Survey Booklet

Adult Targeted Surveillance Survey – Paper Booklet
Form Approved
OMB # 0920-XXXX
Expiration Date: XX/XX/XXXX

ID #

The Community Transformation
Grants Program Evaluation

Survey Booklet

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information
unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road
NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)
Made possible with funding from the Centers for Disease Control and Prevention (CDC)

1

Instructions
We hope you will enjoy completing this survey about health and well-being in your community. We
appreciate your help.
This booklet contains several types of questions. Each question should be answered only about
yourself, not anyone else in your household.


For some questions, you will answer the question by marking inside a circle, like this:

X


2

Yes
No

Number of times per week

You will sometimes be instructed to skip one or more questions. In this example, if your choice is
“No,” you skip to Question 10; otherwise, you continue to the next question.

X


…or like this:

For some questions, you will answer the question by writing in one number per box, like this:
0



Yes
No

Yes
No  Go to 10

Some questions may ask that you write an answer. These questions will have a text box like the
example below.
What is your favorite color?
(Please specify in space below.)

blue


You may find it helpful to refer to the FAQ guide as you complete this survey.

2

Selection Checklist
We need your help to randomly select one person to complete the survey, by using the checklist
below. Please answer each of the following questions to help you determine if you or someone else
in the household qualifies to take the survey.
1

Is today’s date on or before
February 1, 2014?

4

Yes
No  Do not complete this survey
booklet. It must be returned
before February 1, 2014, to
receive the $20 check or $20
gift card to Walmart.

Thinking of all the adults living in this
household, whose birthday is coming
up next?
(Please do not include anyone who is
away at school or away in the military,
or anyone who is visiting temporarily.
Just include adults who currently live in
your household.)
Another adult’s birthday is next

2

My birthday  You qualify. Go to the
next section:
Informed Consent

Is the address printed on this survey’s
envelope your current home address
or main mailing address for personal
mail?
Yes
No  Do not complete this survey
booklet. It must be completed
by a member of the household
that it was mailed to.

3

5

Thank you for completing this selection
checklist.
 Please give this survey booklet
to the adult household member
with the birthday that’s coming
up next and let that person
know he or she should fill out
the rest of the survey.

Are you an adult, at least 18 years of
age or older?
Yes  Go to Question 4
No  Please have an adult member
of your household continue
the survey booklet from this
point forward.

Go to the next page

3

About the Study
RTI International is working with the Centers for Disease Control and Prevention on a study in your
area.


The research study asks about what you eat, your exercise habits, health care, and
physical and mental health. Section 301 of the Public Health Service Act permits the
Centers for Disease Control and Prevention to collect this information.



You were selected at random from other people in your area to be part of the study. You
can choose whether to be in the study or not. If you decide to take part in the study and
change your mind later, you will not be contacted again or asked for any more
information.



About 23,000 people will take this survey this year.



There is no direct benefit to you if you take part. But your answers will help us find out
how to improve the health of your community and others across the country.



The survey takes about 30 minutes. There is very low risk to the survey. We just ask you
to answer questions in a paper booklet. You can skip any questions and stop at any
time. We will not share your answers with anyone not working on the study. No one will
be able to identify you or your answers by looking at the results of the study.



To take part, please record your answers in the booklet using a pen with blue or black
ink.



After we receive your completed survey, we will send you your choice of either a $20
check or a $20 gift card to Walmart. Your contact information will be kept separate
from your answers. We will also keep your contact information private. Sometimes
people call us but do not have a case ID on hand. In such cases, specially trained staff
members will search our records system to find the case ID associated with the callers’
household. These staff members will be trained to carefully avoid sharing your contact
information with anyone. Your contact information will be permanently deleted after you
have completed all parts of the study and have received your check or gift card.

If you have any questions about the survey, please contact Brenna Muldavin, our survey manager. You
can reach her by calling this toll-free number: 1-800-844-8959. Or e-mail her at [email protected].
If you have questions about your rights as a member of this study, please contact RTI’s Office of
Research Protection at this toll-free number: 1-866-214-2043.
If you agree to be part of this study, please complete this survey booklet.

4

About You
This section asks some general questions about you and your household.
6

Has the “Selection Checklist” (page 3)
been completed?

11

Yes, and I was selected.
No  Go back and complete the
Selection Checklist, to identify
the person who should
complete this survey.
7

8

Enter number of children

12

What is today’s date?
Month

No

What is your age?

13

Years

What is your sex?
Male
Female

10

Do any children who are 3 to 17 years
old live in your household?
(Only include children that live in your
household half or more of the time.)
Yes

Day

Must be an adult, at least
18 years of age

9

How many children live in your
household that are less than 18 years
of age?

Including yourself, how many adults
live in your household that are 18
years of age or older?
(Please do not include anyone who is
away at school or away in the military,
or anyone who is visiting temporarily.
Just include adults who currently live in
your household.)
Enter number of adults

What is your current relationship
status?
(Please select only one response.)
Married
Divorced
Widowed
Separated
Never married
A member of an unmarried couple

5

14

What is the highest grade or year of
school you completed?
(Please select only one response.)

17

Never attended school or only
attended kindergarten

15

What is your current employment
status?
(Please select only one response, your
main status now.)
Employed for wages

Grades 1 through 8

Self-employed

Grades 9 through 11

Out of work for more than 1 year

Grade 12 or GED

Out of work for less than 1 year

College 1 year to 3 years

A homemaker

College 4 years or more

A student
Retired

Are you Hispanic or Latino?
(Please answer both Question 15
about ethnicity and Question 16 about
race.)

Unable to work

Yes
No
16

What is your race? Do you consider
yourself…
(Feel free to select all that apply.)

Go to the next section: Physical Activity

White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific
Islander

6

Physical Activity
The following questions are about your physical activity habits. For these questions, please think
about the exercise, recreation, or physical activities you perform, other than your regular job (if
applicable).
18

During the past 30 days, other than
your regular job (if applicable), did you
participate in any physical activities or
exercises, such as running,
calisthenics, golf, gardening, or walking
for exercise?

21

And when you took part in this activity,
for how many minutes or hours did you
usually keep at it?
Minutes
—or—

Yes

Hours

No  Go to 24
19

22

What type of physical activity or
exercise did you spend the most time
doing during the past 30 days?
(Please write your answer in the space
provided below. If needed, refer to FAQ
guide, page 4, for examples.)

None  Go to 24
1 day
2 days
3 days
4 days
5 days
6 days
7 days
23

20

In a typical week, how many days do
you walk or cycle for at least 10
minutes? Include walking or cycling for
leisure, transportation, or exercise.

What is the main reason that you walk
or bicycle?
(Please select only one response.)
Leisure
Transportation
Exercise

How many times per week or per
month did you take part in this activity
during the past 30 days?
Times per week
—or—
Times per month

7

In thinking about the neighborhood where you
live as a place to walk and bicycle, please
indicate if you strongly agree, agree, disagree,
or strongly disagree with each of the following
statements:
24

28

There are bicycle or pedestrian trails in
or near my neighborhood that are easy
to get to.
Strongly agree
Somewhat agree
Somewhat disagree

There are sidewalks on most of the
streets in my neighborhood.

Strongly disagree

Strongly agree
29

Somewhat agree
Somewhat disagree
Strongly disagree
There are no sidewalks
in my neighborhood.  Go to 28

Besides what you already indicated
about the sidewalks and trails in your
neighborhood, why don’t you walk or
cycle more often in your
neighborhood?
(Feel free to select all that apply.)
Weather

25

Lack of time

Most of the sidewalks in my
neighborhood are well maintained
(paved, even, and not a lot of cracks).

Nowhere to go
Medical condition(s)

Strongly agree

Lack of energy/motivation

Somewhat agree

Exercise elsewhere

Somewhat disagree

Safety (crime)

Strongly disagree

I walk or cycle as much as I want to
Other

26

When I am walking on a sidewalk in my
neighborhood, there are parked cars
between me and the road.
Strongly agree
Somewhat agree
Somewhat disagree

Go to the next section: Nutrition

Strongly disagree
27

There is a grass or dirt strip that
separates the streets from the
sidewalks in my neighborhood.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree

8

Nutrition
The next section asks questions about foods and drinks you ate or drank at home and away
from home during the past 30 days.
You can report in either daily, weekly, or monthly amounts: for example, once a day, twice a
week, or three times a month, and so forth.
30

During the past 30 days, how often did
you drink sweetened fruit drinks, such
as Kool-Aid, cranberry juice cocktail,
and lemonade, including fruit drinks
you made at home and added sugar
to?
(If needed, refer to FAQ page 5.)

32

During the past 30 days, how often did
you eat fruit, including fresh, frozen, or
canned fruit?
(Do not count juice or sweetened fruit
drinks.)
(If needed, refer to FAQ page 5.)
Times per day

Times per day

—or—

—or—

Times per week
Times per week

—or—

—or—

Times per month
Times per month

—or—

—or—

Never
Never
33

31

During the past 30 days, how often did
you drink 100% pure fruit juices that
were not fruit-flavored drinks with
added sugar or fruit juice you made at
home and added sugar to?
(If needed, refer to FAQ page 5.)

During the past 30 days, how often did
you eat cooked or canned beans, such
as refried beans, baked beans, black
beans, garbanzo beans, beans in soup,
soybeans, edamame, tofu, or lentils?
(If needed, refer to FAQ page 6.)
Times per day

Times per day

—or—

—or—

Times per week
Times per week

—or—

—or—

Times per month
Times per month

—or—

—or—

Never
Never

9

34

During the past 30 days, how often did
you eat dark green vegetables, for
example, broccoli or dark leafy greens
including romaine, chard, collard
greens, or spinach?
(If needed, refer to FAQ page 6.)

36

Times per day
—or—
Times per week

During the past 30 days, how often did
you eat other vegetables, such as
tomatoes, tomato juice or V8 juice,
corn, eggplant, peas, lettuce, cabbage,
and white potatoes that are not fried,
such as baked or mashed potatoes?
(Do not count the dark green
vegetables and orange-colored
vegetables that you counted in
previous questions.)
(If needed, refer to FAQ page 7.)

—or—

Times per day
Times per month

—or—

—or—

Times per week
Never

35

—or—
Times per month

During the past 30 days, how often did
you eat orange-colored vegetables,
such as sweet potatoes, pumpkin,
winter squash, or carrots?
(If needed, refer to FAQ page 6.)

—or—
Never

Times per day
—or—
Go to the next page

Times per week
—or—
Times per month
—or—
Never

10

Thinking now about buying, preparing, and
eating fruits and vegetables, please indicate if
you strongly agree, somewhat agree, somewhat
disagree, or strongly disagree with each
statement.

41

I do not like the taste of fruits.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree

37

There is a wide variety of fruits and
vegetables where I shop.

42

Strongly agree

Strongly agree

Somewhat agree

Somewhat agree

Somewhat disagree

Somewhat disagree

Strongly disagree
38

I do not like the taste of vegetables.

Strongly disagree

The fruits and vegetables where I shop
are at good prices.

43

Strongly agree
Somewhat agree
Somewhat disagree

During the past 30 days, how many
times per day, week, or month did you
drink milk as a beverage (not in coffee,
not in cereal)? In your answer, please
include chocolate milk and hot
chocolate.

Strongly disagree
39

Times per day
—or—

The fruits and vegetables where I shop
are of good quality.

Times per week

Strongly agree

—or—

Somewhat agree

Times per month

Somewhat disagree

—or—

Strongly disagree
40

Never Go to 46

Fruits and vegetables take too much
time to prepare.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree

11

44

What kind of milk did you drink most of
the time?
(Please select only one response.)
(Mark if the milk was flavored in
Question 45.)

47

During the past 30 days, how many
times per day, week, or month did you
drink plain water? Include tap, bottled,
and unflavored sparkling water.
(If needed, refer to FAQ guide, page 7.)

Whole milk

Times per day

2% fat milk

—or—

1% fat milk

Times per week

Skim, nonfat, or ½% fat milk
—or—

Soy milk

Times per month

Rice milk
Raw, unpasteurized milk

—or—

Other
45

Never

Was the milk you drank usually
flavored, such as chocolate, vanilla,
strawberry, or other flavored milk?

48

Yes
No

Now, consider the foods you keep at
home. How often do you have fruits
available at home? This includes fresh,
dried, canned, and frozen fruits.
Always

46

Most of the time

During the past 30 days, how often did
you drink regular soda or pop that
contains sugar, not including diet soda
or diet pop?
(Please include regular soda that was
mixed with alcohol.)

Sometimes
Rarely
Never

Times per day
—or—

49
Times per week

—or—
Times per month
—or—

How often do you have any of these
dark green vegetables available at
home? Broccoli; spinach and other
greens like collard, mustard, and
turnip greens; and dark green leafy
lettuce like romaine.
Always

Never

Most of the time
Sometimes
Rarely
Never

12

50

During the past 7 days, how many
meals did you get that were prepared
away from home in places such as
restaurants, fast-food places, food
stands, or grocery stores, or came from
vending machines?
(Please do not include meals provided
as part of community programs.)

Go to the next section: Cigarettes

Number of meals away from
home in the past 7 days
51

How many of those meals did you get
from a fast-food or pizza place?
Number of meals away from
home in the past 7 days

52

Are you currently on any kind of diet,
either to lose weight or for some other
health reason?
Yes
No  Go to the next section:
Cigarettes

53

What kind of diet are you on?
(Feel free to select all that apply.)
Weight loss or low calorie diet
Low fat or cholesterol diet
Low salt or sodium diet
Sugar free or low sugar diet
Low fiber diet
High fiber diet
Diabetic diet
Low carbohydrate diet
High protein diet
Weight gain diet
Other

13

Othe

Cigarettes

The next section will ask you some questions about smoking.
54

Have you smoked at least 100
cigarettes in your entire life?
(5 packs = 100 cigarettes)

58

Yes
No  Go to 57
55

Do you now smoke cigarettes every
day, some days, or not at all?

During the past 7 days, not counting
times while you were at work, on how
many days did you breathe the smoke
from someone else who was smoking
in an indoor public place?
(Examples of indoor public places are
the indoor areas of stores, restaurants,
bars, casinos, clubs, and sports
arenas.)
Number of days

Every day  Go to 57
Some days
59

Not at all
56

How long has it been since you last
smoked a cigarette, even one or two
puffs?

At workplaces, do you think smoking
indoors should be…?
(Please select only one.)
Always allowed
Allowed only at some times or in
some places

Within the past month

Never allowed

Within the past 3 months
Within the past 6 months

60

Within the past year
Within the past 5 years
Within the past 10 years

Would you favor a policy that bans
smoking in all areas of multi-unit
housing, including personal living
spaces, such as balconies and patios?
Yes

10 years or more

No
57

Not counting decks, porches, or
garages, inside your home, is
smoking…?
(Please select only one.)
Go to the next section: Health

Always allowed
Allowed only at some times or in
some places
Never allowed

14

Health
The next section will ask you some questions about your health and health care.
61

Is there a place that you usually go to
when you are sick or need advice
about your health?

64

Yes

Don’t get preventive
care anywhere  Go to 65

There is no place  Go to 64
There is more than one place
62

What kind of place do you usually go to
when you need routine or preventive
care, such as a physical examination
or checkup?

Clinic or health center
Doctor’s office or HMO

What kind of place do you go to most
often?

Hospital emergency
room

Clinic or health center

Go to 66

Hospital outpatient
department

Doctor’s office or HMO
Hospital or emergency room

Some other place

Hospital outpatient department

I do not go to one
place most often  Go to 65

Some other place
I do not go to one
place most often  Go to 64
63

65

Is that the same place you usually go
to when you need routine or preventive
care, such as a physical examination
or checkup?

Why don’t you have a usual source of
medical care?
(Feel free to select all that apply.)
Don’t need a doctor/haven’t had any
problems

Yes  Go to 66

Don’t like/trust/believe in doctors

No

Don’t know where to go
Previous doctor is not
available/moved
Too expensive/no insurance/cost
Speak a different language
No care available/care too far away,
not convenient
Put it off/didn’t get around to it
Other

15

66

About how long has it been since you
last visited a doctor for a routine
checkup?
(A routine checkup is a general
physical exam, not an exam for a
specific injury, illness, or condition.)

71

Yes
No

Within the past year

72

Within the past 2 years
Within the past 5 years

No

Never

I do not use salt

Has a doctor or other health
professional ever advised you to
reduce sodium or salt intake?

73

Yes

No  Go to 78

Have you ever been told by a doctor,
nurse, or other health professional that
you have high blood pressure?
(By “other health professional” we
mean a nurse practitioner, a
physician’s assistant, or some other
licensed health professional.)

74

About how long has it been since you
last had your blood cholesterol
checked?
Within the past year
Within the past 2 years

Yes  Go to 69

Within the past 5 years

No  Go to 73

5 or more years ago

Only told borderline high
or pre-hypertensive  Go to 73
69

Blood cholesterol is a fatty substance
found in the blood. Have you ever had
your blood cholesterol checked?
Yes

No
68

Are you cutting down on salt to help
lower or control your high blood
pressure?
Yes

5 or more years ago

67

Are you currently taking medicine for
your high blood pressure?

75

Was this only when you were
pregnant?

Have you ever been told by a doctor,
nurse, or other health professional that
your blood cholesterol is high?
Yes
No  Go to 78

Yes  Go to 73
No
76

Not applicable (male)
70

Are you exercising to help lower or
control your high blood pressure?

Are you exercising to help lower your
cholesterol?
Yes
No

Yes
No

16

77

82

Are you currently taking medicine to
lower your cholesterol?
Yes
No

78

How often in the past 12 months
would you say you were worried or
stressed about having enough money
to pay your rent/mortgage?
Always
Usually

Thinking about your overall physical
health, which includes physical illness
and injury, for how many days during
the past 30 days was your physical
health not good?

Sometimes
Rarely
Never
Not applicable

Number of days
83

If your answer is 0 (zero days)  Go to 80
79

During the past 30 days, for about how
many days did poor physical health
keep you from doing your usual
activities, such as self-care, work, or
recreation?

And how often in the past 12 months
would you say you were worried or
stressed about having enough money
to buy nutritious meals?
Always
Usually
Sometimes
Rarely

Number of days

Never
Not applicable

80

Now, turning to your mental health,
have you ever been told by a doctor or
other health professional that you had
depression?

84

Yes
No
81

Are you now taking medicine or
receiving treatment from a doctor or
other health professional for any type
of mental health condition or
emotional problem?
Yes
No

Have you ever been told by a doctor or
other health professional that you had
anxiety?

85

Yes
No

Now, in thinking about your overall
mental health, which includes stress,
depression, and problems with
emotions, for how many days during the
past 30 days was your mental health not
good?
Number of days
If your answer is 0 (zero days)  Go to 87

17

86

During the past 30 days, for about how
many days did poor mental health
keep you from doing your usual
activities, such as self-care, work, or
recreation?
Number of days

87

How often do you get the social and
emotional support you need?
(Please include support from any
source.)
Always
Usually
Sometimes
Rarely
Never

Go to the next section: Demographics

18

Demographics
The next section asks some basic demographic questions about you.
88

91

Earlier in the survey, you were asked to
self-identify your race. Now, we want to
find out how other people usually
identify you in this country.
How do other people usually classify
you in this country?
(Please select only one response
option. If needed, refer to FAQ guide,
page 6.)

About how much do you weigh without
shoes?
(You may record your weight in either
pounds or kilograms.)
Pounds
—or—
Kilograms

White
92

Black or African American
Hispanic or Latino
Asian
Native Hawaiian or Other Pacific
Islander

/

American Indian or Alaska Native

—or—

Some other group

89

/

How often do you think about your race?

93

Never
Once a year

Feet / Inches

Meters / Centimeters

What is your annual household income
from all sources?
(Please select only one response.)
Less than $10,000

Once a month

$10,000 to $14,999

Once a week

$15,000 to $19,999

Once a day

$20,000 to $24,999

Once an hour

$25,000 to $34,999

Constantly
90

About how tall are you without shoes?
(You may record your height in either
feet and inches or meters and
centimeters.)

$35,000 to $49,999
$50,000 to $74,999

To your knowledge, are you now
pregnant?

$75,000 or more

Yes
No

19

94

Which of the following best represents
how you think of yourself?

96

What do you mean by don't know?
You don’t understand the words
You understand the words, but have
not figured out or are in the process
of figuring out your sexuality.

Lesbian or Gay
Straight, that is,
not lesbian or gay

You mean
something else  Go to 97

Bisexual
Something else  Go to 95
I don’t know the answer  Go to 96
95

Survey complete. $20 thank-you
information on next page.

What do you mean by something else?
You are not straight, but identify with
another label such as queer,
trisexual, omnisexual or pansexual
You are transgender, transsexual or
gender variant
You have not figured out or are in the
process of figuring out your sexuality.

97

You do not think of yourself as having
sexuality
You do not use labels to identify
yourself
You mean
something else  Go to 97

Survey complete. $20 thank-you
information on next page.

20

What do you mean by something else?
(Please write your answer in the space
provided below.)

Thank you for completing the survey!
To receive a $20 check or Walmart gift card as a token of our
appreciation, please read and complete the attached “Incentive
Information” document included with this survey.
Please place your questionnaire in the pre-addressed envelope
provided and mail it back to us.
If the envelope has been misplaced, please mail the questionnaire to:
Community Transformation Grants Program Evaluation
5265 Capital Boulevard
Raleigh, NC 27616-2925