2014 Health Center Patient Survey
NOTE: We will collect patient address and zip code as part of the consent process.
MODULE A: INTRODUCTION
The first few questions are for statistical purposes only, to help us analyze the results of the study.
……………………………………………………………………………………………………
INTDOB.
What is {FILL: your/name’s} date of birth?
___ ___ MONTH [ALLOW 01-31]
___ __ DAY [ALLOW 01-12]
___ ___ ___ ___YEAR [ALLOW 1900–2009]
……………………………………………………………………………………………………
INTAGE.
Can you tell me {FILL: your/name’s} current age?
IF AGE LESS THAN 12 MONTHS – CODE AS 1 YEAR.
PROBE FOR A BEST ESTIMATE IF NECESSARY
___ ___ ___ AGE IN YEARS [ALLOW 000-109]
[DISABLE DK AND RF OPTIONS]
INT3.
IF SELF-RESPONDENT: RECORD; IF NOT OBVIOUS, ASK: What is your gender?
IF PROXY-RESPONDENT, ASK: What is {FILL: name’s} gender?
IF R ANSWERS THAT THEYARE TRANSGENDER AND WHICH KIND IS NOT OBVIOUS – PROBE IF THEY ALTERED GENDER FROM MALE TO FEMALE OR FROM FEMALE TO MALE
[SHOW OPTIONS 3 AND 4 ONLY FOR RESPONDENTS GE 13 YEARS OLD]
1=MALE
2=FEMALE
3=Transgender male/ TRANS MAn/ Female to Male
4=Transgender female /TRANS WOMAn/ male to FEMale
5=Genderqueer
6=Other
[DISABLE DK AND RF OPTIONS]
……………………………………………………………………………………………………
INT6_OTH [IF INT6=6 CONTINUE ELSE GO TO INT4a]
Please specify gender:
[ ] ALLOW 40
……………………………………………………………………………………………………
INT7.
{FILL: Do you/Does name} speak a language other than English at home?
1=YES
2=NO
PROBE: Did you have any difficulty answering this question? [If yes] Tell me more about why this question was difficult.
……………………………………………………………………………………………………
INT7a. [IF INT7=1 CONTINUE ELSE GO TO MODULE B]
What is this language?
SPECIFY LANGUAGE: _____________________________________
[TEXT FIELD, ALLOW 40]
……………………………………………………………………………………………………
INT7b.
How well {FILL: do you/does name} speak English?
1=Very well
2=Well
3=Not well
4=Not at all
PROBE: Did you have any difficulty answering this question? [If yes] How sure are you of your answer?
……………………………………………………………………………………………………
INT1a.
Are {FILL: you/name} of Hispanic, Latino, or Spanish origin?
1=YES
2=NO
……………………………………………………………………………………………………
INT4.
CODE ONE OR MORE.
1=Mexican, Mexican American, Mexicano or Chicano
2=Puerto Rican
3=Central American
4=South American
5=Cuban or Cuban American
6=Dominican (From Dominican Republic)
7=Spanish (From Spain)
8=Other Latin American, Hispanic, Latino or Spanish Origin (Specify)_____________________
PROBE:
Do these options seem appropriate to you?
Are there any categories you think are missing?
Should any of these categories be said in a different way?
……………………………………………………………………………………………………
[IF INT4=8 CONTINUE, ELSE GO TO INT5]
INT4_OTH You selected Other Latin American, Hispanic, Latino or Spanish Origin. Please specify?
[ ] ALLOW 40
……………………………………………………………………………………………………
INT2
What race or races do you consider {FILL: yourself/name} to be? You may select one or more.
{FILL: Are you/Is he/she}...
NOTE: CODE “NATIVE AMERICAN” AS “AMERICAN INDIAN”
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=Tongan
8=Marshallese
9=Asian Indian
10=Chinese
11=Filipino
12=Japanese
13=Korean
14=Vietnamese
15=OTHER (SPECIFY)
PROBE: Do these options seem appropriate to you? Are there any categories you think are missing? Should any of these categories be said in a different way?
……………………………………………………………………………………………………
[IF INT5=15 CONTINUE, ELSE GO TO INT_MULT]
INT5_OTH
You selected Other race. Please specify?
[ ] ALLOW 40
……………………………………………………………………………………………………
INT5_MULT [IF INT5 = > 1 CONTINUE, ELSE GO TO INT6]
Which one of these groups, that is [READ GROUPS] would you say BEST represents [fill: your/name's] race?
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=Tongan
8=Marshallese
9=Asian Indian
10=Chinese
11=Filipino
12=Japanese
13=Korean
14=Vietnamese
15=OTHER (SPECIFY)
PROBE: How did you go about answering this question?
……………………………………………………………………………………………………
INT5.MULT1 [IF INT5_MULT= 15 CONTINUE, ELSE GO TO INT6]
Please tell me which other race group or groups best describes you.
OTHER RACE GROUP: [_____________] ALLOW 20
……………………………………………………………………………………………………
MODULE B: ACCESS TO CARE
The next set of questions ask about availability of various types of health services. When answering the next few questions, do not include dental care, prescription medicines, counseling or mental health treatment.
……………………………………………………………………………………………………
MED1. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a doctor believe {you/name} needed any medical care, tests, or treatment?
1=YES
2=NO
[MEDCHK2 IF MED1=1, THEN CONTINUE; ELSE GO TO MODULE C]
……………………………………………………………………………………………………
MED2. In the last 12 months, {were you/was name} unable to get medical care, tests, or treatments you or a doctor believed necessary?
1=YES
2=NO
[MEDCHK2a IF MED2=1, THEN CONTINUE; ELSE GO TO MED5]
……………………………………………………………………………………………………
MED2a. Please describe the reasons {you were/name was} unable to get medical care, tests, or treatments you or a doctor believed necessary? You may select one or more.
Please look at this show card.
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
……………………………………………………………………………………………………
MED2a_OTH.
Please specify other reason.
[ ] ALLOW 60
……………………………………………………………………………………………………
MED2a1. Which of these was the main reason {you were/name was} unable to get medical care, tests, or treatments you or a doctor believed necessary?
[LIST ONLY SELECTIONS MADE IN MED2a]
Please look at this show card.
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
……………………………………………………………………………………………………
MED3. What kind of care was it that {you/name} needed but did not get?
_____________ [ALLOW 80]
……………………………………………………………………………………………………
MED5. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, were {you/name} delayed in getting medical care, tests, or treatments you or a doctor believed necessary?
1=YES
2=NO
[MEDCHK5a IF MED5=1, THEN CONTINUE; ELSE GO TO MODULE C]
……………………………………………………………………………………………………
MED5a . Please look at this showcard. Which of these best describes the reasons {you were/name was} delayed in getting medical care, tests, or treatments you or a doctor believed necessary? You may select one or more.
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
……………………………………………………………………………………………………
MED5a1. Which of these was the main reason {you were/name was} delayed in getting medical care, tests, or treatments you or a doctor believed necessary?
[LIST ONLY SELECTIONS MADE IN MED5a]
Please look at this show card.
@BSHOW CARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
……………………………………………………………………………………………………
MED6. What kind of medical care, tests, or treatment was it that {you were/name was} delayed in getting?
_____________[ALLOW 40]
……………………………………………………………………………………………………
MODULE C: ROUTINE CARE
Next, I’m going to ask you about health services that {you/name} received in the past 12 months.
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.
________ TIMES [ALLOW 000-365]
……………………………………………………………………………………………………
ROU2a. Thinking about your most recent emergency room visit, did you go to the emergency room either at night or on the weekend?
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c. Tell me which of these apply to your last emergency room visit?
… You didn't have another place to go
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c1. (Tell me which of these apply to your last emergency room visit?)
… Your doctor’s office or clinic was not open
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c2. (Tell me which of these apply to your last emergency room visit?)
… Your health provider advised you to go
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c3. (Tell me which of these apply to your last emergency room visit?)
… The problem was too serious for the doctor’s office or clinic
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c4. (Tell me which of these apply to your last emergency room visit?)
… Only a hospital could help you
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c5. (Tell me which of these apply to your last emergency room visit?)
… the emergency room is your closest provider
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c6. (Tell me which of these apply to your last emergency room visit?)
…you get most of your care at the emergency room
1=YES
2=NO
……………………………………………………………………………………………………
ROU3. (Were you/Was name} ever hospitalized @Uovernight@u in the past 12 months? Do not include an overnight stay in the emergency room.
1=YES
2=NO
……………………………………………………………………………………………………
ROU4. [ROUCHK4 IF ROU3 = 1 CONTINUE ELSE GOTO ROU5]
Altogether, how many nights {were you/was name} in the hospital during the past 12 months?
_______ NIGHTS [ALLOW 000-365]
……………………………………………………………………………………………………
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 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}.
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 given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.
1=YES
2=NO
[ROUCHK9 IF ROU8 =1, CONTINUE; ELSE GO TO ROU10]
……………………………………………………………………………………………………
ROU9. Did you get the pneumonia vaccination at {the reference health center}?
1=YES
2=NO
……………………………………………………………………………………………………
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
[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?
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?
1=YES
2=NO
[ROUCHK9f IF ROU9d =2, CONTINUE; ELSE GO TO ROU10]
……………………………………………………………………………………………………
ROU9f. Please look at this showcard. Please describe the reasons {name} has not had all the shots that he/she is supposed to have at his/her age? You may select one or more.
@BSHOWCARD ROU9f@B
1=DID NOT THINK IT WAS IMPORTANT
2=AFRAID OF THE SIDE EFFECTS OF THE IMMUNIZATION
3=CHILD WAS SICK AND COULD NOT HAVE IMMUNIZATIONS AT THAT TIME
4=I DON’T TRUST THE SHOTS/ I DON’T BELIEVE IN SHOTS
5=COULDN’T AFFORD CARE
6=PROBLEMS GETTING TO DOCTOR'S OFFICE
7=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
8=COULDN’T GET TIME OFF WORK
9=DIDN’T KNOW WHERE TO GO TO GET CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
……………………………………………………………………………………………………
ROU9f1. 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
[LIST ONLY SELECTIONS MADE IN ROU9f]
1=DID NOT THINK IT WAS IMPORTANT
2=AFRAID OF THE SIDE EFFECTS OF THE IMMUNIZATION
3=CHILD WAS SICK AND COULD NOT HAVE IMMUNIZATIONS AT THAT TIME
4=I DON’T TRUST THE SHOTS/ I DON’T BELIEVE IN SHOTS
5=COULDN’T AFFORD CARE
6=PROBLEMS GETTING TO DOCTOR'S OFFICE
7=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
8=COULDN’T GET TIME OFF WORK
9=DIDN’T KNOW WHERE TO GO TO GET CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
……………………………………………………………………………………………………
NOTE FOR SPECS: Make sure to insert the appropriate age categories for these 2 HPV questions (ROU9f2-3). I don’t know what they are off-hand but you can look up.
ROU9f2. Have you ever received an HPV shot or vaccine?
1 Yes
2 No
3 Doctor refused when asked
……………………………………………………………………………………………………
ROU9f3. IF ROU9f2=1 CONTINUE ELSE GO TO ROU10
Did you have your most recent HPV shot or vaccine at the {reference health center} or some other place?
1 REFERENCE HEALTH CENTER
2 SOME OTHER PLACE
……………………………………………………………………………………………………
[IF AGE GE 18, CONTINUE; ELSE GO TO ROUCHK12]
ROU10. These next questions are about general physicals or routine check-ups.
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
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 GO TO ROUCHK12]
……………………………………………………………………………………………………
ROU11a. Please look at this showcard. Please describe the reasons you have not had a general physical exam or routine check-up in the past 2 years? You may select one or more.
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
……………………………………………………………………………………………………
ROU11a1. 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
[LIST ONLY SELECTIONS MADE IN ROU11a]
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
[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 well-child 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
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[
……………………………………………………………………………………………………
ROU13a. Please look at this showcard. Please describe the reasons {you/name} (has/have) not had a well-child check-up or general check-up in the past 2 years? You may select one or more.
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
……………………………………………………………………………………………………
ROU13a1. Please look at this showcard. What is the main reason {you/name} has not had a well-child check-up or general check-up in the past 2 years?
[LIST ONLY SELECTIONS MADE IN ROU13a]
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
……………………………………………………………………………………………………
LEAD SCREENING
ROU14. [IF AGE 9 MONTHS - 5 YEARS CONTINUE, ELSE GO TO MODULE D]
Has {name} ever had a blood test to check the amount of lead in {his/her} blood?
1=YES
2=NO
[ROUCHK15 IF ROU14=1, CONTINUE; ELSE GO TO ROU17]
……………………………………………………………………………………………………
ROU15. How old was {name} the last 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.
……………………………………………………………………………………………………
ROU16. Was that done at the {reference health center}?
1=YES
2=NO
……………………………………………………………………………………………………
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?
1=YES
2=NO
…………………………………………………………………………………………………
MODULE D: CONDITIONS
CON3. How tall {are you/is name} without shoes?
CON3_UNITS. INTERVIEWER: WAS THE RESPONSE IN FEET AND INCHES OR METERS AND CENTIMETERS?
1=FEET AND INCHES
2= CENTIMETERS
CON3a.
_________ FEET OR METERS [ALLOW 0-8]
_________ INCHES OR CENTIMETERS [ALLOW 00-11]
CON3b.
_________ CENTIMETERS [ALLOW 000-300]
……………………………………………………………………………………………………
CON4. {IF CON2a =1 FILL: “How much do you weigh without clothes or shoes before your pregnancy?” ELSE FILL: “How much {do you/does name} weigh without clothes or shoes?”}
[PROGRAMMERS: ALLOW METRIC; DO NOT ALLOW BLANK RESPONSE]
CON4_UNITS. INTERVIEWER: WAS THE RESPONSE IN POUNDS OR KILOGRAMS?
1=POUNDS
2= KILOGRAMS
CON4a ________ POUNDS [ALLOW 000-555]
CON4b. ________ KILOGRAMS [ALLOW 000.0-200.0]
……………………………………………………………………………………………………
These next questions are about the fruits and vegetables {you/name} ate during the past 30 days. Please think about all forms of fruits and vegetables including cooked or raw, fresh, frozen or canned. Please think about all meals, snacks, and food consumed at home and away from home.
I will be asking how often {you/name} ate each one: for example, once a day, twice a week, three times a month, and so forth.
INTERVIEWER NOTE: If respondent responds less than once per month, put “0” times per month. If respondent gives a number without a time frame, ask: “Was that per day, week, or month?”
CON4c. During the past month, not counting juice, how many times per day, week, or month did {you/name} eat fruit? Count fresh, frozen, or canned fruit.
Read only if necessary: “Your best guess is fine. Include apples, bananas, applesauce, oranges, grape fruit, fruit salad, watermelon, cantaloupe or musk melon, papaya, lychees, star fruit, pomegranates, mangos, grapes, and berries such as blueberries and strawberries.”
INTERVIEWER NOTE: Do not count fruit jam, jelly, or fruit preserves.
Do not include dried fruit in ready-to-eat cereals.
Do include dried raisins, cran-raisins if respondent tells you - but due to their small serving size they are not included in the prompt.
Do include cut up fresh, frozen, or canned fruit added to yogurt, cereal, jello, and other meal items.
Include culturally and geographically appropriate fruits that are not mentioned (e.g. genip, soursop, sugar apple, figs, tamarind, bread fruit, sea grapes, carambola, longans, lychees, akee, rambutan, etc.).
_____ ____ [ALLOW 2 DIGITS]
1 = Times per day
2 = Times per week
3 = Times per month
4 = Never
……………………………………………………………………………………………………
CON4e. During the past month, how many times per day, week, or month did {you/name} eat dark green vegetables for example broccoli or dark leafy greens including romaine, chard, collard greens or spinach?
INTERVIEWER NOTE: Each time a vegetable is eaten it counts as one time.
Include all raw leafy green salads including spinach, mesclun, romaine lettuce, bok choy, dark green leafy lettuce, dandelions, komatsuna, watercress, and arugula.
Do not include iceberg (head) lettuce if specifically told type of lettuce. Include all cooked greens including kale, collard greens, choys, turnip greens, mustard greens.
_____ ____ [ALLOW 2 DIGITS]
1 = Times per day
2 = Times per week
3 = Times per month
4 = Never
……………………………………………………………………………………………………
CON4f. During the past month, how many times per day, week, or month did {you/name} eat orange-colored vegetables such as sweet potatoes, pumpkin, winter squash, or carrots?
Read only if needed: “Winter squash have hard, thick skins and deep yellow to orange flesh. They include acorn, buttercup, and spaghetti squash.”
FOR INTERVIEWER: Include all forms of carrots including long or baby-cut.
Include carrot-slaw (e.g. shredded carrots with or without other vegetables or fruit).
Include all forms of sweet potatoes including baked, mashed, casserole, pie, or sweet potatoes fries.
Include all hard-winter squash varieties including acorn, autumn cup, banana, butternut, buttercup, delicate, hubbard, kabocha (Also known as an Ebisu, Delica, Hoka, Hokkaido, or Japanese Pumpkin; blue kuri), and spaghetti squash. Include all forms including soup.
Include pumpkin, including pumpkin soup and pie. Do not include pumpkin bars, cake, bread or other grain-based desert-type food containing pumpkin (i.e. similar to banana bars, zucchini bars we do not include).
_____ ____ [ALLOW 2 DIGITS]
1 = Times per day
2 = Times per week
3 = Times per month
4 = Never
……………………………………………………………………………………………………
CON4g. Not counting what you just told me about, during the past month, about how many times per day, week, or month did {you/name} eat OTHER vegetables? Examples of other vegetables include tomatoes, tomato juice or V-8 juice, corn, eggplant, peas, lettuce, cabbage, and white potatoes that are not fried such as baked or mashed potatoes.
Read only if needed: “Do not count vegetables you have already counted and do not include fried potatoes.”
INTERVIEWER NOTE: Include corn, peas, tomatoes, okra, beets, cauliflower, bean sprouts, avocado, cucumber, onions, peppers (red, green, yellow, orange); all cabbage including American-style cole-slaw; mushrooms, snow peas, snap peas, broad beans, string, wax-, or pole-beans.
Include any form of the vegetable (raw, cooked, canned, or frozen).
Do not include products consumed usually as condiments including ketchup, catsup, salsa, chutney, relish.
Do include tomato juice if respondent did not count in fruit juice.
Include culturally and geographically appropriate vegetables that are not mentioned (e.g. daikon, jicama, oriental cucumber, etc.).
Do not include rice or other grains.
_____ ____ [ALLOW 2 DIGITS]
1 = Times per day
2 = Times per week
3 = Times per month
4 = Never
……………………………………………………………………………………………………
CON4h. About how often do {you/name} drink regular soda or pop that contains sugar? Do not include diet soda or diet pop.
_____ ____ [ALLOW 2 DIGITS]
1 = Times per day
2 = Times per week
3 = Times per month
4 = Never
……………………………………………………………………………………………………
CON4i. About how often do {you/name} drink sweetened fruit drinks, such as Kool-aid, cranberry, and lemonade? Include fruit drinks you made at home and added sugar to.
1 _ _ Times per day
2 _ _ Times per week
3 _ _ Times per month
4 Never
……………………………………………………………………………………………………
CON4j. Over the past 7 days: How many times did {you/name} eat fast food meals or snacks?
1=Less than 1 time
2=1-3 times
3=4 or more times
……………………………………………………………………………………………………
CON4k. I am 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/your household} in the last 12 months, that is since {12 MONTH REFERENCE DATE}
OFTEN TRUE
SOMETIMES TRUE
NEVER TRUE
a. {I/We} worried whether {my/our} food would run out before {I/we} got money to buy more. ____
b. The food that {I/we} bought just didn’t last, and {I/we} didn’t have enough money to get more food. ____
c. {I/We} couldn’t afford to eat balanced meals. ____
……………………………………………………………………………………………………
CON4l. In the last 12 months, since last {DISPLAY CURRENT MONTH AND LAST YEAR }, did {you/you or other adults in your household} ever cut the size of your meals or skip meals because there wasn’t enough money for food?
1=YES
2= NO
[IF R10 = 1 CONTINUE ELSE GO TO R12]
……………………………………………………………………………………………………
CON4m. How often did this happen…?
1 = Almost every month
2 = Some months but not every month
3 = In only 1 or 2 months
…………………………………………………………………………………………………
CON4n. In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?
1=YES
2= NO
……………………………………………………………………………………………………
CON4o. [In the last 12 months], were you ever hungry but didn’t eat because there wasn’t enough money for food?
1=YES
2= NO
……………………………………………………………………………………………………
CON9o. Next I am going to ask you about the time {you spend/name 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/name’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?
1=YES
2=NO
……………………………………………………………………………………………………
IF CON9o = 1 CONTINUE ELSE GO TO CON9r
CON9p. In a typical week, on how many days {do you/does name} 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.
INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES IN THIS QUESTION.
|___|___| DAYS 1-7
REFUSED
DON’T KNOW
……………………………………………………………………………………………………
CON9q. How much time {do you/does name } spend doing vigorous-intensity activities at work on a typical day?
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.
INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.
|___|___|___|
____MINUTES
____HOURS
……………………………………………………………………………………………………
CON9r. Does {your/ name’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?
1=YES
2=NO
7=REFUSED
9=DON’T KNOW
IF CON9r = 1 CONTINUE ELSE GO TO CON9u
……………………………………………………………………………………………………
CON9s. In a typical week, on how many days {do you/does name} 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.
INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.
|___|___| DAYS
REFUSED
DON’T KNOW
……………………………………………………………………………………………………
CON9t. How much time {do you/does name} spend doing moderate-intensity activities at work on a typical day?
PROBE IF NEEDED: Think about a typical day when {you do/he does/she does} moderate-intensity activities during {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.
INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.
|___|___|___|
____MINUTES
____HOURS
…………………………………………………………………………………………………
CON9u. 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/ name travels} to and from places. For example to work, for shopping, to school.
In a typical week {do you/does name} walk or use a bicycle for at least 10 minutes continuously to get to and from places?
1=YES
2=NO
IF CON9u = 1 CONTINUE ELSE GO TO CON9x
……………………………………………………………………………………………………
CON9v. In a typical week, on how many days {do you/does name} walk or bicycle for at least 10 minutes continuously to get to and from places?
|___|___| DAYS
……………………………………………………………………………………………………
CON9w. How much time {do you/does name } spend walking or bicycling for travel on a typical day?
PROBE IF NEEDED: Think about a typical day when {you walk or bicycle/ name walks or bicycles} for travel.
|___|___|___|
1= MINUTES
2= HOURS
…………………………………………………………………………………………………
CON9x. The next questions exclude the work and transportation activities that you have already mentioned. Now I would like to ask you about sports, fitness and recreational activities.
In a typical week {do you/does name } 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?
1=YES
2=NO
IF CON9x = 1 CONTINUE ELSE GO TO CON9z1
……………………………………………………………………………………………………
CON9y. In a typical week, on how many days {do you/does name} 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.
|___|___| DAYS
REFUSED
DON’T KNOW
……………………………………………………………………………………………………
CON9z. How much time {do you/does name} 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.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
ENTER UNIT
1=MINUTES
2=HOURS
……………………………………………………………………………………………………
CON9z1. In a typical week {do you/does name} 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 golf for at least 10 minutes continuously?
1=YES
2=NO
IF CON9z1 = 1 CONTINUE ELSE GO TO CON9z4
……………………………………………………………………………………………………
CON9z2. In a typical week, on how many days {do you/does name } 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.
|___|___|
ENTER NUMBER OF DAYS
……………………………………………………………………………………………………
CON9z3. How much time {do you/does name} spend doing moderate-intensity sports, fitness or recreational activities on a typical day?
IF NEEDED: Think about a typical day when {you do/ name does} moderate-intensity sports, fitness or recreational activities.
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.
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
ENTER UNIT
1=MINUTES
2=HOURS
……………………………………………………………………………………………………
CON9z4. The following question is about sitting at work, 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 name} usually spend sitting on a typical day?
|___|___|___|
ENTER NUMBER OF MINUTES OR HOURS
ENTER UNIT
1=MINUTES
2=HOURS
……………………………………………………………………………………………………
CON9N1 Now I will ask you first about TV watching and then about 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 . . .
1=less than 1 hour
2=1 hour
3=2 hours,
4=3 hours,
5=4 hours,
6=5 hours or more, or
7={You do/ Name does} not watch TV or videos
……………………………………………………………………………………………………
CON9n2. Over the past 30 days, on average how many hours per day did {you/ Name} use a computer or play computer games outside of work or school? Include Playstation, Nintendo DS, or other portable video games. Would you say . . .
NOTE: 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.
1 = less than 1 hour
2 = 1 hour
3 = 2 hours
4 = 3 hours
5 = 4 hours
6 = 5 hours or more, or
7 = {You do/SP does} not use a computer outside of work or school
……………………………………………………………………………………………………
CON9n3. “On average, how many hours of sleep do you get in a 24-hour period?”
|__|__| hours
……………………………………………………………………………………………………
CON1. Would you say {your/name’s} health in general is excellent, very good, good, fair, or poor?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR
……………………………………………………………………………………………………
CON1a. Compared with 12 months ago, that is since {12 MONTH REFERENCE DATE}, would you say {your/name’s} health is now better, worse, or about the same?
1=BETTER
2=WORSE
3=ABOUT THE SAME
……………………………………………………………………………………………………
[IF (INT6=2 OR 3) AND INTAGE = 15-49 CONTINUE ELSE GO TO CON5]
CON2. Have you ever been pregnant?
1=YES
If CON2=1 continue, else go to CON5.
……………………………………………………………………………………………………
CON2a. Are you currently pregnant?
1=YES
2=NO
……………………………………………………………………………………………………
CON5. {IF CON2a=1, FILL: “What did you consider yourself to be before you were pregnant, overweight, underweight, or just about right?” ELSE FILL: “Do you consider yourself now to be overweight, underweight, or just about right?”}
1=OVERWEIGHT
2=UNDERWEIGHT
3=ABOUT RIGHT
……………………………………………………………………………………………………
CON6a. {IF CON2=1 AND AGE UNDER 50 FILL: How much did you weigh a year ago? If you were pregnant a year ago, please tell us how much you weighed before becoming pregnant. ELSE FILL: How much did you weigh a year ago?}
[ALLOW METRIC; DO NOT ALLOW BLANK RESPONSE]
CON6a_UNITS. INTERVIEWER: WAS THE RESPONSE IN POUNDS OR KILOGRAMS?
1=POUNDS
2= KILOGRAMS
3.
TWeight. ________ POUNDS [ALLOW 000-555] [AFTER TWeight, GO TO CON6b]
TWeightM. _______ KILOGRAMS [ALLOW 000.0-200.0]
……………………………………………………………………………………………………
CON6b. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, have you tried to lose weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON6c. How did you try to lose weight?
CODE ONE OR MORE.
1=CHANGED WHAT I ATE OR HOW MUCH I ATE OR WHEN I ATE
2=EXERCISED
3=JOINED A WEIGHT LOSS PROGRAM
4=TOOK DIET PILLS PRESCRIBED BY A DOCTOR
5=TOOK OTHER PILLS, MEDICINES, HERBS, OR SUPPLEMENTS NOT NEEDING A PRESCRIPTION
6=STARTED TO SMOKE OR BEGAN TO SMOKE AGAIN
7=TOOK LAXATIVES OR VOMITED
8=DRANK A LOT OF WATER
9=OTHER (SPECIFY)
……………………………………………………………………………………………………
CON7. During the past 12 months, has a doctor or other health professional told you that you had a problem with your weight?
1=YES
2=NO
……………………………………………………………………………………………………
[IF CON7=1 CONTINUE ELSE GO TO CON8]
CON7a. Was this at {the reference health center} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
……………………………………………………………………………………………………
CON8. Has a doctor or other health professional ever talked to you about things you can do to manage your weight, such as meal planning and nutrition?
1=YES
2=NO
……………………………………………………………………………………………………
[IF CON8=1 CONTINUE ELSE GO TO CON8a3]
CON8a1. Was this at {the reference health center} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
……………………………………………………………………………………………………
CON8a3. Has a doctor or other health professional ever talked to you about things you can do to manage your weight, such as an exercise program?
1=YES
2=NO
……………………………………………………………………………………………………
[IF CON8a3=1 CONTINUE ELSE GO TO CON8a6]
CON8a4. Was this at {the reference health center} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
……………………………………………………………………………………………………
CON8a6. Has a doctor or other health professional ever suggested you visit a nutritionist because of your weight?
1=YES
2=NO
……………………………………………………………………………………………………
[IF CON8a6=1 CONTINUE ELSE GO TO CON8a8]
CON8a7. Was this at {the reference health center} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
…………………………………………………………………………………………………
If CON8=1 continue, else go to CON8b1.
CON8b. Have you made changes to your eating and nutrition practices since receiving advice about your weight?
1=YES
2=NO
……………………………………………………………………………………………………
If CON8a3=1 continue, else go to CON9a.
CON8b1. Have you began an exercise program since receiving advice about your weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON9a. Has a doctor or other health professional ever prescribed medications to help you lose weight?
1=YES
2=NO
……………………………………………………………………………………………………
[IF CON9a=1 CONTINUE ELSE GO TO CON9c]
CON9b1. Was this at {the reference health center} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
……………………………………………………………………………………………………
CON9c. In the past 12 months, {did you/did SP} seek help from a personal trainer, dietitian, nutritionist, doctor or other health professional to lose weight?
YES
NO
REFUSED
DON’T KNOW
……………………………………………………………………………………………………
CON9f. Have you ever sought consultation or been evaluated for any surgical weight loss procedures such as gastric bypass or adjustable gastric band in order to lose weight?
Yes
No
REFUSED
DON’T KNOW
……………………………………………………………………………………………………
If CON9f=1 continue, else go to CON9g.
CON9f1. Have you ever received surgery for weight loss?
Yes
No
REFUSED
DON’T KNOW
……………………………………………………………………………………………………
[IF CON9f1=1 CONTINUE ELSE GO TO CON9g]
CON9f2. How much weight did you lose as a result of the surgery?
|___|___|___| ENTER NUMBER OF POUNDS
GO TO CON10
……………………………………………………………………………………………………
CON9g. How much weight {did you/did SP} lose in {your/his/her} most successful attempt ever to lose weight?
L/K ENTER WEIGHT IN POUNDS OR KILOGRAMS
HELP SCREEN: This question refers only to deliberate attempts to lose weight; it does not refer to weight loss because of illness, side effects of medication, stress, or other unintended causes.
|___|___|___| ENTER NUMBER OF POUNDS
……………………………………………………………………………………………………
HIGH BLOOD PRESSURE
[CONCHK10 IF AGE GE 2, THEN CONTINUE; ELSE GO TO CON11 ]
CON10. Now I am going to ask you about certain medical conditions.
Have you ever been told by a doctor or other health professional that {you/name} had hypertension, also called high blood pressure?
IF NEEDED: Blood pressure is checked by a health care provider using a blood pressure cuff placed on your upper arm and a stethoscope.
1=YES
2=NO
…………………………………………………………………………………………………
CON10b. About how long has it been since {you/name} had {your/his/her} blood pressure checked by a doctor, nurse, or other health professional?
88=BLOOD PRESSURE CHECKED TODAY
99= NEVER
_______ MONTHS AGO [ALLOW 00-12]
_______ YEARS AGO [ALLOW 00-109]
[CONCHK10c IF CON10 = 1 CONTINUE, ELSE GO TO CON11]
……………………………………………………………………………………………………
CON10c. During the most recent visit, were you told {you/name} had high blood pressure?
1=YES
2=NO
PROBE: What does the term “high blood pressure” mean to you?
Did you have any difficulty answering this question? [If yes] Tell me more about that.
……………………………………………………………………………………………………
CON10d. {Are you/Is name} now taking any medications to control {your/his/her} high blood pressure?
1=YES
2=NO
PROBE: What does the term “medications” mean to you?
What does the term “control” mean to you in this question?
……………………………………………………………………………………………………
HEPATITIS B AND C
CON11_hep. Have you EVER been told by a doctor or health professional that {you/name} had hepatitis?
1=YES
2=NO
PROBE: Did you have any difficulty answering this question?
Are you familiar with the term “hepatitis”? [If yes] What does it mean?
……………………………………………………………………………………………………
IF CON11=1 CONTINUE ELSE GO TO CON11a
CON11_hep1. What type of hepatitis were {you/name} diagnosed with? Select one of more.
1=Hepatitis A
2=Hepatitis B
3=Hepatitis C
……………………………………………………………………………………………………
CON14m_current. [IF CON11a1=3 CONTINUE, ELSE GO TO CON11a]
{Do you/Does name} CURRENTLY still have Hepatitis C?
1=YES
2=NO
……………………………………………………………………………………………………
CON11a. {Have/Has} {you/name} EVER received the hepatitis B vaccine?
IF NECESSARY: This is given in three separate doses and has been available since 1991. It is recommended for newborn infants, adolescents, and people such as health care workers, who may be exposed to the hepatitis B virus.
1=YES
2=NO
3=Don’t Know
4=Refused
PROBE: Please repeat the explanation of the vaccine in your own words.
……………………………………………………………………………………………………
If CON11a=1 continue, else go to CON11.
CON11_hepb. Did {you/name} receive at least 3 doses of the hepatitis B vaccine, or less than 3 doses?
1=Received at least 3 doses
2=Received less than 3 doses
PROBE: What does the term “doses” mean to you?
Did you have any difficulty remembering how many doses you received?
……………………………………………………………………………………………………
CON11_test. {Have you/Has name}EVER been tested for the following…
a. Hepatitis B
b. Hepatitis C
1=YES
2=NO
……………………………………………………………………………………………………
CON11_b1. [IF CON11_testa=1 CONTINUE, ELSE GO TO CON11_c1]
When was your most recent test for Hepatitis B?
1= 3 months ago or less
2= 3 months but less than 1 year ago
3= 1 year but less than 3 years ago
4= 3 or more years ago
……………………………………………………………………………………………………
CON11_b2.
Was your most recent test for Hepatitis B here at {reference heath center} or somewhere else?
1= REFERENCE HEALTH CENTER
2= SOMEWHERE ELSE
3=Don’t Know
4=Refused
……………………………………………………………………………………………………
CON11_c1. IF CON11_testb=1 CONTINUE ELSE GO TO CON11
When was your most recent test for Hepatitis C?
1= 3 months ago or less
2= Between 3 months but less than 1 year ago
3= Between 1 year but less than 3 years ago
4 = 3 or more years go
5= Don’t Know
6= Refused
……………………………………………………………………………………………………
CON11_c2.
Was your most recent test for Hepatitis C here at {REFERENCE HEALTH CENTER} or somewhere else?
1= REFERENCE HEALTH CENTER
2= SOMEWHERE ELSE
3= Don’t Know
4= Refused
……………………………………………………………………………………………………
ASTHMA
CON11. Have you ever been told by a doctor or other health professional that {you/name} had asthma?
1=YES
2=NO
[CONCHK11a IF CON11 = 1, CONTINUE; ELSE GOTO CON12]
……………………………………………………………………………………………………
CON11a. {Do you/Does name} still have asthma?
1=YES
2=NO
……………………………………………………………………………………………………
[CONCHK11c IF CON11a = 1, CONTINUE; ELSE GO TO CON12]
CON11b. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have you/has name} had an episode of asthma or an asthma attack?
1=YES
2=NO
……………………………………………………………………………………………………
DIABETES
CON12. Have you ever been told by a doctor or health professional that {you/name} had diabetes or sugar diabetes?
1=YES
2=NO
……………………………………………………………………………………………………
IF CON12 = 1 CONTINUE ELSE GO TO CON12a
CON12a1. Were you told that {youname} had Type 1 or Type 2 diabetes?
1=TYPE 1 DIABETES
2=TYPE 2 DIABETES
……………………………………………………………………………………………………
IF CON12 = 2 CONTINUE ELSE GO TO CON12b
CON12a. Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?
1=Yes
2=No
7=Don‘t know
9=Refused
PROBE: What does the term “borderline” diabetes mean to you?
What does the term “pre-diabetes” mean to you?
[CONCHK12a IF CON12 = 1, CONTINUE; ELSE GO TO CONCHK13]
……………………………………………………………………………………………………
CON12b. How old {were you/was name} when a doctor first told you that {you/he/she)} had diabetes?
________ AGE IN YEARS [ALLOW 000-110]
……………………………………………………………………………………………………
[IF CON12=1 AND FEMALE CONTINUE ELSE GO TO CON13]
CON12c. Was this only when you were pregnant?
1 Yes
2 No
7 Don‘t know
9 Refused
……………………………………………………………………………………………………
OTHER HEALTH CONDITIONS
[CONCHK13 IF AGE GE 18, CONTINUE; ELSE GOTO CON14a]
CON13. These next questions are about blood cholesterol.
About how long has it been since {you/name} had {your/his/her} blood cholesterol checked by a doctor, nurse, or other health professional?
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
6=AT LEAST 4 YRS, LESS THAN 5 YEARS
7=5 OR MORE YEARS AGO
[CONCHK13a IF CON13 = 1 OR DK OR RF, GO TO CON14a; ELSE CONTINUE]
……………………………………………………………………………………………………
CON13a. Was this at {the reference health center} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
……………………………………………………………………………………………………
CON13b. Have you ever been told by a doctor or other health professional that {your/name’s} blood cholesterol level was high?
1=YES
2=NO
……………………………………………………………………………………………………
CON13d. During the most recent visit, were you told {you/name} had high cholesterol?
1=YES
2=NO
PROBE: How sure are you of your answer?
……………………………………………………………………………………………………
CON14a. The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told {you/name} that {you/he/she} had…
congestive heart failure?
1=YES
2=NO
……………………………………………………………………………………………………
CON14b. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told {you/name} that {you/he/she} had…)
coronary heart disease?
1=YES
2=NO
……………………………………………………………………………………………………
CON14c. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told {you/name} that {you/he/she} had…)
Angina, also called angina pectoris?
1=YES
2=NO
……………………………………………………………………………………………………
CON14d. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told {you/name} that {you/he/she} had…)
a heart attack, it is also called myocardial infarction?
1=YES
2=NO
……………………………………………………………………………………………………
CON14e. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told {you/name} that {you/he/she} had…)
a stroke?
1=YES
2=NO
……………………………………………………………………………………………………
CON14f. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told {you/name} that {you/he/she} had…)
chronic obstructive pulmonary disorder (also known as COPD, emphysema or chronic bronchitis)?
1=YES
2=NO
………………………………………………………………………………………
CON14i. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told {you/name} that {you/he/she} had…)
any kind of liver condition other than hepatitis?
1=YES
2=NO
……………………………………………………………………………………………………
CON14j. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told {you/name} that {you/he/she} had…)
weak or failing kidneys
1=YES
2=NO
……………………………………………………………………………………………………
CON14k. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told {you/name} that {you/he/she} had…)
Tuberculosis (TB)
1=YES
2=NO
……………………………………………………………………………………………………
CON9z. A traumatic brain injury may result from a violent blow to the head or when an object pierces the skull and enters the brain tissue. Has a doctor or other health professional ever told you that {you/name} {have/has} suffered a traumatic brain injury (TBI)?
YES
NO
REFUSED
DON’T KNOW
……………………………………………………………………………………………………
CON14i_current. {Do you/Does name} CURRENTLY still have any kind of liver condition other than hepatitis?
1=YES
2=NO
[CONCHK14k_current IF CON14k = 1 (YES) THEN CONTINUE; ELSE MOVE TO LOGIC PRECEDING THE NEXT QUESTION]
……………………………………………………………………………………………………
CON14k_current. {Do you/Does name} CURRENTLY still have Tuberculosis (TB)?
1=YES
2=NO
……………………………………………………………………………………………………
CON14k_current1 [IF CON14k_current=1 CONTINUE ELSE GO TO CON16]
{Do you/Does name} CURRENTLY still have active TB?
1=YES
2=NO
PROBE: Was this question difficult to answer? [If yes] Tell me more about that.
……………………………………………………………………………………………………
CON16. During the past 12 months, {have you/ has name} had Pneumonia?
1=YES
2=NO
[CONCHK19 IF AGE GE 2 GO TO CON19; ELSE GO TO CON25]
……………………………………………………………………………………………………
CANCER
CON19. Have you ever been told by a doctor or other health professional that {you/name} had cancer or a malignancy of any kind?
1=YES
2=NO
[CONCHK20 IF CON19 = 1, CONTINUE; ELSE GO TO CON25]
……………………………………………………………………………………………………
CON20. Please look at this showcard. What kind of cancer was it? You may select up to 3 kinds of cancer.
@BSHOWCARD CON1@B
a __________
b __________
c __________
1=BLADDER
2=BLOOD
3=BONE
4=BRAIN
5=BREAST
6=CERVIX
7=COLON
8=ESOPHAGUS
9=GALLBLADDER
10=KIDNEY
11=LARYNX-WINDPIPE
12=LEUKEMIA
13=LIVER
14=LUNG
15=LYMPHOMA
16=MELANOMA
17=MOUTH/TONGUE/ LIP
18=OVARY
19=PANCREAS
20=PROSTATE
21=RECTUM
22=SKIN (NON-MELANOMA)
23=SKIN (DON’T KNOW WHAT KIND)
24=SOFT TISSUE (MUSCLE OR FAT)
25=STOMACH
26=TESTIS
27=THROAT - PHARYNX
28=THYROID
29=UTERUS
30=OTHER (SPECIFY)
……………………………………………………………………………………………………
HEARING
The next few questions are about {your/name’s} hearing and vision.
CON25. {Are you/Is name} deaf or {do you/does name} have serious difficulty hearing?
1=YES
2=NO
PROBE: What does the term “serious difficulty” mean to you?
Did you have any difficulty answering this question? [If yes] Tell me more about what was difficult about this question.
……………………………………………………………………………………………………
VISION
CON26. Are you/ Is name} blind or do you have serious difficulty seeing, even when wearing glasses?
[IF AGE UNDER 2:] {Does name} have any trouble seeing?
1=YES
2=NO
[CONCHK27 IF AGE GE 10 CONTINUE; ELSE GO TO MODULE E ]
……………………………………………………………………………………………………
CON27a. {Do you/ Does name} have difficulty…
dressing or bathing?
1=YES
2=NO
……………………………………………………………………………………………………
CON27c. {Do you/ Does name} need help with…
eating?
1=YES
2=NO
……………………………………………………………………………………………………
CON27d. {Do you/ Does name} need help with…
getting in or out of bed or chairs?
1=YES
2=NO
……………………………………………………………………………………………………
CON27e. {Do you/ Does name} need help with…
using the toilet, including getting to the toilet?
1=YES
2=NO
……………………………………………………………………………………………………
CON27f. {Do you/ Does name} have serious difficulty…
walking or climbing stairs?
1=YES
2=NO
PROBE: Please tell me what “serious difficulty” means to you.
Did you have any difficulty answering this question? [If yes] Tell me more about what was difficult about this question.
[CONCHK28 IF AGE GE 18, CONTINUE; ELSE GO TO MODULE E]
……………………………………………………………………………………………………
CON28. Because of a physical, mental, or emotional condition, [do you/does name] have difficulty doing errands alone such as visiting a doctor’s office or shopping?
1=YES
2=NO
PROBE: How easy or hard was this question to answer for you? Why?
[CONCHK29 IF AGE GE 18, CONTINUE; ELSE GO TO MODULE E ]
……………………………………………………………………………………………………
CON30. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
1=YES
2=NO
PROBE: Please think out loud about this question. How did you go about answering this question?
………………………………………………………………………………………………
MODULE E: CONDITIONS – FOLLOWUP
HIGH BLOOD PRESSURE
[CONFCHK1 I_INTRO CON10=1, THEN CONTINUE; ELSE GO TO CONFCHK4]
Earlier you mentioned that {you/name} had been told that {you/he/she} had high blood pressure. I’d like to ask a few more questions about that.
[CONFCHK1 IF CON2=1 AND AGE UNDER 50, CONTINUE; ELSE GO TO CONF1a]
CONF1. Did you only have high blood pressure during pregnancy?
1=YES
2=NO
[CONFCHK1a IF CONF1=1, GO TO CONCHK4; ELSE CONTINUE]
………………………………………………………………………………………………
CONF1a. Because of {your/name’s} high blood pressure, has a doctor or other health professional EVER advised {you/him/her} to…..
………………………………………………………………………………………………
CONF1a_a. go on a diet or change {your/his/her} eating habits to help lower {your/his/her} blood pressure?
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_a1. IF CONF1a_a=1 CONTINUE ELSE GO TO CONF1a_a3
Was this at {the reference health center} or some other place?
1=REFERENCE EHALTH CENTER
2=SOME OTHER PLACE
………………………………………………………………………………………………
CONF1a_a2. {Are you/Is Name} now following this advice to go on a diet or change {your/his/her} eating habits to help lower {your/his/her} blood pressure?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_b. (Because of {your/name’s} high blood pressure, has a doctor or other health professional EVER advised {you/him/her} to…)
cut down on salt or sodium in {your/his/her} diet?
1=YES
2=NO
………………………………………………………………………………………………
[IF CONF1a_b=1 CONTINUE ELSE GO TO CONF1a_c.]
CONF1a_b1. Was this at {the reference health center} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
………………………………………………………………………………………………
CONF1a_b3. {Are you/Is Name} now following this advice cut down on salt or sodium in {your/his/her} diet?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_c. (Because of {your/name’s} high blood pressure, has a doctor or other health professional EVER advised {you/him/her} to…)
exercise?
1=YES
2=NO
………………………………………………………………………………………………
[IF CONF1a_c=1 CONTINUE ELSE GO TO CONFCHK1a_d]
CONF1a_c1. Was this at {the reference health center} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
………………………………………………………………………………………………
CONF1a_c3. {Are you/Is Name} now following this advice to exercise?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO
[CONFCHK1a_d IF AGE GE 21 ASK CONF1a_d; ELSE GO TO LOGIC PRECEDING THE NEXT QUESTION]
………………………………………………………………………………………………
CONF1a_d. (Because of {your/name’s} high blood pressure, has a doctor or other health professional EVER advised {you/him/her} to…)
cut down on alcohol use?
1=YES
2=NO
………………………………………………………………………………………………
[IF CONF1a_d=1 CONTINUE ELSE GO TO CONF2]
CONF1a_d1. Was this at {the reference health center} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
………………………………………………………………………………………………
CONF1a_d3. {Are you/Is Name} now following this advice to cut down on alcohol use?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO
………………………………………………………………………………………………
CONF2. IF CON10 = 1 AND CONF1=2 CONTINUE, ELSE GO TO CONFCHK1i_b
Was any medication ever prescribed by a doctor for {your/name’s} high blood pressure?
1=YES
2=NO
………………………………………………………………………………………………
[IF CONF2 =1 CONTINUE ELSE GO TO CONFCHK2a]
CONF2a. Was this at {reference health center} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
[CONFCHK2a IF CONF2= 1, CONTINUE; ELSE GOT TO CONF4 ]
………………………………………………………………………………………………
CONF2a. {Are you/Is Name} now taking any medicine prescribed by a doctor for {your/his/her} high blood pressure?
1=YES
2=NO
[CONFCHK2b IF CONF2a=2 CONTINUE, ELSE GO TO CONF3]
………………………………………………………………………………………………
CONF2b. Did a doctor advise {you/name} to stop taking the medicine?
1=YES
2=NO
………………………………………………………………………………………………
CONF3. {Do you/Does name} regularly check {your/his/her} own blood pressure?
1=YES
2=NO
………………………………………………………………………………………………
CONF3a. During the last 6 months, have you received any of the following to teach {you/him/her} how to take care of {your/his/her} high blood pressure?
A telephone call from {reference health center}?
1=YES
2=NO
………………………………………………………………………………………………
CONF3b. (During the last 6 months, have you received any of the following to teach {you/him/her} how to take care of {your/his/her} high blood pressure?)
An appointment with a nurse at {reference health center}?
1=YES
2=NO
……………………………………………………………………………………………
CONF3c. (During the last 6 months, have you received any of the following to teach {you/him/her} how to take care of {your/his/her} high blood pressure?)
A visit from staff at {reference health center}? That is, someone came to see you.
1=YES
2=NO
………………………………………………………………………………………………
CONF3d. (During the last 6 months, have you received any of the following to teach {you/him/her} how to take care of {your/his/her} high blood pressure?)
A referral from the {reference health center} to see a specialist
1=YES
2=NO
PROBE: What does “referral” mean to you?
……………………………………………………………………………………………
CONF3e. In the past year, {have you/has name} been in the hospital or visited an emergency room because of high blood pressure?
1=YES
2=NO
PROBE: How certain do you feel about your answer? How did you remember that?
………………………………………………………………………………………………
CONF3f. Has any doctor or nurse (you see/name sees) for {your/his/her} high blood pressure given {you/him/her} a plan to manage {your/his/her} own care at home?
1=YES
2=NO
[CONFCHK3g IF CONF3f=1, CONTINUE; ELSE GO TO CONF3h ]
………………………………………………………………………………………………
CONF3g. Was this plan given to {you/name} by a doctor or nurse at {the reference health center}?
1=YES
2=NO
………………………………………………………………………………………………
CONF3h. How confident {are you/is name} that {you/he/she} can control and manage {your/his/her} high blood pressure. {Are you/Is he/she}...
1=Very confident
2=Somewhat confident
3=Not too confident
4=Not at all confident
[CONFCHK4 IF CON11a=1 or CON11b=1, CONTINUE; ELSE GO TO CONFCHK5 ]
………………………………………………………………………………………………
ASTHMA
CONF4. Earlier, you indicated that {you/name} had been told by a doctor or other health professional that {you/he/she} had asthma. I’d like to ask you a few more questions about that.
1=CONTINUE
………………………………………………………………………………………………
CONF4a. In the past year, {have you/has name} been in the hospital or visited an emergency room because of asthma?”
1=YES
2=NO
………………………………………………………………………………………………
CONF4b. {Have you\Has name} ever used a PRESCRIPTION inhaler?
1=YES
2=NO
[CONFCHK4c IF CONF4b=1, CONTINUE; ELSE GO TO CONF4d ]
………………………………………………………………………………………………
CONF4c. Now I'm going to ask you about two different kinds of @Uasthma@U medicine. One is for quick relief. The other does not give quick relief but protects the lungs and prevents symptoms over the long term.
During the past 3 months, {have you/has name} used the kind of prescription inhaler that {you breathe/he/she breathes} in through {your/his/her} mouth, which gives quick relief from asthma symptoms?
1=YES
2=NO
…………………………………………………………………………………………
CONF4d. {Have you/Has name} @Uever@U taken the preventive kind of @U asthma @U medicine used every day to protect {your/his/her} lungs and keep {you/him/her} from having attacks? Include both oral medicine and inhalers. This is different from inhalers used for quick relief.
1=YES
2=NO
[CONCHK4e IF CONF4d=1, CONTINUE; ELSE GO TO CONF4f ]
………………………………………………………………………………………………
CONF4e. {Are you/Is name} @Unow@U taking this medication that protects {your/his/her} lungs daily or almost daily?
1=YES
2=NO
………………………………………………………………………………………………
CONF4f. {Have you/Has name} @Uever@U taken a course or class on how to manage asthma {yourself/himself/herself}?
1=YES
2=NO
………………………………………………………………………………………………
CONF4g. Has a doctor or other health professional @Uever@U taught {you/name} how to….
recognize early signs or symptoms of an asthma episode?
1=YES
2=NO
………………………………………………………………………………………………
CONF4h. Has a doctor or other health professional @Uever@U taught {you/name} how to….
respond to episodes of asthma?
1=YES
2=NO
………………………………………………………………………………………………
CONF4i. Has a doctor or other health professional @Uever@U taught {you/name} how to….
monitor peak flow for daily therapy?
1=YES
2=NO
………………………………………………………………………………………………
CONF4j. Has a doctor or other health professional ever advised {you/name} to change things in {your/his/her} home, school, or work to improve {your/his/her} asthma?
1=YES
2=NO
3=WAS TOLD NO CHANGES NEEDED
………………………………………………………………………………………………
CONF4k1. During the last 6 months, {have you/has name} received any of the following to teach {you/him/her} how to take care of your asthma?
A telephone call from {the reference health center}
1=YES
2=NO
………………………………………………………………………………………………
CONF4k2. (During the last 6 months, {have you/has name} received any of the following to teach {you/him/her} how to take care of your asthma?)
An appointment with nurse at {the reference health center}
1=YES
2=NO
………………………………………………………………………………………………
CONF4k3. (During the last 6 months, {have you/has name} received any of the following to teach {you/him/her} how to take care of your asthma?)
A visit, that is someone came to see you from {the reference health center}
1=YES
2=NO
………………………………………………………………………………………………
CONF4k4. (During the last 6 months, {have you/has name} received any of the following to teach {you/him/her} how to take care of your asthma?)
A referral to a specialist by {the reference health center}
1=YES
2=NO
………………………………………………………………………………………………
CONF4k5. Has a doctor or nurse {you see/name sees} at {the reference health center} for {your/his/her} asthma given {you/him/her} a plan to manage {your/his/her} own care at home?
1=YES
2=NO
[CONFCHK4k6 IF CONF4k5=1, CONTINUE; ELSE GO TO CONFCHK5]
………………………………………………………………………………………………
CONF4k6. Was this plan given to {you/name} by a doctor or nurse at {the reference health center}?
1=YES
2=NO
………………………………………………………………………………………………
CONF4k7. How confident {are you/is name} that {you/he/she} can control and manage {your/his/her} asthma. {Are you/Is he/she}...
1=Very confident
2=Somewhat confident
3=Not too confident
4=Not at all confident
[CONFCHK5 IF CON12=1, CONTINUE; ELSE GO TO CON22]
………………………………………………………………………………………………
CONF5. Earlier, you indicated that {you/name} had diabetes. I’d like to ask you a few more questions about that. {Are you/Is name} now taking insulin?
1=YES
2=NO
[CONFCHK5a IF CONF5=1, CONTINUE; ELSE GO TO CONF5b ]
………………………………………………………………………………………………
CONF5a. {Are you/Is name} now taking diabetic pills to lower {your/his/her} blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.
1=YES
2=NO
………………………………………………………………………………………………
CONF5b. How often {do you check your/does name check his/her} blood for glucose or sugar? Include times when checked by a family member or friend, but do not include times when checked by a doctor or other health professional. Do not include urine tests.
NEVER=0
______ TIMES [ALLOW 0-9]
TIME PERIOD:
1=DAY
2=WEEK
3=MONTH
4=YEAR
………………………………………………………………………………………………
CONF5c. Glycosylated (GLY-CO-SYL-AT-ED) hemoglobin or the “A one C” test measures the average level of blood sugar over the past 3 months, and usually ranges between 5 and 14. During the past 12 months, how many times has a doctor or other health professional checked {you/name} for glycosylated hemoglobin or A one C?
NEVER=0
______ TIMES [ALLOW 0-9]
………………………………………………………………………………………………
The last time a doctor or other health professional checked your blood sugar level, did he or she tell you it was too high, too low, or just right?
1=Too high
2=Too low
3=Just right
………………………………………………………………………………………………
CONF5e1. During the last 6 months, {have you/ has name} received any of the following to teach {you/him/her} how to take care of {your/his/her} diabetes?
A telephone call from {the reference health center}?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e2. (During the last 6 months, {have you/ has name} received any of the following to teach {you/him/her} how to take care of {your/his/her} diabetes?)
An appointment with a nurse at {the reference health center}?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e3. (During the last 6 months, {have you/ has name} received any of the following to teach {you/him/her} how to take care of {your/his/her} diabetes?)
A visit, that is someone came to see you from {the reference health center}?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e4. (During the last 6 months, {have you/ has name} received any of the following to teach {you/him/her} how to take care of {your/his/her} diabetes?)
A referral to a specialist by {the reference health center}?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e4a. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have you/has name} had an eye exam by an optometrist, ophthalmologist, eye doctor, or someone who prescribes eyeglasses?
1=YES
2=NO
PROBE: How hard was it to remember that? ………………………………………………………………………………………………
CONF5e4b. (During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have you/has name} had a foot exam by a foot doctor?
1=YES
2=NO
PROBE: How hard is it to remember about a foot exam over the last 12 months?
Did you have any difficulty answering this question? [If yes] Tell me more about what was difficult about this question. ………………………………………………………………………………………………
CONF5e5. In the past year, {have you/has name} been in the hospital or visited an emergency room because of diabetes?
1=YES
2=NO
PROBE: How certain do you feel about your answer? How did you remember that?
………………………………………………………………………………………………
CONF5e6. Has any doctor or nurse {you see/name sees} for {your/his/her} diabetes given {you/him/her} a plan to manage {your/his/her} own care at home?
1=YES
2=NO
………………………………………………………………………………………………
[CONFCHK5e7 IF CONF5e6 = 1 CONTINUE, ELSE GO TO CON22]
CONF5e7. Was this plan given to {you/name} by a doctor or nurse at {the reference health center}?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e8. How confident {are you/is name} that {you/he/she} can control and manage {your/his/her} diabetes? {Are you/Is he/she}...
1=Very confident
2=Somewhat confident
3=Not too confident
4=Not at all confident
………………………………………………………………………………………………
CHOLESTEROL
[CONCHK22 IF CON13b=1, CONTINUE; ELSE GO TO MODULE F]
CON22. Earlier you mentioned that you were told by a doctor or other health professional that your blood cholesterol level was high.
CON22a. To lower {your/his/her} blood cholesterol, {have you/has name} ever been told by a doctor or other health professional…
to eat fewer high fat or high cholesterol foods?
1=YES
2=NO
……………………………………………………………………………………………………
CON22b. (To lower {your/his/her} blood cholesterol, {have you/has name} ever been told by a doctor or other health professional…)
to control your weight or lose weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON22c. (To lower {your/his/her} blood cholesterol, {have you/has name} ever been told by a doctor or other health professional…)
to increase your physical activity or exercise?
1=YES
2=NO
……………………………………………………………………………………………………
CON22d. To lower {your/his/her} blood cholesterol, {have you/has name} ever been told by a doctor or other health professional…
to take prescribed medicine?
1=YES
2=NO
……………………………………………………………………………………………………
If CON22a, CON22b, CON22c, or CON22d =1 continue, else go to CONCHK23a)
CON24. Did you ever receive this advice from someone at {the reference health center}?
1=YES
2=NO
……………………………………………………………………………………………………
[CONCHK23a IF CON22a=1 (YES), CONTINUE; ELSE GO TO THE LOGIC PRECEDING THE NEXT QUESTION]
……………………………………………………………………………………………………
CON23a. Are you now following this advice to...
eat fewer high fat or high cholesterol foods?
1=YES
2=NO
……………………………………………………………………………………………………
[CONCHK23b IF CON22b=1 (YES), CONTINUE; ELSE GO TO THE LOGIC PRECEDING THE NEXT QUESTION]
CON23b. Are you now following this advice to...
control your weight or lose weight?
1=YES
2=NO
[CONCHK23c IF CON22c=1 (YES), CONTINUE; ELSE GO TO THE LOGIC PRECEDING THE NEXT QUESTION]
……………………………………………………………………………………………………
CON23c. Are you now following this advice to...
increase your physical activity or exercise?
1=YES
2=NO
[CONCHK23d IF CON22d=1 (YES), CONTINUE; ELSE GO TO THE LOGIC PRECEDING THE NEXT QUESTION]
……………………………………………………………………………………………………
CON23d. Are you now following this advice to...
take prescribed medicine?
1=YES
2=NO
……………………………………………………………………………………………………
MODULE F: CANCER SCREENING
[CANCHK1 IF <18, GO TO MODULE G;
ELSE IF AGE GE 18 AND (FEMALE (INT6=2) OR INT6=4), GO TO CAN1;
ELSE IF AGE GE 18 AND INT6=3, GO TO CANCHK3
ELSE IF AGE GE 18 AND MALE, GO TO CANCHK4]
PAP SMEARS
CAN1. Next, I’m going to ask you about any cancer screening procedures that you may have had. Have you ever 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
[CANCHK1a IF CAN1= 1, CONTINUE; ELSE GO TO CAN2 ]
………………………………………………………………………………………………
CAN1a. When did you have your most recent Pap smear or Pap test?
1=A YEAR AGO OR LESS
2=MORE THAN 1 YEAR BUT NOT MORE THAN 2 YEARS
3=MORE THAN 2 YEARS BUT NOT MORE THAN 3 YEARS
4=MORE THAN 3 YEARS BUT NOT MORE THAN 4 YEARS
5=MORE THAN 4 YEARS BUT NOT MORE THAN 5 YEARS
6=OVER 5 YEARS AGO
………………………………………………………………………………………………
CAN1a1. Did you have your most recent Pap smear or Pap test at the {reference health center}?
1=AT REFERENCE HEALTH CENTER
2=SOMEWHERE ELSE
PROBE: Did you have any difficulty answering this question? [If yes] Tell me about that.
………………………………………………………………………………………………
CAN1b. What was the main reason you had this Pap smear or Pap test - was it part of a routine exam, because of a problem, or some other reason?
1=PART OF A ROUTINE EXAM
2=BECAUSE OF A PROBLEM
3=OTHER REASON
………………………………………………………………………………………………
CAN1b1. Have you been tested for human papilloma virus or HPV?
1=YES
2=NO
[CANCHK1b1 IF CAN1b1= 1, CONTINUE; ELSE GO TO CANCHK1b3] ]
………………………………………………………………………………………………
CAN1b2. When did you have your most recent human papilloma virus or HPV test?
1=A YEAR AGO OR LESS
2=MORE THAN 1 YEAR BUT NOT MORE THAN 2 YEARS
3=MORE THAN 2 YEARS BUT NOT MORE THAN 3 YEARS
4=MORE THAN 3 YEARS BUT NOT MORE THAN 4 YEARS
5=MORE THAN 4 YEARS BUT NOT MORE THAN 5 YEARS
6=OVER 5 YEARS AGO
………………………………………………………………………………………………
CAN1b3. Did you have your most recent human papilloma virus or HPV test at the {reference health center}?
1=YES
2=NO
[CANCHK1b3 IF CAN1a=1, 2, 3, THEN CONTINUE; ELSE GO TO CAN2]
………………………………………………………………………………………………
If CAN1b1=2 or CAN1b2=6, continue. Else go to CAN1c1
CAN1c. As a result of @Uany@U of the Pap smear or Pap tests you had done in the past three years, were you told that you should have follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………
IF CAN1b1=1 and CAN1b2<6:
CAN1c1. As a result of @Uany@U of the Pap smear or Pap tests you had done in the past five years, were you told that you should have follow-up tests or treatment?
1=YES
2=NO
[CANCHK1d IF CAN1c = 1 or CAN1c1 = 1, CONTINUE; ELSE GO TO CANCHK3]
………………………………………………………………………………………………
CAN1d. Were the follow-up tests or treatment done?
1=YES
2=NO
[CANCHK1e IF CAN1d = 1, CONTINUE; IF CAN1d=2, GO TO CAN1f1;
ELSE GO TO CANCHK3]
………………………………………………………………………………………………
CAN1e. Did {the reference health center} arrange for the follow-up tests or treatment?
1=YES
2=NO
[CANCHK1e_POST GO TO CANCHK3]
………………………………………………………………………………………………
CAN1f1. CAN1f. Please describe the reasons you did not get the follow-up tests or treatment? You may select one or more.
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
………………………………………………………………………………………………
CAN1f2. Please look at this showcard. Which of these best describes the main reason you did not get the follow-up tests or treatment?
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
………………………………………………………………………………………………
CAN2a. Has anyone at {the reference health center} ever suggested that you have a Pap smear or Pap test?
1=YES
2=NO
………………………………………………………………………………………………
MAMMOGRAMS
[CANCHK3 IF AGE GE 40 AND FEMALE, THEN CONTINUE; ELSE GO TO CANCHK4 ]
CAN3. Have you ever had a mammogram?
IF NECESSARY: A mammogram is an X-ray taken only of the breast by a machine that presses against the breast.
1=YES
2=NO
[CANCHK3a IF CAN3 = 1, CONTINUE; ELSE GO TO CAN3g ]
………………………………………………………………………………………………
CAN3a. When did you have your most recent mammogram?
1=A YEAR AGO OR LESS
2=MORE THAN 1 YEAR BUT NOT MORE THAN 2 YEARS
3=MORE THAN 2 YEARS BUT NOT MORE THAN 3 YEARS
4=MORE THAN 3 YEARS BUT NOT MORE THAN 5 YEARS
5=OVER 5 YEARS AGO
………………………………………………………………………………………………
CAN3a1. Did you have your most recent mammogram at the {reference health center}?
1=YES
2=NO
PROBE: Did you have any difficulty answering this question? [If yes] Tell me about that.
………………………………………………………………………………………………
CAN3b. What was the main reason you had this mammogram - was it part of a routine exam, because of a problem, or some other reason?
MARK ONLY ONE.
1=PART OF A ROUTINE EXAM
2=BECAUSE OF A PROBLEM
3=SOME OTHER REASON
[CANCHK3c IF CAN3a = 1 or 2 THEN CONTINUE; ELSE GO TO CAN3]
………………………………………………………………………………………………
CAN3c. As a result of any mammograms you had done in the past 2 years, were you told that you should have @Ufollow-up@U tests or treatment?
1=YES
2=NO
[CANCHK3d IF CAN3c = 1, CONTINUE;
IF CAN3c = 2, GO TO CANCHK4;
IF CAN3c =DK OR RF GO TO CANCHK4 ]
………………………………………………………………………………………………
CAN3d. Were the @Ufollow-up@U tests or treatment done?
1=YES
2=NO
[CANCHK3e IF CAN3d = 2, THEN GO TO CAN3f1; ELSE CONTINUE ]
………………………………………………………………………………………………
CAN3e. Did {the reference health center} arrange for the @Ufollow-up@U tests or treatments?
1=YES
2=NO
[CANCHK3e_POST GO TO CANCHK4]
………………………………………………………………………………………………
CAN3f. Please describe the reasons you did not get the @Ufollow-up@U tests or treatment? You may select one or more.
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER (SPECIFY)
………………………………………………………………………………………………
CAN3f1. Please look at this showcard. Which of these best describes the main reason you did not get the @Ufollow-up@U tests or treatment?
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER (SPECIFY)
[CANCHK3f_POST GO TO CANCHK4 ]
………………………………………………………………………………………………
CAN3g. What is the main reason why you have {[IF CAN3=2 (NO), THEN FILL:] “never had a mammogram” [IF CAN3a=4 or CAN3A=5, THEN FILL:] “not had a mammogram in the past two years”}?
1=NO REASON/ NEVER THOUGHT ABOUT IT/ DIDN’T KNOW I SHOULD
2=NOT NEEDED/ HAVEN’T HAD ANY PROBLEMS
3=TOO UNPLEASANT OR EMBARRASSING
4=COST TOO MUCH/NO INSURANCE
5=BREASTS MISSING
6=OTHER (SPECIFY)
………………………………………………………………………………………………
CAN3h. Has anyone at {the reference health center} ever suggested that you have a mammogram?
1=YES
2=NO
………………………………………………………………………………………………
COLONOSCOPY/ SIGMOIDOSCOPY EXAM
[CANCHK4 IF AGE GE 50, THEN CONTINUE; ELSE GO TO CANCHK5]
CAN4. Colonoscopy (colon-OS-copy) and Sigmoidoscopy (sigmoid-OS-copy) are exams in which a doctor inserts a tube into the rectum to look for polyps or cancer. For a colonoscopy, the doctor checks the entire colon, and you are given medication through a needle in your arm to make you sleepy, and told to have someone drive you home. For a Sigmoidoscopy, the doctor checks only part of the colon and you are fully awake.
Have you EVER HAD a colonoscopy?
*Read if necessary:
A polyp is a small growth that develops on the inside of the colon or rectum. Before these tests, you are asked to take a medication that causes diarrhea.
1=YES
2=NO
REF
DK
………………………………………………………………………………………………
CAN4a. When did you have your MOST RECENT colonoscopy?
A year ago or less
More than 1 year but not more than 2 years
More than 2 years but not more than 3 years
More than 3 years but not more than 5 years
More than 5 years but not more than 10 years
Over 10 years ago
Refused
Don't know
………………………………………………………………………………………………
CAN4a1. Did you have your most recent exam at the {reference health center}?
1=YES
2=NO
PROBE: Did you have any difficulty answering this question? [If yes] Tell me about that.
………………………………………………………………………………………………
CAN4c. What was the MAIN reason you had this colonoscopy - was it part of a routine exam, because of a problem, as a follow-up test of an earlier test or screening exam, or some other reason?
1 Part of a routine exam
2 Because of a problem
3 Follow-up test of an earlier test or sceening exam
4 Other reason (specify)
7 Refused
9 Don't know
………………………………………………………………………………………………
CAN4d. As a result of this exam, were you told that you should have follow-up tests or treatment?
1=YES
2=NO
[CANCHK4e IF CAN4d = 1, CONTINUE; ELSE GO TO CANCHK5 ]
………………………………………………………………………………………………
CAN4e. Were the follow-up tests or treatment done?
1=YES
2=NO
[CANCHK4f IF CAN4e = 2, THEN GO TO CAN4g; ELSE CONTINUE]
………………………………………………………………………………………………
CAN4f Did {the reference health center} arrange for the follow-up tests or treatment?
1=YES
2=NO
[CANCHK4f_POST GO TO CANCHK5 ]
………………………………………………………………………………………………
CAN4g. Please describe the reasons you did not get the follow-up tests or treatment? You may select one or more.
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER (SPECIFY)
………………………………………………………………………………………………
CAN4g1. Please look at this showcard. Which of these best describes the main reason you did not get the follow-up tests or treatment?
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER (SPECIFY)
………………………………………………………………………………………………
CAN4g2. Recall that a Sigmoidoscopy is similar to a colonoscopy but the doctor checks only
part of the colon and you are fully awake. Have you EVER HAD a Sigmoidoscopy?
1=YES
2=NO
REF
DK
………………………………………………………………………………………………
CAN4g3. When did you have your MOST RECENT Sigmoidoscopy?
A year ago or less
More than 1 year but not more than 2 years
More than 2 years but not more than 3 years
More than 3 years but not more than 5 years
More than 5 years but not more than 10 years
Over 10 years ago
Refused
Don't know
………………………………………………………………………………………………
CAN4g4. What was the MAIN reason you had this Sigmoidoscopy - was it part of a routine exam, because of a problem, as a follow-up test of an earlier test or screening exam, or some other reason?
1 Part of a routine exam
2 Because of a problem
3 Follow-up test of an earlier test or sceening exam
4 Other reason (specify)
7 Refused
9 Don't know
………………………………………………………………………………………………
CAN4g5. As a result of this exam, were you told that you should have follow-up tests or treatment?
1=YES
2=NO
[CANCHK4e IF CAN4d = 1, CONTINUE; ELSE GO TO CANCHK5 ]
………………………………………………………………………………………………
CAN4g6. Were the follow-up tests or treatment done?
1=YES
2=NO
[CANCHK4f IF CAN4e = 2, THEN GO TO CAN4g; ELSE CONTINUE]
………………………………………………………………………………………………
CAN4g7. Did {the reference health center} arrange for the follow-up tests or treatment?
1=YES
2=NO
[CANCHK4f_POST GO TO CANCHK5 ]
………………………………………………………………………………………………
CAN4g8. Please describe the reasons you did not get the follow-up tests or treatment? You may select one or more.
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER (SPECIFY)
………………………………………………………………………………………………
CAN4g9. Please look at this showcard. Which of these best describes the main reason you did not get the follow-up tests or treatment?
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER (SPECIFY)
………………………………………………………………………………………………
CAN4g10. What is the main reason why you have {[IF CAN3i=2 (NO), THEN FILL:] “never had a colonoscopy? [IF CAN3j= 4 or 5 OR 6, THEN FILL:] “not had a more recent colonoscopy”}?
SPECS: CHECK SPECS CAREFULLY HERE.
1=NO REASON/ NEVER THOUGHT ABOUT IT
2=DIDN'T NEED/ DIDN'T KNOW I NEEDED THIS TYPE OF TEST
3=TOO EXPENSIVE/ NO INSURANCE/ COST
4=TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
5=OTHER (SPECIFY)
………………………………………………………………………………………………
CAN4g11. What is the main reason why you have {[IF CANa6b=2 (NO), THEN FILL:] “never had a sigmoidoscopy” [IF CANa6c= 4 or 5 OR 6, THEN FILL:] “not had a more recent sigmoidoscopy”}?
SPECS: CHECK SPECS CAREFULLY HERE.
1=NO REASON/ NEVER THOUGHT ABOUT IT
2=DIDN'T NEED/ DIDN'T KNOW I NEEDED THIS TYPE OF TEST
3=TOO EXPENSIVE/ NO INSURANCE/ COST
4=TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
5=OTHER (SPECIFY)
………………………………………………………………………………………………
CAN4i Has anyone at {the reference health center} ever suggested that you should have a colonoscopy?
1=YES
2=NO
………………………………………………………………………………………………
CAN4i1. Has anyone at {the reference health center} ever suggested that you should have a sigmoidoscopy?
1=YES
2=NO
………………………………………………………………………………………………
BLOOD STOOL OR OCCULT BLOOD TESTS
[CANCHK5 IF AGE GE 50, THEN CONTINUE; ELSE GO TO MODULE G ]
CAN5. The following questions are about the blood stool or occult blood test, a test to determine whether you have blood in your stool or bowel movement. The blood stool test can be done at home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it back to the doctor or lab.
Have you ever had a blood stool test, using a @Uhome@U test kit?
1=YES
2=NO
[CANCHK5a IF CAN5 = 1, CONTINUE; ELSE GO TO CAN5f ]
………………………………………………………………………………………………
CAN5a. When did you have your most recent blood stool test using a kit @Uat home@U?
1=A YEAR AGO OR LESS
2=MORE THAN 1 YEAR BUT NOT MORE THAN 2 YEARS
3=MORE THAN 2 YEARS BUT NOT MORE THAN 3 YEARS
4=MORE THAN 3 YEARS BUT NOT MORE THAN 5 YEARS
5=MORE THAN 5 YEARS BUT NOT MORE THAN 10 YEARS
6=OVER 10 YEARS AGO
[CANCHK5b IF CAN5a = 1,2,3 CONTINUE; ELSE GO TO CAN5g ]
………………………………………………………………………………………………
CAN5a1. Did the {reference health center} provide the kit to you?
1=YES
2=NO
………………………………………………………………………………………………
CAN5b. As a result of this test, did you need follow-up tests or treatment?
1=YES
2=NO
[CANCHK5c IF CAN5b =1, THEN CONTINUE; ELSE GO TO MODULE G ]
………………………………………………………………………………………………
CAN5c. Were the follow-up tests or treatment done?
1=YES
2=NO
[CANCHK5d IF CAN5c = 2 THEN GO TO CAN 5e1; ELSE CONTINUE]
………………………………………………………………………………………………
CAN5d. Did the {reference health center} arrange for the follow-up tests or treatments?
1=YES
2=NO
[CANCHK5d_POST GO TO MODULE G]
………………………………………………………………………………………………
CAN5e. Please look at this showcard. Please describe the reasons you did not get the follow-up tests or treatment? You may select one or more.
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11= OTHER (specify)
………………………………………………………………………………………………
CAN5e1. Please look at this showcard. Which of these best describes the main reason you did not get the follow-up tests or treatment?
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
………………………………………………………………………………………………
IF CAN5=2 OR CAN5a=6 CONTINUE ELSE GOTO CANCHK5a
SPECS: CHECK SPECS CAREFULLY HERE.
CAN5e2. Please describe the reasons why you have never had a blood stool test or have not had one in the specified time frame? You may select one or more.
1=NO REASON/ NEVER THOUGHT ABOUT IT
2=DIDN'T NEED/ DIDN'T KNOW I NEEDED THIS TYPE OF TEST
3=TOO EXPENSIVE/ NO INSURANCE/ COST
4=TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
5=OTHER (specify)
………………………………………………………………………………………………
CAN5e3. What is the main reason why you have never had a blood stool test or have not had one in the specified time frame?
1=NO REASON/ NEVER THOUGHT ABOUT IT
2=DIDN'T NEED/ DIDN'T KNOW I NEEDED THIS TYPE OF TEST
3=TOO EXPENSIVE/ NO INSURANCE/ COST
4=TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
5=OTHER (SPECIFY)
………………………………………………………………………………………………
CAN5f. Has anyone at {the reference health center} ever suggested that you should have a blood stool test?
1=YES
2=NO
………………………………………………………………………………………………
MODULE G: HEALTH CENTER SERVICES
Now, I’d like to ask some questions about the services {you have/name has} received at {the reference health center}.
HEA1. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, how many times have you seen a doctor or other health care professional about {your own/name’s} health at a doctor’s office, a clinic, or some other place? Do not include times {you were/name was} hospitalized overnight, visits to hospital emergency rooms, home visits, or telephone calls. Remember when you answer to think about any doctor’s office or clinic, not just this health center.
NOTE: IF RESPONDENT IS UNSURE- ASK THEM TO PROVIDE AN ESTIMATE
_____ TIMES [ALLOW 00-99]
[HEACHK2 IF HEA1=0, DK, RF THEN GO TO HEA4, ELSE CONTINUE]
………………………………………………………………………………………………
HEA2. How many of those times did you come to {reference health center}?
NOTE: IF RESPONDENT IS UNSURE- ASK THEM TO PROVIDE AN ESTIMATE
_____ TIMES [ALLOW 00-99]
[IF HEA2=0, DK, RE THEN GOTO HEA4, ELSE CONTINUE]
………………………………………………………………………………………………
HEA2a. In the past 12 months, did a medical professional at {the reference health center} think {you/name} should go someplace else to see a different doctor, like a specialist, for a particular health problem?
1=YES
2=NO
[HEACHK2b If HEA2a=1, THEN CONTINUE; ELSE GOTO HEA4]
………………………………………………………………………………………………
HEA2b. If you received more than one referral in the past 12 months, think of the most recent one. Did {you/name} see that doctor?
1=YES
2=NO
[HEACHK2c If HEA2b=1, THEN CONTINUE; IF HEA2b= DK or RF, GO TO HEA4, ELSE GOTO HEA2d1]
………………………………………………………………………………………………
HEA2d IF HEA2b=2 CONTINUE ELSE GO TO HEA3
Please look at this showcard. Please describe the reasons why {you/name} didn't see that doctor? You may select one or more.
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN 8
4=PROBLEMS GETTING TO DOCTOR’S OFFICE 43
5=DIFFERENT LANGUAGE 2
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE 3
10=DIDN’T HAVE TIME OR TOOK TO LONG 19
11=OTHER (SPECIFY) 200
………………………………………………………………………………………………
HEA2d1. Please look at this showcard. Which of these best describes the main reason why {you/name} didn't see that doctor?
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER (SPECIFY)
………………………………………………………………………………………………
HEA4. Please look at this showcard. How did you find out that {you/name} could come here for services? You may select one or more.
@BSHOWCARD HEA1@B
1=FRIEND/FAMILY MEMBER/NEIGHBOR TOLD ME
2=FAMILY TOOK YOU HERE
3=ADVERTISEMENT IN COMMUNITY
4=AT A MEETING
5=CONTACTED BY SOMEONE FROM HEALTH CENTER
6=THROUGH YOUR INSURANCE
7=SOCIAL SERVICES
8=A DOCTOR OR THE EMERGENCY ROOM
9=YOU FOUND OUT THAT THE HEALTH CENTER ACCEPTS UNINSURED PATIENTS
10=YOU FOUND OUT THAT THE HEALTH CENTER ACCEPTS PATIENTS WITH YOUR INSURANCE.
11=OTHER (SPECIFY)
………………………………………………………………………………………………
HEA5. Is there a place that you usually go to when {you are /name is} sick or you need advice about {your/ his/her} health?
1=YES
2=THERE IS NO PLACE
3=MORE THAN ONE PLACE
[HEACHK5a IF HEA5=1, OR 3 CONTINUE, ELSE GOTO HEA5c]
………………………………………………………………………………………………
HEA5a. Please look at this showcard. What kind of place{is it/ are those}?
@BSHOWCARD HEA2@B
1={REFERENCE HEALTH CENTER}
2=CLINIC OR HEALTH CENTER OFFERING A DISCOUNT TO LOW INCOME OR UNINSURED PEOPLE
3=OTHER CLINIC OR HEALTH CENTER
4=DOCTOR'S OFFICE OR HMO
5=HOSPITAL EMERGENCY ROOM
6=HOSPITAL OUTPATIENT DEPARTMENT
7=SOME OTHER PLACE
………………………………………………………………………………………………
IF HEA5a = 7 CONTINUE ELSE GO TO HEA5b
HEA5a_sp. Please specify:
[ ] Allow 40
DK
………………………………………………………………………………………………
HEA5b. {Is this/Are these} the same place{s} you usually go when {you need/name needs} routine or preventive care, such as a physical examination {[IF AGE LE 11, ADD:] or well child check up?}
1=YES
2=NO
[HEACHK5c IF HEA5b=1, THEN GOTO HEACHK6; ELSE CONTINUE]
………………………………………………………………………………………………
HEA5c. Please look at this showcard. What kind of place{s} do you go to when {you need/name needs} routine or preventive care, such as a physical examination or check up?
CODE ONE OR MORE.
@BSHOWCARD HEA2@B
1={REFERENCE HEALTH CENTER}
2=CLINIC OR HEALTH CENTER OFFERING A DISCOUNT TO LOW INCOME OR UNINSURED PEOPLE
3=OTHER CLINIC OR HEALTH CENTER
4=DOCTOR'S OFFICE OR HMO
5=HOSPITAL EMERGENCY ROOM
6=HOSPITAL OUTPATIENT DEPARTMENT
7=SOME OTHER PLACE
………………………………………………………………………………………………
IF HEA5c = 7 CONTINUE ELSE GO TO HEACHK6
HEA5c_sp. Please specify:
[ ] Allow 40
DK
[HEACHK6 IF INT7 =1 GOTO HEA7 ELSE CONTINUE]
………………………………………………………………………………………………
HEA6.
When {you go/name goes} to {the reference health center},
in
what language does your doctor or other health care professional
speak to you?
1=ENGLISH
2=SPANISH
3=CANTONESE
4=VIETNAMESE
5=MANDARIN
6=KOREAN
7=ASIAN INDIAN LANGUAGES
8=RUSSIAN
9=TAGALOG
10=OTHER (SPECIFY)
REFUSED
DON’T KNOW
………………………………………………………………………………………………
HEA6a.
During your last visit to {the reference health center},
did
you need someone to help you understand the doctor?
1=YES
2=NO
REFUSED
DON’T KNOW
………………………………………………………………………………………………
HEA6b. Who was this person who helped you understand the doctor?
IF R RESPONDS “MY CHILD,” PROBE TO SEE IF CHILD IS UNDER AGE 18. IF AGE 18 OR MORE, CODE AS “ADULT FAMILY MEMBER"
1=MINOR CHILD (UNDER AGE 18)
2=AN ADULT FAMILY MEMBER OR FRIEND OF MINE
3=NON-MEDICAL OFFICE STAFF
4=MEDICAL STAFF INCLUDING NURSES/DOCTORS
5=PROFESSIONAL INTERPRETER (BOTH IN PERSON AND ON THE TELEPHONE)
6= OTHER (PATIENTS, SOMEONE ELSE)
7= DID NOT HAVE SOMEONE TO HELP
REFUSED
DON'T KNOW
………………………………………………………………………………………………
HEA6c. IF HEA6b=5 CONTINUE ELSE GO TO HEACHK6a
Did the interpreter help you in-person or over the telephone?
1= IN PERSON
2= OVER THE TELEPHONE
REFUSED
DON'T KNOW
………………………………………………………………………………………………
HEA6d.
How difficult was it for you to find someone to help you understand the doctor?
1=Very difficult
2=Somewhat difficult
3=Not very difficult
4=Not difficult at all
………………………………………………………………………………………………
HEA7a. Has anyone at {the reference health center} ever helped {you/name}...
arrange for medical appointments or other medical services at a place other than {reference health center}?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
[HEACHK7a_IMP IF HEA7a = 1, THEN CONTINUE; ELSE GO TO THE LOGIC PRECEEDING THE NEXT QUESTION]
………………………………………………………………………………………………
HEA7b. Has anyone at {the reference health center} ever helped {you/name}...
NOTE: REPEAT STEM OF QUESTION AS NECESSARY
apply for any government benefits {you/name} needed such as Medicaid, Food Stamps, Social Security, obtaining welfare, public benefits, or TANF?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
[HEACHK7b_imp IF HEA7b = 1, THEN CONTINUE; ELSE GO TO THE LOGIC PRECEEDING THE NEXT QUESTION ]
………………………………………………………………………………………………
HEA7c. (Has anyone at {the reference health center} ever helped {you/name}...)
NOTE: REPEAT STEM OF QUESTION AS NECESSARY
get transportation to medical appointments or provided you with tokens or vouchers to help you pay for transportation to medical appointments?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
[HEACHK7c_IMP IF HEA7c= 1, THEN CONTINUE; ELSE GO TO THE LOGIC PRECEEDING THE NEXT QUESTION ]
………………………………………………………………………………………………
HEA7d. (Has anyone at {the reference health center} ever helped {you/name}...)
NOTE: REPEAT STEM OF QUESTION AS NECESSARY
with basic needs such as:
a. finding a place to live
b. finding a job or job counseling
c. finding childcare
d. helping you obtain food
e. helping you obtain clothing or shoes
f. get free medication
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
[HEACHK7d_IMP IF HEA7d = 1, THEN CONTINUE; ELSE GO TO THE LOGIC PRECEEDING THE NEXT QUESTION ]
………………………………………………………………………………………………
HEA7e. (Has anyone at {the reference health center} ever helped {you/name}...)
NOTE: REPEAT STEM OF QUESTION AS NECESSARY
a. provided {you/name} health education, either in individual or group visits, to talk about things like quitting smoking, changing your diet, or parenting?
b. provided {you/name} any supportive counseling, such as family counseling, domestic violence counseling, or substance abuse counseling?
c. provided {you/name} with a translator or interpreter to help you communicate with the doctor or other health care professional? This person could be at the clinic or on the phone.
d. visited {you/name} at home to talk about your health care needs or other needs?
e. offered you free services outside of the health center, like at a health fair? This could be free flu shots or blood pressure screenings or other services.
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
[HEACHK7e_imp IF HEA7e = 1, THEN CONTINUE; ELSE GO TO THE LOGIC PRECEEDING THE NEXT QUESTION ]
………………………………………………………………………………………………
HEA7f. (Has anyone at {the reference health center} ever helped {you/name}...)
NOTE: REPEAT STEM OF QUESTION AS NECESSARY
with other kinds of problems?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
………………………………………………………………………………………………
HEA7f_sp. Please specify what help you received from {the reference health center}?
[ ] Allow 80
[HEACHK7f_IMP IF HEA7f = 1, THEN CONTINUE; ELSE GO TO THE LOGIC PRECEEDING THE NEXT QUESTION ]
………………………………………………………………………………………………
HEA9. IF SELF-RESPONDENT: How {do you/does name} usually get to the health center?
IF PROXY-RESPONDENT: How do you usually get {name} to the health center?
[PROGRAMMER: PLEASE ALLOW ONLY ONE RESPONSE]
1=WALKING
2=DRIVING
3=BEING DRIVEN BY SOMEONE ELSE
4=BUS, SUBWAY OR OTHER PUBLIC TRANSPORTATION
5=TAXI
6=HEALTH CENTER (OR OTHER AGENCY-PROVIDED) VAN SERVICE
7=OTHER
………………………………………………………………………………………………
HEA9a. How far do you live from the {reference health center}?
____________ MILES
PROBE: Did you have any difficulty answering this question? [If yes] Tell me about that.
………………………………………………………………………………………………
HEA10. About how long does it usually take you to get there?
_____ MINUTES [ALLOW 00-59]
OR
_____ HOURS [ALLOW 0-9]
………………………………………………………………………………………………
The following questions will refer to the health care providers at this health center. Please think of these people as you answer these questions.
HEA11. Is this the health center you usually go to if you need a check-up, want advice about a health problem, or get sick or hurt?
1 =YES
2 =NO
………………………………………………………………………………………………
HEA12. How long have you been going to this health center?
1 =LESS THAN 6 MONTHS
2 =AT LEAST 6 MONTHS BUT LESS THAN 1 YEAR
3 =AT LEAST 1 YEAR BUT LESS THAN 3 YEARS
4 =AT LEAST 3 YEARS BUT LESS THAN 5 YEARS
5 =5 YEARS OR MORE
………………………………………………………………………………………………
HEA13. These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.
In the last 12 months, how many times did you go to this health center to get care for yourself?
0=NONE → GOTO HEA55
1=1 TIME
2=2
3=3
4=4
5=5 TO 9
6=10 OR MORE TIMES
………………………………………………………………………………………………
HEA14. In the last 12 months, did you phone this health center to get an appointment for an illness, injury or condition that needed care right away?
1 =YES
2 =NO → If No, go to HEA17
………………………………………………………………………………………………
HEA15. In the last 12 months, when you phoned this health center to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA16. In the last 12 months, how many days did you usually have to wait for an appointment when you needed care right away?
1=SAME DAY
2=1 DAY
3=2 TO 3 DAYS
4=4 TO 7 DAYS
5=MORE THAN 7 DAYS
………………………………………………………………………………………………
HEA17. In the last 12 months, did you make any appointments for a check-up or routine care with this health center?
1=YES
2=NO → If No, go to HEA19
………………………………………………………………………………………………
HEA18. In the last 12 months, when you made an appointment for a check-up or routine care with this health center, how often did you get an appointment as soon as you needed?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA19. Did this health center give you information about what to do if you needed care during evenings, weekends, or holidays?
1=YES
2=NO
Source: 2011 CAHPS PCMH
………………………………………………………………………………………………
HEA20. In the last 12 months, did you need care for yourself during evenings, weekends, or holidays?
1=YES
2=NO → If No, go to HEA22
………………………………………………………………………………………………
HEA21. In the last 12 months, how often were you able to get the care you needed from this health center during evenings, weekends, or holidays?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA22. In the last 12 months, did you phone this health center with a medical question during regular office hours?
1=YES
2=NO → If No, go to HEA24
………………………………………………………………………………………………
HEA23. In the last 12 months, when you phoned this health center during regular office hours, how often did you get an answer to your medical question that same day?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA24. In the last 12 months, did you phone this health center with a medical question after regular office hours?
1=YES
2=NO → If No, go to HEA26
………………………………………………………………………………………………
HEA25. In the last 12 months, when you phoned this health center after regular office hours, how often did you get an answer to your medical question as soon as you needed?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA26. Some offices remind patients between visits about tests, treatment or appointments. In the last 12 months, did you get any reminders from this health center between visits?
1=YES
2=NO
………………………………………………………………………………………………
HEA27. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see a doctor or other health professional at this health center within 15 minutes of your appointment time?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA28. In the last 12 months, how often did this doctor or other health professional explain things in a way that was easy to understand?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA29. In the last 12 months, how often did this doctor or other health professional listen carefully to you?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA30. In the last 12 months, did you talk with this doctor or other health professional about any health questions or concerns?
1=YES
2=NO → If No, go to HEA32
………………………………………………………………………………………………
HEA31. In the last 12 months, how often did this doctor or other health professional give you easy to understand information about these health questions or concerns?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA32. In the last 12 months, how often did this doctor or other health professional seem to know the important information about your medical history?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA33. In the last 12 months, how often did this doctor or other health professional show respect for what you had to say?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA34. In the last 12 months, how often did this doctor or other health professional spend enough time with you?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA35. In the last 12 months, did this doctor or other health professional order a blood test, x-ray, or other test for you?
1=YES
2=NO → If No, go to HEA37
………………………………………………………………………………………………
HEA36. In the last 12 months, when this doctor or other health professional ordered a blood test, x-ray, or other test for you, how often did someone from this health center follow up to give you those results?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA37. In the last 12 months, did you and this doctor or other health professional talk about starting or stopping a prescription medicine?
1=YES
2=NO → If No, go to HEA39
………………………………………………………………………………………………
HEA38. When you talked about starting or stopping a prescription medicine, how much did this doctor or other health professional talk about the reasons you might want to take a medicine?
1=NOT AT ALL
2=A LITTLE
3=SOME
4=A LOT
………………………………………………………………………………………………
HEA39. When you talked about starting or stopping a prescription medicine, how much did this doctor or other health professional talk about the reasons you might not want to take a medicine?
1=NOT AT ALL
2=A LITTLE
3=SOME
4=A LOT
………………………………………………………………………………………………
HEA40. When you talked about starting or stopping a prescription medicine, did this doctor or other health professional ask you what you thought was best for you?
1=YES
2=NO
………………………………………………………………………………………………
HEA41. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this doctor or other health professional?
0=WORST PROVIDER POSSIBLE
1
2
3
4
5
6
7
8
9
10= BEST PROVIDER POSSIBLE
………………………………………………………………………………………………
HEA41a. Would you recommend this [reference health center] to your family and friends?” [Yes, definitely / Yes, somewhat / No].
1=Yes- Definitely
2=Yes- Somewhat
3=No
………………………………………………………………………………………………
HEA42. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 12 months, did you see a specialist for a particular health problem?
1=YES
2=NO → If No, go to HEA44
……………………………………………………………………………………………
HEA43. In the last 12 months, how often did {the doctor or other health professional at the reference health center} seem informed and up-to-date about the care you got from specialists?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA44. In the last 12 months, did anyone in this health center talk with you about specific goals for your health?
1=YES
2=NO
………………………………………………………………………………………………
HEA45. In the last 12 months, did anyone in this health center ask you if there are things that make it hard for you to take care of your health?
1=YES
2=NO
………………………………………………………………………………………………
HEA46. In the last 12 months, did you take any prescription medicine?
1=YES
2=NO → If No, go to HEA48
………………………………………………………………………………………………
HEA47. In the last 12 months, did you and anyone in this health center talk at each visit about all the prescription medicines you were taking?
1=YES
2=NO
………………………………………………………………………………………………
HEA48. In the last 12 months, did anyone in this health center ask you if there was a period of time when you felt sad, empty, or depressed?
1=YES
2=NO
………………………………………………………………………………………………
HEA49. In the last 12 months, did you and anyone in this health center talk about things in your life that worry you or cause you stress?
1=YES
2=NO
………………………………………………………………………………………………
HEA50. In the last 12 months, did you and anyone in this health center talk about a personal problem, family problem, alcohol use, drug use, or a mental or emotional illness?
1=YES
2=NO
………………………………………………………………………………………………
Clerks and Receptionists at This Health Center
HEA51. In the last 12 months, how often were clerks and receptionists at this health center as helpful as you thought they should be?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA52. In the last 12 months, how often did clerks and receptionists at this health center treat you with courtesy and respect?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA20. What are all the reasons {you go/name goes} to the {reference health center} for {your/name’s} health care instead of someplace else? You may select one or more.
1=CONVENIENT LOCATION
2=CONVENIENT HOURS
3=YOU CAN AFFORD IT
4={YOU/NAME} CAN BE SEEN WITHOUT AN APPOINTMENT OR GET AN
APPOINTMENT RIGHT AWAY
5=AFTER YOU GET THERE, YOU DON'T HAVE TO WAIT LONG TO BE SEEN
6=THEY PROVIDE CHILD CARE
7=THEY PROVIDE TRANSPORTATION OR TRANSPORTATION VOUCHERS
8=THEY HAVE SOMEONE WHO SPEAKS YOUR LANGUAGE
9=QUALITY OF CARE
10=IT'S THE ONLY MEDICAL CARE IN THE AREA
11= THE HEALTH CENTER ACCEPTS UNINSURED PATIENTS
12= THE HEALTH CENTER ACCEPTS PATIENTS WITH MY INSURANCE
13=OTHER (SPEICFY)
………………………………………………………………………………………………
HEA56. Please look at this showcard. What is the main reason {you go/name goes} to the {reference health center} for {your/name’s} health care instead of someplace else?
@BSHOWCARD HEA3@B
1= CONVENIENT LOCATION
2= CONVENIENT HOURS
3= YOU CAN AFFORD IT
4= {YOU/NAME} CAN BE SEEN WITHOUT AN APPOINTMENT OR GET AN
APPOINTMENT RIGHT AWAY
5=AFTER YOU GET THERE, YOU DON'T HAVE TO WAIT LONG TO BE SEEN
6=THEY PROVIDE CHILD CARE
7=THEY PROVIDE TRANSPORTATION OR TRANSPORTATION VOUCHERS
8=THEY HAVE SOMEONE WHO SPEAKS YOUR LANGUAGE
9=QUALITY OF CARE
10=IT'S THE ONLY MEDICAL CARE IN THE AREA
11= THE HEALTH CENTER ACCEPTS UNINSURED PATIENTS
12= THE HEALTH CENTER ACCEPTS PATIENTS WITH MY INSURANCE
13=OTHER (SPECIFY)
……………………………………………………………………………………………
MODULE H: HEALTH INSURANCE
INS6. (Do you/ Does your RELATIONSHIP) currently have health insurance?
I’m interested in all types of health insurance, including insurance obtained through a
job or purchased directly from an insurance company, government programs like Medicare or Medicaid, and programs that provide health care to military personnel and their families.
1 Yes
2 No
Don’t know
Refused
………………………………………………………………………………………………
IF AGE = 13-17 GO TO MODULE I, ELSE CONTINUE
The next questions are about [your/your RELATIONSHIP’s] current health insurance coverage. In answering these questions, I’d like you to exclude plans that only cover one type of service, like dental care plans or plans that pay for prescription drugs.”
IN7. (Are you/Is your RELATIONSHIP) covered by health insurance provided through an employer or union? This could be insurance through a current job, a former job, (your/ your RELATIONSHIP’s) job or someone else’s job.
1 Yes
2 No
Don’t know
Refused
………………………………………………………………………………………………
INS9. How long (have you/has your RELATIONSHIP) had that insurance coverage?
(READ LIST. ENTER ONE ONLY)
1 Less than 3 months
2 3 to 6 months
3 7 to 12 months
4 More than 12 months
Don’t know
Refused
………………………………………………………………………………………………
INS11. Medicare is a health insurance program for people 65 years and older and for people with certain disabilities. (Are you/Is your RELATIONSHIP) covered by Medicare?
1 Yes
2 No
Don’t know
Refused
………………………………………………………………………………………………
INS12 .How long (have you/has your RELATIONSHIP) had that insurance coverage?
(READ LIST. ENTER ONE ONLY)
1 Less than 3 months
2 3 to 6 months
3 7 to 12 months
4 More than 12 months
Don’t know
Refused
………………………………………………………………………………………………
INS12a. [FILL State] has a number of programs that help low and moderate-income people get health insurance coverage. This would include [Medicaid program name] and [SCHIP program name]. You may know [Medicaid Program name] under other names, such as Medicaid, [or other names]. You may know [SCHIP program name] as CHIP.
(Are you/Is your RELATIONSHIP) covered by [Medicaid program name] or [SCHIP program name]?
1 Yes
2 No
Don’t know
Refused
………………………………………………………………………………………………
INS12b. How long (have you/has your RELATIONSHIP) had that insurance coverage?”
1 Less than 3 months
2 3 to 6 months
3 7 to 12 months
4 More than 12 months
Don’t know
Refused
………………………………………………………………………………………………
INS18. (Are you/Is your RELATIONSHIP) covered by a health insurance plan through the [state HIE plan name] that was purchased through [state/federal agency]?
IF NECESSARY: The [state/federal agency] is a government agency that helps individuals purchase health insurance coverage if they do not have access to health insurance through a job.
1 Yes
2 No
Don’t know
Refused
………………………………………………………………………………………………
INS18a1. How long (have you/has your RELATIONSHIP) had that insurance coverage?”
1 Less than 3 months
2 3 to 6 months
3 7 to 12 months
4 More than 12 months
Don’t know
Refused
………………………………………………………………………………………………
INS18a2. (Are you/Is your RELATIONSHIP) covered by a health insurance plan that was purchased directly from an insurance company or an insurance agent, that is, a plan not offered through a current or past employer or union?”
1 Yes
2 No
Don’t know
Refused
………………………………………………………………………………………………
INS18b. How long (have you/has your RELATIONSHIP) had that insurance coverage?”
1 Less than 3 months
2 3 to 6 months
3 7 to 12 months
4 More than 12 months
Don’t know
Refused
………………………………………………………………………………………………
INS18d. (Are you/Is your RELATIONSHIP) covered by some other type of health insurance? For example, coverage for military personnel and their families, such as CHAMPUS, TRICARE, CHAMP-VA and VA?”
1 Yes
2 No
Don’t know
Refused
………………………………………………………………………………………………
INS18e. How long (have you/has your RELATIONSHIP) had that insurance coverage?”
1 Less than 3 months
2 3 to 6 months
3 7 to 12 months
4 More than 12 months
Don’t know
Refused
………………………………………………………………………………………………
INS18f. According to the information you have provided, (you/your RELATIONSHIP) (do/does) not have ANY health insurance now. Is that correct?”
1 Yes, have no health insurance
2 No, have health insurance
Don’t know
Refuse
………………………………………………………………………………………………
IF INS18f = 2 CONTINUE ELSE GO TO INS13
INS18f1. What kind of insurance coverage (do/does) (you/your RELATIONSHIP) have?
(DO NOT READ. ENTER ALL THAT APPLY)
1 Insurance from employer or union
2 Insurance through (state HIE plan name) from (state/federal agency)
3 Insurance purchased directly from a company/agent
4 Medicare
5 [Medicaid program name], Medicaid, [SCHIP program name] (CHIP), or some other public coverage
6 Champus, Tricare, Champ-VA, VA or some other military health care
7 Something else (SPECIFY). _______________
Don’t know
Refuse
………………………………………………………………………………………………
INS18f2. How long (have you/has your RELATIONSHIP) had that insurance coverage?”
1 Less than 3 months
2 3 to 6 months
3 7 to 12 months
4 More than 12 months
Don’t know
Refused
………………………………………………………………………………………………
INS13. ASK ONLY OF INSURED: During the past 12 months, did (you/ your RELATIONSHIP) have health insurance ALL the time, or was there a time during the year that (you/ your RELATIONSHIP) DID NOT have any health coverage?
1 Insured all the time
2 Had a time without insurance
Don’t know
Refused
………………………………………………………………………………………………
INS14. .How many months has it been since (you/your RELATIONSHIP) had a period where (you were/(he/she)was) WITHOUT insurance coverage?
_________ Months (1-12)
Don’t know
Refused
………………………………………………………………………………………………
INS15. What was the MAIN reason that (you are /your RELATIONSHIP is) obtained health insurance coverage at that time?
(DO NOT READ LIST. ENTER ONE ONLY)
(MAY READ RESPONSE BACK TO RESPONDENT TO CONFIRM)
01 Lost job or working less hours
02 Got a job or working more hours
03 Changed jobs
04 Got married
05 Got divorced
06 Had a child
07 Got sick or injured
09 Became eligible for coverage
97 Other (SPECIFY) _________________
Don’t know
Refused
………………………………………………………………………………………………
NOTE: ASK ONLY IF INS13 IS 2 OR INS18f is 1
INS16. INS16 should be asked of respondents who are (a) currently insured but had a time without insurance in the past year AND (b) currently uninsured. How many months were (you/ your RELATIONSHIP) uninsured in the past 12 months? Count a month as uninsured if (you/ your RELATIONSHIP) were uninsured for even one day in the month.
_________ MONTHS UNINSURED (Range = 1-12)
Don’t know
Refused
………………………………………………………………………………………………
INS17. ASKED ONLY IF UNINSURED. How many months has it been since (you/your RELATIONSHIP) last had insurance coverage?
_________ Months
Don’t know
Refused
………………………………………………………………………………………………
INS18. ASKED ONLY IF UNINSURED. When (you/ your RELATIONSHIP) last had health insurance coverage, what kind of insurance coverage did (you/ your RELATIONSHIP) have?
(DO NOT READ. ENTER ONE OR MORE)
01 Insurance from employer or union
02 Insurance purchased directly from a company/agent
04 Medicare
05 Medicaid
06 Champus, Tricare, Champ-VA, VA or some other military health care
07 Something else (SPECIFY) __________
Don’t know
Refused
………………………………………………………………………………………………
INS18_Main. ASKED ONLY IF UNINSURED. What is the MAIN reason that (you are/your RELATIONSHIP is) no longer covered by that insurance?
(DO NOT READ LIST. ENTER ONLY ONE RESPONSE)
01 Lost job or working less hours
02 Got a job or working more hours
03 Changed jobs
04 Got married
05 Got divorced
06 Had a child
07 Got sick or injured
08 Costs too much
09 Became eligible for other coverage
10 Became ineligible for coverage
97 Other (SPECIFY) _________________
Don’t know
Refused
………………………………………………………………………………………………
INS3a. {Does this plan/Do any of these plans} pay for any of the costs for medicines prescribed by a doctor?
1=YES
2=NO
………………………………………………………………………………………………
INS3b. {Does this plan/Do any of these plans} pay for any of the costs for dental care?
1=YES
2=NO
………………………………………………………………………………………………
INS3c. {Does this plan/Do any of these plans} pay for any of the costs for vision care?
1=YES
2=NO
………………………………………………………………………………………………
INS3d. {Does this plan/Do any of these plans} pay for any of the costs for mental health care?
1=YES
2=NO
………………………………………………………………………………………………
INS18g. Earlier you told me that (you/your RELATIONSHIP) (have/has) had (your/his/her) current insurance coverage for less than a year. Did (you/he/she) have any insurance coverage just before that or were (you/he/she) uninsured before (you/he/she) obtained (your/his/her) current insurance coverage?”
(IF NEEDED: By just before I mean in the month before you started your current health insurance coverage.)
1 Yes, had coverage just before
2 No, uninsured just before
Don’t know
Refused
………………………………………………………………………………………………
INS18h. IF INS18g=1 CONTINUE ELSE GO TO INS19
What kind of insurance coverage did (you/your RELATIONSHIP) have just before (your/his/her) current coverage?
1 Insurance from employer or union
2 Insurance through (state HIE plan name) from (state/federal agency)
3 Insurance purchased directly from a company/agent
4 Medicare
5 [Medicaid program name], Medicaid, [SCHIP program name] (CHIP), or some other public coverage
6 Champus, Tricare, Champ-VA, VA or some other military health care
7 Something else (SPECIFY). _______________
Don’t know
Refuse
………………………………………………………………………………………………
INS19. What was the MAIN reason (you/your RELATIONSHIP) changed insurance plans at that time?
(DO NOT READ LIST. ENTER ONE ONLY)
(MAY READ RESPONSE BACK TO RESPONDENT TO CONFIRM)
01 Lost job or working less hours
02 Got a job or working more hours
03 Changed jobs
04 Got married
05 Got divorced
06 Had a child
07 Got sick or injured
08 Costs too much
09 Became eligible for other coverage
10 Became ineligible for coverage
97 Other (SPECIFY) _________________
Don’t know
Refused
………………………………………………………………………………………………
QUESTIONS ON CO-PAYS
INS20. Does [your/ your RELATIONSHIP’s] current health coverage have an annual deductible for medical care? A deductible is the amount [you/ your RELATIONSHIP] [have/has] to pay before the insurance plan will start paying [your/ your RELATIONSHIP’s] medical bills.
IF NEEDED: The deductible is different from a co-pay. A co-pay is the payment for a doctor visit or other medical service and a deductible is the amount you pay before your insurance plan will start paying [your/ your RELATIONSHIP’s] medical bills.
1 Yes
2 No
IF Q.G4 = 2, D, OR R, GO TO Q.G10
………………………………………………………………………………………………
(ASK Q.G8 IF Q.G7a OR Q.G7b = 1)
IF Q.G1 = 1, INSERT “within you plan’s network”
IF INTERVIEWING “SELECTED RESPONDENT” INSERT “your”
IF INTERVIEWING “A PROXY” INSERT, “your RELATIONSHIP”
INS21. For my next question, I’d like you to focus on the annual deductible that applies to physician and hospital care (within your plan’s network). How much is the annual deductible per person under (your/ your RELATIONSHIP’s) current health coverage?
PROBE: Your best estimate is fine.
INTERVIEWER: IF RESPONDENT GIVES RANGE, RECORD LOWEST
AMOUNT AND GO TO G9; OTHERWISE ENTER DD OR RR AND GO TO Q.8a
_____________ AMOUNT ($1-$10K)
LL $10,000 or more
………………………………………………………………………………………………
(ASK Q.G8a IF Q.G8 = DD OR RR)
INS22. Would you say it is…?
(READ LIST. ENTER ONE ONLY)
1 Less than $100
2 $100 to under $500
3 $500 to under $1,000
4 $1,000 to under $2,000
5 $2,000 to under $3,000
6 $3,000 to under $5,000
7 $5000 to under $10,000
8 $10,000 or more
………………………………………………………………………………………………
INS23. Now I’d like to ask about the premiums under (your/ your RELATIONSHIP’s) current health coverage. (Do you/Does your RELATIONSHIP) pay any premiums for your health insurance? This includes money deducted from a paycheck as well as money you pay directly to an insurance company.
1 Yes
2 No
………………………………………………………………………………………………
INS24. About how much (do you/does he/does she) pay (INSERT RESPONSE FROM Q.G11) in premiums, including any amount deducted from a paycheck?
IF NEEDED: This is the premium you pay for the whole plan, even if it covers other
family members.
PROBE: Your best estimate is fine.
INTERVIEWER: IF RESPONDENT GIVES RANGE, RECORD LOWEST
AMOUNT AND GO TO G12; OTHERWISE ENTER DD OR RR AND GO TO
Q.11b
_____________ AMOUNT ($1-$20K)
………………………………………………………………………………………………
(ASK Q.G11a1 IF Q.G11a = DD OR RR)
INS25. Would you say it is…?
(READ LIST. ENTER ONE ONLY)
(P.N. - $ AMOUNT TO BE FILLED IN BASED ON TIME PERIOD FROM Q.G11
[CODES 01-07])
01 Less than (INSERT AMT1)
02 (INSERT AMT1) to under (INSERT AMT2)
03 (INSERT AMT2) to under (INSERT AMT3)
04 (INSERT AMT3) to under (INSERT AMT4)
05 (INSERT AMT4) to under (INSERT AMT5)
06 (INSERT AMT5) to under (INSERT AMT6)
07 (INSERT AMT6) to under (INSERT AMT7)
08 (INSERT AMT7) to under (INSERT AMT8)
09 (INSERT AMT8) to under (INSERT AMT9)
10 (INSERT AMT9) to under (INSERT AMT10)
11 (INSERT AMT10) or more
FILLS FOR PREMIUM PAYMENTS
|
|||||||||||||
G11=01 Week |
G11=02 Two weeks |
G11=03 Twice per month |
G11=04 Month |
G11=05 Three month |
G11=06 Six months |
G11=07 Year |
|||||||
AMT1 |
10 |
20 |
20 |
40 |
125 |
250 |
500 |
||||||
AMT2 |
30 |
60 |
65 |
125 |
375 |
750 |
1500 |
||||||
AMT3 |
60 |
115 |
125 |
250 |
750 |
1500 |
3000 |
||||||
AMT4 |
90 |
175 |
190 |
375 |
1125 |
2250 |
4500 |
||||||
AMT5 |
115 |
230 |
250 |
500 |
1500 |
3000 |
6000 |
||||||
AMT6 |
155 |
310 |
335 |
670 |
2000 |
4000 |
8000 |
||||||
AMT7 |
190 |
385 |
420 |
835 |
2500 |
5000 |
10000 |
||||||
AMT8 |
230 |
460 |
500 |
1000 |
3000 |
6000 |
12000 |
||||||
AMT9 |
290 |
580 |
625 |
1250 |
3750 |
7500 |
15000 |
||||||
AMT1 |
385 |
770 |
835 |
1670 |
5000 |
10000 |
20000 |
||||||
………………………………………………………………………………………………
INS26. Now I’d like to ask about how much you and your family spent “out of pocket” for healthcare in the past 12 months. “Out of pocket” is the amount of money you pay that is not covered by any insurance or special assistance that you might have. It does not include any premiums you pay for your health insurance or any healthcare costs that you will be reimbursed for”.
How much did you and your family spend “out of pocket” in the past 12 months for…?
(If necessary: the premium is the price you pay for the insurance policy)
Probe: your best estimate is fine
A. Prescription medicine
B. Dental and vision care
C. All other medical expenses, including doctors, hospitals, test and equipments
$____________
DON’T KNOW
REFUSED
MODULE I: PRESCRIPTION MEDICATION
The next questions are about prescription medication.
PRS1. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a doctor believe {you/name} needed prescription medicines?
1=YES
2=NO
[PRSCHK2 IF PRS1=1, THEN CONTINUE; ELSE GO TO PRS5]
………………………………………………………………………………………………
PRS2. In the last 12 months, {were you/was name} unable to get prescription medicines you or a doctor believed necessary?
1=YES
2=NO
[PRSCHK2a IF PRS2=1 THEN CONTINUE; ELSE GO TO PRS3]
………………………………………………………………………………………………
PRS2a Please look at this showcard. Which of these best describes the reasons {you were/name was} unable to get prescription medicines you or a doctor believed necessary. You may select one or more.
@BSHOWCARD MED3@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=PHARMACY DID NOT HAVE IN STOCK
12=OTHER (SPECIFY)
………………………………………………………………………………………………
PRS2a1. Please look at this showcard. Which of these best describes the main reason {you were/name was} unable to get prescription medicines you or a doctor believed necessary
@BSHOWCARD MED3@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=PHARMACY DID NOT HAVE IN STOCK
12=OTHER (SPECIFY)
……………………………………………………………………………………………
PRS3. In the last 12 months, {were you/was name} delayed in getting prescription medicines you or a doctor believed necessary?
1=YES
2=NO
[PRSCHK3a IF PRS3= 1, THEN CONTINUE; ELSE GO TO PRSCHK4]
………………………………………………………………………………………………
PRS3a. Please look at this showcard. What are the reasons {you were/name was} delayed in getting prescription medicines you or a doctor believed necessary? You may select one or more.
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTOS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=PHARMACY DID NOT HAVE IN STOCK
12=OTHER (SPECIFY)
………………………………………………………………………………………………
PRS3a1. Please look at this showcard. Which of these best describes the main reason {you were/name was} delayed in getting prescription medicines you or a doctor believed necessary?
@BSHOWCARD MED3@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTOS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=PHARMACY DID NOT HAVE IN STOCK
12=OTHER (SPECIFY)
………………………………………………………………………………………………
PRS3a2. The following questions concern the use of prescription medication 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=Refused
9= Don't know
………………………………………………………………………………………………
PRS3a3. The following questions concern the use of prescription medication 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=Refused
9= Don't know
………………………………………………………………………………………………
PRS3a4. The following questions concern the use of prescription medication 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=Refused
9= Don't know
………………………………………………………………………………………………
PRS3a5. The following questions concern the use of prescription medication 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=Refused
9= Don't know
………………………………………………………………………………………………
PRS3a6. The following questions concern the use of prescription medication DURING THE PAST 12 MONTHS, are any of the following true for you?
…You used alternative therapies to save money.
IF NEEDED: Therapies such as compunction, chiropractic, homeotherapy are some examples of alternative therapy or complementary medicine.
1=Yes
2 =No
7=Refused
9= Don't know
………………………………………………………………………………………………
PRS3a7. The following questions concern the use of prescription medication DURING THE PAST 12 MONTHS, are any of the following true for you?
…You got prescription drugs from a friend or relative.
1=Yes
2 =No
7=Refused
9= Don't know
………………………………………………………………………………………………
PRS5. {Do you/Does name} take any prescription medication on a regular or on-going basis?
1=YES
2=NO
[PRSCHK6 IF PRS5=1, THEN CONTINUE; ELSE GO TO MODULE J ]
………………………………………………………………………………………………
PRS6. Where do you normally get {your/name’s} prescriptions filled?
1=You get them filled at {reference health center}
2=You get some of them filled at {the reference health center} and some of them filled elsewhere
3=You get them filled somewhere other than {the reference health center}
………………………………………………………………………………………………
PRS6_SPEC. IF PRS6=2 or PRS6=3 CONTINUE ELSE GO TO PRS7. Can you tell me where you normally get {your/name’s} prescriptions filled outside of the {reference health center}?
SPECIFY [ ] ALLOW 60
………………………………………………………………………………………………
PRS7. About how many different prescription medicines {do you/does name} usually take in a month?
__________NUMBER/ MEDICINES [ALLOW 00-25]
[PRSCHK8 IF PRS6=1 OR 2 CONTINUE ELSE GO TO MODULE J ]
………………………………………………………………………………………………
PRS8. Think about the last time someone at the {health center} prescribed medication for {you/name}. Were you satisfied with the way the medication was explained to you, such as instructions on how to take it and possible side-effects?
1=YES
2=NO
3=NA - HC HAS NOT PRESCRIBED MEDICATION FOR ME
[PRSCHK9 IF PRS8 = 1 OR 2 CONTINUE, ELSE GO TO MODULE J ]
………………………………………………………………………………………………
PRS9. Were you satisfied with the way your questions about the medication were answered?
1=YES
2=NO
3=DIDN’T HAVE ANY QUESTIONS
………………………………………………………………………………………………
MODULE J: DENTAL
[DENCHK1 IF AGE GE 1, 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]
………………………………………………………………………………………………
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]
………………………………………………………………………………………………
DEN4.
Please look at this showcard. Please describe the main
reasons {you were/name was} unable to get dental care, tests, or
treatments you or a dentist believed necessary? You may select one or
more.
@BSHOWCARD MED2@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DENTIST REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DENTIST’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=AFRAID OF GOING TO THE DENTIST/ HAVING DENTAL WORK DONE
12=OTHER (SPECIFY)
……………………………………………………………………………………………………
DEN5. 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?
@BSHOWCARD MED2@B
[LIST ONLY SELECTIONS MADE IN DEN4]
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DENTIST REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DENTIST’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=AFRAID OF GOING TO THE DENTIST/ HAVING DENTAL WORK DONE
12=OTHER (SPECIFY)
………………………………………………………………………………………………
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
[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)
………………………………………………………………………………………………
DEN8. Please look at this showcard. Please describe the reasons {you were/name was}delayed in getting dental care, tests, or treatments you or a dentist believed necessary? You may select one or more.
@BSHOWCARD MED2@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=AFRAID OF GOING TO THE DENTIST/ HAVING DENTAL WORK DONE
12=OTHER (SPECIFY)
……………………………………………………………………………………………
DEN9. 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?
@BSHOWCARD MED2@B
[LIST ONLY SELECTIONS MADE IN DEN8]
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=AFRAID OF GOING TO THE DENTIST/ HAVING DENTAL WORK DONE
12=OTHER (SPECIFY)
………………………………………………………………………………………………
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]
………………………………………………………………………………………………
DEN10a. What was the main reason [you/name] last visited the dentist?
1=Went in on own for check-up, examination or cleaning
2=Was called in by the dentist for check-up, examination or cleaning
3=Something was wrong, bothering or hurting [me/name]
4=Went for treatment of a condition that dentist discovered at earlier check-up or examination
5=Other (specify)
……………………………………………………………………………………………
DEN10b. IF AGE=18 OR OLDER CONTINUE, ELSE GO TO DEN10e.
[Have you/Has name] ever had an exam for oral cancer in which the doctor or dentist pulls on [your/his/her] tongue, sometimes with gauze wrapped around it, and feels under the tongue and inside the cheeks?
1=Yes
2=No
……………………………………………………………………………………………
DEN10c. [Have you/Has name] ever had an exam for oral cancer in which the doctor or dentist feels [your/his/her] neck?
1=Yes
2=No
……………………………………………………………………………………………
DEN10d. When did [you/name] have [your/his/her] most recent oral or mouth cancer exam? Was it within the past year, between 1 and 3 years ago, or over 3 years ago?
1=Within past year
2=Between 1 and 3 years ago
3=Over 3 years ago
……………………………………………………………………………………………
DEN10e. For {your/name’s} most recent visit, what did {you/name} have done?
1=X-RAYS TAKEN
2=CLEANING TEETH
3=EXAMINATION
4=FILLINGS
5=EXTRACTIONS
6=ROOT CANALS
7=CROWNS
8=BRIDGES, DENTURES, PLATES, ETC. -- EITHER NEW ONES OR REPAIR WORK
9=ORTHODONTIA -- BITE ADJUSTMENT, BRACES, RETAINERS, ETC.
10=PERIODONTIA -- E.G., OF GUM DISEASE TREATMENT
11=BONDING
12=SURGERY
………………………………………………………………………………………………
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 say…
1=All of the visits
2=Some of the visits
3=None of the visits
[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}? Using any number from 0 to 10, where 0 is the worst dental care possible and 10 is the best dental care possible, what number would you use to rate all of the dental care you personally received in the last 12 months?
0 = WORST DENTAL CARE POSSIBLE
1
2
3
4
5
6
7
8
9
10 = BEST DENTAL CARE POSSIBLE
[DENCHK13 If DEN11= 2 OR 3, THEN CONTINUE; ELSE GO TO DEN13a]
………………………………………………………………………………………………
DEN13. Were you referred to the other place where {you/name} got dental services by {reference health center}?
1=YES
2=NO
[DENCHK14 IF AGE LE11 GOTO DEN16a]
………………………………………………………………………………………………
DEN13a. In the last 12 months, how often did you and a dental provider talk about specific things you could do to prevent dental problems?
1 Never
2 Sometimes
3 Usually
4 Always
………………………………………………………………………………………………
Now, I have some questions about the condition of {your/name’s} 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 lost…
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
[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]
………………………………………………………………………………………………
DEN15a. Are any of your missing teeth replaced by full or partial dentures, false teeth, dental implants, bridges or dental plates?
1=YES
2=NO
[DENCHK16a DEN14=2, 3, DK, or RE CONTINUE; ELSE GO TO DEN16b]
………………………………………………………………………………………………
DEN16a. Overall, how would [you/name] rate the health of [your/his/her] teeth and gums?
Would you say...
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor
[DENCHK16a_POST GO TO DEN17a
………………………………………………………………………………………………
DEN16b. Now I have some questions about the condition of {your/name’s} false teeth or dentures. Would you say the condition of {your/name’s} false teeth or dentures is…
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor
………………………………………………………………………………………………
DEN17a. During the past 6 months, {have you/has name} had any of the following problems?
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?)
Bleeding gums?
1=YES
2=NO
………………………………………………………………………………………………
DEN17c. (During the past 6 months, {have you/has name} had any of the following problems?)
Crooked teeth?
1=YES
2=NO
………………………………………………………………………………………………
DEN17e. (During the past 6 months, {have you/has name} had any of the following problems?)
Broken or missing teeth?
1=YES
2=NO
………………………………………………………………………………………………
DEN17f. (During the past 6 months, {have you/has name} had any of the following problems?)
Stained or discolored teeth?
1=YES
2=NO
………………………………………………………………………………………………
DEN17g. (During the past 6 months, {have you/has name} had any of the following problems?)
Broken or missing fillings?
1=YES
2=NO
………………………………………………………………………………………………
DEN17h. (During the past 6 months, {have you/has name} had any of the following problems?)
{[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?}
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?
Pain in {your/his/her} jaw joint?
1=YES
2=NO
………………………………………………………………………………………………
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?
1=YES
2=NO
………………………………………………………………………………………………
DEN18c. (During the past 6 months, {have you/has name} had any of the following problems that lasted more than a day?)
Difficulty eating or chewing?
1=YES
2=NO
………………………………………………………………………………………………
DEN18d. (During the past 6 months, {have you/has name} had any of the following problems that lasted more than a day?)
Bad breath?
1=YES
2=NO
………………………………………………………………………………………………
DEN18f. (During the past 6 months, {have you/has name} had any of the following problems that lasted more than a day?)
Dry mouth?
1=YES
2=NO
[DENCHK19 IF DEN17a-h=1 or DEN18a-f=1, CONTINUE; ELSE GO TO MODULE K]
………………………………………………………………………………………………
DEN19a. Did the problems with {your/name’s} mouth or teeth interfere with any of the following?
job or school?
1=YES
2=NO
3= NOT WORKING / NOT AT SCHOOL
………………………………………………………………………………………………
DEN19b. (Did the problems with {your/name’s} mouth or teeth interfere with any of the following?)
sleeping?
1=YES
2=NO
………………………………………………………………………………………………
DEN19c. (Did the problems with {your/name’s} mouth or teeth interfere with any of the following?)
social activities such as going out or being with other people?
1=YES
2=NO
………………………………………………………………………………………………
DEN19d. (Did the problems with {your/name’s} mouth or teeth interfere with any of the following?)
usual activities at home?
1=YES
2=NO
3= DON'T HAVE A HOME
………………………………………………………………………………………………
MODULE K: MENTAL HEALTH
[MENCHK1 IF AGE GE 18, THEN CONTINUE; ELSE GO TO MENCHK3 ]
MEN1. The next questions are about feelings you may have experienced over the past 30 days. Your answers to these questions are private and will not be shared with anyone at the {reference health center}. You also have the right to refuse any question that you do not want to answer.
@BSHOWCARD MEN1@B
Please look at this showcard. During the past 30 days, how often did you feel…
MEN1a.
so sad that nothing could cheer you up?
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1b. (During the past 30 days, how often did you feel…)
nervous?
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1c. (During the past 30 days, how often did you feel…)
restless or fidgety?
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1d. (During the past 30 days, how often did you feel…)
hopeless?
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1e. (During the past 30 days, how often did you feel…)
that everything was an effort?
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1f. (During the past 30 days, how often did you feel…)
worthless?
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN2. We just talked about a number of feelings you had during the past 30 days. Altogether, how much did these feelings interfere with your life or activities; a lot, some, a little, or not at all?
1=A LOT
2=SOME
3=A LITTLE
4=NOT AT ALL
………………………………………………………………………………………………
[MENCHK3 IF AGE = 2 OR 3, THEN CONTINUE; ELSE GO TO MENCHK3g]
MEN3. The next questions are about feelings {name} may have experienced. Your answers to these questions are private and will not be shared with anyone at the {reference health center}. You also have the right to refuse any question that you do not want to answer.
I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true of {name} during the past 6 months.
MEN3a.
Has been uncooperative?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3b (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true of {name} during the past 6 months.)
Has trouble getting to sleep?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3c. (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true of {name} during the past 6 months.)
Has speech problems?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3d. (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true of {name} during the past 6 months.)
Has been unhappy, sad, or depressed?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3e. (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true of {name} during the past 6 months.)
Has temper tantrums or a hot temper?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3f. (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true of {name} during the past 6 months.)
Has been nervous or high-strung?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
[MENCHK3g IF AGE =4 TO 12, THEN CONTINUE; ELSE GO TO MENCHK4a]
………………………………………………………………………………………………
MEN3g. The next questions are about feelings {name} may have experienced. Your answers to these questions are private and will not be shared with anyone at the {reference health center}. You also have the right to refuse any question that you do not want to answer.
I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true, of {name} during the past 6 months.
Doesn’t get along with other kids?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3h. I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true, of {name} during the past 6 months.
Can’t concentrate or pay attention long?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3i. I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true, of {name} during the past 6 months.
Feels worthless or inferior?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3j. I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true, of {name} during the past 6 months.
Has been unhappy, sad, or depressed?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3k. I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true, of {name} during the past 6 months.
Has been nervous or high-strung or tense?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3l. I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true, of {name} during the past 6 months.
Acts too young for {his/her} age?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
[MENCHK4a IF AGE=13 TO 17, THEN CONTINUE; ELSE GO TO MEN6 ]
………………………………………………………………………………………………
MEN4a. The next questions are about feelings you may have experienced. Your answers to these questions are private and will not be shared with anyone at the {reference health center}. You also have the right to refuse any question that you do not want to answer.
I am going to read a list of items that describe teenagers. For each one, tell me if it has been not true, sometimes true, or often true, of you during the past 6 months.
You can’t concentrate or pay attention long?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4b. (I am going to read a list of items that describe teenagers. For each one, tell me if it has been not true, sometimes true, or often true, of you during the past 6 months.)
You lie or cheat?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4c. (I am going to read a list of items that describe teenagers. For each one, tell me if it has been not true, sometimes true, or often true, of you during the past 6 months.)
You don’t get along with other kids?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4d (I am going to read a list of items that describe teenagers. For each one, tell me if it has been not true, sometimes true, or often true, of you during the past 6 months.)
You have been unhappy, sad, or depressed?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4e. (I am going to read a list of items that describe teenagers. For each one, tell me if it has been not true, sometimes true, or often true, of you during the past 6 months.)
You do poorly at school work?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4f. (I am going to read a list of items that describe teenagers. For each one, tell me if it has been not true, sometimes true, or often true, of you during the past 6 months.)
You have trouble sleeping?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
MEN2a. Has a doctor or other health professional ever told you that you had depression?
1=YES
2=NO
………………………………………………………………………………………………
MEN2b. Has a doctor or other health professional ever told you that you had generalized anxiety?
1=YES
2=NO
………………………………………………………………………………………………
MEN2c Has a doctor or other health professional ever told you that you had panic disorder?
1=YES
2=NO
………………………………………………………………………………………………
MEN5j. Has a doctor or other health professional ever told you that you had schizophrenia?
1=YES
2=NO
………………………………………………………………………………………………
MEN5k. Has a doctor or other health professional ever told you that you were bi-polar?
1=YES
2=NO
………………………………………………………………………………………………
MEN5. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a doctor believe {you/name} should see a professional about your mental health, emotions, or nerves?
1=YES
2=NO
………………………………………………………………………………………………
MEN5a: In the last 12 months, have you seen your primary care doctor or other general practitioner for problems with your mental health, emotions, or nerves?
1=YES
2=NO
………………………………………………………………………………………………
MEN5b. In the last 12 months, have you seen any other professional, such as a counselor, psychiatrist, or social worker for problems with your mental health, emotions, or nerves?
1=YES
2=NO
[MENCHK5 IF MEN6 = 1, CONTINUE; ELSE GO TO MEN8]
………………………………………………………………………………………………
MEN6. In the last 12 months, {were you/was name} unable to get mental health care that you or a doctor believed necessary?
1=YES
2=NO
[MENCHK6a IF MEN7 = 1, CONTINUE; ELSE GO TO MEN8]
………………………………………………………………………………………………
MEN6a. Please look at this showcard. Which of these describes the reasons {you were/name was} unable to get mental health care by a mental health professional you or a doctor believed necessary? You may select one or more.
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
12=OTHER (SPECIFY)
………………………………………………………………………………………………
MEN7a1. Please look at this showcard. Which of these best describes the main reason {you were/name was} unable to get mental health care by a mental health professional you or a doctor believed necessary?
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
12=OTHER (SPECIFY)
………………………………………………………………………………………………
MEN7. In the last 12 months, were {you/name} delayed in getting mental health care you or a doctor believed necessary?
1=YES
2=NO
[MENCHK7a IF MEN8=1, CONTINUE; ELSE GO TO MENCHK8 ]
………………………………………………………………………………………………
MEN7a. Please look at this showcard. Which of these describes the reasons {you were/name was delayed in getting counseling by a mental health professional you or a doctor believed necessary? You may select one or more.
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
12=OTHER (SPECIFY)
………………………………………………………………………………………………
MEN8a2. Please look at this showcard. Which of these best describes the main reason {you were/name was} delayed in getting counseling by a mental health professional you or a doctor believed necessary?
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
12=OTHER (SPECIFY)
………………………………………………………………………………………………
TREATMENT QUESTIONS
[MENCHK8 IF AGE GE 13, THEN CONTINUE; ELSE GO TO MODULE L]
MEN9. Have you ever received any mental health treatment or counseling?
Please include treatment with prescription medication, group, family, couples, or individual counseling with a mental health provider such as a social worker, psychologist, psychiatrist, psychiatric nurse or other mental health professional, and inpatient treatment. Do not include counseling or advice given by a friend, or spiritual counseling through a church or religious group.
1=YES
2=NO
………………………………………………………………………………………………
[IF MEN9=2 CONTINUE ELSE GO TO MENCHK8a]
MEN8. In the past 12 months, did you receive any mental health treatment or counseling?
1=YES
2=NO
[MENCHK8a IF MEN9=1, CONTINUE; ELSE GO TO MODULE L]
………………………………………………………………………………………………
MEN8a. What was this treatment or counseling for? You may select one or more. Was it for …
CODE ALL THAT APPLY
1=Mental or emotional health
2=Alcohol or drug problem
3=Personal or family problems/ relationship problems
4=Other
………………………………………………………………………………………………
MEN9. What kind of treatment and/or counseling was it?
CODE ALL THAT APPLY
1=Individual counseling
2=Group counseling
3=Family or couples counseling
4=Prescription medication
5=Inpatient treatment in a general hospital or mental health treatment facility
………………………………………………………………………………………………
MEN10_where IF MEN10=5 CONTINUE ELSE GOTO MENCHK10
Were you referred to the hospital or facility where you got the treatment by the {reference health center}?
1=YES
2=NO
[MENCHK10 IF MEN10 = 1-4 THEN CONTINUE; ELSE GO TO MODULE L]
………………………………………………………………………………………………
MEN9a. How many of your treatment or counseling sessions you received did you get at {the reference health center}? Would you say…
1=All of the visits
2=Some of the visits
3=None of the visits
[MENCHK9b IF MEN10a=1 OR 2, THEN CONTINUE; ELSE GO TO MENCHK9c]
………………………………………………………………………………………………
MEN9b. Using any number from 0 to 10, where 0 is poor and 10 is excellent, what number would you use to rate the treatment or counseling services you received at {the reference health center}.
0 Poor
1
2
3
4
5
6
7
8
9
10 Excellent
[MENCHK9c IF MEN10a=2 OR 3, THE CONTINUE; ELSE GO TO MODULE L]
………………………………………………………………………………………………
MEN9c. Were you referred to the other place where you got the treatment or counseling services by the {reference health center}?
1=YES
2=NO
………………………………………………………………………………………………
MODULE L: SUBSTANCE USE
[SUBCHK0: IF AGE GE 13, THEN CONTINUE; ELSE GO TO MODULE M]
SUB1a_INTRO. The next questions are about your use of substances. Your answers to these questions are private and will not be shared with anyone at {reference health center}. You also have the right to refuse any question that you do not want to answer.
SUB1a. Have you smoked at least 100 cigarettes in your entire life?
1=YES
2=NO
[SUBCHK1b IF SUB1a= 2, DK, OR RF, GO TO SUB2; ELSE CONTINUE]
………………………………………………………………………………………………
SUB1a1. How old were you when you smoked a whole cigarette for the first time?”
*Enter '6' if less than 6 years old.
*Enter '95' if 95 years old or older.
06-84= 6 - 84 years
85= 85 years or older
96= Never smoked regularly
97= Refused
99= Don't know
PROBE: How did you remember how old you were when you first started smoking regularly? How sure are you of your answer?
………………………………………………………………………………………………
SUB1b. Do you now smoke cigarettes every day, some days or not at all?
1= EVERY DAY
2= SOME DAYS
3= NOT AT ALL
[SUBCHK1b_POST IF SUB1b=2, GO TO SUB1d; IF SUB1b=3, DK, RE, GO TO SUB1t]
………………………………………………………………………………………………
SUB1c. On the average, how many cigarettes do you now smoke a day?
NOTE: IF RESPONSE IS LESS THAN 1 – ENTER 1
_______CIGARETTES [ALLOW 00-99]
[SUBCHK1c_POST GO TO SUB1f]
………………………………………………………………………………………………
SUB1d. During the past 30 days, on how many days did you smoke cigarettes?”
______ DAYS [ALLOW 00-30]
[SUBCHK1e if SUB1d=0, GO TO SUB1f; ELSE CONTINUE]
……………………………………………………………………………………………
SUB1e. On average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?
______ NUMBER OF CIGARETTES [ALLOW 00-99]
………………………………………………………………………………………………
SUB1f. During the past @U12 months@U, have you wanted to stop smoking?
1=YES
2=NO
………………………………………………………………………………………………
SUB1g. Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?
NOTE: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.
1= Every day
2 =Some days
3 =Not at all
………………………………………………………………………………………………..
SUB1h. How old were you the first time you used “smokeless” tobacco?
YEARS OLD: [RANGE: 1 - 110]
PROBE: How did you remember that?
……………………………………………………………………………………………….
SUB1i. Now think about the past 30 days, that is, from [DATEFILL] up to and including today. During the past 30 days, have you used “smokeless” tobacco, even once?
1 Yes
2 No
PROGRAMMER: SHOW 30 DAY CALENDAR
……………………………………………………………………………………………….
SUB1j. How long has it been since you last used “smokeless” tobacco?
1 More than 30 days ago but within the past 12 months
2 More than 12 months ago but within the past 3 years
3 More than 3 years ago
………………………………………………………………………………………………
SUB1k. During the past 12 months, did any doctor or other health care professional advise you to quit smoking cigarettes or quit using any other tobacco products?
1=Yes
2=No
DK/REF
PROGRAMMER: SHOW 12 MONTH CALENDAR
PROBE: What does the word “advise” mean to you?
.................................................................................................................................................
IF SUBk=1 CONTINUE ELSE GO TO SUB1j.
SUB1l. Did you receive this advice at the health center?
1=Yes
2=No
PROGRAMMER: SHOW 12 MONTH CALENDAR
.................................................................................................................................................
SUB1m. How long has it been since you quit smoking cigarettes?
* Enter number for time since quit smoking.
* Enter '95' for 95 years old or older.
01-94= 1 - 94
95= 95+
PROBE: How did you remember when you quit? How sure of your answer are you?
………………………………………………………………………………………………
SUB1n. ASK OF ALL CURRENT SMOKERS. 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
………………………………………………………………………………………………
Previously, you mentioned you tried to quit smoking in the past year. The next few questions ask about your most recent attempt to quit smoking.
SUB1o. When you quit smoking…/The last time you tried to quit smoking, did you call a telephone quitline to help you quit?
1 Yes
2 No
7 Don‘t know / Not sure
9 Refused
………………………………………………………………………………………………
SUB1p. When you quit smoking…/The last time you tried to quit smoking… did you use a program to help you quit?
1 Yes
2 No
7 Don‘t know / Not sure
9 Refused
…………………………………………………………………………………………
SUB1q. When you quit smoking…/The last time you tried to quit smoking… did you receive one-on-one counseling from a health professional to help you quit?
1 Yes
2 No
7 Don‘t know / Not sure
9 Refused
PROBE: Please tell me what the term “one-on-one counseling” means to you?
………………………………………………………………………………………………
SUB1r. When you quit smoking…/The last time you tried to quit smoking… did
you use any of the following medications: a nicotine patch, nicotine gum, nicotine
lozenges, nicotine nasal spray, a nicotine inhaler, or pills such as Wellbutrin®, Zyban®,
buproprion, Chantix®, or varenicline to help you quit?
1 Yes
2 No
7 Don‘t know / Not sure
9 Refused
PROBE: Did you have any difficulty answering this question? [If yes] Tell me about that. Are you familiar with each of the medications listed in this question?
………………………………………………………………………………………………
SUB1s. IF SUB1q=1 CONTINUE ELSE GO TO SUB1r. Was it…
1 Nicotine replacement such as lozenges, nasal spray, inhaler or
2 Medication such as Wellbutrin®, Zyban®,buproprion, Chantix®, or varenicline
………………………………………………………………………………………………
The next few questions are about plans to quit smoking in the future.
SUB1t. Do you have a time frame in mind for quitting?
1 Yes
2 No [Go to Next Module]
7 Don‘t know / Not sure [Go to Next Module]
9 Refused [Go to Next Module]
PROBE: Please tell me in your own words what this question is asking.
………………………………………………………………………………………………
SUB1u. Do you plan to quit smoking cigarettes for good…
Please read:
1 In the next 7 days
2 In the next 30 days
3 In the next 6 months
4 In the next year
5 More than 1 year from now
Do not read:
7 Don‘t know / Not sure
9 Refused
PROBE: Please tell me what you are thinking about this question.
……………………………………………………………………………………………….
SUB2.
@BSHOWCARD SUB1@B
Please look at this showcard. We are interested in whether you have used any of these for @Unon-medical reasons@U. Include prescription drugs that you took only if they were not prescribed for you or you took them only for the experience or feeling they caused.
Some of the substances listed may be prescribed by a doctor (like amphetamines, sedatives, pain medications). For this interview, we will not record medications that are used as prescribed by your doctor. However, if you have taken such medications for reasons other than prescription, or taken them more frequently or at higher doses than prescribed, please let me know.
………………………………………………………………………………………………
SUB2a. In your life, which of the following substances have you ever used? Have you used…
Alcoholic beverages such as beer, wine, or spirits
1=YES
2=NO
………………………………………………………………………………………………
SUB2b. (In your life, which of the following substances have you ever used? Have you used…)
Cannabis or Marijuana? We are asking about @Unon-medical@U use.
These may be known as marijuana, pot, grass, hash, etc.)
1=YES
2=NO
………………………………………………………………………………………………
SUB2c. (In your life, which of the following substances have you ever used? Have you used…)
Cocaine? These may be known as coke, crack, etc.
1=YES
2=NO
………………………………………………………………………………………………
SUB2d. (In your life, which of the following substances have you ever used? Have you used…)
Amphetamine-type Stimulants? These may be known as speed, ecstasy, crystal meth, diet pills, etc..
1=YES
2=NO
………………………………………………………………………………………………
SUB2e. (In your life, which of the following substances have you ever used? Have you used…)
Inhalants? These may be known as nitrous, glue, petrol, paint thinner, etc..
1=YES
2=NO
………………………………………………………………………………………………
SUB2f. (In your life, which of the following substances have you ever used? Have you used…)
Sedatives or Sleeping Pills? We are asking about @Unon-medical@U use.
These may be known as valium, serepax, rohypnol, etc..
1=YES
2=NO
………………………………………………………………………………………………
SUB2g. (In your life, which of the following substances have you ever used? Have you used…)
Hallucinogens? These may be known as LSD, acid, mushrooms, PCP, special K, etc.
1=YES
2=NO
………………………………………………………………………………………………
SUB2h. (In your life, which of the following substances have you ever used? Have you used…)
Opioids? We are asking about @Unon-medical@U use. These may be known as heroin, morphine, methadone, codeine, vicodin, etc..
1=YES
2=NO
………………………………………………………………………………………………
SUB2i. (In your life, which of the following substances have you ever used? Have you used…)
Any Other?
1=YES
2=NO
[IF SUB2i=1, THEN GO TO SUB2i_OTH; ELSE GO TO SUBCHK2a_a ]
………………………………………………………………………………………………
SUB2i_OTH. (SPECIFY)_______ [ALLOW 40]
[SUBCHK2a_a IF SUB2a-i NE 1 (NO YES ANSWERS), GO TO SUB3; IF SUB2a=1 (YES), ASK SUB2a_a through SUB2a_f; ELSE GO TO SUBCHk2b_a ]
………………………………………………………………………………………………
SUB2a_a. In the past three months, how often have you used alcoholic beverages?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
[SUBCHK2a_b IF SUB2a_a=0, DK, OR RE GOTO SUBCHK2b_a ELSE CONTINUE]
………………………………………………………………………………………………
SUB2a_b. During the past three months, how often have you had a strong desire or urge to use alcoholic beverages?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2a_c. During the past three months, how often has your use of alcoholic beverages led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2a_d. During the past three months, how often have you failed to do what was normally expected of you because of your use of alcoholic beverages?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2a_e. How often has a friend or relative or anyone else expressed concern about your use of alcoholic beverages?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
………………………………………………………………………………………………
SUB2a_f. How often have you tried and failed to control, cut down or stop using alcoholic beverages?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
IF SUB2a_a NE 0, DK, RF, GO TO SUB7a; ELSE IF SUB2a=1 CONTINUE; ELSE GO TO SUBCHK2b_a
………………………………………………………………………………………………
SUB7 Did you drink alcohol in the past 12 months?
1=YES
2=NO
[SUBCHK7a IF SUB2a_g=1, CONTINUE; ELSE GO TO SUBCHK2b_a ]
………………………………………………………………………………………………
SUB8. In the past 12 months, on those days that you drank alcoholic beverages, on the average, how many drinks did you have?
______ Number of drinks [ALLOW 00-30]
………………………………………………………………………………………………
SUB8a. In the past 12 months, on how many days did you have 5 or more drinks of any alcoholic beverage?
______ DAYS [ALLOW 000-365]
………………………………………………………………………………………………
SUB9. In past 12 months, have you discussed your use of alcohol with your doctor or other health professional?
1=YES
2=NO
IF SUB2a_j =2, CONTINUE; ELSE GO TO SUBCHK2b]
………………………………………………………………………………………………
SUB9a. In past 12 months has your doctor or other health professional asked you about your use of alcohol?
1=YES
2=NO
………………………………………………………………………………………………
SUB9b. IF SUB9a_j OR SUB2a_j1 = 1 CONTINUE ELSE GO TO SUBCHK11
Was this a doctor or other health professional at {the reference health center} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
[SUBCHK2b_a IF SUB2b=1 (YES), CONTINUE, ELSE GO TO SUBCHK2c_a]
………………………………………………………………………………………………
SUB2b_a. In the past three months, how often have you used cannabis or marijuana?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
[SUBCHK2b_b IF SUB2b_a=0, DK OR REF GOTO SUBCHK2c_a ELSE CONTINUE]
………………………………………………………………………………………………
SUB2b_b. During the past three months, how often have you had a strong desire or urge to use cannabis or marijuana?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2b_c. During the past three months, how often has your use of cannabis or marijuana led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2b_d. During the past three months, how often have you failed to do what was normally expected of you because of your use of cannabis or marijuana?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2b_e. How often has a friend or relative or anyone else expressed concern about your use of cannabis or marijuana?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
………………………………………………………………………………………………
SUB2b_f. How often have you tried and failed to control, cut down or stop using cannabis or marijuana?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
[SUBCHK2c_a IF SUB2c=1 (YES), CONTINUE, ELSE GO TO SUBCHK2d_a]
………………………………………………………………………………………………
SUB2c_a. In the past three months, how often have you used cocaine?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
[SUBCHK2c_b IF SUB2c_a=0, DK OR REF GOTO SUBCHK2d_a ELSE CONTINUE]
………………………………………………………………………………………………
SUB2c_b. During the past three months, how often have you had a strong desire or urge to use cocaine?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2c_c. During the past three months, how often has your use of cocaine led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2c_d. During the past three months, how often have you failed to do what was normally expected of you because of your use of cocaine?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2c_e. How often has a friend or relative or anyone else expressed concern about your use of cocaine?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
………………………………………………………………………………………………
SUB2c_f. How often have you tried and failed to control, cut down or stop using cocaine?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
………………………………………………………………………………………………
[SUBCHK2d_a IF SUB2d=1 (YES), CONTINUE, ELSE GO TO SUBCHK2e_a]
SUB2d_a. In the past three months, how often have you used amphetamine-type stimulants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
[SUBCHK2d_b IF SUB2d_a=0, DK OR REF GOTO SUBCHK2e_a ELSE CONTINUE]
………………………………………………………………………………………………
SUB2d_b. During the past three months, how often have you had a strong desire or urge to use
amphetamine-type stimulants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2d_c. During the past three months, how often has your use of amphetamine-type stimulants led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2d_d. During the past three months, how often have you failed to do what was normally expected of you because of your use of amphetamine-type stimulants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
SUB2d_e. How often has a friend or relative or anyone else expressed concern about your use of amphetamine-type stimulants?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
………………………………………………………………………………………………
SUB2d_f. How often have you tried and failed to control, cut down or stop using amphetamine-type stimulants?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
[SUBCHK2e_a IF SUB2e=1 (YES), CONTINUE, ELSE GO TO SUBCHK2f_a]
………………………………………………………………………………………………
SUB2e_a. In the past three months, how often have you used inhalants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
[SUBCHK2e_b IF SUB2e_a=0, DK OR REF GOTO SUBCHK2f_a ELSE CONTINUE]
………………………………………………………………………………………………
SUB2e_b. During the past three months, how often have you had a strong desire or urge to use inhalants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2e_c. During the past three months, how often has your use of inhalants led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2e_d. During the past three months, how often have you failed to do what was normally expected of you because of your use of inhalants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2e_e. How often has a friend or relative or anyone else expressed concern about your use of inhalants?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
………………………………………………………………………………………………
SUB2e_f. How often have you tried and failed to control, cut down or stop using inhalants?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
[SUBCHK2f_a IF SUB2f=1 (YES), CONTINUE, ELSE GO TO SUBCHK2g_a]
………………………………………………………………………………………………
SUB2f_a. In the past three months, how often have you used sedatives or sleeping pills? We are asking about @Unon-medical@U use.
(VALIUM, SEREPAX, ROHYPNOL, ETC.)
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
[SUBCHK2f_b IF SUB2f_a=0, DK OR REF GOTO SUBCHK2g_a ELSE CONTINUE]
………………………………………………………………………………………………
SUB2f_b. During the past three months, how often have you had a strong desire or urge to use sedatives or sleeping pills?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2f_c. During the past three months, how often has your use of sedatives or sleeping pills led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2f_d. During the past three months, how often have you failed to do what was normally expected of you because of your use of sedatives or sleeping pills?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2f_e. How often has a friend or relative or anyone else expressed concern about your use of sedatives or sleeping pills?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
………………………………………………………………………………………………
SUB2f_f. How often have you tried and failed to control, cut down or stop using sedatives or sleeping pills?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
[SUBCHK2g_a IF SUB2g=1 (YES), CONTINUE, ELSE GO TO SUBCHK2h_a]
………………………………………………………………………………………………
SUB2g_a. In the past three months, how often have you used hallucinogens?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
[SUBCHK2g_b IF SUB2g_a=0, DK OR REF GOTO SUBCHK2h_a ELSE CONTINUE]
………………………………………………………………………………………………
SUB2g_b. During the past three months, how often have you had a strong desire or urge to use hallucinogens?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2g_c. During the past three months, how often has your use of hallucinogens led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2g_d. During the past three months, how often have you failed to do what was normally expected of you because of your use of hallucinogens?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2g_e. How often has a friend or relative or anyone else expressed concern about your use of hallucinogens?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
………………………………………………………………………………………………
SUB2g_f. How often have you tried and failed to control, cut down or stop using hallucinogens?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
[SUBCHK2h_a IF SUB2h=1 (YES), CONTINUE, ELSE GO TO SUBCHK2i_a]
………………………………………………………………………………………………
SUB2h_a. In the past three months, how often have you used opioids? We are asking about @Unon-medical@U use.
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
[SUBCHK2h_b IF SUB2h_a=0, DK OR REF GOTO SUBCHK2i_a ELSE CONTINUE]
………………………………………………………………………………………………
SUB2h_b. During the past three months, how often have you had a strong desire or urge to use opioids?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2h_c. During the past three months, how often has your use of opioids led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2h_d. During the past three months, how often have you failed to do what was normally expected of you because of your use of opioids?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2h_e. How often has a friend or relative or anyone else expressed concern about your use of opioids?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
………………………………………………………………………………………………
SUB2h_f. How often have you tried and failed to control, cut down or stop using opioids?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
[SUBCHK2i_a IF SUB2i=1 (YES), CONTINUE, ELSE GO TO THE LOGIC PRECEEDING THE NEXT QUESTION]
………………………………………………………………………………………………
SUB2i_a. In the past three months, how often have you used {[FILL RESPONSE FROM SUB2i_OTH]}?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
[SUBCHK2i_b IF SUB2i_a=0, DK OR REF GOTO SUB3 ELSE CONTINUE]
………………………………………………………………………………………………
SUB2i_b. During the past three months, how often have you had a strong desire or urge to use {FILL RESPONSE SUB2i_OTH}?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2i_c. During the past three months, how often has your use of {FILL RESPONSE SUB2i_OTH} led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2i_d. During the past three months, how often have you failed to do what was normally expected of you because of your use of {FILL RESPONSE SUB2i_OTH}?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or Almost Daily
………………………………………………………………………………………………
SUB2i_e. How often has a friend or relative or anyone else expressed concern about your use of {FILL RESPONSE SUB2i_OTH}?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
………………………………………………………………………………………………
SUB2i_f. How often have you tried and failed to control, cut down or stop using {FILL RESPONSE SUB2i_OTH}?
Would you say…
1=In the past 3 months
2=Not in the past 3 months
3=Never
………………………………………………………………………………………………
SUB3. Have you ever used any drug by injection? Please include drugs for non-medical use only.
Would you say you used any drug by injection…
1=In the past 3 months
2=More
than 3 months ago but within the past 12 months Not
in the past 3 months
3=More than 12 months ago
4=Never
………………………………………………………………………………………………
DRUG USE
[SUBCHK10 IF SUB2b_a=1,2,3 or 4, SUB2c_a=1,2,3 or 4, SUB2d_a=1,2,3 or 4, SUB2e_a=1,2,3 or 4, SUB2f_a=1,2,3 or 4, SUB2g_a=1,2,3 or 4, SUB2h_a=1,2,3 or 4, OR SUB2i_a = 1,2,3 or 4, GO TO SUB10a; ELSE IF SUB2b =1, SUB2c=1, SUB2d=1, SUB2e=1, SUB2f=1 SUB2g=1, SUB2h=1, OR SUB2i = 1, CONTINUE; ELSE GO TO SUBCHK11;
SUB10. Earlier you indicated that you have used {[FILL FROM SUB2b, c, d, e, f, g, h, i]}. Did you use any of these drugs in the past 12 months?
1=YES
2=NO
[SUBCHK10a IF SUB10=1, CONTINUE; ELSE GO TO SUBCHK11]
………………………………………………………………………………………………
SUB10a. In the past 12 months, have you discussed your use of drugs with a doctor or other health professional?
1=YES
2=NO
[SUBCHK10b IF SUB10a=2, THEN CONTINUE; ELSE GO TO SUB10c ]
………………………………………………………………………………………………
SUB10b. In the past 12 months has a doctor or other health professional asked you about your use of drugs?
1=YES
2=NO
………………………………………………………………………………………………
SUB10c. IF SUB10a OR SUB10b = 1 CONTINUE ELSE GO TO SUBCHK11
Was this a doctor or other health professional at {the reference health center} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
………………………………………………………………………………………………
SUBSTANCE USE TREATMENT
[SUBCHK12a IF SUB2a=1 OR SUB2b, c, d, e, f, g, h, i=0 CONTINUE;
ELSE GO TO SUBCHK12b]
SUB12. In the past 12 months, did you want or need treatment or counseling for your use of alcohol?
1=YES
2=NO
GO TO SUB12c
………………………………………………………………………………………………
[SUBCHK12b IF (SUB1b=0, DK, OR RF) AND SUB2b c, d, e, f, g, h, i, NE 0, DK, RF, CONTINUE; ELSE GO TO MODULE I]
SUB12b. In the past 12 months, did you want or need treatment or counseling for your use of drugs?
1=YES
2=NO
GO TO SUB12d
PROBE: Did you have any difficulty answering this question? [If yes] Tell me about that. When you heard this question, did you think it was asking you to choose between whether you had “wanted” treatment or “needed” treatment? ………………………………………………………………………………………………
SUB12a. In the past 12 months, did you receive treatment or counseling for your use of alcohol?
1=YES
2=NO
[SUBCHK13 IF SUB12c=1 GOT TO SUB13; ELSE GO TO SUBCHK15]
………………………………………………………………………………………………
SUB12d. In the past 12 months, did you receive treatment or counseling for your use of drugs?
1=YES
2=NO
[SUBCHK13 IF SUB12d=1 CONTINUE; ELSE GO TO SUBCHK15] ………………………………………………………………………………………………
SUB13 IF SUB12c=1 CONTINUE ELSE GO TO SUB13a1.
What kind of alcohol treatment was it? You may select one or more.
1=A RESIDENTIAL FACILITY WHERE YOU STAY AT NIGHT
2=AN OUTPATIENT FACILITY WHERE YOU DO NOT STAY AT NIGHT
3=A PRIVATE DOCTOR’S OFFICE
4=A PRISON OR JAIL
5=AA OR NA OR OTHER SELF-HELP GROUP
6=SOME OTHER TREATMENT
………………………………………………………………………………………………
SUB13a_sp. IF SUB13a=6 CONTINUE ELSE GO TO SUB13b.
What other kind of alcohol treatment was it?
[ ] Allow 40
………………………………………………………………………………………………
SUB13b. IF SUB12d=1 CONTINUE ELSE GO TO SUB13b.
What kind of drug treatment was it? You may select one or more.
1=A RESIDENTIAL FACILITY WHERE YOU STAY AT NIGHT
2=AN OUTPATIENT FACILITY WHERE YOU DO NOT STAY AT NIGHT
3=A PRIVATE DOCTOR’S OFFICE
4=A PRISON OR JAIL
5=AA OR NA OR OTHER SELF-HELP GROUP
6=SOME OTHER TREATMENT
………………………………………………………………………………………………
SUB13b_sp. IF SUB13a1=6 CONTINUE ELSE GO TO SUB13b.
What other kind of drug treatment was it?
[ ] Allow 40
[SUBCHK14 IF SUB13 = DK OR RF, GO TO MODULE I; ELSE CONTINUE]
………………………………………………………………………………………………
SUB14. IF SUB12a=1 CONTINUE ELSE GO TO SUB14b.
Did the {reference health center} provide that treatment, pay for that treatment, or refer you to the place where you got treatment for your use of alcohol?
1=PROVIDE TREATMENT
2=PAY FOR TREATMENT
3=REFER TO ANOTHER PLACE
4=NONE
………………………………………………………………………………………………
SUB14a. IF SUB12b=1 CONTINUE ELSE GO TO SUBCHK15.
Did the {reference health center} provide that treatment, pay for that treatment, or refer you to the place where you got treatment for your use of drugs?
1=PROVIDE TREATMENT
2=PAY FOR TREATMENT
3=REFER TO ANOTHER PLACE
4=NONE
[SUBCHK15 IF SUB12 = 2, DK, or RF OR SUB12a=DK or RF GO TO MODULE I, ELSE CONTINUE]
………………………………………………………………………………………………
SUB17. IF SUB12a=1 AND SUB12c=2 CONTINUE ELSE GO TO SUB17b. Please look at this showcard. Which of these statements explain why you did not get the treatment or counseling you needed for your use of alcohol?
@BSHOWCARD
SUB2@B
1=NO WAY TO PAY FOR IT
2=DID NOT KNOW OF OR COULD NOT GET INTO A TREATMENT PROGRAM
3=DID NOT HAVE TIME FOR APROGRAM OR A WAY TO GET THERE, OR PROGRAM NOT CONVENIENT ENOUGH
4=YOU DIDN’T WANT PEOPLE TO FIND OUT THAT YOU HAD A PROBLEM (AT WORK, IN COMMUNITY, ETC...)
5=YOU DIDN’T REALLY THINK THE TREATMENT WOULD HELP
6=OTHER (SPECIFY)
………………………………………………………………………………………………
SUB17_sp.
IF SUB17a=6 CONTINUE ELSE GO TO SUB17b
What other reasons did you have for not getting the treatment or counseling you needed for your use of alcohol?
[ ] Allow 80
………………………………………………………………………………………………
SUB17b. IF SUB12b=1 AND SUB12d=2 CONTINUE ELSE GO TO MODULE I. Please look at this showcard. Which of these statements explain why you did not get the treatment or counseling you needed for your use of drugs?
@BSHOWCARD
SUB2@B
1=NO WAY TO PAY FOR IT
2=DID NOT KNOW OF OR COULD NOT GET INTO A TREATMENT PROGRAM
3=DID NOT HAVE TIME FOR APROGRAM OR A WAY TO GET THERE, OR PROGRAM NOT CONVENIENT ENOUGH
4=YOU DIDN’T WANT PEOPLE TO FIND OUT THAT YOU HAD A PROBLEM (AT WORK, IN COMMUNITY, ETC...)
5=YOU DIDN’T REALLY THINK THE TREATMENT WOULD HELP
6=OTHER (SPECIFY)
PROBE: Please tell me what you were thinking about in answering this question.
………………………………………………………………………………………………
SUB17b_sp.
IF SUB17b=6 CONTINUE ELSE GO TO MODULE I
What other reasons did you have for not getting the treatment or counseling you needed for your use of drugs?
[ ] Allow 80
………………………………………………………………………………………………
NOTE WHEN CREATING CAPI SPECIFICATIONS: In general, for the smoking questions, need to make sure the various questions apply to the appropriate subpopulation (e.g., quit info for former smokers, desire to quit for current smokers (every day and some-day), etc). SUB1i should also be asked of former smokers, if they report quitting within 1 year (therefore move SUB1j before SUB1i).
Add street names for some drugs
………………………………………………………………………………………………
MODULE M: PRENATAL CARE/ FAMILY PLANNING
[PRGCHK0 IF (FEMALE (INT6=2) OR INT6=4) AGE 15-49 CONTINUE; ELSE GO TO MODULE M]
PRENATAL CARE
[PRGCHK1 IF CON2=2, DK, RF GOTO PRG8; ELSE CONTINUE]
PRG1. The next questions are about pregnancy and prenatal care. Have you been pregnant in the past 3 years from date of this interview, that is since {insert reference date}?
1=YES
2=NO
[PRGCHK2 IF PRG1=1, CONTINUE; ELSE GO TO PRG8 ]
………………………………………………………………………………………………
PRG6. In the past three years, was there a time that you needed prenatal care but were unable to get it?
1=YES
2=NO
[PRGCHK7 IF PRG6=1, CONTINUE ELSE GO TO PRG8]
………………………………………………………………………………………………
PRG7. Please look at this showcard. Please describe the reasons you were unable to get prenatal care? You may select one or more.
@BSHOWCARD MED3@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
……………………………………………………………………………………………………
PRG7a. Please look at this showcard. Which of these best describes the main reason you were unable to get prenatal care? You may select[LIST ONLY SELECTIONS MADE IN PRG7a]
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER (SPECIFY)
………………………………………………………………………………………………
The next questions are about the prenatal care you received during your most recent pregnancy. Prenatal care includes visits to a doctor, nurse, or other health care worker before your baby was born to get checkups and advice about pregnancy. (It may help to look at the calendar when you answer these questions.)
PRG2. Did you receive prenatal care for your most recent pregnancy?
IF NECESSARY: Prenatal care includes the services and tests that a woman gets during a pregnancy.
1=YES
2=NO
………………………………………………………………………………………………
PRG2a. How many weeks or months pregnant were you when you had your first visit for prenatal care for your most recent pregnancy? Do not count a visit that was only for a pregnancy test or only for WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children).
[BOX] Weeks
OR
[BOX] Month
[PRGCHK3 IF PRG2=1, THEN CONTINUE; ELSE GO TO PRG6 ]
………………………………………………………………………………………………
PRG3. How many of your prenatal visits did you get at {reference health center}? Would you say….
NOTE: IF RESPONSE IS “MOST” – CODE AS “SOME OF THE VISITS”
1=All of the visits
2=Some of the visits
3=None of the visits
[PRGCHK4 IF PRG3=1-2, THEN CONTINUE; ELSE GO TO PRGCHK5]
………………………………………………………………………………………………
PRG4. On a scale of 0 to 10, where 0 means poor and 10 means excellent, how would you rate the prenatal care services you received at {the reference health center}. Would you say….
0 Poor
1
2
3
4
5
6
7
8
9
10 Excellent
………………………………………………………………………………………………
PRG4a1. During any of your prenatal care visits, did a doctor, nurse, or other health professional talk with you about any of the following…
Please count only discussions, not reading materials or watching videos.
YES
NO
DON’T KNOW
REFUSED
a. How smoking during pregnancy could affect my baby
b. Breastfeeding my baby
c. How drinking alcohol during pregnancy could affect my baby
d. Using a seat belt during my pregnancy
e. Medicines that are safe to take during my pregnancy
f. How illegal drugs could affect my baby
g. Doing tests to screen for birth defects or diseases that run in my family
h. The signs and symptoms of preterm labor, which is labor more than 3 weeks before the baby is due
i. What to do if my labor starts early
j. Getting tested for HIV, the virus that causes AIDS
k. What to do if I feel depressed during my pregnancy or after my baby is born
l. Physical abuse to women by their husbands or partners
………………………………………………………………………………………………
[PRGCHK5 IF PRG3=2 OR 3; THEN CONTINUE; ELSE GO TO OUT1a]
PRG5. Were you referred to the other place where you got prenatal care by {reference health center}?
1=YES
2=NO
……………………………………………………………………………………………
OUTCOMES
PRG6. I understand that you may not want to answer this question in detail. If you are willing to say, did this pregnancy result in a baby or babies born alive, or did it end in some other way?
1=Live birth
2=Some other way
If OUT1a=1, continue. Else, go to PRG8.
………………………………………………………………………………………………
OUT1. How much did (BABYFILL /this (NTH) baby) weigh at birth?
Pounds and ounces _________
………………………………………………………………………………………………
PRG6a. After your most recent pregnancy, did you have a postpartum checkup for yourself? (A postpartum checkup is the regular checkup a woman has about 6 weeks after she gives birth.)
1=YES
2=NO
[IF PRG6a =1; THEN CONTINUE; ELSE GO TO PRG6c]
………………………………………………………………………………………………
PRG6b. Did you have the postpartum checkup for yourself at the {reference health center}?
1=YES
2=NO (If no, follow-up to specify where)
………………………………………………………………………………………………
PRG6c. Was your new baby seen by a doctor, nurse, or other health care worker for a one week check-up after he or she was born?
1=YES
2=NO
[IF PRG6c=1; THEN CONTINUE; ELSE GO TO PRG8]
………………………………………………………………………………………………
PRG6d. Did you have the baby’s one week check-up at the {reference health center}?
1=YES
2=NO (If no, follow-up to specify where)
………………………………………………………………………………………………
FAMILY PLANNING
PRG8. Please look at this showcard. In the past 12 months, that is since {12 MONTH REFERENCE DATE}, have you received @Uany@U of the following family planning services? You may select one or more.
@BSHOWCARD PRG8@B
1=A birth control method or prescription
2=A check-up or medical test related to using a birth control method
3=Counseling about birth control
4=Counseling about getting sterilized
5=Emergency contraception or the "morning-after pill"
6=Counseling or information about emergency contraception or the "morning-after pill"
7=A sterilizing operation
8=OTHER
[PRGCHK9 IF ANY OF PRG8 OPTIONS 1-7 ARE SELECTED, THEN CONTINUE; ELSE GOTO PRG11]
………………………………………………………………………………………………
PRG9. How many of these services did you get at {the reference health center}? Would you say…
1=All of the services
2=Some of the services
3=None of the services
[PRGCHK10a IF PRG9=1 OR 2, THEN CONTINUE; ELSE GO TO PRGCHK10b]
………………………………………………………………………………………………………
PRG10a. On a scale of 0 to 10, where 0 means poor and 10 means excellent, how would you rate the family planning services you received at {the reference health center}. Would you say….
0 Poor
1
2
3
4
5
6
7
8
9
10 Excellent
[PRGCHK10b IF PRG9=2 or 3, THEN CONTINUE; ELSE GO TO PRG11 ]
………………………………………………………………………………………………
PRG10b. Were you referred to the other place where you got the family planning services by {reference health center}?
1=YES
2=NO
………………………………………………………………………………………………
PRG11. Please look at this showcard. In the last 12 months, that is since [DATE OF INTERVIEW], was there a time that you needed any family planning service on the list but were unable to get it? You may select one or more.
@B SHOWCARD PRG11@B
1=A birth control method or prescription
2=A check-up or medical test related to using a birth control method
3=Counseling about birth control
4=Counseling about getting sterilized
5=Emergency contraception or the "morning-after pill"
6=Counseling or information about emergency contraception or the "morning-after pill"
7=A sterilizing operation
8=NO, THERE WASN’T A TIME WHEN I NEEDED A SERVICE BUT COULDN'T GET IT"
9= OTHER (SPECIFY)
[PRGCHK12 IF ANY OF PRG11 OPTIONS 1-7 ARE SELECTED, THEN CONTINUE; ELSE GO TO MODULE M]
………………………………………………………………………………………………………
PRG12. Please look at this showcard. Please describe the reasons you were unable to get that family planning service? You may select one or more.
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER (specify)
……………………………………………………………………………………………
PRG12a. Please look at this showcard. Which of these best describes the main reason you were unable to get that family planning service?
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TO LONG
11=OTHER (SPECIFY)
………………………………………………………………………………………………………
MODULE N: HIV TESTING
[HTGCHK1 IF AGE GE 18 CONTINUE, ELSE GOTO MODULE O]
HTG1. The next questions are about the test for HIV, the virus that causes AIDS. Your answers to these questions are private and will not be shared with anyone at the {reference health center}. You also have the right to refuse any question that you do not want to answer.
Except for tests you may have had as part of blood donations, have you ever been tested for HIV?
1=YES
2=NO
[HTGCHK2 IF HTG1=1, CONTINUEGO TO HTG4; ELSE CONTINUE ]
………………………………………………………………………………………………
HTG1a. When was your last HIV test?
1=0-6 months
2=6-12 months
3=1-2 year
4=2-3 years
5=3-5 years
6=More than 5 years
………………………………………………………………………………………………
HTG1a1. The last time you had an HIV test, did you receive your test results?
1=YES
2=NO
………………………………………………………………………………………………
HTG1b. Where did you have your last HIV test? Was it at…
1= {reference health center}
2= Other health center
3= Private doctor or HMO office
4= Counseling and testing site
5= Hospital
6= Jail or prison (or other correctional facility)
7= Drug treatment facility
8= At home
9= Somewhere else
Probe: How well do you remember this?
………………………………………………………………………………………………
HTG2. Please look at this showcard. I am going to show you a list of reasons why some people have not been tested for HIV, the virus that causes AIDS. Which one of these would you say is the main reason why you have not been tested?
@BSHOWCARD HTG2 @B
1=IT'S UNLIKELY YOU'VE BEEN EXPOSED TO HIV
2=YOU DIDN'T KNOW WHERE TO GET TESTED
3=YOU WERE AFRAID OF LOSING JOB, INSURANCE, HOUSING, FRIENDS, FAMILY, IF PEOPLE KNEW YOU WERE POSITIVE FOR AIDS INFECTION
4=I’M TESTED WHEN I GIVE BLOOD
5=NO PARTICULAR REASON
6=SOME OTHER REASON (Specify)
………………………………………………………………………………………………
HTG2_OTH. Please specify why you have not been tested?
[ ] Allow 60
………………………………………………………………………………………………
HTG3. Has anyone at {the reference health center} ever suggested that you have a test for HIV?
1=YES
2=NO
………………………………………………………………………………………………
HTG4. Has anyone at {the reference health center} ever talked to you about ways to protect yourself and others from getting the HIV virus?
1=YES
2=NO
………………………………………………………………………………………………
HTG5. Have you ever been told by a doctor or other health professional that you are HIV positive or have AIDS?
1=YES
2=NO
[HTGCHK6a IF HTG5=1, THEN CONTINUE; ELSE GO TO MODULE O]
………………………………………………………………………………………………
HTG6a. Are you receiving any medical care now for HIV or AIDS?
1=YES
2=NO
………………………………………………………………………………………………
IF HTG6a = 1 CONTINUE ELSE GO TO HTG6b
HTG6a1. Are you receiving this care at {REFERENCE HEALTH CENTER} or somewhere else?
1=YES
2=SOMEWHERE ELSE
………………………………………………………………………………………………
IF HTG6a1=2 CONTINUE ELSE GO TO HTG6b
HTG6a2. Please specify:
[ ] Allow 40
………………………………………………………………………………………………
HTG6a3. Were you/name referred there by {the reference health center}?
1=YES
2=NO
………………………………………………………………………………………………
HTG6b. Are you receiving antiretroviral therapy for HIV prescribed by a doctor?
1=YES
2=NO
………………………………………………………………………………………………
IF HTG6b = 1 CONTINUE ELSE GO TO HTG6c
HTG6b1. Are you receiving this therapy at {REFERENCE HEALTH CENTER} or somewhere else?
1=YES
2=SOMEWHERE ELSE
………………………………………………………………………………………………
IF HTG6b1=2 CONTINUE ELSE GO TO HTG6c
HTG6b1. Please specify:
[ ] Allow 40
………………………………………………………………………………………………
HTG6b3. Were you/name referred there by {the reference health center}?
1=YES
2=NO
[HTGCHK6d IF HTG6c=2, THEN CONTINUE; ELSE GO TO MODULE O]
………………………………………………………………………………………………
MODULE O: LIVING ARRANGEMENTS
Now I’m going to ask you some questions about where {you are / name is} living right now.
LIV1. Over the past 7 days, where did you usually sleep at night? Pick the single best option.
A house
An apartment or condo
A room (other than at a hotel or motel)
An emergency shelter
A transitional shelter (includes transitional housing)
A church or chapel
An abandoned building
A place of business
A car or other vehicle
Anywhere outside
A hotel or motel (a place with separate rooms you pay for yourself)
Any other place that hasn’t been mentioned, specify: ______________.
[IF LIV1=1 or 2, then go to LIV2;
IF LIV1=3, then go to LIV3;
IF LIV1=4, 5, 6, 7, 8, 9, 10, 11, or 12, then go to LIV10]
[Analytic note: IF LIV1=4, 5, 6, 7, 8, 9, 10, 11, or 12, then classify respondent as “homeless”]
………………………………………………………………………………………………
LIV2. How many rooms are in that {house / apartment }?
______ ROOMS [ALLOW 00-20]
………………………………………………………………………………………………
LIV3. How many people usually sleep in that {house / apartment / room}?
______ NUMBER OF PEOPLE
[Analytic note: If people/rooms > 1, classify as “overcrowded” living conditions according to convention adopted by HUD: Measuring overcrowding in housing, Sept 2007]
………………………………………………………………………………………………
LIV4. Does that {house / apartment / room} belong to you or to someone else?
1=Own place
2=Someone else’s place
[IF LIV4=1 THEN GO TO LIV6, ELSE CONTINUE]
………………………………………………………………………………………………
LIV5.
[IF AGE >=18:] Do you or your family currently have your OWN place to live, such as a house, apartment, or room?
[IF AGE <=12:] Does {name}s family currently have its OWN place to live, such as a house, apartment, or room?
[IF AGE = 13-17:] Does your family currently have its OWN place to live, such as a house, apartment, or room?
1=YES
2=NO
[IF LIV5=1 then go to LIV6.
IF LIV5=2 then go to LIV10.]
[Analytic note: If LIV5=2, then classify respondent as “homeless”]
………………………………………………………………………………………………
***OWN PLACE***
[Respondents: LIV5=1]
LIV6. Have you ever NOT been able to pay your share of the rent or mortgage for your own place, or have you had to borrow money to pay your share of the rent or mortgage?
1=YES
2=NO
………………………………………………………………………………………………
LIV7. In the past 12 months, how many times have you moved?
___ TIMES [RANGE 00-99]
[Analytic note: If LIV6=1 OR LIV7 >= 2 then classify respondent as “unstably housed.” Ref: Kushel JGIM, Cutts AJPH]
………………………………………………………………………………………………
LIV8. Will you be asked or forced to leave your own place in the next 14 days?
1=YES
2=NO
[Analytic note: If LIV8=1, then classify as “homeless” based on 2009 HEARTH Act]
………………………………………………………………………………………………
LIV9. Have you ever NOT had your own place to live?
1=YES
2=NO
[Analytic note: If LIV9=1, then classify respondent as “formerly homeless”]
[If LIV9=1, then go to LIV12. Else, go to Module P.]
………………………………………………………………………………………………
***WITHOUT OWN PLACE***
[Respondents: LIV1=4, 5, 6, 7, 8, 9, 10, 11, or 12 OR LIV5=2]
LIV10.
[IF AGE >=18:] When was the last time you or your family had your own place to live, such as a house, apartment or room?
[IF AGE <=12:] When was the last time {name’s} family had its own place to live, such as a house, apartment or room?
[IF AGE =13-17:] When was the last time your family had its own place to live, such as a house, apartment or room?
ENTER NUMBER THEN SELECT UNIT ON THE NEXT SCREEN.
____ DAYS AGO [ALLOW 00-31 ]
____ WEEKS AGO [ALLOW 00-52]
____ MONTHS AGO [ALLOW 00-12]
____ YEARS AGO [ALLOW 01-AGE]
………………………………………………………………………………………………
LIV11. Including this time, …
[IF AGE >=18:] how MANY times in the past 3 years have you NOT had your own place to live?
[IF AGE <=12:] how MANY times in the past 3 years has {name’s}family NOT had its own place to live?
[IF AGE =13-17:] how MANY times in the past 3 years has your family NOT had its own place to live?
______NUMBER OF TIMES [ALLOW 00-99]
[Analytic note: If LIV10 >= 12 months ago or >= 1 year ago OR LIV11 >= 4, then classify respondent “chronically homeless” per federal definition]
………………………………………………………………………………………………
***EVER WITHOUT OWN PLACE***
[Respondents: LIV1=4, 5, 6, 7, 8, 9, 10, 11, or 12 OR LIV5=2 OR LIV9=1]
LIV12. [IF LIV5=2, then lead with “Including this time, …”]
[IF AGE >=18:] How MANY times in your life have you NOT had your own place to live?
[IF AGE <=12:] How MANY times in {name’s} life has {name’s} family NOT had its own place to live?
[IF AGE =13-17:] How MANY times in your life has your family NOT had its own place to live?
______NUMBER OF TIMES [ALLOW 00-99]
………………………………………………………………………………………………
LIV13. How old {were you/was name} the first time you didn’t have a place of your own to live?
_______ AGE [ALLOW 000-109]
PROGRAMMER: AGE CHECK SO AGE REPORTED HERE IS NOT HIGHER THAN AGE REPORTED FROM INTDOB OR INTAGE.
………………………………………………………………………………………………
LIV14. If you added up all the times in your life that you didn’t have a place of your own to live, how long would you say that was?
[ENTER NUMBER THEN SELECT UNIT OF MEASURE]
____ DAYS / WEEKS / MONTHS / YEARS [ALLOW VALUES UP TO AGE]
[PROBE (for cognitive testing): How did you come up with your answer? How difficult was it to figure that out? How confident are you about your answer?]
………………………………………………………………………………………………
MODULE P: NEIGHBORHOOD FACTORS
NEI1. How safe do you feel in your neighborhood?
1=Very safe
2=Moderately safe
3=Moderately unsafe
4= Very unsafe
………………………………………………………………………………………………
NEI2. How would you rate your neighborhood as a place to raise children? Would you say that it is excellent, good, fair, or poor?
1=EXCELLENT
2=GOOD
3=FAIR
4= POOR
………………………………………………………………………………………………
NEI3. How would you rate the condition of the street in the block where you live?
1=Very good - recent resurfacing, smooth
2=Moderate - kept in good repair
3=Fair - minor repairs needed
4=Poor - potholes and other evidence of neglect
………………………………………………………………………………………………
NEI4. Generally speaking, how much can you trust people who live in your neighborhood. Would you say that you can trust your neighbors a lot, some, only a little, or not at all?
1=A lot
2=Some
3=Only a little
4= Not at all
………………………………………………………………………………………………
NEI5. In the past month, how many times have you had a conversation with a neighbor? Would you say never, once or twice, once a week or less, or more than once a week?
1=NEVER
2=ONCE OR TWICE
3=ONCE A WEEK OR LESS
4= MORE THAN ONCE A WEEK
………………………………………………………………………………………………
NEI6. How would you rate the current quality of the public schools attended by children in your neighborhood? Are they excellent, good, fair, or poor?
1=EXCELLENT
2=GOOD
3=FAIR
4= POOR
………………………………………………………………………………………………
NEI7. Which of the following best describes the immediate area or street (one block, both sides) where you live?
1=Rural farm
2=Rural town
3=Suburban
4=Urban
5=Other (specify)
………………………………………………………………………………………………
NEI8. How close is the nearest public space, park, or playground to your home?
1=Within a half mile
2=More than a half mile but less than a mile
3=More than a mile but less than 2 miles
4=2 or more miles away
………………………………………………………………………………………………
MODULE Q: INCOME AND ASSETS
INC1a. When {you go/name goes} to {reference health center}, does {reference health center} reduce the charge for the services provided because of your income level?
1=YES
2=NO
[INCCHK1B IF AGE 13-17 GOTO INC4; ELSE CONTINUE]
………………………………………………………………………………………………
INC1b. The next questions are about {your total/your total family} income in {last calendar year in 4-digit format} @Ubefore taxes@U. Income is important in analyzing the health information we collect.
PROVIDE SHOWCARD
Please look at this card which lists the types of income we would like for you to include.
IF NECESSARY READ THE FOLLOWING CONTENT OF SHOWCARD: When answering this next question, we would like you to:
include your income PLUS the income of all family members living in your household
include all types of income, including:
Income from child support or alimony;
rental income;
any cash assistance from a state or county welfare program;
income from Worker’s Compensation or unemployment compensation;
any retirement, disability or survivor pension; and
any interest or investment income.
What is your best estimate of the total income of your household?
Please remember to include your income and income of all family members living in your household from all sources, before taxes, in {last calendar year in 4 digit format}?
NOTE: 999996 = $999,995 OR MORE DOLLARS
______ [000,000-999,995] DOLLARS
[INCCHK1c IF INC1b= DK OR RF, GO TO INC1d; ELSE CONTINUE]
………………………………………………………………………………………………
INC1b1a. Was your total family income in the past 12 months?
a. Below $35,000
b. $35,000 or more
c. Don’t Know
PROBE: Please tell me what the term “family income” means, using your own words.
Did you have any difficulty answering this question? [If yes] Tell me about that.
………………………………………………………………………………………………
IF INC1b1a= “a” CONTINUE, ELSE GO TO INC1b2:
INC1b1b. We would like to get a better estimate of your total HOUSEHOLD income in the past 12 months before taxes. Was it...
a. $5,000 to $9,999
b. $10,000 to $14,999
c. $15,000 to $24,999
d. $25,000 to $34,999
………………………………………………………………………………………………
IF INC1b1= “b” CONTINUE, ELSE GO TO INC1c:
INC1b2. We would like to get a better estimate of your total HOUSEHOLD income in the past 12 months before taxes. Was it...
a. 35,000 to $49,999
b. $50,000 to $74,999
c. $75,000 to $99,999
d. $100,000 to $149,999
e. $150,000 to $175,000
f. More than $175,000
………………………………………………………………………………………………
INC1c. Including you, how many family members did that income support for {last calendar year in 4 digit format}?
______ FAMILY MEMBERS [ALLOW 01-20]
[INCCHK1c_POST GOTO INC3a]
………………………………………………………………………………………………
INC1d. Although you were unable to provide your family income for {last calendar year in 4 digit format}, can you tell me how many family members were supported by your family income, including yourself?
______ FAMILY MEMBERS
………………………………………………………………………………………………
Poverty Thresholds for 2012 by Size of Family and Number of Related Children Under 18 Years |
|
|
Size of Family Unit |
FPL (weighted avg) |
|
One person (unrelated individual) |
11,170 |
|
Two people |
15,130 |
|
Three people |
19,090 |
|
Four people |
23,050 |
|
Five people |
27,010 |
|
Six people |
30,970 |
|
Seven people |
34,930 |
|
Eight people |
38,890 |
|
Source: Federal Register, Vol. 77, No. 17, January 26, 2012, pp. 4034-4035 |
||
INC2.
PROGRAMMER: USE TABLE AND RESPONSE TO INC1c TO DETERMINE FILLS FOR FPL AND 2XFPL BELOW:
During {last calendar year in 4-digit format}, was your total family income from all sources less than [FILL FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c], more than [FILL FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c] but less than [FILL 2X FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c] or [FILL 2X FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c] or more?
PROBE: IF RESPONDENT SAYS DON’T KNOW – AUTOMATICALLY REPEAT QUESTION AND ASK RESPONDENT TO GIVE US THEIR BEST ESTIMATE.
1=LESS THAN FPL
2=MORE THAN FPL BUT LESS THAN 2 TIMES FPL
3=TWO TIMES FPL OR MORE
………………………………………………………………………………………………
INC3a. During {last calendar year in 4-digit format}, did {you/name} or anyone else in {your/name’s} household receive any of the following forms of public assistance?
food stamps?
1=YES
2=NO
………………………………………………………………………………………………
INC3b. (During {last calendar year in 4-digit format}, did {you/name} or anyone else in {your/name’s} household receive any of the following forms of public assistance?)
WIC, the women, infants, and children nutrition program?
1=YES
2=NO
………………………………………………………………………………………………
INC3c. (During {last calendar year in 4-digit format}, did {you/name} or anyone else in {your/name’s} household receive any of the following forms of public assistance? )
aid from: (state TANF plan)?
1=YES
2=NO
………………………………………………………………………………………………
INC3d. (During {last calendar year in 4-digit format}, did {you/name} or anyone else in {your/name’s} household receive any of the following forms of public assistance? )
section 8 housing?
1=YES
2=NO
………………………………………………………………………………………………
INC3e. (During {last calendar year in 4-digit format}, did {you/name} or anyone else in {your/name’s} household receive any of the following forms of public assistance? )
any other assistance from the government?
1=YES
2=NO
………………………………………………………………………………………………
MODULE R: DEMOGRAPHICS
DMO_INT. The final questions are about {you/name}.
DMO1. {Were you/Was name} born in the United States?
1=YES
2=NO
………………………………………………………………………………………………
DMO1. IF DMO1=2 CONTINUE ELSE GOTO DMOCHK2: In what country {were you/was name} born?
[ ] ALLOW 40
[DMOCHK2 IF DMO1 =1, DK, OR RF THEN GO TO DMO4 ELSE CONTINUE]
………………………………………………………………………………………………
DMO2. In what year did {you/name} come to the United States?
________ YEAR [ALLOW 1900–2009]
………………………………………………………………………………………………
DMO3. Was [your/Name’s] father born in the United States?”
1=YES
2=NO
………………………………………………………………………………………………
DM03a. IF DMO3=2 CONTINUE ELSE GO TO DOM3b: In what country was your father born?
[LIST COUNTRIES]
PROBE: How do you feel about answering this question?
………………………………………………………………………………………………
DMO3b. Was [your/Name’s] mother born in the United States?”
1=YES
2=NO
………………………………………………………………………………………………
DM03c. IF DMO3=2 CONTINUE ELSE GO TO DOM3b: In what country was your mother born?
[LIST COUNTRIES]
………………………………………………………………………………………………
[DMOCHK4 IF AGE<5 GOTO DMOCHK6 ELSE CONTINUE]
DMO4. What is the HIGHEST grade or year of school {you have/name has} completed?
0=NEVER ATTENDED/KINDERGARTEN
1=1ST GRADE
2=2ND GRADE
3=3RD GRADE
4=4TH GRADE
5=5TH GRADE
6=6TH GRADE
7=7TH GRADE
8=8TH GRADE
9=9TH GRADE
10=10TH GRADE
11=11TH GRADE
12=12TH GRADE, NO DIPLOMA
13=HIGH SCHOOL GRADUATE
14=GED OR EQUIVALENT
15=SOME COLLEGE, NO DEGREE
16=ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR VOCATIONAL PROGRAM
17=ASSOCIATE DEGREE: ACADEMIC PROGRAM
18=BACHELOR’S DEGREE (EXAMPLE: BA, AB, BS, BBA)
19=MASTER’S DEGREE(EXAMPLE: MA, MS, MENG, MED, MBA)
20=PROFESSIONAL SCHOOL OR DOCTORAL DEGREE (EXAMPLE: MD, DDS, DVM, JD, PHD, EDD)
21=OTHER (SPECIFY)
[DMOCHK5 IF DMO1=1, GO TO DMOCHK6; IF DMO4=0, DK, OR RE, GOTO DMOCHK6; ELSE CONTINUE]
………………………………………………………………………………………………
DMO5. During the last year {you/name} were in school, were {you/name} attending a school in the United States?
1=YES
2=NO
[DMOCHK6 IF AGE 3 AND OLDER, THEN CONTINUE; ELSE GO TO DMO7]
………………………………………………………………………………………………
DMO6a. What is the HIGHEST grade or year of school your father has completed?
0=NEVER ATTENDED/KINDERGARTEN
1=1ST GRADE
2=2ND GRADE
3=3RD GRADE
4=4TH GRADE
5=5TH GRADE
6=6TH GRADE
7=7TH GRADE
8=8TH GRADE
9=9TH GRADE
10=10TH GRADE
11=11TH GRADE
12=12TH GRADE, NO DIPLOMA
13=HIGH SCHOOL GRADUATE
14=GED OR EQUIVALENT
15=SOME COLLEGE, NO DEGREE
16=ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR VOCATIONAL PROGRAM
17=ASSOCIATE DEGREE: ACADEMIC PROGRAM
18=BACHELOR’S DEGREE (EXAMPLE: BA, AB, BS, BBA)
19=MASTER’S DEGREE(EXAMPLE: MA, MS, MENG, MED, MBA)
20=PROFESSIONAL SCHOOL OR DOCTORAL DEGREE (EXAMPLE: MD, DDS, DVM, JD, PHD, EDD)
21=OTHER (SPECIFY)
………………………………………………………………………………………………
DMO6b. What is the HIGHEST grade or year of school your mother has completed?
0=NEVER ATTENDED/KINDERGARTEN
1=1ST GRADE
2=2ND GRADE
3=3RD GRADE
4=4TH GRADE
5=5TH GRADE
6=6TH GRADE
7=7TH GRADE
8=8TH GRADE
9=9TH GRADE
10=10TH GRADE
11=11TH GRADE
12=12TH GRADE, NO DIPLOMA
13=HIGH SCHOOL GRADUATE
14=GED OR EQUIVALENT
15=SOME COLLEGE, NO DEGREE
16=ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR VOCATIONAL PROGRAM
17=ASSOCIATE DEGREE: ACADEMIC PROGRAM
18=BACHELOR’S DEGREE (EXAMPLE: BA, AB, BS, BBA)
19=MASTER’S DEGREE(EXAMPLE: MA, MS, MENG, MED, MBA)
20=PROFESSIONAL SCHOOL OR DOCTORAL DEGREE (EXAMPLE: MD, DDS, DVM, JD, PHD, EDD)
21=OTHER (SPECIFY)
………………………………………………………………………………………………
DMO7. How many times {have you/has name} moved in the past 12 months?
9=0
1=1
2=2
3=3
4=4
5=5
6=6-10
7=11-15
8=MORE THAN 15
99=HOMELESS – NOT APPLICABLE
[DMOCHK8 IF DMO7=9, 99, DK, OR RE GOTO DMOCHK9
ELSE CONTINUE]
………………………………………………………………………………………………
DMO8. How many of these moves were related to the work of someone in the family. For example, moving to a place to do farm work there or to look for work there, and moving back home after the farming season ended.
9=0
1=1
2=2
3=3
4=4
5=5
6=6-10
7=11-15
8=MORE THAN 15
………………………………………………………………………………………………
DMO8a: Do you think of yourself as straight or heterosexual, as gay, lesbian or homosexual, or bisexual?
1=STRAIGHT OR HETEROSEXUAL
2=GAY, LESBIAN, OR HOMOSEXUAL
3=BISEXUAL
4=NOT SEXUAL/CELIBATE/NONE
5=OTHER (SPECIFY: _____________)
6=REFUSED
7=DON’T KNOW
PROBE: How do you feel about answering this question?
………………………………………………………………………………………………
MARITAL STATUS
[DMOCHK9 IF AGE GE 15, THEN CONTINUE; ELSE GO TO DMOCHK10]
DMO9. Are you ……?
1=Married
2= Have a domestic partner
2
3=Widowed
3
4=Divorced
4
5=Separated
5
6=Never
married
[DMOCHK9a IF DMO9=1, THEN CONTINUE; ELSE
IF DMO9=2, 3, 4 OR 5, THEN GO TO DMO9b; ELSE
GO TO DMOCHK10]
……………………………………………………………………………………………
DMO9a. Is your [spouse/partner] living with you?
1=YES
2=NO
[IF DMOCHK9b IF DMO9a=1, THEN GO TO DMOCHK10; ELSE CONTINUE]
………………………………………………………………………………………………
VETERAN’S STATUS
[DMOCHK10 IF AGE GE 18, THEN CONTINUE; ELSE GO TO DMOCHK11]
DMO10. Have you ever served on active duty in the U.S. Armed Forces, military Reserves, or the National Guard?
IF NECESSARY: ACTIVE DUTY DOES NOT INCLUDE TRAINING FOR THE RESERVES OR NATIONAL GUARD, BUT DOES INCLUDE ACTIVATION, FOR EXAMPLE, FOR THE PERSIAN GULF WAR.
1=YES
2=NO
[DMOCHK10a IF DMO10=1, THEN CONTINUE; ELSE GO TO DMOCHK11]
………………………………………………………………………………………………
DMO10a. Which of the following best describes your service in the U.S. military?
1=Currently on active duty
2=Currently in the Reserves or National Guard
3=Retired from military service
4=Medically discharged from military service
5=Discharged from military service
[DMOCHK10b IF DMO10a=1 OR 2, THEN GO TO DMOCHK11; ELSE CONTINUE]
………………………………………………………………………………………………
DMO10b. Are you eligible for veteran’s benefits?
1=YES
2=NO
[DMOCHK10b_POST IF DMO10b=2, THEN GO TO DMOCHK11
………………………………………………………………………………………………
DMO10c. In the past 12 months, that is since {12 MONTH REFERENCE DATE}, have you received health care from VA facilities?
1=YES
2=NO
………………………………………………………………………………………………
EMPLOYMENT
[DMOCHK11 IF AGE GE 16, THEN CONTINUE; ELSE GO TO DMOCHK11i]
DMO11. The next few questions are about employment status. Information on employment is important in analyzing the health information we collect. For example, with this information, we can learn whether patients who work full-time use medical services more or less often than those that don’t work full-time.
Which of the following were you doing last week?
1=Working at a job or business
2=With a job or business but not at work
3=Looking for work
4=Working, but not for pay, at family-owned job or business
5=Not working at a job or business and not looking for work
[DMOCHK11a IF DMO11=2, 3 OR 5, THEN CONTINUE; ELSE
IF DMO11=1, THEN GO TO DMO11b; ELSE
IF DMO11=4, THEN GO TO DMO11c; ELSE
GO TO DMO 12]
………………………………………………………………………………………………
DMO11a. What is the main reason you did not [IF DMO11=2 FILL: work last week?] [IF DMO11= 3 OR 5 FILL: have a job or business last week?]
1=TAKING CARE OF HOUSE OR FAMILY
2=GOING TO SCHOOL
3=RETIRED
4=ON A PLANNED VACATION FROM WORK
5=ON FAMILY OR MATERNITY LEAVE
6=TEMPORARILY UNABLE TO WORK FOR HEALTH REASONS
7=HAVE A JOB/CONTRACT AND OFF-SEASON
8=ON LAYOFF
9=DISABLED
10=OTHER (SPECIFY)
[DMOCHK11b IF DMO11a=4, 5, 6, OR 7, THEN CONTINUE; ELSE GO TO DMOCHK11i]
………………………………………………………………………………………………
DMO11b.
{[IF DMO11=1:] Do you have more than one paying job or business?
[ELSE:] When you are working, do you normally have more than one paying job or business?}
1=YES
2=NO
………………………………………………………………………………………………
DMO11c.
{[IF DMO11=1 OR 4:]How many hours did you work @Blast week@B at @Ball@B jobs or businesses?
[ELSE:] How many hours do you @Busually@B work at @Ball@B jobs or businesses?}
_______HOURS LAST WEEK [ALLOW 000-120
[DMOCHK11d (IF DMO11c LE 34, RF, OR DK) AND DMO11 NE 1 OR 4, THEN CONTINUE; ELSE GO TO DMO11e ]
………………………………………………………………………………………………
DMO11d. Do you USUALLY work 35 hours or more per week in total at ALL jobs or businesses?
1=YES
2=NO
[DMOCHK11e IF DMO11b=1 CONTINUE ELSE GO TO DMO11f ]
………………………………………………………………………………………………
DMO11f. Do you currently have paid sick leave on this job or business?
1=YES
2=NO
………………………………………………………………………………………………
DMO11g. Now, I have questions about work you did in {last calendar year in 4 digit format}.
Did you work for pay at any time in {last calendar year in 4 digit format}?
1=YES
2=NO
[DMOCHK111h IF DMO11g=1, THEN CONTINUE; ELSE GO TO DMOCHK12]
………………………………………………………………………………………………
DMO11h. How many months in {last calendar year in 4 digit format} did you have at least one job or business?
_______MONTHS [ALLOW 00-12]
………………………………………………………………………………………………
ASK DMO11i –DMO11k ONLY OF RESPONDENT WHO ARE EMPLOYED
DMO11i. Does your job or business offer health insurance as a benefit to any of its employees?
1=YES
2=NO
[IF DMO11i=1, THEN CONTINUE; ELSE GO TO INS11]
………………………………………………………………………………………………
DMO11j. Does your job or business cover health insurance costs for those employees covered by this benefit?
1=YES
2=NO
………………………………………………………………………………………………
DMO11k. ASK IF INS7=2 AND DMO11i=1 ELSE GO TO INS11.
Why aren’t you included in your employer’s health insurance plan?
CODE ALL THAT APPLY.
1=DO NOT NEED OR WANT ANY HEALTH INSURANCE
2=RARELY SICK
3=TOO MUCH HASSLE/PAPERWORK
4=COULD NOT AFFORD/TOO EXPENSIVE
5=DO NOT WORK ENOUGH HOURS IN A WEEK
6=HAVE NOT WORKED THERE LONG ENOUGH
7=DOUBT ELIGIBLE/REJECTED BECAUSE OF HEALTH CONDITION
8=BENEFIT PACKAGE DIDN’T MEET NEEDS
9=OTHER (SPECIFY)
[DMOCHK12 IF MIGRANT AND AGE GE 12, CONTINUE; ELSE GO TO END]
………………………………………………………………………………………………
DMO12. Have you done farm work in the last 24 months, that is since {24 MONTH REFERENCE DATE}?
1=YES
2=NO
[DMOCHK12a IF DMO12=1, THEN CONTINUE; ELSE GO TO END]
………………………………………………………………………………………………
DMO12a. Are you currently employed by a:
1=grower/rancher
2=contractor
3=packing service
4=packing house
5=non-farm related employer
………………………………………………………………………………………………
DMO12b. Approximately how many years have you done farm work in the U.S.
NOTE: COUNT ANY YEAR IN WHICH 15 DAYS OR MORE WERE WORKED
_______YEARS [ALLOW 000-109]
………………………………………………………………………………………………
DMO12c. Approximately how many years have you done non-farm work in the U.S.?
NOTE: COUNT ANY YEAR IN WHICH 15 DAYS OR MORE WERE WORKED
_______YEARS [ALLOW 000-109]
………………………………………………………………………………………………
DMO12d. Approximately how many months during the past 12 months have you been in the U.S.?
_______MONTHS [ALLOW 00-12]
………………………………………………………………………………………………
END. Thank you very much. These are all the questions I have for you today.
1=CONTINUE
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Tim Flanigan |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |