Download:
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pdfAppendix B: List of Potential Questionnaire Items
The instrument for each cycle of data collection will draw from this list of potential questionnaire items. Each instrument will be
designed to take no longer than 30 minutes to complete. Each final data collection instrument will be submitted to OMB for review and
approval prior to going to the field.
Construct
Affective
Forecasting
Affective
Forecasting
Affective
Forecasting
Affective
Forecasting
Alcohol
Alcohol
Alcohol
Ambiguity
aversion
Question
If I did not get screened forspecific type of cancer] intime frame
specified in corresponding intentions question], I would feel
regret.
If I did notinsert exercise/diet/screening intention here from
prior question] in thespecified intention time frame], I would
feel regret.
Response Options
Strongly disagree; Moderately disagree; Neither
agree nor disagree; Moderately agree; Strongly
agree
Strongly disagree; Moderately disagree; Neither
agree nor disagree; Moderately agree; Strongly
agree
Sometimes people can feel like something is both good and bad
at the same time. Please indicate below how you would feel/felt
7-point likert scale anchored by Strongly Disagree
about getting/having cancer 1. Getting cance (or getting cancer
Strongly Agree
again) would be/Having cancer was: The best thing to happen
in my life 2. Getting cancer w
Sometimes people can feel like something is both good and bad
at the same time. Please indicate below how you would feel/felt
7-point likert scale anchored by Strongly Disagree
about getting/having cancer 1. Getting cancer would be/Having
Strongly Agree
cancer was: The best thing to happen in my life 2. Getting
cancer w
A drink of alcohol is 1 can or bottle of beer, 1 glass of wine, 1 can
or bottle of wine cooler, 1 cocktail, or 1 shot of liquor. During the
past 30 days, how many days per week did you have at least one
drink of any alcoholic beverage?
During the past 30 days, on the days when you drank, about how
many drinks did you drink on the average?
In the past 12 months have you tried to reduce your intake of
alcoholic beverages?
If experts had conflicting opinions about a medical test or
Strongly disagree; Disagree; Agree; Strongly agree
treatment, I would still be willing to try it.
Attention to health Have you heard inconsistent or differing advice from the media
yes; no
information
(e.g., television, newspapers) aboutmammograms/ PSA]?
I have paid no attention, I have paid a little
Attention to health How closely have you followed the debate about mammography
attention, I have paid a lot of attention, I did not
information
in women under the age of 50?
know there was a debate
I have paid no attention, I have paid a little
Attention to health How closely have you followed the debate aboutmammography
attention, I have paid a lot of attention, I did not
information
in women under the age of 50/ PSA testing]?
know there was a debate
Attention to health How has the debate affected how you understand
information
recommendations about mammography?
I am more confused, No change in my
understanding, I am less confused
Attention to health How has the debate affected how you understand
information
recommendations about PSA testing?
I am more confused, No change in my
understanding, I am less confused
Attention to health How much attention do you pay to information about health or
information
medical topics in general magazines?
None to A lot
Attention to health How much attention do you pay to information about health or
information
medical topics in online newspapers?
None to A lot
Attention to health How much attention do you pay to information about health or
information
medical topics in print newspapers?
None to A lot
How much attention do you pay to information about health or
Attention to health
medical topics in special health or medical magazines or
information
newsletters magazines?
None to A lot
Page 1
Construct
Question
Response Options
Attention to health How much attention do you pay to information about health or
information
medical topics on the Internet?
Attention to health How much attention do you pay to information about health or
information
medical topics on the radio?
Attention to health
I am upset when experts disagree about mammograms
information
strongly disagree – strongly agree
Attention to health
I am upset when experts disagree about PSA testing
information
strongly disagree – strongly agree
Some cable and national television news programs include
Attention to health special segments of their newscasts that focus on health issues.
Yes; No
About how often have you watched such cable or national health
information
segments in the past 30 days?
Some local television news programs include special segments
Attention to health of their newscasts that focus on health issues. About how often
0 - 30
information
have you watched such local health segments in the past 30
days?
Some people notice information about health on the Internet,
Attention to health even when they are not trying to find out about a health concern
Yes; No; Refused; Don't know;
information
they have or someone in the family has. Have you read such
health information on the Internet in the past 12 months?
Some people notice information about health on the Internet,
Attention to health even when they are not trying to find out about a health concern
Yes; No; Refused; Don't know;
information
they have or someone in the family has. Have you read such
health information on the Internet in the past 30 days?
Some people notice information about health on the Internet,
Attention to health even when they are not trying to find out about a health concern
Yes; No
information
they have or someone in the family has. Have you read such
health information on the Internet in the past 30 days? (Y/N)
Autonomy Support
Autonomy Support
Autonomy Support
Autonomy Support
Autonomy Support
Autonomy Support
Autonomy Support
Autonomy Support
Strongly Disagree; Moderately Disagree; Slightly
I am able to be open with my health care practitioners about my
Disagree; Neutral; Slightly Agree; Moderately
health
Agree; Strongly Agree
Strongly Disagree; Moderately Disagree; Slightly
I dont feel very good about the way my health care practitioners
Disagree; Neutral; Slightly Agree; Moderately
talk to me about my health.
Agree; Strongly Agree
Strongly Disagree; Moderately Disagree; Slightly
Disagree; Neutral; Slightly Agree; Moderately
I feel a lot of trust in my health care practitioners.
Agree; Strongly Agree
Strongly Disagree; Moderately Disagree; Slightly
I feel able to share my feelings with my health care practitioners. Disagree; Neutral; Slightly Agree; Moderately
Agree; Strongly Agree
Strongly Disagree; Moderately Disagree; Slightly
I feel my health care practitioners understand how I see things
Disagree; Neutral; Slightly Agree; Moderately
with respect to my health.
Agree; Strongly Agree
Strongly Disagree; Moderately Disagree; Slightly
I feel that my health care practitioners accept me whether I
Disagree; Neutral; Slightly Agree; Moderately
follow their recommendations or not.
Agree; Strongly Agree
Strongly Disagree; Moderately Disagree; Slightly
I feel that my health care practitioners care about me as a
Disagree; Neutral; Slightly Agree; Moderately
person.
Agree; Strongly Agree
Strongly Disagree; Moderately Disagree; Slightly
I feel that my health care practitioners have provided me
Disagree; Neutral; Slightly Agree; Moderately
choices and options about my health.
Agree; Strongly Agree
Page 2
Construct
Autonomy Support
Autonomy Support
Autonomy Support
Autonomy Support
Autonomy Support
Autonomy Support
Autonomy Support
Autonomy Support
Question
Response Options
Strongly Disagree; Moderately Disagree; Slightly
My health care practitioners answer my questions related to my
Disagree; Neutral; Slightly Agree; Moderately
health fully and carefully.
Agree; Strongly Agree
Strongly Disagree; Moderately Disagree; Slightly
My health care practitioners convey confidence in my ability to
Disagree; Neutral; Slightly Agree; Moderately
make changes regarding my health.
Agree; Strongly Agree
Strongly Disagree; Moderately Disagree; Slightly
Disagree; Neutral; Slightly Agree; Moderately
My health care practitioners encourage me to ask questions.
Agree; Strongly Agree
Strongly Disagree; Moderately Disagree; Slightly
Disagree; Neutral; Slightly Agree; Moderately
My health care practitioners encourage me to ask questions.
Agree; Strongly Agree
Strongly Disagree; Moderately Disagree; Slightly
Disagree; Neutral; Slightly Agree; Moderately
My health care practitioners handle my emotions very well.
Agree; Strongly Agree
My health care practitioners have made sure I really understand Strongly Disagree; Moderately Disagree; Slightly
my health risk behaviors and the benefits of changing these
Disagree; Neutral; Slightly Agree; Moderately
behaviors without pressuring me to do so.
Agree; Strongly Agree
Strongly Disagree; Moderately Disagree; Slightly
My health care practitioners listen to how I would like to do
Disagree; Neutral; Slightly Agree; Moderately
things regarding my health.
Agree; Strongly Agree
Strongly Disagree; Moderately Disagree; Slightly
My health care practitioners try to understand how I see my
Disagree; Neutral; Slightly Agree; Moderately
health before suggesting any changes.
Agree; Strongly Agree
Avoidance
Are there any other reasons why you avoid seeing your doctor? Yes; No; Refused; Don't know;
Avoidance
I avoid seeing my doctor because I fear I may have a serious
illness.
Avoidance
Avoidance
Avoidance
Strongly agree; Somewhat agree; Somewhat
disagree; Strongly disagree;
Strongly agree; Somewhat agree; Somewhat
I avoid seeing my doctor because it makes me think about dying.
disagree; Strongly disagree;
Strongly disagree; somewhat disagree; somewhat
I avoid seeing my doctor because of financial concerns
agree; strongly agree
I don’t want to know my risk for getting cancer if there is little I
can do to lower my risk
Avoidance
I would not want to know if I had a cancer that was difficult to
treat
Extremely not like me, Somewhat not like me,
Uncertain, Somewhat like me, Extremely like me
Avoidance
I’d rather not know my chances of getting cancer.
Extremely not like me; Somewhat not like me;
Uncertain; Somewhat like me; Extremely like me
Avoidance
If I had cancer, I wouldn’t want to know.
Extremely not like me; Somewhat not like me;
Uncertain; Somewhat like me; Extremely like me
Avoidance
Avoidance
Behavior change
Behavior change
Behavior change
Behavior change
Behavior change
Some people avoid visiting their doctor even when they suspect
they should. Would you say this is true for you, or not true for True; Not true;
you?
Some people who are concerned they may have cancer avoid
visiting their doctor even when they should. Would you say this True; Not true;
is true for you, or not true for you?
How often in the past 12 months have you tried to decrease the
Number of times
amount of fat in your diet?
How often in the past 12 months have you tried to increase the
amount of physical activity or exercise you get?
How often in the past 12 months have you tried to increase your
fruit and vegetable intake?
How often in the past 12 months have you tried to reduce the
number of sugar-sweetened beverages you consume?
How successful do you feel you were in your attempts to
decrease the amount of fat in your diet?
Page 3
Number of times
Number of times
Number of times
1-5 where 1= not at all successful and 5= very
successful
Construct
Behavior change
Behavior change
Behavior change
Behavior change
Bodily Pain
Bodily Pain
Question
Response Options
How successful do you feel you were in your attempts to
increase the amount of physical activity or exercise you get?
1-5 where 1= not at all successful and 5= very
successful
How successful do you feel you were in your attempts to manage 1-5 where 1= not at all successful and 5= very
your weight in the past 12 months?
successful
How successful would you rate your attempts to reduce the
1-5 where 1= not at all successful and 5= very
number of sugar-sweetened beverages you consume?
successful
o How successful do you feel you were in your attempts to
1-5 where 1= not at all successful and 5= very
increase your fruit and vegetable intake?
successful
During the past 4 weeks, how much did bodily pain interfere
Not at all; A little bit; Moderately; Quite a bit;
with your work, including work outside the home and
Extremely
housework?
None; Very Mild; Mild; Moderate; Severe; Very
How much bodily pain have you had during the past 4 weeks?
Severe
Bracing
The closer I get to hearing important news, the more I imagine
the worst will happen.
Extremely not like me; Somewhat not like me;
Uncertain; Somewhat like me; Extremely like me
Breast cancer
4. Has a doctor ever told you that no one is sure if routinely
recommending mammograms for women in their 40s actually
saves lives?
Yes; No; Dont know
Breast cancer
A mammogram is an x-ray of each breast to look for breast
cancer. During the past 12 months, did a doctor, nurse, or other
health professional advise you to get a mammogram?
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
A mammogram is an x-ray of each breast to look for breast
cancer. Have you ever had a mammogram?
A mammogram is an x-ray of each breast to look for cancer.
When did you have your most recent mammogram to check for
breast cancer, if ever?
Before you had the mammogram, did you and a doctor or other
health care professional talk about it?
Compared to the average woman your age, would you say that
you are more likely to get breast cancer, less likely, or about as
likely?
Has a doctor ever asked you whether or not you wanted to have
a mammogram?
Has a doctor ever told you that some doctors routinely
recommend mammograms for women in their 40s and others
do not?
Has a doctor ever told you that… a. Mammograms for women in
their 40s are not always accurate? b. Some types of breast
cancer are slow-growing and need no treatment?
Has your doctor ever told you that experts disagree about
whether recommending mammograms for women in their 40s
actually saves lives?
Have at least one of these biopsies had atypical hyperplasia?
More likely to get breast cancer; Less likely; About
as likely; Don't know; Refused;
Yes; No
Yes; No; Dont know
Yes; No; Not sure
Yes; No; Dont know
No;Yes
Have you and a doctor or other health care professional talked
about mammograms?
Have you thought about getting a mammogram?
How likely do you think it is that you will develop breast cancer
in the future?
How long before your most recent mammogram was the last
one?
How many breast biopsies have you had?
Open ended
How many of your first degree relatives (parents, siblings,
Open ended
children) have had breast cancer?
How often do you worry about getting breast cancer?
Page 4
Construct
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Built Environment
Built Environment
Built Environment
Built Environment
Built Environment
Question
Response Options
If had a mammogram: Before you had the mammogram, did you
and a doctor talk about it?;; if not had a mammogram: Did you Yes; No; DON’T KNOW/DON’T REMEMBER
and a doctor talk about mammograms?
In general, once women start having mammograms, about how
often should they have them?
Is there any particular reason why you haven't had a
mammogram?
When did you and a doctor or other health care professional talk
about your mammogram, if ever?
More often than once a year; Every 1 to < 2 years;
Every 3 to < 5 years; Only when there is a
problem; Other (specify); Don't know; Refused;
Not ascertained; When doctor/health provider
recommends; Depends on age; Every 5 to < 10
years; Ev
Free text (see on-line HINTS codebook for full list
of responses)
A year ago or less; More than 1 but not more than
When did you have your most recent mammogram to check for 2 years ago; More than 2 but not more than 5
breast cancer?
years ago; Over 5 years ago; Refused; Don't
know;
A year or less from now; More than 1 but not more
than 2 years from now; Over 5 years from now;
Refused; Don't know; When doctor/health
When do you expect to have your next mammogram?
provider recommends; More than 2 but not more
than 5 years from now;
Would you say that you plan to get a mammogram, you don't
You plan to get one; You don't plan to get one;
plan to get one, or you're undecided?
Refused; Don't know; You're undecided;
“Community" refers to the place where you live, including your
neighborhood and the neighborhoods within a 10-minute walk N/A
from your home.
During the last 30 days how often did you use any of these
(number of times)
places to be physically active?
During the last 30 days how often did you use any of this
number of times)
equipment to be physically active?
How safe from crime do you feel while you are walking or riding Extremely safe, quite safe, slightly safe, or not at all
your bike in your community
safe)
How safe from traffic do you feel while you are walking or riding Extremely safe, quite safe, slightly safe, or not at all
your bike in your community?
safe)
Built Environment I often walk to places near my home
(yes/no)
There are many destinations (for example, a store, a workplace,
Built Environment a place of worship) to go within easy walking distance from my
home.
There are many places to be physically active in my community
Built Environment
not including streets for walking or jogging.
There is equipment available for physical activity in my
Built Environment
community
• How often do you think about your experience with cancer as
(please rate each one; (1 = never, 5 = very frequently): … a
Cancer
“journey” that has a beginning, ups and downs along the way,
perceptions
and a destination?
…a “weight” that you carry … a “battle”
or “fi
• People with cancer have often talked about their experience
in different ways. When you think about yourself in relation to
Cancer
your cancer, how much do you think each of these phrases
perceptions
describes you? (on 1[not at all] 2[slightly], 3[somewhat],
4[moderately]
Cancer
• Since being treated for cancer, I find it harder to think
perceptions
through all of the alternatives before acting.
There are many destinations (for example, a store,
a workplace, a place of worship) to go within easy
walking distance from my home.
Page 5
(strongly agree, agree, disagree, strongly disagree)
strongly agree, agree, disagree, strongly disagree
1 (never) to 5 (frequently)
1[not at all] 2[slightly], 3[somewhat],
4[moderately], 5very much])
1 (strongly agree) to 5 (strong disagree)
Construct
Question
Response Options
Cancer
perceptions
• When you think about people who have cancer, how much
does each of these phrases describe them? (on 1[not at all] to
1 (not at all) to 5 (very much)
5very much]) A) a cancer victim B) a cancer patient C) a person
who had cancer D) a cancer survivor E) a cancer warrior
Cancer
perceptions
• When you think about yourself in relation to your cancer, how
much does each of these phrases describe you? (on 1[not at all]
1[not at all]; 2; 3;4;[very much])
to 5very much]) A) a cancer victim B) a cancer patient C) a
person who had cancer D) a cancer survivor E) a cancer warrior
Cancer
perceptions
Colon/Lung/Skin cancer is most often caused by a person's
behavior or lifestyle.
Agree; Disagree; Refused; Don't know;
Cancer
perceptions
Getting checked regularly for colon/lung/skin cancer increases
the chances of finding cancer when it's easy to treat.
Agree; Disagree; Refused; Don't know;
Cancer
perceptions
Cancer
perceptions
Cancer
perceptions
How much do you agree or disagree with the following
statements? Cancer is most often caused by a person's behavior
or lifestyle.
How much do you agree or disagree with the following
statements? When I think of cancer, I automatically think of
death.
How often do you think about other people with cancer as:
…being on a “journey” that has a beginning, ups and downs
1[not at all] 2[slightly], 3[somewhat],
along the way, and a destination? (1[not at all] 2[slightly],
4[moderately], 5very much])
3[somewhat], 4[moderately], 5very much])). …having a “weight”
that they carry
Cancer
perceptions
How often do you think about other people with cancer as:
o …being on a “journey” that has a beginning, ups and downs
along the way, and a destination?
…having a “weight” that
they carry … being in a “battle” or “fight” with an opponent
Cancer
perceptions
How often do you think about your experience with cancer as
(please rate each one; (1[not at all] 2[slightly], 3[somewhat],
1[not at all] 2[slightly], 3[somewhat],
4[moderately], 5very much])): … a “journey” that has a
4[moderately], 5very much])
beginning, ups and downs along the way, and a destination? …a
“weight” that y
Cancer
perceptions
It seems like almost everything causes colon/lung/skin cancer.
Cancer
perceptions
Cancer
perceptions
Cancer
perceptions
Cancer
perceptions
Cancer
perceptions
People with cancer have often talked about their experience in
different ways. When you think about people who have had
breast cancer, how much do you think each of these phrases
describes them? (1[not at all] 2[slightly], 3[somewhat],
4[moderately], 5very
People with cancer have often talked about their experience in
different ways. When you think about people who have had lung
cancer, how much do you think each of these phrases describes
them? (1[not at all] 2[slightly], 3[somewhat], 4[moderately],
5very m
People with cancer have often talked about their experience in
different ways. When you think about yourself in relation to
your cancer, how much do you think each of these phrases
describes you? (on 1[not at all] 2[slightly], 3[somewhat],
4[moderately], 5very much]) A) a cancer patient B) a cancer
warrior C) a person who has had cancer D) a cancer victim E) a
cancer survivor
Physical activity or exercise can help lower your chances of
getting which type of cancer?
Since being treated for cancer, I find it harder to multi-task (that
is, to do two or more things at the same time).
Page 6
1 (never) to 5 (frequently)
Agree; Disagree; Refused; Don't know;
1[not at all] 2[slightly], 3[somewhat],
4[moderately], 5very much])
1[not at all] 2[slightly], 3[somewhat],
4[moderately], 5very much])
1[not at all]; 2; 3;4;[very much])
Breast cancer;
1 (strongly agree); 5 (strongly disagree)
Construct
Cancer
perceptions
Cancer
perceptions
Cancer
perceptions
Question
Since being treated for cancer, I find that I am good at resisting
temptation
Since being treated for cancer, I find that I have trouble
concentrating
There's not much you can do to lower your chances of getting
colon/lung/skin cancer.
Cancer
perceptions
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree with the following statements or do
you have no opinion: It seems like everything causes cancer.
Cancer
perceptions
Cancer
perceptions
Cancer
perceptions
Cancer related
knowledge
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree with the following statements or do
you have no opinion: There are so many different
recommendations about preventing cancer, it's hard to know
which ones to follow.
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree with the following statements or do
you have no opinion: There's not much you can do to lower your
chances of getting cancer.
You said you should get tested for cancer. What kinds of tests do
you have in mind?
‘I’m going to list some symptoms that may or may not be
warning signs for cancer. For each one can you tell me the extent
to which you think that it is a warning sign for cancer: An
unexplained lump or swelling; Persistent unexplained pain;
Unexplained ble
Response Options
1 (strongly agree); 5 (strongly disagree)
1 (strongly agree); 5 (strongly disagree)
Agree; Disagree; Refused; Don't know; Agree;
Disagree; Refused; Don't know;
Free text (see on-line HINTS codebook for full list
of responses)
Definitely not a warning sign; Probably not a
warning sign; Probably is a warning sign; Definitely
is a warning sign; Refused; Missing
Cancer related
knowledge
Awareness and Beliefs about Cancer (ABC) Measure
Definitely not a warning sign; Probably not a
warning sign; Probably is a warning sign; Definitely
is a warning sign; Refused; Missing
Cancer related
knowledge
Have you ever heard of "chemobrain"
Yes; no
Cancer related
knowledge
Have you ever heard or read somewhere that some people can
experience memory or other cognitive problems after
completing chemotherapy for cancer treatment?
Have you ever heard or read somewhere that some people can
experience memory or other cognitive problems after
completing chemotherapy for cancer?
How likely is it that someone will experience significant memory
or other cognitive problems after chemotherapy for cancer
cognitive problems like concentration or multi-tasking that
could interfere with work, for example?
People being treated for cancer may have trouble concentrating
or remembering things.
Cancer Risk
Perceptions
{Cancer/Lung Cancer/Skin Cancer/Breast Cancer/Cervical
Cancer/Prostate Cancer} in the United States is:
Cancer Risk
Perceptions
much less likely than cancer1]; less likely than
Compared to cancer, how likely are you to {get heart disease/get
cancer2]; about the same as cancer3]; more likely
diabetes/have a stroke/be in a serious car crash}?
than cancer4]; much more likely than cancer5]
Cancer related
knowledge
Cancer related
knowledge
Cancer related
knowledge
Cancer Risk
Perceptions
Cancer Risk
Perceptions
Cancer Risk
Perceptions
Compared with other {men/women] your age, how likely are
you to get {cancer/lung cancer/skin cancer/breast cancer/
cervical cancer/prostate cancer} in your lifetime?
Do you think that being a particular race or ethnicity increases a
person's chances of getting cancer a lot, a little, or not at all or do
you have no opinion?
Do you think that being hit in the breast increases a person's
chances of getting cancer a lot, a little, or not at all or do you
have no opinion?
Page 7
Yes; Unsure; No
Yes/Unsure/No
Very likely, Somewhat likely, Somewhat unlikely,
Very Unlikely, not at all
very rare; moderately rare; slightly rare; neither
rare nor common; slightly common; moderately
common; very common
much less likely1]; less likely2]; about the same3];
more likley4]; much more likely5]
A lot; A little; Refused; Don't know; No opinion;
Not at all;
A lot; Don't know; No opinion; Not at all; A little;
Construct
Cancer Risk
Perceptions
Cancer Risk
Perceptions
Cancer Risk
Perceptions
Cancer Risk
Perceptions
Cancer Risk
Perceptions
Cancer Risk
Perceptions
Cancer Risk
Perceptions
Cancer Risk
Perceptions
Cancer Risk
Perceptions
Cancer Risk
Perceptions
Question
Do you think that drinking a lot of alcoholic beverages increases
a person's chances of getting cancer a lot, a little, or not at all or
do you have no opinion?
Do you think that eating a high fat diet increases a person's
chances of getting cancer a lot, a little, or not at all or do you
have no opinion?
Do you think that exposure to the sun increases a person's
chances of getting cancer a lot, a little, or not at all or do you
have no opinion?
Do you think that having a family history of cancer increases a
person's chances of getting cancer a lot, a little, or not at all or do
you have no opinion?
Do you think that having many sexual partners increases a
person's chances of getting cancer a lot, a little, or not at all or do
you have no opinion?
Do you think that not eating many fruits and vegetables
increases a person's chances of getting cancer a lot, a little, or
not at all or do you have no opinion?
Do you think that not eating much fiber increases a person's
chances of getting cancer a lot, a little, or not at all or do you
have no opinion?
Do you think that not getting much exercise increases a person's
chances of getting cancer a lot, a little, or not at all or do you
have no opinion?
Do you think that pesticides or food additives increase a
person's chances of getting cancer a lot, a little, or not at all or do
you have no opinion?
Do you think that pollution increases a person's chances of
getting cancer a lot, a little, or not at all or do you have no
opinion?
Response Options
A lot; No opinion; Refused; Not at all; A little;
Don't know;
A lot; No opinion; A little; Not at all; Refused;
Don't know;
A lot; A little; Not at all; Refused; Don't know; No
opinion;
A lot; Not at all; Don't know; No opinion; A little;
A lot; A little; Refused; Don't know; No opinion;
Not at all;
A lot; Not at all; Don't know; No opinion; A little;
A lot; A little; Not at all; No opinion; Don't know;
Cancer Risk
Perceptions
Do you think that radon increases a person's chances of getting
cancer a lot, a little, or not at all or do you have no opinion?
Cancer Risk
Perceptions
Do you think that smoking increases a person's chances of
getting cancer a lot, a little, or not at all or do you have no
opinion?
Cancer Risk
Perceptions
Do you think that stress increases a person's chances of getting
cancer a lot, a little, or not at all or do you have no opinion?
A lot; A little; Not at all; No opinion; Don't know;
Refused;
Cancer Risk
Perceptions
How likely are you to get {cancer/lung cancer/ skin cancer/
breast cancer/ cervical cancer/ prostate cancer} in your
lifetime?
very unlikely (1); unlikely (2); neither unlikely nor
likely (3); likely (4); very likely (5)
Cancer Risk
Perceptions
How likely are you to get colon/lung/skin cancer compared to
the average person your age?
Cancer Risk
Perceptions
How likely do you think it is that you will develop cancer in the
future?
Cancer Risk
Perceptions
How likely is it that the average {male/female} cigarette smoker very unlikely (1); unlikely (2); neither unlikely nor
your age will develop lung cancer in {his/her} lifetime?
likely (3); likely (4); very likely (5)
Cancer Risk
Perceptions
How likely is it that the average {man/woman} your age will
develop {cancer/ lung cancer/ skin cancer/ breast cancer/
cervical cancer/ prostate cancer} in {his/her} lifetime?
very unlikely (1); unlikely (2); neither unlikely nor
likely (3); likely (4); very likely (5)
Cancer Risk
Perceptions
How often do you worry about getting cancer?
Rarely or never; Sometimes; Often; All the time;
Cancer Risk
Perceptions
How will your chances of getting cancer change as you get
older? My chance will...
go up a lot as I get older; go up a little as I get older;
not change as I get older; go down a little as I get
older; go down a lot as I get older
Page 8
A lot; A little; Refused; Don't know; No opinion;
Not at all;
More likely to get cancer; Less likely; About as
likely; Refused; Don't know; Rarely or never;
Sometimes; Often; All the time; Refused; Don't
know;
Very low; Somewhat low; Moderate; Somewhat
high; Very high; Don't know;
Construct
Cancer Screening
Knowledge
Cancer Screening
Knowledge
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Question
How often do you thinkPSA/mammogram/colonoscopy] could
suggest there is noProstate cancer/breast cancer/colon cancer]
when there is cancer present?
How often do you thinkPSA/mammogram/colonoscopy] could
suggestProstate cancer/breast cancer/colon cancer] when there
is none present?
I was able to actively participate in decisions about my
treatment
Response Options
All the time; Most of the time; Some of the time; A
little of the time; It never makes a mistake
All the time; Most of the time; Some of the time; A
little of the time; It never makes a mistake
SA, A, D, SD
It is easy for me to get information about my cancer
SA, A, D, SD
(For smokers only): In the last 12 months, did your follow-up
care doctor or someone from your doctors office or clinic talk
with you about your smoking?
Yes, definitely; Yes, somewhat; No
Are you currently receiving cancer treatment?
At what age were you first told that you had cancer?
Cancer
survivorship
Did any doctor, nurse, or other health professoinal EVER give
you a written summary of all the cancer treatments that you
received?
Did you participate in a clinical trial as part of your cancer
treatment?
Has a doctor, nurse, or other health professional EVER given you
a summary of all the cancer treatments that you received that
was accessible on the Internet?
Has any doctor or other health care professional ever discussed
with you what late or long-term side effects of cancer treatment
you may experience over time?
Have you EVER received instructions from a doctor, nurse, or
other health professional about where you should return or who
you should see for routine cancer check-ups after completing
your treatment for cancer?
How would you rate your follow-up care doctors knowledge of
how cancer and the medical treatments you received for cancer
have affected your quality of life?
How would you rate your follow-up care doctors knowledge of
your medical history?
Cancer
survivorship
How would you rate your follow-up care doctors knowledge of
your responsibilities at home, work, or school?
Poor; Fair; Good; Very good; Excellent
I am confident I can manage my cancer
SA, A, D, SD
I am confident in my ability to understand cancer materials
SA, A, D, SD
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Yes; No; Dont know/Not sure
Yes; No; Dont know/Not sure
Yes; No; Dont know/Not sure
Yes, discussed in detail; Yes, discussed somewhat;
No, did not discuss
Yes; No; Dont know/Not sure
Poor; Fair; Good; Very good; Excellent
Poor; Fair; Good; Very good; Excellent
Cancer
survivorship
In the last 12 months, how often did your follow-up care doctor
give you clear instructions about what to do if your symptoms or Never; Sometimes; Usually; Always
side effects got worse or came back?
Cancer
survivorship
In the last 12 months, did your follow-up care doctor or
someone from your doctors office or clinic give you the help you I didnt want help with this; Yes, definitely; Yes,
wanted to make changes in your habits or lifestyle that would
somewhat; No
improve your health or prevent illness?
Cancer
survivorship
In the last 12 months, did your follow-up care doctor or
someone from your doctors office or clinic give you the help you I didnt want help with this; Yes, definitely; Yes,
wanted to make changes in your habits or lifestyle that would
somewhat; No
improve your health or prevent illness?
Cancer
survivorship
In the last 12 months, did your follow-up care doctor or
someone from your doctors office or clinic talk with you about
how much or what kind of exercise you get?
Page 9
Yes, definitely; Yes, somewhat; No
Construct
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Question
In the last 12 months, did your follow-up care doctor or
someone from your doctors office or clinic talk with you about
how much or what kinds of foods you eat?
In the last 12 months, did your follow-up care doctor or
someone from your doctors office or clinic talk with you about
specific things you could do to improve your health or prevent
illness?
In the last 12 months, did your follow-up care doctor order any
medical tests to check for signs of cancer or other medical
problems?
In the last 12 months, how often did your follow-up care doctor
give you the help you wanted to take care of the symptoms or
side effects that were bothering you?
In the last 12 months, how often did your follow-up care doctor
seem informed and up-to-date about the care you received from
any other doctors or health professionals you saw for cancerrelated issues or problems?
Response Options
Yes, defnitely; Yes, somewhat; No
Yes, definitely; Yes, somewhat; No
Yes; No
Never; Sometimes; Usually; Always
I didnt see any other doctor/health professional for
cancer-related issues in the last 12 months
I made the decisions with little or no input from my
doctor; I made the decisions after seriously
considering my doctors opinion; My doctor and I
made the decision together; My doctor made the
decision after seriously considering my opinion;
My docto
Cancer
survivorship
In the last 12 months, how were the decisions about how to
treat your symtoms or side effects made?
Cancer
survivorship
In the last 12 months, in your opinion, how often did your followup care doctor, the nurses, and staff at your follow-up care
Never; Sometimes; Usually; Always
doctors office or clinic seem to work well together as a team?
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
Cancer
survivorship
In the last 12 months, were you bothered by any symptoms or
treatment-related side effects?
In the last 12 months, when you received any medical tests
ordered by your follow-up care doctor, how often did you get
the tests results in a timely manner?
In the last 12 months, when you received any medical tests
ordered by your follow-up care doctor, how often did your
doctor or someone from your doctors office or clinic explain the
test results in a way you could understand.
In the past 12 months, did you discuss any of these symptoms or
side effects with your follow-up care doctor?
In the past 2 years, when your cancer-related follow up care
doctor(s) ordered any medical tests, how often was the need for
or purpose of these tests explained to you in a way you would
understand?
It is easy for me to ask my doctor questions
Yes; No
Never; Sometimes; Usually; Always
Never; Somtimes; Usually; Always
Yes; No
Never; Sometimes; Usually; Always
SA, A, D, SD
Were these instructions written down or printed on paper for
you? (NOTE: This item is asked in relationship to "Have you
EVER received instructions . . . about where you should return or Yes; No; Dont know/Not sure
who you should see . . . after completing treatment for your
cancer)
Were you EVER denied health insurance or life insurance
Yes; No; Dont know/Not sure
coverage because of your cancer?
Cancer Surgeon; Family Practitioner; General
Surgeon; Gynecologic Oncologist; Internist; Plastic
What type of doctor provides the majority of your health care? Surgeon, Reconstructive Surgeon; Medical
Oncologist; Radiation Oncologist; Urologist; Other;
Dont know/Not sure
Which of the following cancer treatments have you ever
received?
Page 10
Construct
Question
Response Options
Cancer
survivorship
Which of the following options best describes your level of
My level of involvement was less than what I
involvement in making the decisions about how your symptoms wanted; My level of involvement was just right; My
or side-effects should be treated?
level of involvement was more than what I wanted
Cancer
survivorship
With your most recent diagnosis of cancer, did you have health
insurance that paid for all or part of your cancer treatment?
Cervical Cancer
Cervical Cancer
There are situations where people provide regular care or
assistance to a family member or friend who is elderly or has a
long-term illness or disability. During the past month, did you
provide any such care or assistance to a family member or
friend who is 60 years of age or older?
A vaccine to prevent HPV infection is available and is called the
cervical cancer vaccine or HPV shot. Before today, have you
ever heard of the cervical cancer vaccine or HPV shot?
A vaccine to prevent HPV infection is available and is called the
HPV shot, cervical cancer vaccine, GARDASIL®, or Cervarix®.
Has a doctor or other health care professional ever talked with
you about the HPV shot or vaccine?
A vaccine to prevent the human papillomavirus or HPV infection
is recommended for girls ages 11-12 and is called the cervical
cancer vaccine, HPV shot, or GARDASIL. If you had a daughter
that age, would you have her get it?
Before you had the Pap test, did you and a doctor or other health
care professional talk about it?
Do you plan to get another dose of the HPV vaccine for your
daughter (son?) in the next 12 months?
Do you think HPV can cause abnormal Pap smears?
Do you think HPV can cause cervical cancer?
Cervical Cancer
Do you think HPV can go away on its own, without treatment?
Caregiver
Preparedness
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cervical Cancer
Cervical Cancer
Do you think women who get the cervical cancer vaccine or HPV
shot should continue to get screened for cervical cancer with the
Pap test?
Do you think you can get HPV through sexual contact?
Has a doctor or other health care professional ever
recommended thatYOU OR YOUR CHILD/DAUGHTER/SON]
receive HPV shots?
Have you ever been told by a health care provider that you had a
human papillomavirus or HPV infection?
Have you ever been treated for genital warts?
Have you ever had a Pap smear or Pap test?
Have you ever heard of HPV? HPV stands for Human
Papillomavirus. It is not HIV, HSV, or herpes.
How long ago did you have your most recent Pap test to check
for cervical cancer?
How many HPV doses or shots did your daughter (son?)
receive?
The HPV vaccine has recently been recommended for boys to
prevent genital warts. Now thinking about your SON.. Do you
plan to get the HPV vaccine for your him?
Yes; No; Dont know/Not sure
Yes; No; Refused; Don't know;
Yes; No; Not sure/It depends; Refused; Don't
know;
yes; no; dont know
Yes; No; Refused; Don't know;
Yes; No; Refused; Don't know;
Yes; No; Refused; Don't know;
Yes; No; Refused; Don't know;
Yes; No; Don't know;
Yes; No; Refused; Don't know;
Yes; No; Refused; Don't know;
Yes; No; Refused; Don't know;
Yes; No;
1 dose; 2 doses; 3 doses; dont know; refuse
Yes; no; dont know
She doesn't need the vaccine or shot; My child is
not sexually active; It is too expensive; She is too
What is the main reason you would not let your daughter get the
old for the vaccine; Doctor has not recommended
cervical cancer vaccine?
it; Worried about safety of vaccine; I don't know
where to get vaccine; My spouse/family mem
Page 11
Construct
Cervical Cancer
Cervical Cancer
Cervical Cancer
Question
What was the main reason that you had this Pap test?
When did you and a doctor or other health care professional talk
about your Pap test, if ever?
When did you have your most recent Pap test?
Cervical Cancer
When did you have your most recent Pap test?
Cervical Cancer
When do you expect to have your next Pap test?
Cervical Cancer
Cervical Cancer
Cervical Cancer
Chemical
Exposures
Chemical
Exposures
Chemical
Exposures
Chemical
Exposures
Response Options
Routine annual Pap test or part of routine physical
exam; Last Pap test was not normal; A specific
problem; Never had one and thought you should;
Pregnancy/Followup to birth; Other; Refused;
Don't know;
1 year ago or less; More than 1 but not more than
3 years ago; More than 3 but not more than 5
years ago; More than 5 years ago; Refused; Don't
know;
A year or less from now; More than 1 but not more
than 3 years from now; More than 3 but not more
than 5 years from now; Over 5 years from now;
When do you expect to have your next Pap test?
Not planning to have another; If I have symptoms;
When doctor/health care provider recommends;
Refu
Had Pap Screen within last 3 yrs; Had Pap Screen
When was your last Pap Screen? Guidelines based on
recommendations from the U.S. Preventive Services Task Force, more than 3 yrs ago; Never had Pap Screen;
Refused; Don't Know;
2005.
Would you agree to have Pap smears every three years if your
Yes; No; Refused; Don't know;
health care provider recommended it?
Do you feel that inhaling toner from copy machines and/or
printers located in your immediate work environment can lead Yes; No
to respiratory diseases and/or cancers?
Do you feel that you have adequate ventilation while using
Yes; No
household cleaning products?
Do you worry that chemicals in plastics cause cancer?
Yes; No
How many times a week do you eat food that was
heated/cooked in a plastic container?
Daily; 1-2 times per week; 3-4 times per week;
greater than 4 times per week
Gas: from underground pipes serving the
neighborhood; Gas: bottled, tank, or LP 3;
Electricity; Fuel oil, kerosene, etc; Coal or coke;
Wood; Solar energy; Other fuel (Specify:
____________________); No fuel used
Chemical
Exposures
Which fuels are used for heating this (house/apartment)?
Clinical trial
Clinical trials are research studies that involve people. They are
designed to test the safety and effectiveness of new treatments
Yes, No, Refuse, Dont Know
and to compare new treatments with the standard care that
people currently get. Have you ever heard of a clinical trial?
Clinical trial
Clinical trials are research studies that involve people. They are
designed to test how well new treatments work, what effects
they have on the people who take them, and to compare new
Yes, No, Refuse, Dont Know
treatments with the care that is currently offered to people.
Have you ever heard of a clinical trial?
Clinical trial
Clinical trials are research studies with people that test how well
new medical treatments work compared to the standard care
Yes, No, Refuse, Dont Know
people get now. Have you ever heard of a clinical trial?
Page 12
Construct
Question
Response Options
• Doctor, nurse or other medical professional
• Family member or friend
• Internet
• Organization such as NCI/ACS
• Newspaper, television news or the radio
• Entertainment media such as a fictional TV
program, movie or book
• Other source
Clinical trial
From what source did you hear about a clinical trial?
Clinical trial
Has a doctor or other member of the medical team discussed
clinical trials as a treatment option for your cancer?
Yes/No
Have you ever heard of a clinical trial?
Have you ever looked for information about clinical trials for
your type of cancer?
Yes, No, Refuse, Dont Know
Yes/No
Clinical trial
Clinical trial
Clinical trial
Clinical trial
Clinical trial
Clinical trial
Clinical trial
Clinical trial
Clinical trial
Have you ever looked for information about clinical trials?
Have you participated in a clinical trial for treatment of your
cancer?
Have you participated in a clinical trial?
Yes/No
Yes/No
Yes, No, Refuse, Dont Know
• Strongly agree
• Agree
If I were diagnosed with a life-threatening condition, my friends
• Neither agree nor disagree
and family members would encourage me to enroll in a clinical
• Disagree
trial?
• Strongly disagree
• asked my doctor, nurse or other member of my
medical team
• looked on the internet
• talked with friends, family members, or other
people who are not members of your medical team
• contacted an organization such as NCI/ACS
• Other source
If so, where did you look?
• asked my doctor, nurse or other member of my
medical team
• looked on the internet
• talked with friends, family members, or other
people who are not members of your medical team
• contacted an organization such as NCI/ACS
• Other
If so, where did you look?
If you chose to enroll in a clinical trial, what would be the
primary reason for that decision?
Page 13
(select only 1 response)
• doctor recommended
• to help others who will be diagnosed with the
condition in the future
• to advance understanding of cancer prevention
• to understand cancer prevention
• to receive ‘state of the art’ care
• to increase my chances of improvement
• because the current treatment stopped working
• to be monitored closely
• other reason
Construct
Clinical trial
Clinical trial
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Colorectal cancer
Question
Response Options
If you have participated in a clinical trial for treatment of your
cancer, what were the reasons?
• doctor recommended
• to help others who will be diagnosed with the
condition in the future
• to advance understanding of cancer prevention
• to understand cancer prevention
• to receive ‘state of the art’ care
• to increase my chances of improvement
• because the current treatment stopped working
• to be monitored closely
• other reason
• Very likely
• Likely
If you were diagnosed with a life-threatening medical condition,
• Neither likely nor unlikely
how likely is it you would participate in a clinical trial offered
• Unlikely
for that condition?
• Very unlikely
A sigmoidoscopy and a colonoscopy are both tests that examine
the bowel by inserting a tube in the rectum. Have you ever had
either a colonoscopy or a sigmoidoscopy?
At what age are people supposed to start doing home stool
blood tests?
1; 5; 8; 4; 3; 10; 13; 35; 34; 32; 30; 28; 27;
26; 25; 24; 45; 43; 42; 41; 40; 39; 38; 37; 36;
23; 22; 21; 20; 18; 17; 16; 15; 55; 54; 53; 52;
51; 50; 48; 47; 46; Don't know; Refused; When
a doctor/health p
Before you had the test, did you and a doctor or other health
care professional talk about the different tests that are used to
look for colorectal cancer?
Did a doctor, nurse, or other health professional ever advise you
Yes; No; Don't know; Refused;
to get a colonoscopy?
Did the {doctor, nurse, or other health professional} describe
any other test?
Did the {doctor, nurse, or other health professional} describe
colonoscopy?
Did the {the doctor, nurse, or other health professional} describe
Yes; No; Don't Know;
sigmoidoscopy?
Do you believe the stool blood test, colonoscopy, and
sigmoidoscopy are about equally effective in finding colon
cancer, or are some tests more effective than others?
During the past 12 months, did a doctor, nurse, or other health
professional advise you to do a stool blood test using a home
Yes; Don't know; No;
test kit?
Has a doctor ever asked you which test you preferred to have?
Has a doctor, nurse or other health professional ever advised
you to get a test to check for colon cancer?
Have you and a doctor or other health care professional talked
about any of the different tests that are used to look for
colorectal cancer?
Have you ever done a stool blood test using a home kit?
Have you ever had a colonoscopy?
Have you ever had a sigmoidoscopy?
Have you ever had a test to check for colon cancer? These tests
include:
Have you ever heard of a fecal occult or stool blood test?
Have you ever heard of a sigmoidoscopy or colonoscopy?
Page 14
Yes;No
Yes; No; Don't know;
Yes; No;
Yes; No; Refused; Don't know;
Yes; No; Refused; Don't know;
Yes; No; Refused; Don't know;
Construct
Colorectal cancer
Colorectal cancer
Colorectal cancer
Question
Response Options
Have you thought about doing {a/another} home stool blood
Yes; No; Refused; Don't know;
test?
Have you thought about getting {a/another} {sigmoidoscopy or
Yes; No; Refused; Don't know;
colonoscopy?}
How likely do you think it is that you will develop colon cancer
in the future?
Colorectal cancer
If respond yes to having had a test to look for CRC: Before you
had the test, did you and a doctor talk about the different tests
that are used to look for colorectal cancer?;; If responded no:
Did you and a doctor talk about the different tests that are u
Yes; No; Dont know/Dont remember
Colorectal cancer
In general, once people start having sigmoidoscopy or
colonoscopy exams, about how often should they have them?
Free text (see on-line HINTS codebook for full list
of responses)
Colorectal cancer
The following questions are about discussions doctors may have
with patients about tests that are used to look for colorectal
Yes; No; DON’T KNOW/DON’T REMEMBER
cancer: Have you ever had a test to look for colorectal cancer?
Colorectal cancer
Colorectal cancer
What was the main reason you did your most recent stool blood
test using a home kit?
What was the main reason you had your most recent
colonoscopy?
Free text (see on-line HINTS codebook for full list
of responses)
Free text (see on-line HINTS codebook for full list
of responses)
Colorectal cancer
A year ago or less; More than 1 but not more than
When did you do your most recent stool blood test using a home
2 years ago; More than 2 but not more than 5
kit to check for colon cancer?
years ago; Over 5 years ago; Don't know;
Colorectal cancer
When did you have your most recent colonoscopy to check for
colon cancer?
Colorectal cancer
A year ago or less; More than 1 but not more than
When did you have your most recent sigmoidoscopy to check for
5 years ago; More than 5 but not more than 10
colon cancer?
years ago; Over 10 years ago; Don't know;
Colorectal cancer
When was your last Endoscopy?
Colorectal cancer
When was your last Home Stool Blood Test?
Colorectal cancer
Colorectal cancer
Colorectal cancer
A year ago or less; More than 1 but not more than
5 years ago; More than 5 but not more than 10
years ago; Over 10 years ago; Don't know;
Had Sig/Col in past 5/10 yrs; No Sig/Col in past
5/10 yrs ago; Never had Endoscopy; Refused;
Don't Know;
Had home fobt within last 1 yr; Had home fobt
more than 1 yr ago; Never had home fobt;
Refused; Don't know;
When would you say the risk of colon cancer is the highest,
when you're under 40 years old, between 40 and 60 years old,
or over 60 years old?
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree, or do you have no opinion with the
following statements: Getting checked for colon cancer is too
expensive.
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree, or do you have no opinion with the
following statements: You are afraid of finding colon cancer if
you were checked.
Under 40 years old; Refused; Between 40 and 60
years old; Over 60 years old; Don't know;
Comorbidity
Heart attack; angina; CHF; stroke; HBP; chronic
Please tell us whether a doctor or other health care professional lung disease; diabetes; kidney disease; liver
has ever told you that you had any of the following medical
disease; osteoperosis; arthritis; Crohns disease;
conditions
HIV or AIDS; dementia; ulcers; thyroid disease;
blood clots
Consideration of
future
consequences
I act now to avoid problems in the future
Extremely not like me, Somewhat not like me,
Uncertain, Somewhat like me, Extremely like me
Page 15
Construct
Consideration of
future
consequences
Consideration of
future
consequences
Consideration of
future
consequences
Consideration of
future
consequences
Demographics
Question
Response Options
I focus on the present, thinking that I will take care of future
problems when they happen.
Extremely not like me, Somewhat not like me,
Uncertain, Somewhat like me, Extremely like me
I only focus on the present, figuring that I will take care of future Extremely not like me, Somewhat not like me,
problems when they happen.
Uncertain, Somewhat like me, Extremely like me
I only focus on the present, thinking that I will take care of
future problems when they happen
Extremely not like me, Somewhat not like me,
Uncertain, Somewhat like me, Extremely like me
I take action now to avoid problems in the future.
Extremely not like me, Somewhat not like me,
Uncertain, Somewhat like me, Extremely like me
Demographics
Demographics
Demographics
Demographics
Demographics
Are any of the children in your household female?
Are any of the children under the age of 18 in your household
female?
Are you a citizen of the United States?
Are you a permanent resident with a green card / permanent
residence authorization?
Are you currently pregnant?
Are you Hispanic or Latino?
Are you male or female?
Census Tract Poverty Level
Did anyone help you complete this survey?
Demographics
Do you currently rent or own your home?
Demographics
Have you ever served on active duty in the United States Armed
Forces, either in the regular military or in a National Guard or
1 = Yes, 2 = No
military reserve unit? Active duty does not include training for
the Reserves or National Guard, but DOES include activation, fo
Demographics
Demographics
How comfortable do you feel speaking English?
How many adults age 18 or older live in this household?
Demographics
How many children under the age of 18 live in your household? 0; 1; 2; 3; 4; 5; 6; 7; 8; 10; 98;
Demographics
Immigration Status
Yes; No; Application Pending; Refused; Dont Know
Demographics
In general, would you describe your own political views as...
1 Very Conservative, 2 Conservative, 3 Moderate, 4
Liberal, 5 Very liberal, 9 DK/Refused
Demographics
In the past 12 months, have you received some or all of your
health care from VA hospital or clinic?
Demographics
In what year did you come to live in the United States?
Demographics
Including yourself, how many people live in your household?
Demographics
Thinking about members of your family living in this household,
what is your combined annual income, meaning the total pre-tax
income from all sources earned in the past year?
Demographics
Were you born in the United States?
Demographics
What is the highest grade or level of schooling you completed?
Demographics
What is the highest level of school you completed?
Demographics
Demographics
Demographics
Yes; No;
Yes; No
Yes; No; Refused; Don't know;
Male; Female;
N/A
Yes; No;
Own; Rent; Occupied without paying monetary
rent; Refused; Don't know;
1 = Yes, all of my health care; 2=Yes, some of my
health care; No, No VA health care received
1921; 1921; 1925; 1931; 1934; 1937; 1939;
1941; 1943; 1945; 1947; 1948; 1949; 1950;
1951; 1952; 1953; 1954; 1955; 1956; 1957;
1958; 1959; 1960; 1961; 1962; 1963; 1964;
1965; 1966; 1967; 1968; 1969; 1970; 1971;
1972;
1; 2; 3; 4; 5; 6; 7; 8; 9; 10; 11; 12; 13;
Refused; Don't know;
Yes; No;
Page 16
Less than High School; High School Graduate;
Some College; College Graduate;
Construct
Question
Response Options
< $25,000; $25,000 to < $35,000; $35,000 to <
$50,000; $50,000 to < $75,000; >= $75,000;
Refused; Don't know;
18-34; 35-49; 50-64; 65-74; 75+; 45+, exact age
unknown;
Employed; Unemployed; Homemaker; Student;
Retired; Unable to work/disabled; Other;
Refused; Don't know;
Married; Living with a partner; Divorced;
Widowed; Separated; Never been married; Not
Ascertained;
Hispanic; Non-Hispanic White; Non-Hispanic
Black or African American; Non-Hispanic
American Indian or Alaska Native; Non-Hispanic
Asian; Non-Hispanic Native Hawaiian or other
Pacific Islander; Non-Hispanic Multiple Races
Mentioned; Refused; D
Demographics
What is your {combined} annual household income?
Demographics
What is your age?
Demographics
What is your current occupational status?
Demographics
What is your marital status?
Demographics
What is your race/ethnicity?
Demographics
Which one or more of the following would you say is your race? White; Native Hawaiian or Other Pacific Islander;
Depression
During the past 30 days, how often did you feel hopeless?
Depression
During the past 30 days, how often did you feel nervous?
Depression
During the past 30 days, how often did you feel restless or
fidgety?
Depression
During the past 30 days, how often did you feel so sad that
nothing could cheer you up?
Depression
During the past 30 days, how often did you feel that everything
was an effort?
Depression
During the past 30 days, how often did you feel worthless?
Depression
The last few questions were about a number of feelings you had
during the past 30 days. Altogether, how much did these
feelings interfere with your life or activities?
Dietary
Assessment
During the past month, how often did you eat a green leafy or NEVER 0 (DTQ.090) REFUSED 777 (DTQ.090)
lettuce salad, with or without other vegetables? (You can tell me DONT KNOW 999 (DTQ.090) ENTER UNIT DAY 1
per day, per week or per month.)
WEEK 2 MONTH 3 REFUSED 7 DONT KNOW 9
Dietary
Assessment
Dietary
Assessment
Dietary
Assessment
Dietary
Assessment
During the past month, how often did you eat any kind of fried
potatoes, including french fries, home fries, or hash brown
potatoes?
During the past month, how often did you eat any other kind of
potatoes, such as baked, boiled, mashed potatoes, sweet
potatoes, or potato salad?
During the past month, not including what you just told me
about (lettuce salads, potatoes, cooked dried beans), how often
did you eat other vegetables? (You can tell me per day, per week
or per month.)
All of the time; Most of the time; Some of the time;
A little of the time; None of the time; Refused;
Don't know;
All of the time; Most of the time; Some of the time;
A little of the time; None of the time; Refused;
Don't know;
All of the time; Most of the time; Some of the time;
A little of the time; None of the time; Refused;
Don't know;
All of the time; Most of the time; Some of the time;
A little of the time; None of the time; Refused;
Don't know;
All of the time; Most of the time; Some of the time;
A little of the time; None of the time; Refused;
Don't know;
Enter number of times per day, week, month (e.g., 3
times/week)
Enter number of times per day, week, month (e.g., 3
times/week)
NEVER 0 (DTQ.090) REFUSED 777 (DTQ.090)
DONT KNOW 999 (DTQ.090) ENTER UNIT DAY 1
WEEK 2 MONTH 3 REFUSED 7 DONT KNOW 9
During the past month, how often did you drink 100 pure fruit
juice such as orange, mango, apple, grape and pineapple juices? NEVER 0 (DTQ.090) REFUSED 777 (DTQ.090)
Do not include fruit-flavored drinks with added sugar or fruit
DONT KNOW 999 (DTQ.090) ENTER UNIT DAY 1
juice you made at home and added sugar to. (You can tell me per WEEK 2 MONTH 3 REFUSED 7 DONT KNOW 9
day, per week or per month.)
Page 17
Construct
Dietary
Assessment
Question
During the past month, how often did you drink 100% fruit
juice?
Dietary
Assessment
During the past month, how often did you drink 100% pure fruit
juice such as orange, mango, apple, grape, and pineapple juices.
Do not include fruit-flavored drinks with added sugar or fruit
juice you made at home and added sugar to.
Dietary
Assessment
Dietary
Assessment
Dietary
Assessment
Dietary
Assessment
Dietary
Assessment
Dietary
Assessment
Dietary
Assessment
During the past month, how often did you drink coffee or tea
that had sugar or honey added to it? Include coffee and tea you
sweetened yourself and presweetened tea and coffee drinks
such as Arizona Iced Tea and Frappuccino. Do not include
artificially swe
During the past month, how often did you drink regular soda or
pop that contains sugar? Do not include diet soda.
During the past month, how often did you drink sweetened fruit
drinks, sports or energy drinks, such as Kool-aid, lemonade, HiC, cranberry drink, Gatorade, Red Bull or Vitamin Water?
Include fruit juices you made at home and added sugar to. Do
not include
During the past month, how often did you eat a green leafy or
lettuce salad, with or without other vegetables?
During the past month, how often did you eat any kind of fried
potatoes, including French fries, home fires, or hash brown
potatoes? Do not include potato chips?
During the past month, how often did you eat fruit?
Response Options
Enter quantity in days, weeks, or months (e.g., 3
times/day)
Number of times per day, week, or month
Number of times per day, per week, per month
Number of times per day, week, or month
Enter number of times per day, week, or month
(e.g., 2 times per week
Enter quantity in days, weeks, or months (e.g., 3
times/day)
During the past month, how often did you eat fruit? Include
fresh, frozen or canned fruit. Do not include juices.
Dietary
Assessment
Response options: NEVER 0 (DTQ.090) REFUSED
During the past month, how often did you eat fruit? Include
777 (DTQ.090) DONT KNOW 999 (DTQ.090)
fresh, frozen or canned fruit. Do not include juices. (You can tell
ENTER UNIT DAY 1 WEEK 2 MONTH 3 REFUSED 7
me per day, per week or per month.)
DONT KNOW 9
Dietary
Assessment
During the past month, how often did you eat refried beans,
baked beans, beans in soup, pork and beans or any other type of Number of times per day, week, or month
cooked dried beans? Do not include green beans.
Dietary
Assessment
Dietary
Assessment
Dietary
Assessment
Dietary
Assessment
Dietary
Assessment
Endocrine
Disruptors
Endocrine
Disruptors
During the past month, how often did you eat vegetables,
including lettuce salads, potatoes (not fried), and all other
vegetables? Do not include fried potatoes or potato chips.
During the past month, not including what you just told me
about (lettuce salads, potatoes, cooked dried beans), how often
did you/SP eat other vegetables?
How many servings of fruits do you usually eat or drink each
day?
How many servings of vegetables do you usually eat or drink
each day?
When available, how often do you use menu information on
calories in deciding what to order?
Enter number of times per day, week, or month
(e.g., 2 times per week
Free text (see on-line HINTS codebook for full list
of responses)
Free text (see on-line HINTS codebook for full list
of responses)
Do you know what endocrine disruptors are?
Yes/No
Do you think endocrine disruptors are assoicated with cancer?
Yes; No
Environment and
Cancer
Do you think the environment is related to human health? Do
Yes; No
you think environmental exposures are assoicated with cancer?
Environment and
Cancer
Environment and
Cancer
What proportion of cancers are attributable/related to the
environment?
Unknown
When you hear the term environment what do you think of?
All non-genetic factors; Air, water, food, and soil
pullutants
Page 18
Construct
Environmental
Exposure Risk
Perception
Environmental
Exposure Risk
Perception
Environmental
Exposure Risk
Perception
Question
Compared to other {men/women} my age, I am {more/less}
likely to come into contact with harmful substances in the
environment.
How much does _____ negatively affect health
How worried are you about coming in contact with ____?
Page 19
Response Options
men/women; more/less
Very little – Very much for: 1. Air pollution
2. Pesticides
3. Car exhaust
4. Diesel particles (from buses, trains, cargo ships,
trucks, etc)
5. Mercury
6. Lead
7. Nano materials
8. Cell phone use
9. Chemicals from plastics
10. Ozone
11. Flame retardants
12. Hazardous waste
13. lack of exercise,
14. low fruit and vegetable consumption,
15. sun exposure,
16. dietary fat intake,
17. obesity,
18. genes
Not at all – Extremely for: 1. Air pollution
2. Pesticides
3. Car exhaust
4. Diesel particles (from buses, trains, cargo ships,
trucks, etc)
5. Mercury
6. Lead
7. Nano materials
8. Cell phone use
9. Chemicals from plastics
10. Ozone
11. Flame retardants
12. Hazardous waste
Construct
Question
Response Options
Environmental
health information Have you ever looked for information about _____?
seeking
Yes/No for: 1. Outdoor air pollution and asthma
2. Indoor air pollution and asthma
3. Chemicals in the environment and cancer
4. Harmful substances in your household
5. Harmful substances in your personal care
products
6. Chemicals in plastics
7. Cell phone use and human health
8. Proximity to power lines and human health
9. Exposure to lead and human health
10. Nanomaterials and human health
11. Environmental exposures to pregnant mothers
and child health
12. Ozone and human health
13. Global climate change and human health
14. Mold in the home
15. Proximity to a nuclear power plant and human
health
Environmental
Did you feel that you received helpful information? Why? Why
Health Knowledge not?
Open Ended
Environmental
Have you heard that environmental exposures may lead to
Health Knowledge adverse health outcomes?
Yes; No
Environmental
Have you talked with your physician, nurse, or healthcare
Health Knowledge professional about environmental exposures and health?
Yes; No
Environmental
If so, which health condition have you head about?
Health Knowledge
Open Ended
Environmental
If so, which topics?
Health Knowledge
Open Ended
Environmental
When you hear of the term environment, what do you think of?
Health Knowledge
Open Ended
Environmental
When you hear the term environmental health what do you
Health Knowledge think of?
Open Ended
Environmental
Do you find it difficult to know what action to take given all
Health Perception information and recommendations?
Yes; No
Environmental
Do you think that public health experts seem to disagree on
Health Perception what exposures are harmful to human health?
Yes; No
Would you say that harmful environmental exposures are most
Environmental
often the result of personal behavior? Or the result of conditions
Health Perception
outside the person’s control?
Environmental
Have you been looking for environmental health information
Health Seeking
recently?
Behavior
Environmental
Have you ever talked to your physician about environmental
Health Seeking
exposures and its potential impact on your health?
Behavior
Environmental
Health Seeking
If so, what topic area?
Behavior
Page 20
Personal Behavior; Outside the persons control
Yes; No
Yes/No
Open Ended
Construct
Environmental
Health Seeking
Behavior
Environmental
Health Seeking
Behavior
Environmental
Health Seeking
Behavior
Environmental
Health Seeking
Behavior
Question
Response Options
What type of information would stimulate you to take action to
reduce or remove an environmental exposure from your life?
Open Ended
What type of information would stimulate you to take action?
Open Ended
Where do you go for trusted environmental health information? Open Ended
Who do you talk with about environmental health information? Open Ended
Exposure to
Before being contacted for this study had you ever heard of
support Resources Cancer Control of America?
Exposure to
Before being contacted for this study had you ever heard of the
support Resources 1-800-4-Cancer information number?
Exposure to
Before being contacted for this study had you ever heard of the
support Resources 1-800-ACS-2345 cancer information number?
Exposure to
Before being contacted for this study had you ever heard of the
support Resources CDC or the Centers for Disease Control and Prevention?
Exposure to
Before being contacted for this study had you ever heard of the
support Resources National Cancer Institute?
Yes; No; Refused; Don't know;
Exposure to
Before being contacted for this study had you ever heard of the
support Resources National Cancer Institute's Cancer Information Service?
Exposure to
Before being contacted for this study, had you ever heard of the
Yes; Don't know; No;
support Resources American Cancer Society?
Exposure to
Have you ever heard of 2-1-1- Information and Referral Search? Yes; No; Dont know; refuse
support Resources
Exposure to
Have you ever used 2-1-1- Information and Referral Search?
support Resources
Exposures in the
home
Exposures in the
home
Exposures in the
home
Exposures in the
home
Exposures in the
home
Yes; No; Dont know; refuse
Broiling, smoking, grilling or frying inside the house?
Yes; No
Broiling, smoking, grilling or frying outside the house?
Yes; No
Chain saw or other gasoline equipment?
Yes; No
Did you bring home any items from the cleaners that were drycleaned during the past week?
Yes; No
Did you go to the dry cleaners during the past week?
Yes; No
Exposures in the
home
Did you use or were you near somebody else who used cleaning
Yes; No
solutions (including household cleaners and chemicals)?
Exposures in the
home
Exposures in the
home
Exposures in the
home
Exposures in the
home
Do you actively refrain from using insecticides, herbicides, and
fungicides in your home? If so, why?
Yes; If yes explain why; No
Do you allow people to wear shoes in your home? If so, why?
Yes; If yes explain why; No
Do you live in the center of town or on the edge of town?
Center of town; Town Edge
Do you live near farm fields or orchards?
Yes; No
Page 21
Construct
Exposures in the
home
Question
Response Options
Do you live on a farm?
Yes; No
Yes/No for: 1. Wearing shoes in the house
2. Eating foods that are not organic
3. Using pesticides in the house
4. Using pesticides outside your home (on your
lawn or garden)
5. Plastic containers that have BPA
6. Re-heating food in plastic containers
7. Personal care products that have phthalates,
parabens, and fragrances
Exposures in the
home
Do you try to avoid _____? If Yes, why?
Exposures in the
home
Exposures in the
home
Exposures in the
home
Exposures in the
home
Do you use BPA free containers for storing food and beverages?
If so, why?
Do you use certain personal care products that are free of
phthalates, parabens, and fragrances? If so, why?
During the last 48 hours (the study period) did you or anyone
else park a car or other motor vehicle in:
During the last 48 hours (the study period) did you or anyone
else start a car or other motor vehicle in:
Exposures in the
home
During the last 48 hours (the study period) have you operated
or been near diesel engines, (e.g. bus terminal, truck stop)?
Exposures in the
home
Exposures in the
home
Exposures in the
home
Exposures in the
home
Exposures in the
home
Exposures in the
home
During the last 48 hours (the study period) was there any diesel
Yes; No
vehicles parked around the house?
Exposures in the
home
How successful do you feel you have been in using personal care
Unsuccesful - Very Succesful
products that are free of phthalates, parabens, and fragrances?
Exposures in the
home
Exposures in the
home
Exposures in the
home
Exposures in the
home
Yes; If yes explain why; No
Yes; If yes explain why; No
A garage attached to your home; A detached
garage; A carport attached to your home?
A garage attached to your home; A detached
garage; A carport attached to your home?
Yes; No
Dusting?
Yes; No
Gardening?
Yes; No
Gasoline lawn mower?
Yes; No
Glues and adhesives, such as contact cement, super glues, and
aerosol adhesives that contain chemical solvents?)
How successful do you feel you have been in using BPA-free
containers for storing food and beverages?
If so, how often?
Yes; No
Unsuccesful - Very Succesful
Never; Occasionally; Frequently
In or around your home, lawn, or garden, do you (or someone
Yes; No
else) use fungicides to kill mold, mildew, or rot?
In or around your home, lawn, or garden, do you (or someone
Yes; No
else) use herbicides to kill weeds or plants?
In or around your home, lawn, or garden, do you (or someone
else) use insecticides to kill bugs such as ants, roaches, mites or Yes; No
other pests? Include any used on pets.
Exposures in the
home
In the last year has your home suffered water damage?
Exposures in the
home
In the past year has there been a major renovation to this house
or apartment, such as adding a room, putting up or taking down
Open Ended
a wall, replacing windows, or refinishing floors? When was the
last one?
Exposures in the
home
Exposures in the
home
Exposures in the
home
Yes; No
In the past year were new carpets or rugs installed?
Yes; No
In the past year, was the inside of this house or apartment
painted? When was the last time? On how many rooms?
Open Ended
Metal working/welding?
Yes; No
Page 22
Construct
Exposures in the
home
Exposures in the
home
Exposures in the
home
Exposures in the
home
Question
Paints or solvents (paint thinners and removers, typewriter
corrective fluids)?
Response Options
Yes; No
Pesticides sprayed?
Yes; No
Sander and/or saw?
Yes; No
Sweeping indoors?
Yes; No
Exposures in the
home
The following questions are about things that you may have
used or may have been used by someone near you in the last 48 Open Ended
hours. Enter all that applies, if Yes, write for how long.
Exposures in the
home
Vacuuming?
Yes; No
Exposures in the
home
Within the last six months were rugs, drapes or furniture
professionally cleaned? Inside the house? When? What items?
Open Ended
Exposures in the
home
Woodworking?
Yes; No
Family History
Do you have any first-degree relatives (mother, father, sibling,
grandparent) who have cancer?
Yes- please speciify; No
Family History
Do you have any first-degree relatives (mother, father, sibling,
Yes- please speciify; No
or child) who have been diagnosed with cancer in their lifetime?
Family History
Family History
Family History
Family History
Family History
Family History
Family History
Family History
Family History
Food Safety and
Applied Nutrition
Food Safety and
Applied Nutrition
Food Safety and
Applied Nutrition
Food Safety and
Applied Nutrition
Food Safety and
Applied Nutrition
Newspaper; Magazine; Radio; Health professional;
Family member; Social Media; Friend; Television;
From which of the following sources have you read or heard
anything about the importance of knowing your family history? Internet; Other; Have not heard of such test; Not
sure
Newspaper; Magazine; Radio; Health professional;
From which of the following sources have you read or heard
Family member; Social Media; Friend; Television;
anything about the importance of knowing your familys health
Internet; Other; Have not heard of such test; Not
history?
sure
Have you changed your lifestyle (i.e. diet, exercise, smoking or
preventive screening) as a result of someone in your family
being diagnosed with cancer
Have you changed your lifestyle (i.e. diet, exercise, smoking or
preventive screening) to help reduce your risk of a cancer that Yes; No; Not yet but I plan to in the future
runs in your family?
Have you ever actively collected health information from your
Yes; No
relatives for purposes of developing family history?
Have you ever actively collected health information from your
relatives for purposes of documenting your familys health
Yes; No
history?
Have you shared the family history information you collected
Yes; No; Not yet, but I plan to in the future; I have
with a health professional?
not collected Family History
In the past year, have you read or heard about the importance of
Yes; No
knowing your family’s health history
In the past year, have you read or heard about the importance of
Yes; No
knowing your family’s health history for your own health?
All cancers can be avoided by using dietary supplements such as
Strongly agree -- Strongly disagree
herbal supplements
All cancers can be avoided through what one eats and drinks
Strongly agree -- Strongly disagree
All cancers can be cured in the same ways
Strongly agree -- Strongly disagree
All cancers can be prevented in the same ways
Strongly agree -- Strongly disagree
All cancers can be treated by using dietary supplements such as
Strongly agree -- Strongly disagree
herbal supplements instead of drugs or surgery
Page 23
Construct
Food Safety and
Applied Nutrition
Food Safety and
Applied Nutrition
Food Safety and
Applied Nutrition
Food Safety and
Applied Nutrition
Food Safety and
Applied Nutrition
Food Security
Food Security
Genomics
Genomics
Genomics
Genomics
Genomics
Genomics
Question
Response Options
All cancers can be treated in the same ways
Strongly agree -- Strongly disagree
All cancers have the same causes
Strongly agree -- Strongly disagree
a single type of cancer
□ a few or some types of cancer
If an herbal supplement product says on its package that it "may
□ all cancers
produce anticarcinogenic effects in the body," it means the
□ one or more diseases other than cancer (please
product may reduce the risk of:
specify below:_________)
a single type of cancer
□ a few or some types of cancer
If an herbal supplement product says on its package that it "may
□ all cancers
reduce the risk of certain cancers," it means the product may
□ one or more diseases other than cancer (please
reduce the risk of:
specify below:_________)
If you hear or read that an herbal supplement product "may
produce anticarcinogenic effects in the body," do you think this
supplement may do each of the following things:
reduce the risk of cancer(s)
treat cancer(s)
completely prevent cancer(s)
cure cancer(s)
How often in the past 12 months would you say you were
worried or stressed about having enough money to buy
nutritious meals?
These next questions are about the food eaten in your household
in the last 12 months and whether you were able to afford the
food you need. Please read the following statements and
Often true, sometimes true, never true, dont know
indicate whether the statement was OFTEN, SOMETIMES, or
NEVER true for yo
Paternity testing: to determine if a man is the
2. Some companies are offering genetic tests that you can order
father of a child; Ancestry testing: to determine the
directly (such as purchasing in store or by mail, phone, or the
background or geographic/ethnic origin of an
Internet) without the help of a healthcare provider. Which of the
individual’s ancestors; DNA fingerprinting: to
following type(s) of genetic tests are you aware that you can
distinguish between or match individuals using
order directly?
hair, bl
3. Genetic tests that analyze your DNA and lifestyle for
potential health risks are currently being marketed by
Yes; No
companies directly to consumers. Have you heard or read about
these genetic tests?
Genetic tests that analyze your DNA, diet, and lifestyle for
potential health risks are currently being marketed by
Yes; No
companies directly to consumers. Have you heard or read about
these genetic tests?
No; Yes, I ordered the test directly from the
company, but I discussed the results with my
Have you ever had a genetic test that analyzes your DNA and
health care provider; Yes, I ordered the test
lifestyle for potential health risks?
directly from the company and did not discuss the
results with my health care provider
No; Yes, I ordered the test directly from the
company, but I discussed the results with my
Have you ever had a genetic test that analyzes your DNA for
health care provider; Yes, I ordered the test
potential health information?
directly from the company and did not discuss the
results with my health care provider
No; Yes, I ordered the test directly from the
company, but I discussed the results with my
health care provider; Yes, I ordered the test
Have you ever had a genetic test that analyzes your DNA for
potential health information?
directly from the company and did not discuss the
results with my health care provider; Yes, my
health care provider ordered the test.
Page 24
Construct
Question
Genomics
Have you ever had a genetic test that analyzes your DNA, diet,
and lifestyle for potential health risks?
Genomics
Genomics
Have you ever had a genetic test?
Have you heard or read about any genetic tests?
Genomics
If you had a genetic test, to whom did you communicate the
results?
Genomics
Response Options
No; Yes, I ordered the test directly from the
company, but I discussed the results with my
health care provider; Yes, I ordered the test
directly from the company and did not discuss the
results with my health care provider
Yes; No; Refused; Don't know;
Health professional; Family member; Friend;
Other; Did not have this type of test; Did not
communicate the results
Paternity testing: to determine if a man is the
father of a child; Ancestry testing: to determine the
Which of the following type(s) of genetic tests have you heard or background or geographic/ethnic origin of an
read about?
individual’s ancestors; DNA fingerprinting: to
distinguish between or match individuals using
hair, bl
Genomics
Paternity testing; to determine if a man is the
father of a child; Ancestry testing: to determine the
background/ethnic origin of an individuals
ancestors; Disease risk: to determine if an
Which of the following type(s) of genetic tests have you heard or individual might be at a higher or lower risk for
developing a disease; Pharmacogenetic testing: to
read about?
determine the genetic influence on medication
effectiveness and side effects; Carrier status; to
learn if an individual carries a gene for an inherited
disease
Health Behavior
How likely is it that you will tan indoors within the next 12
months? Would you say...
Health Care
About how long has it been since you last visited a doctor for a
routine checkup? A routine checkup is a general physical exam,
not an exam for a specific injury, illness, or condition.
Health Care
Do you have any of the following healthcare coverage options:
Health Care
Do you have any other health care coverage option?
During the past 12 months, did you use any complementary,
alternative, or uncoventional therapies such as herbal
supplements, acupuncture, chiropractic, homeopathy,
meditation, yoga, or Tai Chi?
Health Care
Health Care
Health Care
Health Care
Health Care
Very likely, somewhat likely, not very likely, not at
all likely
Insurance through a current or former employer or
union (of you or another family member);
Medicare; Medicaid, Medical Assistance, or any
kind of government-assistance plan for those with
low incomes or a disability; TRICARE or other
military health care; VA (including those who have
ever used or enrolled for VA health care); Indian
Health Service
Yes; No; Refused; Don't know;
During the past 12 months, not counting times you went to an
None; 1 Time; 2 Times; 3 Times; 4 Times; 5-9
emergency room, how many times did you go to a doctor, nurse,
Times; 10 Or more times; Refused; Don't know;
or other health professional to get care for yourself?
If you had a symptom that you thought might be a sign of cancer
how confident are you that you could get help from a doctor,
nurse or other healthcare professional?
If you noticed a change in bowel or bladder habits how soon
would you contact a doctor, nurse or other healthcare
professional to make an appointment to discuss it?
If you noticed a change in the appearance of a mole how soon
would you contact a doctor, nurse or other healthcare
professional to make an appointment to discuss it?
Page 25
1-7 (1 = Not confident at all; 7 = Very Confident)
Within 1 month; After 1-3 months; After more than
3 months; Never
Within 1 month; After 1-3 months; After more than
3 months; Never
Construct
Health Care
Health Care
Health Care
Health Care
Question
If you noticed a cough or hoarseness how soon would you
contact a doctor, nurse or other healthcare professional to make
an appointment to discuss it?
If you noticed a lump or swelling how soon would you contact a
doctor, nurse or other healthcare professional to make an
appointment to discuss it?
If you use "non-traditional" forms of treatment, how often do
you tell your primary cancer physician about these "nontraditional" treatments?
In the last 6 months, how often did your personal doctor listen
carefully to you
Response Options
Within 1 month; After 1-3 months; After more than
3 months; Never
Within 1 month; After 1-3 months; After more than
3 months; Never
1 Never, 2 Seldom, 3 Sometimes, 4 Often, 5 Always,
9 DK/Refused
never; almost never;sometimes; usually; almost
always; always
Health Care
In the past 12 months, how often did you feel you received
Always; Usually; Sometimes; Never
health care that led to the best possible result for your situation?
Health Care
In the past 12 months, how often did you feel you received the
health care services you needed when you needed them?
Health Care
Health Care
Health Care
Health Care
Health Care
Health Care
Health information
seeking
Health information
seeking
Health information
seeking
Health information
seeking
Health information
seeking
Health information
seeking
In the past 12 months, how often did you feel you received the
health care services you needed?
In the past 12 months, how often did you feel you received the
right tests or procedures for your health care needs?
Not including psychiatrists and other mental health
professionals, is there a particular doctor, nurse, or other health
professional that you see most often?
To what extent do you use "non-traditional" treatments for your
cancer?
Always; Usually; Sometimes; Never
Always; Usually; Sometimes; Never
Always; Usually; Sometimes; Never
Yes; No; Refused; Don't know;
1 Never, 2 Seldom, 3 Sometimes, 4 Often, 5 Always,
9 DK/Refused
Doctor; Nurse; COMPLEMENTARY,
ALTERNATIVE, OR UNCONVENTIONAL
What kind of health professional do you see most often? Do you PRACTITIONER; NURSE PRACTITIONER;
PHYSICIAN'S ASSISTANT; Some other health
see a doctor, nurse, or some other health professional?
professional? (Please specify); Refused; Don't
know;
Would you be willing to participate in a clinical trial?
Yes, No, Dont Know
Based on the results of your most recent search for information
about health or medical topics, how much do you agree or
disagree with the following statements? It took a lot of effort to
get the information you needed.
Based on the results of your most recent search for information
about health or medical topics, how much do you agree or
disagree with the following statements? The information you
found was hard to understand.
Based on the results of your most recent search for information
about health or medical topics, how much do you agree or
disagree with the following statements? You felt frustrated
during your search for the information.
Based on the results of your most recent search for information
about health or medical topics, how much do you agree or
disagree with the following statements? You were concerned
about the quality of the information.
Based on the results of your search for information on cancer
from all sources, how much do you agree or disagree with the
following statements? It took a lot of effort to get the
information you needed.
Based on the results of your search for information on cancer
from all sources, how much do you agree or disagree with the
following statements? The information you found was too hard
to understand.
Page 26
Construct
Question
Based on the results of your search for information on cancer
Health information from all sources, how much do you agree or disagree with the
seeking
following statements? You felt frustrated during your search for
the information.
Based on the results of your search for information on cancer
Health information from all sources, how much do you agree or disagree with the
seeking
following statements? You were concerned about the quality of
the information.
Response Options
Health information Did you look or go anywhere else [for information about health
seeking
or medical topics]?
Health information Have you ever looked for information about cancer from any
seeking
source?
Yes; No; Refused; Don't know;
Health information Have you ever looked for information about health or medical
seeking
topics from any source?
Yes; No; Refused; Don't know;
Health information Have you ever visited an Internet web site to learn specifically
seeking
about cancer?
Yes; No; Don't know;
Health information
How many days since you looked for cancer info?
seeking
1; 2; 3; 4; 5; 6; 7; 10; 14; 15; 21; 28; 30; 42;
56; 60; 63; 90; 120; 150; 180; 210; 240; 270;
300; 330; 360; 365; 390; 420; 450; 480; 540;
731; 900; 960; 1080; 1096; 1461; 1826; 2192;
2557; 2922; 3287; 365
Health information Imagine that you had a strong need to get information about
seeking
cancer. Where would you go first?
Free text (see on-line HINTS codebook for full list
of responses)
Health information Imagine that you had a strong need to get information about
seeking
health or medical topics. Where would you go first?
Health information In the past 12 months, have you done the following things while
seeking
using the Internet? Looked for health or medical information?
In the past 12 months, have you done the following things while
Health information
using the Internet? Looked for information about protecting
Yes; No; Refused; Don't know;
seeking
yourself from the sun?
In the past 12 months, have you done the following things while
Health information
using the Internet? Looked for information about quitting
Yes; No; Refused;
seeking
smoking?
In the past 12 months, have you usedIn the past 12 months, have
Health information
you used the Internet to look for health or medical information
seeking
for yourself?
Health information Is there a specific Internet site you like to go to for health or
seeking
medical information?
Health information Not including your doctor or other health care provider, has
Yes; No; Refused; Don't know;
seeking
someone else ever looked for information about cancer for you?
Health information Overall, how confident are you that you could get advice or
seeking
information about cancer if you needed it?
Health information Overall, how confident are you that you could get health-related Completely confident; Very confident; Somewhat
seeking
advice or information if you needed it?
confident; A little confident; Not confident at all;
Health information Specify which Internet site you especially like as a source of
seeking
health or medical information:
Page 27
Construct
Question
Response Options
Health information The most recent time you looked for cancer information, where Free text (see on-line HINTS codebook for full list
seeking
did you go first?
of responses)
Health information The most recent time you looked for information about health or Myself; Someone else; Both myself and someone
seeking
medical topics who was it for...
else
Health information The most recent time you looked for information about health or
seeking
medical topics, was it for yourself, someone else, or both?
Health information The most recent time you looked for information about health or Free text (see on-line HINTS codebook for full list
seeking
medical topics, where did you go first?
of responses)
Health information
Time since last sought cancer information
seeking
In the last month; 1+ to 6 months ago; 6+ months
to 1 year ago; 1+ to 5 years ago; More than 5 years
ago;
Health information
Were you looking for information on a specific cancer?
seeking
Yes; No;
Health information Were you looking for information on causes of cancer or risk
seeking
factors for cancer?
Yes; No;
Health information
Were you looking for information on coping with cancer?
seeking
Yes; No;
Health information Were you looking for information on paying for medical care or
Yes; No;
seeking
insurance?
Health information
Were you looking for information on where to get medical care? Yes; No;
seeking
Health information
Were you looking for other information related to cancer?
seeking
Yes; No;
Health information
Were your looking for information on cancer organizations?
seeking
Yes; No;
Health information When you need health or medical information, do you usually
seeking
get it from…
Health information Who was that? [that looked for information about cancer for
seeking
you]
Spouse; Information specialist (e.g., librarian);
Other (specify); Don't know; Refused; Cancer
organizations; Co-worker; Friend; Other family
member;
Health Information As far as you know, do your healthcare providers maintain your
Yes; No; Refused; Don't know;
Technology
medical information in a portable, electronic format?
How important is it to you that your healthcare providers are
Health Information
able to share your medical information with each other
Technology
electronically?
Health Information How important would it be for you to get your own medical
Technology
information electronically?
In the past 12 months, have you done the following things while
Health Information using the Internet? Kept track of personal health information,
Technology
such as care received, test results, or upcoming medical
appointments?
Scientists doing research should be able to review my medical
Health Information
information if the information cannot be linked to me
Technology
personally.
Page 28
Construct
Health literacy
Question
If you are allowed to eat 60 g of carbohydrates as a snack, how
much ice cream could you have?
Response Options
Health literacy
How confident are you filling out medical forms by yourself?
Never; Occasionally; Sometimes; Often; Always
Health literacy
How often do you need to have someone help you read and
understand health information?
all of the time; most of the time; some of the time; a
little of the time; none of the time
Health literacy
If you eat the entire container, how many calories will you eat?
Health literacy
If you usually eat 2500 calories in a day, what percentage of
your daily value of calories will you be eating if you eat one
serving?
Health literacy
My doctor/health care provider talks to me about my health
using language that is easy to understand.
Health literacy
My doctor/health care provider talks to me about my health
using words that are easy to understand.
Health literacy
Pretend that you are allergic to the following substances:
penicillin, peanuts, latex gloves, and bee stings. 5. Is it safe for
you to eat this ice cream? 6. (Ask only if the patient responds no
to question 5): Why not?
Health literacy
Your doctor advises you to reduce the amount of saturated fat in
your diet. You usually have 42 g of saturated fat each day, which
includes 1 serving of ice cream. If you stop eating ice cream, how
many grams of saturated fat would you be consuming each day?
Health SelfEfficacy
Overall, how confident are you about your ability to take good
care of your health?
Health SelfEfficacy
Overall, how confident are you that you could get advice or
information about health or medical topics if you needed it?
Strongly agree; Somewhat agree; Somewhat
disagree; Strongly disagree; NA (no usual doctor or
health care provider)
Strongly agree; Somewhat agree; Somewhat
disagree; Strongly disagree; NA (no usual doctor or
health care provider)
Completely confident; Very confident; Somewhat
confident; A little confident; Not confident at all;
75; 80; 84; 85; 86; 87; 88; 89; 90; 93; 94; 95;
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; 1
Health status
About how much do you weigh without shoes?
Health status
About how much do you weigh, in pounds, without shoes?
Health status
About how tall are you without shoes?
43-48; 49-54; 55-60; 61-66; 67-72; 73-78; 7984; Over 84; Refused; Don't Know;
Health status
At what age did you have your first child?
Open ended (restricted to plausible values for age)
Health status
At what age did you have your first menstrual period?
Health status
At what age were you diagnosed with cancer?
Health status
Health status
Health status
Health status
Did you ever receive any treatment for your cancer?
During the past 4 weeks, how much did physical health
problems limit your usual physical activities (such as walking or
climbing stairs)?
Have any of your family members ever had cancer?
Have you ever been diagnosed as having cancer?
Have you had a hysterectomy?
Open ended
1; 5; 7; 8; 9; 14; 15; 17; 18; 19; 20; 21; 22;
23; 24; 25; 26; 27; 28; 29; 30; 31; 32; 34; 35;
36; 37; 38; 39; 40; 41; 42; 43; 44; 45; 46; 47;
48; 49; 50; 51; 52; 53; 54; 55; 56; 57; 58; 59;
60; 61;
Yes; No; Don't know;
Health status
How long ago did you finish your most recent treatment?
Health status
Page 29
not at all; very little; somewhat; quite a lot; could
not do physical activities
Yes; No; Has no family; Refused; Don't know;
Yes; No; Refused; Don't know;
Yes; No; Refused; Don't know;
Still in Treatment; During the past year; 1+ to 2
years ago; 2+ to 3 years ago; 3+ to 4 years ago; 4+
to 5 years ago; Over 5 years ago;
Construct
Health status
Question
In general, would you say your health is…poor, fair, good, very
good, or excellent?
Health status
Overall, how would you rate your health in the past 4 weeks?
Health status
Right now do you feel you are...overweight, slightly overweight,
underweight, slightly underweight, or just about the right weight
for you?
Health status
Time since diagnosed with cancer
Health status
What is your BMI?
Health status
What type of cancer did you have?
excellent; very good; good; fair; poor; very poor;
<=1 Yr Since DX; 2-5 Yrs Since DX; 6-10 Yrs Since
DX; 11+ Yrs Since DX; Refused; Don't Know;
Less than 18.5 (Underweight); 18.5 to less than 25
(Normal); 25 to less than 30 (Overweight); 30 and
Over (Obese);
Free text (see on-line HINTS codebook for full list
of responses)
Health status
What type of cancer have you received treatment for?
Implicit theories
I think your body weight is something basic about you that you
cant change very much.
Implicit theories
I think your body weight is something very basic about you that
you can’t change very much.
Implicit theories
I think your cancer risk is something basic about you that you
cant change very much.
Implicit theories
I think your cancer risk something very basic about you that you
can’t change very much.
Implicit theories
Response Options
I think your health is something basic about you that you cant
change very much.
Implicit theories
I think your health is something very basic about you that you
can’t change very much.
Implicit theories
I think your smoking behavior is something basic about you that
you cant change very much.
Implicit theories
I think your smoking behavior is something very basic about you
that you can’t change very much.
A mutating cancer; Abdominal cancer; Abdominal
mass; Adenocarcinoma; Adenocarcinoma in
epithelial lining of abdominal wall, brain cancer;
Adrenocortical cancer, multiple myeloma;
Adrenocortical carcinoma; Anal cancer, brain
cancer; Angiosarco
1-6; 1= Strongly agree; 2= Moderately agree; 3=
Slightly agree; 4= Slightly disagree; 5= Moderately
disagree; 6= Strongly disagree
1-6; 1= Strongly agree; 2= Moderately agree; 3=
Slightly agree; 4= Slightly disagree; 5= Moderately
disagree; 6= Strongly disagree
1-6; 1= Strongly agree; 2= Moderately agree; 3=
Slightly agree; 4= Slightly disagree; 5= Moderately
disagree; 6= Strongly disagree
1-6; 1= Strongly agree; 2= Moderately agree; 3=
Slightly agree; 4= Slightly disagree; 5= Moderately
disagree; 6= Strongly disagree
1-6; 1= Strongly agree; 2= Moderately agree; 3=
Slightly agree; 4= Slightly disagree; 5= Moderately
disagree; 6= Strongly disagree
1-6; 1= Strongly agree; 2= Moderately agree; 3=
Slightly agree; 4= Slightly disagree; 5= Moderately
disagree; 6= Strongly disagree
1-6; 1= Strongly agree; 2= Moderately agree; 3=
Slightly agree; 4= Slightly disagree; 5= Moderately
disagree; 6= Strongly disagree
1-6; 1= Strongly agree; 2= Moderately agree; 3=
Slightly agree; 4= Slightly disagree; 5= Moderately
disagree; 6= Strongly disagree
I heard about it on television;I heard about it on the
radio;I read about it in a print magazine;I read
about it on the Internet;A family member or friend
told me about it;My healthcare provider told me
about it;I dont remember;Other
Information
Seeking
How did you hear about the cancer risk assessment tool you
used?
Information
Seeking
There are tools available on the Internet that allow you to
estimate your risk of developing cancer. Have you ever used one Yes;No;Dont know
of these risk calculators to learn about your cancer risk?
Information
Seeking
There are tools available on the Internet that can tell you about
your chances of getting cancer based on your answers to
Yes;No;Dont know
medical questions. Have you EVER used one of these tools to
learn about your cancer risk?
Page 30
Construct
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
Question
Response Options
How easy or hard was it to find the information you were
looking for?
Very easy; Easy; Neither easy nor hard; Hard; Very
hard; Don’t Know; Refused;
How much do you agree with the following statement: The Drug Strongly agree; Agree; Neither agree nor disagree;
Facts label is easy to understand.
Disagree; Strongly disagree; Don’t Know; Refused;
How much do you agree with the following statement: The
Strongly agree; Agree; Neither agree nor disagree;
information leaflet for prescription drugs is easy to understand. Disagree; Strongly disagree; Don’t Know; Refused;
In the past six months, did you visit the Food & Drug
Administration’s website (www.fda.gov)?
Yes; No; Refused; Don't know;
Why haven’t you visited the FDA’s website?
Have you ever heard about the recall of any of the following
medical products: gel-filled teethers, automated external
defribrillators, stents, pacemakers, or infant apnea monitors?
How much do you agree or disagree with the following
statements... Advertisements for commonly used medical
products (such as inhalers, glucose test kits, and contact lenses)
do not give enough information about the possible benefits and
positive effects of using these products.
How much do you agree or disagree with the following
statements... Advertisements for commonly used medical
products such as inhalers, glucose test kits, and contact lenses
give enough information about the possible risks and negative
effects of using these products.
How much do you agree or disagree with the following
statements... Advertisements for over-the-counter drugs do not
give enough information about the possible risks and negative
effects of using the drug.
How much do you agree or disagree with the following
statements... Advertisements for over-the-counter drugs give
enough information about benefits and positive effects of using
the drug.
How much do you agree or disagree with the following
statements... Advertisements for prescription drugs do not give
enough information about the possible benefits and positive
effects of using the medication.
How much do you agree or disagree with the following
statements... Advertisements for prescription drugs give enough
information about the possible risks and negative effects of
using the drug.
Yes; No; Refused; Don't know;
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
How much do you agree or disagree with the following
Strongly agree; Agree; Neither agree nor disagree;
statements... Over-the-counter drugs are safer than prescription
Disagree; Strongly disagree; Don’t Know; Refused;
drugs.
How much do you agree or disagree with the following
statements... Over-the-counter drugs are weaker than
prescription drugs.
Page 31
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
Construct
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
Question
Response Options
How much do you agree or disagree with the following
statements: I can easily find information about the foods I eat.
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
How much do you agree or disagree with the following
statements: I can easily find information about the risks of the
drugs I use.
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
How much do you agree or disagree with the following
statements: The information I get about the benefits of the
drugs I use is clear and understandable.
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
How much do you agree or disagree with the following
statements: I can easily find information about the benefits of
the drugs I use.
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
How much do you agree or disagree with the following
statements: The information I get about drug benefits is not
helpful for making drug decisions.
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
How much do you agree or disagree with the following
Strongly agree; Agree; Neither agree nor disagree;
statements: The information I get about drug risks is not helpful
Disagree; Strongly disagree; Don’t Know; Refused;
for making drug decisions.
How much do you agree or disagree with the following
statements: The information I get about the foods I eat is clear
and understandable.
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
How much do you agree or disagree with the following
statements: The information I get about the foods I eat is not
helpful for making food choices.
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
How much do you agree or disagree with the following
statements: The information I get about the risks of the drugs I
use is clear and understantble.
Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
How much do you agree or disagree with the following
statements… Advertisements for prescription drugs give enough Strongly agree; Agree; Neither agree nor disagree;
Disagree; Strongly disagree; Don’t Know; Refused;
information about the possible risks and negative effects of
using the drug.
How much do you agree with the following statement: The
Strongly agree; Agree; Neither agree nor disagree;
information leaflets that come with the medical products I use in
Disagree; Strongly disagree; Don’t Know; Refused;
my home are easy to understand.
InformationSeeking about
Medical Products
and Foods
In the past year, how frequently did you read the information
leaflet that comes with the medical products that you use in your Always; Often; Sometimes; Rarely; Never; Don’t
home? [probe: these include such items as contact lenses, blood Know; Refused;
pressure cuffs, glucose test kits, and pregnancy test kits]
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
In the past year, the first time you use a home medical product
such as contact lenses, blood pressure cuffs, glucose test kits,
and pregnancy test kits, how frequently did you read the
information leaflet that came with it?
On your most recent visit, did you find the information you were
Yes; No; Refused; Don't know;
looking for?
Page 32
Construct
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
InformationSeeking about
Medical Products
and Foods
Insurance status
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Question
Response Options
The information I get about drug benefits does not usually help
me make decisions about whether or not to start taking a drug.
The information I get about drug risks does not usually help me
make decisions about whether or not to start taking a drug.
What would you do if a drug you used had to be recalled?
Would you:
What would you do if a medical product recall affected you?
Have it removed/stopped using it; Contact my
doctor; Contact the manufacturer; Have it
replaced/Find a substitute; Keep using it/Keep it;
Make no change; Other (please specify) ___________;
Unsure/Don’t know; Refused;
When you buy drugs your doctor prescribes, how frequently do Strongly agree; Agree; Neither agree nor disagree;
you read the information leaflet that comes with the drugs?
Disagree; Strongly disagree; Don’t Know; Refused;
When you purchase over-the-counter drugs for the first time,
how frequently do you read the Drug Facts label?
Do you have any kind of health care coverage, including health
insurance, prepaid plans such as HMOs, or government plans
such as Medicare?
A low-dose helical CT is a test to check for lung cancer. During
the past 12 months, did a doctor, nurse, or other health
professional advise you to get a low-dose helical CT?
Compared to the average person your age, would you say that
you are more likely to get lung cancer, less likely, or about as
likely?
During the past 12 months, did you have a low-dose helical CT
test to check for lung cancer
Have you heard of any tests to find lung cancer before the
cancer creates noticeable problems?
How likely do you think it is that you will develop lung cancer in
the future?
How often do you worry about getting lung cancer?
Overall, how many people who develop lung cancer do you think
are cured?
Overall, how many people who develop lung cancer do you think
survive at least 5 years?
Sometimes people can feel like something is both good and bad
at the same time. Please indicate below how you would feel/felt
about getting/having lung cancer 1. Getting lung cancer would
be: 2. Having lung cancer was:
What [lung] tests have you heard of?
What are some things that people can do to reduce their chances
of getting lung cancer?
What are the common symptoms of lung cancer?
Page 33
Always; Often; Sometimes; Rarely; Never; Don’t
Know; Refused;
Yes; No; Refused; Don't know;
Yes; No; Dont know; refuse
More likely to get lung cancer; Less likely; About
as likely; Refused; Don't know;
yes; no; Dont know; refused
Yes; No; Refused; Don't know;
7-point scale with anchors: The worst thing to
happen in my life (1); Neither good nor bad4]; The
best thing to happen in my life7]
MRI; Other;
Stay away from second-hand smoke;
Bronchitis; Chest pain; Coughing; Depression;
Difficulty breathing/shortness of breath/wheezing;
Excessive phlegm/mucus; Fatigue/tiredness; Loss
of appetite; Pneumonia; Spitting up blood;
Swelling of neck and/or face; Weakness; Weight
los
Construct
Question
Lung cancer
Who advised you to have the low-dose helical CT to check for
lung cancer?
Lung cancer
Would you say you agree or disagree with the following
statements? It seems like almost everything causes lung cancer.
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Lung cancer
Media exposure to
contradictory
health information
Media exposure to
contradictory
health information
Mental Models of
Cancer
Mental Models of
Cancer
Mental Models of
Cancer
Mental Models of
Cancer
Mental Models of
Cancer
Would you say you agree or disagree with the following
statements? Lung cancer develops over a period of several
years.
Would you say you agree or disagree with the following
statements? Lung cancer is most often caused by a person's
behavior or lifestyle.
Would you say you agree or disagree with the following
statements? People with lung cancer would have pain or other
symptoms prior to being diagnosed.
Would you say you agree or disagree with the following
statements? There are so many different recommendations
about preventing lung cancer that it's hard to know which ones
to follow.
Would you say you agree or disagree with the following
statements? There are ways to slow down or disrupt the
development of lung cancer.
Would you say you agree or disagree with the following
statements? There's not much you can do to lower your chances
of getting lung cancer.
Would you say you agree or disagree with the following
statements? You are reluctant to get checked for lung cancer
because you fear you may have it.
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree or you have no opinion with the
statement: Whether a person gets lung cancer depends more on
genes than anything else.
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree or you have no opinion with the
statement: Whether a person gets lung cancer depends more on
genes than anything else.
Thinking about the past 12 months, how much conflicting or
contradictory information have you heard from the media
(including television, radio, newspapers, magazines and the
Internet) about each of the following cancer screening
tests?Mammography]
Thinking about the past 12 months, how much conflicting or
contradictory information have you heard from the media
(including television, radio, newspapers, magazines and the
Internet) about each of the following cancer screening
tests?Prostate-specific an
[Breast cancer/ prostate cancer] can be in your body for many
years without causing problems
[Breast cancer/ prostate cancer] is treatable if found early
enough
[Women/ men] die from other causes withbreast cancer/
prostate cancer] they never knew they had in their body
Breast cancer can be in your body for many years without
causing problems
Breast cancer is treatable if found early enough
Page 34
Response Options
I asked my health provider about a low-dose
helical CT scan and he/she ordered it for me; My
health provider recommended a low-dose helical
CT scan; I obtained a low-dose helical CT scan
without involving my health provider.)
Strongly disagree; Disagree; Agree; Strongly agree
Not at all; A little; Some; A lot
Not at all; A little; Some; A lot
agree – disagree)
almost never – almost always
never – often
agree – disagree)
almost never – almost always
Construct
Mental Models of
Cancer
Mental Models of
Cancer
Mental Models of
Cancer
Mental Models of
Cancer
Mental Models of
Cancer
Question
Response Options
Do all breast cancers need to be treated (by surgery,
chemotherapy, radiation, or other methods) as soon as they are never – always
found?
Do allbreast cancers/ prostate cancers] need to be treated (by
surgery, chemotherapy, radiation, or other methods) as soon as
never – always
they are found?
How often does {breast/ prostate} cancer lead to death when it
almost never – almost always
is treated?
How often does {breast/ prostate} cancer lead to death?
almost never – almost always
How often does breast cancer lead to death when it is treated?
almost never – almost always
Mental Models of
Cancer
If a trusted healthcare provider told you that you had breast
cancer that would probably never hurt you, how likely would
you be to seek treatment anyway?
very unlikely – very likely
Mental Models of
Cancer
If a trusted healthcare provider told you that you hadbreast
cancer/ prostate cancer] that would probably never hurt you,
how likely would you be to seek treatment anyway?
very unlikely – very likely
Mental Models of
Cancer
Mental Models of
Cancer
Mental Models of
Cancer
If you had breast cancer and didn’t know about it, how likely
very unlikely – very likely
would it be to cause you harm?
If you hadbreast cancer/ prostate cancer] and didn’t know about
very unlikely – very likely
it, how likely would it be to cause you harm?
Women die from other causes with breast cancer they never
never – often
knew they had in their body
Mental Models of
Screening
How good ismammography/ PSA] at separating women who
very bad – very good
have breast cancer from women who don’t have breast cancer?
Mental Models of
Screening
Mental Models of
Screening
Mental Models of
Screening
How likely are you personally to benefit frommammography/
very unlikely – very likely
PSA]?
How many {men/ women} do you need to screen to prevent one
open
death from {prostate/ breast} cancer?
How many women do you need to screen to prevent one death
open
from breast cancer?
Mental Models of
Screening
Imagine a {man/woman} does not have {prostate/breast
cancer}. What percent of the time will a {PSA/ mammogram}
incorrectly show a positive result (false positive)?
Mental Models of
Screening
Mental Models of
Screening
open
Imagine awoman/ man] hasbreast/ prostate] cancer. What
percent of the time will amammogram/ PSA] correctly show a
open ended
positive result (true positive)?
Imagine over the course of your life that you had 30
{mammograms/ PSAs}. How many of those 30 would you be
willing to have be false positives (indicating high risk for cancer
open
when you do not have cancer) before you stopped having
{mammograms/ PSAa}? *Note that 30 may not be an
appropriate number for PSA*
Mental Models of
Screening
Imagine over the course of your life that you had 30
mammograms. How many of those 30 would you be willing to
open
have be false positives (indicating high risk for cancer when you
do not have cancer) before you stopped having mammograms?
Mental Models of
Screening
What do mammograms test for:
your risk for cancer; whether you have cancer;
whether you have pre-cancer; none of the above
Mental Models of
Screening
What domammograms/ PSAs] test for:
your risk for cancer; whether you have cancer;
whether you have pre-cancer; none of the above
Page 35
Construct
Mental Models of
Screening
Mental Models of
Screening
Mental Models of
Screening
Mental Models of
Screening
Numeracy
Question
What is the level of false positives (being told your
{mammogram/ PSA} places you at high risk for {breast/
prostate} cancer when you do not actually have {breast/
prostate} cancer) you would put up with?
Response Options
I would put up with any amount of false positives
in order to ensure that I detect cancer if I have it – I
would not put up with any amount of false
positives
I would put up with any amount of false positives
What is the level of false positives (being told your mammogram
in order to ensure that I detect cancer if I have it – I
places you at high risk for breast cancer when you do not
would not put up with any amount of false
actually have breast cancer) you would put up with?
positives
What percent of the time does aman/woman] receiving a
positive result on aPSA/mammogram] get a cancer diagnosis?
Which is more common, being told your {PSA/mammogram}
results indicate you are at high risk for cancer when you do not
actually have cancer (false positive), or being told your
{PSA/mammogram} results indicate you are at high risk for
cancer when you do in
How often do you find numerical information to be useful?
Numeracy (Health) How often do you find numerical information to be useful?
open
false positive is much more common – true positive
is much more positive
1=never; 6=very often
Imagine that we flip a fair coin 1,000 times. What is your best
Numeracy (Health) guess about how many times the coin would come up heads in Open ended
1,000 flips? __ times out of 1000.
In ACME Publishing Sweepstakes, the chance of winning a car is
Numeracy (Health) 1 in 1,000. What percent of tickets to ACME Publishing
open ended
Sweepstakes win a car?
In general, how easy or hard do you find it to understand
Numeracy (Health)
Very easy; Easy; Hard; Very hard;
medical statistics?
In general, I depend on numbers and statistics to help me make
Numeracy (Health)
decisions about my health.
In general, I feel uncomfortable with health information that has
Numeracy (Health)
a lot of numbers and statistics.
When I am looking for information about health, I prefer to a)
Numeracy (Health)
Read stories; review statistics
read stories; b) review statistics
When people tell you the chance of something happening do you
Numeracy (Health)
prefer they use words or numbers?
Which of the following numbers represents the biggest risk of
Numeracy (Health)
1 in 100; 1 in 1,000; 1 in 10;
getting a disease? 1 in 100, 1 in 1,000, 1 in 10
Are you concerned about the safety of consuming fish containing
Nutrition
Yes; No
mercury such as tuna?
Are you concerned about the safety of consuming foods such as
beef, chicken, or milkl that were raised on feed containing
Nutrition
Yes; No
growth hormone?
Are you concerned about the safety of eating foods containing
preservatives, pesticides, and other chemicals that are added to Yes; No
Nutrition
foods?
Are you concerned that artifical sweetners may increase your
Nutrition
Yes; No
cancer risk?
Do you believe that organic foods are healthier than
Nutrition
Yes; No
conventional foods sold in grocery stores?
Does your local store have a variety of healthy food options
Nutrition
Yes; No
(fresh fruits and vegetables)?
Nutrition
food label use
often; sometimes; rarely; never
Nutrition
How far to the closest grocery store from home?
Open Ended
Nutrition
How many servings of fruits and vegetables do you think the
average adult should eat each day for good health?
0; 1; 2; 3; 4; 5; 6; 7; 8; 9; 10; 14; 12; 14; 15;
16; 18; 20; 25; 30; 50; Don't know;
Nutrition
How often do you consume organic foods?
Daily; 1-2 times per week; 3-4 times per week;
greater than 4 times per week
Page 36
Construct
Nutrition
Nutrition
Nutrition
Nutrition
Nutrition
Nutrition
Question
How often do you consume products that contain artifical
sweetners such as Phenylalanine (Equal, NutraSweet, Sweet N
Low) and/or Sucralose (Splenda)?
How often do you use menu information on calories in deciding
what to order?
Id like you to think about the labels on many food products that
list ingredients and provide nutrition and other informaiton.
When you buy a product for the first time, how often do you
read this infodrmation?
lt is easy to purchase fresh fruits and vegetables in my
community.
o How useful do you find the menu information on calories
posted in restaurants?
Sunlight helps the body produce Vitamin D naturally. Would you
say you strongly agree, somewhat agree, somewhat disagree, or
strongly disagree?
Response Options
Never, Ocassionally; Frequently
1-5 scale; 1= never; 5= always
often; sometimes; rarely; never
(strongly agree, agree, disagree, strongly disagree)
1-5 scale; 1= not at all useful; 5= very useful
Nutrition
The costs of fruits and vegetables are affordable.
(strongly agree, agree, disagree, strongly disagree)
Nutrition
The produce in my community is of high quality.
(strongly agree, agree, disagree, strongly disagree)
Nutrition
Nutrition
Occupational
Exposures
Occupational
Exposures
Occupational
Exposures
There is a large selection of fresh fruits and vegetables in my
community.
To what extent do you believe that obesity is caused by
overeating ?
(strongly agree, agree, disagree, strongly disagree)
A lot; Some; A little; Not at all; Refused; Don't
Know;
Do you work night shifts on a regular basis?
Yes; No
Were you ever exposed to the following chemicals at work?
[List of chemicals]
What type of job do you have?
Open Ended
Do you always, usually, sometimes or never bring with you to
Patient Activation your doctor visits a list of questions or concerns you want to
cover?
Do you always, usually, sometimes or never make sure you
understand the results of any medical test or procedure? (An
Patient Activation
example would be an x-ray, blood tests, or EKG for heart
conditions)
always; usually; sometimes; never; refused; dont
know
always; usually; sometimes; never; refused; dont
know
Patient Activation
Do you always, usually, sometimes or never read information
about a new prescription, such as side effects and precautions?
Patient Activation
Do you always, usually, sometimes or never take a list of all your always; usually; sometimes; never; not applicable;
prescribed medicines to your doctor visits.
refused; dont know
Patient Activation
Have you ever asked your doctor questions about any treatment,
yes; no; doesnt apply
test or prescription that he or she has recommended?
Have you ever brought a friend or a relative to a doctors
Patient Activation appointment so that they could help ask questions, understand,
or remember what the doctor was telling you?
Have you ever called to check on the results of a medical test
Patient Activation
you had done?
Have you ever checked the medication that a pharmacist gave
Patient Activation
you with the prescription your doctor wrote?
Have you ever consulted with your doctor about the hospital
Patient Activation
you go to?
Have you ever talked to a surgeon about the details of surgery,
Patient Activation such as exactly what they will be doing, how long it will take and
the recovery process?
Patient Activation I do what I can to get checked for cancer
Page 37
always; usually; sometimes; never; refused; dont
know
yes; no; doesnt apply
yes; no; doesnt apply
yes; no; doesnt apply
yes; no; doesnt apply
yes; no; doesnt apply
Construct
Patient Activation
Patient Activation
Patient Activation
Patient Activation
Patient satisfaction
Patient satisfaction
Patient satisfaction
Patient satisfaction
Patient satisfaction
Patient satisfaction
Patient-provider
communication
Patient-provider
communication
Question
Response Options
Please tell me how confident you are that you can identify when very confident; confident; somewhat confident; not
it is necessary for you to get medical care.
at all confident; refused; dont know
Taking an active role in my own health care is the most
important factor in determining my health and ability to
function. OR When all is said and done, I am the person who is
responsible for managing my health condition (each item from
Patient Activatio
The following always, usually, sometimes or never happens:
Before I go to a new doctor, I find out as much as I can about his
or her qualifications.
The following always, usually, sometimes or never happens: I
ask my doctor to explain a test, treatment, or procedure to me in
detail.
During the past 12 months, how often did doctors or other
health providers give you good advice or treatment?
In the past 12 months, how often did you feel you could rely on
your doctors, nurses, or other health care professionals to take
care of your health care needs?
Overall, how satisfied were you with your care in the last three
months
Overall, how would you rate the care you got in the last 6
months from the doctors and nurses ni your personal doctors
office?
Overall, how would you rate the quality of health care you
received in the last 12 months?
Overall, how would you rate the quality of your care in the last
three months
Did you discuss your use of unconventional therapies with any
of your doctors?
During the past 12 months, how often did doctors, nurses, or
other health professionals give you the chance to ask all the
health-related questions you had.
disagree strongly; disagree; agree; agree strongly;
not applicable
always; usually; sometimes; never; not applicable;
refused; dont know
always; usually; sometimes; never; not applicable;
refused; dont know
Always; Usually; Sometimes; Never
Always; Usually; Sometimes; Never;
very satisfied; somewhat satisfied; somewhat
dissatisfied; very dissatisfied
very poor; poor; fair; good; very good; excellent
Poor; Fair; Good; Very Good; Excellent
Yes; No; Refused; Don't know;
Patient-provider
communication
I would prefer to make the decisions with little or
no input from my doctor; I would prefer to make
From the following five options, please mark the one that best
the decisions after seriously considering my
describes your preference for how medical decisions about your
doctors opinion; I would prefer that my doctor and
health care should be made.
I make the decisions together; I woudl prefer my
docto
Patient-provider
communication
How often did doctors, nurses, or other health professionals give
the attention you needed to your feelings and emotions?
Patient-provider
communication
Patient-provider
communication
Patient-provider
communication
Patient-provider
communication
Patient-provider
communication
How often did doctors, nurses, or other health professionals
help you deal with feelings of uncertainty about your health or
health care?
How often did doctors, nurses, or other health professionals
make sure you understood the things you needed to do to take
care of your health?
How often did the health professional you see most often
involve you in decisions about your health care as much as you
wanted?
In the past 12 months when you talked with a health care
professional, how interested were they in hearing about the
information you found on-line?
In the past 12 months, have you talked to a doctor, nurse, or
other health professional about any kind of health information
you have gotten from the Internet?
Page 38
Always; Sometimes; Don't know; Refused; Never;
Usually;
Very interested; Somewhat interested; A little
interested; Not at all interested;
Yes; No;
Construct
Patient-provider
communication
Patient-provider
communication
Patient-provider
communication
Patient-provider
communication
Patient-provider
communication
Patient-provider
communication
Patient-provider
communication
Patient-provider
communication
Patient-provider
communication
Patient-provider
communication
Patient-provider
communication
Perceived
Discrimination
Perceived
Discrimination
Perceived
Discrimination
Question
Response Options
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during
Always; Usually; Sometimes; Never
the past 12 months. How often did they do each of the
following? Spend enough time with you?
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during
the past 12 months. How often did they do each of the
Always; Usually; Sometimes; Never
following?
Explain things in a way you could understand?
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during
the past 12 months. How often did they do each of the
Always; Usually; Sometimes; Never
following?
Give the attention you needed to your feelings and emotions?
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during
the past 12 months. How often did they do each of the
following?
Give you the chance to ask all the health-related questions you
had?
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during
the past 12 months. How often did they do each of the
following?
Help you deal with feelings of uncertainty about your health or
health care?
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during
the past 12 months. How often did they do each of the
following?
Involve you in decisions about your health care as much as you
wanted?
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during
the past 12 months. How often did they do each of the
following?
Listen carefully to you?
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during
the past 12 months. How often did they do each of the
following?
Make sure you understood the things you needed to do to take
care of your health?
The following questions are about your communication with all
doctors, nurses, or other health professionals you saw during
the past 12 months. How often did they do each of the
following?
Show respect for what you had to say?
Were you involved in decisions about your care as much as you
wanted?
Always; Usually; Sometimes; Never
Always; Usually; Sometimes; Never
Always; Usually; Sometimes; Never
Always; Usually; Sometimes; Never
Always; Usually; Sometimes; Never
Always; Usually; Sometimes; Never
Yes, definitely; Yes, somewhat; no
Were you told of your diagnosis in a sensitive manner?
Yes, definitely; Yes, somewhat; no
At work?
Never; once; two or three times; four or more times
From the police or in the courts?
Never; once; two or three times; four or more times
Getting credit, bank loans, or a mortgage
Never; once; two or three times; four or more times
Page 39
Construct
Perceived
Discrimination
Perceived
Discrimination
Perceived
Discrimination
Perceived
Discrimination
Question
Response Options
Getting hired or getting a job?
never; once; two or three times; four or more times
Getting housing?
Never; once; two or three times; four or more times
Getting medical care
Never; once; two or three times; four or more times
Getting service in a store or restaurant
Never; once; two or three times; four or more times
Perceived
Discrimination
How often have you experienced discrimination, been prevented
never; once; two or three times; four or more
from doing something, or been hassled or made to feel inferior
times;
in any of the following situations: At school?
Perceived
Discrimination
On the street or in a public setting?
Never; once; two or three times; four or more times
Perceived
vulnerability
Compared to the average person your age, would you say that
you are more likely to get colon cancer, less likely, or about as
likely?
More likely to get colon cancer; Less likely; About
as likely; Refused; Don't know;
Perceived
vulnerability
Feelings of risk
1=Agree strongly; 2=Agree mildly; 3=Disagree
mildly; 4=Disagree Strongly
Personal
Behaviors
Physical Activity
Physical Activity
Physical Activity
Physical Activity
Physical Activity
Physical Activity
Physical Activity
Physical Activity
Physical Activity
Physical Activity
Physical Activity
Physical Activity
Physical Activity
Have you ever refused or discontinued treatment recommended
by your doctor/dentist based on information you obtained from
the internet?
Are you currently trying to gain weight, lose weight, maintain
your current weight, or none of these?
As far as you know, does physical activity or exercise increase
the chances of getting some types of cancer, decrease the
chances of getting some types of cancer, or does it not make
much difference?
Do you feel safe exercising outdoors in your own
neighborhood/community?
Do you have access (within a reasonable distance) to a health
club, gym, and/or fitness facility?
Have you tried to lose any weight in the past 12 months?
How many days in a typical week do you exercise at least at a
moderate level, making you breathe somewhat harder than
normal?
How many minutes per week of physical activity or exercise of
at least moderate intensity are recommended for the average
adult to stay healthy?
yes; no
Increases chances of cancer; Decreases chances of
cancer; Makes no difference; Refused; Don't
know;
Yes; No
Yes; No
Yes; No; Refused; Don't know;
None; Less than 30 Minutes; 30 Minutes to less
than 1 Hour; 1 Hour to less than 1.5 Hours; 1.5
Hours to less than 2 Hours; 2 Hours to less than 2.5
Hours; Over 2.5 Hours;
How often do you do leisure-time physical activities specifically
designed to strengthen your muscles such as lifting weights or # of times per day/week/month/year
doing calisthenics?
In a typical week, how many days do you do any physical
activity or exercise of at least moderate intensity, such as brisk
walking, bicycling at a regular pace, and swimming at a regular
pace?
In a typical week, how many days do you do any physical
activity or exercise of at least moderate intensity, such as brisk Free text (see on-line HINTS codebook for full list
walking, bicycling at a regular pace, swimming at a regular pace, of responses)
and heavy gardening?
In a typical week, how many days do you do leisure-time
physical activities specifically designed to strengthen your
muscles such as lifting weights or doing calisthenics?
None; Less than 30 Minutes; 30 Minutes to less
On the days that you do any physical activity or exercise of at
than 1 Hour; 1 Hour to less than 1.5 Hours; 1.5
least moderate intensity, how long are you typically doing these
Hours to less than 2 Hours; 2 Hours to less than 2.5
activities?
Hours; Over 2.5 Hours;
Over the past 30 days, on average how many hours per day did
you sit and watch TV/movies or use a computer game console?
Do not include “active gaming” such as Wii.
Page 40
Construct
Physical Activity
Physical Activity
Physical Activity
Physical Activity
Question
Response Options
Over the past 30 days, on average how many hours per day did
you sit and watch TV/movies or use computer/game console?
There are so many different messages about whether being
overweight is harmful to one's health it is hard to know what
weight one should maintain to be healthy.
A lot; Some; A little; Not at all; Refused; Don't
To what extent do you believe that obesity is caused by not
exercising?
Know;
To what extent do you believe that obesity is inherited? Would
you say… a lot, some, a little, or not at all?
Physical Activity
What activities do you typically do to strengthen your muscles?
Pluralistic
ignorance
Pluralistic
ignorance
2. How worried do you think other smokers are that their
smoking will lead to lung cancer?
How worried are you that your smoking will lead to lung
cancer?
(Only males need to answer this question.) The following
questions are about discussions doctors or other health care
professionals may have with their patients about the PSA test
that is used to look for prostate cancer. Have you ever had a PSA
test?
Before you had the PSA test, did you and a doctor or other
health care professional talk about the test?
Did you and a doctor or other health care professional talk about
the PSA test?
During the past 12 months, did a doctor, nurse, or other health
professional advise you to get a PSA test?
Has a doctor ever asked you whether or not you wanted to have
the PSA test?
Has a doctor ever told you that some doctors recommend the
PSA test and others do not?
Has a doctor ever told you that… a. The PSA test is not always
accurate? b. Some types of prostate cancer are slow-growing
and need no treatment? c. The results of the PSA test cannot tell
the difference between slow-growing and fast-growing prostate
canc
Prostate Cancer
Prostate Cancer
Prostate Cancer
Prostate Cancer
Prostate Cancer
Prostate Cancer
Prostate Cancer
Prostate Cancer
Has a doctor or other health care professional ever told you that
no one is sure if using the PSA test actually saves lives?
Prostate Cancer
Has a doctor or other health care professional ever told you that
some doctors recommend the PSA test and others do not?
Prostate Cancer
Prostate Cancer
Number, in hours
Not at all worried; Very worried
Not at all worried; Very worried
Yes; No; Don't know; Had blood test, but dk if
checked psa;
Yes;No
Yes; No; DON’T KNOW
Yes;No;Dont Know
Has a health care provider such as a doctor or nurse ever talked
Yes; No; Don't know;
to you about a PSA test?
Yes; No; Had blood test, but don't know if checked
Have you ever had a PSA test?
psa; Refused; Don't know;
Prostate Cancer
Have you ever heard of a PSA or prostate-specific antigen test?
Prostate Cancer
How likely do you think it is that you will develop prostate
cancer in the future?
Prostate Cancer
How long before your most recent PSA test was the last one?
Prostate Cancer
If Had PSA: Before you had the PSA test, did you and a doctor
talk about the test? If No PSA: Did you and a doctor talk about
the PSA test?
Yes; No; DON’T KNOW/DON’T REMEMBER
Prostate Cancer
When did you have your most recent PSA test?
A year ago or less; More than 1 but not more than
2 years ago; More than 2 but not more than 5
years ago; Over 5 years ago; Don't know;
Page 41
Yes; No; Not ascertained; Don't know;
Construct
Prostate Cancer
Quality of Life
Quality of Life
Radiation
Question
When, if ever, did you and a doctor or other health care
professional talk about the PSA test?
How likely is it that going through a serious illness will one day
lead to positive outcomes for a person?
How much do you agree or disagree with this statement: People
who have survived a serious illness tend to be more self-reliant
than people who have not.
Did the doctor that ordered the test discuss radiation risks of the
test with you?
Response Options
very unlikely; somewhat unlikely; somewhat likely;
very likely
strongly disagree; disagree; agree; strongly agree
Yes; No
Radiation
Do you worry that radiation from cell phones causes cancer?
Yes; No
Radiation
Have you had a CT scan, x-ray, or other medical test using
radiation in the last year?
Yes; No
Radiation
How many hours a day do you use your cell phone?
Less than one hour; one hour; two hours; three
hours; four hours; greater than four hours
Religiosity and
Spirituality
In general, how would you describe your religious or spiritual
beliefs?
1 Very Conservative, 2 Conservative, 3 Moderate, 4
Liberal, 5 Very liberal, 9 DK/Refused
Secondhand
Smoke
At this job or business, that is at {EMPLOYER} as a(n)
{OCCUPATION}, how many hours per day can {you/SP} smell
the smoke from other people’s cigarettes, cigars, and/or pipes?
Open Ended
Secondhand
Smoke
Secondhand
Smoke
Secondhand
Smoke
Secondhand
Smoke
Does your place of work have an official policy that restricts
smoking in any way?
During the PAST TWO WEEKS, has anyone smoked in the area in
which you work?
How many cigarettes per day {do you/does PERSON} usually
smoke anywhere inside the home?
Which of these best describes your place of works smoking
policy for INDOOR PUBLIC OR COMMON AREAS, such as lobbies,
rest rooms, and lunch rooms?
Yes/No
Yes/No
Open Ended
(1) Not allowed in ANY public areas (2) Allowed in
SOME public areas (3) Allowed in ALL public areas
Secondhand
Smoke
Which of these best describes your place of works smoking
policy for WORK AREAS?
(1) Not allowed in ANY work areas (2) Allowed in
SOME work areas (3) Allowed in ALL work areas
Secondhand
Smoke
Which statement best describes the rules about smoking inside
your home?
(No one is allowed to smoke anywhere inside your
house/ Smoking is allowed in some places or at
some times inside your house / Smoking is
permitted anywhere inside your house)
Self-affirmation
1. When I feel threatened or anxious by people or events I find
disagree completely; agree completely
myself thinking about my values
Self-affirmation
2. When I feel threatened or anxious by people or events I find
disagree completely;agree completely
myself thinking about the people who are important to me
Self-affirmation
I feel a sense of choice in my decision making about health
Self-affirmation
I feel controlled in making decisions about health
Self-affirmation
Self-affirmation
When I feel threatened or anxious I find myself thinking about
my core values.
When I feel threatened or anxious I find myself thinking about
the people who are important to me.
Skin cancer
How likely do you think it is that you will develop skin cancer in
the future?
How often do you worry about getting skin cancer?
Skin cancer
What are the common symptoms of skin cancer?
Skin cancer
Page 42
not at all1]; slightly2]; somewhat3]; moderately4];
extremely5]
not at all1]; slightly2]; somewhat3]; moderately4];
extremely5]
disagree completely; agree completely
disagree completely;agree completely
Abnormal growths; Blisters; Blotches; Lesions;
Mole/change in mole; Pigment discoloration;
Rash; Redness of skin; Other (specify);
Construct
Sleep Quality
Social Support
Question
On the average, how many hours of sleep do you get in a 24hour period? Think about the time you actually spend sleeping
or napping, not just the amount of sleep you think you should
get?
Are you currently married or living with a partner?
Response Options
Yes; No
Social Support
Can you count on anyone to provide you with emotional support
Yes; No
(talking over problems or helping you make a difficult decision)?
Social Support
Do you have as much contact as you would like with someone
Yes; No
you feel close to, someone in whom you can trust and confide in?
Sun Safety
Is there someone available to whom you can count on to listen
to you when you need to talk?
Is there someone avaliable to help with daily chores?
Is there someone avaliable to you to give you good advice about
a problem?
Is there someone avaliable to you who shows you love and
affection?
Are you in favor or against restricting children under the age of
18 to have access to tanning beds and booths?
How many times in the past 12 months have you used a tanning
bed or booth?
How often do you stay in the shade or under an umbrella?
Sun Safety
How often do you wear a hat?
Social Support
Social Support
Social Support
Social Support
Sun Safety
Sun Safety
Sun Safety
Sun Safety
Sun Safety
Sun Safety
How often do you wear a shirt with sleeves that cover your
shoulders?
When you are outside for more than one hour on a warm sunny
day, how often do you wear sunscreen?
When you go outside for more than 1 hour on a warm, sunny
day, how often do you wear long pants?
When you go outside for more than 1 hour on a warm, sunny
day, how often do you wear sunscreen?
Tobacco:
Behavioral
Tradeoff
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree or you have no opinion with the
statement: Exercise can undo most of the effects of smoking.
Tobacco:
Behavioral
Tradeoff
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree or you have no opinion with the
statement: There's no risk of getting cancer if someone only
smokes a few years.
Tobacco:
Behavioral
Tradeoff
Would you say you strongly agree, somewhat agree, somewhat
disagree, strongly disagree or you have no opinion with the
statement: Vitamins can undo most of the effects of smoking.
None to All the Time
Yes; No
Yes; No
Yes; No
Strongly in favor, somewhat in favor, somewhat
against, strongly against
0 times; 1 to 2 times; 3 to 10 times; 11 to 24
times; 25 times or more; Don't know;
Always; Often; Sometimes; Rarely; Never;
Refused; Does not go out on sunny day;
Always; Often; Sometimes; Rarely; Never; Don't
know; Does not go out on sunny day;
Tobacco:
Before being contacted for this survey, had you ever heard of 1Cessation: Quitline 800-QUIT-NOW?
Before being contacted for this survey, had you ever heard of
Tobacco:
telephone quit lines such as a toll-free number to call for help in
Cessation: Quitline
quitting smoking?
Tobacco:
Have you ever called a telephone quit line to help you or
Cessation: Quitline someone else quit smoking?
Tobacco:
Have you ever used a website or online program to help you or
Cessation: Website someone else quit smoking?
Tobacco: Implicit
Theories
"I think your smoking behavior is something basic about you
that you can't change very much"
Page 43
Y/N
Construct
Tobacco:
Intentions:
Smokeless
Tobacco:
Intentions:
Smokeless
Tobacco:
Pluralistic
Ignorance
Question
Response Options
How interested are you in switching to a smokeless tobacco
product?
Very Interested/Somewhat Interested/ Not
Interested/ Refused/ Don't know
How likely would you be to switch to a smokeless tobacco
product instead of trying to quit smoking?
How worried are you that your smoking will lead to lung
cancer?
Tobacco:
Pluralistic
Ignorance
How worried do you think other smokers are that their smoking
will lead to lung cancer
Tobacco: Product
Packaging
To what extent does the color of the cigarette pack give you
information on the harmfulness of the cigarette?
Tobacco: Product: What type of cigarette do you now smoke most often -- a
Cigarette
regular, light, ultra light or some other type?
not at all, a little, somewhat, a lot
regular, light, ultra light, some other type, *don't
know
Tobacco: Product: Have you ever used dissolvable tobacco products, such as Ariva,
Y/N
Dissolvable
Stonewall, or Camel orbs, ticks, or strips?
Would you say that using dissolvable tobacco products, such as
much more addictive to much less addictive five
Tobacco: Product:
Ariva, Stonewall, or Camel orbs, ticks, or strips is more addictive
response categories
Dissolvable
or less addictive than smoking regular cigarettes?
Would you say that using dissolvable tobacco products, such as
Tobacco: Product:
Ariva, Stonewall, or Camel orbs, ticks, or strips is more harmful
Dissolvable
or less harmful than smoking regular cigarettes?
much more harmful to much less harmful, five
response categories
Tobacco: Product:
E-cigarettes
Have you ever used an electronic cigarette?
y/n
Tobacco: Product:
E-cigarettes
Where did you hear about electronic cigarettes?
radio, television, newspaper, magazine…
New types of cigarettes are now available called electronic
cigarettes (also known as e-cigarettes or personal vaporizers).
Tobacco: Product:
These products deliver nicotine through a vapor. Have you
E-cigarettes
heard of any products like this?
Y/N (if no, skips next 4 items)
Tobacco: Product: Would you say that e-cigarettes are more addictive or less
E-cigarettes
addictive than smoking regular cigarettes?
much more addictive to much less addictive five
response categories
Tobacco: Product: Would you say that using electronic cigarettes is more harmful
E-cigarettes
or less harmful than smoking regular cigarettes?
much more harmful to much less harmful, five
response categories
Do you believe that menthol cigarettes are (LESS HARMFUL,
Tobacco: Product:
EQUALLY HARMFUL, or MORE HARMFUL) than non-menthol
Menthol
cigarettes?
Do you believe that cigarettes sold in packages labeled as
Tobacco: Product:
"smooth" are (LESS HARMFUL, EQUALLY HARMFUL, or MORE
Smooth
HARMFUL) than cigarettes without those labels?
much more harmful to much less harmful, five
response categories, I have never heard of menthol
cigarettes
much more harmful to much less harmful, five
response categories, I have never heard of smooth
cigarettes
Tobacco: Product:
Waterpipe
Y/N
Have you ever used a waterpipe to smoke tobacco?
Would you say that smoking from a waterpipe (hookah,
Tobacco: Product:
shisha, narghile, Goza) is more addictive or less addictive than
Waterpipe
smoking regular cigarettes?
Page 44
much more addictive to much less addictive, five
response categories
Construct
Question
Response Options
Would you say that smoking from a waterpipe (hookah,
Tobacco: Product:
much more harmful to much less harmful, five
shisha, narghile, goza) is more harmful or less harmful than
Waterpipe
response categories
smoking regular cigarettes?
A type of device known as a waterpipe (also known as hookah,
narghile, shisha, and goza) contains a smoke chamber, a bowl, a
Tobacco: Product: pipe and a hose. Specially made tobacco is heated, and the
Y/N (if no, skips next 3 items)
Waterpipe
smoke passes through water and is then drawn through a
rubber hose to a mouthpiece. Have you heard of any devices like
this?
Tobacco:
Have you ever heard of dissolvable tobacco products, such as
Product:Dissolvabl
Yes/No (if no, skips next 3 items)
Ariva, Stonewall, or Camel orbs, ticks, or strips?
e
For persons who quit smoking during the past six months: To
Tobacco:
what extent did cigarette warnings on cigarette packages or
Regulation:
not at all, at little, some, a lot, don’t know/not
cigarette advertisements influence your decision to quit
Cigarette Warning
applicable
smoking?
Labels
Tobacco:
Regulation:
In the past 30 days, have the warning labels stopped you from
Cigarette Warning having a cigarette when you were about to smoke one?
Labels
never; once; a few times; many times
Check all that apply:
Tobacco:
by covering the warnings up
Regulation:
In the past 30 days, have you made an effort to avoid looking at
by keeping the pack out of sight
Cigarette Warning or thinking about the warning labels?
by using a cigarette case or some other pack
Labels
by not buying packs with particular labels
Tobacco:
Regulation:
In the past 30 days, have you noticed information about the
Yes/No
Cigarette Warning dangers of smoking on cigarette packages?
Labels
Tobacco:
Regulation:
In the past 30 days, have you noticed messages that have
Yes/No (if no, skip next 7 cigarette warning labels
items)
Cigarette Warning encouraged quitting on cigarette packages?
Labels
Tobacco:
In the past 30 days, how often have the warning labels on
Regulation:
never, rarely, sometimes, often, don’t know/not
cigarette packages or cigarette advertisements made you think
applicable
Cigarette Warning
about quitting smoking?
Labels
never; rarely; sometimes; often; very often
Tobacco:
Regulation:
Alternate: every time I saw a package or
In the past 30 days, how often have you noticed the warning
Cigarette Warning labels on cigarette packages or cigarette advertisements?
advertisement; almost every time I saw a package
Labels
or advertisement; sometimes… rarely… I never
noticed the warning labels
Tobacco:
In the past 30 days, how often have you read or looked closely at
Regulation:
never; rarely; sometimes; often; very often (don't
the warning labels on cigarette packages or cigarette
Cigarette Warning
know, not applicable)
advertisements?
Labels
Tobacco:
In the past 30 days, to what extent have warning labels on
Not at all, A little, Somewhat, A lot, I did not see a
Regulation:
cigarette packages or cigarette advertisements made you think warning label on a smokeless tobacco product in
Cigarette Warning
about the health risks of smoking?
the past 30 days
Labels
Tobacco:
Do you believe that government regulation of cigarettes make
Regulation:
Yes/No
cigarettes safer.
General
Tobacco:
make cigarettes less harmful; have no effect, make
Regulation:
Do you believe that government regulation of cigarettes will…
cigarettes more harmful
General
Page 45
Construct
Tobacco:
Regulation:
General
Tobacco:
Regulation:
General
Tobacco:
Regulation:
General
Tobacco:
Regulation:
General
Tobacco:
Regulation:
Smokeless
Warning Labels
Tobacco:
Regulation:
Smokeless
Warning Labels
Tobacco: Risk
Perception:
Cigarette
Tobacco: Risk
Perception:
Cigarette
Tobacco: Risk
Perception:
Cigarette
Question
Response Options
Do you believe that some cigarettes are less harmful than others
Yes/No
because of government regulation?
Do you believe that the government regulates tobacco products
Yes/No (skip)
in the U.S.?
Government regulation of cigarettes make cigarettes less
harmful.
Is tobacco safer now than it was 5 years ago?
In the past 30 days, how often have you noticed the warning
labels on smokeless tobacco packages or smokeless tobacco
advertisements?
In the ppast 30 days, to what extent did warning labels on
smokeless tobacco packages or smokeless tobacco
advertisements make you think about the health risks of
smokeless tobacco?
Based on what you know or believe, does smoking cigarettes
cause: (list specific diseases - head and neck cancer, lung cancer,
cervical cancer, bladder cancer, heart disease, stroke,
Pneumonia, Pancreatic Cancer….)?
strongly agree, agree, disagree, strongly disagree
strongly agree, agree, disagree, strongly disagree
I did not see a smokeless tobacco product during
the past 30 days, Never, Rarely, Sometimes, Most of
the time, Always
Not at all, A little, Somewhat, A lot, I did not see a
warning label on a smokeless tobacco product in
the past 30 days
Check List?
Do you believe that some cigarettes are less harmful than
others?
If a new cigarette were advertised as less harmful than current
cigarettes, how interested would you be in trying it?
Very Interested/Somewhat Interested/ Not
Interested/ Refused/ Don't know
Tobacco: Risk
Compared to other {men/women} your age who smoke the
Perception: Cancer same number of cigarettes and same type of cigarette as you do, 1=5 point scale with 1=very unlikely
how likely are you to get lung cancer in your lifetime?
Smokers Only
Tobacco: Risk
Perception:
Chemicals
Tobacco: Risk
Perception:
Duration
Tobacco: Risk
Perception: ECigarettes
In the past 30 days, how often have you thought about the
harmful chemicals in tobacco products?
How long do you think someone has to smoke before it harms
their health?
Never, Rarely, Sometimes, Often, Very Often
Less than a year, 1 year, 5 years, 10 years, 20 years
or more
If a new electronic cigarette product were advertised as less
Very Interested/Somewhat Interested/ Not
harmful than current cigarettes, how interested would you be in
Interested/ Refused/ Don't know
trying it?
Tobacco: Risk
Perception:
Frequency
How much do you think people risk harming themselves when
they smoke cigarettes every day but less than a pack per day?
No risk, Slight risk, Moderate risk, Great risk
Tobacco: Risk
Perception:
Frequency
Tobacco: Risk
Perception:
Smokeless
Tobacco: Risk
Perception:
Smokeless
Tobacco: Risk
Perception:
Smokeless
How much do you think people risk harming themselves when
they smoke cigarettes some days but not everyday?
No risk, Slight risk, Moderate risk, Great risk
Do you believe that some smokeless tobacco products, such as
chewing tobacco, snus, and snuff, are less harmful than
cigarettes?
How much do you think people risk harming themselves when
they use smokeless tobacco everyday?
No risk, Slight risk, Moderate risk, Great risk
How much do you think people risk harming themselves when
they use smokeless tobacco some days but not everyday?
Page 46
No risk, Slight risk, Moderate risk, Great risk
Construct
Tobacco: Risk
Perception:
Smokeless
Tobacco: Risk
Perceptions:
Cancer
Tobacco: Risk
Perceptions:
Cancer
Tobacco: Risk
Perceptions:
Cancer
Tobacco: Risk
Perceptions:
Cancer
Tobacco: Risk
Perceptions:
Cancer
Question
Response Options
If a new smokeless tobacco product were advertised as less
Very Interested/Somewhat Interested/ Not
harmful than current cigarettes, how interested would you be in
Interested/ Refused/ Don't know
trying it?
Compared with other {men/women} your age, how likely are
you to get lung cancer in your lifetime?
1=5 point scale with 1=very unlikely
How likely are you to get lung cancer in your lifetime?
1-5 point scale with 1= very unlikely
How likely is it that the average {man/woman} cigarette smoker
1=5 point scale with 1=very unlikely
your age will get lung cancer in {his/her} lifetime?
How worried are you about getting lung cancer?
(1) not at all to (5) extremely
Lung Cancer in the United States is:
very rare, moderately rare, slightly rare, neither
rare or common, slightly common, moderately
common, very common
Tobacco: Risk
Perceptions:
Disease Smokers
Only
If you continue to smoke the same number of cigarettes and
same type of cigarette that you currently do every day {for the
next 10 years/ for the next 25 years/ for the rest of your life},
how likely do you think you are to get a disease due to your
smoking?
Tobacco: Risk
Perceptions:
Disease Smokers
Only
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Assuming you continue to smoke the same number of cigarettes
and same type of cigarette that you currently do every day, what
is your risk of getting (lung) cancer {in the next 10 years/ in the
next 25 years/in your lifetime}?
How much would you trust information about cancer from cable
and national television news programs?
How much would you trust information about cancer from local
television news programs?
How much would you trust information about cancer in general
magazines?
How much would you trust information about cancer in online
newspapers?
How much would you trust information about cancer in print
newspapers?
How much would you trust information about cancer in special
health or medical magazines or newsletters?
Response Options would be either a percentage or
Likert scale.
Base on Cognitive Testing
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
Trust and Mistrust How much would you trust information about health or medical
Not at all to A lot
Items
topics from cable and national television news programs?
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
How much would you trust information about health or medical
topics from local television news programs?
How much would you trust information about health or medical
topics in general magazines?
How much would you trust information about health or medical
topics in magazines?
How much would you trust information about health or medical
topics in newspapers?
How much would you trust information about health or medical
topics in online newspapers?
Page 47
Not at all to A lot
Not at all to A lot
Not at all to A lot
Not at all to A lot
Not at all to A lot
Construct
Question
Response Options
Trust and Mistrust How much would you trust information about health or medical
Not at all to A lot
Items
topics in print newspapers?
Trust and Mistrust How much would you trust information about health or medical
Not at all to A lot
Items
topics in special health or medical magazines or newsletters?
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
Trust and Mistrust
Items
How much would you trust the information about cancer from a
doctor or other health professional?
How much would you trust the information about cancer from
family or friends?
How much would you trust the information about cancer from
magazines?
How much would you trust the information about cancer from
newspapers?
How much would you trust the information about cancer from
television?
How much would you trust the information about cancer from
the Internet?
How much would you trust the information about cancer from
the radio?
In general, how much would you trust information about health
or medical topics from family or friends?
In general, how much would you trust information about health
or medical topics in newspapers or magazines?
In general, how much would you trust information about health
or medical topics on television?
In general, how much would you trust information about health
or medical topics on the Internet?
In general, how much would you trust information about health
or medical topics on the radio?
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
In general, how much would you trust information about health
A lot; Some; A little; Not at all; Refused; Don't
Trust and Mistrust
or medical topics from a doctor or other health care
know;
Items
professional? Would you say a lot, some, a little, or not at all?
Trust and Mistrust
Items
Trust and Mistrust
Items
In general, how much would you trust information about health
or medical topics from charitable organizations?
In general, how much would you trust information about health
or medical topics from government health agencies?
A lot; Some; A little; Not at all; Refused; Don't
know;
A lot; Some; A little; Not at all; Refused; Don't
know;
Trust and Mistrust In general, how much would you trust information about health A lot; Some; A little; Not at all; Refused; Don't
Items
or medical topics from religious organizations and leaders?
know;
Trust and Mistrust In general, I think that the information I give doctors is safely
Strongly Agree-Strongly Disagree
Items
guarded when the information is stored in an electronic format.
Trust and Mistrust
Items
Trust and Mistrust
Items
In general, I think that the information I give doctors is safely
guarded when the information is stored on paper
In general, I think that the information I give doctors is safely
guarded.
Strongly Agree-Strongly Disagree
Strongly Agree-Strongly Disagree
“Privacy” refers to your ability to exercise control
over the collection, use, and distribution of your
health information.
Use of Technology (Definitions)
“Security” refers to the technology, tools or
procedures used to protect your health information
from someone who is not authorized to view it.
Page 48
Construct
Question
Response Options
Looked for information about quitting smoking?;
Bought medicine or vitamins on-line?; Participated
in an on-line support group for people with a
similar health ; or medical issue?; Used e-mail or
the Internet to communicate with a doctor or a
doctor's office?; Used a website to help you with
your diet, weight, or physical activity?; Looked for a
Below are some ways people use the Internet. Some people
have done these things, but other people have not. Please tell us healthcare provider?; Downloaded to a mobile
Use of Technology
whether or not you have done each of these things while using device, such as an MP3 player, cell phone, ; tablet
the Internet in the past 12 months.
computer, or electronic book device?; Visited a
"social networking" site, such as "Facebook" or
"LinkedIn"? ; Wrote in an online diary or "blog"
(i.e., Web log)? ; Kept track of personal health
information, such as care received, ; test results, or
upcoming medical appointments? ; Looked for
health or medical information for someone else?
Do you ever go on-line to access the Internet or World Wide
Yes; No; Refused; Don't know;
Web, or to send and receive e-mail?
Do you ever use your cell phones hands free device to minimize
Use of Technology
Yes/No
radiation exposure?
Use of Technology
Use of Technology Do you or anyone in your household have cable or satellite TV?
Yes; No; Refused; Don't know;
Use of Technology Do you use the Internet from home?
Yes; No; Refused; Don't know;
Use of Technology Does anyone in your family have a working cell phone?
Use of Technology Does anyone in your family have a working cellular phone?
Use of Technology
Yes; No;
During a typical weekend, about how many hours do you use the 0; 1; 2; 3; 4; 5; 6; 7; 8; 9; 10; 11; 12; 13; 14;
Internet for personal reasons?
15; 16; 18; 20; 25; 30; Refused; Don't know;
Use of Technology Have you done anything else health-related on the Internet?
Use of Technology
Have you ever posted comments, queries or information about
health or medical matters in an online discussion or a listserv?
How concerned are you with the privacy of your medical
records?
How concerned are you with the security of your medical
Use of Technology
records?
How interested would you be in having your health care
Use of Technology provider communicate with you about health matters using text
messaging?
Use of Technology
I want my health care provider to use a computerized medical
Use of Technology record to store and manage my health information despite any
concerns I might have about privacy and security.
Yes/No
VERY CONCERNED, SOMEWHAT CONCERNED,
NOT CONCERNED
VERY CONCERNED, SOMEWHAT CONCERNED,
NOT CONCERNED
VERY INTERESTED, SOMEWHAT INTERESTED,
NOT AT ALL INTERESTED
STRONGLY AGREE, AGREE, DISAGREE, STRONGLY
DISAGREE
I want my health care providers to use a computer to share my
STRONGLY AGREE, AGREE, DISAGREE, STRONGLY
Use of Technology health information with other health care providers treating me
DISAGREE
despite any concerns I might have about privacy and security.
If medical information about appointments and other
health/medical matters could be shared with you via text
VERY CONCERNED, SOMEWHAT CONCERNED,
Use of Technology
messaging, how concerned are you that an unauthorized person NOT CONCERNED
could intercept that information while it is being sent?
Page 49
Construct
Use of Technology
Use of Technology
Use of Technology
Use of Technology
Use of Technology
Use of Technology
Question
Response Options
If medical information about you is sent from one of your health
VERY CONCERNED, SOMEWHAT CONCERNED,
care providers to another by fax, how concerned are you that an
NOT CONCERNED
unauthorized person would see it?
If medical information about you is sent from one of your health
care providers to another electronically, how concerned are you
VERY CONCERNED, SOMEWHAT CONCERNED,
that an unauthorized person would see it? (Electronically means
NOT CONCERNED
from computer to computer, instead of by telephone, mail, or fax
machine.)
If your health care provider could communicate with you about
health matters via text messaging, how concerned are you that VERY CONCERNED, SOMEWHAT CONCERNED,
an unauthorized person would see it on your cell phone; for
NOT CONCERNED
example, if your cell phone is stolen or lost?
In the past 12 months, have you done the following things while
using the Internet: Downloaded to a portable device, such as an
iPod, cell phone, or PDA?
In the past 12 months, have you done the following things while
using the Internet? Looked for health or medical information for
yourself?
In the past 12 months, have you done the following things while
Yes; No; Refused; Don't know;
using the Internet? Bought medicine or vitamins on-line?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Done anything else health-related on the
Internet? (SPECIFY)
Use of Technology
In the past 12 months, have you done the following things while
using the Internet? Looked for a healthcare provider?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Looked for health or medical information for Yes; No; Refused; Don't know;
someone else?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Looked for information about diet or
Yes; No; Refused;
nutrition?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Looked for information about physical
Yes; No; Refused; Don't know;
activity or exercise?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Participated in an on-line support group for Yes; No; Refused;
people with a similar health or medical issue?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Used a website to help you with your diet,
weight, or physical activity?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Used e-mail or the Internet to communicate Yes; No; Refused;
with a doctor or a doctor's office?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Visited a "social networking" site, such as
MySpace or Second Life?
In the past 12 months, have you done the following things while
Use of Technology using the Internet? Wrote in an online diary or "blog" (i.e., Web
log)?
In the past 12 months, how often did you use the Internet to
Use of Technology look for health or medical information [for yourself (or)
someone else]?
In the past 12 months, how often have you used the Internet to
Use of Technology
look for advice or information about cancer?
Is there at least one telephone inside your home that is currently
Use of Technology
Yes; No;
working and is not a cell phone?
Page 50
Construct
Use of Technology
Question
Response Options
On a typical weekday, about how many hours do you use the
Internet for personal reasons?
Over the past year, have you withheld information from a health
Use of Technology care provider because you were concerned about the privacy of
your medical record?
Please tell me if you ever use the internet to do any of the
following things. Do you ever use the internet to … Participate in
Use of Technology
an online discussion or a listserv that helps people with personal
issues or health problems
Please tell me if you ever use the internet to do any of the
Use of Technology following things. Do you ever use the internet to…Create or
work on your own online journal or blog
Please tell me if you ever use the internet to do any of the
Use of Technology following things. Do you ever use the internet to…Look for
information on Wikipedia
Please tell me if you ever use the internet to do any of the
Use of Technology following things. Do you ever use the internet to…Read someone
else’s online journal or blog
Please tell me if you ever use the internet to do any of the
Use of Technology following things. Do you ever use the internet to…Use a social
networking site like MySpace or Facebook
Please tell me if you ever use the internet to do any of the
following things. Do you ever use the internet to…Use Twitter or
Use of Technology
another service to share updates about yourself or to see
updates about others
0; 1; 2; 3; 4; 5; 6; 7; 8; 9; 10; 11; 12; 14; 15;
18; 20; 24; Not applicable; Refused; Don't know;
Yes/No
Yes/No (Dont know)
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No for: a. Signed up to receive updates about
health or medical issues
b. Read someone else's commentary or experience
about health or medical issues on an online news
group, website or blog
c. Listened to a podcast about health or medical
issues
There are many different activities related to health and medical
f. Consulted rankings or reviews online of doctors
issues a person might do on the internet. I’m going to read a list
or other providers
Use of Technology
of things you may or may not have ever done online related to
g. Consulted rankings or reviews online of hospitals
health and medical issues. Just tell me if you happened to do
or other medical facilities
h. Posted a review online of a doctor
i. Posted a review online of a hospital
j. Shared photos, videos or audio files online about
health or medical issues
k. Tagged or categorized online content about
health or medical issues
Thinking about what you have done on social networking sites
Use of Technology like Facebook and MySpace, have you followed your friends’ or
relatives’ personal health experiences or updates on the site?
Yes/No
Thinking about what you have done on social networking sites
Use of Technology like Facebook and MySpace, have you gotten any health
Yes/No
information on the sites?
Thinking about what you have done on social networking sites
Use of Technology like Facebook and MySpace, have you started or joined a health- Yes/No
related group on a social networking site?
When purchasing a cell phone, do you consider how much
Use of Technology
Yes/No
radiation it emits as part of your purchase decision?
Page 51
Construct
Question
When was the last time you used the Internet to look for
Use of Technology
information about health or medical care?
When you use the Internet at home, do you mainly access it
Use of Technology
through...
When you use the Internet at home, do you mainly access it
through…a wireless device such as a PDA, telephone modem,
Use of Technology
DSL modem, cable or satellite modem, some other way
(SPECIFY)?
When you use the Internet, do you mainly access it through a
Use of Technology
telephone modem or some other way?
Response Options
Do not use the Internet at home
A regular ‘dial-up’ telephone line; Broadband (such
as DSL, cable, FiOS); Mobile wireless broadband
(such as a 4G network); Something else (specify)
Free text (see on-line HINTS codebook for full list
of responses)
Free text (see on-line HINTS codebook for full list
of responses)
Use of Technology Where do you go to use the Internet?
Use of Technology Where do you use the Internet?
Which of the following, if any, are the reasons you do not access
the Internet? Because it costs too much.
Which of the following, if any, are the reasons you do not access
Use of Technology
the Internet? Because it is too complicated to use.
Which of the following, if any, are the reasons you do not access
Use of Technology
the Internet? Because you are not interested.
Which of the following, if any, are the reasons you do not access
Use of Technology
the Internet? Because you do not think it is useful.
Use of Technology
Values/Aspiration
I will be physically healthy
s
Values/Aspiration
My image will be one others find appealing.
s
Values/Aspiration
My physical appearance will be one others find appealing
s
Water Source
Are you concerned there may be chemicals in the water you
drink that may be harmful to you?
Water Source
How often do you use plastic water bottles?
Water Source
Weight Stigma
Concerns
Weight Stigma
Concerns
Weight Stigma
Concerns
Weight Stigma
Concerns
Weight Stigma
Concerns
Weight Stigma
Concerns
Weight Stigma
Concerns
1-5; 1= not at all important; 2= a little important;
3= moderately important; 4= very important; 5=
extremely important
1-5; 1= not at all important; 2= a little important;
3= moderately important; 4= very important; 5=
extremely important
1-5; 1= not at all important; 2= a little important;
3= moderately important; 4= very important; 5=
extremely important
Yes; No
1-2 times per week; 2-4 times per week; 4-6 times
per week; greater than 6 times per week
What is your primary source of drinking water?
Bottles; well; tap; other (please specify)
Strongly Disagree; Disagree, Somewhat Disagree,
Neither Agree nor Disagree; Somewhat Agree;
Being overweight will influence how people will act with me.
Agree; Strongly Agree
Strongly Disagree; Disagree, Somewhat Disagree,
I am afraid that other people will reject me because of my
Neither Agree nor Disagree; Somewhat Agree;
weight.
Agree; Strongly Agree
Strongly Disagree; Disagree, Somewhat Disagree,
I am concerned that I will not be treated fairly by others because
Neither Agree nor Disagree; Somewhat Agree;
of my weight.
Agree; Strongly Agree
Strongly Disagree; Disagree, Somewhat Disagree,
Neither Agree nor Disagree; Somewhat Agree;
Most people will not judge me on the basis of my weight.
Agree; Strongly Agree
Strongly Disagree; Disagree, Somewhat Disagree,
Stereotypes about people who are heavyweight will affect me
Neither Agree nor Disagree; Somewhat Agree;
personally.
Agree; Strongly Agree
Strongly Disagree; Disagree, Somewhat Disagree,
Neither Agree nor Disagree; Somewhat Agree;
Weight Stigma Concerns
Agree; Strongly Agree
Strongly Disagree; Disagree, Somewhat Disagree,
When interacting with people, I am concerned that their opinion
Neither Agree nor Disagree; Somewhat Agree;
of me will be based on my weight.
Agree; Strongly Agree
Page 52
Construct
Weight/Weight
Loss
Worry
Worry
Worry
Question
Response Options
Change eating behaviors; Change physical activity
In your efforts to manage your weight, which of the following
behaviors; Use pills or supplements; Purchase
strategies have you used (check all that apply):
exercise equipment
not at all1]; slightly2]; somewhat3]; moderately4];
How much has worry about cancer affected your daily life?
extremely5]
How much has worry about getting cancer caused you to change not at all1]; slightly2]; somewhat3]; moderately4];
your behavior?
extremely5]
not at all1]; slightly2]; somewhat3]; moderately4];
How worried are you about getting cancer?
extremely5]
Worry
I feel I will get cancer.
strongly disagree1]; disagree2]; Neither disagree
nor agree3]; agree4]; strongly agree5]
Worry
I feel very vulnerable to cancer.
strongly disagree1]; disagree2]; Neither disagree
nor agree3]; agree4]; strongly agree5]
Page 53
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 2011-03-24 |