Form 0920-1061 Even-Numbered Year BRFSS Core Questionnaire

Public reporting burden of this collection of information is estimated to average 14 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061).

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

Core Sections

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

Section 1: Health Status

1.1 Would you say that in general your health is—

Please read:

1 Excellent

2 Very good

Shape1

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

3 Good

4 Fair

5 Poor

Do not read:

7 Don’t know / Not sure

9 Refused

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

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

_ _ Number of days

88 None

77 Don’t know / Not sure

99 Refused

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

_ _ Number of days

88 None [If Q2.1 and Q2.2 = 88 (None), go to next section]

77 Don’t know / Not sure

99 Refused

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

_ _ Number of days

88 None

77 Don’t know / Not sure

99 Refused

Section 3: Health Care Access

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

1 Yes [If using Health Care Access (HCA) Module go to Module 3, Q1, else continue]

2 No

7 Don’t know / Not sure

9 Refused

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

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

1 Yes, only one

2 More than one

3 No

7 Don’t know / Not sure

9 Refused

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

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

CATI NOTE: If using HCA Module, go to Module 3, Q3, else continue.

About how long has it been since you last visited a doctor for a routine checkup?

INTERVIEWER NOTE: A ROUTINE CHECKUP IS A GENERAL PHYSICAL EXAM, NOT AN EXAM FOR A SPECIFIC INJURY, ILLNESS, OR CONDITION.

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

7 Don’t know / Not sure

8 Never

9 Refused

CATI NOTE: If using HCA Module and Q3.1 = 1 go to Module 3 Question 4 or if using HCA Module and Q3.1 = 2, 7, or 9 go to Module 3, Question 4a, or if not using HCA Module go to next section.

Section 4: Exercise

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

INTERVIEWER INSTRUCTION: IF RESPONDENT DOES NOT HAVE A REGULAR JOB OR IS RETIRED, THEY MAY COUNT ANY PHYSICAL ACTIVITY OR EXERCISE THEY DO

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Section 5: Inadequate Sleep

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

INTERVIEWER NOTE: Enter hours of sleep in whole numbers, rounding 30 minutes (1/2 hour) or more up to the next whole hour and dropping 29 or fewer minutes.

_ _ Number of hours [01-24]

7 7 Don’t know / Not sure

9 9 Refused

Section 6: Chronic Health Conditions

Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me Yes, No, Or You’re Not Sure.

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

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

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

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.3 (Ever told) you had a stroke?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.4 (Ever told) you had asthma?

1 Yes

2 No [Go to Q6.6]

7 Don’t know / Not sure [Go to Q6.6]

9 Refused [Go to Q6.6]

6.5 Do you still have asthma?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.6 (Ever told) you had skin cancer?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

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

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.8 (Ever told) you have chronic obstructive pulmonary disease, C.O.P.D., emphysema or chronic bronchitis?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

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

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: Arthritis diagnoses include:

rheumatism, polymyalgia rheumatica
osteoarthritis (not osteoporosis)
tendonitis, bursitis, bunion, tennis elbow
carpal tunnel syndrome, tarsal tunnel syndrome
joint infection, Reiter’s syndrome
ankylosing spondylitis; spondylosis
rotator cuff syndrome
connective tissue disease, scleroderma, polymyositis, Raynaud’s syndrome
vasculitis (giant cell arteritis, Henoch-Schonlein purpura, Wegener’s granulomatosis, polyarteritis nodosa)

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

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.11 Not including kidney stones, bladder infection or incontinence, were you ever told you have kidney disease?

INTERVIEWER NOTE: Incontinence is not being able to control urine flow.

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.12 (Ever told) you have diabetes?

INTERVIEWER NOTE: IF YES AND RESPONDENT IS FEMALE, ASK: WAS THIS ONLY WHEN YOU WERE PREGNANT? IF RESPONDENT SAYS PRE-DIABETES OR BORDERLINE DIABETES, USE RESPONSE CODE 4.

1 Yes

2 Yes, but female told only during pregnancy

3 No

4 No, pre-diabetes or borderline diabetes

7 Don’t know / Not sure

9 Refused

CATI NOTE: If Q6.12 = 1 (Yes), go to next question. If any other response to Q6.12, go to Pre-Diabetes Optional Module (if used). Otherwise, go to next section.

6.13 How old were you when you were told you have diabetes?

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

98 Don‘t know / Not sure

99 Refused

CATI NOTE: Go to Diabetes Optional Module (if used). Otherwise, go to next section.

Section 7: Oral Health

7.1 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?

Read only if necessary:

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

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

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

4 5 or more years ago

Do not read:

7 Don’t know / Not sure

8 Never

9 Refused

7.2 Not including teeth lost for injury or orthodontics, how many of your permanent teeth have been removed because of tooth decay or gum disease?

INTERVIEWER NOTE: If wisdom teeth are removed because of tooth decay or gum disease, they should be included in the count for lost teeth.

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

Section 8: Demographics

8.1 (What was your sex at birth? Was it…)

(What is your sex?)

CATI NOTE: STATES MAY ADOPT ONE OF THE TWO FORMATS OF THE QUESTION. IF FIRST FORMAT IS USED, READ OPTIONS.

1 Male

2 Female

9 Refused

8.2 What is your age?

_ _ Code age in years

07 Don’t know / Not sure

09 Refused

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

If yes, ask: Are you…

INTERVIEWER NOTE: One or more categories may be selected.

1 Mexican, Mexican American, Chicano/a

2 Puerto Rican

3 Cuban

4 Another Hispanic, Latino/a, or Spanish origin

Do not read:

5 No

7 Don’t know / Not sure

9 Refused

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

INTERVIEWER NOTE: Select all that apply.

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

Please read:

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

88 No additional choices

77 Don’t know / Not sure

99 Refused

CATI NOTE: If more than one response to Q8.4; continue. Otherwise, go to Q8.6.

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

INTERVIEWER NOTE: IF RESPONDENT HAS SELECTED MULTIPLE RACES IN PREVIOUS AND REFUSES TO SELECT A SINGLE RACE, CODE “REFUSED.”

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

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

77 Don’t know / Not sure

99 Refused

8.6 Are you…?

Please read:

1 Married

2 Divorced

3 Widowed

4 Separated

5 Never married

6 A member of an unmarried couple

Do not read:

9 Refused

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

Read only if necessary:

1 Never attended school or only attended kindergarten

2 Grades 1 through 8 (Elementary)

3 Grades 9 through 11 (Some high school)

4 Grade 12 or GED (High school graduate)

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

6 College 4 years or more (College graduate)

Shape2

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

Do not read:

9 Refused

8.8 Do you own or rent your home?

1 Own

2 Rent

3 Other arrangement

7 Don’t know / Not sure

9 Refused

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

NOTE: Home is defined as the place where you live most of the time/the majority of the year.

INTERVIEWER NOTE: We ask this question in order to compare health indicators among people with different housing situations.

8.9 In what county do you currently live?

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

7 7 7 Don’t know / Not sure

9 9 9 Refused

8.10 What is the ZIP Code where you currently live?

_ _ _ _ _ ZIP Code

7 7 7 7 7 Don’t know / Not sure

9 9 9 9 9 Refused

CATI NOTE: If cellular telephone interview skip to 8.14 (QSTVER GE 20)

8.11 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?

1 Yes

2 No [Go to Q8.13]

7 Don’t know / Not sure [Go to Q8.13]

9 Refused [Go to Q8.13]

8.12 How many of these telephone numbers are residential numbers?

_ Residential telephone numbers [6 = 6 or more]

7 Don’t know / Not sure

9 Refused

8.13 How many cell phones do you have for personal use?

INTERVIEWER NOTE: INCLUDE CELL PHONES USED FOR BOTH BUSINESS AND PERSONAL USE.

__ Enter number (1-5)

6 Six or more

7 Don’t know / Not sure

8 None

9 Refused

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

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

1 Yes

2 No

Do not read:

7 Don’t know / Not sure

9 Refused

8.15 Are you currently…?

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

Please read:

1 Employed for wages

2 Self-employed

3 Out of work for 1 year or more

4 Out of work for less than 1 year

5 A Homemaker

6 A Student

7 Retired

8 Unable to work

Do not read:

9 Refused

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

_ _ Number of children

8 8 None

9 9 Refused

8.17 Is your annual household income from all sources—

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

Read only if necessary:

0 4 Less than $25,000 If no, ask 05; if yes, ask 03

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

0 3 Less than $20,000 If no, code 04; if yes, ask 02

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

0 2 Less than $15,000 If no, code 03; if yes, ask 01

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

0 1 Less than $10,000 If no, code 02

0 5 Less than $35,000 If no, ask 06

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

0 6 Less than $50,000 If no, ask 07

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

0 7 Less than $75,000 If no, code 08

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

0 8 $75,000 or more

Do not read:

7 7 Don’t know / Not sure

9 9 Refused

8.18 About how much do you weigh without shoes?

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

Round fractions up

_ _ _ _ Weight

(pounds/kilograms)

7 7 7 7 Don’t know / Not sure

9 9 9 9 Refused

8.19 About how tall are you without shoes?

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

Round fractions down

_ _ / _ _ Height

(f t / inches/meters/centimeters)

77/ 77 Don’t know / Not sure

99/ 99 Refused

If male, go to 8.21, if female respondent is 45 years old or older, go to Q8.21

8.20 To your knowledge, are you now pregnant?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Some people who are deaf or have serious difficulty hearing use assistive devices to communicate by phone.

8.21 Are you deaf or do you have serious difficulty hearing?

1 Yes

2 No

7 Don’t know / Not Sure

9 Refused

8.22 Are you blind or do you have serious difficulty seeing, even when wearing glasses?

1 Yes

2 No

7 Don’t know / Not Sure

9 Refused

8.23 Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

8.24 Do you have serious difficulty walking or climbing stairs?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

8.25 Do you have difficulty dressing or bathing?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

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

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Section 9: Tobacco Use

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

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

NOTE: 5 packs = 100 cigarettes

1 Yes

2 No [Go to Q9.5]

7 Don’t know / Not sure [Go to Q9.5]

9 Refused [Go to Q9.5]

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

DO NOT READ

1 Every day

2 Some days

3 Not at all [Go to Q9.4]

7 Don’t know / Not sure [Go to Q9.5]

9 Refused [Go to Q9.5]

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

1 Yes [Go to Q9.5]

2 No [Go to Q9.5]

7 Don’t know / Not sure [Go to Q9.5]

9 Refused [Go to Q9.5]

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

READ IF NECESSARY:

0 1 Within the past month (less than 1 month ago)

0 2 Within the past 3 months (1 month but less than 3 months ago)

0 3 Within the past 6 months (3 months but less than 6 months ago)

0 4 Within the past year (6 months but less than 1 year ago)

0 5 Within the past 5 years (1 year but less than 5 years ago)

0 6 Within the past 10 years (5 years but less than 10 years ago)

0 7 10 years or more

0 8 Never smoked regularly

7 7 Don’t know / Not sure

9 9 Refused

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

Snus (rhymes with ‘goose’)

INTERVIEWER NOTE: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.

DO NOT READ

1 Every day

2 Some days

3 Not at all

Do not read:

7 Don’t know / Not sure

9 Refused

Section 10: Alcohol Consumption

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

1 _ _ Days per week

2 _ _ Days in past 30 days

888 No drinks in past 30 days [Go to next section]

777 Don’t know / Not sure [Go to next section]

999 Refused [Go to next section]

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

INTERVIEWER NOTE: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.

_ _ Number of drinks

77 Don’t know / Not sure

99 Refused

10.3 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?

_ _ Number of times

88 None

77 Don’t know / Not sure

99 Refused

10.4 During the past 30 days, what is the largest number of drinks you had on any occasion?

_ _ Number of drinks

77 Don’t know / Not sure

99 Refused

Section 11: Immunization

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

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.

1 Yes

2 No [Go to Q11.4]

7 Don’t know / Not sure [Go to Q11.4]

9 Refused [Go to Q11.4]

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

_ _ / _ _ _ _ Month / Year

77 / 7777 Don’t know / Not sure

99 / 9999 Refused

11.3 At what kind of place did you get your last flu shot or vaccine?

Read only 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 (Probe: How would you describe the place where you went to get your most recent flu vaccine?)

99 Refused

11.4 Have you ever had a pneumonia shot also known as a pneumococcal vaccine?

INTERVIEWER NOTE: IF RESPONDENT IS CONFUSED READ: THERE ARE TWO TYPES OF PNEUMONIA SHOTS: POLYSACCHARIDE, ALSO KNOWN AS PNEUMOVAX, AND CONJUGATE, ALSO KNOWN AS PREVNAR.

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Section 12: Falls

If respondent is 45 years or older continue, otherwise go to next section.

12.1 In the past 12 months, how many times have you fallen?

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

8 8 None [Go to next section]

7 7 Don’t know / Not sure [Go to next section]

9 9 Refused [Go to next section]

INTERVIEWER NOTE: By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.

12.2 [Fill in Did this fall (from Q12.1) cause an injury?]. If only one fall from Q12.1 and response is Yes (caused an injury); code 01. If response is No, code 88.

How many of these falls caused an injury that limited your regular activities for at least a day?

INTERVIEWER NOTE: 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.

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

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

Section 13: Seat Belt Use and Drinking and Driving

13.1 How often do you use seat belts when you drive or ride in a car? Would you say—

Please read:

1 Always

2 Nearly always

3 Sometimes

4 Seldom

5 Never

Do not read:

7 Don’t know / Not sure

8 Never drive or ride in a car

9 Refused

CATI note: If Q13.1 = 8 (Never drive or ride in a car), go to next section; otherwise continue.

CATI note: If Q10.1 = 888 (No drinks in the past 30 days); go to next section.

13.2 During the past 30 days, how many times have you driven when you’ve had perhaps too much to drink?

_ _ Number of times

88 None

77 Don’t know / Not sure

99 Refused

Section 14: Breast and Cervical Cancer Screening

CATI NOTE: If male go to the next section.

The next questions are about breast and cervical cancer.

14.1 Have you ever had a mammogram?

INTERVIEWER NOTE: A mammogram is an x-ray of each breast to look for breast cancer.

1 Yes

2 No [Go to Q14.3]

Don’t know / Not sure [Go to Q14.3]

9 Refused [Go to Q14.3]

14.2 How long has it been since you had your last mammogram?

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

Don’t know / Not sure

9 Refused

14.3 Have you ever had a Pap test?

INTERVIEWER NOTE: A Pap test is a test for cancer of the cervix.

1 Yes

2 No [Go to Q14.5]

Don’t know / Not sure [Go to Q14.5]

9 Refused [Go to Q14.5]

14.4 How long has it been since you had your last Pap test?

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

14.5 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?

INTERVIEWER NOTE: HUMAN PAPILLOMAVIRUS (PAP-UH-LOH-MUH VIRUS)

1 Yes

2 No [Go to Q14.7]

Don’t know/Not sure [Go to Q14.7]

9 Refused [Go to Q14.7]

14.6 How long has it been since you had your last H.P.V. test?

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

CATI NOTE: If response to Core Q8.20 = 1 (is pregnant); then go to next section.

14.7 Have you had a hysterectomy?

INTERVIEWER NOTE: A HYSTERECTOMY IS AN OPERATION TO REMOVE THE UTERUS (WOMB).

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Section 15: Prostate Cancer Screening

CATI note: If respondent is <39 years of age, or is female, go to next section.

15.1 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?

INTERVIEWER NOTE: A PROSTATE-SPECIFIC ANTIGEN TEST, ALSO CALLED A P.S.A. TEST, IS A BLOOD TEST USED TO CHECK MEN FOR PROSTATE CANCER.

1 Yes

2 No

7 Don’t Know / Not sure

9 Refused

15.2 Has a doctor, nurse, or other health professional ever talked with you about the disadvantages of the P.S.A. test?

1 Yes

2 No

7 Don’t Know / Not sure

9 Refused

15.3 Has a doctor, nurse, or other health professional ever recommended that you have a P.S.A. test?

7 Don’t Know / Not sure

9 Refused

15.4. Have you ever had a P.S.A. test?

Yes
No [Go to next section]

7 Don’t Know / Not sure [Go to next section]

9 Refused [Go to next section]

15.5. How long has it been since you had your last P.S.A. test?

Read only if necessary:

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

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

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

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

5 5 or more years ago

Do not read:

7 Don’t know / Not sure

9 Refused

15.6. What was the main reason you had this P.S.A. test – was it …?

Please 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

Section 16: Colorectal Cancer Screening

CATI note: If respondent is < 49 years of age, go to next section.

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

1 Yes

2 No [Go to Q16.3]

7 Don't know / Not sure [Go to Q16.3]

9 Refused [Go to Q16.3]

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

Read only if necessary:

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

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

3 Within the past 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

16.3 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?

1 Yes

2 No [Go to next section]

7 Don’t know / Not sure [Go to next section]

9 Refused [Go to next section]

16.4 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?

Sigmoidoscopy
Colonoscopy

7 Don’t know / Not sure

9 Refused

16.5 How long has it been since you had your last sigmoidoscopy or colonoscopy?

Read only if necessary:

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

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

3 Within the past 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

Section 17: HIV/AIDS

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

17.1 Not counting tests you may have had as part of blood donation, have you ever been tested for HIV?

1 Yes

2 No [Go to Q17.3]

7 Don’t know / Not sure [Go to Q17.3]

9 Refused [Go to Q17.3]

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

NOTE: If response is before January 1985, code Don’t know.

CATI INSTRUCTION: 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.

_ _ /_ _ _ _ Code month and year

77/ 7777 Don’t know / Not sure

99/ 9999 Refused / Not sure

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

You have used intravenous drugs in the past year.

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

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

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

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

Do any of these situations apply to you?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Closing statement

CATI NOTE: READ IF NO OPTIONAL MODULES FOLLOW, OTHERWISE CONTINUE TO OPTIONAL MODULES.

Please read:

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

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	CDC
File Modified	0000-00-00
File Created	2021-01-21