Att 3c_Questionnaire & Data Collections FOrms 2015-16

Att_3c _Questionnaire 15-16 101816.docx

National Health and Nutrition Examination Survey

Att 3c_Questionnaire & Data Collections FOrms 2015-16

OMB: 0920-0950

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Attachment 3c

Questionnaires and

MEC Data Collection Forms 2015-16

Form Approved OMB No. 0920-0950 Exp. 12/31/2017

Assurance of Confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347). By law, every employee as well as every agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

NOTICE-Public reporting burden of this collection of information is estimated to average 2.5 hours 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, MS D-74, Atlanta, GA 30333. ATTN: PRA (0920-0950).

NATIONAL HEALTH AND NUTRITION EXAMINATION (NHANES)

QUESTIONNAIRE

Questionnaire TABLE OF CONTENTS

QUESTIONNAIRE TABLE OF CONTENTS 2

1 SCREENER QUESTIONNAIRE 4

1.1 SCREENER (SCQ) 4

2 FAMILY RELATIONSHIP QUESTIONNAIRE 26

2.1 FAMILY RELATIONSHIP (SFQ) 26

3 SAMPLE PERSON QUESTIONNAIRE 38

3.1 RESPONDENT SELECTION SECTION - RIQ - SP QUESTIONNAIRE 38

3.2 EARLY CHILDHOOD (ECQ) 46

3.3 HOSPITAL UTILIZATION AND ACCESS TO CARE (HUQ) 50

3.4 IMUNIZATION (IMQ) 55

3.5 PHYSICAL FUNCTIONING (PFQ) 57

3.6 MEDICAL CONDITIONS SECTION (MCQ) 67

3.7 HEPATITIS (HEQ) 87

3.8 KIDNEY CONDITIONS (KIQ) 88

3.9 DISABILITY (DLQ) 89

3.10 DIABETES (DIQ) 94

3.11 BLOOD PRESSURE SECTION (BPQ) 105

3.12 CARDIOVASCULAR DISEASE (CDQ) 108

3.13 OSTEOPOROSIS (OSQ) 110

3.14 DERMATOLOGY (DEQ) 117

3.15 AUDIOMETRY (AUQ) 119

3.16 ORAL HEALTH (OHQ) 130

3.17 PHYSICAL ACTIVITY AND PHYSICAL FITNESS (PAQ) 140

3.18 SLEEP DISORDERS (SLQ) 152

3.19 DIET BEHAVIOR & NUTRITION (DBQ) 154

3.20 WEIGHT (WHQ) 174

3.21 SMOKING (SMQ) 184

3.22 CODED OCCUPATIONS (OCQ) 197

3.23 ACCULTURATION (ACQ) 217

3.24 DEMOGRAPHICS (DMQ) 221

3.25 HEALTH INSURANCE (HIQ) 242

3.26 DIETARY SUPPLEMENTS AND ANTACIDS SECTION (DSQ) 248

3.27 MAILING ADDRESS -MAQ 282

4 FAMILY QUESTIONNAIRE 287

4.1 RESPONDENT SELECTION SECTION (RIQ) 287

4.2 DEMOGRAPHIC BACKGROUND/OCCUPATION (DMQ) 292

4.3 OCCUPATION (OCQ) 298

4.4 HOUSING CHARACTERISTICS (HOQ) 299

4.5 SMOKING (SMQ) 300

4.6 CONSUMER BEHAVIOR (CBQ) 301

4.7 INCOME (INQ) 305

4.8 FOOD SECURITY (FSQ) 327

4.9 TRACKING AND TRACING (TTQ) 32748

5 MEC QUESTIONNAIRE – CAPI 354

5.1 RESPONDENT SELECTION SECTION (RIQ) 354

5.2 VOLATILE TOXICANT (VTQ) 355

5.3 PESTICIDE USE (PUQ) 360

5.4 CURRENT HEALTH STATUS (HSQ) 360

5.5 DEPRESSION SCREEN (DPQ) 362

5.6 TOBACCO (SMQ) 366

5.7 ALCOHOL USE (ALQ) 372

5.8 REPRODUCTIVE HEALTH (RHQ) 37575

5.9 KIDNEY CONDITIONS (KIQ) 37597

5.10 PHYSICAL ACTIVITY AND PHYSICAL FITNESS (PAQ) 399

5.11 WEIGHT HISTORY (WHQ) 413

5.12 MEC INTERVIEW CRITICAL ITEMS 415

6 MEC QUESTIONNAIRE – ACASI 417

6.1 TOBACCO (SMQ) 417

6.2 ALCOHOL USE (ALQ) 430

6.3 DRUG USE (DUQ) 431

6.4 SEXUAL BEHAVIOR (SXQ) 444

6.5 PUBERTAL MATURATION (PMQ) 474

SCREENER QUESTIONNAIRE
1. Screener (SCQ)

SCREENER MODULE #1 (SCQ)

SCQ_INTR Hello, I’m {INTERVIEWER’S NAME} and we are conducting a survey for the Centers for Disease Control and Prevention (CDC).

SHOW ID CARD.

A letter was sent to you recently explaining a survey which is called the National Health and Nutrition Examination Survey and is about your family’s health.

IF RESIDENT DOES NOT REMEMBER LETTER, HAND NEW COPY.

All the information that you give us is voluntary and will be kept in the strictest confidence. Your name will not be attached to any of your answers without your specific permission.

HELP SCREEN:

Information will be collected under authority of Section 306 of the Public Health Service Act (42 USC 242k) with a guarantee of strict confidence. Federal law (Section 308(d) of the Public Health Service Act (42 USC 242m), the Privacy Act of 1974 (5 USC 552a) and the Confidential Information Protection Act http://aspe.hhs.gov/datacncl/privacy/titleV.pdf,) forbids us to release any information that identifies you or your family to anyone, for any purpose, without your consent. These laws carry stiff fines (up to $250,000) and a jail term if we violate your privacy. Public reporting burden for this collection of information is estimated to average 6.7 hours 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0237).

SCQ.027 INTERVIEWER: IS THIS A DORMITORY ROOM?

YES 1

NO 2

DK 9

RF 7

SCQ.070a I would like to verify your address. Please give me your complete address.

{#} {DIRECTION} {STREET NAME} {STREET/ROAD/AVENUE} {DIRECTION} {#}

{PO BOX} {RURAL ROUTE #} {RURAL ROUTE BOX} {CITY} {STATE} { ZIP}

NO (WRONG ADDRESS) 1 (SCQ_END5)

YES (CORRECTIONS) 2 (SCQ.070b)

YES 3 (SCQ.090)

SCQ.070b I would like to verify your address. Please give me your complete address.

{ADDITIONAL ADDRESS LINE}

{#} {DIRECTION} {STREET NAME} {STREET/ROAD/AVENUE} {DIRECTION}

{UNIT/APT/BLDG} {UNIT #} {PO BOX} {RURAL ROUTE #} {RURAL ROUTE BOX}

{CITY} {STATE} { ZIP}-{ZIP-4}

CAPI INSTRUCTIONS: DISPLAY THE ADDRESS COLUMNS LISTED ABOVE AND ALLOW THE INTERVIEWER TO MAKE CORRECTIONS AS NEEDED. ONCE THE INTERVIEWER IS DONE, SHE WILL PRESS THE NEXT KEY TO CONTINUE.

THE FIELD FOR STATE MAY NOT BE UPDATED.

IF SCQ.070A = 2 AND NONE OF THE ADDRESS FIELDS ARE MODIFIED, AUTO-BACKCODE THE RESPONSE TO SCQ.070A = 3 (YES) AND GO TO SCQ.090.

SCQ.090 To begin, how many people live in this household? Please do not include anyone who usually lives somewhere else.

________

NUMBER

DK 99

RF 77

SCQ.130 What are the names of all of the persons living here? Start with the name of the person, or one of the persons, who owns or rents this home. (Please remember not to include anyone who usually lives somewhere else.)

PROBE: Any others?

______ _______
FIRST MIDDLE LAST SUFFIX GENDER

DK 9

RF 7

CAPI INSTRUCTIONS: WHEN THE FOCUS IS ON THE “GENDER” FIELD, DISPLAY:

ASK IF NOT OBVIOUS:

Is {NAME} male or female?

MALE 1

FEMALE 2

DK 9

RF 7

CAPI INSTRUCTIONS:

HARD EDIT: IF FOCUS IS SHIFTED FROM THE “GENDER” FIELD AND NO ENTRY HAS BEEN MADE FOR GENDER, DISPLAY THE FOLLOWING HARD EDIT:

“REQUIRED VALUE MISSING FOR GENDER IN ROW {ROW IN WHICH GENDER IS MISSING}. PLEASE ENTER A VALUE.”

SOFT EDIT: THE FIRST TIME DK OR RF IS ENTERED FOR GENDER, DISPLAY THE FOLLOWING:

“A MISSING VALUE HERE MAY RESULT IN INCONCLUSIVE SAMPLING. PLEASE RE-ENTER THE VALUE TO CONFIRM.”

ACCEPT THE SECOND ENTRY.

ENSURE THAT EACH NAME (COMBINATION OF FIRST, MIDDLE, LAST, SUFFIX) IS UNIQUE WITHIN THE HOUSEHOLD. IF A DUPLICATE NAME IS ENTERED, DISPLAY THE FOLLOWING HARD EDIT, “NAMES MUST BE UNIQUE. PERSONS # AND # HAVE IDENTICAL NAMES RECORDED. CORRECT THE ERROR TO CONTINUE.”

SCQ.145 I have {TOTAL # OF PERSONS ENUMERATED} {person/people} living here --

[READ NAMES LISTED BELOW.]

______ _______
FIRST MIDDLE LAST SUFFIX GENDER

SCQ.150

Have I missed . . .

SCQ.150 . . . any babies or small children?

SCQ.160 . . . any lodgers, boarders, or persons in your employ who live here?

SCQ.170 . . . anyone who usually lives here but is now away from home?

SCQ.180 . . . anyone else living or staying here?

YES 1 (SCQ.150N, 160N, 170N, 180N)

NO 2 (SCQ.190)

DK 9 (SCQ.190)

RF 7 (SCQ.190)

CAPI INSTRUCTIONS: THE SWEEP QUESTIONS (SCQ.150, 160, 170 AND 180) SHOULD BE DISPLAYED ON A SINGLE SCREEN. A "YES" RESPONSE TO A SWEEP QUESTION BRINGS UP THE HOUSEHOLD COMPOSITION MATRIX. BY CLICKING ON THE “INSERT ROW” BUTTON ON THIS SCREEN, A NEW ROW APPEARS FOR ENTRY OF NAME AND GENDER.

UPON EXITING THE NAME/GENDER SCREEN, THE CURSOR SHOULD RETURN TO THE SCREEN OF SWEEP QUESTIONS WITH THE CURSOR RESIDING ON THE NEXT LINE (QUESTION) THAT REQUIRES AN ANSWER.

IF ALL THE QUESTIONS HAVE BEEN ANSWERED, GO TO SCQ.190.

SCQ.150N [Have I missed any babies or small children?] (What are their names?)

PROBE: Is (he/she) a “Junior”, “Senior”, “the 3rd” or something like that? (What is that?)

PROBE: Any others?

______ _______
FIRST MIDDLE LAST SUFFIX GENDER

DK 9

RF 7

CAPI INSTRUCTIONS: IF THE FOCUS IS ON THE GENDER FIELD, DISPLAY:

ASK IF NOT OBVIOUS:

Is {NAME} male or female?

MALE 1

FEMALE 2

DK 9

RF 7

SCQ.160N [Have I missed any lodgers, boarders, or persons in your employ who live here?] (What are their names?)

PROBE: Any others?

______ _______
FIRST MIDDLE LAST SUFFIX GENDER

DK 9

RF 7

CAPI INSTRUCTIONS: IF THE FOCUS IS ON THE GENDER FIELD, DISPLAY:

ASK IF NOT OBVIOUS:

Is {NAME} male or female?

MALE 1

FEMALE 2

DK 9

RF 7

SCQ.170N [Have I missed anyone who usually lives here but is now away from home?] (What are their names?)

PROBE: Any others?

______ _______
FIRST MIDDLE LAST SUFFIX GENDER

DK 9

RF 7

CAPI INSTRUCTIONS: IF THE FOCUS IS ON THE GENDER FIELD, DISPLAY:

ASK IF NOT OBVIOUS:

Is {NAME} male or female?

MALE 1

FEMALE 2

DK 9

RF 7

SCQ.180N [Have I missed anyone else living or staying here?] (What are their names?)

PROBE: Any others?

______ _______
FIRST MIDDLE LAST SUFFIX GENDER

DK 9

RF 7

CAPI INSTRUCTIONS: IF THE FOCUS IS ON THE GENDER FIELD, DISPLAY:

ASK IF NOT OBVIOUS:

Is {NAME} male or female?

MALE 1

FEMALE 2

DK 9

RF 7

SCQ.190 [VERIFY HOUSEHOLD MEMBERS BY READING NAMES LISTED BELOW.]

______ _______
FIRST MIDDLE LAST SUFFIX GENDER

CAPI INSTRUCTIONS: THE APPLICATION SHOULD ALLOW THE INTERVIEWER TO ADD OR DELETE NAMES OR ROWS FROM THE HH COMPOSITION MATRIX, AS NECESSARY, BASED ON RESPONDENT’S CONFIRMATION OF THE PERSONS WHO HAVE BEEN ENUMERATED.

BOX 1

CHECK ITEM SCQ.191:

APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR GENDER GO TO SCQ.430; ELSE

GO TO BOX 2.

BOX 2

CHECK ITEM SCQ.193:

IF SCQ.027 = YES (1), CODE SCQ.195 AS “YES” (1) AND GO TO SCQ.220; ELSE

CONTINUE.

SCQ.195 Do {you/any of the persons in this household} have a home anywhere else?

STUDENTS LIVING AWAY AT SCHOOL ARE CONSIDERED TO HAVE A HOME SOMEWHERE ELSE.

YES 1 (SCQ.200)

NO 2 (SCQ.220)

SCQ.200 (Who is that?)

SELECT MEMBERS WITH HOME ELSEWHERE.

Name Other Home

CAPI INSTRUCTIONS: DISPLAY FIRST AND LAST NAMES OF ALL PERSONS LISTED ON THE HOUSEHOLD COMPOSITION MATRIX.

PROBE: Anyone else?

CAPI INSTRUCTIONS: THE DEFAULT FILL FOR THE “OTHER HOME” COLUMN IS “NO”. HOWEVER, THE DEFAULT CAN BE TOGGLED TO “YES” BY MOVING THE CURSOR TO THE “OTHER HOME” CELL ASSOCIATED WITH THE PERSON WHO HAS A SECOND RESIDENCE, AND SELECTING “YES”.

IF NONE OF THE “OTHER HOME” CELLS HAVE BEEN SET TO “YES”, DISPLAY THE FOLLOWING BOX:

“. You did NOT select any HH member living in another place.

Button 1: Go back and select a person
Button 2: No one living elsewhere

”

IF BUTTON #1 IS SELECTED, RETURN TO SCQ.200. IF BUTTON #2 IS SELECTED, AUTO-BACKCODE THE RESPONSE TO SCQ.195 TO “NO” AND PROCEED TO SCQ.220.

SCQ.210 Where {do you/does {NAME}} usually live and sleep; here or somewhere else?

Name Live Here

CAPI INSTRUCTIONS: DISPLAY “NAME” AND “LIVE HERE” COLUMNS. THE ANSWER CATEGORIES FOR THE LIVE HERE COLUMN ARE “HERE” (1), “SOMEWHERE ELSE” (2), “DK” (9), AND “RF” (7)

HERE 1

SOMEWHERE ELSE 2

DK 9

RF 7

CAPI INSTRUCTIONS: IF “1”, “9”, OR “7” IS SELECTED, LEAVE THE PERSON ON THE HH COMPOSITION MATRIX; ELSE

IF “2” IS SELECTED AND THIS IS A SINGLE PERSON HOUSEHOLD, OR IF “2” HAS BEEN SELECTED FOR ALL HOUSEHOLD MEMBERS, THE HOUSEHOLD IS “INELIGIBLE” AND THE SCREENER IS TERMINATED AFTER THE COLLECTION OF THE TELEPHONE NUMBER (SCQ.430); ELSE

IF “2” IS SELECTED FOR AT LEAST ONE PERSON AND THE HOUSEHOLD IS MORE THAN A SINGLE PERSON HOUSEHOLD AND “2” HAS NOT BEEN SELECTED FOR ALL MEMBERS OF THE HH, SET A FLAG TO INDICATE THIS PERSON’S PERMANENT RESIDENCE WAS SOMEWHERE ELSE.

THE FLAG IS AN INDICATION THAT ON ALL FUTURE DISPLAYS OF THE HH COMPOSITION MATRIX, THIS PERSON (AND ALL PERSON-LEVEL DATA) WILL NOT BE DISPLAYED.

IF THE REFERENCE PERSON IS NOT ELIGIBLE TO BE THE REFERENCE PERSON BASED ON WHERE S/HE USUALLY LIVES, IDENTIFICATION OF A NEW REFERENCE PERSON IS REQUIRED. RE-APPLY THE REFERENCE PERSON EDIT LOGIC TO IDENTIFY THE REFERENCE PERSON AS THE FIRST PERSON ON THE ENUMEARATION TABLE WHO IS > 18 YEARS OLD; ELSE

IF NO ONE ON THE ENUMBERATION TABLE IS AGE 18 OR OLDER, IDENTIFY THE REFERENCE PERSON AS THE OLDEST PERSON IN THE HOUSEHOLD FOR WHOM THIS IS THE PRIMARY RESIDENCE.

SCQ.220 Are {you/any of the persons in this household} now on full-time active duty with the Armed Forces of the United States?

YES 1 (SCQ.230)

NO 2 (SCQ.245)

DK 9 (SCQ.245)

RF 7 (SCQ.245)

CAPI INSTRUCTIONS: IF CODED “1” AND THIS IS A SINGLE PERSON HOUSEHOLD, OR IF ALL HOUSEHOLD MEMBERS ARE "1", THE HOUSEHOLD IS “INELIGIBLE” AND THE SCREENER IS TERMINATED AFTER THE COLLECTION OF THE TELEPHONE NUMBER (SCQ.430); ELSE

IF THE HOUSEHOLD IS MORE THAN A SINGLE PERSON HOUSEHOLD, THE SKIPS SHOULD BE FOLLOWED AS SPECIFIED ABOVE.

SCQ.230 Who is that?

Name Military

SELECT ACTIVE MILITARY MEMBERS.

CAPI INSTRUCTIONS: DISPLAY FIRST, MIDDLE AND LAST NAMES OF ALL PERSONS LISTED ON THE HOUSEHOLD COMPOSITION MATRIX.

PROBE: Anyone else?

CAPI INSTRUCTIONS: THE CURSOR SHOULD RESIDE IN THE COLUMN “Military”. THE DEFAULT FILL FOR THIS COLUMN SHOULD BE “NO”. HOWEVER, WHEN ON THIS QUESTION, THE DEFAULT CAN BE TOGGLED TO “YES” BY MOVING THE CURSOR TO THE “Military” CELL ASSOCIATED WITH THE PERSON IDENTIFIED AND SELECTING “YES”. WHEN LEAVING THIS SCREEN, IF NONE OF THE “Military” CELLS HAVE BEEN SET TO “YES”, DISPLAY THE FOLLOWING BOX:

You did NOT select any HH member on active duty.

Button 1: Go back and select a person
Button 2: No one on active duty

”

IF BUTTON #1 IS SELECTED, RETURN TO SCQ.230. IF BUTTON #2 IS SELECTED, AUTO-BACKCODE THE RESPONSE TO SCQ.220 TO “NO” AND PROCEED TO SCQ.250.

CONTINUE.

SCQ.240 Where {do you/does {NAME}} usually live and sleep; here or some where else?

HERE 1

SOMEWHERE ELSE 2

DK 9

RF 7

CAPI INSTRUCTIONS: IF “1”, “9”, OR “7” IS ENTERED, LEAVE PERSON ON HH COMPOSITION MATRIX; DO NOT FLAG FOR SAMPLING.

IF “2” IS ENTERED, SET A FLAG TO INDICATE PERSON’S PERMANENT RESIDENCE WAS SOMEWHERE ELSE. THE FLAG IS AN INDICATION THAT ON ALL FUTURE DISPLAYS OF THE HH COMPOSITION MATRIX, THIS PERSON (AND ALL PERSON-LEVEL DATA) WILL NOT BE DISPLAYED.

IN THE EVENT THAT THE PERSON BEING FLAGGED AS LIVING “SOMEWHERE ELSE” IS THE REFERENCE PERSON, IDENTIFICATION OF A NEW REFERENCE PERSON IS REQUIRED. RE-APPLY THE REFERENCE PERSON EDIT LOGIC TO IDENTIFY THE REFERENCE PERSON AS THE FIRST PERSON ON THE ENUMEARATION TABLE WHO IS > 18 YEARS OLD; ELSE

IF NO ONE ON THE ENUMERATION TABLE IS AGE 18 OR OLDER, IDENTIFY THE REFERENCE PERSON AS THE OLDEST PERSON IN THE HOUSEHOLD FOR WHOM THIS IS THE PRIMARY RESIDENCE.

SCQ.245 Has anyone who lives here ever served on active duty in the U.S. Armed Forces, Military Reserves, or National Guard? {Do not include anyone you just told me about who is currently on active duty.}

YES 1 (SCQ.247)

NO 2 (SCQ.250)

DK 9 (SCQ.250)

RF 7 (SCQ.250)

HELP SCREEN:

Active duty does not include training for the Reserves or National Guard, but does include activation, for example, for service in the U.S. or in a foreign country in support of military or humanitarian operations.

CAPI INSTRUCTION: DISPLAY 3 ONLY IF SCQ.220 = 1.

SCQ.247 Who is that?

NAME EVER SERVED IN MILITARY

CAPI INSTRUCTIONS: DISPLAY FIRST, MIDDLE AND LAST NAMES OF ALL PERSONS LISTED ON THE HOUSEHOLD COMPOSITION MATRIX.

PROBE: Anyone else?

CAPI INSTRUCTIONS: THE CURSOR SHOULD RESIDE IN THE COLUMN “EVER SERVED IN MILITARY”. THE DEFAULT FILL FOR THIS COLUMN SHOULD BE “NO”. HOWEVER, WHEN ON THIS QUESTION, THE DEFAULT CAN BE TOGGLED TO “YES” BY MOVING THE CURSOR TO THE “EVER SERVED IN MILITARY” CELL ASSOCIATED WITH THE PERSON IDENTIFIED AND SELECTING “YES”. WHEN LEAVING THIS SCREEN, IF NONE OF THE “EVER SERVED IN MILITARY” CELLS HAVE BEEN SET TO “YES”,

DISPLAY THE FOLLOWING BOX:

You did NOT select any HH member in military.

Button 1: Go back and select a person
Button 2: No one in military

”

IF BUTTON #1 IS SELECTED, RETURN TO SCQ.247. IF BUTTON #2 IS SELECTED, AUTO-BACKCODE THE RESPONSE TO SCQ.245 TO “NO” AND PROCEED TO SCQ.250.

SCQ.250 THESE ARE THE MEMBERS OF THE DU WHO HAVE BEEN LISTED AS HH MEMBERS.

{NAME GENDER}

BOX 3

CHECK ITEM SCQ.255:

APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR PLACE OF RESIDENCE, GO TO SCQ.430; ELSE

CONTINUE.

BOX 3A

CHECK ITEM SCQ.256:

ASK SCQ.260 FOR EACH PERSON ON HH ROSTER.

SCQ.260 [Do you/Does NAME] consider [yourself/himself/herself] to be Hispanic, Latino, or of Spanish origin?

READ IF NECESSARY: Where do {your/his/her} ancestors come from?

Puerto Rican

Cuban/Cuban American

Dominican (Republic)

Mexican/Mexican American

Central/South American

Other Latin American

Other Hispanic or Latino

YES 1

NO 2

DK 9

RF 7

HELP SCREEN:

SPANISH, HISPANIC OR LATINO PEOPLE MAY BE OF ANY RACE. LISTED BELOW ARE HISPANIC OR LATINO CATEGORIES/COUNTRIES.

MEXICAN

PUERTO RICAN

CUBAN

DOMINICAN REPUBLIC

CENTRAL AMERICAN:

COSTA RICAN

GUATEMALAN

HONDURAN

NICARAGUAN

PANAMANIAN

SALVADORAN

OTHER CENTRAL AMERICAN

SOUTH AMERICAN:

ARGENTINEAN

BOLIVIAN

CHILEAN

COLOMBIAN

ECUADORIAN

PARAGUAYAN

PERUVIAN

URUGUAYAN

VENEZUELAN

OTHER SOUTH AMERICAN

OTHER HISPANIC OR LATINO:

SPANIARD

SPANISH

SPANISH AMERICAN

CAPI INSTRUCTIONS: DISPLAY THE FOLLOWING SOFT EDIT THE FIRST TIME A DK OR RF IS ENTERED:

“A missing value here may result in inconclusive sampling. Please re-enter the value to confirm.”

ACCEPT THE SECOND ENTRY.

SCQ.262 WARNING: REVIEW HISPANIC STATUS FOR EACH PERSON! SAMPLING ALGORITHM WILL BE APPLIED.

{NAME ETHNICITY}

CAPI INSTRUCTIONS: DISPLAY NAME AND ETHNICITY FOR EACH ENUMERATED PERSON AS DETERMINED AT SCQ.260. INTERVIEWER MAY BACK-UP TO CORRECT.

BOX 3B

CHECK ITEM SCQ.265:

CYCLE THROUGH SCQ.270 FOR EACH PERSON LISTED ON HH ROSTER.

SCQ.270 HAND CARD #1

What race do you consider {yourself/NAME} to be? Please select one or more.

CHECK ALL THAT APPLY.

AMERICAN INDIAN OR ALASKAN NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR PACIFIC ISLANDER 4

WHITE 5

OTHER 6

DK 9

RF 7

CAPI INSTRUCTIONS: DISPLAY THE FOLLOWING SOFT EDIT THE FIRST TIME A DK OR RF IS ENTERED.

“A missing value here may result in inconclusive sampling. Please re-enter the value to confirm.”

ACCEPT THE SECOND ENTRY.

BOX 3C

CHECK ITEM SCQ.270A:

ASK FOR NEXT PERSON. IF NO NEXT PERSON, CONTINUE WITH BOX 3D.

BOX 3D

CHECK ITEM SCQ.270B:

CYCLE THROUGH BOX 3E THROUGH SCQ.280 FOR EACH PERSON ON HH ROSTER.

BOX 3E

CHECK ITEM SCQ.270C:

CHECK SCQ.260 FOR EACH PERSON. IF PERSON LISTED AS NOT HISPANIC (CODE 2), CONTINUE.

OTHERWISE, SKIP TO BOX 3H.

BOX 3F

CHECK ITEM SCQ.270D:

CHECK SCQ.270 – IF ANY PERSON’S RACE = CODE 6 (OTHER) AND DOES NOT = CODE 2 OR CODE 3 (ASIAN OR BLACK), CONTINUE.

OTHERWISE, SKIP TO BOX 3H.

BOX 3G

CHECK ITEM SCQ.270E:

ASK QUESTION SCQ.280 FOR EACH PERSON ON HH ROSTER WHO MEET THE CRITERIA SPECIFIED IN BOXES 3E AND 3F (CODE 2 IN SCQ.260 AND CODE 6 ALONE OR WITH CODE 1, 4 OR 5 IN SCQ.270.

SCQ.280

Do any of the groups on this card represent {your/NAME’s} national origin or ancestry?

HAND CARD #2

YES 1 (CONTINUE WITH CAPI

INSTRUCTION SCQ.282)

NO 2 (BOX 3H)

SCQ.282

CAPI INSTRUCTION: ADD CODE #2 (ASIAN) AS RACE IN SCQ.270.

BOX 3H

CHECK ITEM SCQ.282A:

CYCLE THROUGH BOX 3D – SCQ.280 FOR NEXT PERSON. IF NO NEXT PERSON, CONTINUE.

SCQ.271 WARNING! REVIEW RACE FOR EACH PERSON! SAMPLING ALGORITHM WILL BE APPLIED.

{NAME RACE}

CAPI INSTRUCTIONS: DISPLAY NAME AND RACE(S) FOR EACH ENUMERATED PERSON AS DETERMINED AT SCQ.270, SCQ.280, or SCQ.282. INTERVIEWER MAY BACK-UP TO CORRECT.

BOX 3I

CHECK ITEM SCQ.282B:

IF SCQ.260 = CODE 1 (YES-HISPANIC), APPLY HISPANIC SAMPLING ALGORITHM AND SKIP TO BOX 4. OTHERWISE, CONTINUE WITH BOX 3J.

BOX 3J

CHECK ITEM SCQ.282C:

IF AT LEAST ONE CODE IN SCQ.270 = CODE 3 (BLACK), APPLY BLACK/AFRICAN AMERICAN SAMPLING ALGORITHM AND SKIP TO BOX 4. OTHERWISE, CONTINUE WITH BOX 3K.

BOX 3K

CHECK ITEM SCQ.282D:

IF SCQ.270 = 2 (ASIAN) OR IF SCQ.280 = 1, APPLY ASIAN SAMPLING ALGORITHM AND SKIP TO BOX 4. OTHERWISE, GO TO BOX 3L.

BOX 3L

CHECK ITEM SCQ.282E:

APPLY WHITE/OTHER SAMPLING ALGORITHM.

BOX 4

CHECK ITEM SCQ.285:

IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FOR ETHNICITY OR RACE, GO TO SCQ.430; OTHERWISE, CONTINUE.

SCQ.290 What is {your/{NAME}’s} birthdate?

____ ____ ____

MM DD YYYY (SCQ.291)

DK 9 (SCQ.292)

RF 7 (SCQ.292)

CAPI INSTRUCTIONS: IF DATE OF BIRTH IS SPECIFIED, CALCULATE AGE AND POST IN THE “AGE” CELL FOR THE APPROPRIATE PERSON WITH THE CURSOR RESIDING IN THAT CELL AND SCQ.291 DISPLAYED ABOVE THE HH COMPOSITION MATRIX; ELSE

GO TO SCQ.292.

SCQ.291 So {you are/{NAME} is} {AGE AS CALCULATED FROM DOB}?

IF NECESSARY, RE-ENTER CORRECT AGE.

CAPI INSTRUCTIONS: IF AGE IS RE-ENTERED BY THE INTERVIEWER, THE APPLICATION SHOULD ADJUST DOB YEAR IF VALID VALUES FOR DOB MONTH AND DAY EXIST. IF DOB MONTH, DAY AND YEAR ARE RF OR DK, DO NOT BACK-FILL THE DOB YEAR BASED ON THE ENTERED AGE.

SCQ.292 How old {are you/is {NAME}}?

IF AGE IS LESS THAN 12 MONTHS, ENTER 0.

_____

AGE (SCQ.301)

DK 999 (SCQ.300)

RF 777 (SCQ.300)

SCQ.300 About how old {are you/is {NAME}}?

{AGE RANGES FOR SAMPLED RACE/ETHNICITY = BLACK OR HISPANIC}/{AGE RANGES FOR SAMPLED RACE/ETHNICITY = ASIAN}/{AGE RANGES FOR SAMPLED RACE/ETHNICITY = WHITES/OTHERS}; {AGE RANGES FOR DK/RF RACE/ETHNICITY}

DK 9999

RF 7777

CAPI INSTRUCTIONS: DISPLAY QUESTION TEXT ABOVE THE HH COMPOSITION MATRIX WITH THE CURSOR RESIDING IN THE “AGE RANGE” CELL ON THE MATRIX.

AGE RANGE CATEGORIES
Black non-Hispanic	M&F	0-11 mos.	White/Other	M&F	0-11 mos.
		1-2 yrs.	Low Income		1-2 yrs.
		3-5 yrs.			3-5 yrs.
	M	6-11 yrs.		M	6-11 yrs.
		12-19 yrs.			12-19 yrs.
		20-39 yrs.			20-29 yrs.
		40-49 yrs.			30-39 yrs.
		50-59 yrs.			40-49 yrs.
		60+ yrs.			50-59 yrs.
	F	6-11 yrs.			60-69 yrs.
		12-19 yrs.			70-79 yrs.
		20-39 yrs.			80+ yrs.
		40-49 yrs.		F	6-11 yrs.
		50-59 yrs.			12-19 yrs.
		60+ yrs.			20-29 yrs.
Hispanic	M&F	0-11 mos.			30-39 yrs.
		1-2 yrs.			40-49 yrs.
		3-5 yrs.			50-59 yrs.
	M	6-11 yrs.			60-69 yrs.
		12-19 yrs.			70-79 yrs.
		20-39 yrs.			80+ yrs.
		40-49 yrs.	White/Other	M&F	0-11 mos.
		50-59 yrs.	Not Low Income		1-2 yrs.
		60+ yrs.			3-5 yrs.
	F	6-11 yrs.		M	6-11 yrs.
		12-19 yrs.			12-19 yrs.
		20-39 yrs.			20-29 yrs.
		40-49 yrs.			30-39 yrs.
		50-59 yrs.			40-49 yrs.
		60+ yrs.			50-59 yrs.
Asian non-Black/	M&F	0-11 mos.			60-69 yrs.
non-Hispanic		1-2 yrs.			70-79 yrs.
		3-5 yrs.			80+ yrs.
	M	6-11 yrs.		F	6-11 yrs.
		12-19 yrs.			12-19 yrs.
		20-39 yrs.			20-29 yrs.
		40-49 yrs.			30-39 yrs.
		50-59 yrs.			40-49 yrs.
		60+ yrs.			50-59 yrs.
	F	6-11 yrs.			60-69 yrs.
		12-19 yrs.			70-79 yrs.
		20-39 yrs.			80+ yrs.
		40-49 yrs.
		50-59 yrs.
		60+ yrs.

DISPLAY THE FOLLOWING SOFT EDIT THE FIRST TIME A DK OR RF IS ENTERED. ACCEPT THE SECOND ENTRY.

“A missing value here may result in inconclusive sampling. Please re-enter the value to confirm.”

ACCEPT THE SECOND ENTRY.

SCQ.301 WARNING: REVIEW AGE FOR EACH PERSON! SAMPLING ALGORITHM WILL BE APPLIED.

{NAME AGE RANGE}

CAPI INSTRUCTIONS: DISPLAY NAME AND AGE AS DETERMINED AT SCQ291, SCQ292, OR SCQ300 FOR EACH ENUMERATED PERSON. INTERVIEWER MAY BACK-UP TO CORRECT.

BOX 5

CHECK ITEM SCQ.303:

APPLY THE SAMPLING ALGORITHM. IF NO PERSON IN THE HOUSEHOLD IS “POTENTIALLY ELIGIBLE” FOR THE STUDY BASED ON SAMPLING MESSAGES FO AGE, GO TO SCQ.430; ELSE

CONTINUE.

BOX 6

CHECK ITEM SCQ.315:

IF SAMPLING MESSAGE FOR LOW INCOME IS SET, CONTINUE; ELSE

GO TO BOX 12.

BOX 7

CHECK ITEM SCQ.320:

IF SCQ.027 = YES (1), GO TO BOX 12; ELSE

CONTINUE.

BOX 8

CHECK ITEM SCQ.325:

IF ALL HOUSEHOLD MEMBER'S SAMPLED RACE/ETHNICITY = HISPANIC (1) OR BLACK (2), GO TO BOX 12; ELSE

IF ANY HOUSEHOLD MEMBER'S SAMPLED RACE/ETHNICITY = WHITE/OTHER (3) AND ONE OR MORE PERSON'S IN THE HOUSEHOLD COULD MEET THE LOW INCOME SAMPLING CRITERIA AND THOSE PERSONS ARE NOT ALL ACTIVE MILITARY, CONTINUE; ELSE

GO TO BOX 12.

BOX 9

CHECK ITEM SCQ.330:

IF ALL HOUSEHOLD MEMBER'S WHO WOULD MEET THE LOW INCOME SAMPLING CRITERIA ARE ALREADY SAMPLED BASED ON GENDER, ETHNICITY, RACE, AGE OR ARE ACTIVE MILITARY, GO TO BOX 12; ELSE

CONTINUE.

SCQ.340 Please think for a moment about the various sources from which the members of this household received income during the last 12 months, that is from {CURRENT MONTH} {LAST YEAR IN 4-DIGITS} to {LAST MONTH} {CURRENT YEAR IN 4-DIGITS}. Thinking about all the sources of income, please tell me whether the total income received by the members of this household during the last 12 months was more or less than {DISPLAY EXACT THRESHOLD DOLLAR AMOUNT FOR # OF PEOPLE LIVING IN HOUSEHOLD}.

INCOME THRESHOLDS:

The 2009 Poverty Guidelines for the 48 Contiguous States and the District of Columbia
Persons in family	Poverty guideline
1	$10,890
2	14,710
3	18,530
4	22,350
5	26,170
6	29,990
7	33,810
8	37,630
For families with more than 8 persons, add $3,740 for each additional person.

SOURCE: Federal Register, Vol. 74, No. 14, January 23, 2009, pp. 4199–4201

CAPI INSTRUCTIONS: IF INCOME EQUAL TO {DISPLAY EXACT THRESHOLD DOLLAR AMOUNT FOR # OF PEOPLE LIVING IN HOUSEHOLD}, CODE 'LESS'.

MORE 1 (BOX 12)

LESS 2 (BOX 12)

DK 9

RF 7

BOX 10

CHECK ITEM SCQ.345:

IF ANY CHILDREN IN HOUSEHOLD <6 YEARS OLD, CONTINUE; ELSE

GO TO BOX 12.

BOX 11

CHECK ITEM SCQ.347:

IF ANY MALES IN HOUSEHOLD >18, GO TO BOX 12; ELSE

TREAT HOUSEHOLD AS LOW INCOME FOR PURPOSES OF SAMPLING.

BOX 12

CHECK ITEM SCQ.355:

IF ANY INDIVIDUAL MEETS THE SPECIFIED SAMPLING CRITERIA BASED ON GENDER, ETHNICITY, RACE, AGE; OR INCOME LEVEL AND IS NOT ON ACTIVE MILITARY STATUS, GO TO SCQ.370; ELSE

IF SAMPLING FOR ALL INDIVIDUALS IS INCONCLUSIVE DUE TO CONFIRMED MISSING DATA (DK/RF) IN THE CRITICAL SAMPLING VARIABLES, GO TO SCQ.430, THEN TERMINATE THE SCREENER WITH AN ASSIGNED STATUS OF “INCOMPLETE”; ELSE

GO TO SCQ.430.

SCQ.370 THIS HOUSEHOLD HAS ELIGIBLE SURVEY PARTICIPANTS.

THE ELIGIBLE PERSON(S) SAMPLED IN THIS HOUSEHOLD ARE:

{UNIQUE NAMES, GENDERS, ETHNICITIES RACES, AGES OF SAMPLED PERSONS}

CAPI INSTRUCTIONS: SINCE THE SAMPLING ALGORITHM HAS BEEN RUN FOR THE LAST TIME, BACK-UP IS NOT ALLOWED AFTER THIS SCREEN.

SCQ.420 Is {REFERENCE PERSON}’s mailing address the same as {his/her} street address?

SFQ.220

YES 1 (SCQ.430)

NO 2 (SCQ.425)

DK 9 (SCQ.430)

RF 7 (SCQ.430)

SCQ.425 Please give me {REFERENCE PERSON}'s complete mailing address.

SFQ.225

{#} {DIRECTION} {STREET NAME} {STREET/ROAD/AVENUE} {DIRECTION} {#}

{PO BOX} {RURAL ROUTE #} {RURAL ROUTE BOX} {CITY} {STATE} { ZIP}

CAPI INSTRUCTIONS: DISPLAY THE COMPLETE ADDRESS OF THE HOUSEHOLD AS COLLECTED IN SCQ070 OR SCQ080 AND ALLOW UPDATES IN ALL FIELDS. IF UPDATES ARE MADE, STORE THIS ADDRESS AS THE MAILING ADDRESS. IF NO UPDATES ARE MADE, RESET SCQ.420 TO “NO” AND CONTINUE TO SCQ.430.

SCQ.430 Please give me your home telephone number in case my office wants to check my work.

SFQ.230

( ) - ______ - __________ - __________

HOME TELEPHONE NUMBER (SCQ.440a)

NO HOME TELEPHONE 2 (SCQ.460)

DK 9 (SCQ.460)

RF 7 (SCQ.460)

CAPI INSTRUCTIONS: THE FIELD FOR "EXTENSION" IS ALLOWED TO BE BLANK.

SCQ.440a In whose name is the telephone listed?

SFQ.240a

INTERVIEWER INSTRUCTION: SELECT NAME FOR TELEPHONE LISTING FROM HOUSEHOLD ROSTER.

________ ________

FIRST LAST (BOX 13)

UNLISTED 1 (BOX 13)

NOT ON LIST 2 (SCQ440b)

DK 9 (BOX 13)

RF 7 (BOX 13)

CAPI INSTRUCTIONS: THE DEFAULT FILL FOR THE “NAME” FIELD SHOULD BE THE FIRST, LAST, AND SUFFIX NAME OF THE REFERENCE PERSON. HOWEVER, MOVING THE FOCUS OF THE CURSOR OVER THE “NAME” FILL PRODUCES A LIST DISPLAYING THE FIRST AND LAST NAMES OF ALL HH MEMBERS ON THE HH COMPOSITION MATRIX AND THE OPTIONS OF “UNLISTED”, AND “NOT ON LIST”.

SCQ.440b [In whose name is the telephone listed?]

SFQ.240b

INTERVIEWER INSTRUCTION: ENTER NAME.

Name ________ ________

{FIRST} {LAST} (BOX 13)

SCQ.460 Is there another number where you can be reached?

( ) - ______ - __________ - __________

OTHER TELEPHONE NUMBER (SCQ461)

NO 2 (BOX 13)

DK 9 (BOX 13)

RF 7 (BOX 13)

CAPI INSTRUCTIONS: THE FIELD FOR "EXTENSION" IS ALLOWED TO BE BLANK.

SCQ461 Where is that telephone located?

WORK 1

RELATIVE’S HOME 2

NEIGHBOR’S HOME 3

CELL PHONE 4

OTHER 5

DK 9

RF 7

BOX 13

CHECK ITEM SCQ.465:

IF THIS IS AN INELIGIBLE HOUSEHOLD, GO TO SCQ_END1; ELSE

IF THIS IS AN ELIGIBLE HOUSEHOLD, GO TO SCQ_END2; ELSE

IF THIS IS A BREAK-OF, GO TO SCQ_END3 AND REQUIRE ENTRY OF DISPOSITION; ELSE

IF MISSING CRITICAL SAMPLING DATA, GO TO SCQ_END4; ELSE

IF SCQ.070 (ADDRESS VERIFICATION) IS “NO (WRONG ADDRESS)”; GO TO SCQ_END 5.

SCQ_END1 Thank you.

BOX 14

CHECK ITEM SCQ.???:

GO TO INTERPRETER MODULE – INT_END1.

SCQ_END2 Thank you. This household has eligible survey participants.

[READ NAMES LISTED BELOW.]

{UNIQUE NAMES, GENDERS, AGES OF SAMPLE PERSONS}

[IF APPROPRIATE, EXPLAIN PARTICIPATION IN STUDY TO RESPONDENT.]

SCQCONT PERFORM THE RELATIONSHIP INTERVIEW AT THIS TIME?

YES 1 SCQ_MODULE 2)

NO 2 (SCQ_END2b)

CAPI INSTRUCTIONS: IF CODED “YES” (1), UPON LEAVING THIS SCREEN, LAUNCH MODULE 2 OF THE SCREENER, COLLECTING RELATIONSHIP INFORMATION.

RIQ.010 SELECT RESPONDENT FOR THE SCREENER MODULE 1 – HOUSEHOLD COMPOSITION.

Respondent

{FIRST NAME} {LAST NAME}

CAPI INSTRUCTIONS: WHEN THE FOCUS OF THE CURSOR IS ON THE “RESPONDENT” FIELD, THE ANSWER CHOICES SHOULD BE A LIST THAT DISPLAYS FIRST AND LAST NAMES OF ALL HH MEMBERS ON THE HH COMPOSITION MATRIX.

MDUREMIN REMINDER: PLEASE COMPLETE THE MISSED-DU PROCEDURE.

CAPI INSTRUCTION: DISPLAY IF CASE SELECTED FOR MDU PROCEDURE.

BOX 15

CHECK ITEM SCQ.???:

GO TO INTERPRETER MODULE – INT_END1.

SCQ_END3 Thank you.

SCQEND3 PROGRAMMER SPEC: AFTER EXITING FROM THIS SCREEN, PRESENT THE LIST OF DISPOSITIONS AND DO NOT ALLOW EXIT FROM THE APPLICATION WITHOUT ENTRY OF A DISPOSITION.

SCQ_END4 Thank you.

[EXPLAIN TO RESPONDENT THAT YOU WILL NEED TO RETURN TO THE HOUSEHOLD TO COLLECT CRITICAL INFORMATION THAT WAS NOT PROVIDED THIS TIME.]

SCQ_END5 Thank you.

LOCATE CORRECT ADDRESS AND RESTART SCREENER.

FAMILY RELATIONSHIP QUESTIONNAIRE
1. Family relationship (SFQ)

SCREENER MODULE #2 (SFQ)

TO BE ADMINISTERED TO ALL ELIGIBLE HOUSEHOLDS

BOX 1

CHECK ITEM SFQ.001:

IF ONLY 1 PERSON HOUSEHOLD, CODE PERSON AS "REFERENCE PERSON", CODE RELATIONSHIP AS "SELF", ASSIGN FAMILY #1 TO PERSON AND GO TO END OF SECTION.

OTHERWISE, CONTINUE.

BOX 2

CHECK ITEM SFQ.004:

CODE FIRST PERSON LISTED ON H.H. MATRIX WHOSE AGE IS > 18 AND IS NOT FLAGGED AS LIVING "SOMEWHERE ELSE" AS "REFERENCE PERSON", HEAD OF FAMILY #1 AND RELATIONSHIP AS "SELF".

BOX 3

LOOP 1:

ASK NEW BOX 3A – SFQ.040 AS APPROPRIATE FOR EACH PERSON {P} LISTED BELOW REFERENCE PERSON ON THE HOUSEHOLD MATRIX.

NEW BOX 3A

CHECK ITEM SFQ.005:

CHECK GENDER OF {PERSON} FROM SCREENER. IF {PERSON} IS MALE, DISPLAY SFQ.006. IF FEMALE, DISPLAY SFQ.007.

SFQ.000 {The next questions are about family relationships.}

SFQ.006 What is {PERSON'S} relationship to {REFERENCE PERSON}?

HAND CARD SFQ1

CAPI DESIGN = RADIO BUTTONS

HUSBAND  01

PARTNER  02

SON (BIOLOGICAL, SON-IN-LAW,
ADOPTIVE, FOSTER, STEP)  03

SON OF PARTNER  04

GRANDSON  05

FATHER  06

BROTHER  07

GRANDFATHER  08

UNCLE  09

NEPHEW  10

OTHER RELATIVE  11

NOT RELATED

HOUSEMATE/ROOMMATE  12

ROOMER/BOARDER  13

OTHER/NON RELATED  14

LEGAL GUARDIAN  15

WARD  16

REFUSED  77

DON’T KNOW  99

CAPI INSTRUCTIONS: IF CODE 1 AND {PERSON} IS <16 YEARS OLD, DISPLAY THE FOLLOWING BOX:

{PERSON} is listed as being under 16 years old. Are you sure {PERSON} should be coded as {HUSBAND/WIFE}?

Button 1: No, change relationship

Button 2: Yes, continue

IF BUTTON #1 IS SELECTED, RETURN TO SFQ.006/007. IF BUTTON #2 IS SELECTED, CONTINUE WITH BOX 5.

SFQ.007 {The next questions are about family relationships.}

What is {PERSON'S} relationship to {REFERENCE PERSON}?

HAND CARD SFQ2

CAPI DESIGN = RADIO BUTTONS

WIFE  01

PARTNER  02

DAUGHTER (BIOLOGICAL,
DAUGHTER-IN-LAW, ADOPTIVE,
FOSTER, STEP)  03

DAUGHTER OF PARTNER  04

GRANDDAUGHTER  05

MOTHER  06

SISTER  07

GRANDMOTHER  08

AUNT  09

NIECE  10

OTHER RELATIVE  11

NOT RELATED

HOUSEMATE/ROOMMATE  12

ROOMER/BOARDER  13

OTHER/NON RELATED  14

LEGAL GUARDIAN  15

WARD  16

REFUSED  77

DON’T KNOW  99

CAPI INSTRUCTIONS: IF CODE 1 AND {PERSON} IS <16 YEARS OLD, DISPLAY THE FOLLOWING BOX:

{PERSON} is listed as being under 16 years old. Are you sure {PERSON} should be coded as {HUSBAND/WIFE}?

Button 1: No, change relationship

Button 2: Yes, continue

IF BUTTON #1 IS SELECTED, RETURN TO SFQ.006/007. IF BUTTON #2 IS SELECTED, CONTINUE WITH BOX 5.

BOX 5

CHECK ITEM SFQ.017:

IF {P} RELATIONSHIP IN SFQ.006 or SFQ.007 = SON OR DAUGHTER (CODE 3), CONTINUE.

OTHERWISE, SKIP TO BOX 6.

SFQ.020 Is {PERSON}, {REFERENCE PERSON'S} biological (natural), adoptive, step, foster {son/daughter} or (son/daughter)-in-law?

BIOLOGICAL (NATURAL) {SON/
DAUGHTER} 1

ADOPTIVE {SON/DAUGHTER} 2

STEP {SON/DAUGHTER} 3

FOSTER {SON/DAUGHTER} 4

{SON/DAUGHTER}-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 6

CHECK ITEM SFQ.025:

IF {P} RELATIONSHIP IN SFQ.006 or SFQ.007 = FATHER OR MOTHER (CODE 6), CONTINUE.

OTHERWISE, GO TO BOX 7.

SFQ.030 Is {PERSON}, {REFERENCE PERSON'S} biological (natural), adoptive, step, or foster parent or {mother/father}-in-law?

BIOLOGICAL (NATURAL) PARENT 1

ADOPTIVE PARENT 2

STEP PARENT 3

FOSTER PARENT 4

{MOTHER/FATHER}-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 7

CHECK ITEM SFQ.035:

IF {P} RELATIONSHIP IN SFQ. 006 or SFQ.007 = BROTHER OR SISTER (CODE 7), CONTINUE.

OTHERWISE, GO TO BOX 8.

SFQ.100 Is {PERSON}, {REFERENCE PERSON'S} full, half, adoptive, step, or foster {brother/sister} or {brother/sister}-in-law?

FULL {BROTHER/SISTER} 1

HALF {BROTHER/SISTER} 2

ADOPTED {BROTHER/SISTER} 3

STEP {BROTHER/SISTER} 4

FOSTER {BROTHER/SISTER} 5

{BROTHER/SISTER}-IN-LAW 6

REFUSED 7

DON'T KNOW 9

BOX 8

END LOOP 1:

ASK NEW BOX 3A – SFQ.040 AS APPROPRIATE FOR NEXT PERSON {P} LISTED BELOW REFERENCE PERSON OR NEXT PERSON RELATED TO HEAD OF FAMILY ON THE HOUSEHOLD MATRIX.

IF NO NEXT PERSON, GO TO BOX 9.

BOX 9

CHECK ITEM SFQ.043:

IF ALL PERSONS IN HOUSEHOLD ARE RELATED (HAVE RELATIONSHIP CODES ASSOCIATED WITH CODES 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15, 16, 77 OR 99 IN SFQ.006 OR SFQ.007), GO TO BOX 20.

OTHERWISE, CONTINUE WITH BOX 10.

BOX 10

CHECK ITEM SFQ.045:

CODE FIRST PERSON REMAINING UNRELATED TO REFERENCE PERSON AND HEADS OF ADDITIONAL FAMILIES AND WHOSE AGE IS >18 AS HEAD OF NEXT FAMILY {H OF F} AS APPROPRIATE (#2, 3, 4, ETC.), AND GO TO BOX 11.

IF NO PERSONS AGE > 18, CODE OLDEST PERSON FROM THIS GROUP AS HEAD OF FAMILY.

BOX 11

CHECK ITEM SFQ.047:

IF MORE THAN ONE PERSON CODED AS UNRELATED, CONTINUE WITH SFQ.050.

OTHERWISE, GO TO BOX 20.

SFQ.050 Now I would like to talk about those persons in the household who are not related to {REFERENCE PERSON/REFERENCE PERSON OR HEADS OF FAMILY}. That is {LIST ALL PERSONS IN HOUSEHOLD NOT RELATED TO {REFERENCE PERSON/REFERENCE PERSON OR HEADS OF FAMILY}.

DISPLAY NAME OF REFERENCE PERSON IF THIS IS THE FIRST TIME THIS QUESTION IS ASKED. DISPLAY NAMES OF REFERENCE PERSON AND ALL HEADS OF ADDITIONAL FAMILIES IF THIS IS NOT THE FIRST TIME QUESTION IS ASKED.

Is {HEAD OF FAMILY #2, 3, 4, ETC} related to anyone in the household?

YES 1

NO 2 (BOX 19)

REFUSED 7

DON'T KNOW 9

SFQ.060 Who is {HEAD OF FAMILY #2, 3, 4, ETC. FROM BOX 10} related to? {DISPLAY LIST OF NAMES OF ALL PERSONS WHO ARE NOT REFERENCE PERSON, OR HEAD OF FAMILY AND WHO ARE NOT RELATED TO ANYONE ELSE IN HOUSEHOLD (DO NOT HAVE RELATIONSHIP CODE = CODE 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15 OR 16)}.

SELECT NAMES OF PERSONS RELATED TO {REFERENCE PERSON OR HEAD(S) OF FAMILY}.

BOX 13

EMBEDDED LOOP 2A:

ASK NEW BOX 3A THROUGH SFQ.040 FOR EACH PERSON SELECTED IN SFQ.060.

BOX 18

END EMBEDDED LOOP 2A:

ASK NEW BOX 3A THROUGH SFQ.040 AS APPROPRIATE FOR NEXT PERSON SELECTED AS RELATED TO HEAD OF FAMILY IN SFQ.060.

IF NO NEXT PERSON, GO TO BOX 19.

BOX 19

END LOOP 2:

IF MORE THAN 1 PERSON REMAINS UNRELATED TO THE REFERENCE PERSON OR THE HEAD OF ADDITION FAMILY:

 DESIGNATE NEXT HEAD OF FAMILY AS INSTRUCTED IN BOX 10.

 ASK NEW BOX 3A THROUGH SFQ.040 FOR NEXT HEAD OF FAMILY AND PERSONS WHO REMAIN AS UNRELATED.

IF NO NEXT PERSONS GO TO BOX 20.

BOX 20

CHECK ITEM SFQ.105:

 IF REFERENCE PERSON OR HEAD OF FAMILY IS MARRIED (CODED AS 01 IN SFQ.006 OR SFQ.007) OR
LIVING WITH A PARTNER (CODED AS UNMARRIED PARTNER IN SFQ.006 OR SFQ.007).

AND

 REFERENCE PERSON OR HEAD OF FAMILY HAS A CHILD OR THE PARTNER HAS A CHILD (CODED AS 03 OR 04 IN SFQ.006 OR SFQ.007), CONTINUE.

OTHERWISE GO TO BOX 23.

BOX 21

LOOP 3:

ASK SFQ.110 FOR EACH PERSON (CHILD OF REFERENCE PERSON AND CHILD OF PARTNER – RELATIONSHIP CODE 3 OR 4).

SFQ.110 I recorded that {NAME OF MOTHER/FATHER OF CHILD – THIS IS SPOUSE OR PARTNER OF REFERENCE PERSON} is the {father/mother} of {NAME OF CHILD – THIS IS CHILD OF REFERENCE PERSON AND SPOUSE OR REFERENCE PERSON AND PARTNER OR CHILD OF PARTNER}. Is {NAME OF CHILD} {his/her} biological, adoptive, step, foster child, (son or daughter)-in-law or a non relative of {NAME OF MOTHER/FATHER}?

BIOLOGICAL CHILD 1

ADOPTIVE CHILD 2

STEP CHILD 3

FOSTER CHILD 4

(SON/DAUGHTER)-IN-LAW 5

NON RELATIVE 6

REFUSED 7

DON'T KNOW 9

BOX 22

END LOOP 3:

ASK SFQ.110 FOR NEXT PERSON (CHILD OR CHILD OF PARTNER).

IF NO NEXT PERSON, CONTINUE WITH BOX 23.

BOX 23

CHECK ITEM 115:

CHECK RELATIONSHIPS. IF ALL HOUSEHOLD MEMBERS HAVE MOTHER, FATHER, AND SPOUSE OR PARTNER IDENTIFIED, GO TO BOX 31.

OTHERWISE, IF ANY OF THESE RELATIONSHIPS FOR EACH PERSON IS NOT ALREADY IDENTIFIED, CONTINUE.

BOX 24

LOOP 4:

ASK SFQ.120 – SFQ.200 AS APPROPRIATE FOR EACH PERSON WHO DOES NOT HAVE A MOTHER AND FATHER AND SPOUSE OR PARTNER IDENTIFIED IN HOUSEHOLD.

BOX 25

CHECK ITEM SFQ.117:

IF PERSON'S MOTHER HAS NOT BEEN IDENTIFIED, AND THERE ARE FEMALES IN THE HOUSEHOLD WHO ARE > 13 YEARS OLDER THAN PERSON, CONTINUE OTHERWISE, GO TO BOX 27.

SFQ.120 Is {PERSON'S} mother a household member? [Include mother-in-law].

IF OBVIOUS, VERIFY ONLY.

CHOOSE MOTHER OVER MOTHER-IN-LAW IF BOTH PRESENT.

YES – MOTHER IN HOUSEHOLD 1

NO – MOTHER NOT IN HOUSEHOLD 2 (BOX 27)

LEGAL GUARDIAN IN HOUSEHOLD 3

REFUSED 7 (BOX 27)

DON'T KNOW 9 (BOX 27)

SFQ.130 Who is that?

[SELECT PERSON FROM HOUSEHOLD MATRIX.

BOX 26

CHECK ITEM SFQ.135:

IF LEGAL GUARDIAN CODED IN SFQ.120, GO TO BOX 27.

OTHERWISE, CONTINUE.

SFQ.140 Is {NAME OF MOTHER IN SFQ.130}, {PERSON'S} biological [natural], adoptive, step, or foster mother or mother-in-law?

BIOLOGICAL MOTHER 1

ADOPTIVE MOTHER 2

STEP MOTHER 3

FOSTER MOTHER 4

MOTHER-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 27

CHECK ITEM SFQ.145:

IF PERSON'S FATHER HAS NOT BEEN IDENTIFIED, AND THERE ARE MALES IN THE HOUSEHOLD WHO ARE > 13 YEARS OLDER THAN PERSON.

OTHERWISE, GO TO BOX 29A.

SFQ.150 Is {PERSON'S} father a household member? [Include father-in-law].

IF OBVIOUS, VERIFY ONLY.

CHOOSE FATHER OVER FATHER-IN-LAW IF BOTH PRESENT.

YES – FATHER IN HOUSEHOLD 1

NO – FATHER NOT IN HOUSEHOLD 2 (BOX 29)

LEGAL GUARDIAN IN HOUSEHOLD 3

REFUSED 7 (BOX 29)

DON'T KNOW 9 (BOX 29)

SFQ.160 Who is that?

[SELECT PERSON FROM HOUSEHOLD MATRIX.

BOX 28

CHECK ITEM SFQ.165:

IF LEGAL GUARDIAN CODED IN SFQ.150, GO TO BOX 29A.

OTHERWISE, CONTINUE.

SFQ.170 Is {NAME OF FATHER IN SFQ.160}, {PERSON'S} biological (natural), adoptive, step, or foster father or father-in-law?

BIOLOGICAL FATHER 1

ADOPTIVE FATHER 2

STEP FATHER 3

FOSTER FATHER 4

FATHER-IN-LAW 5

REFUSED 7

DON'T KNOW 9

BOX 29A

CHECK ITEM SFQ.175:

IF PERSON'S AGE >= 14 AND SPOUSE OR UNMARRIED PARTNER HAS NOT BEEN IDENTIFIED, CONTINUE.

OTHERWISE, GO TO BOX 30.

SFQ.180 Is {PERSON'S NAME} now married, widowed, divorced, separated, never married or living with a partner?

MARRIED 1

WIDOWED 2 (BOX 30)

DIVORCED 3 (BOX 30)

SEPARATED 4 (BOX 30)

NEVER MARRIED 5 (BOX 30)

LIVING WITH PARTNER 6

REFUSED 7 (BOX 30)

DON'T KNOW 9 (BOX 30)

BOX 29B

CHECK ITEM SFQ.185:

IF THERE ARE PERSONS IN THE HOUSEHOLD WHO ARE > = 14 YEARS OLD, CONTINUE.

OTHERWISE, GO TO BOX 30.

SFQ.190 Is {PERSON'S} {spouse/partner} living in the household?

YES 1

NO 2 (BOX 30)

REFUSED 7 (BOX 30)

DON'T KNOW 9 (BOX 30)

SFQ.200 Who is that?

DISPLAY LIST OF ALL NONDELETED HOUSEHOLD MEMBERS WHO ARE 14 YEARS OLD OR OLDER.

BOX 30

END LOOP 4:

ASK SFQ.120 – SFQ.200 FOR NEXT PERSON.

IF NO NEXT PERSON, GO TO BOX 31.

BOX 31

CHECK ITEM SFQ.205:

 APPLY NHANES AND CPS FAMILY DEFINITIONS.

 IF MORE THAN 1 NHANES FAMILY, CONTINUE.

 IF ONLY 1 NHANES FAMILY, GO TO SFQ.210. DO NOT REASK SCQ.430 –
SCQ.461.

OTHERWISE, GO TO SFQ.210.

BOX 32

LOOP 5:

ASK MODULE 1 – SCQ.420 – SCQ.440b FOR EACH ADDITIONAL NHANES FAMILY.

NOTE: THE SUBJECT OF QUESTIONS SHOULD BE EACH ADDITIONAL HEAD OF NHANES FAMILY AND NUMBERED SFQ.220, SFQ.225, SFQ.230 AND SFQ.240a.

DO NOT REASK SCQ.430 – SCQ.461 OF THE FIRST NHANES FAMILY.

SFQEND Thank you. That completes the questions about family relationships.

RIQ.010 SELECT RESPONDENT FOR THE SCREENER MODULE II – HOUSEHOLD RELATIONSHIPS.

Respondent

{FIRST NAME} {LAST NAME}

INT.001 WAS AN INTERPRETER USED FOR INTERVIEW?

YES 1

NO 2 (GO TO THE END

OF THE SECTION)

BOX #1

CHECK ITEM INT.001A:

IF THIS IS SCREENER, SKIP TO INT.003.

OTHERWISE, IF THIS IS RELATIONSHIP MODULE, CONTINUE WITH BOX 2.

BOX #2

CHECK ITEM INT.001B:

IF SCREENER AND RELATIONSHIP COMPLETED DURING SAME SESSION (SCQ_END 2a = YES), SKIP TO INT.003.

OTHERWISE, CONTINUE.

INT.002 IS THIS THE SAME INTERPRETER THAT WAS USED FOR THE SCREENER?

YES 1 {CODE INTERPRETER

SCREENER INFORMATION

AND SKIP TO END OF SECTION)}

NO 2 (CONTINUE)

INT.003 LANGUAGE USED FOR INTERVIEW

AMERICAN SIGN LANGUAGE 1 (SKIP TO INT.005)

CHINESE (CANTONESE) 2 (SKIP TO INT.005)

CHINESE (MANDARIN) 3 (SKIP TO INT.005)

FRENCH 4 (SKIP TO INT.005)

GERMAN 5 (SKIP TO INT.005)

ITALIAN 6 (SKIP TO INT.005)

JAPANESE 7 (SKIP TO INT.005)

KOREAN 8 (SKIP TO INT.005)

RUSSIAN 9 (SKIP TO INT.005)

SPANISH (READER) 10 (SKIP TO INT.005)

VIETNAMESE 11 (SKIP TO INT.005)

OTHER SPECIFY 99

INT.004 ENTER LANGUAGE USED FOR INTERVIEW

_________________________________

INT.005 HOW WAS INTERPRETER OBTAINED

ARRANGED BY FIELD OFFICE 1

RECRUITED DURING VISIT/APPOINTMENT 2 (INT.007)

INT.006 SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME

{DROP DOWN LIST SHOULD HAVE ALL NAMES FROM EVM AND AN “OTHER SPECIFY” TO ALLOW FOR THOSE NAMES THAT HAVE NOT BEEN TRANSFERRED TO INTERVIEWER PENTOP}

BOX #3

CHECK ITEM INT.006A:

IF OTHER (SELECTED IN INT.006) GO TO INT.009.

OTHERWISE, GO TO SFQMISDU.

INT.007 SELECT INTERPRETER SOURCE

RELATIVE LIVING IN HOUSEHOLD 1

NON-RELATIVE LIVING IN HOUSEHOLD 2

NEIGHBOR, RELATIVE OR FRIEND –
NOT IN HOUSEHOLD 3 (SKIP TO INT.009)

INT.008 SELECT NAME OF INTERPRETER FROM HOUSEHOLD ROSTER.

{DISPLAY CAPI PULL DOWN LIST FROM HH ROSTER}

BOX #4

CHECK ITEM INT.008A:

GO TO END OF SECTION.

INT.009 ENTER NAME OF INTERPRETER

______________________________________

INT.010 ENTER PHONE # OF INTERPRETER

___ -___ ____

INT.011 ENTER AGE RANGE OF INTERPRETER

{AGE RANGE CAN BE A PULL DOWN LIST}

RANGES = 18-29

30-59

60+

INT.012 ENTER GENDER OF INTERPRETER

MALE 1

FEMALE 2

SFQMISDU REMINDER: PLEASE COMPLETE THE MISSED-DU PROCEDURE.

CAPI INSTRUCTION: DISPLAY IF CASE SELECTED FOR MDU PROCEDURE.

SAMPLE PERSON QUESTIONNAIRE
1. RESPONDENT SELECTION SECTION - RIQ - SP QUESTIONNAIRE

RESPONDENT SELECTION SECTION - RIQ - SP QUESTIONNAIRE

RIQ.006 SELECT RESPONDENT FOR THE SP QUESTIONNAIRE FOR {SP NAME}.

CAPI INSTRUCTION:

DISPLAY HOUSEHOLD ROSTER FROM SCREENER AND ‘SOMEONE NOT LIVING IN HH’ AS OPTION.

BOX 0

CHECK ITEM RIQ.008:

IF PROXY RESPONDENT FOR SP AGE 15 OR YOUNGER, GO TO RIQ.012.

IF PROXY RESPONDENT FOR SP AGE 16 OR OLDER, GO TO RIQ.014.

OTHERWISE GO TO BOX 1.

RIQ.012 INTERVIEWER: ASK OR MARK IF KNOWN.

(What is your relationship to {SP}?)

MOTHER (BIOLOGICAL/ADOPTIVE/
STEP/FOSTER) 1 (BOX 1)

FATHER (BIOLOGICAL/ADOPTIVE/
STEP/FOSTER) 2 (BOX 1)

GRANDPARENT (GRANDMOTHER/
GRANDFATHER) 3 (BOX 1)

AUNT/UNCLE 4 (BOX 1)

BROTHER/SISTER 5 (BOX 1)

OTHER RELATIVE 6 (BOX 1)

NON-RELATIVE 7 (BOX 1)

REFUSED 77 (BOX 1)

DON'T KNOW 99 (BOX 1)

RIQ.014 INTERVIEWER: ASK OR MARK IF KNOWN.

(What is your relationship to {SP}?)

SPOUSE (WIFE/HUSBAND) OR
PARTNER 1

DAUGHTER OR SON (BIOLOGICAL/
ADOPTIVE/IN-LAW/STEP/FOSTER) 2

PARENT (BIOLOGICAL/ADOPTIVE/
STEP/FOSTER) 3

GRANDPARENT (GRANDMOTHER/
GRANDFATHER) 4

BROTHER/SISTER 5

OTHER RELATIVE 6

NON-RELATIVE 7

REFUSED 77

DON'T KNOW 99

BOX 1

CHECK ITEM *11RIQ.015:

 IF SP IS SELECTED AS RESPONDENT AND SP AGE IS <= 15, GO TO
*11RIQ.020.

 IF SP IS SELECTED AS RESPONDENT AND SP AGE IS >= 16, GO TO
RIQ.080.

 IF SP IS NOT SELECTED AS RESPONDENT AND SP AGE IS <= 15, GO TO
BOX 2.

 IF SP IS NOT SELECTED AS RESPONDENT AND SP AGE IS >= 16, GO TO
RIQ.039.

*11RIQ.020 INTERVIEW SHOULD BE CONDUCTED WITH A PROXY BECAUSE SP IS UNDER 16 YEARS OLD.

ENTER ONE OPTION.

SP IS AN EMANCIPATED MINOR 1 (BOX 3)

PERSON SELECTED AS

RESPONDENT IN ERROR 2 (RIQ.006)

SP AGE ENTERED IN ERROR -- SP IS

AGE 16+ 3 (RIQ.080)

RIQ.039 WHY IS INTERVIEW BEING CONDUCTED WITH A PROXY?

SP HAS COGNITIVE PROBLEMS 1

SP HAS PHYSICAL PROBLEMS

(SPECIFY) 2

*11RIQ.035 DO YOU HAVE SUPERVISOR PERMISSION TO CONDUCT INTERVIEW WITH A PROXY?

YES 1

NO 2 (RIQ.006)

BOX 2

CHECK ITEM RIQ.031:

IF 'SOMEONE NOT LIVING IN HH' SELECTED AS RESPONDENT IN RIQ.006, CONTINUE.

OTHERWISE, GO TO RIQ.080.

RIQ.040 WHY IS INTERVIEW BEING CONDUCTED WITH SOMEONE OUTSIDE THE HOUSEHOLD?

RIQ.050 ENTER RESPONDENT NAME.

FIRST NAME LAST NAME

RIQ.060 ENTER RESPONDENT'S PHONE NUMBER.

ENTER '00' IN AREA CODE IF NO PHONE.

|___|___|___| |___|___|___| - |___|___|___|___|

AREA CODE ENTER PHONE NUMBER

BOX 3

CHECK ITEM *11RIQ.072:

IF SP SELECTED AS RESPONDENT IS <12 YEARS OLD, CONTINUE.

OTHERWISE, GO TO RIQ.080.

*11RIQ.074 EMANCIPATED MINOR MUST BE AT LEAST 12 YEARS OLD.

PRESS ‘ENTER’ TO SELECT ANOTHER RESPONDENT.

CAPI INSTRUCTION:

WHEN ‘ENTER’ IS PRESSED, CAPI SHOULD RETURN TO RIQ.006.

RIQ.080 HAS RESPONDENT SIGNED A HOUSEHOLD INTERVIEW CONSENT FORM?

CAPI INSTRUCTION:

IF 'NO' (CODE 2), DISPLAY THE FOLLOWING MESSAGE: "EACH RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE MUST SIGN A HOUSEHOLD INTERVIEW CONSENT FORM BEFORE THE INTERVIEW CAN BE ADMINISTERED" AND RETURN TO RIQ.080.

NOTE: IF INTERPRETER USED, RESPONDENT MUST SIGN FORM.

YES 1

NO 2

RIQ.085 PLEASE RECORD RESPONDENT’S ANSWER TO THE LINKAGE QUESTION ON THE HOUSEHOLD CONSENT.

RESPONDENT’S ANSWER:

YES (MAY LINK) 1

NO (MAY NOT LINK) 2

BOX 3A

CHECK ITEM RIQ.160:

IF SP AGE LESS THAN 18, GO TO INT.001.

IF SP AGE 18 OR OLDER AND SAME RESPONDENT AS A PREVIOUS INTERVIEW AND GAVE PERMISSION TO RECORD THAT PREVIOUS INTERVIEW, GO TO RIQ.200.

ELSE, CONTINUE.

RIQ.170 DO YOU WANT TO OFFER AUDIO-RECORDING?

YES 1

NO 2 (INT.001)

RIQ.180 A standard part of our quality control procedures is to record interviews. The information being recorded is protected and kept confidential, the same as all of your answers to the questions that are typed into the computer. Only my supervisor or staff at the National Center for Health Statistics will listen to the recording to check my work.

DOES SP AGREE TO AUDIO RECORDING?

YES 1

NO 2 (INT.001)

DID NOT OFFER 3 (INT.001)

CAPI INSTRUCTION: IF RIQ.180 = 1/YES, BEGIN AUDIO RECORDING SO THAT WHEN INTERVIEWER READS RIQ.190, IT IS CAPTURED ON THE RECORDING.

RIQ.190 CAPI INSTRUCTION: BEGIN RECORDING SO THAT WHEN INTERVIEWER READS THIS QUESTION IT IS CAPTURED ON RECORDING.

The computer is now recording our conversation. Do I have your permission to record this interview? This recording will only be used to review the quality of my work.

YES 1 (INT.001)

NO 2 (INT.001)

CAPI INSTRUCTION: IF RIQ.190 = 2/NO, STOP AND DISCARD RECORDING.

RIQ.200 CAPI INSTRUCTION: BEGIN RECORDING SO THAT WHEN INTERVIEWER READS THIS QUESTION IT IS CAPTURED ON RECORDING.

A reminder that the system is now recording our conversation. Do I have your permission to record this interview?

YES 1

NO 2

CAPI INSTRUCTION: IF RIQ.200 = 2/NO, STOP AND DISCARD RECORDING.

INT.001 IS AN INTERPRETER BEING USED FOR INTERVIEW?

YES 1

NO 2 (GO TO THE END

OF THE SECTION)

INT.003 LANGUAGE USED FOR INTERVIEW

AMERICAN SIGN LANGUAGE 1 (INT.013)

CHINESE (CANTONESE) 2 (INT.013)

CHINESE (MANDARIN) 3 (INT.013)

FRENCH 4 (INT.013)

GERMAN 5 (INT.013)

ITALIAN 6 (INT.013)

JAPANESE 7 (INT.013)

KOREAN 8 (INT.013)

RUSSIAN 9 (INT.013)

SPANISH (READER) 10 (INT.013)

VIETNAMESE 11 (INT.013)

OTHER SPECIFY 99

INT.004 ENTER LANGUAGE USED FOR INTERVIEW

_________________________________

INT.013 {DISPLAY INTERPRETER NAMES FROM ALL PREVIOUS INTERVIEWS: SCREENER, RELATIONSHIP, SP, FAMILY QUESTIONNAIRE}

ENTER INTERPRETER NAME INFO

SAME INTERPRETER USED IN OTHER
INTERVIEW FOR HOUSEHOLD 1 (INT.014)

NEW INTERPRETER 2 (INT.005)

INT.014 {DISPLAY LIST OF INTERPRETER NAMES FROM SCREENER, RELATIONSHIP, SP AND/OR FAMILY QUESTIONNAIRES}

{INCLUDE “OTHER” AS A SELECTION}

SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME

BOX 4

CHECK ITEM INT.014a:

IF ‘OTHER’ SELECTED IN INT.014, GO TO INT.005.

OTHERWISE, CODE INTERPRETER INFO FROM PREVIOUS INTERVIEW AND GO TO END OF SECTION.

INT.005 HOW WAS INTERPRETER OBTAINED

ARRANGED BY FIELD OFFICE 1

RECRUITED DURING VISIT/APPOINTMENT 2 (INT.007)

INT.006 SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME

{DROP DOWN LIST SHOULD HAVE ALL NAMES FROM EVM AND AN “OTHER SPECIFY” TO ALLOW FOR THOSE NAMES THAT HAVE NOT BEEN TRANSFERRED TO INTERVIEWER PENTOP}

BOX 6

CHECK ITEM INT.006A:

IF OTHER (SELECTED IN INT.006), GO TO INT.009.

OTHERWISE, GO TO END OF SECTION.

INT.007 SELECT INTERPRETER SOURCE

RELATIVE LIVING IN HOUSEHOLD 1

NON-RELATIVE LIVING IN HOUSEHOLD 2

NEIGHBOR, RELATIVE OR FRIEND –
NOT IN HOUSEHOLD 3 (SKIP TO INT.009)

INT.008 SELECT NAME OF INTERPRETER FROM HOUSEHOLD ROSTER.

{DISPLAY CAPI PULL DOWN LIST FROM HH ROSTER}

BOX 7

CHECK ITEM INT.008A:

GO TO END OF SECTION.

INT.009 ENTER NAME OF INTERPRETER

______________________________________

INT.010 ENTER PHONE # OF INTERPRETER

___ -___ ____

INT.011 ENTER AGE RANGE OF INTERPRETER

{AGE RANGE CAN BE A PULL DOWN LIST}

RANGES = 18-29

30-59

60+

INT.012 ENTER GENDER OF INTERPRETER

MALE 1

FEMALE 2

DMQ.INTRO [{You have/SP has} been chosen to participate in the National Health and Nutrition Examination Survey conducted for the Centers for Disease Control and Prevention (CDC).] [All the information that you give us will be kept in the strictest of confidence. Your name will not be attached to any of your answers without your specific permission.] HAND RESPONDENT THE ADVANCE LETTER.

I would like to begin the health interview by verifying some information about {you/SP}.

DMQ.010 VERIFY OR ASK DATE OF BIRTH AND AGE.

CAPI INSTRUCTION:

DISPLAY PERSON #, NAME, DOB MONTH, DAY AND YEAR AND AGE IN YEARS. ALLOW DOB AND AGE FIELDS TO BE UPDATED.

DMQ.020 VERIFY GENDER.

MALE 1

FEMALE 2

CAPI INSTRUCTION:

PREFILL WITH GENDER FROM SCREENER AND ALLOW UPDATE.

BOX 8

CHECK ITEM DMQ.025:

APPLY SAMPLING ALGORITHM. IF SP IS NO LONGER ELIGIBLE DUE TO GENDER AND AGE CHANGES, CONTINUE.

OTHERWISE, SKIP TO DMQ.040.

DMQ.030 Thank you for your participation in the study. Our scientific, random selection process indicates that {you have/SP has} not been selected for the next part of the study.

BOX 9

CHECK ITEM DMQ.032:

END INTERVIEW AND APPLY DISPOSITION CODE ‘COMPLETE, ELIGIBILITY PROBLEMS’.

DMQ.040 What is {your/SP’s} full name, including middle name?

VERIFY SPELLING.

What is {your/SP’s} first name?

Enter Prefix (Ms, Mr, Mrs, Dr):

Drop Down List

Dr.

Mr.

Mrs.

Ms.

Miss

Master

First Name: __________________________

CAPI INSTRUCTION:

PREFILL FIRST NAME FROM SCREENER AND ALLOW UPDATES.

DMQ.050 [What is {your/SP’s} full name, including middle name?]

VERIFY SPELLING.

What is {your/SP’s} middle name?

Middle Name #1: __________________________

Middle Name #2: __________________________

No middle name 1

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

PREFILL WITH MIDDLE NAME FROM SCREENER AND ALLOW UPDATES.

DMQ.060 [What is {your/SP’s} full name, including middle name?]

VERIFY SPELLING.

What is {your/SP’s} last name?

Last Name #1: __________________________

Last Name #2: __________________________

CAPI INSTRUCTION:

PREFILL WITH LAST NAME FROM SCREENER AND ALLOW UPDATES.

DMQ.070 [What is {your/SP’s} full name, including middle name?]

VERIFY SPELLING.

{Do you/Does SP} have a suffix? [What is it?]

Suffix: _________

CAPI INSTRUCTION:

ALLOW SUFFIX FIELD TO BE LEFT BLANK/NULL.

Early childhood (ECQ)

EARLY CHILDHOOD – ECQ

Target Group: SPs Birth to 15 Years

ECQ.010 First I have some questions about {SP NAME's} birth.

How old was {SP NAME's} biological mother when {s/he} was born?

|___|___|

ENTER AGE IN YEARS

CAPI INSTRUCTION:

HARD EDIT <10 AND >59, SOFT EDIT 10, 11, AND 12

REFUSED 7777

DON'T KNOW 9999

HELP SCREEN:

Biological Mother: The person who gave birth to the child.

ECQ.020 Did {SP NAME's} biological mother smoke at any time while she was pregnant with {him/her}?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

Biological Mother: The person who gave birth to the child.

ECQ.071/ How much did {SP NAME} weigh at birth?

L/O/K/M

IF ANSWER GIVEN IN POUNDS ONLY, PROBE FOR OUNCES.

IF ANSWER GIVEN IN EXACT POUNDS, ENTER NUMBER OF POUNDS AND 0 OUNCES.

ENTER WEIGHT IN POUNDS, KILOGRAMS OR GRAMS.

|___|

ENTER NUMBER OF POUNDS

AND OUNCES 1

ENTER NUMBER IN KILOGRAMS 2

ENTER NUMBER IN GRAMS 3

REFUSED 7 (BOX 1)

DON’T KNOW 9 (BOX 1)

|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 3-13, HARD EDIT 0-20

AND

|___|___|

ENTER NUMBER OF OUNCES

CAPI INSTRUCTION:

HARD EDIT 0-15, NO SOFT EDIT

|___|___|___|

ENTER NUMBER IN KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 1.5-6, HARD EDIT 0-9

|___|___|___|

ENTER NUMBER IN GRAMS

CAPI INSTRUCTION:

SOFT EDIT 1,500-6,000, HARD EDIT 0-9,000

BOX 1

CHECK ITEM ECQ.075:

IF REFUSED (CODE 7) OR DON'T KNOW (CODE 9), CONTINUE.

OTHERWISE, GO TO BOX 2.

ECQ.080 Did {SP NAME} weigh . . .

more than 5-1/2 lbs. (2500 g), or 1

less than 5-1/2 lbs. (2500 g)? 2 (BOX 2)

REFUSED 7 (BOX 2)

DON'T KNOW 9 (BOX 2)

ECQ.090 Did {SP NAME} weigh . . .

more than 9 lbs. (4100 g), or 1

less than 9 lbs. (4100 g)? 2

REFUSED 7

DON'T KNOW 9

BOX 2

CHECK ITEM ECQ.095:

IF SP AGE = 2-15 YEARS, CONTINUE.

OTHERWISE, GO TO End of Section.

WHQ.030e Do you consider {SP} now to be . . .

overweight, 1

underweight, or 2

about the right weight? 3

REFUSED 7

DON’T KNOW 9

MCQ.080e Has a doctor or health professional ever told you that {SP} was overweight?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

HELP SCREEN:

Doctor: The term refers to both medical doctors (M.D.s) and osteopathic physicians (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.

Other Health (Care) Professional: A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, lab technicians, and technicians who administer shots (i.e., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.

ECQ.150 Are you now doing anything to help {SP} control {his/her} weight?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HOSPITAL UTILIZATION AND ACCESS TO CARE (HUQ)

HOSPITAL UTILIZATION AND ACCESS TO CARE - HUQ
Target Group: SPs Birth +

HUQ.010 {First/Next} I have some general questions about {your/SP's} health.

Would you say {your/SP's} health in general is . . .

CAPI INSTRUCTION:

DISPLAY "FIRST" IF SP AGE IS >= 16 YEARS.

excellent, 1

very good, 2

good, 3

fair, or 4

poor? 5

REFUSED 7

DON'T KNOW 9

BOX 1

CHECK ITEM HUQ.015:

IF SP AGE >= 1, CONTINUE.

OTHERWISE, GO TO HUQ.030.

HUQ.020 Compared with 12 months ago, would you say {your/SP's} health is now . . .

better, 1

worse, or 2

about the same? 3

REFUSED 7

DON'T KNOW 9

HUQ.030 Is there a place that {you/SP} usually {go/goes} when {you are/he/she is} sick or {you/s/he} need{s} advice about {your/his/her} health?

CAPI INSTRUCTION:

IF SP AGE < 12, DISPLAY "YOU" IN THE FOURTH DISPLAY AND DON'T DISPLAY THE "S" IN THE FIFTH DISPLAY.

YES 1

THERE IS NO PLACE 2 (HUQ.051)

THERE IS MORE THAN ONE PLACE 3

REFUSED 7 (HUQ.051)

DON'T KNOW 9 (HUQ.051)

HELP SCREEN:

Usual Place: Include walk-in clinic, doctor's office, clinic, health center, Health Maintenance Organization or HMO, hospital emergency room or outpatient clinic, or a military or VA health care facility.

HUQ.041 {What kind of place is it – a clinic, doctor's office, emergency room, or some other place?}

{What kind of place {do you/does SP} go to most often – a clinic, doctor’s office, emergency room, or some other place?}

CLINIC OR HEALTH CENTER 1

DOCTOR'S OFFICE OR HMO 2

HOSPITAL EMERGENCY ROOM 3

HOSPITAL OUTPATIENT DEPARTMENT 4

SOME OTHER PLACE 5

DOESN’T GO TO ONE PLACE MOST

OFTEN 6

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF HUQ.030 = 1 DISPLAY “What kind of place is it – a clinic, doctor's office, emergency room, or some other place?”

IF HUQ.030 = 3 DISPLAY “What kind of place {do you does SP} go to most often – a clinic, doctor's office, emergency room, or some other place?”

HUQ.051 {During the past 12 months, how/How} many times {have you/has SP} seen a doctor or other health care professional about {your/his/her} health at a doctor's office, a clinic or some other place? Do not include times {you were/s/he was} hospitalized overnight, visits to hospital emergency rooms, home visits or telephone calls.

CAPI INSTRUCTION:

DISPLAY "12 MONTHS" ONLY IF SP'S AGE IS >= 1.

NONE 0

1 1 (HUQ.071)

2 TO 3 2 (HUQ.071)

4 TO 5 3 (HUQ.071)

6 TO 7 4 (HUQ.071)

8 TO 9 5 (HUQ.071)

10 TO 12 6 (HUQ.071)

13 TO 15 7 (HUQ.071)

16 OR MORE 8 (HUQ.071)

REFUSED 77 (HUQ.071)

DON'T KNOW 99 (HUQ.071)

HELP SCREEN:

Include: Physician’s, osteopaths, doctor’s assistants, nurse practitioners, nurses, lab technicians and technicians who administer shots (i.e., allergy shots), paramedics, medics and physical therapists who work with or in a doctor’s office.

Do not include: Dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists and psychologists or social workers.

HUQ.061 About how long has it been since {you/SP} last saw or talked to a doctor or other health care professional about {your/his/her} health? Include doctors seen while {you were} {he/she was} a patient in a hospital. Has it been . . .

6 months or less, 1

more than 6 months, but not more than

1 year ago, 2

more than 1 year, but not more than

2 years ago, 3

more than 2 years, but not more than

5 years ago, 4

more than 5 years ago, or 5

never? 6

REFUSED 77

DON'T KNOW 99

HUQ.071 {During the past 12 months, {were you/was SP} a patient in a hospital overnight? Do not include an overnight stay in the emergency room.

CAPI INSTRUCTION:

DISPLAY "12 MONTHS" ONLY IF SP'S AGE IS >= 1.

DISPLAY "WAS SP" WITH LEADING CAPS, IF SP'S AGE IS <1.

YES 1

NO 2 (BOX 2)

REFUSED 7 (BOX 2)

DON'T KNOW 9 (BOX 2)

HELP SCREEN:

Overnight Stay in a Hospital: A person is admitted to a hospital and spends at least one night in the hospital. Note that a person can be “admitted” to a hospital without staying overnight. Do not count as “overnight” when a person is admitted and discharged on the same day. Do not include visits outpatient clinics or stays for non-medical reasons, such as staying with a family member.

HUQ.080 How many different times did {you/SP} stay in any hospital overnight or longer {during the past 12 months}? (Do not count total number of nights, just total number of hospital admissions for stays which lasted 1 or more nights.)

CAPI INSTRUCTION:

DISPLAY "12 MONTHS" ONLY IF SP'S AGE IS >= 1.

HARD EDIT: 1-366.

SOFT EDIT: 1-6.

|___|___|___|

ENTER NUMBER

REFUSED 777

DON'T KNOW 999

CAPI INSTRUCTION:

ELIMINATE CURRENT HELP.

BOX 1A

OMITTED

BOX 2

CHECK ITEM 085:

IF SP AGE >= 4, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

HUQ.090 During the past 12 months, that is since {DISPLAY CURRENT MONTH} of {DISPLAY LAST YEAR}, {have you/has SP} seen or talked to a mental health professional such as a psychologist, psychiatrist, psychiatric nurse or clinical social worker about {your/his/her} health?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN FOR HUQ.041:

Clinic: Refers to a facility where medical care and advice are given by doctors, nurses, or other medical professionals, that is not located at a hospital. (Do not include hospital outpatient departments.) Include a clinic operated solely for employees of a company or industry, regardless of where the clinic is located.

Doctor's Office: In Hospital - An individual office in a hospital where patients are seen on an outpatient basis, or several doctors might occupy a suite of offices in a hospital where patients are treated as outpatients.

Doctor's Office: Not in Hospital - An individual office in the doctor's home or office building, or a suite of offices occupied by several doctors. Suites of doctors offices are not considered clinics.

Health Center: Refers to a facility where medical care and advice are given by doctors, nurses, or other medical professionals that is not located at a hospital.

HMO Clinic: A medical facility sponsored by an HMO that typically includes a group of doctors on staff.

Hospital Outpatient Department: A unit of a hospital providing health and medical services to individuals who receive services from the hospital but do not require hospitalization overnight, such as outpatient surgery centers. Examples of outpatient departments include the following:

Well-baby clinics/pediatric OPD;

Obesity clinics;

Eye, ear, nose, and throat clinics;

Cardiology clinic;

Internal medicine department;

Family planning clinics;

Alcohol and drug abuse clinics;

Physical therapy clinics; and

Radiation therapy clinics.

Hospital outpatient departments may also provide general primary care.

HELP SCREEN FOR HUQ.061:

Hospital: A health care organization that has a governing body, an organized medical staff and professional staff, and inpatient facilities. Hospitals provide medical, nursing, and related services for ill and injured patients 24 hours per day, 7 days per week.

HELP SCREEN FOR HUQ.090:

Mental Health Professional: A person trained to diagnose and treat emotional or mental health problems, including, psychiatrists, psychologists, counselors, and social workers.

Psychologist: A non-physician who specializes in the counseling and testing of persons with mental, addictive or emotional disorders.

Psychiatrist: A physician who specializes in dealing with the prevention, diagnosis, and treatment of mental, addictive, and emotional disorders, such as psychoses, depression, anxiety disorders, substance abuse disorders, developmental disabilities, sexual dysfunctions and adjustment reactions.

Social Worker: A person who assists patients and their families in handling social, environmental and emotional problems associated with illness or injury. Can include social work specialists, such as a medical or psychiatric social worker.

IMUNIZATION (IMQ)

IMMUNIZATION – IMQ

Target Group: SPs Birth +

BOX 0

CHECK ITEM IMQ.005:

IF SP AGE >= 2, CONTINUE.

OTHERWISE, GO TO IMQ.020.

BOX 1

OMITTED

IMQ.011 Hepatitis (Hep-a-ti-tis) A vaccine is given as a two dose series to some children older than 2 years and also to some adults, especially people who travel outside the United States. It has only been available since 1995. {Have you/Has SP} ever received the hepatitis A vaccine?

INTERVIEWER INSTRUCTION: A COMBINATION HEPATITIS A AND HEPATITIS B VACCINE SHOULD BE COUNTED AS THE A VACCINE FOR THE PURPOSE OF THIS QUESTION. CODE 'YES AT LEAST 2 DOSES' IF RESPONDENT ANSWERS 3 OR 4 DOSES WERE RECEIVED. CODE 'LESS THAN 2 DOSES' ONLY IF MENTIONED BY RESPONDENT.

YES AT LEAST 2 DOSES 1

LESS THAN 2 DOSES 2

NO DOSES 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

REMOVE CURRENT HELP.

IMQ.020 Hepatitis (Hep-a-ti-tis) B vaccine is given in three separate doses and has been recommended for all newborn infants since 1991. In 1995, it was recommended that adolescents be given the vaccine. Persons who may be exposed to other people’s blood, such as health care workers, also may have received the vaccine. {Have you/Has SP} ever received the 3-dose series of the hepatitis B vaccine?

INTERVIEWER INSTRUCTION: A COMBINATION HEPATITIS A AND HEPATITIS B VACCINE SHOULD BE COUNTED AS THE B VACCINE FOR THE PURPOSE OF THIS QUESTION. CODE 'YES AT LEAST 3 DOSES' IF RESPONDENT ANSWERS 4 DOSES WERE RECEIVED. CODE 'LESS THAN 3 DOSES' ONLY IF MENTIONED BY RESPONDENT.

YES AT LEAST 3 DOSES 1

LESS THAN 3 DOSES 2

NO DOSES 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

REMOVE CURRENT HELP.

BOX 2

OMITTED

BOX 3

CHECK ITEM IMQ.050:

IF SP = FEMALE AND AGE IS >= 9 AND <= 59, CONTINUE.

IF SP = MALE AND AGE IS >= 9 AND <= 59, GO TO IMQ.070.

OTHERWISE, GO TO END OF SECTION.

IMQ.060 Human Papillomavirus (HPV) vaccine is given to prevent cervical cancer in girls and women. There are two HPV vaccines available called Cervarix and Gardasil. It is given in 3 separate doses over a 6 month period. {Have you/Has SP} ever received one or more doses of the HPV vaccine?

YES 1 (IMQ.080)

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

IMQ.070 Human Papillomavirus (HPV) vaccine is given to prevent HPV infection and genital warts in boys and men. It is given in 3 separate doses over a 6 month period. {Have you/Has SP} ever received one or more doses of the HPV vaccine? (The brand name for the vaccine is Gardasil.)

YES 1 (IMQ.090)

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

IMQ.080 Which of the HPV vaccines did {you/SP} receive, Cervarix or Gardasil?

CERVARIX 1

GARDASIL 2

BOTH 3

REFUSED 7

DON'T KNOW 9

IMQ.090 How old {were you/was SP} when {you/SP} received your first dose of {Cervarix/Gardasil/the vaccine}?

HARD EDIT: IF AGE SP RECEIVED FIRST DOSE IS GREATER THAN SP’S CURRENT AGE, DISPLAY “AGE SP RECEIVED FIRST DOSE CANNOT EXCEED SP’S CURRENT AGE.”

SOFT EDIT: IF DIFFERENCE BETWEEN SP’S CURRENT AGE AND AGE SP RECEIVED FIRST DOSE IS MORE THAN SEVEN YEARS, DISPLAY “UNLIKELY RESPONSE AS HPV VACCINES WERE NOT AVAILABLE AT THAT TIME. PLEASE CONFIRM AGE SP RECEIVED FIRST DOSE.”

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF SP = MALE, THEN FILL GARDASIL

IF IMQ.080 = 1, DISPLAY “Cervarix”; ELSE IF IMQ.080 = 2, DISPLAY “Gardasil”; ELSE DISPLAY “the vaccine”.

IMQ.100 How many doses of {Cervarix/Gardasil/the vaccine} {have you/has SP} received?

1 DOSE 1

2 DOSES 2

3 DOSES 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF SP = MALE, THEN FILL GARDASIL

IF IMQ.080 = 1, DISPLAY “Cervarix”; ELSE IF IMQ.080 = 2, DISPLAY “Gardasil”; ELSE DISPLAY “the vaccine”.

PHYSICAL FUNCTIONING (PFQ)

Shape1

NHANES 2012

PHYSICAL FUNCTIONING - PFQ

Target Group: SPs 3+

BOX 1A

CHECK ITEM PFQ.001:

IF AGE OF SP IS >= 20, GO TO PFQ.049

OTHERWISE, CONTINUE.

PFQ.020 {Do you/Does SP} have an impairment or health problem that limits {your/his/her} ability to {walk, run or play} {walk or run}?

CAPI INSTRUCTION:

IF CHILD'S AGE = 3-15, DISPLAY "WALK, RUN OR PLAY". IF SP'S AGE = 16-19, DISPLAY "WALK OR RUN".

Yes 1

No 2 (BOX 1BB)

Refused 7 (BOX 1BB)

DON'T know 9 (BOX 1BB)

PFQ.030 Is this an impairment or health problem that has lasted, or is expected to last 12 months or longer?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1AA

CHECK ITEM PFQ.032:

IF SP AGE 3-15, CONTINUE.

OTHERWISE, GO TO BOX 1BB.

PFQ.033 {Do you/Does SP} have any impairment or health problem that requires {you/him/her} to use special equipment, such as a brace, a wheelchair, or a hearing aid (excluding ordinary eyeglasses or corrective shoes)?

YES 1

NO 2 (PFQ.041)

REFUSED 7 (PFQ.041)

DON'T KNOW 9 (PFQ.041)

PFQ.037 What special equipment {do you/does he/does she} use?

BRACE 1

WHEELCHAIR 2

HEARING AID 3

OTHER (SPECIFY) 4

REFUSED 7

DON'T KNOW 9

BOX 1BB

CHECK ITEM PFQ.035A:

IF SP AGE <= 17, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

PFQ.041 {Do you/Does SP} receive Special Education or Early Intervention Services?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Special Education: Teaching designed to meet the needs of a child with special needs and/or disabilities. It is designed for children and youths aged 3 to 21. It is paid for by the public school system and may take place at a regular school, a special school, a private school, at home, or at a hospital.

Early Intervention Services: Services designed to meet the needs of very young children with special needs and/or disabilities. They may include but are not limited to: medical and social services, parental counseling, and therapy. They may be provided at the child's home, a medical center, a day care center, or other place. They are provided by the state or school system at no cost to the parent.

BOX 1C

CHECK ITEM PFQ.045:

GO TO END OF SECTION.

PFQ.049 The next set of questions is about limitations caused by any long-term physical, mental or emotional problem or illness. Please do not include temporary conditions, such as a cold [or pregnancy].

Does a physical, mental or emotional problem now keep {you/SP} from working at a job or business?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PFQ.051 {Are you/Is SP} limited in the kind or amount of work {you/s/he} can do because of a physical, mental or emotional problem?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PFQ.054 Because of a health problem, {do you/does SP} have difficulty walking without using any special equipment?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PFQ.057 {Are you/Is SP} limited in any way because of difficulty remembering or because {you/s/he} experience{s} periods of confusion?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1D

CHECK ITEM PFQ.058:

IF 'YES' (CODE 1) IN PFQ.049, PFQ.051, PFQ.054, OR PFQ.057, GO TO PFQ.061.

OTHERWISE, CONTINUE.

PFQ.059 {Are you/Is SP} limited in any way in any activity because of a physical, mental or emotional problem?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1E

CHECK ITEM PFQ.059A:

IF SP AGE IS <=59 AND 'NO' (CODE 2) ENTERED IN PFQ.049, PFQ.057 AND PFQ.059, GO TO PFQ.090.

OTHERWISE, CONTINUE.

PFQ.061
a-t

The next questions ask about difficulties {you/SP} may have doing certain activities because of a health problem. By "health problem" we mean any long-term physical, mental or emotional problem or illness {not including pregnancy}.

By {yourself/himself/herself} and without using any special equipment, how much difficulty {do you/does SP} have . . .

HAND CARD PFQ1

DO NOT INCLUDE TEMPORARY CONDITIONS LIKE PREGNANCY OR BROKEN LIMBS.

CAPI INSTRUCTION:

IF PFQ.054 = '1' (YES), DO NOT DISPLAY 'B' OR 'C'.

IF SP FEMALE, DISPLAY 'NOT INCLUDING PREGNANCY'.

RESPONSES: NO DIFFICULTY = 1, SOME DIFFICULTY = 2, MUCH DIFFICULTY = 3,

UNABLE TO DO = 4, DO NOT DO THIS ACTIVITY = 5, REFUSED = 7, DON'T KNOW = 9.

a. managing {your/his/her} money [such as keeping track of

{your/his/her} expenses or paying bills]? ____

b. walking for a quarter of a mile [that is about 2 or 3 blocks]? ____

c. walking up 10 steps without resting? ____

d. stooping, crouching, or kneeling? ____

e. lifting or carrying something as heavy as 10 pounds [like a

sack of potatoes or rice]? ____

f. doing chores around the house [like vacuuming, sweeping,

dusting, or straightening up]? ____

g. preparing {your/his/her} own meals? ____

h. walking from one room to another on the same level? ____

i. standing up from an armless straight chair? ____

j. getting in or out of bed? ____

k. eating, like holding a fork, cutting food or drinking from a glass? ____

l. dressing {yourself/himself/herself}, including tying shoes,

working zippers, and doing buttons? ____

m. standing or being on {your/his/her} feet for about 2 hours? ____

n. sitting for about 2 hours? ____

o. reaching up over {your/his/her} head? ____

p. using {your/his/her} fingers to grasp or handle small objects? ____

q. going out to things like shopping, movies, or sporting events? ____

r. participating in social activities [visiting friends, attending

clubs or meetings or going to parties]? ____

s. doing things to relax at home or for leisure [reading, watching

TV, sewing, listening to music]? ____

t. pushing or pulling large objects like a living room chair? ____

BOX 1F

CHECK ITEM PFQ.066A:

IF ‘SOME DIFFICULTY’ (CODE 2), ‘MUCH DIFFICULTY’ (CODE 3), OR ‘UNABLE TO DO’ (CODE 4) IN PFQ.061 A THROUGH T, CONTINUE.

OTHERWISE, GO TO PFQ.090.

PFQ.063 What condition or health problem causes {you/SP} to have difficulty with or need help with {NAME OF UP TO 3 ACTIVITIES/these activities}?

HAND CARD PFQ2

ENTER ALL THAT APPLY UP TO 5 BUT DO NOT PROBE.

DO NOT ENTER 'OLD AGE' AS CONDITION -- IF OLD AGE IS REPORTED, PROBE FOR ANY OTHER CONDITION.

CAPI INSTRUCTION:

IF THE TOTAL NUMBER OF ITEMS CODED 'SOME DIFFICULTY' (CODE 2), 'MUCH DIFFICULTY' (CODE 3), OR 'UNABLE TO DO' (CODE 4) IN PFQ.061 A THROUGH T <=3, DISPLAY EACH ITEM NAME IN THE TEXT OF QUESTION. IF MORE THAN 3 ITEMS ARE CODED IN THIS MANNER DISPLAY "THESE ACTIVITIES" IN THE TEXT OF QUESTION.

ARTHRITIS/RHEUMATISM 10

BACK OR NECK PROBLEM 11

BIRTH DEFECT 12

CANCER 13

DEPRESSION/ANXIETY/EMOTIONAL

PROBLEM 14

OTHER DEVELOPMENTAL PROBLEM

(SUCH AS CEREBRAL PALSY) 15

DIABETES 16

FRACTURES, BONE/JOINT INJURY 17

HEARING PROBLEM 18

HEART PROBLEM 19

HYPERTENSION/HIGH BLOOD

PRESSURE 20

LUNG/BREATHING PROBLEM 21

MENTAL RETARDATION 22

OTHER INJURY 23

SENILITY 24

STROKE PROBLEM 25

VISION/PROBLEM SEEING 26

WEIGHT PROBLEM 27

OTHER IMPAIRMENT/PROBLEM 28

REFUSED 77

DON'T KNOW 99

PFQ.090 {Do you/Does SP} now have any health problem that requires {you/him/her} to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN FOR PFQ.020:

Impairment: An objective assessment of anatomical, physiological or mental losses from injury, disease, residuals of disease or birth defects. Impairments may or may not interfere with physical or mental functioning. Examples include missing limbs, digits or other body parts; partial paralysis from an early case of polio, accident or war wound; stiff joints, deformed fingers or other physical evidence of arthritis; and vision or hearing loss.

Problem (Health, Physical, Mental, Emotional): The person’s perception of a chronic, perhaps permanent, departure from physical, mental or emotional well-being. This includes specific health problems, such as a disease or condition, a missing extremity or organ, or any type of impairment. It also includes more vague disorders not always thought of as health related problems or illnesses, such as alcoholism, drug dependency or reaction, senility, depression, retardation, etc. Short-term disabilities (such as pregnancy or injury where full recovery is expected) should not be included as problems.

Health Problem: Respondent defined, should be limited to chronic conditions.

Limited: When a person can only partially perform an activity, can do it fully only part of the time, or cannot do it at all. Do not define this term to the respondent; if asked for a definition, emphasize that we are interested in whether the respondent thinks the person is limited in the specific activity or not.

Limited Activities: Difficulties that limit the child's ability to participate in the activities. We are only interested in difficulties that are associated with an impairment or a physical or mental health problem. Limited activity participation (for example, playing games) means that the child cannot do the activity as long or in the same way as he/she did previous to the impairment or physical or mental health problem, but still does it to some extent (as opposed to not being able to do it at all). If the child has had the impairment or physical or mental health problem since birth, limited activity participation means the child cannot do the activity as well as other children of his/her age, or as well as he/she might if he/she did not have the impairment or health problem.

HELP SCREEN FOR PFQ.030:

Health Problem: Respondent defined, should be limited to chronic conditions.

HELP SCREEN FOR PFQ.049:

Mental Problem: A problem having to do with state of mind; an emotional problem.

Emotional Problem: A kind of mental health problem affecting a person's emotional well being.

Physical Problem: Some people may not do some activities at all, because of a reason other than a health or physical problem. For example, some men may have difficulty preparing meals or doing laundry because their wives have always done it for them. If the respondent says he or she doesn't do the activity at all, remember to ask if that is due to an impairment or a health problem.

Condition: Respondent's perception of a departure from physical or mental well-being. Any response describing a health problem of any kind.

Work (Working): Paid work for wages, salary, commission, tips, or pay "in kind." Examples of pay in kind include meals, living quarters, or supplies provided in place of wages. This definition of employment includes work in the person's own business, professional practice, or farm, paid leaves of absence (including vacations and illnesses), work without pay in a family business or farm run by a relative, exchange work or share work on a farm, and work as a civilian employee of the Department of Defense or the National Guard. This definition excludes unpaid volunteer work (such as for a church or charity), unpaid leaves of absences, temporary layoffs (such as a strike), and work around the house.

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

3. The business is advertised to the public. (Some examples of advertising are: listing in the classified section of the telephone book, displaying a sign, distributing cards or leaflets, or any type of promotion which publicizes the type of work or services offered.)

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

Seasonal activity during the off season; a seasonal business outside of the normal season is not a business. For example, a family that chops and sells Christmas trees from October through December does not have a business in July.

Distributing products such as Tupperware or newspapers. Distributing products is not a business unless the person buys the goods directly from a wholesale distributor or producer, sells them to the consumer, and bears any losses resulting from failure to collect from the consumer.

HELP SCREEN FOR PFQ.051:

Mental Problem: A problem having to do with state of mind; an emotional problem.

Emotional Problem: A kind of mental health problem affecting a person's emotional well being.

HELP SCREEN FOR PFQ.054:

Special Equipment: Any device, tool, utensil, instrument, implement, etc., used as an aid in performing an activity because of a physical, mental or emotional problem. This includes the use of adult "diapers" for incontinence. However, ordinary eyeglasses and hearing aids should not be considered "special equipment." For example: a spoon is not normally considered as "special equipment;" however, a uniquely designed or functioning one used for eating by a person because of physical, mental or emotional problems is considered "special equipment."

Health Problem: Respondent defined, should be limited to chronic conditions.

HELP SCREEN FOR PFQ.057:

In Any Way: This refers to activities that are normal for most people of that age.

Difficulty: It is important to determine for the questions in this section whether the problems that a respondent might have with an activity are because of an impairment or a physical or mental health problem. Some people may not do these activities because of gender or social norms or because of personal preferences. For example, some men may have difficulty preparing meals or doing laundry because their wives have always done it for them. If the respondent says he or she doesn't do the activity at all, remember to ask if that is due to an impairment (deaf), a physical health problem (high blood pressure), or mental health problem (depression).

HELP SCREEN FOR PFQ.059:

In Any Way: This refers to activities that are normal for most people of that age.

Mental Problem: A problem having to do with state of mind; an emotional problem.

Emotional Problem: A kind of mental health problem affecting a person's emotional well being.

HELP SCREEN FOR PFQ.061:

Health Problem: Respondent defined, should be limited to chronic conditions.

Mental Problem: A problem having to do with state of mind; an emotional problem.

Emotional Problem: A kind of mental health problem affecting a person's emotional well being.

HELP SCREEN FOR PFQ.090:

Health Problem: Respondent defined, should be limited to chronic conditions.

Bed: Anything used for lying down or sleeping, including a sofa, cot, or mattress.

mEDICAL cONDITIONS Section (mcQ)

MEDICAL CONDITIONS – MCQ

Target Group: SPs 1+

MCQ.010 The following questions are about different medical conditions.

Has a doctor or other health professional ever told {you/SP} that {you have/s/he/SP has} asthma (az-ma)?

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “YOU” AND “YOU HAVE”.

IF SP AGE = 12-15, DISPLAY "SP" AND “S/HE HAS”.

IF SP AGE < 12, DISPLAY “YOU” AND “SP HAS”.

INTERVIEWER: DO NOT ACCEPT SELF-DIAGNOSED OR DIAGNOSED BY A PERSON WHO IS NOT A DOCTOR OR OTHER HEALTH PROFESSIONAL.

YES 1

NO 2 (MCQ.053)

REFUSED 7 (MCQ.053)

DON'T KNOW 9 (MCQ.053)

HELP SCREEN:

Asthma: Is a disease of the airways that carry air in and out of your lungs. It causes wheezing or whistling sounds when you breathe and can make you short of breath.

MCQ.025 How old {were you/was SP} when {you were/s/he was} first told {you/he/she} had asthma (az-ma)?

IF LESS THAN 1 YEAR, ENTER 1

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY "WERE YOU" AND "YOU WERE".

IF SP AGE = 12-15, DISPLAY "WAS {SP}" AND "S/HE WAS".

IF SP AGE < 12, DISPLAY "WAS {SP}" AND "YOU WERE".

|___|___|___|

ENTER AGE IN YEARS

CAPI INSTRUCTION:

HARD EDIT: 1-120

REFUSED 77777

DON'T KNOW 99999

MCQ.035 {Do you/Does SP} still have asthma (az-ma)?

YES 1

NO 2 (MCQ.053)

REFUSED 7 (MCQ.053)

DON'T KNOW 9 (MCQ.053)

MCQ.040 During the past 12 months, {have you/has SP} had an episode of asthma (az-ma) or an asthma attack?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Episode/attack: When your asthma symptoms become worse than usual it is called an asthma episode or attack.

MCQ.050 [During the past 12 months], {have you/has SP} had to visit an emergency room or urgent care center because of asthma (az-ma)?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AGQ.030 During the past 12 months, {have you/has SP} had an episode of hay fever?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Hay Fever: Hay fever is a collection of symptoms in the nose and eyes, caused by particles of plant pollen in the air. This happens in people who are allergic to these substances. The pollens that cause hay fever vary from person to person and from region to region. Hay fever typically occurs in the Spring, Summer, or Fall when plant pollen is in the air. Examples of plants commonly responsible for hay fever include Trees, Grasses, Flowers, and Ragweed.

MCQ.053 During the past 3 months, {have you/has SP} been on treatment for anemia (a-nee-me-a), sometimes called "tired blood" or "low blood"? [Include diet, iron pills, iron shots, transfusions as treatment.]

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Anemia: Anemia (uh-NEE-me-eh) is a condition in which a person’s blood has a lower than normal number of red blood cells (RBCs).

BOX 2

CHECK ITEM MCQ.055:

IF SP AGE < 6, GO TO END OF SECTION.

IF SP AGE 6-15, GO TO MCQ.092.

IF SP AGE 16+, CONTINUE.

MCQ.080 Has a doctor or other health professional ever told {you/SP} that {you were/s/he/SP was} overweight?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2A

OMITTED

BOX 3

OMITTED

MCQ.092 {Have you/Has SP} ever received a blood transfusion?

YES 1

NO 2 (BOX 7)

REFUSED 7 (BOX 7)

DON'T KNOW 9 (BOX 7)

MCQ.093 In what year did {you/SP} receive {your/his/her} first transfusion?

|___|___|___|___|

ENTER 4-DIGIT YEAR

CAPI INSTRUCTION:

HARD EDIT: >= birth year and <= current year

REFUSED 7777

DON’T KNOW 9999

BOX 4

OMITTED

BOX 6

OMITTED

BOX 7

CHECK ITEM MCQ.145:

IF SP'S AGE >= 20, GO TO MCQ.160.

OTHERWISE, CONTINUE.

BOX 7A

CHECK ITEM MCQ.146:

IF SP AGE 8-11 AND SP IS FEMALE, CONTINUE.

OTHERWISE, GO TO MCQ.203.

MCQ.149 Have {SP's} periods or menstrual (men-stral) cycles started yet?

YES 1

NO 2 (MCQ.203)

REFUSED 7 (MCQ.203)

DON'T KNOW 9 (MCQ.203)

HELP TEXT: When a girl starts having periods or menstrual cycles is a very important milestone in growth and development. Growth and development is very related to physical activity and body weight.

MCQ.151 How old was {SP} when she had {her} first menstrual period?

|___|___| YEARS (MCQ.203)

REFUSED 77 (MCQ.203)

DON'T KNOW 99 (MCQ.203)

Hard edits: maximum of 11 and age of onset must be less than or equal to current age.

Soft edit: if age less than 7.

HELP TEXT: When a girl starts having periods or menstrual cycles is a very important milestone in growth and development. Growth and development is very related to physical activity and body weight.

BOX 8

OMITTED

BOX 8A

OMITTED

MCQ.160 Has a doctor or other health professional ever told {you/SP} that {you/s/he} . . . CAPI INSTRUCTION: TEXT OF QUESTION SHOULD BE OPTIONAL AFTER FIRST ITEM IS READ.	MCQ.170 {Do you/Does SP} still . . . ?	MCQ.180 How old {were you/was SP} when {you were/s/he was} first told {you/s/he} . . .	MCQ.195 Which type of arthritis was it?
a. had arthritis (ar-thry-tis)? YES 1 NO 2 (n) REFUSED 7 (n) DON'T KNOW 9 (n)		had arthritis? \|___\|___\|___\| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999	Osteoarthritis or degenerative arthritis 1 Rheumatoid arthritis 2 Psoriatic arthritis 3 Other 4 REFUSED 7 DON’T KNOW 9
n. had gout? YES 1 NO 2 (b) REFUSED 7 (b) DON'T KNOW 9 (b)		had gout? \|___\|___\|___\| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999
b. had congestive heart failure? YES 1 NO 2 (c) REFUSED 7 (c) DON'T KNOW 9 (c)		had congestive heart failure? \|___\|___\|___\| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999
c. had coronary (kor-o-nare-ee) heart disease? YES 1 NO 2 (d) REFUSED 7 (d) DON'T KNOW 9 (d)		had coronary heart disease? \|___\|___\|___\| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999
d. had angina (an-gī-na), also called angina pectoris? YES 1 NO 2 (e) REFUSED 7 (e) DON'T KNOW 9 (e)		had angina, also called angina pectoris? \|___\|___\|___\| ENTER AGE IN YEARS REFUSED 777 DON'T KNOW 999

e. had a heart attack (also called myocardial infarction (my-O-car-dee-al in-fark-shun))?

YES 1

NO 2 (f)

REFUSED 7 (f)

DON'T KNOW 9 (f)

had a heart attack (also called myocardial infarction)?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

f. had a stroke?

YES 1

NO 2 (g)

REFUSED 7 (g)

DON'T KNOW 9 (g)

had a stroke?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

g. had emphysema (emph-phi-see-ma)?

YES 1

NO 2 (m)

REFUSED 7 (m)

DON'T KNOW 9 (m)

had emphysema?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

m. had a thyroid (thigh-roid) problem?

YES 1

NO 2 (k)

REFUSED 7 (k)

DON'T KNOW 9 (k)

have a thyroid problem?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

had a thyroid problem?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

k. had chronic bronchitis?

YES 1

NO 2 (l)

REFUSED 7 (l)

DON'T KNOW 9 (l)

have chronic bronchitis?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

had chronic bronchitis?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

l. had any kind of liver condition?

YES 1

NO 2 (MCQ.160o)

REFUSED 7 (MCQ.160o)

DON'T KNOW 9 (MCQ.160o)

have this liver condition?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

had this liver condition?

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

MCQ.160o. had COPD?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREENS FOR MCQ.160

MCQ160a

Arthritis: Is a disease that causes pain, swelling or stiffness in joints, for example the hand, the knee, or neck. Common kinds of arthritis are osteoarthritis and rheumatoid arthritis.

MCQ.195

Osteoarthritis: Is the most common kind of arthritis in older persons. It is also called degenerative joint disease. Most often, it affects the knees, the hips, the hands, the feet, and the spine. There is usually bony joint enlargement. There can be joint deformity or pain.

Rheumatoid Arthritis: Causes inflammation, redness and swelling of both hands and knees, but it can affect joints anywhere in the body. You may feel sick and tired, and sometimes there are fevers.

Psoriatic Arthritis: Is arthritis caused by the skin rash Psoriasis. Most often it causes redness and swelling of joints such as the spine, knees, hips and hands.

Arthritis: Is a disease that causes pain, swelling or stiffness in joints, for example the hand, the knee, or neck. Common kinds of arthritis are osteoarthritis and rheumatoid arthritis.

MCQ160n

Gout: Gout attacks are the sudden onset of pain, redness and swelling in a joint. The big toe is the most common joint attacked, but knee and wrist attacks are also common. Gout is caused by uric acid crystal build up in the body.

MCQ160b

Congestive Heart Failure: Is when the heart can't pump enough blood to the body. Blood and fluid "back up" into the lungs, which makes you short of breath. Heart failure causes fluid buildup in and swelling of the feet, legs and ankles.

INTERVIEWER: DO NOT COUNT HEART MURMURS, IRREGULAR HEART BEATS, CHEST PAIN OR HEART ATTACKS.

MCQ160c

Coronary Heart Disease: Is when the blood vessels that bring blood to the heart muscle become narrow and hardened due to plaque (plak). Plaque buildup is called atherosclerosis (ATH-er-o-skler-O-sis). Blocked blood vessels to the heart can cause chest pain or a heart attack.

INTERVIEWER: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR CORONARY HEART DISEASE.

MCQ160d

Angina (Angina Pectoris): (AN-ji-na or an-JI-na). Angina is chest pain or discomfort that occurs when the heart does not get enough blood.

INTERVIEWER: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR ANGINA.

MCQ160e

Heart Attack (Myocardial Infarction): A heart attack happens when there is narrowing of a blood vessel that supplies the heart. A blood clot can form and suddenly cut off the blood supply to the heart muscle. This damage causes crushing chest pain that may also be felt in the arms or neck. There can also be nausea, sweating, or shortness of breath.

MCQ160f

Stroke: Is when the blood supply to a part of the brain is suddenly cut off by a blood clot or a burst blood vessel in the brain. The part of the brain affected can no longer do its job. There can be numbness or weakness on one side of the body; trouble speaking or understanding speech; loss of eyesight; trouble with walking, dizziness, loss of balance or coordination; or severe headache.

MCQ160g

Emphysema: Is disease where the tiny air sacs in the lungs become damaged so less air goes in and out. As a result, the body does not get the oxygen it needs. Emphysema makes it hard to catch your breath. It is often due to smoking.

MCQ160m

Thyroid Problem: The thyroid is a gland in the neck that makes thyroid hormone. The thyroid sets your body's energy level: the temperature and heart rate. Thyroid problems include thyroid levels that are too high or too low, an inflamed or enlarged gland, and thyroid lumps or cancer.

INTERVIEWER: INCLUDE HYPERTHYROID (OVERACTIVE THYROID); HYPOTHYROID (UNDERACTIVE THYROID); GRAVES DISEASE (HYPERTHYROID AND/OR THYROID EYE DISEASE); HASHIMOTO'S THYRODITIS (INFLAMED THYROID); POSTPARTUM THYROIDITIS (INFLAMED THYROID THAT HAPPENS AFTER DELIVERY OF A BABY); GOITER (ENLARGED THYROID); THYROID NODULE (LUMP IN THYROID- NOT CANCER); AND THYROID CANCER.

MCQ160k

Chronic Bronchitis: Is a long lasting breathing problem where you constantly cough up phlegm. Often there is a daily cough with phlegm for several months at a time for two or more years and you are short of breath. It is often due to smoking.

MCQ.160o

COPD: stands for “Chronic Obstructive Pulmonary Disease.” It includes both Emphysema and Chronic Bronchitis. It is lung problem where you have trouble getting air in and out of your lungs. You may also have constant cough and phlegm.

MCQ.203 Has anyone ever told {you/SP} that {you/she/he/SP} had yellow skin, yellow eyes or jaundice? Please do not include infant jaundice, which is common during the first weeks after birth.

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “YOU” AND “YOU”.

IF SP AGE = 12-15, DISPLAY "SP" AND “S/HE”.

IF SP AGE = 6-11, DISPLAY “YOU” AND “SP”.

INTERVIEWER: DO ACCEPT SELF-DIAGNOSED OR DIAGNOSED BY A PERSON WHO IS NOT A DOCTOR OR OTHER HEALTH PROFESSIONAL.

YES 1

NO 2 (BOX 8B)

REFUSED 7 (BOX 8B)

DON'T KNOW 9 (BOX 8B)

HELP SCREEN:

Infant jaundice is a yellow discoloration in a newborn baby’s skin and eyes.

MCQ.206 How old {were you/was SP} when {you were/s/he was} first told {you/s/he} had yellow skin, yellow eyes or jaundice?

INTERVIEWER: IF LESS THAN 1 YEAR, ENTER 0

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY "WERE YOU" AND "YOU WERE" AND “YOU”.

IF SP AGE = 12-15, DISPLAY "WAS {SP}" AND "S/HE WAS" AND “S/HE”.

IF SP AGE = 6-11, DISPLAY "WAS {SP}" AND "YOU WERE" AND “S/HE”.

Hard edit: MCQ.206 > SP AGE

|___|___|___|

ENTER AGE IN YEARS

CAPI INSTRUCTION:

HARD EDIT: 0-120

REFUSED 777

DON'T KNOW 999

HELP SCREEN:

Infant jaundice is a yellow discoloration in a newborn baby’s skin and eyes.

BOX 8AA

CHECK ITEM MCQ.209:

IF SP MCQ.206 = ZERO, CONTINUE.

ELSE, GO TO BOX 8B.

MCQ.207 Please remember not to include infant jaundice, which is common during the first weeks after birth. {Have you/Has SP} been told that {you/he/she} had yellow skin, yellow eyes or jaundice other than during the first weeks after birth?

YES 1 (BOX 8B)

NO 2

REFUSED 7 (BOX 8B)

DON'T KNOW 9 (BOX 8B)

CAPI INSTRUCTION:

IF MCQ.207 = NO, THEN CHANGE MCQ.203 = NO AND MCQ.206 = EMPTY AND CONTINUE TO BOX 8B.

BOX 8B

CHECK ITEM MCQ.208:

IF SP AGE 6-19, GO TO MCQ300b

IF SP AGE ≥ 20, CONTINUE.

MCQ.220 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had cancer or a malignancy (ma-lig-nan-see) of any kind?

YES 1

NO 2 (MCQ.300a)

REFUSED 7 (MCQ.300a)

DON'T KNOW 9 (MCQ.300a)

HELP SCREEN:

Cancer: Is an abnormal growth that can spread to other parts of the body. This causes damage and even death. Most cancers are named for where they start: for example lung cancer or breast cancer. A cancer is also called a "malignancy" or a "malignant tumor".

Malignancy: A tumor or growth that is a cancer. (see Cancer)

MCQ.230 What kind of cancer was it?

ENTER UP TO 3 KINDS. IF RESPONDENT OFFERS MORE THAN 3, ENTER 66 AS THE 4TH RESPONSE.

CAPI INSTRUCTIONS:

ALLOW UP TO 3 ENTRIES.

ALLOW 'MORE THAN 3 KINDS (CODE 66) ONLY AS 4TH ENTRY.

( ) ( ) ( ) ( )

BLADDER 10

BLOOD 11

BONE 12

BRAIN 13

BREAST 14

CERVIX (CERVICAL) 15

COLON 16

ESOPHAGUS (ESOPHAGEAL) 17

GALLBLADDER 18

KIDNEY 19

LARYNX/WINDPIPE 20

LEUKEMIA 21

LIVER 22

LUNG 23

LYMPHOMA/HODGKINS' DISEASE 24

MELANOMA 25

MOUTH/TONGUE/LIP 26

NERVOUS SYSTEM 27

OVARY (OVARIAN) 28

PANCREAS (PANCREATIC) 29

PROSTATE 30

RECTUM (RECTAL) 31

SKIN (NON-MELANOMA) 32

SKIN (DON'T KNOW WHAT KIND) 33

SOFT TISSUE (MUSCLE OR FAT) 34

STOMACH 35

TESTIS (TESTICULAR) 36

THYROID 37

UTERUS (UTERINE) 38

OTHER 39

MORE THAN 3 KINDS 66

REFUSED 77

DON'T KNOW 99

BOX 9

LOOP 1:

ASK MCQ.240 FOR EACH TYPE OF CANCER (CODES 10-39 AND CODE 99) ENTERED IN MCQ.230.

MCQ.240 How old {were you/was SP} when {TYPE OF CANCER/cancer} was first diagnosed?

CAPI INSTRUCTIONS:

DISPLAY TYPE OF CANCER (CODE 10-39) ENTERED IN MCQ.230.

DISPLAY "CANCER " IF DON'T KNOW ENTERED IN MCQ.230.

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

BOX 9A

END LOOP 1:

ASK MCQ.240 FOR NEXT TYPE OF CANCER (CODES 10-39 AND CODE 99) ENTERED IN MCQ.230.

IF NO NEXT TYPE, CONTINUE WITH MCQ.300a.

BOX 10

OMITTED

BOX 10A

OMITTED

MCQ.300
a/b/c

Including living and deceased, were any of {SP’s/your} close biological that is, blood relatives including father, mother, sisters or brothers, ever told by a health professional that they had . . .

CAPI INSTRUCTION:

TEXT OF QUESTION SHOULD BE OPTIONAL, “[ ]’S, AFTER FIRST TIME.

a. a heart attack or angina (an-gī-na) before the age of 50?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

b. asthma (az-ma)?

CAPI INSTRUCTION:

IF SP AGE 6-19, DISPLAY: Including living and deceased, were any of {SP’s/your} close biological that is, blood relatives including father, mother, sisters or brothers, ever told by a health professional that they had . . .

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 10c

OMITTED

BOX 10D

CHECK ITEM MCQ.360:

IF SP AGE 6-15, GO TO END OF SECTION.

IF SP AGE16-19, GO TO MCQ.365.

OTHERWISE, CONTINUE.

c. diabetes?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 11

OMITTED

MCQ.365 To lower {your/SP’s} risk for certain diseases, during the past 12 months {have you/has s/he} ever

a/b/c/d been told by a doctor or health professional to:

RESPONSES: YES = 1, NO = 2, REFUSED = 7, DON’T KNOW = 9

a. control {your/his/her} weight or lose weight? ____

b. increase {your/his/her} physical activity or exercise? ____

c. reduce the amount of sodium or salt in {your/his/her} diet? ____

d. reduce the amount of fat or calories in {your/his/her} diet? ____

HELP SCREEN: Controlling your weight might be recommended to help prevent high blood pressure, diabetes, high cholesterol and other conditions.

MCQ.370 To lower {your/his/her} risk for certain diseases, {are you/is s/he} now doing any of the following:

a/b/c/d

RESPONSES: YES = 1, NO = 2, REFUSED = 7, DON’T KNOW = 9

a. controlling {your/his/her} weight or losing weight? ____

b. increasing {your/his/her} physical activity or exercise? ____

c. reducing the amount of sodium or salt in {your/his/her} diet? ____

d. reducing the amount of fat or calories in {your/his/her} diet? ____

HELP SCREEN: Controlling your weight might be recommended to help prevent high blood pressure, diabetes, high cholesterol and other conditions.

Hepatitis (HEQ)

HEPATITIS (HEQ)

Target Group: SPs 6+

HEQ.010 Has a doctor or other health professional ever told {you/SP} that {you have/s/he/SP has} hepatitis B? (Hepatitis is a form of liver disease. Hepatitis B is an infection of the liver from the hepatitis B virus (HBV).)

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “YOU” AND “YOU HAVE”.

IF SP AGE = 12-15, DISPLAY "SP" AND “S/HE HAS”.

IF SP AGE = 6-11, DISPLAY “YOU” AND “SP HAS”.

INTERVIEWER: DO NOT ACCEPT SELF-DIAGNOSED OR DIAGNOSED BY A PERSON WHO IS NOT A DOCTOR OR OTHER HEALTH PROFESSIONAL.

YES 1

NO 2 (HEQ.030)

REFUSED 7 (HEQ.030)

DON'T KNOW 9 (HEQ.030)

HEQ.020 {Were you/ Was/s/he/SP} ever prescribed any medicine to treat hepatitis B?

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “WERE YOU”.

IF SP AGE = 12-15, DISPLAY "WAS S/HE”.

IF SP AGE = 6-11, DISPLAY “WAS SP”.

INTERVIEWER: Hepatitis B can be treated with medications such as Interferon, entecavir, lamivudine, adefovir, telbivudine or tenofovir.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HEQ.030 Has a doctor or other health professional ever told {you/SP} that {you have/s/he/SP has} hepatitis C? (Hepatitis is a form of liver disease. Hepatitis C is an infection of the liver from the hepatitis C virus (HCV).)

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “YOU” AND “YOU HAVE”.

IF SP AGE = 12-15, DISPLAY "SP" AND “S/HE HAS”.

IF SP AGE = 6-11, DISPLAY “YOU” AND “SP HAS”.

INTERVIEWER: DO NOT ACCEPT SELF-DIAGNOSED OR DIAGNOSED BY A PERSON WHO IS NOT A DOCTOR OR OTHER HEALTH PROFESSIONAL.

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

HEQ.040 {Were you/ Was/s/he/ SP} ever prescribed any medicine to treat hepatitis C?

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “WERE YOU”.

IF SP AGE = 12-15, DISPLAY "WAS S/HE”.

IF SP AGE = 6-11, DISPLAY “WAS SP”.

INTERVIEWER: HEPATITIS C CAN BE TREATED WITH MEDICATIONS SUCH AS INTERFERON AND RIBAVIRIN, BOCEPREVIR OR TELAPREVIR.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

KIDNEY CONDITIONS (KIQ)

KIDNEY CONDITIONS – KIQ

Target Group: SPs 20+

KIQ.022 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had weak or failing kidneys? Do not include kidney stones, bladder (bladd-er) infections, or incontinence (in‑kon‑ti‑nens).

YES 1

NO 2 (KIQ.026)

REFUSED 7 (KIQ.026)

DON'T KNOW 9 (KIQ.026)

HELP SCREEN:

Health Care Professionals (Health Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor's assistants, nurse practitioners, nurses, lab technicians, technicians who administer shots (i.e., allergy shots), and who work with a doctor. Also include paramedics, medics, and physical therapists working with or in a doctor's office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.

KIQ.025 In the past 12 months, {have you/has SP} received dialysis (either hemodialysis (heemo-di-al-i-sis) or peritoneal dialysis (pare-i-ton-nee-al di-al-i-sis))?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

KIQ.026 {Have you/Has SP} ever had kidney stones?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

KIQ.NEW1 In the past 12 months have you passed a kidney stone?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN: If the respondent indicates a stone was not passed but they had it broken up with lithotripsy or removed by a doctor code “YES”.

DISABILITY (DLQ)

DISABILITY (DLQ)

Target Group: SPs 1+

DLQ.010 With this next set of questions, we want to learn about people who have physical, mental, or emotional conditions that cause serious difficulties with their daily activities. Though different, these questions may sound similar to ones I asked earlier.

{Are you/Is SP} deaf or {do you/does he/does she} have serious difficulty hearing?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “YOU” AND “DO YOU”.

IF SP AGE <16, DISPLAY "SP" AND “DOES HE/DOES SHE”.

DLQ.020 {Are you/Is SP} blind or {do you/does he/does she} have serious difficulty seeing even when wearing glasses?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “YOU” AND “DO YOU”.

IF SP AGE <16, DISPLAY "SP" AND “DOES HE/DOES SHE”.

BOX 1

CHECK ITEM DLQ.030:

IF SP AGE < 5, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

DLQ.040 Because of a physical, mental, or emotional condition, {do you/does he/does she} have serious difficulty concentrating, remembering, or making decisions?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “DO YOU”.

IF SP AGE <16, DISPLAY “DOES HE/DOES SHE”.

DLQ.050 {Do you/Does SP} have serious difficulty walking or climbing stairs?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “DO YOU”.

IF SP AGE <16, DISPLAY “DOES SP”.

DLQ.060 {Do you/Does SP} have difficulty dressing or bathing?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2

CHECK ITEM DLQ.070:

IF SP AGE < 15, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

DLQ.080 Because of a physical, mental, or emotional condition, {do you/does he/does she} have difficulty doing errands alone such as visiting a doctor's office or shopping?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “DO YOU”.

IF SP AGE <16, DISPLAY “DOES HE/DOES SHE”.

BOX NEW.001

CHECK ITEM DLQ.NEW.001

IF SP AGE < 18 OR PROXY INTERVIEW, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

NEW.001 How often do you feel worried, nervous or anxious? Would you say daily, weekly, monthly, a few times a year, or never?

DAILY 1

WEEKLY 2

MONTHLY 3

A FEW TIMES A YEAR 4

NEVER 5

REFUSED 7

DON'T KNOW 9

NEW.002 Do you take medication for these feelings?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX NEW.002

CHECK ITEM DLQ.NEW.002

IF NEW.001 = 5, GO TO NEW.004

OTHERWISE, CONTINUE.

NEW.003 Thinking about the last time you felt worried, nervous or anxious, how would you describe the level of these feelings? Would you say a little, a lot, or somewhere in between?

A LITTLE 1

A LOT 2

SOMEWHERE IN BETWEEN A LITTLE AND A LOT 3

REFUSED 7

DON'T KNOW 9

NEW.004 How often do you feel depressed? Would you say daily, weekly, monthly, a few times a year, or never?

DAILY 1

WEEKLY 2

MONTHLY 3

A FEW TIMES A YEAR 4

NEVER 5

REFUSED 7

DON'T KNOW 9

NEW.005 Do you take medication for depression?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX NEW.003

CHECK ITEM DLQ.NEW.003

IF NEW.004 = 5, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

NEW.006 Thinking about the last time you felt depressed, how depressed did you feel? Would you say a little, a lot, or somewhere in between?

A LITTLE 1

A LOT 2

SOMEWHERE IN BETWEEN A LITTLE AND A LOT 3

REFUSED 7

DON'T KNOW 9

DIABETES (DIQ)

DIABETES – DIQ

Target Group: SPs 1+

DIQ.010 {Other than during pregnancy, {have you/has SP}/{Have you/Has SP}} ever been told by a doctor or other health professional that {you have/{s/he/SP} has} diabetes or sugar diabetes?

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY "HAVE YOU" AND "YOU HAVE"

IF SP AGE 12-15, DISPLAY "HAS {SP}" AND "S/HE HAS"

IF SP AGE <12, DISPLAY "HAVE YOU" AND "{SP} HAS"

IF SP IS FEMALE AND AGE >= 20, DISPLAY "OTHER THAN DURING PREGNANCY, {HAVE YOU/HAS SP}".

YES 1

NO 2 (BOX 4)

BORDERLINE OR PREDIABETES 3 (BOX 4)

REFUSED 7 (BOX 4)

DON'T KNOW 9 (BOX 4)

DIQ.040
G/Q

How old {was SP/were you} when a doctor or other health professional first told {you/him/her} that {you/s/he} had diabetes or sugar diabetes?

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY "WERE YOU" AND "YOU" AND "YOU"

IF SP AGE 12-15, DISPLAY "WAS {SP}" AND "HIM/HER" AND "S/HE"

IF SP AGE <12, DISPLAY "WAS {SP}" AND "YOU" AND "S/HE"

|___|

ENTER AGE IN YEARS 1

LESS THAN 1 YEAR 2 (BOX 4)

REFUSED 7 (BOX 4)

DON'T KNOW 9 (BOX 4)

|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

BOX 4

CHECK ITEM DIQ.159:

IF AGE < 12 OR DIQ.010 = 1 (YES) GO TO DIQ.050.

IF AGE >= 12 AND DIQ.010 = 3, GO TO DIQ.170.

OTHERWISE, CONTINUE.

DIQ.160 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/SP has} any of the following: prediabetes, impaired fasting glucose, impaired glucose tolerance, borderline diabetes or that {your/her/his} blood sugar is higher than normal but not high enough to be called diabetes or sugar diabetes?

HAND CARD DIQ1

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN: PREDIABETES, IMPAIRED FASTING GLUCOSE, IMPAIRED GLUCOSE TOLERANCE, OR BORDERLINE DIABETES OCCURS WHEN BLOOD SUGAR (GLUCOSE) LEVELS ARE HIGHER THAN NORMAL BUT NOT HIGH ENOUGH TO BE DIABETES.

DIQ.170 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/s/he has} health conditions or a medical or family history that increases {your/his/her} risk for diabetes?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

DIQ.172 {Do you/Does SP} feel {you/he/she} could be at risk for diabetes or prediabetes?

YES 1

NO 2 (DIQ.180)

REFUSED 7 (DIQ.180)

DON’T KNOW 9 (DIQ.180)

DIQ.175 Why {Do you/Does SP} think {you are/he is/she is} at risk for diabetes or prediabetes?

[Anything else?]

INTERVIEWER INSTRUCTION: DO NOT READ. CODE ALL THAT APPLY.

CAPI INSTRUCTION: IF RESPONDENT ANSWERS “OTHER”, ALLOW ENTRY OF RESPONSE UP TO 250 CHARACTERS.

HAND CARD DIQ2

FAMILY HISTORY 10

OVERWEIGHT 11

AGE 12

POOR DIET 13

RACE . 14

HAD A BABY THAT WEIGHED OVER 9 LBS. AT
BIRTH 15

LACK OF PHYSICAL ACTIVITY OR SEDENTARY
LIFESTYLE …. 16

HIGH BLOOD PRESSURE 17

HIGH BLOOD SUGAR 18

HIGH CHOLESTEROL 19

HYPOGLYCEMIC 20

EXTREME HUNGER 21

TINGLING/NUMBNESS IN HANDS OR FEET 22

BLURRED VISION 23

INCREASED FATIGUE 24

ANYONE COULD BE AT RISK 25

DOCTOR WARNING 26

OTHER, SPECIFY 27

GESTATIONAL DIABETES 28

FREQUENT URINATION 29

THIRST 30

REFUSAL 77

DON’T KNOW 99

DIQ.180 {Have you/Has SP} had a blood test for high blood sugar or diabetes within the past three years?

INTERVIEWER INSTRUCTION: DO NOT INCLUDE URINE TESTS

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

DIQ.050 {Is SP/Are you} now taking insulin?

YES 1

NO 2 (BOX 0)

REFUSED 7 (BOX 0)

DON'T KNOW 9 (BOX 0)

HELP SCREEN:

Insulin: A chemical used in the treatment of diabetes. Typically, insulin is administered with a syringe by the patient.

DIQ.060
G/Q/U

For how long {have you/has SP} been taking insulin?

|___|

ENTER NUMBER (OF MONTHS OR YEARS) 1

LESS THAN 1 MONTH 2 (BOX 0)

REFUSED 7 (BOX 0)

DON'T KNOW 9 (BOX 0)

|___|___|___|

ENTER NUMBER (OF MONTHS OR YEARS)

REFUSED 77777 (BOX 0)

DON'T KNOW 99999 (BOX 0)

ENTER UNIT

|___|

MONTHS 1

YEARS 2

HELP SCREEN:

Insulin: A chemical used in the treatment of diabetes. Typically, insulin is administered with a syringe by the patient.

BOX 0

CHECK ITEM DIQ.065:

IF DIQ.010 = 1 (YES) OR DIQ.160 = 1 (YES) OR DIQ.010 = 3, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

DIQ.070 {Is SP/Are you} now taking diabetic pills to lower {{his/her}/your} blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 8

CHECK ITEM DIQ.229:

IF DIQ.010 = 3 OR DIQ.160 = 1 (YES), GO TO END OF SECTION.

OTHERWISE, CONTINUE.

DIQ.230 When was the last time {you/SP} saw a diabetes nurse educator or dietitian or nutritionist for {your/his/her} diabetes? Do not include doctors or other health professionals.

INTERVIEWER INSTRUCTION: IF RESPONDENT ANSWERS “TODAY” OR A PERIOD LESS THAN A MONTH, CODE 1 – 1 YEAR AGO OR LESS.

1 YEAR AGO OR LESS 1

MORE THAN 1 YEAR AGO BUT NO MORE
THAN 2 YEARS AGO 2

MORE THAN 2 YEARS AGO BUT NO MORE
THAN 5 YEARS AGO 3

MORE THAN 5 YEARS AGO 4

NEVER 5

REFUSED 7

DON’T KNOW 9

HELP SCREEN: A diabetes nurse educator is a nurse who teaches people with diabetes and who is knowledgeable about the day-to-day aspects of diabetes self-care, such as, use of diabetes medications, checking and controlling blood glucose levels, managing weight through diet and physical activity, and maintaining a healthy pregnancy if diabetes is present.

DIQ.240 Is there one doctor or other health professional {you usually see/SP usually sees} for {your/his/her} diabetes? Do not include specialists to whom {you have/SP has} been referred such as diabetes educators, dieticians or foot and eye doctors.

YES 1

NO 2 (DIQ.260)

REFUSED 7 (DIQ.260)

DON’T KNOW 9 (DIQ.260)

HELP SCREEN: A diabetes nurse educator is a nurse who teaches people with diabetes and who is knowledgeable about the day-to-day aspects of diabetes self-care, such as, use of diabetes medications, checking and controlling blood glucose levels, managing weight though diet and physical activity, and maintaining a healthy pregnancy if diabetes is present.

DIQ.250 How many times {have you/has SP} seen this doctor or other health professional in the past 12 months?

|___|___|___|

ENTER NUMBER OF TIMES

CAPI INSTRUCTION:

HARD EDIT: DO NOT ALLOW 0.

NONE 2

REFUSED 7777

DON'T KNOW 9999

BOX 9

CHECK ITEM DIQ.369:

IF DIQ.250 = 2 (NONE), CONTINUE.

OTHERWISE, GO TO BOX 10.

DIQ.370 INTERVIEWER: YOU HAVE ENTERED “NONE” FOR THE NUMBER OF TIMES IN THE PAST 12 MONTHS THAT THE SP HAS SEEN THEIR USUAL DOCTOR OR OTHER HEALTH PROFESSIONAL. THIS IS AN UNLIKELY RESPONSE. IS THIS CORRECT?

YES 1

NO 2 (DIQ.250)

BOX 10

CHECK ITEM DIQ.379:

IF DIQ.250 = 100 OR MORE, CONTINUE.

OTHERWISE, GO TO DIQ.260.

DIQ.380 INTERVIEWER: YOU HAVE ENTERED A VALUE THAT IS OUTSIDE THE EXPECTED RANGE FOR THE NUMBER OF TIMES IN THE PAST 12 MONTHS THAT THE SP HAS SEEN THEIR USUAL DOCTOR OR OTHER HEALTH PROFESSIONAL. THIS IS AN UNLIKELY RESPONSE. IS THIS CORRECT?

YES 1

NO 2 (DIQ.250)

DIQ.260
G/Q/U

How often {do you check your/does SP check his/her} blood for glucose or sugar? Include times when checked by a family member or friend, but do not include times when checked by a doctor or other health professional.

INTERVIEWER INSTRUCTION: DO NOT INCLUDE URINE TESTS.

|___|

ENTER NUMBER OF TIMES 1

NEVER 2 (DIQ.275)

UNABLE TO DO ACTIVITY (BLIND) 3 (DIQ.275)

REFUSED 7 (DIQ.275)

DON'T KNOW 9 (DIQ.275)

|___|___|___|

ENTER NUMBER OF TIMES

CAPI INSTRUCTION: SOFT EDIT 7 OR MORE PER DAY

SOFT EDIT 30 OR MORE PER WEEK.

REFUSED 7777 (DIQ.275)

DON'T KNOW 9999 (DIQ.275)

ENTER UNIT

|___|

PER DAY 1

PER WEEK 2

PER MONTH 3

PER YEAR 4

DIQ.275 Glycosylated (GLY-CO-SYL-AT-ED) hemoglobin or the “A one C” test measures your average level of blood sugar for the past 3 months, and usually ranges between 5.0 and 13.9. During the past 12 months, has a doctor or other health professional checked {your/SP’s} glycosylated hemoglobin or “A one C”?

YES 1

NO 2 (BOX 10A)

REFUSED 7 (BOX 10A)

DON'T KNOW 9 (BOX 10A)

DIQ.280 What was {your/SP’s} last “A one C” level?

CAPI INSTRUCTION:

SOFT EDIT FOR ANY NUMBER LESS THAN 5 OR MORE THAN 14.

|___|___| . |___|

ENTER VALUE

REFUSED 7777

DON'T KNOW 9999

DIQ.291 What does {your/SP’s} doctor or other health professional say {your/his/her} “A one C” level should be? (Pick the lowest level recommended by {your/his/her} health care professional.)

HAND CARD DIQ3

LESS THAN 6 1

LESS THAN 7 2

LESS THAN 8 3

LESS THAN 9 4

LESS THAN 10 5

PROVIDER DID NOT SPECIFY GOAL 6

REFUSED 77

DON'T KNOW 99

BOX 10A

CHECK ITEM DIQ.295:

IF AGE <12, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

DIQ.300
S/D

Blood pressure is usually given as one number over another. What was {your/SP’s} most recent blood pressure in numbers?

|___|___|___| OVER |___|___|___|

SYSTOLIC DIASTOLIC

ENTER VALUES

CAPI INSTRUCTION:

SYSTOLIC RANGE: 0-776 SOFT EDIT: 80-200.

DIASTOLIC RANGE: 0-776 SOFT EDIT: 0-150.

REFUSED 777

DON'T KNOW 999

DIQ.310
G/S/D

What does {your/SP’s} doctor or other health professional say {your/his/her} blood pressure should be?

|___|

ENTER VALUES 1

PROVIDER DID NOT SPECIFY GOAL 2 (DIQ.320)

REFUSED 7 (DIQ.320)

DON'T KNOW 9 (DIQ.320)

|___|___|___| OVER |___|___|___|

SYSTOLIC DIASTOLIC

ENTER VALUES

INTERVIEWER INSTRUCTION:

IF RANGE GIVEN, RECORD UPPER VALUE OF RANGE.

CAPI INSTRUCTION:

SYSTOLIC RANGE: 0-776 SOFT EDIT: 80-200.

DIASTOLIC RANGE: 0-776 SOFT EDIT: 0-150.

REFUSED 777

DON'T KNOW 999

DIQ.320
G/Q

One part of total serum cholesterol in {your/SP’s} blood is a bad cholesterol, called LDL, which builds up and clogs {your/his/her} arteries. What was {your/his/her} most recent LDL cholesterol number?

|___|

ENTER VALUE 1

NEVER HEARD OF LDL 2 (DIQ.341)

NEVER HAD CHOLESTEROL TEST 3 (DIQ.341)

REFUSED 7

DON'T KNOW 9

|___|___|___|

ENTER VALUE

CAPI INSTRUCTION:

RANGE: 0-776 SOFT EDIT: 40-250.

REFUSED 777

DON'T KNOW 999

DIQ.330
G/Q

What does {your/SP’s} doctor or other health professional say {your/his/her} LDL cholesterol should be?

|___|

ENTER VALUE 1

PROVIDER DID NOT SPECIFY GOAL 2 (DIQ.341)

REFUSED 7 (DIQ.341)

DON'T KNOW 9 (DIQ.341)

|___|___|___|

ENTER VALUE

INTERVIEWER INSTRUCTION:

IF RANGE GIVEN, RECORD UPPER VALUE OF RANGE.

CAPI INSTRUCTION:

RANGE: 0-776 SOFT EDIT: 40-250.

REFUSED 777

DON'T KNOW 999

DIQ.341
G/Q

During the past 12 months, about how many times has a doctor or other health professional checked {your/SP’s} feet for any sores or irritations?

|___|

ENTER NUMBER OF TIMES 1

NONE 2

BOTH FEET AMPUTATED 3 (DIQ.360)

REFUSED 7

DON'T KNOW/not sure 9

|___|___|___|

ENTER NUMBER OF TIMES

CAPI INSTRUCTION:

HARD EDIT: DO NOT ALLOW 0.

REFUSED 7777

DON'T KNOW/not sure 9999

DIQ.350
G/Q/U

How often {do you check your feet/does SP check (his/her) feet} for sores or irritations? Include times when checked by a family member or friend, but do not include times when checked by a doctor or other health professional.

|___|

ENTER NUMBER OF TIMES 1

NONE 2 (DIQ.360)

REFUSED 7 (DIQ.360)

DON'T KNOW 9 (DIQ.360)

CAPI INSTRUCTION:

HARD EDIT: DO NOT ALLOW 0.

|___|___|___|

ENTER NUMBER OF TIMES

REFUSED 7777

DON'T KNOW 9999

ENTER UNIT

|___|

PER DAY 1

PER WEEK 2

PER MONTH 3

PER YEAR 4

DIQ.360 When was the last time {you/SP} had an eye exam in which the pupils were dilated? This would have made {you/SP} temporarily sensitive to bright light.

LESS THAN 1 MONTH 1

1-12 MONTHS 2

13-24 MONTHS 3

GREATER THAN 2 YEARS 4

NEVER 5

REFUSED 7

DON'T KNOW 9

DIQ.080 Has a doctor ever told {you/SP} that diabetes has affected {your/his/her} eyes or that {you/s/he} had retinopathy (ret-in-op-ath-ee)?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Retinopathy: Any disorder of the retina.

Diabetes: A glandular disease that impairs the ability of the body to use sugar and causes sugar to appear abnormally in the urine. Common symptoms are persistent thirst and excessive discharge of urine. Do not include gestational diabetes or diabetes that was only present during pregnancy. Also, do not include self-diagnosed diabetes, pre-diabetes or high sugar.

HELP SCREEN FOR DIQ.010/040:

Blood Pressure Section (BPQ)

BLOOD PRESSURE – BPQ

Target Group: SPs 16+

BPQ.020 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had hypertension (hy-per-ten-shun), also called high blood pressure?

IF HIGH BLOOD PRESSURE ONLY DURING PREGNANCY, CODE NO.

INTERVIEWER INSTRUCTION: IF SP SAYS “HIGH NORMAL BLOOD PRESSURE”, “BORDERLINE HYPERTENSION” OR “PREHYPERTENSION” CODE NO.

YES 1

NO 2 (BPQ.080)

REFUSED 7 (BPQ.080)

DON'T KNOW 9 (BPQ.080)

HELP SCREEN:

Hypertension (High Blood Pressure): A repeatedly increased blood pressure with the first number 140 or higher and the second number 90 or higher.

BPQ.030 {Were you/Was SP} told on 2 or more different visits that {you/s/he} had hypertension (hy-per-ten-shun), also called high blood pressure?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BPQ.035 How old {were you/was SP} when {you were/he/she was} first told that {you/he/she} had hypertension or high blood pressure?

|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

BPQ.040a Because of {your/SP’s} (high blood pressure/hypertension) (hy-per-ten-shun), {have you/has s/he} ever been told to take prescribed medicine?

YES 1

NO 2 (BPQ.080)

REFUSED 7 (BPQ.080)

DON’T KNOW 9 (BPQ.080)

HELP SCREEN:

Prescribed Medicine: Prescribed medicines are those ordered by a doctor or other health provider through a written or verbal prescription for a pharmacist to fill. Prescription medicines can also be given by a medical provider directly to a patient to take home, such as free samples.

BOX 1A

OMITTED

BOX 1B

OMITTED

BPQ.050a {Are you/Is SP} now taking a prescribed medicine?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 2

OMITTED

BPQ.080 {Have you/Has SP} ever been told by a doctor or other health professional that {your/his/her} blood cholesterol level was high?

YES 1 (BPQ.070)

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Cholesterol: Cholesterol is a type of fat in the bloodstream and is measured with a blood test, usually done in the morning before you’ve eaten. High levels of cholesterol are a major risk factor for heart disease, which leads to heart attack.

BPQ.060 {Have you/Has SP} ever had {your/his/her} blood cholesterol checked?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

BPQ.070 About how long has it been since {you/SP} last had {your/his/her} blood cholesterol checked? Has it been…

less than 1 year ago, 1

1 year but less than 2 years ago, 2

2 years but less than 5 years ago, or 3

5 years or more? 4

REFUSED 7

DON'T KNOW 9

BPQ.090d To lower {your/his/her} blood cholesterol, {have you/has SP} ever been told by a doctor or other health professional to take prescribed medicine?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

HELP SCREEN:

BOX 3

OMITTED

BPQ.100d {Are you/Is SP} now taking a prescribed medicine?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

BOX 5

OMITTED

BOX 6

OMITTED

BOX 7

OMITTED

BOX 8

OMITTED

BOX 9

OMITTED

CARDIOVASCULAR disease (CDQ)

CARDIOVASCULAR disease – CdQ

Target Group: SPs 40+

CDQ.001 {Have you/Has SP} ever had any pain or discomfort in {your/her/his} chest?

YES 1

NO 2 (CDQ.010)

REFUSED 7 (CDQ.010)

DON'T KNOW 9 (CDQ.010)

CDQ.002 {Do you/Does she/Does he} get it when {you/she/he} {walk/walks} uphill or {hurry/hurries}?

YES 1

NO 2 (CDQ.008)

NEVER WALKS UPHILL OR HURRIES 3

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.003 {Do you/Does she/Does he} get it when {you/she/he} {walk/walks} at an ordinary pace on level ground?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1

CHECK ITEM CDQ.003A:

IF 'YES' (CODE '1') IN CDQ.002 OR CDQ.003, CONTINUE.

OTHERWISE, GO TO CDQ.008.

CDQ.004 What {do you/does she/does he} do if {you/she/he} get it while {you/she/he} are walking? {Do you/Does she/Does he} stop or slow down, or continue at the same pace?

CODE "STOP OR SLOW DOWN" IF SP CARRIES ON AFTER TAKING NITROGLYCERINE.

STOP OR SLOW DOWN 1

CONTINUE AT THE SAME PACE 2 (CDQ.008)

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.005 If {you/she/he} {stand/stands} still, what happens to it? Is the pain or discomfort relieved or not relieved?

RELIEVED 1

NOT RELIEVED 2 (CDQ.008)

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.006 How soon is the pain relieved? Would you say . . .

10 minutes or less or 1

more than 10 minutes? 2 (CDQ.008)

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.009 Please look at this card and show me where the pain or discomfort is located.

CODE ALL THAT APPLY.

PROBE FOR ADDITIONAL AREAS.

HAND CARD CDQ1

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

REFUSED 77

DON'T KNOW 99

CDQ.008 Have {you/she/he} ever had a severe pain across the front of {your/her/his} chest lasting for half an hour or more?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CDQ.010 {Have you/Has SP} had shortness of breath either when hurrying on the level or walking up a slight hill?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2

OMITTED

osteoporosis (osQ)

OSTEOPOROSIS – OSQ

Target Group: Males and Females 40+

OSQ.010 a/b/c	Has a doctor ever told {you/SP} that {you/SP} had broken or fractured {your/his/her} . . .	OSQ.020	How many times {have you/has SP} broken or fractured {your/his/her} {hip/wrist/spine}?

	a. hip? YES 1 NO 2 (b) REFUSED 7 (b) DON'T KNOW 9 (b) HELP SCREEN: Doctor: The term refers to both medical doctors (M.D.s) and osteopathic physicians (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.		\|___\|___\| ENTER NUMBER OF TIMES CAPI INSTRUCTION: HARD EDIT: 1-33. REFUSED 77 DON'T KNOW 99
	b. wrist? YES 1 DO NOT NO 2 (c) INCLUDE REFUSED 7 (c) FOREARM OR DON'T KNOW 9 (c) HAND		\|___\|___\| ENTER NUMBER OF TIMES CAPI INSTRUCTION: HARD EDIT: 1-33. REFUSED 77 DON'T KNOW 99
	c. spine? YES 1 NO 2 (BOX 1) REFUSED 7 (BOX 1) DON'T KNOW 9 (BOX 1)		\|___\|___\| ENTER NUMBER OF TIMES CAPI INSTRUCTION: HARD EDIT: 1-33. REFUSED 77 DON'T KNOW 99

BOX 1

CHECK ITEM OSQ.025:

IF 'YES' (CODE 1) IN OSQ.010 a, b, OR c, CONTINUE WITH LOOP 1.

OTHERWISE, GO TO OSQ.080.

LOOP 1:

ASK OSQ.030 - OSQ.051 FOR EACH TYPE AND EACH INCIDENT OF FRACTURE. (EXAMPLE: HOW OLD WERE YOU WHEN YOU FRACTURED YOUR HIP THE FIRST TIME?)

OSQ.030
a/b/c

How old {were you/was SP} when {you/s/he} fractured {your/his/her} {hip/wrist/spine} {the {1st/2nd/10th or more recent time . . .} time}?

CAPI INSTRUCTION:

IF ONLY BROKE HIP, WRIST OR SPINE 1 TIME, DO NOT DISPLAY "THE {1ST/2ND . . .} TIME".

IF 10TH TIME, DISPLAY {10TH OR MOST RECENT TIME}.

|___|___|___| (BOX 2)

ENTER AGE IN YEARS

CAPI INSTRUCTION: HARD EDIT: 1-120.

REFUSED 777

DON'T KNOW 999

OSQ.040 {Were you/Was SP} . . .

a/b/c

under 50 years old, or 1

50 years old or older? 2

REFUSED 7 (BOX 3)

DON'T KNOW 9 (BOX 3)

BOX 2

CHECK ITEM OSQ.045:

IF AGE IS >= 50 IN OSQ.030 OR OSQ.040, CONTINUE.

OTHERWISE, GO TO BOX 3.

OSQ.051 Did that fracture occur as a result of . . .

a fall from standing height or less, for
example, tripped, slipped, fell out of bed 4

a hard fall, such as falling off a ladder or
step stool, down stairs, or 5

a car accident or other severe trauma? 6

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Additional examples for “a fall from standing height or less” include leg gave way, was dizzy, fell bending over, fell out of a chair. Additional examples for “a hard fall” include being forcibly knocked down by another person or bicycle.

BOX 3

END LOOP1:

ASK OSQ.030 - OSQ.051 FOR NEXT INCIDENT OF FRACTURE.
IF NO NEXT INCIDENT, CONTINUE.

OSQ.080 Has a doctor ever told {you/SP} that {you/s/he} had broken or fractured any other bone after {you were/s/he was} 20 years of age?

YES 1

NO 2 (OSQ.060)

REFUSED 7 (OSQ.060)

DON'T KNOW 9 (OSQ.060)

OSQ.090 Was this fracture the result of severe trauma such as a car accident, being struck by a vehicle, a physical attack, or a hard fall such as falling off a ladder or down stairs?

YES 1 (OSQ.120)

NO 2

REFUSED 7 (OSQ.120)

DON'T KNOW 9 (OSQ.120)

HELP SCREEN:

Do not include a fall from standing height or less, for example, tripped, slipped, fell out of bed, leg gave way, was dizzy, fell bending over, or fell out of a chair.

Additional examples for “a hard fall” include being knocked down by another person or bicycle.

OSQ.100 Please look at this card and tell me where the fracture occurred.

HAND CARD OSQ 1

HEAD/FACE 10

UPPER ARM (HUMERUS) 11

LOWER ARM BETWEEN WRIST AND

ELBOW (DO NOT INCLUDE WRIST) 12

ELBOW 13

HAND 14

FINGERS 15

SHOULDER 16

COLLAR BONE 17

RIBS (EITHER SIDE) 18

PELVIS (NOT HIP) 19

UPPER LEG (THIGH EXCLUDING HIP) 20

LOWER LEG (BETWEEN ANKLE AND

KNEE) 21

KNEE (PATELLA) 22

ANKLE 23

HEEL 24

FOOT 25

TOES 26

OTHER (DO NOT SPECIFY) 27

REFUSED 77

DON'T KNOW 99

OSQ.110 How old {were you/was SP} when {you/SP} fractured {your/his/her} (fracture site selected in OSQ.100) for the first time after age 20?

|___|___|___|

ENTER AGE IN YEARS

CAPI INSTRUCTION: HARD EDIT: 20-120.

REFUSED 777

DON'T KNOW 999

OSQ.120 Has a doctor ever told {you/SP} that {you/s/he} had broken or fractured any other bones after {you were/s/he was} 20 years of age?

YES 1

NO 2 (OSQ.060)

REFUSED 7 (OSQ.060)

DON'T KNOW 9 (OSQ.060)

BOX 4

CHECK ITEM OSQ.129:

IF OSQ120 = 1 (YES), CONTINUE WITH LOOP 2. OTHERWISE, GO TO OSQ.060.

LOOP 2:

ASK OSQ.090 – OSQ.120 FOR NEXT INCIDENT OF FRACTURE. IF NO NEXT INCIDENT, CONTINUE.

OSQ.060 Has a doctor ever told {you/SP} that {you/s/he} had osteoporosis, sometimes called thin or brittle bones?

YES 1

NO 2 (OSQ.130)

REFUSED 7 (OSQ.130)

DON'T KNOW 9 (OSQ.130)

HELP SCREEN:

Osteoporosis: A disease in which bones become less dense, which makes them more fragile and likely to break. Osteoporosis is not always painful. In fact, many people don't know they have osteoporosis unless a bone breaks. A doctor may tell you that you have osteoporosis after you have had a broken bone or a bone density test.

OSQ.072 Please look at the drugs on this card that are prescribed for osteoporosis. {Have you/Has SP} ever been told by a doctor or other health care professional to take a prescribed medicine for osteoporosis?

HAND CARD OSQ 2

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

OSQ.130 {Have you/has SP} ever taken any prednisone or cortisone pills nearly every day for a month or longer? [Prednisone and cortisone are types of steroids.]

YES 1

NO 2 (OSQ.150)

REFUSED 7 (OSQ.150)

DON'T KNOW 9 (OSQ.150)

OSQ.140
Q/U

Please think about {your/SP's} use of prednisone or cortisone during {your/his/her} lifetime. For how long did {you/s/he} use prednisone or cortisone nearly every day? Do not count the months or years when {you were/s/he was} not taking the medicine.

|___|___|

ENTER NUMBER

CAPI INSTRUCTION: SOFT EDIT: 19 OR HIGHER.

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MONTH 1

YEAR 2

REFUSED 7

DON’T KNOW 9

OSQ.150 Including living and deceased, were either of {your/SP's} biological parents ever told by a health professional that they had osteoporosis or brittle bones?

YES 1

NO 2 (OSQ.170)

REFUSED 7 (OSQ.170)

DON'T KNOW 9 (OSQ.170)

OSQ.160 Which biological [blood] parent?

CODE ALL THAT APPLY

MOTHER 1

FATHER 2

REFUSED 7

DON'T KNOW 9

OSQ.170 Did {your/SP's} biological mother ever fracture her hip?

YES 1

NO 2 (OSQ.200)

REFUSED 7 (OSQ.200)

DON'T KNOW 9 (OSQ.200)

OSQ.180 About how old was she when she fractured her hip (the first time)?

|___|___|___| (OSQ.200)

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

OSQ.190 Was she. . .

under 50 years old, or 1

50 years old or older? 2

REFUSED 7

DON'T KNOW 9

OSQ.200 Did {your/SP's} biological father ever fracture his hip?

YES 1

NO 2 (OSQ.new1)

REFUSED 7 (OSQ.new1)

DON'T KNOW 9 (OSQ.new1)

OSQ.210 About how old was he when he fractured his hip (the first time)?

|___|___|___| (END OF SECTION)

ENTER AGE IN YEARS

CAPI INSTRUCTION: HARD EDIT: 20-120.

REFUSED 777

DON'T KNOW 999

OSQ.220 Was he . . .

under 50 years old, or 1

50 years old or older? 2

REFUSED 7

DON'T KNOW 9

OSQ.new1 The following question is about metal objects you may have inside your body.

Do you have any artificial joints, pins, plates, metal suture material, or other types of metal objects in your body? Some common examples are on the hand card.

INTERVIEWER INSTRUCTION: Do not include piercings, crowns, dental braces or retainers, shrapnel, or bullets. The metal object should NOT be visible on the outside of the body or in the mouth.

HAND CARD OSQ3

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DERMATOLOGY (DEQ)

DERMATOLOGY – DEQ

Target Group: SPs 20-59

DEQ.031 Next are some general questions about {your/SP’s} skin.

If after several months of not being in the sun, {you/SP} then went out in the sun without sunscreen or protective clothing for a half hour, which one of these would happen to {your/his/her} skin?

HAND CARD DEQ1

GET A SEVERE SUNBURN WITH

BLISTERS 1

A SEVERE SUNBURN FOR A FEW DAYS

WITH PEELING 2

MILDLY BURNED WITH SOME TANNING 3

TURNING DARKER WITHOUT A

SUNBURN 4

NOTHING WOULD HAPPEN IN HALF AN

HOUR 5

OTHER 6

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

Sun Exposure: If respondent says that it would depend on the time of year or on the UV rating, probe for “in general” or “on average”.

DEQ.034
a/c/d

When {you go/SP goes} outside on a very sunny day, for more than one hour, how often {do you/does SP} . . .

HAND CARD DEQ2

a. Stay in the shade? Would you say . . .

always, 1

most of the time, 2

sometimes, 3

rarely, or 4

never? 5

DON'T GO OUT IN THE SUN 6 (DEQ.038)

REFUSED 77

DON'T KNOW 99

c. Wear a long sleeved shirt? Would you say . . .

always, 1

most of the time, 2

sometimes, 3

rarely, or 4

never? 5

REFUSED 7

DON'T KNOW 9

d. Use sunscreen? Would you say . . .

always, 1

most of the time, 2

sometimes, 3

rarely, or 4

never? 5 (DEQ.038)

REFUSED 7 (DEQ.038)

DON'T KNOW 9 (DEQ.038)

DEQ.038
G/Q

How many times in the past year {have you/has SP} had a sunburn?

|___|

ENTER NUMBER 1

NEVER 2 (DEQ.120)

REFUSED 7 (DEQ.120)

DON'T KNOW 9 (DEQ.120)

|___|___|___|

ENTER NUMBER OF TIMES

REFUSED 77777

DON'T KNOW 99999

CAPI INSTRUCTION:

BUILD HARD EDITS AS 1-365.

DEQ.120
G/Q/U

The next questions ask about the time you spent outdoors during the past 30 days. By outdoors, I mean outside and not under any shade.

How much time did you usually spend outdoors between 9 in the morning and 5 in the afternoon on the days that you worked or went to school?

PROBE IF NEEDED: I am only interested in the amount of time you spent outdoors between 9 in the morning and 5 in the afternoon.

|___|

ENTER AMOUNT OF TIME

(IN MINUTES OR HOURS) 1

NO TIME SPENT OUTDOORS 2 (DEQ.125)

DOES NOT WORK OR GO TO SCHOOL 3 (DEQ.125)

REFUSED 7 (DEQ.125)

DON'T KNOW 9 (DEQ.125)

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

HARD EDIT: The value entered cannot exceed 8 hours or 480 minutes.

REFUSED 77777 (DEQ.125)

DON'T KNOW 99999 (DEQ.125)

ENTER UNIT

|___|

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

DEQ.125
G/Q/U

During the past 30 days, how much time did you usually spend outdoors between 9 in the morning and 5 in the afternoon on the days when you were not working or going to school?

|___|

ENTER AMOUNT OF TIME

(IN MINUTES OR HOURS) 1

NO TIME SPENT OUTDOORS 2 (END OF SECTION)

AT WORK OR SCHOOL

9 TO 5 SEVEN DAYS A WEEK 3 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

HARD EDIT: The value entered cannot exceed 8 hours or 480 minutes.

REFUSED 77777 (END OF SECTION)

DON'T KNOW 99999 (END OF SECTION)

ENTER UNIT

|___|

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

Audiometry (AUQ)

AUDIOMETRY – AUQ

Target Group: SPs 1+

AUQ.054 These next questions are about {your/SP’s} hearing.

Which statement best describes {your/SP’s} hearing (without a hearing aid or other listening devices)? Would you say {your/his/her} hearing is excellent, good, that {you have/s/he has} a little trouble, moderate trouble, a lot of trouble, or {are you/is s/he} deaf?

EXCELLENT 1

GOOD 2

A LITTLE TROUBLE 3

MODERATE HEARING TROUBLE 4

A LOT OF TROUBLE 5

DEAF 6

REFUSED 77

DON’T KNOW 99

HELP SCREEN:

Deaf means that you can't hear in both ears without the use of hearing aids or other devices to help you hear. If you can hear in one ear, you are not deaf.

Hearing Aid: A small electronic device that amplifies the sounds you hear. It is worn in or behind the ear to help you hear.

Other Listening Devices: Other listening devices are any device you use to help you hear. They are also called assistive listening devices. These are:

A pocket talker

An amplified telephone

An amplified or vibrating alarm clock

A light signaler for your doorbell

A TV headset

Closed-captioned TV

TTY (teletypewriter)

TDD (telecommunications device for the deaf)

A telephone relay service

A video relay service

A sign language interpreter

BOX 1

OMITTED

BOX 1A

CHECK ITEM AUQ.055:

IF SP AGE >= 20, AND SP AGE <= 69 AND AUQ.054 = 1, 7, 9, GO TO AUQ.100;

IF SP AGE >= 20, AND SP AGE <= 69 AND AUQ.054 = 2, 3, 4, 5 OR 6, CONTINUE.

IF SP AGE > 69, GO TO AUQ.136.

OTHERWISE, END OF SECTION.

BOX 2

OMITTED

AUQ.060 These next questions refer to hearing without the use of a hearing aid or any other listening devices. If {you have/SP has} one ear that is better than the other, please answer the questions for the hearing in {your/SP’s} better ear.

Can {you/SP} usually hear and understand what a person says without seeing his or her face if that person whispers to {you/him/her} from across a quiet room?

YES 1 (AUQ.100)

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.070 Can {you/SP} usually hear and understand what a person says without seeing his or her face if that person talks in a normal voice to {you/him/her} from across a quiet room?

YES 1 (AUQ.100)

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.080 Can {you/SP} usually hear and understand what a person says without seeing his or her face if that person shouts to {you/him/her} from across a quiet room?

YES 1 (AUQ.100)

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.090 Can {you/SP} usually hear and understand what a person says without seeing his or her face if that person speaks loudly into {your/his/her} better ear?

INTERVIEWER: IF THE INTERVIEWEE HEARS BETTER IN ONE EAR THAN THE OTHER,

RECORD THE RESPONSE FOR SPEAKING LOUDLY INTO THE BETTER EAR.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.100 How often {do you/does SP} find it difficult to follow a conversation if there is background noise, for example, when other people are talking, TV or radio is on, or children are playing? Would you say...

HAND CARD AUQ1

always 1

usually 2

about half the time 3

seldom 4

never 5

REFUSED 7

DON’T KNOW 9

AUQ.110 How often does {your/SP’s} hearing cause {you/him/her} to feel frustrated when talking to members of {your/his/her} family or to friends? Would you say...

HAND CARD AUQ1

always 1

usually 2

about half the time 3

seldom 4

never 5

REFUSED 7

DON’T KNOW 9

AUQ.136 {Have you/Has SP} ever had 3 or more ear infections? Please include ear infections {you/he/she} may have had when {you were/he was/she was} a child.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.138 {Have you/Has SP} ever had a tube placed in {your/his/her} ear to drain the fluid from {your/his/her} ear?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 3

CHECK ITEM AUQ.137:

IF SP AGE > 69, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

AUQ.144 A hearing test by a specialist is one that is done in a sound proof booth or room, or with headphones. Hearing specialists include audiologists, ear nose and throat doctors, and trained technicians or occupational nurses. When was the last time {you had/SP had} {your/his/her} hearing tested by a hearing specialist?

READ CATEGORIES IF NECESSARY

LESS THAN A YEAR AGO 1

1 YEAR TO 4 YEARS AGO 2

5 TO 9 YEARS AGO 3

TEN OR MORE YEARS AGO 4

NEVER 5

REFUSED 7

DON’T KNOW 9

AUQ.146 {Have you/Has SP} ever worn a hearing aid or cochlear implant?

YES 1

NO 2 (AUQ.154)

REFUSED 7 (AUQ.154)

DON'T KNOW 9 (AUQ.154)

HELP SCREEN:

Hearing Aid: A small electronic device that amplifies the sounds you hear. It is worn in or behind the ear to help you hear.

Cochlear Implant: A cochlear implant is an electrical device that a surgeon puts in your ear. It helps you hear by sending sounds directly to the brain. It is used only when you are almost totally deaf.

AUQ.148 Which was it?

CODE ALL THAT APPLY

CAPI INSTRUCTION:

IF BOTH RESPONSE OPTIONS 1 AND 2 ARE SELECTED, GO TO AUQ.152.

A HEARING AID 1

A COCHLEAR IMPLANT 2 (AUQ.154)

REFUSED 7 (AUQ.154)

DON'T KNOW 9 (AUQ.154)

AUQ.152 In the past 12 months, how often {have you/has SP} worn a hearing aid?

HAND CARD AUQ1

ALWAYS 1

USUALLY 2

ABOUT HALF THE TIME 3

SELDOM 4

NEVER 5

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

Hearing Aid: A small electronic device that amplifies the sounds you hear. It is worn in or behind the ear to help you hear.

AUQ.154 {Have you/Has SP} ever used assistive listening devices (ALDs), such as FM systems, closed-captioned television, amplified telephone, relay services, or a sign-language interpreter?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Assistive Listening Devices: These are any device you use to help you hear. Other examples include:

TTY (teletypewriter)

TDD (telecommunications device for the deaf)

A pocket talker

An amplified or vibrating alarm clock

A light signaler for your doorbell

A TV headset

AUQ.191 In the past 12 months, {have you/has SP} been bothered by ringing, roaring, or buzzing in {your/his/her} ears or head that lasts for 5 minutes or more?

YES 1

NO 2 (AUQ.300)

REFUSED 7 (AUQ.300)

DON'T KNOW 9 (AUQ.300)

HELP SCREEN:

Tinnitus (tin-uh-tus) is the medical term for ringing, roaring or buzzing in the ears or head.

AUQ.250 How long {have you/has SP} been bothered by this ringing, roaring, or buzzing in {your/his/her} ears or head?

READ CATEGORIES IF NECESSARY

LESS THAN THREE MONTHS 1

THREE MONTHS TO A YEAR 2

1 TO 4 YEARS 3

5 TO 9 YEARS 4

TEN OR MORE YEARS 5

REFUSED 7

DON’T KNOW 9

AUQ.255 In the past 12 months, how often {have you/has SP} had this ringing, roaring, or buzzing in {your/his/her} ears or head? Would you say...

almost always 1

at least once a day 2

at least once a week 3

at least once a month 4

less frequently than once a month 5

REFUSED 7

DON’T KNOW 9

AUQ.260 {Are you/Is SP} bothered by ringing, roaring, or buzzing in {your/his/her} ears or head only after listening to loud sounds or loud music?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.270 {Are you/Is SP} bothered by ringing, roaring, or buzzing in {your/his/her} ears or head when going to sleep?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.280 How much of a problem is this ringing, roaring, or buzzing in {your/his/her} ears or head?

No problem 1

A small problem 2

A moderate problem 3

A big problem 4

A very big problem 5

REFUSED 7

DON’T KNOW 9

AUQ.300 This next question is about {your/SP’s} use of firearms that {you/he/she} may have used for target shooting, hunting, for {your/his/her} job or in military service. {Have you/Has SP} ever used firearms for any reason?

YES 1

NO 2 (AUQ.330)

REFUSED 7 (AUQ.330)

DON'T KNOW 9 (AUQ.330)

HELP SCREEN:

Firearms include pistols, shotguns, rifles, and other types of guns. Do not include BB or pellet guns.

AUQ.310 How many total rounds {have you/has SP} ever fired?

READ CATEGORIES IF NECESSARY

INTERVIEWER: ONE ROUND EQUALS ONE SHOT. INCLUDE TARGET SHOOTING, HUNTING, YOUR JOB AND MILITARY SERVICE.

1 TO LESS THAN 100 ROUNDS 1

100 TO LESS THAN 1000 ROUNDS 2

1000 TO LESS THAN 10,000 ROUNDS 3

10,000 TO LESS THAN 50,000 ROUNDS 4

50,000 ROUNDS OR MORE 5

REFUSED 7

DON’T KNOW 9

AUQ.320 How often {did you/did SP} wear hearing protection devices (ear plugs, ear muffs) when shooting firearms?

HAND CARD AUQ1

ALWAYS 1

USUALLY 2

ABOUT HALF THE TIME 3

SELDOM 4

NEVER 5

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

Protective Hearing Device: These protect you from noise that is so loud that it might damage your hearing. Examples are ear plugs, protective earmuffs or special headphones.

AUQ.330 These next questions are about noise exposure {you/SP} may have had at work.

{Have you/Has SP} ever had a job, or combination of jobs where {you were/s/he was} exposed to loud sounds or noise for 4 or more hours a day, several days a week? Loud means so loud that {you/s/he} must speak in a raised voice to be heard.

YES 1

NO 2 (AUQ.370)

NEVER WORKED 3 (AUQ.370)

REFUSED 7 (AUQ.370)

DON'T KNOW 9 (AUQ.370)

AUQ.340 For how many months or years {have you/has SP} been exposed at work to loud sounds or noise for 4 or more hours a day, several days a week?

READ CATEGORIES IF NECESSARY

LESS THAN 3 MONTHS 1

3 TO 11 MONTHS 2

1 TO 2 YEARS 3

3 TO 4 YEARS 4

5 TO 9 YEARS 5

10 TO 14 YEARS 6

15 OR MORE YEARS 7

REFUSED 77

DON’T KNOW 99

AUQ.350 In {your/SP’s} work {were you/was he/was she} exposed to very loud noise? Very loud noise is noise that is so loud {you have/he has/she has} to shout in order to be understood by someone standing 3 feet away from {you/him/her}.

YES 1

NO 2 (AUQ.370)

REFUSED 7 (AUQ.370)

DON'T KNOW 9 (AUQ.370)

AUQ.360 This next question is about {your/SP’s} work in jobs where there was very loud noise for 4 or more hours a day, several days a week. Please give me the total number of months or years for all jobs where this has happened.

READ CATEGORIES IF NECESSARY

LESS THAN 3 MONTHS 1

3 TO 11 MONTHS 2

1 TO 2 YEARS 3

3 TO 4 YEARS 4

5 TO 9 YEARS 5

10 TO 14 YEARS 6

15 OR MORE YEARS 7

NOT EXPOSED 8

REFUSED 77

DON’T KNOW 99

AUQ.370 Outside of a job, {have you/has SP} ever been exposed to very loud noise or music for 10 or more hours a week? This is noise so loud that {you have/s/he has} to shout to be understood or heard 3 feet away. Examples are noise from power tools, lawn mowers, farm machinery, cars, trucks, motorcycles, motor boats or loud music.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.380 In the past 12 months, how often {did you/did SP} wear hearing protection devices (ear plugs, ear muffs) when exposed to very loud sounds or noise? Please include both on the job and off the job exposures.

HAND CARD AUQ2

ALWAYS 1

USUALLY 2

ABOUT HALF THE TIME 3

SELDOM 4

NEVER 5

NO NOISE EXPOSURE PAST 12 MONTHS 6

REFUSED 77

DON’T KNOW 99

HELP SCREEN:

Protective Hearing Device: These protect you from noise that is so loud that it might damage your hearing. Examples are ear plugs, protective earmuffs or special headphones.

Oral health (ohq)

Shape17

NHANES 2015

Oral health – ohq

Target Group: SPs 1+

OHQ.030 The next questions are about {your/SP’s} teeth and gums.

About how long has it been since {you/SP} last visited a dentist? Include all types of dentists, such as, orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.

6 MONTHS OR LESS 1

MORE THAN 6 MONTHS, BUT NOT MORE
THAN 1 YEAR AGO 2

MORE THAN 1 YEAR, BUT NOT MORE
THAN 2 YEARS AGO 3

MORE THAN 2 YEARS, BUT NOT MORE
THAN 3 YEARS AGO 4

MORE THAN 3 YEARS, BUT NOT MORE
THAN 5 YEARS AGO 5

MORE THAN 5 YEARS AGO 6

NEVER HAVE BEEN 7 (BOX 0)

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

Dentist: Medical persons whose primary occupation is caring for teeth, gums, and jaws. Dental care includes general work such as fillings, cleaning, extractions, and also specialized work such as root canals, fittings for braces, etc.

OHQ.033 What was the main reason {you/SP} last visited the dentist?

WENT IN ON OWN FOR CHECK-UP,
EXAMINATION OR CLEANING 1

WAS CALLED IN BY THE DENTIST FOR
CHECK-UP, EXAMINATION OR
CLEANING 2

SOMETHING WAS WRONG, BOTHERING
OR HURTING {ME/SP} 3

WENT FOR TREATMENT OF A
CONDITION THAT DENTIST
DISCOVERED AT EARLIER CHECK-UP
OR EXAMINATION 4

OTHER 5

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Cleaning (Dental): Refers to activities performed by a dentist or dental hygienist to maintain healthy teeth and prevent cavities. Cleaning includes scraping tartar deposits off teeth, both above and below the gumline.

Condition: Respondent's perception of a departure from physical or mental well-being. Any response describing a health problem of any kind.

OHQ.770 During the past 12 months, was there a time when {you/SP} needed dental care but could not get it at that time?

YES 1

NO 2 (BOX 0)

REFUSED 7 (BOX 0)

DON'T KNOW 9 (BOX 0)

OHQ.780 What were the reasons that {you/SP} could not get the dental care {you/she/he} needed?

CODE ALL THAT APPLY

HAND CARD OHQ1

COULD NOT AFFORD THE COST 10

DID NOT WANT TO SPEND THE MONEY 11

INSURANCE DID NOT COVER
RECOMMENDED PROCEDURES 12

DENTAL OFFICE IS TOO FAR AWAY 13

DENTAL OFFICE IS NOT OPEN AT
CONVENIENT TIMES 14

ANOTHER DENTIST RECOMMENDED
NOT DOING IT 15

AFRAID OR DO NOT LIKE DENTISTS 16

UNABLE TO TAKE TIME OFF FROM
WORK 17

TOO BUSY 18

I DID NOT THINK ANYTHING SERIOUS
WAS WRONG/EXPECTED DENTAL
PROBLEMS TO GO AWAY 19

OTHER 20

REFUSED 77

DON'T KNOW 99

BOX 0

CHECK ITEM OHQ.550:

IF SP AGE <3, GO TO OHQ.845

IF SP AGE 3-15, CONTINUE.

ELSE IF SP AGE 16+ and OHQ.030 = 1 or 2, GO TO OHQ.610.

ELSE GO TO BOX 2.

OHQ.555
G/Q/U

We would like you to think of the time when {SP} started brushing {his/her} teeth either with your help or alone. At what age did {SP} start brushing {his/her} teeth?

|____|

ENTER AGE 1

HAS NOT STARTED BRUSHING TEETH 2 (OHQ.566)

REFUSED 7 (OHQ.566)

DON'T KNOW 9 (OHQ.566)

|___|___|

ENTER AGE IN MONTHS OR YEARS

REFUSED 7777 (OHQ.566)

DON'T KNOW 9999 (OHQ.566)

ENTER UNIT

MONTHS 1

YEARS 2

CAPI INSTRUCTION:

SOFT EDIT: OHQ.555 >SP’S AGE

ERROR MESSAGE: ‘AGE STARTED BRUSHING TEETH CANNOT BE OLDER THAN SP’S CURRENT AGE.’

OHQ.560
G/Q/U

At what age did {SP} start using toothpaste?

|____|

ENTER AGE 1

HAS NEVER USED TOOTHPASTE 2 (OHQ.566)

REFUSED 7 (OHQ.566)

DON'T KNOW 9 (OHQ.566)

|___|___|

ENTER age IN MONTHS OR YEARS

REFUSED 7777 (OHQ.566)

DON'T KNOW 9999 (OHQ.566)

ENTER UNIT

MONTHS 1

YEARS 2

CAPI INSTRUCTION:

SOFT EDIT: OHQ.560 >SP’S AGE

ERROR MESSAGE: ‘AGE STARTED USING TOOTHPASTE CANNOT BE OLDER THAN SP’S CURRENT AGE.’

OHQ.566 Has {SP} ever received prescription fluoride drops or fluoride tablets?

YES 1

NO 2 (BOX 1)

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

OHQ.571
Q/U

How old in months or years was {SP} when {he/she} started taking prescription fluoride drops or fluoride tablets?

|___|___|

ENTER AGE IN MONTHS OR YEARS

REFUSED 7777 (BOX 1)

DON'T KNOW 9999 (BOX 1)

ENTER UNIT

MONTHS 1

YEARS 2

CAPI INSTRUCTION:

SOFT EDIT: OHQ.571 >SP’S AGE

ERROR MESSAGE: ‘AGE STARTED TAKING FLUORIDE DROPS OR FLUORIDE TABLETS CANNOT BE OLDER THAN SP’S CURRENT AGE.’

OHQ.576
G/Q/U

How old in months or years was {SP} when {he/she} stopped taking prescription fluoride drops or fluoride tablets?

|____|

ENTER AGE 1

STILL TAKING FLUORIDE DROPS OR
TABLETS 2 (BOX 1)

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

|___|___|

ENTER age IN MONTHS OR YEARS

REFUSED 7777 (BOX 1)

DON'T KNOW 9999 (BOX 1)

ENTER UNIT

MONTHS 1

YEARS 2

CAPI INSTRUCTION:

SOFT EDIT: OHQ.576 >SP’S AGE

ERROR MESSAGE: ‘AGE STOPPED TAKING FLUORIDE DROPS OR TABLETS CANNOT BE OLDER THAN SP’S CURRENT AGE.’

IF ‘STILL TAKING FLUORIDE DROPS OR TABLETS SELECTED, FILL OHQ.576 Q/U WITH CURRENT AGE AND GO TO OHQ.580.’

SOFT EDIT: OHQ.575 LESS THAN OHQ.571

ERROR MESSAGE: ‘AGE STOPPED TAKING FLUORIDE DROPS OR TABLETS CANNOT BE YOUNGER THAN AGE WHEN STARTED.’

BOX 1

CHECK ITEM OHQ.592:

IF SP AGE 3-15, GO TO OHQ.845.

OHQ.610 In the past 12 months, did a dentist, hygienist or other dental professional have a direct conversation with {you/SP} about…

… the benefits of giving up cigarettes or other types of tobacco to improve {your/SP’s} dental health?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.612 (In the past 12 months, did a dentist, hygienist or other dental professional have a direct conversation with {you/SP} about…)

… the dental health benefits of checking {your/his/her} blood sugar?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.614 (In the past 12 months, did a dentist, hygienist or other dental professional have a direct conversation with {you/SP} about…)

… the importance of examining {your/his/her} mouth for oral cancer?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2

CHECK ITEM OHQ.616:

IF SP AGE 16-29, GO TO OHQ.845.

IF SP AGE 30+, CONTINUE.

OHQ.620 How often during the last year {have you/has SP} had painful aching anywhere in {your/his/her} mouth? Would you say . . .

HAND CARD OHQ2

Very often, 1

Fairly often, 2

Occasionally, 3

Hardly ever, or 4

Never? 5

REFUSED 7

DON'T KNOW 9

OHQ.640 How often during the last year {have you/has SP} had difficulty doing {your/his/her} usual jobs or attending school because of problems with {your/his/her} teeth, mouth or dentures? Would you say . . .

HAND CARD OHQ2

Very often, 1

Fairly often, 2

Occasionally, 3

Hardly ever, or 4

Never? 5

REFUSED 7

DON'T KNOW 9

OHQ.680 How often during the last year {have you/has SP} been self-conscious or embarrassed because of {your/his/her} teeth, mouth or dentures? Would you say . ..

HAND CARD OHQ2

Very often, 1

Fairly often, 2

Occasionally, 3

Hardly ever, or 4

Never? 5

REFUSED 7

DON'T KNOW 9

OHQ.835 The next questions will ask about the condition of {your/SP’s} teeth and some factors related to gum health.

Gum disease is a common problem with the mouth. People with gum disease might have swollen gums, receding gums, sore or infected gums or loose teeth. {Do you/Does SP} think {you/s/he} might have gum disease?

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.845 Overall, how would {you/SP} rate the health of {your/his/her} teeth and gums? Would you say . . .

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

REFUSED 7

DON’T KNOW 9

BOX 3

CHECK ITEM OHQ.846:

IF SP AGE 3-19, CONTINUE.

IF SP AGE >= 30, GO TO OHQ.850.

OTHERWISE, GO TO END OF SECTION.

OHQ.848 How many times {do you/does SP} brush (your/his/her} teeth in one day?

G/Q

|___|

ENTER NUMBER 1

CHILD DOES NOT BRUSH YET 2 (END OF SECTION)

DOES NOT BRUSH EVERY DAY 3

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

|___|

1 TIME 01

2 TIMES 02

3 TIMES 03

4 TIMES 04

5 TIMES 05

6 TIMES 06

7 TIMES 07

8 TIMES 08

9 OR MORE TIMES 09

REFUSED 77 (END OF SECTION)

DON’T KNOW 99 (END OF SECTION)

OHQ.849 On average, how much toothpaste {do you/does SP} use when brushing {your/his/her} teeth?

HAND CARD OHQ3

FULL LOAD 1 (END OF SECTION)

HALF LOAD 2 (END OF SECTION)

PEA SIZE 3 (END OF SECTION)

SMEAR 4 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

OHQ.850 {Have you/Has SP} ever had treatment for gum disease such as scaling and root planing, sometimes called deep cleaning?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.860 {Have you/Has SP} ever been told by a dental professional that {you/s/he} lost bone around {your/his/her} teeth?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.870 Aside from brushing {your/his/her} teeth with a toothbrush, in the last seven days, how many days did {you/SP} use dental floss or any other device to clean between {your/his/her} teeth?

HARD EDIT 0-7.

INTERVIEWER INSTRUCTION: CODE ‘0’ IF THE SP RESPONDS THAT THEY HAVE NO TEETH OR ONLY DENTURES. PLEASE DO NOT PUT INFORMATION ABOUT NO TEETH IN THE COMMENTS.

|___|

ENTER number of DAYS

REFUSED 77

DON'T KNOW 99

OHQ.880 {Have you/Has SP} ever had an exam for oral cancer in which the doctor or dentist pulls on {your/his/her} tongue, sometimes with gauze wrapped around it, and feels under the tongue and inside the cheeks?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

OHQ.895 When did {you/SP} have {your/his/her} most recent oral or mouth cancer exam? Was it within the past year, between 1 and 3 years ago, or over 3 years ago?

Within past year 1

Between 1 and 3 years ago 2

Over 3 years ago 3 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

OHQ.900 What type of health care professional performed {your/SP’s} most recent oral cancer exam?

Doctor/physician 1

Nurse/nurse practitioner 2

Dentist (include oral surgeons) 3

Dental Hygienist 4

Other 5

REFUSED 7

DON'T KNOW 9

physical activity AND PHYSICAL FITNESS (PAQ)

physical activity AND PHYSICAL FITNESS – PAQ

Target Group: SPs 2+

BOX 1

CHECK ITEM PAQ.700:

IF SP AGE 2-11, GO TO PAQ706.

IF SP AGE <2 OR SP 12-15, GO TO NEXT SECTION.

IF SP AGE 16+, CONTINUE.

PAQ.605 Next I am going to ask you about the time {you spend/SP spends} doing different types of physical activity in a typical week.

Think first about the time {you spend/he spends/she spends} doing work. Think of work as the things that {you have/he has/she has} to do such as paid or unpaid work, household chores, and yard work.

Does {your/SP’s} work involve vigorous-intensity activity that causes large increases in breathing or heart rate like carrying or lifting heavy loads, digging or construction work for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.620)

REFUSED 7 (PAQ.620)

DON'T KNOW 9 (PAQ.620)

PAQ.610 In a typical week, on how many days {do you/does SP} do vigorous-intensity activities as part of {your/his/her} work?

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES IN THIS QUESTION.

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.620)

DON'T KNOW 99 (PAQ.620)

PAQ.615 How much time {do you/does SP} spend doing vigorous-intensity activities at work on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when {you do/he does/she does} vigorous-intensity activities during {your/his/her} work.

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING VIGOROUS-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777 (PAQ.620)

DON'T KNOW 999 (PAQ.620)

ENTER UNIT

MINUTES 1

HOURS 2

PAQ.620 Does {your/SP’s} work involve moderate-intensity activity that causes small increases in breathing or heart rate such as brisk walking or carrying light loads for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.635)

REFUSED 7 (PAQ.635)

DON'T KNOW 9 (PAQ.635)

PAQ.625 In a typical week, on how many days {do you/does SP} do moderate-intensity activities as part of {your/his/her} work?

PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.635)

DON'T KNOW 99 (PAQ.635)

PAQ.630 How much time {do you/does SP} spend doing moderate-intensity activities at work on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when {you do/he does/she does} moderate-intensity activities during {your/his/her} work.

PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING MODERATE-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777 (PAQ.635)

DON'T KNOW 999 (PAQ.635)

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

PAQ.635 The next questions exclude the physical activities at work that you have already mentioned. Now I would like to ask you about the usual way {you travel/SP travels} to and from places. For example to work, for shopping, to school.

In a typical week {do you/does SP} walk or use a bicycle for at least 10 minutes continuously to get to and from places?

YES 1

NO 2 (PAQ.650)

REFUSED 7 (PAQ.650)

DON'T KNOW 9 (PAQ.650)

PAQ.640 In a typical week, on how many days {do you/does SP} walk or bicycle for at least 10 minutes continuously to get to and from places?

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.650)

DON'T KNOW 99 (PAQ.650)

PAQ.645 How much time {do you/does SP} spend walking or bicycling for travel on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when {you walk or bicycle/SP walks or bicycles} for travel.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS WALKING OR BICYCLING TO GET TO AND FROM PLACES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777 (PAQ.650)

DON'T KNOW 999 (PAQ.650)

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

PAQ.650 The next questions exclude the work and transportation activities that you have already mentioned. Now I would like to ask you about sports, fitness and recreational activities.

In a typical week {do you/does SP} do any vigorous-intensity sports, fitness, or recreational activities that cause large increases in breathing or heart rate like running or basketball for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.665)

REFUSED 7 (PAQ.665)

DON'T KNOW 9 (PAQ.665)

PAQ.655 In a typical week, on how many days {do you/does SP} do vigorous-intensity sports, fitness or recreational activities?

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.665)

DON'T KNOW 99 (PAQ.665)

PAQ.660
Q/U

How much time {do you/does SP} spend doing vigorous–intensity sports, fitness or recreational activities on a typical day?

PROBE IF NEEDED: Think about a typical day when {you do/SP does} vigorous-intensity sports, fitness or recreational activities.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING VIGOROUS-INTENSITY RECREATIONAL ACTIVITIES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777 (PAQ.665)

DON'T KNOW 999 (PAQ.665)

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

PAQ.665 In a typical week {do you/does SP} do any moderate-intensity sports, fitness, or recreational activities that cause a small increase in breathing or heart rate such as brisk walking, bicycling, swimming, or golf for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.680)

REFUSED 7 (PAQ.680)

DON'T KNOW 9 (PAQ.680)

PAQ.670 In a typical week, on how many days {do you/does SP} do moderate-intensity sports, fitness or recreational activities?

PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.680)

DON'T KNOW 99 (PAQ.680)

PAQ.675
Q/U

How much time {do you/does SP} spend doing moderate-intensity sports, fitness or recreational activities on a typical day?

PROBE IF NEEDED: Think about a typical day when {you do/SP does} moderate-intensity sports, fitness or recreational activities.

PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING MODERATE-INTENSITY RECREATIONAL ACTIVITIES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777 (PAQ.680)

DON'T KNOW 999 (PAQ.680)

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

PAQ.680
Q/U

The following question is about sitting at work, at home, getting to and from places, or with friends, including time spent sitting at a desk, traveling in a car or bus, reading, playing cards, watching television, or using a computer. Do not include time spent sleeping.

How much time {do you/does SP} usually spend sitting on a typical day?

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 777 (BOX 2)

DON'T KNOW 999 (BOX 2)

ENTER UNIT

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

SOFT EDIT: 18 HOURS OR MORE AND LESS THAN 8 HOURS.

ERROR MESSAGE: PLEASE VERIFY TIMES OF 18 HOURS OR MORE OR LESS THAN 8 HOURS.

HARD EDIT: 24 HOURS OR MORE.

ERROR MESSAGE: THE TIME SHOULD BE LESS THAN 24 HOURS.

BOX 2

CHECK ITEM PAQ.720:

IF SP AGE 16+, GO TO PAQ.710.

PAQ.706 Now I'd like to ask you some questions about {your/SP's} activities.

During the past 7 days, on how many days {were you/was SP} physically active for a total of at least 60 minutes per day? Add up all the time {you/he/she} spent in any kind of physical activity that increased {your/his/her} heart rate and made {you/him/her} breathe hard some of the time.

0 days 0

1 day 1

2 days 2

3 days 3

4 days 4

5 days 5

6 days 6

7 days 7

REFUSED 77

DON’T KNOW 99

PAQ.710 Now I will ask you first about TV watching and then about computer use.

Over the past 30 days, on average how many hours per day did {you/SP} sit and watch TV or videos? Would you say . . .

less than 1 hour, 0

1 hour, 1

2 hours, 2

3 hours, 3

4 hours, 4

5 hours or more, or 5

{You do/SP does} not watch TV or videos 8

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

SOFT EDIT: THE TIME PAQ.710 > THE TIME IN PAQ.680.

ERROR MESSAGE: PLEASE VERIFY PAQ.710 TIME (TV WATCHING) SHOULD NOT BE MORE THAN PAQ.680 (TIME SITTING).

PAQ.715 Over the past 30 days, on average how many hours per day did {you/SP} use a computer or play computer games outside of work or school? Include Playstation, Nintendo DS, or other portable video games. Would you say . . .

less than 1 hour, 0

1 hour, 1

2 hours, 2

3 hours, 3

4 hours, 4

5 hours or more, or 5

{You do/SP does} not use a computer
outside of work or school 8

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

If the SP watches T.V. or video at the same time as working on the computer, count this time as watching T.V. or video.

BOX 2b

CHECK ITEM PAQ.718:

IF 3-11, CONTINUE.

ELSE, GO TO END OF SECTION.

PAQ.722 For the next questions, think about the sports, lessons, or physical activities {you/SP} may have done during the past 7 days? {Please do not include things {you/he/she} did during the school day like PE or gym class.}

Did {you/SP} do any physical activities during the past 7 days?

YES 1

NO 2 (BOX 3)

REFUSED 7 (BOX 3)

DON’T KNOW 9 (BOX 3)

CAPI INSTRUCTION: IF SP AGE IS 3-4 YEARS OLD, DO NOT DISPLAY {Please do not include things {you/he/she} did during the school day like PE or gym class.}

PAQ.724 What physical activities did {you/SP} do during the past 7 days? Don’t include activities {you/SP} did during gym or PE.

[PROBE: Did {you/he/she} do any other physical activities?}

CODE ALL THAT APPLY

AEROBICS/WEIGHT TRAINING/GYM/
EXERCISE 1

BASEBALL/SOFTBALL/CATCH/PITCHING 2

BASKETBALL 3

BIKE RIDING/DIRT BIKING/MOUNTAIN
BIKING 4

CHEERLEADING 5

DANCE 6

FIELD HOCKEY/STREET HOCKEY/
ROLLER HOCKEY 7

FOOTBALL 8

FRISBEE/ULTIMATE FRISBEE 29

GOLF 9

GYMNASTICS/TUMBLING 10

HIKING 11

ICE HOCKEY 12

ICE SKATING 13

JUMPING ROPE 14

LACROSSE 15

MARTIAL ARTS (KARATE/TAE KWON DO/
JUDO, ETC.) 16

PLAYING GAMES (PROBE: WERE YOU
PHYSICALLY ACTIVE? IF NO, DON’T
COUNT) 17

BACKYARD/PLAYGROUND GAMES
AND ACTIVITIES 30

ROLLER BLADING/ROLLER SKATING 18

RUNNING/JOGGING 19

SCOOTER RIDING (PROBE: DOES IT HAVE
A MOTOR? IF YES, DON’T COUNT) 20

SKATEBOARDING 21

SOCCER 22

SWIMMING 23

TENNIS 24

TRACK & FIELD 25

TRAMPOLINE 31

VOLLEYBALL 26

WALKING 27

WRESTLING 28

OTHER (SPECIFY) 91

REFUSED 77

DON’T KNOW 99

BOX 3

CHECK ITEM PAQ.726:

IF SP AGE 3-4, GO TO END OF SECTION.

IF SP AGE 5-11, CONTINUE.

PAQ.731 During the past 7 days, on how many days did {you/SP} play active video games such as Wii Sports, Wii Fit, Xbox 360, Xbox Kinect, Playstation 3, or Dance, Dance Revolution?

0 days 0 (PAQ.755)

1 day 1

2 days 2

3 days 3

4 days 4

5 days 5

6 days 6

7 days 7

REFUSED 77

DON’T KNOW 99

PAQ.733 On average, for how long did {you/SP} play these active video games?

___________

Q/U

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

REFUSED 7777 (PAQ.755)

DON'T KNOW 9999 (PAQ.755)

ENTER UNIT

MINUTES 1

HOURS 2

SOFT EDIT: IF THE HOURS EXCEED 4 SAY UNUSUAL.

SOFT EDIT: IF THE MINUTES ARE LESS THAN 10 CONFIRM THAT IT IS MINUTES NOT HOURS.

PAQ.755 The following are activities that may be done before, during, or after school other than during {PE or gym class/recess}. If {you are/SP is} not currently in school, think about {your/his/her} activities when {you were/he was/she was} last in school.} {Do you/Does SP} participate in school sports or physical activity clubs?

CAPI INSTRUCTION: IF SP AGE 5-11, DISPLAY {recess}

YES 1

NO 2 (PAQ.762)

REFUSED 7 (PAQ.762)

DON’T KNOW 9 (PAQ.762)

PAQ.759 In what school sports or physical activity clubs {do you/does SP} participate?

CODE ALL THAT APPLY

HAND CARD PAQ1

BASEBALL/SOFTBALL 1

BASKETBALL 2

BOCCE BALL 3

CHEERLEADING 4

DANCE 17

FOOTBALL 5

FRISBEE/ULTIMATE FRISBEE 18

GOLF 6

GYMNASTICS 7

HOCKEY 8

LACROSSE 9

RUNNING 19

SOCCER 10

SWIMMING/DIVING 11

TENNIS 12

TRACK AND FIELD 13

TRAMPOLINE 20

VOLLEYBALL 14

WRESTLING 15

OTHER (SPECIFY) 16

REFUSED 77

DON’T KNOW 99

PAQ.762 {Do you/Does SP} have recess during school days?

YES 1

NO 2 (PAQ.750)

REFUSED 7 (PAQ.750)

DON’T KNOW 9 (PAQ.750)

PAQ.764 How often {do you/does SP} have recess?

1 day a week 1

2 days a week 2

3 days a week 3

4 days a week, or 4

Every day 5

REFUSED 7

DON’T KNOW 9

PAQ.766 On average, how long is the recess period?

Less than 10 minutes 1

10-15 minutes 2

16-30 minutes 3

More than 30 minutes 4

REFUSED 7

DON’T KNOW 9

PAQ.750 I am going to read a statement and I want you to let me know if you strongly agree, agree, neither agree nor disagree, disagree or strongly disagree with the statement. {I enjoy participating in PE or gym class.}

CAPI INSTRUCTION: IF SP AGE 5-11, DISPLAY { {SP} enjoys participating in recess}

HAND CARD PAQ2

Strongly agree 1

Agree 2

Neither agree nor disagree 3

Disagree 4

Strongly Disagree 5

REFUSED 7

DON’T KNOW 9

PAQ.770 In the past year, did {you/SP} receive a Physical Fitness Test award, such as a President’s Challenge or Fitnessgram award?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

PAQ.772 What Physical Fitness Test award did {you/SP} receive?

PROBE IF NEEDED: Examples of physical fitness test awards are the FITNESSGRAM and the PRESIDENT’S CHALLENGE. CODE ALL THAT APPLY.

Fitnessgram 1

President’s Challenge 2

OTHER (SPECIFY) 3

REFUSED 7

DON’T KNOW 9

SLEEP DISORDERS (SLQ)

SLEEP DISORDERS – SLQ

Target Group: 16+

SLQ.NEW 1 The next set of questions is about {your/SP’s} sleeping habits. The first two questions refer to the times {you/SP} get in and out of bed in order to sleep, not including naps.

H/M

What time {do you/does SP} usually go to sleep on weekdays or workdays?

|___|___|:

ENTER HOURS

|___|___|

ENTER MINUTES

|___|___|

ENTER AM OR PM

INTERVIEWER INSTRUCTION: 1-9 HOURS PREFILL “0” IN FRONT OF NUMBER. WHEN MINUTES=0, PREFILL “00”

REFUSED 77

DON'T KNOW 99

SLQ.NEW 2 What time {do you/does SP} usually wake up on weekdays or workdays?

H/M

|___|___|:

ENTER HOURS (ALLOW 01-12)

|___|___|

ENTER MINUTES (ALLOW 00-59)

|___|___|

ENTER AM OR PM

INTERVIEWER INSTRUCTION: 1-9 HOURS PREFILL “0” IN FRONT OF NUMBER. WHEN MINUTES=0, PREFILL “00”

REFUSED 77

DON'T KNOW 99

SLQ.030 In the past 12 months, how often did {you/SP} snore while {you were/s/he was} sleeping?

INTERVIEWER INSTRUCTION: IF R SAYS “DON’T KNOW”, PROBE IF ANYONE HAS TOLD THEM THAT THEY SNORE.

Never 0

Rarely (1-2 nights/week) 1

Occasionally (3-4 nights/week) 2

Frequently (5 or more nights/week) 3

REFUSED 7

DON’T KNOW 9

SLQ.040 In the past 12 months, how often did {you/SP} snort, gasp, or stop breathing while {you were/s/he was} asleep?

INTERVIEWER INSTRUCTION: IF THE RESPONDENT ASKS “HOW WOULD I KNOW IF I SNORT, GASP OR STOP BREATHING WHEN I AM SLEEPING? PROBE IF ANYONE TOLD THEM THAT THEY DO THIS.

Never 0

Rarely (1-2 nights/week) 1

Occasionally (3-4 nights/week) 2

Frequently (5 or more nights/week) 3

REFUSED 7

DON’T KNOW 9

SLQ.050 {Have you/Has SP} ever told a doctor or other health professional that {you have/s/he has} trouble sleeping?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SLQ.120 [In the past month, how often did {you/SP}] feel excessively or overly sleepy during the day?

HAND CARD SLQ1

NEVER 0

RARELY – 1 TIME A MONTH 1

SOMETIMES – 2-4 TIMES A MONTH 2

OFTEN – 5-15 TIMES A MONTH 3

ALMOST ALWAYS – 16-30 TIMES A
MONTH 4

REFUSED 7

DON’T KNOW 9

Diet behavior & nutrition (DBQ)

DIET BEHAVIOR and NUTRITION - DBQ

Target Group: SPs Birth + (Questions grouped by age categories)

BOX 1

CHECK ITEM DBQ.005:

IF SP AGE <= 6, CONTINUE.

OTHERWISE, GO TO BOX 2.

DBQ.010 Now I'm going to ask you some general questions about {SP's} eating habits.

Was {SP} ever breastfed or fed breastmilk?

YES 1

NO 2 (DBQ.041)

REFUSED 7 (DBQ.041)

DON'T KNOW 9 (DBQ.041)

DBQ.030
G/Q/U

How old was {SP} when {he/she} completely stopped breastfeeding or being fed breastmilk?

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN MONTHS IS ALLOWED.

|___|

ENTER NUMBER 1

STILL BREASTFEEDING 2 (DBQ.041)

REFUSED 7 (DBQ.041)

DON'T KNOW 9 (DBQ.041)

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.041)

DON'T KNOW 999999 (DBQ.041)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DBQ.041
G/Q/U

How old was {SP} when {he/she} was first fed formula?

|___|

ENTER NUMBER 1

NEVER 2 (DBQ.055)

REFUSED 7 (DBQ.050)

DON'T KNOW 9 (DBQ.050)

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN MONTHS IS ALLOWED.

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.050)

DON'T KNOW 999999 (DBQ.050)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DBQ.050
G/Q/U

How old was {SP} when {he/she} completely stopped drinking formula?

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN MONTHS IS ALLOWED.

|___|

ENTER NUMBER 1

STILL DRINKING FORMULA 2 (DBQ.055)

REFUSED 7 (DBQ.055)

DON'T KNOW 9 (DBQ.055)

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.055)

DON'T KNOW 999999 (DBQ.055)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DBQ.055
G/Q/U

This next question is about the first thing that {SP} was given other than breast milk or formula. Please include juice, cow’s milk, sugar water, baby food, or anything else that {SP} might have been given, even water.

How old was {SP} when {he/she} was first fed anything other than breast milk or formula?

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN MONTHS IS ALLOWED.

INTERVIEWER INSTRUCTION:

DO NOT COUNT MEDICATIONS, VITAMIN DROPS, OR SMALL AMOUNT OF WATER THAT WAS USED FOR ORAL HYGIENE PURPOSES.

|___|

ENTER NUMBER 1

NEVER 2 (BOX 2)

REFUSED 7 (BOX 2)

DON'T KNOW 9 (BOX 2)

|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.061)

DON'T KNOW 999999 (DBQ.061)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DBQ.061
G/Q/U

How old was {SP} when {he/she} was first fed milk?

INCLUDE LACTAID AS MILK.

DO NOT INCLUDE BREASTMILK OR FORMULA.

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN MONTHS IS ALLOWED.

|___|

ENTER NUMBER 1

NEVER 2 (BOX 2)

REFUSED 7 (DBQ.073)

DON'T KNOW 9 (DBQ.073)

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.073)

DON'T KNOW 999999 (DBQ.073)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

HELP SCREEN:

Lactaid: A modified milk product that is often consumed by individuals who have lactose intolerance. Lactaid can be purchased in various forms (i.e., 2%, skim, etc.). If respondent does not give type, probe for type (i.e., was that Lactaid regular, 2%, 1% or skim?).

Formula: A milk mixture or milk substitute that is fed to babies.

DBQ.073 What type of milk was {SP} first fed? Was it . . .

CODE ALL THAT APPLY

whole or regular, 10

2% fat or reduced-fat milk, 11

1% fat or low-fat milk (includes 0.5% fat

milk or “low-fat milk” not further specified), 12

fat-free, skim or nonfat milk, 13

soy milk, or 14

another type? 30

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

BOX 2

CHECK ITEM DBQ.085:

IF SP AGE >= 16, CONTINUE.

IF SP AGE <16 BUT >= 1, GO TO DBQ.197.

OTHERWISE, GO TO FSQ.653.

DBQ.700 Next I have some questions about {your/SP’s} eating habits.

In general, how healthy is {your/his/her} overall diet? Would you say . . .

excellent, 1

very good, 2

good, 3

fair, or 4

poor? 5

REFUSED 7

DON'T KNOW 9

BOX 3

OMITTED

BOX 4

OMITTED

DBQ.197 {Next I have some questions about {SP’s} eating habits.}

{First/Next}, I’m going to ask a few questions about milk products. Do not include their use in cooking.

In the past 30 days, how often did {you/SP} have milk to drink or on {your/his/her} cereal? Please include chocolate and other flavored milks as well as hot cocoa made with milk. Do not count small amounts of milk added to coffee or tea. Would you say . . .

HAND CARD DBQ1

CAPI INSTRUCTION:

THIS SHOULD NOT BE A GATE QUESTION ANYMORE.

CAPI DISPLAY INSTRUCTIONS: IF SP AGE 7-15 YEARS OLD, DISPLAY “{Next I have some questions about {SP’s} eating habits.} First, I’m going to ask about milk products. Do not include their use in cooking.” IF SP AGE <= 6 OR => 16 YEARS OLD, DISPLAY “Next I’m going to ask a few questions about milk products. Do not include their use in cooking.”

never, 0 (BOX 6)

rarely – less than once a week, 1

sometimes – once a week or more, but

less than once a day, or 2

often – once a day or more? 3

VARIED 4

REFUSED 7 (BOX 6)

DON'T KNOW 9 (BOX 6)

DBQ.223 What type of milk was it? Was it usually . . .

IF RESPONDENT CANNOT PROVIDE USUAL TYPE, CODE ALL THAT APPLY.

whole or regular, 10

2% fat or reduced-fat milk, 11

1% fat or low-fat milk (includes 0.5% fat

milk or “low-fat milk” not further specified), 12

fat-free, skim or nonfat milk, 13

soy milk, or 14

another type? 30

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

BOX 6

CHECK ITEM DBQ.225:

IF SP AGE >= 20, CONTINUE.

OTHERWISE, GO TO BOX 9.

DBQ.229 The next question is about regular milk use.

A regular milk drinker is someone who uses any type of milk at least 5 times a week. Using this definition, which statement best describes {you/SP}?

HAND CARD DBQ2

{I've/He's/She's} been a regular milk

drinker for most or all of {my/his/her}

life, including {my/his/her} childhood. 1

{I've/He's/She's} never been a regular

milk drinker. 2 (BOX 8A)

{My/His/Her} milk drinking has varied over

{my/his/her} life – sometimes {I've/he's/

she's} been a regular milk drinker and

sometimes {I have/he has/she has} not

been a regular milk drinker. 3

REFUSED 7 (BOX 8A)

DON'T KNOW 9 (BOX 8A)

DBQ.235
a/b/c

Now, I’m going to ask you how often {you/SP} drank milk at different times in {your/his/her} life.

How often did {you/SP} drink any type of milk, including milk added to cereal, when {you were/s/he was} . . .

HAND CARD DBQ3

IF NECESSARY, PROBE FOR USUAL OR MOST COMMON AMOUNT FOR THIS TIME PERIOD.

CAPI INSTRUCTION:

THESE (A-C) SHOULD NOT BE GATE QUESTIONS ANYMORE.

a. a child between the ages of 5 and 12 years old? Would you say. . .

never, 0

rarely – less than once a week, 1

sometimes – once a week or more, but

less than once a day, or 2

often – once a day or more? 3

VARIED 4

REFUSED 7

DON'T KNOW 9

b. a teenager between the ages of 13 and 17 years old? Would you say . . .

never, 0

rarely – less than once a week, 1

sometimes – once a week or more, but

less than once a day, or 2

often – once a day or more? 3

VARIED 4

REFUSED 7

DON'T KNOW 9

c. a young adult between the ages of 18 and 35 years old? Would you say . . .

never, 0

rarely – less than once a week, 1

sometimes – once a week or more, but

less than once a day, or 2

often – once a day or more? 3

VARIED 4

REFUSED 7

DON'T KNOW 9

BOX 8A

CHECK ITEM DBQ.265A:

IF SP AGE >= 60, CONTINUE.

OTHERWISE, GO TO BOX 15.

DBQ.301 The next questions are about meals provided by community or government programs.

In the past 12 months, did {you/SP} receive any meals delivered to {your/his/her} home from community programs, “Meals on Wheels”, or any other programs?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

DBQ.330 In the past 12 months, did {you/SP} go to a community program or senior center to eat prepared meals?

INCLUDE ADULT DAY CARE

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 8B

CHECK ITEM DBQ.335:

GO TO BOX 15.

BOX 9

CHECK ITEM DBQ.355:

IF SP AGE 4-19, CONTINUE.

OTHERWISE, GO TO BOX 14.

DBQ.360 During the school year, {do you/does SP} attend a kindergarten, grade school, junior or high school?

INTERVIEWER INSTRUCTION: ENTER ‘NO’ IF THE SP IS HOME SCHOOLED.

YES 1

NO 2 (BOX 14)

REFUSED 7 (BOX 14)

DON'T KNOW 9 (BOX 14)

DBQ.370 Does {your/SP's} school serve school lunches? These are complete lunches that cost the same every day.

YES 1

NO 2 (DBQ.400)

REFUSED 7 (DBQ.400)

DON'T KNOW 9 (DBQ.400)

DBQ.381
G/Q

During the school year, about how many times a week {do you/does SP} usually get a complete school lunch?

|___|

ENTER NUMBER 1

NONE 2 (DBQ.400)

REFUSED 7 (DBQ.400)

DON'T KNOW 9 (DBQ.400)

CAPI INSTRUCTION:

HARD EDIT 1-5

|___|

ENTER NUMBER OF TIMES

REFUSED 7777

DON'T KNOW 9999

DBQ.390 {Do you/Does SP} get these lunches free, at a reduced price, or {do you/does he/she} pay full price?

FREE 1

REDUCED PRICE 2

FULL PRICE 3

REFUSED 7

DON'T KNOW 9

DBQ.400 Does {your/SP's} school serve a complete breakfast that costs the same every day?

YES 1

NO 2 (BOX 9A)

REFUSED 7 (BOX 9A)

DON'T KNOW 9 (BOX 9A)

DBQ.411
G/Q

During the school year, about how many times a week {do you/does SP} usually get a complete breakfast at school?

|___|

ENTER NUMBER 1

NONE 2 (BOX 9A)

REFUSED 7 (BOX 9A)

DON'T KNOW 9 (BOX 9A)

CAPI INSTRUCTION:

HARD EDIT 1-5

|___|

ENTER NUMBER OF TIMES

REFUSED 7777

DON'T KNOW 9999

DBQ.421 {Do you/Does SP} get these breakfasts free, at a reduced price, or {do you/does he/she} pay full price?

FREE 1

REDUCED PRICE 2

FULL PRICE 3

REFUSED 7

DON'T KNOW 9

BOX 9A

CHECK ITEM DBQ.422:

IF DBQ.390 = CODE 1 OR CODE 2 OR DBQ.421 = CODE 1 OR CODE 2, CONTINUE.

OTHERWISE, GO TO BOX 14.

DBQ.424 {Do you/Does SP} get a free or reduced price meal at any summer program {you/he/she} attends?

YES 1

NO 2

DID NOT ATTEND SUMMER PROGRAM 3

REFUSED 7

DON’T KNOW 9

BOX 10

OMITTED

BOX 10A

OMITTED

BOX 11

OMITTED

BOX 14

CHECK ITEM DBQ.710:

IF SP AGE > 5, GO TO BOX 15.

OTHERWISE, CONTINUE.

FSQ.653 Next are a few questions about the WIC program.

Has {SP} ever received benefits from WIC, that is, the Women, Infants, and Children program?

YES 1

NO 2 (FSQ.690)

REFUSED 7 (FSQ.690)

DON'T KNOW 9 (FSQ.690)

HELP SCREEN:

WIC: WIC is short for the Special Supplemental Food Program for Women, Infants, and Children. This program provides food assistance and nutritional screening to low-income pregnant and postpartum women and their infants, as well as to low-income children up to age 5.

BOX 14a

OMITTED

FSQ.673 Is {SP} now receiving benefits from the WIC program?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 14B

CHECK ITEM DBQ.710b:

IF SP AGE < 1, GO TO FSQ.685.

OTHERWISE, CONTINUE.

FSQ.675 Did {SP} receive benefits from WIC when {he/she} was less than one year old?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 14C

CHECK ITEM DBQ.950:

IF FSQ.673 = 1 (NOW RECEIVING WIC), GO TO FSQ.685.

OTHERWISE, CONTINUE.

FSQ.682 Did {SP} receive benefits from WIC when {he/she} {was/is} between the ages of {1 to {SP AGE/4} years old/12 to {SP AGE} months old}?

CAPI INSTRUCTION:

If SP age = 1, DISPLAY “12 to {the current age of the SP in months} months old”;

If SP age = 2 or 3, DISPLAY “1 to {the current age of the SP in years} years old”;

If SP age >3, DISPLAY “1 to 4 years old”.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 14d

OMITTED

FSQ.685 How long {did SP receive/has SP been receiving} benefits from the WIC program?

Q/U

CAPI INSTRUCTION:

IF FSQ.673 = 1, DISPLAY "HAS SP BEEN RECEIVING"

OTHERWISE, DISPLAY "DID SP RECEIVE"

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

|__|__|

ENTER NUMBER (OF MONTHS OR YEARS)

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MONTHS 1

YEARS 2

REFUSED 7

DON'T KNOW 9

FSQ.690 Did {SP’s} mother receive benefits from WIC, while she was pregnant with {SP}?

YES 1

NO 2 (BOX 15)

REFUSED 7 (BOX 15)

DON'T KNOW 9 (BOX 15)

FSQ.695 How many months pregnant was {SP’s} mother when she began to receive WIC benefits?

|__|__|

ENTER NUMBER

REFUSED 777

DON'T KNOW 999

BOX 15

CHECK ITEM DBQ.715:

IF SP AGE < 1 GO TO END OF SECTION.

IF SP AGE 12-15 GO TO END OF SECTION.

OTHERWISE, CONTINUE.

BOX 12

OMITTED

BOX 13

OMITTED

DBQ.895
G/Q

Next I’m going to ask you about meals. By meal, I mean breakfast, lunch and dinner. During the past 7 days, how many meals {did you/did SP} get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines?

{Please do not include meals provided as part of the school lunch or school breakfast./Please do not include meals provided as part of the community programs you reported earlier.}

CAPI INSTRUCTION:

IF DBQ381G = 1 OR DBQ.411G = 1, DISPLAY {Please do not include meals provided as part of the school lunch or school breakfast.}

IF DBQ.301 = 1 OR DBQ.330 = 1, DISPLAY {Please do not include meals provided as part of the community programs you reported earlier.}

SOFT EDIT: DISPLAY A MESSAGE FOR ENTRY LARGER THAN “21.” – “Unusually large number entered – Please verify – this is more than 3 meals per day, each day during the past 7 days.”

|___|___|

ENTER NUMBER

NONE 2 (DBQ.905)

REFUSED 7 (DBQ.905)

DON'T KNOW 9 (DBQ.905)

DBQ.900 How many of those meals {did you/did SP} get from a fast-food or pizza place?

G/Q

|___|___|

ENTER NUMBER

NONE 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION: HARD EDIT

NUMBER OF MEALS ENTERED IN DBQ.900 MUST BE EQUAL TO OR LESS THAN NUMBER ENTERED IN DBQ.895. IF NOT, DISPLAY THE FOLLOWING:

“THE NUMBER OF MEALS FROM A FAST FOOD OR PIZZA PLACE CANNOT BE GREATER THAN NUMBER OF MEALS PREPARED AWAY FROM HOME.”

DBQ.905
G/Q/U

Some grocery stores sell “ready to eat” foods such as salads, soups, chicken, sandwiches and cooked vegetables in their salad bars and deli counters.

During the past 30 days, how often did {you/SP} eat “ready to eat” foods from the grocery store? Please do not include sliced meat or cheese you buy for sandwiches and frozen or canned foods.

|___|___|

ENTER NUMBER OF TIMES (PER DAY, WEEK, OR MONTH)

NEVER 2

REFUSED 7

DON’T KNOW 9

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

DBQ.910
G/Q/U

During the past 30 days, how often did {you/SP} eat frozen meals or frozen pizzas? Here are some examples of frozen meals and frozen pizzas.

HAND CARD DBQ4

|___|___|

ENTER NUMBER OF TIMES (PER DAY, WEEK, OR MONTH)

NEVER 2

REFUSED 7

DON’T KNOW 9

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

BOX 15A

CHECK ITEM DBQ.715a:

IF SP AGE < 16, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

CBQ.596 Next I’m going to ask a few questions about the nutritional guidelines recommended for Americans by the federal government.

{Have you/Has SP} heard of My Plate?

YES 1

NO 2 (CBQ.505)

REFUSED 7 (CBQ.505)

DON'T KNOW 9 (CBQ.505)

CBQ.606 {Have you/Has SP} looked up the My Plate plan on the internet?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

CBQ.611 {Have you/Has SP} tried to follow the recommendations in the My Plate plan?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

CBQ.505 In the past 12 months, did {you/SP} buy food from fast food or pizza places?

Yes 1

No 2 (CBQ.550)

REFUSED 7

DON'T KNOW 9

CBQ.535 The last time when {you/SP} ate out or bought food at a fast-food or pizza place, did {you/he/she} see nutrition or health information about any foods on the menu?

YES 1

NO 2 (CBQ.545)

REFUSED 7 (CBQ.545)

DON'T KNOW 9 (CBQ.545)

CBQ.540 Did {you/SP} use the information in deciding which foods to buy?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CBQ.545 If nutrition or health information were readily available in fast food or pizza places, would {you/SP} use it often, sometimes, rarely, or never, in deciding what to order?

HAND CARD DBQ5

OFTEN 1

SOMETIMES 2

RARELY 3

NEVER 4

REFUSED 7

DON'T KNOW 9

CBQ.550 In the past 12 months, did {you/SP} eat at a restaurant with waiter or waitress service?

Yes 1

No 2 (END OF SECTION)

REFUSED 7

DON'T KNOW 9

CBQ.552 Think about the last time {you/SP} ate at a restaurant with a waiter or waitress.

Is it a chain-restaurant?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CBQ.580 Did {you/SP} see nutrition or health information about any foods on the menu?

YES 1

NO 2 (CBQ.590)

REFUSED 7 (CBQ.590)

DON'T KNOW 9 (CBQ.590)

CBQ.585 Did {you/SP} use the information in deciding which foods to buy?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CBQ.590 If nutrition or health information were readily available in restaurants with a waiter or waitress, would {you/SP} use it often, sometimes, rarely, or never, in deciding what to order?

HAND CARD DBQ5

OFTEN 1

SOMETIMES 2

RARELY 3

NEVER 4

REFUSED 7

DON'T KNOW 9

END OF SECTION

WEIGHT (WHq)

WEIGHT HISTORY – WHQ

Target Group: SPs 16+

WHQ.010
G/F/I/M/C

These next questions ask about {your/SP's} height and weight at different times in {your/his/her} life.

How tall {are you/is SP} without shoes?

|___|

ENTER HEIGHT IN FEET AND INCHES 1

ENTER HEIGHT IN METERS

AND CENTIMETERS 2

REFUSED 7 (WHQ.025)

DON’T KNOW 9 (WHQ.025)

|___|___|

ENTER NUMBER OF FEET

REFUSED 7777 (WHQ.025)

DON’T KNOW 9999 (WHQ.025)

AND

|___|___|

ENTER NUMBER OF INCHES

DON’T KNOW 9999 (WHQ.025)

|___|___|

ENTER NUMBER OF METERS

REFUSED 7777 (WHQ.025)

DON’T KNOW 9999 (WHQ.025)

AND

|___|___|___|

ENTER NUMBER OF CENTIMETERS

DON’T KNOW 9999 (WHQ.025)

WHQ.025/
L/K

How much {do you/does SP} weigh without clothes or shoes? [If {you are/she is} currently pregnant, how much did {you/she} weigh before your pregnancy?]

RECORD CURRENT WEIGHT

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you are/she is} currently pregnant . . .] ONLY IF SP IS FEMALE AND AGE IS 16 THROUGH 59.

IF ITEM CHANGED, CHECK MEC COMPONENT.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (WHQ.030)

DON’T KNOW 9 (WHQ.030)

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777

DON’T KNOW 99999

WHQ.030 {Do you/Does SP} consider {your/his/her}self now to be . . . [If {you are/she is} currently pregnant, what did {you/she} consider {your/her}self to be before {you were/she was} pregnant?]

overweight, 1

underweight, or 2

about the right weight? 3

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you are/she is} currently pregnant…] ONLY IF SP IS FEMALE AND AGE IS 16 THROUGH 59.

WHQ.040 Would {you/SP} like to weigh . . .

more, 1

less, or 2

stay about the same? 3

REFUSED 7

DON’T KNOW 9

WHQ.053/
L/K

How much did {you/SP} weigh a year ago? [If {you were/she was} pregnant a year ago, how much did {you/she} weigh before your pregnancy?]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you were/she was} pregnant . . .] ONLY IF SP IS FEMALE AND SP AGE IS 17 THROUGH 60.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (BOX 1)

DON’T KNOW 9 (BOX 1)

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777

DON’T KNOW 99999

BOX 1

CHECK ITEM WHQ.055:

IF WEIGHT IN WHQ.053/L/K IS 10 POUNDS, 4.55 KILOGRAMS, OR MORE THAN WEIGHT IN WHQ.025/L/K (E.G., WHQ.053/L/K = 150 LBS AND WHQ.025/L/K = 135 LBS), CONTINUE.

OTHERWISE, GO TO WHQ.070.

WHQ.061 Was the change between {your/SP's} current weight and {your/his/her} weight a year ago because {you/s/he} tried to lose weight?

YES 1 (WHQ.092/OS)

NO 2

REFUSED 7

DON'T KNOW 9

WHQ.070 During the past 12 months, {have you/has SP} tried to lose weight?

YES 1

NO 2 (WHQ.225)

REFUSED 7 (WHQ.225)

DON’T KNOW 9 (WHQ.225)

WHQ.092/
OS

How did {you/SP} try to lose weight?

HAND CARD WHQ1

CODE ALL THAT APPLY

ATE LESS FOOD (AMOUNT) 100

SWITCHED TO FOODS WITH LOWER

CALORIES 110

ATE LESS FAT 120

ATE FEWER CARBOHYDRATES 125

EXERCISED 130

SKIPPED MEALS 140

ATE “DIET” FOODS OR PRODUCTS 150

USED A LIQUID DIET FORMULA SUCH

AS SLIMFAST OR OPTIFAST 160

JOINED A WEIGHT LOSS PROGRAM

SUCH AS WEIGHT WATCHERS, JENNY

CRAIG, TOPS, OR OVEREATERS

ANONYMOUS 170

FOLLOWED A SPECIAL DIET SUCH AS

DR. ATKINS, SOUTH BEACH, OTHER

HIGH PROTEIN OR LOW

CARBOHYDRATE DIET, CABBAGE

SOUP DIET, ORNISH, NUTRISYSTEM,

BODY-FOR-LIFE 300

TOOK DIET PILLS PRESCRIBED BY A

DOCTOR 310

TOOK OTHER PILLS, MEDICINES, HERBS,

OR SUPPLEMENTS NOT NEEDING A

PRESCRIPTION 320

STARTED TO SMOKE OR BEGAN TO

SMOKE AGAIN 325

TOOK LAXATIVES OR VOMITED 330

HAD WEIGHT LOSS SURGERY 335

DRANK A LOT OF WATER 340

ATE MORE FRUITS, VEGETABLES,

SALADS 350

ATE LESS SUGAR, CANDY, SWEETS 360

CHANGED EATING HABITS (DIDN’T EAT

LATE AT NIGHT, ATE SEVERAL SMALL

MEALS A DAY) 370

ATE LESS JUNK FOOD OR FAST FOOD 380

OTHER (SPECIFY) 400

REFUSED 777

DON’T KNOW 999

BOX 2A

OMITTED

WHQ.225 How many times {have you/has SP} lost 10 pounds or more because {you were/he was/she was} trying to lose weight? Was it . . .

1 to 2, 1

3 to 5, 2

6 to 10, 3

11 times or more, or 4

never? 5

REFUSED 7

DON’T KNOW 9

BOX 2

CHECK ITEM WHQ.105:

IF SP AGE >= 36, CONTINUE.

OTHERWISE, GO TO BOX 3.

WHQ.111/
L/K

How much did {you/SP} weigh 10 years ago? [If you don't know {your/his/her} exact weight, please make your best guess.] [If {you were/she was} pregnant, how much did {you/she} weigh before {your/her} pregnancy?]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you were/she was} . . .] ONLY IF SP IS FEMALE AND AGE IS LESS THAN OR EQUAL TO 69.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (BOX 3)

DON’T KNOW 9 (BOX 3)

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777

DON’T KNOW 99999

BOX 3

CHECK ITEM WHQ.115A:

IF SP AGE >= 27, CONTINUE.

OTHERWISE, GO TO WHQ.147/L/K.

WHQ.121/
L/K

How much did {you/SP} weigh at age 25? [If you don't know {your/his/her} exact weight, please make your best guess.] [If {you were/she was} pregnant, how much did {you/she} weigh before your pregnancy?]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you were/she was} . . .] ONLY IF SP IS FEMALE.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (WHQ.130)

DON’T KNOW 9 (WHQ.130)

|___|___|___|

ENTER NUMBER OF POUNDS

|___|___|___|

ENTER NUMBER OF KILOGRAMS

REFUSED 77777

DON’T KNOW 99999

BOX 3A

CHECK ITEM WHQ.125:

IF SP AGE >= 50, CONTINUE.

OTHERWISE, GO TO WHQ.147/L/K.

WHQ.130/
F/I/M/C

How tall {were you/was SP} at age 25? [If you don't know {your/his/her} exact height, please make your best guess.]

|___|

ENTER HEIGHT IN FEET AND INCHES 1

ENTER HEIGHT IN

METERS AND CENTIMETERS 2

REFUSED 7 (WHQ.147)

DON’T KNOW 9 (WHQ.147)

|___|___|

ENTER NUMBER OF FEET

CAPI INSTRUCTION: HARD EDIT 2-8

AND

|___|___|

ENTER NUMBER OF INCHES

CAPI INSTRUCTION: HARD EDIT 0-11

|___|___|

ENTER NUMBER OF METERS

CAPI INSTRUCTION: HARD EDIT 0-3

AND

|___|___|___|

ENTER NUMBER OF CENTIMETERS

CAPI INSTRUCTION: HARD EDIT 0-99

REFUSED 7777

DON’T KNOW 9999

BOX 4

OMITTED

WHQ.147/
L/K

What is the most {you have/SP has} ever weighed? [Do not include any times when {you were/she was} pregnant.]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE {Do not include . . .} ONLY IF SP IS FEMALE.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (WHQ.190)

DON’T KNOW 9 (WHQ.190)

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777 (WHQ.190)

DON’T KNOW 99999 (WHQ.190)

WHQ.150 How old {were you/was SP} then? [If you don't know {your/his/her} exact age, please make your best guess.]

|___|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

BOX 5

OMITTED

WHQ.190 {Have you/Has SP} ever had weight loss surgery, also called bariatric surgery?

INTERVIEWER INSTRUCTION: DO NOT INCLUDE LIPOSUCTION, TUMMY TUCK, EXTRA SKIN REMOVED OR FAT REMOVAL AS WEIGHT LOSS SURGERY.

YES 1 (WHQ.195)

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

CAPI INSTRUCTION:

IF ITEM CHANGED, CHECK MEC COMPONENT

WHQ.195 Which type of weight loss surgery did {you/SP} have?

HAND CARD WHQ 2

INTERVIEWER INSTRUCTION: IF RESPONDENT ONLY MENTIONS “LIPOSUCTION”, “TUMMY TUCK”, “EXTRA SKIN REMOVED” OR “FAT REMOVAL” GO BACK AND CODE WHQ.190 “NO”.

CODE ALL THAT APPLY

GASTRIC BYPASS (Roux-en-Y gastric
bypass) 1

GASTRIC BANDING (adjustable
gastric banding or gastric
stapling) 2

BARIATRIC SLEEVE (sleeve
gastrectomy) 3

DUODENAL SWITCH (biliopancreatic
diversion OR biliopancreatic
diversion with a duodenal
switch) 4

OTHER (DO NOT SELECT for
liposuction, tummy tuck, extra
skin remove, fat removal) 5

REFUSED 77

DON’T KNOW 99

IF ITEM CHANGED, CHECK MEC COMPONENT

WHQ.200 [How old {were you/was SP} when {you/she/he} had weight loss surgery?]

[How old {were you/was SP} when {you/she/he} had the most recent weight loss surgery?]

CAPI INSTRUCTION:

IF ONE SURGERY SELECTED IN WHQ.195, DISPLAY: “How old {were you/was SP} when {you/she/he} had weight loss surgery?”

IF MORE THAN ONE SURGERY SELECTED IN WHQ.195, DISPLAY: “How old {were you/was SP} when {you/she/he} had the most recent weight loss surgery?”

|___|___|___|

ENTER AGE IN YEARS

REFUSED 7777

DON'T KNOW 9999

IF ITEM CHANGED, CHECK MEC COMPONENT

Smoking (SMQ)

SMOKING AND TOBACCO USE – SMQ

Target Group: SPs 0-11 years and 18+

BOX 0

CHECK ITEM SMQ.005:

IF SP >= 18 YEARS, CONTINUE.

IF SP 12-17 YEARS, GO TO END OF SECTION.

ELSE GO TO BOX 5.

These next questions are about cigarette smoking. Then I will ask about other tobacco products.

SMQ.022 {Have you/Has SP} smoked at least 100 cigarettes in {your/his/her} entire life? This hand card shows you the products we would like you to include and not include when answering this question.

HAND CARD SMQ1

YES 1

NO 2 (SMQ.NEW1)

REFUSED 7 (SMQ.NEW1)

DON'T KNOW 9 (SMQ.NEW1)

SMQ.030 How old {were you/was SP} when {you/s/he} first started to smoke cigarettes regularly?

G/Q

ENTER AGE 1

NEVER SMOKED CIGARETTES
REGULARLY 2 (SMQ.040)

REFUSED 7 (SMQ.040)

DON’T KNOW 9 (SMQ.040)

CAPI INSTRUCTION:

SOFT EDIT: SP AGE <13

DISPLAY “UNLIKELY RESPONSE. PLEASE VERIFY.”

|___|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

HELP SCREEN:

“regularly” refers to age when started smoking cigarettes on a routine basis as opposed to age when tried first cigarette.

SMQ.040 {Do you/Does SP} now smoke cigarettes . . .

every day, 1 (SMQ.078)

some days, or 2 (SMQ.641)

not at all? 3

REFUSED 7 (BOX 5)

DON'T KNOW 9 (BOX 5)

SMQ.050 How long has it been since {you/SP} quit smoking cigarettes?

Q/U

|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777 (BOX 1A)

DON'T KNOW 99999 (BOX 1A)

|___|

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

BOX 1A

CHECK ITEM SMQ.053:

IF SMQ.050Q/U >= 1 YEAR (365 DAYS, 52 WEEKS, 12 MONTHS, OR 1 YEAR), CONTINUE.

OTHERWISE, GO TO SMQ.057.

SMQ.055 How old {were you/was SP} when {you/s/he} last smoked cigarettes { regularly}?

CAPI INSTRUCTION:

DISPLAY “REGULARLY” EXCEPT WHEN SMQ.030 G/Q = 2 (NEVER SMOKED CIGARETTES REGULARLY).

|___|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

SMQ.057 At that time, about how many cigarettes did {you/SP} usually smoke per day?

1 PACK EQUALS 20 CIGARETTES

IF LESS THAN 1 PER DAY, ENTER 1

IF 95 OR MORE PER DAY, ENTER 95

|___|___|___|

ENTER NUMBER OF CIGARETTES (PER DAY)

REFUSED 7777

DON'T KNOW 9999

BOX 1B

CHECK ITEM SMQ.060:

GO TO BOX 5.

SMQ.078 How soon after {you/SP} wake{s} up {do you/does s/he} smoke? Would you say . . .

within 5 minutes, 1

from 6 to 30 minutes, 2

from more than 30 minutes to 1 hour, 3

from more than 1 hour to 2 hours, 4

from more than 2 hours to 3 hours, 5

from more than 3 hours to 4 hours, or 6

more than 4 hours? 7

REFUSED 77

DON'T KNOW 99

SMQ.641 During the past 30 days, on how many days did {you/SP} smoke cigarettes?

|___|___|

ENTER NUMBER OF DAYS

REFUSED 7777

DON'T KNOW 9999

CAPI INSTRUCTION:

ALLOW '0' AS AN ENTRY. IF '0' DK OR RF ENTERED, SKIP TO QUESTION SMQ.093.

SMQ.650 During the past 30 days, on the days that {you/SP} smoked, how many cigarettes did {you/s/he} smoke per day?

1 PACK EQUALS 20 CIGARETTES

IF LESS THAN 1 PER DAY, ENTER 1

IF 95 OR MORE PER DAY, ENTER 95

|___|___|___|

ENTER NUMBER OF CIGARETTES (PER DAY)

REFUSED 7777

DON'T KNOW 9999

SMQ.093 May I please see the pack for the brand of cigarettes {you usually smoke/SP usually smokes}.

TO OBTAIN ACCURATE PRODUCT INFORMATION, IT IS IMPORTANT THAT YOU SEE THE CIGARETTE PACK.

PACK SEEN 1

PACK NOT SEEN 2 (SMQ.100k)

NO USUAL BRAND 3 (SMQ.670)

ROLLS OWN CIGARETTES 4 (SMQ.670)

REFUSED 7 (SMQ.100k)

SMQ.310 ENTER THE UNIVERSAL PRODUCT CODE FROM THE CIGARETTE PACK. UPC MUST CONTAIN 8 OR 12 DIGITS.

SELECT ONE OPTION.

ENTERING 8 DIGIT UPC 1

ENTERING 12 DIGIT UPC 2 (SMQ.330)

UNABLE TO READ CODE-PACK DAMAGED 3 (SMQ.100k)

SMQ.320 ENTER THE 8 DIGIT UPC CODE.

|___|___|___|___|___|___|___|___|

CAPI INSTRUCTION:

DOUBLE ENTRY IS REQUIRED. IF ENTRIES DO NOT MATCH, DISPLAY THE FOLLOWING MESSAGE: ENTRIES DO NOT MATCH. HIGHLIGHT THE ENTRY THAT SHOULD BE CORRECTED AND PRESS ‘ENTER’ TO CHANGE.

BOX 2B

CHECK ITEM SMQ.329:

GO TO BOX 3.

SMQ.330 ENTER THE 12 DIGIT UPC CODE.

|___|___|___|___|___|___|___|___|___|___|___|___|

CAPI INSTRUCTION:

DOUBLE ENTRY IS REQUIRED. IF ENTRIES DO NOT MATCH, DISPLAY THE FOLLOWING MESSAGE: ENTRIES DO NOT MATCH. HIGHLIGHT THE ENTRY THAT SHOULD BE CORRECTED AND PRESS ‘ENTER’ TO CHANGE.

BOX 3

CHECK ITEM SMQ.096A:

IF INVALID CODE OR CODE NOT ON FILE, GO TO SMQ.099.

OTHERWISE, CONTINUE.

SMQ.098 YOU HAVE SELECTED

{DISPLAY BRAND ASSOCIATED WITH CODE}

CORRECT 1 (SMQ.885)

NOT CORRECT 2 (SMQ.100k)

CAPI INSTRUCTION:

DISPLAY BRAND NAME WITH ALL QUALIFIERS – NAME, SIZE (REGULAR, KING, 100, 120), FILTERED/NONFILTERED, MENTHOL/NONMENTHOL, OTHER QUALIFIERS (DELUXE, HARD PACK, LIGHTS, ETC.)

SMQ.099 CODE NOT ON FILE – PRESS ‘ENTER’ TO CONTINUE

SMQ.100k What brand of cigarettes {do you/does SP} usually smoke?

CAPI INSTRUCTION:

FOLLOW THE BASIC FORMAT FOR DIETARY SUPPLEMENT LOOKUP. ONLY ALLOW INTERVIEWER TO ENTER 1 BRAND OF CIGARETTES. ALLOW ENTRY OF DON'T KNOW AND REFUSED.

REFER TO PRODUCT LABEL IF AVAILABLE.

ENTER BRAND NAME OF CIGARETTE.

SMQ.111 PRESS BS TO START THE LOOKUP.

SELECT PRODUCT FROM

LIST OR TYPE

IF PRODUCT NOT ON LIST.

PRESS BS TO

DELETE ENTRY.

TYPE '**'.

PRESS ENTER TO SELECT.

CAPI INSTRUCTION:

Display CAPI cigarette product list. Interviewer should be able to select one product name from list. In addition, interviewer should be able TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN SMQ.100k BY TYPING IN '**'.

BOX 4A

CHECK ITEM SMQ.112:

IF '** PRODUCT NOT ON LIST' SELECTED AT SMQ.111, CONTINUE.

OTHERWISE, GO TO SMQ.885.

SMQ.110a ASK IF NECESSARY:

IS THE CIGARETTE PRODUCT FILTERED OR NON-FILTERED?

ENTER '1' FOR FILTERED

ENTER '0' FOR NON-FILTERED

CAPI INSTRUCTION:

'1' AND '0' SHOULD BE THE ONLY CODES ACCEPTED BY CAPI.

FILTERED 1

NON-FILTERED 0

REFUSED 7777

DON'T KNOW 9999

SMQ.110b ASK IF NECESSARY:

IS THE CIGARETTE PRODUCT MENTHOL OR NON-MENTHOL?

ENTER '1' FOR MENTHOL

ENTER '0' FOR NON-MENTHOL

CAPI INSTRUCTION:

'1' AND '0' SHOULD BE THE ONLY CODES ACCEPTED BY CAPI.

MENTHOL 1

NON-MENTHOL 0

REFUSED 7777

DON'T KNOW 9999

SMQ.110h ASK IF NECESSARY:

WHAT IS THE CIGARETTE PRODUCT SIZE?

CAPI INSTRUCTION:

THIS ITEM IS STORED IN SMQ.110f IN THE DATA BASE.

REGULARS 1

KINGS 2

100S 3

120S 4

REFUSED 7777

DON'T KNOW 9999

SMQ.110i REFER TO PRODUCT LABEL, IF AVAILABLE – ASK IF NECESSARY.

WHAT ARE THE OTHER NAME BRAND QUALIFIERS FOR THE CIGARETTE PRODUCT?

CAPI INSTRUCTION:

SHOULD BE A 'CODE ALL THAT APPLY' EXCEPT IF "REF", "DK" OR "NONE" SELECTED. NO OTHER RESPONSE OPTION SHOULD BE ALLOWED. THE "OTHER SPECIFY" RESPONSE SHOULD REQUIRE A TEXT ENTRY.

SMOOTH 9

DELUXE 10

HARD PACK 11

LIGHTS 12

MILDS 13

SLIMS 14

SPECIALS 15

SUPER 16

ULTRA LIGHTS 17

OTHER (SPECIFY) 18

NONE 19

REF 77

DK 99

SMQ.885 INTERVIEWER: ASK OR MARK IF KNOWN: What is the main color on the cigarette pack of {your/his/her} usual brand?

RED 1

BLUE 2

SILVER 3

GOLD 4

BLACK 5

WHITE 6

ORANGE 7

PURPLE 8

GREEN 9

YELLOW 10

ANOTHER COLOR 11

RF 77

DK 99

SMQ.670 During the past 12 months, {have you/has SP} stopped smoking for one day or longer because {you were/he was/she was} trying to quit smoking?

YES 1

NO 2 (SMQ.890)

REFUSED 7 (SMQ.890)

DON'T KNOW 9 (SMQ.890)

SMQ.848 During the past 12 months, how many times {have you/has SP} stopped smoking cigarettes because {you were/he was/she was} trying to quit smoking?

|___|___|

ENTER NUMBER OF TIMES (1-20 TIMES)

REFUSED 777

DON'T KNOW 999

CAPI INSTRUCTION:

IF MORE THAN 20 TIMES ENTER 20

SMQ.852 The last time {you/SP} tried to quit, how long {were you/was he/was she} able to stop smoking?

Q/U

CAPI INSTRUCTION:

SOFT EDIT: SMQ.852 CANNOT BE GREATER THAN 364 DAYS, 11 MONTHS OR 51 WEEKS.

|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS OR MONTHS)

REFUSED 7777

DON'T KNOW 9999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

REFUSED 7

DON’T KNOW 9

SMQ.NEW1 Have {you/SP} EVER smoked a cigarette EVEN ONE TIME?

YES 1

NO 2 (SMQ.890)

REFUSED 7 (SMQ.890)

DON'T KNOW 9 (SMQ.890)

SMQ.NEW2 How old were {you/SP} the first time you smoked all or part of a cigarette?

CAPI INSTRUCTION:

SOFT EDIT: SP AGE <13

DISPLAY “UNLIKELY RESPONSE. PLEASE VERIFY.”

|___|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

SMQ.NEW3 {Do you/Does SP} now smoke cigarettes . . .

every day, 1

some days, or 2

not at all? 3 (SMQ.890)

REFUSED 7 (SMQ.890)

DON'T KNOW 9 (SMQ.890)

SMQ.NEW4 On how many of the PAST 30 DAYS did {you/SP} smoke cigarettes?

|___|___|

ENTER NUMBER OF DAYS

REFUSED 7777

DON'T KNOW 9999

CAPI INSTRUCTION:

ALLOW '0' AS AN ENTRY. IF '0' DK OR RF ENTERED, SKIP TO QUESTION SMQ.890.

SMQ.NEW5 How long has it been since {you/SP} smoked a cigarette?

Q/U

|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777

DON'T KNOW 99999

|___|

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

SMQ.890 Have {you/SP} EVER smoked a regular cigar, cigarillo or little filtered cigar EVEN ONE TIME? This hand card shows examples of some cigars; however there are others not included here.

HAND CARD SMQ2

YES 1

NO 2 (SMQ.900)

REFUSED 7 (SMQ.900)

DON'T KNOW 9 (SMQ.900)

SMQ.895 During the past 30 days, on how many days did {you/SP} smoke a regular cigar, cigarillo or little filtered cigar?

|___|___|

ENTER NUMBER OF DAYS

REFUSED 7777

DON'T KNOW 9999

CAPI INSTRUCTION: ALLOW '0' AS AN ENTRY.

SMQ.900 The next question is about e-cigarettes. These are battery-powered devices that usually contain liquid nicotine, and don’t produce smoke

Have {you/SP} EVER used an e-cigarette EVEN ONE TIME? This hand card shows examples of some e-cigarettes and other devices used to inhale liquid nicotine; however there are others not included here.

HAND CARD SMQ3

YES 1

NO 2 (SMQ.910)

REFUSED 7 (SMQ.910)

DON'T KNOW 9 (SMQ.910)

HELP SCREEN for SMQ.900: E-cigarettes and other similar products are bought as disposable or reusable kits with a cartridge or with refillable container. They usually contain nicotine or flavored liquid, called “e-liquid” or “e-juice”.

SMQ.905 During the past 30 days, on how many days did {you/SP} use e-cigarettes?

|___|___|

ENTER NUMBER OF DAYS

REFUSED 7777

DON'T KNOW 9999

CAPI INSTRUCTION: ALLOW '0' AS AN ENTRY.

SMQ.910 Smokeless tobacco products are placed in the mouth and nose and include chewing tobacco, snuff, dip, snus (pronounced as “snoose”) and dissolvable tobacco.

Have {you/SP} EVER used smokeless tobacco EVEN ONE TIME? This hand card shows examples of smokeless products; however there are others not included here.

HAND CARD SMQ4

YES 1

NO 2 (SMQ.856)

REFUSED 7 (SMQ.856)

DON'T KNOW 9 (SMQ.856)

SMQ.915 During the past 30 days, on how many days did {you/SP} use smokeless tobacco?

|___|___|

ENTER NUMBER OF DAYS

REFUSED 7777

DON'T KNOW 9999

CAPI INSTRUCTION: ALLOW '0' AS AN ENTRY.

BOX 5

CHECK ITEM SMQ.854:

IF SP AGE 0-11, GO SMQ.860.

OTHERWISE, CONTINUE.

SMQ.856 I will now ask you about tobacco smoke in other places.

During the last 7 days, {were you/was SP} working at a job or business outside of the home?

YES 1

NO 2 (SMQ.860)

REFUSED 7 (SMQ.860)

DON'T KNOW 9 (SMQ.860)

SMQ.858 While {you were/SP was} working at a job or business outside of the home, did someone else smoke cigarettes or other tobacco products indoors?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SMQ.860 {I will now ask you about smoking in other places.} During the last 7 days, did {you/SP} spend time in a restaurant?

YES 1

NO 2 (BOX 6)

REFUSED 7 (BOX 6)

DON'T KNOW 9 (BOX 6)

CAPI INSTRUCTION:

DISPLAY ‘I will now ask you about smoking in other places’ IF SP AGE 0-11 YEARS.

SMQ.862 While {you were/SP was} in a restaurant, did someone else smoke cigarettes or other tobacco products indoors?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 6

CHECK ITEM SMQ.864:

IF SP >=18 YEARS, CONTINUE.

OTHERWISE, GO TO SMQ.870.

SMQ.866 During the last 7 days, {did you/SP} spend time in a bar?

YES 1

NO 2 (SMQ.870)

REFUSED 7 (SMQ.870)

DON'T KNOW 9 (SMQ.870)

SMQ.868 While {you were/SP was} in a bar, did someone else smoke cigarettes or other tobacco products indoors?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SMQ.870 During the last 7 days, did {you/SP} ride in a car or motor vehicle?

YES 1

NO 2 (SMQ.874)

REFUSED 7 (SMQ.874)

DON'T KNOW 9 (SMQ.874)

SMQ.872 While {you were/SP was} riding in a car or motor vehicle, did someone else smoke cigarettes or other tobacco products?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SMQ.874 During the last 7 days, did {you/SP} spend time in a home other than {your/his/her} own?

YES 1

NO 2 (SMQ.878)

REFUSED 7 (SMQ.878)

DON'T KNOW 9 (SMQ.878)

SMQ.876 While {you were/SP was} in a home other than {your/his/her} own, did someone else smoke cigarettes or other tobacco products indoors?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SMQ.878 During the last 7 days,{were you/was SP} in any other indoor area?

INTERVIEWER: IF RESPONDENT ASKS WHAT IS MEANT BY OR DOESN’T SEEM TO UNDERSTAND “ANY OTHER INDOOR AREA” SAY “OTHER THAN AT WORK, IN A BAR, RESTAURANT, CAR, OTHER MOTOR VEHICLE, OR A HOUSE.”

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

SMQ.880 While {you were/SP was} in the other indoor area, did someone else smoke cigarettes or other tobacco products?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

coded occupations (ocQ)

OCCUPATION – OCQ

Target Group: SPs 16+

OCQ.152 In this part of the survey I will ask you questions about {your/SP's} work experience.

Which of the following {were you/was SP} doing last week . . .

working at a job or business, 1 (OCQ.180)

with a job or business but not at work, 2 (OCQ.210)

looking for work, or 3 (OCQ.385G/Q)

not working at a job or business? 4 (OCQ.380)

REFUSED 7 (OCQ.385G/Q)

DON'T KNOW 9 (OCQ.385G/Q)

OCQ.180 How many hours did {you/SP} work last week at all jobs or businesses?

|___|___|___|

ENTER NUMBER OF HOURS

CAPI INSTRUCTION:

HARD EDIT 1-168.

REFUSED 77777

DON'T KNOW 99999

BOX 1

CHECK ITEM OCQ.200:

IF HOURS IN OCQ.180 <= 34, OR REFUSED (CODE 777), OR DON'T KNOW (CODE 999), CONTINUE.

OTHERWISE, GO TO OCQ.220.

OCQ.210 {Do you/Does SP} usually work 35 hours or more per week in total at all jobs or businesses?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OCQ.220 For whom did {you/SP} work at {your/his/her} main job or business? (What is the name of the company, business, organization or employer?)

IF MORE THAN 1 JOB, PROBE FOR MAIN JOB.

ENTER NAME OF EMPLOYER

REFUSED 7---77

DON'T KNOW 9---99

OCQ.230 What kind of business or industry is this? (For example: a TV or radio station, retail shoe store, state labor department, farm.)

ENTER NAME OF BUSINESS OR INDUSTRY

REFUSED 7---77

DON'T KNOW 9---99

OCQ.240 What kind of work {were you/was SP} doing? (For example: farming, mail clerk, computer specialist.)

ENTER NAME OF OCCUPATION

REFUSED 7---77

DON'T KNOW 9---99

OCQ.250 What were {your/SP's} most important activities on this job? (For example: sells cars, keeps account books, operates printing press.)

ENTER NAME OF DUTIES

REFUSED 7---77

DON'T KNOW 9---99

OCQ.260 Looking at the card, which of these best describes this job or work situation?

ASK IF NOT CLEAR.

HAND CARD OCQ1

AN EMPLOYEE OF A PRIVATE COMPANY,

BUSINESS, OR INDIVIDUAL FOR WAGES,

SALARY, OR COMMISSION 1

A FEDERAL GOVERNMENT EMPLOYEE 2

A STATE GOVERNMENT EMPLOYEE 3

A LOCAL GOVERNMENT EMPLOYEE 4

SELF-EMPLOYED IN OWN BUSINESS,

PROFESSIONAL PRACTICE OR FARM 5

WORKING WITHOUT PAY IN FAMILY

BUSINESS OR FARM 6

REFUSED 77

DON'T KNOW 99

OCQ.270 About how long {have you/has SP} worked for {EMPLOYER} as a(n) {OCCUPATION}?

Q/U

CAPI INSTRUCTIONS:

DISPLAY AS LEFT HEADER "EMPLOYER:" AND EMPLOYER FROM OCQ.220.

DISPLAY AS LEFT HEADER "OCCUPATION:" AND OCCUPATION FROM OCQ.240.

IF OCQ.220 AND/OR OCQ.240 ARE DK/RF, DISPLAY “AT YOUR MAIN JOB.” IF PROXY, DISPLAY {HIS/HER MAIN JOB}.

DO NOT ALLOW MORE THAN THE SP’S AGE, OR >90 DAYS OR >104 WEEKS OR GREATER THAN 48 MONTHS OR GREATER THAN 60 YEARS.

|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 777777 (BOX 3)

DON'T KNOW 999999 (BOX 3)

|___|

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

OCQ.New1 At {your/SP's} job as a(n) {OCCUPATION} for {EMPLOYER}, how often {do you/does SP} wear protective hearing devices?

CAPI INSTRUCTIONS:

DISPLAY AS LEFT HEADER "OCCUPATION:" AND OCCUPATION FROM OCQ.240.

ALWAYS………………………………..……………………1

USUALLY……………………………….………………… ..2

ABOUT HALF THE TIME………………………………..3

SELDOM………………………………………………………4

NEVER………………………………………………………..5

NO NOISE EXPOSURE PAST 12 MONTHS…….….6

REFUSED...................................................... 7

DON'T KNOW ............................................... 9

HELP SCREEN: PROTECTIVE HEARING DEVICES INCLUDE PLUGS AND EARMUFFS

These next questions are about noise at work. First we are going to ask about loud noise. Loud means so loud that {you/s/he} must speak in a raised voice to be heard by someone three feet away when not using hearing protection. After that we will ask about very loud noise. Very loud noise is noise that is so loud {you have/he has/she has} to shout to be heard by someone three feet away when not using hearing protection.

OCQ.New2 How many days per month are you usually exposed to loud noise at {your/SP's} job as a(n) {OCCUPATION} for {EMPLOYER}. (Loud means so loud that {you/s/he} must speak in a raised voice to be heard by someone three feet away when not using hearing protection.)

CAPI INSTRUCTIONS:

DISPLAY AS LEFT HEADER "EMPLOYER:" AND EMPLOYER FROM OCQ.220 .

DISPLAY AS LEFT HEADER "OCCUPATION:" AND OCCUPATION FROM OCQ.240.

IF NOT IN RANGE 0-31 HAVE HARD EDIT. IF IN RANGE 25-31 DO SOFT EDIT.

|___|___|

ENTER NUMBER OF DAYS

REFUSED ..................................................... 77

DON'T KNOW ............................................... 99

OCQ.New3 On average, during days when you are exposed to this loud noise, for how many hours per day {have you/has SP} been exposed? (Loud means so loud that {you/s/he} must speak in a raised voice to be heard by someone three feet away when not using hearing protection.)

IF NOT IN RANGE 1-24 HAVE HARD EDIT. IF IN RANGE 13-24 DO SOFT EDIT.

IF LESS THAN 1 HOUR, ENTER 1

|___|___|

ENTER NUMBER OF HOURS

REFUSED ..................................................... 77

DON'T KNOW ............................................... 99

OCQ.New4 How many days per month are you usually exposed to very loud noise at {your/SP's} job as a(n) {OCCUPATION} for {EMPLOYER}. (Very loud noise is noise that is so loud {you have/he has/she has} to shout to be heard by someone three feet away when not using hearing protection.)

CAPI INSTRUCTIONS:

DISPLAY AS LEFT HEADER "EMPLOYER:" AND EMPLOYER FROM OCQ.220.

DISPLAY AS LEFT HEADER "OCCUPATION:" AND OCCUPATION FROM OCQ.240.

IF NOT IN RANGE 0-31 HAVE HARD EDIT. IF IN RANGE 25-31 DO SOFT EDIT.

|___|___|

ENTER NUMBER OF DAYS

REFUSED ..................................................... 77

DON'T KNOW ............................................... 99

OCQ.New5 On average, during days when you are exposed to this very loud noise, for how many hours per day {have you/has SP} been exposed? (Very loud noise is noise that is so loud {you have/he has/she has} to shout in order to be understood by someone standing 3 feet away from {you/him/her} when you aren’t wearing hearing protection.)

IF NOT IN RANGE 1-24 HAVE HARD EDIT. IF IN RANGE 13-24 DO SOFT EDIT.

IF LESS THAN 1 HOUR, ENTER 1

|___|___|

ENTER NUMBER OF HOURS

REFUSED ..................................................... 77

DON'T KNOW ............................................... 99

…

BOX 3

CHECK ITEM OCQ.370:

GO TO OCQ.392G/Q.

OCQ.380 What is the main reason {you/SP} did not work last week?

TAKING CARE OF HOUSE OR FAMILY 1

GOING TO SCHOOL 2

RETIRED 3

UNABLE TO WORK FOR HEALTH

REASONS 4

ON LAYOFF 5

DISABLED 6

OTHER 7

REFUSED 77

DON'T KNOW 99

OCQ.385
G/Q

Thinking of all the paid jobs {you/SP} ever had, what kind of work {were you/was s/he} doing the longest? (For example, electrical engineer, stock clerk, typist, farmer.)

CAPI INSTRUCTION:

IF CURRENT OCCUPATION HAS BEEN ENTERED IN OCQ.240, DISPLAY AS LEFT HEADER "CURRENT OCCUPATION: {OCQ.240}".

|___|

ENTER OCCUPATION 1

ARMED FORCES 3 (OCQ.393)

NEVER WORKED 4 (END OF SECTION)

REFUSED 7 (OCQ.393)

DON'T KNOW 9 (OCQ.393)

ENTER OCCUPATION

REFUSED 7----7

DON'T KNOW 9----9

OCQ.389 What kind of business or industry {did you/did SP} work in for the longest period of time as a (DISPLAY LONGEST OCCUPATION AS “LONGEST OCCUPATION” {OCQ385Q})? (For example, a TV or radio station, retail shoe store, state labor department, farm.)

(OCQ.393)

ENTER DESCRIPTION FOR KIND OF BUSINESS/INDUSTRY

REFUSED 7---77 (OCQ.393)

DON'T KNOW 9---99 (OCQ.393)

OCQ.392
G/Q

Thinking of all the paid jobs {you/SP} ever had, what kind of work {were you/was s/he} doing the longest? (For example, electrical engineer, stock clerk, typist, farmer.)

CAPI INSTRUCTION:

IF CURRENT OCCUPATION HAS BEEN ENTERED IN OCQ.240, DISPLAY AS LEFT HEADER "CURRENT OCCUPATION: {OCQ.240}".

|___|

ENTER OCCUPATION 1

SAME AS CURRENT OCCUPATION 2 (END OF SECTION)

ARMED FORCES 3 (OCQ.393)

REFUSED 7 (OCQ.393)

DON'T KNOW 9 (OCQ.393)

ENTER OCCUPATION

REFUSED 7------7 (OCQ.394)

DON'T KNOW 9-----9 (OCQ.394)

OCQ.394 What kind of business or industry {did you/did SP} work in for the longest period of time as a (DISPLAY LONGEST OCCUPATION AS “LONGEST OCCUPATION” {OCQ392Q})? (For example, a TV or radio station, retail shoe store, state labor department, farm.)

ENTER DESCRIPTION FOR KIND OF BUSINESS/INDUSTRY

REFUSED 7---77

DON'T KNOW 9---99

OCQ.393 What were {your/SP's} most important activities on this job or business? (For example: sells cars, keeps account books, operates printing press.)

ENTER NAME OF DUTIES

REFUSED 7---77

DON'T KNOW 9---99

OCQ.395 About how long did {you/SP} work at that job or business?

Q/U

CAPI INSTRUCTION:

DISPLAY "LONGEST OCCUPATION: {OCQ.385G/Q or OCQ.392G/Q}" AS LEFT HEADER.

DO NOT ALLOW LESS THAN SP’S AGE OR <90 DAYS OR <104 WEEKS OR <48 MONTHS OR <60 YEARS.

|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777 (END OF SECTION)

DON'T KNOW 99999 (END OF SECTION)

|___|

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

BOX 4

OMITTED

BOX 4A

OMITTED

BOX 5A

OMITTED

BOX 5B

OMITTED

BOX 6

OMITTED

HELP SCREEN FOR OCQ.152:

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

Looking for Work: To be looking for work, a person has to have conducted an active job search. An active job search means that the person took steps necessary to put him/herself in a position to be hired for a job. Active job search methods include:

1. Filled out applications or sent out resumes;

2. Placed or answered classified ads;

3. Checked union/professional registers;

4. Bid on a contract or auditioned for a part in a play;

5. Contacted friends or relatives about possible jobs;

6. Contacted school/college university employment office;

7. Contacted employment directly.

Job search methods that are not active include the following:

1. Looked at ads without responding to them;

2. Picked up a job application without filling it out.

HELP SCREEN FOR OCQ.180:

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

Hours Worked Last Week: The number of hours actually worked last week. Hours worked will include overtime if the person worked overtime last week. The actual hours worked is often not the same as the hours on which the person's salary is based. We want the actual hours spent working on the job, whether the hours were paid or not. However, unpaid hours spent traveling to and from work are not included in hours worked last week.

HELP SCREEN FOR OCQ.210:

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

HELP SCREEN FOR OCQ.220:

Main Job: The job or business where the person worked the most hours.

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

HELP SCREEN FOR OCQ.250:

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

HELP SCREEN FOR OCQ.260:

Private Company or Business: Employees of an organization whose operations are owned by private individuals and not a governmental entity. This employer may be a large corporation or a single individual, but must not be part of any government organization. This category also includes private organizations doing contract work for government agencies.

Federal Government: Include individuals working for any branch of the federal government, as well as paid elected officials, civilian employees of the Armed Forces and some members of the National Guard. Include employees of international organizations like the United Nations and employees of foreign governments such as persons employed by the French embassy.

State Government: Include individuals working for agencies of state governments, as well as paid state officials, the state police, employees of state universities and colleges, and statewide JTPP administrators.

Local Government: Include individuals employed by cities, towns, counties, parishes, and other local areas, as well as employees of city-owned businesses, such as electric power companies, water and sewer services, etc. Also included here would be city-owned bus lines and employees of public elementary and secondary schools who worked for the local government.

Self-employed: Persons working for profit or fees in their own business, shop, office, farm, etc. Include persons who have their own tools or equipment and provide services on a contract, subcontract, or job basis such as carpenters, plumbers, independent taxicab operators or independent truckers.

Working Without Pay: Working on a farm or in a business operated by a related member of the household, without receiving wages or salary for work performed.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

HELP SCREEN FOR OCQ.380:

Taking Care of House or Family: Doing any type of work around the house, such as cleaning, cooking, maintaining the yard, caring for children or family, etc.

Going to School: Attending any type of public or private educational establishment both in and out of the regular school system.

Retired: Respondent defined.

Unable to Work for Health Reasons: Respondent defined.

On Layoff: Is when a person is waiting to be called back to a job from which they were temporarily laid-off or furloughed. Layoffs can be due to slack work, plant retooling or remodeling, inventory taking, and the like. Do not consider a person who was not working because of a labor dispute at his or her place of employment as being in layoff.

Disabled: Respondent defined.

HELP SCREEN FOR OCQ.385:

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

HELP SCREEN FOR OCQ.392:

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

HELP SCREEN FOR OCQ.395:

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

ACCULTURATION (ACQ)

ACCULTURATION – ACQ

Target Group: SPs 3+

BOX 1

OMITTED

BOX 1B

CHECK ITEM ACQ.006:

IF SP CODED HISPANIC IN SCREENER, GO TO ACQ.042.
Else if SP coded Asian in screener, go to ACQ.049.
IF CODED BOTH HISPANIC AND ASIAN IN SCREENER, GO TO acq.042

OTHERWISE, CONTINUE.

ACQ.011 Now I'm going to ask you about language use.

What language(s) {do you/does SP} usually speak at home?

CODE ALL THAT APPLY

ENGLISH 1

SPANISH 8

OTHER 9

REFUSED 77

DON'T KNOW 99

BOX 2

CHECK ITEM ACQ.015:

GO TO END OF SECTION.

ACQ.042 Now I’m going to ask you about language use.

What language(s) {do you/does SP} usually speak at home? {Do you/Does he/Does she} speak only Spanish, more Spanish than English, both equally, more English than Spanish, or only English?

HAND CARD ACQ1

ONLY SPANISH, 1

MORE SPANISH THAN ENGLISH, 2

BOTH EQUALLY, 3

MORE ENGLISH THAN SPANISH, OR 4

ONLY ENGLISH 5

REFUSED 7

DON'T KNOW 9

BOX 3

CHECK ITEM ACQ.045:

GO TO ACQ.120.

ACQ.049 Now I’m going to ask you about language use.

What language(s) {do you/does SP} usually speak at home?

CODE ALL THAT APPLY

HAND CARD ACQ2

English 10

Chinese 11

Farsi/Persian 12

Hindi 13

Japanese 14

Khmer/Cambodian 15

Korean 16

Tagalog/Filipino 17

Urdu 18

Vietnamese 19

Other (SPECIFY) 20

REFUSED 77 (ACQ.120)

DON'T KNOW 99 (ACQ.120)

BOX 4

CHECK ITEM ACQ.090:

IF ACQ.049 = 10 ONLY, GO TO ACQ.120.

IF ACQ.049 = 10 AND ONE OTHER RESPONSE 11-20, GO TO ACQ.110.

IF ACQ.049 DOES NOT EQUAL 10, GO TO ACQ.120

IF ACQ.049 = 10 AND TWO OR MORE OTHER RESPONSES 11-20, GO TO ACQ.101.

ACQ.101 Of these languages {ACQ.049 responses 11-20}, which {do you/does SP} speak more of at home?

CAPI INSTRUCTION:

FILL NON-ENGLISH RESPONSE OPTIONS SELECTED IN ACQ.049 AND/OR ACQ.049OS SEPARATING WITH A COMMA. BEFORE LAST RESPONSE DISPLAY “and”. FOR RESPONSE OPTION 20, DISPLAY OTHER SPECIFY TEXT.
DISPLAY ONLY NON-ENGLISH RESPONSE OPTIONS SELECTED IN ACQ.049 AND/OR ACQ.049OS THAT WERE SELECTED.

Chinese 11

Farsi/Persian 12

Hindi 13

Japanese 14

Khmer/Cambodian 15

Korean 16

Tagalog/Filipino 17

Urdu 18

Vietnamese 19

{ACQ.049OS} 20

REFUSED 77 (ACQ.120)

DON'T KNOW 99 (ACQ.120)

ACQ.110 {Do you/Does SP} speak only (NON-ENGLISH LANGUAGE), more (NON-ENGLISH LANGUAGE) than English, both equally, more English than (NON-ENGLISH LANGUAGE), or only English?

CAPI INSTRUCTION:

IF ENGLISH AND ONE OTHER RESPONSE OPTION 11-20 WAS SELECTED IN ACQ.049, FILL NON-ENGLISH LANGUAGE WITH RESPONSE OPTION 11-20.
IF ENGLISH AND TWO OR MORE OTHER OPTIONS 11-20 WERE SELECTED IN ACQ.049, FILL NON-ENGLISH WITH RESPONSE TO QUESTION ACQ.101.

ONLY (NON-ENGLISH LANGUAGE), 1

MORE (NON-ENGLISH), THAN ENGLISH, 2

BOTH EQUALLY, 3

MORE ENGLISH THAN (NON-ENG), OR 4

ONLY ENGLISH 5

REFUSED 7

DON'T KNOW 9

ACQ.120 In what country was {your/SP’s} father born?

United States, except puerto rico 1

puerto rico 2

Cambodia 3

CHINA 4

cuba 5

dominican republic 6

El salvador 7

india 8

iran 9

Japan 10

korea 11

MEXICO 12

nicaragua 13

Pakistan 14

PHIlippines 15

vietnam 16

Other (Specify) 17

REFUSED 77

DON'T KNOW 99

ACQ.130 In what country was {your/SP’s} mother born?

United States, except puerto rico 1

puerto rico 2

Cambodia 3

CHINA 4

cuba 5

dominican republic 6

El salvador 7

india 8

iran 9

Japan 10

korea 11

MEXICO 12

nicaragua 13

Pakistan 14

PHIlippines 15

vietnam 16

Other (Specify) 17

REFUSED 77

DON'T KNOW 99

demographics (dmQ)

DEMOGRAPHICS INFORMATION – DMQ – SP

Target Group: SPs Birth +

BOX 1A

CHECK ITEM DMQ.030:

IF SP AGE >= 6, CONTINUE.

OTHERWISE, GO TO DMQ.061.

DMQ.141 What is the highest grade or level of school {you have/SP has} completed or the highest degree {you have/s/he has} received?

HAND CARD DMQ1

READ HAND CARD CATEGORIES IF NECESSARY.

Enter highest level of school.

NEVER ATTENDED/KINDERGARTEN

ONLY 0 (BOX 1B)

1ST GRADE 1

2ND GRADE 2

3RD GRADE 3

4TH GRADE 4

5TH GRADE 5

6TH GRADE 6

7TH GRADE 7

8TH GRADE 8

9TH GRADE 9

10TH GRADE 10

11TH GRADE 11

12TH GRADE, NO DIPLOMA 12

HIGH SCHOOL GRADUATE 13

GED OR EQUIVALENT 14

SOME COLLEGE, NO DEGREE 15

ASSOCIATE DEGREE: OCCUPATIONAL,

TECHNICAL, OR VOCATIONAL

PROGRAM 16

ASSOCIATE DEGREE: ACADEMIC

PROGRAM 17

BACHELOR’S DEGREE (EXAMPLE: BA,

AB, BS, BBA) 18

MASTER’S DEGREE (EXAMPLE: MA,

MS, MEng, MEd, MBA) 19

PROFESSIONAL SCHOOL DEGREE

(EXAMPLE: MD, DDS, DVM, JD) 20

DOCTORAL DEGREE (EXAMPLE:

PhD, EdD) 21

REFUSED 77

DON’T KNOW 99

CAPI INSTRUCTION:

EDITS:

(DMQ.141 = 19, 20 OR 21 AND SP AGE < 22) OR

(DMQ.141 = 15, 16, 17 OR 18 AND SP AGE < 18) OR

(DMQ.141 = 10, 11, 12, 13 OR 14 AND SP AGE < 14) OR

(DMQ.141 = 5, 6, 7, 8 OR 9 AND SP AGE < 8)

DISPLAY “IMPROBABLE ANSWER DUE TO SP’s AGE {SP AGE}. PLEASE VERIFY.”

BOX 1AA

CHECK ITEM DMQ.035:

IF SP AGE <= 19, CONTINUE

OTHERWISE, GO TO DMQ.052.

DMQ.037 {Are you/Is SP} now . . .

going to school, 1

between grades, or 2

neither? 3

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

Going to School: Attending any type of public or private educational establishment both in and out of the regular school system.

BOX 1B

CHECK ITEM DMQ.040:

IF SP AGE >= 17, CONTINUE.

OTHERWISE, GO TO DMQ.061.

DMQ.052 {Have you/Has SP} ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard? (Active duty does not include training for the Reserves or National Guard, but does include activation, for service in the U.S. or in a foreign country, in support of military or humanitarian operations.)

YES 1

NO 2 (DMQ.061)

REFUSED 7 (DMQ.061)

DON'T KNOW 9 (DMQ.061)

HELP SCREEN:

Armed Forces: Non-civilian members of any of the armed services of the federal government (Army, Navy, Air Force, Coast Guard, Marines).

DMQ.054 Did {you/SP} ever serve in a foreign country during a time of armed conflict or on a humanitarian or peace-keeping mission? (This would include National Guard or reserve or active duty monitoring or conducting peace keeping operations in Bosnia and Kosovo, in the Sinai between Egypt and Israel, or in response to the 2004 tsunami or Haiti in 2010.)

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DMQ.057 When did {you/SP} serve on active duty in the U.S. Armed Forces?

HAND CARD DMQ2

CODE ALL THAT APPLY

INTERVIEWER: CHECK ALL PERIODS IN WHICH THIS PERSON SERVED. CHECK THE ITEM EVEN IF THE SP SERVED FOR JUST FOR PART OF THAT PERIOD.

SEPT 2001 OR LATER 10

AUGUST 1990 TO AUGUST 2001 (INCLUDING PERSIAN

GULF WAR) 11

SEPTEMBER 1980 TO JULY 1990 12

MAY 1975 TO AUGUST 1980 13

AUGUST 1964 TO APRIL 1975 (VIETNAM ERA) 14

MARCH 1961 TO JULY 1964 15

FEBRUARY 1955 TO FEBRUARY 1961 16

JULY 1950 TO JANUARY 1955 (KOREAN WAR) 17

JANUARY 1947 TO JUNE 1950 18

DECEMBER 1941 TO DECEMBER 1946 (WORLD WAR II) 19

NOVEMBER 1941 OR EARLIER 20

REFUSED 77

DON'T KNOW 99

NEW BOX 1BB

CHECK ITEM DMQ.058:

IF CODE 11 (AUGUST 1990 TO AUGUST 2001) IN DMQ.057, CONTINUE.

OTHERWISE, GO TO DMQ.061.

DMQ.059 Did {you/SP} serve in the Persian Gulf during Operation Desert Shield or Operation Desert Storm between August 1990 and April 1991?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DMQ.061 Next I have a few questions about {your/SP’s} name. {Do you/Does SP} usually go by another first name besides {DISPLAY FIRST NAME FROM DMQ-SPIV.040}?

CAPI INSTRUCTION:

DISPLAY "FIRST NAME:" AND FIRST NAME FROM DMQ-SPIV.040 AS LEFT HEADER.

YES 1

NO 2 (NEW BOX 1BB2)

REFUSED 7 (NEW BOX 1BB2)

DON'T KNOW 9 (NEW BOX 1BB2)

DMQ.071 What is this other first name?

VERIFY SPELLING

____________________________________

ENTER NAME

REFUSED 7----7

DON'T KNOW 9----9

NEW BOX 1BB2

CHECK ITEM DMQ.072:

IF SP AGE <16, CONTINUE.

OTHERWISE, GO TO BOX 1BBB.

DMQ.400 What is {SP’s} mother’s full name, including middle name? Please give me the name as it appears on {SP}’s birth certificate.

What is {SP’s} mother’s first name?

INTERVIEWER INSTRUCTION: VERIFY SPELLING.

First Name: __________________________

REFUSED 7----7

DON’T KNOW 9----9

DMQ.405 [What is {SP's} mother’s full name, including middle name? Please give me the name as it appears on

G/Q {SP}’s birth certificate.]

DMQ.410 What is {SP's} mother’s middle name?

INTERVIEWER INSTRUCTION: VERIFY SPELLING.

|___|

ENTER MIDDLE NAME 1

NO MIDDLE NAME 2 (DMQ.415)

REFUSED 7 (DMQ.415)

DON'T KNOW 9 (DMQ.415)

MIDDLE Name #1: __________________________

MIDDLE Name #2: __________________________

CAPI INSTRUCTION: ALLOW MIDDLE NAME #2 TO BE BLANK/NULL

DMQ.415 [What is {SP’s} mother’s full name, including middle name? Please give me the name as it appears on

G/Q {SP}’s birth certificate.]

DMQ.420 What is {SP’s} mother’s last name?

INTERVIEWER INSTRUCTION: VERIFY SPELLING.

|___|

ENTER LAST NAME 1

REFUSED 7 (DMQ.425)

DON'T KNOW 9 (DMQ.425)

Last Name #1: __________________________

Last Name #2: __________________________

CAPI INSTRUCTION: ALLOW LAST NAME #2 TO BE BLANK/NULL

DMQ.425 What is {SP’s} father’s full name, including middle name? Please give me the name as it appears on {SP}’s birth certificate.

What is {SP’s}father’s first name?

INTERVIEWER INSTRUCTION: VERIFY SPELLING.

First Name: __________________________

REFUSED 7----7

DON’T KNOW 9----9

DMQ.430 [What is {SP's} father’s full name, including middle name? Please give me the name as it appears on

G/Q {SP}’s birth certificate.]

DMQ.435 What is {SP's} father’s middle name?

INTERVIEWER INSTRUCTION: VERIFY SPELLING.

|___|

ENTER MIDDLE NAME 1

NO MIDDLE NAME 2 (DMQ.440)

REFUSED 7 (DMQ.440)

DON'T KNOW 9 (DMQ.440)

MIDDLE Name #1: __________________________

MIDDLE Name #2: __________________________

CAPI INSTRUCTION: ALLOW MIDDLE NAME #2 TO BE BLANK/NULL

DMQ.440 [What is {SP’s} father’s full name, including middle name? Please give me the name as it appears on

G/Q {SP}’s birth certificate.]

DMQ.445 What is {SP’s} father’s last name?

INTERVIEWER INSTRUCTION: VERIFY SPELLING.

|___|

ENTER LAST NAME 1

REFUSED 7 (BOX 1BBB)

DON'T KNOW 9 (BOX 1BBB)

Last Name #1: __________________________

Last Name #2: __________________________

CAPI INSTRUCTION: ALLOW LAST NAME #2 TO BE BLANK/NULL

BOX 1BBB

CHECK ITEM DMQ.073a:

IF AGE >= 14, CONTINUE.

OTHERWISE, GO TO BOX 1D.

DMQ.380 {Are you/Is SP} now married, widowed, divorced, separated, never married or living with a partner?

MARRIED 1

WIDOWED 2

DIVORCED 3

SEPARATED 4

NEVER MARRIED 5 (BOX 1D)

LIVING WITH PARTNER 6

REFUSED 77

DON'T KNOW 99

BOX 1C

CHECK ITEM DMQ.075A:

IF SP IS MALE, GO TO BOX 1D.

OTHERWISE, CONTINUE.

DMQ.081 {Do you/Does SP} have a maiden name?

ASK IF NOT KNOWN

YES 1

NO 2 (BOX 1D)

REFUSED 7 (BOX 1D)

DON'T KNOW 9 (BOX 1D)

DMQ.090 What is {your/SP's} maiden name?

G/Q

VERIFY SPELLING

CAPI INSTRUCTION:

DISPLAY "LAST NAME:" AND SP'S CURRENT LAST NAME FROM DMQ-SPIV.060 AS LEFT HEADER.

|___|

ENTER MAIDEN NAME 1

SAME AS CURRENT LAST NAME 2 (BOX 1D)

REFUSED 7 (BOX 1D)

DON'T KNOW 9 (BOX 1D)

____________________________________

REFUSED 7----7

DON'T KNOW 9----9

BOX 1D

CHECK ITEM DMQ.094:

IF SP AGE >= 16, CONTINUE.

OTHERWISE, GO TO DMQ.241.

DMQ.101 What is {your/SP's} father's last name?

G/Q

VERIFY SPELLING

CAPI INSTRUCTION:

DISPLAY "LAST NAME:" AND SP'S CURRENT LAST NAME FROM DMQ-SPIV.060 AS LEFT HEADER.

IF MAIDEN NAME ENTERED IN DMQ.090G/Q, AND MAIDEN NAME IS DIFFERENT FROM CURRENT LAST NAME, ALSO DISPLAY "MAIDEN NAME:" AND MAIDEN NAME FROM DMQ.090G/Q AS LEFT HEADER.

CAPI INSTRUCTION:

HARD EDIT: IF SP MALE, DO NOT ALLOW RESPONSE 3.

|___|

ENTER NAME 1

SAME AS CURRENT LAST NAME 2 (DMQ.241)

SAME AS MAIDEN NAME 3 (DMQ.241)

REFUSED 7 (DMQ.241)

DON'T KNOW 9 (DMQ.241)

____________________________________

REFUSED 7----7

DON'T KNOW 9----9

DMQ.241 {Do you/Does SP} consider {yourself/himself/herself} to be Hispanic, Latino, or of Spanish origin?

READ IF NECESSARY: Where {do your/do his/do her} ancestors come from?

Puerto Rican

Cuban/Cuban American

Dominican Republic

Mexican/Mexican American

Central/South American

Other Latin American

Other Hispanic or Latino

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

SPANISH, HISPANIC OR LATINO PEOPLE MAY BE OF ANY RACE. LISTED BELOW ARE HISPANIC OR LATINO CATEGORIES/COUNTRIES.

MEXICAN

PUERTO RICAN

CUBAN

DOMINICAN REPUBLIC

CENTRAL AMERICAN:

COSTA RICAN

GUATEMALAN

HONDURAN

NICARAGUAN

PANAMANIAN

SALVADORAN

OTHER CENTRAL AMERICAN

SOUTH AMERICAN:

ARGENTINEAN

BOLIVIAN

CHILEAN

COLOMBIAN

ECUADORIAN

PARAGUAYAN

PERUVIAN

URUGUAYAN

VENEZUELAN

OTHER SOUTH AMERICAN

OTHER HISPANIC OR LATINO:

SPANIARD

SPANISH

SPANISH AMERICAN

BOX 3E

OMITTED

BOX 3F

OMITTED

BOX 3G

OMITTED

BOX 3H

OMITTED

BOX 3I

CHECK ITEM DMQ.242:

IF YES (CODE 1) IN DMQ.241 AND YES IN SCQ.260 GO TO DMQ.253.

IF NO (CODE 2) IN DMQ.241 AND NO IN SCQ.260 GO TO DMQ.263.

OTHERWISE, GO TO BOX 3J.

BOX 3J

CHECK ITEM DMQ.249:

IF YES (CODE 1) OR DK IN DMQ.241 AND NO (CODE 2) IN SCQ.260, DISPLAY SOFT EDIT MESSAGE “WARNING – SCREENER ETHNICITY IS NOT HISPANIC – SP MAY BE DESAMPLED. HAND CARD DMQ3 TO RESPONDENT AND READ CATEGORIES.

OTHERWISE, GO TO BOX 3K.

BOX 3K

CHECK ITEM DMQ.254:

IF NO (CODE 2) OR DK IN DMQ.241 AND YES (CODE 1) IN SCQ.260, DISPLAY SOFT EDIT MESSAGE “WARNING – SCREENER ETHNICITY IS HISPANIC – SP MAY BE DESAMPLED. HAND CARD DMQ3 TO RESPONDENT AND READ CATEGORIES.

OTHERWISE, GO TO BOX 3K-1.

BOX 3K-1

CHECK ITEM DMQ.256:

IF YES IN DMQ.241, CONTINUE.

OTHERWISE, GO TO DMQ.263.

DMQ.253 Please give me the number of the group that represents {your/SP's} Hispanic/Latino or Spanish origin or ancestry. Please select 1 or more of these categories.

PROBE: Where do you/your ancestors come from?

HAND CARD DMQ3

SELECT 1 OR MORE

MEXICAN 10

PUERTO RICAN 11

CUBAN 12

DOMINICAN REPUBLIC 13

CENTRAL AMERICAN:

COSTA RICAN 14

GUATEMALAN 15

HONDURAN 16

NICARAGUAN 17

PANAMANIAN 18

SALVADORAN 19

OTHER CENTRAL AMERICAN 20

SOUTH AMERICAN:

ARGENTINEAN 21

BOLIVIAN 22

CHILEAN 23

COLOMBIAN 24

ECUADORIAN 25

PARAGUAYAN 26

PERUVIAN 27

URUGUAYAN 28

VENEZUELAN 29

OTHER SOUTH AMERICAN 30

OTHER HISPANIC OR LATINO:

FILIPINO 31

SPANIARD 32

SPANISH 33

SPANISH AMERICAN 34

HISPANO/HISPANA 35

HISPANIC/LATINO 36

OTHER HISPANIC/LATINO (SPECIFY) 40

CHICANA/CHICANO 41

REFUSED 77

DON'T KNOW 99

BOX 3L

CHECK ITEM DMQ.255:

IF ‘OTHER SPECIFY’ (CODE 40) IN DMQ.253, DISPLAY SOFT ERROR MESSAGE “PLEASE REVIEW THE LIST AND SELECT RESPONSE FROM LIST BEFORE TYPING. THE LIST IS MEANT TO INCLUDE ALL CATEGORIES” AND CAPI SHOULD RETURN TO DMQ.253.

DMQ.263 Please look at the categories on this card. What race or races {do you/does SP} consider {yourself/himself/herself} to be? Please select one or more.

HAND CARD DMQ4

CHECK ALL THAT APPLY.

AMERICAN INDIAN OR ALASKAN NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR PACIFIC ISLANDER 4

WHITE 5

OTHER 6

DK 9

RF 7

NEW BOX L-1

CHECK ITEM DMQ.310:

IF CODE 2 (ASIAN) IN DMQ.263 AND CODE 2 (ASIAN) IN SCQ.270, GO TO DMQ.336.

IF NOT CODE 2 (ASIAN) IN DMQ.263 AND NOT CODE 2 (ASIAN) IN SCQ.270, GO TO BOX L-4d.

OTHERWISE, GO TO NEW BOX L-2.

NEW BOX L-2

CHECK ITEM DMQ.315:

IF CODE 2 (ASIAN) OR DK IN DMQ.263 AND NOT (CODE 2) IN SCQ.270, DISPLAY SOFT EDIT MESSAGE “WARNING – SCREENER RACE IS NOT ASIAN – SP MAY BE DESAMPLED.”

OTHERWISE, GO TO NEW BOX L-3.

NEW BOX L-3

CHECK ITEM DMQ.320:

IF NOT CODE 2 OR DK IN DMQ.263 AND CODE 2 (ASIAN) IN SCQ.270, DISPLAY SOFT EDIT MESSAGE “WARNING – SCREENER RACE IS ASIAN – SP MAY BE DESAMPLED.

OTHERWISE, GO TO NEW BOX L-4.

NEW BOX L-4

CHECK ITEM DMQ.325:

IF CODE 2 (ASIAN) IN DMQ.263, GO TO DMQ.336.

OTHERWISE, GO TO NEW BOX L-4a.

NEW BOX L-4a

CHECK ITEM DMQ.327:

IF CODE 3 (BLACK) IN DMQ.263 AND CODE 3 (BLACK) IN SCQ.270, GO TO NEW BOX L-4d.

IF NOT CODE 3 (BLACK) IN DMQ.263 AND NOT CODE 3 (BLACK) IN SCQ.270, GO TO NEW BOX L-4d.

OTHERWISE, GO TO NEW BOX L-4b.

NEW BOX L-4b

CHECK ITEM DMQ.332:

IF CODE 3 (BLACK) OR DK IN DMQ.263 AND NOT CODE 3 IN SCQ.270, DISPLAY SOFT EDIT MESSAGE “WARNING-SCREENER RACE IS NOT BLACK/AFRICAN AMERICAN-SP MAY BE DESAMPLED.”

OTHERWISE, GO TO NEW BOX L-4c.

NEW BOX L-4c

CHECK ITEM DMQ.338:

IF NOT 3 OR DK IN DMQ.263 AND CODE 3 (BLACK/AFRICAN AMERICAN) IN SCQ.270, DISPLAY SOFT EDIT MESSAGE “WARNING-SCREENER RACE IS BLACK/AFRICAN AMERICAN-SP MAY BE DESAMPLED.”

OTHERWISE, GO TO NEW BOX L-4d.

NEW BOX L-4d

CHECK ITEM DMQ.339:

IF CODE 4 (NHPI) IN DMQ.263, GO TO DMQ.350.

IF NOT CODE 4 (NHPI) IN DMQ.263, GO TO NEW BOX L-5.

NEW BOX L-5

CHECK ITEM DMQ.330:IF CODE 6 (OTHER) IN DMQ.263 AND CODE 1 (YES-HISPANIC) IN DMQ.241, GO TO DMQ.266.

OTHERWISE, GO TO DMQ.107.

DMQ.350 Please give me the number of the group that represents {your/SP’s} Native Hawaiian or Pacific Islander origin or ancestry. Please select one or more of these categories.

HAND CARD DMQ5

PROBE: Where do your ancestors come from?

NATIVE HAWAIIAN 1

GUAMANIAN OR CHAMORRO 2

SAMOAN 3

OTHER PACIFIC ISLANDER 4

REFUSED 7

DON’T KNOW 9

BOX L-5a

CHECK ITEM DMQ.355:

GO TO NEW BOX L-5.

DMQ.336 Please give me the number of the group that represents {your/SP’s} Asian origin or ancestry. Please select one or more of these categories.

HAND CARD DMQ6

PROBE: Where do your ancestors come from?

ASIAN INDIAN 10

BANGLADESHI 11

BENGALESE 12

BHARAT 13

BHUTANESE 14

BURMESE 15

CAMBODIAN 16

CANTONESE 17

CHINESE 18

DRAVIDIAN 19

EAST INDIAN 20

FILIPINO 21

GOANESE 22

HMONG 23

INDOCHINESE 24

INDONESIAN 25

IWO JIMAN 26

JAPANESE 27

KOREAN 28

LAOHMONG 29

LAOTIAN 30

MADAGASCAR/MALAGASY 31

MALAYSIAN 32

MALDIVIAN 33

MONG 34

NEPALESE 35

NIPPONESE 36

OKINAWAN 37

PAKISTANI 38

SIAMESE 39

SINGAPOREAN 40

SRI LANKAN 41

TAIWANESE 42

THAI 43

VIETNAMESE 44

REFUSED 77

DON'T KNOW 99

NEW BOX L-6

CHECK ITEM DMQ.340:

SKIP TO DMQ.107.

DMQ.266 CODE SP ANSWER TO ‘OTHER RACE’.

MEXICAN 10

PUERTO RICAN 11

CUBAN 12

DOMINICAN REPUBLIC 13

CENTRAL AMERICAN:

COSTA RICAN 14

GUATEMALAN 15

HONDURAN 16

NICARAGUAN 17

PANAMANIAN 18

SALVADORAN 19

OTHER CENTRAL AMERICAN 20

SOUTH AMERICAN:

ARGENTINEAN 21

BOLIVIAN 22

CHILEAN 23

COLOMBIAN 24

ECUADORIAN 25

PARAGUAYAN 26

PERUVIAN 27

URUGUAYAN 28

VENEZUELAN 29

OTHER SOUTH AMERICAN 30

OTHER HISPANIC OR LATINO:

SPANIARD 32

SPANISH 33

SPANISH AMERICAN 34

HISPANO/HISPANA 35

HISPANIC/LATINO 36

OTHER (SPECIFY) 40

REFUSED 77

DON'T KNOW 99

BOX 3M

CHECK ITEM DMQ.268:

IF ‘OTHER SPECIFY’ (CODE 40) IN DMQ.266, DISPLAY SOFT ERROR MESSAGE – “PLEASE REVIEW THE LIST AND SELECT RESPONSE FROM LIST BEFORE TYPING. THE LIST IS MEANT TO INCLUDE ALL CATEGORIES.” AND CAPI SHOULD RETURN TO QUESTION DMQ.266.

DMQ.107 In what country {were you/was SP} born?

UNITED STATES 1 (DMQ.130)

OTHER COUNTRY 2 (NEW BOX 3N)

REFUSED 7 (BOX 5)

DON'T KNOW 9 (BOX 5)

NEW BOX 3N

CHECK ITEM DMQ.108:

IF CODE 2 (ASIAN) IN DMQ.263, GO TO DMQ.125.

OTHERWISE, CONTINUE.

DMQ.112 SELECT COUNTRY OF BIRTH

ARGENTINA 1 (DMQ.160 M/Y)

BELIZE 2 (DMQ.160 M/Y)

BOLIVIA 3 (DMQ.160 M/Y)

BRAZIL 4 (DMQ.160 M/Y)

CHILE 5 (DMQ.160 M/Y)

COLOMBIA 6 (DMQ.160 M/Y)

COSTA RICA 7 (DMQ.160 M/Y)

CUBA 8 (DMQ.160 M/Y)

DOMINICAN REPUBLIC 9 (DMQ.160 M/Y)

ECUADOR 10 (DMQ.160 M/Y)

EL SALVADOR 11 (DMQ.160 M/Y)

GUATEMALA 12 (DMQ.160 M/Y)

HONDURAS 13 (DMQ.160 M/Y)

MEXICO 14 (DMQ.160 M/Y)

NICARAGUA 15 (DMQ.160 M/Y)

PANAMA 16 (DMQ.160 M/Y)

PARAGUAY 17 (DMQ.160 M/Y)

PERU 18 (DMQ.160 M/Y)

PHILIPPINES 19 (DMQ.160 M/Y)

PUERTO RICO 20 (DMQ.160 M/Y)

SPAIN 21 (DMQ.160 M/Y)

URUGUAY 22 (DMQ.160 M/Y)

VENEZUELA 23 (DMQ.160 M/Y)

OTHER COUNTRY (CAPI INSTRUCTION:

DISPLAY DMQ.112 COUNTRY LIST.) 40 (DMQ.160 M/Y)

CAPI INSTRUCTION:

IF ‘OTHER’ SELECTED, DISPLAY COUNTRY LIST IN ALPHABETICAL ORDER. INTERVIEWER SHOULD BE ABLE TO SELECT ONE FROM THE LIST.

DMQ.125 SELECT COUNTRY OF BIRTH

BANGLADESH 1

BHUTAN 2

BURMA/MYANMAR 3

CAMBODIA 4

CHINA 5

HONG KONG 6

INDIA 7

INDONESIA 8

JAPAN 9

KOREA 10

LAOS 11

MACAU 12

MADAGASCAR 13

MALAYSIA 14

MALDIVES 15

NEPAL 16

PAKISTAN 17

PHILIPPINES 18

SINGAPORE 19

SRI LANKA 20

TAIWAN 21

THAILAND 22

TIBET 23

VIETNAM 24

OTHER (CAPI INSTRUCTION: DISPLAY

DMQ.125 COUNTRY LIST.) 25

CAPI INSTRUCTION:

IF ‘OTHER’ SELECTED, DISPLAY COUNTRY LIST IN ALPHABETICAL ORDER. INTERVIEWER SHOULD BE ABLE TO SELECT ONE FROM THE LIST.

DMQ.160 In what month and year did {you/SP} come to the United States to stay?

M/Y

CAPI INSTRUCTION:

HARD EDIT: NOT BEFORE SP’S DATE OF BIRTH AND NOT AFTER CURRENT DATE. IF OUT OF RANGE DISPLAY “DATE OF IMMIGRATION MUST BE AFTER DATE OF BIRTH {DOB YYYY} AND BEFORE TODAY.”

|___|___|

ENTER MONTH NUMBER

REFUSED 7777

DON'T KNOW 9999

|___|___|___|___|

ENTER 4-DIGIT YEAR

REFUSED 777777

DON'T KNOW 999999

DMQ.170 {Are you/Is SP} a citizen of the United States?

[Information about citizenship is being collected by the Centers for Disease Control and Prevention to perform health related research. Providing this information is voluntary and is collected under the authority of the Public Health Service Act. There will be no effect on pending immigration or citizenship petitions.]

HAND CARD DMQ7

YES, BORN IN UNITED STATES 1

YES, BORN IN PUERTO RICO, GUAM,

AMERICAN VIRGIN ISLANDS, OR

OTHER U.S. TERRITORY 2

YES, BORN ABROAD TO AMERICAN

PARENTS 3

YES, U.S. CITIZEN BY NATURALIZATION 4

NO, NOT A CITIZEN OF THE UNITED

STATES 5

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Naturalization: The process of granting full citizenship to a person of foreign birth.

BOX 4

CHECK ITEM DMQ.172:

IF CODE 1 (BORN IN U.S.) IN DMQ.170 – DISPLAY SOFT ERROR MESSAGE “SP SAYS NOT BORN IN U.S. IN PREVIOUS QUESTION – PLEASE CORRECT.”

BOX 5

CHECK ITEM DMQ.175:

SKIP TO DMQ.281a.

DMQ.130 In what state {were you/was SP} born?

ENTER 2 LETTER STATE ABBREVIATION TO START THE LOOKUP.

SELECT STATE FROM CAPI STATE LIST.

PRESS ENTER TO ACCEPT SELECTION.

CAPI INSTRUCTION:

DISPLAY FIPS STATE LIST. INTERVIEWER ONLY SHOULD BE ABLE TO SELECT 1 STATE FROM LIST. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. THE STATE LOOKUP IN THE SP AND FAMILY QUESTIONNAIRES SHOULD WORK EXACTLY THE SAME.

DMQ.281a

The National Center for Health Statistics will conduct statistical research by combining {your/his/her} survey data with vital, health, nutrition and other related records. {Your/SP’s} social security number is used only for these purposes and the Center will not release it to anyone, including any government agency, for any other reason. Providing this information is voluntary and is collected under the authority of Section 306 of the Public Health Service Act. There will be no effect on {your/his/her} benefits if you do not provide it.

INTERVIEWER INSTRUCTION—ONLY READ IF ASKED. [Public Health Service Act is title 42, United States Code, section 242k.]

What is {your/SP's} Social Security Number?

INTERVIEWER INSTRUCTION:

IF RESPONDENT CANNOT RECALL FROM MEMORY ASK {HIM/HER} TO GET CARD AT THIS TIME.

IF RESPONDENT IS RELUCTANT OR NEEDS MORE INFORMATION, PRESS F1 TO ACCESS THE HELP SCREEN AND FOLLOW THE SCRIPT.

ENTER SOCIAL SECURITY NUMBER 1 (DMQ281b)

DOES NOT HAVE SOCIAL SECURITY NUMBER 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

CAPI INSTRUCTION:

IF SP REFUSES (CODE 7), DISPLAY THE FOLLOWING SOFT ERROR MESSAGE:

I understand your concern. The National Center for Health Statistics has never had a breach of confidentiality in the 50 years we have been conducting this study. I do not have access to this information after I type it. Once I complete the interview all the information is sent to a secure facility. No one takes it home on a computer, no one works on it at home and only one or two people have access to the file to use it for our health research.

HELP TEXT - IF R IS RELUCTANT TO GIVE NUMBER OR IF R ASKS IF THEY MUST GIVE NUMBER –

It is extremely useful to have this information to be able to link to health records such as death certificates and Medicare records in the future. Many years in the future the information you give me can be used to see how health habits and diet at one point in your life influence how healthy you are in the future.

DMQ281b/c

CAPI INSTRUCTION:

REQUIRE DOUBLE ENTRY OF SOCIAL SECURITY NUMBER.

|___|___|___| |___|___| |___|___|___|___|

ENTER SOCIAL SECURITY NUMBER

REFUSED 777777777 (END OF SECTION)

DON'T KNOW 999999999 (END OF SECTION)

DMQ.300 INTERVIEWER: SELECT CATEGORY FOR REPORTING OF SOCIAL SECURITY NUMBER

SELF REPORTED FROM MEMORY 1

SELF REPORTED FROM RECORDS 2

PROXY REPORTED FROM MEMORY 3

PROXY REPORTED FROM RECORDS 4

BOX 6

CHECK ITEM DMQ.450:

IF SP AGE = 0 TO 15 AND DMQ.107 = 1 (SP BORN IN U.S.), CONTINUE.

OTHERWISE, GO TO END OF SECTION.

DMQ.455 The study would like your permission to access {SP}’s birth certificate record. In order for our study staff to request a birth certificate, I will need you to fill out and sign this Birth Certificate consent form and answer a few additional questions specifically needed for that request.

INTERVIEWER: PRESENT BIRTH CERTIFICATE CONSENT FORM AND ANSWER RESPONDENT QUESTIONS.

DID RESPONDENT SIGN THE BIRTH CERTIFICATE CONSENT FORM?

YES 1

NO 2 (END OF SECTION)

DMQ.460 Does {SP}’s mother have a maiden name recorded on {his/her} birth certificate?

INTERVIEWER INSTRUCTION: MOTHER’S MAIDEN NAME AS REPORTED ON BIRTH CERTIFICATE.

YES 1

NO 2 (DMQ.470)

REFUSED 7 (DMQ.470)

DON'T KNOW 9 (DMQ.470)

DMQ.465 What is {SP}’s mother’s maiden name as it appears on the birth certificate?

INTERVIEWER INSTRUCTION: RECORD MOTHER’S MAIDEN NAME AS REPORTED ON BIRTH CERTIFICATE. VERIFY SPELLING.

ENTER MAIDEN NAME

REFUSED 7

DON'T KNOW 9

DMQ.470 What is the name of the hospital or place where {SP} was born?

G/Q

ENTER NAME OF HOSPITAL OR

MEDICAL CENTER 1

BORN AT HOME 2 (DMQ.475)

REFUSED 7 (DMQ.475)

DON'T KNOW 9 (DMQ.475)

____________________________________

ENTER NAME OF HOSPITAL OR MEDICAL CENTER

DMQ.475 In what city was {SP} born?

____________________________________

ENTER BIRTH CITY NAME

REFUSED 7

DON'T KNOW 9

DMQ.480 In what county was {SP} born?

____________________________________

ENTER BIRTH COUNTY NAME

REFUSED 7

DON'T KNOW………………………………… 9

HELP SCREEN FOR DMQ.141:

School: An institution that advances a person toward an elementary or high school diploma, or a college or professional school degree. Do not count schooling in non-regular schools unless the credits are accepted by regular schools.

Regular school includes graded public, private, and parochial schools, colleges, universities, graduate and professional schools, seminaries where a Bachelor's degree is offered, junior colleges specializing in skill training, colleges of education, and nursing schools where a Bachelor's degree is offered.

If the person attended school outside of the "regular" school system, probe to determine if the schooling is applicable here. Use the following guidelines to determine if the schooling should be included:

- Training Programs - Count training received "on the job," in the Armed Forces, or through correspondence school only if it was credited toward a school diploma, high school equivalency (GED), or college degree.

- Vocational, Trade, or Business School - Do not include secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered, and other vocational trade or business schools outside the regular school system.

- General Educational Development (GED) or High School Equivalency - An exam certified equivalent of a high school diploma. If the person has not actually completed all 4 years of high school, but has acquired his/her GED (high school equivalency based on passing the GED exam), count this and enter code "14."

- Adult Education - Adult education classes should not be included as regular school unless such schooling has been counted for credit in a regular school system. If a person has taken adult education classes not for credit, these classes should not be counted as regular school. Adult education courses given in a public school building are part of regular schooling only if their completion can advance a person toward an elementary school certificate, a high school diploma (or GED), or a college degree.

- Other School Systems - If the person attended school in another country, in an ungraded school, in a "normal school", under a tutor, or under other special circumstances, ask the respondent to give the nearest equivalent of years in regular U.S. schooling.

GED (General Educational Development): An exam certified equivalent of a high school diploma.

Occupational/Technical/Vocational Programs: Includes secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered and other trade and business schools outside the regular school system.

Vocational (Trade or Business) School: When determining the highest grade or year of regular school the person ever completed, do not include secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered, and other vocational trade or business schools outside the regular school system.

College: Any junior college, community college, four-year college or university, nursing school or seminary where a college degree is offered, and graduate school or professional school that is attended after obtaining a degree from a 4-year institution.

Bachelor's Degree: An educational degree given by a college or university to a person who has completed a four-year course or its equivalent in the humanities or related studies (B.A.) or in the sciences (B.S.).

Doctorate Degree: The highest educational degree given by a college or university to a person who has completed a prescribed course of advanced graduate study. For example—a Doctor of Philosophy (Ph.D.).

HEALTH INSURANCE (HIQ)

HEALTH INSURANCE – HIQ

Target Group: All Ages

HIQ.011 The next questions are about health insurance.

Include health insurance obtained through employment or purchased directly as well as government programs like Medicare and Medicaid that provide medical care or help pay medical bills.

{Are you/Is SP} covered by health insurance or some other kind of health care plan?

YES 1

NO 2 (BOX 12)

REFUSED 7 (BOX 12)

DON'T KNOW 9 (BOX 12)

HIQ.031 What kind of health insurance or health care coverage {do you/does SP} have? Include those that pay for only one type of service (nursing home care, accidents, or dental care). Exclude private plans that only provide extra cash while hospitalized. If {you have/s/he has} more than one kind of health insurance, tell me all plans that {you have/s/he has}.

CODE ALL THAT APPLY

HAND CARD HIQ1

CAPI INSTRUCTION:

DO NOT ALLOW MORE THAN ONE ANSWER WHEN 40 (NO COVERAGE OF ANY TYPE) IS CODED.

PRIVATE HEALTH INSURANCE 14

MEDICARE 15

MEDI-GAP 16

MEDICAID ({DISPLAY STATE PLAN NAME}) 17

SCHIP (CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM) 18

MILITARY HEALTH CARE (TRICARE/VA/CHAMP-VA) 19

INDIAN HEALTH SERVICE 20

STATE-SPONSORED HEALTH PLAN ({DISPLAY STATE

PLAN NAME}) 21

OTHER GOVERNMENT PROGRAM 22

SINGLE SERVICE PLAN (E.G., DENTAL, VISION,

PRESCRIPTIONS) 23

NO COVERAGE OF ANY TYPE 40

REFUSED 77

DON'T KNOW 99

BOX 2

OMITTED

BOX 3

OMITTED

BOX 4

OMITTED

BOX 5

OMITTED

BOX 10

OMITTED

BOX 11

OMITTED

BOX 12

CHECK ITEM HIQ.065:

IF AGE => 65 AND HIQ.031 = CODE 14 OR CODE 16-99 OR HIQ.031 IS EMPTY, GO TO HIQ.260.
IF AGE = BIRTH+ AND HIQ.031 = CODE 15, GO TO HIQ.502.
OTHERWISE, CONTINUE.

BOX 13

CHECK ITEM HIQ.259:

IF AGE < 65 AND (HIQ.011 = 1 (YES) AND HIQ.031 NOT = 40 (NO COVERAGE), GO TO HIQ.270.

IF AGE < 65 AND (HIQ.011 = 2, 7, OR 9 OR HIQ.031 = 40), GO TO END OF SECTION.

HIQ.260 {Do you/Does SP} have Medicare? This is a health insurance program that virtually all persons 65 and older are eligible for. A card is automatically mailed to you shortly before your 65th birthday, it looks like this.

SHOW HAND CARD HIQ2 OF MEDICARE CARD

YES 1

NO 2 (BOX 14)

REFUSED 7 (BOX 14)

DON’T KNOW 9 (BOX 14)

HIQ.502 May I please see {your/SP's} Medicare card to record the Health Insurance Claim Number?

This number is needed to allow Medicare records of the Center for Medicare and Medicaid Services to be easily and accurately located and identified for statistical or research purposes. We may also need to link it with other records in order to re-contact {you/SP}. Except for these purposes, the Department of Health and Human Services will not release {your/his/her} Health Insurance Claim Number to anyone, including any other government agency. Providing the Health Insurance Claim Number is voluntary and collected under the authority of the Public Health Service Act. Whether the number is given or not, there will be no effect on {your/his/her} benefits. This number will be held in strict confidence. [The Public Health Service Act is Title 42, United States Code, Section 242K.]

CAPI INSTRUCTION:

REQUIRE DOUBLE ENTRY OF NUMBER.

ALLOW UP TO 11 CHARACTERS (LETTERS OR NUMBERS)

|___|___|___|___|___|___|___|___|___|___|___|

ENTER CLAIM NUMBER

REFUSED 77777777777 (BOX 14)

DON'T KNOW 99999999999 (BOX 14)

HIQ.105 INTERVIEWER: ENTER 1 RESPONSE

CARD AVAILABLE 1

CARD NOT AVAILABLE 2 (BOX 14)

BOX 14

CHECK ITEM HIQ.269:

IF (HIQ.011 = 1 AND HIQ.031 NOT = 40) OR HIQ.260 = 1, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

BOX 6

OMITTED

BOX 7

OMITTED

BOX 8

OMITTED

BOX 9

OMITTED

HIQ.270 {Does this plan/Do any of these plans} cover any part of the cost of prescriptions?

CAPI INSTRUCTION:

IF HIQ.031 = 15 or HIQ.260 = 1, DISPLAY: [If you are enrolled in Medicare Part D, also known as the Medicare Prescription Drug Plan, you have some prescription drug coverage.]

Yes 1

No 2

Refused 7

Don't know 9

HIQ.210 In the past 12 months, was there any time when {you/SP} did not have any health insurance coverage?

Yes 1

No 2

Refused 7

Don't know 9

HELP SCREEN FOR HIQ.011:

Health Insurance: Health benefits coverage which provides persons with health-related benefits. Coverage may include the following; hospitalization, major medical, surgical, prescriptions, dental, and vision.

Medicare: A Federal health insurance program for people 65 or older and for certain persons under 65 with long-term disabilities. Almost all Social Security recipients are covered by Medicare. It is run by the Center for Medicare and Medicaid Services of the U.S., Department of Health and Human Services.

Medicare consists of two parts, A and B:

Part A is called the Hospital Insurance Program. It helps pay for inpatient care in a hospital or in a skilled nursing facility, for home health care, and for hospice care. It is available to nearly everyone 65 or older.

Persons who are eligible for either Social Security or Railroad Retirement benefits are not required to pay a monthly premium for Part A of Medicare. However, anyone who is 65 or over and does not qualify for Social Security or Railroad Retirement benefits may pay premiums directly to Social Security to obtain Part A coverage.

Part B is called the Supplementary Medical Insurance Program. It is a voluntary plan that builds upon the hospital insurance protection provided by the basic plan. It helps pay for the doctor and surgeon services, outpatient hospital services, durable medical equipment, and a number of other medical services and supplies that are not already covered under Part A of Medicare.

If a person elects this additional insurance, the monthly premium is deducted from his/her Social Security.

Medicaid: Refers to a medical assistance program that provides health care coverage to low-income and disabled persons. The Medicaid program is a joint federal-state program which is administered by the states.

HELP SCREEN FOR HIQ.031:

Private Health Insurance Plan: Any type of health insurance, including HMOs, that is not a public program. Private health insurance plans may be provided in part or full by a person's employer or union, or may be purchased directly by an individual.

Private Health Insurance Plan through a State or Local Government Program or Community Program: A type of health insurance for which state or local government or community effort pays for part or all of the cost of a private insurance plan, such as Blue Cross/Blue Shield. The individual may also contribute to the cost of the health insurance and may receive a card such as a Blue Cross/Blue Shield card. A community program or effort may include a variety of mechanisms to achieve health insurance for persons who would otherwise be uninsured. An example would be a private company giving a grant to an HMO to pay for health insurance coverage.

Medicare consists of two parts, A and B:

If a person elects this additional insurance, the monthly premium is deducted from his/her Social Security.

Medi-Gap: Refers to private health insurance purchased to supplement Medicare. Medi-Gap will be treated as a private health insurance plan in the detailed questions about health insurance.

CHIP (Children's Health Insurance Program, also called SCHIP): A joint federal and state program, administered by each state, that offers health care coverage to low-income, uninsured children. This law was passed in 1997. In some states, CHIP programs have distinct names.

Military Health Care/VA: Refers to health care available to active duty personnel and their dependents, in addition, the VA provides medical assistance to veterans of the Armed Forces, particularly those with service-connected ailments.

CHAMPUS/TRICARE/CHAMP-VA: CHAMPUS (Comprehensive Health and Medical Plan for the Uniformed Services) provides health care in private facilities for dependents of military personnel on active duty or retired for reasons other than disability. TRICARE is the "managed care" version of CHAMPUS. CHAMP-VA (Comprehensive Health and Medical Plan of the Veterans Administration) provides health care for the spouse, dependents, or survivors of a veteran who has a total, permanent service-connected disability.

Indian Health Service: The federal health care program for Native Americans.

State-Sponsored Health Plan: Any other health care coverage run by a specific state, including public assistance programs other than "Medicaid" that pay for health care.

Other Government Program: A catch-all category for any public program providing health care coverage other than those programs in specific categories.

Single Service Plan (SSP): Health insurance coverage paid for by an individual that provides for only one type of service or treatment for a specific condition. These plans are usually bought to supplement a more comprehensive health insurance plan. Examples of SSPs are dental care, vision care, prescriptions, nursing home care, hospice care, accidents, catastrophic care, cancer treatment, AIDS care, and/or hospitalization.

HELP SCREEN FOR HIQ.502:

Medicare consists of two parts, A and B:

If a person elects this additional insurance, the monthly premium is deducted from his/her Social Security.

Dietary Supplements and Antacids Section (DSQ)

DIETARY SUPPLEMENTS AND PRESCRIPTION MEDICATION – DSQ

Target Group: SPs Birth +

DSQ.012 The next questions are about {your/SP's} use of dietary supplements, nonprescription antacids, and prescription medications during the past 30 days.

{Have you/Has SP} used or taken any vitamins, minerals, herbals or other dietary supplements in the past 30 days? Include prescription and non-prescription supplements.

This card lists some examples of different types of dietary supplements.

HAND CARD DSQ1a

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

RXQ.021 {Have you/Has SP} used or taken any nonprescription antacids in the past 30 days?

HAND CARD DSQ1b

CAPI INSTRUCTION:

IF ITEM CHANGED, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.

Past Month: The past 30 days. From yesterday, 30 days back.

BOX 0

OMITTED

RXQ.033 In the past 30 days, {have you/has SP} used or taken medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. {Please remember to include any prescription birth control products that you are taking or using such as pills or patches.} [Do not include prescription vitamins or minerals you may have already told me about.]

YES 1 (BOX 0AA)

NO 2 (BOX 0AA)

REFUSED 7 (BOX 0AA)

DON'T KNOW 9 (BOX 0AA)

CAPI INSTRUCTION:

IF SP FEMALE AND AGE 16-49 YEARS, DISPLAY ‘Please remember to include prescription birth control products that you are taking or using such as pills or patches.’

CAPI HARD EDIT CHECK #1

IF ‘NO’ (CODE 2) IN RXQ.033 AND ‘YES’ (CODE 1) IN DIQ.050 OR DIQ.070, DISPLAY THE FOLLOWING MESSAGE:

Earlier in the interview you reported currently taking insulin or a diabetic pill. If this is correct, we should count that as prescription medication you have taken in the last 30 days.

{CAPI DISPLAYS THREE QUESTIONS FOR CORRECTION}

DIQ.050 = Taking Insulin

DIQ.070 = Taking Diabetic Pills

RXQ.033 = Prescription Medication in Last 30 Days

CAPI HARD EDIT CHECK #2

IF ‘NO’ (CODE 2) IN RXQ.033 AND ‘YES’ (CODE 1) IN BPQ.050a, DISPLAY THE FOLLOWING MESSAGE:

Earlier in the interview you reported currently taking prescription medication for high blood pressure. If this is correct, we should count that as prescription medication you have taken in the last 30 days.

{CAPI DISPLAYS TWO QUESTIONS FOR CORRECTION}

BPQ.050a = Taking Blood Pressure Medication

RXQ.033 = Prescription Medication in Last 30 Days

CAPI HARD EDIT CHECK #3

IF ‘NO’ (CODE 2) IN RXQ.033 AND ‘YES’ (CODE 1) IN BPQ.100d, DISPLAY THE FOLLOWING MESSAGE:

Earlier in the interview you reported currently taking prescription medication for high cholesterol. If this is correct, we should count that as prescription medication you have taken in the last 30 days.

{CAPI DISPLAYS TWO QUESTIONS FOR CORRECTION}

BPQ.100d = Taking High Cholesterol Medicine

RXQ.033 = Prescription Medication in Last 30 Days

BOX 0A

OMITTED

BOX 0AA

CHECK ITEM RXQ.085:

IF RXQ.033 = 2/NO AND DLQ.150 = 1/YES, CONTINUE.

OTHERWISE, GO TO BOX 0AAA.

RXQ.090 Earlier in the interview you reported taking medication for depression. Was that a prescription medication?

YES 1

NO 2 (BOX 0AAA)

REFUSED 7 (BOX 0AAA)

DON'T KNOW 9 (BOX 0AAA)

RXQ.100 Did you take it in the last 30 days?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 0AAA

CHECK ITEM RXQ.105:

IF RXQ.033 = 2/NO AND DLQ.110 = 1/YES, CONTINUE.

OTHERWISE, GO TO BOX 1.

RXQ.110 Earlier in the interview you reported taking medication for feeling worried, nervous or anxious. Was that a prescription medication?

YES 1

NO 2 (BOX 1)

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

RXQ.120 Did you take it in the last 30 days?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1

CHECK ITEM DSQ.035A:

IF 'YES' (CODE 1) IN DSQ.012, RXQ.021, RXQ.033, RXQ.100 OR RXQ.120, CONTINUE.

OTHERWISE, GO TO BOX 17A.

DSQ.042 May I please see the containers for all the {vitamins, minerals, herbals, and other dietary supplements}, {and} {nonprescription antacids} {and} {prescription medicines} that {you/SP} used or took in the past 30 days?

PRESS ENTER TO CONTINUE

CAPI INSTRUCTION:

DISPLAY {vitamins, minerals, herbals and other dietary supplements,} only if DSQ.012 = yes (1), {nonprescription antacids.} only if RXQ.021 = yes (1), {prescription medicines,} only if RXQ.033, RXQ.100 or RXQ.120 = yes (1), and the word {“and”} only before the last product type if there is more than one product type.

BOX 1A

CHECK ITEM DSQ.045:

IF 'YES' (CODE 1) IN DSQ.012, CONTINUE WITH DSQ.055.

OTHERWISE, GO TO BOX 6.

DSQ.055 I will start with the vitamins, minerals, herbals and other dietary supplements. Please show me any {you have/SP has} taken in the past 30 days.

CHECK THE BACK OF THE PRODUCT LABEL AND VERIFY THAT THIS IS THE ONLY NUTRIENT (ELEMENT) LISTED IN THE SUPPLEMENTS FACTS BOX. IF THERE IS ANYTHING ELSE LISTED, ENTER AS A REGULAR PRODUCT.

IS THIS PRODUCT ON THE LIST BELOW?

YES 1

NO 2 (DSQ.052)

DON’T KNOW 9 (DSQ.052)

VITAMIN A 10

VITAMIN B6 12

VITAMIN B12 13

VITAMIN C (WITH OR WITHOUT ROSE
HIPS) 14

VITAMIN D (D3) 15

VITAMIN E 16

CALCIUM 18

CHROMIUM (CHROMIUM PICOLINATE) 19

FOLATE (FOLIC ACID) 20

IRON (FERROUS XXXATE) 21

MAGNESIUM 27

POTASSIUM 28

SELENIUM 29

ZINC (ZINC GLUCONATE) 40

DSQ.056 WHICH PRODUCT IS IT?

CHECK THE BACK OF THE PRODUCT LABEL AND VERIFY THAT THIS IS THE ONLY NUTRIENT (ELEMENT) LISTED IN THE SUPPLEMENTS FACTS BOX. IF THERE IS ANYTHING ELSE LISTED, ENTER AS A REGULAR PRODUCT.

ENTER 1 PRODUCT CODE

CAPI INSTRUCTION:

IF ITEM CHANGED, CHECK MEC COMPONENT.

VITAMIN A 10

VITAMIN B6 12

VITAMIN B12 13

VITAMIN C (WITH OR WITHOUT ROSE
HIPS) 14

VITAMIN D (D3) 15

VITAMIN E 16

CALCIUM 18

CHROMIUM (CHROMIUM PICOLINATE) 19

FOLATE (FOLIC ACID) 20

IRON (FERROUS XXXATE) 21

MAGNESIUM 27

POTASSIUM 28

SELENIUM 29

ZINC (ZINC GLUCONATE) 40

REFUSED 77 (DSQ.052)

DON’T KNOW 99 (DSQ.052)

BOX 1B

CHECK ITEM DSQ.059:

GO TO DSQ.071.

DSQ.052 REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF DIETARY SUPPLEMENTS USED. ENTER FULL NAME OF SUPPLEMENT, INCLUDING BRAND.

ENTER SUPPLEMENT NAME

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF DON'T KNOW OR REFUSAL, THEN GO TO BOX 6.

SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED.

TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.

IF ITEM CHANGED, CHECK MEC COMPONENT.

DSQ.060s OMITTED

BOX 2

OMITTED

DSQ.057 OMITTED

DSQ.071 INTERVIEWER: ENTER 1 RESPONSE

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

IF ITEM CHANGED, CHECK MEC COMPONENT.

CONTAINER SEEN 1

CONTAINER NOT SEEN 2

BOX 2A

CHECK ITEM DSQ.074:

IF PRODUCT WAS SELECTED FROM SPECIAL PRODUCT LIST (YES, CODE 1 IN DSQ.055) AND CONTAINER SEEN, CONTINUE.
IF PRODUCT WAS NOT SELECTED FROM SPECIAL PRODUCT LIST (NO, CODE 2 IN DSQ.055) AND CONTAINER SEEN, GO TO DSQ.077.
OTHERWISE (IF CONTAINER NOT SEEN), GO TO DSQ.096.

DSQ.066 SELECT STRENGTH FOR {ELEMENT}

a/b/aO/bO

IF STRENGTH NOT ON FRONT OR UNCLEAR, TURN CONTAINER AROUND AND GET STRENGTH FROM FACTS BOX.

PRESS BS TO START LOOKUP.

PRESS ENTER TO SELECT.

CAPI INSTRUCTION:

{ELEMENT} = DISPLAY PRODUCT ELEMENT SELECTED IN DSQ.056. IF PRODUCT SELECTED HAS MORE THAN 1 ELEMENT (EXAMPLE = ), STRENGTH QUESTION SHOULD APPEAR FOR EACH ELEMENT.
IF “OTHER” STRENGTH IS SELECTED, GET OTHER SPECIFY AND INTERVIEWER INSTRUCTION SHOULD READ “ENTER SUPPLEMENT STRENGTH”.
ALL OF THE STRENGTH QUESTION AND INSTRUCTION SHOULD APPEAR WHEN STRENGTH LOOKUP LIST IS DISPLAYED (NO SCROLLING). THIS MAY MEAN PRINTING ALL WORDS ON THE SCREEN FLUSH LEFT IN MULTIPLE LINES.
IF ITEM CHANGED, CHECK MEC COMPONENT.

BOX 3

OMITTED

DSQ.077 WHAT IS THE FORM OF THIS PRODUCT?

CAPSULES 1

TABLETS 2

CHEWABLE TABLETS 3

PILLS 4

CAPLETS 5

SOFT GELS 6

GEL CAPS 7

VEGICAPS 8

PACKAGE/PACKETS 9

LIQUID 10

POWDER 11

WAFERS 12

CHEWS/GUMMIES 13

DOTS 14

GRANULES 15

LOZENGES/COUGH DROPS 16

GEL 17

OTHER FORM (SPECIFY) 91

REFUSED 77

DON’T KNOW 99

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

IF ITEM CHANGED, CHECK MEC COMPONENT.

BOX 3A

CHECK ITEM DSQ.079:

IF PRODUCT NOT SELECTED FROM SPECIAL PRODUCT LIST (NO, CODE 2 IN DSQ.055), CONTINUE.

OTHERWISE, GO TO DSQ.096.

DSQ.081 ENTER MANUFACTURER/DISTRIBUTOR/STORE BRAND NAME.

ENTER AS MUCH INFORMATION AS POSSIBLE.

ENTER MANUFACTURER/DISTRIBUTOR/STORE BRAND NAME

REFUSED 7 (DSQ.088b)

DON'T KNOW 9 (DSQ.088b)

CAPI INSTRUCTION:

FOLLOW THE BASIC FORMAT FOR THE DIETARY SUPPLEMENT LOOKUP. ONLY ALLOW ENTRY OF 1 MANUFACTURER. DISPLAY PRODUCT NAME AS A LEFT HEADER.

DSQ.084 PRESS BS TO START THE LOOKUP.

SELECT MANUFACTURER

FROM LIST.

IF MANUFACTURER NOT

ON LIST – PRESS BS

TO DELETE ENTRY

TYPE '**'.

PRESS ENTER TO SELECT.

CAPI INSTRUCTION:

DISPLAY MANUFACTURER LIST. INTERVIEWER SHOULD BE ABLE TO SELECT ONLY 1 MANUFACTURER OR THE '**' OPTION. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. IF MANUFACTURER IS SELECTED FROM THE LOOKUP LIST, AUTOMATICALLY FILL IN THE CITY AND STATE INFORMATION (DSQ.088).

DISPLAY PRODUCT NAME AS LEFT HEADER.

BOX 4

CHECK ITEM DSQ.085:

IF MANUFACTURER SELECTED FROM LOOKUP, GO TO DSQ.096.

OTHERWISE, CONTINUE.

DSQ.088b ENTER CITY NAME.

ENTER AS MUCH INFORMATION AS POSSIBLE.

ENTER CITY

REFUSED 7

DON’T KNOW 9

DSQ.088c ENTER STATE NAME.

ENTER 2-LETTER

STATE ABBREVIATION.

PRESS ENTER TO

SELECT STATE FROM LIST.

ENTER STATE

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS A LEFT HEADER.

AN ENTRY MUST BE MADE IN ALL DSQ.081 AND DSQ.087 FIELDS (MANUFACTURER INFO). IF THE MANUFACTURER INFO IS DON'T KNOW OR REFUSED, THEN SET THE NO MANUFACTURER INFORMATION VARIABLE.

DSQ.096 For how long {have/has} {you/SP} been taking {PRODUCT NAME} or a similar type of product?

Q/U

CAPI INSTRUCTION:

RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 7777777 (DSQ.103)

DON'T KNOW 9999999 (DSQ.103)

|___|

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DSQ.103 In the past {30 DAYS/NUMBER AND UNIT}, on how many days did {you/SP} take {PRODUCT NAME}?

CAPI INSTRUCTION:

{30 DAYS/NUMBER AND UNIT} = IF NUMBER AND UNIT ENTERED IN DSQ.096 >= 30 DAYS, OR REFUSED (CODE 7), OR DON’T KNOW (CODE 9), DISPLAY “30 DAYS” IN TEXT OF QUESTION. IF NUMBER AND UNIT ENTERED IN DSQ.096 IS < 30 DAYS, DISPLAY ACTUAL NUMBER AND UNIT ENTERED IN DSQ.096 IN TEXT OF QUESTION.
{PRODUCT NAME} = PRODUCT SELECTED AT DSQ.056 OR PRODUCT ENTERED IN DSQ.052.

|___|___|

ENTER NUMBER OF DAYS FROM 1-30

REFUSED 7777

DON'T KNOW 9999

DSQ.123 On the days that {you/SP} took {PRODUCT NAME}, how much did {you/SP} usually take on a single day?

Q/U/OS

CAPI INSTRUCTION:

SOFT EDIT: QUANTITY SHOULD BE LESS THAN 10.

HARD EDIT: NUMBER MUST BE IN 0.20 – 60.0 RANGE.

ERROR MESSAGE: “You said {you/he/she} took {QUANTITY TAKEN}. Is that correct?”

|___|___|___|

ENTER NUMBER

REFUSED 777777 (DSQ.124)

DON'T KNOW 999999 (DSQ.124)

|___|___|

ENTER UNIT/FORM

TABLETS/CAPSULES/PILLS/CAPLETS/
SOFTGELS/GEL CAPS/VEGICAPS/
CHEWABLE TABLETS 1 (07BOX NEW 4A)

DROPPERS 2 (07BOX NEW 4A)

DROPS 3 (07BOX NEW 4A)

INJECTIONS/SHOTS 5 (07BOX NEW 4A)

LOZENGES/COUGH DROPS 6 (07BOX NEW 4A)

MILLILITERS 7 (07BOX NEW 4A)

TABLESPOONS 11 (07BOX NEW 4A)

TEASPOONS 12 (07BOX NEW 4A)

WAFERS 13 (07BOX NEW 4A)

CANS 15 (07BOX NEW 4A)

GRAMS 16 (07BOX NEW 4A)

DOTS 17 (07BOX NEW 4A)

CUPS 18 (07BOX NEW 4A)

SPRAYS/SQUIRTS 19 (07BOX NEW 4A)

CHEWS/GUMMIES 20 (07BOX NEW 4A)

SCOOPS 21 (07BOX NEW 4A)

CAPFULS 23 (07BOX NEW 4A)

OUNCES 27 (07BOX NEW 4A)

PACKAGES/PACKETS 28 (CONTINUE)

VIALS 29 (07BOX NEW 4A)

GUMBALLS 30 (07BOX NEW 4A)

OTHER FORM (SPECIFY) 91 (07BOX NEW 4A)

REFUSED 77 (07BOX NEW 4A)

DON’T KNOW 99 (07BOX NEW 4A)

CAPI INSTRUCTION:

IF FORM CODE 1 THROUGH 8 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 1 AND SKIP TO 07BOX NEW 4A.

IF FORM CODE 12 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 13 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.

IF FORM CODE 13 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 20 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.

IF FORM CODE 14 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 17 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.

IF FORM CODE 16 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 6 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.

IF FORM CODE 9 IN DSQ.077, DISPLAY THE UNIT CODES 1, 6, 7, 11, 12, 13, 15, 16, 17, 18, 20, 21, 23, 27, 28, 30, 91, 77, 99 FOR DSQ.123U.

IF FORM CODE 10, 17 IN DSQ.077, DISPLAY THE UNIT CODES 2, 3, 5, 7, 11, 12, 15, 18, 19, 23, 27, 29, 91, 77, 99 FOR DSQ.123U.

IF FORM CODE 11, 15 IN DSQ.077, DISPLAY THE UNIT CODES 11, 12, 15, 16, 18, 21, 23, 27, 28, 91, 77, 99 FOR DSQ.123U.

IF FORM CODE 91, 77, 99 IN DSQ.077, DISPLAY ENTIRE PICK LIST FOR DSQ.123U.

IF CONTAINER NOT SEEN (CODE 2 IN DSQ.071), DISPLAY ENTIRE PICK LIST FOR DSQ.123U.

DSQ.125 {Did you/Does SP} take an entire packet of {PRODUCT NAME} each time?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

07BOX NEW 4A

CHECK ITEM DSQ.105:

IF PRODUCT NOT SEEN IN DSQ.071 (CODE 2) AND DSQ.123 = 7, 11, 12, 15, 16, 18, 21, 23 OR 27, CONTINUE.

OTHERWISE, SKIP TO DSQ.124.

DSQ.110 Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 77

DON'T KNOW 99

DSQ.124 HAND CARD DSQ2

Looking at this card, what is the reason {you take/SP takes} {PRODUCT NAME}?

(Did {you/SP NAME} decide to take it for reasons of your own or did a doctor or other health provider tell you to take it?)

DECIDED TO TAKE IT FOR REASONS
OF MY OWN 1

A DOCTOR OR OTHER HEALTH
PROVIDER TOLD ME TO 2

REFUSED 7 (DSQ.127)

DON’T KNOW 9 (DSQ.127)

DSQ.136 {For what reason or reasons {do you/does SP} take {PRODUCT NAME}?}

{For what reason or reasons did the doctor or other health professional tell {you/SP} to take {PRODUCT}?}

HAND CARD DSQ3

CODE ALL THAT APPLY.

TO:

BUILD MUSCLE 35

GAIN WEIGHT 36

GET MORE ENERGY 25

IMPROVE DIGESTION 31

IMPROVE MY OVERALL HEALTH 14

MAINTAIN HEALTH (TO STAY HEALTHY) 17

MAINTAIN HEALTHY BLOOD SUGAR
LEVEL, DIABETES 29

PREVENT COLDS, BOOST IMMUNE
SYSTEM 18

PREVENT HEALTH PROBLEMS 13

SUPPLEMENT MY DIET (BECAUSE I
DON’T GET ENOUGH FROM FOOD) 16

FOR:

ANEMIA, SUCH AS LOW IRON 27

BONE HEALTH, BUILD STRONG BONES,
OSTEOPOROSIS 24

EYE HEALTH 20

GOOD BOWEL/COLON HEALTH 10

HEALTHY JOINTS, ARTHRITIS 21

HEALTHY SKIN, HAIR, AND NAILS 22

HEART HEALTH, CHOLESTEROL 19

KIDNEY AND BLADDER HEALTH, URINARY
TRACT HEALTH 30

LIVER HEALTH, DETOXIFICATION,
CLEANSE SYSTEM 34

MENOPAUSE, HOT FLASHES 28

MENTAL HEALTH 12

MUSCLE RELATED ISSUES, MUSCLE
CRAMPS 32

PREGNANCY/BREASTFEEDING 26

PROSTATE HEALTH 11

RELAXATION, DECREASE STRESS,
IMPROVE SLEEP 33

TEETH, PREVENT CAVITIES 15

WEIGHT LOSS 23

OTHER SPECIFY 91

REFUSED 77

DON’T KNOW 99

CAPI INSTRUCTION:

IF CODE 1 IN DSQ.124, DISPLAY For what reason or reasons {do you/does SP} take {PRODUCT NAME}?

IF CODE 2 IN DSQ.124, DISPLAY For what reason or reasons did the doctor or other health professional tell {you/SP} to take {PRODUCT}?

DSQ.127 ARE THERE ANY OTHER VITAMINS, MINERALS, HERBALS OR DIETARY SUPPLEMENTS?

YES 1

NO 2

HELP SCREEN:

Dietary Supplements (Vitamins/Minerals): Dietary supplements are often labeled as "dietary supplements" and are used in addition to foods and beverages. Dietary supplements are not intended to replace food. Include vitamins, minerals, antacid/calcium supplement products, fiber supplements, amino acids, performance enhancers, herbs, herbal medicine products, and plant extracts used as dietary supplements. Include products that are taken orally or given by injection. Do not include beverages, such as tea, and skin creams. Meal replacement beverages, weight loss and performance booster drinks, and food bars are considered foods, not dietary supplements.

BOX 5

CHECK ITEM DSQ.129:

ASK DSQ.127 FOR NEXT VITAMIN (CODE 1 IN DSQ.127). IF NO NEXT VITAMIN (CODE 2 IN DSQ.127), CONTINUE WITH DSQ.131.

DSQ.131 REVIEW TOTAL NUMBER OF DIETARY SUPPLEMENTS AND THEIR NAMES WITH RESPONDENT.

I have listed {TOTAL NUMBER} vitamin(s), mineral(s), herbals or dietary supplement(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME (STRENGTH)}

PRESS ENTER TO CONTINUE

CAPI INSTRUCTION:

DISPLAY LIST OF ALL VITAMIN AND MINERAL NAMES AND STRENGTHS SELECTED AT DSQ.060 AND ENTERED AT DSQ.052. CALCULATE TOTAL NUMBER OF ALL VITAMINS AND MINERALS SELECTED AT DSQ.060 AND ENTERED AT DSQ.052. DISPLAY NUMBER ON SCREEN.

HELP SCREEN:

BOX 6

CHECK ITEM DSQ.133:

IF 'YES' (CODE 1) IN RXQ.021, CONTINUE.

OTHERWISE, GO TO NEW BOX 10AA.

RXQ.141 Now I would like to ask you some questions about {your/SP's} use of nonprescription antacids in the past 30 days.

[First I will record some information about an antacid, then I will ask you some questions about it.]

REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF NONPRESCRIPTION ANTACIDS USED. ENTER FULL BRAND NAME OF ANTACID.

ENTER ANTACID NAME

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF DON'T KNOW OR REFUSED, THEN GO TO BOX 10AA.

SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.

[TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.

IF ITEM CHANGED, CHECK MEC COMPONENT.

HELP SCREEN:

Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.

Past Month: The past 30 days. From yesterday, 30 days back.

RXQ.150s PRESS BS TO START THE LOOKUP.

SELECT ANTACID

FROM LIST.

IF ANTACID NOT

ON LIST – PRESS BS

TO DELETE ENTRY.

TYPE '**'.

PRESS ENTER TO SELECT.

CAPI INSTRUCTION:

DISPLAY CAPI ANTACID PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN RXQ.141 BY TYPING IN "**". THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.

INTERVIEWER SHOULD BE ABLE TO ACCEPT THE KEYED NAME AS A NEW PRODUCT NAME AN UNLIMITED NUMBER OF TIMES. AFTER ENTRY, INTERVIEWER SHOULD RETURN TO THE DATA BASE LIST. IF NO MORE ENTRIES, INTERVIEWERS SHOULD HAVE A WAY OF MOVING INTO LOOP 2.

ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:

DRUG TYPE {3}

GENERIC NAME {60}

THERAPEUTIC CLASS CODE {6}

GENERIC FLAG {1}

THERE IS NO NEED TO DISPLAY THIS INFORMATION.

IF ITEM CHANGED, CHECK MEC COMPONENT.

BOX 7

OMITTED

RXQ.160 INTERVIEWER: ENTER 1 RESPONSE.

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

IF ITEM CHANGED, CHECK MEC COMPONENT.

CONTAINER SEEN 1

CONTAINER NOT SEEN 2

RXQ.180 For how long {have/has} {you/SP} been using or taking {PRODUCT NAME}?

Q/U

CAPI INSTRUCTION:

RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 7777777

DON'T KNOW 9999999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

RXQ.191 In the past {30 DAYS/NUMBER AND UNIT}, on how many days did {you/SP} take {PRODUCT NAME}?

CAPI INSTRUCTION:

{30 DAYS/NUMBER AND UNIT} = IF NUMBER AND UNIT ENTERED IN RXQ.180 >= 30 DAYS, OR REFUSED (CODE 7), OR DON’T KNOW (CODE 9), DISPLAY “30 DAYS” IN TEXT OF QUESTION. IF NUMBER AND UNIT ENTERED IN RXQ.180 IS < 30 DAYS, DISPLAY ACTUAL NUMBER AND UNIT ENTERED IN DSQ.096 IN TEXT OF QUESTION.
{PRODUCT NAME} = PRODUCT SELECTED AT DSQ.056 OR PRODUCT ENTERED IN DSQ.052.

|___|___|

ENTER NUMBER OF DAYS FROM 1-30

REFUSED 7777

DON'T KNOW 9999

RXQ.195
Q/U/OS

On those days that you used or took {PRODUCT NAME}, how much did {you/SP} usually take on a single day?

CAPI INSTRUCTION:

SOFT EDIT: QUANTITY SHOULD BE LESS THAN 10.

ERROR MESSAGE: “You said {you/he/she} took {QUANTITY TAKEN}. Is that correct?”

|___|___|___|

ENTER NUMBER

REFUSED 777777 (RXQ.216)

DON'T KNOW 999999 (RXQ.216)

|___|___|

ENTER UNIT/FORM

TABLETS/CAPSULES/PILLS/CAPLETS/
SOFTGELS/GEL CAPS/VEGICAPS/
CHEWABLE TABLETS 1 (07BOX NEW 8)

DROPPERS 2 (07BOX NEW 8)

DROPS 3 (07BOX NEW 8)

INJECTIONS/SHOTS 5 (07BOX NEW 8)

LOZENGES/COUGH DROPS 6 (07BOX NEW 8)

MILLILITERS 7 (07BOX NEW 8)

TABLESPOONS 11 (07BOX NEW 8)

TEASPOONS 12 (07BOX NEW 8)

WAFERS 13 (07BOX NEW 8)

CANS 15 (07BOX NEW 8)

GRAMS 16 (07BOX NEW 8)

DOTS 17 (07BOX NEW 8)

CUPS 18 (07BOX NEW 8)

SPRAYS/SQUIRTS 19 (07BOX NEW 8)

CHEWS/GUMMIES 20 (07BOX NEW 8)

SCOOPS 21 (07BOX NEW 8)

CAPFULS 23 (07BOX NEW 8)

OUNCES 27 (07BOX NEW 8)

PACKAGES/PACKETS 28 (CONTINUE)

VIALS 29 (07BOX NEW 8)

GUMBALLS 30 (07BOX NEW 8)

OTHER FORM (SPECIFY) 91 (07BOX NEW 8)

REFUSED 77 (07BOX NEW 8)

DON’T KNOW 99 (07BOX NEW 8)

RXQ.200 {Do you/Does SP} take an entire packet each time?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

07BOX NEW 8

CHECK ITEM RXQ.205:

IF RXQ.195U IS 7, 11, 12, 15, 16, 18, 21, 23, OR 27, CONTINUE.

OTHERWISE, SKIP TO RXQ.215a.

DSQ.111 Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 77

DON'T KNOW 99

RXQ.215a Did you take {PRODUCT NAME} as an antacid, as a calcium supplement, or both?

ANTACID 1

CALCIUM SUPPLEMENT 2

BOTH 3

NEITHER 4

REFUSED 7

DON'T KNOW 9

RXQ.216 CHECK CONTAINERS. ARE THERE ANY OTHER NONPRESCRIPTION ANTACIDS?

OR ASK RESPONDENT:

[Are there any other nonprescription antacids that {you/SP} used in the past 30 days?]

YES 1

NO 2

HELP SCREEN:

Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.

BOX 9

CHECK ITEM RXQ.219:

ASK RXQ.141 FOR NEXT ANTACID (CODE 1 IN RXQ.216). IF NO NEXT ANTACID, (CODE 2 IN RXQ.216), CONTINUE WITH RXQ.221.

RXQ.221 REVIEW TOTAL NUMBER OF ANTACIDS AND THEIR NAMES WITH RESPONDENT.

I have listed {TOTAL NUMBER} nonprescription antacid(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}

PRESS ENTER TO CONTINUE

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL ANTACIDS SELECTED AT RXQ.150 AND ENTERED AT RXQ.141. CALCULATE TOTAL NUMBER OF ALL ANTACIDS SELECTED AT RXQ.150 AND ENTERED AT RXQ.141. DISPLAY NUMBER ON SCREEN.

HELP SCREEN:

Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.

BOX 15

OMITTED

BOX 16

OMITTED

BOX 16A

OMITTED

BOX 10A

OMITTED

NEW BOX 10AA

CHECK ITEM RXQ.227:

IF ‘YES’ (CODE 1) TO RXQ.033, RXQ.100 OR RXQ.120, CONTINUE.

OTHERWISE, GO TO NEW BOX 17A.

RXQ.231 Now I would like to talk about prescription medication {you have/SP has} used in the past 30 days. Again, these are products prescribed by a health professional such as a doctor or dentist.

[First I will record some information about the medication, then I will ask you some questions about it.]

REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF PRESCRIPTION MEDICATIONS USED.

ENTER MEDICATION NAME

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF DON'T KNOW OR REFUSED, GO TO NEW BOX 17A.

SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.

TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.

IF ITEM CHANGED, CHECK MEC COMPONENT.

RXQ.240s PRESS BS TO START THE LOOKUP.

SELECT MEDICATION

FROM LIST.

IF MEDICATION NOT

ON LIST – PRESS BS

TO DELETE ENTRY.

TYPE '**'.

PRESS ENTER TO SELECT

CAPI INSTRUCTION:

DISPLAY CAPI MEDICATION PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN RXQ.231 BY TYPING IN "**". THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.

ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:

DRUG TYPE {3}

GENERIC NAME {60}

THERAPEUTIC CLASS CODE {6}

GENERIC FLAG {1}

THERE IS NO NEED TO DISPLAY THIS INFORMATION.

IF ITEM CHANGED, CHECK MEC COMPONENT.

BOX 10B

OMITTED

BOX 11

OMITTED

RXQ.251 INTERVIEWER: ENTER 1 RESPONSE

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS A LEFT HEADER.

CONTAINER SEEN 1

CONTAINER NOT SEEN 2

ONLY PHARMACY PRINT OUT SEEN 3

RXQ.260 For how long {have/has} {you/SP} been using or taking {PRODUCT NAME}?

Q/U

CAPI INSTRUCTION:

RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 7777777

DON'T KNOW 9999999

|___|

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

BOX 13

OMITTED

BOX 13A

CHECK ITEM RXQ.262:

IF RXQ240s = ‘**’ (drug not on list) or drug’s generic id does not exist in the Drug Reason table, GO TO RXQ.290.

RXQ.289 What is the main reason for which (you use/SP uses) {PRODUCT NAME}?

INTERVIEWER: IF NECESSARY, READ REASONS FROM LIST. SELECT UP TO 3 REASONS.

{Reason text} 10 (RXQ.294)

{Reason text} 11 (RXQ.294)

{Reason text} 12 (RXQ.294)

{Reason text} 13 (RXQ.294)

{Reason text} 14 (RXQ.294)

{Reason text} 15 (RXQ.294)

{Reason text} 16 (RXQ.294)

{Reason text} 17 (RXQ.294)

{Reason text} 18 (RXQ.294)

{Reason text} 19 (RXQ.294)

{Reason text} 20 (RXQ.294)

{Reason text} 21 (RXQ.294)

{Reason text} 22 (RXQ.294)

{Reason text} 23 (RXQ.294)

{Reason text} 24 (RXQ.294)

{Reason text} 25 (RXQ.294)

{Reason text} 26 (RXQ.294)

{Reason text} 27 (RXQ.294)

{Reason text} 28 (RXQ.294)

{Reason text} 29 (RXQ.294)

{Reason text} 30 (RXQ.294)

{Reason text} 31 (RXQ.294)

{Reason text} 32 (RXQ.294)

{Reason text} 33 (RXQ.294)

{Reason text} 34 (RXQ.294)

OTHER SPECIFY 97

RF 777 (RXQ.294)

DK 999 (RXQ.294)

CAPI INSTRUCTION: Populate the {Reason text} fields from the Drug Reason table. Allow up to 3 reasons to be selected and populated into RXQ298a, RXQ298b, and RXQ298c.

RXQ.290 What is the main reason for which (you use/SP uses) {PRODUCT NAME}?

REFUSED 7

DON'T KNOW 9

RXQ.294 CHECK CONTAINERS. ARE THERE ANY OTHER PRESCRIPTION MEDICATIONS?

OR ASK RESPONDENT:

[Are there any other prescription medications that {you/SP} used in the past 30 days?]

YES 1

NO 2

REFUSED 77

DON’T KNOW 99

BOX 14

CHECK ITEM RXQ.299:

ASK RXQ.231 - RXQ.294 FOR NEXT MEDICATION (CODE 1 IN RXQ.294). IF NO NEXT MEDICATION (CODE 2 IN RXQ.294), CONTINUE WITH NEW BOX 15.

NEW BOX 15

CHECK ITEM RXQ.370:

IF DIQ.050 = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT EQUAL TO 215), CONTINUE WITH RXQ.372.

OTHERWISE, GO TO NEW BOX 15B.

RXQ.372 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one is insulin?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.

CODE ALL THAT APPLY.

SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION

REFUSED 77

DON’T KNOW 99

NEW BOX 15A

CHECK ITEM RXQ.374:

IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION.

OTHERWISE, CONTINUE.

NEW BOX 15B

CHECK ITEM RXQ.376:

IF DIQ.070 = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT EQUAL TO 213, 214, 216, 271, 282, 309, 314, 371, OR 458), THEN CONTINUE WITH RXQ.378.

OTHERWISE, GO TO NEW BOX 15D.

RXQ.378 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one {are you/is he/is she} taking for diabetes or blood sugar?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.

CODE ALL THAT APPLY.

SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION

REFUSED 77

DON’T KNOW 99

NEW BOX 15C

CHECK ITEM RXQ.380:

IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION.

OTHERWISE, CONTINUE.

NEW BOX 15D

CHECK ITEM RXQ.382:

IF BPQ.050a = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT EQUAL TO 41, 42, 44, 47, 48, 49, 53, 55, 56, 340, OR 342), THEN CONTINUE WITH RXQ.384.

OTHERWISE, GO TO NEW BOX 15F.

RXQ.384 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one {are you/is he/is she} taking to lower {your/his/her} blood pressure?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.

CODE ALL THAT APPLY.

SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION

REFUSED 77

DON’T KNOW 99

NEW BOX 15E

CHECK ITEM RXQ.386:

IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION.

OTHERWISE, CONTINUE.

NEW BOX 15F

CHECK ITEM RXQ.388:

IF BPQ.100d = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT EQUAL TO 19 OR DRUG CODE NOT EQUAL TO d00497), THEN CONTINUE WITH RXQ.390.

OTHERWISE, GO TO NEW BOX 15H.

RXQ.390 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one {are you/is he/is she} taking to lower {your/his/her} cholesterol?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.

CODE ALL THAT APPLY.

SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION

REFUSED 77

DON’T KNOW 99

NEW BOX 15G

CHECK ITEM RXQ.392:

IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION.

OTHERWISE, CONTINUE.

NEW BOX 15H

CHECK ITEM RXQ.545:

IF RXQ.100=1/YES AND ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT TO 249, SKIP TO RXQ.570.

IF DLQ.150 = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT EQUAL TO 249), THEN CONTINUE WITH RXQ.550.

OTHERWISE, GO TO NEW BOX 15J.

RXQ.550 Earlier in the interview you reported that {you have/he has/she has} taken medication for depression. Is this medication for depression a prescription medication?

YES 1

NO 2 (NEW BOX 15J)

REFUSED 7 (NEW BOX 15J)

DON’T KNOW 9 (NEW BOX 15J)

RXQ.560 Did {you/SP} take it in the last 30 days?

YES 1

NO 2 (NEW BOX 15J)

REFUSED 7 (NEW BOX 15J)

DON’T KNOW 9 (NEW BOX 15J)

RXQ.570 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one {are you/is he/is she} taking for depression (feeling depressed)?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.

CODE ALL THAT APPLY.

SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION

REFUSED 777

DON’T KNOW 999

BOX 15I

CHECK ITEM RXQ.575:

IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION.

OTHERWISE, CONTINUE.

BOX 15J

CHECK ITEM RXQ.580:

IF RXQ.120 = 1/YES AND ANY PRODUCT SELECTED FROM LOOKUP DRUG CODE NOT EQUAL TO d00040, d00148, d00149, d00168, d00182, d00189, d00197, d00198, d00288 OR ANY REASON FROM LIST NOT EQUAL TO ANXIETY, SKIP TO RXQ.610.

IF DLQ.110 = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP DRUG CODE NOT EQUAL TO d00040, d00148, d00149, d00168, d00182, d00189, d00197, d00198, d00288 OR ANY REASON FROM LIST NOT EQUAL TO ANXIETY), THEN CONTINUE WITH RXQ.590.

OTHERWISE, GO TO RXQ.295.

RXQ.590 Earlier in the interview you reported that {you have/he has/she has} taken medication for feeling worried, nervous or anxious. Is this medication for feeling worried, nervous or anxious a prescription medication?

YES 1

NO 2 (RXQ.295)

REFUSED 7 (RXQ.295)

DON’T KNOW 9 (RXQ.295)

RXQ.600 Did {you/SP} take it in the last 30 days?

YES 1

NO 2 (RXQ.295)

REFUSED 7 (RXQ.295)

DON’T KNOW 9 (RXQ.295)

RXQ.610 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one {are you/is he/is she} taking for feeling worried, nervous or anxious?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.

CODE ALL THAT APPLY.

SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION

REFUSED 777

DON’T KNOW 999

NEW BOX 15K

CHECK ITEM RXQ.615:

IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION.

OTHERWISE, CONTINUE.

RXQ.295 REVIEW TOTAL NUMBER OF PRESCRIBED MEDICATIONS AND THEIR NAMES WITH RESPONDENT.

I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}

PRESS ENTER TO CONTINUE

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231. CALCULATE TOTAL NUMBER OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231. DISPLAY NUMBER ON SCREEN.

BOX 17A

CHECK ITEM RXQ.500:

IF SP >= 40 YEARS OLD OR MCQ.160C, MCQ.160D, MCQ.160E OR MCQ.160F = 1/YES, CONTINUE WITH RXQ.510.

OTHERWISE, GO TO BOX 18.

RXQ.510 Doctors and other health care providers sometimes recommend that {you take/SP takes) a low-dose aspirin each day to prevent heart attacks, strokes, or cancer. {Have you/Has SP} ever been told to do this?

YES 1

NO 2 (RXQ.520)

REFUSED 7 (RXQ.520)

DON'T KNOW 9 (RXQ.520)

INTERVIEWER INSTRUCTION:

IF THE RESPONDENT VOLUNTEERS THEY HAVE BEEN TOLD TO TAKE AN ASPIRIN EVERY OTHER DAY OR ‘REGULARLY’ FOR THESE REASONS, CODE “YES”.

RXQ.515 {Are you/Is SP} now following this advice?

YES 1 (RXQ.525)

NO 2 (BOX 18)

SOMETIMES 3 (RXQ.525)

STOPPED ASPIRIN USE DUE TO SIDE
EFFECTS 4 (BOX 18)

REFUSED 7 (BOX 18)

DON'T KNOW 9 (BOX 18)

HELP SCREEN:

Side Effect: is an unexpected health problem that is caused by a medicine. Some side effects of aspirin are stomach problems, easy bruising or bleeding, runny nose, wheezing and skin rashes.

RXQ.520 On {your/SP’s} own, {are you/is SP} now taking a low-dose aspirin each day to prevent heart attacks, strokes, or cancer?

YES 1

NO 2 (BOX 18)

REFUSED 7 (BOX 18)

DON'T KNOW 9 (BOX 18)

INTERVIEWER INSTRUCTION:

IF THE RESPONDENT VOLUNTEERS THEY ARE TAKING AN ASPIRIN EVERY OTHER DAY OR ‘REGULARLY’ FOR THESE REASONS, CODE “YES”.

RXQ.525 How often {do you/does SP} take an aspirin?

G/Q/U

|___|

ONE EVERY DAY 1 (RXQ.530)

ONE EVERY OTHER DAY 2 (RXQ.530)

OTHER, ENTER NUMBER/UNIT 3

REFUSED 7 (RXQ.530)

DON'T KNOW 9 (RXQ.530)

|___|

ENTER NUMBER

REFUSED 777 (RXQ.530)

DON'T KNOW 999 (RXQ.530)

|___|

ENTER UNIT

PER DAY 1

PER WEEK 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION: Soft edit: if >2 per day.

RXQ.530 What is the size or dose that {you take/SP takes}?

81 MG 1

325 MG 2

500 MG 3

OTHER (SPECIFY) 4

REFUSED 7

DON'T KNOW 9

|___|___|___|___| MG

ENTER NUMBER

BOX 18

CHECK ITEM DSQ.332:

IF PROXY INTERVIEW IN RIQ, CONTINUE.

IF NOT PROXY INTERVIEW IN RIQ, GO TO DSQ.335.

DSQ.334 INTERVIEWER OBSERVATION: WAS SP PRESENT FOR ALL OR PART OF INTERVIEW?

YES 1

NO 2

DSQ.335 PRESS F10 TO EXIT BLAISE.

HELP SCREEN FOR DSQ.012:

Health (Care) Professional: A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor's assistants, nurse practitioners, nurses, lab technicians, and technicians who administer shots (i.e., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor's office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.

Dentist: Medical professional whose primary occupation is caring for teeth, gums and jaws. Dental care includes general work such as fillings, cleaning, extractions, and also specialized work such as root canals, fittings for braces, etc.

Past Month: The past 30 days. From yesterday, 30 days back.

HELP SCREEN FOR RXQ.033:

Prescription Medication: Prescription medications are those ordered by a physician or other authorized medical professional through a written or verbal prescription for a pharmacist to fill. Prescription medications may also be given by a medical professional directly to a patient to take home, such as free samples.

Prescription medications do not include:

- Medication administered to the patient during the event in the office as part of the treatment (such as an antibiotic shot for an infection, a flu shot, or an oral medication) unless a separate bill for the medication is received;

- Diaphragms and IUD's (Intra-Uterine Devices); or

- Some state laws require prescriptions for over the counter medications. Sometimes physicians write prescriptions for over the counter medications, such as aspirin. Consider any medication a prescription medication if the respondent reports it as prescribed. If it is an over the counter medication, however, the prescription must be a written prescription to be filled by a pharmacist, not just a written or oral instruction. If in doubt, probe whether the patient got a written prescription to fill at a pharmacy.

Past Month: The past 30 days. From yesterday, 30 days back.

HELP SCREEN FOR DSQ.042:

Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.

Prescription medications do not include:

- Diaphragms and IUD's (Intra-Uterine Devices); or

Past Month: The past 30 days. From yesterday, 30 days back.

HELP SCREEN FOR DSQ.052:

Past Month: The past 30 days. From yesterday, 30 days back.

HELP SCREEN FOR RXQ.231:

Prescription medications do not include:

- Diaphragms and IUD's (Intra-Uterine Devices); or

Past Month: The past 30 days. From yesterday, 30 days back.

HELP SCREEN FOR RXQ.294/RXQ.295:

Prescription medications do not include:

- Diaphragms and IUD's (Intra-Uterine Devices); or

mAILING ADDRESS -maq

mailing address – maq

Target Group: SPs Birth +

Placing: Just After Blaise Closes

MAQ.005 Processing Extended SP Questionnaire. Please Wait.

MAQ.020 The National Center for Health Statistics, part of the Centers for Disease Control and Prevention, may wish to contact {you/SP} again. Please give me {your/SP's} complete mailing address.

CRITICAL INFORMATION – CHECK CAREFULLY.

USE PEN OR PRESS 'TAB' KEY TO MOVE TO THE NEXT ENTRY FIELD.

TAP 'NEXT' BUTTON OR PRESS 'ENTER' KEY WHEN FINISHED VERIFYING ADDRESS.

CAPI INSTRUCTION:

DISPLAY THE SCREENER MAILING ADDRESS INFORMATION. ENTRY SHOULD APPEAR IN ALL CAPS – AS IT DOES IN IVQ.

DISPLAY “YOU/YOUR” IF SP AGE >= TO 16. DISPLAY “SP/SP’s” IF SP AGE < 16.

________ ________ ____________________________ __________ ________ _________

STREET # DIR PRE STREET NAME ST/RD/AVE DIR POST APT/LOT #

________ ________ ________ ______________________________ ________ ________

PO BOX # RR # RR BOX CITY STATE ZIP

MAQ.040 I have recorded . . .

{DISPLAY ADDRESS ENTERED IN MAQ.020 IN UPPER CASE}

Is that correct?

YES 1 (MAQ.090)

NO 2

MAQ.060 ENTER CORRECTED MAILING ADDRESS INFORMATION.

PROBE FOR MAILING ADDRESS CORRECTIONS, IF NECESSARY.

USE PEN OR PRESS 'TAB' KEY TO MOVE TO THE NEXT ENTRY FIELD.

TAP 'NEXT' BUTTON OR PRESS 'ENTER' KEY WHEN CORRECTIONS COMPLETED.

{DISPLAY ALL ADDRESS FIELDS AND INFORMATION ENTERED IN MAQ.020 IN UPPER CASE. ALLOW CORRECTIONS.}

MAQ.080 I now have {your/SP's} mailing address as . . .

{DISPLAY CORRECTED ADDRESS FROM MAQ.060 IN UPPER CASE}

Is that correct?

YES 1

NO 2

BOX 2

CHECK ITEM MAQ.090:

IF 'NO' IN MAQ.080, RETURN TO MAQ.060. DISPLAY CORRECTED ADDRESS INFORMATION IN MAQ.060. OTHERWISE, CONTINUE.

BOX 2A

CHECK ITEM MAQ.082:

IF SP AGE 0-4, GO TO MAQ.090.

IF SP AGE 5-15, CONTINUE.

IF SP AGE GREATER THAN 15 AND INT.001 = 1, GO TO MAQ.090.

IF SP AGE GREATER THAN 15 AND INT.001 = 2, CONTINUE.

MAQ.083 How well {do you/does SP} speak English?

Very well 1

Well 2

Not well 3

Not at all 4

REFUSED 7

DON’T KNOW 9

MAQ.090 INTERVIEWER INSTRUCTION:

SPECIFY LANGUAGE IN WHICH HARD COPY MATERIALS SHOULD BE MAILED.

ENGLISH 1

SPANISH 2

VIETNAMESE 3

KOREAN 4

CHINESE (TRADITIONAL SCRIPT) 5

CHINESE (SIMPLIFIED SCRIPT) 6

BOX 3

CHECK TELEPHONE NUMBER LISTED IN SCREENER (SCQ.430). IF NO HOME TELEPHONE (CODE 2), REF (CODE 9), OR DK (CODE 7), CONTINUE.

OTHERWISE, GO TO BOX 4.

MAQ.100 Please give me your home telephone number in case my office wants to check my work.

CAPI INSTRUCTION:

ONLY ALLOW 10 DIGIT PHONE NUMBER. DISPLAY HARD RANGE CHECK MESSAGE IF NOT 10 DIGITS.

|__|__|__|__|__|__|__|__|__|__|

NO HOME TELEPHONE 2

REFUSED 7

DON’T KNOW 9

MAQ.110 Is there another number where you can be reached?

CAPI INSTRUCTION:

ONLY ALLOW 10 DIGIT PHONE NUMBER. DISPLAY HARD RANGE ERROR IF NOT 10 DIGITS.

|__|__|__|__|__|__|__|__|__|__|

NO 2 (BOX 4)

REFUSED 7 (BOX 4)

DON’T KNOW 9 (BOX 4)

MAQ.115 I have recorded . . .

{DISPLAY PHONE ENTERED IN MAQ.110 AS (XXX) XXX-XXXX}

Is that correct?

YES 1

NO 2 (MAQ.110)

MAQ.120 Where is that phone located?

WORK 1

RELATIVE’S HOME 2

NEIGHBOR’S HOME 3

CELL PHONE 4

OTHER 5

REFUSED 7

DON’T KNOW 9

BOX 4

CHECK ITEM MAQ.140:

IF SP AGE >= TO 16 AND MAQ.120 = 4, GO TO MAQ.160.

IF SP AGE >= 16 AND MAQ.120 NOT EQUAL TO 4, GO TO MAQ.150.

IF SP AGE 12-15, GO TO MAQ.150

IF SP AGE <12, GO TO MAQ.130.

MAQ.150 {Do you/does your child} have a cell phone?

CAPI INSTRUCTION:

DISPLAY “DO YOU/YOUR” IF SP AGE >= TO 16. DISPLAY “DOES YOUR CHILD” IF SP AGE 12-15.

YES 1

NO 2 (MAQ.130)

REFUSED 7 (MAQ.130)

DON’T KNOW 9 (MAQ.130)

MAQ.160 We may want to send {you/your child} short text messages about the exam. These messages will not contain confidential information, but will contain reminders about {your/your child’s} participation. There may be fees to get a text message, depending on your plan. May we send {you/your child} text messages?”

CAPI INSTRUCTION:

DISPLAY “YOU/YOUR” IF SP AGE >= TO 16. DISPLAY “YOUR CHILD/YOUR CHILD’S” IF SP AGE 12-15.

YES 1

NO 2 (MAQ.130)

NO TEXT MESSAGING, NOT POSSIBLE 3 (MAQ.130)

REFUSED 7 (MAQ.130)

DON’T KNOW 9 (MAQ.130)

BOX 5

CHECK ITEM MAQ.170:

IF SP AGE >= TO 16 AND MAQ.120 = 4, GO TO MAQ.130.

OTHERWISE, CONTINUE WITH MAQ.180.

MAQ.180 What is {your/your child’s} cell phone number?

CAPI INSTRUCTION:

DISPLAY “YOUR” IF SP AGE >= TO 16. DISPLAY “YOUR CHILD’s” IF SP AGE 12-15.

|__|__|__|__|__|__|__|__|__|__|

REFUSED 7 (MAQ.130)

DON’T KNOW 9 (MAQ.130)

MAQ.185 I have recorded . . .

{DISPLAY PHONE ENTERED IN MAQ.180 AS (XXX) XXX-XXXX}

Is that correct?

YES 1

NO 2 (MAQ.180)

MAQ.130 This is the end of the health interview. Thank you very much for your cooperation.

POST INTERVIEW

BOX 1

CHECK ITEM WTR:

IF SP AGE 0 TO 19 YEARS, CONTINUE.

OTHERWISE, GO TO APPTCONT.

WTR.001 WATER COLLECTION REMINDER FOR HOUSEHOLDS WITH SPs AGE 0 TO 19.

FOLLOW WATER COLLECTION KIT PROCEDURES AS APPROPRIATE.

APPTCONT PERFORM THE APPOINTMENT MODULE AT THIS TIME?

YES 1

NO 2

FAMILY QUESTIONNAIRE
1. RESPONDENT SELECTION SECTION (RIQ)

RESPONDENT SELECTION SECTION – RIQ – FAMILY QUESTIONNAIRE

*11RIQ.010 SELECT RESPONDENT FOR THE FAMILY QUESTIONNAIRE.

CAPI INSTRUCTION:

DISPLAY ALL FAMILY MEMBERS WHO ARE >= 18 YEARS OLD.

IF NO FAMILY MEMBERS ARE >= 18 YEARS OLD, DISPLAY ALL FAMILY MEMBERS >= 12 YEARS OLD.

ALSO DISPLAY ‘SOMEONE OUTSIDE FAMILY’.

BOX 1A

CHECK ITEM *11RIQ.018:

IF ‘SOMEONE OUTSIDE FAMILY’ SELECTED AS RESPONDENT, GO TO *11RIQ.040.

OTHERWISE, GO TO RIQ.080.

*11RIQ.040 INTERVIEW SHOULD BE CONDUCTED WITH FAMILY MEMBER 18 YEARS OR OLDER WHO KNOWS ABOUT FAMILY MATTERS.

WHY IS INTERVIEW BEING CONDUCTED WITH SOMEONE OUTSIDE THE FAMILY?

ONLY FAMILY MEMBER HAS COGNITIVE

PROBLEMS 1

ONLY FAMILY MEMBER IS A CHILD

UNDER 16 (WARD OF STATE) 2 (*11RIQ.045)

‘SOMEONE OUTSIDE THE FAMILY’

SELECTED IN ERROR 3 (*11RIQ.010)

OTHER (SPECIFY) 4

*11RIQ.042 DO YOU HAVE SUPERVISOR PERMISSION TO CONDUCT INTERVIEW WITH SOMEONE OUTSIDE THE FAMILY?

NOTE: IF INTERPRETER USED, RESPONDENT MUST SIGN FORM.

CAPI INSTRUCTION:

IF 'NO' (CODE 2), DISPLAY THE FOLLOWING MESSAGE: "SUPERVISORY PERMISSION IS REQUIRED TO USE A PROXY FOR THIS INTERVIEW. MOVING FORWARD WILL EXIT THIS INTERVIEW" ALLOW RETURN TO 11RIQ.042 WITH BACK BUTTON. MOVING FORWARD EXITS INTERVIEW.

YES 1

NO 2

*11RIQ.045 ENTER RESPONDENT NAME.

FIRST NAME LAST NAME

*11RIQ.047 ENTER RESPONDENT'S PHONE NUMBER.

ENTER '00' IN AREA CODE IF NO PHONE.

|___|___|___| |___|___|___| - |___|___|___|___|

AREA CODE ENTER PHONE NUMBER

*11RIQ.049 DESCRIBE RESPONDENT'S RELATIONSHIP TO SP.

RIQ.080 HAS RESPONDENT SIGNED A HOUSEHOLD INTERVIEW CONSENT FORM?

CAPI INSTRUCTION:

IF 'NO' (CODE 2), DISPLAY THE FOLLOWING MESSAGE: "THE RESPONDENT MUST SIGN A HOUSEHOLD CONSENT FORM BEFORE THE INTERVIEW IS ADMINISTERED" AND RETURN TO RIQ.080.

NOTE: IF INTERPRETER USED, RESPONDENT MUST SIGN FORM.

YES 1

NO 2

BOX 1B

CHECK ITEM RIQ.165:

IF AUDIO_CONSENT FLAG = 1 (SAME SP AS SP INTERVIEW AND GAVE PERMISSION TO RECORD SP INTERVIEW), GO TO RIQ.200.

ELSE, GO TO RIQ.170.

RIQ.170 DO YOU WANT TO OFFER AUDIO-RECORDING?

YES 1

NO 2 (INT.001)

DOES SP AGREE TO AUDIO RECORDING?

YES 1

NO 2 (INT.001)

DID NOT OFFER 3 (INT.001)

CAPI INSTRUCTION: IF RIQ.180 = 1/YES, BEGIN AUDIO RECORDING SO THAT WHEN INTERVIEWER READS RIQ.190, IT IS CAPTURED ON THE RECORDING.

RIQ.190 The computer is now recording our conversation. Do I have your permission to record this interview? This recording will only be used to review the quality of my work.

YES 1 (INT.001)

NO 2 (INT.001)

CAPI INSTRUCTION: IF RIQ.190 = 2/NO, STOP AND DISCARD RECORDING.

RIQ.200 CAPI INSTRUCTION: BEGIN RECORDING SO THAT WHEN INTERVIEWER READS THIS QUESTION IT IS CAPTURED ON RECORDING.

A reminder that the system is now recording our conversation. Do I have your permission to record this interview?

YES 1

NO 2

CAPI INSTRUCTION: IF RIQ.200 = 2/NO, STOP AND DISCARD RECORDING.

INT.001 IS AN INTERPRETER BEING USED FOR INTERVIEW?

YES 1

NO 2 (GO TO THE END

OF THE SECTION)

INT.003 LANGUAGE USED FOR INTERVIEW

AMERICAN SIGN LANGUAGE 1 (INT.013)

CHINESE (CANTONESE) 2 (INT.013)

CHINESE (MANDARIN) 3 (INT.013)

FRENCH 4 (INT.013)

GERMAN 5 (INT.013)

ITALIAN 6 (INT.013)

JAPANESE 7 (INT.013)

KOREAN 8 (INT.013)

RUSSIAN 9 (INT.013)

SPANISH (READER) 10 (INT.013)

VIETNAMESE 11 (INT.013)

OTHER SPECIFY 99

INT.004 ENTER LANGUAGE USED FOR INTERVIEW

_________________________________

INT.013 {DISPLAY INTERPRETER NAMES FROM ALL PREVIOUS INTERVIEWS: SCREENER, RELATIONSHIP, SP, FAMILY QUESTIONNAIRE}

ENTER INTERPRETER NAME INFO

SAME INTERPRETER USED IN OTHER
INTERVIEW FOR HOUSEHOLD 1 (INT.014)

NEW INTERPRETER 2 (INT.005)

INT.014 {DISPLAY LIST OF INTERPRETER NAMES FROM SCREENER, RELATIONSHIP, SP AND/OR FAMILY QUESTIONNAIRES}

{INCLUDE “OTHER” AS A SELECTION}

SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME

BOX 4

CHECK ITEM INT.014a:

IF ‘OTHER’ SELECTED IN INT.014, GO TO INT.005.

OTHERWISE, CODE INTERPRETER INFO FROM PREVIOUS INTERVIEW AND GO TO END OF SECTION.

INT.005 HOW WAS INTERPRETER OBTAINED

ARRANGED BY FIELD OFFICE 1

RECRUITED DURING VISIT/APPOINTMENT 2 (INT.007)

INT.006 SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME

{DROP DOWN LIST SHOULD HAVE ALL NAMES FROM EVM AND AN “OTHER SPECIFY” TO ALLOW FOR THOSE NAMES THAT HAVE NOT BEEN TRANSFERRED TO INTERVIEWER PENTOP}

BOX 6

CHECK ITEM INT.006A:

IF OTHER (SELECTED IN INT.006), GO TO INT.009.

OTHERWISE, GO TO END OF SECTION.

INT.007 SELECT INTERPRETER SOURCE

RELATIVE LIVING IN HOUSEHOLD 1

NON-RELATIVE LIVING IN HOUSEHOLD 2

NEIGHBOR, RELATIVE OR FRIEND –
NOT IN HOUSEHOLD 3 (SKIP TO INT.009)

INT.008 SELECT NAME OF INTERPRETER FROM HOUSEHOLD ROSTER.

{DISPLAY CAPI PULL DOWN LIST FROM HH ROSTER}

BOX 7

CHECK ITEM INT.008A:

GO TO END OF SECTION.

INT.009 ENTER NAME OF INTERPRETER

______________________________________

INT.010 ENTER PHONE # OF INTERPRETER

___ -___ ____

INT.011 ENTER AGE RANGE OF INTERPRETER

{AGE RANGE CAN BE A PULL DOWN LIST}

RANGES = 18-29

30-59

60+

INT.012 ENTER GENDER OF INTERPRETER

MALE 1

FEMALE 2

DEMOGRAPHIC BACKGROUND/OCCUPATION (DMQ)

DEMOGRAPHIC BACKGROUND/OCCUPATION – DMQ - fam

Target Group:  Head of CPS Family (Non-SP)

 Head of CPS Family Spouse (Non-SP)

BOX 1A

RULES FOR ADMINISTERING THE DEMOGRAPHIC AND OCCUPATION SECTION OF THE FAMILY QUESTIONNAIRE:

A CPS FAMILY INCLUDES INDIVIDUALS AND GROUPS OF INDIVIDUALS WHO ARE 16+ AND RELATED BY BIRTH, MARRIAGE OR ADOPTION. STEP CHILDREN, PARENTS OR SIBLINGS ARE INCLUDED. IT ALSO INCLUDES UNMARRIED PARTNERS IF THEY HAVE A BIOLOGICAL OR ADOPTIVE CHILD IN COMMON. IT DOES NOT INCLUDE UNMARRIED PARTNERS WHO DO NOT HAVE A CHILD IN COMMON, FOSTER PARENTS OR FOSTER CHILDREN. NOTE: A CPS FAMILY CAN BE ONE INDIVIDUAL.

BOX 1

LOOP 1:

ASK DMQ.107 – DMQ.141 AS APPROPRIATE FOR NON-SP HEAD OF CPS FAMILY AND NON-SP SPOUSE (RELATIONSHIP OF "MARRIED" IN THE SCREENER) OF HEAD OF CPS FAMILY.

FIRST ASK DMQ.107, 130, AND 141 FOR NON-SP HEAD OF CPS FAMILY.
NEXT, ASK DMQ.141 FOR NON-SP SPOUSE OF HEAD OF CPS FAMILY.
EACH TARGET PERSON SHOULD BE ASKED THIS SECTION ONCE.
IF NO NON-SP HEAD OF CPS FAMILY AND NON-SP SPOUSE, GO TO
END OF SECTION.

DMQ.107 In what country {were you/was NON-SP Head} born?

UNITED STATES 1 (DMQ.130)

OTHER COUNTRY 2

REFUSED 7 (BOX 2)

DON'T KNOW 9 (BOX 2)

DMQ.113 SELECT COUNTRY OF BIRTH

ARGENTINA 1

BANGLADESH 2

BELIZE 3

BHUTAN 4

BOLIVIA 5

BRAZIL 6

BURMA/MYANMAR 7

CAMBODIA 8

CHILE 9

CHINA 10

COLOMBIA 11

COSTA RICA 12

CUBA 13

DOMINICAN REPUBLIC 14

ECUADOR 15

EL SALVADOR 16

GUATEMALA 17

HONDURAS 18

HONG KONG 19

INDIA 20

INDONESIA 21

JAPAN 22

KOREA 23

LAOS 24

MACAU 25

MADAGASCAR 26

MALAYSIA 27

MALDIVES 28

MEXICO 29

NEPAL 30

NICARAGUA 31

PAKISTAN 32

PANAMA 33

PARAGUAY 34

PERU 35

PHILIPPINES 36

PUERTO RICO 37

SINGAPORE 38

SPAIN 39

SRI LANKA 40

TAIWAN 41

THAILAND 42

TIBET 43

URUGUAY 44

VENEZUELA 45

VIETNAM 46

OTHER COUNTRY (CAPI INSTRUCTION:

DO NOT SPECIFY) 50

BOX 2

CHECK ITEM DMQ.120:

IF ANY CODE OTHER THAN 1 (UNITED STATES)IN DMQ.107, GO TO DMQ.141.

DMQ.130 In what state {were you/was NON-SP HEAD} born?

ENTER 2 LETTER STATE ABBREVIATION TO START THE LOOKUP.

SELECT STATE FROM CAPI STATE LIST.

PRESS ENTER TO ACCEPT SELECTION.

CAPI INSTRUCTION:

DISPLAY FIPS STATE LIST. INTERVIEWER SHOULD ONLY BE ABLE TO SELECT 1 STATE FROM THE LIST. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. THE STATE LOOKUP IN THE SP AND FAMILY QUESTIONNAIRES SHOULD WORK EXACTLY THE SAME.

DMQ.141 What is the highest grade or level of school {you have/NON-SP HEAD/NON-SP SPOUSE has} completed or the highest degree {you have/he/she has} received?

HAND CARD DMQ1

READ HAND CARD CATEGORIES IF NECESSARY

Enter highest level of school.

NEVER ATTENDED/KINDERGARTEN

ONLY 0

1ST GRADE 1

2ND GRADE 2

3RD GRADE 3

4TH GRADE 4

5TH GRADE 5

6TH GRADE 6

7TH GRADE 7

8TH GRADE 8

9TH GRADE 9

10TH GRADE 10

11TH GRADE 11

12TH GRADE, NO DIPLOMA 12

HIGH SCHOOL GRADUATE 13

GED OR EQUIVALENT 14

SOME COLLEGE, NO DEGREE 15

ASSOCIATE DEGREE: OCCUPATIONAL,

TECHNICAL, OR VOCATIONAL

PROGRAM 16

ASSOCIATE DEGREE: ACADEMIC

PROGRAM 17

BACHELOR’S DEGREE (EXAMPLE: BA,

AB, BS, BBA) 18

MASTER’S DEGREE (EXAMPLE: MA,

MS, MEng, MEd, MBA) 19

PROFESSIONAL SCHOOL DEGREE

(EXAMPLE: MD, DDS, DVM, JD) 20

DOCTORAL DEGREE (EXAMPLE:

PhD, EdD) 21

REFUSED 77

DON’T KNOW 99

BOX 3

END LOOP 1:

ASK DMQ.107-141 FOR NEXT TARGET PERSON (NON-SP HEAD)
ASK DMQ.141 FOR NEXT TARGET PERSON (NON-SP SPOUSE –
RELATIONSHIP OF "MARRIED" IN THE SCREENER).

IF NO NEXT PERSON, GO TO BOX 4.

BOX 4

LOOP 2:

ASK OCQ.150 - OCQ.380 FOR NON-SP HEAD IF AGE >= 16 AND NON-SP SPOUSE (RELATIONSHIP OF 'MARRIED' IN THE SCREENER) OF HEAD IF NON-SP SPOUSE AGE >= 16.

OCQ.150 The next questions are about {your/NON-SP HEAD'S/NON-SP SPOUSE'S} current job or business. Which of the following {were you/was} {NON-SP HEAD/NON-SP SPOUSE} doing last week . . .

working at a job or business, 1 (BOX 7)

with a job or business but not at work, 2 (BOX 7)

looking for work, or 3 (BOX 7)

not working at a job or business? 4

REFUSED 7 (BOX 7)

DON'T KNOW 9 (BOX 7)

OCQ.380 What is the main reason {you/NON-SP HEAD/NON-SP SPOUSE} did not work last week?

TAKING CARE OF HOUSE OR FAMILY 1

GOING TO SCHOOL 2

RETIRED 3

UNABLE TO WORK FOR HEALTH

REASONS 4

ON LAYOFF 5

DISABLED 6

OTHER 7

REFUSED 77

DON'T KNOW 99

BOX 7

END LOOP 2:

ASK OCQ.150 – OCQ.380 FOR NEXT TARGET PERSON (NON-SP HEAD OR NON-SP SPOUSE - RELATIONSHIP OF "MARRIED" IN THE SCREENER).
IF NO NEXT PERSON, GO TO END OF SECTION.

HELP SCREEN FOR DMQ.141:

Training Programs - Count training received "on the job," in the Armed Forces, or through correspondence school only if it was credited toward a school diploma, high school equivalency (GED), or college degree.

Vocational, Trade, or Business School - Do not include secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered, and other vocational trade or business schools outside the regular school system.

General Educational Development (GED) or High School Equivalency - An exam certified equivalent of a high school diploma. If the person has not actually completed all 4 years of high school, but has acquired his/her GED (high school equivalency based on passing the GED exam), count this and enter code "14."

Adult Education - Adult education classes should not be included as regular school unless such schooling has been counted for credit in a regular school system. If a person has taken adult education classes not for credit, these classes should not be counted as regular school. Adult education courses given in a public school building are part of regular schooling only if their completion can advance a person toward an elementary school certificate, a high school diploma (or GED), or a college degree.

Other School Systems - If the person attended school in another country, in an ungraded school, in a "normal school", under a tutor, or under other special circumstances, ask the respondent to give the nearest equivalent of years in regular U.S. schooling.

GED (General Educational Development): An exam certified equivalent of a high school diploma.

Occupational, Technical, or Vocational Program: Includes secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered and other trade and business schools outside the regular school system.

Bachelor's Degree: An educational degree given by a college or university to a person who has completed a 4-year course or its equivalent in the humanities or related studies (B.A.) or in the sciences (B.S.).

Doctoral Degree: The highest educational degree given by a college or university to a person who has completed a prescribed course of advanced graduate study. For example—a Doctor of Philosophy (Ph.D.).

HELP SCREEN FOR OCQ.150:

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

1. Filled out applications or sent out resumes;

2. Placed or answered classified ads;

3. Checked union/professional registers;

4. Bid on a contract or auditioned for a part in a play;

5. Contacted friends or relatives about possible jobs;

6. Contacted school/college university employment office;

7. Contacted employment directly.

Job search methods that are not active include the following:

1. Looked at ads without responding to them;

2. Picked up a job application without filling it out.

HELP SCREEN FOR OCQ.380:

Taking Care of House or Family: Doing any type of work around the house, such as cleaning, cooking, maintaining the yard, caring for children or family, etc.

Going to School: Attending any type of public or private educational establishment both in and out of the regular school system.

Retired: Respondent defined.

Unable to Work for Health Reasons: Respondent defined.

Disabled: Respondent defined.

OCCUPATION (OCQ)

OCCUPATION – OCQ

Target Group: SPs 16+

BOX 4

LOOP 2:

ASK OCQ.150-OCQ.380 FOR NON-SP HEAD IF AGE >= 16 AND NON-SP SPOUSE (RELATIONSHIP OF 'MARRIED' IN THE SCREENER) OF HEAD IF NON-SP SPOUSE AGE >= 16.

OCQ.150 The next questions are about {your/NON-SP HEAD'S/NON-SP SPOUSE'S} current job or business. Which of the following {were you/was} {NON-SP HEAD/NON-SP SPOUSE} doing last week . . .

working at a job or business, 1 (BOX 7)

with a job or business but not at work, 2 (BOX 7)

looking for work, or 3 (BOX 7)

not working at a job or business? 4

REFUSED 7 (BOX 7)

DON'T KNOW 9 (BOX 7)

OCQ.380 What is the main reason {you/NON-SP HEAD/NON-SP SPOUSE} did not work last week?

TAKING CARE OF HOUSE OR FAMILY 1

GOING TO SCHOOL 2

RETIRED 3

UNABLE TO WORK FOR HEALTH

REASONS 4

ON LAYOFF 5

DISABLED 6

OTHER 7

REFUSED 77

DON'T KNOW 99

BOX 7

END LOOP 2:

ASK OCQ.150 FOR NEXT TARGET PERSON (NON-SP HEAD OR NON-SP SPOUSE - RELATIONSHIP OF "MARRIED" IN THE SCREENER).
IF NO NEXT PERSON, GO TO END OF SECTION.

housing characteristics (HOQ)

housing characteristics – hoq

Target Group: SPs Family

HOQ.050 How many rooms are in this home? Count the kitchen but not the bathroom.

CAPI INSTRUCTION:

HARD EDIT: 1-25

|___|___|

ENTER NUMBER OF ROOMS

REFUSED 777777

DON'T KNOW 999999

HELP SCREEN:

Number of Rooms in House: Do not count bathrooms, laundry rooms, or unfinished basements.

HOQ.065 Is this home owned, being bought, rented, or occupied by some other arrangement by {you/you or someone else in your family}?

OWNED OR BEING BOUGHT 1

RENTED 2

OTHER ARRANGEMENT 3

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Rents or Owns Home: A person rents the home if s/he pays on a continuing basis without gaining any rights to ownership. A person owns the home even if s/he is still paying on a mortgage.

SMOKING (SMQ)

SMOKING – SMQ

Target Group: Household

SMQ.460 Now I would like to ask you a few questions about smoking in this home.

How many people who live here smoke cigarettes, cigars, little cigars, pipes, water pipes, hookah, or any other tobacco product?

INTERVIEWER INSTRUCTION: IF RESPONSE IS NO ONE, ENTER ZERO

|___|___|

ENTER NUMBER OF PERSONS

REFUSED 777

DON'T KNOW 999

HELP SCREEN:

Tobacco products do not include marijuana.

CAPI INSTRUCTION:

ALLOW ‘0’ AS AN ENTRY.

RANGE EDIT: CANNOT BE GREATER THAN # OF PEOPLE IN THE HOUSEHOLD.

IF ‘0’, DK OR RF, GO TO END OF SECTION.

SMQ.470 Not counting decks, porches, or detached garages, how many people who live here smoke cigarettes, cigars, little cigars, pipes, water pipes, hookah, or any other tobacco product inside this home?

|___|___|

ENTER NUMBER OF PERSONS

REFUSED 777

DON'T KNOW 999

HELP SCREEN:

Tobacco products do not include marijuana.

CAPI INSTRUCTION:

ALLOW ‘0’ AS AN ENTRY.

HARD EDIT: NUMBER ENTERED IN SMQ.470 MUST BE EQUAL OR LESS THAN SMQ.460.

IF ‘0’, DK OR RF, GO TO END OF SECTION.

SMQ.480 (Not counting decks, porches, or detached garages) During the past 7 days, that is since last [TODAY’S DAY OF WEEK], on how many days did {anyone who lives here/you}, smoke tobacco inside this home?

|___|

ENTER NUMBER OF DAYS FROM 0 TO 7.

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF ONLY ONE PERSON LIVING IN HOUSEHOLD DISPLAY “you..” IF MORE THAN ONE PERSON

LIVING IN HOUSEHOLD, DISPLAY “anyone who lives here..”

consumer behavior (CBQ)

consumer behavior – CBQ

Target Group: Family Questionnaire

BOX NEW 1A

OMITTED

CBQ.070
Q/U

The next questions are about how much money {your family spends/you spend} on food. First I’ll ask you about money spent at supermarkets or grocery stores. Then we will talk about money spent at other types of stores. When you answer these questions, please do not include money spent on alcoholic beverages.

During the past 30 days, how much money {did your family/did you} spend at supermarkets or grocery stores? Please include purchases made with food stamps. (You can tell me per week or per month.)

INTERVIEWER: ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

$ |___|___|___|___|___|___|___|___|___|

NO MONEY SPENT 0 (CBQ.100)

REFUSED 7 (CBQ.100)

DON'T KNOW 9 (CBQ.100)

ENTER UNIT

WEEK 1

MONTH 2

REFUSED 7

DON'T KNOW 9

CBQ.080 Was any of this money spent on nonfood items such as cleaning or paper products, pet food, cigarettes or alcoholic beverages?

YES 1

NO 2 (CBQ.100)

REFUSED 7 (CBQ.100)

DON'T KNOW 9 (CBQ.100)

CBQ.090
Q/U

About how much money was spent on nonfood items? (You can tell me per week or per month.)

$ |___|___|___|___|___|___|___|___|___|

HARD EDIT: AMOUNT CANNOT BE MORE THAN
THE AMOUNT ENTERED ON CBQ.070.

REFUSED 7

DON'T KNOW 9

ENTER UNIT

WEEK 1

MONTH 2

REFUSED 7

DON'T KNOW 9

CBQ.100 During the past 30 days, {did your family/did you} spend money on food at stores other than grocery stores? Please do not include money that you have already told me about. Here are some examples of stores other than grocery stores where you might buy food.

HAND CARD CBQ1

YES 1

NO 2 (CBQ.120)

REFUSED 7 (CBQ.120)

DON'T KNOW 9 (CBQ.120)

CBQ.110
Q/U

About how much money {did your family/did you} spend on food at these types of stores? Please do not include money you have already told me about. (You can tell me per week or per month.)

INTERVIEWER: ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

$ |___|___|___|___|___|___|___|___|___|

REFUSED 7

DON'T KNOW 9

ENTER UNIT

WEEK 1

MONTH 2

REFUSED 7

DON'T KNOW 9

CBQ.120
Q/U

During the past 30 days, how much money {did your family/did you} spend on eating out? Please include money spent in cafeterias at work or at school or on vending machines, for all family members. (You can tell me per week or per month.)

INTERVIEWER INSTRUCTION: IF RESPONDENT KNOWS ONLY AMOUNT FOR SELF, CODE DK.

INTERVIEWER: ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

$ |___|___|___|___|___|___|___|___|___|

REFUSED 7

DON'T KNOW 9

ENTER UNIT

WEEK 1

MONTH 2

REFUSED 7

DON'T KNOW 9

CBQ.130
Q/U

During the past 30 days, how much money {did your family/did you} spend on food carried out or delivered? Please do not include money you have already told me about. (You can tell me per week or per month.)

INTERVIEWER INSTRUCTION: IF RESPONDENT KNOWS ONLY AMOUNT FOR SELF, CODE DK.

INTERVIEWER: ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

$ |___|___|___|___|___|___|___|___|___|

REFUSED 7

DON'T KNOW 9

ENTER UNIT

WEEK 1

MONTH 2

REFUSED 7

DON'T KNOW 9

INCOME (INQ)

INCOME – INQ

Target Group: SP, Family, Household

Definitions for Testers:

NHANES FAMILY: Everyone related to each other by blood, marriage or a marriage-like relationship including partners and foster children.

FAMILY: Individuals and groups of individuals who are related by birth, marriage or adoption. step children, parents or siblings are included. It also includes unmarried partners if they have a biological or adoptive child in common. It does not include unmarried partners who do not have a child in common, foster parents or foster children. Note: Individuals living alone or with other unrelated individuals are referred to as “unrelated individuals”.

INQ.020 The next questions are about {your/your combined family} income. When answering these questions, please remember that by {"income/combined family income"}, I mean {your income/your income plus the income of {NAMES OF OTHER NHANES FAMILY MEMBERS} for {LAST CALENDAR YEAR}. Did {you/you and OTHER NHANES FAMILY MEMBERS 16+} receive income in {LAST CALENDAR YEAR} from wages and salaries?

[Did {you/you or OTHER FAMILY MEMBERS 16+} get paid for work in {LAST CALENDAR YEAR}.]

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Wages and Salaries: Include tips, bonuses, overtime, commissions, Armed Forces pay, special cash bonuses and subsistence allowances.

Income: Income is an important factor in the analysis of the health information we collect. Access to medical care depends in part on a person or family's financial resources. This information helps us learn if people in one income group use certain types of medical services more or less than people in other income groups. We may also learn if one income group has certain medical conditions more than other income groups.

INQ.012 Did {you/you or any family members 16 and older} receive income in {LAST CALENDAR YEAR} from self-employment including business and farm income?

[Self-employment means you worked for yourself.]

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1B

OMITTED

BOX 1C

OMITTED

INQ.030 When answering the next questions about different kinds of income members of your family might have received in {LAST CALENDAR YEAR}, please consider that we also want to know about family members less than 16 years old. Did {you/you or any family members living here, that is: you or NAME(S) OF OTHER NHANES FAMILY MEMBERS} receive income in {LAST CALENDAR YEAR} from Social Security or Railroad Retirement?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Social Security: Social Security (SS) payments are received by persons who have worked long enough in employment that had SS deductions taken from their salary in order to be entitled to payments. SS payments may be made to the spouse or dependent children of a covered worker. SS also pays benefits to student dependents (under 19 years of age) of eligible social security annuitants who are disabled or deceased.

Railroad Retirement: U.S. Government Railroad Retirement Benefits are based on a person’s long-term employment in the railroad industry.

BOX 1D

OMITTED

BOX 1E

OMITTED

INQ.060 Did {you/you or any family members living here} receive any disability pension [other than Social Security or Railroad Retirement] in {LAST CALENDAR YEAR}?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Disability Pension: The following are the most common types of disability pensions: company or union disability, Federal Government (Civil Service) disability, U.S. military retirement disability, state or local government employee disability, accident or disability insurance annuities, and Black Lung miner's disability.

Railroad Retirement: U.S. Government Railroad Retirement Benefits are based on a person's long-term employment in the railroad industry.

BOX 2A

OMITTED

INQ.080 Did {you/you or any family members living here} receive retirement or survivor pension [other than Social Security or Railroad Retirement or disability pension] in {LAST CALENDAR YEAR}?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2B

OMITTED

INQ.090 Did {you/you or any family members living here} receive Supplemental Security Income [SSI] in {LAST CALENDAR YEAR}?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

SSI: Also known as Supplemental Security Income (SSI), this federal program provides monthly cash payments in accordance with uniform, nationwide eligibility requirements to persons who are both needy and aged (65 years or older), blind, or disabled. A person may be eligible for SSI payments even if they have never worked. SSI is NOT the same as Social Security. A person can get SSI in addition to Social Security. The SSI program is issued by the Social Security Administration. Each state may add to the federal payment from its own funds. This additional money may be included in the federal payment or it may be received as a separate check. If it is combined with the federal payment, the words "STATE PAYMENT INCLUDED" will appear on the federal check. A few states make SSI payments to individuals who do not receive a federal payment.

BOX 2C

OMITTED

BOX 3A

OMITTED

INQ.132 Did {you/you or any family members living here} receive any cash assistance from a state or county welfare program such as {DISPLAY SPECIFIC STATE PROGRAMS} in {LAST CALENDAR YEAR}?

CAPI INSTRUCTION:

DISPLAY FULL NAMES OF ALL STATE PROGRAMS FOR STATE IN WHICH INTERVIEW IS BEING CONDUCTED. NAMES FOR EACH STATE WILL BE SENT TO PROGRAMMING IN A SEPARATE FILE.

DISPLAY “welfare, public assistance, AFDC, or some other program” WHEN NO STATE PROGRAMS FOR STATE IN WHICH INTERVIEW IS BEING CONDUCTED ARE SPECIFIED IN TABLE.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 3AA

OMITTED

BOX 3B

OMITTED

INQ.140 Did {you/you or any family members living here} receive interest from savings or other bank accounts or income from dividends received from stocks or mutual funds or net rental income from property, royalties, estates, or trusts in {LAST CALENDAR YEAR}?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

BOX 3C

OMITTED

INQ.150 Did {you/you or any family members living here} receive income in {LAST CALENDAR YEAR} from child support, alimony, contributions from family or others, VA payments, worker's compensation, or unemployment compensation?

INTERVIEWER INSTRUCTION: CONTRIBUTIONS INCLUDE GIFTS.

INTERVIEWER INSTRUCTION: IF RESPONDENT IS A COLLEGE STUDENT LIVING AWAY FROM THEIR FAMILY PLEASE ADD “INCLUDING MONEY RECEIVED FROM FAMILY FOR COLLEGE TUITION, BOOKS AND LIVING EXPENSES”

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 3D

OMITTED

BOX 4A

OMITTED

BOX 4C

OMITTED

BOX 4B

OMITTED

BOX 5

OMITTED

BOX 7

ASK INQ.200 – 230 FOR EACH FAMILY IN THE HOUSEHOLD.

FOR THE PURPOSE OF ADMINISTERING THE QUESTIONS ABOUT TOTAL INCOME:

 A FAMILY INCLUDES INDIVIDUALS AND GROUPS OF INDIVIDUALS WHO ARE RELATED BY BIRTH, MARRIAGE OR ADOPTION. STEP CHILDREN, PARENTS OR SIBLINGS ARE INCLUDED. IT ALSO INCLUDES UNMARRIED PARTNERS IF THEY HAVE A BIOLOGICAL OR ADOPTIVE CHILD IN COMMON. IT DOES NOT INCLUDE UNMARRIED PARTNERS WHO DO NOT HAVE A CHILD IN COMMON, FOSTER PARENTS OR FOSTER CHILDREN. NOTE: INDIVIDUALS LIVING ALONE OR WITH OTHER UNRELATED INDIVIDUALS ARE REFERRED TO AS “UNRELATED INDIVIDUALS”.

 TOTAL INCOME IS ADMINISTERED FOR EACH FAMILY AND THEN FOR THE ENTIRE HOUSEHOLD.

INQ.200 Now I am going to ask about the total income for {you/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} in {LAST CALENDAR YEAR}, including income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Can you tell me that amount before taxes?

CAPI INSTRUCTIONS:

 DISPLAY "YOU" IF ONLY 1 PERSON IN THE FAMILY.

 DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.

$ |___|___|___|___|___|___|___|___|___| (GO TO INQ.235)

REFUSED 7777777777 (INQ.220)

DON'T KNOW 9999999999 (INQ.220)

CAPI INSTRUCTION:

 REQUIRE DOUBLE ENTRY OF INCOME.

 SCREEN SHOULD READ:

DOUBLE ENTRY OF INCOME REQUIRED.

 IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.

 IF INQ.200 NOT DK OR RF, SET FAMILY ANNUAL INCOME THRESHOLD = INQ.200.

BOX 5A

OMITTED

INQ.220 You may not be able to give us an exact figure for {your/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} income, but can you tell me if this income in {LAST CALENDAR YEAR} was . . .

PROBE: Income is important in using the health information we collect. For example, it helps us to learn whether persons in one income group use certain types of medical services or have certain health conditions more or less often than those in another income group.

CAPI INSTRUCTIONS:

 DISPLAY "YOUR" IF ONLY 1 PERSON IN THE FAMILY.

 DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.

$20,000 or more, or 1

less than $20,000? 2

REFUSED 7 (BOX 9)

DON'T KNOW 9 (INQ.235)

HELP SCREEN:

Household: The entire group of persons who live in one dwelling unit. It may be several persons living together or one person living alone. It includes the household reference person and any of their relatives, as well as roomers, employees, and other non-related persons.

INQ.230
a/b

Of these income groups, can you tell me which letter best represents {your/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} income in {LAST CALENDAR YEAR}?

HAND CARD {INQ1 AND INQ2}

ENTER LETTER(S) CORRESPONDING TO TOTAL COMBINED FAMILY INCOME.

CAPI INSTRUCTIONS:

 DISPLAY "YOUR" IF ONLY 1 PERSON IN THE FAMILY.

 DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.

 IF $20,000 OR MORE, DISPLAY HAND CARD INQ1.

 IF LESS THAN $20,000, DISPLAY HAND CARD INQ2.

 IF INQ.230 NOT EQUAL TO DK OR RF, SET FAMILY ANNUAL INCOME THRESHOLD = LOWER VALUE IN RANGE.

|___|___|

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

BOX 6

OMITTED

INQ.235 What is the total income received last month, {LAST CALENDAR MONTH & CURRENT CALENDAR YEAR} by {you/NAMES OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS}} before taxes?

[Please include income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth.]

[INTERVIEWER INSTRUCTION: IF SP DOES NOT KNOW INCOME OF OTHER FAMILY MEMBERS, ENTER DON’T KNOW.]

SOFT EDIT: AMOUNT REPORTED IN INQ.235 (MONTHLY INCOME) GREATER THAN OR EQUAL TO THE AMOUNT REPORTED IN INQ.200 (ANNUAL INCOME), DISPLAY SOFT EDIT MESSAGE: “INTERVIEWER, YOU HAVE RECORDED AN ANNUAL TOTAL INCOME OF {ANNUAL INCOME REPORTED IN INQ.200} AND LAST MONTH’S TOTAL INCOME WAS RECORDED AS {TOTAL MONTHLY INCOME REPORTED IN INQ.235}. PLEASE CONFIRM WITH SP THAT LAST MONTH’S INCOME OF {TOTAL MONTHLY INCOME REPORTED IN INQ.235} IS CORRECT.

CAPI INSTRUCTION:

 REQUIRE DOUBLE ENTRY OF INCOME.

 SCREEN SHOULD READ:

DOUBLE ENTRY OF INCOME REQUIRED.

IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.
FOR THE CALENDAR FILL: IF CURRENT MONTH IS JANUARY THE PAST CALENDAR YEAR WILL BE SHOWN

$ |___|___|___|___|___|___|___|___|___| (INQ.244N)

REFUSED 7

DON'T KNOW 9

INQ.238 You may not be able to give us an exact figure, but can you tell me if the income for {you/NAMES OF OTHER FAMILY/your family} in {LAST CALENDAR MONTH & CURRENT CALENDAR YEAR} was . . .

{185% or less of monthly poverty

level}, or 1

more than {185% monthly poverty level}? 2 (INQ.244N)

REFUSED 7

DON'T KNOW 9

PROBE: (That would be {12 times 185% monthly poverty level}} per year.)

CAPI INSTRUCTION:

Fill 185% of the monthly poverty level based on family size:

For family size of 1, fill ($1,799 round to nearest 100s = $1,800)

For each additional family member, fill {[$1,799+($626* # of additional person)] round to nearest 100s}

Fill 185% of the annual poverty level based on family size in the PROBE:

For family size of 1, fill [($1,799*12) round to nearest 100s] = $21,600)

For each additional member, fill {[$1,799+($626* # of additional person)]*12 round to nearest 100s}

Persons in Family	185% monthly poverty level		185% annual poverty level
Persons in Family	Raw Number¹	Rounded to nearest 100s²	Raw Number³	Rounded to nearest 100s⁴
1	1,799	1,800	21,588	21,600
2	2,425	2,400	29,100	29,100
3	3,051	3,100	36,612	36,600
4	3,677	3,700	44,124	44,100
5	4,303	4,300	51,636	51,600
6	4,929	4,900	59,148	59,100
7	5,555	5,600	66,660	66,700
8	6,181	6,200	74,172	74,200

¹: $1,799 for family size of 1, thereafter, adding $626 for each additional person.

²: These are the numbers to be used in the response category fills.

³: Multiply by 12 to the raw number of the 185% monthly poverty level.

⁴: These are the numbers to be used in the probe fills.

INQ.241 Was it more or less than {130% monthly poverty level}?

130% or less than monthly poverty level 1

More than 130% of monthly poverty level 2

REFUSED 7

DON'T KNOW 9

PROBE: {That would be 12 times 130% annual poverty level per year.}

CAPI INSTRUCTION:

Fill 130% of the monthly poverty level based on family size:

For family size of 1, fill ($1,264 round to nearest 100s = $1,300)

For each additional family member, fill {[$1,264+($440* # of additional person)] round to nearest 100s}

Fill 130% of the annual poverty level based on family size in the PROBE:

For family size of 1, fill [($1,264*12) round to nearest 100s] = $15,200)

For each additional member, fill {[$1,264+($440* # of additional person)]*12 round to nearest 100s}

Persons in Family	130% monthly poverty level		130% annual poverty level
Persons in Family	Raw Number¹	Rounded to nearest 100s²	Raw Number³	Rounded to nearest 100s⁴
1	1,264	1,300	15,168	15,200
2	1,704	1,700	20,448	20,400
3	2,144	2,100	25,728	25,700
4	2,584	2,600	31,008	31,000
5	3,024	3,000	36,288	36,300
6	3,464	3,500	41,568	41,600
7	3,904	3,900	46,848	46,800
8	4,344	4,300	52,128	52,100

¹: $1,264 for family size of 1, thereafter, adding $440 for each additional person.

²: These are the numbers to be used in the text of question and response category fills.

³: Multiply 12 to the raw number of the 130% monthly poverty level.

⁴: These are the numbers to be used in the probe fills.

INQ.244N Do {you/NAMES OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} have more than $20,000 in savings at this time? Please include money in all types of accounts {you/your family} may have. Here are some examples of the types of accounts.

HAND CARD INQ3

CAPI INSTRUCTION:

DISPLAY “you” for single-person family; DISPLAY “the members of your family” for multi-persons family.

YES 1 (BOX 9)

NO 2

REFUSED 7 (BOX 9)

DON'T KNOW 9 (BOX 9)

INQ.247N Which letter on this card best represents the total savings or cash assets at this time for {you/NAMES OF OTHER FAMILY/your family}?

HAND CARD INQ4

|___| ENTER LETTER

REFUSED 7

DON'T KNOW 9

A: $0 - $3,000

B: $3,001 - $5,000

C: $5,001 - $10,000

D: $10,001 - $15,000

E: $15,001 - $20,000

BOX 8

OMITTED

BOX 9

CHECK ITEM INQ.240:

IF THERE IS MORE THAN ONE NHANES FAMILY IN THE HOUSEHOLD, CONTINUE.

OTHERWISE, GO TO INQ.NEW1.

BOX 9A

CHECK ITEM INQ.249:

HOUSEHOLD INCOME (INQ.250, 260, 270) SHOULD ONLY BE ASKED ONCE OF THE FIRST FAMILY TO COMPLETE THE FAMILY QUESTIONNAIRE REGARDLESS OF FAMILY NUMBER. IT SHOULD NOT BE ASKED TWICE FOR A HOUSEHOLD AND SHOULD NOT BE MISSED IF ONE FAMILY DOES NOT COMPLETE THE FAMILY QUESTIONNAIRE.

INQ.250 Now I am going to ask you about the total household income for the persons we have talked about plus {NAMES OF ALL OTHER PERSONS IN ADDITIONAL NHANES FAMILIES} in {LAST CALENDAR YEAR}, including income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Can you tell me that amount before taxes?

$ |___|___|___|___|___|___|___|___|___| (INQ.NEW1)

REFUSED 7777777777 (INQ.260)

DON'T KNOW 9999999999 (INQ.260)

CAPI INSTRUCTION:

 REQUIRE DOUBLE ENTRY OF INCOME.

 SCREEN SHOULD READ:

DOUBLE ENTRY OF INCOME REQUIRED.

 IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.

INQ.260 You may not be able to give us an exact figure for your total household income, but can you tell me if this income in {LAST CALENDAR YEAR} was . . .

PROBE: Income is important in analyzing the health information we collect. For example, this information helps us to learn whether persons in one income group use certain types of medical services or have certain conditions more or less often than those in another group.

$20,000 or more, or 1

less than $20,000? 2

REFUSED 7 (INQ.NEW1)

DON'T KNOW 9 (INQ.NEW1)

HELP SCREEN:

INQ.270

Of these income groups, can you tell me which letter best represents your total household income in {LAST CALENDAR YEAR}?

HAND CARD {INQ1 AND INQ2}

ENTER LETTER(S) CORRESPONDING TO TOTAL COMBINED HOUSEHOLD INCOME.

|___|___|

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF $20,000 OR MORE, DISPLAY HAND CARD INQ1.

IF LESS THAN $20,000, DISPLAY HAND CARD INQ2.

HELP SCREEN:

INQ.New1 Now I will ask you a question about how your household usually travels to the store for your grocery shopping.

Please look at this card. How do {you/you or anyone who lives in the household} usually get to the store (or stores) where you do most of your grocery shopping?

HAND CARD INQ5

INTERVIEWER INSTRUCTION:

If the respondent cannot decide on one single answer, probe for the “usual/most common” way.
The option “NO USUAL MODE OF TRAVELING TO STORE” was only used when the respondent cannot report a single usual mode for the question. It is not listed in the hand card and not intended to be offered to the respondent voluntarily.
If the respondent reported using different modes for getting to and returning from store, enter the mode of “getting to” the store.

In my car 1

In a car that belongs to someone I live with 2

In a car that belongs to someone who lives elsewhere 3

WALK 4

RIDE BICYCLE 5

BUS, SUBWAY OR OTHER PUBLIC TRANSIT 6

TAXI OR OTHER PAID DRIVER 7

SOMEONE ELSE DELIVERS GROCERIES 8

OTHER 9

NO USUAL MODE OF TRAVELING TO STORE 66

REFUSED 77

DON’T KNOW 99

HELP SCREEN FOR INQ.012:

Self-Employed: Persons working for profit or fees in their own business, shop, office, farm, etc. Include persons who have their own tools or equipment and provide services on a contract, subcontract, or job basis such as carpenters, plumbers, independent taxicab operators or independent truckers.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

HELP SCREEN FOR INQ.080:

Retirement or Survivors Pension: Employment benefit that provides income payments to employees upon their retirement. Pension plans provide benefits to employees who have met specified criteria, normally age and/or length of service requirements. The two main types of pension plans are:

Defined benefit plans - an employer's cost is not predetermined, but the benefit is; and

Defined contribution - the employer's cost is predetermined, but the benefit depends on how much the employee contributes, investment gains and losses, etc.

Include in this item income from 401 K, IRA's, annuities, paid-up life insurance policies and KEOGH accounts.

Railroad Retirement: U.S. Government Railroad Retirement Benefits are based on a person’s long-term employment in the railroad industry.

HELP SCREEN FOR INQ.132:

Government Payments (Welfare, Public Assistance, AFDC, Some Other Program): Aid to Families with Dependent Children (AFDC) or Aid for Dependent Children (ADC) are the old welfare program names. AFDC and ADC have been replaced by Temporary Assistance to Needy Families (TANF; pronounced "tan'iff"). TANF is administered by state and local governments. Each TANF program has a unique name depending on the state or local area.

Eligibility for TANF programs varies from state to state, but usually depends on having low-income. Services provided through TANF programs also vary from state to state. Where AFDC primarily provided cash benefits, TANF provides a wide range of services such as job training, child care, and subsidies to employers.

AFDC (Aid to Families with Dependent Children): Was a government program that provided cash benefits to needy children (and certain others in their households) who had been deprived of parental support or care because their father or mother was absent from the home continuously, incapacitated, deceased, or unemployed. AFDC has been replaced by TANF (Temporary Assistance to Needy Families).

HELP SCREEN FOR INQ.150:

Child Support: Money received from parents for the support of their children. In some cases, child support payments may be delivered to recipients by a government office, court office, or welfare agency.

Workers' Compensation: A system, required by law, of compensating workers injured or disabled in connection with work. This system establishes the liability of an employer for injuries or sickness that arise in the course of employment. The liability is created without regard to the fault or negligence of the employer. The benefits under this system generally include hospital and other medical payments and compensation for loss of income.

Unemployment Compensation: Payment by the state government of a fixed amount of money to an unemployed person, usually at regular intervals over a fixed period of time.

HELP SCREEN FOR INQ.200/250:

Wages and Salaries: Include tips, bonuses, overtime, commissions, Armed Forces pay, special cash bonuses and subsistence allowances.

Retirement Benefits: Employment benefit that provides income payments to employees upon their retirement. Pension plans provide benefits to employees who have met specified criteria, normally age and/or length of service requirements. The two main types of pension plans are:

Defined benefit plans - an employer's cost is not predetermined, but the benefit is; and

Defined contribution - the employer's cost is predetermined, but the benefit depends on how much the employee contributes, investment gains and losses, etc.

Include in this item income from 401 K, IRA's, annuities, paid-up life insurance policies and KEOGH accounts.

INQ1

U. $20,000 - $20,999

V. $21,000 - $21,999

W. $22,000 - $22,999

X. $23,000 - $23,999

Y. $24,000 - $24,999

Z. $25,000 - $25,999

AA. $26,000 - $26,999

BB. $27,000 - $27,999

CC. $28,000 - $28,999

DD. $29,000 - $29,999

EE. $30,000 - $30,999

FF. $31,000 - $31,999

GG. $32,000 - $32,999

HH. $33,000 - $33,999

II. $34,000 - $34,999

JJ. $35,000 - $39,999

KK. $40,000 - $44,999

LL. $45,000 - $49,999

MM. $50,000 - $54,999

NN. $55,000 - $59,999

OO. $60,000 - $64,999

PP. $65,000 - $69,999

QQ. $70,000 - $74,999

RR. $75,000 - $79,999

SS. $80,000 - $84,999

TT. $85,000 - $89,999

UU. $90,000 - $94,999

VV. $95,000 - $99,999

WW. $100,000 and over

INQ2

A. Less than $1,000

B. $1,000 - $1,999

C. $2,000 - $2,999

D. $3,000 - $3,999

E. $4,000 - $4,999

F. $5,000 - $5,999

G. $6,000 - $6,999

H. $7,000 - $7,999

I. $8,000 - $8,999

J. $9,000 - $9,999

K. $10,000 - $10,999

L. $11,000 - $11,999

M. $12,000 - $12,999

N. $13,000 - $13,999

O. $14,000 - $14,999

P. $15,000 - $15,999

Q. $16,000 - $16,999

R. $17,000 - $17,999

S. $18,000 - $18,999

T. $19,000 - $19,999

INQ3

Cash

Checking account

Saving accounts

Stocks

Bonds

Mutual funds

Retirement funds

(such as pensions, IRAs, 401ks, etc.)

Certificates of deposit

INQ4

A: $0 - $3,000

B: $3,001 - $5,000

C: $5,001 - $10,000

D: $10,001 - $15,000

E: $15,001 - $20,000

FOOD SECURITY (FSQ)

FOOD SECURITY – FSQ

Target Group: Household

CAPI DISPLAY INSTRUCTIONS FOR ALL QUESTIONS IN SECTION:

1. IF ONLY ONE PERSON IN HOUSEHOLD

- FOR {YOU/YOUR HOUSEHOLD}, DISPLAY “YOU”

- FOR {I/WE}, {MY/OUR}, DISPLAY “I” AND “MY”

- FOR {YOU/YOU OR OTHER ADULTS IN YOUR HOUSEHOLD}, DISPLAY “YOU”.

2. IF MORE THAN ONE PERSON IN HOUSEHOLD

- FOR {YOU/YOUR HOUSEHOLD}, DISPLAY “YOUR HOUSEHOLD”

- FOR {I/WE}, {MY/OUR}, DISPLAY “WE” AND “OUR”

- FOR {YOU/YOU OR OTHER ADULTS IN YOUR HOUSEHOLD}, DISPLAY “YOU OR OTHER ADULTS IN YOUR HOUSEHOLD”.

FSQ.032 I am going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for {you/your household} in the last 12 months, that is since {DISPLAY CURRENT MONTH AND LAST YEAR}.

CAPI INSTRUCTION:

IF ITEM CHANGED, CHECK MEC COMPONENT.

RESPONSES TO FSQ032A, B, AND C: OFTEN TRUE = 1, SOMETIMES TRUE = 2, NEVER TRUE = 3, REFUSED = 7, DON’T KNOW = 9

a. {I/We} worried whether {my/our} food would run out before {I/we} got money

to buy more. ____

b. The food that {I/we} bought just didn’t last, and {I/we} didn’t have enough

money to get more food. ____

c. {I/We} couldn’t afford to eat balanced meals. ____

HELP SCREEN:

Balanced Meal: A balanced meal includes all the types of food that you think should be in a healthy meal. For example, a starch like potatoes or rice, vegetables or fruit and some protein like meat, fish, cheese or eggs.

BOX 1

IF RESPONSE TO FSQ032 a, b, OR c, IS CODE 1 OR 2 (OFTEN TRUE OR SOMETIMES TRUE), CONTINUE.

OTHERWISE, GO TO BOX 3.

FSQ.041 In the last 12 months, since last { DISPLAY CURRENT MONTH AND LAST YEAR }, did {you/you or other adults in your household} ever cut the size of your meals or skip meals because there wasn’t enough money for food?

YES 1

NO 2 (FSQ.061)

REFUSED 7 (FSQ.061)

DON’T KNOW 9 (FSQ.061)

HELP SCREEN:

FSQ.052 How often did this happen?

Almost every month, 1

some months but not every month, or 2

in only 1 or 2 months? 3

REFUSED 7

DON’T KNOW 9

FSQ.061 In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FSQ.071 [In the last 12 months], were you ever hungry but didn’t eat because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FSQ.081 [In the last 12 months], did you lose weight because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 2

CHECK ITEM FSQ.083:

IF RESPONSE TO FSQ.041, 061, 071, OR 081 IS CODE 1 (YES), CONTINUE.

OTHERWISE GO TO BOX 3.

FSQ.092 [In the last 12 months], did {you/you or other adults in your household} ever not eat for a whole day because there wasn’t enough money for food?

YES 1

NO 2 (BOX 3)

REFUSED 7 (BOX 3)

DON’T KNOW 9 (BOX 3)

HELP SCREEN:

FSQ.102 How often did this happen?

Almost every month, 1

some months but not every month, or 2

in only 1 or 2 months? 3

REFUSED 7

DON’T KNOW 9

BOX 3

CHECK ITEM FSQ.085A:

IF THERE IS AT LEAST 1 CHILD IN THE HOUSEHOLD WHO IS <= 17 (OR IN THE AGE RANGE THAT INCLUDES OR IS LESS THAN THE ONE THAT INCLUDES 17), CONTINUE.

OTHERWISE, GO TO FSQ.151.

CAPI DISPLAY INSTRUCTIONS FOR ALL QUESTIONS:

IF ONLY ONE CHILD IN THE HOUSEHOLD AGED <=17, DISPLAY CHILD’S NAME.

IF MORE THAN ONE CHILD IN HOUSEHOLD AGED <=17, DISPLAY “THE CHILDREN IN YOUR HOUSEHOLD WHO ARE UNDER 18 YEARS OLD”, “THE CHILDREN”, OR “ANY OF THE CHILDREN”.

FSQ032 The next questions are about children living in the household who are under 18 years old.

I am going to read you several statements that people have made about their children’s food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for {CHILD’s NAME/your child/the children in your household who are under 18 years old} in the last 12 months, that is since {DISPLAY CURRENT MONTH AND LAST YEAR}.

RESPONSES TO FSQ032D, E, AND F: OFTEN TRUE = 1, SOMETIMES TRUE = 2, NEVER TRUE = 3, REFUSED = 7, DON’T KNOW = 9

CAPI INSTRUCTION:

IF ITEM CHANGED, CHECK MEC COMPONENT.

d. (I/We) relied on only a few kinds of low-cost foods to feed {CHILD’s

NAME/the children} because there wasn’t enough money for food. ____

e. (I/We) couldn’t feed {(CHILD’s NAME/the children} a balanced meal,

because there wasn’t enough money for food. ____

f. {CHILD’s NAME was/The children were} not eating enough because

there wasn’t enough money for food. ____

HELP SCREEN:

NEW BOX 4

CHECK ITEM FSQ.108:

IF RESPONSE TO FSQ.032d, e, or f, IS CODE 1 OR 2 (OFTEN TRUE OR SOMETIMES TRUE), CONTINUE.

OTHERWISE, GO TO FSQ.151.

FSQ.111 In the last 12 months, since {DISPLAY CURRENT MONTH AND LAST YEAR} did you ever cut the size of {CHILD’S NAME/any of the children’s} meals because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FSQ.121 [In the last 12 months], did {CHILD’S NAME/any of the children} ever skip meals because there wasn’t enough money for food?

YES 1

NO 2 (FSQ.141)

REFUSED 7 (FSQ.141)

DON’T KNOW 9 (FSQ.141)

FSQ.132 How often did this happen?

Almost every month, 1

some months but not every month, or 2

in only 1 or 2 months? 3

REFUSED 7

DON’T KNOW 9

FSQ.141 In the last 12 months, {was CHILD’S NAME/were any of the children} ever hungry, but there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FSQ.146 [In the last 12 months], did {CHILD’S NAME/any of the children} ever not eat for a whole day because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FSQ.151 [In the last 12 months], did {you/you or any member of your household} ever get emergency food from a church, a food pantry, or a food bank, or eat in a soup kitchen?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

Community Kitchen: A place you went to eat because you didn’t have money for food. Do not include a place you went to for social reasons, such as, a senior center or a place you went to for shelter because of something like a hurricane or flood.

BOX 5

CHECK ITEM FSQ.155B:

IF THE HOUSEHOLD INCLUDES:

**A CHILD AGED 5 YEARS OR UNDER, OR IN AN AGE RANGE THAT INCLUDES AGE 5 AND UNDER

** A FEMALE BETWEEN AGES 12 AND 59, OR IN AN AGE RANGE THAT INCLUDES ANY AGES BETWEEN 12 AND 59) CONTINUE

OTHERWISE, GO TO FSQ.755.

FSQ.760 Next are a few questions about the WIC program, that is, the Women, Infants and Children program

Did {you/you or anyone who lives here} receive WIC benefits in the past 30 days? {Here is the list of children 5 years and younger and women ages 12 to 59 years who live here, let me read it to you.}

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL CHILDREN AGES 5 AND UNDER, AND WOMEN AGES 12 TO 59 IN THE HOUSEHOLD, AND HOUSEHOLD MEMBERS WITH UNKNOWN AGE OR GENDER.

CAPI INSTRUCTION:

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “Here is the list of children 5 years and younger and women ages 12 to 59 years who live here, let me read it to you.”

HELP SCREEN:

YES 1

NO 2 (FSQ.162)

REFUSED 7 (FSQ.162)

DON’T KNOW 9 (FSQ.162)

BOX 5AA

CHECK ITEM FSQ.765:

IF FSQ.760 = 1 AND ONLY ONE PERSON IN HOUSEHOLD, FLAG PERSON AS RECEIVING WIC IN FSQ.770, GO TO BOX 5BB.

OTHERWISE CONTINUE.

FSQ.770 Who in the household has received WIC benefits in the past 30 days?

PROBE: Anyone else?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL CHILDREN AGES 5 AND UNDER, AND WOMEN AGES 12 TO 59 IN THE HOUSEHOLD.

INTERVIEWER INSTRUCTION: SELECT NAME(S) FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

HARD EDIT:

IF NO ONE IN THE ROSTER WAS SELECTED, DISPLAY THE FOLLOWING MESSAGE TO VERIFY THE ANSWER TO FSQ.770:

“You said that someone who lives here has received WIC in the last 30 days, is that correct?”

IF YES, GO BACK TO FSQ.770 AND ASK: “Who was that?” WITH ROSTER DISPLAYED.

IF NO, GO BACK TO CODE FSQ.760 AS ‘NO’.

BOX 5BB

CHECK ITEM FSQ.775:

GO TO FSQ.755.

FSQ.162 In the last 12 months, did {you/you or any member of your household} receive benefits from the WIC program?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 5A

OMITTED

BOX 5B

OMITTED

NEW BOX 6

OMITTED

BOX 3

OMITTED

FSQ.755 The next questions are about SNAP, the Supplemental Nutrition Assistance Program, also known as the Food Stamp Program. SNAP benefits are provided on a food stamp benefit card {called the {DISPLAY STATE NAME FOR EBT CARD} card in STATE}/or EBT card}.

Do {you/you or anyone in your household} currently get SNAP or Food Stamps? This includes any SNAP benefits or Food Stamps, even if the amount is small and even if the benefits are received on behalf of children in the household.

CAPI INSTRUCTIONS:

INSERT “OR EBT CARD” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD AND STATE NAME IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

YES 1

NO 2 (FSQ.855)

REFUSED 7 (FSQ.855)

DON’T KNOW 9 (FSQ.855)

BOX 6

CHECK ITEM FSQ.785:

IF FSQ.755 = 1 AND ONLY ONE PERSON IN HOUSEHOLD, FLAG PERSON AS RECEIVING SNAP IN FSQ.790, GO TO FSQ.795.

OTHERWISE CONTINUE.

FSQ.790 Who in the household is currently on the {DISPLAY STATE NAME FOR EBT CARD} card}/or EBT card} to get Food Stamps? Here is the list of people who live here, let me read it to you.

PROBE: Is anyone else on the card?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL HOUSEHOLD MEMBERS.

INTERVIEWER INSTRUCTION:

READ NAMES OF ALL HOUSEHOLD MEMBERS TO THE RESPONDENT

SELECT NAME(S) FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

CAPI INSTRUCTIONS:

INSERT “EBT CARD” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

HARD EDIT:

IF NO ONE IN THE ROSTER WAS SELECTED, DISPLAY THE FOLLOWING MESSAGE TO VERIFY THE ANSWER TO FSQ.790:

“You said someone who lives here is currently getting Food Stamps. Is that correct?”

IF YES, GO BACK TO FSQ.790 AND ASK: “Who was that?” WITH ROSTER DISPLAYED.

IF NO, GO BACK TO CODE FSQ.755 AS ‘NO’.

FSQ.795 During the past 12 months, for how many months did {you/you and NAMES/NAME(S)} get Food Stamps?

CAPI INSTRUCTION:

FOR EVERY HH MEMBER WITH “SELECT (CODE “1”)” IN FSQ.790, ENABLE A FIELD FOR INTERVIEWER TO ENTER THE NUMBER OF MONTHS

INTERVIEWER INSTRUCTION:

ASK FOR EVERY HH MEMBER WITH “SELECT (CODE “1”)” IN FSQ.790.

ENTER ‘1’ FOR LESS THAN ONE MONTH PARTICIPATION

|___|___|

ENTER NUMBER OF MONTHS

REFUSED 77

DON'T KNOW 99

HARD EDIT:

THE RESPONSE NEEDS TO BE BETWEEN 1-12.

BOX 7

CHECK ITEM FSQ.800:

IF ONLY ONE PERSON WITH “SELECTED” IN FSQ.790, GO TO FSQ.810.

OTHERWISE CONTINUE.

FSQ.805 Are {you and NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.790/ NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.790} getting Food Stamps on the same {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

YES 1

NO 2 (FSQ.825)

REFUSED 7

DON’T KNOW 9

FSQ.810

FSQ.811

FSQ.812

On what date were food stamps last put on {your/their/her/his} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE WITHIN PAST 31 DAYS OF CURRENT DATE. IF THE “DAY” FIELD IS DK/RF, THEN THE MONTH/YEAR ENTERED MUST BE WITHIN PAST 1 MONTH OF CURRENT MONTH. INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.815 In {MONTH FROM FSQ.810 /that last time}, what amount in food stamps was put on {your/their/her/his} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “MONTH FROM FSQ.810” IF MONTH FILED FSQ.810 IS NOT MISSING, RF OR DK.

INSERT “THAT LAST TIME” IF MONTH FILED FSQ.810 IS MISSING, RF OR DK.

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

BOX 8

CHECK ITEM FSQ.820:

IF ALL HH MEMBERS ARE MARKED “SELECT” ON FSQ.790, GO TO THE END OF SECTION.

OTHERWISE, CONTINUE WITH FSQ.855

FSQ.825 Among {you and NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.790/ NAME(S) OF ALL HH MEMBER WITH “SELECT” IN FSQ.790}, how many {DISPLAY STATE NAME FOR EBT CARD} /EBT} cards are there?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: RESPONSE CANNOT BE ZERO, AND CANNOT BE MORE THAN THE NUMBER OF PEOPLE “SELECTED (CODE 1)” IN FSQ.790.

|___|___|

NUMBER OF CARDS

REFUSED 77

DON’T KNOW 99

BOX 9

CHECK ITEM FSQ.830:

IF FSQ.825 = DK OR RF, THEN ALLOCATE EACH PERSON WITH ONE CARD, THEN SKIP TO FSQ.840.

IF THE NUMBER OF CARDS EQUALS TO THE NUMBER OF PERSONS LISTED “SELECT” ON FSQ.790, ALLOCATE EACH PERSON WITH ONE CARD, THEN SKIP TO FSQ.840.

OTHERWISE CONTINUE.

FSQ.835 Can you tell me who is on card {#}?

CAPI INSTRUCTIONS:

DISPLAY A GRID SO INTERVIEWER CAN ALLOCATE EACH HH MEMBERS WITH “SELECT” IN FSQ.790 TO EACH OF THE CARDS. EACH CARD SHOULD ALLOW MULTIPLE PERSONS BE SELECTED INTO.

FOR EXAMPLE:

Name	Card 1	Card 2	Card 3
John Doe
Jane Doe
Bobby Jones

HARD EDIT: EACH HH MEMBERS WITH “SELECT” IN FSQ.790 SHOULD BELONG TO ONE CARD, AND ONE CARD ONLY. IF NO MEMBER BELONGS TO A CARD, GO BACK TO FSQ.825 AND CORRECT THE NUMBER OF CARDS.

BOX 10

LOOP 1:

ASK FSQ.840 - FSQ.845 FOR EACH CARD.

FSQ.840

FSQ.841

FSQ.842

On what date were food stamps last put on {your/NAME’S(S’) ON EACH CARD} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE WITHIN PAST 31 DAYS OF CURRENT DATE. IF THE “DAY” FIELD IS DK/RF, THEN THE MONTH/YEAR ENTERED MUST BE WITHIN PAST 1 MONTH OF CURRENT MONTH.

INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.845 In {MONTH FROM FSQ.840/that last time}, what amount in food stamps was put on {your/theirs/his/her} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “MONTH FROM FSQ.840” IF MONTH FILED FSQ.840 IS NOT MISSING, RF OR DK.

INSERT “THAT LAST TIME” IF MONTH FILED FSQ.840 IS MISSING, RF OR DK.

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

BOX 11

END LOOP 1:

ASK FSQ.840 - FSQ.845 FOR SECOND CARD.

IF INFORMATION COLLECTED FOR ALL CARDS, GO TO BOX12.

BOX 12

CHECK ITEM FSQ.850:

IF ALL HH MEMBERS ARE MARKED “SELECT” ON FSQ.790, GO TO THE END OF SECTION.

OTHERWISE, CONTINUE WITH FSQ.855.

FSQ.855 Have {you/you or NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790/ NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790} recently been notified that {you/you or she, you or he, you or they/he, she, they} will start to get Food Stamps later this month or next month?

CAPI INSTRUCTIONS:

IF FSQ.755 = NO, REFUSED, OR DON’T KNOW (NO ONE IN THE HH IDENTIFIED AS “CURRENT SNAP RECIPIENT”), THEN DISPLAY THE QUESTION AS:

“Have {you/you or anyone in your household} recently been notified that {you/you or they} will start to get Food Stamps later this month or next month? {Here is the list of people who live here, let me read it to you.}”

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS.

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “Here is the list of people who live here, let me read it to you.”

YES 1

NO 2 (FSQ.870)

REFUSED 7 (FSQ.870)

DON’T KNOW 9 (FSQ.870)

FSQ.860

FSQ.861

FSQ.862

On what date {do you/ do you, NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790/ does {/NAME(S) OF HH MEMBERS WHO ARE NOT THE RESPONDENT AND WITH “NOT SELECTED (CODE “2”)” IN FSQ.790}} think {you/you or she, you or he, you or they/he, she, they} will start getting Food Stamps?

CAPI INSTRUCTIONS:

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE AT OR AFTER CURRENT DATE. DATE MUST NOT BE MORE THAN TWO MONTHS FROM CURRENT MONTH.

INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.865 What amount in Food Stamps {do you/do you or she, do you or he, do you or they/does he, does she/do they} expect to get at that time?

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

FSQ.870 In the last 12 months, did {you/you or NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790/ NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790} get Food Stamps, even if only for one month? This includes any SNAP benefits or Food Stamps received in the past year, even if the amount was small or if they were received on behalf of children in the household.

CAPI INSTRUCTIONS:

IF FSQ.755 = NO, REFUSED, OR DON’T KNOW (NO ONE IN THE HH IDENTIFIED AS “CURRENT SNAP RECIPIENT”), THEN DISPLAY THE QUESTION AS:

“In the last 12 months, did {you/ you or anyone in your household} get Food Stamps, even if only for one month?” {(Here is the list of people who live here, let me read it to you.)}

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS.

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “(Here is the list of people who live here, let me read it to you.)”

YES 1

NO 2 (FSQ.945)

REFUSED 7 (FSQ.945)

DON’T KNOW 9 (FSQ.945)

BOX 13

CHECK ITEM FSQ.875:

IF FSQ.870 = 1 AND ONLY ONE PERSON IN HOUSEHOLD OR ONE PERSON THAT’S “NOT SELECTED (CODE 2)” IN FSQ.790, FLAG PERSON AS RECEIVING SNAP IN FSQ.880, GO TO FSQ.885.

OTHERWISE CONTINUE.

FSQ.880 Among {you and NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790/NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790}, who was on the {DISPLAY STATE NAME FOR EBT CARD}/or EBT} card to get Food Stamps in the past 12 months?

PROBE: Was anyone else on the card?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL HOUSEHOLD MEMBERS WITH “NOT SELECTED (CODE “2”)” IN FSQ.790.

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

INTERVIEWER INSTRUCTION:

READ NAMES OF ALL HOUSEHOLD MEMBERS WITH “NOT SELCTED (CODE “2”)” IN FSQ.790 TO THE RESPONDENT

SELECT NAME(S) FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF FSQ.755 = NO, REFUSED, OR DON’T KNOW (NO ONE IN THE HH IDENTIFIED AS “CURRENT SNAP RECIPIENT”), THEN DISPLAY THE QUESTION AS:

“Who in the household was on the {DISPLAY STATE NAME FOR EBT CARD} card}/or EBT card} to get Food Stamps in the past 12 months? (Here is the list of people who live here, let me read it to you.”)

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS.

HARD EDIT:

IF NO ONE IN THE ROSTER WAS SELECTED, DISPLAY THE FOLLOWING MESSAGE TO VERIFY THE ANSWER TO FSQ.880:

“You said someone who lives here got Food Stamps in the past 12 months. Is that correct?”

IF YES, GO BACK TO FSQ.880 AND ASK: “Who was that?” WITH ROSTER DISPLAYED.

IF NO, GO BACK TO CODE FSQ.870 AS ‘NO’.

FSQ.885 During the past 12 months, for how many months did {you/{NAME(S)} get Food Stamps?

CAPI INSTRUCTION:

FOR EVERY HH MEMBER WITH “SELECT (CODE “1”)” IN FSQ.880, ENABLE A FIELD FOR INTERVIEWER TO ENTER THE NUMBER OF MONTHS

INTERVIEWER INSTRUCTION:

ASK FOR EVERY HH MEMBER WITH “SELECT (CODE “1”)” IN FSQ.880.

ENTER ‘1’ FOR LESS THAN ONE MONTH PARTICIPATION

|___|___|

ENTER NUMBER OF MONTHS

REFUSED 77

DON'T KNOW 99

HARD EDIT:

THE RESPONSE NEEDS TO BE BETWEEN 1-12.

BOX 14

CHECK ITEM FSQ.890:

IF ONLY ONE PERSON WITH “SELECTED” IN FSQ.880, GO TO FSQ.900.

OTHERWISE CONTINUE.

FSQ.895 Did {you and NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.880/ NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.880} get Food Stamps on the same {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

YES 1

NO 2 (FSQ.915)

REFUSED 7

DON’T KNOW 9

FSQ.900

FSQ.901

FSQ.902

On what date were food stamps last put on {your/their/her/his} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE WITHIN PAST 12 MONTHS OF CURRENT MONTH.

INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.905 In {MONTH FROM FSQ.900 /that last time}, what amount in food stamps was put on {your/their/his/her} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “MONTH FROM FSQ.900” IF MONTH FILED FSQ.900 IS NOT MISSING, RF OR DK.

INSERT “THAT LAST TIME” IF MONTH FILED FSQ.900 IS MISSING, RF OR DK.

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

BOX 15

CHECK ITEM FSQ.910:

IF ALL HH MEMBERS ARE MARKED “SELECTED” ON FSQ.790 OR FSQ.880, GO TO THE END OF SECTION.

OTHERWISE, CONTINUE WITH FSQ.945.

FSQ.915 Among {you and NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.880/ NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.880}, how many {DISPLAY STATE NAME FOR EBT CARD} /EBT} cards are there?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: RESPONSE CANNOT BE ZERO, AND CANNOT BE MORE THAN THE NUMBER OF PEOPLE “SELECTED (CODE 1)” IN FSQ.880.

|___|___|

NUMBER OF CARDS

REFUSED 77

DON’T KNOW 99

BOX 16

CHECK ITEM FSQ.920:

IF FSQ.915 = DK OR RF, THEN ALLOCATE EACH PERSON WITH ONE CARD, THEN SKIP TO FSQ.930.

IF THE NUMBER OF CARDS EQUALS TO THE NUMBER OF PERSONS LISTED “SELECT” ON FSQ.880, ALLOCATE EACH PERSON WITH ONE CARD, THEN SKIP TO FSQ.930.

OTHERWISE CONTINUE.

FSQ.925 Can you tell me who is on card {#}?

CAPI INSTRUCTIONS:

DISPLAY A GRID SO INTERVIEWER CAN ALLOCATE EACH HH MEMBERS WITH “SELECTED” IN FSQ.880 TO EACH OF THE CARDS. EACH CARD SHOULD ALLOW MULTIPLE PERSONS BE SELECTED INTO.

FOR EXAMPLE:

Name	Card 1	Card 2	Card 3
John Doe
Jane Doe
Bobby Jones

HARD EDIT: EACH HH MEMBERS WITH “SELECT” IN FSQ.880 SHOULD BELONG TO ONE CARD, AND ONE CARD ONLY. IF NO MEMBER BELONGS TO A CARD, GO BACK TO FSQ.915 AND CORRECT THE NUMBER OF CARDS.

BOX 17

LOOP 2:

ASK FSQ.930 - FSQ.935 FOR EACH CARD.

FSQ.930

FSQ.931

FSQ.932

On what date were food stamps last put on {your/NAME’S(S’) ON EACH CARD} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE WITHIN PAST 12 MONTHS OF CURRENT MONTH.

INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.935 In {MONTH FROM FSQ.930/that last time}, what amount in food stamps was put on {your/their/his/her} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “MONTH FROM FSQ.930” IF MONTH FILED FSQ.930 IS NOT MISSING, RF OR DK.

INSERT “THAT LAST TIME” IF MONTH FILED FSQ.930 IS MISSING, RF OR DK.

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

BOX 18

END LOOP 2:

ASK FSQ.930 - FSQ.935 FOR SECOND CARD.

IF INFORMATION COLLECTED FOR ALL CARDS, GO TO BOX19.

BOX 19

CHECK ITEM FSQ.940:

IF ALL HH MEMBERS ARE MARKED “SELECTED” ON FSQ.790 OR FSQ.880, GO TO THE END OF SECTION.

OTHERWISE, CONTINUE WITH FSQ.945.

FSQ.945 Have/Has {you/you or NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880/NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880} ever gotten Food Stamps?

CAPI INSTRUCTIONS:

IF BOTH FSQ.755 AND FSQ.870 = NO, REFUSED, OR DON’T KNOW (CODE “2, 7, OR 9”), THEN DISPLAY THE QUESTION AS:

“Have {you/ you or anyone in your household} ever gotten Food Stamps? {Here is the list of people who live here, let me read it to you.}”

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS.

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “Here is the list of people who live here, let me read it to you.”

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

BOX 20

CHECK ITEM FSQ.950:

IF FSQ.945=1 AND ONLY ONE PERSON IN HOUSEHOLD OR ONE PERSON THAT’S “NOT SELECTED (CODE 2)” IN FSQ.790 AND FSQ.880, FLAG PERSON AS RECEIVING SNAP IN FSQ.955, GO TO END OF SECTION.

OTHERWISE CONTINUE.

FSQ.955 Among {you and NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880/NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880}, who has ever gotten Food Stamps?

PROBE: Anyone else?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL HOUSEHOLD MEMBERS WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880.

INTERVIEWER INSTRUCTION:

READ NAMES OF ALL HOUSEHOLD MEMBERS WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880 TO THE RESPONDENT

SELECT NAME(S) FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF BOTH FSQ.755 AND FSQ.870 = NO, REFUSED, OR DON’T KNOW (CODE “2, 7, OR 9”), THEN DISPLAY THE QUESTION AS:

“Who in the household has ever gotten Food Stamps? (Here is the list of people who live here, let me read it to you.)”

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS.

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY (Here is the list of people who live here, let me read it to you.)

HARD EDIT:

IF NO ONE IN THE ROSTER WAS SELECTED, DISPLAY THE FOLLOWING MESSAGE TO VERIFY THE ANSWER TO FSQ.955:

“You said someone who lives here has been on Food Stamps. Is that correct?”

IF YES, GO BACK TO FSQ.955 AND ASK: “Who was that?” WITH ROSTER DISPLAYED.

IF NO, GO BACK TO CODE FSQ.945 AS ‘NO’.

TRACKING AND TRACING (TTQ)

TRACKING AND TRACING – TTQ

Target Group: Family

BOX 1

LOOP 1:

ASK TTQ.010 - TTQ.040 FOR 2 CONTACT PERSONS.

TTQ.005 The Centers for Disease Control and Prevention may wish to contact you again to obtain additional health related information. Please give me the names, addresses, and telephone numbers of 2 relatives or friends who would know where you could be reached in case we have trouble reaching you. (Please give me the names of persons not currently living in the household.)

PRESS F6 IF RESPONDENT REFUSES {ALL/SECOND} CONTACT INFORMATION

PRESS F5 IF RESPONDENT DOESN'T KNOW {ANY/SECOND} CONTACT INFORMATION

PRESS ENTER TO ADD {FIRST/SECOND} CONTACT INFORMATION

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

HELP SCREEN:

Relative: All common relationships that occur through blood (grandfather, daughter), marriage (wife, stepson), or adoption (adopted son or daughter). Include foster relationships and guardian/ward relationships. Also refers to extended relationships by legal marriage. For example, a man and woman are married. The woman's cousin's husband would also be counted as a "relative" of the man.

TTQ.010 REFERRING TO PERSON {1/2}

VERIFY SPELLING.

ENTER FIRST NAME

REFUSED 7

DON'T KNOW 9

PROBE FOR MIDDLE NAME IF NOT REPORTED

ENTER "NMN" FOR NO MIDDLE NAME

ENTER MIDDLE NAME

REFUSED 7

DON'T KNOW 9

ENTER LAST NAME

REFUSED 7

DON'T KNOW 9

TTQ.020 REFERRING TO PERSON {1/2}

What is this person's address? [If there is more than one address, please give us the address used most often.]

ENCOURAGE RESPONDENT TO USE PHONE BOOK OR OTHER DOCUMENTATION IF AVAILABLE.

______________________ ___________________________ _____________________

ENTER STREET NUMBER ENTER STREET NAME ENTER APARTMENT NUMBER

REFUSED 7 REFUSED 7 REFUSED 7

DON'T KNOW 9 DON'T KNOW 9 DON'T KNOW 9

_____________________ |____|____| |___|____|____|____|____|

ENTER TOWN OR ENTER 2 LETTER ENTER POSTAL CODE

CITY NAME STATE ABBREVIATION TO OR ZIPCODE

TO START THE LOOKUP.

SELECT STATE FROM CAPI STATE LIST.

PRESS ENTER TO ACCEPT SELECTION.

REFUSED 7 REFUSED 77 REFUSED 77777

DON'T KNOW 9 DON'T KNOW 99 DON'T KNOW 99999

CAPI INSTRUCTION:

TTQ.030 REFERRING TO PERSON {1/2}

What is this person's telephone number, beginning with the area code?

REPEAT AREA CODE

REPEAT PHONE NUMBER

REPEAT EXTENSION

|___|___|___| |___|___|___| - |___|___|___|___| |___|___|____|____|

ENTER AREA CODE ENTER TELEPHONE NUMBER ENTER EXTENSION

NO PHONE 666 (TTQ.040) REFUSED 7777777 REFUSED 7777

REFUSED 777 (TTQ.040) DON'T KNOW 9999999 DON'T KNOW 9999

DON'T KNOW 999 (TTQ.040)

TTQ.040 REFERRING TO PERSON {1/2}

What is the relationship of this contact person to you?

SPOUSE/EX-SPOUSE NOT LIVING IN HH 1

UNMARRIED PARTNER NOT LIVING IN HH 2

CHILD 3

GRANDCHILD 4

PARENT (MOTHER OR FATHER) 5

BROTHER OR SISTER 6

GRANDPARENT 7

OTHER RELATIVE 8

LEGAL GUARDIAN 9

FRIEND 10

CO-WORKER 11

NEIGHBOR 12

OTHER 13

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

Spouse (Husband/Wife): Persons who are legally married or have a common-law marriage.

Unmarried Partner: Persons who share living quarters because they have a close, personal relationship, but are not legally married (i.e., unmarried couples living together as if they were married).

Child: Male or female child through birth or adoption, regardless of age. Also include stepchildren, foster children and sons/daughters-in-law. Do not include an unmarried partner's children. A stepchild is one's spouse's male or female child by a previous relationship. A foster child is not one's biological child, but lives with one's family as one's son or daughter. A son/daughter-in-law is the spouse of one's child.

Grandchild: A child of one’s daughter or son.

Parent: Include a person’s biological, adoptive, step or foster mother or father, as well as his/her mother or father-in-law.

Mother: One's female parent, including biological, adoptive, step and foster mothers and mothers-in-law. A stepmother is the spouse of one's biological or adoptive father. A foster mother is the mother in one's foster family.

Father: One's male parent, including biological, adoptive, step, and foster fathers and fathers-in-law. A stepfather is the spouse of one's biological or adoptive mother. A foster father is the father in one's foster family.

Brother: Includes biological, adoptive, step, foster and half brothers, and brothers-in-law. A brother is one's male sibling who shares both of the same biological or adoptive parents. A stepbrother is one's stepparent's son by a previous relationship. A half brother is one's male sibling who shares one of the same biological or adoptive parents. A brother-in-law is one's sister's husband. A foster brother is the foster son of one or both of one's parents or the son of one's foster parent(s).

Sister: A sister includes biological, adoptive, step, foster, half sisters and sisters-in-law. A sister is one's female sibling who shares both of the same biological or adoptive parents. A stepsister is one's stepparent's daughter by a previous relationship. A half sister is one's female sibling who shares one of the same biological or adoptive parents. A sister-in-law is one's brother's wife. A foster sister is the foster daughter of one or both of one's parents or the daughter of one's foster parent(s).

Grandfather: The male parent of one's mother or father.

Grandmother: The female parent of one's mother or father.

Legal Guardian: A person appointed to take charge of the affairs of a minor, or of a person not capable of managing his/her own affairs.

BOX 2

END LOOP 1:

ASK TTQ.010 - TTQ.040 FOR SECOND CONTACT PERSON.

IF SECOND CONTACT PERSON INFORMATION COLLECTED, GO TO TTQ.050.

TTQ.050 This is the end of the Family Interview. Thank you very much for your cooperation.

PRESS F10 TO SAVE AND EXIT FORM

MEC QUESTIONNAIRE – CAPI
1. RESPONDENT SELECTION SECTION (RIQ)

RESPONDENT SELECTION SECTION - RIQ - mec

Target Group: SPs 8+

RIQ.005 INTERVIEWER: MARK MAIN RESPONDENT. SPECIFY RELATIONSHIP OF RESPONDENT TO SP IF OTHER THAN SP.

SP 1 (BOX 1)

MOTHER 2

FATHER 3

SPOUSE 4

SISTER OR BROTHER 5

CHILD 6

GRANDPARENT 7

LEGAL GUARDIAN 8

OTHER (SPECIFY) 9

RIQ.030 WHY IS INTERVIEW BEING CONDUCTED WITH A PROXY?

SP HAS COGNITIVE PROBLEMS 1

SP HAS PHYSICAL PROBLEMS

(SPECIFY) 2

OTHER (SPECIFY) 3

RIQ.038 INTERVIEWER: WAS SP PRESENT IN THE ROOM DURING ANY PART OF THE INTERVIEW?

YES 1

NO 2

BOX 1

CHECK ITEM RIQ.149:

IF SP 8-11 YEARS AND INTERVIEW DONE WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), DISPLAY THE FOLLOWING INTRODUCTORY TEXT: “During this interview, I will be asking you questions about your health and weight. Your answers will be kept private. Do you have any questions before we begin?”
IF SP 12 YEARS OR OLDER AND INTERVIEW DONE WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), DISPLAY THE FOLLOWING INTRODUCTORY TEXT: “During this interview, I will be asking you questions about your home, current health status, and on other health behaviors. Remember, all of your responses to these questions will be kept strictly confidential. Do you have any questions before we begin?”
OTHERWISE, DISPLAY THE FOLLOWING INTRODUCTORY TEXT: “During this interview, I will be asking you questions about {SP}'s current health status and on other health behaviors.”

Volatile Toxicant (VTQ)

Shape18

NHANES 2013

Volatile Toxicant – VTQ

Target Group: SPs 12-150 Sub-Sampled into VOC

The VOC section is applicable for only those SPs that are subsampled into VOC. To determine if a particular SP is subsampled into VOC, check the mec_sp_subsample. If the SP in question has a record for subsample 1, they are subsampled for VOC and so should get the VOC section.

VTQ.210_ First, I would like to ask you a few questions about {your/SP's} home.

VTQ.210 Does {your/her/his} home have an attached garage?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.220 Is the source of water for {your/her/his} home from a private well?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.200a {Do you/Does she/Does he} currently store paints or fuels inside {your/her/his} home? Include {your/her/his} basement {and attached garage}.

CAPI INSTRUCTION:

IF SP HAS AN ATTACHED GARAGE (CODED ‘1’ IN VTQ.210), DISPLAY {and attached garage}.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.231a {Do you/Does she/Does he} currently use moth balls, moth crystals or toilet bowl deodorizers inside {your/her/his} home?

HELP SCREEN SHOULD READ: Some toilet bowl deodorizers clip onto the toilet rim, others, such as deodorant blocks and gels, are placed inside the tank or hang inside the wall of the tank. Brand names include Bully, 2000 Flushes, Vanish, X-14, Ty-D-Bol, Toilet Duck, Clorox, Lime-A-Way, and Sno Bol.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.241_ Now I am going to ask you a few questions about {your/SP’s} activities over the last 48 hours. This means today or yesterday.

VTQ.241a In the last 48 hours, did {you/she/he} cook or bake with natural gas?

HELP SCREEN: Natural gas is often informally referred to simply as “gas.” It is the most common fuel source for modern furnaces and is generally purchased through a local utility company. Other fuel sources that are not natural gas are LPG (liquefied petroleum gas) butane, propane, oil, coal or wood.

YES 1

NO 2 (VTQ.244a)

REFUSED 7 (VTQ.244a)

DON'T KNOW 9 (VTQ.244a)

VTQ.241b How long ago, in hours, did {you/she/he} cook or bake with natural gas?

HARD EDIT: Range - 1 – 48

|___|___|

HOURS

REFUSED 777

DON'T KNOW 999

VTQ.244a In the last 48 hours, did {you/she/he} pump gas into a car or other motor vehicle {yourself/herself/ himself}?

YES 1

NO 2 (VTQ.251a)

REFUSED 7 (VTQ.251a)

DON'T KNOW 9 (VTQ.251a)

VTQ.244b How long ago, in hours, did {you/she/he} pump gas into a car or other motor vehicle {yourself/herself/ himself}?

HARD EDIT: Range - 1 – 48

|___|___|

HOURS

REFUSED 777

DON'T KNOW 999

VTQ.251a In the last 48 hours, did {you/she/he} spend any time at a swimming pool, in a hot tub, or in a steam room?

YES 1

NO 2 (VTQ.261a)

REFUSED 7 (VTQ.261a)

DON'T KNOW 9 (VTQ.261a)

VTQ.251b How long ago, in hours, has it been since {you/she/he} spent time at a swimming pool, in a hot tub, or in a steam room?

HARD EDIT: Range - 1 – 48

|___|___|

HOURS

REFUSED 777

DON'T KNOW 999

VTQ.261a In the last 48 hours, did {you/she/he} use dry cleaning solvents, visit a dry cleaning shop or wear clothes that had been dry-cleaned within the last week?

HELP SCREEN: Examples of dry cleaning solvents include Guardsman Dry Cleaning Fluid, Amaway prewash, LPS F-104 Dry Solvent, Dryel At-Home Dry Cleaning starter kit, Woolite Dry Clean at Home, and Bounce 15 minute Dry Cleaner.

YES 1

NO 2 (VTQ.265a)

REFUSED 7 (VTQ.265a)

DON'T KNOW 9 (VTQ.265a)

VTQ.261b How long ago, in hours, has it been since {you/she/he} used dry cleaning solvents, visited a dry cleaning shop or wore clothes that had been dry-cleaned within the last week?

HARD EDIT: Range - 1 – 48

|___|___|

HOURS

REFUSED 777

DON'T KNOW 999

VTQ.265a In the last three days, did {you/she/he} inhale smoke from any source10 or more minutes?

HELP SCREEN SHOULD READ: we see evidence of exposure to VOC combustion products that are not attributable to tobacco smoking. We would like to ask about all inhaled smoke (campfires, fireplaces, marijuana, tobacco, etc.).

YES 1

NO 2 (VTQ.271a)

REFUSED 7 (VTQ.271a)

DON'T KNOW 9 (VTQ.271a)

VTQ.265b When did {you/she/he} last spend 10 or more minutes inhaling smoke?

TODAY………………………………………….. 1

YESTERDAY…………………………………… 2

2 days…………………………………….. 3

REFUSED 777

DON'T KNOW 999

VTQ.271a In the last 48 hours, did {you/she/he} take a hot shower or bath for five minutes or longer?

YES 1

NO 2 (VTQ.281a)

REFUSED 7 (VTQ.281a)

DON'T KNOW 9 (VTQ.281a)

VTQ.271b How long ago, in hours, has it been since {your/SP’s} last shower or hot bath?

HARD EDIT: Range - 1 – 48

|___|___|

HOURS

REFUSED 777

DON'T KNOW 999

VTQ.281a In the last 48 hours, did {you/she/he} breathe fumes from freshly painted indoor surfaces, paints, paint thinner, or varnish?

YES 1

NO 2 (VTQ.281c)

REFUSED 7 (VTQ.281c)

DON'T KNOW 9 (VTQ.281c)

VTQ.281b How long ago, in hours, has it been since {you/she/he} breathed fumes from freshly painted indoor surfaces, paints, paint thinner, or varnish?

HARD EDIT: Range - 1 – 48

|___|___|

HOURS

REFUSED 777

DON'T KNOW 999

VTQ.281c In the last 48 hours, did {you/she/he} breathe fumes from diesel fuel or kerosene?

YES 1

NO 2 (VTQ.281e)

REFUSED 7 (VTQ.281e)

DON'T KNOW 9 (VTQ.281e)

VTQ.281d How long ago, in hours, has it been since {you/she/he} breathed fumes from diesel fuel or kerosene?

HARD EDIT: Range - 1 – 48

|___|___|

HOURS

REFUSED 777

DON'T KNOW 999

VTQ.281e In the last 48 hours, did {you/she/he} breathe fumes from fingernail polish?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

VTQ.281f How long ago, in hours, has it been since {you/she/he} breathed fumes from fingernail polish?

HARD EDIT: Range - 1 – 48

|___|___|

HOURS

REFUSED 777

DON'T KNOW 999

PESTICIDE USE (PUQ)

PESTICIDE USE – PUQ

Target Group: SPs 8+

PUQ.100 In the past 7 days, were any chemical products used in {your/his/her} home to control fleas, roaches, ants, termites, or other insects?

CAPI INSTRUCTION:

IF SP 8-17 YEARS, DISPLAY THE FOLLOWING INTERVIEWER INSTRUCTION: "THIS ITEM IS COLLECTED VIA PROXY FOR SPS 8-17."

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PUQ.110 In the past 7 days, were any chemical products used in {your/his/her} lawn or garden to kill weeds?

CODE ‘NO’ IF THE RESPONDENT SAYS S/HE DOES NOT HAVE A LAWN OR GARDEN.

CAPI INSTRUCTION:

IF SP 8-17 YEARS, DISPLAY THE FOLLOWING INTERVIEWER INSTRUCTION: "THIS ITEM IS COLLECTED VIA PROXY FOR SPS 8-17."

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CURRENT HEALTH STATUS (HSQ)

CURRENT HEALTH STATUS – HSQ

Target Group: SPs 12+

HUQ.010 Next, I have some general questions about {your/SP's} health.

Would you say {your/SP's} health in general is . . .

excellent, 1

very good, 2

good, 3

fair, or 4

poor? 5

REFUSED 7

DON'T KNOW 9

The next questions are about {your/SP's} recent health during the 30 days outlined on the calendar.

HSQ.500 Did {you/SP} have a head cold or chest cold that started during those 30 days?

HAND CARD HSQ1

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HSQ.510 Did {you/SP} have a stomach or intestinal illness with vomiting or diarrhea that started during those 30 days?

HAND CARD HSQ1

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HSQ.520 Did {you/SP} have flu, pneumonia, or ear infections that started during those 30 days?

HAND CARD HSQ1

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1

CHECK ITEM HSQ.560:

IF SP 16 YEARS OR OLDER, CONTINUE WITH HSQ.571.

OTHERWISE, GO TO END OF SECTION.

HSQ.571 During the past 12 months, that is, since {DISPLAY CURRENT MONTH, DISPLAY LAST YEAR}, {have you/has SP} donated blood?

YES 1

NO 2 (HSQ.590)

REFUSED 7 (HSQ.590)

DON'T KNOW 9 (HSQ.590)

HSQ.580 How long ago was {your/SP's} last blood donation?

IF LESS THAN ONE MONTH, ENTER '1'.

CAPI INSTRUCTION:

HARD EDIT VALUES: 1-12.

|___|___|

ENTER # OF MONTHS

REFUSED 77

DON'T KNOW 99

HSQ.590 The next question is about the test for HIV, the virus that causes AIDS. Except for tests {you/SP} may have had as part of blood donations, {have you/has he/has she} ever been tested for HIV?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DEPRESSION SCREEN (DPQ)

DEPRESSION SCREEN – DPQ

Target Group: SPs 12+

BOX 1

CHECK ITEM DPQ.001:

IF INTERVIEW DONE ONLY WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), CONTINUE.
OTHERWISE, GO TO NEXT SECTION.

DPQ.010 Over the last 2 weeks, how often have you been bothered by the following problems:

little interest or pleasure in doing things? Would you say . . .

HANDCARD DPQ1

Not at all, 0

several days, 1

more than half the days, or 2

nearly every day? 3

REFUSED 7

DON’T KNOW 9

DPQ.020 [Over the last 2 weeks, how often have you been bothered by the following problems:]

feeling down, depressed, or hopeless?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.030 [Over the last 2 weeks, how often have you been bothered by the following problems:]

trouble falling or staying asleep, or sleeping too much?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.040 [Over the last 2 weeks, how often have you been bothered by the following problems:]

feeling tired or having little energy?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.050 [Over the last 2 weeks, how often have you been bothered by the following problems:]

poor appetite or overeating?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.060 [Over the last 2 weeks, how often have you been bothered by the following problems:]

feeling bad about yourself – or that you are a failure or have let yourself or your family down?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.070 [Over the last 2 weeks, how often have you been bothered by the following problems:]

trouble concentrating on things, such as reading the newspaper or watching TV?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.080 [Over the last 2 weeks, how often have you been bothered by the following problems:]

moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.090 Over the last 2 weeks, how often have you been bothered by the following problem:

Thoughts that you would be better off dead or of hurting yourself in some way?

HAND CARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

BOX 2

CHECK ITEM DPQ.095:

IF RESPONSE TO ANY OF QUESTIONS DPQ.010 – DPQ.090 = 1, 2, OR 3, GO TO DPQ.100.
OTHERWISE, GO TO NEXT SECTION.

DPQ.100 How difficult have these problems made it for you to do your work, take care of things at home, or get along with people?

Not at all difficult, 0

Somewhat difficult, 1

Very difficult, 2

Extremely difficult? 3

REFUSED 7

DON’T KNOW 9

TOBACCO (SMQ)

TOBACCO – SMQ

Target Group: SPs 12+ (CAPI)

BOX 1

CHECK ITEM SMQ.859:

IF SP AGED 12-17, GO TO SMQ.860.

OTHERWISE, CONTINUE.

SMQ.681 The following questions ask about use of tobacco products in the past 5 days.

During the past 5 days, including today, did {you/he/she} smoke cigarettes, pipes, cigars, little cigars or cigarillos, water pipes, hookahs, or e-cigarettes?

YES 1

NO 2 (SMQ.851)

REFUSED 7 (SMQ.851)

DON’T KNOW 9 (SMQ.851)

SMQ.692 Which of these products did {you/he/she} smoke?

(CHECK ALL THAT APPLY)

Cigarettes 1

Pipes 2

Cigars, or little cigars, or cigarillos 3

Water pipes or Hookahs 4

E-cigarettes 5

REFUSED 77 (SMQ.851)

DON’T KNOW 99 (SMQ.851)

BOX 2

CHECK ITEM SMQ.701:

IF ‘CIGARETTES’ (CODE 1) IN SMQ.691, GO TO SMQ.710.

IF ‘PIPES’ (CODE 2) IN SMQ.691, GO TO SMQ.740.

IF ‘CIGARS’ (CODE 3) IN SMQ.691, GO TO SMQ.771.

IF ‘WATER PIPES OR HOOKAHS’ (CODE 4) IN SMQ.691, GO TO SMQ.845.

IF 'E-CIGARETTE' (CODE 5) IN SMQ.691, GO TO SMQ.849.

SMQ.710 During the past 5 days, including today, on how many days did {you/he/she} smoke cigarettes?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.720 During the past 5 days, including today, on the days {you/he/she} smoked, how many cigarettes did {you/he/she} smoke each day?

IF R SAYS 95 OR MORE CIGARETTES PER DAY, ENTER 95.

HARD EDIT: RANGE 1 – 95.

|___|___|

ENTER NUMBER OF CIGARETTES

REFUSED 777

DON'T KNOW 999

SMQ.725 When did {you/he/she} smoke {your/his/her} last cigarette? Was it . . .

today, 1

yesterday, or 2

3 to 5 days ago? 3

REFUSED 7

DON'T KNOW 9

BOX 3

CHECK ITEM SMQ.731:

IF ‘PIPES’ (CODE 2) IN SMQ.691, GO TO SMQ.740.

IF ‘CIGARS’ (CODE 3) IN SMQ.691, GO TO SMQ.771.

IF ‘WATER PIPES OR HOOKAHS’ (CODE 4) IN SMQ.691, GO TO SMQ.845.

IF 'E-CIGARETTE' (CODE 5) IN SMQ.691, GO TO SMQ.849.

OTHERWISE, GO TO SMQ.851.

SMQ.740 During the past 5 days, including today, on how many days did {you/he/she} smoke a pipe?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 4

CHECK ITEM SMQ.761:

IF ‘CIGARS’ (CODE 3) IN SMQ.691, GO TO SMQ.771.

IF ‘WATER PIPES OR HOOKAH IN SMQ.691, GO TO SMQ.845.

IF 'E-CIGARETTE' (CODE 5) IN SMQ.691, GO TO SMQ.849.

OTHERWISE, GO TO SMQ.851.

SMQ.771 During the past 5 days, including today, on how many days did {you/he/she} smoke cigars, or little cigars or cigarillos?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 5

CHECK ITEM SMQ.791:

IF ‘WATER PIPE’ (CODE 4) IN SMQ.691, GO TO 845.

IF 'E-CIGARETTE' (CODE 5) IN SMQ.691, GO TO 849.

OTHERWISE, GO TO SMQ.851.

SMQ.845 During the past 5 days, including today, on how many days did {you/he/she} smoke tobacco in a water pipe or Hookah?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 6

CHECK ITEM SMQ.847:

IF 'E-CIGARETTE' (CODE 5) IN SMQ.691, GO TO 849.

OTHERWISE, GO TO SMQ.851.

SMQ.849 During the past 5 days, including today, on how many days did {you/he/she} smoke an e-cigarette?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.851 Smokeless tobacco products are placed in the mouth or nose and include chewing tobacco, snuff, snus, or dissolvables.

During the past 5 days, including today, did {you/he/she} use any smokeless tobacco?

(Please do not include nicotine replacement products like patches, gum, lozenge, or spray which are considered products to help {you/him/her} stop smoking.)

YES 1

NO 2 (SMQ.863)

REFUSED 7 (SMQ.863)

DON’T KNOW 9 (SMQ.863)

SMQ.853 Which of these products did {you/he/she} use?

(CHECK ALL THAT APPLY)

Chewing tobacco 1

Snuff 2

Snus 3

Dissolvables 4

REFUSED 7 (SMQ.863)

DON’T KNOW 9 (SMQ.863)

BOX 7

CHECK ITEM SMQ.855:

IF ‘CHEWING’ (CODE 1) IN SMQ.853, GO TO SMQ.800.
IF ‘SNUFF’ (CODE 2) IN SMQ.853, GO TO SMQ.817.
IF ‘SNUS’ (CODE 3) IN SMQ.853, GO TO SMQ.857.
IF ‘DISSOLVABLES’ (CODE 4) IN SMQ.853, GO TO SMQ.861.

SMQ.800 During the past 5 days, including today, on how many days did {you/he/she} use chewing tobacco, such as Redman, Levi Garrett or Beechnut?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 8

CHECK ITEM SMQ.818:

IF ‘SNUFF’ (CODE 2) IN SMQ.853, GO TO SMQ.817.

IF ‘SNUS’ (CODE 3) IN SMQ.853, GO TO SMQ.857.

IF DISSOLVABLES (CODE 4) IN SMQ.853, GO TO SMQ.861.

OTHERWISE, GO TO SMQ.863.

SMQ.817 During the past 5 days, including today, on how many days did {you/he/she} use snuff, such as Skoal, Skoal Bandits, or Copenhagen?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 9

CHECK ITEM SMQ.821:

IF ‘SNUS’ (CODE 3) IN SMQ.853, GO TO SMQ.857.

IF DISSOLVABLES (CODE 4) IN SMQ.853, GO TO SMQ.861.

OTHERWISE, GO TO SMQ.863.

SMQ.857 During the past 5 days, including today, on how many days did {you/he/she} use snus?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 10

CHECK ITEM SMQ.859:

IF DISSOLVABLES (CODE 4), CONTINUE.

OTHERWISE, GO TO SMQ.863.

SMQ.861 During the past 5 days, including today, on how many days did {you/he/she} use dissolvables such as strips or orbs?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.860 The next questions are about {your/his/her} exposure to other people’s tobacco smoke.

During the last 7 days, did {you/SP} spend time in a restaurant?

YES 1

NO 2 (SMQ.870)

REFUSED 7 (SMQ.870)

DON'T KNOW 9 (SMQ.870)

SMQ.862 While {you were/SP was} in a restaurant, did someone else smoke cigarettes or other tobacco products indoors?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SMQ.870 During the last 7 days, did {you/SP} ride in a car or motor vehicle?

YES 1

NO 2 (SMQ.874)

REFUSED 7 (SMQ.874)

DON'T KNOW 9 (SMQ.874)

SMQ.872 While {you were/SP was} riding in a car or motor vehicle, did someone else smoke cigarettes or other tobacco products?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SMQ.874 During the last 7 days, did {you/SP} spend time in a home other than {your/his/her} own?

YES 1

NO 2 (SMQ.878)

REFUSED 7 (SMQ.878)

DON'T KNOW 9 (SMQ.878)

SMQ.876 While {you were/SP was} in a home other than {your/his/her} own, did someone else smoke cigarettes or other tobacco products indoors?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SMQ.878 During the last 7 days, {were you/was SP} in any other indoor area?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

SMQ.880 While {you were/SP was} in the other indoor area, did someone else smoke cigarettes or other tobacco products?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

ALCOHOL USE (ALQ)

ALCOHOL USE – ALQ

Target Group: SPs 18+ (CAPI)

ALQ.101 The next questions are about drinking alcoholic beverages. Included are liquor (such as whiskey or gin), beer, wine, wine coolers, and any other type of alcoholic beverage.

In any one year, {have you/has SP} had at least 12 drinks of any type of alcoholic beverage? By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and a half ounces of liquor.

YES 1 (ALQ.120)

NO 2

REFUSED 7

DON'T KNOW 9

ALQ.110 In {your/SP’s} entire life, {have you/has he/has she} had at least 12 drinks of any type of alcoholic beverage?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

ALQ.120
Q/U

In the past 12 months, how often did {you/SP} drink any type of alcoholic beverage?

PROBE: How many days per week, per month, or per year did {you/SP} drink?

ENTER '0' FOR NEVER.

|___|___|___|

ENTER QUANTITY

REFUSED 777

DON'T KNOW 999

ENTER UNIT

WEEK 1

MONTH 2

YEAR 3

REFUSED 7

DON'T KNOW 9

BOX 1

CHECK ITEM ALQ.125:

IF SP DIDN'T DRINK (CODED '0') IN ALQ.120, GO TO ALQ.151.

OTHERWISE, CONTINUE WITH ALQ.130.

ALQ.130 In the past 12 months, on those days that {you/SP} drank alcoholic beverages, on the average, how many drinks did {you/he/she} have? (By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and a half ounces of liquor.)

IF LESS THAN 1 DRINK, ENTER '1'.

IF 95 DRINKS OR MORE, ENTER '95'.

HARD EDIT: If ALQ.101 = 2 or 9, ALQ.130 must be less than 12.

Error Message: “Number of drinks per day cannot be greater than number of drinks in any one year.”

|___|___|___|

ENTER # OF DRINKS

REFUSED 777

DON'T KNOW 999

ALQ.141
Q/U

In the past 12 months, on how many days did {you/SP} have {DISPLAY NUMBER} or more drinks of any alcoholic beverage?

PROBE: How many days per week, per month, or per year did {you/SP} have {DISPLAY NUMBER} or more drinks in a single day?

ENTER '0' FOR NONE.

CAPI INSTRUCTION:

IF SP = MALE, DISPLAY = 5

IF SP = FEMALE, DISPLAY = 4

HARD EDIT: If ALQ.101 = 2 or 9, ALQ.141 must be less than 3 times per year.

Error Message: “Number of drinks must be less than 3 if SP never had more than 12 drinks per year.”

|___|___|___|

ENTER QUANTITY

REFUSED 777

DON'T KNOW 999

ENTER UNIT

WEEK 1

MONTH 2

YEAR 3

REFUSED 7

DON'T KNOW 9

ALQ.151 Was there ever a time or times in {your/SP's} life when {you/he/she} drank {DISPLAY NUMBER} or more drinks of any kind of alcoholic beverage almost every day?

CAPI INSTRUCTION:

IF SP = MALE, DISPLAY = 5

IF SP = FEMALE, DISPLAY = 4

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

ALQ.155 For about how many years did {you/SP} drink {DISPLAY NUMBER} or more drinks of any kind of alcoholic beverage almost every day?

IF LESS THAN 1 YEAR, ENTER ‘0’.

CAPI INSTRUCTION:

IF SP = MALE, DISPLAY = 5

IF SP = FEMALE, DISPLAY = 4

IF RESPONSE IS CODED AS 0, STORE 666.

HARD EDIT: ALQ.155 MUST BE LESS THAN OR EQUAL TO CURRENT AGE.

ERROR MESSAGE: RESPONSE CANNOT BE GREATER THAN SP’S CURRENT AGE.

|___|___|___|

ENTER QUANTITY

LESS THAN 1 YEAR 666

REFUSED 777

DON'T KNOW 999

REPRODUCTIVE HEALTH (RHQ)

REPRODUCTIVE HEALTH – RHQ

Target Group: Female SPs Ages 12+

RHQ.010 The next series of questions are about {your/SP’s} reproductive history. I will begin by asking some questions about {your/SP’s} period or menstrual cycle.

How old {were you/was SP} when {you/she} had {your/her} first menstrual period?

CODE “0” IF HAVEN’T STARTED YET.

CAPI INSTRUCTION:

SOFT EDIT VALUES: AGE ≤8 AND ≥ 25 YEARS.

ERROR MESSAGE: “UNLIKELY RESPONSE. PLEASE VERIFY.”

HARD EDIT VALUES: AGE OF 1^ST PERIOD CANNOT BE GREATER THAN CURRENT AGE.

ERROR MESSAGE: “AGE MENSTRUAL CYCLE STARTED CANNOT BE GREATER THAN AGE OF SP.”

SOFT EDIT: DISPLAY EDIT WHEN AGE OF SP IS GREATER THAN OR EQUAL TO 20 AND RHQ.010 IS CODED ‘0’.

ERROR MESSAGE: “IT IS UNLIKELY THAT SP’S 20 OR OLDER WILL NOT HAVE BEGUN TO MENSTRUATE. PLEASE VERIFY.”

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON’T KNOW 99

BOX 1

CHECK ITEM RHQ.015:

IF PERIODS HAVEN’T STARTED (CODED ‘0’), GO TO END OF SECTION.
IF PERIODS HAVE STARTED AND SP REPORTS AGE (CODED ‘1’ - ‘76’) IN RHQ.010, OR IF SP REFUSES AGE (CODED ‘77’) IN RHQ.010, GO TO RHQ.031.
OTHERWISE, CONTINUE.

RHQ.020 {Were you/Was SP} . . .

younger than 10, 1

10 to 12, 2

13 to 15, or 3

16 or older? 4

REFUSED 7

DON’T KNOW 9

RHQ.031 {Have you/Has SP} had at least one menstrual period in the past 12 months? Please do not include bleedings caused by medical conditions, hormone therapy, or surgeries.

SOFT EDIT: DISPLAY EDIT WHEN AGE OF SP IS GREATER THAN OR EQUAL TO 60 AND RHQ.031 IS CODED YES.

ERROR MESSAGE: “IT IS UNLIKELY THAT SPS AGED 60 YEARS OR OLDER WILL STILL BE MENSTRUATING. PLEASE VERIFY.”

YES 1

NO 2 (RHQ.043)

REFUSED 7 (RHQ.060)

DON’T KNOW 9 (RHQ.060)

BOX 1A

CHECK ITEM RHQ.033:

IF SP < 20 YEARS OLD AND RHQ.031=1, GO TO BOX 3.
IF SP 20+ YEARS OLD AND RHQ.031=1, GO TO RHQ 282.
OTHERWISE, CONTINUE.

RHQ.043 What is the reason that {you have/SP has} not had a period in the past 12 months?

HAND CARD RHQ 1

PREGNANCY 1 (BOX 3)

BREAST FEEDING 2

HYSTERECTOMY 3

MENOPAUSE/CHANGE OF LIFE 7

OTHER 9

REFUSED 77

DON’T KNOW 99

RHQ.282 {Have you/Has SP} had a hysterectomy, including a partial hysterectomy, that is, surgery to remove {your/her} uterus or womb?

MARK IF KNOWN. OTHERWISE ASK.

YES 1

NO 2 (RHQ.305)

REFUSED 7 (RHQ.305)

DON’T KNOW 9 (RHQ.305)

RHQ.291 How old {were you/was SP} when {you/she} had {your/her} hysterectomy?

CAPI INSTRUCTION:

HARD EDIT: RHQ.291 MUST BE EQUAL TO OR LESS THAN AGE OF SP.

ERROR MESSAGE: “AGE CANNOT BE GREATER THAN AGE OF SP.”

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON’T KNOW 999

RHQ.305 {Have you/Has SP} had both of {your/her} ovaries removed {either when {you/she} had {your/her} uterus removed or at any other time}?

CAPI INSTRUCTION: IF RHQ.282=1 DISPLAY {either when {you/she} had {your/her} uterus removed or at any other time}”

YES 1

NO 2 (BOX 1B)

REFUSED 7 (RHQ.060)

DON’T KNOW 9 (RHQ.060)

RHQ.332 How old {were you/was SP} when {you/she} had {your/her} ovaries removed or last ovary removed if removed at different times?

CAPI INSTRUCTION:

HARD EDIT: RHQ.332 MUST BE EQUAL TO OR LESS THAN AGE OF SP.

ERROR MESSAGE: “AGE CANNOT BE GREATER THAN AGE OF SP.”

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON’T KNOW 999

BOX 1B

CHECK ITEM RHQ.334:

IF RHQ.031 = 1 AND RHQ.282 = 2 AND RHQ.305 = 2, GO TO BOX 3.
OTHERWISE, CONTINUE.

RHQ.060 About how old {were you/was SP} when {you/she} had {your/her} last menstrual period?

SOFT EDIT: DISPLAY EDIT WHEN RHQ.060 IS GREATER THAN 59.

ERROR MESSAGE: “IT IS UNLIKELY THAT AN SP WILL HAVE HER LAST MENSTRUAL PERIOD AFTER AGE 59. PLEASE VERIFY.”

SOFT EDIT: RHQ.060 MUST BE LESS THAN OR EQUAL TO RHQ.291 OR RHQ.332.

ERROR MESSAGE: “AGE OF SP AT LAST MENSTRUAL PERIOD CANNOT BE GREATER THAN AGE OF SP AT HYSTERECTOMY OR AGE OF SP AT OOPHORECTOMY.”

HARD EDIT: RHQ.060 MUST BE EQUAL TO OR LESS THAN AGE OF SP.

ERROR MESSAGE: “AGE OF SP AT LAST MENSTRUAL PERIOD CANNOT BE GREATER THAN AGE OF SP.”

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON’T KNOW 99

BOX 2

CHECK ITEM RHQ.065:

IF SP DOESN’T KNOW AGE AT LAST MENSTRUAL PERIOD (CODED ‘99’) IN RHQ.060, CONTINUE.
OTHERWISE, GO TO BOX 3.

RHQ.070 {Were you/Was SP} . . .

younger than 30, 1

30 to 34, 2

35 to 39, 3

40 to 44, 4

45 to 49, 5

50 to 54, or 6

55 or older? 7

REFUSED 77

DON’T KNOW 99

BOX 3

CHECK ITEM RHQ.072:

IF SP IS 18-59 YEARS OLD, CONTINUE.
OTHERWISE, GO TO RHQ.131.

RHQ.074 The next questions are about {your/SP’s} pregnancy history.

{Have you/Has SP} ever attempted to become pregnant over a period of at least a year without becoming pregnant?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

RHQ.076 {Have you/Has SP} ever been to a doctor or other medical provider because {you have/she has} been unable to become pregnant?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

RHQ.078 {Have you/Has SP} ever been treated for an infection in {your/her} fallopian tubes, uterus or ovaries, also called a pelvic infection, pelvic inflammatory disease, or PID?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

RHQ.131 {The next questions are about {your/SP’s} pregnancy history.}

{Have you/Has SP} ever been pregnant? Please include {current pregnancy,} live births, miscarriages, stillbirths, tubal pregnancies and abortions.

MARK IF KNOWN. OTHERWISE ASK.

CAPI INSTRUCTIONS:

IF SP IS AGED 12-17 OR 60+ DISPLAY {The next questions are about {your/SP’s} pregnancy history.}

IF RHQ.043=1, DISPLAY {current pregnancy}

HELP SCREEN SHOULD READ: Miscarriage: Refers to a pregnancy that terminates naturally during the first 6 months of pregnancy. Stillbirth: Refers to a baby that is born dead after 7 or more months of pregnancy. Tubal Pregnancy: Refers to a pregnancy that occurs in the fallopian tube. Abortion: Refers to a pregnancy that is terminated during the first 6 months using induced methods. Methods include D&C, vacuum extraction, suction, and saline injections.

YES 1

NO 2 (RHQ.420)

REFUSED 7 (RHQ.420)

DON’T KNOW 9 (RHQ.420)

BOX 6

CHECK ITEM RHQ.136:

IF RHQ.031 = 1 AND RHQ.043 = 1, 2, 9, 77, OR 99 AND RHQ.282 = 2, 7, OR 9, CONTINUE.
OTHERWISE, GO TO RHQ.160.

RHQ.143 {Are you/Is SP} pregnant now?

MARK IF KNOWN. OTHERWISE ASK.

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

RHQ.160 How many times {have you/has SP} been pregnant? Please count all {your/her} pregnancies including {current pregnancy,} live births, miscarriages, stillbirths, tubal pregnancies, and abortions.)

CAPI INSTRUCTION: IF RHQ.143=1 DISPLAY {current pregnancy}.

|___|___|

ENTER NUMBER OF PREGNANCIES

REFUSED 77

DON’T KNOW 99

RHQ.162 During {any/your/SP’s} pregnancy, {were you/was SP} ever told by a doctor or other health professional that {you/she} had diabetes, sugar diabetes or gestational diabetes? Please do not include diabetes that {you/SP} may have known about before the pregnancy.

CAPI INSTRUCTION:

IF RHQ.160 = 1, DISPLAY {your/SP’s}. OTHERWISE, DISPLAY {any}.

HELP SCREEN SHOULD READ: Gestational diabetes is a form of diabetes or high blood sugar found in pregnant women.

YES 1

NO 2 (BOX 7)

BORDERLINE 3 (BOX 7)

REFUSED 7 (BOX 7)

DON’T KNOW 9 (BOX 7)

RHQ.163 How old {were you/was SP} when {you were/she was} first told {you/she} had diabetes during a pregnancy?

SOFT EDIT: IF RHQ.143 = 1 AND RHQ.160 = 1, THEN RHQ.163 MUST BE EQUAL TO THE AGE OF THE SP OR THE AGE OF THE SP MINUS 1.

ERROR MESSAGE: “IT IS UNLIKELY YOU WERE FIRST TOLD YOU HAD DIABETES AT THAT AGE SINCE THIS IS YOUR FIRST PREGNANCY. PLEASE VERIFY.”

HARD EDIT: RHQ.163 MUST BE EQUAL TO OR LESS THAN AGE OF SP.

ERROR MESSAGE: “AGE CANNOT BE GREATER THAN AGE OF SP.”

SOFT EDIT: RHQ.163 MUST BE EQUAL TO OR GREATER THAN 12.

ERROR MESSAGE: “UNLIKELY AGE. PLEASE VERIFY.”

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON’T KNOW 99

BOX 7

CHECK ITEM RHQ.165:

IF SP ONLY HAD ONE PREGNANCY (CODED ‘1’) IN RHQ.160 AND CURRENTLY PREGNANT (CODED ‘1’) IN RHQ.143, SKIP TO RHQ.420.
OTHERWISE CONTINUE.

RHQ.166 How many vaginal deliveries {have you/has SP} had? Please count stillbirths as well as live births.

COUNT THE NUMBER OF DELIVERIES, NOT THE NUMBER OF LIVE-BORN CHILDREN. FOR EXAMPLE, IF SP DELIVERED TWINS OR HAD ANY OTHER MULTIPLE BIRTH, COUNT AS A SINGLE DELIVERY.

HARD EDIT: RHQ.166 MUST BE EQUAL TO OR LESS THAN RHQ.160.

ERROR MESSAGE: “NUMBER OF VAGINAL DELIVERIES CANNOT BE GREATER THAN THE NUMBER OF PREGNANCIES.”

SOFT EDIT: IF RHQ.143 = 1, THEN RHQ.166 MUST BE EQUAL TO OR LESS THAN RHQ.160 MINUS 1.

ERROR MESSAGE: “Since you are currently pregnant, it is unlikely that the number of vaginal deliveries is equal to or greater than the number of your pregnancies. Please verify.”

|___|___|

ENTER NUMBER

REFUSED 77

DON’T KNOW 99

BOX 7A

CHECK ITEM RHQ.168:

IF NUMBER OF PREGNANCIES IN RHQ.160 EQUALS THE NUMBER OF VAGINAL DELIVERIES IN RHQ.166, SKIP TO RHQ.172.
IF SP CURRENTLY PREGNANT (CODED ‘1’) IN RHQ.143 AND THE NUMBER OF VAGINAL DELIVERIES IN RHQ.166 EQUALS THE NUMBER OF PREGNANCIES IN RHQ.160 MINUS 1, SKIP TO RHQ.172.
OTHERWISE, CONTINUE WITH RHQ.169.

RHQ.169 How many cesarean deliveries, also known as C-sections, {have you/has SP} had? (Please count stillbirths as well as live births.)

COUNT THE NUMBER OF DELIVERIES, NOT THE NUMBER OF LIVE-BORN CHILDREN. FOR EXAMPLE, IF SP DELIVERED TWINS OR HAD ANY OTHER MULTIPLE BIRTH, COUNT AS A SINGLE DELIVERY.

SOFT EDIT: SUM OF RHQ.166 AND RHQ.169 MUST BE EQUAL TO OR LESS THAN RHQ.160.

ERROR MESSAGE: “It is unlikely that the number of deliveries (vaginal and cesarean deliveries combined) is greater than the number of pregnancies. Please verify.”

SOFT EDIT: IF CURRENTLY PREGNANT (CODED ‘1’ IN RHQ.143) THEN THE SUM OF RHQ.166 AND RHQ.169 SHOULD BE LESS THAN OR EQUAL TO RHQ.160 MINUS 1.

ERROR MESSAGE: “Since SP is currently pregnant, it is unlikely that the number of vaginal and cesarean deliveries is equal to or greater than the number of pregnancies. Please verify.”

HARD EDIT: RHQ.169 MUST BE EQUAL TO OR LESS THAN RHQ.160.

ERROR MESSAGE: “Number of cesarean deliveries cannot be greater than the number of pregnancies.”

|___|___|

ENTER NUMBER

REFUSED 77

DON’T KNOW 99

BOX 7B

CHECK ITEM RHQ.170A:

IF THE NUMBER OF DELIVERIES IN RHQ.166 AND RHQ.169 EQUALS ZERO, GO TO RHQ.420.
OTHERWISE, CONTINUE WITH RHQ.172.

RHQ.172 {Did {your/SP’s} delivery/Did any of {your/SP’s} deliveries} result in a baby that weighed 9 pounds or more at birth? Please count stillbirths as well as live births.

INTERVIEWER INSTRUCTION: IF SP ONLY RECALLS HER BABY’S BIRTH WEIGHT IN KILOS/GRAMS: 9 LB ~ 4.1 KG/ 4,100 G.

CAPI INSTRUCTION:

IF SP HAD ONE DELIVERY (SUM OF RHQ.166 AND RHQ.169 = 1), DISPLAY {YOUR DELIVERY}.

IF SP HAD MORE THAN ONE DELIVERY (SUM OF RHQ.166 AND RHQ.169 > 1), DISPLAY {ANY OF YOUR DELIVERIES}.

YES 1

NO 2 (RHQ.171)

REFUSED 7 (RHQ.171)

DON’T KNOW 9 (RHQ.171)

RHQ.173 How old {were you/was SP} when {you/she} delivered {a/the first} baby that weighed 9 pounds or more? (Please count stillbirths as well as live births.)

INTERVIEWER INSTRUCTION: IF SP ONLY RECALLS HER BABY’S BIRTH WEIGHT IN KILOS/GRAMS: 9 LB ~ 4.1 KG/ 4,100 G.

CAPI INSTRUCTION:

IF SP HAD ONE DELIVERY (SUM OF RHQ.166 AND RHQ.169 = 1), DISPLAY {a}. OTHERWISE, DISPLAY {the first}.

HARD EDIT: RHQ.173 MUST BE EQUAL TO OR LESS THAN AGE OF SP.

ERROR MESSAGE: “AGE CANNOT BE GREATER THAN AGE OF SP.”

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON’T KNOW 99

RHQ.171 How many of {your/her} deliveries resulted {Did {your/her} delivery result} in a live birth?

CAPI INSTRUCTION:

IF SP HAD ONE DELIVERY (SUM OF RHQ.166 AND RHQ.169 = 1), REPLACE {How many of {your/her} deliveries resulted} WITH {Did {your/her} delivery result}.

FOR SINGLE DELIVERIES:

Yes = 1

No = 0

COUNT THE NUMBER OF TOTAL DELIVERIES, NOT NUMBER OF LIVE-BORN CHILDREN. FOR EXAMPLE, IF SP HAD TWINS OR OTHER MULTIPLE BIRTH, COUNT AS A SINGLE DELIVERY.

|___|___|

ENTER NUMBER OF DELIVERIES

REFUSED 77

DON’T KNOW 99

BOX 8

CHECK ITEM RHQ.177:

IF SP HAD NO DELIVERIES THAT RESULTED IN A LIVE BIRTH (CODED ‘0’) IN RHQ.171, GO TO RHQ.184.
IF SP HAD ONE DELIVERY (SUM OF RHQ.166 AND RHQ.169 = 1) AND THAT DELIVERY RESULTED IN A LIVE BIRTH (CODED ‘1’) IN RHQ.171 AND SP DELIVERED ONE BABY THAT WEIGHED 9 POUNDS OR MORE (CODED ‘1’) IN RHQ.172, GO TO RHQ.184.
OTHERWISE, CONTINUE.

RHQ.180 How old {were you/was SP} at the time of {your/her} {first} live birth?

CAPI INSTRUCTION:

IF SP HAD MORE THAN 1 LIVE BIRTH (CODED >= 2) IN RHQ.171, DISPLAY {first}.

CAPI INSTRUCTION:

HARD EDIT: RHQ.180 MUST BE EQUAL TO OR LESS THAN AGE OF SP.

ERROR MESSAGE: “AGE OF SP AT FIRST DELIVERY CANNOT BE GREATER THAN AGE OF SP.”

SOFT EDIT: DISPLAY EDIT WHEN RHQ.180 IS GREATER THAN OR EQUAL TO RHQ.010.

ERROR MESSAGE: “AGE OF SP AT FIRST LIVE BIRTH CANNOT BE LESS THAN AGE WHEN SP’S FIRST PERIOD STARTED.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON’T KNOW 99

RHQ.184 What is the month and year of your last delivery? Please count stillbirths as well as live births.

M/Y

|___|___|

MONTH

REFUSED 77

DON'T KNOW 99

|___|___|___|___| (BOX9A)

YEAR

REFUSED 7777 (RHQ.200)

DON'T KNOW 9999 (RHQ.200)

HARD EDIT: DATE MUST BE EQUAL OR LESS THAN CURRENT MONTH/YEAR.

HARD EDIT VALUES FOR MONTH: 01 – 12.

HARD EDIT VALUES FOR YEAR: 1900 – 2100.

INTERVIEWER INSTRUCTION:

WE ARE ASKING THE BIRTH MONTH AND YEAR OF THE WOMAN’S LAST CHILD OR THE DATE HER LAST PREGNANCY ENDED (IF STILLBIRTH).

CAPI INSTRUCTIONS:

SEPARATE FIELDS FOR MONTH AND YEAR AND ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DISPLAY ERROR WHEN ONLY ONE DIGIT IS ENTERED FOR MONTH.

ERROR MESSAGE: “ENTER TWO DIGITS FOR MONTH.”

BOX 9A

CHECK ITEM RHQ.187:

IF THE DATE OF LAST DELIVERY IN RHQ.184 IS WITHIN THE LAST 24 MONTHS, CONTINUE.
IF THE MONTH IN RHQ.184 IS “REFUSED” OR “DON’T KNOW” AND THE YEAR IN RHQ.184 IS LESS THAN CURRENT YEAR MINUS 3, CONTINUE.
OTHERWISE, GO TO RHQ.420.

RHQ.200 {Are you/Is SP} now breast feeding a child?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

RHQ.420 {Have you/Has SP} ever taken birth control pills for any reason?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 20

CHECK ITEM RHQ.535:

IF SP 20 YEARS OF AGE OR OLDER, CONTINUE.
OTHERWISE, GO TO BOX 24.

RHQ.540 {Have you/Has SP} ever used female hormones such as estrogen and progesterone? Please include any forms of prescription female hormones, such as pills, creams, patches, and injectables, but do not include birth control methods or use for infertility.

IN SITUATIONS OF HORMONE USE FOR NON-MENOPAUSAL CONDITIONS, CODE HRT USE AS “NO”.

YES 1

NO 2 (BOX 24)

REFUSED 7 (BOX 24)

DON’T KNOW 9 (BOX 24)

RHQ.542 Which forms of female hormones {have you/has SP} used?

CODE ALL THAT APPLY

PILLS 10

PATCHES 11

CREAM/SUPPOSITORY/INJECTION 12

OTHER 13

REFUSED 77

DON’T KNOW 99

BOX 21

CHECK ITEM RHQ.552:

IF SP USED FEMALE HORMONE PILLS (CODE ‘10’) IN RHQ.542, CONTINUE.

OTHERWISE, GO TO BOX 22.

RHQ.554 {Have you/Has SP} ever taken female hormone pills containing estrogen only like Premarin? Do not include birth control pills.

YES 1

NO 2 (RHQ.570)

REFUSED 7 (RHQ.570)

DON’T KNOW 9 (RHQ.570)

RHQ.560
Q/U

Not counting any time when {you/SP} stopped taking them, for how long altogether {did you take/did she take} pills containing estrogen only?

CODE “1” FOR LESS THAN 1 MONTH

|___|___|

ENTER NUMBER

REFUSED 77

DON’T KNOW 99

ENTER UNIT

MONTHS 1

YEARS 2

REFUSED 7

DON’T KNOW 9

RHQ.570 {Have you/Has SP} taken female hormone pills containing both estrogen and progestin like Prempro or Premphase? Do not include birth control pills.

YES 1

NO 2 (BOX 22)

REFUSED 7 (BOX 22)

DON’T KNOW 9 (BOX 22)

RHQ.576
Q/U

Not counting any time when {you/SP} stopped taking them, for how long altogether {did you take/did she take} pills containing both estrogen and progestin?

CODE “1” FOR LESS THAN 1 MONTH

|___|___|

ENTER NUMBER

REFUSED 77

DON’T KNOW 99

ENTER UNIT

MONTHS 1

YEARS 2

REFUSED 7

DON’T KNOW 9

BOX 22

CHECK ITEM RHQ.578:

IF SP USED PATCHES (CODE ‘11’) IN RHQ.542, CONTINUE WITH RHQ.580.

OTHERWISE, GO TO BOX 24.

RHQ.580 {Have you/Has SP} ever used female hormone patches containing estrogen only?

YES 1

NO 2 (RHQ.596)

REFUSED 7 (RHQ.596)

DON’T KNOW 9 (RHQ.596)

RHQ.586
Q/U

Not counting any time when {you/SP} stopped using them, for how long altogether {did you use/did she use} patches containing estrogen only?

CODE “1” FOR LESS THAN 1 MONTH

|___|___|

ENTER NUMBER

REFUSED 77

DON’T KNOW 99

ENTER UNIT

MONTHS 1

YEARS 2

REFUSED 7

DON’T KNOW 9

RHQ.596 {Have you/Has SP} used female hormone patches containing both estrogen and progestin?

YES 1

NO 2 (BOX 24)

REFUSED 7 (BOX 24)

DON’T KNOW 9 (BOX 24)

RHQ.602
Q/U

Not counting any time when {you/SP} stopped using them, for how long altogether {did you use/did she use} patches containing both estrogen and progestin?

CODE “1” FOR LESS THAN 1 MONTH

|___|___|

ENTER NUMBER

REFUSED 77

DON’T KNOW 99

ENTER UNIT

MONTHS 1

YEARS 2

REFUSED 7

DON’T KNOW 9

BOX 24

CHECK ITEM RHQ.642:

IF SP CURRENTLY PREGNANT (CODED ‘1’) IN RHQ.143, CONTINUE WITH FSQ.652a.
IF RHQ.184 IS WITHIN THE LAST 24 MONTHS, GO TO FSQ.652b.
IF THE MONTH IN RHQ.184 IS “REFUSED” OR “DON’T KNOW” AND THE YEAR IN RHQ.184 IS LESS THAN CURRENT YEAR MINUS 3, GO TO FSQ.652b.
OTHERWISE, GO TO END OF SECTION.

FSQ.652a These next questions are about participation in WIC, that is, the Women, Infants, and Children Program.

During this pregnancy have you used WIC benefits to buy food for yourself?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

FSQ.672a How many months pregnant were you when you first started to receive WIC benefits to buy food for yourself?

|__|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

BOX 27

CHECK ITEM RHQ.644:

GO TO FSQ.661N.

FSQ.652b These next questions are about participation in WIC, that is, the Women, Infants, and Children Program.

During your last pregnancy, did you use WIC benefits to buy food for yourself? Please include any stillbirth or miscarriage.

YES 1

NO 2 (FSQ.652c)

REFUSED 7 (FSQ.652c)

DON’T KNOW 9 (FSQ.652c)

FSQ.672b How many months pregnant were you when you first started to receive WIC benefits to buy food for yourself?

|__|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

FSQ.652c After your {last} child was born, did you use WIC benefits to buy food for yourself?

IF RHQ.160 > 1, DISPLAY {last}.

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 28

CHECK ITEM RHQ.646:

IF RHQ.184 IS WITHIN THE LAST 12 MONTHS, CONTINUE WITH FSQ.661N.
IF THE MONTH IN RHQ.184 IS “REFUSED” OR “DON’T KNOW” AND THE YEAR IN RHQ.184 IS LESS THAN CURRENT YEAR MINUS 2, CONTINUE.
OTHERWISE, GO TO END OF SECTION.

FSQ.661N Are you now receiving WIC benefits for yourself?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

KIDNEY CONDITIONS (KIQ)

KIDNEY CONDITIONS - KIQ

Target Group: SPs 20+

KIQ.005 Many people have leakage of urine. The next few questions ask about urine leakage.

How often {do you/does SP} have urinary leakage? Would {you/s/he} say . . .

CAPI INSTRUCTION:

HELP SCREEN: Other terms for urinary leakage are not being able to hold your urine until you can reach a toilet, not being able to control your bladder, loss of urine control.

never, 1 (KIQ.042)

less than once a month, 2

a few times a month, 3

a few times a week, or 4

every day and/or night? 5

REFUSED 7 (KIQ.042)

DON’T KNOW 9 (KIQ.042)

KIQ.010 How much urine {do you/does SP} lose each time? Would {you/s/he} say . . .

drops, 1

small splashes, or 2

more? 3

REFUSED 7

DON’T KNOW 9

KIQ.042 During the past 12 months, {have you/has SP} leaked or lost control of even a small amount of urine with an activity like coughing, lifting or exercise?

YES 1

NO 2 (KIQ.044)

REFUSED 7 (KIQ.044)

DON’T KNOW 9 (KIQ.044)

KIQ.430 How frequently does this occur? Would {you/s/he} say this occurs . . .

less than once a month, 1

a few times a month, 2

a few times a week, or 3

every day and/or night? 4

REFUSED 7

DON’T KNOW 9

KIQ.044 During the past 12 months, {have you/has SP} leaked or lost control of even a small amount of urine with an urge or pressure to urinate and {you/s/he} couldn’t get to the toilet fast enough?

YES 1

NO 2 (KIQ.046)

REFUSED 7 (KIQ.046)

DON’T KNOW 9 (KIQ.046)

KIQ.450 How frequently does this occur? Would {you/s/he} say this occurs. . .

less than once a month, 1

a few times a month, 2

a few times a week, or 3

every day and/or night? 4

REFUSED 7

DON’T KNOW 9

KIQ.046 During the past 12 months, {have you/has SP} leaked or lost control of even a small amount of urine without an activity like coughing, lifting, or exercise, or an urge to urinate?

YES 1

NO 2 (BOX 1)

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

KIQ.470 How frequently does this occur? Would {you/s/he} say this occurs . . .

less than once a month, 1

a few times a month, 2

a few times a week, or 3

every day and/or night? 4

REFUSED 7

DON’T KNOW 9

BOX 1

CHECK ITEM KIQ.048A:

IF 'YES' (CODED '1') IN KIQ.042 OR KIQ.044 OR KIQ.046, CONTINUE WITH KIQ.050.
OTHERWISE, GO TO KIQ.480.

KIQ.050 During the past 12 months, how much did {your/her/his} leakage of urine bother {you/her/him}? Please select one of the following choices:

not at all, 1

only a little, 2

somewhat, 3

very much, or 4

greatly? 5

REFUSED 7

DON'T KNOW 9

KIQ.052 During the past 12 months, how much did {your/his/her} leakage of urine affect {your/his/her} day-to-day activities? (Please select one of the following choices:)

not at all, 1

only a little, 2

somewhat, 3

very much, or 4

greatly? 5

REFUSED 7

DON'T KNOW 9

KIQ.480 During the past 30 days, how many times per night did {you/SP} most typically get up to urinate, from the time {you/s/he} went to bed at night until the time {you/he/she} got up in the morning. Would {you/s/he} say . . .

0, 0

1, 1

2, 2

3, 3

4, 4

5 or more? 5

REFUSED 77

DON'T KNOW 99

physical activity AND PHYSICAL FITNESS (PAQ)

physical activity AND PHYSICAL FITNESS – paq

Target Group: SPs 12-15

PAQ.706 I'd like to ask you some questions about {your/SP’s} activities.

0 days 0

1 day 1

2 days 2

3 days 3

4 days 4

5 days 5

6 days 6

7 days 7

REFUSED 77

DON’T KNOW 99

PAQ.605 Next I am going to ask you about the time {you spend/SP spends} doing different types of physical activity in a typical week.

Think first about the time {you spend/he spends/she spends} doing work. Think of work as the things that {you have/he has/she has} to do such as paid or unpaid work, household chores, and yard work.

YES 1

NO 2 (PAQ.620)

REFUSED 7 (PAQ.620)

DON’T KNOW 9 (PAQ.620)

PAQ.610 In a typical week, on how many days {do you/does SP} do vigorous-intensity activities as part of {your/his/her} work?

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES IN THIS QUESTION.

HARD EDIT: LESS THAN 1 DAY OR MORE THAN 7 DAYS

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.620)

DON’T KNOW 99 (PAQ.620)

PAQ.615 How much time {do you/does SP} spend doing vigorous–intensity activities at work on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when {you do/he does/she does} vigorous-intensity activities during {your/his/her} work.

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING VIGOROUS-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: LESS THAN 10 MINUTES OR 24 HOURS OR MORE.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.620)

DON'T KNOW 9999 (PAQ.620)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

YES 1

NO 2 (PAQ.635)

REFUSED 7 (PAQ.635)

DON’T KNOW 9 (PAQ.635)

PAQ.625 In a typical week, on how many days {do you/does SP} do moderate-intensity activities as part of {your/his/her} work?

PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.

HARD EDIT: LESS THAN 1 DAY OR MORE THAN 7 DAYS

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.635)

DON’T KNOW 99 (PAQ.635)

PAQ.630 How much time {do you/does SP} spend doing moderate-intensity activities at work on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when {you do/he does/she does} moderate-intensity activities during {your/his/her} work.

PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING MODERATE-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: LESS THAN 10 MINUTES OR 24 HOURS OR MORE.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.635)

DON'T KNOW 9999 (PAQ.635)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

In a typical week {do you/does SP} walk or use a bicycle for at least 10 minutes continuously to get to and from places?

YES 1

NO 2 (PAQ.650)

REFUSED 7 (PAQ.650)

DON’T KNOW 9 (PAQ.650)

PAQ.640 In a typical week, on how many days {do you/does SP} walk or bicycle for at least 10 minutes continuously to get to and from places?

HARD EDIT: LESS THAN 1 DAY OR MORE THAN 7 DAYS

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.650)

DON’T KNOW 99 (PAQ.650)

PAQ.645 How much time {do you/does SP} spend walking or bicycling for travel on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when {you walk or bicycle/SP walks or bicycles} for travel.

SOFT EDIT: >4 HOURS.

HARD EDIT: LESS THAN 10 MINUTES OR 24 HOURS OR MORE.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.650)

DON'T KNOW 9999 (PAQ.650)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

PAQ.650 The next questions exclude the work and transport activities that you have already mentioned. Now I would like to ask you about sports, fitness and recreational activities.

YES 1

NO 2 (PAQ.665)

REFUSED 7 (PAQ.665)

DON’T KNOW 9 (PAQ.665)

PAQ.655 In a typical week, on how many days {do you/does SP} do vigorous-intensity sports, fitness or recreational activities?

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: LESS THAN 1 DAY OR MORE THAN 7 DAYS

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.665)

DON’T KNOW 99 (PAQ.665)

PAQ.660
Q/U

How much time {do you/does SP} spend doing vigorous-intensity sports, fitness or recreational activities on a typical day?

PROBE IF NEEDED: Think about a typical day when {you do/SP does} vigorous-intensity sports, fitness or recreational activities.

SOFT EDIT: >4 HOURS.

HARD EDIT: LESS THAN 10 MINUTES OR 24 HOURS OR MORE.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.665)

DON'T KNOW 9999 (PAQ.665)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

YES 1

NO 2 (PAQ.680)

REFUSED 7 (PAQ.680)

DON’T KNOW 9 (PAQ.680)

PAQ.670 In a typical week, on how many days {do you/does SP} do moderate-intensity sports, fitness or recreational activities?

PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: LESS THAN 1 DAY OR MORE THAN 7 DAYS

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.680)

DON’T KNOW 99 (PAQ.680)

PAQ.675
Q/U

How much time {do you/does SP} spend doing moderate–intensity sports, fitness or recreational activities on a typical day?

PROBE IF NEEDED: Think about a typical day when {you do/SP does} moderate-intensity sports, fitness or recreational activities.

PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.

SOFT EDIT: >4 HOURS.

HARD EDIT: LESS THAN 10 MINUTES OR 24 HOURS OR MORE.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.680)

DON'T KNOW 9999 (PAQ.680)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

PAQ.680
Q/U

The following question is about sitting at school, at home, getting to and from places, or with friends including time spent sitting at a desk, traveling in a car or bus, reading, playing cards, watching television, or using a computer. Do not include time spent sleeping.

How much time {do you/does SP} usually spend sitting on a typical day?

SOFT EDIT: 18 HOURS OR MORE AND LESS THAN 8 HOURS.

ERROR MESSAGE: PLEASE VERIFY TIMES OF 18 HOURS OR MORE OR LESS THAN 8 HOURS.

HARD EDIT: 24 HOURS OR MORE.

ERROR MESSAGE: THE TIME SHOULD BE LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.710)

DON'T KNOW 9999 (PAQ.710)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

PAQ.710 Now I will ask you first about TV watching and then about computer use.

Over the past 30 days, on average how many hours per day did {you/SP} sit and watch TV or videos? Would you say . . .

less than 1 hour, 0

1 hour, 1

2 hours, 2

3 hours, 3

4 hours, 4

5 hours or more, or 5

{You don’t/SP does not} watch TV or videos 8

REFUSED 77

DON'T KNOW 99

PAQ.715 Over the past 30 days, on average how many hours per day did {you/SP} use a computer or play computer games outside of school? Include Playstation, Nintendo DS, or other portable video games. Would you say . . .

less than 1 hour, 0

1 hour, 1

2 hours, 2

3 hours, 3

4 hours, or 4

5 hours or more, or 5

{You do/SP does} not use a computer
outside of work or school 8

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

If the SP watches T.V. or video at the same time as working on the computer, count this time as watching T.V. or video.

PAQ.722 For the next questions, think about the sports, lessons, or physical activities {you/SP} may have done during the past 7 days? Please do not include things {you/he/she} did during the school day like PE or gym class.

Did {you/SP} do any physical activities during the past 7 days?

YES 1

NO 2 (PAQ.731)

REFUSED 7 (PAQ.731)

DON’T KNOW 9 (PAQ.731)

PAQ.724 What physical activities did {you/SP} do during the past 7 days? Don’t include activities {you/SP} did during gym or PE.

[PROBE: Did {you/he/she} do any other physical activities?}

CODE ALL THAT APPLY

AEROBICS/WEIGHT TRAINING/GYM/
EXERCISE 1

BASEBALL/SOFTBALL/CATCH/PITCHING 2

BASKETBALL 3

BIKE RIDING/DIRT BIKING/MOUNTAIN
BIKING 4

CHEERLEADING 5

DANCE 6

FIELD HOCKEY/STREET HOCKEY/
ROLLER HOCKEY 7

FOOTBALL 8

FRISBEE/ULTIMATE FRISBEE 29

GOLF 9

GYMNASTICS/TUMBLING 10

HIKING 11

ICE HOCKEY 12

ICE SKATING 13

JUMPING ROPE 14

LACROSSE 15

MARTIAL ARTS (KARATE/TAE KWON DO/
JUDO, ETC.) 16

PLAYING GAMES (PROBE: WERE YOU
PHYSICALLY ACTIVE? IF NO, DON’T
COUNT) 17

BACKYARD/PLAYGROUND GAMES
AND ACTIVITIES 30

ROLLER BLADING/ROLLER SKATING 18

RUNNING/JOGGING 19

SCOOTER RIDING (PROBE: DOES IT HAVE
A MOTOR? IF YES, DON’T COUNT) 20

SKATEBOARDING 21

SOCCER 22

SWIMMING 23

TENNIS 24

TRACK & FIELD 25

TRAMPOLINE 31

VOLLEYBALL 26

WALKING 27

WRESTLING 28

OTHER (SPECIFY) 91

REFUSED 77

DON’T KNOW 99

PAQ.731 During the past 7 days, on how many days did {you/SP} play active video games such as Wii Sports, Wii Fit, Xbox 360, Xbox Kinect, Playstation 3, or Dance, Dance Revolution?

0 days 0 (PAQ.677)

1 day 1

2 days 2

3 days 3

4 days 4

5 days 5

6 days 6

7 days 7

REFUSED 77

DON’T KNOW 99

PAQ.733 On average, for how long did {you/SP} play these active video games?

___________

Q/U

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MINUTES 1

HOURS 2

SOFT EDIT: IF THE HOURS EXCEED 4 SAY UNUSUAL.

SOFT EDIT: IF THE MINUTES ARE LESS THAN 10 CONFIRM THAT IT IS MINUTES NOT HOURS.

PAQ.677 In this question you can include activities done in school. On how many of the past 7 days did {you/SP} exercise or participate in physical activity for at least 20 minutes that made {you/him/her} sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar activities?

0 days 0

1 day 1

2 days 2

3 days 3

4 days 4

5 days 5

6 days 6

7 days 7

REFUSED 77

DON’T KNOW 99

PAQ.678 On how many of the past 7 days did {you/SP} do exercises to strengthen or tone {your/his/her} muscles, such as push-ups, sit-ups, or weight lifting?

0 days 0

1 day 1

2 days 2

3 days 3

4 days 4

5 days 5

6 days 6

7 days 7

REFUSED 77

DON’T KNOW 99

PAQ.740 The next questions ask about activities during the school year. If {you are/SP is} not currently in school, think about {your/his/her} activities when {you were/he was/she was} last in school.

Are students at {your/his/her} school allowed to use school facilities during lunch or during a free or elective period, such as the gymnasium, tennis courts, weight room, or track, during school time?

YES 1

NO 2 (PAQ.744)

REFUSED 7 (PAQ.744)

DON’T KNOW 9 (PAQ.744)

PAQ.742 {Do you/Does SP} use school facilities for physical activity during school time?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

PAQ.744 {Do you/does SP} have PE or gym during school days?

YES 1

NO 2 (PAQ.755)

REFUSED 7 (PAQ.755)

DON’T KNOW 9 (PAQ.755)

PAQ.746 How often {do you/does SP} have PE or gym?

1 day a week 1

2 days a week 2

3 days a week 3

4 days a week, or 4

Every day 5

REFUSED 7

DON’T KNOW 9

PAQ.748 On average, how long is the PE or gym class?

LESS THAN 30 MINUTES 1

30-45 MINUTES 2

MORE THAN 45 MINUTES 3

REFUSED 7

DON’T KNOW 9

PAQ.755 The following are activities that may be done before, during, or after school other than during PE or gym class. If {you are/SP is} not currently in school, think about {your/his/her} activities when {you were/he was/she was} last in school.} {Do you/Does SP} participate in school sports or physical activity clubs?

YES 1

NO 2 (PAQ.679)

REFUSED 7 (PAQ.679)

DON’T KNOW 9 (PAQ.679)

PAQ.759 In what school sports or physical activity clubs {do you/does SP} participate?

CODE ALL THAT APPLY

HAND CARD PAQ1

BASEBALL/SOFTBALL 1

BASKETBALL 2

BOCCE BALL 3

CHEERLEADING 4

DANCE 17

FOOTBALL 5

FRISBEE/ULTIMATE FRISBEE 18

GOLF 6

GYMNASTICS 7

HOCKEY 8

LACROSSE 9

RUNNING 19

SOCCER 10

SWIMMING/DIVING 11

TENNIS 12

TRACK AND FIELD 13

TRAMPOLINE 20

VOLLEYBALL 14

WRESTLING 15

OTHER (SPECIFY) 16

REFUSED 77

DON’T KNOW 99

BOX 1

CHECK ITEM PAQ.775:

IF MIA.065 = PROXY, SKIP TO PAQ.770.

OTHERWISE, CONTINUE.

PAQ.679 About how many minutes {do you/does SP} think you should exercise or be physically active each day for good health?

INTERVIEWER: This includes all activities like bicycling, dancing, and playing basketball that {SP does} at school, at home, and anywhere else {SP gets} exercise.

LESS THAN 10 MINUTES, 1

10-15 MINUTES, 2

16-30 MINUTES, 3

31-45 MINUTES, 4

46-60 MINUTES, OR 5

MORE THAN 60 MINUTES 6

REFUSED 7

DON’T KNOW 9

PAQ.750 I am going to read a statement and I want you to let me know if you strongly agree, agree, neither agree nor disagree, disagree or strongly disagree with the statement. I enjoy participating in PE or gym class.

HAND CARD PAQ2

Strongly agree 1

Agree 2

Neither agree nor disagree 3

Disagree 4

Strongly Disagree 5

REFUSED 7

DON’T KNOW 9

PAQ.770 In the past year, did {you/SP} receive a Physical Fitness Test award, such as a President’s Challenge or Fitnessgram award?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

PAQ.772 What Physical Fitness Test award did {you/SP} receive?

PROBE IF NEEDED: Examples of physical fitness test awards are the FITNESSGRAM and the PRESIDENT’S CHALLENGE.

CODE ALL THAT APPLY.

Fitnessgram 1

President’s Challenge 2

OTHER (SPECIFY) 3

REFUSED 7

DON’T KNOW 9

WEIGHT HISTORY (WHQ)

WEIGHT HISTORY – WHQ

Target Group: SPs 8-15 years

BOX 1

CHECK ITEM WHQ.499:

IF INTERVIEW DONE ONLY WITH SURVEY PARTICIPANT (CODED ‘1’) IN RIQ.005 AND NO INTERPRETER USED (INT.001 CODED ‘2’), CONTINUE WITH WHQ.030c.
IF INTERVIEW DONE WITH SURVEY PARTICIPANT (CODED ‘1’) IN RIQ.005 AND INTERPRETER USED (INT.001 CODED ‘1’), AND INTERPRETER SOURCE = 4, 5, 6, 7, OR 99 IN INT.007, CONTINUE WITH WHQ.030c.
OTHERWISE, GO TO NEXT SECTION.

WHQ.030c Do you consider yourself now to be . . .

fat or overweight, 1

too thin, or 2

about the right weight? 3

REFUSED 7

DON’T KNOW 9

WHQ.500 Which of the following are you trying to do about your weight:

lose weight, 1

gain weight, 2

stay the same weight, or. 3

not trying to do anything about your weight? 4

REFUSED 7

DON’T KNOW 9

WHQ.520 In the past year, how often have you tried to lose weight? Would you say . . .

never, 1 sometimes, or 2

a lot? 3

REFUSED 7

DON’T KNOW 9

BOX 2

CHECK ITEM WHQ.709:

IF SP AGE >= 12, CONTINUE.
OTHERWISE, GO TO END OF SECTION.

DBQ.895
G/Q

Next, I’m going to ask you about meals.

By meal, I mean breakfast, lunch and dinner. During the past 7 days, how many meals did you get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines?

Please do not include meals provided as part of the school lunch or school breakfast.

SOFT EDIT VALUES: 0-21

Error message: “Please verify that you ate more than 3 meals prepared away from home every day during the past 7 days.”

|___|___|

ENTER NUMBER

NONE 2 (DBQ.905)

REFUSED 77 (DBQ.905)

DON'T KNOW 99 (DBQ.905)

DBQ.900 How many of those meals did you get from a fast-food or pizza place?

G/Q

HARD EDIT: “DBQ.900 must be equal to or less than DBQ.895.”

Error message: "The number of meals from a fast-food or pizza place cannot be greater than the total number of meals you had that were prepared away from home. Could I have another answer please?"

|___|___|

ENTER NUMBER

NONE 2

REFUSED 77

DON'T KNOW 99

DBQ.905
G/Q/U

Some grocery stores sell “ready to eat” foods such as salads, soups, chicken, sandwiches and cooked vegetables in their salad bars and deli counters.

During the past 30 days, how often did you buy “ready to eat” foods at the grocery store? Please do not count frozen or canned foods.

|___|___|

ENTER NUMBER OF TIMES (PER DAY, WEEK, OR MONTH)

NEVER 2

REFUSED 77

DON’T KNOW 99

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

DBQ.910
G/Q/U

During the past 30 days, how often did you eat frozen meals or frozen pizzas? Here are some examples of frozen meals and frozen pizzas.

HAND CARD WHQ2

|___|___|

ENTER OF TIMES (PER DAY, WEEK, OR MONTH)

NEVER 2

REFUSED 77

DON’T KNOW 99

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

REFUSED 7

DON'T KNOW 9

MEC Interview critical items

MEC Interview

Critical Data Items

Verify Street Address

SCQ.070 I would like to verify {your/SP’s} address. Please give me {your/SP’s} complete address.

SCQ.420 Is {your/SP’s} mailing address the same as {your/SP’s} street address?

Validation Form Q7 Did {you/he/she} live at this address on {SCREENER DISPOSITION DATE}?

Verify Mailing Address

In case we have to contact {you/SP} again, please give me {your/his/her} complete mailing address.

Verify Phone Numbers

Please give me {your/SP’s} home telephone number.

Is there another number where {you/SP} can be reached? Where is that phone located?

Verify SSN

BOX 1

IF DMQ.281b FROM THE HOUSEHOLD INTERVIEW IS MISSING, CODED '222222222', OR CODED ‘999999999’, CONTINUE.
OTHERWISE, GO TO END OF SECTION.

DMQ.280a The National Center for Health Statistics will conduct statistical research by combining {your/his/her} survey data with vital, health, nutrition and other related records. {Your/SP’s} social security number is used only for these purposes and the Center will not release it to anyone, including any government agency, for any other reason. Providing this information is voluntary and is collected under the authority of Section 306 of the Public Health Service Act. There will be no effect on {your/his/her} benefits if you do not provide it.

DMQ.280b What is {your/SP’s} Social Security Number?

MEC QUESTIONNAIRE – ACASI
1. TOBACCO (SMQ)

Shape19 TOBACCO – SMQ

Target Group: SPs 12-17 (Audio-CASI)

SMQ.621__ The following questions are about cigarette smoking and other tobacco use. Do not include cigars or marijuana.

SMQ.621 About how many cigarettes have you smoked in your entire life?

INSTRUCTIONS TO SP:

Please select . . .

I have never smoked, not even a puff 1 (SMQ.681_)

1 or more puffs but never a whole cigarette 2 (SMQ.681_)

1 cigarette 3

2 to 5 cigarettes 4

6 to 15 cigarettes 5

16 to 25 cigarettes 6

26 to 99 cigarettes 7

100 or more cigarettes 8

REFUSED 77 (SMQ.681_)

DON'T KNOW 99 (SMQ.681_)

SMQ.632 How old were you when you smoked a whole cigarette for the first time?

SMQ.632a

INSTRUCTIONS TO SP:

Please enter an age.

CAPI INSTRUCTION:

COMBINATION CONTROL: NUMBER PAD: ENTER AGE

ACCEPTABLE VALUES: 6-18 YEARS, REFUSED, DON’T KNOW.

IF R ENTERS 1-5, STORE 6 YEARS.

HARD EDIT: IF SMQ.632 > RIAAGEYR THEN ERROR.

ERROR MESSAGE: "Your response is older than your recorded age. Please press the “Back” button, press “Clear,” and try again."

HARD EDIT: IF SMQ.632 = 0 THEN ERROR.

ERROR MESSAGE: "Your response must be greater than zero. Please press the “Back” button, press “Clear,” and try again."

|___|___|

ENTER AGE

AGE 1-18

REFUSED 77

DON'T KNOW 99

SMQ.641 During the past 30 days, on how many days did you smoke cigarettes?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

CAPI INSTRUCTION:

ACCEPTABLE VALUES: 0-30, REFUSED, DON’T KNOW

HARD EDIT: IF SMQ.641 > 30 THEN ERROR.

ERROR MESSAGE: "Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again."

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77

DON'T KNOW 99

BOX 1A

CHECK ITEM SMQ.645:

(IF 'NONE' (CODE '00'), 'REFUSED' (CODE '77'), OR 'DON'T KNOW' (CODE '99') IN SMQ.641) AND SMQ.621 NOT EQUAL TO 8, GO TO SMQ.681_.
(IF 'NONE' (CODE '00'), 'REFUSED' (CODE '77'), OR 'DON'T KNOW' (CODE '99') IN SMQ.641) AND SMQ.621 = 8, CONTINUE.

OTHERWISE, GO TO SMQ.650.

SMQ.050 How long has it been since you quit smoking cigarettes?

Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777

DON'T KNOW 99999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

BOX 1A1

CHECK ITEM SMQ.051:

IF SMQ.050 GREATER THAN OR EQUAL TO 1 YEAR (365 DAYS, 52 WEEKS, 12 MONTHS, OR 1 YEAR), CONTINUE.
IF SMQ.050 LESS THAN 30 DAYS GO TO SMQ.650.

OTHERWISE, GO TO SMQ.681_.

SMQ.055 How old were you when you last smoked cigarettes ?

INSTRUCTIONS TO SP:

Please enter an age.

CAPI INSTRUCTION:

HARD EDIT: IF RESPONSE IS LESS THAN SMQ.632, THEN ERROR.

ERROR MESSAGE: “Your response is earlier than your response to the age when you smoked a whole cigarette for the first time. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

BOX 1A2

CHECK ITEM SMQ.056:

GO TO SMQ.681_.

SMQ.650 During the past 30 days, on the days that you smoked, how many cigarettes did you smoke per day?

SMQ.650a

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTION:

IF R SAYS 95 OR MORE CIGARETTES PER DAY, STORE 95.

ACCEPTABLE VALUES: 1-95, REFUSED, DON’T KNOW

HARD EDIT: IF SMQ.650 = 0 THEN ERROR.

ERROR MESSAGE: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER NUMBER OF CIGARETTES

MORE THAN 1 PACK OF CIGARETTES 95

REFUSED 777

DON'T KNOW 999

SMQ.078 How soon after you wake up do you smoke? Would you say . . .

Within 5 minutes 1

From 6 to 30 minutes 2

From more than 30 minutes to one hour 3

From more than 1 hour to 2 hours 4

From more than 2 hours to 3 hours 5

From more than 3 hours to 4 hours 6

More than 4 hours 7

REFUSED 77

DON'T KNOW 99

SMQ.661 During the past 30 days, on the days that you smoked, which brand of cigarettes did you usually smoke?

INSTRUCTIONS TO SP:

Please select one of the following choices

Marlboro 1

Camel 2

Newport 3

Other brand 8

No usual brand 9

Hand-rolled cigarettes 10

REFUSED 77 (SMQ.670)

DON'T KNOW 99 (SMQ.670)

BOX 1B

CHECK ITEM SMQ.663:

IF MARLBORO BRAND (CODE ‘1’), GO TO SMQ,665A.

IF CAMEL (CODE ‘2’), GO TO SMQ.665B.

IF NEWPORT (CODE ‘3’), GO TO SMQ.665C.

IF OTHER BRAND (CODE ‘8’), GO TO SMQ.665D.

OTHERWISE, GO TO SMQ.670.

SMQ.665A Please select the Marlboro pack that looks most like the brand that you smoke. If the pack you smoke is not shown, select ‘other Marlboro.’

CAPI INSTRUCTIONS: SHOW IMAGES OF MARLBORO RED, MARLBORO RED 83S, MARLBORO GOLD, MARLBORO GOLD MENTHOL, MARLBORO SILVER, MARLBORO BLACK, MARLBORO MENTHOL FF AND OTHER MARLBORO.

MARLBORO RED 1 (SMQ.670)

MARLBORO RED 83S 2 (SMQ.670)

MARLBORO GOLD 3 (SMQ.670)

MARLBORO GOLD MENTHOL 4 (SMQ.670)

MARLBORO SILVER 5 (SMQ.670)

MARLBORO BLACK 6 (SMQ.670)

MARLBORO MENTHOL FF 7 (SMQ.670)

OTHER MARLBORO 8 (SMQ.670)

REFUSED 77 (SMQ.670)

DON'T KNOW 99 (SMQ.670)

SMQ.665B Please select the Camel pack that looks most like the brand that you smoke. If the pack you smoke is not shown, select ‘other Camel.’

CAPI INSTRUCTIONS: SHOW IMAGES OF CAMEL FILTERS, CAMEL BLUE, CAMEL CRUSH, CAMEL CRUSH BOLD, CAMEL MENTHOL, CAMEL MENTHOL SILVER, AND OTHER CAMEL.

CAMEL FILTERS 1 (SMQ.670)

CAMEL BLUE 2 (SMQ.670)

CAMEL CRUSH 3 (SMQ.670)

CAMEL CRUSH BOLD 4 (SMQ.670)

CAMEL MENTHOL 5 (SMQ.670)

CAMEL MENTHOL SILVER 6 (SMQ.670)

OTHER CAMEL 7 (SMQ.670)

REFUSED 77 (SMQ.670)

DON'T KNOW 99 (SMQ.670)

SMQ.665C Please select the Newport pack that looks most like the brand that you smoke. If the pack you smoke is not shown, select ‘other Newport.’

CAPI INSTRUCTIONS: SHOW IMAGES OF NEWPORT FF, NEWPORT MENTHOL GOLD, AND OTHER NEWPORT.

NEWPORT FF 1 (SMQ.670)

NEWPORT MENTHOL GOLD 2 (SMQ.670)

OTHER NEWPORT 3 (SMQ.670)

REFUSED 77 (SMQ.670)

DON'T KNOW 99 (SMQ.670)

SMQ.665D Please select the pack that looks most like the brand that you smoke. If the pack you smoke is not shown, select ‘other brand of cigarette.’

CAPI INSTRUCTIONS: SHOW IMAGES OF BASIC FF, DORAL RED 100S, DORAL MENTHOL GOLD BOX 100S, GPC FF, GPC FF MENTHOL, KOOL BLUE MENTHOL 100S, KOOL TRUE MENTHOL, VIRGINIA SLIMS FF, AND OTHER BRAND.

BASIC FF 1

DORAL RED 100S 2

DORAL MENTHOL GOLD BOX 100S 3

GPC FF 4

GPC FF MENTHOL 5

KOOL BLUE MENTHOL 100S 6

KOOL TRUE MENTHOL 7

VIRGINIA SLIMS FF 8

OTHER BRAND 9

REFUSED 77

DON'T KNOW 99

SMQ.670 During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SMQ.681_ The following questions ask about use of tobacco products in the past 5 days.

SMQ.681 During the past 5 days, including today, did you smoke cigarettes, pipes, cigars, little cigars or cigarillos, water pipes, hookahs, or e-cigarettes?

INSTRUCTIONS TO SP:

Please select . . .

CAPI INSTRUCTIONS:

If SMQ.621 = 1 OR 2 or SMQ.641 = 00 then do not display {“cigarettes, “}

Recording Note: 2 wave files needed one with and one without the word cigarettes.

Yes 1

No 2 (SMQ.851)

REFUSED 7 (SMQ.851)

DON’T KNOW 9 (SMQ.851)

BOX 1C

CHECK ITEM SMQ.850:

IF SMQ.621 = 1 OR 2 or SMQ.641 = 00, GO TO SMQ.692B

OTHERWISE, CONTINUE WITH SMQ.692A.

SMQ.692A Which of these products did you smoke? (CHECK ALL THAT APPLY)

INSTRUCTIONS TO SP:

Please select all that you used.

Cigarettes 1 (BOX 2)

Pipes 2 (BOX 2)

Cigars or little cigars or cigarilllos 3 (BOX 2)

Water pipes or Hookahs 4 (BOX 2)

E-cigarettes……………………….. 5 (BOX 2)

REFUSED 77 (SMQ.851)

DON’T KNOW 99 (SMQ.851)

SMQ.692B Which of these products did you smoke? (CHECK ALL THAT APPLY)

INSTRUCTIONS TO SP:

Please select all that you used.

Pipes 1

Cigars, or little cigars, or cigarilllos 2

Water pipes or Hookahs 3

E-cigarettes 4

REFUSED 77 (SMQ.851)

DON’T KNOW 99 (SMQ.851)

BOX 2

CHECK ITEM SMQ.701:

IF ‘CIGARETTES’ (CODE 1) IN SMQ.692A, GO TO SMQ.710.
IF ‘PIPES’ (CODE 2) IN SMQ.692A OR (CODE 1) IN SMQ.692B, GO TO SMQ.740.
IF ‘CIGARS’ (CODE 3) IN SMQ.692A OR (CODE 2) IN SMQ.692B, GO TO SMQ.771.
IF ‘WATER PIPE OR HOOKAH’ (CODE 4) IN SMQ.692A OR (CODE 3) IN SMQ.692B, GO TO SMQ.845.
IF ‘E-CIGARETTE’ (CODE 5) IN SMQ.692A OR (CODE 4) IN 692B, GO TO SMQ.849.

SMQ.710 During the past 5 days, including today, on how many days did you smoke cigarettes?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.710 < 1 OR SMQ.710 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.720 During the past 5 days, including today, on the days you smoked, how many cigarettes did you smoke each day?

SMQ.720a

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTION:

IF R SAYS 95 OR MORE CIGARETTES PER DAY, STORE 95.

HARD EDIT: IF SMQ.720 = 0 THEN ERROR.

ERROR MESSAGE: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER NUMBER OF CIGARETTES

MORE THAN 1 PACK OF CIGARETTES 95

REFUSED 777

DON'T KNOW 999

SMQ.725 When did you smoke your last cigarette? Was it . . .

Today 1

Yesterday 2

3 to 5 days ago 3

REFUSED 7

DON'T KNOW 9

BOX 3

CHECK ITEM SMQ.731:

IF ‘PIPES’ (CODE 2) IN SMQ.692A OR (CODE 1) IN SMQ.692B, GO TO SMQ.740.
IF ‘CIGARS’ (CODE 3) IN SMQ.692A OR (CODE 2) IN SMQ.692B, GO TO SMQ.771.
IF ‘WATER PIPE OR HOOKAH (CODE 4) IN SMQ.692A OR (CODE 3) IN SMQ.692B, GO TO SMQ.845.
IF ‘E-CIGARETTE’ (CODE 5) IN SMQ.692A OR (CODE 4) IN SMQ.692B, GO TO SMQ.849.
OTHERWISE, GO TO SMQ.851.

SMQ.740 During the past 5 days, including today, on how many days did you smoke a pipe?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.740 < 1 OR SMQ.740 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 4

CHECK ITEM SMQ.761:

IF ‘CIGARS’ (CODE 3) IN SMQ.692A OR (CODE 2) IN SMQ.692B, GO TO SMQ.771.
IF ‘WATER PIPES OR HOOKAH’ (CODE 4) IN SMQ.692A OR (CODE 3) IN SMQ.692B, GO TO SMQ.SMQ.845.
IF E-CIGARETTE’ (CODE 5) IN SMO.692A OR (CODE 4) IN SMQ.692B, GO TO SMQ.849
OTHERWISE, GO TO SMQ.851.

SMQ.771 During the past 5 days, including today, on how many days did you smoke cigars or little cigars or cigarillos?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.771 < 1 OR SMQ.771 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 5

CHECK ITEM SMQ.791:

IF ‘WATERPIPE’ (CODE 4) IN SMQ.692A OR (CODE 3) IN SMQ.692B, GO TO SMQ.845.
IF ‘E-CIGARETTE’ (CODE 5) IN SMQ.692A OR (CODE 4) IN SMQ.692B, GO TO SMQ.849
OTHERWISE GO TO SMQ.851.

SMQ.845 During the past 5 days, including today, on how many days did you smoke tobacco in a water pipe or hookah?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.845 < 1 OR SMQ.845 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 6

CHECK ITEM SMQ.847:

IF ‘E-CIGARETTE’ (CODE 5) IN SMQ692A OR (CODE 4) IN SMQ.692B, GO TO SMQ.849.
OTHERWISE GO TO SMQ.851.

SMQ.849 During the past 5 days, including today, on how many days did you smoke an e-cigarette?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

IF SMQ.849 < 1 OR SMQ.849 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.851_ Smokeless tobacco products are placed in the mouth or nose and can include chewing tobacco, snuff, snus or dissolvable tobacco.

SMQ.851 During the past 5 days, including today, did you use any smokeless tobacco?

INSTRUCTIONS TO SP:

Please do not include nicotine replacement therapy products like patches, gum, lozenge or spray which are considered products to help you stop smoking.

Please select . . .

CAPI INSTRUCTIONS:

Yes 1

No 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

SMQ.853 Which of these products did you use? (CHECK ALL THAT APPLY)

INSTRUCTIONS TO SP:

Please select all that you used.

Chewing tobacco 1

Snuff 2

Snus 3

Dissolvables 4

REFUSED 77 (END OF SECTION)

DON’T KNOW 99 (END OF sECTION)

BOX 7

CHECK ITEM SMQ.855:

IF ‘CHEWING’ (CODE 1) IN SMQ.853, GO TO SMQ.800.
IF ‘SNUFF’ (CODE 2) IN SMQ.853, GO TO SMQ.817.
IF ‘SNUS’ (CODE 3) IN SMQ.853, GO TO SMQ.857.
IF ‘DISSOLVABLES’ (CODE 4) IN SMQ.853, GO TO SMQ.861.

SMQ.800 During the past 5 days, including today, on how many days did you use chewing tobacco, such as Redman, Levi Garrett or Beechnut?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.800 < 1 OR SMQ.800 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 8

CHECK ITEM SMQ.818:

IF ‘SNUFF’ (CODE 2) IN SMQ.853, GO TO SMQ.817.
IF ‘SNUS’ (CODE 3) IN SMQ.853, GO TO SMQ.857.
IF ‘DISSOLVABLES’ (CODE 4) IN SMQ.853, GO TO SMQ.861.

OTHERWISEEND OF SECTION

SMQ.817 During the past 5 days, including today, on how many days did you use snuff, such as Skoal, Skoal Bandits, or Copenhagen?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.817 < 1 OR SMQ.817 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 9

CHECK ITEM SMQ.821:

IF ‘SNUS’ (CODE 3) IN SMQ.853, GO TO SMQ.857.
IF ‘DISSOLVABLES’ (CODE 4) IN SMQ.853, GO TO SMQ.861.

OTHERWISE, END OF SECTION

SMQ.857 During the past 5 days, including today, on how many days did you use snus?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.857 < 1 OR SMQ.857 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 10

CHECK ITEM SMQ.859:

IF ‘DISSOLVABLES’ (CODE 4) IN SMQ.853, GO TO SMQ.861.

OTHERWISE, END OF SECTION

SMQ.861 During the past 5 days, including today, on how many days did you use dissolvables such as strips or orbs?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.861 < 1 OR SMQ.861 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

DON’T KNOW 9 (END OF SECTION)

ALCOHOL use (ALQ)

ALCOHOL use – ALQ

Target Group: SPs 12-17 (Audio-CASI)

ALQ.010_ The following questions ask about alcohol use. This includes beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. This does not include drinking a few sips of wine for religious purposes.

ALQ.010 How old were you when you had your first drink of alcohol, other than a few sips?

INSTRUCTIONS TO SP:

Please select one of the following choices.

HARD EDIT: If (RIAAGEYR < 17 and ALQ.010 = 7) OR (RIAAGEYR < 15 and ALQ.010 in (6, 7)) OR (RIAAGEYR < 13 and ALQ.010 in (5, 6, 7)) then ERROR

Error message: “Your response is older than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

I have never had a drink of alcohol other
than a few sips 1 (END OF SECTION)

8 years old or younger 2

9 or 10 years old 3

11 or 12 years old 4

13 or 14 years old 5

15 or 16 years old 6

17 years old or older 7

REFUSED 77

DON'T KNOW 99

ALQ.022 During your life, on how many days have you had at least one drink of alcohol?

INSTRUCTIONS TO SP:

Please select one of the following choices.

1 or 2 days 2

3 to 9 days 3

10 to 19 days 4

20 to 39 days 5

40 to 99 days 6

100 or more days 7

REFUSED 77

DON'T KNOW 99

ALQ.031 During the past 30 days, on how many days did you have at least one drink of alcohol?

INSTRUCTIONS TO SP:

Please select one of the following choices.

HARD EDIT: If (ALQ.022 = 2 and ALQ.031 in (3,4,5,6,7)) or (ALQ.022 =3 and ALQ.031 in (5,6,7)) or (ALQ.022 = 4 and ALQ.031 in (6,7)) then ERROR

Error message: “Your response is not consistent with your lifetime use. Please press the “Back” button, press “Clear,” and try again.”

0 days 1 (END OF SECTION)

1 or 2 days 2

3 to 5 days 3

6 to 9 days 4

10 to 19 days 5

20 to 29 days 6

All 30 days 7

REFUSED 77

DON'T KNOW 99

ALQ.041 During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours?

INSTRUCTIONS TO SP:

Please select one of the following choices.

HARD EDIT: If (ALQ.031= 2 and ALQ.041 in (4,5,6,7)) or (ALQ.031=3 and ALQ.041 in (5,6,7)) or (ALQ.031 = 4 and ALQ.041 in (6,7)) or (ALQ.031 = 5 and ALQ.041 = 7) then ERROR

Error message: “Your response is not consistent with your use in the past 30 days. Please press the “Back” button, press “Clear,” and try again.”

0 days 1

1 day 2

2 days 3

3 to 5 days 4

6 to 9 days 5

10 to 19 days 6

20 or more days 7

REFUSED 77

DON'T KNOW 99

DRUG USE (DUQ)

DRUG USE – DUQ

Target Group: SPs 12-69 (Audio-CASI)

DUQ.200_ The following questions ask about use of drugs not prescribed by a doctor. Please remember that your answers to these questions are strictly confidential.

BOX 1a

CHECK ITEM DUQ.201:

IF 60 – 69 YEARS GO TO DUQ.240.
ELSE CONTINUE.

DUQ.200 The first questions are about marijuana and hashish. Marijuana is also called pot or grass. Marijuana is usually smoked, either in cigarettes, called joints, or in a pipe. It is sometimes cooked in food. Hashish is a form of marijuana that is also called “hash.” It is usually smoked in a pipe. Another form of hashish is hash oil.

Have you ever, even once, used marijuana or hashish?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.240)

REFUSED 7 (DUQ.240)

DON'T KNOW 9 (DUQ.240)

DUQ.210 How old were you the first time you used marijuana or hashish?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: DUQ.210 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

DUQ.211 Have you ever smoked marijuana or hashish at least once a month for more than one year?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.220G)

REFUSED 7 (DUQ.220G)

DON'T KNOW 9 (DUQ.220G)

DUQ.213 How old were you when you started smoking marijuana or hashish at least once a month for one year?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: DUQ.213 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: DUQ.213 must be equal to or greater than DUQ.210.

Error message: “Your response is earlier than your response to the age when you first used marijuana or hashish. Please press the “Back” button, press “Clear,” and try again.”

DUQ.215 How long has it been since you last smoked marijuana or hashish at least once a month for one year?

INSTRUCTIONS TO SP: Please enter the number of days, weeks, months, or years, then select the unit of time.

CAPI INSTRUCTIONS:

HARD EDIT: If DUQ.215 equal to 0 weeks, 0 months, or 0 years, display error message.

Error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

DUQ.217 During the time that you smoked marijuana or hashish, how often would you usually use it?

INSTRUCTIONS TO SP:

Please select . . .

Once per month 1

2-3 times per month 2

4-8 times per month (about 1-2 times per

week) 3

9-24 times per month (about 3-6 times per

week) 4

25-30 times per month (one or more times

per day) 5

REFUSED 7

DON'T KNOW 9

DUQ.219 During the time that you smoked marijuana or hashish, how many joints or pipes would you usually smoke in a day?

INSTRUCTIONS TO SP:

Please select . . .

1 per day 1

2 per day 2

3-5 per day 3

Six or more per day 4

REFUSED 7

DON'T KNOW 9

DUQ.220 How long has it been since you last used marijuana or hashish?

G/Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

CAPI INSTRUCTIONS:

If SP Ref/DK then store 7/9 in DUQ.220G and DUQ.220U, 7/9-fill in DUQ.220Q.

If a value is entered in Quantity and Unit store Quantity in DUQ.220Q, Unit in DUQ.220U and 1 in DUQ.220G.

HARD EDIT: Response must be equal to or less than current age minus DUQ.210.

Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: If DUQ.220 equal to 0 weeks, 0 months, or 0 years, display error message.

Error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

BOX 1

CHECK ITEM DUQ.225:

IF SP USED MARIJUANA WITHIN THE PAST MONTH (CODED 0-30 DAYS, OR 1-4 WEEKS, OR 1 MONTH IN DUQ.220), CONTINUE WITH DUQ.230.
OTHERWISE, GO TO DUQ.240.

DUQ.230 During the past 30 days, on how many days did you use marijuana or hashish?

INSTRUCTIONS TO SP:

Please enter a number.

HARD EDIT VALUES: 1-30.

If DUQ.230 = 0, display error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

If DUQ.230 > 30, display error message: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER A NUMBER

REFUSED 77

DON'T KNOW 99

DUQ.240 Have you ever used cocaine, crack cocaine, heroin, or methamphetamine?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.370_)

REFUSED 7 (DUQ.370_)

DON'T KNOW 9 (DUQ.370_)

DUQ.250_ The following questions are about cocaine, including all the different forms of cocaine such as powder, ‘crack’, ‘free base’, and coca paste.

DUQ.250 Have you ever, even once, used cocaine, in any form?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.290_)

REFUSED 7 (DUQ.290_)

DON'T KNOW 9 (DUQ.290_)

BOX 2a

CHECK ITEM DUQ.255:

IF 60 – 69 YEARS GO TO DUQ.290_.
ELSE CONTINUE.

DUQ.260 How old were you the first time you used cocaine, in any form?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: DUQ.260 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

DUQ.270 How long has it been since you last used cocaine, in any form?

G/Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select unit of time.

CAPI INSTRUCTIONS:

If SP Ref/DK then store 7/9 in DUQ.270G and DUQ.270U, 7/9-fill in DUQ.270Q.

If a value is entered in Quantity and Unit store Quantity in DUQ.270Q, Unit in DUQ.270U and 1 in DUQ.270G.

HARD EDIT: Response must be equal to or less than current age minus DUQ.260.

Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: If DUQ.270 equal to 0 weeks, 0 months, or 0 years, display error message.

Error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

DUQ.272 During your life, altogether how many times have you used cocaine, in any form?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Once 1

2-5 times 2

6-19 times 3

20-49 times 4

50-99 times 5

100 times or more 6

REFUSED 77

DON’T KNOW 99

BOX 2

CHECK ITEM DUQ.275:

IF SP USED COCAINE WITHIN THE PAST MONTH (CODED 0-30 DAYS, OR 1-4 WEEKS, OR 1 MONTH IN DUQ.270), CONTINUE WITH DUQ.280.
OTHERWISE, GO TO DUQ.290_.

DUQ.280 During the past 30 days, on how many days did you use cocaine, in any form?

INSTRUCTIONS TO SP:

Please enter a number.

HARD EDIT VALUES: 1-30.

If DUQ.280 = 0, display error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

If DUQ.280 > 30, display error message: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER A NUMBER

REFUSED 77

DON'T KNOW 99

DUQ.290_ The following questions are about heroin.

DUQ.290 Have you ever, even once, used heroin?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.330_)

REFUSED 7 (DUQ.330_)

DON'T KNOW 9 (DUQ.330_)

BOX 3a

CHECK ITEM DUQ.295:

IF SP 60-69 YEARS GO TO DUQ.330_.
OTHERWISE, CONTINUE.

DUQ.300 How old were you the first time you used heroin?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: DUQ.300 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

DUQ.310 How long has it been since you last used heroin?

G/Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

CAPI INSTRUCTIONS:

If SP Ref/DK then store 7/9 in DUQ.310G and DUQ.310U, 7/9-fill in DUQ.310Q.

If a value is entered in Quantity and Unit store Quantity in DUQ.310Q, Unit in DUQ.310U and 1 in DUQ.310G.

HARD EDIT: Response must be equal to or less than current age minus DUQ.300.

Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: If DUQ.310 equal to 0 weeks, 0 months, or 0 years, display error message.

Error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

BOX 3

CHECK ITEM DUQ.315:

IF SP USED HEROIN WITHIN THE PAST MONTH (CODED 0-30 DAYS, OR 1-4 WEEKS, OR 1 MONTH IN DUQ.310), CONTINUE WITH DUQ.320.
OTHERWISE, GO TO DUQ.330_.

DUQ.320 During the past 30 days, on how many days did you use heroin?

INSTRUCTIONS TO SP:

Please enter a number.

HARD EDIT VALUES: 1-30.

If DUQ.320 = 0, display error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

If DUQ.320 > 30, display error message: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER A NUMBER

REFUSED 77

DON'T KNOW 99

DUQ.330_ The following questions are about methamphetamine, also known as crank, crystal, ice or speed.

DUQ.330 Have you ever, even once, used methamphetamine?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.370_)

REFUSED 7 (DUQ.370_)

DON'T KNOW 9 (DUQ.370_)

BOX 4a

CHECK ITEM DUQ.335:

IF SP 60-69 YEARS GO TO DUQ.370_.
OTHERWISE, CONTINUE.

DUQ.340 How old were you the first time you used methamphetamine?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: DUQ.340 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

DUQ.350 How long has it been since you last used methamphetamine?

G/Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

CAPI INSTRUCTIONS:

If SP Ref/DK then store 7/9 in DUQ.350G and DUQ.350U, 7/9-fill in DUQ.350Q.

If a value is entered in Quantity and Unit store Quantity in DUQ.350Q, Unit in DUQ.350U and 1 in DUQ.350G.

HARD EDIT: Response must be equal to or less than current age minus DUQ.340.

Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: If DUQ.350 equal to 0 weeks, 0 months, or 0 years, display error message.

Error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

DUQ.352 During your life, altogether how many times have you used methamphetamine?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Once 1

2-5 times 2

6-19 times 3

20-49 times 4

50-99 times 5

100 times or more 6

REFUSED 77

DON’T KNOW 99

BOX 4

CHECK ITEM DUQ.355:

IF SP USED METHAMPHETAMINE WITHIN THE PAST MONTH (CODED 0-30 DAYS, OR 1-4 WEEKS, OR 1 MONTH IN DUQ.350), CONTINUE WITH DUQ.360.
OTHERWISE, GO TO DUQ.370_.

DUQ.360 During the past 30 days, on how many days did you use methamphetamine?

INSTRUCTIONS TO SP:

Please enter a number.

HARD EDIT VALUES: 1-30.

If DUQ.360 = 0, display error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

If DUQ.360 > 30, display error message: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER A NUMBER

REFUSED 77

DON'T KNOW 99

DUQ.370_ The following questions are about the different ways that certain drugs can be used.

DUQ.370 Have you ever, even once, used a needle to inject a drug not prescribed by a doctor?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (BOX 5)

REFUSED 7 (BOX 5)

DON'T KNOW 9 (BOX 5)

DUQ.380 Which of the following drugs have you injected using a needle?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select all the drugs that you injected.

CAPI INSTRUCTION:

SHOW ALL FIVE ITEMS ON SINGLE ACASI SCREEN

Cocaine 1

Heroin 2

Methamphetamine 3

Steroids 4

Any other drugs 5

REFUSED 7

DON'T KNOW 9

DUQ.390 How old were you when you first used a needle to inject any drug not prescribed by a doctor?

(Target 12-69)

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-69

Error message: “Your response cannot exceed 69 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: DUQ.390 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

DUQ.400 How long ago has it been since you last used a needle to inject a drug not prescribed by a doctor?

G/Q/U

(Target 12-69) INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

CAPI INSTRUCTIONS:

If SP Ref/DK then store 7/9 in DUQ.400G and DUQ.400U, 7/9-fill in DUQ.400Q.

If a value is entered in Quantity and Unit store Quantity in DUQ.400Q, Unit in DUQ.400U and 1 in DUQ.400G.

HARD EDIT: Response must be equal to or less than current age minus DUQ.390.

Error message: “Your response to time of last use is earlier than your response to age of first use. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: If DUQ.400 equal to 0 weeks, 0 months, or 0 years, display error message.

Error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 7777

DON'T KNOW 9999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

DUQ.410 During your life, altogether how many times have you injected drugs not prescribed by a doctor?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select one of the following choices.

Once 1 (BOX 5)

2-5 times 2

6-19 times 3

20-49 times 4

50-99 times 5

100 times or more 6

REFUSED 77

DON’T KNOW 99

DUQ.420 Think about the period of your life when you injected drugs the most often. How often did you inject then?

(Target 12-69)

INSTRUCTIONS TO SP:

Please select one of the following choices.

More than once a day 1

About once a day 2

At least once a week but not every day 3

At least once a month but not every week 4

Less than once a month 5

REFUSED 7

DON’T KNOW 9

BOX 5

CHECK ITEM DUQ.426:

IF SP 60-69 YEARS, GO TO END OF SECTION.
IF SP HAS USED MARIJUANA (CODED ‘1’) IN DUQ.200 OR SP HAS USED COCAINE, HEROIN, OR METHAMPHETAMINE (CODED ‘1’) IN DUQ.240, OR SP HAS INJECTED ANY DRUG NOT PRESCRIBED BY A DOCTOR (CODED ‘1’) IN DUQ.370, GO TO DUQ.430.
OTHERWISE, GO TO END OF SECTION.

DUQ.430 Have you ever been in a drug treatment or drug rehabilitation program?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SEXUAL BEHAVIOR (SXQ)

SEXUAL BEHAVIOR – (SXQ)

Target Group: Female SPs 14-69 (Audio-CASI)

SXQ.615_ The next set of questions is about your sexual history. By sex, we mean vaginal, oral, or anal sex. Please remember that your answers are strictly confidential.

BOX 1B

CHECK ITEM SXQ.773:

IF SP AGE GREATER THAN 17, GO TO SXQ.700.
OTHERWISE, CONTINUE.

SXQ.615 Have you ever had any kind of sex?

(Target 14-17)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (BOX 11)

REFUSED 7 (BOX 11)

DON'T KNOW 9 (BOX 11)

SXQ.700 Have you ever had vaginal sex, also called sexual intercourse, with a man? This means a man’s penis in your vagina.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.703 Have you ever performed oral sex on a man? This means putting your mouth on a man’s penis or genitals.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.706 Have you ever had anal sex? This means contact between a man’s penis and your anus or butt.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.709 Have you ever had any kind of sex with a woman? By sex, we mean sexual contact with another woman’s vagina or genitals.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 1A

CHECK ITEM SXQ.762:

IF SP 60-69 YEARS AND SXQ.703 OR SXQ.709 = 1 AND SXQ.700 = 2 AND SXQ.706 = 2, GO TO END OF SECTION.
IF SXQ.700, SXQ.706, AND SXQ.709 NOT EQUAL TO ‘1’ AND SXQ.703 = 1, GO TO BOX 4.
IF SXQ.700, SXQ.703, SXQ.706, AND SXQ.709 NOT EQUAL TO ‘1’, GO TO BOX 11. OTHERWISE, CONTINUE

SXQ.618
(Target 14-69)

How old were you the first time you had any kind of sex, including {vaginal, anal, or oral / vaginal or anal / vaginal or oral / anal or oral / vaginal / anal / oral}?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF SXQ.700 AND SXQ.703 = 1 AND SXQ.706 NOT EQUAL TO ‘1’, DISPLAY {vaginal or oral}.

IF SXQ.700 AND SXQ.709 = 1 AND SXQ.706 NOT EQUAL TO ‘1’, DISPLAY {vaginal or oral}.

IF SXQ.700 AND SXQ.706 = 1 AND SXQ.703 AND SXQ.709 NOT EQUAL TO ‘1’, DISPLAY {vaginal or anal}.

IF SXQ.703 AND SXQ.706 = 1 AND SXQ.700 NOT EQUAL TO ‘1’, DISPLAY {anal or oral}.

IF SXQ.706 AND SXQ.709 = 1 AND SXQ.700 NOT EQUAL TO ‘1’, DISPLAY {anal or oral}.

IF SXQ.700 = 1 AND SXQ.703, SXQ.706, AND SXQ.709 NOT EQUAL TO ‘1’, DISPLAY {vaginal}.

IF SXQ.706 = 1 AND SXQ.700, SXQ.703, AND SXQ.709 NOT EQUAL TO ‘1’, DISPLAY {anal}.

IF SXQ.709 = 1 AND SXQ.700, AND SXQ.706 NOT EQUAL TO ‘1’, DISPLAY {oral}.

OTHERWISE, DISPLAY {vaginal, anal, or oral}.

HARD EDIT VALUES: 0-69

Error message: “Your response cannot exceed 69 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.618 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 1

CHECK ITEM SXQ.701:

IF SP 60-69 YEARS, GO TO SXQ.712.
IF SXQ.703 = 1 AND SXQ.700 AND SXQ.706 NOT EQUAL TO ‘1’, GO TO BOX 3.
IF SXQ.700 = 1 AND SXQ.703 AND SXQ.706 NOT EQUAL TO ‘1’, GO TO BOX 3.
IF SXQ.709 = 1 AND SXQ.700, SXQ.703, AND SXQ.706 NOT EQUAL TO ‘1’, GO TO BOX 3.
OTHERWISE, CONTINUE.

SXQ.712 In your lifetime, with how many men have you had any kind of sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.712 must be greater than 0.

Error message: “Your response is not consistent with your previous responses about male sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 2

CHECK ITEM SXQ.715:

IF SP 60-69 YEARS, GO TO END OF SECTION.
OTHERWISE, GO TO SXQ.718

SXQ.718 In the past 12 months, with how many men have you had any kind of sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.718 must be equal to or less than SXQ.712.

Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 3

CHECK ITEM SXQ.721:

IF SXQ.700 = 1, GO TO SXQ.724.
OTHERWISE, GO TO BOX 4.

SXQ.724 In your lifetime, with how many men have you had vaginal sex? Vaginal sex means a man’s penis in your vagina.

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.724 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about male vaginal sex partners. Please press the “Back” button, press “Clear,” and try again."

HARD EDIT: SXQ.724 must be equal to or less than SXQ.712.

Error message: "Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.727 In the past 12 months, with how many men have you had vaginal sex? Vaginal sex means a man’s penis in your vagina.

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.727 must be equal to or less than SXQ.724.

Error message: “Your response is greater than your lifetime number of male vaginal sex partners. Please press the “Back” button, press “Clear”, and try again.”

SOFT EDIT: SXQ.727 must be equal to or less than SXQ.718.

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

BOX 4

CHECK ITEM SXQ.730:

IF SP 60-69 YEARS, GO TO END OF SECTION.
IF SXQ.703 = 1, GO TO SXQ.621.
OTHERWISE, GO TO BOX 6.

SXQ.621 How old were you when you first performed oral sex on a man? Performing oral sex means your mouth on a man’s penis or genitals.

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.621 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

SXQ.624 In your lifetime, on how many men have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.624 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about male oral sex partners. Please press the “Back” button, press “Clear,” and try again."

SXQ.627 In the past 12 months, on how many men have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.627 must be equal to or less than SXQ.624.

Error message: “Your response is greater than your lifetime number of male oral sex partners. Please press the “Back” button, press “Clear,” and try again.”

SOFT EDIT: SXQ.627 must be equal to or less than SXQ.718.

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

BOX 5

CHECK ITEM SXQ.765:

IF SP HAD ONLY 1 LIFETIME ORAL SEX PARTNER (CODED ‘1’) IN SXQ.624, GO TO BOX 6.
OTHERWISE CONTINUE.

SXQ.630 How long has it been since the last time you performed oral sex on a new male partner? A new sexual partner is someone that you had never had sex with before.

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777

DON'T KNOW 99999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

HARD EDIT: Response must be equal to or less than current age minus SXQ.621.

Error message: “Your response is earlier than your response to the age when you first performed oral sex on a man. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.630 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 6

CHECK ITEM SXQ.733:

IF SXQ.709 = 1, GO TO SXQ.736.
OTHERWISE, GO TO BOX 7.

SXQ.736 In your lifetime with how many women have you had sex? By sex, we mean sexual contact with another woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.736 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about sex with a female partner. Please press the “Back” button, press “Clear,” and try again."

SXQ.739 In the past 12 months, with how many women have you had sex? By sex, we mean sexual contact with another woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.739 must be equal to or less than SXQ.736.

Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear”, and try again.”

SXQ.741 Have you ever performed oral sex on a woman? Performing oral sex means your mouth on a woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (BOX 7A)

REFUSED 7 (BOX 7A)

DON'T KNOW 9 (BOX 7A)

SXQ.633 How old were you when you first performed oral sex on a woman? Performing oral sex means your mouth on a woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.633 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

SXQ.636 In your lifetime, on how many women have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.636 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about female oral sex partners. Please press the “Back” button, press “Clear,” and try again."

SXQ.639 In the past 12 months, on how many women have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.639 must be equal to or less than SXQ.636.

Error message: “Your response is greater than your lifetime number of female oral sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 6B

CHECK ITEM SXQ.768:

IF SP HAD ONLY 1 LIFETIME ORAL SEX PARTNER (CODED ‘1’) IN SXQ.636, GO TO BOX 7A.
OTHERWISE, CONTINUE.

SXQ.642 How long has it been since the last time you performed oral sex on a new female partner? A new sexual partner is someone that you had never had sex with before.

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777

DON'T KNOW 99999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

HARD EDIT: Response must be equal to or less than current age minus SXQ.633.

Error message: “Your response is earlier than your response to the age when you first performed oral sex on a woman. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.642 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 7A

CHECK ITEM SXQ.744:

IF SP DID NOT HAVE A PARTNER IN PAST 12 MONTHS (SXQ.718, SXQ.727, SXQ.627, SXQ.639, AND SXQ.739 CODED ‘0000’ OR MISSING), GO TO SXQ.260.
IF SXQ.709 = 1 AND SXQ.700, SXQ.703, OR SXQ.706 = 1, THEN DISPLAY “The next set of questions is about all of your partners, males and females.”, THEN GO TO BOX 7.
OTHERWISE, GO TO BOX 7.

BOX 7

CHECK ITEM SXQ.747:

IF SP HAD ORAL SEX PARTNER IN PAST 12 MONTHS (SXQ.627 OR SXQ.639 GREATER THAN ‘0000’), THEN GO TO SXQ.645.
OTHERWISE, GO TO BOX 7B.

SXQ.645 When you performed oral sex in the past 12 months, how often would you use protection, like a condom or dental dam?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 1

Rarely 2

Usually 3

Always 4

Unsure 5

REFUSED 7

DON'T KNOW 9

BOX 7B

CHECK ITEM SXQ.771:

IF SXQ.718, SXQ.727, OR SXQ.739 GREATER THAN ‘0000’, GO TO SXQ.648.
OTHERWISE, GO TO BOX 9.

SXQ.648 In the past 12 months, did you have any kind of sex with a person that you never had sex with before?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 8A

CHECK ITEM SXQ.759:

IF SXQ.700 OR SXQ.706 = 1, THEN CONTINUE.
OTHERWISE, GO TO BOX 9,

SXQ.610 In the past 12 months, about how many times have you had {vaginal or anal/vaginal/anal} sex?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 0

Once 1

2-11 times 2

12-51 times 3

52-103 times 4

104-364 times 5

365 times or more 6

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTON:

IF SXQ.700 = 1 AND SXQ.706 = 2, DISPLAY {vaginal}.

IF SXQ.700 = 2 AND SXQ.706 = 1, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal or anal}.

BOX 8

CHECK ITEM SXQ.246:

IF SP DID NOT HAVE VAGINAL OR ANAL SEX (CODED ‘0’) IN SXQ.610, GO TO BOX 9.
OTHERWISE, CONTINUE WITH SXQ.250.

SXQ.250 In the past 12 months, about how often have you had {vaginal or anal/vaginal/anal} sex without using a condom?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 1

Less than half of the time 2

About half of the time 3

Not always, but more than half of the time 4

Always 5

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTON:

IF SXQ.700 = 1 AND SXQ.706 = 2, DISPLAY {vaginal}.

IF SXQ.700 = 2 AND SXQ.706 = 1, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal or anal}.

BOX 9

CHECK ITEM SXQ.750:

IF SP 14-29 YEARS AND IF SP HAD PARTNER IN PAST 12 MONTHS (SXQ.718, SXQ.727, SXQ.627, SXQ.639, OR SXQ.739 GREATER THAN ‘0000’), GO TO SXQ.651.
OTHERWISE, GO TO SXQ.260.

SXQ.651 Of the persons you had any kind of sex with in the past 12 months, how many were five or more years older than you?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT FOR FEMALES: SXQ.651 must be equal to or less than (sum of SXQ.627, SXQ.639, SXQ.718, SXQ.727, and SXQ.739)

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

SXQ.654 Of the persons you had any kind of sex with in the past 12 months, how many were five or more years younger than you?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT FOR FEMALES: SXQ.654 must be equal to or less than (sum of SXQ.627, SXQ.639, SXQ.718, SXQ.727, and SXQ.739)

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT (combined) for SXQ.651 and SXQ.654

HARD EDIT FOR FEMALES: (sum of SXQ.651 and SXQ.654) must be equal to or less than (sum of SXQ.627, SXQ.639, SXQ.718, SXQ.727, and SXQ.739)

Error message: "Your responses to the last two questions are not consistent with your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again."

SXQ.260 Has a doctor or other health care professional ever told you that you had genital herpes?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.265 Has a doctor or other health care professional ever told you that you had genital warts?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (SXQ.753)

REFUSED 7 (SXQ.753)

DON'T KNOW 9 (SXQ.753)

SXQ.267 How old were you when you were first told that you had genital warts?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-69

Error message: “Your response cannot exceed 69 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.618 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

SXQ.753 Has a doctor or other health care professional ever told you that you had human papillomavirus or HPV?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.270 In the past 12 months, has a doctor or other health care professional told you that you had gonorrhea, sometimes called GC or clap?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.272 In the past 12 months, has a doctor or other health care professional told you that you had chlamydia?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 11

CHECK ITEM SXQ.756:

IF SP 18-59 YEARS, GO TO SXQ.294.
OTHERWISE, GO TO END OF SECTION.

SXQ.294 Which of the following best represents how you think of yourself? . . .

(Target 18-59)

Lesbian or Gay 1

Straight, that is, not lesbian or gay 2

Bisexual 3

Something else 4

I don’t know the answer 9

REFUSED 7

EXUAL BEHAVIOR – (SXQ)

Target Group: Male SPs 14-69 (Audio-CASI)

SXQ.615_ The next set of questions is about your sexual history. By sex, we mean vaginal, oral, or anal sex.

Please remember that your answers are strictly confidential.

BOX 1B

CHECK ITEM SXQ.873:

IF SP AGE GREATER THAN 17, GO TO SXQ.800.
OTHERWISE, CONTINUE.

SXQ.615 Have you ever had any kind of sex?

(Target 14-17)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (BOX 8)

REFUSED 7 (BOX 8)

DON'T KNOW 9 (BOX 8)

SXQ.800 Have you ever had vaginal sex, also called sexual intercourse, with a woman? This means your penis in a woman’s vagina.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.803 Have you ever performed oral sex on a woman? This means putting your mouth on a woman’s vagina or genitals.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.806 Have you ever had anal sex with a woman? Anal sex means contact between your penis and a woman’s anus or butt.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.809 Have you ever had any kind of sex with a man, including oral or anal?

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 1A

CHECK ITEM SXQ.862:

IF SXQ.803 = 1 AND SXQ.800, SXQ.806, AND SXQ.809 NOT EQUAL TO ‘1’, GO TO BOX 4.
IF SXQ.800, SXQ.803, SXQ.806, AND SXQ.809 NOT EQUAL TO ‘1’, GO TO BOX 8.
OTHERWISE, CONTINUE.

SXQ.618
(Target 14-69)

How old were you the first time you had any kind of sex, including {vaginal, anal, or oral / vaginal or anal / vaginal or oral / anal or oral / vaginal / anal / oral}?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF SXQ.800 AND SXQ.803 = 1 AND SXQ.806 AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal or oral}.

IF SXQ.800 AND SXQ.806 = 1 AND SXQ.803 AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal or anal}.

IF SXQ.809 = 1 AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal or oral}.

IF SXQ.803 AND SXQ.806 = 1 AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal or oral}.

IF SXQ.800 = 1 AND SXQ.803, SXQ.806, AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal}.

IF SXQ.806 = 1 AND SXQ.800, SXQ.803, AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal, anal, or oral}.

HARD EDIT VALUES: 0-69

Error message: “Your response cannot exceed 69 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.618 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 1

CHECK ITEM SXQ.801:

IF SP 60-69 YEARS, GO TO SXQ.812.
IF SXQ.803=1 AND SXQ.800 AND SXQ.806 NOT EQUAL TO ‘1’, GO TO BOX 3.
IF SXQ.800=1 AND SXQ.803 AND SXQ.806 NOT EQUAL TO ‘1’, GO TO BOX 3.
IF SXQ.809=1 AND SXQ.800, SXQ.803, AND SXQ.806 NOT EQUAL TO ‘1’, GO TO BOX 3.
OTHERWISE, CONTINUE.

SXQ.812 In your lifetime, with how many women have you had any kind of sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.812 must be greater than zero.

Error message: “Your response is not consistent with your previous responses about female sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 2

CHECK ITEM SXQ.815:

IF SP 60-69 YEARS AND SXQ.809 = 1, GO TO SXQ.410.
IF SP 60-69 YEARS AND SXQ.809 NOT EQUAL TO 1, GO TO END OF SECTION.
OTHERWISE, CONTINUE WITH SXQ.818.

SXQ.818 In the past 12 months, with how many women have you had any kind of sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.818 must be equal to or less than SXQ.812.

Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 3

CHECK ITEM SXQ.821:

IF SXQ.800 = 1, GO TO SXQ.824.
OTHERWISE, GO TO BOX 4.

SXQ.824 In your lifetime, with how many women have you had vaginal sex? Vaginal sex means your penis in a woman’s vagina.

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.824 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about female vaginal sex partners. Please press the “Back” button, press “Clear,” and try again."

HARD EDIT: SXQ.824 must be equal to or less than SXQ.812.

Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.827 In the past 12 months, with how many women have you had vaginal sex? Vaginal sex means your penis in a woman’s vagina.

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.827 must be equal to or less than SXQ.824.

Error message: “Your response is greater than your lifetime number of female vaginal sex partners. Please press the “Back” button, press “Clear”, and try again.”

SOFT EDIT: SXQ.827 must be equal to or less than SXQ.818.

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear”, and try again.”

BOX 4

CHECK ITEM SXQ.830:

IF SP 60-69 YEARS, GO TO END OF SECTION.
IF SXQ.803 = 1, GO TO SXQ.633.
OTHERWISE, GO TO BOX 5.

SXQ.633 How old were you when you first performed oral sex on a woman? Performing oral sex means your mouth on a woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.633 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

SXQ.636 In your lifetime, on how many women have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.636 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about female oral sex partners. Please press the “Back” button, press “Clear,” and try again."

SXQ.639 In the past 12 months, on how many women have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.639 must be equal to or less than SXQ.636.

Error message: “Your response is greater than your lifetime number of female oral sex partners. Please press the “Back” button, press “Clear,” and try again.”

SOFT EDIT: SXQ.639 must be equal to or less than SXQ.818.

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

BOX 4B

CHECK ITEM SXQ.868:

IF SP HAD ONLY 1 LIFETIME ORAL SEX PARTNER (CODED ‘1’) IN SXQ.636, GO TO BOX 5.
OTHERWISE CONTINUE.

SXQ.642 How long has it been since the last time you performed oral sex on a new female partner? A new sexual partner is someone that you had never had sex with before.

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777

DON'T KNOW 99999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

HARD EDIT: Response must be equal to or less than current age minus SXQ.633.

Error message: “Your response is earlier than your response to the age when you first performed oral sex on a woman. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.642 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 5

CHECK ITEM SXQ.833:

IF SXQ.809 = 1, GO TO SXQ.410.
OTHERWISE, GO TO BOX 9.

SXQ.410 In your lifetime, with how many men have you had anal or oral sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.410 must be greater than zero.

Error message: “Your response is not consistent with your previous responses about male sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 5B

CHECK ITEM SXQ.875:

IF SP IS 60-69 YEARS, GO TO SXQ.836.
OTHERWISE, CONTINUE WITH SXQ.550.

SXQ.550 In the past 12 months, with how many men have you had anal or oral sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.550 must be equal to or less than SXQ.410.

Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.836 In your lifetime, with how many men have you had anal sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

BOX 6

CHECK ITEM SXQ.839:

IF SP IS 60-69 YEARS, GO TO SXQ.853.
IF SP HAD NO ANAL SEX PARTNERS (CODED ‘0000’ IN SXQ.836), GO TO SXQ.853.
OTHERWISE, CONTINUE WITH SXQ.841.

SXQ.841 In the past 12 months, with how many men have you had anal sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.841 must be equal to or less than SXQ.836.

Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.853 Have you ever performed oral sex on a man? Performing oral sex means your mouth on a man’s penis or genitals.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 7

CHECK ITEM SXQ.847:

IF SP NEVER HAD ORAL MALE PARTNER (CODED ‘2’, ‘7’, OR ‘9’) IN SXQ.853 AND SP IS 60-69 YEARS, GO TO END OF SECTION.
IF SP NEVER HAD ORAL MALE PARTNER (CODED ‘2’, ‘7’, OR ‘9’) IN SXQ.853 AND SP IS 14-59 YEARS, GO TO BOX 9A.
OTHERWISE, CONTINUE WITH SXQ.621.

SXQ.621 How old were you when you first performed oral sex on a man? Performing oral sex means your mouth on a man’s penis or genitals.

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-69

Error message: “Your response cannot exceed 69 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.621 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

SXQ.624 In your lifetime, on how many men have you performed oral sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.624 must be greater than zero.

Error message: "Your response is not consistent with your previous responses about male oral sex partners. Please press the “Back” button, press “Clear,” and try again."

BOX 8

CHECK ITEM SXQ.850:

IF SP 60-69 YEARS, GO TO END OF SECTION.
IF SP 14-17 YEARS AND SXQ.615 = 2, 7, OR 9, GO TO SXQ.280.
IF SXQ.800, SXQ.803, SXQ.806, AND SXQ.809 = 2, 7, OR 9, GO TO SXQ.280.
OTHERWISE, CONTINUE WITH SXQ.627.

SXQ.627 In the past 12 months, on how many men have you performed oral sex?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.627 must be equal to or less than SXQ.624.

Error message: “Your response is greater than your lifetime number of male oral sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 8B

CHECK ITEM SXQ.865:

IF SP HAD ONLY 1 LIFETIME MALE ORAL SEX PARTNER (CODED ‘1’) IN SXQ.624, GO TO BOX 9A.
OTHERWISE CONTINUE.

SXQ.630 How long has it been since the last time you performed oral sex on a new male partner? A new sexual partner is someone that you had never had sex with before.

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777

DON'T KNOW 99999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

HARD EDIT: Response must be equal to or less than current age minus SXQ.621.

Error message: “Your response is earlier than your response to the age when you first performed oral sex on a man. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.630 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 9A

CHECK ITEM SXQ.844:

IF SP DID NOT HAVE A PARTNER IN PAST 12 MONTHS (SXQ.627, SXQ.639, SXQ.818, SXQ.827, AND SXQ.841 CODED ‘0000’ OR MISSING), GO TO SXQ.260.
IF SXQ.809 = 1 AND SXQ.800, SXQ.803, OR SXQ.806 = 1, THEN DISPLAY “The next set of questions is about all of your partners, males and females.”, THEN GO TO BOX 9.
OTHERWISE, GO TO BOX 9.

BOX 9

CHECK ITEM SXQ.845:

IF SP HAD ORAL SEX PARTNER IN PAST 12 MONTHS (SXQ.627 OR SXQ.639 GREATER THAN ‘0000’), GO TO SXQ.645.
OTHERWISE, GO TO BOX 9B.

SXQ.645 When you performed oral sex in the past 12 months, how often would you use protection, like a condom or dental dam?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 1

Rarely 2

Usually 3

Always 4

Unsure 5

REFUSED 7

DON'T KNOW 9

BOX 9B

CHECK ITEM SXQ.871:

IF SXQ.818, SXQ.841, OR SXQ.827 GREATER THAN ‘0000’, GO TO SXQ.648.
OTHERWISE, GO TO BOX 11.

SXQ.648 In the past 12 months, did you have any kind of sex with a person that you never had sex with before?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 10A

CHECK ITEM SXQ.859:

IF SXQ.800, SXQ.806, AND SXQ.809 NOT EQUAL TO ‘1’, GO TO BOX 11.
OTHERWISE, GO TO SXQ.610.

SXQ.610 In the past 12 months, about how many times have you had {vaginal or anal/vaginal/anal} sex?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 0

Once 1

2-11 times 2

12-51 times 3

52-103 times 4

104-364 times 5

365 times or more 6

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF SXQ.800 = 1 AND SXQ.806 AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal}.

IF SXQ.806 = 1 AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal}.

IF SXQ.836 GREATER THAN ‘0000’ AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal or anal}.

BOX 10

CHECK ITEM SXQ.245:

IF SP DID NOT HAVE VAGINAL OR ANAL SEX (CODED ‘0’) IN SXQ.610, GO TO BOX 11.
OTHERWISE, CONTINUE WITH SXQ.250.

SXQ.250 In the past 12 months, about how often have you had {vaginal or anal/vaginal/anal} sex without using a condom?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 1

Less than half of the time 2

About half of the time 3

Not always, but more than half of the time 4

Always 5

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTON:

IF SXQ.800 = 1 AND SXQ.806 AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal}.

IF SXQ.806 = 1 AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal or anal}.

BOX 11

CHECK ITEM SXQ.856:

IF SP 14-29 YEARS AND IF SP HAD PARTNER IN PAST 12 MONTHS (SXQ.627, SXQ.639, SXQ.818, SXQ.827, OR SXQ.841 GREATER THAN ‘0000’), GO TO SXQ.651.
OTHERWISE, GO TO SXQ.260.

SXQ.651 Of the persons you had any kind of sex with in the past 12 months, how many were five or more years older than you?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT FOR MALES: SXQ.651 must be equal to or less than (sum of SXQ.627, SXQ.639, SXQ.818, SXQ.827, and SXQ.841)

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

SXQ.654 Of the persons you had any kind of sex with in the past 12 months, how many were five or more years younger than you?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT FOR MALES: SXQ.654 must be equal to or less than (sum of SXQ.627, SXQ.639, SXQ.818, SXQ.827, and SXQ.841).

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT (combined) for SXQ.651 and SXQ.654

HARD EDIT FOR MALES: (sum of SXQ.651 and SXQ.654) must be equal to or less than (sum of SXQ.627, SXQ.639, SXQ.818, SXQ.827, and SXQ.841).

SXQ.260 Has a doctor or other health care professional ever told you that you had genital herpes?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.265 Has a doctor or other health care professional ever told you that you had genital warts?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (SXQ.753)

REFUSED 7 (SXQ.753)

DON'T KNOW 9 (SXQ.753)

SXQ.267 How old were you when you were first told that you had genital warts?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-69

Error message: “Your response cannot exceed 69 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.618 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

SXQ.270 In the past 12 months, has a doctor or other health care professional told you that you had gonorrhea, sometimes called GC or clap?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.272 In the past 12 months, has a doctor or other health care professional told you that you had chlamydia?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.280 Are you circumcised or uncircumcised?

INSTRUCTIONS TO SP:

Please select . . .

CAPI INSTRUCTIONS:

Display the sketches below each selection. Sketch should display by default.

ACASI FIGURE SXQ1 – CLINICAL SKETCH OF CIRCUMCISED PENIS

ACASI FIGURE SXQ2 – CLINICAL SKETCH OF UNCIRCUMCISED PENIS

Circumcised 1

Uncircumcised 2

REFUSED 7

DON'T KNOW 9

BOX 12

CHECK ITEM SXQ.285:

IF SP 18-59 YEARS, CONTINUE WITH SXQ.292.
OTHERWISE, GO TO END OF SECTION.

SXQ.292 Which of the following best represents how you think of yourself? .

(Target 18-59)

Gay 1

Straight, that is, not gay 2

Bisexual 3

Something else 4

I don’t know the answer 9

REFUSED 7

Pubertal Maturation (PMQ)

Pubertal Maturation – PMQ

Target Group: SPs 8-19 (Audio-CASI)

PMQ.INT_ The following questions ask about changes that happen during puberty. Puberty is the time when your body develops into a young adult. The answers to questions about your body help us to understand how children and teenagers grow and change. Your answers will be kept private. Nobody can see your answers and we will not show them to anyone.

Please press the Next button to begin.

CAPI INSTRUCTION: The introduction above should appear by itself on its own screen.

BOX 1

CHECK ITEM PMQ.005:

IF SP = FEMALE, CONTINUE.
OTHERWISE, GO TO PMQ.070.

PMQ.010_ The next screen shows stages of breast development. Please look at the drawings and listen to the descriptions. Then choose the drawing that looks the most like your body.

Please press the Next button to continue.

CAPI INSTRUCTION: The breast introduction above should appear by itself on its own screen.

BOX 2

CHECK ITEM PMQ.015:

IF SP = FEMALE AND AGE = 8 OR 9, CONTINUE.
OTHERWISE, GO TO PMQ.030.

PMQ.020 Please choose the drawing that looks the most like your body.

CAPI INSTRUCTION: Display female breast images 1-4 on buttons. Highlight each button as the description of the development stage is read. Label each button below the image: Drawing 1, Drawing 2, Drawing 3, Drawing 4.

STAGE 1 FEMALE BREAST DESCRIPTION DISPLAY: Drawing 1: The breasts are flat. The nipples stick out a little.

STAGE 2 FEMALE BREAST DESCRIPTION DISPLAY: Drawing 2: The breasts are small mounds. The nipples stick out more than in Drawing 1. There is more of the dark skin around the nipples than in Drawing 1.

STAGE 3 FEMALE BREAST DESCRIPTION DISPLAY: Drawing 3: The breasts and the darker skin around the nipples are bigger than in Drawing 2.

STAGE 4 FEMALE BREAST DESCRIPTION DISPLAY: Drawing 4: The nipple and the darker skin around the nipples make a mound that sticks out from the breast.

STAGE 1 FEMALE BREAST 1 (PMQ.040_)

STAGE 2 FEMALE BREAST 2 (PMQ.040_)

STAGE 3 FEMALE BREAST 3 (PMQ.040_)

STAGE 4 FEMALE BREAST 4 (PMQ.040_)

REFUSED 7 (PMQ.040_)

DON'T KNOW 9 (PMQ.040_)

PMQ.030 Please choose the drawing that looks the most like your body.

CAPI INSTRUCTION: Display female breast images 1-5 on buttons. Highlight each button as the description of the development stage is read. Label each button below the image: Drawing 1, Drawing 2, Drawing 3, Drawing 4, Drawing 5.

STAGE 1 FEMALE BREAST DESCRIPTION DISPLAY: Drawing 1: The breasts are flat. The nipples stick out a little.

STAGE 2 FEMALE BREAST DESCRIPTION DISPLAY: Drawing 2: The breasts are small mounds. The nipples stick out more than in Drawing 1. There is more of the dark skin around the nipples than in Drawing 1.

STAGE 3 FEMALE BREAST DESCRIPTION DISPLAY: Drawing 3: The breasts and the darker skin around the nipples are bigger than in Drawing 2.

STAGE 4 FEMALE BREAST DESCRIPTION DISPLAY: Drawing 4: The nipple and the darker skin around the nipples make a mound that sticks out from the breast.

STAGE 5 FEMALE BREAST DESCRIPTION DISPLAY: Drawing 5: Only the nipples stick out from the breast. The darker skin around the nipples does not stick out.

STAGE 1 FEMALE BREAST 1

STAGE 2 FEMALE BREAST 2

STAGE 3 FEMALE BREAST 3

STAGE 4 FEMALE BREAST 4

STAGE 5 FEMALE BREAST 5

REFUSED 7

DON'T KNOW 9

PMQ.040 The next screen shows stages of hair growth in your private area. Please look at the drawings and listen to the descriptions. Then choose the drawing that looks the most like your body.

Please press the next button to continue.

CAPI INSTRUCTION: The female hair growth introduction above should appear by itself on its own screen.

BOX 3

CHECK ITEM PMQ.045:

IF SP = FEMALE AND AGE = 8 OR 9, CONTINUE. OTHERWISE, GO TO PMQ.060.

PMQ.050 Please choose the drawing that looks the most like your body.

CAPI INSTRUCTION: Display female hair growth images 1-4 on buttons. Highlight each button as the description of the development stage is read. Label each button below the image: Drawing 1, Drawing 2, Drawing 3, Drawing 4.

STAGE 1 FEMALE HAIR DESCRIPTION DISPLAY: Drawing 1: There is no hair in this area.

STAGE 2 FEMALE HAIR DESCRIPTION DISPLAY: Drawing 2: There are a few long, soft hairs in the private area. The hairs can be straight or curly.

STAGE 3 FEMALE HAIR DESCRIPTION DISPLAY: Drawing 3: The hair is thicker and curlier and has spread out over more of the private area than in Drawing 2.

STAGE 4 FEMALE HAIR DESCRIPTION DISPLAY: Drawing 4: The hair is darker and curlier and covers a bigger area than in Drawing 3.

STAGE 1 FEMALE HAIR 1 (END OF SECTION)

STAGE 2 FEMALE HAIR 2 (END OF SECTION)

STAGE 3 FEMALE HAIR 3 (END OF SECTION)

STAGE 4 FEMALE HAIR 4 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

PMQ.060 Please choose the drawing that looks the most like your body.

CAPI INSTRUCTION: Display female hair growth images 1-5 on buttons. Highlight each button as the description of the development stage is read. Label each button below the image: Drawing 1, Drawing 2, Drawing 3, Drawing 4, Drawing 5.

STAGE 1 FEMALE HAIR DESCRIPTION DISPLAY: Drawing 1: There is no hair in this area.

STAGE 2 FEMALE HAIR DESCRIPTION DISPLAY: Drawing 2: There are a few long, soft hairs in the private area. The hairs can be straight or curly.

STAGE 3 FEMALE HAIR DESCRIPTION DISPLAY: Drawing 3: The hair is thicker and curlier and has spread out over more of the private area than in Drawing 2.

STAGE 4 FEMALE HAIR DESCRIPTION DISPLAY: Drawing 4: The hair is darker and curlier and covers a bigger area than in Drawing 3. There is no hair on the inside of the thighs.

STAGE 5 FEMALE HAIR DESCRIPTION DISPLAY: Drawing 5: There is hair on the inside of the thighs. The hair covers an area that is shaped like a triangle.

STAGE 1 FEMALE HAIR 1 (END OF SECTION)

STAGE 2 FEMALE HAIR 2 (END OF SECTION)

STAGE 3 FEMALE HAIR 3 (END OF SECTION)

STAGE 4 FEMALE HAIR 4 (END OF SECTION)

STAGE 5 FEMALE HAIR 5 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

PMQ.070_ The next screen shows stages of penis, testicle, and scrotum growth in your private area. Please look at the drawings and listen to the descriptions. Then choose the drawing that looks the most like your body.

Please press the next button to continue.

CAPI INSTRUCTION: The penis, testicle, and scrotum growth introduction above Should appear by itself on its own screen.

BOX 4

CHECK ITEM PMQ.075:

IF SP = MALE AND AGE = 8 or 9, CONTINUE. OTHERWISE, GO TO PMQ.090.

PMQ.080 Please choose the drawing that looks the most like your body.

CAPI INSTRUCTION: Display male penis, testicle, and scrotum growth images 1-4 on buttons. Highlight each button as the description of the development stage is read. Label each button below the image: Drawing 1, Drawing 2, Drawing 3, Drawing 4.

STAGE 1 MALE penis DESCRIPTION DISPLAY: Drawing 1: The penis, testicles (balls), and scrotum are about the same size as when you were younger.

STAGE 2 MALE penis DESCRIPTION DISPLAY: Drawing 2: The testicles (balls) are larger than in Drawing 1 and the scrotum is lower. The penis is only a little bigger compared to Drawing 1.

STAGE 3 MALE penis DESCRIPTION DISPLAY: Drawing 3: The penis is longer than Drawing 2. The testicles (balls) and scrotum are larger and have dropped lower than in Drawing 2.

STAGE 4 MALE penis DESCRIPTION DISPLAY: Drawing 4: The penis is longer and wider than in Drawing 3. The scrotum is bigger and the skin there is darker.

STAGE 1 MALE PENIS 1 (PMQ.100_)

STAGE 2 MALE PENIS 2 (PMQ.100_)

STAGE 3 MALE PENIS 3 (PMQ.100_)

STAGE 4 MALE PENIS 4 (PMQ.100_)

REFUSED 7 (PMQ.100_)

DON'T KNOW 9 (PMQ.100_)

PMQ.090 Please choose the drawing that looks the most like your body.

CAPI INSTRUCTION: Display male penis, testicle, and scrotum growth images 1-5 on buttons. Highlight each button as the description of the development stage is read. Label each button below the image: Drawing 1, Drawing 2, Drawing 3, Drawing 4, Drawing 5.

STAGE 1 MALE penis DESCRIPTION DISPLAY: Drawing 1: The penis, testicles (balls), and scrotum are about the same size as when you were younger.

STAGE 2 MALE penis DESCRIPTION DISPLAY: Drawing 2: The testicles (balls) are larger than in Drawing 1 and the scrotum is lower. The penis is only a little bigger compared to Drawing 1.

STAGE 3 MALE penis DESCRIPTION DISPLAY: Drawing 3: The penis is longer than Drawing 2. The testicles (balls) and scrotum are larger and have dropped lower than in Drawing 2.

STAGE 4 MALE penis DESCRIPTION DISPLAY: Drawing 4: The penis is longer and wider than in Drawing 3. The scrotum is bigger and the skin there is darker.

STAGE 5 MALE penis DESCRIPTION DISPLAY: Drawing 5: The penis, scrotum and testicles are bigger than in Drawing 4.

STAGE 1 MALE PENIS 1

STAGE 2 MALE PENIS 2

STAGE 3 MALE PENIS 3

STAGE 4 MALE PENIS 4

STAGE 5 MALE PENIS 5

REFUSED 7

DON'T KNOW 9

PMQ.100_ The next screen shows stages of hair growth in your private area. Please look at the drawings and listen to the descriptions. Then choose the drawing that looks the most like your body.

Please press the next button to continue.

CAPI INSTRUCTION: The male hair growth introduction above should appear by itself on its own screen.

BOX 5

CHECK ITEM PMQ.105:

IF SP = MALE AND AGE = 8 or 9, CONTINUE. OTHERWISE, GO TO PMQ.120.

PMQ.110 Please choose the drawing that looks the most like your body.

CAPI INSTRUCTION: Display male hair growth images 1-4 on buttons. Highlight each button as the description of the development stage is read. Label each button below the image: Drawing 1, Drawing 2, Drawing 3, Drawing 4.

STAGE 1 MALE HAIR DESCRIPTION DISPLAY: Drawing 1: There is no hair.

STAGE 2 MALE HAIR DESCRIPTION DISPLAY: Drawing 2: There are a few long, soft hairs at the base of the penis. The hairs can be straight or curly.

STAGE 3 MALE HAIR DESCRIPTION DISPLAY: Drawing 3: The hair is thicker and curlier. There is hair growing on a bigger area than in Drawing 2.

STAGE 4 MALE HAIR DESCRIPTION DISPLAY: Drawing 4: The hair is darker and curlier and covers a bigger area than in Drawing 3.

STAGE 1 MALE HAIR 1 (END OF SECTION)

STAGE 2 MALE HAIR 2 (END OF SECTION)

STAGE 3 MALE HAIR 3 (END OF SECTION)

STAGE 4 MALE HAIR 4 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

PMQ.120 Please choose the drawing that looks the most like your body.

CAPI INSTRUCTION: Display male hair growth images 1-5 on buttons. Highlight each button as the description of the development stage is read. Label each button below the image: Drawing 1, Drawing 2, Drawing 3, Drawing 4, Drawing 5.

STAGE 1 MALE HAIR DESCRIPTION DISPLAY: Drawing 1: There is no hair.

STAGE 2 MALE HAIR DESCRIPTION DISPLAY: Drawing 2: There are a few long, soft hairs at the base of the penis. The hairs can be straight or curly.

STAGE 3 MALE HAIR DESCRIPTION DISPLAY: Drawing 3: The hair is thicker and curlier. There is hair growing on a bigger area than in Drawing 2.

STAGE 4 MALE HAIR DESCRIPTION DISPLAY: Drawing 4: The hair is darker and curlier and covers a bigger area than in Drawing 3. There is no hair on the inside of the thighs.

STAGE 5 MALE HAIR DESCRIPTION DISPLAY: Drawing 5: The hair has spread to the inside of the thighs. The hair covers an area that is shaped like a triangle.

STAGE 1 MALE HAIR 1

STAGE 2 MALE HAIR 2

STAGE 3 MALE HAIR 3

STAGE 4 MALE HAIR 4

STAGE 5 MALE HAIR 5

REFUSED 7

DON'T KNOW 9

PMQ.INT_

PMQ.010_

PMQ.020

PMQ.030

PMQ.040_

PMQ.050

PMQ.060

PMQ.070_

PMQ.080

PMQ.090

PMQ.100_

PMQ.110

PMQ.120

PMQ.130

PMQ.140 (Female)

Training Question (Ages 8-9)

Training Question (Ages 10-19)

MEC DATA COLLECTION FORMS

MEC Data Collection Forms

Anthropometry

Audiometry

Dietary Interview

Dual X-Ray Absorptiometry

Body Composition

Osteoporosis, spinal fractures and aortic calcification (DXA)

HPV swab collection

Oral Health

HPV Oral Rinse

Physician Examination

Urine collection

Venipuncture

Second venipuncture

*No data collection forms for urine collections, HPV swabs and follow-up oral HPV collections

ANTHROPOMETRY NHANES 2013-2014 (All ages)

AMPUTATION QUESTIONS: Information is recorded during the body measurement examination for all ages. Questions may be asked if the information is not obvious to the examiner. The responses are used to interpret body measurement results, particularly the body weight data.

Are there any amputations? Recorder codes YES/NO IF YES to the amputation question, continue with information on the site(s) of the amputation(s):

Target Age Groups: Anthropometry Measurements and Questions

Birth+	2mo+	2yr+	3yr+	8yr+
Weight	Weight	Weight	Weight	Weight
Recumbent length	Recumbent length	Recumbent length (through 47 mos.)
Head circumference	Head circumference (through 6 mos.)
		Standing height	Standing height	Standing height
	Upper arm length	Upper arm length	Upper arm length	Upper arm length
	Mid-upper arm circumference	Mid-upper arm circumference	Mid-upper arm circumference	Mid-upper arm circumference
		Waist circumference	Waist circumference	Waist circumference
			Maximal calf circumference	Maximal calf circumference (through 15 yr.)
			Calf skinfold	Calf skinfold (through 15 yr.)
			Triceps skinfold	Triceps skinfold (through 15 yr.)
			Subscapular skinfold	Subscapular skinfold (through 15 yr.)
				Upper leg length
				Sagittal Abdominal Diameter
Would you like to know your height and weight?	Would you like to know your height and weight?	Would you like to know your height and weight?	Would you like to know your height and weight?	Would you like to know your height and weight?

AUDIOMETRY (20-69 years)

Tech. No. _____________ SP No. _____________

Otoscope No. _________ Tympanometer No. _________ Audiometer No. __________

A. CONDITIONS AFFECTING TEST RESULTS

1. Do you now have a tube in your right or left ear? (If yes indicate affected ear(s))	 No
	 Yes, Right ear
	 Yes, Left ear
	 Yes, Both ears
	 Refused
	 Don’t Know
2. Have you had a cold, sinus problem or earache in the past 24 hours?	 Yes (2b)
	 No (3)
	 Refused (3)
	 Don’t Know (3)
2b. Which have you had? (mark all that apply)	 Cold
	 Sinus problem
	 Earache, right ear
	 Earache, left ear
	 Earache, both
	 Refused
	 Don’t Know
3. Have you been exposed to loud noise or listened to music with headphones in the past 24 hours?	 Yes (3b)
	 No (4)
	 Refused (4)
	 Don’t Know (4)
3b. How many hours ago did the noise or music end?	\|__\|__\| # hours
	 Refused
	 Don’t Know
4. Do you hear better in one ear or the other?	 Yes, right ear
	 Yes, left ear
	 No/Don’t Know
	 Refused

B. OTOSCOPY EXAM

Right Ear	 Normal
	 Excessive cerumen*
	 Impacted cerumen*
	 Other abnormality (comment)
	 Collapsing ear canal

Left Ear	 Normal
	 Excessive cerumen*
	 Impacted cerumen*
	 Other abnormality (comment)
	 Collapsing ear canal

RESULTS OF OTOSCOPY	 Test complete
	 Test partially complete
	 Test not done

REASONS TEST INCOMPLETE OR NOT DONE

		 Safety exclusion
		 Physical limitation
		 SP refusal
		 SP ill/emergency
		 Out of time
		 Equipment failure
		 Communication problem
		 Other (specify): ________

* TYMPANOMETRY will not be done on ears with cerumen blockage. Cerumen blockage does not exclude an SP from audiometry.

C. TYMPANOMETRY**


Right Ear	 Obtained
	 Not obtained

Left Ear	 Obtained
	 Not obtained

RESULTS OF TYMPANOMETRY

 Test complete

 Test partially complete

 Test not done

REASONS TEST INCOMPLETE OR NOT DONE

 Safety exclusion

		 Physical limitation
		 SP refusal
		 SP ill/emergency
		 Out of time
		 Equipment failure

		 Communication problem
		 Other (specify): ______________________

** Tympanometry will not be done on ears with cerumen blockage found in otoscopy.


D. PURE TONE AUDIOMETRY ***
START HERE IF SP NUMBER ODD OR SP HEARS BETTER IN LEFT EAR			START HERE IF SP NUMBER EVEN OR SP HEARS BETTER IN RIGHT EAR
AIR CONDUCTION-LEFT EAR			AIR CONDUCTION-RIGHT EAR
Hearing Level (dB)	Frequency (Hz)	Hearing Level with Masking on R(dB)	Hearing Level (dB)	Frequency (Hz)	Hearing Level with Masking on L(dB)
	1000			1000
	2000			2000
	3000			3000
	4000			4000
	6000			6000
	8000			8000
	1000			1000
	500			500

RESULTS OF AUDIOMETRY				 Test complete
				 Test partially complete
				 Test not done

REASONS TEST INCOMPLETE OR NOT DONE				 Safety exclusion
				 Physical limitation
				 SP refusal
				 SP ill/emergency
				 Out of time
				 Equipment failure
				 Communication problem
				 Other (specify):______

*** Audiometry will not be done on SP's with flat tympanogram.

DIETARY INTERVIEW (All ages)

24-Hour Dietary Recall Interview

Information will be obtained on all foods and beverages that were consumed during a 24-hour time period (midnight to midnight). The information that is obtained for foods and beverages includes the following:

Time of day -Time when the food was eaten

Meal name code - The name of the eating occasion is selected from a list of options.

Meal place - Whether the meal was eaten at home.

Food item name - The name of the food is either typed in or selected from a list of food item names.

Food item description - Detailed description of the food including information about commercial product name (if applicable), preparation method, and major recipe ingredients.

Fat added in preparation - A preparation fat probe is asked for certain foods. The type of fat used during food preparation is specified as well.

Amount of food eaten - The amount of food consumed by the respondent.

Food source - The place where the food was obtained is selected from a list of options

24-Hour Dietary Recall Interview Scripts - In-Person Interview:

A. Introduction script

First, we’ll make a list of the foods you/SP ate and drank yesterday, Monday. It may help you remember what you/SP ate by thinking about where you/he/she were, who you/he/she were with, or what you/he/she were doing, like working, eating out, or watching television.

Please tell me everything you/SP had to eat and drink all day yesterday, Monday, from midnight to midnight. Include everything you/he/she had at home and away, even snacks, coffee, soft drinks, water, and alcoholic beverages. I’ll ask you for specific details and amounts of the foods in a few minutes. At this time, just tell me what you/SP had.

B. Forgotten food probes script

Your answers are important, so we’d like this list to be as complete as possible.

In addition to the foods you have/SP has already told me about, did you have any coffee, tea, soft drinks, milk or juice?

Beer, wine, cocktails or other drinks?

Cookies, candy, ice cream or other sweets?

Chips, crackers, popcorn, pretzels, nuts, or other snack foods?

Fruits, vegetables, or cheese?

Bread, rolls or tortillas?

Anything else?

C. Food detail probes script

Now we’re going to fill in your list with more detail. When I ask how much {you/SP} ate, you can tell me the amount by using the models on the table and in the racks.

You may use the grid for rectangular or square shapes and the circles for circular or round shapes. Use the wedge for wedge shaped foods.

You can use the thickness bars to show me the thickness of a food and the bean bags and mounds to describe the amounts of solid foods.

When you use the cups, bowls, and glasses, please show me which line best describes the portion {you/SP/he/she} ate or drank. When you use any of the spoons, please tell me the quantity in LEVEL spoonfuls.

24-Hour Dietary Recall Interview Scripts - Telephone Interview:

A. Greeting script

Hello, Mr./Mrs. {SP/Proxy}, my name is {interviewer’s name}. I am calling for the National Health and Nutrition Examination Survey to conduct {your/SP’s} second dietary interview over the telephone.

You will need the food measuring guides that we gave you during your MEC visit. I’ll wait while you locate them.

Do you have them? Yes/No/Needs to reschedule

If yes, go to next question.

If no:

Let’s go ahead with the interview today anyway. Do you have a ruler or some measuring cups and measuring spoons in your home that you can use for this interview?

If SP needs to reschedule:

We can schedule another appointment for the interview. Is there a time that will be convenient? Enter date/ Enter time/ Verify contact phone

If SP is not willing to reschedule:

We cannot ask everyone in the country to be in our study. You are special because you have been chosen to participate. No one else can take your place. We hope that you will help us with this interview. It will only take about 20 minutes, you will receive $30 for participating, and it is such an important part of the health survey.

If SP still says no:

Thank you for your time.

B. Introduction script

C. Follow-up probing script

Your answers are important, so we’d like this list to be as complete as possible. Here are some foods people often forget.

In addition to the foods you have/SP has already told me about, did you have any coffee, tea, soft drinks, milk or juice?

Beer, wine, cocktails or other drinks?

Cookies, candy, ice cream or other sweets?

Chips, crackers, popcorn, pretzels, nuts, or other snack foods?

Fruits, vegetables, or cheese?

Bread, rolls or tortillas?

Anything else?

D. Food detail probes script

When I ask how much {you/SP} ate, you can tell me the amount by using the drawings in the Food Model Booklet, the measuring cups and spoons, the ruler, and any of your own dishes and glasses. Feel free to check the labels on any food packages during the interview.

Post-dietary Recall Questions

NHANES III

REC.155 Was the amount of food that {you/NAME} ate yesterday much more than usual, usual, or much less than usual?

MUCH MORE THAN USUAL 1

USUAL 2

MUCH LESS THAN USUAL 3

REFUSED 7

DON’T KNOW 9

CSFII

REC.265 When you drink tap water, what is the main source of the tap water? Is the city water supply (community water supply); a well or rain cistern; a spring; or something else?

COMMUNITY WATER 1

A WELL OR RAIN CISTERN 2

A SPRING 3

NEVER DRINK TAP WATER 4

REFUSED 7

DON’T KNOW 9

OTHER (SPECIFY) 91

[RECORD Drinking fountain AS COMMUNITY WATER SUPPLY.]

NHANES III

REC.325 Now I'll be asking some questions about {your/NAME's} use of table salt.

What type of salt {do you/does NAME} usually add to {your/his/her} food at the table? Would you say it is ordinary or seasoned salt, lite salt, or a salt substitute?

ORDINARY, SEA, SEASONED, OR OTHER FLAVORED SALT

[includes regular iodized salt,

sea salt and seasoning salts

made with regular salt] 1

LITE SALT 2

SALT SUBSTITUTE 3

NONE 4 (REC.335)

REFUSED 7 (REC.335)

DON'T KNOW 9 (REC.335)

NHANES III

REC.330 How often {do you/does NAME} add {REC325 ANSWER} to {your/his/her} food at the table? Is it rarely, occasionally, or very often?

RARELY, 1

OCCASIONALLY 2

VERY OFTEN 3

REFUSED 7

DON'T KNOW 9

CSFII

REC.335 How often is ordinary salt or seasoned salt added in cooking or preparing foods in your household? Is it never, rarely, occasionally, or very often?

NEVER 1

RARELY 2

OCCASIONALLY 3

VERY OFTEN 4

REFUSED 7

DON'T KNOW 9

[THIS QUESTION APPLIES ONLY TO USE OF ORDINARY SALT OR SEASONED SALT AND NOT TO LITE SALT OR SALT SUBSTITUTES.]

CSFII

REC.340 {Are you/Is NAME} currently on any kind of diet, either to lose weight or for some other health-related reason?

YES 1

NO 2 (Box 1)

REFUSED 7 (Box 1)

DON’T KNOW 9 (Box 1)

CSFII

REC.345 What kind of diet {are you/is NAME} on?

[READ AS NEEDED: Is it a weight loss or low calorie diet; low fat or cholesterol diet; low salt or sodium diet; diabetic diet; or another type of diet?]

WEIGHT LOSS OR LOW CALORIE DIET 1

LOW FAT OR CHOLESTEROL DIET 2

LOW SALT OR SODIUM DIET 3

SUGAR FREE OR LOW SUGAR DIET 4

LOW FIBER DIET 5

HIGH FIBER DIET 6

DIABETIC DIET 7

LOW CARBOHYDRATE DIET 8

HIGH PROTEIN DIET 9

WEIGHT GAIN DIET 10

OTHER 91

(SPECIFY) ___________

REFUSED 77

DON’T KNOW 99

BOX 1

IF SP < 1 YEAR OLD, GO TO BOX 2.

OTHERWISE, CONTINUE.

NHANES 1999

DRQ.361 Please look at this list of fish. During the past 30 days, did you eat any types of fish listed on this card? Include any foods that had fish in them such as sandwiches, soups, or salads.

YES 1

NO 2 (DRQ.380)

REFUSED 7 (DRQ.380)

DON’T KNOW 9 (DRQ.380)

NHANES 1999

DRQ. 370 During the past 30 days, which types of fish did you eat and how many times did you eat them?

Type listed: breaded fish products, tuna (canned or fresh), bass, catfish, cod, flatfish, haddock, mackerel, perch, pike, pollock, porgy, salmon, sardines, sea bass, shark, swordfish, trout, walleye, other type of fish and unknown type of fish.

Interviewer instruction:

Check each type of shellfish the SP reports eating, and then ask and record the number of times each type was eaten.

NHANES 1999

DRQ.380 Please look at this list of shellfish. During the past 30 days, did you eat any types of shellfish listed on this card? Include any foods that had shellfish in them such as sandwiches, soups, or salads.

YES 1

NO 2 (Box 5)

REFUSED 7 (Box 5)

DON’T KNOW 9 (Box 5)

NHANES 1999

DRQ. 390 During the past 30 days, which types of shellfish did you eat and how many times did you eat them?

Type listed: clams, crab, crayfish (crawfish), lobster, mussels, oysters, scallops, shrimp, other shellfish (for example, octopus, squid) and unknown type of shellfish.

Interviewer instruction:

Check each type of shellfish the SP reports eating, and then ask and record the number of times each type was eaten.

BOX 5

IF SP 1-11 YEARS OLD, CONTINUE.

OTHERWISE, GO TO THE END OF THE SECTION.

HSQ.500 The next questions are about {your/SP's} recent health during the 30 days outlined on the calendar.

Did {you/SP} have a head cold or chest cold that started during those 30 days?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HSQ.510 Did {you/SP} have a stomach or intestinal illness with vomiting or diarrhea that started during those 30 days?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HSQ.520 Did {you/SP} have flu, pneumonia, or ear infections that started during those 30 days?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 6

IF SP 6-7 YEARS OLD, CONTINUE.

OTHERWISE, GO TO THE END OF THE SECTION.

PUQ.100 In the past 7 days, were any chemical products used in {your/his/her} home to control fleas, roaches, ants, termites, or other insects?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PUQ.110 In the past 7 days, were any chemical products used in {your/his/her} lawn or garden to kill weeds?

CODE ‘NO’ IF THE RESPONDENT SAYS S/HE DOES NOT HAVE A LAWN OR GARDEN.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DIETARY SUPPLEMENTS (All ages)

24-Hour Dietary Supplements Recall Interview

Information will be obtained on all vitamins, minerals, herbals and other dietary supplements that were consumed during a 24-hour time period (midnight to midnight). The information that is obtained for dietary supplements includes the following:

Verifying that dietary supplement(s) reported during the Dietary Supplement Section in the Household Interview was also taken during the 24-Hour time period. – Dietary supplement information is collected during the SP Household Interview. The interviewer will first ask if the supplements reported during the Household Interview were also taken during the 24-Hour time period.
Dietary supplement Name – The name of any new/additional dietary supplements are typed and selected from a list of dietary supplement names.
Amount of dietary supplement taken – The amount of dietary supplement consumed by the respondent during the 24-Hour time period.

24-Hour Dietary Supplement Recall Interview Scripts – In-Person Interview:

Script for respondents that reported taking a dietary supplement or antacid during the Dietary Supplements Section in the Household Interview:

The next questions are about {your/SPs} use of dietary supplements, vitamins, minerals and herbals all day yesterday, {day}, between midnight and midnight. This includes prescription and over the counter dietary supplements.

During the interview in your home {you/SP reported taking} {supplement}.

Did {you/SP} take this supplement yesterday {day}. (between midnight and midnight)?

Was {supplement} a {form}?

You said {you/SP} took ___, is that correct? Was that a liquid or powder?

Between midnight and midnight, how much did {you/SP} take?

It was also reported {you/SP} took {supplement}.

All day yesterday, {day}, between midnight and midnight, did {you/SP} take any other vitamins, minerals, herbals or other dietary supplements? Include any prescription and over the counter dietary supplements.

What is the name of the supplement {you/SP} took?

Between midnight and midnight, how much did {you/SP} take?

Any others?

The next questions are about {your/SPs} use of non-prescription antacids.

During the interview in your home {you/SP reported taking} {antacid}.

Did {you/SP} take this antacid yesterday (between midnight and midnight )?

Between midnight and midnight how much did {you/SP} take?

It was also reported {you/SP} took {antacid}.

All day yesterday, {day}, between midnight and midnight did {you/SP} take any other antacids?

What is the name of the antacid {you/SP} took?

Between midnight and midnight how much did {you/SP} take?

Any others?

Script for respondents that did not report taking a dietary supplement or antacid during the Dietary Supplement Section in the Household Interview:

The next questions are about {your/SPs} use of dietary supplements, including prescription and over the counter supplements. All day yesterday, {day}, between midnight and midnight did {you/SP} take any vitamins, minerals, herbals or other dietary supplements?

What is the name of the supplement {you/SP} took?

Between midnight and midnight how much did {you/SP} take?

Any others?

The next questions are about {your/SPs} use of non-prescription antacids All day yesterday, {day}, between midnight and midnight did {you/SP} take any antacids?

What is the name of the antacid {you/SP} took?

Between midnight and midnight how much did {you/SP} take?

Any others?

24-Hour Dietary Supplement Recall Interview Scripts – Telephone Interview:

Same as above, except respondent is asked to get their dietary supplements and read from the container the name of any new supplements they have taken since the 24-hour dietary supplement recall in-person interview.

Script for respondents that reported taking a dietary supplement or antacid during the Dietary Supplements Section in the Household Interview or during the 24-hour dietary supplement recall in-person interview:

During the interview in your home and our exam center {you/SP reported taking} {supplement}.

Did {you/SP} take this supplement yesterday {day} (between midnight and midnight)?

Was {supplement} a {form}?

You said {you/SP} took ___, is that correct? Was that a liquid or powder?

Between midnight and midnight, how much did {you/SP} take?

It was also reported {you/SP} took {supplement}.

Can you please locate the containers for all the dietary supplements {you/SP}took?

I will wait while you get them.

Can you please read to me all the words on the front label?

What is the name of the supplement {you/SP} took?

Between midnight and midnight, how much did {you/SP} take?

Any others?

The next questions are about {your/SPs} use of non-prescription antacids.

During the interview in your home and our exam center {you/SP reported taking} {antacid}.

Did {you/SP} take this antacid yesterday (between midnight and midnight )?

Between midnight and midnight how much did {you/SP} take?

It was also reported {you/SP} took {antacid}.

All day yesterday, {day}, between midnight and midnight did {you/SP} take any other antacids?

What is the name of the antacid {you/SP} took?

Between midnight and midnight how much did {you/SP} take?

Any others?

Script for respondents that did not report taking a dietary supplement or antacid during the Dietary Supplement Section in the Household Interview or the 24-hour dietary supplement recall in-person interview:

Can you please locate the containers for all the dietary supplements {you/SP}took?

I will wait while you get them.

Can you please read to me all the words on the front label?

What is the name of the supplement {you/SP} took?

Between midnight and midnight how much did {you/SP} take?

Any others?

The next questions are about {your/SPs} use of non-prescription antacids All day yesterday, {day}, between midnight and midnight did {you/SP} take any antacids?

What is the name of the antacid {you/SP} took?

Between midnight and midnight how much did {you/SP} take?

Any others?

Probes

Probes for collecting dietary supplement names

Multivitamin and/or Multimineral:

What is the brand name?
Did it also include minerals like iron, zinc, or calcium?
Iron only

Was it a special type?(silver, women’s, men’s, prenatal, liquid)

Single / double nutrient:

What is the brand name?
How much (ingredient name) was in it?(or what was the strength of X)

Other supplement type:

Please describe the label name or type of supplement
What is the brand name?

Probes for collecting antacid names

What is the brand name? Was it extra strength, regular strength, ultra, maximum strength?

Probes for collecting the quantity the respondent took – UNIT

Was it a tablet, capsule, pill, caplet, softgel, or something else?

Dual X-Ray Absorptiometry (whole body)

Body Composition (Ages 8-59 years)

Excluded from scan if body weight is over 450 pounds or if yes to one of the following items;

1. Do you have any amputations of your legs and feet other than toes?

2. Are you currently pregnant?

3. Have you had a medical test with contrast material such as dyes or barium in the last 7 days?

Whole Body Tissue Information:

Total Body Tissue grams

Bone Mineral Content grams

Fat grams

Lean Mass grams

Lean Mass + Bone Mineral Content grams

Percent fat %

Values for each of the variables listed above will be given for the following regions:

Head

Left Arm

Right Arm

Trunk

Left Leg

Right Leg

Subtotal

Total

Whole Body Bone Information:

Area cm²

Bone Mineral Content grams

Bone Mineral Density grams/cm²

Values for each of the variables listed above will be given for the following regions:

Head

Left Arm

Right Arm

Left Ribs

Right Ribs

Thoracic Spine

Lumbar Spine

Pelvis

Left Leg

Right Leg

Dual X-Ray Absorptiometry (femur and spine)

Osteoporosis, spinal fractures and aortic calcification

(Ages 40 and older)

Excluded from femur or spine scans if body weight is over 450 pounds or if yes to one of the following items;

1. Are you currently pregnant?

2. Have you had a medical test with contrast material such as dyes or barium in the last 7 days?

3. Have you fractured both hips, had replacements of both hips, or have pins in both hips? (exclusion for femur scan)

4. Do you have a Harrington rod in your spine? (exclusion for spine scans)

Femur and Lumbar Spine Information:

Area cm²

Bone Mineral Content grams

Bone Mineral Density grams/cm²

Values for each of the variables listed above will be given for the following femur regions:

Femoral Neck

Trochanter

Intertrochanter

Ward’s Triangle

Total

Values for each of the variables listed above will be given for the following lumbar spine regions:

Vertebrae 1-4

Total

Lateral and Anterior/Posterior (AP) Spine Information:

Identification of Deformities

Description of Spinal Shape

Assessment of Vertebral Fracture Risk

Assessment of Abdominal Aortic Calcification

ORAL HEALTH (Ages 1 and older)

Medical Exclusion Questions (Ages 30 and older)

All adults aged 30 years and older will be eligible for the health screening questions. A positive response to any one of these 4 questions will result in an individual being EXCLUDED from the periodontal examination:

1. Have you had a heart transplant?

2. Do you have an artificial heart valve?

3. Have you had heart disease since birth?

4. Have you had a bacterial infection of the heart, also called Bacterial?

Endocarditis?

Oral Health Examination (Ages 1 and older)

1+ years	3-19 years	6-19 years	30 years and older
Tooth count
Dental Caries
	Dental Sealants
			Medical History Screening
			Periodontal Exam
		Dental Fluorosis/Images
Miscellaneous / Report of Findings

PHYSICIAN EXAMINATION (All ages)

Blood Pressure (ages 8 years and older)*

Have you had any of the following in the past 30 minutes? (food, coffee, alcohol, cigarettes) Check all that apply:

Arm selected Right/left/Could not obtain

Cuff size selected Infant/Child/Adult/Large Arm/Thigh

Heart Rate/Pulse Beats per minute

Pulse type

Radial/Brachial

Maximum Inflation Level mm Hg

Systolic Blood Pressure (Readings 1,2,3) mm Hg

Diastolic Blood Pressure (Readings 1,2,3) mm Hg

Average Blood Pressure mm Hg (mean of last 2 measurements will be used)

VENIPUNCTURE 1 (Ages 1 year and older) AND VENIPUNCTURE 2 (Ages 12 year and older AM)

SP ID______________ Tech ID_______________

Pre venipuncture questions (Q1-Q5 only asked during morning session: Q4-Q5 of those 12 and older)

Q1. When did you last have anything at all to eat or drink other than water?

HH:MM (AM PM NOON) MMDDYY

Q2. Have you had coffee, tea, soda, alcoholic beverages, gum, breath mints, cough drops or vitamins since [TIME/DATE IN Q3]?

YES (probe and edit response in Q3)

Q3. You have not had anything to drink, other than water, since [TIME/DATE IN Q3]. Is this correct?

YES

NO (probe and edit response in Q3)

Q4. Are you now taking insulin?

⁪Yes(OGTT will not be conducted)

⁪No

⁪Refused

⁪Don’t know

Q5. Are you now taking diabetic pills to lower your blood sugar?

⁪Yes(OGTT will not be conducted)

⁪No

⁪Refused

⁪Don’t know

Q6. Do you have hemophilia?

⁪Yes(Venipuncture and OGTT will not be conducted)

⁪No

⁪Refused

⁪Don’t know

Q7. Have you received cancer chemotherapy in the past four weeks?

⁪Yes(Venipuncture and OGTT will not be conducted)

⁪No

⁪Refused

⁪Don’t know

Pregnancy Status

⁪Positive (OGTT will not be conducted if SP reports pregnancy at home

interview or has a positive pregnancy test prior to first venipuncture)

⁪Negative

RESULTS OF FIRST VENIPUNCTURE

⁪Test complete

⁪Test partially complete

⁪Test not done

REASONS TEST INCOMPLETE OR NOT DONE

⁪Safety exclusion

Pregnancy

⁪Physical limitation

⁪SP refusal

⁪SP ill/emergency

⁪Out of time

⁪Equipment failure

⁪Communication problem

Trutol Administration (12 and older morning session only)

SP ID______________ Tech ID_______________

Please drink this solution within 10 minutes

Timer 10

Start ____

Stop _____

Total ____

Amount of Trutol drank

⁪ All

⁪ Some

⁪None

RESULTS OF Trutol Administration

⁪Test complete

⁪Test partially complete

⁪Test not done

REASONS TEST INCOMPLETE OR NOT DONE

⁪Solution not consumed within 10 minutes

⁪Physical limitation

⁪SP refusal

⁪SP ill/emergency

⁪Out of time

⁪Equipment failure???

⁪Communication problem

VENIPUNCTURE 2 (ages 12 year and older if Trutol administered)

SP ID______________ Tech ID_______________

OGTT tubes

⁪ 2 ml grey ⁪Obtained all

Phlebotomy tubes not collected

⁪ of 3 4 ml lavender ⁪Obtained all

⁪ of 4 15 ml red

⁪ of 2 10 ml red

RESULTS OF SECOND VENIPUNCURE

⁪Test complete

⁪Test partially complete

⁪Test not done

REASONS TEST INCOMPLETE OR NOT DONE

⁪Solution not consumed within 10 minutes

⁪Physical limitation

⁪SP refusal

⁪SP ill/emergency

⁪Out of time

⁪Equipment failure

⁪Communication problem

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	2009 Dried Blood Spot Methodology Study – Phase I
Author	Brenda Lewis
File Modified	0000-00-00
File Created	2021-01-21