Form QID Eye Tracking Questionnaire

SURVEY 1

Survey 1 – Page 1 (definition after Question)

During the past 12 months, have you talked with a health care professional about your health?

Yes

No

Have you EVER received the hepatitis A vaccine?

The hepatitis A vaccine is given as a two dose series routinely to some children starting at 1 year of age, and to some adults and people who travel outside the United States. Although it can be given as a combination vaccine with hepatitis B, it is different from the hepatitis B shot, and has only been available since 1995.

Yes

No

Don’t know

Have you received a tetanus shot in the past 10 years?

Yes

No

Don’t know

Survey 1 – Page 2 (definition before question)

Have you ever had chickenpox?

Yes

No

Shingles is an outbreak of a rash or blisters on the skin that may be associated with severe pain. The pain is generally on one side of the body or face. Shingles is caused by the chicken pox virus. A vaccine for shingles has been available since May 2006.

Have you ever had the Zoster (ZOSS-ter) or Shingles vaccine, also called Zostavax®?

Yes

No

Have you ever received an HPV shot or vaccine?

Yes

No

Survey 1 – Page 3 (definition inside matrix)

We would now like to ask you about your use of tobacco products.

Have you ever smoked cigarettes?
Have you smoked at least 100 cigarettes in your entire life?
Have you ever smoked cigars regularly? (Yes mean more than 1 cigar for one year at any time in your life)
Have you ever used smokeless tobacco products at least 20 times in your entire life?

Survey 1 – Page 4 (include/exclude within question first followed by bulleted include/exclude)

1. Do you or anyone in your household use mass transportation serviced such as bus, subway, mini-bus or train? Include all commuter services.

Yes

No

2. What is the usual monthly cost to use mass transit? Exclude expenses covered by employer-provided transit subsidies.

3. Since the first of January, have you or any member of your household had expenses for parking?

INCLUDE: Parking meters Garage fees Garage/space rentals

EXCLUDE: Work related expenses Reimbursable fees Parking tickets

Yes

No

Survey 2

Survey 2– Page 1 (definition before question)

During the past 12 months, have you talked with a health care professional about your health?

Yes

No

Shingles is an outbreak of a rash or blisters on the skin that may be associated with severe pain. The pain is generally on one side of the body or face. Shingles is caused by the chicken pox virus. A vaccine for shingles has been available since May 2006.

Have you ever had the Zoster (ZOSS-ter) or Shingles vaccine, also called Zostavax®?

Have you ever received an HPV shot or vaccine?

Yes

No

Survey 2 Page 2 (definition after question)

Have you ever had chickenpox?

Yes

No

Have you EVER received the hepatitis A vaccine?

The hepatitis A vaccine is given as a two dose series routinely to some children starting at 1 year of age, and to some adults and people who travel outside the United States. Although it can be given as a combination vaccine with hepatitis B, it is different from the hepatitis B shot, and has only been available since 1995.

Yes

No

Don’t know

Have you received a tetanus shot in the past 10 years?

Yes

No

Don’t know

Survey 2– Page 3 (definition inside matrix)

We would now like to ask you about your use of tobacco products.

	Yes	No
Have you ever smoked cigarettes?
Have you smoked at least 100 cigarettes in your entire life?
Have you ever smoked cigars regularly? (Yes mean more than 1 cigar for one year at any time in your life)
Have you ever used smokeless tobacco products at least 20 times in your entire life?

Survey 2 Page 4 (bulleted include/exclude first followed by include/exclude in question)

Since the first of January, have you or any member of your household had expenses for parking?

INCLUDE: Parking meters Garage fees Garage/space rentals

EXCLUDE: Work related expenses Reimbursable fees Parking tickets

Yes

No

Do you or anyone in your household use mass transportation serviced such as bus, subway, mini-bus or train? Include all commuter services.

Yes

No

What is the usual monthly cost to use mass transit? Do not include expenses covered by employer-provided transit subsidies.