4 Final HCPS Questionnaire_English_09302019_psg
Health Center Patient Survey (HCPS_
Attachment 1 Final HCPS Questionnaire_English_09302019_psg
Health Center Patient Survey Patient Survey Instrument
OMB: 0915-0368
OMB No. 0915-0368
Exp. XX/XX/20XX
Public Burden Statement: The information collected through the Health Center Patient Survey (HCPS) informs HRSA on how health centers provide access to primary and preventative health care from the patients’ perspectives. It is the only nationally-representative survey of its type that focuses on the health care of populations seeking care at health centers. 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. The OMB control number for this information collection is 0915-0368 and it is valid until XX/XX/XXXX. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].
HCPS Questionnaire - English
MODULE A: INTRODUCTION
INTINTRO. The first few questions are for statistical purposes only, to help us analyze the results of the study.
PRESS 1 TO CONTINUE
[PROGRAMMER: PLACE AT BOTTOM OF THIS FIRST SCREEN:
NOTE: The 60 minute estimate is for an adult interview, 50 for an adolescent interview and 45 for a parent proxy interview. These will need to change based on what type of interview they receive.
……………………………………………………………………………………………………
INT_TEENPAR
INTERVIEWER: IS THIS INTERVIEW WITH THE PARENT/GUARDIAN OF A PATIENT OR THE 13 TO 17-YEAR-OLD PATIENT?
1= PARENT / GUARDIAN OF 13 TO 17-YEAR-OLD PATIENT
2=13 TO 17-YEAR-OLD PATIENT
……………………………………………………………………………………………………
INT_TEENROUT. [IF INT_TEENPAR=1 GO TO INS2, ELSE CONTINUE]
……………………………………………………………………………………………………
INTDOB. What is the month and year that {you were/NAME was} born?
________________ MONTH [ALLOW 01-12]
________________ YEAR [ALLOW 1900–2020]
[PROGRAMMER: CALCULATE AGE BASED ON RESPONSE FROM INTDOB AND POPULATE CALCULATED AGE IN INTAGE_VER. IF INTAGE LESS THAN 12 MONTHS, CODE AS 1 YEAR.]
……………………………………………………………………………………………………
INTAGE_VER.
This would make {you/NAME} {CALCULATED AGE}, is this correct?
1=YES
2=NO
[IF INTAGE_VER=1, POPULATE THE CALCULATED AGE IN INTAGE, ELSE GO TO INTAGE]
……………………………………………………………………………………………………
INTAGE. [IF INTDOB = DK OR RE CONTINUE, ELSE GOTO INT3]
Can you tell me {your/NAME’s} current age?
IF AGE LESS THAN 12 MONTHS CODE AS 1 YEAR.
IF NEEDED: PROBE FOR A BEST ESTIMATE.
________________ AGE IN YEARS [ALLOW 001-109]
[IF INTAGE=DK OR RE, INTAGE_HARDCHECK] This question is important and will help me better route you through the survey. REPEAT QUESTION.
……………………………………………………………………………………………………
INT3. What sex {were you/was NAME} assigned at birth, on {your/NAME’s} original birth certificate?
1=MALE
2=FEMALE
3=DON’T KNOW
4=REFUSED
[IF INTAGE <=12 AND INT3=3 OR 4]: Thank you but we cannot continue with the interview as we need the gender of your child to properly route the survey instrument
[GO TO END (NONINTERVIEW)]
[IF INT3=DK OR REF, INT3_SOFTCHECK] This question is important and will help me better route you through the survey. REPEAT QUESTION.
……………………………………………………………………………………………………
INT4. {Do you/Does NAME} speak a language other than English at home?
1=YES
2=NO
……………………………………………………………………………………………………
INT4a. [IF INT4=1 CONTINUE, ELSE GO TO INT1a]
What other language {do you/does NAME} speak at home?
________________ [ALLOW 40]
……………………………………………………………………………………………………
INT4b. How well {do you/does NAME} speak English? Would you say…?
1=Very well
2=Well
3=Not well
4=Not at all
……………………………………………………………………………………………………
INT1a. {Are you/is NAME} of Hispanic, Latino, or Spanish origin?
1=YES
2=NO
……………………………………………………………………………………………………
INT5. [IF INT1a=1 CONTINUE, ELSE GO TO INT2]
SHOWCARD INT0
Please look at this showcard.
Which of the following best describes {your/NAME’s} Hispanic, Latino or Spanish origin? You may select one or more.
1=Mexican, Mexican American, Mexicano or Chicano
2=Puerto Rican
3=Central American
4=South American
5=Cuban or Cuban American
6=Dominican (From Dominican Republic)
7=Spanish (From Spain)
8=Other Latin American, Hispanic, Latino or Spanish Origin
……………………………………………………………………………………………………
INT5_OTH. [IF INT5=8 CONTINUE, ELSE GO TO INT2]
Please specify {your/NAME’s} Hispanic, Latino or Spanish origin.
________________ [ALLOW 40]
……………………………………………………………………………………………………
INT2. Please look at this showcard. What race or races do you consider {yourself/NAME} to be? You may select one or more.
SHOWCARD INT1
NOTE: CODE “NATIVE AMERICAN” AS “AMERICAN INDIAN”
INTERVIEWER NOTE: IF RESPONDENT PROVIDES A RESPONSE OTHER THAN WHAT IS PROVIDED ON THIS SHOWCARD, PLEASE PROBE: This question is important to our overall analysis, could you again review the showcard to determine a race or races that you consider {yourself/NAME} to be? IF RESPONDENT CANNOT PROVIDE A CATEGORY, SELECT 99 NOT A VALID RESPONSE.
NOTE: IF NEEDED YOU CAN ALSO SELECT [CTRL][M] TO ADD AN INTERVIEWER COMMENT.
1=WHITE
2=BLACK OR AFRICAN AMERICAN
3=AMERICAN INDIAN OR ALASKA NATIVE (AMERICAN INDIAN INCLUDES NORTH AMERICAN, CENTRAL AMERICAN, AND SOUTH AMERICAN INDIANS)
4=NATIVE HAWAIIAN
5=GUAMANIAN OR CHAMORRO
6=SAMOAN
7=TONGAN
8=MARSHALLESE
9=ASIAN INDIAN
10=CHINESE
11=FILIPINO
12=JAPANESE
13=KOREAN
14=VIETNAMESE
15=OTHER ASIAN
16=OTHER NATIVE AMERICAN/AMERICAN INDIAN
17=OTHER PACIFIC ISLANDER
99=NOT A VALID RESPONSE
……………………………………………………………………………………………………
INT2_OTH_ASIAN. [IF INT2=15 CONTINUE, ELSE GO TO INT2_OTH_INDIAN]
Please specify the other Asian race you consider {yourself/NAME} to be.
________________ [ALLOW 40]
……………………………………………………………………………………………………
INT2_OTH_INDIAN. [IF INT2=16 CONTINUE, ELSE GO TO INT2_OTH_PACIFIC]
Please specify the other Native American/American Indian race you consider {yourself/NAME} to be.
________________ [ALLOW 40]
……………………………………………………………………………………………………
INT2_OTH_PACIFIC. [IF INT2=17 CONTINUE, ELSE GO TO INT2_MULTI]
Please specify the other Pacific Islander race you consider {yourself/NAME} to be.
________________ [ALLOW 40]
……………………………………………………………………………………………………
INT2_MULT. [IF MORE THAN ONE RESPONSE TO INT2 CONTINUE, ELSE GO TO MEDINTRO]
Which one of these groups, that is {FILL RESPONSES FROM INT2 AND INT2_OTH} would you say best represents {your/NAME's} race?
[LIST ONLY SELECTIONS MADE IN INT2]
1=WHITE
2=BLACK OR AFRICAN AMERICAN
3=AMERICAN INDIAN OR ALASKA NATIVE (AMERICAN INDIAN INCLUDES NORTH AMERICAN, CENTRAL AMERICAN, AND SOUTH AMERICAN INDIANS)
4=NATIVE HAWAIIAN
5=GUAMANIAN OR CHAMORRO
6=SAMOAN
7=TONGAN
8=MARSHALLESE
9=ASIAN INDIAN
10=CHINESE
11=FILIPINO
12=JAPANESE
13=KOREAN
14=VIETNAMESE
15=OTHER ASIAN
16=OTHER NATIVE AMERICAN/AMERICAN INDIAN
17=OTHER PACIFIC ISLANDER
……………………………………………………………………………………………………
MODULE B: ACCESS TO CARE
MEDINTRO. The next set of questions asks about availability of various types of health services. When answering the next few questions, do not include dental care, prescription medicines, counseling or mental health treatment.
……………………………………………………………………………………………………
MED1. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a doctor or other health professional believe {you/NAME} needed any medical care, tests, or treatment?
1=YES
2=NO
……………………………………………………………………………………………………
MED2. [IF MED1=1 CONTINUE, ELSE GO TO ROUINTRO]
In the last 12 months, {were you/was NAME} unable to get medical care, tests, or treatments you or a doctor or other health professional believed necessary?
1=YES
2=NO
……………………………………………………………………………………………………
MED2a. [IF MED2=1 CONTINUE, ELSE GO TO MED5]
Please look at this showcard. What is the main reason {you were/NAME was} unable to get medical care, tests, or treatments you or a doctor or other health professional believed necessary?
SHOWCARD MED1
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=VA DOES NOT PROVIDE COVERAGE FOR CONDITION
12=OTHER
……………………………………………………………………………………………………
MED2a_OTH. [IF MED2a=12 CONTINUE, ELSE GO TO MED4]
Please specify the other reason {you were/NAME was} unable to get medical care, tests, or treatments you or a doctor or other health professional believed necessary.
_________________ [ALLOW 60]
……………………………………………………………………………………………………
MED4. What kind of care was it that {you/NAME} needed but did not get? CODE ONE OR MORE RESPONSES
SHOWCARD MED4
1= Needed a diagnostic procedure
2= Care for a chronic condition
3= Needed to see a Medical Specialist
4= Needed to obtain Prescription medication
5= Care to address pain
6= Mental health related-issue
7= Some other reason
……………………………………………………………………………………………………
MED4_OTH. [IF MED4=7 CONTINUE, ELSE GO TO MED5]
Please specify the other kind of care {you were/NAME} needed but did not get.
_____________ [ALLOW 60]
……………………………………………………………………………………………………
MED5. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, {were you/was NAME} delayed in getting medical care, tests, or treatments you or a doctor or other health professional believed necessary?
1=YES
2=NO
……………………………………………………………………………………………………
MED5a. [IF MED5=1 CONTINUE, ELSE GO TO ROUINTRO]
Please look at this showcard. What is the main reason {you were/NAME was} delayed in getting medical care, tests, or treatments you or a doctor or other health professional believed necessary?
SHOWCARD MED1
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=VA DOES NOT PROVIDE COVERAGE FOR CONDITION
12=OTHER
……………………………………………………………………………………………………
MED5a_OTH. [IF MED5a=12 CONTINUE, ELSE GO TO MED6]
Please specify the other reason {you were/NAME was} delayed in getting medical care, tests, or treatments you or a doctor or other health professional believed necessary.
_________________ [ALLOW 60]
……………………………………………………………………………………………………
MED6.
What kind of care was it that {you were/NAME was} delayed in getting?
_____________[ALLOW 60]
……………………………………………………………………………………………………
MODULE C: ROUTINE CARE
ROUINTRO. Next, I’m going to ask you about health services that {you/NAME} received in the past 12 months.
1=CONTINUE
……………………………………………………………………………………………………
ROU2. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, how many times {have you/has NAME} gone to a hospital emergency room about {your own/his/her} health? This includes emergency room visits that resulted in a hospital admission.
1 = 1 time
2 = 2 times
3 = 3 times
4 = 4 or more times
5 = Have not gone to an emergency room in the past 12 months
……………………………………………………………………………………………………
ROU2a. [IF ROU2=5 GOTO ROU5, ELSE CONTINUE]
Thinking about {your/NAME’s} most recent emergency room visit, did {you/NAME} go to the emergency room either at night or on the weekend?
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c. Tell me which of these apply to {your/NAME’s} last emergency room visit.
{You/NAME} didn't have another place to go.
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c1. (Tell me which of these apply to {your/NAME’s} last emergency room visit.)
{Your/NAME’s} doctor’s office or clinic was not open.
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c2. (Tell me which of these apply to {your/NAME’s} last emergency room visit.)
{Your/NAME’s} health provider advised you to go.
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c3. (Tell me which of these apply to {your/NAME’s} last emergency room visit.)
The problem was too serious for the doctor’s office or clinic.
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c4. (Tell me which of these apply to {your/NAME’s} last emergency room visit.)
Only a hospital could help {you/NAME}.
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c5. (Tell me which of these apply to {your/NAME’s} last emergency room visit.)
The emergency room was {your/NAME’s} closest provider.
1=YES
2=NO
……………………………………………………………………………………………………
ROU2c6. {Do you/Does NAME} get most of {your/his/her} care at the emergency room?
1=YES
2=NO
……………………………………………………………………………………………………
ROU3. During the past 12 months, (have you/has NAME} been hospitalized overnight? Do not include an overnight stay in the emergency room.
1=YES
2=NO
……………………………………………………………………………………………………
ROU4. [IF ROU3=1 CONTINUE, ELSE GOTO ROU5]
During the last 12 months, how many different times did {did you/did NAME} stay in any hospital overnight or longer?
1 = 1 time
2 = 2 times
2 = 3 to 4 times
3 = 5 to 6 times
4 = 7 or more times
……………………………………………………………………………………………………
ROU5. There are two types of flu vaccinations. One is a shot and the other is a spray, mist, or drop in the nose.
During the past 12 months, {have you/has NAME} had a flu vaccination? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
IF NEEDED: A flu vaccination is usually given in the fall and protects against influenza for the flu season.
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
……………………………………………………………………………………………………
ROU8. [IF INTAGE GE 65 CONTINUE, ELSE GO TO ROU9f2]
Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine. Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
……………………………………………………………………………………………………
ROU9f2. [IF INTAGE=11-64 CONTINUE ELSE GO TO ROU9a]
{Have you/Has NAME} ever received an HPV shot or vaccine? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
IF NEEDED: HPV is Human papillomavirus. The HPV vaccines are called Cervarix or Gardisil. Genital human papillomavirus is the most common sexually transmitted disease
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
……………………………………………………………………………………………………
ROU9a. [IF INTAGE LE 6 YEARS CONTINUE, ELSE GO TO ROU10]
The next few questions are about all of the shots that {NAME} may have received in the last 12 months. This includes shots you may have already told me about.
Did {NAME} receive any shots in the last 12 months? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
……………………………………………………………………………………………………
ROU9e. Has {NAME} received all of the shots recommended for {his/her} age according to the immunization schedule?
INTERVIEWER PROBE: For example, your child has received all of the recommended shots for his/her age.
1=YES
2=NO
……………………………………………………………………………………………………
ROU9f. [IF ROU9e=2 CONTINUE, ELSE GO TO ROU10]
Please look at this showcard. What is the main reason {NAME} has not had all the shots that {he/she} is supposed to have at {his/her} age.
SHOWCARD ROU1
1=DID NOT THINK IT WAS IMPORTANT
2=AFRAID OF THE SIDE EFFECTS OF THE IMMUNIZATION
3=CHILD WAS SICK AND COULD NOT HAVE IMMUNIZATIONS AT THAT TIME
4=I DON’T TRUST THE SHOTS/ I DON’T BELIEVE IN SHOTS
5=COULDN’T AFFORD CARE
6=PROBLEMS GETTING TO DOCTOR'S OFFICE / TRANSPORTATION
7=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
8=COULDN’T GET TIME OFF WORK
9=DIDN’T KNOW WHERE TO GO TO GET CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=OTHER
……………………………………………………………………………………………………
ROU9f_OTH. [IF ROU9f=11 CONTINUE, ELSE GO TO ROU10]
Please specify the other reason {NAME} has not had all the shots that {he/she} is supposed to have at {his/her} age.
________________ [ALLOW 40]
……………………………………………………………………………………………………
ROU10. [IF INTAGE GE 18 CONTINUE, ELSE GO TO ROU12]
These next questions are about general physicals or routine check-ups.
About how long has it been since your last general physical exam or routine check-up by a medical doctor or other health professional? Do not include a visit about a specific problem.
1=NEVER
2=LESS THAN 1 YEAR AGO
3=AT LEAST 1 YEAR BUT LESS THAN 2 YEARS
4=AT LEAST 2 YEARS BUT LESS THAN 3 YEARS
5=AT LEAST 3 YEARS BUT LESS THAN 4 YEARS
6=AT LEAST 4 YEARS BUT LESS THAN 5 YEARS
7=5 OR MORE YEARS AGO
……………………………………………………………………………………………………
ROU11. [IF ROU10=2 OR 3 CONTINUE, ELSE GO TO ROU11a]
Did you get this check-up at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
……………………………………………………………………………………………………
ROU11a. [IF ROU10=1, 4, 5, 6, OR 7 CONTINUE, ELSE GO TO ROU12]
Please look at this showcard. Please describe the reasons you have not had a general physical exam or routine check-up in the past 2 years.
SHOWCARD ROU2
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=VA DOES NOT PROVIDE COVERAGE FOR CONDITION
12=OTHER
……………………………………………………………………………………………………
ROU11a_OTH. [IF ROU11a=11 CONTINUE, ELSE GO TO ROU12]
Please specify the other reason you have not had a general physical exam or routine check-up in the past 2 years.
________________ [ALLOW 40]
……………………………………………………………………………………………………
ROU12. [IF INTAGE LESS THAN 18 CONTINUE, ELSE GO TO ROU14]
These next questions are about well-child check-ups, that is a general check-up, performed when {you were/NAME was} not sick or injured. About how long has it been since {you/he/she} received a well-child or general check-up?
1=NEVER
2=LESS THAN 1 YEAR AGO
3=AT LEAST 1 YEAR BUT LESS THAN 2 YEARS
4=AT LEAST 2 YEARS BUT LESS THAN 3 YEARS
5=AT LEAST 3 YEARS BUT LESS THAN 4 YEARS
6=AT LEAST 4 YEARS BUT LESS THAN 5 YEARS
7=5 OR MORE YEARS AGO
……………………………………………………………………………………………………
ROU13. [IF ROU12=2 OR 3 CONTINUE, ELSE GO TO ROU13a]
Did {you/he/she} get this check-up at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
……………………………………………………………………………………………………
ROU13a. [IF ROU12=1, 4, 5, 6, OR 7 CONTINUE, ELSE GO TO ROU14]
Please look at this showcard. What is the main reason {you have/NAME has} not had a well-child check-up or general check-up in the past year.
SHOWCARD ROU2
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=VA DOES NOT PROVIDE COVERAGE FOR CONDITION
12=OTHER
……………………………………………………………………………………………………
ROU13a_OTH. [IF ROU13a=11 CONTINUE, ELSE GO TO ROU14]
Please specify the other reason {you have/NAME has} not had a well-child check-up or general check-up in the past year.
________________ [ALLOW 40]
……………………………………………………………………………………………………
ROU14. [IF INTAGE LE 5 CONTINUE, ELSE GO TO CON3_VALUE]
Has {NAME} ever had a blood test to check the amount of lead in {his/her} blood? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
……………………………………………………………………………………………………
ROU15. [IF ROU14=1 OR 2 CONTINUE, ELSE GO TO ROU17]
How old was {NAME} the last time this test was done?
IF LESS THAN 1 YEAR, ENTER 1.
______ AGE [ALLOW 00-05]
[PROGRAMMER: NEED AGE CHECK SO AGE REPORTED IS NOT HIGHER THAN ACTUAL AGE REPORTED IN INTAGE EARLIER IN THE INTERVIEW.]
……………………………………………………………………………………………………
ROU17. Has a doctor or other health professional ever talked to you about things that might cause {NAME} to be exposed to lead, such as living in or visiting a house or apartment built before 1978?
1=YES
2=NO
…………………………………………………………………………………………………
MODULE D: CONDITIONS
CON3_VALUE. How tall {are you/is NAME} without shoes?
INTERVIEWER: ENTER RESPONSE NUMBERS
EXAMPLES:
5FT
6IN = 5 6
1.65 METERS = 1 65
165 CENTIMETERS = 0 165
______ _______
[HARD CHECK REQUIRED]
……………………………………………………………………………………………………
CON3_UNITS. (How tall {are you/is NAME} without shoes?)
INTERVIEWER: ENTER RESPONSE UNIT
1=FEET/INCHES
2=METERS/CENTIMETERS
3=CENTIMETERS
[HARD CHECK REQUIRED]
……………………………………………………………………………………………………
CON4. How much {do you/does NAME} weigh without clothes or shoes?
[PROGRAMMERS: ALLOW METRIC; DO NOT ALLOW BLANK RESPONSE]
_______________
[HARD CHECK REQUIRED]
……………………………………………………………………………………………………
CON4_UNITS.
INTERVIEWER: WAS THE RESPONSE IN POUNDS OR KILOGRAMS?
1=POUNDS
2=KILOGRAMS
[HARD CHECK REQUIRED]
……………………………………………………………………………………………………
CON9o.
During the past 7 days, on how many days {were you/was NAME} physically active for a total of at least 60 minutes per day? Add up all the time {your/NAME} spent in any kind of physical activity that increased {your/his/her} heart rate and made {you/him/her} breathe hard some of the time.
1 = 1 day
2 = 2 days
3 = 3 days
4 = 4 days
5 = 5 days
6 = 6 days
7 = 7 days …………………………………………………………………………………………………
CON9x. How often {do you/does NAME} do light or moderate leisure-time physical activities for at least 10 minutes that cause only light sweating or a slight to moderate increase in breathing or heart rate?
IF NEEDED: How many times per day, per week, per month, or per year do you do these activities?
__________TIME(S)
ENTER 88 IF UNABLE TO DO THIS TYPE OF ACTIVITY
ENTER 99 IF NEVER
……………………………………………………………………………………………………
CON9x_UNITS. [IF CON9x=88 OR 99 GO TO CON9N1, ELSE CONTINUE]
(How often {do you/does NAME} do light or moderate leisure-time physical activities for at least 10 minutes that cause only light sweating or a slight to moderate increase in breathing or heart rate?)
INTERVIEWER: ENTER RESPONSE UNIT
1=PER DAY
2=PER WEEK
3=PER MONTH
[HARD CHECK REQUIRED]
……………………………………………………………………………………………………
CON9y. About how long {do you/does NAME} do these light or moderate leisure-time physical activities each time?
__________
ENTER 88 IF UNABLE TO DO THIS TYPE OF ACTIVITY
ENTER 99 IF NEVER
……………………………………………………………………………………………………
CON9y_UNITS. [IF CON9y=88 OR 99 GO TO CON9N1, ELSE CONTINUE]
(About how long {do you/does NAME} do these light or moderate leisure-time physical activities each time?)
INTERVIEWER: ENTER RESPONSE UNIT
1=MINUTES
2=HOURS
[HARD CHECK REQUIRED]
……………………………………………………………………………………………………
CON9z. [IF CON9z=88 OR 99 GO TO CON9N1, ELSE CONTINUE] How often {do you/does NAME} do vigorous leisure-time physical activities for at least 10 minutes that cause heavy sweating or large increases in breathing or heart rate?
IF NEEDED: How many times per day, per week, per month, or per year do you do these activities?
__________TIME(S)
ENTER 88 IF UNABLE TO DO THIS TYPE OF ACTIVITY
ENTER 99 IF NEVER
……………………………………………………………………………………………………
CON9z_UNITS. [IF CON9z=88 OR 99 GO TO CON9N1, ELSE CONTINUE]
(How often {do you/does NAME} do vigorous leisure-time physical activities for at least 10 minutes that cause heavy sweating or large increases in breathing or heart rate?)
INTERVIEWER: ENTER RESPONSE UNIT
1=PER DAY
2=PER WEEK
3=PER MONTH
[HARD CHECK REQUIRED]
……………………………………………………………………………………………………
CON9z1. About how long {do you/does NAME} do these vigorous leisure-time physical activities each time?
__________
……………………………………………………………………………………………………
CON9z1_UNITS. (About how long {do you/does NAME} do these vigorous leisure-time physical activities each time?)
INTERVIEWER: ENTER RESPONSE UNIT
1=MINUTES
2=HOURS
[HARD CHECK REQUIRED]
…………………………………………………………………………………………………
CON9N1. Now I will ask you first about TV watching and then about computer use.
On an average
weekday, about how
much time {do you/does NAME} usually
spend in front of a TV watching TV programs, videos, or playing video
games?
1=LESS THAN 1 HOUR
2=1 HOUR BUT LESS THAN 2 HOURS
3=2 HOURS BUT LESS THAN 3 HOURS
4=3 HOURS BUT LESS THAN 4 HOURS
5=4 HOURS OR MORE
6={DO/DOES NOT} WATCH TV OR VIDEOS
……………………………………………………………………………………………………
CON9n2. On an average weekday, about how much time {do you/does NAME} usually spend with computers, cell phones, handheld videogames and other electronic devices doing things other than work or school?
1=LESS THAN 1 HOUR
2=1 HOUR BUT LESS THAN 2 HOURS
3=2 HOURS BUT LESS THAN 3 HOURS
4=3 HOURS BUT LESS THAN 4 HOURS
5=4 HOURS OR MORE
6 =DO/DOES NOT USE AN ELECTRONIC DEVICE OUTSIDE OF WORK OR SCHOOL
……………………………………………………………………………………………………
CON9n3. On average, how many hours of sleep {do you/does NAME} get in a 24-hour period?
____ HOURS [ALLOW 01 – 20]
……………………………………………………………………………………………………
CON1. Would you say {your/NAME’s} health in general is excellent, very good, good, fair, or poor?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR
……………………………………………………………………………………………………
CON1a. Compared with 12 months ago, that is since {12 MONTH REFERENCE DATE}, would you say {your/NAME’s} health is now better, worse, or about the same?
1=BETTER
2=WORSE
3=ABOUT THE SAME
……………………………………………………………………………………………………
CON2. [IF (INT3=2) AND INTAGE=15-49 CONTINUE, ELSE GO TO CON5]
The next series of questions are about your weight. In order to ask the right questions, we need to know about any possible changes to your body.
Have you ever been pregnant?
2=NO
……………………………………………………………………………………………………
CON2a. [If CON2=1 continue, else go to CON5]
Are you currently pregnant?
1=YES
2=NO
……………………………………………………………………………………………………
CON5. [IF CON2a=1 FILL:] What did you consider yourself to be before you were pregnant, overweight, underweight, or just about right? [ELSE FILL:] Do you consider {yourself/NAME} now to be overweight, underweight, or just about right?
1=OVERWEIGHT
2=UNDERWEIGHT
3=ABOUT RIGHT
……………………………………………………………………………………………………
CON6b. During the past 12 months {have you/has NAME} tried to lose weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON6c. [IF CON6b=1 AND INTAGE GE 13 CONTINUE, ELSE GO TO CON7]
Please look at this showcard. How did you try to lose weight? You may select all that apply.
[ALLOW MULTIPLE RESPONSES]
SHOWCARD CON1
SELECT ALL THAT APPLY
1=CHANGED WHAT I ATE OR HOW MUCH I ATE OR WHEN I ATE
2=EXERCISED
3=JOINED A WEIGHT LOSS PROGRAM
4=TOOK DIET PILLS PRESCRIBED BY A DOCTOR
5=TOOK OTHER PILLS, MEDICINES, HERBS, OR SUPPLEMENTS NOT NEEDING A PRESCRIPTION
6=STARTED TO SMOKE OR BEGAN TO SMOKE AGAIN
7=TOOK LAXATIVES OR VOMITED
8=DRANK A LOT OF WATER
9=CHANGED WHAT I DRANK/REDUCED OR GAVE UP SOFT DRINKS/BEVERAGES WITH SUGAR
10=OTHER
……………………………………………………………………………………………………
CON6c_SPEC. [IF CON6c=10 CONTINUE, ELSE GO TO CON7]
Please describe the other way that you tried to lose weight.
_________[ALLOW 40]
……………………………………………………………………………………………………
CON7. [IF CON5=3: The next few questions ask whether a doctor or other health professional has discussed weight management with {you/name}, regardless of whether {you are /he is/she is} are overweight, underweight or of average weight.]
During the past 12 months, has a doctor or other health professional told you that {you/NAME} had a problem with {your/his/her} weight? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
……………………………………………………………………………………………………
CON8. During the past 12 months, has a doctor or other health professional talked to you about things {you/NAME} can do to manage {your/his/her} weight, such as meal planning and nutrition? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
……………………………………………………………………………………………………
CON8a3. (During the past 12 months, has a doctor or other health professional talked to you about things {you/NAME} can do to manage {your/his/her} weight, such as…)
An exercise program? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
……………………………………………………………………………………………………
CON8a6. (During the past 12 months, has a doctor or other health professional…)
Suggested you visit a nutritionist because of {your/NAME’s} weight? (Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No? )
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
…………………………………………………………………………………………………
CON8b. [If CON8=1 OR 2 or CON8a6=1 OR 2 continue, else go to CON8B1]
Have you made changes to {your/NAME’s} eating and nutrition practices since receiving advice about {your/NAME’s} weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON8b1. [If CON8a3=1 OR 2 continue, else go to CON10]
{Have you/Has NAME} began an exercise program since receiving advice about {your/NAME’s} weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON9a. [IF INTAGE GE 13 CONTINUE, ELSE GO TO CON9c]
Has a doctor or other health professional ever prescribed medications to help you lose weight? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
……………………………………………………………………………………………………
CON9c. In the past 12 months, did you seek help from a personal trainer, dietitian, nutritionist, doctor or other health professional to help {you/NAME} lose weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON10. [IF INTAGE GE 2 CONTINUE, ELSE GO TO CON11_hep]
Now I am going to ask you about certain medical conditions.
Have you ever been told by a doctor or other health professional that {you/NAME} had hypertension, also called high blood pressure?
IF NEEDED: Blood pressure is checked by a health care provider using an electronic automated blood pressure device or blood pressure cuff placed on your upper arm and a stethoscope.
1=YES
2=NO
…………………………………………………………………………………………………
CON10b. About how long has it been since {you/NAME} had {your/his/her} blood pressure checked by a doctor or other health professional?
99=NEVER
_________________
[HARD CHECK REQUIRED]
……………………………………………………………………………………………………
CON10b_UNITS. (About how long has it been since {you/NAME} had {your/his/her} blood pressure checked by a doctor or other health professional?)
INTERVIEWER: ENTER RESPONSE UNIT
1=DAYS AGO
2=WEEKS AGO
3=MONTHS AGO
4=YEARS AGO
88=TODAY
99=NEVER
[HARD CHECK REQUIRED]
……………………………………………………………………………………………………
CON10c. [IF CON10=1 CONTINUE, ELSE GO TO CON11_hep]
During the most recent visit, were you told {you/NAME} had high blood pressure?
1=YES
2=NO
……………………………………………………………………………………………………
CON10d. {Are you/Is NAME} now taking any medications to control {your/his/her} high blood pressure?
1=YES
2=NO
……………………………………………………………………………………………………
CON11_hep. Have you ever been told by a doctor or other health professional that {you/NAME} had hepatitis?
1=YES
2=NO
……………………………………………………………………………………………………
CON11_hep1. [IF CON11_hep=1 CONTINUE, ELSE GO TO CON11a_2]
What types of hepatitis {were you/was NAME} diagnosed with?
SELECT ALL THAT APPLY
1=HEPATITIS A
2=HEPATITIS B
3=HEPATITIS C
……………………………………………………………………………………………………
CON14m_current. [IF CON11_hep1=3 CONTINUE, ELSE GO TO CON11a_2]
{Do you/Does NAME} currently have hepatitis C?
1=YES
2=NO
……………………………………………………………………………………………………
CON11a_2. {Have you/ Has NAME} ever received the hepatitis B vaccine?
IF NEEDED: This is given in three separate doses and has been available since 1991. It is recommended for newborn infants, adolescents, and people such as health care workers, who may be exposed to the hepatitis B virus.
1=YES
2=NO
……………………………………………………………………………………………………
CON11_hepb. [If CON11a_2=1 CONTINUE, ELSE GO TOCON11a_test]
Did {you/NAME} receive at least 3 doses of the hepatitis B vaccine, or less than 3 doses?
1=RECEIVED AT LEAST 3 DOSES
2=RECEIVED LESS THAN 3 DOSES
……………………………………………………………………………………………………
CON11a_test. [IF CON11_hep1=1 OR 3 CONTINUE, ELSE GO TO CON11b_test]
{Have you/Has NAME} ever been tested for hepatitis B? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
……………………………………………………………………………………………………
CON11_b1. [IF CON11a_test=1 OR 2 CONTINUE, ELSE GO TO CON11b_test]
When was (your/NAME’s) most recent test for hepatitis B?
1=3 months ago or less
2=More than 3 months but less than 1 year ago
3=1 year but less than 3 years ago
4=3 or more years ago
……………………………………………………………………………………………………
CON11b_test. [IF CON11_hep1=1 OR 2 CONTINUE, ELSE GO TO CON11 ]
{Have you/Has NAME} ever been tested for hepatitis C? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
……………………………………………………………………………………………………
CON11_c1. [IF CON11b_test=1 OR 2 CONTINUE, ELSE GO TO CON11]
When was (your/NAME’s) most recent test for hepatitis C?
1=3 months ago or less
2=More than 3 months but less than 1 year ago
3=1 year but less than 3 years ago
4=3 or more years ago
……………………………………………………………………………………………………
CON11. Have you ever been told by a doctor or other health professional that {you/NAME} had asthma? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
……………………………………………………………………………………………………
CON11a. [IF CON11=1 OR 2 CONTINUE, ELSE GOTO CON12]
{Do you/Does NAME} still have asthma?
1=YES
2=NO
……………………………………………………………………………………………………
CON11b. [IF CON11a=1 CONTINUE, ELSE GO TO CON12]
During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have you/has NAME} had an episode of asthma or an asthma attack?
1=YES
2=NO
……………………………………………………………………………………………………
CON12. In the past 3 years, has a doctor or other health professional told you that {you/NAME} had diabetes or sugar diabetes?
Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
……………………………………………………………………………………………………
CON12_FAM. Has your/ Has NAME’s} mother, father, brother, or sister ever been told by a doctor or other health professional that they have diabetes or sugar diabetes? Include only blood relatives. Do not include step-relatives or those unrelated by blood.
1=Yes
2=No
3=Unsure
……………………………………………………………………………………………………
CON12a1. [IF CON12=1 OR 2 CONTINUE, ELSE GO TO CON12a]
Were you told that {you/NAME} had Type 1 or Type 2 diabetes?
1=TYPE 1 DIABETES
2=TYPE 2 DIABETES
……………………………………………………………………………………………………
CON12a. [IF CON12=3 CONTINUE, ELSE GO TO CON12b]
Have you ever been told by a doctor or other health professional that (you have/NAME has) pre-diabetes or borderline diabetes?
IF NEEDED: Before people develop type 2 diabetes, they almost always have “prediabetes” in which blood glucose levels are higher than normal but not yet high enough to be diagnosed as diabetes. Doctors sometimes refer to prediabetes as impaired glucose tolerance (IGT) or impaired fasting glucose (IFG), depending on what test was used when it was detected.
1=YES
2=NO
……………………………………………………………………………………………………
CON12b. [IF CON12=1 OR 2 CONTINUE, ELSE GO TO CON13]
How old {were you/was NAME} when a doctor or other health professional first told you that {you/he/she} had diabetes?
________ AGE IN YEARS [ALLOW 000-110]
……………………………………………………………………………………………………
CON12c. [IF CON12=1 OR 2 AND CON2=1 CONTINUE, ELSE GO TO CON13]
Was this only when you were pregnant?
1=YES
2=NO
……………………………………………………………………………………………………
CON13. [IF INTAGE GE 18 CONTINUE, ELSE GO TO CON14a]
These next questions are about blood cholesterol.
About how long has it been since you had your blood cholesterol checked by a doctor or other health professional?
1=NEVER
2=LESS THAN 1 YEAR AGO
3=AT LEAST 1 YEAR BUT LESS THAN 2 YEARS
4=AT LEAST 2 YEARS BUT LESS THAN 3 YEARS
5=AT LEAST 3 YEARS BUT LESS THAN 4 YEARS
6=AT LEAST 4 YEARS BUT LESS THAN 5 YEARS
7=5 OR MORE YEARS AGO
……………………………………………………………………………………………………
CON13a. [IF CON13 = 2, 3, 4, 5, 6, OR 7 CONTINUE, ELSE GO TO CON14a]
Was this at {REFERENCE HEALTH CENTER} or some other place?
1={REFERENCE HEALTH CENTER}
2=SOME OTHER PLACE
……………………………………………………………………………………………………
CON13b. Have you ever been told by a doctor or other health professional that your blood cholesterol level was high?
1=YES
2=NO
……………………………………………………………………………………………………
CON13d. (IF CON13b=1 CONTINUE, ELSE GO TO CON14a)
During the most recent visit, were you told you had high cholesterol?
1=YES
2=NO
……………………………………………………………………………………………………
CON14a. The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told you that {you/he/she} had…
Congestive heart failure?
1=YES
2=NO
……………………………………………………………………………………………………
CON14b. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told you that {you/he/she} had…)
Coronary heart disease or ischemic heart disease?
1=YES
2=NO
……………………………………………………………………………………………………
CON14c. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told you that {you/he/she} had…)
Angina, also called angina pectoris?
1=YES
2=NO
……………………………………………………………………………………………………
CON14d. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told you that {you/he/she} had…)
A heart attack, it is also called myocardial infarction?
1=YES
2=NO
……………………………………………………………………………………………………
CON14e. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told you that {you/he/she} had…)
A stroke or cerebrovascular disease?
1=YES
2=NO
……………………………………………………………………………………………………
CON14f. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told you that {you/he/she} had…)
Chronic obstructive pulmonary disorder (also known as COPD, emphysema or chronic bronchitis)?
1=YES
2=NO
………………………………………………………………………………………
CON14i. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told you that {you/he/she} had…)
Any kind of liver condition other than hepatitis?
1=YES
2=NO
……………………………………………………………………………………………………
CON14j. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told you that {you/he/she} had…)
Weak or failing kidneys?
1=YES
2=NO
……………………………………………………………………………………………………
CON14k. (The next questions are about other health conditions. Please tell me yes or no for the following conditions. Has a doctor or other health professional ever told you that {you/he/she} had…)
Tuberculosis (TB)?
1=YES
2=NO
……………………………………………………………………………………………………
CON9z1a. A traumatic brain injury may result from a bump, blow, or jolt to the head or when an object pierces the skull and enters the brain tissue. Has a doctor or other health professional ever told you that {you have/NAME has} suffered a traumatic brain injury (TBI)?
1=YES
2=NO
……………………………………………………………………………………………………
CON14i_current. [IF CON14i=1 CONTINUE, ELSE GO TO CON14k_current]
{Do you/Does NAME} currently have any kind of liver condition other than hepatitis?
1=YES
2=NO
……………………………………………………………………………………………………
CON14k_current. [IF CON14k=1 CONTINUE, ELSE GO TO CON14k_current1]
{Do you/Does NAME} currently have Tuberculosis (TB)?
1=YES
2=NO
……………………………………………………………………………………………………
CON14k_current1 [IF CON14k_current=1 CONTINUE, ELSE GO TO CON16]
{Do you/Does NAME} currently have active TB?
1=YES
2=NO
……………………………………………………………………………………………………
CON16. During the past 12 months, {have you/ has NAME} had Pneumonia?
1=YES
2=NO
……………………………………………………………………………………………………
CON19. [IF INTAGE GE 2 CONTINUE, ELSE GO TO CON25]
Have you ever been told by a doctor or other health professional that {you/NAME} had cancer or a malignancy of any kind?
1=YES
2=NO
……………………………………………………………………………………………………
CON20. [IF CON19=1 CONTINUE, ELSE GO TO CON25]
Please look at this showcard. What kind of cancer was it? You may select up to 3 kinds of cancer.
SHOWCARD CON2
SELECT UP TO 3 KINDS OF CANCER
1=BLADDER
2=BLOOD
3=BONE
4=BRAIN
5=BREAST
6=CERVIX
7=COLON
8=ESOPHAGUS
9=GALLBLADDER
10=KIDNEY
11=LARYNX-WINDPIPE
12=LEUKEMIA
13=LIVER
14=LUNG
15=LYMPHOMA
16=MELANOMA
17=MOUTH/TONGUE/ LIP
18=OVARY
19=PANCREAS
20=PROSTATE
21=RECTUM
22=SKIN (NON-MELANOMA)
23=SKIN (DON’T KNOW WHAT KIND)
24=SOFT TISSUE (MUSCLE OR FAT)
25=STOMACH
26=TESTIS
27=THROAT - PHARYNX
28=THYROID
29=UTERUS
30=OTHER
……………………………………………………………………………………………………
CON25. The next few questions are about {your/NAME’s} hearing and vision.
{Are you/Is NAME} deaf or {do you/does NAME} have serious difficulty hearing?
1=YES
2=NO
……………………………………………………………………………………………………
CON26. [IF INTAGE GE 2:] {Are you/Is NAME} blind or {do you/does NAME} have serious difficulty seeing, even when wearing glasses?
[IF INTAGE LT 2:] Does {NAME} have any trouble seeing?
1=YES
2=NO
……………………………………………………………………………………………………
CON27a. [IF INTAGE GE 18 CONTINUE, ELSE GO TO CONF1]
The next questions ask about difficulty {you /NAME} may have doing regular activities.
Do you have any difficulty with…
Self-care, such as washing all over or dressing? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?
1=NO DIFFICULTY
2=SOME DIFFICULTY
3=A LOT OF DIFFICULTY
4=UNABLE TO DO THIS ACTIVITY
……………………………………………………………………………………………………
CON27c. Do you have any difficulty with…
Eating? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?
1=NO DIFFICULTY
2=SOME DIFFICULTY
3=A LOT OF DIFFICULTY
4=UNABLE TO DO THIS ACTIVITY
……………………………………………………………………………………………………
CON27d. Do you have any difficulty with…
Getting in or out of bed or chairs? (Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?)
1=NO DIFFICULTY
2=SOME DIFFICULTY
3=A LOT OF DIFFICULTY
4=UNABLE TO DO THIS ACTIVITY
……………………………………………………………………………………………………
CON27e. Do you have any difficulty with…
Using the toilet, including getting to the toilet? (Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?)
1=NO DIFFICULTY
2=SOME DIFFICULTY
3=A LOT OF DIFFICULTY
4=UNABLE TO DO THIS ACTIVITY
……………………………………………………………………………………………………
CON27f. Do you have any difficulty …
Walking or climbing stairs? (Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?)
1=NO DIFFICULTY
2=SOME DIFFICULTY
3=A LOT OF DIFFICULTY
4=UNABLE TO DO THIS ACTIVITY
……………………………………………………………………………………………………
CON28. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?
1=NO DIFFICULTY
2=SOME DIFFICULTY
3=A LOT OF DIFFICULTY
4=UNABLE TO DO THIS ACTIVITY
……………………………………………………………………………………………………
CON28a. 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?
_______ NUMBER OF DAYS
……………………………………………………………………………………………………
CON30. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?
1=NO DIFFICULTY
2=SOME DIFFICULTY
3=A LOT OF DIFFICULTY
4=UNABLE TO DO THIS ACTIVITY
………………………………………………………………………………………………
CON30a. Are you limited in any way because of difficulty remembering or because you experience periods of confusion?
1=YES
2=NO
………………………………………………………………………………………………
CON30b. Because of a physical, mental, or emotional condition, do you have serious difficulty managing your money such as keeping track of expenses or paying bills?
1=YES
2=NO
………………………………………………………………………………………………
CON31a. In the past 12 months, have you fallen?
1=YES
2=NO
………………………………………………………………………………………………
CON31b. [IF CON31a=1 CONTINUE, ELSE GO TO CONF1] In the past 12 months, how many times have you fallen?
________ TIMES [ALLOW 00-99]
………………………………………………………………………………………………
CON32. [IF CON31b GE 1 CONTINUE, ELSE GO TO CONF1]
Were you injured as a result of the fall(s)?
1=YES
2=NO
………………………………………………………………………………………………
CON33. How many of these falls caused an injury that limited your regular activities for at least a day or caused you to go see a doctor or other health professional?
________ TIMES [ALLOW 00-99]
[SOFTCHECK: VALUE IN CON33 MUST BE LESS THAN OR EQUAL TO VALUE IN CON31b]
………………………………………………………………………………………………
MODULE E: CONDITIONS – FOLLOWUP
CONF1. [IF CON10=1 AND CON2=1 CONTINUE, ELSE GO TO CONF1a_a] [IF INTAGE <=12 GOTO CONF1a_a, ELSE CONTINUE]
Earlier you mentioned that you had been told that you had high blood pressure. I’d like to ask a few more questions about that.
Did you only have high blood pressure during pregnancy?
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_a. [IF CON10=1 AND CONF1=2 OR BLANK CONTINUE, ELSE GO TO CON4]
Because of {your/NAME’s} high blood pressure, has a doctor or other health professional ever advised {you/him/her} to…
Go on a diet or change {your/his/her} eating habits to help lower {your/his/her} blood pressure? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CONF1a_a2. {Are you/Is NAME} now following this advice to go on a diet or change {your/his/her} eating habits to help lower {your/his/her} blood pressure?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_b. (Because of {your/NAME’s} high blood pressure, has a doctor or other health professional ever advised {you/him/her} to…)
Cut down on salt or sodium in {your/his/her} diet? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CONF1a_b3. [IF CONF1a_b=1 OR 2 CONTINUE, ELSE GO TO CONF1a_c]
{Are you/Is NAME} now following this advice to cut down on salt or sodium in {your/his/her} diet?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_c. (Because of {your/NAME’s} high blood pressure, has a doctor or other health professional ever advised {you/him/her} to…)
Exercise? (Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?)
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CONF1a_c3. [IF CONF1a_c=1 OR 2 CONTINUE, ELSE GO TO CONF1a_d]
{Are you/Is Name} now following this advice to exercise?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO
………………………………………………………………………………………………
CONF1a_d. [IF INTAGE GE 21 CONTINUE, ELSE GO TO CONF2]
(Because of your high blood pressure, has a doctor or other health professional ever advised you to…)
Cut down on alcohol use? (Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?)
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CONF1a_d3. [IF CONF1a_d=1 OR 2 CONTINUE, ELSE GO TO CONF2]
Are you now following this advice to cut down on alcohol use?
NOTE: IF RESPONSE IS “SOMETIMES” – CODE AS “YES”
1=YES
2=NO
………………………………………………………………………………………………
CONF2. [IF CON10=1 AND CONF1=2 OR BLANK CONTINUE, ELSE GO TO CONF4]
Was any medication ever prescribed by a doctor or other health professional for {your/NAME’s} high blood pressure? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CONF2a. [IF CONF2=1 OR 2 CONTINUE, ELSE GO TO CONF4]
{Are you/Is NAME} now taking any medicine prescribed by a doctor or other health professional for {your/his/her} high blood pressure?
1=YES
2=NO
………………………………………………………………………………………………
CONF2b. [IF CONF2a=2 CONTINUE, ELSE GO TO CONF3]
Did a doctor or other health professional advise you to stop {taking/giving NAME} the medicine?
1=YES
2=NO
………………………………………………………………………………………………
CONF3. Do you regularly check {your/his/her} blood pressure?
1=YES
2=NO
………………………………………………………………………………………………
CONF3a. During the last 6 months, have you received any of the following to teach you how to take care of {your/his/her} high blood pressure…
Contacted by {REFERENCE HEALTH CENTER} through a telephone call, email, or text message?
1=YES
2=NO
………………………………………………………………………………………………
CONF3b. (During the last 6 months, have you received any of the following to teach you how to take care of {your/his/her} high blood pressure…)
An appointment with a nurse at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
……………………………………………………………………………………………
CONF3c. (During the last 6 months, have you received any of the following to teach you how to take care of {your/his/her} high blood pressure…)
A visit from staff at {REFERENCE HEALTH CENTER}? That is, someone came to see you.
1=YES
2=NO
………………………………………………………………………………………………
CONF3d. (During the last 6 months, have you received any of the following to teach you how to take care of {your/his/her} high blood pressure…)
A referral from the {REFERENCE HEALTH CENTER} to see a specialist?
1=YES
2=NO
……………………………………………………………………………………………
CONF3e. In the past year, {have you/has NAME} been in the hospital or visited an emergency room because of high blood pressure?
1=YES
2=NO
………………………………………………………………………………………………
CONF3f. Has any doctor or other health professional (you see/NAME sees) for {your/his/her} high blood pressure given you a plan to manage {your/his/her} own care at home? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CONF3h. [IF CONF3f=1 OR 2 CONTINUE, ELSE GO TO CONF4] How confident are you that you can control and manage {your/his/her} high blood pressure? Are you...
1=Very confident
2=Somewhat confident
3=Not too confident
4=Not at all confident
………………………………………………………………………………………………
CONF4. [IF CON11a=1 CONTINUE, ELSE GO TO CONF5]
Earlier, you indicated that {you/NAME} had been told by a doctor or other health professional that {you/he/she} had asthma. I’d like to ask you a few more questions about that.
1=CONTINUE
………………………………………………………………………………………………
CONF4a. In the past year, {have you/has NAME} been in the hospital or visited an emergency room because of asthma?
1=YES
2=NO
………………………………………………………………………………………………
CONF4b. {Have you\Has NAME} ever used a prescription inhaler?
1=YES
2=NO
………………………………………………………………………………………………
CONF4c. [IF CONF4b=1 CONTINUE, ELSE GO TO CONF4d]
Now I'm going to ask you about two different kinds of asthma medicine. One is for quick relief. The other does not give quick relief but protects the lungs and prevents symptoms over the long term.
During the past 3 months, {have you/has NAME} used the kind of prescription inhaler that {you breathe/he/she breathes} in through {your/his/her} mouth, which gives quick relief from asthma symptoms?
1=YES
2=NO
…………………………………………………………………………………………
CONF4d. {Have you/Has NAME} ever taken the preventive kind of asthma medicine used every day to protect {your/his/her} lungs and keep {you/him/her} from having attacks? Include both oral medicine and inhalers. This is different from inhalers used for quick relief.
1=YES
2=NO
………………………………………………………………………………………………
CONF4e. [IF CONF4d=1 CONTINUE, ELSE GO TO CONF4f]
{Are you/Is NAME} now taking this medication that protects {your/his/her} lungs daily or almost daily?
1=YES
2=NO
………………………………………………………………………………………………
CONF4f. {Have you/Have you or NAME} ever taken a course or class on how to manage asthma {yourself/himself/herself}?
1=YES
2=NO
………………………………………………………………………………………………
CONF4g. Has a doctor or other health professional ever taught {you/NAME} how to….
Recognize early signs or symptoms of an asthma episode?
1=YES
2=NO
………………………………………………………………………………………………
CONF4h. Has a doctor or other health professional ever taught {you/NAME} how to….
Respond to episodes of asthma?
1=YES
2=NO
………………………………………………………………………………………………
CONF4i. (Has a doctor or other health professional ever taught {you/NAME} how to….)
Monitor peak flow for daily therapy?
1=YES
2=NO
………………………………………………………………………………………………
CONF4j. Has a doctor or other health professional ever advised you to change things in your home, school, or work to improve {your/his/her} asthma?
1=YES
2=NO
3=WAS TOLD NO CHANGES NEEDED
………………………………………………………………………………………………
CONF4k1. During the last 6 months, have you received any of the following to teach you how to take care of {your/his/her} asthma…
Contacted by {REFERENCE HEALTH CENTER} through a telephone call, email, or text message?
1=YES
2=NO
………………………………………………………………………………………………
CONF4k2. (During the last 6 months, have you received any of the following to teach you how to take care of {your/his/her} asthma…)
An appointment with a nurse at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF4k3. (During the last 6 months, have you received any of the following to teach you how to take care of {your/his/her} asthma…)
A visit, that is, someone came to see you from {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF4k4. (During the last 6 months, have you received any of the following to teach you how to take care of {your/his/her} asthma…)
A referral to a specialist by {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF4k5. Has a doctor or other health professional treating {you/NAME} for asthma given {you/him/her} a plan to manage {your/his/her} own care at home? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CONF4k7. [IF CONF4k5=1 OR 2 CONTINUE, ELSE GO TO CONF5] How confident are you that you can control and manage {your/his/her} asthma? Are you
1=Very confident
2=Somewhat confident
3=Not too confident
4=Not at all confident
………………………………………………………………………………………………
CONF5. [IF CON12=1 OR 2 CONTINUE, ELSE GO TO CON22]
Earlier, you indicated that {you/NAME} had diabetes. I’d like to ask you a few more questions about that. {Are you/Is NAME} now taking insulin?
1=YES
2=NO
………………………………………………………………………………………………
CONF5a.
{Are you/Is NAME} now taking diabetic pills to lower {your/his/her} blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.
1=YES
2=NO
………………………………………………………………………………………………
CONF5b. How often {do you check your/does NAME check his/her} blood for glucose or sugar? Include times when checked by a family member or friend, but do not include times when checked by a doctor or other health professional. Do not include urine tests.
______ TIMES [ALLOW 0-9]
………………………………………………………………………………………………
CONF5b_UNIT. (How often {do you check your/does NAME check his/her} blood for glucose or sugar?)
INTERVIEWER: ENTER RESPONSE UNIT
1= PER DAY
2= PER WEEK
3= PER MONTH
4= PER YEAR
………………………………………………………………………………………………
CONF5c. Glycosylated (GLY-CO-SYL-AT-ED) hemoglobin or the “A one C” test measures the average level of blood sugar over the past 3 months, and usually ranges between 5 and 14.
During the past 12 months, how many times has a doctor or other health professional checked {you/NAME} for glycosylated hemoglobin or A one C?
NEVER=0
______ TIMES [ALLOW 0-9]
………………………………………………………………………………………………
CONF5d. The last time a doctor or other health professional checked {your/NAME’s} blood sugar level, did he or she tell you it was too high, too low, or just right?
1=TOO HIGH
2=TOO LOW
3=JUST RIGHT
………………………………………………………………………………………………
CONF5e1. During the last 6 months, have you received any of the following to teach {you/NAME} how to take care of {your/his/her} diabetes…
Contacted by {REFERENCE HEALTH CENTER} through a telephone call, email, or text message?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e2. (During the last 6 months, have you received any of the following to teach {you/NAME} how to take care of {your/his/her} diabetes …)
An appointment with a nurse at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e3. (During the last 6 months, have you received any of the following to teach {you/NAME} how to take care of {your/his/her} diabetes …)
A visit, that is, someone came to see {you/NAME} from {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e4. (During the last 6 months, have you received any of the following to teach {you/NAME} how to take care of {your/his/her} diabetes …)
A referral to a specialist by {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e4a. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, {have you/has NAME} had an eye exam by an optometrist, ophthalmologist, eye doctor, or someone who prescribes eyeglasses?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e4b. During the past 12 months, {have you/has NAME} had a foot exam by a foot doctor?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e5. In the past 12 months, {have you/has NAME} been in the hospital or visited an emergency room because of diabetes?
1=YES
2=NO
………………………………………………………………………………………………
CONF5e6. Has any doctor or other health professional {you see/NAME sees} for {your/his/her} diabetes given {you/him/her} a plan to manage {your/his/her} care at home? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CONF5e8. [IF CONF5e6=1 OR 2 CONTINUE, ELSE GO TO CON22] How confident are you that you can control and manage {your/his/her} diabetes? Are you
1=Very confident
2=Somewhat confident
3=Not too confident
4=Not at all confident
………………………………………………………………………………………………
CON22. [IF CON13b=1 CONTINUE, ELSE GO TO CAN1]
Earlier you mentioned that you were told by a doctor or other health professional that your blood cholesterol level was high.
1=CONTINUE
………………………………………………………………………………………………
CON22a. To lower {your/his/her} blood cholesterol, {have you/has NAME} ever been told by a doctor or other health professional…
To eat fewer high fat or high cholesterol foods?
1=YES
2=NO
……………………………………………………………………………………………………
CON22b. (To lower {your/his/her} blood cholesterol, {have you/has NAME} ever been told by a doctor or other health professional…)
To control your weight or lose weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON22c. (To lower {your/his/her} blood cholesterol, {have you/has NAME} ever been told by a doctor or other health professional…)
To increase your physical activity or exercise?
1=YES
2=NO
……………………………………………………………………………………………………
CON22d. (To lower {your/his/her} blood cholesterol, {have you/has NAME} ever been told by a doctor or other health professional…)
To take prescribed medicine?
1=YES
2=NO
……………………………………………………………………………………………………
CON24. [If CON22a=1 OR CON22b=1 OR CON22c=1 OR CON22d=1 CONTINUE, ELSE GO TO CON23a]
Did you ever receive this advice from someone at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
……………………………………………………………………………………………………
CON23a. [IF CON22a=1CONTINUE, ELSE GO TO CON23b]
Are you now following this advice to...
Eat fewer high fat or high cholesterol foods?
1=YES
2=NO
……………………………………………………………………………………………………
CON23b. [IF CON22b=1 CONTINUE, ELSE GO TO CON23c]
Are you now following this advice to...
Control your weight or lose weight?
1=YES
2=NO
……………………………………………………………………………………………………
CON23c. [IF CON22c=1CONTINUE, ELSE GO TO CON23d]
Are you now following this advice to...
Increase your physical activity or exercise?
1=YES
2=NO
……………………………………………………………………………………………………
CON23d. [IF CON22d=1 CONTINUE, ELSE GO TO CAN1]
Are you now following this advice to...
Take prescribed medicine?
1=YES
2=NO
……………………………………………………………………………………………………
MODULE F: CANCER SCREENING
CAN1. [IF INTAGE GE 18 AND INT3=2 CONTINUE]
[IF INTAGE LE 17 GO TO HEA1, ELSE IF INTAGE GE 18 AND INT3=1, DK, OR RE GO TO CAN4]
Next, I’m going to ask you about any cancer screening procedures that you may have had. Have you ever had a Pap smear or Pap test? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
IF NEEDED: A Pap smear or Pap test is a routine test for women in which a doctor or other health professional examines the cervix, takes a cell sample from the cervix with a long Q-tip , and sends it to the lab.
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CAN1a. [IF CAN1=1 OR 2 CONTINUE, ELSE GO TO CAN1b1]
When did you have your most recent Pap smear or Pap test?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO
4=3 YEARS BUT LESS THAN 4 YEARS AGO
5=4 YEARS BUT LESS THAN 5 YEARS AGO
6=5 OR MORE YEARS AGO
………………………………………………………………………………………………
CAN1a1. Did you have your most recent Pap smear or Pap test at {REFERENCE HEALTH CENTER} or somewhere else?
1={REFERENCE HEALTH CENTER}
2=SOMEWHERE ELSE
………………………………………………………………………………………………
CAN1b. What was the main reason you had this Pap smear or Pap test - was it part of a routine exam, because of a problem, or some other reason?
1=PART OF A ROUTINE EXAM
2=BECAUSE OF A PROBLEM
3=SOME OTHER REASON
………………………………………………………………………………………………
CAN1b1. Have you been tested for human papilloma virus or HPV?
IF NEEDED: Genital human papillomavirus is the most common sexually transmitted disease
1=YES
2=NO
………………………………………………………………………………………………
CAN1b2. [IF CAN1b1=1 CONTINUE, ELSE GO TO CAN1c]
When did you have your most recent human papilloma virus or HPV test?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO
4=3 YEARS BUT LESS THAN 4 YEARS AGO
5=4 YEARS BUT LESS THAN 5 YEARS AGO
6=5 OR MORE YEARS AGO
………………………………………………………………………………………………
CAN1b3. Did you have your most recent human papilloma virus or HPV test at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CAN1c. [IF CAN1a=1, 2 OR 3 CONTINUE, ELSE GO TO CAN1c1]
As a result of any of the Pap smear or Pap tests you had done in the past three years, were you told that you should have follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………
CAN1c1. [IF CAN1a=4 OR 5 CONTINUE, ELSE GO TO CAN1d]
As a result of any of the Pap smear or Pap tests you had done in the past three years, were you told that you should have follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………
CAN1d. [IF CAN1c=1 OR CAN1c1=1 CONTINUE, ELSE GO TO CAN3]
Were follow-up tests or treatment arranged? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CAN1f. [IF CAN1d=3 CONTINUE, ELSE GO TO CAN2a]
Please look at this showcard. What is the main reason you did not get the follow-up tests or treatment?
SHOWCARD CAN1
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=VA DOES NOT PROVIDE COVERAGE FOR CONDITION
12=OTHER
………………………………………………………………………………………………
CAN1f1_OTH. [IF CAN1f1=12 CONTINUE, ELSE GO TO CAN2a]
Please specify the other reason you did not get follow-up tests or treatment?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN2a. Has anyone ever suggested that you have a Pap smear or Pap test? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CAN3. [IF INTAGE GE 40 AND INT3=2 CONTINUE, ELSE GO TO CAN4]
Have you ever had a mammogram?
IF NEEDED: A mammogram is an X-ray taken only of the breast by a machine that presses against the breast.
1=YES
2=NO
………………………………………………………………………………………………
CAN3a. [IF CAN3=1 CONTINUE, ELSE GO TO CAN3g]
When did you have your most recent mammogram?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO
4=3 YEARS BUT LESS THAN 5 YEARS AGO
5=5 OR MORE YEARS AGO
………………………………………………………………………………………………
CAN3a1. Did you have your most recent mammogram at {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
CAN3b. What was the main reason you had this mammogram - was it part of a routine exam, because of a problem, or some other reason?
1=PART OF A ROUTINE EXAM
2=BECAUSE OF A PROBLEM
3=SOME OTHER REASON
………………………………………………………………………………………………
CAN3c. [IF CAN3a=1 OR 2 CONTINUE, ELSE GO TO CAN4]
As a result of any mammograms you had done in the past 2 years, were you told that you should have follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………
CAN3d. [IF CAN3c=1 CONTINUE, ELSE GO TO CAN4]
Were follow-up tests or treatment arranged? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CAN3f. [IF CAN3d=3 CONTINUE, ELSE GO TO CAN4]
Please look at this showcard. What is the main reason you did not get the follow-up tests or treatment?
SHOWCARD CAN1
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=VA DOES NOT PROVIDE COVERAGE FOR CONDITION
12=OTHER
………………………………………………………………………………………………
CAN3f_OTH. [IF CAN3f=12 CONTINUE, ELSE GO TO CAN3g]
Please specify the other reason you did not get follow-up tests or treatment?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN3g. [IF CAN3 NE DK, RE CONTINUE, ELSE GO TO CAN3H]
What is the main reason why you have {[IF CAN3=2 FILL:] never had a mammogram? [IF CAN3a=4 OR 5 FILL:] not had a mammogram in the past two years}?
1=NO REASON/ NEVER THOUGHT ABOUT IT/ DIDN’T KNOW I SHOULD
2=NOT NEEDED/ HAVEN’T HAD ANY PROBLEMS
3=TOO UNPLEASANT OR EMBARRASSING
4=COST TOO MUCH/NO INSURANCE
5=BREASTS MISSING
6=OTHER
………………………………………………………………………………………………
CAN3g_OTH. [IF CAN3g=6 CONTINUE, ELSE GO TO CAN3h]
Please specify the main reason why you have {[IF CAN3=2 FILL:] never had a mammogram [IF CAN3a=4 OR 5 FILL:] not had a mammogram in the past two years}?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN3h. Has anyone ever suggested that you have a mammogram? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CAN4. [IF INTAGE GE 50 CONTINUE, ELSE GO TO CAN5]
Colonoscopy (colon-OS-copy) and Sigmoidoscopy (sigmoid-OS-copy) are exams in which a doctor or other health professional inserts a tube into the rectum to look for polyps or cancer. For a colonoscopy, the doctor checks the entire colon, and you are given medication through a needle in your arm to make you sleepy, and told to have someone drive you home. For a Sigmoidoscopy, the doctor checks only part of the colon and you are fully awake.
Have you ever had a colonoscopy? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
IF NEEDED: A polyp is a small growth that develops on the inside of the colon or rectum. Before these tests, you are asked to take a medication that causes diarrhea.
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CAN4a. [IF CAN4=1 OR 2 CONTINUE, ELSE GO TO CAN4b]
When did you have your most recent colonoscopy?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO
4=3 YEARS BUT LESS THAN 5 YEARS AGO
5=5 YEARS BUT LESS THAN 10 YEARS AGO
6=10 OR MORE YEARS AGO
………………………………………………………………………………………………
CAN4b. [IF CAN4=3 OR CAN4a=4, 5, OR 6 CONTINUE, ELSE GO TO CAN4c]
What is the main reason why you have {[IF CAN4=2 FILL:] never had a colonoscopy [IF CAN4a= 4, 5 OR 6 FILL:] not had a more recent colonoscopy}?
1=NO REASON/ NEVER THOUGHT ABOUT IT
2=DIDN'T NEED/ DIDN'T KNOW I NEEDED THIS TYPE OF TEST
3=TOO EXPENSIVE/ NO INSURANCE/ COST
4=TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
5=OTHER
………………………………………………………………………………………………
CAN4b_OTH. [IF CAN4b=5 CONTINUE, ELSE TO GO CAN4i]
Please specify the main reason you have {[IF CAN4=2 FILL:] never had a colonoscopy [IF CAN4a=4, 5 OR 6 FILL:] not had a more recent colonoscopy}?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN4i. Has anyone at {REFERENCE HEALTH CENTER} ever suggested that you should have a colonoscopy?
1=YES
2=NO
………………………………………………………………………………………………
CAN4c. [IF CAN4=1 CONTINUE, ELSE TO GO CAN4g2]
What was the main reason you had this colonoscopy - was it part of a routine exam, because of a problem, as a follow-up test of an earlier test or screening exam, or some other reason?
1=PART OF A ROUTINE EXAM
2=BECAUSE OF A PROBLEM
3=FOLLOW-UP TEST OF AN EARLIER TEST OR SCREENING EXAM
4=SOME OTHER REASON
………………………………………………………………………………………………
CAN4c_OTH. [IF CAN4c=4 CONTINUE, ELSE GO TO CAN4d]
What was the main reason you had this colonoscopy?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN4d. As a result of this exam, were you told that you should have follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………
CAN4e. [IF CAN4d=1 CONTINUE, ELSE GO TO CAN4g2]
Were follow-up tests or treatment arranged? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CAN4g. [IF CAN4e=3 CONTINUE, ELSE GO TO CAN4g2] Please look at this showcard. What is the main reason you did not get the follow-up tests or treatment?
SHOWCARD CAN1
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=VA DOES NOT PROVIDE COVERAGE FOR CONDITION
12=OTHER
………………………………………………………………………………………………
CAN4g_OTH. [IF CAN4g=12 CONTINUE, ELSE GO TO CAN4g2]
Please describe the other reason you did not get the follow-up tests or treatment?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN4g2. Recall that a sigmoidoscopy is similar to a colonoscopy but the doctor or other health professional checks only part of the colon and you are fully awake. Have you ever had a sigmoidoscopy?
1=YES
2=NO
………………………………………………………………………………………………
CAN4g3. [IF CAN4g2=1 CONTINUE, ELSE GO TO CAN4g3a]
When did you have your most recent sigmoidoscopy?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO
4=3 YEARS BUT LESS THAN 5 YEARS AGO
5=5 YEARS BUT LESS THAN 10 YEARS AGO
6=10 OR MORE YEARS AGO
………………………………………………………………………………………………
CAN4g3a. [IF CAN4g2=2 OR CAN4g3=4, 5, OR 6 CONTINUE, ELSE GO TO CAN4g4]
What is the main reason why you have {[IF CAN4g2=2 FILL:] never had a sigmoidoscopy [IF CAN4g3=4, 5 OR 6 FILL:] not had a more recent sigmoidoscopy}?
1=NO REASON/ NEVER THOUGHT ABOUT IT
2=DIDN'T NEED/ DIDN'T KNOW I NEEDED THIS TYPE OF TEST
3=TOO EXPENSIVE/ NO INSURANCE/ COST
4=TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
5=OTHER
………………………………………………………………………………………………
CAN4g3a_OTH. [IF CAN4g3a=5 CONTINUE, ELSE GO TO CAN4g3b]
What is the main reason why you have {[IF CAN4g2=2 FILL:] never had a sigmoidoscopy [IF CAN4g3= 4, 5 OR 6 FILL:] not had a more recent sigmoidoscopy}?
………………………………………………………………………………………………
CAN4g3b. Has anyone ever suggested that you should have a sigmoidoscopy? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CAN4g4. [IF CAN4g2=1 CONTINUE, ELSE GO TO CAN5]
What was the main reason you had this sigmoidoscopy - was it part of a routine exam, because of a problem, as a follow-up test of an earlier test or screening exam, or some other reason?
1=PART OF A ROUTINE EXAM
2=BECAUSE OF A PROBLEM
3=FOLLOW-UP TEST OF AN EARLIER TEST OR SCREENING EXAM
4=SOME OTHER REASON
………………………………………………………………………………………………
CAN4g4_OTH. [IF CAN4g4=4 CONTINUE, ELSE GO TO CAN4g5]
What is the main reason you had this sigmoidoscopy?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN4g5. As a result of this exam, were you told that you should have follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………
CAN4g6. [IF CAN4g5=1 CONTINUE, ELSE GO TO CAN5]
Were follow-up tests or treatment arranged? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CAN4g8. [IF CAN4g6=3 CONTINUE, ELSE GO TO GO TO CAN5] Please look at this showcard. What is the main reason you did not get the follow-up tests or treatment?
SHOWCARD CAN1
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=VA DOES NOT PROVIDE COVERAGE FOR CONDITION
12=OTHER
………………………………………………………………………………………………
CAN4g8_OTH. [IF CAN4g8=12 CONTINUE, ELSE GO TO CAN5]
Please describe the other reason you did not get the follow-up tests or treatment?
________________ [ALLOW 40]
………………………………………………………………………………………………
………………………………………………………………………………………………
[IF INTAGE GE 50 CONTINUE, ELSE GO TO HEA1]
CAN5. The following questions are about the blood stool or occult blood test, a test to determine whether you have blood in your stool or bowel movement. The blood stool test can be done at home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it back to the doctor or lab.
Have you ever had a blood stool test, using a home test kit?
1=YES
2=NO
………………………………………………………………………………………………
CAN5a. [IF CAN5=1 CONTINUE, ELSE GO TO CAN5e2]
When did you have your most recent blood stool test using a kit at home?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO
4=3 YEARS BUT LESS THAN 5 YEARS AGO
5=5 YEARS BUT LESS THAN 10 YEARS AGO
6=10 OR MORE YEARS AGO
………………………………………………………………………………………………
CAN5a1. [IF CAN5a=1, 2, 3 OR 4 CONTINUE, ELSE GO TO CAN5f]
Did {REFERENCE HEALTH CENTER} provide the kit to you?
1=YES
2=NO
………………………………………………………………………………………………
CAN5b. As a result of this test, did you need follow-up tests or treatment?
1=YES
2=NO
………………………………………………………………………………………………
CAN5c. [IF CAN5b=1 CONTINUE, ELSE GO TO CAN5f]
Were follow-up tests or treatment arranged? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
CAN5e. [IF CAN5c= 3 CONTINUE, ELSE GO TO CAN5e2]
Please look at this showcard. What is the main reason you did not get the follow-up tests or treatment?
SHOWCARD CAN1
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE / TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=VA DOES NOT PROVIDE COVERAGE FOR CONDITION
12=OTHER
………………………………………………………………………………………………
CAN5e_OTH. [IF CAN5e=12 CONTINUE, ELSE GO TO CAN5e2]
Please specify the other reason you did not get the follow-up tests or treatments?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN5e2. [IF CAN5=2 OR CAN5a=6 CONTINUE, ELSE GO TO CAN5f]
What is the main reason why you have {(IF CAN5=2 FILL: never had a blood stool test) OR (IF CAN5a=6 FILL have not had a more recent blood stool test)}?
1=NO REASON/ NEVER THOUGHT ABOUT IT
2=DIDN'T NEED/ DIDN'T KNOW I NEEDED THIS TYPE OF TEST
3=TOO EXPENSIVE/ NO INSURANCE/ COST
4=TOO PAINFUL, UNPLEASANT, OR EMBARRASSING
5=OTHER
………………………………………………………………………………………………
CAN5e2_OTH. [IF CAN5e2=5 CONTINUE, ELSE GO TO CAN5e3]
Please specify the other reason why you have never had a blood stool test or have not had one in the specified time frame?
________________ [ALLOW 40]
………………………………………………………………………………………………
CAN5f. Has anyone ever suggested that you should have a blood stool test? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
MODULE G: HEALTH CENTER SERVICES
HEA1. During the past 12 months, that is since {12 MONTH REFERENCE DATE}, how many times have you seen a doctor or other health professional about {your own/NAME’s} health at a doctor’s office, a clinic, or some other place? Do not include times {you were/NAME was} hospitalized overnight, visits to hospital emergency rooms, home visits, or telephone calls. Remember when you answer to think about any doctor’s office or clinic, not just this health center.
NOTE: IF RESPONDENT IS UNSURE - ASK THEM TO PROVIDE AN ESTIMATE
1 = 1 to 2 times
2 = 3 to 4 times
3 = 5 to 7 times
4 = 8 to 10 times
5 = 11 or more times
6 = HAVE NOT SEEN A DOCTOR OR OTHER HEALTH PROFESSIONAL IN PAST 12 MONTHS
………………………………………………………………………………………………
HEA2. [IF HEA1=6 GO TO HEA4, ELSE CONTINUE]
How many of those times did you come to {REFERENCE HEALTH CENTER}?
NOTE: IF RESPONDENT IS UNSURE - ASK THEM TO PROVIDE AN ESTIMATE
1 = 1 to 2 times
2 = 3 to 4 times
3 = 5 to 7 times
4 = 8 to 10 times
5 = 11 or more times 6 = HAVE NOT SEEN A DOCTOR OR OTHER HEALTH PROFESSIONAL AT {REFERENCE HEALTH CENTER} IN PAST 12 MONTHS
………………………………………………………………………………………………
HEA2a. [IF HEA2=6 GOTO HEA4, ELSE CONTINUE]
In the past 12 months, did a medical professional at {REFERENCE HEALTH CENTER} think {you/NAME} should go someplace else to see a different doctor, like a specialist, for a particular health problem?
1=YES
2=NO
………………………………………………………………………………………………
HEA2b. [IF HEA2a=1 CONTINUE, ELSE GO TO HEA4]
If you received more than one referral in the past 12 months, think of the most recent one. Did {you/NAME} see that doctor?
1=YES
2=NO
………………………………………………………………………………………………
HEA2d. [IF HEA2b=2 CONTINUE, ELSE GO TO HEA4]
Please look at this showcard. What is the main reason why {you/NAME} didn't see that doctor?
SHOWCARD HEA1
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE/TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=DO NOT HAVE HEALTH INSURANCE
12=MEDICAID WOULD NOT COVER CARE
13=VA DOES NOT PROVIDE COVERAGE FOR CONDITION
14=OTHER
………………………………………………………………………………………………
HEA2d_OTH. [IF HEA2d=14 CONTINUE, ELSE GO TO HEA4]
Please describe the other reasons why {you/NAME} didn’t see that doctor?
________________ [ALLOW 40]
………………………………………………………………………………………………
HEA4. Please look at this showcard. How did you find out that {you/NAME} could come to {REFERENCE HEALTH CENTER} for services?
SHOWCARD HEA2
1=FRIEND/FAMILY MEMBER/NEIGHBOR TOLD ME
2=FAMILY TOOK YOU/HIM/HER HERE
3=ADVERTISEMENT IN COMMUNITY
4=AT A MEETING
5=CONTACTED BY SOMEONE FROM HEALTH CENTER
6=THROUGH YOUR/HIS/HER INSURANCE
7=SOCIAL SERVICES
8=A DOCTOR OR THE EMERGENCY ROOM
9=YOU FOUND OUT THAT THE HEALTH CENTER ACCEPTS UNINSURED PATIENTS
10=YOU FOUND OUT THAT THE HEALTH CENTER ACCEPTS PATIENTS WITH YOUR INSURANCE.
11=OTHER
………………………………………………………………………………………………
HEA4_OTH. [IF HEA4=11 CONTINUE, ELSE GO TO HEA5a]
Please describe how you found out that {you/NAME} could come here for services.
________________ [ALLOW 40]
………………………………………………………………………………………………
HEA5a. Please look at this showcard. What is the place or places that you usually go to when {you are/NAME is} sick or you need advice about {your/his/her} health?
SHOWCARD HEA3-a
YOU MAY SELECT ONE OR MORE LOCATIONS
1=THIS HEALTH CENTER
2=CLINIC OR HEALTH CENTER OFFERING A DISCOUNT TO LOW INCOME OR UNINSURED PEOPLE
3=OTHER CLINIC OR HEALTH CENTER
4=DOCTOR'S OFFICE OR HMO
5=HOSPITAL EMERGENCY ROOM
6=HOSPITAL OUTPATIENT DEPARTMENT
7=FACILITY OPERATED BY THE VETERAN’S ADMINISTRATION
8=OTHER
………………………………………………………………………………………………
HEA5a_OTH. [IF HEA5a=8 CONTINUE, ELSE GO TO HEA5b]
Please specify what kind of place it is.
________________ [ALLOW 40]
………………………………………………………………………………………………
HEA5b. [IF HEA5a=9 GO TO HEA6]
[IF HEA5a=1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8]: Is this the same place you usually go when (you need/NAME needs} routine or preventive care, such as a physical examination {[IF INTAGE LE 12 ADD:] or well-child check-up?}
[IF HEA5a=MORE THAN ONE RESPONSE]: Are these the same places you usually go when {you need/NAME needs} routine or preventive care, such as a physical examination {[IF INTAGE LE 12 ADD:] or well-child check-up?}
1=YES
2=NO
………………………………………………………………………………………………
HEA5c. [IF HEA5b=2 CONTINUE, ELSE GO TO HEA6]
Please look at this showcard. What kind of {place/IF MORE THAN ONE RESPONSE TO HEA5c places} do you go to when {you need/NAME needs} routine or preventive care, such as a physical examination or check up? You may select one or more.
SHOWCARD HEA3
1=THIS HEALTH CENTER
2=CLINIC OR HEALTH CENTER OFFERING A DISCOUNT TO LOW INCOME OR UNINSURED PEOPLE
3=OTHER CLINIC OR HEALTH CENTER
4=DOCTOR'S OFFICE OR HMO
5=HOSPITAL EMERGENCY ROOM
6=HOSPITAL OUTPATIENT DEPARTMENT
7=FACILITY OPERATED BY THE VETERAN’S ADMINISTRATION
8=OTHER
9=THERE IS NO USUAL PLACE
………………………………………………………………………………………………
HEA5c_OTH. [IF HEA5c=8 CONTINUE, ELSE GO TO HEA6]
Please specify the other kind of {place/IF MORE THAN ONE RESPONSE TO HEA5c USE places} you go to when {you need/NAME needs} routine or preventive care, such as a physical examination or check-up.
________________ [ALLOW 40]
………………………………………………………………………………………………
HEA6. [IF INT4=1 CONTINUE, ELSE GO TO HEA7a]
When {you go/NAME goes} to {REFERENCE HEALTH CENTER}, in what language {does your/does NAME’s} doctor or other health care professional speak to you?
1=ENGLISH
2=SPANISH
3=CANTONESE
4=VIETNAMESE
5=MANDARIN
6=KOREAN
7=ASIAN INDIAN LANGUAGES
8=RUSSIAN
9=TAGALOG
10=OTHER
………………………………………………………………………………………………
HEA6_OTH. [IF HEA6=10 CONTINUE, ELSE GO TO HEA6a]
In what language {does your/ does NAME’s} doctor or other health care professional speak to you?
________________ [ALLOW 40]
………………………………………………………………………………………………
HEA6a. During your last visit to {REFERENCE HEALTH CENTER}, did you need someone to help you understand the doctor?
1=YES
2=NO
………………………………………………………………………………………………
HEA6b. [IF HEA6a=1 CONTINUE, ELSE GO TO HEA7a]
Who was this person who helped you understand the doctor?
IF R RESPONDS “MY CHILD,” PROBE TO SEE IF CHILD IS UNDER AGE 18. IF AGE 18 OR MORE, CODE AS “ADULT FAMILY MEMBER."
1=MINOR CHILD (UNDER AGE 18)
2=AN ADULT FAMILY MEMBER OR FRIEND OF MINE
3=NON-MEDICAL OFFICE STAFF
4=MEDICAL STAFF INCLUDING NURSES/DOCTORS
5=PROFESSIONAL INTERPRETER (BOTH IN PERSON AND ON THE TELEPHONE)
6=OTHER (PATIENTS, SOMEONE ELSE)
7=DID NOT HAVE SOMEONE TO HELP
………………………………………………………………………………………………
HEA6c. [IF HEA6b=5 CONTINUE, ELSE GO TO HEA7a]
Did this person help you in-person or over the telephone?
1=IN PERSON
2=OVER THE TELEPHONE
………………………………………………………………………………………………
HEA6d. How difficult was it for you to find someone to help you understand the doctor?
1=Very difficult
2=Somewhat difficult
3=Not very difficult
4=Not difficult at all
………………………………………………………………………………………………
HEA7a. Has anyone at {REFERENCE HEALTH CENTER} ever helped you...
Arrange for medical appointments or other medical services at a place other than {REFERENCE HEALTH CENTER}?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
………………………………………………………………………………………………
HEA7b. [IF INTAGE 0-12 OR 18-110 CONTINUE, ELSE GO TO HEA7e_a]
Has anyone at {REFERENCE HEALTH CENTER} ever helped you...
Apply for any government benefits {you/NAME} needed such as Medicaid, Food Stamps, Social Security, obtaining welfare, public benefits, or TANF?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
………………………………………………………………………………………………
HEA7c. (Has anyone at {the REFERENCE HEALTH CENTER} ever helped you...)
Get transportation to medical appointments or provided you with tokens or vouchers to help you pay for transportation to {your/NAME’s} medical appointments?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
………………………………………………………………………………………………
HEA7d. (Has anyone at {REFERENCE HEALTH CENTER} ever helped you...)
With basic needs such as:
[IF INTAGE GE 18:] a. finding a place to live?
[IF INTAGE GE 18:] b. finding a job or job counseling?
[IF INTAGE GE 18:] c. finding childcare?
[IF INTAGE GE 18:] d. helping you obtain food?
e. helping {you/NAME} obtain clothing or shoes?
f. helping {you/NAME} obtain free medication?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THIS SERVICE
………………………………………………………………………………………………
HEA7e_a. [IF INTAGE GE 18 CONTINUE, ELSE GO TO HEA7e_b]
(Has anyone at {REFERENCE HEALTH CENTER} ever provided you…)
Health education, either in individual or group visits, to talk about things like quitting smoking or changing your diet?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THIS SERVICE
………………………………………………………………………………………………
HEA7e_b. [IF INTAGE GE 13 CONTINUE, ELSE GO TO HEA7e_c]
Has anyone at {REFERENCE HEALTH CENTER} ever provided you any supportive counseling, such as family counseling, domestic violence counseling, or substance abuse counseling?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THIS SERVICE
………………………………………………………………………………………………
HEA7e_c. [IF INT4b=2, 3, 4, DK OR RE CONTINUE, ELSE GO TO HEA7e_d}
Has anyone at {REFERENCE HEALTH CENTER} ever provided you with a translator or interpreter to help you communicate with {your/NAME’s} doctor or other health care professional? This person could be at the clinic or on the phone.
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THIS SERVICE
………………………………………………………………………………………………
HEA7e_d. Has anyone at {REFERENCE HEALTH CENTER} ever visited {you/NAME} at home to talk about {your/his/her} health care needs or other needs?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THIS SERVICE
………………………………………………………………………………………………
HEA7e_e. Has anyone at {REFERENCE HEALTH CENTER} ever offered {you/NAME} free services outside of the health center, like at a health fair? This could be free flu shots or blood pressure screenings or other services.
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THIS SERVICE
………………………………………………………………………………………………
HEA7e_f. Has anyone at {REFERENCE HEALTH CENTER} ever talked with you about how to set up your home so {you/NAME} can move around safely?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THIS SERVICE
………………………………………………………………………………………………
HEA7f. Has anyone at {REFERENCE HEALTH CENTER} ever helped {you/NAME} with other kinds of problems?
1=YES
2=NO
3=N/A - HAVE NOT NEEDED THESE SERVICES
…………………………………………………………………………………………
HEA8. [IF HEA7f=1 CONTINUE, ELSE GO TO HEA9]
Please specify what kind of help {you/ NAME} received to address these other kinds of problems?
________________ [ALLOW 80]
………………………………………………………………………………………………
HEA9.
IF INTAGE GE 13: How do you usually get to {REFERENCE HEALTH CENTER}?
ELSE IF INTAGE LE 12: How do you usually get {NAME} to the health center?
1=WALKING
2=DRIVING
3=BEING DRIVEN BY SOMEONE ELSE
4=BUS, SUBWAY OR OTHER PUBLIC TRANSPORTATION
5=TAXI
6=HEALTH CENTER (OR OTHER AGENCY-PROVIDED) VAN SERVICE
7=OTHER
………………………………………………………………………………………………
HEA9a. [IF INTAGE GE 13 CONTINUE, ELSE GO TO HEA20]
How many miles do you live from {REFERENCE HEALTH CENTER}?
____________ MILES [ALLOW 3 DIGITS]
………………………………………………………………………………………………
HEA10. About how long does it usually take you to get there?
_____ MINUTES [ALLOW 00-59]
_____ HOURS [ALLOW 0-9]
………………………………………………………………………………………………
HEA12. How long have you been going to {REFERENCE HEALTH CENTER}??
1=LESS THAN 6 MONTHS
2=AT LEAST 6 MONTHS BUT LESS THAN 1 YEAR
3=AT LEAST 1 YEAR BUT LESS THAN 3 YEARS
4=AT LEAST 3 YEARS BUT LESS THAN 5 YEARS
5=AT LEAST 5 YEARS BUT LESS THAN 10 YEARS
6=10 YEARS OR MORE
………………………………………………………………………………………………
HEA13. For the next series of questions, please do not include dental care visits or care you received when you stayed overnight in a hospital.
In the last 12 months, that is since {12 MONTH REFERENCE DATE}, how many times did you go to this health center to get care for yourself?
0=NONE
1=1 TIME
2=2
3=3
4=4
5=5 TO 9
6=10 OR MORE TIMES
………………………………………………………………………………………………
HEA14. Please hold on to this showcard as you may need to reference it for the following questions.
SHOWCARD HEA3-b
In the last 12 months, did you contact this health center to get an appointment for an illness, injury or condition that needed care right away?
1=YES
2=NO
………………………………………………………………………………………………
HEA15. [IF HEA14=1 CONTINUE, ELSE GO TO HEA17]
SHOWCARD HEA3-b
(In the last 12 months…)
When you contacted this health center to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed? Would you say never, sometimes, usually or always?
1=NEVER
2=SOMETIMES
3=USUALLY
4=ALWAYS
………………………………………………………………………………………………
HEA17.
(In the last 12 months…)
Did you make any appointments for a check-up or routine care with this health center?
1=YES
2=NO
………………………………………………………………………………………………
HEA18. [IF HEA17=1 CONTINUE, ELSE GO TO HEA22]
SHOWCARD HEA3-b
(In the last 12 months…)
When you made an appointment for a check-up or routine care with this health center, how often did you get an appointment as soon as you needed? Would you say…
1= Never
2=Sometimes
3=Usually
4=Always
………………………………………………………………………………………………
HEA22.
(In the last 12 months…)
Did you contact this health center with a medical question during regular office hours?
1=YES
2=NO
………………………………………………………………………………………………
HEA23. [IF HEA22=1 CONTINUE, ELSE GO TO HEA24]
SHOWCARD HEA3-b
(In the last 12 months…)
When you contacted this health center during regular office hours, how often did you get an answer to your medical question that same day? Would you say…
1= Never
2=Sometimes
3=Usually
4=Always
………………………………………………………………………………………………
HEA24.
(In the last 12 months…)
Did you contact this health center with a medical question after regular office hours?
1=YES
2=NO
………………………………………………………………………………………………
HEA25. [IF HEA24=1 CONTINUE, ELSE GO TO HEA26]
SHOWCARD HEA3-b
(In the last 12 months…)
When you contacted this health center after regular office hours, how often did you get an answer to your medical question as soon as you needed? Would you say…
1= Never
2=Sometimes
3=Usually
4=Always
………………………………………………………………………………………………
HEA26. Some offices remind patients between visits about tests, treatment or appointments. In the last 12 months, did you get any reminders from this health center between visits?
1=YES
2=NO
………………………………………………………………………………………………
HEA27.
SHOWCARD HEA3-b
Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see a doctor or other health professional at this health center within 15 minutes of your appointment time? Would you say…
1= Never
2=Sometimes
3=Usually
4=Always
………………………………………………………………………………………………
HEA28.
SHOWCARD HEA3-b
(In the last 12 months…)
How often did a doctor or other health professional at this health center explain things in a way that was easy to understand? Would you say…
1= Never
2=Sometimes
3=Usually
4=Always
………………………………………………………………………………………………
HEA29.
SHOWCARD HEA3-b
(In the last 12 months…)
How often did a doctor or other health professional at this health center listen carefully to you? Would you say…
1= Never
2=Sometimes
3=Usually
4=Always
………………………………………………………………………………………………
HEA30.
SHOWCARD HEA3-b
(In the last 12 months…)
Did you talk with a doctor or other health professional at this health center about any health questions or concerns?
1=YES
2=NO
………………………………………………………………………………………………
HEA31. [IF HEA30=1 CONTINUE, ELSE GO TO HEA32]
SHOWCARD HEA3-b
(In the last 12 months…)
How often did a doctor or other health professional at this health center give you easy to understand information about these health questions or concerns? Would you say…
1= Never
2=Sometimes
3=Usually
4=Always
………………………………………………………………………………………………
HEA32.
SHOWCARD HEA3-b
(In the last 12 months…)
How often did a doctor or other health professional at this health center seem to know the important information about your medical history? Would you say…
1= Never
2=Sometimes
3=Usually
4=Always
………………………………………………………………………………………………
HEA33.
SHOWCARD HEA3-b
(In the last 12 months…)
How often did a doctor or other health professional at this health center show respect for what you had to say? Would you say…
1= Never
2=Sometimes
3=Usually
4=Always
………………………………………………………………………………………………
HEA34.
SHOWCARD HEA3-b
(In the last 12 months…)
How often did a doctor or other health professional at this health center spend enough time with you? Would you say…
1= Never
2=Sometimes
3=Usually
4=Always
………………………………………………………………………………………………
HEA35.
(In the last 12 months…)
Did a doctor or other health professional at this health center order a blood test, x-ray, or other test for you?
1=YES
2=NO
………………………………………………………………………………………………
HEA36. [IF HEA35=1 CONTINUE, ELSE GO TO HEA41]
SHOWCARD HEA3-b
(In the last 12 months…)
When a doctor or other health professional at this health center ordered a blood test, x-ray, or other test for you, how often did someone from this health center follow up to give you those results? Would you say…
1= Never
2=Sometimes
3=Usually
4=Always
………………………………………………………………………………………………
HEA41. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate the doctor or other health professional at this health center?
0=WORST PROVIDER POSSIBLE
1
2
3
4
5
6
7
8
9
10= BEST PROVIDER POSSIBLE
………………………………………………………………………………………………
HEA41a. Would you recommend {REFERENCE HEALTH CENTER} to your family and friends? Would you say yes definitely, yes somewhat or no?
1=YES - DEFINITELY
2=YES - SOMEWHAT
3=NO
………………………………………………………………………………………………
HEA51.
SHOWCARD HEA3-b
In the last 12 months, how often were clerks and receptionists at this health center as helpful as you thought they should be? Would you say…
1= Never
2=Sometimes
3=Usually
4=Always
………………………………………………………………………………………………
HEA52.
SHOWCARD HEA3-b
In the last 12 months, how often did clerks and receptionists at this health center treat you with courtesy and respect? Would you say…
1= Never
2=Sometimes
3=Usually
4=Always
………………………………………………………………………………………………
HEA20. Please look at this showcard. What is the main reason {you go/NAME goes} to {REFERENCE HEALTH CENTER} for {your/his/her} health care instead of someplace else?
1=CONVENIENT LOCATION
2=CONVENIENT HOURS
3=YOU CAN AFFORD IT
4= YOU CAN BE SEEN WITHOUT AN APPOINTMENT OR GET AN
APPOINTMENT RIGHT AWAY
5=AFTER YOU GET THERE, YOU DON'T HAVE TO WAIT LONG TO BE SEEN
6=THEY PROVIDE CHILD CARE
7=THEY PROVIDE TRANSPORTATION OR TRANSPORTATION VOUCHERS
8=THEY HAVE SOMEONE WHO SPEAKS YOUR LANGUAGE
9=QUALITY OF CARE
10=IT'S THE ONLY MEDICAL CARE IN THE AREA
11= THE HEALTH CENTER ACCEPTS UNINSURED PATIENTS
12= THE HEALTH CENTER ACCEPTS PATIENTS WITH MY INSURANCE
13=OTHER
………………………………………………………………………………………………
HEA20_OTH. Please specify the other reasons {you go/NAME goes} to {REFERENCE HEALTH CENTER} for {your/NAME’s} health instead of someplace else.
________________ [ALLOW 80]
………………………………………………………………………………………………
HEA57. Please look at this showcard. Many healthcare providers use information technologies to communicate with and provide care services to their patients.
SHOWCARD HEA5
Have you ever used any of the services listed on this card, if provided by {REFERENCE HEALTH CENTER}? You may select all that apply.
SELECT ALL THAT APPLY
1=CALLED TO REMIND {YOU/HIM/HER} OF APPOINTMENT
2=Sending you reminders of appointments or prescription refills by emails or texts
3=Providing a website that allows you to manage {your/HIS/HER} healthcare needs, such as making appointments and checking test results
4=Providing a mobile app that allows you to manage {your/HIS/HER} healthcare needs, such as making appointmentS and checking test results
5=Using social media to provide service information and healthcare advice
6=Another form of communication [excluding telephone calls, in-person communication, or through U.S. mail]
7=THIS HEALTH CENTER DOES NOT PROVIDE ANY OF THESE SERVICES
……………………………………………………………………………………………
HEA57_OTH. [IF HEA57=6CONTINUE, ELSE GO TO INS2] Please specify the other way in which {REFERENCE HEALTH CENTER} communicates with you.
________________ [ALLOW 80]
……………………………………………………………………………………………
MODULE H: HEALTH INSURANCE
INS2.
[IF INT_TEENPAR=1: The first few questions are about {your/NAME’s} current health insurance coverage. In answering these questions, I’d like you to exclude plans that only cover one type of service, like dental care plans or plans that pay for prescription drugs.]
[IF INT_TEENPAR=2: The next questions are about {your/NAME’s} current health insurance coverage. In answering these questions, I’d like you to exclude plans that only cover one type of service, like dental care plans or plans that pay for prescription drugs.]
INS2. {Are you/Is NAME} covered by health insurance provided through an employer or union? This could be insurance through a current job, a former job, or someone else’s job.
1=YES 2=NO |
INS4. Medicare is a health insurance program for people 65 years and older and for people with certain disabilities. {Are you/Is NAME} covered by Medicare?
1=YES 2=NO |
INS5. {FILL STATE} has a number of programs that help low and moderate-income people get health insurance coverage. This would include {MEDICAID PROGRAM NAME} and {SCHIP PROGRAM NAME}. You may know {MEDICAID PROGRAM NAME} under other names, such as Medicaid or other names. You may know {SCHIP PROGRAM NAME} as CHIP. {Are you/Is NAME} covered by {MEDICAID PROGRAM NAME} or {SCHIP PROGRAM NAME}?
1=YES 2=NO
|
INS6. {Are you/Is NAME} covered by a health insurance plan through the {STATE HIE PLAN NAME} that was purchased through {STATE/FEDERAL AGENCY}? IF NEEDED: The {STATE/FEDERAL AGENCY} is a government agency that helps individuals purchase health insurance coverage if they do not have access to health insurance through a job.
1=YES 2=NO
|
INS7. {Are you/Is NAME} covered by a health insurance plan that was purchased directly from an insurance company or an insurance agent, that is, a plan not offered through a current or past employer or union?
1=YES 2=NO
|
INS8. {Are you/Is NAME} covered by some other type of health insurance? For example, coverage for military personnel and their families, such as CHAMPUS, TRICARE, CHAMP-VA and VA?
1=YES 2=NO
[IF INS8=1 GOTO INS10_OTH]
|
INS9. [IF INS2, INS4, INS5, INS6, INS7 AND INS8 = 2, DK, OR RE CONTINUE, ELSE GO TO INS11]
According to the information you have provided, {you do/NAME does} not have any health insurance now. Is that correct?
1=YES 2=NO
|
INS10. [IF INS9 = 2 CONTINUE, ELSE GO TO INS11]
What kind of insurance coverage {do you/does NAME} have? CODE ONE OR MORE
1=Insurance from employer or union 2=Insurance through {STATE HIE PLAN NAME} from {STATE/FEDERAL AGENCY} 3=Insurance purchased directly from an insurance company or agent 4=Medicare 5={MEDICAID PROGRAM NAME}, Medicaid, {SCHIP PROGRAM NAME}, CHIP, or some other public coverage 6=Champus, Tricare, Champ-VA, VA or some other military health care 7=SOME OTHER COVERAGE
|
………………………………………………………………………………………………
INS11. [IF INS2, INS4, INS5, INS6, INS7 OR INS8=1 OR INS9=2 CONTINUE, ELSE GO TO INS14]
During the past 12 months, that is since {12 MONTH REFERENCE DATE}, did {you/ NAME} have health insurance all the time, or was there a time during the year that (you/ NAME} did not have any health coverage?
1=INSURED ALL THE TIME
2=HAD A TIME WITHOUT INSURANCE
………………………………………………………………………………………………
………………………………………………………………………………………………
INS13. [IF INS11=2 CONTINUE, ELSE GO TO INS3a] Please look at this showcard. What was the main reason that {you /NAME} did not have health insurance coverage at that time?
[ALLOW ONLY ONE RESPONSE]
SHOWCARD INS1
1=LOST JOB OR WORKING LESS HOURS
2=GOT A JOB OR WORKING MORE HOURS
3=CHANGED JOBS
4=GOT MARRIED
5=GOT DIVORCED
6=HAD A CHILD
7=GOT SICK OR INJURED
8=COSTS TOO MUCH
9=BECAME ELIGIBLE FOR OTHER COVERAGE
10=BECAME INELIGIBLE FOR COVERAGE
11=OTHER
………………………………………………………………………………………………
INS13_OTH. [IF INS13=11 CONTINUE, ELSE GO TO INS14]
Please specify the other reason that {you /NAME} did not have health insurance coverage?
________________ [ALLOW 40]
………………………………………………………………………………………………
INS14. [IF INS2, INS4, INS5, INS6, INS7 AND INS8 = 2, DK, OR RE AND INS9 = 1 CONTINUE, ELSE GO TO INS15]
Please look at this showcard. When {you/ NAME} last had health insurance coverage, what kind of insurance coverage did {you/ NAME} have?
SHOWCARD INS2
1=INSURANCE FROM EMPLOYER OR UNION
2=INSURANCE THROUGH A STATE HIE PLAN FROM A STATE/FEDERAL AGENCY
3=INSURANCE PURCHASED DIRECTLY FROM AN INSURANCE COMPANY OR AGENT
4=MEDICARE
5=MEDICAID, SCHIP, CHIP, OR SOME OTHER PUBLIC COVERAGE
6=CHAMPUS, TRICARE, CHAMP-VA, VA OR SOME OTHER MILITARY HEALTH CARE
7=SOME OTHER COVERAGE
8=HAVE NEVER HAD INSURANCE
[IF INS14=8, DK, RE GOTO INS25a]
………………………………………………………………………………………………
INS14_OTH. [IF INS14=7 CONTINUE, ELSE GO TO INS15]
Please specify the other type of coverage {you/NAME} last had?
________________ [ALLOW 40]
………………………………………………………………………………………………
INS15. [IF INS14=1, 2, 3, 4, 5, 6, OR 7 CONTINUE, ELSE GO TO INS3a]
Please look at this showcard. What is the main reason that {you are/NAME is} no longer covered by that insurance?
[ALLOW ONLY ONE RESPONSE]
SHOWCARD INS1
1=LOST JOB OR WORKING LESS HOURS
2=GOT A JOB OR WORKING MORE HOURS
3=CHANGED JOBS
4=GOT MARRIED
5=GOT DIVORCED
6=HAD A CHILD
7=GOT SICK OR INJURED
8=COSTS TOO MUCH
9=BECAME ELIGIBLE FOR OTHER COVERAGE
10=BECAME INELIGIBLE FOR COVERAGE
11=OTHER
………………………………………………………………………………………………
INS15_OTH. [IF INS15=11 CONTINUE, ELSE GO TO INS3a]
Please specify the other reason {you are /NAME is} no longer covered by that insurance?
________________ [ALLOW 40]
………………………………………………………………………………………………
INS3a. {IF ONLY ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1 OR INS9 = 2 Does this plan OR ONLY ONE RESPONSE (1-7) IN INS14: Did this plan/ IF MORE THAN ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1 OR INS9 = 2 Do any of these plans OR MORE THAN ONE RESPONSE (1-7) IN INS14: Did any of these plans} pay for any of the costs for medicines prescribed by a doctor?
1=YES
2=NO
………………………………………………………………………………………………
INS3b. {IF ONLY ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1 OR INS9 = 2 Does this plan OR ONLY ONE RESPONSE (1-7) IN INS14: Did this plan/ IF MORE THAN ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1 OR INS9 = 2 Do any of these plans OR MORE THAN ONE RESPONSE (1-7) IN INS14: Did any of these plans} pay for any of the costs for dental care?
1=YES
2=NO
………………………………………………………………………………………………
INS3c. {IF ONLY ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1 OR INS9 = 2 Does this plan OR ONLY ONE RESPONSE (1-7) IN INS14: Did this plan/ IF MORE THAN ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1 OR INS9 = 2 Do any of these plans OR MORE THAN ONE RESPONSE (1-7) IN INS14: Did any of these plans} pay for any of the costs for vision care?
1=YES
2=NO
………………………………………………………………………………………………
INS3d. {IF ONLY ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1 OR INS9 = 2 Does this plan OR ONLY ONE RESPONSE (1-7) IN INS14: Did this plan/ IF MORE THAN ONE OF THE FOLLOWING (INS2, INS4, INS5, INS6, INS7 OR INS8 = 1 OR INS9 = 2 Do any of these plans OR MORE THAN ONE RESPONSE (1-7) IN INS14: Did any of these plans} pay for any of the costs for mental health care?
1=YES
2=NO
………………………………………………………………………………………………
INS19. [IF INS2, INS4, INS5, INS6, INS7 OR INS8=1 OR INS9=2 CONTINUE, ELSE GO TO INS25a]
For my next question, I’d like you to focus on the annual deductible that applies to physician and hospital care within your plan’s network. Does {your/ NAME’s} current health coverage have an annual deductible for medical care? A deductible is the amount you have to pay before the insurance plan will start paying {your/ NAME’s} medical bills.
IF NEEDED: The deductible is different from a co-pay. A co-pay is the payment for a doctor visit or other medical service and a deductible is the amount you pay before your insurance plan will start paying {your/ NAME’s} medical bills.
1=YES
2=NO
………………………………………………………………………………………………
INS21. [IF INS19=1 CONTINUE, ELSE GO TO INS22]
How much is the annual deductible per person under {your/ NAME’s} current health coverage?
Would you say it is…?
1=Less than $100
2=Between $100 and $499
3=Between $500 to $999
4=Between $1,000 to $1,999
5=Between $2,000 to $2,999
6=Between $3,000 to $4,999
7=Between $5000 to $9,999
8=$10,000 or more
………………………………………………………………………………………………
INS22. Do you pay any monthly premiums for {your/NAME’s} health insurance? This includes money deducted from a paycheck as well as money you pay directly to an insurance company.
1=YES
2=NO
………………………………………………………………………………………………
INS23. [IF INS22 = 1 CONTINUE, ELSE GO TO INS25a]
About how much do you pay in monthly premiums, including any amount deducted from a paycheck?
IF NEEDED: This is the premium you pay for the whole plan, even if it covers other family members.
IF NEEDED: Your best estimate is fine.
_____________MONTHLY [ALLOW $1 to $20,000]
………………………………………………………………………………………………
INS24. [IF INS23 = DK OR RE CONTINUE, ELSE GO TO INS25a]
Would you say it is…?
1=Less than $100 a month
2=Between $100 and $249 a month
3=Between $250 to $499 a month
4=Between $500 to $749 a month
5=Between $750 to $999 a month
6=Between $1,000 to $1,499 a month
7=$1,500 or more a month
………………………………………………………………………………………………
INS25a. Now I’d like to ask about how much you and your family spent “out of pocket” for health care in the past 12 months, that is since {12 MONTH REFERENCE DATE}. “Out of pocket” is the amount of money you pay that is not covered by any insurance or special assistance that you might have. It does not include any monthly premiums you pay for your health insurance or any health care costs that you will be reimbursed for.
How much did you and your family spend “out of pocket” in the past 12 months for…
Prescription medicine?
IF NEEDED: The premium is the price you pay for the insurance policy
IF NEEDED: Your best estimate is fine
$____________ [ALLOW $0-$9,999]
………………………………………………………………………………………………
INS25b. (How much did you and your family spend “out of pocket” in the past 12 months for…)
Dental and vision care?
$____________ [ALLOW $0-$9,999]
………………………………………………………………………………………………
INS25c. (How much did you and your family spend “out of pocket” in the past 12 months for…)
All other medical expenses, including doctors, hospitals, tests and equipment?
$___________ [ALLOW $0-$9,999]
MODULE I: PRESCRIPTION MEDICATION
PRS1. [IF INT_TEENPAR=1 GO TO INC1a, ELSE CONTINUE]
The next questions are about prescription medication.
In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a doctor believe {you/NAME} needed prescription medicines?
1=YES
2=NO
………………………………………………………………………………………………
PRS2. [IF PRS1=1 CONTINUE, ELSE GO TO PRS5]
In the last 12 months, {were you/was NAME} unable to get prescription medicines you or a doctor believed necessary?
1=YES
2=NO
………………………………………………………………………………………………
PRS2a [IF PRS2=1 CONTINUE, ELSE GO TO PRS3]
Please look at this showcard. What is the main reason {you were/NAME was} unable to get prescription medicines you or a doctor believed necessary?
SHOWCARD PRS1
1=COULD NOT AFFORD PRESCRIPTION MEDICINES
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR PRESCRIPTION MEDICINES
3=PHARMACY REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO PHARMACY / TRANSPORTATION
5=DIDN’T KNOW WHERE TO GO TO GET PRESCRIPTION MEDICINES
6=PHARMACY DID NOT HAVE IN STOCK
7=VA does not provide coverage for MEDICATION
8= DID NOT HAVE SAFE OR SUITABLE LOCATION TO STORE MEDICATION
9=OTHER
………………………………………………………………………………………………
PRS2a_OTH. [IF PRS2a=9 CONTINUE, ELSE GO TO PRS3]
What was the other reason {you were/NAME was} unable to get prescription medicines you or a doctor believed necessary?
________________ [ALLOW 40]
………………………………………………………………………………………………
PRS3. In the last 12 months, {were you/was NAME} delayed in getting prescription medicines you or a doctor believed necessary?
1=YES
2=NO
………………………………………………………………………………………………
PRS3a. [IF PRS3= 1 CONTINUE, ELSE GO TO PRS5]
Please look at this showcard. What is the main reason {you were/NAME was} delayed in getting prescription medicines you or a doctor believed necessary?
SHOWCARD PRS1
1=COULD NOT AFFORD PRESCRIPTION MEDICINES
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR PRESCRIPTION MEDICINES
3=PHARMACY REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO PHARMACY / TRANSPORTATION
5=DIDN’T KNOW WHERE TO GO TO GET PRESCRIPTION MEDICINES
6=PHARMACY DID NOT HAVE IN STOCK
7= VA does not provide coverage for MEDICATION
8= DID NOT HAVE SAFE OR SUITABLE LOCATION TO STORE MEDICATION
9=OTHER
………………………………………………………………………………………………
PRS3a_OTH. [IF PRS3a=9 CONTINUE, ELSE GO TO PRS5]
What was the other reason {you were/NAME was} delayed in getting prescription medicines you or a doctor believed necessary?
________________ [ALLOW 40]
………………………………………………………………………………………………
………………………………………………………………………………………………
PRS5. {Do you/Does NAME} take any prescription medication on a regular or on-going basis?
1=YES
2=NO
………………………………………………………………………………………………
PRS5a [IF PRS5=1 CONTINUE, ELSE GO TO PRS7a]
Did a doctor or other health professional from {REFERENCE HEALTH CENTER} talk with you about all the prescription and over-the-counter medicines you were taking?
1=YES
2=NO
………………………………………………………………………………………………
PRS6.
Where do you normally get {your/NAME’s} prescriptions filled? Do you get…?
1=them filled at {REFERENCE HEALTH CENTER}
2=some of them filled at {REFERENCE HEALTH CENTER} and some of them filled elsewhere
3=them filled somewhere other than {REFERENCE HEALTH CENTER}
………………………………………………………………………………………………
PRS6a. [IF PRS6=2 OR 3 CONTINUE, ELSE GO TO PRS7]
Can you tell me where you normally get {your/NAME’s} prescriptions filled outside of {REFERENCE HEALTH CENTER}?
1=Drugstore Pharmacy
2=Pharmacy Not attached to A drugstore
3=Health Clinic, Hospital OR Health Center
4=Mail Order Pharmacy
5=Other
………………………………………………………………………………………………
PRS7. About how many different prescription medicines {do you/does NAME} usually take in a month?
2 = 3 TO 4
3 = 5 TO 7
4 = 8 TO 10
5 = 11 OR MORE
………………………………………………………………………………………………
PRS7a. During the past 30 days, did {you/ NAME} have physical pain that interfered with usual activities, such as self-care, work, or recreation?
1 = YES
2 = NO
………………………………………………………………………………………………
PRS7b. [IF PRS7a = 1 CONTINUE, ELSE GO TO PRS8]
During the past 30 days, for about how many days did pain make it hard for {you/ NAME} to do {your/ his/her} usual activities?
________
# OF DAYS [ALLOW 0-30]
………………………………………………………………………………………………
PRS7c. During the past 30 days, did {you/ NAME} need medicine for pain?
1 = YES
2 = NO
………………………………………………………………………………………………
PRS7d. Is {your/NAME’s} pain currently under control? Would you say…
1 = Yes, with
medication or treatment
2 = Yes, without medication or
treatment
3 = No, with medication or treatment
4 = No,
without medication or treatment
………………………………………………………………………………………………
PRS7e. During the past 30 days, how often was {your/NAME’s} pain well controlled? Would you say never, sometimes, usually, or always?
1
= Never
2 = Sometimes
3 = Usually
4 = Always
………………………………………………………………………………………………
PRS8. [IF PRS6=1 OR 2 CONTINUE, ELSE GO TO PRS10]
Think about the last time someone at {REFERENCE HEALTH CENTER} prescribed medication for {you/NAME}. Were you satisfied with the way the medication was explained to you, such as instructions on how to take it and possible side-effects?
1=YES
2=NO
………………………………………………………………………………………………
PRS9. Were you satisfied with the way your questions about the medication were answered?
1=YES
2=NO
3=DIDN’T HAVE ANY QUESTIONS
………………………………………………………………………………………………
PRS10. [IF INTAGE=18 OR OLDER CONTINUE, ELSE GO TO DENPRE]
During the past 12 months, were any of the following true for you?
…You skipped medication doses to save money.
1=YES
2=NO
………………………………………………………………………………………………
PRS11. During the past 12 months, were any of the following true for you?
…You took less medicine to save money.
1=YES
2=NO
……………………………………………………………………………………………
PRS12. (During the past 12 months, were any of the following true for you?)
…You delayed filling a prescription to save money.
1=YES
2=NO
………………………………………………………………………………………………
PRS13. (During the past 12 months, were any of the following true for you?)
…You asked your doctor for a lower cost medication to save money.
1=YES
2=NO
………………………………………………………………………………………………
PRS14. (During the past 12 months, were any of the following true for you?)
…You bought prescription drugs from another country to save money.
1=YES
2=NO
………………………………………………………………………………………………
PRS15. (During the past 12 months, were any of the following true for you?)
…You used alternative therapies to save money.
1=YES
2=NO
………………………………………………………………………………………………
MODULE J: DENTAL
DENPRE. [IF INTAGE GE 1 CONTINUE, ELSE GO TO MEN1]
[IF INTAGE=LE2 CONTINUE, ELSE GO TO DEN1]
Does your child have any baby teeth?
1=YES
2=NO
………………………………………………………………………………………………
DEN1. [IF DENPRE=1 OR INTAGE GE 2 CONTINUE, ELSE GO TO MEN1]
The next questions are about dental care.
In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a dentist believe {you/NAME} needed any dental care, tests, or treatment?
NOTE: CODE YES IF A DOCTOR BELIEVED DENTAL CARE WAS NECESSARY
1=YES
2=NO
………………………………………………………………………………………………
DEN2. [IF DEN1=1 CONTINUE, ELSE GO TO DEN10]
In the last 12 months, {were you/was NAME} unable to get dental care, tests, or treatments you or a dentist believed necessary?
1=YES
2=NO
………………………………………………………………………………………………
DEN3. [IF DEN2=1 CONTINUE, ELSE GO TO DEN6]
What kind of dental care, test, or treatment was it that {you/NAME} needed but did not get? You may select one or more.
SHOWCARD DEN2
SELECT ALL THAT APPLY
1=X-RAYS TAKEN
2=CLEANING TEETH
3=EXAMINATION
4=FILLINGS
5=EXTRACTIONS
6=ROOT CANALS
7=CROWNS OR CAPS
8=BRIDGES, DENTURES, PLATES, ETC. -- EITHER NEW ONES OR REPAIR WORK
9=ORTHODONTIA -- BITE ADJUSTMENT, BRACES, RETAINERS, ETC.
10=PERIODONTIA -- E.G., OF GUM DISEASE TREATMENT
11=BONDING
12=SURGERY
13=OTHER
………………………………………………………………………………………………
DEN4. Please look at this showcard. What is the main reason {you were/NAME was} unable to get dental care, tests, or treatments you or a dentist believed necessary?
SHOWCARD DEN1
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DENTIST REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=COULDN’T GET TIME OFF WORK
5=DIDN’T KNOW WHERE TO GO TO GET CARE
6=WAS REFUSED SERVICES
7=COULDN’T GET CHILD CARE
8=AFRAID OF GOING TO THE DENTIST/ HAVING DENTAL WORK DONE
9=VA does not provide coverage for DENTAL CONDITION
10=OTHER
………………………………………………………………………………………………
DEN4_OTH. [IF DEN4=10 CONTINUE, ELSE GO TO DEN6]
Please specify the other reason {you were/NAME was} unable to get dental care, tests, or treatments you or a dentist believed necessary?
______________________ [ALLOW 40]
………………………………………………………………………………………………
DEN6. In the last 12 months, {were you/was NAME} delayed in getting dental care, tests, or treatments you or a dentist believed necessary?
1=YES
2=NO
………………………………………………………………………………………………
DEN7. [IF DEN6=1 CONTINUE, ELSE GO TO DEN10]
What kind of dental care, test, or treatment was it that {you were/NAME was} delayed in getting? You may select one or more.
SHOWCARD DEN2
PLEASE SELECT ALL THAT APPLY
1=X-RAYS TAKEN
2=CLEANING TEETH
3=EXAMINATION
4=FILLINGS
5=EXTRACTIONS
6=ROOT CANALS
7=CROWNS OR CAPS
8=BRIDGES, DENTURES, PLATES, ETC. -- EITHER NEW ONES OR REPAIR WORK
9=ORTHODONTIA -- BITE ADJUSTMENT, BRACES, RETAINERS, ETC.
10=PERIODONTIA -- E.G., OF GUM DISEASE TREATMENT
11=BONDING
12=SURGERY
13=OTHER
…………………………………………………………………………………………………
DEN8. Please look at this showcard. What is the main reason {you were/NAME was} delayed in getting dental care, tests, or treatments you or a dentist believed necessary?
SHOWCARD DEN1
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DENTIST REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=COULDN’T GET TIME OFF WORK
5=DIDN’T KNOW WHERE TO GO TO GET CARE
6=WAS REFUSED SERVICES
7=COULDN’T GET CHILD CARE
8=AFRAID OF GOING TO THE DENTIST/ HAVING DENTAL WORK DONE
9=VA does not provide coverage for DENTAL CONDITION
10=OTHER
………………………………………………………………………………………………
DEN8_OTH. [IF DEN8=10 CONTINUE, ELSE GO TO DEN10]
Please specify the other reasons {you were/NAME was} delayed in getting dental care, tests, or treatments you or a dentist believed necessary?
_________________ [ALLOW 40]
………………………………………………………………………………………………
DEN10. About how long has it been since {you/NAME} last visited a dentist?
Include all types of dentists, such as, orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.
1=6 MONTHS OR LESS
2=MORE THAN 6 MONTHS, BUT NOT MORE THAN 1 YEAR AGO
3=MORE THAN 1 YEAR, BUT NOT MORE THAN 2 YEARS AGO
4=MORE THAN 2 YEARS, BUT NOT MORE THAN 5 YEARS AGO
5=MORE THAN 5 YEARS AGO
99=NEVER HAVE BEEN
…………………………………………………………………………………………………
DEN10b. [IF INTAGE=18 OR OLDER CONTINUE, ELSE GO TO DEN10e]
Have you ever had an exam for oral cancer in which the doctor or dentist pulls on your tongue, sometimes with gauze wrapped around it, and feels under the tongue and inside the cheeks?
1=YES
2=NO
……………………………………………………………………………………………
DEN10c. Have you ever had an exam for oral cancer in which the doctor or dentist feels your neck?
1=YES
2=NO
……………………………………………………………………………………………
DEN10d. [IF DEN10b=1 OR DEN10c=1 CONTINUE, ELSE GO TO DEN10e]
When did you have your most recent oral or mouth cancer exam? Was it within the past year, between 1 and 3 years ago, or over 3 years ago?
1=WITHIN PAST YEAR
2=BETWEEN 1 AND 3 YEARS AGO
3=OVER 3 YEARS AGO
……………………………………………………………………………………………
DEN10e. [IF DEN10=1 OR 2 CONTINUE, ELSE GO TO DEN13a]
In the past 12 months, what did {you/NAME} have done? You may select one or more.
SHOWCARD DEN2
1=X-RAYS TAKEN
2=CLEANING TEETH
3=EXAMINATION
4=FILLINGS
5=EXTRACTIONS
6=ROOT CANALS
7=CROWNS
8=BRIDGES, DENTURES, PLATES, ETC. -- EITHER NEW ONES OR REPAIR WORK
9=ORTHODONTIA -- BITE ADJUSTMENT, BRACES, RETAINERS, ETC.
10=PERIODONTIA -- E.G., OF GUM DISEASE TREATMENT
11=BONDING
12=SURGERY
13=OTHER
…………………………………………………………………………………………………
DEN11. In the past 12 months, when {you/NAME} did see a dentist, how many of {your/his/her} visits were at {REFERENCE HEALTH CENTER}? Would you say…?
1=All of the visits
2=Some of the visits
3=None of the visits
………………………………………………………………………………………………
DEN12. [IF DEN11=1 OR 2 CONTINUE, ELSE GO TO DEN13]
How would you rate the dental services {you/NAME} received at {REFERENCE HEALTH CENTER}? Using any number from 0 to 10, where 0 is the worst dental care possible and 10 is the best dental care possible, what number would you use to rate all of the dental care {you/NAME} received at {REFERENCE HEALTH CENTER} in the last 12 months?
0 = WORST DENTAL CARE POSSIBLE
1
2
3
4
5
6
7
8
9
10 = BEST DENTAL CARE POSSIBLE
………………………………………………………………………………………………
DEN13. [IF DEN11= 2 OR 3 CONTINUE, ELSE GO TO DEN13a]
{IF DEN11=2: Earlier you mentioned that only some
of {your/NAME’s} dental visits were at {REFERENCE HEALTH
CENTER}}
Were you referred to the other place where {you/ NAME} got dental services by {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
DEN13a. [IF INTAGE GE 13 CONTINUE, ELSE GO TO DEN16a]
In the last 12 months, that is since {12 MONTH REFERENCE DATE}, how often did you and a dental provider talk about specific things you could do to prevent dental problems?
1=Never
2=Sometimes
3=Usually
4=Always
…………………………………………………………………………………………………….
DEN14. [IF INTAGE GE 13 CONTINUE, ELSE GO TO DEN16a]
Now, I have some questions about the condition of your teeth and gums.
The following question asks about the number of adult teeth you have lost. Do not count as "lost" missing wisdom teeth, "baby" teeth, or teeth which were pulled for orthodontia. Have you lost…?
IF ASKED: Orthodontia means straightening the teeth.
1=All of your adult teeth
2=Some of your adult teeth
3=None of your adult teeth
………………………………………………………………………………………………
DEN15. [IF DEN14=2 CONTINUE, ELSE GO TO DEN15a]
How many of your adult teeth have you lost?
1 = 1 TO 2 TEETH
2 = 3 TO 5 TEETH
3 = 6 TO 8 TEETH
4 = 9 TO 10 TEETH
5 = 11 OR MORE TEETH
………………………………………………………………………………………………
DEN15a. [IF DEN14=1 OR 2 CONTINUE, ELSE GO TO DEN16a]
Are any of your missing teeth replaced by full or partial dentures, false teeth, dental implants, bridges or dental plates?
1=YES
2=NO
…………………………………………………………………………………………………
DEN16a. [IF INTAGE LE 12 OR DEN15a=2 CONTINUE, ELSE GO TO DEN16b]
Overall, how would you rate the health of {your/his/her} teeth and gums?
Would you say...?
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor
………………………………………………………………………………………………
DEN16b. [IF DEN15a=1 CONTINUE, ELSE GO TO DEN17a]
Now I have some questions about the condition of your false teeth or dentures. Would you say the condition of your false teeth or dentures is…?
1=Excellent
2=Very Good
3=Good
4=Fair
5=Poor
…………………………………………………………………………………………………
DEN17a. During the past 6 months, that is since {6 MONTH REFERENCE DATE}, {have you/has NAME} had any of the following problems…
A toothache or sensitive teeth?
1=YES
2=NO
………………………………………………………………………………………………
DEN17b. (During the past 6 months, {have you/has NAME} had any of the following problems…)
Bleeding gums?
1=YES
2=NO
………………………………………………………………………………………………
DEN17c. (During the past 6 months, {have you/has NAME} had any of the following problems…)
Crooked teeth?
1=YES
2=NO
………………………………………………………………………………………………
DEN17e. (During the past 6 months, {have you/has NAME} had any of the following problems…)
Broken or missing teeth?
1=YES
2=NO
………………………………………………………………………………………………
DEN17f. (During the past 6 months, {have you/has NAME} had any of the following problems…)
Stained or discolored teeth?
1=YES
2=NO
………………………………………………………………………………………………
DEN17g. (During the past 6 months, {have you/has NAME} had any of the following problems…)
Broken or missing fillings?
1=YES
2=NO
………………………………………………………………………………………………
DEN17h. (During the past 6 months, {have you/has NAME} had any of the following problems…)
[IF INTAGE GE 13, FILL:] Loose teeth not due to injury?
[IF INTAGE LE 12, FILL:] Loose teeth not due to injury or losing baby teeth?
1=YES
2=NO
………………………………………………………………………………………………
DEN18a. During the past 6 months, {have you/has NAME} had any of the following problems that lasted more than a day…
Pain in {your/his/her} jaw joint?
1=YES
2=NO
………………………………………………………………………………………………
DEN18b. (During the past 6 months, {have you/has NAME} had any of the following problems that lasted more than a day…)
Sores in {your/his/her} mouth?
1=YES
2=NO
………………………………………………………………………………………………
DEN18c. (During the past 6 months, {have you/has NAME} had any of the following problems that lasted more than a day…)
Difficulty eating or chewing?
1=YES
2=NO
………………………………………………………………………………………………
DEN18d. (During the past 6 months, {have you/has NAME} had any of the following problems that lasted more than a day…)
Bad breath?
1=YES
2=NO
………………………………………………………………………………………………
DEN18f. (During the past 6 months, {have you/has NAME} had any of the following problems that lasted more than a day…)
Dry mouth?
1=YES
2=NO
………………………………………………………………………………………………
DEN19a. [IF DEN17a, DEN17b, DEN17c, DEN17e, DEN17f, DEN17g, DEN17h, DEN18a, DEN18b, DEN18c, DEN18d OR DEN18f=1 CONTINUE, ELSE GO TO MEN1]
[IF INTAGE GE 5 CONTINUE, ELSE GO TO DEN19b]
Did the problems with {your/NAME’s} mouth or teeth interfere with any of the following...
Job or school?
1=YES
2=NO
3=NOT WORKING / NOT AT SCHOOL
………………………………………………………………………………………………
DEN19b. Did the problems with {your/NAME’s} mouth or teeth interfere with any of the following...
Sleeping?
1=YES
2=NO
………………………………………………………………………………………………
DEN19c. (Did the problems with {your/NAME’s} mouth or teeth interfere with any of the following...)
Social activities such as going out or being with other people?
1=YES
2=NO
………………………………………………………………………………………………
DEN19d. (Did the problems with {your/NAME’s} mouth or teeth interfere with any of the following...)
Usual activities at home?
1=YES
2=NO
3=DON'T HAVE A HOME
………………………………………………………………………………………………
MODULE K: MENTAL HEALTH
MEN1. [IF INTAGE GE 18 CONTINUE, ELSE GO TO MEN2_AUT]
The next questions are about feelings you may have experienced over the past 30 days. Your answers to these questions are private and will not be shared with anyone at {REFERENCE HEALTH CENTER}. You also have the right to refuse any question that you do not want to answer.
1=CONTINUE
………………………………………………………………………………………………
MEN1a. Please look at this showcard. During the past 30 days, how often did you feel…
So sad that nothing could cheer you up?
SHOWCARD MEN1
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1b. (During the past 30 days, how often did you feel…)
Nervous?
SHOWCARD MEN1
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1c. (During the past 30 days, how often did you feel…)
Restless or fidgety?
SHOWCARD MEN1
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1d. (During the past 30 days, how often did you feel…)
Hopeless?
SHOWCARD MEN1
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1e. (During the past 30 days, how often did you feel…)
That everything was an effort?
SHOWCARD MEN1
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN1f. (During the past 30 days, how often did you feel…)
Worthless?
SHOWCARD MEN1
1=ALL OF THE TIME
2=MOST OF THE TIME
3=SOME OF THE TIME
4=A LITTLE OF THE TIME
5=NONE OF THE TIME
………………………………………………………………………………………………
MEN2. We just talked about a number of feelings you had during the past 30 days. Altogether, how much did these feelings interfere with your life or activities? Would you say: a lot, some, a little, or not at all?
1=A LOT
2=SOME
3=A LITTLE
4=NOT AT ALL
………………………………………………………………………………………………
MEN2_AUT. [IF INTAGE LE 17 CONTINUE, ELSE GO TO MEN3] Has a doctor or health professional ever told you that {you have / NAME has} ...
Autism,
Asperger’s disorder, pervasive developmental disorder, or
autism spectrum disorder?
1=YES
2=NO
………………………………………………………………………………………………
MEN2_DD. Has a doctor or health professional ever told you that {you have / NAME has} ...
Any other developmental delay?
1=YES
2=NO
………………………………………………………………………………………………
MEN2_ADHD.
{Do you/Does NAME} have Attention Deficit Hyperactivity Disorder
(ADHD) or Attention Deficit Disorder (ADD)?
1=YES
2=NO
………………………………………………………………………………………………
MEN2_HAVID.
{Do you/Does NAME} have an Intellectual disability, also known as
mental retardation?
1=YES
2=NO
………………………………………………………………………………………………
MEN2_HAVAUT. {Do you/Does NAME} have autism, asperger’s disorder, pervasive developmental disorder, or autism spectrum disorder?
1=YES
2=NO
………………………………………………………………………………………………
MEN3. [IF INTAGE=2 OR 3 CONTINUE, ELSE GO TO MEN3g]
The next questions are about feelings {NAME} may have experienced. Your answers to these questions are private and will not be shared with anyone at {REFERENCE HEALTH CENTER}. You also have the right to refuse any question that you do not want to answer.
I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true of {NAME} during the past 2 months.
1=CONTINUE
………………………………………………………………………………………………
MEN3a.
Has been uncooperative?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3b (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true of {NAME} during the past 2 months.)
Has trouble getting to sleep?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3c. (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true of {NAME} during the past 2 months.)
Has speech problems?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3d. (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true of {NAME} during the past 2 months.)
Has been unhappy, sad, or depressed?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3e. (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true of {NAME} during the past 2 months.)
Has temper tantrums or a hot temper?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3f. (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true of {NAME} during the past 2 months.)
Has been nervous or high-strung?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3g. [IF INTAGE=4-12 CONTINUE, ELSE GO TO MEN4a]
The next questions are about feelings {NAME} may have experienced. Your answers to these questions are private and will not be shared with anyone at {REFERENCE HEALTH CENTER}. You also have the right to refuse any question that you do not want to answer.
I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true, of {NAME} during the past 2 months.
Doesn’t get along with other kids?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3h. (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true, of {NAME} during the past 2 months.)
Can’t concentrate or pay attention long?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3i. (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true, of {NAME} during the past 2 months.)
Feels worthless or inferior?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3j. (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true, of {NAME} during the past 2 months.)
Has been unhappy, sad, or depressed?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3k. (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true, of {NAME} during the past 2 months.)
Has been nervous, high-strung or tense?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN3l. (I am going to read a list of items that describe children. For each one, tell me if it has been not true, sometimes true, or often true, of {NAME} during the past 2 months.)
Acts too young for {his/her} age?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4a. [IF INTAGE=13-17 CONTINUE, ELSE GO TO MEN2a]
The next questions are about feelings you may have experienced. Your answers to these questions are private and will not be shared with anyone at {REFERENCE HEALTH CENTER}. You also have the right to refuse any question that you do not want to answer.
I am going to read a list of items that describe teenagers. For each one, tell me if it has been not true, sometimes true, or often true, of you during the past 2 months.
You can’t concentrate or pay attention long?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4b. (I am going to read a list of items that describe teenagers. For each one, tell me if it has been not true, sometimes true, or often true, of you during the past 2 months.)
You lie or cheat?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4c. (I am going to read a list of items that describe teenagers. For each one, tell me if it has been not true, sometimes true, or often true, of you during the past 2 months.)
You don’t get along with other kids?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4d (I am going to read a list of items that describe teenagers. For each one, tell me if it has been not true, sometimes true, or often true, of you during the past 2 months.)
You have been unhappy, sad, or depressed?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4e. (I am going to read a list of items that describe teenagers. For each one, tell me if it has been not true, sometimes true, or often true, of you during the past 2 months.)
You do poorly at school work?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN4f. (I am going to read a list of items that describe teenagers. For each one, tell me if it has been not true, sometimes true, or often true, of you during the past 2 months.)
You have trouble sleeping?
1=NOT TRUE
2=SOMETIMES TRUE
3=OFTEN TRUE
………………………………………………………………………………………………
MEN2a. [IF INTAGE >=13 CONTINUE, ELSE GO TO MEN5]
Has a doctor or other health professional ever told you that you had depression?
1=YES
2=NO
………………………………………………………………………………………………
MEN2b. Has a doctor or other health professional ever told you that you had generalized anxiety?
INTERVIEWER: Generalized anxiety is characterized by persistent and excessive worry about a number of different things. People with generalized anxiety may anticipate disaster and may be overly concerned about money, health, family, work, or other issues.
1=YES
2=NO
………………………………………………………………………………………………
MEN2c Has a doctor or other health professional ever told you that you had panic disorder?
1=YES
2=NO
………………………………………………………………………………………………
MEN5c. Has a doctor or other health professional ever told you that you had schizophrenia?
1=YES
2=NO
………………………………………………………………………………………………
MEN5d. Has a doctor or other health professional ever told you that you were bipolar?
1=YES
2=NO
………………………………………………………………………………………………
MEN5. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, did you or a doctor believe {you/NAME} should see a professional about {your/his/her} mental health, emotions, or nerves?
1=YES
2=NO
………………………………………………………………………………………………
MEN5a. [IF MEN5=1 CONTINUE, ELSE GO TO MEN9a2]
In the last 12 months, {have you/has NAME} seen a primary care doctor or other general practitioner for problems with {your/his/her} mental health, emotions, or nerves?
1=YES
2=NO
………………………………………………………………………………………………
MEN5b. In the last 12 months, {have you/has NAME} seen any other professional, such as a counselor, psychiatrist, or social worker for problems with {your/his/her} mental health, emotions, or nerves?
1=YES
2=NO
………………………………………………………………………………………………
MEN6. In the last 12 months, {were you/was NAME} unable to get mental health care that you or a doctor believed necessary?
1=YES
2=NO
………………………………………………………………………………………………
MEN6a. [IF MEN6=1 CONTINUE, ELSE GO TO MEN7]
Please look at this showcard. What is the main reason {you were/NAME was} unable to get mental health care by a mental health professional you or a doctor believed necessary?
SHOWCARD MEN3
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE/TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
12=VA DOES NOT PROVIDE COVERAGE FOR CONDITION
13=OTHER
………………………………………………………………………………………………
MEN6a_OTH. [IFMEN6a=13 CONTINUE, ELSE GO TO MEN7]
Please specify the other reason {you were/NAME was} unable to get mental care by a mental professional you or a doctor believed was necessary.
________________ [ALLOW 40]
………………………………………………………………………………………………
MEN7. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, {were you/was NAME} delayed in getting mental health care you or a doctor believed necessary?
1=YES
2=NO
………………………………………………………………………………………………
MEN7a. [IF MEN7=1 CONTINUE, ELSE GO TO MEN9a2]
Please look at this showcard. What is the main reason {you were/NAME was} delayed in getting counseling by a mental health professional you or a doctor believed necessary?
SHOWCARD MEN3
1=COULD NOT AFFORD CARE
2=INSURANCE COMPANY WOULDN’T APPROVE, COVER, OR PAY FOR CARE
3=DOCTOR REFUSED TO ACCEPT FAMILY’S INSURANCE PLAN
4=PROBLEMS GETTING TO DOCTOR’S OFFICE/TRANSPORTATION
5=DIFFERENT LANGUAGE FROM DOCTORS OR NURSES
6=COULDN’T GET TIME OFF WORK
7=DIDN’T KNOW WHERE TO GO TO GET CARE
8=WAS REFUSED SERVICES
9=COULDN’T GET CHILD CARE
10=DIDN’T HAVE TIME OR TOOK TOO LONG
11=WAS EMBARRASSED/DID NOT FEEL COMFORTABLE ASKING FOR HELP/ DID NOT WANT OTHER PEOPLE TO KNOW ABOUT PROBLEM
12=VA DOES NOT PROVIDE COVERAGE FOR CONDITION
13=OTHER
………………………………………………………………………………………………
MEN7a_OTH. [IF MEN7a=13 CONTINUE, ELSE GO TO MEN9a2]
Please specify the other reason {you were/NAME was} delayed in getting counseling by a mental health professional you or a doctor believed necessary.
________________ [ALLOW 40]
………………………………………………………………………………………………
MEN9a2. [IF INTAGE GE 13 CONTINUE, ELSE GO TO MEN11_INTRO]
Have you ever received any mental health treatment or counseling?
Please include treatment with prescription medication, group, family, couples, or individual counseling with a mental health provider such as a social worker, psychologist, psychiatrist, psychiatric nurse or other mental health professional, and inpatient treatment. Do not include counseling or advice given by a friend, or spiritual counseling through a church or religious group.
1=YES
2=NO
………………………………………………………………………………………………
MEN8. [IF MEN9a2=1 CONTINUE, ELSE GO TO MEN11_INTRO]
In the past 12 months, that is since {12 MONTH REFERENCE DATE}, did you receive any mental health treatment or counseling? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
MEN8a. [IF MEN8=1 OR 2 CONTINUE, ELSE GO TO MEN11_INTRO]
What was this treatment or counseling for? You may select one or more. Was it for …?
CODE ALL THAT APPLY
1=Mental or emotional health
2=Alcohol or drug problems
3=Personal or family problems/ relationship problems
4=Something else
………………………………………………………………………………………………
MEN9. What kind of treatment and/or counseling was it? You may select one or more. Was it …?
CODE ALL THAT APPLY
1=Individual counseling
2=Group counseling
3=Family or couples counseling
4=Prescription medication
5=Inpatient treatment in a general hospital or mental health treatment facility
………………………………………………………………………………………………
MEN10. [IF MEN9=5 CONTINUE, ELSE GOTO MEN9a]
Were you referred to the general hospital or mental health facility where you got the treatment by {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
MEN9a. [IF MEN9=1-4 CONTINUE, ELSE GO TO MEN11_INTRO]
How many of your treatment or counseling sessions you received did you get at {REFERENCE HEALTH CENTER}? Would you say…?
1=All of the visits
2=Some of the visits
3=None of the visits
………………………………………………………………………………………………
MEN9b. [IF MEN9a=1 OR 2 CONTINUE, ELSE GO TO MEN9c]
Using any number from 0 to 10, where 0 is poor and 10 is excellent, what number would you use to rate the treatment or counseling services you received at {REFERENCE HEALTH CENTER}.
0 Poor
1
2
3
4
5
6
7
8
9
10 Excellent
………………………………………………………………………………………………
MEN9c. [IF MEN9a=2 OR 3 CONTINUE, ELSE GO TO MEN11_INTRO]
Were you referred to the other place where you got the treatment or counseling services by {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
MEN11_INTRO. [IF INTAGE=13 OR OLDER CONTINUE, ELSE GO TO SUB1a_INTRO] The next questions are about your thoughts about suicide. Your answers to these questions are private and will not be shared with anyone at {REFERENCE HEALTH CENTER}. You also have the right to refuse any question that you do not want to answer.
MEN11. At any time in the past 12 months, did you seriously think about trying to kill yourself?
1=YES
2=NO
………………………………………………………………………………………………
MEN12. During the past 12 months, did you make any plans to kill yourself?
1=YES
2=NO
………………………………………………………………………………………………
MEN13.
During the past 12 months, did you try to kill yourself?
1=YES
2=NO
………………………………………………………………………………………………
MODULE L: SUBSTANCE USE
[IF INTAGE GE 13 CONTINUE, ELSE GO TO PRG1]
SUB1a_INTRO. The next questions are about your use of electronic cigarettes and traditional tobacco products. As a reminder, your answers to these questions are private and will not be shared with anyone at {REFERENCE HEALTH CENTER} and you have the right to refuse any question that you do not want to answer.
1=CONTINUE
………………………………………………………………………………………………
SUB1_ECIG1. Electronic cigarettes (e-cigarettes) and other electronic “vaping” products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy.
Have you ever used an e-cigarette or other electronic “vaping” product, even just one time, in your entire life?
1=Yes
2=No
………………………………………………………………………………………………
SUB1_ECIG2. [IF SUB1_ECIG1=1 CONTINUE, ELSE GOTO SUB1a] What are the reasons you have used e-cigarettes? Select all that apply.
SHOWCARD SUB_ECIG
1= I have never tried an e-cigarette
2= Friend or family member used them
3= To try to quit using other tobacco products, such as cigarettes
4= They cost less than other tobacco products, such as cigarettes
5= They are easier to get than other tobacco products, such as cigarettes
6= Famous people on TV or in movies use them
7= They are less harmful than other forms of tobacco, such as cigarettes
8= They are available in flavors, such as mint, candy, fruit, or chocolate
9= They can be used in areas where other tobacco products, such as cigarettes, are not allowed
10= They can be used with marijuana, THC or Hash oil, or THC wax
11= I used them for some other reason
………………………………………………………………………………………………
SUB1_ECIG3. What types of e-cigarettes or e-liquid do you use? Please select all that apply.
1=Products with flavors (taste like menthol, mint, clove, spice, candy, fruit, chocolate etc.)
2=Products contain nicotine
3. Products contain cannabidiol (CBD)
4=Products contain marijuana
5=Unsure of what you are vaping
6=OTHER
………………………………………………………………………………………………
SUB1a. Have you smoked at least 100 cigarettes in your entire life?
1=YES
2=NO
………………………………………………………………………………………………
SUB1a1. [IF SUB1a=1 CONTINUE, ELSE GO TO SUB1g]
How old were you when you smoked a whole cigarette for the first time?
ENTER 6 IF 6 YEARS OLD OR YOUNGER
ENTER 98 IF 98 YEARS OLD OR OLDER
_____[ALLOW 06 – 99]
………………………………………………………………………………………………
SUB1b. Do you now smoke cigarettes every day, some days or not at all?
1=EVERY DAY
2=SOME DAYS
3=NOT AT ALL
………………………………………………………………………………………………
SUB1c. [IF SUB1b=1 CONTINUE, ELSE GO TO SUB1f]
On the average, how many cigarettes do you now smoke a day?
NOTE: IF RESPONSE IS LESS THAN 1 – ENTER 1
_______CIGARETTES [ALLOW 01-99]
………………………………………………………………………………………………
SUB1d. [IF SUB1b=2 CONTINUE, ELSE, GO TO SUB1f]
During the past 30 days, on how many days did you smoke cigarettes?
______ DAYS [ALLOW 00-30]
……………………………………………………………………………………………
SUB1e. [IF SUB1d GE 1 CONTINUE, ELSE GO TO SUB1f]
On average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?
______ NUMBER OF CIGARETTES [ALLOW 00-99]
………………………………………………………………………………………………
SUB1f. [IF SUB1b=1 OR 2 CONTINUE, ELSE GO TO SUB1g]
During the past 12 months have you wanted to stop smoking?
1=YES
2=NO
………………………………………………………………………………………………
SUB1f1. [IF SUB1b=1 OR 2 CONTINUE, ELSE GO TO SUB1g]
During the past 12 months, have you stopped smoking for more than one day because you were trying to quit smoking?
1=YES
2=NO
………………………………………………………………………………………………
SUB1g. The next questions are about your use of “smokeless” tobacco such as snuff, dip, chewing tobacco, or “snus.”
Have you ever used “smokeless” tobacco, even once?
IF NEEDED: Snus, which is Swedish for snuff, is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.
1=YES
2=NO
………………………………………………………………………………………………..
SUB1h. [IF SUB1g= 1 CONTINUE, ELSE GO TO SUB1k]
How old were you the first time you used “smokeless” tobacco?
________ [RANGE: 01 - 99]
……………………………………………………………………………………………….
SUB1h1. [IF SUB1g=1 CONTINUE, ELSE GO TO SUB1k]
Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?
IF NEEDED: Snus, which is Swedish for snuff, is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.
1=EVERY DAY
2=SOME DAYS
3=NOT AT ALL
………………………………………………………………………………………………..
SUB1i. [IF SUB1h1=2 CONTINUE, ELSE GO TO SUB1j]
Now think about the past 30 days that is since {30 DAY REFERENCE DATE}. During the past 30 days, have you used “smokeless” tobacco, even once?
1=YES
2=NO
……………………………………………………………………………………………….
SUB1j. [IF SUB1h1=3 OR SUB1i=2 CONTINUE, ELSE GO TO SUB1k]
How long has it been since you last used “smokeless” tobacco? Would you say…
1=More than 30 days ago but within the past 12 months,
2=More than 12 months ago but within the past 3 years, or
3=More than 3 years ago?
………………………………………………………………………………………………..
SUB1k. [IF (SUB1h1=1 OR 2) OR (SUB1b=1 OR 2) CONTINUE, ELSE GO TO SUB2]
During the past 12 months, did any doctor or other health care professional advise you to quit smoking cigarettes or quit using any other tobacco products? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
.................................................................................................................................................
SUB1m. [IF SUB1b=3 CONTINUE, ELSE GO TO SUBPRE1t]
How long has it been since you quit smoking cigarettes?
__________
………………………………………………………………………………………………
SUB1m_UNITS. (How long has it been since you quit smoking cigarettes?)
INTERVIEWER: ENTER RESPONSE UNIT
1=DAYS AGO
2=WEEKS AGO
3=MONTHS AGO
4=YEARS AGO
[HARD CHECK REQUIRED]
………………………………………………………………………………………………
SUB1o. The last time you tried to quit smoking or using any other tobacco products, did you…
Call a telephone quit line to help you quit?
1=YES
2=NO
………………………………………………………………………………………………
SUB1p. (The last time you tried to quit smoking or using any other tobacco products, did you…)
Use a program to help you quit?
1=YES
2=NO
…………………………………………………………………………………………
SUB1q. (The last time you tried to quit smoking or using any other tobacco products, did you…)
Receive one-on-one counseling from a health professional to help you quit?
1=YES
2=NO
………………………………………………………………………………………………
SUB1r. (The last time you tried to quit smoking or using any other tobacco products, did you…)
Use any of the following medications: a nicotine patch, nicotine gum, nicotine
lozenges, nicotine nasal spray, a nicotine inhaler, or pills such as Wellbutrin®, Zyban®,
buproprion, Chantix®, or varenicline to help you quit?
1=YES
2=NO
………………………………………………………………………………………………
SUB1s. [IF SUB1r=1 CONTINUE, ELSE GO TO SUBPRE1t]
Was it…
1=Nicotine replacement such as lozenges, nasal spray, inhaler or
2=Medication such as Wellbutrin®, Zyban®, bupropion, Chantix®, or varenicline
3=SOME OTHER MEDICATION
………………………………………………………………………………………………
SUBPRE1t. The next few questions are about plans to quit smoking in the future.
Do you have plans in the future to quit smoking for good?
1=YES
2=NO
……………………………………………………………………………………………
SUB1t. [IF SUBPRE1t=1 CONTINUE, ELSE GO TO SUB2]
Do you have a time frame in mind for quitting?
1=YES
2=NO
………………………………………………………………………………………………
SUB1u. [IF SUB1t=1 CONTINUE, ELSE GO TO SUB2]
Do you plan to quit smoking cigarettes for good…
1=In the next 7 days,
2=In the next 30 days,
3=In the next 6 months,
4=In the next year, or
5=More than 1 year from now?
……………………………………………………………………………………………….
SUB2.
We are interested in whether you have used any of these for non-medical reasons. Include prescription drugs that you took only if they were not prescribed for you or you took them only for the experience or feeling they caused.
Some of the substances that we ask about may be prescribed by a doctor like amphetamines, sedatives, and pain medications. For this interview, we will not record medications that are used as prescribed by your doctor. However, if you have taken such medications for reasons other than prescription or taken them more frequently or at higher doses than prescribed, please let me know.
1=CONTINUE
………………………………………………………………………………………………
SUB2a. Please look at this showcard.
SHOWCARD SUB1
In your life, which of the following substances have you ever used? Have you drank…
Alcoholic beverages such as beer, wine, or spirits?
1=YES
2=NO
………………………………………………………………………………………………
SUB2b. In your life, which of the following substances have you ever used? Have you used…
Cannabis or Marijuana? We are asking about non-medical use.
These may be known as marijuana, pot, grass or hash.
1=YES
2=NO
………………………………………………………………………………………………
SUB2c. (In your life, which of the following substances have you ever used? Have you used…)
Cocaine?
This may be known as powder, ‘crack,’ free base, and coca paste
1=YES
2=NO
………………………………………………………………………………………………
SUB2d. (In your life, which of the following substances have you ever used? Have you used…)
Amphetamine-type stimulants?
These may be known as speed, ecstasy, crystal meth or diet pills.
1=YES
2=NO
………………………………………………………………………………………………
SUB2e. (In your life, which of the following substances have you ever used? Have you used…)
Inhalants?
These may be known as nitrous, glue, petrol or paint thinner.
1=YES
2=NO
………………………………………………………………………………………………
SUB2f. (In your life, which of the following substances have you ever used? Have you used…)
Sedatives or sleeping pills? We are asking about non-medical use.
These may be known as Valium, Serepax, or Rohypnol.
1=YES
2=NO
………………………………………………………………………………………………
SUB2g. (In your life, which of the following substances have you ever used? Have you used…)
Hallucinogens?
These may be known as LSD, acid, mushrooms, PCP, Ecstasy or Molly, also called MDMA or Special K
1=YES
2=NO
………………………………………………………………………………………………
SUB2h. (In your life, which of the following substances have you ever used? Have you used…)
Opioids? We are asking about non-medical use.These may be known as heroin, morphine, methadone, codeine, Vicodin, hydrocodone, hydromorphone, oxymorphone, tramadol, and fentanyl
1=YES
2=NO
………………………………………………………………………………………………
SUB2i. (In your life, which of the following substances have you ever used? Have you used…)
Any other substances?
1=YES
2=NO
………………………………………………………………………………………………
SUB2i_OTH. [IF SUB2i=1 CONTINUE, ELSE GO TO SUB2a_a]
Please specify the other substances you have ever used.
_______ [ALLOW 40]
………………………………………………………………………………………………
SUB2a_a. [IF SUB2a=1 CONTINUE, ELSE GOTO SUB2b_a]
In the past three months, how often have you drank alcoholic beverages?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2a_b. [IF SUB2a_a=1, 2, 3 OR 4 CONTINUE, ELSE GOTO SUB7]
In the past three months, how often have you had a strong desire or urge to drink alcoholic beverages?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2a_c. In the past three months, how often has your use of alcoholic beverages led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2a_d. In the past three months, how often have you failed to do what was normally expected of you because of your use of alcoholic beverages?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2a_e. In the past three months, how often has a friend or relative or anyone else expressed concern about your drinking of alcoholic beverages?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2a_f. In the past three months, how often have you tried and failed to control, cut down or stop drinking alcoholic beverages?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB7 [IF SUB2a_a=0, DK OR RE CONTINUE, ELSE GO TO SUB8]
Did you drink alcohol in the past 12 months?
1=YES
2=NO
………………………………………………………………………………………………
SUB8. [IF SUB7=1 OR (SUB2a_a=1, 2, 3, OR 4) CONTINUE, ELSE GO TO SUB9a]
In the past 12 months, on those days that you drank alcoholic beverages, on the average, how many drinks did you have?
______ Number of drinks [ALLOW 00-30]
………………………………………………………………………………………………
SUB8a. In the past 12 months, on how many days did you have 5 or more drinks of any alcoholic beverage?
______ DAYS [ALLOW 000-365]
………………………………………………………………………………………………
SUB9. In the past 12 months, have you discussed your use of alcohol with your doctor or other health professional?
1=YES
2=NO
………………………………………………………………………………………………
SUB9a. [IF SUB7=2 CONTINUE, ELSE GO TO SUB2b_a]
In the past 12 months has your doctor or other health professional asked you about your use of alcohol? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
SUB2b_a. [IF SUB2b=1CONTINUE, ELSE GO TO SUB2c_a]
In the past three months, how often have you used cannabis or marijuana?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2b_b. [IF SUB2b_a=2, 3 OR 4 CONTINUE, ELSE GOTO SUB2c_a]
In the past three months, how often have you had a strong desire or urge to use cannabis or marijuana?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2b_c. In the past three months, how often has your use of cannabis or marijuana led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2b_d. In the past three months, how often have you failed to do what was normally expected of you because of your use of cannabis or marijuana?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2b_e. In the past three months, how often has a friend or relative or anyone else expressed concern about your use of cannabis or marijuana?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2b_f. In the past three months, how often have you tried and failed to control, cut down or stop using cannabis or marijuana?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2c_a. [IF SUB2c=1CONTINUE, ELSE GO TO SUB2d_a]
In the past three months, how often have you used cocaine?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2c_b. [IF SUB2c_a=1, 2, 3 OR 4 CONTINUE, ELSE GOTO SUB2d_a]
In the past three months, how often have you had a strong desire or urge to use cocaine?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2c_c. In the past three months, how often has your use of cocaine led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2c_d. In the past three months, how often have you failed to do what was normally expected of you because of your use of cocaine?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2c_e. In the past three months, how often has a friend or relative or anyone else expressed concern about your use of cocaine?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2c_f. In the past three months, how often have you tried and failed to control, cut down or stop using cocaine?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2d_a. [IF SUB2d=1CONTINUE, ELSE GO TO SUB2e_a]
In the past three months, how often have you used amphetamine-type stimulants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2d_b. [IF SUB2d_a=1, 2, 3 OR 4 CONTINUE, ELSE GOTO SUB2e_a]
In the past three months, how often have you had a strong desire or urge to use
amphetamine-type stimulants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2d_c. In the past three months, how often has your use of amphetamine-type stimulants led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2d_d. In the past three months, how often have you failed to do what was normally expected of you because of your use of amphetamine-type stimulants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2d_e. In the past three months, how often has a friend or relative or anyone else expressed concern about your use of amphetamine-type stimulants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2d_f. In the past three months, how often have you tried and failed to control, cut down or stop using amphetamine-type stimulants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2e_a. [IF SUB2e=1CONTINUE, ELSE GO TO SUB2f_a]
In the past three months, how often have you used inhalants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2e_b. [IF SUB2e_a=1, 2 3 OR 4 CONTINUE, ELSE GOTO SUB2f_a]
In the past three months, how often have you had a strong desire or urge to use inhalants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2e_c. In the past three months, how often has your use of inhalants led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2e_d. In the past three months, how often have you failed to do what was normally expected of you because of your use of inhalants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2e_e. In the past three months, how often has a friend or relative or anyone else expressed concern about your use of inhalants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2e_f. In the past three months, how often have you tried and failed to control, cut down or stop using inhalants?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2f_a. [IF SUB2f=1 CONTINUE, ELSE GO TO SUB2g_a]
In the past three months, how often have you used sedatives or sleeping pills? We are asking about non-medical use.
IF NEEDED: These may be known as valium, serepax or rohypnol.
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2f_b. [IF SUB2f_a=1, 2, 3, OR 4 CONTINUE, ELSE GOTO SUB2g_a]
In the past three months, how often have you had a strong desire or urge to use sedatives or sleeping pills?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2f_c. In the past three months, how often has your use of sedatives or sleeping pills led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2f_d. In the past three months, how often have you failed to do what was normally expected of you because of your use of sedatives or sleeping pills?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2f_e. In the past three months, how often has a friend or relative or anyone else expressed concern about your use of sedatives or sleeping pills?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2f_f. In the past three months, how often have you tried and failed to control, cut down or stop using sedatives or sleeping pills?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2g_a. [IF SUB2g=1CONTINUE, ELSE GO TO SUB2h_a]
In the past three months, how often have you used hallucinogens?
IF NEEDED: These may be known as LSD, acid, mushrooms, PCP, Ecstasy or Molly, also called MDMA or Special K
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2g_b. [IF SUB2g_a=1, 2, 3 OR 4 CONTINUE, ELSE GOTO SUB2h_a]
In the past three months, how often have you had a strong desire or urge to use hallucinogens?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2g_c. In the past three months, how often has your use of hallucinogens led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2g_d. In the past three months, how often have you failed to do what was normally expected of you because of your use of hallucinogens?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2g_e. In the past three months, how often has a friend or relative or anyone else expressed concern about your use of hallucinogens?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2g_f. In the past three months, how often have you tried and failed to control, cut down or stop using hallucinogens?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
3=Never
………………………………………………………………………………………………
SUB2h_a. [IF SUB2h=1 CONTINUE, ELSE GO TO SUB2i_a]
In the past three months, how often have you used opioids? We are asking about non-medical use.
IF NEEDED: These may be known as heroin, morphine, methadone, codeine or vicodin.
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2h_b. [IF SUB2h_a=1, 2, 3, OR 4 CONTINUE, ELSE GOTO SUB2i_a]
In the past three months, how often have you had a strong desire or urge to use opioids?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2h_c. In the past three months, how often has your use of opioids led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2h_d. In the past three months, how often have you failed to do what was normally expected of you because of your use of opioids?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2h_e. In the past three months, how often has a friend or relative or anyone else expressed concern about your use of opioids?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2h_f. In the past three months, how often have you tried and failed to control, cut down or stop using opioids?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2i_a. [IF SUB2i=1 CONTINUE, ELSE GO TO SUB3]
In the past three months, how often have you used {RESPONSE FROM SUB2i_OTH}?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2i_b. [IF SUB2i_a=1, 2, 3 OR 4 CONTINUE, ELSE GOTO SUB3]
In the past three months, how often have you had a strong desire or urge to use {RESPONSE FROM SUB2i_OTH}?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2i_c. In the past three months, how often has your use of {RESPONSE FROM SUB2i_OTH} led to health, social, legal or financial problems?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2i_d. In the past three months, how often have you failed to do what was normally expected of you because of your use of {RESPONSE FROM SUB2i_OTH}?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2i_e. In the past three months, how often has a friend or relative or anyone else expressed concern about your use of {RESPONSE FROM SUB2i_OTH}?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB2i_f. In the past three months, how often have you tried and failed to control, cut down or stop using {RESPONSE FROM SUB2i_OTH}?
Would you say…
0=Never
1=Once or twice
2=Monthly
3=Weekly
4=Daily or almost daily
………………………………………………………………………………………………
SUB3.
Have you ever, even once, used a needle to inject any drug that was not prescribed to you? Please include drugs for non-medical use only.
1=YES
2=NO
………………………………………………………………………………………………
SUB3a. [IF SUB3=1 CONTINUE, ELSE GO TO SUB10]
How long has it been since you last used a needle to inject any drug that was not prescribed to you?
1=In the past 3 months
2=More than 3 months ago but within the past 12 months
3=More than 12 months ago
………………………………………………………………………………………………
SUB10. [IF SUB2b =1, SUB2c=1, SUB2d=1, SUB2e=1, SUB2f=1 SUB2g=1, SUB2h=1, OR SUB2i = 1, CONTINUE]
[IF SUB2b_a=1,2,3 or 4, SUB2c_a=1,2,3 or 4, SUB2d_a=1,2,3 or 4, SUB2e_a=1,2,3 or 4, SUB2f_a=1,2,3 or 4, SUB2g_a=1,2,3 or 4, SUB2h_a=1,2,3 or 4, OR SUB2i_a = 1,2,3 or 4, GO TO SUB10a]
[ELSE GO TO SUB12]
Earlier you indicated that you have used…
[IF SUB2b=1: Cannabis or Marijuana]
[IF SUB2c=1: Cocaine]
[IF SUB2d=1: Amphetamine-type stimulants]
[IF SUB2e=1: Inhalants]
[IF SUB2f=1: Sedatives or sleeping pills]
[IF SUB2g=1: Hallucinogens]
[IF SUB2h=1: Opioids]
[IF SUB2i=1: FILL RESPONSE FROM SUB2i_OTH]
Did you use any of these drugs in the past 12 months?
1=YES
2=NO
………………………………………………………………………………………………
SUB10a. [IF SUB10=1 CONTINUE, ELSE GO TO SUB12]
In the past 12 months, have you discussed your use of drugs with a doctor or other health professional?
1=YES
2=NO
………………………………………………………………………………………………
SUB10b. [IF SUB10a=2 CONTINUE, ELSE GO TO SUB12]
In the past 12 months has a doctor or other health professional asked you about your use of drugs? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
SUB12. [IF SUB2a=1 CONTINUE, ELSE GO TO SUB12b]
In the past 12 months, did you want or need treatment or counseling for your use of alcohol?
1=YES
2=NO
………………………………………………………………………………………………
SUB12b. [IF SUB2b =1, SUB2c=1, SUB2d=1, SUB2e=1, SUB2f=1 SUB2g=1, SUB2h=1, OR SUB2i = 1, CONTINUE, ELSE GO TO PRG1]
In the past 12 months, did you want or need treatment or counseling for your use of drugs?
1=YES
2=NO
………………………………………………………………………………………………
SUB12a. [IF SUB12=1 CONTINUE, ELSE GO TO SUB12d]
In the past 12 months, did you receive treatment or counseling for your use of alcohol?
1=YES
2=NO
………………………………………………………………………………………………
SUB12d. [IF SUB12b=1 CONTINUE, ELSE GO TO SUB14]
In the past 12 months, did you receive treatment or counseling for your use of drugs?
1=YES
2=NO
………………………………………………………………………………………………
SUB14. [IF SUB12a=1 CONTINUE, ELSE GO TO SUB15]
Did {REFERENCE HEALTH CENTER} provide that treatment, pay for that treatment, or refer you to the place where you got treatment for your use of alcohol?
1=PROVIDE TREATMENT
2=PAY FOR TREATMENT
3=REFER TO ANOTHER PLACE
4=NONE
………………………………………………………………………………………………
SUB14_MAT1. In the past 12 months, did you use medication to help reduce or stop you use of alcohol?
1=Yes
2=No
………………………………………………………………………………………………
SUB14_MAT2. [IF SUB14_MAT1=1 CONTINUE, ELSE GO TO SUB15] On how many days in the past 12 months did you use this medication?
_______ Total Number of Days [ALLOW 000-365]
………………………………………………………………………………………………
SUB14a. [IF SUB12d=1 CONTINUE ELSE GO TO SUB15]
Did {REFERENCE HEALTH CENTER} provide that treatment, pay for that treatment, or refer you to the place where you got treatment for your use of drugs?
1=PROVIDE TREATMENT
2=PAY FOR TREATMENT
3=REFER TO ANOTHER PLACE
4=NONE
………………………………………………………………………………………………
SUB14a_MAT1. In the past 12 months, did you use medication to help reduce or stop you use of drugs?
1=Yes
2=No
………………………………………………………………………………………………
SUB14a_MAT2. [IF SUB14a_MAT1=1 CONTINUE, ELSE GO TO SUB15] On how many days in the past 12 months did you use this medication?
_______ Total Number of Days [ALLOW 000-365]
………………………………………………………………………………………………
SUB15. Using any number from 0 to 10, where 0 is poor and 10 is excellent, what number would you use to rate the treatment or counseling services you received at {REFERENCE HEALTH CENTER}.
0 Poor
1
2
3
4
5
6
7
8
9
10 Excellent
………………………………………………………………………………………………
SUB17. [IF SUB12=1 AND SUB12a=2 CONTINUE, ELSE GO TO PRG1]
Please look at this showcard. What is the main reason why you did not get the treatment or counseling you needed for your use of alcohol?
SHOWCARD SUB2
1=NO WAY TO PAY FOR IT
2=DID NOT KNOW OF OR COULD NOT GET INTO A TREATMENT PROGRAM
3=DID NOT HAVE TIME FOR A PROGRAM OR A WAY TO GET THERE, OR PROGRAM NOT CONVENIENT ENOUGH
4=YOU DIDN’T WANT PEOPLE TO FIND OUT THAT YOU HAD A PROBLEM (AT WORK, IN COMMUNITY, ETC...)
5=YOU DIDN’T REALLY THINK THE TREATMENT WOULD HELP
6=OTHER
………………………………………………………………………………………………
SUB17_SP [IF SUB17=6 CONTINUE, ELSE GO TO PRG1]
What other reasons did you have for not getting the treatment or counseling you needed for your use of alcohol?
_____ [Allow 80]
………………………………………………………………………………………………
MODULE M: PRENATAL CARE/ FAMILY PLANNING
PRG1. [IF INT3=2 AND INTAGE=15-49 CONTINUE, ELSE GO TO HTG1]
[IF CON2=2, DK, RF GO TO PRG8, ELSE CONTINUE]
Have you been pregnant in the past 3 years, which is since {3 YEAR REFERENCE DATE}?
1=YES
2=NO
………………………………………………………………………………………………
PRG1a. [IF PRG1=1 CONTINUE, ELSE GO TO PRG8]
When was your last pregnancy?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 TO 3 YEARS AGO
………………………………………………………………………………………………
PRG6.
The next questions are about the prenatal care you received during your most recent pregnancy. Prenatal care includes visits to a doctor, nurse, or other health care worker before your baby was born to get checkups and advice about pregnancy.
In the past 3 years, was there a time that you needed prenatal care but were unable to get it?
1=YES
2=NO
………………………………………………………………………………………………
PRG2.
Thinking about your most recent pregnancy, did you receive prenatal care ? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
PRG2a. Thinking about your most recent pregnancy, how many weeks or months pregnant were you when you had your first visit for prenatal care? Do not count a visit that was only for a pregnancy test or only for WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children).
________________ (ALLOW 1-40)
………………………………………………………………………………………………
PRG2a_UNIT (Thinking about your most recent pregnancy, how many weeks or months pregnant were you when you had your first visit for prenatal care?)
1=WEEKS
2=MONTHS
………………………………………………………………………………………………
PRG3. [IF PRG2=1 CONTINUE, ELSE GO TO PRG8]
How many of your prenatal visits did you get at {REFERENCE HEALTH CENTER}? Would you say….?
NOTE: IF RESPONSE IS “MOST” – CODE AS 2 “SOME OF THE VISITS”
1=All of the visits
2=Some of the visits
3=None of the visits
………………………………………………………………………………………………
PRG4. [IF PRG3=1 OR 2 CONTINUE, ELSE GO TO PRG5]
On a scale of 0 to 10, where 0 means poor and 10 means excellent, how would you rate the prenatal care services you received at {REFERENCE HEALTH CENTER}. Would you say….?
0=Poor
1
2
3
4
5
6
7
8
9
10=Excellent
………………………………………………………………………………………………
PRG4a. During any of your prenatal care visits, did a doctor or other health professional talk with you about any of the following…?
Please count only discussions, not reading materials or watching videos.
Press ENTER to continue.
………………………………………………………………………………………………
PRG4aa. (During any of your prenatal care visits, did a doctor or other health professional talk with you about any of the following…?)
How smoking during pregnancy could affect your baby
1=YES
2=NO
………………………………………………………………………………………………
PRG4ab. (During any of your prenatal care visits, did a doctor or other health professional talk with you about any of the following…?)
Breastfeeding your baby
1=YES
2=NO
………………………………………………………………………………………………
PRG4ac. (During any of your prenatal care visits, did a doctor or other health professional talk with you about any of the following…?)
How drinking alcohol during pregnancy could affect your baby
1=YES
2=NO
………………………………………………………………………………………………
PRG4ad. (During any of your prenatal care visits, did a doctor or other health professional talk with you about any of the following…?)
Using a seat belt during your pregnancy
1=YES
2=NO
………………………………………………………………………………………………
PRG4ae. (During any of your prenatal care visits, did a doctor or other health professional talk with you about any of the following…?)
Medicines that are safe to take during your pregnancy
1=YES
2=NO
………………………………………………………………………………………………
PRG4af. (During any of your prenatal care visits, did a doctor or other health professional talk with you about any of the following…?)
How illegal drugs could affect your baby
1=YES
2=NO
………………………………………………………………………………………………
PRG4ag. (During any of your prenatal care visits, did a doctor or other health professional talk with you about any of the following…?)
Doing tests to screen for birth defects or diseases that run in your family
1=YES
2=NO
………………………………………………………………………………………………
PRG4ah. (During any of your prenatal care visits, did a doctor or other health professional talk with you about any of the following…?)
The signs and symptoms of preterm labor, which is labor more than 3 weeks before the baby is due
1=YES
2=NO
………………………………………………………………………………………………
PRG4ak. (During any of your prenatal care visits, did a doctor or other health professional talk with you about any of the following…?)
What to do if you feel depressed during your pregnancy or after your baby is born
1=YES
2=NO
………………………………………………………………………………………………
PRG4al. (During any of your prenatal care visits, did a doctor or other health professional talk with you about any of the following…?)
Physical abuse to women by their husbands or partners
1=YES
2=NO
………………………………………………………………………………………………
PRG5. [IF PRG3=2 OR 3 CONTINUE, ELSE GO TO PRG5a]
Were you referred to the other place where you got prenatal care by {REFERENCE HEALTH CENTER}?
1=YES
2=NO
……………………………………………………………………………………………
PRG5a. These next questions are about the time after your most recent pregnancy. Could you tell me if this pregnancy resulted in a baby or babies born alive, or did it end some other way?
NOTE: IF CURRENTLY PREGNANT – RESPONDENT SHOULD THINK OF PREVIOUS
PREGNANCY
1=LIVE BIRTH
2=SOME OTHER WAY / CURRENTLY PREGNANT AND NO PREVIOUS PREGNANCY
………………………………………………………………………………………………
PRG5a1. [IF PRG5a=1 CONTINUE, ELSE GO TO PRG8] Was this child born more than three weeks before his or her due date?
1=YES
2=NO
………………………………………………………………………………………………
PRG5b.
How much did your baby weigh at birth?
__________ Pounds [ALLOW 00-11] __________ Ounces [ALLOW 00-16]
[PROGRAMMING NOTE: CAN WE ALLOW FOR KILOGRAMS?]
………………………………………………………………………………………………
PRG6a. After your most recent pregnancy, did you have a postpartum checkup for yourself? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
IF NEEDED: A postpartum checkup is the regular checkup a woman has about 4-6 weeks after she gives birth.
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
………………………………………………………………………………………………
PRG6b_OTH. [IF PRG6a=2 CONTINUE, ELSE GO TO PRG6c]
Where did you go for your postpartum checkup?
1=My family doctor’s office
2=My OB/GYN’s office
3=Hospital clinic
4=Health department clinic
5=OTHER LOCATION
………………………………………………………………………………………………
PRG6c. Was your new baby seen by a doctor or other health care worker for a one-week check-up after he or she was born? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
3= NO
4= My baby was still in the hospital at that time
………………………………………………………………………………………………
………………………………………………………………………………………………
PRG6d_OTH. [IF PRG6c=2 CONTINUE, ELSE GO TO PRG6e]
Where did you have the baby’s one-week check-up?
1=AT HOME
2=My family doctor’s office
3=My OB/GYN’s office
4=Hospital clinic
5=Health department clinic
6=OTHER LOCATION
………………………………………………………………………………………………
PRG6e. In which one position do you most often lay your baby down to sleep? Would you say on his or her side, back, or stomach?
1=On his or her side
2=On his or her back
3=On his or her stomach
………………………………………………………………………………………………
PRG6f. In the past 2 weeks, how often has your new baby slept alone in his or her own crib or bed? Would you say…
1= Always
2= Often
3= Sometimes
4= Rarely
5= Never
………………………………………………………………………………………………
PRG7a. Did you ever breastfeed or pump breast milk to feed your new baby, even for a short period of time?
1=YES
2=NO
………………………………………………………………………………………………
PRG7b. [IF PRG7a=1 CONTINUE, ELSE GO TO PRG8
Are you currently breastfeeding or feeding pumped milk to your new baby?
1=YES
2=NO
………………………………………………………………………………………………
PRG7c. How many weeks or months did you breastfeed or feed pumped milk to your baby?
__________ [ALLOW 00-52]
……………………………………………………………………………………………………
PRG7c_UNITS. INTERVIEWER: ENTER RESPONSE UNIT
1=WEEKS
2=MONTHS
[HARD CHECK REQUIRED]
……………………………………………………………………………………………………
PRG8. Please look at this showcard. In the past 12 months, that is since {12 MONTH REFERENCE DATE}, have you received any of the following family planning services? You may select one or more.
SHOWCARD PRG1
1=A BIRTH CONTROL METHOD OR PRESCRIPTION
2=A CHECK-UP OR MEDICAL TEST RELATED TO USING A BIRTH CONTROL METHOD
3=COUNSELING ABOUT BIRTH CONTROL
4=COUNSELING ABOUT GETTING STERILIZED
5=EMERGENCY CONTRACEPTION OR THE "MORNING-AFTER PILL"
6=COUNSELING OR INFORMATION ABOUT EMERGENCY CONTRACEPTION OR THE "MORNING-AFTER PILL"
7=A STERILIZING OPERATION
8=OTHER
9=NONE OF THE ABOVE
………………………………………………………………………………………………
PRG9. [IF PRG8=1, 2, 3, 4, 5, 6, 7 OR 8 CONTINUE, ELSE GO TO PRG11]
How many of these services did you get at {REFERENCE HEALTH CENTER}? Would you say…?
1=All of the services
2=Some of the services
3=None of the services
…………………………………………………………………………………………………
PRG10a. [IF PRG9=1 OR 2 CONTINUE, ELSE GO TO PRG10b]
On a scale of 0 to 10, where 0 means poor and 10 means excellent, how would you rate the family planning services you received at {REFERENCE HEALTH CENTER}. Would you say….?
0=Poor
1
2
3
4
5
6
7
8
9
10=Excellent
………………………………………………………………………………………………
PRG10b. [IF PRG9=2 OR 3 CONTINUE, ELSE GO TO PRG11]
Were you referred to the other place where you got the family planning services by {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
PRG11. Please look at this show card. In the last 12 months, that is since {12 MONTH REFERENCE DATE}, was there a time that you needed any family planning service on the list but were unable to get it? You may select one or more.
SHOWCARD PRG2
1=A BIRTH CONTROL METHOD OR PRESCRIPTION
2=A CHECK-UP OR MEDICAL TEST RELATED TO USING A BIRTH CONTROL METHOD
3=COUNSELING ABOUT BIRTH CONTROL
4=COUNSELING ABOUT GETTING STERILIZED
5=EMERGENCY CONTRACEPTION OR THE "MORNING-AFTER PILL"
6=COUNSELING OR INFORMATION ABOUT EMERGENCY CONTRACEPTION OR THE "MORNING-AFTER PILL"
7=A STERILIZING OPERATION
8=NO, THERE WASN’T A TIME WHEN I NEEDED A SERVICE BUT COULDN'T GET IT
9= OTHER
10=NONE OF THE ABOVE
………………………………………………………………………………………………
PRG11_OTH. [IF PRG11=9 CONTINUE, ELSE GO TO HTG1]
Please specify the other family planning service you needed but were unable to get.
________________ [ALLOW 40]
MODULE N: HIV TESTING
HTG1. [IF INTAGE GE 18 CONTINUE, ELSE GO TO LIV1]
The next questions are about the test for HIV, the virus that causes AIDS. Your answers to these questions are private and will not be shared with anyone at {REFERENCE HEALTH CENTER}. You also have the right to refuse any question that you do not want to answer.
Except for tests you may have had as part of blood donations, have you ever been tested for HIV?
1=YES
2=NO
………………………………………………………………………………………………
HTG1a. [IF HTG1=1 CONTINUE, ELSE GO TO HTG2]
When was your last HIV test?
1=LESS THAN A YEAR AGO
2=1 YEAR BUT LESS THAN 2 YEARS AGO
3=2 YEARS BUT LESS THAN 3 YEARS AGO
4=3 YEARS BUT LESS THAN 4 YEARS AGO
5=4 YEARS BUT LESS THAN 5 YEARS AGO
6=5 OR MORE YEARS AGO
………………………………………………………………………………………………
HTG1a1. The last time you had an HIV test, did you receive your test results?
1=YES
2=NO
………………………………………………………………………………………………
HTG1b. Where did you have your last HIV test? Was it at…
1=REFERENCE HEALTH CENTER
2=Other health center
3=Private doctor or HMO office
4=Counseling and testing site
5=Hospital
6=Jail, prison or other correctional facility
7=Drug treatment facility
8=At home
9=Somewhere else
………………………………………………………………………………………………
HTG2. [IF HTG1=2 CONTINUE, ELSE GO TO HTG3]
Please look at this showcard. I am going to show you a list of reasons why some people have not been tested for HIV, the virus that causes AIDS. What is the main reason why you have not been tested?
SHOWCARD HTG1
1=IT'S UNLIKELY I’VE BEEN EXPOSED TO HIV
2=I DIDN'T KNOW WHERE TO GET TESTED
3=I WAS AFRAID OF LOSING A JOB, INSURANCE, HOUSING, FRIENDS, FAMILY, IF PEOPLE KNEW I WAS POSITIVE FOR AIDS INFECTION
4=I’M TESTED WHEN I GIVE BLOOD
5=NO PARTICULAR REASON
6=SOME OTHER REASON
………………………………………………………………………………………………
HTG2_OTH. [IF HTG2=6 CONTINUE, ELSE GO TO HTG3]
Please specify why you have not been tested?
________________ [ALLOW 60]
………………………………………………………………………………………………
HTG3. Has anyone at {REFERENCE HEALTH CENTER} ever suggested that you have a test for HIV?
1=YES
2=NO
………………………………………………………………………………………………
HTG4. Has anyone at {REFERENCE HEALTH CENTER} ever talked to you about ways to protect yourself and others from getting the HIV virus?
1=YES
2=NO
………………………………………………………………………………………………
HTG5. Have you ever been told by a doctor or other health professional that you are HIV positive or have AIDS?
1=YES
………………………………………………………………………………………………
HTG6a. [IF HTG5=1 CONTINUE, ELSE GO TO LIV1]
Are you receiving any medical care now for HIV or AIDS? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
………………………………………………………………………………………………
HTG6a1a. [IF HTG6a=2 CONTINUE, ELSE GO TO HTG6b]
Please specify where you are receiving this care:
________________ [ALLOW 40]
………………………………………………………………………………………………
HTG6a3. Were you referred there by {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
HTG6b. Are you receiving antiretroviral therapy for HIV prescribed by a doctor or other health professional? Would you say, Yes at {REFERENCE HEALTH CENTER}, Yes at some other place, or No?
[ALLOW MULTIPLE RESPONSES FOR RESPONSE 1 AND 2]
1= YES - {REFERENCE HEALTH CENTER}
2= YES - SOME OTHER PLACE
………………………………………………………………………………………………
HTG6a2. [IF HTG6b=2 CONTINUE, ELSE GO TO LIV1]
Please specify where you are receiving this care:
________________ [ALLOW 40]
………………………………………………………………………………………………
HTG6b3. Were you referred there by {REFERENCE HEALTH CENTER}?
1=YES
2=NO
………………………………………………………………………………………………
MODULE O: LIVING ARRANGEMENTS
LIV1. Now I’m going to ask you some questions about where {you are / NAME is} living right now.]
Please look at this showcard. Over the past 7 days, where did {you/NAME} usually sleep at night? Pick the single best option.
SHOWCARD LIV1
1=A HOUSE, TOWNHOUSE OR MOBILE HOME
2=AN APARTMENT OR CONDO
3=A ROOM OTHER THAN AT A HOTEL OR MOTEL
4=AN EMERGENCY SHELTER
5=A TRANSITIONAL SHELTER INCLUDES TRANSITIONAL HOUSING
6=A CHURCH OR CHAPEL
7=AN ABANDONED BUILDING
8=A PLACE OF BUSINESS
9=A CAR OR OTHER VEHICLE
10=ANYWHERE OUTSIDE
11=A HOTEL OR MOTEL (A PLACE WITH SEPARATE ROOMS YOU PAY FOR YOURSELF)
12=A family member or friend’s room, apartment, or house without payMENT OF rent
13= SOME OTHER PLACE
………………………………………………………………………………………………
LIV1_OTH. [IF LIV1=13 CONTINUE, ELSE GO TO LIV2]
Please describe the other place {you have/NAME has} usually slept over the past 7 days?
________________ [ALLOW 40]
………………………………………………………………………………………………
LIV2. [IF LIV1=1 OR 2 CONTINUE, ELSE GO TO LIV3]
How many bedrooms are in that {house / apartment}?
1 = 1 BEDROOM
2 = 2 BEDROOMS
3 = 3 BEDROOMS
4 = 4 BEDROOMS
5 = 5 BEDROOMS
6 = 6 OR MORE BEDROOMS ………………………………………………………………………………………………
LIV3. [IF LIV1=3 CONTINUE, ELSE GO TO LIV4]
Counting yourself, how many people usually sleep in that {house / apartment / room}?
1 = 1 PERSON
2 = 2 PEOPLE
3 = 3 PEOPLE
4 = 4 PEOPLE
5 = 5 OR MORE PEOPLE
………………………………………………………………………………………………
LIV4. [IF LIV1=1 OR 2 OR 3 CONTINUE, ELSE GO TO LIV5]
Do you own or rent that {house / apartment / room}?
IF NEEDED: This includes making payments on a mortgage.
1=YES – Own or rent
2=NO – Do not own or rent
………………………………………………………………………………………………
LIV5. Are you paying lower rent because the Federal, State, or local government is paying part of the cost?
1=YES
2=NO
3=OWN THEIR HOME
………………………………………………………………………………………………
LIV6. [IF LIV4=1 CONTINUE, ELSE GO TO LIV10]
{IF INTAGE GE 18 Have you or your family/IF INTAGE LE 12 Has NAME’s family/IF INTAGE=13-17your family}} ever not been able to pay {your/their} share of the rent or mortgage for {you or your family’s/their/your} own place, or have {you or your family/they} had to borrow money to pay {your/their} share of the rent or mortgage?
[PROGRAMMERS: BELOW IS HOW THE FILLS SHOULD LOOK]
[IF INTAGE GE 18] Have you or your family ever not been able to pay your share of the rent or mortgage for you or your family’s own place, or have you or your family had to borrow money to pay your share of the rent or mortgage?
[IF INTAGE LE 12] Has NAME’s family ever not been able to pay their share of the rent or mortgage for their own place, or have they had to borrow money to pay their share of the rent or mortgage?
[IF INTAGE=13-17] Has your family ever not been able to pay their share of the rent or mortgage for your own place, or have they had to borrow money to pay their share of the rent or mortgage?
1=YES
2=NO
………………………………………………………………………………………………
LIV8. [IF LIV6=1 CONTINUE, ELSE GO TO LIV9]
Will you be asked or forced to leave your own place in the next 14 days?
1=YES
2=NO
………………………………………………………………………………………………
LIV9. Have you ever NOT had your own place to live?
1=YES
2=NO
………………………………………………………………………………………………
LIV10. [IF LIV1=4,5,6,7,8,9,10,11, 12 OR IF LIV4=2 CONTINUE AND IF LIV9=1 CONTINUE, ELSE GO TO LIV15a]
[IF INTAGE GE 18] When was the last time you or your family had your own place to live, such as a house, apartment or room}?
[IF INTAGE LE 12] When was the last time {NAME’s} family had its own place to live, such as a house, apartment or room?
[IF INTAGE=13-17] When was the last time your family had its own place to live, such as a house, apartment or room?
_____________
………………………………………………………………………………………………
LIV10_UNITS. (When was the last time…had…own place to live, such as a house, apartment or room?)
INTERVIEWER: ENTER RESPONSE UNIT
1=DAYS AGO
2=WEEKS AGO
3=MONTHS AGO
4=YEARS AGO
[HARD CHECK REQUIRED]
………………………………………………………………………………………………
LIV11. Including this time…
[IF INTAGE GE18 FILL] how many times in the past 3 years, that is since {3 YEAR REFERENCE DATE}, have you not had your own place to live?
[IF INTAGE LE12 FILL] how many times in the past 3 years, that is since {3 YEAR REFERENCE DATE}, has {NAME’s} family not had its own place to live?
[IF INTAGE = 13-17 FILL] how many times in the past 3 years, that is since {3 YEAR REFERENCE DATE}, has your family not had its own place to live?
1 = 1 TIME
2 = 2 TIMES
3 = 3 TIMES
4 = 4 TIMES
5 = 5 TIMES 6 = 6 OR MORE TIMES
………………………………………………………………………………………………
LIV12. [IF LIV1=4, 5, 6, 7, 8, 9, 10, 11, 12 OR IF LIV5=2 AND IF LIV9=1]
[IF LIV5=2] Including this time…
[IF INTAGE GE 18] How many times in your life have you not had your own place to live?
[IF INTAGE LE 12] How many times in {NAME’s} life has {NAME’s} family not had its own place to live?
[IF INTAGE=13-17] How many times in your life has your family not had its own place to live?
1 = 1 TIME
2 = 2 TIMES
3 = 3 TIMES
4 = 4 TIMES
5 = 5 TIMES 6 = 6 OR MORE TIMES
………………………………………………………………………………………………
LIV13. How old {were you/was NAME} the first time {you/he/she} didn’t have a place of {your/his/her} own to live?
________________ AGE [ALLOW 000-109]
PROGRAMMER: AGE CHECK SO AGE REPORTED HERE IS NOT HIGHER THAN AGE REPORTED FROM INTDOB OR INTAGE.
………………………………………………………………………………………………
LIV14. If you added up all the times in {your/NAME’s} life that {you/he/she} didn’t have a place of {your/his/her} own to live, how long would you say that was?
__________
………………………………………………………………………………………………
LIV14_UNITS. (If you added up all the times in {your/NAME’s} life that {you/he/she} didn’t have a place of {your/his/her} own to live, how long would you say that was??)
INTERVIEWER: ENTER RESPONSE UNIT
1=DAYS
2=WEEKS
3=MONTHS
4=YEARS
[HARD CHECK REQUIRED]
……………………………………………………………………………………………
LIV15a. I’m going to read you several statements that people have made about their food situation in the last 12 months. For these statements, please tell me whether the statement was often true, sometimes true, or never true.
The food that I bought just didn’t last, and I didn’t have money to get more.
Would you say often true, sometimes true, or never true for your household in the last 12 months?
INTERVIEWER: THE FOLLOWING QUESTIONS ARE DESIGNED TO CAPTURE DATA AT THE HOUSEHOLD LEVEL AND NOT FOCUSED ON THE INDIVIDUAL PATIENT.
1=Often true
2=Sometimes true
3=Never true
………………………………………………………………………………………………
LIV15b. (I’m going to read you several statements that people have made about their food situation in the last 12 months.)
I couldn’t afford to eat balanced meals.
Would you say often true, sometimes true, or never true for your household in the last 12 months?
1=Often true
2=Sometimes true
3=Never true
……………………………………………………………………………………………
LIV15c. In the last 12 months, did you ever cut the size of your meals or skip meals because there wasn't enough money for food?
1=YES
2=No
……………………………………………………………………………………………
LIV15d. [IF LIV15c=1 CONTINUE, ELSE GO TO LIV15e]
How often did this happen—almost every month, some months but not every month, or in only one or two months?
1=Almost
every month
2=Some months but not every month
3=Only one
or two months
……………………………………………………………………………………………
LIV15e. In
the last 12 months, did you ever eat less than you felt you should
because there wasn't enough money for food?
1=YES
2=No
……………………………………………………………………………………………
LIV15f.
In the last 12 months, were you ever hungry but didn't eat because
there wasn't enough money for food? Please think about hunger you may
have experienced and not hunger of other people in your household.
1=YES
2=No
……………………………………………………………………………………………
MODULE P: NEIGHTBORHOOD CHARACTERISTICS
The next few questions are about your neighborhood.
NEI1. How safe do you feel in your neighborhood?
1=Very safe
2=Moderately safe
3=Moderately unsafe
4=Very unsafe
………………………………………………………………………………………………
NEI2. How would you rate your neighborhood as a place to raise children? Would you say that it is excellent, very good, good, fair, or poor?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR
………………………………………………………………………………………………
NEI3. How would you rate the condition of the street in the block where you live?
1=Very good – The street has been recently resurfaced or is smooth
2=Moderate – The street is kept in good repair
3=Fair – Only minor street repairs are needed
4=Poor – There are potholes or other signs of neglect
………………………………………………………………………………………………
NEI4. Generally speaking, how much can you trust people who live in your neighborhood. Would you say that you can trust your neighbors a lot, some, only a little, or not at all?
1=A LOT
2=SOME
3=ONLY A LITTLE
4=NOT AT ALL
………………………………………………………………………………………………
NEI 5. In the past month, how many times have you had a conversation with a neighbor? Would you say never, once or twice, once a week or less, or more than once a week?
1=NEVER
2=ONCE OR TWICE
3=ONCE A WEEK OR LESS
4=MORE THAN ONCE A WEEK
………………………………………………………………………………………………
NEI 6. How would you rate the current quality of the public schools attended by children in your neighborhood? Are they excellent, very good, good, fair, or poor?
1=EXCELLENT
2=VERY GOOD
3=GOOD
4=FAIR
5=POOR
………………………………………………………………………………………………
NEI 7. Which of the following best describes the immediate area or street (one block, both sides) where you live?
1=Rural farm
2=Rural town
3=Suburban
4=Urban
5=Other
………………………………………………………………………………………………
NEI 8. How close is the nearest public space, park, or playground to your home?
1=Within a half mile
2=More than a half mile but less than a mile
3=More than a mile but less than 2 miles
4=2 or more miles away
………………………………………………………………………………………………
MODULE Q: INCOME AND ASSETS
INC1a. When {you go/NAME goes} to {REFERENCE HEALTH CENTER}, does {REFERENCE HEALTH CENTER} reduce the charge for the services provided because of your income level?
1=YES
2=NO
………………………………………………………………………………………………
INC1b.
The next questions are about {your/NAME’s} total family income in {LAST CALENDAR YEAR IN 4-DIGIT FORMAT} before taxes. Income is important in analyzing the health information we collect.
Please look at this card which lists the types of income we would like for you to include.
SHOWCARD INC1
IF NEEDED: READ THE FOLLOWING CONTENT.
When answering this next question, we would like you to:
Include your income PLUS the income of all family members living in your household
Include all types of income, including:
Income from child support or alimony;
Rental income;
Any cash assistance from a state or county welfare program;
Income from Worker’s Compensation or unemployment compensation;
Any retirement, disability or survivor pension; and
Any interest or investment income.
What is your best estimate of the total income of {your/NAME’s} household? Please remember to include your income and the income of all family members living in your household from all sources, before taxes, in {LAST CALENDAR YEAR IN 4 DIGIT FORMAT}?
$________________ DOLLARS [ALLOW 000,000-999,995]
………………………………………………………………………………………………
INC1b1. [IF INC1b= DK OR RF CONTINUE, ELSE GO TO INC1c]
Was {your/NAME’s} total family income in the past 12 months…?
1=Below $35,000
2=$35,000 or more
………………………………………………………………………………………………
INC1b1b. [IF INC1b1= 1 CONTINUE ELSE GO TO INC1b2]
We would like to get a better estimate of your total household income in the past 12 months before taxes. Was it...?
1=$5,000 to $9,999
2=$10,000 to $14,999
3=$15,000 to $24,999
4=$25,000 to $34,999
………………………………………………………………………………………………
INC1b2. [IF INC1b1= 2 CONTINUE, ELSE GO TO INC1c.]
We would like to get a better estimate of your total household income in the past 12 months before taxes. Was it...?
1=35,000 to $49,999
2=$50,000 to $74,999
3=$75,000 to $99,999
4=$100,000 to $149,999
5=$150,000 to $175,000
6=More than $175,000
………………………………………………………………………………………………
INC1c. [IF INC1b NE DK, RE CONTINUE, ELSE GO TO INC1d]
Including {you/NAME}, how many family members did that income support for {LAST CALENDAR YEAR IN 4 DIGIT FORMAT}?
______ FAMILY MEMBERS [ALLOW 01-20]
SOFT CHECK: This question is important, please provide a response.
………………………………………………………………………………………………
INC1d. [IF INC1b or INC1b1=DK, RE CONTINUE, ELSE GO TO INC3a] Although you were unable to provide {your/NAME’s} family income for {LAST CALENDAR YEAR IN 4 DIGIT FORMAT}, can you tell me how many family members were supported by {your/NAME’s} family income, including {yourself/NAME}?
______ FAMILY MEMBERS [ALLOW 01-20]
………………………………………………………………………………………………
IF INC1c OR INC1d NOT EQUAL TO DK OR RE, CONTINUE ELSE GOTO INC3a
Note: Poverty threshold tables will be updated when 2019 tables are available.
-
Poverty Thresholds for 2018 by Size of Family and Number of Related Children Under 18 Years – 48 Contiguous States + DC
Size of Family Unit
FPL (weighted avg)
One person (unrelated individual)
$ 12,060
Two people
16,240
Three people
20,420
Four people
24,600
Five people
28,780
Six people
32,960
Seven people
37,140
Eight people
41,320
For families/households with more than 8 persons, add $4,180 for each additional person.
Source: Federal Register – Published January 2018
-
Poverty Thresholds for 2018 by Size of Family and Number of Related Children Under 18 Years – Alaska
Size of Family Unit
FPL (weighted avg)
One person (unrelated individual)
$15,180
Two people
20,580
Three people
25,980
Four people
31,380
Five people
36,780
Six people
42,180
Seven people
47,580
Eight people
52,980
For families/households with more than 8 persons, add $5,400 for each additional person.
Source: Federal Register – Published January 2018
-
Poverty Thresholds for 2018 by Size of Family and Number of Related Children Under 18 Years – Hawaii
Size of Family Unit
FPL (weighted avg)
One person (unrelated individual)
$13,960
Two people
18,930
Three people
23,900
Four people
28,870
Five people
33,840
Six people
38,810
Seven people
43,780
Eight people
48,750
For families/households with more than 8 persons, add $4,970 for each additional person.
Source: Federal Register – Published January 2018
INC2.
[USE TABLE AND RESPONSE TO INC1c TO DETERMINE FILLS FOR FPL AND 2XFPL BELOW].
During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, was {your/NAME’s} total family income from all sources less than {FILL FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c}, more than {FILL FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c} but less than {FILL 2X FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c} or {FILL 2X FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c} or more?
[IF RESPONDENT SAYS DK – AUTOMATICALLY REPEAT QUESTION AND ASK RESPONDENT TO GIVE US THEIR BEST ESTIMATE.]
1=LESS THAN {FILL FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1d}
2=MORE THAN {FILL FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1d} BUT LESS THAN {FILL 2X FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1c}
3= {FILL 2X FAMILY POVERTY LEVEL BASED ON RESPONSE TO INC1d} OR MORE
………………………………………………………………………………………………
INC3a. During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, did {you/NAME} or anyone else in {your/his/her} household receive any of the following forms of public assistance?
Food stamps?
1=YES
2=NO
………………………………………………………………………………………………
INC3b. (During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, did {you/NAME} or anyone else in {your/his/her} household receive any of the following forms of public assistance?)
WIC—the Women, Infants, and Children nutrition program?
1=YES
2=NO
………………………………………………………………………………………………
INC3c. (During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, did {you/NAME} or anyone else in {your/his/her} household receive any of the following forms of public assistance?)
Aid from a state Temporary Assistance for Needy Families (TANF) plan?
1=YES
2=NO
………………………………………………………………………………………………
INC3d. (During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, did {you/NAME} or anyone else in {your/his/her} household receive any of the following forms of public assistance?)
Section 8 or Housing Choice Voucher?
1=YES
2=NO
………………………………………………………………………………………………
INC3e. (During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, did {you/NAME} or anyone else in {your/his/her} household receive any of the following forms of public assistance?)
Project-based Section 8?
1=YES
2=NO
………………………………………………………………………………………………
INC3f. (During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, did {you/NAME} or anyone else in {your/his/her} household receive any of the following forms of public assistance?)
Public housing?
1=YES
2=NO
………………………………………………………………………………………………
INC3g. (During {LAST CALENDAR YEAR IN 4-DIGIT FORMAT}, did {you/NAME} or anyone else in {your/his/her} household receive any of the following forms of public assistance?)
Any other assistance from the government?
1=YES
2=NO
………………………………………………………………………………………………
MODULE R: DEMOGRAPHICS
DMO_INT.
We just have a few questions remaining.
1=CONTINUE
POSTLOGIC: [IF INT_TEENPAR=1 GO TO DMO4, ELSE CONTINUE]
………………………………………………………………………………………………
DMO5. [IF INT3=2 CONTINUE, ELSE GO TO DMO5_M] [IF INTAGE GE 13 CONTINUE, ELSE GO TO DMO1]
Which of the following best represents how you think of yourself?
1= Lesbian or gay
2= Straight, that is not lesbian or gay
3= Bisexual
4= Something else
5= I don’t know the answer
…………………………………………………………………………………………………
DMO5_M. [IF INT3=1 CONTINUE, ELSE GO TO DMO1] [IF INTAGE GE 13 CONTINUE, ELSE GO TO DMO6a]
Which of the following best represents how you think of yourself?
1= Gay
2= Straight, that is not gay
3= Bisexual
4= Something else
5= I don’t know the answer
…………………………………………………………………………………………………
DMO6a. [IF INTAGE >=13 CONTINUE, ELSE GO TO DMO1]
Do you currently describe yourself as male, female, or transgender?
1=MALE
2=FEMALE
3=TRANSGENDER
4=NONE OF THESE
……………………………………………………………………………………………………
DMO6b. [IF INT3=1 and DMO6a=2] OR [IF INT3=2 and DMO6a =1] OR [DMO6a=3 OR 4 CONTINUE, ELSE GO TO DMO1]
Just to confirm, you were assigned {IF INT3=1: FILL “male” }{IF INT3=2: FILL “female”} at birth and now you describe yourself as {IF DMO6a=1: FILL “male”}{IF DMO6a=2: FILL “female”} { DMO6a =3: FILL “transgender”} {IF DMO6a =4: FILL “none of these”}. Is that correct?
1=YES
2=NO
3=DON’T KNOW
4=REFUSED
………………………………………………………………………………………………
DMO1. {Were you/Was NAME} born in the United States?
1=YES
2=NO
………………………………………………………………………………………………
DMO1a. [IF DMO1=2 CONTINUE, ELSE GOTO DMO3]
In what country {were you/was NAME} born?
________ [LIST COUNTRIES SHOWN IN DOM3a BELOW]
………………………………………………………………………………………………
DMO2. In what year did {you/NAME} come to the United States?
________ YEAR [ALLOW 1910–2020]
………………………………………………………………………………………………
DMO3. Was {your/NAME’s} father born in the United States?
1=YES
2=NO
………………………………………………………………………………………………
DMO3a. [IF DMO3=2 CONTINUE, ELSE GO TO DOM3b]
In what country was {your/NAME’s} father born?
________ [LIST COUNTRIES]
1 |
Bermuda |
2 |
Canada |
3 |
Greenland |
4 |
Saint Pierre and Miquelon |
5 |
Anguilla |
6 |
Antigua and Barbuda |
7 |
Aruba |
8 |
Bahamas |
9 |
Barbados |
10 |
British Virgin Islands |
11 |
Cayman Islands |
12 |
Cuba |
13 |
Dominica |
14 |
Dominican Republic |
15 |
Grenada |
16 |
Guadeloupe |
17 |
Haiti |
18 |
Jamaica |
19 |
Martinique |
20 |
Montserrat |
21 |
Netherlands Antilles |
22 |
Puerto Rico |
23 |
Saint-Barthelemy |
24 |
Saint Kitts and Nevis |
25 |
Saint Lucia |
26 |
Saint Martin (France) |
27 |
Saint Vincent and the Grenadines |
28 |
Trinidad and Tobago |
29 |
Turks and Caicos Islands |
30 |
Belize |
31 |
Costa Rica |
32 |
El Salvador |
33 |
Guatemala |
34 |
Honduras |
35 |
Mexico |
36 |
Nicaragua |
37 |
Panama |
38 |
Argentina |
39 |
Bolivia |
40 |
Brazil |
41 |
Chile |
42 |
Colombia |
43 |
Ecuador |
44 |
Falkland Islands (Malvinas) |
45 |
French Guiana |
46 |
Guyana |
47 |
Paraguay |
48 |
Peru |
49 |
Suriname |
50 |
Uruguay |
51 |
Venezuela |
52 |
Belarus |
53 |
Bulgaria |
54 |
Czech Republic |
55 |
Hungary |
56 |
Poland |
57 |
Moldova |
58 |
Romania |
59 |
Russian Federation |
60 |
Slovakia |
61 |
Ukraine |
62 |
Aland Islands |
63 |
Channel Islands |
64 |
Denmark |
65 |
Estonia |
66 |
Faeroe Islands |
67 |
Finland |
68 |
Guernsey |
69 |
Iceland |
70 |
Republic of Ireland |
71 |
Isle of Man |
72 |
Jersey |
73 |
Latvia |
74 |
Lithuania |
75 |
Norway |
76 |
Svalbard and Jan Mayen Islands |
77 |
Sweden |
78 |
United Kingdom |
79 |
Austria |
80 |
Belgium |
81 |
France |
82 |
Germany |
83 |
Liechtenstein |
84 |
Luxembourg |
85 |
Monaco |
86 |
Netherlands |
87 |
Switzerland |
88 |
Albania |
89 |
Andorra |
90 |
Bosnia and Herzegovina |
91 |
Croatia |
92 |
Gibraltar |
93 |
Greece |
94 |
Vatican City |
95 |
Italy |
96 |
Malta |
97 |
Montenegro |
98 |
Portugal |
99 |
Republic of Macedonia |
100 |
San Marino |
101 |
Serbia |
102 |
Slovenia |
103 |
Spain |
104 |
Australia |
105 |
New Zealand |
106 |
Norfolk Island |
107 |
Fiji |
108 |
New Caledonia |
109 |
Papua New Guinea |
110 |
Solomon Islands |
111 |
Vanuatu |
112 |
Guam |
113 |
Kiribati |
114 |
Marshall Islands |
115 |
Micronesia (Federated States of) |
116 |
Nauru |
117 |
Northern Mariana Islands |
118 |
Palau |
119 |
American Samoa |
120 |
Cook Islands |
121 |
French Polynesia |
122 |
Niue |
123 |
Pitcairn |
124 |
Samoa |
125 |
Tokelau |
126 |
Tonga |
127 |
Tuvalu |
128 |
Wallis and Futuna Islands |
129 |
Burundi |
130 |
Comoros |
131 |
Djibouti |
132 |
Eritrea |
133 |
Ethiopia |
134 |
Kenya |
135 |
Madagascar |
136 |
Malawi |
137 |
Mauritius |
138 |
Mayotte |
139 |
Mozambique |
140 |
Reunion |
141 |
Rwanda |
142 |
Seychelles |
143 |
Somalia |
144 |
Uganda |
145 |
United Republic of Tanzania |
146 |
Zambia |
147 |
Zimbabwe |
148 |
Angola |
149 |
Cameroon |
150 |
Central African Republic |
151 |
Chad |
152 |
Democratic Republic of the Congo |
153 |
Equatorial Guinea |
154 |
Gabon |
155 |
Republic of the Congo |
156 |
Algeria |
157 |
Egypt |
158 |
Libya |
159 |
Morocco |
160 |
Sudan |
161 |
Tunisia |
162 |
Western Sahara |
163 |
Botswana |
164 |
Lesotho |
165 |
Namibia |
166 |
South Africa |
167 |
Swaziland |
168 |
Benin |
169 |
Burkina Faso |
170 |
Cape Verde |
171 |
Cote d'Ivoire |
172 |
Gambia |
173 |
Ghana |
174 |
Guinea |
175 |
Guinea-Bissau |
176 |
Liberia |
177 |
Mali |
178 |
Mauritania |
179 |
Niger |
180 |
Nigeria |
181 |
Saint Helena |
182 |
Senegal |
183 |
Sierra Leone |
184 |
Togo |
185 |
Kazakhstan |
186 |
Kyrgyzstan |
187 |
Tajikistan |
188 |
Turkmenistan |
189 |
Uzbekistan |
190 |
Afghanistan |
191 |
Bangladesh |
192 |
Bhutan |
193 |
India |
194 |
Iran |
195 |
Maldives |
196 |
Nepal |
197 |
Pakistan |
198 |
Sri Lanka |
199 |
Armenia |
200 |
Azerbaijan |
201 |
Bahrain |
202 |
Cyprus |
203 |
Georgia |
204 |
Iraq |
205 |
Israel |
206 |
Jordan |
207 |
Kuwait |
208 |
Lebanon |
209 |
Oman |
210 |
Palestinian territories (West Bank and Gaza Strip) |
211 |
Qatar |
212 |
Saudi Arabia |
213 |
Syrian Arab Republic |
214 |
Turkey |
215 |
United Arab Emirates |
216 |
Yemen |
217 |
China - the People's Republic of China (including Hong Kong and Macao) |
218 |
Taiwan (the Republic of China) |
219 |
Japan |
220 |
Mongolia |
221 |
North Korea |
222 |
South Korea |
223 |
Brunei Darussalam |
224 |
Cambodia |
225 |
Indonesia |
226 |
Lao People's Democratic Republic |
227 |
Malaysia |
228 |
Myanmar (Burma) |
229 |
Philippines |
230 |
Singapore |
231 |
Thailand |
232 |
Timor-Leste |
233 |
Vietnam |
234 |
Other |
………………………………………………………………………………………………
DMO3b. Was {your/NAME’s} mother born in the United States?
1=YES
2=NO
………………………………………………………………………………………………
DMO3c. [IF DMO3b=2 CONTINUE, ELSE GO TO DMO4.]
In what country was {your/NAME’s} mother born?
________ [LIST COUNTRIES]
1 |
Bermuda |
2 |
Canada |
3 |
Greenland |
4 |
Saint Pierre and Miquelon |
5 |
Anguilla |
6 |
Antigua and Barbuda |
7 |
Aruba |
8 |
Bahamas |
9 |
Barbados |
10 |
British Virgin Islands |
11 |
Cayman Islands |
12 |
Cuba |
13 |
Dominica |
14 |
Dominican Republic |
15 |
Grenada |
16 |
Guadeloupe |
17 |
Haiti |
18 |
Jamaica |
19 |
Martinique |
20 |
Montserrat |
21 |
Netherlands Antilles |
22 |
Puerto Rico |
23 |
Saint-Barthelemy |
24 |
Saint Kitts and Nevis |
25 |
Saint Lucia |
26 |
Saint Martin (France) |
27 |
Saint Vincent and the Grenadines |
28 |
Trinidad and Tobago |
29 |
Turks and Caicos Islands |
30 |
Belize |
31 |
Costa Rica |
32 |
El Salvador |
33 |
Guatemala |
34 |
Honduras |
35 |
Mexico |
36 |
Nicaragua |
37 |
Panama |
38 |
Argentina |
39 |
Bolivia |
40 |
Brazil |
41 |
Chile |
42 |
Colombia |
43 |
Ecuador |
44 |
Falkland Islands (Malvinas) |
45 |
French Guiana |
46 |
Guyana |
47 |
Paraguay |
48 |
Peru |
49 |
Suriname |
50 |
Uruguay |
51 |
Venezuela |
52 |
Belarus |
53 |
Bulgaria |
54 |
Czech Republic |
55 |
Hungary |
56 |
Poland |
57 |
Moldova |
58 |
Romania |
59 |
Russian Federation |
60 |
Slovakia |
61 |
Ukraine |
62 |
Aland Islands |
63 |
Channel Islands |
64 |
Denmark |
65 |
Estonia |
66 |
Faeroe Islands |
67 |
Finland |
68 |
Guernsey |
69 |
Iceland |
70 |
Republic of Ireland |
71 |
Isle of Man |
72 |
Jersey |
73 |
Latvia |
74 |
Lithuania |
75 |
Norway |
76 |
Svalbard and Jan Mayen Islands |
77 |
Sweden |
78 |
United Kingdom |
79 |
Austria |
80 |
Belgium |
81 |
France |
82 |
Germany |
83 |
Liechtenstein |
84 |
Luxembourg |
85 |
Monaco |
86 |
Netherlands |
87 |
Switzerland |
88 |
Albania |
89 |
Andorra |
90 |
Bosnia and Herzegovina |
91 |
Croatia |
92 |
Gibraltar |
93 |
Greece |
94 |
Vatican City |
95 |
Italy |
96 |
Malta |
97 |
Montenegro |
98 |
Portugal |
99 |
Republic of Macedonia |
100 |
San Marino |
101 |
Serbia |
102 |
Slovenia |
103 |
Spain |
104 |
Australia |
105 |
New Zealand |
106 |
Norfolk Island |
107 |
Fiji |
108 |
New Caledonia |
109 |
Papua New Guinea |
110 |
Solomon Islands |
111 |
Vanuatu |
112 |
Guam |
113 |
Kiribati |
114 |
Marshall Islands |
115 |
Micronesia (Federated States of) |
116 |
Nauru |
117 |
Northern Mariana Islands |
118 |
Palau |
119 |
American Samoa |
120 |
Cook Islands |
121 |
French Polynesia |
122 |
Niue |
123 |
Pitcairn |
124 |
Samoa |
125 |
Tokelau |
126 |
Tonga |
127 |
Tuvalu |
128 |
Wallis and Futuna Islands |
129 |
Burundi |
130 |
Comoros |
131 |
Djibouti |
132 |
Eritrea |
133 |
Ethiopia |
134 |
Kenya |
135 |
Madagascar |
136 |
Malawi |
137 |
Mauritius |
138 |
Mayotte |
139 |
Mozambique |
140 |
Reunion |
141 |
Rwanda |
142 |
Seychelles |
143 |
Somalia |
144 |
Uganda |
145 |
United Republic of Tanzania |
146 |
Zambia |
147 |
Zimbabwe |
148 |
Angola |
149 |
Cameroon |
150 |
Central African Republic |
151 |
Chad |
152 |
Democratic Republic of the Congo |
153 |
Equatorial Guinea |
154 |
Gabon |
155 |
Republic of the Congo |
156 |
Algeria |
157 |
Egypt |
158 |
Libya |
159 |
Morocco |
160 |
Sudan |
161 |
Tunisia |
162 |
Western Sahara |
163 |
Botswana |
164 |
Lesotho |
165 |
Namibia |
166 |
South Africa |
167 |
Swaziland |
168 |
Benin |
169 |
Burkina Faso |
170 |
Cape Verde |
171 |
Cote d'Ivoire |
172 |
Gambia |
173 |
Ghana |
174 |
Guinea |
175 |
Guinea-Bissau |
176 |
Liberia |
177 |
Mali |
178 |
Mauritania |
179 |
Niger |
180 |
Nigeria |
181 |
Saint Helena |
182 |
Senegal |
183 |
Sierra Leone |
184 |
Togo |
185 |
Kazakhstan |
186 |
Kyrgyzstan |
187 |
Tajikistan |
188 |
Turkmenistan |
189 |
Uzbekistan |
190 |
Afghanistan |
191 |
Bangladesh |
192 |
Bhutan |
193 |
India |
194 |
Iran |
195 |
Maldives |
196 |
Nepal |
197 |
Pakistan |
198 |
Sri Lanka |
199 |
Armenia |
200 |
Azerbaijan |
201 |
Bahrain |
202 |
Cyprus |
203 |
Georgia |
204 |
Iraq |
205 |
Israel |
206 |
Jordan |
207 |
Kuwait |
208 |
Lebanon |
209 |
Oman |
210 |
Palestinian territories (West Bank and Gaza Strip) |
211 |
Qatar |
212 |
Saudi Arabia |
213 |
Syrian Arab Republic |
214 |
Turkey |
215 |
United Arab Emirates |
216 |
Yemen |
217 |
China - the People's Republic of China (including Hong Kong and Macao) |
218 |
Taiwan (the Republic of China) |
219 |
Japan |
220 |
Mongolia |
221 |
North Korea |
222 |
South Korea |
223 |
Brunei Darussalam |
224 |
Cambodia |
225 |
Indonesia |
226 |
Lao People's Democratic Republic |
227 |
Malaysia |
228 |
Myanmar (Burma) |
229 |
Philippines |
230 |
Singapore |
231 |
Thailand |
232 |
Timor-Leste |
233 |
Vietnam |
234 |
Other |
………………………………………………………………………………………………
DMO4. [IF INTAGE =13-17 GOTO END, ELSE CONTINUE]
What is the highest grade or year of school you have completed?
0=NEVER ATTENDED
1=KINDERGARTEN
2=1ST GRADE
3=2ND GRADE
4=3RD GRADE
5=4TH GRADE
6=5TH GRADE
7=6TH GRADE
8=7TH GRADE
9=8TH GRADE
10=9TH GRADE
11=10TH GRADE
12=11TH GRADE
13=12TH GRADE, NO DIPLOMA
14=HIGH SCHOOL GRADUATE
15=GED OR EQUIVALENT
16=SOME COLLEGE, NO DEGREE
17=ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR VOCATIONAL PROGRAM
18=ASSOCIATE DEGREE: ACADEMIC PROGRAM
19=BACHELOR’S DEGREE (EXAMPLE: BA, AB, BS, BBA)
20=MASTER’S DEGREE (EXAMPLE: MA, MS, MENG, MED, MBA)
21=PROFESSIONAL SCHOOL OR DOCTORAL DEGREE (EXAMPLE: MD, DDS, DVM, JD, PHD, EDD)
22=OTHER
………………………………………………………………………………………………
DMO4_OTH. [IF DMO4=22 CONTINUE, ELSE GO TO DMO7]
Please describe the highest grade or year of school you have completed?
_________ [ALLOW 60]
………………………………………………………………………………………………
DMO7. How many times {you have/NAME has} moved in the past 12 months, that is since {12 MONTH REFERENCE DATE}?
9=0
1=1
2=2
3=3
4=4
5=5
6=6-10
7=11-15
8=MORE THAN 15
99=HOMELESS – NOT APPLICABLE
………………………………………………………………………………………………
DMO8. [IF DMO7=1-8 CONTINUE, ELSE GO TO DMO9]
How many of these moves were related to the work of someone in the family? For example, moving to a place to do farm work there or to look for work there, and moving back home after the farming season ended.
9=0
1=1
2=2
3=3
4=4
5=5
6=6-10
7=11-15
8=MORE THAN 15
………………………………………………………………………………………………
DMO9. [IF INTAGE =13-17 GOTO END, ELSE CONTINUE]
Are you ……?
1=Married
2=Have a domestic partner
3=Widowed
4=Divorced
5=Separated
6=Never married
……………………………………………………………………………………………
DMO9a. [IF DMO9=1 OR 2 CONTINUE, ELSE GO TO DMO10]
Is your spouse or partner living with you?
1=YES
2=NO
………………………………………………………………………………………………
DMO10.
Have you ever served in the U.S. Armed Forces, military Reserves, or the National Guard?
1=YES
2=NO
………………………………………………………………………………………………
DMO10a. [IF DMO10=1 CONTINUE, ELSE GO TO DMO11]
Which of the following best describes your service in the U.S. military?
1=Currently on active duty
2=Currently in the Reserves or National Guard
3=Retired from military service
4=Medically discharged from military service
5=Discharged from military service
………………………………………………………………………………………………
DMO10b. [IF DMO10a=3, 4 OR 5 CONTINUE, ELSE GO TO DMO11]
Are you eligible for veteran’s benefits? Would you say Yes, No, or the VA does not provide coverage for my medical condition?
1=YES
2=NO
3=VA does not provide coverage for my medical condition
………………………………………………………………………………………………
DMO10b_OTH. [IF DMO10b=3 CONTINUE, ELSE GO TO DMO10c]
What medical condition or treatment does the VA not provide coverage for?
________________ [ALLOW 80]
………………………………………………………………………………………………
DMO10c. [IF DMO10b=1 CONTINUE, ELSE GO TO DMO11]
In the past 12 months, that is since {12 MONTH REFERENCE DATE}, have you received health care from VA facilities?
1=YES
2=NO
………………………………………………………………………………………………
DMO11.
The next few questions are about employment status. Information on employment is important in analyzing the health information we collect. For example, with this information, we can learn whether patients who work full-time use medical services more or less often than those that don’t work full-time.
Which of the following were you doing last week?
1=Working at a job or business
2=With a job or business but not at work
3=Looking for work
4=Working, but not for pay, at family-owned job or business
5=Not working at a job or business and not looking for work
………………………………………………………………………………………………
DMO11a. [IF DMO11=2, 3 OR 5 CONTINUE; IF DMO11=1 GO TO DMO11b; IF DMO11=4 GO TO DMO11c; IF DMO11=DK OR RE GO TO DMO12]
What is the main reason you did not…
[IF DMO11=2] work last week?
[IF DMO11= 3 OR] have a job or business last week?
1=TAKING CARE OF HOUSE OR FAMILY
2=GOING TO SCHOOL
3=RETIRED
4=ON A PLANNED VACATION FROM WORK
5=ON FAMILY OR MATERNITY LEAVE
6=TEMPORARILY UNABLE TO WORK FOR HEALTH REASONS
7=HAVE A JOB/CONTRACT AND OFF-SEASON
8=ON LAYOFF
9=DISABLED
10=OTHER
………………………………………………………………………………………………
DMO11a_OTH. [IF DMO11a=10 CONTINUE, ELSE GO TO DMO11b]
What is the other reason you did not…
[IF DMO11=2] work last week?
[IF DMO11=3 OR 5] have a job or business last week?
________________ [ALLOW 60]
………………………………………………………………………………………………
DMO11b.
[IF DMO11=1] Do you have more than one paying job or business?
[IF DMO11=2, 3 OR 5] When you were working, did you normally have more than one paying job or business?
1=YES
2=NO
………………………………………………………………………………………………
DMO11c.
[IF DMO11=1 OR 4] How many hours did you work last week at all jobs or businesses?
[IF DMO11=2, 3 OR 5] How many hours did you usually work per week at all jobs or businesses?
_______HOURS [ALLOW 000-120]
………………………………………………………………………………………………
DMO11d. [IF (DMO11c LE 34, RE OR DK) AND (DMO11 = 1 OR 4) CONTINUE, ELSE GO TO DMO11g]
Do you usually work 35 hours or more per week in total at all jobs or businesses?
1=YES
2=NO
………………………………………………………………………………………………
DMO11f. [IF DMO11=1 OR 4 CONTINUE, ELSE GO TO DMO11g]
Do you currently have paid sick leave on this job or business?
1=YES
2=NO
………………………………………………………………………………………………
DMO11g. Now, I have questions about work you did in {LAST CALENDAR YEAR IN 4 DIGIT FORMAT}.
Did you work for pay at any time in {LAST CALENDAR YEAR IN 4 DIGIT FORMAT}?
1=YES
2=NO
………………………………………………………………………………………………
DMO11h. [IF DMO11g=1 CONTINUE, ELSE GO TO DMO12]
How many months in {LAST CALENDAR YEAR IN 4 DIGIT FORMAT} did you have at least one job or business?
________________MONTHS [ALLOW 00-12]
………………………………………………………………………………………………
DMO11j. [IF DMO11h GE 1 CONTINUE, ELSE GO TO DMO12]
Does your job or business cover any health insurance costs for any of its employees?
1=YES
2=NO
………………………………………………………………………………………………
DMO11k. [IF INS7=2 AND DMO11j=2 CONTINUE, ELSE GO TO DMO12].
Why aren’t you included in your employer’s health insurance plan?
CODE ALL THAT APPLY
1=DO NOT NEED OR WANT ANY HEALTH INSURANCE
2=RARELY SICK
3=TOO MUCH HASSLE/PAPERWORK
4=COULD NOT AFFORD/TOO EXPENSIVE
5=DO NOT WORK ENOUGH HOURS IN A WEEK
6=HAVE NOT WORKED THERE LONG ENOUGH
7=DOUBT ELIGIBLE/REJECTED BECAUSE OF HEALTH CONDITION
8=BENEFIT PACKAGE DIDN’T MEET NEEDS
9=OTHER
………………………………………………………………………………………………
DMO11k_OTH. [IF DMO11k=9 CONTINUE, ELSE GO TO DMO12]
What is the other reason you are not included in your employer’s health insurance plan?
________________ [ALLOW 40]
………………………………………………………………………………………………
DMO12. [IF [SCREENER S2a] =1 CONTINUE, ELSE GO TO END]
Have you done farm work in the last 24 months, that is since {24 MONTH REFERENCE DATE}?
1=YES
2=NO
………………………………………………………………………………………………
DMO12a. [IF DMO12=1 CONTINUE, ELSE GO TO END]
Are you currently employed by a grower or rancher, contractor, packing service, packing house or a non-farm related employer?
1=GROWER/RANCHER
2=CONTRACTOR
3=PACKING SERVICE
4=PACKING HOUSE
5=NON-FARM RELATED EMPLOYER
6=NOT EMPLOYED
………………………………………………………………………………………………
DMO12b. Approximately how many years have you done farm work in the U.S.?
NOTE: COUNT ANY YEAR IN WHICH 15 DAYS OR MORE WERE WORKED
________________ YEARS [ALLOW 000-112]
………………………………………………………………………………………………
DMO12c. Approximately how many years have you done non-farm work in the U.S.?
NOTE: COUNT ANY YEAR IN WHICH 15 DAYS OR MORE WERE WORKED
________________ YEARS [ALLOW 000-112]
………………………………………………………………………………………………
DMO12d. Approximately how many months during the past 12 months, that is since {12 MONTH REFERENCE DATE} have you been in the U.S.?
________________ MONTHS [ALLOW 00-12]
………………………………………………………………………………………………
END. Thank you very much. These are all the questions I have for you today.
1=CONTINUE
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | swicegood |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |
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