Form approved
OMB No. 0920-0214
Approval Expires 08/31/2014
2013 National Health Interview Survey Follow-Back Survey on the
Affordable Care Act
Web and CATI Instrument Specifications*
Sponsored by the National Center for Health Statistics,
Centers for Disease Control and Prevention
Conducted by the United States Census Bureau
Questionnaire Version (5.4): October 22, 2012
SECTION 1: LOCATE ELIGIBLE 2012 NHIS SAMPLE ADULT RESPONDENT…………….
SECTION 2: CONFIRM IDENTITY OF ELIGIBLE RESPONDENT…………………………...
SECTION 3: INFORMED CONSENT………………….................................................................
SECTION 4: FINANCIAL BURDEN OF MEDICAL CARE……..................................................
SECTION 5: HEALTH STATUS…………………………………….............................................
SECTION 6: ACCESS & UTILIZATION OF HEALTH CARE.....................................................
SECTION 7: HEALTH INSURANCE.............................................................................................
SECTION 8: PREVENTIVE SERVICES........................................................................................
SECTION 9: FAMILY FOOD SECURITY…….............................................................................
SECTION 10: SMOKING..................................................................................................................
SECTION 11: MARITAL & EMPLOYMENT STATUS…..............................................................
SECTION 12: CONTACT INFORMATION.....................................................................................
CALLBACK & ANSWERING MACHINE SCRIPTS.......................................................................
The following public burden estimate statement must available as a CATI and Web screen.
Assurance of Confidentiality (NOTICE): Information contained on this form which would permit identification of any individual or establishment has been collected with a guarantee that it will be held in strict confidence, will be used only for purposes stated for this study, and will not be disclosed or released to others 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 (44 USC 3501 note).
Congress authorized the NHIS data collection in Section 306 of the Public Health Service Act (42 USC 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act (PL 107-347). If any federal employee, contractor, or agent gives out confidential information no authorized by law, he or she can be fired, fined and/or imprisoned.
Public reporting burden of this collection of information is estimated to average about 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports, Clearance Officer; Paperwork Reduction Project (0920-0214), 1600 Clifton Rd., MS D-74, Atlanta, GA 30333.
Data collection conducted under contract to the CDC by the United States Census Bureau.
TEXT FORMAT KEY
Yellow highlighted text: Help screen text
Blue highlighted text: Update or pre-fill with pertinent variable name, information, or data from the 2012 NHIS.
[TEXT IN ALL CAPS & BRACKETS]: Programmer instructions for the 2013 Follow-Back Survey, or text fills.
Text in Italics Information or examples that telephone interviewers need to read to 2013 Follow-Back CATI respondents. For web respondents, this text will appear on the screen to read him/herself.
TEXT IN ALL CAPS & ITALICS: Instructions to interviewers or response options that should not be read, only selected if applicable
PRELOADED DATA FROM 2012 NHIS VARIABLES TO USE IN THE 2013 FOLLOW-BACK SURVEY:
2012 NHIS VARIABLE NAME |
2012 NHIS VARIABLE NAME DESCRIPTION |
VARIABLE TYPE |
# OF CHARACTERS |
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Interview month |
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Interview year |
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Sample adult name (F, M, L) |
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Sample adult age and DOB |
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Sample adult sex |
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Household roster (names, DOB, sex) |
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SECTION 1:
Locate Eligible 2012 NHIS Sample Adult Respondent
[IF THIS IS AN interviewer-initiated first call or follow-up call without an appointment, go to INTRO_A;
IF THIS IS an Interviewer-initiated follow-up call with appointment, Go to INTRO_B;
If this is a Respondent-initiated call to toll-free number in response to advance mailing, email or voice mail, go to INTRO_C]
Scenario A: Interviewer-initiated first call or follow-up call without appointment
INTRO_A If AT ANY TIME the person who picks up the phone asks why we’re looking for the person with at name or those characteristics, respond with: “We’re conducting a survey on health care cost and utilization among people who share the same or similar characteristics, such as age or gender.”
Do not, under any circumstances, indicate in any way that someone in that household, including the SA, previously participated in the NHIS.
Hello, my name is _________________. I’m calling on behalf of the CDC's National Center for Health Statistics or N-C-H-S.
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS, GENDER, AND AGE ARE KNOWN: “May I please speak to the [FEMALE/MALE] whose [name is/initials are] _____ and who is about [ESTIMATED AGE] years old?”]
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS AND AGE ARE KNOWN: “May I please speak to the person whose [name is/initials are] _____ and who is about [ESTIMATED AGE] years old?”]
[IF ONLY THE 2012 SAMPLE ADULT’S NAME OR INITIALS ARE KNOWN: “May I please speak to [NAME/“a person whose initials are ____"]?”]
[IF ONLY THE 2012 SAMPLE ADULT’S GENDER AND AGE ARE KNOWN: “May I please speak to the [MALE/FEMALE] adult who is about [ESTIMATED AGE] years old?”]
[IF ONLY GENDER IS KNOWN: “How many [MALES/FEMALES] live in your household?” IF ONLY ONE PERSON OF THE SAMPLE ADULT GENDER, SAY: “May I please speak to [HIM/HER]?”]
[IF ONLY AGE IS KNOWN: “Does someone live in your household who is about [ESTIMATED AGE] years old?” IF YES, SAY: “Is there anyone else of that age in your household?” IF ONLY ONE PERSON OF APPROXIMATE SAMPLE ADULT AGE, SAY: “May I please speak to the person who is about [ESTIMATED AGE] years old?”]
1 I am that person
Skip Instructions: go to [PHONE]
2 Yes, let me get him or her
Skip Instructions: go to [INTRO_A]
3 Let me go get an adult
Skip Instructions: go to [INTRO_A]
4 No, that person has moved or has a new phone number
Skip Instructions: go to [LOC_A]
5 No, that person has died
Skip Instructions: go to [DECEASED]
6 AM/VM indicates business
Skip Instructions: go to [SALZ_BUS]
7 HUDI (HANG UP DURING INTRODUCTION)
8 Respondent wants a copy of the advance letter mailed
Skip Instructions: go to [M1_NAME]
9 Respondent says they will call toll-free line after reviewing the survey website or advance letter
Skip Instructions: go to [EXIT]
10 Respondent says to call back at a later time
Skip Instructions: go to [CALBK]
11 Respondent indicates this is a business line
Skip Instructions: go to [SALZ_BUS]
97 REFUSED
Skip Instructions: go to [UNKNOWN]
99 Don’t know
Skip Instructions: go to [UNKNOWN]
Scenario B: Interviewer-initiated follow-up call with appointment
INTRO_B If AT ANY TIME the person who picks up the phone asks why we’re looking for the person with at name or those characteristics, respond with: “We’re conducting a survey on health care cost and utilization among people who share the same or similar characteristics, such as age or gender.”
Do not, under any circumstances, indicate in any way that someone in that household, including the SA, previously participated in the NHIS.
Hello, my name is _________________. I’m calling on behalf of the CDC's National Center for Health Statistics. We spoke with someone at this phone number earlier [TODAY/THIS WEEK/THIS MONTH] who asked us to call back at this time.
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS, GENDER, AND AGE ARE KNOWN: “Is the [FEMALE/MALE] whose [name is/initials are] ______, and who is about [ESTIMATED AGE] years old available?”]
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS AND AGE ARE KNOWN: “Is the person whose [name is/initials are] ______ and who is about [ESTIMATED AGE] years old available?”]
[IF ONLY THE 2012 SAMPLE ADULT’S NAME OR INITIALS ARE KNOWN: “Is [NAME/a person whose initials are ______] available?”]
[IF ONLY THE 2012 SAMPLE ADULT’S GENDER AND AGE ARE KNOWN: “Is the [MALE/FEMALE] adult who is about [ESTIMATED AGE] years old available?”]
[IF ONLY AGE IS KNOWN: “Is an adult who is about [ESTIMATED AGE] years old available?”]
[IF GENDER IS KNOWN: “Is a [MALE/FEMALE] adult available?”]
[IF NO INFORMATION IS KNOWN: “Is the person I previously spoke to available?”]
1 I am that person
Skip Instructions: go to [PHONE]
2 Yes, let me get him or her
Skip Instructions: go to [INTRO_A]
3 Let me go get an adult
Skip Instructions: go to [INTRO_A]
4 No, that person has moved or has a new phone number
Skip Instructions: go to [LOC_A]
5 No, that person has died
Skip Instructions: go to [DECEASED]
6 AM/VM indicates business
Skip Instructions: go to [SALZ_BUS]
7 HUDI (HANG UP DURING INTRODUCTION)
8 Respondent wants a copy of the advance letter mailed
Skip Instructions: go to [M1_NAME]
9 Respondent says they will call toll-free line after reviewing the survey website or advance letter
Skip Instructions: go to [EXIT]
10 Respondent says to call back at a later time
Skip Instructions: go to [CALBK]
11 Respondent indicates this is a business line
Skip Instructions: go to [SALZ_BUS]
97 REFUSED
Skip Instructions: go to [UNKNOWN]
99 Don’t know
Skip Instructions: go to [UNKNOWN]
Scenario C: Respondent-initiated call to toll-free number in response to advance mailing, email or voice mail
ANSWER_C ANSWER the phone and say the following or similar:
Hello, this is the call center for the CDC's National Center for Health Statistics.my name is _________________. How may I assist you?
After respondent indicates he or she is calling about the Follow-Back Survey, say:
Thank you for your interest in the survey and for taking the time to call us to participate. Let me first collect some basic information from you.
FNAME_C What is your first name?
____________________ENTER NAME
97 REFUSED
99 DON’T KNOW
MNAME_C What is your middle name or initial?
____________________ENTER MIDDLE NAME OR INITIAL
97 REFUSED
99 DON’T KNOW
LNAME_C What is your last name?
____________________ ENTER LAST NAME
97 REFUSED
99 DON’T KNOW
TITLE_C What is your title?
____________________ ENTER TITLE
97 REFUSED
99 DON’T KNOW
DOB_C What is your date of birth?
[IF MONTH_C OR DAY_C OR YEAR_C IN (97, 99, 997, 9999):
It is critical that we know your [MONTH/DAY/YEAR] of birth.
MONTH_C ENTER MONTH
__ [VALID RANGE: 1 THROUGH 12]
97 REFUSED
99 DON’T KNOW
[ADD RANGE CHECK]
DAY_C ENTER DAY
__ [VALID RANGE: 1 THROUGH 31]
97 REFUSED
99 DON’T KNOW
[ADD RANGE CHECK; ALLOW FOR EXTRA DAY IN LEAP YEARS]
YEAR_C ENTER YEAR
____ [VALID RANGE: 1900 THROUGH 2000]
9997 REFUSED
9999 DON’T KNOW
[ADD RANGE CHECK]
AGE_YR What is your age?
___ ENTER AGE [VALID RANGE: 018 THROUGH 125]
997 REFUSED
999 DON’T KNOW
[ADD RANGE CHECK]
SEX_C Are you male or female?
1 Male
2 Female
7 REFUSED
9 Don’t know
ROSTER_C [COMPUTER DISPLAYS HOUSEHOLD ROSTER FROM 2012 NHIS;
INCLUDE names, aliases, gender, age, DOB FOR ALL HH MEMBERS;
Offset SAMPLE ADULT INFORMATION AT TOP OF LIST, in all caps]
Compare Respondent information to household roster
Respondent demographics match up with those of the SA
Skip Instructions: go to [V0]
Demographics match up with someone else in the SA’s household
Skip Instructions: go to [INTRO_C]
Demographics do not match up with anyone in the household
Skip Instructions: go to [IN_EXIT]
INTRO_C If AT ANY TIME the person who picks up the phone asks why we’re looking for the person with at name or those characteristics, respond with: “We’re conducting a survey on health care cost and utilization among people who share the same or similar characteristics, such as age or gender.”
Do not, under any circumstances, indicate in any way that someone in that household, including the SA, previously participated in the NHIS.
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS, GENDER, AND AGE ARE KNOWN: “We are looking for the [FEMALE/MALE] whose [name is/initials are] _____ and who is about [ESTIMATED AGE] years old.” Is [HE/SHE] available?]
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS AND AGE ARE KNOWN: “We are looking for the person whose [name is/initials are] _____ and who is about [ESTIMATED AGE] years old.” Is [HE/SHE] available?]
[IF THE 2012 SAMPLE ADULT’S NAME OR INITIALS ARE KNOWN: “We’re looking for [SAMPLE ADULT NAME]. Is that person available?]”
[IF ONLY THE 2012 SAMPLE ADULT’S GENDER AND AGE ARE KNOWN: “We’re looking for the [MALE/FEMALE] who is about [ESTIMATED AGE]. Is [HE/SHE] available?”]
[IF ONLY GENDER IS KNOWN AND SA GENDER IS DIFFERENT THAN RESPONDENT GENDER: “We are looking for the [MALE/FEMALE] adult who lives in your household? “Is [HE/SHE] available?”]
[IF ONLY GENDER IS KNOWN AND SA GENDER IS THE SAME AS RESPONDENT GENDER: “We are looking for the other [MALE/FEMALE] adult who lives in your household? “Is [HE/SHE] available?”]
[IF ONLY AGE IS KNOWN: “We’re looking for the adult who is about [ESTIMATED AGE] years old. Is that person available?”]
1 I am that person
Skip Instructions: go to [PHONE]
2 Yes, let me get him or her
Skip Instructions: go to [INTRO_A]
3 Let me go get an adult
Skip Instructions: go to [INTRO_A]
4 No, that person has moved or has a new phone number
Skip Instructions: go to [LOC_A]
5 No, that person has died
Skip Instructions: go to [DECEASED]
6 AM/VM indicates business
Skip Instructions: go to [SALZ_BUS]
7 HUDI (HANG UP DURING INTRODUCTION)
8 Respondent wants a copy of the advance letter mailed
Skip Instructions: go to [M1_NAME]
9 Respondent says they will call toll-free line after reviewing the survey website or advance letter
Skip Instructions: go to [EXIT]
10 Respondent says to call back at a later time
Skip Instructions: go to [CALBK]
11 Respondent indicates this is a business line
Skip Instructions: go to [SALZ_BUS]
97 REFUSED
Skip Instructions: go to [UNKNOWN]
99 Don’t know
Skip Instructions: go to [UNKNOWN]
PHONE Are you speaking on a landline or cell phone?
LANDLINE
CELL PHONE
7 REFUSED
9 DON’T KNOW
Skip Instructions: <1> go to [V0]; <2,7,9> go to [DRIVE]
DRIVE Are you currently driving a car or other motorized vehicle?
EVEN IF THE RESPONDENT IS USING A HANDS-FREE DEVICE WHILE DRIVING, YOU MUST END THE CALL
1 NO
2 YES
3 R PREFERS DIFFERENT NUMBER
4 WRONG TIME ZONE
Skip Instructions: <1> go to [V0]; <2, 3, 4> go to [CALBK]
CALBK I will call you back at another time. What day and time is convenient for you?
CB_DATE ENTER DAY
__ [VALID RANGE: 1 THROUGH 31]
97 REFUSED
99 DON’T KNOW
[ADD RANGE CHECK; ALLOW FOR EXTRA DAY IN LEAP YEARS]
ENTER MONTH
__ [VALID RANGE: 1 THROUGH 12]
97 REFUSED
99 DON’T KNOW
[ADD RANGE CHECK]
CB_TIME ENTER TIME
__:__ [FORMAT: HH:MM]
97 REFUSED
99 DON’T KNOW
CB_AMPM ENTER AM OR PM
AM
PM
7 refused
9 DON’T KNOW
NUMBER At which number would you like me to call you?
SAME NUMBER [PRE-LOAD NUMBER]
DIFFERENT NUMBER; __ RECORD [ADD LINE TO ALLOW RECORDING OF NEW NUMBER; FORMAT: XXX-XXX-XXXX]
7 refused
9 DON’T KNOW
CELL_TZ In what time zone are you located?
1 KEEP SAME TIME ZONE
2 ATLANTIC
3 EASTERN STANDARD
4 CENTRAL STANDARD
5 STANDARD MOUNTAIN
6 US STANDARD MOUNTAIN (ARIZONA)
7 PACIFIC STANDARD
8 ALASKAN STANDARD
9 HAWAIIAN STANDARD
97 REFUSED
99 DON’T KNOW
Skip Instructions: <1-99> go to [CB_EXIT]
SALZ_BUS We are interviewing only private residences. Thank you very much. [END CALL]
M1_NAME TO SEND A LETTER TO THE PERSON ANSWERING THE PHONE SAY:
In order to send you a letter, I will need to collect your name and mailing address. The letter will contain a toll-free number that you may call to complete the interview at your convenience.
READ IF NECESSARY: If you feel uncomfortable giving me your name, I can send the letter to "Resident".)
M1_NAME Name:
M1_Street1 Street1:
M1_Street2 Street2:
M1_City City:
M1_State State:
M1_Zip Zip:
1 Terminate the interview
7 refused
9 DON’T KNOW
Skip Instructions: <1-9> go to [EXIT]
LOC_A Do you know what their new telephone number is?
1 RESPONDENT CAN PROVIDE A NUMBER
2 NO TELEPHONE
7 refused
9 DON’T KNOW
Skip Instructions: <1> go to [LOC_AA]; <2-9> go to [LOC_F]
LOC_AA ENTER NUMBER
__ [FORMAT: XXX-XXX-XXXX]
97 DON’T KNOW
88 NONE
97 refused
99 DON’T KNOW
LOC_B Is that a landline or cell phone number?
LANDLINE
CELL
7 refused
9 DON’T KNOW
LOC_C Does this person have any other number where they might be reached?
1 YES
2 NO
7 refused
9 DON’T KNOW
Skip Instructions: <1> go to [LOC_D]; <2-9> go to [LOC_F]
LOC_D What is that telephone number?
__ ENTER NUMBER [FORMAT: XXX-XXX-XXXX]
88 NONE
97 REFUSED
99 DON’T KNOW
Skip Instructions: <97-99> go to [LOC_F]; else go to [LOC_E]
LOC_E Is that a landline or cellular telephone number?
1 LANDLINE
2 CELL
7 REFUSED
9 DON’T KNOW
LOC_F What is their name?
__ ENTER VERBATIM RESPONSE [ALLOW UP TO 50 CHARACTERS]
97 refused
99 DON’T KNOW
Skip Instructions: go to [LOC_EXIT]
UNKNOWN Do you know anyone who would be able to tell us how to get in contact with this person?
YES
2 NO
7 refused
9 DON’T KNOW
Skip Instructions: <1> go to [INFNAM]; <2-9> go to [EXIT]
INFNAM What is their name?
__ ENTER VERBATIM RESPONSE [ALLOW UP TO 50 CHARACTERS]
97 REFUSED
99 DON’T KNOW
Skip Instructions: <1-99> go to [INFNUM]
INFNUM What is [INFNAM/that person’s] number?
__ ENTER NUMBER [FORMAT: XXX-XXX-XXXX]
88 NONE
97 REFUSED
99 DON’T KNOW
Skip Instructions: <97-99> go to [LOC_EXIT]
EXIT Thank you for your time. Have a nice day.
CB_EXIT Thank you for your time. We look forward to speaking with you on [CB_DATE] at [CB_TIME] [CB_AMPM].
IN_EXIT Those are all the questions I have. You are not eligible for this survey. I’d like to thank you on behalf of the CDC’s National Center for Health Statistics for the time and effort you’ve spent answering these questions.
TERMINATE CALL
LOC_EXIT Thank you for providing this contact information. We will try to contact [HIM/HER]. Thanks for your time and have a nice day.
TERMINATE CALL THEN SET CALLING RULES TO
IMMEDIATELY DIAL THE NUMBER ENTERED AT LOC_AA
THEN TRY THE NUMBER ENTERED AT LOC_D IF LOC_AA IS NOT SUCCESSFUL
DECEASED I’m sorry to hear that. I do not need to continue. Thank you, and please accept my condolences. Goodbye. TERMINATE CALL
SECTION 2:
Confirm Identity of Eligible Respondent
[RESPONDENT SELF-ADMINISTERED WEB INSTRUMENT (RS-AWI) BEGINS HERE]
V0 Around [MONTH] of last year, did someone [Fill based on completion mode of 2012 NHIS: VISIT YOUR HOME AND CONDUCT THE NATIONAL HEALTH INTERVIEW SURVEY / CONDUCT THE NATIONAL HEALTH INTERVIEW SURVEY OVER THE TELEPHONE] with you?
YES
NO
7 [PHONE CATI: refused / RS-AWI: “Prefer not to answer”]
9 DON’T KNOW
Skip Instructions:
If PHONE CATI: [<1> and SA name is known] go to [VSANAME]; [<1> and ROSTER_C = <1>] go to [INTRO_IC]; else go to [FNAME_V]
If RS-AWI: go to [VSADOB]
VSANAME [DISPLAY PRELOADS AND ALLOW EDITING OF THE DATA IN EACH FIELD BELOW VSA_TITLE THROUGH VSA_SUFFIX AS NEEDED]
We want to make sure our records are correct. Is your name [PRE-LOADED TITLE, FIRST NAME, MIDDLE NAME/INITIAL, LAST NAME, SUFFIX]?
1 YES
2 NOT EXACTLY, MAKE CORRECTION [ALLOW EDITS TO PRE-LOADED FIELDS]
3 NO
7 [PHONE CATI: refused/RS-AWI: “Prefer not to answer”]
9 DON’T KNOW
VSA_TITLE Title: ^I_SATITLE
VSA_FNAME First Name: ^I_SAFNAME
VSA_MNAME Middle Name: ^I_SAMNAME
VSA_LNAME Last Name: ^I_SALNAME
VSA_SUFFX Suffix: ^I_SASUFFIX
Skip Instructions: <1,2, 7,9> go to [VSADOB]; <3> go to [FNAME_V]
VSADOB What is your date of birth?
[DISPLAY PRELOADS AND ALLOW EDITING OF THE DATA IN EACH FIELD BELOW VSAMO THROUGH VSAYR AS NEEDED]
9997 [PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
9999 DON’T KNOW
VSAMONTH Month: ^I_SAMONTH
VSADAY Day: ^I_SADAY
VSAYR Year: ^I_SAYEAR
Skip Instructions: go to SEX_C
FNAME_V What is your first name?
__ ENTER VERBATIM RESPONSE [ALLOW UP TO 50 CHARACTERS]
97 [PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
99 DON’T KNOW
MNAME_V What is your middle name or initial?
__ ENTER VERBATIM RESPONSE [ALLOW UP TO 50 CHARACTERS]
97 [PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
99 DON’T KNOW
LNAME_V What is your last name?
__ ENTER VERBATIM RESPONSE [ALLOW UP TO 50 CHARACTERS]
97 [PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
99 DON’T KNOW
TITLE_V What is your title?
__ ENTER VERBATIM RESPONSE [ALLOW UP TO 10 CHARACTERS]
97 [PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
99 DON’T KNOW
DOB_V What is your date of birth?
[IF MONTH_C OR DAY_C OR YEAR_C IN (97, 99, 997, 9999) ]
It is critical that we know your [MONTH/DAY/YEAR] of birth.
MONTH_V ENTER MONTH
__ [VALID RANGE: 1 THROUGH 12]
97 [PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
99 DON’T KNOW
[ADD RANGE CHECK]
DAY_V ENTER DAY
__ [VALID RANGE: 1 THROUGH 31]
97 [PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
99 DON’T KNOW
[ADD RANGE CHECK; ALLOW FOR EXTRA DAY IN LEAP YEARS]
YEAR_V ENTER YEAR
____ [VALID RANGE: 1900 THROUGH 2000]
9997 [PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
9999 DON’T KNOW
[ADD RANGE CHECK]
AGE_V What is your age?
___ [VALID RANGE: 018 THROUGH 125]
997 [PHONE CATI: REFUSED/RS-AWI: “PREFER NOT TO ANSWER”]
999 DON’T KNOW
[ADD RANGE CHECK]
SEX_C Are you male or female?
1 MALE
2 FEMALE
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
SECTION 3:
Informed Consent
INTRO_IC Thank you for completing the National Health Interview Survey last year. As you might recall, at that time we mentioned that we might re-contact you. The Census Bureau is conducting this follow-up survey to help the CDC learn how the health care system is currently working for you.
CONSENT Before we continue, I'd like you to know that taking part in this research is voluntary. You may choose not to answer any question you don't wish to answer, or end the interview at any time with no impact on the benefits you may receive. On average, the survey will take about 15 minutes to complete. We are required by Federal law to develop and follow strict procedures to protect the confidentiality of your information and use your answers only for statistical research. I can describe these laws if you wish. In appreciation for your time, we will send you $10 after you complete the interview. In order to review my work, this call will be recorded and my supervisor may listen as I ask the questions. I'd like to continue now unless you have any questions.
READ IF NECESSARY: The Public Health Service Act is Title 42 of the US Code, Section 242k. The collection of information in this survey is authorized by Section 306 of this Act. Through the National Center for Health Statistics, the confidentiality of your responses is assured by Section 308d of this Act and by the Confidential Information Protection and Statistical Efficiency Act. Would you like me to read the Confidential Information Protection provisions to you?
IF RESPONDENT WOULD LIKE TO HEAR PROVISIONS, READ: The information you provide will be used for statistical purposes only. In accordance with the Confidential Information Protection provisions of Title V, Subtitle A, Public Law 107-347 and other applicable Federal laws, only those NCHS employees, our specially designated agents including the US Census Bureau, and our full research partners who must use your personal information for a specific reason can see your answers. Everyone else who uses this data can do so only after all information that could identify you and your family is removed. By law, every employee of the National Center for Health Statistics, the US Census Bureau, and their agents and contractors who work on this survey has taken an oath and is subject to a jail term of up to 5 years, a fine of up to $250,000, or both, if he or she willingly discloses ANY identifiable information about you or your household members.
1 CONTINUE, RECORDING ACCEPTABLE
2 CONTINUE, DO NOT RECORD
SECTION 4:
Financial Burden of Medical Care
WFQ001 The first question is about money that you or your family spent out of pocket on medical care. We do NOT want you to count health insurance premiums, over the counter drugs, or costs that you will be reimbursed for.
IN THE PAST 12 MONTHS, about how much did you spend for medical care and dental care?
0 NOTHING
1 LESS THAN $500
2 $500 - $1,999
3 $2,000 - $2,999
4 $3,000 - $4,999
5 $5,000 OR MORE
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ002 IN THE PAST 12 MONTHS did you have problems paying or were unable to pay any medical bills?
Include bills for doctors, dentists, hospitals, therapists, medication, equipment, nursing home or home care.
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ003 Do you currently have any medical bills that are being paid off over time?
This could include medical bills being paid off with a credit card, through personal loans, or bill paying arrangements with hospitals or other providers. The bills can be from earlier years as well as this year.
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: [<1,2,7,9> and WFQ002=2] go to [WFQ005]; else go to [WFQ004]
WFQ004 Do you currently have any medical bills that you are unable to pay at all?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ005 If you get sick or have an accident, how worried are you that you will be able to pay your medical bills? Would you say you are very worried, somewhat worried, or not at all worried?
1 VERY WORRIED
2 SOMEWHAT WORRIED
3 NOT AT ALL WORRIED
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
SECTION 5:
Health Status
WFQ006 Would you say your health in general is excellent, very good, good, fair, or poor?
1 EXCELLENT
2 VERY GOOD
3 GOOD
4 FAIR
5 POOR
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ007 About how long has it been since you last saw or talked to a doctor or other health care professional about your own health?
Include doctors seen while a patient in a hospital.
DO NOT READ ANSWER CHOICES—SELECT BASED ON RESPONDENT’S ANSWER; IF ANSWER UNCLEAR, READ CHOICES
0 NEVER
1 6 MONTHS OR LESS
2 MORE THAN 6 MONTHS, BUT NOT MORE THAN 1 YEAR AGO
3 MORE THAN 1 YEAR, BUT NOT MORE THAN 2 YEARS AGO
4 MORE THAN 2 YEARS, BUT NOT MORE THAN 5 YEARS AGO
5 MORE THAN 5 YEARS AGO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ008 About how long has it been since you last saw a dentist? Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.
DO NOT READ ANSWER CHOICES—SELECT BASED ON RESPONDENT’S ANSWER; IF ANSWER UNCLEAR, READ CHOICES
0 NEVER
1 6 MONTHS OR LESS
2 MORE THAN 6 MONTHS, BUT NOT MORE THAN 1 YEAR AGO
3 MORE THAN 1 YEAR, BUT NOT MORE THAN 2 YEARS AGO
4 MORE THAN 2 YEARS, BUT NOT MORE THAN 5 YEARS AGO
5 MORE THAN 5 YEARS AGO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ009 DURING THE PAST 12 MONTHS, were you prescribed medication by a doctor or other health professional?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
SECTION 6:
Access and Utilization of Health Care
WFQ010 Is there a place that you USUALLY go to when you are sick or need advice about your health?
1 YES
2 THERE IS NO PLACE
3 THERE IS MORE THAN ONE PLACE
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: <1,3> go to [WFQ011]; else go to [WFQ012]
WFQ011 [IF WFQ010=1: “What kind of place is it - a clinic, doctor's office, emergency room, or some other place?”
[IF WFQ010=3: “What kind of place do you go to most often - a clinic, doctor's office, emergency room, or some other place?”]
DO NOT READ ANSWER CHOICES—SELECT BASED ON RESPONDENT’S ANSWER; IF ANSWER UNCLEAR, READ CHOICES
1 Clinic or health center
2 Doctor's office or HMO
3 Hospital emergency room
4 Hospital outpatient department
5 Some other place
6 Doesn't go to one place most often
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: <6> go to [WFQ012]; else go to [WFQ013]
WFQ012 What is the main reason you do not have a usual source of medical care?
DO NOT READ ANSWER CHOICES—SELECT BASED ON RESPONDENT’S ANSWER; IF ANSWER UNCLEAR, READ CHOICES
01 DOESN'T NEED A DOCTOR/HAVEN'T HAD ANY PROBLEMS
02 DOESN'T LIKE/TRUST/BELIEVE IN DOCTORS
03 DOESN'T KNOW WHERE TO GO
04 PREVIOUS DOCTOR IS NOT AVAILABLE/MOVED
05 TOO EXPENSIVE/NO INSURANCE/COST
06 SPEAK A DIFFERENT LANGUAGE
07 NO CARE AVAILABLE/CARE TOO FAR AWAY, NOT CONVENIENT
08 PUT IT OFF/DIDN'T GET AROUND TO IT
09 OTHER
97 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
99 DON’T KNOW
Skip Instructions: <01-99> go to [WFQ025]
WFQ013 IN THE PAST 12 MONTHS, did you visit your usual provider for a check-up or routine care?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ014 IN THE PAST 12 MONTHS, when you made an appointment for a check-up or routine care with your usual provider, how often did you get an appointment as soon as you needed? Would you say never, sometimes, usually, or always?
1 NEVER
2 SOMETIMES
3 USUALLY
4 ALWAYS
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ015 IN THE PAST 12 MONTHS, how often did this provider explain things in a way that was easy to understand?
READ IF NECESSARY: Would you say never, sometimes, usually, or always?
1 NEVER
2 SOMETIMES
3 USUALLY
4 ALWAYS
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ016 IN THE PAST 12 MONTHS, how often did this provider listen carefully to you?
READ IF NECESSARY: Would you say never, sometimes, usually, or always?
1 NEVER
2 SOMETIMES
3 USUALLY
4 ALWAYS
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ017 IN THE PAST 12 MONTHS, how often did this provider seem to know the important information about your medical history?
READ IF NECESSARY: Would you say never, sometimes, usually, or always?
1 NEVER
2 SOMETIMES
3 USUALLY
4 ALWAYS
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ018 IN THE PAST 12 MONTHS, how often did this provider show respect for what you had to say?
READ IF NECESSARY: Would you say never, sometimes, usually, or always?
1 NEVER
2 SOMETIMES
3 USUALLY
4 ALWAYS
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ019 IN THE PAST 12 MONTHS, how often did this provider spend enough time with you?
READ IF NECESSARY: Would you say never, sometimes, usually, or always?
1 NEVER
2 SOMETIMES
3 USUALLY
4 ALWAYS
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ020 IN THE PAST 12 MONTHS, did this provider order a blood test, x-ray, or other test for you?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ021 IN THE PAST 12 MONTHS, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you the results?
READ IF NECESSARY: Would you say never, sometimes, usually, or always?
1 NEVER
2 SOMETIMES
3 USUALLY
4 ALWAYS
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ022 Health care providers may ask during routine checkups about health-related behaviors like alcohol use. At your last routine checkup with this provider, did a doctor or other health professional ask you in person or on a form if you drink alcohol?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ023 At your last routine checkup, were you asked in person or on a form how much you drink?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ024 At your last routine checkup, were you offered advice about what level of drinking is harmful or risky to your health?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ025 These next questions ask about which types of doctors you may have seen in the past year. DURING THE PAST 12 MONTHS have you seen or talked to…
…A general doctor who treats a variety of illnesses (a doctor in general practice, family medicine, or internal medicine)?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ026 ...A doctor who specializes in women's health (an obstetrician/gynecologist)?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Universe: Female Sample Adults
WFQ027 ...An optometrist, ophthalmologist (AHF-thal-MOL-oh-jist), or eye doctor (someone who prescribes eyeglasses)?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ028 …A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ029 ...A medical doctor who specializes in a particular medical disease or problem (other than obstetrician/gynecologist, psychiatrist, or ophthalmologist (AHF-thal-MOL-ohjist))?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ030 DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they would not accept you as a new patient?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ031 DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they did not accept your health care coverage?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ032 DURING THE PAST 12 MONTHS, have you DELAYED seeking medical care because of worry about the cost?
Please do not include dental care in your answer.
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ033 DURING THE PAST 12 MONTHS, was there any time when you needed medical care but DID NOT GET IT because you couldn't afford it?
Please do not include dental care in your answer.
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ034 DURING THE PAST 12 MONTHS, was there any time when you needed dental care but didn't get it because you couldn't afford it?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ035 DURING THE PAST 12 MONTHS, was there any time you needed to see a specialist for care but did not get the care because you couldn’t afford it?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ036 The next questions are about prescription medicine. DURING THE PAST 12 MONTHS, was there any time when you needed prescription medicines but didn't get them because you couldn't afford them?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ037 DURING THE PAST 12 MONTHS, are any of the following true for you?
…You skipped medication doses to save money
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ038 READ IF NECESSARY: DURING THE PAST 12 MONTHS, are any of the following true for you?
…You took less medicine to save money
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ039 READ IF NECESSARY: DURING THE PAST 12 MONTHS, are any of the following true for you?
…You delayed filling a prescription to save money
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ040 READ IF NECESSARY: DURING THE PAST 12 MONTHS, are any of the following true for you?
…You asked your doctor for a lower cost medication to save money.
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ041 READ IF NECESSARY: DURING THE PAST 12 MONTHS, are any of the following true for you?
…You bought prescription drugs from another country to save money.
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ042 READ IF NECESSARY: DURING THE PAST 12 MONTHS, are any of the following true for you?
…You used alternative therapies to save money.
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
SECTION 7:
Health Insurance
WFQ043 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.
What kinds of health insurance or health care coverage do you 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. Do you have…
SELECT ALL THAT APPLY.
01 Private health insurance
02 Medicare
03 Medi-Gap
04 Medicaid
05 Military health care (Tricare/Va/Champ-Va)
06 Indian Health Service
07 Other type of health plan
08 Single service plan (e.g., dental, vision, prescriptions)
09 No coverage of any type
97 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
99 DON’T KNOW
Skip Instructions: if response contains <1,3> go to [WFQ045]; if response contains <7> go to [WFQ044]; if response contains <9> go to [WFQ047]; else go to [WQF046]
WFQ044 What is the name of your plan?
Name of plan: __________________________________
WFQ045 Which one of these categories best describes how this plan was obtained?
01 Through employer, union, or professional association
02 Purchased directly
03 Through school
04 Through a parent
05 Through a state/local government or community program
06 Other
97 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
99 DON’T KNOW
WFQ046 IN THE PAST 12 MONTHS, was there any time when you did NOT have ANY health insurance or coverage?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: <1> go to [WFQ047]; <2,7,9> go to [WFQ048]
WFQ047 IN THE PAST 12 MONTHS, about how many months were you without coverage?
0 LESS THAN ONE MONTH
1-12 1-12 MONTHS WITHOUT COVERAGE
97 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
99 DON’T KNOW
WFQ048 In regard to your health insurance or health care coverage, how does it compare to a year ago? Is it better, worse, or about the same?
1 BETTER
2 WORSE
3 ABOUT THE SAME
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ049 If you or anyone in your family had to buy a health plan on your own with no help from your employer, how confident are you that you would be able to obtain affordable coverage. Would you say very confident, somewhat confident, not to confident, not confident at all?
1 VERY CONFIDENT
2 SOMEWHAT CONFIDENT
3 NOT TOO CONFIDENT
4 NOT CONFIDENT AT ALL
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ050 [This question will be turned off for the first few months of the survey, and will be switched on IN JUNE OR JULY after exchanges go into effect.]
DURING THE PAST 3 MONTHS, did you look into purchasing health insurance through an exchange set up by your state?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
SECTION 8:
Preventive Services
WFQ051 These next questions are about your lifestyle and use of preventive services. DURING THE PAST 12 MONTHS, did a doctor or other health professional RECOMMEND that you BEGIN or CONTINUE to do any type of exercise or physical activity?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ052 DURING THE PAST 12 MONTHS, has a doctor or other health professional talked to you about your diet?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ053 DURING THE PAST 12 MONTHS, have you had your blood pressure checked by a doctor, nurse, or other health professional?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ054 DURING THE PAST 12 MONTHS, have you had your blood cholesterol checked by a doctor, nurse, or other health professional?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ055 DURING THE PAST 12 MONTHS have you had a Pap smear or Pap test?
READ IF NECESSARY: A Pap smear or Pap test is a routine test for women in which the doctor examines the cervix, takes a cell sample from the cervix with a small stick or brush, and sends it to the lab.
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Universe: Female Sample Adults
WFQ056 DURING THE PAST 12 MONTHS have you had a Mammogram?
READ IF NECESSARY: A mammogram is an x-ray of each breast to look for breast cancer.
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Universe: Female Sample Adults
WFQ057 DURING THE PAST 12 MONTHS, have you had any test done for colon cancer?
READ IF NECESSARY: Colon cancer tests include blood stool tests, colonoscopy and sigmoidoscopy. A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. A sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems.
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ058 Have you had a fasting test for high blood sugar or diabetes DURING THE PAST 12 MONTHS?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
SECTION 9:
Family Food Security
WFQ059 These next questions are about whether you were always able to afford the food you needed in the last 30 days. I'm going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for you or your family in the last 30 days.
The first statement is:
“We worried whether our food would run out before we got money to buy more.” Was that often true, sometimes true, or never true for your family IN THE LAST 30 DAYS?
1 OFTEN TRUE
2 SOMETIMES TRUE
3 NEVER TRUE
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ060 "The food that we bought just didn't last, and we didn't have money to get more."
READ IF NECESSARY: Was that often true, sometimes true, or never true for your family in the last 30 days?
1 OFTEN TRUE
2 SOMETIMES TRUE
3 NEVER TRUE
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ061 "We couldn't afford to eat balanced meals."
READ IF NECESSARY: Was that often true, sometimes true, or never true for your family in the last 30 days?
1 OFTEN TRUE
2 SOMETIMES TRUE
3 NEVER TRUE
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: <1,2> or [<3,D,R> and [WFQ059 in <1,2> or WFQ060 in <1,2>]] go to [WFQ062]; else go to [WFQ069]
WFQ062 IN THE LAST 30 DAYS, did you or other adults in your family ever cut the size of your meals or skip meals because there wasn't enough money for food?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: <1> go to [WFQ063]; else go to [WFQ064]
WFQ063 IN THE LAST 30 DAYS, how many days did this happen?
Number of days: _____
WFQ064 IN THE LAST 30 DAYS, did you ever eat less than you felt you should because there wasn't enough money for food?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ065 IN THE LAST 30 DAYS, were you ever hungry but didn't eat because there wasn't enough money for food?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ066 IN THE LAST 30 DAYS, did you lose weight because there wasn't enough money for food?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: <1> or [<2,R,D> and [WFQ062 or WFQ064 or WFQ065=<1>]] go to [WFQ067]; else go to [WFQ069]
WFQ067 IN THE LAST 30 DAYS, did you or other adults in your family ever not eat for a whole day because there wasn't enough money for food?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: <1> go to [WFQ068]; else go to [WFQ069]
WFQ068 IN THE LAST 30 DAYS, how many days did this happen?
Number of days: _____
SECTION 10:
Smoking
WFQ069 These next few questions are about cigarette smoking. Have you smoked at least 100 cigarettes in your ENTIRE LIFE?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: <1> go to [WFQ070]; else go to [WFQ073]
WFQ070 Do you NOW smoke cigarettes every day, some days or not at all?
1 Every day
2 Some days
3 Not at all
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: <1,2,3> go to [WFQ071]; else go to [WFQ073]
WFQ071 DURING THE PAST 12 MONTHS, have you stopped smoking for more than one day BECAUSE YOU WERE TRYING TO QUIT SMOKING?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ072 DURING THE PAST 12 MONTHS, has a doctor or other health professional talked to you about your smoking?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
SECTION 11:
Marital & Employment Status
WFQ073 We’re almost finished with the interview. This next section asks general questions about your household.
How many people including yourself, currently live in your household?
__ ENTER NUMBER OF PEOPLE
97 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
99 DON’T KNOW
WFQ074 How many children under age 18 currently live in your household?
__ ENTER NUMBER OF CHILDREN UNDER 18
97 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
99 DON’T KNOW
WFQ075 Are you now married, widowed, divorced, separated, never married, or living with a partner?
1 MARRIED
2 WIDOWED
3 DIVORCED
4 SEPARATED
5 NEVER MARRIED
6 LIVING WITH PARTNER
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ076 Are you currently enrolled in school?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ077 The next few questions are about employment status. DURING THE PAST 12 MONTHS, has there been a change in your employment status?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
WFQ078 Which of the following best describes what you were doing LAST WEEK? Were you…
1 Employed
2 Unemployed
3 Retired
4 On extended leave (e.g. medical, family, or maternity leave, etc.)
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: <1,4> go to [WFQ080]; <2> go to [WFQ081]; <3> go to [WFQ079]; else go to [WFQ082]
WFQ079 Are you working for pay more than 1 hour per week during your retirement?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: <1> go to [WFQ080]; else go to [WFQ082]
WFQ080 Approximately how many hours do you usually work per week?
__ ENTER NUMBER OF HOURS
97 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
99 DON’T KNOW
Skip Instructions: go to [WFQ082]
WFQ081 Are you currently looking for work?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: go to [ADVNOT]
WFQ082 DURING THE PAST 12 MONTHS, have you had a period of unemployment?
1 YES
2 NO
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
SECTION 12:
Contact Information
ADVNOT Thank you. We’re almost finished. Do you remember seeing an email or advance letter notifying you about this survey?
IF RESPONDENT SAYS ONLY “YES” ASK ABOUT EACH ONE SEPARATELY.
YES, EMAIL
YES, ADVANCE LETTER
YES, BOTH EMAIL AND LETTER
NO
OTHER, ___________________ ENTER RESPONSE
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
MODESEL What made you decide to complete this survey [IF PHONE CATI: over the phone/ IF RS-AWI: online]? Select all that apply.
[If RS-AWI, Display ONLY ANSWER CHOICES 1-3. IF PHONE CATI, DISPLAY ALL ANSWER CHOICES IN ALL CAPS AND ITALICS]
Convenience
Faster time
Other, please specify ________________________
DOESN’T HAVE INTERNET ACCESS
DOESN’T USE/FEEL COMFORTABLE USING COMPUTERS
ALREADY ON THE PHONE WITH THE FR
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions:
PHONE CATI: go to [PHONEDEV]
RS-AWI: go to [WEBDEV]
PHONDEV Did you complete this survey on a landline or cell phone?
LANDLINE
CELL PHONE
7 REFUSED
9 DON’T KNOW
Skip Instructions: go to [RECONT]
WEBDEV On what kind of device did you complete this survey?
Computer (e.g., PC or Mac desktop or laptop)
Smartphone
Tablet
Other, please specify ____________________ ENTER RESPONSE
RECONT Since we are interested in how health changes over time, we may be re-contacting you in the future. How would you prefer to complete future surveys? Would you like…
1 A questionnaire sent in the mail
2 An email with a link to an internet questionnaire that you can fill out on the online
3 A telephone interview
4 Something else ________________ ENTER RESPONSE
5 No preference
7 [PHONE CATI: REFUSED / RS-AWI: “PREFER NOT TO ANSWER”]
9 DON’T KNOW
Skip Instructions: <7> go to [CLOSING]; else go to [CONTACT]
CONTACT Please provide phone number, e-mail and address information where you can be reached.
ENTER RESPONSES…
Daytime Phone Number _____________________
Evening Phone Number _____________________
E-mail Address ______________________________________________
Verify E-Mail ____________________________________________
Address Number/Street _____________________________________
City/Town ______________________________
State ___ SELECT FROM DROP-DOWN LIST
ZIP CODE _________
CLOSING Those are all the questions [IF PHONE CATI: “I” / IF RS-AWI: “we”] have. [IF PHONE CATI: “I would” / IF RS-AWI: “we would”] like to thank you on behalf of the CDC’s National Center for Health Statistics for the time and effort you’ve spent answering these questions. If you have any questions about this survey, you may call my supervisor toll-free at [NUMBER]. If you have questions about your rights as a survey participant, you may call the chairperson of the NCHS Research Ethics Review Board at 1-800-223-8118 and say you are calling about protocol XXXX-XX. Thank you again.
CALLBACK & ANSWERING MACHINE SCRIPTS
NO CONTACT YET:
Hello. I’m calling on behalf of the CDC’s National Center for Health Statistics. We are conducting a survey on health, the health care system, and insurance. Should you be eligible to participate, we will send you $10 after you complete the interview in appreciation for your time. If you would like to participate right away, please call our toll-free number, at [NUMBER]. Thank you.
RE-CONTACT WITH ELIGIBLE SA (NO APPOINTMENT):
Hello. I am calling on behalf of the CDC’s National Center for Health Statistics regarding a survey about health, the health care system, and insurance. When we spoke previously about this important study, you requested that we call you back. I'm sorry that we've missed you. We'll try to contact you again soon but please feel free to return our call anytime at [NUMBER]. In appreciation for your time, we will send you $10 after you complete the interview. Thank you.
SCHEDULED INTERVIEW APPOINTMENTS:
Hello. I am calling on behalf of the CDC’s National Center for Health Statistics regarding a survey about health, the health care system, and insurance. When we spoke previously about this important study, you requested that we call you back at this time. I'm sorry that we've missed you. We'll try to contact you again soon but please feel free to return our call anytime at [NUMBER]. In appreciation for your time, we will send you $10 after you complete the interview. Thank you.
| File Type | application/msword |
| File Title | 2008 SCG Web Instrument Specifications |
| Author | pilke001 |
| Last Modified By | Moien, Mary (CDC/OSELS/NCHS) |
| File Modified | 2012-11-27 |
| File Created | 2012-11-27 |