0920-1061 2019 BRFSS Questionnaire

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
C03.01		HLTHPLN1	2 No 7 Don’t know/Not Sure 9 Refused			108
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
HYPER.01		BPHIGH4	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		112
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
C06.04	(Ever told) (you had) asthma?	ASTHMA3	2 No 7 Don’t know / Not sure 9 Refused	Go to C06.06		120
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
C06.11	(Ever told) (you had) diabetes?	DIABETE3	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.		127
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
C07.01		HAVARTH3	2 No 7 Don’t know / Not sure 9 Refused	Go to next section		130
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
C08.10		NUMHHOL3	2 No 7 Don’t know / Not sure 9 Refused	Go to C08.13		184
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
C09.01		SMOKE100	2 No 7 Don’t know/Not Sure 9 Refused	Go to C09.05		208
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
C10.01		ALCDAY5	888 No drinks in past 30 days 777 Don’t know / Not sure 999 Refused	Go to next section		214-216
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
C11.01		EXERANY2	2 No 7 Don’t know/Not Sure 9 Refused	Go to C 11.08		223
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
C11.02		EXRACT11	77 Don’t know/ Not Sure 99 Refused	Go to C11.08		224-225
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
C11.05		EXRACT21	88 No other activity 77 Don’t know/ Not Sure 99 Refused	Go to C11.08		232-233
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
C13.01		FLUSHOT7	2 No 7 Don’t know / Not sure 9 Refused	Go to C13.03			261
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
C14.01		HIVTST7	2 No 7 Don’t know/ not sure 9 Refused	Go to C14.03		270
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
M03.01		TOLDCFS	2 No 7 Don’t know / Not sure 9 Refused	Go to next section	My-al-gic En-ceph-a-lo-my-eli-tis	296
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
M04.01		TOLDHEPC	2 No 7 Don’t know / Not sure 9 Refused	Go to HTV.05		299
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
M04.05		HAVEHEPB	2 No 7 Don’t know/ Not sure 9 Refused	Go to next section		303
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
M08.01		LCSFIRST	888 Never smoked cigarettes regularly	Go to M08.04		311-313
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
M09.01		HADMAM	2 No 7 Don’t know/ not sure 9 Refused	Go to M09.03		321
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
M09.03	Have you ever had a Pap test?	HADPAP2	2 No 7 Don’t know / Not sure 9 Refused	Go to M09.05		323
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
M09.05		HPVTEST	2 No 7 Don’t know / Not sure 9 Refused	Go to M09.07	Human papillomarvirus (pap-uh-loh-muh virus)	325
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
M10.04	Have you ever had a P.S.A. test?	PSATEST1	2 No 7 Don’t know / Not sure 9 Refused	Go to next section		331
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
M12.01		BLDSTOOL	2 No 7 Don’t know/ not sure 9 Refused	Go to M12.03		336
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
M12.03		HADSIGM3	2 No 7 Don’t know / Not sure 9 Refused	Go to next section		338
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
M13.01		CNCRDIFF	7 Don’t know / Not sure 9 Refused	Go to next module		341
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
M13.07		CSRVRTRN	2 No 7 Don’t know/ not sure 9 Refused	Go to M13.09		350
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
M13.12		CSRVPAIN	2 No 7 Don’t know/ not sure 9 Refused	Go to next module		355
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

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
M16.02		HOMRGCHK	2 No 7 Don’t know / Not sure 9 Refused	Go to next section		361
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 professional~~provider~~? 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
M16.04		SHAREBP	Do not read: 4 Do not share information 7 Don’t know / Not sure 9 Refused			363

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
M20.03		CDASSIST	4 Rarely 5 Never Do not read: 7 Don't know/Not sure 9 Refused	Go to M20.05		379
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
M23.02		TYPCNTR8	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		406-407
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
M25.01		MARIJAN1	88 None 77 Don’t know/not sure 99 Refused	Go to next module		415-416
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
M31.01		CASTHDX2	2 No 7 Don’t know/ not sure 9 Refused	Go to next module		666
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

2 March 2021

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Modified	0000-00-00
File Created	0000-00-00

0920-1061 2019 BRFSS Questionnaire

2019 Field Test Behavioral Risk Factor Surveillance System (BRFSS)

Attachment 5 2019 BRFSS Questionnaire 11-19

BRFSS Core Survey

OMB: 0920-1061

Table of Contents

OMB Header and Introductory Text

Landline Introduction

Cell Phone Introduction

Core Section 1: Health Status

Core Section 2: Healthy Days

Core Section 3: Healthcare Access

Core Section 4: Hypertension Awareness

Core Section 6: Chronic Health Conditions

Core Section 7: Arthritis

Core Section 8: Demographics

Core Section 9: Tobacco Use

Core Section 10: Alcohol Consumption

Core Section 13: Immunization

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

Closing Statement/ Transition to Modules

Optional Modules

Module 1: Prediabetes

Module 2: Diabetes

Module 3: ME/CFS

Module 4: Hepatitis Treatment

Module 5: HPV - Vaccination

Module 6: Place of Flu Vaccination

Module 7: Shingles Vaccination

Module 8: Lung Cancer Screening

Module 9: Breast and Cervical Cancer Screening

Module 10: Prostate Cancer Screening

Module 11: Prostate Cancer Decision Making

Module 12: Colorectal Cancer Screening

Module 13: Cancer Survivorship

Module 14: Healthcare Access

Module 17: Sodium or Salt-Related Behavior

Module 20: Cognitive Decline

Module 21: Caregiver

Module 22: Adverse Childhood Experiences

Module 23: Family Planning

Module 25: Marijuana Use

Module 28: Sex at Birth

Module 29: Sexual Orientation and Gender Identity

Closing Statement