Form 1 Survey

Attachment 2
HCPS Instrument

CONTENTS
MODULE A: INTRODUCTION ................................................................................................... 2
MODULE B: ACCESS TO CARE................................................................................................. 7
MODULE C: ROUTINE CARE .................................................................................................. 11
MODULE D: CONDITIONS ....................................................................................................... 21
MODULE E: CONDITIONS – FOLLOWUP .............................................................................. 41
MODULE F: CANCER SCREENING ........................................................................................ 55
MODULE G: HEALTH CENTER SERVICES ........................................................................... 71
MODULE H: HEALTH INSURANCE........................................................................................ 87
MODULE J: DENTAL ............................................................................................................... 101
MODULE K: MENTAL HEALTH ............................................................................................ 112
MODULE L: SUBSTANCE USE .............................................................................................. 125
MODULE M: PRENATAL CARE/ FAMILY PLANNING ..................................................... 154
MODULE N: HIV TESTING ..................................................................................................... 162
MODULE O: LIVING ARRANGEMENTS .............................................................................. 166
MODULE P: INCOME AND ASSETS ..................................................................................... 170
MODULE Q: DEMOGRAPHICS .............................................................................................. 174

1

MODULE A: INTRODUCTION
INTINTRO. The first few questions are for statistical purposes only, to help us analyze the
results of the study.
PRESS 1 TO CONTINUE
……………………………………………………………………………………………………
INTDOB. What is {your/NAME’s} date of birth?
________________ MONTH [ALLOW 01-12]
________________ DAY [ALLOW 01-31]
________________ YEAR [ALLOW 1900–2014]
[PROGRAMMER: CALCULATE AGE BASED ON RESPONSE FROM INTDOB.
POPULATE THE FOLLOIWNG VARIABLE INTAGE. IF INTAGE LESS THAN 12
MONTHS, CODE AS 1 YEAR.]
……………………………………………………………………………………………………
INTAGE. [IF INTDOB = DK OR RE CONTINUE, ELSE GOTO INT3]
Can you tell me {your/NAME’s} current age?
IF AGE LESS THAN 12 MONTHS CODE AS 1 YEAR.
IF NEEDED: PROBE FOR A BEST ESTIMATE.
________________

AGE IN YEARS [ALLOW 001-109]

[IF INTAGE=DK OR RE, INTAGE_HARDCHECK] This question is important and will
help me better route you through the survey. REPEAT QUESTION.
……………………………………………………………………………………………………
INT3. What is {your/NAME’s} gender?
[IF INTAGE GE13]: NOTE: IF R ANSWERS THAT THEYARE TRANSGENDER AND
WHICH KIND IS NOT OBVIOUS – PROBE IF THEY ALTERED GENDER FROM MALE
TO FEMALE OR FROM FEMALE TO MALE
1=MALE
2=FEMALE
[IF INTAGE GE 13: 3=FEMALE TO MALE TRANSGENDER / TRANS MAN]
[IF INTAGE GE 13: 4=MALE TO FEMALE TRANSGENDER /TRANS WOMAN]
[IF INTAGE GE 13: 5=GENDERQUEER]
[IF INTAGE GE 13: 6=OTHER]

2

[IF INT3=3, USE INT3=2 FOR SKIP PATTERNS]
[IF INT3=4, USE INT3=1 FOR SKIP PATTERNS]
[IF INT3=DK OR REF, INT3_HARDCHECK] This question is important and will help me
better route you through the survey. REPEAT QUESTION.
……………………………………………………………………………………………………
INT3_OTH. [IF INT3=6 CONTINUE, ELSE GO TO INT3_SPEC]
Please specify {your/NAME’s} gender.
________________ [ALLOW 40]
……………………………………………………………………………………………………
INT3_SPEC. [IF INT3=5 OR 6 CONTINUE, ELSE GO TO INT4]
We have entered your gender as {INT3 RESPONSE: Genderqueer OR INT3_OTH RESPONSE:
FILL}. In this interview, questions will appear based on gender. For example, we only ask
questions about mammograms to females of a specific age. Since this is a research study
collecting medical-related data, could you tell us your biological gender at birth?
NOTE: IF RESPONDENT SAYS THEY WERE BORN WITH BOTH GENITALIA, PROBE
TO DETERMINE WHICH SEX WAS LISTED ON THEIR BIRTH CERTIFICATE.
1=MALE
2=FEMALE
[IF INT3_SPEC=DK OR RE, INT3_SPEC HARDCHECK] This question is important and
will help me better route you through the survey. REPEAT QUESTION.
……………………………………………………………………………………………………
INT4. {Do you/Does NAME} speak a language other than English at home?
1=YES
2=NO
……………………………………………………………………………………………………
INT4a. [IF INT4=1 CONTINUE, ELSE GO TO INT1a]
What other language {do you/does NAME} speak at home?
________________ [ALLOW 40]
……………………………………………………………………………………………………

3

INT4b. How well {do you/does NAME} speak English? Would you say…?
1=Very well
2=Well
3=Not well
4=Not at all
……………………………………………………………………………………………………
INT1a. {Are you/is NAME} of Hispanic, Latino, or Spanish origin?
1=YES
2=NO
……………………………………………………………………………………………………
INT5. [IF INT1a=1 CONTINUE, ELSE GO TO INT2]
SHOWCARD INT0
Please look at this showcard.
Which of the following best describes {your/NAME’s} Hispanic, Latino or Spanish origin? You
may select one or more.
1=MEXICAN, MEXICAN AMERICAN, MEXICANO OR CHICANO
2=PUERTO RICAN
3=CENTRAL AMERICAN
4=SOUTH AMERICAN
5=CUBAN OR CUBAN AMERICAN
6=DOMINICAN (FROM DOMINICAN REPUBLIC)
7=SPANISH (FROM SPAIN)
8=OTHER LATIN AMERICAN, HISPANIC, LATINO OR SPANISH ORIGIN
……………………………………………………………………………………………………
INT5_OTH. [IF INT5=8 CONTINUE, ELSE GO TO INT2]
Please specify {your/NAME’s} Hispanic, Latino or Spanish origin.
________________ [ALLOW 40]
……………………………………………………………………………………………………

4

INT2. Please look at this showcard. What race or races do you consider {yourself/NAME} to be?
You may select one or more.
SHOWCARD INT1
NOTE: CODE “NATIVE AMERICAN” AS “AMERICAN INDIAN”
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=TONGAN
8=MARSHALLESE
9=ASIAN INDIAN
10=CHINESE
11=FILIPINO
12=JAPANESE
13=KOREAN
14=VIETNAMESE
15=OTHER
……………………………………………………………………………………………………
INT2_OTH. [IF INT2=15 CONTINUE, ELSE GO TO INT2_MULT]
What other race {do you/does he/she} consider {yourself/himself/herself} to be?
________________ [ALLOW 40]
……………………………………………………………………………………………………
INT2_MULT. [IF MORE THAN ONE RESPONSE TO INT2 CONTINUE, ELSE GO TO
MEDINTRO]
Which one of these groups, that is {FILL RESPONSES FROM INT2 AND INT2_OTH} would
you say best represents {your/NAME's} race?
[LIST ONLY SELECTIONS MADE IN INT2]
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

5

6=SAMOAN
7=TONGAN
8=MARSHALLESE
9=ASIAN INDIAN
10=CHINESE
11=FILIPINO
12=JAPANESE
13=KOREAN
14=VIETNAMESE
15=OTHER
……………………………………………………………………………………………………

6

MODULE B: ACCESS TO CARE
MEDINTRO. The next set of questions asks about availability of various types of health
services. When answering the next few questions, do not include dental care, prescription
medicines, counseling or mental health treatment.
……………………………………………………………………………………………………
MED1. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a
doctor believe {you/NAME} needed any medical care, tests, or treatment?
1=YES
2=NO
……………………………………………………………………………………………………
MED2. [IF MED1=1 CONTINUE, ELSE GO TO ROUINTRO]
In the last 12 months, {were you/was NAME} unable to get medical care, tests, or treatments
you or a doctor believed necessary?
1=YES
2=NO
……………………………………………………………………………………………………
MED2a. [IF MED2=1 CONTINUE, ELSE GO TO MED5]
Please look at this showcard. Which of these best describes the reasons {you were/NAME was}
unable to get medical care, tests, or treatments you or a doctor believed necessary. You may
select one or more.
SHOWCARD MED1
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 FROM DOCTORS OR NURSES
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
……………………………………………………………………………………………………

7

MED2a_OTH. [IF MED2a=11 CONTINUE, ELSE GO TO MED3]
Please specify the other reason {you were/NAME was} unable to get medical care, tests, or
treatments you or a doctor believed necessary.
_________________ [ALLOW 60]
……………………………………………………………………………………………………
MED3. [IF MORE THAN ONE RESPONSE RECORDED IN MED2a CONTINUE, ELSE GO
TO MED4] Which of the reasons you just told me about best describes the main reason {you
were/NAME was} unable to get medical care, tests, or treatments you or a doctor believed
necessary?
[LIST ONLY SELECTIONS MADE IN MED2a]
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 FROM DOCTORS OR NURSES
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
……………………………………………………………………………………………………
MED4. What kind of care was it that {you/NAME} needed but did not get?
_____________ [ALLOW 60]
……………………………………………………………………………………………………
MED5. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, {were you/was
NAME} delayed in getting medical care, tests, or treatments you or a doctor believed necessary?
1=YES
2=NO
……………………………………………………………………………………………………

8

MED5a. [IF MED5=1 CONTINUE, ELSE GO TO ROUINTRO]
Please look at this showcard. Which of these best describes the reasons {you were/NAME was}
delayed in getting medical care, tests, or treatments you or a doctor believed necessary? You
may select one or more.
SHOWCARD MED1
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 FROM DOCTORS OR NURSES
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
……………………………………………………………………………………………………
MED5a_OTH. [IF MED5a=11 CONTINUE, ELSE GO TO MED5a1]
Please specify the other reason {you were/NAME was} delayed in getting medical care, tests, or
treatments you or a doctor believed necessary.
_________________ [ALLOW 40]
……………………………………………………………………………………………………
MED5a1. [IF MORE THAN ONE RESPONSE RECORDED IN MED5a CONTINUE, ELSE
GO TO ROUINTRO]
Which of the reasons you just told me about best describes the main reason {you were/NAME
was} delayed in getting medical care, tests, or treatments you or a doctor believed necessary?
[LIST ONLY SELECTIONS MADE IN MED5a]
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 FROM DOCTORS OR NURSES
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

9

10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER
……………………………………………………………………………………………………
MED6. What kind of care was it that {you were/NAME was} delayed in getting?
_____________[ALLOW 60]
……………………………………………………………………………………………………

10

MODULE C: ROUTINE CARE
ROUINTRO. Next, I’m going to ask you about health services that {you/NAME} received in the
past 12 months.
1=CONTINUE
……………………………………………………………………………………………………
ROU2. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, 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.
_____________ [ALLOW 000-365]
……………………………………………………………………………………………………
ROU2a. [IF ROU2 GE 1 CONTINUE, ELSE GO TO ROU5]
Thinking about {your/NAME’s} most recent emergency room visit, did {you/NAME} go to the
emergency room either at night or on the weekend?
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c. Tell me which of these apply to {your/NAME’s} last emergency room visit?
{You/NAME} didn't have another place to go.
1=YES
2=NO
..……………………………………………………………………………………………………
ROU2c1. (Tell me which of these apply to {your/NAME’s} last emergency room visit?)
{Your/NAME’s} doctor’s office or clinic was not open.
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c2. (Tell me which of these apply to {your/NAME’s} last emergency room visit?)
{Your/NAME’s} health provider advised you to go.
1=YES
2=NO

11

……………………………………………………………………………………………………
ROU2c3. (Tell me which of these apply to {your/NAME’s} last emergency room visit?)
The problem was too serious for the doctor’s office or clinic.
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c4. (Tell me which of these apply to {your/NAME’s} last emergency room visit?)
Only a hospital could help {you/NAME}.
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c5. (Tell me which of these apply to {your/NAME’s} last emergency room visit?)
The emergency room was {your/NAME’s} closest provider.
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c6. {Do you/Does NAME} get most of {your/his/her} care at the emergency room?
1=YES
2=NO
……………………………………………………………………………………………………
ROU3. (Were you/Was NAME} hospitalized overnight in the past 12 months? Do not include
an overnight stay in the emergency room.
1=YES
2=NO
……………………………………………………………………………………………………
ROU4. [IF ROU3=1 CONTINUE, ELSE GOTO ROU5]
Altogether, how many nights {were you/was NAME} in the hospital during the past 12 months?
___________ [ALLOW 001-365]
……………………………………………………………………………………………………

12

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 INTAGE GE 18: 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.
IF NEEDED: This influenza vaccine is called FluMist™.
1=YES
2=NO
……………………………………………………………………………………………………
ROU7. [IF ROU5=1 OR ROU6=1 CONTINUE, ELSE GO TO ROU8]
Did {you/NAME} get the flu shot or vaccine sprayed in {your/his/her} nose at {REFERENCE
HEALTH CENTER}?
1=YES
2=NO
……………………………………………………………………………………………………
ROU8. [IF INTAGE GE 65 CONTINUE, ELSE GO TO ROU9a]
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
……………………………………………………………………………………………………
ROU9. [IF ROU8=1 CONTINUE, ELSE GO TO ROU9f2]
Did you get the pneumonia vaccination at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
……………………………………………………………………………………………………

13

ROU9a. [IF INTAGE LE 6 YEARS CONTINUE, ELSE GO TO ROU9f2]
The next few questions are about all of the shots that {NAME} may have received in the last 12
months. This includes shots you may have already told me about.
Did {NAME} receive any shots in the last 12 months?
1=YES
2=NO
……………………………………………………………………………………………………
ROU9b. [IF ROU9a=1 CONTINUE, ELSE GO TO ROU9f2]
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
……………………………………………………………………………………………………
ROU9c. [IF ROU9b=2 OR 3 CONTINUE, ELSE GO TO ROU9d]
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
……………………………………………………………………………………………………
ROU9e. In your opinion, has {NAME} received all of the recommended shots for {his/her} age?
1=YES
2=NO
……………………………………………………………………………………………………

14

ROU9f. [IF ROU9e=2 CONTINUE, ELSE GO TO ROU10]
Please look at this showcard. Please describe the reasons {NAME} has not had all the shots that
{he/she} is supposed to have at {his/her} age. You may select one or more.
SHOWCARD ROU1
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 / TRANSPORTATION
7=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
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
……………………………………………………………………………………………………
ROU9f_OTH. [IF ROU9f=11 CONTINUE, ELSE GO TO ROU9f1]
Please specify the other reason {NAME} has not had all the shots that {he/she} is supposed to
have at {his/her} age.
________________ [ALLOW 40]
……………………………………………………………………………………………………
ROU9f1. [IF MORE THAN ONE RESPONSE RECORDED IN ROU9f CONTINUE, ELSE GO
TO ROU9f2]
Which of the reasons you just told me about best describes the main reason {NAME} has not
had all the shots that {he/she} is supposed to have at {his/her} age?
[LIST ONLY SELECTIONS MADE IN ROU9f]
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 / TRANSPORTATION
7=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
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
15

……………………………………………………………………………………………………
ROU9f2. [IF INTAGE=18-64 CONTINUE ELSE GO TO ROU10]
Have you ever received an HPV shot or vaccine?
IF NEEDED: HPV is Human papillomavirus. The HPV vaccines are called Cervarix or Gardisil.
Genital human papillomavirus is the most common sexually transmitted disease
1=YES
2=NO
……………………………………………………………………………………………………
ROU9f3. [IF ROU9f2=1 CONTINUE, ELSE GO TO ROU10]
Did you have your most recent HPV shot or vaccine at {REFERENCE HEALTH CENTER} or
some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
……………………………………………………………………………………………………
ROU10. [IF INTAGE GE 18 CONTINUE, ELSE GO TO ROU12]
These next questions are about general physicals or routine check-ups.
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.
1=NEVER
2=LESS THAN 1 YEAR AGO
3=AT LEAST 1 YEAR BUT LESS THAN 2 YEARS
4=AT LEAST 2 YEARS BUT LESS THAN 3 YEARS
5=AT LEAST 3 YEARS BUT LESS THAN 4 YEARS
6=AT LEAST 4 YEARS BUT LESS THAN 5 YEARS
7=5 OR MORE YEARS AGO
……………………………………………………………………………………………………
ROU11. [IF ROU10=2 OR 3 CONTINUE, ELSE GO TO ROU11a]
Did you get this check-up at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
……………………………………………………………………………………………………

16

ROU11a. [IF ROU10=1, 4, 5, 6, OR 7 CONTINUE, ELSE GO TO ROU12]
Please look at this showcard. Please describe the reasons you have not had a general physical
exam or routine check-up in the past 2 years. You may select one or more.
SHOWCARD ROU2
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 FROM DOCTORS OR NURSES
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
……………………………………………………………………………………………………
ROU11a_OTH. [IF ROU11a=11 CONTINUE, ELSE GO TO ROU11a1]
Please specify the other reason you have not had a general physical exam or routine check-up in
the past 2 years.
________________ [ALLOW 40]
……………………………………………………………………………………………………
ROU11a1. [IF MORE THAN ONE RESPONSE RECORDED IN ROU11a CONTINUE, ELSE
GO TO ROU12]
Which of the reasons you just told me about best describes the main reason you have not had a
general physical exam or routine check-up in the past 2 years?
[LIST ONLY SELECTIONS MADE IN ROU11a]
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 FROM DOCTORS OR NURSES
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

17

.……………………………………………………………………………………………………
ROU12. [IF INTAGE LESS THAN 18 CONTINUE, ELSE GO TO ROU14]
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 YEAR BUT LESS THAN 2 YEARS
4=AT LEAST 2 YEARS BUT LESS THAN 3 YEARS
5=AT LEAST 3 YEARS BUT LESS THAN 4 YEARS
6=AT LEAST 4 YEARS BUT LESS THAN 5 YEARS
7=5 OR MORE YEARS AGO
……………………………………………………………………………………………………
ROU13. [IF ROU12=2 OR 3 CONTINUE, ELSE GO TO ROU13a]
Did {you/he/she} get this check-up at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
……………………………………………………………………………………………………
ROU13a. [IF ROU12=1, 4, 5, 6, OR 7 CONTINUE, ELSE GO TO ROU14]
Please look at this showcard. Please describe the reasons {you have/NAME has} not had a wellchild check-up or general check-up in the past 2 years. You may select one or more.
SHOWCARD ROU2
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 FROM DOCTORS OR NURSES
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
……………………………………………………………………………………………………

18

ROU13a_OTH. [IF ROU13a=11 CONTINUE, ELSE GO TO ROU13a1]
Please specify the other reason {you have/NAME has} not had a well-child check-up or general
check-up in the past 2 years.
________________ [ALLOW 40]
……………………………………………………………………………………………………
ROU13a1. [IF MORE THAN ONE RESPONSE RECORDED IN ROU13a CONTINUE, ELSE
GO TO ROU14]
Which of the reasons you just told me about best describes the main reason {you have/NAME
has} not had a well-child check-up or general check-up in the past 2 years?
[LIST ONLY SELECTIONS MADE IN ROU13a]
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 FROM DOCTORS OR NURSES
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
……………………………………………………………………………………………………
ROU14. [IF INTAGE LE 5 CONTINUE, ELSE GO TO CON3_VALUE]
Has {NAME} ever had a blood test to check the amount of lead in {his/her} blood?
1=YES
2=NO
……………………………………………………………………………………………………
ROU15. [IF ROU14=1 CONTINUE, ELSE GO TO ROU17]
How old was {NAME} the last time this test was done?
IF LESS THAN 1 YEAR, ENTER 0.
______ AGE [ALLOW 00-05]
[PROGRAMMER: NEED AGE CHECK SO AGE REPORTED IS NOT HIGHER THAN
ACTUAL AGE REPORTED IN INTAGE EARLIER IN THE INTERVIEW.]

19

……………………………………………………………………………………………………
ROU16. Was that done at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
……………………………………………………………………………………………………
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
……………………………………………………………………………………………………

20

MODULE D: CONDITIONS
CON3_VALUE. How tall {are you/is NAME} without shoes?
INTERVIEWER: ENTER RESPONSE NUMBERS
EXAMPLES:
5FT 6IN =

5

1.65 METERS =

6
1

165 CENTIMETERS =

65
0

165

______ _______
……………………………………………………………………………………………………
CON3_UNITS. (How tall {are you/is NAME} without shoes?)
INTERVIEWER: ENTER RESPONSE UNIT
1=FEET/INCHES
2=METERS/CENTIMETERS
3=CENTIMETERS
……………………………………………………………………………………………………
CON4. How much {do you/does NAME} weigh without clothes or shoes?
[PROGRAMMERS: ALLOW METRIC; DO NOT ALLOW BLANK RESPONSE]
_______________
……………………………………………………………………………………………………
CON4_UNITS.
INTERVIEWER: WAS THE RESPONSE IN POUNDS OR KILOGRAMS?
1=POUNDS
2=KILOGRAMS
……………………………………………………………………………………………………

21

CON9o.
During the past 7 days, on how many days {were you/was NAME}physically active for a total
of at least 60 minutes per day? Add up all the time {your/NAME} spent in any kind of physical
activity that increased {your/his/her} heart rate and made {you/him/her} breathe hard some of
the time.
0 = 0 DAYS
1 = 1 DAY
2 = 2 DAYS
3 = 3 DAYS
4 = 4 DAYS
5 = 5 DAYS
6 = 6 DAYS
7 = 7 DAYS

……………………………………………………………………………………………………
CON9p.

……………………………………………………………………………………………………
CON9q.

…………………………………………………………………………………………………

22

CON9u. [IF INTAGE GE 13 CONTINUE, ELSE GOTO CON9N1]
The next questions exclude the physical activities at work that you have already mentioned. Now
I would like to ask you about the usual way you travel to and from places. For example to work,
for shopping, or to school.
In a typical week do you walk or use a bicycle for at least 10 minutes continuously to get to
and from places?
1=YES
2=NO
……………………………………………………………………………………………………
CON9v. [IF CON9u=1 CONTINUE, ELSE GO TO CON9x]
In a typical week, on how many days do you walk or bicycle for at least 10 minutes
continuously to get to and from places?
_____ DAYS [ALLOW 00-07]
……………………………………………………………………………………………………
CON9w. On average, how long do you spend walking or bicycling for travel on those days?
IF NEEDED: Think about a typical day when you walk or bicycle for travel.
_____ [ALLOW 00-59]
……………………………………………………………………………………………………
CON9w_UNITS. (How much time do you spend walking or bicycling for travel on a typical
day?)
INTERVIEWER: ENTER RESPONSE UNIT
1=MINUTES
2=HOURS
…………………………………………………………………………………………………

……………………………………………………………………………………………………

23

CON9N1. Now I will ask you first about TV watching and then about computer use.
Over the past 30 days, on average how many hours per day did {you/NAME} sit and watch TV
or videos?
1=LESS THAN 1 HOUR
2=1 HOUR BUT LESS THAN 2 HOURS
3=2 HOURS BUT LESS THAN 3 HOURS
4=3 HOURS BUT LESS THAN 4 HOURS
5=4 HOURS BUT LESS THAN 5 HOURS
6=5 HOURS OR MORE
7=DO/DOES NOT WATCH TV OR VIDEOS
……………………………………………………………………………………………………
CON9n2. Over the past 30 days, on average how many hours per day did {you/name} use a
computer or play computer games outside of school?
NOTE: INCLUDE TIME SPENT PLAYING GAMES ON A CELL PHONE OR OTHER
PORTABLE DEVICE. IF THEY WATCH TV OR VIDEO AT THE SAME TIME AS
WORKING ON THE COMPUTER, COUNT THIS TIME AS WATCHING TV OR VIDEO.
1=LESS THAN 1 HOUR
2=1 HOUR BUT LESS THAN 2 HOURS
3=2 HOURS BUT LESS THAN 3 HOURS
4=3 HOURS BUT LESS THAN 4 HOURS
5=4 HOURS BUT LESS THAN 5 HOURS
6=5 HOURS OR MORE
7 =DO/DOES NOT USE A COMPUTER OUTSIDE OF WORK OR SCHOOL
……………………………………………………………………………………………………
CON9n3. On average, how many hours of sleep {do you/does NAME} get in a 24-hour period?
____ HOURS [ALLOW 01 – 20]
……………………………………………………………………………………………………
CON1. Would you say {your/NAME’s} health in general is excellent, very good, good, fair, or
poor?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR
..……………………………………………………………………………………………………

24

CON1a. Compared with 12 months ago, that is since {12 MONTH REFERENCE DATE},
would you say {your/NAME’s} health is now better, worse, or about the same?
1=BETTER
2=WORSE
3=ABOUT THE SAME
……………………………………………………………………………………………………
CON2. [IF (INT3=2 OR 3) AND INTAGE=15-49 CONTINUE, ELSE GO TO CON5]
The next series of questions are about your weight. In order to ask the right questions, we need to
know about any possible changes to your body.
Have you ever been pregnant?
1=YES
2=NO
……………………………………………………………………………………………………
CON2a. [If CON2=1 continue, else go to CON5]
Are you currently pregnant?
1=YES
2=NO
……………………………………………………………………………………………………
CON5. [IF CON2a=1 FILL:] What did you consider yourself to be before you were pregnant,
overweight, underweight, or just about right? [ELSE FILL:] Do you consider
{yourself/NAME} now to be overweight, underweight, or just about right?
1=OVERWEIGHT
2=UNDERWEIGHT
3=ABOUT RIGHT
……………………………………………………………………………………………………
CON6a. [IF CON2=1 FILL:] How much did you weigh a year ago? If you were pregnant a year
ago, please tell us how much you weighed before becoming pregnant.
[ELSE FILL:] How much did {you/NAME} weigh a year ago?
[ALLOW METRIC; DO NOT ALLOW BLANK RESPONSE]
________________
……………………………………………………………………………………………………

25

CON6a_UNITS. INTERVIEWER: WAS THE RESPONSE IN POUNDS OR KILOGRAMS?
1=POUNDS [ALLOW 000-555]
2=KILOGRAMS [ALLOW 000.0-200.0]
……………………………………………………………………………………………………
CON6b. During the past 12 months, that is since, {have you/has NAME} tried to lose weight?
1=YES
2=NO
.……………………………………………………………………………………………………
CON6c. [IF CON6b=1 AND INTAGE GE 13 CONTINUE, ELSE GO TO CON7]
Please look at this showcard. How did you try to lose weight?
SHOWCARD CON1
1=CHANGED WHAT I ATE OR HOW MUCH I ATE OR WHEN I ATE
2=EXERCISED
3=JOINED A WEIGHT LOSS PROGRAM
4=TOOK DIET PILLS PRESCRIBED BY A DOCTOR
5=TOOK OTHER PILLS, MEDICINES, HERBS, OR SUPPLEMENTS NOT NEEDING A
PRESCRIPTION
6=STARTED TO SMOKE OR BEGAN TO SMOKE AGAIN
7=TOOK LAXATIVES OR VOMITED
8=DRANK A LOT OF WATER
9=OTHER
……………………………………………………………………………………………………
CON6c_SPEC. [IF CON6c=9 CONTINUE, ELSE GO TO CON7]
Please describe the other way that you tried to lose weight.
_________[ALLOW 40]
……………………………………………………………………………………………………
CON7. [IF CON5=3: The next few questions ask whether a doctor or other health professional
has discussed weight management with {you/name}, regardless of whether {you are /he is/she
is} are overweight, underweight or of average weight.]
During the past 12 months, has a doctor or other health professional told you that {you/NAME}
had a problem with {your/his/her} weight?
1=YES
2=NO

26

……………………………………………………………………………………………………
CON7a. [IF CON7=1 CONTINUE, ELSE GO TO CON8]
Was this at {REFERENCE HEALTH CENTER} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
……………………………………………………………………………………………………
CON8. Has a doctor or other health professional ever talked to you about things {you/NAME}
can do to manage {your/his/her} weight, such as meal planning and nutrition?
1=YES
2=NO
……………………………………………………………………………………………………
CON8a1. [IF CON8=1 CONTINUE, ELSE GO TO CON8a3]
Was this at {REFERENCE HEALTH CENTER} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
……………………………………………………………………………………………………
CON8a3. (Has a doctor or other health professional ever talked to you about things
{you/NAME} can do to manage {your/his/her} weight, such as…)
An exercise program?
1=YES
2=NO
……………………………………………………………………………………………………
CON8a4. [IF CON8a3=1 CONTINUE, ELSE GO TO CON8a6]
Was this at {REFERENCE HEALTH CENTER} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
……………………………………………………………………………………………………

27

CON8a6. (Has a doctor or other health professional ever…)
Suggested you visit a nutritionist because of {your/NAME’s} weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON8a7. [IF CON8a6=1 CONTINUE, ELSE GO TO CON8b]
Was this at {REFERENCE HEALTH CENTER} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
…………………………………………………………………………………………………
CON8b. [If CON8=1 or CON8a6=1 continue, else go to CON8B1]
Have you made changes to {your/NAME’s} eating and nutrition practices since receiving advice
about {your/NAME’s} weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON8b1. [If CON8a3=1 CONTINUE, ELSE GO TO CON10]
{Have you/Has NAME} began an exercise program since receiving advice about
{your/NAME’s} weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON9a. [IF INTAGE GE 13 CONTINUE, ELSE GO TO CON9c]
Has a doctor or other health professional ever prescribed medications to help you lose weight?
1=YES
2=NO
……………………………………………………………………………………………………

28

CON9b1. [IF CON9a=1 CONTINUE, ELSE GO TO CON9c]
Was this at {REFERENCE HEALTH CENTER} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
……………………………………………………………………………………………………
CON9c. In the past 12 months, did you seek help from a personal trainer, dietitian, nutritionist,
doctor or other health professional to help {you/NAME} lose weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON10. [IF INTAGE GE 2 CONTINUE, ELSE GO TO CON11_hep]
Now I am going to ask you about certain medical conditions.
Have you ever been told by a doctor or other health professional that {you/NAME} had
hypertension, also called high blood pressure?
IF NEEDED: Blood pressure is checked by a health care provider using a blood pressure cuff
placed on your upper arm and a stethoscope.
1=YES
2=NO
…………………………………………………………………………………………………
CON10b. About how long has it been since {you/NAME} had {your/his/her} blood pressure
checked by a doctor, nurse, or other health professional?
99=NEVER
_________________
……………………………………………………………………………………………………
CON10b_UNITS. (About how long has it been since {you/NAME} had {your/his/her} blood
pressure checked by a doctor, nurse, or other health professional?)
INTERVIEWER: ENTER RESPONSE UNIT
1=DAYS AGO
2=WEEKS AGO
3=MONTHS AGO
4=YEARS AGO

29

88=TODAY
99=NEVER
..……………………………………………………………………………………………………
CON10c. [IF CON10=1 CONTINUE, ELSE GO TO CON11_hep]
During the most recent visit, were you told {you/NAME} had high blood pressure?
1=YES
2=NO
……………………………………………………………………………………………………
CON10d. {Are you/Is NAME} now taking any medications to control {your/his/her} high blood
pressure?
1=YES
2=NO
……………………………………………………………………………………………………
CON11_hep. Have you ever been told by a doctor or health professional that {you/NAME} had
hepatitis?
1=YES
2=NO
……………………………………………………………………………………………………
CON11_hep1. [IF CON11_hep=1 CONTINUE, ELSE GO TO CON11a_2]
What types of hepatitis {were you/was NAME} diagnosed with?
SELECT ALL THAT APPLY
1=HEPATITIS A
2=HEPATITIS B
3=HEPATITIS C
……………………………………………………………………………………………………
CON14m_current. [IF CON11_hep1=3 CONTINUE, ELSE GO TO CON11a_2]
{Do you/Does NAME} currently have hepatitis C?
1=YES
2=NO
……………………………………………………………………………………………………

30

CON11a_2. {Have you/ Has NAME} ever received the hepatitis B vaccine?
IF NEEDED: This is given in three separate doses and has been available since 1991. It is
recommended for newborn infants, adolescents, and people such as health care workers, who
may be exposed to the hepatitis B virus.
1=YES
2=NO
……………………………………………………………………………………………………
CON11_hepb. [If CON11a_2=1 CONTINUE, ELSE GO TOCON11a_test]
Did {you/NAME} receive at least 3 doses of the hepatitis B vaccine, or less than 3 doses?
1=RECEIVED AT LEAST 3 DOSES
2=RECEIVED LESS THAN 3 DOSES
……………………………………………………………………………………………………
CON11a_test. [IF CON11_hep1=1 OR 3 CONTINUE, ELSE GO TO CON11b_test]
{Have you/Has NAME} ever been tested for hepatitis B?
1=YES
2=NO
……………………………………………………………………………………………………
CON11b_test. [IF CON11_hep1=1 OR 2 CONTINUE, ELSE GO TO CON11_b1]
{Have you/Has NAME} ever been tested for hepatitis C?
1=YES
2=NO
……………………………………………………………………………………………………
CON11_b1. [IF CON11a_test=1 CONTINUE, ELSE GO TO CON11_c1]
When was (your/NAME’s) most recent test for hepatitis B?
1=3 months ago or less
2=More than 3 months but less than 1 year ago
3=1 year but less than 3 years ago
4=3 or more years ago
……………………………………………………………………………………………………

31

CON11_b2. Was (your/NAME’s) most recent test for hepatitis B here at {REFERENCE
HEALTH CENTER} or somewhere else?
1=REFERENCE HEALTH CENTER
2=SOMEWHERE ELSE
……………………………………………………………………………………………………
CON11_c1. [IF CON11b_test=1 CONTINUE, ELSE GO TO CON11]
When was (your/NAME’s) most recent test for hepatitis C?
1=3 months ago or less
2=More than 3 months but less than 1 year ago
3=1 year but less than 3 years ago
4=3 or more years ago
……………………………………………………………………………………………………
CON11_c2. Was (your/NAME’s) most recent test for hepatitis C here at {REFERENCE
HEALTH CENTER} or somewhere else?
1=REFERENCE HEALTH CENTER
2=SOMEWHERE ELSE
……………………………………………………………………………………………………
CON11. Have you ever been told by a doctor or other health professional that {you/NAME} had
asthma?
1=YES
2=NO
……………………………………………………………………………………………………
CON11a. [IF CON11=1 CONTINUE, ELSE GOTO CON12]
{Do you/Does NAME} still have asthma?
1=YES
2=NO
……………………………………………………………………………………………………
CON11b. [IF CON11a=1 CONTINUE, ELSE GO TO CON12]
During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have you/has
NAME} had an episode of asthma or an asthma attack?
1=YES
2=NO

32

……………………………………………………………………………………………………
CON12. Have you ever been told by a doctor or health professional that {you/NAME} had
diabetes or sugar diabetes?
1=YES
2=NO
……………………………………………………………………………………………………
CON12a1. [IF CON12=1 CONTINUE, ELSE GO TO CON12a]
Were you told that {you/NAME} had Type 1 or Type 2 diabetes?
1=TYPE 1 DIABETES
2=TYPE 2 DIABETES
……………………………………………………………………………………………………
CON12a. [IF CON12=2 CONTINUE, ELSE GO TO CON12b]
Have you ever been told by a doctor or other health professional that (you have/NAME has) prediabetes or borderline diabetes?
IF NEEDED: Before people develop type 2 diabetes, they almost always have “prediabetes” in
which blood glucose levels are higher than normal but not yet high enough to be diagnosed as
diabetes. Doctors sometimes refer to prediabetes as impaired glucose tolerance (IGT) or
impaired fasting glucose (IFG), depending on what test was used when it was detected.
1=YES
2=NO
……………………………………………………………………………………………………
CON12b. [IF CON12=1 CONTINUE, ELSE GO TO CON13]
How old {were you/was NAME} when a doctor first told you that {you/he/she} had diabetes?
________ AGE IN YEARS [ALLOW 000-110]
.……………………………………………………………………………………………………
CON12c. [IF CON12=1 AND CON2=1 CONTINUE, ELSE GO TO CON13]
Was this only when you were pregnant?
1=YES
2=NO
……………………………………………………………………………………………………

33

CON13. [IF INTAGE GE 18 CONTINUE, ELSE GO TO CON14a]
These next questions are about blood cholesterol.
About how long has it been since you had your blood cholesterol checked by a doctor, nurse, or
other health professional?
1=NEVER
2=LESS THAN 1 YEAR AGO
3=AT LEAST 1 YEAR BUTLESS THAN 2 YEARS
4=AT LEAST 2 YEARS BUT LESS THAN 3 YEARS
5=AT LEAST 3 YEARS BUT LESS THAN 4 YEARS
6=AT LEAST 4 YEARS BUT LESS THAN 5 YEARS
7=5 OR MORE YEARS AGO
……………………………………………………………………………………………………
CON13a. [IF CON13 = 2, 3, 4, 5, 6, OR 7 CONTINUE, ELSE GO TO CON14a]
Was this at {REFERENCE HEALTH CENTER} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
.……………………………………………………………………………………………………
CON13b. Have you ever been told by a doctor or other health professional that your blood
cholesterol level was high?
1=YES
2=NO
. ……………………………………………………………………………………………………
CON13d. (IF CON13b=1 CONTINUE, ELSE GO TO CON14a)
During the most recent visit, were you told you had high cholesterol?
1=YES
2=NO
……………………………………………………………………………………………………

34

CON14a. The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…
Congestive heart failure?
1=YES
2=NO
.……………………………………………………………………………………………………
CON14b. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
Coronary heart disease?
1=YES
2=NO
……………………………………………………………………………………………………
CON14c. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
Angina, also called angina pectoris?
1=YES
2=NO
.……………………………………………………………………………………………………
CON14d. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
A heart attack, it is also called myocardial infarction?
1=YES
2=NO
.……………………………………………………………………………………………………

35

CON14e. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
A stroke?
1=YES
2=NO
.……………………………………………………………………………………………………
CON14f. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
Chronic obstructive pulmonary disorder (also known as COPD, emphysema or chronic
bronchitis)?
1=YES
2=NO
…………….………………………………………………………………………………………
CON14i. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
Any kind of liver condition other than hepatitis?
1=YES
2=NO
……………………………………………………………………………………………………
CON14j. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
Weak or failing kidneys
1=YES
2=NO
.……………………………………………………………………………………………………

36

CON14k. (The next questions are about other health conditions. Please tell me yes or no for the
following conditions. Has a doctor or other health professional ever told you that {you/he/she}
had…)
Tuberculosis (TB)
1=YES
2=NO
……………………………………………………………………………………………………
CON9z1a. A traumatic brain injury may result from a violent blow to the head or when an object
pierces the skull and enters the brain tissue. Has a doctor or other health professional ever told
you that {you have/NAME has} suffered a traumatic brain injury (TBI)?
1=YES
2=NO
……………………………………………………………………………………………………
CON14i_current. [IF CON14i=1 CONTINUE, ELSE GO TO CON14k_current]
{Do you/Does NAME} currently have any kind of liver condition other than hepatitis?
1=YES
2=NO
……………………………………………………………………………………………………
CON14k_current. [IF CON14k=1 CONTINUE, ELSE GO TO CON14k_current1]
{Do you/Does NAME} currently have Tuberculosis (TB)?
1=YES
2=NO
……………………………………………………………………………………………………
CON14k_current1 [IF CON14k_current=1 CONTINUE, ELSE GO TO CON16]
{Do you/Does NAME} currently have active TB?
1=YES
2=NO
……………………………………………………………………………………………………
CON16. During the past 12 months, {have you/ has NAME} had Pneumonia?
1=YES
2=NO

37

.……………………………………………………………………………………………………
CON19. [IF INTAGE GE 2 CONTINUE, ELSE GO TO CON25]
Have you ever been told by a doctor or other health professional that {you/NAME} had cancer
or a malignancy of any kind?
1=YES
2=NO
.……………………………………………………………………………………………………
CON20. [IF CON19=1 CONTINUE, ELSE GO TO CON25]
Please look at this showcard. What kind of cancer was it? You may select up to 3 kinds of
cancer.
SHOWCARD CON2
1=BLADDER
2=BLOOD
3=BONE
4=BRAIN
5=BREAST
6=CERVIX
7=COLON
8=ESOPHAGUS
9=GALLBLADDER
10=KIDNEY
11=LARYNX-WINDPIPE
12=LEUKEMIA
13=LIVER
14=LUNG
15=LYMPHOMA
16=MELANOMA
17=MOUTH/TONGUE/ LIP
18=OVARY
19=PANCREAS
20=PROSTATE
21=RECTUM
22=SKIN (NON-MELANOMA)
23=SKIN (DON’T KNOW WHAT KIND)
24=SOFT TISSUE (MUSCLE OR FAT)
25=STOMACH
26=TESTIS
27=THROAT - PHARYNX
28=THYROID

38

29=UTERUS
30=OTHER
……………………………………………………………………………………………………
CON25. The next few questions are about {your/NAME’s} hearing and vision.
{Are you/Is NAME} deaf or {do you/does NAME} have serious difficulty hearing?
1=YES
2=NO
……………………………………………………………………………………………………
CON26. [IF INTAGE GE 2:]{Are you/Is NAME} blind or {do you/does NAME} have serious
difficulty seeing, even when wearing glasses?
[IF INTAGE LT 2:] Does {NAME} have any trouble seeing?
1=YES
2=NO
……………………………………………………………………………………………………
CON27a. [IF INTAGE GE 10 CONTINUE, ELSE GO TO CONF1]
{Do you/ Does NAME} have difficulty…
Dressing or bathing?
1=YES
2=NO
……………………………………………………………………………………………………
CON27c. {Do you/ Does NAME} need help with…
Eating?
1=YES
2=NO
……………………………………………………………………………………………………
CON27d. {Do you/ Does NAME} need help with…
Getting in or out of bed or chairs?
1=YES
2=NO
……………………………………………………………………………………………………

39

CON27e. {Do you/ Does NAME} need help with…
Using the toilet, including getting to the toilet?
1=YES
2=NO
……………………………………………………………………………………………………
CON27f. {Do you/ Does NAME} have serious difficulty…
Walking or climbing stairs?
1=YES
2=NO
……………………………………………………………………………………………………
CON28. [IF INTAGE GE 18 CONTINUE, ELSE GO TO CONF1]
Because of a physical, mental, or emotional condition, do you have difficulty doing errands
alone such as visiting a doctor’s office or shopping?
1=YES
2=NO
……………………………………………………………………………………………………
CON30. Because of a physical, mental, or emotional condition, do you have serious difficulty
concentrating, remembering, or making decisions?
1=YES
2=NO
………………………………………………………………………………………………

40

MODULE E: CONDITIONS – FOLLOWUP
CONF1. [IF CON10=1 AND CON2=1 CONTINUE, ELSE GO TO CONF1a_a]
Earlier you mentioned that {you/NAME} had been told that {you/she} had high blood pressure.
I’d like to ask a few more questions about that.
Did you only have high blood pressure during pregnancy?
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_a. [IF CON10=1 AND CONF1=2 OR BLANK CONTINUE, ELSE GO TO CON4]
Because of {your/NAME’s} high blood pressure, has a doctor or other health professional ever
advised {you/him/her} to…
Go on a diet or change {your/his/her} eating habits to help lower {your/his/her} blood pressure?
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_a1. [IF CONF1a_a=1 CONTINUE, ELSE GO TO CONF1a_b]
Was this at {REFERENCE HEALTH CENTER} or some other place?
1=REFERENCE EHALTH CENTER
2=SOME OTHER PLACE
………………………………………………………………………………………………
CONF1a_a2. {Are you/Is NAME} now following this advice to go on a diet or change
{your/his/her} eating habits to help lower {your/his/her} blood pressure?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO
………………………………………………………………………………………………

41

CONF1a_b. (Because of {your/NAME’s} high blood pressure, has a doctor or other health
professional ever advised {you/him/her} to…)
Cut down on salt or sodium in {your/his/her} diet?
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_b1. [IF CONF1a_b=1 CONTINUE, ELSE GO TO CONF1a_c]
Was this at {REFERENCE HEALTH CENTER} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
………………………………………………………………………………………………
CONF1a_b3. {Are you/Is NAME} now following this advice to cut down on salt or sodium in
{your/his/her} diet?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_c. (Because of {your/NAME’s} high blood pressure, has a doctor or other health
professional ever advised {you/him/her} to…)
Exercise?
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_c1. [IF CONF1a_c=1 CONTINUE, ELSE GO TO CONF1a_d]
Was this at {REFERENCE HEALTH CENTER} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
………………………………………………………………………………………………

42

CONF1a_c3. {Are you/Is Name} now following this advice to exercise?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_d. [IF INTAGE GE 21 CONTINUE, ELSE GO TO CONF2]
(Because of your high blood pressure, has a doctor or other health professional ever advised you
to…)
Cut down on alcohol use?
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_d1. [IF CONF1a_d=1 CONTINUE, ELSE GO TO CONF2]
Was this at {REFERENCE HEALTH CENTER} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
………………………………………………………………………………………………
CONF1a_d3. Are you now following this advice to cut down on alcohol use?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO
………………………………………………………………………………………………
CONF2. [IF CON10=1 AND CONF1=2 OR BLANK CONTINUE, ELSE GO TO CONF4]
Was any medication ever prescribed by a doctor for {your/NAME’s} high blood pressure?
1=YES
2=NO
………………………………………………………………………………………………

43

CONF2a_1. [IF CONF2=1 CONTINUE, ELSE GO TO CONF2]
Was this at {REFERENCE HEALTH CENTER} or some other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
………………………………………………………………………………………………
CONF2a. [IF CONF2=1 CONTINUE, ELSE GOT TO CONF4]
{Are you/Is NAME} now taking any medicine prescribed by a doctor for {your/his/her} high
blood pressure?
1=YES
2=NO
………………………………………………………………………………………………
CONF2b. [IF CONF2a=2 CONTINUE, ELSE GO TO CONF3]
Did a doctor advise you to stop {taking/giving NAME} the medicine?
1=YES
2=NO
………………………………………………………………………………………………
CONF3. Do you regularly check {your/his/her} blood pressure?
1=YES
2=NO
………………………………………………………………………………………………
CONF3a. During the last 6 months, have you received any of the following to teach you how to
take care of {your/his/her} high blood pressure…
A telephone call from {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………

44

CONF3b. (During the last 6 months, have you received any of the following to teach you how
to take care of {your/his/her} high blood pressure…)
An appointment with a nurse at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
……………………………………………………………………………………………
CONF3c. (During the last 6 months, have you received any of the following to teach you how to
take care of {your/his/her} high blood pressure…)
A visit from staff at {REFERENCE HEALTH CENTER}? That is, someone came to see you.
1=YES
2=NO
………………………………………………………………………………………………
CONF3d. (During the last 6 months, have you received any of the following to teach you how
to take care of {your/his/her} high blood pressure…)
A referral from the {REFERENCE HEALTH CENTER} to see a specialist?
1=YES
2=NO
……………………………………………………………………………………………
CONF3e. In the past year, {have you/has NAME} been in the hospital or visited an emergency
room because of high blood pressure?
1=YES
2=NO
………………………………………………………………………………………………
CONF3f. Has any doctor or nurse (you see/NAME sees) for {your/his/her} high blood pressure
given you a plan to manage {your/his/her} own care at home?
1=YES
2=NO
………………………………………………………………………………………………

45

CONF3g. [IF CONF3f=1 CONTINUE, ELSE GO TO CONF3h]
Was this plan given to you by a doctor or nurse at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF3h. How confident are you that you can control and manage {your/his/her} high blood
pressure? Are you...
1=Very confident
2=Somewhat confident
3=Not too confident
4=Not at all confident
………………………………………………………………………………………………
CONF4. [IF CON11a=1 or CON11b=1 CONTINUE, ELSE GO TO CON5]
Earlier, you indicated that {you/NAME} had been told by a doctor or other health professional
that {you/he/she} had asthma. I’d like to ask you a few more questions about that.
1=CONTINUE
………………………………………………………………………………………………
CONF4a. In the past year, {have you/has NAME} been in the hospital or visited an emergency
room because of asthma?
1=YES
2=NO
………………………………………………………………………………………………
CONF4b. {Have you\Has NAME} ever used a prescription inhaler?
1=YES
2=NO
………………………………………………………………………………………………
CONF4c. [IF CONF4b=1 CONTINUE, ELSE GO TO CONF4d]
Now I'm going to ask you about two different kinds of asthma medicine. One is for quick relief.
The other does not give quick relief but protects the lungs and prevents symptoms over the long
term.

46

During the past 3 months, {have you/has NAME} used the kind of prescription inhaler that
{you breathe/he/she breathes} in through {your/his/her} mouth, which gives quick relief from
asthma symptoms?
1=YES
2=NO
…….…………………………………………………………………………………………
CONF4d. {Have you/Has NAME} ever taken the preventive kind of asthma medicine used
every day to protect {your/his/her} lungs and keep {you/him/her} from having attacks? Include
both oral medicine and inhalers. This is different from inhalers used for quick relief.
1=YES
2=NO
………………………………………………………………………………………………
CONF4e. [IF CONF4d=1 CONTINUE, ELSE GO TO CONF4f]
{Are you/Is NAME} now taking this medication that protects {your/his/her} lungs daily or
almost daily?
1=YES
2=NO
………………………………………………………………………………………………
CONF4f. {Have you/Have you or NAME} ever taken a course or class on how to manage
asthma {yourself/himself/herself}?
1=YES
2=NO
………………………………………………………………………………………………
CONF4g. Has a doctor or other health professional ever taught {you/NAME} how to….
Recognize early signs or symptoms of an asthma episode?
1=YES
2=NO
………………………………………………………………………………………………
CONF4h. (Has a doctor or other health professional ever taught {you/NAME} how to….)
Respond to episodes of asthma?
1=YES
2=NO

47

………………………………………………………………………………………………
CONF4i. (Has a doctor or other health professional ever taught {you/NAME} how to….)
Monitor peak flow for daily therapy?
1=YES
2=NO
………………………………………………………………………………………………
CONF4j. Has a doctor or other health professional ever advised you to change things in your
home, school, or work to improve {your/his/her} asthma?
1=YES
2=NO
3=WAS TOLD NO CHANGES NEEDED
………………………………………………………………………………………………
CONF4k1. During the last 6 months, have you received any of the following to teach you how
to take care of {your/his/her} asthma…
A telephone call from {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF4k2. (During the last 6 months, {have you/has NAME} received any of the following to
teach {you/him/her} how to take care of your asthma…)
An appointment with nurse at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF4k3. (During the last 6 months, {have you/has NAME} received any of the following to
teach {you/him/her} how to take care of your asthma…)
A visit, that is, someone came to see you from {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………

48

CONF4k4. (During the last 6 months, {have you/has NAME} received any of the following to
teach {you/him/her} how to take care of your asthma…)
A referral to a specialist by {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF4k5. Has a doctor or nurse {you see/NAME sees} at {REFERENCE HEALTH CENTER}
for {your/his/her} asthma given {you/him/her} a plan to manage {your/his/her} own care at
home?
1=YES
2=NO
………………………………………………………………………………………………
CONF4k6. [IF CONF4k5=1 CONTINUE, ELSE GO TO CONF5]
Was this plan given to {you/NAME} by a doctor or nurse at {REFERENCE HEALTH
CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF4k7. How confident {are you/is NAME} that {you/he/she} can control and manage
{your/his/her} asthma? {Are you/Is he/she}...
1=Very confident
2=Somewhat confident
3=Not too confident
4=Not at all confident
………………………………………………………………………………………………
CONF5. [IF CON12=1 CONTINUE, ELSE GO TO CON22]
Earlier, you indicated that {you/NAME} had diabetes. I’d like to ask you a few more questions
about that. {Are you/Is NAME} now taking insulin?
1=YES
2=NO
………………………………………………………………………………………………

49

CONF5a. [IF CONF5=1 CONTINUE, ELSE GO TO CONF5b]
{Are you/Is NAME} now taking diabetic pills to lower {your/his/her} blood sugar? These are
sometimes called oral agents or oral hypoglycemic agents.
1=YES
2=NO
………………………………………………………………………………………………
CONF5b. How often {do you check your/does NAME check his/her} blood for glucose or
sugar? Include times when checked by a family member or friend, but do not include times
when checked by a doctor or other health professional. Do not include urine tests.
______ TIMES [ALLOW 0-9]
………………………………………………………………………………………………
CONF5b_UNIT. (How often {do you check your/does NAME check his/her} blood for glucose
or sugar?)
INTERVIEWER: ENTER RESPONSE UNIT
1=DAY
2=WEEK
3=MONTH
4=YEAR
………………………………………………………………………………………………
CONF5c. Glycosylated (GLY-CO-SYL-AT-ED) hemoglobin or the “A one C” test measures the
average level of blood sugar over the past 3 months, and usually ranges between 5 and 14.
During the past 12 months, how many times has a doctor or other health professional checked
{you/NAME} for glycosylated hemoglobin or A one C?
NEVER=0
______ TIMES [ALLOW 0-9]
………………………………………………………………………………………………
CONF5d. The last time a doctor or other health professional checked {your/NAME’s} blood
sugar level, did he or she tell you it was too high, too low, or just right?
1=TOO HIGH
2=TOO LOW
3=JUST RIGHT
………………………………………………………………………………………………

50

CONF5e1. During the last 6 months, have you received any of the following to teach
{you/NAME} how to take care of {your/his/her} diabetes…
A telephone call from {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e2. (During the last 6 months, have you received any of the following to teach
{you/NAME} how to take care of {your/his/her} diabetes …)
An appointment with a nurse at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e3. (During the last 6 months, have you received any of the following to teach
{you/NAME} how to take care of {your/his/her} diabetes …)
A visit, that is, someone came to see {you/NAME} from {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e4. (During the last 6 months, have you received any of the following to teach
{you/NAME} how to take care of {your/his/her} diabetes …)
A referral to a specialist by {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e4a. During the past 12 months, that is since {12 MONTH REFERENCE DATE},
{have you/has NAME} had an eye exam by an optometrist, ophthalmologist, eye doctor, or
someone who prescribes eyeglasses?
1=YES
2=NO
………………………………………………………………………………………………

51

CONF5e4b. During the past 12 months, {have you/has NAME} had a foot exam by a foot
doctor?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e5. In the past 12 months, {have you/has NAME} been in the hospital or visited an
emergency room because of diabetes?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e6. Has any doctor or nurse {you see/NAME sees} for {your/his/her} diabetes given
{you/him/her} a plan to manage {your/his/her} care at home?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e7. [IF CONF5e6=1 CONTINUE, ELSE GO TO CON22]
Was this plan given to {you/NAME} by a doctor or nurse at {REFERENCE HEALTH
CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e8. How confident {are you/is NAME} that {you/he/she} can control and manage
{your/his/her} diabetes? {Are you/Is he/she}...
1=Very confident
2=Somewhat confident
3=Not too confident
4=Not at all confident
………………………………………………………………………………………………
CON22. [IF CON13b=1 CONTINUE, ELSE GO TO CAN1]
Earlier you mentioned that you were told by a doctor or other health professional that your blood
cholesterol level was high.
1=CONTINUE
………………………………………………………………………………………………

52

CON22a. To lower your blood cholesterol, have you ever been told by a doctor or other health
professional…
To eat fewer high fat or high cholesterol foods?
1=YES
2=NO
.……………………………………………………………………………………………………
CON22b. (To lower your blood cholesterol, have you ever been told by a doctor or other health
professional…)
To control your weight or lose weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON22c. (To lower your blood cholesterol, have you ever been told by a doctor or other health
professional…)
To increase your physical activity or exercise?
1=YES
2=NO
……………………………………………………………………………………………………
CON22d. (To lower your blood cholesterol, have you ever been told by a doctor or other health
professional…)
To take prescribed medicine?
1=YES
2=NO
……………………………………………………………………………………………………
CON24. [If CON22a=1 OR CON22b=1 OR CON22c=1 OR CON22d=1 CONTINUE, ELSE
GO TO CON23a]
Did you ever receive this advice from someone at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
……………………………………………………………………………………………………

53

CON23a. [IF CON22a=1CONTINUE, ELSE GO TO CON23b]
Are you now following this advice to...
Eat fewer high fat or high cholesterol foods?
1=YES
2=NO
……………………………………………………………………………………………………
CON23b. [IF CON22b=1 CONTINUE, ELSE GO TO CON23c]
Are you now following this advice to...
Control your weight or lose weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON23c. [IF CON22c=1CONTINUE, ELSE GO TO CON23d]
Are you now following this advice to...
Increase your physical activity or exercise?
1=YES
2=NO
……………………………………………………………………………………………………
CON23d. [IF CON22d=1 CONTINUE, ELSE GO TO CAN1]
Are you now following this advice to...
Take prescribed medicine?
1=YES
2=NO
……………………………………………………………………………………………………

54

MODULE F: CANCER SCREENING
[IF INTAGE GE 18 AND INT3=2 OR INT3=3 CONTINUE]
[IF INTAGE LE 17 GO TO HEA1, ELSE IF INTAGE GE 18 AND INT3=1, 4, 5, 6, DK, OR
RE GO TO CAN4]
Next, I’m going to ask you about any cancer screening procedures that you may have had. Have
you ever had a Pap smear or Pap test?
IF NEEDED: A Pap smear or Pap test is a routine test for women in which the doctor examines
the cervix, takes a cell sample from the cervix with a small stick or brush, and sends it to the lab.
1=YES
2=NO
………………………………………………………………………………………………
CAN1a. [IF CAN1=1 CONTINUE, ELSE GO TO CAN1b1]
When did you have your most recent Pap smear or Pap test?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO
4=3 YEARS BUT LESS THAN 4 YEARS AGO
5=4 YEARS BUT LESS THAN 5 YEARS AGO
6=5 OR MORE YEARS AGO
………………………………………………………………………………………………
CAN1a1. Did you have your most recent Pap smear or Pap test at {REFERENCE HEALTH
CENTER}?
1=REFERENCE HEALTH CENTER
2=SOMEWHERE ELSE
………………………………………………………………………………………………
CAN1b. What was the main reason you had this Pap smear or Pap test - was it part of a routine
exam, because of a problem, or some other reason?
1=PART OF A ROUTINE EXAM
2=BECAUSE OF A PROBLEM
3=SOME OTHER REASON
………………………………………………………………………………………………

55

CAN1b1. Have you been tested for human papilloma virus or HPV?
IF NEEDED: Genital human papillomavirus is the most common sexually transmitted disease
1=YES
2=NO
………………………………………………………………………………………………
CAN1b2. [IF CAN1b1=1 CONTINUE, ELSE GO TO CAN1c]
When did you have your most recent human papilloma virus or HPV test?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO
4=3 YEARS BUT LESS THAN 4 YEARS AGO
5=4 YEARS BUT LESS THAN 5 YEARS AGO
6=5 OR MORE YEARS AGO
………………………………………………………………………………………………
CAN1b3. Did you have your most recent human papilloma virus or HPV test at {REFERENCE
HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CAN1c. [IF CAN1a=1, 2 OR 3 CONTINUE, ELSE GO TO CAN1c1]
As a result of any of the Pap smear or Pap tests you had done in the past three years, were you
told that you should have follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………
CAN1c1. [IF CAN1a=4 OR 5 CONTINUE, ELSE GO TO CAN1d]
As a result of any of the Pap smear or Pap tests you had done in the past five years, were you
told that you should have follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………

56

CAN1d. [IF CAN1c=1 OR CAN1c1=1 CONTINUE, ELSE GO TO CAN3]
Were the follow-up tests or treatment done?
1=YES
2=NO
………………………………………………………………………………………………
CAN1e. [IF CAN1d=1 CONTINUE, ELSE GO TO CAN1f]
Did {REFERENCE HEALTH CENTER} arrange for the follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………
CAN1f. [IF CAN1d=2 CONTINUE, ELSE GO TO CAN2a]
Please look at this showcard. Which of these best describes the reasons you did not get the
follow-up tests or treatment? You may select one or more.
SHOWCARD CAN1
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 FROM DOCTORS OR NURSES
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
………………………………………………………………………………………………
CAN1f1_OTH. [IF CAN1f1=11 CONTINUE, ELSE GO TO CAN1f2]
Please specify the other reason you did not get follow-up tests or treatment?
________________ [ALLOW 40]
………………………………………………………………………………………………

57

CAN1f2. [IF MORE THAN ONE RESPONSE RECORDED IN CAN1f1 CONTINUE, ELSE
GO TO CAN2a]
Which of the reasons you just told me about best describes the main reason you did not get the
follow-up tests or treatment?
[LIST ONLY SELECTIONS MADE IN CAN1f1]
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 FROM DOCTORS OR NURSES
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
………………………………………………………………………………………………
CAN2a. Has anyone at {REFERENCE HEALTH CENTER} ever suggested that you have a Pap
smear or Pap test?
1=YES
2=NO
………………………………………………………………………………………………
CAN3. [IF INTAGE GE 40 AND INT3=2 OR 3 CONTINUE, ELSE GO TO CAN4]
Have you ever had a mammogram?
IF NEEDED: A mammogram is an X-ray taken only of the breast by a machine that presses
against the breast.
1=YES
2=NO
………………………………………………………………………………………………
CAN3a. [IF CAN3=1 CONTINUE, ELSE GO TO CAN3g]
When did you have your most recent mammogram?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO

58

4=3 YEARS BUT LESS THAN 5 YEARS AGO
5=5 OR MORE YEARS AGO
..………………………………………………………………………………………………
CAN3a1. Did you have your most recent mammogram at {REFERENCE HEALTH
CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CAN3b. What was the main reason you had this mammogram - was it part of a routine exam,
because of a problem, or some other reason?
1=PART OF A ROUTINE EXAM
2=BECAUSE OF A PROBLEM
3=SOME OTHER REASON
………………………………………………………………………………………………
CAN3c. [IF CAN3a=1 OR 2 CONTINUE, ELSE GO TO CAN4]
As a result of any mammograms you had done in the past 2 years, were you told that you should
have follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………
CAN3d. [IF CAN3c=1 CONTINUE, ELSE GO TO CAN4]
Were the follow-up tests or treatment done?
1=YES
2=NO
………………………………………………………………………………………………
CAN3e. [IF CAN3d=1 CONTINUE, ELSE GO TO CAN3f]
Did {REFERENCE HEALTH CENTER} arrange for the follow-up tests or treatments?
1=YES
2=NO
………………………………………………………………………………………………

59

CAN3f. [IF CAN3d=2 CONTINUE, ELSE GO TO CAN4]
Please look at this showcard. Which of these best describes the reasons you did not get the
follow-up tests or treatment? You may select one or more.
SHOWCARD CAN1
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 FROM DOCTORS OR NURSES
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
………………………………………………………………………………………………
CAN3f_OTH. [IF CAN3f=11 CONTINUE, ELSE GO TO CAN3f1]
Please specify the other reason you did not get follow-up tests or treatment?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN3f1. [IF MORE THAN ONE RESPONSE RECORDED IN CAN3f CONTINUE, ELSE GO
TO CAN3g]
Which of the reasons you just told me about best describes the main reason you did not get the
follow-up tests or treatment?
[LIST ONLY SELECTIONS MADE IN CAN3f]
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 DOCTORS OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
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

60

………………………………………………………………………………………………
CAN3g. [IF CAN3 NE DK, RE CONTINUE, ELSE GO TO CAN3H]
What is the main reason why you have {[IF CAN3=2 FILL:] never had a mammogram? [IF
CAN3a=4 OR 5 FILL:] not had a mammogram in the past two years}?
1=NO REASON/ NEVER THOUGHT ABOUT IT/ DIDN’T KNOW I SHOULD
2=NOT NEEDED/ HAVEN’T HAD ANY PROBLEMS
3=TOO UNPLEASANT OR EMBARRASSING
4=COST TOO MUCH/NO INSURANCE
5=BREASTS MISSING
6=OTHER
………………………………………………………………………………………………
CAN3g_OTH. [IF CAN3g=6 CONTINUE, ELSE GO TO CAN3h]
Please specify the main reason why you have {[IF CAN3=2 FILL:] never had a mammogram
[IF CAN3a=4 OR 5 FILL:] not had a mammogram in the past two years}?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN3h. Has anyone at {REFERENCE HEALTH CENTER} ever suggested that you have a
mammogram?
1=YES
2=NO
………………………………………………………………………………………………
CAN4. [IF INTAGE GE 50 CONTINUE, ELSE GO TO CAN5]
Colonoscopy (colon-OS-copy) and Sigmoidoscopy (sigmoid-OS-copy) are exams in which a
doctor inserts a tube into the rectum to look for polyps or cancer. For a colonoscopy, the doctor
checks the entire colon, and you are given medication through a needle in your arm to make you
sleepy, and told to have someone drive you home. For a Sigmoidoscopy, the doctor checks only
part of the colon and you are fully awake.
Have you ever had a colonoscopy?
IF NEEDED: A polyp is a small growth that develops on the inside of the colon or rectum.
Before these tests, you are asked to take a medication that causes diarrhea.
1=YES
2=NO
………………………………………………………………………………………………

61

CAN4a. [IF CAN4=1 CONTINUE, ELSE GO TO CAN4b]
When did you have your most recent colonoscopy?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO
4=3 YEARS BUT LESS THAN 5 YEARS AGO
5=5 YEARS BUT LESS THAN 10 YEARS AGO
6=10 OR MORE YEARS AGO
………………………………………………………………………………………………
CAN4a1. Did you have your most recent exam at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CAN4b. [IF CAN4=2 OR CAN4a=4, 5, OR 6 CONTINUE, ELSE GO TO CAN4c]
What is the main reason why you have {[IF CAN4=2 FILL:] never had a colonoscopy [IF
CAN4a= 4, 5 OR 6 FILL:] not had a more recent colonoscopy}?
1=NO REASON/ NEVER THOUGHT ABOUT IT
2=DIDN'T NEED/ DIDN'T KNOW I NEEDED THIS TYPE OF TEST
3=TOO EXPENSIVE/ NO INSURANCE/ COST
4=TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
5=OTHER
………………………………………………………………………………………………
CAN4b_OTH. [IF CAN4b=5 CONTINUE, ELSE TO GO CAN4i]
Please specify the main reason you have {[IF CAN4=2 FILL:] never had a colonoscopy [IF
CAN4a=4, 5 OR 6 FILL:] not had a more recent colonoscopy}?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN4i. Has anyone at {REFERENCE HEALTH CENTER} ever suggested that you should
have a colonoscopy?
1=YES
2=NO

62

………………………………………………………………………………………………
CAN4c. [IF CAN4=1 CONTINUE, ELSE TO GO CAN4g2]
What was the main reason you had this colonoscopy - was it part of a routine exam, because of a
problem, as a follow-up test of an earlier test or screening exam, or some other reason?
1=PART OF A ROUTINE EXAM
2=BECAUSE OF A PROBLEM
3=FOLLOW-UP TEST OF AN EARLIER TEST OR SCREENING EXAM
4=SOME OTHER REASON
………………………………………………………………………………………………
CAN4c_OTH. [IF CAN4c=4 CONTINUE, ELSE GO TO CAN4d]
What was the main reason you had this colonoscopy?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN4d. As a result of this exam, were you told that you should have follow-up tests or
treatment?
1=YES
2=NO
………………………………………………………………………………………………
CAN4e. [IF CAN4d=1 CONTINUE, ELSE GO TO CAN4g2]
Were the follow-up tests or treatment done?
1=YES
2=NO
………………………………………………………………………………………………
CAN4f. [IF CAN4e=1 CONTINUE, ELSE GO TO CAN4g]
Did {REFERENCE HEALTH CENTER} arrange for the follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………

63

CAN4g. Please look at this showcard. Please describe the reasons you did not get the follow-up
tests or treatment? You may select one or more.
SHOWCARD CAN1
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 FROM DOCTORS OR NURSES
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
………………………………………………………………………………………………
CAN4g_OTH. [IF CAN4g=11 CONTINUE, ELSE GO TO CAN4g1]
Please describe the other reason you did not get the follow-up tests or treatment?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN4g1. [IF MORE THAN ONE RESPONSE RECORDED IN CAN4g]
Which of the reasons you just told me about best describes the main reason you did not get the
follow-up tests or treatment?
[LIST ONLY SELECTIONS MADE IN CAN4g]
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 FROM DOCTORS OR NURSES
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
………………………………………………………………………………………………

64

CAN4g2. Recall that a sigmoidoscopy is similar to a colonoscopy but the doctor checks only
part of the colon and you are fully awake. Have you ever had a sigmoidoscopy?
1=YES
2=NO
………………………………………………………………………………………………
CAN4g3. [IF CAN4g2=1 CONTINUE, ELSE GO TO CAN4g3a]
When did you have your most recent sigmoidoscopy?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO
4=3 YEARS BUT LESS THAN 5 YEARS AGO
5=5 YEARS BUT LESS THAN 10 YEARS AGO
6=10 OR MORE YEARS AGO
………………………………………………………………………………………………
CAN4g3a. [IF CAN4g2=2 OR CAN4g3=4, 5, OR 6 CONTINUE, ELSE GO TO CAN4g4]
What is the main reason why you have {[IF CAN4g2=2 FILL:] never had a sigmoidoscopy [IF
CAN4g3=4, 5 OR 6 FILL:] not had a more recent sigmoidoscopy}?
1=NO REASON/ NEVER THOUGHT ABOUT IT
2=DIDN'T NEED/ DIDN'T KNOW I NEEDED THIS TYPE OF TEST
3=TOO EXPENSIVE/ NO INSURANCE/ COST
4=TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
5=OTHER
………………………………………………………………………………………………
CAN4g3a_OTH. [IF CAN4g3a=5 CONTINUE, ELSE GO TO CAN4g3b]
Please specify the main reason why you have {[IF CAN4g2=2 FILL:] never had a
sigmoidoscopy [IF CAN4g3= 4, 5 OR 6 FILL:] not had a more recent sigmoidoscopy}?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN4g3b. Has anyone at {REFERENCE HEALTH CENTER} ever suggested that you should
have a sigmoidoscopy?
1=YES
2=NO
………………………………………………………………………………………………

65

CAN4g4. [IF CAN4g2=1 CONTINUE, ELSE GO TO CAN5]
What was the main reason you had this sigmoidoscopy - was it part of a routine exam, because
of a problem, as a follow-up test of an earlier test or screening exam, or some other reason?
1=PART OF A ROUTINE EXAM
2=BECAUSE OF A PROBLEM
3=FOLLOW-UP TEST OF AN EARLIER TEST OR SCREENING EXAM
4=SOME OTHER REASON
………………………………………………………………………………………………
CAN4g4_OTH. [IF CAN4g4=4 CONTINUE, ELSE GO TO CAN4g5]
Please specify the main reason you had this sigmoidoscopy?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN4g5. As a result of this exam, were you told that you should have follow-up tests or
treatment?
1=YES
2=NO
………………………………………………………………………………………………
CAN4g6. [IF CAN4g5=1 CONTINUE, ELSE GO TO CAN5]
Were the follow-up tests or treatment done?
1=YES
2=NO
………………………………………………………………………………………………
CAN4g7. [IF CAN4g6=1 CONTINUE, ELSE GO TO GO TO CAN4g8]
Did {REFERENCE HEALTH CENTER} arrange for the follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………

66

CAN4g8. Please look at this showcard. Please describe the reasons you did not get the follow-up
tests or treatment? You may select one or more.
SHOWCARD CAN1
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 FROM DOCTORS OR NURSES
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
………………………………………………………………………………………………
CAN4g8_OTH. [IF CAN4g8=11 CONTINUE, ELSE GO TO CAN4g9]
Please describe the other reason you did not get the follow-up tests or treatment?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN4g9. [IF MORE THAN ONE RESPONSE RECORDED IN CAN4g8 CONTINUE, ELSE
GO TO CAN5]
Which of the reasons you just told me about best describes the main reason you did not get the
follow-up tests or treatment?
[LIST ONLY SELECTIONS MADE IN CAN4g8]
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 DOCTORS OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
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
.………………………………………………………………………………………………

67

[IF INTAGE GE 50 CONTINUE, ELSE GO TO HEA1]
CAN5. The following questions are about the blood stool or occult blood test, a test to determine
whether you have blood in your stool or bowel movement. The blood stool test can be done at
home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it
back to the doctor or lab.
Have you ever had a blood stool test, using a home test kit?
1=YES
2=NO
………………………………………………………………………………………………
CAN5a. [IF CAN5=1 CONTINUE, ELSE GO TO CAN5e2]
When did you have your most recent blood stool test using a kit at home?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO
4=3 YEARS BUT LESS THAN 5 YEARS AGO
5=5 YEARS BUT LESS THAN 10 YEARS AGO
6=10 OR MORE YEARS AGO
………………………………………………………………………………………………
CAN5a1. [IF CAN5a=1, 2, 3 OR 4 CONTINUE, ELSE GO TO CAN5f]
Did {REFERENCE HEALTH CENTER} provide the kit to you?
1=YES
2=NO
………………………………………………………………………………………………
CAN5b. As a result of this test, did you need follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………
CAN5c. [IF CAN5b=1 CONTINUE, ELSE GO TO CAN5f]
Were the follow-up tests or treatment done?
1=YES
2=NO
………………………………………………………………………………………………

68

CAN5d. [IF CAN5c=1 CONTINUE, ELSE GO TO CAN5e]
Did {REFERENCE HEALTH CENTER} arrange for the follow-up tests or treatments?
1=YES
2=NO
………………………………………………………………………………………………
CAN5e. [IF CAN5c=2 CONTINUE, ELSE GO TO CAN5e2]
Please look at this showcard. Please describe the reasons you did not get the follow-up tests or
treatment? You may select one or more.
SHOWCARD CAN1
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 FROM DOCTORS OR NURSES
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
………………………………………………………………………………………………
CAN5e_OTH. [IF CAN5e=11 CONTINUE, ELSE GO TO CAN5e1]
Please specify the other reason you did not get the follow-up tests or treatments?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN5e1. [IF MORE THAN ONE RESPONSE RECORDED IN CAN5e CONTINUE, ELSE
GO TO CAN5e2]
Which of the reasons you just told me about best describes the main reason you did not get the
follow-up tests or treatment?
[LIST ONLY SELECTIONS MADE IN CAN5e]
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE

69

3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
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
………………………………………………………………………………………………
CAN5e2. [IF CAN5=2 OR CAN5a=6 CONTINUE, ELSE GO TO CAN5f]
Please describe the main reason why you have {(IF CAN5=2 FILL: never had a blood stool test)
OR (IF CAN5a=6 FILL have not had a more recent blood stool test)}?
1=NO REASON/ NEVER THOUGHT ABOUT IT
2=DIDN'T NEED/ DIDN'T KNOW I NEEDED THIS TYPE OF TEST
3=TOO EXPENSIVE/ NO INSURANCE/ COST
4=TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
5=OTHER
………………………………………………………………………………………………
CAN5e2_OTH. [IF CAN5e2=5 CONTINUE, ELSE GO TO CAN5e3]
Please specify the other reason why you have never had a blood stool test or have not had one in
the specified time frame?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN5f. Has anyone at {REFERENCE HEALTH CENTER} ever suggested that you should
have a blood stool test?
1=YES
2=NO
………………………………………………………………………………………………

70

MODULE G: HEALTH CENTER SERVICES
HEA1. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, how many
times have you seen a doctor or other health care professional about {your own/NAME’s} health
at a doctor’s office, a clinic, or some other place? Do not include times {you were/NAME was}
hospitalized overnight, visits to hospital emergency rooms, home visits, or telephone calls.
Remember when you answer to think about any doctor’s office or clinic, not just this health
center.
NOTE: IF RESPONDENT IS UNSURE - ASK THEM TO PROVIDE AN ESTIMATE
________________ TIMES [ALLOW 00-99]
………………………………………………………………………………………………
HEA2. [IF HEA1 GE 1 CONTINUE, ELSE GO TO HEA4]
How many of those times did you come to {REFERENCE HEALTH CENTER}?
NOTE: IF RESPONDENT IS UNSURE - ASK THEM TO PROVIDE AN ESTIMATE
________________ TIMES [ALLOW 00-99]
………………………………………………………………………………………………
HEA2a. [IF HEA2 GE 1 CONTINUE, ELSE GO TO HEA4]
In the past 12 months, did a medical professional at {REFERENCE HEALTH CENTER} think
{you/NAME} should go someplace else to see a different doctor, like a specialist, for a particular
health problem?
1=YES
2=NO
………………………………………………………………………………………………
HEA2b. [IF HEA2a=1 CONTINUE, ELSE GO TO HEA4]
If you received more than one referral in the past 12 months, think of the most recent one. Did
{you/NAME} see that doctor?
1=YES
2=NO
………………………………………………………………………………………………

71

HEA2d. [IF HEA2b=2 CONTINUE, ELSE GO TO HEA4]
Please look at this showcard. Please describe the reasons why {you/NAME} didn't see that
doctor? You may select one or more.
SHOWCARD HEA1
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 FROM DOCTORS OR NURSES
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
………………………………………………………………………………………………
HEA2d_OTH. [IF HEA2d=11 CONTINUE, ELSE GO TO HEA2d1]
Please describe the other reasons why {you/NAME} didn’t see that doctor?
________________ [ALLOW 40]
………………………………………………………………………………………………
HEA2d1. [IF MORE THAN ONE RESPONSE RECORDED IN HEA2d CONTINUE, ELSE
GO TO HEA4]
Which of the reasons you just told me about best describes the main reason why {you/NAME}
didn't see that doctor?
[LIST ONLY SELECTIONS MADE IN HEA2d]
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 FROM DOCTORS OR NURSES
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

72

………………………………………………………………………………………………
HEA4. Please look at this showcard. How did you find out that {you/NAME} could come to
{REFERENCE HEALTH CENTER} for services? You may select one or more.
SHOWCARD HEA2
1=FRIEND/FAMILY MEMBER/NEIGHBOR TOLD ME
2=FAMILY TOOK YOU/HIM/HER HERE
3=ADVERTISEMENT IN COMMUNITY
4=AT A MEETING
5=CONTACTED BY SOMEONE FROM HEALTH CENTER
6=THROUGH YOUR/HIS/HER INSURANCE
7=SOCIAL SERVICES
8=A DOCTOR OR THE EMERGENCY ROOM
9=YOU FOUND OUT THAT THE HEALTH CENTER ACCEPTS UNINSURED PATIENTS
10=YOU FOUND OUT THAT THE HEALTH CENTER ACCEPTS PATIENTS WITH YOUR
INSURANCE.
11=OTHER
………………………………………………………………………………………………
HEA4_OTH. [IF HEA4=11 CONTINUE, ELSE GO TO HEA5]
Please describe how you found out that {you/NAME} could come here for services.
________________ [ALLOW 40]
………………………………………………………………………………………………
HEA5a. Please look at this showcard. What is the place or places that you usually go to when
{you are/NAME is} sick or you need advice about {your/his/her} health?
SHOWCARD HEA3
1=THIS HEALTH CENTER
2=CLINIC OR HEALTH CENTER OFFERING A DISCOUNT TO LOW INCOME OR
UNINSURED PEOPLE
3=OTHER CLINIC OR HEALTH CENTER
4=DOCTOR'S OFFICE OR HMO
5=HOSPITAL EMERGENCY ROOM
6=HOSPITAL OUTPATIENT DEPARTMENT
7=OTHER
8=THERE IS NO USUAL PLACE
………………………………………………………………………………………………

73

HEA5a_OTH. [IF HEA5a=7 CONTINUE, ELSE GO TO HEA5b]
Please specify what kind of place it is.
________________ [ALLOW 40]
………………………………………………………………………………………………
HEA5b. [IF HEA5a=8 GO TO HEA6]
[IF HEA5a=1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7]: Is this the same place you usually go when
(you need/NAME needs} routine or preventive care, such as a physical examination {[IF
INTAGE LE 12 ADD:] or well-child check-up?}
[IF HEA5a=MORE THAN ONE RESPONSE]: Are these the same places you usually go when
{you need/NAME needs} routine or preventive care, such as a physical examination {[IF
INTAGE LE 12 ADD:] or well-child check-up?}
1=YES
2=NO
………………………………………………………………………………………………
HEA5c. [IF HEA5b=2 CONTINUE, ELSE GO TO HEA6]
Please look at this showcard. What kind of {place/IF MORE THAN ONE RESPONSE TO
HEA5a places} do you go to when {you need/NAME needs} routine or preventive care, such as
a physical examination or check up? You may select one or more.
SHOWCARD HEA3
1=THIS HEALTH CENTER
2=CLINIC OR HEALTH CENTER OFFERING A DISCOUNT TO LOW INCOME OR
UNINSURED PEOPLE
3=OTHER CLINIC OR HEALTH CENTER
4=DOCTOR'S OFFICE OR HMO
5=HOSPITAL EMERGENCY ROOM
6=HOSPITAL OUTPATIENT DEPARTMENT
7=OTHER
8=THERE IS NO USUAL PLACE
………………………………………………………………………………………………
HEA5c_OTH. [IF HEA5c=7 CONTINUE, ELSE GO TO HEA6]
Please specify the other kind of {place/IF MORE THAN ONE RESPONSE TO HEA5a USE
places} you go to when {you need/NAME needs} routine or preventive care, such as a physical
examination or check-up.
________________ [ALLOW 40]

74

.………………………………………………………………………………………………
HEA6. [IF INT4=1 CONTINUE, ELSE GO TO HEA7a]
When {you go/NAME goes} to {REFERENCE HEALTH CENTER}, in what language {does
your/does NAME’s} doctor or other health care professional speak to you?
1=ENGLISH
2=SPANISH
3=CANTONESE
4=VIETNAMESE
5=MANDARIN
6=KOREAN
7=ASIAN INDIAN LANGUAGES
8=RUSSIAN
9=TAGALOG
10=OTHER
………………………………………………………………………………………………
HEA6_OTH. [IF HEA6=10 CONTINUE, ELSE GO TO HEA6a]
In what language {does your/ does NAME’s} doctor or other health care professional speak to
you?
________________ [ALLOW 40]
………………………………………………………………………………………………
HEA6a. During your last visit to {REFERENCE HEALTH CENTER}, did you need someone to
help you understand the doctor?
1=YES
2=NO
………………………………………………………………………………………………
HEA6b. [IF HEA6a=1 CONTINUE, ELSE GO TO HEA7a]
Who was this person who helped you understand the doctor?
IF R RESPONDS “MY CHILD,” PROBE TO SEE IF CHILD IS UNDER AGE 18. IF AGE 18
OR MORE, CODE AS “ADULT FAMILY MEMBER."
1=MINOR CHILD (UNDER AGE 18)
2=AN ADULT FAMILY MEMBER OR FRIEND OF MINE
3=NON-MEDICAL OFFICE STAFF
4=MEDICAL STAFF INCLUDING NURSES/DOCTORS
5=PROFESSIONAL INTERPRETER (BOTH IN PERSON AND ON THE TELEPHONE)

75

6=OTHER (PATIENTS, SOMEONE ELSE)
7= DID NOT HAVE SOMEONE TO HELP
………………………………………………………………………………………………
HEA6c. [IF HEA6b=5 CONTINUE, ELSE GO TO HEA7a]
Did this person help you in-person or over the telephone?
1=IN PERSON
2=OVER THE TELEPHONE
………………………………………………………………………………………………
HEA6d. How difficult was it for you to find someone to help you understand the doctor?
1=Very difficult
2=Somewhat difficult
3=Not very difficult
4=Not difficult at all
………………………………………………………………………………………………
HEA7a. Has anyone at {REFERENCE HEALTH CENTER} ever helped you...
Arrange for medical appointments or other medical services at a place other than {REFERENCE
HEALTH CENTER}?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
………………………………………………………………………………………………
HEA7b. [IF INTAGE 0-12 OR 18-110 CONTINUE, ELSE GO TO HEA7e_a]
(Has anyone at {REFERENCE HEALTH CENTER} ever helped you...)
Apply for any government benefits {you/NAME} needed such as Medicaid, Food Stamps,
Social Security, obtaining welfare, public benefits, or TANF?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
………………………………………………………………………………………………

76

HEA7c. (Has anyone at {the REFERENCE HEALTH CENTER} ever helped you...)
Get transportation to medical appointments or provided you with tokens or vouchers to help you
pay for transportation to {your/NAME’s} medical appointments?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
………………………………………………………………………………………………
HEA7d. (Has anyone at {REFERENCE HEALTH CENTER} ever helped you...)
With basic needs such as:
[IF INTAGE GE 18:] a. finding a place to live
[IF INTAGE GE 18:] b. finding a job or job counseling
[IF INTAGE GE 18:] c. finding childcare
[IF INTAGE GE 18:] d. helping you obtain food
e. helping {you/NAME} obtain clothing or shoes
f. helping {you/NAME} obtain free medication
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THIS SERVICE
………………………………………………………………………………………………
HEA7e_a. [IF INTAGE GE 18 CONTINUE, ELSE GO TO HEA7e_b]
(Has anyone at {REFERENCE HEALTH CENTER} ever provided you…)
Health education, either in individual or group visits, to talk about things like quitting smoking,
changing your diet, or parenting?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THIS SERVICE
………………………………………………………………………………………………

77

HEA7e_b. [IF INTAGE GE 13 CONTINUE, ELSE GO TO HEA7e_c]
Has anyone at {REFERENCE HEALTH CENTER} ever provided you any supportive
counseling, such as family counseling, domestic violence counseling, or substance abuse
counseling?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THIS SERVICE
………………………………………………………………………………………………
HEA7e_c. [IF INT4b=2, 3, 4, DK OR RE CONTINUE, ELSE GO TO HEA7e_d}
Has anyone at {REFERENCE HEALTH CENTER} ever provided you with a translator or
interpreter to help you communicate with {your/NAME’s} doctor or other health care
professional? This person could be at the clinic or on the phone.
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THIS SERVICE
………………………………………………………………………………………………
HEA7e_d. Has anyone at {REFERENCE HEALTH CENTER} ever visited {you/NAME} at
home to talk about {your/his/her} health care needs or other needs?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THIS SERVICE
………………………………………………………………………………………………
HEA7e_e. Has anyone at {REFERENCE HEALTH CENTER} ever offered {you/NAME} free
services outside of the health center, like at a health fair? This could be free flu shots or blood
pressure screenings or other services.
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THIS SERVICE
………………………………………………………………………………………………
HEA7f. Has anyone at {REFERENCE HEALTH CENTER} ever helped {you/NAME} with
other kinds of problems?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
………………………………………………………………………………………………

78

HEA8. [IF HEA7f=1 CONTINUE, ELSE GO TO HEA9]
Please specify what kind of help {you/ NAME} received to address these other kinds of
problems?
________________ [ALLOW 80]
………………………………………………………………………………………………
HEA9.
IF INTAGE GE 13: How do you usually get to the health center?
ELSE IF INTAGE LE 12: How do you usually get {NAME} to the health center?
1=WALKING
2=DRIVING
3=BEING DRIVEN BY SOMEONE ELSE
4=BUS, SUBWAY OR OTHER PUBLIC TRANSPORTATION
5=TAXI
6=HEALTH CENTER (OR OTHER AGENCY-PROVIDED) VAN SERVICE
7=OTHER
………………………………………………………………………………………………
HEA9a. [IF INTAGE GE 13 CONTINUE, ELSE GO TO HEA20]
How many miles do you live from {REFERENCE HEALTH CENTER}?
____________ MILES [ALLOW 3 DIGITS]
………………………………………………………………………………………………
HEA10. About how long does it usually take you to get there?
_____ MINUTES [ALLOW 00-59]
_____ HOURS [ALLOW 0-9]
.………………………………………………………………………………………………
HEA12. How long have you been going to this health center?
1=LESS THAN 6 MONTHS
2=AT LEAST 6 MONTHS BUT LESS THAN 1 YEAR
3=AT LEAST 1 YEAR BUT LESS THAN 3 YEARS
4=AT LEAST 3 YEARS BUT LESS THAN 5 YEARS
5=5 YEARS OR MORE
………………………………………………………………………………………………

79

HEA13. For the next series of questions, please do not include dental care visits or care you
received when you stayed overnight in a hospital.
In the last 12 months, that is since {12 MONTH REFERENCE DATE}, how many times did
you go to this health center to get care for yourself?
0=NONE
1=1 TIME
2=2
3=3
4=4
5=5 TO 9
6=10 OR MORE TIMES
………………………………………………………………………………………………
HEA14. In the last 12 months, did you phone this health center to get an appointment for an
illness, injury or condition that needed care right away?
1=YES
2=NO
………………………………………………………………………………………………
HEA15. [IF HEA14=1 CONTINUE, ELSE GO TO HEA17]
In the last 12 months, when you phoned this health center to get an appointment for care you
needed right away, how often did you get an appointment as soon as you needed? Would you
say never, sometimes, usually or always?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA17. In the last 12 months, did you make any appointments for a check-up or routine care
with this health center?
1=YES
2=NO
………………………………………………………………………………………………

80

HEA18. [IF HEA17=1 CONTINUE, ELSE GO TO HEA22]
In the last 12 months, when you made an appointment for a check-up or routine care with this
health center, how often did you get an appointment as soon as you needed?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA22. In the last 12 months, did you phone this health center with a medical question during
regular office hours?
1=YES
2=NO
………………………………………………………………………………………………
HEA23. [IF HEA22=1 CONTINUE, ELSE GO TO HEA24]
In the last 12 months, when you phoned this health center during regular office hours, how often
did you get an answer to your medical question that same day?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA24. In the last 12 months, did you phone this health center with a medical question after
regular office hours?
1=YES
2=NO
………………………………………………………………………………………………
HEA25. [IF HEA24=1 CONTINUE, ELSE GO TO HEA26]
In the last 12 months, when you phoned this health center after regular office hours, how often
did you get an answer to your medical question as soon as you needed?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………

81

HEA26. Some offices remind patients between visits about tests, treatment or appointments. In
the last 12 months, did you get any reminders from this health center between visits?
1=YES
2=NO
………………………………………………………………………………………………
HEA27. In the last 12 months, how often did you see a doctor or other health professional at this
health center within 15 minutes of your appointment time?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA29. In the last 12 months, how often did this doctor or other health professional listen
carefully to you?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA30. In the last 12 months, did you talk with this doctor or other health professional about
any health questions or concerns?
1=YES
2=NO
………………………………………………………………………………………………
HEA31. [IF HEA30=1 CONTINUE, ELSE GO TO HEA32]
In the last 12 months, how often did this doctor or other health professional give you easy to
understand information about these health questions or concerns?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………

82

HEA32. In the last 12 months, how often did this doctor or other health professional seem to
know the important information about your medical history?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA33. In the last 12 months, how often did this doctor or other health professional show
respect for what you had to say?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA34. In the last 12 months, how often did this doctor or other health professional spend
enough time with you?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA35. In the last 12 months, did this doctor or other health professional order a blood test, xray, or other test for you?
1=YES
2=NO
………………………………………………………………………………………………
HEA36. [IF HEA35=1 CONTINUE, ELSE GO TO HEA41]
In the last 12 months, when this doctor or other health professional ordered a blood test, x-ray,
or other test for you, how often did someone from this health center follow up to give you those
results?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………

83

HEA41. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the
best provider possible, what number would you use to rate this doctor or other health
professional?
0=WORST PROVIDER POSSIBLE
1
2
3
4
5
6
7
8
9
10= BEST PROVIDER POSSIBLE
………………………………………………………………………………………………
HEA41a. Would you recommend {REFERENCE HEALTH CENTER} to your family and
friends? Would you say yes definitely, yes somewhat or no?
1=YES - DEFINITELY
2=YES - SOMEWHAT
3=NO
………………………………………………………………………………………………
HEA51. In the last 12 months, how often were clerks and receptionists at this health center as
helpful as you thought they should be?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA52. In the last 12 months, how often did clerks and receptionists at this health center treat
you with courtesy and respect?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………

84

HEA20. What are all the reasons {you go/NAME goes} to {REFERENCE HEALTH CENTER}
for {your/his/her} health care instead of someplace else? You may select one or more.
SHOWCARD HEA4
1=CONVENIENT LOCATION
2=CONVENIENT HOURS
3=YOU CAN AFFORD IT
4= YOU CAN BE SEEN WITHOUT AN APPOINTMENT OR GET AN
APPOINTMENT RIGHT AWAY
5=AFTER YOU GET THERE, YOU DON'T HAVE TO WAIT LONG TO BE SEEN
6=THEY PROVIDE CHILD CARE
7=THEY PROVIDE TRANSPORTATION OR TRANSPORTATION VOUCHERS
8=THEY HAVE SOMEONE WHO SPEAKS YOUR LANGUAGE
9=QUALITY OF CARE
10=IT'S THE ONLY MEDICAL CARE IN THE AREA
11= THE HEALTH CENTER ACCEPTS UNINSURED PATIENTS
12= THE HEALTH CENTER ACCEPTS PATIENTS WITH MY INSURANCE
13=OTHER
………………………………………………………………………………………………
HEA20_OTH. Please specify the other reasons {you go/NAME goes} to {REFERENCE
HEALTH CENTER} for {your/NAME’s} health instead of someplace else.
________________ [ALLOW 80]
………………………………………………………………………………………………
HEA56. [IF MORE THAN ONE RESPONSE RECORDED IN HEA20 CONTINUE, ELSE GO
TO INS2]
Which of the reasons you just told me about best describes the main reason {you go/NAME
goes} to {REFERENCE HEALTH CENTER} for {your/his/her} health care instead of
someplace else?
[LIST ONLY SELECTIONS MADE IN HEA20]
1= CONVENIENT LOCATION
2= CONVENIENT HOURS
3= YOU CAN AFFORD IT
4= YOU CAN BE SEEN WITHOUT AN APPOINTMENT OR GET AN
APPOINTMENT RIGHT AWAY
5=AFTER YOU GET THERE, YOU DON'T HAVE TO WAIT LONG TO BE SEEN
6=THEY PROVIDE CHILD CARE
7=THEY PROVIDE TRANSPORTATION OR TRANSPORTATION VOUCHERS
8=THEY HAVE SOMEONE WHO SPEAKS YOUR LANGUAGE
9=QUALITY OF CARE

85

10=IT'S THE ONLY MEDICAL CARE IN THE AREA
11= THE HEALTH CENTER ACCEPTS UNINSURED PATIENTS
12= THE HEALTH CENTER ACCEPTS PATIENTS WITH MY INSURANCE
13=OTHER
……………………………………………………………………………………………

86

MODULE H: HEALTH INSURANCE
INS2. [IF INTAGE=13-17 GO TO PRS1, ELSE CONTINUE]
The next questions are about {your/NAME’s} current health insurance coverage. In answering
these questions, I’d like you to exclude plans that only cover one type of service, like dental care
plans or plans that pay for prescription drugs.
INS2. {Are you/Is NAME} covered by health
insurance provided through an employer or
union? This could be insurance through a
current job, a former job, or someone else’s job.
1=YES
2=NO

INS2a. [IF INS2=1 CONTINUE, ELSE GO
TO INS4]
How long {have you/has NAME} been
covered by health insurance provided
through an employer or union?
1=Less than 3 months
2=3 months but less than 6 months
3=6 months but less than 12 months
4=12 or more months

INS4. Medicare is a health insurance program
for people 65 years and older and for people
with certain disabilities. {Are you/Is NAME}
covered by Medicare?

INS4a. [IF INS4=1 CONTINUE, ELSE GO
TO INS5]
How long {have you/has NAME} had
Medicare coverage?

1=YES
2=NO

1=Less than 3 months
2=3 months but less than 6 months
3=6 months but less than 12 months
4=12 or more months

INS5. {FILL STATE} has a number of
programs that help low and moderate income
people get health insurance coverage. This
would include {MEDICAID PROGRAM
NAME} and {SCHIP PROGRAM NAME}.
You may know {MEDICAID PROGRAM
NAME} under other names, such as Medicaid
or other names. You may know {SCHIP
PROGRAM NAME} as CHIP.
{Are you/Is NAME} covered by {MEDICAID
PROGRAM NAME} or {SCHIP PROGRAM
NAME}?
1=YES
2=NO

87

INS5a. [IF INS5=1 CONTINUE, ELSE GO
TO INS6]
How long {have you/has NAME} had
{MEDICAID PROGRAM NAME} or
{SCHIP PROGRAM NAME}coverage?
1=Less than 3 months
2=3 months but less than 6 months
3=6 months but less than 12 months
4=12 or more months

INS6. {Are you/Is NAME} covered by a health
insurance plan through the {STATE HIE PLAN
NAME} that was purchased through
{STATE/FEDERAL AGENCY}?
IF NEEDED: The {STATE/FEDERAL
AGENCY} is a government agency that helps
individuals purchase health insurance coverage
if they do not have access to health insurance
through a job.
1=YES
2=NO
INS7. {Are you/Is NAME} covered by a health
insurance plan that was purchased directly from
an insurance company or an insurance agent,
that is, a plan not offered through a current or
past employer or union?
1=YES
2=NO

INS6a. [IF INS6=1 CONTINUE, ELSE GO
TO INS7]
How long {have you/has NAME} had
insurance through the {STATE HIE PLAN
NAME}?
1=Less than 3 months
2=3 months but less than 6 months
3=6 months but less than 12 months
4=12 or more months

INS7a. [IF INS7=1 CONTINUE, ELSE GO
TO INS8]
How long {have you/has NAME} had
insurance purchased directly from an
insurance company or an insurance agent?
1=Less than 3 months
2=3 months but less than 6 months
3=6 months but less than 12 months
4=12 or more months

INS8. {Are you/Is NAME} covered by some
other type of health insurance? For example,
coverage for military personnel and their
families, such as CHAMPUS, TRICARE,
CHAMP-VA and VA?

INS8a. [IF INS8=1 CONTINUE, ELSE GO
TO INS9]
How long {have you/has NAME} been
covered by this other type of health
insurance?

1=YES
2=NO

1=Less than 3 months
2=3 months but less than 6 months
3=6 months but less than 12 months
4=12 or more months

INS9. [IF INS2, INS4, INS5, INS6, INS7 AND
INS8 = 2 CONTINUE, ELSE GO TO INS11]
According to the information you have
provided, {you do/NAME does} not have any
health insurance now. Is that correct?
1=YES
2=NO

88

INS10. [IF INS9 = 2 CONTINUE, ELSE GO
TO INS11]

INS10_OTH. [IF INS10=7 CONTINUE,
ELSE GO TO INS11]

What kind of insurance coverage {do you/does
NAME} have? CODE ONE OR MORE

Please specify the other type of coverage
{you have/NAME has}?

1=Insurance from employer or union
________________ [ALLOW 40]
2=Insurance through {STATE HIE PLAN
NAME} from {STATE/FEDERAL AGENCY} INS10a. How long {have you/has NAME}
3=Insurance purchased directly from an
had that insurance coverage?
insurance company or agent
4=Medicare
1=Less than 3 months
5={MEDICAID PROGRAM NAME},
2=3 months but less than 6 months
Medicaid, {SCHIP PROGRAM NAME},
3=6 months but less than 12 months
CHIP, or some other public coverage
4=12 or more months
6=Champus, Tricare, Champ-VA, VA or some
other military health care
7=SOME OTHER COVERAGE
………………………………………………………………………………………………
INS11. [IF INS2, INS4, INS5, INS6, INS7 OR INS8=1 OR INS9=2 CONTINUE, ELSE GO
TO INS14]
During the past 12 months, that is since {12 MONTH REFERENCE DATE}, did {you/
NAME} have health insurance all the time, or was there a time during the year that (you/
NAME} did not have any health coverage?
1=INSURED ALL THE TIME
2=HAD A TIME WITHOUT INSURANCE
………………………………………………………………………………………………
INS12. [IF INS11=2 CONTINUE, ELSE GO TO INS3a]
How many months has it been since (you/NAME) had a period where {you were/ he was/she
was} without insurance coverage?
________________MONTHS [ALLOW 01 – 12]
………………………………………………………………………………………………

89

INS13. Please look at this showcard. What was the main reason that {you /NAME} did not
have health insurance coverage at that time?
[ALLOW ONLY ONE RESPONSE]
SHOWCARD INS1
1=LOST JOB OR WORKING LESS HOURS
2=GOT A JOB OR WORKING MORE HOURS
3=CHANGED JOBS
4=GOT MARRIED
5=GOT DIVORCED
6=HAD A CHILD
7=GOT SICK OR INJURED
8=COSTS TOO MUCH
9=BECAME ELIGIBLE FOR OTHER COVERAGE
10=BECAME INELIGIBLE FOR COVERAGE
11=OTHER
………………………………………………………………………………………………
INS13_OTH. [IF INS13=10 CONTINUE, ELSE GO TO INS14]
Please specify the other reason that {you /NAME} did not have health insurance coverage?
________________ [ALLOW 40]
………………………………………………………………………………………………

INS14. [IF INS2, INS4, INS5, INS6, INS7 AND INS8 = 2 AND INS9 = 1 CONTINUE, ELSE
GO TO INS15]
Please look at this showcard. When {you/ NAME} last had health insurance coverage, what kind
of insurance coverage did {you/ NAME} have?
SHOWCARD INS2
1=INSURANCE FROM EMPLOYER OR UNION
2=INSURANCE THROUGH A STATE HIE PLAN FROM A STATE/FEDERAL AGENCY
3=INSURANCE PURCHASED DIRECTLY FROM AN INSURANCE COMPANY OR
AGENT
4=MEDICARE
5=MEDICAID, SCHIP, CHIP, OR SOME OTHER PUBLIC COVERAGE
6=CHAMPUS, TRICARE, CHAMP-VA, VA OR SOME OTHER MILITARY HEALTH
CARE
7=SOME OTHER COVERAGE
8=HAVE NEVER HAD INSURANCE

90

………………………………………………………………………………………………
INS14_OTH. [IF INS14=7 CONTINUE, ELSE GO TO INS15]
Please specify the other type of coverage {you/NAME} last had?
________________ [ALLOW 40]
………………………………………………………………………………………………
INS15. [IF INS14=1, 2, 3, 4, 5, 6, OR 7 CONTINUE, ELSE GO TO INS3a]
Please look at this showcard. What is the main reason that {you are/NAME is} no longer
covered by that insurance?
[ALLOW ONLY ONE RESPONSE]
SHOWCARD INS1
1=LOST JOB OR WORKING LESS HOURS
2=GOT A JOB OR WORKING MORE HOURS
3=CHANGED JOBS
4=GOT MARRIED
5=GOT DIVORCED
6=HAD A CHILD
7=GOT SICK OR INJURED
8=COSTS TOO MUCH
9=BECAME ELIGIBLE FOR OTHER COVERAGE
10=BECAME INELIGIBLE FOR COVERAGE
11=OTHER
………………………………………………………………………………………………
INS15_OTH. [IF INS15=11 CONTINUE, ELSE GO TO INS3a]
Please specify the other reason {you are /NAME is} no longer covered by that insurance?
________________ [ALLOW 40]
………………………………………………………………………………………………
INS3a. {IF ONLY ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1
OR INS9 = 2 Does this plan OR ONLY ONE RESPONSE (1-7) IN INS14: Did this plan/ IF
MORE THAN ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1 OR
INS9 = 2 Do any of these plans OR MORE THAN ONE RESPONSE (1-7) IN INS14: Did any
of these plans} pay for any of the costs for medicines prescribed by a doctor?
1=YES
2=NO

91

………………………………………………………………………………………………
INS3b. {IF ONLY ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1
OR INS9 = 2 Does this plan OR ONLY ONE RESPONSE (1-7) IN INS14: Did this plan/ IF
MORE THAN ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1 OR
INS9 = 2 Do any of these plans OR MORE THAN ONE RESPONSE (1-7) IN INS14: Did any
of these plans} pay for any of the costs for dental care?
1=YES
2=NO
………………………………………………………………………………………………
INS3c. {IF ONLY ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1
OR INS9 = 2 Does this plan OR ONLY ONE RESPONSE (1-7) IN INS14: Did this plan/ IF
MORE THAN ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1 OR
INS9 = 2 Do any of these plans OR MORE THAN ONE RESPONSE (1-7) IN INS14: Did any
of these plans} pay for any of the costs for vision care?
1=YES
2=NO
………………………………………………………………………………………………
INS3d. {IF ONLY ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1
OR INS9 = 2 Does this plan OR ONLY ONE RESPONSE(1-7) IN INS14: Did this plan/ IF
MORE THAN ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1 OR
INS9 = 2 Do any of these plans OR MORE THAN ONE RESPONSE (1-7) IN INS14: Did any
of these plans} pay for any of the costs for mental health care?
1=YES
2=NO
………………………………………………………………………………………………
INS16. [(IF INS2a, INS4a, INS5a, INS6a, INS7a OR INS8a = 4 OR INS10a = 4) OR (IF INS2,
INS4, INS5, INS6, INS7 AND INS8 = 2 AND INS9 = 1 CONTINUE) GO TO INS19, ELSE
CONTINUE]
Earlier you told me that {you have/NAME has) had {your/his/her} current insurance coverage
for less than a year. Did {you/he/she} have any insurance coverage just before that or {were you/
was he/she} uninsured before {you/he/she} obtained {your/his/her} current insurance coverage?
IF NEEDED: By “just before” I mean in the month before you started your current health
insurance coverage.
1=HAD COVERAGE JUST BEFORE
2=UNINSURED JUST BEFORE
………………………………………………………………………………………………

92

INS17. [IF INS16=1 CONTINUE, ELSE GO TO INS19]
What kind of insurance coverage did (you/NAME} have just before {your/his/her} current
coverage? CODE ONE OR MORE
1=Insurance from employer or union
2=Insurance through {STATE HIE PLAN NAME} from {STATE/FEDERAL AGENCY}
3=Insurance purchased directly from an insurance company or agent
4=Medicare
5= {MEDICAID PROGRAM NAME}, Medicaid, {SCHIP PROGRAM NAME} CHIP, or some
other public coverage
6=Champus, Tricare, Champ-VA, VA or some other military health care
7=SOME OTHER COVERAGE
8=HAVE NEVER HAD INSURANCE
………………………………………………………………………………………………
INS17_OTH. [IF INS17=7 CONTINUE, ELSE GO TO INS18]
Please specify the other insurance coverage (you/NAME} had just before {your/his/her} current
coverage.
________________ [ALLOW 40]
………………………………………………………………………………………………
INS18. What was the main reason {you/NAME} changed insurance plans at that time?
[ALLOW ONLY ONE RESPONSE]
1=LOST JOB OR WORKING LESS HOURS
2=GOT A JOB OR WORKING MORE HOURS
3=CHANGED JOBS
4=GOT MARRIED
5=GOT DIVORCED
6=HAD A CHILD
7=GOT SICK OR INJURED
8=COSTS TOO MUCH
9=BECAME ELIGIBLE FOR OTHER COVERAGE
10=BECAME INELIGIBLE FOR COVERAGE
11=OTHER
.………………………………………………………………………………………………
INS18_OTH. [IF INS18=11 CONTINUE, ELSE GO TO INS19]
Please specify the other reason {you /NAME} changed insurance plans?
________________ [ALLOW 40]

93

………………………………………………………………………………………………
INS19. [IF INS2, INS4, INS5, INS6, INS7 OR INS8=1 OR INS9=2 CONTINUE, ELSE GO TO
INS25a]
For my next question, I’d like you to focus on the annual deductible that applies to physician and
hospital care within your plan’s network. Does {your/ NAME’s} current health coverage have an
annual deductible for medical care? A deductible is the amount you have to pay before the
insurance plan will start paying {your/ NAME’s} medical bills.
IF NEEDED: The deductible is different from a co-pay. A co-pay is the payment for a doctor
visit or other medical service and a deductible is the amount you pay before your insurance plan
will start paying {your/ NAME’s} medical bills.
1=YES
2=NO
………………………………………………………………………………………………
INS20. [IF INS19=1 CONTINUE, ELSE GO TO INS22]
How much is the annual deductible per person under {your/ NAME’s} current health coverage?
Would you say it is…?
1=Less than $100
2=Between $100 and $499
3=Between $500 to $999
4=Between $1,000 to $1,999
5=Between $2,000 to $2,999
6=Between $3,000 to $4,999
7=Between $5000 to $9,999
8=$10,000 or more
………………………………………………………………………………………………
INS22. Do you pay any monthly premiums for {your/NAME’s} health insurance? This includes
money deducted from a paycheck as well as money you pay directly to an insurance company.
1=YES
2=NO
………………………………………………………………………………………………

94

INS23. [IF INS22 = 1 CONTINUE, ELSE GO TO INS25]
About how much do you pay in monthly premiums, including any amount deducted from a
paycheck?
IF NEEDED: This is the premium you pay for the whole plan, even if it covers other family
members.
IF NEEDED: Your best estimate is fine.
_____________MONTHLY [ALLOW $1 to $20,000]
………………………………………………………………………………………………
INS24. [IF INS23 = DK OR RE CONTINUE, ELSE GO TO INS25]
Would you say it is…?
1=Less than $100 a month
2=Between $100 and $249 a month
3=Between $250 to $499 a month
4=Between $500 to $749 a month
5=Between $750 to $999 a month
6=Between $1,000 to $1,499 a month
7=$1,500 or more a month
………………………………………………………………………………………………
INS25a. Now I’d like to ask about how much you and your family spent “out of pocket” for
health care in the past 12 months, that is since {12 MONTH REFERENCE DATE}. “Out of
pocket” is the amount of money you pay that is not covered by any insurance or special
assistance that you might have. It does not include any monthly premiums you pay for your
health insurance or any health care costs that you will be reimbursed for.
How much did you and your family spend “out of pocket” in the past 12 months for…
Prescription medicine?
IF NEEDED: The premium is the price you pay for the insurance policy
IF NEEDED: Your best estimate is fine
$____________ [ALLOW $0-$9,999]
………………………………………………………………………………………………

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INS25b. (How much did you and your family spend “out of pocket” in the past 12 months
for…)
Dental and vision care?
$____________ [ALLOW $0-$9,999]
………………………………………………………………………………………………
INS25c. (How much did you and your family spend “out of pocket” in the past 12 months for…)
All other medical expenses, including doctors, hospitals, tests and equipment?
$___________ [ALLOW $0-$9,999]MODULE I: PRESCRIPTION MEDICATION
………………………………………………………………………………………………
PRS1. The next questions are about prescription medication.
In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a doctor
believe {you/NAME} needed prescription medicines?
1=YES
2=NO
………………………………………………………………………………………………
PRS2. [IF PRS1=1 CONTINUE, ELSE GO TO PRS5]
In the last 12 months, {were you/was NAME} unable to get prescription medicines
{you/he/she} or a doctor believed necessary?
1=YES
2=NO
………………………………………………………………………………………………
PRS2a [IF PRS2=1 CONTINUE, ELSE GO TO PRS3]
Please look at this showcard. Which of these best describes the reasons {you were/NAME was}
unable to get prescription medicines you or a doctor believed necessary. You may select one or
more.
SHOWCARD PRS1
1=COULD NOT AFFORD PRESCRIPTION MEDICINES
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR
PRESCRIPTION MEDICINES
3=PHARMACY REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO PHARMACY / TRANSPORTATION

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5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=DIFFERENT LANGUAGE FROM PHARMACY STAFF
7=COULDN’T GET TIME OFF WORK
8=DIDN’T KNOW WHERE TO GO TO GET PRESCRIPTION MEDICINES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=PHARMACY DID NOT HAVE IN STOCK
12=OTHER
………………………………………………………………………………………………
PRS2a_OTH. [IF PRS2a=12 CONTINUE, ELSE GO TO PRS2a1]
What was the other reason {you were/NAME was} unable to get prescription medicines you or
a doctor believed necessary?
________________ [ALLOW 40]
………………………………………………………………………………………………
PRS2a1. [IF MORE THAN ONE RESPONSE RECORDED IN PRS2a CONTINUE, ELSE GO
TO PRS3]
Which of the reasons you just told me about best describes the main reason {you were/NAME
was} unable to get prescription medicines you or a doctor believed necessary.
[LIST ONLY ITEMS SELECTED FROM PRS2a]
1=COULD NOT AFFORD PRESCRIPTION MEDICINES
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR
PRESCRIPTION MEDICINES
3=PHARMACY REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO PHARMACY / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=DIFFERENT LANGUAGE FROM PHARMACY STAFF
7=COULDN’T GET TIME OFF WORK
8=DIDN’T KNOW WHERE TO GO TO GET PRESCRIPTION MEDICINES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=PHARMACY DID NOT HAVE IN STOCK
12= OTHER
……………………………………………………………………………………………
PRS3. In the last 12 months, {were you/was NAME} delayed in getting prescription medicines
you or a doctor believed necessary?
1=YES
2=NO

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………………………………………………………………………………………………
PRS3a. [IF PRS3= 1 CONTINUE, ELSE GO TO PRS5]
Please look at this showcard. What are the reasons {you were/NAME was} delayed in getting
prescription medicines you or a doctor believed necessary? You may select one or more.
SHOWCARD PRS1
1=COULD NOT AFFORD PRESCRIPTION MEDICINES
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR
PRESCRIPTION MEDICINES
3=PHARMACY REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO PHARMACY / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=DIFFERENT LANGUAGE FROM PHARMACY STAFF
7=COULDN’T GET TIME OFF WORK
8=DIDN’T KNOW WHERE TO GO TO GET PRESCRIPTION MEDICINES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=PHARMACY DID NOT HAVE IN STOCK
12=OTHER
………………………………………………………………………………………………
PRS3a_OTH. [IF PRS3a=12 CONTINUE, ELSE GO TO PRS3a1]
What was the other reason {you were/NAME was} delayed in getting prescription medicines
you or a doctor believed necessary?
________________ [ALLOW 40]
………………………………………………………………………………………………
PRS3a1. [IF MORE THAN ONE RESPONSE RECORDED IN PRS3a CONTINUE, ELSE GO
TO PRS5]
Which of the reasons you just told me about best describes the main reason {you were/NAME
was} delayed in getting prescription medicines you or a doctor believed necessary?
[LIST ONLY ITEMS SELECTED FROM PRS3a]
1=COULD NOT AFFORD PRESCRIPTION MEDICINES
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR
PRESCRIPTION MEDICINES
3=PHARMACY REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO PHARMACY / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES

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6=DIFFERENT LANGUAGE FROM PHARMACY STAFF
7=COULDN’T GET TIME OFF WORK
8=DIDN’T KNOW WHERE TO GO TO GET PRESCRIPTION MEDICINES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=PHARMACY DID NOT HAVE IN STOCK
12=OTHER
………………………………………………………………………………………………
PRS5. {Do you/Does NAME} take any prescription medication on a regular or on-going basis?
1=YES
2=NO
………………………………………………………………………………………………
PRS6. [IF PRS5=1 CONTINUE, ELSE GO TO DENPRE]
Where do you normally get {your/NAME’s} prescriptions filled? Do you get…?
1=them filled at {REFERENCE HEALTH CENTER}
2=some of them filled at {REFERENCE HEALTH CENTER} and some of them filled elsewhere
3=them filled somewhere other than {REFERENCE HEALTH CENTER}
………………………………………………………………………………………………
PRS6a. [IF PRS6=2 OR 3 CONTINUE, ELSE GO TO PRS7]
Can you tell me where you normally get {your/NAME’s} prescriptions filled outside of
{REFERENCE HEALTH CENTER}?
________________ [ALLOW 60]
………………………………………………………………………………………………
PRS7. About how many different prescription medicines {do you/does NAME} usually take in a
month?
________________ NUMBER MEDICINES [ALLOW 00-25]
………………………………………………………………………………………………
PRS8. [IF PRS6=1 OR 2 CONTINUE, ELSE GO TO DEN1]
Think about the last time someone at {REFERENCE HEALTH CENTER} prescribed
medication for {you/NAME}. Were you satisfied with the way the medication was explained to
you, such as instructions on how to take it and possible side-effects?
1=YES
2=NO

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………………………………………………………………………………………………
PRS9. Were you satisfied with the way your questions about the medication were answered?
1=YES
2=NO
3=DIDN’T HAVE ANY QUESTIONS
………………………………………………………………………………………………

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MODULE J: DENTAL
DENPRE. [IF INTAGE GE 1 CONTINUE, ELSE GO TO MEN1]
[IF INTAGE=LE2 CONTINUE, ELSE GO TO DEN1]
Does your child have any baby teeth?
1=YES
2=NO
………………………………………………………………………………………………
DEN1. [IF DENPRE=1 OR INTAGE GE 2 CONTINUE, ELSE GO TO MEN1]
The next questions are about dental care.
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?
NOTE: CODE YES IF A DOCTOR BELIEVED DENTAL CARE WAS NECESSARY
1=YES
2=NO
………………………………………………………………………………………………
DEN2. [IF DEN1=1 CONTINUE, ELSE GO TO DEN10]
In the last 12 months, {were you/was NAME} unable to get dental care, tests, or treatments you
or a dentist believed necessary?
1=YES
2=NO
………………………………………………………………………………………………
DEN3. [IF DEN2=1 CONTINUE, ELSE GO TO DEN6]
What kind of dental care, test, or treatment was it that {you/NAME} needed but did not get?
________________ [ALLOW 40]
………………………………………………………………………………………………

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DEN4. Please look at this showcard. Please describe the reasons {you were/NAME was} unable
to get dental care, tests, or treatments you or a dentist believed necessary? You may select one or
more.
SHOWCARD DEN1
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 FROM DENTIST
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
………………………………………………………………………………………………
DEN4_OTH. [IF DEN4=12 CONTINUE, ELSE GO TO DEN5]
Please specify the other reason {you were/NAME was} unable to get dental care, tests, or
treatments you or a dentist believed necessary?
______________________ [ALLOW 40]
………………………………………………………………………………………………
DEN5. [IF MORE THAN ONE RESPONSE RECORDED IN DEN4 CONTINUE, ELSE GO
TO DEN6]
Which of the reasons you just told me about best describes the main reason {you were/NAME
was} unable to get dental care, tests, or treatments you or a dentist believed necessary?
[LIST ONLY SELECTIONS MADE IN DEN4]
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 FROM DENTIST
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

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11=AFRAID OF GOING TO THE DENTIST/ HAVING DENTAL WORK DONE
12=OTHER
…………………………………………………………………………………………………
DEN6. In the last 12 months, {were you/was NAME} delayed in getting dental care, tests, or
treatments you or a dentist believed necessary?
1=YES
2=NO
.………………………………………………………………………………………………
DEN7. [IF DEN6=1 CONTINUE, ELSE GO TO DEN10] [IF DEN6=1 CONTINUE, ELSE GO
TO DEN10]
What kind of dental care, test, or treatment was it that {you were/NAME was} delayed in
getting?
________________ ALLOW 40]
…………………………………………………………………………………………………
DEN8. Please look at this showcard. Please describe the reasons {you were/NAME was}
delayed in getting dental care, tests, or treatments you or a dentist believed necessary? You may
select one or more.
SHOWCARD DEN1
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 FROM DENTIST
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
………………………………………………………………………………………………
DEN8_OTH. [IF DEN8=12 CONTINUE, ELSE GO TO DEN09]
Please specify the other reasons {you were/NAME was} delayed in getting dental care, tests, or
treatments you or a dentist believed necessary?
_________________ [ALLOW 40]

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………………………………………………………………………………………………
DEN9. [IF MORE THAN ONE RESPONSE RECORDED IN DEN8 CONTINUE, ELSE GO
TO DEN10]
Which of the reasons you just told me about best describes the main reason {you were/NAME
was} delayed in getting dental care you or a dentist believed necessary?
[LIST ONLY SELECTIONS MADE IN DEN8]
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 FROM DENTIST
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
…………………………………………………………………………………………………
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.
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
…………………………………………………………………………………………………
DEN10b. [IF INTAGE=18 OR OLDER CONTINUE, ELSE GO TO DEN10e]
Have you ever had an exam for oral cancer in which the doctor or dentist pulls on your tongue,
sometimes with gauze wrapped around it, and feels under the tongue and inside the cheeks?
1=YES
2=NO
……………………………………………………………………………………………

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DEN10c. Have you ever had an exam for oral cancer in which the doctor or dentist feels your
neck?
1=YES
2=NO
……………………………………………………………………………………………
DEN10d. [IF DEN10b=1 OR DEN10c=1 CONTINUE, ELSE GO TO DEN10e]
When did you have your most recent oral or mouth cancer exam? Was it within the past year,
between 1 and 3 years ago, or over 3 years ago?
1=WITHIN PAST YEAR
2=BETWEEN 1 AND 3 YEARS AGO
3=OVER 3 YEARS AGO
……………………………………………………………………………………………
DEN10e. For {your/NAME’s} most recent visit, what did {you/NAME} have done? You may
select one or more.
SHOWCARD DEN2
1=X-RAYS TAKEN
2=CLEANING TEETH
3=EXAMINATION
4=FILLINGS
5=EXTRACTIONS
6=ROOT CANALS
7=CROWNS
8=BRIDGES, DENTURES, PLATES, ETC. -- EITHER NEW ONES OR REPAIR WORK
9=ORTHODONTIA -- BITE ADJUSTMENT, BRACES, RETAINERS, ETC.
10=PERIODONTIA -- E.G., OF GUM DISEASE TREATMENT
11=BONDING
12=SURGERY
…………………………………………………………………………………………………
DEN11. In the past 12 months, when {you/NAME} did see a dentist, how many of
{your/his/her} visits were at {REFERENCE HEALTH CENTER}? Would you say…?
1=All of the visits
2=Some of the visits
3=None of the visits
………………………………………………………………………………………………

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DEN12. [IF DEN11=1 OR 2 CONTINUE, ELSE GO TO DEN13]
How would you rate the dental services {you/NAME} received at {REFERENCE HEALTH
CENTER}? Using any number from 0 to 10, where 0 is the worst dental care possible and 10 is
the best dental care possible, what number would you use to rate all of the dental care
{you/NAME} received at {REFERENCE HEALTH CENTER} in the last 12 months?
0 = WORST DENTAL CARE POSSIBLE
1
2
3
4
5
6
7
8
9
10 = BEST DENTAL CARE POSSIBLE
………………………………………………………………………………………………
DEN13. [IF DEN11= 2 OR 3 CONTINUE, ELSE GO TO DEN13a]
{IF DEN11=2: Earlier you mentioned that only some of {your/NAME’s} dental visits were at
{REFERENCE HEALTH CENTER}}
Were you referred to the other place where {you/ NAME} got dental services by {REFERENCE
HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
DEN13a. [IF INTAGE GE 13 CONTINUE, ELSE GO TO DEN16a]
In the last 12 months, that is since {12 MONTH REFERENCE DATE}, how often did you and
a dental provider talk about specific things you could do to prevent dental problems?
1=Never
2=Sometimes
3=Usually
4=Always
…………………………………………………………………………………………………….

106

DEN14. [IF INTAGE GE 13 CONTINUE, ELSE GO TO DEN16a]
Now, I have some questions about the condition of your teeth and gums.
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…?
IF ASKED: Orthodontia means straightening the teeth.
1=All of your adult teeth
2=Some of your adult teeth
3=None of your adult teeth
………………………………………………………………………………………………
DEN15. [IF DEN14=2 CONTINUE, ELSE GO TO DEN15a]
How many of your adult teeth have you lost?
__________ TEETH [ALLOW 00-20]
.………………………………………………………………………………………………
DEN15a. [IF DEN14=1 OR 2 CONTINUE, ELSE GO TO DEN16a]
Are any of your missing teeth replaced by full or partial dentures, false teeth, dental implants,
bridges or dental plates?
1=YES
2=NO
…………………………………………………………………………………………………
DEN16a. [IF INTAGE LE 12 OR DEN15a=2 CONTINUE, ELSE GO TO DEN16b]
Overall, how would you rate the health of {your/his/her} teeth and gums?
Would you say...?
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor
………………………………………………………………………………………………

107

DEN16b. [IF DEN15a=1 CONTINUE, ELSE GO TO DEN17a]
Now I have some questions about the condition of your false teeth or dentures. Would you say
the condition of your false teeth or dentures is…?

1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor
…………………………………………………………………………………………………
DEN17a. During the past 6 months, that is since {6 MONTH REFERENCE DATE}, {have
you/has NAME} had any of the following problems…
A toothache or sensitive teeth?
1=YES
2=NO
………………………………………………………………………………………………
DEN17b. (During the past 6 months, {have you/has NAME} had any of the following
problems…)
Bleeding gums?
1=YES
2=NO
………………………………………………………………………………………………
DEN17c. (During the past 6 months, {have you/has NAME} had any of the following
problems…)
Crooked teeth?
1=YES
2=NO
………………………………………………………………………………………………

108

DEN17e. (During the past 6 months, {have you/has NAME} had any of the following
problems…)
Broken or missing teeth?
1=YES
2=NO
………………………………………………………………………………………………
DEN17f. (During the past 6 months, {have you/has NAME} had any of the following
problems…)
Stained or discolored teeth?
1=YES
2=NO
………………………………………………………………………………………………
DEN17g. (During the past 6 months, {have you/has NAME} had any of the following
problems…)
Broken or missing fillings?
1=YES
2=NO
………………………………………………………………………………………………
DEN17h. (During the past 6 months, {have you/has NAME} had any of the following
problems…)
[IF INTAGE GE 13, FILL:] Loose teeth not due to injury?
[IF INTAGE LE 12, FILL:] Loose teeth not due to injury or losing baby teeth?
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
………………………………………………………………………………………………

109

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 more than a day…)
Difficulty eating or chewing?
1=YES
2=NO
………………………………………………………………………………………………
DEN18d. (During the past 6 months, {have you/has NAME} had any of the following problems
that lasted more than a day…)
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?
1=YES
2=NO
………………………………………………………………………………………………
DEN19a. [IF DEN17a, DEN17b, DEN17c, DEN17e, DEN17f, DEN17g, DEN17h, DEN18a,
DEN18b, DEN18c, DEN18d OR DEN18f=1 CONTINUE, ELSE GO TO MEN1]
[IF INTAGE GE 5 CONTINUE, ELSE GO TO DEN19b]
Did the problems with {your/NAME’s} mouth or teeth interfere with any of the following...
Job or school?
1=YES

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2=NO
3=NOT WORKING / NOT AT SCHOOL
………………………………………………………………………………………………
DEN19b. Did the problems with {your/NAME’s} mouth or teeth interfere with any of the
following...
Sleeping?
1=YES
2=NO
………………………………………………………………………………………………
DEN19c. (Did the problems with {your/NAME’s} mouth or teeth interfere with any of the
following...)
Social activities such as going out or being with other people?
1=YES
2=NO
………………………………………………………………………………………………
DEN19d. (Did the problems with {your/NAME’s} mouth or teeth interfere with any of the
following...)
Usual activities at home?
1=YES
2=NO
3=DON'T HAVE A HOME
………………………………………………………………………………………………

111

MODULE K: MENTAL HEALTH
MEN1. [IF INTAGE GE 18 CONTINUE, ELSE GO TO MEN3]
The next questions are about feelings you may have experienced over the past 30 days. Your
answers to these questions are private and will not be shared with anyone at {REFERENCE
HEALTH CENTER}. You also have the right to refuse any question that you do not want to
answer.
1=CONTINUE
………………………………………………………………………………………………
MEN1a. Please look at this showcard. During the past 30 days, how often did you feel…
So sad that nothing could cheer you up?
SHOWCARD MEN1
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1b. (During the past 30 days, how often did you feel…)
Nervous?
SHOWCARD MEN1
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1c. (During the past 30 days, how often did you feel…)
Restless or fidgety?
SHOWCARD MEN1
1=ALL OF THE TIME
2=MOST OF THE TIME

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3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
.………………………………………………………………………………………………
MEN1d. (During the past 30 days, how often did you feel…)
Hopeless?
SHOWCARD MEN1
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1e. (During the past 30 days, how often did you feel…)
That everything was an effort?
SHOWCARD MEN1
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1f. (During the past 30 days, how often did you feel…)
Worthless?
SHOWCARD MEN1
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………

113

MEN2. We just talked about a number of feelings you had during the past 30 days. Altogether,
how much did these feelings interfere with your life or activities? Would you say: a lot, some, a
little, or not at all?
1=A LOT
2=SOME
3=A LITTLE
4=NOT AT ALL
………………………………………………………………………………………………
MEN3. [IF INTAGE=2 OR 3 CONTINUE, ELSE GO TO MEN3g]
The next questions are about feelings {NAME} may have experienced. Your answers to these
questions are private and will not be shared with anyone at {REFERENCE HEALTH
CENTER}. You also have the right to refuse any question that you do not want to answer.
I am going to read a list of items that describe children. For each one, tell me if it has been not
true, sometimes true, or often true of {NAME} during the past 6 months.
1=CONTINUE
………………………………………………………………………………………………
MEN3a.
Has been uncooperative?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3b (I am going to read a list of items that describe children. For each one, tell me if it has
been not true, sometimes true, or often true of {NAME} during the past 6 months.)
Has trouble getting to sleep?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………

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MEN3c. (I am going to read a list of items that describe children. For each one, tell me if it has
been not true, sometimes true, or often true of {NAME} during the past 6 months.)
Has speech problems?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3d. (I am going to read a list of items that describe children. For each one, tell me if it has
been not true, sometimes true, or often true of {NAME} during the past 6 months.)
Has been unhappy, sad, or depressed?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3e. (I am going to read a list of items that describe children. For each one, tell me if it has
been not true, sometimes true, or often true of {NAME} during the past 6 months.)
Has temper tantrums or a hot temper?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3f. (I am going to read a list of items that describe children. For each one, tell me if it has
been not true, sometimes true, or often true of {NAME} during the past 6 months.)
Has been nervous or high-strung?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3g. [IF INTAGE=4-12 CONTINUE, ELSE GO TO MEN4a]
The next questions are about feelings {NAME} may have experienced. Your answers to these
questions are private and will not be shared with anyone at {REFERENCE HEALTH
CENTER}. You also have the right to refuse any question that you do not want to answer.

115

I am going to read a list of items that describe children. For each one, tell me if it has been not
true, sometimes true, or often true, of {NAME} during the past 6 months.
Doesn’t get along with other kids?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
.………………………………………………………………………………………………
MEN3h. (I am going to read a list of items that describe children. For each one, tell me if it has
been not true, sometimes true, or often true, of {NAME} during the past 6 months.)
Can’t concentrate or pay attention long?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
..………………………………………………………………………………………………
MEN3i. (I am going to read a list of items that describe children. For each one, tell me if it has
been not true, sometimes true, or often true, of {NAME} during the past 6 months.)
Feels worthless or inferior?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3j. (I am going to read a list of items that describe children. For each one, tell me if it has
been not true, sometimes true, or often true, of {NAME} during the past 6 months.)
Has been unhappy, sad, or depressed?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
..………………………………………………………………………………………………

116

MEN3k. (I am going to read a list of items that describe children. For each one, tell me if it has
been not true, sometimes true, or often true, of {NAME} during the past 6 months.)
Has been nervous, high-strung or tense?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
..………………………………………………………………………………………………
MEN3l. (I am going to read a list of items that describe children. For each one, tell me if it has
been not true, sometimes true, or often true, of {NAME} during the past 6 months.)
Acts too young for {his/her} age?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4a. [IF INTAGE=13-17 CONTINUE, ELSE GO TO MEN5]
The next questions are about feelings you may have experienced. Your answers to these
questions are private and will not be shared with anyone at {REFERENCE HEALTH
CENTER}. You also have the right to refuse any question that you do not want to answer.
I am going to read a list of items that describe teenagers. For each one, tell me if it has been not
true, sometimes true, or often true, of you during the past 6 months.
You can’t concentrate or pay attention long?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4b. (I am going to read a list of items that describe teenagers. For each one, tell me if it has
been not true, sometimes true, or often true, of you during the past 6 months.)
You lie or cheat?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………

117

MEN4c. (I am going to read a list of items that describe teenagers. For each one, tell me if it has
been not true, sometimes true, or often true, of you during the past 6 months.)
You don’t get along with other kids?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4d (I am going to read a list of items that describe teenagers. For each one, tell me if it has
been not true, sometimes true, or often true, of you during the past 6 months.)
You have been unhappy, sad, or depressed?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4e. (I am going to read a list of items that describe teenagers. For each one, tell me if it has
been not true, sometimes true, or often true, of you during the past 6 months.)
You do poorly at school work?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4f. (I am going to read a list of items that describe teenagers. For each one, tell me if it has
been not true, sometimes true, or often true, of you during the past 6 months.)
You have trouble sleeping?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN2a. Has a doctor or other health professional ever told you that you had depression?
1=YES
2=NO
.………………………………………………………………………………………………

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MEN2b. Has a doctor or other health professional ever told you that you had generalized
anxiety?
1=YES
2=NO
.………………………………………………………………………………………………
MEN2c Has a doctor or other health professional ever told you that you had panic disorder?
1=YES
2=NO
………………………………………………………………………………………………
MEN5c. Has a doctor or other health professional ever told you that you had schizophrenia?
1=YES
2=NO
………………………………………………………………………………………………
MEN5d. Has a doctor or other health professional ever told you that you were bipolar?
1=YES
2=NO
………………………………………………………………………………………………
MEN5. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a
doctor believe {you/NAME} should see a professional about {your/his/her} mental health,
emotions, or nerves?
1=YES
2=NO
………………………………………………………………………………………………
MEN5a. [IF MEN5=1 CONTINUE, ELSE GO TO MEN9a2]
In the last 12 months, {have you/has NAME} seen a primary care doctor or other general
practitioner for problems with {your/his/her} mental health, emotions, or nerves?
1=YES
2=NO
………………………………………………………………………………………………

119

MEN5b. In the last 12 months, {have you/has NAME} seen any other professional, such as a
counselor, psychiatrist, or social worker for problems with {your/his/her} mental health,
emotions, or nerves?
1=YES
2=NO
………………………………………………………………………………………………
MEN6. In the last 12 months, {were you/was NAME} unable to get mental health care that you
or a doctor believed necessary?
1=YES
2=NO
………………………………………………………………………………………………
MEN6a. [IF MEN6=1 CONTINUE, ELSE GO TO MEN7]
Please look at this showcard. Which of these describes the reasons {you were/NAME was}
unable to get mental health care by a mental health professional you or a doctor believed
necessary? You may select one or more.
SHOWCARD MEN2
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 FROM DOCTORS OR NURSES
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=WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID
NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
12=OTHER
………………………………………………………………………………………………
MEN6a_OTH. [IFMEN6a=12 CONTINUE, ELSE GO TO MEN7a1]
Please specify the other reason {you were/NAME was} unable to get mental care by a mental
professional you or a doctor believed was necessary.
________________ [ALLOW 40]
………………………………………………………………………………………………

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MEN7a1. [IF MORE THAN ONE RESPONSE RECORDED IN MEN6a CONTINUE, ELSE
GO TO MEN7]
Which of the reasons you just told me about best describes the main reason {you were/NAME
was} unable to get mental health care by a mental health professional you or a doctor believed
necessary?
[LIST ONLY SELECTIONS MADE IN MEN6a]
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 FROM DOCTORS OR NURSES
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=WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID
NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
12=OTHER
..………………………………………………………………………………………………
MEN7. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, {were you/was
NAME} delayed in getting mental health care you or a doctor believed necessary?
1=YES
2=NO
.………………………………………………………………………………………………
MEN7a. [IF MEN7=1 CONTINUE, ELSE GO TO MEN9]
Please look at this showcard. Which of these describes the reasons {you were/NAME was}
delayed in getting counseling by a mental health professional you or a doctor believed
necessary? You may select one or more.
SHOWCARD MEN2
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 FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE

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8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID
NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
12=OTHER
………………………………………………………………………………………………
MEN7a_OTH. [IF MEN7a=12 CONTINUE, ELSE GO TO MEN8a2]
Please specify the other reason {you were/NAME was} delayed in getting counseling by a
mental health professional you or a doctor believed necessary.
________________ [ALLOW 40]
………………………………………………………………………………………………
MEN8a2. [IF MORE THAN ONE RESPONSE RECORDED IN MEN7a CONTINUE, ELSE
GO TO MEN9a2]
Which of the reasons you just told me about best describes the main reason {you were/NAME
was} delayed in getting counseling by a mental health professional you or a doctor believed
necessary?
[LIST ONLY SELECTIONS MADE IN MEN7a]
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 FROM DOCTORS OR NURSES
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=WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID
NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
12=OTHER
………………………………………………………………………………………………
MEN9a2. [IF INTAGE GE 13 CONTINUE, ELSE GO TO SUB1a_INTRO]
Have you ever received any mental health treatment or counseling?
Please include treatment with prescription medication, group, family, couples, or individual
counseling with a mental health provider such as a social worker, psychologist, psychiatrist,

122

psychiatric nurse or other mental health professional, and inpatient treatment. Do not include
counseling or advice given by a friend, or spiritual counseling through a church or religious
group.
1=YES
2=NO
………………………………………………………………………………………………
MEN8. [IF MEN9a2=1 CONTINUE, ELSE GO TO SUB1a_INTRO]
In the past 12 months, that is since {12 MONTH REFERENCE DATE}, did you receive any
mental health treatment or counseling?
1=YES
2=NO
………………………………………………………………………………………………
MEN8a. [IF MEN8=1 CONTINUE, ELSE GO TO SUB1a_INTRO]
What was this treatment or counseling for? You may select one or more. Was it for …?
1=Mental or emotional health
2=Alcohol or drug problems
3=Personal or family problems/ relationship problems
4=Something else
………………………………………………………………………………………………
MEN9. What kind of treatment and/or counseling was it? You may select one or more. Was it
…?
1=Individual counseling
2=Group counseling
3=Family or couples counseling
4=Prescription medication
5=Inpatient treatment in a general hospital or mental health treatment facility
………………………………………………………………………………………………
MEN10. [IF MEN9=5 CONTINUE, ELSE GOTO MEN9a]
Were you referred to the general hospital or mental health facility where you got the treatment by
{REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………

123

MEN9a. [IF MEN9=1-4 CONTINUE, ELSE GO TO SUB1a_INTRO]
How many of your treatment or counseling sessions you received did you get at {REFERENCE
HEALTH CENTER}? Would you say…?
1=All of the visits
2=Some of the visits
3=None of the visits
………………………………………………………………………………………………
MEN9b. [IF MEN9a=1 OR 2 CONTINUE, ELSE GO TO MEN9c]
Using any number from 0 to 10, where 0 is poor and 10 is excellent, what number would you use
to rate the treatment or counseling services you received at {REFERENCE HEALTH
CENTER}.
0 Poor
1
2
3
4
5
6
7
8
9
10 Excellent
………………………………………………………………………………………………
MEN9c. [IF MEN9a=2 OR 3 CONTINUE, ELSE GO TO SUB1a_INTRO]
Were you referred to the other place where you got the treatment or counseling services by
{REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………

124

MODULE L: SUBSTANCE USE
[IF INTAGE GE 13 CONTINUE, ELSE GO TO PRG1]
SUB1a_INTRO. The next questions are about your use of substances. Your answers to these
questions are private and will not be shared with anyone at {REFERENCE HEALTH
CENTER}. You also have the right to refuse any question that you do not want to answer.
1=CONTINUE
………………………………………………………………………………………………
SUB1a. Have you smoked at least 100 cigarettes in your entire life?
1=YES
2=NO
………………………………………………………………………………………………
SUB1a1. [IF SUB1a=1 CONTINUE, ELSE GO TO SUB1g]
How old were you when you smoked a whole cigarette for the first time?
ENTER 6 IF 6 YEARS OLD OR YOUNGER
ENTER 98 IF 98 YEARS OLD OR OLDER
_____[ALLOW 06 – 99]
………………………………………………………………………………………………
SUB1b. Do you now smoke cigarettes every day, some days or not at all?
1=EVERY DAY
2=SOME DAYS
3=NOT AT ALL
………………………………………………………………………………………………
SUB1c. [IF SUB1b=1 CONTINUE, ELSE GO TO SUB1f]
On the average, how many cigarettes do you now smoke a day?
NOTE: IF RESPONSE IS LESS THAN 1 – ENTER 1
_______CIGARETTES [ALLOW 01-99]
………………………………………………………………………………………………

125

SUB1d. [IF SUB1b=2 CONTINUE, ELSE, GO TO SUB1f]
During the past 30 days, on how many days did you smoke cigarettes?
______ DAYS [ALLOW 00-30]
……………………………………………………………………………………………
SUB1e. [IF SUB1d GE 1 CONTINUE, ELSE GO TO SUB1f]
On average, when you smoked during the past 30 days, about how many cigarettes did you
smoke a day?
______ NUMBER OF CIGARETTES [ALLOW 00-99]
………………………………………………………………………………………………
SUB1f. [IF SUB1b=1 OR 2 CONTINUE, ELSE GO TO SUB1g]
During the past 12 months have you wanted to stop smoking?
1=YES
2=NO
………………………………………………………………………………………………
SUB1f1. [IF SUB1b=1 OR 2 CONTINUE, ELSE GO TO SUB1h1]
During the past 12 months, have you stopped smoking for more than one day because you were
trying to quit smoking?
1=YES
2=NO
………………………………………………………………………………………………
SUB1g. Have you ever used chewing tobacco, snuff, or snus?
IF NEEDED: Snus, which is Swedish for snuff, is a moist smokeless tobacco, usually sold in
small pouches that are placed under the lip against the gum.
1=YES
2=NO
………………………………………………………………………………………………..
SUB1h. [IF SUB1g= 1 CONTINUE, ELSE GO TO SUB1k]
How old were you the first time you used “smokeless” tobacco?
________ [RANGE: 01 - 99]

126

……………………………………………………………………………………………….
SUB1h1. [IF SUB1g=1 CONTINUE, ELSE GO TO SUB1k]
Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?
IF NEEDED: Snus, which is Swedish for snuff, is a moist smokeless tobacco, usually sold in
small pouches that are placed under the lip against the gum.
1=EVERY DAY
2=SOME DAYS
3=NOT AT ALL
………………………………………………………………………………………………..
SUB1i. [IF SUB1h1=2 CONTINUE, ELSE GO TO SUB1j]
Now think about the past 30 days that is since {30 DAY REFERENCE DATE}. During the past
30 days, have you used “smokeless” tobacco, even once?
1=YES
2=NO
……………………………………………………………………………………………….
SUB1j. [IF SUB1g=3 OR SUB1i=2 CONTINUE, ELSE GO TO SUB1k]
How long has it been since you last used “smokeless” tobacco? Would you say…
1=More than 30 days ago but within the past 12 months,
2=More than 12 months ago but within the past 3 years, or
3=More than 3 years ago?
………………………………………………………………………………………………..
SUB1k. [IF (SUB1h1=1 OR 2) OR (SUB1b=1 OR 2) CONTINUE, ELSE GO TO SUB2]
During the past 12 months, did any doctor or other health care professional advise you to quit
smoking cigarettes or quit using any other tobacco products?
1=YES
2=NO
.................................................................................................................................................

127

SUB1l. [IF SUB1k=1 CONTINUE, ELSE GO TO SUB1m]
Did you receive this advice at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
.................................................................................................................................................
SUB1m. [IF SUB1b=3 CONTINUE, ELSE GO TO SUBPRE1t]
How long has it been since you quit smoking cigarettes?
__________
………………………………………………………………………………………………
SUB1m_UNITS. (How long has it been since you quit smoking cigarettes?)
INTERVIEWER: ENTER RESPONSE UNIT
1=DAYS AGO
2=WEEKS AGO
3=MONTHS AGO
4=YEARS AGO
………………………………………………………………………………………………
SUB1o. The last time you tried to quit smoking, did you…
Call a telephone quit line to help you quit?
1=YES
2=NO
………………………………………………………………………………………………
SUB1p. (The last time you tried to quit smoking, did you…)
Use a program to help you quit?
1=YES
2=NO
…………………………………………………………………………………………

128

SUB1q. (The last time you tried to quit smoking, did you…)
Receive one-on-one counseling from a health professional to help you quit?
1=YES
2=NO
………………………………………………………………………………………………
SUB1r. (The last time you tried to quit smoking, did you…)
Use any of the following medications: a nicotine patch, nicotine gum, nicotine
lozenges, nicotine nasal spray, a nicotine inhaler, or pills such as Wellbutrin®, Zyban®,
buproprion, Chantix®, or varenicline to help you quit?
1=YES
2=NO
………………………………………………………………………………………………
SUB1s. [IF SUB1r=1 CONTINUE, ELSE GO TO SUB1t]
Was it…
1=Nicotine replacement such as lozenges, nasal spray, inhaler or
2=Medication such as Wellbutrin®, Zyban®,buproprion, Chantix®, or varenicline
3=SOME OTHER MEDICATION
………………………………………………………………………………………………
SUBPRE1t. The next few questions are about plans to quit smoking in the future.
Do you have plans in the future to quit smoking for good?
1=YES
2=NO
……………………………………………………………………………………………
SUB1t. [IF SUBPRE1t=1 CONTINUE, ELSE GO TO SUB2]
Do you have a time frame in mind for quitting?
1=YES
2=NO
………………………………………………………………………………………………

129

SUB1u. [IF SUB1t=1 CONTINUE, ELSE GO TO SUB2]
Do you plan to quit smoking cigarettes for good…
1=In the next 7 days,
2=In the next 30 days,
3=In the next 6 months,
4=In the next year, or
5=More than 1 year from now?
……………………………………………………………………………………………….
SUB2. Please look at this showcard.
SHOWCARD SUB1
We are interested in whether you have used any of these for non-medical reasons. Include
prescription drugs that you took only if they were not prescribed for you or you took them only
for the experience or feeling they caused.
Some of the substances listed may be prescribed by a doctor like amphetamines, sedatives, and
pain medications. For this interview, we will not record medications that are used as prescribed
by your doctor. However, if you have taken such medications for reasons other than prescription,
or taken them more frequently or at higher doses than prescribed, please let me know.
1=CONTINUE
………………………………………………………………………………………………
SUB2a. In your life, which of the following substances have you ever used? Have you drank…
Alcoholic beverages such as beer, wine, or spirits?
1=YES
2=NO
………………………………………………………………………………………………
SUB2b. In your life, which of the following substances have you
Have you used…
Cannabis or Marijuana? We are asking about non-medical use.
These may be known as marijuana, pot, grass or hash.
1=YES
2=NO
………………………………………………………………………………………………

130

SUB2c. (In your life, which of the following substances have you ever used? Have you used…)
Cocaine?
This may be known as coke or crack.
1=YES
2=NO
………………………………………………………………………………………………
SUB2d. (In your life, which of the following substances have you ever used? Have you used…)
Amphetamine-type stimulants?
These may be known as speed, ecstasy, crystal meth or diet pills.
1=YES
2=NO
………………………………………………………………………………………………
SUB2e. (In your life, which of the following substances have you ever used? Have you used…)
Inhalants?
These may be known as nitrous, glue, petrol or paint thinner.
1=YES
2=NO
………………………………………………………………………………………………
SUB2f. (In your life, which of the following substances have you ever used? Have you used…)
Sedatives or sleeping pills? We are asking about non-medical use.
These may be known as valium, serepax or rohypnol.
1=YES
2=NO
………………………………………………………………………………………………

131

SUB2g. (In your life, which of the following substances have you ever used? Have you used…)
Hallucinogens?
These may be known as LSD, acid, mushrooms, PCP or special K.
1=YES
2=NO
………………………………………………………………………………………………
SUB2h. (In your life, which of the following substances have you ever used? Have you used…)
Opioids? We are asking about non-medical use.
These may be known as heroin, morphine, methadone, codeine or vicodin.
1=YES
2=NO
………………………………………………………………………………………………
SUB2i. (In your life, which of the following substances have you ever used? Have you used…)
Any other substances?
1=YES
2=NO
………………………………………………………………………………………………
SUB2i_OTH. [IF SUB2i=1 CONTINUE, ELSE GO TO SUB2a_a]
Please specify the other substances you have ever used.
_______ [ALLOW 40]
………………………………………………………………………………………………
SUB2a_a. [IF SUB2a=1 CONTINUE, ELSE GOTO SUB2b_a]
In the past three months, how often have you used alcoholic beverages?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………

132

SUB2a_b. [IF SUB2a_a=1, 2, 3 OR 4 CONTINUE, ELSE GOTO SUB7]
In the past three months, how often have you had a strong desire or urge to use alcoholic
beverages?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2a_c. In the past three months, how often has your use of alcoholic beverages led to
health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2a_d. In the past three months, how often have you failed to do what was normally
expected of you because of your use of alcoholic beverages?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2a_e. In the past three months, how often has a friend or relative or anyone else expressed
concern about your use of alcoholic beverages?
Would you say…
0=Never
1=Once or twice

133

2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2a_f. In the past three months, how often have you tried and failed to control, cut down or
stop using alcoholic beverages?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB7 [IF SUB2a_a=0, DK OR RE CONTINUE, ELSE GO TO SUB8]
Did you drink alcohol in the past 12 months?
1=YES
2=NO
.………………………………………………………………………………………………
SUB8. [IF SUB7=1 OR (SUB2a_a=1, 2, 3, OR 4) CONTINUE, ELSE GO TO SUB9a]
In the past 12 months, on those days that you drank alcoholic beverages, on the average, how
many drinks did you have?
______ Number of drinks [ALLOW 00-30]
.………………………………………………………………………………………………
SUB8a. In the past 12 months, on how many days did you have 5 or more drinks of any
alcoholic beverage?
______ DAYS [ALLOW 000-365]
.………………………………………………………………………………………………
SUB9. In the past 12 months, have you discussed your use of alcohol with your doctor or other
health professional?
1=YES
2=NO
.………………………………………………………………………………………………

134

SUB9a. [IF SUB7=2 CONTINUE, ELSE GO TO SUB2b_a]
In the past 12 months has your doctor or other health professional asked you about your use of
alcohol?
1=YES
2=NO
………………………………………………………………………………………………
SUB9b. [IF SUB9a=1 CONTINUE, ELSE GO TO SUB2b_a]
Was this a doctor or other health professional at {REFERENCE HEALTH CENTER} or some
other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
………………………………………………………………………………………………
SUB2b_a. [IF SUB2b=1 CONTINUE, ELSE GO TO SUB2c_a]
In the past three months, how often have you used cannabis or marijuana?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2b_b. [IF SUB2b_a=2, 3 OR 4 CONTINUE, ELSE GOTO SUB2c_a]
In the past three months, how often have you had a strong desire or urge to use cannabis or
marijuana?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………

135

SUB2b_c. In the past three months, how often has your use of cannabis or marijuana led to
health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2b_d. In the past three months, how often have you failed to do what was normally
expected of you because of your use of cannabis or marijuana?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2b_e. In the past three months, how often has a friend or relative or anyone else expressed
concern about your use of cannabis or marijuana?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2b_f. In the past three months, how often have you tried and failed to control, cut down or
stop using cannabis or marijuana?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily

136

………………………………………………………………………………………………
SUB2c_a. [IF SUB2c=1CONTINUE, ELSE GO TO SUB2d_a]
In the past three months, how often have you used cocaine?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2c_b. [IF SUB2c_a=1, 2, 3 OR 4 CONTINUE, ELSE GOTO SUB2d_a]
In the past three months, how often have you had a strong desire or urge to use cocaine?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2c_c. In the past three months, how often has your use of cocaine led to health, social,
legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………

137

SUB2c_d. In the past three months, how often have you failed to do what was normally
expected of you because of your use of cocaine?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2c_e. In the past three months, how often has a friend or relative or anyone else expressed
concern about your use of cocaine?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2c_f. In the past three months, how often have you tried and failed to control, cut down or
stop using cocaine?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2d_a. [IF SUB2d=1CONTINUE, ELSE GO TO SUB2e_a]
In the past three months, how often have you used amphetamine-type stimulants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly

138

4=Daily or almost daily
………………………………………………………………………………………………
SUB2d_b. [IF SUB2d_a=1, 2, 3 OR 4 CONTINUE, ELSE GOTO SUB2e_a]
In the past three months, how often have you had a strong desire or urge to use
amphetamine-type stimulants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2d_c. In the past three months, how often has your use of amphetamine-type stimulants led
to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2d_d. In the past three months, how often have you failed to do what was normally
expected of you because of your use of amphetamine-type stimulants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………

139

SUB2d_e. In the past three months, how often has a friend or relative or anyone else expressed
concern about your use of amphetamine-type stimulants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2d_f. In the past three months, how often have you tried and failed to control, cut down or
stop using amphetamine-type stimulants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2e_a. [IF SUB2e=1CONTINUE, ELSE GO TO SUB2f_a]
In the past three months, how often have you used inhalants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2e_b. [IF SUB2e_a=1, 2 3 OR 4 CONTINUE, ELSE GOTO SUB2f_a]
In the past three months, how often have you had a strong desire or urge to use inhalants?
Would you say…
0=Never
1=Once or twice
2=Monthly

140

3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2e_c. In the past three months, how often has your use of inhalants led to health, social,
legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2e_d. In the past three months, how often have you failed to do what was normally
expected of you because of your use of inhalants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
.………………………………………………………………………………………………
SUB2e_e. In the past three months, how often has a friend or relative or anyone else expressed
concern about your use of inhalants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
.………………………………………………………………………………………………

141

SUB2e_f. In the past three months, how often have you tried and failed to control, cut down or
stop using inhalants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2f_a. [IF SUB2f=1 CONTINUE, ELSE GO TO SUB2g_a]
In the past three months, how often have you used sedatives or sleeping pills? We are asking
about non-medical use.
IF NEEDED: These may be known as valium, serepax or rohypnol.
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2f_b. [IF SUB2f_a=1, 2, 3, OR 4 CONTINUE, ELSE GOTO SUB2g_a]
In the past three months, how often have you had a strong desire or urge to use sedatives or
sleeping pills?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………

142

SUB2f_c. In the past three months, how often has your use of sedatives or sleeping pills led to
health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
.………………………………………………………………………………………………
SUB2f_d. In the past three months, how often have you failed to do what was normally
expected of you because of your use of sedatives or sleeping pills?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
.………………………………………………………………………………………………
SUB2f_e. In the past three months, how often has a friend or relative or anyone else expressed
concern about your use of sedatives or sleeping pills?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
.………………………………………………………………………………………………
SUB2f_f. In the past three months, how often have you tried and failed to control, cut down or
stop using sedatives or sleeping pills?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily

143

………………………………………………………………………………………………
SUB2g_a. [IF SUB2g=1CONTINUE, ELSE GO TO SUB2h_a]
In the past three months, how often have you used hallucinogens?
IF NEEDED: These may be known as LSD, acid, mushrooms, PCP or special K.
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2g_b. [IF SUB2g_a=1, 2, 3 OR 4 CONTINUE, ELSE GOTO SUB2h_a]
In the past three months, how often have you had a strong desire or urge to use hallucinogens?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2g_c. In the past three months, how often has your use of hallucinogens led to health,
social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………

144

SUB2g_d. In the past three months, how often have you failed to do what was normally
expected of you because of your use of hallucinogens?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2g_e. In the past three months, how often has a friend or relative or anyone else expressed
concern about your use of hallucinogens?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
.………………………………………………………………………………………………
SUB2g_f. In the past three months, how often have you tried and failed to control, cut down or
stop using hallucinogens?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
3=Never
………………………………………………………………………………………………
SUB2h_a. [IF SUB2h=1 CONTINUE, ELSE GO TO SUB2i_a]
In the past three months, how often have you used opioids? We are asking about non-medical
use.
IF NEEDED: These may be known as heroin, morphine, methadone, codeine or vicodin.
Would you say…

145

0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2h_b. [IF SUB2h_a=1, 2, 3, OR 4 CONTINUE, ELSE GOTO SUB2i_a]
In the past three months, how often have you had a strong desire or urge to use opioids?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2h_c. In the past three months, how often has your use of opioids led to health, social,
legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2h_d. In the past three months, how often have you failed to do what was normally
expected of you because of your use of opioids?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………

146

SUB2h_e. In the past three months, how often has a friend or relative or anyone else expressed
concern about your use of opioids?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
.………………………………………………………………………………………………
SUB2h_f. In the past three months, how often have you tried and failed to control, cut down or
stop using opioids?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2i_a. [IF SUB2i=1 CONTINUE, ELSE GO TO SUB3]
In the past three months, how often have you used {RESPONSE FROM SUB2i_OTH}?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2i_b. [IF SUB2i_a=1, 2, 3 OR 4 CONTINUE, ELSE GOTO SUB3]
In the past three months, how often have you had a strong desire or urge to use {RESPONSE
FROM SUB2i_OTH}?
Would you say…
0=Never
1=Once or twice

147

2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2i_c. In the past three months, how often has your use of {RESPONSE FROM
SUB2i_OTH} led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
.………………………………………………………………………………………………
SUB2i_d. In the past three months, how often have you failed to do what was normally
expected of you because of your use of {RESPONSE FROM SUB2i_OTH}?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
.………………………………………………………………………………………………
SUB2i_e. In the past three months, how often has a friend or relative or anyone else expressed
concern about your use of {RESPONSE FROM SUB2i_OTH}?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
.………………………………………………………………………………………………
SUB2i_f. In the past three months, how often have you tried and failed to control, cut down or
stop using {RESPONSE FROM SUB2i_OTH}?
Would you say…

148

0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
.………………………………………………………………………………………………
SUB3. Have you ever used any drug by injection? Please include drugs for non-medical use
only.
1=YES
2=NO
………………………………………………………………………………………………
SUB3a. [IF SUB3=1 CONTINUE, ELSE GO TO SUB10]
Would you say you used any drug by injection…
1=In the past 3 months
2=More than 3 months ago but within the past 12 months
3=More than 12 months ago
4=Never
………………………………………………………………………………………………
SUB10. [IF SUB2b =1, SUB2c=1, SUB2d=1, SUB2e=1, SUB2f=1 SUB2g=1, SUB2h=1, OR
SUB2i = 1, CONTINUE]
[IF SUB2b_a=1,2,3 or 4, SUB2c_a=1,2,3 or 4, SUB2d_a=1,2,3 or 4, SUB2e_a=1,2,3 or 4,
SUB2f_a=1,2,3 or 4, SUB2g_a=1,2,3 or 4, SUB2h_a=1,2,3 or 4, OR SUB2i_a = 1,2,3 or 4, GO
TO SUB10a]
[ELSE GO TO SUB12]
Earlier you indicated that you have used…
[IF SUB2b=1: Cannabis or Marijuana]
[IF SUB2c=1: Cocaine]
[IF SUB2d=1: Amphetamine-type stimulants]
[IF SUB2e=1: Inhalants]
[IF SUB2f=1: Sedatives or sleeping pills]
[IF SUB2g=1: Hallucinogens]
[IF SUB2h=1: Opioids]
[IF SUB2i=1: FILL RESPONSE FROM SUB2i_OTH]

149

Did you use any of these drugs in the past 12 months?
1=YES
2=NO
………………………………………………………………………………………………
SUB10a. [IF SUB10=1 CONTINUE, ELSE GO TO SUB12]
In the past 12 months, have you discussed your use of drugs with a doctor or other health
professional?
1=YES
2=NO
………………………………………………………………………………………………
SUB10b. [IF SUB10a=2 CONTINUE, ELSE GO TO SUB10c]
In the past 12 months has a doctor or other health professional asked you about your use of
drugs?
1=YES
2=NO
………………………………………………………………………………………………
SUB10c. [IF SUB10a=1 OR SUB10b=1 CONTINUE, ELSE GO TO SUB12]
Was this a doctor or other health professional at {REFERENCE HEALTH CENTER} or some
other place?
1=REFERENCE HEALTH CENTER
2=SOME OTHER PLACE
………………………………………………………………………………………………
SUB12. [IF SUB2a=1 CONTINUE, ELSE GO TO SUB12b]
In the past 12 months, did you want or need treatment or counseling for your use of alcohol?
1=YES
2=NO
………………………………………………………………………………………………
SUB12b. [IF SUB2b =1, SUB2c=1, SUB2d=1, SUB2e=1, SUB2f=1 SUB2g=1, SUB2h=1, OR
SUB2i = 1, CONTINUE, ELSE GO TO PRG1]

150

In the past 12 months, did you want or need treatment or counseling for your use of drugs?
1=YES
2=NO
………………………………………………………………………………………………
SUB12a. [IF SUB12=1 CONTINUE, ELSE GO TO SUB12d]
In the past 12 months, did you receive treatment or counseling for your use of alcohol?
1=YES
2=NO
………………………………………………………………………………………………
SUB12d. [IF SUB12b=1 CONTINUE, ELSE GO TO SUB14]
In the past 12 months, did you receive treatment or counseling for your use of drugs?
1=YES
2=NO
………………………………………………………………………………………………
SUB14. [IF SUB12a=1 CONTINUE, ELSE GO TO PRG1]
Did {REFERENCE HEALTH CENTER} provide that treatment, pay for that treatment, or refer
you to the place where you got treatment for your use of alcohol?
1=PROVIDE TREATMENT
2=PAY FOR TREATMENT
3=REFER TO ANOTHER PLACE
4=NONE
………………………………………………………………………………………………
SUB14a. [IF SUB12d=1 CONTINUE ELSE GO TO SUB17]
Did {REFERENCE HEALTH CENTER} provide that treatment, pay for that treatment, or refer
you to the place where you got treatment for your use of drugs?
1=PROVIDE TREATMENT
2=PAY FOR TREATMENT
3=REFER TO ANOTHER PLACE
4=NONE
………………………………………………………………………………………………

151

SUB17. [IF SUB12=1 AND SUB12a=2 CONTINUE, ELSE GO TO SUB17b]
Please look at this showcard. Which of these statements explain why you did not get the
treatment or counseling you needed for your use of alcohol?
SHOWCARD SUB2
1=NO WAY TO PAY FOR IT
2=DID NOT KNOW OF OR COULD NOT GET INTO A TREATMENT PROGRAM
3=DID NOT HAVE TIME FOR APROGRAM OR A WAY TO GET THERE, OR PROGRAM
NOT CONVENIENT ENOUGH
4=YOU DIDN’T WANT PEOPLE TO FIND OUT THAT YOU HAD A PROBLEM (AT
WORK, IN COMMUNITY, ETC...)
5=YOU DIDN’T REALLY THINK THE TREATMENT WOULD HELP
6=OTHER
………………………………………………………………………………………………
SUB17_SP [IF SUB17=6 CONTINUE, ELSE GO TO SUB17b]
What other reasons did you have for not getting the treatment or counseling you needed for your
use of alcohol?
_____ [Allow 80]
………………………………………………………………………………………………
SUB17b. [IF SUB12b=1 AND SUB12d=2 CONTINUE, ELSE GO TO PRG1]
Which of the reasons you just told me about best describes the main reason why you did not get
the treatment or counseling you needed for your use of drugs?
[LIST ONLY SELECTIONS MADE IN SUB17]
1=NO WAY TO PAY FOR IT
2=DID NOT KNOW OF OR COULD NOT GET INTO A TREATMENT PROGRAM
3=DID NOT HAVE TIME FOR APROGRAM OR A WAY TO GET THERE, OR PROGRAM
NOT CONVENIENT ENOUGH
4=YOU DIDN’T WANT PEOPLE TO FIND OUT THAT YOU HAD A PROBLEM (AT
WORK, IN COMMUNITY, ETC...)
5=YOU DIDN’T REALLY THINK THE TREATMENT WOULD HELP
6=OTHER
………………………………………………………………………………………………

152

SUB17b_SP. [IF SUB17b=6 CONTINUE, ELSE GO TO PRG1]
What other reasons did you have for not getting the treatment or counseling you needed for your
use of drugs?
_____ [Allow 80]
………………………………………………………………………………………………

153

MODULE M: PRENATAL CARE/ FAMILY PLANNING
PRG1. [IF INT3=2 OR 4 AND INTAGE=15-49 CONTINUE, ELSE GO TO HTG1]
[IF CON2=2, DK, RF GO TO PRG8, ELSE CONTINUE]
The next questions are about pregnancy and prenatal care. Have you been pregnant in the past 3
years, which is since {3 YEAR REFERENCE DATE}?
1=YES
2=NO
………………………………………………………………………………………………
PRG6. [IF PRG1=1 CONTINUE, ELSE GO TO PRG8]
In the past 3 years, was there a time that you needed prenatal care but were unable to get it?
1=YES
2=NO
………………………………………………………………………………………………
PRG2. The next questions are about the prenatal care you received during your most recent
pregnancy. Prenatal care includes visits to a doctor, nurse, or other health care worker before
your baby was born to get checkups and advice about pregnancy.
Did you receive prenatal care for your most recent pregnancy?
1=YES
2=NO
………………………………………………………………………………………………
PRG2a. Thinking about your most recent pregnancy, how many weeks or months pregnant were
you when you had your first visit for prenatal care? Do not count a visit that was only for a
pregnancy test or only for WIC (the Special Supplemental Nutrition Program for Women,
Infants, and Children).
________________ (ALLOW 1-40)
………………………………………………………………………………………………
PRG2a_UNIT (Thinking about your most recent pregnancy, how many weeks or months
pregnant were you when you had your first visit for prenatal care?)
1=WEEKS
2=MONTHS
………………………………………………………………………………………………

154

PRG3. [IF PRG2=1 CONTINUE, ELSE GO TO PRG8]
How many of your prenatal visits did you get at {REFERENCE HEALTH CENTER}? Would
you say….?
NOTE: IF RESPONSE IS “MOST” – CODE AS 2 “SOME OF THE VISITS”
1=All of the visits
2=Some of the visits
3=None of the visits
………………………………………………………………………………………………
PRG4. [IF PRG3=1 OR 2 CONTINUE, ELSE GO TO PRG5]
On a scale of 0 to 10, where 0 means poor and 10 means excellent, how would you rate the
prenatal care services you received at {REFERENCE HEALTH CENTER}. Would you say….?
0=Poor
1
2
3
4
5
6
7
8
9
10=Excellent
………………………………………………………………………………………………
PRG4a. During any of your prenatal care visits, did a doctor, nurse, or other health professional
talk with you about any of the following…?
Please count only discussions, not reading materials or watching videos.
1=YES
2=NO
………………………………………………………………………………………………
PRG4b. (During any of your prenatal care visits, did a doctor, nurse, or other health professional
talk with you about any of the following…?)
How smoking during pregnancy could affect your baby
1=YES
2=NO

155

………………………………………………………………………………………………
PRG4c. (During any of your prenatal care visits, did a doctor, nurse, or other health professional
talk with you about any of the following…?)
Breastfeeding your baby
1=YES
2=NO
………………………………………………………………………………………………
PRG4d. (During any of your prenatal care visits, did a doctor, nurse, or other health professional
talk with you about any of the following…?)
How drinking alcohol during pregnancy could affect your baby
1=YES
2=NO
………………………………………………………………………………………………
PRG4e. (During any of your prenatal care visits, did a doctor, nurse, or other health professional
talk with you about any of the following…?)
Using a seat belt during your pregnancy
1=YES
2=NO
………………………………………………………………………………………………
PRG4f. (During any of your prenatal care visits, did a doctor, nurse, or other health professional
talk with you about any of the following…?)
Medicines that are safe to take during your pregnancy
1=YES
2=NO
………………………………………………………………………………………………
PRG4g. (During any of your prenatal care visits, did a doctor, nurse, or other health professional
talk with you about any of the following…?)
Doing tests to screen for birth defects or diseases that run in your family
1=YES
2=NO
………………………………………………………………………………………………

156

PRG4h. (During any of your prenatal care visits, did a doctor, nurse, or other health professional
talk with you about any of the following…?)
The signs and symptoms of preterm labor, which is labor more than 3 weeks before the baby is
due
1=YES
2=NO
………………………………………………………………………………………………
PRG4i. (During any of your prenatal care visits, did a doctor, nurse, or other health professional
talk with you about any of the following…?)
What to do if your labor starts early
1=YES
2=NO
………………………………………………………………………………………………
PRG4j. (During any of your prenatal care visits, did a doctor, nurse, or other health professional
talk with you about any of the following…?)
Getting tested for HIV, the virus that causes AIDS
1=YES
2=NO
………………………………………………………………………………………………
PRG4k. (During any of your prenatal care visits, did a doctor, nurse, or other health professional
talk with you about any of the following…?)
What to do if you feel depressed during your pregnancy or after your baby is born
1=YES
2=NO
………………………………………………………………………………………………
PRG4l. (During any of your prenatal care visits, did a doctor, nurse, or other health professional
talk with you about any of the following…?)
Physical abuse to women by their husbands or partners
1=YES
2=NO
………………………………………………………………………………………………

157

PRG5. [IF PRG3=2 OR 3 CONTINUE, ELSE GO TO PRG5a]
Were you referred to the other place where you got prenatal care by {REFERENCE HEALTH
CENTER}?
1=YES
2=NO
……………………………………………………………………………………………
PRG5a. These next questions are about the time after your most recent pregnancy. Could you
tell me if this pregnancy resulted in a baby or babies born alive, or did it end some other way?
1=LIVE BIRTH
2=SOME OTHER WAY
………………………………………………………………………………………………
PRG5b. [IF PRG5a=1 CONTINUE, ELSE GO TO PRG8]
How much did your baby weigh at birth?
__________ Pounds [ALLOW 00-11] __________ Ounces [ALLOW 00-16]
………………………………………………………………………………………………
PRG6a. After your most recent pregnancy, did you have a postpartum checkup for yourself?
IF NEEDED: A postpartum checkup is the regular checkup a woman has about 6 weeks after she
gives birth.
1=YES
2=NO
………………………………………………………………………………………………
PRG6b. [IF PRG6a=1 CONTINUE, ELSE GO TO PRG6c]
Did you have the postpartum checkup at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
PRG6b_OTH. [IF PRG6b=2 CONTINUE, ELSE GO TO PRG6c]
Where did you have the postpartum checkup?
________________ [ALLOW 40]

158

………………………………………………………………………………………………
PRG6c. Was your new baby seen by a doctor, nurse, or other health care worker for a one week
check-up after he or she was born?
1=YES
2=NO
………………………………………………………………………………………………
PRG6d. [IF PRG6c=1 CONTINUE, ELSE GO TO PRG8]
Did you have the baby’s one week check-up at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
PRG6d_OTH. [IF PRG6d=2 CONTINUE, ELSE GO TO PRG8]
Where did you have the baby’s one week check-up?
________________ [ALLOW 40]
………………………………………………………………………………………………
PRG8. Please look at this showcard. In the past 12 months, that is since {12 MONTH
REFERENCE DATE}, have you received any of the following family planning services? You
may select one or more.
SHOWCARD PRG1
1=A BIRTH CONTROL METHOD OR PRESCRIPTION
2=A CHECK-UP OR MEDICAL TEST RELATED TO USING A BIRTH CONTROL
METHOD
3=COUNSELING ABOUT BIRTH CONTROL
4=COUNSELING ABOUT GETTING STERILIZED
5=EMERGENCY CONTRACEPTION OR THE "MORNING-AFTER PILL"
6=COUNSELING OR INFORMATION ABOUT EMERGENCY CONTRACEPTION OR THE
"MORNING-AFTER PILL"
7=A STERILIZING OPERATION
8=OTHER
9=NONE OF THE ABOVE
………………………………………………………………………………………………

159

PRG9. [IF PRG8=1, 2, 3, 4, 5, 6, 7OR 8 CONTINUE, ELSE GO TO PRG11]
How many of these services did you get at {REFERENCE HEALTH CENTER}? Would you
say…?
1=All of the services
2=Some of the services
3=None of the services
…………………………………………………………………………………………………
PRG10a. [IF PRG9=1 OR 2 CONTINUE, ELSE GO TO PRG10b]
On a scale of 0 to 10, where 0 means poor and 10 means excellent, how would you rate the
family planning services you received at {REFERENCE HEALTH CENTER}. Would you
say….?
0=Poor
1
2
3
4
5
6
7
8
9
10=Excellent
………………………………………………………………………………………………
PRG10b. [IF PRG9=2 OR 3 CONTINUE, ELSE GO TO PRG11]
Were you referred to the other place where you got the family planning services by
{REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
PRG11. Please look at this show card. In the last 12 months, that is since {12 MONTH
REFERENCE DATE}, was there a time that you needed any family planning service on the list
but were unable to get it? You may select one or more.
SHOWCARD PRG2
1=A BIRTH CONTROL METHOD OR PRESCRIPTION

160

2=A CHECK-UP OR MEDICAL TEST RELATED TO USING A BIRTH CONTROL
METHOD
3=COUNSELING ABOUT BIRTH CONTROL
4=COUNSELING ABOUT GETTING STERILIZED
5=EMERGENCY CONTRACEPTION OR THE "MORNING-AFTER PILL"
6=COUNSELING OR INFORMATION ABOUT EMERGENCY CONTRACEPTION OR THE
"MORNING-AFTER PILL"
7=A STERILIZING OPERATION
8=NO, THERE WASN’T A TIME WHEN I NEEDED A SERVICE BUT COULDN'T GET IT
9= OTHER
10=NONE OF THE ABOVE
………………………………………………………………………………………………
PRG11_OTH. [IF PRG11=9 CONTINUE, ELSE GO TO HTG1]
Please specify the other family planning service you needed, but were unable to get.
________________ [ALLOW 40]

161

MODULE N: HIV TESTING
HTG1. [IF INTAGE GE 18 CONTINUE, ELSE GO TO LIV1]
The next questions are about the test for HIV, the virus that causes AIDS. Your answers to these
questions are private and will not be shared with anyone at {REFERENCE HEALTH
CENTER}. You also have the right to refuse any question that you do not want to answer.
Except for tests you may have had as part of blood donations, have you ever been tested for
HIV?
1=YES
2=NO
………………………………………………………………………………………………
HTG1a. [IF HTG1=1 CONTINUE, ELSE GO TO HTG2]
When was your last HIV test?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO
4=3 YEARS BUT LESS THAN 4 YEARS AGO
5=4 YEARS BUT LESS THAN 5 YEARS AGO
6=5 OR MORE YEARS AGO
………………………………………………………………………………………………
HTG1a1. The last time you had an HIV test, did you receive your test results?
1=YES
2=NO
………………………………………………………………………………………………
HTG1b. Where did you have your last HIV test? Was it at…
1=REFERENCE HEALTH CENTER
2=Other health center
3=Private doctor or HMO office
4=Counseling and testing site
5=Hospital
6=Jail, prison or other correctional facility
7=Drug treatment facility
8=At home
9=Somewhere else
………………………………………………………………………………………………

162

HTG2. [IF HTG1=2 CONTINUE, ELSE GO TO HTG3]
Please look at this showcard. I am going to show you a list of reasons why some people have not
been tested for HIV, the virus that causes AIDS. Which one of these would you say is the main
reason why you have not been tested?
SHOWCARD HTG1
1=IT'S UNLIKELY I’VE BEEN EXPOSED TO HIV
2=I DIDN'T KNOW WHERE TO GET TESTED
3=I WAS AFRAID OF LOSING A JOB, INSURANCE, HOUSING, FRIENDS, FAMILY, IF
PEOPLE KNEW I WAS POSITIVE FOR AIDS INFECTION
4=I’M TESTED WHEN I GIVE BLOOD
5=NO PARTICULAR REASON
6=SOME OTHER REASON
………………………………………………………………………………………………
HTG2_OTH. [IF HTG2=6 CONTINUE, ELSE GO TO HTG3]
Please specify why you have not been tested?
________________ [ALLOW 60]
………………………………………………………………………………………………
HTG3. Has anyone at {REFERENCE HEALTH CENTER} ever suggested that you have a test
for HIV?
1=YES
2=NO
………………………………………………………………………………………………
HTG4. Has anyone at {REFERENCE HEALTH CENTER} ever talked to you about ways to
protect yourself and others from getting the HIV virus?
1=YES
2=NO
………………………………………………………………………………………………
HTG5. Have you ever been told by a doctor or other health professional that you are HIV
positive or have AIDS?
1=YES
2=NO
………………………………………………………………………………………………

163

HTG6a. [IF HTG5=1 CONTINUE, ELSE GO TO LIV1]
Are you receiving any medical care now for HIV or AIDS?
1=YES
2=NO
………………………………………………………………………………………………
HTG6a1. [IF HTG6a =1 CONTINUE, ELSE GO TO LIV1]
Are you receiving this care at {REFERENCE HEALTH CENTER} or somewhere else?
1=REFERENCE HEALTH CENTER
2=SOMEWHERE ELSE
………………………………………………………………………………………………
HTG6a1a. [IF HTG6a1=2 CONTINUE, ELSE GO TO HTG6b]
Please specify where you are receiving this care:
________________ [ALLOW 40]
………………………………………………………………………………………………
HTG6a3. Were you referred there by {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
HTG6b. Are you receiving antiretroviral therapy for HIV prescribed by a doctor?
1=YES
2=NO
………………………………………………………………………………………………
HTG6b1. [IF HTG6b = 1 CONTINUE, ELSE GO TO LIV1]
Are you receiving this therapy at {REFERENCE HEALTH CENTER} or somewhere else?
1=REFERENCE HEALTH CENTER
2=SOMEWHERE ELSE
………………………………………………………………………………………………

164

HTG6a2. [IF HTG6b1=2 CONTINUE, ELSE GO TO LIV1]
Please specify where you are receiving this care:
________________ [ALLOW 40]
………………………………………………………………………………………………
HTG6b3. Were you referred there by {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………

165

MODULE O: LIVING ARRANGEMENTS
LIV1. Now I’m going to ask you some questions about where {you are / NAME is} living right
now.]
Please look at this showcard. Over the past 7 days, where did {you/NAME} usually sleep at
night? Pick the single best option.
SHOWCARD LIV1
1=A HOUSE, TOWNHOUSE OR MOBILE HOME
2=AN APARTMENT OR CONDO
3=A ROOM OTHER THAN AT A HOTEL OR MOTEL
4=AN EMERGENCY SHELTER
5=A TRANSITIONAL SHELTER INCLUDES TRANSITIONAL HOUSING
6=A CHURCH OR CHAPEL
7=AN ABANDONED BUILDING
8=A PLACE OF BUSINESS
9=A CAR OR OTHER VEHICLE
10=ANYWHERE OUTSIDE
11=A HOTEL OR MOTEL (A PLACE WITH SEPARATE ROOMS YOU PAY FOR
YOURSELF)
12= SOME OTHER PLACE
………………………………………………………………………………………………
LIV1_OTH. [IF LIV1=12 CONTINUE, ELSE GO TO LIV2]
Please describe the other place {you have/NAME has} usually slept over the past 7 days?
________________ [ALLOW 40]
………………………………………………………………………………………………
LIV2. [IF LIV1=1 OR 2 CONTINUE, ELSE GO TO LIV3]
How many bedrooms are in that {house / apartment}?
______ ROOMS [ALLOW 00-20]
………………………………………………………………………………………………
LIV3. [IF LIV1=3 CONTINUE, ELSE GO TO LIV4]
How many people usually sleep in that {house / apartment / room}?
______ NUMBER OF PEOPLE [ALLOW 00-20]
………………………………………………………………………………………………

166

LIV4. [IF LIV1=1 OR 2 OR 3 CONTINUE, ELSE GO TO LIV10]
Do you own or rent that {house / apartment / room}?
IF NEEDED: This includes making payments on a mortgage.
1=YES
2=NO
………………………………………………………………………………………………
LIV6. [IF LIV4=1 CONTINUE, ELSE GO TO LIV10]
{IF INTAGE GE 18 Have you or your family/IF INTAGE LE 12 Has NAME’s family/IF
INTAGE=13-17your family}} ever not been able to pay {your/their} share of the rent or
mortgage for {you or your family’s/their/your} own place, or have {you or your family/they}
had to borrow money to pay {your/their} share of the rent or mortgage?
[PROGRAMMERS: BELOW IS HOW THE FILLS SHOULD LOOK]
[IF INTAGE GE 18] Have you or your family ever not been able to pay your share of the rent
or mortgage for you or your family’s own place, or have you or your family had to borrow
money to pay your share of the rent or mortgage?
[IF INTAGE LE 12] Has NAME’s family ever not been able to pay their share of the rent or
mortgage for their own place, or have they had to borrow money to pay their share of the rent or
mortgage?
[IF INTAGE=13-17] Has your family ever not been able to pay their share of the rent or
mortgage for your own place, or have they had to borrow money to pay their share of the rent or
mortgage?
1=YES
2=NO
………………………………………………………………………………………………
LIV7. In the past 12 months, how many times have you moved?
__________ TIMES [RANGE 00-99]
………………………………………………………………………………………………
LIV8. [IF LIV6=1 CONTINUE, ELSE GO TO LIV9]
Will you be asked or forced to leave your own place in the next 14 days?
1=YES
2=NO
………………………………………………………………………………………………

167

LIV9. Have you ever NOT had your own place to live?
1=YES
2=NO
………………………………………………………………………………………………
LIV10. [IF LIV1=4,5,6,7,8,9,10,11, 12 OR IF LIV4=2 CONTINUE AND IF LIV9=1
CONTINUE, ELSE GO TO INC1a]
[IF INTAGE GE 18] When was the last time you or your family had your own place to live,
such as a house, apartment or room}?
[IF INTAGE LE 12] When was the last time {NAME’s} family had its own place to live, such
as a house, apartment or room?
[IF INTAGE=13-17] When was the last time your family had its own place to live, such as a
house, apartment or room?
_____________
………………………………………………………………………………………………
LIV10_UNITS. (When was the last time…had…own place to live, such as a house, apartment or
room?)
INTERVIEWER: ENTER RESPONSE UNIT
1=DAYS AGO
2=WEEKS AGO
3=MONTHS AGO
4=YEARS AGO
………………………………………………………………………………………………
LIV11. Including this time…
[IF INTAGE GE18 FILL] how many times in the past 3 years, that is since {3 YEAR
REFERENCE DATE}, have you not had your own place to live?
[IF INTAGE LE12 FILL] how many times in the past 3 years, that is since {3 YEAR
REFERENCE DATE}, has {NAME’s} family not had its own place to live?
[IF INTAGE = 13-17 FILL] how many times in the past 3 years, that is since {3 YEAR
REFERENCE DATE}, has your family not had its own place to live?
________________ NUMBER OF TIMES [ALLOW 00-99]
………………………………………………………………………………………………

168

LIV12. [IF LIV1=4, 5, 6, 7, 8, 9, 10, 11, 12 OR IF LIV5=2 AND IF LIV9=1]
[IF LIV5=2] Including this time…
[IF INTAGE GE 18] How many times in your life have you not had your own place to live?
[IF INTAGE LE 12] How many times in {NAME’s} life has {NAME’s} family not had its
own place to live?
[IF INTAGE=13-17] How many times in your life has your family not had its own place to
live?
__________ NUMBER OF TIMES [ALLOW 00-99]
………………………………………………………………………………………………
LIV13. How old {were you/was NAME} the first time {you/he/she} didn’t have a place of
{your/his/her} own to live?
________________ AGE [ALLOW 000-109]
PROGRAMMER: AGE CHECK SO AGE REPORTED HERE IS NOT HIGHER THAN AGE
REPORTED FROM INTDOB OR INTAGE.
………………………………………………………………………………………………
LIV14. If you added up all the times in {your/NAME’s} life that {you/he/she} didn’t have a
place of {your/his/her} own to live, how long would you say that was?
__________
………………………………………………………………………………………………
LIV14_UNITS. (If you added up all the times in {your/NAME’s} life that {you/he/she} didn’t
have a place of {your/his/her} own to live, how long would you say that was??)
INTERVIEWER: ENTER RESPONSE UNIT
1=DAYS AGO
2=WEEKS AGO
3=MONTHS AGO
4=YEARS AGO
………………………………………………………………………………………………

169

MODULE P: INCOME AND ASSETS
INC1a. When {you go/NAME goes} to {REFERENCE HEALTH CENTER}, does
{REFERENCE HEALTH CENTER} reduce the charge for the services provided because of
your income level?
1=YES
2=NO
.………………………………………………………………………………………………
INC1b. [IF INTAGE=13-17 GO TO DMO_INT, ELSE CONTINUE]
The next questions are about {your/NAME’s} total family income in {LAST CALENDAR
YEAR IN 4-DIGIT FORMAT} before taxes. Income is important in analyzing the health
information we collect.
Please look at this card which lists the types of income we would like for you to include.
SHOWCARD INC1
IF NEEDED: READ THE FOLLOWING CONTENT.
When answering this next question, we would like you to:
•
•

Include your income PLUS the income of all family members living in your household
Include all types of income, including:
o Income from child support or alimony;
o Rental income;
o Any cash assistance from a state or county welfare program;
o Income from Worker’s Compensation or unemployment compensation;
o Any retirement, disability or survivor pension; and
o Any interest or investment income.

What is your best estimate of the total income of {your/NAME’s} household? Please remember
to include your income and the income of all family members living in your household from all
sources, before taxes, in {LAST CALENDAR YEAR IN 4 DIGIT FORMAT}?
$________________ DOLLARS [ALLOW 000,000-999,995]
………………………………………………………………………………………………
INC1b1. [IF INC1b= DK OR RF CONTINUE, ELSE GO TO INC1c]
Was {your/NAME’s} total family income in the past 12 months…?
1=Below $35,000
2=$35,000 or more

170

………………………………………………………………………………………………
INC1b1b. [IF INC1b1= 1 CONTINUE ELSE GO TO INC1b2]
We would like to get a better estimate of your total household income in the past 12 months
before taxes. Was it...?
1=$5,000 to $9,999
2=$10,000 to $14,999
3=$15,000 to $24,999
4=$25,000 to $34,999
………………………………………………………………………………………………
INC1b2. [IF INC1b1a= 2 CONTINUE, ELSE GO TO INC1c.]
We would like to get a better estimate of your total household income in the past 12 months
before taxes. Was it...?
1=35,000 to $49,999
2=$50,000 to $74,999
3=$75,000 to $99,999
4=$100,000 to $149,999
5=$150,000 to $175,000
6=More than $175,000
………………………………………………………………………………………………
INC1c. [IF INC1b NE DK, RE CONTINUE, ELSE GO TO INC1d]
Including {you/NAME}, how many family members did that income support for {LAST
CALENDAR YEAR IN 4 DIGIT FORMAT}?
______ FAMILY MEMBERS [ALLOW 01-20]
………………………………………………………………………………………………
INC1d. [IF INC1B=DK, RE CONTINUE, ELSE GO TO INC3a] Although you were unable to
provide {your/NAME’s} family income for {LAST CALENDAR YEAR IN 4 DIGIT
FORMAT}, can you tell me how many family members were supported by {your/NAME’s}
family income, including {yourself/NAME}?
______ FAMILY MEMBERS [ALLOW 01-20]
………………………………………………………………………………………………

171

Poverty Thresholds for 2012 by Size of Family and Number
of Related Children Under 18 Years
Size of Family Unit

FPL (weighted avg)

One person (unrelated individual)
11,170
Two people
15,130
Three people
19,090
Four people
23,050
Five people
27,010
Six people
30,970
Seven people
34,930
Eight people
38,890
Source: Federal Register, Vol. 77, No. 17, January 26, 2012,
pp. 4034-4035
INC2.
[USE TABLE AND RESPONSE TO INC1c TO DETERMINE FILLS FOR FPL AND 2XFPL
BELOW].
During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, was {your/NAME’s} total family
income from all sources less than {FILL FAMILY POVERTY LEVEL BASED ON
RESPONSE TO INC1c}, more than {FILL FAMILY POVERTY LEVEL BASED ON
RESPONSE TO INC1c} but less than {FILL 2X FAMILY POVERTY LEVEL BASED ON
RESPONSE TO INC1c} or {FILL 2X FAMILY POVERTY LEVEL BASED ON RESPONSE
TO INC1c} or more?
[IF RESPONDENT SAYS DK – AUTOMATICALLY REPEAT QUESTION AND ASK
RESPONDENT TO GIVE US THEIR BEST ESTIMATE.]
1=LESS THAN {FILL FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c}
2=MORE THAN{FILL FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c}
BUT LESS THAN {FILL 2X FAMILY POVERTY LEVEL BASED ON RESPONSE TO
INC1c}
3={FILL 2X FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c} OR MORE
………………………………………………………………………………………………
INC3a. During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, did {you/NAME} or
anyone else in {your/his/her} household receive any of the following forms of public assistance?
Food stamps?
1=YES
2=NO
………………………………………………………………………………………………

172

INC3b. (During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, did {you/NAME} or
anyone else in {your/his/her} household receive any of the following forms of public
assistance?)
WIC—the Women, Infants, and Children nutrition program?
1=YES
2=NO
………………………………………………………………………………………………
INC3c. (During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, did {you/NAME} or
anyone else in {your/his/her} household receive any of the following forms of public
assistance?)
Aid from a state Temporary Assistance for Needy Families (TANF) plan?
1=YES
2=NO
………………………………………………………………………………………………
INC3d. (During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, did {you/NAME} or
anyone else in {your/his/her} household receive any of the following forms of public
assistance?)
Section 8 housing?
1=YES
2=NO
………………………………………………………………………………………………
INC3e. (During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, did {you/NAME} or
anyone else in {your/his/her} household receive any of the following forms of public
assistance?)
Any other assistance from the government?
1=YES
2=NO
………………………………………………………………………………………………

173

MODULE Q: DEMOGRAPHICS
DMO_INT. The final questions are about {you/NAME}.
1=CONTINUE
………………………………………………………………………………………………
DMO1. {Were you/Was NAME} born in the United States?
1=YES
2=NO
………………………………………………………………………………………………
DMO1a. [IF DMO1=2 CONTINUE, ELSE GOTO DMO4]
In what country {were you/was NAME} born?
______ [ALLOW 40]
………………………………………………………………………………………………
DMO1a_OTH. SPECIFY OTHER COUNTRY
_______________________
………………………………………………………………………………………………
DMO2. In what year did {you/NAME} come to the United States?
________ YEAR [ALLOW 1900–2014]
………………………………………………………………………………………………
DMO3. Was {your/NAME’s} father born in the United States?
1=YES
2=NO
………………………………………………………………………………………………
DMO3a. [IF DMO3=2 CONTINUE, ELSE GO TO DOM3b]
In what country was {your/NAME’s} father born?
________ [LIST COUNTRIES]
1
2

Bermuda
Canada
174

3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45

Greenland
Saint Pierre and Miquelon
Anguilla
Antigua and Barbuda
Aruba
Bahamas
Barbados
British Virgin Islands
Cayman Islands
Cuba
Dominica
Dominican Republic
Grenada
Guadeloupe
Haiti
Jamaica
Martinique
Montserrat
Netherlands Antilles
Puerto Rico
Saint-Barthelemy
Saint Kitts and Nevis
Saint Lucia
Saint Martin (France)
Saint Vincent and the Grenadines
Trinidad and Tobago
Turks and Caicos Islands
Belize
Costa Rica
El Salvador
Guatemala
Honduras
Mexico
Nicaragua
Panama
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Falkland Islands (Malvinas)
French Guiana
175

46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88

Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Belarus
Bulgaria
Czech Republic
Hungary
Poland
Moldova
Romania
Russian Federation
Slovakia
Ukraine
Aland Islands
Channel Islands
Denmark
Estonia
Faeroe Islands
Finland
Guernsey
Iceland
Republic of Ireland
Isle of Man
Jersey
Latvia
Lithuania
Norway
Svalbard and Jan Mayen Islands
Sweden
United Kingdom
Austria
Belgium
France
Germany
Liechtenstein
Luxembourg
Monaco
Netherlands
Switzerland
Albania
176

89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131

Andorra
Bosnia and Herzegovina
Croatia
Gibraltar
Greece
Vatican City
Italy
Malta
Montenegro
Portugal
Republic of Macedonia
San Marino
Serbia
Slovenia
Spain
Australia
New Zealand
Norfolk Island
Fiji
New Caledonia
Papua New Guinea
Solomon Islands
Vanuatu
Guam
Kiribati
Marshall Islands
Micronesia (Federated States of)
Nauru
Northern Mariana Islands
Palau
American Samoa
Cook Islands
French Polynesia
Niue
Pitcairn
Samoa
Tokelau
Tonga
Tuvalu
Wallis and Futuna Islands
Burundi
Comoros
Djibouti
177

132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174

Eritrea
Ethiopia
Kenya
Madagascar
Malawi
Mauritius
Mayotte
Mozambique
Reunion
Rwanda
Seychelles
Somalia
Uganda
United Republic of Tanzania
Zambia
Zimbabwe
Angola
Cameroon
Central African Republic
Chad
Democratic Republic of the Congo
Equatorial Guinea
Gabon
Republic of the Congo
Algeria
Egypt
Libya
Morocco
Sudan
Tunisia
Western Sahara
Botswana
Lesotho
Namibia
South Africa
Swaziland
Benin
Burkina Faso
Cape Verde
Cote d'Ivoire
Gambia
Ghana
Guinea
178

175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217

Guinea-Bissau
Liberia
Mali
Mauritania
Niger
Nigeria
Saint Helena
Senegal
Sierra Leone
Togo
Kazakhstan
Kyrgyzstan
Tajikistan
Turkmenistan
Uzbekistan
Afghanistan
Bangladesh
Bhutan
India
Iran
Maldives
Nepal
Pakistan
Sri Lanka
Armenia
Azerbaijan
Bahrain
Cyprus
Georgia
Iraq
Israel
Jordan
Kuwait
Lebanon
Oman
Palestinian territories (West Bank and Gaza Strip)
Qatar
Saudi Arabia
Syrian Arab Republic
Turkey
United Arab Emirates
Yemen
China - the People's Republic of China (including Hong Kong and Macao)
179

218
Taiwan (the Republic of China)
219
Japan
220
Mongolia
221
North Korea
222
South Korea
223
Brunei Darussalam
224
Cambodia
225
Indonesia
226
Lao People's Democratic Republic
227
Malaysia
228
Myanmar (Burma)
229
Philippines
230
Singapore
231
Thailand
232
Timor-Leste
233
Vietnam
234
Other
………………………………………………………………………………………………
DMO3a_OTH. SPECIFY OTHER COUNTRY
_______________________
………………………………………………………………………………………………
DMO3b. Was {your/NAME’s} mother born in the United States?
1=YES
2=NO
………………………………………………………………………………………………
DMO3c. [IF DMO3b=2 CONTINUE, ELSE GO TO DMO4.]
In what country was {your/NAME’s} mother born?
________ [LIST COUNTRIES]
1
2
3
4
5
6
7
8

Bermuda
Canada
Greenland
Saint Pierre and Miquelon
Anguilla
Antigua and Barbuda
Aruba
Bahamas

180

9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51

Barbados
British Virgin Islands
Cayman Islands
Cuba
Dominica
Dominican Republic
Grenada
Guadeloupe
Haiti
Jamaica
Martinique
Montserrat
Netherlands Antilles
Puerto Rico
Saint-Barthelemy
Saint Kitts and Nevis
Saint Lucia
Saint Martin (France)
Saint Vincent and the Grenadines
Trinidad and Tobago
Turks and Caicos Islands
Belize
Costa Rica
El Salvador
Guatemala
Honduras
Mexico
Nicaragua
Panama
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Falkland Islands (Malvinas)
French Guiana
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
181

52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94

Belarus
Bulgaria
Czech Republic
Hungary
Poland
Moldova
Romania
Russian Federation
Slovakia
Ukraine
Aland Islands
Channel Islands
Denmark
Estonia
Faeroe Islands
Finland
Guernsey
Iceland
Republic of Ireland
Isle of Man
Jersey
Latvia
Lithuania
Norway
Svalbard and Jan Mayen Islands
Sweden
United Kingdom
Austria
Belgium
France
Germany
Liechtenstein
Luxembourg
Monaco
Netherlands
Switzerland
Albania
Andorra
Bosnia and Herzegovina
Croatia
Gibraltar
Greece
Vatican City
182

95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137

Italy
Malta
Montenegro
Portugal
Republic of Macedonia
San Marino
Serbia
Slovenia
Spain
Australia
New Zealand
Norfolk Island
Fiji
New Caledonia
Papua New Guinea
Solomon Islands
Vanuatu
Guam
Kiribati
Marshall Islands
Micronesia (Federated States of)
Nauru
Northern Mariana Islands
Palau
American Samoa
Cook Islands
French Polynesia
Niue
Pitcairn
Samoa
Tokelau
Tonga
Tuvalu
Wallis and Futuna Islands
Burundi
Comoros
Djibouti
Eritrea
Ethiopia
Kenya
Madagascar
Malawi
Mauritius
183

138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180

Mayotte
Mozambique
Reunion
Rwanda
Seychelles
Somalia
Uganda
United Republic of Tanzania
Zambia
Zimbabwe
Angola
Cameroon
Central African Republic
Chad
Democratic Republic of the Congo
Equatorial Guinea
Gabon
Republic of the Congo
Algeria
Egypt
Libya
Morocco
Sudan
Tunisia
Western Sahara
Botswana
Lesotho
Namibia
South Africa
Swaziland
Benin
Burkina Faso
Cape Verde
Cote d'Ivoire
Gambia
Ghana
Guinea
Guinea-Bissau
Liberia
Mali
Mauritania
Niger
Nigeria
184

181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223

Saint Helena
Senegal
Sierra Leone
Togo
Kazakhstan
Kyrgyzstan
Tajikistan
Turkmenistan
Uzbekistan
Afghanistan
Bangladesh
Bhutan
India
Iran
Maldives
Nepal
Pakistan
Sri Lanka
Armenia
Azerbaijan
Bahrain
Cyprus
Georgia
Iraq
Israel
Jordan
Kuwait
Lebanon
Oman
Palestinian territories (West Bank and Gaza Strip)
Qatar
Saudi Arabia
Syrian Arab Republic
Turkey
United Arab Emirates
Yemen
China - the People's Republic of China (including Hong Kong and Macao)
Taiwan (the Republic of China)
Japan
Mongolia
North Korea
South Korea
Brunei Darussalam
185

224
Cambodia
225
Indonesia
226
Lao People's Democratic Republic
227
Malaysia
228
Myanmar (Burma)
229
Philippines
230
Singapore
231
Thailand
232
Timor-Leste
233
Vietnam
234
Other
………………………………………………………………………………………………
DMO4. [IF INTAGE IS GE 5 CONTINUE, ELSE GO TO DMO7.]
What is the highest grade or year of school {you have/NAME has} completed?
0=NEVER ATTENDED
1=KINDERGARTEN
2=1ST GRADE
3=2ND GRADE
4=3RD GRADE
5=4TH GRADE
6=5TH GRADE
7=6TH GRADE
8=7TH GRADE
9=8TH GRADE
10=9TH GRADE
11=10TH GRADE
12=11TH GRADE
13=12TH GRADE, NO DIPLOMA
14=HIGH SCHOOL GRADUATE
15=GED OR EQUIVALENT
16=SOME COLLEGE, NO DEGREE
17=ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR VOCATIONAL
PROGRAM
18=ASSOCIATE DEGREE: ACADEMIC PROGRAM
19=BACHELOR’S DEGREE (EXAMPLE: BA, AB, BS, BBA)
20=MASTER’S DEGREE (EXAMPLE: MA, MS, MENG, MED, MBA)
21=PROFESSIONAL SCHOOL OR DOCTORAL DEGREE (EXAMPLE: MD, DDS, DVM,
JD, PHD, EDD)
22=OTHER
………………………………………………………………………………………………

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DMO4_OTH. [IF DMO4=22 CONTINUE, ELSE GO TO DMO5]
Please describe the highest grade or year of school {you have/NAME has} completed?
_________ [ALLOW 60]
………………………………………………………………………………………………
DMO5. [IF DMO4=1-22 CONTINUE, ELSE GO TO DMO7]
During the last year {you were/NAME was} in school, {were you/was NAME} attending a
school in the United States?
1=YES
2=NO
………………………………………………………………………………………………
DMO7. How many times {have you/has NAME} moved in the past 12 months that is since {12
MONTH REFERENCE DATE}?
9=0
1=1
2=2
3=3
4=4
5=5
6=6-10
7=11-15
8=MORE THAN 15
99=HOMELESS – NOT APPLICABLE
………………………………………………………………………………………………
DMO8. [IF DMO7=1-8 CONTINUE, ELSE GO TO DMO8a]
How many of these moves were related to the work of someone in the family? For example,
moving to a place to do farm work there or to look for work there, and moving back home after
the farming season ended.
9=0
1=1
2=2
3=3
4=4
5=5
6=6-10
7=11-15
8=MORE THAN 15

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………………………………………………………………………………………………
DMO8a. [IF INTAGE GE 15 CONTINUE, ELSE GO TO DMO12]
Do you think of yourself as straight or heterosexual, as gay, lesbian or homosexual, or as
bisexual?
1=STRAIGHT OR HETEROSEXUAL
2=GAY, LESBIAN, OR HOMOSEXUAL
3=BISEXUAL
4=NOT SEXUAL/CELIBATE/NONE
5=OTHER
………………………………………………………………………………………………
DMO8a_OTH. [IF DMO8a=5 CONTINUE, ELSE GO TO DMO9]
Please specify your sexual orientation.
________________ [ALLOW 40]
………………………………………………………………………………………………
DMO9. [IF INTAGE GE 18 CONTINUE, ELSE GO TO DMO10]
Are you ……?
1=Married
2=Have a domestic partner
3=Widowed
4=Divorced
5=Separated
6=Never married
……………………………………………………………………………………………
DMO9a. [IF DMO9=1 OR 2 CONTINUE, ELSE GO TO DMO10]
Is your spouse or partner living with you?
1=YES
2=NO
………………………………………………………………………………………………
DMO10. [IF INTAGE GE 18 CONTINUE, ELSE GO TO DMO11]
Have you ever served on active duty in the U.S. Armed Forces, military Reserves, or the
National Guard?

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IF NEEDED: Active duty does not include training for the Reserves or National Guard, but does
include activation, for example, for the Persian Gulf War.
1=YES
2=NO
………………………………………………………………………………………………
DMO10a. [IF DMO10=1 CONTINUE, ELSE GO TO DMO11]
Which of the following best describes your service in the U.S. military?
1=Currently on active duty
2=Currently in the Reserves or National Guard
3=Retired from military service
4=Medically discharged from military service
5=Discharged from military service
………………………………………………………………………………………………
DMO10b. [IF DMO10a=3, 4 OR 5 CONTINUE, ELSE GO TO DMO11]
Are you eligible for veteran’s benefits?
1=YES
2=NO
………………………………………………………………………………………………
DMO10c. [IF DMO10b=1 CONTINUE, ELSE GO TO DMO11]
In the past 12 months, that is since {12 MONTH REFERENCE DATE}, have you received
health care from VA facilities?
1=YES
2=NO
………………………………………………………………………………………………
DMO11. [IF INTAGE GE 16 CONTINUE, ELSE GO TO DMO12]
The next few questions are about employment status. Information on employment is important in
analyzing the health information we collect. For example, with this information, we can learn
whether patients who work full-time use medical services more or less often than those that don’t
work full-time.
Which of the following were you doing last week?
1=Working at a job or business
2=With a job or business but not at work

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3=Looking for work
4=Working, but not for pay, at family-owned job or business
5=Not working at a job or business and not looking for work
………………………………………………………………………………………………
DMO11a. [IF DMO11=2, 3 OR 5 CONTINUE; IF DMO11=1 GO TO DMO11b; IF DMO11=4
GO TO DMO11c; IF DMO11=DK OR RE GO TO DMO12]
What is the main reason you did not…
[IF DMO11=2] work last week?
[IF DMO11= 3 OR] have a job or business last week?
1=TAKING CARE OF HOUSE OR FAMILY
2=GOING TO SCHOOL
3=RETIRED
4=ON A PLANNED VACATION FROM WORK
5=ON FAMILY OR MATERNITY LEAVE
6=TEMPORARILY UNABLE TO WORK FOR HEALTH REASONS
7=HAVE A JOB/CONTRACT AND OFF-SEASON
8=ON LAYOFF
9=DISABLED
10=OTHER
………………………………………………………………………………………………
DMO11a_OTH. [IF DMO11a=10 CONTINUE, ELSE GO TO DMO11b]
What is the other reason you did not…
[IF DMO11=2] work last week?
[IF DMO11=3 OR 5] have a job or business last week?
________________ [ALLOW 60]
………………………………………………………………………………………………
DMO11b.
[IF DMO11=1] Do you have more than one paying job or business?
[IF DMO11=2, 3 OR 5] When you were working, did you normally have more than one paying
job or business?
1=YES
2=NO
………………………………………………………………………………………………

190

DMO11c.
[IF DMO11=1 OR 4] How many hours did you work last week at all jobs or businesses?
[IF DMO11=2, 3 OR 5] How many hours did you usually work at all jobs or businesses?
_______HOURS [ALLOW 000-120]
………………………………………………………………………………………………
DMO11d. [IF (DMO11c LE 34, RE OR DK) AND (DMO11 NE 1 OR 4) CONTINUE, ELSE
GO TO DMO11g]
Do you usually work 35 hours or more per week in total at all jobs or businesses?
1=YES
2=NO
………………………………………………………………………………………………
DMO11f. [IF DMO11=1 OR 4 CONTINUE, ELSE GO TO DMO11g]
Do you currently have paid sick leave on this job or business?
1=YES
2=NO
………………………………………………………………………………………………
DMO11g. Now, I have questions about work you did in {LAST CALENDAR YEAR IN 4
DIGIT FORMAT}.
Did you work for pay at any time in {LAST CALENDAR YEAR IN 4 DIGIT FORMAT}?
1=YES
2=NO
………………………………………………………………………………………………
DMO11h. [IF DMO11g=1 CONTINUE, ELSE GO TO DMO12]
How many months in {LAST CALENDAR YEAR IN 4 DIGIT FORMAT} did you have at least
one job or business?
________________MONTHS [ALLOW 00-12]
………………………………………………………………………………………………

191

DMO11j. [IF DMO11h GE 1 CONTINUE, ELSE GO TO DMO12]
Does your job or business cover any health insurance costs for any of its employees?
1=YES
2=NO
………………………………………………………………………………………………
DMO11k. [IF INS7=2 AND DMO11j=2 CONTINUE, ELSE GO TO DMO12].
Why aren’t you included in your employer’s health insurance plan?
CODE ALL THAT APPLY
1=DO NOT NEED OR WANT ANY HEALTH INSURANCE
2=RARELY SICK
3=TOO MUCH HASSLE/PAPERWORK
4=COULD NOT AFFORD/TOO EXPENSIVE
5=DO NOT WORK ENOUGH HOURS IN A WEEK
6=HAVE NOT WORKED THERE LONG ENOUGH
7=DOUBT ELIGIBLE/REJECTED BECAUSE OF HEALTH CONDITION
8=BENEFIT PACKAGE DIDN’T MEET NEEDS
9=OTHER
………………………………………………………………………………………………
DMO11k_OTH. [IF DMO11k=9 CONTINUE, ELSE GO TO DMO12]
What is the other reason you are not included in your employer’s health insurance plan?
________________ [ALLOW 40]
………………………………………………………………………………………………
DMO12. [IFS2a=1AND INTAGE GE 13 CONTINUE, ELSE GO TO END]
Have you done farm work in the last 24 months, that is since {24 MONTH REFERENCE
DATE}?
1=YES
2=NO
………………………………………………………………………………………………
DMO12a. [IF DMO12=1 CONTINUE, ELSE GO TO END]
Are you currently employed by a grower or rancher, contractor, packing service, packing house
or a non-farm related employer?

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1=GROWER/RANCHER
2=CONTRACTOR
3=PACKING SERVICE
4=PACKING HOUSE
5=NON-FARM RELATED EMPLOYER
………………………………………………………………………………………………
DMO12b. Approximately how many years have you done farm work in the U.S.?
NOTE: COUNT ANY YEAR IN WHICH 15 DAYS OR MORE WERE WORKED
________________ YEARS [ALLOW 000-109]
………………………………………………………………………………………………
DMO12c. Approximately how many years have you done non-farm work in the U.S.?
NOTE: COUNT ANY YEAR IN WHICH 15 DAYS OR MORE WERE WORKED
________________ YEARS [ALLOW 000-109]
………………………………………………………………………………………………
DMO12d. Approximately how many months during the past 12 months, that is since {12
MONTH REFERENCE DATE} have you been in the U.S.?
________________ MONTHS [ALLOW 00-12]
………………………………………………………………………………………………
END. Thank you very much. These are all the questions I have for you today.
1=CONTINUE

193