BRFSS Core Survey

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2021 BRFSS Questionnaire
DRAFT



Table of Contents
OMB Header and Introductory Text	4
Landline Introduction	5
Cell Phone Introduction	11
Core Section 1: Health Status	16
Core Section 2: Healthy Days	17
Core Section 3: Health Care Access	19
Core Section 4: Exercise	21
Core Section 5: Hypertension Awareness	22
Core Section 6: Cholesterol Awareness	23
Core Section 7: Chronic Health Conditions	25
Core Section 8: Arthritis	28
Core Section 9: Demographics	31
Core Section 10: Disability	37
Core Section 11: Tobacco Use	39
Core Section 12: Alcohol Consumption	40
Core Section 13: Immunization	42
Core Section 14: H.I.V./AIDS	44
Core Section 15: Fruits and Vegetables	45
Closing Statement/ Transition to Modules	49
Optional Modules	50
Module 1: Prediabetes	51
Module 2: Diabetes	52
Module 3: ME/CFS	55
Module 4: Hepatitis Treatment	56
Module 5: HPV - Vaccination	58
Module 6: Tetanus Diphtheria (Tdap) (Adults)	59
Module 7: Shingles Vaccination	60
Module 8: COVID Vaccination	61
Module 9: Lung Cancer Screening	64
Module 10: Breast and Cervical Cancer Screening	66
Module 11: Prostate Cancer Screening	68
Module 12: Colorectal Cancer Screening	70
Module 13: Cancer Survivorship: Type of Cancer	76
Module 14: Cancer Survivorship: Course of Treatment	80
Module 15: Cancer Survivorship: Pain Management	83
Module 16: Home/ Self-measured Blood Pressure	84
Module 17: Sodium or Salt-Related Behavior	86
Module 18: Cognitive Decline	87
Module 19: Caregiver	90
Module 20: Adverse Childhood Experiences	94
Module 21: Marijuana Use	98
Module 22: Tobacco Cessation	100
Module 23: Firearm Safety	102
Module 24: Industry and Occupation	103
Module 25: Random Child Selection	104
Module 26: Childhood Asthma Prevalence	108
Module 27: Sex at Birth	109
Module 28: Sexual Orientation and Gender Identity (SOGI)	110
Asthma Call-Back Permission Script	114
Closing Statement	116



OMB Header and Introductory Text

Read if necessary
Read
Interviewer instructions 
(not read)
Public reporting burden of this collection of information is estimated to average 27 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-1061).

Form Approved
OMB No. 0920-1061
Exp. Date 3/31/2021

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

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



Landline Introduction

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
LL01.

Is this [PHONE NUMBER]?
CTELENM1

1 Yes
Go to LL02





2 No
TERMINATE
Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time.

LL02.

Is this a private residence?
PVTRESD1

1 Yes
Go to LL04
Read if necessary: By private residence we mean someplace like a house or apartment.
Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.




2 No

Go to LL03
If no, business phone only: thank you very much but we are only interviewing persons on residential phones lines at this time.
NOTE:  Business numbers which are also used for personal communication are eligible.




3 No, this is a business

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

LL03.

Do you live in college housing?
COLGHOUS

1 Yes
Go to LL04
Read if necessary:  By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.




2 No
TERMINATE
Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.

LL04.

Do you currently live in__(state)____?
STATERE1

1 Yes
Go to LL05





2 No
TERMINATE
Thank you very much but we are only interviewing persons who live in [STATE] at this time.

LL05.
Is this a cell phone?
CELPHONE 
1 Yes, it is a cell phone 
TERMINATE
Read: Thank you very much but we are only interviewing by landline telephones in private residences or college housing at this time.




2 Not a cell phone
Go to LL06
Read if necessary: By cell phone we mean a telephone that is mobile and usable outside your neighborhood.
Do not read: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).

LL06.

Are you 18 years of age or older?
LADULT1

1 Yes

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





2 No
IF COLLEGE HOUSING = “YES,” Terminate; OTHERWISE GO TO ADULT RANDOM SELECTION]
Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.


LL07.
Are you male or female?

COLGSEX
1 Male
2 Female

ONLY for respondents who are LL and COLGHOUS= 1.






7 Don’t know/Not sure
9 Refused
TERMINATE
Thank you for your time, your number may be selected for another survey in the future.

LL08.
I need to randomly select one adult who lives in your household to be interviewed. Excluding adults living away from home, such as students away at college, how many members of your household, including yourself, are 18 years of age or older?
NUMADULT

1
Go to LL09
Read: Are you that adult? 
If yes: Then you are the person I need to speak with. 
If no: May I speak with the adult in the household?




2-6 or more
Go to LL10.


LL09. 
Are you male or female?

LANDSEX
1 Male
2 Female

GO to Transition Section 1. 





7 Don’t know/Not sure
9 Refused
TERMINATE
Thank you for your time, your number may be selected for another survey in the future.

LL10.
How many of these adults are men?
NUMMEN

_ _ Number 
77 Don’t know/ Not sure
99 Refused



LL11.
So the number of women in the household is [X]. Is that correct?
NUMWOMEN


Do not read: Confirm the number of adult women or clarify the total number of adults in the household.
Read: The persons in your household that I need to speak with is [Oldest/Youngest/ Middle//Male /Female].

LL12
The person in your household that I need to speak with is [Oldest/Youngest/ Middle//Male /Female]. Are you the [Oldest/Youngest/ Middle//Male /Female] in this household?
RESPSLCT
1 Male
2 Female

If person indicates that they are not the selected respondent, ask for correct respondent and re-ask LL12. (See CATI programming)





7 Don’t know/Not sure
9 Refused
TERMINATE
Thank you for your time, your number may be selected for another survey in the future. 

Transition to Section 1. 


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

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

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



Cell Phone Introduction

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)







CP01.

Is this a safe time to talk with you?
SAFETIME

1 Yes
Go to CP02





2 No
 ([set appointment if possible]) TERMINATE]
Thank you very much. We will call you back at a more convenient time.  

CP02.

Is this [PHONE NUMBER]?
CTELNUM1

1 Yes
Go to CP03





2 No
TERMINATE


CP03.

Is this a cell phone?
CELLFON5

1 Yes
Go to CADULT1





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

CP04.

Are you 18 years of age or older?
CADULT1

1 Yes







2 No
TERMINATE
Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.

CP05.
Are you male or female?

CELLSEX
1 Male
2 Female






7 Don’t Know/ Not sure
9 Refused
TERMINATE
Thank you for your time, your number may be selected for another survey in the future. 

CP06.

Do you live in a private residence?
PVTRESD3

1 Yes
Go to CP08
Read if necessary: By private residence we mean someplace like a house or apartment
Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.




2 No
Go to CP07


CP07.

Do you live in college housing?
CCLGHOUS

1 Yes
Go to CP08
Read if necessary:  By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.




2 No
TERMINATE
Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.

CP08.

Do you currently live in___(state)____?
CSTATE1

1 Yes
Go to CP10





2 No
Go to CP09


CP09.

In what state do you currently live?
RSPSTAT1

1 Alabama
2 Alaska
4 Arizona
5 Arkansas
6 California
8 Colorado
9 Connecticut
10 Delaware
11 District of Columbia
12 Florida
13 Georgia
15 Hawaii
16 Idaho
17 Illinois
18 Indiana
19 Iowa
20 Kansas
21 Kentucky
22 Louisiana
23 Maine
24 Maryland
25 Massachusetts
26 Michigan
27 Minnesota
28 Mississippi
29 Missouri
30 Montana
31 Nebraska
32 Nevada
33 New Hampshire
34 New Jersey
35 New Mexico
36 New York
37 North Carolina
38 North Dakota
39 Ohio
40 Oklahoma
41 Oregon
42 Pennsylvania
44 Rhode Island
45 South Carolina
46 South Dakota
47 Tennessee
48 Texas
49 Utah
50 Vermont
51 Virginia
53 Washington
54 West Virginia
55 Wisconsin
56 Wyoming
66 Guam
72 Puerto Rico
78 Virgin Islands






77 Live outside US and participating territories
99 Refused
TERMINATE
Read: Thank you very much, but we are only interviewing persons who live in the US.

CP10.

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

1 Yes
2 No
7 Don’t know/ Not sure
9 Refused

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

CP11.
How many members of your household, including yourself, are 18 years of age or older?
HHADULT
_ _ Number 
77 Don’t know/ Not sure
99 Refused
If CP07 = yes then number of adults is automatically set to 1


Transition to section 1. 


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




Core Section 1: Health Status



Core Section 2: Healthy Days

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
CHD.01

Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?	
PHYSHLTH
_ _ Number of days (01-30)
88 None
77 Don’t know/not sure
99 Refused

88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs. 

CHD.02
Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
MENTHLTH
_ _ Number of days (01-30)
88 None
77 Don’t know/not sure
99 Refused

88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.





Skip CHD.03 if CHD.01, PHYSHLTH, is 88 and CHD.02, MENTHLTH, is 88


CHD.03
During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?
POORHLTH
_ _ Number of days (01-30)
88 None
77 Don’t know/not sure
99 Refused

88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.



Core Section 3: Health Care Access

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
CHCA.01

What is the current primary source of your health insurance?
***NEW***

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 99 Refused

 

If respondent has multiple sources of insurance, ask for the one used most often. 
If respondents give the name of a health plan rather than the type of coverage
ask whether this is insurance purchased independently, through their employer, or whether it is through Medicaid or CHIP. 








CHCA.02
Do you have one person or a group of doctors that you think of as your personal health care provider?
***NEW***

1 Yes, only one
2 More than one
3 No 
7 Don’t know / Not sure
9 Refused

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

CHCA.03
Was there a time in the past 12 months when you needed to see a doctor but could not because you could not afford it?
***NEW***

1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CHCA.04
About how long has it been since you last visited a doctor for a routine checkup?
CHECKUP1
Read if necessary:
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 5 years (2 years but less than 5 years ago) 
4 5 or more years ago
Do not read:
7 Don’t know / Not sure 
8 Never
9 Refused

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



Core Section 4: Exercise

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
CEX.01

During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
EXERANY2
1 Yes
2 No
7 Don’t know / Not sure
9 Refused

Do not read: If respondent does not have a regular job or is retired, they may count any physical activity or exercise they do



Core Section 5: Hypertension Awareness


Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
C05.01

Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
BPHIGH4
1 Yes

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

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




2 Yes, but female told only during pregnancy 
3 No 
4 Told borderline high or pre-hypertensive 
7 Don’t know / Not sure 
9 Refused
Go to next section


C05.02
Are you currently taking prescription medicine for your high blood pressure?
BPMEDS
1 Yes
2 No
7 Don’t know / Not sure
9 Refused 





Core Section 6: Cholesterol Awareness

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
C06.01

Cholesterol is a fatty substance found in the blood. About how long has it been since you last had your blood cholesterol checked?
CHOLCHK2
1 Never
Go to next section.
  




2 Within the past year (anytime less than one year ago)
3 Within the past 2 years (1 year but less than 2 years ago)
4 Within the past 3 years (2 years but less than 3 years ago)
5 Within the past 4 years (3 years but less than 4 years ago)
6 Within the past 5 years (4 years but less than 5 years ago)
8 5 or more years ago






7 Don’t know/ Not sure
9 Refused
Go to next section


C06.02
Have you ever been told by a doctor, nurse or other health professional that your blood cholesterol is high?
TOLDHI2
1 Yes


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




2 No
7 Don’t know / Not sure
9 Refused
Go to next section.


C06.03

Are you currently taking medicine prescribed by your doctor or other health professional for your blood cholesterol?
CHOLMED2
1 Yes
2 No
7 Don’t know / Not sure
9 Refused





Core Section 7: Chronic Health Conditions

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
Prologue
Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me Yes, No, Or You’re Not Sure.





CCHC.01

Ever told you that you had a heart attack also called a myocardial infarction?
CVDINFR4

1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CCHC.02
(Ever told) (you had) angina or coronary heart disease?
CVDCRHD4

1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CCHC.03
(Ever told) (you had) a stroke?
CVDSTRK3

1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CCHC.04
(Ever told) (you had) asthma?
ASTHMA3
1 Yes






2 No
7 Don’t know / Not sure
9 Refused
Go to CCHC.06


CCHC.05
Do you still have asthma?
ASTHNOW
1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CCHC.06
(Ever told) (you had) skin cancer?
CHCSCNCR

1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CCHC.07
(Ever told) (you had) any other types of cancer?
CHCOCNCR

1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CCHC.08
(Ever told) (you had) C.O.P.D. (chronic obstructive pulmonary disease), emphysema or chronic bronchitis?
CHCCOPD2

1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CCHC.09
(Ever told) (you had) a depressive disorder (including depression, major depression, dysthymia, or minor depression)?
ADDEPEV3

1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CCHC.10
Not including kidney stones, bladder infection or incontinence, were you ever told you had kidney disease?  
CHCKDNY2

1 Yes
2 No
7 Don’t know / Not sure
9 Refused

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

CCHC.11
(Ever told) (you had) diabetes?
DIABETE4

1 Yes


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




2 Yes, but female told only during pregnancy
3 No
4 No, pre-diabetes or borderline diabetes
7 Don’t know / Not sure
9 Refused
Go to Pre-Diabetes Optional Module (if used). Otherwise, go to next section.


CCHC.12
How old were you when you were told you had diabetes?
DIABAGE3
_ _ Code age in years [97 = 97 and older] 
98 Don‘t know / Not sure 
99 Refused
Go to Diabetes Module if used, otherwise go to next section. 




Core Section 8: Arthritis

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
C08.01
Has a doctor, nurse or other health professional ever told you that you had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?
HAVARTH3

1 Yes


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




2 No
7 Don’t know / Not sure
9 Refused
Go to next section


C08.02
Has a doctor or other health professional ever suggested physical activity or exercise to help your arthritis or joint symptoms?
ARTHEXER
1 Yes
2 No
7 Don’t know / Not sure
9 Refused

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

C08.03
Have you ever taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?
ARTHEDU
1 Yes
2 No
7 Don’t know / Not sure
9 Refused



C08.04
Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?
LMTJOIN3
1 Yes
2 No
7 Don’t know / Not sure
9 Refused

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

C08.05
In the next question, we are referring to work for pay.  Do arthritis or joint symptoms now affect whether you work, the type of work you do or the amount of work you do?
ARTHDIS2
1 Yes
2 No
7 Don’t know / Not sure
9 Refused

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

C08.06
Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication.  During the past 30 days, how bad was your joint pain on average on a scale of 0 to 10 where 0 is no pain and 10 is pain or aching as bad as it can be?
JOINPAI2
__ __ Enter number [00-10]
77 Don’t know/ Not sure
99 Refused





Core Section 9: Demographics

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
CDEM.01
What is your age?
AGE

_ _ Code age in years
07   Don’t know / Not sure
09 Refused



CDEM.01
In what year were you born?
***NEW***
_ _ _ _ Code year of birth



CDEM.02
Are you Hispanic, Latino/a, or Spanish origin?
HISPANC3

If yes, read: Are you…	
1 Mexican, Mexican American, Chicano/a
2 Puerto Rican
3 Cuban
4 Another Hispanic, Latino/a, or Spanish origin
Do not read:
5 No
7 Don’t know / Not sure
9 Refused

One or more categories may be selected.

CDEM.03
Which one or more of the following would you say is your race?
MRACE1

Please read:
10 White  
20 Black or African American 
30 American Indian or Alaska Native
40 Asian
41 Asian Indian
42 Chinese
43 Filipino
44 Japanese
45 Korean
46 Vietnamese
47 Other Asian
50 Pacific Islander
51 Native Hawaiian
52 Guamanian or Chamorro
53 Samoan
54 Other Pacific Islander
Do not read:
60 Other
88 No additional choices
77 Don’t know / Not sure
99 Refused
.
If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.
One or more categories may be selected.





If more than one response to CDEM.03; continue. Otherwise, go to CDEM.05


CDEM.04
Which one of these groups would you say best represents your race?
ORACE3

Please read:
10 White  
20 Black or African American 
30 American Indian or Alaska Native
40 Asian
41 Asian Indian
42 Chinese
43 Filipino
44 Japanese
45 Korean
46 Vietnamese
47 Other Asian
50 Pacific Islander
51 Native Hawaiian
52 Guamanian or Chamorro
53 Samoan
54 Other Pacific Islander
Do not read:
60 Other
77 Don’t know / Not sure
99 Refused

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

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






If using Sex at Birth Module, insert here


CDEM.05
Are you…
MARITAL

Please read:
1 Married
2 Divorced
3 Widowed
4 Separated
5 Never married
Or
6 A member of an unmarried couple
Do not read:
9 Refused



CDEM.06
What is the highest grade or year of school you completed?
EDUCA

Read if necessary:
1 Never attended school or only attended kindergarten
2 Grades 1 through 8 (Elementary)
3 Grades 9 through 11 (Some high school)
4 Grade 12 or GED (High school graduate)
5 College 1 year to 3 years (Some college or technical school)
6 College 4 years or more (College graduate)
Do not read:
9 Refused



CDEM.07
Do you own or rent your home?
RENTHOM1

1 Own
2 Rent
3 Other arrangement
7 Don’t know / Not sure
9 Refused

Other arrangement may include group home, staying with friends or family without paying rent. Home is defined as the place where you live most of the time/the majority of the year.  
Read if necessary:  We ask this question in order to compare health indicators among people with different housing situations.   

CDEM.08
In what county do you currently live?
CTYCODE2

_  _  _ANSI County Code 
777 Don’t know / Not sure
999 Refused



CDEM.09
What is the ZIP Code where you currently live?
ZIPCODE1

_ _ _ _ _
77777 Do not know
99999 Refused







If cell interview  go to CDEM12



CDEM.10
Not including cell phones or numbers used for computers, fax machines or security systems, do you have more than one telephone number in your household?  
NUMHHOL3

1 Yes







2 No
7 Don’t know / Not sure
9 Refused
Go to CDEM.12


CDEM.11
How many of these telephone numbers are residential numbers?
NUMPHON3

__ Enter number (1-5)
6 Six or more
7 Don’t know / Not sure	
8 None	
9 Refused



CDEM.12
How many cell phones do you have for personal use?
CPDEMO1B

__ Enter number (1-5)
6 Six or more
7 Don’t know / Not sure	
8 None	
9 Refused
Last question needed for partial complete.
Read if necessary: Include cell phones used for both business and personal use.

CDEM.13
Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?
VETERAN3

1 Yes
2 No
7 Don’t know / Not sure
9 Refused

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

CDEM.14
Are you currently…?
EMPLOY1

Read:
1 Employed for wages
2 Self-employed
3 Out of work for 1 year or more 
4 Out of work for less than 1 year
5 A Homemaker
6 A Student
7 Retired
Or
8 Unable to work
Do not read:
9 Refused

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

CDEM.15
How many children less than 18 years of age live in your household?
CHILDREN

_  _ Number of children
88 None
99 Refused



CDEM.16
Is your annual household income from all sources—
***NEW***

Read if necessary:
01 Less than $10,000?
02 Less than $15,000? ($10,000 to less than $15,000) 
03 Less than $20,000? ($15,000 to less than $20,000)
04 Less than $25,000
If no, ask 05; if yes, ask
05 Less than $35,000 If 
($25,000 to less than $35,000)
06 Less than $50,000 If 
($35,000 to less than $50,000)
 07 Less than $75,000? ($50,000 to less than $75,000)
08 Less than $100,000? ($75,000 to less than $100,000)
09 Less than $150,000? ($100,000 to less than $150,000)?
10 Less than $200,000? ($150,000 to less than $200,000)
11 $200,000 or more

Do not read:
77 Don’t know / Not sure
99 Refused
SEE CATI information of order of coding
If respondent refuses at ANY income level, code ‘99’ (Refused)






Skip if Male (MSAB.01, BIRTHSEX, is coded 1). If MSAB.01=missing and (CP05=1 or LL12=1; or LL09 = 1 or LL07 =1).
 or AGE (CDEM.01), is greater than 49


CDEM.17
To your knowledge, are you now pregnant?
PREGNANT

1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CDEM.18
About how much do you weigh without shoes?
WEIGHT2

_  _  _  _ Weight (pounds/kilograms)
7777 Don’t know / Not sure
9999 Refused

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

CDEM.19
About how tall are you without shoes?
HEIGHT3

_  _ / _ _ Height (ft / inches/meters/centimeters)
77/ 77	Don’t know / Not sure
99/ 99 	Refused

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

Core Section 10: Disability
Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
CDIS.01
Some people who are deaf or have serious difficulty hearing use assistive devices to communicate by phone. Are you deaf or do you have serious difficulty hearing?
DEAF

1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CDIS.02
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
BLIND

1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CDIS.03
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
DECIDE

1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CDIS.04
Do you have serious difficulty walking or climbing stairs?
DIFFWALK
1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CDIS.05
Do you have difficulty dressing or bathing?
DIFFDRES
1 Yes
2 No
7 Don’t know / Not sure
9 Refused



CDIS.06
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
DIFFALON
1 Yes
2 No
7 Don’t know / Not sure
9 Refused





Core Section 11: Tobacco Use

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
CTOB.01

Have you smoked at least 100 cigarettes in your entire life?
SMOKE100

1 Yes

Do not include: electronic cigarettes (e-cigarettes, njoy, bluetip, JUUL), herbal cigarettes, cigars, cigarillos, little cigars, pipes, bidis, kreteks, water pipes (hookahs) or marijuana. 
5 packs = 100 cigarettes.




2 No
7 Don’t know/Not Sure
9 Refused
Go to CTOB.03


CTOB.02
Do you now smoke cigarettes every day, some days, or not at all?	
SMOKDAY2

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



CTOB.03
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
STOPSMK2

1 Yes
2 No
7 Don’t know / Not sure
9 Refused







Go to CTOB.05


CTOB.03
Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?
USENOW3
1 Every day
2 Some days
3 Not at all
7 Don’t know / Not sure
9 Refused

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

CTOB.04
Do you now use e-cigarettes or other electronic vaping products every day, some days or not at all?
ECIGNOW
1 Every day
2 Some days
3 Not at all
7 Don’t know / Not sure
9 Refused

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. 
Interviewer note: These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.


Core Section 12: Alcohol Consumption
Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
CALC.01

During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?
ALCDAY5

1 _ _ Days per week
2 _ _ Days in past 30 days

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




888 No drinks in past 30 days 
777 Don’t know / Not sure
999 Refused
Go to next section


CALC.02
One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?
AVEDRNK3

_ _ Number of drinks
88 None
77 Don’t know / Not sure
99 Refused

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

CALC.03
Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI X = 5 for men, X = 4 for women] or more drinks on an occasion?
DRNK3GE5

_ _ Number of times 
77 Don’t know / Not sure
99 Refused
CATI X = 5 for men, X = 4 for women (states may use sex at birth to determine sex if module is adopted)


CALC.04
During the past 30 days, what is the largest number of drinks you had on any occasion?
MAXDRNKS
_ _ Number of drinks
77 Don’t know / Not sure
99 Refused





Core Section 13: Immunization
Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
CIMM.01

During the past 12 months, have you had either a flu vaccine that was sprayed in your nose or a flu shot injected into your arm? 
FLUSHOT7
1 Yes

Read if necessary: 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.




2 No
7 Don’t know / Not sure
9 Refused	
Go to CIMM.04


CIMM.02
During what month and year did you receive your most recent flu vaccine that was sprayed in your nose or flu shot injected into your arm?
FLSHTMY3
_ _ / _ _ _ _ Month / Year
77 / 7777 Don’t know / Not sure
09 / 9999 Refused



C11.03
At what kind of place did you get your last flu shot or vaccine?
IMFVPLAC

Read if necessary:
01 A doctor’s office or health maintenance organization (HMO)
02 A health department
03 Another type of clinic or health center (a community health center)
04 A senior, recreation, or community center
05 A store (supermarket, drug store)
06 A hospital (inpatient)
07 An emergency room
08 Workplace
09 Some other kind of place
11 A school
Do not read:
10 Received vaccination in Canada/Mexico
77 Don’t know / Not sure
99 Refused

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





If age <50 GOTO CIMM.04.


CIMM.04
Have you ever had a pneumonia shot also known as a pneumococcal vaccine?
PNEUVAC4
1 Yes
2 No
7 Don’t know / Not sure
9 Refused

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




Core Section 14: H.I.V./AIDS
Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
CHIV.01

Including fluid testing from your mouth, but not including tests you may have had for blood donation, have you ever been tested for H.I.V?
HIVTST7

1 Yes

Please remember that your answers are strictly confidential and that you don’t have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.





2 No
7 Don’t know/ not sure
9 Refused
Go to Next section


CHIV.02
Not including blood donations, in what month and year was your last H.I.V. test?
HIVTSTD3

_ _ /_ _ _ _ Code month and year 
77/ 7777 Don’t know / Not sure 99/ 9999 Refused 
If response is before January 1985, code "777777".
INTERVIEWER NOTE: If the respondent remembers the year but cannot remember the month, code the first two digits 77 and the last four digits for the year.


Core Section 15: Fruits and Vegetables

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
CFV.01
Now think about the foods you ate or drank during the past month, that is, the past 30 days, including meals and snacks.
Not including juices, how often did you eat fruit? You can tell me times per day, times per week or times per month.	
FRUIT2
1_ _ Day
2_ _ Week
3_ _ Month
300 Less than once a month
555 Never
777 Don’t Know
999 Refused

If a respondent indicates that they consume a food item every day then enter the number of times per day.  If the respondent indicates that they eat a food less than daily, then enter times per week or time per month.  Do not enter time per day unless the respondent reports that he/she consumed that food item each day during the past month.
Enter quantity in times per day, week, or month. 
If respondent gives a number without a time frame, ask “was that per day, week, or month?”
Read if respondent asks what to include or says ‘i don’t know’: include fresh, frozen or canned fruit. Do not include dried fruits.



CFV.02
Not including fruit-flavored drinks or fruit juices with added sugar, how often did you drink 100% fruit juice such as apple or orange juice?	
FRUITJU2
1_ _ Day
2_ _ Week
3_ _ Month
300 Less than once a month
555 Never
777 Don’t Know
999 Refused

Read if respondent asks about examples of fruit-flavored drinks: “do not include fruit-flavored drinks with added sugar like cranberry cocktail, Hi-C, lemonade, Kool-Aid, Gatorade, Tampico, and sunny delight. Include only 100% pure juices or 100% juice blends.”
Enter quantity in times per day, week, or month. 
If respondent gives a number without a time frame, ask “Was that per day, week, or month?”	


CFV.03
How often did you eat a green leafy or lettuce salad, with or without other vegetables?
FVGREEN1
1_ _ Day
2_ _ Week
3_ _ Month
300 Less than once a month
555 Never
777 Don’t Know
999 Refused

Enter quantity in times per day, week, or month. 
If respondent gives a number without a time frame, ask “Was that per day, week, or month?”	
Read if respondent asks about spinach: “Include spinach salads.”


CFV.04
How often did you eat any kind of fried potatoes, including French fries, home fries, or hash browns?
FRENCHF1
1_ _ Day
2_ _ Week
3_ _ Month
300 Less than once a month
555 Never
777 Don’t Know
999 Refused

Enter quantity in times per day, week, or month. 
If respondent gives a number without a time frame, ask “Was that per day, week, or month?”
Read if respondent asks about potato chips: “Do not include potato chips.”


CFV.05
How often did you eat any other kind of potatoes, or sweet potatoes, such as baked, boiled, mashed potatoes, or potato salad?
POTATOE1
1_ _ Day
2_ _ Week
3_ _ Month
300 Less than once a month
555 Never
777 Don’t Know
999 Refused

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

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



CFV.06
Not including lettuce salads and potatoes, how often did you eat other vegetables?
VEGETAB2
1_ _ Day
2_ _ Week
3_ _ Month
300 Less than once a month
555 Never
777 Don’t Know
999 Refused

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

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






Closing Statement/ Transition to Modules

Read if necessary
Read
CATI instructions 
(not read)
That was my last question.  Everyone’s answers will be combined to help us provide information about the health practices of people in this state.  Thank you very much for your time and cooperation.

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



Optional Modules

Module 1: Prediabetes

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
M01.01

Have you had a test for high blood sugar or diabetes within the past three years?
PDIABTST
1 Yes
2 No
7 Don’t know/ not sure
9 Refused
Skip if Section CCHC.12, DIABETE4, is coded 1


M01.02
Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?
PREDIAB1
1 Yes
2 Yes, during pregnancy
3 No
7 Don’t know / Not sure
9 Refused
Skip if Section CCHC.12, DIABETE4, is coded 1; If CCHC.12, DIABETE4, is coded 4 automatically code M01.02, PREDIAB1, equal to 1 (yes);
If Yes and respondent is female, ask: Was this only when you were pregnant?



Module 2: Diabetes

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)




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


M02.01

Are you now taking insulin?	
INSULIN

1 Yes
2 No
7 Don’t know/ not sure
9 Refused



M02.02
About how often do you check your blood for glucose or sugar?  

BLDSUGAR

1 _  _  Times per day
2 _  _  Times per week
3 _  _  Times per month	
4 _  _  Times per year	
888 Never	
777 Don’t know / Not sure
999 Refused

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

Do not read: If the respondent uses a continuous glucose monitoring system (a sensor inserted under the skin to check glucose levels continuously), fill in ‘98 times per day.’

M02.03
Including times when checked by a family member or friend, about how often do you check your feet for any sores or irritations?  
FEETCHK3

1 _  _  Times per day
2 _  _  Times per week
3 _  _  Times per month	
4 _  _  Times per year
555 No feet	
888 Never	
777 Don’t know / Not sure
999 Refused



M02.04
About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
DOCTDIAB

_ _ Number of times [76 = 76 or more]
88 None
77 Don’t know / Not sure
99 Refused



M02.05
About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for A-one-C?	
CHKHEMO3

_ _  Number of times [76 = 76 or more]
88 None
98 Never heard of A-one-C test
77 Don’t know / Not sure
99 Refused

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

M02.06
About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?	
FEETCHK
_ _ Number of times [76 = 76 or more]
88 None
77 Don’t know / Not sure
99 Refused
If M02.03 = 555 (No feet), go to M02.07


M02.07
When was the last time you had an eye exam in which the pupils were dilated, making you temporarily sensitive to bright light?  
EYEEXAM1
Read if necessary:
1 Within the past month (anytime less than 1 month ago)
2 Within the past year (1 month but less than 12 months ago)
3 Within the past 2 years (1 year but less than 2 years ago)
4  2 or more years ago
Do not read: 
7 Don’t know / Not sure
8 Never
9 Refused



M02.08
Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
DIABEYE
1 Yes
2 No
7 Don’t know/ not sure
9 Refused



M02.09
Have you ever taken a course or class in how to manage your diabetes yourself?		
DIABEDU
1 Yes
2 No
7 Don’t know/ not sure
9 Refused





Module 3: ME/CFS

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
M03.01

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


My-al-gic
En-ceph-a-lo-my-eli-tis




2 No
7 Don’t know / Not sure
9 Refused	
Go to next section


M03.02
Do you still have Chronic Fatigue Syndrome (CFS) or (Myalgic Encephalomyelitis) ME?
HAVECFS
1 Yes
2 No
7 Don’t know/ Not sure
9 Refused

My-al-gic
En-ceph-a-lo-my-eli-tis

M03.03
Thinking about your CFS or ME, during the past 6 months, how many hours a week on average have you been able to work at a job or business for pay?
WORKCFS
Read if necessary
1   0 or no hours -- cannot work at all because of CFS or ME
2    1 - 10 hours a week
3  11- 20 hours a week
4   21- 30 hours a week 
5  31 - 40 hours a week
Do not read
7 Don’t know/ Not sure
9 Refused





Module 4: Hepatitis Treatment 

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
M04.01

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

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




2 No
7 Don’t know / Not sure
9 Refused	
Go to M04.05


M04.02
Were you treated for Hepatitis C in 2015 or after? 
TRETHEPC
1 Yes
2 No
7 Don’t know/ Not sure
9 Refused

Most hepatitis C treatments offered in 2015 or after were oral medicines or pills. Including Harvoni, Viekira, Zepatier, Epclusa and others. 

M04.03
Were you treated for Hepatitis C prior to 2015?
PRIRHEPC
1 Yes
2 No
7 Don’t know/ Not sure
9 Refused

Most hepatitis C treatments offered prior to 2015 were shots and pills given weekly or more often over many months.

M04.04
Do you still have Hepatitis C?
HAVEHEPC
1 Yes
2 No
7 Don’t know/ Not sure
9 Refused

You may still have Hepatitis C and feel healthy. Your blood must be tested again to tell if you still have Hepatitis C. 

M04.05
The next question is about Hepatitis B.
Has a doctor, nurse, or other health professional ever told you that you had hepatitis B?
HAVEHEPB
1 Yes

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




2 No
7 Don’t know/ Not sure
9 Refused
Go to next section


M04.06
Are you currently taking medicine to treat hepatitis B?
MEDSHEPB
1 Yes
2 No
7 Don’t know/ Not sure
9 Refused





Module 5: HPV - Vaccination

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Columns
M05.01

Have you ever had the Human Papilloma virus vaccination or HPV vaccination?
HPVADVC3 

1 Yes
To be asked of respondents between the ages of 18 and 49 years; otherwise, go to next module
A vaccine to prevent the human papilloma virus or HPV infection is available and is called the cervical cancer or genital warts vaccine, HPV shot, [Fill: if female “GARDASIL or CERVARIX”, if male “GARDASIL”]. (Human Papilloma Virus (Human Pap•uh•loh•muh Virus), Gardasil (Gar•duh• seel), Cervarix (Serv a rix)) 





2 No
7 Don’t know / Not sure
9 Refused	
Go to next module


M05.02
How many HPV shots did you receive? 

HPVADSHT 

_ _ Number of shots (1-2)
3 All shots
77 Don’t know / Not sure
99 Refused





Module 6: Tetanus Diphtheria (Tdap) (Adults)

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
M06.01

Have you received a tetanus shot in the past 10 years?	
TETANUS2
1 Yes, received Tdap
2 Yes, received tetanus shot, but not Tdap
3 Yes, received tetanus shot but not sure what type
4 No, did not receive any tetanus shot in the past 10 years
7 Don’t know/Not sure
9  Refused

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




Module 7: Shingles Vaccination

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)




If age ≤ 49 Go to next section.


M07.01
Have you ever had the shingles or zoster vaccine?
SHINGLE2

1 Yes
2 No
7 Don’t know / Not sure
9 Refused

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. 



Module 8: Lung Cancer Screening

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
M08.01


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

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

_ _ _ Age in Years (001 – 100)
777 Don't know/Not sure
999 Refused
If CTOB.01=1 (yes) and CTOB.02 = 1, 2, or 3 (every day, some days, or not at all) continue, else go to question M09.04.
Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all).
If respondent indicates age inconsistent with previously entered age, verify that this is the correct answer and change the age of the respondent regularly smoking or make a note to correct the age of the respondent.




888 Never smoked cigarettes regularly
Go to M09.04


M08.02
How old were you when you last smoked cigarettes regularly?
LCSLAST
_ _ _ Age in Years (001 – 100)
777 Don't know/Not sure
999 Refused



M08.03
On average, when you [smoke/ smoked] regularly, about how many cigarettes {do/did} you usually smoke each day?
LCSNUMCG
_ _ _	Number of cigarettes
777 Don't know/Not sure
999 Refused

Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all).
Respondents may answer in packs instead of number of cigarettes. Below is a conversion table: 0.5 pack = 10 cigarettes/ 1.75 pack = 35 cigarettes/ 0.75 pack = 15 cigarettes/ 2 packs = 40 cigarettes/ 1 pack = 20 cigarettes/ 2.5 packs= 50 cigarettes/ 1.25 pack = 25 cigarettes/ 3 packs= 60 cigarettes/ 1.5 pack = 30 cigarettes

M08.04
The next question is about CT or CAT scans. During this test, you lie flat on your back on a table. While you hold your breath, the table moves through a donut shaped x-ray machine while the scan is done. In the last 12 months, did you have a CT or CAT scan?
LCSCTSCN
Read if necessary:
1 Yes, to check for lung cancer
2 No (did not have a CT scan)
3 Had a CT scan, but for some other reason
Do not read:
7 Don't know/not sure
9 Refused




Module 9: Breast and Cervical Cancer Screening

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
M09.01

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

1 Yes
Skip to next module if male 
A mammogram is an x-ray of each breast to look for breast cancer. 		




2 No
7 Don’t know/ not sure
9 Refused
Go to M09.03


M09.02
How long has it been since you had your last mammogram? 	
HOWLONG

Read if necessary:
1 Within the past year (anytime less than 12 months ago) 
2 Within the past 2 years (1 year but less than 2 years ago) 
3 Within the past 3 years (2 years but less than 3 years ago) 
4 Within the past 5 years (3 years but less than 5 years ago) 
5 5 or more years ago
7 Don’t know / Not sure 
9  Refused



M09.03
How long has it been since you had your last cervical cancer screening test?
***NEW***
Read if necessary:
1 Within the past year (anytime less than 12 months ago) 
2 Within the past 2 years (1 year but less than 2 years ago) 
3 Within the past 3 years (2 years but less than 3 years ago) 
4 Within the past 5 years (3 years but less than 5 years ago) 
5 5 or more years ago
7 Don’t know / Not sure 
9  Refused






2 No	 	 
7 Don’t know / Not sure 
9 Refused
Go to M09.06


M09.04
At your most recent cervical cancer screening, did you have a Pap test?
***NEW***
1 Yes
2 No	  
7 Don’t know / Not sure 
9 Refused



M10.05
At your most recent cervical cancer screening, did you have an H.P.V. test?
***NEW***
1 Yes
2 No	  
7 Don’t know / Not sure 
9 Refused

H.P.V. stands for Human papillomarvirus (pap-uh-loh-muh virus)

M09.06
Have you had a hysterectomy? 	
HADHYST2
1 Yes 
2 No 
7 Don’t know / Not sure 
9 Refused
If response to Core CDEM.17 = 1 (is pregnant) do not ask and go to next section.
Read if necessary: A hysterectomy is an operation to remove the uterus (womb).



Module 10: Prostate Cancer Screening
Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)




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


M10.01
Have you ever had a P.S.A. test?		
PSATEST1

1 Yes






2 No	  
7 Don’t know / Not sure 
9 Refused
Go to next section


M10.02
About how long has it been since your most recent PSA test?
***NEW***
Read if necessary:
1 Within the past year (anytime less than 12 months ago) 
2 Within the past 2 years (1 year but less than 2 years ago) 
3 Within the past 3 years (2 years but less than 3 years ago) 
4 Within the past 5 years (3 years but less than 5 years ago) 
5 5 or more years ago
Do not read:
7 Don’t know / Not sure 
9 Refused












M10.03
What was the main reason you had this P.S.A. test – was it …?
***NEW***
Read:
1 Part of a routine exam
2 Because of a prostate problem
3 Because of a family history of prostate cancer
4 Because you were told you had prostate cancer
3. Some other reason
Do not read:
7 Don’t know / Not sure 	
9 Refused 



M10.04

When you met with a doctor, nurse, or other health professional did they talk about the advantages, the disadvantages or both advantages and disadvantages of the Prostate-Specific Antigen or P.S.A. test?
***NEW***

1 Advantages 2 Disadvantages
3 Both Advantages and disadvantages
7 Don’t know/ not sure
9 Refused

A PSA test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.



Module 12: Colorectal Cancer Screening

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)




If Section CDEM.01, AGE, is less than 45 go to next section.


M11.01
Colonoscopy and sigmoidoscopy are exams to check for colon cancer. Have you ever had either of these exams?
HADSIGM3
1 Yes
Go to M11.02





2 No
7 Don’t know/ not sure
9 Refused
Go to M11.06


M11.02
Have you had a colonoscopy, a sigmoidoscopy, or both?
***NEW***
1 Colonoscopy

Go to M11.03





2 Sigmoidoscopy
Go to M11.04





3 Both 
7 Don’t know/Not sure
Go to M11.05





9 Refused
Go toM11.06


M11.03
How long has it been since your most recent colonoscopy? 
***NEW***
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 5 or more years ago
Do not read:
7 Don't know / Not sure
9 Refused



M11.04
How long has it been since your most recent sigmoidoscopy? 
***NEW***
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 5 or more years ago
Do not read:
7 Don't know / Not sure
9 Refused



M11.05
How long has it been since your most recent colonoscopy or sigmoidoscopy?
LASTSIG3
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 5 or more years ago
Do not read:
7 Don't know / Not sure
9 Refused



M11.06
Have you ever had any other kind of test for colorectal cancer, such as virtual colonoscopy, CT colonography, blood stool test, FIT DNA, or Cologuard test?
***NEW***
1 Yes
Go to M11.07





2 No 
7 Don’t Know/Not sure
9 Refused
Go to Next Section


M11.07
A virtual colonoscopy uses a series of X-rays to take pictures of inside the colon.  Have you ever had a virtual colonoscopy?
***NEW***
1 Yes
Go to M11.08
CT colonography, sometimes called virtual colonoscopy, is a new type of test that looks for cancer in the colon. Unlike regular colonoscopies, you do not need medication to make you sleepy during the test. In this new test, your colon is filled with air and you are moved through a donut-shaped X-ray machine as you lie on your back and then your stomach.




2 No 
7 Don’t Know/Not sure
9 Refused
Go to M11.09


M11.08
When was your most recent CT colonography or virtual colonoscopy?
***NEW***
Read if necessary:
1 Within the past year (anytime less than 12 months ago) 
2 Within the past 2 years (1 year but less than 2 years ago) 
3 Within the past 3 years (2 years but less than 3 years ago) 
4 Within the past 5 years (3 years but less than 5 years ago) 
5 5 or more years ago
Do not read:
7 Don’t know / Not sure 
9  Refused



M11.09

One stool test uses a special kit to obtain a small amount of stool at home and returns the kit to the doctor or the lab. Have you ever had this test?
***NEW***

1 Yes
Go to M11.10
The blood stool or occult blood test, fecal immunochemical or FIT test determine whether you have blood in your stool or bowel movement and 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 or FIT test, using a home test kit?




2 No
7 Don’t know/ not sure
9 Refused
Go to M12.11


M11.10
How long has it been since you had this test?
***NEW***

Read if necessary:
1 Within the past year (anytime less than 12 months ago) 
2 Within the past 2 years (1 year but less than 2 years ago) 
3 Within the past 3 years (2 years but less than 3 years ago) 
4 Within the past 5 years (3 years but less than 5 years ago) 
5 5 or more years ago
Do not read:
7 Don’t know / Not sure 
9  Refused



M11.11
Another stool test uses a special kit to obtain an entire bowel movement at home and returns the kit to a lab.   Have you ever had this Cologuard test?
***NEW***
1 Yes
Go to M11.12
Cologuard is a new type of stool test for colon cancer. Unlike other stool tests, Cologuard looks for changes in DNA in addition to checking for blood in your stool. The Cologuard test is shipped to your home in a box that includes a container for your stool sample.




2 No 
7 Don’t Know/Not sure
9 Refused
Go to Next Section


M11.12
Was the blood stool or FIT (you reported earlier) conducted as part of a Cologuard test?
***NEW***
1 Yes
2 No 
7 Don’t Know/Not sure
9 Refused



M11.13
How long has it been since you had this test?
***NEW***
Read if necessary:
1 Within the past year (anytime less than 12 months ago) 
2 Within the past 2 years (1 year but less than 2 years ago) 
3 Within the past 3 years (2 years but less than 3 years ago) 
4 Within the past 5 years (3 years but less than 5 years ago) 
5 5 or more years ago
Do not read:
7 Don’t know / Not sure 
9  Refused





Module 12: Cancer Survivorship: Type of Cancer

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)




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


MTOC.01

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

How many different types of cancer have you had?
CNCRDIFF

1 Only one
2 Two
3 Three or more







7 Don’t know / Not sure		
9 Refused
Go to next module


MTOC.02
At what age were you told that you had cancer?
CNCRAGE

 _ _ Age in Years (97 = 97 and older)
98 Don't know/Not sure
99 Refused

If MTOC.01= 2 (Two) or 3 (Three or more), ask: At what age were you first diagnosed with cancer?
Read if necessary: This question refers to the first time they were told about their first cancer.





If CCHC.06 = 1 (Yes) and MTOC.01 = 1 (Only one): ask Was it Melanoma or other skin cancer?  then code MTOC.03 as a response of 21 if Melanoma or 22 if other skin cancer

CATI note: If CCCS.06 = 4 (Because you were told you had Prostate Cancer) and Q1 = 1 (Only one) then code MTOC.03 as a response of 19.


MTOC.03
What type of cancer was it?
CNCRTYP1

Read if respondent needs prompting for cancer type:
01 Breast cancer
Female reproductive (Gynecologic) 
02 Cervical cancer (cancer of the cervix)
03 Endometrial cancer (cancer of the uterus)
04 Ovarian cancer (cancer of the ovary)
Head/Neck
05 Head and neck cancer
06 Oral cancer
07 Pharyngeal (throat) cancer
08 Thyroid
09 Larynx
Gastrointestinal 
10 Colon (intestine) cancer
11 Esophageal (esophagus)
12 Liver cancer
13 Pancreatic (pancreas) cancer
14 Rectal (rectum) cancer
15 Stomach
Leukemia/Lymphoma (lymph nodes and bone marrow)
16 Hodgkin's Lymphoma (Hodgkin’s disease)
17 Leukemia (blood) cancer 
18 Non-Hodgkin’s Lymphoma
Male reproductive
19 Prostate cancer
20 Testicular cancer
Skin
21 Melanoma
22 Other skin cancer
Thoracic
23 Heart
24 Lung
Urinary cancer 
 25 Bladder cancer
26 Renal (kidney) cancer
Others
27 Bone 
28 Brain
29 Neuroblastoma 
30 Other	
Do not read:
77 Don’t know / Not sure
99 Refused

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




Module 13: Cancer Survivorship: Course of Treatment

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)




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


MCOT.01
Are you currently receiving treatment for cancer?
CSRVTRT3

Read if necessary:
1 Yes
Go to next module
Read if necessary: By treatment, we mean surgery, radiation therapy, chemotherapy, or chemotherapy pills.




2 No, I’ve completed treatment
 
Continue





3 No, I’ve refused treatment
4 No, I haven’t started treatment
 5 Treatment was not necessary
7 Don’t know / Not sure
9 Refused
Go to next module


MCOT.02
What type of doctor provides the majority of your health care? Is it a….

CSRVDOC1

Read:
01 Cancer Surgeon
02 Family Practitioner   
03 General Surgeon                  
04 Gynecologic Oncologist
05 General Practitioner, Internist   
06 Plastic Surgeon, Reconstructive Surgeon
07 Medical Oncologist
08 Radiation Oncologist
09 Urologist
10 Other
Do not read:
77 Don’t know / Not sure
99 Refused

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

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

MCOT.03
Did any doctor, nurse, or other health professional ever give you a written summary of all the cancer treatments that you received?
CSRVSUM

1 Yes
2 No
7 Don’t know/ not sure
9 Refused

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


MCOT.04
Have you ever received instructions from a doctor, nurse, or other health professional about where you should return or who you should see for routine cancer check-ups after completing your treatment for cancer?
CSRVRTRN

1 Yes







2 No
7 Don’t know/ not sure
9 Refused
Go to MCOT.06


MCOT.05
Were these instructions written down or printed on paper for you?	
CSRVINST
1 Yes
2 No
7 Don’t know/ not sure
9 Refused



MCOT.06
With your most recent diagnosis of cancer, did you have health insurance that paid for all or part of your cancer treatment?
CSRVINSR
1 Yes
2 No
7 Don’t know/ not sure
9 Refused

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

MCOT.07
Were you ever denied health insurance or life insurance coverage because of your cancer?
CSRVDEIN
1 Yes
2 No
7 Don’t know/ not sure
9 Refused



MCOT.08
Did you participate in a clinical trial as part of your cancer treatment?
CSRVCLIN
1 Yes
2 No
7 Don’t know/ not sure
9 Refused





Module 14: Cancer Survivorship: Pain Management


Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)




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


MCPM.01
Do you currently have physical pain caused by your cancer or cancer treatment?
CSRVPAIN
1 Yes






2 No
7 Don’t know/ not sure
9 Refused
Go to next module


MCPM.02
Would you say your pain is currently under control…?  
CSRVCTL2
Read:
1 With medication (or treatment)
2 Without medication (or treatment)
3 Not under control, with medication (or treatment)
4 Not under control, without medication (or treatment)
Do not read:
7 Don’t know / Not sure
9 Refused





Module 15: Home/ Self-measured Blood Pressure

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
M15.01

Has your doctor, nurse or other health professional recommended you check your blood pressure outside of the office or at home?
HOMBPCHK
1 Yes
2 No
7 Don’t know / Not sure
9 Refused

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

M15.02
Do you regularly check your blood pressure outside of your healthcare professional’s office or at home? 
HOMRGCHK
1 Yes






2 No
7 Don’t know / Not sure
9 Refused
Go to next section


M15.03
Do you take it mostly at home or on a machine at a pharmacy, grocery or similar location?
WHEREBP
1 At home 
2 On a machine at a pharmacy, grocery or similar location 
3 Do not check it 
7 Don’t know / Not sure 
9 Refused



M15.04
How do you share your blood pressure numbers that you collected with your health professional? Is it mostly by telephone, other methods such as emails, internet portal or fax, or in person?
SHAREBP
Do not read:
1 Telephone 
2 Other methods such as email, internet portal,  or fax, or
3 In person 






Do not read:
4 Do not share information
7 Don’t know / Not sure
9 Refused





Module 16: Sodium or Salt-Related Behavior

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
M16.01
Are you currently watching or reducing your sodium or salt intake?
WTCHSALT
1 Yes
2 No
7 Don’t know/ Not sure
9 Refused



M16.02
Has a doctor or other health professional ever advised you to reduce sodium or salt intake?
DRADVISE
1 Yes
2 No
7 Don’t know/ Not sure
9 Refused




Module 17: Cognitive Decline

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)




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


M17.01

The next few questions ask about difficulties in thinking or remembering that can make a big difference in everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you recently met, which is normal. This refers to confusion or memory loss that is happening more often or getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would normally know. We want to know how these difficulties impact you. 

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

1 Yes


Go to M17.02





2 No
Go to next module





7 Don’t know/ not sure
Go to M17.02





9 Refused
Go to next module


M17.02
During the past 12 months, as a result of confusion or memory loss, how often have you given up day-to-day household activities or chores you used to do, such as cooking, cleaning, taking medications, driving, or paying bills? Would you say it is…
CDHOUSE

Read:		
1 Always 
2 Usually 
3 Sometimes 
4 Rarely
5 Never
Do not read:
7 Don't know/Not sure
9 Refused



M17.03
As a result of confusion or memory loss, how often do you need assistance with these day-to-day activities? Would you say it is…
CDASSIST

Read:	
1 Always 
2 Usually 
3 Sometimes 






4 Rarely
5 Never
Do not read:
7 Don't know/Not sure
9 Refused
Go to M17.05


M17.04
When you need help with these day-to-day activities, how often are you able to get the help that you need? Would you say it is…
CDHELP

Read:	
1 Always 
2 Usually 
3 Sometimes 
4 Rarely
5 Never
Do not read:
7 Don't know/Not sure
9 Refused



M17.05
During the past 12 months, how often has confusion or memory loss interfered with your ability to work, volunteer, or engage in social activities outside the home? Would you say it is…
CDSOCIAL
Read:		
1 Always 
2 Usually 
3 Sometimes 
4 Rarely
5 Never
Do not read:
7 Don't know/Not sure
9 Refused



M17.06
Have you or anyone else discussed your confusion or memory loss with a health care professional?
CDDISCUS
1 Yes
2 No
7 Don’t know/ not sure
9 Refused





Module 18: Caregiver

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
M18.01

During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability?
CAREGIV1

1 Yes

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




2 No                                             
7  Don’t know/Not sure  
Go to M18.09





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





9 Refused
Go to M18.09


M18.02
What is his or her relationship to you?
CRGVREL3

01 Mother
02 Father
03 Mother-in-law
04 Father-in-law
05 Child
06 Husband
07 Wife
08 Live-in partner
09 Brother or brother-in-law
10 Sister or sister-in-law
11 Grandmother
12 Grandfather
13 Grandchild
14 Other relative                          
15 Non-relative/ Family friend
77 Don’t know/Not sure
99  Refused

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

M18.03
For how long have you provided care for that person? 
CRGVLNG1

Read if necessary:
1 Less than 30 days
2 1 month to less than 6 months
3 6 months to less than 2 years
4  2 years to less than 5 years
5 More than 5 years
Do not read:
7  Don’t Know/ Not Sure
9    Refused



M18.04
In an average week, how many hours do you provide care or assistance? 
CRGVHRS1

Read if necessary:                                                                                                                                  
1 Up to 8 hours per week
2 9 to 19 hours per week
3 20 to 39 hours per week
4 40 hours or more
Do not read:
7 Don’t know/Not sure
9 Refused



M18.05
What is the main health problem, long-term illness, or disability that the person you care for has?
CRGVPRB3

01 Arthritis/ rheumatism
02 Asthma
03 Cancer
04 Chronic respiratory conditions such as emphysema or COPD
05 Alzheimer’s disease, dementia or other cognitive impairment disorder
06 Developmental disabilities such as autism, Down’s Syndrome, and spina bifida
07 Diabetes
08 Heart disease, hypertension, stroke
09 Human Immunodeficiency Virus Infection (H.I.V.)
10 Mental illnesses, such as anxiety, depression, or schizophrenia
11 Other organ failure or diseases such as kidney or liver problems
12 Substance abuse or addiction disorders
13 Injuries, including broken bones 
14 Old age/ infirmity/frailty
15 Other
77  Don’t know/Not sure
99 Refused
If M18.05 = 5 (Alzheimer’s disease, dementia or other cognitive impairment disorder), go to M19.07.
Otherwise, continue


M18.06
Does the person you care for also have Alzheimer’s disease, dementia or other cognitive impairment disorder? 
CRGVALZD
1 Yes
2 No
7 Don’t know/ Not sure
9 Refused



M18.07
In the past 30 days, did you provide care for this person by managing personal care such as giving medications, feeding, dressing, or bathing?                                         
CRGVPER1
1 Yes
2 No
7 Don’t know/ not sure
9 Refused



M18.08
In the past 30 days, did you provide care for this person by managing household tasks such as cleaning, managing money, or preparing meals?
CRGVHOU1
1 Yes
2 No
7 Don’t know/ not sure
9 Refused







If M18.01 = 1 or 8, go to next module


M18.09
In the next 2 years, do you expect to provide care or assistance to a friend or family member who has a health problem or disability?                                                                            
CRGVEXPT
1 Yes
2 No
7 Don’t know/ not sure
9 Refused





Module 19: Adverse Childhood Experiences

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
Prologue
I'd like to ask you some questions about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life and may help others in the future. This is a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer. All questions refer to the time period before you were 18 years of age. 



Be aware of the level of stress introduced by questions in this section and be familiar with the crisis plan.

 M19.01
Now, looking back before you were 18 years of age---. 
1) Did you live with anyone who was depressed, mentally ill, or suicidal? 
ACEDEPRS
1 Yes
2 No
7 Don’t Know/Not Sure
9 Refused



 M19.02
Did you live with anyone who was a problem drinker or alcoholic?
ACEDRINK
1 Yes
2 No
7 Don’t Know/Not Sure
9 Refused



 M19.03
Did you live with anyone who used illegal street drugs or who abused prescription medications? 

ACEDRUGS
1 Yes
2 No
7 Don’t Know/Not Sure
9 Refused



 M19.04
Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility? 
ACEPRISN
1 Yes
2 No
7 Don’t Know/Not Sure
9 Refused



 M19.05
Were your parents separated or divorced?
ACEDIVRC
1 Yes
2 No
8 Parents not married
7 Don’t Know/Not Sure
9 Refused



 M19.06
How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up?
Was it… 
ACEPUNCH
Read:
1 Never 
2 Once 
3 More than once 
Don’t Read:
7 Don’t know/Not Sure 
9 Refused



 M19.07
Not including spanking, (before age 18), how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Was it— 
ACEHURT1
Read:
1 Never 
2 Once 
3 More than once 
Don’t Read:
7 Don’t know/Not Sure 
9 Refused




 M19.08
How often did a parent or adult in your home ever swear at you, insult you, or put you down? Was it…
ACESWEAR
Read:
1 Never 
2 Once 
3 More than once 
Don’t Read:
7 Don’t know/Not Sure 
9 Refused



 M19.09
How often did anyone at least 5 years older than you or an adult, ever touch you sexually? Was it…
ACETOUCH
Read:
1 Never 
2 Once 
3 More than once 
Don’t Read:
7 Don’t know/Not Sure 
9 Refused



 M19.10
How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually? Was it…
ACETTHEM
Read:
1 Never 
2 Once 
3 More than once 
Don’t Read:
7 Don’t know/Not Sure 
9 Refused



 M19.11
How often did anyone at least 5 years older than you or an adult, force you to have sex? Was it…
ACEHVSEX
Read:
1 Never 
2 Once 
3 More than once 
Don’t Read:
7 Don’t know/Not Sure 
9 Refused




M19.12
For how much of your childhood was there an adult in your household who made you feel safe and protected? Would you say never, a little of the time, some of the time, most of the time, or all of the time?
***NEW***
1. Never
2. A little of the time 
3. Some of the time 
4. Most of the time 
5. All of the time 
7 Don’t Know/Not sure 
9 Refused




M19.13
For how much of your childhood was there an adult in your household who tried hard to make sure your basic needs were met? Would you say never, a little of the time, some of the time, most of the time, or all of the time?
***NEW****
1. Never
2. A little of the time 
3. Some of the time 
4. Most of the time 
5. All of the time 
7 Don’t Know/Not sure 
9 Refused




Would you like for me to provide a toll-free number for an organization that can provide information and referral for the issues in the last few questions.



If yes provide number [STATE TO INSERT NUMBER HERE]




Module 20: Marijuana Use

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
M20.01

During the past 30 days, on how many days did you use marijuana or cannabis?
MARIJAN1

_  _ 01-30 Number of days

If asked, participants should be advised NOT to include hemp-based CBD products.




88 None 	
77 Don’t know/not sure 	
99 Refused
Go to next module


M20.02
During the past 30 days, which one of the following ways did you use marijuana the most often? Did you usually…
USEMRJN2

Read:
1 Smoke it (for example, in a joint, bong, pipe, or blunt). 
2 Eat it (for example, in brownies, cakes, cookies, or candy) 
3 Drink it (for example, in tea, cola, or alcohol) 
4 Vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device) 
5 Dab it (for example, using a dabbing rig, knife, or dab pen), or
6 Use it some other way.
Do not read:
7 Don’t know/not sure 
9 Refused

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

Read parentheticals only if asked for more detail.

M20.03
When you used marijuana or cannabis during the past 30 days, was it usually:
RSNMRJN1
Read: 
1 For medical reasons (like to treat or decrease symptoms of a health condition); 
2 For non-medical reasons (like to have fun or fit in), or 
3 For both medical and non-medical reasons. 
Do not read:
7 Don’t know/Not sure
9 Refused	







Module 21: Tobacco Cessation

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)




Ask if SMOKE100 = 1. 


M21.01
How long has it been since you last smoked a cigarette, even one or two puffs?    
LASTSMK2

Read if necessary:
01 Within the past month (less than 1 month ago)
02 Within the past 3 months (1 month but less than 3 months ago)
03 Within the past 6 months (3 months but less than 6 months ago)
04 Within the past year (6 months but less than 1 year ago)
05 Within the past 5 years (1 year but less than 5 years ago)
06 Within the past 10 years (5 years but less than 10 years ago)
07 10 years or more 
08 Never smoked regularly
77 Don’t know / Not sure
99 Refused







Ask if SMOKDAY2 = 1 or 2.


M21.02
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
STOPSMK2

1 Yes
2 No
7 Don’t know / Not sure
9 Refused




Module 22: Firearm Safety

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
Prologue
The next questions are about safety and firearms. Some people keep guns for recreational purposes such as hunting or sport shooting. People also keep guns in the home for protection. Please include firearms such as pistols, revolvers, shotguns, and rifles; but not BB guns or guns that cannot fire. Include those kept in a garage, outdoor storage area, or motor vehicle.

M22.01

Are any firearms now kept in or around your home?

1 Yes

Do not include guns that cannot fire; include those kept in cars, or outdoor storage. 




2 No
7 Don’t know/ not sure
9 Refused
Go to Next module


M22.02
Are any of these firearms now loaded?

1 Yes








2 No
7 Don’t know/ not sure
9 Refused	
Go to Next module


M22.03
Are any of these loaded firearms also unlocked?

1 Yes
2 No
7 Don’t know/ not sure
9 Refused

By unlocked, we mean you do not need a key or a combination or a hand/fingerprint to get the gun or to fire it. Don’t count the safety as a lock.








Module 23: Industry and Occupation

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)




If CDEM.14 = 1 (Employed for wages) or 2 (Self-employed) or 4 (Employed for wages or out of work for less than 1 year), continue, else go to next module/section.
If CDEM.14 = 4 (Out of work for less than 1 year) ask, “What kind of work did you do? For example, registered nurse, janitor, cashier, auto mechanic.”

Else go to next module	


M23.01

What kind of work do you do? For example, registered nurse, janitor, cashier, auto mechanic.	
TYPEWORK
 _______Record answer
99 Refused

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

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

M23.02
What kind of business or industry do you work in? For example, hospital, elementary school, clothing manufacturing, restaurant
TYPEINDS
_______Record answer
99 Refused
If Core CDEM.14 = 4 (Out of work for less than 1 year) ask, “What kind of business or industry did you work in? For example, hospital, elementary school, clothing manufacturing, restaurant.” 



Module 24: Random Child Selection

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
Intro text and screening
If C08.15 = 1, Interviewer please read:  Previously, you indicated there was one child age 17 or younger in your household.  I would like to ask you some questions about that child.

If C08.15 is >1 and C08.15 does not equal 88 or 99, Interviewer please read:  Previously, you indicated there were [number] children age 17 or younger in your household. Think about those [number] children in order of their birth, from oldest to youngest.  The oldest child is the first child and the youngest child is the last. Please include children with the same birth date, including twins, in the order of their birth.


If CDEM.15 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module.
	
CATI INSTRUCTION:  RANDOMLY SELECT ONE OF THE CHILDREN.  This is the Xth child. Please substitute Xth child’s number in all questions below.
INTERVIEWER PLEASE READ: I have some additional questions about one specific child. The child I will be referring to is the Xth [CATI: please fill in correct number] child in your household.  All following questions about children will be about the Xth [CATI: please fill in] child.


M24.01

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

_ _ /_ _ _ _ Code month and year
77/ 7777  Don’t know / Not sure
99/ 9999  Refused



M24.02
Is the child a boy or a girl?
RCSGENDR
1 Boy 
2 Girl
9 Refused



M24.03
Is the child Hispanic, Latino/a, or Spanish origin?
		
RCHISLA1
Read if response is yes:
1 Mexican, Mexican American, Chicano/a
2 Puerto Rican
3 Cuban
4 Another Hispanic, Latino/a, or Spanish origin
Do not read:
5 No
7 Don’t know / Not sure
9 Refused

If yes, ask: Are they…

M24.04
Which one or more of the following would you say is the race of the child?
RCSRACE1
10 White  
20 Black or African American 
30 American Indian or Alaska Native
40 Asian
41 Asian Indian
42 Chinese
43 Filipino
44 Japanese
45 Korean
46 Vietnamese
47 Other Asian
50 Pacific Islander
51 Native Hawaiian
52 Guamanian or Chamorro
53 Samoan
54 Other Pacific Islander
Do not read:
60 Other
77 Don’t know / Not sure
99 Refused
[CATI NOTE: IF MORE THAN ONE RESPONSE TO M21.04; CONTINUE. OTHERWISE, GO TO M21.06.]
Select all that apply

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

M24.05
Which one of these groups would you say best represents the child’s race?
RCSBRAC2
10 White  
20 Black or African American 
30 American Indian or Alaska Native
40 Asian
41 Asian Indian
42 Chinese
43 Filipino
44 Japanese
45 Korean
46 Vietnamese
47 Other Asian
50 Pacific Islander
51 Native Hawaiian
52 Guamanian or Chamorro
53 Samoan
54 Other Pacific Islander
Do not read:
60 Other
88 No additional choices
 77 Don’t know / Not sure
99 Refused

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

M24.06
How are you related to the child? Are you a….
RCSRLTN2
Please read:
 1 Parent (include biologic, step, or adoptive parent)
2 Grandparent
3 Foster parent or guardian 
4 Sibling (include biologic, step, and adoptive sibling)
5 Other relative
6 Not related in any way 
Do not read:
7 Don’t know / Not sure
9  Refused






Module 25: Childhood Asthma Prevalence

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)




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


M25.01

The next two questions are about the Xth child. 
Has a doctor, nurse or other health professional EVER said that the child has asthma?	
CASTHDX2


1 Yes

Fill in correct [Xth] number.





2 No
7 Don’t know/ not sure
9 Refused
Go to next module


M25.02
Does the child still have asthma?	
CASTHNO2
1 Yes
2 No
7 Don’t know/ not sure
9 Refused








Module 26: Sex at Birth

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
MSAB.01
What was your sex at birth? Was it male or female?
BIRTHSEX
1 Male
2 Female
7 Don’t know/Not sure
9 Refused

This question refers to the original birth certificate of the respondent.  It does not refer to amended birth certificates. 


Module 27: Sexual Orientation and Gender Identity (SOGI)

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
Prologue
The next two questions are about sexual orientation and gender identity









If sex= male (using BIRTHSEX, CELLSEX, LANDSEX ) continue, otherwise go to MSOGI.01b.


MSOGI.01a

Which of the following best represents how you think of yourself?	
SOMALE
1 = Gay
2 = Straight, that is, not gay
3 = Bisexual
4 = Something else
7 = I don't know the answer
9 = Refused

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

Please say the number before the text response.  Respondent can answer with either the number or the text/word.
551




If sex= female (using BIRTHSEX, CELLSEX, LANDSEX ) continue, otherwise go to MSOGI.02.


MSOGI.01b
Which of the following best represents how you think of yourself?
SOFEMALE
1 = Lesbian or Gay
2 = Straight, that is, not gay
3 = Bisexual
4 = Something else
7 = I don't know the answer
9 = Refused
.
Read if necessary: We ask this question in order to better understand the health and health care needs of people with different sexual orientations.

Please say the number before the text response.  Respondent can answer with either the number or the text/word.
552
MSOGI.02
Do you consider yourself to be transgender?  
TRNSGNDR
1  Yes, Transgender, male-to-female  
2  Yes, Transgender, female to male
3 Yes, Transgender, gender nonconforming
4 No
7 Don’t know/not sure
9 Refused

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

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

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

Please say the number before the text response.  Respondent can answer with either the number or the text/word.
553


Asthma Call-Back Permission Script

Question Number
Question text
Variable names
Responses 
(DO NOT READ UNLESS OTHERWISE NOTED)
SKIP INFO/ CATI Note
Interviewer Note (s)
Column(s)
Text

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





CB01.01
Would it be okay if we called you back to ask additional asthma-related questions at a later time?
CALLBACK
1 Yes
2 No





CB01.02
Which person in the household was selected as the focus of the asthma call-back?
ADLTCHLD
1 Adult
2 Child




CB01.03
Can I please have either (your/your child’s) first name or initials, so we will know who to ask for when we call back?

                        
____________________ Enter first name or initials.






Closing Statement

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