Adult Targeted Surveillance Survey - telephone screener

Targeted Surveillance and Biometric Studies for Enhanced Evaluation of CTGs

Att 7C_ATSS_PhoneInterview

Adult Targeted Surveillance Survey - screener

OMB: 0920-0977

Document [docx]

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Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Adult Targeted Surveillance Survey - Telephone

Public reporting burden of this collection of information varies from 2 to 30 minutes with an estimated average of 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)

Telephone Screener 3

Consent Script 21

Telephone Interview 26

Telephone Screener

[VARIABLES THAT WILL BE PASSED TO CATI-CMS FROM THE SAMPLE FILE:

VARIABLE NAME	VARIABLE LOCATION	VALUES
SampleType	Sample File	YE, TS
AwardeeID	Sample File	1 Character, A-K
WAVEID	Sample File	1 number digit
CASEID	Sample File	8 alpha-numeric
Address1	Sample File	60 characters
City_Name	Sample File	28 characters
State_Code	Sample File	2 characters
ZIP	Sample File	Truncated to first 5 digits, sample file includes Zip and Zip4
CountyName	Sample File	60 characters
PhoneType	Sample File	M, H
phone	Sample File	10 number digit
POBox	Sample File	Y, N
AdultOnlyInterview	Sample File	0, 1

[THE ROSTER LINE PHONE TYPE SHOULD BE SET TO LANDLINE IF SAMPLEFILE’s PHONETYPE=M OR IF SOMEONE MANUALLY ENTERS A NUMER AS A LANDLINE.]

INTRO_A. Hello, I am calling on behalf of the Centers for Disease Control and Prevention and their contractor, RTI International. My name is {name}.

1 - CONTINUE

[IF STATUS=1220, GOTO INT_START_C; ELSE {IF PhoneType = H (Landline) & SCREENER_PART NE S go to INTRO; IF PhoneType = H (Landline) & SCREENER_PART = S go to CELL1; If PhoneType = M (Cell), go to CELL1.}]

CELL1. Before I continue, I need to know, have I reached you on a cell phone?

READ ONLY IF NECESSARY: “By cell phone, we mean a telephone that is mobile and usable outside of your neighborhood.”

1> YES {GO TO CELL}

2> NO {IF SCREENER_PART = S, GO TO INT_START_A; ELSE GO TO INTRO}

3 DON’T KNOW--[END CALL, SCHEDULE SOFT CALLBACK]

6 REFUSED -- [END CALL– GOTO REF_CTG (Refusal case) ]

CELL. Are you driving or doing anything that requires your full attention right now?

1 YES—GO TO Cell2B

2 NO— [IF SCREENER_PART = S, GO TO INT_START_A; ELSE GO TO INTRO]

3 DON’T KNOW--[END CALL]

6 REFUSED [END CALL]

CELL2B. When would be a better time to call you?

[IF RESPONDENT INDICATES THAT THEY ARE WILLING TO TALK NOW BUT THEY ARE DRIVING, SAY: “I’m sorry, but for your safety we’re not able to continue while you’re driving.”]

SELECT NEXT TO SCHEDULE CALLBACK

[SET CALLBACK]

INTRO. [IF REFUSAL_SCRIPT=1, SKIP TO INT1] We are interested in the health, experiences, and perspectives of people in <<county name>>.

SAY ONLY IF NEEDED: (I am calling on behalf of the United States Centers for Disease Control and Prevention (the CDC) and their contractor, RTI International).

[IF (SAMPLETYPE=TS (MAIN SAMPLE)), If someone in your household is *eligible* and completes a full survey, we’ll send that person a $20 gift card *or* a $20 check (whichever he or she chooses), as a token of our appreciation.]

[IF (SAMPLETYPE=YE (YOUTH ENRICHED SAMPLE)), SAY ONLY IF NEEDED: (If your household is *eligible* and the adult invited to participate completes *both parts* of our study, we’ll give that person $60 as a token of our appreciation. The $60 will be given in two parts: $20 in the form of a check or gift card after the completion of the telephone interview and then $40 in cash after completion of an in-home visit).]

In order to find out if anyone is eligible, I need to ask a few preliminary questions. To evaluate my performance, my supervisors may record and listen as we talk.

1 - CONTINUE

2 - NUMBER IS FOR BUSINESS

3 –NUMBER IS FOR GROUP QUARTERS

[IF INTRO=1, CONTINUE; ELSE GO TO BUSIVERIFY]

INT1. ASK IF NEEDED: Are you an adult, that is, are you 18 years old or older?

1 - YES

2 - NO

3 DON’T KNOW [END CALL, SCHEDULE SOFT CB]

6 REFUSED [END CALL, SCHEDULE SOFT CB]

[IF NOT AN ADULT (INT1=2), ASK INT1A; IF INT1=1 & (CELL1=1 & POBox=N,GO TO MOB1; IF INT1=1 & (CELL1=1 OR CELL1=2) & POBox=Y, GO TO INT2A; IF INT1=1 & CELL1=2 & POBox=N, GO TO INT2; IF INT1 =3 OR 6 (DK or RF), END CALL, SCHEDULE SOFT CB; ELSE GO TO CELL1H.]

INT1A. May I speak with an adult in this household?

1. ADULT COMES TO PHONE [GO TO REINTRO]

2. NO ADULT AVAILABLE AT THIS TIME [END CALL AND SCHEDULE CB]

3. NO ADULTS LIVE IN THIS HOUSEHOLD [BREAK OFF AND CODE AS INELIGIBLE HOUSEHOLD – NO ADULTS: 2345]

4 DON’T KNOW [END CALL, SCHEDULE SOFT CB]

5 REFUSED [END CALL, SCHEDULE SOFT CB]

REINTRO. Hello, my name is {name}. I am calling on behalf of the United States Centers for Disease Control and Prevention (the CDC) and their contractor, RTI International. We are interested in the health, experiences, and perspectives of people in <<county name>>.

[IF (SAMPLETYPE=TS (MAIN SAMPLE)), If someone in your household is *eligible* and completes a full survey, we’ll send that person a $20 gift card *or* a $20 check (whichever he or she chooses), as a token of our appreciation.]

In order to find out if anyone is eligible, I need to ask a few preliminary questions. To evaluate my performance, my supervisors may record and listen as we talk.

1 – CONTINUE [IF CELL1=1 & POBox=N, GO TO MOB1; IF (CELL1=1 OR CELL1=2) & POBox=Y, GO TO INT2A; IF CELL1=2 & POBox=N, GO TO INT2; ELSE GO TO CELL1H]

CELL1H. Have I reached you on a cell phone?

READ ONLY IF NECESSARY: “By cell phone, we mean a telephone that is mobile and usable outside of your neighborhood.”

1> YES {CHANGE PhoneType = M (CELL) & GO TO CELLH}

2> NO [IF POBox=Y (ADDRESS IS A PO BOX, PER THE SAMPLE FILE), THEN GO TO INT2A; ELSE GO TO INT2]

3 DON’T KNOW--[END CALL , SCHEDULE SOFT CB]

6 REFUSED -- [END CALL – GOTO REF_CTG (Refusal case)]

CELLH. Are you driving or doing anything that requires your full attention right now?

1 YES—GO TO Cell2BH

2 NO— [IF POBox=Y (ADDRESS IS A PO BOX, PER THE SAMPLE FILE), THEN GO TO INT2A; ELSE GO TO INT2]

3 DON’T KNOW--[END CALL , SCHEDULE SOFT CB]

6 REFUSED [END CALL – GOTO REF_CTG (Refusal case)]

CELL2BH. When would be a better time to call you?

[IF RESPONDENT INDICATES THAT THEY ARE WILLING TO TALK NOW BUT THEY ARE DRIVING, SAY: “I’m sorry, but for your safety we’re not able to continue while you’re driving.”]

SELECT NEXT TO SCHEDULE CALLBACK

[SET CALLBACK]

INT2.Have I reached {fill sampled address; street, unit, and zip code only; no city}?

– YES [GO TO INT3]
- NO [GO TO THK1A]

3 DON’T KNOW [END CALL, SCHEDULE SOFT CB]

6 REFUSED [END CALL – GOTO REF_CTG (Refusal case)]

MOB1. Do you live or work at {fill sampled address; street, unit, and zip code only; no city}?”

- YES
- NO [GO TO THK1A]

3 DON’T KNOW [END CALL, SCHEDULE SOFT CB]

4 REFUSED [END CALL – GOTO REF_CTG (Refusal case)]

INT3. Is this a private residence ({fill sampled address; street, unit, and zip code only; no city}?)?

(READ AS MUCH OF THE FOLLOWING AS IS HELPFUL TO CLARIFY: Private residences are places where people live, like houses, apartments, condominiums, or mobile homes; but are not places used exclusively by businesses.)IF VOLUNTEERS THAT UNIT AT ADDRESS IS ONLY A VACATION HOME OR OTHER TEMPORARY RESIDENCE, SELECT CODE 3 BELOW.

1 – YES

2 - NO [GO TO THK2]

3 – TEMPORARY RESIDENCE

4 DON’T KNOW [END CALL, SCHEDULE SOFT CB]

6 REFUSED [END CALL – GOTO REF_CTG (Refusal case)]

[IF INT3=1, SKIP TO KIDS; IF INT3=3, GO TO THK3]

[PRESENT INT2A IF SAMPLEFILE:POBox=Y (ADDRESS IS A PO BOX, PER THE SAMPLE FILE)]

INT2A. Do you receive mail at {fill sampled address, POB and zip code}?

2 NO [GO TO THK1A]

3 DON’T KNOW [END CALL, SCHEDULE SOFT CB]

6 REFUSED [END CALL – GOTO REF_CTG (Refusal case)]

INT3A. Is this address used for a business or for personal mail?

1 PERSONAL

2 BUSINESS [GO TO THK2]

3 BOTH PERSONAL AND BUSINESS

4 DON’T KNOW [END CALL, SCHEDULE SOFT CB]

6 REFUSED [END CALL – GOTO REF_CTG (Refusal case)]

KIDS. Learning about the health of *children* in your community is an important part of our study.

Do any children who are 3 to 17 years old live in your household?

SAY, IF NEEED: (Only include children that live in your household half or more of the time.)

1 - YES

2 - NO

3 DON’T KNOW

6 REFUSED

[IF KIDS=1, GO TO INT4]

[IF (SAMPLETYPE=TS (MAIN SAMPLE)) AND (KIDS= 3 OR 6), GO TO INT4]

[IF SAMPLETYPE=YE (YOUTH ENRICHED SAMPLE) AND (KIDS= 3) AND AdultOnlyInterview=0, END CALL, SCHEDULE SOFT CB]

[IF SAMPLETYPE=YE (YOUTH ENRICHED SAMPLE) AND (KIDS= 6) AND AdultOnlyInterview=0, GO TO REF_CTG]

[IF SAMPLE_TYPE= YE (YOUTH ENRICHED SAMPLE) AND NO CHILDREN LIVE IN THE HOUSEHOLD (KIDS=2) AND AdultOnlyInterview=0, THEN GO TO NOKIDS]

[ELSE GO TO INT4]

NOKIDS. Those were all the questions I have for you today. We appreciate your help.

READ ONLY IF NEEDED: Since we are currently focusing on households with children aged 3-17 years old and you have no children in your household in that age range, your household is not eligible to participate at this time.

[AFTER NOKIDS, CODE CASE OUT AS “NO ELIGIBLE CHILDREN”: 2320]

INT4. I need to randomly select one adult who lives in your household to be interviewed. 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 {IF POBox=Y, FILL“receiving mail”} at {fill sampled address; street, unit}. How many members of your household, including yourself, are 18 years of age or older?

INTERVIEWER:

IF THE RESPONSE IS DK, BREAK OFF AND SCHEDULE A SOFT APPOINTMENT

IF THE RESPONSE IS RF, BREAK OFF AND CODE AS A REFUSAL

__ NUMBER OF ADULTS [RANGE 0 – 17]

[IF INT4 =0, GO TO THK4]

[IF INT4 >=1, THEN SET INDICATOR: ATSSELIGIBLE]

[IF ONLY ONE ADULT HOUSEHOLD MEMBER (INT4=1) GO TOINT4A; ELSE IF THERE IS MORE THAN ONE ADULT HOUSEHOLD MEMBER, GO TO INT5]

INT4ERROR

INTERVIEWER:

VERIFY THE NUMBER OF ADULT HOUSEHOLD MEMBERS WITH RESPONDENT. IF 17 OR MORE ADULTS IN HOUSEHOLD RECORD 17 FOR NUMBER OF ADULTS.

ENTER 1 TO RETURN TO ENTRY SCREEN

1. CONTINUE

INT4A. Are you the adult (who lives in this household)?

1 YES, PERSON ON PHONE IS TARGETED R – [GO TO INT5A]

2 NO [GO TO INT5A]

6 WON’T SAY/REFUSING/HUNG-UP ETC. [END CALL – GOTO REF_CTG (Refusal case)]

INT5. We would like to speak with the adult resident whose birthday is coming up next.

1 CONTINUE

INT5A.

{IF INT4=1 AND INT4A=1, SHOW, “In case we get disconnected, would you please tell me your name? (ONLY IF NEEDED: Your initials will be fine.) ”}

{IF INT4>1 OR IF INT4A=2, SHOW, “What is this adult’s first name? (ONLY IF NEEDED: We would like to speak with the adult resident whose birthday is coming up next. (His)/(her) initials will be fine.) }

IF THE RESPONDENT REFUSES TO GIVE NAME OR INITIALS, ENTER DESCRIPTION: {IF INT4=1, FILL “only adult HHM” OR IF INT4>1, THEN FILL “Adult with Next Birthday After {CURRENT INTERVIEW DATE}” .}

__________ RECORD RESPONDENTS FIRST NAME OR INITITALS

[DISABLE DK AND RF OPTIONS]

_________________________________________________________________________

[IF INT4A=1 (PERSON ON PHONE IS THE RESPONDENT), THEN SKIP TO INT6; ELSE SHOW INT5B]

[IF INT5A= 1, SET SCREENER_PART = S]

INT5b. May I please speak with {FILL NAME OR INITIALS FROM INT5A}?

1 R COMES TO PHONE—[GO TO REINTRO2]

2 R UNAVAILABLE—GO TO INT5C.

3 PERSON ON PHONE IS R [GO TO INT6]

5DON’T KNOW [END CALL, SCHEDULE SOFT CB]

6 REFUSED [END CALL – GOTO REF_CTG (Refusal case)]

INT5c. Should we call {FILL NAME OR INITIALS FROM INT5A} using this telephone number or a different one?

1 YES – CALLBACK USING THIS NUMBER [SET CALL BACK; UPON CB SHOULD SEE INTSTART_A]

2 NO – CALLBACK USING A DIFFERENT NUMBER [SKIP TO ROSTER LINE PROMPT AND ADD NEW NUMBER, THEN APPOINTMENT SCHEDULING SCREEN;]

REINTRO2. (Hello, my name is {name}. I am calling on behalf of the United States Centers for Disease Control and Prevention (the CDC) and their contractor, RTI International.) We are interested in the health, experiences, and perspectives of people in <<county name>>.

[IF (SAMPLETYPE=TS (MAIN SAMPLE)): You have been randomly selected as eligible to participate. If you complete a full survey, we’ll send you a $20 gift card or a $20 check (whichever you choose), as a token of our appreciation.]

I would like to tell you more about our study. In order to evaluate my performance, my supervisors may record and listen as we talk.

INT6. Is this a good time to tell you more about the study?

– YES [IF ATSSRCONSENT= 1, LAUNCH HATTERAS AT POINT OF BREAKOFF; ELSE, {IF (SAMPLETYPE= TS (MAIN SAMPLE)), Go to CONSENT1 ; IF (SAMPLETYPE=YE (YOUTH ENRICHED SAMPLE)), GO TO INT8A}]
- NO [go to INT7]

6 – REFUSED [END CALL – GOTO REF_CTG (Refusal case)]

INT7. When would be a good time to talk?

SELECT CONTINUE TO SET AN APPOINTMENT

[SELECT 1 TO CONTINUE]

[IF SAMPLETYPE=YE (YOUTH ENRICHED SAMPLE), PRESENT INT8A, OTHERWISE GO TO CONSENT SCRIPT]

INT8A. Participation in our study involves both a telephone interview and an in-home visit from one of our study staff members. The telephone interview averages about 30 minutes. The meeting with one of our staff members in your home averages less than TEXTFILL IF KIDS=1, “two hours”, ELSE “1 hour]. If you complete both the telephone interview and in-home visit, you will be given a total of $60, as a token of our appreciation. (The $60 will be given in two parts: $20 in the form of a check *or* gift card after the completion of the telephone interview and then $40 in cash after completion of the in-home visit). [TEXTFILL IF KIDS=1, “If a child also participates during the in-home visit, we will give another $10 in cash, also as a token of our appreciation.”]

1 – CONTINUE -ASK FOR INTEREST TO PARTICIPATE

2- DETAILS ON PHYSICAL MEASUREMENTS - SELECT ONLY IF ASKED

3 –DETAILS ON CHILD PARTICIPATION - SELECT ONLY IF ASKED FOR HH WITH CHILDREN

4 –DETAILS ON ACCELEROMETRY - SELECT ONLY IF ASKED

[IF INT8A=1, GO TO INT8E; IF INT8A=2, GO TO INT8B; IF INT8A=3, GO TO INT8C; IF INT8A=4, GO TO INT8D]

INT8B. SAY ONLY IF NEEDED: During the in-home visit, we’ll ask to take some simple physical measurements. We will measure your height, weight, waist circumference, blood pressure, and take a sample of your saliva, to measure cotinine (a measure of recent tobacco smoke exposure). We will also ask questions related to the physical measures. (For example, we may ask whether you are fasting, about your current medication use, recent weight loss or gain, and any recent diagnoses of high blood pressure.)

1 – CONTINUE - ASK FOR INTEREST TO PARTICIPATE

3 –DETAILS ON CHILD PARTICIPATION - SELECT ONLY IF ASKED FOR HH WITH CHILDREN

4 –DETAILS ON ACCELEROMETRY - SELECT ONLY IF ASKED

[IF INT8B=1, GO TO INT8E; IF INT8B=3, GO TO INT8C; IF INT8B=4, GO TO INT8D]

INT8C. SAY ONLY IF NEEDED: If you are interested in participating, we would also like to invite a child in your household to participate. The child’s participation would take place during the in-home visit, when a parent or legal guardian is present. At that time, the selected child will be asked questions about physical activity and healthy eating; and will have some physical measurements taken, specifically, height, weight, waist circumference, and saliva cotinine (a measure of recent tobacco smoke exposure).

1 – CONTINUE

2 – DETAILS ON PHYSICAL MEASUREMENTS - SELECT ONLY IF ASKED

4 –DETAILS ON ACCELEROMETRY - SELECT ONLY IF ASKED

[IF INT8C=1, GO TO INT8E; IF INT8C=2, GO TO INT8B; IF INT8C=4, GO TO INT8D]

INT8D. SAY ONLY IF NEEDED: If you agree to participate in the in-home visit [TEXTFILL IF KIDS=1, “along with a child in your household,] you [TEXTFILL IF KIDS=1, “and the child may also be eligible" ELSE "may also be eligible"] to participate in an additional component of this study in which you use an accelerometer to monitor your physical activity and sedentary behavior over a 7 day period.

1 – CONTINUE TO ASK FOR INTEREST TO PARTICIPATE

2 – DETAILS ON PHYSICAL MEASUREMENTS - SELECT ONLY IF ASKED

3 –DETAILS ON CHILD PARTICIPATION - SELECT ONLY IF ASKED FOR HH WITH CHILDREN

[IF INT8D=1, GO TO INT8E; IF INT8D=2, GO TO INT8B; IF INT8D=3, GO TO INT8C]

INT8E. We will give you more details later, but from what you’ve heard so far, do you think that you [TEXTFILL IF KIDS=1, “and a child in your household”] would be interested in participating both by completing a telephone interview and by meeting with one of our study staff members, in your home?

(We expect that the in- home visit will last less than [TEXTFILL IF KIDS=1, “two hours”, ELSE “1 hour”].)ADDRESS QUESTIONS AND CONCERNS USING FAQS; PROVIDE # FOR SURVEY MANAGERS IF NEEDED: 1-800-844-8959

1. YES [GO TO INT9]

2. NO [GO TO NOINT]

NOINT. Thank you for taking the time to talk with me today.

READ ONLY IF NEEDED: Since you are not interested in participating both by completing a telephone interview and by meeting with one of our study staff members, we cannot include you in our study at this time.

[END AND CODE AS REFUSAL BY SUBJECT: 2405]

INT9. Thank you. (I’d like to tell you more about the telephone interview I mentioned earlier.) [GO TO CONSENT1]

THK1A. I seem to have dialed the wrong number.

IF NEEDED SAY, “Before I go, would you please tell me how your address differs from the address I mentioned ({sampled address; street, unit} )?”

SELECT ALL THAT APPLY. READ OPTIONS ONLY IF NEEDED.

1. name of street is wrong

2. number of street is wrong

3. unit number is wrong

4. zip code is wrong

5. NO INFORMATION PROVIDED

[IF THE ANSWER(S) TO THK1A INCLUDE 4 (ZIP CODE) ASK OTHERZIP, ELSE END CALL; IF NUMBER DIALED=SAMPLEFILE: PHONE, CODE EVENT AS MISMATCHED: 1276 AND CODE STATUS AS 1909, ELSE CODE OUT ROSTER LINE AS BAD NUMBER 1272.]

OTHERZIP. Would you please tell me your zip code?

SAY, IF NEEDED: “Knowing your zip code will help our analysts figure out why we have the wrong telephone number for the address we were trying to reach.”

_____ ZIP CODE [RANGE 00501- 99950, GOTO BADZIP IF OUTSIDE RANGE]

[AFTER ASKING OTHERZIP, END CALL; IF NUMBER DIALED=SAMPLEFILE: PHONE, CODE EVENT AS MISMATCHED: 1276 AND CODE STATUS AS 1909, ELSE CODE OUT ROSTER LINE AS BAD NUMBER 1272.]

BADZIP. INTERVIEWER: THE ZIP CODE YOU ENTERED WAS NOT WITHIN THE VALID RANGE OF 00501 – 99950. PLEASE CHECK YOUR ENTRY.

ENTER 1 TO RETURN TO THE ZIP CODE ENTRY SCREEN

1. CONTINUE

THK2. Thank you very much, but we are only interviewing members of households in private residences.

IF NEEDED SAY, “Before I go, may I ask if this is a business?”

1. BUSINESS

2. GROUP QUARTERS UNIT

3. UNKNOWN

[IF THK2=1, END AND CODE 1310; IF THK2=2, END AND CODE 1330; IF THK2=3 END CALL, CODE OUT AS NONRESIDENTIAL: 1310]

THK3. Thank you very much, but temporary residences (such as vacation homes) are excluded from our study.

[END CALL, CODE OUT AS TEMPOARY RESIDENCE: 1305/2305]

THK4. Thank you very much, but we are only interviewing households with adult members.

INTERVIEWER:

IF RESPONDENT CLARIFIES THAT THEY ARE AN ADULT AND HAD NOT COUNTED THEMSELVES, BACK TO INT4 AND ENTER 1.

[END CALL, CODE OUT INELIGIBLE HOUSEHOLD – NO ADULTS: 1345/2345]

THANK_EVT. Thank you for your time. Have a nice (day/evening) .

1 – Continue [END, IF NUMBER DIALED=SAMPLEFILE: PHONE, CODE EVENT AS MISMATCHED: 1276 AND CODE STATUS AS 1909, ELSE CODE OUT ROSTER LINE AS BAD NUMBER 1272.]

TEXT FOR AUXILLIARY SCREENS IN THE CASE MANAGEMENT SYSTEM

PRIVMAN. PRIVACY MANAGER SCREEN.

IF ASKED TO STATE NAME: I’m calling about a health survey for <<county name>> residents.

IF ASKED TO STATE TELEPHONE NUMBER: 1-855-500-1437

1 SOMEONE PICKS UP

1201 RING NO ANSWER

1202 BUSY SIGNAL/ALL CIRCUITS BUSY

1264 ANSWERING MACHINE

1285 BLOCKED LINE

[IF PRIVMAN=1, GO TO INTRO_A;

IF PRIVMAN=1264 and CALLCOUNT=1st, 4th, 7th, 10th, 15th GO TO ANSPRMPT1, ELSE END AND CODE 1286]

ANSPRMPT1. ANSWERING MACHINE MESSAGE. I’m calling on behalf of the Centers for Disease Control and Prevention and their contractor, RTI International about a health survey for <<county name>> residents.

[SHOW ONLY IF RESPONDENT SELECTED (SCREENER_PART = S): We’re trying to reach {Fill Name from: INT5A}]

[IF SCREENER_PART NE S & SAMPLETYPE=TS): If someone in your household is eligible and completes a full survey, we’ll send that person a $20 gift card or a $20 check (whichever he or she chooses), as a token of our appreciation.]

[IF SCREENER_PART NE S & SAMPLETYPE=YE): We need to speak briefly with an adult household member to find out if anyone in your household is eligible to participate.]

One of our interviewers will try to contact you again in the next couple of days. Or, if you would prefer, you can call us back at our toll-free number, 1-855-500-1437. If you do call, please let us know the following study number: {fill case ID}.

We look forward to your participation in this study.

<1> LEFT MESSAGE ON MACHINE [END AND CODE 1263]

<2> SOMEONE PICKED UP [GO TO INTRO_A]

<3> BUSINESS ANSWERING MACHINE [END AND CODE 1268]

REFUSAL_SCRIPT. [IF STATUS = REFUSAL STATUS, INITIATE CALL AT SCREEN REFUSAL_SCRIPT] Hello, my name is ____. I’m calling about a health survey for <<county name>> residents. We’re trying to learn more about the health of people in your community.

[IF SCREENER_PART NE S, Your household has been selected at random to be included in the study. ]

[IF SCREENER_PART = S, “May I speak with”{FILL NAME OR INITIALS FROM I5A}? (In a previous call to this number, they were selected to help participate in the survey)

WAIT FOR R TO COME TO PHONE, REPEAT INTRODUCTION]

If you have any concerns about the study, I’d be happy to address them.

ADDRESS CONCERNS USING FAQs

[IF SCREENER_PART NE S, We need to speak briefly with an adult household member to find out if anyone in your household is eligible to participate.]

[IF SCREENER_PART NE S & SAMPLETYPE=TS (MAIN SAMPLE): If someone in your household is eligible and completes a full survey, we’ll send that person a $20 gift card *or* a $20 check (whichever he or she chooses), as a token of our appreciation.]

1 CONTINUE FROM POINT OF BREAKOFF

2 R UNAVAILABLE, SET CALLBACK

6 STILL REFUSES TO PARTICIPATE

[IF REFUSAL_SCRIPT=1 & SCREENER_PART NE S, GO TO CELL1; IF REFUSAL_SCRIPT=1 & (SCREENER_PART =S & ATSSRCONSENT=0) GO TO INT6; IF REFUSAL_SCRIPT=1 & ATSSRCONSENT=1, LAUNCH HATTERAS FROM POINT OF PRIOR BREAKOFF; IF REFUSAL_SCRIPT=2, SET CALL BACK; IF REFUSAL_SCRIPT=6 END AND CODE AS REFUSAL]

INT_START_A. [SHOWS WHEN A SCREENING HAS ALREADY BEEN COMPLETED (SCREENER_PART = S) AND A CASE IS BEING CALLED BACK TO COMPLETE AN INTERVIEW, e.g. INT5A has name entered]

INTERVIEWER {FILL NAME OF RESPONDENT: INT5A} IS THE SELECTED RESPONDENT

SAY IF NOT ALREADY MENTIONED: (Hello, my name is {name}.)

We recently spoke with someone in your household about a research study we are conducting on behalf of the Centers for Disease Control and Prevention and their contractor, RTI International.

May I speak with {FILL NAME OF RESPONDENT FROM INT5A}?

FOR REFUSALS BREAKOFF AND CODE AS SUCH

1. YES, R COMES TO PHONE

2. NO, BUT CB LATER

3. KNOWS R, BUT WRONG # FOR R

4. DOES NOT KNOW R

[IF INT_START_A=1 (YES) & ATSSRCONSENT=0 GO TO REINTRO2; ELSE IF ATSSRCONSENT=1, GO TO INT_START_B]

[IF INSTART_A=2 (NO, CB LATER), GO TO APPOINTMENT SCHEDULING SCREENS]

[IF INSTART_A=3 (WRONG NUMBER FOR R), GO TO PHONEUPDATE]

[IF INSTART_A=4 (DO NOT KNOW R), GO TO ADDCONF]

INT_START_B. SAY ONLY IF NEEDED, “We recently spoke with you about a research study we are conducting on behalf of the Centers for Disease Control and Prevention and their contractor, RTI International.”

Would now be a good time to continue the survey with you?

1. YES

2. NO, BUT CB LATER

6 REFUSED

[IF INT_START_B=1, LAUNCH HATTERAS AT BREAKOFF; IF INT_START_B=2, SET CALL BACK; IF INT_START_B=3, GOTO REF_CTG]

PHONEUPDATE. Is there a better telephone number for us to call to reach {FILL NAME OF RESPONDENT: INT5A}?

1. NEW CONTACT INFO PROVIDED

2. NO NEW NUMBER PROVIDED

6. REFUSED

[IF PHONEUPDATE=1, CODE OUT ROSTER LINE AS 1272 (BAD NUMBER) AND ADD NEW ROSTER LINE NUMBER; IF PHONEUPDATE=2 AND IF NUMBER DIALED NE SAMPLEFILE:PHONE CODE OUT ROSTER LINE AS 1272 (BAD NUMBER); IF PHONUPDATE=6 GO TO REF_CTG; ELSE END CALL, GO TO PROBLOG AND CODE 1579]

**ADDCONF is only asked if we are calling back for the selected respondent and the person reached does not know the respondent.**

ADDCONF. Have I reached {fill sampled address; street, unit, and zip code only; no city}?

1. YES

2. NO

3 DON’T KNOW

6 REFUSED

[IF ADDCONF=1, END AND CODE 1579 AND GO TO PROBLOG; IF ADDCONF=2 AND NUMBER DIALED=/=SAMPLEFILE:PHONE END AND CODE OUT ROSTER LINE AS BAD NUMBER; IF ADDCONF=2 AND NUMBER DIALED=SAMPLEFILE:PHONE END AND CODE 1276; IF ADDCONF=3, SET CALL BACK; IF ADDCONF=6 AND NUMBER DIALED=SAMPLEFILE:PHONE, GOTO REF_CTG; IF ADDCONF=6 AND NUMBER DIALED==/=SAMPLEFILE:PHONE END AND CODE OUT ROSTER LINE AS BAD NUMBER]

INT_START_C. [SHOWS WHEN A CASE THAT HAS ALREADY BEEN CONTACTED IS A BUSINESS OR GROUP QUARTERS AND NEEDS TO HAVE ITS ADDRESS VERIFIED (STATUS CODE 1220)]

My notes from a previous call indicate that this is a business or a group quarters unit, such as a dormitory or half-way home. For this call I need to find out if I have reached either a business or group quarters, and I also need to confirm the address for this phone number.

IF NEEDED, SAY: (Have I reached a business or a group quarters unit?)

1. BUSINESS

2. GROUP QUARTERS UNIT

3. PRIVATE RESIDENCE

[IF INT_START_C=1, GO TO BUSIVERIFY; IF INT_START_C=2, GO TO BUSIVERIFY; IF INT_START_C=3, GO TO CELL1]

1201 RING, NO ANSWER

1202 BUSY/ALL CIRCUITS BUSY

1263 OTHER ANSWERING MACHINE

1268 BUSINESS ANSWERING MACHINE

1281 MODEM/FAX

1274 LINE TROUBLE/TEMP DISC

1282 BEEPER/PAGER

1285 PAY PHONE/BLOCKED NUMBER

1273 NONWORKING/DISCONNECTED/NON-PUBLISHED NUMBER/ CALL CANNOT BE COMPLETED AS DIALED

1287 PRIVACY MANAGER

1546 TDD (TELEPHONE DEVICE FOR THE DEAF) OR TTY (SOUNDS LIKE LITTLE BELLS)

9 GO TO FIRST INTRO SCREEN

[IF NC=1268 END AND CODE 1268 ;

IF NC=1287, GO TO PRIVMAN;

IF NC=9 & SCREENER_PART NE S & STATUS NE REFUSAL STATUS, GO TO INTRO_A;

IF NC=9 & (SCREENER_PART = S) & STATUS NE REFUSAL STATUS, GO TO INT_START_A;

IF NC=9 & STATUS = REFUSAL STATUS, GO TO REFUSAL_SCRIPT;

IF NC=1201, END AND CODE 1201;

IF NC=1202, END AND CODE 1202;

IF NC=1281, END AND CODE 1281;

IF NC=1274, END AND CODE 1274;

IF NC=1282, END AND CODE 1282;

IF NC=1285, END AND CODE 1285;

IF NC=1273 END AND CODE 1273;

IF NC=1546, END AND CODE 1546;

IF NC=1263 and CALLCOUNT=1st, 4th, 7th, 10th, 15th ANSPRMPT, ELSE END AND CODE 1262]

OTHER CODES

1 OUT OF THE COUNTRY

2 INSTITUTIONALIZED/INCARCERATED

3 DECEASED

4 LANGUAGE BARRIER

5 REFUSED

6 SET CALLBACK

7 INCAPABALE/INCAPACITATED

8 NO PHONE

9 UNAVAILABLE FOR STUDY DURATION

10 HEARING IMPAIRED

11 OTHER LIVING QUARTERS

13 BUSINESS

[IF OTHER CODES=1, GO TO OUTCOUNTRY;

IF OTHER CODES=2, END AND CODE 1242;

IF OTHER CODES=3, END AND CODE 1550;

IF OTHER CODES=4, GO TO LANG;

IF OTHER CODES=5, GO TO REF_CTG;

IF OTHER CODES=6, SET CALL BACK;

IF OTHER CODES=7, END AND CODE 1554;

IF OTHER CODES=8, END AND CODE 1240;

IF OTHER CODES=9, END AND CODE 1241;

IF OTHER CODES=10, END AND CODE 1546]

**Other living quarters logic**

[IF OTHER CODES=11, THEN (IF INT2=1, END AND CODE AS 1330; IF INT2A=1, END AND CODE AS 1330; ELSE END AND CODE 1220)]

**Business logic**

[IF OTHER CODES=13, THEN (IF INT2=1, END AND CODE AS 1310; IF INT2A=1, END AND CODE AS 1310; ELSE END AND CODE 1220)]

** Programmer Note: The indented statements are part of one full statement with sub-statements. If INT2A=1 then phone number called was associated with sampled address.

If INT2=1 then phone number called was associated with sampled address

OUTCOUNTRY

Will {IF SCREENER_PART=S, FILL “{INT5A}” ELSE FILL “the household member(s)”} move back to the United States before 1/1/14

<1> YES [SET CALLBACK]

<2> NO [END AND CODE 1243/2243]

BUSIVERIFY

SAY, IF NEEDED: (Thank you, but this survey is for residential households. However, before I go, may I ask….)

Is the address for this phone number {fill sampled address; street, unit, and zip code only; no city}?

1. YES

2. NO

[IF BUSIVERIFY=1 & INTRO=2, END AND CODE AS 2310; IF BUSIVERIFY=1 & INT_START_C=1, END AND CODE AS 2310; IF BUSIVERIFY=1 & INT_START_C=2, END AND CODE AS 2330; IF BUSIVERIFY=1 & INTRO=3, END AND CODE AS 2330; IF BUSIVERIFY =2, IF NUMBER DIALED=SAMPLEFILE: PHONE, CODE EVENT AS MISMATCHED: 1276 AND CODE STATUS AS 1909, ELSE CODE OUT ROSTER LINE AS BAD NUMBER 1272

PROBLOG

RECORD A PROBLEM SHEET FOR CASE AND PLACE CASE INTO SUPERVISOR QUEUE FOR REVIEW

Consent Script

A copy of the phone-administered consent is also provided as Attachment 6B

CONSENT1. IF RESPONDENT INTERRUPTS, YOU MAY SAY: Before we can continue, I need to read this entire statement word for word.

RTI International, a nonprofit research group, is doing a study on health issues in your area under contract for the Centers for Disease Control and Prevention. The 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 this study. About 23,000 people will take this survey this year. In order to evaluate my performance, my supervisor may record and listen as I ask you questions.

[SELECT 1 TO CONTINUE]

CONSENT2. You can choose to take part 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. There are no direct benefits to you for being in this study. But your answers to the survey will help us to understand what can be done to improve people’s health in communities like yours.

The interview will take about 28 minutes. There is very low risk to participation. We will just ask you questions over the telephone. You don’t have to answer any question you don’t want to answer and you can stop the interview at any time.

Your answers are protected and private. And the results of the survey will only be reported for groups of people. No one will be able to identify you or your answers by looking at the results of the study.

[SELECT 1 TO CONTINUE]

CONSENT3. After you complete the interview, I’ll ask you for your full name and your current address so that we can send you your choice of a $20 check or a $20 gift card to Walmart as a thank-you for your help.

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.

[SELECT 1 TO CONTINUE]

CONSENT4. I’m now going to tell you how to contact our survey manager and the committee that makes sure the study is conducted in an ethical way. You may want to write this down in case you have questions later about the study or the rights you have for being part of the study.

If you have 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.

Being part of this study gives you certain rights. If you have questions about your rights or if you feel you may have been harmed by being in this study, please contact the Office of Research Protection which oversees this study. It is located at RTI International and can be reached by calling this toll-free number: 1-866-214-2043.

[SELECT 1 TO CONTINUE]

CONSENT5. If you have any questions or you’d like me to repeat any of this information, please let me know.

*PAUSE* BEFORE CONTINUING, TO ENSURE FULL OPPORTUNITY TO ASK AND ANSWER QUESTIONS USING FAQs

IF NO OBJECTIONS, CONTINUE WITH INTERVIEW, OTHERWISE IF RESPONDENT REFUSES TO PARTICIPATE BREAKOFF AND CODE AS REFUSAL.

[SELECT 1 TO CONTINUE]

[SET ATSSRCONSENT=1;

IF PHONETYPE=M, GO TO Consent_cell; ELSE CALL ATSS HATTERAS INSTRUMENT]

{PRESENT IF PHONETYPE=M}

Consent_cell. Before we begin, I want to make sure this is a good time for you to talk and that you are in a safe and private place to use your cell phone. If at any point you want to go to another room or if you want to use a different phone where I could call you back, just let me know.

1 CONTINUE— [CALL ATSS HATTERAS INSTRUMENT]

2 CALL ALTERNATE NUMBER {GO TO ALTNUM}

ALTNUM. What number would you like me to use to call you back?

PRESS BREAK, ENTER NEW ROSTER LINE WITH ALTERNATIVE NUMBER, THEN CALL BACK.

BREAKOFF

BREAKOFF OPTIONS

1 SET CALLBACK

2 HUNG UP OR PERSON REFUSED TO CONTINUE

3 LANGUAGE BARRIER

4 ALREADY COMPLETED PAPER SURVEY

5 CHILD/MINOR’S NUMBER - BELONGS TO NON-ADULT

7 NUMBER NOT CONNECTED TO ADDRESS

8 RETURN TO MAIN MENU

9 OTHER CODES

[IF BREAKOFF=1, SET CALLBACK; IF BREAKOFF=2, Go To REF_CTG; IF BREAKOFF=3, Go To LANG; IF BREAKOFF=4, & YABSQUOTA for Caller’s AwardeeID =1, GO TO YABSLATE;

IF BREAKOFF=, 4 & YABSQUOTA for Caller’s AwardeeID =0, GO TO YABSTRANSITION; IF BREAKOFF=5, END AND CODE 1277; IF BREAKOFF=7, GO TO THANK_EVT]

YABSTRANSITION

Thank you for your participation in this very important survey. You may be eligible to participate in another part of the study. I would like to tell you more about that part of the study and ask you some questions.

1 CONTINUE— [GO TO B1 (CALL-IN SPECS)]

**YABSLATE is only shown if a caller volunteers that s/he already completed the paper survey and in-home visits are not/no longer being conducted in his or her community.**

YABSLATE

Thank you for completing the survey already. Once RTI International has received your completed survey booklet, we will send your choice of $20 gift card or check. You should receive it in an envelope with a blue RTI logo in about 3 to 7 weeks from the time you mailed it.

If you have any questions about the study you can contact our survey manager, toll-free, at 1-800-844-8959. Thank you and have a good day/evening.

[END AND CODE 1289, ATSS PENDING – NO YABS]

REF_CTG

WAS THIS A REFUSAL BY AN *ADULT* WHO HAS HEARD THE NAME OF THE STUDY’S *SPONSOR* AND ABOUT THE *PURPOSE* OF THE STUDY?

<1> YES

<2> NO

[IF REF_CTG=1, GO TO WHO_REF; ELSE GO TO REF_STRONG

WHO_REF

INTERVIEWER: WAS THE REFUSAL BY THE SELECTED ADULT

<1> YES

<2> NO

<9> DON'T KNOW

REF_STRONG

STRENGTH OF REFUSAL OR COMMENT BEFORE HANG UP

<1> MILD

<2> FIRM

<3> HOSTILE

REF

DESCRIBE WHAT HAPPENED DURING THE CONTACT (ENTER ALL THAT APPLY) PRESS NEXT TO CONTINUE

<1> TOO BUSY NO TIME

<2> NOT INTERESTED

<3> DOES NOT DO SURVEYS

<4> TOPIC OF THE SURVEY

<5> SALES/MARKING CALL

<6> ON DO-NOT-CALL LIST

<7> GOVERNMENT INTRUDING ON PRIVACY

<8> CELL PHONE/PAY FOR MINUTES

<9> ASKED HOW WE GOT THIS NUMBER

<10> ASKED NOT TO CALL ANY MORE

<11> ASKED ABOUT PURPOSE OF STUDY

<12> ASKED ABOUT SPONSOR OF STUDY

<13> ASKED ABOUT SURVEY LENGTH

<15> RAISED VOICE/USED SWEAR WORDS

<16> HUNG UP

<17> HOME VISIT REFUSED

<18> OTHER SPECIFY

[IF REF_CTG NE 1, GO TO HUNGUP1;

IF REF_CTG=1 & REF=17, GO TO WHY_REF_CMS;

IF REF_STRONG=3 & REF NE 17, END AND CODE 1401 (Refusal – Hostile);

IF REF=15 & REF NE 17, END AND CODE 1401 (Refusal – Hostile);

IF REF_CTG=1 & WHO_REF=1 & REF=8 & REF_STRONG NE 3 & REF NE 15 & REF NE 17, END AND CODE 1433 (Refusal – Cell Phone – By Subject);

IF REF_CTG=1 & WHO_REF NE 1 & REF=8 & REF_STRONG NE 3 & REF NE 15 & REF NE 17, END AND CODE 1434 (Refusal – Cell Phone –By Other);

IF REF_CTG=1 & WHO_REF=2 & REF_STRONG NE 3 & REF NE 15 & REF NE 17 & REF NE 8, END AND CODE 1430 (Refusal by Other);

IF REF_CTG=1 & WHO_REF=1 & REF_STRONG=2 & REF NE 15 & REF NE 17 & REF NE 8, END AND CODE 1405 (Hard Refusal by Subject);

IF REF_CTG=1 & WHO_REF=1 & REF_STRONG=1 & REF NE 15 & REF NE 17 & REF NE 8, END AND CODE 1410 (Soft Refusal by Subject);

ELSE END AND CODE 1441 (REFUSAL)]

HUNGUP1

DESCRIBE WHEN THE HANG UP OCCURRED. PRESS NEXT TO CONTINUE

<1> HUNG UP BEFORE THE INTRODUCTION.

<2> HUNG UP DURING THE INTRODUCTION SCRIPT.

[IF REF_STRONG=3 OR REF=15, END AND CODE 1401 (Refusal – Hostile), ELSE {IF HUNGUP1=1, END AND CODE 1206 (Hung Up Before Introduction); IF HUNGUP1=2, END AND CODE 1208 (Subject Hung Up During Introduction)}]

WHY_REF_CMS

PLEASE SELECT THE REASON(S) GIVEN FOR REFUSING PARTICIPATION DUE TO THE IN-HOME VISIT:

<1> DON'T WANT SOMEONE COMING TO HOUSE.

<2> INCENTIVE IS NOT ENOUGH FOR INCONVENIENCE

<3> A SPECIFIC BIOMETRIC MEASUREMENT FEELS TOO INTRUSIVE

<4> LENGTH OF VISIT

<5> DON'T WANT CHILD TO BE MEASURED

<6> OTHER SPECIFY

<9> DON’T KNOW

[ALLOW MULTIPLE SELECTIONS]

[IF REF_STRONG=3, END AND CODE 1401 (Refusal – Hostile);

IF REF=15, END AND CODE 1401 (Refusal – Hostile);

IF REF_CTG=1 & WHO_REF=1 & REF=8 & REF_STRONG NE 3 & REF NE 15, END AND CODE 1433 (Refusal – Cell Phone – By Subject);

IF REF_CTG=1 & WHO_REF NE 1 & REF=8 & REF_STRONG NE 3 & REF NE 15, END AND CODE 1434 (Refusal – Cell Phone –By Other);

IF REF_CTG=1 & WHO_REF=2 & REF_STRONG NE 3 & REF NE 15 & REF NE 8, END AND CODE 1430 (Refusal by Other);

IF REF_CTG=1 & WHO_REF=1 & REF_STRONG=2 & REF NE 15 & REF NE 8, END AND CODE 1405 (Hard Refusal by Subject);

IF REF_CTG=1 & WHO_REF=1 & REF_STRONG=1 & REF NE 15 & REF NE 8, END AND CODE 1410 (Soft Refusal by Subject);

ELSE END AND CODE 1441 (REFUSAL)]

-END-

HATTERAS TO CATI-CMS EVENTS

If a 1579 is returned to CATI from Hatteras, it should get the code 1579 in CATI and sent to Supervisor review. And it should launch symphony automatically to enter the problem sheet

VARIABLE VALUES TO PASS FROM CATI-CMS TO HATTERAS ATSS (BACK-END)

INT5A
KIDS

VARIABLE VALUES TO PASS FROM CATI-CMS TO NIRVANA

ALTNUM
SCREENED [IF INT5A= NON-BLANK, SET SCREENER_PART = S]
ATSSRCONSENT [IF CONSENT4=1, SET ATSSRCONSENT=1]

Telephone Interview

[INTERVIEWER SHOULD ONLY READ STATEMENTS IN lower case.]

[INSTRUCTIONS TO INTERVIEWERS ARE IN UPPER CASE]

IF B5=1, SET TIMESTAMP: BACKENDBEGIN & go to INTRO_YABS

IF B5=2, 5, or 6, SET TIMESTAMP: BACKENDBEGIN & go to INTRO_ABS

[HARD CHECK FOR ANSWER ENTRY UNLESS OTHERWISE SPECIFIED:

PLEASE RECORD THE RESPONDENT’S ANSWER.

IF THE RESPONDENT SAID DON’T KNOW, PRESS THE “ALT” AND “1” KEYS TOGETHER (ALT+1)

IF THE RESPONDENT REFUSED TO ANSWER, PRESS THE “ALT” AND “2” KEYS TOGETHER (ALT+2)]

[SCREENS WITH MULTIPLE ENTRY FIELDS CANNOT ALLOW ONE FIELD TO BE DK AND THE OTHER FIELD TO BE REF]

[set INDICATOR version = 1]

[INTRODUCTION]

Intro. I’d like to start by finding out about you and the people in your household.

[SET TIMESTAMP: ATSSCOREBEGIN_DT]

{SELECT NEXT}

INTRO_1. What is your age?

_ _ {RANGE 0 – 99}

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[ASK INTRO_1_CONF IF (INTRO_1<18 and NE DK/RF), IF DK/RF GO TO INTRO_1a; ELSE GO TO INTRO_2]

INTRO_1_CONF. IN A NEUTRAL TONE, ASK: You said that you were {fill number from INTRO_1 } years old, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if no, DK or RF, go back TO INTRO_1, IF YES go to age_inelig]

INTRO_1a. (What is your age,) are you….

if needed, say: (A person’s age is one of the most important factors influencing health. While you do not need to tell us your exact age, knowing your age within a certain range will be critical for our study.)

INTERVIEWER INSTRUCTION: PROBE For AGE ONLY READing AS MANY RESPONSE OPTIONS AS NECESSARY

1. younger than 18

2. between 18 and 24

3. between 25 and 34

4. between 35 and 44

5. between 45 and 54

6. between 55 and 64

7. older than 65

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if INTRO_1a=1, go to age_inelig; if intro_1a = DK or RF go to DEMrefused; else go to INTRO_2]

Age_inelig. Unfortunately this survey can only be administered to an adult resident of the household who is 18 years or older. Those are all the questions that I have for you today. Thank you.

END INTERVIEW AND SUBMIT A PROBLEM SHEET

[END survey, set STATUS to 1579, AND PLACE IN SUPERVISOR REVIEW QUEUE]

DEMrefused. Thank you for your participation. We understand that you do not wish to answer the previous question. Unfortunately, factors such as age are so important to understanding health and health care outcomes that we are unable to continue with the survey at this time. However, …..

1 – CONTINUE

[GO TO INCENTIVE]

INTRO_2 INTERVIEWER INDICATE sex of respondent. ask only if necessary.

if necessary, say: (For survey purposes, I need to confirm, are you male or female?)

if unable to determine gender and respondent will not answer question, please record your best guess and log a problem sheet for this case

1 MALE
2 FEMALE

[DISABLE DK/RF]

INTRO_3 Are you currently ….?

IF NEEDED, SAY: (Please choose the category that describes your current situation the best.)

1 Married
2 Divorced
3 Widowed
4 Separated
5 Never married, or

6 A member of an unmarried couple

-1 DON’T KNOW
-2 REFUSED

INTRO_4 How many children less than 18 years of age live in your household?

_ _ Number of children {range 0 – 20}

-1 DON’T KNOW
-2 REFUSED

INTRO_5. What is the highest grade or year of school you completed?

Read only if necessary:

1 Never attended school or only attended kindergarten

2 Grades 1 through 8 (Elementary)

3 Grades 9 through 11 (Some high school)

4 Grade 12 or GED (High school graduate)

5 College 1 year to 3 years (Some college or technical school)

6 College 4 years or more (College graduate)

-1 DON’T KNOW / NOT SURE

-2 REFUSED

D_01. Are you Hispanic or Latino?

1 YES
2 NO
-1 DON’T KNOW / NOT SURE
-2 REFUSED

D_02. What is your race? I am going to read a list. You can select one or more options from the list. Do you consider yourself…

RECORD ALL ANSWERS GIVEN BY RESPONDENT, BUT DO NOT PROBE FURTHER. OPTION #6, “OTHER,” MAY BE USED AS A RECORDING OPTION FOR NON-CONFORMING RESPONSES. OPTION #6 SHOULD NOT BE PRESENTED AS A RESPONSE OPTION.

{ONE OR MORE CATEGORIES MAY BE SELECTED}

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Other Pacific Islander

6. OTHER

7. DON’T KNOW/NOT SURE

8. REFUSED.

INTRO_6. Are you currently….?

IF NEEDED, SAY: (Which one of these would you say is your main status now?)

1 Employed for wages
2 Self-employed
3 Out of work for more than 1 year
4 Out of work for less than 1 year
5 A Homemaker
6 A Student
7 Retired

8 Unable to work

-1 DON’T KNOW

-2 REFUSED

[SET TIMESTAMP: INTROEND_DT]

[PHYSICAL ACTIVITY]

P_INTRO. Now, I am going to ask you a few questions about your physical activity habits. For these questions, think about the exercise, recreation, or physical activities you perform{TEXT FILL IF INTRO_6=1, 2 (EMPLOYED) “, other than your regular job duties.”}

[SET TIMESTAMP: PABEGIN_DT]

{SELECT NEXT}

PA00. During the past month, {TEXT FILL IF INTRO_6=1, 2 (EMPLOYED) “, other than your regular job,”} did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

1 YES

2 NO {GO TO PA04}

-1 DON’T KNOW {GO TO PA04}
-2 REFUSED {GO TO PA04}

PA01. What type of physical activity or exercise did you spend the most time doing during the past month?

If the respondent’s activity is not included in the Coding List, choose the option listed as “Other “.

Housework may be included as a physical activity or exercise spent and can be coded as “Other”.

01 ACTIVE GAMING DEVICES (WII FIT, DANCE DANCE REVOLUTION)

02 AEROBICS VIDEO OR CLASS

03 BACKPACKING

04 BADMINTON

05 BASKETBALL

06 BICYCLING MACHINE EXERCISE

07 BICYCLING

08 BOATING (CANOEING, ROWING, KAYAKING, SAILING FOR PLEASURE OR CAMPING)

09 BOWLING

10 BOXING

11 CALISTHENICS

12 CANOEING/ROWING IN COMPETITION

13 CARPENTRY

14 DANCING-BALLET, BALLROOM, LATIN, HIP HOP, ETC

15 ELLIPTICAL/EFX MACHINE EXERCISE

16 FISHING FROM RIVER BANK OR BOAT

17 FRISBEE

18 GARDENING (SPADING, WEEDING, DIGGING, FILLING)

19 GOLF (WITH MOTORIZED CART)

20 GOLF (WITHOUT MOTORIZED CART)

21 HANDBALL

22 HIKING – CROSS-COUNTRY

23 HOCKEY

24 HORSEBACK RIDING

25 HUNTING LARGE GAME – DEER, ELK

26 HUNTING SMALL GAME – QUAIL

27 INLINE SKATING

28 JOGGING

29 LACROSSE

30 MOUNTAIN CLIMBING

31 MOWING LAWN

32 PADDLEBALL

33 PAINTING/PAPERING HOUSE

34 PILATES

35 RACQUETBALL

36 RAKING LAWN

37 RUNNING

38 ROCK CLIMBING

39 ROPE SKIPPING

40 ROWING MACHINE EXERCISE

41 RUGBY

42 SCUBA DIVING

43 SKATEBOARDING

44 SKATING – ICE OR ROLLER

45 SLEDDING, TOBOGGANING

46 SNORKELING

47 SNOW BLOWING

48 SNOW SHOVELING BY HAND

49 SNOW SKIING

50 SNOWSHOEING

51 SOCCER

52 SOFTBALL/BASEBALL

53 SQUASH

54 STAIR CLIMBING/STAIR MASTER

55 STREAM FISHING IN WADERS

56 SURFING

57 SWIMMING

58 SWIMMING IN LAPS

59 TABLE TENNIS

60 TAI CHI

61 TENNIS

62 TOUCH FOOTBALL

63 VOLLEYBALL

64 WALKING

66 WATERSKIING

67 WEIGHT LIFTING

68 WRESTLING

69 YOGA

70 OTHER

-1 DON’T KNOW / NOT SURE [GO TO PA04]
-2 REFUSED [GO TO PA04]

[IF PA01=70, PRESENT PA01_OTH; ELSE GO TO PA02]

PAO1_OTH. PLEASE SPECIFY “OTHER” _____________ [ACCEPT UP TO 500 CHARACTERS]

PA02. How many times per week or per month did you take part in this activity during the past month?

IF NEEDED, ASK: “Is that __ times per week or __ times per month?”

Number of Times ____ {0-90}

1 per week

2 per month

Never
-1 DON’T KNOW / NOT SURE
-2 REFUSED

{HARD CHECK TEXT TO SHOW WHEN TRIES TO PROCEED WITH BLANKS: BOTH NUMBER OF TIMES AND UNIT (WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF}

{HARD CHECK TEXT FOR OUT OF RANGE ANSWERS: “PLEASE ENTER A WHOLE NUMBER BETWEEN 0 AND 90. YOU MUST CORRECT THIS PROBLEM BEFORE YOU CONTINUE.”}

[ASK PA02_CONF IF (Times per week > 5) OR (Times per month >15). DO NOT ASK pa02_CONF IF PA02 EQ DK/RF]

PA02_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from PA02} times per {fill unit from PA02}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF YES OR RF, CONTINUE; IF NO OR DK , GO BACK]

pa03. And when you took part in this activity, for how many minutes or hours did you usually keep at it?

IF NEEDED, ASK: “Is that ___ hours or __ minutes?”

IF ANSWERS WITH JUST ONE UNIT, THEN ENTER 0 FOR THE OTHER UNIT }

HELP POP-UP

IF RESPONDENT SAYS RECORD

QUARTER OF AN HOUR 0 HOURS 15 MINUTES

HALF OF AN HOUR 0 HOURS 30 MINUTES

THREE QUARTERS OF AN HOUR 0 HOURS 45 MINUTES

AN HOUR AND A QUARTER 1 HOURS 15 MINUTES

AN HOUR AND A HALF 1 HOURS 30 MINUTES

AN HOUR AND THREE QUARTERS 1 HOURS 45 MINUTES

…

_ _ Hours {RANGE 0 – 23}

_ _ minutes {RANGE 0 – 60}
-1 DON’T KNOW / NOT SURE
-2 REFUSED

{ALLOW ENTRIES IN BOTH HOURS AND/OR MINUTES}

{HARD CHECK TEXT FOR HOURS: PLEASE MAKE SURE THAT YOU HAVE ENTERED A WHOLE NUMBER IN THE TEXT FIELD FOR HOURS THAT IS LESS THAN 24.}

{HARD CHECK TEXT FOR MINUTES: PLEASE MAKE SURE THAT YOU HAVE ENTERED A WHOLE NUMBER IN THE TEXT FIELD FOR MINUTES THAT IS LESS THAN 60.. }

[ASK PA03_CONF IF (PA03 SUM OF hours AND (MINUTES/60)>=2 hours). DO NOT ASK PA03_CONF IF PA03 EQ DK/RF in any data entry point]

PA03_CONF. IN A NEUTRAL TONE, ASK: You said {FILL HOURS NUMBER FROM PA03} hours and {FILL MINUTES NUMBER FROM PA03}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF YES OR RF, CONTINUE; IF NO OR DK , GO BACK]

pa05. 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 for exercise.

0. None {go to pa04}

1. _1 day

2. _2 days

3. _3 days

4. _4 days

5. _5 days

6. _6 days

7. _7 days

-1__DON’T KNOW/NOT SURE

-2__REFUSED

pa05a [SKIP IF PA05=0]. What is the main reason that you walk or bicycle? Is it for leisure, transportation or exercise?

__1. LEISURE

__2. TRANSPORTATION

__3. EXERCISE

__-1. DON’T KNOW/NOT SURE

__-2. REFUSED

pa04. Now, I would like to talk about your neighborhood as a place for walking and cycling.

In thinking about the neighborhood where you live as a place to walk and bicycle, please tell me if you strongly agree, somewhat agree, somewhat disagree or strongly disagree with the following statements.

{SELECT NEXT}

pa04a. There are sidewalks on most of the streets in my neighborhood. Would you say….

1 Strongly agree

2 Somewhat agree

3 Somewhat disagree

4 Strongly disagree

5 THERE ARE NO SIDEWALKS IN MY NEIGHBORHOOD

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if Pa04a=5 (no Sidewalks in neighborhood), then skip to PA04c]

pa04b. Most of the sidewalks in my neighborhood are well maintained (paved, even, and not a lot of cracks). Would you say….

1 Strongly agree

2 Somewhat agree

3 Somewhat disagree

4 Strongly disagree

5 THERE ARE NO SIDEWALKS IN MY NEIGHBORHOOD

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if Pa04a=5 or PA04b=5 (no Sidewalks in neighborhood), then skip to PA04c]

pa04d. When I am walking on a sidewalk in my neighborhood, there are parked cars between me and the road. (Would you say….

READ OPTIONS IF NEEDED

1 STRONGLY AGREE

2 SOMEWHAT AGREE

3 SOMEWHAT DISAGREE

4 STRONGLY DISAGREE

5 THERE ARE NO SIDEWALKS IN MY NEIGHBORHOOD

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[if Pa04a=5 or PA04b=5 or pa04d=5 (no Sidewalks in neighborhood), then skip to PA04c]

PA04e. There is a grass or dirt strip that separates the streets from the sidewalks in my neighborhood. (Would you say….

READ OPTIONS IF NEEDED

1 STRONGLY AGREE

2 SOMEWHAT AGREE

3 SOMEWHAT DISAGREE

4 STRONGLY DISAGREE

5 THERE ARE NO SIDEWALKS IN MY NEIGHBORHOOD

-1 DON’T KNOW / NOT SURE
-2 REFUSED

pa04c. There are bicycle or pedestrian trails in or near my neighborhood that are easy to get to. (Would you say….

READ OPTIONS IF NEEDED

1 STRONGLY AGREE

2 SOMEWHAT AGREE

3 SOMEWHAT DISAGREE

4 STRONGLY DISAGREE

-1 DON’T KNOW / NOT SURE
-2 REFUSED

pa06. Besides what you already told me about the sidewalks and trails in your neighborhood, why don’t you walk or cycle more often in your neighborhood?

ACCEPT ALL ANSWERS AND PROBE UNTIL R INDICATES NO OTHERS APPLY: Any others?

{ALLOW MULTIPLE RESPONSES}

1 Weather
2 Lack of time
3 Nowhere to go
4 No sidewalks
5 Too much traffic
6 Medical conditions
7 Lack of energy / motivation
8 Exercise elsewhere
9 Safety (crime)

10 I WALK OR CYCLE AS MUCH AS I WANT TO
11 Other
12 Don't know / Not sure
13 REFUSED

[SET TIMESTAMP: PABEND_DT]

[NUTRITION]

[SET TIMESTAMP: NBEGIN_DT]

N_INTRO. Now I’d like to ask you about foods and drinks you have recently eaten.

Let’s start by talking about the fruits and vegetables you ate or drank 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 ate or drank each one: for example, once a day, twice a week, three times a month, and so forth.

Keep in mind that there are no right or wrong answers. We want to know what you ate in the past 30 days. Your best estimates are fine.

{SELECT NEXT}

N_05. During the past month, that is since { FILL IN DATE 30 DAYS AGO: MONTH DAY, YEAR }, 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 respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If says less than once per month, SELECT NEVER.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Fruit drinks are sweetened beverages that often contain some fruit juice or flavoring.)

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC DRINK, SAY YES IF IT IS ON THE ‘DO INCLUDE’ LIST AND NO IF IT IS ON THE ‘DO NOT INCLUDE’ LIST. IF THE SPECIFIC DRINK IS NOT IN ANY LIST, RE-READ QUESTION.

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

Do Include Do not Include

Shape4

Sweetened Fruit Drinks mixed with Alcohol 100% Fruit Juice Energy drinks

Coffee Drinks Sports drinks

Sweet Tea

NUMBER OF TIMES ____ {RANGE 0 – 999}

1 per day
2 per week
3 per month
4 never
-1 DON’T KNOW / NOT SURE
-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_05_CONF. IF (Times per day > 5) OR (times per week>35) or (Times per month >150). DO NOT ASK n_05_CONF IF N_05 EQ DK/RF in any data entry point.]

N_05_CONF. IN A NEUTRAL TONE, ASK: You said you drink sweetened fruit drinks {fill number from N_05} times per {fill unit from N_05}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF YES OR RF, CONTINUE; IF NO OR DK , GO BACK]

N_01. During the past month, (that is since { FILL IN DATE 30 DAYS AGO: MONTH DAY, YEAR },) how many times per day, week or month 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 respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If says less than once per month, SELECT NEVER.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Only include 100% Pure Fruit Juices, 100% Pure Juice from Concentrate and 100% Juice Blends. Do not include Vegetable Juices or Fruit Juices with added sugar. )

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

Do Include Do not Include

Shape6

Apple Grape Cranberry Cocktail Gatorade

Grapefruit Mango Fruitopia Hi-C

Orange-Pineapple Orange-Tangerine Kool-Aid Lemonade

Papaya Pineapple Power-Ade Snapple

Sunny Delight Tampico

V8 Yogurt Drinks

NUMBER OF TIMES ____ {RANGE 0 – 999}

1 Per day
2 Per week
3 Per month
4 never
-1 DON’T KNOW / NOT SURE
-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_01_CONF. IF (Times per day > 5) OR (times per week>35) or (Times per month >150). DO NOT ASK N_01_CONF IF n_01 EQ DK/RF in any data entry point.]

N_01_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_01} times per {fill unit from N_01}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF YES OR RF, CONTINUE; IF NO OR DK , GO BACK]

N_02. During the past month,(that is since [FILL IN DATE 30 DAYS AGO: MONTH DAY, YEAR],) not counting juice or sweetened fruit drinks, how many times per day, week, or month did you eat fruit, including fresh, frozen, or canned fruit?

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If says less than once per month, SELECT NEVER.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Include cut up fresh, frozen, or canned fruit. Do not include dried fruit in ready-to-eat cereals. Do not include fruit jams and similar products. )

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC FOOD, SAY YES IF IT IS ON THE ‘DO INCLUDE’ LIST AND NO IF IT IS ON THE ‘DO NOT INCLUDE’ LIST. IF THE SPECIFIC FOOD IS NOT IN ANY LIST, RE-READ QUESTION.

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

Do Include Do not Include

Shape8

Apples Applesauce Akee Fruit Jam Jelly

Bananas Blueberries Bread Fruit Fruit added to Cereal

Cantaloupe Carambola Figs Fruit added to Jell-o

Genip Grape fruit Grapes Fruit added to Yogurt

Fruit salad Longans Lychees Fruit Preserves

Mangos Musk Melon Oranges

Papaya Pomegranates Rambutan

Sea Grapes Soursop Star Fruit

Strawberries Sugar Apple Tamarind

Watermelon

NUMBER OF TIMES ____ {RANGE 0 – 999}

1 Per day
2 Per week
3 Per month

4 never
-1 DON’T KNOW / NOT SURE
-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_02_CONF. IF (Times per day > 8) OR (times per week>56) or (Times per month >240). DO NOT ASK n_02_CONF IS n_02 EQ DK/RF in any data entry point.]

N_02_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_02} times per {fill unit from N_02}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF YES OR RF, CONTINUE; IF NO OR DK , GO BACK]

N_13 During the past month, (that is since [FILL IN DATE 30 DAYS AGO: MONTH DAY, YEAR]) how many times per day, week, or month did you eat cooked or canned beans, such as refried, baked, black, garbanzo beans, beans in soup, soybeans, edamame, tofu or lentils. Do not include long green beans.

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If respondent responds less than once per month, SELECT NEVER.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Include round or oval beans, soybeans, and bean burgers. Do not include long green beans. )

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

Do Include Do not Include

Shape10

Black-eyed Peas Cow Peas Broad Beans Pole Beans

Edamame Falafel String Beans Winged Beans

Garden Burgers Hummus

Lentils Lima beans

Kidney Beans Navy Beans

Pinto Beans Soy Beans

Split Peas Tempeh

Tofu Veggie Burgers

White beans

NUMBER OF TIMES ____ {RANGE 0 – 999}

1 Per day
2 Per week
3 Per month

4 NEVER

-1 DON’T KNOW / NOT SURE

-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_13_CONF. IF (Times per day > 4) OR (times per week>28) or (Times per month >120). DO NOT ASK n_13_CONF IF n_13 EQ DK/RF in any data entry point.]

N_13_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_13} times per {fill unit from N_13}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF YES OR RF, CONTINUE; IF NO OR DK , GO BACK]

N_14 During the past month, (that is since [FILL IN DATE 30 DAYS AGO: MONTH DAY, YEAR],) how many times per day, week, or month did you eat dark green vegetables, for example, broccoli or dark leafy greens including romaine, chard, collard greens or spinach?

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If respondent responds less than once per month, SELECT NEVER.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Include all raw leafy green salads and cooked greens, but do not include iceberg lettuce. )

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

Do Include Do not Include

Shape12

Arugula Bok Choy Iceburg Lettuce

Choys Collard Greens

Dandelions Kale

Komatsuna Mesclun

Mustard Greens Romaine Lettuce

Spinach Turnip greens

Watercress

NUMBER OF TIMES ____ {RANGE 0 – 999}

1 Per day
2 Per week
3 Per month

4 NEVER

-1 DON’T KNOW / NOT SURE

-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_14_CONF. IF (Times per day > 4) OR (times per week>28) or (Times per month >120). DO NOT ASK n_14_CONF IF n_14 EQ DK/RF in any data entry point.]

N_14_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_14} times per {fill unit from N_14}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF YES OR RF, CONTINUE; IF NO OR DK , GO BACK]

N_15 During the past month, (that is since [FILL IN DATE 30 DAYS AGO: MONTH DAY, YEAR],) how many times per day, week, or month did you eat orange-colored vegetables such as sweet potatoes, pumpkin, winter squash, or carrots?

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If respondent responds less than once per month, SELECT NEVER.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Include all forms of carrots and winter squash and all forms of sweet potatoes, including in soups. Also include all forms of pumpkin, but do not include grain-based dessert-type food containing pumpkin. )

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

Do Include Do not Include

Shape14

Acorn Squash Autumn Cup Squash Pumpkin Bars Pumpkin Bread

Baby-cut Carrots Baked Sweet Potato Pumpkin Cake

Banana Squash Buttercup Squash

Butternut Squash Carrot-Slaw

Delicata Squash Hubbard Squash

Kabocha Squash Long Carrots

Mashed Sweet Potato (mashed, casserole, pie)

Pumpkin Pumpkin Soup

Pumpkin Pie Spaghetti Squash

Sweet Potatoes Fries

NUMBER OF TIMES ____ {RANGE 0 – 999}

1 Per day
2 Per week

3 Per month

4 NEVER

-1 DON’T KNOW / NOT SURE

-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_15_CONF. IF (Times per day > 4) OR (times per week>28) or (Times per month >120). DO NOT ASK n_15_CONF IF n_15 EQ DK/RF in any data entry point.]

N_15_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_15} times per {fill unit from N_15}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF YES OR RF, CONTINUE; IF NO OR DK , GO BACK]

N_16 Not counting what you just told me about (beans and dark green or orange-colored vegetables), during the past month, (that is since [FILL IN DATE 30 DAYS AGO: MONTH DAY, YEAR],) about how many times per day, week, or month did you eat other vegetables, such as 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?

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If SAYS less than once per month, SELECT NEVER.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Include any form of vegetable (raw, cooked, canned, or frozen) not listed in the examples above. Do not include products consumed usually as condiments. Do not include rice or other grains.)

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST

Do Include Do NOT Include

Shape16

American-style cole-slaw Avocado Catsup Chutney

Bean Sprouts Beets Fried potatoes Ketchup

Broad Beans Cabbage Relish Salsa

Cauliflower Corn

Cucumber Daikon

Jicama Mushrooms

Okra Onions

Oriental cucumber Peas

Peppers (red, green, yellow, orange)

Pole-beans Snap Peas

Snow Peas String Beans

Tomatoes Tomato Juice

Wax-beans

NUMBER OF TIMES ____ {RANGE 0 – 999}

1 Per day
2 Per week
3 Per month

4 NEVER

-1 DON’T KNOW / NOT SURE

-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_16_CONF. IF (Times per day > 8) OR (times per week>56) or (Times per month >240). DO NOT ASK n_16_CONF IF n_16 EQ DK/RF in any data entry point.]

N_16_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_16} times per {fill unit from N_16}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF YES OR RF, CONTINUE; IF NO OR DK , GO BACK]

N_11 Thinking now about buying, preparing, and eating fruits and vegetables, please say if you strongly agree, somewhat agree, somewhat disagree or strongly disagree with each statement.

{SELECT NEXT}

N_11a There is a wide variety of fruits and vegetables where I shop. (Would you say….

1 Strongly Agree

2 Somewhat Agree

3 Somewhat Disagree

4 Strongly Disagree

-1 DON’T KNOW/NOT SURE

-2 REFUSED

N_11b The fruits and vegetables where I shop are at good prices. (Would you say….

1 Strongly Agree

2 Somewhat Agree

3 Somewhat Disagree

4 Strongly Disagree

-1 DON’T KNOW/NOT SURE

-2 REFUSED

N_11c The fruits and vegetables where I shop are of good quality. (Would you say….

1 Strongly Agree

2 Somewhat Agree

3 Somewhat Disagree

4 Strongly Disagree

-1 DON’T KNOW/NOT SURE

-2 REFUSED

N_11d Fruits and vegetables take too much time to prepare. (Would you say….

READ OPTIONS IF NEEDED

1 STRONGLY AGREE

2 SOMEWHAT AGREE

3 SOMEWHAT DISAGREE

4 STRONGLY DISAGREE

-1 DON’T KNOW/NOT SURE

-2 REFUSED

N_11e I do not like the taste of fruits. (Would you say….

READ OPTIONS IF NEEDED

1 STRONGLY AGREE

2 SOMEWHAT AGREE

3 SOMEWHAT DISAGREE

4 STRONGLY DISAGREE

-1 DON’T KNOW/NOT SURE

-2 REFUSED

N_11f I do not like the taste of vegetables. (Would you say….

READ OPTIONS IF NEEDED

1 STRONGLY AGREE

2 SOMEWHAT AGREE

3 SOMEWHAT DISAGREE

4 STRONGLY DISAGREE

-1 DON’T KNOW/NOT SURE

-2 REFUSED

N_17 Now, let’s talk about non-fruit drinks that you may have recently drunk.

During the past month, (that is since [FILL IN DATE 30 DAYS AGO: month day, year],) how many times per day, week or month did you drink milk as a beverage that was not in coffee and not in cereal. In your answer, please include chocolate milk and hot chocolate.

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If says less than once per month, SELECT NEVER.

IF NEEDED, SAY: (Include all types of milk, including whole milk, 2% milk, soy milk, rice milk, etc)

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

NUMBER OF TIMES ____ {RANGE 0 – 999}

1 Per day
2 Per week
3 Per month

4 NEVER

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_17_CONF. IF (Times per day > 5) OR (times per week>35) or (Times per month >150). DO NOT ASK n_17_CONF IF n_17 EQ DK/RF in any data entry point.]

N_17_CONF. IN A NEUTRAL TONE, ASK: You said you drink milk as a beverage {fill number from N_17} times per {fill unit from N_17}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF YES OR RF, CONTINUE; IF NO OR DK , GO BACK]

N_17a . [SKIP IF N_17 = 0] What kind of milk did you drink most of the time?

IF RESPONDENT INDICATES A FLAVORED MILK, SUCH AS “CHOCOLATE MILK,” PROBE FOR A BEST GUESS THAT FITS ANSWER OPTIONS BEFORE CODING AS OTHER

Read answer options only if necessary:

__ 1. Whole milk

____ 2. 2% fat milk

____ 3. 1% fat milk

____ 4. Skim, nonfat, or ½% fat milk

____ 5. Soy milk

____ 6. Rice milk

___ 7. Raw, unpasteurized milk

____ 8. Other

-1 DON’T KNOW / NOT SURE
-2 REFUSED

N_17b . [SKIP IF N_17 = 0] IF NECESSARY SAY: (Was the [FILL FROM N17a; IF N_17a=DK/RF FILL= “milk”] you drank usually flavored, such as a chocolate, vanilla, strawberry, or other flavored milk?)

if respondent gave a response such as “chocolate milk” in the previous question select yes and continue, else ask question

2 No

-1 DON’T KNOW / NOT SURE
-2 REFUSED

N_04.

During the past 30 days, (that is since [FILL IN DATE 30 DAYS AGO: MONTH DAY, YEAR],) how often did you drink regular soda or pop that contains sugar, not including diet soda or diet pop?

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If says less than once per month, SELECT NEVER.

IF NEEDED, SAY: (Please include regular soda that was mixed with alcohol.)

IF NEEDED, SAY: (We know it may be hard to remember, so your best guess is fine.)

NUMBER OF TIMES ____ {RANGE 0 – 999}

1 per day
2 per week
3 per month

4 NEVER
-1 DON’T KNOW / NOT SURE
-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_04_CONF. IF (Times per day > 5 ) OR (times per week>35) or (Times per month >150). DO NOT ASK n_04_CONF IF n_04 EQ DK/RF in any data entry point.]

N_04_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_04} times per {fill unit from N_04}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF YES OR RF, CONTINUE; IF NO OR DK , GO BACK]

N_03 During the past month, (that is since [FILL IN DATE 30 DAYS AGO: MONTH DAY, YEAR],) how many times per day, week or month, did you drink plain water? Include tap, bottled, and unflavored sparkling water.

If respondent gives a number without a time frame, ask: “Was that per day, per week, or per month?”

If says less than once per month, SELECT NEVER.

IF NEEDED, SAY: (We know it may be hard to remember, so your best estimate is fine.)

HELP POP-UP:

IF NEEDED, SAY: (Include only zero-calorie waters.)

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST

Do Include	Do NOT Include
Bottled water Crystal Light Dasani water Tap water Unflavored sparkling water	Water with calories

NUMBER OF TIMES ____ {RANGE 0 – 999}

1 per day
2 per week
3 per month

4 NEVER
-1 DON’T KNOW / NOT SURE
-2 REFUSED

[HARD CHECK TEXT: BOTH NUMBER OF TIMES AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF]

[ASK N_03_CONF. IF (Times per day > 8) OR (times per week>56) or (Times per month >240). DO NOT ASK n_03_CONF IF n_03 EQ DK/RF in any data entry point.]

N_03_CONF. IN A NEUTRAL TONE, ASK: You said you drink water {fill number from N_03} times per {fill unit from N_03}, is that correct?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF YES OR RF, CONTINUE; IF NO OR DK , GO BACK]

N_08. Now, let’s talk about what foods you keep at home.

How often do you have fruits available at home? This includes fresh, dried, canned and frozen fruits. Would you say . . . ?

1. Always

2. Most of the time

3. Sometimes

4. Rarely or

5. Never

-1 DON’T KNOW/ NOT SURE

-2 REFUSED

N_09. 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. Would you say….?

1. Always

2. Most of the time

3. Sometimes

4. Rarely or

5. Never

-1 DON’T KNOW/ NOT SURE

-2 REFUSED

N_06. 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, grocery stores, or from vending machines? Please do not include meals provided as part of community programs.

IF NEEDED, SAY: (Grocery store ready to eat foods include: salads, soups, chicken, sandwiches and cooked vegetables in salad bars and deli counters.)

IF NEEDED, SAY: (Community program meals include those that are delivered to your home such as “Meals on Wheels” or meals prepared by a senior center, community-kitchen, or faith-related organization.)

____ Number {RANGE 0 – 28}

-1 DON’T KNOW/ NOT SURE
-2 REFUSED

[SOFT EDIT CHECK: DISPLAY A MESSAGE FOR ENTRY LARGER THAN 21: “UNUSUALLY LARGE NUMBER ENTERED – PLEASE VERIFY – “Is this more than 3 meals per day, each day during the past 7 days?”

YES
NO – RETURN TO QUESTION N_06 AND FIX ANSWER

N_07. [skip ONLY if N_06=0] How many of those meals did you get from a fast-food or pizza place?

____ NUMBER {RANGE 0 – 28}

-1 DON’T KNOW/ NOT SURE
-2 REFUSED

[HARD EDIT CHECK: ANSWER TO N_07 MUST BE LESS THAN OR EQUAL TO N_06.]

N_12 Our last question in this section is, are you currently on any kind of diet, either to lose weight or for some other health reason?

1. YES

_ 2. NO

-1 DON’T KNOW/ NOT SURE
-2 REFUSED

N_12a. [SKIP IF N_12=2, -1 or -2] What kind of diet are you on?

ACCEPT ALL ANSWER AND PROBE UNTIL R INDICATES NO OTHERS APPLY: Any others?

[ALLOW MORE THAN ONE ANSWER]

__ 1. Weight loss or low calorie diet

__ 2. Low fat or cholesterol diet

__ 3. Low salt or sodium diet

__ 4. Sugar free or low sugar diet

_ 5. Low fiber diet

__ 6. High fiber diet

__ 7. Diabetic diet

__ 8. Low carbohydrate diet

__ 9. High protein diet

__ 10. Weight gain diet

__ 11. Other

12 DON’T KNOW/ NOT SURE
13 REFUSED

[SET TIMESTAMP: NEND_DT]

[CIGARETTES]

C_INTRO. Now, I’d like to ask you some questions about smoking.

{SELECT NEXT}

[SET TIMESTAMP: CGBEGIN_DT]

CG01. To begin, have you smoked at least 100 cigarettes in your entire life?

IF NEEDED, SAY: (5 packs = 100 cigarettes)

1. Yes

2. No [Go to CG05]

-1 DON’T KNOW / NOT SURE

-2 REFUSED

CG02. Do you now smoke cigarettes every day, some days, or not at all?

1. Every day [Go to CG05]

2. Some days

3. Not at all

-1 - DON’T KNOW / NOT SURE

-2 - REFUSED

CG03. How long has it been since you last smoked a cigarette, even one or two puffs?

READ ANSWER CATEGORIES ONLY IF NEEDED

Within the past month (less than 1 month ago)
Within the past 3 months (1 month but less than 3 months ago)
Within the past 6 months (3 months but less than 6 months ago)
Within the past year (6 months but less than 1 year ago)
Within the past 5 years (1 year but less than 5 years ago)
Within the past 10 years (5 years but less than 10 years ago)

07. 10 years or more

-1. DON’T KNOW / NOT SURE

-2. REFUSED

CG05. Not counting decks, porches, or garages, inside your home, is smoking …?

1. Always allowed

2. Allowed only at some times or in some places

3. Never allowed

4. Family does not have a smoking policy

-1 DON’T KNOW/NOT SURE

-2 REFUSED

CG06. During the past 7 days, that is, since last {TODAY’S DAY OF WEEK},{IF=INTRO_6 = 1,2 FILL=”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?

IF NEEDED, SAY: (Examples of indoor public places are the indoor areas of stores, restaurants, bars, casinos, clubs, and sports arenas.)

____ NUMBER OF DAYS {RANGE 0 – 7}

-1 DON’T KNOW
-2 REFUSED

{HARD CHECK TEXT: CANNOT ENTER MORE THAN 7 AS VALID RESPONSE}

CG07. At workplaces, do you think smoking indoors should be…?

1. Always allowed

2. Allowed only at some times or in some places

3. Never allowed

-1. DON’T KNOW/NOT SURE

-2. REFUSED

CG08. Would you favor a policy that bans smoking in all areas of multi-unit housing, including personal living spaces, such as balconies and patios?

1. YES

2. NO

-1. DON’T KNOW/NOT SURE

-2. REFUSED

[SET TIMESTAMP: CGEND_DT]

[HEALTH]

H_INTRO. Now, I’d like to ask you a few questions about your health and health care.

[SET TIMESTAMP: HBEGIN_DT]

{SELECT NEXT}

H_01. To begin, is there a place that you usually go to when you are sick or need advice about your health?

1 YES

2 THERE IS NO PLACE {GO TO H_01c}

3 THERE IS MORE THAN ONE PLACE

-1. DON’T KNOW/NOT SURE {GO TO H_01c}

-2. REFUSED {GO TO H_01c}

H_01a. {TEXT FILL IF H_01=3, “What kind of place do you go to most often” ELSE “What kind of place”} is it - a clinic, doctor's office, emergency room, or some other place?

1 CLINIC OR HEALTH CENTER

2 DOCTOR'S OFFICE OR HMO

3 HOSPITAL EMERGENCY ROOM

4 HOSPITAL OUTPATIENT DEPARTMENT

5 (SOME) OTHER PLACE

6 DOESN'T GO TO ONE PLACE MOST OFTEN {GO TO H_01c}

-1. DON’T KNOW/NOT SURE {GO TO H_01c}

-2. REFUSED {GO TO H_01c}

[WHEN H1_01a=5, THEN THE FILL FOR H_01B SHOULD BE “place (that you just mentioned)”; ELSE THE FILL SHOULD BE A LOWER CAPS VERSION OF THE OPTION CHOSEN IN H_01A.]

H_01b. Is that {fill: H_01a)} the same place you usually go to when you need routine or preventive care, such as a physical examination or check up?

1 YES {GO TO H_17}

2 NO {GO TO H_01c}

-1. DON’T KNOW/NOT SURE {GO TO H_01c}

-2. REFUSED {GO TO H_01c}

H_01c. What kind of place do you usually go to when you need routine or preventive care, such as a physical examination or check-up?

Read answer options only if necessary:

1 Doesn't get preventive care anywhere

2 Clinic or health center

3 Doctor's office or HMO

4 Hospital emergency room

5 Hospital outpatient department

6 SOME OTHER PLACE

7 DOESN'T GO TO ONE PLACE MOST OFTEN

-1. DON’T KNOW/NOT SURE

-2. REFUSED

{IF H_01=2 (THERE IS NO PLACE USUALLY GOES WHEN SICK) AND H_01c=(1 or 7OR ) (NO USUAL PLACE FOR PREVENTIVE CARE), GO TO H_01d, ELSE GO TO H_17}

H_01d. Why don’t you have a usual source of medical care?

cHOOSE ALL THAT APPLY

ACCEPT ALL ANSWER AND PROBE UNTIL R INDICATES NO OTHERS APPLY: Any others?

Read answer options only if necessary:

1 Doesn't need a doctor/haven't had any problems

2 Doesn't like/trust/believe in doctors

3 Doesn't know where to go

4 Previous doctor is not available/moved

5 Too expensive/no insurance/cost

6 Speak a different language

7 No care available/care too far away, not convenient

8 Put it off/didn't get around to it

9 OTHER

10. DON’T KNOW/NOT SURE

11. REFUSED

{ALLOW MULTIPLE SELECTIONS}

H_17 About how long has it been since you last visited a doctor for a routine checkup?

READ ONLY IF NECESSARY: (A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.)

Read answer options only if necessary:

1 Within past year (anytime less than 12 months ago)
2 Within past 2 years (1 year but less than 2 years ago)
3 Within past 5 years (2 years but less than 5 years ago)
4 5 or more years ago

5 NEVER
-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_02. Has a doctor or other health professional ever advised you to reduce sodium or salt intake?

1. Yes

2. No

-1. Don’t know/not sure

-2. REFUSED

H_03. Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?

READ ONLY IF NECESSARY: (By "other health professional" we mean a nurse practitioner, a physician‘s assistant, or some other licensed health professional.)

1 Yes {IF H_03=1 & INTRO_2=2, go to H_03a; IF H_03=1 & INTRO_2=1, GO TO H_05}
2 No [Go to H_08 ]
3 Told borderline high or pre-hypertensive [Go to H_08 ]
-1 DON’T KNOW / NOT SURE [Go to H_08]
-2 REFUSED [Go to H_08]

H_03a. Was this only when you were pregnant?

1 Yes [Go to H_08]
2 No [Go to H_05]

-1. Don’t know/not sure [Go to H_05]

-2. REFUSED [Go to H_05]

H_05. Are you exercising to help lower or control your high blood pressure?

1 Yes
2 No
-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_06. Are you currently taking medicine for your high blood pressure?

1 Yes
2 No
-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_07. Are you cutting down on salt to help lower or control your high blood pressure?

1 Yes
2 No
3 Do not use salt
-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_08. Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?

1 Yes
2 No {Go to H_18}
-1 DON’T KNOW / NOT SURE {Go to H_18}
-2 REFUSED {Go to H_18}

H_09. About how long has it been since you last had your blood cholesterol checked?

Read answer options only if necessary:

1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 5 years (2 years but less than 5 years ago)
4 5 or more years ago

-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_10. Have you ever been told by a doctor, nurse or other health professional that your blood cholesterol is high?

1 Yes [Go to H_14]
2 No[Go To h_18]
-1 DON’T KNOW / NOT SURE [Go to H_18]
-2 REFUSED [Go to H_18]

H_14. Are you exercising to help lower your cholesterol?

1 Yes
2 No
-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_15. Are you currently taking medicine to lower your cholesterol?

1 Yes
2 No
-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_18. Thinking about your overall physical health, which includes physical illness and injury, for how many days during the past 30 days, (that is since [FILL IN DATE30 DAYS AGO],) was your physical health not good?

_ _ Number of days {RANGE 0 – 30}

-1 DON’T KNOW / NOT SURE
-2 REFUSED

H_18a. [skip ONLY if h_18=0] During the past 30 days, (that is since [FILL IN DATE30 DAYS AGO],) for about how many days did poor physical health keep you from doing your usual activities, such as self-care, work, or recreation?

_ _ Number of days {Range 0 – 30}

-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_19. Now, turning to your mental health, have you ever been told by a doctor or other health professional that you had depression?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_20. Have you ever been told by a doctor or other health professional that you had anxiety?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE

-2 REFUSED

HF_01 How often in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage? Would you say you were worried or stressed---

1 Always

2 Usually

3 Sometimes

4 Rarely or

5 Never

6 I DO NOT OWN OR RENT A HOME/APARTMENT

-1 DON’T KNOW / NOT SURE

-2 REFUSED

HF_02 And how often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say you were worried or stressed ….

1 Always

2 Usually

3 Sometimes

4 Rarely or

5 Never

6 NOT APPLICABLE

-1 DON’T KNOW / NOT SURE

-2 REFUSED

H_13 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?

1. YES

2. NO

-1. DON’T KNOW / NOT SURE

-2. REFUSED

H_11. 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, (that is since [FILL IN DATE30 DAYS AGO],) was your mental health not good?

_ _ Number of days {Range 0 – 30}

-1 DON’T KNOW / NOT SURE

-2 REFUSED

{HARD CHECK TEXT: CANNOT ENTER MORE THAN 30 AS VALID RESPONSE}

H_12. [skip ONLY if h_11=0] During the past 30 days, (that is since [FILL IN DATE30 DAYS AGO],) 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 {Range 0 – 30}

-1 DON’T KNOW / NOT SURE

-2 REFUSED

{HARD CHECK TEXT: CANNOT ENTER MORE THAN 30 AS VALID RESPONSE}

H_16. How often do you get the social and emotional support you need?

IF NEEDED , SAY: “Please include support from any source.”

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

-1 DON’T KNOW / NOT SURE

-2 REFUSED

[SET TIMESTAMP: HEND_DT]

[DEMOGRAPHICS]

D_INTRO. We are almost done. The last questions are about you.

[SET TIMESTAMP: DBEGIN_DT]

{SELECT NEXT}

D_09. Earlier in the survey I asked you to self-identify your race. Now, I want to find out how other people usually identify you in this country.

How do other people usually classify you in this country? Would you say: White, Black or African American, Hispanic or Latino, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, or some other group?

IF NEEDED, SAY: We want to know how other people usually classify you in this country, which might be different from how you classify yourself.‖

ONLY ONE SELECTION ALLOWED.

IF NEEDED, SAY: “How do other people usually classify you in this country?”

1 WHITE

2 BLACK OR AFRICAN AMERICAN

3 HISPANIC OR LATINO

4 ASIAN

5 NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

6 AMERICAN INDIAN OR ALASKA NATIVE

7 SOME OTHER GROUP

-1 DON’T KNOW / NOT SURE

-2 REFUSED

D_10. How often do you think about your race? Would you say never, once a year, once a

month, once a week, once a day, once an hour, or constantly?

1 NEVER

2 ONCE A YEAR

3 ONCE A MONTH

4 ONCE A WEEK

5 ONCE A DAY

6 ONCE AN HOUR

7 CONSTANTLY

-1 DON’T KNOW / NOT SURE

-2 REFUSED

D_06. {ASK IF INTRO_1<=50 & INTRO_2=2 (LESS THAN 50 YEARS OLD AND IS FEMALE), ELSE GO TO D_07}

To your knowledge, are you now pregnant?

1 YES
2 NO
-1 DON’T KNOW / NOT SURE
-2 REFUSED

D_07. About how much do you weigh without shoes?

RECORD WEIGHT IN EITHER POUNDS *OR* KILOGRAMS (NOT BOTH)

IF NEEDED, CLARIFY: Is that ___ pounds or ___ kilograms?

PROBE FOR CLOSEST WHOLE NUMBER IF NEEDED

_ _ _ _ WEIGHT (POUNDS) {RANGE 1 – 800 }

_ _ _ _ WEIGHT (KILOGRAMS) {RANGE 1 – 363 }
-1 DON’T KNOW / NOT SURE
-2REFUSED

{HARD CHECK TO APPEAR WHEN BOTH LEFT BLANK: WEIGHT MUST EITHER BE NON-ZERO FOR POUNDS OR KILOGRAMS, UNLESS DK/RF}

{HARD CHECK TO APPEAR WHEN BOTH POUNDS AND KILOGRAMS NONMISSING: YOU MAY ENTER WEIGHT IN POUNDS OR KILOGRAMS, BUT NOT BOTH.

YOU CAN CLEAR DK AND RF BY ENTERING 0 AND THEN DELETING THE 0.}

[CONVERT WEIGHT REPORTED IN KILOGRAMS TO POUNDS USING THIS FORMULA: KG X 2.20462= POUNDS. ALL WEIGHT REPORTED SHOULD BE IN POUNDS FOR BMI CALCULATION TO FOLLOW]

D_08. About how tall are you without shoes?

Record height in either feet and inches *or* in meters and centimeters

IF HEIGHT IS REPORTED IN AN EXACT FOOT INCREMENT ENTER 0 FOR INCHES

IF HEIGHT IS REPORTED IN CENTIMETERS ONLY ENTER 0 FOR METERS

PROBE FOR CLOSEST WHOLE NUMBER IF NEEDED

__ FEET {RANGE 2 – 9 }

__INCHES {RANGE 0 – 11}

__METERS {0 – 3 }

__CENTIMETERS {RANGE 0 - 275 }

-1 DON’T KNOW /NOT SURE
-2 REFUSED

{ALLOW ENTRIES TO BE MADE IN FEET AND INCHES -OR- METERS AND/OR CENTIMERS}

{HARD CHECK TEXT TO APPEAR WHEN TI TRIES TO PROCEED WITHOUT ENTERING VALUES in BOTH FEET AND INCHES *OR* METERS AND/OR CENTIMETERS: “VERIFY THAT YOU HAVE ENTERED A HEIGHT IN BOTH FEET AND INCHES, OR THAT YOU HAVE ENTERED A HEIGHT IN METERS AND/OR CENTIMETERS.”}

{HARD CHECK TO APPEAR WHEN BOTH US CUSTOMARY (FEET AND INCHES) AND METRIC (CENTIMETERS AND METER) VALUES ARE NONMISSING: ““DO NOT COMBINE U.S. CUSTOMARY AND METRIC UNITS.

YOU CAN CLEAR DK AND RF BY ENTERING 0 AND THEN DELETING THE 0.”}

[IF ANY ANSWERS TO D_07 OR D_08 ARE DK (-1) OR RF (-2), THEN SKIP D_CONF AND GO TO INTRO_7 INSTEAD.]

[CONVERT HEIGHT REPORTED IN FEET/INCHES TO INCHES USING THIS FORMULA: feet X 12=in; CONVERT METERS/CENTIMETERS TO INCHES USING THIS FORMULA: METER X 39.3701 = INCHES; cm x 0.393701* = in. ALL HEIGHT REPORTED SHOULD BE CONVERTED TO INCHES FOR BMI CALCULATION]

[BMI CALCULATION: CALCULATE BMI AS FOLLOWS: (WEIGHT IN POUNDS/[(HEIGHT IN INCHES) X (HEIGHT IN INCHES)] X 703.06958 = BMI). IF BMI LT 19 OR GT 39), ASK D_CONF, ELSE GO TO INTRO_7.

IF D_07 WAS ANSWERED IN POUNDS, ^FILL1 SHOULD SAY “{fill first number from D_07} pounds”

IF D_07 WAS ANSWERED IN KG, ^FILL1 SHOULD SAY “{fill second number from D_07} kilograms”

IF D_08 WAS ANSWERED IN FEET/INCHES, ^FILL2 SHOULD SAY “{fill first number from D_08} feet {fill second number from D_08} inches”

IF D_08 WAS ANSWERED IN METERS ANDCENTIMTERES, ^FILL2 SHOULD SAY “{fill third number from D_08} meters and {fill fourth number from D_08} centimeters”]

IF D_08 WAS ANSWERED IN CENTIMTERES ONLY, ^FILL2 SHOULD SAY “{fill fourth number from D_08} centimeters”]

D_CONF.

IN A NEUTRAL TONE, ASK:

You said you weigh ^FILL1 and are ^FILL2, is that correct?

IF RESPONDENT SAYS NO, ASK “Would you like me to correct your weight, height, or both”

1 YES

2 NO , WEIGHT NEEDS CORRECTION

3 NO, HEIGHT NEEDS CORRECTION

4 NO, BOTH WEIGHT AND HEIGHT NEED CORRECTION

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF YES, DK, RF, GO TO INTRO_7]

IF d_CONF = 2, GO TO d_COR_W

iF d_conf = 3, GO TO d_COR_h

IF d_CONF = 4, GO TO d_cOR_W THEN GO TO d_COR_H]

D_COR_W. About how much do you weigh without shoes?

RECORD WEIGHT IN EITHER POUNDS OR KILOGRAMS

IF NEEDED, CLARIFY: Is that ___ pounds or ___ kilograms?

PROBE FOR CLOSEST WHOLE NUMBER IF NEEDED

_ _ _ _ WEIGHT (POUNDS) {RANGE 1 – 800 }

_ _ _ _ WEIGHT (KILOGRAMS) {RANGE 1 – 363 }
-1 DON’T KNOW / NOT SURE
-2REFUSED

{HARD CHECK TO APPEAR WHEN BOTH LEFT BLANK: WEIGHT MUST EITHER BE NON-ZERO FOR POUNDS OR KILOGRAMS, UNLESS DK/RF}

{HARD CHECK TO APPEAR WHEN BOTH POUNDS AND KILOGRAMS NONMISSING: YOU MAY ENTER WEIGHT IN POUNDS OR KILOGRAMS, BUT NOT BOTH

YOU CAN CLEAR DK AND RF BY ENTERING 0 AND THEN DELETING THE 0.}

[IF d_CONF = 3 or 4, PRESENT d_COR_H, ELSE INTRO_7]

D_COR_H. About how tall are you without shoes?

Record height in either feet and inches or in meters and centimeters

IF HEIGHT IS REPORTED IN AN EXACT FOOT INCREMENT ENTER 0 FOR INCHES

IF HEIGHT IS REPORTED IN CENTIMETERS ONLY ENTER 0 FOR METERS

PROBE FOR CLOSEST WHOLE NUMBER FOR FEET AND INCHES IF NEEDED

__ FEET {RANGE 2 – 9 }

__INCHES {RANGE 0 – 11}

__METERS {0 – 3 }

__CENTIMETERS {RANGE 0 - 275 }

-1 DON’T KNOW /NOT SURE
-2 REFUSED

{ALLOW ENTRIES TO BE MADE IN FEET AND INCHES -OR- METERS AND/OR CENTIMERS.--HARD CHECK TO APPEAR WHEN BOTH (FEET OR INCHES) AND (METERS OR CENTIMETERS) NONMISSING: “DO NOT COMBINE U.S. CUSTOMARY AND METRIC UNITS.

YOU CAN CLEAR DK AND RF BY ENTERING 0 AND THEN DELETING THE 0.”}

{HARD CHECK TEXT TO APPEAR WHEN TI TRIES TO PROCEED WITHOUT ENTERING VALUES IN BOTH FEET AND INCHES *OR* METERS AND/ORCENTIMETERS: VERIFY THAT YOU HAVE ENTERED A HEIGHT IN BOTH FEET AND INCHES, OR THAT YOU HAVE ENTERED A HEIGHT IN METERS AND/OR CENTIMETERS.}

INTRO_7. What is your annual household income from all sources -

IF RESPONDENT HESITATES OR REFUSES, DO NOT PROBE HERE, JUST CODE REFUSED

_________ {RANGE: 0-1,000,000}

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF INTRO_7=-1 (dk) OR -2 (rf), GO TO INTRO_7_04, ELSE GO TO -D_11a-]

INTRO_7_04 – (What is your annual household income from all sources?) Is it less than $25,000?

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[If INTRO_7_04=“no,” ask INTRO_7_05; if “yes,” ask INTRO_7_03; if -1 or -2, GO TO - D_11a -

INTRO_7_03 - – (What is your annual household income from all sources?) Is it less than $20,000

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[If INTRO_7_03=“no,” GO TO -D_11a-; if “yes,” ask INTRO_7_02; if -1 or -2, GO TO - D_11a -]

INTRO_7_02 - – (What is your annual household income from all sources?) Is it less than $15,000

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[If INTRO_7_02=“no,” GO TO -D_11a-; if “yes,” ask INTRO_7_01; if -1 or -2, GO TO - D_11a -]

INTRO_7_01 - – (What is your annual household income from all sources?) Is it less than $10,000

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[After presenting INTRO_7_01, GO TO -D_11a-]

INTRO_7_05 - – (What is your annual household income from all sources?) Is it less than $35,000

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF INTRO_7_05=YES, GO TO -D_11a-; If “no,” ask INTRO_7_06; if -1 or -2, GO TO - D_11a -]

INTRO_7_06 - – (What is your annual household income from all sources?) Is it less than $50,000

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[IF INTRO_7_06=YES, GO TO -D_11a-; If “no,” ask INTRO_7_07; if -1 or -2, GO TO - D_11a -]

INTRO_7_07 - – (What is your annual household income from all sources?) Is it less than $75,000

1 YES

2 NO

-1 DON’T KNOW / NOT SURE
-2 REFUSED

[After presenting INTRO_7_07, GO TO - D_11a -]

D_11a. [ASK IF INTRO_2 = 1 (Male)] Which of the following best represents how you think of yourself?

1. Gay

2. Straight, that is, not gay

3. Bisexual

4. Something Else

5. I don't know the answer

-2.REFUSED

[IF D_11a = 4, GO TO D_12; IF D_11a = 5, go to D_13; ELSE GO TO END]

D_11b. [ASK IF INTRO_2 = 2] Which of the following best represents how you think of yourself?

1. Lesbian or gay

2. Straight, that is, not lesbian or gay

3. Bisexual

4. Something else

5. I don't know the answer

-2. REFUSED

[IF D_11a = 4, GO TO D_12; IF D_11a = 5, go to D_13; ELSE GO TO END]

D_12. What do you mean by something else?

1. You are not straight, but identify with another label such as queer, trisexual, omnisexual or pansexual.

2. You are transgender, transsexual or gender variant.

3. You have not figured out or are in the process of figuring out your sexuality.

4. You do not think of yourself as having sexuality.

5. You do not use labels to identify yourself.

6. You mean something else

-1. DON’T KNOW

-2. REFUSED

[IF D_12 = 6, GO TO D_14; ELSE GO TO END]

D_13. What do you mean by don't know?

1. You don’t understand the words

2. You understand the words, but you have not figured out or are in the process of figuring out, your sexuality

3. You mean something else

-1. DON’T KNOW

-2. REFUSED

[IF D_13 = 3, GO TO D_14; ELSE GO TO END]

D_14. What do you mean by something else?

_____________ [ACCEPT UP TO 1000 CHARACTERS]

-END-

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Adult Targeted Surveillance Survey - telephone screener

Targeted Surveillance and Biometric Studies for Enhanced Evaluation of CTGs

Att 7C_ATSS_PhoneInterview

Adult Targeted Surveillance Survey - screener

OMB: 0920-0977

Table of Contents

Telephone Screener

Consent Script

Telephone Interview