ACBS Consent and Survey - adult

Attachment 5e –

ACBS ADULT Consent and Survey – 2013

_______________________________________________________________________________

Section Subject Page

Section 1 Introduction……........................................................... 02

Section 2 Informed Consent.......................................................... 03

Section 3 Recent History.............….................................…….…. 05

Section 4 History of Asthma (Symptoms & Episodes)............… 07

Section 5 Health Care Utilization.................................................. 10

Section 6 Knowledge of Asthma/Management Plan..................... 14

Section 7 Modifications to Environment....................................... 16

Section 8 Medications........................... ......................................… 21

Section 9 Cost of Asthma Care ....................……….…………… 32

Section 10 Work Related Asthma ………………………………… 33

Section 11 Comorbid Conditions................................................................... 37

Section 12 Complimentary and Alternative Therapies………… 38

______________________________________________________________________________

Section 1. Introduction

INTRODUCTION TO THE Asthma call-back for Adult respondents with asthma:

Hello, my name is ________________. I’m calling on behalf of the {STATE NAME} health department and the Centers for Disease Control and Prevention about an asthma {ALTERNATE: a health} study we are doing in your state. During a recent phone interview {sample person first name or initials} indicated {he/she} would be willing to participate in this study.

ALTERNATE (no reference to asthma):

Hello, my name is ________________. I’m calling on behalf of the {STATE NAME} health department and the Centers for Disease Control and Prevention about a health study we are doing in your state. During a recent phone interview {sample person first name or initials} indicated {he/she} would be willing to participate in this study.

1. Are you {sample person’s name}?

1. Yes (go to informed consent)

2. No

2. May I speak with {sample person’s name}?

1. Yes (go to 1.4 when sample person comes to phone)

2. No

If not available set time for return call in 1.3

1.3 Enter time/date for return call _________________

1.4 Hello, my name is ________________. I’m calling on behalf of the {STATE NAME} state health department and the Centers for Disease Control and Prevention about an asthma study we are doing in your state. During a recent phone interview you indicated that you had asthma and would be able to complete the follow-up interview on asthma at this time.

ALTERNATE (no reference to asthma):

Hello, my name is ________________. I’m calling on behalf of the {STATE NAME} state health department and the Centers for Disease Control and Prevention about a health study we are doing in your state. During a recent phone interview you indicated that you would be able to complete the follow-up interview at this time.

CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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-xxxx).

Section 2: Informed Consent

INFORMED CONSENT

Before we continue, I’d like you to know that this survey is authorized by the U.S. Public Health Service Act

You were selected to participate in this study about asthma because of your responses to questions in a prior survey.

[If “yes” to lifetime and “no” to still in Core BRFSS survey, read:]

Your answers to the asthma questions during the earlier survey indicated that a doctor or other health professional told you that you had asthma sometime in your life, but you do not have it now. Is that correct?

(IF YES, READ:) (IF NO, Go to REPEAT (2.0)

Since you no longer have asthma, your interview will be very brief (about 5 minutes). You may choose not to answer any question you don’t want to answer or stop at any time. In order to evaluate my performance, my supervisor may listen as I ask the questions. I’d like to continue now unless you have any questions. [Go to section 3]

[If “yes” to lifetime and “yes” to still in Core BRFSS survey, read:]

Your answers to the asthma questions in the earlier survey indicated that that a doctor or other health professional told you that you had asthma sometime in your life, and that you still have asthma. Is that correct?

(IF YES, READ:) (IF NO, Go to REPEAT (2.0)

Since you have asthma now, your interview will last about 15 minutes. You may choose not to answer any question you don’t want to answer or stop at any time. In order to evaluate my performance, my supervisor may listen as I ask the questions. I’d like to continue now unless you have any questions. [Go to section 3]

REPEAT (2.0) (Respondent did not agree with previously BRFSS recorded asthma status so double check if correct person from core survey is on phone.)

Ask:

Is this {sample person’s name} and are you {sample person’s age} years old?

1. Yes [continue to EVER_ASTH (2.1)]

2. No

   1. Correct person is available and can come to phone [return to question 1.1]

   2. Correct person is not available [return to question 1.3 to set call date/time]

   3. Correct person unknown, interview ends [disposition code 306 is assigned]

EVER_ASTH (2.1) I would like to repeat the questions from the previous survey now to make sure you qualify for this study.

Have you ever been told by a doctor or other health professional that you have asthma?

(1) YES

(2) NO [Go to TERMINATE]

(7) Don’t know [Go to TERMINATE]

(9) Refused [Go to TERMINATE]

CUR_ASTH (2.2) Do you still have asthma?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

READ: You do qualify for this study, I’d like to continue unless you have any questions.

You may choose not to answer any question you don’t want to answer or stop at any time. In order to evaluate my performance, my supervisor may listen as I ask the questions

[If YES to 2.2 read:]

Since you have asthma now, your interview will last about 15 minutes. [Go to section 3]

[If NO to 2.2 read:]

Since you do not have asthma now, your interview will last about 5 minutes. [Go to section 3]

[If Don’t know or refused to 2.2 read:]

Since you are not sure if you have asthma now, your interview will probably last about 10 minutes. [Go to section 3]

Some states may require the following section before going to section 3:

READ: Some of the information that you shared with us when we called you before could be useful in this study.

PERMISS (2.3) May we combine your answers to this survey with your answers from the survey you did a few weeks ago?

(1) YES (Skip to Section 3)

(2) NO (GO TO TERMINATE)

(7) DON’T KNOW (GO TO TERMINATE)

9. REFUSED (GO TO TERMINATE)

TERMINATE:

Upon survey termination, READ:

Those are all the questions I have. I’d like to thank you on behalf of the {STATE NAME} Health Department and the Centers for Disease Control and Prevention for answering these questions. If you have any questions about this survey, you may call my supervisor toll-free at 1 – xxx-xxx-xxxx. If you have questions about your rights as a survey participant, you may call the chairman of the Institutional Review Board at 1‑800‑xxx-xxxx. Thanks again. Goodbye

Section 3. Recent History

AGEDX (3.1) How old were you when you were first told by a doctor or other health professional that you had asthma?

__ __ __(ENTER AGE IN YEARS)

(777) DON’T KNOW

(888) under one year old

(999) REFUSED

INCIDNT (3.2) How long ago was that? Was it ..” READ CATEGORIES

1. Within the past 12 months

2. 1-5 years ago

3. more than 5 years ago

7. DON’T KNOW

9. REFUSED

LAST_MD (3.3) How long has it been since you last talked to a doctor or other health professional about your asthma? This could have been in your doctor’s office, the hospital, an emergency room or urgent care center.

[INTERVIEWER: READ RESPONSE OPTIONS IF NECESSARY]

[INTERVIEWER: OTHER PROFESSIONAL INCLUDES HOME NURSE]

(88) Never

(04) Within the past year

(05) 1 YEAR to less than 3 years ago

(06) 3 YEARS to 5 years ago

(07) More than 5 years ago

(77) DON’T KNOW

(99) REFUSED

LAST_MED (3.4) How long has it been since you last took asthma medication?

[INTERVIEWER: READ RESPONSE OPTIONS IF NECESSARY]

(88) Never

(01) Less than one day ago

(02) 1-6 days ago

(03) 1 week to less than 3 months ago

(04) 3 months to less than 1 year ago

(05) 1 YEAR to less than 3 years ago

(06) 3 YEARS to 5 years ago

(07) More than 5 years ago

(77) Don’t Know

(99) Refused

INTRODUCTION FOR LASTSYMP:

READ: Symptoms of asthma include coughing, wheezing, shortness of breath, chest tightness or phlegm production when you do not have a cold or respiratory infection.

LASTSYMP (3.5) How long has it been since you last had any symptoms of asthma?

[INTERVIEWER: READ RESPONSE OPTIONS IF NECESSARY]

(88) Never

(01) Less than one day ago

(02) 1-6 days ago

(03) 1 week to less than 3 months ago

(04) 3 months to less than 1 year ago

(05) 1 YEAR to less than 3 years ago

(06) 3 YEARS to 5 years ago

(07) More than 5 years ago

(77) Don’t Know

(99) Refused

Section 4. History of Asthma (Symptoms & Episodes in past year)

[SKIP: If the response to last symptoms (LASTSYMP, question 3.5) was 3 months to 1 year ago, then the respondent skips to episode introduction (EPIS_INT between question 4.4 and 4.5).]

[SKIP: If the response to last symptoms (LASTSYMP) was 1-5+ years ago or “never,” then the respondent skips to Section 5.]

[CONTINUE: If the response to last symptoms (LASTSYMP) was within the past 3 months, “Don’t know” or “Refused” then the respondent continues.]

SYMP_30D (4.1) During the past 30 days, on how many days did you have any symptoms of asthma?



__ __DAYS

[1-29, 77, 99] [SKIP TO 4.3 ASLEEP30]

(88) NO SYMPTOMS IN THE PAST 30 DAYS [SKIP TO EPIS_INT]

(30) EVERY DAY [CONTINUE]

(77) DON’T KNOW [SKIP TO 4.3 ASLEEP30]

(99) REFUSED [SKIP TO 4.3 ASLEEP30]

DUR_30D (4.2) Do you have symptoms all the time? “All the time” means symptoms that continue throughout the day. It does not mean symptoms for a little while each day.

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

ASLEEP30 (4.3) During the past 30 days, on how many days did symptoms of asthma make it difficult for you to stay asleep?

__ __ DAYS/NIGHTS

(88) NONE

(30) EVERY DAY (Added 1/24/08)

(77) DON’T KNOW

(99) REFUSED

SYMPFREE (4.4) During the past two weeks, on how many days were you completely symptom-free, that is no coughing, wheezing, or other symptoms of asthma?

__ __ Number of days

(88) NONE

(77) DON’T KNOW

(99) REFUSED

[RESUME: If the response to last symptoms (question 3.5) was 3 months to 1 year ago (LASTSYMP = 4) respondent resumes interview here.]

[CONTINUE: If the response to last symptoms was within the past 3 months, don’t know or refused (LASTSYMP = 1, 2, 3, 77, or 99), respondent continues. (Respondents with no symptoms in the past year were skipped to section 5.)]

EPIS_INT READ: Asthma attacks, sometimes called episodes, refer to periods of worsening asthma symptoms that make you limit your activity more than you usually do, or make you seek medical care.

EPIS_12M (4.5) During the past 12 months, have you had an episode of asthma or an asthma attack?

(1) YES

(2) NO [SKIP TO INS1 (section 5)]

(7) DON’T KNOW [SKIP TO INS1 (section 5)]

(9) REFUSED [SKIP TO INS1 (section 5)]

EPIS_TP (4.6) During the past three months, how many asthma episodes or attacks have you had?

__ __ __

(888) NONE

(777) DON’T KNOW

(999) REFUSED

DUR_ASTH (4.7) How long did your MOST RECENT asthma episode or attack last?

1_ _ Minutes

2_ _ Hours

3_ _ Days

4_ _ Weeks

5 5 5 Never

7 7 7 Don’t know / Not sure

9 9 9 Refused

COMPASTH (4.8) Compared with other episodes or attacks, was this most recent attack shorter, longer, or about the same?

1. SHORTER

2. LONGER

3. ABOUT THE SAME

4. THE MOST RECENT ATTACK WAS ACTUALLY THE FIRST ATTACK

7. DON’T KNOW

9. REFUSED

Section 5. Health Care Utilization

[RESUME: All respondents continue the interview here.]

INS1 (5.01) Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare or Medicaid?

(1) YES [continue]

(2) NO [SKIP TO NER_TIME]

(7) DON’T KNOW [SKIP TO NER_TIME]

(9) REFUSED [SKIP TO NER_TIME]

INS2 (5.02) During the past 12 months was there any time that you did not have any health insurance or coverage?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[SKIP: If the respondent does not currently have asthma (responded “no,” “don’t know” or “refused” to the ACBS question CUR_ASTH, if asked, or if not asked, to the BRFSS core question “do you still have asthma?”) and has not seen a doctor (LAST_MD), has not had asthma symptoms (LASTSYMP) and has not taken asthma medication (LAST_MED) in the past year, the respondent skips to section 6.]

[SKIP: If the respondent does not currently have asthma (responded “no,” “don’t know” or “refused” to the ACBS question CUR_ASTH, if asked, or if not asked, to the BRFSS core question “do you still have asthma?”) and has not seen a doctor (LAST_MD) in the past year but has had symptoms (LASTSYMP) or taken medication (LAST_MED) in the past year, the respondent skips to question 5.8A MISS_DAY.]

[CONTINUE: If the respondent does not currently have asthma (responded “no,” “don’t know” or “refused” to ACBS question CUR_ASTH, if asked, or if not asked, to the BRFSS core question “do you still have asthma?”) and has had asthma symptoms (LASTSYMP) or taken asthma medication (LAST_MED) in the past year, the respondent continues with section 5, question 5.1 NER_TIME.]

[SKIP: If the respondent currently has asthma (responded “yes” to the ACBS question CUR_ASTH if asked, or if not asked, to the BRFSS core question “do you still have asthma?” but has not seen a doctor (LAST_MD) in the past year the respondent skips to question 5.8A MISS_DAY.]

[CONTINUE: If the respondent currently has asthma (responded “yes” to the ACBS question CUR_ASTH if asked, or if not asked, to the BRFSS core question “do you still have asthma?” and has seen a doctor in the past year, the respondent continues with section 5 question 5.1 NER_TIME .]

NER_TIME (5.1) During the past 12 months how many times did you see a doctor or other health professional for a routine checkup for your asthma?

__ __ __ ENTER NUMBER

(888) NONE

(777) DON’T KNOW

(999) REFUSED

ER_VISIT (5.2) An urgent care center treats people with illnesses or injuries that must be addressed immediately and cannot wait for a regular medical appointment. During the past 12 months, have you had to visit an emergency room or urgent care center because of your asthma?

(1) YES

(2) NO [SKIP TO URG_TIME]

(7) DON’T KNOW [SKIP TO URG_TIME]

(9) REFUSED [SKIP TO URG_TIME]

ER_TIMES (5.3) During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma?

__ __ __ ENTER NUMBER

(888) NONE (Skip back to 5.2)

(777) DON’T KNOW

(999) REFUSED

[HELP SCREEN: An urgent care center treats people with illnesses or injuries that must be addressed immediately and cannot wait for a regular medical appointment.]

URG_TIME (5.4) [IF ONE OR MORE ER VISITS (ER_TIMES (5.3)) INSERT “Besides those emergency room or urgent care center visits,”]

During the past 12 months, how many times did you see a doctor or other health professional for urgent treatment of worsening asthma symptoms or for an asthma episode or attack?

__ __ __ ENTER NUMBER

(888) NONE

(777) DON’T KNOW

(999) REFUSED

[HELP SCREEN: An urgent care center treats people with illnesses or injuries that must be addressed immediately and cannot wait for a regular medical appointment.]

[SKIP: If the response to LASTSYMP is never or more than one year ago, then respondent skips to MISS_DAY. Respondents who have not had symptoms in the past year skip the questions on hospital stays.]

HOSP_VST (5.5) During the past 12 months, that is since [1 YEAR AGO TODAY], have you had to stay overnight in a hospital because of your asthma? Do not include an overnight stay in the emergency room.

(1) YES

(2) NO [SKIP TO MISS_DAY]

(7) DON’T KNOW [SKIP TO MISS_DAY]

(9) REFUSED [SKIP TO MISS_DAY]

HOSPTIME (5.6A) During the past 12 months, how many different times did you stay in any hospital overnight or longer because of your asthma?

__ __ __ TIMES

(777) DON’T KNOW

(999) REFUSED

HOSPPLAN (5.7) The last time you left the hospital, did a health professional TALK with you about how to prevent serious attacks in the future?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators. This should not be coded yes if the respondent only received a pamphlet or instructions to view a website or video since the question clearly states “talk with you”.]

[RESUME: Respondents who have not seen an MD in the past year but have had symptoms resume the interview here]

MISS_DAY (5.8A) During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma?

[INTERVIEWER: If response is, “I don’t work”, emphasize USUAL ACTIVITIES”]

__ __ __ENTER NUMBER DAYS

(888) ZERO

(777) DON’T KNOW

(999) REFUSED

ACT_DAYS30 (5.9) During just the past 30 days, would you say you limited your usual activities due to asthma not at all, a little, a moderate amount, or a lot?

[NOTE: the wording for this question was changed in 2012 and is no longer comparable to ACT_DAYS from prior survey years.]

(1) NOT AT ALL

(2) A LITTLE

(3) A MODERATE AMOUNT

(4) A LOT

(7) DON’T KNOW

(9) REFUSED

Section 6. Knowledge of Asthma/Management Plan

[RESUME: All respondents continue the interview here.]

TCH_SIGN (6.1) Has a doctor or other health professional ever taught you...

a. How to recognize early signs or symptoms of an asthma episode?

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

TCH_RESP (6.2) Has a doctor or other health professional ever taught you...

b. What to do during an asthma episode or attack?

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

TCH_MON (6.3) A peak flow meter is a hand held device that measures how quickly you can blow air out of your lungs. Has a doctor or other health professional ever taught you…

c. How to use a peak flow meter to adjust your daily medications?

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

MGT_PLAN (6.4) An asthma action plan, or asthma management plan, is a form with instructions about when to change the amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room.

Has a doctor or other health professional EVER given you an asthma action plan?

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

MGT_CLAS (6.5) Have you ever taken a course or class on how to manage your asthma?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

Section 7. Modifications to Environment

[All respondents continue the interview.]

HH_INT READ: The following questions are about your household and living environment. I will be asking about various things that may be related to experiencing symptoms of asthma.

AIRCLEANER (7.1) An air cleaner or air purifier can filter out pollutants like dust, pollen, mold and chemicals. It can be attached to the furnace or free standing. It is not, however, the same as a normal furnace filter.

Is an air cleaner or purifier regularly used inside your home?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

DEHUMID (7.2) A dehumidifier is a small, portable appliance which removes moisture from the air.

Is a dehumidifier regularly used to reduce moisture inside your home?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

KITC_FAN (7.3) Is an exhaust fan that vents to the outside used regularly when cooking in your kitchen?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

COOK_GAS (7.4) Is gas used for cooking?

(1) Yes

(2) NO

(7) DON’T KNOW

(9) REFUSED

ENV_MOLD (7.5) In the past 30 days, has anyone seen or smelled mold or a musty odor inside your home? Do not include mold on food.

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

ENV_PETS (7.6) Does your household have pets such as dogs, cats, hamsters, birds or other feathered or furry pets that spend time indoors?

(1) YES

(2) NO (SKIP TO 7.8)

(7) DON’T KNOW (SKIP TO 7.8)

(9) REFUSED (SKIP TO 7.8)

PETBEDRM (7. 7) Are pets allowed in your bedroom?

(1) YES

(2) NO

(3) SOME ARE/SOME AREN’T

(7) DON’T KNOW

(9) REFUSED

C_ROACH (7.8) In the past 30 days, has anyone seen a cockroach inside your home?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: Studies have shown that cockroaches may be a cause of asthma. Cockroach droppings and carcasses can also cause symptoms of asthma].

C_RODENT (7.9) In the past 30 days, has anyone seen mice or rats inside your home? Do not include mice or rats kept as pets.

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: Studies have shown that rodents may be a cause of asthma.]

WOOD_STOVE (7.10) Is a wood burning fireplace or wood burning stove used in your home?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: OCCASIONAL USE SHOULD BE CODED AS “YES”.]

GAS_STOVE (7.11) Are unvented gas logs, unvented gas fireplaces, or unvented gas stoves used in your home?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: “Unvented” means no chimney or the chimney flue is kept closed during operation.]

S_INSIDE (7.12) In the past week, has anyone smoked inside your home?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: “The intent of this question is to measure smoke resulting from tobacco products (cigarettes, cigars, pipes) or illicit drugs (cannabis, marijuana) delivered by smoking (inhaling intentionally). Do not include things like smoke from incense, candles, or fireplaces, etc.]”

MOD_ENV (7.13) Interviewer READ: Now, back to questions specifically about you.

Has a health professional ever advised you to change things in your home, school, or work to improve your asthma?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]

MATTRESS (7.14) Do you use a mattress cover that is made especially for controlling dust mites?

[INTERVIEWER: If needed: This does not include normal mattress covers used for padding or sanitation (wetting). These covers are for the purpose of controlling allergens (like dust mites) from inhabiting the mattress. They are made of special fabric, entirely enclose the mattress, and have zippers.]

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

E_PILLOW (7.15) Do you use a pillow cover that is made especially for controlling dust mites?

[INTERVIEWER: If needed: This does not include normal pillow covers used for fabric protection. These covers are for the purpose of controlling allergens (like dust mites) from inhabiting the pillow. They are made of special fabric, entirely enclose the pillow, and have zippers.]

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

CARPET (7.16) Do you have carpeting or rugs in your bedroom? This does not include throw rugs small enough to be laundered.

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

HOTWATER (7.17) Are your sheets and pillowcases washed in cold, warm, or hot water?

(1) COLD

(2) WARM

(3) HOT

DO NOT READ

(4) VARIES

(7) DON’T KNOW

(9) REFUSED

BATH_FAN (7.18) In your bathroom, do you regularly use an exhaust fan that vents to the outside?

(1) YES

(2) NO OR “NO FAN”

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: IF RESPONDENT INDICATES THEY HAVE MORE THAN ONE BATHROOM, THIS QUESTION REFERS TO THE BATHROOM THEY USE MOST FREQUENTLY FOR SHOWERING AND BATHING.]

Section 8. Medications

[SKIP: If respondent has never taken asthma medication (LAST_MED = 88 NEVER), respondent skips to Section 9]

OTC (8.1) The next set of questions is about medications for asthma. The first few questions are very general, but later questions are very specific to your medication use.

Over-the-counter medication can be bought without a doctor’s order. Have you ever used over-the-counter medication for your asthma?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

INHALERE (8.2) Have you ever used a prescription inhaler?

(1) YES

(2) NO [SKIP TO SCR_MED1]

(7) DON’T KNOW [SKIP TO SCR_MED1]

(9) REFUSED [SKIP TO SCR_MED1]

INHALERH (8.3) Did a doctor or other health professional show you how to use the inhaler?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]

INHALERW (8.4) Did a doctor or other health professional watch you use the inhaler?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[SKIP: If respondent has not taken asthma medication in the past 3 months (LAST_MED = 4, 5, 6, 7, 77, or 99), respondent skips to Section 9.]

SCR_MED1 (8.5) Now I am going to ask questions about specific prescription medications you may have taken for asthma in the past 3 months. I will be asking for the names, amount, and how often you take each medicine. I will ask separately about medication taken in various forms: pill or syrup, inhaler, and Nebulizer.

It will help to get your medicines so you can read the labels.

Can you please go get the asthma medicines while I wait on the phone?

1. YES

2. NO [SKIP TO INH_SCR]

3. RESPONDENT KNOWS THE MEDS [SKIP TO INH_SCR]

7. DON’T KNOW [SKIP TO INH_SCR]

9. REFUSED [SKIP TO INH_SCR]

SCR_MED3 (8.7) [when Respondent returns to phone:] Do you have all the medications?

[INTERVIEWER: Read if necessary]

1. YES I HAVE ALL THE MEDICATIONS

2. YES I HAVE SOME OF THE MEDICATIONS BUT NOT ALL

3. NO

7. DON’T KNOW

9. REFUSED

[SKIP: If respondent has never used an inhaler, (8.2 INHALERE= 2 NO) the respondent skips to PILLS]

INH_SCR (8.8) In the past 3 months have you taken prescription asthma medicine using an inhaler?

(1) YES

(2) NO [SKIP TO PILLS]

(7) DON’T KNOW [SKIP TO PILLS]

(9) REFUSED [SKIP TO PILLS]

INH_MEDS (8.9) In the past 3 months, what prescription asthma medications did you take by inhaler? [MARK ALL THAT APPLY. PROBE: Any other prescription asthma inhaler medications?]

[INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION. MARK ALL THAT APPLY. PROBE: Any other prescription asthma inhaler medications?]

[Note: For the following inhalers the respondent can report up to eight medications; each medication can only be reported once. When 66 (Other) is selected as a response, the series of questions ILP03 (8.13) to ILP10 (8.19) is not asked for that response. Numbers 37, 38, 39, 40, 41, and 42 are medications that were added in 2008. Number 25 was changed from Pulmicort Turbuhaler to Pulmicort Flexhaler in 2012. Numbers 43 and 44 were added in 2013. Brethaire, Intal and Tilade were dropped in 2013.]

	Medication	Pronunciation
01	Advair (+ A. Diskus)	ăd-vâr (or add-vair)
02	Aerobid	â-rō'bĭd (or air-row-bid)
03	Albuterol ( + A. sulfate or salbutamol)	ăl'-bu'ter-ōl (or al-BYOO-ter-ole) săl-byū'tə-môl'
04	Alupent	al-u-pent
43	Alvesco (+ Ciclesonide)	al-ves-co
40	Asmanex (twisthaler)	as-muh-neks twist-hey-ler
05	Atrovent	At-ro-vent
06	Azmacort	az-ma-cort
07	Beclomethasone dipropionate	bek"lo-meth'ah-son dī' pro’pe-o-nāt (or be-kloe-meth-a-sone)
08	Beclovent	be' klo-vent" (or be-klo-vent)
09	Bitolterol	bi-tōl'ter-ōl (or bye-tole-ter-ole)
11	Budesonide	byoo-des-oh-nide
12	Combivent	com-bi-vent
13	Cromolyn	kro'mŏ-lin (or KROE-moe-lin)
44	Dulera	do-lair-a
14	Flovent	flow-vent
15	Flovent Rotadisk	flow-vent row-ta-disk
16	Flunisolide	floo-nis'o-līd (or floo-NISS-oh-lide)
17	Fluticasone	flue-TICK-uh-zone
34	Foradil	FOUR-a-dil
35	Formoterol	for moh' te rol
19	Ipratropium Bromide	ĭp-rah-tro'pe-um bro'mīd (or ip-ra-TROE-pee-um)
37	Levalbuterol tartrate	lev-al-BYOU-ter-ohl
20	Maxair	măk-sâr
21	Metaproteronol	met"ah-pro-ter'ĕ-nōl (or met-a-proe-TER-e-nole)
39	Mometasone furoate	moe-MET-a-sone
22	Nedocromil	ne-DOK-roe-mil
23	Pirbuterol	pēr-bu'ter-ōl (or peer-BYOO-ter-ole)
41	Pro-Air HFA	proh-air HFA
24	Proventil	pro"ven-til' (or pro-vent-il)
25	Pulmicort Flexhaler	pul-ma-cort flex-hail-er
36	QVAR	q -vâr (or q-vair)
03	Salbutamol (or Albuterol)	săl-byū'tə-môl'
26	Salmeterol	sal-ME-te-role
27	Serevent	Sair-a-vent
42	Symbicort	sim-buh-kohrt
28	Terbutaline (+ T. sulfate)	ter-bu'tah-lēn (or ter-BYOO-ta-leen)
30	Tornalate	tor-na-late
31	Triamcinolone acetonide	tri"am-sin'o-lōn as"ĕ-tō-nīd' (or trye-am-SIN-oh-lone)
32	Vanceril	van-sir-il
33	Ventolin	vent-o-lin
38	Xopenex HFA	ZOH-pen-ecks
66	Other, Please Specify	[SKIP TO OTH_I1]

[IF RESPONDENT SELECTS ANY ANSWER <66, SKIP TO ILP03]

(88) NO PRESCRIPTION INHALERS [SKIP TO PILLS]

(77) DON’T KNOW [SKIP TO PILLS]

(99) REFUSED [SKIP TO PILLS]

OTH_I1 (8.10) ENTER OTHER MEDICATION FROM (8.9) IN TEXT FIELD

IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE.

[[NOTE: Questions ILP01, ILP02 and ILP07 from years before 2012 are no longer asked. Question ILP03 was revised in 2012 and is no longer comparable to previous survey years]

[NOTE: QUESTIONS ILP03 THRU ILP10 ARE ADMINSTERED FOR UP TO EIGHT INHALED MEDICATIONS REPORTED IN INH_MEDS, BUT NOT FOR 66 (OTHER). THE SPECIFIC MEDICATION NAME IS REFFERED TO IN EACH QUESTION, ILP03 THROUGH ILP10]

[SKIP: IF [MEDICINE FROM INH_MEDS SERIES] IS ADVAIR (01) OR FLOVENT ROTADISK (15) OR MOMETASONE FUROATE (39) OR ASMANEX (40) OR FORADIL (34) OR MAZAIR (20) OR PULMICORT (25) OR SEREVENT (27) OR SYMBICORT (42) SKIP TO 8.14. These inhalers are not used with spacers.]

ILP03 (8.13) A spacer is a small attachment for an inhaler that makes it easier to use. Do you use a spacer with [MEDICINE FROM INH_MEDS SERIES]?

(1) YES

(2) NO

(3) Medication is a dry powder inhaler or disk inhaler not a canister inhaler

(4) Medication has a built-in spacer/does not need a spacer

(7) DON’T KNOW

(9) REFUSED

[HELP SCREEN: A spacer is a device that attaches to a metered dose inhaler. It holds the medicine in its chamber long enough for you to inhale it in one or two slow, deep breaths. The spacer makes it easy to take the medicines the right way.]

[HELP SCREEN: The response category 3 (disk or dry powder) and 4 (built in spacer) are primarily intended for medications Beclomethosone (7) Beclovent (08), Budesonide (11) and QVAR (36), which are known to come in disk or breathe activated inhalers (which do not use a spacer). However, new medications may come on the market that will need either category, so 3 or 4 can be used for other medications as well.]

ILP04 (8.14) In the past 3 months, did you take [MEDICINE FROM INH_MEDS SERIES] when you had an asthma episode or attack?

(1) YES

(2) NO

(3) NO ATTACK IN PAST 3 MONTHS

(7) DON’T KNOW

(9) REFUSED

ILP05 (8.15) In the past 3 months, did you take [MEDICINE FROM INH_MEDS SERIES] before exercising?

(1) YES

(2) NO

(3) DIDN’T EXERCISE IN PAST 3 MONTHS

(7) DON’T KNOW

(9) REFUSED

ILP06 (8.16) In the past 3 months, did you take [MEDICINE FROM INH_MEDS SERIES] on a regular schedule everyday?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

ILP08 (8.18) How many times per day or per week do you use [MEDICINE FROM INH_MEDS SERIES]?

3 _ _ Times per DAY

4 _ _ Times per WEEK

5 5 5 Never

6 6 6 LESS OFTEN THAN ONCE A WEEK

7 7 7 Don’t know / Not sure

9 9 9 Refused

[SKIP: ASK ILP10 ONLY IF INH_MEDS = 3, 4, 9, 10, 20, 21, 23, 24, 28, 30, 33, 37, 38, 41 OTHERWISE SKIP TO PILLS (8.20). These are SABA inhalers.]

ILP10 (8.19) How many canisters of [MEDICINE FROM INH_MEDS SERIES] have you used in the past 3 months?

[INTERVIEWER: IF RESPONDENT USED LESS THAN ONE FULL CANISTER IN THE PAST THREE MONTHS, CODE IT AS ‘88’]

___ CANISTERS

(77) DON’T KNOW

(88) NONE

(99) REFUSED

[HELP SCREEN: IF RESPONDENT INDICATES HE/SHE HAS MULTIPLE CANISTERS, (I.E., ONE IN THE CAR, ONE IN PURSE, ETC.) ASK THE RESPONDENT TO ESTIMATE HOW MANY FULL CANISTERS HE/SHE USED. THE INTENT IS TO ESTIMATE HOW MUCH MEDICATION IS USED, NOT HOW MANY DIFFERNT INHALERS.]

PILLS (8.20) In the past 3 months, have you taken any prescription medicine in pill form for your asthma?

(1) YES

(2) NO [SKIP TO SYRUP]

(7) DON’T KNOW [SKIP TO SYRUP]

(9) REFUSED [SKIP TO SYRUP]

PILLS_MD (8.21) What prescription asthma medications do you take in pill form?

[INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION. MARK ALL THAT APPLY. PROBE: Any other prescription asthma pills?]

[Note: For the following pills the respondent can report up to five medications; each medication can only be reported once. Number 48 and 49 were added in 2008.]

	Medication	Pronunciation
01	Accolate	ac-o-late
02	Aerolate	air-o-late
03	Albuterol	ăl'-bu'ter-ōl (or al-BYOO-ter-all)
04	Alupent	al-u-pent
49	Brethine	breth-een
05	Choledyl (oxtriphylline)	ko-led-il
07	Deltasone	del-ta-sone
08	Elixophyllin	e-licks-o-fil-in
11	Medrol	Med-rol
12	Metaprel	Met-a-prell
13	Metaproteronol	met"ah-pro-ter'ĕ-nōl (or met-a-proe-TER-e-nole)
14	Methylpredinisolone	meth-ill-pred-niss-oh-lone (or meth-il-pred-NIS-oh-lone)
15	Montelukast	mont-e-lu-cast
17	Pediapred	Pee-dee-a-pred
18	Prednisolone	pred-NISS-oh-lone
19	Prednisone	PRED-ni-sone
21	Proventil	pro-ven-til
23	Respid	res-pid
24	Singulair	sing-u-lair
25	Slo-phyllin	slow- fil-in
26	Slo-bid	slow-bid
48	Terbutaline (+ T. sulfate)	ter byoo' ta leen
28	Theo-24	thee-o-24
30	Theochron	thee -o-kron
31	Theoclear	thee-o-clear
32	Theodur	thee-o-dur
33	Theo-Dur	thee-o-dur
35	Theophylline	thee-OFF-i-lin
37	Theospan	thee-o-span
40	T-Phyl	t-fil
42	Uniphyl	u-ni-fil
43	Ventolin	vent-o-lin
44	Volmax	vole-max
45	Zafirlukast	za-FIR-loo-kast
46	Zileuton	zye-loo-ton
47	Zyflo Filmtab	zye-flow film tab
66	Other, please specify	[SKIP TO OTH_P1]

[IF RESPONDENT SELECTS ANY ANSWER FROM 01-49 SKIP TO PILL01]

(88) NO PILLS [SKIP TO SYRUP]

(77) DON’T KNOW [SKIP TO SYRUP]

(99) REFUSED [SKIP TO SYRUP]

OTH_P1 ENTER OTHER MEDICATION IN TEXT FIELD

IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE.

[NOTE: Question PILLX was dropped and replaced with PILL01 in 2012]

[QUESTION PILL01 IS ADMINISTERED FOR UP TO FIVE PILLS 01-49 REPORTED IN PILLS_MD, BUT NOT FOR 66 (OTHER). THE REPORTED MEDICINE NAME FROM PILLS_MD SERIES IS INSERTED INTO PILL01]

PILL01 (8.22) In the past 3 months, did you take [MEDICATION LISTED IN PILLS_MD] on a regular schedule every day?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

SYRUP (8.23) In the past 3 months, have you taken any prescription asthma medication in syrup form?

(1) YES

(2) NO [SKIP TO NEB_SCR]

(7) DON’T KNOW [SKIP TO NEB_SCR]

(9) REFUSED [SKIP TO NEB_SCR]

SYRUP_ID (8.24) What prescription asthma medications have you taken as a syrup?

[INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION. MARK ALL THAT APPLY. PROBE: Any other prescription syrup medications for asthma?]

[For the following syrups the respondent can report up to four medications; each medication can only be reported once.]

	Medication	Pronunciation
01	Aerolate	air-o-late
02	Albuterol	ăl'-bu'ter-ōl (or al-BYOO-ter-ole)
03	Alupent	al-u-pent
04	Metaproteronol	met"ah-pro-ter'ĕ-nōl (or met-a-proe-TER-e-nole)
05	Prednisolone	pred-NISS-oh-lone
06	Prelone	pre-loan
07	Proventil	Pro-ven-til
08	Slo-Phyllin	slow-fil-in
09	Theophyllin	thee-OFF-i-lin
10	Ventolin	vent-o-lin
66	Other, Please Specify:	[SKIP TO OTH_S1]

(88) NO SYRUPS [SKIP TO NEB_SCR]

(77) DON’T KNOW [SKIP TO NEB_SCR]

(99) REFUSED [SKIP TO NEB_SCR]

OTH_S1 ENTER OTHER MEDICATION.

IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE.

NEB_SCR (8. 25) Read: A nebulizer is a small machine with a tube and facemask or mouthpiece that you breathe through continuously. In the past 3 months, were any of your prescription asthma medicines used with a nebulizer?

(1) YES

(2) NO [SKIP TO Section 9]

(7) DON’T KNOW [SKIP TO Section 9]

(9) REFUSED [SKIP TO Section 9]

NEB_PLC (8.26) I am going to read a list of places where you might have used a nebulizer. Please answer yes if you have used a nebulizer in the place I mention, otherwise answer no.

In the past 3 months did you use a nebulizer…

(8.26a) AT HOME

(1) YES (2) NO (7) DK (9) REF

(8.26b) AT A DOCTOR’S OFFICE

(1) YES (2) NO (7) DK (9) REF

(8.26c) IN AN EMERGENCY ROOM

(1) YES (2) NO (7) DK (9) REF

(8.26d) AT WORK OR AT SCHOOL

(1) YES (2) NO (7) DK (9) REF

(8.26e) AT ANY OTHER PLACE

(1) YES (2) NO (7) DK (9) REF

NEB_ID (8.27) In the past 3 months, what prescriptions asthma medications have you taken using a nebulizer?

[INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION. [MARK ALL THAT APPLY. PROBE: Have you taken any other prescription asthma medications with your nebulizer in the past 3 months?]

[For the following nebulizers the respondent can report up to five medications; each medication can only be used once. Medication numbers 17 and 18 were added in 2013.]

	Medication	Pronunciation
01	Albuterol	ăl'-bu'ter-ōl (or al-BYOO-ter-ole)
02	Alupent	al-u-pent
03	Atrovent	At-ro-vent
04	Bitolterol	bi-tōl'ter-ōl (or bye-tole-ter-ole)
05	Budesonide	byoo-des-oh-nide
17	Combivent Inhalation solution	com-bi-vent
06	Cromolyn	kro'mŏ-lin (or KROE-moe-lin)
07	DuoNeb	DUE-ow-neb
08	Intal	in-tel
09	Ipratroprium bromide	ĭp-rah-tro'pe-um bro'mīd (or ip-ra-TROE-pee-um)
10	Levalbuterol	lev al byoo' ter ol
11	Metaproteronol	met"ah-pro-ter'ĕ-nōl (or met-a-proe-TER-e-nole)
18	Perforomist (Formoterol)	per-form-ist
12	Proventil	Pro-ven-til
13	Pulmicort	pul-ma-cort
14	Tornalate	tor-na-late
15	Ventolin	vent-o-lin
16	Xopenex	ZOH-pen-ecks
66	Other, Please Specify:	[SKIP TO OTH_N1]

(88) NO Nebulizers [SKIP TO Section 9]

(77) DON’T KNOW [SKIP TO Section 9]

(99) REFUSED [SKIP TO Section 9]

OTH_N1 ENTER OTHER MEDICATION

IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE.

[NOTE: QUESTIONS NEB01, NEB02, AND NEB03 WERE ADDED IN 2012. QUESTIONS NEB01 THRU NEB03 ARE ADMINSTERED FOR UP TO FIVE NEBULIZER MEDICATIONS REPORTED IN NEB_ID, BUT NOT FOR 66 (OTHER). THE SPECIFIC MEDICATION NAME IS REFERED TO IN EACH QUESTION, NEB01 THROUGH NEB03]

NEB01 (8.28) In the past 3 months, did you take [MEDICINE FROM NEB_ID SERIES] when you had an asthma episode or attack?

(1) YES

(2) NO

(3) NO ATTACK IN PAST 3 MONTHS

(7) DON’T KNOW

(9) REFUSED

NEB02 (8.29) In the past 3 months, did you take [MEDICINE FROM NEB_ID SERIES] on a regular schedule everyday?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

NEB03 (8.30) How many times per day or per week do you use [MEDICINE FROM NEB_ID SERIES]?

3__ __ DAYS

4__ __ WEEKS

(555) NEVER

(666) LESS OFTEN THAN ONCE A WEEK

(777) DON’T KNOW / NOT SURE

(999) REFUSED

Section 9. Cost of Care

[NOTE: The skip pattern for this section changed in 2010. Previously only respondents who responded “yes” to the question “do you still have asthma were asked questions in this section. Beginning in 2010, respondents who reported symptoms, medication use or a physician visit in the past year are asked questions in this section even if they did not respond “yes” to the question “do you still have asthma.]

[SKIP: If the respondent does not currently have asthma (responded “no,” “don’t know” or “refused” to the ACBS question CUR_ASTH, if asked, or if not asked, to the BRFSS core question “do you still have asthma?”) and has not seen a doctor (LAST_MD), has not had asthma symptoms (LASTSYMP) and has not taken asthma medication (LAST_MED) in the past year, the respondent skips to section 10.]

[CONTINUE: If the respondent does not currently have asthma (responded “no,” “don’t know” or “refused” to ACBS question CUR_ASTH, if asked, or if not asked, to the BRFSS core question “do you still have asthma?”) and has had asthma symptoms (LASTSYMP), taken asthma medication (LAST_MED), or seen a doctor for asthma (LAST_MD) in the past year, the respondent continues with section 9.]

[CONTINUE: If the respondent currently has asthma (responded “yes” to the ACBS question CUR_ASTH if asked, or if not asked, to the BRFSS core question “do you still have asthma, the respondent continues with section 9.]

ASMDCOST (9.1) Was there a time in the past 12 months when you needed to see your primary care doctor for your asthma but could not because of the cost?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

ASSPCOST (9.2) Was there a time in the past 12 months when you were referred to a specialist for asthma care but could not go because of the cost?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

ASRXCOST (9.3) Was there a time in the past 12 months when you needed to buy medication for your asthma but could not because of the cost?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

Section 10. Work Related Asthma

[NOTE: SECTION 10 WAS SUBSTANTIALLY REVISED IN 2012]

[RESUME: All respondents continue the interview here.]

EMP_STAT (10.1) Next, we are interested in things that affect asthma in the workplace. However, first I’d like to ask how you would describe your current employment status? Would you say …

[INTERVIEWER: Include self employed as employed. Full time is 35+ hours per week.]

1. EMPLOYED FULL-TIME [SKIP TO WORKENV5 (10.4)]

2. EMPLOYED PART-TIME [SKIP TO WORKENV5 (10.4)]

3. NOT EMPLOYED

(7) DON’T KNOW [SKIP TO EMPL_EVER1 (10.3)]

(9) REFUSED [SKIP TO EMPL_EVER1 (10.3)]

UNEMP_R (10.2) What is the main reason you are not now employed?

(01) KEEPING HOUSE

(02) GOING TO SCHOOL

(03) RETIRED

(04) DISABLED

(05) UNABLE TO WORK FOR OTHER HEALTH REASONS

(06) LOOKING FOR WORK

(07) LAID OFF

(08) OTHER

(77) DON'T KNOW

(99) REFUSED

EMP_EVER (10.3) Have you ever been employed?

[INTERVIEWER: Code self employed as ”YES”.]

(1) YES [SKIP TO WORKENV7 (10.6)]

(2) NO [SKIP TO SECTION 11]

(7) DON’T KNOW [SKIP TO SECTION 11]

9. REFUSED [SKIP TO SECTION 11]

[SKIP: If the respondent is not currently employed and has never been employed, the respondent skips to section 11.]

[SKIP: If the respondent is not currently employed and but has been employed in the past, the respondent skips to question 10.6 about previous jobs.]

[SKIP: If the respondent is currently employed and does not currently have asthma (responded “no,” “don’t know” or “refused” to the ACBS question CUR_ASTH, if asked, or if not asked, to the BRFSS core question “do you still have asthma?”) and has not seen a doctor (LAST_MD), has not had asthma symptoms (LASTSYMP) and has not taken asthma medication (LAST_MED) in the past year, the respondent skips to question 10.5.]

[CONTINUE: If the respondent does not currently have asthma (responded “no,” “don’t know” or “refused” to ACBS question CUR_ASTH, if asked, or if not asked, to the BRFSS core question “do you still have asthma?”) but has had asthma symptoms (LASTSYMP) in the past year or has taken asthma medication (LAST_MED) in the past year, or has seen a doctor for asthma (LAST_MD) in the past year the respondent continues with question 10.4.]

[CONTINUE: If the respondent currently has asthma (responded “yes” to the ACBS question CUR_ASTH if asked, or if not asked, to the BRFSS core question “do you still have asthma?” continues with question 10.4 ]

WORKENV5 (10.4) Things in the workplace such as chemicals, smoke, dust or mold can make asthma symptoms worse in people who already HAVE asthma or can actually CAUSE asthma in people who have never had asthma before.

Are your asthma symptoms MADE WORSE by things like chemicals, smoke, dust or mold in your CURRENT job?

(1) YES

(2) NO

(7) DON’T KNOW

9. REFUSED

[HELP SCREEN: “Some examples of things in the workplace that may cause asthma or make asthma symptoms worse include: flour dust in a bakery, normal dust in an office, smoke from a manufacturing process, smoke from a co-worker’s cigarette, cleaning chemicals in a hospital, mold in a basement classroom, a co-worker’s perfume, or mice in a research laboratory.”]

WORKENV6 (10.5) Was your asthma first CAUSED by things like chemicals, smoke, dust or mold in your CURRENT job?

(1) YES [SKIP TO WORKTALK (10.9)]

(2) NO

(7) DON’T KNOW

9. REFUSED

[HELP SCREEN: “Some examples of things in the workplace that may cause asthma or make asthma symptoms worse include: flour dust in a bakery, normal dust in an office, smoke from a manufacturing process, smoke from a co-worker’s cigarette, cleaning chemicals in a hospital, mold in a basement classroom, a co-worker’s perfume, or mice in a research laboratory.”]

[SKIP: If the respondent is currently employed and the current job initially caused the asthma, questions about previous jobs are not asked. The respondent skips to question 10.9.]

WORKENV7 (10.6) [READ THIS INTRO TO 10.6 ONLY IF EMP_EVER1 (10.3) = 1 (yes); OTHERWISE SKIP INTRO AND JUST READ THE QUESTION]

Things in the workplace such as chemicals, smoke, dust or mold can make asthma symptoms worse in people who already HAVE asthma or can actually CAUSE asthma in people who have never had asthma before.

Were your asthma symptoms MADE WORSE by things like chemicals, smoke, dust or mold in any PREVIOUS job you ever had?

(1) YES

(2) NO

(7) DON’T KNOW

9. REFUSED

[HELP SCREEN: “Some examples of things in the workplace that may cause asthma or make asthma symptoms worse include: flour dust in a bakery, normal dust in an office, smoke from a manufacturing process, smoke from a co-worker’s cigarette, cleaning chemicals in a hospital, mold in a basement classroom, a co-worker’s perfume, or mice in a research laboratory.”]

WORKENV8 (10.7) Was your asthma first CAUSED by things like chemicals, smoke, dust or mold in any PREVIOUS job you ever had?

(1) YES

(2) NO

(7) DON’T KNOW

9. REFUSED

[HELP SCREEN: “Some examples of things in the workplace that may cause asthma or make asthma symptoms worse include: flour dust in a bakery, normal dust in an office, smoke from a manufacturing process, smoke from a co-worker’s cigarette, cleaning chemicals in a hospital, mold in a basement classroom, a co-worker’s perfume, or mice in a research laboratory.”]

SKIP BEFORE 10.8 [ASK 10.8 ONLY IF:

WORKENV7 (10.6) = 1 (YES) OR

WORKENV8 (10.7) = 1 (YES)

OTHERWISE SKIP TO WORKTALK (10.9)]

[SKIP: If asthma symptoms were made worse by a previous job or if a previous job caused the asthma, the respondent is asked question 10.8. If a previous job did not cause or aggravate the respondent’s asthma then question 10.8 is not asked.]

WORKQUIT1 (10.8) Did you ever lose or quit a job because things in the workplace, like chemicals, smoke, dust or mold, caused your asthma or made your asthma symptoms worse?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[INTERVIEWER: RESPONDENTS WHO WERE FIRED BECAUSE THINGS IN THE WORKPLACE AFFECTED THEIR ASTHMA SHOULD BE CODED AS “YES”.]

WORKTALK (10.9) Did you and a doctor or other health professional ever DISCUSS whether your asthma could have been caused by, or your symptoms made worse by, any job you ever had?

(1) YES

(2) NO

(7) DON’T KNOW

9. REFUSED

WORKSEN3 (10.10) Have you ever been TOLD BY a doctor or other health professional that your asthma was caused by, or your symptoms made worse by, any job you ever had?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

WORKSEN4 (10.11) Have YOU ever TOLD a doctor or other health professional that your asthma was caused by, or your symptoms made worse by, any job you ever had?

(1) YES

(2) NO

(7) DON’T KNOW

9. REFUSED

Section 11. Comorbid Conditions

[RESUME: All respondents continue the interview here.]

We have just a few more questions. Besides asthma we are interested in some other medical conditions you may have.

COPD (11.1) Have you ever been told by a doctor or health professional that you have chronic obstructive pulmonary disease also known as COPD?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

EMPHY (11.2) Have you ever been told by a doctor or other health professional that you have emphysema?

(1) YES

(2) NO

(7) DON’T KNOW

9. REFUSED

BRONCH (11.3) Have you ever been told by a doctor or other health professional that you have Chronic Bronchitis?

(1) YES

(2) NO

(7) DON’T KNOW

9. REFUSED

[HELP SCREEN: Chronic Bronchitis is repeated attacks of bronchitis over a long period of time. Chronic Bronchitis is not the type of bronchitis you might get occasionally with a cold.]

DEPRESS (11.4) Have you ever been told by a doctor or other health professional that you were depressed?

(1) YES

(2) NO

(7) DON’T KNOW

9. REFUSED

Section 12. Complimentary and Alternative Therapy

[NOTE: The skip pattern changed in 2010. Previously only respondents who responded “yes” to the question “do you still have asthma were asked question in section 12. Beginning in 2010, respondents who reported symptoms, medication use or a physician visit in the past year are asked question in section 12 even if they did not respond “yes” to the question “do you still have asthma.]

[SKIP: If the respondent does not currently have asthma (responded “no,” “don’t know” or “refused” to the ACBS question CUR_ASTH, if asked, or if not asked, to the BRFSS core question “do you still have asthma?”) and has not seen a doctor (LAST_MD), has not had asthma symptoms (LASTSYMP) and has not taken asthma medication (LAST_MED) in the past year, the respondent skips to the interview termination (CWEND).]

[CONTINUE: If the respondent does not currently have asthma (responded “no,” “don’t know” or “refused” to ACBS question CUR_ASTH, if asked, or if not asked, to the BRFSS core question “do you still have asthma?”) and has had asthma symptoms (LASTSYMP), taken asthma medication (LAST_MED), or seen a doctor for asthma (LAST_MD) in the past year, the respondent continues with section 12.]

[CONTINUE: If the respondent currently has asthma (responded “yes” to the ACBS question CUR_ASTH if asked, or if not asked, to the BRFSS core question “do you still have asthma, the respondent continues with section 12.]

READ: Sometimes people use methods other than prescription medications to help treat or control their asthma. These methods are called non-traditional, complementary, or alternative health care. I am going to read a list of these alternative methods. For each one I mention, please answer “yes” if you have used it to control your own asthma in the past 12 months. Answer “no” if you have not used it in the past 12 months.

In the past 12 months, have you used … to control your asthma?

[interviewer: repeat prior phasing as needed]

CAM_HERB (12.1) herbs (1) YES (2) NO (7) DK (9) REF

CAM_VITA (12.2) vitamins (1) YES (2) NO (7) DK (9) REF

CAM_PUNC (12.3) acupuncture (1) YES (2) NO (7) DK (9) REF

CAM_PRES (12.4) acupressure (1) YES (2) NO (7) DK (9) REF

CAM_AROM (12.5) aromatherapy (1) YES (2) NO (7) DK (9) REF

CAM_HOME (12.6) homeopathy (1) YES (2) NO (7) DK (9) REF

CAM_REFL (12.7) reflexology (1) YES (2) NO (7) DK (9) REF

CAM_YOGA (12.8) yoga (1) YES (2) NO (7) DK (9) REF

CAM_BR (12.9) breathing techniques (1) YES (2) NO (7) DK (9) REF

CAM_NATR (12.10) naturopathy (1) YES (2) NO (7) DK (9) REF

[INTERVIEWER: If respondent does not recognize the term “naturopathy” the response should be no”]

[HELP SCREEN: Naturopathy (nay-chur-o-PATH-ee) is an alternative treatment based on the principle that there is a healing power in the body that establishes, maintains, and restores health. Naturopaths prescribe treatments such as nutrition and lifestyle counseling, dietary supplements, medicinal plants, exercise, homeopathy, and treatments from traditional Chinese medicine.]

CAM_OTHR (12.11) Besides the types I have just asked about, have you used any other type of alternative care for your asthma in the past 12 months?

1. YES

2. NO [SKIP TO CWEND]

(7) DON’T KNOW [SKIP TO CWEND]

(9) REFUSED [SKIP TO CWEND]

CAM_TEXT (12.13) What else have you used?

ENTER OTHER ALTERNATIVE MEDICINE IN TEXT FIELD

IF MORE THAN ONE IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE.

CWEND Those are all the questions I have. I’d like to thank you on behalf of the {STATE NAME} Health Department and the Centers for Disease Control and Prevention for the time and effort you’ve spent answering these questions. If you have any questions about this survey, you may call my supervisor toll-free at 1 – xxx-xxx-xxxx. If you have questions about your rights as a survey participant, you may call the chairman of the Institutional Review Board at 1‑800‑xxx-xxxx. Thanks again.