Research and Development Survey (RANDS) Cognitive Interviewing Sub-Study

Attachment 2: 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(d)) 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

Please be aware that green text is used below to highlight those items that will be included among the split samples.

(Note: Assign PHSTATA to respondents in split Sample “A”. Assign PHSTATB to respondents in split Sample “B”.)

PHSTATA		Would you say your health in general is excellent, very good, good, fair, or poor?
	1	Excellent
	2	Very good
	3	Good
	4	Fair
	5	Poor
	-7	[Don’t Know]
	-9	[Refused]

PHSTATB		Would you say your health in general is very good, good, fair, bad, or very bad?
	1	Very good
	2	Good
	3	Fair
	4	Bad
	5	Very bad
	-7	[Don’t Know]
	-9	[Refused]

The next few questions are about health insurance, including health insurance obtained through employment or purchased directly, as well as government programs like Medicare and Medicaid that provide Medical care or help pay medical bills.

FHICOV		Are you covered by any kind of health insurance or some other kind of health care plan?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

Skip: (If FHICOV=2, Skip to WRKCOR; Otherwise, continue)

HIKIND		Do you have any of the following kinds of health insurance or health care coverage? Include those plans that pay for only one type of service, such as nursing home care, accidents, or dental care. Exclude private plans that only provide extra cash while hospitalized. (Select all that apply)
	1	Private Health Insurance
	2	Medicare
	3	Medi-Gap
	4	Medicaid
	5	SCHIP (CHIP/Children's Health Insurance Program)
	6	Military health care (TRICARE/VA/CHAMP-VA)
	7	Indian Health Service
	8	State-sponsored health plan
	9	Other government program
	10	Single service plan (e.g., dental, vision, prescriptions)
	-7	[Don’t Know]
	-9	[Refused]

Skip: (If HIKIND inc. 1, continue; otherwise, skip to WRKCOR)

PLNMGD		What type of private plan do you have?
	1	HMO (Health Maintenance Organization)
	2	IPA (Individual Practice Plan)
	3	PPO (Preferred Provider Organization)
	4	POS (Point of Service)
	5	Fee-for-Service
	6	Indemnity
	7	Some other kind of plan
	-7	[Don’t Know]
	-9	[Refused]

MGCHMD		Under your private plan, can you choose any doctor or must you choose one from a specific group or list of doctors?
	1	Choose any doctor
	2	Choose from a group or list
	-7	[Don’t Know]
	-9	[Refused]

PCPREQ		Does this plan require you to have a primary care doctor who approves all your care?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

WRKCOR		Which of the following were you doing last week?
	1	Working for pay at a job or business
	2	With a job or business but not at work
	3	Looking for work
	4	Working, but not for pay, at a family-owned job or business
	5	Not working at a job or business and not looking for work
	-7	[Don’t Know]
	-9	[Refused]

HYPEV		Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

Skip: (If code 1 in HYPEV, Continue; Otherwise, Skip to NEWLUNG)

HYPMDEV2		Has a doctor ever prescribed any medicine for your high blood pressure?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

HYPMED2		Are you now taking any medicine prescribed by a doctor for your high blood pressure?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

CHLEV		Have you ever been told by a doctor or other health professional that you had high cholesterol?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

CHLYR		During the past 12 months, have you had high cholesterol?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

CHLMDEV2		Was any medication ever prescribed by a doctor to help lower your cholesterol?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

CHLMDNW2		Are you now taking any medicine prescribed by a doctor to help lower your cholesterol?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

(Note: Assign EPHEV, COPDEV, and CBRCHYR to respondents in split Sample “C”)

EPHEV		Have you ever been told by a doctor or other health professional that you have emphysema?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

COPDEV		Have you ever been told by a doctor or other health professional that you had chronic obstructive pulmonary disease, also called COPD?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

(Note: Assign NEWLUNG to respondents in split Sample “D”)

NEWLUNG		Have you ever been told by a doctor or other medical professional that you have Chronic Obstructive Pulmonary Disease or COPD, emphysema, or chronic bronchitis?
	1	Yes
	2	No
	-7	Don’t Know
	9	Refused

AASMEV		Have you ever been told by a doctor or other health professional that you had asthma?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

AASSTILL		Do you still have asthma?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

Skip (If AASSTILL=1, continue; otherwise skip to AASMYR)

AASMYR		During the past 12 months have you had an episode of asthma, or an asthma attack?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

AASMERYR		During the past 12 months have you had to visit an emergency room or urgent care center because of asthma?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

DIBPRE1		Have you ever been told by a doctor or other health professional that you have any of the following: prediabetes, impaired fasting glucose, impaired glucose tolerance, borderline diabetes, or high blood sugar?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

Skip: (If code 1 in DIBPRE1, Skip to INSLN; Otherwise, Continue)

DIBEV		(If Respondent is FEMALE, display:) Other than during pregnancy, have you ever been told by a doctor or other health professional that you have diabetes or sugar diabetes? (If Respondent is MALE, display:) Have you ever been told by a doctor or other health professional that you have diabetes or sugar diabetes?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

Skip: (If DIBEV=1, skip to DIBAGE; If DIBEV=3, skip to INSLN; otherwise, skip to CBRCHRY)

DIBAGE		How old were you when a doctor or other health professional first told you that you had diabetes or sugar diabetes?
	1	______
	-7	[Don’t Know]
	-9	[Refused]

INSLN		Are you now taking insulin?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

DIBPILL		Are you now taking diabetic pills to lower your blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

CBRCHYR		During the past 12 months, have you been told by a doctor or other health professional that you had chronic bronchitis?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

(Note: Assign CHPAIN6M, PAINLMT6, and PAIN_4 to respondents in split Sample “E”)

CHPAIN6M		In the past six months, how often did you have pain? Would you say...
	1	Never
	2	Some days
	3	Most days
	4	Every day
	-7	[Don’t Know]
	-9	[Refused]

Skip (If CHPAIN6M=2-4, continue; otherwise, skip to RX12M)

PAINLMT6		Over the past six months, how often did pain limit your life or work activities? Would you say...
	1	Never
	2	Some days
	3	Most days
	4	Every day
	-7	[Don’t Know]
	-9	[Refused]

PAIN_4		Thinking about the last time you had pain, how much pain did you have? Would you say…
	1	A little
	2	A lot
	3	Somewhere in between a little and a lot
	-7	[Don’t Know]
	-9	[Refused]

(Note: Assign PAIN_2, PAINLMT3, and PAIN_4 to respondents in split Sample “F”)

PAIN_2		In the past 3 months, how often did you have pain? Would you say…
	1	Never
	2	Some Days
	3	Most Days
	4	Every Day
	-7	[Don’t Know]
	-9	[Refused]

Skip (If PAIN_2=2-4, continue; otherwise, skip to RX12M)

PAINLMT3		Over the past three months, how often did pain limit your life or work activities? Would you say...
	1	Never
	2	Some days
	3	Most days
	4	Every day
	-7	[Don’t Know]
	-9	[Refused]

PAIN_4		Thinking about the last time you had pain, how much pain did you have? Would you say…
	1	A little
	2	A lot
	3	Somewhere in between a little and a lot
	-7	[Don’t Know]
	-9	[Refused]

RX12M		During the past 12 months, were you prescribed medication by a doctor or other health professional?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

OPIOID1		These next questions are about the use of prescription pain relievers called opioids. When answering these questions, please do not include over-the-counter pain relievers such as aspirin, Tylenol, Advil, or Aleve. During the past 12 months, have you taken any opioid pain relievers prescribed by a doctor or dentist? Examples include hydrocodone, Vicodin, Norco, Lortab, oxycodone, OxyContin, Percocet and Percodan.
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

OPIOID2		During the past 3 months, have you taken any opioid pain relievers prescribed by a doctor or dentist?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

Skip (If OPIOID2=1, continue; otherwise skip to SMKEV)

OPIOID3		During the past 3 months, how often did you take a prescription opioid? Would you say some days, most days, or every day?
	1	Some days
	2	Most days
	3	Every day
	-7	[Don’t Know]
	-9	[Refused]

These next questions are about cigarette smoking.

SMKEV		Have you smoked at least 100 cigarettes in your entire life?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

Skip: (If code 1 in SMKEV, Continue; Otherwise, Skip to SMKANY)

SMKNOW		How often 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	[Refused]

Skip: (If code 3 in SMKNOW, Continue; If code 1 or 2 in SMKNOW, Skip to CIGQTRY; Otherwise, Skip to MODNO)

SMKQTNO		How long has it been since you quit smoking cigarettes?
	1	_________
	-7	[Don’t Know]
	-9	[Refused]

Skip: (All in SMKQTNO_N/SMKQTNO_F, Skip to MODNO)

CIGQTYR		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	[Refused]

(Skip: All in CIGQTRY, Skip to MODNO)

SMKANY		Have you ever smoked a cigarette even one time?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

(Note: show ECIGEV_AE to respondents in split sample “E”; show ECIGEV_AF and PROBE1 to respondents in split sample “G”)

ECIGEV_AE		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	[Refused]

(Note: show ECIGEV_AF and PROBE1 to respondents in split sample “H”)

ECIGEV_AF		Have you ever used an e-cigarette even one time?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

PROBE1		When answering the previous question were you thinking of: (select all that apply)
	1	Regular e-cigarette
	2	vape pen
	3	hookah-pen
	4	e-hookah
	5	e-vaporizer
	6	regular cigarette
	7	marijuana cigarette
	8	cigar
	9	Other (please specify)

The next questions are about physical activities (exercise, sports, physically active hobbies…) that you may do in your leisure time.

MODNO		How often do you do light or moderate leisure time physical activities for at least 10 minutes that cause only light sweating or a slight to moderate increase in breathing or heart rate?
	1	______
	-7	[Don’t Know]
	-9	[Refused]

Skip: (If code 0 or BLANK in MODNO, Skip to VIGNO; Otherwise, Continue)

MODLNGNO		About how long do you do these light or moderate leisure-time physical activities each time?
	1	______
	-7	[Don’t Know]
	-9	[Refused]

VIGNO		How often do you do vigorous leisure-time physical activities for at least 10 minutes that cause heavy sweating or large increases in breathing or heart rate?
	1	______
	-7	[Don’t Know]
	-9	[Refused]

Skip: (If code 0 or BLANK in MODNO, Skip to STRNGNO; Otherwise, Continue)

VIGLNGNO		About how long do you do these vigorous leisure-time physical activities each time?
	1	______
	-7	[Don’t Know]
	-9	[Refused]

STRNGNO		How often do you do leisure time physical activities specifically designed to strengthen your muscles such as lifting weights or doing calisthenics?
	1	______
	-7	[Don’t Know]
	-9	[Refused]

These next questions are about drinking alcoholic beverages. Included are liquor such as whiskey or gin, beer, wine, wine coolers, and any other type of alcoholic beverage.

ALC1YR		In any one year, have you had at least 12 drinks of any type of alcoholic beverage?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

Skip: (If code 1 in ALC1YR, Skip to ALC12MNO; Otherwise, Continue)

ALC5UPNO		(If code 2 in DEMO_GENDER, display:) In the past year, on how many days did you have 4 or more drinks of any alcoholic beverage? (If code 1 in DEMO_GENDER, display:) In the past year, on how many days did you have 5 or more drinks of any alcoholic beverage?
	1	______
	-7	[Don’t Know]
	-9	[Refused]

BINGE		(If code 2 in DEMO_GENDER, display:) Considering all types of alcoholic beverages, during the past 30 days, how many times did you have 4 or more drinks on an occasion? (If code 1 in DEMO_GENDER, display:) Considering all types of alcoholic beverages, during the past 30 days, how many times did you have 5 or more drinks on an occasion?
	1	______
	-7	[Don’t Know]
	-9	[Refused]

ACISLEEP		On average, how many hours of sleep do you get in a 24-hour period?
	1	______
	-7	[Don’t Know]
	-9	[Refused]

ACISLPFL		In the past week, how many times did you have trouble falling asleep?
	1	______
	-7	[Don’t Know]
	-9	[Refused]

ACISLPST		In the past week, how many times did you have trouble staying asleep?
	1	______
	-7	[Don’t Know]
	-9	[Refused]

ACISLPMD		In the past week, how many times did you take medication to help you fall asleep or stay asleep?
	1	______
	-7	[Don’t Know]
	-9	[Refused]

ACIREST		In the past week, on how many days did you wake up feeling well rested?
	1	______
	-7	[Don’t Know]
	-9	[Refused]

The next questions are about feelings you may have experienced over the past 30 days.

During the past 30 days, how often did you feel…

ACISAD		So sad that nothing could cheer you up?
	1	All of the time
	2	Most of the time
	3	Some of the time
	4	A little of the time
	5	None of the time
	-7	[Don’t Know]
	-9	[Refused]

ACINERV		Nervous?
	1	All of the time
	2	Most of the time
	3	Some of the time
	4	A little of the time
	5	None of the time
	-7	[Don’t Know]
	-9	[Refused]

ACIRSTLS		Restless or fidgety?
	1	All of the time
	2	Most of the time
	3	Some of the time
	4	A little of the time
	5	None of the time
	-7	[Don’t Know]
	-9	[Refused]

ACIHOPLS		Hopeless?
	1	All of the time
	2	Most of the time
	3	Some of the time
	4	A little of the time
	5	None of the time
	-7	[Don’t Know]
	-9	[Refused]

ACIEFFRT		That everything was an effort?
	1	All of the time
	2	Most of the time
	3	Some of the time
	4	A little of the time
	5	None of the time
	-7	[Don’t Know]
	-9	[Refused]

ACIWTHLS		Worthless?
	1	All of the time
	2	Most of the time
	3	Some of the time
	4	A little of the time
	5	None of the time
	-7	[Don’t Know]
	-9	[Refused]

Now I’m going to ask you some questions about your ability to do different activities, and how you’ve been feeling. Although some of these questions may seem similar to ones you have already answered, it is important that we ask them all.

ANX_1		How often do you feel worried, nervous, or anxious? Would you say…
	1	Daily
	2	Weekly
	3	Monthly
	4	A few times a year
	5	Never
	-7	[Don’t Know]
	-9	[Refused]

ANX_2		Do you take medication for these feelings?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

Skip: (If ANX_1=5 AND ANX_2=2, skip to DEP_1; otherwise, continue)

ANX_3		Thinking about the last time you felt worried, nervous, or anxious, how would you describe the level of these feelings? Would you say…
	1	A little
	2	A lot
	3	Somewhere in between a little and a lot
	-7	[Don’t Know]
	-9	[Refused]

DEP_1		How often do you feel depressed? Would you say…
	1	Daily
	2	Weekly
	3	Monthly
	4	A few times a year
	5	Never
	-7	[Don’t Know]
	-9	[Refused]

DEP_2		Do you take medication for depression?
	1	Yes
	2	No
	-7	[Don’t Know]
	-9	[Refused]

Skip: (If DEP_2=1,-7,-9, continue; if DEP_2=2, DEP_1=5, AND CHPAIN6M=2-4,-7,-9, skip to PAIN_2; otherwise, skip to TIRED_1 )

DEP_3		Thinking about the last time you felt depressed, how depressed did you feel? Would you say…
	1	A little
	2	A lot
	3	Somewhere in between a little and a lot
	-7	[Don’t Know]
	-9	[Refused]

TIRED_1		In the past 3 months, how often did you feel very tired or exhausted? Would you say…
	1	Never
	2	Some Days
	3	Most Days
	4	Every Day
	-7	[Don’t Know]
	-9	[Refused]

Skip (If TIRED_1=1, skip to NEWINJ_1; otherwise continue)

TIRED_2		Thinking about the last time you felt very tired or exhausted, how long did it last? Would you say…
	1	Some of the day
	2	Most of the day
	3	All of the day
	-7	[Don’t Know]
	-9	[Refused]

TIRED_3		Thinking about the last time you felt this way, how would you describe the level of tiredness? Would you say…
	1	A little
	2	A lot
	3	Somewhere in between a little and a lot
	-7	[Don’t Know]
	-9	[Refused]

(Note: assign PHQ1-PHQImp to split sample “G”; assign GAD1-GADImp to split sample “H”)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

PHQ1		Little interest or pleasure in doing things
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

PHQ2		Feeling down, depressed, or hopeless
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

PHQ3		Trouble falling or staying asleep, or sleeping too much
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

PHQ4		Feeling tired or having little energy
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

PHQ5		Poor appetite or overeating
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

PHQ6		Feeling bad about yourself — or that you are a failure or have let yourself or your family down
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

PHQ7		Trouble concentrating on things, such as reading the newspaper or watching television
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

PHQ8		Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

Skip: (If any of PHQ1-PHQ8 = 2,3,4, continue; otherwise skip to NEWLUNG)

PHQImp		How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
	1	Not at all difficult
	2	Somewhat difficult
	3	Very difficult
	4	Extremely difficult

(Note: assign GAD1-GADImp to split sample “H”)

Over the last 2 weeks, how often have you been bothered by the following problems?

GAD1		Feeling nervous, anxious or on edge
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

GAD2		Not being able to stop or control worrying
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

GAD3		Worrying too much about different things
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

GAD4		Trouble relaxing
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

GAD5		Being so restless that it is hard to sit still
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

GAD6		Becoming easily annoyed or irritable
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

GAD7		Feeling afraid as if something awful might happen
	1	Not at all
	2	Several days
	3	More than half the days
	4	Nearly every day

Skip: (If any of GAD1-GAD7 = 2,3,4, continue; otherwise skip to NEWLUNG)

GADImp		If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
	1	Not difficult at all
	2	Somewhat difficult
	3	Very difficult
	4	Extremely difficult

(END OF QUESTIONNAIRE)

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