Form 0920-1061 2019 Approved Quesions by Optional Module

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M03.01	Have you ever been told by a doctor or other health professional that you had Chronic Fatigue Syndrome (CFS) or (Myalgic Encephalomyelitis) ME?		1 Yes		My-al-gic En-ceph-a-lo-my-eli-tis
M03.01			2 No 7 Don’t know / Not sure 9 Refused	Go to next section	My-al-gic En-ceph-a-lo-my-eli-tis
M03.02	Do you still have Chronic Fatigue Syndrome (CFS) or (Myalgic Encephalomyelitis) ME?		1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		My-al-gic En-ceph-a-lo-my-eli-tis
M03.03	Thinking about your CFS or ME, during the past 6 months, how many hours a week on average have you been able to work at a job or business for pay?	IMFVPLAC	Read if necessary 1 0 or no hours -- cannot work at all because of CFS or ME 2 1 - 10 hours a week 3 11- 20 hours a week 4 21- 30 hours a week 5 31 - 40 hours a week Do not read 7 Don’t know/ Not sure 9 Refused

Module: Hepatitis Treatment

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M04.01	Have you ever been told by a doctor or other health professional that you had Hepatitis C?		1 Yes		Hepatitis C is an infection of the liver from the Hepatitis C virus
M04.01			2 No 7 Don’t know / Not sure 9 Refused	Go to HTV.05
M04.02	Were you treated for Hepatitis C in 2015 or after?		1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		Most hepatitis C treatments offered in 2015 or after were oral medicines or pills. Including Harvoni, Viekira, Zepatier, Epclusa and others.
M04.03	Were you treated for Hepatitis C prior to 2015?		1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		Most hepatitis C treatments offered prior to 2015 were shots and pills given weekly or more often over many months.
M04.04	Do you still have Hepatitis C?		1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		You may still have Hepatitis C and feel healthy. Your blood must be tested again to tell if you still have Hepatitis C.
M04.05	The next question is about Hepatitis B. Has a doctor, nurse, or other health professional ever told you that you had hepatitis B?		1 Yes		Hepatitis B is an infection of the liver from the hepatitis B virus.
M04.05			2 No 7 Don’t know/ Not sure 9 Refused	Go to HTV.07
M04.06	Are you currently taking medicine to treat hepatitis B?		1 Yes 2 No 7 Don’t know/ Not sure 9 Refused

Module: Aspirin for CVD Prevention

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M15.01

How often do you take an aspirin to prevent or control heart disease, heart attacks or stroke? Would you say….

Read:

1 Daily

2 Some days

3 Used to take it but had to stop due to side effects, or

4 Do not take it

Do not read:

7 Don’t know / Not sure

9 Refused

Module: Home/ Self-measured Blood Pressure

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M16.01	Has your doctor nurse or other healthcare professional recommended you check your blood pressure outside of the office or at home?		1 Yes 2 No 7 Don’t know / Not sure 9 Refused		By other healthcare professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.
M16.02	Do you regularly check your blood pressure outside of your healthcare professional’s office or at home?		1 Yes
M16.02			2 No 7 Don’t know / Not sure 9 Refused	Go to next section
M16.03	Do you take it mostly at home or on a machine at a pharmacy, grocery or similar location?		1 At home 2 On a machine at a pharmacy, grocery or similar location 3 Do not check it 7 Don’t know / Not sure 9 Refused
M16.04	How do you share your blood pressure numbers that you collected with your healthcare professional? Is it mostly by telephone, other methods such as emails, internet portal or fax, or in person?		Do not read: 1 Telephone 2 Other methods such as email, internet portal, or fax, or 3 In person
M16.04			Do not read: 4 Do not share information 7 Don’t know / Not sure 9 Refused

Module: Adverse Childhood Experiences

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
Prologue	I'd like to ask you some questions about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life, and may help others in the future. This is a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer. All questions refer to the time period before you were 18 years of age.				Be aware of the level of stress introduced by questions in this section and be familiar with the crisis plan.
M22.01	Now, looking back before you were 18 years of age---. 1) Did you live with anyone who was depressed, mentally ill, or suicidal?		1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused
M22.02	Did you live with anyone who was a problem drinker or alcoholic?		1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused
M22.03	Did you live with anyone who used illegal street drugs or who abused prescription medications?		1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused
M22.04	Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?		1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused
M22.05	Were your parents separated or divorced?		1 Yes 2 No 8 Parents not married 7 Don’t Know/Not Sure 9 Refused
M22.06	How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up? Was it…		Read: 1 Never 2 Once 3 More than once Don’t Read: 7 Don’t know/Not Sure 9 Refused
M22.07	Not including spanking, (before age 18), how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Was it—		Read: 1 Never 2 Once 3 More than once Don’t Read: 7 Don’t know/Not Sure 9 Refused
M22.08	How often did a parent or adult in your home ever swear at you, insult you, or put you down? Was it…		Read: 1 Never 2 Once 3 More than once Don’t Read: 7 Don’t know/Not Sure 9 Refused
M22.09	How often did anyone at least 5 years older than you or an adult, ever touch you sexually? Was it…		Read: 1 Never 2 Once 3 More than once Don’t Read: 7 Don’t know/Not Sure 9 Refused
M22.10	How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually? Was it…		Read: 1 Never 2 Once 3 More than once Don’t Read: 7 Don’t know/Not Sure 9 Refused
M22.11	How often did anyone at least 5 years older than you or an adult, force you to have sex? Was it…		Read: 1 Never 2 Once 3 More than once Don’t Read: 7 Don’t know/Not Sure 9 Refused
M22.12	For how much of your childhood was there an adult in your household who made you feel safe and protected? Would you say never, a little of the time, some of the time, most of the time, or all of the time?		1. Never 2. A little of the time 3. Some of the time 4. Most of the time 5. All of the time 7. Don’t Know 9. Refused
M22.13	For how much of your childhood was there an adult in your household who tried hard to make sure your basic needs were met? Would you say never, a little of the time, some of the time, most of the time, or all of the time?		1. Never 2. A little of the time 3. Some of the time 4. Most of the time 5. All of the time 7. Don’t Know 9. Refused
Prologue	For these next questions, your responses should reflect your experiences in the last 12 months (i.e., in the past year).
M22.14	In the last 12 months, how many times have you attempted suicide?		1. 0 times 2. 1 time 3. 2 or 3 times 4. 4 or 5 times 5. 6 or more times 7. Don’t know/ Not sure 9. Refused
M22.15	In the last 12 months, how many times have you taken prescription pain medicine without a doctor’s prescription or differently than how a doctor told you to use it?		1. 0 times 2. 1-2 times 3. 3-9 times 4. 10-19 times 5. 20-39 times 5. 40 or more times 7. Don’t know/ Not sure 9. Refused		Count drugs such as codeine, Vicodin, OxyContin, Hydrocodone, and Percocet.
M22.16	In the last 12 months, how many times have you used heroin, also called smack, junk, or China White?		1. 0 times 2. 1-2 times 3. 3-9 times 4. 10-19 times 5. 20-39 times 5. 40 or more times 7. Don’t know/ Not sure 9. Refused

Module: Food Stamps

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M27.01

In the past 12 months, have you received food stamps, also called SNAP, the Supplemental Nutrition Assistance Program on an EBT card?

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused

Food Stamps or SNAP (Supplemental Nutrition Assistance Program) is a government program that provides plastic cards, also known as EBT (Electronic Benefit Transfer) cards, that can be used to buy food. In the past, SNAP was called the Food Stamp Program and gave people benefits in paper coupons or food stamps.

2015-2018 Questionnaire Modules (previously approved)

Module 1: Pre-Diabetes

NOTE: Only asked of those not responding Yes (code = 1) to Core Q6.12 (Diabetes awareness question).

1. Have you had a test for high blood sugar or diabetes within the past three years?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

CATI note: If Core Q6.12 = 4 (No, pre-diabetes or borderline diabetes); answer Q2 Yes (code = 1).

2. Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?

If Yes and respondent is female, ask: Was this only when you were pregnant?

1 Yes

2 Yes, during pregnancy

3 No

7 Don’t know / Not sure

9 Refused

Module 2: Diabetes

CATI note: To be asked following Core Q6.13; if response to Q6.12 is Yes (code = 1)

1. Are you now taking insulin?

1 Yes

2 No

9 Refused

2. About how often do you check your blood for glucose or sugar?

INTERVIEWER NOTE: Include times when checked by a family member or friend, but do not include times when checked by a health professional.

1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

4 _ _ Times per year

8 8 8 Never

7 7 7 Don’t know / Not sure

9 9 9 Refused

INTERVIEWER NOTE: If the respondent uses a continuous glucose monitoring system (a sensor inserted under the skin to check glucose levels continuously), fill in ‘98 times per day.’

Including times when checked by a family member or friend by not including times when checked by a health professional, about how often do you check your feet for any sores or irritations?

1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

4 _ _ Times per year

555 No feet

888 Never

777 Don’t know / Not sure

999 Refused

About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?

_ _ Number of times [76 = 76 or more]

88 None

77 Don’t know / Not sure

99 Refused

5. About how many times in the past 12 months has a doctor, nurse, or other

health professional checked you for A-one-C?

Interviewer note: A test for A one C measures the average level of blood sugar over the past three months.

_ _ Number of times [76 = 76 or more]

8 8 None

98 Never heard of A one C test

77 Don’t know / Not sure

99 Refused

CATI note: If Q3 = 555 (No feet), go to Q7.

6. About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?

_ _ Number of times [76 = 76 or more]

88 None

77 Don’t know / Not sure

99 Refused

7. When was the last time you had an eye exam in which the pupils were dilated, making you temporarily sensitive to bright light?

Read only if necessary:

1 Within the past month (anytime less than 1 month ago)

2 Within the past year (1 month but less than 12 months ago)

3 Within the past 2 years (1 year but less than 2 years ago)

4 2 or more years ago

Do not read:

7 Don’t know / Not sure

Never

9 Refused

8. Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

9. Have you ever taken a course or class in how to manage your diabetes yourself?

1 Yes

2 No

7 Don't know / Not sure

Refused

Module 3: Health Care Access

Do you have Medicare?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Note: Medicare is a coverage plan for people age 65 or over and for certain disabled people.

2. What is the primary source of your health care coverage? Is it…

Please Read

01 A plan purchased through an employer or union (including plans purchased through another person's employer)

02 A plan that you or another family member buys on your own

03 Medicare

04 Medicaid or other state program

05 TRICARE (formerly CHAMPUS), VA, or Military

06 Alaska Native, Indian Health Service, Tribal Health Services

07 Some other source

08 None (no coverage)

Do not read:

Don't know/Not sure

99 Refused

INTERVIEWER NOTE: If the respondent indicates that they purchased health insurance through the Health Insurance Marketplace (name of state Marketplace), ask if it was a private health insurance plan purchased on their own or by a family member (private) or if they received Medicaid (state plan)? If purchased on their own (or by a family member), select 02, if Medicaid select 04.

CATI NOTE: Go to Core Q3.2.

Have you delayed getting medical care for one of the following reasons in the past 12 months? Was it because…..

INTERVIEWER NOTE: IF RESPONDENT PROVIDES MORE THAN ONE REASON, SAY: WHICH WAS THE MOST IMPORTANT REASON YOU DELAYED GETTING CARE

Please read

1 You couldn’t get through on the telephone.

2 You couldn’t get an appointment soon enough.

3 Once you got there, you had to wait too long to see the doctor.

4 The clinic or doctor’s office wasn’t open when you got there.

5 You didn’t have transportation.

Do not read:

Other ____________ (specify)

8 No, I did not delay getting medical care/did not need medical care

7 Don’t know/Not sure

9 Refused

CATI NOTE: Go to Core Q3.4.

CATI NOTE: If Q3.1 = 1 (Yes) continue, else go to Q4a.

4. In the past 12 months was there any time when you did not have any health

insurance or coverage?

1 Yes [Go to Q5]

2 No [Go to Q5]

7 Don’t know/Not sure [Go to Q5]

9 Refused [Go to Q5]

CATI Note: If Q3.1 = 2, 7, or 9 continue, else go to next question (Q5).

4a. About how long has it been since you last had health care coverage?

READ IF NECESSARY:

1 6 months or less

2 More than 6 months, but not more than 1 year ago

3 More than 1 year, but not more than 3 years ago

4 More than 3 years

5 Never

7 Don’t know/Not sure

9 Refused

5. How many times have you been to a doctor, nurse, or other health professional in the past 12 months?

_ _ Number of times

88 None

77 Don’t know/Not sure

99 Refused

6. Not including over the counter (OTC) medications, was there a time in the past 12 months when you did not take your medication as prescribed because of cost?

1 Yes

2 No

Do not read:

3 No medication was prescribed

7 Don’t know/Not sure

9 Refused

7. In general, how satisfied are you with the health care you received? Would you say—

Please read:

1 Very satisfied

2 Somewhat satisfied

3 Not at all satisfied

Do not read:

8 Not applicable

7 Don’t know/Not sure

9 Refused

8. Do you currently have any health care bills that are being paid off over time?

INTERVIEWER NOTE: This could include medical bills being paid off with a credit card, through personal loans, or bill paying arrangements with hospitals or other providers. The bills can be from earlier years as well as this year.

INTERVIEWER NOTE: Health care bills can include medical, dental, physical therapy and/or chiropractic cost.

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

CATI NOTE: Go to Core Section 4.

Module 4: Cognitive Decline

CATI Note: If respondent is 45 years of age or older continue, else go to next module

Introduction: The next few questions ask 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, which is normal. This refers to confusion or memory loss that is happening more often or getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would normally know. We want to know how these difficulties impact you.

1. During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse?

DO NOT READ:

1 Yes

2 No [Go to next module]

7 Don't know [Go to Q2]

9 Refused [Go to next module]

2. During the past 12 months, as a result of confusion or memory loss, how often have you given up day-to-day household activities or chores you used to do, such as cooking, cleaning, taking medications, driving, or paying bills? Would you say it is…. READ:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

DO NOT READ:

7 Don't know

9 Refused

As a result of confusion or memory loss, how often do you need assistance with these day-to-day activities? Would you say it is….

READ

1 Always

2 Usually

3 Sometimes

4 Rarely [Go to Q5]

5 Never [Go to Q5]

DO NOT READ

7 Don't know

9 Refused

CATI NOTE: If Q3 = 1, 2, or 3, continue. If Q3 = 4 or 5, go to Q5.

4. When you need help with these day-to-day activities, how often are you able to get the help that you need? Would you say it is….

READ

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

DO NOT READ

7 Don't know

9 Refused

5. During the past 12 months, how often has confusion or memory loss interfered with your ability to work, volunteer, or engage in social activities outside the home? Would you say it is….

READ

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

DO NOT READ

7 Don't know

9 Refused

6. Have you or anyone else discussed your confusion or memory loss with a health care professional?

DO NOT READ

1 Yes

2 No

7 Don't know

9 Refused

Module 5: Caregiver

During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability?

INTERVIEWER INSTRUCTIONS: If caregiving recipient has died in the past 30 days, code 8 and say: I’m so sorry to hear of your loss..

Yes
No [Go to Question 9]

7 Don’t know/Not sure [Go to Question 9]

8 Caregiving recipient died in past 30 days [Go to next module]

9 Refused [Go to Question 9]

What is his or her relationship to you?

INTERVIEWER NOTE: If more than one person, say: Please refer to the person to whom you are giving the most care.

DO NOT READ:

Mother
Father
Mother-in-law
Father-in-law
Child
Husband
Wife
Live in partner
Brother or brother-in-law
Sister or sister-in-law
Grandmother
Grandfather
Grandchild
Other relative
Non-relative/Family friend

77 Don’t know/Not sure

99 Refused

For how long have you provided care for that person? ~~Would you say…~~

Read if necessary:

1 Less than 30 days

2 1 month to less than 6 months

3 6 months to less than 2 years

4 2 years to less than 5 years

5 More than 5 years

7 Don’t Know/ Not Sure

9 Refused

In an average week, how many hours do you provide care or assistance? ~~Would you say…~~

Read if necessary:

Up to 8 hours per week
9 to 19 hours per week
20 to 39 hours per week
40 hours or more

7 Don’t know/Not sure

9 Refused

What is the main health problem, long-term illness, or disability that the person you care for has?

IF NECESSARY: Please tell me which one of these conditions would you say is the major problem?

[DO NOT READ: RECORD ONE RESPONSE]

Arthritis/Rheumatism
Asthma
Cancer
Chronic respiratory conditions such as Emphysema or COPD
Alzheimer’s disease, Dementia or other Cognitive Impairment Disorders, ~~Alzheimer’s disease~~ (go to M21.07.)
Developmental Disabilities such as Autism, Down’s Syndrome, and Spina Bifida
Diabetes
Heart Disease, Hypertension, Stroke
Human Immunodeficiency Virus Infection (HIV)
Mental Illnesses, such as Anxiety, Depression, or Schizophrenia
Other organ failure or diseases such as kidney or liver problems
Substance Abuse or Addiction Disorders
Injuries, including broken bones
Old age/infirmity/frailty
Other

Don’t know/Not sure

99 Refused

I8. Does the person you care for also have Alzheimer’s disease, dementia or other cognitive impairment disorder?

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused

~~Of the following support services, which one do you, as a caregiver, most need that you are not currently getting?~~

~~[INTERVIEWER NOTE: IF RESPONDENT ASKS WHAT RESPITE CARE IS]: Respite care means short-term breaks for people who provide care.~~

~~[READ OPTIONS 1 – 6]~~

~~Classes about giving care, such as giving medications~~
~~Help in getting access to services~~
~~Support groups~~
~~Individual counseling to help cope with giving care~~
~~Respite care~~
~~You don’t need any of these support services~~

~~[DO NOT READ]~~

~~7 Don’t Know /Not Sure~~

~~9 Refused~~

7. In the past 30 days, did you provide care for this person by…

Managing personal care such as giving medications, feeding, dressing, or bathing?

1 Yes

2 No

7 Don’t Know /Not Sure

9 Refused

8. In the past 30 days, did you provide care for this person by…

Managing household tasks such as cleaning, managing money, or preparing meals?

1 Yes

2 No

7 Don’t Know /Not Sure

9 Refused

[If Q1 = 1 or 8, GO TO NEXT MODULE]

9. In the next 2 years, do you expect to provide care or assistance to a friend or family member who has a health problem or disability?

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

Module 6: E-Cigarettes

Read if necessary: Electronic cigarettes (e-cigarettes) and other electronic vaping products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy.

INTERVIEWER NOTE: THESE QUESTIONS CONCERN ELECTRONIC VAPING PRODUCTS FOR NICOTINE USE. THE USE OF ELECTRONIC VAPING PRODUCTS FOR MARIJUANA USE IS NOT INCLUDED IN THESE QUESTIONS.

1. Have you ever used an e-cigarette or other electronic vaping product, even just one time, in your entire life?

1	Yes
2	No [Go to next module]
7	Don’t know / Not Sure [Go to next module]
9	Refused [Go to next module]

2. Do you now use e-cigarettes or other electronic vaping products every day, some days, or not at all?

DO NOT READ:

1	Every day
2	Some days
3	Not at all
7	Don’t know / Not sure
9	Refused

Module 7: Marijuana Use

1. During the past 30 days, on how many days did you use marijuana or cannabis?

_ _ 01-30 Number of Days

88 None [Go to next module]

77 Don’t know/not sure [Go to next module]

99 Refused [Go to next module]

2. [CATI NOTE: ASKED ONLY OF CURRENT MARIJUANA USERS]. During the past 30 days, what was the primary mode you used marijuana? Did you primarily…

Read:

1 Smoke it (for example, in a joint, bong, pipe, or blunt).

2 Eat it (for example, in brownies, cakes, cookies, or candy)

3 Drink it (for example, in tea, cola, or alcohol)

4 Vaporize it (for example, in an e-cigarette-like vaporizer or another

vaporizing device)

5 Dab it (for example, using waxes or concentrates).

6 Use it some other way.

Do not read:

7 Don’t know/not sure

9 Refused

3. [CATI NOTE: ASKED ONLY OF CURRENT MARIJUANA USERS]. When you used marijuana or cannabis during the past 30 days, was it primarily:

Read:

1 For medical reasons (like to treat or decrease symptoms of a health condition);

2 For non-medical reasons (like to have fun or fit in);

3 For both medical and non-medical reasons;

Do not read:

7 Don’t know/Not sure

9 Refused

Module 8: Sleep Disorder

1. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?

__ __ 01-14 days

None

77 Don’t know/Not sure

99 Refused

Over the last 2 weeks, how many days did you unintentionally fall asleep during the day?

__ __ 01-14 days

88 None

77 Don’t know/Not sure

99 Refused

3. Have you ever been told that you snore loudly?

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

4. Has anyone ever observed that you stop breathing during your sleep?

INTERVIEWER NOTE: ALSO ENTER YES IF RESPONDENT MENTIONS HAVING A MACHINE OR CPAP THAT RECORDS THAT BREATHING SOMETIMES STOPS DURING THE NIGHT.

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

Module 9: Anxiety and Depression

1 Over the last 2 weeks, how often have you been bothered by having little interest or pleasure in doing things. Would you say this happens...

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

9.2 Over the last 2 weeks, how often have you been bothered by feeling down, depressed or hopeless? Would you say this happens…

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

9.3 Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge? Would you say this happens…

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

9.4 Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying? Would you say this happens…

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

Module 10: Adult Asthma History

CATI NOTE: If Yes to Core Q6.4; continue. Otherwise, go to next module.

Previously you said you were told by a doctor, nurse or other health professional that you had asthma.

1. How old were you when you were first told by a doctor, nurse, or other health professional that you had asthma?

_ _ Age in years 11 or older [96 = 96 and older]

97 Age 10 or younger

98 Don’t know / Not sure

99 Refused

CATI NOTE: If Yes to Core Q6.5, continue. Otherwise, go to next module.

2. During the past 12 months, have you had an episode of asthma or an asthma attack?

1 Yes

2 No [Go to Q5]

7 Don’t know / Not sure [Go to Q5] 9 Refused [Go to Q5]

During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma?

_ _ Number of visits [87 = 87 or more]

88 None

98 Don’t know / Not sure

99 Refused

4. [If one or more visits to Q3, fill in Besides those emergency room or urgent care center visits,] During the past 12 months, how many times did you see a doctor, nurse or other health professional for urgent treatment of worsening asthma symptoms?

_ _ Number of visits [87 = 87 or more]

88 None

Don’t know / Not sure

99 Refused

During the past 12 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma?

_ _ Number of visits [87 = 87 or more]

88 None

98 Don’t know / Not sure

99 Refused

6. During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma?

_ _ _ Number of days

888 None

777 Don’t know / Not sure

999 Refused

7. Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness and phlegm production when you don’t have a cold or respiratory infection. During the past 30 days, how often did you have any symptoms of asthma? Would you say —

NOTE: Phlegm (‘flem’)

Please read:

8 Not at any time [Go to Q9]

1 Less than once a week

2 Once or twice a week

3 More than 2 times a week, but not every day

4 Every day, but not all the time

5 Every day, all the time

Do not read:

7 Don’t know / Not sure

9 Refused

8. During the past 30 days, how many days did symptoms of asthma make it difficult for you to stay asleep? Would you say —

Please read:

8 None

1 One or two

2 Three to four

3 Five

4 Six to ten

5 More than ten

Do not read:

7 Don’t know / Not sure

9 Refused

9. During the past 30 days, how many days did you take a prescription asthma medication to prevent an asthma attack from occurring?

READ IF NECESSARY

8 Never

1 1 to 14 days

2 15 to 24 days

3 25 to 30 days

Do not read:

7 Don’t know / Not sure

9 Refused

10. During the past 30 days, how often did you use a prescription asthma inhaler during an asthma attack to stop it?

INTERVIEWER NOTE: HOW OFTEN (NUMBER OF TIMES) DOES NOT EQUAL NUMBER OF PUFFS. TWO TO THREE PUFFS ARE USUALLY TAKEN EACH TIME THE INHALER IS USED.

READ IF NECESSARY:

8 Never (include no attack in past 30 days)

1 1 to 4 times (in the past 30 days)

2 5 to 14 times (in the past 30 days)

3 15 to 29 times (in the past 30 days)

4 30 to 59 times (in the past 30 days)

5 60 to 99 times (in the past 30 days)

6 100 or more times (in the past 30 days)

Do not read:

7 Don’t know / Not sure

9 Refused

Module 11: Respiratory Health (COPD Symptoms)

The next few questions are about breathing problems you may have.

During the past 3 months, did you have a cough on most days?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

During the past 3 months, did you cough up phlegm [FLEM] or mucus on most days?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Do you have shortness of breath either when hurrying on level ground or when walking up a slight hill or stairs?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Have you ever been given a breathing test to diagnose breathing problems?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Over your lifetime, how many years have you smoked tobacco products?

_ _ Number of years (01-76)

88 Never smoked or smoked less than one year

77 Don’t know/Not sure

99 Refused

Module 12: Indoor Tanning

1. Not including spray-on tans, during the past 12 months, how many times have you used an indoor tanning device such as a sunlamp, tanning bed, or booth?

DO NOT READ:

Enter number (0-365) __ __ __

777 Don’t know/ Not sure

999 Refused

Module 13: Excess Sun Exposure

1. During the past 12 months, how many times have you had a sunburn?

DO NOT READ:

Enter number (0-365) __ __ __

777 Don’t know/ Not sure

999 Refused

2. When you go outside on a warm sunny day for more than one hour, how often do you protect yourself from the sun? Is that….

INTERVIEWER NOTE: PROTECTION FROM THE SUN MAY INCLUDE USING SUNSCREEN, WEARING A WIDE-BRIMMED HAT, OR WEARING A LONG-SLEEVED SHIRT

READ:

1 Always

2 Most of the time

3 Sometimes

4 Rarely

5 Never

DO NOT READ:

6 Don’t stay outside for more than one hour on warm sunny days

8 Don’t go outside at all on warm sunny days

7 Don’t know/ Not sure

9 Refused

3. On weekdays, in the summer, how long are you outside per day between 10am and 4pm?

INTERVIEWER NOTE: FRIDAY IS A WEEKDAY

INTERVIEWER NOTE: IF RESPONDENT SAYS NEVER CODE 01

DO NOT READ:

1 Less than half an hour

2 (More than half an hour) up to 1 hour

3 (More than 1 hour) up to 2 hours

4 (More than 2 hours) up to 3 hours

5 (More than 3 hours) up to 4 hours

6 (More than 4 hours) up to 5 hours

7 (More than 5) up to 6 hours

77 Don’t know/ Not sure

99 Refused

4. On weekends in the summer, how long are you outside each day between 10am and 4pm?

INTERVIEWER NOTE: FRIDAY IS A WEEKDAY

INTERVIEWER NOTE: IF RESPONDENT SAYS NEVER CODE 01

DO NOT READ:

1 Less than half an hour

2 (More than half an hour) up to 1 hour

3 (More than 1 hour) up to 2 hours

4 (More than 2 hours) up to 3 hours

5 (More than 3 hours) up to 4 hours

6 (More than 4 hours) up to 5 hours

7 (more than 5) up to 6 hours

77 Don’t know/ Not sure

99 Refused

Module 14: Lung Cancer Screening

CATI NOTE: IF CORE Q9.1=1 (YES) AND Q9.2 = 1, 2, OR 3 (EVERY DAY, SOME DAYS, OR NOT AT ALL) CONTINUE, ELSE GO TO QUESTION 4.

You’ve told us that you have smoked in the past or are currently smoking. The next questions are about screening for lung cancer.

1. How old were you when you first started to smoke cigarettes regularly?

_ _ _ Age in Years (001 – 100)

888 Never smoked cigarettes regularly [GO TO Q4]

777 Don't know/Not sure

999 Refused

INTERVIEWER NOTE 1: REGULARLY IS AT LEAST ONE CIGARETTE OR MORE ON DAYS THAT A RESPONDENT SMOKES (EITHER EVERY DAY OR SOME DAYS) OR SMOKED (NOT AT ALL).

[CATI INSTRUCTION/ INTERVIEWER NOTE: (IF RESPONDENT INDICATES AGE INCONSISTENT WITH PREVIOUSLY ENTERED AGE) THE RESPONDENT INDICATED THEIR AGE TO BE __ YEARS OLD. YOU INDICATED THEY STARTED SMOKING REGULARLY AT THE AGE OF ___ YEARS. PLEASE VERIFY THAT THIS IS THE CORRECT ANSWER AND CHANGE THE AGE OF THE RESPONDENT REGULARLY SMOKING OR MAKE A NOTE TO CORRECT THE AGE OF THE RESPONDENT.]

2. How old were you when you last smoked cigarettes regularly?

_ _ _ Age in Years

777 Don't know/Not sure

999 Refused

INTERVIEWER NOTE 1: REGULARLY IS AT LEAST ONE CIGARETTE OR MORE ON DAYS THAT A RESPONDENT SMOKES (EITHER EVERY DAY OR SOME DAYS) OR SMOKED (NOT AT ALL).

3. On average, when you {smoke/smoked} regularly, about how many cigarettes {do/did} you usually smoke each day?

_ _ _ Number of cigarettes

777 Don't know/Not sure

999 Refused

INTERVIEWER NOTE 1: REGULARLY IS AT LEAST ONE CIGARETTE OR MORE ON DAYS THAT A RESPONDENT SMOKES (EITHER EVERY DAY OR SOME DAYS) OR SMOKED (NOT AT ALL).

INTERVIEWER NOTE 2: RESPONDENTS MAY ANSWER IN PACKS INSTEAD OF NUMBER OF CIGARETTES. BELOW IS A CONVERSION TABLE:

0.5 PACK = 10 CIGARETTES 1.75 PACK = 35 CIGARETTES

0.75 PACK = 15 CIGARETTES 2 PACKS = 40 CIGARETTES

1 PACK = 20 CIGARETTES 2.5 PACKS= 50 CIGARETTES

1.25 PACK = 25 CIGARETTES 3 PACKS= 60 CIGARETTES

1.5 PACK = 30 CIGARETTES

4. The next question is about CT or CAT scans. During this test, you lie flat on your back on a table. While you hold your breath, the table moves through a donut shaped x-ray machine while the scan is done. In the last 12 months, did you have a CT or CAT scan?

Read only if necessary:

1. Yes, to check for lung cancer

2. No (did not have a CT scan)

3. Had a CT scan, but for some other reason

Do not read:

7. Don't know/not sure

9. Refused

Module 15: Cancer Survivorship

CATI note: If Core Q6.6 or Q6.7 = 1 (Yes) or Q15.6 = 4 (Because you were told you had prostate cancer) continue, else go to next module.

You’ve told us that you have had cancer. I would like to ask you a few more questions about your cancer.

1. How many different types of cancer have you had?

1 Only one

2 Two

3 Three or more

7 Don’t know / Not sure [Go to next module]

9 Refused [Go to next module]

2. At what age were you told that you had cancer?

_ _ Code age in years [97 = 97 and older]

98 Don’t know / Not sure

99 Refused

CATI note: If Q1= 2 (Two) or 3 (Three or more), ask: At what age were you first diagnosed with cancer?

INTERVIEWER NOTE: This question refers to the first time they were told about their first cancer.

CATI note: If Core Q6.6 = 1 (Yes) and Q1 = 1 (Only one): ask Was it Melanoma or other skin cancer? then code 21 if Melanoma or 22 if other skin cancer

CATI note: If Core Q16.6 = 4 (Because you were told you had Prostate Cancer) and Q1 = 1 (Only one) then code 19.

3. What type of cancer was it?

If Q1 = 2 (Two) or 3 (Three or more), ask: With your most recent diagnoses of cancer, what type of cancer was it?

INTERVIEWER NOTE: Read list only if respondent needs prompting for cancer type (i.e., name of cancer) [1-30]:

Breast

01 Breast cancer

Female reproductive (Gynecologic)

02 Cervical cancer (cancer of the cervix)

03 Endometrial cancer (cancer of the uterus)

04 Ovarian cancer (cancer of the ovary)

Head/Neck

05 Head and neck cancer

06 Oral cancer

07 Pharyngeal (throat) cancer

08 Thyroid

09 Larynx

Gastrointestinal

10 Colon (intestine) cancer

11 Esophageal (esophagus)

12 Liver cancer

13 Pancreatic (pancreas) cancer

14 Rectal (rectum) cancer

15 Stomach

Leukemia/Lymphoma (lymph nodes and bone marrow)

16 Hodgkin's Lymphoma (Hodgkin’s disease)

17 Leukemia (blood) cancer

18 Non-Hodgkin’s Lymphoma

Male reproductive

19 Prostate cancer

20 Testicular cancer

Skin

21 Melanoma

22 Other skin cancer

Thoracic

23 Heart

24 Lung

Urinary cancer:

25 Bladder cancer

26 Renal (kidney) cancer

Others

27 Bone

28 Brain

29 Neuroblastoma

30 Other

Do not read:

77 Don’t know / Not sure

99 Refused

Are you currently receiving treatment for cancer?

INTERVIEWER NOTE: BY TREATMENT, WE MEAN SURGERY, RADIATION THERAPY, CHEMOTHERAPY, OR CHEMOTHERAPY PILLS.

READ IF NECESSARY:

1 Yes [Go to next module]

2 No, I’ve completed treatment

3 No, I’ve refused treatment [Go to next module]

4 No, I haven’t started treatment [Go to next module]

7 Don’t know / Not sure [Go to next module]

9 Refused [Go to next module]

5. What type of doctor provides the majority of your health care?

INTERVIEWER NOTE: If the respondent requests clarification of this question, say: We want to know which type of doctor you see most often for illness or regular health care (Examples: annual exams and/or physicals, treatment of colds, etc.).

INTERVIEWER NOTE: AN ONCOLOGIST IS A MEDICAL DOCTOR WHO MANAGES A PERSON’S CARE AND TREATMENT AFTER A CANCER DIAGNOSIS.

Read [1-10]:

01 Cancer Surgeon

02 Family Practitioner

03 General Surgeon

04 Gynecologic Oncologist

05 General Practitioner, Internist

06 Plastic Surgeon, Reconstructive Surgeon

07 Medical Oncologist

08 Radiation Oncologist

09 Urologist

10 Other

Do not read:

77 Don’t know / Not sure

99 Refused

6. Did any doctor, nurse, or other health professional EVER give you a written summary of all the cancer treatments that you received?

Read only if necessary: By ‘other healthcare professional’, we mean a nurse practitioner, a physician’s assistant, social worker, or some other licensed professional.

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

7. Have you ever received instructions from a doctor, nurse, or other health professional about where you should return or who you should see for routine cancer check-ups after completing your treatment for cancer?

1 Yes

2 No [Go to Q9]

7 Don’t know / Not sure [Go to Q9]

9 Refused [Go to Q9]

8. Were these instructions written down or printed on paper for you?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

9. With your most recent diagnosis of cancer, did you have health insurance that paid for all or part of your cancer treatment?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: HEALTH INSURANCE ALSO INCLUDES MEDICARE, MEDICAID, OR OTHER TYPES OF STATE HEALTH PROGRAMS.

10. Were you ever denied health insurance or life insurance coverage because of your cancer?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

11. Did you participate in a clinical trial as part of your cancer treatment?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

12. Do you currently have physical pain caused by your cancer or cancer treatment?

1 Yes

2 No [Go to next module]

7 Don’t know / Not sure [Go to next module]

9 Refused [Go to next module]

13. Would you say your pain currently under control…?

Please read:

With medication (or treatment)
Without medication (or treatment)
Not under control, with medication (or treatment)
Not under control, without medication (or treatment)

Do not read:

7 Don’t know / Not sure

9 Refused

Module 16: Prostate Cancer Screening Decision Making

CATI NOTE: If core section Q15, question 4 = 1 (has had a P.S.A. test) continue, else go to next module.

Which one of the following best describes the decision to have the P.S.A. test done? Please read:

4. You don’t remember how the decision was made [Go to next module]

Do not read:

9 Refused

Who made the decision with you?

INTERVIEWER NOTE: SELECT ONE RESPONSE. IF RESPONDENT OFFERS MORE THAN ONE RESPONSE ASK FOR PRIMARY PERSON WHO MADE DECISION.

READ IF NECESSARY:

Doctor/nurse /health care provider
Spouse/significant other
Other family member
Friend/non-relative

DO NOT READ:

7. Don’t know / Not sure

9. Refused

Module 17: Adult Human Papillomavirus (HPV) - Vaccination

CATI NOTE: To be asked of respondents between the ages of 18 and 49 years; otherwise, go to next module.

NOTE: Human Papillomavirus (Human Pap·uh·loh·muh virus); Gardasil (Gar·duh· seel); Cervarix (Sir·var· icks)

1. A vaccine to prevent the human papillomavirus or HPV infection is available and is called the cervical cancer or genital warts vaccine, HPV shot, [Fill: if female GARDASIL or CERVARIX; if male: GARDASIL].

Have you EVER had an HPV vaccination?

2 No [Go to next module]

3 Doctor refused when asked [Go to next module]

7 Don’t know / Not sure [Go to next module]

9 Refused [Go to next module]

2. How many HPV shots did you receive?

_ _ Number of shots

03 All shots

77 Don’t know / Not sure

99 Refused

Module 18: Tetanus Diphtheria (Tdap) (Adults)

1. Have you received a tetanus shot in the past 10 years?

If yes, ask: Was this Tdap, the tetanus shot that also has pertussis or whooping cough vaccine?

Yes, received Tdap
Yes, received tetanus shot, but not Tdap
Yes, received tetanus shot but not sure what type
No, did not receive any tetanus in the past 10 years

7 Don’t know/Not sure

9 Refused

Module 19: Shingles (Zostavax or ZOS)

CATI NOTE: If respondent is < 49 years of age, go to next section.

The next question is about the Shingles vaccine.

1. Have you ever had the shingles or zoster vaccine?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: SHINGLES IS AN ILLNESS THAT RESULTS IN A RASH OR BLISTERS ON THE SKIN, AND IS USUALLY PAINFUL. THERE ARE TWO VACCINES NOW AVAILABLE FOR SHINGLES; ZOSTAVAX, WHICH REQUIRES 1 SHOT, AND SHINGRIX, A NEW VACCINE WHICH REQUIRES 2 SHOTS.

Module 20: Industry and Occupation

If Core Q8.15 = 1 or 4 (Employed for wages or out of work for less than 1 year) or 2 (Self-employed), continue else go to next module.

Now I am going to ask you about your work.

If Core Q8.15 = 1 (Employed for wages) or 2 (Self-employed) ask,

1. What kind of work do you do? For example, registered nurse, janitor, cashier, auto mechanic.

INTERVIEWER NOTE: If respondent is unclear, ask: What is your job title?

INTERVIEWER NOTE: If respondent has more than one job ask: What is your main job?

[Record answer] _________________________________

99 Refused

If Core Q8.15 = 4 (Out of work for less than 1 year) ask,

What kind of work did you do? For example, registered nurse, janitor, cashier, auto mechanic.

INTERVIEWER NOTE: If respondent is unclear, ask: What was your job title?

INTERVIEWER NOTE: If respondent has more than one job ask: What was your main job?

[Record answer] _________________________________

99 Refused

If Core Q8.15 = 1 (Employed for wages) or 2 (Self-employed) ask,

2. What kind of business or industry do you work in? For example, hospital, elementary school, clothing manufacturing, restaurant.

[Record answer] _________________________________

99 Refused

If Core Q8.15 = 4 (Out of work for less than 1 year) ask,

What kind of business or industry did you work in? For example, hospital, elementary school, clothing manufacturing, restaurant.

[Record answer] _________________________________

99 Refused

Note: Module 21 will not be used and has been deleted.

Module 22: Sexual Orientation and Gender Identity

The next two questions are about sexual orientation and gender identity.

INTERVIEWER NOTE: We ask this question in order to better understand the health and health care needs of people with different sexual orientations.

INTERVIEWER NOTE: Please say the number before the text response. Respondent can answer with either the number or the text/word.

1a. (Ask if Sex=1)

Which of the following best represents how you think of yourself?

1 Gay

2 Straight, that is, not lesbian or gay

3 Bisexual

4 Something else

7 I don't know the answer

9 Refused

1b. (Ask if Sex=2)

Which of the following best represents how you think of yourself?

1 Lesbian or gay

2 Straight, that is, not lesbian or gay

3 Bisexual

4 Something else

7 I don't know the answer

9 Refused

2. Do you consider yourself to be transgender?

If yes, ask Do you consider yourself to be 1. male-to-female, 2. female-to-male, or 3. gender non-conforming?

INTERVIEWER NOTE: Please say the number before the text response. Respondent can answer with either the number or the text/word.

1 Yes, Transgender, male-to-female

2 Yes, Transgender, female to male

3 Yes, Transgender, gender nonconforming

4 No

7 Don’t know/not sure

9 Refused

INTERVIEWER NOTE: If asked about definition of transgender:

Some people describe themselves as transgender when they experience a different gender identity from their sex at birth. For example, a person born into a male body, but who feels female or lives as a woman would be transgender. Some transgender people change their physical appearance so that it matches their internal gender identity. Some transgender people take hormones and some have surgery. A transgender person may be of any sexual orientation – straight, gay, lesbian, or bisexual.

INTERVIEWER NOTE: If asked about definition of gender non-conforming:

Some people think of themselves as gender non-conforming when they do not identify only as a man or only as a woman.

Module 23: Random Child Selection

CATI NOTE: If Core Q8.16 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module.

If Core Q8.16 = 1, Interviewer please read: Previously, you indicated there was one child age 17 or younger in your household. I would like to ask you some questions about that child. [Go to Q1]

If Core Q8.16 is >1 and Core Q8.16 does not equal 88 or 99, Interviewer please read: Previously, you indicated there were [number] children age 17 or younger in your household. Think about those [number] children in order of their birth, from oldest to youngest. The oldest child is the first child and the youngest child is the last. Please include children with the same birth date, including twins, in the order of their birth.

CATI INSTRUCTION: RANDOMLY SELECT ONE OF THE CHILDREN. This is the Xth child. Please substitute Xth child’s number in all questions below.

INTERVIEWER PLEASE READ:

I have some additional questions about one specific child. The child I will be referring to is the Xth [CATI: please fill in correct number] child in your household. All following questions about children will be about the Xth [CATI: please fill in] child.

1. What is the birth month and year of the Xth child?

_ _ /_ _ _ _ Code month and year

77/ 7777 Don’t know / Not sure

99/ 9999 Refused

CATI INSTRUCTION: Calculate the child’s age in months (CHLDAGE1=0 to 216) and also in years (CHLDAGE2=0 to 17) based on the interview date and the birth month and year using a value of 15 for the birth day. If the selected child is < 12 months old enter the calculated months in CHLDAGE1 and 0 in CHLDAGE2. If the child is > 12 months enter the calculated months in CHLDAGE1 and set CHLDAGE2=Truncate (CHLDAGE1/12).

2. Is the child a boy or a girl?

1 Boy

2 Girl

9 Refused

3. Is the child Hispanic, Latino/a, or Spanish origin?

If yes, ask: Are they…

INTERVIEWER NOTE: ONE OR MORE CATEGORIES MAY BE SELECTED

READ

1 Mexican, Mexican American, Chicano/a

2 Puerto Rican

3 Cuban

4 Another Hispanic, Latino/a, or Spanish origin

Do not read:

5 No

7 Don’t know / Not sure

9 Refused

4. Which one or more of the following would you say is the race of the child?

(Select all that apply)

INTERVIEWER NOTE: If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

88 No additional choices

77 Don’t know / Not sure

99 Refused

[CATI NOTE: IF MORE THAN ONE RESPONSE TO Q4; CONTINUE. OTHERWISE, GO TO Q6.]

5. Which one of these groups would you say best represents the child’s race?

INTERVIEWER NOTE: If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

77 Don’t know / Not sure

99 Refused

6. How are you related to the child?

Please read:

1 Parent (include biologic, step, or adoptive parent)

2 Grandparent

3 Foster parent or guardian

4 Sibling (include biologic, step, and adoptive sibling)

5 Other relative

6 Not related in any way

Do not read:

7 Don’t know / Not sure

9 Refused

Module 24: Childhood Asthma Prevalence

CATI NOTE: If response to Core Q8.16 = 88 (None) or 99 (Refused), go to next module.

The next two questions are about the Xth [CATI: please fill in correct number] child.

1. Has a doctor, nurse or other health professional EVER said that the child has asthma?

1 Yes

2 No [Go to next module]

7 Don’t know / Not sure [Go to next module]

9 Refused [Go to next module]

2. Does the child still have asthma?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Module 25: Actions to Control High Blood Pressure

[CATI NOTE: IF CORE Q4.1 = 1 (YES); CONTINUE. OTHERWISE, GO TO NEXT MODULE. ]

Earlier you stated that you had been diagnosed with high blood pressure.

Are you now doing any of the following to help lower or control your high blood pressure?

1. (Are you) changing your eating habits (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

2. (Are you) cutting down on salt (to help lower or control your high blood pressure)?

1 Yes

2 No

3 Do not use salt

7 Don‘t know / Not sure

9 Refused

3. (Are you) reducing alcohol use (to help lower or control your high blood pressure)?

1 Yes

2 No

3 Do not drink

7 Don‘t know / Not sure

9 Refused

4. (Are you) exercising (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

Has a doctor or other health professional ever advised you to do any of the following to help lower or control your high blood pressure?

5. (Ever advised you to) change your eating habits (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

6. (Ever advised you to) cut down on salt (to help lower or control your high blood pressure)?

1 Yes

2 No

3 Do not use salt

7 Don‘t know / Not sure

9 Refused

7. (Ever advised you to) reduce alcohol use (to help lower or control your high blood pressure)?

1 Yes

2 No

3 Do not drink

7 Don‘t know / Not sure

9 Refused

8. (Ever advised you to) exercise (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

9. (Ever advised you to) take medication (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

10. Were you told on two or more different visits by a doctor or other health professional that you had high blood pressure?

INTERVIEWER NOTE: IF “YES” AND RESPONDENT IS FEMALE, ASK: “WAS THIS ONLY WHEN YOU WERE PREGNANT?”

1 Yes

2 Yes, but female told only during pregnancy

3 No

4 Told borderline or pre-hypertensive

7 Don‘t know / Not sure

9 Refused

Module 26: Arthritis Management

[CATI NOTE: IF CORE Q6.9 = 1 (YES), CONTINUE. OTHERWISE, GO TO NEXT MODULE.]

1. Earlier you indicated that you had arthritis or joint symptoms. Thinking about your arthritis or joint symptoms, which of the following best describes you today? (331)

Please read:

1 I can do everything I would like to do

2 I can do most things I would like to do

3 I can do some things I would like to do

4 I can hardly do anything I would like to do

Do not read:

7 Don’t know / Not sure

9 Refused

2. Has a doctor or other health professional EVER suggested losing weight to help your arthritis or joint symptoms?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

3. Has a doctor or other health professional ever suggested physical activity or exercise to help your arthritis or joint symptoms?

INTERVIEWER NOTE: IF THE RESPONDENT IS UNCLEAR ABOUT WHETHER THIS MEANS AN INCREASE OR DECREASE IN PHYSICAL ACTIVITY, THIS MEANS INCREASE.

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

4. Have you EVER taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Module 27: Healthy Days (Symptoms)

1. During the past 30 days, for about how many days did pain make it hard for you to do your usual activities, such as self-care, work, or recreation?

_ _ Number of days

88 None

77 Don’t know / Not sure

99 Refused

2. During the past 30 days, for about how many days have you felt sad, blue, or depressed?

_ _ Number of days

88 None

77 Don’t know / Not sure

99 Refused

3. During the past 30 days, for about how many days have you felt worried, tense, or anxious?

_ _ Number of days

88 None

77 Don’t know / Not sure

99 Refused

4. During the past 30 days, for about how many days have you felt very healthy and full of energy?

_ _ Number of days

88 None

77 Don’t know / Not sure

99 Refused

Module 28: Alcohol Screening & Brief Intervention (ASBI)

CATI NOTE: IF CORE Q3.4 = 1, OR 2 (HAD A CHECKUP WITHIN THE PAST 2 YEARS) CONTINUE, ELSE GO TO NEXT MODULE.

Healthcare providers may ask during routine checkups about behaviors like alcohol use, whether you drink or not. We want to know about their questions.

1. You told me earlier that your last routine checkup was [within the past year/within the past 2 years]. At that checkup, were you asked in person or on a form if you drink alcohol?

1 Yes

2 No

7 Don't know / Not sure

9 Refused

2. Did the health care provider ask you in person or on a form how much you drink?

1 Yes

2. No

7 Don't know / Not sure

9 Refused

3. Did the healthcare provider specifically ask whether you drank [5 FOR MEN /4 FOR WOMEN] or more alcoholic drinks on an occasion?

1 Yes

2 No

7 Don't know / Not sure

9 Refused

4. Were you offered advice about what level of drinking is harmful or risky for your health?

1 Yes

2 No

7 Don't know / Not sure

9 Refused

[CATI NOTE: IF QUESTION 1, 2, OR 3 = 1 (YES) CONTINUE, ELSE GO TO NEXT MODULE.]

5. Healthcare providers may also advise patients to drink less for various reasons. At your last routine checkup, were you advised to reduce or quit your drinking?

1 Yes

2 No

7 Don't know / Not sure

9 Refused

Module 29: Sugar Sweetened Beverages

1. During the past 30 days, how often did you drink regular soda or pop that contains sugar? Do not include diet soda or diet pop.

Please read: You can answer times per day, week, or month: for example, twice a day, once a week, and so forth.

1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

Do not read:

888 None

777 Don’t know / Not sure

999 Refused

2. During the past 30 days, how often did you drink sugar-sweetened fruit drinks (such as Kool-aid™ and lemonade), sweet tea, and sports or energy drinks (such as Gatorade™ and Red Bull™)? Do not include 100% fruit juice, diet drinks, or artificially sweetened drinks.

Please read: You can answer times per day, week, or month: for example, twice a day, once a week, and so forth.

1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

Do not read:

888 None

777 Don’t know / Not sure

999 Refused

Module 30: Sodium or Salt-Related Behavior

1. Are you currently watching or reducing your salt intake?

1. Yes

2. No

7. Don’t know/not sure

9. Refused

2. Has a doctor or other health professional ever advised you to reduce salt intake?

1. Yes

2. No

7. Don’t know/not sure

9. Refused

Module 31: Preconception Health/Family Planning

[CATI NOTE: IF RESPONDENT IS FEMALE AND GREATER THAN 49 YEARS OF AGE, HAS HAD A HYSTERECTOMY, IS PREGNANT, OR IF RESPONDENT IS MALE GO TO THE NEXT MODULE.]

The next set of questions asks you about your thoughts and experiences with family planning. Please remember that all of your answers will be kept confidential.

1. The last time you had sex with a man, did you or your partner do anything to keep you from getting pregnant? ~~Did you or your partner do anything the last time you had sex to keep you from getting pregnant?~~

1 Yes

2 No [GO TO Q3]

3 No partner/not sexually active [GO TO NEXT MODULE]

4 Same sex partner [GO TO NEXT MODULE]

5 Has had a Hysterectomy [GO TO NEXT MODULE]

7 Don’t know/Not sure [GO TO Q3]

9 Refused [GO TO Q3].

2. The last time you had sex with a man, what did you or your partner do to keep you from getting pregnant? ~~What did you or your partner do the last time you had sex to keep you from getting pregnant?~~

INTERVIEWER NOTE: IF RESPONDENT REPORTS USING MORE THAN ONE METHOD, PLEASE CODE THE METHOD THAT OCCURS FIRST ON THE LIST.

INTERVIEWER NOTE: IF RESPONDENT REPORTS USING “CONDOMS,” PROBE TO DETERMINE IF “FEMALE CONDOMS” OR MALE CONDOMS.”

INTERVIEWER NOTE: IF RESPONDENT REPORTS USING AN “IUD” PROBE TO DETERMINE IF “LEVONORGESTREL IUD” OR “COPPER-BEARING IUD.”

INTERVIEWER NOTE: IF RESPONDENT REPORTS “OTHER METHOD,” ASK RESPONDENT TO “PLEASE BE SPECIFIC” AND ENSURE THAT THEIR RESPONSE DOES NOT FIT INTO ANOTHER CATEGORY. IF RESPONSE DOES FIT INTO ANOTHER CATEGORY, PLEASE MARK APPROPRIATELY.

Read only if necessary:

01 Female sterilization (ex. Tubal ligation, Essure, Adiana) [GO TO NEXT MODULE]

02 Male sterilization (vasectomy) [GO TO NEXT MODULE]

03 Contraceptive implant (ex. Implanon) [GO TO NEXT MODULE]

04 Levonorgestrel (LEE-voe-nor-JES-trel) (LNG) or hormonal IUD (ex. Mirena) [GO TO NEXT MODULE]

05 Copper-bearing IUD (ex. ParaGard) [GO TO NEXT MODULE]

06 IUD, type unknown [GO TO NEXT MODULE]

07 Shots (ex. Depo-Provera) [GO TO NEXT MODULE]

08 Birth control pills, any kind [GO TO NEXT MODULE]

09 Contraceptive patch (ex. Ortho Evra) [GO TO NEXT MODULE]

10 Contraceptive ring (ex. NuvaRing) [GO TO NEXT MODULE]

11 Male condoms [GO TO NEXT MODULE]

12 Diaphragm, cervical cap, sponge [GO TO NEXT MODULE]

13 Female condoms [GO TO NEXT MODULE]

14 Not having sex at certain times (rhythm or natural family planning) [GO TO NEXT MODULE]

15 Withdrawal (or pulling out) [GO TO NEXT MODULE]

16 Foam, jelly, film, or cream [GO TO NEXT MODULE]

17 Emergency contraception (morning after pill) [GO TO NEXT MODULE]

18 Other method [GO TO NEXT MODULE]

Do not read:

77 Don’t know/Not sure

99 Refused

Some reasons for not doing anything to keep you from getting pregnant the last time you had sex might include wanting a pregnancy, not being able to pay for birth control, or not thinking that you can get pregnant.

3. Some reasons for not doing anything to keep you from getting pregnant the last time you had sex might include wanting a pregnancy, not being able to pay for birth control, or not thinking that you can get pregnant.

What was your main reason for not using a method to prevent pregnancy the last time you had sex with a man?

~~What was your main reason for not doing anything the last time you had sex to keep you from getting pregnant?~~

INTERVIEWER NOTE: IF RESPONDENT REPORTS “OTHER REASON,” ASK RESPONDENT TO “PLEASE SPECIFY” AND ENSURE THAT THEIR RESPONSE DOES NOT FIT INTO ANOTHER CATEGORY. IF RESPONSE DOES FIT INTO ANOTHER CATEGORY, PLEASE MARK APPROPRIATELY.

Read only if necessary:

01 You didn’t think you were going to have sex/no regular partner

02 You just didn’t think about it

03 Don’t care if you get pregnant

04 You want a pregnancy

05 You or your partner don’t want to use birth control

06 You or your partner don’t like birth control/side effects

07 You couldn’t pay for birth control

08 You had a problem getting birth control when you needed it

09 Religious reasons

10 Lapse in use of a method

11 Don’t think you or your partner can get pregnant (infertile or too old)

12 You had tubes tied (sterilization)

13 You had a hysterectomy

14 Your partner had a vasectomy (sterilization)

15 You are currently breast-feeding

16 You just had a baby/postpartum

17 You are pregnant now

18 Same sex partner

19 Other reasons

77 Don’t know/Not sure

99 Refused

Module 32: Emotional Support and Life Satisfaction

1. How often do you get the social and emotional support you need?

INTERVIEWER NOTE: IF ASKED, SAY “PLEASE INCLUDE SUPPORT FROM ANY SOURCE.”

Please read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

7 Don't know / Not sure

9 Refused

2. In general, how satisfied are you with your life? (475)

Please read:

1 Very satisfied

2 Satisfied

3 Dissatisfied

4 Very dissatisfied

Do not read:

7 Don't know / Not sure

9 Refused

Module 33: Social Determinants of Health

1. During the last 12 months, was there a time when you were not able to pay your mortgage, rent or utility bills?

1 Yes

2 No

7 Don’t know/not sure

9 Refused

2. In the last 12 months, how many times have you moved from one home to another?

__ __ Number of moves in past 12 months [01-52]

88 None (Did not move in past 12 months)

77 Don’t know/Not sure

99 Refused

3. How safe from crime do you consider your neighborhood to be? Would you say…

Please read:

1 Extremely safe

2 Safe

3 Unsafe

4 Extremely unsafe

Do not read:

7 Don’t know/Not sure

9 Refused

4. For the next two statements, please tell me whether the statement was often true, sometimes true, or never true for you in the last 12 months (that is, since last [CATI NOTE: NAME OF CURRENT MONTH]). The first statement is, “The food that I bought just didn’t last, and I didn’t have money to get more.”

Was that often, sometimes, or never true for you in the last 12 months?

1 Often true,

2 Sometimes true, or

3 Never true

Do not read:

7 Don’t Know/Not sure

9 Refused

5. “I couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for you in the last 12 months?

1 Often true,

2 Sometimes true, or

3 Never true

Do not read:

7 Don’t Know /Not sure

9 Refused

6. In general, how do your finances usually work out at the end of the month? Do you find that you usually:

Please read:

1 End up with some money left over,

2 Have just enough money to make ends meet, or

3 Do not have enough money to make ends meet

Do not read:

7 Don’t Know/Not sure

9 Refused

7. Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his/her mind is troubled all the time. Within the last 30 days, how often have you felt this kind of stress?

Please read:

1 None of the time,

2 A little of the time,

3 Some of the time,

4 Most of the time, or

5 All of the time

Do not read:

7. Don't know/not sure

9. Refused

Module 34: Sleep Disorder

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

INTERVIEWER NOTE: ENTER HOURS OF SLEEP IN WHOLE NUMBERS, ROUNDING 30 MINUTES (1/2 HOUR) OR MORE UP TO THE NEXT WHOLE HOUR AND DROPPING 29 OR FEWER MINUTES.

__ __ Number of hours [01-24]

77 Don’t know/Not sure

99 Refused

Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?

__ __ 01-14 days

88 None

77 Don’t know/Not sure

99 Refused

3. Over the last 2 weeks, how many days did you unintentionally fall asleep during the day?

__ __ 01-14 days

88 None

77 Don’t know/Not sure

99 Refused

4. Have you ever been told that you snore loudly?

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

5. Has anyone ever observed that you stop breathing during your sleep? (366)

INTERVIEWER NOTE: ALSO ENTER “YES” IF RESPONDENT MENTIONS HAVING A MACHINE OR CPAP THAT RECORDS THAT BREATHING SOMETIMES STOPS DURING THE NIGHT.

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

Module 35: Health Literacy

How difficult is it for you to get advice or information about health or medical topics if you need it?
1. Not at all
2. A little
3. Somewhat, or
4. Very difficult or
5. Never tried to get advice or information

7. Don’t know/not sure

9. Refused

How difficult is it for you to understand information that doctors, nurses and other health professionals tell you?

Not at all
A little
Somewhat, or
Very difficult or
Never tried to get advice or information

7. Don’t know/not sure

9. Refused

You can find written information about health on the Internet, in newspapers and magazines, and in brochures in the doctor’s office and clinic. In general, how difficult is it for you to understand written health information?

Not at all
A little
Somewhat, or
Very difficult or
Never tried to get advice or information

7. Don’t know/not sure

9. Refused

Module 36: Clinical Breast Exam

CATI NOTE: If respondent is male, go to the next section.

A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you ever had a clinical breast exam?

2 No [Go to next module]

7 Don’t know / Not sure [Go to next module]

9 Refused [Go to next module]

How long has it been since your last breast exam?

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

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 3 years (2 years but less than 3 years ago)

4 Within the past 5 years (3 years but less than 5 years ago)

5 5 or more years ago

7 Don’t know / Not sure

9 Refused

Module 37: Flu Vaccination Location

1 At what kind of place did you get your last flu shot or vaccine?

Read only if necessary:

01 A doctor’s office or health maintenance organization (HMO)

02 A health department

03 Another type of clinic or health center (a community health center)

04 A senior, recreation, or community center

05 A store (supermarket, drug store)

06 A hospital (inpatient)

07 An emergency room

08 Workplace

09 Some other kind of place

11 A school

Do not read:

10 Received vaccination in Canada/Mexico

77 Don’t know / Not sure (Probe: How would you describe the place here you went to get your most recent flu vaccine?)

99 Refused

Modules under consideration for 2020-2022

Emerging Core Opioid Questions

Example Emerging Core Questions
Question	Response set Do not read unless otherwise noted	CATI Instructions	Interviewer Notes
Q1. In the last 12 months, have you taken any prescription pain relievers when it was prescribed to you by a doctor, dentist, nurse practitioner, or other healthcare provider?	1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused	If Q1= 2, 7, 9 Go to next section	Pain relievers include Codeine, morphine, Lortab, Vicodin, Tylenol #3, Percocet, OxyContin, Xanax, Valium, Ativan. We only want to know about prescription medication that is not available over the counter.
Q2. The last time you filled a prescription for pain medication in the past year, did you use any of the pain medication more frequently or in higher doses than directed by a doctor?	1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused	If Q2= 2,7,9 Go to Q4
Q3. What was the main reason you used the medication differently than prescribed? Would you say…	Read if necessary: 1 To relieve pain, prescribed dose did not relieve pain 2 To relieve other physical symptoms 3 To relieve anxiety or depression 4 For fun, good feeling, getting high, peer pressure (friends were doing it) 5 To prevent or relieve withdrawal symptoms Do not read 7 Don't Know/Not sure 9 Refused
Example Optional Module Questions: Prescribed Opioids
Q1. In the past year, have you had any pain medication left over from a prescription?	1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused	If Q4 = 2, 7, 9 Go to next section.
Q2. What did you do with the leftover prescription pain medication?	1 Kept it 2 Disposed of it 3 Gave it to someone else 4 Sold it 5 Used it for another unrelated pain/ other purpose 7 Don't know/Not sure 9 Refused
Q3. The last time you used pain medication that was prescribed to you, what was the main reason?	Read if necessary 1 pain related to cancer 2 post-surgical care/medical care 3 back pain, short term 4 back pain, long term 5 joint pain, short term 6 joint pain, long term 7 carpal tunnel syndrome 8 arthritis 9 work-related injury 10 other injury causing short term pain 11 other injury causing long term pain 12 other physical conditions causing pain 13 to prevent or relieve withdrawal symptoms 14 dental pain 15 pain due to diabetes-related nerve damage Do not read: 77. Don’t know 99. Refused
Q4 In the past year, what prescription pain medications were prescribed to you by a doctor?	1 Butorphanol Tartrate 2 Carisoprodol 3 Celebrex 4 Codeine 5 Darvocet 6 Darvon 7 Demerol 8 Dilaudid 9 Duragesic 10 Embeda 11 Fentanyl 12 Fentora 13 Gabapentin 14 Hydrocodone 15 Hydromorphone 16 Ibuprofen / Motrin 17 Kadian 18 Levorphanol 19 Lortab 20 Lorcet 21 Meperidine 22 Methadone 23 Morphine 24 Naproxen 25 Narcan 26 Neurontin 27 Opium Tincture 28 Oxycodone 29 Oxycontin 30 Pentazocine 31 Percocet 32 Percodan 33 Propoxyphene 34 Roxicet 35 Soma 36 Stadol 37 Suboxone 38 Subutex 39 Toradol 40 Tramadol 41 Tylenol with codeine (Tylenol #3) 42 Tylox 43 Ultram (Ultram ER) 44 Ultracet 45 Vicodin 46 Other (specify_____) {28 character limit} 77 Don’t know / not sure 99 Refused	This question could be coded for multiple response
Example Optional Module Questions: Use of Opioids Not Prescribed
Q1. In the past year, did you use a prescription pain medication that was not prescribed specifically for you by a doctor, dentist, nurse practitioner, or healthcare providers?	1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused	If OMQ1 = 2, 7, 9 Go to OMQ5
Q2. From whom did you obtain the prescription pain medication?	1 = From a friend or relative 2 = From an acquaintance 3 = From a street dealer or other person I did not know 4 = Online 5 = Other 7 = Don't know/Not sure 9 = Refused
Q3. About how often in the past 12 months did you use prescription pain relievers including that were not prescribed to you by a doctor, dentist, nurse practitioner, or other healthcare providers? Would you say....	Read 1 Never 2 Every day or nearly every day 3 Several times a month 4 Several times a year Do not read: 7 Don't know/Not sure 9 Refused		Pain relievers include Codeine, morphine, Lortab, Vicodin, Tylenol #3, Percocet, OxyContin, Xanax, Valium, Ativan. We only want to know about medication that is not available over the counter.
Q4. In the past 12 months, did you shoot up or inject any drugs other than those prescribed for you? By shooting up, I mean anytime you might have used drugs with a needle, either by mainlining, skin popping, or muscling.	1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused
Example Optional Module Questions: Opioid Dependency
Q5. How long has it been since you used any prescription pain reliever?	Read only if necessary 1 Within the past 30 days (or currently taking) 2 More than 30 days ago but within the past 12 months 3 More than 12 months ago 4 Never 7 Don’t know/Not sure 9 Refused		Pain relievers include Codeine, morphine, Lortab, Vicodin, Tylenol #3, Percocet, OxyContin, Xanax, Valium, Ativan. We only want to know about medication that is not available over the counter.
Q6. In the past year have you felt dependent on prescription pain medication or experienced trouble getting off of the medication when you no longer needed it for medical reasons?	1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused		Pain relievers include Codeine, morphine, Lortab, Vicodin, Tylenol #3, Percocet, OxyContin, Xanax, Valium, Ativan. We only want to know about medication that is not available over the counter.
Thank you for answering these questions. If you would like assistance with any of these issues, please call the XXX at XXXX to find out about mental health and substance related disorder services available in your area.

Anxiety and Depression

Now, I am going to ask you some questions about your mood. When answering these questions, please think about how many days each of the following has occurred in the past 2 weeks.

1. Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?

(435-436)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

2. Over the last 2 weeks, how many days have you felt down, depressed or hopeless?

(437-438)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

3. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?

(439-440)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

4. Over the last 2 weeks, how many days have you felt tired or had little energy?

(441-442)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

5. Over the last 2 weeks, how many days have you had a poor appetite or eaten too much?

(443-444)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

6. Over the last 2 weeks, how many days have you felt bad about yourself or that you were a failure or had let yourself or your family down?

(445-446)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

7. Over the last 2 weeks, how many days have you had trouble concentrating on things, such as reading the newspaper or watching the TV?

(447-448)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

8. Over the last 2 weeks, how many days have you moved or spoken so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you were

moving around a lot more than usual?

(449-450)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

9. Are you now taking medicine or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem?

(451)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

10. Has a doctor or other healthcare provider EVER told you that you have an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder,

obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or

social anxiety disorder)?

(452)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Mental Illness and Stigma

Now, I am going to ask you some questions about how you have been feeling lately.

1. About how often during the past 30 days did you feel nervous — would you say all of the

time, most of the time, some of the time, a little of the time, or none of the time?

(338)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused

2. During the past 30 days, about how often did you feel hopeless — all of the time, most of the time, some of the time, a little of the time, or none of the time?

(339)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused

3. During the past 30 days, about how often did you feel restless or fidgety?

[If necessary: all, most, some, a little, or none of the time?]

(340)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused

4. During the past 30 days, about how often did you feel so depressed that nothing could

cheer you up?

[If necessary: all, most, some, a little, or none of the time?]

(341)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused

5. During the past 30 days, about how often did you feel that everything was an effort?

Note: If respondent asks what does “everything was an effort” means; say, “Whatever it means to you”

[If necessary: all, most, some, a little, or none of the time?]

(342)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused

6. During the past 30 days, about how often did you feel worthless?

[If necessary: all, most, some, a little, or none of the time?]

(343)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused

7. During the past 30 days, for about how many days did a mental health condition or emotional problem keep you from doing your work or other usual activities?

(344-345)

_ _ Number of days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

INTERVIEWER NOTE: If asked, "usual activities" includes housework, self-care, care giving, volunteer work, attending school, studies, or recreation.

8. Are you now taking medicine or receiving treatment from a doctor or other health

professional for any type of mental health condition or emotional problem?

(346)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

These next questions ask about peoples' attitudes toward mental illness and its treatment.

9. Treatment can help people with mental illness lead normal lives. Do you –agree slightly

or strongly, or disagree slightly or strongly?

(347)

Read only if necessary:

1 Agree strongly

2 Agree slightly

3 Neither agree nor disagree

4 Disagree slightly

5 Disagree strongly

Do not read:

7 Don’t know / Not sure

9 Refused

10. People are generally caring and sympathetic to people with mental illness. Do you –

agree slightly or strongly, or disagree slightly or strongly?

(348)

Read only if necessary:

1 Agree strongly

2 Agree slightly

3 Neither agree nor disagree

4 Disagree slightly

5 Disagree strongly

Do not read:

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: If asked for the purpose of Q9 or Q10: say: “answers to these questions will be used by health planners to help understand public attitudes about mental illness and its treatment and to help guide health education programs”.

Social Context

Now, I am going to ask you about several factors that can affect a person’s health.

If Core Q7.21 = 1 or 2 (own or rent) continue, else go to Q2.

1. How often in the past 12 months would you say you were worried or stressed

about having enough money to pay your rent/mortgage? Would you say you were worried or stressed---

(349)

Please read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

8 Not applicable

7 Don’t know / Not sure

9 Refused

2. How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say you were worried or

stressed---

(350)

Please read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

8 Not applicable

7 Don’t know / Not sure

9 Refused

If Core Q7.9 = 1 (Employed for wages) or 2 (Self-employed), go to Q3 and Q4.

If Core Q7.9 = 3 (Out of work for more than 1 year), 4 (Out of work for less than 1 year), or

7 (Retired), go to Q5 and Q6.

If Core Q7.9 = 5 (A homemaker), 6 (A student), or 8 (Unable to work), go to next module.

3. At your main job or business, how are you generally paid for the work you do. Are you:

(351)

1 Paid by salary

2 Paid by the hour

3 Paid by the job/task (e.g. commission, piecework)

4 Paid some other way

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: If paid in multiple ways at their main job, select option 4 (Paid some other way).

4. About how many hours do you work per week at all of your jobs and businesses combined?

(352-353)

_ _ Hours (01-96 or more) [Go to next module]

9 7 Don't know / Not sure [Go to next module]

9 8 Does not work [Go to next module]

9 9 Refused [Go to next module]

5. Thinking about the last time you worked, at your main job or business, how were you

generally paid for the work you did? Were you:

(354)

1 Paid by salary

2 Paid by the hour

3 Paid by the job/task (e.g. commission, piecework)

4 Paid some other way

7 Don’t know / Not sure

9 Refused

6. Thinking about the last time you worked, about how many hours did you work per week

at all of your jobs and businesses combined?

(355-356)

_ _ Hours (01-96 or more)

9 7 Don't know / Not sure

9 8 Does not work

9 9 Refused

General Preparedness

The next series of questions asks about how prepared you are for a large-scale disaster or emergency. By large-scale disaster or emergency we mean any event that leaves you isolated in your home or displaces you from your home for at least 3 days. This might include natural disasters such as hurricanes, tornados, floods, and ice storms, or man-made disasters such as explosions, terrorist events, or blackouts.

1. How well prepared do you feel your household is to handle a large-scale disaster or emergency? Would you say…

(357)

Please read:

1 Well prepared

2 Somewhat prepared

3 Not prepared at all

Do not read:

7 Don’t know / Not sure

9 Refused

2. Does your household have a 3-day supply of water for everyone who lives there? A 3-day supply of water is 1 gallon of water per person per day.

(358)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

3. Does your household have a 3-day supply of nonperishable food for everyone who lives there? By nonperishable we mean food that does not require refrigeration or cooking.

(359)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

4. Does your household have a 3-day supply of prescription medication for each person who takes prescribed medicines?

(360)

1 Yes

2 No

3 No one in household requires prescribed medicine

7 Don’t know / Not sure

9 Refused

5. Does your household have a working battery operated radio and working batteries for your use if the electricity is out?

(361)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6. Does your household have a working flashlight and working batteries for your use if the electricity is out?

(362)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

7. In a large-scale disaster or emergency, what would be your main method or way of

communicating with relatives and friends?

(363)

Read only if necessary:

1 Regular home telephones

2 Cell phones

3 Email

4 Pager

5 2-way radios

6 Other

Do not read:

7 Don’t know / Not sure

9 Refused

8. What would be your main method or way of getting information from authorities in a large-scale disaster or emergency?

(364)

Read only if necessary:

1 Television

2 Radio

3 Internet

4 Print media

5 Neighbors

6 Other

Do not read:

7 Don’t know / Not sure

9 Refused

9. Does your household have a written disaster evacuation plan for how you will leave your home, in case of a large-scale disaster or emergency that requires evacuation?

(365)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

10. If public authorities announced a mandatory evacuation from your community due to a large-scale disaster or emergency, would you evacuate?

(366)

1 Yes [Go to next module]

2 No

7 Don’t know / Not sure

9 Refused

11. What would be the main reason you might not evacuate if asked to do so?

(367-368)

Read only if necessary:

0 1 Lack of transportation

0 2 Lack of trust in public officials

0 3 Concern about leaving property behind

0 4 Concern about personal safety

0 5 Concern about family safety

0 6 Concern about leaving pets

0 7 Concern about traffic jams and inability to get out

0 8 Health problems (could not be moved)

0 9 Other

Do not read:

7 7 Don’t know / Not sure

9 9 Refused

Veteran’s Health

CATI NOTE: If Core Q7.5 = 1 (Yes) continue, else go to next module.

The next questions relate to veteran’s health.

1. Did you ever serve in a combat or war zone?

(369)

1 Yes

2 No

Don’t know / Not sure

9 Refused

2. Has a doctor or other health professional ever told you that you have depression, anxiety, or post traumatic stress disorder (PTSD)?

(370)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

3. A traumatic brain injury may result from a violent blow to the head or when an object pierces the skull and enters the brain tissue. Has a doctor or other health professional

ever told you that you have suffered a traumatic brain injury (TBI)?

(371)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

4. In the past 12 months, did you receive any psychological or psychiatric counseling or treatment?

(372)

Please read:

1 Yes, from a VA facility

2 Yes, from a non-VA facility

3 Yes, from both VA and non-VA facilities

4 No

Do not read:

7 Don’t know / Not sure

9 Refused

The next few questions are a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer.

5. Has there been a time in the past 12 months when you thought of taking your own life?

(373)

1 Yes

2 No [Go to next module]

7 Don’t know / Not sure [Go to next module]

9 Refused [Go to next module]

6. During the past 12 months, did you attempt to commit suicide? Would you say---

(374)

Please read:

1 Yes, but did not require treatment

2 Yes, was treated at a VA facility

3 Yes, was treated at a non-VA facility

4 No

Do not read:

Don’t know / Not sure

9 Refused

As I mentioned, I would give you a phone number for an organization that can provide information and referral for these issues. You can dial the National Crisis line at 1-800-273-TALK (8255). You can also speak directly to your doctor or health provider.

Reactions to Race

Earlier I asked you to self-identify your race. Now I will ask you how other people identify you and treat you.

1. How do other people usually classify you in this country? Would you say: White, Black or African American, Hispanic or Latino, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, or some other group?

(332)

1 White

2 Black or African American

3 Hispanic or Latino

4 Asian

5 Native Hawaiian or Other Pacific Islander

6 American Indian or Alaska Native

8 Some other group (please specify) _________________________

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: If the respondent requests clarification of this question, say: “We want to know how OTHER people usually classify you in this country, which might be different from how you classify yourself.”

2. How often do you think about your race? Would you say never, once a year, once a

month, once a week, once a day, once an hour, or constantly?

(333)

1 Never

2 Once a year

3 Once a month

4 Once a week

5 Once a day

6 Once an hour

8 Constantly

7 Don’t know / Not sure

9 Refused

INTERVIEWER INSTRUCTION: The responses can be interpreted as meaning “at least” the indicated time frequency. If a respondent cannot decide between two categories, check the response for the lower frequency. For example, if a respondent says that they think about their race between once a week and once a month, check “once a month” as the response.

[CATI skip pattern: This question should only be asked of those who are “employed for wages,” “self-employed,” or “out of work for less than one year.”]

3. Within the past 12 months at work, do you feel you were treated worse than, the same as, or better than people of other races?

(334)

1 Worse than other races

2 The same as other races

3 Better than other races

Do not read:

4 Worse than some races, better than others

5 Only encountered people of the same race

7 Don’t know / Not sure

9 Refused

4. Within the past 12 months, when seeking health care, do you feel your experiences were worse than, the same as, or better than for people of other races?

(335)

1 Worse than other races

2 The same as other races

3 Better than other races

Do not read:

4 Worse than some races, better than others

5 Only encountered people of the same race

6 No health care in past 12 months

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: If the respondent indicates that they do not know about other people’s experiences when seeking health care, say: “This question is asking about your perceptions when seeking health care. It does not require specific knowledge about other people’s experiences.”

5. Within the past 30 days, have you experienced any physical symptoms, for example, a headache, an upset stomach, tensing of your muscles, or a pounding heart, as a result of how you were treated based on your race?

(336)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6. Within the past 30 days, have you felt emotionally upset, for example angry, sad, or frustrated, as a result of how you were treated based on your race?

(337)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Pierannunzi, Carol (CDC/ONDIEH/NCCDPHP)
File Modified	0000-00-00
File Created	2021-01-16

Form 0920-1061 2019 Approved Quesions by Optional Module

Behavioral Risk Factor Surveillance System (BRFSS)

Attachment 4-2019 Approved Questions by Optional Module

BRFSS Optional Modules

OMB: 0920-1061

Table of Contents

Optional Modules With Question Text

2019 Questionnaire New Modules

Module: ME/CFS

Module: Hepatitis Treatment

Module: Aspirin for CVD Prevention

Module: Home/ Self-measured Blood Pressure

Module: Adverse Childhood Experiences

Module: Food Stamps

2015-2018 Questionnaire Modules (previously approved)

Module 25: Actions to Control High Blood Pressure

Module 26: Arthritis Management

Module 27: Healthy Days (Symptoms)

Module 28: Alcohol Screening & Brief Intervention (ASBI)

Module 29: Sugar Sweetened Beverages

Module 30: Sodium or Salt-Related Behavior

Module 31: Preconception Health/Family Planning

Module 32: Emotional Support and Life Satisfaction

Module 33: Social Determinants of Health

Module 34: Sleep Disorder

Module 37: Flu Vaccination Location

Modules under consideration for 2020-2022

Emerging Core Opioid Questions

Example Optional Module Questions: Prescribed Opioids

Example Optional Module Questions: Use of Opioids Not Prescribed

Example Optional Module Questions: Opioid Dependency

Anxiety and Depression

Mental Illness and Stigma

Social Context

General Preparedness

Veteran’s Health

Reactions to Race