3 Attachment E Questionnaire Content

attachment E: Questionnaire CONTENT (Hints 5 Questionnaire Draft 2/22/2016)

1. Is there more than one person age 18 or older living in this household?

Yes

No GO TO A1 on the next page

2. Including yourself, how many people age 18 or older live in this household?

3. The adult with the next birthday should complete this questionnaire. This way, across all households, HINTS will include responses from adults of all ages.

4. Please write the first name, nickname or initials of the adult with the next birthday. This is the person who should complete the questionnaire.

Si prefiere recibir la encuesta en español, por favor llame 1-888-738-6812

STATEMENT OF PRIVACY: Collection of this information is authorized by The Public Health Service Act, Sections 411 (42 USC 285 a) and 412 (42 USC 285a-1.a and 285a1.3). The purpose of this data collection is to evaluate whether the survey questions are easy to understand.  The results of the data collection will be used to improve the survey instrument.  Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private under the Privacy Act and will only be seen by people authorized to work on this project.  The report summarizing the findings will not contain any names or identifying information. Identifying information will be destroyed when the project ends.

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN: Public reporting burden for this collection of information is estimated to average 90 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0920-0589). Do not return the completed form to this address.

A: Looking For Health Information

A1. Have you ever looked for information about health or medical topics from any source?

Yes

No   GO TO A6 in the next column

X

A2. The most recent time you looked for information about health or medical topics, where did you go first?

Mark only one.

Books

Brochures, pamphlets, etc.

Cancer organization

Family

Friend/Co-worker

Doctor or health care provider

Internet

Library

Magazines

Newspapers

Telephone information number

Complementary, alternative, or unconventional practitioner

A3. The most recent time you looked for information about health or medical topics, who was it for?

Myself

Someone else

Both myself and someone else

A4. Have you ever looked for information about cancer from any source?

Yes

No   GO TO A6 in the next column

A5. Based on the results of your most recent search for information about health or medical topics, how much do you agree or disagree with each of the following statements?

a. It took a lot of effort to get the information you needed
b. You felt frustrated during your search for the information
c. You were concerned about the quality of the information
d. The information you found was hard to understand

A6. Overall, how confident are you that you could get advice or information about health or medical topics if you needed it?

Completely confident

Very confident

Somewhat confident

A little confident

Not confident at all

A7. In general, how much would you trust information about health or medical topics from each of the following?

a. A doctor
b. Family or friends
c. Newspapers or magazines
d. Radio
e. Internet
f. Television
g. Government health agencies
h. Charitable organizations
i. Religious organizations and leaders

A8. Imagine that you had a strong need to get information about health or medical topics. Where would you go first?

X

Mark only one.

Books

Brochures, pamphlets, etc.

Cancer organization

Family

Friend/Co-worker

Doctor or health care provider

Internet

Library

Magazines

Newspapers

Telephone information number

Complementary, alternative, or unconventional
practitioner

Other-Specify

B: Using the Internet to Find Information

B1. Do you ever go on-line to access the Internet or World Wide Web, or to send and receive e-mail?

Yes

No   GO TO B4 in the next column

B2. When you use the Internet, do you access it through...

		Yes	No
a. A regular dial-up telephone line
b. Broadband such as DSL, cable or FiOS
c. A cellular network (i.e., phone, 3G/4G)
d. A wireless network (Wi-Fi)

B3. How often do you access the Internet through each of the following?

• 

a. Computer at home
b. Computer at work
c. Computer at school
d. Computer in a public place (library, community center, other)
e. On a mobile device (cell phone/smart phone/tablet)
f. On a gaming device/ “Smart TV”
g. Other

X

B4. Please indicate if you have each of the following.

Mark all that apply.

Tablet computer like an iPad, Samsung Galaxy, Motorola Xoom, or Kindle Fire

Smartphone, such as an iPhone, Android, Blackberry, or Windows phone

Basic cell phone only

I do not have any of the above

B5. On your tablet or smartphone, do you have any software applications or “apps” related to health?

Yes

No GO TO B7

Don’t know    GO TO B7

Do not have a

tablet or smartphone GO TO B7

B6. Have these apps done any of the following?

		Yes	No
a. Helped you achieve a health-related goal such as quitting smoking, losing weight, or increasing physical activity
b. Helped you make a decision about how to treat an illness or condition
c. Led you to ask a health care provider new questions, or to get a second opinion from another health care provider

B7. Have you used an electronic device or application that monitors or tracks your health within the last year? Examples include electronically tracking your fitness, monitoring your blood glucose levels or blood pressure.

Yes

No GO TO B9

Don’t know   GO TO B9

B8.Have you shared health information from the monitoring device with a health care provider/professional within the last year?

Yes

No

Don’t know   

B9.Sometimes people use the Internet to connect with other people online through social networks like Facebook or Twitter. This is often called “social media”.

In the last 12 months, have you used the Internet for any of the following reasons?

		Yes	No
a. Visited a social networking site, such as Facebook or LinkedIn
b. Shared health information on social networking sites, such as Facebook or Twitter
c. Wrote in an online diary or blog (i.e., Web log)
d. Participated in an online forum or support group for people with a similar health or medical issue
e. Watched a health-related video on YouTube

B10. In the past 12 months, have you used the Internet to look for information about cancer for yourself?

Yes

No

B11. Have you sent or received a text message from your healthcare provider within the last year?

Yes

No

Don’t know

C: Your Health Care

C1. Not including psychiatrists and other mental health professionals, is there a particular doctor, nurse, or other health professional that you see most often?

Yes

No

C2. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?

Yes

No

C3. 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.

Within past year
(anytime less than 12 months ago)

Within past 2 years
(1 year but less than 2 years ago)

Within past 5 years
(2 years but less than 5 years ago)

5 or more years ago

Don't know

Never

C4. In the past 12 months, not counting times you went to an emergency room, how many times did you go to a doctor, nurse, or other health professional to get care for yourself?

None   GO TO D1 on the next page

1 time

2 times

3 times

4 times

5-9 times

10 or more times

C5. 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?
	a. Give you the chance to ask all the health-related questions you had
	b. Give the attention you needed to your feelings and emotions
	c. Involve you in decisions about your health care as much as you wanted
	d. Make sure you understood the things you needed to do to take care of your health
	e. Explain things in a way you could understand
	f. Spend enough time with you
	g. Help you deal with feelings of uncertainty about your health or health care

C6. Overall, how would you rate the quality of health care you received in the past 12 months?

Excellent

Very good

Good

Fair

Poor

C7. In the past 12 months, when getting care for a medical problem, was there a time when you...

		Yes	No
a. Had to bring an X-ray, MRI, or other type of test result with you to the appointment?
b. Had to wait for test results longer than you thought reasonable?
c. Had to redo a test or procedure because the earlier test results were not available?
d. Had to provide your medical history again because your chart could not be found?
e. Had to tell a health care provider about your medical history because they had not gotten your records from another health care provider?
f. Have had to put together your medical information across your health care providers?

D: Medical Records

D1. Do any of your doctors or other health care providers maintain your medical information in a computerized system?

Yes

No – GO TO D5

D2. Does the doctor, nurse, or other health professional that you see most often maintain your medical information in a computerized system?

Yes

No

D3. Within the last 12 months, have you requested that your medical record be sent electronically –that is, by computer or other device - to another health care provider? Electronic does not include telephone, mail or fax.

Yes

No – GO TO D4

D4. Did the provider agree to send the medical record electronically?

Yes

No

Do not know

D5. During the past 12 months, has a medical laboratory given you direct access to any test results, such as blood test results, in either paper or electronic format?

Yes

No – GO TO D7

D6. In what format did the medical laboratory provide the test results – paper or electronic?

Paper

Electronic

Both paper and electronic

D7. Have you ever been offered online access to your medical record by your…

		Yes	No
a. health care provider?
b. health insurer?

[If you answered no to D7a and D7b, go to D18. Otherwise, go to D8]

D8. How many times did you access your online medical record in the last 12 months?

None

1 to 2 times – GO TO D10  

3 to 5 times – GO TO D10

6 to 9 times – GO TO D10

10 or more times – GO TO D10

D9. Why have you not accessed your medical records online? Is it because…

		Yes	No
a. You prefer to speak to your health care provider directly
b. You do not have a way to access the website
c. You did not have a need to use your online medical record
d. You were concerned about privacy or security of the website that had your medical records
e. Was not provided instructions on how to access medical information online
f. Cost to access medical information electronically
g. Process to login to access my record too complicated
i. Language barriers (e.g. information not in my first language)
j. Other

[If you have not accessed any medical records, go to D18. Otherwise, go to D10]

D10. How do you view your online medical record?

Mark all that apply

Smartphone app

Health provider or health insurer’s patient portal or website

Software that combines medical records from all your health providers (e.g. personal health record)

Other:_____________________________

D11. How easy or difficult was it to understand the health information in your online medical record?

Very easy

Somewhat easy

Somewhat difficult

Very difficult

D12. Did any health care provider, including doctors, nurses, or office staff encourage you to use an online medical record?

Yes

No

Do not know

D13. Does your online medical record include the following types of medical information?

	Yes	No	Don’t Know
a. Laboratory test results
b. Current list of medications
c. List of health/medical problems
d. Allergy list
e. Summaries of your office visit
f. Clinical notes
g. Immunization history

D14. In the past 12 months, have you used your online medical record to…

	Yes	No	Don’t know
a. Set or track goals related to your health
b. Made appointments with a health care provider
c. Request refill of medications
d. Securely message health care provider and staff (e.g. e-mail)
e. Track health care charges and costs
f. Filled out forms or paperwork related to your health care
g. Look up test results
h. Monitor your health
i. Download your health information to your computer or mobile device, such as a cell phone or tablet
j. Add health information to share with your health care provider, such as health concerns, symptoms, and side-effects
k. Request correction of inaccurate information
l. Help you make a decision about how to treat an illness or condition
m. Ask your health care provider new questions, or to get a second opinion from another health care provider

D15.Have you electronically sent your medical information to any of the following?

	Yes	No	Don’t Know
a. Another health care provider
b. A family member or another person involved with your care
c. A third party that can help manage and store your health information, such as a personal health record or app on mobile device

D16. In general, how useful are your online medical records for monitoring your health?

Very useful

Somewhat useful

Not very useful

Not at all useful

Not applicable

D17. How confident are you that safeguards (including the use of technology) are in place to protect your medical records from being seen by people who aren’t permitted to see them?

Very confident

Somewhat confident

Not confident

D18. Have you ever kept information from your health care provider because you were concerned about the privacy or security of your medical record?

Yes

No

D19. If your medical information is sent electronically – that is, by computer -- from one health care provider to another, how concerned are you that an unauthorized person would see it?

Very concerned

Somewhat concerned

Not concerned

D20. Are you currently caring for or making health care decisions for a child, a spouse/partner, a parent, or other close family member, friend, or non-relative with a medical/behavioral/disability/other condition? Please check all that apply.

Yes, a child/children

Yes, a spouse/partner

Yes, a parent/parents

Yes, a close family member, friend, or non-relative (or multiple)

No – Go to E1

D21. Thinking of all of the kinds of help you provide/provided for this person or persons, about how many hours do you/did you spend in an average week providing care?

Hours

D22. If you selected more than one person in F1, please think about the individual for whom you have provided the most care. Please check all conditions that your care-recipient has/had, for which they needed your care.

Cancer

Alzheimer’s, confusion, dementia, forgetfulness

Orthopedic/Musculoskeletal Issues (examples: back problems, broken bones, arthritis, mobility problems, can’t get around, feeble, unsteady, falling)

Aging

Mental Health/Behavioral/Substance Abuse Issues (examples: mental illness; emotional problems; depression; anxiety; substance/drug/alcohol abuse)

Chronic Conditions (examples: high blood pressure/hypertension; diabetes; heart disease; heart attack; lung disease; emphysema; Chronic Obstructive Pulmonary Disease (COPD); Parkinson’s)

Neurological/Developmental Issues (examples: brain damage or injury; developmental or intellectual disorder; mental retardation; Down syndrome; stroke)

Acute Conditions (examples: surgery, wounds/injuries)

Other (specify) __________________

Not sure/ Don’t know

None of the above

D23.How many times did you access a family member or close friend’s online medical record in the last 12 months?

None – GO TOE1

1 to 2 times

3 to 5 times

6 to 9 times

10 or more times

D24. How did you access a family member or close friend’s personal health information?

		Yes	No
a. Used family member’s login and password
b. Used a login and password assigned to me to access their record

E: Medical Research

E1. Doctors use DNA tests to analyze someone’s DNA for health reasons. Have you heard or read about this type of genetic test?

Yes

No - Go to F1

Don’t know – Go to F1

E2. Which of the following uses of a genetic test have you heard of?

Mark all that apply

Determining risk or likelihood of getting a particular disease

Determining how a disease should be treated after diagnosis (“precision medicine”)

Determining which drug(s) may or may not work for an individual

Determining the likelihood of passing an inherited disease to your children

X

E3. Have you ever had any of the following type(s) of genetic tests?

  Mark all that apply.

Paternity testing: To determine if a man is the father of a child

Ancestry testing: To determine the background or geographic/ethnic origin of an individual’s ancestors

DNA fingerprinting: To distinguish between or match individuals using hair, blood, or other biological material

Cystic Fibrosis (CF) carrier testing: To determine if a person is at risk of having a child with cystic fibrosis

BRCA 1/2 testing: To determine if a person has more than an average chance of developing breast cancer or ovarian cancer

Lynch syndrome testing: To determine if a person has more than an average chance of developing colon cancer

None of the above

Not sure

Other-Specify

   

F: Your Overall Health

F1. In general, would you say your health is...

Excellent,

Very good,

Good,

Fair, or

Poor?

F2. Overall, how confident are you about your ability to take good care of your health?

Completely confident

Very confident

Somewhat confident

A little confident

Not confident at all

F3. Has a doctor or other health professional ever told you that you had any of the following medical conditions:

		Yes	No
a. Diabetes or high blood sugar?
b. High blood pressure or hypertension?
c. A heart condition such as heart attack, angina, or congestive heart failure?
d. Chronic lung disease, asthma, emphysema, or chronic bronchitis?
e. Arthritis or rheumatism?
f. Depression or anxiety disorder?

F4. About how tall are you without shoes?

Feet  and

Inches

F5. About how much do you weigh, in pounds, without shoes?

Pounds

F6. Over the past 2 weeks, how often have you been bothered by any of the following problems?

a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
c. Feeling nervous, anxious, or on edge
d. Not being able to stop or control worrying

F7. Is there anyone you can count on to provide you with emotional support when you need it – such as talking over problems or helping you make difficult decisions?

Yes

No

F8. Do you have friends or family members that you talk to about your health?

Yes

No

F9. If you needed help with your daily chores, is there someone who can help you?

Yes

No

G: Health and Nutrition

G1. When available, how often do you use menu information on calories in deciding what to order?

Always

Often

Sometimes

Rarely

Never   

1 cup of fruit could be:

• 1 small apple

• 1 large banana

• 1 large orange

• 8 large strawberries

• 1 medium pear

• 2 large plums

• 32 seedless grapes

• 1 cup (8 oz.) fruit juice

• ½ cup dried fruit

• 1 inch-thick wedge of watermelon

G2. About how many cups of fruit (including 100% pure fruit juice) do you eat or drink each day?

None

½ cup or less

½ cup to 1 cup

1 to 2 cups

2 to 3 cups

3 to 4 cups

4 or more cups

G3. About how many cups of vegetables (including 100% pure vegetable juice) do you eat or drink each day?

None

½ cup or less

½ cup to 1 cup

1 to 2 cups

2 to 3 cups

3 to 4 cups

1 cup of vegetables could be:

• 3 broccoli spears

• 1 cup cooked leafy greens

• 2 cups lettuce or raw greens

• 12 baby carrots

• 1 medium potato

• 1 large sweet potato

• 1 large ear of corn

• 1 large raw tomato

• 2 large celery sticks

• 1 cup of cooked beans

4 or more cups

G4. How much do you agree or disagree with this statement: “Body weight is something basic about a person that they can’t change very much.”

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

H: Physical Activity and Exercise

H1. 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?

None   GO TO H3 below

1 day per week

2 days per week

3 days per week

4 days per week

5 days per week

6 days per week

7 days per week

H2. On the days that you do any physical activity or exercise of at least moderate intensity, how long do you typically do these activities?

Write a number in one box below.

Minutes

Hours

H3. Over the past 30 days, in your leisure time, how many hours per day, on average, did you sit and watch TV or movies, surf the web, or play computer games? Do not include “active gaming” such as Wii.

Hours per day

H4. How many times in the past 12 months have you used a tanning bed or booth?

0 times

1 to 2 times

3 to 10 times

11 to 24 times

25 or more times

H5. When you are outside for more than one hour on a warm, sunny day, how often do you wear sunscreen?

Always

Often

Sometimes

Rarely

Never

Don’t go out on sunny days

I: Tobacco Products

I1. Have you smoked at least 100 cigarettes in your entire life?

Yes

No   GO TO I5

I2. How often do you now smoke cigarettes?

Everyday

Some days

Not at all   GO TO I5

I3. At any time in the past year, have you stopped smoking for one day or longer because you were trying to quit?

Yes

No

I4. Are you seriously considering quitting smoking in the next six months?

Yes

No

I5.At any time in the past year, have you talked with your doctor or other health professional about having a test to check for lung cancer?

Yes

No

Don’t know

I6. How much do you agree or disagree with this statement: “Smoking behavior is something basic about a person that they can’t change very much.”

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

I7. In your opinion, do you think that some smokeless tobacco products, such as chewing tobacco, snus, and snuff are less harmful to a person’s health than cigarettes?

Yes

No

Don’t know

I8. New types of cigarettes are now available called electronic cigarettes (also known as e-cigarettes or personal vaporizers). These products deliver nicotine through a vapor. Compared to smoking cigarettes, would you say that electronic cigarettes are …

Much less harmful,

Less harmful,

Just as harmful,

More harmful,

Much more harmful, or

I’ve never heard of electronic cigarettes

I9. A hookah pipe (or shisha) is a large water pipe. People smoke tobacco using hookah pipes in groups at cafes or bars. Compared to smoking cigarettes, would you say that smoking tobacco using a hookah is…

Much less harmful,

Less harmful,

Just as harmful,

More harmful,

Much more harmful, or

I’ve never heard of Hookah.

J: Screening for Cancer

J1. Are you male or female?

Male   GO TO J6

Female

J2. Has a doctor ever told you that you could choose whether or not to have the Pap test?

Yes

No

J3. How long ago did you have your most recent Pap test to check for cervical cancer?

A year ago or less

More than 1, up to 2 years ago

More than 2, up to 3 years ago

More than 3, up to 5 years ago

More than 5 years ago

I have never had a Pap test

J4. A mammogram is an x-ray of each breast to look for cancer.

Has a doctor ever told you that you could choose whether or not to have a mammogram?

Yes

No

J5. When did you have your most recent mammogram to check for breast cancer, if ever?

A year ago or less

More than 1, up to 2 years ago

More than 2, up to 3 years ago

More than 3, up to 5 years ago

More than 5 years ago

I have never had a mammogram

J6. 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?

Yes

No

J7. Has a doctor ever discussed with you whether or not you should have the PSA test?

Yes

No   

K: HPV Awareness

K1. Have you ever heard of HPV? HPV stands for Human Papillomavirus. It is not HIV, HSV, or herpes.

Yes

No   GO TO K5

K2. Do you think HPV can cause…

		Yes	No	Not sure
a. Cervical Cancer?
b. Penile Cancer?
c. Anal Cancer?
d. Oral Cancer?

K3. Do you think that HPV is a sexually transmitted disease (STD)?

Yes

No   

Not sure  

K4. Do you think HPV requires medical treatment or will it usually go away on its own without treatment?

Requires medical treatment

Will usually go away on its own  

K5. A vaccine to prevent HPV infection is available and is called the HPV shot, cervical cancer vaccine, GARDASIL®, or Cervarix®.

Before today, have you ever heard of the cervical cancer vaccine or HPV shot?

Yes

No

K6. In your opinion, how successful is the HPV vaccine at preventing cervical cancer?

Not at all successful

A little successful

Pretty successful

Very successful

Don’t know

K7. Including yourself, is anyone in your immediate family between the ages of 9 and 27 years old?

Yes

No   GO TO K10 on the next page

K8. In the last 12 months, has a doctor or health care professional ever talked with you or an immediate family member about the HPV shot or vaccine?

Yes

No

Don’t know

K9. In the last 12 months, has a doctor or health care professional recommended that you or someone in your immediate family get an HPV shot or vaccine?

Yes

No

Don’t know

L: Your Cancer History

L1. Have you ever been diagnosed as having cancer?

Yes

No   GO TO M1

X

L2. What type of cancer did you have?

Mark all that apply.

Bladder cancer

Bone cancer

Breast cancer

Cervical cancer (cancer of the cervix)

Colon cancer

Endometrial cancer (cancer of the uterus)

Head and neck cancer

Hodgkin's lymphoma

Leukemia/Blood cancer

Liver cancer

Lung cancer

Melanoma

Non-Hodgkin lymphoma

Oral cancer

Ovarian cancer

Pancreatic cancer

Pharyngeal (throat) cancer

Prostate cancer

Rectal cancer

Renal (kidney) cancer

Skin cancer, non-melanoma

Stomach cancer

Other-Specify

L3. At what age were you first told that you had cancer?

Age

L4. Did you ever receive any treatment for your cancer?

Yes

No   GO TO L8 in the next column

L5. Which of the following cancer treatments have you ever received?

	Yes	No
a. Chemotherapy (IV or pills)
b. Radiation
c. Surgery
d. Other

GO TO L10 in the next column

L6. About how long ago did you receive your last cancer treatment?

Still receiving treatment    

Less than 1 year ago

1 year ago to less than 5 years ago

5 years ago to less than 10 years ago

10 or more years ago

L7. Did you ever receive a summary document from your doctor or other health care professional that listed all of the treatments you received for your cancer?

Yes

No

L8. Were you ever denied health insurance coverage because of your cancer?

Yes

No

L9. Looking back, since the time you were first diagnosed with cancer, how much, if at all, has cancer and its treatment hurt your financial situation?

Not at all

A little

Some

A lot

L10. Clinical trials are research studies that involve people. They are designed to test the safety and effectiveness of new treatments and to compare new treatments with the standard care that people currently get. Have you ever participated in a clinical trial for treatment of your cancer?

Yes

No    GO TO L12 on the next page

Don’t know

L11. Has a doctor or other member of your medical team discussed clinical trials as a treatment option for your cancer?

Yes

No

L12. At any time since you were first diagnosed with cancer, did any doctor or other healthcare provider ever discuss with you the impact of cancer or its treatment on your ability to work?

Discussed it with me in detail

Briefly discussed it with me

Did not discuss it at all

I don’t remember

I was not working at the time of my diagnosis.

M: Beliefs About Cancer

Think about cancer in general when answering the questions in this section.

M1. How likely are you to get cancer in your lifetime?

Very unlikely

Unlikely

Neither unlikely nor likely

Likely

Very likely

M2. How much do you agree or disagree with each of the following statements?

a. It seems like everything causes cancer
b. There’s not much you can do to lower your chances of getting cancer
c. There are so many different recommendations about preventing cancer, it's hard to know which ones to follow
d. In adults, cancer is more common than heart disease
e. When I think about cancer, I automatically think about death

M3. How much do you agree or disagree with the statement: “I’d rather not know my chance of getting cancer.”

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

M4. How worried are you about getting cancer?

Not at all

Slightly

Somewhat

Moderately

Extremely

M5. Have any of your family members ever had cancer?

Yes

No

Not sure

N: You and Your Household

N1. What is your age?

Years old

X

N2. What is your current occupational status?

Mark only one.

Employed

Unemployed

Homemaker

Student

Retired

Disabled

Other-Specify

N3. Have you ever served on active duty in the U.S. Armed Forces, military Reserves or National Guard? Active duty does not include training in the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.

Yes, now on active duty

Yes, on active duty in the last 12 months but
not now

Yes, on active duty in the past, but not in the
last 12 months

No, training for Reserves or
National Guard only

No, never served in the military

GO TO N5

In the next column

N4. In the past 12 months, have you received some or all of your health care from a VA hospital or clinic?

Yes, all of my health care

Yes, some of my health care

No, no VA health care received

X

N5. What is your marital status?

Mark only one.

Married

Living as married

Divorced

Widowed

Separated

Single, never been married

N6. What is the highest grade or level of schooling you completed?

Less than 8 years

8 through 11 years

12 years or completed high school

Post high school training other than college
(vocational or technical)

Some college

College graduate

Postgraduate

N7. Were you born in the United States?

Yes   GO TO N9 below

No

N8. In what year did you come to live in the United States?

Year

N9. How well do you speak English?

Very well

Well

Not well

Not at all

N10. If a person speaks to you in a quiet room, how much can you understand what the person says?

All of what they said

Most of what they said

Some to little of what they said

Did not understand what they said

X

X

N11. Are you of Hispanic, Latino/a, or Spanish origin? One or more categories may be selected.

Mark all that apply.

No, not of Hispanic, Latino/a, or Spanish origin

Yes, Mexican, Mexican American, Chicano/a

Yes, Puerto Rican

Yes, Cuban

Yes, another Hispanic, Latino/a, or Spanish origin

N12. Do you think of yourself as…

Heterosexual, or straight

Homosexual, or gay or lesbian

Bisexual

Something else – Specify

• 

X

X

N13. What is your race? One or more categories may be selected.

Mark all that apply.

White

Black or African American

American Indian or Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

N14. Including yourself, how many people live in your household?

Number of people

N15. Starting with yourself, please mark the sex, and write in the age and month of birth for each adult 18 years of age or older living at this address.

Sex

Age

Month Born
(01-12)

SELF

Male

Female

Adult 2

Male

Female

Adult 3

Male

Female

Adult 4

Male

Female

Adult 5

Male

Female

N16. How many children under the age of 18 live in your household?

Number of children under 18

N17. Do you currently rent or own your home?

Own

Rent

Occupied without paying monetary rent

N18. Does anyone in your family have a working cell phone?

Yes

No

N19. Is there at least one telephone inside your home that is currently working and is not a cell phone?

Yes

No

N20. 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?

$0 to $9,999

$10,000 to $14,999

$15,000 to $19,999

$20,000 to $34,999

$35,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $199,999

$200,000 or more

N21. About how long did it take you to complete the survey?

Write a number in one box below.

Minutes

Hours

X

N22. At which of the following types of addresses does your household currently receive residential mail?

Mark all that apply.

A street address with a house or building number

An address with a rural route number

A U.S. post office box (P.O. Box)

A commercial mail box establishment (such as Mailboxes R Us, and Mailboxes Etc.)

Thank you!

Please return this questionnaire in the postage-paid envelope within 2 weeks.

If you have lost the envelope, mail the completed questionnaire to:

HINTS Study, TC 1046F

Westat

1600 Research Boulevard

Rockville, MD 20850

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