Caregiver Survey

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Caregiver Survey

Public reporting burden of this collection of information is estimated to average 20 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)

Caregiver Survey

PASSED VARIABLES FROM ATSS:

• ID

• Adult respondent’s name [PRLD_Rname]

• Child name [PRLD_ChildName]

• Child age

• Legal guardian name [PRLD_GrdName]

• Relationship of adult respondent or legal guardian to child [PRLD_GrdRelation]

• Did parent/guardian give permission during ATSS? [PRLD_PGrdPermission]

• Phone number [CONTACTNUMS – Home; CONTACTNUMS – Cell FROM BACK END]

• Notes on appointment – best times to contact

• Date of ATSS interview [PRLD_ATSSDate]

• Gender [PRLD_Rgender]

• VERSION FLAG (Set to 1.0 for initial deployment)

[HARD CHECK – ALL SCREENS MUST HAVE AN ANSWER UNLESS OTHERWISE SPECIFIED.]

[NOTE TO PROGRAMMERS – FOR QUESTIONS WITH NUMBER AND UNIT, IF A VALUE IS ENTERED FOR NUMBER, A UNIT MUST BE SELECTED BUT IF DK OR RE IS ENTERED, IT IS ONLY REQUIRED FOR ONE FIELD.]

INTRODUCTION

INTERVIEWER SHOULD ONLY READ STATEMENTS IN LOWER CASE.

INSTRUCTIONS TO INTERVIEWERS ARE IN UPPER CASE

WELCOME TO THE YOUTH AND CAREGIVER TARGETED SURVEILLANCE INSTRUMENT. BEFORE BEGINNING THE INTERVIEW, YOU WILL NEED TO VERIFY A FEW PIECES OF INFORMATION AND COLLECT ASSENT FROM THE CHILD RESPONDENT AND CONSENT FROM THE ADULT GUARDIAN.

SELECT NEXT TO CONTINUE

[SET TIMESTAMP, VARIABLE NAME: YCBEGIN; FORMAT: DAY, MONTH, YEAR, HOUR, MINUTE, A.M./P.M.; e.g. 7/26/2012: 11:51 A.M.]

DISPLAY SCREEN

CHILD IDENTIFIED IN ATSS: [CHILD NAME]

[CHILD AGE]

INTRO_1_cy. ASK IF NEEDED OF EITHER ADULT CAREGIVER OR CHILD: What is your/the child’s age?

____ AGE [3 – 18]

[DISABLE DK/RF]

[HARD EDIT CHECK: IF INTRO_1_cy = 18, ASK:]

Verify_age_cy. Did you turn 18 after [DATE OF ATSS INTERVIEW]?

1. YES

2. NO – CHILD IS NOT ELIGIBLE FOR STUDY – BREAK OFF INTERVIEW

[DISABLE DK/RF]

[SET {S.C.} AGE = INTRO_1_cy.]

INTRO_2_cy. ASK IF NEEDED OF EITHER ADULT CAREGIVER OR CHILD: What is your/the child’s name?

______ NAME [50 CHARACTERS]

[SET {S.C.} = INTRO_2_cy.]

[DISABLE DK/RF]

IF S.C. >11, SKIP TO VERIFY_3_cy

INTRO_3_cy. ASK IF NEEDED OF THE ADULT CAREGIVER: What is your name?

NOTE: THE ADULT CAREGIVER MAY NOT NECESSARILY BE THE SAME PERSON AS THE ADULT RESPONDENT FOR THE ADULT BIOMETRIC INTERVIEW

______ NAME [50 CHARACTERS]

[SET {CG} = INTRO_3_cy.]

VERIFY_3_cy

WHAT IS THE CHILD’S GENDER

1. MALE

2. FEMALE

[DISABLE DK/RE]

INTRO_4_cy. YOU HAVE INDICATED THAT YOU WILL BE INTERVIEWING [TEXTFILL IF {S.C.}AGE<12, “THE ADULT CATEGIVER OF {S.C.}”; ELSE {S.C.}.]

[SET TIMESTAMP, VARIABLE NAME: CONSENTBREAK; FORMAT: DAY, MONTH, YEAR, HOUR, MINUTE, A.M./P.M.; e.g. 7/26/2012: 11:51 A.M.]

INTRO_4a_cy. HAVE YOU OBTAINED SIGNED CONSENT ON THE ADULTS WITH CHILDREN FORM [TEXTFILL IF {S.C.} AGE>6, “AND YOUTH ASSENT FORM”]

1. YES

2. NO [HARD CHECK ERROR: COLLECT SIGNED CONSENT AND/OR ASSENT PRIOR TO BEGINNING INTERVIEW]

[DISABLE DK/RF]

[SET TIMESTAMP, VARIABLE NAME: CONSENTRESUME; FORMAT: DAY, MONTH, YEAR, HOUR, MINUTE, A.M./P.M.; e.g. 7/26/2012: 11:51 A.M.]

IF S.C. >11, SKIP TO INTRO_7_cy

INTRO_5_cy. “How are you related to {S.C}?”

1. BIOLOGICAL MOTHER

2. BIOLOGICAL FATHER

3. ADOPTIVE/STEP/FOSTER/MOTHER

4. ADOPTIVE/STEP/FOSTERFATHER

5. PARTNER OF CHILD’S MOTHER OR FATHER

6. GRANDPARENT

7. BROTHER/SISTER (BIOLOGICAL/ADOPTIVE/STEP/IN-LAW/FOSTER

8. AUNT/UNCLE

9. OTHER RELATIVE

10. OTHER NONRELATIVE

11. LEGAL GUARDIAN

12. CHILD IS WARD OF STATE OR OF THE COURT

-1. DON’T KNOW

-2. REFUSED

[IF INTRO_5_cy= 1, 2, 3, 4, 11, SKIP TO INTRO_7_cy]

INTRO_6_cy. [ASK IF {S.C.}AGE<12, ELSE SKIP TO INTRO_7_cy] Are you {S.C}’s legal guardian?

1 YES

2. NO

-1. DON’T KNOW

-2. REFUSED

INTRO_7_cy. What grade [TEXTFILL IF {S.C.} AGE<11, is {S.C} ELSE “are you”] enrolled in or will be enrolled in during the 2013-2014 school year?

INTERVIEWER INSTRUCTION: IF REPORTED AS HOMESCHOOLED, PROBE FOR GRADE EQUIVALENT FOR HOME SCHOOL AND RECORD BOTH ANSWERS

1. PRESCHOOL

2. KINDERGARTEN

3. 1ST GRADE

4. 2ND GRADE

5. 3RD GRADE

6. 4TH GRADE

7. 5TH GRADE

8. 6TH GRADE

9. 7TH GRADE

10. 8TH GRADE

11. 9TH GRADE

12. 10TH GRADE

13. 11TH GRADE

14. 12TH GRADE

15. Not in school

____HOMESCHOOL

-1. DON’T KNOW

-2. REFUSED

[ALLOW HOMESCHOOLED TO BE SELECTED IN ADDITION TO ANY OTHER OPTION]

PA_INTRO_cy.

PHYSICAL ACTIVITY

Let’s begin by talking about the [TEXTFILL IF {S.C} AGE<12 “recreational activities that {S.C} did with or without you”, ELSE “sports, fitness, or recreational activities that you did”] during the past week.

[SELECT NEXT TO CONTINUE]

PA_01_cy. [ASK ONLY IF {S.C} AGE>5, ELSE SKIP] During the past week, on how many days did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] walk or bicycle [TEXTFILL IF {S.C} AGE<12”, with or without you,”] for at least 10 minutes continuously to get to and from places?

___ DAYS [RANGE 0 -7]

__-1. DON’T KNOW

__-2. REFUSED

PA_04_cy. [ASK ONLY IF {S.C} AGE>5, ELSE SKIP] Thinking about the past week, not counting any walking that you already mentioned, on how many days did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] walk or bike for at least 10 minutes continuously for leisure?

IF NEEDED, SAY: (Think about only the walking or biking that [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] did for at least 10 minutes at a time.)

_____ Days per week {RANGE 0 – 7}

-1. DON’T KNOW

-2. REFUSED

PA_20_cy. [ASK ONLY IF {S.C} AGE<6, ELSE SKIP] During the past week, how many days did {S.C.} play with other children [TEXTFILL IF VERIFY_3_cy = 1 “his” IF VERIFY_3_cy = 2 “her”] age?

RECORD NUMBER OF DAYS

___ DAYS [RANGE 0 – 7]

__-1. DON’T KNOW

__-2. REFUSED

PA_07_cy. [ASK ONLY IF {S.C} AGE<6, ELSE SKIP] During the past week, how many days did you or any family member take {S.C.} on any kind of outing, such as to the park, library, zoo, shopping, church, restaurants, or family gatherings?

RECORD NUMBER OF DAYS

___ DAYS [RANGE 0 – 7]

__-1. DON’T KNOW

__-2. REFUSED

PA_08_ cy. [ASK ONLY IF {S.C} AGE>5, ELSE SKIP] During the past week, on how many days did [TEXTFILL IF {S.C.} AGE<12 “{S.C.}”, ELSE “you”] exercise, play a sport, or participate in physical activity for at least 20 minutes that made [TEXTFILL IF {S.C.} AGE<12 IF VERIFY_3 = 1“ him” IF VERIFY_3=2 “her”, ELSE “you”] sweat and breath hard?

IF NEEDED, SAY: Include active sports such as baseball, softball, basketball, swimming, soccer, tennis, or football: riding a bike or rollerskating; walking or jogging; jumping rope; gymnastics; or active dance such as ballet.

___ DAYS {RANGE 0 – 7}

__-1. DON’T KNOW

__-2. REFUSED

[PA_12_cy AND PA_13_cy ARE COUPLED TOGETHER. IF PA_12 _cy IS SKIPPED, ALSO SKIP PA_13_cy.]

PA_12_ cy. [ASK IF {S.C.} AGE >4, ELSE SKIP TO PA_14_cy]. (During the past week,) on how many days did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] play active video games such as Wii Sports, Wii Fit, Xbox 360, Xbox Kinect, Playstation 3, or Dance, Dance Revolution?

___ DAYS {RANGE 0 – 7} [IF PA_12_cy=0, GO TO PA_14_cy; ELSE CONTINUE]

__-1. DON’T KNOW {GO TO PA_14_cy}

__-2. REFUSED {GO TO PA_13_cy}

PA_13_ cy. On average, for how long did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] play these active video games on a typical day?

IF NEEDED, PROBE SAYING: (“How much time in total did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”]spend playing active video games on Wednesday?”)

___ ___ Hours per day {RANGE 0 – 24}

___ ___ Minutes per day {RANGE 0 – 59}

-1. DON’T KNOW

-2. REFUSED

[DK/RF response is required for either hours OR minutes, but not both]

PA_14_cy. The following questions are about the total time [TEXTFILL IF {S.C} AGE<12 “{S.C} spends” ELSE “you spend”] sitting anywhere, such as at school, [TEXTFILL IF {S.C} AGE<6 “at day care,”] [TEXTFILL IF {S.C} AGE>14 “at work,”] home, getting to and from places, or with friends, including time spent sitting at a desk, traveling in a car or bus, reading, playing cards, watching television, or using a computer. Do not include time spent sleeping.

(Thinking about the past week,) on a typical day how much time [TEXTFILL IF {S.C} AGE<12 “did {S.C}” ELSE “did you”] spend sitting?

IF NEEDED, PROBE SAYING: (“How much time in total [TEXTFILL IF {S.C} AGE<12 “did {S.C}” ELSE “did you”] spend sitting on Wednesday?”)

_ _ HOURS {RANGE 0 – 24}

_ _ MINUTES {RANGE 0 – 59}

-1 DON’T KNOW

-2 REFUSED

1 NONE

[FI SHOULD EITHER ENTER HOURS AND MINUTES or NONE]

[IF fI ENTERS HOURS/MINUTES AND NONE, DISPLAY ERROR MESSAGE “You should not have hours/minutes entered at the same time as NONE.  Please correct.”

[DK/RF RESPONSE IS REQUIRED FOR EITHER HOURS OR MINUTES, BUT NOT BOTH]

[ASK PA_14_CONF_cy IF (PA_14_cy SUM OF hours AND (MINUTES/60)>17 hours)]

PA_14_CONF_cy. IN A NEUTRAL TONE, ASK: You said {FILL HOURS NUMBER FROM PA_14_cy } (hours) and {FILL MINUTES NUMBER FROM PA_14_cy } (minutes), is that correct?

1 YES

2 NO

-1 DON’T KNOW
-2 REFUSED

[if yes, continue; IF no, DK or RF, go back TO pa_14_cy]

PA_18_cy. Let’s talk now about your neighborhood and community. Please tell me if the following places and things are available in your neighborhood, even if [TEXTFILL IF {S.C} AGE<12 “{S.C} does” ELSE “you do”] not actually use them.

PA_18a_cy . Sidewalks or walking paths?

IF NEEDED, SAY: Do those exist in your neighborhood?

1 YES

2 NO

-1 DON’T KNOW
-2 REFUSED

PA_18b_cy . A park or playground area?

IF NEEDED, SAY: Do those exist in your neighborhood?

1 YES

2 NO

-1 DON’T KNOW
-2 REFUSED

PA_18c_cy . A recreation center, community center, or boys’ or girls’ club?

IF NEEDED, SAY: Do those exist in your neighborhood?

1 YES

2 NO

-1 DON’T KNOW
-2 REFUSED

PA_19_cy. How often do you feel [TEXTFILL IF {S.C} AGE<12 “{S.C} is”] safe in your community or neighborhood? Would you say….

1. Always

2. Usually

3. Sometimes

4. Never

-1 DON’T KNOW
-2 REFUSED

N_INTRO_cy.

NUTRITION

Now I have some questions about [TEXTFILL IF {S.C} AGE<12 “{S.C.’s}” ELSE “your”] eating habits.

These questions are about the different kinds of foods [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] ate or drank during the past month, that is, since [FILL IN WITH DAY 30 DAYS AGO]. When answering, please include meals and snacks eaten [TEXTFILL IF {S.C} AGE<12 “by {S.C}” ELSE “by you”] at home, at [TEXTFILL IF {S.C} AGE>14 “at work,”] school, [TEXTFILL IF {S.C} AGE<6 “at day care,”] in restaurants, and any place else. Keep in mind there are no right or wrong answers. Your best guess is fine.

[NOTE TO PROGRAMMERS – FOR NUTRITION QUESTIONS WITH TIME AND A UNIT, IF THERE IS A VALUE ENTERED FOR NUMBER, A UNIT OF TIME SHOULD BE SELECTED. IF DK OR RE IS ENTERED, IT IS ONLY REQUIRED FOR ONE OF THE FIELDS. DISABLE DK/RE FOR UNIT UNLESS OTHERWISE SPECIFIED. IF NEVER IS SELECTED, THERE SHOULD NOT BE A TIME OR UNIT.]

N_03_cy (During the past month), since [FILL IN DATE 30 DAYS AGO) how often did [TEXTFILL IF {S.C} AGE<12 “{S.C.}” ELSE “you”] have milk either to drink or on cereal? You can answer by telling me how often [TEXTFILL IF {S.C} AGE<12 “{S.C.}” ELSE “you”] drank milk on an average day, average week, or for the entire month.

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

HELP POP-UP:

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

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

D o Include Do not Include

Buttermilk Chocolate Milk Cream

Lactose-free Milk Low-fat Milk

No-fat Milk Other Flavored Milks

Skim Milk Whole Milk

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
4 never {GO TO N_04_cy)
-1 DON’T KNOW {GO TO N_04_cy)
-2 REFUSED {GO TO N_04_cy)

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

[ASK N_03_cy_CONF IF (N_03_ cy Times per day > 5 or TIMES PER WEEK > 35 OR TIMES PER MONTH >150)]

N_03_ cy _CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_03_ cy} {fill unit from N_03_ cy }, is that correct?

1 YES

2 NO

-1 DON’T KNOW
-2 REFUSED

[if yes, continue; IF no, DK or RF, go back]

N_03a_cy. What type of milk was it?

IF RESPONDENT CANNOT PROVIDE USUAL TYPE, CODE ALL THAT APPLY.

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

-2 REFUSED

[ALLOW MULTIPLE SELECTIONS]

N_03b_cy . IF NEEDED SAY: (Was the milk [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] usually drank flavored?)

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

1 Yes

2 No

-1 DON’T KNOW
-2 REFUSED

N_04_cy. During the past month, how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] drink regular soda, or pop that contained sugar? Do not include diet soda. (You can tell me per day, per week or per month.)

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

IF NEEDED, SAY: (Keep in mind there are no right or wrong answers. Your best guess is fine.)

HELP POP-UP:

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC TYPE OF 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.

D o Include Do not Include

Manzanita Penafiel sodas Diet Fruit Drinks Juices in Cans

Sugar-free Fruit Drinks Tea in Cans

Coke Pepsi Diet Coke Diet Pepsi

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
4 never
-1 DON’T KNOW
-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_cy_CONF IF (N_04_cy TIMES PER DAY >5OR TIMES PER WEEK > 35 OR TIMES PER MONTH >150)]

N_04_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_04_ cy} and {fill unit from N_04_cy }, is that correct?

1 YES

2 NO

-1 DON’T KNOW
-2 REFUSED

[if yes, continue; IF no, DK or RF, go back]

N_05_cy. (During the past month), since (POPULATE WITH DATE 30 DAYS AGO) how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] drink 100% pure fruit juice such as orange, mango, apple, grape and pineapple juices? Do not include fruit-flavored drinks with added sugar or fruit juice [TEXTFILL IF {S.C} AGE<12 “you or {S.C}” ELSE “you”] made at home and added sugar to. (You can tell me per day, per week or per month.)

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

IF NEEDED, SAY: (Keep in mind there are no right or wrong answers. Your best guess is fine.)

HELP POP-UP:

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC TYPE OF 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.

D o Include Do not Include

100% Pure Juices Fruit-flavored Drinks with Added Sugar

Cranberry Cocktail Gatorade

Hi-C Kool-Aid

Lemonade Sunny Delight

Tampico

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
4 never
-1 DON’T KNOW
-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_cy_CONF IF (N_05_cy Times per day > 5 or TIMES PER WEEK > 35 OR TIMES PER MONTH >150 )]

N_05_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_05_ cy} and {fill unit from N_05_cy }, is that correct?

1 YES

2 NO

-1 DON’T KNOW
-2 REFUSED

[if yes, continue; IF no, DK or RF, go back TO n_05_cy]

N_06_cy. Now we are going to ask about fruit-flavored drinks with added sugar. (During the past month), how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] drink sweetened fruit drinks, sports or energy drinks, such as Kool-aid, lemonade, Hi-C, cranberry drink, Gatorade, Red Bull or Vitamin Water? Include fruit juices you made at home and added sugar to. Do not include diet drinks or artificially sweetened drinks. (You can tell me per day, per week or per month.)

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

IF NEEDED, SAY: (Keep in mind there are no right or wrong answers. Your best guess is fine.)

HELP POP-UP:

IF RESPONDENT ASKS WHETHER TO COUNT A SPECIFIC TYPE OF 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.

D o Include Do not Include

Drinks with Added Sugar 100% fruit juices Carbonated Water

Tampico Sunny Delight Fruit-Flavored teas Soda

Twister Yogurt drinks

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
4 never
-1 DON’T KNOW
-2 REFUSED

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

[ASK N_06_cy_CONF IF (N_06_cy Times per day > 5 or TIMES PER WEEK > 35 OR TIMES PER MONTH >150)]

N_06_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_06_ cy} and {fill unit from N_06_cy }, is that correct?

1 YES

2 NO

-1 DON’T KNOW
-2 REFUSED

[if yes, continue; IF no, DK or RF, go back]

N_07_cy (During the past month), how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] eat fruit? Include fresh, frozen or canned fruit. Do not include juices. (You can tell me per day, per week or per month.)

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

IF NEEDED, SAY: (Keep in mind there are no right or wrong answers. Your best guess is fine.)

HELP POP-UP:

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

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

D o Include Do not Include

Apples Applesauce Dried Fruits

Bananas Berries

Fruit Salad Grapes

Mangos Melon

Oranges Papayas

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
4 never
-1 DON’T KNOW
-2 REFUSED

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

[ASK N_07_cy_CONF IF (N_07_cy TIMES PER DAY>8 TIMES PER WEEK > 56 OR TIMES PER MONTH >240)]

N_07_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_07_ cy} and {fill unit from N_07_cy }, is that correct?

1 YES

2 NO

-1 DON’T KNOW
-2 REFUSED

[if yes, continue; IF no, DK or RF, go back TO n_07_cy]

N_08_cy. (During the past month), how often did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] eat vegetables? Include salads, cooked beans, and all types of potatoes, except for fried potatoes such as French fries. (You can tell me per day, per week or per month.)

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

IF NEEDED, SAY:

• (Keep in mind there are no right or wrong answers. Your best guess is fine.)

HELP POP-UP:

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

YOU MAY READ EXAMPLES FROM LIST UPON REQUEST.

D o Include Do not Include

Black Beans Black-Eyed Peas French Fries Fried Potatoes

Bean Sprouts Broccoli Hash Brown Potatoes Home fries

Cow Peas Cabbage

Carrots Collard Greens

Corn Garbanzo

Green Beans Green Leafy Salad

Kidney Lentils

Lettuce Salad Lima Beans

Pinto Beans Potatoes au Gratin

Scalloped Potatoes Soybeans

Spinach Salad Tomatoes

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]
4 never
-1 DON’T KNOW
-2 REFUSED

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

[ASK N_08_cy_CONF IF (N_08_cy TIMES PER DAY>8 TIMES PER WEEK > 56 OR TIMES PER MONTH >240]

N_08_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_08_ cy} {fill unit from N_08_cy }, is that correct?

1 YES

2 NO

-1 DON’T KNOW
-2 REFUSED

[if yes, continue; IF no, DK or RF, go back]

N_13_cy. During the past month, (that is since [FILL IN DATE 30 DAYS AGO],) how many times per day, week or month, did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] drink 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: (Keep in mind there are no right or wrong answers. Your best guess is fine.)

1 _ _ Times per day [RANGE 0 – 999]
2 _ _ Times per week [RANGE 0 – 999]
3 _ _ Times per month [RANGE 0 - 999]

4 NEVER
-1 DON’T KNOW
-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_cy_CONF IF (N_13_cy TIMES PER DAY>8 TIMES PER WEEK > 56 OR TIMES PER MONTH >240)]

N_13_cy_CONF. IN A NEUTRAL TONE, ASK: You said {fill number from N_13_ cy} and {fill unit from N_13_cy}, is that correct?

1 YES

2 NO

-1 DON’T KNOW
-2 REFUSED

[if yes, continue; IF no, DK or RF, go back]

N_14_cy. 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

-2 REFUSED

N_15_cy. 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

-2 REFUSED

N_16_cy. How often do you have fat-free or low-fat (1%) milk at home?  (Would you say ...?)

1. Always

2. Most of the time

3. Sometimes

4. Rarely or

5. Never

-1 DON’T KNOW

-2 REFUSED

N_17_cy. How often does your family/do you have soft drinks, fruit-flavored drinks, or fruit punch available at home? Do not include diet drinks, 100 percent juice or sports drinks. (Would you say…?)

1. Always

2. Most of the time

3. Sometimes

4. Rarely or

5. Never

-1 DON’T KNOW

-2 REFUSED

N_20_cy. Our next question about food is about whole meals. By meal, I mean breakfast, lunch and dinner. During the past 7 days, how many meals did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] eat 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 the school lunch or school breakfast.

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

____ Number [MEALS 0 - 28]

-1 DON’T KNOW
-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?”

1. YES

2. NO – RETURN TO QUESTION N_20 AND FIX ANSWER

[IF N_20_cy = 0, SKIP TO N_21_cy].

N_20a_cy. How many of those meals did you get from a fast-food or pizza place?

___NUMBER [MEALS 0 – 28]

-1 DON’T KNOW

-2 REFUSED

HARD EDIT CHECK: ANSWER TO N_20a_cy MUST BE LESS THAN OR EQUAL TO N_20_cy.

N_21_cy. What food or foods did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] eat during [TEXTFILL IF {S.C.’s} AGE<12 “{S.C}’s” ELSE “your”] last meal or snack? Please tell me all the food and drinks [TEXTFILL IF {S.C} AGE<12 “{S.C} had” ELSE “you have had”] during [TEXTFILL IF {S.C} AGE<12 “{S.C}’s” ELSE “your”] last meal or snack.

________[4000 MAX CHARACTERS]

-1 DON‘T KNOW
-2 REFUSED

N_22_cy. [TEXTFILL IF {S.C.}AGE<12 “Has your child” ELSE “Have you”] had anything to eat or drink within the last 30 minutes?

1. YES

2. NO

-1 DON’T KNOW

-2 REFUSED

CG_INTRO_cy. SMOKING

Now, let’s turn to a few questions about smoking.

CG_01_cy. During the past 7 days, on how many days [TEXTFIL IF {S.C} AGE<12 “was your child” ELSE “were you”] in the same room with somebody who was smoking cigarettes?

RECORD NUMBER OF DAYS

___ DAYS [RANGE 0 – 7]

__-1. DON’T KNOW

__-2. REFUSED

[IF {S.C.} AGE<12, SKIP TO H_INTRO_cy, ELSE CONTINUE]

SHOW RESPONDENT SHOWCARD 1

CG_02_cy. Have you ever tried cigarette smoking, even one or two puffs? Please just tell me the letter on the showcard that represents your answer.

1. A - YES

2. B - NO

-1 DON’T KNOW

-2 REFUSED

SHOW RESPONDENT SHOWCARD 1B

CG_03_cy. In addition to what you just told me about cigarettes, do you currently smoke cigarillos, cigars or pipes?

1. A - YES

2. B - NO

-1. DON’T KNOW

-2. REFUSED

[IF CG_02_cy = 2 & CG_03_cy= 2, GO TO cg_11_cy; ELSE CONTINUE]

SHOW RESPONDENT SHOWCARD 2

CG_04_cy. [SKIP IF CG_02_cy=2] During the past 30 days, on how many days did you smoke cigarettes?

READ ANSWER CATEGORIES ONLY IF NEEDED

1. A - 0 days

2. B - 1 or 2 days

3. C - 3 to 5 days

4. D - 6 to 9 days

5. E - 10 to 19 days

6. F - 20 to 29 days

7. G - All 30 days

-1 DON’T KNOW

-2 REFUSED

SHOW RESPONDENT SHOWCARD 3A

CG_05_cy. Please read the question on this card and tell me a number. Thinking about [TEXT FILL IF [SKIP IF CG_04_cy=1 (0 DAYS) “cigarettes”,] cigarillos, cigars and pipes, please tell me how much you usually smoke per day?

SHOW RESPONDENT SHOWCARD 3

CG_05a_cy. [SKIP IF cg_02_cy=2 OR cg_04_cy=1] Of cigarettes…. (How many do you usually smoke per day?)

___ NUMBER [RANGE 0 – 999]

-1. DON’T KNOW

-2. REFUSED

SHOW RESPONDENT SHOWCARD 4

CG_05b_cy. Of cigarillos …. (How many do you usually smoke per day?)

___ NUMBER [RANGE 0 – 999]

-1. DON’T KNOW

-2. REFUSED

SHOW RESPONDENT SHOWCARD 5

CG_05c_cy. Of cigars …. (How many do you usually smoke per day?)

___ NUMBER [RANGE 0 – 999]

-1. DON’T KNOW

-2. REFUSED

SHOW RESPONDENT SHOWCARD 6

CG_05d_cy. Of pipes …. (How many do you usually smoke per day?)

___ NUMBER [RANGE 0 – 999]

-1. DON’T KNOW

-2. REFUSED

SHOW RESPONDENT SHOWCARD 7

CG_06_cy. How long has it been since you last smoked a [TEXT FILL IF [CG_02_cy=1, “cigarette,”] cigarillo, cigar or pipe, even one or two puffs? You can tell me in hours, days or months ago.

number ___

1 _ _ HOURS AGO [RANGE 0 – 999]
2 _ _ DAYS AGO [RANGE 0 – 999]
3 _ _ MONTHS AGO [RANGE 0 - 999]

4 _ _ NEVER SMOKED

-1. DON’T KNOW

-2. REFUSED

[HARD CHECK TEXT: BOTH NUMBER AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS NEVER, DK/RF] IF DK OR RE ENTERED, ONLY REQUIRED FOR ONE FIELD, NOT BOTH.

SHOW RESPONDENT SHOWCARD 8

CG_07_cy. [SKIP IF CG_02_cy=2 OR cg_04_cy=0] Please read the question on this card and tell me the letter that matches your answer. During the past 30 days, how did you usually get your own cigarettes?

IF NEEDED, PROBE FOR SINGLE BEST ANSWER THAT MATCHES RESPONSE OPTIONS

1. A - I did not smoke cigarettes during the past 30 days

2. B - I bought them in a store such as a convenience store, supermarket, discount store, or gas station

3. C - I bought them from a vending machine

4. D - I gave someone else money to buy them for me

5. E - I borrowed (or bummed) them from someone else

6. F -A person 18 years old or older gave them to me

7. G -I took them from a store or family member

8. H - I got them some other way

-1 DON’T KNOW

-2 REFUSED

SHOW RESPONDENT SHOWCARD 9

CG_08_cy. DURING THE PAST 12 MONTHS, DID YOU EVER TRY TO QUIT SMOKING CIGARETTES?

1. A - Yes

2. B -No

3. (IF VOLUNTEERED) I did not smoke during the past 12 months

-1 DON’T KNOW

-2 REFUSED

SHOW RESPONDENT SHOWCARD 9B

CG_ 09_cy. ARE YOU CURRENTLY USING ANYTHING TO HELP YOU QUIT SMOKING LIKE A NICOTINE PATCH, NICOTINE GUM, NASAL SPRAY OR INHALER?

1. A - YES

2. B - NO

-1. DON’T KNOW

-2. REFUSED

[IF cg_09_cy=2 OR DK/RF, GO TO cg_11_cy; ELSE CONTINUE]

SHOW RESPONDENT SHOWCARD 10

CG_ 10_cy. When did you last use any of these things that are designed to help you quit smoking? You can tell me in hours, days or months ago.

number: ____

1 _ _ HOURS AGO [RANGE 0 – 999]
2 _ _ DAYS AGO [RANGE 0 – 999]
3 _ _ MONTHS AGO [RANGE 0 - 999]

4 _ _ CURRENTLY USING (E.G. PATCH)

-1. DON’T KNOW

-2. REFUSED

[HARD CHECK TEXT: BOTH NUMBER AND UNIT (DAY, WEEK OR MONTH) MUST BE REPORTED, UNLESS CURRENTLY USING, DK/RF] IF DK OR RE ENTERED, ONLY NEED FOR ONE FIELD, NOT BOTH.]

SHOW RESPONDENT SHOWCARD 11

CG_11_cy. Please read the question on this card and tell me the letter that matches your answer. Do you currently use chewing tobacco, snuff, or dip such as Redman, Skoal, or Copenhagen?

1. A. YES – SKIP TO H_INTRO_cy

2. B. NO –

-1. DON’T KNOW

-2. REFUSED –

SHOW RESPONDENT SHOWCARD 12

CG_12_cy. Approximately how long ago did you last use any of those? You can tell me in hours, days or months ago.

NUMBER: ___

1 _ _ HOURS AGO [RANGE 0 – 999]
2 _ _ DAYS AGO [RANGE 0 – 999]
3 _ _ MONTHS AGO [RANGE 0 - 999]

4 _ _ NEVER USED

-1. DON’T KNOW

-2. REFUSED

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

H_INTRO_cy

[HEALTH AND HEALTH CARE ACCESS]

Our next questions are about [TEXTFILL IF {S.C} AGE<12 “{S.C.'s}” ELSE “your”] health care and health.

H_01_cy. To begin, is there a place that [TEXTFILL IF {S.C} AGE<12 “{S.C} usually goes when [TEXTFILL IF VERIFY_3_cy = 1 “he is” ELSE “she is” ELSE “you usually go when you are”] sick or you need advice about [TEXTFILL IF {S.C} AGE<12 {TEXTFILL IF VERIFY_3_cy= 1“his” IF VERIFY_3_cy+2”her”} ELSE “your"] health?

1 YES

2 THERE IS NO PLACE {GO TO H_01c_cy }

3 THERE IS MORE THAN ONE PLACE

-1. DON’T KNOW {GO TO H_01c_cy }

-2. REFUSED {GO TO H_01c_cy }

H_01a_cy. {TEXT FILL IF H_01_cy=3, “What kind of place [TEXTFILL IF {S.C} AGE<12 “does {S.C}” ELSE “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_cy }

-1. DON’T KNOW {GO TO H_02c_cy }

-2. REFUSED {GO TO H_02c_cy }

H_01b_cy. Is that [TEXTFILL IF H_01a_cy=1,2,3,4 “{H_01a_cy}” IF H_01a_cy=5 “other place”] the same place [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] usually [TEXTFILL IF {S.C} AGE<12 “goes” ELSE “go”] when [TEXTFILL IF {S.C.}AGE<12 {TEXTFILL IF VERIFY_3_cy=1 “he needs” IF VERIFY_3_cy=2 “she needs”} ELSE “you need”] routine or preventive care, such as a physical examination or [IF {S.C.} AGE<12, “(well baby/child)”] check up?

1 YES {GO TO H_02_cy}

2 NO {GO TO H_02_cy }

-1. DON’T KNOW {GO TO H_02_cy }

-2. REFUSED {GO TO H_02_cy }

H_01c_cy. What kind of place [TEXTFILL IF {S.C} AGE<12 “Does {S.C}” ELSE “Do you”] usually go to when [TEXTFILL IF {VERIFY_3_cy =1“he needs” IF VERIFY_3_cy=2 “she needs” AGE<12 “{S.C}” ELSE “you need”] routine or preventive care, such as a physical examination or[IF {S.C.} AGE<12, “(well baby/child)”] 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

-2. REFUSED

{IF H_01_cy =2 (THERE IS NO PLACE USUALLY GOES WHEN SICK) AND H_01c_cy =(1 or 7) (NO USUAL PLACE FOR PREVENTIVE CARE), GO TO H_01d_cy, ELSE GO TO H_02_cy }

H_01d_cy. Why [IF {S.C.} AGE<12, “doesn’t {S.C.}” ELSE “don’t you”] have a usual source of medical care? [IF {S.C.} AGE>11, “(My parents and/or I feel….”]

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

-1. DON’T KNOW

-2. REFUSED

{ALLOW MULTIPLE SELECTIONS}

H_02_cy. During the past 12 months did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] see a doctor, nurse, or other health care professional for any kind of medical care, including sick-child care, well-child check-ups, physical exams, and hospitalizations?

1. YES

2. NO {SKIP TO H_04_cy }

-1. DON’T KNOW {SKIP TO H_04_cy }

-2. REFUSED {SKIP TO H_04_cy }

H_03_cy. During the past 12 months how many times did [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] see a doctor, nurse, or other health care provider for preventive medical care such as a physical exam or well-child checkup?

NUMBER_____ (RANGE 1-99)

-1. DON’T KNOW

-2. REFUSED

H_04_cy. [TEXTFILL IF {S.C} AGE<12 “Has {S.C}” ELSE “Have you”] had any colds, flus or other illnesses in the last two weeks?

1. YES

2. NO

-1. DON’T KNOW

-2. REFUSED

H_05_cy. Mental health professionals include psychiatrists, psychologists, psychiatric nurses, and clinical social workers. During the past 12 months, [TEXTFILL IF {S.C} AGE<12 “has {S.C}” ELSE “have you”] received any treatment or counseling from a mental health professional in or outside of [IF {S.C} AGE<12, “day-care or”] school?

1 YES

2 NO

-1 DON’T KNOW

-2 REFUSED

H_06_cy. Now I am going to read you a list of health problems, concerns or conditions [TEXTFILL IF {S.C.} AGE<12, “that may affect {S.C.’s} behavior, learning, or growth”]. For each condition, please tell me if a doctor or other health care provider ever told you [TEXTFILL IF {S.C} AGE>11, “or your parents”] that [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] had the condition, even if [TEXTFILL IF {S.C} AGE<12 {IF VERIFY_3_cy = 1 “he doesn’t” IF VERIFY 3_cy=2 “she doesn’t”} ELSE “you don’t"] have the condition now.

INTERVIEWER INSTRUCTION: IF THE RESPONDENT HAS NEVER HEARD OF THE MEDICAL CONDITION OR DOES NOT KNOW WHAT THE CONDITION IS, THEN A DOCTOR OR OTHER HEALTH CARE PROVIDER PROBABLY HAS NOT TOLD THE RESPONDENT THAT S/HE HAS THE CONDITION. IF A DOCTOR OR OTHER HEALTH CARE PROVIDER HAS NOT TOLD THE RESPONDENT THAT S/HE HAS THE CONDITION, BUT THE RESPONDENT INSISTS THAT S/HE HAS THE CONDITION, WE STILL NEED TO CODE THE ANSWER AS “NO.”

[SELECT NEXT TO CONTINUE]

H_06a_cy. Has a doctor or other health care provider ever told you [TEXTFILL IF {S.C} AGE>11, “or your parents”] that [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] had depression?

IF NEEDED, SAY: (Depression is an illness that involves the body, mood, and thoughts. It is marked by persistent sadness or an anxious or empty mood. It affects how a person feels, and the way a person eats, sleeps, and functions.)

1 YES

2 NO

-1 DON’T KNOW

-2 REFUSED

H_06b_cy. Has a doctor or other health care provider ever told you [TEXTFILL IF {S.C} AGE>11, “or your parents”] that [TEXTFILL IF {S.C} AGE<12 “{S.C}” ELSE “you”] had anxiety problems?

IF NEEDED, SAY: (Anxiety is a feeling of constant worrying. Children with severe anxiety problems may be diagnosed as having anxiety disorders. Anxiety disorders include panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and phobias.)

1 YES

2 NO

-1 DON’T KNOW

-2 REFUSED

H_06c_cy. Has a doctor or other health care provider ever told you [TEXTFILL IF {S.C} AGE>11, “or your parents”] that[TEXTFILL IF {S.C} AGE<12 “{S.C} has” ELSE “you had”] diabetes?

IF NEEDED, SAY: (Diabetes is a disease in which the body does not properly make or use insulin.)

1 YES

2 NO

-1 DON’T KNOW

-2 REFUSED

H_06d_cy. Has a doctor or other health care provider ever told you [TEXTFILL IF {S.C} AGE>11, “or your parents”] that [TEXTFILL IF {S.C} AGE<12 “{S.C} was” ELSE “you were”] overweight?

1 YES

2 NO

-1 DON’T KNOW

-2 REFUSED

H_06e_cy [TEXTFILL IF {S.C} AGE<12 “Does {S.C}” ELSE “Do you”]have an impairment or health problem that limits [TEXTFILL IF {S.C} AGE<12 {IF VERIFY_3_cy=1 “his” IF VERIFY3_CY=2 “her”} ELSE “your"] ability to walk, run, or play?

1 YES

2 NO

-1 DON’T KNOW

-2 REFUSED

H_06f_cy. [TEXTFILL IF {S.C} AGE<12 “Is {S.C}” ELSE “Are you”] limited in any way in any activity because of a physical, mental or emotional problem?

1 YES

2 NO

-1 DON’T KNOW

-2 REFUSED

Demographics

[DEMOGRAPHICS]

D_01_cy [TEXTFILL IF {S.C} AGE<12 “Is {S.C}” ELSE “Are you”] Hispanic or Latino? 

1 YES
2 NO
-1 DON’T KNOW
-2 REFUSED

D_02_cy. What [TEXTFILL, IF {S.C.} AGE<12, “do you consider to be {S.C.’s}” ELSE “do you consider to be your”] race? I am going to read a list. You can select one or more options from the list.

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

-1 DON’T KNOW

-2 REFUSED.

D_03-ad. (In the last question), I asked you to [TEXTFILL IF {S.C} AGE<12 “identify {S.C.’s}” ELSE “self-identify your”] race. Now, I want to find out how other people usually classify [TEXTFILL IF {S.C} AGE<12 “{S.C.}” ELSE “you”] in this country.

Would you say (other people this country usually classify [TEXTFILL IF {S.C} AGE<12 “{S.C.}” ELSE “you”]as): 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 [TEXTFILL IF {S.C} AGE<12 “{S.C.}” ELSE “you”] in this country, which might be different from how you classify [TEXTFILL IF {S.C} AGE<12 “{S.C.}” ELSE “yourself”].‖

ONLY ONE SELECTION ALLOWED.

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

-2 REFUSED

47