Telephone Dietary Recall

Attachment 3h

Telephone Dietary Recall and Dietary Supplements

Form Approved

OMB No. 0920-0950

Exp. Date XX/XX/20XX

CDC estimates the average public reporting burden for this collection of information as 30 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, SD-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0950).

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 USC 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA every NCHS employee, contractor and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

Telephone Post Dietary Recall Questionnaire Scripts - Telephone Interview:

A. Greeting script

Hello, Mr./Mrs. {SP/Proxy}, my name is {interviewer’s name}. I am calling for the National Health and Nutrition Examination Survey to conduct {your/SP’s} second dietary interview over the telephone.

You will need the food measuring guides that we gave you during your MEC visit. I’ll wait while you locate them.

Do you have them? Yes/No/Needs to reschedule

If yes, go to next question.

If no:

Let’s go ahead with the interview today anyway. Do you have a ruler or some measuring cups and measuring spoons in your home that you can use for this interview?

If SP needs to reschedule:

We can schedule another appointment for the interview. Is there a time that will be convenient? Enter date/ Enter time/ Verify contact phone

If SP is not willing to reschedule:

We cannot ask everyone in the country to be in our study. You are special because you have been chosen to participate. No one else can take your place. We hope that you will help us with this interview. It will only take about 20 minutes, you will receive $30 for participating, and it is such an important part of the health survey.

If SP still says no:

Thank you for your time.

B. Introduction script

First, we’ll make a list of the foods you/SP ate and drank yesterday, Monday. It may help you remember what you/SP ate by thinking about where you were/he was/she was, who you/he/she were with, or what you/he/she were doing, like working, eating out, or watching television.

Please tell me everything you/SP had to eat and drink all day yesterday, Monday, from midnight to midnight. Include everything you/he/she had at home and away, even snacks, water, soft drinks, and alcoholic beverages. I’ll ask you for specific details and amounts of the foods in a few minutes. At this time, just tell me what you/SP had.

C. Follow-up probing script

Your answers are important, so we’d like this list to be as complete as possible. In addition to the foods you have/SP has already told me about, did you have any coffee, tea, soft drinks, milk or juice?

Beer, wine, cocktails or other drinks?

Cookies, candy, ice cream or other sweets?

Chips, crackers, popcorn, pretzels, nuts, or other snack foods?

Fruits, vegetables, or cheese?

Bread, rolls or tortillas?

Anything else?

D. Food detail probes script

When I ask how much {you/SP} ate, you can estimate the amount by using the drawings in the Food Model Booklet, the measuring cups and spoons, the ruler, and any of your own dishes and glasses. Feel free to check the labels on any food packages during the interview.

DIETARY SUPPLEMENTS – DSA

DAY 2 PHONE QUESTIONNAIRE

Target Group: Phone Dietary Respondents

BOX 1

IF SUPPLEMENTS COLLECTED IN PREVIOUS INTERVIEW, GO TO BOX 2

ELSE CONTINUE.

DSA001 The next questions are about {your/SP’s} use of dietary supplements, including prescription and over the counter supplements. All day yesterday, {day}, between midnight and midnight, did {you/SP} take any vitamins, minerals, herbals or other dietary supplements?

[REFER SP TO SUPPLEMENT HANDCARD]

YES……………………………………………….…1 (BOX 7)

NO.......................................................................2 (BOX 10)

REFUSED…………………………………………. 7 (BOX 10)

DON’T KNOW……………………………………...9 (BOX 10)

BOX 2

SUPPLEMENT REVIEW TABLE

PRESENT DSA010 THROUGH DSA040 AS A GRID WHERE EACH ROW CONTAINS THE RELEVANT INFORMATION ABOUT A SUPPLEMENT COLLECTED IN THE PREVIOUS INTERVIEW.

(THIS INCLUDES VARIABLES DSQ056, DSQ052, DSQ060S, DSQ066A, DSQ066B AND DSQ071 FROM THE HOUSEHOLD INTERVIEW.)

CONTINUE.

DSA020 {Taken Last 24 Hours}

TEXT 1: The next questions are about {your/SP’s} use of dietary supplements, vitamins, minerals and herbals all day yesterday, {day}, between midnight and midnight. This includes prescription and over the counter dietary supplements. During the interview in {your home and our exam center/your home/our exam center} {you reported taking/it was reported {you/he/she} took} {SUPPLEMENT NAME FROM DSA010.}

TEXT 2: It was also reported {you/SP} took {SUPPLEMENT NAME FROM DSA010}.

Did {you/SP} take this supplement yesterday {day}, (between midnight and midnight)?

[CONTINUE ASKING ABOUT EACH SUPPLEMENT LISTED IN TABLE]

CAPI INSTRUCTION: IF THIS IS THE FIRST SUPPLEMENT BEING REVIEWED, DISPLAY TEXT 1

ELSE DISPLAY TEXT 2.

CAPI INSTRUCTION: IF SP Age > 15 DISPLAY ‘you reported taking’ ELSE DISPLAY ‘it was reported

{you/he/she} took’.

YES 1

NO 2 (BOX 6)

REFUSED 7 (BOX 6)

DON'T KNOW 9 (BOX 6)

BOX 3

IF THE FORM IS KNOWN FROM PREVIOUS INTERVIEW QUESTION DSQ077 CONTINUE, ELSE GO TO DSA030.

DSA025 {Form Taken}

Was {SUPPLEMENT NAME FROM DSA010} a {FORM FROM PREVIOUS INTERVIEW QUESTION DSQ077}?

YES 1 (DSA030)

NO 2

REFUSED 7 (DSA030)

DON'T KNOW 9 (DSA030)

BOX 4

CHANGE DSA020 TO “NO” AND INSERT A NEW LINE IN THE GRID.

PREFILL DSA020 ON THE NEW LINE TO “YES”.

GO TO DSA010 ON THE NEW LINE.

DSA010 {Supplements}

Can you please locate the containers for all the dietary supplements you took? I will wait while you get them.

Can you please read to me all the words on the front label?

[REPEAT UNTIL ALL SUPPLEMENTS HAVE BEEN REPORTED]

[PROBES: Record the name. Use name probes.

Multivitamin and/or Multimineral:

What is the brand name?

Did it also include minerals like iron, zinc, or calcium?

Iron only

Was it a special type? {(silver, women’s, men’s, prenatal, liquid)/(chewable, complete, with iron, with

extra C)}

Single/double nutrient:

What is the brand name?

How much (ingredient name) was in it? (or what was the strength of X)

Other supplement type:

Please describe the label name or type of supplement {(fluoride)}

What is the brand name?]

CAPI INSTRUCTION: IF SP IS UNDER 12 YEARS OLD, DISPLAY ‘(chewable, complete, with iron, with extra C)’

ELSE DISPLAY ‘(silver, women’s, men’s, prenatal, liquid)’.

CAPI INSTRUCTION: IF SP IS UNDER 12 YEARS OLD, DISPLAY ‘(fluoride)’.

HARD EDIT: AT LEAST ONE SUPPLEMENT SHOULD BE ENTERED (DSA010 FILLED)

ERROR MESSAGE: “YOU MUST COLLECT INFORMATION FOR AT LEAST ONE SUPPLEMENT OR

BACK UP AND ANSWER “NO” TO DSA001.”

____________________________________

ENTER SUPPLEMENT NAME

REFUSED 7

DON'T KNOW 9

DSA030 {Quantity Taken}

Between midnight and midnight, how much did {you/SP} take?

[ENTER THE NUMBER]

SOFT EDIT: Quantity should be less than 10

Error Message: “YOU SAID YOU TOOK {QUANTITY TAKEN}. IS THAT CORRECT?”

____________________________________

ENTER QUANTITY

REFUSED 7

DON'T KNOW 9

BOX 5

IF THE FORM IS KNOWN FROM PREVIOUS INTERVIEW QUESTION DSQ077, PREFILL DSA035 WITH DSQ077 AND GO TO BOX 6, ELSE CONTINUE.

DSA035 {Unit Taken}

OS (Was it a tablet, capsule, pill, caplet, softgel, or something else?)

[SELECT FORM/UNIT]

Tablets, capsules, pills, caplets, softgels,

gelcaps, vegicaps, chewable tablets 1 (BOX 6)

Droppers 2 (BOX 6)

Drops 3 (BOX 6)

Injection/Shots 5 (BOX 6)

Lozenges/Cough Drops 6 (BOX 6)

Milliliters 7

Tablespoons 11

Teaspoons 12

Wafers 13 (BOX 6)

Cans 15

Grams 16

Dots 17 (BOX 6)

Cups 18

Sprays/Squirts 19 (BOX 6)

Chews/Gummies 20 (BOX 6)

Scoops 21

Capfuls 23

Ounces 27

Packages/Packets 28 (BOX 6)

Vials 29 (BOX 6)

Gumballs 30 (BOX 6)

Other form (specify) 91 (BOX 6)

REFUSED 77 (BOX 6)

DON’T KNOW 99 (BOX 6)

DSA040 {Liquid/Powder}

Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 7

DON'T KNOW 9

BOX 6

IF THERE ARE MORE SUPPLEMENTS TO REVIEW, GO TO DSA020 FOR THE NEXT SUPPLEMENT, ELSE CONTINUE.

DSA060 All day yesterday, {day}, between midnight and midnight, did {you/SP} take any other vitamins,

minerals, herbals or other dietary supplements? Include any prescription and over the counter

dietary supplements.

[REFER SP TO SUPPLEMENT HANDCARD]

YES 1

NO 2 (BOX 10)

REFUSED 7 (BOX 10)

DON'T KNOW 9 (BOX 10)

BOX 7

New Supplements Table

PRESENT DSA070 THROUGH DSA115 AS A GRID.

IF THERE WERE SUPPLEMENTS REVIEWED (Supplement Review Table) THEN DISPLAY THOSE VALUES HERE IN THE FIRST ROWS.

CONTINUE.

DSA070 {Supplements}

{Can you please locate the containers for all the dietary supplements {you/SP} took? I will wait while you get them./Any others?}

Can you please read to me all the words on the front label?

{[REPEAT UNTIL ALL SUPPLEMENTS HAVE BEEN REPORTED]}

[PROBES: Record the name. Use name probes.

Multivitamin and/or Multimineral:

What is the brand name?

Did it also include minerals like iron, zinc, or calcium?

Iron only

Was it a special type? {(silver, women’s, men’s, prenatal, liquid)/(chewable, complete, with iron, with

extra C)}

Single/double nutrient:

What is the brand name?

How much (ingredient name) was in it? (or what was the strength of X)

Other supplement type:

Please describe the label name or type of supplement {(fluoride)}

What is the brand name?]

CAPI INSTRUCTION: IF FIRST TIME ON THIS SCREEN, DISPLAY ‘Can you please locate the containers for all the dietary supplements {you/SP} took? I will wait while you get them.’ ELSE DISPLAY ‘Any others? [REPEAT UNTIL ALL SUPPLEMENTS HAVE BEEN REPORTED]’.

CAPI INSTRUCTION: IF SP IS UNDER 12 YEARS OLD, DISPLAY (chewable, complete, with iron, with extra C)

ELSE DISPLAY (silver, women’s, men’s, prenatal, liquid).

CAPI INSTRUCTION: IF SP IS UNDER 12 YEARS OLD, DISPLAY (fluoride).

HARD EDIT: AT LEAST ONE SUPPLEMENT SHOULD BE ENTERED (DSA070 FILLED)

ERROR MESSAGE: “YOU MUST COLLECT INFORMATION FOR AT LEAST ONE SUPPLEMENT OR

BACK UP AND ANSWER “NO” TO DSA060.”

____________________________________

ENTER SUPPLEMENT NAME

REFUSED 7

DON'T KNOW 9

BOX 8

IF SUPPLEMENT NAME ENTERED, CONTINUE

ELSE GO TO BOX 10.

DSA105 {Quantity Taken}

Between midnight and midnight, how much did {you/SP} take?

[ENTER THE NUMBER]

SOFT EDIT: Quantity should be less than 10

Error Message: “YOU SAID YOU TOOK {QUANTITY TAKEN}. IS THAT CORRECT?”

____________________________________

ENTER QUANTITY

REFUSED 7

DON'T KNOW 9

DSA110 {Unit Taken}

OS (Was it a tablet, capsule, pill, caplet, softgel, or something else?)

[SELECT FORM/UNIT]

Tablets, capsules, pills, caplets, softgels,

gelcaps, vegicaps, chewable tablets 1 (BOX 9)

Droppers 2 (BOX 9)

Drops 3 (BOX 9)

Injection/Shots 5 (BOX 9)

Lozenges/Cough Drops 6 (BOX 9)

Milliliters 7

Tablespoons 11

Teaspoons 12

Wafers 13 (BOX 9)

Cans 15

Grams 16

Dots 17 (BOX 9)

Cups 18

Sprays/Squirts 19 (BOX 9)

Chews/Gummies 20 (BOX 9)

Scoops 21

Capfuls 23

Ounces 27

Packages/Packets 28 (BOX 9)

Vials 29 (BOX 9)

Gumballs 30 (BOX 9)

Other form (specify) 91 (BOX 9)

REFUSED 77 (BOX 9)

DON’T KNOW 99 (BOX 9)

DSA115 {Liquid/Powder}

Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 7

DON'T KNOW 9

DSQ.096 For how long {have/has} {you/SP} been taking {PRODUCT NAME} or a similar type of product?

Q/U

CAPI INSTRUCTION:

RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 777

DON'T KNOW 999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

BOX 9

GO TO DSA070 ON NEXT ROW.

BOX 10

IF ANTACIDS COLLECTED IN PREVIOUS INTERVIEW, GO TO BOX 11,

ELSE CONTINUE.

DSA005 The next questions are about {your/SP’s} use of non-prescription antacids. All day yesterday, {day}, between midnight and midnight did {you/SP} take any antacids?

[REFER SP TO ANTACID HANDCARD]

YES 1 (BOX 13)

NO .... 2 (BOX 16)

REFUSED…………………………………… 7 (BOX 16)

DON’T KNOW…………………………………. 9 (BOX 16)

BOX 11

Antacid Review Table

PRESENT DSA145 THROUGH DSA165 AS A GRID WHERE EACH ROW CONTAINS THE RELEVANT INFORMATION ABOUT AN ANTACID COLLECTED IN THE PREVIOUS INTERVIEW.

(THIS INCLUDES VARIABLES RXQ141, RXQ150S AND RXQ160 FROM THE HOUSEHOLD INTERVIEW.)

CONTINUE.

DSA145 {Taken Last 24 Hours}

TEXT 1: The next questions are about {your/SP’s} use of non-prescription antacids. During the interview in

{your home and our exam center/your home/our exam center} {you reported taking/it was reported {you/he/she} took} {ANTACID NAME}.

TEXT 2: It was also reported {you/SP} took {ANTACID NAME}.

Did you take this antacid yesterday {day}, (between midnight and midnight)?

[CONTINUE ASKING ABOUT EACH ANTACID LISTED IN TABLE]

CAPI INSTRUCTION: IF THIS IS THE FIRST ANTACID BEING REVIEWED, DISPLAY TEXT 1,

ELSE DISPLAY TEXT 2.

CAPI INSTRUCTION: IF SP Age > 15, DISPLAY ‘you reported taking’ ELSE DISPLAY ‘it was reported

{you/he/she} took’.

YES 1

NO 2 (BOX 12)

REFUSED 7 (BOX 12)

DON'T KNOW 9 (BOX 12)

DSA155 {Quantity Taken}

Between midnight and midnight, how much did {you/SP} take?

[ENTER THE NUMBER]

SOFT EDIT: Quantity should be less than 10

Error Message: “YOU SAID YOU TOOK {QUANTITY TAKEN}. IS THAT CORRECT?”

____________________________________

ENTER QUANTITY

REFUSED 7

DON'T KNOW 9

DSA160 {Unit Taken}

OS (Was it a tablet, capsule, pill, caplet, softgel, or something else?)

[SELECT FORM/UNIT]

Tablets, capsules, pills, caplets, softgels,

gelcaps, vegicaps, chewable tablets 1 (BOX 12)

Droppers 2 (BOX 12)

Drops 3 (BOX 12)

Injection/Shots 5 (BOX 12)

Lozenges/Cough Drops 6 (BOX 12)

Milliliters 7

Tablespoons 11

Teaspoons 12

Wafers 13 (BOX 12)

Cans 15

Grams 16

Dots 17 (BOX 12)

Cups 18

Sprays/Squirts 19 (BOX 12)

Chews/Gummies 20 (BOX 12)

Scoops 21

Capfuls 23

Ounces 27

Packages/Packets 28 (BOX 12)

Vials 29 (BOX 12)

Gumballs 30 (BOX 12)

Other form (specify) 91 (BOX 12)

REFUSED 77 (BOX 12)

DON’T KNOW 99 (BOX 12)

DSA165 {Liquid/Powder}

Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 7

DON'T KNOW 9

BOX 12

IF THERE ARE MORE ANTACIDS TO REVIEW, GO TO DSA145 FOR THE NEXT ANTACID, ELSE CONTINUE.

DSA065 All day yesterday, {day}, between midnight and midnight, did {you/SP} take any other antacids?

[REFER SP TO ANTACID HANDCARD]

YES 1

NO 2 (BOX 16)

REFUSED 7 (BOX 16)

DON'T KNOW 9 (BOX 16)

BOX 13

New Antacids Table

PRESENT DSA170 THROUGH DSA215 AS A GRID.

IF THERE WERE ANTACIDS REVIEWED (Antacid Review Table), THEN DISPLAY THOSE VALUES HERE IN THE FIRST ROWS.

CONTINUE.

DSA170 {Antacids}

{Can you please locate the containers for all the antacids {you/SP} took? I will wait while you get them./Any others?}

Can you please read to me all the words on the front label?

{[REPEAT UNTIL ALL ANTACIDS HAVE BEEN REPORTED]}

[PROBES: What is the brand name? Was it extra strength, regular strength, ultra, maximum strength?]

[IF ANTACID NOT ON LIST, TYPE “**Product not on list”]

CAPI INSTRUCTION: IF FIRST TIME ON THIS SCREEN, DISPLAY ‘Can you please locate the containers for all the antacids {you/SP} took? I will wait while you get them’

ELSE DISPLAY ‘Any others? [REPEAT UNTIL ALL ANTACIDS HAVE BEEN REPORTED]’.

HARD EDIT: AT LEAST ONE ANTACID SHOULD BE ENTERED (DSA170 FILLED)

ERROR MESSAGE: “YOU MUST COLLECT INFORMATION FOR AT LEAST ONE ANTACID OR

BACK UP AND ANSWER “NO” TO {DSA005/DSA065.}”

CAPI INSTRUCTION: IF ANTACIDS WAS COLLECTED IN PREVIOUS INTERVIEW, DISPLAY

“DSA065”; OTHERWISE DISPLAY “DSA005”.

____________________________________

ENTER ANTACID NAME

REFUSED 7

DON'T KNOW 9

BOX 14

IF ANTACID ENTERED, CONTINUE, ELSE GO TO BOX 16.

DSA175 {Pick List}

{Can you please locate the containers for all the antacids {you/SP} took? I will wait while you get them./Any others?}

Can you please read to me all the words on the front label?

{[REPEAT UNTIL ALL ANTACIDS HAVE BEEN REPORTED]}

[PROBES: What is the brand name? Was it extra strength, regular strength, ultra, maximum strength?]

[IF ANTACID NOT ON LIST, TYPE “**Product not on list”]

CAPI INSTRUCTION: IF FIRST TIME ON THIS SCREEN, DISPLAY ‘Can you please locate the containers for all the antacids {you/SP} took? I will wait while you get them.’

ELSE DISPLAY ‘Any others? [REPEAT UNTIL ALL ANTACIDS HAVE BEEN REPORTED]’.

____________________________________

ENTER ANTACID NAME FROM LIST OR

ENTER”**PRODUCT NOT ON LIST”

REFUSED 7

DON'T KNOW 9

DSA205 {Quantity Taken}

Between midnight and midnight, how much did {you/SP} take?

[ENTER THE NUMBER]

SOFT EDIT: Quantity should be less than 10

Error Message: “YOU SAID YOU TOOK {QUANTITY TAKEN}. IS THAT CORRECT?”

____________________________________

ENTER QUANTITY

REFUSED 7

DON'T KNOW 9

DSA210 {Unit Taken}

OS (Was it a tablet, capsule, pill, caplet, softgel, or something else?)

[SELECT FORM/UNIT]

Tablets, capsules, pills, caplets, softgels,

gelcaps, vegicaps, chewable tablets 1 (BOX 15)

Droppers 2 (BOX 15)

Drops 3 (BOX 15)

Injection/Shots 5 (BOX 15)

Lozenges/Cough Drops 6 (BOX 15)

Milliliters 7

Tablespoons 11

Teaspoons 12

Wafers 13 (BOX 15)

Cans 15

Grams 16

Dots 17 (BOX 15)

Cups 18

Sprays/Squirts 19 (BOX 15)

Chews/Gummies 20 (BOX 15)

Scoops 21

Capfuls 23

Ounces 27

Packages/Packets 28 (BOX 15)

Vials 29 (BOX 15)

Gumballs 30 (BOX 15)

Other form (specify) 91 (BOX 15)

REFUSED 77 (BOX 15)

DON’T KNOW 99 (BOX 15)

DSA215 {Liquid/Powder}

Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 7

DON'T KNOW 9

BOX 15

GO TO DSA170 ON NEXT ROW.

BOX 16

END