Attachment 1a: 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).
Age
How old are you?
________Age in years
Marital status
The next questions are about marriage and cohabitation. Are you now married, living with a partner together as an unmarried couple, or neither?
Married
Living with a partner together as an unmarried couple
Neither
[ASK IF MARRIED OR LIVING WITH A PARTNER]
Is your spouse/cohabiting partner male or female?
Male
female
[ASK IF NOT CURRENTLY MARRIED]
What is your current legal marital status?
Married
Widowed
Divorced
Separated
Never married
Education (from NHANES)
For some questions on this survey, I’ll ask you to look at numbered cards that list answer choices. After you’ve read the choices on the card, you can tell me your answer or, if you prefer, you can just tell me the number next to the answer you choose.
Looking at CARD 1, what is the highest grade or level of school you have completed or the highest degree you have received?
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
[HAND RESPONDENT THE LIFE HISTORY CALENDAR (Attachment 1b)]
This is a calendar to help you remember when things happened, when they come up in the interview. We will be talking about dates during the interview, and getting accurate dates is very important. At times I will ask you to enter specific events on the calendar. The boxes are small but you can use abbreviations that are meaningful to you. You may also wish to draw a line between the beginning and end of an event, such as a pregnancy.
Notice that the calendar's boxes start with January 2017. Some things that I ask about will have happened since then and others will have happened longer ago. The column labeled "Before January 2017" is for you to note things that happened before January 2017.
Now I’d like you to write your date of birth on the calendar on the line marked “Your Date of Birth”. Then, find the month and year of your last birthday and write your age in the box right underneath it (read if necessary: the row labeled “Your Age”). Now, please write your age under your birth month for the other years on the calendar.
[INTERVIEWER: Demonstrate, monitor, and help when needed.]
Now let's continue with the interview.
Education dates
[ASK IF HS DIPLOMA/GED OR HIGHER]
In what month and year did you get your high school diploma or GED?
_______Month/year
Please record this on your calendar in the row marked "Education", in the box for the month and year that it happened. Remember, if you received your diploma before January 2017, please record this in the "Before 2017" space in the "Education" row. You might write “HS” or some other abbreviation that you will recognize later.
[ASK IF RESPONDENT HAS A BA OR HIGHER]
In what month and year did you get your Bachelor’s degree?
_________Month/year
Please record this on your calendar in the row marked "Education", in the box for the month and year that it happened. Remember, if you received your diploma before 2017, please record this in the "Before 2017" space in the "Education" row. You might write “Coll” or some other abbreviation that you will recognize later.
Pregnancies
How many times have you been pregnant in your life?
__________ number of times
[ASK IF EVER BEEN PREGNANT; ELSE GO TO SEXUAL ACTIVITY]
How many of those pregnancies started or ended since January 2017?
__________ number of times
[ASK IF ANY PREGNANCIES SINCE JAN, 2017]
Please look at the calendar and think of pregnancies that have ended since January 2017 including those that ended in a birth, stillbirth, miscarriage or ectopic pregnancy or an abortion. Please record the pregnancy ending date in the “Birth or Pregnancy Ending Dates” section below the calendar.
Now please record each pregnancy in the “Births & other pregnancies” row in the calendar. Start by marking the month the year the baby was born or the pregnancy ended and draw a line back to the month the pregnancy began. If you are pregnant now, please record the month when this pregnancy began in the appropriate box on the “Births & Other Pregnancies” row of the calendar.
Sexual activity
[ASK IF NOT ALREADY KNOWN THAT THEY’VE HAD SEXUAL INTERCOURSE (BASED ON PREGNANCY OR MARITAL STATUS), ELSE SKIP TO NEXT QUESTION.]
At any time in your life, have you ever had sexual intercourse with a man, that is, made love, had sex, or gone all the way?
Yes
No [END INTERVIEW]
Please look at the calendar and think back to the very first time in your life that you ever had sexual intercourse with a man. In what month and year was that?
___________Month/year
Please record your date of first intercourse in the “Date of First Intercourse” section below the calendar.
Marriages, cohabitations, and sexual partners
[ASK IF LEGAL MARITAL STATUS IS ANY CATEGORY EXCEPT NEVER MARRIED. ELSE GO TO COHABITATIONS.]
(Including your present marriage) how many times have you ever been married?
__________ number of times
How many of these marriages started or ended/did this marriage start or end since January 2017? (IF NECESSARY READ: Please also include your current marriage)
__________ number of times
[ASK IF AT LEAST ONE MARRIAGE SINCE JAN, 2017]
In what month and year were you and your spouse married?
__________Month/year
Please record your spouse's initials in the box for this month and year on the "Marriages, Cohabs, Partners" row of your calendar. If this happened before January 2017, please write the date and their initials in the "Before January 2017" column.
[IF MARRIAGE IS NOT A CURRENT MARRIAGE, SAY:]
Please record something in the appropriate box on the “Marriages, Cohabs, Partners” row to indicate when this marriage ended.
Number of cohabitations
(Including your current cohabiting partner/(and any partners you later married)) how many times have you ever lived with a sexual partner as an unmarried couple?
__________number of times
How many of these times started or ended since January 2017? (Please also include your current cohabiting union)
__________number of times
[FOR EACH COHABITATION MENTIONED SINCE 2017, ASK:]
In what month and year did you and your cohabiting partner begin living together?
__________Month/year
Please record your partner’s initials in the box for this month and year on the "Marriages, Cohabs, Partners" row of your calendar. If this happened before January 2017, please write the date and their initials in the "Before January 2017" column.
[IF COHABITATION IS NOT CURRENT SAY:]
Please mark the appropriate box on the “Marriages, Cohabs, Partners” row to indicate when this cohabitation ended.
Please look at the calendar and think of all of your sexual relationships since 2017. This includes spouses, cohabiting partners, and other sexual partners, if any.
Please record the month of first and last sexual intercourse of each relationship in the “Marriages, Cohabs, Partners” row in the calendar. You might use “LSEX” and their initials or some other abbreviation you will recognize later to mark the month of last sexual intercourse with this partner. You might use “FSEX” for the month of first intercourse with this partner. If first intercourse with this partner occurred before January 2017 please record this in the “Before 2017” space in the “Marriages, Cohabs, Partners” row. You may want to draw a line from the month of first and last intercourse with each partner.
Monthly sexual activity
Have you had sexual intercourse since January 2017?
Yes
No [GO TO CONTRACEPTIVE USE QUESTIONS]
Many women have times when they are not having intercourse at all, for example, because of pregnancy, separation, not dating anyone, illness, or other reasons. I’d like to know the months since (the first time you had intercourse (if it was after January 2017) or January 2017] that you did not have intercourse at all for the entire month.
Since ([DATE OF FIRST SEX]/ January 2017, have there been any times when you were not having intercourse at all for one month or more? [INTERVIEWER: 'Yes' means the respondent had at least one month of no intercourse, and 'No' means R had intercourse every month.]
Yes
No [GO TO CONTRACEPTIVE USE QUESTIONS]
Start with the current month, [MONTH OF INTERVIEW], and think about each month one at a time, going back to (January 2017/[DATE OF FIRST SEX]). On the row labeled “Intercourse”, please mark an “x” in the box for each month during which you had intercourse at least once. So the boxes in this row that are blank will be the ones during which you did not have intercourse at all for the whole month.
Now think about last year, [YEAR OF INTERVIEW- 1]. Start with December, and think about each month one at a time, going back to (January 2019/[DATE OF FIRST SEX]). Please mark an “x” in the box for each month during which you had intercourse at least once.
Finally, start with December 2018, and think about each month one at a time, going back to January 2017/[DATE OF FIRST SEX]). Please mark an “x” in the box for each month during which you had intercourse at least once.
Contraceptive use section
[SHOW RESPONDENT HANDCARD 2]
CARD 2 lists contraceptive methods that some people use to prevent pregnancy or to prevent sexually transmitted diseases. Please circle each of these methods, if any, that you have ever used for any reason even if you have only used the method once.
[ASK IF USED ANY CONTRACEPTION]
Now I need to ask about the very first time in your life that you used a birth control method for any reason. Please look at your calendar and tell me in what month and year you first used a method (for any reason).
___________ Month/year
Please write this on your calendar on the “Birth Control Methods” row, in the box for this month and year. You can use an abbreviation for the method, or anything that you will recognize later. If this date is before January 2017, write the date and method in the “Before January 2017” box.
[ASK IF USED ANY CONTRACEPTION]
The next questions are about birth control methods you may have used between January 2017 and now. Remember that this also refers to methods men use, such as condoms, vasectomy, and withdrawal.
There will also be a chance to report methods you used during this time, that you may not have reported earlier, if any. If you used more than one method in the same month, it’s important for me to record both or all of them.
Earlier you indicated you had used METHOD. If you have used this method at any time since January 2017, please indicate that in the box for each month that you used it, going back to START OF CALENDAR, on the birth control methods row.
Now, write any other methods you have used since January 2017, on the calendar, even if you did not mention earlier that you had used it.
[ASK IF ANY METHOD REPORTED IN JAN, 2017]
For how many months altogether had you been using the METHOD IN January 2017, without a break before January 2017? If it is easier to recall, you can tell me the month and year you started.
_____________ Number of months OR month/year started using the method reported in Jan, 2017
Card 1
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
Card 2
Birth control pills
Condoms or rubbers
Female sterilizing operation (such as tubal sterilization and hysterectomy)
Partner’s vasectomy
Depo-Provera® injectables (shot given every 3 months)
Withdrawal, pulling out
Calendar rhythm method
Standard Days or CycleBeads method
Safe period by temperature or cervical mucus test (for example: Two Day Method, Billings Ovulation Method, Symptothermal Method)
Contraceptive patch (Ortho-Evra® or XulaneTM)
Vaginal contraceptive ring (NuvaRing®)
Emergency contraception (for example: Plan B™, Preven™, Ella®, Next Choice™)
Hormonal implant
Diaphragm
Female condom, vaginal pouch
Foam
Jelly or cream
Cervical cap
Suppository, insert
Intrauterine device: IUD/coil/loop; for example: Copper-T™, Paragard™, Mirena™, Skyla™, LilettaTM, KyleenaTM
LunelleTM (once-a-month shot)
Other method
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| File Type | application/msword |
| File Title | New Protocol, Request for IRB Review |
| Author | zfk9 |
| Last Modified By | SYSTEM |
| File Modified | 2019-12-16 |
| File Created | 2019-12-16 |