Form 1 Active Follow-up Sub-cohort

National Institute of Environmental Health Sciences (NIEHS)
Version 1.0 (04/08/2013)

GuLF STUDY

OMB#0925-XXXX
EXP. XX/XXXX

Active Follow-up Sub-cohort
Telephone Questionnaire

Public reporting burden for this collection of information is estimated to average 30 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. An agency may not conduct
or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance
Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0626). Do not
return the completed form to this address.

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Table of Contents
Part 1: Introductory Scripts (Estimated Burden: 2 Minutes) ...........................3
SECTION A: Introduction............................................................................................. 4
SECTION B: Deceased or Incapacitated Participants ................................................. 7
Part 2: Follow-up Questionnaire (Estimated Burden: 30 Minutes)................16
SECTION C: Background Information ....................................................................... 17
SECTION D: Demographic Measures ....................................................................... 19
SECTION E: Clean-up Related Tasks and Exposures During Clean-up ................... 20
SECTION F: Health ................................................................................................... 22
SECTION G: Mental Health ....................................................................................... 41
SECTION H: Lifestyle - Alcohol ................................................................................. 48
SECTION I: Lifestyle - Tobacco ................................................................................. 51
SECTION J: Socioeconomic Factors ......................................................................... 54
SECTION K: Residential History ............................................................................... 57
SECTION L: Experiences with Hurricane Katrina ...................................................... 58
Part 3: Scripts – Post-Telephone Scripts (Estimated Burden: 2 Minutes) ...60
SECTION M: Wrap-up ............................................................................................... 61

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Part 1: Introductory Scripts (Estimated
Burden: 2 Minutes)

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SECTION A: Introduction
SECTION 1: Initial Contact
SECTION 1: NO ANSWER
Voicemail Script:
Hi, I’m calling about the oil spill health study also known as the GuLF STUDY, sponsored by the
National Institutes of Health. I am trying to reach [PARTICIPANT’S NAME]. I am sorry I missed
you and will call you back later. You are also welcome to call us, toll-free at 1-855-644-4853.
Thank you.

[TERMINATE CALL]
SECTION 1: ANSWER
Contact Script:
Hi, I’m calling from the GuLF STUDY, the oil spill health study sponsored by the National
Institutes of Health. May I please speak to [PARTICIPANT’S NAME]?
A1. CODE ONE OF THE FOLLOWING 7:
1. LEFT PARTICIPANT VOICEMAIL
2. PARTICIPANT TEMPORARILY NOT AVAILABLE
CONTINUE TO A2
3. PARTICIPANT MOVED
CONTACT SCRIPT QUESTION A3
4. PARTICIPANT REACHED (CONTINUE)
GO TO SECTION A4
5. PARTICIPANT PREVIOUSLY CONTACTED
GO TO SECTION A8
6. PARTICIPANT DECEASED
SECTION B1
7. PARTICIPANT INCAPACITATED
SECTION B13
Participant Temporarily Not Available:
A2. I am sorry I missed [HIM/HER/NAME]. What is the best time to reach [HIM/HER/NAME]?
A2.a. DATE 1: __/__/___ [MM/DD/YYYY]
TIME OF DAY 1: _/_/ [AM/PM]
A2.b. DATE 2: __/__/___ [MM/DD/YYYY]
TIME OF DAY 2: _/_/ [AM/PM]

[TERMINATE CALL]
Participant Moved:
A3. It is important that we speak to [PARTICIPANT]. Do you have a telephone number or
address where [PARTICIPANT’S NAME] can be reached?
YES .......................... 1
NO ............................ 2 [TERMINATE CALL]
DON’T KNOW ........... 8 [TERMINATE CALL]
REFUSED................. 9 [TERMINATE CALL]
A3.a. What is the phone number?
I_I_I_I_I_I_I_I_I_I_I TEN DIGIT #

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DON’T KNOW ........... 8 [GO TO A3.c]
REFUSED ................. 9 [GO TO A3.c]
A3.b. Is this a cell phone number?
YES ........................... 1
NO............................. 2
DON’T KNOW ........... 3
REFUSED ................. 4
A3.c. What is the address?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
Zip Code: ___/___/___/___/___/
DON’T KNOW ........... 8
REFUSED ................. 9
Thank you.

[TERMINATE CALL]
SECTION A4: Introduction to the Study

[IF PARTICIPANT INITIALLY ANSWERED THE PHONE]
Hi, my name is [INTERVIEWER’S NAME]. Thank you for enrolling in the GuLF STUDY and for
completing the initial interview earlier. We recently sent you a mailing inviting you to take part in
a follow-up interview about your health. The interview should take only 30 to 40 minutes to
complete. All of your responses are confidential, and you may refuse to answer any questions.
If you complete this survey, you will be entered into a drawing where you will have a chance to
receive a $500 gift card. This drawing will be held after every 500th participant completes a
telephone interview. There is no cost associated with entering the drawing or accepting the
prize.
A4.a. Are you in a place where you can safely talk on the phone?
YES ............... 1 [GO TO A5]
NO................. 2
I will attempt to contact you again soon. Thank you for your time.

[TERMINATE CALL]

INTRODUCTION / CONSENT SCRIPTS: CONTINUE FOR ALL PARTICIPANTS
A5. Great! So, if I have your permission, we can get started.
YES .......................... .................................. 1 [GO TO SECTION C]

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NO ............................ .................................. 2 [GO TO SECTION A7]
NEEDS TIME TO CONSIDER ..................... 3 [GO TO SECTION A6]
SECTION A6: Reschedule
We appreciate your willingness to complete the follow-up interview. When would you like to
receive a callback?
[SCHEDULE CALL BACK IN CALL SOFTWARE]
Thank you. We’ll call you then. In the meantime, if you have any questions or would like to
schedule the interview, you can call us toll-free at 855 NIH GuLF (855-644-4853).

[TERMINATE CALL]
SECTION A7: Response to Refusals
A7.a. May I ask why you do not want to participate?
RECORD REASON – FREE TEXT FIELD
A7.b. WAS A REFUSAL CONVERSION SUCCESSFUL?
YES ............... 1 [GO TO SECTION C]
NO................. 2
Thank you.

[TERMINATE CALL]

SECTION A8: Previously Contacted
[PARTICIPANT’S NAME], I apologize for the inconvenience. We thank you for speaking with us
before. If you have any questions or concerns please call the study hotline toll-free at 855 NIH
GuLF (855-644-4853). Thank you.

[TERMINATE CALL]

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SECTION B: Deceased or Incapacitated Participants
SECTION B1: Apparently Deceased Participant
I’m very sorry to hear that.
B1. Would it be okay if I asked you a few questions about [PARTICIPANT’S NAME]?
This will only take about 5 minutes. The information you provide will help us to identify
health needs of people involved in oil spills and could change public health responses to
similar disasters.
YES ........................................................ 1
NO……................................................... 2 [GO TO SECTION B11]
NEEDS TIME TO CONSIDER ............... 3 [GO TO SECTION B12]
REFUSED .............................................. 9 [GO TO SECTION B11]
SECTION B2: Collection of Information and Confirmation of Identity
Thank you for doing this. I understand that this may be difficult for you. If there is a
question you don’t want to answer, just let me know.
B2. Can you tell me how he/she died?
YES ___________________[FREE TEXT FIELD]
DON’T KNOW ……………8
REFUSED ………………...9
B3. When did he/she die?
[INTERVIEWER: IF RESPONDENT HAS TROUBLE ANSWERING, ASK “Can you tell
me the month and year when he/she died?”; ENTER AS MUCH DETAIL AS
PROVIDED, FILLING IN DAY AS “EE”, “MM”, OR “LL” FOR EARLY, MIDDLE, OR
LATE, RESPECTIVELY, OR AS 88 IF NO INFORMATION IS PROVIDED ON THE
TIMING WITHIN THE MONTH.]
___ ___ / ___ ___ / ___ ___ ___ ___ [MM/DD/YYYY]
DON’T KNOW ............ 88 88 8888
REFUSED .................. 99 99 9999
B4. What state did he/she die in?
[DROP DOWN BOX OF 50 USA STATES]
[OUTSIDE OF THE USA]……..77
DON’T KNOW ..........................88
REFUSED ................................99
B5. What was his/her address at the time that he/she died?
House number: _________________[FREE TEXT FIELD]
Street name: ___________________[FREE TEXT FIELD]
Apartment number: ______________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
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State: _______________[STATE DROP DOWN BOX]
Zip Code: ___/___/___/___/___/
DON’T KNOW ...................8
REFUSED ... .....................9
B6. Is there any other address that he/she may have used when he/she enrolled in the
GuLF STUDY?
YES ........................ 1
NO……................... 2 [GO TO QUESTION B7]
DON’T KNOW ........ 8 [GO TO QUESTION B7]
REFUSED .............. 9 [GO TO QUESTION B7]
B6.a. What was it?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ____________________[FREE TEXT FIELD]
City: ________________________________[FREE TEXT FIELD]
State: [STATE DROP DOWN BOX]
DON’T KNOW .........8
REFUSED ... ..........9
B7. What was his/her social security number?
[PROBE: His/Her social security number will help us link to the correct health records
for him/her and help us make sure we have the correct person in our files. Reporting
his/her social security number is voluntary. We will not share this information with others
and we will do everything possible to keep it private.]
__/__/__/ - __/__/ - __/__/__/__/ [GO TO QUESTION B8]
DON’T HAVE ...............................HHH HH HHHH
DON’T KNOW ..............................KKK KK KKKK
REFUSED ....................................RRR RR RRRR [GO TO QUESTION B8]
B7.a. Would you be willing or able to tell me the last four digits of his/her social
security number? The last four digits of his/her social security number are not
unique to him/her. Other people have those same last four digits. However, it will
help us do a better job of linking to his/her public health records.
Last 4 numbers of SSN - __ __ __ __
DON’T HAVE .....................HHHH
DON’T KNOW ...................KKKK
REFUSED .........................RRRR
SECTION: End of Call for Deceased Participants
B8. What was your relationship to him/her?
[PULL-DOWN MENU]

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B9. Would you please tell me your name? [SPELL FIRST, MI, THEN LAST NAME]
FIRST: _______________ [FREE TEXT FIELD]
MI: _________________[FREE TEXT FIELD]
LAST: ________________[FREE TEXT FIELD]
REFUSED ... 9
B9.a. Is there an address and phone number where we can reach you in the
future in case we have any questions regarding [PARTICIPANTS NAME] and
[his/her] involvement in the oil spill clean up?
I_I_I_I_I_I_I_I_I_I_I TEN DIGIT #

House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ____________________[FREE TEXT FIELD]
City: ________________________________[FREE TEXT FIELD]
State: [STATE DROP DOWN BOX]
REFUSED ... ..........9
That is all of the questions I have for you. Thank you for taking the time to talk with me
today.
B10. Do you have any questions for me?
[INTERVIEWER: RESPOND TO CONCERNS BASED ON INFORMATION FROM THE
FAQs]
If you have any other questions about the study, you may call us toll-free at 855-NIHGuLF (855-644-4853). You can also visit the website at www.gulfstudy.nih.gov.
Thank you again for talking with me. Again, I am sorry for your loss.
[TERMINATE CALL]
SECTION B11: Response to Refusals
[IF A REASON IS GIVEN FOR REFUSAL GO TO SECTION B11.a.;
IF A REASON IS NOT GIVEN FOR REFUSAL GO TO SECTION B11.b.]
SECTION B11.a. I understand you said …
RESTATE REASONS AND USE TELEPHONE INTERVIEW Q & A BENEFITS TO
ATTEMPT A CONVERSION
If you don't mind, I'd like to make a note of your reason. This information will help
us improve the GuLF STUDY.

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B11.a.1. [RECORD REASON – FREE TEXT FIELD]
[IF CONVERSION ATTEMPT IS SUCCESSFUL GO TO SECTION B2; IF
CONVERSION ATTEMPT IS UNSUCCESSFUL GO TO SECTION B11.c.]
SECTION B11.b. May I ask why you do not want to answer any questions?
[INTERVIEWER: USE TELEPHONE INTERVIEW Q & A TO RESPOND TO REASON
FOR REFUSAL BY STATING THE BENEFITS]
B11.b.1[RECORD REASON– FREE TEXT FIELD]
[IF CONVERSION ATTEMPT IS SUCCESSFUL GO TO SECTION B2; IF
CONVERSION ATTEMPT IS UNSUCCESSFUL GO TO SECTION B11.c.]
SECTION B11.c. End of Call for Refusals
Thank you for your time. Again, I want to extend my condolences to you.
[TERMINATE CALL]
SECTION B12: Reschedule Call
We appreciate your willingness to consider answering our questions. When might you
have time for a 5 minute call?
DATE 1: __/__/___ [MM/DD/YYYY]
TIME OF DAY 1: _/_/ [AM/PM]
Thank you. We’ll call you then. In the meantime, if you have any questions you can call
us toll-free at 855-NIH-GuLF (855-644-4853).
Thank you for your time. Again, I want to extend my condolences to you.
SECTION B13: Apparently Incapacitated Participant
I’m very sorry to hear that.
B13. Would it be okay if I asked you a few questions about [PARTICIPANT’S NAME]?
This will take only 5 minutes. The information you provide will help us to identify health
needs of people involved in oil spills and could change public health responses to
similar disasters.
YES ........................................................ 1
NO……................................................... 2 [GO TO B26]
NEEDS TIME TO CONSIDER ............... 8 [GO TO B28]
REFUSED .............................................. 9 [GO TO B26]
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SECTION: Collection of Information and Confirmation of Identity
Thank you for doing this. I understand that this may be difficult for you. If there is a
question you don’t want to answer, just let me know.
B14. [INTERVIEWER: IF RESPONDENT HAS PROVIDED THE NATURE / CAUSE OF
INCAPACITATION] If you don't mind, I'd like a moment to make a note.
B15. [FREE TEXT] [RECORD NATURE/CAUSE OF INCAPACITATION PROVIDED BY
RESPONDENT]
[INTERVIEWER: IF THE RESPONDENT HAS NOT PROVIDED THE REASON OF
PARTICIPANT INCAPACITATION]
B16. What is the cause of [PARTICIPANT’S NAME] incapacitation?
[FREE TEXT] [RECORD NATURE/CAUSE OF INCAPACITATION PROVIDED BY
RESPONDENT]
DON’T KNOW ........ 8
REFUSED .............. 9
B17. When did he/she become incapacitated?
___ ___ / ___ ___ / ___ ___ ___ ___ [MM/DD/YYYY]
DON’T KNOW ............ 88 88 8888
REFUSED .................. 99 99 9999
B18. Is there an alternate telephone number where s/he or his/her caretaker can be
reached?
I_I_I_I_I_I_I_I_I_I_I TEN DIGIT #

DON’T KNOW ........ 888 888 8888
REFUSED .............. 999 999 9999
B19. What is his/her address?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
Zip Code: ___/___/___/___/___/
DON’T KNOW ........ 8
REFUSED .............. 9
B20. Is there any other address that he/she may have given when he/she enrolled in the
GuLF STUDY?
YES ........................ 1
NO……................... 2 [GO TO QUESTION B21]
DON’T KNOW ........ 8 [GO TO QUESTION B21]
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REFUSED .............. 9 [GO TO QUESTION B21]
B20.a. What was it?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
DON’T KNOW
8
REFUSED.... 9
B21. What is his/her social security number?
[PROBE: His/Her social security number will help us link to the correct health records
for him/her. Reporting his/her social security number is voluntary. We will not share this
information with others and we will do everything possible to keep it private.]
[PROGRAMMER NOTE: ONLY DISPLAY SSN QUESTIONS IF WE DID NOT OBTAIN FULL
SSN DURING THE LAST INTERVIEW].

__/__/__/ - __/__/ - __/__/__/__/ [GO TO QUESTION B22]
DON’T HAVE IT ..........................HHH HH HHHH
DON’T KNOW ..............................KKK KK KKKK
REFUSED ....................................RRR RR RRRR [GO TO QUESTION B22]
B21.a. Would you be willing or able to tell me the last four digits of his/her social
security number? The last four digits of his/her social security number are not
unique to him/her. Other people have those same last four digits. However, it will
help us do a better job of linking to his/her public health records.
Last 4 numbers of SSN - __ __ __ __
DON’T HAVE .....................HHHH
DON’T KNOW ...................KKKK
REFUSED .........................RRRR
SECTION: End of Call for Incapacitated Participants
B22. What is your relationship to him/her?
[PULL-DOWN MENU]
B23. Would you please tell me your name? [SPELL FIRST, MI, THEN LAST NAME]
FIRST: _______________ [FREE TEXT FIELD]
MI: _________________[FREE TEXT FIELD]
LAST: ________________[FREE TEXT FIELD]
REFUSED ... 9
B24. Is there an address where we can reach you in the future in case we have any
questions regarding [PARTICIPANTS NAME] and [his/her] involvement in the oil spill
clean up?
House number: _______________________[FREE TEXT FIELD]
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Street name: _________________________[FREE TEXT FIELD]
Apartment number: ____________________[FREE TEXT FIELD]
City: ________________________________[FREE TEXT FIELD]
State: [STATE DROP DOWN BOX]
REFUSED .. .......... 9
B24.a. What is the best phone number to reach you?
|_|_|_|-|_|_|_|-|_|_|_|_|
DON’T KNOW ….. 888-888-8888
REFUSED ………. 999-999-9999
B24.b. Is this number a cellphone?
YES……………….. 1
NO………………… 2
DON’T KNOW ….. 8
REFUSED ………. 9
B24.c. ALTERNATE NUMBER (IF VOLUNTEERED)
|_|_|_|-|_|_|_|-|_|_|_|_|
DON’T KNOW ….. 888-888-8888 [GO TO B26]
REFUSED ………. 999-999-9999 [GO TO B26]
B24.d. Is this number a cell phone?
YES……………….. 1
NO………………… 2
DON’T KNOW ….. 8
REFUSED ………. 9
That is all of the questions I have for you. Thank you for taking the time to talk with me
today.
B25. Do you have any questions for me?
[INTERVIEWER: RESPOND TO CONCERNS BASED ON INFORMATION FROM THE
FAQS]
If you have any other questions about the study, you may call us toll-free at 855-NIHGuLF (855-644-4853). You can also visit our website at www.gulfstudy.nih.gov.
Thank you again for talking with me. Please don’t hesitate to contact us if you have any
questions later. Again, I am sorry to hear about what happened to [PARTICIPANT’S
NAME].
[TERMINATE CALL]
SECTION B26: Response to Refusals
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[IF A REASON IS GIVEN FOR REFUSAL GO TO SECTION B27.a.;
IF A REASON IS NOT GIVEN FOR REFUSAL GO TO SECTION B27.b.]
SECTION B26.a: I understand you said …
RESTATE REASONS AND USE TELEPHONE INTERVIEW Q & A BENEFITS TO
ATTEMPT A CONVERSION
If you don't mind, I'd like to make a note of your reason. This information will help
us improve the GuLF STUDY.
B26.a.1. [RECORD REASON – FREE TEXT FIELD]
[IF CONVERSION ATTEMPT IS SUCCESSFUL GO TO SECTION B14; IF
CONVERSION ATTEMPT IS UNSUCCESSFUL GO TO SECTION B28]

SECTION B26.b: May I ask why you do not want to answer any questions?
[INTERVIEWER: USE TELEPHONE INTERVIEW Q & A TO RESPOND TO REASON
FOR REFUSAL BY STATING THE BENEFITS]
B26.b.1. [RECORD REASON– FREE TEXT FIELD]
[IF CONVERSION ATTEMPT IS SUCCESSFUL GO TO SECTION C; IF
CONVERSION ATTEMPT IS UNSUCCESSFUL GO TO SECTION B27]
SECTION B27. End of Call for Refusals
Thank you for your time. Again, I am sorry to hear about what happened to
[PARTICIPANT’S NAME].
[TERMINATE CALL]
SECTION B28: Reschedule Call
B28. We appreciate your willingness to consider answering our questions. When might
you have time for a 5 minute call?
DATE 1: __/__/___ [MM/DD/YYYY] [CALENDAR]
TIME OF DAY 1: _/_/ [AM/PM]

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Thank you. We’ll call you then. In the meantime, if you have any questions you can call
us toll-free at 855-NIH-GuLF (855-644-4853).
Thank you for your time.

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Part 2: Follow-up Questionnaire (Estimated
Burden: 30 Minutes)

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SECTION C: Background Information
Thank you for agreeing to take part in the study. Before we get started, I would like to
confirm your information.
C1. We have your name spelled [INTERVIEWER: SPELL NAME AND CONFIRM
JR/SR SUFFIX, IF APPLICABLE.] [PROGRAMMER: DISPLAY NAME ON FILE;
INCLUDE CONFIRMATION CHECK IF NAME IS EDITED.]
FIRST NAME
MIDDLE INITIAL
LAST NAME
SUFFIX

DISPLAY FIRST NAME
DISPLAY MIDDLE INITIAL
DISPLAY LAST NAME
DISPLAY SUFFIX

ENTER ANY CORRECTIONS TO BE SAVED HERE:
FIRST NAME
MIDDLE INITIAL
LAST NAME
SUFFIX
C2. We have your date of birth as: [PROGRAMMER: DISPLAY DOB ON FILE;
INCLUDE CONFIRMATION CHECK IF DOB IS EDITED.]
Date of Birth
DISPLAY DOB
ENTER ANY CORRECTIONS TO BE SAVED HERE:
[PROGRAMMER NOTE: INPUT RANGE CHECK TO INCLUDE +/- 20 YEARS FROM
PREVIOUS DATE GIVEN, FOR JR./SR. ISSUES]
Date of Birth
MM/DD/YYYY
I would like to confirm your current physical address. This should not be a post-office
box or rural route number.
[INTERVIEWER: READ THE ADDRESS DISPLAYED BELOW.]
[PROGRAMMER NOTE: DISPLAY THE CURRENT PHYSICAL ADDRESS FOR THE
PARTICIPANT.]
HOUSE NUMBER
STREET NAME
APARTMENT NUMBER
CITY
STATE
ZIP CODE

DISPLAY HOUSE NUMBER
DISPLAY STREET NAME
DISPLAY APARTMENT NUMBER
DISPLAY CITY
DISPLAY STATE
DISPLAY ZIPCODE

C3. IS THE ADDRESS CORRECT?
YES ................................... 1 [GO TO C4]
NO ..................................... 2
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C3.a. What is your current physical address?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
Zip Code: ___/___/___/___/___/
C4. Is your mailing address different from your current address?
YES ........................ 1
NO……................... 2 [GO TO C5]
DON’T KNOW ........ 8 [GO TO C5]
REFUSED .............. 9 [GO TO C5]
C4.a. What is your mailing address?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
Zip Code: ___/___/___/___/___/
DON’T KNOW
8
REFUSED.... 9
C5. Do you have any additional telephone numbers?
Phone1

Phone2

Phone3

Phone4

Type
[DROP DOWN:
UNKNOWN, HOME,
WORK, OTHER]
[DROP DOWN:
UNKNOWN, HOME,
WORK, OTHER]
[DROP DOWN:
UNKNOWN, HOME,
WORK, OTHER]
[DROP DOWN:
UNKNOWN, HOME,
WORK, OTHER]

Phone Number
(_/_/_) _/_/_ - _/_/_/_

Ext.
_/_/_/_/_

Cell?


(_/_/_) _/_/_ - _/_/_/_

_/_/_/_/_





(_/_/_) _/_/_ - _/_/_/_

_/_/_/_/_





(_/_/_) _/_/_ - _/_/_/_

_/_/_/_/_





Best?


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SECTION D: Demographic Measures
D1. Are you now married, widowed, divorced, separated, never married, or living with a
partner?
MARRIED ..................................1
WIDOWED ................................2
DIVORCED ...............................3
SEPARATED .............................4
NEVER MARRIED ....................5
LIVING WITH PARTNER ...........6
DON’T KNOW ...........................8
REFUSED .................................9

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SECTION E: Clean-up Related Tasks and Exposures During Clean-up
[PROGRAMMER NOTE: ASK QUESTION E1 ONLY FOR PARTICIPANTS WHO
INDICATED THAT THEY WERE STILL WORKING ON THE SPILL AT THE TIME OF
LAST INTERVIEW. OTHERWISE SKIP TO E2.]
E1. You were still working on the oil spill clean-up when we last spoke with you in
[YEAR OF LAST INTERVIEW].You had started working on the clean-up around [DATE
STARTED CLEAN-UP WORK ]. Approximately what month and year did you stop
working on the clean-up?
MONTH _____________ [GO TO E2]
YEAR _/_/_/_
[GO TO E2]
STILL WORKING .............. 7 [GO TO E2]
DON’T KNOW ................... 8
REFUSED ......................... 9
E1.a. About how many days, weeks, or months altogether did you work on the
cleanup?
|__|__|__| Units
Days ............ .....................1
Weeks ......... .....................2
Months ......... .....................3
DON’T KNOW ...................8
REFUSED ... .....................9
E2. Within the past two years, have you participated in any oil spill clean-up work?
[INTERVIEWER NOTE: IF PARTICIPANT HAS ANSWERED E1, CONFIRM THAT
THIS CLEAN UP WORK IS SEPARATE FROM WORK DESCRIBED IN E1]
YES ........................ 1
NO .......................... 2 [GO TO SECTION F]
DON’T KNOW ........ 8 [GO TO SECTION F]
REFUSED .............. 9 [GO TO SECTION F]
E2.a. When did you begin this clean-up work?
__/__/____ DATE FIELD
DON’T KNOW .........8
REFUSED...............9
E2.b. When did you stop this clean-up work?
__/__/____ DATE FIELD
DON’T KNOW .........8
REFUSED...............9
[PROGRAMMER NOTE: ASK E2.c EVEN IF E2.a AND E2.b ARE
ANSWERED BECAUSE THIS WORK MAY NOT HAVE BEEN
CONTINUOUS.]
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E2.c. About how many days, weeks, or months altogether did you work on
this cleanup?
|__|__|__| Units
Days.. .....................1
Weeks .....................2
Months ....................3
DON’T KNOW .........8
REFUSED...............9
E2.d. What were your job duties during this clean-up work?
[FREE TEXT FIELD]
DON’T KNOW .........8
REFUSED...............9
E2.e. Where did you complete this clean up work? Did you work on …
[CHECK ALL THAT APPLY]
The Beach ................................... 1
Land other than the beach ........... 2
A Barge ........................................ 3
A Ship or Boat.............................. 4
Other [FREE TEXT FIELD] .......... 5
DON’T KNOW .............................. 8
REFUSED.................................... 9
E2.f. What state did you complete this clean up work in or near?
STATE [DROP DOWN BOX] ....... 1
OUT IN THE GULF ...................... 2
DON’T KNOW .............................. 8
REFUSED.................................... 9

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SECTION F: Health
This next section will focus on your health.
F1. In general, how would you rate your overall health?
Excellent................. 1
Very Good .............. 2
Good ...................... 3
Fair ......................... 4
Poor........................ 5
DON’T KNOW ........ 8
REFUSED .............. 9
F2. In general, how would you rate your quality of life?
Excellent................. 1
Very Good .............. 2
Good ...................... 3
Fair ......................... 4
Poor........................ 5
DON’T KNOW ........ 8
REFUSED .............. 9
F3. In general, how would you rate your physical health?
Excellent................. 1
Very Good .............. 2
Good ...................... 3
Fair ......................... 4
Poor........................ 5
DON’T KNOW ........ 8
REFUSED .............. 9
F4. In general, how would you rate your mental health, including your mood and ability
to think?
Excellent................. 1
Very Good .............. 2
Good ...................... 3
Fair ......................... 4
Poor........................ 5
DON’T KNOW ........ 8
REFUSED .............. 9
F5. In general, how would you rate your satisfaction with your social activities and
relationships?
Excellent................. 1
Very Good .............. 2
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Good ...................... 3
Fair ......................... 4
Poor........................ 5
DON’T KNOW ........ 8
REFUSED .............. 9
F6. In general, please rate how well you carry out your usual social activities and roles.
[INTERVIEWER PROBE: This includes activities at home, at work, and in your
community, and responsibilities as a parent, child, spouse, employee, friend, etc.]
Excellent................. 1
Very Good .............. 2
Good ...................... 3
Fair ......................... 4
Poor........................ 5
DON’T KNOW ........ 8
REFUSED .............. 9
F7. To what extent are you able to carry out your everyday physical activities?
[INTERVIEWER PROBE: Such as walking, climbing stairs, carrying groceries, or
moving a chair.]
Completely ............. 1
Mostly ..................... 2
Moderately ............. 3
A little ..................... 4
Not at all ................. 5
DON’T KNOW ........ 8
REFUSED .............. 9
F8. In the past 7 days, how often have you been bothered by emotional problems such
as feeling anxious, depressed, or irritable?
Never...................... 1
Rarely ..................... 2
Sometimes ............. 3
Often ...................... 4
Always .................... 5
DON’T KNOW ........ 8
REFUSED .............. 9
F9. In the past 7 days, how would you rate your fatigue on average?
None....................... 1
Mild......................... 2
Moderate ................ 3
Severe .................... 4
Extreme .................. 5
DON’T KNOW ........ 8
REFUSED .............. 9
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F10. In the past 7 days, how would you rate your pain, on average, on a scale 0 to 10,
with 0 being no pain and 10 being worst imaginable pain?
I_I_I UNITS
DON’T KNOW ........ 8
REFUSED .............. 9
F11. Do you mind telling me how much you currently weigh?
|___|___|___| lbs [OR]
|___|___|___| kg
DON’T KNOW ...... 8
REFUSED ............ 9
Respiratory Symptoms
The next set of questions is about chest and respiratory symptoms.
F12. In the past 12 months, have you had problems with coughing?
YES ........................ 1
NO .......................... 2[GO TO QUESTION F14]
DON’T KNOW ........ 8[GO TO QUESTION F14]
REFUSED .............. 9[GO TO QUESTION F14]
F12.a. Do you usually cough like this on most days for as much as 3 months
each year?
YES ...................................1
NO .....................................2 [GO TO QUESTION F12.c]
DON’T KNOW ...................8 [GO TO QUESTION F12.c]
REFUSED .........................9 [GO TO QUESTION F12.c]
F12.b. For how many years have you had this cough?
I_I_I Years
DON’T KNOW ...................8
REFUSED .........................9
F12.c. During the past 12 months, have you had a dry cough at night that lasted
14 days or more, not counting a cough associated with a cold or chest infection ?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F13. Do you usually bring up phlegm on most days for as much as 3 months each year?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F14]
DON’T KNOW ........ 8 [GO TO QUESTION F14]
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REFUSED .............. 9 [GO TO QUESTION F14]
F13.a. For how many years have you had trouble with phlegm?
I_I_I Years
DON’T KNOW ...................8
REFUSED .........................9
F14. In the past 12 months have you had wheezing or whistling in your chest?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F15]
DON’T KNOW ........ 8 [GO TO QUESTION F15]
REFUSED .............. 9 [GO TO QUESTION F15]
F14.a. In the past 12 months, how many attacks of wheezing or whistling have
you had?
I_I_I_I Number of Attacks
DON’T KNOW ...................8
REFUSED .........................9
F14.b. In the past 12 months, how often, on average, has your sleep been
disturbed because of wheezing?
I______I OPEN TEXT FIELD
DON’T KNOW ...................8
REFUSED .........................9
F14.c. In the past 12 months, has your chest sounded wheezy during or after
exercise or physical activity?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F14.d. In the past 12 months, how many times have you gone to a doctor’s office
or the hospital for one of these attacks of wheezing or whistling?
I_I_I_I Number of Visits
DON’T KNOW ...................8
REFUSED .........................9
F14.e. During the past 12 months, how much did you limit your usual activities
due to wheezing or whistling?
I_I_I_I Number of Times
DON’T KNOW ...................8
REFUSED .........................9
F14.f. During the past 12 months, how many days of work or school did you miss
due to wheezing or whistling?
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I_I_I_I Number of Days
DON’T KNOW ...................8
REFUSED .........................9
F14.g. In the past 12 months, have you taken any medication prescribed by your
doctor for wheezing or whistling?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F15. Do you have difficulty walking because of a condition other than heart or lung
disease?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
F16. Are you troubled by shortness of breath when hurrying on a level surface or
walking up a slight hill?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
F17. Do you have to walk slower than people of your age on a level surface because of
breathlessness?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
F18. Do you ever stop for breath when walking at your own pace on a level surface?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
F19. Do you ever stop for breath after walking about 100 yards (or for a few minutes) on
a level surface?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
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F20. Are you ever too breathless to leave the house or do you ever become breathless
when dressing or undressing?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
F21. Has a doctor or health professional ever told you that you have asthma (az-ma)?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F22]
DON’T KNOW ........ 8 [GO TO QUESTION F22]
REFUSED .............. 9 [GO TO QUESTION F22]
F21.a. How old were you when you were first told you had asthma?
I_I_I AGE
DON’T KNOW ...................8
REFUSED .........................9
F21.b. Do you still have asthma?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F21.c. During the past 12 months, have you had an episode of asthma or an
asthma attack?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F21.d. During the past 12 months, have you had to visit the emergency room or
urgent care center because of your asthma?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F21.e. During the past 3 months, have you taken medication prescribed by your
doctor or health professional for asthma?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F22. Has a doctor or health professional ever told you that you have chronic bronchitis?
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YES ........................ 1
NO .......................... 2 [GO TO QUESTION F23]
DON’T KNOW ........ 8 [GO TO QUESTION F23]
REFUSED .............. 9 [GO TO QUESTION F23]
F22.a. How old were you when you were first told you had chronic bronchitis?
I_I_I AGE
DON’T KNOW ...................8
REFUSED .........................9
F22.b. Do you still have chronic bronchitis?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F22.c. During the past 12 months, have you had an episode of bronchitis?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F22.d. During the past 12 months, have you had to visit an emergency room or
urgent care center because of bronchitis?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F22.e. During the past 3 months, have you taken any medication prescribed by
your doctor or health professional for bronchitis?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F23. Has a doctor or health professional ever told you that you have emphysema or
chronic obstructive pulmonary disease, also known as COPD?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F24]
DON’T KNOW ........ 8 [GO TO QUESTION F24]
REFUSED .............. 9 [GO TO QUESTION F24]
F23.a. How old were you when you were first told you had emphysema or
COPD?
I_I_I AGE
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DON’T KNOW ...................8
REFUSED .........................9
F24. In the past 12 months, have you had pneumonia?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F25]
DON’T KNOW ........ 8 [GO TO QUESTION F25]
REFUSED .............. 9 [GO TO QUESTION F25]
F24.a. Was it confirmed by a doctor?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F25. Has a doctor or health professional ever told you that you have eczema?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F26]
DON’T KNOW ........ 8 [GO TO QUESTION F26]
REFUSED .............. 9 [GO TO QUESTION F26]
F25.a. When were you first told you had eczema?
__ __/__ __ __ __ [MM/YYYY] OR
I_I_I AGE
DON’T KNOW ...................8
REFUSED .........................9
F25.b. During the past 12 months, have you had a bad case of eczema?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F26. Has a doctor or health professional ever told you that you have allergies?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F26.c]
DON’T KNOW ........ 8 [GO TO QUESTION F26.c]
REFUSED .............. 9 [GO TO QUESTION F26.c]
F26.a. How old were you when you were first told you had allergies?
I_I_I AGE
DON’T KNOW ...................8
REFUSED .........................9
F26.b. During the past 12 months, have you had any allergy symptoms or an
allergy attack?
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YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F26.c. During the past 12 months, have you had a problem with sneezing, or a
runny, or blocked nose when you did not have a cold or the flu?
YES ...................................1
NO .....................................2 [GO TO QUESTION F26.e]
DON’T KNOW ...................8 [GO TO QUESTION F26.e]
REFUSED .........................9 [GO TO QUESTION F26.e]
F26.d. In which season or seasons did this occur?
SEASON [DROP DOWN BOX; SELECT ALL THAT APPLY]
DON’T KNOW ...................8
REFUSED .........................9
F26.e. Has a doctor or health professional ever told you that you have hay fever?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F27]
DON’T KNOW ........ 8 [GO TO QUESTION F27]
REFUSED .............. 9 [GO TO QUESTION F27]
F26.f. How old were you when you were first told you had hay fever?
I_I_I AGE
DON’T KNOW ...................8
REFUSED .........................9
F26.g. During the past 12 months, have you had an episode of hay fever?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F27. Has a doctor ever told you that you have peripheral neuropathy? [PROBE:
Peripheral neuropathy means that you have nerve damage in your hands or feet that is
not due to an injury. NOTE TO INTERVIEWER: THIS INCLUDES TINGLING,
NUMBNESS, LOSS OF SENSATION]
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F28]
DON’T KNOW ........ 8 [GO TO QUESTION F28]
REFUSED .............. 9 [GO TO QUESTION F28]
F27.a. When were you first told that you had peripheral neuropathy?
__ __ / __ __ __ __ [MM/YYYY] OR
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I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9
F28. Has a doctor ever told you that you have epilepsy or a seizure disorder?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F29]
DON’T KNOW ........ 8 [GO TO QUESTION F29]
REFUSED .............. 9 [GO TO QUESTION F29]
F28.a. When were you first told that you had epilepsy or a seizure disorder?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9
F29. Has a doctor ever told you that you have diabetes or sugar diabetes?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F30]
DON’T KNOW ........ 8 [GO TO QUESTION F30]
REFUSED .............. 9 [GO TO QUESTION F30]
F29.a. When were you first told that you had diabetes or sugar diabetes?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9
[ONLY IF PARTICIPANT IS FEMALE]
F29.b. Did you have diabetes only while you were pregnant?
YES ……………… 1
NO ………………. 2
DON’T KNOW ….. 8
REFUSED ………. 9
F30. Has a doctor ever told you that you have hypertension or high blood pressure?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F31]
DON’T KNOW ........ 8 [GO TO QUESTION F31]
REFUSED .............. 9 [GO TO QUESTION F31]
F30.a. When were you first told you had hypertension?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
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REFUSED .............. 9
F31. Has a doctor ever told you that you had a heart attack, also called a myocardial
infarction or “MI”?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F32]
DON’T KNOW ........ 8 [GO TO QUESTION F32]
REFUSED .............. 9 [GO TO QUESTION F32]
F31.a. When were you first told that you had a heart attack?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9
F32. Has a doctor ever told you that you had a blockage in the arteries of the heart?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F33]
DON’T KNOW ........ 8 [GO TO QUESTION F33]
REFUSED .............. 9 [GO TO QUESTION F33]
F32.a. When were you first told that you had a blockage in the arteries of the
heart?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9
F32.b.Did you ever have a balloon or stent placed to open up a blocked artery?
YES ............................................. 1
NO ............................................... 2 [GO TO QUESTION F33]
DON’T KNOW ............................. 8 [GO TO QUESTION F33]
REFUSED
........ 9 [GO TO QUESTION F33]
F32.c. When did you first have a balloon or stent placed to open up a blocked
artery?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9
F33. Has a doctor ever told you that you have congestive heart failure?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F34]
DON’T KNOW ........ 8 [GO TO QUESTION F34]
REFUSED .............. 9 [GO TO QUESTION F34]
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F33.a. When were you first told you have congestive heart failure?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9
F34. Has a doctor ever told you that you have angina?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F35]
DON’T KNOW ........ 8 [GO TO QUESTION F35]
REFUSED .............. 9 [GO TO QUESTION F35]
F34.a. When were you first told you have angina?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9
F35. Has a doctor ever told you that you have arrhythmia or an irregular heart beat?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F36]
DON’T KNOW ........ 8 [GO TO QUESTION F36]
REFUSED .............. 9 [GO TO QUESTION F36]
F35.a. When were you first told you have arrhythmia or an irregular heart beat?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9
F36. Has a doctor ever told you that you had a stroke or a cerebral hemorrhage?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F37]
DON’T KNOW ........ 8 [GO TO QUESTION F37]
REFUSED .............. 9 [GO TO QUESTION F37]
F36.a. When were you first told you had a stroke or cerebral hemorrhage?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9
F37. Has a doctor ever told you that you had a TIA or transient ischemic attack or mini
stroke?
YES ........................ 1
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NO .......................... 2 [GO TO QUESTION F38]
DON’T KNOW ........ 8 [GO TO QUESTION F38]
REFUSED .............. 9 [GO TO QUESTION F38]
F37.a. When were you first told you had a TIA or transient ischemic attack or
mini stroke?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9

F38. Has a doctor ever told you that you have a thyroid disorder?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION F39]
DON’T KNOW ........ 8 [GO TO QUESTION F39]
REFUSED .............. 9 [GO TO QUESTION F39]
F38.a. Was it an overactive thyroid, such as Grave’s disease or thyrotoxicosis;
an underactive thyroid or hypothyroidism, such as Hashimoto’s disease or
thyroiditis; an enlarged thyroid or goiter; or was it something else ?
OVERACTIVE THYROID ....................................................... 1
UNDERACTIVE THYROID ..................................................... 2
ENLARGED THYROID ........................................................... 3
OTHER ....... .......................................................................... 4
DON’T KNOW ........................................................................ 8
REFUSED ... .......................................................................... 9
F38.b Do you remember the name of the thyroid condition?
______SPECIFY [FREE TEXT FIELD]
F38.c. When were you first told you have a thyroid disorder?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9
F39. Has a doctor ever told you that you have cancer?
YES ...................... 1
NO ........................ 2 [GO TO SECTION F40]
DON’T KNOW ...... 8 [GO TO SECTION F40]
REFUSED ............ 9 [GO TO SECTION F40]

BLADDER .................... 10

CANCER OPTIONS
LIVER ........................... 22

SKIN (NON-MELANOMA)32
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BLOOD......................... .11
BONE ........................... 12

BRAIN ........................... 13

BREAST ........................ 14
CERVIX (CERVICAL) .. 15
COLON ......................... 16
ESOPHAGUS
(ESOPHAGEAL) ........... 17
GALLBLADDER ........... 18
KIDNEY ......................... 19
LARYNX/WINDPIPE ... 20
LEUKEMIA. ................... 21

LUNG ............................ 23
LYMPHOMA (NON
HODGKIN’S)................. 40
LYMPHOMA (HODGKIN’S
DISEASE) .................... .24
LYMPHOMA (DON’T
KNOW; NOT SPECIFIED)
..................................... .42
MULTIPLE MYELOMA .41

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SKIN (MELANOMA) ..... 25
SKIN (DON'T KNOW; NOT
SPECIFIED) ..................33
SOFT TISSUE (MUSCLE/
FAT) ..............................34

STOMACH ..................35

MOUTH/TONGUE/LIP .. 26

TESTIS (TESTICULAR) 36
THYROID ......................37
UTERUS (UTERINE).....38

NERVOUS SYSTEM .... 27

OTHER (SPECIFY) .......39

OVARY (OVARIAN)...... 28
PANCREAS (PANCREATIC)
DON’T KNOW ...............77
...................................... 29
PROSTATE .................. 30
REFUSED .....................99
RECTUM (RECTAL) ..... 31

F39.a. What kind of cancer was it?
Type 1: [SELECT FROM CANCER OPTIONS]
F39.b. When were you first told you had [FIRST TYPE OF CANCER]?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9
F39.c. Has a doctor ever told that you have any other types of cancer?
YES ........................ 1
NO .......................... 2 [GO TO F40]
DON’T KNOW ........ 8 [GO TO F40]
REFUSED ………...9 [GO TO F40]
F39.d. What kind of cancer was it?
Type 2: [SELECT FROM CANCER OPTIONS]
F39.e. When were you first told you had [SECOND TYPE OF CANCER]?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ........ 8
REFUSED .............. 9

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Health Symptoms
Now I’m going to ask you about your health during the past thirty days. Please tell me
how often you have these symptoms. Answer with one of the following choices: All the
time, Most of the time, Sometimes, Rarely, or Never. [INTERVIEWER NOTE: AFTER
EVERY 5 QUESTIONS, REPEAT RESPONSE OPTIONS.]
F40. During the past thirty days, how often have you…
All of
the Time

F40.a.

had a severe headache or migraine?

F40.b.

felt dizzy or lightheaded?

F40.c.

been nauseated?

F40.d.

experienced vomiting?

F40.e.

experienced nose bleeds?

Most of
the
Time

Sometimes

Rarely

Never

Don't
Know

During the past thirty days, how often have you…
F40.f.
F40.g.

experienced episodes of excessive or
unusual hair loss?
experienced seizures?

F40.h.

had insomnia?

F40.i.

experienced ear bleeds?

F40.j.

had blurred or distorted vision?

During the past thirty days, how often have you…
F40.k.

had a tingling or a “pins and needles” feeling
in your hands, arms, feet, or legs?
F40.m had numbness, where parts of your body “go
.
to sleep” for no apparent reason, in your
hands, arms, feet, or legs?
During the past thirty days, how often did you…
F40.n.

stumble while walking?

F40.o.

experience heart palpitations (heart
pounding or racing) at rest?

F40.p.

sweat heavily for no reason?

During the past thirty days, how often have you…
had trouble urinating, such as taking a long
F40.q.
time to urinate or having to strain to

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start the urine flow?
F40.r.

had unusually frequent urination

F40.s.

F40.u.

had lower back pain?
had excessive fatigue or extreme
tiredness?
had diarrhea or frequent bowel
movements?

F40.v.

been constipated?

F40.t.

F41. In the past thirty days, how often have you had any red, inflamed skin, rashes,
sores or blisters?
All the time ............. 1
Most of the time ...... 2
Sometimes ............. 3
Rarely ..................... 4
Never...................... 5 [GO TO QUESTION F42]
DON’T KNOW ........ 8 [GO TO QUESTION F42]
REFUSED .............. 9 [GO TO QUESTION F42]
F41.a. Have any of these lasted two or more days?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
F41.b. Were these conditions …?
[SELECT ALL THAT APPLY]
A Red rash.............. 1
A Bumpy rash ......... 2
Sores ...................... 3
Blisters or pustules . 4
Spots ...................... 5
Peeling skin ............ 6
Dry .......................... 7
Flaky ....................... 10
Oozing .................... 11
Itchy ........................ 12
Painful .................... 13
Something else ....... 14
Please explain _________ [FREE TEXT]
DON’T KNOW ........ 8
REFUSED .............. 9
F41.c. Were these conditions examined by a doctor?
YES ...................................1
NO .....................................2
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DON’T KNOW ...................8
REFUSED .........................9
F41.d. Where did you have the [ANSWER PIPED IN FROM F41.b.]? Was it on
your …
[SELECT ALL THAT APPLY]
Hands ..................... 01
Arms ....................... 02
Head ....................... 03
Neck ....................... 04
Chest ...................... 05
Stomach ................. 06
Back ....................... 07
Groin ....................... 08
Rear end ................. 09
Legs ........................ 10
Feet ........................ 11
DON’T KNOW ........ 88
REFUSED .............. 99
F41.e. For how long in total have you had [ANSWER PIPED IN FROM F41.b.]?
|___|___|___| Units
Days ...................... 1
Weeks .................... 2
Months .................... 3
Years ...................... 4
DON’T KNOW ........ 888
REFUSED .............. 999
F41.f. Were any of these on a part of your body that touched or came into
contact with oil or chemical dispersant that you believe came from the Deepwater
Horizon oil spill?
YES ...................................1
NO .....................................2
DON’T KNOW ...................8
REFUSED .........................9
F42. Have you been hospitalized for any condition in the past 12 months?
YES ........................ 1
NO ......................... 2[GO TO QUESTION F43]
DON’T KNOW ....... 8[GO TO QUESTION F43]
REFUSED .............. 9[GO TO QUESTION F43]
F42.a. Why were you hospitalized?
[FREE TEXT FIELD]
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DON’T KNOW .........8
REFUSED.... ..........9
F42.b. Were you hospitalized at least overnight?
YES ........................ 1
NO ......................... 2 [GO TO QUESTION F43]
DON’T KNOW ....... 8 [GO TO QUESTION F43]
REFUSED .............. 9 [GO TO QUESTION F43]
F42.c. How many times were you hospitalized in the past 12 months?
I__II__I NUMBER OF TIMES
DON’T KNOW ....... 8
REFUSED .............. 9
Access to Healthcare
Now I would like to ask you a few questions about health insurance.
F43. Do you have any kind of health care coverage? This could include health
insurance, membership in a health maintenance organization or HMO, or government
plans such as Medicaid, Medicare, TRICARE, Veterans Benefits, or state health care
plans?
YES ................................... 1
NO ..................................... 2 [GO TO F44]
DON’T KNOW ................... 8 [GO TO F44]
REFUSED ......................... 9 [GO TO F44]
F43.a. Does your health care plan include mental health coverage?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
F44. Do you have someone you think of as your personal doctor or health care
provider?
YES ................................... 1
NO ..................................... 2 [GO TO QUESTION F45]
DON’T KNOW ................... 8 [GO TO QUESTION F45]
REFUSED ......................... 9 [GO TO QUESTION F45]
F44.a. Is there more than one person who you think of as your personal doctor
or health care provider?
YES, MORE THAN ONE ............. 1
NO, JUST ONE PERSON ........... 2
DON’T KNOW ............................. 8
REFUSED ................................... 9
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F45. Do you know of a clinic or health care provider where you can go to get medical
care?
YES ................................... 1
NO ..................................... 2
DON’T KNOW ................... 8
REFUSED ......................... 9

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SECTION G: Mental Health
Now I am going to ask you some questions about stress and mental health.
SOCIAL CONTEXT
G1. During the past 12 months, how often have you been worried or stressed about
having enough money to pay your rent or mortgage? Have you been worried or
stressed…
Always ............................. 1
Usually ............................ 2
Sometimes ...................... 3
Rarely .............................. 4
Never............................... 5
DON’T KNOW ................. 8
REFUSED ....................... 9
G2. During the past 12 months, how often would you say you were worried or stressed
about having enough money to buy food? Would you say you were worried or
stressed….
Always ............................. 1
Usually ............................ 2
Sometimes ...................... 3
Rarely .............................. 4
Never............................... 5
DON’T KNOW ................. 8
REFUSED ....................... 9
G3. During the past 12 months, how much have you worried about your future physical
health? Would you say…
A lot ................................. 1
Some ............................... 2
A little, or ......................... 3
Not at all .......................... 4
DON’T KNOW ................. 8
REFUSED ....................... 9
CLINICAL DIAGNOSES
Now I would like to ask you some questions about any health conditions a doctor may
have told you about.
G4. Has a doctor ever told you that you have acute stress disorder?
YES ................................................................... 1
NO ..................................................................... 2 [GO TO QUESTION G5]
DON’T KNOW ................................................... 8 [GO TO QUESTION G5]
REFUSED ......................................................... 9 [GO TO QUESTION G5]
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G4.a. When were you first told?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ......88 8888
REFUSED ............99 9999
G4.b. Have you seen a doctor or been treated for this in the past 12 months?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
G5. Has a doctor ever told you that you have anxiety or an anxiety disorder?
YES………………………… ............................... 1
NO ..................................................................... 2 [GO TO QUESTION G6]
DON’T KNOW ................................................... 8 [GO TO QUESTION G6]
REFUSED ......................................................... 9 [GO TO QUESTION G6]
G5.a. When were you first told?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ......88 8888
REFUSED ............99 9999
G5.b. Have you seen a doctor or been treated for this in the past 12 months?
YES ...................... 1
NO ........................ 2
DON’T KNOW ...... 8
REFUSED ............ 9
G6. Has a doctor ever told you that you have panic disorder?
YES ................................................................... 1
NO ..................................................................... 2 [GO TO QUESTION G7]
DON’T KNOW ................................................... 8 [GO TO QUESTION G7]
REFUSED ......................................................... 9 [GO TO QUESTION G7]
G6.a. When were you first told?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ......88 8888
REFUSED ............99 9999
G6.b. Have you seen a doctor or been treated for this in the past 12 months?
YES ...................... 1
NO ........................ 2
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DON’T KNOW ...... 8
REFUSED ............ 9
G7. Has a doctor ever told you that you have post-traumatic stress disorder?
YES ................................................................... 1
NO ..................................................................... 2 [GO TO QUESTION G8]
DON’T KNOW ................................................... 8 [GO TO QUESTION G8]
REFUSED ......................................................... 9 [GO TO QUESTION G8]
G7.a. When were you first told?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ......88 8888
REFUSED ............99 9999
G7.b. Have you seen a doctor or been treated for this in the past 12 months?
YES ...................... 1
NO ........................ 2
DON’T KNOW ...... 8
REFUSED ............ 9
G8. Has a doctor ever told you that you have depression?
YES ................................. 1
NO ................................... 2 [GO TO QUESTION G9]
DON’T KNOW ................. 8 [GO TO QUESTION G9]
REFUSED ....................... 9 [GO TO QUESTION G9]
G8.a. When were you first told?
__ __ / __ __ __ __ [MM/YYYY] OR
I__II__I AGE
DON’T KNOW ......88 8888
REFUSED ............99 9999
G8.b. Have you seen a doctor or been treated for this in the past 12 months?
YES ...................... 1
NO ........................ 2
DON’T KNOW ...... 8
REFUSED ............ 9
PERCEIVED STRESS SCALE
G9. In the last month, how often have you felt that you were unable to control the
important things in your life?
Never............................... 1
Almost Never ................... 2
Sometimes ...................... 3
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Fairly Often...................... 4
Very Often ....................... 5
DON’T KNOW ................. 8
REFUSED ....................... 9
G10. In the last month, how often have you felt confident about your ability to handle
your personal problems?
Never............................... 1
Almost Never ................... 2
Sometimes ...................... 3
Fairly Often...................... 4
Very Often ....................... 5
DON’T KNOW ................. 8
REFUSED ....................... 9
G11. In the last month, how often have you felt that things were going your way?
Never............................... 1
Almost Never ................... 2
Sometimes ...................... 3
Fairly Often...................... 4
Very Often ....................... 5
DON’T KNOW ................. 8
REFUSED ....................... 9
G12. In the last month, how often have you felt like difficulties were piling up so high
that you could not overcome them?
Never............................... 1
Almost Never ................... 2
Sometimes ...................... 3
Fairly Often...................... 4
Very Often ....................... 5
DON’T KNOW ................. 8
REFUSED ....................... 9
Received Mental Health Care
The following questions are about mental health care you may have received in the past
12 months.
G13. In the past 12 months, have you received any sort of counseling for problems with
your emotions, nerves, or mental health?
YES ................................... 1
NO ..................................... 2[GO TO G14]
DON’T KNOW ................... 8[GO TO G14]
REFUSED ......................... 9[GO TO G14]
G13.a. When did you last receive any sort of counseling?
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__ __ / __ __ __ __ [MM/YYYY]
DON’T KNOW88 8888
REFUSED..99 9999
G14. In the past 12 months, were you prescribed medication for problems with your
emotions, nerves, or mental health?
YES ................................... 1
NO ..................................... 2 [GO TO G15]
DON’T KNOW ................... 8 [GO TO G15]
REFUSED ......................... 9 [GO TO G15]
G14.a. When were you last prescribed such medication?
__ __ / __ __ __ __ [MM/YYYY]
DON’T KNOW88 8888
REFUSED..99 9999
Quick Inventory of Depressive Symptoms (K6)
The following questions ask about how you have been feeling during the past 30 days.
Some of them may sound like ones I’ve already asked you, but they’re a little different
and it’s important that you answer them as best you can.
G15. During the past 30 days, about how often did you feel...
G15.a. Nervous?
All of the time .......................... 1
Most of the time ...................... 2
Some of the time .................... 3
A little of the time .................... 4
None of the time ..................... 5
DON’T KNOW ........................ 8
REFUSED .............................. 9
G15.b. Hopeless?
All of the time .......................... 1
Most of the time ...................... 2
Some of the time .................... 3
A little of the time .................... 4
None of the time ..................... 5
DON’T KNOW ........................ 8
REFUSED .............................. 9
G15.c. Restless or fidgety?
All of the time .......................... 1
Most of the time ...................... 2
Some of the time .................... 3
A little of the time .................... 4
None of the time ..................... 5
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DON’T KNOW ........................ 8
REFUSED .............................. 9
G16. During the past 30 days, about how often did you feel so depressed that nothing
could cheer you up?
All of the time .......................... 1
Most of the time ...................... 2
Some of the time .................... 3
A little of the time .................... 4
None of the time ..................... 5
DON’T KNOW ........................ 8
REFUSED .............................. 9
G17. About how often did you feel that everything was an effort?
All of the time .......................... 1
Most of the time ...................... 2
Some of the time .................... 3
A little of the time .................... 4
None of the time ..................... 5
DON’T KNOW ........................ 8
REFUSED .............................. 9
G18. About how often did you feel worthless?
All of the time .......................... 1
Most of the time ...................... 2
Some of the time .................... 3
A little of the time .................... 4
None of the time ..................... 5
DON’T KNOW ........................ 8
REFUSED .............................. 9
[PROGRAMMER NOTE: IF ANY OF G15-G18=1-4, ELSE GO TO NEXT SECTION
LIFESTYLE - ALCOHOL]
G19. The last six questions asked about feelings that might have occurred during the
past 30 days. Taking them altogether, did these feelings occur?
A lot more often than usual ............................ 1
Somewhat more often than usual ................... 2
A little more often than usual .......................... 3
About the same as usual ............................... 4
A little less often than usual............................ 4
Somewhat less often than usual .................... 5
A lot less often than usual .............................. 6
DON’T KNOW ................................................ 8
REFUSED ...................................................... 9

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G20. During the past 30 days, how many days out of 30 were you totally unable to work
or carry out your normal activities because of these feelings?
__ __ Number of days
DON’T KNOW ........ 88
REFUSED .............. 99
[PROGRAMMER: OMIT THE FIRST PHRASE (“Not counting the [FILL IN FROM G20]
days you just reported,”) IF G20=0, DK, OR MISSING.]
G21. Not counting the [FILL IN FROM G20] days you just reported, how many days in
the past 30 were you able to do only half or less of what you would normally have been
able to do, because of these feelings?
__ __ Number of days
DON’T KNOW ........ 88
REFUSED .............. 99
G22. During the past 30 days, how many times did you see a doctor or other health
professional about these feelings?
__ __ Number of times
DON’T KNOW ........ 88
REFUSED .............. 99
G23. During the past 30 days, how often have physical health problems been the main
cause of these feelings?
All of the time ......... 1
Most of the time ...... 2
Some of the time .... 3
A little of the time .... 4
None of the time ..... 5
DON’T KNOW ........ 8
REFUSED .............. 9

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SECTION H: Lifestyle - Alcohol
Thank you. These next questions are about drinking alcohol. This includes wine coolers,
beer, wine, champagne, liquor such as whiskey, rum, gin, vodka, scotch, or liqueurs,
and also any other type of alcohol.
H1. In your entire life, have you had at least 1 drink of any kind of alcohol, not counting
small tastes or sips?
[INTERVIEWER NOTE: Definition of a standard drink: 1 12oz bottle of beer, 1 4oz glass
of non-fortified wine, 1 mixed drink with 1oz liquor.]
YES ........................ 1
NO .......................... 2 [GO TO NEXT SECTION]
DON’T KNOW ........ 8 [GO TO NEXT SECTION]
REFUSED .............. 9 [GO TO NEXT SECTION]
H2. Have you had an alcoholic beverage in the past 12 months?
YES ........................ 1 [GO TO QUESTION H4]
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
H3. How old were you when you last drank alcohol?
|_| |_| AGE ............. [GO TO QUESTION H6]
DON’T KNOW ........ 8[GO TO QUESTION H6]
REFUSED .............. 9[GO TO QUESTION H6]
H4. During the past 12 months, about how many days per week, per month, or in total
have you had alcoholic beverages?
|_| |_| # DAYS
PER WEEK .................................1
PER MONTH................................2
TOTAL FOR PAST 12 MONTHS .3
DON’T KNOW ..............................8
REFUSED ....................................9
H5. During the past 12 months, about how many drinks would you have on the days
that you drank? [INTERVIEWER NOTE: Definition of a standard drink: 1 12oz bottle of
beer, 1 4oz glass of non-fortified wine, 1 mixed drink with 1oz liquor.]
|_| |_| # DRINKS / DAY
DON’T KNOW ..............................8
REFUSED ....................................9

H6. Did you ever drink four or more alcoholic beverages in a row, in one sitting?
YES ........................ 1
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NO. ......................... 2 [GO TO QUESTION H7]
DON’T KNOW ........ 8 [GO TO QUESTION H7]
REFUSED .............. 9 [GO TO QUESTION H7]
H6.a. How many times has this happened in the past 12 months?
|_| |_| # TIMES
PER WEEK ................................. 1
PER MONTH .............................. 2
TOTAL FOR 12 MONTHS ........... 3
DON’T KNOW ...................………8
REFUSED .........................………9
H7. Have you ever been told by a doctor or a health professional that your drinking was
hurting your health?
YES ........................ 1
NO .......................... 2
DON'T KNOW ....... 8
REFUSED .............. 9
H7.a.Has this happened in past 12 months?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
H8. Has a close friend or relative told you that your drinking was hurting your health?
YES ........................ 1
NO .......................... 2
DON'T KNOW ....... 8
REFUSED .............. 9
H8.a.Has this happened in past 12 months?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
H9. Have you ever woken up in the morning after you had been drinking and find that
you couldn’t remember where you had been or what had happened?
YES ........................ 1
NO .......................... 2
DON'T KNOW ....... 8
REFUSED .............. 9
H9.a.Has this happened in past 12 months?
YES ........................ 1
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NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9

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SECTION I: Lifestyle - Tobacco
Now I would like to ask you some questions about your tobacco use.
I1. In the past 12 months, have you smoked at least 20 cigarettes? Do not include
cigars or marijuana. [NOTE TO INTERVIEWER: 20 CIGARETTES = APPROXIMATELY
1 PACK]
YES ........................ 1
NO .......................... 2 [GO TO QUESTION I10]
DON’T KNOW ........ 8 [GO TO QUESTION I10]
REFUSED .............. 9 [GO TO QUESTION I10]
I2. How old were you when you first started to smoke cigarettes fairly regularly?
__ | __ | __ AGE IN YEARS
NEVER SMOKED CIGARETTES REGULARLY .................... 777
DON’T KNOW ........................................................................ 888
REFUSED .............................................................................. 999
I3. Do you now smoke cigarettes?
Every day ............... 1 [GO TO QUESTION I9]
Some days ............. 2
Not at all ................. 3 [GO TO QUESTION I6]
DON’T KNOW ........ 8 [GO TO QUESTION I9]
REFUSED .............. 9 [GO TO QUESTION I10]
SOME DAYS SMOKER COLLECTION
I4. Have you smoked cigarettes every day for at least six months in the past year?
YES ..............................................1
NO ................................................2
DON’T KNOW ..............................8
REFUSED ....................................9
I5. On how many of the past 30 days did you smoke cigarettes?
| __ | __ | # DAYS [RANGE: 0 - 30]
DON’T KNOW ................... 88 [GO TO QUESTION I10]
REFUSED ......................... 99 [GO TO QUESTION I10]
I5.a. On average, on those [# DAYS] days, how many cigarettes did you usually
smoke each day?
| __ | __ | # CIGARETTES PER DAY [RANGE: 0 - 97] [GO TO I10]
DON’T KNOW ........ 88 [GO TO I10]
REFUSED .............. 99 [GO TO I10]
FORMER SMOKER COLLECTION
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[PROGRAMMER NOTE: TO MAKE UP FOR A PROGRAMMING ERROR IN THE
TELEPHONE ENROLLMENT CATI, ALSO DISPLAY THE FORMER SMOKER
COLLECTION QUESTIONS TO PARTICIPANTS WHO INDICATED THAT THEY
WERE A FORMER SMOKER DURING THEIR TELEPHONE ENROLLMENT
INTERVIEW; IF THEY DID NOT RECEIVE THESE QUESTIONS AT THAT TIME.]
I6. Have you ever smoked cigarettes every day for at least six months?
YES ..............................................1
NO ................................................2 [SKIP TO I7]
DON’T KNOW ..............................8 [SKIP TO I7]
REFUSED ....................................9 [SKIP TO I7]
I6.a. When you last smoked every day, on average how many cigarettes did you
smoke each day?
| __ | __ | # CIGARETTES PER DAY [RANGE: 1 - 97]
DON’T KNOW ........ 88
REFUSED .............. 99
I7. About how long has it been since you completely quit smoking cigarettes?
|_|_| Units
DAYS ..................... 1
WEEKS .................. 2
MONTHS................ 3
YEARS ................... 4
DON’T KNOW ........ 88
REFUSED .............. 99
I8. When you last smoked fairly regularly, on average how many cigarettes did you
smoke each day?
| __ | __ | # CIGARETTES PER DAY [RANGE: 1 - 97] [GO TO I10]
DON’T KNOW ................... 88 [GO TO I10]
REFUSED ......................... 99 [GO TO I10]
EVERYDAY SMOKER COLLECTION
I9. On average, about how many cigarettes do you now smoke each day?
| __ | __ | # CIGARETTES PER DAY [RANGE: 1 - 97]
DON’T KNOW ................... 88
REFUSED ......................... 99
Other Tobacco Use
I10. In the past 12 months, have you . . .
I10.a. …smoked at least 10 cigars?
YES ........................ 1
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NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
I10.b. …smoked a pipe at least 10 times?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
I10.c. …used snuff, such as Skoal®, Skoal Bandit® or Copenhagen® at least 10
times?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
I10.d. …used chewing tobacco, such as Redman®, Levi Garrett® or Beechnut®
at least 10 times?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
Environmental tobacco smoke
I11. About how many hours or minutes per day are you exposed to other people’s
tobacco smoke? Include all locations, such as home, car, work, and all other places you
spend time where others might smoke.
None ............................... 1
Less than 30 minutes ..... 2
30-59 minutes ................. 3
1-2 hours ........................ 4
3-4 hours ........................ 5
5-6 hours ........................ 6
7-8 hours ........................ 7
More than 8 hours .......... 10
DON’T KNOW ................ 8
REFUSED ...................... 9

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SECTION J: Socioeconomic Factors
J1. What was your total household income in 2012 before taxes, including income from
all sources such as wages, salaries, Social Security or retirement benefits, help from
relatives and so forth?
PROBE: Income is important in analyzing the health information we collect. For
example, this information helps us to learn whether persons in one income group use
certain types of medical services or have certain conditions more or less often than
those in another group. Please include all sources of income including wages, salary,
commissions, bonuses, tips from all jobs, self-employment income, annuities, interest,
dividends, net rental income, royalties, income from estates and trusts, Social Security
or Railroad retirement, Supplemental Security Income (SSI), any public assistance or
welfare payments, pensions (including retirement, survivor or disability), Veteran’s (VA)
payments, unemployment compensation, child support or alimony payments.
$ |___|___|___|___|___|___|___|___|___| [GO TO J2]
REFUSED ..................................... 8888888888
DON'T KNOW ............................... 9999999999
J1a. You may not be able to give us an exact figure for your total household
income, but can you tell me if this income in 2012 was . . .
Less than $10,000 .............1
$10,001 to $20,000............2
$20,001 to $30,000............3
$30,001 to $40,000............4
$40,001 to $50,000............5
$50,001 to $60,000............6
$60,001 to $70,000............7
$70,001 to $80,000............8
$80,001 to $90,000............9
$90,001 to $100,000..........10
$100,001 to $150,000…… 11
$150,001 to $200,000 ……12
More than $200,001 ..........13
DON'T KNOW ...................88
REFUSED .........................99
J2. How many people, including yourself, were supported by this income?
[VERIFY THAT PARTICIPANT HAS INCLUDED HIMSELF/HERSELF IN THE TOTAL
NUMBER.]
|__|__| # PEOPLE
1, ELSE GO TO J3>
J2.a. How many of these people were under 18 years old?
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|__|__| # PEOPLE
J2.b. How many were 65 or older?
|__|__| # PEOPLE
J3.Thinking of all the paid jobs you have had in the past 2 years, what was your job title
or what kind of work did you do the longest?
[FREE TEXT FIELD] OCCUPATION
NEVER WORKED ........................7 [GO TO QUESTION J4]
DON’T KNOW ..............................8 [GO TO QUESTION J4]
REFUSED ....................................9 [GO TO QUESTION J4]
J3.a. What kind of business or industry did you work in the longest during the
past 2 years as a [J3 – LONGEST OCCUPATION]?
[FREE TEXT FIELD] TYPE OF BUSINESS
DON’T KNOW ...................88
REFUSED .........................99
J3.b. What were your most important activities on this job in this business?
[FREE TEXT FIELD] DUTIES
DON’T KNOW ...................8
REFUSED .........................9
J3.c. About how long did you work at that job in this business?
|___|___|___| Units
DAYS .................................1
WEEKS .............................2
MONTHS ...........................3
YEARS ..............................4
DON’T KNOW ...................888
REFUSED .........................999
J4. What is your current work status? Are you working now, temporarily laid off, on sick
leave or maternity leave, looking for work, retired, disabled, keeping house, a student,
or something else?
WORKING NOW .................................... 1
ONLY TEMPORARILY LAID OFF, SICK LEAVE OR
MATERNITY LEAVE .................................................... 2
LOOKING FOR WORK OR UNEMPLOYED ................ 3 [GO TO NEXT SECTION]
RETIRED .................................................................... 4 [GO TO NEXT SECTION]
DISABLED, PERMANENTLY OR TEMPORARILY ..... 5 [GO TO NEXT SECTION]
KEEPING HOUSE ....................................................... 6 [GO TO NEXT SECTION]
STUDENT ................................................................... 7 [GO TO NEXT SECTION]
OTHER......................................................................... 8 J4.a. Specify: ___________
DON’T KNOW .............................................................. 88 [GO TO NEXT SECTION]
REFUSED .................................................................... 99 [GO TO NEXT SECTION]
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J5. What kind of business or industry do you work in?
SAME AS REPORTED IN J3 [PIPE IN RESPONSE FROM J3] [GO TO NEXT
SECTION]
[FREE TEXT FIELD] TYPE OF BUSINESS
DON’T KNOW……8
REFUSED ............ 9
J6. What is your job title or what kind of work do you do?
[FREE TEXT FIELD] TYPE OF WORK
DON’T KNOW ...... 8
REFUSED ............ 9
J7. What are your most important activities on this job?
[FREE TEXT FIELD] DUTIES
DON’T KNOW ...... 8
REFUSED ............ 9
J8. About how long have you worked for this company, in this job?
|___|___|___| Units
DAYS ................. 1
WEEKS ............... 2
MONTHS............. 3
YEARS ................ 4
DON’T KNOW ..... 888
REFUSED ........... 999

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SECTION K: Residential History
I’m now going to ask you about all the places you have lived for 6 months or longer
since we last spoke in [MONTH/YEAR].
K1. How long have you lived at your current address?
|__|__|__| UNITS
DAYS ................................ 1
WEEKS ............................. 2
MONTHS........................... 3
YEARS .............................. 4
DON’T KNOW ................888
REFUSED……………….999[GO TO L1]
[PROGRAMMER NOTE: IF K1 >= TIME SINCE LAST INTERVIEW, GO TO L1]
K2. What address did you live at before that for at least 6 months? [INTERVIEWER: IF
PARTICIPANT CAN’T REMEMBER THE FULL ADDRESS, ASK FOR CROSS
STREETS AND CITY, STATE, AND NEARBY LANDMARK(S)]
__________________________ [ADDRESS FIELDS]
DON’T KNOW ................... 8
REFUSED ......................... 9 [GO TO L1]
K2.a. How long did you live at that address?
_/_ MONTHS _/_ YEARS
DON’T KNOW ........ 888
REFUSED .............. 999 [GO TO L1]
[PROGRAMMER NOTE: IF SUM OF DURATIONS AT EACH ADDRESS, INCLUDING
CURRENT ADDRESS, >=TIME SINCE LAST INTERVIEW, GO TO L1].
K3. Did you move in there before or after your last interview in [MONTH/YEAR]?
BEFORE ........................... 1
AFTER .............................. 2 [GO TO K2]
DON’T KNOW ................... 8
REFUSED ......................... 9

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SECTION L: Experiences with Hurricane Katrina
[PROGRAMMER NOTE: ASK ONLY IF NOT COLLECTED AT PRIOR INTERVIEW.]
Now I would like to ask you some questions regarding your experiences with Hurricane
Katrina.
L1. Were you living in the Gulf region at the time of Hurricane Katrina?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION L6]
DON’T KNOW ........ 8 [GO TO QUESTION L6]
REFUSED .............. 9 [GO TO QUESTION L6]
L1.a. Please provide the city and state that you lived in at the time of Hurricane
Katrina.
City_________________________ [FREE TEXT FIELD]
State ________________________[DROP-DOWN MENU]
L2. Were you forced to leave your residence because of the hurricane?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION L6]
DON’T KNOW ........ 8
REFUSED .............. 9 [GO TO QUESTION L6]
L3. After the hurricane, did you return to your prior residence or to a different residence?
PRIOR .............................. 1 [GO TO QUESTION L5]
DIFFERENT ..................... 2
DIDN’T RETURN............... 3 [GO TO QUESTION L6]
DON’T KNOW ........ .......... 8
REFUSED .............. .......... 9 [GO TO QUESTION L6]
L4. Was your new residence in the same city or town and neighborhood?
Same city or town, same neighborhood ...................... 1
Same city or town, different neighborhood ................... 2
Different city or town .................................................... 3
DON’T KNOW .............................................................. 8
REFUSED .................................................................... 9 [GO TO QUESTION L6]
L5. For how many months were you unable to return?
| __ | __ | Months
DON’t KNOW .................... 8
REFUSED ......................... 9
L6. Did you lose your job as a result of the hurricane?
YES ....................................................... 1
NO .......................... ............................... 2 [GO TO QUESTION L7]
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WAS UNEMPLOYED BEFORE ............ 3
DON’T KNOW ........ ............................... 8
REFUSED .............. ............................... 9 [GO TO QUESTION L7]
L6.a.How long were you unemployed after the hurricane?
| __ | __ | # of units
DAYS ...................................................................................... 1
WEEKS .................................................................................. 2
MONTHS ................................................................................ 3
YEARS ................................................................................... 4
HAVE NOT WORKED SINCE THE HURRICANE .................. 66
DID NOT WORK UNTIL THE OIL SPILL CLEAN-UP ............. 77
DON’T KNOW ........................................................................ 88
REFUSED .............................................................................. 99
L7. Did you experience the loss of a loved one or a serious injury to a loved one during
the Hurricane?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
L8. Did you experience serious injury to yourself during the Hurricane?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9

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Part 3: Scripts – Post-Telephone Scripts
(Estimated Burden: 2 Minutes)

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SECTION M: Wrap-up
Thank you for your responses so far. I would like to confirm some additional information and
then your interview will be complete.
SECTION : SSN, Addresses and Transition
[PROGRAMMER NOTE: ONLY DISPLAY SSN QUESTIONS IF WE DID NOT OBTAIN FULL
SSN DURING THE LAST INTERVIEW].
M1. What is your social security number? [PROBE: Your social security number will help us
keep in touch with you over the years and allow us to link to the correct records about your
health. Reporting your social security number is voluntary. We will not share your social
security number with others and we will do everything possible to keep it private.]
__/__/__/ - __/__/ - __/__/__/__/
[GO TO QUESTION M2]
DON’T HAVE ................................... [GO TO QUESTION M2]
DON’T KNOW .................................. 8
REFUSED........................................ 9
M1.a. Would you be willing to tell me the last four digits of your social security number?
The last four digits of your Social Security Number are not unique to you. Other people
have those same last four digits. However, it will help us do a better job of keeping up
with you and your public health records over the years.
Last 4 numbers of SSN - __ __ __ __
DON’T HAVE........................
DON’T KNOW ...................... 8
REFUSED ............................ 9
M2. What is your email address? [INTERVIEWER: READ BACK FOR ACCURACY]
[FREE TEXT FIELD] EMAIL
DON’T HAVE .......... 7
DON’T KNOW ......... 8
REFUSED............... 9
SECTION: Text Messaging Opt-in / Opt-out
[PROGRAMMER NOTE: ONLY DISPLAY M3 TO PARTICIPANTS WHO SAID NO, DON’T
KNOW, OR REFUSED AT THE TELEPHONE ENROLLMENT INTERVIEW.]
M3. Would you like to receive periodic text messages on your mobile phone with GuLF STUDY
news and updates? Please note that your cell phone service provider may charge for text
messages as part of your individual service plan.
YES ….. .......................................... 1
NO……. .......................................... 2 [SKIP TO QUESTION M4]
DON’T KNOW…….. ......................... 8 [SKIP TO QUESTION M4]
REFUSED........................................ 9 [SKIP TO QUESTION M4]

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[PROGRAMMER NOTE: DISPLAY M3.a. FOR PARTICIPANTS WHO SAID YES TO M3
DURING THIS INTERVIEW OR TO L.1.0.1 DURING THE TELEPHONE
ENROLLMENT INTERVIEW.]
M3.a. Would you please provide me with a mobile phone number that we should use to
send you text messages?
SAME PHONE NUMBER CALLED TO REACH PARTICIPANT ….. 1
Phone Number I_I_I_I_I_I_I_I_I_I_I TEN DIGIT #
DON’T KNOW ........... 8
REFUSED ..... ........... 9
Thank you.
SECTION:Additional Contact
M4. May I have contact information for a person who would know how to reach you should we
have difficulty contacting you in the future?
YES ...................................... 1
NO ........................................ 2[GO TO QUESTION M5]
DON’T KNOW ....................... 8[GO TO QUESTION M5]
REFUSED............................. 9[GO TO QUESTION M5]
M4.a. What is this person’s relationship to you?
[DROP DOWN BOX]
REFUSED ........ ............ 9
M4.b. What is their name?
_____________________ [FREE TEXT FIELD]
REFUSED ..... ………9
M4.c. What is their phone number?
I_I_I_I_I_I_I_I_I_I_I TEN DIGIT # [INTERVIEWER: ENTER PHONE NUMBER IN THIS
FORMAT: 123-456-7890]
DON’T KNOW ........... 8 [GO TO QUESTION M4.d]
REFUSED ................. 9 [GO TO QUESTION M4.d]
M4.c.1 Is this number a cell phone?
YES ............... .......... 1
NO ................. .......... 2
DON’T KNOW .......... 8
REFUSED...... .......... 9
M4.d. What is their street address?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
Zip Code: ___/___/___/___/___/
DON’T KNOW…….. 8
REFUSED
………9

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M4.e. Is this also their mailing address?
YES .......................... 1[GO TO QUESTION M5]
NO............................. 2
DON’T KNOW .......... 8[GO TO QUESTION M5]
REFUSED ................ 9[GO TO QUESTION M5]
M4.e.1. What is their mailing address?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
Zip Code: ___/___/___/___/___/
DON’T KNOW……..8 [GO TO QUESTION M5]
REFUSED
………9 [GO TO QUESTION M5]

[PROGRAMMER NOTE: CONDUCT ADDITIONAL MENTAL HEALTH MODULE
HERE FOR TARGETED SUBSET OF PARTICIPANTS]
SECTION M5.
These are all of the study questions I have for you. Do you have any questions about the study
or anything that we discussed today?
[PARTICIPANT’S NAME], I really appreciate your time. If you have any questions or concerns,
you can call our toll-free number and a member of the study staff will assist you. That toll-free
number is 855 NIH GuLF (855-644 4853).

[TERMINATE CALL]

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