OMB_Chinese_Materials

Health Center Patient Survey
Cognitive Interviewing Materials
(Chinese)

1

1. Introductory text in Cognitive interviews

2014 年健康中心患者調查
認知協議
開始前，請允許我向您介紹若干相關資訊。
我們正在對一項關於健康中心患者所接受的醫療保健之調查問卷進行測試。此問卷最終會
向全國患者提供。我們之所以聯絡您，是因為您近期曾到健康中心就診。
我們在不同人群中對該等調查問題進行測試，旨在檢驗所提的問題是否可行。我們希望能
夠瞭解：所設計的問題是否容易理解？ 這些問題的難易程度如何？ 我們亦希望瞭解您
對每個問題的認識，以及您獲得答案的過程。這將有助於我們確定此問卷是否存在任何問
題。您的反饋將在我們制定此調查問卷時提供幫助。此問卷並無標準答案。我們概不會詢
問您有關法律地位或移民狀態的問題。
測試的方式是：我們將一起詳細討論此問卷。我把問題讀給您聽，然後您告訴我答案。在
您思考問題答案時，我希望您可以邊想邊說。這樣我就可以明白您是如何得出答案的。或
許此做法令您感到不習慣，但這會有助我理解您如何決定您的答案以及您對此問題的看法。
再次強調下，此問卷並無標準答案。下面將舉例說明我希望您怎麼做：
假設我問您：您有幾台電視？
不要只是回答：兩台電視
而是應該回答：我們家客廳有一台電視，我的臥室裡也有一台電視。我的兒子和我住在一

起，他房間裡也有一台電視。我女兒的房間裡還有一台電視，但是她多數時間與她的姑母
住在一起，只是週末才和我一起。所以，我不確定是否要把這些算在內。
如您所見，若只是回答兩台電視，那我們就不會知道您孩子使用的電視機了。在該等採訪
中，瞭解您是如何得出答案的比答案本身更重要。
您對此範例是否存有任何疑問？
在向您提問此調查中的若干問題後，我還會提出若干後續問題。然而，即使我沒有問到，
您也可以隨時說出您對任何問題的想法。您還可就任何似乎難以理解的問題向我提問。
開始前，請允許我向您提供此同意書。此同意書對本研究進行解釋，並闡明將要求您進行
的事項。如您存有任何疑問，請隨時打斷我。
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提供同意書。查看同意書的要點。
一旦準備就緒，請在簽名線[指著簽名線]上簽署，以表示您瞭解您的職責並自願參與。我
亦會向您提供一份同意書副本，供您保存。同意書上載有相關電話號碼，如您在日後對本
研究存有任何疑問，請致電諮詢。
收取已簽署的同意書。
開始前，您是否有任何疑問？

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2. Consent Forms
(1) Adult consent form
成年人參與健康中心患者調查預調查
之知情同意書

關於調查
健康中心患者調查是一項由 RTI International 開展的研究項目。此調查由健康資源及服務管理署
(HRSA) 的基層保健局發起，與在類似此健康中心的場所接受醫療保健的人群相關。此調查將盡
力找出人們面臨的各類健康問題，並識別健康中心滿足患者需求的能力。在開展此調查前，我們
需要確定我們擬詢問的問題是否易於理解。本「預調查」的目的在於測試該等問題的可行程度。
RTI 已選擇約 71 名人士參與，您為其中的一員。
參與
若您同意參與，我們將詢問您若干有關您的健康狀況以及在此健康中心獲得的服務之問題。部分
問題可能屬於私人問題，例如關於使用藥物或酒精以及您的感受之問題。此外，可能還有關於
HIV/愛滋病的問題。多數問題都是關於不那麼敏感的事情，例如所接受的醫療保健以及您是否患
有哮喘或糖尿病等病症。在回答該等問題時，請盡可能邊想邊說。我會問一些後續問題，以瞭解
您得出答案的過程。若問題不好理解，或讓您感到不舒服，請告訴我。有些人的採訪時間較短，
有些人的採訪時間則較長。採訪可能持續約 75 分鐘。
自願參與
您可自願選擇是否參與。若您選擇不參與其中，將不會影響您在健康中心或從任何其他計劃中可
能獲得的任何服務。若您不希望回答所問的部分問題，則無須作答。若您決定不完成餘下的問題，
亦可隨時終止。部分問題或許會讓您感到不舒服，或出現情緒波動。若您需要休息，請隨時告訴
我。
福利
參與調查並不會令您獲得任何直接福利。然而，您將幫助我們瞭解更多有關如何開展健康中心患
者調查的資訊。如上所述，此調查與使用類似此健康中心的場所的人群之健康需求相關。
參與補償
若您參與，將向您提供現金 $50 作為抽空參與之補償。每個採訪平均需時約 75 分鐘。
參與研究的風險
參與研究涉及兩種風險。第一種風險是我們提出的問題可能讓您感到不舒服或不安。若感到不舒
服或不安，您可要求採訪者讓您休息或跳過任何問題。第二種風險是其他人可能會得知您在採訪
中告訴我們的事情。為避免此情況發生，我們將在無人能聽到您回答的私密場所進行採訪。我們
還會創建並使用編號代替您的名字，以識別您的採訪。此舉將使其他人無法得知您的回答。
您的隱私
您告知我的任何事項均屬保密資訊。由於您答案的隱私性至關重要，所以請允許我更深入地談談
這點。參與此研究的每個人均已簽署一份協議，其中聲明他們將保護您所提供資訊的隱私性。概
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不會向此健康中心的任何人透露您告知我的資訊。我們概不會詢問您有關法律地位或移民狀態的
問題。
疑問
若您對此研究存有任何疑問，請撥打 [1(XXX) XXX-XXXX] 聯絡 [XXXXX]。若您對作為一名研
究參與者的權利存有任何疑問，請撥打 RTI 的研究保障辦公室免費電話 1-866-214-2043。
關於是否參與本研究，您是否存有任何疑問？
一經簽署，即表示您同意參與。請僅在如下情況下，簽署本同意書：
 您瞭解本同意書所述研究的相關資訊；
 您所有的疑問已獲悉數答覆；及
 您希望參與。
您將獲提供本同意書的副本，以供保存。
受訪者簽名：______________________________________________

日期：_________

採訪者簽名：______________________________________________

日期：_________

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(2) Parent/guardian proxy interview consent form
家長/監護人代替所監護兒童
參與健康中心患者調查預調查採訪
之知情同意書

關於調查
健康中心患者調查是一項由 RTI International 開展的研究項目。此調查由健康資源及服務管理署
(HRSA) 的基層保健局發起，與在類似此健康中心的場所接受醫療保健的人群相關。此調查將盡
力找出人們面臨的各類健康問題，並識別健康中心滿足患者需求的能力。在開展此調查前，我們
需要確定我們擬詢問的問題是否易於理解。本「預調查」的目的在於測試該等問題的可行程度。
RTI 已選擇約 71 名人士參與，您的小孩 [小孩姓名] 為其中的一員。由於 [小孩姓名] 不滿 13 歲，
我們希望向您詢問若干有關他/她的健康狀況以及在此健康中心獲得的服務之問題。
參與
若您同意參與，我們將詢問您若干有關您小孩的健康狀況以及在此健康中心獲得的服務之問題。
部分問題可能屬於私人問題，例如關於您的小孩使用藥物或酒精以及他/她的感受之問題。此外，
可能還有關於 HIV/愛滋病的問題。但多數問題都是關於不那麼敏感的事情，例如所接受的醫療保
健以及您的小孩是否患有哮喘或糖尿病等病症。在回答該等問題時，請盡可能邊想邊說。我會問
一些後續問題，以瞭解您得出答案的過程。若問題不好理解，或讓您感到不適，請告訴我。有些
人的採訪時間較短，有些人的採訪時間則較長。採訪可能持續約 75 分鐘。
自願參與
您可自願選擇是否參與。若您選擇不參與其中，將不會影響您的小孩或家人在健康中心或從任何
其他計劃中可能獲得的任何服務。若您不希望回答所問的部分問題，則無須作答。若您決定不完
成餘下的問題，亦可隨時終止。部分問題或許會讓您感到不舒服，或出現情緒波動。若您需要休
息，請隨時告訴我。
福利
參與調查並不會令您或您的小孩獲得任何直接福利。然而，您將幫助我們瞭解更多有關如何開展
健康中心患者調查的資訊。如上所述，此調查與使用類似此健康中心的場所的人群之健康需求相
關。
參與補償
若您參與，將向您提供現金 $50 作為抽空參與之補償。每個採訪平均需時約 75 分鐘。
參與研究的風險
參與研究涉及兩種風險。第一種風險是我們提出的問題可能讓您感到不舒服或不安。若感到不舒
服或不安，您可要求採訪者讓您休息或跳過任何問題。第二種風險是其他人可能會得知您在採訪
中告訴我們的事情。為避免此情況發生，我們將在無人能聽到您回答的私密場所進行採訪。我們
還會創建並使用編號代替您的名字，以識別您的採訪。此舉將使其他人無法得知您的回答。
您的隱私
6

您告知我的任何事項均屬保密資訊。由於您答案的隱私性至關重要，所以請允許我更深入地談談
這點。參與此研究的每個人均已簽署一份協議，其中聲明他們將保護您所提供資訊的隱私性。概
不會向此健康中心的任何人透露您告知我的資訊。我們概不會詢問您有關法律地位或移民狀態的
問題。
疑問
若您對此研究存有任何疑問，請撥打 [1(XXX) XXX-XXXX] 聯絡 [XXXXX]。若您對作為一名研
究參與者的權利存有任何疑問，請撥打 RTI 的研究保障辦公室免費電話 1-866-214-2043。
關於是否參與本研究，您是否存有任何疑問？
一經簽署，即表示您同意參與。請僅在如下情況下，簽署本同意書：
 您瞭解本同意書所述研究的相關資訊；
 您所有的疑問已獲悉數答覆；及
 您希望參與。
您將獲提供本同意書的副本，以供保存。
受訪者簽名：______________________________________________

日期：_________

採訪者簽名：______________________________________________

日期：_________

7

(3) Parent/guardian proxy interview consent form
受監護青少年（13–17 歲）
參與健康中心患者調查預調查
之家長/監護人同意書

關於調查
健康中心患者調查是一項由 RTI International 開展的研究項目。此調查由健康資源及服務管理署
(HRSA) 的基層保健局發起。此調查與在類似此健康中心的場所接受醫療保健的人群相關。此調
查將盡力找出人們面臨的各類健康問題，並識別健康中心滿足患者需求的能力。在開展此調查前，
我們需要確定我們擬詢問的問題是否易於理解。本「預調查」的目的在於測試該等問題的可行程
度。RTI 已選擇約 71 名人士參與，您的孩子為其中的一員。
參與
若您的孩子同意參與，我們將詢問他/她若干有關其健康狀況以及在此健康中心獲得的服務之問題。
部分問題可能屬於私人問題，例如關於您的孩子使用藥物或酒精以及他/她的感受之問題。此外，
可能還有關於 HIV/愛滋病的問題。多數問題是關於沒那麼敏感的事情，例如所接受的醫療保健以
及您的孩子是否患有哮喘或糖尿病等病症。在回答該等問題時，我們會要求您的孩子盡可能邊想
邊說。我會問一些後續問題，以瞭解他/她得出答案的過程。若問題不好理解，或讓他/她感到不
舒服，請讓其請告訴我。有些人的採訪時間較短，有些人的採訪時間則較長。採訪可能持續約 75
分鐘。
自願參與
您的孩子可自願選擇是否參與。若您選擇不向我們提供准許，或您的小孩選擇不參與其中，將不
會影響您的孩子或家人在健康中心或從任何其他計劃中可能獲得的任何服務。若您的孩子不希望
回答所問的部分問題，則無須作答。若您的孩子決定不完成餘下的問題，亦可隨時終止。部分問
題或會讓您的孩子感到不舒服，或出現情緒波動。若他/她需要休息，請讓其隨時告訴我。
福利
參與調查並不會令您或您的孩子獲得任何直接福利。然而，他/她將幫助我們瞭解更多有關如何開
展健康中心患者調查的資訊。如上所述，此調查與使用類似此健康中心的場所的人群之健康需求
相關。
參與補償
此外，若您的孩子參與，將獲得現金 $50 作為抽空參與之補償。每個採訪平均需時約 75 分鐘。
參與研究的風險
參與研究涉及兩種風險。第一種風險是我們提出的問題可能讓您的孩子感到不舒服或不安。若感
到不舒服或不安，他/她可要求採訪者讓其休息或跳過任何問題。第二種風險是其他人可能會得知
您的孩子在採訪中告訴我們的事情。為避免此情況發生，我們將在無人能聽到他/她回答的私密場
所進行採訪。我們還會創建並使用編號代替您孩子的名字，以識別您孩子的採訪。此舉將使其他
人無法得知您孩子的回答。
您孩子的隱私
8

您孩子告知我的任何事項均屬保密資訊。由於他/她答案的隱私性至關重要，所以請允許我更深入
地談談這點。參與此研究的每個人均已簽署一份協議，其中聲明他們將保護所提供資訊的隱私性。
概不會向您或此健康中心的任何人透露您孩子告知我的資訊。我們概不會詢問您的孩子有關法律
地位或其移民狀態的問題。
疑問
若您對此研究存有任何疑問，請撥打 [1(XXX) XXX-XXXX] 聯絡 [XXXXX]。若您對作為一名研
究參與者的權利存有任何疑問，請撥打 RTI 的研究保障辦公室免費電話 1-866-214-2043。
關於是否要准許您的孩子參與本研究，您是否存有任何疑問？
一經簽署，即表示您准許您的孩子參與上述研究。請僅在如下情況下，簽署本同意書：
 您瞭解本同意書所述研究的相關資訊；
 您所有的疑問已獲悉數答覆；及
 您准許您的孩子參與。
您將獲提供本同意書的副本，以供保存。
孩子姓名：______________________________________________
家長/監護人簽名：______________________________________________

日期：_________

採訪者簽名：__________________________________________________

日期：_________

9

(4) Consent form for minor children’s interview

受監護青少年（13–17 歲）
參與健康中心患者調查預調查
之同意書

關於調查
健康中心患者調查是一項由 RTI International 開展的研究項目。此調查由健康資源及服務管理署 (HRSA) 的基層
保健局發起，與在類似此健康中心的場所接受醫療保健的人群相關。此調查將盡力找出人們面臨的各類健康問題，
並識別健康中心滿足患者需求的能力。在開展此調查前，我們需要確定我們擬詢問的問題是否易於理解。本「預
調查」的目的在於測試該等問題的可行程度。RTI 已選擇約 71 名人士參與，您為其中的一員。
參與
[家長/監護人姓名] 同意我邀請您與我談論有關您的健康狀況以及在此健康中心獲得的服務。若您也同意的話，
請允許我詢問您若干問題。部分問題可能屬於私人問題，例如關於使用藥物或酒精以及您的感受之問題。此外，
可能還有關於 HIV/愛滋病的問題。多數問題都是關於不那麼敏感的事情，例如所接受的醫療保健以及您是否患
有哮喘或糖尿病等病症。在回答該等問題時，請盡可能邊想邊說。我會問一些後續問題，以瞭解您得出答案的過
程。若問題不好理解，或讓您感到不舒服，請告訴我。有些人的採訪時間較短，有些人的採訪時間則較長。採訪
可能持續約 75 分鐘。
自願參與
您可自願選擇是否參與。若您選擇不參與其中，將不會影響您在健康中心或從任何其他計劃中可能獲得的任何服
務。若您不希望回答所問的部分問題，則無須作答。若您決定不完成餘下的問題，亦可隨時終止。部分問題或許
會讓您感到不舒服，或出現情緒波動。若您需要休息，請隨時告訴我。
福利
參與調查並不會令您獲得任何直接福利。然而，您將幫助我們瞭解更多有關如何開展健康中心患者調查的資訊。
如上所述，此調查與使用類似此健康中心的場所的人群之健康需求相關。
參與補償
若您參與，將向您提供現金 $50 作為抽空參與之補償。每個採訪平均需時約 75 分鐘。
參與研究的風險
參與研究涉及兩種風險。第一種風險是我們提出的問題可能讓您感到不舒服或不安。若感到不舒服或不安，您可
要求採訪者讓您休息或跳過任何問題。第二種風險是其他人可能會得知您在採訪中告訴我們的事情。為避免此情
況發生，我們將在無人能聽到您回答的私密場所進行採訪。我們還會創建並使用編號代替您的名字，以識別您的
採訪。此舉將使其他人無法得知您的回答。

您的隱私
您告知我的任何事項均屬保密資訊。由於您答案的隱私性至關重要，所以請允許我更深入地談談這點。參與此研
究的每個人均已簽署一份協議，其中聲明他們將保護您所提供資訊的隱私性。概不會向此健康中心的任何人透露
您告知我的資訊。您的家長/監護人將無法查看您的回答，我們亦不會與其討論您的任何回答。

10

疑問
若您對此研究存有任何疑問，請撥打 [1(XXX) XXX-XXXX] 聯絡 [XXXXX]。若您對作為一名研究參與者的權利
存有任何疑問，請撥打 RTI 的研究保障辦公室免費電話 1-866-214-2043。
關於是否參與本研究，您是否存有任何疑問？
一經簽署，即表示您同意參與。請僅在如下情況下，簽署本同意書：
 您瞭解本同意書所述研究的相關資訊；
 您所有的疑問已獲悉數答覆；及
 您希望參與。
您將獲提供本同意書的副本，以供保存。
受訪者簽名：______________________________________________

日期：_________

採訪者簽名：______________________________________________

日期：_________

11

3. Hand-out

您會講[XXX]嗎？
受邀測試調查問卷的患者
即可獲支付 $50！！
________________________________________________
非營利研究機構 RTI International 正在本健康中心招募多名患者參與一項調
查，患者需要花 75 分鐘來回答[XXX]健康調查問卷中的一些問題。
 13-17 歲的青少年
 12 歲及以下兒童的父母
 18 歲及以上的男性及女性
我們有意採訪講[XXX]的人士。即使您的英語講得不流利也沒關係。
符合條件的患者即可參與，不論其移民身份為何。
參與者將收到 $50 的現金，作為參與 75 分鐘面對面採訪的回報。參與者提供的一切資
訊將會保密處理，概不向健康中心提供。
如需瞭解更多資訊，請撥打 1(XXX) XXX-XXXX 聯絡 XXXXXX

________________________________________________

12

4. Flyer

您會講[XXX]嗎？

受邀測試若干調查問題的患者
即可獲支付 $50！

非營利研究機構 RTI International 正在本健康中心招募多名患者參與一項調查，患者需
要花 75 分鐘來回答[XXX]健康調查問卷中的一些問題。
 13-17 歲的青少年
 12 歲及以下兒童的父母
 18 歲及以上的男性及女性

我們有意採訪講[XXX]的人士。即使您的英語講得不流利也沒關係。
符合條件的患者即可參與，不論其移民身份為何。

參與者將收到 $50 的現金，作為參與 75 分鐘面對面採訪的回報。參與者提供的一切資
訊將會保密處理，概不向健康中心提供。
如需瞭解更多資訊，請撥打 1(XXX) XXX-XXXX 聯絡 XXXXXX

RTI 健康調查（賺取 $50）
(XXX) XXX-XXXX

RTI 健康調查（賺取 $50）
(XXX) XXX-XXXX

RTI 健康調查（賺取 $50）
(XXX) XXX-XXXX

RTI 健康調查（賺取 $50）
(XXX) XXX-XXXX

RTI 健康調查（賺取 $50）
(XXX) XXX-XXXX]

RTI 健康調查（賺取 $50）
(XXX) XXX-XXXX

RTI 健康調查（賺取 $50）
(XXX) XXX-XXXX

RTI 健康調查（賺取 $50）
(XXX) XXX-XXXX

RTI 健康調查（賺取 $50）
(XXX) XXX-XXXX]

RTI 健康調查（賺取 $50）
(XXX) XXX-XXXX

RTI 健康調查（賺取 $50）
(XXX) XXX-XXXX

13

5. Incentive receipt

現金獎勵收據

RTI 項目編號 ________--- __________

個案 ID 編號 ________________

本研究十分重要，為感謝您抽出寶貴時間回答相關問題，我們獲授權向您提供 $50 的現金獎勵。對我
們而言，保護您資訊的保密性至關重要，因此請勿在本表上填寫您的全名。但採訪者必須在本表上簽名
並註明日期，以證明您已收取（或拒絕）此現金款項。
已接受 $50 的現金獎勵
已拒絕 $50 的現金獎勵
接受者簡簽（請勿簽署您的全名）_____________

日期：___/ ___/ ___

採訪者簽名：

FI ID 編號 ___________

____________________________

收據的保存： 原件連同個案材料予 RTI，黃色副本予監督方，金色副本予受訪者。

14

6. Questionnaire
(1) Module D: Routine care

COLOR CODE DESCRIPTIONS
Yellow: Items not to be translated. For the most part this are programming instructions or
certain interviewer instructions.
Green: These are either reference date or reference health center variable fills and do not
need to be translated. The computerized program will automatically place the pertinent
information.
Turquoise:These are variable fills that will trigger the system whether the question is being
asked about the participant himself/herself or some else (name). If the item “name” is shown
on this variable fill item, it will remain in English and will be automatically replaced by the
pertinent individual's name by the system. However, the translation around these variable
fills need to be adapted for both scenarios.
Pink: If applicable, these are items that have a programming code for either underline or
bolding before and after the wording. For example: @UXXXXX@u. Please leave those
codes as is and translate the wording inside them.

ORIGINAL ENGLISH
MODULE D:

ROUTINE CARE

TRANSLATION
MODULE D:

ROUTINE CARE

Next, I’m going to ask you about health services that
{you/name} received in the past 12 months.

接下來，我將要就{您/name}在過去 12 個月內接受
的醫療服務提問。

ROU1a. During the past 12 months, that is since {12
MONTH REFERENCE DATE}, {have you/has
name} seen or talked to any of the following health
care providers about {your own/his/her} health?
Please tell me yes or no for each of the following by
an
optometrist, ophthalmologist, eye doctor, or someone
who prescribes eyeglasses?

ROU1a.過去 12 個月內，也就是從{12 MONTH
REFERENCE DATE}起至今，{您/name}是否就{您
自己/他/她}的健康問題去找過下列醫療服務提供者
或與其交談？下列各項，請分別回答是或否。
驗光師、眼科專家、眼科醫生或配鏡師？
1=是
2=否

1=YES
2=NO
ROU1b. (During the past 12 months, that is since {12
MONTH REFERENCE DATE}, {have you/has
name} seen or talked to any of the following health
care providers about {your own/his/her} health?
Please tell me yes or no for each of the following…)
Afoot doctor?
1=YES
2=NO

ROU1b.（過去 12 個月內，也就是從{12 MONTH
REFERENCE DATE}起至今，{您/name}是否就{您
自己/他/她}的健康問題去找過下列醫療服務提供者
或與其交談？下列各項，請分別回答是或否…）
足科醫生？
1=是
2=否
15

ROU1c. (During the past 12 months, that is since {12
MONTH REFERENCE DATE}, {have you/has
name} seen or talked to any of the following health
care providers about {your own/his/her} health?
Please tell me yes or no for each of the following…)

ROU1c.（過去 12 個月內，也就是從{12 MONTH
REFERENCE DATE}起至今，{您/name}是否就{您
自己/他/她}的健康問題去找過下列醫療服務提供者
或與其交談？下列各項，請分別回答是或否…）

A chiropractor?

手療師？

IF NEEDED, YOU MAY EXPLAIN: “A chiropractor
uses a system of therapy in which disease is considered
IF NEEDED, YOU MAY EXPLAIN:「手療師使用一個
the result of abnormal function of the nervous system.
The method of treatment usually involves manipulation of 治療系統進行治療，此系統中，疾病被認為是由神經
系統機能異常引起的。此治療方法通常包含對脊柱及
the spinal column and other body structures.”
其他身體結構的推拿。」
1=YES
2=NO
1=是
2=否
ROU1d. (During the past 12 months, that is since {12
MONTH REFERENCE DATE}, {have you/has
name} seen or talked to any of the following health
care providers about {your own/his/her} health?
Please tell me yes or no for each of the following…)
A medical doctor who specializes in a particular medical
disease or problem other than obstetrician, gynecologist,
psychiatrist, or ophthalmologist
1=YES
2=NO

ROU2.
During the past 12 months, how many
times {have you/has name}gone to a hospital
emergency room about {your own/his/her) health?
This includes emergency room visits that resulted in a
hospital admission.

ROU1d.（過去 12 個月內，也就是從{12 MONTH
REFERENCE DATE}起至今，{您/name}是否就{您
自己/他/她}的健康問題去找過下列醫療服務提供者
或與其交談？下列各項，請分別回答是或否…）
除產科醫生、婦科醫生、心理醫生或眼科專家以外，
專精於治療特定疾病或問題的醫生
1=是
2=否

ROU2.
過去 12 個月內，{您/name}就{您自己/
他/她)的健康問題去過多少次醫院急診室？這裡包
括後來需要住院的急診室就診。
________ TIMES [ALLOW 000-365]

________ TIMES [ALLOW 000-365]
ROU3.
(Were you/Was name} ever hospitalized
@Uovernight@u in the past 12 months? Do not
include an overnight stay in the emergency room.
1=YES
2=NO
[ROUCHK4 IF ROU3 = 1 CONTINUE ELSE
GOTO ROU5 ]

ROU3.
(您/name}過去 12 個月內是否有@U 過
夜@u 住院的經歷？不包括在急診室內過夜。
1=是
2=否
[ROUCHK4 IF ROU3 = 1 CONTINUE ELSE GOTO
ROU5 ]

16

ROU4.
Altogether, how many nights {were
you/was name} in the hospital during the past 12
months?
_______ NIGHTS [ALLOW 000-365]
ROU5.
During the past 12 months, {have
you/has name} had a flu shot? A flu shot is usually
given in the fall and protects against influenza for the
flu season. The flu shot is injected in the arm. Do not
include an influenza vaccine sprayed in the nose.
1=YES
2=NO
ROU6: During the past 12 months, {have you/has
name} had a flu vaccine sprayed in {your/his/her}
nose by a doctor or other health professional? {IF
AGE GE 18 ADD: A health professional may have
let you spray it.} This vaccine is usually given in the
fall and protects against influenza for the flu season.

ROU4.
晚？

{您/name}在過去 12 個月內總共住院幾

_______ NIGHTS [ALLOW 000-365]
ROU5.
過去 12 個月內，{您/name}是否打過流
感疫苗？流感疫苗通常是在秋天注射，用於在流感
季節預防流感。流感疫苗在手臂上注射。不包括噴
到鼻腔內的流感疫苗。
1=是
2=否

ROU6:過去 12 個月內，{您/name}是否接受了醫生
或其他醫療專業人員在{您/他/她}的鼻腔內使用的
流感疫苗噴霧？{IF AGE GE 18 ADD:醫療專業人
員可能讓您自己噴流感疫苗噴霧。}此疫苗通常是
在秋天使用，用於在流感季節預防流感。

READ IF NECESSARY: This influenza vaccine is called
FluMist{trademark}.

READ IF NECESSARY:此流感疫苗被稱為 FluMist{商
標}。

1=YES
2=NO

1=是
2=否

[ROUCHK7
IF ROU6=1 OR ROU5=1,
THEN CONTINUE; ELSE GO TO ROUCHK8]

ROU7.
Did {you/name} get the flu shot or
vaccine sprayed in the nose at {the reference health
center}?
1=YES
2=NO
[ROUCHK8
IF AGE GE 65, CONTINUE;
ELSE GO TO ROU9a]

[ROUCHK7
IF ROU6=1 OR ROU5=1,
THEN CONTINUE; ELSE GO TO ROUCHK8]
ROU7.
{您/name}是否在{the reference health
center}打過流感疫苗或在鼻腔內使用流感疫苗噴霧
？
1=是
2=否

[ROUCHK8
IF AGE GE 65, CONTINUE;
ELSE GO TO ROU9a]

17

ROU8. Have you ever had a pneumonia shot? This
shot is usually given only once or twice in a person’s
lifetime and is different from the flu shot. It is also
called the pneumococcal vaccine.
1=YES
2=NO

ROU8.您是否打過肺炎疫苗？與流感疫苗不同，人
的一生中通常只接受一到兩次此疫苗。此疫苗亦被
稱為肺炎鏈球菌疫苗。
1=是
2=否

[ROUCHK9
IF ROU8 =1, CONTINUE;
ELSE GO TO ROU10]

[ROUCHK9
IF ROU8 =1, CONTINUE;
ELSE GO TO ROU10]

ROU9.
Did you get the pneumonia vaccination
at {the reference health center}?

ROU9.
您是否在{the reference health center}接
受過肺炎疫苗？

1=YES
2=NO
ROU9a. [IF AGE = 4 MONTH – 6 YEARS
CONTINUE, ELSE GO TO ROU10]
Did {name} receive any shots in the last 12 months?
1=YES
2=NO
[ROUCHK9b IF ROU9a =1, CONTINUE; ELSE
GO TO ROU10]
ROU9b. How many of the shots {name} received in the
past 12 months were provided by {reference health
center}? Would you say all, some, or none?
1=ALL
2=SOME
3=NONE
[ROUCHK9c IF ROU9b =2 OR 3, CONTINUE;
ELSE GO TO ROU9d]
ROU9c. Were you referred to the other place where
{name} got the shots by {reference health center}?
1=YES
2=NO
ROU9d. Are you the person who took {name}for
most of {his/her} shots? Most means at least half of
the shots.
1=YES
2=NO

1=是
2=否
ROU9a.[IF AGE = 4 MONTH – 6 YEARS
CONTINUE, ELSE GO TO ROU10]
{name}在過去 12 個月內是否注射過任何疫苗？
1=是
2=否
[ROUCHK9b IF ROU9a =1, CONTINUE; ELSE
GO TO ROU10]
ROU9b.{name}在過去 12 個月內接受的注射疫苗有
多少是由{reference health center}提供的？您可以說
全部、部分或無？
1=全部
2=部分
3=無
[ROUCHK9c IF ROU9b =2 OR 3, CONTINUE;
ELSE GO TO ROU9d]
ROU9c.您是否被{reference health center}轉診到其
他地方， {name}在那裡接受注射疫苗？
1=是
2=否
ROU9d.您帶{name}去注射{他/她}的大部分疫苗嗎
？「大部分」表示至少半數的疫苗。
1=是
2=否

18

[ROUCHK9e IF ROU9d =1, CONTINUE; ELSE
GO TO ROU10]

[ROUCHK9e IF ROU9d =1, CONTINUE; ELSE
GO TO ROU10]

ROU9e. In your opinion, has{name}received all of
the recommended shots for {his/her} age?

ROU9e.依您看，{name}是否接受了{他/她}的年齡
段建議的所有疫苗注射？

1=YES
2=NO
[ROUCHK9f IF ROU9d =2, CONTINUE; ELSE
GO TO ROU10]
ROU9f. Please look at this showcard. What is the
main reason {name} has not had all the shots that
he/she is supposed to have at his/her age?
@BSHOWCARD ROU9f@B
1=DID NOT THINK IT WAS IMPORTANT
2=AFRAID OF THE SIDE EFFECTS OF THE
IMMUNIZATION
3=CHILD WAS SICK AND COULD NOT HAVE
IMMUNIZATIONS AT THAT TIME
4=I DON’T TRUST THE SHOTS/ I DON’T BELIEVE
IN SHOTS
5=COULDN’T AFFORD CARE
6=PROBLEMS GETTING TO DOCTOR'S OFFICE
7=DIFFERENT LANGUAGE
8=COULDN’T GET TIME OFF WORK
9=DIDN’T KNOW WHERE TO GO TO GET CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER

1=是
2=否
[ROUCHK9f IF ROU9d =2, CONTINUE; ELSE
GO TO ROU10]
ROU9f.請看這張卡片。{name}沒有接受在其年齡段
應接受的所有疫苗注射，主要原因是什麼？
@BSHOWCARD ROU9f@B
1=認為疫苗注射不重要
2=害怕免疫接種出現副作用
3=小孩感冒了，當時無法接受免疫接種
4=我對疫苗注射不信任/我不相信疫苗注射
5=無法承擔護理費用
6=到診所有困難
7=語言障礙
8=無法從工作中抽身
9=不知道去哪裡獲取護理
10=沒有時間或花費了太長時間
11=其他原因

ROU10. [IF AGE GE 18, CONTINUE; ELSE GO
TO ROUCHK12]

ROU10.[IF AGE GE 18, CONTINUE; ELSE GO
TO ROUCHK12]

These next questions are about general physicals or
routine check-ups.

下列幾個問題和一般體檢或例行檢查有關。

About how long has it been since your last general
physical exam or routine check-up by a medical
doctor or other health professional? Do not include a
visit about a specific problem.

上次接受醫生或其他醫療專業人員的一般體檢或例
行檢查至今大約多長時間？不包括針對特定問題的
就診。

1=NEVER
2=LESS THAN 1 YEAR AGO
3=AT LEAST 1 YR, LESS THAN 2 YEARS
4=AT LEAST 2 YRS, LESS THAN 3 YEARS
5=AT LEAST 3 YRS, LESS THAN 4 YEARS
6=AT LEAST 4 YRS, LESS THAN 5 YEARS
7=5 OR MORE YEARS AGO
[ROUCHK11 IF ROU10= 2 OR 3, CONTINUE;

1=從沒接受過
2=不到 1 年前
3=至少 1 年、不到 2 年
4=至少 2 年、不到 3 年
5=至少 3 年、不到 4 年
6=至少 4 年、不到 5 年
7=5 年或更長時間以前
19

ELSE IF ROU10=DK OR RF, GO TO
ROUCHK12; ELSE GO TO ROU11a ]

ROU11. Did you get this check-up at {the reference
health center}?
1=YES
2=NO
[ROUCHK11a GO TO ROUCHK12]

[ROUCHK11 IF ROU10= 2 OR 3, CONTINUE;
ELSE IF ROU10=DK OR RF, GO TO
ROUCHK12; ELSE GO TO ROU11a ]
ROU11.您是否在{the reference health center}接受過
此檢查？
1=是
2=否
[ROUCHK11a GO TO ROUCHK12]

20

ROU11a. Please look at this showcard. What is the
main reason you have not had a general physical
exam or routine check-up in the past 2 years?
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T
APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S
INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER
[ROUCHK12 IF AGE <18, THEN CONTINUE;
ELSE, GO TO ROU14]
ROU12. These next questions are about well-child
check-ups, that is a general check-up, performed
when {you were/name was} not sick or injured.
About how long has it been since {you/he/she}
received a well-child or general check-up?
1=NEVER
2=LESS THAN 1 YEAR AGO
3=AT LEAST 1 YR, LESS THAN 2 YEARS
4=AT LEAST 2 YRS, LESS THAN 3 YEARS
5=AT LEAST 3 YRS, LESS THAN 4 YEARS
6=AT LEAST 4 YRS, LESS THAN 5 YEARS
7=5 OR MORE YEARS AGO
[ROUCHK13 IF ROU12=2 OR 3, CONTINUE;
ELSE IF ROU12=DK OR RF, GO
TO ROU14
ELSE GO TO ROU13a]
ROU13. Did {you/he/she} get this check-up at {the
reference health center}?
1=YES
2=NO

ROU11a.請看看此卡片。您在過去 2 年內沒接受一
般體檢或例行檢查的主要原因是什麼？
@BSHOWCARD MED1@B
1=無法承擔護理費用
2=保險公司不批准、承保或支付護理費用
3=醫生拒絕接受醫療保險
4=到診所有困難
5=語言障礙
6=無法從工作中抽身
7=不知道去哪裡獲取護理
8=要求服務時遭到拒絕
9=孩子沒人看護
10=沒有時間或護理花費了太長時間
11=其他原因
[ROUCHK12 IF AGE <18, THEN CONTINUE;
ELSE, GO TO ROU14]
ROU12.下列幾個問題和健康兒童體檢有關，也就
是在{您/name}未生病或未受傷時接受的一般體
檢。上次{您/他/她}接受健康兒童體檢或一般體檢
至今大約多長時間了？
1=從沒接受過
2=不到 1 年前
3=至少 1 年、不到 2 年
4=至少 2 年、不到 3 年
5=至少 3 年、不到 4 年
6=至少 4 年、不到 5 年
7=5 年或更長時間以前
[ROUCHK13 IF ROU12=2 OR 3, CONTINUE;
ELSE IF ROU12=DK OR RF, GO TO
ROU14
ELSE GO TO ROU13a]
ROU13.{您/他/她}是否在{the reference health
center}接受過此檢查？
1=是
2=否

[ROUCHK13a GO TO ROU14[
[ROUCHK13a GO TO ROU14[

21

ROU13a. Please look at this showcard. What is the
main reason {you/name} has not had a general
physical exam or routine check-up in the past 2
years?
@BSHOWCARD MED1@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T
APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S
INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER

ROU13a.請看這張卡片。{您/name}在過去 2 年內沒
接受一般體檢或例行檢查的主要原因是什麼？
@BSHOWCARD MED1@B
1=無法承擔護理費用
2=保險公司不批准、承保或支付護理費用
3=醫生拒絕接受醫療保險
4=到診所有困難
5=語言障礙
6=無法從工作中抽身
7=不知道去哪裡獲取護理
8=要求服務時遭到拒絕
9=孩子沒人看護
10=沒有時間或花費了太長時間
11=其他原因

LEAD SCREENING

LEAD SCREENING

ROU14. [IF AGE 9 MONTHS - 5 YEARS
CONTINUE, ELSE GO TO MODULE E]

ROU14.[IF AGE 9 MONTHS - 5 YEARS
CONTINUE, ELSE GO TO MODULE E]

Has {name} ever had a blood test to check the
amount of lead in {his/her} blood?
1=YES
2=NO
[ROUCHK15 IF ROU14=1, CONTINUE; ELSE
GO TO ROU17]

ROU15. How old was {name} the last time this test
was done?
______AGE [ALLOW 00-12]
PROGRAMMER: NEED AGE CHECK SO AGE
REPORTED IS NOT HIGHER THAN ACTUAL
AGE REPORTED EARLIER IN THE INTERVIEW.

{name}是否做過血液化驗以檢測{他/她}血液中的
鉛含量？
1=是
2=否
[ROUCHK15 IF ROU14=1, CONTINUE; ELSE
GO TO ROU17]
ROU15.{name}上次做化驗時的年齡是多少？
______AGE [ALLOW 00-12]
PROGRAMMER:NEED AGE CHECK SO AGE
REPORTED IS NOT HIGHER THAN ACTUAL AGE
REPORTED EARLIER IN THE INTERVIEW.

ROU16.是否在{reference health center}做的化驗？
ROU16. Was that done at the {reference health
center}?
1=YES
2=NO

1=是
2=否

22

ROU17. Has anyone ever talked to you about things
that might cause {name} to be exposed to lead, such
as living in or visiting a house or apartment built
before 1978?
1=YES
2=NO

ROU17.是否有人告訴您關於有可能造成{name}接
觸到鉛的 Çé›r，例如住在或造訪 1978 年以前修建
的房屋或公寓？
1=是
2=否

23

(2) Module J: Dental

COLOR CODE DESCRIPTIONS
Yellow: Items not to be translated. For the most part this are programming instructions or
certain interviewer instructions.
Green: These are either reference date or reference health center variable fills and do not
need to be translated. The computerized program will automatically place the pertinent
information.
Turquoise: These are variable fills that will trigger the system whether the question is being
asked about the participant himself/herself or some else (name). If the item “name” is shown
on this variable fill item, it will remain in English and will be automatically replaced by the
pertinent individual's name by the system. However, the translation around these variable
fills need to be adapted for both scenarios.
Pink: If applicable, these are items that have a programming code for either underline or
bolding before and after the wording. For example: @UXXXXXX@u. Please leave those
codes as is and translate the wording inside them.
******************************************************************
ORIGINAL ENGLISH
TRANSLATION
MODULE J: DENTAL

[DENCHK1 IF AGE GE 2, THEN CONTINUE;
ELSE GO TO MODULE K]

MODULE J:DENTAL
[DENCHK1 IF AGE GE 2, THEN CONTINUE;
ELSE GO TO MODULE K]
下列幾個問題和牙科護理有關。

The next questions are about dental care.
DEN1. In the last 12 months, that is since {12
MONTH REFERENCE DATE}, did you or a dentist
believe {you/name} needed any dental care, tests, or
treatment?

DEN1.過去 12 個月內，也就是從{12 MONTH
REFERENCE DATE}至今，您或牙科醫生是否認為
{您/name}需要接受任何牙科護理、檢查或治療？
NOTE:如果認為有必要接受牙科護理，則選「是」

NOTE: CODE YES IF A DOCTOR BELIEVED
DENTAL CARE WAS NECESSARY

1=是
2=否

1=YES
2=NO
[DENCHK2 IF DEN1=1, THEN CONTINUE;
ELSE GO TO DEN10]

[DENCHK2 IF DEN1=1, THEN CONTINUE;
ELSE GO TO DEN10]

DEN2. In the last 12 months, {were you/was name}
unable to get dental care, tests, or treatments you or a
dentist believed necessary?

DEN2.過去 12 個月內，{您/name}是否無法獲得您
或牙科醫生認為有必要接受的牙科護理、檢查或治
療？

1=YES
2=NO

1=是
2=否

[DENCHK3 IF DEN2=1, THEN CONTINUE;
24

ELSE GO TO DEN6 ]

[DENCHK3 IF DEN2=1, THEN CONTINUE;
ELSE GO TO DEN6 ]

DEN3. What kind of dental care, test, or treatment
was it that {you/name} needed but did not get?

DEN3.{您/name}需要但沒獲得的是什麼類型的牙科
護理、檢查或治療？

________________ [ALLOW 40]

________________ [ALLOW 40]

DEN4. Please look at this showcard. Please describe
the main reason {you were/name was} unable to get
dental care, tests, or treatments you or a dentist
believed necessary?

DEN4.請看这张卡片。請选择{您/name}無法獲得您
或牙科醫生認為有必要接受的牙科護理、檢查或治
療的主要原因？

@BSHOWCARD MED2@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE,
COVER, OR PAY FOR CARE
3=DENTIST REFUSED TO ACCEPT FAMILY’S
INSURANCE PLAN
4=PROBLEMS GETTING TO DENTIST’S OFFICE
/ TRANSPORTATION
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=AFRAID OF GOING TO THE DENTIST/
HAVING DENTAL WORK DONE
12=OTHER
DEN5. How much of a problem was it that
{you/name} did not get dental care, tests, or
treatments you or a dentist believed necessary?
Would you say that it was a...
1=A big problem,
2=A small problem
3=Not a problem

@BSHOWCARD MED2@B
1=無法承擔護理費用
2=保險公司不批准、承保或支付護理費用
3=牙科醫生拒絕接受医疗保險
4=到牙科醫生辦公室有困難/交通問題
5=語言障礙
6=無法從工作中抽身
7=不知道去哪裡獲取護理
8=要求服務時遭到拒絕
9=孩子沒人看護 10=沒有時間或護理花費了太長時
間
11=害怕去找牙科醫生/接受牙科治療
12=其他原因

DEN5.{您/name}沒獲得您或牙科醫生認為有必要接
受的牙科護理、檢查或治療，這個問題有多大？您
會說這是一個…
1=大問題
2=小問題
3=不是問題

25

DEN6. In the last 12 months, {were you/was name}
delayed in getting dental care, tests, or treatments you
or a dentist believed necessary?

DEN6.過去 12 個月內，{您/name}是否延遲獲得您
或牙科醫生認為有必要接受的牙科護理、檢查或治
療？

1=YES
2=NO

1=是
2=否

[DENCHK7 IF DEN6=1, THEN CONTINUE;
ELSE GO TO DEN10]

[DENCHK7 IF DEN6=1, THEN CONTINUE;
ELSE GO TO DEN10]

DEN7. What kind of dental care, test, or treatment
was it that {you were/name was}delayed in getting?

DEN7.{您/name}延遲獲得的是什麼類型的牙科護理
、檢查或治療？

________________ (allow 40)

________________ (allow 40)

DEN8. Please look at this showcard. Which of these
best describes the main reason {you were/name
was}delayed in getting dental care, tests, or
treatments you or a dentist believed necessary?

DEN8.請看這張卡片。下列哪一項最適合描述{您
/name}延遲獲得您或牙科醫生認為有必要接受的牙
科護理、檢查或治療的主要原因？

@BSHOWCARD MED2@B
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE,
COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S
INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE
/ TRANSPORTATION
5=DIFFERENT LANGUAGE
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=AFRAID OF GOING TO THE DENTIST/
HAVING DENTAL WORK DONE
12=OTHER

@BSHOWCARD MED2@B
1=無法承擔護理費用
2=醫療保險公司不批准、承保或支付護理費用
3=醫生拒絕接受醫療保險
4=到醫生辦公室有困難/交通問題
5=語言障礙
6=無法從工作中抽身
7=不知道去哪裡獲取護理
8=要求服務時遭到拒絕
9=孩子沒人看護
10=沒有時間或花費了太長時間
11=害怕去找牙科醫生/接受牙科治療
12=其他原因

DEN9. How much of a problem was it that {you
were/name was}delayed in getting dental care you or
a dentist believed necessary? Would you say that it
was a...

DEN9.{您/name}延遲獲得您或牙科醫生認為有必要
接受的牙科護理，這個問題有多大？您會說這是一
個...

1=A big problem,
2=A small problem
3=Not a problem

1=大問題
2=小問題
3=不是問題

26

DEN10. About how long has it been since
{you/name} last visited a dentist?
Include all types of dentists, such as, orthodontists,
oral surgeons, and all other dental specialists, as well
as dental hygienists.

DEN10.{您/name}上次去找牙科醫生至今大約間隔
了多長時間？
包括所有類型的牙科醫生，例如牙科矯正醫生、口
腔外科醫生以及所有其他牙科專家，還有牙科保健
師（即潔牙師）。

1=6 MONTHS OR LESS
2=MORE THAN 6 MONTHS, BUT NOT MORE
THAN 1 YEAR AGO
3=MORE THAN 1 YEAR, BUT NOT MORE
THAN 2 YEARS AGO
4=MORE THAN 2 YEARS, BUT NOT MORE
THAN 5 YEARS AGO
5=MORE THAN 5 YEARS AGO
99=NEVER HAVE BEEN

1=6 個月或以下
2=超過 6 個月，但不超過 1 年
3=超過 1 年，但不超過 2 年
4=超過 2 年，但不超過 5 年
5=超過 5 年
99=從來沒有

[DENCHK11 If DEN10=1 or 2, CONTINUE;
ELSE GO TO DEN14]
DEN11. In the past 12 months, when {you/name} did
see a dentist, how many of {your/his/her} visits were
at {the reference health center}? Would you say…
1=All of the visits
2=Some of the visits
3=None of the visits
[DENCHK12 If DEN11=1 or 2, THEN
CONTINUE; ELSE GO TO DENCHK13]

[DENCHK11 If DEN10=1 or 2, CONTINUE;
ELSE GO TO DEN14]
DEN11.過去 12 個月內，{您/name}去看牙科醫生時
，{您/他/她}有多少次就診是在{the reference health
center}？您會說...
1=所有就診
2=部分就診
3=從來沒有在那裡就診
[DENCHK12 If DEN11=1 or 2, THEN
CONTINUE; ELSE GO TO DENCHK13]

DEN12. How would you rate the dental services
{you/name} received at {the reference health
center}? Would you say…

DEN12.關於{您/name}在{the reference health center}
接受的牙科服務，您作何評價？您會說...

1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor

1=極好
2=非常好
3=良好
4=一般
5=較差

[DENCHK13 If DEN11= 2 OR 3, THEN
CONTINUE; ELSE GO TO DEN14]

[DENCHK13 If DEN11= 2 OR 3, THEN
CONTINUE; ELSE GO TO DEN14]

27

DEN13 Were you referred to the other place where
{you/name} got dental services by {reference health
center}?
1=YES
2=NO
[DENCHK14 IF AGE LE11 GOTO DEN16a]

DEN13 您是否被轉介到{您/name}接受{reference
health center}提供的牙科服務的其他地方？
您
是否被{reference health center}轉診到其他地方，{
您/name}在那裡接受牙科服務？
1=是
2=否
[DENCHK14 IF AGE LE11 GOTO DEN16a]

Now, I have some questions about the condition of
{your/name’s} teeth and gums.

現在，我要就{您/name}的牙齒和牙齦的狀況提一
些問題。

DEN14. The following question asks about the
number of adult teeth you have lost. Do not count as
"lost" missing wisdom teeth, "baby" teeth, or teeth
which were pulled for orthodontia. Have you lost…

DEN14.下列問題要問您掉了多少顆恆牙。不要將缺
失的智齒、乳齒或畸齒矯正術拔出的牙齒算入所
「掉」的牙齒總數內。您掉了…

IF ASKED: Orthodontia means straightening the
teeth.

IF ASKED:畸齒矯正術即是對牙齒進行矯正。

1=All of your adult teeth
2=Some of your adult teeth
3=None of your adult teeth
[DENCHK15 .IF DEN14=1, GO TO DENT15a;
IF DEN14=2, CONTINUE; ELSE
IF DEN12=3, DK, RE, GO TO DENCHK16a]

1=全部恆牙
2=部分恆牙
3=無掉過恆牙
[DENCHK15 .IF DEN14=1, GO TO DENT15a; IF
DEN14=2, CONTINUE; ELSE
IF DEN12=3, DK, RE, GO TO DENCHK16a]

DEN15. How many of your adult teeth have you lost?

DEN15.您掉了多少顆恆牙？

__________ TEETH [ALLOW 00-20]

__________ 顆牙齒[ALLOW 00-20]

DEN15a. Are any of your missing teeth replaced by
full or partial dentures, false teeth, bridges or dental
plates?

DEN15a.是否用全口/局部義齒、假牙、牙橋或牙板
替代所掉的牙齒？

1=YES
2=NO
[DENCHK16a DEN14=2, 3, DK, or RE
CONTINUE; ELSE GO TO DEN16b ]

1=是
2=否
[DENCHK16a DEN14=2, 3, DK, or RE
CONTINUE; ELSE GO TO DEN16b ]

DEN16a. How would you describe the condition of
{your/name’s} teeth? Would you say...

DEN16a.您會如何描述{您/name}的牙齒狀況？您會
說...

1=Excellent
2=Very Good
3=Good

1=極好
2=非常好
28

4=Fair
5=Poor
[DENCHK16a_POST GO TO DEN17a]

3=良好
4=一般
5=較差
[DENCHK16a_POST GO TO DEN17a]

DEN16b Now I have some questions about the
condition of {your/name’s} gums and false teeth or
dentures. Would you say the condition of
{your/name’s} gums and false teeth or dentures is…
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor

DEN16b 現在，我要就{您/name}牙齦，假牙或義
齒的狀況提一些問題。關於{您/name}牙齦，假牙
或義齒的狀況，您會說¡­¡­
1=極好
2=非常好
3=良好
4=一般
5=較差

DEN17a. During the past 6 months, {have you/has
name} had any of the following problems?

DEN17a.過去 6 個月內，{您/name}是否出現了下列
問題？

A toothache or sensitive teeth?

牙疼或牙齒過敏？

1=YES
2=NO

1=是
2=否

DEN17b. (During the past 6 months, {have you/has
name} had any of the following problems?)

DEN17b.（過去 6 個月內，{您/name}是否出現了下
列問題？）

Bleeding gums?

牙齦出血？

1=YES
2=NO

1=是
2=否

DEN17c. (During the past 6 months, {have you/has
name} had any of the following problems?)

DEN17c.（過去 6 個月內，{您/name}是否出現了下
列問題？）

Crooked teeth?

牙齒歪斜？

1=YES
2=NO

1=是
2=否

DEN17e. (During the past 6 months, {have you/has
name} had any of the following problems?)

DEN17e.（過去 6 個月內，{您/name}是否出現了下
列問題？）

29

Broken or missing teeth?

牙齒折斷或缺失？

1=YES
2=NO

1=是
2=否

DEN17f. (During the past 6 months, {have you/has
name} had any of the following problems?)

DEN17f.（過去 6 個月內，{您/name}是否出現了下
列問題？）

Stained or discolored teeth?

牙漬或牙色改變？

1=YES
2=NO

1=是
2=否

DEN17g. (During the past 6 months, {have you/has
name} had any of the following problems?)

DEN17g.（過去 6 個月內，{您/name}是否出現了下
列問題？）

Broken or missing fillings?

補牙折斷或缺失？

1=YES
2=NO

1=是
2=否

DEN17h. (During the past 6 months, {have you/has
name} had any of the following problems?)

DEN17h.（過去 6 個月內，{您/name}是否出現了下
列問題？）

{[IF AGE GREATER THAN 11, FILL:] Loose
teeth not due to injury? [IF AGE LE11:] Loose teeth
not due to injury or losing baby teeth?}

{[IF AGE GREATER THAN 11, FILL:]不是因受傷
造成的牙齒鬆動？[IF AGE LE11:]不是因受傷或乳
牙缺失造成的牙齒鬆動？}

1=YES
2=NO
DEN18a. During the past 6 months, {have you/has
name} had any of the following problems that lasted
more than a day?
Pain in {your/his/her} jaw joint?
1=YES
2=NO
DEN18b. (During the past 6 months, {have you/has
name} had any of the following problems that lasted
more than a day?)
Sores in {your/his/her} mouth?
1=YES
2=NO
DEN18c. (During the past 6 months, {have you/has
name} had any of the following problems that lasted

1=是
2=否
DEN18a.過去 6 個月內，{您/name}是否出現了下列
問題並且持續了一天以上？
{您/他/她}的下頜關節是否出現疼痛？
1=是
2=否
DEN18b.（過去 6 個月內，{您/name}是否出現了下
列問題並且持續了一天以上？）
{您/他/她}是否出現口腔潰瘍？
1=是
2=否
DEN18c.（過去 6 個月內，{您/name}是否出現了下
30

more than a day?)

列問題並且持續了一天以上？）

Difficulty eating or chewing?

進食或咀嚼困難？

1=YES
2=NO

1=是
2=否

DEN18d. (During the past 6 months, {have you/has
name} had any of the following problems that lasted
more than a day?)

DEN18d.（過去 6 個月內，{您/name}是否出現了下
列問題並且持續了一天以上？）

Bad breath?
1=YES
2=NO
DEN18f. (During the past 6 months, {have you/has
name} had any of the following problems that lasted
more than a day?)
Dry mouth?

口臭？
1=是
2=否

DEN18f.（過去 6 個月內，{您/name}是否出現了下
列問題並且持續了一天以上？）
口乾？

1=YES
2=NO

1=是
2=否

[DENCHK19 IF DEN17a-h=1 or DEN18a-f=1,
CONTINUE; ELSE GO TO MODULE K]

[DENCHK19 IF DEN17a-h=1 or DEN18a-f=1,
CONTINUE; ELSE GO TO MODULE K]

31

DEN19a. Did the problems with {your/name’s}
mouth or teeth interfere with any of the following?

DEN19a.{您/name}的口腔或牙齒問題是否影響下列
事情？

job or school?

工作或上學？

1=YES
2=NO
3=NOT WORKING / NOT AT SCHOOL

1=是
2=否
3=不工作/沒上學

DEN19b. (Did the problems with {your/name’s}
mouth or teeth interfere with any of the following?)

DEN19b.（{您/name}的口腔或牙齒問題是否影響下
列事情？）

sleeping?

睡眠？

1=YES
2=NO

1=是
2=否

DEN19c. (Did the problems with {your/name’s}
mouth or teeth interfere with any of the following?)

DEN19c.（{您/name}的口腔或牙齒問題是否影響下
列事情？）

social activities such as going out or being with other
people?

社交活動，例如外出或與他人相處？

1=YES
2=NO

1=是
2=否

DEN19d. (Did the problems with {your/name’s}
mouth or teeth interfere with any of the following?)

DEN19d.（{您/name}的口腔或牙齒問題是否影響下
列事情？）

usual activities at home?

家庭日常活動？

1=YES
2=NO
3=DON'T HAVE A HOME

1=是
2=否
3=沒有家庭

32

7.

Cognitive interview screening form

Health Center Patient Survey
Cognitive Interview Screening Form
Chinese/Korean/Vietnamese speakers only
INTERVIEWER:
 PATIENTS 18 YEARS OF AGE AND OLDER CAN BE APPROACHED DIRECTLY.
 PATIENTS 13-17 YEARS OF AGE, A PARENT/GUARDIAN NEEDS TO BE READ THE INTRO
AND CHILD CAN COMPLETE THE SCREENING QUESTIONS WITH PARENT’S APPROVAL.
 PATIENTS 12 YEARS OF AGE AND YOUNGER, ONLY PARENTS CAN BE SCREENED.
Hello, this is [NAME] from RTI International. (Were you calling about the [ad/flyer]?)
PS1. First, just let me verify: Are you 18 or older? YES _________ (GO TO PS2)
NO _________ (GO TO PS3)
PS2. Are you calling on behalf of a child who is less than 13 years old?: YES _______ (GO TO PS4)
NO _______ (GO TO INTRO ADULT)
PS3. Are you between 13 and 17 years of age? YES _______ (ASK TO TALK TO PARENT/GUARDIAN AND GO
TO INTRO PROXY 13-17 YEARS OLD)
NO _______ (IF YOUNGER THAN 13, ASK TO TALK TO
PARENT/GUARDIAN AND START WITH
QUESTION PS1)
PS4. Are you this child’s parent or legal guardian?

YES _______ (GO TO INTRO PROXY LESS THAN 13
YEARS OLD)
NO _______ (R NOT ELIGIBLE – THANK R AND END)

INTRO ADULT
Let me tell you a little about the study. We are testing a questionnaire about health care received by patients of health
centers. This questionnaire will eventually be provided to patients across the country. We are testing these survey
questions with different people to see how well the questions work. We want to know: Do they make sense? How easy or
difficult are they to answer? We want to understand what you think each question means and how you arrive at your
answers. This will help us find out whether there are any problems with the questionnaire. Your feedback will help us
during the development of the survey questionnaire. There are no right or wrong answers. We will not ask about your
legal situation nor your immigration status.
If you are interested and eligible, we would like to schedule an in-person interview, which will take about 75 minutes. At
the end of the interview you will receive $50 in cash. To make sure (you are eligible for the study, I need to ask you a few
brief screening questions. This will only a few minutes. Is this a good time?
INTRO PROXY (13-17 YEARS OLD)
33

Let me tell you a little about the study. We are testing a questionnaire about health care received by patients of health
centers. This questionnaire will eventually be provided to patients across the country. We are testing these survey
questions with different people to see how well the questions work. We want to know: Do they make sense? How easy or
difficult are they to answer? We want to understand what your child thinks each question means and how he/she arrives
at his/her answers. This will help us find out whether there are any problems with the questionnaire. There are no right or
wrong answers. We will not ask about his/her legal situation nor your immigration status.
If your child is interested and he/she is eligible, we would like to schedule an in-person interview, which will take about
75 minutes. At the end of the interview your child will receive $50 in cash. To make sure he/she is eligible for the study, I
need to ask him/her a few brief screening questions. Or, you can answer on his/her behalf. This will only a few minutes. Is
this a good time?

INTRO PROXY (LESS THAN 13 YEARS OLD)
Let me tell you a little about the study. We are testing a questionnaire about health care received by patients of health
centers. This questionnaire will eventually be provided to patients across the country. We are testing these survey
questions with different people to see how well the questions work. We want to know: Do they make sense? How easy or
difficult are they to answer? We want to understand what you think each question means and how you arrive at your
answers. This will help us find out whether there are any problems with the questionnaire. Because your child is less than
13 years old, we would like to ask you to answer questions and get your feedback, which will help us during the
development of the survey questionnaire. There are no right or wrong answers. We will not ask about your legal situation
nor your immigration status.
If you are interested and you are eligible, we would like to schedule an in-person interview, which will take about 75
minutes. At the end of the interview you will receive $50 in cash. To make sure you are eligible for the study, I need to
ask you a few brief screening questions. This will only a few minutes. Is this a good time?
INTERVIEWER:
FOR ADULTS THE SCREENING QUESTIONS WILL BE ABOUT THEMSELVES.
FOR PARENTS/GUARDIANS OF CHILDREN LESS THAN 13 YEARS OLD, THE SCREENING QUESTIONS
WILL BE ABOUT THE PARENTS, EXCEPT QUESTION S1.
FOR CHILDREN 13-17 YEARS OLD, ALL SCREENING QUESTIONS WILL BE ABOUT THE CHILD.
S1.

(Have you/Has your child) received services from a health care professional such as a doctor, nurse, drug
counselor, mental health counselor, or dentist at {THE REFERENCE HEALTH CENTER / A HEALTH
CENTER} in the last 12 months?
YES ................................ 1
NO.................................. 2
REFUSED ...................... 7
DON’T KNOW.............. 9

GO TO S1a
(R NOT ELIGIBLE – THANK R AND END)
(R NOT ELIGIBLE – THANK R AND END)
(R NOT ELIGIBLE – THANK R AND END)

S1a. IF HEALTH CENTER NOT KNOWN: What is the name of the health center (you/your minor
child) visited in the past 12 months? ___________________________________________________
34

S2.

What is (your/child’s) age?
S3.

______ YEARS

IF S2=13-18: Are you currently living with a parent or guardian?
YES ................................... 1
NO..................................... 2 (R NOT ELIGIBLE – THANK R AND END)

S4.

RECORD GENDER. (IF NECESSARY, ASK: (Are you/Is your child) male or female?
FEMALE……………..1
MALE………………...2

S5.

In what country (were you/was your child) born? (SPECIFY COUNTRY ON SCREENING FORM.)

U.S. ............................... 1
OTHER………………..2 SPECIFY ________________________________

S6.

What race or races do you consider (yourself/your child) to be? You may select all that apply.
Are you…
1=White
2=Black or African American
3=American Indian or Alaska Native (American Indian includes North American, Central American, and
South American Indians)
4=Native Hawaiian
5=Guamanian or Chamorro
6=Samoan
7=Other Pacific Islander
8=Asian (Including: Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese)
9=OTHER (SPECIFY)___________________________________

S6a. IF ASIAN:
Which group best describes (your/your child’s) ethnic background?
1=Asian Indian
2=Chinese
3=Filipino
4=Japanese
5=Korean
35

6=Vietnamese
7=Other Asian
S7.

(Do you/Does your child) speak (IF S8a=2 SAY “CHINESE”/IF S8a=5 SAY “KOREAN”/IF S8a=6 SAY
“VIETNAMESE”) as your native or primary language?
YES…….. 1 CONTINUE
NO……… 2 (R NOT ELEGIBLE – THANK R AND END)

QS8 AND S9a FOR CHINESE SPEAKERS ONLY:
S8. What is your dominant or preferred dialect?
Mandarin………. 1 GO TO QS10
Cantonese……….2 GO TO QS10
Fukanese……….. 3 GO TO QS9a
Other Specify: ___________________GO TO QS9a
S9a.

Are you able to communicate in Mandarin (or Cantonese) without difficulty?
1. YES (SPECIFY MANDARIN OR CANTONESE)…… CONTINUE
2. NO………………… (R NOT ELEGIBLE – THANK R AND END)

S9.

In addition to (MANDARIN/CANTONESE/KOREAN/VIETNAMESE), (do you/does your child) speak any
English?
1. YES……. . CONTINUE
2. NO………(CODE “NOT AT ALL” TO QS13 AND RECRUIT)

S10.

How well (do you/does your child) speak English? Would you say….
1. Very well, (R NOT ELEGIBLE FOR SPANISH TESTING– THANK R AND END)
2. Well, (R NOT ELEGIBLE SPANISH TESTING – THANK R AND END)
3. Not well (RECRUIT)
4. Not at all (RECRUIT)

ELIGIBILITY: IF RESPONDENT MEETS THESE CRITERIA – CONTINUE WITH COLLECTION OF CONTACT
INFORMATION, OTHERWISE THANK THEM FOR THEIR TIME AND EXPLAIN THAT THEY DO NOT MEET
THE REQUIREMENTS OF THE STUDY
S1

ONLY YES RESPONSE ELIGIBLE

S3

ONLY YES RESPONSE ELIGIBLE

S7/S10

CHINESE, KOREAN, AND VIETNAMESE SPEAKERS PREFERRED BUT STILL ELIGIBLE FOR
ENGLISH COGNITIVE TESTING IF THEY ONLY SPEAK ENGLISH OR PREFER ENGLISH OVER
THE ASIAN LANGUAGE.

36

NAME: ___________________________________________
GENDER: ( ) MALE

( ) FEMALE

TELEPHONE #: ____________________________ ALTERNATE TELEPHONE # ____________________________
BEST TIME TO CALL: ________________

37