOURS 2
PAQ.635 The next questions exclude the physical activities at work that you have already mentioned. Now I would like to ask you about the usual way {you travel/SP travels} to and from places. For example to school, for shopping, to work.
{Do you/Does SP} walk or use a bicycle for at least 10 minutes continuously to get to and from places?
YES 1
NO 2 (PAQ.650)
REFUSED 7 (PAQ.650)
DON’T KNOW 9 (PAQ.650)
PAQ.640 In a typical week, on how many days {do you/does SP} walk or bicycle for at least 10 minutes continuously to get to and from places?
HARD EDIT: LESS THAN 1 DAY OR MORE THAN 7 DAYS.
ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 77 (PAQ.650)
DON’T KNOW 99 (PAQ.650)
PAQ.645 How much time {do you/does SP} spend walking or bicycling for travel on a typical day?
Q/U
PROBE IF NEEDED: Think about a typical day when {you walk or bicycle/SP walks or bicycles} for travel.
SOFT EDIT: >4 HOURS.
ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS WALKING OR BICYCLING TO GET TO AND FROM PLACES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.
HARD EDIT: LESS THAN 10 MINUTES OR 24 HOURS OR MORE.
ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
REFUSED 7777 (PAQ.650)
DON'T KNOW 9999 (PAQ.650)
|___|
ENTER UNIT
MINUTES 1
HOURS 2
PAQ.650 The next questions exclude the work and transport activities that you have already mentioned. Now I would like to ask you about sports, fitness and recreational activities.
{Do you/Does SP} do any vigorous-intensity sports, fitness, or recreational activities that cause large increases in breathing or heart rate like running or basketball for at least 10 minutes continuously?
YES 1
NO 2 (PAQ.665)
REFUSED 7 (PAQ.665)
DON’T KNOW 9 (PAQ.665)
PAQ.655 In a typical week, on how many days {do you/does SP} do vigorous-intensity sports, fitness or recreational activities?
PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.
HARD EDIT: LESS THAN 1 DAY OR MORE THAN 7 DAYS.
ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 77 (PAQ.665)
DON’T KNOW 99 (PAQ.665)
PAQ.660 |
How much time {do you/does SP} spend doing vigorous-intensity sports, fitness or recreational activities on a typical day? |
PROBE IF NEEDED: Think about a typical day when {you do/SP does} vigorous-intensity sports, fitness or recreational activities.
SOFT EDIT: >4 HOURS.
ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING VIGOROUS-INTENSITY RECREATIONAL ACTIVITIES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.
HARD EDIT: LESS THAN 10 MINUTES OR 24 HOURS OR MORE.
ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
REFUSED 7777 (PAQ.665)
DON'T KNOW 9999 (PAQ.665)
|___|
ENTER UNIT
MINUTES 1
HOURS 2
PAQ.665 {Do you/Does SP} do any moderate-intensity sports, fitness, or recreational activities that cause a small increase in breathing or heart rate such as brisk walking, bicycling, swimming, or volleyball for at least 10 minutes continuously?
YES 1
NO 2 (PAQ.680)
REFUSED 7 (PAQ.680)
DON’T KNOW 9 (PAQ.680)
PAQ.670 In a typical week, on how many days {do you/does SP} do moderate-intensity sports, fitness or recreational activities?
PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.
HARD EDIT: LESS THAN 1 DAY OR MORE THAN 7 DAYS.
ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.
|___|___|
ENTER NUMBER OF DAYS
REFUSED 77 (PAQ.680)
DON’T KNOW 99 (PAQ.680)
PAQ.675 |
How much time {do you/does SP} spend doing moderate–intensity sports, fitness or recreational activities on a typical day? |
PROBE IF NEEDED: Think about a typical day when {you do/SP does} moderate-intensity sports, fitness or recreational activities.
PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.
SOFT EDIT: >4 HOURS.
ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING MODERATE-INTENSITY RECREATIONAL ACTIVITIES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.
HARD EDIT: LESS THAN 10 MINUTES OR 24 HOURS OR MORE.
ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
REFUSED 7777 (PAQ.680)
DON'T KNOW 9999 (PAQ.680)
|___|
ENTER UNIT
MINUTES 1
HOURS 2
PAQ.680 |
The following question is about sitting at school, at 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. |
How much time {do you/does SP} usually spend sitting on a typical day?
SOFT EDIT: 18 HOURS OR MORE.
ERROR MESSAGE: PLEASE VERIFY TIMES OF 18 HOURS OR MORE.
HARD EDIT: 24 HOURS OR MORE.
ERROR MESSAGE: THE TIME SHOULD BE LESS THAN 24 HOURS.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
REFUSED 7777 (PAQ.710)
DON'T KNOW 9999 (PAQ.710)
|___|
ENTER UNIT
MINUTES 1
HOURS 2
PAQ.710 Now I will ask you about TV watching and computer use.
Over the past 30 days, on average how many hours per day did {you/SP} sit and watch TV or videos? Would you say . . .
less than 1 hour, 0
1 hour, 1
2 hours, 2
3 hours, 3
4 hours, 4
5 hours or more, or 5
none, {you don’t/SP does not} watch TV or
videos 8
REFUSED 77
DON'T KNOW 99
PAQ.715 Over the past 30 days, on average how many hours per day did {you/SP} use a computer or play computer games outside of school? Include Playstation, Nintendo DS, or other portable video games. Would you say . . .
less than 1 hour, 0
1 hour, 1
2 hours, 2
3 hours, 3
4 hours, or 4
5 hours or more, or 5
{You do/SP does} not use a computer
outside of work or
school? 8
REFUSED 77
DON'T KNOW 99
HELP SCREEN:
If the SP watches T.V. or video at the same time as working on the computer, count this time as watching T.V. or video.
PAQ.722 For the next questions, think about the sports, lessons, or physical activities {you/SP} may have done during the past 7 days? {(Please do not include things {you/he/she} did during the school day like PE or gym class.)}
Did {you/SP} do any physical activities during the past 7 days?
YES 1
NO 2 (BOX 3)
REFUSED 7 (BOX 3)
DON’T KNOW 9 (BOX 3)
CAPI INSTRUCTION: IF SP AGE IS 3-4 YEARS OLD, DO NOT DISPLAY {(Please do not include things {you/he/she} did during the school day like PE or gym class.)}
PAQ.723 What physical activities did {you/SP} do during the past 7 days?
[PROBE: Did {you/he/she} do any other physical activities?}
CODE ALL THAT APPLY
AEROBICS/WEIGHT TRAINING/GYM/
EXERCISE 1
BASEBALL/SOFTBALL/CATCH/PITCHING 2
BASKETBALL 3
BIKE RIDING/DIRT BIKING/MOUNTAIN
BIKING 4
CHEERLEADING 5
DANCE 6
FIELD HOCKEY/STREET HOCKEY/
ROLLER HOCKEY 7
FOOTBALL 8
GOLF 9
GYMNASTICS/TUMBLING 10
HIKING 11
ICE HOCKEY 12
ICE SKATING 13
JUMPING ROPE 14
LACROSSE 15
MARTIAL ARTS (KARATE/TAE KWON DO/
JUDO, ETC.) 16
PLAYING GAMES (PROBE: WERE YOU
PHYSICALLY ACTIVE? IF NO, DON’T
COUNT) 17
ROLLER BLADING/ROLLER SKATING 18
RUNNING/JOGGING 19
SCOOTER RIDING (PROBE: DOES IT HAVE
A MOTOR? IF YES, DON’T
COUNT) 20
SKATEBOARDING 21
SOCCER 22
SWIMMING 23
TENNIS 24
TRACK & FIELD 25
VOLLEYBALL 26
WALKING 27
WRESTLING 28
OTHER (SPECIFY) 91
REFUSED 77
DON’T KNOW 99
BOX 3
CHECK ITEM PAQ.726: IF SP AGE 3-4, GO TO END OF SECTION. IF SP AGE 5-15, CONTINUE.
|
PAQ.730 During the past 7 days, on how many days did {you/SP} play active video games such as Wii or Dance, Dance Revolution?
0 days 1 (BOX 4)
1 day 2
2 days 3
3 days 4
4 days 5
5 days 6
6 days 7
7 days 8
REFUSED 77
DON’T KNOW 99
PAQ.733 On average, for how long did {you/SP} play these active video games?
___________
G/Q/U
|___|___|___|
ENTER NUMBER (OF MINUTES OR HOURS)
REFUSED 777
DON'T KNOW 999
ENTER UNIT
MINUTES 1
HOURS 2
SOFT EDIT: IF THE HOURS EXCEED 4 SAY UNUSUAL,
SOFT EDIT: IF THE MINUTES ARE LESS THAN 10 CONFIRM THAT IT IS MINUTES NOT HOURS.
BOX 4
CHECK ITEM PAQ.736: IF SP AGE 5-11, SKIP TO PAQ.755. IF SP AGE 12-15, CONTINUE.
|
PAQ.677 On how many of the past 7 days did {you/SP} exercise or participate in physical activity for at least 20 minutes that made {you/him/her} sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar activities?
0 days 1
1 day 2
2 days 3
3 days 4
4 days 5
5 days 6
6 days 7
7 days 8
REFUSED 77
DON’T KNOW 99
PAQ.678 On how many of the past 7 days did {you/SP} do exercises to strengthen or tone {your/his/her} muscles, such as push-ups, sit-ups, or weight lifting?
0 days 1
1 day 2
2 days 3
3 days 4
4 days 5
5 days 6
6 days 7
7 days 8
REFUSED 77
DON’T KNOW 99
The next questions ask about activities during the school year. If {you are/SP is} not currently in school, think about {your/his/her} activities when {you were/he was/she was} last in school.
PAQ.740 Are students at {your/his/her} school allowed to use school facilities during lunch or during a free or elective period, such as the gymnasium, tennis courts, weight room, or track, during school time?
YES 1
NO 2 (PAQ.744)
REFUSED 7 (PAQ.744)
DON’T KNOW 9 (PAQ.744)
PAQ.742 {Do you/Does SP} use school facilities for physical activity during school time?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
PAQ.744 {Do you/does SP} have PE or gym during school days?
YES 1
NO 2 (PAQ.755)
REFUSED 7 (PAQ.755)
DON’T KNOW 9 (PAQ.755)
PAQ.746 How often {do you/does SP} have PE or gym?
1 day a week 1
2 days a week 2
3 days a week 3
4 days a week 4
Every day 5
REFUSED 7
DON’T KNOW 9
PAQ.748 On average, how long is the PE or gym class?
Less than 30 minutes 1
30-45 minutes 2
More than 45 minutes 3
REFUSED 7
DON’T KNOW 9
PAQ.755 The following are activities that may be done before, during, or after school other than during {PE or gym class/recess}. If {you are/SP is} not currently in school, think about {your/his/her} activities when {you were/he was/she was} last in school.} {Do you/Does SP} participate in school sports or physical activity clubs?
CAPI INSTRUCTION: IF SP AGE 5-11, DISPLAY {recess}
YES 1
NO 2 (BOX 5)
REFUSED 7 (BOX 5)
DON’T KNOW 9 (BOX 5)
PAQ.758 In what school sports or physical activity clubs {do you/does SP} participate?
CODE ALL THAT APPLY
BASEBALL/SOFTBALL 1
BASKETBALL 2
BOCCE BALL 3
CHEERLEADING 4
FOOTBALL 5
GOLF 6
GYMNASTICS 7
HOCKEY 8
LACROSSE 9
SOCCER 10
SWIMMING/DIVING 11
TENNIS 12
TRACK AND FIELD 13
VOLLEYBALL 14
WRESTLING 15
OTHER (SPECIFY) 16
REFUSED 77
DON’T KNOW 99
BOX 5
CHECK ITEM PAQ.760: IF SP AGE 5-11, CONTINUE WITH PAQ.762. IF SP AGE 12-15, GO TO PAQ.679.
|
PAQ.762 {Do you/Does SP} have recess during school days?
YES 1
NO 2 (PAQ.770)
REFUSED 7 (PAQ.770)
DON’T KNOW 9 (PAQ.770)
PAQ.764 How often {do you/does SP} have recess?
1 day a week 1
2 days a week 2
3 days a week 3
4 days a week 4
Every day 5
REFUSED 7
DON’T KNOW 9
PAQ.766 On average, how long is the recess period?
Less than 10 minutes 1
10-15 minutes 2
16-30 minutes 3
More than 30 minutes 4
REFUSED 7
DON’T KNOW 9
BOX 6
CHECK ITEM PAQ.768: IF SP AGE 5-11, GO TO PAQ.750.
|
PAQ.679 About how many minutes {do you/does SP} think you should exercise or be physically active each day for good health? (This includes all activities like bicycling, dancing, and playing basketball that {you do/SP does} at school, at home, and anywhere else {you get/he gets/she gets} exercise?)
Less than 10 minutes, 1
10-15 minutes, 2
16-30 minutes, 3
31-45 minutes, 4
46-60 minutes, or 5
More than 60 minutes 6
REFUSED 7
DON’T KNOW 9
PAQ.750 I am going to read a statement and I want you to let me know if you strongly agree, agree, neither agree nor disagree, disagree or strongly disagree with the statement. {I enjoy participating in PE or gym class.}
CAPI INSTRUCTION: IF SP AGE 5-11, DISPLAY { {SP} enjoys participating in recess}
HAND CARD PAQ1
Strongly agree 1
Agree 2
Neither agree nor disagree 3
Disagree 4
Strongly Disagree 5
REFUSED 7
DON’T KNOW 9
PAQ.770 In the past year, did {you/SP} receive a Physical Fitness Test award, such as a President’s Challenge or Fitnessgram award?
YES 1
NO 2 (END OF SECTION)
REFUSED 7 (END OF SECTION)
DON’T KNOW 9 (END OF SECTION)
PAQ.772 What Physical Fitness Test award did {you/SP} receive?
PROBE IF NEEDED: Examples of physical fitness test awards are the FITNESSGRAM and the PRESIDENT’S CHALLENGE. CODE ALL THAT APPLY.
Fitnessgram 1
President’s Challenge 2
OTHER (SPECIFY) 3
REFUSED 7
DON’T KNOW
D
NHANES NYFS
Target Group: 3 to 15 years
BOX 9
CHECK ITEM DBQ.355: IF SP AGE GT 4, CONTINUE. OTHERWISE, GO TO DBQ.895
|
DBQ.360 During the school year, {do you/does SP} attend a kindergarten, grade school, junior or high school?
INTERVIEWER INSTRUCTION: ENTER ‘NO’ IF THE SP IS HOME SCHOOLED.
YES....................................................................... 1
NO......................................................................... 2 (DBQ.895)
REFUSED............................................................ 7 (DBQ.895)
DON'T KNOW...................................................... 9 (DBQ.895)
DBQ.381 |
During the school year, about how many times a week does {SP} usually get a complete school lunch? |
CAPI INSTRUCTION:
HARD EDIT 1-5
|___|
ENTER NUMBER OF TIMES
NONE 2 (DBQ.400)
REFUSED 7 (DBQ.400)
DON'T KNOW 9 (DBQ.400)
DBQ.390 Does {SP} get these lunches free, at a reduced price, or does {he/she} pay full price?
FREE 1
REDUCED PRICE 2
FULL PRICE 3
REFUSED 7
DON'T KNOW 9
DBQ.400 Does {SP's} school serve a complete breakfast that costs the same every day?
YES 1
NO 2 (DBQ.895)
REFUSED 7 (DBQ.895)
DON'T KNOW 9 (DBQ.895
DBQ.411 |
During the school year, about how many times a week does {SP} usually get a complete breakfast at school? |
CAPI INSTRUCTION:
HARD EDIT 1-5
|___|
ENTER NUMBER OF TIMES
NONE 2 (DBQ.895)
REFUSED 7 (DBQ.895)
DON'T KNOW 9 (DBQ.895)
DBQ.421 Does {SP} get these breakfasts free, at a reduced price, or does {he/she} pay full price?
FREE 1
REDUCED PRICE 2
FULL PRICE 3
REFUSED 7
DON'T KNOW 9
DBQ.895 Next I’m going to ask you about meals. By meal, I mean breakfast, lunch and dinner. During the past 7 days, how many meals did {SP} get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines?
{Please do not include meals provided as part of the school lunch or school breakfast.}
CAPI INSTRUCTION:
IF DBQ381G = 1 OR DBQ.411G = 1, DISPLAY {Please do not include meals provided as part of the school lunch or school breakfast.}
SOFT EDIT: DISPLAY A MESSAGE FOR ENTRY LARGER THAN “21.” – “Unusually large number entered – Please verify – this is more than 3 meals per day, each day during the past 7 days.”
|___|___|
ENTER NUMBER
NONE 2 (DBQ.905)
REFUSED 7 (DBQ.905)
DON'T KNOW 9 (DBQ.905)
DBQ.900 How many of those meals did {SP} get from a fast-food or pizza place?
|___|___|
ENTER NUMBER
NONE 2
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION: HARD EDIT
NUMBER OF MEALS ENTERED IN DBQ.900 MUST BE EQUAL TO OR LESS THAN NUMBER ENTERED IN DBQ.895. IF NOT, DISPLAY THE FOLLOWING:
“THE NUMBER OF MEALS FROM A FAST FOOD OR PIZZA PLACE CANNOT BE GREATER THAN NUMBER OF MEALS PREPARED AWAY FROM HOME.”
DBQ.905 Some grocery stores sell “ready to eat” foods such as salads, soups, chicken, sandwiches and cooked vegetables in their salad bars and deli counters.
During the past 30 days, how often did {SP} eat “ready to eat” foods from the grocery store? Please do not include sliced meat or cheese you buy for sandwiches and frozen or canned foods.
|___|___|
ENTER NUMBER OF TIMES (PER DAY, WEEK, OR MONTH)
NEVER 2
REFUSED 7
DON’T KNOW 9
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DBQ.910 During the past 30 days, how often did {SP} eat frozen meals or frozen pizzas? Here are some examples of frozen meals and frozen pizzas.
HAND CARD DBQ4
|___|___|
ENTER NUMBER OF TIMES (PER DAY, WEEK, OR MONTH)
NEVER 2
REFUSED 7
DON’T KNOW 9
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
ACCULTURATION – ACQ
Target Group: SPs 3-15
BOX 1B
CHECK ITEM ACQ.006:
OTHERWISE, CONTINUE. |
ACQ.011 Now I'm going to ask you about language use.
What language(s) {do you/does SP} usually speak at home?
CODE ALL THAT APPLY
ENGLISH 1
SPANISH 8
OTHER 9
REFUSED 77
DON'T KNOW 99
BOX 2
CHECK ITEM ACQ.015: GO TO END OF SECTION.
|
ACQ.042 Now I’m going to ask you about language use.
What language(s) {do you/does SP} usually speak at home? {Do you/Does he/Does she} speak only Spanish, more Spanish than English, both equally, more English than Spanish, or only English?
HAND CARD ACQ1
ONLY SPANISH, 1
MORE SPANISH THAN ENGLISH, 2
BOTH EQUALLY, 3
MORE ENGLISH THAN SPANISH, OR 4
ONLY ENGLISH 5
REFUSED 7
DON'T KNOW 9
BOX 3
CHECK ITEM ACQ.045: GO TO ACQ.120.
|
ACQ.049 Now I’m going to ask you about language use.
What language(s) {do you/does SP} usually speak at home?
CODE ALL THAT APPLY
HAND CARD ACQ2
English 10
Chinese 11
Farsi/Persian 12
Hindi 13
Japanese 14
Khmer/Cambodian 15
Korean 16
Tagalog/Filipino 17
Urdu 18
Vietnamese 19
Other (SPECIFY) 20
REFUSED 77 (ACQ.120)
DON'T KNOW 99 (ACQ.120)
BOX 4
CHECK ITEM ACQ.090: IF ACQ.049 = 10 ONLY, GO TO ACQ.120. IF ACQ.049 = 10 AND ONE OTHER RESPONSE 11-20, GO TO ACQ.110. IF ACQ.049 DOES NOT EQUAL 10, GO TO ACQ.120 IF ACQ.049 = 10 AND TWO OR MORE OTHER RESPONSES 11-20, GO TO ACQ.101. |
ACQ.101 Of these languages {ACQ.049 responses 11-20}, which {do you/does SP} speak more of at home?
CAPI INSTRUCTION:
FILL NON-ENGLISH RESPONSE OPTIONS SELECTED IN ACQ.049 AND/OR ACQ.049OS SEPARATING WITH A COMMA. BEFORE LAST RESPONSE DISPLAY “and”. FOR RESPONSE OPTION 20, DISPLAY OTHER SPECIFY TEXT.
DISPLAY ONLY NON-ENGLISH RESPONSE OPTIONS SELECTED IN ACQ.049 AND/OR ACQ.049OS THAT WERE SELECTED.
Chinese 11
Farsi/Persian 12
Hindi 13
Japanese 14
Khmer/Cambodian 15
Korean 16
Tagalog/Filipino 17
Urdu 18
Vietnamese 19
{ACQ.049OS} 20
REFUSED 77 (ACQ.120)
DON'T KNOW 99 (ACQ.120)
ACQ.110 {Do you/Does SP} speak only (NON-ENGLISH LANGUAGE), more (NON-ENGLISH LANGUAGE) than English, both equally, more English than (NON-ENGLISH LANGUAGE), or only English?
CAPI INSTRUCTION:
IF ENGLISH AND ONE OTHER RESPONSE OPTION 11-20 WAS SELECTED IN ACQ.049, FILL NON-ENGLISH LANGUAGE WITH RESPONSE OPTION 11-20.
IF ENGLISH AND TWO OR MORE OTHER OPTIONS 11-20 WERE SELECTED IN ACQ.049, FILL NON-ENGLISH WITH RESPONSE TO QUESTION ACQ.101.
ONLY (NON-ENGLISH LANGUAGE), 1
MORE (NON-ENGLISH), THAN ENGLISH, 2
BOTH EQUALLY, 3
MORE ENGLISH THAN (NON-ENG), OR 4
ONLY ENGLISH 5
REFUSED 7
DON'T KNOW 9
ACQ.120 In what country was {your/SP’s} father born?
United States, except puerto rico 1
puerto rico 2
Cambodia 3
CHINA 4
cuba 5
dominican republic 6
El salvador 7
india 8
iran 9
Japan 10
korea 11
MEXICO 12
nicaragua 13
Pakistan 14
PHIlippines 15
vietnam 16
Other (Specify) 17
REFUSED 77
DON'T KNOW 99
ACQ.130 In what country was {your/SP’s} mother born?
United States, except puerto rico 1
puerto rico 2
Cambodia 3
CHINA 4
cuba 5
dominican republic 6
El salvador 7
india 8
iran 9
Japan 10
korea 11
MEXICO 12
nicaragua 13
Pakistan 14
PHIlippines 15
vietnam 16
Other (Specify) 17
REFUSED 77
DON'T KNOW 99
D
NYFS
Target Group: SPs 3 to 15 years
BOX 1A
CHECK ITEM DMQ.030: IF SP AGE >= 6, CONTINUE. OTHERWISE, GO TO DMQ.061.
|
DMQ.141 What is the highest grade or level of school {you have/SP has} completed or the highest degree {you have/s/he has} received?
HAND CARD DMQ1
READ HAND CARD CATEGORIES IF NECESSARY.
Enter highest level of school.
NEVER ATTENDED/KINDERGARTEN
ONLY 0 (DMQ.061)
1ST GRADE 1
2ND GRADE 2
3RD GRADE 3
4TH GRADE 4
5TH GRADE 5
6TH GRADE 6
7TH GRADE 7
8TH GRADE 8
9TH GRADE 9
10TH GRADE 10
11TH GRADE 11
12TH GRADE, NO DIPLOMA 12
HIGH SCHOOL GRADUATE 13
GED OR EQUIVALENT 14
SOME COLLEGE, NO DEGREE 15
ASSOCIATE DEGREE: OCCUPATIONAL,
TECHNICAL, OR VOCATIONAL
PROGRAM 16
ASSOCIATE DEGREE: ACADEMIC
PROGRAM 17
BACHELOR’S DEGREE (EXAMPLE: BA,
AB, BS, BBA) 18
MASTER’S DEGREE (EXAMPLE: MA,
MS, MEng, MEd, MBA) 19
PROFESSIONAL SCHOOL DEGREE
(EXAMPLE: MD, DDS, DVM, JD) 20
DOCTORAL DEGREE (EXAMPLE:
PhD, EdD) 21
REFUSED 77
DON’T KNOW 99
DMQ.037 {Are you/Is SP} now . . .
going to school, 1
on vacation from school (between
grades), or 2
neither? 3
REFUSED 7
DON’T KNOW 9
HELP SCREEN:
Going to School: Attending any type of public or private educational establishment both in and out of the regular school system.
DMQ.061 Next I have a few questions about {your/SP’s} name. {Do you/Does SP} usually go by another first name besides {DISPLAY FIRST NAME FROM DMQ-SPIV.040}?
CAPI INSTRUCTION:
DISPLAY "FIRST NAME:" AND FIRST NAME FROM DMQ-SPIV.040 AS LEFT HEADER.
YES 1
NO 2 (BOX 1BBB)
REFUSED 7 (BOX 1BBB)
DON'T KNOW 9 (BOX 1BBB)
DMQ.071 What is this other first name?
VERIFY SPELLING
____________________________________
ENTER NAME
REFUSED 7
DON'T KNOW 9
BOX 1BBB
CHECK ITEM DMQ.073a: IF AGE >= 14, CONTINUE. OTHERWISE, GO TO DMQ.241.
|
DMQ.380 {Are you/Is SP} now married, widowed, divorced, separated, never married or living with a partner?
MARRIED 1
WIDOWED 2
DIVORCED 3
SEPARATED 4
NEVER MARRIED 5
LIVING WITH PARTNER 6
REFUSED 77
DON'T KNOW 99
DMQ.241 {Do you/Does SP} consider {yourself/himself/herself} to be Hispanic or Latino?
READ IF NECESSARY: Where {do your/do his/do her} ancestors come from?
Puerto Rican
Cuban/Cuban American
Dominican Republic
Mexican/Mexican American
Central/South American
Other Latin American
Other Hispanic or Latino
YES 1
NO 2 (DMQ.263)
REFUSED 7 (DMQ.263)
DON'T KNOW 9 (DMQ.263)
HELP SCREEN:
SPANISH, HISPANIC OR LATINO PEOPLE MAY BE OF ANY RACE. LISTED BELOW ARE HISPANIC OR LATINO CATEGORIES/COUNTRIES.
MEXICAN
PUERTO RICAN
CUBAN
DOMINICAN REPUBLIC
CENTRAL AMERICAN:
COSTA RICAN
GUATEMALAN
HONDURAN
NICARAGUAN
PANAMANIAN
SALVADORAN
OTHER CENTRAL AMERICAN
SOUTH AMERICAN:
ARGENTINEAN
BOLIVIAN
CHILEAN
COLOMBIAN
ECUADORIAN
PARAGUAYAN
PERUVIAN
URUGUAYAN
VENEZUELAN
OTHER SOUTH AMERICAN
OTHER HISPANIC OR LATINO:
SPANIARD
SPANISH
SPANISH AMERICAN
DMQ.252 Please give me the number of the group that represents {your/SP's} Hispanic/Latino origin or ancestry. Please select 1 or more of these categories.
PROBE: Where do you/your ancestors come from?
HAND CARD DMQ2
SELECT 1 OR MORE
MEXICAN 10
PUERTO RICAN 11
CUBAN 12
DOMINICAN REPUBLIC 13
CENTRAL AMERICAN:
COSTA RICAN 14
GUATEMALAN 15
HONDURAN 16
NICARAGUAN 17
PANAMANIAN 18
SALVADORAN 19
OTHER CENTRAL AMERICAN 20
SOUTH AMERICAN:
ARGENTINEAN 21
BOLIVIAN 22
CHILEAN 23
COLOMBIAN 24
ECUADORIAN 25
PARAGUAYAN 26
PERUVIAN 27
URUGUAYAN 28
VENEZUELAN 29
OTHER SOUTH AMERICAN 30
OTHER HISPANIC OR LATINO:
FILIPINO 31
SPANIARD 32
SPANISH 33
SPANISH AMERICAN 34
HISPANO/HISPANA 35
HISPANIC/LATINO 36
OTHER HISPANIC/LATINO (SPECIFY) 40
REFUSED 77
DON'T KNOW 99
BOX 3L
CHECK ITEM DMQ.255: IF ‘OTHER SPECIFY’ (CODE 40) IN DMQ.252, DISPLAY SOFT ERROR MESSAGE “PLEASE REVIEW THE LIST AND SELECT RESPONSE FROM LIST BEFORE TYPING. THE LIST IS MEANT TO INCLUDE ALL CATEGORIES” AND CAPI SHOULD RETURN TO DMQ.252.
|
DMQ.263 Please look at the categories on this card. What race or races {do you/does SP} consider {yourself/himself/herself} to be? Please select one or more.
HAND CARD DMQ3
CHECK ALL THAT APPLY.
AMERICAN INDIAN OR ALASKAN NATIVE 1
ASIAN 2
BLACK OR AFRICAN AMERICAN 3
NATIVE HAWAIIAN OR PACIFIC ISLANDER 4
WHITE 5
OTHER 6
DK 9
RF 7
NEW BOX L-1
CHECK ITEM DMQ.310: IF CODE 2 (ASIAN) IN DMQ.263, GO TO DMQ.336. OTHERWISE, GO TO NEW BOX L-5. |
NEW BOX L-5
CHECK ITEM DMQ.330: IF CODE 6 (OTHER) IN DMQ.263 AND CODE 1 (YES-HISPANIC) IN DMQ.241, GO TO DMQ.266. OTHERWISE, GO TO DMQ.107.
|
DMQ.336 Please give me the number of the group that represents {your/SP’s} Asian origin or ancestry. Please select one or more of these categories.
HAND CARD DMQ4
PROBE: Where do your ancestors come from?
ASIAN INDIAN 10
BANGLADESHI 11
BENGALESE 12
BHARAT 13
BHUTANESE 14
BURMESE 15
CAMBODIAN 16
CANTONESE 17
CHINESE 18
DRAVIDIAN 19
EAST INDIAN 20
FILIPINO 21
GOANESE 22
HMONG 23
INDOCHINESE 24
INDONESIAN 25
IWO JIMAN 26
JAPANESE 27
KOREAN 28
LAOHMONG 29
LAOTIAN 30
MADAGASCAR/MALAGASY 31
MALAYSIAN 32
MALDIVIAN 33
MONG 34
NEPALESE 35
NIPPONESE 36
OKINAWAN 37
PAKISTANI 38
SIAMESE 39
SINGAPOREAN 40
SRI LANKAN 41
TAIWANESE 42
THAI 43
VIETNAMESE 44
REFUSED 77
DON'T KNOW 99
NEW BOX L-6
CHECK ITEM DMQ.340: SKIP TO DMQ.107.
|
DMQ.266 CODE SP ANSWER TO ‘OTHER RACE’.
MEXICAN 10
PUERTO RICAN 11
CUBAN 12
DOMINICAN REPUBLIC 13
CENTRAL AMERICAN:
COSTA RICAN 14
GUATEMALAN 15
HONDURAN 16
NICARAGUAN 17
PANAMANIAN 18
SALVADORAN 19
OTHER CENTRAL AMERICAN 20
SOUTH AMERICAN:
ARGENTINEAN 21
BOLIVIAN 22
CHILEAN 23
COLOMBIAN 24
ECUADORIAN 25
PARAGUAYAN 26
PERUVIAN 27
URUGUAYAN 28
VENEZUELAN 29
OTHER SOUTH AMERICAN 30
OTHER HISPANIC OR LATINO:
SPANIARD 32
SPANISH 33
SPANISH AMERICAN 34
HISPANO/HISPANA 35
HISPANIC/LATINO 36
OTHER (SPECIFY) 40
REFUSED 77
DON'T KNOW 99
BOX 3M
CHECK ITEM DMQ.268: IF ‘OTHER SPECIFY’ (CODE 40) IN DMQ.266, DISPLAY SOFT ERROR MESSAGE – “PLEASE REVIEW THE LIST AND SELECT RESPONSE FROM LIST BEFORE TYPING. THE LIST IS MEANT TO INCLUDE ALL CATEGORIES.” AND CAPI SHOULD RETURN TO QUESTION DMQ.266.
|
DMQ.107 In what country {were you/was SP} born?
UNITED STATES 1 (END OF SECTION)
OTHER COUNTRY 2 (NEW BOX 3N)
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
NEW BOX 3N
CHECK ITEM DMQ.108: IF CODE 2 (ASIAN) IN DMQ.263, GO TO DMQ.125. OTHERWISE, CONTINUE.
|
DMQ.112 SELECT COUNTRY OF BIRTH
ARGENTINA 1 (END OF SECTION)
BELIZE 2 (END OF SECTION)
BOLIVIA 3 (END OF SECTION)
BRAZIL 4 (END OF SECTION)
CHILE 5 (END OF SECTION)
COLOMBIA 6 (END OF SECTION)
COSTA RICA 7 (END OF SECTION)
CUBA 8 (END OF SECTION)
DOMINICAN REPUBLIC 9 (END OF SECTION)
ECUADOR 10 (END OF SECTION)
EL SALVADOR 11 (END OF SECTION)
GUATEMALA 12 (END OF SECTION)
HONDURAS 13 (END OF SECTION)
MEXICO 14 (END OF SECTION)
NICARAGUA 15 (END OF SECTION)
PANAMA 16 (END OF SECTION)
PARAGUAY 17 (END OF SECTION)
PERU 18 (END OF SECTION)
PHILIPPINES 19 (END OF SECTION)
PUERTO RICO 20 (END OF SECTION)
SPAIN 21 (END OF SECTION)
URUGUAY 22 (END OF SECTION)
VENEZUELA 23 (END OF SECTION)
OTHER COUNTRY (CAPI INSTRUCTION:
DISPLAY DMQ.112 COUNTRY LIST.) 40 (END OF SECTION)
CAPI INSTRUCTION:
IF ‘OTHER’ SELECTED, DISPLAY COUNTRY LIST IN ALPHABETICAL ORDER. INTERVIEWER SHOULD BE ABLE TO SELECT ONE FROM THE LIST.
DMQ.125 SELECT COUNTRY OF BIRTH
BANGLADESH 1
BHUTAN 2
BURMA/MYANMAR 3
CAMBODIA 4
CHINA 5
HONG KONG 6
INDIA 7
INDONESIA 8
JAPAN 9
KOREA 10
LAOS 11
MACAU 12
MADAGASCAR 13
MALAYSIA 14
MALDIVES 15
NEPAL 16
PAKISTAN 17
PHILIPPINES 18
SINGAPORE 19
SRI LANKA 20
TAIWAN 21
THAILAND 22
TIBET 23
VIETNAM 24
OTHER (CAPI INSTRUCTION: DISPLAY
DMQ.125 COUNTRY LIST.) 25
CAPI INSTRUCTION:
IF ‘OTHER’ SELECTED, DISPLAY COUNTRY LIST IN ALPHABETICAL ORDER. INTERVIEWER SHOULD BE ABLE TO SELECT ONE FROM THE LIST.
H
NHANES NYFS
Target Group: 3 to 15 years
HIQ.011 The next questions are about health insurance.
Include health insurance obtained through employment or purchased directly as well as government programs like Medicare and Medicaid that provide medical care or help pay medical bills.
Is {SP} covered by health insurance or some other kind of health care plan?
YES 1
NO 2 (BOX 12)
REFUSED 7 (BOX 12)
DON'T KNOW 9 (BOX 12)
HIQ.031 What kind of health insurance or health care coverage does {does SP} have? Include those that pay for only one type of service (nursing home care, accidents, or dental care). Exclude private plans that only provide extra cash while hospitalized. If {you have/s/he has} more than one kind of health insurance, tell me all plans that {you have/s/he has}.
CODE ALL THAT APPLY
HAND CARD HIQ1
CAPI INSTRUCTION:
DO NOT ALLOW MORE THAN ONE ANSWER WHEN 40 (NO COVERAGE OF ANY TYPE) IS CODED.
PRIVATE HEALTH INSURANCE 14
MEDICARE 15
MEDI-GAP 16
MEDICAID ({DISPLAY STATE PLAN NAME}) 17
SCHIP (CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM) 18
MILITARY HEALTH CARE (TRICARE/VA/CHAMP-VA) 19
INDIAN HEALTH SERVICE 20
STATE-SPONSORED HEALTH PLAN ({DISPLAY STATE
PLAN NAME}) 21
OTHER GOVERNMENT PROGRAM 22
SINGLE SERVICE PLAN (E.G., DENTAL, VISION,
PRESCRIPTIONS) 23
NO COVERAGE OF ANY TYPE 40
REFUSED 77
DON'T KNOW 99
BOX 13
CHECK ITEM HIQ.259: IF AGE < 65 AND (HIQ.011 = 1 (YES) AND HIQ.031 NOT = 40 (NO COVERAGE), GO TO HIQ.270. IF AGE < 65 AND (HIQ.011 = 2, 7, OR 9 OR HIQ.031 = 40), GO TO END OF SECTION.
|
BOX 14
CHECK ITEM HIQ.269: IF (HIQ.011 = 1 AND HIQ.031 NOT = 40) OR HIQ.260 = 1, CONTINUE. OTHERWISE, GO TO END OF SECTION.
|
D
NHANES 2011
Target Group: SPs Birth +
DSQ.012 The next questions are about {your/SP's} use of dietary supplements, nonprescription antacids, and prescription medications during the past 30 days.
{Have you/Has SP} used or taken any vitamins, minerals, herbals or other dietary supplements in the past 30 days? Include prescription and non-prescription supplements.
This card lists some examples of different types of dietary supplements.
HAND CARD DSQ1a
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
RXQ.021 {Have you/Has SP} used or taken any nonprescription antacids in the past 30 days?
HAND CARD DSQ1b
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
HELP SCREEN:
Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.
Past Month: The past 30 days. From yesterday, 30 days back.
BOX 0
OMITTED
|
RXQ.032 In the past 30 days, {have you/has SP} used or taken medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. [Do not include prescription vitamins or minerals you may have already told me about.]
YES 1 (BOX 1)
NO 2 (BOX 0A)
REFUSED 7 (BOX 1)
DON'T KNOW 9 (BOX 1)
CAPI HARD EDIT CHECK #1
IF ‘NO’ (CODE 2) IN RXQ.032 AND ‘YES’ (CODE 1) IN DIQ.050 OR DIQ.070, DISPLAY THE FOLLOWING MESSAGE:
Earlier in the interview you reported currently taking insulin or a diabetic pill. If this is correct, we should count that as prescription medication you have taken in the last 30 days.
{CAPI DISPLAYS THREE QUESTIONS FOR CORRECTION}
DIQ.050 = Taking Insulin
DIQ.070 = Taking Diabetic Pills
RXQ.032 = Prescription Medication in Last 30 Days
CAPI HARD EDIT CHECK #2
IF ‘NO’ (CODE 2) IN RXQ.032 AND ‘YES’ (CODE 1) IN BPQ.050a, DISPLAY THE FOLLOWING MESSAGE:
Earlier in the interview you reported currently taking prescription medication for high blood pressure. If this is correct, we should count that as prescription medication you have taken in the last 30 days.
{CAPI DISPLAYS TWO QUESTIONS FOR CORRECTION}
RXQ.032 = Prescription Medication in Last 30 Days
CAPI HARD EDIT CHECK #3
IF ‘NO’ (CODE 2) IN RXQ.032 AND ‘YES’ (CODE 1) IN BPQ.100d, DISPLAY THE FOLLOWING MESSAGE:
Earlier in the interview you reported currently taking prescription medication for high cholesterol. If this is correct, we should count that as prescription medication you have taken in the last 30 days.
{CAPI DISPLAYS TWO QUESTIONS FOR CORRECTION}
RXQ.032 = Prescription Medication in Last 30 Days
BOX 0A
CHECK ITEM DSQ.038: IF ‘NO’ (CODE 2) IN RXQ.032 AND ‘YES’ (CODE 1) IN MCQ.051, CONTINUE OTHERWISE, GO TO BOX 1.
|
RXQ.040 Earlier in the interview, you reported that {you took/SP took} prescription medication for Asthma sometime in the past three months. {Have you/Has he/Has she} taken this prescription medicine for asthma in the past 30 days?
YES 1 {CODE RXQ.032
YES – CODE 1}
NO 2
BOX 1
CHECK ITEM DSQ.035A: IF 'YES' (CODE 1) IN DSQ.012, RXQ.021, OR RXQ.032, CONTINUE. OTHERWISE, GO TO BOX 17A.
|
DSQ.042 May I please see the containers for all the {vitamins, minerals, herbals, and other dietary supplements}, {and} {nonprescription antacids} {and} {prescription medicines} that {you/SP} used or took in the past 30 days?
PRESS ENTER TO CONTINUE
CAPI INSTRUCTION:
DISPLAY {vitamins, minerals, herbals and other dietary supplements,} only if DSQ.012 = yes (1), {nonprescription antacids.} only if RXQ.021 = yes (1), {prescription medicines,} only if RXQ.032 = yes (1), and the word {“and”} only before the last product type if there is more than one product type.
BOX 1A
CHECK ITEM DSQ.045: IF 'YES' (CODE 1) IN DSQ.012, CONTINUE WITH DSQ.047. OTHERWISE, GO TO BOX 6.
|
DSQ.047 I will start with the vitamins, minerals, herbals and other dietary supplements. Please show me any {you have/SP has} taken in the past 30 days.
CHECK PRODUCT LABEL OR ASK PRODUCT NAME.
IS THIS PRODUCT ON THE LIST BELOW?
YES 1
NO 2 (DSQ.052)
DON’T KNOW 9 (DSQ.052)
SINGLE ELEMENTS
VITAMIN A 10
VITAMIN B6 12
VITAMIN B12 13
VITAMIN C (WITH OR WITHOUT ROSE
HIPS) 14
VITAMIN D 15
VITAMIN E 16
CALCIUM 18
CHROMIUM (CHROMIUM PICOLINATE) 19
FOLATE (FOLIC ACID) 20
IRON (FERROUS XXXATE) 21
MAGNESIUM 27
POTASSIUM 28
SELENIUM 29
ZINC (ZINC GLUCONATE) 40
MULTI ELEMENTS
VITAMINS A & D 50
CALCIUM & VITAMIN D 51
CALCIUM & MAGNESIUM 52
DSQ.049 WHICH PRODUCT IS IT?
ENTER 1 PRODUCT CODE
VITAMIN A 10
VITAMIN B6 12
VITAMIN B12 13
VITAMIN C (WITH OR WITHOUT ROSE
HIPS) 14
VITAMIN D 15
VITAMIN E 16
CALCIUM 18
CHROMIUM (CHROMIUM PICOLINATE) 19
FOLATE (FOLIC ACID) 20
IRON (FERROUS XXXATE) 21
MAGNESIUM 27
POTASSIUM 28
SELENIUM 29
ZINC (ZINC GLUCONATE) 40
VITAMINS A & D 50
CALCIUM & VITAMIN D 51
CALCIUM & MAGNESIUM 52
REFUSED 77 (DSQ.052)
DON’T KNOW 99 (DSQ.052)
BOX 1B
CHECK ITEM DSQ.059: GO TO DSQ.071.
|
DSQ.052 REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF DIETARY SUPPLEMENTS USED. ENTER FULL NAME OF SUPPLEMENT, INCLUDING BRAND.
ENTER SUPPLEMENT NAME
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION:
IF DON'T KNOW OR REFUSAL, THEN GO TO BOX 6.
SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED.
TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.
DSQ.060s OMITTED
BOX 2
OMITTED
|
DSQ.057 OMITTED
DSQ.071 INTERVIEWER: ENTER 1 RESPONSE
CAPI INSTRUCTION:
DISPLAY PRODUCT NAME AS LEFT HEADER.
CONTAINER SEEN 1
CONTAINER NOT SEEN 2
BOX 2A
CHECK ITEM DSQ.074:
|
DSQ.066 SELECT STRENGTH FOR {ELEMENT}
a/b/aO/bO
IF STRENGTH NOT ON FRONT OR UNCLEAR, TURN CONTAINER AROUND AND GET STRENGTH FROM FACTS BOX.
PRESS BS TO START LOOKUP.
PRESS ENTER TO SELECT.
CAPI INSTRUCTION:
{ELEMENT} = DISPLAY PRODUCT ELEMENT SELECTED IN DSQ.049. IF PRODUCT SELECTED HAS MORE THAN 1 ELEMENT (EXAMPLE = ), STRENGTH QUESTION SHOULD APPEAR FOR EACH ELEMENT.
IF “OTHER” STRENGTH IS SELECTED, GET OTHER SPECIFY AND INTERVIEWER INSTRUCTION SHOULD READ “ENTER SUPPLEMENT STRENGTH”.
ALL OF THE STRENGTH QUESTION AND INSTRUCTION SHOULD APPEAR WHEN STRENGTH LOOKUP LIST IS DISPLAYED (NO SCROLLING). THIS MAY MEAN PRINTING ALL WORDS ON THE SCREEN FLUSH LEFT IN MULTIPLE LINES.
BOX 3
OMITTED
|
DSQ.077 WHAT IS THE FORM OF THIS PRODUCT?
OS
CAPSULES 1
TABLETS 2
CHEWABLE TABLETS 3
PILLS 4
CAPLETS 5
SOFT GELS 6
GEL CAPS 7
VEGICAPS 8
PACKAGE/PACKETS 9
LIQUID 10
POWDER 11
WAFERS 12
CHEWS/GUMMIES 13
DOTS 14
GRANULES 15
LOZENGES/COUGH DROPS 16
GEL 17
OTHER FORM (SPECIFY) 91
REFUSED 77
DON’T KNOW 99
CAPI INSTRUCTION:
DISPLAY PRODUCT NAME AS LEFT HEADER.
BOX 3A
CHECK ITEM DSQ.079: IF PRODUCT NOT SELECTED FROM SPECIAL PRODUCT LIST (NO, CODE 2 IN DSQ.047), CONTINUE. OTHERWISE, GO TO DSQ.096.
|
DSQ.081 ENTER MANUFACTURER/DISTRIBUTOR/STORE BRAND NAME.
ENTER AS MUCH INFORMATION AS POSSIBLE.
ENTER MANUFACTURER/DISTRIBUTOR/STORE BRAND NAME
REFUSED 7 (DSQ.088b)
DON'T KNOW 9 (DSQ.088b)
CAPI INSTRUCTION:
FOLLOW THE BASIC FORMAT FOR THE DIETARY SUPPLEMENT LOOKUP. ONLY ALLOW ENTRY OF 1 MANUFACTURER. DISPLAY PRODUCT NAME AS A LEFT HEADER.
DSQ.084 PRESS BS TO START THE LOOKUP.
SELECT MANUFACTURER
FROM LIST.
IF MANUFACTURER NOT
ON LIST – PRESS BS
TO DELETE ENTRY
TYPE '**'.
PRESS ENTER TO SELECT.
CAPI INSTRUCTION:
DISPLAY MANUFACTURER LIST. INTERVIEWER SHOULD BE ABLE TO SELECT ONLY 1 MANUFACTURER OR THE '**' OPTION. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. IF MANUFACTURER IS SELECTED FROM THE LOOKUP LIST, AUTOMATICALLY FILL IN THE CITY AND STATE INFORMATION (DSQ.088).
DISPLAY PRODUCT NAME AS LEFT HEADER.
BOX 4
CHECK ITEM DSQ.085: IF MANUFACTURER SELECTED FROM LOOKUP, GO TO DSQ.096. OTHERWISE, CONTINUE.
|
DSQ.088b ENTER CITY NAME.
ENTER AS MUCH INFORMATION AS POSSIBLE.
ENTER CITY
REFUSED 7
DON’T KNOW 9
DSQ.088c ENTER STATE NAME.
ENTER 2-LETTER
STATE ABBREVIATION.
PRESS ENTER TO
SELECT STATE FROM LIST.
ENTER STATE
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION:
DISPLAY PRODUCT NAME AS A LEFT HEADER.
AN ENTRY MUST BE MADE IN ALL DSQ.081 AND DSQ.087 FIELDS (MANUFACTURER INFO). IF THE MANUFACTURER INFO IS DON'T KNOW OR REFUSED, THEN SET THE NO MANUFACTURER INFORMATION VARIABLE.
DSQ.096 For how long {have/has} {you/SP} been taking {PRODUCT NAME} or a similar type of product?
Q/U
CAPI INSTRUCTION:
RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.
|___|___|___|___|
ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)
REFUSED 777
DON'T KNOW 999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
DSQ.103 In the past {30 DAYS/NUMBER AND UNIT}, on how many days did {you/SP} take {PRODUCT NAME}?
CAPI INSTRUCTION:
{30 DAYS/NUMBER AND UNIT} = IF NUMBER AND UNIT ENTERED IN DSQ.096 >= 30 DAYS, OR REFUSED (CODE 7), OR DON’T KNOW (CODE 9), DISPLAY “30 DAYS” IN TEXT OF QUESTION. IF NUMBER AND UNIT ENTERED IN DSQ.096 IS < 30 DAYS, DISPLAY ACTUAL NUMBER AND UNIT ENTERED IN DSQ.096 IN TEXT OF QUESTION.
{PRODUCT NAME} = PRODUCT SELECTED AT DSQ.049 OR PRODUCT ENTERED IN DSQ.052.
|___|___|
ENTER NUMBER OF DAYS FROM 1-30
REFUSED 777
DON'T KNOW 999
DSQ.123 On the days that {you/SP} took {PRODUCT NAME}, how much did {you/SP} usually take on a single day?
Q/U/OS
CAPI INSTRUCTION:
SOFT EDIT: QUANTITY SHOULD BE LESS THAN 10.
HARD EDIT: NUMBER MUST BE IN 0.20 – 60.0 RANGE.
ERROR MESSAGE: “You said {you/he/she} took {QUANTITY TAKEN}. Is that correct?”
|___|___|___|
ENTER NUMBER
REFUSED 7777 (DSQ.124)
DON'T KNOW 9999 (DSQ.124)
|___|___|
ENTER UNIT/FORM
TABLETS/CAPSULES/PILLS/CAPLETS/
SOFTGELS/GEL
CAPS/VEGICAPS/
CHEWABLE TABLETS 1 (07BOX NEW 4A)
DROPPERS 2 (07BOX NEW 4A)
DROPS 3 (07BOX NEW 4A)
INJECTIONS/SHOTS 5 (07BOX NEW 4A)
LOZENGES/COUGH DROPS 6 (07BOX NEW 4A)
MILLILITERS 7 (07BOX NEW 4A)
TABLESPOONS 11 (07BOX NEW 4A)
TEASPOONS 12 (07BOX NEW 4A)
WAFERS 13 (07BOX NEW 4A)
CANS 15 (07BOX NEW 4A)
GRAMS 16 (07BOX NEW 4A)
DOTS 17 (07BOX NEW 4A)
CUPS 18 (07BOX NEW 4A)
SPRAYS/SQUIRTS 19 (07BOX NEW 4A)
CHEWS/GUMMIES 20 (07BOX NEW 4A)
SCOOPS 21 (07BOX NEW 4A)
CAPFULS 23 (07BOX NEW 4A)
OUNCES 27 (07BOX NEW 4A)
PACKAGES/PACKETS 28 (CONTINUE)
VIALS 29 (07BOX NEW 4A)
GUMBALLS 30 (07BOX NEW 4A)
OTHER FORM (SPECIFY) 91 (07BOX NEW 4A)
REFUSED 77 (07BOX NEW 4A)
DON’T KNOW 99 (07BOX NEW 4A)
CAPI INSTRUCTION:
IF FORM CODE 1 THROUGH 8 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 1 AND SKIP TO 07BOX NEW 4A.
IF FORM CODE 12 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 13 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.
IF FORM CODE 13 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 20 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.
IF FORM CODE 14 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 17 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.
IF FORM CODE 16 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 6 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.
IF FORM CODE 9 IN DSQ.077, DISPLAY THE UNIT CODES 1, 6, 7, 11, 12, 13, 15, 16, 17, 18, 20, 21, 23, 27, 28, 30, 91, 77, 99 FOR DSQ.123U.
IF FORM CODE 10, 17 IN DSQ.077, DISPLAY THE UNIT CODES 2, 3, 5, 7, 11, 12, 15, 18, 19, 23, 27, 29, 91, 77, 99 FOR DSQ.123U.
IF FORM CODE 11, 15 IN DSQ.077, DISPLAY THE UNIT CODES 11, 12, 15, 16, 18, 21, 23, 27, 28, 91, 77, 99 FOR DSQ.123U.
IF FORM CODE 91, 77, 99 IN DSQ.077, DISPLAY ENTIRE PICK LIST FOR DSQ.123U.
IF CONTAINER NOT SEEN (CODE 2 IN DSQ.071), DISPLAY ENTIRE PICK LIST FOR DSQ.123U.
DSQ.125 {Did you/Does SP} take an entire packet of {PRODUCT NAME} each time?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
07BOX NEW 4A
CHECK ITEM DSQ.105: IF PRODUCT NOT SEEN IN DSQ.071 (CODE 2) AND DSQ.123 = 7, 11, 12, 15, 16, 18, 21, 23 OR 27, CONTINUE. OTHERWISE, SKIP TO DSQ.124.
|
DSQ.110 Was that a liquid or powder?
LIQUID 1
POWDER 2
REFUSED 77
DON'T KNOW 99
DSQ.124 HAND CARD DSQ2
Looking at this card, what is the reason {you take/SP takes} {PRODUCT NAME}?
(Did {you/SP NAME} decide to take it for reasons of your own or did a doctor or other health provider tell you to take it?)
DECIDED TO TAKE IT FOR REASONS
OF MY OWN 1
A DOCTOR OR OTHER HEALTH
PROVIDER TOLD ME TO 2
REFUSED 7 (DSQ.127)
DON’T KNOW 9 (DSQ.127)
DSQ.132 {For what reason or reasons {do you/does SP} take {PRODUCT NAME}?}
{For what reason or reasons did the doctor or other health professional tell {you/SP} to take {PRODUCT}?}
HAND CARD DSQ3
CODE ALL THAT APPLY.
TO: GET MORE ENERGY 25 IMPROVE DIGESTION 31 IMPROVE MY OVERALL HEALTH 14 MAINTAIN HEALTH (TO STAY HEALTHY) 17
MAINTAIN HEALTHY BLOOD SUGAR
PREVENT COLDS, BOOST IMMUNE PREVENT HEALTH PROBLEMS 13
SUPPLEMENT MY DIET (BECAUSE I
|
FOR: ANEMIA, SUCH AS LOW IRON 27
BONE HEALTH, BUILD STRONG BONES, EYE HEALTH 20 GOOD BOWEL/COLON HEALTH 10 HEALTHY JOINTS, ARTHRITIS 21 HEALTHY SKIN, HAIR, AND NAILS 22 HEART HEALTH, CHOLESTEROL 19
KIDNEY AND BLADDER HEALTH, URINARY
LIVER HEALTH, DETOXIFICATION, MENOPAUSE, HOT FLASHES 28 MENTAL HEALTH 12
MUSCLE RELATED ISSUES, MUSCLE PREGNANCY/BREASTFEEDING 26 PROSTATE HEALTH 11
RELAXATION, DECREASE STRESS, TEETH, PREVENT CAVITIES 15 WEIGHT LOSS 23 |
OTHER SPECIFY 91
REFUSED 77
DON’T KNOW 99
CAPI INSTRUCTION:
IF CODE 1 IN DSQ.124, DISPLAY For what reason or reasons {do you/does SP} take {PRODUCT NAME}?
IF CODE 2 IN DSQ.124, DISPLAY For what reason or reasons did the doctor or other health professional tell {you/SP} to take {PRODUCT}?
DSQ.127 ARE THERE ANY OTHER VITAMINS, MINERALS, HERBALS OR DIETARY SUPPLEMENTS?
YES 1
NO 2
HELP SCREEN:
Dietary Supplements (Vitamins/Minerals): Dietary supplements are often labeled as "dietary supplements" and are used in addition to foods and beverages. Dietary supplements are not intended to replace food. Include vitamins, minerals, antacid/calcium supplement products, fiber supplements, amino acids, performance enhancers, herbs, herbal medicine products, and plant extracts used as dietary supplements. Include products that are taken orally or given by injection. Do not include beverages, such as tea, and skin creams. Meal replacement beverages, weight loss and performance booster drinks, and food bars are considered foods, not dietary supplements.
BOX 5
CHECK ITEM DSQ.129: ASK DSQ.127 FOR NEXT VITAMIN (CODE 1 IN DSQ.127). IF NO NEXT VITAMIN (CODE 2 IN DSQ.127), CONTINUE WITH DSQ.131.
|
DSQ.131 REVIEW TOTAL NUMBER OF DIETARY SUPPLEMENTS AND THEIR NAMES WITH RESPONDENT.
I have listed {TOTAL NUMBER} vitamin(s), mineral(s), herbals or dietary supplement(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME (STRENGTH)}
PRESS ENTER TO CONTINUE
CAPI INSTRUCTION:
DISPLAY LIST OF ALL VITAMIN AND MINERAL NAMES AND STRENGTHS SELECTED AT DSQ.060 AND ENTERED AT DSQ.052. CALCULATE TOTAL NUMBER OF ALL VITAMINS AND MINERALS SELECTED AT DSQ.060 AND ENTERED AT DSQ.052. DISPLAY NUMBER ON SCREEN.
HELP SCREEN:
Dietary Supplements (Vitamins/Minerals): Dietary supplements are often labeled as "dietary supplements" and are used in addition to foods and beverages. Dietary supplements are not intended to replace food. Include vitamins, minerals, antacid/calcium supplement products, fiber supplements, amino acids, performance enhancers, herbs, herbal medicine products, and plant extracts used as dietary supplements. Include products that are taken orally or given by injection. Do not include beverages, such as tea, and skin creams. Meal replacement beverages, weight loss and performance booster drinks, and food bars are considered foods, not dietary supplements.
BOX 6
CHECK ITEM DSQ.133: IF 'YES' (CODE 1) IN RXQ.021, CONTINUE. OTHERWISE, GO TO NEW BOX 10AA.
|
RXQ.141 Now I would like to ask you some questions about {your/SP's} use of nonprescription antacids in the past 30 days.
[First I will record some information about an antacid, then I will ask you some questions about it.]
REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF NONPRESCRIPTION ANTACIDS USED. ENTER FULL BRAND NAME OF ANTACID.
ENTER ANTACID NAME
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION:
IF DON'T KNOW OR REFUSED, THEN GO TO BOX 10AA.
SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.
[TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.
HELP SCREEN:
Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.
Past Month: The past 30 days. From yesterday, 30 days back.
RXQ.150s PRESS BS TO START THE LOOKUP.
SELECT ANTACID
FROM LIST.
IF ANTACID NOT
ON LIST – PRESS BS
TO DELETE ENTRY.
TYPE '**'.
PRESS ENTER TO SELECT.
CAPI INSTRUCTION:
DISPLAY CAPI ANTACID PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN RXQ.141 BY TYPING IN "**". THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.
INTERVIEWER SHOULD BE ABLE TO ACCEPT THE KEYED NAME AS A NEW PRODUCT NAME AN UNLIMITED NUMBER OF TIMES. AFTER ENTRY, INTERVIEWER SHOULD RETURN TO THE DATA BASE LIST. IF NO MORE ENTRIES, INTERVIEWERS SHOULD HAVE A WAY OF MOVING INTO LOOP 2.
ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:
DRUG TYPE {3}
GENERIC NAME {60}
THERAPEUTIC CLASS CODE {6}
GENERIC FLAG {1}
THERE IS NO NEED TO DISPLAY THIS INFORMATION.
BOX 7
OMITTED
|
RXQ.160 INTERVIEWER: ENTER 1 RESPONSE.
CAPI INSTRUCTION:
DISPLAY PRODUCT NAME AS LEFT HEADER.
CONTAINER SEEN 1
CONTAINER NOT SEEN 2
RXQ.180 For how long {have/has} {you/SP} been using or taking {PRODUCT NAME}?
CAPI INSTRUCTION:
RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.
|___|___|___|___|
ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)
REFUSED 777
DON'T KNOW 999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 7
DON'T KNOW 9
RXQ.191 In the past {30 DAYS/NUMBER AND UNIT}, on how many days did {you/SP} take {PRODUCT NAME}?
CAPI INSTRUCTION:
{30 DAYS/NUMBER AND UNIT} = IF NUMBER AND UNIT ENTERED IN RXQ.180 >= 30 DAYS, OR REFUSED (CODE 7), OR DON’T KNOW (CODE 9), DISPLAY “30 DAYS” IN TEXT OF QUESTION. IF NUMBER AND UNIT ENTERED IN RXQ.180 IS < 30 DAYS, DISPLAY ACTUAL NUMBER AND UNIT ENTERED IN DSQ.096 IN TEXT OF QUESTION.
{PRODUCT NAME} = PRODUCT SELECTED AT DSQ.049 OR PRODUCT ENTERED IN DSQ.052.
|___|___|
ENTER NUMBER OF DAYS FROM 1-30
REFUSED 7777
DON'T KNOW 9999
RXQ.195 |
On those days that you used or took {PRODUCT NAME}, how much did {you/SP} usually take on a single day? |
CAPI INSTRUCTION:
SOFT EDIT: QUANTITY SHOULD BE LESS THAN 10.
ERROR MESSAGE: “You said {you/he/she} took {QUANTITY TAKEN}. Is that correct?”
|___|___|___|
ENTER NUMBER
REFUSED 7777 (RXQ.216)
DON'T KNOW 9999 (RXQ.216)
ENTER UNIT/FORM
TABLETS/CAPSULES/PILLS/CAPLETS/
SOFTGELS/GEL
CAPS/VEGICAPS/
CHEWABLE TABLETS 1 (07BOX NEW 8)
DROPPERS 2 (07BOX NEW 8)
DROPS 3 (07BOX NEW 8)
INJECTIONS/SHOTS 5 (07BOX NEW 8)
LOZENGES/COUGH DROPS 6 (07BOX NEW 8)
MILLILITERS 7 (07BOX NEW 8)
TABLESPOONS 11 (07BOX NEW 8)
TEASPOONS 12 (07BOX NEW 8)
WAFERS 13 (07BOX NEW 8)
CANS 15 (07BOX NEW 8)
GRAMS 16 (07BOX NEW 8)
DOTS 17 (07BOX NEW 8)
CUPS 18 (07BOX NEW 8)
SPRAYS/SQUIRTS 19 (07BOX NEW 8)
CHEWS/GUMMIES 20 (07BOX NEW 8)
SCOOPS 21 (07BOX NEW 8)
CAPFULS 23 (07BOX NEW 8)
OUNCES 27 (07BOX NEW 8)
PACKAGES/PACKETS 28 (CONTINUE)
VIALS 29 (07BOX NEW 8)
GUMBALLS 30 (07BOX NEW 8)
OTHER FORM (SPECIFY) 91 (07BOX NEW 8)
REFUSED 77 (07BOX NEW 8)
DON’T KNOW 99 (07BOX NEW 8)
RXQ.200 {Do you/Does SP} take an entire packet each time?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
07BOX NEW 8
CHECK ITEM RXQ.205: IF RXQ.195U IS 7, 11, 12, 15, 16, 18, 21, 23, OR 27, CONTINUE. OTHERWISE, SKIP TO RXQ.215a.
|
DSQ.110 Was that a liquid or powder?
LIQUID 1
POWDER 2
REFUSED 77
DON'T KNOW 99
RXQ.215a Did you take {PRODUCT NAME} as an antacid, as a calcium supplement, or both?
ANTACID 1
CALCIUM SUPPLEMENT 2
BOTH 3
NEITHER 4
REFUSED 7
DON'T KNOW 9
RXQ.216 CHECK CONTAINERS. ARE THERE ANY OTHER NONPRESCRIPTION ANTACIDS?
OR ASK RESPONDENT:
[Are there any other nonprescription antacids that {you/SP} used in the past 30 days?]
YES 1
NO 2
HELP SCREEN:
Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.
BOX 9
CHECK ITEM RXQ.219: ASK RXQ.141 FOR NEXT ANTACID (CODE 1 IN RXQ.216). IF NO NEXT ANTACID, (CODE 2 IN RXQ.216), CONTINUE WITH RXQ.221.
|
RXQ.221 REVIEW TOTAL NUMBER OF ANTACIDS AND THEIR NAMES WITH RESPONDENT.
I have listed {TOTAL NUMBER} nonprescription antacid(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}
PRESS ENTER TO CONTINUE
CAPI INSTRUCTION:
DISPLAY NAMES OF ALL ANTACIDS SELECTED AT RXQ.150 AND ENTERED AT RXQ.141. CALCULATE TOTAL NUMBER OF ALL ANTACIDS SELECTED AT RXQ.150 AND ENTERED AT RXQ.141. DISPLAY NUMBER ON SCREEN.
HELP SCREEN:
Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.
BOX 15
OMITTED
|
BOX 16
OMITTED
|
BOX 16A
OMITTED
|
BOX 10A
OMITTED |
NEW BOX 10AA
CHECK ITEM RXQ.227: IF ‘YES’ (CODE 1) TO RXQ.032, CONTINUE. OTHERWISE, GO TO NEW BOX 17A.
|
RXQ.231 Now I would like to talk about prescription medication {you have/SP has} used in the past 30 days. Again, these are products prescribed by a health professional such as a doctor or dentist.
[First I will record some information about the medication, then I will ask you some questions about it.]
REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF PRESCRIPTION MEDICATIONS USED.
ENTER MEDICATION NAME
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION:
IF DON'T KNOW OR REFUSED, GO TO NEW BOX 17A.
SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.
TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.
RXQ.240s PRESS BS TO START THE LOOKUP.
SELECT MEDICATION
FROM LIST.
IF MEDICATION NOT
ON LIST – PRESS BS
TO DELETE ENTRY.
TYPE '**'.
PRESS ENTER TO SELECT
CAPI INSTRUCTION:
DISPLAY CAPI MEDICATION PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN RXQ.231 BY TYPING IN "**". THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.
INTERVIEWER SHOULD BE ABLE TO ACCEPT THE KEYED NAME AS A NEW PRODUCT NAME AN UNLIMITED NUMBER OF TIMES. AFTER ENTRY, INTERVIEWER SHOULD RETURN TO THE DATA BASE LIST. IF NO MORE ENTRIES, INTERVIEWERS SHOULD HAVE A WAY OF MOVING INTO LOOP 3.
ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:
DRUG TYPE {3}
GENERIC NAME {60}
THERAPEUTIC CLASS CODE {6}
GENERIC FLAG {1}
THERE IS NO NEED TO DISPLAY THIS INFORMATION.
BOX 10B
OMITTED |
BOX 11
OMITTED
|
RXQ.250 INTERVIEWER: ENTER 1 RESPONSE
CAPI INSTRUCTION:
DISPLAY PRODUCT NAME AS A LEFT HEADER.
CONTAINER SEEN 1
CONTAINER NOT SEEN 2
RXQ.260 For how long {have/has} {you/SP} been using or taking {PRODUCT NAME}?
Q/U
CAPI INSTRUCTION:
RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.
|___|___|___|___|
ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)
REFUSED 777
DON'T KNOW 999
ENTER UNIT
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
BOX 13
OMITTED
|
RXQ.290 What is the main reason for which (you use/SP uses) {PRODUCT NAME}?
REFUSED 7
DON'T KNOW 9
RXQ.294 CHECK CONTAINERS. ARE THERE ANY OTHER PRESCRIPTION MEDICATIONS?
OR ASK RESPONDENT:
[Are there any other prescription medications that {you/SP} used in the past 30 days?]
YES 1
NO 2
REFUSED 77
DON’T KNOW 99
BOX 14
CHECK ITEM RXQ.298: ASK RXQ.231 - RXQ.294 FOR NEXT MEDICATION (CODE 1 IN RXQ.294). IF NO NEXT MEDICATION (CODE 2 IN RXQ.294), CONTINUE WITH NEW BOX 15.
|
NEW BOX 15
CHECK ITEM RXQ.370: IF DIQ.050 = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT EQUAL TO 215), CONTINUE WITH RXQ.372. OTHERWISE, GO TO NEW BOX 15B.
|
RXQ.372 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one is insulin?
CAPI INSTRUCTION:
DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.
CODE ALL THAT APPLY.
SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION
REFUSED 77
DON’T KNOW 99
NEW BOX 15A
CHECK ITEM RXQ.374: IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION. OTHERWISE, CONTINUE.
|
NEW BOX 15B
CHECK ITEM RXQ.376: IF DIQ.070 = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT EQUAL TO 213, 214, 216, 271, 282, 309, OR 314), THEN CONTINUE WITH RXQ.378. OTHERWISE, GO TO NEW BOX 15D.
|
RXQ.378 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one {are you/is he/is she} taking for diabetes or blood sugar?
CAPI INSTRUCTION:
DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.
CODE ALL THAT APPLY.
SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION
REFUSED 77
DON’T KNOW 99
NEW BOX 15C
CHECK ITEM RXQ.380: IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION. OTHERWISE, CONTINUE.
|
NEW BOX 15D
CHECK ITEM RXQ.382: IF BPQ.050a = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT EQUAL TO 41, 42, 44, 47, 48, 49, 53, 55, 56, 340, OR 342), THEN CONTINUE WITH RXQ.384. OTHERWISE, GO TO NEW BOX 15F.
|
RXQ.384 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one {are you/is he/is she} taking to lower {your/his/her} blood pressure?
CAPI INSTRUCTION:
DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.
CODE ALL THAT APPLY.
SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION
REFUSED 77
DON’T KNOW 99
NEW BOX 15E
CHECK ITEM RXQ.386: IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION. OTHERWISE, CONTINUE.
|
NEW BOX 15F
CHECK ITEM RXQ.388: IF BPQ.100d = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT EQUAL TO 19), THEN CONTINUE WITH RXQ.390. OTHERWISE, GO TO RXQ.295.
|
RXQ.390 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one {are you/is he/is she} taking to lower {your/his/her} cholesterol?
CAPI INSTRUCTION:
DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.
SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION
REFUSED 77
DON’T KNOW 99
NEW BOX 15G
CHECK ITEM RXQ.392: IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION. OTHERWISE, CONTINUE.
|
RXQ.295 REVIEW TOTAL NUMBER OF PRESCRIBED MEDICATIONS AND THEIR NAMES WITH RESPONDENT.
I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}
PRESS ENTER TO CONTINUE
CAPI INSTRUCTION:
DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231. CALCULATE TOTAL NUMBER OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231. DISPLAY NUMBER ON SCREEN.
BOX 17A
CHECK ITEM RXQ.500: IF SP >= 40 YEARS OLD, CONTINUE WITH RXQ.510. OTHERWISE, GO TO BOX 18. |
RXQ.510 Doctors and other health care providers sometimes recommend that {you take/SP takes) a low-dose aspirin each day to prevent heart attacks, strokes, or cancer. {Have you/Has SP} ever been told to do this?
YES 1
NO 2 (RXQ.520)
REFUSED 7 (RXQ.520)
DON'T KNOW 9 (RXQ.520)
INTERVIEWER INSTRUCTION:
IF THE RESPONDENT VOLUNTEERS THEY HAVE BEEN TOLD TO TAKE AN ASPIRIN EVERY OTHER DAY OR ‘REGULARLY’ FOR THESE REASONS, CODE “YES”.
RXQ.515 {Are you/Is SP} now following this advice?
YES 1 (RXQ.525)
NO 2 (BOX 18)
SOMETIMES 3 (RXQ.525)
STOPPED ASPIRIN USE DUE TO SIDE
EFFECTS 4 (BOX 18)
REFUSED 7 (BOX 18)
DON'T KNOW 9 (BOX 18)
HELP SCREEN:
Side Effect: is an unexpected health problem that is caused by a medicine. Some side effects of aspirin are stomach problems, easy bruising or bleeding, runny nose, wheezing and skin rashes.
RXQ.520 On {your/SP’s} own, {are you/is SP} now taking a low-dose aspirin each day to prevent heart attacks, strokes, or cancer?
YES 1
NO 2 (BOX 18)
REFUSED 7 (BOX 18)
DON'T KNOW 9 (BOX 18)
INTERVIEWER INSTRUCTION:
IF THE RESPONDENT VOLUNTEERS THEY ARE TAKING AN ASPIRIN EVERY OTHER DAY OR ‘REGULARLY’ FOR THESE REASONS, CODE “YES”.
RXQ.525 How often {do you/does SP} take an aspirin?
G/Q/U
ONE EVERY DAY 1
ONE EVERY OTHER DAY 2
OTHER, ENTER NUMBER/UNIT 3
|___|
ENTER NUMBER
REFUSED 77
DON'T KNOW 99
ENTER UNIT
PER DAY 1
PER WEEK 2
REFUSED 7
DON'T KNOW 9
CAPI INSTRUCTION: Soft edit: if >2 per day.
RXQ.530 What is the size or dose that {you take/SP takes}?
81 MG 1
325 MG 2
500 MG 3
OTHER (SPECIFY) 4
REFUSED 7
DON'T KNOW 9
|___|___|___|___| MG
ENTER NUMBER
BOX 18
CHECK ITEM DSQ.332: IF PROXY INTERVIEW IN RIQ, CONTINUE. IF NOT PROXY INTERVIEW IN RIQ, GO TO DSQ.335.
|
DSQ.334 INTERVIEWER OBSERVATION: WAS SP PRESENT FOR ALL OR PART OF INTERVIEW?
YES 1
NO 2
DSQ.335 PRESS F10 TO EXIT BLAISE.
HELP SCREEN FOR DSQ.012:
Dietary Supplements (Vitamins/Minerals): Dietary supplements are often labeled as "dietary supplements" and are used in addition to foods and beverages. Dietary supplements are not intended to replace food. Include vitamins, minerals, antacid/calcium supplement products, fiber supplements, amino acids, performance enhancers, herbs, herbal medicine products, and plant extracts used as dietary supplements. Include products that are taken orally or given by injection. Do not include beverages, such as tea, and skin creams. Meal replacement beverages, weight loss and performance booster drinks, and food bars are considered foods, not dietary supplements.
Health (Care) Professional: A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor's assistants, nurse practitioners, nurses, lab technicians, and technicians who administer shots (i.e., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor's office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.
Dentist: Medical professional whose primary occupation is caring for teeth, gums and jaws. Dental care includes general work such as fillings, cleaning, extractions, and also specialized work such as root canals, fittings for braces, etc.
Doctor: The term refers to both medical doctors (M.D.s) and osteopathic physicians (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Past Month: The past 30 days. From yesterday, 30 days back.
HELP SCREEN FOR RXQ.032:
Prescription Medication: Prescription medications are those ordered by a physician or other authorized medical professional through a written or verbal prescription for a pharmacist to fill. Prescription medications may also be given by a medical professional directly to a patient to take home, such as free samples.
Prescription medications do not include:
- Medication administered to the patient during the event in the office as part of the treatment (such as an antibiotic shot for an infection, a flu shot, or an oral medication) unless a separate bill for the medication is received;
- Diaphragms and IUD's (Intra-Uterine Devices); or
- Some state laws require prescriptions for over the counter medications. Sometimes physicians write prescriptions for over the counter medications, such as aspirin. Consider any medication a prescription medication if the respondent reports it as prescribed. If it is an over the counter medication, however, the prescription must be a written prescription to be filled by a pharmacist, not just a written or oral instruction. If in doubt, probe whether the patient got a written prescription to fill at a pharmacy.
Past Month: The past 30 days. From yesterday, 30 days back.
HELP SCREEN FOR DSQ.042:
Dietary Supplements (Vitamins/Minerals): Dietary supplements are often labeled as "dietary supplements" and are used in addition to foods and beverages. Dietary supplements are not intended to replace food. Include vitamins, minerals, antacid/calcium supplement products, fiber supplements, amino acids, performance enhancers, herbs, herbal medicine products, and plant extracts used as dietary supplements. Include products that are taken orally or given by injection. Do not include beverages, such as tea, and skin creams. Meal replacement beverages, weight loss and performance booster drinks, and food bars are considered foods, not dietary supplements.
Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.
Prescription Medication: Prescription medications are those ordered by a physician or other authorized medical professional through a written or verbal prescription for a pharmacist to fill. Prescription medications may also be given by a medical professional directly to a patient to take home, such as free samples.
Prescription medications do not include:
- Medication administered to the patient during the event in the office as part of the treatment (such as an antibiotic shot for an infection, a flu shot, or an oral medication) unless a separate bill for the medication is received;
- Diaphragms and IUD's (Intra-Uterine Devices); or
- Some state laws require prescriptions for over the counter medications. Sometimes physicians write prescriptions for over the counter medications, such as aspirin. Consider any medication a prescription medication if the respondent reports it as prescribed. If it is an over the counter medication, however, the prescription must be a written prescription to be filled by a pharmacist, not just a written or oral instruction. If in doubt, probe whether the patient got a written prescription to fill at a pharmacy.
Past Month: The past 30 days. From yesterday, 30 days back.
HELP SCREEN FOR DSQ.052:
Dietary Supplements (Vitamins/Minerals): Dietary supplements are often labeled as "dietary supplements" and are used in addition to foods and beverages. Dietary supplements are not intended to replace food. Include vitamins, minerals, antacid/calcium supplement products, fiber supplements, amino acids, performance enhancers, herbs, herbal medicine products, and plant extracts used as dietary supplements. Include products that are taken orally or given by injection. Do not include beverages, such as tea, and skin creams. Meal replacement beverages, weight loss and performance booster drinks, and food bars are considered foods, not dietary supplements.
Health (Care) Professional: A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor's assistants, nurse practitioners, nurses, lab technicians, and technicians who administer shots (i.e., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor's office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.
Dentist: Medical professional whose primary occupation is caring for teeth, gums and jaws. Dental care includes general work such as fillings, cleaning, extractions, and also specialized work such as root canals, fittings for braces, etc.
Doctor: The term refers to both medical doctors (M.D.s) and osteopathic physicians (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Past Month: The past 30 days. From yesterday, 30 days back.
HELP SCREEN FOR RXQ.231:
Prescription Medication: Prescription medications are those ordered by a physician or other authorized medical professional through a written or verbal prescription for a pharmacist to fill. Prescription medications may also be given by a medical professional directly to a patient to take home, such as free samples.
Prescription medications do not include:
- Medication administered to the patient during the event in the office as part of the treatment (such as an antibiotic shot for an infection, a flu shot, or an oral medication) unless a separate bill for the medication is received;
- Diaphragms and IUD's (Intra-Uterine Devices); or
- Some state laws require prescriptions for over the counter medications. Sometimes physicians write prescriptions for over the counter medications, such as aspirin. Consider any medication a prescription medication if the respondent reports it as prescribed. If it is an over the counter medication, however, the prescription must be a written prescription to be filled by a pharmacist, not just a written or oral instruction. If in doubt, probe whether the patient got a written prescription to fill at a pharmacy.
Past Month: The past 30 days. From yesterday, 30 days back.
HELP SCREEN FOR RXQ.294/RXQ.295:
Prescription Medication: Prescription medications are those ordered by a physician or other authorized medical professional through a written or verbal prescription for a pharmacist to fill. Prescription medications may also be given by a medical professional directly to a patient to take home, such as free samples.
Prescription medications do not include:
- Medication administered to the patient during the event in the office as part of the treatment (such as an antibiotic shot for an infection, a flu shot, or an oral medication) unless a separate bill for the medication is received;
- Diaphragms and IUD's (Intra-Uterine Devices); or
- Some state laws require prescriptions for over the counter medications. Sometimes physicians write prescriptions for over the counter medications, such as aspirin. Consider any medication a prescription medication if the respondent reports it as prescribed. If it is an over the counter medication, however, the prescription must be a written prescription to be filled by a pharmacist, not just a written or oral instruction. If in doubt, probe whether the patient got a written prescription to fill at a pharmacy.
m
NHANES 2011
Target Group: SPs Birth +
Placing: Just After Blaise Closes
MAQ.005 Processing Extended SP Questionnaire. Please Wait.
MAQ.020 The National Center for Health Statistics, part of the Centers for Disease Control and Prevention, may wish to contact {you/SP} again. Please give me {your/SP's} complete mailing address.
CRITICAL INFORMATION – CHECK CAREFULLY.
USE PEN OR PRESS 'TAB' KEY TO MOVE TO THE NEXT ENTRY FIELD.
TAP 'NEXT' BUTTON OR PRESS 'ENTER' KEY WHEN FINISHED VERIFYING ADDRESS.
CAPI INSTRUCTION:
DISPLAY THE SCREENER MAILING ADDRESS INFORMATION. ENTRY SHOULD APPEAR IN ALL CAPS – AS IT DOES IN IVQ.
DISPLAY “YOU/YOUR” IF SP AGE >= TO 16. DISPLAY “SP/SP’s” IF SP AGE < 16.
________ ________ ____________________________ __________ ________ _________
STREET # DIR PRE STREET NAME ST/RD/AVE DIR POST APT/LOT #
________ ________ ________ ______________________________ ________ ________
PO BOX # RR # RR BOX CITY STATE ZIP
MAQ.040 I have recorded . . .
{DISPLAY ADDRESS ENTERED IN MAQ.020 IN UPPER CASE}
Is that correct?
YES 1 (MAQ.090)
NO 2
MAQ.060 ENTER CORRECTED MAILING ADDRESS INFORMATION.
PROBE FOR MAILING ADDRESS CORRECTIONS, IF NECESSARY.
USE PEN OR PRESS 'TAB' KEY TO MOVE TO THE NEXT ENTRY FIELD.
TAP 'NEXT' BUTTON OR PRESS 'ENTER' KEY WHEN CORRECTIONS COMPLETED.
{DISPLAY ALL ADDRESS FIELDS AND INFORMATION ENTERED IN MAQ.020 IN UPPER CASE. ALLOW CORRECTIONS.}
MAQ.080 I now have {your/SP's} mailing address as . . .
{DISPLAY CORRECTED ADDRESS FROM MAQ.060 IN UPPER CASE}
Is that correct?
YES 1
NO 2
BOX 2
CHECK ITEM MAQ.090:
IF 'NO' IN MAQ.080, RETURN TO MAQ.060. DISPLAY CORRECTED ADDRESS INFORMATION IN MAQ.060. OTHERWISE, CONTINUE.
MAQ.090 INTERVIEWER INSTRUCTION:
SPECIFY LANGUAGE IN WHICH HARD COPY MATERIALS SHOULD BE MAILED.
ENGLISH 1
SPANISH 2
VIETNAMESE 3
KOREAN 4
CHINESE (TRADITIONAL SCRIPT) 5
CHINESE (SIMPLIFIED SCRIPT) 6
BOX 3
CHECK TELEPHONE NUMBER LISTED IN SCREENER (SCQ.430). IF NO HOME TELEPHONE (CODE 2), REF (CODE 9), OR DK (CODE 7), CONTINUE.
OTHERWISE, GO TO BOX 4.
MAQ.100 Please give me your home telephone number in case my office wants to check my work.
CAPI INSTRUCTION:
ONLY ALLOW 10 DIGIT PHONE NUMBER. DISPLAY HARD RANGE CHECK MESSAGE IF NOT 10 DIGITS.
|__|__|__|__|__|__|__|__|__|__|
NO HOME TELEPHONE 2
REFUSED 7
DON’T KNOW 9
MAQ.110 Is there another number where you can be reached?
CAPI INSTRUCTION:
ONLY ALLOW 10 DIGIT PHONE NUMBER. DISPLAY HARD RANGE ERROR IF NOT 10 DIGITS.
|__|__|__|__|__|__|__|__|__|__|
NO 2 (BOX 4)
REFUSED 7 (BOX 4)
DON’T KNOW 9 (BOX 4)
MAQ.115 I have recorded . . .
{DISPLAY PHONE ENTERED IN MAQ.110 AS (XXX) XXX-XXXX}
Is that correct?
YES 1
NO 2 (MAQ.110)
MAQ.120 Where is that phone located?
WORK 1
RELATIVE’S HOME 2
NEIGHBOR’S HOME 3
CELL PHONE 4
OTHER 5
REFUSED 7
DON’T KNOW 9
BOX 4
CHECK ITEM MAQ.140:
IF SP AGE >= TO 16 AND MAQ.120 = 4, GO TO MAQ.160.
IF SP AGE >= 16 AND MAQ.120 NOT EQUAL TO 4, GO TO MAQ.150.
IF SP AGE 12-15, GO TO MAQ.150
IF SP AGE <12, GO TO MAQ.130.
MAQ.150 {Do you/does your child} have a cell phone?
CAPI INSTRUCTION:
DISPLAY “DO YOU/YOUR” IF SP AGE >= TO 16. DISPLAY “DOES YOUR CHILD” IF SP AGE 12-15.
YES 1
NO 2 (MAQ.130)
REFUSED 7 (MAQ.130)
DON’T KNOW 9 (MAQ.130)
MAQ.130 This is the end of the health interview. Thank you very much for your cooperation.
NYFS
Target Group: Head of household
DMQ.107 In what country {were you/was NON-SP Head} born?
UNITED STATES 1 (DMQ.141)
OTHER COUNTRY 2
REFUSED 7 (DMQ.141)
DON'T KNOW 9 (DMQ.141)
DMQ.113 SELECT COUNTRY OF BIRTH
ARGENTINA 1
BANGLADESH 2
BELIZE 3
BHUTAN 4
BOLIVIA 5
BRAZIL 6
BURMA/MYANMAR 7
CAMBODIA 8
CHILE 9
CHINA 10
COLOMBIA 11
COSTA RICA 12
CUBA 13
DOMINICAN REPUBLIC 14
ECUADOR 15
EL SALVADOR 16
GUATEMALA 17
HONDURAS 18
HONG KONG 19
INDIA 20
INDONESIA 21
JAPAN 22
KOREA 23
LAOS 24
MACAU 25
MADAGASCAR 26
MALAYSIA 27
MALDIVES 28
MEXICO 29
NEPAL 30
NICARAGUA 31
PAKISTAN 32
PANAMA 33
PARAGUAY 34
PERU 35
PHILIPPINES 36
PUERTO RICO 37
SINGAPORE 38
SPAIN 39
SRI LANKA 40
TAIWAN 41
THAILAND 42
TIBET 43
URUGUAY 44
VENEZUELA 45
VIETNAM 46
OTHER COUNTRY (CAPI INSTRUCTION:
DO NOT SPECIFY) 50
DMQ.141 What is the highest grade or level of school {you have/NON-SP Head has} completed or the highest degree {you have/he/she has} received?
HAND CARD DMQ1
READ HAND CARD CATEGORIES IF NECESSARY
Enter highest level of school.
NEVER ATTENDED/KINDERGARTEN
ONLY 0
1ST GRADE 1
2ND GRADE 2
3RD GRADE 3
4TH GRADE 4
5TH GRADE 5
6TH GRADE 6
7TH GRADE 7
8TH GRADE 8
9TH GRADE 9
10TH GRADE 10
11TH GRADE 11
12TH GRADE, NO DIPLOMA 12
HIGH SCHOOL GRADUATE 13
GED OR EQUIVALENT 14
SOME COLLEGE, NO DEGREE 15
ASSOCIATE DEGREE: OCCUPATIONAL,
TECHNICAL, OR VOCATIONAL
PROGRAM 16
ASSOCIATE DEGREE: ACADEMIC
PROGRAM 17
BACHELOR’S DEGREE (EXAMPLE: BA,
AB, BS, BBA) 18
MASTER’S DEGREE (EXAMPLE: MA,
MS, MEng, MEd, MBA) 19
PROFESSIONAL SCHOOL DEGREE
(EXAMPLE: MD, DDS, DVM, JD) 20
DOCTORAL DEGREE (EXAMPLE:
PhD, EdD) 21
REFUSED 77
DON’T KNOW 99
I
NYFS
Target Group: Family, Household
INQ.200 The next questions are about your family’s income. When answering these questions, please remember that by "family income", I mean your income plus the income of {NAMES OF OTHER NHANES FAMILY MEMBERS} for {LAST CALENDAR YEAR}.
Now I am going to ask about the total income for {you/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} in {LAST CALENDAR YEAR}, including income from all sources listed on this card such as wages, salaries, help from relatives and so forth. Can you tell me that amount before taxes?
HAND CARD INQ1
CAPI INSTRUCTIONS:
DISPLAY "YOU" IF ONLY 1 PERSON IN THE FAMILY.
DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.
$ |___|___|___|___|___|___|___|___|___| (GO TO BOX 9)
REFUSED 7777777777 (INQ.220)
DON'T KNOW 9999999999 (INQ.220)
CAPI INSTRUCTION:
REQUIRE DOUBLE ENTRY OF INCOME.
SCREEN SHOULD READ:
“INCOME FOR {NAMES OF FAMILY MEMBERS} HAS BEEN RECORDED AS {INCOME ENTERED IN INQ.200} DOUBLE ENTRY OF INCOME REQUIRED.”
IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.
INQ.220 You may not be able to give us an exact figure for {your/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} income, but can you tell me if this income in {LAST CALENDAR YEAR} was . . .
PROBE: Income is important in using the health information we collect. For example, it helps us to learn whether persons in one income group use certain types of medical services or have certain health conditions more or less often than those in another income group.
CAPI INSTRUCTIONS:
DISPLAY "YOUR" IF ONLY 1 PERSON IN THE FAMILY.
DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.
$20,000 or more, or 1
less than $20,000? 2
REFUSED 7 (BOX 9)
DON'T KNOW 9 (BOX 9)
INQ.230 |
Of these income groups, can you tell me which letter best represents {your/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} income in {LAST CALENDAR YEAR}? |
HAND CARD {INQ2 AND INQ3}
ENTER LETTER(S) CORRESPONDING TO TOTAL COMBINED FAMILY INCOME.
CAPI INSTRUCTIONS:
DISPLAY "YOUR" IF ONLY 1 PERSON IN THE FAMILY.
DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.
IF $20,000 OR MORE, DISPLAY HAND CARD INQ2.
IF LESS THAN $20,000, DISPLAY HAND CARD INQ3.
|___|___|
A B C D E F G H |
I J K L M N O P |
Q R S T U V W X |
Y Z AA BB CC DD EE FF |
GG HH II JJ KK LL MM NN |
OO PP RR SS TT UU VV WW |
REFUSED 77
DON'T KNOW 99
BOX 9
CHECK ITEM INQ.240: IF THERE IS MORE THAN ONE NHANES FAMILY IN THE HOUSEHOLD, CONTINUE. OTHERWISE, GO TO END OF SECTION.
|
BOX 9A
CHECK ITEM INQ.new1: HOUSEHOLD INCOME (iNq.250, 260, 270) SHOULD ONLY BE ASKED ONCE OF THE FIRST FAMILY TO COMPLETE THE FAMILY QUESTIONNAIRE. IT SHOULD NOT BE ASEKD TWICE FOR A HOUSEHOLD AND SHOULD NOT BE MISSED IF ONE FAMILY DOES NOT COMPLETE THE FAMILY QUESTIONNAIRE. |
INQ.250 Now I am going to ask you about the total household income for the persons we have talked about plus {NAMES OF ALL OTHER PERSONS IN ADDITIONAL NHANES FAMILIES} in {LAST CALENDAR YEAR}, including income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Can you tell me that amount before taxes?
$ |___|___|___|___|___|___|___|___|___| (GO TO END OF SECTION)
REFUSED 7777777777 (INQ.260)
DON'T KNOW 9999999999 (INQ.260)
CAPI INSTRUCTION:
REQUIRE DOUBLE ENTRY OF INCOME.
SCREEN SHOULD READ:
“INCOME FOR YOUR HOUSEHOLD HAS BEEN RECORDED AS {INCOME ENTERED IN INQ.250} DOUBLE ENTRY OF INCOME REQUIRED.”
IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.
INQ.260 You may not be able to give us an exact figure for your total household income, but can you tell me if this income in {LAST CALENDAR YEAR} was . . .
PROBE: Income is important in analyzing the health information we collect. For example, this information helps us to learn whether persons in one income group use certain types of medical services or have certain conditions more or less often than those in another group.
$20,000 or more, or 1
less than $20,000? 2
REFUSED 7 (END OF SECTION)
DON'T KNOW 9 (END OF SECTION)
INQ.270 |
Of these income groups, can you tell me which letter best represents your total household income in {LAST CALENDAR YEAR}? |
HAND CARD {INQ2 AND INQ3}
ENTER LETTER(S) CORRESPONDING TO TOTAL COMBINED HOUSEHOLD INCOME.
|___|___|
A B C D E F G H |
I J K L M N O P |
Q R S T U V W X |
Y Z AA BB CC DD EE FF |
GG HH II JJ KK LL MM NN |
OO PP RR SS TT UU VV WW |
REFUSED 77
DON'T KNOW 99
CAPI INSTRUCTION:
IF $20,000 OR MORE, DISPLAY HAND CARD INQ2.
IF LESS THAN $20,000, DISPLAY HAND CARD INQ3.
nyfs MEC DATA COLLECTION FORMS
NYFS EXAMINATION DATA COLLECTION FORMS
Anthropometry
Dietary Interview
Endurance Performance—Treadmill
General Exclusion Questions
Lower Body Muscle Strength
MEC Interview Private Questions for 12-15 Year Olds
Modified pull-up
Physical Activity Monitor
Plank
Test of Gross Motor Development (TGMD)
Upper Body Muscle Strength
*No data collection forms for physical activity monitor
ANTHROPOMETRY NYFS (Ages 3-15)
AMPUTATION QUESTIONS: Information is recorded during the body measurement examination for all ages. Questions may be asked if the information is not obvious to the examiner. The responses are used to interpret body measurement results, particularly the body weight data.
Are there any amputations? Recorder codes YES/NO IF YES to the amputation question, continue with information on the site(s) of the amputation(s):
Target Age Groups: Anthropometry Measurements and Questions
4-7 years |
8-15 years |
Weight |
Weight |
Standing height |
Standing height
|
Upper arm length |
Upper arm length
|
Mid-upper arm circumference
|
Mid-upper arm circumference
|
Waist circumference
|
Waist circumference |
|
Upper leg length |
Triceps, medial calf and subscapular skinfolds |
Triceps, medial calf and subscapular skinfolds |
Would you like to know your height and weight? |
Would you like to know your height and weight? |
DIETARY INTERVIEW (3-15)
24-Hour Dietary Recall Interview
Information will be obtained on all foods and beverages that were consumed during a 24-hour time period (midnight to midnight). The information that is obtained for foods and beverages includes the following:
Time of day -Time when the food was eaten
Meal name code - The name of the eating occasion is selected from a list of options.
Meal place - Whether the meal was eaten at home.
Food item name - The name of the food is either typed in or selected from a list of food item names.
Food item description - Detailed description of the food including information about commercial product name (if applicable), preparation method, and major recipe ingredients.
Fat added in preparation - A preparation fat probe is asked for certain foods. The type of fat used during food preparation is specified as well.
Amount of food eaten - The amount of food consumed by the respondent.
Food source - The place where the food was obtained is selected from a list of options
24-Hour Dietary Recall Interview Scripts - In-Person Interview:
A. Introduction script
First, we’ll make a list of the foods you/SP ate and drank yesterday, Monday. It may help you remember what you/SP ate by thinking about where you/he/she were, who you/he/she were with, or what you/he/she were doing, like working, eating out, or watching television.
Please tell me everything you/SP had to eat and drink all day yesterday, Monday, from midnight to midnight. Include everything you/he/she had at home and away, even snacks, coffee, soft drinks, water, and alcoholic beverages. I’ll ask you for specific details and amounts of the foods in a few minutes. At this time, just tell me what you/SP had.
B. Forgotten food probes script
Your answers are important, so we’d like this list to be as complete as possible.
In addition to the foods you have/SP has already told me about, did you have any coffee, tea, soft drinks, milk or juice?
Beer, m, cocktails or other drinks?
Cookies, candy, ice cream or other sweets?
Chips, crackers, popcorn, pretzels, nuts, or other snack foods?
Fruits, vegetables, or cheese?
Bread, rolls or tortillas?
Anything else?
C. Food detail probes script
Now we’re going to fill in your list with more detail. When I ask how much {you/SP} ate, you can tell me the amount by using the models on the table and in the racks.
You may use the grid for rectangular or square shapes and the circles for circular or round shapes. Use the wedge for wedge shaped foods.
You can use the thickness bars to show me the thickness of a food and the bean bags and mounds to describe the amounts of solid foods.
When you use the cups, bowls, and glasses, please show me which line best describes the portion {you/SP/he/she} ate or drank. When you use any of the spoons, please tell me the quantity in LEVEL spoonfuls.
Post-dietary Recall Questions
REC.155 Was the amount of food that {you/NAME} ate yesterday much more than usual, usual, or much less than usual?
MUCH MORE THAN USUAL 1
USUAL 2
MUCH LESS THAN USUAL 3
REFUSED 7
DON’T KNOW 9
REC.265 When you drink tap water, what is the main source of the tap water? Is the city water supply (community water supply); a well or rain cistern; a spring; or something else?
COMMUNITY WATER 1
A WELL OR RAIN CISTERN 2
A SPRING 3
NEVER DRINK TAP WATER 4
REFUSED 7
DON’T KNOW 9
OTHER (SPECIFY) 91
[RECORD Drinking fountain AS COMMUNITY WATER SUPPLY.]
REC.325 Now I'll be asking some questions about {your/NAME's} use of table salt.
What type of salt {do you/does NAME} usually add to {your/his/her} food at the table? Would you say it is ordinary or seasoned salt, lite salt, or a salt substitute?
ORDINARY, SEA, SEASONED, OR OTHER FLAVORED SALT
[includes regular iodized salt,
sea salt and seasoning salts
made with regular salt] 1
LITE SALT 2
SALT SUBSTITUTE 3
NONE 4 (REC.335)
REFUSED 7 (REC.335)
DON'T KNOW 9 (REC.335)
REC.330 How often {do you/does NAME} add {REC325 ANSWER} to {your/his/her} food at the table? Is it rarely, occasionally, or very often?
RARELY, 1
OCCASIONALLY 2
VERY OFTEN 3
REFUSED 7
DON'T KNOW 9
REC.335 How often is ordinary salt or seasoned salt added in cooking or preparing foods in your household? Is it never, rarely, occasionally, or very often?
NEVER 1
RARELY 2
OCCASIONALLY 3
VERY OFTEN 4
REFUSED 7
DON'T KNOW 9
[THIS QUESTION APPLIES ONLY TO USE OF ORDINARY SALT OR SEASONED SALT AND NOT TO LITE SALT OR SALT SUBSTITUTES.]
REC.340 {Are you/Is NAME} currently on any kind of diet, either to lose weight or for some other health-related reason?
YES 1
NO 2 (Box 1)
REFUSED 7 (Box 1)
DON’T KNOW 9 (Box 1)
REC.345 What kind of diet {are you/is NAME} on?
[READ AS NEEDED: Is it a weight loss or low calorie diet; low fat or cholesterol diet; low salt or sodium diet; diabetic diet; or another type of diet?]
WEIGHT LOSS OR LOW CALORIE DIET 1
LOW FAT OR CHOLESTEROL DIET 2
LOW SALT OR SODIUM DIET 3
SUGAR FREE OR LOW SUGAR DIET 4
LOW FIBER DIET 5
HIGH FIBER DIET 6
DIABETIC DIET 7
LOW CARBOHYDRATE DIET 8
HIGH PROTEIN DIET 9
WEIGHT GAIN DIET 10
OTHER 91
(SPECIFY) ___________
REFUSED 77
DON’T KNOW 99
24-Hour Dietary Supplements Recall Interview
Information will be obtained on all vitamins, minerals, herbals and other dietary supplements that were consumed during a 24-hour time period (midnight to midnight). The information that is obtained for dietary supplements includes the following:
Verifying that dietary supplement(s) reported during the Dietary Supplement Section in the Household Interview was also taken during the 24-Hour time period. – Dietary supplement information is collected during the SP Household Interview. The interviewer will first ask if the supplements reported during the Household Interview were also taken during the 24-Hour time period.
Dietary supplement Name – The name of any new/additional dietary supplements are typed and selected from a list of dietary supplement names.
Amount of dietary supplement taken – The amount of dietary supplement consumed by the respondent during the 24-Hour time period.
24-Hour Dietary Supplement Recall Interview Scripts – In-Person Interview:
Script for respondents that reported taking a dietary supplement or antacid during the Dietary Supplements Section in the Household Interview:
The next questions are about {your/SPs} use of dietary supplements, vitamins, minerals and herbals all day yesterday, {day}, between midnight and midnight. This includes prescription and over the counter dietary supplements.
During the interview in your home {you/SP reported taking} {supplement}.
Did {you/SP} take this supplement yesterday {day}. (between midnight and midnight)?
Was {supplement} a {form}?
You said {you/SP} took ___, is that correct? Was that a liquid or powder?
Between midnight and midnight, how much did {you/SP} take?
It was also reported {you/SP} took {supplement}.
All day yesterday, {day}, between midnight and midnight, did {you/SP} take any other vitamins, minerals, herbals or other dietary supplements? Include any prescription and over the counter dietary supplements.
What is the name of the supplement {you/SP} took?
Between midnight and midnight, how much did {you/SP} take?
Any others?
The next questions are about {your/SPs} use of non-prescription antacids.
During the interview in your home {you/SP reported taking} {antacid}.
Did {you/SP} take this antacid yesterday (between midnight and midnight )?
Between midnight and midnight how much did {you/SP} take?
It was also reported {you/SP} took {antacid}.
All day yesterday, {day}, between midnight and midnight did {you/SP} take any other antacids?
What is the name of the antacid {you/SP} took?
Between midnight and midnight how much did {you/SP} take?
Any others?
Script for respondents that did not report taking a dietary supplement or antacid during the Dietary Supplement Section in the Household Interview:
The next questions are about {your/SPs} use of dietary supplements, including prescription and over the counter supplements. All day yesterday, {day}, between midnight and midnight did {you/SP} take any vitamins, minerals, herbals or other dietary supplements?
What is the name of the supplement {you/SP} took?
Between midnight and midnight how much did {you/SP} take?
Any others?
The next questions are about {your/SPs} use of non-prescription antacids All day yesterday, {day}, between midnight and midnight did {you/SP} take any antacids?
What is the name of the antacid {you/SP} took?
Between midnight and midnight how much did {you/SP} take?
Any others?
ENDURANCE PERFORMANCE—TREADMILL (AGES 6-15)
Test protocol (ages 6-11)
Each participant will perform to volitional fatigue. The protocol involves maintaining a fairly constant speed with an increase in incline by 2.5% at 2 minute stages. The main goals of the protocol are: 1) the child will be able to perform the test for 5-12 minutes, and 2) the maximum incline will not exceed 12%. To ensure that most children will be able to perform the test, the protocol will start slowly with walking and then increase in speed at the later stages for very fit children. After a 2 minute warm-up walk, 6-7 year old children will walk at an average speed of 2.75 mph with an increasing incline; 8-9 year old children will walk at an average speed of 3.25 mph, increase to a run of 4.5 mph at the last two stages, with an increasing incline; and 10-11 year old children will walk at an average speed of 3.5 mph, increase to a run of 5.0 mph at the last two stages, with an increasing incline. The protocol includes 7-8 stages as well as warm up and recovery/cool down stages. Children are not expected to be able to complete all stages.
Data collected: Heart rate (before the test and at the end of each stage), treadmill speed and grade, total duration on the treadmill, reasons why participant stopped exercising
ENDURANCE PERFORMANCE—TREADMILL (AGES 6-15) continued
Test protocol (ages 12-15)
The speed and grade for participants 12-15 will be identical to those in the NHANES cardiovascular fitness component from 1999-2006 and based on age, gender, BMI and self reported physical activity level. There will be 4 stages: warm up, stage 1, stage 2 and cool down.
Data collected: Heart rate (before the test and at the end of each stage), treadmill speed and grade, reasons why participant stopped exercising and perceived exertion level during each stage.
Exclusion Criteria (AGES 3-15)
All exclusion questions will be asked of the parent/guardian at the check-in to the examination center to identify children who cannot participate in survey components. Pregnant girls will be excluded from the health examination. All other children will be able to participate in the dietary recall interview.
Exclusion criteria |
Exclusions |
1. Parents/guardians of girls ages 8-11 years who are menstruating and all girls 12-15 years will be asked: Is your child pregnant?
Parents/guardians of girls 8-11 years will be asked in the household interview if the participant had started menstruating, and if yes, when she began.
|
Pregnant girls will be excluded from all examination center components. |
2. Is the participant in a wheelchair (observation only)?
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If Yes, exclude from the treadmill, lower body muscle strength, modified pull-up, plank, and gross motor skills components.
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3. Has a doctor ever said your child should not participate in sports or other activities because of a health condition?
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If Yes, Refused, or Don’t Know, exclude from the treadmill, lower body muscle strength, grip strength, modified pull-up, plank, and gross motor skills components.
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4. Has a doctor ever said that your child should only do sports or other physical recommended by a doctor?
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If Yes, Refused, or Don’t Know, exclude from the treadmill, lower body muscle strength, grip strength, modified pull-up, plank, and gross motor skills components.
|
5. Have any of your child’s close biological relatives, that is, blood relatives including grandparents, father, mother, sisters or brothers, died of heart problems or sudden death before the age of 35?
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If Yes, Refused, or Don’t Know, exclude from the treadmill component. |
6. Does your child have any amputations other than toes? If Yes, where is the amputation? |
If Yes, Refused, or Don’t Know, exclude from modified pull-up, plank, and gross motor skills components.
If yes and the amputation is of a leg or foot, exclude from the treadmill component.
If yes and both legs or feet have been amputated, exclude from the lower body muscle strength component.
If yes and both arms, hands, or thumbs have been amputated, exclude from the grip strength component.
If yes and both arms have been amputated, exclude from the physical activity monitor component.
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7. Does your child have a pacemaker or automatic defibrillator?
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If Yes, Refused, or Don’t Know, exclude from the treadmill component.
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8. Does your child lose {his/her} balance because of dizziness? |
If Yes, Refused, or Don’t Know, exclude from the treadmill component.
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9. Does your child ever lose consciousness? |
If Yes, Refused, or Don’t Know, exclude from the treadmill component.
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10. Has your child ever been told that {he/she} has exercise induced asthma?
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* See below. |
11. Since the interview in your home on {date of household interview}, is your child taking any additional prescription medications?
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** See below. |
12. Does your child have a bone or joint problem that could be made worse by walking? |
If Yes, Refused, or Don’t Know, exclude from the treadmill component.
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13. Do you know of any reason why your child should not walk or run on a treadmill? |
If Yes, Refused, or Don’t Know, exclude from the treadmill component.
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14. Has your child had any surgery on {his/her} hands, wrists, arms, or shoulders in the past three months?
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If Yes, Refused, or Don’t Know, exclude from the modified pull-up, plank, and gross motor skills components.
If Yes and surgery was conducted on both hands, both wrists, or both arms, exclude from the grip strength component.
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15. Does your child have any paralysis of the {his/her} hands, wrists, or arms?
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If Yes, Refused, or Don’t Know, exclude from modified pull-up, plank, and gross motor skills components.
If Yes and both hands, wrists, or arms are paralyzed, exclude from the grip strength component.
If Yes and both hands, wrists, or arms are paralyzed, exclude from the physical activity monitor component.
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16. We will be asking your child to pull {himself/herself} up off the ground using {his/her} arms and holding the position. Do you know of any reason why your child should not do this test?
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If Yes, Refused, or Don’t Know, exclude from the modified pull up and plank components
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17. We will be asking your child to push {his/her} legs as hard as {he/she} can against an object. Do you know of any reason why your child should not do this test?
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If Yes, Refused, or Don’t Know, exclude from the lower body muscle strength component
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18. Body weight of 500 pounds or greater as measured in the Body Measurements component. |
Exclude from the treadmill component. |
* If the answer to the question is ‘Yes,’ ‘Don’t Know,’ or ‘Refused,’ the nurse practitioner/physician’s assistant at the examination center will review the question with the parent/guardian to determine if the participant should be excluded from the treadmill test based on the response to the question. If the nurse practitioner/physician’s assistant determines that there is no indication for exclusion to the treadmill test, the child will be included in the test. Albuterol will be available in Emergency Supplies to treat exercised-induced asthma that may have been undiagnosed.
** The nurse practitioner/physician’s assistant will review the list of medications taken by the child with the parent/guardian to determine if the participant should be excluded from the treadmill test. If the nurse practitioner/physician’s assistant determines that there is no indication for exclusion to the treadmill test, the child will be included in the test. However, if the participant has exercised-induced asthma for which he/she regularly takes albuterol, but does not bring the inhaler to the examination, the participant will be excluded from the treadmill test. The list of exclusionary medications for the treadmill test is provided below.
Exclusionary Medications |
Class Codes (RXQ240C) |
Anti Arrhythmics Amiodarone (Cordarone) Bretylium (Bretylol) Disopyramide (Norpace) Encainide (Enkaid) Ethmozine (Moricizine) Flecanide (Tambocor) Lidocaine (Xylocaine, Xylocard) Mexiletine (Mexitil) Moricizine (Ethmozine) Posicor (Mibefradil) Procainamide (Pronestyl, Procan SR) Propafenone (Rhythmol) Quinidine (Quinora, Quinalan, Cardioquin, Quinidex, Quinaglute) Tocainide (Tonocard) |
350500, 351000, 352000, 353000, 354000, 355000 |
Beta Blockers Acebutolol (Sectral) Atenolol (Tenormin) Betagan Betaxolol (Kerlone) Bisoprolol (Zebeta) Carteolol (Cartrol) Carvedilol (Coreg) Esmolol (Brevibloc) Labetalol (Normodyne) Levobunolol Metoprolol Succinate (Toprol-XL) Metoprolol Tartrate (Lopressor) Nadolol (Corgard) Oxprenolol (Trasicor, Slow Trasicor) Penbutolol (Levatol) Pindolol (Visken) Propranolol (Inderal) Sotolol (Betapace) Timolol (Blocadren) Trandate |
331000, 332000, 333000
|
Beta Blockers/Diuretic Combinations Corzide Inderide Lopressor Hydrochlorothiazide Tenorectic Timolide Ziac |
369920 |
Digitalis Digoxin (Lanoxin) |
312000 |
Eye Drops/ Beta Blockers Betagen Eye Drops Betoptic Eye Drops Levobunolol Eye Drops Metipranolol (Optipranolol) Timoptic Eye Drops |
862500, 862599 |
Nitrates and Nitroglycerin Isosorbide Dinitrate (Isordil, Diltrate) Isosorbide Mononitrate (Ismo, Monoket) Nitroglycerin, Translingual (Nitrostat, Nitrolingual Spray) Nitroglycerin, Transmucosal (Nitrogard) Nitroglycerin, Topical (Nitrol, Nitro-Bid, Transderm Nitro, Nitro-Dur II, Nitrodisc, Minitran, Deponit, Nitroderm) Nitroglycerin, Sustained Release (Nitrong, Nitrocine, Nitroglyn) Pentaerythritol Tetranitrate (Cardilate) |
321000 |
LOWER BODY MUSCLE STRENGTH- QUADRICEPS/HAMSTRINGS (AGES 6-15)
One exclusion question specific to the lower body muscle strength (asked of parents or guardians of children):
In this test, we will be asking your child to push {his/her} legs as hard as {he/she} can against an object. Do you know of any reason why your child should not do the test?
1 Yes (EXCLUDE FROM EXAM)
2 No
3 REFUSED (EXCLUDE FROM EXAM)
4 DON'T KNOW (EXCLUDE FROM EXAM)
IF YES, SPECIFY REASON ________________
Test protocol
Children will be tested in a sitting position. Maximum isometric knee extension will be measured using a hand held dynamometer (HHD). The knee will be positioned in approximately 90 degrees of flexion and the dynamometer placed just below the shoe top on the shin. The participant’s hips and thigh will be secured to the chair with straps. The participant presses into the HHD slightly to stabilize the device. Participants will then be asked to take 1 or 2 seconds to come to maximum effort, during which they are to push as hard as possible into the HHD. The counterforce to the knee extension force is supplied by a strap with stabilization by a staff person through the HHD. Participants will be given encouragement and asked to stop after 4 to 5 seconds. Participants will be given three tests of each lower extremity.
Data collected: Peak force in pounds/kilograms.
M
NHANES NYFS
TOBACCO – SMQ
Target Group: SPs 12-15
The following questions are about cigarette smoking.
SMQ.621 About how many cigarettes have you smoked in your entire life?
Please check box by answer . . .
I have never smoked, not even a puff 1 ☐ Go to PAGE 2
1 or more puffs but never a whole cigarette 2 ☐ Go to PAGE 2
1 cigarette 3 ☐
2 to 5 cigarettes 4 ☐
6 to 15 cigarettes 5 ☐
16 to 25 cigarettes 6 ☐
26 to 99 cigarettes 7 ☐
100 or more cigarettes 8 ☐
I refuse to answer 77 ☐ Go to PAGE 2
I don’t know 99 ☐ Go to PAGE 2
SMQ.631 How old were you when you smoked a whole cigarette for the first time?
SMQ.631a
Please write zero for never smoked a whole cigarette.
|___|___|
ENTER AGE
I refuse to answer 77 ☐
I don’t know 99 ☐
SMQ.640 During the past 30 days, on how many days did you smoke cigarettes?
Please enter a number or enter zero for none.
|___|___|
ENTER NUMBER OF DAYS
I refuse to answer 77 ☐
I don’t know 99 ☐
A
NHANES NYFS
Target Group: SPs 12-15
The following questions ask about alcohol use. This includes beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. This does not include drinking a few sips of wine for religious purposes.
ALQ.010 How old were you when you had your first drink of alcohol, other than a few sips?
Please select one of the following choices.
I have never had a drink of alcohol other
than a few sips 1
☐ Go to PAGE 3
8 years old or younger 2 ☐
9 or 10 years old 3 ☐
11 or 12 years old 4 ☐
13 or 14 years old 5 ☐
15 or 16 years old 6 ☐
17 years old or older 7 ☐
I refuse to answer 77 ☐ Go to PAGE 3
I don’t know 99 ☐ Go to PAGE 3
ALQ.031 During the past 30 days, on how many days did you have at least one drink of alcohol?
Please select one of the following choices.
0 days 1 ☐
1 or 2 days 2 ☐
3 to 5 days 3 ☐
6 to 9 days 4 ☐
10 to 19 days 5 ☐
20 to 29 days 6 ☐
All 30 days 7 ☐
I refuse to answer 77 ☐
I don’t know 99 ☐
D
NHANES NYFS
Target Group: SPs 12-15
The following questions ask about use of drugs not prescribed by a doctor. Please remember that your answers to these questions are strictly confidential.
DUQ.200 The first questions are about marijuana and hashish. Marijuana is also called pot or grass. Marijuana is usually smoked, either in cigarettes, called joints, or in a pipe. It is sometimes cooked in food. Hashish is a form of marijuana that is also called “hash.” It is usually smoked in a pipe. Another form of hashish is hash oil.
Have you ever, even once, used marijuana or hashish?
Please select . . .
Yes 1 ☐
No 2 ☐ You are finished questions
I refuse to answer 7 ☐ You are finished questions
I don’t know 9 ☐ You are finished questions
DUQ.230 During the past 30 days, on how many days did you use marijuana or hashish?
Please enter a number.
|___|___|
ENTER A NUMBER
I refuse to answer 77 ☐
I don’t know 99 ☐
MODIFIED PULL UP (AGES 5-15 YEARS)
One exclusion question specific to the modified pull-up (asked of parents or guardians of children)
In this test, we will be asking your child to pull {himself/herself} up off the ground using their arms and holding the position. Do you know of any reason why your child should not do the test?
1 Yes (EXCLUDE FROM EXAM)
2 No
3 REFUSED (EXCLUDE FROM EXAM)
4 DON'T KNOW (EXCLUDE FROM EXAM)
IF YES, SPECIFY REASON ________________
Test protocol
With the participant lying on his/her back on a flat surface, the horizontal bar should be positioned about 1-2 inches above the participant’s outstretched arms. The participant is asked to clasp the horizontal bar with an overhand grasp, palms facing away from the body. When the participant is ready, the examiner gives the signal "Go." On hearing the signal "Go," the participant raises his/her body by flexing the arm until the chest touches an elastic band or plate that hangs 8 inches down from the horizontal bar. The body should be kept straight with the hips up and only the heels touching. Then the participant lowers back to the starting position. This procedure should be repeated as many times as possible. The test will stop when the participant pauses for two or more seconds.
Data collected: Number of pull-ups completed
PLANK (AGES 3-15 YEARS)
Test protocol
Participants will be tested with the front plank. For this exercise, the participant lies face down on a mat resting on the forearms with palms on the floor. Then the participant pushes off the floor, raising up onto toes and resting on the elbows. The back is kept straight without the stomach dropping or the hips rising up.
Participants should maintain the position for as long as possible. Participants will be able to self-select when they want to stop the test; no undue stress or pressure will be placed on the participant. The test ends when a straight back can no longer be maintained and the hips drop toward the floor, or the participant requests to stop.
Data collected: number of seconds the plank position is held
TOTAL GROSS MOTOR DEVELOPMENT (AGES 3-5 YEARS)
Test protocol
The Test of Gross Motor Development – Second Edition (TGMD-2) will be used for the motor skills test. The TGMD-2 is a norm-referenced measure of common gross motor skills that develop early in life. The TGMD-2 is made up of 12 skills (six for each subtest):
Locomotor: run, gallop, hop, leap, horizontal jump, slide
Object Control: striking a stationary ball, stationary dribble, kick, catch, overhand throw, and underhand roll
Data Collected: Each gross motor skill includes several behavioral components which are presented as performance criteria. For example, performance criteria for the run skill are 1) arms move in opposition to legs, elbows bent, 2) brief period where both feet are off the ground, 3) narrow foot placement landing on heel or toe (i.e., not flat-footed), and 4) nonsupport leg bent approximately 90 degrees (i.e., close to buttocks). If the child performs a behavioral component correctly, DHANES staff will record a 1, if the child does not perform a behavioral component correctly, the staff will record a 0. A partial score, such as 0.5 to show that the child displays the criterion, but is inconsistent, is not allowed.
After recording the result for each of the two trials, staff will total the scores of the two trials to obtain a raw skill set score for each behavioral component. The skill scores add up to a raw subtest score (Locomotor, Object control), which is converted to a standard score using a table in the TGMD-2 Examiner’s Manual. Then these standard scores are combined and converted to an overall Gross Motor Quotient.
UPPER BODY MUSCLE STRENGTH (Age 6-15 years)
I. Pre-Test Questions:
Participants are excluded from this component if they are unable to hold the dynamometer with both hands (e.g., missing both arms, hands, or thumbs on both hands, or paralysis of both hands). Participants who are able to grip the dynamometer with one hand will still perform the component. Participants who had surgery on either hand or wrist in the last three months will not be tested on that particular hand.
The following pre-test questions are asked about the hand or hands that are eligible for the Grip Test.
MGQ.050 Have you ever had surgery on your hands or wrists for arthritis or carpal tunnel syndrome? If Yes,which hand.
MGQ.070 Have you had any pain, aching or stiffness in your right hand in the past 7 days? If Yes ask the next two questions.
MGQ.080 Is the pain, aching or stiffness in your right hand caused by arthritis, tendonitis, or carpal tunnel syndrome?
MGQ.090 Has the pain, aching or stiffness in your right hand gotten worse in the past 7 days?
MGQ.100 Have you had any pain, aching or stiffness in your left hand in the past 7 days? If Yes ask the next two questions.
MGQ.110 Is the pain, aching or stiffness in your left hand caused by arthritis, tendonitis, or carpal tunnel syndrome?
MGQ.120 Has the pain, aching or stiffness in your left hand gotten worse in the past 7 days?
MGQ.130 Are you right-handed, left-handed, or do you use both hands equally?
II. Grip Test:
Three data points per hand are captured and the results are recorded in kilograms (kg) to one digit after the decimal point.
Right hand grip strength (readings 1, 2, and 3) kg
Left hand grip strength (readings 1, 2, and 3) kg
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SAMPLE PERSON QUESTIONNAIRE |
| Author | bvw4 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |