0920-1061 Odd-Numbered Year BRFSS Core Questionnaire
Behavioral Risk Factor Surveillance System (BRFSS)
Attachment 3b Odd-numbered Year Core Questionnaire
BRFSS Core Survey
OMB: 0920-1061
Attachment 3b: Odd-numbered Year Core Questionnaire
2019/2021
Behavioral Risk Factor Surveillance System
Core Questionnaire
July 12, 2017
Form Approved
OMB No. 0920-1061
Exp. Date 3/31/2018
Public reporting burden of this collection of information is estimated to average 14 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061).
NOTE: Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Carol Pierannunzi at [email protected]. |
Behavioral Risk Factor Surveillance System 2019/ 2021 Questionnaire
Section 2: Healthy Days — Health-Related Quality of Life 4
Section 3: Health Care Access 5
Section 4: Hypertension Awareness 7
Section 5: Cholesterol Awareness 8
Section 6: Chronic Health Conditions 8
Section 7: Arthritis Burden 12
Section 10: Alcohol Consumption 25
Section 11: Exercise (Physical Activity) 26
Core Sections
[CATI/INTERVIEWER NOTE: ITEMS IN PARENTHESES ANYWHERE THROUGHOUT THE QUESTIONNAIRE DO NOT NEED TO BE READ]
To Correct Respondent:
I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will be confidential. If you have any questions about the survey, please call (give appropriate state telephone number).
1.1 Would you say that in general your health is—
Please read:
1 Excellent
2 Very good
NOTE:
Items in parentheses at any place in the questions or response DO
NOT need to be read.
4 Fair
Or
5 Poor
Do not read:
7 Don’t know / Not sure
9 Refused
Section 2: Healthy Days — Health-Related Quality of Life
2.1 Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
_ _ Number of days
88 None
77 Don’t know / Not sure
99 Refused
2.2 Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
_ _ Number of days
88 None [If Q2.1 and Q2.2 = 88 (None), go to next section]
77 Don’t know / Not sure
99 Refused
2.3 During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?
_ _ Number of days
88 None
77 Don’t know / Not sure
99 Refused
Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, government plans such as Medicare, or Indian Health Service?
1 Yes [If using Health Care Access (HCA) Module go to Module 3, Q1, else continue]
2 No
7 Don’t know / Not sure
9 Refused
3.2 Do you have one person you think of as your personal doctor or health care provider?
If No, ask: Is there more than one, or is there no person who you think of as your personal doctor or health care provider?
1 Yes, only one
2 More than one
3 No
7 Don’t know / Not sure
9 Refused
3.3 Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
CATI NOTE: If using HCA Module, go to Module 3, Q3, else continue.
About how long has it been since you last visited a doctor for a routine checkup?
INTERVIEWER NOTE: A ROUTINE CHECKUP IS A GENERAL PHYSICAL EXAM, NOT AN EXAM FOR A SPECIFIC INJURY, ILLNESS, OR CONDITION.
READ IF NECESSARY:
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 5 years (2 years but less than 5 years ago)
4 5 or more years ago
7 Don’t know / Not sure
8 Never
9 Refused
CATI NOTE: If using HCA Module and Q3.1 = 1 go to Module 3 Question 4 or if using HCA Module and Q3.1 = 2, 7, or 9 go to Module 3, Question 4a, or if not using HCA Module go to next section.
Section 4: Hypertension Awareness
4.1 Have you EVER been told by a doctor, nurse, or other health professional that you have
high blood pressure?
Read only if necessary: By “other health professional” we mean a nurse practitioner, a physician’s assistant, or some other licensed health professional.
If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”
1 Yes
2 Yes, but female told only during pregnancy [GO TO NEXT SECTION]
3 No [GO TO NEXT SECTION]
4 Told borderline high or pre-hypertensive [GO TO NEXT SECTION]
7 Don’t know / Not sure [GO TO NEXT SECTION]
9 Refused [GO TO NEXT SECTION]
4.2 Are you currently taking medicine for your high blood pressure?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Section 5: Cholesterol Awareness
5.1 Blood cholesterol is a fatty substance found in the blood. About how long has it been since you last had your blood cholesterol checked?
Read only if necessary:
1 Never [GO TO NEXT SECTION]
2 Within the past year (anytime less than 12 months ago)
3 Within the past 2 years (1 year but less than 2 years ago)
4 Within the past 5 years (2 years but less than 5 years ago)
5 5 or more years ago
Do not read:
7 Don’t know / Not sure
9 Refused [GO TO NEXT SECTION]
5.2 Have you EVER been told by a doctor, nurse or other health professional that your blood cholesterol is high?
1 Yes
2 No [GO TO NEXT SECTION]
7 Don’t know / Not sure [GO TO NEXT SECTION]
9 Refused [GO TO NEXT SECTION]
5.3 Are you currently taking medicine prescribed by a doctor or other health professional for your blood cholesterol?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Section 6: Chronic Health Conditions
Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me Yes, No, Or You’re Not Sure.
6.1 (Ever told) you that you had a heart attack also called a myocardial infarction?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.2 (Ever told) you had angina or coronary heart disease?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.3 (Ever told) you had a stroke?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.4 (Ever told) you had asthma?
1 Yes
2 No [Go to Q6.6]
7 Don’t know / Not sure [Go to Q6.6]
9 Refused [Go to Q6.6]
6.5 Do you still have asthma?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.6 (Ever told) you had skin cancer?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.7 (Ever told) you had any other types of cancer?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.8 (Ever told) you have chronic obstructive pulmonary disease, C.O.P.D., emphysema or chronic bronchitis?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.9 (Ever told) you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
INTERVIEWER NOTE: Arthritis diagnoses include:
rheumatism, polymyalgia rheumatica
osteoarthritis (not osteoporosis)
tendonitis, bursitis, bunion, tennis elbow
carpal tunnel syndrome, tarsal tunnel syndrome
joint infection, Reiter’s syndrome
ankylosing spondylitis; spondylosis
rotator cuff syndrome
connective tissue disease, scleroderma, polymyositis, Raynaud’s syndrome
vasculitis (giant cell arteritis, Henoch-Schonlein purpura, Wegener’s granulomatosis, polyarteritis nodosa)
6.10 (Ever told) you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.11 Not including kidney stones, bladder infection or incontinence, were you ever told you have kidney disease?
INTERVIEWER NOTE: Incontinence is not being able to control urine flow.
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.12 (Ever told) you have diabetes?
INTERVIEWER NOTE: IF YES AND RESPONDENT IS FEMALE, ASK: WAS THIS ONLY WHEN YOU WERE PREGNANT? IF RESPONDENT SAYS PRE-DIABETES OR BORDERLINE DIABETES, USE RESPONSE CODE 4.
1 Yes
2 Yes, but female told only during pregnancy
3 No
4 No, pre-diabetes or borderline diabetes
7 Don’t know / Not sure
9 Refused
CATI NOTE: If Q6.12 = 1 (Yes), go to next question. If any other response to Q6.12, go to Pre-Diabetes Optional Module (if used). Otherwise, go to next section.
6.13 How old were you when you were told you have diabetes?
_ _ Code age in years [97 = 97 and older]
98 Don‘t know / Not sure
99 Refused
CATI NOTE: Go to Diabetes Optional Module (if used). Otherwise, go to next section.
Section 7: Arthritis Burden
[CATI NOTE: IF Q6.9 = 1 (YES) THEN CONTINUE, ELSE GO TO NEXT SECTION.]
Next,
I will ask you about your arthritis.
Arthritis
can cause symptoms like pain, aching, or stiffness in or around a
joint.
7.1 Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
INTERVIEWER INSTRUCTION: IF A QUESTION ARISES ABOUT MEDICATIONS OR TREATMENT, THEN THE INTERVIEWER SHOULD SAY: “PLEASE ANSWER THE QUESTION BASED ON YOUR CURRENT EXPERIENCE, REGARDLESS OF WHETHER YOU ARE TAKING ANY MEDICATION OR TREATMENT.”
INTERVIEWER NOTE: Q7.2 SHOULD BE ASKED OF ALL RESPONDENTS REGARDLESS OF EMPLOYMENT. STATUS.
7.2 In this next question, we are referring to work for pay. Do arthritis or joint symptoms now affect whether you work, the type of work you do, or the amount of work you do?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
INTERVIEWER INSTRUCTION: IF RESPONDENT GIVES AN ANSWER TO EACH ISSUE (WHETHER RESPONDENT WORKS, TYPE OF WORK, OR AMOUNT OF WORK), THEN IF ANY ISSUE IS “YES” MARK THE OVERALL RESPONSE AS “YES.”
IF A QUESTION ARISES ABOUT MEDICATIONS OR TREATMENT, THEN THE INTERVIEWER SHOULD SAY: “PLEASE ANSWER THE QUESTION BASED ON YOUR CURRENT EXPERIENCE, REGARDLESS OF WHETHER YOU ARE TAKING ANY MEDICATION OR TREATMENT.”
7.3 During the past 30 days, to what extent has your arthritis or joint symptoms interfered with your normal social activities, such as going shopping, to the movies, or to religious or social gatherings?
Please read [1-3]:
1 A lot
2 A little
3 Not at all
Do not read:
7 Don’t know / Not sure
9 Refused
INTERVIEWER INSTRUCTION: IF A QUESTION ARISES ABOUT MEDICATIONS OR TREATMENT, THEN THE INTERVIEWER SHOULD SAY: “PLEASE ANSWER THE QUESTION BASED ON YOUR CURRENT EXPERIENCE, REGARDLESS OF WHETHER YOU ARE TAKING ANY MEDICATION OR TREATMENT.”
7.4 Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. On a scale of 0 to 10 where 0 is no pain or aching and 10 is pain or aching as bad as it can be, DURING THE PAST 30 DAYS, how bad was your joint pain ON AVERAGE?
_ _ Enter number [00-10]
77 Don’t know / Not sure
99 Refused
Section 8: Demographics
8.1 (What was your sex at birth? Was it…)
(What is your sex?)
CATI NOTE: STATES MAY ADOPT ONE OF THE TWO FORMATS OF THE QUESTION. IF FIRST FORMAT IS USED, READ OPTIONS.
1 Male
2 Female
9 Refused
8.2 What is your age?
_ _ Code age in years
07 Don’t know / Not sure
09 Refused
8.3 Are you Hispanic, Latino/a, or Spanish origin?
If yes, ask: Are you…
INTERVIEWER NOTE: One or more categories may be selected.
1 Mexican, Mexican American, Chicano/a
2 Puerto Rican
3 Cuban
4 Another Hispanic, Latino/a, or Spanish origin
Do not read:
5 No
7 Don’t know / Not sure
9 Refused
8.4 Which one or more of the following would you say is your race?
INTERVIEWER NOTE: Select all that apply.
INTERVIEWER NOTE: IF 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.
Please read:
10 White
20 Black or African American
30 American Indian or Alaska Native
40 Asian
41 Asian Indian
42 Chinese
43 Filipino
44 Japanese
45 Korean
46 Vietnamese
47 Other Asian
50 Pacific Islander
51 Native Hawaiian
52 Guamanian or Chamorro
53 Samoan
54 Other Pacific Islander
Do not read:
60 Other
88 No additional choices
77 Don’t know / Not sure
99 Refused
CATI NOTE: If more than one response to Q8.4; continue. Otherwise, go to Q8.6.
8.5 Which one of these groups would you say best represents your race?
INTERVIEWER NOTE: IF RESPONDENT HAS SELECTED MULTIPLE RACES IN PREVIOUS AND REFUSES TO SELECT A SINGLE RACE, CODE “REFUSED.”
INTERVIEWER NOTE: If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategory underneath major heading.
10 White
20 Black or African American
30 American Indian or Alaska Native
40 Asian
41 Asian Indian
42 Chinese
43 Filipino
44 Japanese
45 Korean
46 Vietnamese
47 Other Asian
50 Pacific Islander
51 Native Hawaiian
52 Guamanian or Chamorro
53 Samoan
54 Other Pacific Islander
Do not read:
60 Other
77 Don’t know / Not sure
99 Refused
8.6 Are you…?
Please read:
1 Married
2 Divorced
3 Widowed
4 Separated
5 Never married
Or
6 A member of an unmarried couple
Do not read:
9 Refused
8.7 What is the highest grade or year of school you completed?
Read only if necessary:
1 Never attended school or only attended kindergarten
2 Grades 1 through 8 (Elementary)
3 Grades 9 through 11 (Some high school)
4 Grade 12 or GED (High school graduate)
5 College 1 year to 3 years (Some college or technical school)
6 College 4 years or more (College graduate)
NOTE:
Items in parentheses at any place in the questions or response DO
NOT need to be read.
9 Refused
8.8 Do you own or rent your home?
1 Own
2 Rent
3 Other arrangement
7 Don’t know / Not sure
9 Refused
INTERVIEWER NOTE: Other arrangement may include group home, staying with friends or family without paying rent.
NOTE: Home is defined as the place where you live most of the time/the majority of the year.
INTERVIEWER NOTE: We ask this question in order to compare health indicators among people with different housing situations.
8.9 In what county do you currently live?
_ _ _ ANSI County Code (formerly FIPS county code)
777 Don’t know / Not sure
999 Refused
8.10 What is the ZIP Code where you currently live?
_ _ _ _ _ ZIP Code
77777 Don’t know / Not sure
99999 Refused
CATI NOTE: If cellular telephone interview skip to 8.14 (QSTVER GE 20)
8.11 Not including cell phones or numbers used for computers, fax machines or security systems, do you have more than one telephone number in your household?
1 Yes
2 No [Go to Q8.13]
7 Don’t know / Not sure [Go to Q8.13]
9 Refused [Go to Q8.13]
8.12 How many of these telephone numbers are residential numbers?
_ Residential telephone numbers [6 = 6 or more]
7 Don’t know / Not sure
9 Refused
8.13 How many cell phones do you have for personal use?
INTERVIEWER NOTE: INCLUDE CELL PHONES USED FOR BOTH BUSINESS AND PERSONAL USE.
__ Enter number (1-5)
6 Six or more
7 Don’t know / Not sure
8 None
9 Refused
8.14 Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?
INTERVIEWER NOTE: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.
1 Yes
2 No
Do not read:
7 Don’t know / Not sure
9 Refused
8.15 Are you currently…?
INTERVIEWER NOTE: IF MORE THAN ONE, SAY “SELECT THE CATEGORY WHICH BEST DESCRIBES YOU”.
Please read:
1 Employed for wages
2 Self-employed
3 Out of work for 1 year or more
4 Out of work for less than 1 year
5 A Homemaker
6 A Student
7 Retired
Or
8 Unable to work
Do not read:
9 Refused
8.16 How many children less than 18 years of age live in your household?
_ _ Number of children
88 None
99 Refused
8.17 Is your annual household income from all sources—
If respondent refuses at ANY income level, code ‘99’ (Refused)
Read only if necessary:
04 Less than $25,000 If no, ask 05; if yes, ask 03
($20,000 to less than $25,000)
03 Less than $20,000 If no, code 04; if yes, ask 02
($15,000 to less than $20,000)
02 Less than $15,000 If no, code 03; if yes, ask 01
($10,000 to less than $15,000)
01 Less than $10,000 If no, code 02
05 Less than $35,000 If no, ask 06
($25,000 to less than $35,000)
06 Less than $50,000 If no, ask 07
($35,000 to less than $50,000)
07 Less than $75,000 If no, code 08
($50,000 to less than $75,000)
08 $75,000 or more
Do not read:
77 Don’t know / Not sure
99 Refused
8.18 About how much do you weigh without shoes?
NOTE: If respondent answers in metrics, put 9 in column XXX.
Round fractions up
_ _ _ _ Weight
(pounds/kilograms)
7777 Don’t know / Not sure
9999 Refused
8.19 About how tall are you without shoes?
NOTE: If respondent answers in metrics, put 9 in column XXX.
Round fractions down
_ _ / _ _ Height
(f t / inches/meters/centimeters)
77/ 77 Don’t know / Not sure
99/ 99 Refused
If male, go to 8.21, if female respondent is 45 years old or older, go to Q8.21
8.20 To your knowledge, are you now pregnant?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Some people who are deaf or have serious difficulty hearing use assistive devices to communicate by phone.
8.21 Are you deaf or do you have serious difficulty hearing?
1 Yes
2 No
7 Don’t know / Not Sure
9 Refused
8.22 Are you blind or do you have serious difficulty seeing, even when wearing glasses?
1 Yes
2 No
7 Don’t know / Not Sure
9 Refused
8.23 Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
8.24 Do you have serious difficulty walking or climbing stairs?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
8.25 Do you have difficulty dressing or bathing?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
8.26 Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Section 9: Tobacco Use
9.1 Have you smoked at least 100 cigarettes in your entire life?
INTERVIEWER NOTE: 5 PACKS = 100 CIGARETTES
1 Yes
2 No [GO TO Q9.5]
7 Don’t know / Not sure [GO TO Q9.5]
9 Refused [GO TO Q9.5]
INTERVIEWER NOTE: “FOR CIGARETTES, DO NOT INCLUDE: ELECTRONIC CIGARETTES (E-CIGARETTES, NJOY, BLUETIP), HERBAL CIGARETTES, CIGARS, CIGARILLOS, LITTLE CIGARS, PIPES, BIDIS, KRETEKS, WATER PIPES (HOOKAHS), OR MARIJUANA.”
9.2 Do you now smoke cigarettes every day, some days, or not at all?
Do not read:
1 Every day
2 Some days
3 Not at all [GO TO Q9.4]
7 Don’t know / Not sure [GO TO Q9.5]
9 Refused [GO TO Q9.5]
9.3 During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
1 Yes [GO TO Q9.5]
2 No [GO TO Q9.5]
7 Don’t know / Not sure [GO TO Q9.5]
9 Refused [GO TO Q9.5]
9.4 How long has it been since you last smoked a cigarette, even one or two puffs?
Read only if necessary:
01 Within the past month (less than 1 month ago)
02 Within the past 3 months (1 month but less than 3 months ago)
03 Within the past 6 months (3 months but less than 6 months ago)
04 Within the past year (6 months but less than 1 year ago)
05 Within the past 5 years (1 year but less than 5 years ago)
06 Within the past 10 years (5 years but less than 10 years ago)
07 10 years or more
08 Never smoked regularly
Do not read:
77 Don’t know / Not sure
99 Refused
9.5 Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?
INTERVIEWER NOTE: SNUS (RHYMES WITH ‘GOOSE’)/ SNUS (SWEDISH FOR SNUFF) IS A MOIST SMOKELESS TOBACCO, USUALLY SOLD IN SMALL POUCHES THAT ARE PLACED UNDER THE LIP AGAINST THE GUM.
Do not read:
1 Every day
2 Some days
3 Not at all
Do not read:
7 Don’t know / Not sure
9 Refused
Section 10: Alcohol Consumption
10.1 During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?
1 _ _ Days per week
2 _ _ Days in past 30 days
888 No drinks in past 30 days [GO TO NEXT SECTION]
777 Don’t know / Not sure [GO TO NEXT SECTION]
999 Refused [GO TO NEXT SECTION]
10.2 One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?
INTERVIEWER NOTE: A 40 OUNCE BEER WOULD COUNT AS 3 DRINKS, OR A COCKTAIL DRINK WITH 2 SHOTS WOULD COUNT AS 2 DRINKS.
_ _ Number of drinks
77 Don’t know / Not sure
99 Refused
10.3 Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI NOTE: X = 5 FOR MEN, X = 4 FOR WOMEN] or more drinks on an occasion?
_ _ Number of times
88 None
77 Don’t know / Not sure
99 Refused
10.4 During the past 30 days, what is the largest number of drinks you had on any occasion?
_ _ Number of drinks
77 Don’t know / Not sure
99 Refused
Section 11: Exercise (Physical Activity)
INTERVIEWER INSTRUCTION: If respondent does not have a regular job or is retired, they may count the physical activity or exercise they spend the most time doing in a regular month.
11.1 During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
1 Yes
2 No [GO TO Q11.8]
7 Don’t know / Not sure [GO TO Q11.8]
9 Refused [GO TO Q11.8]
11.2 What type of physical activity or exercise did you spend the most time doing during the past month?
_ _ (Specify) [See Physical Activity Coding List]
77 Don’t know / Not Sure [GO TO Q11.8]
99 Refused [GO TO Q11.8]
INTERVIEWER INSTRUCTION: IF THE RESPONDENT’S ACTIVITY IS NOT INCLUDED IN THE PHYSICAL ACTIVITY CODING LIST, CHOOSE THE OPTION LISTED AS “OTHER”.
11.3 How many times per week or per month did you take part in this activity during the past month?
1_ _ Times per week
2_ _ Times per month
777 Don’t know / Not sure
999 Refused
11.4 And when you took part in this activity, for how many minutes or hours did you usually keep at it?
_:_ _ Hours and minutes
777 Don’t know / Not sure
999 Refused
11.5 What other type of physical activity gave you the next most exercise during the past month?
_ _ (Specify) [See Physical Activity Coding List]
88 No other activity [GO TO Q11.8]
77 Don’t know / Not Sure [GO TO Q11.8]
99 Refused [GO TO Q11.8]
INTERVIEWER INSTRUCTION: IF THE RESPONDENT’S ACTIVITY IS NOT INCLUDED IN THE CODING PHYSICAL ACTIVITY LIST, CHOOSE THE OPTION LISTED AS “OTHER”.
11.6 How many times per week or per month did you take part in this activity during the past month?
1_ _ Times per week
2_ _ Times per month
777 Don’t know / Not sure
999 Refused
11.7 And when you took part in this activity, for how many minutes or hours did you usually keep at it?
_:_ _ Hours and minutes
777 Don’t know / Not sure
999 Refused
11.8 During the past month, how many times per week or per month did you do physical activities or exercises to strengthen your muscles?
INTERVIEWER NOTE: DO NOT COUNT AEROBIC ACTIVITIES LIKE WALKING, RUNNING, OR BICYCLING. COUNT ACTIVITIES USING YOUR OWN BODY WEIGHT LIKE YOGA, SIT-UPS OR PUSH-UPS AND THOSE USING WEIGHT MACHINES, FREE WEIGHTS, OR ELASTIC BANDS.
1_ _ Times per week
2_ _ Times per month
888 Never
777 Don’t know / Not sure
999 Refused
Section 12: Fruits and Vegetables
Now think about the foods you ate or drank during the past month, that is, the past 30 days, including meals and snacks.
INTERVIEWER INSTRUCTIONS: IF A RESPONDENT INDICATES THAT THEY CONSUME A FOOD ITEM EVERY DAY THEN ENTER THE NUMBER OF TIMES PER DAY. IF THE RESPONDENT INDICATES THAT THEY EAT A FOOD LESS THAN DAILY, THEN ENTER TIMES PER WEEK OR TIME PER MONTH. DO NOT ENTER TIME PER DAY UNLESS THE RESPONDENT REPORTS THAT HE/SHE CONSUMED THAT FOOD ITEM EACH DAY DURING THE PAST MONTH.
12.1 Not including juices, how often did you eat fruit? You can tell me times per day, times per week or times per month.
INTERVIEWER NOTE: ENTER QUANTITY IN TIMES PER DAY, WEEK, OR MONTH.
IF RESPONDENT GIVES A NUMBER WITHOUT A TIME FRAME, ASK “WAS THAT PER DAY, WEEK, OR MONTH?”
READ IF RESPONDENT ASKS WHAT TO INCLUDE OR SAYS ‘I DON’T KNOW’: INCLUDE FRESH, FROZEN OR CANNED FRUIT. DO NOT INCLUDE DRIED FRUITS.
300 Less than once a month
12.2 Not including fruit-flavored drinks or fruit juices with added sugar, how often did you drink 100% fruit juice such as apple or orange juice?
INTERVIEWER NOTE: ENTER QUANTITY IN TIMES PER DAY, WEEK, OR MONTH.
INTERVIEWER NOTE: IF RESPONDENT GIVES A NUMBER WITHOUT A TIME FRAME, ASK “WAS THAT PER DAY, WEEK, OR MONTH?”
READ IF RESPONDENT ASKS ABOUT EXAMPLES OF FRUIT-FLAVORED DRINKS: “DO NOT INCLUDE FRUIT-FLAVORED DRINKS WITH ADDED SUGAR LIKE CRANBERRY COCKTAIL, HI-C, LEMONADE, KOOL-AID, GATORADE, TAMPICO, AND SUNNY DELIGHT. INCLUDE ONLY 100% PURE JUICES OR 100% JUICE BLENDS.”
300 Less than once a month
12.3 How often did you eat a green leafy or lettuce salad, with or without other vegetables?
INTERVIEWER NOTE: ENTER QUANTITY IN IN TIMES PER DAY, WEEK, OR MONTH.
INTERVIEWER NOTE: IF RESPONDENT GIVES A NUMBER WITHOUT A TIME FRAME, ASK “WAS THAT PER DAY, WEEK, OR MONTH?
READ IF RESPONDENT ASKS ABOUT SPINACH: “INCLUDE SPINACH SALADS.”
300 Less than once a month
12.4 How often did you eat any kind of fried potatoes, including french fries, home fries, or hash browns?
INTERVIEWER NOTE: ENTER QUANTITY IN TIMES PER DAY, WEEK, OR MONTH.
INTERVIEWER NOTE: IF RESPONDENT GIVES A NUMBER WITHOUT A TIME FRAME, ASK “WAS THAT PER DAY, WEEK, OR MONTH?
READ IF RESPONDENT ASKS ABOUT POTATO CHIPS: “DO NOT INCLUDE POTATO CHIPS.”
1_ _ Day
300 Less than once a month
12.5 How often did you eat any other kind of potatoes, or sweet potatoes, such as baked, boiled, mashed potatoes, or potato salad?
INTERVIEWER NOTE: ENTER QUANTITY IN TIMES PER DAY, WEEK, OR MONTH.
INTERVIEWER NOTE: IF RESPONDENT GIVES A NUMBER WITHOUT A TIME FRAME, ASK “WAS THAT PER DAY, WEEK, OR MONTH?”
READ IF RESPONDENT ASKS ABOUT WHAT TYPES OF POTATOES TO INCLUDE: “INCLUDE ALL TYPES OF POTATOES EXCEPT FRIED. INCLUDE POTATOES AU GRATIN, SCALLOPED POTATOES.”
1_ _ Day
2_ _ Week
3_ _ Month
300 Less than once a month
555 Never
777 Don’t Know
999 Refused
12.6 Not including lettuce salads and potatoes, how often did you eat other vegetables?
INTERVIEWER NOTE: ENTER QUANTITY IN TIMES PER DAY, WEEK, OR MONTH.
INTERVIEWER NOTE: IF RESPONDENT GIVES A NUMBER WITHOUT A TIME FRAME, ASK “WAS THAT PER DAY, WEEK, OR MONTH?”
READ IF RESPONDENT ASKS ABOUT WHAT TO INCLUDE: “INCLUDE TOMATOES, GREEN BEANS, CARROTS, CORN, CABBAGE, BEAN SPROUTS, COLLARD GREENS, AND BROCCOLI. INCLUDE RAW, COOKED, CANNED, OR FROZEN VEGETABLES. DO NOT INCLUDE RICE.”
300 Less than once a month
Section 13: Immunization
13.1 During the past 12 months, have you had either a flu shot or a flu vaccine that was sprayed in your nose?
Read if necessary: A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.
1 Yes
2 No [Go to Q13.4]
7 Don’t know / Not sure [Go to Q13.4]
9 Refused [Go to Q13.4]
13.2 During what month and year did you receive your most recent flu shot injected into your arm or flu vaccine that was sprayed in your nose?
_ _ / _ _ _ _ Month / Year
77 / 7777 Don’t know / Not sure
99 / 9999 Refused
13.3 At what kind of place did you get your last flu shot or vaccine?
Read only if necessary:
01 A doctor’s office or health maintenance organization (HMO)
02 A health department
03 Another type of clinic or health center (a community health center)
04 A senior, recreation, or community center
05 A store (supermarket, drug store)
06 A hospital (inpatient)
07 An emergency room
08 Workplace
09 Some other kind of place
11 A school
Do not read:
10 Received vaccination in Canada/Mexico
77 Don’t know / Not sure (Probe: How would you describe the place where you went to get your most recent flu vaccine?)
99 Refused
13.4 Have you ever had a pneumonia shot also known as a pneumococcal vaccine?
INTERVIEWER NOTE: IF RESPONDENT IS CONFUSED READ: THERE ARE TWO TYPES OF PNEUMONIA SHOTS: POLYSACCHARIDE, ALSO KNOWN AS PNEUMOVAX, AND CONJUGATE, ALSO KNOWN AS PREVNAR.
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Section 14: HIV/AIDS
The next few questions are about the national health problem of HIV, the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don’t have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.
14.1 Not counting tests you may have had as part of blood donation, have you ever been tested for HIV?
1 Yes
2 No [Go to Q14.3]
7 Don’t know / Not sure [Go to Q14.3]
9 Refused [Go to Q14.3]
14.2 Not including blood donations, in what month and year was your last HIV test?
NOTE: If response is before January 1985, code Don’t know.
CATI INSTRUCTION: If the respondent remembers the year but cannot remember the month, code the first two digits 77 and the last four digits for the year.
_ _ /_ _ _ _ Code month and year
77/ 7777 Don’t know / Not sure
99/ 9999 Refused / Not sure
14.3 I am going to read you a list. When I am done, please tell me if any of the situations apply to you. You do not need to tell me which one.
You have used intravenous drugs in the past year.
You have been treated for a sexually transmitted or venereal disease in the past year.
You have given or received money or drugs in exchange for sex in the past year.
You had anal sex without a condom in the past year.
You had four or more sex partners in the past year.
Do any of these situations apply to you?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Closing Statement
That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.
Or
Continue to module(s) and/or state-added questions
Activity List for Common Leisure Activities
(To be used for Section 12: Physical Activity)
Code Description (Physical Activity, Questions 13.2 and 13.5 above)
01
Active Gaming Devices (Wii Fit, Dance, Dance revolution)
02 Aerobics video or class
03 Backpacking
04 Badminton
05 Basketball
06 Bicycling machine exercise
07 Bicycling
08 Boating (Canoeing, rowing, kayaking, sailing for pleasure or camping)
09 Bowling
10 Boxing
11 Calisthenics
12 Canoeing/rowing in competition
13 Carpentry
14 Dancing-ballet, ballroom, Latin, hip hop, Zumba, etc.
15 Elliptical/EFX machine exercise
16 Fishing from river bank or boat
17 Frisbee
18 Gardening (spading, weeding, digging, filling)
19 Golf (with motorized cart)
20 Golf (without motorized cart)
21 Handball
22 Hiking – cross-country
23 Hockey
24 Horseback riding
25 Hunting large game – deer, elk
26 Hunting small game – quail
27 Inline Skating
28 Jogging
29 Lacrosse
30 Mountain climbing
31 Mowing lawn
32 Paddleball
33 Painting/papering house
34 Pilates
35 Racquetball
36 Raking lawn/trimming hedges
37 Running
38 Rock climbing
39 Rope skipping
40 Rowing machine exercises
41 Rugby
42 Scuba diving
43 Skateboarding
44 Skating – ice or roller
45 Sledding, tobogganing
46 Snorkeling
47 Snow blowing
48 Snow shoveling by hand
49 Snow skiing
50 Snowshoeing
51 Soccer
52 Softball/Baseball
53 Squash
54 Stair climbing/Stair master
55 Stream fishing in waders
56 Surfing
57 Swimming
58 Swimming in laps
59 Table tennis
60 Tai Chi
61 Tennis
62 Touch football
63 Volleyball
64 Walking
66 Waterskiing
67 Weight lifting
68 Wrestling
69 Yoga
71 Childcare
72 Farm/Ranch Work (caring for livestock, stacking hay, etc.)
73 Household Activities (vacuuming, dusting, home repair, etc.)
74 Karate/Martial Arts
75 Upper Body Cycle (wheelchair sports, ergometer
76 Yard work (cutting/gathering wood, trimming, etc.)
98 Other_____
99 Refused
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CDC |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |
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