Participant Questionnaire

Form Approved

OMB No. 0920-xxxx

Expiration date: xx/xx/xxxx

Participant Questionnaire

Public reporting burden of this collection of information is estimated to average 10 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, M/S D74, Atlanta, GA 30333, ATTN: PRA 0920-xxxx.

This is an interviewer-administered questionnaire

Date of Clinic Visit: ____/____/______

First, I would like to verify the spelling of your name, your address, and your telephone numbers:

Participant Name: __________________________________________

Address: __________________________________________________

What is the best telephone number at which to reach you?

Telephone number: _________________________________________

Is there another telephone number at which we can reach you?

Telephone number:_________________________________________

Are there any other telephone numbers at which we can reach you?

Telephone number: ________________________________________

INSTRUCTIONS FOR INTERVIEWER: Record information on race and ethnicity from “Telephone Recruitment and Screening Script” form:

Gender: ______Female ______Male

Ethnicity: _____Hispanic _____Non-Hispanic

Race: ____White _____Black _____Asian_____ American Indian or Alaska Native _____Native Hawaiian or Other Pacific Islander

(Select one or more.)

INSTRUCTIONS FOR INTERVIEWER: The following question is asked to verify that age has not changed, i.e., a birthday occurred, since recruitment and screening.

What is your age? Age: __________ years

Do you live alone or with someone?

______Alone  

______Live with someone/others

______Refused

______Don’t know


Do you currently smoke cigarettes? 

_____Yes (current smoker) 

_____No (not current smoker)

_____Refused

_____Don’t know

HELP FOR INTERVIEWER: Cigarette: Respondent defined. Do not include cigars or marijuana.

Have you ever been told by a doctor or other health professional that you had hypertension (hy-per-ten-shun), also called high blood pressure?

______Yes

______No

______Refused

______Don’t know

INTERVIEWER INSTRUCTION:IF HIGH BLOOD PRESSURE ONLY DURING PREGNANCY, CODE “No.”

IF SAYS “HIGH NORMAL BLOOD PRESSURE”, “BORDERLINE HYPERTENSION” OR “PREHYPERTENSION” CODE “No”.

HELP FOR INTERVIEWER:Hypertension (High Blood Pressure): A repeatedly increased blood pressure with the first number 140 or higher and the second number 90 or higher.

IF YES [participant has hypertension/high blood pressure],

Because of your high blood pressure/hypertension (hy-per-ten-shun), have you ever been told to take prescribed medicine?

____Yes

____No

____Don’t know

____Refused

HELP FOR INTERVIEWER:

Prescribed Medicine: Prescribed medicines are those ordered by a doctor or other health provider through a written or verbal prescription for a pharmacist to fill. Prescription medicines can also be given by a medical provider directly to a patient to take home, such as free samples.

If YES [ever told to take prescribed medicine],

Are you now taking a prescribed medicine [for your high blood pressure/ hypertension (hy-per-ten-shun)?

____Yes

____No

____Don’t know

____Refused

INTERVIEWER INSTRUCTIONS: In the next questions Read “Other than during Pregnancy” for FEMALES ONLY:

[FOR FEMALES ONLY: Other than during pregnancy], have you ever been told by a doctor or other health professional that you have diabetes or sugar diabetes?

____Yes

____No

____BORDERLINE OR PREDIABETES

____Don’t know

____Refused

HELP FOR INTERVIEWERS: PREDIABETES, IMPAIRED FASTING GLUCOSE, IMPAIRED GLUCOSE TOLERANCE, OR BORDERLINE DIABETES OCCURS WHEN BLOOD SUGAR (GLUCOSE) LEVELS ARE HIGHER THAN NORMAL BUT NOT HIGH ENOUGH TO BE DIABETES. INTERVIEWER INSTRUCTIONS: If participant states they were told they have one of these please check “BORDERLINE or PREDIABETES”

If YES (been told have diabetes or sugar diabetes):

Are you currently taking insulin or diabetic pills to lower your blood sugar?

______Yes

______No

______ Don’t know

______ Refused

HELP FOR INTERVIEWERS : Insulin: A chemical used in the treatment of diabetes. Typically, insulin is administered with a syringe by the patient. Diabetic pills are sometimes called oral agents or oral hypoglycemic agents.

What is the highest grade or level of school you have completed or the highest degree you have received?

English Instructions:

HAND CARD DMQ1 READ HAND CARD CATEGORIES IF NECESSARY ENTER HIGHEST LEVEL OF SCHOOL

_____Less than 9^th grade

_____9-11th Grade (Includes 12th grade with no diploma)

_____ High School Grad/GED or Equivalent

_____ Some College or AA degree

_____ College Graduate or above

_____ Refused/ Don’t know