Form 0920-0222 Questions to be Cognitively Tested

Attachment 1: Questions to be cognitively tested

Form Approved

OMB No. 0920-0222

Exp. Date: 08/31/2021

Notice - CDC estimates the average public reporting burden for this collection of information as 55 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0222).

Assurance of confidentiality - We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347).

WALKING

WALK1. The next questions are about walking for transportation. I will ask you separately about walking for other reasons like relaxation or exercise. DURING THE PAST 7 DAYS, did you walk for transportation?

1. Yes

2. No

7. Don’t know

9. Refused

Skip Instructions: If Yes: go to WALK2

If No, DK, or Refused: go to WALK4

WALK2. IN THE PAST 7 DAYS, how many times did you do that? Read if necessary: Walk for at least 10 minutes to get some place.

_____ Number of times

WALK3. [How long did that walk take?/ On average, how long did those walks take?]

_____ Number of minutes or hours

WALK4. Sometimes you may walk for fun, relaxation, exercise, or to walk the dog. DURING THE PAST 7 DAYS, did you walk for any of these reasons?

1. Yes

2. No

7. Don’t know

9. Refused

Skip Instructions: If Yes: go to WALK5

If No, DK, or Refused: go to WALK8

WALK5. IN THE PAST 7 DAYS, how many times did you do that?

_____ Number of times

WALK6. [How long did that walk take?/On average, how long did those walks take?]

_____ Number of minutes or hours

WALK7. How often (or frequently?) does the [Leisure, Transportation, Leisure and Transportation] walking you reported earlier take place where you live? 

Read if necessary: By ‘where you live’, we mean “in your neighborhood?”

Almost always

Most of the time

Some of the time

A little of the time

Never

Refused

Don’t know

WALK8. The next questions are about where you live. Read if necessary: These questions are about your walking or places you can walk, not walking by other people.

Where you live what is the main type of housing?

Single-family houses

Multi-unit homes (duplexes, 4-plexes, row houses)

Apartments or condominiums

Apartments above street retail

Other

Refused

Don’t know

SLEEP

SLEEP1. On average, how many hours of sleep do you get in a 24 hour period?

Interviewer instructions: Do not read answer categories, until after respondent gives initial answers. If respondent gives an exact number that doesn’t fit in the range ask if which of neighboring 2 are best.

Less than 5 hours

5-6 hours

6-7 hours

7-8 hours

8-9 hours

More than 9 hours

Refused

Don’t know

SMOKING

SMOKE1: In your life, have you ever smoked cigarettes?

1. Yes

2. No

7. Don’t know

9. Refused

Skip Instructions: If Yes: go to SMOKE2

If No, DK, or Refused: go to next section (LUNG1)

SMOKE2: On average, about how many cigarettes do you NOW smoke a day?

____________ Cigarettes a day

SMOKE3: On how many of the PAST 30 DAYS did you smoke a cigarette?

_____________ Days

Skip Instructions: If 0: go to SMOKE5

Else; go to SMOKE4

SMOKE4: On average, when you smoked during the PAST 30 DAYS, about how many

cigarettes did you smoke a day?

____________Cigarettes a day

SMOKE5: Have you ever smoked fairly regularly?

1. Yes

2. No

7. Don’t know

9. Refused

Skip Instructions: If Yes: go to SMOKE6

If No, DK, or Refused: go to next section (LUNG1)

SMOKE5: How old were you when you FIRST started to smoke fairly regularly?

_____________Years old

SMOKE6: How long has it been since you quit smoking cigarettes?

______________Years/Months/Days

SMOKE7: When you last smoked FAIRLY REGULARLY, how many cigarettes did you usually smoke per day?

____________Cigarettes a day

SMOKE8: What is the average number of cigarettes that you smoked daily during the longest period that you smoked?

____________Cigarettes a day

CT Scans and X-rays of Chest Area

LUNG1. The following questions are about CT scans. During this test, you lie down on your back and are moved through a donut shaped x-ray machine while holding your breath. You DO NOT swallow any dye or need an injection before you have a low-dose CT scan.

Have you EVER had a low-dose CT scan of your chest area?

1. Yes

2. No

7. Don’t know

9. Refused

Skip Instructions: If Yes: go to LUNG2

If No, DK, or Refused: go to next section (OPIOIDS1)

LUNG2. Lung cancer screening is when someone who does not have any symptoms of lung cancer is given a low-dose CT scan of the chest to screen for lung cancer. Were any of the CT scans of your chest area done to screen for lung cancer?

1. Yes

2. No

7. Don’t know

9. Refused

LUNG3. At the time of your MOST RECENT low-dose CT scan, were you experiencing any of the following symptoms related to lung cancer: coughing up blood, cough that had gotten worse recently, shortness of breath that had gotten worse recently, or unexplained weight loss?

1. Yes

2. No

7. Don’t know

9. Refused

LUNG4: Sometimes people get a chest CT because they have symptoms that are related to lung cancer, and a doctor needs to determine if cancer is causing those symptoms. Other times people have been a heavy cigarette smoker for many years and have reached an age where a low-dose CT test is used to screen for cancer at an early stage. Why did you have a CT scan or chest x-ray? Read if necessary: Lung cancer symptoms include coughing up blood, a bad cough that gets worse over time, shortness of breath that gets worse over time, or unexplained weight loss.

1 Because I had symptoms

2 To screen for cancer, because I was a heavy smoker who didn’t have any lung cancer symptoms.

7 Refused

9 Don't know

OPIOIDS

PAIN1. In the past three months, how often did you have pain?

Never

Some days

Most days

Every day

PAIN2. Over the past three months, how often did pain limit your life or work activities?

Never

Some days

Most days

Every day

PAIN3. Thinking about the last time you had pain, how much pain did you have?

A little

A lot

Somewhere in between

PAIN4. Which of the following statements, if any, describe your pain in the past three months?

It is constantly present

Sometimes I’m in a lot of pain and sometimes it’s not so bad

When I get my mind on other things, I’m not aware of the pain

It is occasional and does not last

Medication can take my pain away completely

My pain is because of my work

My pain is because of exercise

OPIOID1. Have you ever, in your entire life, taken opioid painkillers prescribed to you by a doctor or dentist for any kind of injury, surgery, or chronic condition? Examples include hydrocodone, Vicodin, Norco, Lortab, oxycodone, OxyContin, Percocet, Percodan, and Tramadol.  Please do not include over-the-counter pain relievers such as aspirin, Tylenol, Advil, or Aleve.

 

Yes

No

                                  

Skip Instructions:       If Yes: go to OPIOID2

If No: go to OPIOID16

OPIOID2. In the last 12 months, have you taken any opioid painkillers prescribed to you for a surgery, injury, or chronic condition?

 

Yes

No

                            

Skip Instructions:      If Yes: go to OPIOID3

If No: go to OPIOID9

OPIOID3. Which opioid painkillers have you taken in the last 12 months? If you took more than one, please provide the name for each.

 

List prescriptions: _____________________________________________________________________________

OPIOID4.  Are you still taking any of these?

Yes

No

Skip Instructions:      If Yes: go to OPIOID5

If No: go to OPIOID9

OPIOID5.  About how long have you been taking opioid pain medication?

 

Less than a week

1 to 4 weeks

1 to 6 months

6 months to a year

1 to 5 years

5 years or more

 

OPIOID6.  How concerned would you be to lose access to your medication?

 

Very concerned

A little concerned

Not at all concerned

OPIOID7.  If you stopped taking your medication, do you believe that you would…

 

7a. Have intolerable pain

Yes

No

7b. Be unable to sleep

Yes

No

7c. Go through withdrawal

Yes

No

OPIOID8.  Are you concerned that you may be addicted to opioids?

Yes

No

Skip Instructions:     All go to OPIOID11.

OPIOID9.  About how long were you taking opioid painkillers?

 

Less than a week

1 to 4 weeks

1 to 6 months

6 months to a year

1 to 5 years

5 years or more

OPIOID10.  Did you stop taking the painkillers because… [mark all that apply]

There was no longer a medical reason to take them

They were not helping

You could no longer get a prescription

You were worried about becoming addicted

You were addicted and wanted to quit

 

OPIOID11.  In the past year, have you had any opioid pain medicine left over from a prescription? 

Yes

No

Skip Instructions:      If Yes: go to OPIOID12.

If No: go to OPIOID13.

OPIOID12.  What did you do with the leftover medicine?

 

Disposed of it

Kept it

Used it myself 

Gave it to someone else to use

Sold it

OPIOID13.  Did you ever take your prescription opioid pain medicine more frequently or in higher doses than was prescribed?

                        

Yes

No

Skip Instructions:      If Yes: go to OPIOID14.

If No: go to OPIOID16.

OPIOID14. About how often in the past 12 months did you take pain medicine more frequently or in higher doses than was prescribed to you?

 

Never  

Once or twice in the year

Once or twice a month or so

Every day or nearly every day

OPIOID15. What were the reasons you used the pain medicine more frequently or in higher doses than was prescribed?

To help with pain for which I already had a prescription

To help with an injury or pain for which I never had a prescription

To get high

Because I am dependent on them and need to have them

To help with my energy level

Because of suicidal thoughts

Other reasons not already listed: (please explain):_______________

OPIOID16.  Have you ever in your life taken someone else’s opioid medication, that is, pain relievers not prescribed to you by your doctor?

 

Yes

No

 

Skip Instructions:      If Yes: go to OPIOID17

If No to OPIOID16 but Yes to OPOIOD1: go to OPIOID19

If No to OPIOID16 and No to OPIOID1: go to OPIOID21

OPIOID17.  About how often in the past 12 months did you take prescription pain relievers not prescribed to you?

 

Never  

Once or twice in the year

Once or twice a month or so

Every day or nearly every day

 

OPIOID18. What were the reasons you used opioid pain killers not prescribed to you?

To help with pain for which I already had a prescription

To help with an injury or pain for which I never had a prescription

To get high

Because I am dependent on them and need to have them

To help with my energy level

Because of suicidal thoughts

Other reasons not already listed: (please explain):_______________

OPIOID19. Have you ever experienced withdrawal symptoms or had trouble getting off an opioid?

 

Yes

No

 

Skip Instructions:      If Yes: go to OPIOID20

If No: go to OPIOID21

OPIOID20. Did you experience these withdrawal symptoms or have trouble getting off an opioid in the last year?

 

Yes

No

OPIOID21. Please select the statements, if any, which apply to you:

I’m not sure what an opioid is

I have never taken an opioid painkiller in my life

I don’t like to take pills; I’m not a pill person

I have only taken opioid pills briefly to help recover from injury or medical surgery  

I have pain that requires me to take opioid painkillers

I use opioid pain relievers responsibly

I’m addicted or used to be addicted to opioids

I understand the harm opioids can cause

I have heard about the opioid crisis in the news

I know someone who has been hurt by opioid painkillers

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