2016 Approved Questions
Attachment 4b-2016 Approved questions by opt mod.docx
Behavioral Risk Factor Surveillance System (BRFSS)
2016 Approved Questions
OMB: 0920-1061
Optional Modules
NOTE: Only asked of those not responding “Yes” (code = 1) to Core Q6.12 (Diabetes awareness question).
Have you had a test for high blood sugar or diabetes within the past three years?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
CATI note: If Core Q6.12 = 4 (No, pre-diabetes or borderline diabetes); answer Q2 “Yes” (code = 1).
Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?
If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”
1 Yes
2 Yes, during pregnancy
3 No
7 Don’t know / Not sure
9 Refused
CATI note: To be asked following Core Q6.13; if response to Q6.12 is "Yes" (code = 1)
1. Are you now taking insulin?
1 Yes
2 No
9 Refused
2. About how often do you check your blood for glucose or sugar? Include times when checked by a family member or friend, but do NOT include times when checked by a health professional.
1 _ _ Times per day
2 _ _ Times per week
3 _ _ Times per month
4 _ _ Times per year
8 8 8 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused
3. About how often do you check your feet for any sores or irritations? Include times when checked by a family member or friend, but do NOT include times when checked by a health professional.
1 _ _ Times per day
2 _ _ Times per week
3 _ _ Times per month
4 _ _ Times per year
5 5 5 No feet
8 8 8 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused
4. About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
_ _ Number of times [76 = 76 or more]
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
5. A test for "A one C" measures the average level of blood sugar over the past three
months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for "A one C"?
_ _ Number of times [76 = 76 or more]
8 8 None
9 8 Never heard of “A one C” test
7 7 Don’t know / Not sure
9 9 Refused
CATI NOTE: If Q3 = 555 (No feet), go to Q7.
6. About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
_ _ Number of times [76 = 76 or more]
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
7. When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light.
Read only if necessary:
1 Within the past month (anytime less than 1 month ago)
2 Within the past year (1 month but less than 12 months ago)
3 Within the past 2 years (1 year but less than 2 years ago)
4 2 or more years ago
Do not read:
Don’t know / Not sure
Never
9 Refused
8. Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
9. Have you ever taken a course or class in how to manage your diabetes yourself?
1 Yes
2 No
7 Don't know / Not sure
9 Refused
Module 3: Healthy Days (Symptoms)
The next few questions are about health-related problems or symptoms.
1. During the past 30 days, for about how many days did pain make it hard for you to do your usual activities, such as self-care, work, or recreation?
_ _ Number of days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
2. During the past 30 days, for about how many days have you felt sad, blue, or depressed?
_ _ Number of days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
3. During the past 30 days, for about how many days have you felt worried, tense, or anxious?
_ _ Number of days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
4. During the past 30 days, for about how many days have you felt very healthy and full of energy?
_ _ Number of days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
People may provide regular care or assistance to a friend or family member who has a health problem or disability.
During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability?
Yes
No [Go to Question 9]
7 Don’t know/Not sure [Go to Question 9]
9 Refused [Go to Question 9]
CATI NOTE: If caregiving recipient has died in the past 30 days, say “I’m so sorry to hear of your loss.” and skip to the next module.
What is his or her relationship to you? For example is he or she your (mother or daughter or father or son)?
[DO NOT READ; CODE RESPONSE USING THESE CATEGORIES]
Mother
Father
Mother-in-law
Father-in-law
Child
Husband
Wife
Same-sex partner
Brother or brother-in-law
Sister or sister-in-law
Grandmother
Grandfather
Grandchild
Other relative
Non-relative/Family friend
77 Don’t know/Not sure
99 Refused
For how long have you provided care for that person? Would you say…
1 Less than 30 days
2 1 month to less than 6 months
3 6 months to less than 2 years
4 2 years to less than 5 years
5 More than 5 years
7 Don’t Know/ Not Sure
9 Refused
In an average week, how many hours do you provide care or assistance? Would you say…
Up to 8 hours per week
9 to 19 hours per week
20 to 39 hours per week
40 hours or more
7 Don’t know/Not sure
9 Refused
What is the main health problem, long-term illness, or disability that the person you care for has?
IF NECESSARY: Please tell me which one of these conditions would you say is the major problem?
[DO NOT READ: RECORD ONE RESPONSE]
Arthritis/Rheumatism
Asthma
Cancer
Chronic respiratory conditions such as Emphysema or COPD
Dementia and other Cognitive Impairment Disorders
Developmental Disabilities such as Autism, Down’s Syndrome, and Spina Bifida
Diabetes
Heart Disease, Hypertension
Human Immunodeficiency Virus Infection (HIV)
Mental Illnesses, such as Anxiety, Depression, or Schizophrenia
Other organ failure or diseases such as kidney or liver problems
Substance Abuse or Addiction Disorders
Other
Don’t know/Not sure
99
Refused
In the past 30 days, did you provide care for this person by…
…Managing personal care such as giving medications, feeding, dressing, or bathing?
1 Yes
2 No
7 Don’t Know /Not Sure
9 Refused
7. In the past 30 days, did you provide care for this person by…
…Managing household tasks such as cleaning, managing money, or preparing meals?
1 Yes
2 No
7 Don’t Know /Not Sure
9 Refused
8. Of the following support services, which one do you MOST need, that you are not currently getting?
[INTERVIEWER NOTE: IF RESPONDENT ASKS WHAT RESPITE CARE IS]: Respite care means short-term or long-term breaks for people who provide care.
[READ OPTIONS 1 – 6]
Classes about giving care, such as giving medications
Help in getting access to services
Support groups
Individual counseling to help cope with giving care
Respite care
You don’t need any of these support services
[DO NOT READ]
7 Don’t Know /Not Sure
9 Refused
[If Q1 = YES, GO TO NEXT MODULE]
9. In the next 2 years, do you expect to provide care or assistance to a friend or family member who has a health problem or disability?
1 Yes
2 No
7 Don’t know/Not sure
9 Refused
Module 5: Visual Impairment and Access to Eye Care
CATI NOTE: If respondent is less than 40 years of age go to next module.
Now I would like to ask you questions about your vision. These questions are for all respondents regardless of whether or not you wear glasses or contact lenses. If you wear glasses or contact lenses, answer questions as if you are wearing them.
1. How much difficulty, if any, do you have in recognizing a friend across the street? Would you say—
Please read:
1 No difficulty
2 A little difficulty
3 Moderate difficulty
4 Extreme difficulty
5 Unable to do because of eyesight
Or
6 Unable to do for other reasons
Do not read:
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
2. How much difficulty, if any, do you have reading print in newspapers, magazines, recipes, menus, or numbers on the telephone? Would you say—
Please read:
1 No difficulty
2 A little difficulty
3 Moderate difficulty
4 Extreme difficulty
5 Unable to do because of eyesight
Or
6 Unable to do for other reasons
Do not read:
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
3. When was the last time you had your eyes examined by any doctor or eye care provider?
Read only if necessary:
1 Within the past month (anytime less than 1 month ago) [Go to Q5]
2 Within the past year (1 month but less than 12 months ago) [Go to Q5]
3 Within the past 2 years (1 year but less than 2 years ago)
4 2 or more years ago
5 Never
Do not read:
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
4. What is the main reason you have not visited an eye care professional in the past 12 months?
Read only if necessary:
0 1 Cost/insurance
0 2 Do not have/know an eye doctor
0 3 Cannot get to the office/clinic (too far away, no transportation)
0 4 Could not get an appointment
0 5 No reason to go (no problem)
0 6 Have not thought of it
0 7 Other
Do not read:
7 7 Don’t know / Not sure
0 8 Not Applicable (Blind) [Go to next module]
9 9 Refused
CATI NOTE: Skip Q5, if any response to Module 2 (Diabetes) Q7.
5. When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light.
Read only if necessary:
1 Within the past month (anytime less than 1 month ago)
2 Within the past year (1 month but less than 12 months ago)
3 Within the past 2 years (1 year but less than 2 years ago)
4 2 or more years ago
5 Never
Do not read:
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
6. Do you have any kind of health insurance coverage for eye care?
1 Yes
2 No
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
7. Have you been told by an eye doctor or other health care professional that you NOW have cataracts?
1 Yes
2 No, I had them removed
3 No
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
8. Have you EVER been told by an eye doctor or other health care professional that you had glaucoma?
1 Yes
2 No
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
Please read:
Age-related Macular Degeneration (AMD) is a disease that affects the macula, the part of the eye that allows you to see fine detail.
NOTE: Age-related Macular Degeneration (Age-related Mak·yuh·luh r Di·jen·uh·rey·shuh n)
9. Have you EVER been told by an eye doctor or other health care professional that you had age-related macular degeneration?
1 Yes
2 No
7 Don’t know / Not sure
8 Not applicable (Blind)
9 Refused
CATI Note: If respondent is 45 years of age or older continue, else go to next module
Introduction: The next few questions ask about difficulties in thinking or remembering that can make a big difference in everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you recently met, which is normal. This refers to confusion or memory loss that is happening more often or getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would normally know. We want to know how these difficulties impact you.
1. During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse?
1 Yes
2 No [Go to next module]
7 Don't know [Go to Q2]
9 Refused [Go to next module]
2.
During the past 12 months, as a result of confusion or memory loss,
how often have you given up day-to-day household activities or
chores you used to do, such as cooking, cleaning, taking
medications, driving, or paying bills?
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never
7 Don't know
9 Refused
3. As a result of confusion or memory loss, how often do you need assistance with these day-to-day activities?
1 Always
2 Usually
3 Sometimes
4 Rarely [Go to Q5]
5 Never [Go to Q5]
7 Don't know
9 Refused
CATI NOTE: If Q3 = 1, 2, or 3, continue. If Q3 = 4 or 5, go to Q5.
4. When you need help with these day-to-day activities, how often are you able to get the help that you need?
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never
7 Don't know
9 Refused
5. During the past 12 months, how often has confusion or memory loss interfered with your ability to work, volunteer, or engage in social activities outside the home?
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never
7 Don't know
9 Refused
6. Have you or anyone else discussed your confusion or memory loss with a health care professional?
1 Yes
2 No
7 Don't know
9 Refused
Module 7: Sodium or Salt-Related Behavior
Now I would like to ask you some questions about sodium or salt intake.
Most of the sodium or salt we eat comes from processed foods and foods prepared in restaurants. Salt also can be added in cooking or at the table.
1. Are you currently watching or reducing your sodium or salt intake?
1 Yes
2 No [Go to Q3]
7 Don’t know/not sure [Go to Q3]
9 Refused [Go to Q3]
2. How many days, weeks, months, or years have you been watching or reducing your sodium or salt intake?”
1_ _ Day(s)
2_ _ Week(s)
3_ _ Month(s)
4_ _ Year(s)
5 5 5 All my life
7 7 7 Don’t know/not sure
9 9 9 Refused
3. Has a doctor or other health professional ever advised you to reduce sodium or salt intake? (344)
1 Yes
2 No
7 Don’t know/not sure
9 Refused
Module 8: Adult Asthma History
CATI NOTE: If "Yes" to Core Q6.4; continue. Otherwise, go to next module.
Previously you said you were told by a doctor, nurse or other health professional that you had asthma.
1. How old were you when you were first told by a doctor, nurse, or other health professional that you had asthma?
_ _ Age in years 11 or older [96 = 96 and older]
9 7 Age 10 or younger
9 8 Don’t know / Not sure
9 9 Refused
CATI NOTE: If "Yes" to Core Q6.5, continue. Otherwise, go to next module.
2. During the past 12 months, have you had an episode of asthma or an asthma attack?
1 Yes
2 No [Go to Q5]
7 Don’t know / Not sure [Go to Q5]
9 Refused [Go to Q5]
3. During the past 12 months, how many times did you visit an emergency room or urgent
care center because of your asthma?
_ _ Number of visits [87 = 87 or more]
8 8 None
9 8 Don’t know / Not sure
9 9 Refused
4. [If one or more visits to Q3, fill in “Besides those emergency room or urgent care center visits,”] During the past 12 months, how many times did you see a doctor, nurse or other health professional for urgent treatment of worsening asthma symptoms?
_ _ Number of visits [87 = 87 or more]
8 8 None
9 8 Don’t know / Not sure
9 9 Refused
5. During the past 12 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma?
_ _ Number of visits [87 = 87 or more]
8 8 None
9 8 Don’t know / Not sure
9 9 Refused
6. During the past 12 months, how many days were you unable to work or carry out your
usual activities because of your asthma?
_ _ _ Number of days
8 8 8 None
7 7 7 Don’t know / Not sure
9 9 9 Refused
7. Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness and phlegm production when you don’t have a cold or respiratory infection. During the past 30 days, how often did you have any symptoms of asthma? Would you say —
NOTE: Phlegm (‘flem’)
Please read:
8 Not at any time [Go to Q9]
1 Less than once a week
2 Once or twice a week
3 More than 2 times a week, but not every day
4 Every day, but not all the time
Or
5 Every day, all the time
Do not read:
7 Don’t know / Not sure
9 Refused
8. During the past 30 days, how many days did symptoms of asthma make it difficult for you
to stay asleep? Would you say —
Please read:
8 None
1 One or two
2 Three to four
3 Five
4 Six to ten
Or
5 More than ten
Do not read:
7 Don’t know / Not sure
9 Refused
9. During the past 30 days, how many days did you take a prescription asthma medication
to PREVENT an asthma attack from occurring?
Please read:
8 Never
1 1 to 14 days
2 15 to 24 days
3 25 to 30 days
Do not read:
7 Don’t know / Not sure
9 Refused
10. During the past 30 days, how often did you use a prescription asthma inhaler DURING AN ASTHMA ATTACK to stop it?
INTERVIEWER INSTRUCTION: How often (number of times) does NOT equal number of puffs. Two to three puffs are usually taken each time the inhaler is used.
Read only if necessary:
8 Never (include no attack in past 30 days)
1 1 to 4 times (in the past 30 days)
2 5 to 14 times (in the past 30 days)
3 15 to 29 times (in the past 30 days)
4 30 to 59 times (in the past 30 days)
5 60 to 99 times (in the past 30 days)
6 100 or more times (in the past 30 days)
Do not read:
7 Don’t know / Not sure
9 Refused
Module 9: Cardiovascular Health
I would like to ask you a few more questions about your cardiovascular or heart health.
CATI NOTE: If Core Q6.1 = 1 (Yes), ask Q1. If Core Q6.1 = 2, 7, or 9 (No, Don’t know, or Refused),
skip Q1.
Following your heart attack, did you go to any kind of outpatient rehabilitation? This is
sometimes called "rehab."
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
CATI NOTE: If Core Q6.3 = 1 (Yes), ask Q2. If Core Q6.3 = 2, 7, or 9 (No, Don’t know, or Refused), skip Q2.
Following your stroke, did you go to any kind of outpatient rehabilitation? This is
sometimes called "rehab."
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Interviewer NOTE: Question 3 is asked for all respondents
3. Do you take aspirin daily or every other day?
Interviewer NOTE: Aspirin can be prescribed by a health care provider or obtained as an over-the-counter (OTC) medication.
1 Yes [Go to question 5]
2 No
7 Don’t know / Not sure
9 Refused
4. Do you have a health problem or condition that makes taking aspirin unsafe for you?
If "Yes," ask "Is this a stomach condition?” Code upset stomach as stomach problems.
1 Yes, not stomach related [Go to next module]
2 Yes, stomach problems [Go to next module]
3 No [Go to next module]
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
5. Do you take aspirin to relieve pain?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6. Do you take aspirin to reduce the chance of a heart attack?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
7. Do you take aspirin to reduce the chance of a stroke?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Module 10: Arthritis Management
CATI NOTE: If Core Q6.9 = 1 (Yes), continue. Otherwise, go to next module.
1. Earlier you indicated that you had arthritis or joint symptoms. Thinking about your arthritis or joint symptoms, which of the following best describes you today?
Please read:
1 I can do everything I would like to do
2 I can do most things I would like to do
3 I can do some things I would like to do
4 I can hardly do anything I would like to do
Do not read:
7 Don’t know / Not sure
9 Refused
2. Has a doctor or other health professional EVER suggested losing weight to help your arthritis or joint symptoms?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3. Has a doctor or other health professional ever suggested physical activity or exercise to help your arthritis or joint symptoms?
NOTE: If the respondent is unclear about whether this means an increase or decrease in physical activity, this means increase.
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
4. Have you EVER taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?
1 Yes
2 No
7 Don’t know / Not sure
Module 11: Tetanus Diphtheria (Tdap) (Adults)
Next, I will ask you about the tetanus diphtheria vaccination.
1. Since 2005, have you had a tetanus shot?
If yes, ask: “Was this Tdap, the tetanus shot that also has pertussis or whooping cough vaccine?”
Yes, received Tdap
Yes, received tetanus shot, but not Tdap
Yes, received tetanus shot but not sure what type
No, did not receive any tetanus since 2005
7 Don’t know/Not sure
9 Refused
Module 12: Adult Human Papillomavirus (HPV) - Vaccination
CATI NOTE: To be asked of respondents between the ages of 18 and 49 years; otherwise, go to next module.
NOTE: Human Papillomavirus (Human Pap·uh·loh·muh virus);
Gardasil (Gar·duh· seel); Cervarix (Sir·var· icks)
1. A vaccine to prevent the human papillomavirus or HPV infection is available and is called
the cervical cancer or genital warts vaccine, HPV shot, [Fill: if female “GARDASIL or CERVARIX”; if male “ or GARDASIL”].
Have you EVER had an HPV vaccination?
Yes
2 No [Go to next module]
3 Doctor refused when asked [Go to next module]
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
2. How many HPV shots did you receive?
_ _ Number of shots
0 3 All shots
7 7 Don’t know / Not sure
9 9 Refused
Module 13: Shingles (Zostavax or ZOS)
CATI NOTE: If respondent is < 49 years of age, go to next section.
The next question is about the Shingles vaccine.
1. Have you ever had the shingles or zoster vaccine?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
INTERVIEWER NOTE (Read if necessary): Shingles is caused by the chicken pox virus. It is an outbreak of rash or blisters on the skin that may be associated with severe pain. A vaccine for shingles has been available since May 2006; it is called Zostavax®, the zoster vaccine, or the shingles vaccine.
Module 14: Breast and Cervical Cancer Screening
CATI NOTE: If respondent is male, go to the next section.
The next questions are about breast and cervical cancer.
A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
1 Yes
2 No [Go to Q3]
7 Don’t know / Not sure [Go to Q3]
9 Refused [Go to Q3]
How long has it been since you had your last mammogram?
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 5 or more years ago
7 Don’t know / Not sure
9 Refused
A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?
1 Yes
2 No [Go to Q5]
7 Don’t know / Not sure [Go to Q5]
9 Refused [Go to Q5]
How long has it been since you had your last Pap test?
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 5 or more years ago
7 Don’t know / Not sure
9 Refused
An HPV test is sometimes given with the Pap test for cervical cancer screening.
Have you ever had an HPV test?
1 Yes
2 No [Go to Q7]
7 Don’t know/Not sure [Go to Q7]
9 Refused [Go to Q7]
How long has it been since you had your last HPV test?
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 5 or more years ago
7 Don’t know / Not sure
9 Refused
CATI NOTE: If response to Core Q7.21 = 1 (is pregnant); then go to next section.
Have you had a hysterectomy?
Read only if necessary: A hysterectomy is an operation to remove the uterus (womb).
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Module 15: Clinical Breast Exam for Breast Cancer Screening
A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you ever had a clinical breast exam?
Yes
2 No [Go to next module]
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
How long has it been since your last breast exam?
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 5 or more years ago
7 Don’t know / Not sure
9 Refused
Module 16: Colorectal Cancer Screening
CATI NOTE: If respondent is < 49 years of age, go to next section.
The next questions are about colorectal cancer screening.
1. A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?
)
1 Yes
2 No [Go to Q3]
7 Don't know / Not sure [Go to Q3]
9 Refused [Go to Q3]
2. How long has it been since you had your last blood stool test using a home kit?
Read only if necessary:
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 5 or more years ago
Do not read:
7 Don’t know / Not sure
9 Refused
3. Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems. Have you ever had either
of these exams?
1 Yes
2 No [Go to next module]
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
4. For a SIGMOIDOSCOPY, a flexible tube is inserted into the rectum to look for problems.
A COLONOSCOPY is similar, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test. Was your MOST RECENT exam a sigmoidoscopy or
a colonoscopy?
Sigmoidoscopy
Colonoscopy
7 Don’t know / Not sure
9 Refused
5. How long has it been since you had your last sigmoidoscopy or colonoscopy?
)
Read only if necessary:
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 Within the past 10 years (5 years but less than 10 years ago)
6 10 or more years ago
Do not read:
7 Don't know / Not sure
9 Refused
Module 17: Prostate Cancer Screening
CATI NOTE: If respondent is <39 years of age, or is female, go to next section.
Now, I will ask you some questions about prostate cancer screening.
A Prostate-Specific Antigen test, also called a PSA test, is a blood test used to check
men for prostate cancer. Has a doctor, nurse, or other health professional EVER talked with you about the advantages of the PSA test?
1 Yes
2 No
7 Don’t Know / Not sure
9 Refused
Has a doctor, nurse, or other health professional EVER talked with you about the
disadvantages of the PSA test?
1 Yes
2 No
7 Don’t Know / Not sure
9 Refused
3. Has a doctor, nurse, or other health professional EVER recommended that you have a PSA test?
Yes
No
7 Don’t Know / Not sure
9 Refused
4. Have you EVER HAD a PSA test?
Yes
No [Go to next module]
7 Don’t Know / Not sure [Go to next module
9 Refused [Go to next module]
5. How long has it been since you had your last PSA test?
Read only if necessary:
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years)
3 Within the past 3 years (2 years but less than 3 years)
4 Within the past 5 years (3 years but less than 5 years)
5 5 or more years ago
Do not read:
7 Don’t know / Not sure
9 Refused
6. What was the MAIN reason you had this PSA test – was it …?
Please read:
1 Part of a routine exam
2 Because of a prostate problem
3 Because of a family history of prostate cancer
4 Because you were told you had prostate cancer
5 Some other reason
Do Not Read:
7 Don’t know / Not sure
9 Refused
Module 18: Prostate Cancer Screening Decision Making
CATI NOTE: If module 17, question 4 = 1 (has had a PSA test) continue, else go to next module.
Which one of the following best describes the decision to have the PSA test done? Please read:
You made the decision alone [Go to next module]
Your doctor, nurse, or health care provider made the decision alone
[Go to next module]
You and one or more other persons made the decision together
4 You don’t remember how the decision was made [Go to next module]
Do not read:
9 Refused
Who made the decision with you? (Mark all that apply)
Doctor/nurse /health care provider
Spouse/significant other
Other family member
Friend/non-relative
8 No additional choices
7 Don’t know / Not sure
9 Refused
Module 19: Industry and Occupation
If Core Q7.15 = 1 or 4 (Employed for wages or out of work for less than 1 year) or 2 (Self-employed), continue else go to next module.
Now I am going to ask you about your work.
If Core Q7.15 = 1 (Employed for wages) or 2 (Self-employed) ask,
1. What kind of work do you do? (for example, registered nurse, janitor, cashier, auto mechanic)
INTERVIEWER NOTE: If respondent is unclear, ask “What is your job title?”
INTERVIEWER NOTE: If respondent has more than one job then ask, “What is your main job?”
[Record answer] _________________________________
99 Refused
Or
If Core Q7.15 = 4 (Out of work for less than 1 year) ask,
What kind of work did you do? (for example, registered nurse, janitor, cashier, auto mechanic) (429-453)
INTERVIEWER NOTE: If respondent is unclear, ask “What was your job title?”
INTERVIEWER NOTE: If respondent had more than one job then ask, “What was your main job?”
[Record answer] _________________________________
99 Refused
If Core Q7.15 = 1 (Employed for wages) or 2 (Self-employed) ask,
2. What kind of business or industry do you work in? (for example, hospital, elementary school, clothing manufacturing, restaurant)
[Record answer] _________________________________
99 Refused
Or
If Core Q7.9 = 4 (Out of work for less than 1 year) ask,
What kind of business or industry did you work in? (for example, hospital, elementary school, clothing manufacturing, restaurant)
[Record answer] _________________________________
99 Refused
Now, I am going to ask you about several factors that can affect a person’s health.
If Core Q7.8 = 1 or 2 (own or rent) continue, else go to Q2.
1. How often in the past 12 months would you say you were worried or stressed
about having enough money to pay your rent/mortgage? Would you say you were worried or stressed---
Please read:
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never
Do not read:
8 Not applicable
7 Don’t know / Not sure
9 Refused
2. How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say you were worried or
stressed---
Please read:
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never
Do not read:
8 Not applicable
7 Don’t know / Not sure
9 Refused
If Core Q7.15 = 1 (Employed for wages) or 2 (Self-employed), go to Q3 and Q4.
If Core Q7.15 = 3 (Out of work for 1 year or more), 4 (Out of work for less than 1 year), or
7 (Retired), go to Q5 and Q6.
If Core Q7.15 = 5 (A homemaker), 6 (A student), or 8 (Unable to work), go to Q6.
3. At your main job or business, how are you generally paid for the work you do. Are you:
1 Paid by salary
2 Paid by the hour
3 Paid by the job/task (e.g. commission, piecework)
4 Paid some other way
7 Don’t know / Not sure
9 Refused
INTERVIEWER NOTE: If paid in multiple ways at their main job, select option 4 (Paid some other way).
4. About how many hours do you work per week at all of your jobs and businesses combined?
_ _ Hours (01-96 or more) [Go to next module]
9 7 Don't know / Not sure [Go to next module]
9 8 Does not work [Go to next module]
9 9 Refused [Go to next module]
5. Thinking about the last time you worked, at your main job or business, how were you
generally paid for the work you did? Were you:
1 Paid by salary
2 Paid by the hour
3 Paid by the job/task (e.g. commission, piecework)
4 Paid some other way
7 Don’t know / Not sure
9 Refused
6. Thinking about the last time you worked, about how many hours did you work per week
at all of your jobs and businesses combined?
_ _ Hours (01-96 or more)
9 7 Don't know / Not sure
9 8 Does not work
9 9 Refused
Module 21: Sexual Orientation and Gender Identity
The next two questions are about sexual orientation and gender identity.
INTERVIEWER NOTE: We ask this question in order to better understand the health and health care needs of people with different sexual orientations.
INTERVIEWER NOTE: Please say the number before the text response. Respondent can answer with either the number or the text/word.
1. Do you consider yourself to be:
Please read:
1 1 Straight
2 2 - Lesbian or gay
3 3 - Bisexual
Do not read:
4 Other
Don’t know/Not sure
9 Refused
2. Do you consider yourself to be transgender?
If yes, ask “Do you consider yourself to be 1. male-to-female, 2. female-to-male, or 3. gender non-conforming?
INTERVIEWER NOTE: Please say the number before the “yes” text response. Respondent can answer with either the number or the text/word.
1 Yes, Transgender, male-to-female
2 Yes, Transgender, female to male
3 Yes, Transgender, gender nonconforming
4 No
7 Don’t know/not sure
9 Refused
INTERVIEWER NOTE: If asked about definition of transgender:
Some
people describe themselves as transgender when they experience a
different gender identity from their sex at birth. For example,
a person born into a male body, but who feels female or lives as a
woman would be transgendered.
Some transgender people change their physical appearance so that it
matches their internal gender identity. Some transgender people take
hormones and some have surgery. A transgender person may be of any
sexual orientation – straight, gay, lesbian, or bisexual.
INTERVIEWER NOTE: If asked about definition of gender non-conforming:
Some people think of themselves as gender non-conforming when they do not identify only as a man or only as a woman.
Module 22: Random Child Selection
CATI NOTE: If Core Q7.16 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module.
If Core Q7.16 = 1, Interviewer please read: “Previously, you indicated there was one child age 17 or younger in your household. I would like to ask you some questions about that child.” [Go to Q1]
If Core Q7.16 is >1 and Core Q7.16 does not equal 88 or 99, Interviewer please read: “Previously, you indicated there were [number] children age 17 or younger in your household. Think about those [number] children in order of their birth, from oldest to youngest. The oldest child is the first child and the youngest child is the last. Please include children with the same birth date, including twins, in the order of their birth.”
CATI INSTRUCTION: RANDOMLY SELECT ONE OF THE CHILDREN. This is the “Xth” child. Please substitute “Xth” child’s number in all questions below.
INTERVIEWER PLEASE READ:
I have some additional questions about one specific child. The child I will be referring to is the “Xth” [CATI: please fill in correct number] child in your household. All following questions about children will be about the “Xth” [CATI: please fill in] child.
1. What is the birth month and year of the “Xth” child?
_ _ /_ _ _ _ Code month and year
7 7/ 7 7 7 7 Don’t know / Not sure
9 9/ 9 9 9 9 Refused
CATI INSTRUCTION: Calculate the child’s age in months (CHLDAGE1=0 to 216) and also in years (CHLDAGE2=0 to 17) based on the interview date and the birth month and year using a value of 15 for the birth day. If the selected child is < 12 months old enter the calculated months in CHLDAGE1 and 0 in CHLDAGE2. If the child is > 12 months enter the calculated months in CHLDAGE1 and set CHLDAGE2=Truncate (CHLDAGE1/12).
2. Is the child a boy or a girl?
1 Boy
2 Girl
9 Refused
3. Is the child Hispanic, Latino/a, or Spanish origin?
If yes, ask: Are they…
Interviewer NOTE: One or more categories may be selected
1 Mexican, Mexican American, Chicano/a
2 Puerto Rican
3 Cuban
4 Another Hispanic, Latino/a, or Spanish origin
Do not read:
5 No
7 Don’t know / Not sure
9 Refused
4. Which one or more of the following would you say is the race of the child?
(Select all that apply)
Interviewer NOTE: If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.
10 White
20 Black or African American
30 American Indian or Alaska Native
40 Asian
41 Asian Indian
42 Chinese
43 Filipino
44 Japanese
45 Korean
46 Vietnamese
47 Other Asian
50 Pacific Islander
51 Native Hawaiian
52 Guamanian or Chamorro
53 Samoan
54 Other Pacific Islander
Do not read:
60 Other
88 No additional choices
77 Don’t know / Not sure
99 Refused
5. Which one of these groups would you say best represents the child’s race?
Interviewer NOTE: If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.
10 White
20 Black or African American
30 American Indian or Alaska Native
40 Asian
41 Asian Indian
42 Chinese
43 Filipino
44 Japanese
45 Korean
46 Vietnamese
47 Other Asian
50 Pacific Islander
51 Native Hawaiian
52 Guamanian or Chamorro
53 Samoan
54 Other Pacific Islander
Do not read:
60 Other
77 Don’t know / Not sure
99 Refused
6. How are you related to the child?
Please read:
1 Parent (include biologic, step, or adoptive parent)
2 Grandparent
3 Foster parent or guardian
4 Sibling (include biologic, step, and adoptive sibling)
5 Other relative
6 Not related in any way
Do not read:
7 Don’t know / Not sure
9 Refused
Module 23: Childhood Asthma Prevalence
CATI NOTE: If response to Core Q7.16 = 88 (None) or 99 (Refused), go to next module.
The next two questions are about the “Xth” [CATI: please fill in correct number] child.
1. Has a doctor, nurse or other health professional EVER said that the child has asthma?
1 Yes
2 No [Go to next module]
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
2. Does the child still have asthma?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Module 24: Emotional Support and Life Satisfaction
The next two questions are about emotional support and your satisfaction with life.
1. How often do you get the social and emotional support you need?
INTERVIEWER NOTE: If asked, say “please include support from any source.”
Please read:
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never
Do not read:
7 Don't know / Not sure
9 Refused
2. In general, how satisfied are you with your life?
Please read:
1 Very satisfied
2 Satisfied
3 Dissatisfied
4 Very dissatisfied
Do not read:
7 Don't know / Not sure
9 Refused
Module 25: Anxiety and Depression
Now, I am going to ask you some questions about your mood. When answering these questions, please think about how many days each of the following has occurred in the past 2 weeks.
1. Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
2. Over the last 2 weeks, how many days have you felt down, depressed or hopeless?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
3. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
4. Over the last 2 weeks, how many days have you felt tired or had little energy?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
5. Over the last 2 weeks, how many days have you had a poor appetite or eaten too much?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
6. Over the last 2 weeks, how many days have you felt bad about yourself or that you were a failure or had let yourself or your family down?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
7. Over the last 2 weeks, how many days have you had trouble concentrating on things, such as reading the newspaper or watching the TV?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
8. Over the last 2 weeks, how many days have you moved or spoken so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you were moving around a lot more than usual?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
9. Are you now taking medicine or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem?
1 Yes
2 No
7 Don‘t know / Not sure
9 Refused
10. Has a doctor or other healthcare provider EVER told you that you have an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder)?
1 Yes
2 No
7 Don‘t know / Not sure
9 Refused
1. The next question is about eating out at fast food and chain restaurants. When calorie information is available in the restaurant, how often does this information help you decide what to order?
Please read:
01 Always
02 Most of the time
03 About half the time
04 Sometimes
05 Never
Do not read:
06 Never noticed or never looked for calorie information
08 Usually cannot find calorie information
55 Do not eat at fast food or chain restaurants
77 Don’t know / Not sure
99 Refused
1. During the past 30 days, on how many days did you use marijuana or hashish?
_ _ 01-30 Number of Days
8 8. None
7 7. Don’t know/not sure
9 9. Refused
2. During the past 30 days, how did you use marijuana? Please tell me all that apply. Did you….
[INTERVIEWER NOTE: Use clarification in parentheses only if needed. Please slowly read all modes in succession]
Smoke it? (for example: in a joint, bong, pipe, or blunt)
Eat it? (for example, in brownies, cakes, cookies, or candy)
Drink it? (for example, in tea, cola, alcohol)
Vaporize it? (for example in an e-cigarette-like vaporizer)
Dab it? (for example using butane hash oil, wax or concentrates)
or
Was it used in some other way?
Don’t know/Not sure
9 Refused
I would like to ask you a few questions about your sleep patterns.
1. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?
__ __ 01-14 days
8 8 None
7 7 Don’t know/Not sure
9 9 Refused
Over the last 2 weeks, how many days did you unintentionally fall asleep during the day?
(400-401)
__ __ 01-14 days
8 8 None
7 7 Don’t know/Not sure
9 9 Refused
3. Have you ever been told that you snore loudly? (402)
1 Yes
2 No
7 Don’t know/Not sure
9 Refused
4. Has anyone ever observed that you stop breathing during your sleep? (403)
1 Yes
2 No
7 Don’t know/Not sure
9 Refused
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| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |
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