BRFSS questionnaire

A
ttachment 5:

2018 BRFSS Questionnaire

Table of Contents

OMB Header and Introductory Text 5

Landline Introduction 6

Cell Phone Introduction 9

Core Section 1: Health Status 13

Core Section 2: Healthy Days 14

Core Section 3: Health Care Access 15

Core Section 4: Exercise 17

Core Section 5: Inadequate Sleep 18

Core Section 6: Chronic Health Conditions 19

Core Section 7: Oral Health 22

Core Section 8: Demographics 24

Core Section 9: Tobacco Use 31

Core Section 10: Alcohol Consumption 34

Core Section 11: Immunization 35

Core Section 12: Falls 37

Core Section 13: Seat Belt Use and Drinking and Driving 38

Core Section 14: Breast and Cervical Cancer Screening 39

Core Section 15: Prostate Cancer Screening 42

Core Section 16: Colorectal Cancer Screening 45

Core Section 17: H.I.V./AIDS 48

Closing Statement/ Transition to Modules 50

Optional Modules 51

Module 1: Prediabetes 52

Module 2: Diabetes 53

Module 3: Health Care Access 56

Module 4: Cognitive Decline 61

Module 5: Caregiver 64

Module 6: E-Cigarettes 69

Module 7: Marijuana Use 70

Module 8: Sleep Disorder 72

Module 9: Depression and Anxiety 73

Module 10: Respiratory Health 75

Module 11: Indoor Tanning 77

Module 12: Excess Sun Exposure 78

Module 13: Lung Cancer Screening 81

Module 14: Cancer Survivorship 83

Module 15: Prostate Cancer Screening Decision Making 89

Module 16: Clinical Breast Exam 91

Module 17: Adult Human Papillomavirus (HPV) - Vaccination 93

Module 18: Tetanus Diphtheria (Tdap) (Adults) 94

Module 19: Shingles (Zostavax or ZOS) 95

Module 20: Industry and Occupation 96

Module 21: Sexual Orientation and Gender Identity (SOGI) 98

Module 22: Random Child Selection 100

Module 23: Childhood Asthma Prevalence 104

Asthma Call-Back Permission Script 105

Reproductive Health Call-Back Permission Script 107

Closing Statement 108

OMB Header and Introductory Text

Read if necessary	Read	Interviewer instructions (not read)
Public reporting burden of this collection of information is estimated to average 27 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).		Form Approved OMB No. 0920-1061 Exp. Date 3/31/2018 Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Carol Pierannunzi at [email protected].
	HELLO, I am calling for the (health department). My name is (name). We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices.

Landline Introduction

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
LL01.	Is this [PHONE NUMBER]?	CTELENM1	1 Yes	Go to LL02		63
			2 No	TERMINATE
LL02.	Is this a private residence?	PVTRESD1	1 Yes	Go to LL04	Read if necessary: By private residence we mean someplace like a house or apartment. Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.	64
			2 No	Go to LL03
			3 No, this is a business		Read: Thank you very much but we are only interviewing persons on residential phones at this time.
LL03.	Do you live in college housing?	COLGHOUS	1 Yes	Go to LL04	Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.	65
			2 No	TERMINATE	Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
LL04.	Do you currently live in__(state)____?	STATERE1	1 Yes	Go to LL05		66
			2 No	TERMINATE	Thank you very much but we are only interviewing persons who live in [STATE] at this time.
LL05.	Is this a cell phone?	CELLFON4	1 Yes, it is a cell phone	TERMINATE	Read: Thank you very much but we are only interviewing by landline telephones in private residences at this time.
			2 Not a cell phone	Go to LL06	Read if necessary: By cell phone we mean a telephone that is mobile and usable outside your neighborhood. Do not read: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).
LL06.	Are you 18 years of age or older?	LADULT	1 Yes, male respondent 2 Yes, female respondent		Do not read: Sex will be asked again in demographics section.	68
			3 No	TERMINATE	Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
LL07.	I need to randomly select one adult who lives in your household to be interviewed. Excluding adults living away from home, such as students away at college, how many members of your household, including yourself, are 18 years of age or older?	NUMADULT	1	Go to Transition to Section 1.	Read: Are you that adult? Then you are the person I need to speak with.	69-70
			2-6 or more	Go to LL08.
LL08.	How many of these adults are men?	NUMMEN	_ _ Number 77 Don’t know/ Not sure 99 Refused			71-72
LL09.	So the number of women in the household is [X]. Is that correct?	NUMWOMEN			Do not read: Confirm the number of adult women or clarify the total number of adults in the household. Read: The persons in your household that I need to speak with is [XXX].	73-74
Transition to Section 1.			I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call (give appropriate state telephone number).		Do not read: Introductory text may be reread when selected respondent is reached.

Cell Phone Introduction

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CP01.	Is this a safe time to talk with you?	SAFETIME	1 Yes	Go to CP02		75
			2 No	([set appointment if possible]) TERMINATE]	Thank you very much. We will call you back at a more convenient time.
CP02.	Is this [PHONE NUMBER]?	CTELNUM1	1 Yes	Go to CP03		76
			2 No	TERMINATE
CP03.	Is this a cell phone?	CELLFON5	1 Yes	Go to CADULT		77
			2 No	TERMINATE	Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
CP04.	Are you 18 years of age or older?	CADULT	1 Yes, male respondent 2 Yes, female respondent		Do not read: Sex will be asked again in demographics section.	78
			3 No	TERMINATE	Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
CP05.	Do you live in a private residence?	PVTRESD3	1 Yes	Go to CP07	Read if necessary: By private residence we mean someplace like a house or apartment Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.	79
			2 No	Go to CP06	Read: Thank you very much, but we are only interviewing persons who live in a private residence or college housing at this time.
CP06.	Do you live in college housing?	CCLGHOUS	1 Yes	Go to CP07	Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.	80
			2 No	TERMINATE	Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
CP07.	Do you currently live in___(state)____?	CSTATE1	1 Yes	Go to CP09		81
			2 No	Go to CP08
CP08.	In what state do you currently live?	RSPSTAT1	1 Alabama 2 Alaska 4 Arizona 5 Arkansas 6 California 8 Colorado 9 Connecticut 10 Delaware 11 District of Columbia 12 Florida 13 Georgia 15 Hawaii 16 Idaho 17 Illinois 18 Indiana 19 Iowa 20 Kansas 21 Kentucky 22 Louisiana 23 Maine 24 Maryland 25 Massachusetts 26 Michigan 27 Minnesota 28 Mississippi 29 Missouri 30 Montana 31 Nebraska 32 Nevada 33 New Hampshire 34 New Jersey 35 New Mexico 36 New York 37 North Carolina 38 North Dakota 39 Ohio 40 Oklahoma 41 Oregon 42 Pennsylvania 44 Rhode Island 45 South Carolina 46 South Dakota 47 Tennessee 48 Texas 49 Utah 50 Vermont 51 Virginia 53 Washington 54 West Virginia 55 Wisconsin 56 Wyoming 66 Guam 72 Puerto Rico 78 Virgin Islands 99 Refused			82-83
CP09.	Do you also have a landline telephone in your home that is used to make and receive calls?	LANDLINE	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		Read if necessary: By landline telephone, we mean a regular telephone in your home that is used for making or receiving calls. Please include landline phones used for both business and personal use.	84
CP10.	How many members of your household, including yourself, are 18 years of age or older?	HHADULT	_ _ Number 77 Don’t know/ Not sure 99 Refused	If CP06 = yes then number of adults is automatically set to 1		85-86
Transition to section 1.			I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call (give appropriate state telephone number).

Core Section 1: Health Status

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C01.01	Would you say that in general your health is—	GENHLTH	Read: 1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor Do not read: 7 Don’t know/Not sure 9 Refused			90

Core Section 2: Healthy Days

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C02.01	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?	PHYSHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused			91-92
C02.02	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?	MENTHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused			93-94
C02.03	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?	POORHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused	Skip if C02.01, PHYSHLTH, is 88 and C02.02, MENTHLTH, is 88		95-96

Core Section 3: Health Care Access

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C03.01	Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, or Indian Health Service?	HLTHPLN1	1 Yes	If using Health Care Access (HCA) Module go to Module 03, M03.01, else continue		97
			2 No 7 Don’t know/Not Sure 9 Refused
C03.02	Do you have one person you think of as your personal doctor or health care provider?	PERSDOC2	1 Yes, only one 2 More than one 3 No 7 Don’t know / Not sure 9 Refused		If No, read: Is there more than one, or is there no person who you think of as your personal doctor or health care provider?	98
C03.03	Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?	MEDCOST	1 Yes 2 No 7 Don’t know / Not sure 9 Refused	If using HCA Module, go to Module 03, M03.03, else continue.		99
C03.04	About how long has it been since you last visited a doctor for a routine checkup?	CHECKUP1	Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 5 years (2 years but less than 5 years ago) 4 5 or more years ago Do not read: 7 Don’t know / Not sure 8 Never 9 Refused	If using HCA Module and C03.01 = 1 go to Module 03 M03.04 or if using HCA Module and C03,01 = 2, 7, or 9 go to Module 03, M03.04A, else go to next section.	Read if necessary: A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.	100

Core Section 4: Exercise

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C04.01	During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?	EXERANY2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Do not read: If respondent does not have a regular job or is retired, they may count any physical activity or exercise they do	101

Core Section 5: Inadequate Sleep

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C05.01	On average, how many hours of sleep do you get in a 24-hour period?	SLEPTIM1	_ _ Number of hours [01-24] 77 Don’t know / Not sure 99 Refused		Do not read: Enter hours of sleep in whole numbers, rounding 30 minutes (1/2 hour) or more up to the next whole hour and dropping 29 or fewer minutes.	102-103

Core Section 6: Chronic Health Conditions

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C06.01	Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me Yes, No, Or You’re Not Sure. Ever told) you that you had a heart attack also called a myocardial infarction?	CVDINFR4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			104
C06.02	(Ever told) you had angina or coronary heart disease?	CVDCRHD4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			105
C06.03	(Ever told) you had a stroke?	CVDSTRK3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			106
C06.04	(Ever told) you had asthma?	ASTHMA3	1 Yes			107
			2 No 7 Don’t know / Not sure 9 Refused	Go to C06.06
C06.05	Do you still have asthma?	ASTHNOW	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			108
C06.06	(Ever told) you had skin cancer?	CHCSCNCR	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			109
C06.07	(Ever told) you had any other types of cancer?	CHCOCNCR	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			110
C06.08	(Ever told) you have chronic obstructive pulmonary disease, C.O.P.D., emphysema or chronic bronchitis?	CHCCOPD1	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			111
C06.09	(Ever told) you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?	HAVARTH3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Do not read: Arthritis diagnoses include: rheumatism, polymyalgia rheumatic, osteoarthritis (not osteoporosis), tendonitis, bursitis, bunion, tennis elbow, carpal tunnel syndrome, tarsal tunnel syndrome, joint infection, Reiter’s syndrome, ankylosing spondylitis; spondylosis, rotator cuff syndrome, connective tissue disease, scleroderma, polymyositis, Raynaud’s syndrome, vasculitis, giant cell arteritis, Henoch-Schonlein purpura, Wegener’s granulomatosis, polyarteritis nodosa)	112
C06.10	(Ever told) you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?	ADDEPEV2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			113
C06.11	Not including kidney stones, bladder infection or incontinence, were you ever told you have kidney disease?	CHCKDNY1	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Read if necessary: Incontinence is not being able to control urine flow.	114
C06.12	(Ever told) you have diabetes?	DIABETE3	1 Yes		If yes and respondent is female, ask: was this only when you were pregnant? If respondent says pre-diabetes or borderline diabetes, use response code 4.	115
			2 Yes, but female told only during pregnancy 3 No 4 No, pre-diabetes or borderline diabetes 7 Don’t know / Not sure 9 Refused	Go to Pre-Diabetes Optional Module (if used). Otherwise, go to next section.
C06.13	How old were you when you were told you have diabetes?	DIABAGE2	_ _ Code age in years [97 = 97 and older] 98 Don‘t know / Not sure 99 Refused	Go to Diabetes Module if used, otherwise go to next section.		116-117

Core Section 7: Oral Health

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C07.01	Including all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists, how long has it been since you last visited a dentist or a dental clinic for any reason?	LASTDEN4	Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 5 years (2 years but less than 5 years ago) 4 5 or more years ago Do not read: 7 Don’t know / Not sure 8 Never 9 Refused			118
C07.02	Not including teeth lost for injury or orthodontics, how many of your permanent teeth have been removed because of tooth decay or gum disease?	RMVTETH4	Read if necessary: 1 1 to 5 2 6 or more but not all 3 All 8 None Do not read: 7 Don’t know / Not sure 9 Refused		Read if necessary: If wisdom teeth are removed because of tooth decay or gum disease, they should be included in the count for lost teeth.	119

Core Section 8: Demographics

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C08.01	Format 1: What is your sex? Format 2: What was your sex at birth? Was it…	SEX1	Read if format 2 is selected: 1 Male 2 Female Do not read: 7 Don’t know / Not sure 9 Refused	States may adopt one of the two formats of the question. If second format is used, read options.	[NOTE DELETED HERE]	120
C08.02	What is your age?	AGE	_ _ Code age in years 07 Don’t know / Not sure 09 Refused			121-122
C08.03	Are you Hispanic, Latino/a, or Spanish origin?	HISPANC3	If yes, read: Are you… 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		One or more categories may be selected.	123-126
C08.04	Which one or more of the following would you say is your race?	MRACE1	Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 88 No additional choices 77 Don’t know / Not sure 99 Refused	If more than one response to C08.04; continue. Otherwise, go to C08.06.	If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. One or more categories may be selected.	127-154
C08.05	Which one of these groups would you say best represents your race?	ORACE3	Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 77 Don’t know / Not sure 99 Refused		If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. If respondent has selected multiple races in previous and refuses to select a single race, code refused	155-156
C08.06	Are you…	MARITAL	Please read: 1 Married 2 Divorced 3 Widowed 4 Separated 5 Never married Or 6 A member of an unmarried couple Do not read: 9 Refused			157
C08.07	What is the highest grade or year of school you completed?	EDUCA	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			158
C08.08	Do you own or rent your home?	RENTHOM1	1 Own 2 Rent 3 Other arrangement 7 Don’t know / Not sure 9 Refused		Other arrangement may include group home, staying with friends or family without paying rent. Home is defined as the place where you live most of the time/the majority of the year. Read if necessary: We ask this question in order to compare health indicators among people with different housing situations.	159
C08.09	In what county do you currently live?	CTYCODE2	_ _ _ANSI County Code 777 Don’t know / Not sure 999 Refused			160-162
C08.10	What is the ZIP Code where you currently live?	ZIPCODE1	_ _ _ _ _ 77777 Do not know 99999 Refused			163-167
C08.11	Not including cell phones or numbers used for computers, fax machines or security systems, do you have more than one telephone number in your household?	NUMHHOL3	1 Yes	If cellular telephone interview skip to 8.14 (QSTVER GE 20)		168
			2 No 7 Don’t know / Not sure 9 Refused	Go to C08.13
C08.12	How many of these telephone numbers are residential numbers?	NUMPHON3	__ Enter number (1-5) 6 Six or more 7 Don’t know / Not sure 8 None 9 Refused			169
C08.13	How many cell phones do you have for personal use?	CPDEMO1B	__ Enter number (1-5) 6 Six or more 7 Don’t know / Not sure 8 None 9 Refused	Last question needed for partial complete.	Read if necessary: Include cell phones used for both business and personal use.	170
C08.14	Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?	VETERAN3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Read if necessary: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.	171
C08.15	Are you currently…?	EMPLOY1	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 Or 8 Unable to work Do not read: 9 Refused		If more than one, say “select the category which best describes you”.	172
C08.16	How many children less than 18 years of age live in your household?	CHILDREN	_ _ Number of children 88 None 99 Refused			173-174
C08.17	Is your annual household income from all sources—	INCOME2	Read 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		If respondent refuses at ANY income level, code ‘99’ (Refused)	175-176
C08.18	About how much do you weigh without shoes?	WEIGHT2	_ _ _ _ Weight (pounds/kilograms) 7777 Don’t know / Not sure 9999 Refused		If respondent answers in metrics, put 9 in first column. Round fractions up	177-180
C08.19	About how tall are you without shoes?	HEIGHT3	_ _ / _ _ Height (ft / inches/meters/centimeters) 77/ 77 Don’t know / Not sure 99/ 99 Refused		If respondent answers in metrics, put 9 in first column. Round fractions up	181-184
C08.20	To your knowledge, are you now pregnant?	PREGNANT	1 Yes 2 No 7 Don’t know / Not sure 9 Refused	Skip if C08.01, SEX, is coded 1; or C08.02, AGE, is greater than 49		185
C08.21	Some people who are deaf or have serious difficulty hearing use assistive devices to communicate by phone. Are you deaf or do you have serious difficulty hearing?	DEAF	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			186
C08.22	Are you blind or do you have serious difficulty seeing, even when wearing glasses?	BLIND	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			187
C08.23	Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?	DECIDE	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			188
C08.24	Do you have serious difficulty walking or climbing stairs?	DIFFWALK	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			189
C08.25	Do you have difficulty dressing or bathing?	DIFFDRES	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			190
C08.26	Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?	DIFFALON	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			191

Core Section 9: Tobacco Use

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C09.01	Have you smoked at least 100 cigarettes in your entire life?	SMOKE100	1 Yes		Do not include: electronic cigarettes (e-cigarettes, njoy, bluetip), herbal cigarettes, cigars, cigarillos, little cigars, pipes, bidis, kreteks, water pipes (hookahs) or marijuana. 5 packs = 100 cigarettes	192
			2 No 7 Don’t know/Not Sure 9 Refused	Go to C09.05
C09.02	Do you now smoke cigarettes every day, some days, or not at all?	SMOKDAY2	1 Every day 2 Some days			193
			3 Not at all	Go to C09.04
			7 Don’t know / Not sure 9 Refused	Go to C09.05
C09.03	During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?	STOPSMK2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused	Go to C09.05		194
C09.04	How long has it been since you last smoked a cigarette, even one or two puffs?	LASTSMK2	Read if necessary: 01 Within the past month (less than 1 month ago) 02 Within the past 3 months (1 month but less than 3 months ago) 03 Within the past 6 months (3 months but less than 6 months ago) 04 Within the past year (6 months but less than 1 year ago) 05 Within the past 5 years (1 year but less than 5 years ago) 06 Within the past 10 years (5 years but less than 10 years ago) 07 10 years or more 08 Never smoked regularly 77 Don’t know / Not sure 99 Refused			195-196
C09.05	Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?	USENOW3	1 Every day 2 Some days 3 Not at all 7 Don’t know / Not sure 9 Refused		Read if necessary: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.	197

Core Section 10: Alcohol Consumption

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C10.01	During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?	ALCDAY5	1 _ _ Days per week 2 _ _ Days in past 30 days			198-200
			888 No drinks in past 30 days 777 Don’t know / Not sure 999 Refused	Go to next section
C10.02	One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?	AVEDRNK2	_ _ Number of drinks 88 None 77 Don’t know / Not sure 99 Refused		Read if necessary: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.	201-202
C10.03	Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI X = 5 for men, X = 4 for women] or more drinks on an occasion?	DRNK3GE5	_ _ Number of times 77 Don’t know / Not sure 99 Refused	CATI X = 5 for men, X = 4 for women		203-204
C10.04	During the past 30 days, what is the largest number of drinks you had on any occasion?	MAXDRNKS	_ _ Number of drinks 77 Don’t know / Not sure 99 Refused			205-206

Core Section 11: Immunization

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C11.01	During the past 12 months, have you had either a flu shot or a flu vaccine that was sprayed in your nose?	FLUSHOT6	1 Yes		Read if necessary: A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.	207
			2 No 7 Don’t know / Not sure 9 Refused	Go to C11.04
C11.02	During what month and year did you receive your most recent flu shot injected into your arm or flu vaccine that was sprayed in your nose?	FLSHTMY2	_ _ / _ _ _ _ Month / Year 77 / 7777 Don’t know / Not sure 09 / 9999 Refused			208-213
C11.03	At what kind of place did you get your last flu shot or vaccine?	IMFVPLAC	Read if necessary: 01 A doctor’s office or health maintenance organization (HMO) 02 A health department 03 Another type of clinic or health center (a community health center) 04 A senior, recreation, or community center 05 A store (supermarket, drug store) 06 A hospital (inpatient) 07 An emergency room 08 Workplace 09 Some other kind of place 11 A school Do not read: 10 Received vaccination in Canada/Mexico 77 Don’t know / Not sure 99 Refused		Read if necessary: How would you describe the place where you went to get your most recent flu vaccine?	214-215
C11.04	Have you ever had a pneumonia shot also known as a pneumococcal vaccine?	PNEUVAC4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Read if necessary: There are two types of pneumonia shots: polysaccharide, also known as pneumovax, and conjugate, also known as prevnar.	216

Core Section 12: Falls

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C12.01	In the past 12 months, how many times have you fallen?	FALL12MN	_ _ Number of times	Skip if Section 08.02, AGE, coded 18-44	Read if necessary: By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.	217-218
			88 None 77 Don’t know / Not sure 99 Refused	Go to Next Section
C12.02	Did this fall cause an injury that limited your regular activities for at least a day or caused you to go to see a doctor? How many of these falls caused an injury that limited your regular activities for at least a day or caused you to go to see a doctor?	FALLINJ3	_ _ Number of falls [76 = 76 or more] 88 None 77 Don’t know / Not sure 99 Refused	If C12.01 =1 ask first version of question, if C12.01 > 1 ask second version. If only one fall from C12.01 and response is Yes (caused an injury); code 01. If response is No, code 88.	Read if necessary: By an injury, we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor.	219-220

Core Section 13: Seat Belt Use and Drinking and Driving

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C13.01	How often do you use seat belts when you drive or ride in a car? Would you say—	SEATBELT	Read: 1 Always 2 Nearly always 3 Sometimes 4 Seldom 5 Never Do not read: 7 Don’t know / Not sure			221
			8 Never drive or ride in a car	Go to next section
			9 Refused
C13.02	During the past 30 days, how many times have you driven when you’ve had perhaps too much to drink?	DRNKDRI2	_ _ Number of times 88 None 77 Don’t know / Not sure 99 Refused	If C10.01 = 888 (No drinks in the past 30 days); go to next section.		222-223

Core Section 14: Breast and Cervical Cancer Screening

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C14.01	The next questions are about breast and cervical cancer. Have you ever had a mammogram?	HADMAM	1 Yes	Skip if male.	A mammogram is an x-ray of each breast to look for breast cancer.	224
			2 No 7 Don’t know/ not sure 9 Refused		Go to C14.03
C14.02	How long has it been since you had your last mammogram?	HOWLONG	Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 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			225
C14.03	Have you ever had a Pap test?	HADPAP2	1 Yes			226
			2 No 7 Don’t know / Not sure 9 Refused	Go to C14.05
C14.04	How long has it been since you had your last Pap test?	LASTPAP2	Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 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			227
C14.05	An H.P.V. test is sometimes given with the Pap test for cervical cancer screening. Have you ever had an H.P.V. test?	HPVTEST	1 Yes		Human papillomarvirus (pap-uh-loh-muh virus)	228
			2 No 7 Don’t know / Not sure 9 Refused	Go to C14.07
C14.06	How long has it been since you had your last H.P.V. test?	HPLSTTST	Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 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			229
C14.07	Have you had a hysterectomy?	HADHYST2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused	If response to Core Q8.20 = 1 (is pregnant); then go to next section.	Read if necessary: A hysterectomy is an operation to remove the uterus (womb).	230

Core Section 15: Prostate Cancer Screening

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C15.01	Has a doctor, nurse, or other health professional ever talked with you about the advantages of the Prostate-Specific Antigen or P.S.A. test?	PCPSAAD3	1 Yes 2 No 7 Don’t know/ not sure 9 Refused	If respondent is ≤39 years of age, or C08.01 is coded 2, female, go to next section.	Read if necessary: A prostate-specific antigen test, also called a P.S.A. test, is a blood test used to check men for prostate cancer.	231
C15.02	Has a doctor, nurse, or other health professional ever talked with you about the disadvantages of the P.S.A. test?	PCPSADI1	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			232
C15.03	Has a doctor, nurse, or other health professional ever recommended that you have a P.S.A. test?	PCPSARE1	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			233
C15.04	Have you ever had a P.S.A. test?	PSATEST1	1 Yes			234
			2 No 7 Don’t know / Not sure 9 Refused	Go to next section
C15.05	How long has it been since you had your last P.S.A. test?	PSATIME	Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 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 Do not read: 7 Don’t know / Not sure 9 Refused			235
C15.06	What was the main reason you had this P.S.A. test – was it …?	PCPSARS1	Read: 1 Part of a routine exam 2 Because of a prostate problem 3 Because of a family history of prostate cancer 4 Because you were told you had prostate cancer 5 Some other reason Do not read: 7 Don’t know / Not sure 9 Refused			236

Core Section 16: Colorectal Cancer Screening

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C16.01	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?	BLDSTOOL	1 Yes	Skip if Section 08.02, AGE, is less than 50		237
			2 No 7 Don’t know/ not sure 9 Refused	Go to C16.03
C16.02	How long has it been since you had your last blood stool test using a home kit?	LSTBLDS3	Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 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 Do not read: 7 Don’t know / Not sure 9 Refused			238
C16.03	Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems. Have you ever had either of these exams?	HADSIGM3	1 Yes			239
			2 No 7 Don’t know / Not sure 9 Refused	Go to next section
C16.04	For a sigmoidoscopy, a flexible tube is inserted into the rectum to look for problems. A colonoscopy is similar, but uses a longer tube, and 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. Was your most recent exam a sigmoidoscopy or a colonoscopy?	HADSGCO1	1 Sigmoidoscopy 2 Colonoscopy 7 Don’t know / Not sure 9 Refused			240
C16.05	How long has it been since you had your last sigmoidoscopy or colonoscopy?	LASTSIG3	Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 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 Do not read: 7 Don't know / Not sure 9 Refused			241

Core Section 17: H.I.V./AIDS

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C17.01	The next few questions are about the national health problem of H.I.V., the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don’t have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had. Have you ever been tested for H.I.V.? Do not count tests you may have had as part of a blood donation. Include testing fluid from your mouth.	HIVTST6	1 Yes			242
			2 No 7 Don’t know/ not sure 9 Refused	Go to C17.03
C17.02	Not including blood donations, in what month and year was your last H.I,V.test?	HIVTSTD3	_ _ /_ _ _ _ Code month and year 77/ 7777 Don’t know / Not sure 99/ 9999 Refused	If response is before January 1985, code "777777".	INTERVIEWER NOTE: If the respondent remembers the year but cannot remember the month, code the first two digits 77 and the last four digits for the year.	243-248
C17.03	I am going to read you a list. When I am done, please tell me if any of the situations apply to you. You do not need to tell me which one. You have injected any drug other than those prescribed for you in the past year.  You have been treated for a sexually transmitted disease or STD in the past year. You have given or received money or drugs in exchange for sex in the past year. You had anal sex without a condom in the past year. You had four or more sex partners in the past year.  Do any of these situations apply to you? Do any of these situations apply to you?	HIVRISK5	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			249

Closing Statement/ Transition to Modules

Read if necessary	Read	CATI instructions (not read)
That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.		Read if no optional modules follow, otherwise continue to optional modules.

Optional Modules

Module 1: Prediabetes

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M01.01	Have you had a test for high blood sugar or diabetes within the past three years?	PDIABTST	1 Yes 2 No 7 Don’t know/ not sure 9 Refused	Skip if Section C06.12, DIABETE3, is coded 1		250
M01.02	Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?	PREDIAB1	1 Yes 2 Yes, during pregnancy 3 No 7 Don’t know / Not sure 9 Refused	Skip if Section 06.12, DIABETE3, is coded 1; If C06.12, DIABETE3, is coded 4 automatically code M01.02, PREDIAB1, equal to 1 (yes);	If Yes and respondent is female, ask: Was this only when you were pregnant?	251

Module 2: Diabetes

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M02.01	Are you now taking insulin?	INSULIN	1 Yes 2 No 7 Don’t know/ not sure 9 Refused	To be asked following Core Q6.13; if response to Q6.12 is Yes (code = 1)		252
M02.02	About how often do you check your blood for glucose or sugar?	BLDSUGAR	1 _ _ Times per day 2 _ _ Times per week 3 _ _ Times per month 4 _ _ Times per year 888 Never 777 Don’t know / Not sure 999 Refused		Read if necessary: Include times when checked by a family member or friend, but do not include times when checked by a health professional. Do not read: If the respondent uses a continuous glucose monitoring system (a sensor inserted under the skin to check glucose levels continuously), fill in ‘98 times per day.’	253-255
M02.03	Including times when checked by a family member or friend, about how often do you check your feet for any sores or irritations?	FEETCHK3	1 _ _ Times per day 2 _ _ Times per week 3 _ _ Times per month 4 _ _ Times per year 555 No feet 888 Never 777 Don’t know / Not sure 999 Refused			256-258
M02.04	About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?	DOCTDIAB	_ _ Number of times [76 = 76 or more] 88 None 77 Don’t know / Not sure 99 Refused			259-260
M02.05	About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for A-one-C?	CHKHEMO3	_ _ Number of times [76 = 76 or more] 88 None 98 Never heard of A-one-C test 77 Don’t know / Not sure 99 Refused		Read if necessary: A test for A-one-C measures the average level of blood sugar over the past three months.	261-262
M02.06	About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?	FEETCHK	_ _ Number of times [76 = 76 or more] 88 None 77 Don’t know / Not sure 99 Refused	If M02.03 = 555 (No feet), go to M02.07		263-264
M02.07	When was the last time you had an eye exam in which the pupils were dilated, making you temporarily sensitive to bright light?	EYEEXAM1	Read if necessary: 1 Within the past month (anytime less than 1 month ago) 2 Within the past year (1 month but less than 12 months ago) 3 Within the past 2 years (1 year but less than 2 years ago) 4 2 or more years ago Do not read: 7 Don’t know / Not sure 8 Never 9 Refused			265
M02.08	Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?	DIABEYE	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			266
M02.09	Have you ever taken a course or class in how to manage your diabetes yourself?	DIABEDU	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			267

Module 3: Health Care Access

Question Number	Question text		Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M03.01	Do you have Medicare?	MEDICARE	1 Yes 2 No 7 Don’t know/ not sure 9 Refused	Go to C03.02	Read if necessary: Medicare is a coverage plan for people age 65 or over and for certain disabled people.	268
M03.02	What is the primary source of your health care coverage? Is it…	HLTHCVR1	Read: 01 A plan purchased through an employer or union (including plans purchased through another person's employer) 02 A plan that you or another family member buys on your own 03 Medicare 04 Medicaid or other state program 05 TRICARE (formerly CHAMPUS), VA, or Military 06 Alaska Native, Indian Health Service, Tribal Health Services Or 07 Some other source 08 None (no coverage) Do not read: 77 Don't know/Not sure 99 Refused	Go to C03.04 If M03.01 = 1 (Yes) continue, else go to M03.04a	If the respondent indicates that they purchased health insurance through the Health Insurance Marketplace (name of state Marketplace), ask if it was a private health insurance plan purchased on their own or by a family member (private) or if they received Medicaid (state plan)? If purchased on their own (or by a family member), select 02, if Medicaid select 04.	269-270
M03.03	Other than cost, have you delayed getting medical care for one of the following reasons in the past 12 months? Was it because…..	DELAYME1	Read: 1 You couldn’t get through on the telephone. 2 You couldn’t get an appointment soon enough. 3 Once you got there, you had to wait too long to see the doctor. 4 The clinic or doctor’s office wasn’t open when you got there. 5 You didn’t have transportation. Do not read: 8 No, I did not delay getting medical care/did not need medical care 7 Don’t know/Not sure 9 Refused		If respondent provides more than one reason, say: “Which was the most important reason you delayed getting care?”	271
		DLYOTHER	6 Other ____________ (specify)			272-296
M03.04	In the past 12 months was there any time when you did not have any health insurance or coverage?	NOCOV121	1 Yes 2 No 7 Don’t know/ not sure 9 Refused	If C03.01 = 2, 7, or 9 continue, else Go to M03.05		297
M03.04a	About how long has it been since you last had health care coverage?	LSTCOVRG	Read if necessary: 1 6 months or less 2 More than 6 months, but not more than 1 year ago 3 More than 1 year, but not more than 3 years ago 4 More than 3 years 5 Never Do not read: 7 Don’t know/Not sure 9 Refused			298
M03.05	How many times have you been to a doctor, nurse, or other health professional in the past 12 months?	DRVISITS	_ _ Number of times [76 = 76 or more] 88 None 98 Never heard of A-one-C test 77 Don’t know / Not sure 99 Refused			299-300
M03.06	Not including over the counter (OTC) medications, was there a time in the past 12 months when you did not take your medication as prescribed because of cost?	MEDSCOS1	1 Yes 2 No 3 No medication was prescribed 7 Don’t know/ not sure 9 Refused			301
M03.07	In general, how satisfied are you with the health care you received? Would you say—	CARERCVD	Read: 1 Very satisfied 2 Somewhat satisfied 3 Not at all satisfied Do not read: 8 Not applicable 7 Don’t know/Not sure 9 Refused			302
M03.08	Do you currently have any health care bills that are being paid off over time?	MEDBILL1	1 Yes 2 No 7 Don’t know/ not sure 9 Refused	Go to Core Section 4.	Read if necessary: This could include medical bills being paid off with a credit card, through personal loans, or bill paying arrangements with hospitals or other providers. The bills can be from earlier years as well as this year. Read if necessary: Health care bills can include medical, dental, physical therapy and/or chiropractic cost.	303

Module 4: Cognitive Decline

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M04.01	The next few questions ask about difficulties in thinking or remembering that can make a big difference in everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you recently met, which is normal. This refers to confusion or memory loss that is happening more often or getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would normally know. We want to know how these difficulties impact you. During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse?	CIMEMLOS	1 Yes	If respondent is 45 years of age or older continue, else go to next module. Go to M04.02		304
			2 No	Go to next module
			7 Don’t know/ not sure	Go to M04.02
			9 Refused	Go to next module
M04.02	During the past 12 months, as a result of confusion or memory loss, how often have you given up day-to-day household activities or chores you used to do, such as cooking, cleaning, taking medications, driving, or paying bills? Would you say it is…	CDHOUSE	Read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never Do not read: 7 Don't know/Not sure 9 Refused			305
M04.03	As a result of confusion or memory loss, how often do you need assistance with these day-to-day activities? Would you say it is…	CDASSIST	Read: 1 Always 2 Usually 3 Sometimes			306
			4 Rarely 5 Never	Go to M04.05
			Do not read: 7 Don't know/Not sure 9 Refused
M04.04	When you need help with these day-to-day activities, how often are you able to get the help that you need? Would you say it is…	CDHELP	Read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never Do not read: 7 Don't know/Not sure 9 Refused			307
M04.05	During the past 12 months, how often has confusion or memory loss interfered with your ability to work, volunteer, or engage in social activities outside the home? Would you say it is…	CDSOCIAL	Read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never Do not read: 7 Don't know/Not sure 9 Refused			308
M04.06	Have you or anyone else discussed your confusion or memory loss with a health care professional?	CDDISCUS	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			309

Module 5: Caregiver

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M05.01	During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability?	CAREGIV1	1 Yes		If caregiving recipient has died in the past 30 days, code 8 and say: I’m so sorry to hear of your loss	310
			2 No 7 Don’t know/Not sure	Go to M05.09
			8 Caregiving recipient died in past 30 days	Go to next module
			9 Refused	Go to M05.09
M05.02	What is his or her relationship to you?	CRGVREL2	01 Mother 02 Father 03 Mother-in-law 04 Father-in-law 05 Child 06 Husband 07 Wife 08 Live-in partner 09 Brother or brother-in-law 10 Sister or sister-in-law 11 Grandmother 12 Grandfather 13 Grandchild 14 Other relative 15 Non-relative/ Family friend 77 Don’t know/Not sure 99 Refused		If more than one person, say: Please refer to the person to whom you are giving the most care.	311-312
M05.03	For how long have you provided care for that person? Would you say…	CRGVLNG1	Read: 1 Less than 30 days 2 1 month to less than 6 months 3 6 months to less than 2 years 4 2 years to less than 5 years 5 More than 5 years Do not read: 7 Don’t Know/ Not Sure 9 Refused			313
M05.04	In an average week, how many hours do you provide care or assistance? Would you say…	CRGVHRS1	Read: 1 Up to 8 hours per week 2 9 to 19 hours per week 3 20 to 39 hours per week 4 40 hours or more Do not read: 7 Don’t know/Not sure 9 Refused			314
M05.05	What is the main health problem, long-term illness, or disability that the person you care for has?	CRGVPRB2	01 Arthritis/ rheumatism 02 Asthma 03 Cancer 04 Chronic respiratory conditions such as emphysema or COPD 05 Alzheimer’s disease, dementia or other cognitive impairment disorder 06 Developmental disabilities such as autism, Down’s Syndrome, and spina bifida 07 Diabetes 08 Heart disease, hypertension, stroke 09 Human Immunodeficiency Virus Infection (H.I.V.) 10 Mental illnesses, such as anxiety, depression, or schizophrenia 11 Other organ failure or diseases such as kidney or liver problems 12 Substance abuse or addiction disorders 13 Injuries, including broken bones 14 Old age/ infirmity/frailty 15 Other 77 Don’t know/Not sure 99 Refused			315-316
M05.06	In the past 30 days, did you provide care for this person by managing personal care such as giving medications, feeding, dressing, or bathing?	CRGVPERS	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			317
M05.07	In the past 30 days, did you provide care for this person by managing household tasks such as cleaning, managing money, or preparing meals?	CRGVHOUS	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			318
M05.08	Of the following support services, which one do you, as a caregiver, most need that you are not currently getting?	CRGVMST3	Read: 1 Classes about giving care, such as giving medications 2 Help in getting access to services 3 Support groups 4 Individual counseling to help cope with giving care 5 Respite care, or 6 You don’t need any of these support services Do not read: 7 Don’t Know /Not Sure 9 Refused		If respondent asks what respite care is read: “Respite care means short-term breaks for people who provide care.”	319
M05.09	In the next 2 years, do you expect to provide care or assistance to a friend or family member who has a health problem or disability?	CRGVEXPT	1 Yes 2 No 7 Don’t know/ not sure 9 Refused	If M05.01 = 1 or 8, go to next module		320

Module 6: E-Cigarettes

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M06.01	Have you ever used an e-cigarette or other electronic vaping product, even just one time, in your entire life?	ECIGARET	1 Yes		Read if necessary: Electronic cigarettes (e-cigarettes) and other electronic vaping products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy. Interviewer note: These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.	321
			2 No 7 Don’t know/Not sure 9 Refused	Go to next module
M06.02	Do you now use e-cigarettes or other electronic vaping products every day, some days, or not at all?	ECIGNOW	1 Every day 2 Some days 3 Not at all 7 Don’t know / Not sure 9 Refused		Interviewer note: These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.	322

Module 7: Marijuana Use

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M07.01	During the past 30 days, on how many days did you use marijuana or cannabis?	MARIJAN1	_ _ 01-30 Number of days			323-324
			88 None 77 Don’t know/not sure 99 Refused	Go to next module
M07.02	During the past 30 days, which one of the following ways did you use marijuana the most often? Did you usually…	USEMRJN2	Read: 1 Smoke it (for example, in a joint, bong, pipe, or blunt). 2 Eat it (for example, in brownies, cakes, cookies, or candy) 3 Drink it (for example, in tea, cola, or alcohol) 4 Vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device) 5 Dab it (for example, using waxes or concentrates), or 6 Use it some other way. Do not read: 7 Don’t know/not sure 9 Refused		Select one. If respondent provides more than one say: which way did you use it most often.	325
M07.03	When you used marijuana or cannabis during the past 30 days, was it usually:	RSNMRJN1	Read: 1 For medical reasons (like to treat or decrease symptoms of a health condition); 2 For non-medical reasons (like to have fun or fit in), or 3 For both medical and non-medical reasons. Do not read: 7 Don’t know/Not sure 9 Refused			326

Module 8: Sleep Disorder

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M08.01	Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?	ADSLEEP	_ _ 01-14 Number of days 88 None 77 Don’t know/not sure 99 Refused			327-328
M08.02	Over the last 2 weeks, how many days did you unintentionally fall asleep during the day?	SLEPDAY1	_ _ 01-14 Number of days 88 None 77 Don’t know/not sure 99 Refused			329-330
M08.03	Have you ever been told that you snore loudly?	SLEPSNO2	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			331
M08.04	Has anyone ever observed that you stop breathing during your sleep?	SLEPBRTH	1 Yes 2 No 7 Don’t know/ not sure 9 Refused		Enter yes (1) if respondent mentions having a machine or CPAP that records that breathing sometimes stops during the night.	332

Module 9: Depression and Anxiety

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M09.01	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...	ADPLEAS1	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			333
M09.02	Over the last 2 weeks, how often have you been bothered by feeling down, depressed or hopeless? Would you say this happens…	ADDOWN1	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			334
M09.03	Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge? Would you say this happens…	FEELNERV	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			335
M09.04	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…	STOPWORY	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			336

Module 10: Respiratory Health

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M10.01	During the past 3 months, did you have a cough on most days?	COPDCOGH	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			337
M10.02	During the past 3 months, did you cough up phlegm [FLEM] or mucus on most days?	COPDFLEM	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			338
M10.03	Do you have shortness of breath either when hurrying on level ground or when walking up a slight hill or stairs?	COPDBRTH	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			339
M10.04	Have you ever been given a breathing test to diagnose breathing problems?	COPDBTST	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			340
M10.05	Over your lifetime, how many years have you smoked tobacco products?	COPDSMOK	_ _ Number of years (01-76) 88 Never smoked or smoked less than one year 77 Don’t know/Not sure 99 Refused			341-342

Module 11: Indoor Tanning

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M11.01	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?	INDORTAN	_ _ _ Number (0-365) 777 Don’t know/ Not sure 999 Refused			343-345

Module 12: Excess Sun Exposure

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M12.01	During the past 12 months, how many times have you had a sunburn?	NUMBURN3	_ _ _ Number (0-365) 777 Don’t know/ Not sure 999 Refused			346-348
M12.02	When you go outside on a warm sunny day for more than one hour, how often do you protect yourself from the sun? Is that….	SUNPRTCT	Read: 1 Always 2 Most of the time 3 Sometimes 4 Rarely 5 Never Do not read: 6 Don’t stay outside for more than one hour on warm sunny days 8 Don’t go outside at all on warm sunny days 7 Don’t know/ Not sure 9 Refused		Protection from the sun may include using sunscreen, wearing a wide-brimmed hat, or wearing a long-sleeved shirt.	349
M12.03	On weekdays, in the summer, how long are you outside per day between 10am and 4pm?	WKDAYOUT	01 Less than half an hour 02 (More than half an hour) up to 1 hour 03 (More than 1 hour) up to 2 hours 04 (More than 2 hours) up to 3 hours 05 (More than 3 hours) up to 4 hours 06 (More than 4 hours) up to 5 hours 07 (More than 5) up to 6 hours 77 Don’t know/ Not sure 99 Refused		Friday is a weekday. If respondent says never code 01.	350-351
M12.04	On weekends in the summer, how long are you outside each day between 10am and 4pm?	WKENDOUT	01 Less than half an hour 02 (More than half an hour) up to 1 hour 03 (More than 1 hour) up to 2 hours 04 (More than 2 hours) up to 3 hours 05 (More than 3 hours) up to 4 hours 06 (More than 4 hours) up to 5 hours 07 (More than 5) up to 6 hours 77 Don’t know/ Not sure 99 Refused		Friday is a weekday. If respondent says never code 01.	352-353

Module 13: Lung Cancer Screening

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M13.01	You’ve told us that you have smoked in the past or are currently smoking. The next questions are about screening for lung cancer. How old were you when you first started to smoke cigarettes regularly?	LCSFIRST	_ _ _ Age in Years (001 – 100) 777 Don't know/Not sure 999 Refused	If C09.01=1 (yes) and C09.02 = 1, 2, or 3 (every day, some days, or not at all) continue, else go to question M13.04.	Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all). If respondent indicates age inconsistent with previously entered age, verify that this is the correct answer and change the age of the respondent regularly smoking or make a note to correct the age of the respondent.	354-356
			888 Never smoked cigarettes regularly	Go to M13.04
M13.02	How old were you when you last smoked cigarettes regularly?	LCSLAST	_ _ _ Age in Years (001 – 100) 777 Don't know/Not sure 999 Refused			357-359
M13.03	On average, when you {smoke/smoked} regularly, about how many cigarettes {do/did} you usually smoke each day?	LCSNUMCG	_ _ _ Number of cigarettes 777 Don't know/Not sure 999 Refused		Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all). Respondents may answer in packs instead of number of cigarettes. Below is a conversion table: 0.5 pack = 10 cigarettes/ 1.75 pack = 35 cigarettes/ 0.75 pack = 15 cigarettes/ 2 packs = 40 cigarettes/ 1 pack = 20 cigarettes/ 2.5 packs= 50 cigarettes/ 1.25 pack = 25 cigarettes/ 3 packs= 60 cigarettes/ 1.5 pack = 30 cigarettes	360-362
M13.04	The next question is about CT or CAT scans. During this test, you lie flat on your back on a table. While you hold your breath, the table moves through a donut shaped x-ray machine while the scan is done. In the last 12 months, did you have a CT or CAT scan?	LCSCTSCN	Read if necessary: 1 Yes, to check for lung cancer 2 No (did not have a CT scan) 3 Had a CT scan, but for some other reason Do not read: 7 Don't know/not sure 9 Refused			363

Module 14: Cancer Survivorship

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M14.01	You’ve told us that you have had cancer. I would like to ask you a few more questions about your cancer. How many different types of cancer have you had?	CNCRDIFF	1 Only one 2 Two 3 Three or more	If C06.06 or C06.07 = 1 (Yes) or C15.06 = 4 (Because you were told you had prostate cancer) continue, else go to next module.		364
			7 Don’t know / Not sure 9 Refused	Go to next module
M14.02	At what age were you told that you had cancer?	CNCRAGE	_ _ Age in Years (97 = 97 and older) 98 Don't know/Not sure 99 Refused		If M14.01= 2 (Two) or 3 (Three or more), ask: At what age were you first diagnosed with cancer? Read if necessary: This question refers to the first time they were told about their first cancer.	365-366
M14.03	What type of cancer was it?	CNCRTYP1	Read if respondent needs prompting for cancer type: 01 Breast cancer Female reproductive (Gynecologic) 02 Cervical cancer (cancer of the cervix) 03 Endometrial cancer (cancer of the uterus) 04 Ovarian cancer (cancer of the ovary) Head/Neck 05 Head and neck cancer 06 Oral cancer 07 Pharyngeal (throat) cancer 08 Thyroid 09 Larynx Gastrointestinal 10 Colon (intestine) cancer 11 Esophageal (esophagus) 12 Liver cancer 13 Pancreatic (pancreas) cancer 14 Rectal (rectum) cancer 15 Stomach Leukemia/Lymphoma (lymph nodes and bone marrow) 16 Hodgkin's Lymphoma (Hodgkin’s disease) 17 Leukemia (blood) cancer 18 Non-Hodgkin’s Lymphoma Male reproductive 19 Prostate cancer 20 Testicular cancer Skin 21 Melanoma 22 Other skin cancer Thoracic 23 Heart 24 Lung Urinary cancer 25 Bladder cancer 26 Renal (kidney) cancer Others 27 Bone 28 Brain 29 Neuroblastoma 30 Other Do not read: 77 Don’t know / Not sure 99 Refused	If C06.06 = 1 (Yes) and M14.01 = 1 (Only one): ask Was it Melanoma or other skin cancer? then code 21 if Melanoma or 22 if other skin cancer CATI note: If C16.06 = 4 (Because you were told you had Prostate Cancer) and Q1 = 1 (Only one) then code 19.	If M14.01 = 2 (Two) or 3 (Three or more), ask: With your most recent diagnoses of cancer, what type of cancer was it?	367-368
M14.04	Are you currently receiving treatment for cancer?	CSRVTRT2	Read if necessary: 1 Yes	Go to next module	Read if necessary: By treatment, we mean surgery, radiation therapy, chemotherapy, or chemotherapy pills.	369
			2 No, I’ve completed treatment
			3 No, I’ve refused treatment 4 No, I haven’t started treatment 7 Don’t know / Not sure 9 Refused	Go to next module
M14.05	What type of doctor provides the majority of your health care? Is it a….	CSRVDOC1	Read: 01 Cancer Surgeon 02 Family Practitioner 03 General Surgeon 04 Gynecologic Oncologist 05 General Practitioner, Internist 06 Plastic Surgeon, Reconstructive Surgeon 07 Medical Oncologist 08 Radiation Oncologist 09 Urologist 10 Other Do not read: 77 Don’t know / Not sure 99 Refused		If the respondent requests clarification of this question, say: We want to know which type of doctor you see most often for illness or regular health care (Examples: annual exams and/or physicals, treatment of colds, etc.). Read if necessary: An oncologist is a medical doctor who manages a person’s care and treatment after a cancer diagnosis.	370-371
M14.06	Did any doctor, nurse, or other health professional ever give you a written summary of all the cancer treatments that you received?	CSRVSUM	1 Yes 2 No 7 Don’t know/ not sure 9 Refused		Read if necessary: By ‘other healthcare professional’, we mean a nurse practitioner, a physician’s assistant, social worker, or some other licensed professional.	372
M14.07	Have you ever received instructions from a doctor, nurse, or other health professional about where you should return or who you should see for routine cancer check-ups after completing your treatment for cancer?	CSRVRTRN	1 Yes			373
			2 No 7 Don’t know/ not sure 9 Refused	Go to M14.09
M14.08	Were these instructions written down or printed on paper for you?	CSRVINST	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			374
M14.09	With your most recent diagnosis of cancer, did you have health insurance that paid for all or part of your cancer treatment?	CSRVINSR	1 Yes 2 No 7 Don’t know/ not sure 9 Refused		Read if necessary: Health insurance also includes Medicare, Medicaid, or other types of state health programs.	375
M14.10	Were you ever denied health insurance or life insurance coverage because of your cancer?	CSRVDEIN	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			376
M14.11	Did you participate in a clinical trial as part of your cancer treatment?	CSRVCLIN	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			377
M14.12	Do you currently have physical pain caused by your cancer or cancer treatment?	CSRVPAIN	1 Yes			378
			2 No 7 Don’t know/ not sure 9 Refused	Go to next module
M14.13	Would you say your pain is currently under control…?	CSRVCTL1	Read: 1 With medication (or treatment) 2 Without medication (or treatment) 3 Not under control, with medication (or treatment) 4 Not under control, without medication (or treatment) Do not read: 7 Don’t know / Not sure 9 Refused			379

Module 15: Prostate Cancer Screening Decision Making

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M15.01	Which one of the following best describes the decision to have the P.S.A. test done?	PCPSADE1		If C15.01 = 4 continue, otherwise go to next module.		380
			Read: 1 You made the decision alone 2 Your doctor, nurse, or health care provider made the decision alone	Go to next module.
			3 You and one or more other persons made the decision together
			4 You don’t know how the decision was made Do not read: 9 Refused	Go to next module
M15.02	Who made the decision with you?	PCDMDEC1	Read if necessary: 1 Doctor/nurse /health care provider 2 Spouse/significant other 3 Other family member 4 Friend/non-relative Do not read: 7 Don’t know / Not sure 9 Refused		Select one response. If respondent offers more than one response ask for primary person who made decision.	381

Module 16: Clinical Breast Exam

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M16.01	A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you ever had a clinical breast exam?	PROFEXAM		If respondent is male, go to the next module.		382
			1 Yes
			2 No 7 Don’t know/ not sure 9 Refused	Go to next module.
M16.02	How long has it been since your last breast exam?	LENGEXAM	Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 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 Do not read: 7 Don’t know / Not sure 9 Refused			383

Module 17: Adult Human Papillomavirus (HPV) - Vaccination

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M17.01	A vaccine to prevent the human papillomavirus or H.P.V. infection is available and is called the cervical cancer or genital warts vaccine, H.P.V. shot, [Fill: if female GARDASIL or CERVARIX; if male: GARDASIL]. Have you ever had an H.P.V. vaccination?	HPVADVC2	1 Yes	To be asked of respondents between the ages of 18 and 49 years; otherwise, go to next module.	Human Papillomavirus (Human Pap·uh·loh·muh virus); Gardasil (Gar·duh· seel); Cervarix (Sir·var· icks)	384
			2 No 3 Doctor refused when asked 7 Don’t know/ not sure 9 Refused	Go to next module
M17.02	How many H.P.V. shots did you receive?	HPVADSHT	_ _ Number of shots 03 All shots 77 Don’t know / Not sure 99 Refused			385-386

Module 18: Tetanus Diphtheria (Tdap) (Adults)

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M18.01	Have you received a tetanus shot in the past 10 years?	TETANUS1	1 Yes, received Tdap 2 Yes, received tetanus shot, but not Tdap 3 Yes, received tetanus shot but not sure what type 4 No, did not receive any tetanus shot in the past 10 years 7 Don’t know/Not sure 9 Refused		If yes, ask: Was this Tdap, the tetanus shot that also has pertussis or whooping cough vaccine?	387

Module 19: Shingles (Zostavax or ZOS)

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M19.01	Have you ever had the shingles or zoster vaccine?	SHINGLE2	1 Yes 2 No 7 Don’t know/ not sure 9 Refused	If respondent is < 49 years of age, go to next section.	Shingles is an illness that results in a rash or blisters on the skin, and is usually painful. There are two vaccines now available for shingles; Zostavax, which requires 1 shot, and Shingrix, a new vaccine which requires 2 shots.	388

Module 20: Industry and Occupation

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M20.01	What kind of work do you do? For example, registered nurse, janitor, cashier, auto mechanic.	TYPEWORK	_______Record answer 99 Refused	If C08.15 = 1 or 4 (Employed for wages or out of work for less than 1 year) or 2 (Self-employed), continue. If C08.15 = 4 (Out of work for less than 1 year) ask, “What kind of work did you do? For example, registered nurse, janitor, cashier, auto mechanic.” Else go to next module	If respondent is unclear, ask: What is your job title? If respondent has more than one job ask: What is your main job?	389-488
M20.02	What kind of business or industry do you work in? For example, hospital, elementary school, clothing manufacturing, restaurant	TYPEINDS	_______Record answer 99 Refused	If Core Q8.15 = 4 (Out of work for less than 1 year) ask, “What kind of business or industry did you work in? For example, hospital, elementary school, clothing manufacturing, restaurant.”		489-588

Module 21: Sexual Orientation and Gender Identity (SOGI)

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M21.01	The next two questions are about sexual orientation and gender identity. Do you consider yourself to be 1-Straight, 2-Lesbian or Gay, 3-Bisexual or 4-other orientation?	SXORIENT	1 Straight 2 Lesbian or gay 3 Bisexual 4 Other 7 Don’t know/Not sure 9 Refused		Read if necessary: We ask this question in order to better understand the health and health care needs of people with different sexual orientations. Please say the number before the text response. Respondent can answer with either the number or the text/word.	589
M21.02	Do you consider yourself to be transgender?	TRNSGNDR	1 Yes, Transgender, male-to-female 2 Yes, Transgender, female to male 3 Yes, Transgender, gender nonconforming 4 No 7 Don’t know/not sure 9 Refused		Read if necessary: 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. 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. If yes, ask Do you consider yourself to be 1. male-to-female, 2. female-to-male, or 3. gender non-conforming? Please say the number before the text response. Respondent can answer with either the number or the text/word.	590

Module 22: Random Child Selection

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
Intro text and screening	If C08.16 = 1 and C08.16 does not equal 88 or 99, Interviewer please read: Previously, you indicated there was one child age 17 or younger in your household. I would like to ask you some questions about that child. If C0.16 is >1 and C08.16 does not equal 88 or 99, Interviewer please read: Previously, you indicated there were [number] children age 17 or younger in your household. Think about those [number] children in order of their birth, from oldest to youngest. The oldest child is the first child and the youngest child is the last. Please include children with the same birth date, including twins, in the order of their birth.			If C08.16 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module. CATI INSTRUCTION: RANDOMLY SELECT ONE OF THE CHILDREN. This is the Xth child. Please substitute Xth child’s number in all questions below. INTERVIEWER PLEASE READ: I have some additional questions about one specific child. The child I will be referring to is the Xth [CATI: please fill in correct number] child in your household. All following questions about children will be about the Xth [CATI: please fill in] child.
M22.01	What is the birth month and year of the [Xth] child?	RCSBIRTH	_ _ /_ _ _ _ Code month and year 77/ 7777 Don’t know / Not sure 99/ 9999 Refused			591-596
M22.02	Is the child a boy or a girl?	RCSGENDR	1 Boy 2 Girl 9 Refused			597
M22.03	Is the child Hispanic, Latino/a, or Spanish origin?	RCHISLA1	Read if response is yes: 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		If yes, ask: Are they…	598-601
M22.04	Which one or more of the following would you say is the race of the child?	RCSRACE1	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	[CATI NOTE: IF MORE THAN ONE RESPONSE TO Q4; CONTINUE. OTHERWISE, GO TO Q6.]	Select all that apply If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.	602-629
M22.05	Which one of these groups would you say best represents the child’s race?	RCSBRAC2	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		If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.	630-631
M22.06	How are you related to the child? Are you a….	RCSRLTN2	Please read: 1 Parent (include biologic, step, or adoptive parent) 2 Grandparent 3 Foster parent or guardian 4 Sibling (include biologic, step, and adoptive sibling) 5 Other relative 6 Not related in any way Do not read: 7 Don’t know / Not sure 9 Refused			632

Module 23: Childhood Asthma Prevalence

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M23.01	The next two questions are about the Xth child. Has a doctor, nurse or other health professional EVER said that the child has asthma?	CASTHDX2	1 Yes	If response to C08.16 = 88 (None) or 99 (Refused), go to next module. Fill in correct [Xth] number.		633
			2 No 7 Don’t know/ not sure 9 Refused	Go to next module
M23.02	Does the child still have asthma?	CASTHNO2	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			634

Asthma Call-Back Permission Script

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
Text	We would like to call you again within the next 2 weeks to talk in more detail about (your/your child’s) experiences with asthma. The information will be used to help develop and improve the asthma programs in <STATE>. The information you gave us today and any you give us in the future will be kept confidential. If you agree to this, we will keep your first name or initials and phone number on file, separate from the answers collected today. Even if you agree now, you or others may refuse to participate in the future.
CB01.01	Would it be okay if we called you back to ask additional asthma-related questions at a later time?	CALLBACK	1 Yes 2 No			635
CB01.02	Which person in the household was selected as the focus of the asthma call-back?	ADLTCHLD	1 Adult 2 Child			636

Reproductive Health Call-Back Permission Script

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CB02.01	We would like to call you again to talk in more detail about your reproductive health. The information will be used to help develop and improve the programs in <STATE>. Would it be okay if we called you back to ask questions related to reproductive health at a later time?	CALLBCKZ	1 Yes 2 No			637

Closing Statement

Read

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

47

21 January 2021