Form 0920-1291 Survey Questionnaire for ABS Online Respondents

Attachment 3: Survey Questionnaire for ABS Online Respondents

/***Formatting Notes:

• Blue text appears for programming, testing, and analysis purposes. It will not appear on screens for respondents.

• For the RDD Push-to-Web pilot:

  • As a default setting, questions will appear in bold in most desktop browsers.

  • This survey will only be offered in English.

  • During testing, question labels may appear on the screen but they will not appear in the final version shown to sample members.

  • Numeric codes will not appear next to fixed-choice answer options. Selection bubbles or boxes will appear instead.

  • At the top of the screen, the study name (CDC Health Survey) and the RTI International logo will appear.

  • At the bottom of each screen, the following static text will appear:

If you would like more information about the study, please call our survey manager at 833-997-2717 or send an email to [email protected]”

OMB Control Number: 0920-1291 Expiration 3/31/3023.

To confirm the legitimacy of this survey directly with the CDC,

please call 1-800-CDC-INFO (1-800-232-4636).

/***

[Experimental variables:

Arthritis_exp (split-ballot):

1=brfss version

2=new version

marijuana_exp (split-ballot):

1=brfss version

2=new version

Disability_exp (split-ballot):

1=brfss version

2=new version

Due to system constraints for variable length, in the raw data, the experimental variable names will be shortened to be 12 characters or shorter. However, in the final data, the full names will be used.]

/***Notes for programmer:

Alerts/ soft Edit Checks

Rs can skip any of the other questions on the survey except for two questions: WADULT and sex.  There will be soft edit checks for items that have logical ranges (or known from prior data collection), but Rs do not have to answer them to move on or submit the survey.  These soft edit checks will explicitly state the issue (e.g., high or low value, question not answered).

 ***/

[INTRODUCTORY PAGE]

(INTRO1).

[For the BRFSS Push-to-Web, show:

Welcome to our survey. Your participation will help the Centers for Disease Control and Prevention (the CDC) understand how to protect and improve the health of [state of residence from screener, spelled out (not abbreviated)] residents like you. After you complete the survey, we will send you a $5 Visa gift code, as a thank you.

]

[For other pilots, show:

Thank you for participating in this important research study on health for the Centers for Disease Control and Prevention, the CDC.

]

(INTRO2).

On each screen, you will be asked about your health and experience. Click on your answer or type in an answer, and then click the “Next>” button to continue to the next screen. With a few exceptions, you can skip any question by leaving the question blank and clicking the “Next>” button a second time. The questions that are required are used to determine which questions you will receive.

If you need to review or change an answer, you can go to the bottom of the screen and click the “<Back” button to go back to an earlier screen.

Do not click the backwards arrow that appears at the top of your browser.

(INTRO3).

The survey will take approximately 15-25 minutes, on average. Participation is voluntary, and you can stop or quit the survey at any time. No information that could personally identify you will be given to the CDC or anyone else. Your answers will be kept private to the extent allowable by law.

If you have any questions about this survey, you may contact our survey manager at RTI International at 833-997-2717 or send an email to [email protected].

1. I have read this information and would like to start the survey now. [CONTINUE to WADULT]

2. I choose NOT to participate in this survey. [GO TO CLOSE_Z]

[IF INTRO3=2 OR MISSING]

CLOSE_Z: If you change your mind and decide you would like to participate, please press the “<Back” button. Otherwise, please click “Submit” to close the survey.

[Record date and time when first show the first question after the consent script: WADULT]

[Date_STRT_W]

[Time_STRT_W]

[SCREENING QUESTIONS]

/**NOTE TO PROGRAMMER:

IF R MOVES FORWARD WITHOUT ANSWERING WADULT OR SEX, BRING THEM BACK TO THE QUESTION AND SHOW MESSAGE IN RED: “Answer is required.”

***/

[SHOW THE REST OF THE SURVEY ONLY IF INTRO3=1

S1. (WADULT)

Are you an adult, 18 years of age or older?

1 Yes

2 No

[IF WADULT=YES, GO TO SEX.]

[ELSE IF WADULT=NO, THEN SHOW UNDER18]

S1a. (UNDER18)

We are only interviewing adults aged 18 or older, so those are all the questions we have for you. Please click “Submit” to close the survey. Thank you for your time.

[AFTER SHOWING UNDER18,TERMINATE.]

S2. (SEX)

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

1. Male

2. Female

Q1. (GENHLTH)

First are some questions about your health…

Would you say that in general your health is—

1 Excellent

2 Very Good

3 Good

4 Fair

5 Poor

Q2. (PHYSHLTH)

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

_ _ Number of days [RANGE: 0-30]

77 Don’t know / Not sure

Q3. (MENTHLTH)

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

_ _ Number of days [RANGE: 0-30]

77 Don’t know/not sure

Q4. (POORHLTH)

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 [RANGE: 0-30]

77 Don’t know/not sure

Q5. (HLTHINS)

What is the current primary source of your health insurance?

If you have multiple sources of insurance, please think about the one used most often.

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

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

03 Medicare

04 Medigap

05 Medicaid

06 Children's Health Insurance Program (CHIP)

07 Military related health care: TRICARE (CHAMPUS) / VA health care / CHAMP- VA

08 Indian Health Service

09 State sponsored health plan

10 Other government program

88 No coverage of any type

77 Don’t Know/Not Sure

Q6. (CHECKUP1)

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

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

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

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

3 Within the past 5 years (2 years but less than 5 years ago)

4 5 or more years ago

8 Never

7 Don’t know / Not sure

Q7. (LASTDEN4)

Including all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists, how long has it been since you last visited a dentist or a dental clinic for any reason?

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

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

3 Within the past 5 years (2 years but less than 5 years ago)

4 5 or more years ago

8 Never

7 Don’t know / Not sure

Q8. (RMVTETH4)

Not including teeth lost for injury or orthodontics, how many of your permanent teeth have been removed because of tooth decay or gum disease?

If wisdom teeth are removed because of tooth decay or gum disease, they should be included in the count for lost teeth.

1 1 to 5

2 6 or more but not all

3 All

8 None

7 Don’t know / Not sure

Q9. (BPHIGH4)

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

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

1 Yes

3 No

4 Told borderline high or pre-hypertensive

[IF BPHIGH4=YES AND SEX=FEMALE, GO TO BPHIGH_PREG. ELSE GO TO CVDINFR4.]

Q9A. (BPHIGH_PREG).

Was this only when you were pregnant?

1 Yes

2 No

[SHOW TO ALL WHO CONSENTED TO PARTICIPATE (INTRO3=1)]

Q10. (CVDINFR4)

Has a doctor, nurse, or other health professional ever told you that…

You had a heart attack also called a myocardial infarction?

1 Yes

2 No

Q11. (CVDCRHD4)

Has a doctor, nurse, or other health professional ever told you that…

You had angina or coronary heart disease?

1 Yes

2 No

Q12. (ASTHMA3)

Has a doctor, nurse, or other health professional ever told you that…

You had asthma?

1 Yes

2 No

Q13. (CHCOCNCR)

Has a doctor, nurse, or other health professional ever told you that…

You had any types of cancer?

Include skin cancer.

1 Yes

2 No

Q14. (ADDEPEV3)

Has a doctor, nurse, or other health professional ever told you that…

You had a depressive disorder (including depression, major depression, dysthymia, or minor depression)?

1 Yes

2 No

Q15. (DIABETE5)

Has a doctor, nurse, or other health professional ever told you that you had diabetes?

1 Yes

2 No

3 Pre-diabetes or borderline diabetes

[IF DIABETE5=YES AND SEX=FEMALE, GO TO DIABETE_PREG. ELSE GO TO INSTRUCTION BEFORE HAVARTH3.]

Q15A. (DIABETE_PREG)

Was this only when you were pregnant?

1 Yes

2 No

[IF Arthritis_exp=1, ASK HAVARTH3. ELSE IF Arthritis_exp=2, ASK ARTH_ALT1]

Q16A. (HAVARTH3)

Has a doctor, nurse or other health professional ever told you that you had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?

1 Yes

2 No

[IF HAVARTH3=YES, ASK HAVARTH3FU. ELSE GO TO SKIP INSTRUCTION BEFORE ARTH_ALT1]

Q16A1. (HAVARTH3FU)

What type of arthritis condition have you been diagnosed with?

1. Osteoarthritis

2. Rheumatoid arthritis

3. Psoriatic arthritis

4. Gout

5. Fibromyalgia

6. Lupus

7. Other arthritis

8. Don’t know/not sure

[IF Arthritis_exp=2, ASK ARTH_ALT1. ELSE IF Arthritis_exp =1, GO TO TOLDCFS.]

Q16B. (ARTH_ALT1)

Has a doctor, nurse or other health professional ever told you that you had some form of arthritis?

1 Yes

2 No

[IF ARTH_ALT1=YES, ASK ARTH_ALT2. ELSE GO TO TOLDCFS]

Q16B1. (ARTH_ALT2)

What type of arthritis condition have you been diagnosed with?

1. Osteoarthritis

2. Rheumatoid arthritis

3. Psoriatic arthritis

4. Gout

5. Fibromyalgia

6. Lupus

7. Other arthritis

8. Don’t know / not sure

[SHOW TO ALL WHO CONSENTED TO PARTICIPATE (INTRO3=1)]

Q17. (TOLDCFS)

Have you ever been told by a doctor or other health professional that you had Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME)?

1 Yes

2 No

Q18. (TOLDHEPC)

Have you ever been told by a doctor or other health professional that you had Hepatitis C?

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

1 Yes

2 No

Q19. (FLUSHOT7)

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

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

1 Yes

2 No

7 Don’t know / Not sure

Q20. (TETANUS3)

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

1 Yes

2 No

7 Don’t know / Not sure

[IF TETANUS3=YES, GO TO TETANUS2_FU. ELSE GO TO AGE]

Q20A. (TETANUS2_FU).

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

1 Yes, it was Tdap

2 No, It was not Tdap

7 Don’t know / Not sure

D3a. (AGE).

What is your age?

____ years [RANGE: 18-79]

80 I am 80 years old or older.

[IF AGE>=50, GO TO SHINGLE2. ELSE GO TO DEAF]

Q21. (SHINGLE2)

Have you ever had the shingles or zoster vaccine?

Shingles is an illness that results in a rash or blisters on the skin, and is usually painful. There are two vaccines now available for shingles: Zostavax, which requires 1 shot and Shingrix which requires 2 shots.

1 Yes

2 No

7 Don’t know / Not sure

[IF disability_exp=1, ASK DEAF TO DIFFALON. ELSE IF disability_exp =2, ASK DIS_ALT1]

Q22A. (DEAF)

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

1 Yes

2 No

[ASK IF disability_exp=1]

Q23A. (BLIND)

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

1 Yes

2 No

[ASK IF disability_exp=1]

Q24A. (DECIDE)

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

1 Yes

2 No

[ASK IF disability_exp=1]

Q25A. (DIFFWALK)

Do you have serious difficulty walking or climbing stairs?

1 Yes

2 No

[ASK IF disability_exp=1]

Q26A. (DIFFDRES)

Do you have difficulty dressing or bathing?

1 Yes

2 No

[ASK IF disability_exp=1]

Q27A. (DIFFALON)

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

1 Yes

2 No

[IF disability_exp =2, ASK DIS_ALT1. ELSE IF disability_exp=1, GO TO SLEPTIM1.]

Q22B (DIS_ALT1).

Do you have difficulty seeing, even if wearing glasses? Would you say you have…

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all

[ASK IF disability_exp=2]

Q23B. (DIS_ALT2)

Do you have difficulty hearing, even if using a hearing aid? Would you say you have…

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all

[ASK IF disability_exp=2]

Q24B. (DIS_ALT3)

Do you have difficulty walking or climbing steps? Would you say you have…

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all

[ASK IF disability_exp=2]

Q25B. (DIS_ALT4)

Do you have difficulty remembering or concentrating? Would you say you have…

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all

[ASK IF disability_exp=2]

Q26B. (DIS_ALT5)

Do you have difficulty with self-care, such as washing all over or dressing? Would you say you have…

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all

[ASK IF disability_exp=2]

Q27B1. (DIS_ALT6)

Using your usual language, do you have difficulty communicating, for example, understanding or being understood? Would you say you have…

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all

[ASK IF disability_exp=2]

Q27B2. (DIS_ALT7)

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

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all

[SHOW TO ALL WHO CONSENTED TO PARTICIPATE (INTRO3=1)]

Q31A. (SLEPTIM1)

(Section Intro) Next are some questions about your life and your lifestyle…

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

_ _ Number of hours [0-24]

Q31B. (SUPPORT)

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

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Q31C. (EXERANY2)

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

If you do not have a regular job or are retired, you may count any physical activity or exercise you do.

1 Yes

2 No

Q31D. (ALCDAY5)

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

A 40-ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.

1 One or more days per week

2 Less than one day per week but at least one day in the past 30 days

888 No drinks in past 30 days

777 Don’t know / Not sure

[SHOW IF ALCDAY5=1]

Q31D. (ALCDAY5_wk)

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

_ _ Days per week [RANGE: 1-7]

888 No drinks in past 30 days

777 Don’t know / Not sure

[SHOW IF ALCDAY5=2]

Q31D. (ALCDAY5_mn)

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

_ _ Days in past 30 days [RANGE: 1-30 ]

888 No drinks in past 30 days

777 Don’t know / Not sure

[IF “No drinks in past 30 days” WAS SELECTED AT ALCDAY5 OR ALCDAY5_wk OR ALCDAY5_mn) SKIP TO NEXT QUESTION NOT RELATED TO ALCOHOL CONSUMPTION: SMOKDAY2]

[SHOW IF ALCDAY5≠888 AND ALCDAY5_wk≠888 AND ALCDAY5_mn≠888]

Q31E. (DRNK3GE5)

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

A 40-ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.

_ _ Number of times [RANGE: 0-9999]

77777 Don’t know / Not sure

[SHOW IF ALCDAY5≠888 AND ALCDAY5_wk≠888 AND ALCDAY5_mn≠888]

Q31F. (MAXDRNKS)

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

_ _ Number of drinks [RANGE: 0-999]

7777 Don’t know / Not sure

Q31G. (SMOKDAY2)

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

1 Every day

2 Some days

3 Not at all

Q31H. (ECIGNOW)

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

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. Brands you may have heard of are JUUL, NJOY, or blu.

1 Every day

2 Some days

3 Not at all

Q31I. (HIVTST7)

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

1 Yes

2 No

7 Don’t know / Not sure

[IF MARIJUANA_exp=1, GO TO MARIJAN1. ELSE IF MARIJUANA_exp =2, ASK MARIJAN_ALT1]

Q31J. (MARIJAN1)

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

Do not include hemp-based CBD products.

_ _ Number of days [RANGE: 0-30]

77 Don’t know / Not sure

[ASK IF MARIJUANA_exp=1 AND MARIJAN1 >0 AND MARIJAN1<=30]

Q31K. (MARIJAN2)

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

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

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

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

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

5 Dab it (for example, using a dabbing rig, knife, or dab pen)

6 Use it some other way

[ASK IF MARIJUANA_exp=1 AND MARIJAN1 >0 AND MARIJAN1<=30]

Q31L. (MARIJAN3)

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

1 For medical reasons

2 For non-medical reasons

3 For both medical and non-medical reasons

[IF MARIJUANA_exp =2, ASK MARIJAN_ALT1; IF MARIJUANA_exp=1, GO TO PREPARE1.]

Q31J2. (MARIJAN_ALT1)

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

_ _ Number of days [RANGE: 0-30]

77 Don’t know/not sure

[ASK IF MARIJUANA_exp=2 AND MARIJAN_ALT1 >0 AND MARIJAN1_ALT1<=30]

Q31K2 (MARIJAN_ALT2)

During the past 30 days, in which of the following ways did you use marijuana?

Check all that apply.

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

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

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

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

5 Dab it (for example, using a dabbing rig, knife, or dab pen)

6 Use it some other way

[ASK IF MARIJUANA_exp=2 AND MARIJAN_ALT1 >0 AND MARIJAN1_ALT1<=30]

Q31L2. (MARIJAN_ALT3)

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

1 For medical reasons

2 For non-medical reasons

3 For both medical and non-medical reasons.

Q32. (PREPARE1)

Next are some questions about how prepared your household is for disaster or emergency.

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

1 Well prepared

2 Somewhat prepared

3 Not prepared at all

Q33. (PREPARE2)

Does your household have a 3-day supply of water for everyone who lives there?

A 3-day supply of water is 1 gallon of water per person per day.

1 Yes

2 No

7 Don’t know / Not sure

Q34. (PREPARE3)

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

1 Yes

2 No

7 Don’t know / Not sure

Q35. (FRUIT2)

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

Not including juices, how often did you eat fruit?

Include fresh, frozen or canned fruit.

Do not include dried fruits.

1 Every day

2 More than once per week but not every day

3 Less than once per week but at least once per month

4 Less than once per month

5 Never

7 Don’t know / Not sure

[ASK IF FRUIT2=1]

Q35b. (FRUIT2_pD)

Not including juices, how many times per day did you usually eat fruit?

Include fresh, frozen or canned fruit.

Do not include dried fruits.

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

__ times per day [RANGE: 1-99]

777 Don’t Know / Not sure

[ASK IF FRUIT2=2]

Q35b. (FRUIT2_pW)

Not including juices, how many times per week did you usually eat fruit?

Include fresh, frozen or canned fruit.

Do not include dried fruits.

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

__ times per week [RANGE: 1-99]

777 Don’t Know / Not sure

[ASK IF FRUIT2=3]

Q35b. (FRUIT2_pM)

Not including juices, how many times in the past 30 days did you eat fruit?

Include fresh, frozen or canned fruit.

Do not include dried fruits.

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

__ times in the past 30 days [RANGE: 1-999]

7777 Don’t Know / Not sure

Q36. (FRUITJU2)

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

Do not include fruit-flavored drinks with added sugar like cranberry cocktail, Hi-C, lemonade, Kool-Aid, Gatorade, Tampico, and Sunny Delight.

Include only 100% pure juices or 100% juice blends.

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

1 Every day

2 More than once per week but not every day

3 Less than once per week but at least once per month

4 Less than once per month

5 Never

7 Don’t know / Not sure

[ASK IF FRUITJU2=1]

Q35b. (FRUITJU2_pD)

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

Do not include fruit-flavored drinks with added sugar like cranberry cocktail, Hi-C, lemonade, Kool-Aid, Gatorade, Tampico, and Sunny Delight.

Include only 100% pure juices or 100% juice blends.

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

__ times per day [RANGE: 1-99]

777 Don’t Know / Not sure

[ASK IF FRUITJU2=2]

Q35b. (FRUITJU2_pW)

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

Do not include fruit-flavored drinks with added sugar like cranberry cocktail, Hi-C, lemonade, Kool-Aid, Gatorade, Tampico, and Sunny Delight.

Include only 100% pure juices or 100% juice blends.

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

__ times per week [RANGE: 1-99]

777 Don’t Know / Not sure

[ASK IF FRUITJU2=3]

Q35b. (FRUITJU2_pM)

Not including fruit-flavored drinks or fruit juices with added sugar, how many times in the past 30 days did you drink 100% fruit juice such as apple or orange juice?

Do not include fruit-flavored drinks with added sugar like cranberry cocktail, Hi-C, lemonade, Kool-Aid, Gatorade, Tampico, and Sunny Delight.

Include only 100% pure juices or 100% juice blends.

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

__ times per month [RANGE: 1-999]

7777 Don’t Know / Not sure

Q37. (FVGREEN1)

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

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

1 Every day

2 More than once per week but not every day

3 Less than once per week but at least once per month

4 Less than once per month

5 Never

7 Don’t know / Not sure

[ASK IF FVGREEN1=1]

Q35b. (FVGREEN1_pD)

How many times per day did you usually eat a green leafy or lettuce salad, with or without other vegetables?

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

__ times per day [RANGE: 1-99]

777 Don’t Know / Not sure

[ASK IF FVGREEN1=2]

Q35b. (FVGREEN1_pW)

How many times per week did you usually eat a green leafy or lettuce salad, with or without other vegetables?

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

__ times per week [RANGE: 1-99]

777 Don’t Know / Not sure

[ASK IF FVGREEN1=3]

Q35b. (FVGREEN1_pM)

How many times in the past 30 days did you eat a green leafy or lettuce salad, with or without other vegetables?

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

__ times in the past 30 days [RANGE: 1-999]

7777 Don’t Know / Not sure

Q38. (FRENCHF1)

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

Do not include potato chips.

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

1 Every day

2 More than once per week but not every day

3 Less than once per week but at least once per month

4 Less than once per month

5 Never

7 Don’t know / Not sure

[ASK IF FRENCHF1=1]

Q35b. (FRENCHF1_pD)

How many times per day did you usually eat any kind of fried potatoes, including French fries, home fries, or hash browns?

Do not include potato chips.

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

__ times per day [RANGE: 1-99]

777 Don’t Know / Not sure

[ASK IF FRENCHF1=2]

Q35b. (FRENCHF1_pW)

How many times per week did you usually eat any kind of fried potatoes, including French fries, home fries, or hash browns?

Do not include potato chips.

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

__ times per week [RANGE: 1-99]

777 Don’t Know / Not sure

[ASK IF FRENCHF1=3]

Q35b. (FRENCHF1_pM)

How many times in the past 30 days did you usually eat any kind of fried potatoes, including French fries, home fries, or hash browns?

Do not include potato chips.

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

__ times in the past 30 days [RANGE: 1-999]

7777 Don’t Know / Not sure

Q39. (POTATOE1)

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

Include all types of potatoes except fried. Include potatoes au gratin, scalloped potatoes

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

1 Every day

2 More than once per week but not every day

3 Less than once per week but at least once per month

4 Less than once per month

5 Never

7 Don’t know / Not sure

[ASK IF POTATOE1=1]

Q35b. (POTATOE1_pD)

How many times per day did you usually eat any other kind of potatoes, or sweet potatoes, such as baked, boiled, mashed potatoes, or potato salad?

Include all types of potatoes except fried. Include potatoes au gratin, scalloped potatoes

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

__ times per day [RANGE: 1-99]

777 Don’t Know / Not sure

[ASK IF POTATOE1=2]

Q35b. (POTATOE1_pW)

How many times per week did you usually eat any other kind of potatoes, or sweet potatoes, such as baked, boiled, mashed potatoes, or potato salad?

Include all types of potatoes except fried. Include potatoes au gratin, scalloped potatoes

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

__ times per week [RANGE: 1-99]

777 Don’t Know / Not sure

[ASK IF POTATOE1=3]

Q35b. (POTATOE1_pM)

How many times in the past 30 days did you eat any other kind of potatoes, or sweet potatoes, such as baked, boiled, mashed potatoes, or potato salad?

Include all types of potatoes except fried. Include potatoes au gratin, scalloped potatoes

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

__ times in the past 30 days [RANGE: 1-999]

7777 Don’t know / Not sure

Q40. (VEGETAB2)

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

Include tomatoes, green beans, carrots, corn, cabbage, bean sprouts, collard greens, and broccoli. Include raw, cooked, canned, or frozen vegetables.

Do not include rice.

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

1 Every day

2 More than once per week but not every day

3 Less than once per week but at least once per month

4 Less than once per month

5 Never

7 Don’t know / Not sure

[ASK IF VEGETAB2=1]

Q35b. (VEGETAB2_pD)

Not including lettuce salads and potatoes, how many times per day did you usually eat other vegetables?

Include tomatoes, green beans, carrots, corn, cabbage, bean sprouts, collard greens, and broccoli. Include raw, cooked, canned, or frozen vegetables.

Do not include rice.

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

__ times per day [RANGE: 1-99]

777 Don’t Know / Not sure

[ASK IF VEGETAB2=2]

Q35b. (VEGETAB2_pW)

Not including lettuce salads and potatoes, how many times per week did you usually eat other vegetables?

Include tomatoes, green beans, carrots, corn, cabbage, bean sprouts, collard greens, and broccoli. Include raw, cooked, canned, or frozen vegetables.

Do not include rice.

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

__ times per week [RANGE: 1-99]

777 Don’t Know / Not sure

[ASK IF VEGETAB2=3]

Q35b. (VEGETAB2_pM)

Not including lettuce salads and potatoes, how many times in the past 30 days did you eat other vegetables?

Include tomatoes, green beans, carrots, corn, cabbage, bean sprouts, collard greens, and broccoli. Include raw, cooked, canned, or frozen vegetables.

Do not include rice.

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

__ times in the past 30 days [RANGE: 1-999]

7777 Don’t Know / Not sure

[DEMOGRAPHIC QUESTIONS]

D1. (STATE)

(Demo intro)

Lastly, some questions about yourself. These questions are included to compare health indicators by groups.

In what state do you currently live?

D1a. (ZIPCODE1)

What is the ZIP Code where you currently live?

________ REQUIRE EXACTLY 5 DIGITS]

[IF STATE FROM THE BRFSS PUSH-TO-WEB CATI SCREENER (RPSTAT1_S) IS THE SAME AS THE STATE IN THIS WEB SURVEY AND ALREADY HAVE COUNTY WHERE R LIVES FROM BRFSS PUSH-TO-WEB CATI SCREENER, SHOW CITYCODE2_CONF, OTHERWISE SKIP TO CTYCODE2]

D1b1. (CTYCODE2_CNF)

Do you live in the following county?

[fill CTYCODE2_S from BRFSS PUSH-TO-WEB CATI SCREENER]

1. Yes

2. No

[IF CTYCODE2_CNF=2 OR CTYCODE2_CNF IS MISSING, SHOW CTYCODE2]

D1b2. (CTYCODE2)

In what county do you currently live?

[provide pick list of counties, code county answers using FIPS county codes. For final data delivery, these will be converted to ANSI county codes. A “Don’t know / Not sure option will appear in the pick list too. This will be coded as 777.]

D1c. (RENTHOM).

Do you own or rent your home?

1 Own

2 Rent

3 Other arrangement

D1d (CURRES).

How long have you lived at your current residence?

1 Less than a year

2 One year or longer

[SHOW IF CURRES=1]

D1d1 (CURRES_M).

How many months have you lived at your current residence?

__ Months [RANGE: 0-11]

[SHOW IF CURRES=2]

D1d2 (CURRES_Y).

How many years have you lived at your current residence?

__ Years [RANGE: 0-99]

D2. (HHSIZE)

How many adults aged 18 and above live at this address?

_ _ Number of adults [RANGE: 0-999]

D2A. (CHILDREN)

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

_ _ Number of children [RANGE: 0-999]

D3. (BIRTHYEAR).

In what year were you born?

_____ [RANGE: 1910-2003]

D4. (HISPANC3)

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

1 Yes

2 No

D5. (MRACE1)

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

Check all that apply.

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

50 Pacific Islander

60 Other

[IF MRACE1=ASIAN, ASK ASIAN_A]

D5a. (ASIAN_A).

Are you…?

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

[IF MRACE1=PACIFIC ISLANDER, ASK PI_A]

D5b. (PI_A)

Are you…?

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

D6. (MARITAL)

Are you…?

1 Married

2 Divorced

3 Widowed

4 Separated

5 Never married, or

6 A member of an unmarried couple

D7. (EDUCA)

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

1 Never attended school or only attended kindergarten

2 Grades 1 through 8 (Elementary)

3 Grades 9 through 11 (Some high school)

4 Grade 12 or GED (High school graduate)

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

6 College 4 years or more (College graduate)

D8. (VETERAN3)

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

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

1 Yes

2 No

D9. (EMPLOY1)

Are you currently…?

1 Employed for wages

2 Self-employed

3 Out of work for 1 year or more

4 Out of work for less than 1 year

5 A Homemaker

6 A Student

7 Retired, or

8 Unable to work

D10. (HHINCOME)

Is your annual household income from all sources—?

01 Less than $10,000

02 $10,000 to less than $15,000

03 $15,000 to less than $20,000

04 $20,000 to less than $25,000

05 $25,000 to less than $35,000

06 $35,000 to less than $50,000

07 $50,000 to less than $75,000

08 $75,000 to less than $100,000

09 $100,000 to less than $150,000

10 $150,000 to less than $200,000

11 $200,000 or more

D11. (WEIGHT2)

About how much do you weigh without shoes?

_ _ _ _ pounds. [RANGE: 5-999]

7777 Don’t know / Not sure

6666 I prefer to report in kilograms.

[IF WEIGHT2=6666, ASK WEIGHT2_KG]

D11a. (WEIGHT2_KG)

About how much do you weigh without shoes, in kilograms?

_ _ _ _ kilograms. [RANGE: 2-999]

7777 Don’t know / Not sure

D12. (HEIGHT3_F and HEIGHT3_I)

About how tall are you without shoes?

_ _ feet _ _ inches [RANGE FOR FEET: 1-8] [RANGE FOR INCHES: 0-12]

HEIGHT3 77/ 77 Don’t know / Not sure

66/66 I prefer to report in meters.

67/67 I prefer to report in centimeters.

[IF HEIGHT3=66/66, ASK HEIGHT3_M]

D12a. (HEIGHT3_M)

About how tall are you without shoes, in meters?

_ _ _ _ meters. [RANGE: 0.3-3.0]

77 Don’t know / Not sure

[IF HEIGHT3=67/67, ASK HEIGHT3_CM]

D12b. (HEIGHT3_CM)

About how tall are you without shoes, in centimeters?

_ _ _ _ centimeters. [RANGE: 30-300]

7777 Don’t know / Not sure

[IF SEX=MALE, GO TO SOMALE. ELSE GO TO SOFEMALE]

D13A. (SOMALE)

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

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

This question is asked to better understand the health and health care needs of people with different sexual orientations.

1 = Gay

2 = Straight, that is, not gay

3 = Bisexual

4 = Something else

7 = Don’t know / Not sure

[IF SEX=FEMALE, ASK SOFEMALE]

D13B. (SOFEMALE)

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

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

This question is asked to better understand the health and health care needs of people with different sexual orientations.

1 = Lesbian or gay

2 = Straight, that is, not gay

3 = Bisexual

4 = Something else

7 = Don’t know / Not sure

[SHOW TO ALL WHO CONSENTED TO PARTICIPATE (INTRO3=1)]

D14. (TRNSGNDR)

Do you consider yourself to be transgender?

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

A transgender person may be of any sexual orientation – straight, gay, lesbian, or bisexual.

1 Yes

2 No

7 Don’t know / Not sure

[IF TRNSGNDR=YES, ASK TRNSGNDR_FU.]

D14A. (TRNSGNDR_FU).

Do you consider yourself to be…?

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

1 male-to-female

2 female-to-male, or

3 gender non-conforming

[Mark case with a completed (CO) status after TRNSGNDR_FU has been completed]

[Record date and time when first showed the first incentive question: INCENT_EMAIL]

[Date_END_W]

[Time_END_W]

[SHOW INCENT – EMAILTHANKS FOR BRFSS PUSH-TO-WEB ONLY.]

[ASK IF WE HAVE EMAIL FROM BRFSS PtW CATI]

INCENT_EMAIL.

To thank you for your participation, we would like to send you an electronic Visa gift code for $5.

Is your email address <FILL EMAIL ADDRESS FROM BRFSS PtW CATI>?

1. Email address is correct [GO TO EMAILTHANKS]

2. Email address is not correct [GO TO INCENT]

3. Decline $5 [GO TO THANKS2]

[ASK IF WE DO NOT HAVE EMAIL FROM BRFSS PtW CATI]

INCENT

To thank you for your participation, we would like to email you an electronic Visa gift code for $5. Do you have an email address?

1. Yes [GO IEMAIL]

2. No [GO TO CHECK]

3. Decline $5 [GO TO THANKS2]

[ASK IF INCENT=01]

IEMAIL

Please enter your e-mail address.

[TEXT BOX MUST MATCH FORMAT FOR E-MAIL]

_______________ [GO TO IEMAIL2]

[ASK IF INCENT=01]

IEMAIL2

Please re-enter your e-mail address for verification.

[TEXT BOX MUST MATCH FORMAT FOR E-MAIL]

_______________

[IF IEMAIL2 DOES NOT MATCH IEMAIL, GO TO EMAILCHECK. ELSE GO TO EMAILTHANKS]

EMAILCHECK

The e-mail address you provided does not match. Please enter e-mail address again.

01 CONTINUE [GO TO IEMAIL]

[ASK IF INCENT = 02]

CHECK

If you do not have an e-mail address, we can mail you a check for $5 instead. This will require your full name and mailing address. Would you like us to mail you a check?

01 Yes [GO TO ADDRESS]

02 No [GO TO THANKS2]

ADDRESS

Please provide your full name and mailing address in the fields below.

FNAME Full name: ______________ [50 character text box]

ADDR1 Address: ______________ [50 character text box]

ADDR2 Address: ______________ [50 character text box]

ICITY City: ______________ [50 character text box]

ISTATE State: __ [TWO LETTER BOX]

ZIP Zip code: _____ [FIVE DIGITS ONLY]

[GO TO THANKS2]

[SHOW IF INCENT_EMAIL = 01 OR INCENT = 01]

EMAILTHANKS

Thank you for providing us with your e-mail address. Within the next few minutes, we will send an e-mail with your electronic VISA gift code. If you do not see the email in your inbox soon, you may need to check your junk mail folder for an email entitled “Thank you for participating in the CDC Health Survey.”

[SHOW CLOSING STATEMENT TO ALL WHO CONSENTED TO PARTICIPATE (INTRO3=1)]

[SHOW IF INCENT_EMAIL = 03 OR INCENT = 02 OR CHECK = 02 OR ADDRESS =01]

THANKS2

Thank you for completing these questions. Your answers will be combined with others to help us provide information about the health practices of people in your state. Thank you very much for your time and cooperation.

Please click “submit” to submit your responses.

(Final screen)

Thank you for participation.

54