Form 0920-1061 2018 BRFSS Field Test Questionnaire

Attachment 13b:

2018 BRFSS

Field Test Questionnaire

Table of Contents

OMB Header and Introductory Text 4

Landline Introduction 5

Cell Phone Introduction 8

Core Section 1: Health Status 12

Core Section 2: Healthy Days 13

Rotating Module: Healthcare Access 14

Core Section 6: Chronic Health Conditions 16

Rotating Core Section: Arthritis 19

Core Section 8: Demographics 21

Rotating Core Section: Hypertension Awareness 27

Rotating Core Section: Cholesterol Awareness 29

Module: Aspirin for CVD Prevention 31

Module: Home/ Self Measured Blood Pressure 31

Core Section 9: Tobacco Use 33

Core Section 10: Alcohol Consumption 35

Core Section 11: Immunization 37

Module: ME/CFS 40

Module: Hepatitis Treatment and Vaccination 41

Module: Family Planning 43

Module: Caregiving 47

Closing Statement 51

OMB Header and Introductory Text

Read if necessary	Read	Interviewer instructions (not read)
Public reporting burden of this collection of information is estimated to average 27 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061).		Form Approved OMB No. 0920-1061 Exp. Date 3/31/2018 Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Carol Pierannunzi at [email protected].
	HELLO, I am calling for the (health department). My name is (name). We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices.

Landline Introduction

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
LL01.	Is this [PHONE NUMBER]?	CTELENM1	1 Yes	Go to LL02		63
			2 No	TERMINATE
LL02.	Is this a private residence?	PVTRESD1	1 Yes	Go to LL04	Read if necessary: By private residence we mean someplace like a house or apartment. Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.	64
			2 No	Go to LL03
			3 No, this is a business		Read: Thank you very much but we are only interviewing persons on residential phones at this time.
LL03.	Do you live in college housing?	COLGHOUS	1 Yes	Go to LL04	Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.	65
			2 No	TERMINATE	Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
LL04.	Do you currently live in__(state)____?	STATERE1	1 Yes	Go to LL05		66
			2 No	TERMINATE	Thank you very much but we are only interviewing persons who live in [STATE] at this time.
LL05.	Is this a cell phone?	CELLFON4	1 Yes, it is a cell phone	TERMINATE	Read: Thank you very much but we are only interviewing by landline telephones in private residences or college housing at this time.
			2 Not a cell phone	Go to LL06	Read if necessary: By cell phone we mean a telephone that is mobile and usable outside your neighborhood. Do not read: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).
LL06.	Are you 18 years of age or older?	LADULT	1 Yes, male respondent 2 Yes, female respondent		Do not read: Sex will be asked again in demographics section.	68
			3 No	TERMINATE	Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
Transition to Section 1.			I will not ask for your last name, address, or other 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 personal information that you provide will not be used to identify you. If you have any questions about the survey, please call (give appropriate state telephone number).		Do not read: Introductory text may be reread when selected respondent is reached.

Cell Phone Introduction

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

Core Section 1: Health Status

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

Core Section 2: Healthy Days

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C02.01	Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?	PHYSHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused			91-92
C02.02	Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?	MENTHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused			93-94
C02.03	During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?	POORHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused	Skip if C02.01, PHYSHLTH, is 88 and C02.02, MENTHLTH, is 88		95-96

Rotating Module: Healthcare Access

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
HC.01	What is the primary source of your health care coverage? Is it…	HLTHCVR1	1 A plan purchased through an employer or union Notes: includes plans purchased through another person's employer 2 A plan that you or another family member buys on your own 3 Medicare 4 Medicaid or other state program 5 TRICARE (formerly CHAMPUS), VA, or Military 6 Alaska Native, Indian Health Service, Tribal Health Services 7 Some other source 8 None (no coverage) 77 Don’t know/Not Sure 99 Refused

Core Section 6: Chronic Health Conditions

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C06.01	Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me Yes, No, Or You’re Not Sure. Ever told) you that you had a heart attack also called a myocardial infarction?	CVDINFR4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.02	(Ever told) you had angina or coronary heart disease?	CVDCRHD4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.03	(Ever told) you had a stroke?	CVDSTRK3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.04	(Ever told) you had asthma?	ASTHMA3	1 Yes
			2 No 7 Don’t know / Not sure 9 Refused	Go to C06.06
C06.05	Do you still have asthma?	ASTHNOW	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.06	(Ever told) you had skin cancer?	CHCSCNCR	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.07	(Ever told) you had any other types of cancer?	CHCOCNCR	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.08	(Ever told) you have chronic obstructive pulmonary disease, C.O.P.D., emphysema or chronic bronchitis?	CHCCOPD1	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.10	(Ever told) you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?	ADDEPEV2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.11	Not including kidney stones, bladder infection or incontinence, were you ever told you have kidney disease?	CHCKDNY1	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Read if necessary: Incontinence is not being able to control urine flow.
C06.12	(Ever told) you have diabetes?	DIABETE3	1 Yes		If yes and respondent is female, ask: was this only when you were pregnant? If respondent says pre-diabetes or borderline diabetes, use response code 4.
			2 Yes, but female told only during pregnancy 3 No 4 No, pre-diabetes or borderline diabetes 7 Don’t know / Not sure 9 Refused	Go to Pre-Diabetes Optional Module (if used). Otherwise, go to next section.
C06.13	How old were you when you were told you have diabetes?	DIABAGE2	_ _ Code age in years [97 = 97 and older] 98 Don‘t know / Not sure 99 Refused	Go to Diabetes Module if used, otherwise go to next section.

Rotating Core Section: Arthritis

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
ARTH.01	(Ever told) you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?	HAVARTH3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Do not read: Arthritis diagnoses include: rheumatism, polymyalgia rheumatic, osteoarthritis (not osteoporosis), tendonitis, bursitis, bunion, tennis elbow, carpal tunnel syndrome, tarsal tunnel syndrome, joint infection, Reiter’s syndrome, ankylosing spondylitis; spondylosis, rotator cuff syndrome, connective tissue disease, scleroderma, polymyositis, Raynaud’s syndrome, vasculitis, giant cell arteritis, Henoch-Schonlein purpura, Wegener’s granulomatosis, polyarteritis nodosa)
ARTH.02	Has a doctor or other health professional ever suggested physical activity or exercise to help your arthritis or joint symptoms?	ARTHEXER	1 Yes 2 No 7 Don’t know / Not sure 9 Refused	If Arth01 = 2, 7 or 9, skip to next section	If the respondent is unclear about whether this means increase or decrease in physical activity, this means increase.
ARTH.03	Have you ever taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?	ARTHEDU	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
ARTH.04	Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?	LMTJOIN2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		If a respondent question arises about medication, then the interviewer should reply: "Please answer the question based on how you are when you are taking any of the medications or treatments you might use
ARTH.05	In the 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?	ARTHDIS2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		If respondent gives an answer to each issue (whether 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."
ARTH.06	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. During the past 30 days, how bad was your joint pain on average on a scale of 0 to 10 where 0 is no pain and 10 is pain or aching as bad as it can be.	JOINPAIN	__ __ Enter number [00-10] 77 Don’t know/ Not sure 99 Refused

Core Section 8: Demographics

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C08.01	Format 1: What is your sex? Format 2: What was your sex at birth? Was it…	SEX1	Read if format 2 is selected: 1 Male 2 Female Do not read: 7 Don’t know / Not sure 9 Refused	States may adopt one of the two formats of the question. If second format is used, read options.
C08.02	What is your age?	AGE	_ _ Code age in years 07 Don’t know / Not sure 09 Refused
C08.03	Are you Hispanic, Latino/a, or Spanish origin?	HISPANC3	If yes, read: Are you… 1 Mexican, Mexican American, Chicano/a 2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino/a, or Spanish origin Do not read: 5 No 7 Don’t know / Not sure 9 Refused		One or more categories may be selected.
C08.04	Which one or more of the following would you say is your race?	MRACE1	Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 88 No additional choices 77 Don’t know / Not sure 99 Refused	If more than one response to C08.04; continue. Otherwise, go to C08.06.	If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. One or more categories may be selected.
C08.05	Which one of these groups would you say best represents your race?	ORACE3	Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 77 Don’t know / Not sure 99 Refused		If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. If respondent has selected multiple races in previous and refuses to select a single race, code refused
C08.06	Are you…	MARITAL	Please read: 1 Married 2 Divorced 3 Widowed 4 Separated 5 Never married Or 6 A member of an unmarried couple Do not read: 9 Refused
C08.07	What is the highest grade or year of school you completed?	EDUCA	Read if necessary: 1 Never attended school or only attended kindergarten 2 Grades 1 through 8 (Elementary) 3 Grades 9 through 11 (Some high school) 4 Grade 12 or GED (High school graduate) 5 College 1 year to 3 years (Some college or technical school) 6 College 4 years or more (College graduate) Do not read: 9 Refused
C08.08	Do you own or rent your home?	RENTHOM1	1 Own 2 Rent 3 Other arrangement 7 Don’t know / Not sure 9 Refused		Other arrangement may include group home, staying with friends or family without paying rent. Home is defined as the place where you live most of the time/the majority of the year. Read if necessary: We ask this question in order to compare health indicators among people with different housing situations.
C08.14	Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?	VETERAN3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Read if necessary: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.
C08.15	Are you currently…?	EMPLOY1	Read: 1 Employed for wages 2 Self-employed 3 Out of work for 1 year or more 4 Out of work for less than 1 year 5 A Homemaker 6 A Student 7 Retired Or 8 Unable to work Do not read: 9 Refused		If more than one, say “select the category which best describes you”.
FOODSTAMP.01	In the past 12 months, have you received food stamps, also called SNAP, the Supplemental Nutrition Assistance Program on an EBT card?	***NEW***	1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused		Food Stamps or SNAP (Supplemental Nutrition Assistance Program) is a government program that provides plastic cards, also known as EBT (Electronic Benefit Transfer) cards, that can be used to buy food. In the past, SNAP was called the Food Stamp Program and gave people benefits in paper coupons or food stamps.
C08.16	How many children less than 18 years of age live in your household?	CHILDREN	_ _ Number of children 88 None 99 Refused
C08.17	Is your annual household income from all sources—	INCOME2	Read if necessary: 04 Less than $25,000 If no, ask 05; if yes, ask 03 ($20,000 to less than $25,000) 03 Less than $20,000 If no, code 04; if yes, ask 02 ($15,000 to less than $20,000) 02 Less than $15,000 If no, code 03; if yes, ask 01 ($10,000 to less than $15,000) 01 Less than $10,000 If no, code 02 05 Less than $35,000 If no, ask 06 ($25,000 to less than $35,000) 06 Less than $50,000 If no, ask 07 ($35,000 to less than $50,000) 07 Less than $75,000 If no, code 08 ($50,000 to less than $75,000) 08 $75,000 or more Do not read: 77 Don’t know / Not sure 99 Refused		If respondent refuses at ANY income level, code ‘99’ (Refused)
C08.18	About how much do you weigh without shoes?	WEIGHT2	_ _ _ _ Weight (pounds/kilograms) 7777 Don’t know / Not sure 9999 Refused		If respondent answers in metrics, put 9 in first column. Round fractions up
C08.19	About how tall are you without shoes?	HEIGHT3	_ _ / _ _ Height (ft / inches/meters/centimeters) 77/ 77 Don’t know / Not sure 99/ 99 Refused		If respondent answers in metrics, put 9 in first column. Round fractions down
C08.20	To your knowledge, are you now pregnant?	PREGNANT	1 Yes 2 No 7 Don’t know / Not sure 9 Refused	Skip if C08.01, SEX, is coded 1; or C08.02, AGE, is greater than 49

Rotating Core Section: Hypertension Awareness

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
HYPER.01	When was the last time you had your blood pressure checked by a doctor, nurse or other health professional?	***NEW***	1 Never 2 Within the past year (anytime less than one year ago) 3 Within the past 2 years (1 year but less than 2 years ago) 4 Within the past 3 years (2 years but less than 3 years ago) 5 Within the past 4 years (3 years but less than 4 years ago) 6 Within the past 5 years (4 years but less than 5 years ago) 8 6 or more years ago 7 Don’t know/ Not sure 9 Refused		By other health professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.
HYPER.02	Have you ever been told by a doctor, nurse or other health professional that you have high blood pressure?	BPHIGH4	1 Yes 2 Yes, but female told only during pregnancy 3 No 4 Told borderline high or pre-hypertensive 7 Don’t know / Not sure 9 Refused	If HYPER.02 = 2,3,4,7,9 Go to next section	If “yes” and respondent is female, ask: “Was this only when you were pregnant? By other health professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.
HYPER.03	Do you currently have a prescription medicine for your high blood pressure?		1 Yes 2 No 7 Don’t know / Not sure 9 Refused
HYPER.04	Would you say that...		Read: 1 You take it as directed 2 You sometimes take it as directed 3 You do not take the prescribed medication, or 4 Medication was not prescribed Do not read: 7 Don’t know/ Not sure 9 Refused

Rotating Core Section: Cholesterol Awareness

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CHOL.01	When was the last time you had your blood cholesterol checked?	***NEW***	1 Never 2 Within the past year (anytime less than one year ago) 3 Within the past 2 years (1 year but less than 2 years ago) 4 Within the past 3 years (2 years but less than 3 years ago) 5 Within the past 4 years (3 years but less than 4 years ago) 6 Within the past 5 years (4 years but less than 5 years ago) 8 6 or more years ago 7 Don’t know/ Not sure 9 Refused		Blood cholesterol is a fatty substance found in the blood.
CHOL.02	Have you ever been told by a doctor, nurse or other health professional that blood cholesterol is high?	BPHIGH4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused	If HYPER.02 = 2,3,4,7,9 Go to next section	If “yes” and respondent is female, ask: “Was this only when you were pregnant? By other health professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.
CHOL.03	Do you currently have a prescription medicine for your blood cholesterol?		1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CHOL.04	Would you say that...		Read: 1 You take it as directed 2 You sometimes take it as directed 3 You do not take the prescribed medication, or 4 Medication was not prescribed Do not read: 7 Don’t know/ Not sure 9 Refused

Module: Aspirin for CVD Prevention

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
ASP.01	How often do you take an aspirin to prevent or control heart disease, heart attacks or stroke? Would you say….		Read: 1 Daily 2 Some days 3 Used to take it but had to stop due to side effects, or 4 Do not take it Do not read: 7 Don’t know / Not sure 9 Refused

Module: Home/ Self Measured Blood Pressure

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
HSBP.01	Has your healthcare provider recommended you check your blood pressure out of the office?		1 Yes 2 No 7 Don’t know / Not sure 9 Refused	If HYPER.02 = 1 continue, else go to next section	By other healthcare provider we mean nurse practitioner, a physician assistant, or some other licensed health professional.
HSBP.02	Do you regularly check your blood pressure outside of your healthcare provider’s office?		1 Yes 2 No 7 Don’t know / Not sure 9 Refused	If HSBP = 2, 7, 9 Go to next section
HSBP.03	Where do you check your blood pressure outside of your healthcare provider? Is it….		Read: 1 Mostly at home 2 Mostly on a free machine at a pharmacy, grocery or similar location 3 Do not check it Do not read: 7 Don’t know / Not sure 9 Refused

Core Section 9: Tobacco Use

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

Core Section 10: Alcohol Consumption

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

Core Section 11: Immunization

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C11.01	Now I will ask you questions about the flu vaccine. There are two ways to get the flu vaccine, one is a shot in the arm and the other is a spray, mist, or drop in the nose called FluMist™. Description: During the past 12 months, have you had either a flu shot or a flu vaccine that was sprayed in your nose?	FLUSHOT6	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		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.
C11.02	During what month and year did you receive your most recent flu shot injected into your arm or flu vaccine that was sprayed in your nose?	FLSHTMY2	_ _ / _ _ _ _ Month/ Year 777777 Don’t know/ Not sure 999999 Refused
C11.03	At what kind of place did you get your last flu shot or vaccine?	IMFVPLAC	Read if necessary: 01 A doctor’s office or health maintenance organization (HMO) 02 A health department 03 Another type of clinic or health center (a community health center) 04 A senior, recreation, or community center 05 A store (supermarket, drug store) 06 A hospital (inpatient) 07 An emergency room 08 Workplace 09 Some other kind of place 11 A school Do not read: 10 Received vaccination in Canada/Mexico 77 Don’t know / Not sure 99 Refused		Read if necessary: How would you describe the place where you went to get your most recent flu vaccine?	C11.03
C11.04	A vaccine to prevent the human papilloma virus or HPV infection is available and is called the cervical cancer or genital warts vaccine, HPV shot, [Fill: if female “GARDASIL or CERVARIX”, if male “GARDASIL”]. Have you ever had the HPV vaccination?	HPVADVC2	1 Yes		(Human Papilloma Virus (Human Pap•uh•loh•muh Virus), Gardasil (Gar•duh• seel), Cervarix (Serv a rix))
			2 No 7 Don’t know / Not sure 9 Refused	Go to C11.06
C11.05	How many HPV shots did you receive?	HPVADSHT	_ _ Number of shots (1-2) 3 All shots 77 Don’t know / Not sure 99 Refused
C11.06	Have you ever had the shingles or zoster vaccine?	SHINGLE2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Shingles is an illness that results in a rash or blisters on the skin, and is usually painful. There are two vaccines now available for shingles: Zostavax, which requires 1 shot and Shingrix which requires 2 shots.

Module: ME/CFS

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
ME/CFS.01	Have you ever been told by a doctor or other health professional that you had Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME)?	***NEW***	1 Yes		My-al-gic En-ceph-a-lo-my-eli-tis
			2 No 7 Don’t know / Not sure 9 Refused	Go to next section
ME/CFS.02	Do you still have Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME)?	***NEW***	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		My-al-gic En-ceph-a-lo-my-eli-tis
ME/CFS.03	Thinking about your CFS or ME, during the past 6 months, how many hours a week on average have you been able to work at a job or business for pay?	IMFVPLAC	Read if necessary 1 0 or no hours -- cannot work at all because of CFS or ME 2 1 - 10 hours a week 3 11- 20 hours a week 4 21- 30 hours a week 5 31 - 40 hours a week Do not read 7 Don’t know/ Not sure 9 Refused

Module: Hepatitis Treatment and Vaccination

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
HTV.01	Have you ever been told by a doctor or other health professional that you had Hepatitis C?	***NEW***	1 Yes		Hepatitis C is an infection of the liver from the Hepatitis C virus
			2 No 7 Don’t know / Not sure 9 Refused	Go to HTV.05
HTV.02	Were you treated for Hepatitis C in 2015 or after?	***NEW***	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		Most hepatitis C treatments offered in 2015 or after were oral medicines or pills. Including Harvoni, Viekira, Zepatier, Epculsa and others.
HTV.03	Were you treated for Hepatitis C prior to 2015?	***NEW***	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		Most hepatitis C treatments offered prior to 2015 were shots and pills given weekly or more often over many months.
HTV.04	Do you still have Hepatitis C?	***NEW***	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		You may still have Hepatitis C and feel healthy. Your blood must be tested again to tell if you still have Hepatitis C.
HTV.05	Has a doctor, nurse, or other health professional ever told you that you had hepatitis B?	***NEW***	1 Yes		Hepatitis B is an infection of the liver from the hepatitis B virus.
			2 No 7 Don’t know/ Not sure 9 Refused	Go to HTV.07
HTV.06	Are you currently taking medicine to treat hepatitis B?	***NEW***	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused
HTV.07	Have you ever received the Hepatitis B vaccine?	***NEW***	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		The Hepatitis B vaccine is completed after a third shot is given. Only code “yes” if respondent indicates all shots have been completed.
HTV.08	Have you ever received the Hepatitis A vaccine?	***NEW***	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused

Module: Family Planning

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
FP.01	The last time you had sex with a man, did you or your partner do anything to keep you from getting pregnant?	***NEW***	1 Yes	Continue
			2 No	Go to FP.04
			3 No partner/ not sexually active 4 Same sex partner 7 Don’t know / Not sure 9 Refused	Go to next section
FP.02	The last time you had sex with a man, what did you or your partner do to keep you from getting pregnant?	***NEW***	Read if necessary: 01 Female sterilization (ex. Tubal ligation, Essure, Adiana) 02 Male sterilization (vasectomy) 03 Contraceptive implant (ex. Nexplanon, Jadelle, Sino Implant, Implanon) 04 IUD, Levonorgestrel (LNG) or other hormonal (ex. Mirena, Skyla, Liletta, Kylena) 05 IUD, Copper-bearing (ex. ParaGard) 06 IUD, type unknown 07 Shots (ex. Depo-Provera or DMPA) 08 Birth control pills, any kind 09 Contraceptive patch (ex. Ortho Evra, Xulane) 10 Contraceptive ring (ex. NuvaRing)	Go to FP.03	If respondent reports using more than one method, please code the method that occurs first on the list. If respondent reports using “condoms,” probe to determine if “female condoms” or “male condoms.” If respondent reports using an “I.U.D.” probe to determine if “levonorgestrel I.U.D.” or “copper-bearing I.U.D.” If respondent reports “other method,” ask respondent to “please specific” and ensure that their response does not fit into another category. If response does fit into another category, please mark appropriately.
			11 Male condoms 12 Diaphragm, cervical cap, sponge 13 Female condoms 14 Not having sex at certain times (rhythm or natural family planning) 15 Withdrawal (or pulling out) 16 Foam, jelly, film, or cream 17 Emergency contraception (morning after pill) 18 Other method Do not read: 77 Don’t know/ Not sure 99 Refused	Go to next module
FP.04	Some reasons for not doing anything to keep you from getting pregnant the last time you had sex might include wanting a pregnancy, not being able to pay for birth control, or not thinking that you can get pregnant. What was your main reason for not using a method to prevent pregnancy the last time you had sex with a man?	***NEW***	Read if necessary: 01 You didn’t think you were going to have sex/no regular partner 02 You just didn’t think about it 03 Don’t care if you get pregnant 04 You want a pregnancy 05 You or your partner don’t want to use birth control 06 You or your partner don’t like birth control/side effects 07 You couldn’t pay for birth control 08 You had a problem getting birth control when you needed it 09 Religious reasons 10 Lapse in use of a method 11 Don’t think you or your partner can get pregnant (infertile or too old) 12 You had tubes tied (sterilization) 13 You had a 14 Your partner had a vasectomy (sterilization 15 You are currently breast-feeding 16 You just had a baby/postpartum 17 You are pregnant now 18 Same sex partner 19 Other reasons Do not read: 77 Don’t know/Not sure 99 Refused		If respondent reports “other reason,” ask respondent to “please specify” and ensure that their response does not fit into another category. If response does fit into another category, please mark appropriately.

Module: Caregiving

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CG.01	People may provide regular care or assistance to a friend or family member who has a health problem or disability. During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability?	CAREGIV1	1 Yes	Continue	If caregiving recipient has died in the past 30 days, say “I’m so sorry to hear of your loss.” and code 8.
			2 No 7 Don’t know / Not sure 9 Refused	Go to CG.09
			8 Caregiving recipient died in past 30 days	Go to next section
CG.02	What is his or her relationship to you?	CRGREL1	01 Mother 02 Father 03 Mother-in-law 04 Father-in-law 05 Child 06 Husband 07 Wife 08 Same-sex partner 09 Brother or brother-in-law 10 Sister or sister-in-law 11 Grandmother 12 Grandfather 13 Grandchild 14 Other relative 15 Non-relative/ Family friend 16 Unmarried partner 77 Don’t know/Not sure 99 Refused		For example is he or she your mother or daughter or father or son? If more than one person, say: “Please refer to the person to whom you are giving the most care.”
CG.03	For how long have you provided care for that person? Would you say…	CRGVLNG1	Read: 1 Less than 30 days 2 1 month to less than 6 months 3 6 months to less than 2 years 4 2 years to less than 5 years 5 5 years or more Do not read: 7 Don’t Know/ Not Sure 9 Refused
CG.04	In an average week, how many hours do you provide care or assistance? Would you say…	CRGVHRS1	Read: 1 Up to 8 hours per week 2 9 to 19 hours per week 3 20 to 39 hours per week 4 40 hours or more Do not read: 7 Don’t know/Not sure 9 Refused
CG.05	What is the main health problem, long-term illness, or disability that the person you care for has?	CRGVPRB2	1 Arthritis/ Rheumatism 2 Asthma 3 Cancer 4 Chronic respiratory conditions such as Emphysema or COPD 5 Dementia and other Cognitive Impairment Disorders such as Alzheimer’s disease 6 Developmental Disabilities such as Autism, Down’s Syndrome, and Spina Bifida 7 Diabetes 8 Heart Disease, Hypertension 9 Human Immunodeficiency Virus Infection (HIV) 10 Mental Illnesses, such as Anxiety, Depression, or Schizophrenia 11 Other organ failure or diseases such as kidney or liver problems 12 Substance Abuse or Addiction Disorders 13 Injuries, including broken bones 14 Old age/ infirmity/frailty 15 Other Do not read: 77 Don’t know/Not sure 99 Refused		If respondent provides more than one say: “Please tell me which one of these conditions would you say is the major problem?”
CG.06	Does the person you care for also have Alzheimer’s disease, dementia or other cognitive impairment disorder?	***NEW***	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused
CG.07	In the past 30 days, did you provide care for this person by managing personal care such as giving medications, feeding, dressing, or bathing?	CRGVPERS	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused
CG.08	(In the past 30 days, did you provide care for this person by…) managing household tasks such as cleaning, managing money, or preparing meals?	CRGVHOUS	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused	If CG.01 = 1 or 8, go to next module
CG.09	In the next 2 years, do you expect to provide care or assistance to a friend or family member who has a health problem or disability?	CRGVEXPT	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused

Closing Statement

Read if necessary	Read	CATI instructions (not read)
	That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.

18

21 January 2021