Form 1 Acculturation Questionnaire

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OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL Visit 2 - Acculturation Questionnaire
FORM CODE: ACE
VERSION: 1, 12/10/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

Administrative Information

/

0a. Completion Date:
Month

/
Day

0b. Staff ID:
Year

Instructions: Enter the answer given by the participant for each response. Use the CDART Notelog window to code
'Don’t know/refused, Missing, etc.' for those questions that do not list these as an option.

A. Acculturation
Although you may speak many languages, the following questions refer to only English and Spanish.
1. In general, what language(s) do you read and speak?
Only Spanish
1
Spanish better than English 2
Both equally
3
English better than Spanish 4
Only English
5
2. What was the language(s) you used as a child?
Only Spanish
1
More Spanish than English 2
Both equally
3
More English than Spanish 4
Only English
5
3. What language(s) do you usually speak at home?
Only Spanish
1
More Spanish than English 2
Both equally
3
More English than Spanish 4
Only English
5
4. In which language(s) do you usually think?
Only Spanish
1
More Spanish than English 2
Both equally
3
More English than Spanish 4
Only English
5

ACE-Aculturation-12-10-2013.docx

ID NUMBER:

FORM CODE: ACE
VERSION: 1, 12/10/2013

Contact
Occasion

0

2

SEQ #

5. What language(s) do you usually speak with your friends?
Only Spanish
1
More Spanish than English 2
Both equally
3
More English than Spanish 4
Only English
5
6. In general, what language(s) are the movies, T.V. and radio programs you prefer to watch and listen to?
Only Spanish
1
More Spanish than English 2
Both equally
3
More English than Spanish 4
Only English
5
7. Your close friends are…
All Hispanic/Latino
More Hispanic/Latino than non-Hispanic/non-Latino
About half and half
More non-Hispanic/non-Latino than Hispanic/Latino
All non-Hispanic/non-Latino

1
2
3
4
5

8. You prefer going to social gatherings/parties at which people are…
All Hispanic/Latino
More Hispanic/Latino than non-Hispanic/non-Latino
About half and half
More non-Hispanic/non-Latino than Hispanic/Latino
All non-Hispanic/non-Latino

1
2
3
4
5

9. The persons you visit or who visit you are…
All Hispanic/Latino
More Hispanic/Latino than non-Hispanic/non-Latino
About half and half
More non-Hispanic/non-Latino than Hispanic/Latino
All non-Hispanic/non-Latino

1
2
3
4
5

10. If you could choose your children’s friends you would want them to be…
All Hispanic/Latino
1
More Hispanic/Latino than non-Hispanic/non-Latino
2
About half and half
3
More non-Hispanic/non-Latino than Hispanic/Latino
4
All non-Hispanic/non-Latino
5

ACE-Aculturation-12-10-2013.docx

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FORM CODE: ACE
VERSION: 1, 12/10/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

B. Visits to Country of Origin
11. In the past year, how many separate times have you returned to your country of origin/your family’s country of
origin?
Times
12. Across all visits in the past year, for approximately how long did you stay in your country of origin/your
family’s country of origin?
Days OR

ACE-Aculturation-12-10-2013.docx

Months

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