ACBS Consent and Survey - child

Behavioral Risk Factor Surveillance System (BRFSS) Asthma Call-back Survey (ACBS)

Att5f ACBS Chld Cnsnt and Srvy

ACBS Consent and Survey - child

OMB: 0920-1204

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Attachment 5f –

ACBS Child Consent and Survey - 2013

______________________________________________________________________________

Section Subject Page

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

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

Section 3 Recent History.............…......................................……. 04

Section 4 History of Asthma (Symptoms & Episodes)............… 06

Section 5 Health Care Utilization.................................................. 09

Section 6 Knowledge of Asthma/Management Plan..................... 13

Section 7 Modifications to Environment....................................... 15

Section 8 Medications........................... ........................................… 20

Section 9 Cost of Care...................................................................… 30

Section 10 School Related Asthma ………………………………… 31

Section 11 Complimentary and Alternative Therapy …….……… 36

Section 12 Additional Child Demographics …………………...…… 38

Appendix A: Language for Identifying Most Knowledgeable Person…

during the BRFSS interview……….…………………….. 40

Appendix B: Language for Identifying Most Knowledgeable Person…

at the Call-back………………………………………….. 47

______________________________________________________________________________

Section 1. Introduction

For states identifying the Most Knowledgeable Person/Parent (MKP) at the BRFSS interview use language in Appendix A.

For states identifying the Most Knowledgeable Person/Parent (MKP) at the Asthma Call-Back use language in Appendix B.

Shape1

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

For states identifying the Most Knowledgeable Person/Parent (MKP) at the BRFSS interview use language in Appendix A.

For states identifying the Most Knowledgeable Person/Parent (MKP) at the Asthma Call-Back use language in Appendix B.

Section 3. Recent History

AGEDX (3.1) How old was {child’s name} when a doctor or other health professional first said {he/she} had asthma

__ __ __(ENTER AGE IN YEARS)

(777) DON’T KNOW

(888) Under 1 year old

(999) REFUSED

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

Within the past 12 months
1-5 years ago
more than 5 years ago

DON’T KNOW

REFUSED

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

[INTERVIEWER: READ RESPONSE OPTIONS IF NECESSARY]

(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 {he/she} 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 {child’s name} did not have a cold or respiratory infection.

LASTSYMP (3.5) How long has it been since {he/she} 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 {child’s name} 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) Does { he/she } 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 { him/her } to stay asleep?

__ __ DAYS/NIGHTS

(88) NONE

(30) Every day

(77) DON’T KNOW

(99) REFUSED

SYMPFREE (4.4) During the past two weeks, on how many days was {child’s name} 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’ has {child’s name} had an episode of asthma or an asthma attack?

(1) YES

(2) NO [SKIP TO INS1 in Section 5]

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

(9) REFUSED [SKIP TO INS1 in Section 5]

EPIS_TP (4.6) During the past three months, how many asthma episodes or attacks has { he/she } had?

__ __

(888) NONE

(777) DON’T KNOW

(999) REFUSED

DUR_ASTH (4.7) How long did {his/her} 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?

SHORTER
LONGER
ABOUT THE SAME
THE MOST RECENT ATTACK WAS ACTUALLY THE FIRST ATTACK

DON’T KNOW

REFUSED

Section 5. Health Care Utilization

[RESUME: All respondents continue the interview here.]

INS1 (5.1) Does {child’s name} 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 FLU_SHOT]

(7) DON’T KNOW [SKIP TO FLU_SHOT]

(9) REFUSED [SKIP TO FLU_SHOT]

INS_TYP (5.2) What kind of health care coverage does {he/she} have? Is it paid for through the parent’s employer, or is it Medicaid, Medicare, Children's Health Insurance Program (CHIP), or some other type of insurance?

parent’s employer
Medicaid/Medicare
CHIP {replace with state specific name}
Other

(7) DON’T KNOW

(9) REFUSED

INS2 (5.3) During the past 12 months was there any time that { he/she } did not have any health insurance or coverage?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

FLU_SHOT (5.4) A flu shot is an influenza vaccine injected in your arm. During the past 12 months, did {CHILD’S NAME} have a flu shot?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

FLU_SPRAY (5.5) A flu vaccine that is sprayed in the nose is called FluMist^TM. During the past 12 months, did {he/she} have a flu vaccine that was sprayed in his/her nose?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[SKIP: If the child does not currently have asthma (response of “no,” “don’t know” or “refused” to the ACBS question CUR_ASTH, if asked, or if not asked, to the BRFSS child module question “Does the child 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.]

[CONTINUE: If the child does not currently have asthma (response of “no,” “don’t know” or “refused” to ACBS question CUR_ASTH, if asked, or if not asked, to the BRFSS child module question “Does the child 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 question 5.6.]

[CONTINUE: If the child does currently have asthma (response of “yes” to the ACBS question CUR_ASTH if asked, or if not asked, to the BRFSS child module question “Does the child still have asthma?”), the respondent continues with question 5.6.]

ACT_DAYS (5.6) During just the past 30 days, would you say {child’s name} limited {his/her} 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

[SKIP: If the child has not seen a doctor (LAST_MD) in the past year, the respondent skips to section 6.]

NER_TIME (5.7) During the past 12 months how many times did {he/she} see a doctor or other health professional for a routine checkup for {his/her} asthma?

[NOTE: formerly NR_Times]

__ __ __ ENTER NUMBER

(888) NONE

(777) DON’T KNOW

(999) REFUSED

ER_VISIT (5.8) 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, has {child’s name} had to visit an emergency room or urgent care center because of {his/her} 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 (5.9) During the past 12 months, how many times did{ he/she } visit an emergency room or urgent care center because of {his/her} asthma?

__ __ __ ENTER NUMBER

(888) ZERO (skip back to 5.8)

(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 (5.10) [IF ONE OR MORE ER VISITS (ER_VISIT (5.8) = 1) INSERT “Besides those emergency room or urgent care center visits,”]

During the past 12 months, how many times did {child’s name} see a doctor or other health professional for urgent treatment of worsening asthma symptoms or 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 the respondent skips to Section 6. If the child has not had symptoms in the past year the questions on hospital stays are not asked.]

HOSP_VST (5.11) During the past 12 months, that is since [1 YEAR AGO TODAY], has {child’s name} had to stay overnight in a hospital because of {his/her} asthma? Do not include an overnight stay in the emergency room.

(1) YES

(2) NO [SKIP TO Section 6]

(7) DON’T KNOW [SKIP TO Section 6]

(9) REFUSED [SKIP TO Section 6]

HOSPTIME (5.12) During the past 12 months, how many different times did {he/she} stay in any hospital overnight or longer because of {his/her} asthma?

__ __ __ TIMES

(777) DON’T KNOW

(999) REFUSED

HOSPPLAN (5.13) The last time {he/she} left the hospital, did a health professional TALK with you or {child’s name} 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”. ]

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 or {child’s name}...

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 or {child’s name}...

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 or {child’s name}...

c. How to use a peak flow meter to adjust his/her 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 or {child’s name}....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 or {child’s name} ever taken a course or class on how to manage {his/her} 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 {child’s name} 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 {child’s name} 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 {his/her} 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 the kitchen in {his/her} home?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

COOK_GAS (7.4) Is gas used for cooking in {his/her} home?

(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 in {his/her} home? Do not include mold on food.

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

ENV_PETS (7.6) Does {child’s name} home 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) Is the pet allowed in {his/her} 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 cockroaches inside {child’s name} 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 {his/her} 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 {child’s name} 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 {his/her} 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 {his/her} 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 {child’s name}.

Has a health professional ever advised you to change things in {his/her} home, school, or work to improve his/her 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) Does {he/she} 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) Does {he/she} 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) Does {child’s name} have carpeting or rugs in {his/her} 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 {his/her} 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 {child’s name} bathroom, does {he/she} 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 THE CHILD USES MOST FREQUENTLY FOR SHOWERING AND BATHING. ]

Section 8. Medications

[SKIP: If child 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 {child’s name} medication use.

Over-the-counter medication can be bought without a doctor’s order. Has {child’s name} ever used over-the-counter medication for {his/her} asthma?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

INHALERE (8.2) Has {he/she} 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 health professional show {him/her} 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 { him/her } 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 {child’s name} may have taken for asthma in the past 3 months. I will be asking for the names, amount, and how often {he/she} takes each medicine. I will ask separately about medication taken in various forms: pill or syrup, inhaler, and Nebulizer.

It will help to get {child’s name} medicines so you can read the labels.

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

NO [SKIP TO INH_SCR]
RESPONDENT KNOWS THE MEDS [SKIP TO INH_SCR]

DON’T KNOW [SKIP TO INH_SCR]

REFUSED [SKIP TO INH_SCR]

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

[INTERVIEWER: Read if necessary]

YES I HAVE ALL THE MEDICATIONS
YES I HAVE SOME OF THE MEDICATIONS BUT NOT ALL
NO

DON’T KNOW

REFUSED

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

INH_SCR (8.8) In the past 3 months has {child’s name} 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 {he/she} take by inhaler

[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. Does {he/she} 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 {child’s name} take [MEDICINE FROM INH_MEDS SERIES] when he/she 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 {he/she} 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 {he/she} 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 did {he/she} 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] has {child’s name} 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 THAT <CHILD> HAS MULTIPLE CANISTERS, (I.E., ONE IN THE CAR, ONE AT SCHOOL, 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, has {he/she} taken any PRESCRIPTION medicine in pill form for his/her 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 does {child’s name} 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 {child’s name} 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, has {he/she} taken prescription medicine 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 has {child’s name} 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) 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 {child’s name} 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 your child might have used a nebulizer. Please answer yes if your child has used a nebulizer in the place I mention, otherwise answer no.

In the past 3 months did {child’s name} 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 prescription ASTHMA medications has {he/she} taken using a nebulizer?

[INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION. [MARK ALL THAT APPLY. PROBE: Has your child taken any other prescription asthma medications using a 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-forom-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) NONE [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 {child’s name} take [MEDICINE FROM NEB_ID SERIES] when he/she 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 he/she take [MEDICINE FROM NEB_ID SERIES] on a regular schedule every day?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

NEB03 (8.30) How many times per day or per week does he/she 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 those who responded “yes” to the question “Does the child still have asthma?” were asked questions in this section. Beginning in 2010, respondents who reported the child had 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 “Does the child still have asthma?”]

ASMDCOST (9.1) Was there a time in the past 12 months when {child’s name} needed to see his/her primary care doctor for 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 {his/her} 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 {he/she} needed medication for his/her asthma but you could not buy it because of the cost?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

Section 10. School Related Asthma

[RESUME: All respondents continue the interview here.]

SCH_STAT (10.1) Next, we are interested in things that might affect {child’s name} asthma when he/she is not at home.

Does {child’s name} currently go to school or pre school outside the home?

(1) YES [SKIP TO SCHGRADE]

(2) NO

(7) DON’T KNOW

(9) REFUSED

NO_SCHL (10.2) What is the main reason {he/she} is not now in school? READ RESPONSE CATEGORIES

(1) NOT OLD ENOUGH [SKIP TO DAYCARE]

(2) HOME SCHOOLED [SKIP TO SCHGRADE]

(3) UNABLE TO ATTEND FOR HEALTH REASONS

(4) ON VACATION OR BREAK

(5) OTHER

(7) DON'T KNOW

(9) REFUSED

SCHL_12 (10.3) Has {child’s name} gone to school in the past 12 months?

(1) YES

(2) NO [SKIP TO DAYCARE]

(7) DON’T KNOW [SKIP TO DAYCARE]

(9) REFUSED [SKIP TO DAYCARE]

SCHGRADE (10.4) [IF SCHL_12 = 1] What grade was {he/she} in the last time he/she was in school?

[IF SCH_STAT = 1 OR NO_SCHL = 2] What grade is {he/she} in?

(88) PRE SCHOOL

KINDERGARDEN

__ __ ENTER GRADE 1 TO 12

DON’T KNOW

REFUSED

[NOTE: The skip pattern for this section changed in 2010. Previously only those who responded “yes” to the question “Does the child still have asthma?” were asked question 10.5 to 10.7. Beginning in 2010, respondents who reported the child had symptoms, medication use, or a physician visit in the past year, are asked question 10.5 to 10.7 even if they did not respond “yes” to the question “Does the child still have asthma?”]

MISS_SCHL (10.5) During the past 12 months, about how many days of school did {he/she} miss because of {his/her} asthma?

__ __ __ENTER NUMBER DAYS

(888) ZERO

(777) DON’T KNOW

(999) REFUSED

[SKIP: If child is home schooled (NO_SCHL = 2) skip to section 11.]

[IF SCHL_12 (10.3) = 1 READ ‘PLEASE ANSWER THESE NEXT FEW QUESTIONS ABOUT THE SCHOOL {CHILD’S NAME} WENT TO LAST]

SCH_APL (10.6) Earlier I explained that an asthma action plan contains instructions about how to care for the child’s asthma.

Does {child’s name} have a written asthma action plan or asthma management plan on file at school?

(1) YES

(2) NO

(7) DON’T KNOW

REFUSED

SCH_MED (10.7) Does the school {he/she} goes to allow children with asthma to carry their medication with them while at school?

(1) YES

(2) NO

(7) DON’T KNOW

REFUSED

SKIP: IF NO_SCHL = 2 (HOME SCHOOLED) SKIP TO SECTION 11

SCH_ANML (10.8) Are there any pets such as dogs, cats, hamsters, birds or other feathered or furry pets in {his/her} CLASSROOM?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

SCH_MOLD (10.9) Are you aware of any mold problems in {child’s name} school?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

[

SKIP: IF CHLDAGE2 > 10 YEARS OR 131 MONTHS SKIP TO SECTION 11

DAYCARE (10.10) Does {child’s name} go to day care outside his/her home?

(1) YES [SKIP TO MISS_DCAR]

(2) NO

(7) DON’T KNOW [SKIP TO SECTION 11]

(9) REFUSED [SKIP TO SECTION 11]

DAYCARE1 (10.11) Has {he/she} gone to daycare in the past 12 months?

(1) YES

(2) NO [SKIP TO SECTION 11]

(7) DON’T KNOW [SKIP TO SECTION 11]

(9) REFUSED [SKIP TO SECTION 11]

[NOTE: The skip pattern for this section changed in 2010. Previously only those who responded “yes” to the question “Does the child still have asthma?” were asked question 10.12 and 10.13. Beginning in 2010, respondents who reported the child had symptoms, medication use, or a physician visit in the past year, are asked question 10.2 and 10.13 even if they did not respond “yes” to the question “Does the child still have asthma?”]

MISS_DCAR (10.12) [SKIP: If the child does not currently have asthma (response of “no,” “don’t know” or “refused” to the ACBS question CUR_ASTH, if asked, or if not asked, to the BRFSS child module question “Does the child 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 10.14.]

During the past 12 months, about how many days of daycare did {he/she} miss because of {his/her} asthma?

__ __ __ENTER NUMBER DAYS

(888) ZERO

(777) DON’T KNOW

(999) REFUSED

DCARE_APL (10.13) [IF DAYCARE1 (10.11) = YES (1) THEN READ: “Please answer these next few questions about the daycare {child’s name} went to last. “

Does {child’s name} have a written asthma action plan or asthma management plan on file at daycare?

(1) YES

(2) NO

(7) DON’T KNOW

REFUSED

DCARE_ANML(10.14) Are there any pets such as dogs, cats, hamsters, birds or other feathered or furry pets in {his/her} room at daycare?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

DCARE_MLD (10.15) Are you aware of any mold problems in {his/her} daycare?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

DCARE_SMK (10.16) Is smoking allowed at {his/her} daycare?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

Section 11. Complimentary and Alternative Therapy

[NOTE: The skip pattern for this section changed in 2010. Previously only those who responded “yes” to the question “Does the child still have asthma?” were asked section 11. Beginning in 2010, respondents who reported the child had symptoms, medication use, or a physician visit in the past year, are asked section 11 even if they did not respond “yes” to the question “Does the child still have asthma?”]

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 {child’s name} has used it to control asthma in the past 12 months. Answer “no” if {he/she} has not used it in the past 12 months.

In the past 12 months, has {he/she} used … to control asthma?

[interviewer: repeat prior phasing as needed]

CAM_HERB (11.1) herbs (1) YES (2) NO (7) DK (9) REF

CAM_VITA (11.2) vitamins (1) YES (2) NO (7) DK (9) REF

CAM_PUNC (11.3) acupuncture (1) YES (2) NO (7) DK (9) REF

CAM_PRES (11.4) acupressure (1) YES (2) NO (7) DK (9) REF

CAM_AROM (11.5) aromatherapy (1) YES (2) NO (7) DK (9) REF

CAM_HOME (11.6) homeopathy (1) YES (2) NO (7) DK (9) REF

CAM_REFL (11.7) reflexology (1) YES (2) NO (7) DK (9) REF

CAM_YOGA (11.8) yoga (1) YES (2) NO (7) DK (9) REF

CAM_BR (11.9) breathing techniques (1) YES (2) NO (7) DK (9) REF

CAM_NATR (11.10) 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 (11.11) Besides the types I have just asked about, has {child’s name} used any other type of alternative care for asthma in the past 12 months?

YES
NO [SKIP TO SECTION 12]

(7) DON’T KNOW [SKIP TO SECTION 12]

(9) REFUSED [SKIP TO SECTION 12]

CAM_TEXT (11.13) What else has {he/she} used?

ENTER OTHER ALTERNATIVE MEDICINE IN TEXT FIELD

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

Section 12. Additional Child Demographics

READ “I have just a few more questions about {child’s name}.”

HEIGHT1 (12.1) How tall is {child’s name}?

[INTERVIEWER: if needed: Ask the respondent to give their best guess.]

_ _ _ _ = Height (ft/inches)

7 7 7 7 = Don’t know/Not sure

9 9 9 9 = Refused

[HELP SCREEN: WE ARE INTERESTED IN LOOKING AT HOW HEIGHT AND WEIGHT MAY BE RELATED TO ASTHMA.]

WEIGHT1 (12.2) How much does {he/she} weigh?

[INTERVIEWER: if needed: Ask the respondent to give their best guess.]

_ _ _ _ Weight (pounds/kilograms)

7 7 7 7 Don’t know / Not sure

9 9 9 9 Refused

[HELP SCREEN: WE ARE INTERESTED IN LOOKING AT HOW HEIGHT AND WEIGHT MAY BE RELATED TO ASTHMA.]

BIRTHW1 (12.3) How much did {he/she} weigh at birth (in pounds)?

_ _ _ _ _ _ Weight (pounds/kilograms)

7 7 7 7 7 7 Don’t know / Not sure

9 9 9 9 9 9 Refused

[SKIP: If birth weight is provided, skip to the end of the interview (CWEND).]

[CONTINUE: If birth weight is not provided (12.3 BIRTHW1 is DON’T KNOW or REFUSED) ask 12.4 BIRTHRF.]

BIRTHRF (12.4) At birth, did {child’s name} weigh less than 5 ½ pounds?

[INTERVIEWER NOTE: 5 ½ pounds = 2500 GRAMS]

DON’T KNOW

REFUSED

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.

Appendix A:

Language for Identifying Most Knowledgeable Person during the BRFSS interview

Consent scripts for use during BRFSS 2011 Child asthma module when the most knowledgeable adult is identified during the BRFSS interview.

Child asthma module:

If BRFSS respondent indicates that the randomly selected child has ever had asthma (CASTHDX2 = 1 “yes”) and the BRFSS adult never had asthma then arrange for a call-back interview. If both the BRFSS adult and the randomly selected child both have asthma the child is randomly selected for the call-back 50% of the time.

Only respondents who are the parent/guardian of the selected child with asthma are eligible for the child asthma call-back interview. This is required because the parent/guardian must give permission to collect information about the child even if the information is being given by someone else. (RCSRELN1 = 1, 3 )

READ: We would like to call again within the next 2 weeks to talk in more detail about your child’s experiences with asthma. The information will be used to help develop and improve the asthma programs in {state name}.

ADULTPERM

Would it be all right if we call back at a later time to ask additional questions about your child’s asthma?

(1) Yes

(2) No (GO TO BRFSS closing or next module)

(7) Don’t know/Not Sure (GO TO BRFSS closing or next module)

(9) Refused (GO TO BRFSS closing or next module)

CHILDName

Can I please have your child's first name, initials or nickname so we can ask about the right child when we call back? This is the {#} year old child which is the {FIRST CHILD, SECOND, etc.} CHILD.

[CATI: If more than one child, show child age {#} and which child was selected (FIRST, SECOND, etc.) from child selection module]

Enter child’s first name, initials or nickname: ____________

ADULTName

Can I please have your first name, initials or nickname so we know who refer to when we call back?

Enter respondent’s first name, initials or nickname: ____________

MOSTKNOW

Are you the parent or guardian in the household who knows the most about {CHILDName}’s asthma?

(1) Yes [CATI SET MKPName = ADULTName]

(2) No (GO TO ALTName)

(7) Don’t know/Not Sure (GO TO ALTName)

(9) Refused (GO TO ALTName)

CBTIME: What is a good time to call you back? For example, evenings, days, weekends?

Enter day/time: _________________

READ: The information you gave us today and will give us when we call back will be kept confidential. We will keep identifying information like your child’s name and your name and phone number on file, separate from the answers collected today. Even though you agreed today, you may refuse to participate in the future.

[If state requires active linking consent continue, if not, go to BRFSS closing or next module]

LINKING CONSENT

READ: Some of the information that you shared with us today could be useful when combined with the information we will ask for during your child’s asthma interview. If the information from the two interviews is combined, identifying information such as your phone number, your name, and your child’s name will not be included.

PERMISS: May we combine your answers from today with your answers from the interview about your child’s asthma that will be done in the next two weeks?

(1) Yes (GO TO BRFSS closing or next module)

(2) No (GO TO BRFSS closing or next module)

(7) Don’t Know (GO TO BRFSS closing or next module)

(9) Refused (GO TO BRFSS closing or next module)

ALTName Can I please have the first name, initials or nickname of the person who knows the most about {CHILDName}’s asthma so we will know who to ask for when we call back?

Alternate’s Name:__________________________________

[CATI SET MKPName = ALTName]

ALTCBTime:

When would be a good time to call back and speak with {ALTName}. For example, evenings, days, weekends?

Enter day/time: _________________

READ: The information you gave us today and that {ALTName} will give us when we call back will be kept confidential. We will keep their name and phone number, and your child’s name on file, separate from the answers collected today. Even though you agreed today, {ALTName} may refuse to participate in the future.

[If state requires linking consent, continue; if not, go to BRFSS closing or next module]

LINKING CONSENT

PERMISS: May we combine your answers from today with the answers {ALTName} gives us during the interview about your child’s asthma?

(1) Yes (GO TO BRFSS closing or next module)

(2) No (GO TO BRFSS closing or next module)

(7) Don’t Know (GO TO BRFSS closing or next module)

(9) Refused (GO TO BRFSS closing or next module)

Introduction and consent sections for use during the Child Asthma Call-Back when the most knowledgeable adult is identified during the BRFSS interview:

[CATI: CHILDName, ADULTName, ALTName, MKPName, CASTHDX2, and CASTHNO2, RCSGENDR, calculated child’s age, are from the BRFSS child asthma module and must be carried to the asthma call-back]

[CATI: BRFSS Respondent’s SEX also should be carried to the Asthma call-back]

[CATI: IF INTERVIEW BREAKS OFF AT ANY POINT LEAVE REMAINING FIELDS BLANK. DO NOT FILL WITH ANY VALUE.]

Section 1. Introduction

INTRODUCTION TO THE BRFSS Asthma call back for Adult parent/guardian of child 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 study we are doing in your state.

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.

Are you {MKPName}?

Yes (GO TO 1.5)
No

May I speak with {MKPName }?

Yes (GO TO 1.4 when person comes to phone)
Person not available

1.3 When would be a good time to call back and speak with {MKPName}. For example, evenings, days, weekends?

Enter day/time: _________________

READ: Thank you we will call again later to speak with {MKPName}.

[CATI: Start over at introduction at next 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” if MKPName=ADULTName OR “ADULTName” if MKPName=ALTName} gave us permission to call again to ask some questions about {CHILDName}’s asthma and said that you knew the most about that child’s asthma.

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” if MKPName=ADULTName OR “ADULTName” if MKPName=ALTName} gave us permission to call again to ask some questions about {CHILDName}’s health and said that you knew the most about that child’s health.

GO TO SECTION 2

1.5 During a recent phone interview {“you” if MKPName=ADULTName OR “ADULTName” if MKPName=ALTName} gave us permission to call again to ask some questions about {CHILDName}’s asthma and said that you knew the most about that child’s asthma.

ALTERNATE (no reference to asthma):

During a recent phone interview {“you” if MKPName=ADULTName OR “ADULTName” if MKPName=ALTName} gave us permission to call again to ask some questions about {CHILDName}’s health and said that you knew the most about that child’s health.

GO TO SECTION 2

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 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.

{CHILDName} was selected to participate in this study about asthma because of responses to questions about his or her asthma in a prior survey.

[If responses for sample child were “yes” (1) to CASTHDX2 and “no” (2) to CASTHNO2 in core BRFSS interview:]

READ: The answers to asthma questions during the earlier survey indicated that a doctor or other health professional said that {CHILDName} had asthma sometime in {his/her} life, but does not have it now. Is that correct?

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

Since {CHILDName} no longer has asthma, your interview will be very brief (about 5 minutes). [Go to section 3]

[If responses for sample child were “yes” (1) to CASTHDX2 and “yes” (1) to CASTHNO2 in core BRFSS survey:]

READ: Answers to the asthma questions in the earlier survey indicated that a doctor or other health professional said that {CHILDName} had asthma sometime in his or her life, and that {CHILDName} still has asthma. Is that correct?

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

Since {CHILDName} has asthma now, your interview will last about 15 minutes. [Go to section 3]

REPEAT (2.0)

READ: I would like to repeat the questions from the previous survey now to make sure {CHILDName} qualifies for this study.

EVER_ASTH (2.1) Have you ever been told by a doctor or other health professional that {CHILDName} had asthma?

(1) YES

(2) NO [Go to TERMINATE]

(7) Don’t know [Go to TERMINATE]

(9) Refused [Go to TERMINATE]

CUR_ASTH (2.2) Does {he/she} still have asthma?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

RELATION (2.3) What is your relationship to {CHILDName}?

(1) MOTHER (BIRTH/ADOPTIVE/STEP) [go to READ]

(2) FATHER (BIRTH/ADOPTIVE/STEP) [go to READ]

(3) BROTHER/SISTER (STEP/FOSTER/HALF/ADOPTIVE)

(4) GRANDPARENT (FATHER/MOTHER)

(5) OTHER RELATIVE

(6) UNRELATED

(7) DON’T KNOW

(9) REFUSED

GUARDIAN (2.4) Are you the legal guardian for {CHILDName}

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

READ: {CHILDName} does qualify for this study, I’d like to continue unless you have any questions.

[If YES to 2.2 read:]

Since {CHILDName} does have asthma now, your interview will last about 15 minutes. [Go to section 3]

[If NO to 2.2 read:]

Since {CHILDName} does 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 {CHILDName} has asthma now, your interview will probably last about 10 minutes. [Go to section 3]

TERMINATE:

Upon survey termination, READ:

I’m sorry {CHILDName} does not qualify for this study. I’d like to thank you on behalf of the {STATE} 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 {1–800-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.

Appendix B:

Language for Identifying Most Knowledgeable Person at the Call-back

Consent scripts for use during BRFSS 2011 Child asthma module when the most knowledgeable adult is identified at the call-back interview.

Child asthma module:

If BRFSS respondent indicates that the randomly selected child has ever had asthma then arrange for a call-back interview.

CATI: (RCSRELN1 = 1 or 3 and CASTHDX2 = 1 “yes”)

READ: We would like to call again within the next 2 weeks to talk in more detail about your child’s experiences with asthma. The information will be used to help develop and improve the asthma programs in {state name}.

ADULTPERM

Would it be all right if we call back at a later time to ask additional questions about your child’s asthma?

(1) Yes

(2) No (GO TO BRFSS closing or next module)

(7) Don’t know/Not Sure (GO TO BRFSS closing or next module)

(9) Refused (GO TO BRFSS closing or next module)

CHILDName

[CATI: If more than one child, show child age {#}and which child was selected (FIRST, SECOND, ETC.) from child selection module]

Enter child’s first name, initials or nickname: ____________

ADULTName

Can I please have your first name, initials or nickname so we know who to ask for when we call back?

Enter respondent’s first name, initials or nickname: ____________

CBTIME: What is a good time to call you back? For example, evenings, days, weekends?

Enter day/time: _________________

READ: The information you gave us today and will give us when we call back will be kept confidential. We will keep identifying information like your child’s name and your name and phone number on file, separate from the answers collected today. Even though you agreed today, you may refuse to participate in the future.

[CATI: If state requires active linking consent continue, if not, go to BRFSS closing or next module]

LINKING CONSENT

PERMISS: May we combine your answers from today with your answers from the interview about your child’s asthma that will be done in the next two weeks?

(1) Yes (GO TO BRFSS closing or next module)

(2) No (GO TO BRFSS closing or next module)

(7) Don’t Know (GO TO BRFSS closing or next module)

(9) Refused (GO TO BRFSS closing or next module)

Introduction and consent sections for use during the Child Asthma Call-Back when the most knowledgeable adult is identified at call-back interview:

[CATI: CHILDName, ADULTName, ALTName, MKPName, CASTHDX2, and CASTHNO2, RCSGENDR, calculated child’s age, are from the BRFSS child asthma module and must be carried to the asthma call-back]

[CATI: BRFSS Respondent’s SEX also should be carried to the Asthma call-back]

[CATI: IF INTERVIEW BREAKS OFF AT ANY POINT LEAVE REMAINING FIELDS BLANK. DO NOT FILL WITH ANY VALUE.]

Section 1. Introduction

INTRODUCTION TO THE BRFSS Asthma call back for Adult parent/guardian of child with asthma:

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.

1.1 Are you {ADULTName}?

(1) Yes (go to 1.5 READ)

(2) No

1.2 May I speak with {ADULTName}?

(1) Yes (go to 1.4 READ when person comes to phone)

(2) Person not available

1.3 When would be a good time to call back and speak with {ADULTName}. For example, evenings, days, weekends?

Enter day/time: _________________

READ: Thank you we will call again later to speak with {ADULTName}.

[CATI: Start over at introduction at next call.]

ADULTName comes to the phone:

1.4 READ: Hello, my name is ________________. I’m calling on behalf of the {STATE} state health department and the Centers for Disease Control and Prevention about an asthma study we are doing in your state. (GO TO 1.5)

ALTERNATE (no reference to asthma):

Hello, my name is ________________. I’m calling on behalf of the {STATE} state health department and the Centers for Disease Control and Prevention about a health study we are doing in your state.

READ: During a recent phone interview you gave us permission to call again to ask some questions about {CHILDName}’s asthma.

ALTERNATE (no reference to asthma):

During a recent phone interview you gave us permission to call again to ask some questions about {CHILDName}’s health.

KNOWMOST: Are you the parent or guardian in the household who knows the most about {CHILDName}’s asthma?

(1) YES (GO TO SECTION 2: Informed consent)

(2) NO

(7) DON’T KNOW/NOT SURE

(9) REFUSED

ALTPRESENT: If the parent or guardian who knows the most about {CHILDName}’s asthma is present, may I speak with that person now?

(1) YES [respondent transfers phone to alternate] GO TO READ ALTERNATE ADULT:

(2) Person is not available

(7) DON’T KNOW/NOT SURE [GO TO TERMINATE]

(9) REFUSED [GO TO TERMINATE]

ALTName Can I please have the first name, initials or nickname of the person so we can call back and ask for them by name?

Alternate’s Name:__________________________________

ALTCBTime:

When would be a good time to call back and speak with {ALTName}. For example, evenings, days, weekends?

Enter day/time: _________________ [CATI: AT NEXT CALL START AT 1.6]

READ ALTERNATE ADULT:

Hello, my name is ________________. I’m calling on behalf of the {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 {ADULTName} indicated {he/she} would be willing to participate in this study about {CHILDName}’s asthma. {ADULTName} has now indicated that you are more knowledgeable about {CHILDName}’s asthma. It would be better if you would complete this interview

I will not ask for your name, address, or other personal information that can identify you or {CHILDName}. Any information you give me will be confidential. If you have any questions, I can provide a telephone number for you to call to get more information.

[GO TO SECTION 2]

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.

ALTERNATE (no reference to asthma):

1.7 Are you {ALTName}?

(1) Yes (go to 1.10 READ ALT 1)

(2) No

1.8 May I speak with {ALTName}?

(1) Yes (go to 1.11 READ ALT 2 when person comes to phone)

(2) Person not available

1.9 When would be a good time to call back and speak with {ALTName}. For example, evenings, days, weekends?

Enter day/time: _________________

READ: Thank you we will call again later to speak with {ALTName}.

[CATI: Start over at 1.6 at next call.]

1.10 READ ALT 1

During a recent phone interview {ADULTName} indicated {CHILDName} had asthma and that you were more knowledgeable about {his/her} asthma. It would be better if you would complete this interview about {CHILDName}.

I will not ask for your name, address, or other personal information that can identify you or {CHILDName}. Any information you give me will be confidential. If you have any questions, I will provide a telephone number for you to call to get more information.

[GO TO SECTION 2]

1.11 READ ALT 2:

Hello, my name is ________________. I’m calling on behalf of the {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 {ADULTName} indicated {CHILDName} had asthma and that you were more knowledgeable about {his/her} asthma. It would be better if you would complete this interview about {CHILDName}.

I will not ask for your name, address, or other personal information that can identify you or {CHILDName}. Any information you give me will be confidential. If you have any questions, I will provide a telephone number for you to call to get more information.

[GO TO SECTION 2]

Section 2. Informed Consent

INFORMED CONSENT

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

{CHILDName} was selected to participate in this study about asthma because of responses to questions about his or her asthma in a prior survey.

[If responses for sample child were “yes” (1) to CASTHDX2 and “no” (2) to CASTHNO2 in core BRFSS interview:]

READ: The answers to asthma questions during the earlier survey indicated that a doctor or other health professional said that {CHILDName} had asthma sometime in {his/her} life, but does not have it now. Is that correct?

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

Since {CHILDName} no longer has asthma, your interview will be very brief (about 5 minutes). [Go to section 3]

[If responses for sample child were “yes” (1) CASTHDX2 to and “yes” (1) to CASTHNO2 in core BRFSS survey:]

READ: Answers to the asthma questions in the earlier survey indicated that that a doctor or other health professional said that {CHILDName} had asthma sometime in his or her life, and that {CHILDName} still has asthma. Is that correct?

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

Since {child’s name} has asthma now, your interview will last about 15 minutes. [Go to section 3]

REPEAT (2.0)

I would like to repeat the questions from the previous survey now to make sure {CHILDName} qualifies for this study.

EVER_ASTH (2.1) Have you ever been told by a doctor or other health professional that {CHILDName} had asthma?

(1) YES

(2) NO [Go to TERMINATE]

(7) Don’t know [Go to TERMINATE]

(9) Refused [Go to TERMINATE]

CUR_ASTH (2.2) Does {he/she} still have asthma?

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

RELATION (2.3) What is your relationship to {CHILDName}?

(1) MOTHER (BIRTH/ADOPTIVE/STEP) [go to READ]

(2) FATHER (BIRTH/ADOPTIVE/STEP) [go to READ]

(3) BROTHER/SISTER (STEP/FOSTER/HALF/ADOPTIVE)

(4) GRANDPARENT (FATHER/MOTHER)

(5) OTHER RELATIVE

(6) UNRELATED

(7) DON’T KNOW

(9) REFUSED

GUARDIAN (2.4) Are you the legal guardian for {CHILDName}

(1) YES

(2) NO

(7) DON’T KNOW

(9) REFUSED

READ: {CHILDName} does qualify for this study.

[If YES to 2.2 read:]

Since {CHILDName} does have asthma now, your interview will last about 15 minutes. [Go to section 3]

[If NO to 2.2 read:]

Since {CHILDName} does 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 {CHILDName} has asthma now, your interview will probably last about 10 minutes. [Go to section 3]

TERMINATE:

Upon survey termination, READ:

101

BRFSS Asthma Call-back Survey - Child 2013 Questionnaire

Public release version, 2014

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	BRFSS/ASTHMA SURVEY
Author	Comeau
File Modified	0000-00-00
File Created	2021-01-23