Form Screening Question Screening Question Screening Questions

National Mental Health Study Field Test,
Supporting Statement
Attachment I – Housing Unit and Group
Quarters Unit Screening Questions

2017 NATIONAL MENTAL HEALTH
STUDY (NMHS): OMB DRAFT
SCREENER SPECIFICATIONS FOR
PROGRAMMING

Substance Abuse and Mental Health Services Administration
Center for Behavioral Health Statistics and Quality
Rockville, Maryland
National Institute of Mental Health
Rockville, Maryland
Last Revised: March 13th, 2017

2017 NATIONAL MENTAL HEALTH
STUDY (NMHS): OMB DRAFT
SCREENER SPECIFICATIONS FOR
PROGRAMMING
Contract No. HHSS283201300001C
RTI Project No. 0213985.301.002.001
RTI Authors:
Frank Mierzwa
Gretchen McHenry
Tennyson Chen
Christine Carr

RTI Project Director:
Suzanne Triplett

SAMHSA Project Officer:
Peter Tice
NIMH Project Officer:
Lisa Colpe

For questions about this report, please email [email protected].
Prepared for Substance Abuse and Mental Health Services Administration,
Rockville, Maryland and National Institute of Mental Health, Rockville,
Maryland
Prepared by RTI International, Research Triangle Park, North Carolina
Last Revised: March 13th, 2017
Recommended Citation: Center for Behavioral Health Statistics and Quality.
(2016). 2017 National Mental Health Study (NMHS): Screener Specifications
for Programming. Substance Abuse and Mental Health Services
Administration; National Institute of Mental Health, Rockville, MD.

Acknowledgments
This publication was developed for the Substance Abuse and Mental Health Services
Administration (SAMHSA), Center for Behavioral Health Statistics and Quality (CBHSQ),
and the National Institute of Mental Health (NIMH), by RTI International, a trade name of
Research Triangle Institute, Research Triangle Park, North Carolina, under Contract No.
HHSS283201300001C. Significant other contributors to this document at RTI include Rachel
Caspar and Suzanne Triplett who were reviewers. Contributors to this report from CBHSQ
include Grace Medley, and Dicy Painter.

Table of Contents
Section

Page

1.

HU Screening ......................................................................................................... 1-1

2

GQU Screening ...................................................................................................... 2-1

3.

Parent Contact Information .................................................................................... 3-1

4.

Select Case Screen Options .................................................................................... 4-1

5

Record of Calls ....................................................................................................... 5-1

6.

Screening and Interview Refusals .......................................................................... 6-1

7

Verification............................................................................................................. 7-1

8.

GPS Data Collection .............................................................................................. 8-1

9.

FI Debriefing Questions ......................................................................................... 9-1

10.

Parental Introductory Script ................................................................................. 10-1

11.

Interview Verification Specifications................................................................... 11-1

NMHS Screening Application Specifications
Section 1
HU Screening
Document Format:
 Screen names bolded
 Screen/question/instructional text designated by black and non-italicized text in parenthesis. In
the program, upper-lower black text to be read and red text is instructions to FI
 Fills designated by parenthesis and italics
 Logic designated by brackets
 Text of instructional message boxes provided in bracketed logic
 Response categories underlined

The line number and address are located at the top of each screen. During the roster questions asking
about age through military, touch the address line to see DU LINE box, an enlarged display of the
CaseID and address. If a case is an Added DU, the DU LINE box displays the link line number.

STUDY INTRODUCTION
Hello, my name is (FI NAME) with RTI International in North Carolina. We are conducting a
nationwide study sponsored by the U.S. Department of Health and Human Services.
[IF NOT ADDED DU] You should have received a letter explaining the study.
[IF NOT ADDED DU] HAND R COPY OF LETTER IF NEEDED
[IF ADDED DU] HAND R LEAD LETTER, ALLOW TIME TO READ
Next [IDENTIFY SR]

IDENTIFY SR [IF STUDY INTRODUCTION = NEXT]
First, just let me verify: do you live here?
IF NOT OBVIOUS:
And are you 18 or older?
IF NO TO EITHER, ASK FOR AN ADULT RESIDENT, TOUCH “PREVIOUS”, AND BEGIN
AGAIN.
SR Available [ADDRESS VERIFICATION]
SR Not Available [EXIT SCREENING: “ARE YOU SURE YOU WANT TO EXIT
SCREENING?” IF Yes, RECORD OF CALLS. IF No, IDENTIFY SR.]

ADDRESS VERIFICATION [IF IDENTIFY SR = SR AVAILABLE]
1-1

I just need to verify -- is this
STREET: (NUMBER AND STREET)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
Address Is Correct [INFORMED CONSENT]
Need to Edit Address [EDIT ADDRESS]
FI At Wrong Address [SELECT CASE]

EDIT ADDRESS [IF ADDRESS VERIFICATION = NEED TO EDIT ADDRESS]
TOUCH THE ITEM YOU NEED TO EDIT
STREET # (NUMBER)
STREET: (STREET)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
Update [SAVE UPDATED ADDRESS, THEN ADDRESS VERIFICATION]

INFORMED CONSENT [IF ADDRESS VERIFICATION = ADDRESS IS CORRECT]
GIVE PERSON STUDY DESCRIPTION AND SAY
Please read this statement. It describes the survey and the legislation that assures the
confidentiality of any information you provide. It also explains that your answers are used for
statistical purposes only and that your participation is voluntary. First I need to ask a few general
questions. As a thank you for completing this screening, you will receive [FILL $5/$10] in cash.
If anyone is selected for the full interview, that person will receive $40 in cash after the interview
is completed.
Next [MISSED DUs]

MISSED DUs [IF INFORMED CONSENT = NEXT]
FOR REGULAR HUs SUCH AS INDIVIDUAL HOUSES, TOWNHOUSES, DUPLEXES,
TRAILERS, COTTAGES
Are there any other living quarters within this structure or on this property, such as a separate
apartment with a separate entrance?
Yes [MISSED DU ADDRESS]
[IF MISSED DU: CANNOT ADD UNIT
“YOU CANNOT ADD A MISSED DU
FROM A DU THAT HAS BEEN ADDED”
MISSED DUs]

1-2

No [OCCUPANCY]

FOR APARTMENT/CONDO HUs: DON'T ASK, JUST TOUCH "APT/CONDO" (BELOW)
TO CONTINUE.
APT/CONDO [OCCUPANCY]

MISSED DU ADDRESS [IF MISSED DUs = YES]
RECORD STREET ADDRESS OR DESCRIPTION OF UNIT
STREET #:
STREET:
Update [OCCUPANCY]

Cancel [CANCEL DU: “ARE YOU SURE
YOU WANT TO CANCEL ADDITION OF THIS DU?
IF Yes, OCCUPANCY. IF No, MISSED DU
ADDRESS.]

OCCUPANCY [IF MISSED DUs = NO OR APT/CONDO OR MISSED DU ADDRESS = UPDATE
OR CANCEL MISSED DU = YES]
(Have/Will) you or anyone else in this household (lived/live) here for most of the time during the
months of (CURRENT QUARTER)?
Yes [TOTAL SDU MEMBERS]

No [OCCUPANCY – CONFIRMATION: YOUR
‘NO’ RESPONSE WILL CONCLUDE THIS
SCREENING AND FINALIZE THIS CASE. DO YOU
WANT TO CHANGE YOUR ANSWER? (‘YES’
WILL CONTINUE SCREENING. ‘NO’ WILL
FINALIZE THE CASE.) IF Yes, OCCUPANCY. IF
No, OCCUPANCY-CLOSE CASE: ARE YOU SURE
YOU WANT TO CLOSE OUT THIS CASE? IF Yes,
VERIFICATION. IF No, OCCUPANCY]

TOTAL SDU MEMBERS [IF OCCUPANCY= YES]
(Including yourself), how many people in this household (lived/will live) here for most of the time
during (CURRENT QUARTER)? (Do not include anyone who (lived/will live) at school or
somewhere else for most of the time during (CURRENT QUARTER).)
ENTER NUMBER 1-20 [MEMBERS 13 OR OLDER]
[IF 1 TOTAL SDU MEMBERS = 1, ONLY HOUSEHOLD MEMBER: “CONFIRM
RESPONSE: IS THERE ONLY 1 PERSON IN THIS HOUSEHOLD?” IF No, TOTAL
SDU MEMBERS. IF Yes, ONLY ELIGIBLE HH MEMBER: “Is that you?” IS
THIS SCREENING RESPONDENT THE ONE ELIGIBLE RESIDENT OF THE DU?
IF No, HOUSEHOLDER AGE USING ‘THIS PERSON’ FILL. IF Yes,
HOUSEHOLDER AGE USING ‘YOUR’ FILL.]

MEMBERS 13 OR OLDER [IF TOTAL SDU MEMBERS NE BLANK AND >1]
1-3

Of these (TOTAL SDU MEMBERS) people, how many are now age 13 or older?
ENTER SUBSET OF TOTAL SDU MEMBERS [ROSTER INTRO]
[IF MEMBERS 13 OR OLDER = 1, ONLY ELIGIBLE MEMBER: “CONFIRM
RESPONSE: IS THERE ONLY 1 PERSON AGE 13 OR OLDER IN THIS
HOUSEHOLD?” IF No, MEMBERS 13 OR OLDER. IF Yes, ONLY ELIGBLE HH
MEMBER: “(Is that you?) IS THIS SCREENING RESPONDENT THE ONE
ELIGIBLE RESIDENT OF THE DU? IF No, HOUSEHOLDER AGE USING ‘THIS
PERSON’ FILL. IF Yes, HOUSEHOLDER AGE USING ‘YOUR’ FILL.]

ROSTER INTRO [IF MEMBERS 13 OR OLDER NE 1 OR BLANK]
Next I'll ask a few questions about the people who live here. Let's start with the person or one of
the persons living here who owns or rents this home. We'll refer to this person as the
householder.
Next [HOUSEHOLDER AGE]

HOUSEHOLDER AGE [IF ROSTER INTRO NE BLANK OR ROSTER NE BLANK OR
CONFIRM ROSTER FOR HOUSEHOLDER = NO]
Please tell me the age of this person on his or her last birthday.
IF SR IS HOUSEHOLDER:
Please tell me your age on your last birthday.
ENTER AGE [SCREENING RESPONDENT]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HOUSEHOLDER AGE. IF Yes, THIS PERSON: IS THIS
PERSON THE SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE.
IS THIS PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE
CONFIRM RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE
AND = No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT
CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.]

SCREENING RESPONDENT [IF HOUSEHOLDER AGE NE BLANK OR IF
AGE NE BLANK AND SCREENING RESPONDENT NE YES]
IS THIS (HOUSEHOLDER AGE/AGE) YEAR OLD PERSON THE SCREENING
RESPONDENT? IF UNSURE ASK: “Is that you?”
Yes [SETS LANGUAGE FOR SUBSEQUENT ROSTER QUESTIONS USING
‘YOU/YOUR’]
No [SETS LANGUAGE FOR SUBSEQUENT ROSTER QUESTIONS USING
‘THIS PERSON.’]
[IF HOUSEHOLDER, HOUSEHOLDER GENDER OTHERWISE, RELATION]

1-4

HOUSEHOLDER GENDER [IF SCREENING RESPONDENT NE BLANK FOR
HOUSEHOLDER]
ASK ONLY IF NOT OBVIOUS
(Are you/Is this person) male or female?
Male
Female
[HOUSEHOLDER HISPANIC]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HOUSEHOLDER GENDER. IF Yes, THIS PERSON: IS THIS
PERSON THE SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE.
IS THIS PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE
CONFIRM RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE
AND = No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT
CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.]

HOUSEHOLDER HISPANIC [IF HOUSEHOLDER GENDER NE BLANK]
(Are you/Is he/Is she) of Hispanic, Latino or Spanish origin?
(That is, do any of these groups describe (your/his/her) national origin or ancestry – Puerto Rican,
Cuban, Cuban-American, Mexican, Mexican-American, Chicano, Central or South American, or
origin in some other Spanish-speaking country?)
Yes
No
[HOUSEHOLDER RACE]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HOUSEHOLDER HISPANIC. IF Yes, THIS PERSON: IS THIS
PERSON THE SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE.
IS THIS PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE
CONFIRM RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE
AND = No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT
CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.]

HOUSEHOLDER RACE [IF HOUSEHOLDER HISPANIC NE BLANK]
(Are you/Is he/Is she) White, Black or African American, American Indian or Alaska Native,
Native Hawaiian or other Pacific Islander, or Asian?
White
Black or African American
American Indian or Alaska Native
Native Hawaiian/other Pacific Islander
Asian
Other
(CHECK ALL THAT APPLY)

1-5

[HOUSEHOLDER MILITARY OR IF HOUSEHOLDER AGE NE 17-65 CONFIRM
ROSTER]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HOUSEHOLDER RACE. IF Yes, THIS PERSON: IS THIS
PERSON THE SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE.
IS THIS PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE
CONFIRM RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE
AND = No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT
CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.]

HOUSEHOLDER MILITARY [IF HOUSEHOLDER RACE NE BLANK AND
HOUSEHOLDER AGE = 17-65
(Are you/Is he/Is she) currently on active duty in the United States military?
Yes
No
Refused
[CONFIRM ROSTER]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HOUSEHOLDER MILITARY. IF Yes, THIS PERSON: IS
THIS PERSON THE SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE:
PLEASE CONFIRM RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT
CHANGE AND = No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES
NOT CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.]

CONFIRM ROSTER [IF HOUSEHOLDER MILITARY NE BLANK OR IF
HOUSEHOLDER AGE NE 17-65 AND HOUSEHOLDER RACE NE BLANK]
[IF RACE, HISPANIC, AND/OR MILITARY IS ‘OTHER’, ‘DK’, OR ‘REF’ OMIT
RESPECTIVE FILLS FROM CONFIRM ROSTER SCREEN.]
I have listed (a/an, IF SR: you as a/an) (AGE) year old (GENDER) householder. (She is/He is/IF
SR: You are) (RACE), (HISPANIC), and (is/is not/IF SR: are/are not) on active duty in the
United States military.
Is this correct?
Yes [OTHER MEMBERS] [IF ROSTER NE BLANK , THEN VERIFY ROSTER DATA]
No [HOUSEHOLDER AGE]

OTHER MEMBERS [IF CONFIRM ROSTER = YES AND MEMBERS 13 OR OLDER ≥ 2]
1-6

READ TO RESPONDENT:
Now I need some general information about (the other person/all of the other people) in this
household who (is/are) 13 years old or older. [IF MEMBERS 13 OR OLDER >2] Let's start with
the oldest and work down to the youngest.
Next [AGE]

AGE [IF OTHER MEMBERS NE BLANK OR CONFIRM ROSTER = NO]
[IF MEMBERS 13 OR OLDER = 2] Please tell me the age of this person on his or her last
birthday.
[IF MEMBERS 13 OR OLDER > 2 HH MEMBERS] Please tell me the age of the (oldest/next
oldest) person on his or her last birthday.
ENTER AGE [IF ANY SCREENING RESPONDENT = YES, RELATION. IF ALL
SCREENING RESPONDENT = BLANK OR NO, SCREENING
RESPONDENT]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, AGE. IF Yes, THIS PERSON: IS THIS PERSON THE SR? IF
Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS PERSON
THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND = No,
PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT CHANGE AND =
Yes, PERSON = SCREENING RESPONDENT.]

RELATION [IF AGE NE BLANK AND ANY SCREENING RESPONDENT =YES]
[IF SCREENING RESPONDENT = YES FOR THIS MEMBER] How are you related to the
householder?
[IF SCREENING RESPONDENT = YES FOR HOUSEHOLDER] How is this person related to
you, the householder?
[IF SCREENING RESPONDENT = NO FOR THIS MEMBER AND SCREENING
RESPONDENT = NO FOR HOUSEHOLDER] How is this person related to the householder?
Husband
Wife
Son (includes step, foster, or adoptive)
Daughter (includes step, foster, or adoptive)
Son-in-law/Daughter-in-law
Brother (includes half, step, foster, or adoptive)
Sister (includes half, step, foster, or adoptive)
Brother-in-law/Sister-in-law
Parent/Guardian (incl. step, foster, or adoptive)
Parent-in-law
Aunt/Uncle
Nephew/Niece
Grandparent
Grandchild
Cousin

1-7

Ex-Spouse
Unmarried Partner
Housemate or Roommate
Tenant/Boarder/Exch Student
Other relative
Other Non-relative
Relationship Unspecified
[IF RELATION = HUSBAND, WIFE, SON, DAUGHTER, BROTHER OR SISTER
HISPANIC, OTHERWISE GENDER]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, RELATION. IF Yes, THIS PERSON: IS THIS PERSON THE
SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS
PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND = No,
PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT CHANGE AND =
Yes, PERSON = SCREENING RESPONDENT.]

GENDER [IF RELATION NE HUSBAND, WIFE, SON, DAUGHTER, BROTHER OR SISTER]
ASK ONLY IF NOT OBVIOUS
(Are you/Is this person) male or female?
Male
Female
Refused
[HISPANIC]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, GENDER. IF Yes, THIS PERSON: IS THIS PERSON THE SR?
IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS PERSON
THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND = No,
PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT CHANGE AND =
Yes, PERSON = SCREENING RESPONDENT.

HISPANIC [IF GENDER NE BLANK]
(Are you/Is he/Is she/Is this person) of Hispanic, Latino or Spanish origin?
(That is, do any of these groups describe (your/his/her/their) national origin or ancestry – Puerto
Rican, Cuban, Cuban-American, Mexican, Mexican-American, Chicano, Central or South
American, or origin in some other Spanish-speaking country?)
Yes
No
Refused
Unknown
[RACE]

1-8

[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HISPANIC. IF Yes, THIS PERSON: IS THIS PERSON THE SR?
IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS PERSON
THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND = No,
PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT CHANGE AND =
Yes, PERSON = SCREENING RESPONDENT.]

RACE [IF HISPANIC NE BLANK]
(Are you/Is he/Is she/Is this person) White, Black or African American, American Indian or
Alaska Native, Native Hawaiian or other Pacific Islander, or Asian?
White
Black or African American
American Indian or Alaska Native
Native Hawaiian/other Pacific Islander
Asian
Other
(CHECK ALL THAT APPLY)
Refused
Unknown
[IF AGE 17-65, MILITARY, OTHERWISE CONFIRM ROSTER]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, RACE. IF Yes, THIS PERSON: IS THIS PERSON THE SR? IF
Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS PERSON
THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND = No,
PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT CHANGE AND =
Yes, PERSON = SCREENING RESPONDENT.]

MILITARY [IF RACE NE BLANK AND AGE 17-65 AND SCREENING RESPONDENT = NO
FOR THIS MEMBER]
(Are you/Is he/Is she/Is this person) currently on active duty in the United States military?
Yes
No
Refused
Unknown
[CONFIRM ROSTER]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, MILITARY. IF Yes, THIS PERSON: IS THIS PERSON THE
SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS
PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM

1-9

RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND = No,
PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT CHANGE AND =
Yes, PERSON = SCREENING RESPONDENT.

CONFIRM ROSTER [IF AGE 17-65 AND MILITARY IS NE BLANK, OTHERWISE
RACE NE BLANK]
[IF RACE, HISPANIC, AND/OR MILITARY IS ‘OTHER’, ‘DK’, OR ‘REF’ OMIT
RESPECTIVE FILLS FROM CONFIRM ROSTER SCREEN.]
I have listed a/an (AGE) year old (RELATIONSHIP). (He/She) is (RACE), (HISPANIC) [IF AGE
17-65] and (is/is not) on active duty the United States military.
Is this correct?
Yes [AGE FOR NEXT HH MEMBER, OTHERWISE VERIFY ROSTER DATA]
No [AGE]

VERIFY ROSTER DATA [IF CONFIRM ROSTER = YES ]
[IF CONFIRM ROSTER = YES AND MEMBERS 13 OR OLDER=1]
DO NOT READ TO RESPONDENT. WHEN READY, TOUCH NEXT TO MAKE
SELECTION.
TO MAKE CORRECTIONS: TOUCH AND HOLD THE ROSTER LINE THAT YOU WANT
TO EDIT, THEN TOUCH 'EDIT' FROM THE POP-UP MENU.
[IF CONFIRM ROSTER = YES AND MEMBERS 13 OR OLDER>=2]
I need to make sure this list is accurate. I have listed...
[READ AGES AND RELATIONSHIPS ROSTERED].
TO MAKE CORRECTIONS: TOUCH AND HOLD THE ROSTER LINE THAT YOU WANT
TO EDIT, THEN TOUCH 'EDIT’ FROM THE POP-UP MENU.
Relation (Relationship)
AGE (Age)
SR (Y for Screening Respondent)
[TOUCH AND HOLD ANY ROSTER LINE, SELECT Show Details]
Relation: Relationship
Age: Age
Gender: M, F, R
Hispanic: Y, N, U, R
Race: W, B, I, P, A, O
Military: Y, N, U, R

1-10

Eligible: E, I)
[TOUCH AND HOLD ANY ROSTER LINE, SELECT Edit. EDIT ROSTER RECORD: DO YOU
WANT TO EDIT THE ROSTER INFORMATION FOR THE (AGE) YEAR OLD (RELATION)? IF
Yes, EDIT ROSTER MEMBER. IF No, VERIFY ROSTER DATA.]
[+MEMBER OR FUNCTIONS TO ADD ROSTER MEMBERS]
Next [START SELECTION]

START SELECTION
THE PROGRAM WILL START THE SELECTION PROCESS. ARE YOU SURE YOU ARE
READY TO MAKE THE SELECTIONS?
Yes [RESPONDENT SELECTION]
No [VERIFY ROSTER DATA]

ADOL INITIALS
NICKNAME

[IF ONE ADOLESCENT SELECTED] The [AGE] child who lives in this house
has been selected for an interview. Please tell me the initials of this [AGE]
(child). We use this information only as a reminder about which child was
selected. We will get permission from a parent or guardian and the child before
conducting an interview.
_______________________
ALLOW 10 CHARACTERS

NICKNAME2

[IF TWO ADOLESCENTS SELECTED] Both the [AGE] child and [AGE] child
who live in this house have been selected for an interview. Please tell me the
initials of [AGE] (child). We use this information only as a reminder about which
child was selected. We will get permission from a parent or guardian and the
child before conducting an interview.
_______________________
ALLOW 10 CHARACTERS

NICKNAME2b

[IF TWO ADOLESCENTS SELECTED] Please tell me the initials of [AGE]
child.
_______________________
ALLOW 10 CHARACTERS

RESPONDENT SELECTION [START SELECTION = YES]
Interview A
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Relation: (Relationship to householder, BLANK)

1-11

Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

Interview B
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Relation: (Relationship to householder, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

ALL INELIGIBLE [START SELECTION = YES AND ALL ROSTER MEMBERS MILITARY OR
INELIGIBLE]
ALL MEMBER(S) WERE INDICATED AS MILITARY OR INELIGIBLE. NO ONE IS
ELIGIBLE FOR SELECTION.
OK [VERIFICATION]

ADDITIONAL SCREEN SHOULD DISPLAY AFTER RESPONDENT SELECTION
COMPLETED
SINCENT01 HAND RESPONDENT [FILL $5/$10] CASH.
MARK THE APPROPRIATE “CASH ACCEPTANCE” BOX ON THE
INTERVIEW INCENTIVE RECEIPT.
SIGN AND DATE INTERVIEW INCENTIVE RECEIPT AND GIVE TOP
COPY TO RESPONDENT.
I have signed this form to indicate that I have given you [FILL $5/$10] for this
screening. Thank you for your help.
Next [INCENT01]
INCENT01

Did this respondent accept the [FILL $5/$10] screening incentive payment?
1
YES
2
NO

Next [INCENT02]
INCENT02

[IF INCENT01 = 2] Why didn’t this respondent accept the screening incentive
payment?
1-12

TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPACE BAR
BETWEEN EACH CATEGORY YOU SELECT.
1
2
3
4

DIDN’T FEEL IT WAS NECESSARY
DIDN’T WANT TO ACCEPT MONEY FROM THE GOVERNMENT
DIDN’T NEED THE MONEY
FELT IT WAS INAPPROPRIATE TO OFFER MONEY IN
EXCHANGE FOR PARTICIPATION

5

SOME OTHER REASON

DK
Next [INCENT03]
INCENT03

[IF INCENT02 = 5] Why didn’t this respondent accept the screening incentive
payment?
[ALLOW 200 CHARACTERS]
DK

Next [INCENT04]
INCENT04

[IF INCENT01 = 1] How much do you think the screening incentive payment
influenced this respondent’s decision to participate in the screening?
1
2
3
DK

A LOT
A LITTLE
NOT AT ALL

Next [INCENT05]
INCENT05

[IF INCENT04 = 1 OR 2] Do you think you would have been successful in
convincing this respondent to participate in the screening if you had not been able
to offer the screening incentive payment?
1
2
3
4
DK

DEFINITELY YES
PROBABLY YES
PROBABLY NOT
DEFINITELY NOT
1-13

Next [INCENT06]
INCENT06

[IF INCENT01 = 1] Do you think the screening incentive payment allowed you to
work this case more efficiently, that is, make fewer visits to the household or
spend less time gaining cooperation than you would have?
1
2
DK

YES
NO

Next [INCENT07]
INCENT07

[IF INCENT01 = 1] Did this respondent make any comments that suggested
[he/she] would have participated in the survey without the screening incentive?
1
2
DK

YES
NO

Next [INCENT08]
INCENT08

Did the respondent already know about the screening incentive before you told
[him/her]?
1
2
DK

YES
NO

Next [INCENT09]
INCENT09

[IF INCENT08 = 2] Did this respondent show any reluctance to participate in the
interview before you mentioned the screening incentive payment to [him/her]?
1
2
DK

YES
NO

Next [INCENT10]

1-14

INCENT10

[IF INCENT08 = 1] How did this respondent find out about the screening
incentive payment?
TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPACE BAR
BETWEEN EACH CATEGORY YOU SELECT.
1
2
3
4
5
6
DK

FROM THE LEAD LETTER
FROM THE Q & A BROCHURE
FROM ANOTHER MEMBER OF THE HOUSEHOLD
FROM A NEIGHBOR/BUILDING MANAGER/ETC.
FROM ANOTHER INTERVIEWER
SOME OTHER WAY

1-15

This page intentionally left blank.

1-16

NMHS Screening Application Specifications
Section 2
GQU Screening
Document Format:
 Screen names bolded
 Screen/question/instructional text designated by black and non-italicized text in parenthesis. In
the program, upper-lower black text to be read and red text is instructions to FI
 Fills designated by parenthesis and italics
 Logic designated by brackets
 Text of instructional message boxes provided in bracketed logic
 Response categories underlined

STUDY INTRODUCTION
Hello, my name is (FI NAME) with RTI International in North Carolina. We are conducting a
nationwide study sponsored by the U.S. Department of Health and Human Services.
You should have received a letter explaining the study.
Next [IDENTIFY SR]

IDENTIFY SR [IF STUDY INTRODUCTION = NEXT]
First, just let me verify: do you live here?
IF NOT OBVIOUS:
And are you 18 or older?
IF NO TO EITHER, ASK FOR AN ADULT RESIDENT, TOUCH “PREVIOUS”, AND BEGIN
AGAIN.
SR Available [ADDRESS VERIFICATION]
SR Not Available [EXIT SCREENING: “ARE YOU SURE YOU WANT TO EXIT
SCREENING?” IF Yes, RECORD OF CALLS. IF No,
IDENTIFY SR.]

2-1

ADDRESS VERIFICATION [IF IDENTIFY SR = SR AVAILABLE]
I just need to verify -- is this
STREET: (NUMBER AND STREET)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
Address Is Correct [INFORMED CONSENT]
Need to Edit Address [EDIT ADDRESS]
FI At Wrong Address [SELECT CASE]

EDIT ADDRESS [IF ADDRESS VERIFICATION = NEED TO EDIT ADDRESS]
TOUCH THE ITEM YOU NEED TO EDIT
STREET #: (NUMBER)
STREET: (STREET)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
Update [SAVE UPDATED ADDRESS, THEN ADDRESS VERIFICATION]

INFORMED CONSENT [IF ADDRESS VERIFICATION = ADDRESS IS CORRECT]
GIVE PERSON STUDY DESCRIPTION AND SAY
Please read this statement. It describes the survey and the legislation that assures the
confidentiality of any information you provide. It also explains that your answers are used for
statistical purposes only and that your participation is voluntary. First I need to ask a few general
questions. As a thank you for completing this screening, you will receive [FILL $5/$10] in cash.
If anyone is selected for the full interview, that person will receive $40 in cash after the interview
is completed.
Next [TRANSIENT]

TRANSIENT [IF INFORMED CONSENT = NEXT]
INTERVIEWER: IS THIS GQU A TRANSIENT SHELTER?
Yes [UNIT TYPE]
No [OCCUPANCY]

UNIT TYPE [IF TRANSIENT = YES]
ARE THE LISTED UNITS…

2-2

ROOMS [TOTAL GQU MEMBERS]
BEDS, OR [ROSTER #1 AGE]
PERSONS? [ROSTER #1 AGE]

OCCUPANCY [IF TRANSIENT = NO]
(Did/Will) you or anyone else in this room live here for most of the time during the
months of (CURRENT QUARTER)?
Yes [TOTAL GQU MEMBERS]

No [OCCUPANCY – CONFIRMATION:
YOUR ‘NO’ RESPONSE WILL
CONCLUDE THIS SCREENING
AND FINALIZE THIS CASE. DO
YOU WANT TO CHANGE YOUR
ANSWER? (‘YES’ WILL CONTINUE
SCREENING. ‘NO’ WILL FINALIZE THE
CASE.) IF Yes, OCCUPANCY. IF No,
OCCUPANCY-CLOSE CASE: ARE YOU SURE
YOU WANT TO CLOSE OUT THIS CASE? IF
Yes, VERIFICATION. IF No, OCCUPANCY]

TOTAL GQU MEMBERS [IF OCCUPANCY = YES OR IF UNIT TYPE = ROOMS]
[IF TRANSIENT = YES AND UNIT TYPE = ROOMS] (Including yourself) How many people
are staying in this room?
[IF TRANSIENT = NO] (Including yourself) How many people (lived/will live) in this room for
most of the time during (CURRENT QUARTER)?
ENTER NUMBER 1-20 [MEMBERS 13 OR OLDER]
[IF TOTAL GQU MEMBERS = 1, ONLY MEMBER: CONFIRM RESPONSE: IS
THERE ONLY 1 PERSON LIVING HERE? IF No, TOTAL GQU MEMBERS. IF
Yes AND UNIT TYPE = ROOMS, ROSTER #1 AGE. IF Yes AND TRANSIENT =
NO, ROSTER: IS THIS SCREENING RESPONDENT THE ONE ELIGIBLE
RESIDENT OF THE DU? IF Yes, ROSTER #1 AGE USING ‘YOUR’ FILL. IF No,
ROSTER #1 AGE USING ‘THIS PERSON’ FILL].

MEMBERS 13 OR OLDER [IF TOTAL GQU MEMBERS NE BLANK AND >1]
[IF TRANSIENT = YES] How many of these [TOTAL GQU MEMBERS] people are now age 13
or older.
[IF TRANSIENT = NO] Of these [TOTAL GQU MEMBERS] people, how many are now age 13
or older?
ENTER SUBSET OF TOTAL GQU MEMBERS ROSTER # AGE
[IF MEMBERS 13 OR OLDER = 1, ONLY ELIGIBLE MEMBER: “CONFIRM
RESPONSE: IS THERE ONLY 1 PERSON AGE 13 OR OLDER IN THIS UNIT?” IF

2-3

No, MEMBERS 13 OR OLDER. IF Yes AND UNIT TYPE = ROOMS ROSTER # 1
AGE. IF Yes AND TRANSIENT = NO, ROSTER: IS THIS SCREENING
RESPONDENT THE ONE ELIGIBLE RESIDENT OF THE DU? IF Yes, ROSTER #1
AGE USING ‘YOUR’ FILL. IF No, ROSTER #1 AGE USING ‘THIS PERSON’
FILL].

ROSTER #1 AGE [IF MEMBERS 13 OR OLDER NE BLANK OR TOTAL GQU MEMBERS = 1
OR IF UNIT TYPE = BEDS OR PERSONS]
Please tell me your age on your last birthday.
ENTER AGE [ROSTER #1 NAME]

ROSTER #1 NAME [IF ROSTER #1 AGE NE BLANK]
What is your first name?
ENTER FIRST NAME [ROSTER #1 GENDER]

ROSTER #1 GENDER [IF ROSTER #1 NAME NE BLANK]
ASK ONLY IF NOT OBVIOUS
Are you male or female?
Male
Female
[ROSTER #1 HISPANIC]

ROSTER #1 HISPANIC [IF ROSTER #1 GENDER NE BLANK]
Are you of Hispanic, Latino or Spanish origin?
(That is, do any of these groups describe your national origin or ancestry – Puerto Rican, Cuban,
Cuban-American, Mexican, Mexican-American, Chicano, Central or South American, or origin
in some other Spanish-speaking country?)
Yes
No
[ROSTER #1 RACE]

ROSTER #1 RACE [IF ROSTER #1 HISPANIC NE BLANK]
Are you White, Black or African American, American Indian or Alaska Native, Native Hawaiian
or other Pacific Islander, or Asian?

2-4

White
Black or African American
American Indian or Alaska Native
Native Hawaiian/other Pacific Islander
Asian
Other
(CHECK ALL THAT APPLY)
[ROSTER #1 MILITARY OR IF ROSTER #1 AGE NE 17-65 CONFIRM ROSTER]

ROSTER #1 MILITARY [IF ROSTER #1 RACE NE BLANK AND ROSTER #1 AGE = 17-65]
Are you currently on active duty in the United States military?
Yes
No
Refused
[CONFIRM ROSTER]

CONFIRM ROSTER [IF ROSTER #1 MILITARY NE BLANK OR IF
ROSTER #1 AGE NE 17-65 AND ROSTER #1 RACE NE
BLANK]
[IF RACE, HISPANIC, AND/OR MILITARY IS ‘OTHER’, ‘DK’, OR ‘REF’ OMIT
RESPECTIVE FILLS FROM CONFIRM ROSTER SCREEN.]
I have listed you as a/an (AGE) year old (GENDER) resident. You are (RACE), (HISPANIC) [IF
AGE =17-65] and (are/are not) on active duty in the United States military.
Is this correct?
Yes [IF MEMBERS 13 OR OLDER ≥ 2 OTHER MEMBERS. IF UNIT TYPE = BEDS OR
PERSONS OR UNIT TYPE = ROOMS AND TOTAL GQU MEMBERS OR MEMBERS
13 OR OLDER =1 VERIFY ROSTER DATA]
No [ROSTER #1 AGE]

2-5

OTHER MEMBERS [IF CONFIRM ROSTER = YES AND MEMBERS 13 OR OLDER ≥ 2]
READ TO RESPONDENT:
Now I need some general information about (the other person/all of the other people) who
(is/are) 13 years old or older. [IF MEMBERS 13 OR OLDER >2] Let's start with the oldest and
work down to the youngest.
Next [AGE]

AGE [IF OTHER MEMBERS NE BLANK OR CONFIRM ROSTER = NO]
[IF MEMBERS 13 OR OLDER = 2] Please tell me the age of this person on his or her last
birthday.
[IF MEMBERS 13 OR OLDER > 2 HH MEMBERS] Please tell me the age of the (oldest/next
oldest) person on his or her last birthday.
ENTER AGE [NAME]

NAME [IF AGE NE BLANK]
What is this person’s first name?
ENTER FIRST NAME [GENDER]

GENDER [IF NAME NE BLANK]
ASK ONLY IF NOT OBVIOUS
Is this person male or female?
Male
Female
Refused
[HISPANIC]

2-6

HISPANIC [IF GENDER NE BLANK]
(Is he/Is she/Is this person) of Hispanic, Latino or Spanish origin?
(That is, do any of these groups describe (his/her/their) national origin or ancestry – Puerto
Rican, Cuban, Cuban-American, Mexican, Mexican-American, Chicano, Central or South
American, or origin in some other Spanish-speaking country?)
Yes
No
Refused
Unknown
[RACE]

RACE [IF HISPANIC NE BLANK]
(Is he/Is she/Is this person) White, Black or African American, American Indian or Alaska
Native, Native Hawaiian or other Pacific Islander, or Asian?
White
Black or African American
American Indian or Alaska Native
Native Hawaiian/other Pacific Islander
Asian
Other
(CHECK ALL THAT APPLY)
Refused
Unknown

[IF AGE 17-65, MILITARY, OTHERWISE CONFIRM ROSTER]

MILITARY [IF RACE NE BLANK AND AGE 17-65]
(Is he/Is she/Is this person) currently on active duty in the United States military?
Yes
No
Refused
Unknown
[CONFIRM ROSTER]

2-7

CONFIRM ROSTER [IF AGE 17-65 AND MILITARY IS NE BLANK, OTHERWISE
RACE NE BLANK]
[IF RACE, HISPANIC, AND/OR MILITARY IS ‘OTHER’, ‘DK’, OR ‘REF’ OMIT
RESPECTIVE FILLS FROM CONFIRM ROSTER SCREEN.]
I have listed a/an (AGE) year old (GENDER) resident. (He/She) is (RACE), (HISPANIC) [IF
AGE 17-65] and (is/is not) on active duty in the United States military.
Is this correct?
Yes [AGE FOR NEXT GQU MEMBER, OTHERWISE VERIFY ROSTER DATA]
No [AGE]

VERIFY ROSTER DATA [IF CONFIRM ROSTER = YES]
[IF CONFIRM ROSTER = YES AND MEMBERS 13 OR OLDER=1]
DO NOT READ TO RESPONDENT. WHEN READY, TOUCH NEXT TO MAKE
SELECTION.
TO MAKE CORRECTIONS: TOUCH AND HOLD THE ROSTER LINE THAT YOU WANT
TO EDIT, THEN TOUCH 'EDIT' FROM THE POP-UP MENU.
[IF CONFIRM ROSTER = YES AND MEMBERS 13 OR OLDER>=2]
I need to make sure this list is accurate. I have listed...
[READ LIST OF OCCUPANTS’ AGES AND NAMES].
TO MAKE CORRECTIONS: TOUCH AND HOLD THE ROSTER LINE THAT YOU WANT
TO EDIT, THEN TOUCH 'EDIT' FROM THE POP-UP MENU.
Name (First Name)
AGE (Age)
SR (Y for Screening Respondent)
[UPON TOUCHING ON ANY ROSTER LINE, SELECT SHOW DETAILS]
Name: First Name
Age: Age
Gender: M, F, R
Hispanic: Y, N, U, R
Race: W, B, I, P, A, O
Military: Y, N, U, R
Eligible: E, I
[+MEMBER OR FUNCTIONS TO ADD ROSTER MEMBERS]
Next [START SELECTION]

START SELECTION
2-8

THE PROGRAM WILL START THE SELECTION PROCESS. ARE YOU SURE YOU ARE
READY TO MAKE THE SELECTIONS?
Yes [RESPONDENT SELECTION]
No [VERIFY ROSTER DATA]

RESPONDENT SELECTION [START SELECTION = YES]
Interview A
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Name: (First Name, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

Interview B
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Name: (First Name, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

ADDITIONAL SCREEN SHOULD DISPLAY AFTER RESPONDENT SELECTION
COMPLETED
SINCENT02 HAND RESPONDENT [FILL $5/$10] CASH.
MARK THE APPROPRIATE “CASH ACCEPTANCE” BOX ON THE
INTERVIEW INCENTIVE RECEIPT.
SIGN AND DATE INTERVIEW INCENTIVE RECEIPT AND GIVE TOP
COPY TO RESPONDENT.
I have signed this form to indicate that I have given you [FILL $5/$10] for this
screening. Thank you for your help.
Next [INCENT01a]

2-9

INCENT01a Did this respondent accept the [FILL $5/$10] screening incentive payment?
1
YES
2
NO
Next [INCENT02b]
INCENT02b [IF INCENT01a = 2] Why didn’t this respondent accept the screening incentive
payment?
TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPACE BAR
BETWEEN EACH CATEGORY YOU SELECT.
1
2
3
4

DIDN’T FEEL IT WAS NECESSARY
DIDN’T WANT TO ACCEPT MONEY FROM THE GOVERNMENT
DIDN’T NEED THE MONEY
FELT IT WAS INAPPROPRIATE TO OFFER MONEY IN
EXCHANGE FOR PARTICIPATION

5

SOME OTHER REASON

DK
Next [INCENT03c]
INCENT03c [IF INCENT02b = 5] Why didn’t this respondent accept the screening incentive
payment?
[ALLOW 200 CHARACTERS]
DK
Next [INCENT04d]
INCENT04d [IF INCENT01a = 1] How much do you think the screening incentive payment
influenced this respondent’s decision to participate in the screening?
1
2
3
DK

A LOT
A LITTLE
NOT AT ALL

Next [INCENT05e]
2-10

INCENT05e [IF INCENT04d = 1 OR 2] Do you think you would have been successful in
convincing this respondent to participate in the screening if you had not been able
to offer the screening incentive payment?
1
2
3
4
DK

DEFINITELY YES
PROBABLY YES
PROBABLY NOT
DEFINITELY NOT

Next [INCENT06f]
INCENT06f [IF INCENT01a = 1] Do you think the screening incentive payment allowed you
to work this case more efficiently, that is, make fewer visits to the household or
spend less time gaining cooperation than you would have?
1
2
DK

YES
NO

Next [INCENT07g]
INCENT07g [IF INCENT01a = 1] Did this respondent make any comments that suggested
[he/she] would have participated in the survey without the screening incentive?
1
2
DK

YES
NO

Next [INCENT08h]
INCENT08h [IF SCREENING INCENTIVE CASE AND R WAS ALSO SR] Did the
respondent already know about the screening incentive before you told [him/her]?
1
2
DK

YES
NO

Next [INCENT09i]

2-11

INCENT09i [IF INCENT08h = 2] Did this respondent show any reluctance to participate in
the interview before you mentioned the screening incentive payment to [him/her]?
1
2
DK

YES
NO

Next [INCENT10j]
INCENT10j [IF INCENT08h = 1] How did this respondent find out about the screening
incentive payment?
TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPACE BAR
BETWEEN EACH CATEGORY YOU SELECT.
1
2
3
4
5
6
DK

FROM THE LEAD LETTER
FROM THE Q & A BROCHURE
FROM ANOTHER MEMBER OF THE HOUSEHOLD
FROM A NEIGHBOR/BUILDING MANAGER/ETC.
FROM ANOTHER INTERVIEWER
SOME OTHER WAY

2-12

NMHS FT Screening Application Specifications
Section 3
Parental Contact Information
After the Respondent Selection Screen and parental consent popup, if at least one adolescent respondent
is selected, the following module will appear.
Your [AGE] (child/children) (has been/have been) selected to take part in an important study for the U.S.
Department of Health and Human Services called the National Mental Health Study (NMHS).
Knowledge gained from this study will improve our ability to describe and understand mental health
issues in the United States. RTI International is conducting the NMHS on behalf of the Substance Abuse
and Mental Health Services Agency (SAMHSA) and the National Institute of Mental Health (NIMH).
Both of these agencies are part of the U.S. Department of Health and Human Services.
We would like you to take part in the National Mental Health Study Parent Interview to answer questions
about [IF ONE ADOLESCENT SELECTED FILL: child; IF TWO ADOLESCENTS SELECTED FILL:
children]’s health, development and family background. A parent’s perspective is very important in
getting an accurate description of a child’s health and development so we hope you’ll agree to participate.
You will receive $30 as a token of our appreciation for completing the survey. It will take approximately
30 minutes to complete. If possible, please complete the interview in the next three days.
HAND PARENT STUDY DESCRIPTION TO RESPONDENT. Please read this statement. It describes
the survey and the legislation that assures the confidentiality of information you provide.
FI_CARD

FI: COMPLETE A CARD FOR EACH SELECTED ADOLESCENT. RECORD THE
ADOLESCENT’S INITIALS AND THE CORRECT CASE ID ON THE CARD. BE
SURE TO WRITE LEGIBLY!

INSTRUCT1 [IF ONE ADOLESCENT SELECTED] Thank you. I’ve recorded the information you’ll
need to access the interview on this card. You can participate via the web or over the
phone. If you want to do the interview via the web you just need to type this website into
your internet browser (POINT TO WEBSITE ON CARD) and once you’re connected to
the website you’ll use this access code (POINT TO ACCESS CODE ON CARD) to start
your interview. If you want to complete the interview via phone call 1-800-XXXXXXX. Please be sure to answer the questions about the child I’ve listed on the card.
[IF TWO ADOLESCENTS WERE SELECTED] Thank you. I’ve recorded the
information you’ll need to access the survey for each of your children on these two cards.
You can participate via the web or over the phone. If you want to do the interview via

3-1

the web you just need to type this website into your internet browser (POINT TO WEBSITE ON CARD)
and once you’re connected to the website you’ll use this specific access code (POINT TO
ACCESS CODES ON EACH CARD) to start your interview. If you want to complete
the interview via phone call 1-800-XXX-XXXX. Please be sure to answer the questions
about the child I’ve listed on the card. After you complete the survey for one of your
children you’ll be able to enter the access code for your other child who was selected and
answer the same questions about them.
Do you have any questions? (ANSWER QUESTIONS AS NEEDED)

EMAIL

Next, in case we need to follow up with you I need a couple of pieces of
information. What is your email address?
(IF NO EMAIL ADDRESS, TAP NEXT)
____________
REF
ALLOW 50 CHARACTERS

CELL

What is your cell phone number?
PLEASE ENTER 3 DIGIT AREA CODE AND 7 DIGIT NUMBER.
(IF NO CELL PHONE, TAP NEXT)
_____________
REF

[ALLOW 3+3+4 NUMERIC AND BLANKS AND CHECK AGAINST LOOKUP TABLE OF VALID AREA CODE. ADMINISTER A SOFT CHECK IF
NOT FOUND, “PLEASE VERIFY THIS AREA CODE WITH RESPONDENT.
PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.]
DK/REF
ALLOW 10 CHARACTERS AND BLANKS

PHONE

IF R DOESN’T HAVE CELL PHONE: What is your telephone number?
PLEASE ENTER 3 DIGIT AREA CODE AND 7 DIGIT NUMBER.

_____________
REF

[ALLOW 3+3+4 NUMERIC AND BLANKS AND CHECK AGAINST LOOKUP TABLE OF VALID AREA CODE. ADMINISTER A SOFT CHECK IF

3-2

NOT FOUND, “PLEASE VERIFY THIS AREA CODE WITH RESPONDENT.
PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.]
DK/REF

PINCENT01 HAND RESPONDENT $30 CASH.
MARK THE APPROPRIATE “CASH ACCEPTANCE” BOX ON THE
INTERVIEW INCENTIVE RECEIPT.
SIGN AND DATE INTERVIEW INCENTIVE RECEIPT AND GIVE TOP
COPY TO RESPONDENT.
I have signed this form to indicate that I have given you $30 for this interview. At
the bottom of this form, we have included national hotline numbers that you can
call if you ever feel you need to talk to someone about mental health or drug use
issues.
Thank you in advance for your participation.

PRESS [ENTER] TO CONTINUE.
PROGRAMMERS: We need the QUESTIDs generated by the screener to link correctly with NICKNAME
and NICKNAME2.

3-3

This page intentionally left blank.

NMHS Screening Application Specifications
Section 4
Select Case Screen Options
Document Format:
 Screen/menu names bolded
 Screen/question/instructional text designated by black and non-italicized text in parenthesis. In
the program, upper-lower black text to be read and red text is instructions to FI
 Fills designated by parentheses and italics
 Logic designated by brackets
 Text of instructional message boxes provided in bracketed logic
 Response categories underlined
 Explanatory text in italics.

Select Case screen contains the date, time, battery level, CaseID, (list of cases), Address, Results for S
(Screening), A (Interview A), and B (Interview) and menus detailed below.

ACTIONS MENU [ TOUCH AND HOLD CASE UNTIL ACTIONS MENU APPEARS]
Items on the Actions Menu are case specific. First a case is selected on the screen, then the action from
the Actions Menu is selected.
Screen DU/Re-Open Case
Go To Record Of Calls
View Selections
View Roster
Edit Address
Add Missed DU
Place Case On Hold/Take Case Off Hold
View Verification Information
Add Appointment
View Call Distribution

View Letters
SCREEN DU [SELECT CASE, SCREEN DU]
[IF SCREENING COMPLETED, RE-OPEN CASE DISPLAYS ON ACTIONS
MENU. RE-OPENING CONFIRMATION: “CASE (CASEID) HAS ALREADY
BEEN COMPLETED. DO YOU WISH TO RE-OPEN THIS CASE? IF No, SELECT
CASE. IF Yes, CASE RE-OPEN CODE: “ENTER THE CODE TO RE-OPEN THIS
CASE, THEN TOUCH ‘OK’ TO CONTINUE.” ENTER CORRECT CODE, OK,
STUDY INTRODUCTION]

GO TO RECORD OF CALLS [SELECT CASE, GO TO RECORD OF CALLS – FOR
DETAILS SEE SECTION 6]

VIEW SELECTIONS [SELECT CASE, VIEW SELECTIONS]
4-1

RESPONDENT SELECTION [IF CASE COMPLETED WITH FINAL
RESULT CODE = [31, 32]
Interview A
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Relation: (Relationship to householder, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

Interview B
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Relation: (Relationship to householder, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

Done [SELECT CASE]
Roster [VERIFY ROSTER DATA]
ROC [RECORD OF CALLS]

VIEW ROSTER [SELECT CASE, VIEW ROSTER]
[IF CASE COMPLETED WITH FINAL RESULT CODE = 30, 31, 32, VERIFY
ROSTER DATA]
[VERIFY ROSTER DATA – FOR DETAILS, SEE SECTIONS 1& 2]
Done [SELECT CASE]
Selections [RESPONDENT SELECTION]
ROC [RECORD OF CALLS]

EDIT ADDRESS [SELECT CASE, EDIT ADDRESS]
[EDIT ADDRESS – FOR DETAILS, SEE SECTIONS 1 & 2]

ADD MISSED DU [SELECT CASE, ADD MISSED DU]
[MISSED DU ADDRESS – FOR DETAILS, SEE SECTION 1]
[IF CASE SELECTED IS MISSED DU: CANNOT ADD UNIT: “YOU CANNOT
ADD A MISSED DU FROM A DU THAT HAS BEEN ADDED.” OK, SELECT
CASE.]
[IF ATTEMPTING TO ADD A DU TO A GQU: MISSED GQU: “YOU CANNOT
ADD MISSED GROUP QUARTERS UNITS (GQUS). YOU CAN ONLY ADD A
MISSED HOUSING UNIT THAT IS ASSOCIATED WITH A SELECTED LINE IN A
GROUP QUARTERS STRUCTURE. ARE YOU CERTAIN THE UNIT YOU WANT
TO ADD IS A HOUSING UNIT AND NOT A GROUP QUARTERS UNIT?”]

4-2

Yes [READY TO ADD: “DO YOU WANT TO ADD AN HU LINKED TO CASE
(CASEID)?” IF Yes, MISSED DU ADDRESS. IF No, SELECT CASE]
No [CALL FS: “IF THERE ARE MISSED GROUP QUARTERS UNITS IN THE
STRUCTURE, OBTAIN INFORMATION ABOUT ALL MISSED UNITS THEN
CALL YOUR FS.” OK, SELECT CASE.]

PLACE CASE ON HOLD [SELECT CASE, PLACE CASE ON HOLD]
This menu option toggles between “Place Case On Hold” and “Take Case Off Hold,”
depending on the on-hold status of the case. When a case is on hold, data for that case are
transmitted, but are not pulled into the control system—the data is maintained in a separate
location to be accessed, as necessary. This allows putting a case ‘On Hold’ for
troubleshooting.
[IF CASE NOT ON HOLD, PLACE CASE ON HOLD: “ARE YOU SURE YOU
WANT TO PUT CASE (CASEID) ON HOLD?” IF No, SELECT CASE WITH CASE
NOT ON HOLD. IF Yes, SELECT CASE WITH ‘On Hold’ NEXT TO CASEID.]
[IF CASE ON HOLD, TAKE CASE OFF HOLD: “ARE YOU SURE YOU WANT TO
TAKE CASE (CASEID) OFF HOLD?” IF No, SELECT CASE WITH CASE ON
HOLD. IF Yes, SELECT CASE WITH ‘On Hold” REMOVED AND CASE NOT ON
HOLD.]

VIEW VERIFICATION INFORMATION [SELECT CASE, VIEW VERIFICATION
INFORMATION]
[IF VERIFICATION INFORMATION AVAILABLE, VERIFICATION.]
[IF NO VERIFICATION INFORMATION AVAILABLE: “No Verification data found”
OK, SELECT CASE]

ADD APPOINTMENT [SELECT CASE, ADD APPOINTMENT]
This optional calendar can be used to post work and personal appointments to help with time
management and scheduling of interview appointments.

NEW APPOINTMENT
SHOW CALENDAR WHEN DONE? (check box)
CASE: (Case ID)
FROM: (current date with link to calendar to select a beginning date) (time of day)
[IF SELECT A DIFFERENT DATE, Set CHANGES DATE,
Cancel MAINTAINS CURRENT DATE]
IF SELECT A DIFFERENT TIME, Set CHANGES TIME,
Cancel MAINTAINS CURRENT TIME]
TO: (current date with link to calendar to select a ending date) (time of day)
[IF SELECT A DIFFERENT DATE, Set CHANGES DATE,
Cancel MAINTAINS CURRENT DATE]
IF SELECT A DIFFERENT TIME, Set CHANGES TIME,
Cancel MAINTAINS CURRENT TIME]

4-3

ALL DAY? (check box)
REMINDER: (Drop-down box with incremental time choices)
TYPE: (Drop-down box with: Select Type, Screening, Interview A, Interview B, S/I
Other, Other)
DESCRIPTION: (text entry with comments describing appointment)
Done [Detail View containing appointment information, then side arrow to display
CALENDAR.] This calendar is an interactive stock tablet tool that allows calendar
viewing by day, week, month and list. Touching the day on the calendar will show any
entered appointments. New appointments can be added, and appointments for the
current day display at the bottom of the screen.
Back Arrow [SELECT CASE]

VIEW CALL DISTRIBUTION [SELECT CASE, VIEW CALL DISTRIBUTION]
This optional case management feature can be used to view past work patterns based on ROC
data and to determine the times/days when contact has not been attempted at SDUs.
CALL DISTRIBUTION
Link: (line number and address of link line case)

SELECT A CASE OR SEGMENT (Drop-down list of cases and segments
that have associated ROC data entered. FI chooses desired selection
criteria.) [IF SELECT ALL CASES ROC INFORMATION ON ALL
CASES IS DISPLAYED. IF SELECT AN INDIVIDUAL CASE, ONLY
ROC DATA FROM THAT CASE DISPLAYED. IF SELECT AN
INDIVIDUAL SEGMENT, ROC DATA FROM CASES WITHIN THAT
SEGMENT ONLY IS DISPLAYED.]
SCREENING RECORDS ONLY (Drop-down list of selection criteria to
customize ROC data displayed.) [IF SELECT ALL ROC TYPE
RECORDS, ALL ROCS ENTERED DISPLAY. IF SELECT
SCREENING RECORDS ONLY, ONLY SCREENING RECORDS
DISPLAY. IF SELECT INTERIVEW A OR B RECORDS ONLY,
ONLY INTERVIEW A AND B RECORDS DISPLAY. IF SELECT
INTERVIEW A RECORDS ONLY, ONLY INTERVIEW A ROCS
DISPLAY. IF SELECT INTERVIEW B RECORDS ONLY, ONLY
INTERVIEW B ROCS DISPLAY. IF SELECT CHOOSE ROC
CODE(S), A DROP DOWN LIST OF ALL ROC CODES APPEARS TO
CHOOSE FROM.]
DATE RANGE (INCLUSIVE)
BEGIN DATE: [SELECT A DATE] Date appears allowing beginning
date selection to narrow down the ROC results SET chooses the date
entered [CALL DISTRIBUTION], CANCEL, [CALL
DISTRIBUTION].)
END DATE: [SELECT A DATE] Date appears allowing beginning
date selection to narrow down the ROC results SET chooses the date
4-4

entered [CALL DISTRIBUTION], CANCEL, [CALL
DISTRIBUTION].)
Su
M
Tu
W
Th
F
Sa
All

6A-10A 10A-12P 12P-4P 4P-6P 6P-10P 10P-6A All
-

Done [SELECT CASE]
Refresh (Refreshes displayed data based on most recent selection criteria
entered.) [IF NO CASE SELECTED, “PLEASE SELECT A CASE OR
SEGMENT FROM THE LIST THEN TOUCH “REFRESH”]
OK [CALL DISTRIBUTION]
ROC [IF CASE SELECTED, RECORD OF CALLS]
VIEW LETTERS [SELECT CASE, VIEW LETTERS]
[IF LETTER SENT, LETTERS. IF NO LETTER SENT, “NO LETTERS
FOUND” OK, SELECT CASE]
LETTERS [IF REFUSAL LETTER HAS BEEN SENT
AND IF RECORD OF CALLS = CALL RECORD SELECTED,
FUNCTIONS, VIEW LETTERS]
(Date letter requested – letter code – result code – FS that submitted
request)
ADMINISTRATIVE TOOLS MENU [SELECT CASE, FUNCTIONS, ADMINISTRATIVE
TOOLS]

Items on Administrative Tools Menu are administrative.
Set Name and Id
Reconcile Missed DUs
Reload Training Cases
Erase Training Cases

SET NAME AND ID [SELECT CASE, FUNCTIONS, ADMINISTRATIVE TOOLS, SET
NAME AND ID]

NMHS SYSTEM IDENTIFICATION [SELECT CASE, ADMINISTRATIVE
TOOLS, SET NAME AND ID]
Government ID: (Government ID issued to iPAQ)
FIID: (RTI FI ID Number)

4-5

First Name: (FI First Name to be used on Study Introduction screen)
Last Name: (FI Last Name to be used on Study Introduction screen)
Save [SELECT CASE]
Cancel [SELECT CASE]

RECONCILE MISSED DUS [SELECT CASE, FUNCTIONS, ADMINISTRATIVE
TOOLS, RECONCILE MISSED DUS]
[IF NO MISSED DUs TO BE RECONCILED, NO MISSED DUs: “THERE ARE NO
MISSED DUs TO RECONCILE.” OK, SELECT CASE.]
[IF MISSED DUs TO BE RECONCILED, SEGMENTS AND MISSED DUs]

SEGMENTS AND MISSED DUs [SELECT CASE, FUNCTIONS,
ADMINISTRATIVE TOOLS, RECONCILE MISSED DUs]
SEGMENT (SEGID)
STREET ADDRESS (MISSED DU STREET ADDRESS)
TO RECONCILE A SEGMENT: TOUCH AND HOLD ON THE LINE, THEN
TOUCH ‘RECONCILE’ FROM THE POP-UP MENU.
Reconcile [RECONCILATION CONFIRMATION: “YOU WILL
BE REQUIRED TO RECONCILE ALL DUs WITHIN THE
SELECTED SEGMENTS. ARE YOU READY TO PROCEED?” IF
No, SEGMENTS AND MISSED DUs. IF Yes, MDU-SEGMENT
KIT CHECK.]
Exit [SELECT CASE]

MDU-SEGMENT KIT CHECK [SEGMENTS AND MISSED DUs =
RECONCILE AND RECONCILATION CONFIRMATION = YES]
Link: (line number and address of link line case)
INTERVIEWER: CONSULT YOUR SEGMENT KIT AND ANSWER THE
FOLLOWING QUESTION(S):
IS THE UNIT THAT YOU ARE ATTEMPTING TO ADD
(Missed DU Street Address)
ALREADY ON THE HANDWRITTEN LIST OF DWELLING UNITS?
(MAKE SURE YOU ARE LOOKING AT THE FULL LIST OF DWELLING
UNITS, NOT THE SELECTED DU LIST.)
Yes (UNIT NOT ADDED) [IF ANOTHER MISSED DU, NEXT
MISSED DU: “PLEASE ANSWER THE FOLLOWING QUESTIONS
TO RECONCILE THE NEXT MISSED DU.” OK, MDU-SEGMENT
KIT CHECK FOR NEXT MISSED DU.]

4-6

[IF NO OTHER MISSED DU, SELECT CASE]
No [MDU SDU CHECK]
Exit [SELECT CASE]

MDU SDU CHECK [MDU-SEGMENT KIT CHECK = NO]
Link: (line number and address of link line case)
IS THE MISSED UNIT LOCATED WITHIN THE SDU OR ON THE SDU
PROPERTY, AS WELL AS LOCATED WITHIN THE SEGMENT
BOUNDARIES?
REFER TO YOUR FI MANUAL AND YOUR SEGMENT MAPS OR CALL
YOUR FS IF YOU ARE UNSURE WHETHER THIS UNIT SHOULD BE
ADDED. IF YOU CANNOT DO THAT RIGHT NOW, TOUCH THE Exit
BUTTON TO EXIT THIS SCREEN. YOU CAN RECONCILE THIS DU
LATER.
Yes (UNIT ADDED) [MDU-ADDRESS VERIFICATION]
No (UNIT NOT ADDED) [IF ANOTHER MISSED DU, NEXT
MISSED DU: “PLEASE ANSWER THE FOLLOWING QUESTIONS
TO RECONCILE THE NEXT MISSED DU.” OK, MDU-SEGMENT
KIT CHECK FOR NEXT MISSED DU.]
[IF NO OTHER MISSED DU, SELECT CASE]
Exit [SELECT CASE]

MDU-ADDRESS VERIFICATION
Link: (line number and address of link line case)
THIS UNIT WILL BE ADDED TO THE SAMPLE. PLEASE VERIFY THE
INFORMATION BELOW. TOUCH ANY LINE TO EDIT IT.
STREET #: (street number)
STREET: (street name)
CITY: (city)
STATE: (state)
ZIP: (zip code)
CASE #: (CaseID assigned to Added DU)
Update [IF ADDITIONAL MISSED DUs TO RECONCILE,
RECONCILE NEXT: “THE ADDED DU HAS BEEN
SUCCESFULLY RECONCILED. PLEASE ANSWER THE
FOLLOWING
QUESTIONS TO RECONCILE THE NEXT MISSED DU.” OK,
MDU-SEGMENT KIT CHECK FOR NEXT MISSED DU]
[IF NO ADDITIONAL MISSED DUs TO RECONCILE, SELECT
CASE]
Exit [SELECT CASE, WITH RECONCILIATION PENDING]

4-7

RELOAD TRAINING CASES [SELECT CASE, FUNCTIONS, ADMINISTRATIVE
TOOLS,RELOAD TRAINING CASES]
RE-LOAD TRAINING CASES: “ARE YOU SURE YOU WANT TO REMOVE
AND RELOAD ALL TRAINING CASES?” IF No, SELECT CASE. IF Yes,
SELECT CASE WITH TRAINING CASES REMOVED AND RELOADED.

ERASE TRAINING CASES [SELECT CASE, FUNCTIONS, ADMINISTRATIVE
TOOLS, ERASE TRAINING CASES]
ERASE TRAINING CASES: “ARE YOU SURE YOU WANT TO ERASE ALL
TRAINING CASES?” IF No, SELECT CASE. IF Yes, SELECT CASE WITH
TRAINING CASES REMOVED.

VIEW/SORT MENU [SELECT CASE, FUNCTIONS, VIEW/SORT]
View/Sort is a case management feature that allows an FI to view and sort cases in his/her assignment by
subgroups and varying orders on the Select Case screen. The View and Sort options can be used in a
variety of combinations.

VIEW/SORT PREFERENCES
To modify the View and Sort options, Touch “View” and “Sort” then select an option from the
list.
To go back to “SELECT CASE”, touch the Done button.
View [VIEW]
Sort [SORT]
Done [SELECT CASE]

VIEW
Pending Cases (All Screening and Interview cases with Result Codes 00-09, 50-59)
Pending Screenings (All Screening cases with Result Codes 00-09)
Pending Interviews (All Interview cases with Result Codes 50-59)
Group Quarters Units (All GQU cases)
All Cases (All cases)
Final Screenings (Screening cases with Result Codes 10-32)
Final Interviews (Interview cases with Result Codes 70-79)
Added DUs (All added DUs)
On Hold Cases (All cases on hold)
Segment (View cases for each segments)
Cancel [VIEW/SORT PREFERENCES]

SORT
By Case ID (Alphanumerical order by CaseID)
By Street (Alphanumerical order by street name within segment and number)
By Screening Code (Numerical order by Screening Result Code)
By Interview A Code (Numerical order by Interview A Result Code)
By Interview B Code (Numerical order by Interview B Result Code)

4-8

By ROC Date, Ascending (Ascending date order using most recent Record of Calls entry)
By ROC Date, Descending (Descending date order using most recent Record of Calls entry)
Cancel [VIEW/SORT PREFERENCES]

CALL DISTRIBUTION [SELECT CASE, FUNCTIONS, CALL DISTRIBUTION] (See Call
Distribution explanation under Actions Menu above)

ADD APPOINTMENT [SELECT CASE, FUNCTIONS, ADD APPOINTMENT] (See Add
Appointment explanation under Actions Menu above)
CALENDAR [SELECT CASE, FUNCTIONS, CALENDAR] (See Calendar explanation within the Add
Appointment portion under Actions Menu above)
TRANSMIT [SELECT CASE, FUNCTIONS, TRANSMIT]
TRANSMISSION LOG
Done [SELECT CASE]
Transmit [BEGINS DATA TRANSMISSION]

4-9

This page intentionally left blank.

NMHS Screening Application Specifications
Section 5
Record of Calls
Document Format:
 Screen names bolded
 Screen/question/instructional text designated by black and non-italicized text in parenthesis. In
the program, upper-lower black text to be read and red text is instructions to FI
 Fills designated by parentheses and italics
 Logic designated by brackets
 Text of instructional message boxes provided in bracketed logic
 Response categories underlined

RECORD OF CALLS [SELECT CASE, GO TO RECORD OF CALLS
OR ON ANY SUBSEQUENT SCREEN EXIT OR VERIFICATION, DONE OR
RESPONDENT SELECTION, DONE]
Type (Data Type: S, A, B)
Result (Result Code)
Date/time (Date, time, and day of the week ROC entered)
Done [SELECT CASE]
Add [IF CODE = PENDING SCREENING CODE, SCREENING CALL RECORD. FOR
PENDING INTERVIEW CODES, CHOOSE ROC TYPE]
CD [IF CALL RECORD ENTERED, CALL DISTRIBUTION FOR DETAILS SEE
SECTION 5]
Roster [IF CODE = 22, 25, 26, 30, 31, OR 32, VERIFY ROSTER DATA FOR DETAILS
SEE SECTION 1]
Selections [If CODE = 31 or 32, RESPONDENT SELECTION]

ACTIONS MENU [RECORD OF CALLS, TOUCH AND HOLD CASE UNTIL ACTIONS
MENU APPEARS]
Edit [IF ROC EVENT SELECTED, SCREENING CALL RECORD or
INTERVIEW CALL RECORD]
Delete [IF UNTRANSMITTED, NON-SYSTEM-GENERATED ROC EVENT (NE 26,
30, 31, 32), DELETES EVENT, RECORD OF CALLS]
View Refusal [IF CODE 07, 17, 57, 58, 77, 78, REFUSAL REPORT -FOR DETAILS
SEE SECTION 7]
View Other Specify [IF CODE 09, 23, 59, or 79, CODE [fill with 09, 23, 59, or 79]:
OTHER SPECIFY CATEGORIES]

FUNCTIONS MENU [RECORD OF CALLS, FUNCTIONS]
Add [IF PENDING CODE, CALL RECORD]
5-1

Call Distribution [IF ROCs ENTERED, CALL DISTRIBUTION]
View Roster [IF CODE = 22, 25, 26, 30, 31, OR 32, VERIFY ROSTER DATA]
View Selections [IF CODE 31 OR 32 RESPONDENT SELECTION]
Add Appointment [NEW APPOINTMENT]
Calendar [CALENDAR]
View Verification Information [IF CODE 10, 13, 18, 26, OR 30, VERIFICATION]
CHOOSE ROC TYPE [IF CODE = 32, AND BOTH INTERVIEW CASES NOT FINAL, RECORD
OF CALLS, ADD]
WHICH TYPE OF CALL RECORD DO YOU WANT TO ENTER?
Screening [Option listed but not available as screening is final]
Interview A [INTERVIEW A CALL RECORD]
Interview B [INTERVIEW B CALL RECORD]
Cancel [RECORD OF CALLS]

SCREENING CALL RECORD [IF AT COMPLETION OF SCREENING PROCESS
RESPONDENT SELECTION = DONE OR IF VERIFICATION = DONE AND CODE = 22, 25,
26 OR 30 OR IF RECORD OF CALLS = ADD]
RESULT (01-23, 25, 26, 29-32)
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
25
26
29
30
31

No one at DU
SR Unavailable
Neighbor Indicates Occupancy
Pending Incapable
Pending Lang. Barrier (Spanish)
Pending Lang. Barrier (Other)
Pending Refusal
Unable to Locate SDU
Pending Other – Specify
Vacant
No one at DU - Repeated
SR Unavailable - Repeated
Not Primary Residence
Final Incapable
Final Lang. Barrier (Spanish)
Final Lang. Barrier (Other)
Final Refusal
Not a Dwelling Unit
GQU Listed as HU
HU Listed as GQU
Denied Access
All Military
Final Other – Specify
No Eligible Members
R in DU Less Than ½ Quarter
Listing Error
No one selected
One person selected

5-2

32 Two persons selected
COMMENTS: (text entry)
DO NOT CHANGE ROC DATE/TIME UNLESS INSTRUCTED BY TECH SUPPORT
OR FS.
DAY/DATE: (Day of week and Date ROC event entered)
TIME: HOUR (1-12) MINUTE (00-59) AM/PM (AM, PM)
Commit [IF CODE = 32, INTERVIEW EVENT: “REMEMBER TO ENTER CALL
RECORDS FOR INTERVIEWS A AND B.” OK, RECORD OF CALLS.]
[IF CODE = 31, INTERVIEW EVENT: “REMEMBER TO ENTER INTERVIEW
CALL RECORD FOR INTERVIEW A.” OK, RECORD OF CALLS]
[IF CODE = 10, 13, 18, 26, OR 30, VERIFICATION]
[IF 07 OR 17, REFUSAL REPORT -FOR DETAILS SEE SECTION 7]
[IF 09 OR 23, OTHER, SPECIFY]
[IF 6 OR 16, OTHER LANGUAGE]
[IF 04, 14, 54 OR 74, INCAPABLE, SPECIFY]
Cancel [ARE YOU SURE?: “ARE YOU SURE YOU WANT TO CANCEL THIS CALL
RECORD?” IF Yes, SELECT CASE. IF No, SCREENING CALL RECORD]

INTERVIEW CALL RECORD [RECORD OF CALLS, ADD, IF CODE 32 AND BOTH
INTERVIEW CASES NOT FINAL, CHOOSE ROC TYPE, A OR B]
RESULT (50-59, 70-79)
50
51
52
53
54
55
56
57
58
59
70
71
72
73
74
75
76
77
78
79

Appointment for Interview
No one at DU
R Unavailable
Pending Break-off (Partial Interview)
Pending Incapable
Pending Lang. Barrier (Spanish)
Pending Lang. Barrier (Other)
Pending Refusal
Pending Parental Refusal for age 13-17
Pending Other – Specify
Interview complete
No One at DU - Repeated
R Unavailable - Repeated
Final Break-off (Partial Interview)
Final Incapable
Final Lang. Barrier (Spanish)
Final Lang. Barrier (Other)
Final Refusal
Final Parental Refusal for age 13-17
Final Other - Specify

COMMENTS: (text entry)
DO NOT CHANGE ROC DATE/TIME UNLESS INSTRUCTED BY TECHNICAL SUPPORT
OR FS.

5-3

DAY/DATE: (Day of week and Date ROC event entered)
TIME: HOUR (1-12) MINUTE (00-59) AM/PM (AM, PM)
Relation (HU) or Name (GQU), Gender, Age, Race of selected respondent displays
Commit [SAVES DATA, RECORD OF CALLS]
[IF 57, 58, 77, 78, REFUSAL REPORT -FOR DETAILS SEE SECTION 7]
[IF 59 OR 79, OTHER, SPECIFY]
Cancel [ARE YOU SURE?: “ARE YOU SURE YOU WANT TO CANCEL THIS CALL
RECORD?” Yes, SELECT CASE, No, INT. CALL RECORD-A OR B]

CODE 09: OTHER SPECIFY CATEGORIES [SCREENING CALL RECORD =
RESULT CODE 09]
OTHER SPECIFY CATEGORIES
Screening breakoff
Selected wrong line number
Added in error
Safety issue
Controlled access
Possible vacant
Possible vacation/not primary residence
GQU is institution (ONLY ACTIVE FOR GQU CASES)
Other listing problem
Need to discuss with FS
Something else, Specify
Done [RECORD OF CALLS]

CODE 23: OTHER SPECIFY CATEGORIES [SCREENING CALL RECORD = FINAL
RESULT CODE 23]
OTHER SPECIFY CATEGORIES
Added in error
Safety issue
GQU is institution (ONLY ACTIVE FOR GQU CASES)
Something else, Specify
Done [RECORD OF CALLS]

CODE 59: OTHER SPECIFY CATEGORIES [INTERVIEW A CALL RECORD OR
INTERVIEW B CALL RECORD = RESULT CODE 59]
OTHER SPECIFY CATEGORIES
R moved
R under age 13
R in military
R rostered in error
R deceased
Interviewed wrong person

5-4

Screened wrong line
Safety issue
Controlled access
Need to discuss with FS
Something else, Specify
Done [RECORD OF CALLS]

CODE 79: OTHER SPECIFY CATEGORIES [INTERVIEW A CALL RECORD OR
INTERVIEW B CALL RECORD = RESULT CODE 79]
OTHER SPECIFY CATEGORIES
R moved
R under age 13
R in military
R rostered in error
R deceased
Interviewed wrong person
Screened wrong line
Safety issue
Controlled access
Something else, Specify
Done [RECORD OF CALLS]

OTHER LANGUAGE [SCREENING CALL RECORD = 06 OR 16, INTERVIEW A CALL
RECORD OR INTERVIEW B CALL RECORD = 56 OR 76]
LANGUAGE CATEGORIES
Arabic
Chinese
French
German
Italian
Korean
Polish
Portuguese
Russian
Tagalog
Vietnamese
Other, Specify
Specify other language or comments: (text entry)
Done [RECORD OF CALLS]
INCAPABLE, SPECIFY [SCREENING CALL RECORD = 04 OR 14, INTERVIEW A CALL
RECORD OR INTERVIEW B CALL RECORD = 54 OR 74]
CODE [fill with 04 or 14 or 54 or 74]: INCAPABLE CATEGORIES

5-5

Physically Incapable
Mentally Incapable
Done [RECORD OF CALLS]

5-6

NMHS Screening Application Specifications
Section 6
Screening and Interview Refusals
Document Format:
 Screen names bolded
 Screen/question/instructional text designated by black and non-italicized text in parenthesis. In
the program, upper-lower black text to be read and red text is instructions to FI
 Fills designated by parentheses and italics
 Logic designated by brackets
 Text of instructional message boxes provided in bracketed logic
 Response categories underlined

REFUSAL REPORT [IF SCREENING CALL RECORD = 07 P REFUSAL OR
IF SCREENING CALL RECORD = 17 F REFUSAL AND ALREADY HAS A PENDING
REFUSAL ENTERED OR IF INTERVIEW CALL RECORD = 57 P REFUSAL OR IF
INTERVIEW CALL RECORD = 58 P PARENTAL REFUSAL OR IF INTERVIEW CALL
RECORD = 77 F REFUSAL AND ALREADY HAS A PENDING REFUSAL ENTERED OR
IF INTERVIEW CALL RECORD = 78 F PARENTAL REFUSAL AND ALREADY HAS A
PENDING REFUSAL ENTERED]
[IF SCREENING CALL RECORD = 17 F REFUSAL AND DOES NOT ALREADY HAVE A
PENDING REFUSAL ENTERED: RESULT CODE ERROR: “TRY AT LEAST ONE
MORE TIME BEFORE ASSIGNING THIS FINAL CODE.” OK. SCREENING CALL
RECORD]
[IF INTERVIEW CALL RECORD = 77 F REFUSAL AND DOES NOT ALREADY HAVE A
PENDING REFUSAL ENTERED, OR IF INTERVIEW CALL RECORD = 78 F PARENTAL
REFUSAL AND DOES NOT ALREADY HAVE A PENDING REFUSAL ENTERED:
RESULT CODE ERROR: “TRY AT LEAST ONE MORE TIME BEFORE ASSIGNING
THIS FINAL CODE.” OK. INTERVIEW CALL RECORD]
Too busy/no time/did too many already
Surveys/Govt. invasive/teen exposure
Clarify confidentiality, legitimacy, selection
“Nothing in it for me”/Uncooperative
Gatekeeper/Parent/HH member disallow
Welfare/INS/ICE/USCIS concern
Too ill/house messy/not dressed
Need to discuss with FS
Comment: (text entry)
Done [SAVES REASON FOR REFUSALAND COMMENTS ENTERED, RECORD OF
CALLS]

6-1

Screening and Interview Refusal Functions on ROC
1. View refusal report or edit refusal report prior to transmission:
REFUSAL REPORT [IF RECORD OF CALLS = TOUCH AND HOLD CALL RECORD, ACTION
MENU, VIEW REFUSAL]
Reason for refusal
Too busy/no time/did too many already
Surveys/Govt. invasive/teen exposure
Clarify confidentiality, legitimacy, selection
“Nothing in it for me”/Uncooperative
Gatekeeper/Parent/HH member disallow
Welfare/INS/ICE/USCIS concern
Too ill/house messy/not dressed
Need to discuss with FS
Comment: (text entry)
Done [IF EDITED (BEFORE TRANSMISSION) SAVES REASON FOR REFUSAL AND
COMMENTS ENTERED, THEN RECORD OF CALLS]

6-2

NMHS Screening Application Specifications
Section 7
Verification
Document Format:
 Screen names bolded
 Screen/question/instructional text designated by black and non-italicized text in
parenthesis. In the program, upper-lower black text to be read and red text is instructions
to FI
 Fills designated by parentheses and italics
 Logic designated by brackets
 Text of instructional message boxes provided in bracketed logic
 Response categories underlined

VERIFICATION [IF SCREENING RESULT CODE = 10, 13, 18, 22, 26 OR IF
RESPONDENT SELECTION = ‘NONE’ FOR BOTH A AND B INTERVIEW]
So that my supervisor may check the quality of my work, may I please have your
first name and telephone number?
FIRST NAME: (Screening Respondent’s first name)
Not Avail.
Ref.
PHONE: (Area code and phone number)
Home
Cell
Work
Not Avail.
Ref.
CONFIRM NUMBER WITH R.
NOTES TO VERIFICATION CALLER: (Text field for notes about best
times to call screening respondent or clarification about work number if
caller has to go through an operator.)
Done [CHECKS FOR COMPLETE DATA ENTRY, RECORD OF CALLS]
Clear [VERIFICATION WITH ENTRY CLEARED]

7-1

This page intentionally left blank.

NMHS Screening Application Specifications
Section 8
GPS Data Collection
After a code 70 has been entered in the ROC for each interview generated at an SDU:
GPS1

Did this respondent give permission for GPS data to be collected?
YES
NO

If two interviews generated at this SDU, stop at GPS1 until second interview has been
completed.
If only one interview generated at this SDU or two interviews generated and GPS1 = YES for
both cases:
GPS2

INTERVIEWER ENTER GPS DATA NOW OUTSIDE THE ENTRANCE TO THE
RESIDENCE

8-1

NMHS Screening Application Specifications
Section 9
FI Debriefing Questions
Document Format:
 Screen names bolded
 Screen/question/instructional text designated by black and non-italicized text in
parenthesis. In the program, upper-lower black text to be read and red text is instructions to FI
 Fills designated by parentheses and italics
 Logic designated by brackets
 Text of instructional message boxes provided in bracketed logic
 Response categories underlined
INTERVIEW DEBRIEFING QUESTIONS:
THESE QUESTIONS ARE FOR YOU TO ANSWER. DO NOT READ TO THE R.

FIDBF1
Did you conduct this interview at the respondent’s home, either inside or outside?
YES
NO
Next [IF FIDBF1=YES, GO TO FIDBF3]
FIDBF2 [IF FIDBF1=NO]
Where did you conduct this interview?
1. AT THE RESPONDENT’S WORKPLACE
2. AT THE HOME OF THE RESPONDENT’S RELATIVE OR FRIEND
3. IN SOME TYPE OF CONFERENCE ROOM IN A RESIDENCE HALL, SCHOOL OR
APARTMENT COMPLEX
4. AT A LIBRARY
5. IN SOME TYPE OF COMMON AREA, SUCH AS A LOBBY, HALLWAY, STAIRWELL,
OR LAUNDRY ROOM
6. SOME OTHER PLACE
Next [IF FIDBF2=6, GO TO FIDBF2a]
FIDBF2a [IF FIDBF2=6]
Where did the interview take place?
9-1

ALLOW 140 CHARACTERS
Next [FIDBF3]
FIDBF3
Please estimate for how much of the ACASI interview the respondent had their headphones on.
1.
2.
3.
4.
5.

NONE/R TOOK HEADPHONES OFF IMMEDIATELY
LESS THAN HALF OF THE ACASI INTERVIEW
ABOUT HALF OF THE ACASI INTERVIEW
MORE THAN HALF OF THE ACASI INTERVIEW
ALL OF THE ACASI INTERVIEW

Next [FIDBF4]
FIDBF4
How cooperative was the respondent?
1.
2.
3.
4.

VERY COOPERATIVE
FAIRLY COOPERATIVE
NOT VERY COOPERATIVE
OPENLY HOSTILE

Next [FIDBF5]
FIDBF5
Please indicate how private the interview was. Do not count yourself or a project observer as
another person in the room.
1. COMPLETELY PRIVATE – NO ONE WAS IN THE ROOM OR COULD OVERHEAR
ANY PART OF THE INTERVIEW
2. MINOR DISTRACTIONS – PERSON(S) IN THE ROOM OR LISTENING LESS THAN
1/3 OF THE TIME
3. PERSON(S) IN THE ROOM OR LISTENING ABOUT 1/3 OF THE TIME
4. SERIOUS INTERRUPTIONS OF PRIVACY MORE THAN HALF THE TIME
5. CONSTANT PRESENCE OF OTHER PERSON(S)
Next [IF FIDBF5=1, GO TO FIDBF8; IF FIDBF5 NE1, GO TO FIDBF6]
FIDBF6 [IF FIDBF5 NE1]
Not including yourself or project observers, who were the other people present or listening to the
interview?
Check all that apply
1. PARENT(S)
9-2

2.
3.
4.
5.
6.
7.

SPOUSE
LIVE-IN PARTNER/BOYFRIEND/GIRLFRIEND
OTHER ADULT RELATIVE(S)
OTHER ADULT(S)
CHILD(REN) UNDER 18
OTHER

Next [IF FIDBF6=1, 2, 3, 4, 5, OR 6, GO TO FIDBF8]
FIDBF7 [IF FIDBF6=7]
Please enter a description of the other person(s) present or listening to the interview. This
description may be relationship to the respondent if you have this information, or simply the
gender and estimated age.
ALLOW 140 CHARACTERS
Next [FIDBF8]
FIDBF8 [IF FIDBF5=1; OR IF FIDBF6=1, 2, 3, 4, 5, OR 6; OR IF FIDBF7 NE BLANK]
Did the respondent make any comments about the interview being too long?
YES
NO
Next [FIDBF9]
FIDBF9
Did the respondent have trouble understanding any questions asked during the interview?
YES
NO
Next [IF FIDBF9=NO, GO TO FIDBF10]
FIDBF9a [IF FIDBF9=YES]
Enter the screen name and a brief description of what the respondent found confusing. If you do
not know the screen name, please provide as much information as possible.
ALLOW 140 CHARACTERS
Next [FIDBF10]
FIDBF10
How often did this respondent let you know what his or her answers were as he or she completed
9-3

the ACASI portion of the interview?
1.
2.
3.
4.
5.

NONE OF THE TIME – I DO NOT KNOW WHAT ANY OF THE ANSWERS ARE
A LITTLE OF THE TIME – I KNOW WHAT A FEW OF THE ANSWERS ARE
SOME OF THE TIME – I KNOW WHAT SOME OF THE ANSWERS ARE
A LOT OF THE TIME – I KNOW WHAT A LOT OF THE ANSWERS ARE
ALL OF THE TIME – I KNOW WHAT ALL OF THE ANSWERS ARE

Next [FIDBF11]
FIDBF11
Please note anything else you think would be helpful for the interpretation and understanding of
this interview.
ALLOW 250 CHARACTERS
IF PARENT SELECTED FOR PARENT INTERVIEW
Next
PAR1a
IF NO PARENT INTERVIEW AND R SELECTED FOR CRS
Next CRS1a
IF NO PARENT INTERVIEW AND NO CRS INTERVIEW GO TO RECORD OF CALLS

IF PARENT SELECTED FOR PARENT INTERVIEW
PAR1a

Did the parent agree to participate in the parent interview?
1
YES
2
NO
DK

Next [PAR1]
PAR1

[IF PAR1a = 1] Did the parent respondent accept the $30 parent interview
incentive payment?
3
4
DK

YES
NO

Next [PAR2]
9-4

PAR2 [IF PAR1 = 2] Why didn’t this respondent accept the parent interview incentive
payment?
TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPACE BAR
BETWEEN EACH CATEGORY YOU SELECT.
1
2
3
4

DIDN’T FEEL IT WAS NECESSARY
DIDN’T WANT TO ACCEPT MONEY FROM THE GOVERNMENT
DIDN’T NEED THE MONEY
FELT IT WAS INAPPROPRIATE TO OFFER MONEY IN
EXCHANGE FOR PARTICIPATION

6

SOME OTHER REASON

DK
Next [PAR3]
PAR3 [IF PAR2 = 6] Why didn’t this respondent accept the parent interview incentive
payment?
[ALLOW 200 CHARACTERS]
DK
Next [PAR4]
PAR4

[IF PAR1 = 1] How much do you think the parent interview incentive payment
influenced this respondent’s decision to participate in the parent interview?
1
2
3
DK

A LOT
A LITTLE
NOT AT ALL

Next [PAR5]
PAR5

[IF PAR4 = 1 OR 2] Do you think you would have been successful in convincing
this respondent to participate in the parent interview if you had not been able to
offer the parent interview incentive payment?
1
2
3
4
DK

DEFINITELY YES
PROBABLY YES
PROBABLY NOT
DEFINITELY NOT

Next [PAR6]
9-5

PAR6

[IF PAR1 = 1] Did this respondent show any reluctance to participate in the
parent interview before you mentioned the incentive payment to [him/her]?
1
2
DK

YES
NO

Next [PAR7]
PAR7

[IF PARENT SELECTED FOR PARENT INTERVIEW] Please note anything
else you think would be helpful in terms of the parent interview gaining
cooperation process.
ALLOW 250 CHARACTERS

IF R SELECTED FOR CRS: Next CRS1a
IF NO CRS INTERVIEW GO TO RECORD OF CALLS

IF SELECTED FOR CRS
CRS1a

Did the respondent agree to participate in the CRS interview?
1
YES
2
NO
DK

Next [CRS1]
CRS1

[IF CRS1a = 1] Did the respondent accept the $40 CRS interview incentive
payment?
1
2
DK

YES
NO

Next [CRS2]
CRS1P

[IF SELECTED FOR A PARENT CRS INTERVIEW AND CRS1a = 1] Did the
parent respondent accept the $30 CRS interview incentive payment?
1
2
DK

YES
NO

9-6

Next [CRS2]
CRS2

[IF CRS1 OR CRS1P = 2] Why didn’t this respondent accept the CRS interview
incentive payment?
TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPACE BAR
BETWEEN EACH CATEGORY YOU SELECT.
1
2
3
4

DIDN’T FEEL IT WAS NECESSARY
DIDN’T WANT TO ACCEPT MONEY FROM THE GOVERNMENT
DIDN’T NEED THE MONEY
FELT IT WAS INAPPROPRIATE TO OFFER MONEY IN
EXCHANGE FOR PARTICIPATION

6

SOME OTHER REASON

DK
Next [CRS3]
CRS3

[IF CRS2 = 6] Why didn’t this respondent accept the CRS interview incentive
payment?
[ALLOW 200 CHARACTERS]
DK

Next [CRS4]
CRS4

[IF CRS1 OR CRS1P = 1] How much do you think the CRS interview incentive
payment influenced this respondent’s decision to participate in the CRS
interview?
1
2
3
DK

A LOT
A LITTLE
NOT AT ALL

Next [CRS5]
CRS5

[IF CRS4 = 1 OR 2] Do you think you would have been successful in convincing
this respondent to participate in the CRS interview if you had not been able to
offer the CRS interview incentive payment?
1

DEFINITELY YES
9-7

2
3
4
DK

PROBABLY YES
PROBABLY NOT
DEFINITELY NOT

Next [CRS6]
CRS6

[IF CRS1 OR CRS1P = 1] Did this respondent show any reluctance to participate
in the CRS interview before you mentioned the incentive payment to [him/her]?
1 YES
2 NO
DK

Next [CRS7]
CRS7

[IF SELECTED FOR CRS INTERVIEW] Please note anything else you think would

be helpful in terms of the CRS interview gaining cooperation process.
ALLOW 250 CHARACTERS
Next [CHKPT]
CHKPT
IF PARENT CRS RESPONDENT QUESTIONS NOT ASKED SET CHKPT = 1
IF PARENT CRS RESPONDENT QUESTIONS ASKED SET CHKPT = 2
IF NO PARENT CRS RESPONDENT SET CHKPT = 3
IF CHKPT = 1 GO TO CRS1P
IF CHKPT = 2 GO TO RECORD OF CALLS
IF CHKPT = 3 GO TO RECORD OF CALLS

9-8

NMHS Screening Application Specifications
Section 10
Parental Introductory Script
Document Format:
 Screen/question/instructional text designated by black and non-italicized text in
parenthesis. In the program, upper-lower black text to be read and red text is instructions to FI
 Fills designated by parentheses and italics
 Logic designated by brackets
 Text of instructional message boxes provided in bracketed logic
 Response categories underlined
INTRODUCE YOURSELF/STUDY AS NECESSARY:
Hello, I’m ________with RTI International. We are conducting a nationwide study sponsored by
the U.S. Department of Health and Human Services. You should have received a letter about this
study. (SHOW LEAD LETTER, IF NECESSARY.)

ONE YOUTH IS SELECTED:
Your (AGE) year-old child has been selected for an interview. I would like to talk with
him/her to see if he/she is interested in participating in this study which asks about various
common mental health issues that children face, such as depression or sadness, anxiety and fears,
attention and concentration difficulties, and other health related issues.
If your child is interested, I will give both of you more information and ask for permission to
complete the interview. (Is [he/she] available?)

TWO YOUTHS ARE SELECTED:
Your (AGE) year-old and (AGE) year-old children have been selected for an interview. I would
like to talk with them to see if they are interested in participating in this study which asks
about various common mental health issues that children face, such as depression or sadness,
anxiety and fears, attention and concentration difficulties and other health related issues.
If they are interested, I will give all of you more information and ask for permission to complete
the interview. (Are they available?)
10-1

NMHS Interview Verification Specifications
Section 11

CASEID

PREFILLED BY SCREENER PROGRAM.

PHONE

ENTER 10 DIGIT PHONE NUMBER INTO TABLET AND PRESS ENTER. IF
R REFUSES, MARK “REFUSED” ON TABLET AND PRESS ENTER.

ADDRESS

CONFIRM ADDRESS PREFILED BY SCREENER PROGRAM.

PARENTAL PERMISSION

IF MINOR RESPONDENT, ENTER PARENT OR
GUARDIAN WHO PROVIDED PERMISSION FOR
MINOR TO COMPLETE THE INTERIEW

11-1