Attach 1 HIS Redesign Qnne vcb 051017kw no confid pledge change

Attachment 1: 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 Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).

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

ADULT UTILIZATION - USUAL PLACE OF CARE, WELL VISITS, URGENT CARE

LASTDR_A. About how long has it been since you last saw any doctor or other health professional about your health?

0 Never

1 Within the past year (anytime less than 12 months ago)

2 Within the last 2 years (1 year but less than 2 years ago)

3 Within the last 3 years (2 years but less than 3 years ago)

4 Within the last 5 years (3 years but less than 5 years ago)

5 Within the last 10 years (5 years but more than 10 years ago)

6 10 years ago or more

7 Don't Know

9 Refuse

USUALPL_A. Is there a place that you USUALLY go to if you are sick?

1 Yes

2 There is NO place

3 There is MORE THAN ONE place

7 Don’t know

9 Refuse

[IF 2 ‘There is NO place’ go to WELLVIS_A, else go to USPLKIND_A]

USPLKIND_A. What kind of place (IS IT / DO YOU GO TO MOST OFTEN) - a doctor's office or health center; a walk-in clinic, urgent care center, or retail clinic in a pharmacy or grocery store; an emergency room; a VA Medical Center or VA outpatient clinic; or some other place?

1 A doctor's office or health center

2 Walk-in clinic, urgent care center, or retail clinic in a pharmacy or grocery store

3 Emergency Room

4 A VA Medical Center or VA outpatient clinic

5 Some other place

6 Does not go to one place most often

7 Don't Know

9 Refuse

WELLVIS_A. About how long has it been since you last saw a doctor or other health professional for a "wellness visit," physical examination, preventive care, or general purpose check-up?

0 Never

1 Within the past year (anytime less than 12 months ago)

2 Within the last 2 years (1 year but less than 2 years ago)

3 Within the last 3 years (2 years but less than 3 years ago)

4 Within the last 5 years (3 years but less than 5 years ago)

5 Within the last 10 years (5 years but more than 10 years ago)

6 10 years ago or more

7 Don’t know

9 Refuse

[IF 0 ‘Never’ go to URGENT12M_A, else go to WELLKIND_A]

WELLKIND_A. What kind of place did you go to for your most recent "wellness visit," physical examination, preventive care, or general purpose check-up - a doctor's office or health center; a walk-in clinic, urgent care center, or retail clinic in a pharmacy or grocery store; an emergency room; a VA Medical Center or VA outpatient clinic; or some other place?

1 A doctor's office or health center

2 Walk-in clinic, urgent care center, or retail clinic in a pharmacy or grocery store

3 Emergency Room

4 A VA Medical Center or VA outpatient clinic

5 Some other place

7 Don't Know

9 Refuse

URGENT12M_A. During the past 12 months, how many times have you gone to a walk-in clinic such as an urgent care center, or clinic in a pharmacy or grocery store about your health?

_______ Times visited walk-in clinic

ADULT MENTAL HEALTH

MHRX_A. During the past 12 months, did you take any prescription medication to help you with your emotions, concentration, behavior or mental health?

1 Yes

2 No

7 Don't Know

9 Refuse

MHTHRPY_A. During the past 12 months, did you receive counseling, therapy, or other non-medication treatment from a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker?

1 Yes

2 No

7 Don't Know

9 Refuse

[IF 2 ‘No’ go to MHTHDLY_A, else go to MHTPYNOW_A]

MHTPYNOW_A. Are you currently receiving counseling or therapy or other non-medication from a mental health professional?

1 Yes

2 No

7 Don't Know

9 Refuse

MHTHDLY_A. During the past 12 months, have you delayed getting counseling, therapy, or other non-medication treatment from a mental health professional because of the cost?

1 Yes

2 No

7 Don't Know

9 Refuse

MHTHND_A. During the past 12 months, was there any time when you needed counseling, therapy, or other non-medication treatment from a mental health professional, but did not get it because of the cost?

1 Yes

2 No

7 Don't Know

9 Refuse

E-CIGARETTES AND USING E-CIGARETTES IN SMOKING CESSATION

SMKEV_A. These next questions are about cigarette smoking. Have you smoked at least 100 cigarettes in your ENTIRE LIFE?

1 Yes

2 No

7 Don't Know

9 Refuse

[IF 2 ‘No’ go to ECIGEV_A, else go to SMKNOW_A]

SMKNOW_A. Do you NOW smoke cigarettes every day, some days or not at all?

1 Every day

2 Some days

3 Not at all

7 Don't Know

9 Refuse

ECIGEV_A. The next question is about electronic cigarettes or e-cigarettes. You may also know them as vape-pens, hookah-pens, e-hookahs, or e-vaporizers. Some look like cigarettes, and others look like pens or small pipes. These are battery-powered, usually contain liquid nicotine, and produce vapor instead of smoke. Have you EVER used an e-cigarette EVEN ONE TIME?

1 Yes

2 No

7 Don't Know

9 Refuse

[IF 1 ‘Yes’ go to ECIGNOW_A, else FINISHED WITH SAMPLE ADULT QUESTIONS]

ECIGNOW_A. Do you now use e-cigarettes every day, some days, or not at all?

1 Every day

2 Some days

3 Not at all

7 Don't Know

9 Refuse

{ASK SMKQTN_A IF SMKNOW_A = 3 ‘Not at all’}

SMKQTN_A. How long has it been since you quit smoking cigarettes?

_______ Time since quitting smoking

Enter time period for time since quit smoking.

1 Day(s)

2 Week(s)

3 Month(s)

4 Year(s)

{ASK SMKQTN_A IF SMKNOW_A = 1 ‘Every day’ OR 2 ‘Some days’}

SMKQT12M_A. During the PAST 12 MONTHS, have you stopped smoking for more than one day BECAUSE YOU WERE TRYING TO QUIT SMOKING?

1 Yes

2 No

7 Don't Know

9 Refuse

{ASK SMKQTN_A IF SMKNOW_A = 3 ‘Not at all’}

QTECIGF_A. Thinking back to when you stopped smoking completely, did you use e-cigarettes to help you quit smoking regular cigarettes?

1 Yes

2 No

7 Don't Know

9 Refuse

{ASK QTECIGC_A IF SMKQT12M_A = 1 ‘Yes’ AND ECIGEV_A = 1 ‘Yes’}

QTECIGC_A. Thinking back to the last time you tried to quit smoking, did you use e-cigarettes to help you quit smoking regular cigarettes?

1 Yes

2 No

7 Don't Know

9 Refuse

DOCTOR ADVISING QUITTING SMOKING

{ASK SMKTLK_A IF SMKEV_A = 1 ‘Yes’}

SMKTLK_A. In the past 12 months, has a doctor, dentist, or other health professional ADVISED you about ways to quit using tobacco or prescribed medication to help you quit?

1 Yes

2 No

7 Don't Know

9 Refuse

CHILD UTILIZATION - USUAL PLACE OF CARE, WELL VISITS, URGENT CARE

First I would like to ask you about (CHILD’S NAME) health care.

LASTDR_C. About how long has it been since (CHILD’S NAME) last saw any doctor or other health professional about (HIS / HER) health?

0 Never

1 Within the past year (anytime less than 12 months ago)

2 Within the last 2 years (1 year but less than 2 years ago)

3 Within the last 3 years (2 years but less than 3 years ago)

4 Within the last 5 years (3 years but less than 5 years ago)

5 Within the last 10 years (5 years but more than 10 years ago)

6 10 years ago or more

7 Don't Know

9 Refuse

USUALPL_C. Is there a place that (CHILD’S NAME) USUALLY goes to if (HE / SHE) is sick?

1 Yes

2 There is NO place

3 There is MORE THAN ONE place

7 Don't Know

9 Refuse

[IF 2 ‘There is NO place’ go to WELLVIS_C else go to USPLKIND_C]

USUALPL_C. Is there a place that (CHILD’S NAME) USUALLY goes to if (HE / SHE) is sick?

1 Yes

2 There is NO place

3 There is MORE THAN ONE place

7 Don't Know

9 Refuse

USPLKIND_C. What kind of place (IS IT / DOES HE/SHE GO TO MOST OFTEN) - a doctor's office or health center; a walk-in clinic, urgent care center, or retail clinic in a pharmacy or grocery store; an emergency room; or some other place?

1 A doctor's office or health center

2 Walk-in clinic, urgent care center, or retail clinic in a pharmacy or grocery store

3 Emergency Room

4 Some other place

5 Does not go to one place most often

7 Don't Know

9 Refuse

WELLVIS_C. About how long has it been since (CHILD’S NAME) last saw a doctor or other health professional for a well (BABY / CHILD) visit, physical examination, preventive care, or general purpose check-up?

0 Never

1 Within the past year (anytime less than 12 months ago)

2 Within the last 2 years (1 year but less than 2 years ago)

3 Within the last 3 years (2 years but less than 3 years ago)

4 Within the last 5 years (3 years but less than 5 years ago)

5 Within the last 10 years (5 years but more than 10 years ago)

6 10 years ago or more

7 Don't Know

9 Refuse

[IF 0 ‘Never’ go to URGENT12M_C, else go to WELLKIND_C]

WELLKIND_C. What kind of place did (CHILD’S NAME) get (HIS / HER) most recent well (BABY / CHILD) visit, physical examination, preventive care, or general purpose check-up?

1 A doctor's office or health center

2 Walk-in clinic, urgent care center, or retail clinic in a pharmacy or grocery store

3 Emergency Room

4 Some other place

7 Don't Know

9 Refuse

URGENT12M_C. During the past 12 months, how many times has (CHILD’S NAME) gone to a walk-in clinic such as an urgent care center, or clinic in a pharmacy or grocery store about (HIS / HER) health?

_______ Times visited walk-in clinic

CHILD MENTAL HEALTH

MHRX_C. During the past 12 months, did (CHILD’S NAME) take any prescription medication to help with (HIS / HER) emotions, concentration, behavior or mental health?

1 Yes

2 No

7 Don't Know

9 Refuse

MHTHRPY_C. During the past 12 months, did (CHILD’S NAME) receive counseling, therapy, or other non-medication treatment from a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker?

1 Yes

2 No

7 Don't Know

9 Refuse

MHTHDLY_C. During the past 12 months, has (CHILD’S NAME) been delayed in getting counseling, therapy, or other non-medication treatment from a mental health professional because of the cost?

1 Yes

2 No

Don't Know

Refuse

MHTHND_C. During the past 12 months, was there any time when (CHILD’S NAME) needed counseling, therapy, or other non-medication treatment from a mental health professional, but did not get it because of the cost?

1 Yes

2 No

Don't Know

Refuse

ADVERSE LIFE EVENTS FOR CHILDREN

VIOLENEV_C. The next questions are about events that may have happened during (CHILD’S NAME) life. These things can happen in any family, but some people may feel uncomfortable with these questions. You may skip any questions you do not want to answer. Has (CHILD’S NAME) ever been the victim of violence or witnessed violence in (HIS / HER) neighborhood?

1 Yes

2 No

7 Don't Know

9 Refuse

JAILEV_C. Did (CHILD’S NAME) ever live with a parent or guardian who served time in jail or prison after (CHILD’S NAME) was born?

1 Yes

2 No

7 Don't Know

9 Refuse

MENTDEPEV_C. Did (CHILD’S NAME) ever live with anyone who was mentally ill or severely depressed?

1 Yes

2 No

7 Don't Know

9 Refuse

ALCDRUGEV_C. Did (CHILD’S NAME) ever live with anyone who had a problem with alcohol or drugs?

1 Yes

2 No

7 Don't Know

9 Refuse

PHYSICAL ACTIVITY FOR CHILDREN

SPORT_C. In the past 12 months, did (CHILD’S NAME) play or participate on a sports team or club or take sports lessons either at school or in the community?

1 Yes

2 No

7 Don't Know

9 Refuse

PEGYM_C. In a typical week during the school year, does (CHILD’S NAME) go to a physical education or gym class?

1 Yes

2 No

7 Don't Know

9 Refuse

PADAYS_C. In a typical week during the school year, how often does (CHILD’S NAME) exercise, play a sport, or participate in physical activity for at least 60 minutes a day? Would you say every day, most days, some days, few days, or no days?

1 Every day

2 Most days

3 Some days

4 Few days

5 No days

7 Don't Know

9 Refuse

WALKBIKE_C. In a typical week during the school year, how often does (CHILD’S NAME) walk or ride a bike for at least 10 minutes at a time?

1 Every day

2 Most days

3 Some days

4 Few days

5 No days

Don't Know

Refuse

LIVESCHL_C. How far does (CHILD’S NAME) live from school?

1 Less than ½ mile

2 Between a ½ mile to 1 mile

3 1 mile to 2 miles

4 More than 2 miles from school

5 Home schooled or not in school

7 Refused

9 Don’t know

WALKSCHL_C. During a usual school week, how many times does (CHILD’S NAME) walk to or from school? (e.g., if he/she walked to and from school every day, the answer would be 10 times).

______ Number of times walk to school

00 Never

96 Unable to walk

97 Refused

99 Don’t know

SCREEN TIME FOR CHILDREN

WSCREEN_C. On a typical day during the school year, about how many hours does (CHILD’S NAME) usually spend playing with a smartphone or computer, watching TV or movies, or playing video games?

______ Time spent on computer/smartphone during school year

SCRNRULE_C. Do you have a rule for how much screen time (CHILD’S NAME) is allowed in a given day?

1 Yes

2 No

7 Don't Know

9 Refuse

SCRNPLACE_C. Do you have places in your home were (CHILD’S NAME) is NOT allowed to use a smartphone or computer, watch TV or movies, or play video games?

1 Yes

2 No

7 Don't Know

9 Refuse

SLEEPING FOR CHILDREN

SLPH_C. (INCLUDING NAPS), how much sleep does (CHILD’S NAME) usually get in a 24 hour period...on a typical school day /weekday?

_______ Hours of sleep during school week

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