0920-1061 2019 BRFSS Questionnaire

Behavioral Risk Factor Surveillance System (BRFSS)

Attachment 5 2019 BRFSS Questionnaire 11-19

BRFSS Core Survey

OMB: 0920-1061

Document [docx]
Download: docx | pdf



Attachment 5

2019 BRFSS Questionnaire




Table of Contents

OMB Header and Introductory Text 4

Landline Introduction 5

Cell Phone Introduction 10

Core Section 1: Health Status 15

Core Section 2: Healthy Days 16

Core Section 3: Healthcare Access 17

Core Section 4: Hypertension Awareness 19

Core Section 5: Cholesterol Awareness 20

Core Section 6: Chronic Health Conditions 22

Core Section 7: Arthritis 25

Core Section 8: Demographics 28

Core Section 9: Tobacco Use 35

Core Section 10: Alcohol Consumption 37

Core Section 11: Exercise (Physical Activity) 39

Core Section 12: Fruits and Vegetables 41

Core Section 13: Immunization 44

Core Section 14: H.I.V./AIDS 46

Closing Statement/ Transition to Modules 50

Optional Modules 51

Module 1: Prediabetes 52

Module 2: Diabetes 53

Module 3: ME/CFS 56

Module 4: Hepatitis Treatment 57

Module 5: HPV - Vaccination 59

Module 6: Place of Flu Vaccination 60

Module 7: Shingles Vaccination 61

Module 8: Lung Cancer Screening 62

Module 9: Breast and Cervical Cancer Screening 64

Module 10: Prostate Cancer Screening 67

Module 11: Prostate Cancer Decision Making 69

Module 12: Colorectal Cancer Screening 71

Module 13: Cancer Survivorship 74

Module 14: Healthcare Access 80

Module 15: Aspirin for CVD Prevention 82

Module 16: Home/ Self-measured Blood Pressure 83

Module 17: Sodium or Salt-Related Behavior 85

Module 18: Indoor Tanning 86

Module 19: Excess Sun Exposure 87

Module 20: Cognitive Decline 89

Module 21: Caregiver 92

Module 22: Adverse Childhood Experiences 96

Module 23: Family Planning 99

Module 24: Alcohol Screening & Brief Intervention (ASBI) 103

Module 25: Marijuana Use 105

Module 26: Industry and Occupation 107

Module 27: Food Stamps 108

Module 28: Sex at Birth 109

Module 29: Sexual Orientation and Gender Identity 110

Module 30: Random Child Selection 113

Module 31: Childhood Asthma Prevalence 117

Asthma Call-Back Permission Script 118

Closing Statement 120




OMB Header and Introductory Text


Read if necessary

Read

Interviewer instructions

(not read)

Public reporting burden of this collection of information is estimated to average 27 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061).


Form Approved

OMB No. 0920-1061

Exp. Date 3/31/2018


Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Carol Pierannunzi at [email protected].


HELLO, I am calling for the (health department). My name is (name). We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices.




Landline Introduction


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

LL01.


Is this [PHONE NUMBER]?

CTELENM1


1 Yes

Go to LL02


63

2 No

TERMINATE

Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time.

LL02.


Is this a private residence?

PVTRESD1


1 Yes

Go to LL04

Read if necessary: By private residence we mean someplace like a house or apartment.

Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.

64

2 No


Go to LL03

If no, business phone only: thank you very much but we are only interviewing persons on residential phones lines at this time.

NOTE: Business numbers which are also used for personal communication are eligible.

3 No, this is a business


Read: Thank you very much but we are only interviewing persons on residential phones at this time.

LL03.


Do you live in college housing?

COLGHOUS


1 Yes

Go to LL04

Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.

65

2 No

TERMINATE

Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.

LL04.


Do you currently live in__(state)____?

STATERE1


1 Yes

Go to LL05


66

2 No

TERMINATE

Thank you very much but we are only interviewing persons who live in [STATE] at this time.

LL05.

Is this a cell phone?

CELPHONE

1 Yes, it is a cell phone

TERMINATE

Read: Thank you very much but we are only interviewing by landline telephones in private residences or college housing at this time.

67

2 Not a cell phone

Go to LL06

Read if necessary: By cell phone we mean a telephone that is mobile and usable outside your neighborhood.

Do not read: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).

LL06.


Are you 18 years of age or older?

LADULT1


1 Yes


[CATI NOTE: IF COLLEGE HOUSING = “YES,” CONTINUE; OTHERWISE GO TO ADULT RANDOM SELECTION]


68

2 No

TERMINATE

Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.

LL07.

Are you male or female?


COLGSEX

1 Male

2 Female


ONLY for respondents who are LL and COLGHOUS= 1.



69

7 Don’t know/Not sure

9 Refused

TERMINATE

Thank you for your time, your number may be selected for another survey in the future.

LL08.

I need to randomly select one adult who lives in your household to be interviewed. Excluding adults living away from home, such as students away at college, how many members of your household, including yourself, are 18 years of age or older?

NUMADULT


1

Go to Transition to Section 1.

Go to LL09

Read: Are you that adult?

If yes: Then you are the person I need to speak with.

If no: May I speak with the adult in the household?

70-71

2-6 or more

Go to LL10.


LL09.

Are you male or female?


LANDSEX

1 Male

2 Female


GO to Transition Section 1.


72

7 Don’t know/Not sure

9 Refused

TERMINATE

Thank you for your time, your number may be selected for another survey in the future.

LL10.

How many of these adults are men?

NUMMEN


_ _ Number

77 Don’t know/ Not sure

99 Refused



73-74

LL11.

So the number of women in the household is [X]. Is that correct?

NUMWOMEN



Do not read: Confirm the number of adult women or clarify the total number of adults in the household.

Read: The persons in your household that I need to speak with is [Oldest/Youngest/ Middle//Male /Female].

75-76

LL12

The person in your household that I need to speak with is [Oldest/Youngest/ Middle//Male /Female]. Are you the [Oldest/Youngest/ Middle//Male /Female] in this household?

RESPSLCT

1 Male

2 Female




77

7 Don’t know/Not sure

9 Refused

TERMINATE

Thank you for your time, your number may be selected for another survey in the future.

Transition to Section 1.



I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call (give appropriate state telephone number).


Do not read: Introductory text may be reread when selected respondent is reached.


Do not read: The sentence “Any information you give me will not be connected to any personal information” may be replaced by “Any personal information that you provide will not be used to identify you.” If the state coordinator approves the change.




Cell Phone Introduction


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)








CP01.


Is this a safe time to talk with you?

SAFETIME


1 Yes

Go to CP02


78

2 No

([set appointment if possible]) TERMINATE]

Thank you very much. We will call you back at a more convenient time.

CP02.


Is this [PHONE NUMBER]?

CTELNUM1


1 Yes

Go to CP03


79

2 No

TERMINATE


CP03.


Is this a cell phone?

CELLFON5


1 Yes

Go to CADULT


80

2 No

TERMINATE

If "no”: thank you very much, but we are only interviewing persons on cell telephones at this time

CP04.


Are you 18 years of age or older?

CADULT1


1 Yes




81

2 No

TERMINATE

Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.

CP05.

Are you male or female?


CELLSEX

1 Male

2 Female



82

7 Don’t Know/ Not sure

9 Refused

TERMINATE

Thank you for your time, your number may be selected for another survey in the future.

CP06.


Do you live in a private residence?

PVTRESD3


1 Yes

Go to CP08

Read if necessary: By private residence we mean someplace like a house or apartment

Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.

83

2 No

Go to CP07


CP07.


Do you live in college housing?

CCLGHOUS


1 Yes

Go to CP08

Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.

84

2 No

TERMINATE

Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.

CP08.


Do you currently live in___(state)____?

CSTATE1


1 Yes

Go to CP10


85

2 No

Go to CP09


CP09.


In what state do you currently live?

RSPSTAT1


1 Alabama

2 Alaska

4 Arizona

5 Arkansas

6 California

8 Colorado

9 Connecticut

10 Delaware

11 District of Columbia

12 Florida

13 Georgia

15 Hawaii

16 Idaho

17 Illinois

18 Indiana

19 Iowa

20 Kansas

21 Kentucky

22 Louisiana

23 Maine

24 Maryland

25 Massachusetts

26 Michigan

27 Minnesota

28 Mississippi

29 Missouri

30 Montana

31 Nebraska

32 Nevada

33 New Hampshire

34 New Jersey

35 New Mexico

36 New York

37 North Carolina

38 North Dakota

39 Ohio

40 Oklahoma

41 Oregon

42 Pennsylvania

44 Rhode Island

45 South Carolina

46 South Dakota

47 Tennessee

48 Texas

49 Utah

50 Vermont

51 Virginia

53 Washington

54 West Virginia

55 Wisconsin

56 Wyoming

66 Guam

72 Puerto Rico

78 Virgin Islands

99 Refused



86-87

CP10.


Do you also have a landline telephone in your home that is used to make and receive calls?

LANDLINE


1 Yes

2 No

7 Don’t know/ Not sure

9 Refused


Read if necessary: By landline telephone, we mean a regular telephone in your home that is used for making or receiving calls. Please include landline phones used for both business and personal use.

88

CP11.

How many members of your household, including yourself, are 18 years of age or older?

HHADULT

_ _ Number

77 Don’t know/ Not sure

99 Refused

If CP07 = yes then number of adults is automatically set to 1


89-90

Transition to section 1.



I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call (give appropriate state telephone number).





Core Section 1: Health Status


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C01.01


Would you say that in general your health is—

GENHLTH

Read:

1 Excellent

2 Very Good

3 Good

4 Fair

5 Poor

Do not read:

7 Don’t know/Not sure

9 Refused



101



Core Section 2: Healthy Days


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C02.01


Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

PHYSHLTH

_ _ Number of days (01-30)

88 None

77 Don’t know/not sure

99 Refused



102-103

C02.02

Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

MENTHLTH

_ _ Number of days (01-30)

88 None

77 Don’t know/not sure

99 Refused



104-105

C02.03

During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

POORHLTH

_ _ Number of days (01-30)

88 None

77 Don’t know/not sure

99 Refused

Skip if C02.01, PHYSHLTH, is 88 and C02.02, MENTHLTH, is 88


106-107



Core Section 3: Healthcare Access


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C03.01


Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, or Indian Health Service?

HLTHPLN1


1 Yes

If using Healthcare Access (HCA) Module go to HCA.01, else continue


108

2 No

7 Don’t know/Not Sure

9 Refused



C03.02

Do you have one person you think of as your personal doctor or health care provider?

PERSDOC2


1 Yes, only one

2 More than one

3 No

7 Don’t know / Not sure

9 Refused


If No, read: Is there more than one, or is there no person who you think of as your personal doctor or health care provider?

109

C03.03

Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?

MEDCOST


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



110

C03.04

About how long has it been since you last visited a doctor for a routine checkup?

CHECKUP1

Read if necessary:

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 5 years (2 years but less than 5 years ago)

4 5 or more years ago

Do not read:

7 Don’t know / Not sure

8 Never

9 Refused


Read if necessary: A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.

111



Core Section 4: Hypertension Awareness



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

HYPER.01


Have you EVER been told by a doctor, nurse, or other health professional that you have high blood pressure?

BPHIGH4

1 Yes


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



By other health professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.

112

2 Yes, but female told only during pregnancy

3 No

4 Told borderline high or pre-hypertensive

7 Don’t know / Not sure

9 Refused

Go to next section

HYPER.02

Are you currently taking prescription medicine for your high blood pressure?

BPMEDS

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



113



Core Section 5: Cholesterol Awareness


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CHOL.01


Blood cholesterol is a fatty substance found in the blood. About how long has it been since you last had your blood cholesterol checked?

CHOLCHK2

1 Never

2 Within the past year (anytime less than one year ago)

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

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

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

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

8 5 or more years ago

7 Don’t know/ Not sure

9 Refused

If response = 1, 9.

GOTO Next section.

Blood cholesterol is a fatty substance found in the blood.

114

CHOL.02

Have you ever been told by a doctor, nurse or other health professional that your blood cholesterol is high?

TOLDHI2

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

If response = 2, 7, 9 GOTO next section.

By other health professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.

115

CHOL.03


Are you currently taking medicine prescribed by your doctor for your blood cholesterol?

CHOLMED2

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



116



Core Section 6: Chronic Health Conditions


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C06.01


Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me Yes, No, Or You’re Not Sure.

(Ever told) you that you had a heart attack also called a myocardial infarction?

CVDINFR4


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



117

C06.02

(Ever told) (you had) angina or coronary heart disease?

CVDCRHD4


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



118

C06.03

(Ever told) (you had) a stroke?

CVDSTRK3


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



119

C06.04

(Ever told) (you had) asthma?

ASTHMA3

1 Yes



120

2 No

7 Don’t know / Not sure

9 Refused

Go to C06.06


C06.05

Do you still have asthma?

ASTHNOW

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



121

C06.06

(Ever told) (you had) skin cancer?

CHCSCNCR


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



122

C06.07

(Ever told) (you had) any other types of cancer?

CHCOCNCR


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



123

C06.08

(Ever told) (you had) chronic obstructive pulmonary disease, C.O.P.D., emphysema or chronic bronchitis?

CHCCOPD1


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



124

C06.09

(Ever told) (you had) a depressive disorder (including depression, major depression, dysthymia, or minor depression)?

ADDEPEV2


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



125

C06.10

Not including kidney stones, bladder infection or incontinence, were you ever told you have kidney disease?

CHCKDNY2


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Read if necessary: Incontinence is not being able to control urine flow.

126

C06.11

(Ever told) (you had) diabetes?

DIABETE3


1 Yes



If yes and respondent is female, ask: was this only when you were pregnant? If respondent says pre-diabetes or borderline diabetes, use response code 4.

127

2 Yes, but female told only during pregnancy

3 No

4 No, pre-diabetes or borderline diabetes

7 Don’t know / Not sure

9 Refused

Go to Pre-Diabetes Optional Module (if used). Otherwise, go to next section.


C06.12

How old were you when you were told you have diabetes?

DIABAGE2

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

98 Don‘t know / Not sure

99 Refused

Go to Diabetes Module if used, otherwise go to next section.


128-129



Core Section 7: Arthritis


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C07.01

(Ever told) (you had) have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?

HAVARTH3


1 Yes



Arthritis diagnoses include: rheumatism, polymyalgia rheumatic, osteoarthritis (not osteoporosis), tendonitis, bursitis, bunion, tennis elbow, carpal tunnel syndrome, tarsal tunnel syndrome, joint infection, Reiter’s syndrome, ankylosing spondylitis; spondylosis, rotator cuff syndrome, connective tissue disease, scleroderma, polymyositis, Raynaud’s syndrome, vasculitis, giant cell arteritis, Henoch-Schonlein purpura, Wegener’s granulomatosis, polyarteritis nodosa)

130

2 No

7 Don’t know / Not sure

9 Refused

Go to next section

C07.02

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

ARTHEXER

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


If the respondent is unclear about whether this means increase or decrease in physical activity, this means increase.

131

C07.03

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

ARTHEDU

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



132

C07.04

Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?

LMTJOIN3

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


If a respondent question arises about medication, then the interviewer should reply: "Please answer the question based on how you are when you are taking any of the medications or treatments you might use

133

C07.05

In the next question, we are referring to work for pay. Do arthritis or joint symptoms now affect whether you work, the type of work you do or the amount of work you do?

ARTHDIS2

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


If respondent gives an answer to each issue (whether works, type of work, or amount of work), then if any issue is "yes" mark the overall response as "yes." If a question arises about medications or treatment, then the interviewer should say: "Please answer the question based on your current experience, regardless of whether you are taking any medication or treatment."

134

C07.06

Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. During the past 30 days, how bad was your joint pain on average on a scale of 0 to 10 where 0 is no pain and 10 is pain or aching as bad as it can be?

JOINPAI2

__ __ Enter number [00-10]

77 Don’t know/ Not sure

99 Refused



135-136




Core Section 8: Demographics


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue





Read if necessary:

I will ask you some questions about yourself in the next section. We include these questions so that we can compare health indicators by groups.


C08.01

What is your age?

AGE


_ _ Code age in years

07 Don’t know / Not sure

09 Refused



137-138

C08.02

Are you Hispanic, Latino/a, or Spanish origin?

HISPANC3


If yes, read: Are you…

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


One or more categories may be selected.

139-142

C08.03

Which one or more of the following would you say is your race?

MRACE1


Please read:

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

If more than one response to C08.04; continue. Otherwise, go to C08.06.

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

One or more categories may be selected.

143-170

C08.04

Which one of these groups would you say best represents your race?

ORACE3


Please read:

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


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


If respondent has selected multiple races in previous and refuses to select a single race, code refused


171-172

C08.05

Are you…

MARITAL


Please read:

1 Married

2 Divorced

3 Widowed

4 Separated

5 Never married

Or

6 A member of an unmarried couple

Do not read:

9 Refused



173

C08.06

What is the highest grade or year of school you completed?

EDUCA


Read if necessary:

1 Never attended school or only attended kindergarten

2 Grades 1 through 8 (Elementary)

3 Grades 9 through 11 (Some high school)

4 Grade 12 or GED (High school graduate)

5 College 1 year to 3 years (Some college or technical school)

6 College 4 years or more (College graduate)

Do not read:

9 Refused



174

C08.07

Do you own or rent your home?

RENTHOM1


1 Own

2 Rent

3 Other arrangement

7 Don’t know / Not sure

9 Refused


Other arrangement may include group home, staying with friends or family without paying rent. Home is defined as the place where you live most of the time/the majority of the year.

Read if necessary: We ask this question in order to compare health indicators among people with different housing situations.

175

C08.08

In what county do you currently live?

CTYCODE2


_ _ _ANSI County Code

777 Don’t know / Not sure

999 Refused



176-178

C08.09

What is the ZIP Code where you currently live?

ZIPCODE1


_ _ _ _ _

77777 Do not know

99999 Refused



179-183


C08.10

Not including cell phones or numbers used for computers, fax machines or security systems, do you have more than one telephone number in your household?

NUMHHOL3


1 Yes


If cellular telephone interview skip to 8.13 (Veteran3)


184

2 No

7 Don’t know / Not sure

9 Refused

Go to C08.13


C08.11

How many of these telephone numbers are residential numbers?

NUMPHON3


__ Enter number (1-5)

6 Six or more

7 Don’t know / Not sure

8 None

9 Refused



185

C08.12

How many cell phones do you have for personal use?

CPDEMO1B


__ Enter number (1-5)

6 Six or more

7 Don’t know / Not sure

8 None

9 Refused

Last question needed for partial complete.

Read if necessary: Include cell phones used for both business and personal use.

186

C08.13

Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?

VETERAN3


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Read if necessary: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.

187

C08.14

Are you currently…?

EMPLOY1


Read:

1 Employed for wages

2 Self-employed

3 Out of work for 1 year or more

4 Out of work for less than 1 year

5 A Homemaker

6 A Student

7 Retired

Or

8 Unable to work

Do not read:

9 Refused


If more than one, say “select the category which best describes you”.

188

C08.15

How many children less than 18 years of age live in your household?

CHILDREN


_ _ Number of children

88 None

99 Refused



189-190

C08.16

Is your annual household income from all sources—

INCOME2


Read if necessary:

04 Less than $25,000

If no, ask 05; if yes, ask 03 ($20,000 to less than $25,000)

03 Less than $20,000 If no, code 04; if yes, ask 02 ($15,000 to less than $20,000)

02 Less than $15,000 If no, code 03; if yes, ask 01 ($10,000 to less than $15,000)

01 Less than $10,000 If no, code 02

05 Less than $35,000 If no, ask

06 ($25,000 to less than $35,000)

06 Less than $50,000 If no, ask

07 ($35,000 to less than $50,000)

07 Less than $75,000 If no, code 08

($50,000 to less than $75,000)

08 $75,000 or more

Do not read:

77 Don’t know / Not sure

99 Refused


If respondent refuses at ANY income level, code ‘99’ (Refused)


191-192

C08.17

About how much do you weigh without shoes?

WEIGHT2


_ _ _ _ Weight (pounds/kilograms)

7777 Don’t know / Not sure

9999 Refused


If respondent answers in metrics, put 9 in first column. Round fractions up

193-196

C08.18

About how tall are you without shoes?

HEIGHT3


_ _ / _ _ Height (ft / inches/meters/centimeters)

77/ 77 Don’t know / Not sure

99/ 99 Refused


If respondent answers in metrics, put 9 in first column. Round fractions down

197-200

C08.19

To your knowledge, are you now pregnant?

PREGNANT


1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Skip if M28.01, BIRTHSEX, is coded 1; or CP05=1 or LL12=1; or LL09 = 1 or LL07 =1

or C08.01, AGE, is greater than 49


201

C08.20

Some people who are deaf or have serious difficulty hearing use assistive devices to communicate by phone. Are you deaf or do you have serious difficulty hearing?

DEAF


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



202

C08.21

Are you blind or do you have serious difficulty seeing, even when wearing glasses?

BLIND


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



203

C08.22

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

DECIDE


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



204

C08.23

Do you have serious difficulty walking or climbing stairs?

DIFFWALK

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



205

C08.24

Do you have difficulty dressing or bathing?

DIFFDRES

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



206

C08.25

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

DIFFALON

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



207


Core Section 9: Tobacco Use


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C09.01


Have you smoked at least 100 cigarettes in your entire life?

SMOKE100


1 Yes


Do not include: electronic cigarettes (e-cigarettes, njoy, bluetip), herbal cigarettes, cigars, cigarillos, little cigars, pipes, bidis, kreteks, water pipes (hookahs) or marijuana.

5 packs = 100 cigarettes

208

2 No

7 Don’t know/Not Sure

9 Refused

Go to C09.05


C09.02

Do you now smoke cigarettes every day, some days, or not at all?

SMOKDAY2


1 Every day

2 Some days



209

3 Not at all


Go to C09.04


7 Don’t know / Not sure

9 Refused

Go to C09.05


C09.03

During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

STOPSMK2


1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Go to C09.05


210

C09.04

How long has it been since you last smoked a cigarette, even one or two puffs?

LASTSMK2


Read if necessary:

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

02 Within the past 3 months (1 month but less than 3 months ago)

03 Within the past 6 months (3 months but less than 6 months ago)

04 Within the past year (6 months but less than 1 year ago)

05 Within the past 5 years (1 year but less than 5 years ago)

06 Within the past 10 years (5 years but less than 10 years ago)

07 10 years or more

08 Never smoked regularly

77 Don’t know / Not sure

99 Refused



211-212

C09.05

Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?

USENOW3

1 Every day

2 Some days

3 Not at all

7 Don’t know / Not sure

9 Refused


Read if necessary: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.

213



Core Section 10: Alcohol Consumption

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C10.01


During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?

ALCDAY5


1 _ _ Days per week

2 _ _ Days in past 30 days


INTERVIEWER NOTE:

One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor.

214-216

888 No drinks in past 30 days

777 Don’t know / Not sure

999 Refused

Go to next section


C10.02

One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?

AVEDRNK2


_ _ Number of drinks

88 None

77 Don’t know / Not sure

99 Refused


Read if necessary: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.

217-218

C10.03

Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI X = 5 for men, X = 4 for women] or more drinks on an occasion?

DRNK3GE5


_ _ Number of times

88 None

77 Don’t know / Not sure

99 Refused

CATI X = 5 for men, X = 4 for women


219-220

C10.04

During the past 30 days, what is the largest number of drinks you had on any occasion?

MAXDRNKS

_ _ Number of drinks

77 Don’t know / Not sure

99 Refused



221-222



Core Section 11: Exercise (Physical Activity)


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C11.01

During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

EXERANY2

1 Yes


If respondent does not have a regular job or is retired, they may count the physical activity or exercise they spend the most time doing in a regular month.

223

2 No

7 Don’t know/Not Sure

9 Refused

Go to C 11.08

C11.02

What type of physical activity or exercise did you spend the most time doing during the past month?

EXRACT11

__ __ Specify from Physical Activity Coding List


See Physical Activity Coding List.

If the respondent’s activity is not included in the physical activity coding list, choose the option listed as “other”.


224-225

77 Don’t know/ Not Sure

99 Refused

Go to C11.08

C11.03

How many times per week or per month did you take part in this activity during the past month?

EXEROFT1

1_ _ Times per week

2_ _ Times per month

777 Don’t know / Not sure

999 Refused



226-228

C11.04

And when you took part in this activity, for how many minutes or hours did you usually keep at it?

EXERHMM1

_:_ _ Hours and minutes

777 Don’t know / Not sure

999 Refused



229-231

C11.05

What other type of physical activity gave you the next most exercise during the past month?

EXRACT21

__ __ Specify from Physical Activity List


See Physical Activity Coding List.


If the respondent’s activity is not included in the physical activity coding list, choose the option listed as “other”.


232-233

88 No other activity

77 Don’t know/ Not Sure

99 Refused

Go to C11.08

C11.06

How many times per week or per month did you take part in this activity during the past month?

EXEROFT2

1_ _ Times per week

2_ _ Times per month

777 Don’t know / Not sure

999 Refused



234-236

C11.07

And when you took part in this activity, for how many minutes or hours did you usually keep at it?

EXERHMM2

_:_ _ Hours and minutes

777 Don’t know / Not sure

999 Refused



237-239

C11.08

During the past month, how many times per week or per month did you do physical activities or exercises to strengthen your muscles?

STRENGTH

1_ _ Times per week

2_ _Times per month

888 Never

777 Don’t know / Not sure

999 Refused


Do not count aerobic activities like walking, running, or bicycling. Count activities using your own body weight like yoga, sit-ups or push-ups and those using weight machines, free weights, or elastic bands.

240-242


Core Section 12: Fruits and Vegetables


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C12.01

Now think about the foods you ate or drank during the past month, that is, the past 30 days, including meals and snacks.

Not including juices, how often did you eat fruit? You can tell me times per day, times per week or times per month.

FRUIT2

1_ _ Day

2_ _ Week

3_ _ Month

300 Less than once a month

555 Never

777 Don’t Know

999 Refused


If a respondent indicates that they consume a food item every day then enter the number of times per day. If the respondent indicates that they eat a food less than daily, then enter times per week or time per month. Do not enter time per day unless the respondent reports that he/she consumed that food item each day during the past month.

Enter quantity in times per day, week, or month.

If respondent gives a number without a time frame, ask “was that per day, week, or month?”

Read if respondent asks what to include or says ‘i don’t know’: include fresh, frozen or canned fruit. Do not include dried fruits.


243-245

C12.02

Not including fruit-flavored drinks or fruit juices with added sugar, how often did you drink 100% fruit juice such as apple or orange juice?

FRUITJU2

1_ _ Day

2_ _ Week

3_ _ Month

300 Less than once a month

555 Never

777 Don’t Know

999 Refused


Read if respondent asks about examples of fruit-flavored drinks: “do not include fruit-flavored drinks with added sugar like cranberry cocktail, Hi-C, lemonade, Kool-Aid, Gatorade, Tampico, and sunny delight. Include only 100% pure juices or 100% juice blends.”

Enter quantity in times per day, week, or month.

If respondent gives a number without a time frame, ask “Was that per day, week, or month?”

246-248

C12.03

How often did you eat a green leafy or lettuce salad, with or without other vegetables?

FVGREEN1

1_ _ Day

2_ _ Week

3_ _ Month

300 Less than once a month

555 Never

777 Don’t Know

999 Refused


Enter quantity in times per day, week, or month.

If respondent gives a number without a time frame, ask “Was that per day, week, or month?”

Read if respondent asks about spinach: “Include spinach salads.”

249-251

C12.04

How often did you eat any kind of fried potatoes, including French fries, home fries, or hash browns?

FRENCHF1

1_ _ Day

2_ _ Week

3_ _ Month

300 Less than once a month

555 Never

777 Don’t Know

999 Refused


Enter quantity in times per day, week, or month.

If respondent gives a number without a time frame, ask “Was that per day, week, or month?”

Read if respondent asks about potato chips: “Do not include potato chips.”

252-254

C12.05

How often did you eat any other kind of potatoes, or sweet potatoes, such as baked, boiled, mashed potatoes, or potato salad?

POTATOE1

1_ _ Day

2_ _ Week

3_ _ Month

300 Less than once a month

555 Never

777 Don’t Know

999 Refused


Enter quantity in times per day, week, or month.

If respondent gives a number without a time frame, ask “Was that per day, week, or month?”


Read if respondent asks about what types of potatoes to include: “Include all types of potatoes except fried. Include potatoes au gratin, scalloped potatoes.”


255-257

C12.06

Not including lettuce salads and potatoes, how often did you eat other vegetables?

VEGETAB2

1_ _ Day

2_ _ Week

3_ _ Month

300 Less than once a month

555 Never

777 Don’t Know

999 Refused


Enter quantity in times per day, week, or month.

If respondent gives a number without a time frame, ask “Was that per day, week, or month?”


Read if respondent asks about what to include: “Include tomatoes, green beans, carrots, corn, cabbage, bean sprouts, collard greens, and broccoli. Include raw, cooked, canned, or frozen vegetables. Do not include rice.”

258-260


Core Section 13: Immunization


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C13.01

During the past 12 months, have you had either a flu vaccine that was sprayed in your nose or a flu shot injected into your arm?

FLUSHOT7

1 Yes



A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.

261

2 No

7 Don’t know / Not sure

9 Refused

Go to C13.03

C13.02

During what month and year did you receive your most recent flu vaccine that was sprayed in your nose or flu shot injected into your arm?

FLSHTMY3

_ _ / _ _ _ _ Month/ Year

777777 Don’t know/ Not sure

999999 Refused

Module on Place of Flu Shot Vaccination may be inserted after this question.


262-267

C13.03


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

TETANUS1

1 Yes, received Tdap

2 Yes, received tetanus shot, but not Tdap

3 Yes, received tetanus shot but not sure what type

4 No, did not receive any tetanus shot in the past 10 years

7 Don’t know/Not sure

9 Refused


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

268

C13.04

Have you ever had a pneumonia shot also known as a pneumococcal vaccine?

PNEUVAC4

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Read if necessary: There are two types of pneumonia shots: polysaccharide, also known as Pneumovax, and conjugate, also known as Prevnar.

269







Core Section 14: H.I.V./AIDS

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C14.01


The next few questions are about the national health problem of H.I.V., the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don’t have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.


Including fluid testing from your mouth, but not including tests you may have had for blood donation, have you ever been tested for H.I.V?

HIVTST7


1 Yes



270

2 No

7 Don’t know/ not sure

9 Refused

Go to C14.03

C14.02

Not including blood donations, in what month and year was your last H.I.V. test?

HIVTSTD3


_ _ /_ _ _ _ Code month and year

77/ 7777 Don’t know / Not sure 99/ 9999 Refused

If response is before January 1985, code "777777".

INTERVIEWER NOTE: If the respondent remembers the year but cannot remember the month, code the first two digits 77 and the last four digits for the year.

271-276

C14.03

I am going to read you a list. When I am done, please tell me if any of the situations apply to you. You do not need to tell me which one.


You have injected any drug other than those prescribed for you in the past year. 

You have been treated for a sexually transmitted disease or STD in the past year.

You have given or received money or drugs in exchange for sex in the past year.

You had anal sex without a condom in the past year.

You had four or more sex partners in the past year. 

Do any of these situations apply to you?


Do any of these situations apply to you?

HIVRISK5

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



277



Closing Statement/ Transition to Modules


Read if necessary

Read

CATI instructions

(not read)

That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.


Read if no optional modules follow, otherwise continue to optional modules.




Optional Modules


Module 1: Prediabetes


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M01.01


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

PDIABTST

1 Yes

2 No

7 Don’t know/ not sure

9 Refused

Skip if Section C06.112, DIABETE3, is coded 1


278

M01.02

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

PREDIAB1

1 Yes

2 Yes, during pregnancy

3 No

7 Don’t know / Not sure

9 Refused

Skip if Section 06.11, DIABETE3, is coded 1; If C06.11, DIABETE3, is coded 4 automatically code M01.02, PREDIAB1, equal to 1 (yes);

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

279



Module 2: Diabetes


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M02.01


Are you now taking insulin?

INSULIN


1 Yes

2 No

7 Don’t know/ not sure

9 Refused

To be asked following Core Q6.12; if response to Q6.11 is Yes (code = 1)


280

M02.02

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


BLDSUGAR


1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

4 _ _ Times per year

888 Never

777 Don’t know / Not sure

999 Refused


Read if necessary: Include times when checked by a family member or friend, but do not include times when checked by a health professional.


Do not read: 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.’

281-283

M02.03

Including times when checked by a family member or friend, about how often do you check your feet for any sores or irritations?

FEETCHK3


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



284-286

M02.04

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

DOCTDIAB


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

88 None

77 Don’t know / Not sure

99 Refused



287-288

M02.05

About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for A-one-C?

CHKHEMO3


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

88 None

98 Never heard of A-one-C test

77 Don’t know / Not sure

99 Refused


Read if necessary: A test for A-one-C measures the average level of blood sugar over the past three months.

289-290

M02.06

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

FEETCHK

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

88 None

77 Don’t know / Not sure

99 Refused

If M02.03 = 555 (No feet), go to M02.07


291-292

M02.07

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

EYEEXAM1

Read 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

8 Never

9 Refused



293

M02.08

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

DIABEYE

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



294

M02.09

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

DIABEDU

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



295



Module 3: ME/CFS


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?

TOLDCFS

1 Yes



My-al-gic

En-ceph-a-lo-my-eli-tis

296

2 No

7 Don’t know / Not sure

9 Refused

Go to next section

M03.02

Do you still have Chronic Fatigue Syndrome (CFS) or (Myalgic Encephalomyelitis) ME?

HAVECFS

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused


My-al-gic

En-ceph-a-lo-my-eli-tis

297

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?

WORKCFS

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



298



Module 4: 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?

TOLDHEPC

1 Yes


Hepatitis C is an infection of the liver from the Hepatitis C virus

299

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?

TRETHEPC

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.

300

M04.03

Were you treated for Hepatitis C prior to 2015?

PRIRHEPC

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.

301

M04.04

Do you still have Hepatitis C?

HAVEHEPC

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.

302

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?

HAVEHEPB

1 Yes


Hepatitis B is an infection of the liver from the hepatitis B virus.

303

2 No

7 Don’t know/ Not sure

9 Refused

Go to next section

M04.06

Are you currently taking medicine to treat hepatitis B?

MEDSHEPB

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused



304



Module 5: HPV - Vaccination


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Columns

C05.01


Have you ever had the Human Papilloma virus vaccination or HPV vaccination?

HPVADVC3


1 Yes

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

A vaccine to prevent the human papilloma virus 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”]. (Human Papilloma Virus (Human Pap•uh•loh•muh Virus), Gardasil (Gar•duh• seel), Cervarix (Serv a rix))


305

2 No

7 Don’t know / Not sure

9 Refused

Go to next module


C05.02

How many HPV shots did you receive?


HPVADSHT


_ _ Number of shots (1-2)

3 All shots

77 Don’t know / Not sure

99 Refused



306-307



Module 6: Place of Flu Vaccination

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C06.01

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

IMFVPLA1


Read 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 or outpatient)

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

99 Refused

This question may be inserted in core after C13.02

Read if necessary: How would you describe the place where you went to get your most recent flu vaccine?

308-309



Module 7: Shingles Vaccination


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C07.01

Have you ever had the shingles or zoster vaccine?

SHINGLE2


1 Yes

2 No

7 Don’t know / Not sure

9 Refused

If age ≤ 49, go to next section

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 which requires 2 shots.

310




Module 8: Lung Cancer Screening


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M08.01




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


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

LCSFIRST


_ _ _ Age in Years (001 – 100)

777 Don't know/Not sure

999 Refused

If C09.01=1 (yes) and C09.02 = 1, 2, or 3 (every day, some days, or not at all) continue, else go to question M08.04.

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).

If respondent indicates age inconsistent with previously entered age, 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.

311-313

888 Never smoked cigarettes regularly

Go to M08.04

M08.02

How old were you when you last smoked cigarettes regularly?

LCSLAST

_ _ _ Age in Years (001 – 100)

777 Don't know/Not sure

999 Refused



314-316

M08.03

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

LCSNUMCG

_ _ _ Number of cigarettes

777 Don't know/Not sure

999 Refused


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).

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

317-319

M08.04

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?

LCSCTSCN

Read 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



320


Module 9: Breast and Cervical Cancer Screening


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M09.01


(The next questions are about breast and cervical cancer.) Have you ever had a mammogram?

HADMAM


1 Yes

Skip if male.

A mammogram is an x-ray of each breast to look for breast cancer.

321

2 No

7 Don’t know/ not sure

9 Refused

Go to M09.03

M09.02

How long has it been since you had your last mammogram?

HOWLONG


Read if necessary:

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



322

M09.03

Have you ever had a Pap test?

HADPAP2


1 Yes



323

2 No

7 Don’t know / Not sure

9 Refused

Go to M09.05

M09.04

How long has it been since you had your last Pap test?

LASTPAP2


Read if necessary:

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



324

M09.05

An H.P.V. test is sometimes given with the Pap test for cervical cancer screening. Have you ever had an H.P.V. test?

HPVTEST


1 Yes


Human papillomarvirus (pap-uh-loh-muh virus)

325

2 No

7 Don’t know / Not sure

9 Refused

Go to M09.07

M09.06

How long has it been since you had your last H.P.V. test?

HPLSTTST

Read if necessary:

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



326

M09.07

Have you had a hysterectomy?

HADHYST2

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

If response to Core Q8.20 = 1 (is pregnant); then go to next section.

Read if necessary: A hysterectomy is an operation to remove the uterus (womb).

327



Module 10: Prostate Cancer Screening

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M10.01


Has a doctor, nurse, or other health professional ever talked with you about the advantages of the Prostate-Specific Antigen or P.S.A. test?

PCPSAAD3


1 Yes

2 No

7 Don’t know/ not sure

9 Refused

If respondent is ≤39 years of age, or 1 is female, go to next section.

Read if necessary: A prostate-specific antigen test, also called a P.S.A. test, is a blood test used to check men for prostate cancer.

328

M10.02

Has a doctor, nurse, or other health professional ever talked with you about the disadvantages of the P.S.A. test?

PCPSADI1


1 Yes

2 No

7 Don’t know/ not sure

9 Refused



329

M10.03

Has a doctor, nurse, or other health professional ever recommended that you have a P.S.A. test?

PCPSARE1


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



330

M10.04

Have you ever had a P.S.A. test?

PSATEST1


1 Yes



331

2 No

7 Don’t know / Not sure

9 Refused

Go to next section

M10.05

How long has it been since you had your last P.S.A. test?

PSATIME

Read if necessary:

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

Do not read:

7 Don’t know / Not sure

9 Refused



332

M10.06

What was the main reason you had this P.S.A. test – was it …?

PCPSARS1

Read:

1 Part of a routine exam

2 Because of a prostate problem

3 Because of a family history of prostate cancer

4 Because you were told you had prostate cancer

5 Some other reason

Do not read:

7 Don’t know / Not sure

9 Refused



333



Module 11: Prostate Cancer Decision Making


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M11.01


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

PCPSADE1


Read:

1 You made the decision alone

If M10.04= 1, continue, otherwise GOTO next module.

If M11.01 = 1, go to next module.


334

Read:

2 Your doctor, nurse, or health care provider made the decision alone


Go to next module.


3 You and one or more other persons made the decision together

Continue with 11.02

4 You don’t know how the decision was made

Do not read:

9 Refused

Go to next module.


M11.02

Who made the decision with you?

PCDMDEC1

Read if necessary:

1 Doctor/nurse /health care provider

2 Spouse/significant other

3 Other family member

4 Friend/non-relative

Do not read: 7 Don’t know / Not sure

9 Refused


Select one response. If respondent offers more than one response ask for primary person who made decision.

335



Module 12: Colorectal Cancer Screening


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M12.01


A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?

BLDSTOOL


1 Yes

Skip if Section 08.02, AGE, is less than 50


336

2 No

7 Don’t know/ not sure

9 Refused

Go to M12.03

M12.02

How long has it been since you had your last blood stool test using a home kit?

LSTBLDS3


Read if necessary:

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

Do not read:

7 Don’t know / Not sure

9 Refused



337

M12.03

Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems. Have you ever had either of these exams?

HADSIGM3


1 Yes



338

2 No

7 Don’t know / Not sure

9 Refused

Go to next section

M12.04

For a sigmoidoscopy, a flexible tube is inserted into the rectum to look for problems. A colonoscopy is similar, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test. Was your most recent exam a sigmoidoscopy or a colonoscopy?

HADSGCO1


1 Sigmoidoscopy

2 Colonoscopy

7 Don’t know / Not sure

9 Refused



339

M12.05

How long has it been since you had your last sigmoidoscopy or colonoscopy?

LASTSIG3

Read if necessary:

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 Within the past 10 years (5 years but less than 10 years ago)

6 10 or more years ago

Do not read:

7 Don't know / Not sure

9 Refused



340




Module 13: Cancer Survivorship


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M13.01


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


How many different types of cancer have you had?

CNCRDIFF


1 Only one

2 Two

3 Three or more


If C06.06 or C06.07 = 1 (Yes) or M10.06 = 4 (Because you were told you had prostate cancer) continue, else go to next module.


341

7 Don’t know / Not sure

9 Refused

Go to next module

M13.02

At what age were you told that you had cancer?

CNCRAGE


_ _ Age in Years (97 = 97 and older)

98 Don't know/Not sure

99 Refused


If M13.01= 2 (Two) or 3 (Three or more), ask: At what age were you first diagnosed with cancer?

Read if necessary: This question refers to the first time they were told about their first cancer.

342-343

M13.03

What type of cancer was it?

CNCRTYP1


Read if respondent needs prompting for cancer type:

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

If C06.06 = 1 (Yes) and M11.01 = 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 C16.06 = 4 (Because you were told you had Prostate Cancer) and Q1 = 1 (Only one) then code 19.

If M13.01 = 2 (Two) or 3 (Three or more), ask: With your most recent diagnoses of cancer, what type of cancer was it?

344-345

M13.04

Are you currently receiving treatment for cancer?

CSRVTRT3


Read if necessary:

1 Yes

Go to next module

Read if necessary: By treatment, we mean surgery, radiation therapy, chemotherapy, or chemotherapy pills.

346

2 No, I’ve completed treatment


3 No, I’ve refused treatment

4 No, I haven’t started treatment

7 Don’t know / Not sure

9 Refused

Go to next module

M13.05

What type of doctor provides the majority of your health care? Is it a….


CSRVDOC1


Read:

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


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.).


Read if necessary: An oncologist is a medical doctor who manages a person’s care and treatment after a cancer diagnosis.

347-348

M13.06

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

CSRVSUM


1 Yes

2 No

7 Don’t know/ not sure

9 Refused


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


349

M13.07

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?

CSRVRTRN


1 Yes




350

2 No

7 Don’t know/ not sure

9 Refused

Go to M13.09

M13.08

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

CSRVINST

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



351

M13.09

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

CSRVINSR

1 Yes

2 No

7 Don’t know/ not sure

9 Refused


Read if necessary: Health insurance also includes Medicare, Medicaid, or other types of state health programs.

352

M13.10

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

CSRVDEIN

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



353

M13.11

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

CSRVCLIN

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



354

M13.12

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

CSRVPAIN

1 Yes



355

2 No

7 Don’t know/ not sure

9 Refused

Go to next module

M13.13

Would you say your pain is currently under control…?

CSRVCTL1

Read:

1 With medication (or treatment)

2 Without medication (or treatment)

3 Not under control, with medication (or treatment)

4 Not under control, without medication (or treatment)

Do not read:

7 Don’t know / Not sure

9 Refused



356



Module 14: Healthcare Access


Question Number

Question text


Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M14.01

What is the primary source of your health care coverage?

HLTHCVR1


Read if necessary:

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

Or

07 Some other source

08 None (no coverage)

Do not read:

77 Don't know/Not sure

99 Refused

Go to C03.02



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.


357-358



Module 15: 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….

ASPIRIN

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



359




Module 16: 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 healthcare provider doctor nurse or other healthcare professional recommended you check your blood pressure outside of the office or at home?

HOMBPCHK

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


By other healthcare provider professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.

360

M16.02

Do you regularly check your blood pressure outside of your healthcare provider professional’s office or at home?

HOMRGCHK

1 Yes



361

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?

WHEREBP

1 Mostly At home

2 Mostly On a machine at a pharmacy, grocery or similar location

3 Do not check it

7 Don’t know / Not sure

9 Refused



362

M16.04

How do you share your blood pressure numbers that you collected with your healthcare professionalprovider? Is it mostly by telephone, other methods such as emails, internet portal or fax, or in person?

SHAREBP

Do not read:

1 Mostly by Telephone

2 Mostly by Other methods such as email, internet portal, or fax, or

3 Mostly In person



363

Do not read:

4 Do not share information

7 Don’t know / Not sure

9 Refused



Module 17: Sodium or Salt-Related Behavior


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M17.01

Are you currently watching or reducing your sodium or salt intake?

WTCHSALT

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused



364

M17.02

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

DRADVISE

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused



365


Module 18: Indoor Tanning



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M18.01


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?

INDORTAN

_ _ _ Number (0-365)

777 Don’t know/ Not sure

999 Refused



366-368









Module 19: Excess Sun Exposure



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M19.01


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

NUMBURN3

_ _ _ Number (0-365)

777 Don’t know/ Not sure

999 Refused



369-371

M19.02

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….

SUNPRTCT

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


Protection from the sun may include using sunscreen, wearing a wide-brimmed hat, or wearing a long-sleeved shirt.

372

M19.03

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

WKDAYOUT

01 Less than half an hour

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

03 (More than 1 hour) up to 2 hours

04 (More than 2 hours) up to 3 hours

05 (More than 3 hours) up to 4 hours

06 (More than 4 hours) up to 5 hours

07 (More than 5) up to 6 hours

77 Don’t know/ Not sure

99 Refused


Friday is a weekday.

If respondent says never, code 01.


373-374

M19.04

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

WKENDOUT

01 Less than half an hour

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

03 (More than 1 hour) up to 2 hours

04 (More than 2 hours) up to 3 hours

05 (More than 3 hours) up to 4 hours

06 (More than 4 hours) up to 5 hours

07 (More than 5) up to 6 hours

77 Don’t know/ Not sure

99 Refused


Friday is a weekday.

If respondent says never, code 01.


375-376





Module 20: Cognitive Decline


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M20.01


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.


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

CIMEMLOS


1 Yes


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


Go to M20.02


377

2 No

Go to next module

7 Don’t know/ not sure

Go to M20.02

9 Refused

Go to next module

M20.02

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…

CDHOUSE


Read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

7 Don't know/Not sure

9 Refused



378

M20.03

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…

CDASSIST


Read:

1 Always

2 Usually

3 Sometimes



379

4 Rarely

5 Never

Do not read:

7 Don't know/Not sure

9 Refused

Go to M20.05

M20.04

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…

CDHELP


Read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

7 Don't know/Not sure

9 Refused



380

M20.05

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…

CDSOCIAL

Read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

7 Don't know/Not sure

9 Refused



381

M20.06

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

CDDISCUS

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



382



Module 21: Caregiver


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M21.01


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?

CAREGIV1


1 Yes


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

383

2 No

7 Don’t know/Not sure

Go to M21.09

8 Caregiving recipient died in past 30 days

Go to next module

9 Refused

Go to M21.09

M21.02

What is his or her relationship to you?

CRGVREL3


01 Mother

02 Father

03 Mother-in-law

04 Father-in-law

05 Child

06 Husband

07 Wife

08 Live-in partner

09 Brother or brother-in-law

10 Sister or sister-in-law

11 Grandmother

12 Grandfather

13 Grandchild

14 Other relative

15 Non-relative/ Family friend

77 Don’t know/Not sure

99 Refused


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

384-385

M21.03

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

CRGVLNG1


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

Do not read:

7 Don’t Know/ Not Sure

9 Refused



386

M21.04

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

CRGVHRS1


Read if necessary:

1 Up to 8 hours per week

2 9 to 19 hours per week

3 20 to 39 hours per week

4 40 hours or more

Do not read:

7 Don’t know/Not sure

9 Refused



387

M21.05

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

CRGVPRB3


01 Arthritis/ rheumatism

02 Asthma

03 Cancer

04 Chronic respiratory conditions such as emphysema or COPD

05 Alzheimer’s disease, dementia or other cognitive impairment disorder

06 Developmental disabilities such as autism, Down’s Syndrome, and spina bifida

07 Diabetes

08 Heart disease, hypertension, stroke

09 Human Immunodeficiency Virus Infection (H.I.V.)

10 Mental illnesses, such as anxiety, depression, or schizophrenia

11 Other organ failure or diseases such as kidney or liver problems

12 Substance abuse or addiction disorders

13 Injuries, including broken bones

14 Old age/ infirmity/frailty

15 Other

77 Don’t know/Not sure

99 Refused

If M21.05 = 5 (Alzheimer’s disease, dementia or other cognitive impairment disorder), go to M21.07.

Otherwise, continue


388-389

M21.06

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

CRGVALZD

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused



390

M21.07

In the past 30 days, did you provide care for this person by managing personal care such as giving medications, feeding, dressing, or bathing?

CRGVPER1

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



391

M21.08

In the past 30 days, did you provide care for this person by managing household tasks such as cleaning, managing money, or preparing meals?

CRGVHOU1

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



392

M21.09

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?

CRGVEXPT

1 Yes

2 No

7 Don’t know/ not sure

9 Refused

If M21.01 = 1 or 8, go to next module


393



Module 22: 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?

ACEDEPRS

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused



394

M22.02

Did you live with anyone who was a problem drinker or alcoholic?

ACEDRINK

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused



395

M22.03

Did you live with anyone who used illegal street drugs or who abused prescription medications?


ACEDRUGS

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused



396

M22.04

Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?

ACEPRISN

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused



397

M22.05

Were your parents separated or divorced?

ACEDIVRC

1 Yes

2 No

8 Parents not married

7 Don’t Know/Not Sure

9 Refused



398

M22.06

How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up?

Was it…

ACEPUNCH

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused



399

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—

ACEHURT1

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused




400

M22.08

How often did a parent or adult in your home ever swear at you, insult you, or put you down? Was it…

ACESWEAR

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused



401

M22.09

How often did anyone at least 5 years older than you or an adult, ever touch you sexually? Was it…

ACETOUCH

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused



402

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…

ACETTHEM

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused



403

M22.11

How often did anyone at least 5 years older than you or an adult, force you to have sex? Was it…

ACEHVSEX

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused




404



Module 23: Family Planning


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M23.01


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

PFPPRVN3

1 Yes

If respondent is female and greater than 49 years of age, has had a hysterectomy (M09.07=1), is pregnant, or if respondent is male go to the next module.


Continue



405

2 No

Go to M23.03

3 No partner/ not sexually active

4 Same sex partner

7 Don’t know / Not sure

9 Refused

Go to next section

M23.02


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

TYPCNTR8

Read if necessary:

01 Female sterilization (ex. Tubal ligation, Essure, Adiana) 02 Male sterilization (vasectomy)

03 Contraceptive implant (ex. Nexplanon, Jadelle, Sino Implant, Implanon)

04 IUD, Levonorgestrel (LNG) or other hormonal (ex. Mirena, Skyla, Liletta, Kylena)

05 IUD, Copper-bearing (ex. ParaGard)

06 IUD, type unknown

07 Shots (ex. Depo-Provera or DMPA)

08 Birth control pills, any kind

09 Contraceptive patch (ex. Ortho Evra, Xulane)

10 Contraceptive ring (ex. NuvaRing)

Go to M23.03

If respondent reports using more than one method, please code the method that occurs first on the list.


If respondent reports using “condoms,” probe to determine if “female condoms” or “male condoms.”


If respondent reports using an “I.U.D.” probe to determine if “levonorgestrel I.U.D.” or “copper-bearing I.U.D.”


If respondent reports “other method,” ask respondent to “please specific” and ensure that their response does not fit into another category. If response does fit into another category, please mark appropriately.



406-407

11 Male condoms

12 Diaphragm, cervical cap, sponge

13 Female condoms

14 Not having sex at certain times (rhythm or natural family planning)

15 Withdrawal (or pulling out)

16 Foam, jelly, film, or cream

17 Emergency contraception (morning after pill)

18 Other method

Do not read:

77 Don’t know/ Not sure

99 Refused

Go to next module

M23.03

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?

NOBCUSE7

Read 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 Do not read:

77 Don’t know/Not sure

99 Refused


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.

408-409




Module 24: Alcohol Screening & Brief Intervention (ASBI)


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M24.01

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?

ASBIALCH

1 Yes

2 No

7 Don’t know/ not sure

9 Refused

If core q3.4 (CHECKUP), = 1 or 2 (had a checkup within the past 2 years) continue, else go to next module.


410

M24.02

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

ASBIDRNK

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



411


M24.03

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

ASBIBING

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



412

M24.04

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

ASBIADVC

1 Yes

2 No

7 Don’t know/ not sure

9 Refused

If question M25.01, 02, or 03 = 1 (yes) continue, else go to next module.]


413

M24.05

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?


ASBIRDUC

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



414




Module 25: Marijuana Use


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M25.01


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

MARIJAN1


_ _ 01-30 Number of days



415-416

88 None

77 Don’t know/not sure

99 Refused

Go to next module

M25.02

During the past 30 days, which one of the following ways did you use marijuana the most often? Did you usually…

USEMRJN2


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), or

6 Use it some other way.

Do not read:

7 Don’t know/not sure

9 Refused


Select one. If respondent provides more than one say: which way did you use it most often.

417

M25.03

When you used marijuana or cannabis during the past 30 days, was it usually:

RSNMRJN1

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), or

3 For both medical and non-medical reasons.

Do not read:

7 Don’t know/Not sure

9 Refused



418



Module 26: Industry and Occupation


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M26.01


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

TYPEWORK

_______Record answer

99 Refused

If C08.15 = 1 (Employed for wages) or 2 (Self-employed) or 4 (Employed for wages or out of work for less than 1 year), continue, else go to next module/section.

If C08.15 = 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.”


Else go to next module

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


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

419-518

M26.02

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

TYPEINDS

_______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.”


519-618


Module 27: 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?

FOODSTMP

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.

619

Module 28: Sex at Birth


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M28.01

What was your sex at birth? Was it male or female?

BIRTHSEX

1 Male

2 Female

7 Don’t know/Not sure

9 Refused

If state does not use option for sex at birth, GOTO C08.06


620



Module 29: Sexual Orientation and Gender Identity


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M29.01a


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

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

SOMALE

READ:

1 = Gay

2 = Straight, that is, not gay

3 = Bisexual

4 = Something else

DO NOT READ:

7 = I don't know the answer/ The respondent did not understand the question

9 = Refused

Ask if Sex= 1.

Read the number of the response to allow respondent to reply with a number.

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


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

If the respondent does not understand the question topic, code 7.

621

M29.01b

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

SOFEMALE

READ:

1 = Lesbian or Gay

2 = Straight, that is, not gay

3 = Bisexual

4 = Something else

DO NOT READ:

7 = I don't know the answer/ Respondent does not understand the question

9 = Refused

Ask if Sex=2.

Read the number of the response to allow respondent to reply with a number.

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


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


If the respondent does not understand the question topic, code 7.

622

M29.02

Do you consider yourself to be transgender?

TRNSGNDR

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

If Yes, read responses 1-3.

Read if necessary: 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.


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.


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


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

623




Module 30: Random Child Selection


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Intro text and screening

If C08.15 > 1 and C08.15 does not equal 88 or 99, 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.


If C08.15 is >1 and C08.15 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.



If C08.15 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module.

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.



M30.01


What is the birth month and year of the [Xth] child?

RCSBIRTH


_ _ /_ _ _ _ Code month and year

77/ 7777 Don’t know / Not sure

99/ 9999 Refused



624-629

M30.02

Is the child a boy or a girl?

RCSGENDR

1 Boy

2 Girl

9 Refused



630

M30.03

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

RCHISLA1

Read if response is yes:

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


If yes, ask: Are they…

631-634

M30.04

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

RCSRACE1

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

[CATI NOTE: IF MORE THAN ONE RESPONSE TO M30.05; CONTINUE. OTHERWISE, GO TO M30.06.]

Select all that apply


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

635-662

M30.05

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

RCSBRAC2

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


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

663-664

M30.06

How are you related to the child? Are you a….

RCSRLTN2

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



665




Module 31: Childhood Asthma Prevalence


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M31.01


The next two questions are about the Xth child.

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

CASTHDX2



1 Yes


If response to C08.15 = 88 (None) or 99 (Refused), go to next module.

Fill in correct [Xth] number.


666

2 No

7 Don’t know/ not sure

9 Refused

Go to next module

M31.02

Does the child still have asthma?

CASTHNO2

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



667









Asthma Call-Back Permission Script


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Text


We would like to call you again within the next 2 weeks to talk in more detail about (your/your child’s) experiences with asthma. The information will be used to help develop and improve the asthma programs in <STATE>. The information you gave us today and any you give us in the future will be kept confidential. If you agree to this, we will keep your first name or initials and phone number on file, separate from the answers collected today. Even if you agree now, you or others may refuse to participate in the future.






CB01.01

Would it be okay if we called you back to ask additional asthma-related questions at a later time?

CALLBACK

1 Yes

2 No




668

CB01.02

Which person in the household was selected as the focus of the asthma call-back?

ADLTCHLD

1 Adult

2 Child



669

CB01.03

Can I please have either (your/your child’s) first name or initials, so we will know who to ask for when we call back?


____________________ Enter first name or initials.







Closing Statement


Read

That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.












49

16 January 2021

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPierannunzi, Carol (CDC/ONDIEH/NCCDPHP)
File Modified0000-00-00
File Created2021-01-16

© 2024 OMB.report | Privacy Policy