NHIS Cognitive Functioning and other questions to be cog

Attachment 1: NHIS Cognitive Functioning and other questions to be cognitively tested

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 07/31/2018

Disability Identification (questions in gray asked for context and not to be tested)
VIS_1	[Do/Does] [you/he/she] have difficulty seeing, even when wearing [your/his/her] glasses]? Would you say… [Read response categories]	1. No difficulty 2. Some difficulty 3. A lot of difficulty 4. Cannot do at all / Unable to do
HEAR_1	[Do/Does] [you/he/she] have difficulty hearing, even when using a hearing aid(s)]? Would you say… [Read response categories]	1. No difficulty 2. Some difficulty 3. A lot of difficulty 4. Cannot do at all / Unable to do
MOB_1	[Do/Does] [you/he/she] have difficulty walking or climbing steps? Would you say… [Read response categories]	1. No difficulty 2. Some difficulty 3. A lot of difficulty 4. Cannot do at all / Unable to do
COM_1	Using [your/his/her] usual language, [do/does] [you/he/she] have difficulty communicating, for example understanding or being understood? Would you say… [Read response categories]	1. No difficulty 2. Some difficulty 3. A lot of difficulty 4. Cannot do at all / Unable to do
COG_1	[Do/does] [you/he/she] have difficulty remembering or concentrating? Would you say… [Read response categories]	1. No difficulty [Go to SC_1] 2. Some difficulty 3. A lot of difficulty 4. Cannot do at all / Unable to do
COG_2	Note to Interviewer: Half of the respondents receive COG_2 the other half receive COG_2a. What is the main reason for your [his/her] difficulty remembering or concentrating?	Intellectual or learning disability Dementia or Alzheimer’s disease Mental illness Traumatic brain injury Stroke Other (____________, please specify) I’m not sure
SC_1	[Do/does] [you/he/she] have difficulty with self-care, such as washing all over or dressing? Would you say…	1. No difficulty 2. Some difficulty 3. A lot of difficulty 4. Cannot do at all / Unable to do
UB_1	[Do/does] [you/he/she] have difficulty with self-care, such as washing all over or dressing? Would you say…	1. No difficulty 2. Some difficulty 3. A lot of difficulty 4. Cannot do at all / Unable to do
ANX_1	How often [do/does] [you/he/she] feel worried, nervous or anxious? Would you say… [Read response categories]	Daily Weekly Monthly A few times a year Never
ANX_2	[Do/Does] [you/he/she] take medication for these feelings?	Yes No

ANX_3	Thinking about the last time [you/he/she] felt worried, nervous or anxious, how would [you/he/she] describe the level of these feelings? Would [you/he/she] say… [Read response categories]	A little A lot Somewhere between a little and a lot
DEP_1	How often [do/does] [you/he/she] feel depressed? Would [you/he/she] say… [Read response categories]	Daily Weekly Monthly A few times a year Never
DEP_2	[Do/Does] [you/he/she] take medication for depression?	Yes No
DEP_3	Thinking about the last time [you/he/she] felt depressed, how depressed did [you/he/she] feel? Would you say… [Read response categories]	A little A lot Somewhere between a little and a lot
GEN_Q005	In general, would you say your health is... ?	1. Excellent 2.Very good 3. Good 4. Fair 5. Poor 8. RF 9. DK
COG_2a	Note to Interviewer: Half of the respondents receive COG_2a the other half receive COG_2. You said you [he/she] have/has difficulty remembering or concentrating? What is the main reason for this difficulty?
GEN_Q015	In general, would you say your mental health is...?	1. Excellent 2.Very good 3. Good 4. Fair 5. Poor 8. RF 9. DK
GEN_Q020	Thinking about the amount of stress in your life, would you say that most of your days are...?	1. Not at all stressful 2. Not very stressful 3. A bit stressful 4.. Quite a bit stressful 5. Extremely stressful 8. RF 9. DK
ACISLEEP	On average, how many hours of sleep do you get in a 24-hour period?	Hours: _____ *Enter hours of sleep in whole numbers, rounding 30 minutes (1/2 hour) or more UP to the next whole hour and dropping 29 or fewer minutes.
ACISLPFL	In the past week, how many times did you have trouble falling asleep?	00 Did not have trouble falling asleep in the past week 01-06 1-6 times 07 7 or more times 97 Refused 99 Don't know
ACISLPMD	In the past week, how many times did you take medication to help you fall asleep or stay asleep?	00 Did not take medication to help sleep in the past week 01-06 1-6 times 07 7 or more times 97 Refused 99 Don't know
ACIREST	In the past week, on how many days did you wake up feeling well rested?	0-7: ­­­­__________
AMDLONG	About how long has it been since you last saw or talked to a doctor or other health care professional about your own health? Include doctors seen while a patient in a hospital.	0. Never 1. 6 months or less 2. More than 6 mos, but not more than 1 yr ago 3. More than 1 yr, but not more than 2 yrs ago 4. More than 2 yrs, but not more than 5 yrs ago 5. More than 5 years ago 7. Refused 9. Don't know
PREV1	About how long has it been since you last had a general physical check-up?	0. Never 1. 6 months or less 2. More than 6 mos, but not more than 1 yr ago 3. More than 1 yr, but not more than 2 yrs ago 4. More than 2 yrs, but not more than 5 yrs ago 5. More than 5 years ago 7. Refused 9. Don't know
PREV2	Where did you go for your last general physical check-up?	1. doctor’s office 2. clinic or health center 3. hospital outpatient 4. VA 5. retail clinic in a pharmacy or other store 6. urgent care center 7. ER 8. some other place
PREV3	What kind of health provider did you go to for your last general physical check-up? (Note – the generation of a list of general response options is one of the objectives for this test, but will likely include the following: a general doctor (family practice), a doctor who specializes in a particular disease of problem, nurse, nurse practitioner, physician’s assistant, midwife, a doctor who specializes in women’s health (OB/GYN) )	1. a general doctor (family practice) 2. a doctor who specializes in a particular disease or problem 3. nurse 4. nurse practitioner 5. physician’s assistant 6. midwife 7. a doctor who specializes in women’s health (OBGYB)

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