18 Years)

Public reporting burden of this collection of information is estimated to average 25 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).

Questions by Section

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. If you have any questions about the survey, please call (give appropriate state telephone number).

Core Section 1: Health Status

1.1 Would you say that in general your health is—

Read:

1 Excellent,

2 Very good,

3 Good,

4 Fair, or

5 Poor.

Do not read:

7 Don’t know / Not sure

9 Refused

Core 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?

_ _ 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?

_ _ 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?

__ Number of days

88 None

77 Don’t know / Not sure

99 Refused

Core Section 3: Demographics

3.1 What was your sex at birth?

Do not read:

1 Male

2 Female

9 Refused

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.

3.2. Which of the following best represents how you think of yourself?”

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

3.3 Do you consider yourself to be transgender?

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.

Read:

1 1. Yes, Transgender, male-to-female

2 2. Yes, Transgender, female to male

3 3. Yes, Transgender, gender nonconforming

4 4. No, not transgender.

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.

3.4 What is your age?

_ _ Code age in years

07 Don’t know / Not sure

09 Refused

3.5 Are you Hispanic, Latino/a, or Spanish origin?

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

3.6 Which one or more of the following would you say is your race?

INTERVIEWER NOTE: Select all that apply.

INTERVIEWER NOTE: 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.

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 Q3.5; continue. Otherwise, go to Q3.6.

3.5 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.

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

3.6 Are you…?

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

3.7 What is the highest grade or year of school you completed?

Read 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)

Do not read:

9 Refused

3.8 Do you own or rent your home?

1 Own

2 Rent

3 Other arrangement

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: “Other arrangement” may include group home, staying with friends or family without paying rent.

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.

3.9 Are you currently…?

Read:

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

8 Unable to work

Do not read:

9 Refused

3.10 In the past 12 months, have you or anyone in your household received food stamps, also called SNAP (the Supplemental Nutrition Assistance Program), or food benefits on EBT (Electronic Benefit Transfer)?

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused

INTERVIEWER NOTE: Food Stamps or SNAP (Supplemental Nutrition Assistance Program) is a government program that provides plastic cards that can be used to buy food. In the past, SNAP was called the Food Stamp Program and gave people benefits in paper coupons or food stamps.

3.11 How many children less than 18 years of age live in your household?

_ _ Number of children

88 None

99 Refused

3.12 Is your annual household income from all sources—

If respondent refuses at ANY income level, code ‘99’ (Refused)

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

3.13 About how much do you weigh without shoes?

NOTE: If respondent answers in metrics, put “9” in column XXX.

Round fractions up

_ _ _ _ Weight (pounds/kilograms)

7777 Don’t know / Not sure

9999 Refused

3.14 About how tall are you without shoes?

NOTE: If respondent answers in metrics, put “9” in column XXX.

Round fractions down

_ _ / _ _ Height

(f t / inches/meters/centimeters)

7 7/ 7 7 Don’t know / Not sure

9 9/ 9 9 Refused

Module Section 4: Depression/ Anxiety

4.1 Over the last 2 weeks, how often have you been bothered by having little interest or pleasure in doing things. Would you say this happens...

Read:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

Do not read:

7 Don’t know/ Not sure

9 Refused

4.2 Over the last 2 weeks, how often have you been bothered by feeling down, depressed or hopeless? Would you say this happens…

Read:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

Do not read:

7 Don’t know/ Not sure

9 Refused

4.3 Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge? Would you say this happens…

Read:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

Do not read:

7 Don’t know/ Not sure

9 Refused

4.4 Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying? Would you say this happens…

Read:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

Do not read:

7 Don’t know/ Not sure

9 Refused

Module Section 5: Indoor Tanning and Excess Sun Exposure

5.1 Not including spray-on tans, during the past 12 months, how many times have you used an indoor tanning device such as a sunlamp, tanning bed, or booth even one time?

Do Not Read:

Enter number (0-365) __ __ __

777 Don’t know/ Not sure

999 Refused

5.2 During the past 12 months, how many times have you had a sunburn?

Do not read:

Enter number (0-365) __ __ __

777 Don’t know/ Not sure

999 Refused

5.3 When you go outside on a warm sunny day for more than one hour, how often do you protect yourself from the sun (for example, using sunscreen, wearing a wide-brimmed hat, or wearing a long-sleeved shirt)? Is that….

Read

1 Always

2 Most of the time

3 Sometimes

4 Rarely

5 Never

Do not Read

6 Don’t go out in the sun

7 Don’t know/ Not sure

9 Refused

5.4 In the summer, on average, how long are you outside per day between 10am and 4pm on weekdays?

Do not read:

1 Less than half an hour

2 (more than half an hour) up to 1 hour

3 (more than 1 hour) up to 2 hours

4 (more than 2 hours) up to 3 hours

5 (more than 3 hours) up to 4 hours

6 (more than 4 hours) up to 5 hours

7 Up to 6 hours

77 Don’t know/ Not sure

99 Refused

5.5 In the summer, on average, how long are you outside per day between 10am and 4pm on weekends?

Do not read:

1 Less than half an hour

2 (more than half an hour) up to 1 hour

3 (more than 1 hour) up to 2 hours

4 (more than 2 hours) up to 3 hours

5 (more than 3 hours) up to 4 hours

6 (more than 4 hours) up to 5 hours

7 Up to 6 hours

77 Don’t know/ Not sure

99 Refused

Module Section 6: Colorectal Cancer Screening (2 Options/ Randomized)

Option 1

6.1.1 A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?

Do not read:

1 Yes

2 No [Go to Q3]

7 Don't know / Not sure [Go to Q3]

9 Refused [Go to Q3]

6.1.2 How long has it been since you had your last blood stool test using a home kit?

Do not read:

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 3 years (2 years but less than 3 years ago)

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

5 5 or more years ago

7 Don't know / Not sure

9 Refused

6.1.3. A sigmoidoscopy uses a flexible tube that is inserted in the rectum to look for problems. Have you ever had a sigmoidoscopy?

Do not read:

1 Yes

2 No [Go to Q5]

7 Don’t know / Not sure [Go to Q5]

9 Refused [Go to Q5]

6.1.4 How long has it been since you had your last sigmoidoscopy?

Do not read:

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 3 years (2 years but less than 3 years ago)

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

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

6 10 or more years ago

7 Don't know / Not sure

9 Refused

6.1.5 A colonoscopy uses a flexible tube that is longer than a sigmoidoscopy. For this test, you are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test. Have you ever had a colonoscopy?

Do not read:

1 Yes

2 No [Go to Q7]

7 Don’t know / Not sure [Go to Q7]

9 Refused [Go to Q7]

6.1 6 How long has it been since you had your last colonoscopy?

Do not read:

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 3 years (2 years but less than 3 years ago)

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

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

6 10 or more years ago

7 Don't know / Not sure

9 Refused

6.1.7 There are several new colorectal cancer screening tests. One is the multi-targeted stool DNA test. It is similar to the blood stool test and looks for blood in the stool. It also looks at changes in DNA, which may be a sign of cancer. Have you ever had a multi-targeted stool DNA test?

Do not read:

1 Yes

2 No [Go to Q9]

7 Don’t know / Not sure [Go to Q9]

9 Refused [Go to Q9]

6.1.8. How long has it been since you had your last multi-targeted stool DNA test?

Do not read:

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 3 years (2 years but less than 3 years ago)

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

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

6 10 or more years ago

7 Don't know / Not sure

9 Refused

6.1.9. The other new test is a CT colonography and uses a series of X-rays to take pictures of the inside of the colon. Have you ever had a CT colonography?

Do not read:

1 Yes

2 No [End module]

7 Don’t know / Not sure [End module]

9 Refused [End module]

6.1.10 How long has it been since you had your last CT colonography?

Do not read:

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 3 years (2 years but less than 3 years ago)

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

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

6 10 or more years ago

7 Don't know / Not sure

9 Refused

Option 2:

6.2.1. There are several kinds of tests for colorectal cancer including a stool test, a flexible sigmoidoscopy, a colonoscopy, and a virtual colonoscopy. Stool tests include using a special kit at home to determine whether the stool contains blood. A flexible sigmoidoscopy and colonoscopy view the inside of the rectum and colon for signs of cancer or other health problems. The colonoscopy includes getting medication through a needle in your arm to make you sleepy and you were told to have someone else drive you home after the test. The virtual colonoscopy uses x-rays so that a doctor can see images of the colon on a computer screen. Have you ever had a test for colorectal cancer screening?

Do not read:

1 Yes

2 No [Go to next module]

7 Don't know / Not sure [Go to next module]

9 Refused [Go to next module]

6.2.2. How long has it been since you had your last test for colorectal cancer screening?

Do not read:

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 3 years (2 years but less than 3 years ago)

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

5 5 or more years ago

7 Don't know / Not sure [Go to next module]

9 Refused [Go to next module]

6.2.3. Was that colorectal cancer screening test a:

Read:

1 Blood stool test (FIT, gFOBT) [go to Q4]

2 Blood stool test that tested for DNA (multi-targeted stool DNA test; FIT-DNA test) [go to next module]

3 Flexible sigmoidoscopy [go to Q6]

4 Colonoscopy [Go to next module]

5 Virtual colonoscopy [Go to next module]

Do not read:

7 Don't know / Not sure [Go to next module]

9 Refused [Go to next module]

6.2.4. A sigmoidoscopy uses a flexible tube that is inserted in the rectum to look for problems. Did you also have a flexible sigmoidoscopy with the blood stool test?

Do not read:

1 Yes

2 No [Go to next module]

7 Don't know / Not sure [Go to next module]

9 Refused [Go to next module]

6.2.5. How long has it been since you had your last sigmoidoscopy?

Do not read:

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 3 years (2 years but less than 3 years ago)

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

5 5 or more years ago

7 Don't know / Not sure [Go to next module]

9 Refused [Go to next module]

6.2.6. Did you also have a blood stool test with the flexible sigmoidoscopy? A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood.

Do not read:

1 Yes

2 No [Go to next module]

7 Don't know / Not sure [Go to next module]

9 Refused [Go to next module]

6.2.7. How long has it been since you had your last blood stool test?

Do not read:

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 3 years (2 years but less than 3 years ago)

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

5 5 or more years ago

7 Don't know / Not sure [Go to next module]

9 Refused [Go to next module]

Closing statement

Thank you for your participation. You answers will be combined with others to determine the best way to understand health risk behaviors and preventive practices.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	CDC
File Modified	0000-00-00
File Created	2021-01-22