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pdfHealth Center Patient Survey
Cognitive Interviewing Materials
(Vietnamese)
1
1. Introductory text in Cognitive interviews
tôi
y không.
—
:
cái Ti Vi?
Hai cái Ti Vi
cái Ti Vi
cái Ti Vi
cái Ti Vi
cái Ti Vi
cái
cái Ti Vi
cái Ti Vi
suy
2
theo.
.
.
3
2. Consent Forms
(1) Adult consent form
nh Cho
–
các câu
Tham Gia
a
4
XXXX].
-866-2142043).
không?
_________________________________________
_________________________________________
_________
_________
5
(2) Parent/guardian proxy interview consent form
n.
–
không.
Tham Gia
HIV/AIDS.
6
XXXX].
-866-2142043).
không?
________________________________________
________________________________________
_________
_________
7
(3) Parent/guardian proxy interview consent form
-
–
không.
Tham Gia
HIV/AIDS.
ng
8
XXXX].
-866-2142043).
khi:
______________________________________________
________________________________________
_________
______________________________________________
_________
9
(4) Consent form for minor children’s interview
-
–
Tham Gia
c.
h
10
-XXXX].
-866-214-2043).
________________________________________
________________________________________
_________
_________
11
3. Hand-out
[XXX]
–
50$!!
________________________________________________
[XXX].
-
[XXX]
-
________________________________________________
12
4. Flyer
[XXX]?
–
XXX]
-
RTI (
ao 50$)
(XXX) XXX-XXXX
RTI (
)
(XXX) XXX-XXXX
RTI (
)
(XXX) XXX-XXXX
RTI (
)
(XXX) XXX-XXXX
RTI (
)
(XXX) XXX-XXXX]
RTI (
)
(XXX) XXX-XXXX
RTI (
)
(XXX) XXX-XXXX
RTI (
Lao 50$)
(XXX) XXX-XXXX
RTI (
)
(XXX) XXX-XXXX]
RTI (
)
(XXX) XXX-XXXX
RTI (
)
(XXX) XXX-XXXX
13
5. Incentive receipt
CASH INCENTIVE RECEIPT
________--- __________
________________
ầ
ầ
___/ ___/ ___
________________________________
___________
Xin Giao:
i tham gia.
14
6. Questionnaire
(1) Module D: Routine care
COLOR CODE DESCRIPTIONS
Yellow: Items not to be translated. For the most part this are programming instructions or
certain interviewer instructions.
Green: These are either reference date or reference health center variable fills and do not
need to be translated. The computerized program will automatically place the pertinent
information.
Turquoise: These are variable fills that will trigger the system whether the question is being
hown
on this variable fill item, it will remain in English and will be automatically replaced by the
pertinent individual's name by the system. However, the translation around these variable
fills need to be adapted for both scenarios.
Pink: If applicable, these are items that have a programming code for either underline or
bolding before and after the wording. For example: @UXXXXX@u. Please leave those
codes as is and translate the wording inside them.
******************************************************************
ORIGINAL ENGLISH
TRANSLATION
MODULE D: ROUTINE
MODULE D: ROUTINE
CARE
CARE
{
}
trong 12 tháng qua.
health services that {you/name}
received in the past 12 months.
ROU1a. During the past 12 months,
that is since {12 MONTH
REFERENCE DATE}, {have you/has
name} seen or talked to any of the
following health care providers about
{your own/his/her} health? Please tell
me yes or no for each of the following
by an
optometrist, ophthalmologist, eye doctor,
or someone who prescribes eyeglasses?
1=YES
2=NO
ROU1b. (During the past 12 months,
{12 MONTH REFERENCE
DATE}, {
}
{
}
ỹ
= Ó
2=KHÔNG
ROU1b. (T
15
that is since {12 MONTH
REFERENCE DATE}, {have you/has
name} seen or talked to any of the
following health care providers about
{your own/his/her} health? Please tell
me yes or no for each of the
w …
{12 MONTH REFERENCE
DATE}, {
}
{
}
ỗ
A foot doctor?
1=YES
2=NO
ROU1c. (During the past 12 months,
that is since {12 MONTH
REFERENCE DATE}, {have you/has
name} seen or talked to any of the
following health care providers about
{your own/his/her} health? Please tell
me yes or no for each of the
w …
1=CÓ
2=KHÔNG
{12 MONTH REFERENCE
DATE}, {
}
{
} hay
ỗ
ỹ
A chiropractor?
IF NEEDED, YOU MAY EXPLAIN
chiropractor uses a system of therapy in
which disease is considered the result of
abnormal function of the nervous system.
The method of treatment usually involves
manipulation of the spinal column and
IF NEEDED, YOU MAY EXPLAIN:
ỹ
1=YES
2=NO
1=CÓ
2=KHÔNG
ROU1d. (During the past 12 months,
that is since {12 MONTH
REFERENCE DATE}, {have you/has
name} seen or talked to any of the
following health care providers about
{your own/his/her} health? Please tell
me yes or no for each of the
w …
{12 MONTH REFERENCE
DATE}, {
}
{
}
ỗ
A medical doctor who specializes in a
particular medical disease or problem
other than obstetrician, gynecologist,
psychiatrist, or ophthalmologist
16
1=YES
2=NO
ROU2.
During the past 12
months, how many times {have
you/has name}gone to a hospital
emergency room about {your
own/his/her) health? This includes
emergency room visits that resulted in
a hospital admission.
1=CÓ
2=KHÔNG
ROU2.
{
Trong 12 tháng qua,
}
{
________ TIMES [ALLOW 000-365]
________ TIMES [ALLOW 000-365]
ROU3.
(Were you/Was name}
ever hospitalized @Uovernight@u in
the past 12 months? Do not include an
overnight stay in the emergency room.
ROU3.
@Uq
đ
}
@u trong 12 tháng
1=YES
2=NO
1=CÓ
2=KHÔNG
[ROUCHK4 IF ROU3 = 1
CONTINUE ELSE GOTO ROU5 ]
[ROUCHK4 IF ROU3 = 1
CONTINUE ELSE GOTO ROU5 ]
ROU4.
Altogether, how many
nights {were you/was name} in the
hospital during the past 12 months?
{
ROU4.
}
12 tháng qua?
_______ NIGHTS [ALLOW 000-365]
_______ NIGHTS [ALLOW 000365]
ROU5.
During the past 12
months, {have you/has name} had a
flu shot? A flu shot is usually given in
the fall and protects against influenza
for the flu season. The flu shot is
injected in the arm. Do not include an
influenza vaccine sprayed in the nose.
1=YES
2=NO
ROU6: During the past 12 months,
{have you/has name} had a flu
vaccine sprayed in {your/his/her}
nose by a doctor or other health
ROU5.
{
Trong 12 tháng qua,
}
iêm vào cánh tay.
-
1=CÓ
2=KHÔNG
ROU6: Trong 12 tháng qua,
{
}
-xin cúm
{
}
17
professional? {IF AGE GE 18 ADD:
A health professional may have let
you spray it.} This vaccine is usually
given in the fall and protects against
influenza for the flu season.
READ IF NECESSARY: This influenza
vaccine is called FluMist {trademark}.
hay không? {IF AGE GE 18 ADD:
}
-xin này th
READ IF NECESSARY
{
}
1=YES
2=NO
[ROUCHK7
IF ROU6=1 OR
ROU5=1, THEN CONTINUE;
ELSE GO TO ROUCHK8]
ROU7.
Did {you/name} get the
flu shot or vaccine sprayed in the nose
at {the reference health center}?
1=YES
2=NO
[ROUCHK8
IF AGE GE 65,
CONTINUE; ELSE GO TO
ROU9a]
ROU8. Have you ever had a
pneumonia shot? This shot is usually
w
lifetime and is different from the flu
shot. It is also called the
pneumococcal vaccine.
1=YES
2=NO
1=CÓ
2=KHÔNG
[ROUCHK7
IF ROU6=1 OR
ROU5=1, THEN CONTINUE; ELSE
GO TO ROUCHK8]
ROU7.
{
}
{the reference health center} hay
không?
1=CÓ
2=KHÔNG
[ROUCHK8
IF AGE GE 65,
CONTINUE; ELSE GO TO ROU9a]
8
-xi
ẩ
1=CÓ
2=KHÔNG
[ROUCHK9
IF ROU8 =1,
CONTINUE; ELSE GO TO
ROU10]
[ROUCHK9
IF ROU8 =1,
CONTINUE; ELSE GO TO ROU10]
ROU9.
Did you get the
pneumonia vaccination at {the
reference health center}?
ROU9.
1=YES
2=NO
{the reference health
center} hay không?
1=CÓ
2=KHÔNG
18
ROU9a. [IF AGE = 4 MONTH – 6
YEARS CONTINUE, ELSE GO
TO ROU10]
Did {name} receive any shots in the
last 12 months?
1=YES
2=NO
ROU9a. [IF AGE = 4 MONTH – 6
YEARS CONTINUE, ELSE GO TO
ROU10]
{name}
trong 12 tháng qua không?
1=CÓ
2=KHÔNG
[ROUCHK9b IF ROU9a =1,
CONTINUE; ELSE GO TO
ROU10]
[ROUCHK9b IF ROU9a =1,
CONTINUE; ELSE GO TO ROU10]
ROU9b. How many of the shots
{name} received in the past 12
months were provided by {reference
health center}? Would you say all,
some, or none?
ROU9b. {name}
1=ALL
2=SOME
3=NONE
[ROUCHK9c IF ROU9b =2 OR 3,
CONTINUE; ELSE GO TO
ROU9d]
ROU9c. Were you referred to the
other place where {name} got the
shots by {reference health center}?
1=YES
2=NO
ROU9d. Are you the person who took
{name} for most of {his/her} shots?
Most means at least half of the shots.
1=YES
2=NO
[ROUCHK9e IF ROU9d =1,
CONTINUE; ELSE GO TO
ROU10]
ROU9e. In your opinion, has {name}
received all of the recommended shots
for {his/her} age?
{reference
health center}
1= Ấ
Ả
= Ộ Ố
3=KHÔNG CÓ
[ROUCHK9c IF ROU9b =2 OR 3,
CONTINUE; ELSE GO TO ROU9d]
9
{name}
{reference health center}?
1=CÓ
2=KHÔNG
ROU9d.
{name}
{
}
1=CÓ
2=KHÔNG
[ROUCHK9e IF ROU9d =1,
CONTINUE; ELSE GO TO ROU10]
ROU9e.
{name}
{
}
19
1=YES
2=NO
1=CÓ
2=KHÔNG
[ROUCHK9f IF ROU9d =2,
CONTINUE; ELSE GO TO
ROU10]
[ROUCHK9f IF ROU9d =2,
CONTINUE; ELSE GO TO ROU10]
9
ROU9f. Please look at this showcard.
What is the main reason {name} has
not had all the shots that he/she is
supposed to have at his/her age?
@BSHOWCARD ROU9f@B
{name}
@BSHOWCARD ROU9f@B
1=DID NOT THINK IT WAS
1=KHÔN
Ĩ Ó
IMPORTANT
Ọ
2=AFRAID OF THE SIDE EFFECTS OF =
Á
Ụ
Ụ
Ệ
THE IMMUNIZATION
Ê
Ừ
3=CHILD WAS SICK AND COULD
= Ẻ ỊỐ
Ê
NOT HAVE IMMUNIZATIONS AT
Ừ
Ầ
Ó
THAT TIME
=
ƯỞ
=
Ố
Ố
=
Ả
Ệ
=
Ă
Ó
6=PROBLEMS GETTING TO
6= Ó Ấ
Ề
Ệ
Ế
DOCTOR'S OFFICE
Ă
Á Ĩ
7=DIFFERENT LANGUAGE
=
Á
Ệ
8=
W
8=
Ệ
9=D
WW
9=
Ế
Ầ
Â
GET CARE
ƯỢ
Ă
Ó
=
=
Ó
Ờ
Ặ
TOO LONG
Ấ
Á
Ề
Ờ
11=OTHER
11=KHÁC
ROU10. [IF AGE GE 18,
CONTINUE; ELSE GO TO
ROUCHK12]
ROU10. [IF AGE GE 18,
CONTINUE; ELSE GO TO
ROUCHK12]
These next questions are about
general physicals or routine checkups.
About how long has it been since your
last general physical exam or routine
check-up by a medical doctor or other
health professional? Do not include a
visit about a specific problem.
1=NEVER
=
Ờ
20
2=LESS THAN 1 YEAR AGO
3=AT LEAST 1 YR, LESS THAN 2
YEARS
4=AT LEAST 2 YRS, LESS THAN 3
YEARS
5=AT LEAST 3 YRS, LESS THAN 4
YEARS
6=AT LEAST 4 YRS, LESS THAN 5
YEARS
7=5 OR MORE YEARS AGO
[ROUCHK11 IF ROU10= 2 OR 3,
CONTINUE; ELSE IF ROU10=DK
OR RF, GO TO ROUCHK12;
ELSE GO TO ROU11a ]
ROU11. Did you get this check-up at
{the reference health center}?
1=YES
2=NO
[ROUCHK11a
= Ầ
Ă
ƯỚ
=
Ấ
Ă
Ă
=
Ấ
Ă
Ă
=
Ấ
Ă
Ă
6=
Ấ
Ă
Ă
=
Ặ
Ề
Ă
Ư
Ế
Ư
Ế
Ư
Ế
Ư
Ế
ƯỚ
[ROUCHK11 IF ROU10= 2 OR 3,
CONTINUE; ELSE IF ROU10=DK
OR RF, GO TO ROUCHK12; ELSE
GO TO ROU11a ]
{the reference health
center} hay không?
1=CÓ
2=KHÔNG
GO TO ROUCHK12]
[ROUCHK11a
GO TO ROUCHK12]
21
ROU11a. Please look at this
showcard. What is the main reason
you have not had a general physical
exam or routine check-up in the past 2
years?
@BSHOWCARD MED1@B
@BSHOWCARD MED1@B
=
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY
W
COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT
4=PROBLEMS GETTING TO
5=DIFFERENT LANGUAGE
6=
F WORK
=
WW
GET CARE
8=WAS REFUSED SERVICES
9=
=
TOO LONG
11=OTHER
[ROUCHK12 IF AGE <18, THEN
CONTINUE; ELSE, GO TO ROU14]
Ả
Ă
Ệ
Ó
=
Ả
Ê
Ệ
Ặ
Ệ
Ă
Ó
= Á Ĩ
Ừ
Ố
Ấ
Ế
Ả
Ì
= Ó Ấ
Ề
Ệ
Ă
Á Ĩ
=
Á
Ệ
6=
Ệ
=
Ế
Ầ
Â
ƯỢ
Ă
Ó
8= Ị Ừ
Ố Ở Á
Ị
9=
Ệ
Ó
Ẻ
=
Ó
Ờ
Ấ
Á
Ề
Ờ
11=KHÁC
Ẽ
Ả
Á
Ứ
Ế
Ụ
Ă
Ặ
[ROUCHK12 IF AGE <18, THEN
CONTINUE; ELSE, GO TO ROU14]
ROU12. These next questions are
about well-child check-ups, that is a
general check-up, performed when
{you were/name was} not sick or
injured. About how long has it been
since {you/he/she} received a wellchild or general check-up?
1=NEVER
2=LESS THAN 1 YEAR AGO
3=AT LEAST 1 YR, LESS THAN 2
YEARS
4=AT LEAST 2 YRS, LESS THAN 3
YEARS
5=AT LEAST 3 YRS, LESS THAN 4
YEARS
khi {
}k
{
=
= Ầ
=
Ă
=
Ă
=
}
Ấ
Ờ
ƯỚ
Ă
Ư
Ế
Ấ
Ă
Ư
Ế
Ấ
Ă
Ư
Ế
Ă
22
6=AT LEAST 4 YRS, LESS THAN 5
YEARS
7=5 OR MORE YEARS AGO
[ROUCHK13 IF ROU12=2 OR 3,
CONTINUE;
ELSE IF ROU12=DK
OR RF, GO TO ROU14
ELSE GO TO ROU13a]
ROU13. Did {you/he/she} get this
check-up at {the reference health
center}?
1=YES
2=NO
[ROUCHK13a GO TO ROU14[
Ă
6=
Ă
=
Ơ
Ấ
Ă
Ă
ƯỚ
Â
Ư
Ặ
Ế
Ề
[ROUCHK13 IF ROU12=2 OR 3,
CONTINUE;
ELSE IF ROU12=DK
OR RF, GO TO ROU14
ELSE GO TO ROU13a]
ROU13. {
} có khám
{the reference
health center} hay không?
1=CÓ
2=KHÔNG
[ROUCHK13a GO TO ROU14[
23
ROU13a. Please look at this
showcard. What is the main reason
{you/name} has not had a general
physical exam or routine check-up in
the past 2 years?
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY
W
COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT
.
{
}
@BSHOWCARD MED1@B
=
Ả
Ă
Ó
=
Ả
Ê
5=DIFFERENT LANGUAGE
6=
W
=
WW
GET CARE
8=WAS REFUSED SERVICES
9=
=
TOO LONG
11=OTHER
Ẽ
Ả
Á
Ứ
Ệ
Ặ
Ệ
4=PROBLEMS GETTING TO
Ệ
Ă
Ó
E
= Á Ĩ
Ừ
Ố
Ấ
Ế
Ả
Ì
= Ó Ấ
Ề
Ệ
Ă
Á Ĩ
=
Á
Ệ
6=
Ệ
=
Ế
Ầ
Â
ƯỢ
Ă
Ó
8= Ị Ừ
Ố Ở Á
Ị
9=
Ệ
SÓC
Ẻ
=
Ó
Ờ
Ấ
Á
Ề
Ờ
11=KHÁC
Ế
Ụ
Ă
Ặ
LEAD SCREENING
LEAD SCREENING
ROU14. [IF AGE 9 MONTHS - 5
YEARS CONTINUE, ELSE GO
TO MODULE E]
ROU14. [IF AGE 9 MONTHS - 5
YEARS CONTINUE, ELSE GO TO
MODULE E]
Has {name} ever had a blood test to
check the amount of lead in {his/her}
blood?
{name}
1=YES
2=NO
1=CÓ
2=KHÔNG
[ROUCHK15 IF ROU14=1,
CONTINUE; ELSE GO TO
ROU17]
[ROUCHK15 IF ROU14=1,
CONTINUE; ELSE GO TO ROU17]
ROU15. How old was {name} the last
ROU15. {name}
{
}
24
time this test was done?
______AGE [ALLOW 00-12]
PROGRAMMER: NEED AGE
CHECK SO AGE REPORTED IS
NOT HIGHER THAN ACTUAL
AGE REPORTED EARLIER IN THE
INTERVIEW.
______AGE [ALLOW 00-12]
PROGRAMMER: NEED AGE
CHECK SO AGE REPORTED IS
NOT HIGHER THAN ACTUAL AGE
REPORTED EARLIER IN THE
INTERVIEW.
………………………………………
………………………………………
……………………
………………………………………
………………………………………
……………………
ROU16. Was that done at the
{reference health center}?
6
{reference health center} hay
không?
1=YES
2=NO
1=CÓ
2=KHÔNG
ROU17. Has anyone ever talked to
you about things that might cause
{name} to be exposed to lead, such as
living in or visiting a house or
apartment built before 1978?
{name}
9 8
không?
1=YES
2=NO
1=CÓ
2=KHÔNG
25
(2) Module J: Dental
COLOR CODE DESCRIPTIONS
Yellow: Items not to be translated. For the most part this are programming instructions or
certain interviewer instructions.
Green: These are either reference date or reference health center variable fills and do not
need to be translated. The computerized program will automatically place the pertinent
information.
Turquoise: These are variable fills that will trigger the system whether the question is being
as
w
on this variable fill item, it will remain in English and will be automatically replaced by the
pertinent individual's name by the system. However, the translation around these variable
fills need to be adapted for both scenarios.
Pink: If applicable, these are items that have a programming code for either underline or
bolding before and after the wording. For example: @UXXXXXX@u. Please leave those
codes as is and translate the wording inside them.
******************************************************************
ORIGINAL ENGLISH
TRANSLATION
MODULE J: DENTAL
MODULE J: DENTAL
[DENCHK1 IF AGE GE 2, THEN
CONTINUE; ELSE GO TO MODULE
K]
[DENCHK1 IF AGE GE 2, THEN
CONTINUE; ELSE GO TO
MODULE K]
The next questions are about dental care.
DEN1. In the last 12 months, that is since
{12 MONTH REFERENCE DATE}, did
you or a dentist believe {you/name}
needed any dental care, tests, or treatment?
NOTE: CODE YES IF A DOCTOR
BELIEVED DENTAL CARE WAS
NECESSARY
1=YES
2=NO
[DENCHK2 IF DEN1=1, THEN
CONTINUE; ELSE GO TO DEN10]
{12 MONTH REFERENCE
DATE}
{ /name}
NOTE
Ằ
Ă
Ó Ế
Ộ
Á Ĩ
Ầ
Ả
Ă
Ó
1=CÓ
2=KHÔNG
[DENCHK2 IF DEN1=1, THEN
CONTINUE; ELSE GO TO
DEN10]
26
DEN2. In the last 12 months, {were
you/was name} unable to get dental care,
tests, or treatments you or a dentist
believed necessary?
1=YES
2=NO
[DENCHK3 IF DEN2=1, THEN
CONTINUE; ELSE GO TO DEN6 ]
DEN3. What kind of dental care, test, or
treatment was it that {you/name} needed
but did not get?
________________ [ALLOW 40]
{
}
1=CÓ
2=KHÔNG
[DENCHK3 IF DEN2=1, THEN
CONTINUE; ELSE GO TO DEN6
]
{
}
________________ [ALLOW 40]
27
DEN4. Please look at this showcard.
Please describe the main reason {you
were/name was} unable to get dental care,
tests, or treatments you or a dentist
believed necessary?
t kê này.
{
}
@BSHOWCARD MED2@B
@BSHOWCARD MED2@B
1=COULD NOT AFFORD CARE
=
W
APPROVE, COVER, OR PAY FOR
CARE
3=DENTIST REFUSED TO ACCEPT
=
Ệ
=
Ê
Ặ
Ệ
=
DEN5. How much of a problem was it that
{you/name} did not get dental care, tests,
or treatments you or a dentist believed
necessary? Would you say that it was a...
1=A big problem,
2=A small problem
3=Not a problem
Ó
Ả
4=PROBLEMS GETTING TO
TRANSPORTATION
5=DIFFERENT LANGUAGE
6=
W
=
WW
GET CARE
8=WAS REFUSED SERVICES
9=
=
TOO LONG
11=AFRAID OF GOING TO THE
DENTIST/ HAVING DENTAL WORK
DONE
12=OTHER
Ả
Ă
Ẽ
Ệ
Ả
Á
Ă
Ó Ứ
Ừ
Ố
Ả
Ĩ
Ế
Ấ
Ì
= Ó Ấ
Ă
Ề
Ệ
Ĩ
Ế
Ệ
=
Á
Ệ
6=
Ệ
=
Ế
Ầ
Â
ƯỢ
Ă
Ó
8= Ị Ừ
Ố Ở Á
Ị
Ụ
9=
Ệ
Ă
Ó
Ẻ
=
Ó
Ờ
Ặ
Ấ
Á
Ề
Ờ
=
Ề Ệ
Ặ
Ĩ
Ự
Ệ
Ệ
Ă
Ó
Ă
12=KHÁC
mà {
}
n
=
=
=
28
6
DEN6. In the last 12 months, {were
you/was name} delayed in getting dental
care, tests, or treatments you or a dentist
believed necessary?
{
1=YES
2=NO
}
1=CÓ
2=KHÔNG
[DENCHK7 IF DEN6=1, THEN
CONTINUE; ELSE GO TO DEN10]
[DENCHK7 IF DEN6=1, THEN
CONTINUE; ELSE GO TO
DEN10]
DEN7. What kind of dental care, test, or
treatment was it that {you were/name
was} delayed in getting?
{
________________ (allow 40)
e}
________________ (allow 40)
8
DEN8. Please look at this showcard.
Which of these best describes the main
reason {you were/name was} delayed in
getting dental care, tests, or treatments you
or a dentist believed necessary?
nh mà
{
}
@BSHOWCARD MED2@B
@BSHOWCARD MED2@B
=
1=COULD NOT AFFORD CARE
W
APPROVE, COVER, OR PAY FOR
CARE
3=DOCTOR REFUSED TO ACCEPT
=
Ệ
Ă
=
Ó
Ả
Ê
Ặ
Ệ
4=PROBLEMS GETTING TO
= Á
TRANSPORTATION
5=DIFFERENT LANGUAGE
6=
W
7=DID
WW
GET CARE
8=WAS REFUSED SERVICES
9=
=
TOO LONG
11=AFRAID OF GOING TO THE
DENTIST/ HAVING DENTAL WORK
DONE
12=OTHER
Ả
Ẽ
Ệ
Ả
Á
Ă
Ó Ứ
Ừ
Ố
Ả
Ĩ
Ế
Ấ
Ì
= Ó Ấ
Ă
Ề
Á
Ệ
Ế
Ĩ Ệ
=
Á
Ệ
6=
Ệ
=
Ế
Ầ
Â
ƯỢ
Ă
Ó
8= Ị Ừ
Ố Ở Á
Ị
9=
Ệ
Ă
Ó
Ẻ
=
Ó
Ờ
Ấ
Á
Ề
Ờ
Ụ
Ặ
29
=
Ề
Ĩ
Ự
Ó
Ă
12=KHÁC
DEN9. How much of a problem was it that
{you were/name was} delayed in getting
dental care you or a dentist believed
necessary? Would you say that it was a...
9
nào mà {
1=A big problem,
2=A small problem
3=Not a problem
DEN10. About how long has it been since
{you/name} last visited a dentist?
Include all types of dentists, such as,
orthodontists, oral surgeons, and all other
dental specialists, as well as dental
hygienists.
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
99=NEVER HAVE BEEN
[DENCHK11 If DEN10=1 or 2,
CONTINUE; ELSE GO TO DEN14]
Ệ
Ặ
Ệ
Ệ
Ă
}
=
=
=
{
}
=6
Á
= Ơ 6
Ặ
Ơ
Á
Ế
= Ơ
Ă
Ă
ƯỚ
= Ơ
Ă
Ế
Ă
= Ơ
Ă
99=CHƯ
Ư
Ă
ƯỚ
Ư
Ơ
Ư
ƯỚ
ƯỚ
Ờ
[DENCHK11 If DEN10=1 or 2,
CONTINUE; ELSE GO TO
DEN14]
DEN11. In the past 12 months, when
{you/name} did see a dentist, how many
of {your/his/her} visits were at {the
reference health center}? Would you
…
1=All of the visits
2=Some of the visits
3=None of the visits
{
}
{
}
{the reference health center}
nói...
=
=
=
30
[DENCHK12 If DEN11=1 or 2, THEN
CONTINUE; ELSE GO TO
DENCHK13]
[DENCHK12 If DEN11=1 or 2,
THEN CONTINUE; ELSE GO TO
DENCHK13]
DEN12. How would you rate the dental
services {you/name} received at {the
reference health center}? Would you
…
{
}
{the
reference health center}?
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor
=
=
=
=
5=Kém
[DENCHK13 If DEN11= 2 OR 3,
THEN CONTINUE; ELSE GO TO
DEN14]
[DENCHK13 If DEN11= 2 OR 3,
THEN CONTINUE; ELSE GO TO
DEN14]
DEN13 Were you referred to the other
place where {you/name} got dental
services by {reference health center}?
{
}
{reference health center}?
1=YES
2=NO
[DENCHK14 IF AGE LE11 GOTO
DEN16a]
1=CÓ
2=KHÔNG
[DENCHK14 IF AGE LE11
GOTO DEN16a]
Now, I have some questions about the
condition of {
} teeth and
gums.
{
}.
DEN14. The following question asks
about the number of adult teeth you have
lost. Do not count as "lost" missing
wisdom teeth, "baby" teeth, or teeth which
were pulled for orthodontia. Have you
…
IF ASKED
IF ASKED: Orthodontia means
straightening the teeth.
=
1=All of your adult teeth
2=Some of your adult teeth
3=None of your adult teeth
=
=
31
[DENCHK15 .IF DEN14=1, GO TO
DENT15a; IF DEN14=2, CONTINUE;
ELSE
IF DEN12=3, DK, RE, GO TO
DENCHK16a]
[DENCHK15 .IF DEN14=1, GO
TO DENT15a; IF DEN14=2,
CONTINUE; ELSE
IF DEN12=3, DK, RE, GO TO
DENCHK16a]
DEN15. How many of your adult teeth
have you lost?
__________ TEETH [ALLOW 00-20]
__________ Ă
……………………………………………
……………………………………………
……
………………………………………
………………………………………
………………
[ALLOW 00-20]
DEN15a. Are any of your missing teeth
replaced by full or partial dentures, false
teeth, bridges or dental plates?
1=YES
2=NO
[DENCHK16a DEN14=2, 3, DK, or RE
CONTINUE; ELSE GO TO DEN16b ]
1=CÓ
2=KHÔNG
[DENCHK16a DEN14=2, 3, DK,
or RE CONTINUE; ELSE GO TO
DEN16b ]
6
qDEN16a. How would you describe the
condition of {
} teeth? Would
you say...
nói...
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor
1=
=
=
=
5=Kém
[DENCHK16a_POST GO TO
DEN17a]
[DENCHK16a_POST GO TO
DEN17a]
{
}
32
DEN16b Now I have some questions
about the condition of {
}
gums and false teeth or dentures. Would
you say the condition of {
}
…
DEN16b
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor
=
=
=
=
5=Kém
DEN17a. During the past 6 months, {have
you/has name} had any of the following
problems?
DEN17a. Trong 6 tháng qua,
{
}
{
}.
{
} …
A toothache or sensitive teeth?
1=YES
2=NO
DEN17b. (During the past 6 months,
{have you/has name} had any of the
following problems?)
1=CÓ
2=KHÔNG
DEN17b. (Trong 6 tháng qua,
{
}
Bleeding gums?
1=YES
2=NO
1=CÓ
2=KHÔNG
DEN17c. (During the past 6 months,
{have you/has name} had any of the
following problems?)
DEN17c. (Trong 6 tháng qua,
{
}
Crooked teeth?
1=YES
2=NO
1=CÓ
2=KHÔNG
DEN17e. (During the past 6 months,
{have you/has name} had any of the
following problems?)
DEN17e. (Trong 6 tháng qua,
{
}
Broken or missing teeth?
1=YES
2=NO
1=CÓ
2=KHÔNG
33
DEN17f. (During the past 6 months, {have
you/has name} had any of the following
problems?)
DEN17f. (Trong 6 tháng qua,
{
}
Stained or discolored teeth?
1=YES
2=NO
1=CÓ
2=KHÔNG
DEN17g. (During the past 6 months,
{have you/has name} had any of the
following problems?)
DEN17g. (Trong 6 tháng qua,
{
}
Broken or missing fillings?
1=YES
2=NO
1=CÓ
2=KHÔNG
DEN17h. (During the past 6 months,
{have you/has name} had any of the
following problems?)
DEN17h. (Trong 6 tháng qua,
{
}
{[IF AGE GREATER THAN 11,
FILL:] Loose teeth not due to injury? [IF
AGE LE11:] Loose teeth not due to injury
or losing baby teeth?}
{[IF AGE GREATER THAN 11,
FILL:
IF AGE LE11:
}
1=YES
2=NO
DEN18a. During the past 6 months, {have
you/has name} had any of the following
problems that lasted more than a day?
1=CÓ
2=KHÔNG
DEN18a. Trong 6 tháng qua,
{
}
không?
Pain in {your/his/her} jaw joint?
{
1=YES
2=NO
}?
1=CÓ
2=KHÔNG
DEN18b. (During the past 6 months,
{have you/has name} had any of the
following problems that lasted more than a
day?)
Sores in {your/his/her} mouth?
DEN18b. (Trong 6 tháng qua,
{
}
không?)
{
}?
34
1=YES
2=NO
1=CÓ
2=KHÔNG
DEN18c. (During the past 6 months,
{have you/has name} had any of the
following problems that lasted more than a
day?)
DEN18c. (Trong 6 tháng qua,
{
}
không?)
Difficulty eating or chewing?
c nhai?
1=YES
2=NO
1=CÓ
2=KHÔNG
DEN18d. (During the past 6 months,
{have you/has name} had any of the
following problems that lasted more than a
day?)
DEN18d. (Trong 6 tháng qua,
{
}
không?)
Bad breath?
1=YES
2=NO
1=CÓ
2=KHÔNG
DEN18f. (During the past 6 months, {have
you/has name} had any of the following
problems that lasted more than a day?)
DEN18f. (Trong 6 tháng qua,
{
}
không?)
Dry mouth?
1=YES
2=NO
[DENCHK19 IF DEN17a-h=1 or
DEN18a-f=1, CONTINUE; ELSE GO
TO MODULE K]
1=CÓ
2=KHÔNG
[DENCHK19 IF DEN17a-h=1 or
DEN18a-f=1, CONTINUE; ELSE
GO TO MODULE K]
35
DEN19a. Did the problems with
{
} mouth or teeth interfere
with any of the following?
9
{
}
job or school?
1=YES
2=NO
3= NOT WORKING / NOT AT SCHOOL
DEN19b. (Did the problems with
{
} mouth or teeth interfere
with any of the following?)
1=CÓ
2=KHÔNG
3= K
Ọ
9
{
}
sleeping?
1=YES
2=NO
DEN19c. (Did the problems with
{
} mouth or teeth interfere
with any of the following?)
1=CÓ
2=KHÔNG
9
{
}
social activities such as going out or being
with other people?
1=YES
2=NO
DEN19d. (Did the problems with
{
} mouth or teeth interfere
with any of the following?)
1=CÓ
2=KHÔNG
9
{
}
usual activities at home?
1=YES
2=NO
3= DON'T HAVE A HOME
1=CÓ
2=KHÔNG
3= KHÔNG CÓ NHÀ
36
7. Cognitive Interview Screening Form
Health Center Patient Survey
Cognitive Interview Screening Form
Chinese/Korean/Vietnamese speakers only
INTERVIEWER:
PATIENTS 18 YEARS OF AGE AND OLDER CAN BE APPROACHED DIRECTLY.
PATIENTS 13-17 YEARS OF AGE, A PARENT/GUARDIAN NEEDS TO BE READ THE INTRO
AND CHILD CAN CO
E E
E
EE I
UE IO
WI
A E ’ A
O A .
PATIENTS 12 YEARS OF AGE AND YOUNGER, ONLY PARENTS CAN BE SCREENED.
Hello, this is [NAME] from RTI International. (Were you calling about the [ad/flyer]?)
PS1. First, just let me verify: Are you 18 or older? YES _________ (GO TO PS2)
NO _________ (GO TO PS3)
PS2. Are you calling on behalf of a child who is less than 13 years old?: YES _______ (GO TO PS4)
NO _______ (GO TO INTRO ADULT)
PS3. Are you between 13 and 17 years of age? YES _______ (ASK TO TALK TO PARENT/GUARDIAN AND GO
TO INTRO PROXY 13-17 YEARS OLD)
NO _______ (IF YOUNGER THAN 13, ASK TO TALK TO
PARENT/GUARDIAN AND START WITH
QUESTION PS1)
PS4.
YES _______ (GO TO INTRO PROXY LESS THAN 13
YEARS OLD)
NO _______ (R NOT ELIGIBLE – THANK R AND END)
INTRO ADULT
Let me tell you a little about the study. We are testing a questionnaire about health care received by patients of health
centers. This questionnaire will eventually be provided to patients across the country. We are testing these survey
questions with different people to see how well the questions work. We want to know: Do they make sense? How easy or
difficult are they to answer? We want to understand what you think each question means and how you arrive at your
answers. This will help us find out whether there are any problems with the questionnaire. Your feedback will help us
during the development of the survey questionnaire. There are no right or wrong answers. We will not ask about your
legal situation nor your immigration status.
If you are interested and eligible, we would like to schedule an in-person interview, which will take about 75 minutes. At
the end of the interview you will receive $50 in cash. To make sure (you are eligible for the study, I need to ask you a few
brief screening questions. This will only a few minutes. Is this a good time?
37
INTRO PROXY (13-17 YEARS OLD)
Let me tell you a little about the study. We are testing a questionnaire about health care received by patients of health
centers. This questionnaire will eventually be provided to patients across the country. We are testing these survey
questions with different people to see how well the questions work. We want to know: Do they make sense? How easy or
difficult are they to answer? We want to understand what your child thinks each question means and how he/she arrives
at his/her answers. This will help us find out whether there are any problems with the questionnaire. There are no right or
wrong answers. We will not ask about his/her legal situation nor your immigration status.
If your child is interested and he/she is eligible, we would like to schedule an in-person interview, which will take about
75 minutes. At the end of the interview your child will receive $50 in cash. To make sure he/she is eligible for the study, I
need to ask him/her a few brief screening questions. Or, you can answer on his/her behalf. This will only a few minutes. Is
this a good time?
INTRO PROXY (LESS THAN 13 YEARS OLD)
Let me tell you a little about the study. We are testing a questionnaire about health care received by patients of health
centers. This questionnaire will eventually be provided to patients across the country. We are testing these survey
questions with different people to see how well the questions work. We want to know: Do they make sense? How easy or
difficult are they to answer? We want to understand what you think each question means and how you arrive at your
answers. This will help us find out whether there are any problems with the questionnaire. Because your child is less than
13 years old, we would like to ask you to answer questions and get your feedback, which will help us during the
development of the survey questionnaire. There are no right or wrong answers. We will not ask about your legal situation
nor your immigration status.
If you are interested and you are eligible, we would like to schedule an in-person interview, which will take about 75
minutes. At the end of the interview you will receive $50 in cash. To make sure you are eligible for the study, I need to
ask you a few brief screening questions. This will only a few minutes. Is this a good time?
INTERVIEWER:
FOR ADULTS THE SCREENING QUESTIONS WILL BE ABOUT THEMSELVES.
FOR PARENTS/GUARDIANS OF CHILDREN LESS THAN 13 YEARS OLD, THE SCREENING QUESTIONS
WILL BE ABOUT THE PARENTS, EXCEPT QUESTION S1.
FOR CHILDREN 13-17 YEARS OLD, ALL SCREENING QUESTIONS WILL BE ABOUT THE CHILD.
S1.
(Have you/Has your child) received services from a health care professional such as a doctor, nurse, drug
counselor, mental health counselor, or dentist at {THE REFERENCE HEALTH CENTER / A HEALTH
CENTER} in the last 12 months?
YES ................................ 1
NO.................................. 2
REFUSED ...................... 7
W.............. 9
GO TO S1a
(R NOT ELIGIBLE – THANK R AND END)
(R NOT ELIGIBLE – THANK R AND END)
(R NOT ELIGIBLE – THANK R AND END)
38
S1a. IF HEALTH CENTER NOT KNOWN: What is the name of the health center (you/your minor
child) visited in the past 12 months? ___________________________________________________
S2.
What is (your/
S3.
) age?
______ YEARS
IF S2=13-18: Are you currently living with a parent or guardian?
YES ................................... 1
NO..................................... 2 (R NOT ELIGIBLE – THANK R AND END)
S4.
RECORD GENDER. (IF NECESSARY, ASK: (Are you/Is your child) male or female?
……………
………………
S5.
In what country (were you/was your child) born? (SPECIFY COUNTRY ON SCREENING FORM.)
U.S. ............................... 1
……………… 2 SPECIFY ________________________________
S6.
What race or races do you consider (yourself/your child) to be? You may select all that apply.
…
1=White
2=Black or African American
3=American Indian or Alaska Native (American Indian includes North American, Central American, and
South American Indians)
4=Native Hawaiian
5=Guamanian or Chamorro
6=Samoan
7=Other Pacific Islander
8=Asian (Including: Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese)
9=OTHER (SPECIFY)___________________________________
S6a. IF ASIAN:
Which group best describes (your
ethnic background?
1=Asian Indian
2=Chinese
3=Filipino
4=Japanese
39
5=Korean
6=Vietnamese
7=Other Asian
S7.
(Do you/Does your child) speak
8 =
as your native or primary language?
8 =
8 =6
…… 1 CONTINUE
……… 2 (R NOT ELEGIBLE – THANK R AND END)
QS8 AND S9a FOR CHINESE SPEAKERS ONLY:
S8. What is your dominant or preferred dialect?
……… 1 GO TO QS10
……… 2 GO TO QS10
……… 3 GO TO QS9a
Other Specify: ___________________GO TO QS9a
S9a.
Are you able to communicate in Mandarin (or Cantonese) without difficulty?
…… CONTINUE
………………… (R NOT ELEGIBLE – THANK R AND END)
S9.
In addition to (MANDARIN/CANTONESE/KOREAN/VIETNAMESE), (do you/does your child) speak any
English?
…… CONTINUE
………(CODE “ O A A
S10.
How well (do you/does your child)
” O
W
13 A D E
UI )
…
1. Very well, (R NOT ELEGIBLE FOR SPANISH TESTING– THANK R AND END)
2. Well, (R NOT ELEGIBLE SPANISH TESTING – THANK R AND END)
3. Not well (RECRUIT)
4. Not at all (RECRUIT)
ELIGIBILITY: IF RESPONDENT MEETS THESE CRITERIA – CONTINUE WITH COLLECTION OF CONTACT
INFORMATION, OTHERWISE THANK THEM FOR THEIR TIME AND EXPLAIN THAT THEY DO NOT MEET
THE REQUIREMENTS OF THE STUDY
S1
ONLY YES RESPONSE ELIGIBLE
S3
ONLY YES RESPONSE ELIGIBLE
S7/S10
CHINESE, KOREAN, AND VIETNAMESE SPEAKERS PREFERRED BUT STILL ELIGIBLE FOR
ENGLISH COGNITIVE TESTING IF THEY ONLY SPEAK ENGLISH OR PREFER ENGLISH OVER
THE ASIAN LANGUAGE.
40
NAME: ___________________________________________
GENDER: ( ) MALE
( ) FEMALE
TELEPHONE #: ____________________________ ALTERNATE TELEPHONE # ____________________________
BEST TIME TO CALL: ________________
41
| File Type | application/pdf |
| File Modified | 2013-04-18 |
| File Created | 2013-04-11 |