Form Attachment 5a-2017 Attachment 5a-2017 2017 BRFSS Core Survey Questionnaire

Public reporting burden of this collection of information is estimated to average XX minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061).

NOTE: Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Carol Pierannunzi at [email protected].

HELLO, I am calling for the (health department) . My name is (name) . We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices.

LL.1 Is this (phone number) ?

[CATI NOTE: IF "NO”: Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time. CATI NOTE: STOP]

PVTRES

LL.2 Is this a private residence?

Read only if necessary: “By private residence, we mean someplace like a house or apartment.”

INTERVIEWER NOTE: PRIVATE RESIDENCE INCLUDES ANY HOME WHERE THE RESPONDENT SPENDS AT LEAST 30 DAYS INCLUDING VACATION HOMES, RVS OR OTHER LOCATIONS IN WHICH THE RESPONDENT LIVES FOR PORTIONS OF THE YEAR.

Yes [GO TO STATE OF RESIDENCE]
No [GO TO COLLEGE HOUSING]

[CATI NOTE: IF NO, BUSINESS PHONE ONLY: THANK YOU VERY MUCH BUT WE ARE ONLY INTERVIEWING PERSONS ON RESIDENTIAL PHONES LINES AT THIS TIME.”STOP]

College Housing

LL.3 Do you live in college housing?

Read only if necessary: “By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.”

Yes [GO TO CELLULAR PHONE]
No

[CATI NOTE: IF NO: THANK YOU VERY MUCH, BUT WE ARE ONLY INTERVIEWING PERSONS WHO LIVE IN A PRIVATE RESIDENCE OR COLLEGE HOUSING AT THIS TIME. STOP]

Cellular Phone

LL.4 Is this a cell telephone?

INTERVIEWER NOTE: TELEPHONE SERVICE OVER THE INTERNET COUNTS AS LANDLINE SERVICE (INCLUDES VONAGE, MAGIC JACK AND OTHER HOME-BASED PHONE SERVICES).

Read only if necessary: “By cell (or cellular) telephone we mean a telephone that is mobile and usable outside of your neighborhood.”

[CATI NOTE: IF “YES”: THANK YOU VERY MUCH, BUT WE ARE ONLY INTERVIEWING BY LAND LINE TELEPHONES AND FOR PRIVATE RESIDENCES OR COLLEGE HOUSING. STOP]

[CATI NOTE: IF (COLLEGE HOUSING = YES) CONTINUE; OTHERWISE GO TO ADULT RANDOM SELECTION]

Adult

LL.5 Are you 18 years of age or older?

1 Yes, respondent is male [GO TO NEXT SECTION]

2 Yes, respondent is female [GO TO NEXT SECTION]

3 No

[CATI NOTE: IF NO: THANK YOU VERY MUCH, BUT WE ARE ONLY INTERVIEWING PERSONS AGED 18 OR OLDER AT THIS TIME. STOP]

Adult Random Selection

I need to randomly select one adult who lives in your household to be interviewed. How many members of your household, including yourself, are 18 years of age or older?

LL.6 __ Number of adults

If "1,": Are you the adult?

If "yes,":

Then you are the person I need to speak with. Enter 1 man or 1 woman below (Ask gender if necessary).

[GO TO PAGE 8]

[CATI NOTE: IF "NO,": IS THE ADULT A MAN OR A WOMAN? ENTER 1 MAN OR 1 WOMAN BELOW. MAY I SPEAK WITH [FILL IN (HIM/HER) FROM PREVIOUS QUESTION]? ]

[GO TO "CORRECT RESPONDENT" ON THE NEXT PAGE]

LL.7 How many of these adults are men?

__ Number of men

So the number of women in the household is ___

__ Number of women

Is that correct?

INTERVIEWER NOTE: CONFIRM NUMBER OF ADULT WOMEN OR CLARIFY THE TOTAL NUMBER OF ADULTS IN THE HOUSEHOLD.

The person in your household that I need to speak with is .

If "you," [GO TO NEXT SECTION]

To Correct Respondent:

Interviewer’s Script Cell Phone

Form Approved

OMB No. 0920-1061

Exp. Date 3/31/2018

Public reporting burden of this collection of information is estimated to average xx minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061).

HELLO, I am calling for the (health department). My name is (name) . We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices.

CP.1 Is this a safe time to talk with you?

Yes [GOTO PHONE]
No

[CATI NOTE: IF "NO”: THANK YOU VERY MUCH. WE WILL CALL YOU BACK AT A MORE CONVENIENT TIME. ([SET APPOINTMENT IF POSSIBLE]) STOP]

Phone

CP.2 Is this (phone number) ?

Yes [GO TO CELLULAR PHONE]
No INTERVIEWER NOTE: CONFIRM TELEPHONE NUMBER

[CATI NOTE: IF "NO”: THANK YOU VERY MUCH, BUT I SEEM TO HAVE DIALED THE WRONG NUMBER. IT’S POSSIBLE THAT YOUR NUMBER MAY BE CALLED AT A LATER TIME. STOP]

Cellular Phone

CP.3 Is this a cell telephone?

Read only if necessary: “By cell telephone, we mean a telephone that is mobile and usable outside of your neighborhood.”

Yes [GO TO ADULT]
No

[CATI NOTE: IF "NO”: THANK YOU VERY MUCH, BUT WE ARE ONLY INTERVIEWING CELL TELEPHONES AT THIS TIME. STOP]

Adult

CP.4 Are you 18 years of age or older?

1. Yes, respondent is male [GO TO PRIVATE RESIDENCE]

2. Yes, respondent is female [GO TO PRIVATE RESIDENCE]

3 No

[CATI NOTE: IF "NO”, THANK YOU VERY MUCH, BUT WE ARE ONLY INTERVIEWING PERSONS AGED 18 OR OLDER AT THIS TIME. STOP]

Private Residence

CP.5 Do you live in a private residence?

Read only if necessary: “By private residence, we mean someplace like a house or apartment.”

Yes [GO TO STATE OF RESIDENCE]
No [GO TO COLLEGE HOUSING]

College Housing

CP.6 Do you live in college housing?

Read only if necessary: “By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.”

Yes [GO TO STATE OF RESIDENCE]
No

[CATI NOTE: IF "NO”: THANK YOU VERY MUCH, BUT WE ARE ONLY INTERVIEWING PERSONS WHO LIVE IN A PRIVATE RESIDENCE OR COLLEGE HOUSING AT THIS TIME. STOP]

State of Residence

CP.7 Do you currently live in ____(state)____?

1. Yes [GO TO LANDLINE]

2. No [GO TO STATE]

State

CP.8 In what state do you currently live?

ENTER FIPS STATE

Landline

CP. 9 Do you also have a landline telephone in your home that is used to make and receive calls?

Read only if necessary: “By landline telephone, we mean a “regular” telephone in your home that is used for making or receiving calls.” Please include landline phones used for both business and personal use.”

INTERVIEWER NOTE: TELEPHONE SERVICE OVER THE INTERNET COUNTS AS LANDLINE SERVICE (INCLUDES VONAGE, MAGIC JACK AND OTHER HOME-BASED PHONE SERVICES.).

[CATI NOTE: IF COLLEGE HOUSING = “YES”, DO NOT ASK NUMBER OF ADULTS QUESTIONS, GO TO CORE.]

NUMADULT

CP.10 How many members of your household, including yourself, are 18 years of age or older?

__ Number of adults

[CATI NOTE: IF COLLEGE HOUSING = “YES” THEN NUMBER OF ADULTS IS SET TO 1.]

Core Sections

I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will be confidential. If you have any questions about the survey, please call (give appropriate state telephone number).

Section 1: Health Status

1.1 Would you say that in general your health is— (90)

Please read:

1 Excellent

2 Very good

3 Good

4 Fair, or

5 Poor

Do not read:

7 Don’t know / Not sure

9 Refused

Section 2: Healthy Days — Health-Related Quality of Life

2.1 Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

(91-92)

_ _ Number of days

88 None

77 Don’t know / Not sure

99 Refused

2.2 Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? (93-94)

_ _ Number of days

88 None [IF Q2.1 AND Q2.2 = 88 (NONE), GO TO NEXT SECTION]

77 Don’t know / Not sure

99 Refused

2.3 During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

(95-96)

_ _ Number of days

88 None

77 Don’t know / Not sure

99 Refused

Section 3: Health Care Access

Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, government plans such as Medicare, or Indian Health Service?

(97)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

3.2 Do you have one person you think of as your personal doctor or health care provider?

If “No” ask: “Is there more than one, or is there no person who you think of as your personal doctor or health care provider?”

(98)

1 Yes, only one

2 More than one

3 No

7 Don’t know / Not sure

9 Refused

3.3 Was there a time in the past 12 months when you needed to see a doctor but could not because of cost? (99)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

3.4 A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition. About how long has it been since you last visited a doctor for a routine checkup?

(100)

Read only if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 5 years (2 years but less than 5 years ago)

4 5 or more years ago

Do not read:

7 Don’t know / Not sure

8 Never

9 Refused

Section 4: Hypertension Awareness

4.1 Have you EVER been told by a doctor, nurse, or other health professional that you have

high blood pressure? (101)

Read only if necessary: By “other health professional” we mean a nurse practitioner, a physician’s assistant, or some other licensed health professional.

If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”

1 Yes

2 Yes, but female told only during pregnancy [GO TO NEXT SECTION]

3 No [GO TO NEXT SECTION]

4 Told borderline high or pre-hypertensive [GO TO NEXT SECTION]

7 Don’t know / Not sure [GO TO NEXT SECTION]

9 Refused [GO TO NEXT SECTION]

4.2 Are you currently taking medicine for your high blood pressure? (102)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Section 5: Cholesterol Awareness

5.1 Blood cholesterol is a fatty substance found in the blood. About how long has it been since you last had your blood cholesterol checked?

(103)

Read only if necessary:

1 Never

2 Within the past year (anytime less than 12 months ago)

3 Within the past 2 years (1 year but less than 2 years ago)

4 Within the past 5 years (2 years but less than 5 years ago)

5 5 or more years ago

Do not read:

7 Don’t know / Not sure

9 Refused

5.2 Have you EVER been told by a doctor, nurse or other health professional that your blood cholesterol is high?

(104)

1 Yes

2 No [GO TO NEXT SECTION]

7 Don’t know / Not sure

9 Refused

5.3 Are you currently taking medicine prescribed by a doctor or other health professional for your blood cholesterol?

(105)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Section 6: Chronic Health Conditions

Has a doctor, nurse, or other health professional EVER told you that you had any of the following? For each, tell me “Yes,” “No,” or you’re “Not sure.”

6.1 (Ever told) you that you had a heart attack also called a myocardial infarction? (106)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.2 (Ever told) you had angina or coronary heart disease? (107)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.3 (Ever told) you had a stroke? (108)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.4 (Ever told) you had asthma? (109)

1 Yes

2 No [GO TO Q6.6]

7 Don’t know / Not sure [GO TO Q6.6]

9 Refused [GO TO Q6.6]

6.5 Do you still have asthma? (110)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.6 (Ever told) you had skin cancer? (111)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.7 (Ever told) you had any other types of cancer? (112)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.8 (Ever told) you have Chronic Obstructive Pulmonary Disease or COPD, emphysema or chronic bronchitis? (113)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.9 (Ever told) you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia? (114)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: ARTHRITIS DIAGNOSES INCLUDE:

RHEUMATISM, POLYMYALGIA RHEUMATICA

OSTEOARTHRITIS (NOT OSTEOPOROSIS)
TENDONITIS, BURSITIS, BUNION, TENNIS ELBOW
CARPAL TUNNEL SYNDROME, TARSAL TUNNEL SYNDROME
JOINT INFECTION, REITER’S SYNDROME
ANKYLOSING SPONDYLITIS; SPONDYLOSIS
ROTATOR CUFF SYNDROME
CONNECTIVE TISSUE DISEASE, SCLERODERMA, POLYMYOSITIS, RAYNAUD’S SYNDROME
VASCULITIS (GIANT CELL ARTERITIS, HENOCH-SCHONLEIN PURPURA, WEGENER’S GRANULOMATOSIS,
POLYARTERITIS NODOSA)

6.10 (Ever told) you have a depressive disorder, including depression, major depression, dysthymia, or minor depression? (115)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.11 (Ever told) you have kidney disease? Do NOT include kidney stones, bladder infection or incontinence. (116)

INTERVIEWER NOTE: INCONTINENCE IS NOT BEING ABLE TO CONTROL URINE FLOW.

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.12 (Ever told) you have diabetes? (117)

If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”;

If respondent says pre-diabetes or borderline diabetes, use response code 4.

1 Yes

2 Yes, but female told only during pregnancy

3 No

4 No, pre-diabetes or borderline diabetes

7 Don’t know / Not sure

9 Refused

[CATI NOTE: IF Q6.12 = 1 (YES), GO TO NEXT QUESTION. IF ANY OTHER RESPONSE TO Q6.12, GO TO PRE-DIABETES OPTIONAL MODULE (IF USED). OTHERWISE, GO TO NEXT SECTION.]

6.13 How old were you when you were told you have diabetes? (118-119)

_ _ Code age in years [97 = 97 and older]

98 Don’t know / Not sure

99 Refused

[CATI NOTE: GO TO DIABETES OPTIONAL MODULE (IF USED). OTHERWISE, GO TO NEXT SECTION. ]

Section 7: Arthritis Burden

[CATI NOTE: IF Q6.9 = 1 (YES) THEN CONTINUE, ELSE GO TO NEXT SECTION.]

Next, I will ask you about your arthritis.

Arthritis can cause symptoms like pain, aching, or stiffness in or around a joint.

7.1 Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms? (120)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

INTERVIEWER INSTRUCTION: IF A QUESTION ARISES ABOUT MEDICATIONS OR TREATMENT, THEN THE INTERVIEWER SHOULD SAY: “PLEASE ANSWER THE QUESTION BASED ON YOUR CURRENT EXPERIENCE, REGARDLESS OF WHETHER YOU ARE TAKING ANY MEDICATION OR TREATMENT.”

INTERVIEWER NOTE: Q13.2 SHOULD BE ASKED OF ALL RESPONDENTS REGARDLESS OF EMPLOYMENT. STATUS.

7.2 In this next question, we are referring to work for pay. Do arthritis or joint symptoms now affect whether you work, the type of work you do, or the amount of work you do?

(121)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

INTERVIEWER INSTRUCTION: IF RESPONDENT GIVES AN ANSWER TO EACH ISSUE (WHETHER RESPONDENT WORKS, TYPE OF WORK, OR AMOUNT OF WORK), THEN IF ANY ISSUE IS “YES” MARK THE OVERALL RESPONSE AS “YES.”

IF A QUESTION ARISES ABOUT MEDICATIONS OR TREATMENT, THEN THE INTERVIEWER SHOULD SAY: “PLEASE ANSWER THE QUESTION BASED ON YOUR CURRENT EXPERIENCE, REGARDLESS OF WHETHER YOU ARE TAKING ANY MEDICATION OR TREATMENT.”

7.3 During the past 30 days, to what extent has your arthritis or joint symptoms interfered with your normal social activities, such as going shopping, to the movies, or to religious or social gatherings?

(122)

Please read [1-3]:

1 A lot

2 A little

3 Not at all

Do not read:

7 Don’t know / Not sure

9 Refused

7.4 Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. On a scale of 0 to 10 where 0 is no pain or aching and 10 is pain or aching as bad as it can be, DURING THE PAST 30 DAYS, how bad was your joint pain ON AVERAGE?

_ _ Enter number [00-10] (123-124)

77 Don’t know / Not sure

99 Refused

Section 8: Demographics

8.1 Are you … (125)

1 Male

2 Female

9 Refused

INTERVIEWER NOTE: THIS QUESTION MUST BE ASKED EVEN IF INTERVIEWER HAD PREVIOUSLY ENTERED SEX IN THE SCREENING QUESTIONS. IT WILL NOT BE ASKED OF PERSONS WHO HAVE SELF-IDENTIFIED SEX IN LL HOUSEHOLD ENUMERATION.

[CATI NOTE: THISQUESTION MAY BE POPULATED BY LANDLINE HOUSEHOLD ENUMERATION ONLY. IT MAY NOT BE POPULATED BY INTERVIEWER ASSIGNMENT OF SEX DURING THE SCREENING FOR CELL PHONE OR PERSONS LIVING IN COLLEGE HOUSING]

8.2 What is your age? (126-127)

_ _ Code age in years

07 Don’t know / Not sure

09 Refused

8.3 Are you Hispanic, Latino/a, or Spanish origin? (128-131)

If yes, ask: Are you…

INTERVIEWER NOTE: One Or More Categories May Be Selected.

1 Mexican, Mexican American, Chicano/a

2 Puerto Rican

3 Cuban

4 Another Hispanic, Latino/a, or Spanish origin

Do not read:

5 No

7 Don’t know / Not sure

9 Refused

8.4 Which one or more of the following would you say is your race? (132-159)

INTERVIEWER NOTE: SELECT ALL THAT APPLY.

INTERVIEWER NOTE: IF 40 (ASIAN) OR 50 (PACIFIC ISLANDER) IS SELECTED READ AND CODE SUBCATEGORIES UNDERNEATH MAJOR HEADING.

Please read:

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

88 No additional choices

77 Don’t know / Not sure

99 Refused

[CATI NOTE: IF MORE THAN ONE RESPONSE TO Q8.4; CONTINUE. OTHERWISE, GO TO Q8.6.]

8.5 Which one of these groups would you say best represents your race?

INTERVIEWER NOTE: IF 40 (ASIAN) OR 50 (PACIFIC ISLANDER) IS SELECTED READ AND CODE SUBCATEGORY UNDERNEATH MAJOR HEADING. IF RESPONDENT HAS SELECTED MULTIPLE RACES IN PREVIOUS AND REFUSES TO SELECT A SINGLE RACE, CODE “REFUSED.”

(160-161)

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

77 Don’t know / Not sure

99 Refused

8.6 Are you…? (162)

Please read:

1 Married

2 Divorced

3 Widowed

4 Separated

5 Never married, or

6 A member of an unmarried couple

Do not read:

9 Refused

8.7 What is the highest grade or year of school you completed? (163)

Read only if necessary:

1 Never attended school or only attended kindergarten

2 Grades 1 through 8 (Elementary)

3 Grades 9 through 11 (Some high school)

4 Grade 12 or GED (High school graduate)

5 College 1 year to 3 years (Some college or technical school)

6 College 4 years or more (College graduate)

Shape1

NOTE: Items in parentheses at any place in the questions or response DO NOT need to be read.

Do not read:

9 Refused

8.8 Do you own or rent your home? (164)

Read only if necessary:

1 Own

2 Rent

3 Other arrangement

Do not read:

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: “OTHER ARRANGEMENT” MAY INCLUDE GROUP HOME, STAYING WITH FRIENDS OR FAMILY WITHOUT PAYING RENT.

INTERVIEWER NOTE: HOME IS DEFINED AS THE PLACE WHERE YOU LIVE MOST OF THE TIME/THE MAJORITY OF THE YEAR.

INTERVIEWER NOTE: WE ASK THIS QUESTION IN ORDER TO COMPARE HEALTH INDICATORS AMONG PEOPLE WITH DIFFERENT HOUSING SITUATIONS.

8.9 In what county do you currently live? (165-167)

_ _ _ ANSI County Code (formerly FIPS county code)

777 Don’t know / Not sure

999 Refused

8.10 What is the ZIP Code where you currently live? (168-172)

_ _ _ _ _ ZIP Code

77777 Don’t know / Not sure

99999 Refused

[CATI NOTE: IF CELL TELEPHONE INTERVIEW SKIP TO 8.14 (QSTVER GE 20)]

8.11 Do you have more than one telephone number in your household? Do not include cell phones or numbers that are only used by a computer or fax machine. (173)

1 Yes

2 No [GO TO Q8.13]

7 Don’t know / Not sure [GO TO Q8.13]

9 Refused [GO TO Q8.13]

8.12 How many of these telephone numbers are residential numbers? (174)

_ Residential telephone numbers [6 = 6 or more]

7 Don’t know / Not sure

9 Refused

8.13 Including phones for business and personal use, do you have a cell phone for personal use?

(175)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

8.14 Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?

INTERVIEWER NOTE: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.

(176)

1 Yes

2 No

Do not read:

7 Don’t know / Not sure

9 Refused

8.15 Are you currently…?

INTERVIEWER NOTE: IF MORE THAN ONE: SAY “SELECT THE CATEGORY WHICH BEST DESCRIBES YOU”.

Please read: (177)

Shape2

NOTE: Do not code 7 for “don’t know” on this question.

1 Employed for wages

2 Self-employed

3 Out of work for 1 year or more

4 Out of work for less than 1 year

5 A Homemaker

6 A Student

7 Retired, or

8 Unable to work

Do not read:

9 Refused

8.16 How many children less than 18 years of age live in your household? (178-179)

_ _ Number of children

88 None

99 Refused

8.17 Is your annual household income from all sources—

INTERVIEWER NOTE: IF RESPONDENT REFUSES AT ANY INCOME LEVEL, CODE ‘99’ (REFUSED) (180-181)

Read only if necessary:

04 Less than $25,000 If “no,” ask 05; if “yes,” ask 03

($20,000 to less than $25,000)

03 Less than $20,000 If “no,” code 04; if “yes,” ask 02

($15,000 to less than $20,000)

02 Less than $15,000 If “no,” code 03; if “yes,” ask 01

($10,000 to less than $15,000)

01 Less than $10,000 If “no,” code 02

05 Less than $35,000 If “no,” ask 06

($25,000 to less than $35,000)

06 Less than $50,000 If “no,” ask 07

($35,000 to less than $50,000)

07 Less than $75,000 If “no,” code 08

($50,000 to less than $75,000)

08 $75,000 or more

Do not read:

77 Don’t know / Not sure

99 Refused

8.18 Have you used the internet in the past 30 days? (182)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

8.19 About how much do you weigh without shoes?

INTERVIEWER NOTE: IF RESPONDENT ANSWERS IN METRICS, PUT “9” IN COLUMN 183. ROUND FRACTIONS UP

(183-186)

_ _ _ _ Weight

(pounds/kilograms)

7777 Don’t know / Not sure

9999 Refused

8.20 About how tall are you without shoes?

INTERVIEWER NOTE: IF RESPONDENT ANSWERS IN METRICS, PUT “9” IN COLUMN 187. ROUND FRACTIONS DOWN (187-190)

_ _ / _ _ Height

(f t / inches/meters/centimeters)

77/ 77 Don’t know / Not sure

99/ 99 Refused

[CATI NOTE: IF MALE, GO TO 8.22, IF FEMALE RESPONDENT IS 50 YEARS OLD OR OLDER, GO TO Q8.22]

8.21 To your knowledge, are you now pregnant? (191)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

The following questions are about health problems or impairments you may have.

Some people who are deaf or have serious difficulty hearing may or may not use equipment to communicate by phone.

8.22 Are you deaf or do you have serious difficulty hearing? (192)

1 Yes

2 No

7 Don’t know / Not Sure

9 Refused

8.23 Are you blind or do you have serious difficulty seeing, even when wearing glasses? (193)

1 Yes

2 No

7 Don’t know / Not Sure

9 Refused

8.24 Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (194)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

8.25 Do you have serious difficulty walking or climbing stairs? (195)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

8.26 Do you have difficulty dressing or bathing? (196)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

8.27 Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? (197)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Section 9: Tobacco Use

9.1 Have you smoked at least 100 cigarettes in your entire life? (198)

INTERVIEWER NOTE: 5 PACKS = 100 CIGARETTES

1 Yes

2 No [GO TO Q9.5]

7 Don’t know / Not sure [GO TO Q9.5]

9 Refused [GO TO Q9.5]

INTERVIEWER NOTE: “FOR CIGARETTES, DO NOT INCLUDE: ELECTRONIC CIGARETTES (E-CIGARETTES, NJOY, BLUETIP), HERBAL CIGARETTES, CIGARS, CIGARILLOS, LITTLE CIGARS, PIPES, BIDIS, KRETEKS, WATER PIPES (HOOKAHS), OR MARIJUANA.”

9.2 Do you now smoke cigarettes every day, some days, or not at all? (199)

Do not read:

1 Every day

2 Some days

3 Not at all [GO TO Q9.4]

7 Don’t know / Not sure [GO TO Q9.5]

9 Refused [GO TO Q9.5]

9.3 During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking? (200)

1 Yes [GO TO Q9.5]

2 No [GO TO Q9.5]

7 Don’t know / Not sure [GO TO Q9.5]

9 Refused [GO TO Q9.5]

9.4 How long has it been since you last smoked a cigarette, even one or two puffs?

(201-202)

Read only if necessary:

01 Within the past month (less than 1 month ago)

02 Within the past 3 months (1 month but less than 3 months ago)

03 Within the past 6 months (3 months but less than 6 months ago)

04 Within the past year (6 months but less than 1 year ago)

05 Within the past 5 years (1 year but less than 5 years ago)

06 Within the past 10 years (5 years but less than 10 years ago)

07 10 years or more

08 Never smoked regularly

Do not read:

77 Don’t know / Not sure

99 Refused

9.5 Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all? (203)

NOTE: SNUS (RHYMES WITH ‘GOOSE’)/ SNUS (SWEDISH FOR SNUFF) IS A MOIST SMOKELESS TOBACCO, USUALLY SOLD IN SMALL POUCHES THAT ARE PLACED UNDER THE LIP AGAINST THE GUM.

Do not read:

1 Every day

2 Some days

3 Not at all

Do not read:

7 Don’t know / Not sure

9 Refused

Section 10: E-Cigarettes

The next 2 questions are about electronic cigarettes and other electronic “vaping” products containing nicotine. Do not include marijuana use.

INTERVIEWER NOTE: THESE QUESTIONS CONCERN ELECTRONIC VAPING PRODUCTS FOR NICOTINE USE. THE USE OF ELECTRONIC VAPING PRODUCTS FOR MARIJUANA USE IS NOT INCLUDED IN THESE QUESTIONS.

Read if necessary: Electronic cigarettes (e-cigarettes) and other electronic “vaping” products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy.

10.1 Have you ever used an e-cigarette or other electronic “vaping” product, even just one time, in your entire life? (204)

		1	Yes
		2	No [GO TO NEXT SECTION]
		7	Don’t know / Not Sure [GO TO NEXT SECTION]
		9	Refused [GO TO NEXT SECTION]

10.2 Do you now use e-cigarettes or other electronic “vaping” products every day, some days, or not at all? (205)

1	Every day
2	Some days
3	Not at all
7	Don’t know / Not sure
9	Refused

Section 11: Alcohol Consumption

11.1 During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?

(206-208)

1 _ _ Days per week

2 _ _ Days in past 30 days

888 No drinks in past 30 days [GO TO NEXT SECTION]

777 Don’t know / Not sure [GO TO NEXT SECTION]

999 Refused [GO TO NEXT SECTION]

11.2 One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?

NOTE: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks. (209-210)

_ _ Number of drinks

77 Don’t know / Not sure

99 Refused

11.3 Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI NOTE: X = 5 FOR MEN, X = 4 FOR WOMEN] or more drinks on an occasion? (211-212)

_ _ Number of times

88 None

77 Don’t know / Not sure

99 Refused

11.4 During the past 30 days, what is the largest number of drinks you had on any occasion? (213-214)

_ _ Number of drinks

77 Don’t know / Not sure

99 Refused

Section 12: Fruits and Vegetables

Now think about the foods you ate or drank during the past month, that is, the past 30 days, including meals and snacks.

INTERVIEWER INSTRUCTIONS: IF A RESPONDENT INDICATES THAT THEY CONSUME A FOOD ITEM EVERY DAY THEN ENTER THE NUMBER OF TIMES PER DAY. IF THE RESPONDENT INDICATES THAT THEY EAT A FOOD LESS THAN DAILY, THEN ENTER TIMES PER WEEK OR TIMES PER MONTH. DO NOT ENTER TIMES PER DAY UNLESS THE RESPONDENT REPORTS THAT HE/SHE CONSUMED THAT FOOD ITEM EACH DAY DURING THE PAST MONTH.

12.1 Not including juices, how often did you eat fruit? You can tell me times per day, times per week or times per month. (215-217)

INTERVIEWER NOTE: ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1_ _ Days

2_ _ Weeks

3_ _ Months

888 Never

777 Don’t Know

999 Refused

12.2 Not including fruit-flavored drinks or fruit juices with added sugar, how often did you drink 100% fruit juice such as apple or orange juice? You can tell me times per day, times per week or times per month. (218-220)

INTERVIEWER NOTE: ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1_ _ Days

2_ _ Weeks

3_ _ Months

888 Never

777 Don’t Know

999 Refused

12.3 How often did you eat a green leafy or lettuce salad, with or without other vegetables?

You can tell me times per day, times per week or times per month.

INTERVIEWER NOTE: ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

(221-223)

1_ _ Days

2_ _ Weeks

3_ _ Months

888 Never

777 Don’t Know

999 Refused

12.4 How often did you eat any kind of fried potatoes, including french fries, home fries, or hash browns? You can tell me times per day, times per week or times per month. (224-226)

INTERVIEWER NOTE: ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1_ _ Days

2_ _ Weeks

3_ _ Months

888 Never

777 Don’t Know

999 Refused

12.5 How often did you eat any other kind of potatoes, or sweet potatoes, such as baked, boiled, mashed potatoes, or potato salad? You can tell me times per day, times per week or times per month. (227-229)

INTERVIEWER NOTE: ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1_ _ Days

2_ _ Weeks

3_ _ Months

888 Never

777 Don’t Know

999 Refused

12.6 Not including lettuce salads and potatoes, how often did you eat other vegetables?

INTERVIEWER NOTE: ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

(230-232)

1_ _ Days

2_ _ Weeks

3_ _ Months

888 Never

777 Don’t Know

999 Refused

Section 13: Exercise (Physical Activity)

The next few questions are about exercise, recreation, or physical activities other than your regular job duties.

INTERVIEWER INSTRUCTION: If respondent does not have a “regular job duty” or is retired, they may count the physical activity or exercise they spend the most time doing in a regular month.

13.1 During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise? (233)

1 Yes

2 No [GO TO Q13.8]

7 Don’t know / Not sure [GO TO Q13.8]

9 Refused [GO TO Q13.8]

13.2 What type of physical activity or exercise did you spend the most time doing during the past month? (234-235)

_ _ (Specify) [See Physical Activity Coding List]

77 Don’t know / Not Sure [GO TO Q13.8]

99 Refused [GO TO Q13.8]

INTERVIEWER INSTRUCTION: IF THE RESPONDENT’S ACTIVITY IS NOT INCLUDED IN THE PHYSICAL ACTIVITY CODING LIST, CHOOSE THE OPTION LISTED AS “OTHER”.

13.3 How many times per week or per month did you take part in this activity during the past month? (236-238)

1_ _ Times per week

2_ _ Times per month

777 Don’t know / Not sure

999 Refused

13.4 And when you took part in this activity, for how many minutes or hours did you usually keep at it? (239-241)

_:_ _ Hours and minutes

777 Don’t know / Not sure

999 Refused

13.5 What other type of physical activity gave you the next most exercise during the past month? (242-243)

_ _ (Specify) [See Physical Activity Coding List]

88 No other activity [GO TO Q13.8]

77 Don’t know / Not Sure [GO TO Q13.8]

99 Refused [GO TO Q13.8]

INTERVIEWER INSTRUCTION: IF THE RESPONDENT’S ACTIVITY IS NOT INCLUDED IN THE CODING PHYSICAL ACTIVITY LIST, CHOOSE THE OPTION LISTED AS “OTHER”.

13.6 How many times per week or per month did you take part in this activity during the past month? (244-246)

1_ _ Times per week

2_ _ Times per month

777 Don’t know / Not sure

999 Refused

13.7 And when you took part in this activity, for how many minutes or hours did you usually keep at it? (247-249)

_:_ _ Hours and minutes

777 Don’t know / Not sure

999 Refused

13.8 During the past month, how many times per week or per month did you do physical activities or exercises to STRENGTHEN your muscles? Do NOT count aerobic activities like walking, running, or bicycling. Count activities using your own body weight like yoga, sit-ups or push-ups and those using weight machines, free weights, or elastic bands.

(250-252)

1_ _ Times per week

2_ _ Times per month

888 Never

777 Don’t know / Not sure

999 Refused

Section 14: Seatbelt Use

14.1 How often do you use seat belts when you drive or ride in a car? Would you say — (253)

Please read: 1 Always

2 Nearly always

3 Sometimes

4 Seldom

5 Never

Do not read:

7 Don’t know / Not sure

8 Never drive or ride in a car

9 Refused

Section 15: Immunization

Now I will ask you questions about the flu vaccine. There are two ways to get the flu vaccine, one is a shot in the arm and the other is a spray, mist, or drop in the nose called FluMist™.

15.1 During the past 12 months, have you had either a flu shot or a flu vaccine that was sprayed in your nose? (254)

Read only if necessary: A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.

1 Yes

2 No [GO TO Q15.3]

7 Don’t know / Not sure [GO TO Q15.3]

9 Refused [GO TO Q15.3]

15.2 During what month and year did you receive your most recent flu shot injected into your arm or flu vaccine that was sprayed in your nose?

(255-260)

_ _ / _ _ _ _ Month / Year

77 / 7777 Don’t know / Not sure

99 / 9999 Refused

15.3 A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person’s lifetime and is different from the flu shot. Have you ever had a pneumonia shot?

(261)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

[CATI NOTE: IF RESPONDENT IS < 49 YEARS OF AGE, GO TO NEXT SECTION.]

15.4. Have you ever had the shingles or zoster vaccine? (262)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE (READ IF NECESSARY): SHINGLES IS CAUSED BY THE CHICKEN POX VIRUS. IT IS AN OUTBREAK OF RASH OR BLISTERS ON THE SKIN THAT MAY BE ASSOCIATED WITH SEVERE PAIN. A VACCINE FOR SHINGLES HAS BEEN AVAILABLE SINCE MAY 2006; IT IS CALLED ZOSTAVAX®, THE ZOSTER VACCINE, OR THE SHINGLES VACCINE.

Section 16: HIV/AIDS

The next few questions are about the national health problem of HIV, the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don’t have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.

16.1 Have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation. Include testing fluid from your mouth. (263)

1 Yes

2 No [GO TO OPTIONAL MODULE TRANSITION]

7 Don’t know /Not sure [GO TO OPTIONAL MODULE TRANSITION]

9 Refused [GO TO OPTIONAL MODULE TRANSITION]

16.2 Not including blood donations, in what month and year was your last HIV test?

INTERVIEWER INSTRUCTIONS: IF RESPONSE IS BEFORE JANUARY 1985, CODE “DON’T KNOW.” IF THE RESPONDENT REMEMBERS THE YEAR BUT CANNOT REMEMBER THE MONTH, CODE THE FIRST TWO DIGITS 77 AND THE LAST FOUR DIGITS FOR THE YEAR.

(264-269)

_ _ /_ _ _ _ Code month and year

77/7777 Don’t know / Not sure

99/9999 Refused / Not sure

16.3 I am going to read you a list. When I am done, please tell me if any of the situations apply to you. You do not need to tell me which one. (270)

You have used intravenous drugs in the past year.

You have been treated for a sexually transmitted or venereal disease in the past year.

You have given or received money or drugs in exchange for sex in the past year.

You had anal sex without a condom in the past year.

You had four or more sex partners in the past year.

Do any of these situations apply to you?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Closing Statement

INTERVIEWER NOTE: IF THERE ARE NO MODULES/STATE ADDED QUESTIONS OR THIS IS AN OUT-OF-STATE CELL PHONE INTERVIEW, PLEASE READ:

That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.

Continue to module(s) and/or state-added questions

Optional Modules

Module 1: Pre-Diabetes

[CATI NOTE: ONLY ASKED OF THOSE NOT RESPONDING “YES” (CODE = 1) TO CORE Q6.12 (DIABETES AWARENESS QUESTION).]

1. Have you had a test for high blood sugar or diabetes within the past three years? (290)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

[CATI NOTE: IF CORE Q6.12 = 4 (NO, PRE-DIABETES OR BORDERLINE DIABETES); ANSWER Q2 “YES” (CODE = 1).]

2. Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?

INTERVIEWER INSTRUCTIONS: IF “YES” AND RESPONDENT IS FEMALE, ASK: “WAS THIS ONLY WHEN YOU WERE PREGNANT?” (291)

1 Yes

2 Yes, during pregnancy

3 No

7 Don’t know / Not sure

9 Refused

Module 2: Diabetes

[CATI NOTE: TO BE ASKED FOLLOWING CORE Q6.13; IF RESPONSE TO Q6.12 IS "YES" (CODE = 1).]

1. Are you now taking insulin? (292)

1 Yes

2 No

9 Refused

2. About how often do you check your blood for glucose or sugar? Include times when checked by a family member or friend, but do NOT include times when checked by a health professional. (293-295)

INTERVIEWER NOTE: ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

4 _ _ Times per year

888 Never

777 Don’t know / Not sure

999 Refused

INTERVIEWER NOTE: IF THE RESPONDENT USES A CONTINUOUS GLUCOSE MONITORING SYSTEM (A SENSOR INSERTED UNDER THE SKIN TO CHECK GLUCOSE LEVELS CONTINUOUSLY), FILL IN ‘98 TIMES PER DAY.’

3. About how often do you check your feet for any sores or irritations? Include times when checked by a family member or friend, but do NOT include times when checked by a health professional.

(296-298)

INTERVIEWER NOTE: ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

4 _ _ Times per year

555 No feet

888 Never

777 Don’t know / Not sure

999 Refused

4. About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes? (299-300)

_ _ Number of times [76 = 76 or more]

88 None

77 Don’t know / Not sure

99 Refused

5. A test for "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for "A one C"? (301-302)

_ _ Number of times [76 = 76 or more]

88 None

98 Never heard of “A one C” test

77 Don’t know / Not sure

99 Refused

[CATI NOTE: IF Q3 = 555 (NO FEET), GO TO Q7.]

6. About how many times in the past 12 months has a health professional checked your feet for any sores or irritations? (303-304)

_ _ Number of times [76 = 76 or more]

88 None

77 Don’t know / Not sure

99 Refused

7. When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light. (305)

Read only if necessary:

1 Within the past month (anytime less than 1 month ago)

2 Within the past year (1 month but less than 12 months ago)

3 Within the past 2 years (1 year but less than 2 years ago)

4 2 or more years ago

Do not read:

Don’t know / Not sure
Never

9 Refused

8. Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy? (306)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

9. Have you ever taken a course or class in how to manage your diabetes yourself?

(307)

1 Yes

2 No

7 Don't know / Not sure

9 Refused

Module 3: Respiratory Health (COPD Symptoms)

The next few questions are about breathing problems you may have.

During the past 3 months, did you have a cough on most days? (308)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

During the past 3 months, did you cough up phlegm [FLEM] or mucus on most days? (309)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Do you have shortness of breath either when hurrying on level ground or when walking up a slight hill or stairs? (310)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Have you ever been given a breathing test to diagnose breathing problems?

(311)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Over your lifetime, how many years have you smoked tobacco products?

(312-313)

00 Never smoked or smoked less than one year

_ _ Number of years (01-76)

77 Don’t know/Not sure

99 Refused

Module 4: Cardiovascular Health

I would like to ask you a few more questions about your cardiovascular or heart health.

[CATI NOTE: IF CORE Q6.1 = 1 (YES), ASK Q1. IF CORE Q6.1 = 2, 7, OR 9 (NO, DON’T KNOW, OR REFUSED), SKIP Q1. ]

1. Following your heart attack, did you go to any kind of outpatient rehabilitation? (This is sometimes called "rehab.") (314)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

[CATI NOTE: IF CORE Q6.3 = 1 (YES), ASK Q2. IF CORE Q6.3 = 2, 7, OR 9 (NO, DON’T KNOW, OR REFUSED), SKIP Q2.]

2. Following your stroke, did you go to any kind of outpatient rehabilitation? This is sometimes called "rehab." (315)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: QUESTION 3 IS ASKED OF ALL RESPONDENTS

3. Do you take aspirin daily or every other day? (316)

INTERVIEWER NOTE: ASPIRIN CAN BE PRESCRIBED BY A HEALTH CARE PROVIDER OR OBTAINED AS AN OVER-THE-COUNTER (OTC) MEDICATION.

1 Yes [GO TO QUESTION 5]

2 No

7 Don’t know / Not sure

9 Refused

4. Do you have a health problem or condition that makes taking aspirin unsafe for you? (317)

If "Yes," ask "Is this a stomach condition?” Code upset stomach as stomach problems.

1 Yes, not stomach related [GO TO NEXT MODULE]

2 Yes, stomach problems [GO TO NEXT MODULE]

3 No [GO TO NEXT MODULE]

7 Don’t know / Not sure [GO TO NEXT MODULE]

9 Refused [GO TO NEXT MODULE]

5. Do you take aspirin to relieve pain? (318)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6. Do you take aspirin to reduce the chance of a heart attack? (319)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

7. Do you take aspirin to reduce the chance of a stroke? (320)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Module 5: Actions to Control High Blood Pressure

[CATI NOTE: IF CORE Q4.1 = 1 (YES); CONTINUE. OTHERWISE, GO TO NEXT MODULE. ]

Earlier you stated that you had been diagnosed with high blood pressure.

Are you now doing any of the following to help lower or control your high blood pressure?

1. (Are you) changing your eating habits (to help lower or control your high blood pressure)? (321)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

2. (Are you) cutting down on salt (to help lower or control your high blood pressure)?

(322)

1 Yes

2 No

3 Do not use salt

7 Don‘t know / Not sure

9 Refused

3. (Are you) reducing alcohol use (to help lower or control your high blood pressure)?

(323)

1 Yes

2 No

3 Do not drink

7 Don‘t know / Not sure

9 Refused

4. (Are you) exercising (to help lower or control your high blood pressure)? (324)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

Has a doctor or other health professional ever advised you to do any of the following to help lower or control your high blood pressure?

5. (Ever advised you to) change your eating habits (to help lower or control your high blood pressure)? (325)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

6. (Ever advised you to) cut down on salt (to help lower or control your high blood pressure)? (326)

1 Yes

2 No

3 Do not use salt

7 Don‘t know / Not sure

9 Refused

7. (Ever advised you to) reduce alcohol use (to help lower or control your high blood pressure)? (327)

1 Yes

2 No

3 Do not drink

7 Don‘t know / Not sure

9 Refused

8. (Ever advised you to) exercise (to help lower or control your high blood pressure)?

(328)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

9. (Ever advised you to) take medication (to help lower or control your high blood pressure)? (329)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

10. Were you told on two or more different visits by a doctor or other health professional that you had high blood pressure? (330)

INTERVIEWER NOTE: IF “YES” AND RESPONDENT IS FEMALE, ASK: “WAS THIS ONLY WHEN YOU WERE PREGNANT?”

1 Yes

2 Yes, but female told only during pregnancy

3 No

4 Told borderline or pre-hypertensive

7 Don‘t know / Not sure

9 Refused

Module 6: Arthritis Management

[CATI NOTE: IF CORE Q6.9 = 1 (YES), CONTINUE. OTHERWISE, GO TO NEXT MODULE.]

1. Earlier you indicated that you had arthritis or joint symptoms. Thinking about your arthritis or joint symptoms, which of the following best describes you today? (331)

Please read:

1 I can do everything I would like to do

2 I can do most things I would like to do

3 I can do some things I would like to do

4 I can hardly do anything I would like to do

Do not read:

7 Don’t know / Not sure

9 Refused

2. Has a doctor or other health professional EVER suggested losing weight to help your arthritis or joint symptoms? (332)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

3. Has a doctor or other health professional ever suggested physical activity or exercise to help your arthritis or joint symptoms?

INTERVIEWER NOTE: IF THE RESPONDENT IS UNCLEAR ABOUT WHETHER THIS MEANS AN INCREASE OR DECREASE IN PHYSICAL ACTIVITY, THIS MEANS INCREASE. (333)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

4. Have you EVER taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms? (334)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Module 7: Adult Asthma History

[CATI NOTE: IF "YES" TO CORE Q6.4; CONTINUE. OTHERWISE, GO TO NEXT MODULE.]

Previously you said you were told by a doctor, nurse or other health professional that you had asthma.

How old were you when you were first told by a doctor, nurse, or other health professional that you had asthma?

(335-336) _ _ Age in years 11 or older [96 = 96 and older]

97 Age 10 or younger

98 Don’t know / Not sure

99 Refused

[CATI NOTE: If "Yes" to Core Q6.5, continue. Otherwise, GO TO NEXT MODULE.]

2. During the past 12 months, have you had an episode of asthma or an asthma attack?

(337)

1 Yes

2 No [GO TO Q5]

7 Don’t know / Not sure [GO TO Q5]

9 Refused [GO TO Q5]

3. During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma? (338-339)

__ Number of visits (INTERVIEWER NOTE: 87 = 87 or more)

88 None

98 Don’t know / Not sure

99 Refused

4. [CATI NOTE:IF ONE OR MORE VISITS TO Q3, FILL IN “BESIDES THOSE EMERGENCY ROOM OR URGENT CARE CENTER VISITS,”] During the past 12 months, how many times did you see a doctor, nurse or other health professional for urgent treatment of worsening asthma symptoms? (340-341)

__ Number of visits [87 = 87 or more]

88 None

98 Don’t know / Not sure

99 Refused

5. During the past 12 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma? (342-343)

__ Number of visits [87 = 87 or more]

88 None

98 Don’t know / Not sure

99 Refused

6. During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma? (344-346)

___ Number of days

888 None

777 Don’t know / Not sure

999 Refused

7. Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness and phlegm production when you don’t have a cold or respiratory infection. During the past 30 days, how often did you have any symptoms of asthma? Would you say —

(347)

INTERVIEWER NOTE: PHLEGM (‘FLEM’)

Please read:

8 Not at any time [GO TO Q9]

1 Less than once a week

2 Once or twice a week

3 More than 2 times a week, but not every day

4 Every day, but not all the time, or

5 Every day, all the time

Do not read:

7 Don’t know / Not sure

9 Refused

8. During the past 30 days, how many days did symptoms of asthma make it difficult for you to stay asleep? Would you say —

(348)

8 None

1 One or two

2 Three to four

3 Five

4 Six to ten, or

5 More than ten

Do not read:

7 Don’t know / Not sure

9 Refused

9. During the past 30 days, how many days did you take a prescription asthma medication to PREVENT an asthma attack from occurring?

(349)

Read only if necessary:

8 Never

1 1 to 14 days

2 15 to 24 days

3 25 to 30 days

Do not read:

7 Don’t know / Not sure

9 Refused

10. During the past 30 days, how often did you use a prescription asthma inhaler DURING AN ASTHMA ATTACK to stop it?

INTERVIEWER INSTRUCTION: HOW OFTEN (NUMBER OF TIMES) DOES NOT EQUAL NUMBER OF PUFFS. TWO TO THREE PUFFS ARE USUALLY TAKEN EACH TIME THE INHALER IS USED.

(350)

Read only if necessary:

8 Never (include no attack in past 30 days)

1 1 to 4 times (in the past 30 days)

2 5 to 14 times (in the past 30 days)

3 15 to 29 times (in the past 30 days)

4 30 to 59 times (in the past 30 days)

5 60 to 99 times (in the past 30 days)

6 100 or more times (in the past 30 days)

Do not read:

7 Don’t know / Not sure

9 Refused

Module 8: Healthy Days (Symptoms)

1. During the past 30 days, for about how many days did pain make it hard for you to do your usual activities, such as self-care, work, or recreation? (351-352)

_ _ Number of days

88 None

77 Don’t know / Not sure

99 Refused

2. During the past 30 days, for about how many days have you felt sad, blue, or depressed?

(352-354)

_ _ Number of days

88 None

77 Don’t know / Not sure

99 Refused

3. During the past 30 days, for about how many days have you felt worried, tense, or anxious?

(355-356)

_ _ Number of days

88 None

77 Don’t know / Not sure

99 Refused

4. During the past 30 days, for about how many days have you felt very healthy and full of energy?

(357-358)

_ _ Number of days

88 None

77 Don’t know / Not sure

99 Refused

Module 9: Sleep Disorder

On average, how many hours of sleep do you get in a 24-hour period?

INTERVIEWER NOTE: ENTER HOURS OF SLEEP IN WHOLE NUMBERS, ROUNDING 30 MINUTES (1/2 HOUR) OR MORE UP TO THE NEXT WHOLE HOUR AND DROPPING 29 OR FEWER MINUTES.

(359-360)

__ __ Number of hours [01-24]

77 Don’t know/Not sure

99 Refused

Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much? (361-362)

__ __ 01-14 days

88 None

77 Don’t know/Not sure

99 Refused

3. Over the last 2 weeks, how many days did you unintentionally fall asleep during the day? (363-364)

__ __ 01-14 days

88 None

77 Don’t know/Not sure

99 Refused

4. Have you ever been told that you snore loudly? (365)

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

5. Has anyone ever observed that you stop breathing during your sleep? (366)

INTERVIEWER NOTE: ALSO ENTER “YES” IF RESPONDENT MENTIONS HAVING A MACHINE OR CPAP THAT RECORDS THAT BREATHING SOMETIMES STOPS DURING THE NIGHT.

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

Module 10: Health Care Access

1. Do you have Medicare? (367)

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

INTERVIEWER NOTE: MEDICARE IS A COVERAGE PLAN FOR PEOPLE AGE 65 OR OVER AND FOR CERTAIN DISABLED PEOPLE.

2. What is the primary source of your health care coverage? Is it… (368-369)

Please read:

A plan purchased through an employer or union (includes plans purchased through

another person's employer)

02 A plan that you or another family member buys on your own

03 Medicare

04 Medicaid or other state program

05 TRICARE (formerly CHAMPUS), VA, or Military

06 Alaska Native, Indian Health Service, Tribal Health Services,

07 Some other source, or

08 None (no coverage)

Do not read:

77 Don't know/Not sure

99 Refused

INTERVIEWER NOTE: IF THE RESPONDENT INDICATES THAT THEY PURCHASED HEALTH INSURANCE THROUGH THE HEALTH INSURANCE MARKETPLACE (NAME OF STATE MARKETPLACE), ASK IF IT WAS A PRIVATE HEALTH INSURANCE PLAN PURCHASED ON THEIR OWN OR BY A FAMILY MEMBER (PRIVATE) OR IF THEY RECEIVED MEDICAID (STATE PLAN)? IF PURCHASED ON THEIR OWN (OR BY A FAMILY MEMBER), SELECT 02, IF MEDICAID SELECT 04.

[CATI NOTE: GO TO CORE Q3.2.]

3. Other than cost, there are many other reasons people delay getting needed medical care. Have you delayed getting needed medical care for any of the following reasons in the past 12 months? Select the most important reason.

Please read: (370)

1 You couldn’t get through on the telephone.

2 You couldn’t get an appointment soon enough.

3 Once you got there, you had to wait too long to see the doctor.

4 The (clinic/doctor’s) office wasn’t open when you got there.

5 You didn’t have transportation.

Do not read:

6 Other ____________ (specify) (371-395)

8 No, I did not delay getting medical care/did not need medical care

7 Don’t know/Not sure

9 Refused

[CATI NOTE: GO TO CORE Q3.4; IF Q3.1 = 1 (YES) CONTINUE, ELSE GO TO Q4B.]

4. In the PAST 12 MONTHS was there any time when you did NOT have ANY health insurance or coverage? (396)

1 Yes [GO TO Q5]

2 No [GO TO Q5]

7 Don’t know/Not sure [GO TO Q5]

9 Refused [GO TO Q5]

[CATI NOTE: IF Q3.1 = 2, 7, OR 9 CONTINUE, ELSE GO TO NEXT QUESTION (Q5).]

5. About how long has it been since you last had health care coverage? (397)

Read only if necessary.

1 6 months or less

2 More than 6 months, but not more than 1 year ago

3 More than 1 year, but not more than 3 years ago

4 More than 3 years

5 Never

Do not read:

7 Don’t know/Not sure

9 Refused

5. How many times have you been to a doctor, nurse, or other health professional in the past 12 months? (398-399)

_ _ Number of times

88 None

77 Don’t know/Not sure

99 Refused

6. Not including over-the-counter (OTC) medications, was there a time in the past 12 months when you did not take your medication as prescribed because of cost?

(400)

1 Yes

2 No

Do not read:

3 No medication was prescribed.

7 Don’t know/Not sure

9 Refused

7. In general, how satisfied are you with the health care you received? Would you say—

(401)

Please read:

1 Very satisfied

2 Somewhat satisfied

3 Not at all satisfied

Do not read:

8 Not applicable

7 Don’t know/Not sure

9 Refused

8. Do you currently have any health care bills that are being paid off over time? (402)

INTERVIEWER NOTE: THIS COULD INCLUDE MEDICAL BILLS BEING PAID OFF WITH A CREDIT CARD, THROUGH PERSONAL LOANS, OR BILL PAYING ARRANGEMENTS WITH HOSPITALS OR OTHER PROVIDERS. THE BILLS CAN BE FROM EARLIER YEARS AS WELL AS THIS YEAR.

INTERVIEWER NOTE: HEALTH CARE BILLS CAN INCLUDE MEDICAL, DENTAL, PHYSICAL THERAPY AND/OR CHIROPRACTIC COST.

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

[CATI NOTE: GO TO CORE SECTION 4.]

Module 11: Visual Impairment and Access to Eye Care

[CATI NOTE: IF RESPONDENT IS LESS THAN 40 YEARS OF AGE, GO TO NEXT MODULE.]

I would like to ask you questions about how much difficulty, if any, you have doing certain activities. If you usually wear glasses or contact lenses, please rate your ability to do them while wearing glasses or contact lenses.

1. How much difficulty, if any, do you have in recognizing a friend across the street? Would you say— (403)

Please read:

1 No difficulty

2 A little difficulty

3 Moderate difficulty

4 Extreme difficulty

5 Unable to do because of eyesight

6 Unable to do for other reasons

Do not read:

7 Don’t know / Not sure

8 Not applicable (Blind) [GO TO NEXT MODULE]

9 Refused

2. How much difficulty, if any, do you have reading print in newspaper, magazine, recipe, menu, or numbers on the telephone? Would you say— (404)

Please read:

1 No difficulty

2 A little difficulty

3 Moderate difficulty

4 Extreme difficulty

5 Unable to do because of eyesight

6 Unable to do for other reasons

Do not read:

7 Don’t know / Not sure

8 Not applicable (Blind) [GO TO NEXT MODULE]

9 Refused

3. When was the last time you had your eyes examined by any doctor or eye care provider? (405)

Read only if necessary:

1 Within the past month (anytime less than 1 month ago) [GO TO Q5]

2 Within the past year (1 month but less than 12 months ago) [GO TO Q5]

3 2 or more years ago

5 Never

Do not read:

7 Don’t know / Not sure

8 Not applicable (Blind) [GO TO NEXT MODULE]

9 Refused

[CATI NOTE: ASK Q4 ONLY IF Q3=3-7 OR 9.]

4. What is the main reason you have not visited an eye care professional in the past 12 months? (406-407)

Read only if necessary:

01 Cost/insurance

02 Do not have/know an eye doctor

03 Cannot get to the office/clinic (too far away, no transportation)

04 Could not get an appointment

05 No reason to go (no problem)

06 Have not thought of it

07 Other

Do not read:

77 Don’t know / Not sure

08 Not Applicable (Blind) [GO TO NEXT MODULE]

99 Refused

[CATI NOTE: IF THE PERSON IS DIABETIC, “YES” TO CORE Q6.12; SKIP Q5.]

5. When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light. (408)

Read only if necessary:

1 Within the past month (anytime less than 1 month ago)

2 Within the past year (1 month but less than 12 months ago)

3 2 or more years ago

5 Never

Do not read:

7 Don’t know / Not sure

8 Not Applicable (Blind) [GO TO NEXT MODULE]

9 Refused

6. Do you have any kind of health insurance coverage for eye care? (409)

1 Yes

2 No

8 Not applicable (Blind) [GO TO NEXT MODULE]

7 Don’t know/Not sure

9 Refused

Module 12: Alcohol Screening & Brief Intervention (ASBI)

CATI NOTE: IF CORE Q3.4 = 1, OR 2 (HAD A CHECKUP WITHIN THE PAST 2 YEARS) CONTINUE, ELSE GO TO NEXT MODULE.

Healthcare providers may ask during routine checkups about behaviors like alcohol use, whether you drink or not. We want to know about their questions.

1. You told me earlier that your last routine checkup was [within the past year/within the past 2 years]. At that checkup, were you asked in person or on a form if you drink alcohol?

(410)

1 Yes

2 No

7 Don't know / Not sure

9 Refused

2. Did the health care provider ask you in person or on a form how much you drink?

(411)

1 Yes

2. No

7 Don't know / Not sure

9 Refused

3. Did the healthcare provider specifically ask whether you drank [5 FOR MEN /4 FOR WOMEN] or more alcoholic drinks on an occasion? (412)

1 Yes

2 No

7 Don't know / Not sure

9 Refused

4. Were you offered advice about what level of drinking is harmful or risky for your health? (413)

1 Yes

2 No

7 Don't know / Not sure

9 Refused

[CATI NOTE: IF QUESTION 1, 2, OR 3 = 1 (YES) CONTINUE, ELSE GO TO NEXT MODULE.]

5. Healthcare providers may also advise patients to drink less for various reasons. At your last routine checkup, were you advised to reduce or quit your drinking? (414)

1 Yes

2 No

7 Don't know / Not sure

9 Refused

Module 13: Cancer Survivorship

[CATI NOTE: IF CORE Q6.6 OR Q6.7 = 1 (YES) OR Q16.6 = 4 (BECAUSE YOU WERE TOLD YOU HAD PROSTATE CANCER) CONTINUE, ELSE GO TO NEXT MODULE.]

You’ve told us that you have had cancer. I would like to ask you a few more questions about your cancer.

1. How many different types of cancer have you had? (415)

Do not read:

1 Only one

2 Two

3 Three or more

7 Don’t know / Not sure [GO TO NEXT MODULE]

Refused [GO TO NEXT MODULE]

At what age were you told that you had cancer? (416-417)

_ _ Code age in years (INTERVIEWER NOTE: 97 = 97 and older)

98 Don’t know / Not sure

99 Refused

[CATI NOTE: IF Q1= 2 (TWO) OR 3 (THREE OR MORE), ASK: “AT WHAT AGE WERE YOU FIRST DIAGNOSED WITH CANCER?]

INTERVIEWER NOTE: THIS QUESTION REFERS TO THE FIRST TIME THEY WERE TOLD ABOUT THEIR FIRST CANCER.

[CATI NOTE: IF CORE Q6.6 = 1 (YES) AND Q1 = 1 (ONLY ONE): ASK “WAS IT “MELANOMA” OR “OTHER SKIN CANCER”? THEN CODE 21 IF “MELANOMA” OR 22 IF “OTHER SKIN CANCER]

[CATI NOTE: IF CORE Q16.6 = 4 (BECAUSE YOU WERE TOLD YOU HAD PROSTATE CANCER) AND Q1 = 1 (ONLY ONE) THEN CODE 19.]

3. What type of cancer was it? (418-419)

[CATI NOTE: IF Q1 = 2 (TWO) OR 3 (THREE OR MORE), ASK: “WITH YOUR MOST RECENT DIAGNOSES OF CANCER, WHAT TYPE OF CANCER WAS IT?]

INTERVIEWER NOTE: PLEASE READ LIST ONLY IF RESPONDENT NEEDS PROMPTING FOR CANCER TYPE (I.E., NAME OF CANCER) [1-30]:

Breast

01 Breast cancer

Female reproductive (Gynecologic)

02 Cervical cancer (cancer of the cervix)

03 Endometrial cancer (cancer of the uterus)

04 Ovarian cancer (cancer of the ovary)

Head/Neck

05 Head and neck cancer

06 Oral cancer

07 Pharyngeal (throat) cancer

08 Thyroid

09 Larynx

Gastrointestinal

10 Colon (intestine) cancer

11 Esophageal (esophagus)

12 Liver cancer

13 Pancreatic (pancreas) cancer

14 Rectal (rectum) cancer

15 Stomach

Leukemia/Lymphoma (lymph nodes and bone marrow)

16 Hodgkin's Lymphoma (Hodgkin’s disease)

17 Leukemia (blood) cancer

18 Non-Hodgkin’s Lymphoma

Male reproductive

19 Prostate cancer

20 Testicular cancer

Skin

21 Melanoma

22 Other skin cancer

Thoracic

23 Heart

24 Lung

Urinary cancer:

25 Bladder cancer

26 Renal (kidney) cancer

Others

27 Bone

28 Brain

29 Neuroblastoma

30 Other

Do not read:

77 Don’t know / Not sure

99 Refused

4. Are you currently receiving treatment for cancer? By treatment, we mean surgery, radiation therapy, chemotherapy, or chemotherapy pills. (420)

Read if necessary:

1 Yes [GO TO NEXT MODULE]

2 No, I’ve completed treatment

3 No, I’ve refused treatment [GO TO NEXT MODULE]

4 No, I haven’t started treatment [GO TO NEXT MODULE]

7 Don’t know / Not sure [GO TO NEXT MODULE]

9 Refused [GO TO NEXT MODULE]

5. What type of doctor provides the majority of your health care? (421-422)

INTERVIEWER NOTE: IF THE RESPONDENT REQUESTS CLARIFICATION OF THIS QUESTION, SAY: “WE WANT TO KNOW WHICH TYPE OF DOCTOR YOU SEE MOST OFTEN FOR ILLNESS OR REGULAR HEALTH CARE (EXAMPLES: ANNUAL EXAMS AND/OR PHYSICALS, TREATMENT OF COLDS, ETC.).”

Please read [1-10]:

01 Cancer Surgeon

02 Family Practitioner

03 General Surgeon

04 Gynecologic Oncologist

05 General Practitioner, Internist

06 Plastic Surgeon, Reconstructive Surgeon

07 Medical Oncologist

08 Radiation Oncologist

09 Urologist

10 Other

Do not read:

77 Don’t know / Not sure

99 Refused

6. Did any doctor, nurse, or other health professional EVER give you a written summary of all the cancer treatments that you received? (423)

Read only if necessary: “By ‘other healthcare professional’, we mean a nurse practitioner, a physician’s assistant, social worker, or some other licensed professional.”

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

7. Have you EVER received instructions from a doctor, nurse, or other health professional about where you should return or who you should see for routine cancer check-ups after completing your treatment for cancer? (424)

1 Yes

2 No [GO TO Q9]

7 Don’t know / Not sure [GO TO Q9]

9 Refused [GO TO Q9]

8. Were these instructions written down or printed on paper for you? (425)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

9. With your most recent diagnosis of cancer, did you have health insurance that paid for all or part of your cancer treatment? (426)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: “HEALTH INSURANCE” ALSO INCLUDES MEDICARE, MEDICAID, OR OTHER TYPES OF STATE HEALTH PROGRAMS.

10. Were you EVER denied health insurance or life insurance coverage because of your cancer? (427)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

11. Did you participate in a clinical trial as part of your cancer treatment?

(428)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

12. Do you currently have physical pain caused by your cancer or cancer treatment?

(429)

1 Yes

2 No [GO TO NEXT MODULE]

7 Don’t know / Not sure [GO TO NEXT MODULE]

9 Refused [GO TO NEXT MODULE]

13. Is your pain currently under control?

(430)

Please read:

1 Yes, with medication (or treatment)

2 Yes, without medication (or treatment)

3 No, with medication (or treatment)

4 No, without medication (or treatment)

Do not read:

7 Don’t know / Not sure

9 Refused

Module 14: Sugar Sweetened Beverages

1. During the past 30 days, how often did you drink regular soda or pop that contains sugar? Do not include diet soda or diet pop. (431-433)

Please read: You can answer times per day, week, or month: for example, twice a day, once a week, and so forth.

1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

Do not read:

888 None

777 Don’t know / Not sure

999 Refused

2. During the past 30 days, how often did you drink sugar-sweetened fruit drinks (such as Kool-aid™ and lemonade), sweet tea, and sports or energy drinks (such as Gatorade™ and Red Bull™)? Do not include 100% fruit juice, diet drinks, or artificially sweetened drinks.

(434-436)

Please read: You can answer times per day, week, or month: for example, twice a day, once a week, and so forth.

1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

Do not read:

888 None

777 Don’t know / Not sure

999 Refused

Module 15: Sodium or Salt-Related Behavior

Most of the sodium or salt we eat comes from processed foods and foods prepared in restaurants. Salt also can be added in cooking or at the table.

1. Are you currently watching or reducing your sodium or salt intake? (437)

1. Yes

2. No

7. Don’t know/not sure

9. Refused

2. Has a doctor or other health professional ever advised you to reduce sodium or salt intake?

(438)

1. Yes

2. No

7. Don’t know/not sure

9. Refused

Module 16: Marijuana

1. During the past 30 days, on how many days did you use marijuana or hashish?

(439-440)

_ _ (1-30) Number of Days

88 None (0 days) [GO TO NEXT MODULE]

77 Don’t know/not sure [GO TO NEXT MODULE]

99 Refused [GO TO NEXT MODULE]

2. [CATI NOTE: ASKED ONLY OF CURRENT MARIJUANA USERS]. During the past 30 days, what was the primary mode you used marijuana? Please select one. Did you…

(441)

Please read:

1 Smoke it, for example, in a joint, bong, pipe, or blunt.

2 Eat it, for example, in brownies, cakes, cookies, or candy.

3 Drink it, for example, in tea, cola, or alcohol.

4 Vaporize it, for example, in an e-cigarette-like vaporizer or another

vaporizing device.

5 Dab it, for example, using waxes or concentrates.

6 Use it some other way.

Do not read:

7 Don’t know/not sure [GO TO NEXT MODULE]

9 Refused

3. [CATI NOTE: ASKED ONLY OF CURRENT MARIJUANA USERS]. When you used marijuana or hashish during the past 30 days, was it for medical reasons to treat or decrease symptoms of a health condition, or was it for non-medical reasons to get pleasure or satisfaction (such as: excitement, to “fit in” with a group, increased awareness, to forget worries, for fun at a social gathering). (442)

Read if necessary:
1 Only for medical reasons to treat or decrease symptoms of a health condition

2 Only for non-medical purposes to get pleasure or satisfaction

3 Both medical and non-medical reasons

Do not read:

7 Don’t know/Not sure

9 Refused

Module 17: Preconception Health/Family Planning

[CATI NOTE: IF RESPONDENT IS FEMALE AND GREATER THAN 49 YEARS OF AGE, HAS HAD A HYSTERECTOMY, IS PREGNANT, OR IF RESPONDENT IS MALE GO TO THE NEXT MODULE.]

The next set of questions asks you about your thoughts and experiences with family planning. Please remember that all of your answers will be kept confidential.

1. Did you or your partner do anything the last time you had sex to keep you from getting pregnant? (443)

1 Yes

2 No [GO TO Q3]

3 No partner/not sexually active [GO TO NEXT MODULE]

4 Same sex partner [GO TO NEXT MODULE]

7 Don’t know/Not sure [GO TO Q3]

9 Refused [GO TO Q3].

2. What did you or your partner do the last time you had sex to keep you from getting pregnant?

INTERVIEWER NOTE: IF RESPONDENT REPORTS USING MORE THAN ONE METHOD, PLEASE CODE THE METHOD THAT OCCURS FIRST ON THE LIST.

INTERVIEWER NOTE: IF RESPONDENT REPORTS USING “CONDOMS,” PROBE TO DETERMINE IF “FEMALE CONDOMS” OR “MALE CONDOMS.”

INTERVIEWER NOTE: IF RESPONDENT REPORTS USING AN “IUD” PROBE TO DETERMINE IF “LEVONORGESTREL IUD” OR “COPPER-BEARING IUD.”

INTERVIEWER NOTE: IF RESPONDENT REPORTS “OTHER METHOD,” ASK RESPONDENT TO “PLEASE BE SPECIFIC” AND ENSURE THAT THEIR RESPONSE DOES NOT FIT INTO ANOTHER CATEGORY. IF RESPONSE DOES FIT INTO ANOTHER CATEGORY, PLEASE MARK APPROPRIATELY.

Read only if necessary: (444-445)

01 Female sterilization (ex. Tubal ligation, Essure, Adiana) [GO TO NEXT MODULE]

02 Male sterilization (vasectomy) [GO TO NEXT MODULE]

03 Contraceptive implant (ex. Implanon) [GO TO NEXT MODULE]

04 Levonorgestrel (LNG) or hormonal IUD (ex. Mirena) [GO TO NEXT MODULE]

05 Copper-bearing IUD (ex. ParaGard) [GO TO NEXT MODULE]

06 IUD, type unknown [GO TO NEXT MODULE]

07 Shots (ex. Depo-Provera) [GO TO NEXT MODULE]

08 Birth control pills, any kind [GO TO NEXT MODULE]

09 Contraceptive patch (ex. Ortho Evra) [GO TO NEXT MODULE]

10 Contraceptive ring (ex. NuvaRing) [GO TO NEXT MODULE]

11 Male condoms [GO TO NEXT MODULE]

12 Diaphragm, cervical cap, sponge [GO TO NEXT MODULE]

13 Female condoms [GO TO NEXT MODULE]

14 Not having sex at certain times (rhythm or natural family planning) [GO TO NEXT MODULE]

15 Withdrawal (or pulling out) [GO TO NEXT MODULE]

16 Foam, jelly, film, or cream [GO TO NEXT MODULE]

17 Emergency contraception (morning after pill) [GO TO NEXT MODULE]

18 Other method [GO TO NEXT MODULE]

Do not read:

77 Don’t know/Not sure

99 Refused

Some reasons for not doing anything to keep you from getting pregnant the last time you had sex might include wanting a pregnancy, not being able to pay for birth control, or not thinking that you can get pregnant.

3. What was your main reason for not doing anything the last time you had sex to keep you from getting pregnant? (446-447)

INTERVIEWER NOTE: IF RESPONDENT REPORTS “OTHER REASON,” ASK RESPONDENT TO “PLEASE SPECIFY” AND ENSURE THAT THEIR RESPONSE DOES NOT FIT INTO ANOTHER CATEGORY. IF RESPONSE DOES FIT INTO ANOTHER CATEGORY, PLEASE MARK APPROPRIATELY.

Read only if necessary:

You didn’t think you were going to have sex/no regular partner [GO TO NEXT
MODULE]

02 You just didn’t think about it [GO TO NEXT MODULE]

03 Don’t care if you get pregnant [GO TO NEXT MODULE]

04 You want a pregnancy [GO TO NEXT MODULE]

05 You or your partner don’t want to use birth control [GO TO NEXT MODULE]

06 You or your partner don’t like birth control/side effects [GO TO NEXT

MODULE]

07 You couldn’t pay for birth control [GO TO NEXT MODULE]

08 You had a problem getting birth control when you needed it [GO TO NEXT MODULE]

09 Religious reasons [GO TO NEXT MODULE]

10 Lapse in use of a method [GO TO NEXT MODULE]

11 Don’t think you or your partner can get pregnant (infertile or too old) [GO TO NEXT MODULE]

12 You had tubes tied (sterilization) [GO TO NEXT MODULE]

13 You had a hysterectomy [GO TO NEXT MODULE]

14 Your partner had a vasectomy (sterilization) [GO TO NEXT MODULE]

15 You are currently breast-feeding [GO TO NEXT MODULE]

16 You just had a baby/postpartum [GO TO NEXT MODULE]

17 You are pregnant now [GO TO NEXT MODULE]

18 Same sex partner [GO TO NEXT MODULE]

19 Other reasons [GO TO NEXT MODULE]

77 Don’t know/Not sure

99 Refused

Module 18: Influenza

[CATI NOTE: IF Q15.1 = 1 (YES) THEN CONTINUE, ELSE GO TO NEXT MODULE.]

1. Earlier, you told me you had received an influenza vaccination in the past 12 months. At what kind of place did you get your last flu shot/vaccine?

Read only if necessary: (448-449)

01 A doctor’s office or health maintenance organization (HMO)

02 A health department

03 Another type of clinic or health center (Example: a community health center)

04 A senior, recreation, or community center

05 A store (Examples: supermarket, drug store)

06 A hospital (Example: inpatient)

07 An emergency room

08 Workplace

09 Some other kind of place

10 Received vaccination in Canada/Mexico (Volunteered – Do not read)

11 A school

77 Don’t know / Not sure (Probe: “How would you describe the place where you went to get your most recent flu vaccine?”

Do not read:

99 Refused

Module 19: Adult Human Papillomavirus (HPV)

[CATI NOTE: TO BE ASKED OF RESPONDENTS BETWEEN THE AGES OF 18 AND 49 YEARS; OTHERWISE, GO TO NEXT MODULE.]

INTERVIEWER NOTE: HUMAN PAPILLOMAVIRUS (HUMAN PAP·UH·LOH·MUH VIRUS); GARDASIL (GAR·DUH· SEEL); CERVARIX (SIR·VAR· ICKS)

1. A vaccine to prevent the human papillomavirus or HPV infection is available and is called the cervical cancer or genital warts vaccine, HPV shot, [Fill: if female “GARDASIL or CERVARIX”; if male “ or GARDASIL”]. Have you EVER had an HPV vaccination?

(450)

1 Yes

2 No [GO TO NEXT MODULE]

3 Doctor refused when asked [GO TO NEXT MODULE]

7 Don’t know / Not sure [GO TO NEXT MODULE]

9 Refused [GO TO NEXT MODULE]

2. How many HPV shots did you receive? (451-452)

_ _ Number of shots

0 3 All shots

77 Don’t know / Not sure

99 Refused

Module 20: Tetanus, Diphtheria, and Acellular Pertussis (Tdap) (Adults)

1. Since 2005, have you had a tetanus shot? (453)

INTERVIEWER NOTE: IF YES, ASK: WAS THIS TDAP, THE TETANUS SHOT THAT ALSO HAS PERTUSSIS OR WHOOPING COUGH VACCINE?

1 Yes, received TDAP

2 Yes, received tetanus shot, but not TDAP

3 Yes, received tetanus shot but not sure what type

4 No, did not receive any tetanus since 2005

7 Don’t know/Not sure

9 Refused

Module 21: Lung Cancer Screening

CATI NOTE: IF CORE Q8.1=1 (YES) AND Q8.2 = 1, 2, OR 3 (EVERY DAY, SOME DAYS, OR NOT AT ALL) CONTINUE, ELSE GO TO NEXT MODULE.

You’ve told us that you have smoked in the past or are currently smoking. The next questions are about screening for lung cancer.

1. How old were you when you first started to smoke cigarettes regularly? (454-455)

_ _ Age in Years

07 Don't know/Not sure

09 Refused

INTERVIEWER NOTE 1: REGULARLY IS AT LEAST ONE CIGARETTE OR MORE EACH DAY.

[CATI INSTRUCTION/ INTERVIEWER NOTE: (IF RESPONDENT INDICATES AGE INCONSISTENT WITH PREVIOUSLY ENTERED AGE) THE RESPONDENT INDICATED THEIR AGE TO BE __ YEARS OLD. YOU INDICATED THEY STARTED SMOKING REGULARLY AT THE AGE OF ___ YEARS. PLEASE VERIFY THAT THIS IS THE CORRECT ANSWER AND CHANGE THE AGE OF THE RESPONDENT REGULARLY SMOKING OR MAKE A NOTE TO CORRECT THE AGE OF THE RESPONDENT.]

2. How old were you when you last smoked cigarettes regularly? (456-457)

_ _ Age in Years

07 Don't know/Not sure

09 Refused

INTERVIEWER NOTE: REGULARLY IS AT LEAST ONE CIGARETTE OR MORE EACH DAY.

3. On average, when you {smoke/smoked} regularly, about how many cigarettes {do/did} you usually smoke each day? (458-459)

_ _ Number of cigarettes

07 Don't know/Not sure

09 Refused

INTERVIEWER NOTE 1: REGULARLY IS AT LEAST ONE CIGARETTE OR MORE EACH DAY.

INTERVIEWER NOTE 2: RESPONDENTS MAY ANSWER IN PACKS INSTEAD OF NUMBER OF CIGARETTES. BELOW IS A CONVERSION TABLE:

0.5 PACK = 10 CIGARETTES 1.75 PACK = 35 CIGARETTES

0.75 PACK = 15 CIGARETTES 2 PACKS = 40 CIGARETTES

1 PACK = 20 CIGARETTES 2.5 PACKS= 50 CIGARETTES

1.25 PACK = 25 CIGARETTES 3 PACKS= 60 CIGARETTES

1.5 PACK = 30 CIGARETTES

4. The next question is about CT or CAT scans. During this test, you lie flat on your back on a table. While you hold your breath, the table moves through a donut shaped x-ray machine while the scan is done. In the last 12 months, did you have a CT or CAT scan?

(460)

Read only if necessary:

1. Yes, to check for lung cancer

2. No (did not have a CT scan)

3. No, had a CT scan, but for some other reason

Do not read:

7. Don't know/not sure

9. Refused

Module 22: Caregiver

People may provide regular care or assistance to a friend or family member who has a health problem or disability.

During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability? (461)

INTERVIEWER INSTRUCTIONS: If caregiving recipient has died in the past 30 days, say “I’m so sorry to hear of your loss.” and code 8.

Yes
No [GO TO QUESTION 9]

7 Don’t know/Not sure [GO TO QUESTION 9]

8 Caregiving recipient died in past 30 days [GO TO NEXT MODULE]

9 Refused [GO TO QUESTION 9]

2. What is his or her relationship to you? For example is he or she your (mother or daughter or father or son)? (462-463)

INTERVIEWER NOTE: IF MORE THAN ONE PERSON, SAY: “PLEASE REFER TO THE PERSON TO WHOM YOU ARE GIVING THE MOST CARE.”

INTERVIEWER INSTRUCTION: DO NOT READ; CODE RESPONSE USING THESE CATEGORIES.

Mother
Father
Mother-in-law
Father-in-law
Child
Husband
Wife
Same-sex partner
Brother or brother-in-law
Sister or sister-in-law
Grandmother
Grandfather
Grandchild
Other relative
Non-relative/Family friend
Unmarried partner

Don’t know/Not sure

Refused

For how long have you provided care for that person? Would you say… (464)

Please read:

1 Less than 30 days

2 1 month to less than 6 months

3 6 months to less than 2 years

4 2 years to less than 5 years

5 More than 5 years

Do not read:

7 Don’t Know/ Not Sure

9 Refused

In an average week, how many hours do you provide care or assistance? Would you say… (465)

Please read:

Up to 8 hours per week
9 to 19 hours per week
20 to 39 hours per week
40 hours or more

Do not read:

7 Don’t know/Not sure

9 Refused

What is the main health problem, long-term illness, or disability that the person you care for has? (466-467)

Read if necessary: Please tell me which one of these conditions would you say is the major problem?

[DO NOT READ: RECORD ONE RESPONSE]

Arthritis/Rheumatism
Asthma
Cancer
Chronic respiratory conditions such as Emphysema or COPD
Dementia and other Cognitive Impairment Disorders
Developmental Disabilities such as Autism, Down’s Syndrome, and Spina Bifida
Diabetes
Heart Disease, Hypertension
Human Immunodeficiency Virus Infection (HIV)
Mental Illnesses, such as Anxiety, Depression, or Schizophrenia
Other organ failure or diseases such as kidney or liver problems
Substance Abuse or Addiction Disorders
Other

Do not read:

77 Don’t know/Not sure

99 Refused

In the past 30 days, did you provide care for this person by…

Managing personal care such as giving medications, feeding, dressing, or bathing?

(468)

1 Yes

2 No

7 Don’t Know /Not Sure

9 Refused

7. In the past 30 days, did you provide care for this person by…

Managing household tasks such as cleaning, managing money, or preparing meals?

(469)

1 Yes

2 No

7 Don’t Know /Not Sure

9 Refused

8. Of the following support services, which one do you most need, that you are not currently getting? (470)

[INTERVIEWER NOTE: IF RESPONDENT ASKS WHAT RESPITE CARE IS]: Respite care means short-term breaks for people who provide care.

Please read options 1 – 6:

Classes about giving care, such as giving medications
Help in getting access to services
Support groups
Individual counseling to help cope with giving care
Respite care
You don’t need any of these support services

Do not read:

7 Don’t Know /Not Sure

9 Refused

[If Q1 = 1 or 8, GO TO NEXT MODULE]

9. In the next 2 years, do you expect to provide care or assistance to a friend or family member who has a health problem or disability? (471)

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

Module 23: Cognitive Decline

[CATI NOTE: IF RESPONDENT IS 45 YEARS OF AGE OR OLDER CONTINUE, ELSE GO TO NEXT MODULE]

The next few questions ask about difficulties in thinking or remembering that can make a big difference in everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you recently met, which is normal. This refers to confusion or memory loss that is happening more often or getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would normally know. We want to know how these difficulties impact you.

1. During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse? (472)

1 Yes

2 No [GO TO NEXT MODULE]

7 Don't know [GO TO Q2]

9 Refused [GO TO NEXT MODULE]

2. During the past 12 months, as a result of confusion or memory loss, how often have you given up day-to-day household activities or chores you used to do, such as cooking, cleaning, taking medications, driving, or paying bills? (473)

Please read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

7 Don't know

9 Refused

3. As a result of confusion or memory loss, how often do you need assistance with these day-to-day activities? (474)

Please read:

1 Always

2 Usually

3 Sometimes

4 Rarely [GO TO Q5]

5 Never [GO TO Q5]

Do not read:

7 Don't know [GO TO Q5]

9 Refused [GO TO Q5]

[CATI NOTE: IF Q3 = 1, 2, OR 3, CONTINUE. IF Q3 = 4 , 5, 7, OR 9 GO TO Q5.]

4. When you need help with these day-to-day activities, how often are you able to get the help that you need? (475)

Please read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

7 Don't know

9 Refused

5. During the past 12 months, how often has confusion or memory loss interfered with your ability to work, volunteer, or engage in social activities outside the home? (476)

Please read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

7 Don't know

9 Refused

6. Have you or anyone else discussed your confusion or memory loss with a health care professional? (477)

1 Yes

2 No

7 Don't know

9 Refused

Module 24: Emotional Support and Life Satisfaction

The next two questions are about emotional support and your satisfaction with life.

1. How often do you get the social and emotional support you need? (478)

INTERVIEWER NOTE: IF ASKED, SAY “PLEASE INCLUDE SUPPORT FROM ANY SOURCE.”

Please read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

7 Don't know / Not sure

9 Refused

2. In general, how satisfied are you with your life? (479)

Please read:

1 Very satisfied

2 Satisfied

3 Dissatisfied

4 Very dissatisfied

Do not read:

7 Don't know / Not sure

9 Refused

Module 25: Social Determinants of Health

1. During the last 12 months, was there a time when you were not able to pay your mortgage, rent or utility bills? (480)

1 Yes

2 No

7 Don’t know/not sure

9 Refused

2. In the last 12 months, how many times have you moved from one home to another?

(481-482)

__ __ Number of moves in past 12 months [01-52]

88 None (Did not move in past 12 months)

77 Don’t know/Not sure

99 Refused

3. How safe from crime do you consider your neighborhood to be? Would you say…

(483)

Please read:

1 Extremely safe

2 Safe

3 Unsafe

4 Extremely unsafe

Do not read:

7 Don’t know/Not sure

9 Refused

4. For the next two statements, please tell me whether the statement was often true, sometimes true, or never true for you in the last 12 months (that is, since last [CATI NOTE: NAME OF CURRENT MONTH]). The first statement is, “The food that I bought just didn’t last, and I didn’t have money to get more.”

Was that often, sometimes, or never true for you in the last 12 months? (484)

Please read:

1 Often true,

2 Sometimes true, or

3 Never true

Do not read:

7 Don’t Know/Not sure

9 Refused

5. I couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for you in the last 12 months? (485)

Please read:

1 Often true,

2 Sometimes true, or

3 Never true

Do not read:

7 Don’t Know /Not sure

9 Refused

6. In general, how do your finances usually work out at the end of the month? Do you find that you usually: (486)

Please read:

1 End up with some money left over,

2 Have just enough money to make ends meet, or

3 Not have enough money to make ends meet

Do not read:

7 Don’t Know/Not sure

9 Refused

7. Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his/her mind is troubled all the time. Within the last 30 days, how often have you felt this kind of stress? (487)

Please read:

1 None of the time,

2 A little of the time,

3 Some of the time,

4 Most of the time, or

5 All of the time

Do not read:

7. Don't know/not sure

9. Refused

Module 26: Industry and Occupation

IF CORE Q7.15 = 1 OR 4 (EMPLOYED FOR WAGES OR OUT OF WORK FOR LESS THAN 1 YEAR) OR 2 (SELF-EMPLOYED), CONTINUE ELSE GO TO NEXT MODULE.

Now I am going to ask you about your work.

[CATI NOTE: IF CORE Q7.15 = 1 (EMPLOYED FOR WAGES) OR 2 (SELF-EMPLOYED) ASK,]

1. What kind of work do you do? For example, registered nurse, janitor, cashier, auto mechanic.

INTERVIEWER NOTE: IF RESPONDENT IS UNCLEAR, ASK “WHAT IS YOUR JOB TITLE?”

INTERVIEWER NOTE: IF RESPONDENT HAS MORE THAN ONE JOB THEN ASK, “WHAT IS YOUR MAIN JOB?” (488-587)

[Record answer]_________________________________

99 Refused

[IF CORE Q7.15 = 4 (OUT OF WORK FOR LESS THAN 1 YEAR) ASK,]

What kind of work did you do? For example, registered nurse, janitor, cashier, auto mechanic.

INTERVIEWER NOTE: IF RESPONDENT IS UNCLEAR, ASK “WHAT WAS YOUR JOB TITLE?”

INTERVIEWER NOTE: IF RESPONDENT HAS MORE THAN ONE JOB THEN ASK, “WHAT WAS YOUR MAIN JOB?”

[Record answer] _________________________________

99 Refused

[IF CORE Q7.15 = 1 (EMPLOYED FOR WAGES) OR 2 (SELF-EMPLOYED) ASK,]

2. What kind of business or industry do you work in? For example, hospital, elementary school, clothing manufacturing, restaurant.

(588-687)

[Record answer] _________________________________

99 Refused

[CATI NOTE: IF CORE Q7.15 = 4 (OUT OF WORK FOR LESS THAN 1 YEAR) ASK,]

What kind of business or industry did you work in? For example, hospital, elementary school, clothing manufacturing, restaurant.

[Record answer] _________________________________

99 Refused

Module 27: Sexual Orientation and Gender Identity

The next two questions are about sexual orientation and gender identity.

INTERVIEWER NOTE: WE ASK THIS QUESTION IN ORDER TO BETTER UNDERSTAND THE HEALTH AND HEALTH CARE NEEDS OF PEOPLE WITH DIFFERENT SEXUAL ORIENTATIONS.

INTERVIEWER NOTE: PLEASE SAY THE NUMBER BEFORE THE TEXT RESPONSE. RESPONDENT CAN ANSWER WITH EITHER THE NUMBER OR THE TEXT/WORD.

1. Do you consider yourself to be: (688)

Please read:

1 1 Straight

2 2 - Lesbian or gay

3 3 - Bisexual

Do not read:

4 Other

7 Don’t know/Not sure

9 Refused

2. Do you consider yourself to be transgender? (689)

IF YES, ASK “DO YOU CONSIDER YOURSELF TO BE 1. MALE-TO-FEMALE, 2. FEMALE-TO-MALE, OR 3. GENDER NON-CONFORMING?

INTERVIEWER NOTE: Please say the number before the “yes” text response. Respondent can answer with either the number or the text/word.

Please read:

1 Yes, Transgender, male-to-female

2 Yes, Transgender, female to male

3 Yes, Transgender, gender nonconforming

4 No

Do not read:

7 Don’t know/not sure

9 Refused

INTERVIEWER NOTE: IF ASKED ABOUT DEFINITION OF TRANSGENDER: SOME PEOPLE DESCRIBE THEMSELVES AS TRANSGENDER WHEN THEY EXPERIENCE A DIFFERENT GENDER IDENTITY FROM THEIR SEX AT BIRTH. FOR EXAMPLE, A PERSON BORN INTO A MALE BODY, BUT WHO FEELS FEMALE OR LIVES AS A WOMAN WOULD BE TRANSGENDER. SOME TRANSGENDER PEOPLE CHANGE THEIR PHYSICAL APPEARANCE SO THAT IT MATCHES THEIR INTERNAL GENDER IDENTITY. SOME TRANSGENDER PEOPLE TAKE HORMONES AND SOME HAVE SURGERY. A TRANSGENDER PERSON MAY BE OF ANY SEXUAL ORIENTATION – STRAIGHT, GAY, LESBIAN, OR BISEXUAL.

INTERVIEWER NOTE: IF ASKED ABOUT DEFINITION OF GENDER NON-CONFORMING: SOME PEOPLE THINK OF THEMSELVES AS GENDER NON-CONFORMING WHEN THEY DO NOT IDENTIFY ONLY AS A MAN OR ONLY AS A WOMAN.

Module 28: Firearm Safety

The next questions are about safety and firearms. Some people keep guns for recreational purposes such as hunting or sport shooting. People also keep guns in the home for protection. Please include firearms such as pistols, revolvers, shotguns, and rifles; but not BB guns or guns that cannot fire. Include those kept in a garage, outdoor storage area, or motor vehicle.

Are any firearms now kept in or around your home? (690)

1. Yes

2. No [GO TO NEXT MODULE]

7. Don’t know/not sure [GO TO NEXT MODULE]

9. Refused [GO TO NEXT MODULE]

Are any of these firearms now loaded? (691)

1. Yes

2. No [GO TO NEXT MODULE]

7. Don’t know/not sure [GO TO NEXT MODULE]

9. Refused [GO TO NEXT MODULE]

Are any of these loaded firearms also unlocked? (692)

1. Yes

2. No

7. Don’t know/not sure

9. Refused

Module 29: Random Child Selection

[CATI NOTE: IF CORE Q7.16 = 88, OR 99 (NO CHILDREN UNDER AGE 18 IN THE HOUSEHOLD, OR REFUSED), GO TO NEXT MODULE.]

CATI NOTE: IF CORE Q7.16 = 1, INTERVIEWER PLEASE READ: “PREVIOUSLY, YOU INDICATED THERE WAS ONE CHILD AGE 17 OR YOUNGER IN YOUR HOUSEHOLD. I WOULD LIKE TO ASK YOU SOME QUESTIONS ABOUT THAT CHILD.” [GO TO Q1]

[CATI NOTE: IF CORE Q7.16 IS >1 AND CORE Q7.16 DOES NOT EQUAL 88 OR 99, INTERVIEWER PLEASE READ: “PREVIOUSLY, YOU INDICATED THERE WERE [NUMBER] CHILDREN AGE 17 OR YOUNGER IN YOUR HOUSEHOLD. THINK ABOUT THOSE [NUMBER] CHILDREN IN ORDER OF THEIR BIRTH, FROM OLDEST TO YOUNGEST. THE OLDEST CHILD IS THE FIRST CHILD AND THE YOUNGEST CHILD IS THE LAST. PLEASE INCLUDE CHILDREN WITH THE SAME BIRTH DATE, INCLUDING TWINS, IN THE ORDER OF THEIR BIRTH.”]

[CATI NOTE: RANDOMLY SELECT ONE OF THE CHILDREN. THIS IS THE “XTH” CHILD. PLEASE SUBSTITUTE “XTH” CHILD’S NUMBER IN ALL QUESTIONS BELOW.]

Please read:

I have some additional questions about one specific child. The child I will be referring to is the “Xth” [CATI NOTE: PLEASE FILL IN CORRECT NUMBER] CHILD IN YOUR HOUSEHOLD. ALL FOLLOWING QUESTIONS ABOUT CHILDREN WILL BE ABOUT THE “XTH” [CATI NOTE: PLEASE FILL IN] CHILD.]

1. What is the birth month and year of the “Xth” child? (693-698)

_ _ /_ _ _ _ Code month and year

77/ 7777 Don’t know / Not sure

99/9999 Refused

CATI NOTE: CALCULATE THE CHILD’S AGE IN MONTHS (CHLDAGE1=0 TO 216) AND ALSO IN YEARS (CHLDAGE2=0 TO 17) BASED ON THE INTERVIEW DATE AND THE BIRTH MONTH AND YEAR USING A VALUE OF 15 FOR THE BIRTH DAY. IF THE SELECTED CHILD IS < 12 MONTHS OLD ENTER THE CALCULATED MONTHS IN CHLDAGE1 AND 0 IN CHLDAGE2. IF THE CHILD IS > 12 MONTHS ENTER THE CALCULATED MONTHS IN CHLDAGE1 AND SET CHLDAGE2=TRUNCATE (CHLDAGE1/12).

2. Is the child a boy or a girl? (699)

1 Boy

2 Girl

9 Refused

3. Is the child Hispanic, Latino/a, or Spanish origin? (700-703)

INTERVIEWER INSTRUCTION: IF YES, ASK: “ARE THEY…

INTERVIEWER NOTE: SELECT ALL THAT APPLY

Please read:

1 Mexican, Mexican American, Chicano/a

2 Puerto Rican

3 Cuban

4 Another Hispanic, Latino/a, or Spanish origin

Do not read:

5 No

7 Don’t know / Not sure

9 Refused

4. Which one or more of the following would you say is the race of the child? (704-731)

INTERVIEWER NOTE: SELECT ALL THAT APPLY

INTERVIEWER NOTE: IF 40 (ASIAN) OR 50 (PACIFIC ISLANDER) IS SELECTED READ AND CODE SUBCATEGORIES UNDERNEATH MAJOR HEADING.

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

88 No additional choices

77 Don’t know / Not sure

99 Refused

5. Which one of these groups would you say best represents the child’s race? (732-733)

INTERVIEWER NOTE: IF 40 (ASIAN) OR 50 (PACIFIC ISLANDER) IS SELECTED READ AND CODE SUBCATEGORIES UNDERNEATH MAJOR HEADING.

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

77 Don’t know / Not sure

99 Refused

6. How are you related to the child? (734)

Please read:

1 Parent (include biologic, step, or adoptive parent)

2 Grandparent

3 Foster parent or guardian

4 Sibling (include biologic, step, and adoptive sibling)

5 Other relative

6 Not related in any way

Do not read:

7 Don’t know / Not sure

9 Refused

Module 30: Childhood Asthma Prevalence

[CATI NOTE: IF RESPONSE TO CORE Q7.16 = 88 (NONE) OR 99 (REFUSED), GO TO NEXT MODULE.]

The next two questions are about the “Xth” [CATI NOTE: PLEASE FILL IN CORRECT NUMBER] child.

1. Has a doctor, nurse or other health professional EVER said that the child has asthma? (735)

1 Yes

2 No [GO TO NEXT MODULE]

7 Don’t know / Not sure [GO TO NEXT MODULE]

9 Refused [GO TO NEXT MODULE]

Does the child still have asthma?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

CLOSING STATEMENT

Activity List for Common Leisure Activities

(To be used for Section 12: Physical Activity)

Code Description (Physical Activity, Questions 12.2 and 12.5 above)

01 Active Gaming Devices (Wii Fit, Dance, Dance revolution)

02 Aerobics video or class

03 Backpacking

04 Badminton

05 Basketball

06 Bicycling machine exercise

07 Bicycling

08 Boating (Canoeing, rowing, kayaking, sailing for pleasure or camping)

09 Bowling

10 Boxing

11 Calisthenics

12 Canoeing/rowing in competition

13 Carpentry

14 Dancing-ballet, ballroom, Latin, hip hop, Zumba, etc.

15 Elliptical/EFX machine exercise

16 Fishing from river bank or boat

17 Frisbee

18 Gardening (spading, weeding, digging, filling)

19 Golf (with motorized cart)

20 Golf (without motorized cart)

21 Handball

22 Hiking – cross-country

23 Hockey

24 Horseback riding

25 Hunting large game – deer, elk

26 Hunting small game – quail

27 Inline Skating

28 Jogging

29 Lacrosse

30 Mountain climbing

31 Mowing lawn

32 Paddleball

33 Painting/papering house

34 Pilates

35 Racquetball

36 Raking lawn/trimming hedges

37 Running

38 Rock climbing

39 Rope skipping

40 Rowing machine exercises

41 Rugby

42 Scuba diving

43 Skateboarding

44 Skating – ice or roller

45 Sledding, tobogganing

46 Snorkeling

47 Snow blowing

48 Snow shoveling by hand

49 Snow skiing

50 Snowshoeing

51 Soccer

52 Softball/Baseball

53 Squash

54 Stair climbing/Stair master

55 Stream fishing in waders

56 Surfing

57 Swimming

58 Swimming in laps

59 Table tennis

60 Tai Chi

61 Tennis

62 Touch football

63 Volleyball

64 Walking

66 Waterskiing

67 Weight lifting

68 Wrestling

69 Yoga

71 Childcare

72 Farm/Ranch Work (caring for livestock, stacking hay, etc.)

73 Household Activities (vacuuming, dusting, home repair, etc.)

74 Karate/Martial Arts

75 Upper Body Cycle (wheelchair sports, ergometer

76 Yard work (cutting/gathering wood, trimming, etc.)

98 Other_____

99 Refused

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Author	CDC
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File Created	2021-01-22