Attachment 4: Questionnaire Content of the BRFSS Feasibility Experiment
Modules:
Diabetes (with screening question from the core) [10 questions total]
Sodium and Salt-related Behavior [2 questions]
Home/ Self-measured Blood Pressure [4 questions]
Excess Sun Exposure [4 questions]
E-cigarettes (from 2018 questionnaire) [2 questions]
Marijuana (from 2018 questionnaire) [3 questions]
Form Approved
OMB No. (OMB #0920-1154)
Participation in this survey is voluntary. You do not have to answer any question you do not want to, and you can end the survey at any time. Any information you provide will not be connected to any personal information. Your responses will be used to assess the health status and health risk behaviors of people who reside in your state. If you have any questions about the survey, please call [XXX].
M03.01 MEDICARE
Do you have Medicare?
Read if necessary: Medicare is a coverage plan for people age 65 or over and for certain disabled people.
1 Yes
2 No
7 Don’t know/ not sure
9 Refused
M03.02 HLTHCVR1
What is the primary source of your health care coverage?
Interviewer note: If the respondent indicates that they purchased health insurance through the Health Insurance Marketplace (name of state Marketplace), ask if it was a private health insurance plan purchased on their own or by a family member (private) or if they received Medicaid (state plan)? If purchased on their own (or by a family member), select 02, if Medicaid select 04.
Read if necessary:
01 A plan purchased through an employer or union (including plans purchased through another person's employer)
02 A plan that you or another family member buys on your own
03 Medicare
04 Medicaid or other state program
05 TRICARE (formerly CHAMPUS), VA, or Military
06 Alaska Native, Indian Health Service, Tribal Health Services
Or
07 Some other source
08 None (no coverage)
Do not read:
77 Don't know/Not sure
99 Refused
M03.03 DELAYME1
Other than cost, have you delayed getting medical care for one of the following reasons in the past 12 months? Was it because…
Interviewer note: If respondent provides more than one reason, say: “Which was the most important reason you delayed getting care?”
Read:
1 You couldn’t get through on the telephone.
2 You couldn’t get an appointment soon enough.
3 Once you got there, you had to wait too long to see the doctor.
4 The clinic or doctor’s office wasn’t open when you got there.
5 You didn’t have transportation.
Do not read:
6 Other ____________ (specify) DLYOTHER
7 Don’t know/Not sure
8 No, I did not delay getting medical care/did not need medical care
9 Refused
C06.11 DIABETE3
Has a doctor, nurse, or other health professional ever told you that you had diabetes?
Interviewer note: If yes and respondent is female, ask: was this only when you were pregnant? If respondent says pre-diabetes or borderline diabetes, use response code 4.
1 Yes
2 Yes, but female told only during pregnancy (Go to next module)
3 No (Go to next module)
4 No, pre-diabetes or borderline diabetes (Go to next module)
7 Don’t know / Not sure (Go to next module)
9 Refused Go to next module)
M02.01 INSULIN
To be asked if response to Q06.11 is Yes (code 1)
Are you now taking insulin?
Read if necessary: Include times when checked by a family member or friend, but do not include times when checked by a health professional.
Interviewer note: If the respondent uses a continuous glucose monitoring system (a sensor inserted under the skin to check glucose levels continuously), fill in ‘98 times per day.’
1 Yes
2 No
7 Don’t know/ not sure
9 Refused
M02.02 BLDSUGAR
About how often do you check your blood for glucose or sugar?
Read if necessary: Include times when checked by a family member or friend, but do not include times when checked by a health professional.
Do not read: If the respondent uses a continuous glucose monitoring system (a sensor inserted under the skin to check glucose levels continuously), fill in ‘98 times per day.’
1 _ _ Times per day
2 _ _ Times per week
3 _ _ Times per month
4 _ _ Times per year
888 Never
777 Don’t know / Not sure
999 Refused
M02.03 FEETCHK3
Including times when checked by a family member or friend, about how often do you check your feet for any sores or irritations?
1 _ _ Times per day
2 _ _ Times per week
3 _ _ Times per month
4 _ _ Times per year
555 No feet
888 Never
777 Don’t know / Not sure
M02.04 DOCTDIAB
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]
88 None
77 Don’t know / Not sure
99 Refused
M02.05 CHKHEMO3
About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for A-one-C?
Read if necessary: A test for A-one-C measures the average level of blood sugar over the past three months.
_ _ Number of times [76 = 76 or more]
88 None
98 Never heard of A-one-C test
77 Don’t know / Not sure
99 Refused
M02.06 FEETCHK
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]
88 None
77 Don’t know / Not sure
99 Refused
If M02.03 = 555 (No feet), go to M02.07
M02.07 EYEEXAM1
When was the last time you had an eye exam in which the pupils were dilated, making you temporarily sensitive to bright light?
Read 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:
7 Don’t know / Not sure
8 Never
9 Refused
M02.08 DIABEYE
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
M02.09 DIABEDU
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
M17.01 WTCHSALT
Are you currently watching or reducing your sodium or salt intake?
1 Yes
2 No
7 Don’t know/ Not sure
9 Refused
M17.02 DRADVISE
Has a doctor or other health professional ever advised you to reduce sodium or salt intake?
1 Yes
2 No
7 Don’t know/ Not sure
9 Refused
M16.01 HOMBPCHK
Has your doctor, nurse or other health professional recommended you check your blood pressure outside of the office or at home?
Interviewer note: By other healthcare professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
M16.02 HOMRGCHK
Do you regularly check your blood pressure outside of your healthcare professional’s office or at home?
1 Yes
2 No (Go to next section)
7 Don’t know / Not sure (Go to next section)
9 Refused (Go to next section)
M16.03 WHEREBP
Do you take it mostly at home or on a machine at a pharmacy, grocery or similar location?
1 At home
2 On a machine at a pharmacy, grocery or similar location
3 Do not check it
7 Don’t know / Not sure
9 Refused
M16.04 SHAREBP
How do you share your blood pressure numbers that you collected with your health professional? Is it mostly by telephone, other methods such as emails, internet portal or fax, or in person?
Do not read:
1 Telephone
2 Other methods such as email, internet portal, or fax, or
3 In person
Do not read:
4 Do not share information
7 Don’t know / Not sure
9 Refused
M19.01 NUMBURN3
During the past 12 months, how many times have you had a sunburn?
_ _ _ Number (0-365)
777 Don’t know/ Not sure
999 Refused
M19.02 SUNPRTCT
When you go outside on a warm sunny day for more than one hour, how often do you protect yourself from the sun? Is that….
Interviewer note: Protection from the sun may include using sunscreen, wearing a wide-brimmed hat, or wearing a long-sleeved shirt.
Read:
1 Always
2 Most of the time
3 Sometimes
4 Rarely
5 Never
Do not read:
6 Don’t stay outside for more than one hour on warm sunny days
8 Don’t go outside at all on warm sunny days
7 Don’t know/ Not sure
9 Refused
M19.03 WKDAYOUT
On weekdays, in the summer, how long are you outside per day between 10am and 4pm?
Interviewer note: Friday is a weekday. If respondent says never, code 01.
01 Less than half an hour
02 (More than half an hour) up to 1 hour
03 (More than 1 hour) up to 2 hours
04 (More than 2 hours) up to 3 hours
05 (More than 3 hours) up to 4 hours
06 (More than 4 hours) up to 5 hours
07 (More than 5) up to 6 hours
77 Don’t know/ Not sure
99 Refused
M19.04 WKENDOUT
On weekends in the summer, how long are you outside each day between 10am and 4pm?
Interviewer note: Friday is a weekday. If respondent says never, code 01.
01 Less than half an hour
02 (More than half an hour) up to 1 hour
03 (More than 1 hour) up to 2 hours
04 (More than 2 hours) up to 3 hours
05 (More than 3 hours) up to 4 hours
06 (More than 4 hours) up to 5 hours
07 (More than 5) up to 6 hours
77 Don’t know/ Not sure
99 Refused
M06.01 ECIGARET
Have you ever used an e-cigarette or other electronic vaping product, even just one time, in your entire life?
Read if necessary: Electronic cigarettes (e-cigarettes) and other electronic vaping products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy.
Interviewer note: These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.
1 Yes
2 No (Go to next module)
7 Don’t know/Not sure (Go to next module)
9 Refused (Go to next module)
M06.02 ECIGNOW
Do you now use e-cigarettes or other electronic vaping products every day, some days, or not at all?
Interviewer note: These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.
1 Every day
2 Some days
3 Not at all
7 Don’t know / Not sure
Marijuana Use (Module 7*)
M07.01 MARIJAN1
During the past 30 days, on how many days did you use marijuana or cannabis?
_ _
01-30 Number of days
88 None (Go to end)
77 Don’t know/not sure (Go to end)
99 Refused (Go to end)
M07.02 USEMRJN2
During the past 30 days, which one of the following ways did you use marijuana the most often? Did you usually…
Interviewer note: Select one. If respondent provides more than one, say: which way did you use it most often.
Read:
1 Smoke it (for example, in a joint, bong, pipe, or blunt).
2 Eat it (for example, in brownies, cakes, cookies, or candy)
3 Drink it (for example, in tea, cola, or alcohol)
4 Vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device)
5 Dab it (for example, using waxes or concentrates), or
6 Use it some other way.
Do not read:
7 Don’t know/not sure
9 Refused
M07.03 RSNMRJN1
When you used marijuana or cannabis during the past 30 days, was it usually:
Read:
1 For medical reasons (like to treat or decrease symptoms of a health condition);
2 For non-medical reasons (like to have fun or fit in), or
3 For both medical and non-medical reasons.
Do not read:
7 Don’t know/Not sure
9 Refused
Content for programming 2019 BRFSS Pilot
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