Household Interview

National Health and Nutrition Examination Survey

Att_3d_HH SP Family Instruments 10_23_18

Household Interview

OMB: 0920-0950

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0950 can be found here:

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Attachment 3d

Household Interview

Form Approved

OMB No. 0920-0950

Exp. Date XX/XX/20XX

CDC estimates the average public reporting burden for this collection of information as 5 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.

Sample Person Questionnnaire 3

RESPONDENT SELECTION SECTION - RIQ - SP QUESTIONNAIRE 3

EARLY CHILDHOOD – ECQ 19

HOSPITAL UTILIZATION AND ACCESS TO CARE – HUQ 25

IMMUNIZATION – IMQ 30

MEDICAL CONDITIONS – MCQ 34

HEPATITIS (HEQ) 53

KIDNEY CONDITIONS – KIQ 55

Functioning (FNQ) 56

DIABETES – DIQ 66

BLOOD PRESSURE – BPQ 79

CARDIOVASCULAR DISEASE – CDQ 84

OSTEOPOROSIS – OSQ 86

AUDIOMETRY – AUQ 95

DERMATOLOGY – DEQ 112

ORAL HEALTH – OHQ 114

STANDING BALANCE – BAQ 126

PHYSICAL ACTIVITY AND PHYSICAL FITNESS – PAQ 136

SLEEP DISORDERS – SLQ 148

DIET BEHAVIOR AND NUTRITION - DBQ 151

WEIGHT HISTORY – WHQ 183

SMOKING AND TOBACCO USE – SMQ 194

OCCUPATION – OCQ 202

ACCULTURATION – ACQ 209

DEMOGRAPHICS INFORMATION – DMQ – SP 212

HEALTH INSURANCE – HIQ 233

INFANT FORMULA Questionnaire - IFQ 240

DIETARY SUPPLEMENTS AND PRESCRIPTION MEDICATION – DSQ 247

MAILING ADDRESS – MAQ 286

FAMILY QUESTIONNAIRE 292

RESPONDENT SELECTION SECTION – RIQ – FAMILY QUESTIONNAIRE 292

DEMOGRAPHIC BACKGROUND/OCCUPATION (DMQ) 302

HOUSING CHARACTERISTICS – HOQ 306

SMOKING – SMQ 308

CONSUMER BEHAVIOR – CBQ 310

INCOME – INQ 317

FOOD SECURITY – FSQ 337

TRACKING AND TRACING – TTQ 363

SALT SAMPLE COLLECTION– SUQ 369

WATER SAMPLE COLLECTION 371

SP Household 19-20 survey instruments

7/1/2018

Sample Person Questionnnaire

Introductory Hand Card

RESPONDENT SELECTION SECTION - RIQ - SP QUESTIONNAIRE

RIQ.006 SELECT RESPONDENT FOR THE SP QUESTIONNAIRE FOR {SP NAME}.

CAPI INSTRUCTION:

DISPLAY HOUSEHOLD ROSTER FROM SCREENER AND ‘SOMEONE NOT LIVING IN HH’ AS OPTION.

DMQ.INTRO [{You have/SP has} been chosen to participate in the National Health and Nutrition Examination Survey conducted for the National Center for Health Statistics, part of the Centers for Disease Control and Prevention (CDC).] [All the information that you give us will be kept confidential. Your name will not be attached to any of your answers without your specific permission.] HAND RESPONDENT THE ADVANCE LETTER.

Before we begin the health interview, I would like to verify some information about {you/SP}.

DMQ.010 VERIFY OR ASK DATE OF BIRTH AND AGE.

CAPI INSTRUCTION:

DISPLAY PERSON #, NAME, DOB MONTH, DAY AND YEAR AND AGE IN YEARS. ALLOW DOB AND AGE FIELDS TO BE UPDATED.

DMQ.020 VERIFY GENDER.

MALE 1

FEMALE 2

CAPI INSTRUCTION:

PREFILL WITH GENDER FROM SCREENER AND ALLOW UPDATE.

BOX 8

CHECK ITEM DMQ.025:

APPLY SAMPLING ALGORITHM. IF SP IS NO LONGER ELIGIBLE DUE TO GENDER AND AGE CHANGES, CONTINUE.

OTHERWISE, SKIP TO DMQ.040.

DMQ.030 Thank you for your participation in the study. Our scientific, random selection process indicates that {you have/SP has} not been selected for the next part of the study.

BOX 9

CHECK ITEM DMQ.032:

END INTERVIEW AND APPLY DISPOSITION CODE ‘COMPLETE, ELIGIBILITY PROBLEMS’.

DMQ.040 What is {your/SP’s} full name, including middle name?

VERIFY SPELLING.

What is {your/SP’s} first name?

First Name: __________________________

CAPI INSTRUCTION:

PREFILL FIRST NAME FROM SCREENER AND ALLOW UPDATES.

DMQ.050 [What is {your/SP’s} full name, including middle name?]

VERIFY SPELLING.

What is {your/SP’s} middle name?

Middle Name #1: __________________________

Middle Name #2: __________________________

No middle name 1

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

PREFILL WITH MIDDLE NAME FROM SCREENER AND ALLOW UPDATES.

DMQ.060 [What is {your/SP’s} full name, including middle name?]

VERIFY SPELLING.

What is {your/SP’s} last name?

Last Name #1: __________________________

Last Name #2: __________________________

CAPI INSTRUCTION:

PREFILL WITH LAST NAME FROM SCREENER AND ALLOW UPDATES.

DMQ.070 [What is {your/SP’s} full name, including middle name?]

VERIFY SPELLING.

{Do you/Does SP} have a suffix? [What is it?]

Suffix: _________

CAPI INSTRUCTION:

ALLOW SUFFIX FIELD TO BE LEFT BLANK/NULL.

BOX 0

CHECK ITEM RIQ.008:

IF PROXY RESPONDENT FOR SP AGE 15 OR YOUNGER, GO TO RIQ.012.

IF PROXY RESPONDENT FOR SP AGE 16 OR OLDER, GO TO RIQ.014.

OTHERWISE GO TO BOX 1.

RIQ.012 INTERVIEWER: ASK OR MARK IF KNOWN.

(What is your relationship to {SP}?)

MOTHER (BIOLOGICAL/ADOPTIVE/
STEP/FOSTER) 1 (BOX 1)

FATHER (BIOLOGICAL/ADOPTIVE/
STEP/FOSTER) 2 (BOX 1)

GRANDPARENT (GRANDMOTHER/
GRANDFATHER) 3 (BOX 1)

AUNT/UNCLE 4 (BOX 1)

BROTHER/SISTER 5 (BOX 1)

OTHER RELATIVE 6 (BOX 1)

NON-RELATIVE 7 (BOX 1)

REFUSED 77 (BOX 1)

DON'T KNOW 99 (BOX 1)

RIQ.014 INTERVIEWER: ASK OR MARK IF KNOWN.

(What is your relationship to {SP}?)

SPOUSE (WIFE/HUSBAND) OR
PARTNER 1

DAUGHTER OR SON (BIOLOGICAL/
ADOPTIVE/IN-LAW/STEP/FOSTER) 2

PARENT (BIOLOGICAL/ADOPTIVE/
STEP/FOSTER) 3

GRANDPARENT (GRANDMOTHER/
GRANDFATHER) 4

BROTHER/SISTER 5

OTHER RELATIVE 6

NON-RELATIVE 7

REFUSED 77

DON'T KNOW 99

BOX 1

CHECK ITEM *11RIQ.015:

 IF SP IS SELECTED AS RESPONDENT AND SP AGE IS <= 15, GO TO *11RIQ.020.

 IF SP IS SELECTED AS RESPONDENT AND SP AGE IS >= 16, GO TO BOX 3AA.

 IF SP IS NOT SELECTED AS RESPONDENT AND SP AGE IS <= 15, GO TO BOX 2.

 IF SP IS NOT SELECTED AS RESPONDENT AND SP AGE IS >= 16, GO TO RIQ.039.

*11RIQ.020 INTERVIEW SHOULD BE CONDUCTED WITH A PROXY BECAUSE SP IS UNDER 16 YEARS OLD.

ENTER ONE OPTION.

SP IS AN EMANCIPATED MINOR 1 (BOX 3)

PERSON SELECTED AS

RESPONDENT IN ERROR 2 (RIQ.006)

SP AGE ENTERED IN ERROR -- SP IS

AGE 16+ 3 (DMQ.010)

RIQ.039 WHY IS INTERVIEW BEING CONDUCTED WITH A PROXY?

SP HAS COGNITIVE PROBLEMS 1

SP HAS PHYSICAL PROBLEMS

(SPECIFY) 2

*11RIQ.035 DO YOU HAVE SUPERVISOR PERMISSION TO CONDUCT INTERVIEW WITH A PROXY?

YES 1

NO 2 (RIQ.006)

BOX 2

CHECK ITEM RIQ.031:

IF 'SOMEONE NOT LIVING IN HH' SELECTED AS RESPONDENT IN RIQ.006, CONTINUE.

OTHERWISE, GO TO BOX 3AA.

RIQ.040 WHY IS INTERVIEW BEING CONDUCTED WITH SOMEONE OUTSIDE THE HOUSEHOLD?

RIQ.050 ENTER RESPONDENT NAME.

FIRST NAME LAST NAME

RIQ.060 ENTER RESPONDENT'S PHONE NUMBER.

ENTER '00' IN AREA CODE IF NO PHONE.

|___|___|___| |___|___|___| - |___|___|___|___|

AREA CODE ENTER PHONE NUMBER

BOX 3

CHECK ITEM *11RIQ.072:

IF SP SELECTED AS RESPONDENT IS <12 YEARS OLD, CONTINUE.

OTHERWISE, GO TO BOX 3AA.

*11RIQ.074 EMANCIPATED MINOR MUST BE AT LEAST 12 YEARS OLD.

PRESS ‘ENTER’ TO SELECT ANOTHER RESPONDENT.

CAPI INSTRUCTION:

WHEN ‘ENTER’ IS PRESSED, CAPI SHOULD RETURN TO RIQ.006.

BOX 3AA

CHECK ITEM RIQ.245:

IF SP SELECTED AS RESPONDENT IS 16 OR 17 YEARS OLD, CONTINUE.

OTHERWISE, GO TO RIQ.250.

RIQ.248 IS SP AN EMANCIPATED MINOR?

YES 1

NO 2

BOX 3B

OMITED

RIQ.250 HAND RESPONDENT COPY OF HOME INTERVIEW CONSENT FORM IN THE LANGUAGE HE/SHE READS.

REVIEW KEY POINTS WITH RESPONDENT OR READ CONSENT FORM OUT LOUD IF NECESSARY.

ANSWER ANY RESPONDENT QUESTIONS. (PRESS NEXT TO CONTINUE)

BOX 3C

CHECK ITEM RIQ.260:

IF RESPONDENT IS 16-17 YEARS OLD AND NOT EMANCIPATED (RIQ.248 = 2/NO OR *11RIQ.020 NOT EQUAL TO 1), CONTINUE.

OTHERWISE, SKIP TO RIQ.278.

RIQ.274 WHO IS PARENT/GUARDIAN CONSENTING FOR {SP}?

CAPI INSTRUCTION:

LIST HH ROSTER MEMBERS WHO ARE 18+ AND ‘SOMEONE NOT LIVING IN HH’ AS RESPONSE OPTIONS.

IF ‘NOT ON LIST’ SELECTED GO TO RIQ.276. IF HH MEMBER SELECTED, GO TO RIQ.278.

RIQ.276 WHAT IS PARENT/GUARDIAN’S NAME?

INTERVIEWER INSTRUCTION: ENTER NAME. VERIFY SPELLING.

FIRST NAME LAST NAME

RIQ.278 CAPI INSTRUCTION:

DISPLAY IMAGE HOME INTERVIEW CONSENT FORM. SHOW TOP OF FORM, INCLUDING FIRST THREE PARAGRAPHS.
DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.
DISPLAY INTERVIEWER INSTRUCTION: “TURN SCREEN TO {SP/PROXY NAME/NAME IN RIQ.274 OR 276} AND EXPLAIN THAT YOU ARE REVIEWING THE SAME FORM HARDCOPY AND ELECTRONICALLY.”
DISPLAY PERSON CONSENTING/SIGNING IN INSTRUCTION #3 AS:
1. ‘SP’ IF ADULT SP RESPONDENT OR
2. ‘PROXY NAME’ IF PROXY FOR ADULT OR CHILD OR
3. ‘NAME FROM RIQ.274 OR RIQ.276’ IF RESPONDENT IS 16-17 YEAR OLD SP AND NOT EMANCIPATED.

RIQ.280a/b EXPLAIN THE HOME INTERVIEW CONSENT AND LINKAGE CHECK BOXES. TURN SCREEN AND ASK {SP/PROXY NAME/NAME IN RIQ.274 OR 276} TO RECORD HIS/HER HOME INTERVIEW CONSENT AND LINKAGE CHOICE BELOW.

I have read the information above. I agree to {allow SP to} proceed with the interview {for SP}.

YES 1

NO 2

We can do additional health research by linking the interview and exam data to vital statistics, health, nutrition, and other related records. May we try to link {your/SP’s} survey records with other records?

YES 1

NO 2

CAPI INSTRUCTION:

DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.
IN RIQ.280 STEM, DISPLAY PERSON CONSENTING/SIGNING IN INSTRUCTION AS:
1. ‘SP’ IF ADULT SP RESPONDENT OR
2. ‘PROXY NAME’ IF PROXY FOR ADULT OR CHILD OR
3. ‘NAME FROM RIQ.274 OR RIQ.276’ IF RESPONDENT IS 16-17 YEAR OLD SP AND NOT EMANCIPATED.
DISPLAY YES/NO OPTIONS AS RADIO BUTTON, ALLOWING ONLY ONE CHOICE.
DISPLAY OMB NUMBER IN UPPER RIGHT OF SCREEN.
DISABLE LINKAGE QUESTION IF RIQ.280a = NO (2).
IF RIQ.280a = 2, DISPLAY THE FOLLOWING MESSAGE: “EACH RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE MUST SIGN A HOUSEHOLD INTERVIEW CONSENT FORM BEFORE THE INTERVIEW CAN BE ADMINISTERED” (FUNCTIONS LIKE CURRENT RIQ.080-081).
FOR RIQ.280a: DISPLAY “allow SP to” WHEN RESPONDENT IS 16-17 YEAR OLD SP AND NOT EMANCIPATED. OTHERWISE LEAVE BLANK.
FOR RIQ.280b: DISPLAY ‘your’ IF ADULT SP RESPONDENT OR 16-17 YEAR OLD SP RESPONDENT WHO IS EMANCIPATED. DISPLAY ‘SP’s’ IF PROXY RESPONDENT FOR SP AGED 0-15 OR 18+. DISPLAY ‘SP’s’ IF RESPONDENT IS SP 16-17 YEAR OLD NON-EMANCIPATED.
FOR RIQ.280a: DISPLAY “for SP” IF PROXY RESPONDENT.

RIQ.320 ADULT RESPONDENT OR PARENT/GUARDIAN OF NON-EMANCIPATED 16-17 YEAR OLD SIGNATURE SCREEN (USED FOR ALL INTERVIEWS)

CAPI INSTRUCTION:

1. DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.

2. CHECK BOX LABELED ‘OFFICE USE ONLY: H’ FOR FI TO CHOOSE IF RESPONDENT REFUSES TO SIGN ELECTRONICALLY BUT WILL SIGN HARDCOPY. IF SELECTED SKIP TO RIQ.080.

3. REFUSED BUTTON LABELED ‘RF’ FOR IF RESPONDENT REFUSES TO CONSENT. IF REFUSED, DISPLAY THE FOLLOWING MESSAGE: “EACH RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE MUST SIGN A HOUSEHOLD INTERVIEW CONSENT FORM BEFORE THE INTERVIEW CAN BE ADMINISTERED” (FUNCTIONS LIKE CURRENT RIQ.080-081).

4. DO NOT ALLOW INSTRUMENT TO MOVE FORWARD WITHOUT A SIGNATURE, RF BUTTON OR HARDCOPY SIGNATURE ENTERED. CODE REFUSAL AS -1.

5. Display “YES I agree to proceed with the interview {for SP}” if RIQ.280a = 1.

6. DISPLAY “YES I permit NHANES to link {my/SP’s} survey records with other records” if RIQ.280b = 1.

DISPLAY “NO I do not permit NHANES to link {my/SP’s} survey records with other records” if RIQ.280b = 2.

7. COLLECT DATE AND TIME STAMP WHEN SIGNATURE IS CAPTURED.

8. ABOVE SIGNATURE BOX, DISPLAY “Sign below.”

9. DISPLAY OMB NUMBER IN UPPER RIGHT OF SCREEN.

10. UNDER SIGNATURE LINE, DISPLAY NAME OF PERSON SIGNING (IF ADULT SP OR EMANCIPATED MINOR, DISPLAY SP NAME. IF 16-17 YEAR OLD NOT EMANCIPATED, DISPLAY NAME FROM RIQ.274 OR RIQ.276).

BOX 3D

CHECK ITEM RIQ.290:

IF RESPONDENT SP 16-17 YEARS OLD AND MINOR (NOT EMANCIPATED (RIQ.248 = 2/NO OR *11RIQ.020 NOT EQUAL TO 1)

IF YES, CONTINUE.

IF NO, GO TO RIQ.350.

IF RESPONDENT REFUSED, EXIT OUT (STEP #3 ABOVE).

IF RESPONDENT REQUESTED HARDCOPY SIGNATURE, SKIP TO RIQ.390.

RIQ.300 GIVE PARENT/GUARDIAN PERMISSION TO AUDIO RECORD HOME INTERVIEW FORM TO PARENT/GUARDIAN IN THE LANGUAGE HE/SHE READS.

REVIEW THAT WE WOULD LIKE TO AUDIO RECORD THE SP’S INTERVIEW OR READ CONSENT FORM OUT LOUD IF NECESSARY.

ANSWER ANY QUESTIONS. (PRESS NEXT TO CONTINUE)

RIQ.305 CAPI INSTRUCTION:

1. DISPLAY IMAGE OF PARENTAL/GUARDIAN PERMISSION TO AUDIO RECORD THE HOME INTERVIEW FORM. DISPLAY TOP OF FORM, INCLUDING TITLE AND FIRST PARAGRAPH.

2. DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.

3. DISPLAY INTERVIEWER INSTRUCTION: “TURN SCREEN TO {NAME IN RIQ.274 OR 276} AND EXPLAIN THAT YOU ARE REVIEWING THE SAME FORM HARDCOPY AND ELECTRONICALLY.”

RIQ.310 INTERVIEWER: TURN SCREEN FOR PARENT/GUARDIAN TO SELECT ANSWER.

I have read the Parent/Guardian Permission to Audio Record the Home Interview.

I agree to have my child’s interview
recorded for quality control 1

I do not agree to have my child’s interview
recorded for quality control 2

CAPI INSTRUCTION:

DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.

DISPLAY RESPONSE OPTIONS AS RADIO BUTTONS, ALLOWING ONLY ONE CHOICE.

DISPLAY OMB NUMBER IN UPPER RIGHT OF SCREEN.

RIQ.332 PARENTAL/GUARDIAN PERMISSION TO AUDIO RECORD THE HOME INTERVIEW SIGNATURE SCREEN

CAPI INSTRUCTION:

1. DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.

2. DO NOT ALLOW INSTRUMENT TO MOVE FORWARD WITHOUT A SIGNATURE,

3. DISPLAY “AGREE to have my child’s interview recorded for quality control.” IF RIQ.310 = 1.

DISPLAY “DO NOT AGREE to have my child’s interview recorded for quality control.” IF RIQ.310 =2.

7. COLLECT DATE AND TIME STAMP WHEN SIGNATURE IS CAPTURED.

8. ABOVE SIGNATURE BOX, DISPLAY “Sign below.”

9. DISPLAY OMB NUMBER IN UPPER RIGHT OF SCREEN.

10. UNDER SIGNATURE LINE, DISPLAY NAME OF PERSON SIGNING (DISPLAY PARENTAL/GUARDIAN NAME FROM RIQ.274 OR RIQ.276).

BOX 3E

*OMITED.

RIQ.334 CAPI INSTRUCTION:

1. DISPLAY IMAGE HOME INTERVIEW CONSENT FORM. SHOW TOP OF FORM, INCLUDING FIRST THREE PARAGRAPHS.

2. DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.

3. DISPLAY INTERVIEWER INSTRUCTION: “TURN SCREEN TO {SP} AND EXPLAIN THAT YOU ARE REVIEWING THE SAME FORM HARDCOPY AND ELECTRONICALLY.”

RIQ.336a/b EXPLAIN THE HOME INTERVIEW CONSENT AND LINKAGE CHECK BOXES. TURN SCREEN AND ASK {SP} TO RECORD HIS/HER HOME INTERVIEW CONSENT AND LINKAGE CHOICE BELOW.

I have read the information above. I agree to proceed with the interview.

YES 1

NO 2

We can do additional health research by linking the interview and exam data to vital statistics, health, nutrition, and other related records. May we try to link your survey records with other records?

YES 1

NO 2

CAPI INSTRUCTION:

DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.

DISPLAY YES/NO OPTIONS AS RADIO BUTTON, ALLOWING ONLY ONE CHOICE.

DISPLAY OMB NUMBER IN UPPER RIGHT OF SCREEN.

DISPLAY LINKAGE QUESTION (RIQ.RIQ.336b) WHEN RIQ.336a = 1 AND RIQ. = 280b = 1.

IF RIQ.336a = 2, DISPLAY THE FOLLOWING MESSAGE: “EACH RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE MUST SIGN A HOUSEHOLD INTERVIEW CONSENT FORM BEFORE THE INTERVIEW CAN BE ADMINISTERED” (FUNCTIONS LIKE CURRENT RIQ.080-081).

RIQ.340 16-17 YEAR OLD SP (NON EMANCIPATED) SIGNATURE SCREEN

CAPI INSTRUCTION:

1. DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.

2. REFUSED BUTTON LABELED ‘RF’ FOR IF RESPONDENT REFUSES TO CONSENT. IF REFUSED, DISPLAY THE FOLLOWING MESSAGE: “EACH RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE MUST SIGN A HOUSEHOLD INTERVIEW CONSENT FORM BEFORE THE INTERVIEW CAN BE ADMINISTERED” (FUNCTIONS LIKE CURRENT RIQ.080-081). CODE REFUSAL AS -1.

3. DO NOT ALLOW INSTRUMENT TO MOVE FORWARD WITHOUT A SIGNATURE, RF BUTTON OR HARDCOPY SIGNATURE ENTERED.

4. DISPLAY “YES I agree to proceed with the interview” if RIQ.336a = 1.

5. DISPLAY “YES I permit NHANES to link my survey records with other records” if RIQ.280b AND RIQ.336B = 1.

6. DISPLAY “NO I do not permit NHANES to link my survey records with other records” if RIQ.336B = 2

6b. DISPLAY “PARENT DID NOT PERMIT NHANES to link my survey records with other records” if RIQ.280b = 2.

7. IF SP IS 16-17 YEARS OLD, AND PARENT AGREED TO HAVE CHILD’S INTERVIEW RECORDED (RIQ.310=1), DISPLAY “PARENT AGREED to have my interview recorded for quality control.”

8. IF SP IS 16-17 YEARS OLD, AND PARENT DID NOT AGREE TO HAVE CHILD’S INTERVIEW RECORDED (RIQ.310=2), DISPLAY “PARENT DID NOT AGREE to have my interview recorded for quality control.”

9. COLLECT DATE AND TIME STAMP WHEN SIGNATURE IS CAPTURED.

10. ABOVE SIGNATURE BOX, DISPLAY “Sign below.” BELOW ALLOW ADEQUATE SPACE FOR RESPONDENT TO SIGN.

11. DISPLAY OMB NUMBER IN UPPER RIGHT OF SCREEN.

12. DISPLAY SP NAME UNDER SIGNATURE LINE.

RIQ.350 IS A WITNESS/INTERPRETER SIGNATURE REQUIRED?

WITNESS 1

INTERPRETER 2 (RIQ.370)

NO 3 (RIQ.380)

RIQ.360 WITNESS SIGNATURE SCREEN

CAPI INSTRUCTION:

1. DISPLAY IN ENGLISH.

2. WITNESS MUST SIGN ELECTRONICALLY IF RESPONDENT DID.

3. DO NOT ALLOW INSTRUMENT TO MOVE FORWARD WITHOUT A SIGNATURE.

4. COLLECT DATE AND TIME STAMP WHEN SIGNATURE IS CAPTURED.

5. ABOVE SIGNATURE BOX, DISPLAY, “I observed the interviewer read this form to the RESPONDENT NAME and {he/she} agreed to participate by electronically signing or marking.” BELOW ALLOW ADEQUATE SPACE FOR WITNESS TO SIGN.

6. SKIP TO RIQ.380.

RIQ.370 INTERPRETER SIGNATURE SCREEN

CAPI INSTRUCTION:

1. DISPLAY IN ENGLISH.

2. INTERPRETER MUST SIGN ELECTRONICALLY IF RESPONDENT DID.

3. DO NOT ALLOW INSTRUMENT TO MOVE FORWARD WITHOUT A SIGNATURE.

4. COLLECT DATE AND TIME STAMP WHEN SIGNATURE IS CAPTURED.

5. ABOVE SIGNATURE BOX, DISPLAY, “I interpreted this form to the RESPONDENT NAME and {he/she} agreed to participate by electronically signing or marking.” BELOW ALLOW ADEQUATE SPACE FOR INTERPRETER TO SIGN.

RIQ.380 DID RESPONDENT REQUEST THAT A COPY OF THE CONSENT FORM(S) WITH HIS/HER SIGNATURE PRINTED BE MAILED?

YES 1 (BOX 3A)

NO 2 (BOX 3A)

CAPI INSTRUCTION:

SET AN ELECTRONIC INDICATOR (VARIABLE/ALERT/FLAG?) TO KNOW WHICH RESPONDENTS REQUESTED THE PRINTED FORMS BE MAILED.

RIQ.390 ASK RESPONDENT TO SIGN TWO COPIES OF THE HOME INTERVIEW CONSENT FORM. HAVE RESPONDENT KEEP ONE COPY AND COLLECT ONE IN THE HH FOLDER AND RETURN TO FIELD OFFICE.

TO COMPLETE THE HARDCOPY FORM:

Print name of person answering questions.

Check boxes regarding linking with other vital records.

IF 16-17 YEAR OLD RESPONDENT ANSWERING FOR HIM/HERSELF, SP SIGNS FORM AND PARENT/GUARDIAN SIGNS FORM.

IF 16-17 YEAR OLD EMANCIPATED MINOR, SP SIGNS FORM AND CHECK BOX FOR EMANCIPATED MINOR TO DOCUMENT THAT A PARENT/GUARDIAN SIGNATURE IS NOT REQUIRED.

IF NOT 16-17 YEAR OLD RESPONDENT, Signed by respondent who is answering for child 0-15, BY ADULT SP, OR PROXY FOR AN ADULT.

Signed by witness/INTERPRETER (if necessary).

Signed by Staff member.

Record HH & Family ID.

Check questionnaire boxes for all completed with respondent (SPs & Family).

Record names of all PROXY INTERVIEWS RESPONDENT is responding for along with SP IDs.

press NEXT to continue.

RIQ.080 HAS RESPONDENT SIGNED A HOUSEHOLD INTERVIEW CONSENT FORM?

CAPI INSTRUCTION:

IF 'NO' (CODE 2), DISPLAY THE FOLLOWING MESSAGE: "EACH RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE MUST SIGN A HOUSEHOLD INTERVIEW CONSENT FORM BEFORE THE INTERVIEW CAN BE ADMINISTERED" AND RETURN TO RIQ.080.

NOTE: IF INTERPRETER USED, RESPONDENT MUST SIGN FORM.

SET FORM TYPE VARIABLE TO HARDCOPY SO ISIS E/S KNOWS A HARDCOPY FORM MUST BE IMAGE SCANNED.

YES 1

NO 2

RIQ.085 PLEASE RECORD RESPONDENT’S ANSWER TO THE LINKAGE QUESTION ON THE HOUSEHOLD CONSENT.

INTERVIEWER INSTRUCTION: IF 16-17 YEAR OLD RESPONDENT, YES MEANS BOTH PARENT/GUARDIAN AND SP AGREE TO LINKING.

RESPONDENT’S ANSWER:

YES (MAY LINK) 1

NO (MAY NOT LINK) 2

BOX 3A

CHECK ITEM RIQ.160:

IF RESPONDENT SP AGE 16 OR 17 NOT EMANCIPATED AND SIGNED HARDCOPY CONSENT (NOT E-CONSENT), GO TO RIQ.210.

IF SP 16-17 NOT EMANCIPATED AND PARENT AGREED TO AUDIO RECORDING (RIQ.310 = 1), GO TO RIQ.230.

IF SP 16-17 NOT EMANCIPATED AND PARENT DID NOT AGREE TO AUDIO RECORDING (RIQ.310 = 2), GO TO INT.001.

IF SAME RESPONDENT AS A PREVIOUS INTERVIEW AND GAVE PERMISSION TO RECORD THAT PREVIOUS INTERVIEW, GO TO RIQ.200. IF NOT SAME RESPONDENT AS PREVIOUS INTERVIEW, GO TO RIQ.230.

RIQ.210 DO YOU HAVE WRITTEN PARENT/GUARDIAN PERMISSION TO AUDIO RECORD THIS INTERVIEW?

YES PARENT AGREED 1

NO PARENT DID NOT AGREE 2 (INT.001)

RIQ.230 CAPI INSTRUCTION: BEGIN RECORDING SO THAT WHEN INTERVIEWER READS THIS QUESTION IT IS CAPTURED ON RECORDING.

A standard part of our quality control procedures is to record interviews.

The information being recorded is protected and kept confidential, the same as all of your answers to the survey.

This recording will be used to improve the quality of our survey and to review the quality of my work.

{Your parent/guardian has already given permission to record the interview.}

The computer is now recording our conversation.

Do I have your permission to record this interview?

CAPI INSTRUCTION: IF SP AGE = 16 OR 17 DISPLAY “Your parent/guardian has already given permission to record the interview.”

YES 1 (INT.001)

NO 2 (INT.001)

CAPI INSTRUCTION: IF RIQ.230 = 2/NO, STOP.

RIQ.200 CAPI INSTRUCTION: BEGIN RECORDING SO THAT WHEN INTERVIEWER READS THIS QUESTION IT IS CAPTURED ON RECORDING.

A reminder that the system is now recording our conversation. Do I have your permission to record this interview?

YES 1

NO 2

CAPI INSTRUCTION: IF RIQ.200 = 2/NO, STOP.

EARLY CHILDHOOD – ECQ

Target Group: SPs Birth to 15 Years

ECQ.010 First I have some questions about {SP NAME's} birth.

How old was {SP NAME's} biological mother when {s/he} was born?

|___|___|

ENTER AGE IN YEARS

CAPI INSTRUCTION:

HARD EDIT <10 AND >59, SOFT EDIT 10, 11, AND 12

REFUSED 7777

DON'T KNOW 9999

HELP SCREEN:

Biological Mother: The person who gave birth to the child.

ECQ.020 Did {SP NAME's} biological mother smoke at any time while she was pregnant with {him/her}?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

Biological Mother: The person who gave birth to the child.

BOX 0

CHECK ITEM ECQ.New0a:

IF SP AGE ≥ 24 MONTH, GO TO ECQ.071,

ELSE, CONTINUE.

ECQ.New1 How much did {SP NAME's} biological mother weigh before she was pregnant with {him/her}?

L/K

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (ECQ.New2)

DON’T KNOW 9 (ECQ.New2)

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777

DON’T KNOW 99999

ECQ.New2 How tall is {SP NAME's} biological mother without shoes?

G/F/I/C

|___|

ENTER HEIGHT IN FEET AND INCHES 1

ENTER HEIGHT IN CENTIMETERS 2

REFUSED 7 (ECQ.071)

DON’T KNOW 9 (ECQ.071)

|___|___|

ENTER NUMBER OF FEET

CAPI INSTRUCTION: HARD EDIT 2-8

REFUSED 7777 (ECQ.071)

DON’T KNOW 9999 (ECQ.071)

AND

|___|___|

ENTER NUMBER OF INCHES

CAPI INSTRUCTION: HARD EDIT 0-11

DON’T KNOW 9999 (ECQ.071)

|___|___|___|

ENTER NUMBER OF CENTIMETERS

CAPI INSTRUCTION: HARD EDIT 61-272

DON’T KNOW 9999 (ECQ.071)

ECQ.071 How much did {SP NAME} weigh at birth?

L/O/K/M

IF ANSWER GIVEN IN POUNDS ONLY, PROBE FOR OUNCES.

IF ANSWER GIVEN IN EXACT POUNDS, ENTER NUMBER OF POUNDS AND 0 OUNCES.

ENTER WEIGHT IN POUNDS, KILOGRAMS OR GRAMS.

|___|

ENTER NUMBER OF POUNDS

AND OUNCES 1

ENTER NUMBER IN KILOGRAMS 2

ENTER NUMBER IN GRAMS 3

REFUSED 7 (BOX 1)

DON’T KNOW 9 (BOX 1)

|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 3-20, HARD EDIT GREATER THAN 20

AND

|___|___|

ENTER NUMBER OF OUNCES

CAPI INSTRUCTION:

HARD EDIT 0-15, NO SOFT EDIT

|___|___|___|

ENTER NUMBER IN KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 1.5-9, HARD EDIT GREATER THAN 9

|___|___|___|

ENTER NUMBER IN GRAMS

CAPI INSTRUCTION:

SOFT EDIT 1,500-9,000, HARD EDIT GREATER THAN 9,000

BOX 1

CHECK ITEM ECQ.075:

IF REFUSED (CODE 7) OR DON'T KNOW (CODE 9), CONTINUE.

OTHERWISE, GO TO BOX 2.

ECQ.080 Did {SP NAME} weigh . . .

more than 5-1/2 lbs. (2 and a half kilograms), or…………..1

less than 5-1/2 lbs. (2 and a half kilograms)?......................2 (BOX 2)

REFUSED………………………………………………………7 (BOX 2)

DON'T KNOW………………………………………………….9 (BOX 2)

ECQ.090 Did {SP NAME} weigh . . .

more than 9 lbs. (4 kilograms), or 1

less than 9 lbs. (4 kilograms)? 2

REFUSED 7

DON'T KNOW 9

BOX 2

CHECK ITEM ECQ.095:

IF SP AGE = 2-15 YEARS, CONTINUE.

OTHERWISE, GO TO End of Section.

WHQ.030e Do you consider {SP} now to be . . .

overweight, 1

underweight, or 2

about the right weight? 3

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

MCQ.080e Has a doctor or health professional ever told you that {SP} was overweight?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

HELP SCREEN:

Doctor: The term refers to both medical doctors (M.D.s) and osteopathic physicians (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.

Other Health (Care) Professional: A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.

ECQ.150 Are you now doing anything to help {SP} control {his/her} weight?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HOSPITAL UTILIZATION AND ACCESS TO CARE – HUQ

Target Group: SPs Birth +

HUQ.010 {First/Next} I have some general questions about {your/SP's} health

Would you say {your/SP's} health in general is . . .

CAPI INSTRUCTION:

DISPLAY "FIRST" IF SP AGE IS >= 16 YEARS.

excellent, 1

very good, 2

good, 3

fair, or 4

poor? 5

REFUSED 7

DON'T KNOW 9

HUQ.030 Is there a place that {you/SP} usually {go/goes} to if {you are/he/she is} sick and need{s} health care?

CAPI INSTRUCTION:

IF SP AGE < 12, DISPLAY "YOU" IN THE FOURTH DISPLAY AND DON'T DISPLAY THE "S" IN THE FIFTH DISPLAY.

YES 1

THERE IS NO PLACE 2 (HUQ.051)

THERE IS MORE THAN ONE PLACE 3

REFUSED 7 (HUQ.051)

DON'T KNOW 9 (HUQ.051)

HELP SCREEN:

Usual Place: Include walk-in clinic, doctor's office, clinic, health center, Health Maintenance Organization or HMO, hospital emergency room or outpatient clinic, or a military or VA health care facility.

HUQ.041 {What kind of place is it/ What kind of place {do you/does SP} go to most often} - a doctor's office or health center; an urgent care center or clinic in a drug store or grocery store; an emergency room; a VA Medical Center or VA outpatient clinic; or some other place [Read if necessary: A doctor's office or health center is a place where you see the same doctor or the same group of doctors every visit, where you usually need to make an appointment ahead of time, and where your medical records are on file.] [Read if necessary: Urgent care centers, and clinics in a drug store or grocery store are places where you do not need to make an appointment ahead of time, and do not usually see the same health care provider.]

A DOCTOR'S OFFICE OR HEALTH CENTER 1

URGENT CARE CENTER OR CLINIC IN A DRUG STORE

OR GROCERY STORE 2

EMERGENCY ROOM 3

A VA MEDICAL CENTER OR VA OUTPATIENT CLINIC 4

SOME OTHER PLACE 5

DOESN’T GO TO ONE PLACE MOST OFTEN 6

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF HUQ.030 = 1 DISPLAY “What kind of place is it -

IF HUQ.030 = 3 DISPLAY “What kind of place {do you/does SP} go to most often -

HUQ.051 {During the past 12 months, how/How} many times {have you/has SP} seen a doctor or other health care professional about {your/his/her} health at a doctor's office, a clinic or some other place? Do not include times {you were/s/he was} hospitalized overnight, visits to hospital emergency rooms, home visits or telephone calls.

CAPI INSTRUCTION:

DISPLAY "12 MONTHS" ONLY IF SP'S AGE IS >= 1.

NONE 0

1 1 (HUQ.071)

2 TO 3 2 (HUQ.071)

4 TO 5 3 (HUQ.071)

6 TO 7 4 (HUQ.071)

8 TO 9 5 (HUQ.071)

10 TO 12 6 (HUQ.071)

13 TO 15 7 (HUQ.071)

16 OR MORE 8 (HUQ.071)

REFUSED 77 (HUQ.071)

DON'T KNOW 99 (HUQ.071)

HELP SCREEN:

Include: Physicians, osteopaths, doctor’s assistants, nurse practitioners, nurses, lab technicians and technicians who administer shots (e.g., allergy shots), paramedics, medics and physical therapists who work with or in a doctor’s office.

Do not include: Dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists and psychologists or social workers.

HUQ.061 About how long has it been since {you/SP} last saw a doctor or other health care professional about {your/his/her} health for any reason? [Read if necessary: Include doctors seen while a patient in a hospital.] [Read if necessary: Do not include dental care.]

never 0

within the past year (anytime less than 12 months ago) 1

within the last 2 years (1 year but less than 2 years ago) 2

within the last 3 years (2 years but less than 3 years ago) 3

within the last 5 years (3 years but less than 5 years ago) 4

within the last 10 years (5 years but less than 10 years ago) 5

10 years ago or more 6

REFUSED 77

DON'T KNOW 99

HUQ.071 During the past 12 months, {have you been/was SP} hospitalized overnight?

CAPI INSTRUCTION:

DISPLAY "12 MONTHS" ONLY IF SP'S AGE IS >= 1.

DISPLAY "WAS SP" WITH LEADING CAPS, IF SP'S AGE IS <1.

YES 1

NO 2 (BOX 2)

REFUSED 7 (BOX 2)

DON'T KNOW 9 (BOX 2)

HELP SCREEN:

Overnight Stay in a Hospital: A person is admitted to a hospital and spends at least one night in the hospital. Note that a person can be “admitted” to a hospital without staying overnight. Do not count as “overnight” when a person is admitted and discharged on the same day. Do not include visits outpatient clinics or stays for non-medical reasons, such as staying with a family member.

BOX 2

CHECK ITEM 085:

IF SP AGE >= 4, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

HUQ.090 During the past 12 months, did {you/SP} receive counseling or therapy from a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN FOR HUQ.041:

Clinic: Refers to a facility where medical care and advice are given by doctors, nurses, or other medical professionals, that is not located at a hospital. (Do not include hospital outpatient departments.) Include a clinic operated solely for employees of a company or industry, regardless of where the clinic is located.

Doctor's Office: In Hospital - An individual office in a hospital where patients are seen on an outpatient basis, or several doctors might occupy a suite of offices in a hospital where patients are treated as outpatients.

Doctor's Office: Not in Hospital - An individual office in the doctor's home or office building, or a suite of offices occupied by several doctors. Suites of doctors offices are not considered clinics.

Health Center: Refers to a facility where medical care and advice are given by doctors, nurses, or other medical professionals that is not located at a hospital.

HMO Clinic: A medical facility sponsored by an HMO that typically includes a group of doctors on staff.

Hospital Outpatient Department: A unit of a hospital providing health and medical services to individuals who receive services from the hospital but do not require hospitalization overnight, such as outpatient surgery centers. Examples of outpatient departments include the following:

Well-baby clinics/pediatric OPD;

Obesity clinics;

Eye, ear, nose, and throat clinics;

Cardiology clinic;

Internal medicine department;

Family planning clinics;

Alcohol and drug abuse clinics;

Physical therapy clinics; and

Radiation therapy clinics.

Hospital outpatient departments may also provide general primary care.

HELP SCREEN FOR HUQ.061:

Hospital: A health care organization that has a governing body, an organized medical staff and professional staff, and inpatient facilities. Hospitals provide medical, nursing, and related services for ill and injured patients 24 hours per day, 7 days per week.

HELP SCREEN FOR HUQ.090:

Mental Health Professional: A person trained to diagnose and treat emotional or mental health problems, including, psychiatrists, psychologists, counselors, and social workers.

Psychologist: A non-physician who specializes in the counseling and testing of persons with mental, addictive or emotional disorders.

Psychiatrist: A physician who specializes in dealing with the prevention, diagnosis, and treatment of mental, addictive, and emotional disorders, such as psychoses, depression, anxiety disorders, substance abuse disorders, developmental disabilities, sexual dysfunctions and adjustment reactions.

Social Worker: A person who assists patients and their families in handling social, environmental and emotional problems associated with illness or injury. Can include social work specialists, such as a medical or psychiatric social worker.

IMMUNIZATION – IMQ

Target Group: SPs Birth +

BOX 0

CHECK ITEM IMQ.005:

IF SP AGE >= 2, CONTINUE.

OTHERWISE, GO TO IMQ.020.

BOX 1

OMITTED

IMQ.011 Hepatitis (Hep-a-ti-tis) A vaccine is given as a two dose series to some children older than 2 years and also to some adults, especially people who travel outside the United States. It has only been available since 1995. {Have you/Has SP} ever received the hepatitis A vaccine?

INTERVIEWER INSTRUCTION: A COMBINATION HEPATITIS A AND HEPATITIS B VACCINE SHOULD BE COUNTED AS THE A VACCINE FOR THE PURPOSE OF THIS QUESTION. CODE 'YES AT LEAST 2 DOSES' IF RESPONDENT ANSWERS 3 OR 4 DOSES WERE RECEIVED. CODE 'LESS THAN 2 DOSES' ONLY IF MENTIONED BY RESPONDENT.

YES AT LEAST 2 DOSES 1

LESS THAN 2 DOSES 2

NO DOSES 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

REMOVE CURRENT HELP.

IMQ.020 Hepatitis (Hep-a-ti-tis) B vaccine is given in three separate doses and has been recommended for all newborn infants since 1991. In 1995, it was recommended that adolescents be given the vaccine. Persons who may be exposed to other people’s blood, such as health care workers, also may have received the vaccine. {Have you/Has SP} ever received the 3-dose series of the hepatitis B vaccine?

INTERVIEWER INSTRUCTION: A COMBINATION HEPATITIS A AND HEPATITIS B VACCINE SHOULD BE COUNTED AS THE B VACCINE FOR THE PURPOSE OF THIS QUESTION. CODE 'YES AT LEAST 3 DOSES' IF RESPONDENT ANSWERS 4 DOSES WERE RECEIVED. CODE 'LESS THAN 3 DOSES' ONLY IF MENTIONED BY RESPONDENT.

YES AT LEAST 3 DOSES 1

LESS THAN 3 DOSES 2

NO DOSES 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

REMOVE CURRENT HELP.

BOX 2

OMITTED

BOX 3

CHECK ITEM IMQ.050:

IF SP = FEMALE AND AGE IS >= 9 AND <= 59, CONTINUE.

IF SP = MALE AND AGE IS >= 9 AND <= 59, GO TO IMQ.070.

OTHERWISE, GO TO END OF SECTION.

IMQ.060 Human Papillomavirus (HPV) vaccine is given to prevent cervical cancer in girls and women. The HPV vaccines available are called Cervarix, Gardasil or Gardasil 9. It is given in 2 or 3 separate doses over a 6 month period. {Have you/Has SP} ever received one or more doses of the HPV vaccine?

YES 1 (IMQ.081)

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

IMQ.070 Human Papillomavirus (HPV) vaccine is given to prevent HPV infection and genital warts in boys and men. It is given in 2 or 3 separate doses over a 6 month period. {Have you/Has SP} ever received one or more doses of the HPV vaccine? (The brand name for the vaccine is Gardasil or Gardasil 9.)

YES 1 (IMQ.090)

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

IMQ.081 Which of the HPV vaccines did {you/SP} receive, Cervarix, Gardasil or Gardasil 9?

INTERVIEWER: CODE ALL THAT APPLY.

CERVARIX 1

GARDASIL 2

GARDASIL 9 3

GARDASIL (NOT SURE WHICH ONE) 4

REFUSED 7

DON'T KNOW 9

IMQ.090 How old {were you/was SP} when {you/SP} received your first dose of {Cervarix/Gardasil/Gardasil 9/ Gardasil or Gardasil 9/the vaccine}?

INTERVIEWER: IF MORE THAN ONE VACCINE WAS REPORTED AND SP ASKS WHICH AGE BE REPORTED, INSTRUCT SP TO PROVIDE AGE OF FIRST VACCINE RECEIVED.

HARD EDIT: IF AGE SP RECEIVED FIRST DOSE IS GREATER THAN SP’S CURRENT AGE, DISPLAY “AGE SP RECEIVED FIRST DOSE CANNOT EXCEED SP’S CURRENT AGE.”

SOFT EDIT: IF DIFFERENCE BETWEEN SP’S CURRENT AGE AND AGE SP RECEIVED FIRST DOSE IS MORE THAN TEN YEARS, DISPLAY “UNLIKELY RESPONSE AS HPV VACCINES WERE NOT AVAILABLE AT THAT TIME. PLEASE CONFIRM AGE SP RECEIVED FIRST DOSE.”

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

CAPI INSTRUCTION:

IF SP = MALE, THEN FILL GARDASIL OR GARDASIL 9

IF IMQ.081 = 1, DISPLAY “Cervarix”; ELSE IF IMQ.081 = 2, DISPLAY “Gardasil”; ELSE IF IMQ.081 = 3, DISPLAY “Gardasil 9”; ELSE IF IMQ.081 = 4, DISPLAY “Gardasil or Gardasil 9”; ELSE DISPLAY “the vaccine”.

IMQ.100 How many doses of {Cervarix/Gardasil/Gardasil or Gardasil 9/the vaccine} {have you/has SP} received?

INTERVIEWER: IF MORE THAN ONE VACCINE WAS REPORTED AND SP ASKS WHICH VACCINE DOSES BE REPORTED, INSTRUCT SP TO PROVIDE DOSES FOR THE FIRST VACCINE RECEIVED.

1 DOSE 1

2 DOSES 2

3 DOSES 3

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF SP = MALE, THEN FILL GARDASIL OR GARDASIL 9

IF IMQ.081 = 1, DISPLAY “Cervarix”; ELSE IF IMQ.081 = 2, DISPLAY “Gardasil”; ELSE if IMQ.081 = 3, DISPLAY “GARDASIL 9”; ELSE IF IMQ.081 = 4, DISPLAY “Gardasil or Gardasil 9”; ELSE DISPLAY “the vaccine”.

MEDICAL CONDITIONS – MCQ

Target Group: SPs 1+

MCQ.010 The following questions are about different medical conditions.

{Have you/Has SP} EVER been told by a doctor or other health professional that {you/he/she} had asthma?

YES 1

NO 2 (MCQ.053)

REFUSED 7 (MCQ.053)

DON'T KNOW 9 (MCQ.053)

HELP SCREEN:

Asthma: Is a disease of the airways that carry air in and out of your lungs. It causes wheezing or whistling sounds when you breathe and can make you short of breath.

MCQ.025 How old {were you/was SP} when {you were/s/he was} first told {you/he/she} had asthma (az-ma)?

IF LESS THAN 1 YEAR, ENTER 1

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY "WERE YOU" AND "YOU WERE".

IF SP AGE = 12-15, DISPLAY "WAS {SP}" AND "S/HE WAS".

IF SP AGE < 12, DISPLAY "WAS {SP}" AND "YOU WERE".

|___|___|___|

ENTER AGE IN YEARS

CAPI INSTRUCTION:

HARD EDIT: 1-120

REFUSED 77777

DON'T KNOW 99999

MCQ.035 {Do you/Does SP} still have asthma (az-ma)?

YES 1

NO 2 (MCQ.053)

REFUSED 7 (MCQ.053)

DON'T KNOW 9 (MCQ.053)

MCQ.040 During the past 12 months, {have you/has SP} had an episode of asthma (az-ma) or an asthma attack?

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Episode/attack: When your asthma symptoms become worse than usual it is called an asthma episode or attack.

MCQ.050 [During the past 12 months], {have you/has SP} had to visit an emergency room or urgent care center because of asthma (az-ma)?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AGQ.030 During the past 12 months, {have you/has SP} been told by a doctor or other health professional that {you/he/she} had hay fever or seasonal allergies?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Hay Fever: Hay fever is a collection of symptoms in the nose and eyes, caused by particles of plant pollen in the air. This happens in people who are allergic to these substances. The pollens that cause hay fever vary from person to person and from region to region. Hay fever typically occurs in the Spring, Summer, or Fall when plant pollen is in the air. Examples of plants commonly responsible for hay fever include Trees, Grasses, Flowers, and Ragweed.

MCQ.053 During the past 3 months, {have you/has SP} been on treatment for anemia (a-nee-me-a), sometimes called "tired blood" or "low blood"? [Include diet, iron pills, iron shots, transfusions as treatment.]

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Anemia: Anemia (uh-NEE-me-eh) is a condition in which a person’s blood has a lower than normal number of red blood cells (RBCs).

BOX 2

CHECK ITEM MCQ.055:

IF SP AGE < 6, GO TO END OF SECTION.

IF SP AGE 6-15, GO TO MCQ.092.

IF SP AGE 16+, CONTINUE.

MCQ.080 Has a doctor or other health professional ever told {you/SP} that {you were/s/he/SP was} overweight?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2AA

CHECK ITEM MCQ.079:

IF SP AGE 16-59, GO TO MCQ.092

IF SP AGE 60+, CONTINUE.

MCQ.084 The next question asks about difficulties in thinking or remembering that can make a big difference in everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you recently met. This refers to things like confusion or memory loss that are happening more often or getting worse. We want to know how these difficulties impact {you/SP}. During the past 12 months, {have you/has she/has he} experienced confusion or memory loss that is happening more often or is getting worse?

YES ............................................................... 1

NO................................................................. 2

REFUSED ..................................................... 7

DON'T KNOW ............................................... 9

BOX 2A

OMITTED

BOX 3

OMITTED

MCQ.092 {Have you/Has SP} ever received a blood transfusion?

YES 1

NO 2 (BOX 7)

REFUSED 7 (BOX 7)

DON'T KNOW 9 (BOX 7)

MCQ.093 In what year did {you/SP} receive {your/his/her} first transfusion?

|___|___|___|___|

ENTER 4-DIGIT YEAR

CAPI INSTRUCTION:

HARD EDIT: IF BIRTH YEAR IS RF OR DK, RANGE = 1900 – 2100.

HARD EDIT: >= birth year and <= current year

REFUSED 777777

DON’T KNOW 999999

BOX 7

CHECK ITEM MCQ.145:

IF SP'S AGE >= 20, GO TO MCQ.160.

IF SP’s AGE = 12-19, GO TO MCQ.500.

IF SP AGE 8-11 AND SP IS FEMALE, CONTINUE.

OTHERWISE, GO TO MCQ.300b.

MCQ.149 Have {SP's} periods or menstrual (men-stral) cycles started yet?

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2 (BOX 8B)

REFUSED 7 (BOX 8B)

DON'T KNOW 9 (BOX 8B)

HELP TEXT: When a girl starts having periods or menstrual cycles is a very important milestone in growth and development. Growth and development is very related to physical activity and body weight.

MCQ.151 How old was {SP} when she had {her} first menstrual period?

|___|___| YEARS (RHQ.018)

REFUSED 77 (BOX 8B)

DON'T KNOW 99 (BOX 8B)

Hard edits: maximum of 11 and age of onset must be less than or equal to current age.

Soft edit: if age less than 7.

HELP TEXT: When a girl starts having periods or menstrual cycles is a very important milestone in growth and development. Growth and development is very related to physical activity and body weight.

RHQ.018 In what month did {SP} have her first menstrual period?

|___|___|

ENTER MONTH NUMBER (BOX 8B)

REFUSED 77 (BOX 8B)

DON'T KNOW 99 (BOX 8B)

HARD EDIT VALUES FOR MONTH: 01 – 12.

HARD EDIT: DISPLAY ERROR WHEN ONLY ONE DIGIT IS ENTERED FOR MONTH.

ERROR MESSAGE: “ENTER TWO DIGITS FOR MONTH.”

IF THIS ITEM CHANGES, CHECK MEC COMPONENT

BOX 8B

CHECK ITEM MCQ.157:

IF SP’s AGE = 6-11, GO TO MCQ.300b.

MCQ.160 {Have you/Has SP} EVER been told by a doctor or other health professional that {you/he/she} had… CAPI INSTRUCTION: TEXT OF QUESTION SHOULD BE OPTIONAL AFTER FIRST ITEM IS READ. *IF ITEMS 160B, C, D, E, OR F CHANGED, CHECK MEC COMPONENT.	MCQ.170 {Do you/Does SP} still . . . ?	MCQ.180 How old {were you/was SP} when {you were/s/he was} first told {you/s/he} . . .	MCQ.195 Which type of arthritis was it?
a. some form of arthritis? YES …………..1 NO …………..2 (n) REFUSED………….7 (n) DON'T KNOW……..9 (n)			Osteoarthritis or degenerative arthritis 1 Rheumatoid arthritis 2 Psoriatic arthritis 3 Other 4 REFUSED 7 DON’T KNOW 9

b. had congestive heart failure*? YES 1 NO 2 (c) REFUSED 7 (c) DON'T KNOW 9 (c)		had congestive heart failure? \|___\|___\|___\| ENTER AGE IN YEARS REFUSED 77777 DON'T KNOW 99999
c. had coronary* (kor-o-nare-ee) heart disease? YES 1 NO 2 (d) REFUSED ……… 7(d) DON'T KNOW 9(d)		had coronary heart disease? \|___\|___\|___\| ENTER AGE IN YEARS REFUSED 77777 DON'T KNOW 99999
d. had angina (*an-gī-na), also called angina pectoris? YES 1 NO 2 (e) REFUSED 7(e) DON'T KNOW 9(e)		had angina, also called angina pectoris? \|___\|___\|___\| ENTER AGE IN YEARS REFUSED 77777 DON'T KNOW 99999
e. had a heart attack (also called myocardial infarction (my-O-car-dee-al in-fark*-shun))? YES 1 NO 2 (f) REFUSED 7(f) DON'T KNOW 9(f)		had a heart attack (also called myocardial infarction)? \|___\|___\|___\| ENTER AGE IN YEARS REFUSED 77777 DON'T KNOW 99999
f. had a stroke, slight stroke, transient ischemic attack or TIA*? YES 1 NO 2 (m) REFUSED 7(m) DON'T KNOW 9(m)		had a stroke, slight stroke, transient ischemic attack or TIA? \|___\|___\|___\| ENTER AGE IN YEARS REFUSED 77777 DON'T KNOW 99999
m. had a thyroid (thigh-roid) problem? YES 1 NO 2 (g) REFUSED 7(g) DON'T KNOW 9(g)	have a thyroid problem? YES 1 NO 2 REFUSED 7 DON'T KNOW 9	had a thyroid problem? \|___\|___\|___\| ENTER AGE IN YEARS REFUSED 77777 DON'T KNOW 99999


o. had chronic obstructive pulmonary disease or COPD, emphysema or chronic bronchitis? YES 1 NO 2 REFUSED 7 DON'T KNOW 9
l. had any kind of liver condition? INTERVIEWER: INCLUDE VIRAL HEPATITIS (INCLUDING HEPATITIS A, HEPATITIS B; AND HEPATITIS C); AUTOIMMUNE LIVER DISEASE (INCLUDING PRIMARY BILIARY CIRRHOSIS; AUTOIMMUNE HEPATITIS, SCLEROSING CHOLANGITIS); GENETIC LIVER DISEASES (INCLUDING ALPHA-1-ANTITRYSIN DEFICIENCY, HEMOCHROMOTOSIS, AND WILSON’S DISEASE); DRUG- OR MEDICATION-INDUCED LIVER DISEASE; ALCOHOLIC LIVER DISEASE; NON-ALCOHOLIC FATTY LIVER DISEASE; FATTY LIVER DISEASE; LIVER CANCER; LIVER CYST; LIVER ABSCESS; LIVER FIBROSIS; AND LIVER CIRRHOSIS. INTERVIEWER DO NOT INCLUDE GALLBLADDER DISEASE; GALLSTONES; OR CHOLECYSTITIS. YES 1 NO 2 (MCQ.520) REFUSED…7 (MCQ.520) DON'T KNOW….9 (MCQ.520)	have this liver condition? YES 1 NO 2 REFUSED 7 DON'T KNOW 9	had this liver condition? \|___\|___\|___\| ENTER AGE IN YEARS REFUSED…77777 (MCQ.510) DON'T KNOW... 99999 (MCQ.510)

HELP SCREENS FOR MCQ.160

MCQ160a

Arthritis: Is a disease that causes pain, swelling or stiffness in joints, for example the hand, the knee, or neck. Common kinds of arthritis are osteoarthritis and rheumatoid arthritis.

MCQ.195

Osteoarthritis: Is the most common kind of arthritis in older persons. It is also called degenerative joint disease. Most often, it affects the knees, the hips, the hands, the feet, and the spine. There is usually bony joint enlargement. There can be joint deformity or pain.

Rheumatoid Arthritis: Causes inflammation, redness and swelling of both hands and knees, but it can affect joints anywhere in the body. You may feel sick and tired, and sometimes there are fevers.

Psoriatic Arthritis: Is arthritis caused by the skin rash Psoriasis. Most often it causes redness and swelling of joints such as the spine, knees, hips and hands.

Arthritis: Is a disease that causes pain, swelling or stiffness in joints, for example the hand, the knee, or neck. Common kinds of arthritis are osteoarthritis and rheumatoid arthritis.

MCQ160b

Congestive Heart Failure: Is when the heart can't pump enough blood to the body. Blood and fluid "back up" into the lungs, which makes you short of breath. Heart failure causes fluid buildup in and swelling of the feet, legs and ankles.

INTERVIEWER: DO NOT COUNT HEART MURMURS, IRREGULAR HEART BEATS, CHEST PAIN OR HEART ATTACKS.

MCQ160c

Coronary Heart Disease: Is when the blood vessels that bring blood to the heart muscle become narrow and hardened due to plaque (plak). Plaque buildup is called atherosclerosis (ATH-er-o-skler-O-sis). Blocked blood vessels to the heart can cause chest pain or a heart attack.

INTERVIEWER: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR CORONARY HEART DISEASE.

MCQ160d

Angina (Angina Pectoris): (AN-ji-na or an-JI-na). Angina is chest pain or discomfort that occurs when the heart does not get enough blood.

INTERVIEWER: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR ANGINA.

MCQ160e

Heart Attack (Myocardial Infarction): A heart attack happens when there is narrowing of a blood vessel that supplies the heart. A blood clot can form and suddenly cut off the blood supply to the heart muscle. This damage causes crushing chest pain that may also be felt in the arms or neck. There can also be nausea, sweating, or shortness of breath.

MCQ160f

Stroke: Is when the blood supply to a part of the brain is suddenly cut off by a blood clot or a burst blood vessel in the brain. The part of the brain affected can no longer do its job. There can be numbness or weakness on one side of the body; trouble speaking or understanding speech; loss of eyesight; trouble with walking, dizziness, loss of balance or coordination; or severe headache.

MCQ160g

Emphysema: Is disease where the tiny air sacs in the lungs become damaged so less air goes in and out. As a result, the body does not get the oxygen it needs. Emphysema makes it hard to catch your breath. It is often due to smoking.

MCQ160m

Thyroid Problem: The thyroid is a gland in the neck that makes thyroid hormone. The thyroid sets your body's energy level: the temperature and heart rate. Thyroid problems include thyroid levels that are too high or too low, an inflamed or enlarged gland, and thyroid lumps or cancer.

INTERVIEWER: INCLUDE HYPERTHYROID (OVERACTIVE THYROID); HYPOTHYROID (UNDERACTIVE THYROID); GRAVES DISEASE (HYPERTHYROID AND/OR THYROID EYE DISEASE); HASHIMOTO'S THYRODITIS (INFLAMED THYROID); POSTPARTUM THYROIDITIS (INFLAMED THYROID THAT HAPPENS AFTER DELIVERY OF A BABY); GOITER (ENLARGED THYROID); THYROID NODULE (LUMP IN THYROID- NOT CANCER); AND THYROID CANCER.

MCQ160k

Chronic Bronchitis: Is a long lasting breathing problem where you constantly cough up phlegm. Often there is a daily cough with phlegm for several months at a time for two or more years and you are short of breath. It is often due to smoking.

MCQ.160o

COPD: stands for “Chronic Obstructive Pulmonary Disease.” It includes both Emphysema and Chronic Bronchitis. It is lung problem where you have trouble getting air in and out of your lungs. You may also have constant cough and phlegm.

MCQ.160l

Liver Condition: The liver is located under your rib cage on your right side. The liver helps your body digest food, store energy, and remove poisons. Liver conditions include viral diseases, autoimmune diseases, liver cancer, and liver disease from medications, poisons or drinking too much alcohol. If the liver forms scar tissue because of an illness, it's called fibrosis or cirrhosis.

MCQ.500 Has a doctor or other health professional ever told {you/SP} that {you/s/he} ever had any kind of liver condition?

INTERVIEWER: INCLUDE VIRAL HEPATITIS (INCLUDING HEPATITIS A, HEPATITIS B; AND HEPATITIS C); AUTOIMMUNE LIVER DISEASE (INCLUDING PRIMARY BILIARY CIRRHOSIS; AUTOIMMUNE HEPATITIS, SCLEROSING CHOLANGITIS); GENETIC LIVER DISEASES (INCLUDING ALPHA-1-ANTITRYSIN DEFICIENCY, HEMOCHROMOTOSIS, AND WILSON’S DISEASE); DRUG- OR MEDICATION-INDUCED LIVER DISEASE; ALCOHOLIC LIVER DISEASE; NON-ALCOHOLIC FATTY LIVER DISEASE; FATTY LIVER DISEASE; LIVER CANCER; LIVER CYST; LIVER ABSCESS; LIVER FIBROSIS; AND LIVER CIRRHOSIS. INTERVIEWER DO NOT INCLUDE GALLBLADDER DISEASE; GALLSTONES; OR CHOLECYSTITIS.

YES 1

NO 2 (BOX 8C)

REFUSED 7 (BOX 8C)

DON'T KNOW 9 (BOX 8C)

HELP SCREEN:

MCQ.510 Which type of liver condition was it . . .

INTERVIEWER: READ OPTIONS. CODE ALL THAT APPLY.

Fatty liver, 1 (BOX 8C)

Liver fibrosis, 2 (BOX 8C)

Liver cirrhosis, 3 (BOX 8C)

Viral hepatitis, 4 (BOX 8C)

Autoimmune hepatitis, or 5 (BOX 8C)

Other liver disease? 6 (BOX 8C)

REFUSED 77 (BOX 8C)

DON’T KNOW 99 (BOX 8C)

BOX 8C

CHECK ITEM MCQ.515:

IF SP'S AGE 12-19, GO TO MCQ.300b.

OTHERWISE, IF SP'S AGE ≥ 20, CONTINUE.

MCQ.520 During the past 12 months {have you/has s/he} had pain in the area shaded on the diagram?

INTERVIEWER INSTRUCTION: For females do not include menstrual pain.

HAND CARD MCQ1

YES 1

NO 2 (MCQ.550)

REFUSED 7 (MCQ.550)

DON'T KNOW 9 (MCQ.550)

MCQ.530 Sometimes people have more than one type of pain. I am going to ask you a few questions about the pain that has been the most uncomfortable in the past 12 months.

For the pain that was most uncomfortable please show me where the pain was located.

INTERVIEWER INSTRUCTION: For females do not include menstrual pain.

HAND CARD MCQ2

1 1

2 2

3 3

REFUSED 7

DON'T KNOW 9

MCQ.540 {Have you/has s/he} ever seen a doctor about this pain?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

MCQ.550 Has a doctor or other health professional ever told {you/SP} that {you/s/he} had gallstones?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Gallstones: Gallstones are hard particles that develop in the gallbladder. The gallbladder is a small, pear-shaped organ located in the upper right abdomen—the area between the chest and hips—below the liver.

MCQ.560 Have {you/s/he} ever had gallbladder surgery?

YES 1

NO 2 (BOX 8B)

REFUSED 7 (BOX 8B)

DON'T KNOW 9 (BOX 8B)

MCQ.570 How old {were you/was SP} when {you /s/he} first had gallbladder surgery?

INTERVIEWER INSTRUCTION: IF LESS THAN 1 YEAR, ENTER 1.

|___|___|___|

ENTER AGE IN YEARS

CAPI INSTRUCTION:

HARD EDIT: 1-120

REFUSED 77777

DON'T KNOW 99999

BOX 8B

CHECK ITEM MCQ.208:

IF SP AGE 6-19, GO TO MCQ300b

IF SP AGE ≥ 20, CONTINUE.

MCQ.220 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had cancer or a malignancy (ma-lig-nan-see) of any kind?

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2 (MCQ.300b)

REFUSED 7 (MCQ.300b)

DON'T KNOW 9 (MCQ.300b)

HELP SCREEN:

Cancer: Is an abnormal growth that can spread to other parts of the body. This causes damage and even death. Most cancers are named for where they start: for example lung cancer or breast cancer. A cancer is also called a "malignancy" or a "malignant tumor".

Malignancy: A tumor or growth that is a cancer. (see Cancer)

MCQ.230 What kind of cancer was it?

ENTER UP TO 3 KINDS. IF RESPONDENT OFFERS MORE THAN 3, ENTER 66 AS THE 4TH RESPONSE.

CAPI INSTRUCTIONS:

ALLOW UP TO 3 ENTRIES.

ALLOW 'MORE THAN 3 KINDS (CODE 66) ONLY AS 4TH ENTRY.

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

( ) ( ) ( ) ( )

BLADDER 10

BLOOD 11

BONE 12

BRAIN 13

BREAST 14

CERVIX (CERVICAL) 15

COLON 16

ESOPHAGUS (ESOPHAGEAL) 17

GALLBLADDER 18

KIDNEY 19

LARYNX/WINDPIPE 20

LEUKEMIA 21

LIVER 22

LUNG 23

LYMPHOMA/HODGKINS' DISEASE 24

MELANOMA 25

MOUTH/TONGUE/LIP 26

NERVOUS SYSTEM 27

OVARY (OVARIAN) 28

PANCREAS (PANCREATIC) 29

PROSTATE 30

RECTUM (RECTAL) 31

SKIN (NON-MELANOMA) 32

SKIN (DON'T KNOW WHAT KIND) 33

SOFT TISSUE (MUSCLE OR FAT) 34

STOMACH 35

TESTIS (TESTICULAR) 36

THYROID 37

UTERUS (UTERINE) 38

OTHER 39

MORE THAN 3 KINDS 66

REFUSED 77

DON'T KNOW 99

BOX 10

OMITTED

BOX 10A

OMITTED

MCQ.300
a/b/c

Including living and deceased, were any of {SP’s/your} close biological that is, blood relatives including father, mother, sisters or brothers, ever told by a health professional that they had . . .

CAPI INSTRUCTION:

TEXT OF QUESTION SHOULD BE OPTIONAL, “[ ]’S, AFTER FIRST TIME.

HELP SCREEN:

Close biological relatives: Include SP’s parents, full siblings, and children.

b. asthma (az-ma)?

CAPI INSTRUCTION:

IF SP AGE 6-19, DISPLAY: Including living and deceased, were any of {SP’s/your} close biological that is, blood relatives including father, mother, sisters or brothers, ever told by a health professional that they had . . .

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 10D

CHECK ITEM MCQ.360:

IF SP AGE 6-15, GO TO END OF SECTION.

IF SP AGE16-19, GO TO MCQ.366.

OTHERWISE, CONTINUE.

c. diabetes?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

a. a heart attack or angina (an-gī-na) before the age of 50?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

MCQ.366 During the past 12 months {have you/has s/he} ever been told by a doctor or health professional to:

a/b/c/d

RESPONSES: YES = 1, NO = 2, REFUSED = 7, DON’T KNOW = 9

a. control {your/his/her} weight or lose weight? ____

b. increase {your/his/her} physical activity or exercise? ____

c. watch or reduce the amount of sodium or salt in {your/his/her} diet? ____

d. watch or reduce the amount of fat or calories in {your/his/her} diet? ____

HELP SCREEN: Controlling your weight might be recommended to help prevent high blood pressure, diabetes, high cholesterol and other conditions.

MCQ.371 {Are you/Is s/he} now doing any of the following:

a/b/c/d

RESPONSES: YES = 1, NO = 2, REFUSED = 7, DON’T KNOW = 9

a. controlling {your/his/her} weight or losing weight? ____

b. increasing {your/his/her} physical activity or exercise? ____

c. watching or reducing the amount of sodium or salt in {your/his/her} diet? ____

d. watching or reducing the amount of fat or calories in {your/his/her} diet? ____

HELP SCREEN: Controlling your weight might be recommended to help prevent high blood pressure, diabetes, high cholesterol and other conditions.

BOX 13

CHECK ITEM MCQ.385:

IF SP AGE LESS THAN 40, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

OSQ.230 The following question is about metal objects you may have inside your body.

Do you have any artificial joints, pins, plates, metal suture material, or other types of metal objects in your body? Some common examples are on the hand card.

INTERVIEWER INSTRUCTION: Do not include piercings, crowns, dental braces or retainers, shrapnel, or bullets. The metal object should NOT be visible on the outside of the body or in the mouth.

HAND CARD OSQ3

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HEPATITIS (HEQ)

Target Group: SPs 6+

HEQ.010 Has a doctor or other health professional ever told {you/SP} that {you have/s/he/SP has} hepatitis B? (Hepatitis is a form of liver disease. Hepatitis B is an infection of the liver from the hepatitis B virus (HBV).)

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “YOU” AND “YOU HAVE”.

IF SP AGE = 12-15 OR >=16 AND PROXY INTERVIEW, DISPLAY "SP" AND “S/HE HAS”.

IF SP AGE = 6-11, DISPLAY “YOU” AND “SP HAS”.

INTERVIEWER: DO NOT ACCEPT SELF-DIAGNOSED OR DIAGNOSED BY A PERSON WHO IS NOT A DOCTOR OR OTHER HEALTH PROFESSIONAL.

YES 1

NO 2 (HEQ.030)

REFUSED 7 (HEQ.030)

DON'T KNOW 9 (HEQ.030)

HEQ.020 Please look at the drugs on this card that are prescribed for hepatitis B. {Were you/ Was/s/he/SP} ever prescribed any medicine to treat hepatitis B?

HAND CARD HEQ1

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “WERE YOU”.

IF SP AGE = 12-15 OR >=16 AND PROXY INTERVIEW, DISPLAY "WAS S/HE”.

IF SP AGE = 6-11, DISPLAY “WAS SP”.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HEQ.030 Has a doctor or other health professional ever told {you/SP} that {you have/s/he/SP has} hepatitis C? (Hepatitis is a form of liver disease. Hepatitis C is an infection of the liver from the hepatitis C virus (HCV).)

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “YOU” AND “YOU HAVE”.

IF SP AGE = 12-15 OR >=16 AND PROXY INTERVIEW, DISPLAY "SP" AND “S/HE HAS”.

IF SP AGE = 6-11, DISPLAY “YOU” AND “SP HAS”.

INTERVIEWER: DO NOT ACCEPT SELF-DIAGNOSED OR DIAGNOSED BY A PERSON WHO IS NOT A DOCTOR OR OTHER HEALTH PROFESSIONAL.

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

HEQ.040 Please look at the drugs on this card that are prescribed for hepatitis C. {Were you/ Was/s/he/ SP} ever prescribed any medicine to treat hepatitis C?

HAND CARD HEQ2

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY “WERE YOU”.

IF SP AGE = 12-15 OR >=16 AND PROXY INTERVIEW, DISPLAY "WAS S/HE”.

IF SP AGE = 6-11, DISPLAY “WAS SP”.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

KIDNEY CONDITIONS – KIQ

Target Group: SPs 20+

KIQ.022 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had weak or failing kidneys? Do not include kidney stones, bladder (bladd-er) infections, or incontinence (in‑kon‑ti‑nens).

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2 (KIQ.026)

REFUSED 7 (KIQ.026)

DON'T KNOW 9 (KIQ.026)

HELP SCREEN:

Health Care Professionals (Health Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor's assistants, nurse practitioners, nurses, lab technicians, technicians who administer shots (e.g., allergy shots), and who work with a doctor. Also include paramedics, medics, and physical therapists working with or in a doctor's office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.

KIQ.025 In the past 12 months, {have you/has SP} received dialysis (either hemodialysis (heemo-di-al-i-sis) or peritoneal dialysis (pare-i-ton-nee-al di-al-i-sis))?

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

KIQ.026 {Have you/Has SP} ever had kidney stones?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

KIQ.029 In the past 12 months {have you/has SP} passed a kidney stone?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

If the respondent indicates a stone was not passed but they had it broken up with lithotripsy or removed by a doctor, code ‘Yes’.

Functioning (FNQ)

Target Group: SPs 5+

BOX 1

CHECK ITEM FNQ.005

IF SP AGE ≥ 18 YEARS, GO TO FNQ.400,

ELSE, CONTINUE.

FNQ.010 I would like to ask you some questions about difficulties {you/SP} may have.

{Do you/Does SP} wear glasses or contact lenses?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FNQ.020 {When wearing {your/his/her} glasses or contact lenses} {Do you/Does SP} have difficulty seeing? Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

HAND CARD FNQ1

no difficulty 1

some difficulty 2

a lot of difficulty 3

CANNOT DO AT ALL 4

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

IF YES (CODE 1) IN FNQ.010, DISPLAY “When wearing {your/his/her} glasses or contact lenses”

FNQ.030 {Do you/Does SP} use a hearing aid?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FNQ.040 {When using {your/his/her} hearing aid} {Do you/Does SP} have difficulty hearing sounds like peoples’ voices or music? [Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?]

HAND CARD FNQ1

NO DIFFICULTY 1

SOME DIFFICULTY 2

A LOT OF DIFFICULTY 3

CANNOT DO AT ALL 4

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

IF YES (CODE 1) IN FNQ.030, DISPLAY “When using {your/his/her} hearing aid”

FNQ.050 {Do you/Does SP} use any equipment or receive assistance for walking?

Yes 1

NO 2 (FNQ.080)

REFUSED 7 (FNQ.080)

DON’T KNOW 9 (FNQ.080)

FNQ.060 Without {your/his/her} equipment or assistance, {do you/does SP} have difficulty walking 100 yards/meters on level ground? That would be about the length of 1 football field. Would you say {you have/SP has}: some difficulty, a lot of difficulty, or cannot do at all?

HAND CARD FNQ2

some difficulty 2

a lot of difficulty 3 (FNQ.100)

cannot do at all 4 (FNQ.100)

REFUSED 7

DON’T KNOW 9

FNQ.070 Without {your/his/her} equipment or assistance, {do you/does SP} have difficulty walking 500 yards/meters on level ground? That would be about the length of 5 football fields. [Would you say {you have/SP has}: some difficulty, a lot of difficulty, or cannot do at all?]

HAND CARD FNQ2

some difficulty 2 (FNQ.100)

a lot of difficulty 3 (FNQ.100)

cannot do at all 4 (FNQ.100)

REFUSED 7 (FNQ.100)

DON’T KNOW 9 (FNQ.100)

FNQ.080 Compared with children of the same age, {do you/does SP} have difficulty walking 100 yards/meters on level ground? That would be about the length of 1 football field. [Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?]

HAND CARD FNQ1

no difficulty 1

some difficulty 2

a lot of difficulty 3 (FNQ.100)

cannot do at all 4 (FNQ.100)

REFUSED 7

DON’T KNOW 9

FNQ.090 Compared with children of the same age, {do you/does SP} have difficulty walking 500 yards/meters on level ground? That would be about the length of 5 football fields. [Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?]

HAND CARD FNQ1

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.100 When {you speak/SP speaks}, {do you/does he/she} have difficulty being understood by people inside of this household? Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

HAND CARD FNQ3

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.110 When {you speak/SP speaks}, {do you/does he/she} have difficulty being understood by people outside of this household? [Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?]

HAND CARD FNQ3

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.120 Compared with children of the same age, {do you/does SP} have difficulty learning things? [Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?]

HAND CARD FNQ3

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.130 Compared with children of the same age, {Do you/Does SP} have difficulty controlling {your/his/her} behavior? [Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?]

HAND CARD FNQ3

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.140 How often {do you feel/does SP seem} very anxious, nervous or worried? Would you say daily, weekly, monthly, a few times a year or never?

Daily 1

Weekly 2

monthly 3

A FEW TIMES A YEAR 4

NEVER 5

REFUSED 7

DON’T KNOW 9

FNQ.150 How often {do you feel/does SP seem} very sad or depressed? Would you say daily, weekly, monthly, a few times a year or never?

Daily 1 (END OF SECTION)

Weekly 2 (END OF SECTION)

monthly 3 (END OF SECTION)

A FEW TIMES A YEAR 4 (END OF SECTION)

NEVER 5 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

FNQ.400 Now I am going to ask you some questions about {your/SP’s} ability to do different activities, and how {you have/s/he has} been feeling.

{Do you/Does SP} wear glasses or contact lenses?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FNQ.410 {Do you/Does SP} have difficulty seeing {even if wearing glasses or contact lenses}? Would you say no difficulty, some difficulty, a lot of difficulty, or {you/s/he} cannot do this at all?

HAND CARD FNQ1

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

IF YES (CODE 1) IN FNQ.400, DISPLAY “even if wearing glasses or contact lenses”

FNQ.420 {Do you/Does SP} use a hearing aid?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FNQ.430 {Do you/Does SP} have difficulty hearing {even if using a hearing aid}? Would you say no difficulty, some difficulty, a lot of difficulty, or {you/s/he} cannot do this at all?

HAND CARD FNQ1

NO DIFFICULTY 1

SOME DIFFICULTY 2

A LOT OF DIFFICULTY 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

IF YES (CODE 1) IN FNQ.420, DISPLAY “even if using a hearing aid”

FNQ.440 {Do you/Does SP} have difficulty walking or climbing steps? [Would you say no difficulty, some difficulty, a lot of difficulty, or {you/s/he} cannot do this at all?]

HAND CARD FNQ1

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.450 Using {your/his/her} usual language, {do you/does SP} have difficulty communicating, for example, understanding or being understood? [Would you say no difficulty, some difficulty, a lot of difficulty, or {you/s/he} cannot do this at all?]

HAND CARD FNQ1

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.460 {Do you/Does SP} have difficulty remembering or concentrating? [Would you say no difficulty, some difficulty, a lot of difficulty, or {you/s/he} cannot do this at all?]

HAND CARD FNQ1

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.470 {Do you/Does SP} have difficulty with self-care, such as washing all over and dressing? [Would you say no difficulty, some difficulty, a lot of difficulty, or {you/s/he} cannot do this at all?]

HAND CARD FNQ1

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.480 {Do you/Does SP} have difficulty raising a 2 liter bottle of water or soda from waist to eye level? [Would you say no difficulty, some difficulty, a lot of difficulty, or {you/s/he} cannot do this at all?]

HAND CARD FNQ1

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.490 {Do you/Does SP} have difficulty using {your/his/her} hands and fingers, such as picking up small objects, for example, a button or pencil, or opening or closing containers or bottles? [Would you say no difficulty, some difficulty, a lot of difficulty, or {you/s/he} cannot do this at all?]

HAND CARD FNQ1

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.500 Because of a physical, mental, or emotional condition, {do you/does SP} have difficulty doing errands alone such as visiting a doctor’s office or shopping? [Would you say no difficulty, some difficulty, a lot of difficulty, or {you/s/he} cannot do this at all?]

HAND CARD FNQ1

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.510 How often {do you/does SP} feel worried, nervous, or anxious? Would you say…

Daily, 1

Weekly, 2

Monthly, 3

A few times a year, or 4

Never? 5 (FNQ.530)

REFUSED 7 (FNQ.530)

DON’T KNOW 9 (FNQ.530)

FNQ.520 Thinking about the last time {you/ SP} felt worried, nervous, or anxious, how would {you/s/he} describe the level of these feelings? Would you say…

A little, 1

A lot, or 2

Somewhere in between a little and a lot? 3

REFUSED 7

DON’T KNOW 9

FNQ.530 How often {do you/does SP} feel depressed? Would you say…

Daily, 1

Weekly, 2

Monthly, 3

A few times a year, or 4

Never? 5 (FNQ.550)

REFUSED 7 (FNQ.550)

DON’T KNOW 9 (FNQ.550)

FNQ.540 Thinking about the last time {you/ SP} felt depressed, how depressed did {you/s/he} feel? Would you say…

A little, 1

A lot, or 2

Somewhere in between a little and a lot? 3

REFUSED 7

DON’T KNOW 9

FNQ.550 {Do you/Does SP} have difficulty participating in social activities such as visiting friends, attending clubs and meetings, going to parties? Would you say no difficulty, some difficulty, a lot of difficulty, or {you/s/he} cannot do this at all?

HAND CARD FNQ1

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.560 {Are you/is SP} limited in the kind or amount of work {you/s/he} can do because of a physical, mental, or emotional problem?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

DIABETES – DIQ

Target Group: SPs 1+

DIQ.010 {Other than during pregnancy, {have you/has SP}/{Have you/Has SP}} ever been told by a doctor or other health professional that {you have/{s/he/SP} has} diabetes or sugar diabetes?

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY "HAVE YOU" AND "YOU HAVE"

IF SP AGE 12-15, DISPLAY "HAS {SP}" AND "S/HE HAS"

IF SP AGE <12, DISPLAY "HAVE YOU" AND "{SP} HAS"

IF SP IS FEMALE AND AGE >= 20, DISPLAY "OTHER THAN DURING PREGNANCY, {HAVE YOU/HAS SP}".

YES 1

NO 2 (BOX 4)

BORDERLINE OR PREDIABETES 3 (BOX 4)

REFUSED 7 (BOX 4)

DON'T KNOW 9 (BOX 4)

DIQ.040
G/Q

How old {was SP/were you} when a doctor or other health professional first told {you/him/her} that {you/s/he} had diabetes or sugar diabetes?

CAPI INSTRUCTION:

IF SP AGE >= 16, DISPLAY "WERE YOU" AND "YOU" AND "YOU"

IF SP AGE 12-15, DISPLAY "WAS {SP}" AND "HIM/HER" AND "S/HE"

IF SP AGE <12, DISPLAY "WAS {SP}" AND "YOU" AND "S/HE"

|___|

ENTER AGE IN YEARS 1

LESS THAN 1 YEAR 2 (BOX 4)

REFUSED 7 (BOX 4)

DON'T KNOW 9 (BOX 4)

|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

BOX 4

CHECK ITEM DIQ.159:

IF AGE < 12 OR DIQ.010 = 1 (YES) GO TO DIQ.050.

IF AGE >= 12 AND DIQ.010 = 3, GO TO DIQ.180.

IF AGE < 12, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

DIQ.160 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/SP has} any of the following: prediabetes, impaired fasting glucose, impaired glucose tolerance, borderline diabetes or that {your/her/his} blood sugar is higher than normal but not high enough to be called diabetes or sugar diabetes?

HAND CARD DIQ1

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN: PREDIABETES, IMPAIRED FASTING GLUCOSE, IMPAIRED GLUCOSE TOLERANCE, OR BORDERLINE DIABETES OCCURS WHEN BLOOD SUGAR (GLUCOSE) LEVELS ARE HIGHER THAN NORMAL BUT NOT HIGH ENOUGH TO BE DIABETES.

DIQ.180 {Have you/Has SP} had a blood test for high blood sugar or diabetes within the past three years?

INTERVIEWER INSTRUCTION: DO NOT INCLUDE URINE TESTS

YES 1 (BOX 0)

NO 2 (BOX 0)

REFUSED 7 (BOX 0)

DON’T KNOW 9 (BOX 0)

DIQ.050 Insulin can be taken by shot or pump. {Is SP/Are you} now taking insulin?

YES 1

NO 2 (BOX 0)

REFUSED 7 (BOX 0)

DON'T KNOW 9 (BOX 0)

HELP SCREEN:

Insulin: A chemical used in the treatment of diabetes. Typically, insulin is administered with a syringe by the patient.

DIQ.060
G/Q/U

For how long {have you/has SP} been taking insulin?

|___|

ENTER NUMBER (OF MONTHS OR YEARS) 1

LESS THAN 1 MONTH 2 (BOX 0)

REFUSED 7 (BOX 0)

DON'T KNOW 9 (BOX 0)

|___|___|___|

ENTER NUMBER (OF MONTHS OR YEARS)

REFUSED 77777 (BOX 0)

DON'T KNOW 99999 (BOX 0)

ENTER UNIT

|___|

MONTHS 1

YEARS 2

HELP SCREEN:

Insulin: A chemical used in the treatment of diabetes. Typically, insulin is administered with a syringe by the patient.

BOX 0

CHECK ITEM DIQ.065:

IF DIQ.010 = 1 (YES) OR DIQ.160 = 1 (YES) OR DIQ.010 = 3, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

DIQ.070 {Is SP/Are you} now taking diabetic pills to lower {{his/her}/your} blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 8

CHECK ITEM DIQ.229:

IF DIQ.010 = 3 OR DIQ.160 = 1 (YES), GO TO END OF SECTION.

OTHERWISE, CONTINUE.

DIQ.230 When was the last time {you/SP} saw a diabetes nurse educator or dietitian or nutritionist for {your/his/her} diabetes? Do not include doctors or other health professionals.

INTERVIEWER INSTRUCTION: CODE 5 FOR NEVER. IF RESPONDENT ANSWERS “TODAY” OR A PERIOD LESS THAN A MONTH, CODE 1 – 1 YEAR AGO OR LESS.

1 YEAR AGO OR LESS 1

MORE THAN 1 YEAR AGO BUT NO MORE
THAN 2 YEARS AGO 2

MORE THAN 2 YEARS AGO BUT NO MORE
THAN 5 YEARS AGO 3

MORE THAN 5 YEARS AGO 4

NEVER 5

REFUSED 7

DON’T KNOW 9

HELP SCREEN: A diabetes nurse educator is a nurse who teaches people with diabetes and who is knowledgeable about the day-to-day aspects of diabetes self-care, such as, use of diabetes medications, checking and controlling blood glucose levels, managing weight through diet and physical activity, and maintaining a healthy pregnancy if diabetes is present.

DIQ.240 Is there one doctor or other health professional {you usually see/SP usually sees} for {your/his/her} diabetes? Do not include specialists to whom {you have/SP has} been referred such as diabetes educators, dieticians or foot and eye doctors.

YES 1

NO 2 (DIQ.260)

REFUSED 7 (DIQ.260)

DON’T KNOW 9 (DIQ.260)

HELP SCREEN: A diabetes nurse educator is a nurse who teaches people with diabetes and who is knowledgeable about the day-to-day aspects of diabetes self-care, such as, use of diabetes medications, checking and controlling blood glucose levels, managing weight though diet and physical activity, and maintaining a healthy pregnancy if diabetes is present.

DIQ.250 How many times {have you/has SP} seen this doctor or other health professional in the past 12 months?

G/Q

|___|___|___|

ENTER NUMBER OF TIMES

CAPI INSTRUCTION:

HARD EDIT: DO NOT ALLOW 0.

NONE 2

REFUSED 7777

DON'T KNOW 9999

BOX 9

CHECK ITEM DIQ.369:

IF DIQ.250 = 2 (NONE), CONTINUE.

OTHERWISE, GO TO BOX 10.

DIQ.370 INTERVIEWER: YOU HAVE ENTERED “NONE” FOR THE NUMBER OF TIMES IN THE PAST 12 MONTHS THAT THE SP HAS SEEN THEIR USUAL DOCTOR OR OTHER HEALTH PROFESSIONAL. THIS IS AN UNLIKELY RESPONSE. IS THIS CORRECT?

YES 1

NO 2 (DIQ.250)

BOX 10

CHECK ITEM DIQ.379:

IF DIQ.250 = 100 OR MORE, CONTINUE.

OTHERWISE, GO TO DIQ.260.

DIQ.380 INTERVIEWER: YOU HAVE ENTERED A VALUE THAT IS OUTSIDE THE EXPECTED RANGE FOR THE NUMBER OF TIMES IN THE PAST 12 MONTHS THAT THE SP HAS SEEN THEIR USUAL DOCTOR OR OTHER HEALTH PROFESSIONAL. THIS IS AN UNLIKELY RESPONSE. IS THIS CORRECT?

YES 1

NO 2 (DIQ.250)

DIQ.260
G/Q/U

How often {do you check your/does SP check his/her} blood for glucose or sugar? Include times when checked by a family member or friend, but do not include times when checked by a doctor or other health professional.

INTERVIEWER INSTRUCTION: DO NOT INCLUDE URINE TESTS.

|___|

ENTER NUMBER OF TIMES 1

NEVER 2 (DIQ.275)

UNABLE TO DO ACTIVITY (BLIND) 3 (DIQ.275)

REFUSED 7 (DIQ.275)

DON'T KNOW 9 (DIQ.275)

|___|___|___|

ENTER NUMBER OF TIMES

CAPI INSTRUCTION: SOFT EDIT 7 OR MORE PER DAY

SOFT EDIT 30 OR MORE PER WEEK.

REFUSED 7777 (DIQ.275)

DON'T KNOW 9999 (DIQ.275)

ENTER UNIT

|___|

PER DAY 1

PER WEEK 2

PER MONTH 3

PER YEAR 4

DIQ.275 Glycosylated (GLY-CO-SYL-AT-ED) hemoglobin or the “A one C” test measures your average level of blood sugar for the past 3 months, and usually ranges between 5.0 and 13.9. During the past 12 months, has a doctor or other health professional checked {your/SP’s} glycosylated hemoglobin or “A one C”?

YES 1

NO 2 (BOX 10A)

REFUSED 7 (BOX 10A)

DON'T KNOW 9 (BOX 10A)

DIQ.280 What was {your/SP’s} last “A one C” level?

CAPI INSTRUCTION:

SOFT EDIT FOR ANY NUMBER LESS THAN 5 OR MORE THAN 14.

|___|___| . |___|

ENTER VALUE

REFUSED 7777

DON'T KNOW 9999

DIQ.291 What does {your/SP’s} doctor or other health professional say {your/his/her} “A one C” level should be? (Pick the lowest level recommended by {your/his/her} health care professional.)

HAND CARD DIQ3

LESS THAN 6 1

LESS THAN 7 2

LESS THAN 8 3

LESS THAN 9 4

LESS THAN 10 5

PROVIDER DID NOT SPECIFY GOAL 6

REFUSED 77

DON'T KNOW 99

BOX 10A

CHECK ITEM DIQ.295:

IF AGE <12, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

DIQ.300
S/D

Blood pressure is usually given as one number over another. What was {your/SP’s} most recent blood pressure in numbers?

|___|___|___| OVER |___|___|___|

SYSTOLIC DIASTOLIC

ENTER VALUES

CAPI INSTRUCTION:

SYSTOLIC RANGE: 0-776 SOFT EDIT: 80-200.

DIASTOLIC RANGE: 0-776 SOFT EDIT: 0-150.

REFUSED 777

DON'T KNOW 999

DIQ.310
G/S/D

What does {your/SP’s} doctor or other health professional say {your/his/her} blood pressure should be?

|___|

ENTER VALUES 1

PROVIDER DID NOT SPECIFY GOAL 2 (DIQ.320)

REFUSED 7 (DIQ.320)

DON'T KNOW 9 (DIQ.320)

|___|___|___| OVER |___|___|___|

SYSTOLIC DIASTOLIC

ENTER VALUES

INTERVIEWER INSTRUCTION:

IF RANGE GIVEN, RECORD UPPER VALUE OF RANGE.

CAPI INSTRUCTION:

SYSTOLIC RANGE: 0-776 SOFT EDIT: 80-200.

DIASTOLIC RANGE: 0-776 SOFT EDIT: 0-150.

REFUSED 777

DON'T KNOW 999

DIQ.320
G/Q

One part of total serum cholesterol in {your/SP’s} blood is a bad cholesterol, called LDL, which builds up and clogs {your/his/her} arteries. What was {your/his/her} most recent LDL cholesterol number?

|___|

ENTER VALUE 1

NEVER HEARD OF LDL 2 (DIQ.341)

NEVER HAD CHOLESTEROL TEST 3 (DIQ.341)

REFUSED 7

DON'T KNOW 9

|___|___|___|

ENTER VALUE

CAPI INSTRUCTION:

RANGE: 0-776 SOFT EDIT: 40-250.

REFUSED 777

DON'T KNOW 999

DIQ.330
G/Q

What does {your/SP’s} doctor or other health professional say {your/his/her} LDL cholesterol should be?

|___|

ENTER VALUE 1

PROVIDER DID NOT SPECIFY GOAL 2 (DIQ.341)

REFUSED 7 (DIQ.341)

DON'T KNOW 9 (DIQ.341)

|___|___|___|

ENTER VALUE

INTERVIEWER INSTRUCTION:

IF RANGE GIVEN, RECORD UPPER VALUE OF RANGE.

CAPI INSTRUCTION:

RANGE: 0-776 SOFT EDIT: 40-250.

REFUSED 777

DON'T KNOW 999

DIQ.341
G/Q

During the past 12 months, about how many times has a doctor or other health professional checked {your/SP’s} feet for any sores or irritations?

|___|

ENTER NUMBER OF TIMES 1

NONE 2

BOTH FEET AMPUTATED 3 (DIQ.360)

REFUSED 7

DON'T KNOW/not sure 9

|___|___|___|

ENTER NUMBER OF TIMES

CAPI INSTRUCTION:

HARD EDIT: DO NOT ALLOW 0.

REFUSED 7777

DON'T KNOW/not sure 9999

DIQ.350
G/Q/U

How often {do you check your feet/does SP check (his/her) feet} for sores or irritations? Include times when checked by a family member or friend, but do not include times when checked by a doctor or other health professional.

|___|

ENTER NUMBER OF TIMES 1

NONE 2 (DIQ.360)

REFUSED 7 (DIQ.360)

DON'T KNOW 9 (DIQ.360)

CAPI INSTRUCTION:

HARD EDIT: DO NOT ALLOW 0.

|___|___|___|

ENTER NUMBER OF TIMES

REFUSED 7777 (DIQ.360)

DON'T KNOW 9999 (DIQ.360)

ENTER UNIT

|___|

PER DAY 1

PER WEEK 2

PER MONTH 3

PER YEAR 4

DIQ.360 When was the last time {you/SP} had an eye exam in which the pupils were dilated? This would have made {you/SP} temporarily sensitive to bright light.

LESS THAN 1 MONTH 1

1-12 MONTHS 2

13-24 MONTHS 3

GREATER THAN 2 YEARS 4

NEVER 5

REFUSED 7

DON'T KNOW 9

DIQ.080 Has a doctor ever told {you/SP} that diabetes has affected {your/his/her} eyes or that {you/s/he} had retinopathy (ret-in-op-ath-ee)?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Retinopathy: Any disorder of the retina.

Diabetes: A glandular disease that impairs the ability of the body to use sugar and causes sugar to appear abnormally in the urine. Common symptoms are persistent thirst and excessive discharge of urine. Do not include gestational diabetes or diabetes that was only present during pregnancy. Also, do not include self-diagnosed diabetes, pre-diabetes or high sugar.

HELP SCREEN FOR DIQ.010/040:

BLOOD PRESSURE – BPQ

Target Group: SPs 16+

BPQ.020 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had hypertension (hy-per-ten-shun), also called high blood pressure?

IF HIGH BLOOD PRESSURE ONLY DURING PREGNANCY, CODE NO.

INTERVIEWER INSTRUCTION: IF SP SAYS “HIGH NORMAL BLOOD PRESSURE”, “BORDERLINE HYPERTENSION” OR “PREHYPERTENSION” CODE NO.

YES 1

NO 2 (BPQ.080)

REFUSED 7 (BPQ.080)

DON'T KNOW 9 (BPQ.080)

HELP SCREEN:

Hypertension (High Blood Pressure): A repeatedly increased blood pressure with the first number 140 or higher and the second number 90 or higher.

BPQ.030 {Were you/Was SP} told on 2 or more different visits that {you/s/he} had hypertension (hy-per-ten-shun), also called high blood pressure?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BPQ.035
G/Q

How old {were you/was SP} when {you were/he/she was} first told that {you/he/she} had hypertension or high blood pressure?

HARD EDIT: SP AGE CANNOT BE LESS THAN 6.

SOFT EDIT: PLEASE VERIFY THAT SP WAS LESS THAN 11 YEARS OLD.

|___|

ENTER AGE IN YEARS 1

REFUSED 7 (BPQ.040a)

DON'T KNOW 9 (BPQ.040a)

|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON’T KNOW 999

BPQ.040a Because of {your/SP’s} (high blood pressure/hypertension) (hy-per-ten-shun), {have you/has s/he} ever been told to take prescribed medicine?

YES 1

NO 2 (BPQ.080)

REFUSED 7 (BPQ.080)

DON’T KNOW 9 (BPQ.080)

HELP SCREEN:

Prescribed Medicine: Prescribed medicines are those ordered by a doctor or other health provider through a written or verbal prescription for a pharmacist to fill. Prescription medicines can also be given by a medical provider directly to a patient to take home, such as free samples.

BOX 1A

OMITTED

BOX 1B

OMITTED

BPQ.050a {Are you/Is SP} now taking a prescribed medicine?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 2

OMITTED

BPQ.080 {Have you/Has SP} ever been told by a doctor or other health professional that {your/his/her} blood cholesterol level was high?

YES 1 (BPQ.070)

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Cholesterol: Cholesterol is a type of fat in the bloodstream and is measured with a blood test, usually done in the morning before you’ve eaten. High levels of cholesterol are a major risk factor for heart disease, which leads to heart attack.

BPQ.060 {Have you/Has SP} ever had {your/his/her} blood cholesterol checked?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

BPQ.070 About how long has it been since {you/SP} last had {your/his/her} blood cholesterol checked? Has it been…

less than 1 year ago, 1

1 year but less than 2 years ago, 2

2 years but less than 5 years ago, or 3

5 years or more? 4

REFUSED 7

DON'T KNOW 9

BPQ.090d To lower {your/his/her} blood cholesterol, {have you/has SP} ever been told by a doctor or other health professional to take prescribed medicine?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

HELP SCREEN:

BOX 3

OMITTED

BPQ.100d {Are you/Is SP} now taking a prescribed medicine?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

BOX 5

OMITTED

BOX 6

OMITTED

BOX 7

OMITTED

BOX 8

OMITTED

BOX 9

OMITTED

CARDIOVASCULAR DISEASE – CDQ

Target Group: SPs 40+

CDQ.001 {Have you/Has SP} ever had any pain or discomfort in {your/her/his} chest?

YES 1

NO 2 (CDQ.010)

REFUSED 7 (CDQ.010)

DON'T KNOW 9 (CDQ.010)

CDQ.002 {Do you/Does she/Does he} get it when {you/she/he} {walk/walks} uphill or {hurry/hurries}?

YES 1

NO 2 (CDQ.008)

NEVER WALKS UPHILL OR HURRIES 3

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.003 {Do you/Does she/Does he} get it when {you/she/he} {walk/walks} at an ordinary pace on level ground?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 1

CHECK ITEM CDQ.003A:

IF 'YES' (CODE '1') IN CDQ.002 OR CDQ.003, CONTINUE.

OTHERWISE, GO TO CDQ.008.

CDQ.004 What {do you/does she/does he} do if {you/she/he} get it while {you/she/he} are walking? {Do you/Does she/Does he} stop or slow down, or continue at the same pace?

CODE "STOP OR SLOW DOWN" IF SP CARRIES ON AFTER TAKING NITROGLYCERINE.

STOP OR SLOW DOWN 1

CONTINUE AT THE SAME PACE 2 (CDQ.008)

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.005 If {you/she/he} {stand/stands} still, what happens to it? Is the pain or discomfort relieved or not relieved?

RELIEVED 1

NOT RELIEVED 2 (CDQ.008)

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.006 How soon is the pain relieved? Would you say . . .

10 minutes or less or 1

more than 10 minutes? 2 (CDQ.008)

REFUSED 7 (CDQ.008)

DON'T KNOW 9 (CDQ.008)

CDQ.009 Please look at this card and show me where the pain or discomfort is located.

CODE ALL THAT APPLY.

PROBE FOR ADDITIONAL AREAS.

HAND CARD CDQ1

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

REFUSED 77

DON'T KNOW 99

CDQ.008 Have {you/she/he} ever had a severe pain across the front of {your/her/his} chest lasting for half an hour or more?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CDQ.010 {Have you/Has SP} had shortness of breath either when hurrying on the level or walking up a slight hill?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2

OMITTED

OSTEOPOROSIS – OSQ

*Target Group: Males and Females 50+

OSQ.010 a/b/c	Has a doctor or other health professional ever told {you/SP} that {you/SP} had broken or fractured {your/his/her} . . .	OSQ.020	How many times {have you/has SP} broken or fractured {your/his/her} {hip/wrist/spine}?

	a. hip? YES 1 NO 2 (b) REFUSED 7 (b) DON'T KNOW 9 (b) HELP SCREEN: Doctor: The term refers to both medical doctors (M.D.s) and osteopathic physicians (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc. Other Health (Care) Professional: A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.		\|___\|___\| ENTER NUMBER OF TIMES CAPI INSTRUCTION: HARD EDIT: 1-33. SOFT EDIT: 13-33, DISPLAY “UNLIKELY RESPONSE. PLEASE VERIFY.” REFUSED 77 DON'T KNOW 99
	b. wrist? YES 1 DO NOT NO 2 (c) INCLUDE REFUSED 7 (c) FOREARM OR DON'T KNOW 9 (c) HAND		\|___\|___\| ENTER NUMBER OF TIMES CAPI INSTRUCTION: HARD EDIT: 1-33. REFUSED 77 DON'T KNOW 99
	c. spine? YES 1 NO 2 (BOX 1) REFUSED 7 (BOX 1) DON'T KNOW 9 (BOX 1)		\|___\|___\| ENTER NUMBER OF TIMES CAPI INSTRUCTION: HARD EDIT: 1-33. REFUSED 77 DON'T KNOW 99

BOX 1

CHECK ITEM OSQ.025:

IF 'YES' (CODE 1) IN OSQ.010 a, b, OR c, CONTINUE WITH LOOP 1.

OTHERWISE, GO TO OSQ.080.

LOOP 1:

ASK OSQ.030 - OSQ.051 FOR EACH TYPE AND EACH INCIDENT OF FRACTURE. (EXAMPLE: HOW OLD WERE YOU WHEN YOU FRACTURED YOUR HIP THE FIRST TIME?)

OSQ.030
a/b/c

How old {were you/was SP} when {you/s/he} fractured {your/his/her} {hip/wrist/spine} {the {1st/2nd/10th or more recent time . . .} time}?

CAPI INSTRUCTION:

IF ONLY BROKE HIP, WRIST OR SPINE 1 TIME, DO NOT DISPLAY "THE {1ST/2ND . . .} TIME".

IF 10TH TIME, DISPLAY {10TH OR MOST RECENT TIME}.

|___|___|___| (BOX 2)

ENTER AGE IN YEARS

CAPI INSTRUCTION: HARD EDIT: 1-120.

REFUSED 777

DON'T KNOW 999

CAPI INSTRUCTION:

IF OSQ.030 = DK, RF OR NULL AND SP AGE < 50, CODE OSQ.040 = 1 (UNDER 50).

IF OSQ.030 = DK, RF OR NULL AND SP AGE >= 50, CONTINUE.

OSQ.040 {Were you/Was SP} . . .

a/b/c

under 50 years old, or 1

50 years old or older? 2

REFUSED 7 (BOX 3)

DON'T KNOW 9 (BOX 3)

BOX 2

CHECK ITEM OSQ.045:

IF AGE IS >= 50 IN OSQ.030 OR OSQ.040, CONTINUE.

OTHERWISE, GO TO BOX 3.

OSQ.051 Did that fracture occur as a result of . . .

a fall from standing height or less, for
example, tripped, slipped, fell out of bed 4

a hard fall, such as falling off a ladder or
step stool, down stairs, or 5

a car accident or other severe trauma? 6

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Additional examples for “a fall from standing height or less” include leg gave way, was dizzy, fell bending over, fell out of a chair. Additional examples for “a hard fall” include being forcibly knocked down by another person or bicycle.

BOX 3

END LOOP1:

ASK OSQ.030 - OSQ.051 FOR NEXT INCIDENT OF FRACTURE.
IF NO NEXT INCIDENT, CONTINUE.

OSQ.080 Has a doctor or other health professional ever told {you/SP} that {you/s/he} had broken or fractured any other bone after {you were/s/he was} 20 years of age?

YES 1

NO 2 (OSQ.060)

REFUSED 7 (OSQ.060)

DON'T KNOW 9 (OSQ.060)

OSQ.090 Was this fracture the result of severe trauma such as a car accident, being struck by a vehicle, a physical attack, or a hard fall such as falling off a ladder or down stairs?

YES 1 (OSQ.120)

NO 2

REFUSED 7 (OSQ.120)

DON'T KNOW 9 (OSQ.120)

HELP SCREEN:

Do not include a fall from standing height or less, for example, tripped, slipped, fell out of bed, leg gave way, was dizzy, fell bending over, or fell out of a chair.

Additional examples for “a hard fall” include being knocked down by another person or bicycle.

OSQ.100 Please look at this card and tell me where the fracture occurred.

HAND CARD OSQ 1

HEAD/FACE 10

UPPER ARM (HUMERUS) 11

LOWER ARM BETWEEN WRIST AND

ELBOW (DO NOT INCLUDE WRIST) 12

ELBOW 13

HAND 14

FINGERS 15

SHOULDER 16

COLLAR BONE 17

RIBS (EITHER SIDE) 18

PELVIS (NOT HIP) 19

UPPER LEG (THIGH EXCLUDING HIP) 20

LOWER LEG (BETWEEN ANKLE AND

KNEE) 21

KNEE (PATELLA) 22

ANKLE 23

HEEL 24

FOOT 25

TOES 26

OTHER (DO NOT SPECIFY) 27

REFUSED 77

DON'T KNOW 99

OSQ.110 How old {were you/was SP} when {you/SP} fractured {your/his/her} (fracture site selected in OSQ.100) for the first time after age 20?

|___|___|___|

ENTER AGE IN YEARS

CAPI INSTRUCTION: HARD EDIT: 20-120.

REFUSED 777

DON'T KNOW 999

OSQ.120 Has a doctor or other health professional ever told {you/SP} that {you/s/he} had broken or fractured any other bones after {you were/s/he was} 20 years of age?

YES 1

NO 2 (OSQ.060)

REFUSED 7 (OSQ.060)

DON'T KNOW 9 (OSQ.060)

BOX 4

CHECK ITEM OSQ.129:

IF OSQ120 = 1 (YES), CONTINUE WITH LOOP 2. OTHERWISE, GO TO OSQ.060.

LOOP 2:

ASK OSQ.090 – OSQ.120 FOR NEXT INCIDENT OF FRACTURE. IF NO NEXT INCIDENT, CONTINUE.

OSQ.060 Has a doctor or other health professional ever told {you/SP} that {you/s/he} had osteoporosis, sometimes called thin or brittle bones?

YES 1

NO 2 (OSQ.130)

REFUSED 7 (OSQ.130)

DON'T KNOW 9 (OSQ.130)

HELP SCREEN:

Osteoporosis: A disease in which bones become less dense, which makes them more fragile and likely to break. Osteoporosis is not always painful. In fact, many people don't know they have osteoporosis unless a bone breaks. A doctor may tell you that you have osteoporosis after you have had a broken bone or a bone density test.

OSQ.072 Please look at the drugs on this card that are prescribed for osteoporosis. {Have you/Has SP} ever been told by a doctor or other health professional to take a prescribed medicine for osteoporosis?

HAND CARD OSQ 2

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

OSQ.130 {Have you/has SP} ever taken any prednisone or cortisone pills nearly every day for a month or longer? [Prednisone and cortisone are types of steroids.]

YES 1

NO 2 (OSQ.150)

REFUSED 7 (OSQ.150)

DON'T KNOW 9 (OSQ.150)

OSQ.140
Q/U

Please think about {your/SP's} use of prednisone or cortisone during {your/his/her} lifetime. For how long did {you/s/he} use prednisone or cortisone nearly every day? Do not count the months or years when {you were/s/he was} not taking the medicine.

|___|___|

ENTER NUMBER (OF MONTHS OR YEARS)

CAPI INSTRUCTION: SOFT EDIT: 19 OR HIGHER.

REFUSED 777

DON'T KNOW 999

ENTER UNIT

MONTH 1

YEAR 2

REFUSED 7

DON’T KNOW 9

OSQ.150 Including living and deceased, were either of {your/SP's} biological parents ever told by a doctor or other health professional that they had osteoporosis or brittle bones?

YES 1

NO 2 (OSQ.170)

REFUSED 7 (OSQ.170)

DON'T KNOW 9 (OSQ.170)

OSQ.160 Which biological [blood] parent?

CODE ALL THAT APPLY

MOTHER 1

FATHER 2

REFUSED 7

DON'T KNOW 9

OSQ.170 Did {your/SP's} biological mother ever fracture her hip?

YES 1

NO 2 (OSQ.200)

REFUSED 7 (OSQ.200)

DON'T KNOW 9 (OSQ.200)

OSQ.180 About how old was she when she fractured her hip (the first time)?

|___|___|___| (OSQ.200)

ENTER AGE IN YEARS

CAPI INSTRUCTION:

HARD EDIT: 0-120.

SOFT EDIT: 0-19.

ERROR MESSAGE: ‘THAT IS AN UNUSUAL AGE, PLEASE VERIFY.’

REFUSED 777

DON'T KNOW 999

OSQ.190 Was she. . .

under 50 years old, or 1

50 years old or older? 2

REFUSED 7

DON'T KNOW 9

OSQ.200 Did {your/SP's} biological father ever fracture his hip?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

OSQ.210 About how old was he when he fractured his hip (the first time)?

|___|___|___| (END OF SECTION)

ENTER AGE IN YEARS

CAPI INSTRUCTION:

HARD EDIT: 0-120.

SOFT EDIT: 0-19.

ERROR MESSAGE: ‘THAT IS AN UNUSUAL AGE, PLEASE VERIFY.’

REFUSED 777

DON'T KNOW 999

OSQ.220 Was he . . .

under 50 years old, or 1

50 years old or older? 2

REFUSED 7

DON'T KNOW 9

AUDIOMETRY – AUQ

Target Group: SPs 1+

AUQ.054 These next questions are about {your/SP’s} hearing.

Which statement best describes {your/SP’s} hearing (without a hearing aid, personal sound amplifier, or other listening devices)? Would you say {your/his/her} hearing is excellent, good, that {you have/s/he has} a little trouble, moderate trouble, a lot of trouble, or {are you/is s/he} deaf?

EXCELLENT 1

GOOD 2

A LITTLE TROUBLE 3

MODERATE HEARING TROUBLE 4

A LOT OF TROUBLE 5

DEAF 6

REFUSED 77

DON’T KNOW 99

HELP SCREEN:

Deaf means that you can’t hear in both ears without the use of hearing aids or other devices to help you hear. If you can hear in one ear, you are not deaf.

Hearing Aid: A small electronic device that amplifies the sounds you hear. It is worn in or behind the ear to help you hear.

Personal Sound Amplifier: A wearable electronic product that is intended to amplify sounds for people with normal hearing who need a little “boost” in some situations. They are sold direct to the consumer over-the-counter or online, and are not customized for individuals’ hearing loss. Although not designed for people with hearing loss, they are frequently used by hearing impaired individuals as a low-cost alternative to hearing aids.

Other Listening Devices: Other listening devices are any device you use to help you hear. They are also called assistive listening devices. These are:

A pocket talker

An amplified telephone

An amplified or vibrating alarm clock

A light signaler for your doorbell

A TV headset

Closed-captioned TV

TTY (teletypewriter)

TDD (telecommunications device for the deaf)

A telephone relay service

A video relay service

A sign language interpreter

BOX 1A

CHECK ITEM AUQ.055:

IF {SP AGE >= 6, AND SP AGE <= 19 OR SP AGE > 69} AND {AUQ.054 = 1, 7, 9}, GO TO AUQ.420;

IF {SP AGE >= 6, AND SP AGE <= 19 OR SP AGE > 69} AND {AUQ.054 = 2, 3, 4, 5 OR 6}, CONTINUE.

OTHERWISE, END OF SECTION.

AUQ.060 These next questions refer to hearing without the use of a hearing aid or any other listening devices. If {you have/SP has} one ear that is better than the other, please answer the questions for the hearing in {your/SP’s} better ear.

Can {you/SP} usually hear and understand what a person says without seeing his or her face if that person whispers to {you/him/her} from across a quiet room?

YES 1 (BOX 2A)

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.070 Can {you/SP} usually hear and understand what a person says without seeing his or her face if that person talks in a normal voice to {you/him/her} from across a quiet room?

YES 1 (BOX 2A)

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.080 Can {you/SP} usually hear and understand what a person says without seeing his or her face if that person shouts to {you/him/her} from across a quiet room?

YES 1 (BOX 2A)

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.090 Can {you/SP} usually hear and understand what a person says without seeing his or her face if that person speaks loudly into {your/his/her} better ear?

INTERVIEWER: IF THE INTERVIEWEE HEARS BETTER IN ONE EAR THAN THE OTHER,

RECORD THE RESPONSE FOR SPEAKING LOUDLY INTO THE BETTER EAR.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2A

CHECK ITEM AUQ.395:

IF AUQ.054 = {3, 4, 5 OR 6} CONTINUE.

OTHERWISE, GO TO AUQ.420.

AUQ.400 How old {were you/was SP} when {you/he/she} began to have any hearing loss?

READ CATEGORIES IF NECESSARY

BEFORE AGE 1 YEAR OLD 1

BETWEEN 2 AND 5 YEARS OLD 2

BETWEEN 6 AND 19 YEARS OLD 3

BETWEEN 20 AND 39 YEARS OLD 4

BETWEEN 40 AND 59 YEARS OLD 5

BETWEEN 60 AND 69 YEARS OLD 6

70 YEARS AND OLDER 7

NO HEARING LOSS 8

REFUSED 77

DON’T KNOW 99

AUQ.410 What are the main causes of {your/SP’s} hearing loss?

INTERVIEWER INSTRUCTION: CODE ALL THAT APPLY

HAND CARD AUQ1

GENETIC/HEREDITARY CAUSES 1

EAR INFECTIONS (INCLUDING FLUID IN EARS) 2

EAR DISEASES (OTOSCLEROSIS, MENIERES, TUMOR) 3

ILLNESS/INFECTIONS (MEASLES, MENINGITIS, MUMPS) 4

DRUGS/MEDICATIONS 5

HEAD OR NECK INJURY/TRAUMA 6

LOUD BRIEF EXPLOSIVE NOISE/SOUNDS 7

NOISE EXPOSURE, LONG-TERM (MACHINERY, ETC.) 8

AGING, GETTING OLDER 9

OTHER CAUSES 10

SPECIFY:

REFUSED 77

DON’T KNOW 99

AUQ.156 Because of hearing loss, {have you/has SP} ever used any of the following to improve {your/his/her} communication: FM systems, closed-captioned television, instant or text messages, live video streaming, amplified telephone, relay services, or a sign-language interpreter?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

This question asks about the use of “Assistive Listening Devices,” which include any device {you use/SP uses} to help {you hear/SP hear}. Some examples include:

FM system, which provides direct input to your hearing aid or another earpiece.

Closed-captioned television, which displays the audio portion of a television program as text on the TV screen.

Instant or text messages, when used because {you have/SP has} difficulty hearing on the telephone

Live video streaming, for example, video on computers or phones using sign language or other means to communicate.

Amplified telephone, which improves telephone communication through amplified volume, loud ringers, light signalers, voice enhancers, etc.

Relay services, in which a third party transmits messages between {you/SP} and another person

Sign language interpreter, translate from spoken to signed language.

AUQ.420 {Have you/Has SP} ever had ear infections or ear aches?

YES 1

NO 2 (AUQ.144)

REFUSED 7 (AUQ.144)

DON'T KNOW 9 (AUQ.144)

AUQ.430 {Have you/Has SP} ever had 3 or more ear infections or ear aches?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.139 {Have you/Has SP} ever had a tube placed in {your/his/her} ear to drain the fluid from {your/his/her} ear or to treat ear infections?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.144 A hearing test by a specialist is one that is done in a sound proof booth or room, or with headphones. Hearing specialists include audiologists, ear nose and throat doctors, and trained technicians or occupational nurses. When was the last time {you/SP} had {your/his/her} hearing tested by a hearing specialist?

READ CATEGORIES IF NECESSARY

LESS THAN A YEAR AGO 1

1 YEAR TO 4 YEARS AGO 2

5 TO 9 YEARS AGO 3

TEN OR MORE YEARS AGO 4

NEVER 5

REFUSED 7

DON’T KNOW 9

AUQ.147 {Do you/Does SP} now wear or use a hearing aid, a personal sound amplifier, or cochlear implant?

YES 1

NO 2 (AUQ.630)

REFUSED 7 (AUQ.630)

DON'T KNOW 9 (AUQ.630)

HELP SCREEN:

Hearing Aid: A small electronic device that amplifies the sounds you hear. It is worn in or behind the ear to help you hear.

Personal Sound Amplifier: A wearable electronic product that is intended to amplify sounds for people with normal hearing who need a little “boost” in some situations. They are sold direct to the consumer over-the-counter or online, and are not customized for an individual’s hearing loss. Although not designed for people with hearing loss, they are frequently used by hearing-impaired individuals as a low-cost alternative to hearing aids.

Cochlear Implant: A cochlear implant is an electrical device that a surgeon puts in your ear. It helps you hear by sending sounds directly to the brain. It is used only when you are almost totally deaf.

AUQ.149 Which was it?

CODE ALL THAT APPLY

CAPI INSTRUCTION:

IF ANY OR ALL RESPONSE OPTIONS 1, 2, OR 3 ARE SELECTED, GO TO AUQ.153.

A HEARING AID 1

A PERSONAL SOUND AMPLIFIER 2

A COCHLEAR IMPLANT 3

REFUSED 7 (BOX 4A)

DON'T KNOW 9 (BOX 4A)

AUQ.153 In the past 2 weeks, how often {have you/has SP} worn a {hearing aid and/or personal sound amplifier and/or cochlear implant}?

If unsure, provide your best estimate of the average amount of time {you have/he has/she has} worn {your/his/her} {hearing aid, and/or personal sound amplifier, and/or cochlear implant}.

CAPI INSTRUCTION:

IF AUQ.149 = 1, DISPLAY “hearing aid”

IF AUQ.149 = 2, DISPLAY “personal sound amplifier”

IF AUQ.149 = 3, DISPLAY “cochlear implant”

IF AUQ.149 = 1 AND AUQ.149 = 2, DISPLAY “hearing aid and/or personal sound amplifier”

IF AUQ.149 = 1 AND AUQ.149 = 3, DISPLAY “hearing aid and/or cochlear implant”

IF AUQ.149 = 2 AND AUQ.149 = 3, DISPLAY “personal sound amplifier and/or cochlear implant”

IF AUQ.149 = 1 AND AUQ.149 = 2 AND AUQ.149 = 3, DISPLAY “hearing aid and/or personal sound amplifier and/or cochlear implant”

READ CATEGORIES IF NECESSARY

LESS THAN 1 HOUR A DAY 1 (BOX 4A)

1 TO 3 HOURS A DAY 2 (BOX 4A)

4 TO 7 HOURS A DAY 3 (BOX 4A)

8 OR MORE HOURS PER DAY 4 (BOX 4A)

NEVER 5 (BOX 4A)

REFUSED 7 (BOX 4A)

DON’T KNOW 9 (BOX 4A)

HELP SCREEN:

Hearing Aid: A small electronic device that amplifies the sounds you hear. It is worn in or behind the ear to help you hear.

Personal Sound Amplifier: A wearable electronic product that is intended to amplify sounds for people with normal hearing who need a little “boost” in some situations. They are sold direct to the consumer over-the-counter or online, and are not customized for an individual’s hearing loss. Although not designed for people with hearing loss, they are frequently used by hearing-impaired individuals as a low-cost alternative to hearing aids.

AUQ.630 {Have you/Has SP} ever worn or used a hearing aid, a personal sound amplifier, or cochlear implant in the past?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 4A

CHECK ITEM AUQ.435:

IF SP AGE >= 6 AND SP AGE <= 15 CONTINUE.

OTHERWISE, GO TO AUQ.101.

AUQ.440 Has SP ever received Special Education or Early Intervention Services for speech-language, reading, hearing or listening skills, intellectual disability, movement or mobility difficulties (e.g., using arms or legs), or other developmental or disability problems?

YES 1

NO 2 (AUQ.460)

REFUSED 7 (AUQ.460)

DON'T KNOW 9 (AUQ.460)

HELP SCREEN:

Special Education: Teaching designed to meet the needs of a child with special needs and/or disabilities. It is paid for by the public school system and may take place at a regular school, a special school, a private school, at home, or at a hospital.

Early Intervention Services: Services designed to meet the needs of very young children with special needs and/or disabilities. They may include but are not limited to: medical and social services, parental counseling, and therapy. They may be provided at the child's home, a medical center, a day care center, or other place. They are provided by the state or school system at no cost to the parent.

AUQ.450 Which was it?

INTERVIEWER INSTRUCTION: CODE ALL THAT APPLY

HAND CARD AUQ2

SPEECH-LANGUAGE 1

READING 2

HEARING OR LISTENING SKILLS 3

INTELLECTUAL DISABILITY 4

MOVEMENT OR MOBILITY DIFFICULTIES 5

OTHER DEVELOPMENTAL OR DISABILITY
PROBLEMS 6

REFUSED 77

DON'T KNOW 99

AUQ.460 Has SP ever been exposed to very loud noise or music for 10 or more hours a week for a period of 3 months or longer?

This is noise so loud {he/she has} to shout to be understood or heard 3 feet away.

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

AUQ.470 How long has SP been exposed to very loud noise or music for 10 or more hours a week?

This is noise so loud that {he/she has} to shout to be understood or heard 3 feet away.

READ CATEGORIES IF NECESSARY

LESS THAN 1 YEAR 1 (END OF SECTION)

1 TO 2 YEARS 2 (END OF SECTION)

3 TO 4 YEARS 3 (END OF SECTION)

5 OR MORE YEARS 4 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

AUQ.101 How often {do you/does SP} have difficulty hearing and understanding if there is background noise, for example, when other people are talking, TV or radio is on, or children are playing? Would you say...

HAND CARD AUQ3

Always, 1

Usually, 2

About half the time, 3

Seldom, or 4

Never? 5

REFUSED 7

DON’T KNOW 9

AUQ.110 How often does {your/SP’s} hearing cause {you/him/her} to feel frustrated when talking to members of {your/his/her} family or to friends? Would you say...

HAND CARD AUQ3

ALWAYS, 1

USUALLY, 2

ABOUT HALF THE TIME, 3

SELDOM, OR 4

NEVER? 5

REFUSED 7

DON’T KNOW 9

AUQ.480 How often does {your/SP’s} hearing cause {you/him/her} to avoid groups of people, limiting or hampering {your/his/her} personal or social life? Would you say…

HAND CARD AUQ3

ALWAYS, 1

USUALLY, 2

ABOUT HALF THE TIME, 3

SELDOM, OR 4

NEVER? 5

REFUSED 7

DON’T KNOW 9

AUQ.490 During the past 12 months, {have you/has SP} had a problem with dizziness, lightheadedness, feeling as if {you are/s/he is} going to pass out or faint, unsteadiness or imbalance?

INTERVIEWER INSTRUCTION: DO NOT INCLUDE TIMES WHEN DRINKING ALCOHOL.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.191 In the past 12 months, {have you/has SP} been bothered by ringing, roaring, or buzzing in {your/his/her} ears or head that lasts for 5 minutes or more?

YES 1

NO 2 (AUQ.300)

REFUSED 7 (AUQ.300)

DON'T KNOW 9 (AUQ.300)

HELP SCREEN:

Tinnitus (tin-uh-tus) is the medical term for ringing, roaring or buzzing in the ears or head.

AUQ.250 How long {have you/has SP} been bothered by this ringing, roaring, or buzzing in {your/his/her} ears or head?

READ CATEGORIES IF NECESSARY

LESS THAN THREE MONTHS 1

THREE MONTHS TO A YEAR 2

1 TO 4 YEARS 3

5 TO 9 YEARS 4

TEN OR MORE YEARS 5

REFUSED 7

DON’T KNOW 9

AUQ.255 In the past 12 months, how often {have you/has SP} had this ringing, roaring, or buzzing in {your/his/her} ears or head? Would you say...

almost always, 1

at least once a day, 2

at least once a week, 3

at least once a month, or 4

less frequently than once a month? 5

REFUSED 7

DON’T KNOW 9

AUQ.260 {Are you/Is SP} bothered by ringing, roaring, or buzzing in {your/his/her} ears or head only after listening to loud sounds or loud music?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.270 {Are you/Is SP} bothered by ringing, roaring, or buzzing in {your/his/her} ears or head when going to sleep?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.280 How much of a problem is this ringing, roaring, or buzzing in {your/his/her} ears or head? Would you say...

No problem, 1

A small problem, 2

A moderate problem, 3

A big problem, or 4

A very big problem? 5

REFUSED 7

DON’T KNOW 9

AUQ.500 {Have you/Has SP} ever discussed this ringing, roaring, or buzzing in {your/his/her} ears or head with {your/his/her} doctor or other health care professional?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AUQ.300 This next question is about {your/SP’s} use of firearms that {you/he/she} may have used for target shooting, hunting, for {your/his/her} job or in military service. {Have you/Has SP} ever used firearms for any reason?

YES 1

NO 2 (AUQ.330)

REFUSED 7 (AUQ.330)

DON'T KNOW 9 (AUQ.330)

HELP SCREEN:

Firearms include pistols, shotguns, rifles, and other types of guns. Do not include BB or pellet guns.

AUQ.310 How many total rounds {have you/has SP} ever fired?

READ CATEGORIES IF NECESSARY

INTERVIEWER: ONE ROUND EQUALS ONE SHOT. INCLUDE TARGET SHOOTING, HUNTING, YOUR JOB AND MILITARY SERVICE.

1 TO LESS THAN 100 ROUNDS 1

100 TO LESS THAN 1000 ROUNDS 2

1000 TO LESS THAN 10,000 ROUNDS 3

10,000 TO LESS THAN 50,000 ROUNDS 4

50,000 ROUNDS OR MORE 5

REFUSED 7

DON’T KNOW 9

AUQ.320 How often {did you/did SP} wear hearing protection devices (ear plugs, ear muffs) when shooting firearms?

INTERVIEWER: PROTECTIVE HEARING DEVICES INCLUDE PLUGS AND EARMUFFS.

HAND CARD AUQ3

Always, 1

Usually, 2

About half the time, 3

Seldom, or 4

Never? 5

REFUSED 7

DON’T KNOW 9

AUQ.330 These next questions are about noise exposure {you/SP} may have had at work.

{Have you/Has SP} ever had a job, or combination of jobs where {you were/s/he was} exposed to loud sounds or noise for 4 or more hours a day, several days a week?

(Loud means so loud that {you/s/he} must speak in a raised voice to be heard.)

YES 1

NO 2 (AUQ.370)

NEVER WORKED 3 (AUQ.370)

REFUSED 7 (AUQ.370)

DON'T KNOW 9 (AUQ.370)

AUQ.340 For how many months or years {have you/has SP} been exposed at work to loud sounds or noise for 4 or more hours a day, several days a week?

READ CATEGORIES IF NECESSARY

LESS THAN 3 MONTHS 1

3 TO 11 MONTHS 2

1 TO 2 YEARS 3

3 TO 4 YEARS 4

5 TO 9 YEARS 5

10 TO 14 YEARS 6

15 OR MORE YEARS 7

REFUSED 77

DON’T KNOW 99

AUQ.350 In {your/SP’s} work {were you/was he/was she} exposed to very loud noise? (Very loud noise is noise that is so loud {you have/he has/she has} to shout in order to be understood by someone standing 3 feet away from {you/him/her}.)

YES 1

NO 2 (AUQ.370)

REFUSED 7 (AUQ.370)

DON'T KNOW 9 (AUQ.370)

AUQ.360 This next question is about {your/SP’s} work in jobs where there was very loud noise for 4 or more hours a day, several days a week.

Please give me the total number of months or years for all jobs where this has happened.

READ CATEGORIES IF NECESSARY

LESS THAN 3 MONTHS 1

3 TO 11 MONTHS 2

1 TO 2 YEARS 3

3 TO 4 YEARS 4

5 TO 9 YEARS 5

10 TO 14 YEARS 6

15 OR MORE YEARS 7

NOT EXPOSED 8

REFUSED 77

DON’T KNOW 99

AUQ.370 Outside of a job, {have you/has SP} ever been exposed to very loud noise or music for 10 or more hours a week? This is noise so loud that {you have/s/he has} to shout to be understood or heard 3 feet away. Examples are noise from power tools, lawn mowers, farm machinery, cars, trucks, motorcycles, motor boats or loud music.

YES 1

NO 2 (AUQ.380)

REFUSED 7 (AUQ.380)

DON'T KNOW 9 (AUQ.380)

AUQ.510 How long {have you/has SP} been exposed to very loud noise or music for 10 or more hours a week?

This is noise so loud that {you have/s/he has} to shout to be understood or heard 3 feet away.

READ CATEGORIES IF NECESSARY

LESS THAN 1 YEAR 1

1 TO 2 YEARS 2

3 TO 4 YEARS 3

5 OR MORE YEARS 4

REFUSED 7

DON’T KNOW 9

AUQ.380 In the past 12 months, how often did {you/SP} wear hearing protection devices (ear plugs, ear muffs) when exposed to very loud sounds or noise?

INTERVIEWER INSTRUCTION: PLEASE INCLUDE BOTH ON THE JOB AND OFF THE JOB EXPOSURES.

HAND CARD AUQ4

ALWAYS 1

USUALLY 2

ABOUT HALF THE TIME 3

SELDOM 4

NEVER 5

NO NOISE EXPOSURE PAST 12 MONTHS 6

REFUSED 77

DON’T KNOW 99

HELP TEXT:

Hearing Protection Device: A device such as an earplug or earmuff designed to protect you from noise that is so loud that it might damage your hearing.

DERMATOLOGY – DEQ

Target Group: SPs 20-59

DEQ.034
a/c/d

When {you go/SP goes} outside on a very sunny day, for more than one hour, how often {do you/does SP}.

HAND CARD DEQ2

a. Stay in the shade? Would you say . . .

always, 1

most of the time, 2

sometimes, 3

rarely, or 4

never? 5

DON'T GO OUT IN THE SUN 6 (DEQ.120)

REFUSED 77

DON'T KNOW 99

c. Wear a long sleeved shirt? Would you say . . .

always, 1

most of the time, 2

sometimes, 3

rarely, or 4

never? 5

REFUSED 7

DON'T KNOW 9

d. Use sunscreen? Would you say . . .

always, 1

most of the time, 2

sometimes, 3

rarely, or 4

never? 5 (DEQ.120)

REFUSED 7 (DEQ.120)

DON'T KNOW 9 (DEQ.120)

DEQ.120
G/Q/U

The next questions ask about the time you spent outdoors during the past 30 days. By outdoors, I mean outside and not under any shade.

How much time did you usually spend outdoors between 9 in the morning and 5 in the afternoon on the days that you worked or went to school?

PROBE IF NEEDED: I am only interested in the amount of time you spent outdoors between 9 in the morning and 5 in the afternoon.

|___|

ENTER AMOUNT OF TIME

(IN MINUTES OR HOURS) 1

NO TIME SPENT OUTDOORS 2 (DEQ.125)

DOES NOT WORK OR GO TO SCHOOL 3 (DEQ.125)

REFUSED 7 (DEQ.125)

DON'T KNOW 9 (DEQ.125)

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

HARD EDIT: The value entered cannot exceed 8 hours or 480 minutes.

REFUSED 77777 (DEQ.125)

DON'T KNOW 99999 (DEQ.125)

ENTER UNIT

|___|

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

DEQ.125
G/Q/U

During the past 30 days, how much time did you usually spend outdoors between 9 in the morning and 5 in the afternoon on the days when you were not working or going to school?

|___|

ENTER AMOUNT OF TIME

(IN MINUTES OR HOURS) 1

NO TIME SPENT OUTDOORS 2 (END OF SECTION)

AT WORK OR SCHOOL

9 TO 5 SEVEN DAYS A WEEK 3 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

|___|___|___|

ENTER NUMBER (OF MINUTES OR HOURS)

HARD EDIT: The value entered cannot exceed 8 hours or 480 minutes.

REFUSED 77777 (END OF SECTION)

DON'T KNOW 99999 (END OF SECTION)

ENTER UNIT

|___|

MINUTES 1

HOURS 2

REFUSED 7

DON'T KNOW 9

ORAL HEALTH – OHQ

Target Group: SPs 1+

OHQ.030 The next questions are about {your/SP’s} teeth and gums.

About how long has it been since {you/SP} last visited a dentist? Include all types of dentists, such as, orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.

6 MONTHS OR LESS 1

MORE THAN 6 MONTHS, BUT NOT MORE
THAN 1 YEAR AGO 2

MORE THAN 1 YEAR, BUT NOT MORE
THAN 2 YEARS AGO 3

MORE THAN 2 YEARS, BUT NOT MORE
THAN 3 YEARS AGO 4

MORE THAN 3 YEARS, BUT NOT MORE
THAN 5 YEARS AGO 5

MORE THAN 5 YEARS AGO 6

NEVER HAVE BEEN 7 (BOX 0)

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

Dentist: Medical persons whose primary occupation is caring for teeth, gums, and jaws. Dental care includes general work such as fillings, cleaning, extractions, and also specialized work such as root canals, fittings for braces, etc.

OHQ.033 What was the main reason {you/SP} last visited the dentist?

HAND CARD OHQ1

WENT IN ON OWN FOR CHECK-UP,
EXAMINATION OR CLEANING 1

WAS CALLED IN BY THE DENTIST FOR
CHECK-UP, EXAMINATION OR
CLEANING 2

SOMETHING WAS WRONG, BOTHERING
OR HURTING {ME/SP} 3

WENT FOR TREATMENT OF A
CONDITION THAT DENTIST
DISCOVERED AT EARLIER CHECK-UP
OR EXAMINATION 4

OTHER 5

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Cleaning (Dental): Refers to activities performed by a dentist or dental hygienist to maintain healthy teeth and prevent cavities. Cleaning includes scraping tartar deposits off teeth, both above and below the gumline.

Condition: Respondent's perception of a departure from physical or mental well-being. Any response describing a health problem of any kind.

OHQ.770 During the past 12 months, was there a time when {you/SP} needed dental care but could not get it at that time?

YES 1

NO 2 (BOX 0)

REFUSED 7 (BOX 0)

DON'T KNOW 9 (BOX 0)

OHQ.780 What were the reasons that {you/SP} could not get the dental care {you/she/he} needed?

CODE ALL THAT APPLY

HAND CARD OHQ2

COULD NOT AFFORD THE COST 10

DID NOT WANT TO SPEND THE MONEY 11

INSURANCE DID NOT COVER
RECOMMENDED PROCEDURES 12

DENTAL OFFICE IS TOO FAR AWAY 13

DENTAL OFFICE IS NOT OPEN AT
CONVENIENT TIMES 14

ANOTHER DENTIST RECOMMENDED
NOT DOING IT 15

AFRAID OR DO NOT LIKE DENTISTS 16

UNABLE TO TAKE TIME OFF FROM
WORK 17

TOO BUSY 18

I DID NOT THINK ANYTHING SERIOUS
WAS WRONG/EXPECTED DENTAL
PROBLEMS TO GO AWAY 19

OTHER 20

REFUSED 77

DON'T KNOW 99

BOX 0

CHECK ITEM OHQ.550:

IF SP AGE <3, GO TO OHQ.845

IF SP AGE 3-15, CONTINUE.

ELSE IF SP AGE 16+ and OHQ.030 = 1 or 2, GO TO OHQ.610.

ELSE GO TO BOX 2.

OHQ.555
G/Q/U

We would like you to think of the time when {SP} started brushing {his/her} teeth either with your help or alone. At what age did {SP} start brushing {his/her} teeth?

|____|

ENTER AGE 1

HAS NOT STARTED BRUSHING TEETH 2 (OHQ.566)

REFUSED 7 (OHQ.566)

DON'T KNOW 9 (OHQ.566)

|___|___|

ENTER AGE IN MONTHS OR YEARS

REFUSED 7777 (OHQ.566)

DON'T KNOW 9999 (OHQ.566)

ENTER UNIT

MONTHS 1

YEARS 2

CAPI INSTRUCTION:

SOFT EDIT: OHQ.555 >SP’S AGE

ERROR MESSAGE: ‘AGE STARTED BRUSHING TEETH CANNOT BE OLDER THAN SP’S CURRENT AGE.’

OHQ.560
G/Q/U

At what age did {SP} start using toothpaste?

|____|

ENTER AGE 1

HAS NEVER USED TOOTHPASTE 2 (OHQ.566)

REFUSED 7 (OHQ.566)

DON'T KNOW 9 (OHQ.566)

|___|___|

ENTER age IN MONTHS OR YEARS

REFUSED 7777 (OHQ.566)

DON'T KNOW 9999 (OHQ.566)

ENTER UNIT

MONTHS 1

YEARS 2

CAPI INSTRUCTION:

SOFT EDIT: OHQ.560 >SP’S AGE

ERROR MESSAGE: ‘AGE STARTED USING TOOTHPASTE CANNOT BE OLDER THAN SP’S CURRENT AGE.’

OHQ.566 Has {SP} ever received prescription fluoride drops or fluoride tablets?

YES 1

NO 2 (BOX 1)

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

OHQ.571
Q/U

How old in months or years was {SP} when {he/she} started taking prescription fluoride drops or fluoride tablets?

|___|___|

ENTER AGE IN MONTHS OR YEARS

REFUSED 7777 (BOX 1)

DON'T KNOW 9999 (BOX 1)

ENTER UNIT

MONTHS 1

YEARS 2

CAPI INSTRUCTION:

SOFT EDIT: OHQ.571 >SP’S AGE

ERROR MESSAGE: ‘AGE STARTED TAKING FLUORIDE DROPS OR FLUORIDE TABLETS CANNOT BE OLDER THAN SP’S CURRENT AGE.’

OHQ.576
G/Q/U

How old in months or years was {SP} when {he/she} stopped taking prescription fluoride drops or fluoride tablets?

|____|

ENTER AGE 1

STILL TAKING FLUORIDE DROPS OR
TABLETS 2 (BOX 1)

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

|___|___|

ENTER age IN MONTHS OR YEARS

REFUSED 7777 (BOX 1)

DON'T KNOW 9999 (BOX 1)

ENTER UNIT

MONTHS 1

YEARS 2

CAPI INSTRUCTION:

SOFT EDIT: OHQ.576 >SP’S AGE

ERROR MESSAGE: ‘AGE STOPPED TAKING FLUORIDE DROPS OR TABLETS CANNOT BE OLDER THAN SP’S CURRENT AGE.’

IF ‘STILL TAKING FLUORIDE DROPS OR TABLETS SELECTED, FILL OHQ.576 Q/U WITH CURRENT AGE AND GO TO BOX 1.’

SOFT EDIT: OHQ.575 LESS THAN OHQ.571

ERROR MESSAGE: ‘AGE STOPPED TAKING FLUORIDE DROPS OR TABLETS CANNOT BE YOUNGER THAN AGE WHEN STARTED.’

BOX 1

CHECK ITEM OHQ.592:

IF SP AGE 3-15, GO TO OHQ.845.

OHQ.610 In the past 12 months, did a dentist, hygienist or other dental professional have a direct conversation with {you/SP} about…

… the benefits of giving up cigarettes or other types of tobacco to improve {your/SP’s} dental health?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.612 (In the past 12 months, did a dentist, hygienist or other dental professional have a direct conversation with {you/SP} about…)

… the dental health benefits of checking {your/his/her} blood sugar?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 2

CHECK ITEM OHQ.616:

IF SP AGE 0-2, GO TO OHQ.845.

IF SP AGE 3+, CONTINUE.

OHQ.620 How often during the last year {have you/has SP} had painful aching anywhere in {your/his/her} mouth? Would you say . . .

HAND CARD OHQ3

Very often, 1

Fairly often, 2

Occasionally, 3

Hardly ever, or 4

Never? 5

REFUSED 7

DON'T KNOW 9

NEW BOX

CHECK ITEM OHQ.NEW:

IF SP AGE 3-29, GO TO OHQ.845.

IF SP AGE 30+, CONTINUE.

OHQ.640 How often during the last year {have you/has SP} had difficulty doing {your/his/her} usual jobs or attending school because of problems with {your/his/her} teeth, mouth or dentures? Would you say . . .

HAND CARD OHQ3

VERY OFTEN, 1

FAIRLY OFTEN, 2

OCCASIONALLY, 3

HARDLY EVER, OR 4

NEVER? 5

REFUSED 7

DON'T KNOW 9

OHQ.835 The next questions will ask about the condition of {your/SP’s} teeth and some factors related to gum health.

Gum disease is a common problem with the mouth. People with gum disease might have swollen gums, receding gums, sore or infected gums or loose teeth. {Do you/Does SP} think {you/s/he} might have gum disease?

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.845 Overall, how would {you/SP} rate the health of {your/his/her} teeth and gums? Would you say . . .

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

REFUSED 7

DON’T KNOW 9

BOX 3

CHECK ITEM OHQ.846:

IF SP AGE 3-19, CONTINUE.

IF SP AGE >= 30, GO TO OHQ.850.

OTHERWISE, GO TO END OF SECTION.

OHQ.848 How many times {do you/does SP} brush (your/his/her} teeth in one day?

G/Q

|___|

ENTER NUMBER 1

CHILD DOES NOT BRUSH YET 2 (END OF SECTION)

DOES NOT BRUSH EVERY DAY 3 (OHQ.849)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

|___|

1 TIME 01

2 TIMES 02

3 TIMES 03

4 TIMES 04

5 TIMES 05

6 TIMES 06

7 TIMES 07

8 TIMES 08

9 OR MORE TIMES 09

REFUSED 77 (END OF SECTION)

DON’T KNOW 99 (END OF SECTION)

OHQ.849 On average, how much toothpaste {do you/does SP} use when brushing {your/his/her} teeth?

HAND CARD OHQ4

FULL LOAD 1 (END OF SECTION)

HALF LOAD 2 (END OF SECTION)

PEA SIZE 3 (END OF SECTION)

SMEAR 4 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

OHQ.850 {Have you/Has SP} ever had treatment for gum disease such as scaling and root planing, sometimes called deep cleaning?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.860 {Have you/Has SP} ever been told by a dental professional that {you/s/he} lost bone around {your/his/her} teeth?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OHQ.870 Aside from brushing {your/his/her} teeth with a toothbrush, in the last seven days, how many days did {you/SP} use dental floss or any other device to clean between {your/his/her} teeth?

HARD EDIT 0-7.

INTERVIEWER INSTRUCTION: CODE ‘0’ IF THE SP RESPONDS THAT THEY HAVE NO TEETH OR ONLY DENTURES. PLEASE DO NOT PUT INFORMATION ABOUT NO TEETH IN THE COMMENTS.

|___|

ENTER number of DAYS

REFUSED 77

DON'T KNOW 99

OHQ.880 In the past 12 months {Have you/Has SP} had an exam for oral cancer in which the doctor or dentist pulls your tongue, sometimes with gauze wrapped around it, and feels under the tongue and inside the cheeks?

YES 1 (END OF SECTION)

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

STANDING BALANCE – BAQ
TARGET GROUP: SPs 40+

BAQ.new1 The next questions are about dizziness sensations and difficulty with balance.

Have {you/SP} EVER had a problem with dizziness, light-headedness, feeling as if {you are/SP is} going to pass out or faint, or with unsteadiness or feeling off-balance?

Do not include times when drinking alcohol, using recreational drugs, or taking medications that cause dizziness.

YES…………………………………………………………………..……………………… 1

NO…………………………………………………………………..……………………….. 2

REFUSED…………………………………………………………………..………………. 77

Balance disorder or problem is a disturbance that causes an individual to feel unsteady when standing or walking. The individual experiences loss of equilibrium (balance) and may fall since she/he is unable to maintain a standing position, or walk, without support. .

Dizziness: A general descriptive term that includes various symptoms, such as vertigo (the illusion of a spinning, rocking, falling or other motion), or blurred vision when moving your head.

Light-headedness: a feeling that your sense of space is mildly distorted or not quite sharp, but not that you or objects around you are moving. With light-headedness, you may feel as if you are going to pass out or faint.

DON’T KNOW…………………………………………………………………..………… .. 99

This next question is about symptoms of dizziness, light-headedness, or balance problems. Please tell me if you have had any of these problems in the past 12 months. Please say yes or no to each.

Do not include times when drinking alcohol, using recreational drugs, or taking medications that cause dizziness.

BAQ.new2 … vertigo – a sensation of spinning, tilting, swaying or rocking of yourself or your surroundings?

[Help screen: Vertigo is an illusion of rotation, rocking, or other motion, such as riding a carousel.]

YES…………………………………………………………………..……………………… 1

NO…………………………………………………………………..……………………….. 2

REFUSED…………………………………………………………………..………………. 77

DON’T KNOW…………………………………………………………………..………….. 99

[READ (optional): This next question is about symptoms of dizziness, light-headedness, or balance problems. Please tell me if you have had any of these problems in the past 12 months. Please say yes or no to each.]

[READ (optional) Do not include times when drinking alcohol, using recreational drugs, or taking medications that cause dizziness.]

BAQ.new3 … blurring of your vision when you move your head?

YES…………………………………………………………………..……………………… 1

NO…………………………………………………………………..……………………….. 2

REFUSED…………………………………………………………………..………………. 77

DON’T KNOW…………………………………………………………………..………….. 99

[READ (optional): This question is about symptoms of dizziness, light-headedness, or balance problems. Please tell me if you have had any of these problems in the past 12 months. Please say yes or no to each.]

[READ (optional): Do not include times when drinking alcohol, using recreational drugs, or taking medications that cause dizziness.]

BAQ.new4 … unsteady – a feeling of being off-balance or not stable when standing or sitting upright?

YES…………………………………………………………………..……………………… 1

NO…………………………………………………………………..……………………….. 2

REFUSED…………………………………………………………………..………………. 77

DON’T KNOW…………………………………………………………………..………….. 99

[READ (optional): Do not include times when drinking alcohol, using recreational drugs, or taking medications that cause dizziness.]

BAQ.new5 … light-headed – a feeling your sense of space is mildly distorted, or not quite sharp, but not that you or objects around you are moving?

[Help screen: Without “a sense of motion” means NOT feeling like you are moving or that your space (room or other surroundings) is moving.]

YES…………………………………………………………………..……………………… 1

NO…………………………………………………………………..……………………….. 2

REFUSED…………………………………………………………………..………………. 77

DON’T KNOW…………………………………………………………………..………….. 99

[READ (optional): This question is about symptoms of dizziness or balance problems. Please tell me if you have had any of these problems in the past 12 months. Please say yes or no to each.]

[READ (optional): Do not include times when drinking alcohol, using recreational drugs, or taking medications that cause dizziness.]

BAQ.new6 … fainting – a feeling you are going to pass out or faint?

YES…………………………………………………………………..……………………… 1

NO…………………………………………………………………..……………………….. 2

REFUSED…………………………………………………………………..………………. 77

DON’T KNOW…………………………………………………………………..………….. 99

[READ (optional): Do not include times when drinking alcohol, using recreational drugs, or taking medications that cause dizziness.]

BAQ.new7 … disconnected – a detached, floating, or spacey sensation?

YES…………………………………………………………………..……………………… 1

NO…………………………………………………………………..……………………….. 2

REFUSED…………………………………………………………………..………………. 77

DON’T KNOW…………………………………………………………………..………….. 99

READ (optional): This next question is about symptoms of dizziness, light-headedness, or balance problems. Please tell me if you have had any of these problems in the past 12 months. Please say yes or no to each.]

[READ (optional): Do not include times when drinking alcohol, using recreational drugs, or taking medications that cause dizziness.]

BAQ.new8 …other – problems with balance, dizziness or light-headedness that are not well-described by the above list of symptoms?

YES…………………………………………………………………..……………………… 1

NO…………………………………………………………………..……………………….. 2

REFUSED…………………………………………………………………..………………. 77

DON’T KNOW…………………………………………………………………..………….. 99

Shape13

If none of the responses to the 7 questions (BAQ.new2–BAQ.new8) is “Yes”, GO TO BAQ.new28;

If only one response to the 7 questions, BAQ.new2–BAQ.new8, is “Yes”,

GO TO BAQnew10;

If more than one response is “Yes”, CONTINUE TO BAQ.new9

Potential BAQ.new9 response options will only be populated for symptoms with a “Yes” response recorded in questions BAQ.new2 to BAQ.new8

This next section focuses on {your/the SP’s} most bothersome symptom in the past 12 months.

BAQ.new9 During the past 12 months, which one of these problems with dizziness, balance, or light-headedness bothered {you/SP} the most?

vertigo: a sensation of spinning, tilting, swaying or rocking

of you or your surroundings ………………………………………….….…. 1

blurring of your vision when you move your head ………………..... 2

unsteady: a feeling of being off-balance or not stable

when standing or sitting upright ….………………………………..……… 3

light-headed: a feeling your sense of space is mildly distorted,

or not quite sharp, but not that you or objects around you are Moving.………………………………………………………………………………….. .. 4

fainting – a feeling you are going to pass out or faint …………. .. 5

disconnected: a detached, floating, or spacey sensation …….. .. 6

other: problems with balance, dizziness or light-headedness that

are not well-described by the above list of symptoms ………….. 7

REFUSED…………………………………………………………………..………………. 77 (GO TO BAQ.new15)

DON'T KNOW…………………………………………………………….………………... 99 (GO TO BAQ.new15)

BAQ.new10 About how old were {you/SP} when {FILL: most bothersome or only symptom} FIRST happened?

AGE IN YEARS ………………………………....………………………………………….. 001–120 REFUSED……………………………………………………………………………………. 777 (GO TO BAQ.new15)

DON'T KNOW…………………………………………………………………..…………… 999

BAQ.new11 During the past 12 months, how long from the beginning-to-end did each occurrence – episode, bout, or attack – of {your/SP’s} {FILL: most bothersome or only symptom} usually last?

Note: Do not include how long it takes to recover from accompanying conditions, such as nausea, vomiting, muscle weakness, etc.

LESS THAN 2 MINUTES ……………………………….…………………………………. 1

2 MINUTES TO LESS THAN 20 MINUTES ……………..………………………………. 2

20 MINUTES TO LESS THAN 8 HOURS …………………………………….…………. 3

8 HOURS TO LESS THAN 24 HOURS (ONE DAY) …………………………………… 4

1 DAY TO LESS THAN 14 DAYS (2 WEEKS) .……………………………................... 5

2 WEEKS TO LESS THAN 3 MONTHS …………………………………………………. 6

3 MONTHS OR LONGER ………………………..……………………………………...... 7

REFUSED……………………………………………………………………………………. 77 (GO TO BAQ.new15)

DON'T KNOW……………………………………………………………………………...... 99

BAQ.new12 During the past 12 months, about how often {have you/has SP} had the {FILL: most bothersome or only symptom}?

1 OR 2 TIMES IN THE PAST YEAR …..……………………………….………………… 1

3 TO 6 TIMES IN THE PAST YEAR …..………………………………………….……… 2

ABOUT ONCE A MONTH (7 TO 18 TIMES LAST YEAR) ………..………….……….. 3

2 TO 3 TIMES A MONTH …………………………………………………………………. 4

1 OR 2 TIMES A WEEK …...……………………………............................................... 5

3 TO 6 TIMES A WEEK .…………………………………………………………………... 6

1 OR 2 TIMES A DAY…………………………………………………………………….... 7

3 OR MORE TIMES A DAY ………………………..……………………………………... 8

ALMOST ALWAYS OR CONSTANTLY …………..……………………………………... 9 REFUSED………………………………………………………………………………….… 77 (GO TO BAQ.new15)

DON'T KNOW……………………………………………………………………………….. 99

BAQ.new13 During the past 12 months, were {your/SP’s} episodes for your {most bothersome or only symptom}

triggered by any of the following:

Read List (or Show Hand Card BAQ 1) and Mark all that apply:

GETTING UP AFTER SITTING OR LYING DOWN.……………………………………. 1

BENDING DOWN OR LEANING OVER……………………………..…………………... 2

LOOKING UP OR LEANING HEAD BACK ..……………………………….……………. 3

LOOKING AT MOVING OBJECTS – PASSING TRAFFIC OR A TRAIN..…………… 4

BEING IN A PLACE WITH A LOT OF PEOPLE MOVING AROUND ………………… 5

BEING IN WIDE-OPEN SPACES ………………………………………………………… 6

MOTION SICKNESS FROM RIDING IN A CAR OR MOVING VEHICLE …............... 7

QUICK HEAD MOVEMENT FROM SIDE-TO-SIDE ……………..…..………………… 8

ROLLING OVER IN BED ……….……………..…………………………………………... 9

STANDING ON YOUR FEET FOR A LONG TIME …………………………………….. 10

REFUSED……………………………………………………………………………………. 77 (GO TO BAQ.new15)

DON'T KNOW……………………………………………………………………………….. 99

BAQ.new14 During the past 12 months, were {your/SP’s} episodes for your {most bothersome or only symptom}

accompanied by any of the following:

[Help screen: “Accompanied by” means a few hours before, after, or at the same time as the episode.]

Read List (or Show Hand Card BAQ 2) and Mark all that apply:

NAUSEA OR VOMITING ………………………………………………………………….. 1

MIGRAINE OR SEVERE HEADACHE …..………………………………………………. 2

TINNITUS (RINGING, BUZZING OR ROARING IN EARS OR HEAD) ……………… 3

SINUS CONGESTION …………………………………………………………………….. 4

DEPRESSION ……………………………………………………………………………… 5

EAR FULLNESS, PRESSURE OR STUFFED-UP FEELING, WITHOUT PAIN ……. 6

HEARING TROUBLE (WORSE HEARING) …………………………………………….. 7

REFUSED……………………………………………………………………………………. 77

DON'T KNOW……………………………………………………………………………….. 99

BAQ.new15 During the past 12 months, {did your/SP’s} dizziness or balance problem(s) prevent {you/SP} from doing things you otherwise would do?

[Help screen: Time period involved is “at the time of the dizziness or balance problem or afterwards” – dizziness or balance problems can prevent normal activities, even if the dizziness or balance problem happened just once. Episodes that happen once may have either short-term or long-term effects. Both occur.]

YES…………………………………………………………………..………………………. 1

NO…………………………………………………………………..………………………… 2 (GO TO BAQ.new17)

REFUSED…………………………………………………………………..……………….. 77

DON’T KNOW…………………………………………………………………..…………… 99

BAQ.new16 During the past 12 months, did problems with balance, dizziness, or light-headedness prevent {you/SP} from doing any of the following?

Read List and Mark all that apply:

WORKING……………………………………………………………………………………. YES NO

ATTEND SCHOOL …….…………………………………………………………………… YES NO

ATTEND SOCIAL ACTIVITIES …………………………………………………………… YES NO

DRIVE OR RIDE IN A MOVING VEHICLE………………………………………………. YES NO

EXERCISE OR TAKE WALKS…………………………………………………………..… YES NO

READ WHILE SITTING AT REST……………………..………………………………..… YES NO

ROUTINE HOUSEHOLD CHORES (CLEANING, LAUNDRY, ETC.) ..…………….… YES NO

STAND ON YOUR FEET FOR 30 MINUTES OR LONGER…………………………… YES NO

WALK UP OR DOWN A FLIGHT OF STAIRS……………………………………….….. YES NO

REFUSED …………………………………………………………………………………… YES NO

DON'T KNOW ………………………………………………………………………….…… YES NO

BAQ.new17 During the past 12 months, how much of a problem was {your/his/her} problem with balance, dizziness, or light-headedness?

[Help screen: If respondent is unclear how to answer because episodes vary, then just ask the respondent to think about their typical episode to respond.]

NO PROBLEM …………………………………………… ………………………………… 1

A SMALL PROBLEM …………………………………………... ………………………….. 2

A MODERATE PROBLEM ……………………………………………………………….... 3

A BIG PROBLEM……………………….. ………………………………………………….. 4

A VERY BIG PROBLEM………………………………………. …………………………... 5

REFUSED………………………………………………………. …………………………… 77

DON'T KNOW………………………………………………... ……………………………... 99

Thinking of any time you have had symptoms of dizziness, imbalance, etc.

BAQ.new18 Have {you/SP} EVER seen a doctor or other health professional, including emergency room physicians, about {your/his/her} problem(s) with balance, dizziness, or light-headedness?

YES…………………………………………………………………..………………………. 1

NO…………………………………………………………………..………………………... 2 (GO TO BAQ.new24)

REFUSED…………………………………………………………………..……………….. 77 (GO TO BAQ.new24)

DON’T KNOW…………………………………………………………………..…………... 99 (GO TO BAQ.new24)

BAQ.new19 How long ago did {you/SP} FIRST see a doctor or other health professional, including emergency room physicians, about {your/his/her} problem(s) with balance, dizziness or light-headedness?

LESS THAN 3 MONTHS ……………………………….………………………................ 1

3 MONTHS TO LESS THAN 12 M0NTHS (1 YEAR) ....……………………………….. 2

1 YEAR TO LESS THAN 5 YEARS ……………………….…………………………..…. 3

5 YEARS TO LESS THAN 10 YEARS ……….……………………………………….…. 4

10 YEARS OR LONGER…………………………………………………………………... 5

REFUSED………………………………………………………………………………….… 77

DON'T KNOW………………………………………………………………………….……. 99

BAQ.new20 Did any doctors or health care professionals EVER tell {you/SP} the cause or give you a diagnosis for {your/SPs} problem(s) with balance, dizziness or light-headedness?

YES…………………………………………………………………..………… 1

NO…………………………………………………………………..…………… 2 (GO TO BAQ.new24)

REFUSED…………………………………………………………………..…… 77 (GO TO BAQ.new24)

DON’T KNOW………………………………………………………………….. 99 (GO TO BAQ.new24)

BAQ.new21 Did your doctor(s) or health care professional(s) tell {you/SP} the cause or causes of {your/his/her} problem(s) with balance, dizziness, or light-headedness was any of the following health conditions?

Read List (or Show Hand Card BAQ 3) and Mark all that apply:

ANEMIA………………………………………………………………………………………. 1

ANXIETY OR PANIC ATTACKS ................................................................................. 2

DIABETES ………………………………………………………………………………...... 3

HEART DISEASE…………………………………………………………………………… 4

HORMONAL CHANGES (INCLUDING PREGNANCY)………………………………… 5

LOW BLOOD PRESSURE OR HYPOTENSION ………………………………………. 6

LOW BLOOD SUGAR OR HYPOGLYCEMIA …………………………………………... 7

STROKE……………………………………………………………………………………… 8

NONE OF THESE…………………………………………………………………………… 9

REFUSED……………………………………………………………………………………. 77

DON'T KNOW…………………………………………………………………………..…… 99

BAQ.new22 Did your doctor(s) or health care professional(s) tell {you/SP} the cause or causes of {your/his/her} problems with balance, dizziness, or light-headedness was due to any of the following specific reasons?

Read List (or Show Hand Card BAQ 4) and Mark all that apply:

AUTO-IMMUNE DISEASE, SUCH AS RHEUMATOROID ARTHRITIS, LUPUS, SJOGREN’S ..1

BENIGN POSITIONAL VERTIGO (BPV OR BPPV)………………………………………………. 2

CRYSTALS—LOOSE OR DISLODGED IN EAR………………………………………………….. 3

HEAD OR NECK TRAUMA OR CONCUSSION…………………………………………………… 4

INNER EAR INFECTION, VIRAL LABRYNTHITIS………………………………………………… 5

MÉNIÈRE’S (Men-e-AIRZ) DISEASE ………………………………………………………………. 6

MIGRAINES OR HEADACHES....…………………………………………………………………… 7

NEUROLOGICAL CONDITION, SUCH AS MULTIPLE SCLEROSIS, PARKINSON’S……….. 8

SIDE EFFECTS FROM MEDICATIONS, SUCH AS CANCER TREATMENTS, ANTIBIOTICS. 9

NONE OF THESE……………………………………………………………………………………… 10

REFUSED………………………………………………………………………………………………. 777

DON'T KNOW………………………………………………………………………………………….. 999

BAQ.new23 {Have you/has SP} ever been treated by a doctor or other health professional for problem(s) with

balance, dizziness, or light-headedness?

YES ……………………………………………..………………………………………………. 1

NO TREATMENT WAS RECOMMENDED……….………………………………………… 2

NO, BECAUSE I DID NOT WANT TREATMENT………………………………………….. 3

REFUSED………………………………………………………………………………………. 77

DON'T KNOW………………………………………………………………………………….. 99

BAQ.new24 Have you ever tried anything to treat {your/SP’s} problem(s) with balance, dizziness, or light-headedness?

YES…………………………………………………………………..………………………….. 1

NO…………………………………………………………………..………………………….... 2 (GO TO BAQ.new27)

REFUSED…………………………………………………………………..…………………... 77

DON’T KNOW…………………………………………………………………..…………….... 99

BAQ.new25 During the past 5 years, {have you/has SP} had or tried any of the following to treat {your/his/her} problem(s) with balance, dizziness, or light-headedness? Please respond for ANY treatments you tried, whether recommended by a healthcare provider, friend or relative, or the internet.

Read List (or Show Hand Card BAQ 5) and Mark all that apply:

EXERCISES AT HOME, WHICH WERE NOT BEGUN IN A CLINIC …………………… 1

EXERCISES OR PHYSICAL THERAPY BEGUN IN A CLINIC …………………………. 2

BED REST FOR SEVERAL HOURS OR DAYS …………………………………………… 3

HEAD ROLLING OR EPLEY MANEUVER BY A DOCTOR OR THERAPIST………….. 4

STEROID INJECTIONS INTO THE EAR…………………………………………………… 5

GENTAMICIN (jen-tah-MI-sin) INJECTIONS INTO THE EAR……………………………. 6

PRESCRIPTION MEDICINES……………………………………………………………….. 7

PSYCHIATRIC OR PSYCHOLOGICAL TREATMENT……………………………………. 8

SURGERY TO THE EAR …………………………………………………………………..... 9

SOME OTHER TYPE OF SURGERY ………………………………………………………. 10

NONE OF THESE……………………………………………………………………………… 11

REFUSED………………………………………………………………………………………. 77

DON'T KNOW………………………………………………………………………………….. 99

BAQ.new26 During the past 5 years, {have you/has SP} had or tried any of the following alternative treatments for {your/his/her} problem(s) with balance, dizziness, or light-headedness? Please respond for ANY treatments you tried, whether recommended by a healthcare provider, friend or relative, or the internet.

Read List (or Show Hand Card BAQ 6) and Mark all that apply:

OVER-THE-COUNTER MEDICINES OR DRUGS ………………………………………….. 1

DIETARY RESTRICTIONS: LOW SALT DIET, AVOIDING CERTAIN FOODS OR DRINKS,

SUCH AS CHOCOLATE, COFFEE, OR ALCOHOL………………………………………... 2

QUITTING OR REDUCING USE OF TOBACCO OR CIGARETTES……………………… 3

MASSAGE THERAPY OR CHIROPRACTIC TREATMENTS OR MANIPULATIONS…… 4

HERBAL REMEDY: FEVERFEW LEAF, GINGER, GINKGO BILOBA, ETC……………… 5

WEARING MAGNETS OR ACUPRESSURE WRISTBAND………………………………… 6

COUNSELING OR STRESS MANAGEMENT……………………………………………….. 7

ACUPUNCTURE…………………………………………………………………………………. 8

NONE OF THESE………………………………………………………………………………... 9

REFUSED………………………………………………………………………………………… 77

DON'T KNOW……………………………………………………………………………………. 99

BAQ.new27 {Do you/does SP} regularly take medicine that makes (your/SP’s} problem(s) with balance, dizziness, or light-headedness worse?

YES…………………………………………………………………..……………………………. 1

NO…………………………………………………………………..……………………………... 2

REFUSED…………………………………………………………………..…………………….. 77

DON’T KNOW…………………………………………………………………..………………... 99

The next questions are about frequency of falling and associated injuries.

By “falling”, we mean unexpectedly or unintentionally dropping to a lower surface – the floor or ground– for example,

from a standing, seated, walking, or bending position.

[Help screen: A fall can be from any position]

BAQ.new28 During the past 5 years, how many times {have you/has SP} fallen?

NEVER …..………….……………………………………………………………… 1 (GO TO BAQ.new32)

1 OR 2 TIMES …..………….…………………………………. …………………… 2

3 TO 4 TIMES…..………….…………………………………. …………………… 3

ABOUT EVERY YEAR…..………….……………………………………………… 4

ABOUT EVERY MONTH …………………………………………………………… 5

ABOUT EVERY WEEK ……………………………………………………………… 6

DAILY OR CONSTANTLY …………………………………………………………… 7

REFUSED …………………………………………………………………………… 77(GO TO BAQ.new32)

DON'T KNOW ……………………………………………………………………… 99(GO TO BAQ.new32)

BAQ.new29 During the past 5 years, how often did any of {your/SP’s} falls occur just before or around the time {you, SP} were having problem(s) with balance, dizziness, or light-headedness?

NEVER OR RARELY …………………………………………………………………………… 1

SOMETIMES ……………………………………………………………………………………… 2

ABOUT HALF THE TIME ………………………………………………………………………... 3

ALMOST ALWAYS OR ALWAYS ………………………………………………………………. 4

REFUSED …………………………………………………………………………………………. 77

DON'T KNOW …………………………………………………………………………………….. 99

BAQ.new30 During the past 12 months, how many times {have you/has SP} fallen?

NEVER ……………………………………………………………………………………………. 1

1 OR 2 TIMES ……………………………………………………………………………………. 2

3 TO 4 TIMES …………………………………………………………………………………….. 3

5 TO 9 TIMES …………………………………………………………………………………….. 4

10 OR MORE TIMES …………………………………………………………………………….. 5

REFUSED…………………………………………………………………………………………. 77

DON'T KNOW ……………………………………………………………………………………... 99

BAQ.new31 During the past 12 months, did {you/SP} have an injury that resulted from falling?

Note: Injuries include cuts or wounds, dislocation of joints, fractures or broken bones, pain, ache or strain to the spine or back, head or neck injury, sprain or torn ligament or muscle, and swelling or bruising.

YES…………………………………………………………………..……………………………. 1

NO…………………………………………………………………..……………………………... 2

REFUSED…………………………………………………………………..…………………….. 77

DON’T KNOW…………………………………………………………………..………………... 99

BAQ.new32 During the past 12 months, how many times {have you/has SP} tripped or slipped, losing {your/his/her} balance, but were able to regain balance before/without falling?

NEVER ……………………………………………………………………………………………. 1

1 OR 2 TIMES ……………………………………………………………………………………. 2

3 TO 4 TIMES …………………………………………………………………………………….. 3

5 TO 9 TIMES …………………………………………………………………………………….. 4

10 OR MORE TIMES ……………………………………………………………………………... 5

REFUSED …………………………………………………………………………………………. 77

DON'T KNOW …………………………………………………………………………………….. 99

BAQ.new33 {Have you/Has SP} ever had any of the following health problems?

Read List (or Show Hand Card BAQ 7) and Mark all that apply:

ANXIETY OR PANIC ATTACKS……………………………………….…………………………. 1

AUTO-IMMUNE DISEASE, SUCH AS RHEUMATOROID ARTHRITIS, LUPUS, SJOGREN’S… 2

COGNITIVE PROBLEMS, SUCH AS MEMORY, ATTENTION, LEARNING………………… 3

DEPRESSION ………………………………………………………………………………………. 4

HEAD INJURY OR CONCUSSION ………………………………………………………………. 5

HEART RYTHEM PROBLEMS OR HEART FAILURE ………………………………………… 6

MIGRAINE(S) OR SEVERE HEADACHES……………………………………………………… 7

NUMBNESS IN THE HANDS OR FEET LASTING DAYS OR LONGER …………………… 8

NEUROLOGICAL DISORDER, SUCH AS PARKINSON’S, MULTIPLE SCHEROSIS SEIZURES.. 9

VISUAL DISTURBANCES, SUCH AS DOUBLE VISION, OR EXTREME LIGHT SENSITIVITY….. 10

NO—NONE OF THESE …………………………………………………………………………… 11

REFUSED…………………………………………………………………………….……….…….. 77

DON'T KNOW ………………………………………………………………………………………. 99

PHYSICAL ACTIVITY AND PHYSICAL FITNESS – PAQ

Target Group: SPs 2+

BOX 1

CHECK ITEM PAQ.700:

IF SP AGE 2-11 OR 16-17, GO TO PAQ706.

IF SP AGE <2 OR SP 12-15, GO TO NEXT SECTION.

IF SP AGE 18+, CONTINUE.

PAQ.605 Next I am going to ask you about the time {you spend/SP spends} doing different types of physical activity in a typical week.

Think first about the time {you spend/he spends/she spends} doing work. Think of work as the things that {you have/he has/she has} to do such as paid or unpaid work, household chores, and yard work.

Does {your/SP’s} work involve vigorous-intensity activity that causes large increases in breathing or heart rate like carrying or lifting heavy loads, digging or construction work for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.620)

REFUSED 7 (PAQ.620)

DON'T KNOW 9 (PAQ.620)

PAQ.610 In a typical week, on how many days {do you/does SP} do vigorous-intensity activities as part of {your/his/her} work?

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES IN THIS QUESTION.

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.620)

DON'T KNOW 99 (PAQ.620)

PAQ.615 How much time {do you/does SP} spend doing vigorous-intensity activities at work on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when {you do/he does/she does} vigorous-intensity activities during {your/his/her} work.

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING VIGOROUS-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.620)

DON'T KNOW 9999 (PAQ.620)

ENTER UNIT

MINUTES 1

HOURS 2

PAQ.620 Does {your/SP’s} work involve moderate-intensity activity that causes small increases in breathing or heart rate such as brisk walking or carrying light loads for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.635)

REFUSED 7 (PAQ.635)

DON'T KNOW 9 (PAQ.635)

PAQ.625 In a typical week, on how many days {do you/does SP} do moderate-intensity activities as part of {your/his/her} work?

PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.635)

DON'T KNOW 99 (PAQ.635)

PAQ.630 How much time {do you/does SP} spend doing moderate-intensity activities at work on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when {you do/he does/she does} moderate-intensity activities during {your/his/her} work.

PROBE IF NEEDED: Moderate-intensity activity causes small increases in breathing or heart rate and is done for at least 10 minutes continuously.

INTERVIEWER: REMEMBER, WE ARE ONLY ASKING ABOUT WORK AND CHORES.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING MODERATE-INTENSITY ACTIVITIES AT WORK ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.635)

DON'T KNOW 9999 (PAQ.635)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

PAQ.635 The next questions exclude the physical activities at work that you have already mentioned. Now I would like to ask you about the usual way {you travel/SP travels} to and from places. For example to work, for shopping, to school.

In a typical week {do you/does SP} walk or use a bicycle for at least 10 minutes continuously to get to and from places?

YES 1

NO 2 (PAQ.650)

REFUSED 7 (PAQ.650)

DON'T KNOW 9 (PAQ.650)

PAQ.640 In a typical week, on how many days {do you/does SP} walk or bicycle for at least 10 minutes continuously to get to and from places?

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.650)

DON'T KNOW 99 (PAQ.650)

PAQ.645 How much time {do you/does SP} spend walking or bicycling for travel on a typical day?

Q/U

PROBE IF NEEDED: Think about a typical day when {you walk or bicycle/SP walks or bicycles} for travel.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS WALKING OR BICYCLING TO GET TO AND FROM PLACES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.650)

DON'T KNOW 9999 (PAQ.650)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

PAQ.650 The next questions exclude the work and transportation activities that you have already mentioned. Now I would like to ask you about sports, fitness and recreational activities.

In a typical week {do you/does SP} do any vigorous-intensity sports, fitness, or recreational activities that cause large increases in breathing or heart rate like running or basketball for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.665)

REFUSED 7 (PAQ.665)

DON'T KNOW 9 (PAQ.665)

PAQ.655 In a typical week, on how many days {do you/does SP} do vigorous-intensity sports, fitness or recreational activities?

PROBE IF NEEDED: Vigorous-intensity activity causes large increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.665)

DON'T KNOW 99 (PAQ.665)

PAQ.660
Q/U

How much time {do you/does SP} spend doing vigorous–intensity sports, fitness or recreational activities on a typical day?

PROBE IF NEEDED: Think about a typical day when {you do/SP does} vigorous-intensity sports, fitness or recreational activities.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING VIGOROUS-INTENSITY RECREATIONAL ACTIVITIES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.665)

DON'T KNOW 9999 (PAQ.665)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

PAQ.665 In a typical week {do you/does SP} do any moderate-intensity sports, fitness, or recreational activities that cause a small increase in breathing or heart rate such as brisk walking, bicycling, swimming, or golf for at least 10 minutes continuously?

YES 1

NO 2 (PAQ.680)

REFUSED 7 (PAQ.680)

DON'T KNOW 9 (PAQ.680)

PAQ.670 In a typical week, on how many days {do you/does SP} do moderate-intensity sports, fitness or recreational activities?

PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.

HARD EDIT: 1-7.

ERROR MESSAGE: THE NUMBER OF DAYS SHOULD BE BETWEEN 1 AND 7.

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77 (PAQ.680)

DON'T KNOW 99 (PAQ.680)

PAQ.675
Q/U

How much time {do you/does SP} spend doing moderate-intensity sports, fitness or recreational activities on a typical day?

PROBE IF NEEDED: Think about a typical day when {you do/SP does} moderate-intensity sports, fitness or recreational activities.

PROBE IF NEEDED: Moderate-intensity sports, fitness or recreational activities cause small increases in breathing or heart rate and is done for at least 10 minutes continuously.

SOFT EDIT: >4 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 4 HOURS DOING MODERATE-INTENSITY RECREATIONAL ACTIVITIES ON A TYPICAL DAY. PLEASE CONFIRM WITH SP THAT OVER 4 HOURS IS CORRECT.

HARD EDIT: >24 HOURS.

HARD EDIT: <10 MINUTES.

ERROR MESSAGE: THE TIME SHOULD BE 10 MINUTES OR MORE, BUT LESS THAN 24 HOURS.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.680)

DON'T KNOW 9999 (PAQ.680)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

PAQ.680
Q/U

The following question is about sitting at work, at home, getting to and from places, or with friends, including time spent sitting at a desk, traveling in a car or bus, reading, playing cards, watching television, or using a computer. Do not include time spent sleeping.

How much time {do you/does SP} usually spend sitting on a typical day?

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (BOX 2)

DON'T KNOW 9999 (BOX 2)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

SOFT EDIT: 18 HOURS OR MORE.

ERROR MESSAGE: PLEASE VERIFY TIMES OF 18 HOURS OR MORE.

HARD EDIT: 24 HOURS OR MORE.

ERROR MESSAGE: THE TIME SHOULD BE LESS THAN 24 HOURS.

BOX 2

CHECK ITEM PAQ.720:

IF SP AGE 18+, GO TO NEXT SECTION.

PAQ.706 Now I'd like to ask you some questions about {your/SP's} activities.

During the past 7 days, on how many days {were you/was SP} physically active for a total of at least 60 minutes per day? Add up all the time {you/he/she} spent in any kind of physical activity that increased {your/his/her} heart rate and made {you/him/her} breathe hard some of the time.

0 days 0

1 day 1

2 days 2

3 days 3

4 days 4

5 days 5

6 days 6

7 days 7

REFUSED 77

DON’T KNOW 99

PAQ.New1 On a typical day during the school year, about how many hours {do you/does SP} usually spend playing with a smartphone or computer, watching TV or movies, or playing video games?

|___|___|

ENTER NUMBER OF HOURS

REFUSED 77

DON'T KNOW 99

SOFT EDIT: 18 HOURS OR MORE.

ERROR MESSAGE: PLEASE VERIFY TIMES OF 18 HOURS OR MORE.

HARD EDIT: 24 HOURS OR MORE.

ERROR MESSAGE: THE TIME SHOULD BE LESS THAN 24 HOURS.

SLEEP DISORDERS – SLQ

Target Group: 16+

SLQ.300

The next set of questions is about {your/SP’s} sleep and work behavior.

What time {do you/does SP} usually fall asleep on weekdays or workdays?

|__|__| : |__|__| ENTER AM OR PM

HH MM

INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS INTO BED. ENTER TIME AS HH:MM AM OR PM. IF RESPONDENT SAYS TWELVE “MIDNIGHT” CODE AS 12:00 AM.

REFUSED 77777777

DON'T KNOW 99999999

SLQ.310

What time {do you/does SP} usually wake up on weekdays or workdays?

|__|__| : |__|__| ENTER AM OR PM

HH MM

INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS OUT OF BED. ENTER TIME AS HH:MM AM OR PM.

REFUSED 77777777

DON'T KNOW 99999999

CAPI INSTRUCTION:

SOFT EDIT: LESS THAN 4 HOURS OR MORE THAN 12 HOURS OF TOTAL SLEEP. IF SLQ.300 OR 310 IS DK OR RF, DO NOT APPLY SOFT EDIT.

ERROR MESSAGE: PLEASE VERIFY SLEEP TIMES OF LESS THAN 4 HOURS OR MORE THAN 12 HOURS.

SLQ.320 What time {do you/does SP} usually fall asleep on weekends or non-workdays?

|__|__| : |__|__| ENTER AM OR PM

HH MM

INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS INTO BED.

INTERVIEWER INSTRUCTION: ENTER TIME AS HH:MM AM OR PM. IF RESPONDENT SAYS TWELVE “MIDNIGHT” CODE AS 12:00 AM.

INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS DOES NOT WORK, ASK IF THE TIME THAT THE RESPONDENT FALLS ASLEEP IS DIFFERENT ON WEEKENDS. IF NOT, ENTER SAME TIME AS SLQ.300.

REFUSED 77777777

DON'T KNOW 99999999

SLQ.330 What time {do you/does SP} usually wake up on weekends or non-workdays?

|__|__| : |__|__| ENTER AM OR PM

HH MM

INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS OUT OF BED.

INTERVIEWER INSTRUCTION: ENTER TIME AS HH:MM AM OR PM.

REFUSED 77777777

DON'T KNOW 99999999

INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS DOES NOT WORK, ASK IF THE TIME THAT THE RESPONDENT WAKES UP IS DIFFERENT ON WEEKENDS. IF NOT, ENTER SAME TIME AS SLQ.310.

CAPI INSTRUCTION:

SOFT EDIT: LESS THAN 4 HOURS OR MORE THAN 12 HOURS OF TOTAL SLEEP. IF SLQ.320 OR 330 IS DK OR RF, DO NOT APPLY SOFT EDIT.

ERROR MESSAGE: PLEASE VERIFY SLEEP TIMES OF LESS THAN 4 HOURS OR MORE THAN 12 HOURS.

SLQ.030 In the past 12 months, how often did {you/SP} snore while {you were/s/he was} sleeping?

INTERVIEWER INSTRUCTION: IF R SAYS “DON’T KNOW”, PROBE IF ANYONE HAS TOLD THEM THAT THEY SNORE.

Never, 0

Rarely – 1-2 nights a week, 1

Occasionally – 3-4 nights a week, or 2

Frequently – 5 or more nights a week? 3

REFUSED 7

DON’T KNOW 9

SLQ.040 In the past 12 months, how often did {you/SP} snort, gasp, or stop breathing while {you were/s/he was} asleep?

INTERVIEWER INSTRUCTION: IF THE RESPONDENT ASKS “HOW WOULD I KNOW IF I SNORT, GASP OR STOP BREATHING WHEN I AM SLEEPING? PROBE IF ANYONE TOLD THEM THAT THEY DO THIS.

Never, 0

Rarely – 1-2 nights a week, 1

Occasionally – 3-4 nights a week, or 2

Frequently – 5 or more nights a week? 3

REFUSED 7

DON’T KNOW 9

SLQ.050 {Have you/Has SP} ever told a doctor or other health professional that {you have/s/he has} trouble sleeping?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SLQ.120 In the past month, how often did {you/SP} feel excessively or overly sleepy during the day?

HAND CARD SLQ1

NEVER 0

RARELY – 1 TIME A MONTH 1

SOMETIMES – 2-4 TIMES A MONTH 2

OFTEN – 5-15 TIMES A MONTH 3

ALMOST ALWAYS – 16-30 TIMES A
MONTH 4

REFUSED 7

DON’T KNOW 9

DIET BEHAVIOR AND NUTRITION - DBQ

Target Group: SPs Birth + (Questions grouped by age categories)

BOX 1

CHECK ITEM DBQ.005:

IF SP AGE <= 6, CONTINUE.

OTHERWISE, GO TO BOX 2.

DBQ.010 Now I'm going to ask you some general questions about {SP's} eating habits.

Was {SP} ever breastfed or fed breastmilk?

YES 1

NO 2 (DBQ.041)

REFUSED 7 (DBQ.041)

DON'T KNOW 9 (DBQ.041)

DBQ.030
G/Q/U

How old was {SP} when {he/she} completely stopped breastfeeding or being fed breastmilk?

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN MONTHS IS ALLOWED.

|___|

ENTER NUMBER 1

STILL BREASTFEEDING 2 (DBQ.New1)

REFUSED 7 (DBQ.041)

DON'T KNOW 9 (DBQ.041)

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.041)

DON'T KNOW 999999 (DBQ.041)

ENTER UNIT (DBQ.041)

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DBQ.New1 Some children might drink breast milk from a bottle, cup (including sippy cup), or spoon as well as at the breast. How was {SP} drinking breast milk in the past 2 weeks?

Only at the breast, 1

At the breast and also from a bottle, cup, or spoon, or 2

Only from a bottle, cup, or spoon 3

REFUSED 7

DON'T KNOW 9

DBQ.041
G/Q/U

How old was {SP} when {he/she} was first fed formula?

|___|

ENTER NUMBER 1

NEVER 2 (Box 1a)

REFUSED 7 (DBQ.050)

DON'T KNOW 9 (DBQ.050)

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN MONTHS IS ALLOWED.

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.050)

DON'T KNOW 999999 (DBQ.050)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DBQ.050
G/Q/U

How old was {SP} when {he/she} completely stopped drinking formula?

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN MONTHS IS ALLOWED.

|___|

ENTER NUMBER 1

STILL DRINKING FORMULA 2 (Box 1a)

REFUSED 7 (Box 1a)

DON'T KNOW 9 (Box 1a)

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (Box 1a)

DON'T KNOW 999999 (Box 1a)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

BOX 1a

CHECK ITEM DBQ.New0a:

IF SP AGE ≥ 24 MONTH, GO TO DBQ055,

ELSE IF DBQ030≠2 AND DBQ050≠2, GO TO DBQ055,

ELSE IF DBQ.New1=1 AND DBQ050≠2, GO TO DBQ055,

ELSE IF DBQ010=2 AND DBQ050=2, GO TO BOX 1c,

ELSE, IF DBQ.New1≠1 AND DBQ050=2, CONTINUE,

ELSE, GO TO BOX1b.

DBQ.New2 In the past 2 weeks, was {SP} fed formula mixed with breast milk in the same bottle?

YES 1

NO 2 (BOX 1b)

REFUSED 7 (BOX 1b)

DON'T KNOW 9 (BOX 1b)

DBQ.New3 How were the formula and breast milk usually mixed?

Added formula powder to breast milk, 1

Added prepared (mixed up) formula or

ready-to-feed formula to breast milk, or 2

Added liquid formula concentrate

to breast milk 3

REFUSED 7

DON'T KNOW 9

BOX 1b

CHECK ITEM DBQ.New0b:

IF DBQ030≠2 OR DBQ.New1=1, GO TO DBQ.New5,

ELSE CONTINUE.

DBQ.New4 In the past 2 weeks, how often was water added to breast milk before feeding it to {SP}?

HAND CARD DBQ1

NEVER, 1

RARELY, 2

EVERY FEW DAYS, 3

ABOUT ONCE A DAY, 4

AT MOST FEEDINGS, OR 5

EVERY FEEDING? 6

REFUSED 7

DON'T KNOW 9

BOX 1c

CHECK ITEM DBQ.New0c:

IF DBQ.New1≠1 AND DBQ050≠2, GO TO DBQ.New6,

ELSE CONTINUE.

DBQ.New5 In the past 2 weeks, how often did you add more water to the formula than the instructions on the package say?

HAND CARD DBQ1

INTERVIEWER INSTRUCTION: IF THE RESPONDENT WAS NOT SURE WHETHER THE PACKAGE INSTRUCTIONS WERE FOLLOWED, ENTER DON’T KNOW.

NEVER, 1

RARELY, 2

EVERY FEW DAYS, 3

ABOUT ONCE A DAY, 4

AT MOST FEEDINGS, OR 5

EVERY FEEDING? 6

DOES NOT PREPARE FORMULA 7

REFUSED 77

DON'T KNOW 99

DBQ.New6 In the past 2 weeks, was baby cereal added to {SP}’s bottle of formula or breast milk?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.New7 In the past 2 weeks, was a sweetener, such as juice, honey, sugar, or flavored beverage, added to {SP}’s bottle of formula or breast milk?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.New8 In the past 2 weeks, were vitamins or minerals added to {SP}’s bottle of formula or breast milk?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.New9 In the past 30 days, was medicine such as acetaminophen, ibuprofen, gas drops, colic drops, or antibiotics added to {SP}’s bottle of formula or breast milk?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.055
G/Q/U

This next question is about the first thing that {SP} was given other than breast milk or formula. Please include juice, cow’s milk, sugar water, baby food, or anything else that {SP} might have been given, even water.

How old was {SP} when {he/she} was first fed anything other than breast milk or formula?

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN MONTHS IS ALLOWED.

INTERVIEWER INSTRUCTION:

DO NOT COUNT MEDICATIONS, VITAMIN DROPS, OR SMALL AMOUNT OF WATER THAT WAS USED FOR ORAL HYGIENE PURPOSES.

|___|

ENTER NUMBER 1

NEVER 2 (BOX 2)

REFUSED 7 (BOX 1d)

DON'T KNOW 9 (BOX 1d)

|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.061)

DON'T KNOW 999999 (DBQ.061)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DBQ.061
G/Q/U

How old was {SP} when {he/she} was first fed milk?

INCLUDE LACTAID AS MILK.

DO NOT INCLUDE BREASTMILK OR FORMULA.

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN MONTHS IS ALLOWED.

|___|

ENTER NUMBER 1

NEVER 2 (BOX 1d)

REFUSED 7 (DBQ.073)

DON'T KNOW 9 (DBQ.073)

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.073)

DON'T KNOW 999999 (DBQ.073)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

HELP SCREEN:

Lactaid: A modified milk product that is often consumed by individuals who have lactose intolerance. Lactaid can be purchased in various forms (i.e., 2%, skim, etc.). If respondent does not give type, probe for type (i.e., was that Lactaid regular, 2%, 1% or skim?).

Formula: A milk mixture or milk substitute that is fed to babies.

DBQ.073 What type of milk was {SP} first fed? Was it . . .

CODE ALL THAT APPLY

whole or regular, 10

2% fat or reduced-fat milk, 11

1% fat or low-fat milk (includes 0.5% fat

milk or “low-fat milk” not further specified), 12

fat-free, skim or nonfat milk, 13

soy milk, or 14

another type? 30

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

BOX 1d

CHECK ITEM DBQ.New0d:

IF SP AGE ≥ 24 MONTH, GO TO BOX 2,

ELSE, CONTINUE.

DBQ.New10 How old was {SP} when {he/she} was first fed grains, such as cereal, puffs, teething biscuits, crackers, bread, pasta, or rice? Include baby cereal added to a bottle.

HAND CARD DBQ2

NEVER 1

0-3 MONTHS 2

4-5 MONTHS 3

6-7 MONTHS 4

8-9 MONTHS 5

10-11 MONTHS 6

12 MONTHS OR OLDER 7

REFUSED 77

DON'T KNOW 99

DBQ.New11 How old was {SP} when {he/she} was first fed a vegetable, including jarred baby food or cooked, pureed, cut up or mashed vegetables, or vegetable juice?

HAND CARD DBQ2

NEVER 1

0-3 MONTHS 2

4-5 MONTHS 3

6-7 MONTHS 4

8-9 MONTHS 5

10-11 MONTHS 6

12 MONTHS OR OLDER 7

REFUSED 77

DON'T KNOW 99

DBQ.New12 How old was {SP} when {he/she} was first fed a fruit including jarred baby food or cooked, pureed, cut up, or mashed fruits or fruit juice?

HAND CARD DBQ2

NEVER 1

0-3 MONTHS 2

4-5 MONTHS 3

6-7 MONTHS 4

8-9 MONTHS 5

10-11 MONTHS 6

12 MONTHS OR OLDER 7

REFUSED 77

DON'T KNOW 99

DBQ.New13 How old was {SP} when {he/she} was first fed dairy products other than milk, such as yogurt, cottage cheese, or cheese?

HAND CARD DBQ2

NEVER 1

0-3 MONTHS 2

4-5 MONTHS 3

6-7 MONTHS 4

8-9 MONTHS 5

10-11 MONTHS 6

12 MONTHS OR OLDER 7

REFUSED 77

DON'T KNOW 99

DBQ.New14 How old was {SP} when {he/she} was first fed an egg, meat, poultry, or seafood (for example, beef, pork, chicken, turkey, sausage, fish, eggs)?

HAND CARD DBQ2

NEVER 1

0-3 MONTHS 2

4-5 MONTHS 3

6-7 MONTHS 4

8-9 MONTHS 5

10-11 MONTHS 6

12 MONTHS OR OLDER 7

REFUSED 77

DON'T KNOW 99

DBQ.New15 How old was {SP} when {he/she} was first fed legumes, such as black beans, kidney beans, pinto beans or lentils?

HAND CARD DBQ2

INTERVIEWER INSTRUCTION: INCLUDE SPLIT PEAS, CHICKPEAS, HUMMUS. DO NOT INCLUDE GREEN PEAS, GREEN BEANS, OR OTHER VEGETABLES THAT ARE NOT LEGUMES.

NEVER 1

0-3 MONTHS 2

4-5 MONTHS 3

6-7 MONTHS 4

8-9 MONTHS 5

10-11 MONTHS 6

12 MONTHS OR OLDER 7

REFUSED 77

DON'T KNOW 99

DBQ.New16 How old was {SP} when {he/she} was first fed soy products such as tofu, soy beans, meat substitutes made with soy, or other foods prepared with soy ingredients?

HAND CARD DBQ2

NEVER 1

0-3 MONTHS 2

4-5 MONTHS 3

6-7 MONTHS 4

8-9 MONTHS 5

10-11 MONTHS 6

12 MONTHS OR OLDER 7

REFUSED 77

DON'T KNOW 99

DBQ.New17 How old was {SP} when {he/she} was first fed nuts or seeds, such as peanuts or peanut butter, almonds, or other nut or seed products? On this card are other examples.

HAND CARDS DBQ2 AND DBQ3

INTERVIEWER INSTRUCTION: INCLUDE ALMOND MILK

NEVER 1

0-3 MONTHS 2

4-5 MONTHS 3

6-7 MONTHS 4

8-9 MONTHS 5

10-11 MONTHS 6

12 MONTHS OR OLDER 7

REFUSED 77

DON'T KNOW 99

BOX 2

CHECK ITEM DBQ.085:

IF SP AGE >= 16, CONTINUE.

IF SP AGE <16 BUT >= 1, GO TO DBQ.197.

OTHERWISE, GO TO FSQ.653.

DBQ.700 Next I have some questions about {your/SP’s} eating habits.

In general, how healthy is {your/his/her} overall diet? Would you say . . .

excellent, 1

very good, 2

good, 3

fair, or 4

poor? 5

REFUSED 7

DON'T KNOW 9

BOX 3

OMITTED

BOX 4

OMITTED

DBQ.197 {Next I have some questions about {SP’s} eating habits.}

{First/Next}, I’m going to ask a few questions about milk products. Do not include their use in cooking.

In the past 30 days, how often did {you/SP} have milk to drink or on {your/his/her} cereal? Please include chocolate and other flavored milks as well as hot cocoa made with milk. Do not count small amounts of milk added to coffee or tea. Would you say . . .

HAND CARD DBQ4

INTERVIEWER INSTRUCTION: INCLUDE ALL TYPES OF MILK (FOR EXAMPLE, LACTAID AND OTHER LACTOSE-FREE MILKS; SOY MILK, ALMOND MILK, RICE MILK, COCONUT MILK, EVAPORATED MILK, ETC.)

CAPI INSTRUCTION:

THIS SHOULD NOT BE A GATE QUESTION ANYMORE.

CAPI DISPLAY INSTRUCTIONS: IF SP AGE 7-15 YEARS OLD, DISPLAY “{Next I have some questions about {SP’s} eating habits.} First, I’m going to ask about milk products. Do not include their use in cooking.” IF SP AGE <= 6 OR => 16 YEARS OLD, DISPLAY “Next I’m going to ask a few questions about milk products. Do not include their use in cooking.”

never, 0 (BOX 6)

rarely – less than once a week, 1

sometimes – once a week or more, but

less than once a day, or 2

often – once a day or more? 3

VARIED 4

REFUSED 7 (BOX 6)

DON'T KNOW 9 (BOX 6)

DBQ.223 What type of milk was it? Was it usually . . .

INTERVIEWER INSTRUCTION: IF LACTAID OR ANOTHER TYPE OF LACTOSE-FREE MILK IS REPORTED, ASK WHETHER IT WAS WHOLE/REGULAR, 2%, 1%, FAT FREE/SKIM. ENTER OTHER TYPES OF MILK (ALMOND, RICE, COCONUT MILK, ETC.) AS “ANOTHER TYPE”.

IF RESPONDENT CANNOT PROVIDE USUAL TYPE, CODE ALL THAT APPLY.

whole or regular, 10

2% fat or reduced-fat milk, 11

1% fat or low-fat milk (includes 0.5% fat

milk or “low-fat milk” not further specified), 12

fat-free, skim or nonfat milk, 13

soy milk, or 14

another type? 30

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

BOX 6

CHECK ITEM DBQ.225:

IF SP AGE >= 20, CONTINUE.

OTHERWISE, GO TO BOX 9.

DBQ.229 The next question is about regular milk use.

A regular milk drinker is someone who uses any type of milk at least 5 times a week. Using this definition, which statement best describes {you/SP}?

HAND CARD DBQ5

{I've/He's/She's} been a regular milk

drinker for most or all of {my/his/her}

life, including {my/his/her} childhood. 1

{I've/He's/She's} never been a regular

milk drinker. 2 (BOX 8A)

{My/His/Her} milk drinking has varied over

{my/his/her} life – sometimes {I've/he's/

she's} been a regular milk drinker and

sometimes {I have/he has/she has} not

been a regular milk drinker. 3

REFUSED 7 (BOX 8A)

DON'T KNOW 9 (BOX 8A)

DBQ.235
a/b/c

Now, I’m going to ask you how often {you/SP} drank milk at different times in {your/his/her} life.

How often did {you/SP} drink any type of milk, including milk added to cereal, when {you were/s/he was} . . .

HAND CARD DBQ6

IF NECESSARY, PROBE FOR USUAL OR MOST COMMON AMOUNT FOR THIS TIME PERIOD.

CAPI INSTRUCTION:

THESE (A-C) SHOULD NOT BE GATE QUESTIONS ANYMORE.

a. a child between the ages of 5 and 12 years old? Would you say. . .

never, 0

rarely – less than once a week, 1

sometimes – once a week or more, but

less than once a day, or 2

often – once a day or more? 3

VARIED 4

REFUSED 7

DON'T KNOW 9

b. a teenager between the ages of 13 and 17 years old? Would you say . . .

NEVER, 0

RARELY – LESS THAN ONCE A WEEK, 1

SOMETIMES – ONCE A WEEK OR MORE,

BUT LESS THAN ONCE A DAY, OR 2

OFTEN – ONCE A DAY OR MORE? 3

VARIED 4

REFUSED 7

DON'T KNOW 9

c. a young adult between the ages of 18 and 35 years old? Would you say . . .

NEVER, 0

RARELY – LESS THAN ONCE A WEEK, 1

SOMETIMES – ONCE A WEEK OR MORE,

BUT LESS THAN ONCE A DAY, OR 2

OFTEN – ONCE A DAY OR MORE? 3

VARIED 4

REFUSED 7

DON'T KNOW 9

BOX 8A

CHECK ITEM DBQ.265A:

IF SP AGE >= 60, CONTINUE.

OTHERWISE, GO TO BOX 15.

DBQ.301 The next questions are about meals provided by community or government programs.

In the past 12 months, did {you/SP} receive any meals delivered to {your/his/her} home from community programs, “Meals on Wheels”, or any other programs?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

DBQ.330 In the past 12 months, did {you/SP} go to a community program or senior center to eat prepared meals?

INCLUDE ADULT DAY CARE

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 8B

CHECK ITEM DBQ.335:

GO TO BOX 15.

BOX 9

CHECK ITEM DBQ.355:

IF SP AGE 4-19, CONTINUE.

OTHERWISE, GO TO BOX 14.

DBQ.360 During the school year, {do you/does SP} attend a kindergarten, grade school, junior or high school?

INTERVIEWER INSTRUCTION: ENTER ‘NO’ IF THE SP IS HOME SCHOOLED.

YES 1

NO 2 (BOX 14)

REFUSED 7 (BOX 14)

DON'T KNOW 9 (BOX 14)

DBQ.370 Does {your/SP's} school serve school lunches? These are complete lunches that cost the same every day.

YES 1

NO 2 (DBQ.400)

REFUSED 7 (DBQ.400)

DON'T KNOW 9 (DBQ.400)

DBQ.381
G/Q

During the school year, about how many times a week {do you/does SP} usually get a complete school lunch?

|___|

ENTER NUMBER 1

NONE 2 (DBQ.400)

REFUSED 7 (DBQ.400)

DON'T KNOW 9 (DBQ.400)

CAPI INSTRUCTION:

HARD EDIT 1-5

|___|

ENTER NUMBER OF TIMES

REFUSED 7777

DON'T KNOW 9999

DBQ.390 {Do you/Does SP} get these lunches free, at a reduced price, or {do you/does he/she} pay full price?

FREE 1

REDUCED PRICE 2

FULL PRICE 3

REFUSED 7

DON'T KNOW 9

DBQ.400 Does {your/SP's} school serve a complete breakfast that costs the same every day?

YES 1

NO 2 (BOX 9A)

REFUSED 7 (BOX 9A)

DON'T KNOW 9 (BOX 9A)

DBQ.411
G/Q

During the school year, about how many times a week {do you/does SP} usually get a complete breakfast at school?

|___|

ENTER NUMBER 1

NONE 2 (BOX 9A)

REFUSED 7 (BOX 9A)

DON'T KNOW 9 (BOX 9A)

CAPI INSTRUCTION:

HARD EDIT 1-5

|___|

ENTER NUMBER OF TIMES

REFUSED 7777

DON'T KNOW 9999

DBQ.421 {Do you/Does SP} get these breakfasts free, at a reduced price, or {do you/does he/she} pay full price?

FREE 1

REDUCED PRICE 2

FULL PRICE 3

REFUSED 7

DON'T KNOW 9

BOX 9A

CHECK ITEM DBQ.422:

IF DBQ.390 = CODE 1 OR CODE 2 OR DBQ.421 = CODE 1 OR CODE 2, CONTINUE.

OTHERWISE, GO TO BOX 14.

DBQ.424 {Do you/Does SP} get a free or reduced price meal at any summer program {you/he/she} attends?

YES 1

NO 2

DID NOT ATTEND SUMMER PROGRAM 3

REFUSED 7

DON’T KNOW 9

BOX 10

OMITTED

BOX 10A

OMITTED

BOX 11

OMITTED

BOX 14

CHECK ITEM DBQ.710:

IF SP AGE > 5, GO TO BOX 15.

OTHERWISE, CONTINUE.

FSQ.653 Next are a few questions about the WIC program.

Has {SP} ever received benefits from WIC, that is, the Women, Infants, and Children program?

YES 1 (FSQ.673)

NO 2

REFUSED 7 (FSQ.690)

DON'T KNOW 9 (FSQ.690)

HELP SCREEN:

WIC: WIC is short for the Special Supplemental Nutrition Program for Women, Infants, and Children. This program provides food assistance and nutritional screening to low-income pregnant and postpartum women and their infants, as well as to low-income children up to age 5.

FSQ.New1 Why didn’t (SP) ever receive benefits from WIC?

HAND CARD FSQ1

CODE ALL THAT APPLY

CHILD DOES NOT QUALIFY FOR WIC

(FAMILY INCOME TOO HIGH) 1

CHILD DOESN’T NEED WIC BECAUSE

FAMILY RECEIVES SUPPORT FROM

RELATIVES OR FRIENDS 2

CHILD DOESN’T NEED WIC BECAUSE

FAMILY RECEIVES SUPPORT FROM

SNAP, A FOOD BANK, OR ANOTHER PROGRAM 3

NEVER THOUGHT ABOUT APPLYING FOR WIC 4

PARENT/CAREGIVER CANNOT FIND

TIME TO GET TO THE WIC CLINIC 5

PARENT OR CAREGIVER DOES NOT HAVE

TRANSPORTATION TO GET TO WIC 6

THE STORES THAT ACCEPT WIC ARE

NOT CLOSE TO FAMILY’S HOME 7

WIC FOODS ARE DIFFICULT TO FIND IN

THE GROCERY STORE 8

USING WIC AT THE GROCERY STORE IS

UNCOMFORTABLE 9

OTHER, SPECIFY 10

REFUSED 77

DON'T KNOW 99

BOX 14a

OMITTED

FSQ.673 Is {SP} now receiving benefits from the WIC program?

YES 1 (BOX 14B)

NO 2

REFUSED 7 (BOX 14B)

DON'T KNOW 9 (BOX 14B)

FSQ.New2 Why did (SP) stop receiving WIC benefits?

HAND CARD FSQ2

CODE ALL THAT APPLY

CHILD NO LONGER QUALIFIES FOR WIC

(FAMILY INCOME TOO HIGH) 1

CHILD NO LONGER NEEDS WIC BECAUSE

FAMILY RECEIVES SUPPORT FROM

RELATIVES OR FRIENDS 2

CHILD NO LONGER NEEDS WIC BECAUSE

FAMILY RECEIVES SUPPORT FROM

SNAP, A FOOD BANK OR ANOTHER PROGRAM 3

PARENT OR CAREGIVER COULD NOT

FIND TIME TO GO TO THE WIC CLINIC 4

PARENT OR CAREGIVER COULD NOT FIND

TRANSPORTATION TO GET TO WIC 5

WIC CLINIC WAIT TIMES WERE TOO LONG 6

THE STORES THAT ACCEPT WIC WERE

NOT CLOSE TO FAMILY’S HOME 7

WIC FOODS WERE DIFFICULT TO FIND IN

THE GROCERY STORE 8

USING WIC AT THE GROCERY STORE WAS

UNCOMFORTABLE 9

CHECKING OUT AT THE STORE WITH WIC

FOODS TOOK A LONG TIME 10

CHILD DID NOT LIKE THE WIC FOODS 11

OTHER, SPECIFY 12

REFUSED 77

DON'T KNOW 99

BOX 14B

CHECK ITEM DBQ.710b:

IF SP AGE < 1, GO TO FSQ.685.

OTHERWISE, CONTINUE.

FSQ.675 Did {SP} receive benefits from WIC when {he/she} was less than one year old?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 14C

CHECK ITEM DBQ.950:

IF FSQ.673 = 1 (NOW RECEIVING WIC), GO TO FSQ.685.

OTHERWISE, CONTINUE.

FSQ.682 Did {SP} receive benefits from WIC when {he/she} {was/is} between the ages of {1 to {SP AGE/4} years old/12 to {SP AGE} months old}?

CAPI INSTRUCTION:

If SP age = 1, DISPLAY “12 to {the current age of the SP in months} months old”;

If SP age = 2 or 3, DISPLAY “1 to {the current age of the SP in years} years old”;

If SP age >3, DISPLAY “1 to 4 years old”.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 14D

OMITTED

FSQ.685 How long {did SP receive/has SP been receiving} benefits from the WIC program?

Q/U

CAPI INSTRUCTION:

IF FSQ.673 = 1, DISPLAY "HAS SP BEEN RECEIVING"

OTHERWISE, DISPLAY "DID SP RECEIVE"

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

|__|__|

ENTER NUMBER (OF MONTHS OR YEARS)

REFUSED 777 (FSQ.690)

DON'T KNOW 999 (FSQ.690)

|__|

ENTER UNIT

MONTHS 1

YEARS 2

FSQ.690 Did {SP’s} mother receive benefits from WIC, while she was pregnant with {SP}?

YES 1

NO 2 (BOX 15)

REFUSED 7 (BOX 15)

DON'T KNOW 9 (BOX 15)

FSQ.695 How many months pregnant was {SP’s} mother when she began to receive WIC benefits?

|__|__|

ENTER NUMBER

REFUSED 777

DON'T KNOW 999

BOX 15

CHECK ITEM DBQ.715:

IF SP AGE < 1 GO TO END OF SECTION.

IF SP AGE 12-15 GO TO END OF SECTION.

OTHERWISE, CONTINUE.

BOX 12

OMITTED

BOX 13

OMITTED

DBQ.895
G/Q

Next I’m going to ask you about meals. By meal, I mean breakfast, lunch and dinner. During the past 7 days, how many meals {did you/did SP} get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines?

{Please do not include meals provided as part of the school lunch or school breakfast./Please do not include meals provided as part of the community programs you reported earlier.}

CAPI INSTRUCTION:

IF DBQ381G = 1 OR DBQ.411G = 1, DISPLAY {Please do not include meals provided as part of the school lunch or school breakfast.}

IF DBQ.301 = 1 OR DBQ.330 = 1, DISPLAY {Please do not include meals provided as part of the community programs you reported earlier.}

SOFT EDIT: DISPLAY A MESSAGE FOR ENTRY LARGER THAN “21.” – “Unusually large number entered – Please verify – this is more than 3 meals per day, each day during the past 7 days.”

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

|___|___|

ENTER NUMBER

NONE 2 (DBQ.905)

REFUSED 7 (DBQ.905)

DON'T KNOW 9 (DBQ.905)

DBQ.900 How many of those meals {did you/did SP} get from a fast-food or pizza place?

G/Q

ENTER NUMBER 1

NONE 2 (DBQ.905)

REFUSED 7 (DBQ.905)

DON'T KNOW 9 (DBQ.905)

|___|___|

ENTER NUMBER

CAPI INSTRUCTION: HARD EDIT

NUMBER OF MEALS ENTERED IN DBQ.900 MUST BE EQUAL TO OR LESS THAN NUMBER ENTERED IN DBQ.895. IF NOT, DISPLAY THE FOLLOWING:

“THE NUMBER OF MEALS FROM A FAST FOOD OR PIZZA PLACE CANNOT BE GREATER THAN NUMBER OF MEALS PREPARED AWAY FROM HOME.”

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

DBQ.905
G/Q/U

Some grocery stores sell “ready to eat” foods such as salads, soups, chicken, sandwiches and cooked vegetables in their salad bars and deli counters.

During the past 30 days, how often did {you/SP} eat “ready to eat” foods from the grocery store? Please do not include sliced meat or cheese you buy for sandwiches and frozen or canned foods.

ENTER NUMBER OF TIMES 1

NEVER 2 (DBQ.910)

REFUSED 7 (DBQ.910)

DON’T KNOW 9 (DBQ.910)

|___|___|

ENTER NUMBER OF TIMES (PER DAY, WEEK, OR MONTH)

|___|

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

CAPI INSTRUCTION:

SOFT EDIT IF RESPONSE IS GREATER THAN 6 TIMES A DAY. “THIS IS AN UNUSUALLY LARGE NUMBER OF TIMES PER DAY, PLEASE VERIFY THE ANSWER.”

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

DBQ.910
G/Q/U

During the past 30 days, how often did {you/SP} eat frozen meals or frozen pizzas? Here are some examples of frozen meals and frozen pizzas.

HAND CARD DBQ7

ENTER NUMBER 1

NEVER 2 (BOX 15A)

REFUSED 7 (BOX 15A)

DON’T KNOW 9 (BOX 15A)

|___|___|

ENTER NUMBER OF TIMES (PER DAY, WEEK, OR MONTH)

|___|

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

CAPI INSTRUCTION: SOFT EDIT IF RESPONSE IS GREATER THAN 6 TIMES A DAY. “THIS IS AN UNUSUALLY LARGE NUMBER OF TIMES PER DAY, PLEASE VERIFY THE ANSWER.”

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

BOX 15A

CHECK ITEM DBQ.715a:

IF SP AGE < 16, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

CBQ.596 Next I’m going to ask a few questions about the nutritional guidelines recommended for Americans by the federal government.

{Have you/Has SP} heard of My Plate?

YES 1

NO 2 (DBQ.930)

REFUSED 7 (DBQ.930)

DON'T KNOW 9 (DBQ.930)

CBQ.606 {Have you/Has SP} looked up the My Plate plan on the internet?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

CBQ.611 {Have you/Has SP} tried to follow the recommendations in the My Plate plan?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

DBQ.930 {Are you/Is SP} the person who does most of the planning or preparing of meals in {your/SP’s} family?

INTERVIEWER INSTRUCTION: IF SP ANSWERS “SOMETIMES” OR “50/50”, ENTER YES.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.935 {Do you/Does SP} share in the planning or preparing of meals with someone else?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.940 {Are you/Is SP} the person who does most of the shopping for food in {your/SP’s} family?

INTERVIEWER INSTRUCTION: IF SP ANSWERS “SOMETIMES” OR “50/50”, ENTER YES.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.945 {Do you/Does SP} share in the shopping for food with someone else?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

END OF SECTION

WEIGHT HISTORY – WHQ

Target Group: SPs 16+

WHQ.010
G/F/I/C

These next questions ask about {your/SP's} height and weight at different times in {your/his/her} life.

How tall {are you/is SP} without shoes?

|___|

ENTER HEIGHT IN FEET AND INCHES 1

ENTER HEIGHT IN

CENTIMETERS 2

REFUSED 7 (WHQ.025)

DON’T KNOW 9 (WHQ.025)

|___|___|

ENTER NUMBER OF FEET

CAPI INSTRUCTION: HARD EDIT 2-8

REFUSED 7777 (WHQ.025)

DON’T KNOW 9999 (WHQ.025)

AND

|___|___|

ENTER NUMBER OF INCHES

CAPI INSTRUCTION: HARD EDIT 0-11

DON’T KNOW 9999 (WHQ.025)

|___|___|___|

ENTER NUMBER OF CENTIMETERS

CAPI INSTRUCTION: HARD EDIT 61-272

DON’T KNOW 9999 (WHQ.025)

WHQ.025/
L/K

How much {do you/does SP} weigh without clothes or shoes? [If {you are/she is} currently pregnant, how much did {you/she} weigh before your pregnancy?]

RECORD CURRENT WEIGHT. ENTER WEIGHT IN POUNDS OR KILOGRAMS.

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you are/she is} currently pregnant . . .] ONLY IF SP IS FEMALE AND AGE IS 16 THROUGH 59.

IF ITEM CHANGED, CHECK MEC COMPONENT.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (WHQ.030)

DON’T KNOW 9 (WHQ.030)

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777

DON’T KNOW 99999

WHQ.030 {Do you/Does SP} consider {your/his/her}self now to be . . . [If {you are/she is} currently pregnant, what did {you/she} consider {your/her}self to be before {you were/she was} pregnant?]

overweight, 1

underweight, or 2

about the right weight? 3

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you are/she is} currently pregnant…] ONLY IF SP IS FEMALE AND AGE IS 16 THROUGH 59.

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

WHQ.040 Would {you/SP} like to weigh . . .

more, 1

less, or 2

stay about the same? 3

REFUSED 7

DON’T KNOW 9

WHQ.053/
L/K

How much did {you/SP} weigh a year ago? [If {you were/she was} pregnant a year ago, how much did {you/she} weigh before your pregnancy?]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you were/she was} pregnant . . .] ONLY IF SP IS FEMALE AND SP AGE IS 17 THROUGH 60.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (BOX 1)

DON’T KNOW 9 (BOX 1)

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777

DON’T KNOW 99999

BOX 1

CHECK ITEM WHQ.055:

IF WEIGHT IN WHQ.053/L/K IS 10 POUNDS, 4.55 KILOGRAMS, OR MORE THAN WEIGHT IN WHQ.025/L/K (E.G., WHQ.053/L/K = 150 LBS AND WHQ.025/L/K = 135 LBS), CONTINUE.

OTHERWISE, GO TO WHQ.070.

WHQ.061 Was the change between {your/SP's} current weight and {your/his/her} weight a year ago because {you/s/he} tried to lose weight?

YES 1 (WHQ.092/OS)

NO 2

REFUSED 7

DON'T KNOW 9

WHQ.070 During the past 12 months, {have you/has SP} tried to lose weight?

YES 1

NO 2 (WHQ.225)

REFUSED 7 (WHQ.225)

DON’T KNOW 9 (WHQ.225)

WHQ.092/
OS

How did {you/SP} try to lose weight?

HAND CARD WHQ1

CODE ALL THAT APPLY

ATE LESS FOOD (AMOUNT) 100

SWITCHED TO FOODS WITH LOWER

CALORIES 110

ATE LESS FAT 120

ATE FEWER CARBOHYDRATES 125

EXERCISED 130

SKIPPED MEALS, FASTED 140

ATE “DIET” FOODS OR PRODUCTS 150

USED A LIQUID DIET FORMULA SUCH

AS SLIMFAST, OPTIFAST, OR

SHAKEOLOGY 160

JOINED A WEIGHT LOSS PROGRAM

SUCH AS WEIGHT WATCHERS, JENNY

CRAIG, TOPS, OR OVEREATERS

ANONYMOUS 170

FOLLOWED A SPECIAL DIET SUCH AS

DR. ATKINS, SOUTH BEACH, OTHER

HIGH PROTEIN OR LOW

CARBOHYDRATE DIET, CABBAGE

SOUP DIET, ORNISH, NUTRISYSTEM,

BODY-FOR-LIFE, JUICE DIET 300

TOOK DIET PILLS PRESCRIBED BY A

DOCTOR 310

TOOK OTHER PILLS, MEDICINES, HERBS,

OR SUPPLEMENTS NOT NEEDING A

PRESCRIPTION 320

STARTED TO SMOKE OR BEGAN TO

SMOKE AGAIN 325

TOOK LAXATIVES OR VOMITED 330

HAD WEIGHT LOSS SURGERY SUCH AS

GASTRIC BYPASS 335

DRANK A LOT OF WATER 340

ATE MORE FRUITS, VEGETABLES,

SALADS 350

ATE LESS SUGAR, CANDY, SWEETS,

DRANK LESS SODA, DRANK LESS

SUGAR SWEETENED BEVERAGES 360

CHANGED EATING HABITS (DIDN’T EAT

LATE AT NIGHT, ATE SEVERAL SMALL

MEALS A DAY, ATE AT HOME MORE) 370

ATE LESS JUNK FOOD OR FAST FOOD 380

OTHER (SPECIFY) 400

REFUSED 777

DON’T KNOW 999

BOX 2A

OMITTED

WHQ.225 How many times {have you/has SP} lost 10 pounds or more because {you were/he was/she was} trying to lose weight? Was it . . .

1 to 2, 1

3 to 5, 2

6 to 10, 3

11 times or more, or 4

never? 5

REFUSED 7

DON’T KNOW 9

BOX 2

CHECK ITEM WHQ.105:

IF SP AGE >= 36, CONTINUE.

OTHERWISE, GO TO BOX 3.

WHQ.111/
L/K

How much did {you/SP} weigh 10 years ago? [If you don't know {your/his/her} exact weight, please make your best guess.] [If {you were/she was} pregnant, how much did {you/she} weigh before {your/her} pregnancy?]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you were/she was} . . .] ONLY IF SP IS FEMALE AND AGE IS LESS THAN OR EQUAL TO 69.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (BOX 3)

DON’T KNOW 9 (BOX 3)

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777

DON’T KNOW 99999

BOX 3

CHECK ITEM WHQ.115A:

IF SP AGE >= 27, CONTINUE.

OTHERWISE, GO TO WHQ.147/L/K.

WHQ.121/
L/K

How much did {you/SP} weigh at age 25? [If you don't know {your/his/her} exact weight, please make your best guess.] [If {you were/she was} pregnant, how much did {you/she} weigh before your pregnancy?]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you were/she was} . . .] ONLY IF SP IS FEMALE.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (WHQ.130)

DON’T KNOW 9 (WHQ.130)

|___|___|___|

ENTER NUMBER OF POUNDS

|___|___|___|

ENTER NUMBER OF KILOGRAMS

REFUSED 77777

DON’T KNOW 99999

BOX 3A

CHECK ITEM WHQ.125:

IF SP AGE >= 50, CONTINUE.

OTHERWISE, GO TO WHQ.147/L/K.

WHQ.130/
F/I/C

How tall {were you/was SP} at age 25? [If you don't know {your/his/her} exact height, please make your best guess.]

|___|

ENTER HEIGHT IN FEET AND INCHES 1

ENTER HEIGHT IN

CENTIMETERS 2

REFUSED 7 (WHQ.147)

DON’T KNOW 9 (WHQ.147)

|___|___|

ENTER NUMBER OF FEET

CAPI INSTRUCTION: HARD EDIT 2-8

AND

|___|___|

ENTER NUMBER OF INCHES

CAPI INSTRUCTION: HARD EDIT 0-11

|___|___|___|

ENTER NUMBER OF CENTIMETERS

CAPI INSTRUCTION: HARD EDIT 61-272

REFUSED 7777

DON’T KNOW 9999

BOX 4

OMITTED

WHQ.147/
L/K

What is the most {you have/SP has} ever weighed? [Do not include any times when {you were/she was} pregnant.]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE {Do not include . . .} ONLY IF SP IS FEMALE.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777 (END OF SECTION)

DON’T KNOW 99999 (END OF SECTION)

WHQ.150 How old {were you/was SP} then? [If you don't know {your/his/her} exact age, please make your best guess.]

|___|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

BOX 5

OMITTED

SMOKING AND TOBACCO USE – SMQ

Target Group: SPs 0-11 years and 18+

BOX 0

CHECK ITEM SMQ.005:

IF SP >= 18 YEARS, CONTINUE.

IF SP 12-17 YEARS, GO TO END OF SECTION.

ELSE GO TO BOX 5.

These next questions are about cigarette smoking. Then I will ask about other tobacco products.

SMQ.022 {Have you/Has SP} smoked at least 100 cigarettes in {your/his/her} entire life? This hand card shows you the products we would like you to include and not include when answering this question.

HAND CARD SMQ1

YES 1

NO 2 (SMQ.890)

REFUSED 7 (SMQ.890)

DON'T KNOW 9 (SMQ.890)

SMQ.030 How old {were you/was SP} when {you/s/he} first started to smoke cigarettes fairly regularly?

G/Q

ENTER AGE 1

NEVER SMOKED CIGARETTES
REGULARLY 2 (SMQ.040)

REFUSED 7 (SMQ.040)

DON’T KNOW 9 (SMQ.040)

CAPI INSTRUCTION:

SOFT EDIT: SP AGE <13

DISPLAY “UNLIKELY RESPONSE. PLEASE VERIFY.”

|___|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

HELP SCREEN:

“fairly regularly” refers to age when started smoking cigarettes on a routine basis as opposed to age when tried first cigarette.

SMQ.040 {Do you/Does SP} now smoke cigarettes . . .

every day, 1 (SMQ.078)

some days, or 2 (SMQ.641)

not at all? 3

REFUSED 7 (SMQ.890)

DON'T KNOW 9 (SMQ.890)

SMQ.050 How long has it been since {you/SP} quit smoking cigarettes?

Q/U

|___|___|___|

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

REFUSED 77777

DON'T KNOW 99999

|___|

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

BOX 1A

OMITTED

SMQ.057 At that time, about how many cigarettes did {you/SP} usually smoke a day?

1 PACK EQUALS 20 CIGARETTES

IF LESS THAN 1 PER DAY, ENTER 1

IF 95 OR MORE PER DAY, ENTER 95

|___|___|___|

ENTER NUMBER OF CIGARETTES (PER DAY)

REFUSED 7777

DON'T KNOW 9999

BOX 1B

CHECK ITEM SMQ.060:

GO TO SMQ.890.

SMQ.078 How soon after {you/SP} wake{s} up {do you/does s/he} smoke? Would you say . . .

within 5 minutes, 1

from 6 to 30 minutes, 2

from more than 30 minutes to 1 hour, 3

from more than 1 hour to 2 hours, 4

from more than 2 hours to 3 hours, 5

from more than 3 hours to 4 hours, or 6

more than 4 hours? 7

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

SMQ.641 On how many of the past 30 days did {you/SP} smoke cigarettes?

|___|___|

ENTER NUMBER OF DAYS

REFUSED 7777

DON'T KNOW 9999

CAPI INSTRUCTION:

ALLOW '0' AS AN ENTRY. IF '0' DK OR RF ENTERED, SKIP TO QUESTION SMQ.093.

SMQ.650 On average, when {you/SP} smoked during the past 30 days, how many cigarettes did {you/s/he} smoke a day?

1 PACK EQUALS 20 CIGARETTES

IF LESS THAN 1 PER DAY, ENTER 1

IF 95 OR MORE PER DAY, ENTER 95

|___|___|___|

ENTER NUMBER OF CIGARETTES (PER DAY)

REFUSED 7777

DON'T KNOW 9999

SMQ.110a Do you usually smoke filtered or non-filtered cigarettes?

ENTER '1' FOR FILTERED

ENTER '0' FOR NON-FILTERED

CAPI INSTRUCTION:

'1' AND '0' SHOULD BE THE ONLY CODES ACCEPTED BY CAPI.

FILTERED 1

NON-FILTERED 0

REFUSED 7777

DON'T KNOW 9999

SMQ.110b Do you usually smoke menthol or non-menthol cigarettes?

ENTER '1' FOR MENTHOL

ENTER '0' FOR NON-MENTHOL

CAPI INSTRUCTION:

'1' AND '0' SHOULD BE THE ONLY CODES ACCEPTED BY CAPI.

MENTHOL 1

NON-MENTHOL 0

REFUSED 7777

DON'T KNOW 9999

SMQ.670 During the past 12 months, {have you/has SP} stopped smoking for longer than a day because {you were/he was/she was} trying to quit smoking?

YES 1

NO 2 (SMQ.890)

REFUSED 7 (SMQ.890)

DON'T KNOW 9 (SMQ.890)

BOX 5

CHECK ITEM SMQ.854:

IF SP AGE 0-11, GO SMQ.860.

OTHERWISE, CONTINUE.

SMQ.856 I will now ask you about tobacco smoke in other places.

During the last 7 days, {were you/was SP} working at a job or business outside of the home?

YES 1

NO 2 (SMQ.860)

REFUSED 7 (SMQ.860)

DON'T KNOW 9 (SMQ.860)

SMQ.858 While {you were/SP was} working at a job or business outside of the home, did someone else smoke cigarettes or other tobacco products indoors?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SMQ.860 {I will now ask you about smoking in other places.} During the last 7 days, did {you/SP} spend time in a restaurant?

YES 1

NO 2 (BOX 6)

REFUSED 7 (BOX 6)

DON'T KNOW 9 (BOX 6)

CAPI INSTRUCTION:

DISPLAY ‘I will now ask you about smoking in other places’ IF SP AGE 0-11 YEARS.

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

SMQ.862 While {you were/SP was} in a restaurant, did someone else smoke cigarettes or other tobacco products indoors?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

BOX 6

CHECK ITEM SMQ.864:

IF SP >=18 YEARS, CONTINUE.

OTHERWISE, GO TO SMQ.870.

SMQ.866 During the last 7 days, {did you/SP} spend time in a bar?

YES 1

NO 2 (SMQ.870)

REFUSED 7 (SMQ.870)

DON'T KNOW 9 (SMQ.870)

SMQ.868 While {you were/SP was} in a bar, did someone else smoke cigarettes or other tobacco products indoors?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SMQ.870 During the last 7 days, did {you/SP} ride in a car or motor vehicle?

YES 1

NO 2 (SMQ.874)

REFUSED 7 (SMQ.874)

DON'T KNOW 9 (SMQ.874)

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

SMQ.872 While {you were/SP was} riding in a car or motor vehicle, did someone else smoke cigarettes or other tobacco products?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

SMQ.874 During the last 7 days, did {you/SP} spend time in a home other than {your/his/her} own?

YES 1

NO 2 (SMQ.878)

REFUSED 7 (SMQ.878)

DON'T KNOW 9 (SMQ.878)

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

SMQ.876 While {you were/SP was} in a home other than {your/his/her} own, did someone else smoke cigarettes or other tobacco products indoors?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

SMQ.878 During the last 7 days,{were you/was SP} in any other indoor area?

INTERVIEWER: IF RESPONDENT ASKS WHAT IS MEANT BY OR DOESN’T SEEM TO UNDERSTAND “ANY OTHER INDOOR AREA” SAY “OTHER THAN AT WORK, IN A BAR, RESTAURANT, CAR, OTHER MOTOR VEHICLE, OR A HOUSE.”

YES 1

NO 2 (SMQ.940)

REFUSED 7 (SMQ.940)

DON'T KNOW 9 (SMQ.940)

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

SMQ.880 While {you were/SP was} in the other indoor area, did someone else smoke cigarettes or other tobacco products?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

SMQ.940 The next question is about e-cigarettes.

During the last 7 days, {were you/was SP} in an indoor place where someone was using an e-cigarette, e‑hookah, vape-pen or other similar electronic product?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OCCUPATION – OCQ

Target Group: SPs 16+

OCQ.152 In this part of the survey I will ask you questions about {your/SP's} work experience.

Which of the following {were you/was SP} doing last week . . .

working at a job or business, 1 (OCQ.180)

with a job or business but not at work, 2 (OCQ.210)

looking for work, or 3 (END OF SECTION)

not working at a job or business? 4 (OCQ.380)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

OCQ.180 How many hours did {you/SP} work last week in total at all jobs or businesses?

|___|___|___|

ENTER NUMBER OF HOURS

CAPI INSTRUCTION:

HARD EDIT 1-168.

REFUSED 77777

DON'T KNOW 99999

BOX 1

CHECK ITEM OCQ.200:

IF HOURS IN OCQ.180 <= 34, OR REFUSED (CODE 777), OR DON'T KNOW (CODE 999), CONTINUE.

OTHERWISE, GO TO OCQ.NEW1.

OCQ.210 {Do you/Does SP} usually work 35 hours or more per week in total at all jobs or businesses?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OCQ.New1 How many days per week do you usually work?

|___|

ENTER NUMBER OF DAYS

CAPI INSTRUCTION:

HARD EDIT 1-7.

REFUSED 77

DON'T KNOW 99

OCQ.670 Which of the following best describes your overall work schedule (include all jobs) for the last three months?

Traditional 9 AM to 5 PM day 1 (END OF SECTION)

Evening or nights 2 (END OF SECTION)

Early mornings 3 (END OF SECTION)

Variable (early mornings, days, and nights) 5 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

OCQ.380 What is the main reason {you/SP} did not work last week?

TAKING CARE OF HOUSE OR FAMILY 1

GOING TO SCHOOL 2

RETIRED 3

UNABLE TO WORK FOR HEALTH

REASONS/DISABLED 4

CAN’T FIND WORK/ON LAYOFF 5

SEASONAL/CONTRACT WORK 6

OTHER………………………………………….. 7

REFUSED 77

DON'T KNOW 99

HELP SCREEN FOR OCQ.152:

Work (Working): Paid work for wages, salary, commission, tips, or pay "in kind." Examples of pay in kind include meals, living quarters, or supplies provided in place of wages. This definition of employment includes work in the person's own business, professional practice, or farm, paid leaves of absence (including vacations and illnesses), work without pay in a family business or farm run by a relative, exchange work or share work on a farm, and work as a civilian employee of the Department of Defense or the National Guard. This definition excludes unpaid volunteer work (such as for a church or charity), unpaid leaves of absences, temporary layoffs (such as a strike), and work around the house.

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

3. The business is advertised to the public. (Some examples of advertising are: listing in the classified section of the telephone book, displaying a sign, distributing cards or leaflets, or any type of promotion which publicizes the type of work or services offered.)

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

Seasonal activity during the off season; a seasonal business outside of the normal season is not a business. For example, a family that chops and sells Christmas trees from October through December does not have a business in July.

Distributing products such as Tupperware or newspapers. Distributing products is not a business unless the person buys the goods directly from a wholesale distributor or producer, sells them to the consumer, and bears any losses resulting from failure to collect from the consumer.

Looking for Work: To be looking for work, a person has to have conducted an active job search. An active job search means that the person took steps necessary to put him/herself in a position to be hired for a job. Active job search methods include:

1. Filled out applications or sent out resumes;

2. Placed or answered classified ads;

3. Checked union/professional registers;

4. Bid on a contract or auditioned for a part in a play;

5. Contacted friends or relatives about possible jobs;

6. Contacted school/college university employment office;

7. Contacted employment directly.

Job search methods that are not active include the following:

1. Looked at ads without responding to them;

2. Picked up a job application without filling it out.

HELP SCREEN FOR OCQ.180:

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

Hours Worked Last Week: The number of hours actually worked last week. Hours worked will include overtime if the person worked overtime last week. The actual hours worked is often not the same as the hours on which the person's salary is based. We want the actual hours spent working on the job, whether the hours were paid or not. However, unpaid hours spent traveling to and from work are not included in hours worked last week.

HELP SCREEN FOR OCQ.210:

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3.A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

HELP SCREEN FOR OCQ.380:

Taking Care of House or Family: Doing any type of work around the house, such as cleaning, cooking, maintaining the yard, caring for children or family, etc.

Going to School: Attending any type of public or private educational establishment both in and out of the regular school system.

Retired: Respondent defined.

Unable to Work for Health Reasons/Disabled: Respondent defined.

Can’t find work/On Layoff: Is when a person is waiting to be called back to a job from which they were temporarily laid-off or furloughed. Layoffs can be due to slack work, plant retooling or remodeling, inventory taking, and the like. Do not consider a person who was not working because of a labor dispute at his or her place of employment as being in layoff.

ACCULTURATION – ACQ

Target Group: SPs 3+

BOX 1

OMITTED

BOX 1B

CHECK ITEM ACQ.006:

IF SP CODED HISPANIC IN SCREENER, GO TO ACQ.042.
Else if SP coded Asian in screener, go to ACQ.049.
IF CODED BOTH HISPANIC AND ASIAN IN SCREENER, GO TO acq.042

OTHERWISE, CONTINUE.

ACQ.011 Now I'm going to ask you about language use.

What language(s) {do you/does SP} usually speak at home?

CODE ALL THAT APPLY

ENGLISH 1

SPANISH 8

OTHER 9

REFUSED 77

DON'T KNOW 99

BOX 2

CHECK ITEM ACQ.015:

GO TO END OF SECTION.

ACQ.042 Now I’m going to ask you about language use.

What language(s) {do you/does SP} usually speak at home? {Do you/Does he/Does she} speak only Spanish, more Spanish than English, both equally, more English than Spanish, or only English?

HAND CARD ACQ1

ONLY SPANISH, 1

MORE SPANISH THAN ENGLISH, 2

BOTH EQUALLY, 3

MORE ENGLISH THAN SPANISH, OR 4

ONLY ENGLISH 5

REFUSED 7

DON'T KNOW 9

BOX 3

CHECK ITEM ACQ.045:

END OF SECTION.

ACQ.049 Now I’m going to ask you about language use.

What language(s) {do you/does SP} usually speak at home?

CODE ALL THAT APPLY

HAND CARD ACQ2

English 10

Chinese 11

Farsi/Persian 12

Hindi 13

Japanese 14

Khmer/Cambodian 15

Korean 16

Tagalog/Filipino 17

Urdu 18

Vietnamese 19

Other (SPECIFY) 20

REFUSED 77 (END OF SECTION)

DON'T KNOW 99 (END OF SECTION)

BOX 4

CHECK ITEM ACQ.090:

IF ACQ.049 = 10 ONLY, END OF SECTION.

IF ACQ.049 = 10 AND ONE OTHER RESPONSE 11-20, GO TO ACQ.110.

IF ACQ.049 DOES NOT EQUAL 10, END OF SECTION.

IF ACQ.049 = 10 AND TWO OR MORE OTHER RESPONSES 11-20, GO TO ACQ.101.

ACQ.101 Of these languages {ACQ.049 responses 11-20}, which {do you/does SP} speak more of at home?

CAPI INSTRUCTION:

FILL NON-ENGLISH RESPONSE OPTIONS SELECTED IN ACQ.049 AND/OR ACQ.049OS SEPARATING WITH A COMMA. BEFORE LAST RESPONSE DISPLAY “and”. FOR RESPONSE OPTION 20, DISPLAY OTHER SPECIFY TEXT.
DISPLAY ONLY NON-ENGLISH RESPONSE OPTIONS SELECTED IN ACQ.049 AND/OR ACQ.049OS THAT WERE SELECTED.

Chinese 11

Farsi/Persian 12

Hindi 13

Japanese 14

Khmer/Cambodian 15

Korean 16

Tagalog/Filipino 17

Urdu 18

Vietnamese 19

{ACQ.049OS} 20

REFUSED 77 (END OF SECTION)

DON'T KNOW 99 (END OF SECTION)

ACQ.110 {Do you/Does SP} speak only (NON-ENGLISH LANGUAGE), more (NON-ENGLISH LANGUAGE) than English, both equally, more English than (NON-ENGLISH LANGUAGE), or only English?

CAPI INSTRUCTION:

IF ENGLISH AND ONE OTHER RESPONSE OPTION 11-20 WAS SELECTED IN ACQ.049, FILL NON-ENGLISH LANGUAGE WITH RESPONSE OPTION 11-20.
IF ENGLISH AND TWO OR MORE OTHER OPTIONS 11-20 WERE SELECTED IN ACQ.049, FILL NON-ENGLISH WITH RESPONSE TO QUESTION ACQ.101.

ONLY (NON-ENGLISH LANGUAGE), 1

MORE (NON-ENGLISH), THAN ENGLISH, 2

BOTH EQUALLY, 3

MORE ENGLISH THAN (NON-ENG), OR 4

ONLY ENGLISH 5

REFUSED 7

DON'T KNOW 9

DEMOGRAPHICS INFORMATION – DMQ – SP

Target Group: SPs Birth +

BOX 1A

CHECK ITEM DMQ.030:

IF SP AGE >= 6, CONTINUE.

OTHERWISE, GO TO DMQ.061.

DMQ.141 What is the highest grade or level of school {you have/SP has} completed or the highest degree {you have/s/he has} received?

HAND CARD DMQ1

READ HAND CARD CATEGORIES IF NECESSARY.

Enter highest level of school.

NEVER ATTENDED/KINDERGARTEN

ONLY 0 (BOX 1B)

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

REFUSED 77

DON’T KNOW 99

CAPI INSTRUCTION:

EDITS:

(DMQ.141 = 19, 20 OR 21 AND SP AGE < 22) OR

(DMQ.141 = 15, 16, 17 OR 18 AND SP AGE < 18) OR

(DMQ.141 = 10, 11, 12, 13 OR 14 AND SP AGE < 14) OR

(DMQ.141 = 5, 6, 7, 8 OR 9 AND SP AGE < 8)

DISPLAY “IMPROBABLE ANSWER DUE TO SP’s AGE {SP AGE}. PLEASE VERIFY.”

BOX 1AA

CHECK ITEM DMQ.035:

IF SP AGE <= 19, CONTINUE

OTHERWISE, GO TO DMQ.052.

DMQ.037 Are {you/SP} currently enrolled in or attending school?

Yes, 1

No 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

Attending or enrolled in any type of public or private educational establishment both in and out of the regular school system. School includes elementary, middle, and high school, college, trade school, and professional school. Students may be enrolled part-time or full-time.

BOX 1B

CHECK ITEM DMQ.040:

IF SP AGE >= 17, CONTINUE.

OTHERWISE, GO TO DMQ.061.

DMQ.052 {Have you/Has SP} ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard? (Active duty does not include training for the Reserves or National Guard, but does include activation, for service in the U.S. or in a foreign country, in support of military or humanitarian operations.)

YES 1

NO 2 (DMQ.061)

REFUSED 7 (DMQ.061)

DON'T KNOW 9 (DMQ.061)

HELP SCREEN:

Armed Forces: Non-civilian members of any of the armed services of the federal government (Army, Navy, Air Force, Coast Guard, Marines).

DMQ.054 Did {you/SP} ever serve in a foreign country during a time of armed conflict or on a humanitarian or peace-keeping mission? (This would include National Guard or reserve or active duty monitoring or conducting peace keeping operations in Bosnia and Kosovo, in the Sinai between Egypt and Israel, or in response to the 2004 tsunami or Haiti in 2010.)

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DMQ.061 Next I have a few questions about {your/SP’s} name. {Do you/Does SP} usually go by another first name besides {DISPLAY FIRST NAME FROM DMQ-SPIV.040}?

CAPI INSTRUCTION:

DISPLAY "FIRST NAME:" AND FIRST NAME FROM DMQ-SPIV.040 AS LEFT HEADER.

YES 1

NO 2 (BOX 1BBB)

REFUSED 7 (BOX 1BBB)

DON'T KNOW 9 (BOX 1BBB)

DMQ.071 What is this other first name?

VERIFY SPELLING

____________________________________

ENTER NAME

REFUSED 7----7

DON'T KNOW 9----9

NEW BOX 1BB2

OMITTED

BOX 1BBB

CHECK ITEM DMQ.073a:

IF AGE >= 14, CONTINUE.

OTHERWISE, GO TO BOX 1D.

DMQ.380 {Are you/Is SP} now married, widowed, divorced, separated, never married or living with a partner?

MARRIED 1

WIDOWED 2

DIVORCED 3

SEPARATED 4

NEVER MARRIED 5 (BOX 1D)

LIVING WITH PARTNER 6

REFUSED 77

DON'T KNOW 99

BOX 1C

CHECK ITEM DMQ.075A:

IF SP IS MALE, GO TO BOX 1D.

OTHERWISE, CONTINUE.

DMQ.081 {Do you/Does SP} have a maiden name?

ASK IF NOT KNOWN

YES 1

NO 2 (BOX 1D)

REFUSED 7 (BOX 1D)

DON'T KNOW 9 (BOX 1D)

DMQ.090 What is {your/SP's} maiden name?

G/Q

VERIFY SPELLING

CAPI INSTRUCTION:

DISPLAY "LAST NAME:" AND SP'S CURRENT LAST NAME FROM DMQ-SPIV.060 AS LEFT HEADER.

|___|

ENTER MAIDEN NAME 1

SAME AS CURRENT LAST NAME 2 (BOX 1D)

REFUSED 7 (BOX 1D)

DON'T KNOW 9 (BOX 1D)

____________________________________

REFUSED 7----7

DON'T KNOW 9----9

BOX 1D

CHECK ITEM DMQ.094:

IF SP AGE >= 16, CONTINUE.

OTHERWISE, GO TO DMQ.241.

DMQ.101 What is {your/SP's} father's last name?

G/Q

VERIFY SPELLING

CAPI INSTRUCTION:

DISPLAY "LAST NAME:" AND SP'S CURRENT LAST NAME FROM DMQ-SPIV.060 AS LEFT HEADER.

IF MAIDEN NAME ENTERED IN DMQ.090G/Q, AND MAIDEN NAME IS DIFFERENT FROM CURRENT LAST NAME, ALSO DISPLAY "MAIDEN NAME:" AND MAIDEN NAME FROM DMQ.090G/Q AS LEFT HEADER.

CAPI INSTRUCTION:

HARD EDIT: IF SP MALE, DO NOT ALLOW RESPONSE 3.

|___|

ENTER NAME 1

SAME AS CURRENT LAST NAME 2 (DMQ.241)

SAME AS MAIDEN NAME 3 (DMQ.241)

REFUSED 7 (DMQ.241)

DON'T KNOW 9 (DMQ.241)

____________________________________

REFUSED 7----7

DON'T KNOW 9----9

DMQ.241 {Do you/Does SP} consider {yourself/himself/herself} to be Hispanic, Latino, or of Spanish origin?

READ IF NECESSARY: Where {do your/do his/do her} ancestors come from?

Puerto Rican

Cuban/Cuban American

Dominican Republic

Mexican/Mexican American

Central/South American

Other Latin American

Other Hispanic or Latino

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

SPANISH, HISPANIC OR LATINO PEOPLE MAY BE OF ANY RACE. LISTED BELOW ARE HISPANIC OR LATINO CATEGORIES/COUNTRIES.

MEXICAN

PUERTO RICAN

CUBAN

DOMINICAN REPUBLIC

CENTRAL AMERICAN:

COSTA RICAN

GUATEMALAN

HONDURAN

NICARAGUAN

PANAMANIAN

SALVADORAN

OTHER CENTRAL AMERICAN

SOUTH AMERICAN:

ARGENTINEAN

BOLIVIAN

CHILEAN

COLOMBIAN

ECUADORIAN

PARAGUAYAN

PERUVIAN

URUGUAYAN

VENEZUELAN

OTHER SOUTH AMERICAN

OTHER HISPANIC OR LATINO:

SPANIARD

SPANISH

SPANISH AMERICAN

BOX 3E

OMITTED

BOX 3F

OMITTED

BOX 3G

OMITTED

BOX 3H

OMITTED

BOX 3I

CHECK ITEM DMQ.242:

IF YES (CODE 1) IN DMQ.241 AND YES IN SCQ.260 GO TO DMQ.253.

IF NO (CODE 2) IN DMQ.241 AND NO IN SCQ.260 GO TO DMQ.263.

OTHERWISE, GO TO BOX 3J.

BOX 3J

CHECK ITEM DMQ.249:

IF YES (CODE 1) OR DK IN DMQ.241 AND NO (CODE 2) IN SCQ.260, DISPLAY SOFT EDIT MESSAGE “WARNING – SCREENER ETHNICITY IS NOT HISPANIC – SP MAY BE DESAMPLED. HAND CARD DMQ3 TO RESPONDENT AND READ CATEGORIES.

OTHERWISE, GO TO BOX 3K.

BOX 3K

CHECK ITEM DMQ.254:

IF NO (CODE 2) OR DK IN DMQ.241 AND YES (CODE 1) IN SCQ.260, DISPLAY SOFT EDIT MESSAGE “WARNING – SCREENER ETHNICITY IS HISPANIC – SP MAY BE DESAMPLED. HAND CARD DMQ3 TO RESPONDENT AND READ CATEGORIES.

OTHERWISE, GO TO BOX 3K-1.

BOX 3K-1

CHECK ITEM DMQ.256:

IF YES IN DMQ.241, CONTINUE.

OTHERWISE, GO TO DMQ.263.

DMQ.253 Please give me the number of the group that represents {your/SP's} Hispanic/Latino or Spanish origin or

OS ancestry. Please select 1 or more of these categories.

PROBE: Where do you/your ancestors come from?

HAND CARD DMQ3

SELECT 1 OR MORE

MEXICAN 10

PUERTO RICAN 11

CUBAN 12

DOMINICAN REPUBLIC 13

CENTRAL AMERICAN:

COSTA RICAN 14

GUATEMALAN 15

HONDURAN 16

NICARAGUAN 17

PANAMANIAN 18

SALVADORAN 19

OTHER CENTRAL AMERICAN 20

SOUTH AMERICAN:

ARGENTINEAN 21

BOLIVIAN 22

CHILEAN 23

COLOMBIAN 24

ECUADORIAN 25

PARAGUAYAN 26

PERUVIAN 27

URUGUAYAN 28

VENEZUELAN 29

OTHER SOUTH AMERICAN 30

OTHER HISPANIC OR LATINO:

FILIPINO 31

SPANIARD 32

SPANISH 33

SPANISH AMERICAN 34

HISPANO/HISPANA 35

HISPANIC/LATINO 36

OTHER HISPANIC/LATINO (SPECIFY) 40

CHICANA/CHICANO 41

REFUSED 77

DON'T KNOW 99

BOX 3L

CHECK ITEM DMQ.255:

IF ‘OTHER SPECIFY’ (CODE 40) IN DMQ.253, DISPLAY SOFT ERROR MESSAGE “PLEASE REVIEW THE LIST AND SELECT RESPONSE FROM LIST BEFORE TYPING. THE LIST IS MEANT TO INCLUDE ALL CATEGORIES” AND CAPI SHOULD RETURN TO DMQ.253.

DMQ.263 Please look at the categories on this card. What race or races {do you/does SP} consider {yourself/himself/herself} to be? Please select one or more.

HAND CARD DMQ4

CHECK ALL THAT APPLY.

AMERICAN INDIAN OR ALASKA NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR PACIFIC ISLANDER 4

WHITE 5

OTHER 6

DK 99

RF 77

NEW BOX L-1

CHECK ITEM DMQ.310:

IF CODE 2 (ASIAN) IN DMQ.263 AND CODE 2 (ASIAN) IN SCQ.270, GO TO DMQ.336.

IF NOT CODE 2 (ASIAN) IN DMQ.263 AND NOT CODE 2 (ASIAN) IN SCQ.270, GO TO BOX L-4d.

OTHERWISE, GO TO NEW BOX L-2.

NEW BOX L-2

CHECK ITEM DMQ.315:

IF CODE 2 (ASIAN) OR DK IN DMQ.263 AND NOT (CODE 2) IN SCQ.270, DISPLAY SOFT EDIT MESSAGE “WARNING – SCREENER RACE IS NOT ASIAN – SP MAY BE DESAMPLED.”

OTHERWISE, GO TO NEW BOX L-3.

NEW BOX L-3

CHECK ITEM DMQ.320:

IF NOT CODE 2 OR DK IN DMQ.263 AND CODE 2 (ASIAN) IN SCQ.270, DISPLAY SOFT EDIT MESSAGE “WARNING – SCREENER RACE IS ASIAN – SP MAY BE DESAMPLED.

OTHERWISE, GO TO NEW BOX L-4.

NEW BOX L-4

CHECK ITEM DMQ.325:

IF CODE 2 (ASIAN) IN DMQ.263, GO TO DMQ.336.

OTHERWISE, GO TO NEW BOX L-4a.

NEW BOX L-4a

CHECK ITEM DMQ.327:

IF CODE 3 (BLACK) IN DMQ.263 AND CODE 3 (BLACK) IN SCQ.270, GO TO NEW BOX L-4d.

IF NOT CODE 3 (BLACK) IN DMQ.263 AND NOT CODE 3 (BLACK) IN SCQ.270, GO TO NEW BOX L-4d.

OTHERWISE, GO TO NEW BOX L-4b.

NEW BOX L-4b

CHECK ITEM DMQ.332:

IF CODE 3 (BLACK) OR DK IN DMQ.263 AND NOT CODE 3 IN SCQ.270, DISPLAY SOFT EDIT MESSAGE “WARNING-SCREENER RACE IS NOT BLACK/AFRICAN AMERICAN-SP MAY BE DESAMPLED.”

OTHERWISE, GO TO NEW BOX L-4c.

NEW BOX L-4c

CHECK ITEM DMQ.338:

IF NOT 3 OR DK IN DMQ.263 AND CODE 3 (BLACK/AFRICAN AMERICAN) IN SCQ.270, DISPLAY SOFT EDIT MESSAGE “WARNING-SCREENER RACE IS BLACK/AFRICAN AMERICAN-SP MAY BE DESAMPLED.”

OTHERWISE, GO TO NEW BOX L-4d.

NEW BOX L-4d

CHECK ITEM DMQ.339:

IF CODE 4 (NHPI) IN DMQ.263, GO TO DMQ.350.

IF NOT CODE 4 (NHPI) IN DMQ.263, GO TO NEW BOX L-5.

NEW BOX L-5

CHECK ITEM DMQ.330:IF CODE 6 (OTHER) IN DMQ.263 AND CODE 1 (YES-HISPANIC) IN DMQ.241, GO TO DMQ.266.

OTHERWISE, GO TO DMQ.107.

DMQ.350 Please give me the number of the group that represents {your/SP’s} Native Hawaiian or Pacific Islander origin or ancestry. Please select one or more of these categories.

HAND CARD DMQ5

PROBE: Where do your ancestors come from?

NATIVE HAWAIIAN 1

GUAMANIAN OR CHAMORRO 2

SAMOAN 3

OTHER PACIFIC ISLANDER 4

REFUSED 7

DON’T KNOW 9

BOX L-5a

CHECK ITEM DMQ.355:

GO TO NEW BOX L-5.

DMQ.336 Please give me the number of the group that represents {your/SP’s} Asian origin or ancestry. Please select one or more of these categories.

HAND CARD DMQ6

PROBE: Where do your ancestors come from?

ASIAN INDIAN 10

BANGLADESHI 11

BENGALESE 12

BHARAT 13

BHUTANESE 14

BURMESE 15

CAMBODIAN 16

CANTONESE 17

CHINESE 18

DRAVIDIAN 19

EAST INDIAN 20

FILIPINO 21

GOANESE 22

HMONG 23

INDOCHINESE 24

INDONESIAN 25

IWO JIMAN 26

JAPANESE 27

KOREAN 28

LAOHMONG 29

LAOTIAN 30

MADAGASCAR/MALAGASY 31

MALAYSIAN 32

MALDIVIAN 33

MONG 34

NEPALESE 35

NIPPONESE 36

OKINAWAN 37

PAKISTANI 38

SIAMESE 39

SINGAPOREAN 40

SRI LANKAN 41

TAIWANESE 42

THAI 43

VIETNAMESE 44

REFUSED 77

DON'T KNOW 99

NEW BOX L-6

CHECK ITEM DMQ.340:

SKIP TO DMQ.107.

DMQ.266 CODE SP ANSWER TO ‘OTHER RACE’.

MEXICAN 10

PUERTO RICAN 11

CUBAN 12

DOMINICAN REPUBLIC 13

CENTRAL AMERICAN:

COSTA RICAN 14

GUATEMALAN 15

HONDURAN 16

NICARAGUAN 17

PANAMANIAN 18

SALVADORAN 19

OTHER CENTRAL AMERICAN 20

SOUTH AMERICAN:

ARGENTINEAN 21

BOLIVIAN 22

CHILEAN 23

COLOMBIAN 24

ECUADORIAN 25

PARAGUAYAN 26

PERUVIAN 27

URUGUAYAN 28

VENEZUELAN 29

OTHER SOUTH AMERICAN 30

OTHER HISPANIC OR LATINO:

SPANIARD 32

SPANISH 33

SPANISH AMERICAN 34

HISPANO/HISPANA 35

HISPANIC/LATINO 36

OTHER (SPECIFY) 40

REFUSED 77

DON'T KNOW 99

BOX 3M

CHECK ITEM DMQ.268:

IF ‘OTHER SPECIFY’ (CODE 40) IN DMQ.266, DISPLAY SOFT ERROR MESSAGE – “PLEASE REVIEW THE LIST AND SELECT RESPONSE FROM LIST BEFORE TYPING. THE LIST IS MEANT TO INCLUDE ALL CATEGORIES.” AND CAPI SHOULD RETURN TO QUESTION DMQ.266.

DMQ.New1 Were you born in the United States or a United States territory?

YES 1 (DMQ.130)

NO 2

REFUSED 7 (BOX 5)

DON'T KNOW 9 (BOX 5)

DMQ.160 In what month and year did {you/SP} come to the United States to stay?

M/Y

CAPI INSTRUCTION:

HARD EDIT: NOT BEFORE SP’S DATE OF BIRTH AND NOT AFTER CURRENT DATE. IF OUT OF RANGE DISPLAY “DATE OF IMMIGRATION MUST BE AFTER DATE OF BIRTH {DOB YYYY} AND BEFORE TODAY.”

|___|___|

ENTER MONTH NUMBER

REFUSED 7777

DON'T KNOW 9999

|___|___|___|___|

ENTER 4-DIGIT YEAR

REFUSED 777777

DON'T KNOW 999999

BOX 5

CHECK ITEM DMQ.175:

SKIP TO DMQ.281a.

DMQ.130 In what state or U.S. territory {were you/was SP} born?

ENTER 2 LETTER STATE ABBREVIATION TO START THE LOOKUP.

SELECT STATE FROM CAPI STATE LIST.

PRESS ENTER TO ACCEPT SELECTION.

CAPI INSTRUCTION:

DISPLAY FIPS STATE LIST. INTERVIEWER ONLY SHOULD BE ABLE TO SELECT 1 STATE FROM LIST. WHEN A STATE ABBREVIATION IS SELECTED, PREFILL THE FOLLOWING:

DMQ130A – STATES FIPS CODE

DMQ130B = STATE NAME

DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS.

THE STATE LOOKUP IN THE SP AND FAMILY QUESTIONNAIRES SHOULD WORK EXACTLY THE SAME.

DMQ.281a

The National Center for Health Statistics will conduct statistical research by combining {your/his/her} survey data with vital, health, nutrition and other related records. {Your/SP’s} social security number is used only for these purposes. Providing this information is voluntary and is collected under the authority of Section 306 of the Public Health Service Act. There will be no effect on {your/his/her} benefits if you do not provide it.

INTERVIEWER INSTRUCTION—ONLY READ IF ASKED. [Public Health Service Act is title 42, United States Code, section 242k.]

What is {your/SP's} Social Security Number?

INTERVIEWER INSTRUCTION:

IF RESPONDENT CANNOT RECALL FROM MEMORY ASK {HIM/HER} TO GET CARD AT THIS TIME.

IF RESPONDENT IS RELUCTANT OR NEEDS MORE INFORMATION OR REFUSES, READ: I understand your concern. By matching NHANES data with other health-related records, researchers can study health conditions like heart attacks and diabetes in depth. They can also better understand health care use and health care costs for all Americans. These findings will help doctors assist patients in making smart choices. Here are other examples (HAND CARD DMQ8) of things we have learned when we matched records from different sources. May I please have {your/SP’s} Social Security Number?

ENTER SOCIAL SECURITY NUMBER 1 (DMQ281b)

DOES NOT HAVE SOCIAL SECURITY NUMBER 2 (BOX 6)

REFUSED 7 (BOX 6)

DON'T KNOW 9 (BOX 6)

CAPI INSTRUCTION:

IF SP REFUSES (CODE 7), DISPLAY THE FOLLOWING SOFT ERROR MESSAGE:

Make sure you have read the required text on the screen.

DMQ281b/c

CAPI INSTRUCTION:

REQUIRE DOUBLE ENTRY OF SOCIAL SECURITY NUMBER.

|___|___|___| |___|___| |___|___|___|___|

ENTER SOCIAL SECURITY NUMBER

REFUSED 777777777 (BOX 6)

DON'T KNOW 999999999 (BOX 6)

HARD EDIT:

Validate that there are 9 digits entered for an SSN. Do not accept entry less than 9 digits for DMQ281b/c. If a less than 9 digits number was entered, display the message “The SSN should be a 9-digit number, please verify.”

The SSN is a 3-part number (3-digit Area Number + 2-DIGit Group Number + 4-digit Serial Number). None of these compartments can be all zeros. Please verify and display error message “It is unlikely that the SSN starts with “000”, has “00” as its middle 2-digits, or has “0000” as its last 4 digits, please verify that you have the complete number.”

DMQ.300 INTERVIEWER: SELECT CATEGORY FOR REPORTING OF SOCIAL SECURITY NUMBER

SELF REPORTED FROM MEMORY 1

SELF REPORTED FROM RECORDS 2

PROXY REPORTED FROM MEMORY 3

PROXY REPORTED FROM RECORDS 4

BOX 6

OMITTED

HELP SCREEN FOR DMQ.141:

School: An institution that advances a person toward an elementary or high school diploma, or a college or professional school degree. Do not count schooling in non-regular schools unless the credits are accepted by regular schools.

Regular school includes graded public, private, and parochial schools, colleges, universities, graduate and professional schools, seminaries where a Bachelor's degree is offered, junior colleges specializing in skill training, colleges of education, and nursing schools where a Bachelor's degree is offered.

If the person attended school outside of the "regular" school system, probe to determine if the schooling is applicable here. Use the following guidelines to determine if the schooling should be included:

- Training Programs - Count training received "on the job," in the Armed Forces, or through correspondence school only if it was credited toward a school diploma, high school equivalency (GED), or college degree.

- Vocational, Trade, or Business School - Do not include secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered, and other vocational trade or business schools outside the regular school system.

- General Educational Development (GED) or High School Equivalency - An exam certified equivalent of a high school diploma. If the person has not actually completed all 4 years of high school, but has acquired his/her GED (high school equivalency based on passing the GED exam), count this and enter code "14."

- Adult Education - Adult education classes should not be included as regular school unless such schooling has been counted for credit in a regular school system. If a person has taken adult education classes not for credit, these classes should not be counted as regular school. Adult education courses given in a public school building are part of regular schooling only if their completion can advance a person toward an elementary school certificate, a high school diploma (or GED), or a college degree.

- Other School Systems - If the person attended school in another country, in an ungraded school, in a "normal school", under a tutor, or under other special circumstances, ask the respondent to give the nearest equivalent of years in regular U.S. schooling.

GED (General Educational Development): An exam certified equivalent of a high school diploma.

Occupational/Technical/Vocational Programs: Includes secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered and other trade and business schools outside the regular school system.

Vocational (Trade or Business) School: When determining the highest grade or year of regular school the person ever completed, do not include secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered, and other vocational trade or business schools outside the regular school system.

College: Any junior college, community college, four-year college or university, nursing school or seminary where a college degree is offered, and graduate school or professional school that is attended after obtaining a degree from a 4-year institution.

Bachelor's Degree: An educational degree given by a college or university to a person who has completed a four-year course or its equivalent in the humanities or related studies (B.A.) or in the sciences (B.S.).

Doctorate Degree: The highest educational degree given by a college or university to a person who has completed a prescribed course of advanced graduate study. For example—a Doctor of Philosophy (Ph.D.).

HEALTH INSURANCE – HIQ

Target Group: All Ages

HIQ.011 The next questions are about health insurance. Include health insurance obtained through employment or purchased directly as well as government programs like Medicare, Medicaid and the Children's Health Insurance Program that provide medical care or help pay medical bills. Are you covered by any kind of health insurance or some other kind of health care plan?

YES 1

NO 2 (BOX 12)

REFUSED 7 (BOX 12)

DON'T KNOW 9 (BOX 12)

HIQ.031 What kinds of health insurance or health care coverage {do you/does SP} have? Is it...Private health insurance, Medicare, Medigap, Medicaid, Children's Health Insurance Program or CHIP, military related health care including TRICARE, CHAMPUS, VA health care and CHAMP-VA, Indian Health Service, a state-sponsored health plan, or an other government program?

CODE ALL THAT APPLY

HAND CARD HIQ1

CAPI INSTRUCTION:

DO NOT ALLOW MORE THAN ONE ANSWER WHEN 140 (NO COVERAGE OF ANY TYPE) IS CODED.

PRIVATE HEALTH INSURANCE 14

MEDICARE 2

MEDI-GAP 3

MEDICAID 4

CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) 5

MILITARY RELATED HEALTH CARE: TRICARE (CHAMPUS)/

VA HEALTH CARE/ CHAMP-VA 6

INDIAN HEALTH SERVICE 7

STATE-SPONSORED HEALTH PLAN……………………………………. ...8

OTHER GOVERNMENT PROGRAM 9

NO COVERAGE OF ANY TYPE 140

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

SOFT EDIT: IF SP AGE LESS THAN 18 AND HIQ.031 = 2 (MEDICARE) DISPLAY ERROR MESSAGE, “PLEASE VERIFY THAT CHILD SP HAS MEDICARE. Only disabled children or children with kidney failure can get Medicare. Children who have Medicare are almost always also receiving Social Security or SSI and have Medicaid.”

SOFT EDIT: IF SP AGE EQUAL TO OR GREATER THAN 18 AND LESS THAN 65 AND HIQ.031 – 2 (MEDICARE) DISPLAY ERROR MESSAGE, “PLEASE VERIFY THAT SP AGE 18-64 HAS MEDICARE. Only disabled adults or adults with kidney failure under 65 years old can have Medicare. They are almost always receiving disability checks from Social Security or SSI.”

HARD EDIT: IF HIQ.031 = 3 (MEDI-GAP) AND 2 (MEDICARE) IS NOT SELECTED, DISPLAY ERROR MESSAGE, “Medi-Gap refers to Medicare Supplemental Insurance. You must have Medicare to be eligible to purchase Medi-Gap. PLEASE VERIFY IF SP HAS MEDI-GAP AND, IF YES, IF HE/SHE HAS Medicare.”

{CAPI DISPLAYS ONE QUESTION FOR CORRECTION}

HIQ.031

BOX 2

OMITTED

BOX 3

OMITTED

BOX 4

OMITTED

BOX 5

OMITTED

BOX 10

OMITTED

BOX 11

OMITTED

BOX 12

CHECK ITEM HIQ.065:

IF AGE => 65 AND HIQ.031 = CODE 14 OR CODE 3-99 OR HIQ.031 IS EMPTY, GO TO HIQ.260.
IF AGE = BIRTH+ AND HIQ.031 = CODE 2, GO TO HIQ.502.
OTHERWISE, CONTINUE.

BOX 13

CHECK ITEM HIQ.259:

IF AGE < 65 AND (HIQ.011 = 1 (YES) AND HIQ.031 NOT = 140 (NO COVERAGE), GO TO HIQ.270.

IF AGE < 65 AND (HIQ.011 = 2, 7, OR 9 OR HIQ.031 = 140), GO TO END OF SECTION.

HIQ.260 {Do you/Does SP} have Medicare? This is a health insurance program that virtually all persons 65 and older are eligible for. A card is automatically mailed to you shortly before your 65th birthday, it looks like this.

SHOW HAND CARD HIQ2 OF MEDICARE CARD

YES 1

NO 2 (BOX 14)

REFUSED 7 (BOX 14)

DON’T KNOW 9 (BOX 14)

HIQ.502 May I please see {your/SP's} Medicare card to record the Health Insurance Claim Number?

This number is needed to allow Medicare records of the Center for Medicare and Medicaid Services to be easily and accurately located and identified for statistical or research purposes. Providing the Health Insurance Claim Number is voluntary and collected under the authority of Section 306 of the Public Health Service Act. Whether the number is given or not, there will be no effect on {your/his/her} benefits. This number will be held confidential. [The Public Health Service Act is Title 42, United States Code, Section 242K.]

CAPI INSTRUCTION:

REQUIRE DOUBLE ENTRY OF NUMBER.

ALLOW UP TO 11 CHARACTERS (LETTERS OR NUMBERS)

|___|___|___|___|___|___|___|___|___|___|___|

ENTER CLAIM NUMBER

REFUSED 77777777777 (BOX 14)

DON'T KNOW 99999999999 (BOX 14)

HIQ.105 INTERVIEWER: ENTER 1 RESPONSE

CARD AVAILABLE 1

CARD NOT AVAILABLE 2 (BOX 14)

BOX 14

CHECK ITEM HIQ.269:

IF (HIQ.011 = 1 AND HIQ.031 NOT = 140) OR HIQ.260 = 1, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

BOX 6

OMITTED

BOX 7

OMITTED

BOX 8

OMITTED

BOX 9

OMITTED

HIQ.270 Does the plan pay for any of the costs for medications prescribed by a doctor?

CAPI INSTRUCTION:

IF HIQ.031 = 2 or HIQ.260 = 1, DISPLAY: [If you are enrolled in Medicare Part D, also known as the Medicare Prescription Drug Plan, you have some prescription drug coverage.]

Yes 1

No 2

Refused 7

Don't know 9

HIQ.210 In the past 12 months, was there any time when {you/SP} did not have any health insurance or coverage?

Yes 1

No 2

Refused 7

Don't know 9

HELP SCREEN FOR HIQ.011:

Health Insurance: Health benefits coverage which provides persons with health-related benefits. Coverage may include the following; hospitalization, major medical, surgical, prescriptions, dental, and vision.

Medicare: A Federal health insurance program for people 65 or older and for certain persons under 65 with long-term disabilities. Almost all Social Security recipients are covered by Medicare. It is run by the Center for Medicare and Medicaid Services of the U.S., Department of Health and Human Services.

Medicare consists of two parts, A and B:

Part A is called the Hospital Insurance Program. It helps pay for inpatient care in a hospital or in a skilled nursing facility, for home health care, and for hospice care. It is available to nearly everyone 65 or older.

Persons who are eligible for either Social Security or Railroad Retirement benefits are not required to pay a monthly premium for Part A of Medicare. However, anyone who is 65 or over and does not qualify for Social Security or Railroad Retirement benefits may pay premiums directly to Social Security to obtain Part A coverage.

Part B is called the Supplementary Medical Insurance Program. It is a voluntary plan that builds upon the hospital insurance protection provided by the basic plan. It helps pay for the doctor and surgeon services, outpatient hospital services, durable medical equipment, and a number of other medical services and supplies that are not already covered under Part A of Medicare.

If a person elects this additional insurance, the monthly premium is deducted from his/her Social Security.

Medicaid: Refers to a medical assistance program that provides health care coverage to low-income and disabled persons. The Medicaid program is a joint federal-state program which is administered by the states.

HELP SCREEN FOR HIQ.031:

Private Health Insurance Plan: Any type of health insurance, including HMOs, that is not a public program. Private health insurance plans may be provided in part or full by a person's employer or union, or may be purchased directly by an individual.

Private Health Insurance Plan through a State or Local Government Program or Community Program: A type of health insurance for which state or local government or community effort pays for part or all of the cost of a private insurance plan, such as Blue Cross/Blue Shield. The individual may also contribute to the cost of the health insurance and may receive a card such as a Blue Cross/Blue Shield card. A community program or effort may include a variety of mechanisms to achieve health insurance for persons who would otherwise be uninsured. An example would be a private company giving a grant to an HMO to pay for health insurance coverage.

Medicare consists of two parts, A and B:

If a person elects this additional insurance, the monthly premium is deducted from his/her Social Security.

Medi-Gap: Refers to private health insurance purchased to supplement Medicare. Medi-Gap will be treated as a private health insurance plan in the detailed questions about health insurance.

CHIP (Children's Health Insurance Program, also called SCHIP): A joint federal and state program, administered by each state, that offers health care coverage to low-income, uninsured children. This law was passed in 1997. In some states, CHIP programs have distinct names.

Military Health Care/VA: Refers to health care available to active duty personnel and their dependents, in addition, the VA provides medical assistance to veterans of the Armed Forces, particularly those with service-connected ailments.

CHAMPUS/TRICARE/CHAMP-VA: TRICARE, formally known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) provides civilian health benefits for U.S. Armed Forces military personnel, military retirees, and their dependents. Several variations of the plan exist including (but not limited to): TRICARE Reserve Select, TRICARE Prime, TRICARE Select, U.S. Family Health Plan, TRICARE Select Overseas, TRICARE for Life. CHAMP-VA (Comprehensive Health and Medical Plan of the Veterans Administration) provides health care for the spouse, dependents, or survivors of a veteran who has a total, permanent service-connected disability.

Indian Health Service: The federal health care program for Native Americans.

State-Sponsored Health Plan: Any other health care coverage run by a specific state, including public assistance programs other than "Medicaid" that pay for health care.

Other Government Program: A catch-all category for any public program providing health care coverage other than those programs in specific categories.

HELP SCREEN FOR HIQ.502:

Medicare consists of two parts, A and B:

INFANT FORMULA Questionnaire - IFQ

Target Group: SPs Birth to 24 Months

BOX 1

IF SP ≥24 MONTHS, GO TO THE END OF THE SECTION.

IF DBQ050= MISSING, GO TO END OF SECTION.

IF DBQ050G=1 AND THE DIFFERENCE BETWEEN AGE REPORTED IN DBQ.050 AND THE DATE OF INTERVIEW <=2 WEEKS, CONTINUE. IF THE DIFFERENCE BETWEEN AGE REPORTED IN DBQ.050 AND THE DATE OF INTERVIEW >2 WEEKS, GO TO END OF SECTION.

IFQ.001 Now I’d like to know about any infant and toddler formulas {SP} had in the past two weeks. May I please see the containers for all the infant and toddler formulas that were fed to {SP} (in the past two weeks)?

INTERVIEWER INSTRUCTION: TODDLER FORMULAS MAY ALSO BE CALLED TODDLER MILK, GROWING UP MILK, OR FOLLOW-ON FORMULA.

ENTER INFANT AND TODDLER

FORMULA NAME 1

DID NOT TAKE INFANT OR

TODDLER FORMULA .................................... 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

CAPI INSTRUCTION: IFQ.005 THROUGH IFQ.040 SHOULD APPEAR ON 1 LINE ON A GRID ALLOWING UP TO 5 ENTRIES.

IFQ.005

IFQ.005OS PRESS BS TO START THE LOOKUP.

SELECT FORMULA FROM LIST.

IF FORMULA NOT ON LIST – PRESS BS

TO DELETE ENTRY

TYPE '**'.

PRESS ENTER TO SELECT.

INTERVIEWER INSTRUCTION FOR IFQ.005OS: ENTER THE FULL NAME OF THE FORMULA INCLUDING BRAND, BASE, FORM, QUALIFIERS, AND AGE.

CAPI INSTRUCTION:

DISPLAY FORMULA LIST. INTERVIEWER SHOULD BE ABLE TO SELECT ONLY 1 FORMULA OR THE '**' OPTION.

DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS.

DISPLAY PRODUCT NAME AS LEFT HEADER.

DISPLAY “IFQ.005” OR “IFQ.005OS” AS COLUMN HEADER

IF ‘**’ OPTION IS SELECTED, DISPLAY ‘OS’ ENTRY FIELD OF 215 CHARACTERS.

IF ‘**’ OPTION IS SELECTED, DISPLAY ‘OS’ ENTRY IN HEADER IN SUBSEQUENT QUESTIONS INSTEAD OF FORMULA SELECTED FROM LIST.

FORMULA NAME SELECTED

REFUSED 77

DON'T KNOW 99

IFQ.010 INTERVIEWER: ENTER 1 RESPONSE

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

DISPLAY “IFQ.010” AS COLUMN HEADER

CONTAINER SEEN 1

CONTAINER NOT SEEN 2

BOX 2

CHECK ITEM IFQ.NEW4:

IF FORMULA ON LIST AND CODE 1 FOR IFQ.010, SKIP TO IFQ.055.

OTHERWISE, CONTINUE.

IFQ.015 INTERVIEWER: WHAT IS THE BASE OF THIS FORMULA? SELECT ONE RESPONSE.

IF CONTAINER IS NOT SEEN, PROBE IF NECESSARY BY READING POSSIBLE RESPONSE OPTIONS.

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

DISPLAY “IFQ.015” AS COLUMN HEADER

MILK 1

SOY 2

OTHER 3

IFQ.020 INTERVIEWER: WHAT IS THE FORM OF THIS FORMULA?. SELECT ONE RESPONSE.

IF CONTAINER IS NOT SEEN, PROBE IF NECESSARY BY READING POSSIBLE RESPONSE OPTIONS.

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

DISPLAY “IFQ.020” AS COLUMN HEADER

POWDER 1

READY TO USE 2

LIQUID CONCENTRATE 3

OTHER 4

IFQ.025 INTERVIEWER: WHAT ARE THE QUALIFIERS FOR THIS FORMULA? SELECT ALL THAT APPLY.

IFQ.025OS

IF CONTAINER IS NOT SEEN, PROBE IF NECESSARY BY READING POSSIBLE RESPONSE OPTIONS.

INTERVIEWER INSTRUCTION FOR IFQ.025OS: SPECIFY QUALIFIER.

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

DISPLAY “IFQ.025” OR “IFQ.025OS” AS COLUMN HEADER

CODE ALL THAT APPLY.

EDIT: “NO QUALIFIERS” MAY NOT BE CHOSEN WITH ANY OTHER ENTRY

NO QUALIFIERS 1

IRON 2

LOW IRON 3

ARA 4

DHA 5

LUTEIN 6

NON-GMO 7

ORGANIC 8

PREBIOTIC 9

PROBIOTIC 10

VITAMIN E 11

OTHER (SPECIFY) 91

IFQ.030 INTERVIEWER: WHAT IS THE AGE FOR THIS FORMULA? SELECT ONE RESPONSE.

IFQ.030OS IF CONTAINER IS NOT SEEN, PROBE IF NECESSARY BY READING POSSIBLE RESPONSE OPTIONS

INTERVIEWER: INSTRUCTION FOR IFQ.030OS: SPECIFY AGE.

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

DISPLAY “IFQ.030” OR “IFQ.030OS” AS COLUMN HEADER

NO AGE RANGE 1

BIRTH TO 12 MONTHS 2

FIRST 12 MONTHS 3

THROUGH 12 MONTHS 4

0-3 MONTHS 5

0-24 MONTHS 6

6-12 MONTHS 7

9 MONTHS & UP 8

9-18 MONTHS 9

9-36 MONTHS 10

12 MONTHS & UP 11

1-3 YEARS 12

OTHER (SPECIFY) 91

IFQ.035

IFQ.035OS PRESS BS TO START THE LOOKUP.

SELECT MANUFACTURER FROM LIST.

IF MANUFACTURER NOT

ON LIST – PRESS BS

TO DELETE ENTRY

TYPE '**'.

PRESS ENTER TO SELECT.

INTERVIEWER INSTRUCTION FOR IFQ.035OS: ENTER MANUFACTURER NAME.

CAPI INSTRUCTION:

DISPLAY MANUFACTURER LIST. INTERVIEWER SHOULD BE ABLE TO SELECT ONLY 1 MANUFACTURER OR THE '**' OPTION.

DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS.

IF ‘**’ OPTION IS SELECTED, DISPLAY ‘OS’ ENTRY FIELD OF 50 CHARACTERS.

DISPLAY PRODUCT NAME AS LEFT HEADER.

DISPLAY “IFQ.035” OR “IFQ.035OS” AS COLUMN HEADER

BOX 3

CHECK ITEM IFQ.040:

IF NOT ON MANUFACTURER LIST, CONTINUE.

IF ON MANUFACTURER LIST, SKIP TO IFQ.055.

IFQ.045 INTERVIEWER: ENTER MANUFACTURER CITY

INTERVIEWER: IF FORMULA IS FROM A FOREIGN COUNTRY, ENTER COUNTRY OF MANUFACTURER.

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

DISPLAY “IFQ.045” AS COLUMN HEADER

DISPLAY TEXT ENTRY FIELD

IFQ.050 PRESS BS TO START THE LOOKUP.

SELECT STATE FROM LIST.

IF FORMULA IS FROM A FOREIGN COUNTRY, ENTER DON’T KNOW.

PRESS ENTER TO SELECT.

CAPI INSTRUCTION:

DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS.

DISPLAY PRODUCT NAME AS LEFT HEADER.

DISPLAY “IFQ.050” AS COLUMN HEADER

IFQ.055 For how long has {SP} been fed this formula?

Q/U

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

DISPLAY IFQ.055 AS COLUMN HEADER

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.

EDIT: LENGTH OF TIME CANNOT BE GREATER THAN SP’S AGE

|___|___|___|___|

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

REFUSED 7777777 (IFQ.005 ON NEXT LINE)

DON'T KNOW 9999999 (IFQ.005 ON NEXT LINE)

|___|

ENTER UNIT

DAYS 1 (IFQ.005 ON NEXT LINE)

WEEKS 2 (IFQ.005 ON NEXT LINE)

MONTHS 3 (IFQ.005 ON NEXT LINE)

YEARS 4 (IFQ.005 ON NEXT LINE)

IFQ.060 CHECK CONTAINERS. ARE THERE ANY OTHER FORMULAS?

OR ASK RESPONDENT:

[Did SP drink any other infant or toddler formulas in the past two weeks?]

CAPI INSTRUCTIONS:

DISPLAY PRODUCT NAME AS LEFT HEADER.

DISPLAY IFQ.060 AS COLUMN HEADER

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 4

CHECK ITEM IFQ.NEW2:

ASK IFQ.005-IFQ.055 FOR NEXT FORMULA (CODE 1 IN IFQ.060). IF NO NEXT FORMULA (CODE 2,7,9 IN IFQ.060), CONTINUE

IFQ.070 REVIEW TOTAL NUMBER OF FORMULAS AND THEIR NAMES WITH RESPONDENT.

I have listed {TOTAL NUMBER} formula(s) that {SP} has taken in the past two weeks: {PRODUCT NAME(S)}

PRESS ENTER TO CONTINUE

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL FORMULAS SELECTED AT IFQ.005 AND ENTERED IN IFQ.005OS. CALCULATE TOTAL NUMBER OF ALL FORMULAS SELECTED AT IFQ.005 AND ENTERED IN IFQ.005OS. DISPLAY NUMBER ON SCREEN.

DIETARY SUPPLEMENTS AND PRESCRIPTION MEDICATION – DSQ

Target Group: SPs Birth +

DSQ.012 The next questions are about {your/SP's} use of dietary supplements, nonprescription antacids, and prescription medications during the past 30 days.

{Have you/Has SP} used or taken any vitamins, minerals, herbals or other dietary supplements in the past 30 days? Include prescription and non-prescription supplements.

This card lists some examples of different types of dietary supplements.

HAND CARD DSQ1a

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

RXQ.021 {Have you/Has SP} used or taken any nonprescription antacids in the past 30 days?

HAND CARD DSQ1b

CAPI INSTRUCTION:

IF ITEM CHANGED, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.

Past Month: The past 30 days. From yesterday, 30 days back.

BOX 0

OMITTED

RXQ.033 In the past 30 days, {have you/has SP} used or taken medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. {Please remember to include any prescription birth control products that you are taking or using such as pills or patches.} [Do not include prescription vitamins or minerals you may have already told me about.]

YES 1 (BOX 0AA)

NO 2 (BOX 0AA)

REFUSED 7 (BOX 0AA)

DON'T KNOW 9 (BOX 0AA)

CAPI INSTRUCTION:

IF SP FEMALE AND AGE 16-49 YEARS, DISPLAY ‘Please remember to include prescription birth control products that you are taking or using such as pills or patches.’

CAPI HARD EDIT CHECK #1

IF ‘NO’ (CODE 2) IN RXQ.033 AND ‘YES’ (CODE 1) IN DIQ.050 OR DIQ.070, DISPLAY THE FOLLOWING MESSAGE:

Earlier in the interview you reported currently taking insulin or a diabetic pill. If this is correct, we should count that as prescription medication you have taken in the last 30 days.

{CAPI DISPLAYS THREE QUESTIONS FOR CORRECTION}

DIQ.050 = Taking Insulin

DIQ.070 = Taking Diabetic Pills

RXQ.033 = Prescription Medication in Last 30 Days

CAPI HARD EDIT CHECK #2

IF ‘NO’ (CODE 2) IN RXQ.033 AND ‘YES’ (CODE 1) IN BPQ.050a, DISPLAY THE FOLLOWING MESSAGE:

Earlier in the interview you reported currently taking prescription medication for high blood pressure. If this is correct, we should count that as prescription medication you have taken in the last 30 days.

{CAPI DISPLAYS TWO QUESTIONS FOR CORRECTION}

BPQ.050a = Taking Blood Pressure Medication

RXQ.033 = Prescription Medication in Last 30 Days

CAPI HARD EDIT CHECK #3

IF ‘NO’ (CODE 2) IN RXQ.033 AND ‘YES’ (CODE 1) IN BPQ.100d, DISPLAY THE FOLLOWING MESSAGE:

Earlier in the interview you reported currently taking prescription medication for high cholesterol. If this is correct, we should count that as prescription medication you have taken in the last 30 days.

{CAPI DISPLAYS TWO QUESTIONS FOR CORRECTION}

BPQ.100d = Taking High Cholesterol Medicine

RXQ.033 = Prescription Medication in Last 30 Days

BOX 0A

OMITTED

DSQ.042 May I please see the containers for all the {vitamins, minerals, herbals, and other dietary supplements}, {and} {nonprescription antacids} {and} {prescription medicines} that {you/SP} used or took in the past 30 days?

PRESS ENTER TO CONTINUE

CAPI INSTRUCTION:

DISPLAY {vitamins, minerals, herbals and other dietary supplements,} only if DSQ.012 = yes (1), {nonprescription antacids.} only if RXQ.021 = yes (1), {prescription medicines,} only if RXQ.033, RXQ.100 or RXQ.120 = yes (1), and the word {“and”} only before the last product type if there is more than one product type.

BOX 1A

CHECK ITEM DSQ.045:

IF 'YES' (CODE 1) IN DSQ.012, CONTINUE WITH DSQ.055.

OTHERWISE, GO TO BOX 6.

DSQ.055 I will start with the vitamins, minerals, herbals and other dietary supplements. Please show me any {you have/SP has} taken in the past 30 days.

CHECK THE BACK OF THE PRODUCT LABEL AND VERIFY THAT THIS IS THE ONLY NUTRIENT (ELEMENT) LISTED IN THE SUPPLEMENTS FACTS BOX. IF THERE IS ANYTHING ELSE LISTED, ENTER AS A REGULAR PRODUCT.

IS THIS PRODUCT ON THE LIST BELOW?

YES 1

NO 2 (DSQ.052)

DON’T KNOW 9 (DSQ.052)

VITAMIN A 10

VITAMIN B6 12

VITAMIN B12 13

VITAMIN C (WITH OR WITHOUT ROSE
HIPS) 14

VITAMIN D (D3) 15

VITAMIN E 16

CALCIUM 18

CHROMIUM (CHROMIUM PICOLINATE) 19

FOLATE (FOLIC ACID) 20

IRON (FERROUS XXXATE) 21

MAGNESIUM 27

POTASSIUM 28

SELENIUM 29

ZINC (ZINC GLUCONATE) 40

DSQ.056 WHICH PRODUCT IS IT?

CHECK THE BACK OF THE PRODUCT LABEL AND VERIFY THAT THIS IS THE ONLY NUTRIENT (ELEMENT) LISTED IN THE SUPPLEMENTS FACTS BOX. IF THERE IS ANYTHING ELSE LISTED, ENTER AS A REGULAR PRODUCT.

ENTER 1 PRODUCT CODE

CAPI INSTRUCTION:

IF ITEM CHANGED, CHECK MEC COMPONENT.

VITAMIN A 10

VITAMIN B6 12

VITAMIN B12 13

VITAMIN C (WITH OR WITHOUT ROSE
HIPS) 14

VITAMIN D (D3) 15

VITAMIN E 16

CALCIUM 18

CHROMIUM (CHROMIUM PICOLINATE) 19

FOLATE (FOLIC ACID) 20

IRON (FERROUS XXXATE) 21

MAGNESIUM 27

POTASSIUM 28

SELENIUM 29

ZINC (ZINC GLUCONATE) 40

REFUSED 77 (DSQ.052)

DON’T KNOW 99 (DSQ.052)

BOX 1B

CHECK ITEM DSQ.059:

GO TO DSQ.071.

DSQ.052 REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF DIETARY SUPPLEMENTS USED. ENTER FULL NAME OF SUPPLEMENT, INCLUDING BRAND.

ENTER SUPPLEMENT NAME

REFUSED 7---7

DON'T KNOW 9---9

CAPI INSTRUCTION:

IF DON'T KNOW OR REFUSAL, THEN GO TO BOX 6.

SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED.

TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.

IF ITEM CHANGED, CHECK MEC COMPONENT.

DSQ.060s OMITTED

BOX 2

OMITTED

DSQ.057 OMITTED

DSQ.071 INTERVIEWER: ENTER 1 RESPONSE

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

IF ITEM CHANGED, CHECK MEC COMPONENT.

CONTAINER SEEN 1

CONTAINER NOT SEEN 2

BOX 2A

CHECK ITEM DSQ.074:

IF PRODUCT WAS SELECTED FROM SPECIAL PRODUCT LIST (YES, CODE 1 IN DSQ.055) AND CONTAINER SEEN, CONTINUE.
IF PRODUCT WAS NOT SELECTED FROM SPECIAL PRODUCT LIST (NO, CODE 2 IN DSQ.055) AND CONTAINER SEEN, GO TO DSQ.077.
OTHERWISE (IF CONTAINER NOT SEEN), GO TO DSQ.096.

DSQ.066 SELECT STRENGTH FOR {ELEMENT}

a/aO

IF STRENGTH NOT ON FRONT OR UNCLEAR, TURN CONTAINER AROUND AND GET STRENGTH FROM FACTS BOX.

PRESS BS TO START LOOKUP.

PRESS ENTER TO SELECT.

CAPI INSTRUCTION:

{ELEMENT} = DISPLAY PRODUCT ELEMENT SELECTED IN DSQ.056.
DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS.
IF “OTHER” STRENGTH IS SELECTED, GET OTHER SPECIFY AND INTERVIEWER INSTRUCTION SHOULD READ “ENTER SUPPLEMENT STRENGTH”.
ALL OF THE STRENGTH QUESTION AND INSTRUCTION SHOULD APPEAR WHEN STRENGTH LOOKUP LIST IS DISPLAYED (NO SCROLLING). THIS MAY MEAN PRINTING ALL WORDS ON THE SCREEN FLUSH LEFT IN MULTIPLE LINES.
IF ITEM CHANGED, CHECK MEC COMPONENT.

BOX 3

OMITTED

DSQ.077 WHAT IS THE FORM OF THIS PRODUCT?

CAPSULES 1

TABLETS 2

CHEWABLE TABLETS 3

PILLS 4

CAPLETS 5

SOFT GELS 6

GEL CAPS 7

VEGICAPS 8

PACKAGE/PACKETS 9

LIQUID 10

POWDER 11

WAFERS 12

CHEWS/GUMMIES 13

DOTS 14

GRANULES 15

LOZENGES/COUGH DROPS 16

GEL 17

OTHER FORM (SPECIFY) 91

REFUSED 77

DON’T KNOW 99

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

IF ITEM CHANGED, CHECK MEC COMPONENT.

BOX 3A

CHECK ITEM DSQ.079:

IF PRODUCT NOT SELECTED FROM SPECIAL PRODUCT LIST (NO, CODE 2 IN DSQ.055), CONTINUE.

OTHERWISE, GO TO DSQ.096.

DSQ.081K ENTER MANUFACTURER/DISTRIBUTOR/STORE BRAND NAME.

ENTER AS MUCH INFORMATION AS POSSIBLE.

ENTER MANUFACTURER/DISTRIBUTOR/STORE BRAND NAME

REFUSED 7----7 (DSQ.088b)

DON'T KNOW 9----9 (DSQ.088b)

CAPI INSTRUCTION:

FOLLOW THE BASIC FORMAT FOR THE DIETARY SUPPLEMENT LOOKUP. ONLY ALLOW ENTRY OF 1 MANUFACTURER. DISPLAY PRODUCT NAME AS A LEFT HEADER.

DSQ.084 PRESS BS TO START THE LOOKUP.

SELECT MANUFACTURER

FROM LIST.

IF MANUFACTURER NOT

ON LIST – PRESS BS

TO DELETE ENTRY

TYPE '**'.

PRESS ENTER TO SELECT.

CAPI INSTRUCTION:

DISPLAY MANUFACTURER LIST. INTERVIEWER SHOULD BE ABLE TO SELECT ONLY 1 MANUFACTURER OR THE '**' OPTION.

DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS.

IF MANUFACTURER IS SELECTED FROM THE LOOKUP LIST, AUTOMATICALLY FILL IN THE CITY (DSQ088B) AND STATE INFORMATION (DSQ.088C).

IF ‘**’ OPTION IS SELECTED, DSQ088A (MANUFACTURER NAME) IS OBTAINED FROM DSQ081K.

DISPLAY PRODUCT NAME AS LEFT HEADER.

BOX 4

CHECK ITEM DSQ.085:

IF MANUFACTURER SELECTED FROM LOOKUP, GO TO DSQ.096.

OTHERWISE, CONTINUE.

DSQ.088b ENTER CITY NAME.

ENTER AS MUCH INFORMATION AS POSSIBLE.

ENTER CITY

REFUSED 7---7

DON’T KNOW 9---9

DSQ.088c ENTER STATE NAME.

ENTER 2-LETTER

STATE ABBREVIATION.

PRESS ENTER TO

SELECT STATE FROM LIST.

ENTER STATE

REFUSED 7777

DON'T KNOW 9999

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS A LEFT HEADER.

AN ENTRY MUST BE MADE IN ALL DSQ.081 AND DSQ.087 FIELDS (MANUFACTURER INFO). IF THE MANUFACTURER INFO IS DON'T KNOW OR REFUSED, THEN SET THE NO MANUFACTURER INFORMATION VARIABLE.

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 7777777 (DSQ.103)

DON'T KNOW 9999999 (DSQ.103)

|___|

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DSQ.103 In the past {30 DAYS/NUMBER AND UNIT}, on how many days did {you/SP} take {PRODUCT NAME}?

CAPI INSTRUCTION:

{30 DAYS/NUMBER AND UNIT} = IF NUMBER AND UNIT ENTERED IN DSQ.096 >= 30 DAYS, OR REFUSED (CODE 7), OR DON’T KNOW (CODE 9), DISPLAY “30 DAYS” IN TEXT OF QUESTION. IF NUMBER AND UNIT ENTERED IN DSQ.096 IS < 30 DAYS, DISPLAY ACTUAL NUMBER AND UNIT ENTERED IN DSQ.096 IN TEXT OF QUESTION.
{PRODUCT NAME} = PRODUCT SELECTED AT DSQ.056 OR PRODUCT ENTERED IN DSQ.052.

|___|___|

ENTER NUMBER OF DAYS FROM 1-30

REFUSED 7777

DON'T KNOW 9999

DSQ.123 On the days that {you/SP} took {PRODUCT NAME}, how much did {you/SP} usually take on a single day?

Q/U/OS

CAPI INSTRUCTION:

SOFT EDIT: QUANTITY SHOULD BE LESS THAN 10.

HARD EDIT: NUMBER MUST BE IN 0.20 – 60.0 RANGE.

ERROR MESSAGE: “You said {you/he/she} took {QUANTITY TAKEN}. Is that correct?”

|___|___|___|

ENTER NUMBER

REFUSED 777777 (DSQ.124)

DON'T KNOW 999999 (DSQ.124)

|___|___|

ENTER UNIT/FORM

TABLETS/CAPSULES/PILLS/CAPLETS/
SOFTGELS/GEL CAPS/VEGICAPS/
CHEWABLE TABLETS 1 (07BOX NEW 4A)

DROPPERS 2 (07BOX NEW 4A)

DROPS 3 (07BOX NEW 4A)

INJECTIONS/SHOTS 5 (07BOX NEW 4A)

LOZENGES/COUGH DROPS 6 (07BOX NEW 4A)

MILLILITERS 7 (07BOX NEW 4A)

TABLESPOONS 11 (07BOX NEW 4A)

TEASPOONS 12 (07BOX NEW 4A)

WAFERS 13 (07BOX NEW 4A)

CANS 15 (07BOX NEW 4A)

GRAMS 16 (07BOX NEW 4A)

DOTS 17 (07BOX NEW 4A)

CUPS 18 (07BOX NEW 4A)

SPRAYS/SQUIRTS 19 (07BOX NEW 4A)

CHEWS/GUMMIES 20 (07BOX NEW 4A)

SCOOPS 21 (07BOX NEW 4A)

CAPFULS 23 (07BOX NEW 4A)

OUNCES 27 (07BOX NEW 4A)

PACKAGES/PACKETS 28 (CONTINUE)

VIALS 29 (07BOX NEW 4A)

GUMBALLS 30 (07BOX NEW 4A)

OTHER FORM (SPECIFY) 91 (07BOX NEW 4A)

REFUSED 77 (07BOX NEW 4A)

DON’T KNOW 99 (07BOX NEW 4A)

CAPI INSTRUCTION:

IF FORM CODE 1 THROUGH 8 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 1 AND SKIP TO 07BOX NEW 4A.

IF FORM CODE 12 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 13 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.

IF FORM CODE 13 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 20 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.

IF FORM CODE 14 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 17 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.

IF FORM CODE 16 IN DSQ.077, AUTOMATICALLY CODE THE UNIT CODE 6 FOR DSQ.123U AND SKIP TO 07BOX NEW 4A.

IF FORM CODE 9 IN DSQ.077, DISPLAY THE UNIT CODES 1, 6, 7, 11, 12, 13, 15, 16, 17, 18, 20, 21, 23, 27, 28, 30, 91, 77, 99 FOR DSQ.123U.

IF FORM CODE 10, 17 IN DSQ.077, DISPLAY THE UNIT CODES 2, 3, 5, 7, 11, 12, 15, 18, 19, 23, 27, 29, 91, 77, 99 FOR DSQ.123U.

IF FORM CODE 11, 15 IN DSQ.077, DISPLAY THE UNIT CODES 11, 12, 15, 16, 18, 21, 23, 27, 28, 91, 77, 99 FOR DSQ.123U.

IF FORM CODE 91, 77, 99 IN DSQ.077, DISPLAY ENTIRE PICK LIST FOR DSQ.123U.

IF CONTAINER NOT SEEN (CODE 2 IN DSQ.071), DISPLAY ENTIRE PICK LIST FOR DSQ.123U.

DSQ.125 {Did you/Does SP} take an entire packet of {PRODUCT NAME} each time?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

07BOX NEW 4A

CHECK ITEM DSQ.105:

IF PRODUCT NOT SEEN IN DSQ.071 (CODE 2) AND DSQ.123 = 7, 11, 12, 15, 16, 18, 21, 23 OR 27, CONTINUE.

OTHERWISE, SKIP TO DSQ.124.

DSQ.110 Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 77

DON'T KNOW 99

DSQ.124 What is the reason {you take/SP takes} {PRODUCT NAME}?

Did {you/SP NAME} decide to take it for reasons of your own or did a doctor or other health provider tell you to take it?

DECIDED TO TAKE IT FOR REASONS
OF MY OWN 1

A DOCTOR OR OTHER HEALTH
PROVIDER TOLD ME TO 2

REFUSED 7 (DSQ.127)

DON’T KNOW 9 (DSQ.127)

DSQ.136 {For what reason or reasons {do you/does SP} take {PRODUCT NAME}?}

DSQ137OS {For what reason or reasons did the doctor or other health professional tell {you/SP} to take {PRODUCT}?}

HAND CARD DSQ2

CODE ALL THAT APPLY.

TO:

BUILD MUSCLE 35

GAIN WEIGHT 36

GET MORE ENERGY 25

IMPROVE DIGESTION 31

IMPROVE MY OVERALL HEALTH 14

MAINTAIN HEALTH (TO STAY HEALTHY) 17

MAINTAIN HEALTHY BLOOD SUGAR
LEVEL, DIABETES 29

PREVENT COLDS, BOOST IMMUNE
SYSTEM 18

PREVENT HEALTH PROBLEMS 13

SUPPLEMENT MY DIET (BECAUSE I
DON’T GET ENOUGH FROM FOOD) 16

FOR:

ANEMIA, SUCH AS LOW IRON 27

BONE HEALTH, BUILD STRONG BONES,
OSTEOPOROSIS 24

EYE HEALTH 20

GOOD BOWEL/COLON HEALTH 10

HEALTHY JOINTS, ARTHRITIS 21

HEALTHY SKIN, HAIR, AND NAILS 22

HEART HEALTH, CHOLESTEROL 19

KIDNEY AND BLADDER HEALTH, URINARY
TRACT HEALTH 30

LIVER HEALTH, DETOXIFICATION,
CLEANSE SYSTEM 34

MENOPAUSE, HOT FLASHES 28

MENTAL HEALTH 12

MUSCLE RELATED ISSUES, MUSCLE
CRAMPS 32

PREGNANCY/BREASTFEEDING 26

PROSTATE HEALTH 11

RELAXATION, DECREASE STRESS,
IMPROVE SLEEP 33

TEETH, PREVENT CAVITIES 15

WEIGHT LOSS 23

OTHER SPECIFY 91

REFUSED 77

DON’T KNOW 99

CAPI INSTRUCTION:

IF CODE 1 IN DSQ.124, DISPLAY For what reason or reasons {do you/does SP} take {PRODUCT NAME}?

IF CODE 2 IN DSQ.124, DISPLAY For what reason or reasons did the doctor or other health professional tell {you/SP} to take {PRODUCT}?

DSQ.127 ARE THERE ANY OTHER VITAMINS, MINERALS, HERBALS OR DIETARY SUPPLEMENTS?

YES 1

NO 2

HELP SCREEN:

Dietary Supplements (Vitamins/Minerals): Dietary supplements are often labeled as "dietary supplements" and are used in addition to foods and beverages. Dietary supplements are not intended to replace food. Include vitamins, minerals, antacid/calcium supplement products, fiber supplements, amino acids, performance enhancers, herbs, herbal medicine products, and plant extracts used as dietary supplements. Include products that are taken orally or given by injection. Do not include beverages, such as tea, and skin creams. Meal replacement beverages, weight loss and performance booster drinks, and food bars are considered foods, not dietary supplements.

BOX 5

CHECK ITEM DSQ.129:

ASK DSQ.127 FOR NEXT VITAMIN (CODE 1 IN DSQ.127). IF NO NEXT VITAMIN (CODE 2 IN DSQ.127), CONTINUE WITH DSQ.131.

DSQ.131 REVIEW TOTAL NUMBER OF DIETARY SUPPLEMENTS AND THEIR NAMES WITH RESPONDENT.

I have listed {TOTAL NUMBER} vitamin(s), mineral(s), herbals or dietary supplement(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME (STRENGTH)}

PRESS ENTER TO CONTINUE

CAPI INSTRUCTION:

DISPLAY LIST OF ALL VITAMIN AND MINERAL NAMES AND STRENGTHS SELECTED AT DSQ.056 AND ENTERED AT DSQ.052. CALCULATE TOTAL NUMBER OF ALL VITAMINS AND MINERALS SELECTED AT DSQ.056 AND ENTERED AT DSQ.052. DISPLAY NUMBER ON SCREEN.

HELP SCREEN:

BOX 6

CHECK ITEM DSQ.133:

IF 'YES' (CODE 1) IN RXQ.021, CONTINUE.

OTHERWISE, GO TO NEW BOX 10AA.

RXQ.141 Now I would like to ask you some questions about {your/SP's} use of nonprescription antacids in the past 30 days.

[First I will record some information about an antacid, then I will ask you some questions about it.]

REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF NONPRESCRIPTION ANTACIDS USED. ENTER FULL BRAND NAME OF ANTACID.

ENTER ANTACID NAME

REFUSED 7---7

DON'T KNOW 9---9

CAPI INSTRUCTION:

IF DON'T KNOW OR REFUSED, THEN GO TO BOX 10AA.

SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.

[TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.

IF ITEM CHANGED, CHECK MEC COMPONENT.

HELP SCREEN:

Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.

Past Month: The past 30 days. From yesterday, 30 days back.

RXQ.150s PRESS BS TO START THE LOOKUP.

SELECT ANTACID

FROM LIST.

IF ANTACID NOT

ON LIST – PRESS BS

TO DELETE ENTRY.

TYPE '**'.

PRESS ENTER TO SELECT.

CAPI INSTRUCTION:

DISPLAY CAPI ANTACID PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN RXQ.141 BY TYPING IN "**". THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.

INTERVIEWER SHOULD BE ABLE TO ACCEPT THE KEYED NAME AS A NEW PRODUCT NAME AN UNLIMITED NUMBER OF TIMES. AFTER ENTRY, INTERVIEWER SHOULD RETURN TO THE DATA BASE LIST. IF NO MORE ENTRIES, INTERVIEWERS SHOULD HAVE A WAY OF MOVING INTO LOOP 2.

ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:

DRUG TYPE {3}

GENERIC NAME {60}

THERAPEUTIC CLASS CODE {6}

GENERIC FLAG {1}

THERE IS NO NEED TO DISPLAY THIS INFORMATION.

IF ITEM CHANGED, CHECK MEC COMPONENT.

BOX 7

OMITTED

RXQ.160 INTERVIEWER: ENTER 1 RESPONSE.

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS LEFT HEADER.

IF ITEM CHANGED, CHECK MEC COMPONENT.

CONTAINER SEEN 1

CONTAINER NOT SEEN 2

RXQ.180 For how long {have/has} {you/SP} been using or taking {PRODUCT NAME}?

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 7777777 (RXQ.191)

DON'T KNOW 9999999 (RXQ.191)

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

RXQ.191 In the past {30 DAYS/NUMBER AND UNIT}, on how many days did {you/SP} take {PRODUCT NAME}?

CAPI INSTRUCTION:

{30 DAYS/NUMBER AND UNIT} = IF NUMBER AND UNIT ENTERED IN RXQ.180 >= 30 DAYS, OR REFUSED (CODE 7), OR DON’T KNOW (CODE 9), DISPLAY “30 DAYS” IN TEXT OF QUESTION. IF NUMBER AND UNIT ENTERED IN RXQ.180 IS < 30 DAYS, DISPLAY ACTUAL NUMBER AND UNIT ENTERED IN DSQ.096 IN TEXT OF QUESTION.
{PRODUCT NAME} = PRODUCT SELECTED AT DSQ.056 OR PRODUCT ENTERED IN DSQ.052.

|___|___|

ENTER NUMBER OF DAYS FROM 1-30

REFUSED 7777

DON'T KNOW 9999

RXQ.195
Q/U/OS

On those days that you used or took {PRODUCT NAME}, how much did {you/SP} usually take on a single day?

CAPI INSTRUCTION:

SOFT EDIT: QUANTITY SHOULD BE LESS THAN 10.

ERROR MESSAGE: “You said {you/he/she} took {QUANTITY TAKEN}. Is that correct?”

|___|___|___|

ENTER NUMBER

REFUSED 777777 (RXQ.216)

DON'T KNOW 999999 (RXQ.216)

|___|___|

ENTER UNIT/FORM

TABLETS/CAPSULES/PILLS/CAPLETS/
SOFTGELS/GEL CAPS/VEGICAPS/
CHEWABLE TABLETS 1 (07BOX NEW 8)

DROPPERS 2 (07BOX NEW 8)

DROPS 3 (07BOX NEW 8)

INJECTIONS/SHOTS 5 (07BOX NEW 8)

LOZENGES/COUGH DROPS 6 (07BOX NEW 8)

MILLILITERS 7 (07BOX NEW 8)

TABLESPOONS 11 (07BOX NEW 8)

TEASPOONS 12 (07BOX NEW 8)

WAFERS 13 (07BOX NEW 8)

CANS 15 (07BOX NEW 8)

GRAMS 16 (07BOX NEW 8)

DOTS 17 (07BOX NEW 8)

CUPS 18 (07BOX NEW 8)

SPRAYS/SQUIRTS 19 (07BOX NEW 8)

CHEWS/GUMMIES 20 (07BOX NEW 8)

SCOOPS 21 (07BOX NEW 8)

CAPFULS 23 (07BOX NEW 8)

OUNCES 27 (07BOX NEW 8)

PACKAGES/PACKETS 28 (CONTINUE)

VIALS 29 (07BOX NEW 8)

GUMBALLS 30 (07BOX NEW 8)

OTHER FORM (SPECIFY) 91 (07BOX NEW 8)

REFUSED 77 (07BOX NEW 8)

DON’T KNOW 99 (07BOX NEW 8)

RXQ.200 {Do you/Does SP} take an entire packet each time?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

07BOX NEW 8

CHECK ITEM RXQ.205:

IF RXQ.195U IS 7, 11, 12, 15, 16, 18, 21, 23, OR 27, CONTINUE.

OTHERWISE, SKIP TO RXQ.216.

DSQ.111 Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 7

DON'T KNOW 9

RXQ.216 CHECK CONTAINERS. ARE THERE ANY OTHER NONPRESCRIPTION ANTACIDS?

OR ASK RESPONDENT:

[Are there any other nonprescription antacids that {you/SP} used in the past 30 days?]

YES 1

NO 2

HELP SCREEN:

Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.

BOX 9

CHECK ITEM RXQ.219:

ASK RXQ.141 FOR NEXT ANTACID (CODE 1 IN RXQ.216). IF NO NEXT ANTACID, (CODE 2 IN RXQ.216), CONTINUE WITH RXQ.221.

RXQ.221 REVIEW TOTAL NUMBER OF ANTACIDS AND THEIR NAMES WITH RESPONDENT.

I have listed {TOTAL NUMBER} nonprescription antacid(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}

PRESS ENTER TO CONTINUE

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL ANTACIDS SELECTED AT RXQ.150 AND ENTERED AT RXQ.141. CALCULATE TOTAL NUMBER OF ALL ANTACIDS SELECTED AT RXQ.150 AND ENTERED AT RXQ.141. DISPLAY NUMBER ON SCREEN.

HELP SCREEN:

Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.

BOX 15

OMITTED

BOX 16

OMITTED

BOX 16A

OMITTED

BOX 10A

OMITTED

NEW BOX 10AA

CHECK ITEM RXQ.227:

IF ‘YES’ (CODE 1) TO RXQ.033, RXQ.100 OR RXQ.120, CONTINUE.

OTHERWISE, GO TO NEW BOX 17A.

RXQ.231 Now I would like to talk about prescription medication {you have/SP has} used in the past 30 days. Again, these are products prescribed by a health professional such as a doctor or dentist.

[First I will record some information about the medication, then I will ask you some questions about it.]

REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF PRESCRIPTION MEDICATIONS USED.

ENTER MEDICATION NAME

REFUSED 7---7

DON'T KNOW 9---9

CAPI INSTRUCTION:

IF THE ONLY PRESCRIPTION MEDICATION IS DON'T KNOW OR REFUSED, GO TO NEW BOX 17A.

SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.

TEXT SHOULD BE OPTIONAL, "[ ]"S, AFTER THE FIRST TIME.

IF ITEM CHANGED, CHECK MEC COMPONENT.

RXQ.240s PRESS BS TO START THE LOOKUP.

SELECT MEDICATION

FROM LIST.

IF MEDICATION NOT

ON LIST – PRESS BS

TO DELETE ENTRY.

TYPE '**'.

PRESS ENTER TO SELECT

CAPI INSTRUCTION:

DISPLAY CAPI MEDICATION PRODUCT LIST. INTERVIEWER SHOULD BE ABLE TO ACCEPT THE PRODUCT NAME AS IT WAS KEYED IN RXQ.231 BY TYPING IN "**". THE LOOKUP BOX SHOULD BE LOW ENOUGH ON THE SCREEN SO THAT THE INSTRUCTION ABOUT HOW TO ACCEPT THE KEYED PRODUCT NAME IS SHOWING ABOVE THE LOOKUP BOX. THE LOOKUP SHOULD ONLY SHOW THE PRODUCT NAMES WITH THE OTHER LOOKUP INFO OFF THE SCREEN TO THE RIGHT.

ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:

DRUG TYPE {3}

GENERIC NAME {60}

THERAPEUTIC CLASS CODE {6}

GENERIC FLAG {1}

THERE IS NO NEED TO DISPLAY THIS INFORMATION.

IF ITEM CHANGED, CHECK MEC COMPONENT.

BOX 10B

OMITTED

BOX 11

OMITTED

RXQ.251 INTERVIEWER: ENTER 1 RESPONSE

CAPI INSTRUCTION:

DISPLAY PRODUCT NAME AS A LEFT HEADER.

CONTAINER SEEN 1

CONTAINER NOT SEEN 2

ONLY PHARMACY PRINT OUT SEEN 3

RXQ.260 For how long {have/has} {you/SP} been using or taking {PRODUCT NAME}?

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 7777777

DON'T KNOW 9999999

|___|

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

BOX 13

OMITTED

BOX 13A

CHECK ITEM RXQ.262:

IF RXQ240s = ‘**’ (drug not on list) or drug’s generic id does not exist in the Drug Reason table, GO TO RXQ.290.

RXQ.289 What is the main reason for which (you use/SP uses) {PRODUCT NAME}?

INTERVIEWER: IF NECESSARY, READ REASONS FROM LIST. SELECT UP TO 3 REASONS.

{Reason text} 10 (RXQ.294)

{Reason text} 11 (RXQ.294)

{Reason text} 12 (RXQ.294)

{Reason text} 13 (RXQ.294)

{Reason text} 14 (RXQ.294)

{Reason text} 15 (RXQ.294)

{Reason text} 16 (RXQ.294)

{Reason text} 17 (RXQ.294)

{Reason text} 18 (RXQ.294)

{Reason text} 19 (RXQ.294)

{Reason text} 20 (RXQ.294)

{Reason text} 21 (RXQ.294)

{Reason text} 22 (RXQ.294)

{Reason text} 23 (RXQ.294)

{Reason text} 24 (RXQ.294)

{Reason text} 25 (RXQ.294)

{Reason text} 26 (RXQ.294)

{Reason text} 27 (RXQ.294)

{Reason text} 28 (RXQ.294)

{Reason text} 29 (RXQ.294)

{Reason text} 30 (RXQ.294)

{Reason text} 31 (RXQ.294)

{Reason text} 32 (RXQ.294)

{Reason text} 33 (RXQ.294)

{Reason text} 34 (RXQ.294)

OTHER SPECIFY 97

RF 777 (RXQ.294)

DK 999 (RXQ.294)

CAPI INSTRUCTION: Populate the {Reason text} fields from the Drug Reason table. Allow up to 3 reasons to be selected and populated into RXQ298a, RXQ298b, and RXQ298c.

RXQ.290 What is the main reason for which (you use/SP uses) {PRODUCT NAME}?

REFUSED 7----7

DON'T KNOW 9----9

RXQ.294 CHECK CONTAINERS. ARE THERE ANY OTHER PRESCRIPTION MEDICATIONS?

OR ASK RESPONDENT:

[Are there any other prescription medications that {you/SP} used in the past 30 days?]

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 14

CHECK ITEM RXQ.299:

ASK RXQ.231 - RXQ.294 FOR NEXT MEDICATION (CODE 1 IN RXQ.294). IF NO NEXT MEDICATION (CODE 2 IN RXQ.294), CONTINUE WITH NEW BOX 15.

NEW BOX 15

CHECK ITEM RXQ.370:

IF DIQ.050 = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT EQUAL TO 215), CONTINUE WITH RXQ.372.

OTHERWISE, GO TO NEW BOX 15B.

RXQ.372 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one is insulin?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.

CODE ALL THAT APPLY.

SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION

REFUSED 77

DON’T KNOW 99

NEW BOX 15A

CHECK ITEM RXQ.374:

IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION.

OTHERWISE, CONTINUE.

NEW BOX 15B

CHECK ITEM RXQ.376:

IF DIQ.070 = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT EQUAL TO 213, 214, 216, 271, 282, 309, 314, 371, OR 458), THEN CONTINUE WITH RXQ.378.

OTHERWISE, GO TO NEW BOX 15D.

RXQ.378 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one {are you/is he/is she} taking for diabetes or blood sugar?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.

CODE ALL THAT APPLY.

SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION

REFUSED 77

DON’T KNOW 99

NEW BOX 15C

CHECK ITEM RXQ.380:

IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION.

OTHERWISE, CONTINUE.

NEW BOX 15D

CHECK ITEM RXQ.382:

IF BPQ.050a = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT EQUAL TO 41, 42, 44, 47, 48, 55, 56, 154, 155, 156, 340, OR 342 OR DRUG CODES NOT EQUAL TO d00132 OR d00135), THEN CONTINUE WITH RXQ.384.

OTHERWISE, GO TO NEW BOX 15F.

RXQ.384 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one {are you/is he/is she} taking to lower {your/his/her} blood pressure?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.

CODE ALL THAT APPLY.

SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION

REFUSED 77

DON’T KNOW 99

NEW BOX 15E

CHECK ITEM RXQ.386:

IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION.

OTHERWISE, CONTINUE.

NEW BOX 15F

CHECK ITEM RXQ.388:

IF BPQ.100d = 1 AND (ANY PRODUCT SELECTED FROM LOOKUP CLASS CODES NOT EQUAL TO 19 OR DRUG CODE NOT EQUAL TO d00497), THEN CONTINUE WITH RXQ.390.

OTHERWISE, GO TO RXQ.295.

RXQ.390 I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}. Which one {are you/is he/is she} taking to lower {your/his/her} cholesterol?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231.

CODE ALL THAT APPLY.

SELECT MEDICATION FROM DISPLAY
OR SELECT OTHER-NEW MEDICATION

REFUSED 77

DON’T KNOW 99

NEW BOX 15G

CHECK ITEM RXQ.392:

IF NEW MEDICATION IS SELECTED, ENTER ON NEW GRID AND ASK RXQ.231 – RXQ.294 FOR THIS MEDICATION.

OTHERWISE, CONTINUE.

RXQ.295 REVIEW TOTAL NUMBER OF PRESCRIBED MEDICATIONS AND THEIR NAMES WITH RESPONDENT.

I have listed {TOTAL NUMBER} prescription medication(s) that {you have/SP has} taken in the past 30 days: {PRODUCT NAME(S)}

PRESS ENTER TO CONTINUE

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231. CALCULATE TOTAL NUMBER OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQ.240 AND ENTERED AT RXQ.231. DISPLAY NUMBER ON SCREEN.

BOX 17A

CHECK ITEM RXQ.500:

IF SP >= 40 YEARS OLD OR MCQ.160C, MCQ.160D, MCQ.160E OR MCQ.160F = 1/YES, CONTINUE WITH RXQ.510.

OTHERWISE, GO TO BOX 18.

RXQ.510 Doctors and other health care providers sometimes recommend that {you take/SP takes) a low-dose aspirin each day to prevent heart attacks, strokes, or cancer. {Have you/Has SP} ever been told to do this?

YES 1

NO 2 (RXQ.520)

REFUSED 7 (RXQ.520)

DON'T KNOW 9 (RXQ.520)

INTERVIEWER INSTRUCTION:

IF THE RESPONDENT VOLUNTEERS THEY HAVE BEEN TOLD TO TAKE AN ASPIRIN EVERY OTHER DAY OR ‘REGULARLY’ FOR THESE REASONS, CODE “YES”.

RXQ.515 {Are you/Is SP} now following this advice?

YES 1 (BOX 18)

NO 2 (BOX 18)

SOMETIMES 3 (BOX 18)

STOPPED ASPIRIN USE DUE TO SIDE
EFFECTS 4 (BOX 18)

REFUSED 7 (BOX 18)

DON'T KNOW 9 (BOX 18)

HELP SCREEN:

Side Effect: is an unexpected health problem that is caused by a medicine. Some side effects of aspirin are stomach problems, easy bruising or bleeding, runny nose, wheezing and skin rashes.

RXQ.520 On {your/SP’s} own, {are you/is SP} now taking a low-dose aspirin each day to prevent heart attacks, strokes, or cancer?

YES 1

NO 2 (BOX 18)

REFUSED 7 (BOX 18)

DON'T KNOW 9 (BOX 18)

INTERVIEWER INSTRUCTION:

IF THE RESPONDENT VOLUNTEERS THEY ARE TAKING AN ASPIRIN EVERY OTHER DAY OR ‘REGULARLY’ FOR THESE REASONS, CODE “YES”.

BOX 18

CHECK ITEM DSQ.332:

IF PROXY INTERVIEW IN RIQ, CONTINUE.

IF NOT PROXY INTERVIEW IN RIQ, GO TO DSQ.335.

DSQ.334 INTERVIEWER OBSERVATION: WAS SP PRESENT FOR ALL OR PART OF INTERVIEW?

YES 1

NO 2

DSQ.335 PRESS F10 TO EXIT BLAISE.

HELP SCREEN FOR DSQ.012:

Health (Care) Professional: A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor's assistants, nurse practitioners, nurses, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor's office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.

Dentist: Medical professional whose primary occupation is caring for teeth, gums and jaws. Dental care includes general work such as fillings, cleaning, extractions, and also specialized work such as root canals, fittings for braces, etc.

Past Month: The past 30 days. From yesterday, 30 days back.

HELP SCREEN FOR RXQ.033:

Prescription Medication: Prescription medications are those ordered by a physician or other authorized medical professional through a written or verbal prescription for a pharmacist to fill. Prescription medications may also be given by a medical professional directly to a patient to take home, such as free samples.

Prescription medications do not include:

- Medication administered to the patient during the event in the office as part of the treatment (such as an antibiotic shot for an infection, a flu shot, or an oral medication) unless a separate bill for the medication is received;

- Diaphragms and IUD's (Intra-Uterine Devices); or

- Some state laws require prescriptions for over the counter medications. Sometimes physicians write prescriptions for over the counter medications, such as aspirin. Consider any medication a prescription medication if the respondent reports it as prescribed. If it is an over the counter medication, however, the prescription must be a written prescription to be filled by a pharmacist, not just a written or oral instruction. If in doubt, probe whether the patient got a written prescription to fill at a pharmacy.

Past Month: The past 30 days. From yesterday, 30 days back.

HELP SCREEN FOR DSQ.042:

Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.

Prescription medications do not include:

- Diaphragms and IUD's (Intra-Uterine Devices); or

Past Month: The past 30 days. From yesterday, 30 days back.

HELP SCREEN FOR DSQ.052:

Past Month: The past 30 days. From yesterday, 30 days back.

HELP SCREEN FOR RXQ.231:

Prescription medications do not include:

- Diaphragms and IUD's (Intra-Uterine Devices); or

Past Month: The past 30 days. From yesterday, 30 days back.

HELP SCREEN FOR RXQ.294/RXQ.295:

Prescription medications do not include:

- Diaphragms and IUD's (Intra-Uterine Devices); or

MAILING ADDRESS – MAQ

Target Group: SPs Birth +

Placing: Just After Blaise Closes

MAQ.005 Processing Extended SP Questionnaire. Please Wait.

MAQ.020 The National Center for Health Statistics may wish to contact {you/SP} again. Please give me {your/SP's} complete mailing address.

CRITICAL INFORMATION – CHECK CAREFULLY.

USE PEN OR PRESS 'TAB' KEY TO MOVE TO THE NEXT ENTRY FIELD.

TAP 'NEXT' BUTTON OR PRESS 'ENTER' KEY WHEN FINISHED VERIFYING ADDRESS.

CAPI INSTRUCTION:

DISPLAY THE SCREENER MAILING ADDRESS INFORMATION. ENTRY SHOULD APPEAR IN ALL CAPS – AS IT DOES IN IVQ.

DISPLAY “YOU/YOUR” IF SP AGE >= TO 16. DISPLAY “SP/SP’s” IF SP AGE < 16.

________ ________ _______________ __________ ________ _________

STREET # DIR PRE STREET NAME ST/RD/AVE DIR POST APT/LOT #

________ ________ ________ ______________________________ ________ _____

PO BOX # RR # RR BOX CITY STATE ZIP

MAQ.040 I have recorded . . .

{DISPLAY ADDRESS ENTERED IN MAQ.020 IN UPPER CASE}

Is that correct?

YES 1 (MAQ.080ck)

NO 2

MAQ.060 ENTER CORRECTED MAILING ADDRESS INFORMATION.

PROBE FOR MAILING ADDRESS CORRECTIONS, IF NECESSARY.

USE PEN OR PRESS 'TAB' KEY TO MOVE TO THE NEXT ENTRY FIELD.

TAP 'NEXT' BUTTON OR PRESS 'ENTER' KEY WHEN CORRECTIONS COMPLETED.

{DISPLAY ALL ADDRESS FIELDS AND INFORMATION ENTERED IN MAQ.020 IN UPPER CASE. ALLOW CORRECTIONS.}

MAQ.080 I now have {your/SP's} mailing address as . . .

{DISPLAY CORRECTED ADDRESS FROM MAQ.060 IN UPPER CASE}

Is that correct?

YES 1

NO 2

BOX 2

CHECK ITEM MAQ.080ck:

IF 'NO' IN MAQ.080, RETURN TO MAQ.060. DISPLAY CORRECTED ADDRESS INFORMATION IN MAQ.060. OTHERWISE, CONTINUE.

BOX 2AA

CHECK ITEM MAQ.195:

IF SP AGE 0-15, GO TO BOX 2A;

OTHERWISE, CONTINUE.

MAQ.200 Do you have an e-mail account?

YES 1

NO 2 (BOX 2A)

REFUSED 7 (BOX 2A)

DON’T KNOW 9 (BOX 2A)

MAQ.210 What is your e-mail address?

|_____________________________________|

REFUSED 7 (BOX 2A)

DON’T KNOW 9 (BOX 2A)

CAPI INSTRUCTION:

HARD EDITS:

1. IF THERE ARE SPACES IN THE EMAIL ADDRESS, DISPLAY “EMAIL ADDRESS DOES NOT ALLOW SPACES.”

2. IF EMAIL ADDRESS IS MISSING THE @ SYMBOL, DISPLAY “EMAIL ADDRESS IS MISSING THE @ SYMBOL – PLEASE GO BACK AND CORRECT.”

3. IF TEXT IS MISSING TO THE LEFT OR RIGHT OF THE @ SYMBOL, DISPLAY “PART OF THE EMAIL ADDRESS IS MISSING – PLEASE GO BACK AND CORRECT.”

MAQ.220 I have recorded . . .

{DISPLAY E-MAIL ADDRESS ENTERED IN MAQ.210}

Is that correct?

YES 1

NO 2 (MAQ.210)

BOX 2A

CHECK ITEM MAQ.083:

MAQ.090 INTERVIEWER INSTRUCTION:

SPECIFY LANGUAGE IN WHICH HARD COPY MATERIALS SHOULD BE MAILED.

ENGLISH 1

SPANISH 2

BOX 3

CHECK TELEPHONE NUMBER LISTED IN SCREENER (SCQ.430). IF NO HOME TELEPHONE (CODE 2), REF (CODE 9), OR DK (CODE 7), CONTINUE.

OTHERWISE, GO TO BOX 4.

MAQ.100 Please give me your home telephone number in case my office wants to check my work.

CAPI INSTRUCTION:

ONLY ALLOW 10 DIGIT PHONE NUMBER. DISPLAY HARD RANGE CHECK MESSAGE IF NOT 10 DIGITS.

|__|__|__|__|__|__|__|__|__|__|

NO HOME TELEPHONE 2

REFUSED 7

DON’T KNOW 9

MAQ.110 Is there another number where you can be reached?

CAPI INSTRUCTION:

ONLY ALLOW 10 DIGIT PHONE NUMBER. DISPLAY HARD RANGE ERROR IF NOT 10 DIGITS.

|__|__|__|__|__|__|__|__|__|__|

NO 2 (BOX 4)

REFUSED 7 (BOX 4)

DON’T KNOW 9 (BOX 4)

MAQ.115 I have recorded . . .

{DISPLAY PHONE ENTERED IN MAQ.110 AS (XXX) XXX-XXXX}

Is that correct?

YES 1

NO 2 (MAQ.110)

MAQ.120 Where is that phone located?

WORK 1

RELATIVE’S HOME 2

NEIGHBOR’S HOME 3

CELL PHONE 4

OTHER 5

REFUSED 7

DON’T KNOW 9

BOX 4

CHECK ITEM MAQ.140:

IF SP AGE >= TO 16 AND MAQ.120 = 4, GO TO MAQ.160.

IF SP AGE >= 16 AND MAQ.120 NOT EQUAL TO 4, GO TO MAQ.150.

IF SP AGE 12-15, GO TO MAQ.150

IF SP AGE <12, GO TO MAQ.130.

MAQ.150 {Do you/Does SP/Does your child} have a cell phone?

CAPI INSTRUCTION:

DISPLAY “DO YOU/YOUR” IF SP AGE >= TO 16. DISPLAY “DOES YOUR CHILD” IF SP AGE 12-15.

YES 1

NO 2 (MAQ.130)

REFUSED 7 (MAQ.130)

DON’T KNOW 9 (MAQ.130)

MAQ.160 We may want to send {you/SP/your child} short text messages about the exam. These messages will not contain confidential information, but will contain reminders about {your/SP’s/your child’s} participation. There may be fees to get a text message, depending on your plan. May we send {you/him/her/your child} text messages?”

CAPI INSTRUCTION:

DISPLAY “YOU/YOUR” IF SP AGE >= TO 16. DISPLAY “YOUR CHILD/YOUR CHILD’S” IF SP AGE 12-15.

YES 1

NO 2 (MAQ.130)

NO TEXT MESSAGING, NOT POSSIBLE 3 (MAQ.130)

REFUSED 7 (MAQ.130)

DON’T KNOW 9 (MAQ.130)

BOX 5

CHECK ITEM MAQ.170:

IF SP AGE >= TO 16 AND MAQ.120 = 4, GO TO MAQ.130.

OTHERWISE, CONTINUE WITH MAQ.180.

MAQ.180 What is {your/your child’s} cell phone number?

CAPI INSTRUCTION:

DISPLAY “YOUR” IF SP AGE >= TO 16. DISPLAY “YOUR CHILD’s” IF SP AGE 12-15.

|__|__|__|__|__|__|__|__|__|__|

REFUSED 7 (MAQ.130)

DON’T KNOW 9 (MAQ.130)

MAQ.185 I have recorded . . .

{DISPLAY PHONE ENTERED IN MAQ.180 AS (XXX) XXX-XXXX}

Is that correct?

YES 1

NO 2 (MAQ.180)

MAQ.130 This is the end of the health interview. Thank you very much for your cooperation.

BOX 6

CHECK ITEM MAQ.305:

IF CASE IS FLAGGED FOR THE PROMISED INCENTIVE, CONTINUE.

OTHERWISE GO TO POST INTERVIEW.

CCQ.010 As a thank you for answering these questions, will you accept a ${INCENTIVE} cash card today?

DID THE RESPONDENT ACCEPT THE INCENTIVE?

YES 1

NO 2 (POST INTERVIEW)

CAPI INSTRUCTIONS:

IF THE CASE IS FLAGGED FOR THE PROMISED SCREENER OR PROMISED SP INCENTIVE, DISPLAY INCENTIVE AMOUNT.

DISPLAY QUESTION ONLY IF INCENTIVE PILOT ACTIVE IN STAND.

CCQ.020 {IF RESPONDENT ALREADY HAS A CARD WITH THE CARD CARRIER SHEET, ASK IF HE/SHE WANTS THE INCENTIVE ADDED TO SAME CARD OR ON A NEW CARD. IF NECESSARY,} TAKE OUT A NEW DEBIT CARD FROM YOUR SUPPLY .

OPEN THE ENVELOPE.

SHOW THE RESPONDENT THE DEBIT CARD ATTACHED TO THE CARRIER SHEET.

Here is your Health Study debit card. This debit card is a VISA© Card and is accepted anywhere VISA© is accepted. The card cannot be used to withdraw money from an ATM. Your payment will be available for use on the card within 3 business days. You can find answers to most commonly asked questions on the card carrier sheet along with phone numbers to call for additional information.

SCAN BARCODE OR MANUALLY ENTER THE 13 DIGIT NUMBER SHOWN ON THE CARD CARRIER SHEET.

CAPI INSTRUCTION:

EDIT CHECK: ENTRY MUST BE 13 DIGITS. IF NOT, DISPLAY “THE BARCODE NUMBER SHOULD BE 13 DIGITS. PLEASE RE-ENTER.”

DISPLAY QUESTION ONLY IF INCENTIVE PILOT ACTIVE IN STAND.

BOX 1

CHECK ITEM CCQ.025:

IF NUMBER ENTERED USING SCANNER, SKIP TO CCQ.040.

IF NUMBER MANUALLY ENTERED, CONTINUE.

CCQ.030 RE-ENTER THE 13 DIGIT NUMBER SHOWN ON THE CARD CARRIER SHEET.

CAPI INSTRUCTION:

EDIT CHECK: ENTRY MUST BE 13 DIGITS. IF NOT, DISPLAY “THE BARCODE NUMBER SHOULD BE 13 DIGITS. PLEASE RE-ENTER.”

EDIT CHECK: THE NUMBER ENTERED IN CCQ.025 MUST MATCH THE NUMBER ENTERED IN CCQ.020. IF NUMBERS DO NOT MATCH, DISPLAY “THE TWO BARCODE NUMBERS DO NOT MATCH, PLEASE CHECK ENTRIES.”

DISPLAY QUESTION ONLY IF INCENTIVE PILOT ACTIVE IN STAND.

CCQ.040 RECORD THE NAME OF THE CARD RECIPIENT AND THE AMOUNT ADDED TO THE CARD ON THE CARD CARRIER SHEET.

NAME AND AMOUNT RECORDED 1

CAPI INSTRUCTION:

DISPLAY QUESTION ONLY IF INCENTIVE PILOT ACTIVE IN STAND.

CCQ.050 TO WHOM DID YOU GIVE THE CARD?

CARD RECIPIENT

{FIRST NAME} {LAST NAME}

CAPI INSTRUCTIONS:

WHEN THE FOCUS OF THE CURSOR IS ON THE “CARD RECIPIENT” FIELD, THE ANSWER CHOICES SHOULD BE A LIST THAT DISPLAYS FIRST AND LAST NAMES OF ALL HH MEMBERS ON THE HH COMPOSITION MATRIX. THE LIST SHOULD BE SORTED BY ORDER ON ROSTER BUT THE RESPONDENT SELECTED IN RIQ SHOULD DEFAULT TO THE TOP OF THE LIST.

DISPLAY QUESTION ONLY IF INCENTIVE PILOT ACTIVE IN STAND.

FAMILY QUESTIONNAIRE

6/28/2018

RESPONDENT SELECTION SECTION – RIQ – FAMILY QUESTIONNAIRE

*11RIQ.010 SELECT RESPONDENT FOR THE FAMILY QUESTIONNAIRE.

CAPI INSTRUCTION:

DISPLAY ALL FAMILY MEMBERS WHO ARE >= 18 YEARS OLD.

IF NO FAMILY MEMBERS ARE >= 18 YEARS OLD, DISPLAY ALL FAMILY MEMBERS >= 12 YEARS OLD.

ALSO DISPLAY ‘SOMEONE OUTSIDE FAMILY’.

BOX 1A

CHECK ITEM *11RIQ.018:

IF ‘SOMEONE OUTSIDE FAMILY’ SELECTED AS RESPONDENT, GO TO *11RIQ.040.

OTHERWISE, GO TO BOX 3B.

*11RIQ.040 INTERVIEW SHOULD BE CONDUCTED WITH FAMILY MEMBER 18 YEARS OR OLDER WHO KNOWS ABOUT FAMILY MATTERS.

WHY IS INTERVIEW BEING CONDUCTED WITH SOMEONE OUTSIDE THE FAMILY?

ONLY FAMILY MEMBER HAS COGNITIVE

PROBLEMS 1

ONLY FAMILY MEMBER IS A CHILD

UNDER 16 (WARD OF STATE) 2 (*11RIQ.045)

‘SOMEONE OUTSIDE THE FAMILY’

SELECTED IN ERROR 3 (*11RIQ.010)

OTHER (SPECIFY) 4

*11RIQ.042 DO YOU HAVE SUPERVISOR PERMISSION TO CONDUCT INTERVIEW WITH SOMEONE OUTSIDE THE FAMILY?

NOTE: IF INTERPRETER USED, RESPONDENT MUST SIGN FORM.

CAPI INSTRUCTION:

IF 'NO' (CODE 2), DISPLAY THE FOLLOWING MESSAGE: "SUPERVISORY PERMISSION IS REQUIRED TO USE A PROXY FOR THIS INTERVIEW. MOVING FORWARD WILL EXIT THIS INTERVIEW" ALLOW RETURN TO 11RIQ.042 WITH BACK BUTTON. MOVING FORWARD EXITS INTERVIEW.

YES 1

NO 2

*11RIQ.045 ENTER RESPONDENT NAME.

FIRST NAME LAST NAME

*11RIQ.047 ENTER RESPONDENT'S PHONE NUMBER.

ENTER '00' IN AREA CODE IF NO PHONE.

|___|___|___| |___|___|___| - |___|___|___|___|

AREA CODE ENTER PHONE NUMBER

*11RIQ.049 DESCRIBE RESPONDENT'S RELATIONSHIP TO SP.

BOX 3B

OMITTED

RIQ.250 HAND RESPONDENT COPY OF HOME INTERVIEW CONSENT FORM IN THE LANGUAGE HE/SHE READS.

REVIEW KEY POINTS WITH RESPONDENT OR READ CONSENT FORM OUT LOUD IF NECESSARY.

ANSWER ANY RESPONDENT QUESTIONS. (PRESS NEXT TO CONTINUE)

BOX 3C

OMITTED

RIQ.278 CAPI INSTRUCTION:

DISPLAY IMAGE HOME INTERVIEW CONSENT FORM. SHOW TOP OF FORM, INCLUDING FIRST THREE PARAGRAPHS.
DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.
DISPLAY INTERVIEWER INSTRUCTION: “TURN SCREEN TO {RESPONDENT} AND EXPLAIN THAT YOU ARE REVIEWING THE SAME FORM HARDCOPY AND ELECTRONICALLY.”
DISPLAY RESPONDENT NAME FROM *11RIQ.010 OR *11RIQ.045

RIQ.280a EXPLAIN THE HOME INTERVIEW CONSENT. ASK {RESPONDENT} TO RECORD HIS/HER HOME INTERVIEW CONSENT CHOICE BELOW.

I have read the information above. I agree to proceed with the interview.

YES 1

NO 2

CAPI INSTRUCTION:

DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.

DISPLAY YES/NO OPTIONS AS RADIO BUTTON, ALLOWING ONLY ONE CHOICE.

DISPLAY OMB NUMBER IN UPPER RIGHT OF SCREEN.

IF RIQ.280a = 2, DISPLAY THE FOLLOWING MESSAGE: “EACH RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE MUST SIGN A HOUSEHOLD INTERVIEW CONSENT FORM BEFORE THE INTERVIEW CAN BE ADMINISTERED” (FUNCTIONS LIKE CURRENT RIQ.080-081).

DISPLAY RESPONDENT NAME FROM *11RIQ.010 OR *11RIQ.045.

RIQ.320 ADULT RESPONDENT SIGNATURE SCREEN (USED FOR ALL INTERVIEWS)

CAPI INSTRUCTION:

1. DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.

2. CHECK BOX LABELED ‘OFFICE USE ONLY: H’ FOR FI TO CHOOSE IF RESPONDENT REFUSES TO SIGN ELECTRONICALLY BUT WILL SIGN HARDCOPY. IF SELECTED SKIP TO RIQ.080.

4. DO NOT ALLOW INSTRUMENT TO MOVE FORWARD WITHOUT A SIGNATURE, RF BUTTON OR HARDCOPY SIGNATURE ENTERED. CODE REFUSAL AS -1.

5. Display “YES I agree to continue with the interview” if RIQ.280a = 1.

6. COLLECT DATE AND TIME STAMP WHEN SIGNATURE IS CAPTURED.

7. ABOVE SIGNATURE BOX, DISPLAY “Sign below.”

8. DISPLAY OMB NUMBER IN UPPER RIGHT OF SCREEN.

9. UNDER SIGNATURE LINE, DISPLAY NAME OF PERSON SIGNING

BOX 3E

CHECK ITEM RIQ.330:

IF RESPONDENT REQUESTED HARDCOPY SIGNATURE, SKIP TO RIQ.390.

RIQ.350 IS A WITNESS/INTERPRETER SIGNATURE REQUIRED?

WITNESS 1

INTERPRETER 2 (RIQ.370)

NO 3 (RIQ.380)

RIQ.360 WITNESS SIGNATURE SCREEN

CAPI INSTRUCTION:

1. DISPLAY IN ENGLISH.

2. WITNESS MUST SIGN ELECTRONICALLY IF RESPONDENT DID.

3. DO NOT ALLOW INSTRUMENT TO MOVE FORWARD WITHOUT A SIGNATURE.

4. COLLECT DATE AND TIME STAMP WHEN SIGNATURE IS CAPTURED.

6. SKIP TO RIQ.380.

RIQ.370 INTERPRETER SIGNATURE SCREEN

CAPI INSTRUCTION:

1. DISPLAY IN ENGLISH.

2. INTERPRETER MUST SIGN ELECTRONICALLY IF RESPONDENT DID.

3. DO NOT ALLOW INSTRUMENT TO MOVE FORWARD WITHOUT A SIGNATURE.

4. COLLECT DATE AND TIME STAMP WHEN SIGNATURE IS CAPTURED.

RIQ.380 DID RESPONDENT REQUEST THAT A COPY OF THE CONSENT FORM(S) WITH HIS/HER SIGNATURE PRINTED BE MAILED?

YES 1 (BOX 1B)

NO 2 (BOX 1B)

CAPI INSTRUCTION:

SET AN ELECTRONIC INDICATOR (VARIABLE/ALERT/FLAG) TO KNOW WHICH RESPONDENTS REQUESTED THE PRINTED FORMS BE MAILED.

RIQ.390 ASK RESPONDENT TO SIGN TWO COPIES OF THE HOME INTERVIEW CONSENT FORM. HAVE RESPONDENT KEEP ONE COPY AND COLLECT ONE IN THE HH FOLDER AND RETURN TO FIELD OFFICE.

TO COMPLETE THE HARDCOPY FORM:

Print name of person answering questions.

Check boxes regarding linking with other vital records IF HE/SHE WILL BE RESPONDING TO SP INTERVIEWS LATER.

IF 16-17 YEAR OLD EMANCIPATED MINOR, SP SIGNS FORM AND CHECK BOX FOR EMANCIPATED MINOR TO DOCUMENT THAT A PARENT/GUARDIAN SIGNATURE IS NOT REQUIRED.

Signed by witness/INTERPRETER (if necessary).

Signed by Staff member.

Record HH & Family ID.

Check questionnaire boxes for all completed with respondent (SPs & Family).

Record names of all PROXY INTERVIEWS RESPONDENT is responding for along with SP IDs.

press NEXT to continue.

RIQ.080 HAS RESPONDENT SIGNED A HOUSEHOLD INTERVIEW CONSENT FORM?

CAPI INSTRUCTION:

NOTE: IF INTERPRETER USED, RESPONDENT MUST SIGN FORM.

SET FORM TYPE VARIABLE TO HARDCOPY SO ISIS E/S KNOWS A HARDCOPY FORM MUST BE IMAGE SCANNED.

YES 1

NO 2

BOX 3F

OMITTED.

BOX 1B

CHECK ITEM RIQ.165:

IF AUDIO_CONSENT FLAG = 1 (SAME SP AS SP INTERVIEW AND GAVE PERMISSION TO RECORD SP INTERVIEW), GO TO RIQ.200.

ELSE, GO TO RIQ.230.

RIQ.230 CAPI INSTRUCTION: BEGIN RECORDING SO THAT WHEN INTERVIEWER READS THIS QUESTION IT IS CAPTURED ON RECORDING.

A standard part of our quality control procedures is to record interviews.

The information being recorded is protected and kept confidential, the same as all of your answers to the survey.

This recording will be used to improve the quality of our survey and to review the quality of my work.

The computer is now recording our conversation.

Do I have your permission to record this interview?

YES 1 (INT.001)

NO 2 (INT.001)

CAPI INSTRUCTION: IF RIQ.230 = 2/NO, STOP.

RIQ.200 CAPI INSTRUCTION: BEGIN RECORDING SO THAT WHEN INTERVIEWER READS THIS QUESTION IT IS CAPTURED ON RECORDING.

A reminder that the system is now recording our conversation. Do I have your permission to record this interview?

YES 1

NO 2

CAPI INSTRUCTION: IF RIQ.200 = 2/NO, STOP.

INT.001 IS AN INTERPRETER BEING USED FOR INTERVIEW?

YES 1

NO 2 (GO TO THE END

OF THE SECTION)

INT.003 LANGUAGE USED FOR INTERVIEW

AMERICAN SIGN LANGUAGE 1 (INT.013)

CHINESE (CANTONESE) 2 (INT.013)

CHINESE (MANDARIN) 3 (INT.013)

FRENCH 4 (INT.013)

GERMAN 5 (INT.013)

ITALIAN 6 (INT.013)

JAPANESE 7 (INT.013)

KOREAN 8 (INT.013)

RUSSIAN 9 (INT.013)

SPANISH (READER) 10 (INT.013)

VIETNAMESE 11 (INT.013)

OTHER SPECIFY 99

INT.004 ENTER LANGUAGE USED FOR INTERVIEW

_________________________________

INT.013 {DISPLAY INTERPRETER NAMES FROM ALL PREVIOUS INTERVIEWS: SCREENER, RELATIONSHIP, SP, FAMILY QUESTIONNAIRE}

ENTER INTERPRETER NAME INFO

SAME INTERPRETER USED IN OTHER
INTERVIEW FOR HOUSEHOLD 1 (INT.014)

NEW INTERPRETER 2 (INT.005)

INT.014 {DISPLAY LIST OF INTERPRETER NAMES FROM SCREENER, RELATIONSHIP, SP AND/OR FAMILY QUESTIONNAIRES}

{INCLUDE “OTHER” AS A SELECTION}

SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME

BOX 4

CHECK ITEM INT.014a:

IF ‘OTHER’ SELECTED IN INT.014, GO TO INT.005.

OTHERWISE, CODE INTERPRETER INFO FROM PREVIOUS INTERVIEW AND GO TO END OF SECTION.

INT.005 HOW WAS INTERPRETER OBTAINED

ARRANGED BY FIELD OFFICE 1

RECRUITED DURING VISIT/APPOINTMENT 2 (INT.007)

INT.006 SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME

{DROP DOWN LIST SHOULD HAVE ALL NAMES FROM EVM AND AN “OTHER SPECIFY” TO ALLOW FOR THOSE NAMES THAT HAVE NOT BEEN TRANSFERRED TO INTERVIEWER PENTOP}

BOX 6

CHECK ITEM INT.006A:

IF OTHER (SELECTED IN INT.006), GO TO INT.009.

OTHERWISE, GO TO END OF SECTION.

INT.007 SELECT INTERPRETER SOURCE

RELATIVE LIVING IN HOUSEHOLD 1

NON-RELATIVE LIVING IN HOUSEHOLD 2

NEIGHBOR, RELATIVE OR FRIEND –
NOT IN HOUSEHOLD 3 (SKIP TO INT.009)

INT.008 SELECT NAME OF INTERPRETER FROM HOUSEHOLD ROSTER.

{DISPLAY CAPI PULL DOWN LIST FROM HH ROSTER}

BOX 7

CHECK ITEM INT.008A:

GO TO END OF SECTION.

INT.009 ENTER NAME OF INTERPRETER

______________________________________

INT.010 ENTER PHONE # OF INTERPRETER

___ -___ ____

INT.011 ENTER AGE RANGE OF INTERPRETER

{AGE RANGE CAN BE A PULL DOWN LIST}

RANGES = 18-29

30-59

60+

INT.012 ENTER GENDER OF INTERPRETER

MALE 1

FEMALE 2

DEMOGRAPHIC BACKGROUND/OCCUPATION (DMQ)

Target Group:  Head of CPS Family (Non-SP)

 Head of CPS Family Spouse (Non-SP)

BOX 1A

RULES FOR ADMINISTERING THE DEMOGRAPHIC AND OCCUPATION SECTION OF THE FAMILY QUESTIONNAIRE:

A CPS FAMILY INCLUDES INDIVIDUALS AND GROUPS OF INDIVIDUALS WHO ARE 16+ AND RELATED BY BIRTH, MARRIAGE OR ADOPTION. STEP CHILDREN, PARENTS OR SIBLINGS ARE INCLUDED. IT ALSO INCLUDES UNMARRIED PARTNERS IF THEY HAVE A BIOLOGICAL OR ADOPTIVE CHILD IN COMMON. IT DOES NOT INCLUDE UNMARRIED PARTNERS WHO DO NOT HAVE A CHILD IN COMMON, FOSTER PARENTS OR FOSTER CHILDREN, OR WARDS.

BOX 1

LOOP 1:

ASK DMQ.NEW1 – DMQ.141 AS APPROPRIATE FOR NON-SP HEAD OF CPS FAMILY AND NON-SP SPOUSE (RELATIONSHIP OF "MARRIED" IN THE SCREENER) OF HEAD OF CPS FAMILY.

FIRST ASK DMQ.NEW1, 130, AND 141 FOR NON-SP HEAD OF CPS FAMILY.
NEXT, ASK DMQ.141 FOR NON-SP SPOUSE OF HEAD OF CPS FAMILY.
EACH TARGET PERSON SHOULD BE ASKED THIS SECTION ONCE.
IF NO NON-SP HEAD OF CPS FAMILY AND NON-SP SPOUSE, GO TO
END OF SECTION.

DMQ.New1 Were you born in the United States or a United States territory?

YES 1

NO 2 (DMQ.141)

REFUSED 7 (DMQ.141)

DON'T KNOW 9 (DMQ.141)

DMQ.130 In what state or U.S. territory {were you/was NON-SP HEAD} born?

ENTER 2 LETTER STATE ABBREVIATION TO START THE LOOKUP.

SELECT STATE FROM CAPI STATE LIST.

PRESS ENTER TO ACCEPT SELECTION.

CAPI INSTRUCTION:

DISPLAY FIPS STATE LIST. INTERVIEWER SHOULD ONLY BE ABLE TO SELECT 1 STATE FROM THE LIST. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. THE STATE LOOKUP IN THE SP AND FAMILY QUESTIONNAIRES SHOULD WORK EXACTLY THE SAME.

DMQ.141 What is the highest grade or level of school {you have/NON-SP HEAD/NON-SP SPOUSE has} completed or the highest degree {you have/he/she has} received?

HAND CARD DMQ1

READ HAND CARD CATEGORIES IF NECESSARY

Enter highest level of school.

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

REFUSED 77

DON’T KNOW 99

BOX 3

END LOOP 1:

ASK DMQ.NEW1 141 FOR NEXT TARGET PERSON (NON-SP HEAD)
ASK DMQ.141 FOR NEXT TARGET PERSON (NON-SP SPOUSE –
RELATIONSHIP OF "MARRIED" IN THE SCREENER).

IF NO NEXT PERSON, GO TO END OF SECTION.

HELP SCREEN FOR DMQ.141:

Training Programs - Count training received "on the job," in the Armed Forces, or through correspondence school only if it was credited toward a school diploma, high school equivalency (GED), or college degree.

Vocational, Trade, or Business School - Do not include secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered, and other vocational trade or business schools outside the regular school system.

General Educational Development (GED) or High School Equivalency - An exam certified equivalent of a high school diploma. If the person has not actually completed all 4 years of high school, but has acquired his/her GED (high school equivalency based on passing the GED exam), count this and enter code "14."

Adult Education - Adult education classes should not be included as regular school unless such schooling has been counted for credit in a regular school system. If a person has taken adult education classes not for credit, these classes should not be counted as regular school. Adult education courses given in a public school building are part of regular schooling only if their completion can advance a person toward an elementary school certificate, a high school diploma (or GED), or a college degree.

Other School Systems - If the person attended school in another country, in an ungraded school, in a "normal school", under a tutor, or under other special circumstances, ask the respondent to give the nearest equivalent of years in regular U.S. schooling.

GED (General Educational Development): An exam certified equivalent of a high school diploma.

Occupational, Technical, or Vocational Program: Includes secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered and other trade and business schools outside the regular school system.

Bachelor's Degree: An educational degree given by a college or university to a person who has completed a 4-year course or its equivalent in the humanities or related studies (B.A.) or in the sciences (B.S.).

Doctoral Degree: The highest educational degree given by a college or university to a person who has completed a prescribed course of advanced graduate study. For example—a Doctor of Philosophy (Ph.D.).

HOUSING CHARACTERISTICS – HOQ

Target Group: SPs Family

HOQ.012 I would like to ask you a few questions about your home.

Please look at this card. Which best describes your house or building?

HAND CARD HOQ1

A ONE-FAMILY HOUSE DETACHED FROM ANY OTHER HOUSE 1

A ONE-FAMILY HOUSE ATTACHED TO ONE OR MORE HOUSES 2

A BUILDING WITH 2 APARTMENTS 3

A BUILDING WITH 3 OR 4 APARTMENTS 4

A BUILDING WITH 5 TO 9 APARTMENTS 5

A BUILDING WITH 10 TO 19 APARTMENTS 6

A BUILDING WITH 20 TO 49 APARTMENTS 7

A BUILDING WITH 50 OR MORE APARTMENTS 8

A MOBILE HOME, TRAILER, OR MANUFACTURED HOME 9

A DORMITORY OR SIMILAR BOARDING HOUSE 10

REFUSED 77

DON'T KNOW 99

HOQ.060 How long {have you/has your family} lived at this address?

G/Q/U

|___|___|___|

ENTER NUMBER (OF MONTHS OR YEARS)

LESS THAN ONE MONTH............................ 666 (HOQ.065)

REFUSED ............................................. 777777 (HOQ.065)

DON'T KNOW ....................................... 999999 (HOQ.065)

ENTER UNIT

MONTHS....................................................... 1

YEARS .......................................................... 2

HOQ.065 Is this home owned, being bought, rented, or occupied by some other arrangement by {you/you or someone else in your family}?

OWNED OR BEING BOUGHT 1

RENTED 2

OTHER ARRANGEMENT 3

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Rents or Owns Home: A person rents the home if s/he pays on a continuing basis without gaining any rights to ownership. A person owns the home even if s/he is still paying on a mortgage.

HOQ.070 What is the source of tap water in this home? Is it a private or public water company, a private or public well, or something else?

PRIVATE/PUBLIC WATER COMPANY ........ 1

PRIVATE/PUBLIC WELL .............................. 2

SOMETHING ELSE....................................... 3

REFUSED ..................................................... 7

DON'T KNOW ............................................... 9

HOQ.080 Are any of the water treatment devices listed on this card used in your home?

HAND CARD HOQ2

YES ......................................................... 1

NO............................................................ 2 (HOQ.NEW1)

REFUSED ............................................... 7 (HOQ.NEW1)

DON'T KNOW ......................................... 9 (HOQ.NEW1)

HELP SCREEN:

Water Treatment Devices: Any device intended to improve the safety and quality of water in the home.

There are eight main types of treatments: carbon filters, fiber filters, reverse osmosis units, neutralizers,

chemical feed pumps, disinfection and softeners. Devices such as Brita and other pitcher water filters should

be counted as water treatment devices.

HOQ.083 Which of these water treatment devices are now used in your home?

HAND CARD HOQ2

CODE ALL THAT APPLY

BRITA OR OTHER PITCHER

WATER FILTER .......................................... 1

CERAMIC OR CHARCOAL FILTER ............. 2

WATER SOFTENER ..................................... 3

AERATOR ..................................................... 4

REVERSE OSMOSIS.................................... 5

REFUSED ..................................................... 7

DON'T KNOW ............................................... 9

HELP SCREEN:

Water Treatment Devices: Any device intended to improve the safety and quality of water in the home.

There are eight main types of treatments: carbon filters, fiber filters, reverse osmosis units, neutralizers,

chemical feed pumps, disinfection and softeners. Devices such as Brita and other pitcher water filters should be counted as water treatment devices.

HOQ.NEW1 Do you use tap water when cooking/preparing meals?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

SMOKING – SMQ

Target Group: Household

SMQ.460 Now I would like to ask you a few questions about smoking in this home.

How many people who live here smoke cigarettes, cigars, little cigars, pipes, water pipes, hookah, or any other tobacco product?

INTERVIEWER INSTRUCTION: IF RESPONSE IS NO ONE, ENTER ZERO

|___|___|

ENTER NUMBER OF PERSONS

REFUSED 777

DON'T KNOW 999

HELP SCREEN:

Tobacco products do not include marijuana.

CAPI INSTRUCTION:

ALLOW ‘0’ AS AN ENTRY.

RANGE EDIT: CANNOT BE GREATER THAN # OF PEOPLE IN THE HOUSEHOLD.

IF ‘0’, DK OR RF, GO TO END OF SECTION.

SMQ.470 Not counting decks, porches, or detached garages, how many people who live here smoke cigarettes, cigars, little cigars, pipes, water pipes, hookah, or any other tobacco product inside this home?

|___|___|

ENTER NUMBER OF PERSONS

REFUSED 777

DON'T KNOW 999

HELP SCREEN:

Tobacco products do not include marijuana.

CAPI INSTRUCTION:

ALLOW ‘0’ AS AN ENTRY.

HARD EDIT: NUMBER ENTERED IN SMQ.470 MUST BE EQUAL OR LESS THAN SMQ.460.

IF ‘0’, DK OR RF, GO TO END OF SECTION.

SMQ.480 (Not counting decks, porches, or detached garages) During the past 7 days, that is since last [TODAY’S DAY OF WEEK], on how many days did {anyone who lives here/you}, smoke tobacco inside this home?

|___|

ENTER NUMBER OF DAYS FROM 0 TO 7.

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF ONLY ONE PERSON LIVING IN HOUSEHOLD DISPLAY “you..” IF MORE THAN ONE PERSON LIVING IN HOUSEHOLD, DISPLAY “anyone who lives here..”

CONSUMER BEHAVIOR – CBQ

Target Group: Family Questionnaire

BOX NEW 1A

OMITTED

CBQ.071
Q/U

The next questions are about how much money {your family spends/you spend} on food. First I’ll ask you about money spent at supermarkets or grocery stores. Then we will talk about money spent at other types of stores. When you answer these questions, please do not include money spent on alcoholic beverages.

During the past 30 days, how much money {did your family/did you} spend at supermarkets or grocery stores? Please include purchases made with food stamps. (You can tell me per week or per month.)

INTERVIEWER: ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

$ |___|___|___|___|___|___|___|___|___|

ENTER AMOUNT

NO MONEY SPENT 0 (CBQ.101)

REFUSED 7----7 (CBQ.101)

DON'T KNOW 9----9 (CBQ.101)

ENTER UNIT

WEEK 1

MONTH 2

CBQ.081 Was any of this money spent on nonfood items such as cleaning or paper products, pet food, cigarettes or alcoholic beverages?

YES 1

NO 2 (CBQ.101)

REFUSED 7 (CBQ.101)

DON'T KNOW 9 (CBQ.101)

CBQ.091
Q/U

About how much money was spent on nonfood items? (You can tell me per week or per month.)

$ |___|___|___|___|___|___|___|___|___|

ENTER AMOUNT

HARD EDIT: AMOUNT CANNOT BE MORE THAN
THE AMOUNT ENTERED ON CBQ.071.

REFUSED 7----7 (CBQ.101)

DON'T KNOW 9----9 (CBQ.101)

ENTER UNIT

WEEK 1

MONTH 2

CBQ.101 During the past 30 days, {did your family/did you} spend money on food at stores other than grocery stores? Please do not include money that you have already told me about. Here are some examples of stores other than grocery stores where you might buy food.

HAND CARD CBQ1

YES 1

NO 2 (CBQ.121)

REFUSED 7 (CBQ.121)

DON'T KNOW 9 (CBQ.121)

CBQ.111
Q/U

About how much money {did your family/did you} spend on food at these types of stores? Please do not include money you have already told me about. (You can tell me per week or per month.)

INTERVIEWER: ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

$ |___|___|___|___|___|___|___|___|___|

ENTER AMOUNT

REFUSED 7----7 (CBQ.121)

DON'T KNOW 9----9 (CBQ.121)

ENTER UNIT

WEEK 1

MONTH 2

CBQ.121
Q/U

During the past 30 days, how much money {did your family/did you} spend on eating out? Please include money spent in cafeterias at work or at school or on vending machines, for all family members. (You can tell me per week or per month.)

INTERVIEWER INSTRUCTION: IF RESPONDENT KNOWS ONLY AMOUNT FOR SELF, CODE DK.

INTERVIEWER: ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

$ |___|___|___|___|___|___|___|___|___|

ENTER AMOUNT

REFUSED 7----7 (CBQ.131)

DON'T KNOW 9----9 (CBQ.131)

ENTER UNIT

WEEK 1

MONTH 2

CBQ.131
Q/U

During the past 30 days, how much money {did your family/did you} spend on food carried out or delivered? Please do not include money you have already told me about. (You can tell me per week or per month.)

INTERVIEWER INSTRUCTION: IF RESPONDENT KNOWS ONLY AMOUNT FOR SELF, CODE DK.

INTERVIEWER: ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

$ |___|___|___|___|___|___|___|___|___|

ENTER AMOUNT

REFUSED 7----7

DON'T KNOW 9----9

ENTER UNIT

WEEK 1

MONTH 2

BOX 2

CHECK ITEM CBQ.205:

IF THE FAMILY INCLUDES AT LEAST ONE SP AGED 1-15 YEARS OLD, CONTINUE;

OTHERWISE, GO TO THE END OF SECTION.

CBQ.210 Who is the person who does most of the planning or preparing of meals in your family?

CAPI INSTRUCTION:

DISPLAY NAMES, GENDERS, AND AGES OF ALL HOUSEHOLD MEMBERS.
SORT THE LIST BY FAMILY, AND DISPLAY THE FAMILY OF THE CURRENT RESPONDENT FIRST.
WITHIN EACH FAMILY, SORT THE FAMILY MEMBERS BY AGE FROM OLDEST TO YOUNGEST.
BLOCK ALL MEMBERS 10 YEAR OR YOUNGER FROM BEING SELECTED.
ONLY ALLOW ONE PERSON TO BE SELECTED.

INTERVIEWER INSTRUCTION: SELECT NAME FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

MMP CALCULATION INSTRUCTION

PERSON SELECTED AS FCBS RESPONDENT MUST BE 16 YEARS OR OLDER.

SELECT 1

NOT SELECT 2 (CBQ.240)

REFUSED 7 (CBQ.240)

DON'T KNOW 9 (CBQ.240)

SOFT EDIT:

IF THE SELECTED PERSON IS LESS THAN 18 YEARS OLD, DISPLAY THE FOLLOWING MESSAGE: “PLEASE VERIFY THAT THE PERSON SELECTED IS YOUNGER THAN 18 YEARS OLD.”

SOFT EDIT:

IF CBQ.210 EQUALS 2-NOT SELECT OR DK FOR EVERY HH MEMBER, DISPLAY THE FOLLOWING MESSAGE: “PLEASE VERIFY THAT NO ONE LISTED DOES MOST OF THE PLANNING AND PREPARING OF MEALS IN THE SP’S FAMILY.”

CBQ.220 {Do you/Does he/she} share in the planning or preparing of meals with someone else?

YES 1

NO 2 (CBQ.240)

REFUSED 7 (CBQ.240)

DON'T KNOW 9 (CBQ.240)

CBQ.230 Who is the person who shares in the planning or preparing of meals with {you/him/her}?

CAPI INSTRUCTION:

DISPLAY NAMES, GENDERS, AND AGES OF ALL HOUSEHOLD MEMBERS, EXCEPT THE ONE NAMED IN CBQ.210.
SORT THE LIST BY FAMILY, AND DISPLAY THE FAMILY OF THE CURRENT RESPONDENT FIRST.
WITHIN EACH FAMILY, SORT THE FAMILY MEMBERS BY AGE FROM OLDEST TO YOUNGEST.
BLOCK ALL MEMBERS 10 YEAR OR YOUNGER FROM BEING SELECTED.
ONLY ALLOW ONE PERSON TO BE SELECTED.

INTERVIEWER INSTRUCTION: SELECT NAME FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

MMP CALCULATION INSTRUCTION

PERSON SELECTED AS FCBS RESPONDENT MUST BE 16 YEARS OR OLDER.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

SOFT EDIT:

IF THE SELECTED PERSON IS LESS THAN 18 YEARS OLD, DISPLAY THE FOLLOWING MESSAGE: “PLEASE VERIFY THAT THE PERSON SELECTED IS YOUNGER THAN 18 YEARS OLD.”

CBQ.240 Who is the person who does most of the shopping for food in your family?

CAPI INSTRUCTION:

DISPLAY NAMES, GENDERS, AND AGES OF ALL HOUSEHOLD MEMBERS.
SORT THE LIST BY FAMILY, AND DISPLAY THE FAMILY OF THE CURRENT RESPONDENT FIRST.
WITHIN EACH FAMILY, SORT THE FAMILY MEMBERS BY AGE FROM OLDEST TO YOUNGEST.
BLOCK ALL MEMBERS 10 YEAR OR YOUNGER FROM BEING SELECTED.
ONLY ALLOW ONE PERSON TO BE SELECTED.

INTERVIEWER INSTRUCTION: SELECT NAME FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

MMP CALCULATION INSTRUCTION

PERSON SELECTED AS FCBS RESPONDENT MUST BE 16 YEARS OR OLDER.

SELECT 1

NOT SELECT 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

SOFT EDIT:

IF THE SELECTED PERSON IS LESS THAN 18 YEARS OLD, DISPLAY THE FOLLOWING MESSAGE: “PLEASE VERIFY THAT THE PERSON SELECTED IS YOUNGER THAN 18 YEARS OLD.”

SOFT EDIT:

IF CBQ.240 EQUALS 2-NOT SELECT OR DK FOR EVERY HH MEMBER, DISPLAY THE FOLLOWING MESSAGE: “PLEASE VERIFY THAT NO ONE LISTED DOES MOST OF THE SHOPPING FOR FOOD IN THE SP’S FAMILY.”

CBQ.250 {Do you/Does he/she} share in the shopping for food with someone else?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

CBQ.260 Who is the person who shares the food shopping with {you/him/her}?

CAPI INSTRUCTION:

DISPLAY NAMES, GENDERS, AND AGES OF ALL HOUSEHOLD MEMBERS, EXCEPT THE ONE NAMED IN CBQ.240.
SORT THE LIST BY FAMILY, AND DISPLAY THE FAMILY OF THE CURRENT RESPONDENT FIRST.
WITHIN EACH FAMILY, SORT THE FAMILY MEMBERS BY AGE FROM OLDEST TO YOUNGEST.
BLOCK ALL MEMBERS 10 YEAR OR YOUNGER FROM BEING SELECTED.
ONLY ALLOW ONE PERSON BEING SELECTED.

INTERVIEWER INSTRUCTION: SELECT NAME FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

MMP CALCULATION INSTRUCTION

PERSON SELECTED AS FCBS RESPONDENT MUST BE 16 YEARS OR OLDER.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

SOFT EDIT:

IF THE SELECTED PERSON IS LESS THAN 18 YEARS OLD, DISPLAY THE FOLLOWING MESSAGE: “PLEASE VERIFY THAT THE PERSON SELECTED IS YOUNGER THAN 18 YEARS OLD.”

INCOME – INQ

Target Group: SP, Family, Household

Definitions for Testers:

NHANES FAMILY: Everyone related to each other by blood, marriage or a marriage-like relationship including partners and foster children.

FAMILY: Individuals and groups of individuals who are related by birth, marriage or adoption. step children, parents or siblings are included. It also includes unmarried partners if they have a biological or adoptive child in common. It does not include unmarried partners who do not have a child in common, foster parents or foster children. Note: Individuals living alone or with other unrelated individuals are referred to as “unrelated individuals”.

INQ.New1 The next questions are about {your/your combined family} income. When answering these questions, please remember that by {"income/combined family income"}, I mean {your income/your income plus the income of {NAMES OF OTHER NHANES FAMILY MEMBERS} for {LAST CALENDAR YEAR}. In {LAST CALENDAR YEAR}, did {you/you and OTHER NHANES FAMILY MEMBERS} receive income from wages, salaries, commissions, bonuses, tips, or self-employment?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Wages and Salaries: Include tips, bonuses, overtime, commissions, Armed Forces pay, special cash bonuses and subsistence allowances.

Income: Income is an important factor in the analysis of the health information we collect. Access to medical care depends in part on a person or family's financial resources. This information helps us learn if people in one income group use certain types of medical services more or less than people in other income groups. We may also learn if one income group has certain medical conditions more than other income groups.

Self-Employed: Persons working for profit or fees in their own business, shop, office, farm, etc. Include persons who have their own tools or equipment and provide services on a contract, subcontract, or job basis such as carpenters, plumbers, independent taxicab operators or independent truckers.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

Household: The entire group of persons who live in one dwelling unit. It may be several persons living together or one person living alone. It includes the household reference person and any of their relatives, as well as roomers, employees, and other non-related persons.

BOX 1B

OMITTED

BOX 1C

OMITTED

INQ.New2 In {LAST CALENDAR YEAR}, did {you/you or any family members living here} receive income from interest-bearing accounts or investments, dividends from stocks or mutual funds, net rental income, royalty income, or income from estates and trusts?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

INQ.New3 In {LAST CALENDAR YEAR}, did {you/you or any family members living here} receive Supplemental Security Income, SSI, or Social Security Disability Income, SSDI? These are different from Social Security, which will be asked about next?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

SSI: Also known as Supplemental Security Income (SSI), this federal program provides monthly cash payments in accordance with uniform, nationwide eligibility requirements to persons who are both needy and aged (65 years or older), blind, or disabled. A person may be eligible for SSI payments even if they have never worked. SSI is NOT the same as Social Security. A person can get SSI in addition to Social Security. The SSI program is issued by the Social Security Administration. Each state may add to the federal payment from its own funds. This additional money may be included in the federal payment or it may be received as a separate check. If it is combined with the federal payment, the words "STATE PAYMENT INCLUDED" will appear on the federal check. A few states make SSI payments to individuals who do not receive a federal payment.

INQ.New4 In {LAST CALENDAR YEAR}, did {you/you or any family members living here} receive income from Social Security or Railroad Retirement?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Social Security: Social Security (SS) payments are received by persons who have worked long enough in employment that had SS deductions taken from their salary in order to be entitled to payments. SS payments may be made to the spouse or dependent children of a covered worker. SS also pays benefits to student dependents (under 19 years of age) of eligible social security annuitants who are disabled or deceased.

Railroad Retirement: U.S. Government Railroad Retirement Benefits are based on a person’s long-term employment in the railroad industry.

BOX 1D

OMITTED

BOX 1E

OMITTED

INQ.New5 In {LAST CALENDAR YEAR}, did {you/you or any family members living here} receive any public assistance or welfare payments from the state or local welfare office?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

Public assistance or welfare payments from the state or local welfare office include programs such as: Temporary Assistance to Needy Families (TANF, pronounced "tan'iff"), Aid to Families with Dependent Children (AFDC), or Aid for Dependent Children (ADC). AFDC or ADC are the old welfare program names, and they have been replaced by the TANF program. TANF is administered by state and local governments. Each TANF program has a unique name depending on the state or local area. Eligibility for TANF programs varies from state to state, but usually depends on having low-income. Services provided through TANF programs also vary from state to state. Where AFDC primarily provided cash benefits, TANF provides a wide range of services such as job training, child care, and subsidies to employers.

INQ.New6 In {LAST CALENDAR YEAR}, did~~Did~~ {you/you or any family members living here} receive income from retirement, survivor, or disability pensions?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Retirement or Survivors Pension: Employment benefit that provides income payments to employees upon their retirement. Pension plans provide benefits to employees who have met specified criteria, normally age and/or length of service requirements. The two main types of pension plans are:

Defined benefit plans - an employer's cost is not predetermined, but the benefit is; and

Defined contribution - the employer's cost is predetermined, but the benefit depends on how much the employee contributes, investment gains and losses, etc.

Include in this item income from 401 K, IRA's, annuities, paid-up life insurance policies and KEOGH accounts.

Disability Pension: The following are the most common types of disability pensions: company or union disability, Federal Government (Civil Service) disability, U.S. military retirement disability, state or local government employee disability, accident or disability insurance annuities, and Black Lung miner's disability.

BOX 2A

OMITTED

BOX 2B

OMITTED

BOX 2C

OMITTED

BOX 3A

OMITTED

BOX 3AA

OMITTED

BOX 3B

OMITTED

BOX 3C

OMITTED

INQ.New7 Did {you/you or any family members living here} receive income from any other sources of income such as Veterans' (VA) payments, unemployment compensation, child support, or alimony?

INTERVIEWER INSTRUCTION: INCLUDE GIFTS.

INTERVIEWER INSTRUCTION: IF RESPONDENT IS A COLLEGE STUDENT LIVING AWAY FROM THEIR FAMILY PLEASE ADD “INCLUDING MONEY RECEIVED FROM FAMILY FOR COLLEGE TUITION, BOOKS AND LIVING EXPENSES”

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

Child Support: Money received from parents for the support of their children. In some cases, child support payments may be delivered to recipients by a government office, court office, or welfare agency.

Unemployment Compensation: Payment by the state government of a fixed amount of money to an unemployed person, usually at regular intervals over a fixed period of time.

BOX 3D

OMITTED

BOX 4A

OMITTED

BOX 4C

OMITTED

BOX 4B

OMITTED

BOX 5

OMITTED

BOX 7

ASK INQ.200 – 230 FOR EACH FAMILY IN THE HOUSEHOLD.

FOR THE PURPOSE OF ADMINISTERING THE QUESTIONS ABOUT TOTAL INCOME:

 A FAMILY INCLUDES INDIVIDUALS AND GROUPS OF INDIVIDUALS WHO ARE RELATED BY BIRTH, MARRIAGE OR ADOPTION. STEP CHILDREN, PARENTS OR SIBLINGS ARE INCLUDED. IT ALSO INCLUDES UNMARRIED PARTNERS IF THEY HAVE A BIOLOGICAL OR ADOPTIVE CHILD IN COMMON. IT DOES NOT INCLUDE UNMARRIED PARTNERS WHO DO NOT HAVE A CHILD IN COMMON, FOSTER PARENTS OR FOSTER CHILDREN. NOTE: INDIVIDUALS LIVING ALONE OR WITH OTHER UNRELATED INDIVIDUALS ARE REFERRED TO AS “UNRELATED INDIVIDUALS”.

 TOTAL INCOME IS ADMINISTERED FOR EACH FAMILY AND THEN FOR THE ENTIRE HOUSEHOLD.

INQ.200 Now I am going to ask about the total income for {you/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} in {LAST CALENDAR YEAR}, including income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Can you tell me that amount before taxes?

CAPI INSTRUCTIONS:

 DISPLAY "YOU" IF ONLY 1 PERSON IN THE FAMILY.

 DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.

$ |___|___|___|___|___|___|___|___|___| (GO TO INQ.235)

REFUSED 77777777777 (INQ.220)

DON'T KNOW 99999999999 (INQ.220)

CAPI INSTRUCTION:

 REQUIRE DOUBLE ENTRY OF INCOME.

 SCREEN SHOULD READ:

DOUBLE ENTRY OF INCOME REQUIRED.

 IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.

 IF INQ.200 NOT DK OR RF, SET FAMILY ANNUAL INCOME THRESHOLD = INQ.200.

Wages and Salaries: Include tips, bonuses, overtime, commissions, Armed Forces pay, special cash bonuses and subsistence allowances.

Retirement Benefits: Employment benefit that provides income payments to employees upon their retirement. Pension plans provide benefits to employees who have met specified criteria, normally age and/or length of service requirements. The two main types of pension plans are:

Defined benefit plans - an employer's cost is not predetermined, but the benefit is; and

Defined contribution - the employer's cost is predetermined, but the benefit depends on how much the employee contributes, investment gains and losses, etc.

Include in this item income from 401 K, IRA's, annuities, paid-up life insurance policies and KEOGH accounts.

BOX 5A

OMITTED

INQ.220 You may not be able to give us an exact figure for {your/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} income, but can you tell me if this income in {LAST CALENDAR YEAR} was . . .

PROBE: Income is important in using the health information we collect. For example, it helps us to learn whether persons in one income group use certain types of medical services or have certain health conditions more or less often than those in another income group.

CAPI INSTRUCTIONS:

 DISPLAY "YOUR" IF ONLY 1 PERSON IN THE FAMILY.

 DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.

$20,000 or more, or 1

less than $20,000? 2

REFUSED 7 (BOX 9)

DON'T KNOW 9 (INQ.235)

HELP SCREEN:

INQ.230
a/b

Of these income groups, can you tell me which letter best represents {your/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} income in {LAST CALENDAR YEAR}?

HAND CARD {INQ1 AND INQ2}

ENTER LETTER(S) CORRESPONDING TO TOTAL COMBINED FAMILY INCOME.

CAPI INSTRUCTIONS:

 DISPLAY "YOUR" IF ONLY 1 PERSON IN THE FAMILY.

 DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.

 IF $20,000 OR MORE, DISPLAY HAND CARD INQ1.

 IF LESS THAN $20,000, DISPLAY HAND CARD INQ2.

 IF INQ.230 NOT EQUAL TO DK OR RF, SET FAMILY ANNUAL INCOME THRESHOLD = LOWER VALUE IN RANGE.

|___|___|

REFUSED 7777

DON'T KNOW 9999

HELP SCREEN:

BOX 6

OMITTED

INQ.235 What is the total income received last month, {LAST CALENDAR MONTH & CURRENT CALENDAR

d/e YEAR} by {you/NAMES OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS}} before taxes?

[Please include income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth.]

[INTERVIEWER INSTRUCTION: IF SP DOES NOT KNOW INCOME OF OTHER FAMILY MEMBERS, ENTER DON’T KNOW.]

SOFT EDIT: AMOUNT REPORTED IN INQ.235 (MONTHLY INCOME) GREATER THAN OR EQUAL TO THE AMOUNT REPORTED IN INQ.200 (ANNUAL INCOME), DISPLAY SOFT EDIT MESSAGE: “INTERVIEWER, YOU HAVE RECORDED AN ANNUAL TOTAL INCOME OF {ANNUAL INCOME REPORTED IN INQ.200} AND LAST MONTH’S TOTAL INCOME WAS RECORDED AS {TOTAL MONTHLY INCOME REPORTED IN INQ.235}. PLEASE CONFIRM WITH SP THAT LAST MONTH’S INCOME OF {TOTAL MONTHLY INCOME REPORTED IN INQ.235} IS CORRECT.

CAPI INSTRUCTION:

 REQUIRE DOUBLE ENTRY OF INCOME.

 SCREEN SHOULD READ:

DOUBLE ENTRY OF INCOME REQUIRED.

IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.
FOR THE CALENDAR FILL: IF CURRENT MONTH IS JANUARY THE PAST CALENDAR YEAR WILL BE SHOWN

$ |___|___|___|___|___|___|___|___|___| (INQ.300)

REFUSED 77777777777

DON'T KNOW 99999999999

INQ.238 You may not be able to give us an exact figure, but can you tell me if the income for {you/NAMES OF OTHER FAMILY/your family} in {LAST CALENDAR MONTH & CURRENT CALENDAR YEAR} was . . .

{185% of monthly poverty

level} or less, or 1

more than {185% monthly poverty level}? 2 (INQ.300)

REFUSED 7

DON'T KNOW 9

PROBE: (That would be {12 times 185% monthly poverty level}} per year.)

CAPI INSTRUCTION:

 Fill 185% of the monthly poverty level based on family size:

For family sizes 1-8, use the numbers in the 3^rd column in the table below.

For family size > 8, with each additional family member, fill {[$6,534+($666 * # of additional person past 8)] round to nearest 100s}.

 Fill 185% of the annual poverty level based on family size in the PROBE:

For family sizes 1-8, use the numbers in the 5^th column in the table below.

For family size > 8, with each additional member, fill {[$78,403+($7,992 * # of additional person past 8)] round to nearest 100s}.

Persons in Family	185% monthly poverty level		185% annual poverty level
Persons in Family	Raw Number¹	Rounded to nearest 100s²	Raw Number³	Rounded to nearest 100s⁴
1	1,872	1,900	22,459	22,500
2	2,538	2,500	30,451	30,500
3	3,204	3,200	38,443	38,400
4	3,870	3,900	46,435	46,400
5	4,536	4,500	54,427	54,400
6	5,202	5,200	62,419	62,400
7	5,868	5,900	70,411	70,400
8	6,534	6,500	78,403	78,400

¹: $1,872 for family size of 1. Thereafter, adding $666 for each additional person.

²: These are the numbers to be used in the response category fills.

³: Multiply by 12 to the raw number of the 185% monthly poverty level.

⁴: These are the numbers to be used in the probe fills.

INQ.241 Was it more or less than {130% monthly poverty level}?

{130% monthly poverty level} OR LESS,

OR 1

MORE THAN {130% of monthly poverty

level} 2

REFUSED 7

DON'T KNOW 9

PROBE: {That would be 12 times 130% annual poverty level per year.}

CAPI INSTRUCTION:

 Fill 130% of the monthly poverty level based on family size:

For family sizes 1-8, use the numbers in the 3^rd column in the table below.

For family size > 8, with each additional family member, fill {[$4,591+($468 * # of additional person past 8)] round to nearest 100s}.

 Fill 130% of the annual poverty level based on family size in the PROBE:

For family sizes 1-8, use the numbers in the 5^th column in the table below.

For family size > 8, with each additional member, fill {[$55,094+($5,616 * # of additional person past 8)] round to nearest 100s}

Persons in Family	130% monthly poverty level		130% annual poverty level
Persons in Family	Raw Number¹	Rounded to nearest 100s²	Raw Number³	Rounded to nearest 100s⁴
1	1,315	1,300	15,782	15,800
2	1,783	1,800	21,398	21,400
3	2,251	2,300	27,014	27,000
4	2,719	2,700	32,630	32,600
5	3,187	3,200	38,246	38,200
6	3,655	3,700	43,862	43,900
7	4,123	4,100	49,478	49,500
8	4,591	4,600	55,094	55,100

¹: $1,315 for family size of 1. Thereafter, adding $468 for each additional person.

²: These are the numbers to be used in the text of question and response category fills.

³: Multiply 12 to the raw number of the 130% monthly poverty level.

⁴: These are the numbers to be used in the probe fills.

NEW BOX 7A

OMITTED

NEW BOX 7B

OMITTED

INQ.300 Do {you/NAMES OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} have more than $20,000 in savings at this time? Please include money in all types of accounts {you/your family} may have. Here are some examples of the types of accounts.

HAND CARD INQ3

CAPI INSTRUCTION:

DISPLAY “you” for single-person family; DISPLAY “the members of your family” for multi-persons family.

YES 1 (BOX 9)

NO 2

REFUSED 7 (BOX 9)

DON'T KNOW 9 (BOX 9)

INQ.310 Which letter on this card best represents the total savings or cash assets at this time for {you/NAMES OF OTHER FAMILY/your family}?

HAND CARD INQ4

|___| ENTER LETTER

REFUSED 7

DON'T KNOW 9

A: $0 - $3,000

B: $3,001 - $5,000

C: $5,001 - $10,000

D: $10,001 - $15,000

E: $15,001 - $20,000

BOX 8

OMITTED

BOX 9

CHECK ITEM INQ.240:

IF THERE IS MORE THAN ONE NHANES FAMILY IN THE HOUSEHOLD, CONTINUE.

OTHERWISE, GO TO INQ.320.

BOX 9A

CHECK ITEM INQ.249:

HOUSEHOLD INCOME (INQ.250, 260, 270) SHOULD ONLY BE ASKED ONCE OF THE FIRST FAMILY TO COMPLETE THE FAMILY QUESTIONNAIRE REGARDLESS OF FAMILY NUMBER. IT SHOULD NOT BE ASKED TWICE FOR A HOUSEHOLD AND SHOULD NOT BE MISSED IF ONE FAMILY DOES NOT COMPLETE THE FAMILY QUESTIONNAIRE.

INQ.250 Now I am going to ask you about the total household income for the persons we have talked about plus {NAMES OF ALL OTHER PERSONS IN ADDITIONAL NHANES FAMILIES} in {LAST CALENDAR YEAR}, including income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Can you tell me that amount before taxes?

$ |___|___|___|___|___|___|___|___|___| (GO TO INQ.320)

REFUSED 77777777777 (INQ.260)

DON'T KNOW 99999999999 (INQ.260)

CAPI INSTRUCTION:

 REQUIRE DOUBLE ENTRY OF INCOME.

 SCREEN SHOULD READ:

DOUBLE ENTRY OF INCOME REQUIRED.

 IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.

Wages and Salaries: Include tips, bonuses, overtime, commissions, Armed Forces pay, special cash bonuses and subsistence allowances.

Defined benefit plans - an employer's cost is not predetermined, but the benefit is; and

Defined contribution - the employer's cost is predetermined, but the benefit depends on how much the employee contributes, investment gains and losses, etc.

Include in this item income from 401 K, IRA's, annuities, paid-up life insurance policies and KEOGH accounts.

INQ.260 You may not be able to give us an exact figure for your total household income, but can you tell me if this income in {LAST CALENDAR YEAR} was . . .

PROBE: Income is important in analyzing the health information we collect. For example, this information helps us to learn whether persons in one income group use certain types of medical services or have certain conditions more or less often than those in another group.

$20,000 or more, or 1

less than $20,000? 2

REFUSED 7 (INQ.320)

DON'T KNOW 9 (INQ.320)

HELP SCREEN:

INQ.270

Of these income groups, can you tell me which letter best represents your total household income in {LAST CALENDAR YEAR}?

HAND CARD {INQ1 AND INQ2}

ENTER LETTER(S) CORRESPONDING TO TOTAL COMBINED HOUSEHOLD INCOME.

|___|___|

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF $20,000 OR MORE, DISPLAY HAND CARD INQ1.

IF LESS THAN $20,000, DISPLAY HAND CARD INQ2.

HELP SCREEN:

INQ.320 Now I will ask you a question about how your household usually travels to the store for your grocery shopping.

Please look at this card. How do {you/you or anyone who lives in the household} usually get to the store (or stores) where you do most of your grocery shopping?

HAND CARD INQ5

INTERVIEWER INSTRUCTION:

1. If the respondent cannot decide on one single answer, probe for the “usual/most common” way.

2. select “NO USUAL MODE OF TRAVELING TO STORE” only when the respondent cannot report a single usual mode for the question.

3. If the respondent uses different modes for getting to and returning from store, enter the mode of “getting to” the store.

IN MY CAR 1

IN A CAR THAT BELONGS TO SOMEONE
I LIVE WITH 2

IN A CAR THAT BELONGS TO SOMEONE
WHO LIVES ELSEWHERE 3

WALK 4

RIDE BICYCLE 5

BUS, SUBWAY OR OTHER PUBLIC
TRANSIT 6

TAXI OR OTHER PAID DRIVER 7

SOMEONE ELSE DELIVERS GROCERIES 8

OTHER 9

NO USUAL MODE OF TRAVELING TO
STORE 66

REFUSED 77

DON’T KNOW 99

FOOD SECURITY – FSQ

Target Group: Household

CAPI DISPLAY INSTRUCTIONS FOR ALL QUESTIONS IN SECTION:

1. IF ONLY ONE PERSON IN HOUSEHOLD

- FOR {YOU/YOUR HOUSEHOLD}, DISPLAY “YOU”

- FOR {I/WE}, {MY/OUR}, DISPLAY “I” AND “MY”

- FOR {YOU/YOU OR OTHER ADULTS IN YOUR HOUSEHOLD}, DISPLAY “YOU”.

2. IF MORE THAN ONE PERSON IN HOUSEHOLD

- FOR {YOU/YOUR HOUSEHOLD}, DISPLAY “YOUR HOUSEHOLD”

- FOR {I/WE}, {MY/OUR}, DISPLAY “WE” AND “OUR”

- FOR {YOU/YOU OR OTHER ADULTS IN YOUR HOUSEHOLD}, DISPLAY “YOU OR OTHER ADULTS IN YOUR HOUSEHOLD”.

FSQ.032 I am going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for {you/your household} in the last 12 months, that is since {DISPLAY CURRENT MONTH AND LAST YEAR}.

HAND CARD FSQ1

CAPI INSTRUCTION:

IF ITEM CHANGED, CHECK MEC COMPONENT.

RESPONSES TO FSQ032A, B, AND C: OFTEN TRUE = 1, SOMETIMES TRUE = 2, NEVER TRUE = 3, REFUSED = 7, DON’T KNOW = 9

a. {I/We} worried whether {my/our} food would run out before {I/we} got money

to buy more. ____

b. The food that {I/we} bought just didn’t last, and {I/we} didn’t have enough

money to get more food. ____

c. {I/We} couldn’t afford to eat balanced meals. ____

HELP SCREEN:

Balanced Meal: A balanced meal includes all the types of food that you think should be in a healthy meal. For example, a starch like potatoes or rice, vegetables or fruit and some protein like meat, fish, cheese or eggs.

BOX 1

IF RESPONSE TO FSQ032 a, b, OR c, IS CODE 1 OR 2 (OFTEN TRUE OR SOMETIMES TRUE), CONTINUE.

OTHERWISE, GO TO BOX 3.

FSQ.041 In the last 12 months, since last { DISPLAY CURRENT MONTH AND LAST YEAR }, did {you/you or other adults in your household} ever cut the size of your meals or skip meals because there wasn’t enough money for food?

YES 1

NO 2 (FSQ.061)

REFUSED 7 (FSQ.061)

DON’T KNOW 9 (FSQ.061)

HELP SCREEN:

FSQ.052 How often did this happen?

Almost every month, 1

some months but not every month, or 2

in only 1 or 2 months? 3

REFUSED 7

DON’T KNOW 9

FSQ.061 In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FSQ.071 [In the last 12 months], were you ever hungry but didn’t eat because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FSQ.081 [In the last 12 months], did you lose weight because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 2

CHECK ITEM FSQ.083:

IF RESPONSE TO FSQ.041, 061, 071, OR 081 IS CODE 1 (YES), CONTINUE.

OTHERWISE GO TO BOX 3.

FSQ.092 [In the last 12 months], did {you/you or other adults in your household} ever not eat for a whole day because there wasn’t enough money for food?

YES 1

NO 2 (BOX 3)

REFUSED 7 (BOX 3)

DON’T KNOW 9 (BOX 3)

HELP SCREEN:

FSQ.102 How often did this happen?

Almost every month, 1

some months but not every month, or 2

in only 1 or 2 months? 3

REFUSED 7

DON’T KNOW 9

BOX 3

CHECK ITEM FSQ.085A:

IF THERE IS AT LEAST 1 CHILD IN THE HOUSEHOLD WHO IS <= 17 (OR IN THE AGE RANGE THAT INCLUDES OR IS LESS THAN THE ONE THAT INCLUDES 17), CONTINUE.

OTHERWISE, GO TO FSQ.151.

CAPI DISPLAY INSTRUCTIONS FOR ALL QUESTIONS:

IF ONLY ONE CHILD IN THE HOUSEHOLD AGED <=17, DISPLAY CHILD’S NAME.

IF MORE THAN ONE CHILD IN HOUSEHOLD AGED <=17, DISPLAY “THE CHILDREN IN YOUR HOUSEHOLD WHO ARE UNDER 18 YEARS OLD”, “THE CHILDREN”, OR “ANY OF THE CHILDREN”.

FSQ.032 The next questions are about children living in the household who are under 18 years old.

I am going to read you several statements that people have made about their children’s food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for {CHILD’s NAME/your child/the children in your household who are under 18 years old} in the last 12 months, that is since {DISPLAY CURRENT MONTH AND LAST YEAR}.

RESPONSES TO FSQ032D, E, AND F: OFTEN TRUE = 1, SOMETIMES TRUE = 2, NEVER TRUE = 3, REFUSED = 7, DON’T KNOW = 9

HAND CARD FSQ1

CAPI INSTRUCTION:

IF ITEM CHANGED, CHECK MEC COMPONENT.

d. (I/We) relied on only a few kinds of low-cost foods to feed {CHILD’s

NAME/the children} because there wasn’t enough money for food. ____

e. (I/We) couldn’t feed {(CHILD’s NAME/the children} a balanced meal,

because there wasn’t enough money for food. ____

f. {CHILD’s NAME was/The children were} not eating enough because

there wasn’t enough money for food. ____

HELP SCREEN:

NEW BOX 4

CHECK ITEM FSQ.108:

IF RESPONSE TO FSQ.032d, e, or f, IS CODE 1 OR 2 (OFTEN TRUE OR SOMETIMES TRUE), CONTINUE.

OTHERWISE, GO TO FSQ.151.

FSQ.111 In the last 12 months, since {DISPLAY CURRENT MONTH AND LAST YEAR} did you ever cut the size of {CHILD’S NAME/any of the children’s} meals because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FSQ.121 [In the last 12 months], did {CHILD’S NAME/any of the children} ever skip meals because there wasn’t enough money for food?

YES 1

NO 2 (FSQ.141)

REFUSED 7 (FSQ.141)

DON’T KNOW 9 (FSQ.141)

FSQ.132 How often did this happen?

Almost every month, 1

some months but not every month, or 2

in only 1 or 2 months? 3

REFUSED 7

DON’T KNOW 9

FSQ.141 In the last 12 months, {was CHILD’S NAME/were any of the children} ever hungry, but there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FSQ.146 [In the last 12 months], did {CHILD’S NAME/any of the children} ever not eat for a whole day because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FSQ.151 [In the last 12 months], did {you/you or any member of your household} ever get emergency food from a church, a food pantry, or a food bank, or eat in a soup kitchen?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

Community Kitchen: A place you went to eat because you didn’t have money for food. Do not include a place you went to for social reasons, such as, a senior center or a place you went to for shelter because of something like a hurricane or flood.

BOX 5

CHECK ITEM FSQ.155B:

IF THE HOUSEHOLD INCLUDES:

**A CHILD AGED 5 YEARS OR UNDER, OR IN AN AGE RANGE THAT INCLUDES AGE 5 AND UNDER

** A FEMALE BETWEEN AGES 12 AND 59, OR IN AN AGE RANGE THAT INCLUDES ANY AGES BETWEEN 12 AND 59) CONTINUE

OTHERWISE, GO TO FSQ.755.

FSQ.760 Next are a few questions about the WIC program, that is, the Women, Infants and Children program

Did {you/you or anyone who lives here} receive WIC benefits in the past 30 days? {Here is the list of children 5 years and younger and women ages 12 to 59 years who live here, let me read it to you.}

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL CHILDREN AGES 5 AND UNDER, AND WOMEN AGES 12 TO 59 IN THE HOUSEHOLD, AND HOUSEHOLD MEMBERS WITH UNKNOWN AGE OR GENDER.

CAPI INSTRUCTION:

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “Here is the list of children 5 years and younger and women ages 12 to 59 years who live here, let me read it to you.”

HELP SCREEN:

WIC: WIC is short for the Special Supplemental Food Program for Women, Infants, and Children. This program provides food assistance and nutritional screening to low-income pregnant and postpartum women and their infants, as well as to low-income children up to age 5.

YES 1

NO 2 (FSQ.162)

REFUSED 7 (FSQ.162)

DON’T KNOW 9 (FSQ.162)

BOX 5AA

CHECK ITEM FSQ.765:

IF FSQ.760 = 1 AND ONLY ONE PERSON IN HOUSEHOLD, FLAG PERSON AS RECEIVING WIC IN FSQ.770, GO TO BOX 5BB.

OTHERWISE CONTINUE.

FSQ.770 Who in the household has received WIC benefits in the past 30 days?

PROBE: Anyone else?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL CHILDREN AGES 5 AND UNDER, AND WOMEN AGES 12 TO 59 IN THE HOUSEHOLD.

INTERVIEWER INSTRUCTION: SELECT NAME(S) FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

HARD EDIT:

IF NO ONE IN THE ROSTER WAS SELECTED, DISPLAY THE FOLLOWING MESSAGE TO VERIFY THE ANSWER TO FSQ.770:

“You said that someone who lives here has received WIC in the last 30 days, is that correct?”

IF YES, GO BACK TO FSQ.770 AND ASK: “Who was that?” WITH ROSTER DISPLAYED.

IF NO, GO BACK TO CODE FSQ.760 AS ‘NO’.

BOX 5BB

CHECK ITEM FSQ.775:

GO TO FSQ.755.

FSQ.162 In the last 12 months, did {you/you or any member of your household} receive benefits from the WIC program?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 5A

OMITTED

BOX 5B

OMITTED

NEW BOX 6

OMITTED

BOX 3

OMITTED

FSQ.755 The next questions are about SNAP, the Supplemental Nutrition Assistance Program, also known as the Food Stamp Program. SNAP benefits are provided on a food stamp benefit card {called the {DISPLAY STATE NAME FOR EBT CARD} card in STATE}/or EBT card}.

Do {you/you or anyone in your household} currently get SNAP or Food Stamps? This includes any SNAP benefits or Food Stamps, even if the amount is small and even if the benefits are received on behalf of children in the household.

CAPI INSTRUCTIONS:

INSERT “OR EBT CARD” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD AND STATE NAME IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

YES 1

NO 2 (FSQ.855)

REFUSED 7 (FSQ.855)

DON’T KNOW 9 (FSQ.855)

BOX 6

CHECK ITEM FSQ.785:

IF FSQ.755 = 1 AND ONLY ONE PERSON IN HOUSEHOLD, FLAG PERSON AS RECEIVING SNAP IN FSQ.790, GO TO FSQ.795.

OTHERWISE CONTINUE.

FSQ.790 Who in the household is currently on the {DISPLAY STATE NAME FOR EBT CARD} card}/or EBT card} to get Food Stamps? Here is the list of people who live here, let me read it to you.

PROBE: Is anyone else on the card?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL HOUSEHOLD MEMBERS.

INTERVIEWER INSTRUCTION:

READ NAMES OF ALL HOUSEHOLD MEMBERS TO THE RESPONDENT

SELECT NAME(S) FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

CAPI INSTRUCTIONS:

INSERT “EBT CARD” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

HARD EDIT:

IF NO ONE IN THE ROSTER WAS SELECTED, DISPLAY THE FOLLOWING MESSAGE TO VERIFY THE ANSWER TO FSQ.790:

“You said someone who lives here is currently getting Food Stamps. Is that correct?”

IF YES, GO BACK TO FSQ.790 AND ASK: “Who was that?” WITH ROSTER DISPLAYED.

IF NO, GO BACK TO CODE FSQ.755 AS ‘NO’.

FSQ.795 During the past 12 months, for how many months did {you/you and NAMES/NAME(S)} get Food Stamps?

CAPI INSTRUCTION:

FOR EVERY HH MEMBER WITH “SELECT (CODE “1”)” IN FSQ.790, ENABLE A FIELD FOR INTERVIEWER TO ENTER THE NUMBER OF MONTHS

INTERVIEWER INSTRUCTION:

ASK FOR EVERY HH MEMBER WITH “SELECT (CODE “1”)” IN FSQ.790.

ENTER ‘1’ FOR LESS THAN ONE MONTH PARTICIPATION

|___|___|

ENTER NUMBER OF MONTHS

REFUSED 77

DON'T KNOW 99

HARD EDIT:

THE RESPONSE NEEDS TO BE BETWEEN 1-12.

BOX 7

CHECK ITEM FSQ.800:

IF ONLY ONE PERSON WITH “SELECTED” IN FSQ.790, GO TO FSQ.810.

OTHERWISE CONTINUE.

FSQ.805 Are {you and NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.790/ NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.790} getting Food Stamps on the same {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

YES 1

NO 2 (FSQ.825)

REFUSED 7

DON’T KNOW 9

FSQ.810

FSQ.811

FSQ.812

On what date were food stamps last put on {your/their/her/his} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE WITHIN PAST 31 DAYS OF CURRENT DATE. IF THE “DAY” FIELD IS DK/RF, THEN THE MONTH/YEAR ENTERED MUST BE WITHIN PAST 1 MONTH OF CURRENT MONTH. INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.815 In {MONTH FROM FSQ.810 /that last time}, what amount in food stamps was put on {your/their/her/his} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “MONTH FROM FSQ.810” IF MONTH FILED FSQ.810 IS NOT MISSING, RF OR DK.

INSERT “THAT LAST TIME” IF MONTH FILED FSQ.810 IS MISSING, RF OR DK.

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

BOX 8

CHECK ITEM FSQ.820:

IF ALL HH MEMBERS ARE MARKED “SELECT” ON FSQ.790, GO TO THE END OF SECTION.

OTHERWISE, CONTINUE WITH FSQ.855

FSQ.825 Among {you and NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.790/ NAME(S) OF ALL HH MEMBER WITH “SELECT” IN FSQ.790}, how many {DISPLAY STATE NAME FOR EBT CARD} /EBT} cards are there?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: RESPONSE CANNOT BE ZERO, AND CANNOT BE MORE THAN THE NUMBER OF PEOPLE “SELECTED (CODE 1)” IN FSQ.790.

|___|___|

NUMBER OF CARDS

REFUSED 77

DON’T KNOW 99

BOX 9

CHECK ITEM FSQ.830:

IF FSQ.825 = DK OR RF, THEN ALLOCATE EACH PERSON WITH ONE CARD, THEN SKIP TO FSQ.840.

IF THE NUMBER OF CARDS EQUALS TO THE NUMBER OF PERSONS LISTED “SELECT” ON FSQ.790, ALLOCATE EACH PERSON WITH ONE CARD, THEN SKIP TO FSQ.840.

OTHERWISE CONTINUE.

FSQ.835 Can you tell me who is on card {#}?

CAPI INSTRUCTIONS:

DISPLAY A GRID SO INTERVIEWER CAN ALLOCATE EACH HH MEMBERS WITH “SELECT” IN FSQ.790 TO EACH OF THE CARDS. EACH CARD SHOULD ALLOW MULTIPLE PERSONS BE SELECTED INTO.

FOR EXAMPLE:

Name	Card 1	Card 2	Card 3
John Doe
Jane Doe
Bobby Jones

HARD EDIT: EACH HH MEMBERS WITH “SELECT” IN FSQ.790 SHOULD BELONG TO ONE CARD, AND ONE CARD ONLY. IF NO MEMBER BELONGS TO A CARD, GO BACK TO FSQ.825 AND CORRECT THE NUMBER OF CARDS.

BOX 10

LOOP 1:

ASK FSQ.840 - FSQ.845 FOR EACH CARD.

FSQ.840

FSQ.841

FSQ.842

On what date were food stamps last put on {your/NAME’S(S’) ON EACH CARD} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE WITHIN PAST 31 DAYS OF CURRENT DATE. IF THE “DAY” FIELD IS DK/RF, THEN THE MONTH/YEAR ENTERED MUST BE WITHIN PAST 1 MONTH OF CURRENT MONTH.

INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.845 In {MONTH FROM FSQ.840/that last time}, what amount in food stamps was put on {your/theirs/his/her} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “MONTH FROM FSQ.840” IF MONTH FILED FSQ.840 IS NOT MISSING, RF OR DK.

INSERT “THAT LAST TIME” IF MONTH FILED FSQ.840 IS MISSING, RF OR DK.

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

BOX 11

END LOOP 1:

ASK FSQ.840 - FSQ.845 FOR SECOND CARD.

IF INFORMATION COLLECTED FOR ALL CARDS, GO TO BOX12.

BOX 12

CHECK ITEM FSQ.850:

IF ALL HH MEMBERS ARE MARKED “SELECT” ON FSQ.790, GO TO THE END OF SECTION.

OTHERWISE, CONTINUE WITH FSQ.855.

FSQ.855 Have {you/you or NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790/ NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790} recently been notified that {you/you or she, you or he, you or they/he, she, they} will start to get Food Stamps later this month or next month?

CAPI INSTRUCTIONS:

IF FSQ.755 = NO, REFUSED, OR DON’T KNOW (NO ONE IN THE HH IDENTIFIED AS “CURRENT SNAP RECIPIENT”), THEN DISPLAY THE QUESTION AS:

“Have {you/you or anyone in your household} recently been notified that {you/you or they} will start to get Food Stamps later this month or next month? {Here is the list of people who live here, let me read it to you.}”

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS.

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “Here is the list of people who live here, let me read it to you.”

YES 1

NO 2 (FSQ.870)

REFUSED 7 (FSQ.870)

DON’T KNOW 9 (FSQ.870)

FSQ.860

FSQ.861

FSQ.862

On what date {do you/ do you, NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790/ does {/NAME(S) OF HH MEMBERS WHO ARE NOT THE RESPONDENT AND WITH “NOT SELECTED (CODE “2”)” IN FSQ.790}} think {you/you or she, you or he, you or they/he, she, they} will start getting Food Stamps?

CAPI INSTRUCTIONS:

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE AT OR AFTER CURRENT DATE. DATE MUST NOT BE MORE THAN TWO MONTHS FROM CURRENT MONTH.

INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE. IF THERE ARE MULTIPLE ANTICIPATED STARTING DATES, ENTER THE ONE CLOSEST TO THE CURRENT DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.865 What amount in Food Stamps {do you/do you or she, do you or he, do you or they/does he, does she/do they} expect to get at that time?

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

FSQ.870 In the last 12 months, did {you/you or NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790/ NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790} get Food Stamps, even if only for one month? This includes any SNAP benefits or Food Stamps received in the past year, even if the amount was small or if they were received on behalf of children in the household.

CAPI INSTRUCTIONS:

IF FSQ.755 = NO, REFUSED, OR DON’T KNOW (NO ONE IN THE HH IDENTIFIED AS “CURRENT SNAP RECIPIENT”), THEN DISPLAY THE QUESTION AS:

“In the last 12 months, did {you/ you or anyone in your household} get Food Stamps, even if only for one month?” {(Here is the list of people who live here, let me read it to you.)}

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS ENCLOSED IN PARENTHESES.

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “(Here is the list of people who live here, let me read it to you.)”

YES 1

NO 2 (FSQ.945)

REFUSED 7 (FSQ.945)

DON’T KNOW 9 (FSQ.945)

BOX 13

CHECK ITEM FSQ.875:

IF FSQ.870 = 1 AND ONLY ONE PERSON IN HOUSEHOLD OR ONE PERSON THAT’S “NOT SELECTED (CODE 2)” IN FSQ.790, FLAG PERSON AS RECEIVING SNAP IN FSQ.880, GO TO FSQ.885.

OTHERWISE CONTINUE.

FSQ.880 Among {you and NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790/NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790}, who was on the {DISPLAY STATE NAME FOR EBT CARD}/or EBT} card to get Food Stamps in the past 12 months?

PROBE: Was anyone else on the card?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL HOUSEHOLD MEMBERS WITH “NOT SELECTED (CODE “2”)” IN FSQ.790.

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

INTERVIEWER INSTRUCTION:

READ NAMES OF ALL HOUSEHOLD MEMBERS WITH “NOT SELCTED (CODE “2”)” IN FSQ.790 TO THE RESPONDENT

SELECT NAME(S) FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF FSQ.755 = NO, REFUSED, OR DON’T KNOW (NO ONE IN THE HH IDENTIFIED AS “CURRENT SNAP RECIPIENT”), THEN DISPLAY THE QUESTION AS:

“Who in the household was on the {DISPLAY STATE NAME FOR EBT CARD} card}/or EBT card} to get Food Stamps in the past 12 months? (Here is the list of people who live here, let me read it to you.”)

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS ENCLOSED IN PARENTHESES.

HARD EDIT:

IF NO ONE IN THE ROSTER WAS SELECTED, DISPLAY THE FOLLOWING MESSAGE TO VERIFY THE ANSWER TO FSQ.880:

“You said someone who lives here got Food Stamps in the past 12 months. Is that correct?”

IF YES, GO BACK TO FSQ.880 AND ASK: “Who was that?” WITH ROSTER DISPLAYED.

IF NO, GO BACK TO CODE FSQ.870 AS ‘NO’.

FSQ.885 During the past 12 months, for how many months did {you/{NAME(S)} get Food Stamps?

CAPI INSTRUCTION:

FOR EVERY HH MEMBER WITH “SELECT (CODE “1”)” IN FSQ.880, ENABLE A FIELD FOR INTERVIEWER TO ENTER THE NUMBER OF MONTHS

INTERVIEWER INSTRUCTION:

ASK FOR EVERY HH MEMBER WITH “SELECT (CODE “1”)” IN FSQ.880.

ENTER ‘1’ FOR LESS THAN ONE MONTH PARTICIPATION

|___|___|

ENTER NUMBER OF MONTHS

REFUSED 77

DON'T KNOW 99

HARD EDIT:

THE RESPONSE NEEDS TO BE BETWEEN 1-12.

BOX 14

CHECK ITEM FSQ.890:

IF ONLY ONE PERSON WITH “SELECTED” IN FSQ.880, GO TO FSQ.900.

OTHERWISE CONTINUE.

FSQ.895 Did {you and NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.880/ NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.880} get Food Stamps on the same {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

YES 1

NO 2 (FSQ.915)

REFUSED 7

DON’T KNOW 9

FSQ.900

FSQ.901

FSQ.902

On what date were food stamps last put on {your/their/her/his} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE WITHIN PAST 12 MONTHS OF CURRENT MONTH.

INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.905 In {MONTH FROM FSQ.900 /that last time}, what amount in food stamps was put on {your/their/his/her} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “MONTH FROM FSQ.900” IF MONTH FILED FSQ.900 IS NOT MISSING, RF OR DK.

INSERT “THAT LAST TIME” IF MONTH FILED FSQ.900 IS MISSING, RF OR DK.

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

BOX 15

CHECK ITEM FSQ.910:

IF ALL HH MEMBERS ARE MARKED “SELECTED” ON FSQ.790 OR FSQ.880, GO TO THE END OF SECTION.

OTHERWISE, CONTINUE WITH FSQ.945.

FSQ.915 Among {you and NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.880/ NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.880}, how many {DISPLAY STATE NAME FOR EBT CARD} /EBT} cards are there?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: RESPONSE CANNOT BE ZERO, AND CANNOT BE MORE THAN THE NUMBER OF PEOPLE “SELECTED (CODE 1)” IN FSQ.880.

|___|___|

NUMBER OF CARDS

REFUSED 77

DON’T KNOW 99

BOX 16

CHECK ITEM FSQ.920:

IF FSQ.915 = DK OR RF, THEN ALLOCATE EACH PERSON WITH ONE CARD, THEN SKIP TO FSQ.930.

IF THE NUMBER OF CARDS EQUALS TO THE NUMBER OF PERSONS LISTED “SELECT” ON FSQ.880, ALLOCATE EACH PERSON WITH ONE CARD, THEN SKIP TO FSQ.930.

OTHERWISE CONTINUE.

FSQ.925 Can you tell me who is on card {#}?

CAPI INSTRUCTIONS:

DISPLAY A GRID SO INTERVIEWER CAN ALLOCATE EACH HH MEMBERS WITH “SELECTED” IN FSQ.880 TO EACH OF THE CARDS. EACH CARD SHOULD ALLOW MULTIPLE PERSONS BE SELECTED INTO.

FOR EXAMPLE:

Name	Card 1	Card 2	Card 3
John Doe
Jane Doe
Bobby Jones

HARD EDIT: EACH HH MEMBERS WITH “SELECT” IN FSQ.880 SHOULD BELONG TO ONE CARD, AND ONE CARD ONLY. IF NO MEMBER BELONGS TO A CARD, GO BACK TO FSQ.915 AND CORRECT THE NUMBER OF CARDS.

BOX 17

LOOP 2:

ASK FSQ.930 - FSQ.935 FOR EACH CARD.

FSQ.930

FSQ.931

FSQ.932

On what date were food stamps last put on {your/NAME’S(S’) ON EACH CARD} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE WITHIN PAST 12 MONTHS OF CURRENT MONTH.

INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.935 In {MONTH FROM FSQ.930/that last time}, what amount in food stamps was put on {your/their/his/her} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “MONTH FROM FSQ.930” IF MONTH FILED FSQ.930 IS NOT MISSING, RF OR DK.

INSERT “THAT LAST TIME” IF MONTH FILED FSQ.930 IS MISSING, RF OR DK.

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

BOX 18

END LOOP 2:

ASK FSQ.930 - FSQ.935 FOR SECOND CARD.

IF INFORMATION COLLECTED FOR ALL CARDS, GO TO BOX19.

BOX 19

CHECK ITEM FSQ.940:

IF ALL HH MEMBERS ARE MARKED “SELECTED” ON FSQ.790 OR FSQ.880, GO TO THE END OF SECTION.

OTHERWISE, CONTINUE WITH FSQ.945.

FSQ.945 Have/Has {you/you or NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880/NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880} ever gotten Food Stamps?

CAPI INSTRUCTIONS:

IF BOTH FSQ.755 AND FSQ.870 = NO, REFUSED, OR DON’T KNOW (CODE “2, 7, OR 9”), THEN DISPLAY THE QUESTION AS:

“Have {you/ you or anyone in your household} ever gotten Food Stamps? {(Here is the list of people who live here, let me read it to you.)}”

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS ENCLOSED IN PARENTHESES.

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “(Here is the list of people who live here, let me read it to you.)”

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

BOX 20

CHECK ITEM FSQ.950:

IF FSQ.945=1 AND ONLY ONE PERSON IN HOUSEHOLD OR ONE PERSON THAT’S “NOT SELECTED (CODE 2)” IN FSQ.790 AND FSQ.880, FLAG PERSON AS RECEIVING SNAP IN FSQ.955, GO TO END OF SECTION.

OTHERWISE CONTINUE.

FSQ.955 Among {you and NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880/NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880}, who has ever gotten Food Stamps?

PROBE: Anyone else?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL HOUSEHOLD MEMBERS WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880.

INTERVIEWER INSTRUCTION:

READ NAMES OF ALL HOUSEHOLD MEMBERS WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880 TO THE RESPONDENT

SELECT NAME(S) FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF BOTH FSQ.755 AND FSQ.870 = NO, REFUSED, OR DON’T KNOW (CODE “2, 7, OR 9”), THEN DISPLAY THE QUESTION AS:

“Who in the household has ever gotten Food Stamps? (Here is the list of people who live here, let me read it to you.)”

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS ENCLOSED IN PARENTHESES.

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY (Here is the list of people who live here, let me read it to you.)

HARD EDIT:

IF NO ONE IN THE ROSTER WAS SELECTED, DISPLAY THE FOLLOWING MESSAGE TO VERIFY THE ANSWER TO FSQ.955:

“You said someone who lives here has been on Food Stamps. Is that correct?”

IF YES, GO BACK TO FSQ.955 AND ASK: “Who was that?” WITH ROSTER DISPLAYED.

IF NO, GO BACK TO CODE FSQ.945 AS ‘NO’.

TRACKING AND TRACING – TTQ

Target Group: Family

BOX 1

LOOP 1:

ASK TTQ.010 - TTQ.040 FOR 2 CONTACT PERSONS.

TTQ.005 The National Center for Health Statistics may wish to contact you again to obtain additional health related information. Please give me the names, addresses, and telephone numbers of 2 relatives or friends who would know where you could be reached in case we have trouble reaching you. (Please give me the names of persons not currently living in the household.)

PRESS F6 IF RESPONDENT REFUSES {ALL/SECOND} CONTACT INFORMATION

PRESS F5 IF RESPONDENT DOESN'T KNOW {ANY/SECOND} CONTACT INFORMATION

PRESS ENTER TO ADD {FIRST/SECOND} CONTACT INFORMATION

REFUSED 777777 (END OF SECTION)

DON'T KNOW 999999 (END OF SECTION)

HELP SCREEN:

Relative: All common relationships that occur through blood (grandfather, daughter), marriage (wife, stepson), or adoption (adopted son or daughter). Include foster relationships and guardian/ward relationships. Also refers to extended relationships by legal marriage. For example, a man and woman are married. The woman's cousin's husband would also be counted as a "relative" of the man.

TTQ.010 REFERRING TO PERSON {1/2}

VERIFY SPELLING.

ENTER FIRST NAME

REFUSED 7----7

DON'T KNOW 9----9

PROBE FOR MIDDLE NAME IF NOT REPORTED

ENTER "NMN" FOR NO MIDDLE NAME

ENTER MIDDLE NAME

REFUSED 7----7

DON'T KNOW 9----9

ENTER LAST NAME

REFUSED 7----7

DON'T KNOW 9----9

TTQ.020 REFERRING TO PERSON {1/2}

What is this person's address? [If there is more than one address, please give us the address used most often.]

ENCOURAGE RESPONDENT TO USE PHONE BOOK OR OTHER DOCUMENTATION IF AVAILABLE.

______________________ ___________________________ _____________________

a. ENTER STREET NUMBER b. ENTER STREET NAME c. ENTER APARTMENT NUMBER

REFUSED 7777777777 REFUSED 7----7 REFUSED 77777777

DON'T KNOW 9999999999 DON'T KNOW 9----9 DON'T KNOW 99999999

_____________________ |____|____| |___|____|____|____|____|

d. ENTER TOWN OR e. ENTER 2 LETTER f. ENTER POSTAL CODE

CITY NAME STATE ABBREVIATION TO OR ZIPCODE

TO START THE LOOKUP.

SELECT STATE FROM CAPI STATE LIST.

PRESS ENTER TO ACCEPT SELECTION.

REFUSED 7----7 REFUSED 777777 REFUSED 77777777777

DON'T KNOW 9----9 DON'T KNOW 999999 DON'T KNOW 99999999999

CAPI INSTRUCTION:

SAVE STATE LOOKUP NAME AS TTQ.020g AND STATE FIPS LOOKUP CODE AS TTQ.020h.

TTQ.030 REFERRING TO PERSON {1/2}

What is this person's telephone number, beginning with the area code?

REPEAT AREA CODE

REPEAT PHONE NUMBER

REPEAT EXTENSION

|___|___|___| |___|___|___| - |___|___|___|___| |___|___|____|____|

ENTER AREA CODE ENTER TELEPHONE NUMBER ENTER EXTENSION

NO PHONE 666 (TTQ.040) REFUSED 7777777777 REFUSED 7777

REFUSED 777777Q.040) DON'T KNOW 9999999999 DON'T KNOW 9999999

DON'T KNOW 999999 (TTQ.040)

CAPI: ALLOW TTQ030c (PHONE EXTENSION) TO BE BLANK.

TTQ.040 REFERRING TO PERSON {1/2}

What is the relationship of this contact person to you?

SPOUSE/EX-SPOUSE NOT LIVING IN HH 1

UNMARRIED PARTNER NOT LIVING IN HH 2

CHILD 3

GRANDCHILD 4

PARENT (MOTHER OR FATHER) 5

BROTHER OR SISTER 6

GRANDPARENT 7

OTHER RELATIVE 8

LEGAL GUARDIAN 9

FRIEND 10

CO-WORKER 11

NEIGHBOR 12

OTHER 13

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

Spouse (Husband/Wife): Persons who are legally married or have a common-law marriage.

Unmarried Partner: Persons who share living quarters because they have a close, personal relationship, but are not legally married (i.e., unmarried couples living together as if they were married).

Child: Male or female child through birth or adoption, regardless of age. Also include stepchildren, foster children and sons/daughters-in-law. Do not include an unmarried partner's children. A stepchild is one's spouse's male or female child by a previous relationship. A foster child is not one's biological child, but lives with one's family as one's son or daughter. A son/daughter-in-law is the spouse of one's child.

Grandchild: A child of one’s daughter or son.

Parent: Include a person’s biological, adoptive, step or foster mother or father, as well as his/her mother or father-in-law.

Mother: One's female parent, including biological, adoptive, step and foster mothers and mothers-in-law. A stepmother is the spouse of one's biological or adoptive father. A foster mother is the mother in one's foster family.

Father: One's male parent, including biological, adoptive, step, and foster fathers and fathers-in-law. A stepfather is the spouse of one's biological or adoptive mother. A foster father is the father in one's foster family.

Brother: Includes biological, adoptive, step, foster and half brothers, and brothers-in-law. A brother is one's male sibling who shares both of the same biological or adoptive parents. A stepbrother is one's stepparent's son by a previous relationship. A half brother is one's male sibling who shares one of the same biological or adoptive parents. A brother-in-law is one's sister's husband. A foster brother is the foster son of one or both of one's parents or the son of one's foster parent(s).

Sister: A sister includes biological, adoptive, step, foster, half sisters and sisters-in-law. A sister is one's female sibling who shares both of the same biological or adoptive parents. A stepsister is one's stepparent's daughter by a previous relationship. A half sister is one's female sibling who shares one of the same biological or adoptive parents. A sister-in-law is one's brother's wife. A foster sister is the foster daughter of one or both of one's parents or the daughter of one's foster parent(s).

Grandfather: The male parent of one's mother or father.

Grandmother: The female parent of one's mother or father.

Legal Guardian: A person appointed to take charge of the affairs of a minor, or of a person not capable of managing his/her own affairs.

BOX 2

END LOOP 1:

ASK TTQ.010 - TTQ.040 FOR SECOND CONTACT PERSON.

IF SECOND CONTACT PERSON INFORMATION COLLECTED, GO TO TTQ.050.

TTQ.050 This is the end of the Family Interview. Thank you very much for your cooperation.

PRESS F10 TO SAVE AND EXIT FORM

SALT SAMPLE COLLECTION– SUQ

Target Group: Household

SUQ.010 Now I'll be asking some questions about the types of salt used most often in your household.

G/Q May I please see the container for the salt that is usually added to food at the table and the salt that is usually used in cooking or preparing foods. This includes ordinary salt, sea salt, seasoning salts, lite salt and salt substitutes.

READ IF PARTICIPANT WANTS TO REPORT MORE THAN 2 SALTS: This is the salt most frequently used and not salts you may use occasionally. You may report up to 2 salts.

INTERVIEWER INSTRUCTION: DO NOT INCLUDE “SALT FREE” SEASONINGS SUCH AS MRS. DASH OR BENSON'S GOURMET SEASONINGS’ TABLE TASTY.

ENTER NUMBER OF CONTAINERS SEEN 1

SALT IS USED BUT NO CONTAINER AVAILABLE 0 (END OF SECTION)

SALT IS NOT USED IN THE HOUSEHOLD 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

|___|

ENTER NUMBER OF CONTAINERS SEEN

BOX 1

LOOP 1:

ASK SUQ.020 – SUQ.090 FOR EACH CONTAINER SHOWN.

SUQ.020 Is this salt used most frequently at the table, in cooking, or do you use it for both?

a/b

INTERVIEWER INSTRUCTION: HOLDING THE [FIRST, SECOND] SALT IDENTIFIED.

AT THE TABLE ……..1

IN COOKING ..2

AT THE TABLE AND IN COOKING 3

REFUSED ……7

DON'T KNOW 9

SUQ.030 DOES THE PACKAGING MENTION THAT THE SALT IS “LITE”, “LOWER SODIUM”, “LESS

a/b SODIUM”, “SODIUM FREE”, OR A “SALT SUBSTITUTE”?

YES 1

NO 2

NO PACKAGE AVAILABLE 3 (BOX 2)

SUQ.040 IS “POTASSIUM CHLORIDE” INCLUDED IN THE INGREDIENT LIST?

a/b

YES 1

NO 2

SUQ.050 DOES THE PACKAGING MENTION THAT THE SALT “SUPPLIES IODINE,” OR IS “IODIZED”?

a/b

YES 1

NO 2

SUQ.060 IS THE WORD “IODINE” INCLUDED IN THE NUTRITION FACTS PANEL OR THE INGREDIENT

a/b LIST?

YES 1

NO 2

BOX 2

CHECK ITEM SUQ.065:

IF SUQ.030 = 3 OR SUQ.050 = 1 OR SUQ.060 = 1,

GO TO SUQ.070

ELSE, GO TO BOX 3.

SUQ.070 NHANES is studying the salt used in people’s homes. I would like to collect about 2 teaspoons of this

a/b salt for our study. May I please take a small sample of this salt?

YES 1

NO 2 (BOX 3)

SUQ.080 COLLECT SALT SAMPLE FOLLOWING PROTOCOL INSTRUCTIONS ON SALT HANDCARD.

WAS A SAMPLE OF SALT OBTAINED FOR TESTING?

a/b

YES 1

NO, NOT ENOUGH SALT PROVIDED (BOX 3)

NO, COLLECTOR ERROR (BOX 3)

NO, OTHER (SPECIFY) (BOX 3)

SUQ.090 SCAN SALT SAMPLE LABEL OR ENTER 8 DIGIT KIT NUMBER.

a/b

|___|___|___|___|___|___|___|___|

CAPI INSTRUCTION:

ALLOW INTERVIEWER TO SCAN THE BARCODE OR MANUALLY ENTER THE SALT SAMPLE ID.

HARD EDIT: ENTRY HAS TO BE 8 DIGITS WITH NO LEADING ZEROS. DISPLAY THE FOLLOWING ERROR MESSAGE, “THE SALT SAMPLE ID MUST CONTAIN 8 DIGITS AND NOT BEGIN WITH ZERO. PLEASE RE-ENTER ALL NUMBERS.”

BOX 3

END LOOP 1:

ASK SUQ.020 – SUQ.090 FOR THE NEXT CONTAINER SHOWN.

IF INFORMATION COLLECTED FOR BOTH CONTAINERS, GO TO END OF SECTION.

WATER SAMPLE COLLECTION

WATER MODULE (HWC)

Target Group: Households with SPs Birth to 19 Years

BOX 1

CHECK ITEM HWC.005:

IF SP IN HOUSEHOLD IS 0-19 YEARS OLD, CONTINUE.

OTHERWISE, END MODULE.

HWC.007 NHANES is studying the water used in people’s homes for fluoride. I would like to collect about 1 teaspoon of tap water for our study. May I please collect a water sample from the water source you use for cooking and drinking?

INTERVIEWER INSTRUCTION:

COLLECT WATER FOLLOWING INSTRUCTIONS ON WATER HANDCARD.

YES 1

NO 2 (BOX 1)

HWC.010 HAS WATER BEEN COLLECTED FROM THE HOUSEHOLD?

YES 1

NO 2 (HWC.021)

HWC.011 SCAN KIT LABEL.

CAPI INSTRUCTION:

ENABLE CAMERA ON LAPTOP TO SCAN BARCODE LABEL FROM WATER KIT.

Shape17

BOX 1

CHECK ITEM HWC.012:

Default HWC.010 to Collected (Code 1) and go to HWC.040

HWC.021 ENTER THE REASON WATER WAS NOT COLLECTED.

SP REFUSED 1 (END OF SECTION)

LOST 2 (END OF SECTION)

INTERVIEW NOT CONDUCTED IN HOME 3 (END OF SECTION)

OTHER SPECIFY 4 (HWC.030)

HWC.030 SPECIFY WHY THE WATER WAS NOT COLLECTED

(END OF SECTION)

HWC.040 ENTER THE DATE AND TIME WATER WAS COLLECTED.

____ ____ ____ ____ : ____ AM/PM

MM DD YYYY HH MM

CAPI INSTRUCTION: DISPLAY CALENDAR AUTOPOPULATED WITH CURRENT DATE AND TIME WHEN SCREEN FIRST LAUNCHED. ALLOW DATE AND TIME TO BE CHANGED BY CLICKING ON THE DATE FIELD TO OPEN THE CALENDAR

HWC.050 IS THERE A FILTER ATTACHED TO THE FAUCET WHERE THE TAP WATER WAS DRAWN?

YES 1

NO 2

HWC.060 IS THIS HOME TAP WATER USED AS A PRIMARY DRINKING OR FOOD PREPARATION SOURCE?

YES 1

NO 2

HWC.070 What is the source of tap water in this home? Is it a private or public water company, a private or public well, or something else?

PRIVATE/PUBLIC WATER COMPANY ........ 1

PRIVATE/PUBLIC WELL .............................. 2

SOMETHING ELSE....................................... 3

REFUSED ..................................................... 7

DON'T KNOW ............................................... 9

HWC.080 Are any of the water treatment devices listed on this card used in your home?

HAND CARD HWC1

YES ............................................................... 1

NO.......................................................... .. .. 2 (HWC.090)

REFUSED ..................................................... 7 (HWC.090)

DON'T KNOW ............................................... 9 (HWC.090)

HELP SCREEN:

Water Treatment Devices: Any device intended to improve the safety and quality of water in the home.

There are eight main types of treatments: carbon filters, fiber filters, reverse osmosis units, neutralizers,

chemical feed pumps, disinfection and softeners. Devices such as Brita and other pitcher water filters should

be counted as water treatment devices.

HWC.083 Which of these water treatment devices are now used in your home?

HAND CARD HWC1

CODE ALL THAT APPLY

BRITA OR OTHER PITCHER

WATER FILTER ........................................ .. 1

CERAMIC OR CHARCOAL FILTER ............. 2

WATER SOFTENER ..................................... 3

AERATOR ..................................................... 4

REVERSE OSMOSIS................................... 5

REFUSED .................................................... 7

DON'T KNOW .............................................. 9

HELP SCREEN:

Water Treatment Devices: Any device intended to improve the safety and quality of water in the home.

There are eight main types of treatments: carbon filters, fiber filters, reverse osmosis units, neutralizers,

chemical feed pumps, disinfection and softeners. Devices such as Brita and other pitcher water filters should

be counted as water treatment devices.

HWC.090 Do you use tap water when cooking/preparing meals?

YES ............................................................... 1

NO.......................................................... .. .. 2

REFUSED ..................................................... 7

DON'T KNOW ............................................... 9

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Dupree, Natalie (CDC/OPHSS/NCHS)
File Modified	0000-00-00
File Created	2021-01-20

Household Interview

National Health and Nutrition Examination Survey

Att_3d_HH SP Family Instruments 10_23_18