Att 7D_ATSS_ItemSources_2013_0718

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI
1

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Divergence?

N/A

N/A

RTI Developed

N/A

N/A

RTI Developed

N/A

N/A

4

Thinking about the adults living in this
household, whose birthday is coming up next?
(Please do not include anyone who is away at
RTI Developed
school or away in the military, or anyone who
is visiting temporarily. Just include adults who
currently live in your household.)

N/A

N/A

5

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

N/A

N/A

6

Has the "Selection Checklist" (page 3) been
completed?

RTI Developed

N/A

N/A

7

What is today's date?

RTI Developed

N/A

N/A

INTRO_1 What is your age?

8

What is your age?

BRFSS 2012 Section
What is your age?
7: Demographics

No

INTERVIEWER INDICATE SEX OF RESPONDENT. ASK
ONLY IF NECESSARY.
INTRO_2
IF NECESSARY, SAY: (For survey purposes, I need to
confirm, are you male or female?)

9

What is your sex?

BRFSS 2012 Section Indicate sex of respondent. Ask only if
7: Demographics
necessary.

Yes

2
3

Is today's date on or before February 1, 2014? RTI Developed

Original Text in Source

Is the address printed on this survey's
envelope your current home address or main
mailing address for personal mail?
Are you an adult, at least 18 years of age or
older?

Page 1 of 31

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

Are you…?

Are you currently ….?

Please read:

IF NEEDED, SAY: (Please choose the category that
describes your current situation the best.)
INTRO_3 1 Married
2 Divorced
3 Widowed
4 Separated
5 Never married, or
6 A member of an unmarried couple

10

What is your current relationship status?
(Please select only one response)

1 Married
2 Divorced
3 Widowed
BRFSS 2012 Section
4 Separated
7: Demographics
5 Never married

Yes

Or
6 A member of an unmarried couple
Do not read:

INTRO_4

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

11

How many children live in your household that BRFSS 2012 Section How many children less than 18 years of age
are less than 18 years of age?
7: Demographics
live in your household?

No

12

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

N/A

N/A

13

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

N/A

N/A

Page 2 of 31

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

What is the highest grade or year of school you
completed?
What is the highest grade or year of school you
completed?
READ ONLY IF NECESSARY:
1 Never attended school or only attended
kindergarten
INTRO_5 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)

Read only if necessary:

14

1 Never attended school or only attended
kindergarten
2 Grades 1 through 8 (Elementary)
What is the highest grade or year of school you BRFSS 2012 Section 3 Grades 9 through 11 (Some high school)
completed? (Please select only one response) 7: Demographics
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)

No

Do not read:
9 Refused
Please answer BOTH Question 5 about Hispanic
origin and Question 6 about race. For this
survey, Hispanic origins are not races.
Is Person 1 of Hispanic, Latino, or Spanish
origin?

D_01

Are you Hispanic or Latino?

15

Adapted from ACS
Are you Hispanic or Latino? (Please answer
to align with the
both Question 15 about ethnicity and Question HHS Policy for
-No, not of Hispanic, Latino, or Spanish origin
16 about race.)
Improving Race and
-Yes, Mexican, Mexican Am., Chicano
Ethnicity Data
-Yes, Puerto Rican
-Yes, Cuban
-Yes, another Hispanic, Latino, or Spanish origin Print:______

Page 3 of 31

Yes

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

What is your race? Do you consider
yourself…(Feel free to select all that apply.)
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander

What is Person 1's race? Mark (X) one or more
boxes.
-White
-Black, African Am., or Negro
-American Indian or Alaska Native - Print:
______
-Asian Indian
Adapted from ACS
-Chinese
to align with the
-Filipino
HHS Policy for
-Other Asian - Print:_______
Improving Race and
-Japanese
Ethnicity Data
-Korean
-Vietnamese
-Native Hawaiian
-Guamanian or Chamorro
-Samoan
-Other Pacific Islander - Print:______
-Some other race - Print: _______

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…

D_02

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.

16

{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

Original Text in Source

Divergence?

Yes

Are you currently…?
Please read:
Are you currently….?
IF NEEDED, SAY: (Which one of these would you
say is your main status now?)
1 Employed for wages
INTRO_6 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

17

What is your current employment status?
(Please select only one response, 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
BRFSS 2012 Section
6 A Student
7: Demographics
7 Retired
Or
8 Unable to work
Do not read:

Page 4 of 31

Yes

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

18

During the past 30 days, other than your
regular job (if applicable), did you participate in
BRFSS 2012, Section
any physical activities or exercises such as
4: Exercise
running, calisthenics, golf, gardening, or
walking for exercise?

19

What type of physical activity or exercise did
you spend the most time doing during the past
What type of physical activity or exercise did
BRFSS 2011 Section
month? (Please write your answer in the space
you spend the most time doing during the past
10: Exercise
provided below. If needed, refer to FAQ guide,
month?
page 4, for examples.)

No

20

How many times per week or per month did
How many times per week or per month did
BRFSS 2011 Section
you take part in this activity during the past 30
you take part in this activity during the past
10: Exercise
days?
month?

Yes

21

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

Yes

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.

22

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

In a typical week, on how many days do you
walk or bicycle for at least 10 minutes
continuously to get to and from places?

Yes

pa05a

What is the main reason that you walk or bicycle?
Is it for leisure, transportation or exercise?

23

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

N/A

N/A

PA00

PA01

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?

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

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

How many times per week or per month did you
take part in this activity during the past month?
PA02
IF NEEDED, ASK: “Is that __ times per week or __
times per month?”
And when you took part in this activity, for how
many minutes or hours did you usually keep at it?
pa03
IF NEEDED, ASK: “Is that ___ hours or __
minutes?”

Page 5 of 31

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

And when you took part in this activity, for how
BRFSS 2011 Section
many minutes or hours did you usually keep at
10: Exercise
it?

RTI Developed

No

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

pa04

pa04a

pa04b

pa04d

PA04e

pa04c

Item Text in CATI

Item
Number
in PAPI

Now, I would like to talk about the neighborhood
where you live 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 disagree, somewhat disagree, somewhat
agree or strongly agree with the following
statements.
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
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
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
There is a grass/dirt strip that separates the
streets from the sidewalks in my neighborhood.
(Would you say…
READ OPTIONS IF NEEDED
There are bicycle or pedestrian trails in or near my
neighborhood that are easy to get to. (Would you
say…
READ OPTIONS IF NEEDED

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

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

Please circle the answer that best applies to you
and your neighborhood

Yes

24

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

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

No

25

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

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

No

26

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

Sidewalks are separated from the road/traffic in
my neighborhood by parked cars.

No

27

There is a grass or dirt strip that separates the
streets from the sidewalks in my
NEWS
neighborhood.

There is a grass/dirt strip that separates the
streets from the sidewalks in my neighborhood.

No

28

There are bicycle or pedestrian trails in or near
NEWS
my neighborhood that are easy to get to.

There are bicycle or pedestrian trails in or near
my neighborhood that are easy to get to.

No

Page 6 of 31

NEWS

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

pa06

Item Text in CATI
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?
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?

Item
Number
in PAPI

29

IF RESPONDENT RESPONDS LESS THAN ONCE PER
MONTH, SELECT NEVER.
IF NEEDED, SAY:
• (Fruit drinks are sweetened beverages that often
contain some fruit juice or flavoring.)

Item Text in PAPI

Data Source

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

Original Text in Source

What is the number one reason that you did not
walk more frequently in your neighborhood?

Divergence?

Yes

During the past 30 days, how often did you
drink sweetened fruit drinks, such as Kool-aid,
cranberry juice cocktail, and lemonade? Include
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?”

N_05

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

30

Interviewer note: Fruit drinks are sweetened
beverages that often contain some fruit juice or
flavoring. Do not include 100% fruit juice,
During the past 30 days, how often did you
sweet tea, coffee drinks, sports drinks, or
drink sweetened fruit drinks, such as Kool-aid,
BRFSS 2012 Module energy drinks.
cranberry juice cocktail, and lemonade,
5: Sugar sweetened
including fruit drinks you made at home and
beverages
1 _ _ Times per day
added sugar to? (If needed, refer to FAQ page
2 _ _ Times per week
5.)
3 _ _ Times per month

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.

Do not read:
8 8 8 None
7 7 7 Don’t know / Not sure
9 9 9 Refused

YOU MAY READ EXAMPLES FROM LIST UPON
REQUEST.
• Do Include sweetened fruit drinks that they
mixed with alcohol.
• Do not include 100% fruit juice, sweet tea, coffee

Page 7 of 31

Yes

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

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 RESPONDS LESS THAN ONCE PER
MONTH, SELECT NEVER.
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.)

Divergence?

During the past month, how many times per
day, week or month did you drink 100% PURE
fruit juices? Do not include fruit-flavored drinks
with added sugar or fruit juice you
made at home and added sugar to. Only
include 100% juice.
(265-267)

IF RESPONDENT GIVES A NUMBER WITHOUT A
TIME FRAME, ASK: “Was that per day, per week,
or per month?”

N_01

Original Text in Source

31

During the past 30 days, 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 needed, refer to
FAQ page 5.)

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 inclue 100% pure juices including apple,
grapefruit, orange-pineapple, papaya, grape,
mango, orange-tangerine, pineapple.
• Do not include cranberry cocktail, Fruitopia, KoolAid, Power-Ade, Sunny Deight, V8, Gatorade, Hi-C,

1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
5 5 5 Never
7 7 7 Don’t know / Not sure
BRFSS 2012 Module
9 9 9 Refused
8: Fruits and
vegetables
INTERVIEWER NOTE: Do not include fruit drinks
with added sugar or other added sweeteners
like Kool-aid, Hi-C, lemonade, cranberry
cocktail, Tampico, Sunny Delight, Snapple,
Fruitopia, Gatorade, Power-Ade, or yogurt
drinks.
Do not include fruit juice drinks that provide
100% daily vitamin C but include added sugar.
Do not include vegetable juices such as tomato
and V8 if respondent provides but include in
“other vegetables” question 6.

Page 8 of 31

Yes

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

During the past month,(that is since [FILL IN DAY
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?”

N_02

Divergence?

During the past month, not counting juice, how
many times per day, week, or month did you
eat fruit? Count fresh, frozen, or canned fruit
(268-270)
1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
5 5 5 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused

IF RESPONDENT RESPONDS LESS THAN ONCE PER
MONTH, SELECT NEVER.
IF NEEDED, SAY: (Include cut up fresh, frozen, or
canned fruit. Do not include dried fruit in ready-toeat cereals. Do not include fruit jams and similar
products.)

Original Text in Source

32

During the past 30 days, how often did you eat
BRFSS 2012 Module
fruit, including fresh, frozen, or canned fruit?
8: Fruits and
(Do not count juice or sweetened fruit drinks.)
vegetables
(If needed, refer to FAQ page 5.)

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.

Read only if necessary: “Your best guess is fine.
Include apples, bananas, applesauce, oranges,
grape fruit, fruit salad, watermelon, cantaloupe
or musk melon, papaya, lychees, star fruit,
pomegranates, mangos, grapes, and berries
such as blueberries and strawberries.”
INTERVIEWER NOTE: Do not count fruit jam,
jelly, or fruit preserves.
Do not include dried fruit in ready-to-eat
cereals.

YOU MAY READ EXAMPLES FROM LIST UPON
REQUEST.
• Do inclue apples, applesauce, akee, bananas,
blueberries, bread fruit, cantaloupe, carambola,
figs, genip, grapefruit, grapes, fruit salad, longans,
lychees, mangos, must, melon, oranges, papaya,
pomegranates, rambutan, sea grapes, soursop,
star fruit, strawberries, sugar apple, tamarind,

Do include dried raisins, cran-raisins if
respondent tells you - but due to their small
serving size they are not included in the prompt.
Do include cut up fresh, frozen, or canned fruit
added to yogurt, cereal, jello, and other meal

Page 9 of 31

Yes

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

Item Text in PAPI

Data Source

Original Text in Source

During the past month, (that is since [FILL IN DAY
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.

During the past month, 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.
(271-273)

IF RESPONDENT GIVES A NUMBER WITHOUT A
TIME FRAME, ASK: “Was that per day, per week,
or per month?”

1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
5 5 5 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused

IF RESPONDENT RESPONDS LESS THAN ONCE PER
MONTH, SELECT NEVER.
N_13

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

IF NEEDED, SAY:
• (Include round or oval beans, soybeans, and
bean burgers. Do not include long green beans.)
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 inlclude black-eyed peas, cow peas,
edamame, falafel, garden burgers, hummus,
lentils, lima beans, kidney beans, navy beans, pinto
beans, soy beans, split peas, tempeh, tofu, veggie
bugers and white beans.
• Do not include broad beans, pole beans, string

33

During the past 30 days, how often did you eat
cooked or canned beans, such as refried beans,
baked beans, black beans, garbanzo beans,
BRFSS 2012
beans in soup, soybeans, edamame, tofu, or
lentils? (If needed, refer to FAQ page 6.)

Read only if necessary: “Include round or oval
beans or peas such as navy, pinto, split peas,
cow peas, hummus, lentils, soy beans and tofu.
Do NOT include long green beans such as string
beans, broad or winged beans, or pole beans.”
INTERVIEWER NOTE: Include soybeans also
called edamame, TOFU (BEAN CURD MADE
FROM SOYBEANS), kidney, pinto, hummus,
lentils, black, black-eyed peas, cow peas, lima
beans and white beans.
Include bean burgers including garden burgers
and veggie burgers.
Include falafel and tempeh

Page 10 of 31

Divergence?

Yes

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

Item Text in PAPI

Data Source

Original Text in Source

During the past month, (that is since [FILL IN DAY
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?

During the past month, 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?
(274-276)

IF RESPONDENT GIVES A NUMBER WITHOUT A
TIME FRAME, ASK: “Was that per day, per week,
or per month?”

1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
5 5 5 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused

IF RESPONDENT RESPONDS LESS THAN ONCE PER
MONTH, SELECT NEVER.
N_14

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

IF NEEDED, SAY
• (Include all raw leafy green salads and cooked
greens, but do not inclulde iceberg lettuce.)
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 arugula, bok choy, choys, collard
greens, dandelions, kale, komatsuna, mesclun,
mustard greens, romaine lettuce, spinach, turnip
greens, watercress
• Do not include iceberg lettuce

34

During the past 30 days, how often did you eat
dark green vegetables, for example, broccoli
or dark leafy greens including romaine, chard, BRFSS 2012
collard greens or spinach? (If needed, refer to
FAQ page 6.)

Yes
INTERVIEWER NOTE: Each time a vegetable is
eaten it counts as one time.
INTERVIEWER NOTE: Include all raw leafy green
salads including spinach, mesclun, romaine
lettuce, bok choy, dark green leafy lettuce,
dandelions, komatsuna, watercress, and
arugula.
Do not include iceberg (head) lettuce if
specifically told type of lettuce. Include all
cooked greens including kale, collard greens,
choys, turnip greens, mustard greens.

Page 11 of 31

Divergence?

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

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

During the past month, how many times per
day, week, or month did you eat orangecolored vegetables such as sweet potatoes,
pumpkin, winter squash, or carrots?
(277-279)

IF RESPONDENT GIVES A NUMBER WITHOUT A
TIME FRAME, ASK: “Was that per day, per week,
or per month?”

1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
5 5 5 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused

IF RESPONDENT RESPONDS LESS THAN ONCE PER
MONTH, SELECT NEVER.

N_15

Original Text in Source

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 desserttype food containing pumpkin. )
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 acorn squash, autumn cup squash,
bab-cut carrots, baked sweet potato, banana
squash, buttercup squash, butternut squash,
carrot-slaw, delicata squash, hubbard squash,
kabocha squash, long carrots, mashed sweet
potato (mashed, casserole, pie), pumpkin,

35

During the past 30 days, how often did you eat
orange-colored vegetables such as sweet
BRFSS 2012
potatoes, pumpkin, winter squash, or carrots?
(If needed, refer to FAQ page 6.)

Read only if needed: “Winter squash have hard,
thick skins and deep yellow to orange flesh.
They include acorn, buttercup, and spaghetti
squash.”
FOR INTERVIEWER: Include all forms of carrots
including long or baby-cut.
Include carrot-slaw (e.g. shredded carrots with
or without other vegetables or fruit).
Include all forms of sweet potatoes including
baked, mashed, casserole, pie, or sweet
potatoes fries.
Include all hard-winter squash varieties
including acorn, autumn cup, banana,

Page 12 of 31

Divergence?

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

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 DAY
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?

N_11

IF SAYS LESS THAN ONCE PER MONTH, SELECT
NEVER.
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.)
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 american-style cole-slaw, avocado,
bean sprouts, beets, broad beans, cabbage,
Thinking now about buying, preparing, and eating
fruits and vegetables, please say if you strongly
disagree, somewhat disagree, somewhat agree or
strongly agree with each statement.

Divergence?

Not counting what you just told me about,
during the past month, about how many times
per day, week, or month did you eat OTHER
vegetables? Examples of other vegetables
include tomatoes, tomato juice or V-8 juice,
corn, eggplant, peas, lettuce, cabbage, and
white potatoes that are not fried such as baked
or mashed potatoes.
(280-282)

IF RESPONDENT GIVES A NUMBER WITHOUT A
TIME FRAME, ASK: “Was that per day, per week,
or per month?”
N_16

Original Text in Source

36

During the past 30 days, how often 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? (Do not
BRFSS 2012
count the dark green vegetables and orangecolored vegetables that you counted in the
previous questions.) (If needed, refer to FAQ
page 7.)

1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
5 5 5 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused

Yes

Read only if needed: “Do not count vegetables
you have already counted and do not include
fried potatoes.”
INTERVIEWER NOTE: Include corn, peas,
tomatoes, okra, beets, cauliflower, bean
sprouts, avocado, cucumber, onions, peppers
(red, green, yellow, orange); all cabbage
including American-style cole-slaw; mushrooms,
snow peas, snap peas, broad beans, string, wax, or pole-beans.

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

Page 13 of 31

Include any form of the vegetable (raw, cooked,
HBS

Indicate how strongly you agree with each item
using the following scale:

Yes

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI
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

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

37

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

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

Yes

38

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

HBS

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

No

39

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

HBS

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

No

40

Fruits and vegetables take too much time to
prepare.

HBS

It takes too much time to prepare fruits and
vegetables.

Yes

N_11e

I do not like the taste of fruits. (Would you say…
1 Strongly Agree
2 Somewhat Agree
3 Somewhat Disagree
4 Strongly Disagree

41

I do not like the taste of fruits.

HBS

I enjoy eating fresh fruits.

Yes

N_11f

I do not like the taste of vegetables. (Would you
say…
1 Strongly Agree
2 Somewhat Agree
3 Somewhat Disagree
4 Strongly Disagree

42

I do not like the taste of vegetables.

HBS

I enjoy eating fresh raw and cooked vegetables.

Yes

N_11a

N_11b

N_11c

N_11d

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
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
Fruits and vegetables take too much time to
prepare. (Would you say…
1 Strongly Agree
2 Somewhat Agree
3 Somewhat Disagree
4 Strongly Disagree

Page 14 of 31

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

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.
N_17

IF RESPONDENT GIVES A NUMBER WITHOUT A
TIME FRAME, ASK: “Was that per day, per week,
or per month?”

In the past 30 days, how often did {you/SP}
have milk to drink or on {your/his/her} cereal?
Please include chocolate and other flavored
milks as well as hot cocoa made with milk. Do
not count small amounts of milk added to
coffee or tea. Would you say…

43

During the past 30 days, how many times per
day, week or month did you drink milk as a
NHANES 2006: Food
beverage (not in coffee, not in cereal)? In your Frequency
answer, please include chocolate milk and hot Questionnaire
chocolate.

44

What kind of milk did you drink most of the
NHANES 2006: Food
time? (Please select only one response.) (Mark Frequency
What type of milk was it? Was it usually…
if the milk was flavored in Question 45.)
Questionnaire

Yes

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)
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
N_17a

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

Page 15 of 31

Yes

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

N_17b

Item Text in CATI

[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?)

Item
Number
in PAPI

N_04

46

During the past 30 days, how often did you
drink regular soda or pop that contains sugar, BRFSS 2012 Module
not including diet soda or diet pop? (Please
5: Sugar sweetened
include regular soda that was mixed with
beverages
alcohol.)

During the past month, (that is since [FILL IN
DATE30 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?”

Data Source

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

IF SAYS LESS THAN ONCE PER MONTH, SELECT
NEVER.
IF NEEDED, SAY: (Please include regular soda that
was mixed with alcohol.)

N_03

Item Text in PAPI

45

IF RESPONDENT GAVE A RESPONSE SUCH AS
“CHOCOLATE MILK” IN THE PREVIOUS QUESTION
SELECT YES AND CONTINUE, ELSE ASK QUESTION

During the past 30 days, (that is since [FILL IN DAY
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?”

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

47

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

IF SAYS LESS THAN ONCE PER MONTH, SELECT
NEVER.

Page 16 of 31

Original Text in Source

N/A

Divergence?

N/A

Interviewer note: Please remind respondents
to include regular soda that they mixed with
alcohol.
Yes
During the past 30 days, how often did you
drink regular soda or pop that contains sugar?
Do not include diet soda or diet pop.

During the past 7 days, how many times did you
drink an 8 ounce bottle or glass of plain water?
Count tap, bottled, and unflavored sparkling
water.

Yes

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

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
5. Never

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
5. Never

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

48

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

How often {does your family/do you} have fruits
available at home? This includes fresh, dried,
NHANES 2010:
canned and frozen fruits. Would you say always,
Consumer Behavior
most of the time, sometimes, rarely, or never?
HAND CARD CBQ1

Yes

49

How often {does your family/do you} have any
of these dark green vegetables available at
How often do you have any of these dark green
home? This includes fresh, dried, canned, and
vegetables available at home? Broccoli;
frozen vegetables. [Would you say always, most
NHANES 2010:
spinach and other greens like collard, mustard,
of the time, sometimes, rarely, or never?]
Consumer Behavior
and turnip greens; and dark green leafy lettuce
HAND CARD CBQ2 and HAND CARD CBQ3.
like romaine.
INTERVIEWER INSTRUCTION: DO NOT INCLUDE
ICEBERG, BUTTERHEAD, BOSTON, AND MANOA
LETTUCE

Yes

Page 17 of 31

Original Text in Source

Divergence?

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

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.
N_06

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.)

50

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Original Text in Source

During the past 7 days, how many meals {did
you/did SP} get that were prepared away from
During the past 7 days, how many meals did
home in places such as restaurants, fast food
you get that were prepared away from home
NHANES 2010: Diet places, food stands, grocery stores, or from
in places such as restaurants, fast-food places,
Behavior and
vending machines? {Please do not include meals
food stands, grocery stores, or from vending
Nutrition
provided as part of the school lunch or school
machines? (Please do not include meals
breakfast./Please do not include meals provided
provided as part of community programs.)
as part of the community programs you
reported earlier.}

Page 18 of 31

Divergence?

No

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Original Text in Source

NHANES 2010: Diet
How many of those meals {did you/did SP} get
Behavior and
from a fast-food or pizza place?
Nutrition

Divergence?

N_07

How many of those meals did you get from a fastfood or pizza place?

51

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

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?

52

Are you currently on any kind of diet, either to NHANES 2010:
lose weight or for some other health reason? Dietary Interview

{Are you/Is NAME} on any kind of diet, either to
lose weight or for some other health-related
reason?

Yes

53

What kind of diet are you on? (Feel free to
select all that apply.)

NHANES 2010:
Dietary Interview

What kind of diet {are you/is NAME} on? [READ
AS NEEDED: Is it a weight loss or low calorie
diet; low fat or low cholesterol diet; low salt or
sodium diet; diabetic diet; or another type of
diet?]

N/A

BRFSS 2012 Section Have you smoked at least 100 cigarettes in your
9: Tobacco Use
entire life? NOTE: 5 packs = 100 cigarettes

No

What kind of diet are you on?
N_12a

ACCEPT ALL ANSWERS AND PROBE UNTIL R
INDICATES NO OTHERS APPLY: Any others?
[ALLOW MORE THAN ONE ANSWER]

CG01

To begin, have you smoked at least 100 cigarettes
in your entire life? IF NEEDED, SAY: (5 packs = 100
cigarettes)

54

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

CG02

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

55

Do you now smoke cigarettes every day, some BRFSS 2012 Section Do you now smoke cigarettes every day, some
days, or not at all?
9: Tobacco Use
days, or not at all?

Page 19 of 31

No

No

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item
Number
in PAPI

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

56

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

BRFSS 2012 Section How long has it been since you last smoked a
9: Tobacco Use
cigarette, even one or two puffs?

No

57

Not counting decks, porches, or garages, inside
Not counting decks, porches, or garages, inside BRFSS 2011 Module your home, is smoking…
your home, is smoking …? (Please select only 16: Secondhand
1 Always allowed
one.)
Smoke
2 Allowed only at some times or in some places
3 Never allowed

No

58

The next question asks about tobacco use in
indoor public places. Examples of indoor public
places are the indoor areas of stores,
During the past 7 days, not counting times
restaurants, bars, casinos, clubs, and sports
while you were at work, on how many days did
you breathe the smoke from someone else
BRFSS 2011 Module arenas.
4. [If Q8.9 = 1 (Employed) or Q8.9
who was smoking in an indoor public place?
16: Secondhand
‖ = 2 (Selfemployed); say “Not counting
(Examples of indoor public places are the
Smoke
times while you were at work, ] during the past
indoor areas of stores, restaurants, bars,
7 days, that is, since last [TODAY‟S DAY OF
casinos, clubs, and sports arenas.)
WEEK], on how many days did you breathe the
smoke from someone else who was smoking in
an indoor public place?

Yes

59

At workplaces, do you think smoking indoors
should be…? (Please select only one)

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

No

CG08

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

60

Would you favor a policy that bans smoking in
all areas of multi-unit housing, including
NY-ATS 2009
personal living spaces, such as balconies and
patios?

Would you be in favor of a policy in your
residential building that bans smoking in all
area, including personal living spaces such as
balconies and patios?

Yes

H_01

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

61

Is there a place that you usually go to when
NHIS 2012
you are sick or need advice about your health?

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

Yes

CG03

Item Text in CATI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

How long has it been since you last smoked a
cigarette, even one or two puffs?
READ ANSWER CATEGORIES ONLY IF NEEDED
Not counting decks, porches, or garages, inside
your home, is smoking …?

CG05

CG06

1. Always allowed
2. Allowed only at some times or in some places
3. Never allowed

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

CG07

1. Always allowed
2. Allowed only at some times or in some places
3. Never allowed

Page 20 of 31

NATS 2009-2010

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

H_01a

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?

H_01b

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

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

NHIS 2012

[Fill1: What kind of place is it - a clinic, doctor's
office, emergency room, or some other place?
[Fill2: What kind of place do you go to most
often - 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

Yes

62

What kind of place do you go to most often?

63

Is that the same place you usually go to when
you need routine or preventive care, such as a NHIS 2012
physical examination or check up?

Is that {fill: place from (APLKIND)} the same
place you USUALLY go when you need routine
or preventive care, such as a physical
examination or check up?

No

64

What kind of place do you usually go to when
you need routine or preventive care, such as a NHIS 2012
physical examination or check-up?

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

No

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

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

Page 21 of 31

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

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

H_01d

CHOOSE ALL THAT APPLY
ACCEPT ALL ANSWER AND PROBE UNTIL R
INDICATES NO OTHERS APPLY: Any others?
READ ANSWER OPTIONS ONY 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

65

Why don’t you have a usual source of medical
NHIS 2012
care? (Feel free to select all that apply.)

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

No

66

About how long has it been since you last
visited a doctor for a routine checkup? (A
BRFSS 2012 Section
routine checkup is a general physical exam, not 3: Health Care
an exam for a specific injury, illness, or
Access
condition.)

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

Yes

67

Has a doctor or other health professional ever
BRFSS 2011 Module advised you to do any of the following to help
Has a doctor or other health professional ever
10: Actions to
lower or control your high blood pressure?
advised you to reduce sodium or salt intake?
Control High BP
(Ever advised you to) cut down on salt (to help
lower or control your high blood pressure)?

Yes

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

H_17

H_02

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

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

Page 22 of 31

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

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

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

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

68

Have you ever been told by a doctor, nurse, or
other health professional that you have high
BRFSS 2011 Section
blood pressure? (By "other health
4: Hypertension
professional" we mean a nurse practitioner, a
Awareness
physician's assistant, or some other licensed
health professional.)

Original Text in Source
Have you EVER been told by a doctor, nurse, or
other health professional that you have
high blood pressure?
(84)
‖
Read only if necessary: By ―other health
professional we mean a nurse practitioner, a
physician‘s assistant, or some other licensed
health professional

Divergence?

Yes

H_03a

Was this only when you were pregnant?

69

Was this only when you were pregnant?

BRFSS 2011 Section
4: Hypertension
“Was this only when you were pregnant?”
Awareness

No

H_05

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

70

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

BRFSS 2011 Module
(Are you) exercising (to help lower or control
10: Actions to
your high blood pressure)?
Control High BP

No

H_06

Are you currently taking medicine for your high
blood pressure?

71

BRFSS 2011 Module
Are you currently taking medicine for your high
Are you currently taking medicine for your high
4: Hypertension
blood pressure?
blood pressure?
Awareness

No

H_07

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

72

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

BRFSS 2011 Module
(Are you) cutting down on salt (to help lower or
10: Actions to
control your high blood pressure)?
control High BP

No

H_08

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

73

Blood cholesterol is a fatty substance found in BRFSS 2011 Section Blood cholesterol is a fatty substance found in
the blood. Have you ever had your blood
5: Cholesterol
the blood. Have you EVER had your blood
cholesterol checked?
Awareness
cholesterol checked?

Page 23 of 31

No

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

74

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

BRFSS 2011 Section
About how long has it been since you last had
5: Cholesterol
your blood cholesterol checked?
Awareness

No

75

Adapted from
Have you ever been told by a doctor, nurse or
Have you EVER been told by a doctor, nurse or
BRFSS 2011 Section
other health professional that your blood
other health professional that your blood
5: Cholesterol
cholesterol is high?
cholesterol is high?
Awareness

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

H_09

H_10

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

H_05

Are you exercising to help lower your cholesterol?

H_06

Are you currently taking medicine to lower your
cholesterol?

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?

76

Are you exercising to help lower your
cholesterol?

Adapted from
BRFSS 2011 Section
(Are you) exercising (to help lower or control
10: Actions to
your high blood pressure)?
Control High Blood
Pressure

77

Are you currently taking medicine to lower
your cholesterol?

Adapted from
BRFSS 2011 Section Are you currently taking medicine for your high
4: Hypertension
blood pressure?
Awareness

Yes

78

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

Now thinking about your physical health, which
BRFSS 2012 Section includes physical illness and injury, for how
2: Healthy Days
many days during the past 30 days was your
physical health not good?

Yes

Page 24 of 31

Yes

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

During the past 30 days, for about how many
BRFSS 2012 Section days did poor physical or mental health keep
2: Healthy Days
you from doing your usual activities, such as selfcare, work, or recreation?

Yes

H_18a

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?

79

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

H_19

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

80

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

Have you EVER been told by a doctor or other
Adapted from NHIS
health professional that you had
2012
…Depression?

Yes

H_20

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

81

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

Have you EVER been told by a doctor or other
Adapted from NHIS
health professional that you had
2012
…Depression?

Yes

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---

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--HF_01

1 Always
2 Usually
3 Sometimes
4 Rarely or
5 Never

82

How often in the past 12 months would you
BRFSS 2012 Module Please read:
say you were worried or stressed about having
18: Social Context
1 Always
enough money to pay your rent/mortgage?
2 Usually
3 Sometimes
4 Rarely
5 Never

Page 25 of 31

Yes

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

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
5 Never

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?

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?

H12

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?

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

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--Please read:

83

And how often in the past 12 months would
BRFSS 2012 Module
you say you were worried or stressed about
18: Social Context
having enough money to buy nutritious meals?
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never

Yes

84

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?

Are you now taking medicine or receiving
BRFSS 2012 Module
treatment from a doctor or other health
17: Mental Illness
professional for any type of mental health
and Stigma
condition or emotional problem?

No

85

Now, in thinking about your overall mental
health, which includes stress, depression, and
problems with emotions, for how many days
during the past 30 days was your mental
health not good?

Now thinking about your mental health, which
includes stress, depression, and problems with
BRFSS 2012 Section
emotions, for how many days during the past
2: Healthy Days
30 days was your mental health not
good?

Yes

86

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

During the past 30 days, for about how many
BRFSS 2012 Section days did poor physical or mental health keep
2: Healthy Days
you from doing your usual activities, such as selfcare, work, or recreation?

Yes

Page 26 of 31

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

IF NEEDED , SAY: “Please include support from
any source.”
87
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never

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?

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

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

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

H19

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

INTERVIEWER NOTE: If asked, say “please
include support from any source.”
BRFSS 2012 Module (420)
How often do you get the social and emotional
27: Emotional
support you need? (Please include support
Please read:
Support and Life
from any source.)
Satisfaction
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never

No

88

Earlier in this survey, you were asked to selfidentify your race. Now, we want to find out
BRFSS 2012
how other people usually identify you in this
Reactions to Race
country? (Please select only one response
option. If needed, refer to FAQ guide, page 6.)

Earlier I asked you to self-identify your race.
Now I will ask you how other people identify
you and treat you.
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?

Yes

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?

89

How often do you think about your race?

BRFSS 2012
Reactions to Race

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?

No

D_06

To your knowledge, are you now pregnant?

90

To your knowledge, are you now pregnant?

BRFSS 2012 Section
To your knowledge, are you now pregnant?
7: Demographics

D_09

IF NEEDED, SAY: We want to know how other
people usually classify you in this country, which
might be different from how ou classify yourself.
ONLY ONE SELECTION ALLOWED.
IF NEEDED, SAY: "How do other people usually
classsify you in this country?

Page 27 of 31

No

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

D_07

Item Text in CATI
About how much do you weigh without shoes?
RECORD WEIGHT IN EITHER POUNDS *OR*
KILOGRAMS (NOT BOTH)

Item
Number
in PAPI

Data Source

Original Text in Source

Divergence?

About how much do you weigh without shoes?
BRFSS 2012 Section
(You may record your weight in earlier pounds
About how much do you weigh without shoes?
7: Demographics
or kilograms.)

No

92

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

No

About how tall are you without shoes?
RECORD HEIGHT IN EITHER FEET AND INCHES OR
IN METERS AND CENTIMETERS

Item Text in PAPI

91

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

D_08

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Page 28 of 31

BRFSS 2012 Section
About how tall are you without shoes?
7: Demographics

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

Item Text in CATI

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Original Text in Source

Divergence?

Is your annual household income from all
sources—
If respondent refuses at ANY income level,
code ‘99’ (Refused)
Read only if necessary:
INTRO_7. What is your annual household income
from all sources INTRO_7_04 – (What is your annual household
income from all sources?) Is it less than $25,000?
INTRO_7_03 - – (What is your annual household
income from all sources?) Is it less than $20,000
INTRO_7_02 - – (What is your annual household
income from all sources?) Is it less than $15,000
INTRO_7
INTRO_7_01 - – (What is your annual household
income from all sources?) Is it less than $10,000
INTRO_7_05 - – (What is your annual household
income from all sources?) Is it less than $35,000 I
NTRO_7_06 - – (What is your annual household
income from all sources?) Is it less than $50,000
INTRO_7_07 - – (What is your annual household
income from all sources?) Is it less than $75,000

What is your annual household income from
all sources? (Please select only one response.)

93

0 4 Less than $25,000 If “no,” ask 05; if “yes,”
ask 03
($20,000 to less than $25,000)
0 3 Less than $20,000 If “no,” code 04; if “yes,”
ask 02
BRFSS 2012 Section ($15,000 to less than $20,000)
7: Demographics
0 2 Less than $15,000 If “no,” code 03; if “yes,”
ask 01
($10,000 to less than $15,000)

○ Less than $10,000
○ $10,000 to $14,999
○ $15,000 to $19,999
○ $20,000 to $24,999
○ $25,000 to $34,999
○ $35,000 to $49,999
○ $50,000 to $74,999
○ $75,000 or more

0 1 Less than $10,000 If “no,” code 02
0 5 Less than $35,000 If “no,” ask 06
($25,000 to less than $35,000)
0 6 Less than $50,000 If “no,” ask 07
($35,000 to less than $50,000)
0 7 Less than $75,000 If “no,” code 08
($50,000 to less than $75,000)

Page 29 of 31

Yes

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

D_11a
D_11b

Item Text in CATI
Which of the following best represents how you
think of yourself?
1. [For men] Gay [For women] Lesbian or gay
2. [For men] Straight, that is, not gay
[For women] Straight, that is, not lesbian
or gay
3. Bisexual
4. Something Else
5. I don't know the answer
-2.REFUSED

Item
Number
in PAPI

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

Lesbian or gay
Straight, that is, not lesbian or gay
Bisexual
Something Else
I don’t know the answer

NHIS 2013

No

NHIS 2013

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
7 Refused
9 Don't know

No

NHIS 2013

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
7 Refused
9 Don't know

No

What do you mean by something else?

D_12.

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

95

What do you mean by something else?
1. You are not straight, but identify with
another label such as queer, trisexual,
omnisexual or pan-sexual
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

What do you mean by don't know?

D_13

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

96

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

Page 30 of 31

Divergence?

Which of the following best represents how you
think of yourself?
1 [For men] Gay
[For women] Lesbian or gay
2 [For men] Straight, that is, not gay
[For women] Straight, that is, not
lesbian or gay
3 Bisexual
4 Something Else
5 I don't know the answer
7 Refused

Which of the following best represents how
you think of yourself?
94

Original Text in Source

Adult Targeted Surveillance Survey - Documentation of Question Provenance
ACS = American Community Survey
BRFSS = Behavioral Risk Factor Surveillance System
CPPW BRFSS = Communities Putting Prevention to Work BRFSS Module
GPAQ = Global Physical Activity Questionnaire (World Health Organization)
Item
Name in
CATI

D_14

Item Text in CATI

What do you mean by something else?

Item
Number
in PAPI

97

HBS = Health Behavior Survey (Sallis, 2001)
NEWS = Neighborhood Environment Walkability Scale (Sallis, 2002)
NHANES = National Health and Nutrition Examination Survey
NHIS = National Health Interview Survey
NY-ATS = New York Adult Tobacco Survey

Item Text in PAPI

Data Source

What do you mean by something else?

Page 31 of 31

NHIS 2013

Original Text in Source

What do you mean by something else?

Divergence?

No