CDC Letterhead
[date]
Dear Resident,
Your family has been chosen to take part in a survey. The survey is being conducted by the Centers for Disease Control and Prevention (CDC). The results of this survey will give public health experts information about health issues in the United States.
In the next two weeks, a person from a group called ICF International will call you. This group is working with CDC to conduct the survey. When they call, they will ask you how many people live in your house. After that, they will chose a person in your house to answer some questions. The questions will be about foods you eat and health issues. If they choose someone between 12 and 17 years old, a parent or guardian will need to give permission for the young person to answer the questions. If you are called at a bad time, please let the person calling know and they will set another time to call you.
The survey will take about 20 minutes. You may choose not to take part in the survey or to answer only some questions. The survey is confidential which means you or your family will not be identified in any of the results.
If you have any questions about the survey or this letter, please call XXX at (XXX) XXX-XXXX. Please leave a message including your name and phone number.
Thank you,
XXX
Form Approved
OMB No. 0920-1112
FoodNet Population Survey
Adolescent, Adult, and Pediatric
Questionnaire
2016 - 2017
Participant screening 3
Section 1. Food exposures VERSION 1 5
Section 2. Food exposures VERSION 2 108
Section 3. Food exposures WEB ONLY VERSION 10
Section 43. DIET 912
Section 45. ANIMAL CONTACT VERION 1 141
Section 5. ANIMAL CONTACT VERSION 2 12
Section 6. DRINKING AND RECREATIONAL WATER VERSION 1 136
Section 7. DRINKING AND RECREATIONAL WATER VERSION 2 158
Section 8. TRAVEL 196
Section 9. HEALTH 1207
Section 10. COMMUNITY 263
Section 11. WEB-ONLY ADMINISTRATION 130
Closing Statement 404
Public reporting burden of this collection of information is estimated to average 20 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, Georgia 30333; ATTN: PRA (0920-1112).
Participant Screening
Hello, I’m calling for the Centers for Disease Control and Prevention. My name is ________. I work for ICF International, the research firm that is helping to gather information on the health of {insert state} residents. Your phone number has been chosen randomly, and I’d like to ask some questions about health and health practices.
Continue
No answer
Normal busy
Answering machine
Number is not the same {END SURVEY}
{PRIVATE} Is this a private residence?
Yes
No, non-residential {END SURVEY}
{STATE} Can you please tell me, what state do you live in?
{Insert state from sample}
Other {END SURVEY}
Refused {END SURVEY}
{COUNTY} {If STATE = CA, CO, NY} Can you please tell me, what county do you live in?
{Insert county from sample}
{Insert county from sample}
{Insert county from sample}
88 Other {END SURVEY}
77 DK {END SURVEY}
99 Refused {END SURVEY}
CA |
1 |
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Alameda |
NY |
1 |
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Albany |
39 |
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Greene |
97 |
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Schuyler |
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13 |
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Contra Costa |
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3 |
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Allegany |
41 |
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Hamilton |
99 |
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Seneca |
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75 |
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San Francisco |
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9 |
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Cattaraugus |
51 |
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Livingston |
101 |
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Steuben |
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81 |
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San Mateo |
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13 |
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Chautauqua |
55 |
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Monroe |
113 |
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Warren |
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85 |
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Santa Clara |
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15 |
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Chemung |
57 |
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Montgomery |
115 |
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Washington |
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19 |
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Clinton |
63 |
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Niagara |
117 |
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Wayne |
CO |
1 |
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Adams |
|
21 |
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Columbia |
69 |
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Ontario |
121 |
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Wyoming |
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5 |
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Arapahoe |
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25 |
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Delaware |
73 |
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Orleans |
123 |
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Yates |
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13 |
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Boulder |
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29 |
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Erie |
77 |
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Otsego |
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14 |
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Broomfield |
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31 |
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Essex |
83 |
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Rensselaer |
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31 |
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Denver |
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33 |
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Franklin |
91 |
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Saratoga |
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35 |
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Douglas |
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35 |
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Fulton |
93 |
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Schenectady |
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59 |
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Jefferson |
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37 |
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Genesee |
95 |
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Schoharie |
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{ADULTS} Our study requires that we randomly select one person who lives in your household to be interviewed. How many children and adult, including yourself, are there in your household?
___ ___ Number of people in household
{If ADULTS = 1}
{YOURTHE1} Then you are the person I need to speak with.
{PERAGE} What is your age?
___ ___ years {IF ≥18 GO TO CONSENT; IF 12-17 GO TO ASSENT; IF <12, GUARDIAN}
{If ADULTS >1}
{MEN} How many of these people are male?
___ ___
{If MEN < ADULTS}
{WOMEN} How many of these people are female?
___ ___
{ASKFOR} The person randomly selected is __________.
{FIRSTNAME} What is this person’s first name?
__________________________
{PERAGE} What is this person’s age?
____ ____ years {
{AREYOU} Are you _____?
Yes {IF ≥18, GO TO CONSENT; IF 12-17 GO TO ASSENT; IF <12, GUARDIAN}
No
{GUARDIAN}
Since ______ is less than 12 years old, I will need to speak to the child’s parent or guardian and ask them the questions instead. Are you the child’s parent or guardian?
Yes {GO TO CONSENT FORMS}
No
{GETGUARDIAN} May I speak to the child’s parent or guardian?
Yes {GO TO CONSENT FORMS}
No {Suspend and schedule a call back with child’s parent}
{ASSENT}
Since ____ is between 12 and 17 years old, I need to ask that child’s guardian for permission to interview him/her. Are you the child’s parent or guardian?
Yes {GO TO CONSENT FORMS}
No
{GETGUADIAN2} May I speak to the child’s parent or guardian?
Yes {GO TO CONSENT/ASSENT FORMS}
No {Suspend and schedule a call back with child’s parent}
{CONSENT}
May I speak with _____?
Yes {GO TO CONSENT FORMS}
No {Suspend and schedule a call back}
Food Module—Version 1
Time estimate: 4.5-6.5m
To be administered to 50% of respondents.
Next I’ll ask you about foods eaten in the past 7 days, which is [insert day, date] to [today, date]. Some of the questions might seem repetitive, but please answer, even if you think it was already covered. Unless I say otherwise, I’m interested in the food whether it was prepared at home or outside the home, such as in a restaurant, deli, fast food, take-out, or catered event, and no matter where you ate it. Ready?
The first questions are about eggs. Tell me if {you/your child} ate any of these in the past 7 days, since [insert day, date]. |
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N |
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Eggs or egg-containing dishes such as quiche or egg salad If yes… |
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Eggs at home |
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Eggs away outside thefrom home, such as a restaurant, deli, fast food, take-out, or catered event |
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Raw, runny, or over-easy eggs |
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Anything made with raw eggs such as dough, sauce, homemade ice cream, or homemade mayonnaise |
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These next questions are about poultry. This does not include canned items, but the poultry could have been fresh or frozen unless I say otherwise. These foods could have been eaten alone, as a deli meat, or as part of a dish. They could have been eaten at home or outside the home, unless I say otherwise. Please tell me if {you/your child} ate these in the past 7 days, since [insert day, date]. |
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Y |
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N |
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Chicken or any foods dishes containing chicken, such as chicken breasts or wings, ground chicken, chicken casserole, or chicken sausage If yes… |
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Chicken prepared outside the away from home, such as in a restaurant or from a store like rotisserie or tenders |
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Chicken prepared at home, not including take-out If yes… |
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Chicken prepared at home that was refrigerated and raw when purchased |
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Chicken prepared at home that was frozen and raw when purchased |
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Ground chicken prepared at home or outside the away from home |
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Turkey or any dishes containing turkey, such as turkey casserole, ground turkey, deli meat, turkey bacon, or turkey sausage If yes… |
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Any turkey prepared outside the away from home, such as in a restaurant, deli, fast food, take-out, or catered event |
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Ground turkey prepared at home or outside the away from home |
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Next, I have a few questions about processed meats. Did {you/your child} eat any of these in the past 7 days, since [insert day, date]? |
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Y |
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N |
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Pre-packaged sliced deli meats |
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Sliced deli meats that were not pre-packaged |
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Hot dogs, corn dogs, Polish sausage, Kielbasa, or other similar product |
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Salami, pepperoni, or other Italian-style meat |
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Dried meat strips or jerky |
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These next questions are about seafood. This does not include canned items, but it could have been fresh or frozen unless I say otherwise. These foods could have been eaten alone or as part of a dish, sauce, or dip. They could have been eaten at home or outside the home. Did {you/your child} eat any of these in the past 7 days, since [insert day, date]? |
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Y |
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N |
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Store- or restaurant-bought fish, not including shellfish If yes… |
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Fish that was raw or undercooked such as sushi, sashimi, or ceviche |
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Other seafood or shellfish such as crab, shrimp, oysters, or clams If yes… |
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Other seafood or shellfish that was raw or undercooked such as raw oysters or clams If yes… |
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Raw oysters |
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Raw clams, mussels, scallops, or other shellfish |
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Next, I have a few questions about fresh fruits. This does not include canned, cooked, dried, or frozen fruits. They could have been eaten at home or outside the home. Did {you/your child} eat any of these in the past 7 days, since [insert day, date]?? |
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Y |
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N |
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Apples |
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Pears |
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Peaches, nectarines, apricots, or plums |
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Cantaloupe |
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Honeydew |
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Watermelon |
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Pre-packaged, store-bought fresh fruit salad |
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Now I’ll ask you about raw vegetables in the past 7 days. Don’t say yes if the vegetable was cooked, had been frozen, or came in a can. They could have been eaten at home or outside the home. In the past 7 days, since [insert day, date], did {you/you child} eat any of the following raw or uncooked vegetables? |
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Y |
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N |
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Celery |
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Carrots |
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Green onions or scallions |
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Avocado or guacamole |
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Fresh tomatoes, including in a sandwich, burger, or salad If yes… |
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Roma tomatoes |
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Small, bite-sized tomatoes such as grape or cherry tomatoes |
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Fresh salsa or pico de gallo, not from a jar or can |
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Zucchini, yellow, or other summer squash |
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Sprouts such as alfalfa, bean, or clover, or broccoli |
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Cabbage |
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Leafy greens such as lettuce, spinach, or kale such as in a salad, on a sandwich or burger |
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Iceberg lettuce, such as in a salad, on a sandwich or burger |
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Romaine lettuce, such as in a salad, on a sandwich or burger |
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Spinach |
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Arugula |
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Kale |
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Pre-packaged salad mix |
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Now tell me if {you/your child} ate any of these foods that originally came in frozen packages. In the past 7 days, since [insert day, date], did {you/your child} eat…? |
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Y |
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N |
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Frozen stuffed chicken products |
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Frozen snack foods like mozzarella sticks, jalapeño poppers, potato skins, or hot pockets |
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Frozen pizza |
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Frozen Mexican-style items |
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Just a few more! In the past 7 days, since [insert day, date], did {you/your child} eat…? |
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Y |
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N |
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Hummus |
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Sesame seeds or other product made from sesame seeds including tahini or halva |
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Seeds such as flax, chia, or hemp |
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Unpasteurized or raw juice or cider |
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Tofu, tempeh, or seitan |
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Food Module—Version 2
Time estimate: 4.5-5m
To be administered to 50% of respondents.
Next I’ll ask you about foods eaten in the past 7 days, which is [insert day, date] to [today, date]. Some of the questions might seem repetitive, but please answer, even if you think it was already covered. Unless I say otherwise, I’m interested in the food whether it was prepared at home or outside the home, such as in a restaurant, deli, fast food, take-out, or catered event, and no matter where you ate it. Ready, OK?
The first questions are about dairy and cheese. They could have been eaten at home or outside the home. Tell me if {you/your child} ate any of these in the past 7 days, since [insert day, date].
Y |
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N |
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Yogurt, including kefir and in smoothies |
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Ice cream |
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Pasteurized milk from any animal |
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Unpasteurized or raw milk from any animal |
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Cheese made from pasteurized milk |
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Cheese made from unpasteurized or raw milk including homemade, farm-fresh, and door-to-door cheeses |
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Other dairy products that were raw or unpasteurized including yogurts and ice cream made from raw milk |
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Soft cheese such as Brie or queso fresco If yes… |
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Unpasteurized soft cheese |
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Mexican- or Latin-style soft cheese such as queso fresco or queso blanco |
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Blue-veined cheese such as Bleu or gorgonzola |
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Feta |
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Goat cheese |
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Brie or Camembert |
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Thanks! These next questions are about meat. This does not include canned items, but the meat could have been fresh, frozen, or it could have been eaten as deli meat or as part of a dish. They could have been eaten at home or outside the home, unless I say otherwise. Please tell me if {you/your child} ate these in the past 7 days, since [insert day, date]. |
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Y |
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N |
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Beef or any dishes containing beef If yes… |
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Any type of beef prepared outside the away from home, such as in a restaurant, deli, fast food, take-out, or catered event |
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Ground beef that was prepared either at home or outside the away from home If yes… |
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Ground beef that was undercooked or raw |
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Pre-formed hamburger patties eaten at home |
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Other beef such as steaks or roasts that were prepared either at home or outside the away from home |
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Pork, such as pork chops, pork roasts, bacon, ham or sausage, not including ham If yes… |
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Ground pork, such as sausage |
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Whole cuts of pork, such as pork chops or pork roast |
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Lamb |
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Liver paté from any animal |
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Raw, undercooked, or pink liver |
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Bison or buffalo meat |
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Next, I have a few questions about fresh fruits. This does not include canned, cooked, dried, or frozen fruits. They could have been eaten at home or outside the home. Did {you/your child} eat any of these fresh fruits in the past 7 days, since [insert day, date]?? |
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Y |
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N |
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Oranges |
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Tangerines, mandarins, or clementines |
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Strawberries |
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Raspberries |
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Blueberries |
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Blackberries |
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Other berries, such as cranberries, goji berries, or boysenberries |
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Pineapple |
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Mango |
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Now I’ll ask you about raw vegetables in the past 7 days. Don’t say yes if the vegetable was cooked, had been frozen, or came in a can. They could have been eaten at home or outside the home. In the past 7 days, since [insert day, date], did {you/you child} eat any of the following raw or uncooked vegetables? |
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Y |
? |
N |
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Pre-cut vegetables or vegetable mixes |
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Cucumbers |
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Broccoli or cauliflower |
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Pea pods, snap peas, or snow peas |
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Hot chili peppers such as jalapeños or serranos |
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Other peppers such as sweet or green, red, orange, or yellow bell |
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Fresh basil |
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Fresh parsley |
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Fresh cilantro |
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Other fresh herbs |
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Tell me if {you/your child} ate any of these foods that originally came in frozen packages. In the past 7 days, since [insert day, date], did {you/your child} eat…? |
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Y |
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N |
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Frozen vegetables |
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Frozen berries, such as in smoothies |
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Other frozen fruit or frozen fruit pulp, such as in smoothies |
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These next questions are about other foods. These could have been eaten alone or as part of another dish. Did {you/your child} eat any in the past 7 days since [day, date]? |
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Y |
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N |
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Peanuts |
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Peanut butter in a jar |
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Fresh-ground peanut butter |
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Other ground nut butter or spread such as Nutella or almond butter |
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Almonds, (whole or pieces) |
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Walnuts, (whole or pieces) |
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Cashews, (whole or pieces) |
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Pistachios, (whole or pieces) |
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Pecans, (whole or pieces) |
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Hazelnuts or filberts, (whole or pieces) |
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Other nuts or nut mixes such as in trail mix |
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Dried fruit alone or in trail mix |
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Food Module – Web Only
Now I’d like to ask you about foods {you have/your child has} eaten recently. First, I’ll ask you about foods eaten in the past 14 days and then in the past 30 days. Unless I say, I am referring to both raw and cooked items and items eaten either at home or outside the home. For each item, give me a “yes” or “no” if you remember eating or even tasting it during that time. It doesn’t matter whether the food was prepared at home or outside the home—ready?
Did {you/your child} eat any fresh raw cilantro, alone, as part of a dish, or garnish, in the past 14 days, since [insert date]?
Yes
No
7 Don’t know / Not sure
9 Refused
Did {you/your child} eat any raw pea pods, snap peas, or snow peas in the past 14 days, since [insert date]?
Yes
No
7 Don’t know / Not sure
9 Refused
Did {you/your child} eat any berries from a package of frozen berries, such as in smoothies in the past 30 days, since [insert date]?
Yes
No
7 Don’t know / Not sure
9 Refused
Now I’d like to ask you about raw foods {you/your child} or anyone else in {your/your child’s} household may have prepared or come in contact with handled in your home, whether or not {you/your child} ate it. I’m interested in whether anyone in {your/your child’s} household handled these foods, either fresh or frozen, in the past 7 days, since [insert date].
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Raw poultry, such as chicken or turkey, fresh or frozen |
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Raw beef, fresh or frozen |
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Raw fish or seafood, fresh or frozen |
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Raw wild game meat, fresh or frozen (Wild game includes animals hunted or caught in traps, such as deer (venison), wild boar, or wild rabbit. It does not include farm-raised animals.) |
Raw Milk
In the past year, since [insert date], did {you/your child} drink any unpasteurized or raw milk?
Yes
No {GO TO NEXT MODULE}
7 Don’t know / Not sure {GO TO NEXT MODULE}
9 Refused {GO TO NEXT MODULE}
1a. How often do {you/your child} drink unpasteurized or raw milk?
{READ}
Most weeks
Every month
Every 2-3 months
Twice a year
Once a year
{DO NOT READ}
7 Don’t know/ Not sure
9 Refused
1b. Where {do you/does your child} get unpasteurized or raw milk?
{READ} {YES = 1; NO = 2; DK = 7; RF = 9}
1b_01 Through a cow- or goat-sharing program
1b_02 Directly from the farm
1b_03 At a farmer’s market or similar stand
1b_04 From cows or goats on your farm or a farm of someone you know
1b_05 Through a pet store, labeled as “pet food”
1b_06 Grocery store or retail market
1b_07 Other
Diet Module
Time estimate: 0.5-1m
Now I would like to ask you some questions about {your/your child’s} diet the foods {you eat/your child eats} in general. I am not referring to specific foods {you/your child} may have eaten in the past 7 days, but rather types of foods that {you/your child} may or may not be a part ofhave eaten {your/your child’s} diet for any reason within the past year.
Did{Do you/Does your child} eat any dairy products such as butter, dairy milk, or cheese, in the past year?
Yes
No
7 Don’t know / Not sure
9 Refused
Did {Do you/Does your child} eat eggs in the past year?
Yes
No
7 Don’t know / Not sure
9 Refused
Did {Do you/Does your child} eat poultry, such as chicken or turkey, in the past year?
Yes
No
7 Don’t know / Not sure
9 Refused
Did {Do you/Does your child} eat pork in the past year?
Yes
No
7 Don’t know / Not sure
9 Refused
Did {Do you/Does your child} eat red meat, such as beef, in the past year?
Yes
No
7 Don’t know / Not sure
9 Refused
Did {Do you/Does your child} eat seafood, such as fish, crab, or shrimp, in the past year?
Yes
No
7 Don’t know / Not sure
9 Refused
Did {Do you/Does your child} follow a Halal or Kosher diet in the past year?
1 Yes, Halal
2 Yes, Kosher
3 No
7 Don’t know / Not sure
9 Refused
{IF <2 YEARS OLD}
Does Did your child drink any breast milk in the past year?
Yes
No
7 Don’t know / Not sure
9 Refused
{IF <2 YEARS OLD}
Does Did your child drink any formula in the past year?
Yes
No
7 Don’t know / Not sure
9 Refused
Animal Contact Module—Version 1
Time estimate: 1.5m
Now I’d like to ask you a few questions about any animals, animal food, and animal settings {you/your child} may have had contact with in the past 7 days either in your home or elsewhere.
In the past 7 days, since [insert day, date], did {you/your child} have any contact with any of the following?
Y |
? |
N |
|
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Cat |
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Puppy (<6 months) |
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Dog older than puppy (≥6 months) |
|
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Lizard, including iguana or gecko |
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Turtle |
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Other reptile, such as snake |
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Amphibian, such as frog |
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Pet fish, including fish in an aquarium or pond |
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Other small mammalian household pet, such as hamster, or guinea pig, or hedgehog |
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Any pet that had diarrhea |
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Baby chick or duckling |
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Live poultry of any age, such as Other poultry including adult chicken or, duck, turkey, or goose |
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Other Bbirds, such as pet or wild birds, such as parrots or pigeons not including poultry |
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Cow, sheep, or goat |
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Pig |
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Commercial Ddry or wet dog or catpet food or treats |
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Canned or “wet” dog or cat food |
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Dog or cat “treats” |
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Store-bought raw pet food |
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Frozen or fresh feeder rodents |
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Pet store, petting zoo, ranch, or farm where there were animals present |
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Other event where animals were present, such as a fair, exhibit, or trade show |
Animal Contact Module—Version 2
Now I’d like to ask you a few questions about {your/your child’s} exposure to any animals in the past 7 days. Exposure includes touching the animal or the area where the animal is housed or being in a home, school room, or day care with the animal.
In the past 7 days, did {you/your child} have exposure to any of the following animals?
Y |
? |
N |
|
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|
Kitten (<6 months) |
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Cat (≥6 months) |
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Puppy (<6 months) |
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Dog (≥6 months) |
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Other small mammalian household pet, such as hamster or guinea pig |
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Bird, not including poultry |
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|
Lizard, including iguana or gecko |
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Turtle |
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Other reptile, such as snake |
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Amphibian, such as frog |
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|
Pet fish, including fish in an aquarium or pond |
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Any pet that had diarrhea |
Now, I’d like to ask you about other animals. Again, exposure includes touching the animal or the area where the animal is housed or being in a home or room with the animal.
In the past 7 days, did {you/your child} have exposure to any of the following animals?
Y |
? |
N |
|
|
|
|
Baby chick or duckling |
|
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|
Other poultry including adult chicken, duck, turkey, or goose |
|
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|
Cow |
|
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|
Sheep or goat |
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Pig |
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|
Horse |
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Other animal |
Lastly, I’d like to ask you about any animal settings {you/your child} may have visited.
In the past 7 days, did {you/your child} visit any of the following animal settings?
Y |
? |
N |
|
|
|
|
Pet store |
|
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Petting zoo |
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Ranch or farm with animals present |
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|
Other event where animals were present, such as a fair, exhibit, trade show, or live animal market |
Drinking and Recreational Water Module—Version 1
Time estimate: 1-1.5m
To be administered to 50% of respondents.
Now I’d like to ask you a few questions about the water {you drinkuse/your child drinksuses}. This includes drinking and recreational water.
Where does most of the water for {your/your child’s} home come from?
{READ}
Water from a utility, also known as municipal water or public water system Public or private water system
Individual or private well
Some other source, such as spring, cistern, lake, stream, or river
Bottled
{DO NOT READ}
7 Don’t know / Not sure
9 Refused
In the past 7 days, since [insert day, date], did {you/your child} drink any of the following kinds of waters at home, school, work, or other locations?
{READ} {YES = 1; NO = 2; DK = 7; RF = 9}
2_01 Tap water, directly from the faucet that was not filtered
2_02 Water from a refrigerator dispenser
2_03 Tap water that was filtered, such as in a pitcher, on a faucet, or under a sink
2_04 Bottled water
In the past 7 days, since [insert day, date], did you notice any of the following in {your/your child’s} home tap water?
{READ} {YES = 1; NO = 2; DK = 7; RF = 9}
3_01 Low water pressure
3_02 Loss of water service
3_03 Change in odor, taste, or color of your water
Now I’d like to ask you a question about the water that {you useenter/your child usesenters} tofor swimming, wade, or just relax in. This includes water in places such as an ocean, lake, hot tub/spa, pool, waterpark, water playground, or spray park, but not in a bathtub or shower.
In the past 30 days, since [insert date], did {you/your child} enter any water to swim in, wade in, or relax in, enter any recreational water such as an ocean, lake, hot tub/spa, or pool, waterpark, water playground, or spray park?
Yes
No {GO TO NEXT MODULE}
7 Don’t know / Not sure {GO TO NEXT MODULE}
9 Refused {GO TO NEXT MODULE}
4a. In the past 30 days, since [insert date], did {you/your child} enter any water to swim in, wade in, or relax in enter any water at an…
{READ} {YES = 1; NO = 2; DK = 7; RF = 9}
4a_01 Ocean beach
4a_02 Lake, pond, river, stream, or hot spring
4a_03 Hot tub or spa
4a_04 Swimming pool, waterpark, or water playground, or spray park (also known as an interactive fountain or splash pad)
4b. {ASK FOR EACH ‘YES’ RESPONSE IN Q4} On how many days did {you/your child} swim or enter {insert response from Q4a} in the past 30 days, since [insert date]?
___ ___ (##)
77 Don’t know / Not sure
99 Refused
Drinking and Recreational Water Module—Version 2
Time estimate: 1m
To be administered to 50% of respondents.
Now I’d like to ask you a few questions about the water {you used/your child useds} in the past 7 days [insert date, date]. This includes drinking and recreational water. For each question, my question will be “Iin the past 7 days, since [insert day, date], did {you/your child}… drink or use that water.”
Y |
? |
N |
|
|
|
|
Use water from a private well as the primary source of drinking water? |
|
|
|
Live in a home with a septic system? |
|
|
|
Swim, wade in, or enter an ocean, lake, pond, river, stream, or natural spring? |
|
|
|
Swim, wade in, or enter a pool, hot tub, spa, fountain, or waterpark with treated water, such as chlorinated? |
Travel Module
Time estimate: 10s
Now I would like to ask you about {your/your child’s} recent travel.
In the past 30 days, since [insert date], did {you/your child} travel outside the United States? {Include US territories}
Yes
No {GO TO NEXT MODULE}
7 Don’t know / Not sure {GO TO NEXT MODULE}
9 Refused {GO TO NEXT MODULE}
1a. Did {you/your child} take any antibiotics while traveling or in the 7 days after you returned? Please don’t include any antibiotics {you/your child} began taking before you traveled.
Yes
No {GO TO NEXT MODULE}
7 Don’t know / Not sure {GO TO NEXT MODULE}
9 Refused {GO TO NEXT MODULE}
1b. Did you get these antibiotics in the United States?
{READ}
Yes
No
{DO NOT READ}
7 Don’t know / Not sure
9 Refused
Health Module
Time estimate: 3-5.5m
The Adult and Child AGI modules will be conducted on a split sample:
50% of respondents will be given an AGI module assessing a 7-day history or AGI and
50% of respondents will be given an AGI module assessing a 30-day history of AGI.
Now I would like to ask you some questions about {your/your child’s} health and medical history. If you aren’t sure about an answer, you can say you don’t know and you can refuse to answer any question. First, I’ll ask about {your/your child’s} health in general, and then I’ll ask specifically about the last {7/30} days, since [insert day, date].
{Do you/Does your child} have any long-lasting or chronic illness or condition {an illness that has lasted longer than 1 month} in which diarrhea or vomiting is a major symptom, such as irritable bowel syndrome, ulcerative colitis {Co-lie-tis}, Crohn’s disease, or other stomach or esophagus problem?
Yes
No
7 Don’t know / Not sure
9 Refused
As far as you know, have you EVER been told by a physician that {you have/your child has} any condition that compromises your immune system such as HIV, AIDS, or an organ transplant?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
In the past {7/30} days, since [insert day, date], did {you/your child} take any of the following drugs or medical treatments?
{READ} {YES = 1; NO = 2; DK = 7; RF = 9}
3_01 Medicines that suppress stomach acid such antacids, Zantac, or Prilosec
3_02 Antibiotics, such as those used to treat or prevent an infection or for acne
3_031 Prednisone {pred-na-zone} or other steroid pill that you swallow
3_052 Chemotherapy for cancer
3_04 Medicines that suppress stomach acid such antacids, Zantac, or Prilosec
3_04 Antibiotics, such as those used to treat or prevent an infection or for acne
{Females >= 12 years old and <50 years old}
Were {you/your child} pregnant at any time during the past {7/30} days, since [insert day, date]?
Yes
No
7 Don’t know / Not sure
9 Refused
In the past {7/30} days, since [insert day, date], did {you/your child} have a household member with diarrhea, or did {you/your child} spend any time with someone with diarrhea? contact with a household member or other close contact with diarrhea?
Yes
No
7 Don’t know / Not sure
9 Refused
Interview script: Now I would like to ask you some questions about diarrhea {you/your child} may have experienced. If {you/your child} had more than one diarrheal illness in the last {7/30} days, we are interested in the most recent illness.
In the last {7/30} days, since [insert day, date], did {you/your child} have diarrhea? We consider diarrhea as having 3 or more loose stools in 24 hours.
Yes
No {GO TO Q7}
7 Don’t know / Not sure {GO TO Q7}
9 Refused {GO TO Q7}
6a. What was the maximum number of bowel movements with loose stools {you/your child} had in any 24-hour period? Please count one bowel movement as 1 sit-down on the toilet.
{READ}
1
2
3
4
5
More than 5
{DO NOT READ}
7 Don’t know / Not sure
9 Refused
6b. For how many days did {you/your child} have diarrhea during this most recent illness?
___ ___ {Enter number of days}
77 Don’t know / Not sure
99 Refused
6c. During this illness, did {you/your child} ever have bloody diarrhea? I mean blood mixed with the stool, not a streak of red blood on top of the stool. {Interview note: If respondent had more than one diarrheal illness in the last {7/30} days, since [insert day, date], we are interested in the most recent illness.}
Yes
No
7 Don’t know / Not sure
9 Refused
6d. Did {you/your child} have any vomiting with this diarrheal illness?
Yes
No {GO TO Q7}
7 Don’t know / Not sure {GO TO Q7}
9 Refused {GO TO Q7}
6e. For how many days did {you/your child} have both diarrhea and vomiting during this most recent illness?
__ __ {Enter number of days} {GO TO Q7a}
77 Don’t know {GO TO Q7a}
99 Refused {GO TO Q7a}
Interview script: Now I would like to ask you some questions about vomiting {you/your child} may have experienced. If {you/your child} had more than one vomiting illness in the last {7/30} days, we are interested in the most recent illness.
In the last {7/30} days, since [insert day, date], did {you/your child} have any vomiting? We consider vomiting as vomiting 1 or more times in 24 hours.
Yes
No {IF Q6=NO THEN GO TO Q16END MODULE; IF Q6=YES THEN GO TO Q8}
7 Don’t know / Not sure {IF Q6=NO THEN GO TO Q16END MODULE; IF Q6=YES THEN GO TO Q8}
9 Refused {IF Q6=NO THEN GO TO Q16END MODULE; IF Q6=YES THEN GO TO Q8}
7a. What was the maximum number of times that {you/your child} vomited in any 24-hour period?
{READ}
1
2
3
4
5
More than 5
{DO NOT READ}
Don’t know / Not sure
9 Refused
7b. For how many days did {you/your child} have vomiting during this most recent illness?
___ ___ {Enter number of days}
77 Don’t know / Not sure
99 Refused
Are {you/your child} still having any of the following?
{READ}
Vomiting
Diarrhea
3 Both diarrhea and vomiting
4 None of the above
{DO NOT READ}
7 Don’t know / Not sure
9 Refused
During this most recent illness, did {you/your child} also have any of the following? Interviewer note: If respondent had more than one diarrheal or vomiting illness in the last {7/30} days, since [insert day, date], we are interested in the most recent illness.
{READ} {YES = 1; NO = 2; DK = 7; RF = 9}
9_01 Sore throat
9_02 Cough
9_03 Fever
Did this illness begin during or within 30 days after any travel outside of the United States?
{READ}
Did not travel outside of the United States
Illness began during travel outside of the United States
Illness began within 30 days after travel outside of the United States
{DO NOT READ}
7 Don’t know / Not sure
9 Refused
Did {you/your child} visit a doctor, nurse, or other health professional for this illness? {Read only when necessary:} By “other health professional”, we mean a nurse practitioner, a physician’s assistant, or some other licensed health professional.
Yes
No {GO TO Q12}
7 Don’t know / Not sure {GO TO Q12}
9 Refused {GO TO Q12}
11a. Did {you/your child} visit any of the following places for this illness?
{READ} {YES = 1; NO = 2; DK = 7; RF = 9}
11a_01 Doctor’s office or clinic (includes after-hours clinic) {GO TO Q12}
11a_02 Urgent care, including Minute Clinic, Healthcare Clinic or other walk-in clinic {GO TO Q12}
11a_03 Emergency room
11a_04 Hospital
11a_05 Other care facility {GO TO Q12}
11b. Were {you/your child} admitted overnight to a hospital for this illness?
Yes
No {GO TO Q12}
7 Don’t know / Not sure {GO TO Q12}
9 Refused {GO TO Q12}
11c. How many nights did {you/your child} spend in the hospital?
___ ___ {Enter number of nights}
77 Don’t know / Not sure
99 Refused
As a result of this illness, were {you/your child} asked to give a stool sample for testing? This might have been in a cup or as a swab from where the stool comes out.
Yes
No {GO TO Q13}
7 Don’t know / Not sure {GO TO Q13}
9 Refused {GO TO Q13}
12a. As a result of this illness, did {you/your child} provide a stool sample for testing?
Yes
No
7 Don’t know / Not sure
9 Refused
Did this most recent illness keep {you/your child} from doing {your/his or her} usual activities? {Read only when necessary:} Examples of “usual activities” are: attending work, school, daycare, and social events.
Yes
No {GO TO Q14}
7 Don’t know / Not sure {GO TO Q14}
9 Refused {GO TO Q14}
13a. For how many days, did this most recent illness keep {you/your child} from doing {your/his or her} usual activities?
___ ___ {Enter number of days}
77 Don’t know / Not sure
99 Refused
Do you think the diarrhea or vomiting {you/your child} experienced was due to any of the following?
{READ} {YES = 1; NO = 2; DK = 7; RF = 9}
14_01 A dDigestive issue (you have/your child has) had for a long time, such as irritable bowel or colitis A diagnosed long-term illness such as irritable bowel syndrome or colitis
14_02 A food sensitivity
14_03 Medication or treatment
14_04 {if female and ≥>12 years of age} Pregnancy or menstrual-related
14_05 {if ≥>12 years of age} Alcohol consumption
14_06 Other ongoing digestive issues
Did {you/your child} take any antibiotics for this illness? Interviewer note: if child doesn’t know, ask them to please ask a parent}
Yes
No
7 Don’t know / Not sure
9 Refused
How often do {you/your child} have diarrhea that keeps {you/your child} from doing the usual activities? {Read only when necessary:} Examples of “usual activities” are attending work, school, daycare, and social events.
{READ}
More than once a month
Once a month
Every few months
Once or twice a year
Less than once a year
{DO NOT READ}
7 Don’t know / Not sure
9 Refused
Community Module
Time estimate: 2m
The next few questions are about you and your community.
What is {your/your child’s} age?
__ __ Years
{READ ONLY IF AGE IS ONE (1) year old or less} What is your child’s age in months? __ __ months
{Consistency check: If Q1 does not equal age in screener: “I want to make sure that I heard you correctly, you said that {you were/your child was} {insert age} years old. Is that correct?” 1=Yes, 2=No {restore Q1}}
What is {your/your child’s} gender?
Male
Female
7 Don’t know / Not sure
9 Refused
Including {yourself/your child}, how many people live in {your/your child’s} household?
__ __ Record response
77 Don’t know / Not sure
Refused
{Are you/Is your child} of Spanish, Hispanic, or Latino origin?
Yes
No
7 Don’t know / Not sure
9 Refused
Which of the following would you say is {your/your child’s} race?
{READ}
White
Black or African American
American Indian or Alaska Native
Asian (if selected, read and code subcategories)
4a. Asian Indian
4b. Chinese
4c. Filipino
4d. Japanese
4e. Korean
4f. Vietnamese
4g. Other Asian
Pacific Islander (if selected, read and code subcategories)
5a. Native Hawaiian
5b. Guamanian or Chamorro
5c. Samoan
5d. Other Pacific Islander
6 More than one of the above
{DO NOT READ}
77 Don’t know / Not sure
88 No additional choices
99 Refused
{INTERVIEWER for Q6:
PROXY interview:
Please read: Now we are going to ask some questions about you, not your child.
INDIVIDUAL BEING INTERVIEWED BET AGE 12 AND AGE 18:
Please read: Now we are going to ask some questions about your parents.
INDIVIDUAL BEING INTERVIEWED GREATER THAN 18 YEARS OF AGE:
Read question 6 AS IS}
What is the highest level of school {you/your parents} completed?
{READ IF NECESSARY}
Never attended school or only attended kindergarten
Some elementary school, grades 1 through 8
Some high school, grades 9 through 11
Graduated from high school or got GED
GED 1 to 3 years of cCollege or any technical school for 1 to 3 years
Graduated from college
{DO NOT READ}
Don’t know / Not sure
9 Refused
Now I am going to read you a list of income categories. Please stop me when a category best describes your total household income, before taxes, in 2015? Was it…
{If child does not know, ask them to ask their parents}
{READ}
Less than $15,000
$15,000 up to $25,000
$25,000 up to $40,000
$40,000 up to $55,000
$55,000 up to $75,000
$75,000 up to $100,000
More than $100,000
{DO
NOT READ}
77 Don’t
know / Not sure
{Do you/Does your child} have any medical insurance? {Interview: If child does not know, ask them to ask their parents. Include Medicaid, Medicare, HMO plans, PPO plans, etc.}
Yes
No
7 Don’t know / Not sure
9 Refused
Now I am going to read you a list of income categories. Please stop me when a category best describes your total household income, before taxes, in 2015? Was it…
{If child does not know, ask them to ask their parents}
{READ}
Less than $15,000
$15,000 up to $25,000
$25,000 up to $40,000
$40,000 up to $55,000
$55,000 up to $75,000
$75,000 up to $100,000
More than $100,000
{DO
NOT READ}
77 Don’t
know / Not sure
Which of the following places best describes where {you live/your child lives}?
{READ}
City or urban area
Suburban area
Town or village
Rural but not on a farm
On a farm
{DO NOT READ}
7 Don’t know / Not sure
9 Refused
{Do you/Does your child} currently live in any of the following settings?Which of the following best describes the setting in which {you/your child} currently lives?
{READ}
Nursing home or assisted living facility
Dormitory or other congregate setting such as military barracks
Tribal nation
OtherNone of the above
{DO NOT READ}
7 Don’t know / Not sure
9 Refused
What county {do you/does your child} live in?
Can either leave as fill in or as ANSI county code – might depend on admin mode
________________________ COUNTY or ANSI CODE
77 Don’t know / Not sure
99 Refused
What is the zip code where {you live/your child lives}?
__ __ __ __ __ZIP CODE
77 Don’t know / Not sure
99 Refused
{Consistency check: If Q101 does not equal sample size code, “I want to make sure that I heard you correctly. You stated that your zip code is _____?”}
{INTERVIEWER for Q11:
PROXY interview:
Please read: Now we are going to ask some questions about you, not your child.
INDIVIDUAL BEING INTERVIEWED BET AGE 12 AND AGE 18:
Please read: Now we are going to ask some questions about your parents.
INDIVIDUAL BEING INTERVIEWED GREATER THAN 18 YEARS OF AGE:
Read question 6 AS IS}
What is the highest level of school {you/your parents} completed?
{READ IF NECESSARY}
Never attended school or only attended kindergarten
Some elementary school, grades 1 through 8
Some high school, grades 9 through 11
Graduated from high school or got GED
1 to 3 years of college or any technical school
Graduated from college
{DO NOT READ}
Don’t know / Not sure
9 Refused
Now I am going to read you a list of income categories. Please stop me when a category best describes your total household income, before taxes, in 2015? Was it…
{If child does not know, ask them to ask their parents}
{READ}
Less than $15,000
$15,000 up to $25,000
$25,000 up to $40,000
$40,000 up to $55,000
$55,000 up to $75,000
$75,000 up to $100,000
More than $100,000
{DO
NOT READ}
77 Don’t
know / Not sure
99 Refused
Yogurts and Probiotics
50% of respondents asked about 7 day time period (same that are asked 7 day AGI module)
50% of respondents asked about 30 day time period (same that are asked 30 day AGI module)
The next few questions are about probiotics. Probiotics are live microorganisms (such as certain types of bacteria) that may benefit your health. These can take the form of pills, powders, yogurts, and other fermented dairy products, as well as anything labeled as containing “live and active cultures” or “probiotics.”
In the past {7/30} days, since [insert day, date], did {you/your child} take a probiotic, such as yogurt, fermented dairy products, capsules, pills, powders, or other foods and drinks labeled as containing “live and active cultures” or “probiotics”?
Yes
No {GO TO NEXT QUESTION)
7 Don’t know / Not sure {GO TO NEXT QUESTION)
9 Refused {GO TO NEXT QUESTION)
1a. What form of probiotic did {you/your child} take?
{READ} {YES = 1; NO = 2; DK = 7; RF = 9}
1a_01 Yogurt or yogurt drink
1a_02 Capsule, pill or powder
1a_03 Other “probiotic” foods or drinks
1b. {Only ask if 1a_02=1} Was the capsule, pill, or powder kept refrigerated at all times?
Yes
No
7 Don’t know / Not sure
9 Refused
1c. What is the main reason {you/your child} took a probiotic in the last {7/30} days?
{READ}
Because it’s good for me
Antibiotic use
International travel
Gastrointestinal symptoms (not related to antibiotic use or recent travel)
Other
7 Don’t know / Not sure
9 Refused
1d. In the past 7 days, since [insert day, date], how often did {you/your child} take a probiotic? {or}
On average, on how many days per week did {you/your child} take a probiotic in the past 30
days, since [insert day, date]?
1-3 days
4-6 days
Every day
Foods
Now I’d like to ask you about foods {you have/your child has} eaten recently. First, I’ll ask you about foods eaten in the past 14 days and then in the past 30 days. Unless I say, I am referring to both raw and cooked items. For each item, give me a “yes” or “no” if you remember eating or even tasting it during that time. It doesn’t matter whether the food was prepared at home or outside the home—ready?
Did {you/your child} eat any fresh raw cilantro in the past 14 days?
Yes
No
7 Don’t know / Not sure
9 Refused
Did {you/your child} eat any pea pods, snap peas, or snow peas in the past 14 days?
Yes
No
7 Don’t know / Not sure
9 Refused
Did {you/your child} eat any berries from a package of frozen berries in the past 30 days?
Yes
No
7 Don’t know / Not sure
9 Refused
Now I’d like to ask you about foods {you/your child} or anyone else
in {your/your child’s} household may have handled
in your home, whether or not {you/your child} ate it. I’m interested in whether anyone in {your/your child’s} household handled these foods, either fresh or frozen, in the past 7 days.
|
|
|
Raw poultry, fresh or frozen |
|
|
|
Raw beef, fresh or frozen |
|
|
|
Raw fish or seafood, fresh or frozen |
|
|
|
Raw wild game meat, fresh or frozen |
Raw Milk
In the past year, did {you/your child} drink any unpasteurized or raw milk?
Yes
No {GO TO NEXT MODULE}
7 Don’t know / Not sure {GO TO NEXT MODULE}
9 Refused {GO TO NEXT MODULE}
1a. How often do {you/your child} drink unpasteurized or raw milk?
{READ}
Most weeks
Every month
Every 2-3 months
Twice a year
Once a year
{DO NOT READ}
7 Don’t know/ Not sure
9 Refused
1b. Where {do you/does your child} get unpasteurized or raw milk?
{READ} {YES = 1; NO = 2; DK = 7; RF = 9}
1b_01 Through a cow- or goat-sharing program
1b_02 Directly from the farm
1b_03 At a farmer’s market or similar stand
1b_04 From cows or goats on your farm or a farm of someone you know
1b_05 Through a pet store, labeled as “pet food”
1b_06 Grocery store or retail market
1b_07 Other
Food Safety Module (≥18 years old)
Web-only administration
The next few questions are about how you prepare meals in your home.
Where you live, do you have a refrigerator and either a stove or microwave?
Yes
No {GO TO NEXT MODULE}
7 Don’t know / Not sure
9 Refused
How often do you prepare the main meal in your household? Do you prepare the main meal… When you eat cooked food at home, how often are you the one who cooks or prepares the food?
{READ}
All or nearly all of the time
Only some of the time
Never {GO TO Q3 THEN NEXT MODULE}
{DO NOT READ}
7 Don’t know / Not sure {GO TO Q3 THEN NEXT MODULE}
9 Refused {GO TO Q3 THEN NEXT MODULE}
Before you begin preparing food, how often do you wash your hands with soap?
{READ}
All of the time
Most of the time
Some of the time
Rarely
{DO NOT READ}
7 Don’t know / Not sure
9 Refused
When you cook food at home, do you ever prepare meals where you s tart with raw meat or chicken?
{READ}
1 Yes
2 No {GO TO NEXT MODULE}
7 Don’t know / Not sure {GO TO NEXT MODULE}
9 Refused {GO TO NEXT MODULE}
After handling raw meat or chicken, do you usually continue cooking, or do you first rinse your hands with water, or wipe them, or wash them with soap?
{READ}
1 Continue cooking
2 Rinse or wipe hands
3 Wash with soap
{DO NOT READ}
Never handle raw meat or chicken
7 Don’t know / Not sure
9 Refused
After you have used a cutting board or other surface for cutting raw meat or chicken, do you use it as is for food to be eaten raw for the same meal, or do you first rinse it, or wipe it, or wash it with soap?
{READ}
Use as it is
Rinse or wipe it
Wash with soap
{DO NOT READ}
Wash with bleach
Use a different board
Don’t cut raw meat or poultry
Don’t know / Not sure
9 Refused
In your home, are hamburgers usually served…{If different ways for different people: what is the rarest degree of doneness hamburgers are served?}
{READ}
Rare {GO TO Q11}
Medium-rare
Medium
Medium-well
Well done {GO TO Q11}
{DO NOT READ}
Hamburgers are never served {GO TO Q11}
Don’t know / Not sure {GO TO Q11}
9 Refused {GO TO Q11}
6a. When you say hamburgers are usually served “medium”, do you mean they are…
{READ}
Brown all the way through
Still have some pink in the middle
{DO NOT READ}
7 Don’t know / Not sure
9 Refused
Do you have a food thermometer, such as a meat thermometer?
Yes
No {GO TO Q11}
7 Don’t know / Not sure {GO TO Q11}
9 Refused {GO TO Q11}
Over the past 12 months, when you prepare roasts or other large pieces of meat, how often do you use a thermometer when you cook roasts?
{READ}
Always
Often
Sometimes
Never
{DO NOT READ}
5 Never cook the food
7 Don’t know / Not sure
9 Refused
Over the past 12 months, when you prepare chicken parts, such as breasts or legs, how often do you use a thermometer when you cook chicken parts?
{READ}
Always
Often
Sometimes
Never
{DO NOT READ}
Never cook the food
7 Don’t know / Not sure
9 Refused
Over the past 12 months, when you prepare hamburgers from any type of meat, how often do you use a thermometer when you cook hamburgers?
{READ}
Always
Often
Sometimes
Never
{DO NOT READ}
Never cook the food
7 Don’t know / Not sure
9 Refused
If you cook a large pot of soup, stew, or other food with meat or chicken and want to save it for the next day, when do you put the food in the refrigerator?
{READ}
Immediately {GO TO NEXT MODULE}
After first cooling it to room temperature
After first cooling it in cold water {GO TO NEXT MODULE }
{DO NOT READ}
Do not cook such foods {GO TO NEXT MODULE }
Would not refrigerate it {GO TO NEXT MODULE }
7 Don’t know / Not sure {GO TO NEXT MODULE }
9 Refused {GO TO NEXT MODULE }
11a. For about how long would you let it cool at room temperature?
{DO NOT READ}
Less than two hours
Two hours or more
7 Don’t know / Not sure
9 Refused
Chicken Module (≥18 years old)
Web-only administration
The next few questions are about how you prepare chicken dishes in your home. {If proxy} Please answer the next questions about yourself, not your child.
About how many times in the past 30 days, since [insert date], did someone buy raw fresh or frozen chicken for your household?
{READ}
More than weekly
Weekly
Once
Never {GO TO NEXT MODULE}
{DO NOT READ}
7 Don’t know / Not sure
9 Refused
{Remaining questions only asked of those ≥18 years, respondents or proxies}
In the last month, did you prepare any raw chicken?
Yes
No {GO TO NEXT MODULE}
7 Don’t know / Not sure {GO TO NEXT MODULE}
9 Refused {GO TO NEXT MODULE}
Now think to the last time you prepared chicken, what type did you make?
{READ}
Whole chicken (e.g., roaster)
Chicken parts (e.g., wings, legs, breasts, etc.)
{DO NOT READ}
7 Don’t know / Not sure
9 Refused
After you handled the packaging that held raw chicken, did you…
Continue cooking
Rinse or wipe hands
Wash hands with soap
7 Don’t know / Not sure
9 Refused
The last time you prepared raw chicken, was it initially…
{READ}
Fresh raw chicken
Frozen raw chicken {GO TO Q6}
{DO NOT READ}
7 Don’t know / Not sure {GO TO Q6}
9 Refused {GO TO Q4}
5a. About how long did you store the fresh raw chicken in the refrigerator before you cooked it?
Less than a day {GO TO Q7}
One day {GO TO Q7}
Two days {GO TO Q7}
Three days {GO TO Q7}
Four days {GO TO Q7}
Five or more days {GO TO Q7}
Don’t know / Not sure {GO TO Q7}
9 Refused {GO TO Q7}
The last time you prepared raw frozen chicken, how did you thaw it?
Microwave
Placed in refrigerator {GO TO Q6b}
Placed under running water {GO TO Q6c}
Placed in container of water in sink or on counter {GO TO Q6c}
Placed on counter {GO TO Q6d}
Did not thaw. Cooked from frozen. {GO TO Q7}
Don’t know / Not sure {GO TO Q7}
9 Refused {GO TO Q7}
6a. When you thawed the chicken in the microwave, did you cook it within an hour?
Yes {GO TO Q7}
No {GO TO Q7}
7 Don’t know / Not sure {GO TO Q7}
9 Refused {GO TO Q7}
6b. When you thawed the chicken in the refrigerator, how long did you leave it in the refrigerator before you cooked it?
Less than 24 hours {GO TO Q7}
24 to <48 hours (1 to <2 days) {GO TO Q7}
48 to <72 hours (2 to <3 days) {GO TO Q7}
72 or more (3 or more days) {GO TO Q7}
Don’t know / Not sure {GO TO Q7}
9 Refused
6c. When you thawed the chicken in the water, how long did you leave it in the water before you cooked it?
Less than an hour {GO TO Q7}
1 to <2 hours {GO TO Q7}
2 to <3 hours {GO TO Q7}
3 hours or more {GO TO Q7}
Don’t know / Not sure {GO TO Q7}
9 Refused
6d. When you thawed the chicken on the counter, how long did you leave it on the counter before you cooked it?
Less than an hour
1 to <2 hours
2 to <3 hours
3 hours or more
Don’t know / Not sure
9 Refused
7. What did you do after you used a cutting board for cutting raw chicken?
Use it as is to prepare items that will not be further cooked
Use it as is to prepare items that will be cooked
Rinse or wipe it and then use it to prepare items that will not be further cooked
Wash with soap and water and then use it to prepare the rest of the meal
Rinse or wash the cutting board and put it away
Did not use a cutting board
7 Don’t know / Not sure
9 Refused
8. What did you do with the knife after you used it for cutting raw chicken?
Use it as is to cut items that will not be further cooked
Use it as is to prepare items that will be cooked
Rinse or wipe it and then use it to prepare items that will not be further cooked
Wash it with soap and water and then use it to prepare the rest of the meal
Rinse or wash the knife and put it away
Did not use a knife
7 Don’t know / Not sure
9 Refused
After you handled the raw chicken, did you…
Continue cooking
Rinse or wipe your hands
Wash your hands with soap
7 Don’t know / Not sure
9 Refused
Site Modules
Web-only administration
Just a few more questions about the foods {you eat/your child eats}.
California {≥18 years old}
Did you shop at an Asian grocery store or market in the past 7 days, since [insert day, date]?
Yes
No
7 Don’t know / Not sure
9 Refused
Did you shop at a Hispanic grocery store or market in the past 7 days, since [insert day, date]?
Yes
No
7 Don’t know / Not sure
9 Refused
Did you dine in or take-out food from an Asian restaurant in the past 7 days, since [insert day, date]?
Yes
No
7 Don’t know / Not sure
9 Refused
Did you dine in or take-out food from a Hispanic restaurant in the past 7 days, since [insert day, date]?
Yes
No
7 Don’t know / Not sure
9 Refused
Did you purchase any meats from live animal markets in the past 7 days, since [insert day, date]?
Yes
No
7 Don’t know / Not sure
9 Refused
Do you follow a gluten-free or lactose-free diet? If so, which?
Yes, gluten-free
Yes, lactose-free
Yes, both
Neither
7 Don’t know / Not sure
9 Refused
Colorado
In the past 7 days, since [insert day, date], did {you/your child} eat any of the following?
Y |
? |
N |
|
|
|
|
Any meat (prepared or unprepared) that was from a carnicería or other specialty meat store |
|
|
|
Roasted green chile peppers such as Hatch or Pueblo chiles |
|
|
|
Dried red chiles such as chile Nuevo Mexico, chile California, or chile de arbol |
Connecticut
(if drank raw milk) Did {you/your child} see any labeling on the product describing possible health risks associated with drinking raw milk?
Yes
No
7 Don’t know / Not sure
9 Refused
(≥18 years old) How often do you look for or check health department inspection scores or ratings when you eat in a restaurant?
Always
Sometimes
Rarely
Never {GO TO NEXT MODULE}
Do not eat in restaurants {GO TO NEXT MODULE}
7 Don’t know / Not sure {GO TO NEXT MODULE}
9 Refused {GO TO NEXT MODULE}
2a. Where do you look for or check for the health department inspection score or rating?
{1 = Yes; 2 = No; 7 = DK/NS; 9 = RF}
2a_1 Posting at the restaurant
2a_2 Listing on a local health department website
2a_3 Listing on Yelp or other restaurant rating website
2a_4 Other
2b. How often does the inspection score or rating impact your decision to eat at a specific restaurant?
Always
Sometimes
Rarely
Never
7 Don’t know / Not sure
9 Refused
Georgia
Now I have a few questions about where the food came from that {you/your child} ate at home in the past 7 days. This isn’t necessarily where {you/your child} shopped during the week, but where what {you/your child} actually ate came from.
Did {you/your child} eat foods from any of the following in the past 7 days, since [insert day, date]?
Y |
? |
N |
|
|
|
|
Grocery stores or supermarkets |
|
|
|
Health food stores or co-ops |
|
|
|
Warehouse stores (such as Costco or Sam’s Club) |
|
|
|
Fish or meat specialty stores |
|
|
|
Farmer’s markets, roadside stands, open-air markets, or food purchased directly from a farm |
|
|
|
Other |
Now I have a few questions about where {you/your child} may have eaten outside of your home in the past 7 days, since [insert date].
Did {you/your child} eat at any of the following types of restaurants in the past 7 days, since [insert day, date]?
Y |
? |
N |
|
|
|
|
Barbeque-style restaurant |
|
|
|
Mexican-style restaurant |
Maryland
Are you or any members of your household employed in any of the following industries?
Y |
? |
N |
|
|
|
|
Poultry industry |
|
|
|
Fisheries/shellfish industry |
|
|
|
Farming such as of produce or grain (not dairy or other animals) |
|
|
|
Health care |
|
|
|
Food service |
|
|
|
Adult or child day care |
Minnesota
In the past 7 days, since [insert day, date], did {you/your child} live or work on a farm where there are livestock or poultry?
Yes
No
7 Don’t know / Not sure
9 Refused
In the past 7 days, since [insert day, date], did {you/your child} visit a farm where there are livestock or poultry?
Yes
No
7 Don’t know / Not sure
9 Refused
In the past 7 days, since [insert day, date], did {you/your child} visit a petting zoo, educational exhibit, fair, or other venue with animals?
Yes
No
7 Don’t know / Not sure
9 Refused
When {you/your child} buy produce from the grocery store, is it primarily organic?
Yes
No
7 Don’t know / Not sure
9 Refused
In the past 7 days, since [insert day, date], did {you/your child} eat food from any sandwich restaurants, like Subway or Jimmy John’s?
Yes
No
7 Don’t know / Not sure
9 Refused
New Mexico
In the past 7 days, since [insert day, date], did {you/your child} eat or even taste any of the following foods, either at home or away from your home?
Y |
? |
N |
|
|
|
|
Homemade beef jerky |
|
|
|
Homemade salsa from fresh ingredients |
|
|
|
Meat or poultry purchased at a farmer’s market |
|
|
|
Roasted chile peppers |
|
|
|
Any food from a roadside or traveling vendor |
New York {≥18 years old}
How often do you purchase foods labeled as organically grown and produced?
Always
Most of the time
Some of the time
Rarely
Don’t food shop
7 Don’t know / Not sure
9 Refused
How often do you purchase unpasteurized products (milk, cheese, yogurt, cider)?
Always
Most of the time
Some of the time
Rarely
Don’t food shop
7 Don’t know / Not sure
9 Refused
Oregon {≥18 years old}
In the past 7 days, since [insert day, date], did you consume any food, candy, snack, or beverage that contained marijuana, a marijuana extract, or marijuana infusion?
Yes
No
7 Don’t know / Not sure
9 Refused
Tennessee {≥18 years old}
Does the grocery you go to most often have sanitizing wipes at the entrance to the store?
Yes
No {GO TO NEXT MODULE}
7 Don’t know / Not sure {GO TO NEXT MODULE}
9 Refused {GO TO NEXT MODULE}
1a. Do you use them to wipe the grocery cart or basket?
Yes
No {GO TO NEXT MODULE}
7 Don’t know / Not sure {GO TO NEXT MODULE}
9 Refused {GO TO NEXT MODULE}
1b. Why do you use the wipes?
To prevent getting germs from other people who used the cart or basket
To preventing getting germs from the food that was carried in the basket previously
Both 1 and 2
7 Don’t know / Not sure
9 Refused
Closing Statement
That’s my last question. Thank you very much for your time and cooperation.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Marder, Ellyn P. (CDC/OID/NCEZID) (CTR) |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |