MEC Questionnaire and Exam

National Health and Nutrition Examination Survey

Att_3f_MEC Questionnaire Exam 081718

OMB: 0920-0950

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Attachment 3f

MEC Interview and Examination

Data Collection Forms

Form Approved

OMB No. 0920-0950

Exp. Date XX/XX/20XX

CDC estimates the average public reporting burden for this collection of information as 4 hours per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, SD-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0950).

Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice or an establishment will be used only for statistical purposes. NCHS staff, contractors and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA every NCHS employee, contractor and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

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National health and Nutrition Examination Survey (NHANES)

Mobile Examination Center (MEC) Interview & Exam

TABLE OF CONTENTS

MEC Interview – CAPI 4

RESPONDENT SELECTION SECTION - RIQ - mec 4

PESTICIDE USE – PUQ 5

Volatile Toxicant – VTQ 6

SEXUAL BEHAVIOR – (SXQ 15

CURRENT HEALTH STATUS – HSQ 17

DEPRESSION SCREEN – DPQ 17

TOBACCO – SMQ 21

ALCOHOL USE – ALQ 30

REPRODUCTIVE HEALTH – RHQ 36

KIDNEY CONDITIONS - KIQ 54

PHYSICAL ACTIVITY AND PHYSICAL FITNESS – PAQ 57

WEIGHT HISTORY – WHQ 58

MEC Interview 62

Critical Data Items 62

MEC Interview– ACASI 65

TOBACCO – SMQ 65

ALCOHOL USE – ALQ 78

DRUG USE – DUQ 81

SEXUAL BEHAVIOR – (SXQ) 87

SEXUAL BEHAVIOR – (SXQ) 102

DIETARY INTERVIEW 119

24-Hour Dietary Recall Interview 119

Post-dietary Recall Questions 120

DIETARY SUPPLEMENTS 126

MEC DATA COLLECTION FORMS 143

ANTHROPOMETRY 144

AUDIOMETRY 146

Standing Balance (ages 40+) 155

COGNITIVE FUNCTIONING (MOCA-SA) 158

Dual X-Ray Absorptiometry (whole body) 163

Dual X-Ray Absorptiometry (femur and spine) 164

ORAL HEALTH 165

PHYSICIAN EXAMINATION 166

VENIPUNCTURE 167

Hepatic (liver) Steatosis and Fibrosis Ultrasound Elastography form 169

MEC Interview – CAPI

RESPONDENT SELECTION SECTION - RIQ - mec

Target Group: SPs 8+

RIQ.005 INTERVIEWER: MARK MAIN RESPONDENT. SPECIFY RELATIONSHIP OF RESPONDENT TO SP IF OTHER THAN SP.

SP 1 (BOX 1)

MOTHER 2

FATHER 3

SPOUSE 4

SISTER OR BROTHER 5

CHILD 6

GRANDPARENT 7

LEGAL GUARDIAN 8

OTHER (SPECIFY) 9

RIQ.030 WHY IS INTERVIEW BEING CONDUCTED WITH A PROXY?

SP HAS COGNITIVE PROBLEMS 1

SP HAS PHYSICAL PROBLEMS

(SPECIFY) 2

OTHER (SPECIFY) 3

RIQ.038 INTERVIEWER: WAS SP PRESENT IN THE ROOM DURING ANY PART OF THE INTERVIEW?

YES 1

NO 2

BOX 1

CHECK ITEM RIQ.149:

IF SP 8-11 YEARS AND INTERVIEW DONE WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), DISPLAY THE FOLLOWING INTRODUCTORY TEXT: “During this interview, I will be asking you questions about your health and weight. Your answers will be kept private. Do you have any questions before we begin?”
IF SP 12-17 YEARS OR 60+ YEARS AND INTERVIEW DONE WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), DISPLAY THE FOLLOWING INTRODUCTORY TEXT: “During this interview, I will be asking you questions about your home, current health status, and on other health behaviors. Remember, all of your responses to these questions will be kept confidential. Do you have any questions before we begin?”
IF SP 18-59 YEARS AND INTERVIEW DONE WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), DISPLAY THE FOLLOWING INTRODUCTORY TEXT: “During this interview, I will be asking you questions about your home, sexual orientation, current health status, and on other health behaviors. Remember, all of your responses to these questions will be kept confidential. Do you have any questions before we begin?”
OTHERWISE, DISPLAY THE FOLLOWING INTRODUCTORY TEXT: “During this interview, I will be asking you questions about {SP}'s current health status and on other health behaviors.”

PESTICIDE USE – PUQ

Target Group: SPs 8+

PUQ.100 In the past 7 days, were any chemical products used in {your/his/her} home to control fleas, roaches, ants, termites, or other insects?

CAPI INSTRUCTION:

IF SP 8-17 YEARS, DISPLAY THE FOLLOWING INTERVIEWER INSTRUCTION: "THIS ITEM IS COLLECTED VIA PROXY FOR SPS 8-17."

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

PUQ.110 In the past 7 days, were any chemical products used in {your/his/her} lawn or garden to kill weeds?

CODE ‘NO’ IF THE RESPONDENT SAYS S/HE DOES NOT HAVE A LAWN OR GARDEN.

CAPI INSTRUCTION:

IF SP 8-17 YEARS, DISPLAY THE FOLLOWING INTERVIEWER INSTRUCTION: "THIS ITEM IS COLLECTED VIA PROXY FOR SPS 8-17."

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

Volatile Toxicant – VTQ

Target Group: SPs 12-150 Sub-Sampled into VOC

The VOC section is applicable for only those SPs that are subsampled into VOC. To determine if a particular SP is subsampled into VOC, check the mec_sp_subsample. If the SP in question has a record for subsample 1, they are subsampled for VOC and so should get the VOC section.

VTQ.210_ First, I would like to ask you a few questions about {your/SP's} home.

VTQ.210 Does {your/her/his} home have an attached garage?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.220 Is the source of water for {your/her/his} home from a private well?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.200a {Do you/Does she/Does he} currently store paints or fuels inside {your/her/his} home? Include {your/her/his} basement {and attached garage}.

CAPI INSTRUCTION:

IF SP HAS AN ATTACHED GARAGE (CODED ‘1’ IN VTQ.210), DISPLAY {and attached garage}.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.231a {Do you/Does she/Does he} currently use moth balls, moth crystals or toilet bowl deodorizers inside {your/her/his} home?

HELP SCREEN SHOULD READ: Some toilet bowl deodorizers clip onto the toilet rim, others, such as deodorant blocks and gels, are placed inside the tank or hang inside the wall of the tank. Brand names include Bully, 2000 Flushes, Vanish, X-14, Ty-D-Bol, Toilet Duck, Clorox, Lime-A-Way, and Sno Bol.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

VTQ.233a In the last three days, did {you/she/he} inhale smoke from any source for 10 or more minutes?

HELP SCREEN: Inhaled smoke includes smoke from campfires, fireplaces, marijuana, and tobacco products such as cigarettes, cigars and pipes.

YES 1

NO 2 (VTQ.241_)

REFUSED 7 (VTQ.241_)

DON'T KNOW 9 (VTQ.241_)

VTQ.233b When did {you/she/he} last spend 10 or more minutes inhaling smoke?

TODAY 1

YESTERDAY 2

MORE THAN 2 DAYS 3

REFUSED 7

DON'T KNOW 9

VTQ.241_ Now I am going to ask you a few questions about {your/SP’s} activities over the last 48 hours. This means today or yesterday.

VTQ.241a In the last 48 hours, did {you/she/he} cook or bake with natural gas?

HELP SCREEN: Natural gas is often informally referred to simply as “gas.” It is the most common fuel source for modern furnaces and is generally purchased through a local utility company. Other fuel sources that are not natural gas are LPG (liquefied petroleum gas) butane, propane, oil, coal or wood.

YES 1

NO 2 (VTQ.244a)

REFUSED 7 (VTQ.244a)

DON'T KNOW 9 (VTQ.244a)

VTQ.241b How long ago, in hours, did {you/she/he} cook or bake with natural gas?

G/Q/D/T

CAPI INSTRUCTION:

IF “1” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER NUMBER OF HOURS WITH A HARD EDIT RANGE OF 1 – 48.

IF “2” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER “DATE EVENT OCCURRED” WITH A CALENDAR WHERE DATE CAN BE SELECTED AND “TIME EVENT OCCURRED”. CALCULATE “HOURS SINCE EVENT OCCURRED” BASED ON THE CURRENT DATE AND TIME AND DISPLAY RESULT ON SCREEN. THE RESULT OF THE CALCULATION USING THE CALENDAR AND TIME GOES INTO Q. HARD EDIT RANGE IS 1 – 48.

THE APPLICATION WILL PERFORM THE FOLLOWING CONSISTENCY CHECKS AND ROUNDING RULE:

“DATE EVENT OCCURRED” AND “TIME EVENT OCCURRED” COMBINED MUST BE BEFORE CURRENT DATE AND TIME COMBINED.

WHEN “TIME SINCE EVENT OCCURRED” FALLS EXACTLY ON THE ONE-HALF, ROUND TO THE NEAREST EVEN WHOLE NUMBER.

|___|___|

HOURS

ENTER DATE AND TIME 2

REFUSED 77

DON'T KNOW 99

VTQ.244a In the last 48 hours, did {you/she/he} pump gas into a car or other motor vehicle {yourself/herself/ himself}?

YES 1

NO 2 (VTQ.251a)

REFUSED 7 (VTQ.251a)

DON'T KNOW 9 (VTQ.251a)

VTQ.244b How long ago, in hours, did {you/she/he} pump gas into a car or other motor vehicle {yourself/herself/

G/Q/D/T himself}?

CAPI INSTRUCTION:

IF “1” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER NUMBER OF HOURS WITH A HARD EDIT RANGE OF 1 – 48.

THE APPLICATION WILL PERFORM THE FOLLOWING CONSISTENCY CHECKS AND ROUNDING RULE:

“DATE EVENT OCCURRED” AND “TIME EVENT OCCURRED” COMBINED MUST BE BEFORE CURRENT DATE AND TIME COMBINED.

WHEN “TIME SINCE EVENT OCCURRED” FALLS EXACTLY ON THE ONE-HALF, ROUND TO THE NEAREST EVEN WHOLE NUMBER.

|___|___|

HOURS

ENTER DATE AND TIME 2

REFUSED 77

DON'T KNOW 99

VTQ.251a In the last 48 hours, did {you/she/he} spend any time at a swimming pool, in a hot tub, or in a steam room?

YES 1

NO 2 (VTQ.261a)

REFUSED 7 (VTQ.261a)

DON'T KNOW 9 (VTQ.261a)

VTQ.251b How long ago, in hours, has it been since {you/she/he} spent time at a swimming pool, in a hot tub, or

G/Q/D/T in a steam room?

CAPI INSTRUCTION:

IF “1” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER NUMBER OF HOURS WITH A HARD EDIT RANGE OF 1 – 48.

THE APPLICATION WILL PERFORM THE FOLLOWING CONSISTENCY CHECKS AND ROUNDING RULE:

“DATE EVENT OCCURRED” AND “TIME EVENT OCCURRED” COMBINED MUST BE BEFORE CURRENT DATE AND TIME COMBINED.

WHEN “TIME SINCE EVENT OCCURRED” FALLS EXACTLY ON THE ONE-HALF, ROUND TO THE NEAREST EVEN WHOLE NUMBER.

|___|___|

HOURS

ENTER DATE AND TIME 2

REFUSED 77

DON'T KNOW 99

VTQ.261a In the last 48 hours, did {you/she/he} use dry cleaning solvents, visit a dry cleaning shop or wear clothes that had been dry-cleaned within the last week?

HELP SCREEN: Examples of dry cleaning solvents include Guardsman Dry Cleaning Fluid, Amway prewash, LPS F-104 Dry Solvent, Dryel At-Home Dry Cleaning starter kit, Woolite Dry Clean at Home, and Bounce 15 minute Dry Cleaner.

YES 1

NO 2 (VTQ.271a)

REFUSED 7 (VTQ.271a)

DON'T KNOW 9 (VTQ.271a)

VTQ.261b How long ago, in hours, has it been since {you/she/he} used dry cleaning solvents, visited a dry

G/Q/D/T cleaning shop or wore clothes that had been dry-cleaned within the last week?

CAPI INSTRUCTION:

IF “1” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER NUMBER OF HOURS WITH A HARD EDIT RANGE OF 1 – 48.

THE APPLICATION WILL PERFORM THE FOLLOWING CONSISTENCY CHECKS AND ROUNDING RULE:

“DATE EVENT OCCURRED” AND “TIME EVENT OCCURRED” COMBINED MUST BE BEFORE CURRENT DATE AND TIME COMBINED.

WHEN “TIME SINCE EVENT OCCURRED” FALLS EXACTLY ON THE ONE-HALF, ROUND TO THE NEAREST EVEN WHOLE NUMBER.

|___|___|

HOURS

ENTER DATE AND TIME 2

REFUSED 77

DON'T KNOW 99

VTQ.271a In the last 48 hours, did {you/she/he} take a hot shower or bath for five minutes or longer?

YES 1

NO 2 (VTQ.281a)

REFUSED 7 (VTQ.281a)

DON'T KNOW 9 (VTQ.281a)

VTQ.271b How long ago, in hours, has it been since {your/SP’s} last shower or hot bath?

G/Q/D/T

CAPI INSTRUCTION:

IF “1” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER NUMBER OF HOURS WITH A HARD EDIT RANGE OF 1 – 48.

THE APPLICATION WILL PERFORM THE FOLLOWING CONSISTENCY CHECKS AND ROUNDING RULE:

“DATE EVENT OCCURRED” AND “TIME EVENT OCCURRED” COMBINED MUST BE BEFORE CURRENT DATE AND TIME COMBINED.

WHEN “TIME SINCE EVENT OCCURRED” FALLS EXACTLY ON THE ONE-HALF, ROUND TO THE NEAREST EVEN WHOLE NUMBER.

|___|___|

HOURS

ENTER DATE AND TIME 2

REFUSED 77

DON'T KNOW 99

VTQ.281a In the last 48 hours, did {you/she/he} breathe fumes from freshly painted indoor surfaces, paints, paint thinner, or varnish?

YES 1

NO 2 (VTQ.281c)

REFUSED 7 (VTQ.281c)

DON'T KNOW 9 (VTQ.281c)

VTQ.281b How long ago, in hours, has it been since {you/she/he} breathed fumes from freshly painted indoor

G/Q/D/T surfaces, paints, paint thinner, or varnish?

CAPI INSTRUCTION:

IF “1” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER NUMBER OF HOURS WITH A HARD EDIT RANGE OF 1 – 48.

THE APPLICATION WILL PERFORM THE FOLLOWING CONSISTENCY CHECKS AND ROUNDING RULE:

“DATE EVENT OCCURRED” AND “TIME EVENT OCCURRED” COMBINED MUST BE BEFORE CURRENT DATE AND TIME COMBINED.

WHEN “TIME SINCE EVENT OCCURRED” FALLS EXACTLY ON THE ONE-HALF, ROUND TO THE NEAREST EVEN WHOLE NUMBER.

|___|___|

HOURS

ENTER DATE AND TIME 2

REFUSED 77

DON'T KNOW 99

VTQ.281c In the last 48 hours, did {you/she/he} breathe fumes from diesel fuel or kerosene?

YES 1

NO 2 (VTQ.281e)

REFUSED 7 (VTQ.281e)

DON'T KNOW 9 (VTQ.281e)

VTQ.281d How long ago, in hours, has it been since {you/she/he} breathed fumes from diesel fuel or kerosene?

G/Q/D/T

CAPI INSTRUCTION:

IF “1” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER NUMBER OF HOURS WITH A HARD EDIT RANGE OF 1 – 48.

THE APPLICATION WILL PERFORM THE FOLLOWING CONSISTENCY CHECKS AND ROUNDING RULE:

“DATE EVENT OCCURRED” AND “TIME EVENT OCCURRED” COMBINED MUST BE BEFORE CURRENT DATE AND TIME COMBINED.

WHEN “TIME SINCE EVENT OCCURRED” FALLS EXACTLY ON THE ONE-HALF, ROUND TO THE NEAREST EVEN WHOLE NUMBER.

|___|___|

HOURS

ENTER DATE AND TIME 2

REFUSED 77

DON'T KNOW 99

VTQ.281e In the last 48 hours, did {you/she/he} breathe fumes from fingernail polish?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

VTQ.281f How long ago, in hours, has it been since {you/she/he} breathed fumes from fingernail polish?

G/Q/D/T

CAPI INSTRUCTION:

IF “1” IS ENTERED FOR GATE, ALLOW INTERVIEWER TO ENTER NUMBER OF HOURS WITH A HARD EDIT RANGE OF 1 – 48.

THE APPLICATION WILL PERFORM THE FOLLOWING CONSISTENCY CHECKS AND ROUNDING RULE:

“DATE EVENT OCCURRED” AND “TIME EVENT OCCURRED” COMBINED MUST BE BEFORE CURRENT DATE AND TIME COMBINED.

WHEN “TIME SINCE EVENT OCCURRED” FALLS EXACTLY ON THE ONE-HALF, ROUND TO THE NEAREST EVEN WHOLE NUMBER.

|___|___|

HOURS

ENTER DATE AND TIME 2

REFUSED 77

DON'T KNOW………………………………… 99

SEXUAL BEHAVIOR – (SXQ)

Target Group: SPs 18-59 (CAPI)

BOX 1

CHECK ITEM SXQ.300:

IF INTERVIEW NOT DONE ONLY WITH SURVEY PARTICIPANT (RIQ.005 NOT EQUAL TO 1), GO TO END OF SECTION.
IF SP = FEMALE AND SP = 18 – 59 YEARS, CONTINUE WITH SXQ.295.
ELSE IF SP = MALE AND SP = 18 – 59 YEARS, CONTINUE WITH SXQ.296.
OTHERWISE, GO TO END OF SECTION.

SXQ.295 Do you think of yourself as lesbian or gay; straight, that is, not lesbian or gay; bisexual; something else; or you don’t know the answer?

(Target 18-59)

HAND CARD SXQ1

LESBIAN OR GAY……………………………….. 1 (END OF SECTION)

STRAIGHT, THAT IS, NOT LESBIAN OR GAY. 2 (END OF SECTION)

BISEXUAL……………………………………….. 3 (END OF SECTION)

SOMETHING ELSE……………………………. 4 (END OF SECTION)

I DON’T KNOW THE ANSWER………………. 9 (END OF SECTION)

REFUSED………………………………………. 77 (END OF SECTION)

DON’T KNOW…………………………………… 99 (END OF SECTION)

SXQ.296 Do you think of yourself as gay; straight, that is, not gay; bisexual; something else; or you don’t know the answer?

(Target 18-59)

HAND CARD SXQ2

GAY 1

STRAIGHT, THAT IS, NOT GAY 2

BISEXUAL 3

SOMETHING ELSE 4

I DON’T KNOW THE ANSWER 9

REFUSED 77

DON’T KNOW 99

CURRENT HEALTH STATUS – HSQ

Target Group: SPs 16+ (CAPI)

HSQ.590 The next question is about the test for HIV, the virus that causes AIDS. Except for tests {you/SP} may have had as part of blood donations, {have you/has he/has she} ever been tested for HIV?

YES 1

NO 2

REFUSED 7

DON'T KNOW…………………………………. 9

DEPRESSION SCREEN – DPQ

Target Group: SPs 12+

BOX 1

CHECK ITEM DPQ.001:

IF INTERVIEW DONE ONLY WITH SURVEY PARTICIPANT (CODED ‘1’ IN RIQ.005), CONTINUE.
OTHERWISE, GO TO NEXT SECTION.

DPQ.010 Over the last 2 weeks, how often have you been bothered by the following problems:

little interest or pleasure in doing things? Would you say . . .

HANDCARD DPQ1

Not at all, 0

several days, 1

more than half the days, or 2

nearly every day? 3

REFUSED 7

DON’T KNOW 9

DPQ.020 [Over the last 2 weeks, how often have you been bothered by the following problems:]

feeling down, depressed, or hopeless?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.030 [Over the last 2 weeks, how often have you been bothered by the following problems:]

trouble falling or staying asleep, or sleeping too much?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.040 [Over the last 2 weeks, how often have you been bothered by the following problems:]

feeling tired or having little energy?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.050 [Over the last 2 weeks, how often have you been bothered by the following problems:]

poor appetite or overeating?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.060 [Over the last 2 weeks, how often have you been bothered by the following problems:]

feeling bad about yourself – or that you are a failure or have let yourself or your family down?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.070 [Over the last 2 weeks, how often have you been bothered by the following problems:]

trouble concentrating on things, such as reading the newspaper or watching TV?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.080 [Over the last 2 weeks, how often have you been bothered by the following problems:]

moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?

HANDCARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

DPQ.090 Over the last 2 weeks, how often have you been bothered by the following problem:

Thoughts that you would be better off dead or of hurting yourself in some way?

HAND CARD DPQ1

NOT AT ALL 0

SEVERAL DAYS 1

MORE THAN HALF THE DAYS 2

NEARLY EVERY DAY 3

REFUSED 7

DON’T KNOW 9

BOX 2

CHECK ITEM DPQ.095:

IF RESPONSE TO ANY OF QUESTIONS DPQ.010 – DPQ.090 = 1, 2, OR 3, GO TO DPQ.100.
OTHERWISE, GO TO NEXT SECTION.

DPQ.100 How difficult have these problems made it for you to do your work, take care of things at home, or get along with people?

Not at all difficult, 0

Somewhat difficult, 1

Very difficult, 2

Extremely difficult? 3

REFUSED 7

DON’T KNOW 9

TOBACCO – SMQ

Target Group: SPs 12+ (CAPI)

BOX 1

CHECK ITEM SMQ.859:

IF SP AGED 12-17, GO TO SMQ.860.

OTHERWISE, CONTINUE.

SMQ.682 The following questions ask about use of tobacco products in the past 5 days.

During the past 5 days, including today, did {you/he/she} smoke cigarettes, pipes, regular cigars, cigarillos or little filtered cigars, water pipes or hookahs with tobacco?

HAND CARD SMQ1

YES 1

NO 2 (SMQ.846)

REFUSED 7 (SMQ.846)

DON’T KNOW 9 (SMQ.846)

SMQ.692 Which of these products did {you/he/she} smoke?

HAND CARD SMQ1

(CHECK ALL THAT APPLY)

Cigarettes 1

Pipes 2

Regular cigars, cigarillos or little filtered cigars..3

Water pipes or Hookahs with tobacco 4

REFUSED 77 (SMQ.846)

DON’T KNOW 99 (SMQ.846)

BOX 2

CHECK ITEM SMQ.701:

IF ‘CIGARETTES’ (CODE 1) IN SMQ.692, GO TO SMQ.710.

IF ‘PIPES’ (CODE 2) IN SMQ.692, GO TO SMQ.740.

IF ‘CIGARS’ (CODE 3) IN SMQ.692, GO TO SMQ.771.

IF ‘WATER PIPES OR HOOKAHS’ (CODE 4) IN SMQ.692, GO TO SMQ.845.

SMQ.710 During the past 5 days, including today, on how many days did {you/he/she} smoke cigarettes?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.720 During the past 5 days, including today, on the days {you/he/she} smoked, how many cigarettes did {you/he/she} smoke each day?

IF R SAYS 95 OR MORE CIGARETTES PER DAY, ENTER 95.

HARD EDIT: RANGE 1 – 95.

|___|___|

ENTER NUMBER OF CIGARETTES

REFUSED 777

DON'T KNOW 999

SMQ.725 When did {you/he/she} smoke {your/his/her} last cigarette? Was it . . .

today, 1

yesterday, or 2

3 to 5 days ago? 3

REFUSED 7

DON'T KNOW 9

BOX 3

CHECK ITEM SMQ.731:

IF ‘PIPES’ (CODE 2) IN SMQ.692, GO TO SMQ.740.

IF ‘CIGARS’ (CODE 3) IN SMQ.692, GO TO SMQ.771.

IF ‘WATER PIPES OR HOOKAHS’ (CODE 4) IN SMQ.692, GO TO SMQ.845.

OTHERWISE, GO TO SMQ.846.

SMQ.740 During the past 5 days, including today, on how many days did {you/he/she} smoke a pipe?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 4

CHECK ITEM SMQ.761:

IF ‘CIGARS’ (CODE 3) IN SMQ.692, GO TO SMQ.771.

IF ‘WATER PIPES OR HOOKAH IN SMQ.692, GO TO SMQ.845.

OTHERWISE, GO TO SMQ.846.

SMQ.771 During the past 5 days, including today, on how many days did {you/he/she} smoke regular cigars, or cigarillos, or little filtered cigars?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 5

CHECK ITEM SMQ.791:

IF ‘WATER PIPE’ (CODE 4) IN SMQ.692, GO TO 845.

OTHERWISE, GO TO SMQ.846.

SMQ.845 During the past 5 days, including today, on how many days did {you/he/she} smoke tobacco in a water pipe or Hookah?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.846 During the past 5 days, including today, did (you/he/she) use e-cigarettes? You may also know them as JUUL^TM, vape-pens, vapes, hookah-pens, e-hookahs, or vaporizers. These are battery-powered, usually contain liquid nicotine, and produce vapor instead of smoke?

INTERVIEWER INSTRUCTION: THESE QUESTIONS CONCERN ELECTRONIC VAPING PRODUCTS FOR NICOTINE USE. THE USE OF ELECTRONIC VAPING PRODUCTS FOR MARIJUANA USE IS NOT INCLUDED IN THESE QUESTIONS.

YES 1

NO 2 (SMQ.851)

REFUSED 7 (SMQ.851)

DON’T KNOW 9 (SMQ.851)

SMQ.849 During the past 5 days, including today, on how many days did {you/he/she} use e-cigarettes?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.851 Smokeless tobacco products are placed in the mouth or nose and can include chewing tobacco, snuff, dip, snus (PRONOUNCED SNOOSE), or dissolvable tobacco.

During the past 5 days, including today, did {you/he/she} use any smokeless tobacco?

(Please do not include nicotine replacement products like patches, gum, lozenge, or spray which are considered products to help {you/him/her} stop smoking.)

YES 1

NO 2 (SMQ.863)

REFUSED 7 (SMQ.863)

DON’T KNOW 9 (SMQ.863)

SMQ.853 Which of these products did {you/he/she} use?

(CHECK ALL THAT APPLY)

Chewing tobacco 1

Snuff 2

Snus 3

Dissolvables 4

Dip…………………………………………………..5

REFUSED 7 (SMQ.863)

DON’T KNOW 9 (SMQ.863)

BOX 7

CHECK ITEM SMQ.855:

IF ‘CHEWING’ (CODE 1) IN SMQ.853, GO TO SMQ.800.
IF ‘SNUFF’ (CODE 2) IN SMQ.853, GO TO SMQ.817.
OTHERWISE, GO TO SMQ.863

SMQ.800 During the past 5 days, including today, on how many days did {you/he/she} use chewing tobacco, such as Redman, Levi Garrett or Beechnut?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 8

CHECK ITEM SMQ.818:

IF ‘SNUFF’ (CODE 2) IN SMQ.853, GO TO SMQ.817.

OTHERWISE, GO TO SMQ.863.

SMQ.817 During the past 5 days, including today, on how many days did {you/he/she} use snuff, such as Skoal, Skoal Bandits, or Copenhagen?

HARD EDIT: RANGE 1 – 5.

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.863 During the past 5 days, including today, did {you/he/she} use any nicotine replacement therapy products such as nicotine patches, gum, lozenges, inhalers, or nasal sprays?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

SMQ.831 During the past 5 days, including today, on how many days did {you/he/she} use any nicotine replacement therapy products such as nicotine patches, gum, lozenges, inhalers, or nasal sprays?

HARD EDIT: RANGE 1 – 5.

|___| (END OF SECTION)

ENTER NUMBER OF DAYS

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

SMQ.860 The next questions are about {your/his/her} exposure to other people’s tobacco smoke.

During the last 7 days, did {you/SP} spend time in a restaurant?

YES 1

NO 2 (SMQ.870)

REFUSED 7 (SMQ.870)

DON'T KNOW 9 (SMQ.870)

SMQ.862 While {you were/SP was} in a restaurant, did someone else smoke cigarettes or other tobacco products indoors?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SMQ.870 During the last 7 days, did {you/SP} ride in a car or motor vehicle?

YES 1

NO 2 (SMQ.874)

REFUSED 7 (SMQ.874)

DON'T KNOW 9 (SMQ.874)

SMQ.872 While {you were/SP was} riding in a car or motor vehicle, did someone else smoke cigarettes or other tobacco products?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SMQ.874 During the last 7 days, did {you/SP} spend time in a home other than {your/his/her} own?

YES 1

NO 2 (SMQ.878)

REFUSED 7 (SMQ.878)

DON'T KNOW 9 (SMQ.878)

SMQ.876 While {you were/SP was} in a home other than {your/his/her} own, did someone else smoke cigarettes or other tobacco products indoors?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SMQ.878 During the last 7 days, {were you/was SP} in any other indoor area?

YES 1

NO 2 (SMQ.940)

REFUSED 7 (SMQ.940)

DON'T KNOW 9 (SMQ.940)

SMQ.880 While {you were/SP was} in the other indoor area, did someone else smoke cigarettes or other tobacco products?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SMQ.940 The next question is about e-cigarettes.

During the last 7 days, {were you/was SP} in an indoor place where someone was using an e‑cigarette, e‑hookah, vape‑pen or other similar electronic product?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

ALCOHOL USE – ALQ

Target Group: SPs 18+ (CAPI)

ALQ.111 The next questions are about drinking alcoholic beverages. Included are liquor (such as whiskey or gin), beer, wine, wine coolers, and any other type of alcoholic beverage.

In {your/SP’s} entire life, {have you/has he/has she} had at least 1 drink of any kind of alcohol, not counting small tastes or sips? By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and a half ounces of liquor.

HAND CARD ALQ1

YES 1

NO 2 (END OF SECTION)

REFUSED 7

DON'T KNOW 9

ALQ.121

During the past 12 months, about how often did {you/SP} drink any type of alcoholic beverage?

PROBE: How many days per week, per month, or per year did {you/SP} drink?

HAND CARD ALQ2

EVERY DAY 1

NEARLY EVERY DAY 2

3 TO 4 TIMES A WEEK 3

2 TIMES A WEEK 4

ONCE A WEEK 5

2 TO 3 TIMES A MONTH 6

ONCE A MONTH 7

7 TO 11 TIMES IN THE LAST YEAR 8

3 TO 6 TIMES IN THE LAST YEAR 9

1 TO 2 TIMES IN THE LAST YEAR 10

NEVER IN THE LAST YEAR 0

REFUSED 77

DON’T KNOW 99

BOX 1

CHECK ITEM ALQ.125:

IF SP DIDN'T DRINK (CODED '0') IN ALQ.121, GO TO ALQ.151.

OTHERWISE, CONTINUE WITH ALQ.130.

ALQ.130 During the past 12 months, on those days that {you/SP} drank alcoholic beverages, on average, how many drinks did {you/he/she} have? (By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and a half ounces of liquor.)

HAND CARD ALQ1

IF LESS THAN 1 DRINK, ENTER '1'.

IF 95 DRINKS OR MORE, ENTER '95'.

CAPI INSTRUCTION:

SOFT EDIT: IF RESPONSE >=20, THEN DISPLAY “YOU SAID ON THE DAYS THAT YOU DRINK YOU HAVE ON AVERAGE {DISPLAY QUANTITY} DRINKS, IS THAT CORRECT?”

HARD EDIT: Range – 1-95

|___|___|___|

ENTER # OF DRINKS

REFUSED 777

DON'T KNOW 999

ALQ.142

During the past 12 months, about how often did {you/SP} have {DISPLAY NUMBER} or more drinks of any alcoholic beverage?

PROBE: How many days per week, per month, or per year did {you/SP} have {DISPLAY NUMBER} or more drinks in a single day?

HAND CARD ALQ2

INTERVIEWER INSTRUCTION: IF SP ANSWERS NONE, PLEASE CODE ‘0’, NEVER IN THE LAST YEAR.

CAPI INSTRUCTION:

IF SP = MALE, DISPLAY = 5

IF SP = FEMALE, DISPLAY = 4

HARD EDIT: ALQ.142 CANNOT HAVE A LOWER CODED VALUE THAN ALQ.121, UNLESS ALQ.142 IS CODED ‘0’.

ERROR MESSAGE: “SP HAS REPORTED DRINKING MORE TIMES IN THIS QUESTION THAN WAS PREVIOUSLY REPORTED IN ALQ.121.”

EVERY DAY 1

NEARLY EVERY DAY 2

3 TO 4 TIMES A WEEK 3

2 TIMES A WEEK 4

ONCE A WEEK 5

2 TO 3 TIMES A MONTH 6

ONCE A MONTH 7

7 TO 11 TIMES IN THE LAST YEAR 8

3 TO 6 TIMES IN THE LAST YEAR 9

1 TO 2 TIMES IN THE LAST YEAR 10

NEVER IN THE LAST YEAR 0 (ALQ.151)

REFUSED 77

DON’T KNOW 99

ALQ.270 During the past 12 months, about how often did {you/SP} have {DISPLAY NUMBER} or more drinks in a period of two hours or less?

HAND CARD ALQ2

CAPI INSTRUCTION:

IF SP = MALE, DISPLAY = 5

IF SP = FEMALE, DISPLAY = 4

HARD EDIT: ALQ.270 CANNOT HAVE A LOWER CODED VALUE THAN ALQ.121, UNLESS ALQ.270 IS CODED ‘0’.

ERROR MESSAGE: “SP HAS REPORTED DRINKING MORE TIMES IN THIS QUESTION THAN WAS PREVIOUSLY REPORTED IN ALQ.121.”

EVERY DAY 1

NEARLY EVERY DAY 2

3 TO 4 TIMES A WEEK 3

2 TIMES A WEEK 4

ONCE A WEEK 5

2 TO 3 TIMES A MONTH 6

ONCE A MONTH 7

7 TO 11 TIMES IN THE LAST YEAR 8

3 TO 6 TIMES IN THE LAST YEAR 9

1 TO 2 TIMES IN THE LAST YEAR 10

NEVER IN THE LAST YEAR 0

REFUSED 77

DON’T KNOW 99

ALQ.280

During the past 12 months, about how often did {you/SP} have 8 or more drinks in a single day?

HAND CARD ALQ2

HARD EDIT: ALQ.280 CANNOT HAVE A LOWER CODED VALUE THAN ALQ.121, UNLESS ALQ.280 IS CODED ‘0’.

ERROR MESSAGE: “SP HAS REPORTED DRINKING MORE TIMES IN THIS QUESTION THAN WAS PREVIOUSLY REPORTED IN ALQ.121.”

EVERY DAY 1

NEARLY EVERY DAY 2

3 TO 4 TIMES A WEEK 3

2 TIMES A WEEK 4

ONCE A WEEK 5

2 TO 3 TIMES A MONTH 6

ONCE A MONTH 7

7 TO 11 TIMES IN THE LAST YEAR 8

3 TO 6 TIMES IN THE LAST YEAR 9

1 TO 2 TIMES IN THE LAST YEAR 10

NEVER IN THE LAST YEAR 0 (ALQ.151)

REFUSED 77

DON’T KNOW 99

ALQ.290

During the past 12 months, about how often did {you/SP} have 12 or more drinks in a single day?

HAND CARD ALQ2

HARD EDIT: ALQ.290 CANNOT HAVE A LOWER CODED VALUE THAN ALQ.121, UNLESS ALQ.290 IS CODED ‘0’.

ERROR MESSAGE: “SP HAS REPORTED DRINKING MORE TIMES IN THIS QUESTION THAN WAS PREVIOUSLY REPORTED IN ALQ.121.”

EVERY DAY 1

NEARLY EVERY DAY 2

3 TO 4 TIMES A WEEK 3

2 TIMES A WEEK 4

ONCE A WEEK 5

2 TO 3 TIMES A MONTH 6

ONCE A MONTH 7

7 TO 11 TIMES IN THE LAST YEAR 8

3 TO 6 TIMES IN THE LAST YEAR 9

1 TO 2 TIMES IN THE LAST YEAR 10

NEVER IN THE LAST YEAR 0

REFUSED 77

DON’T KNOW 99

ALQ.151 Was there ever a time or times in {your/SP's} life when {you/he/she} drank {DISPLAY NUMBER} or more drinks of any kind of alcoholic beverage almost every day?

CAPI INSTRUCTION:

IF SP = MALE, DISPLAY = 5

IF SP = FEMALE, DISPLAY = 4

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

REPRODUCTIVE HEALTH – RHQ

Target Group: Female SPs Ages 12+ (CAPI)

RHQ.010 The next series of questions are about {your/SP’s} reproductive history. I will begin by asking some questions about {your/SP’s} period or menstrual cycle.

How old {were you/was SP} when {you/she} had {your/her} first menstrual period?

CODE “0” IF HAVEN’T STARTED YET.

CAPI INSTRUCTION:

SOFT EDIT VALUES: AGE ≤8 AND ≥ 25 YEARS.

ERROR MESSAGE: “UNLIKELY RESPONSE. PLEASE VERIFY.”

HARD EDIT VALUES: AGE OF 1^ST PERIOD CANNOT BE GREATER THAN CURRENT AGE.

ERROR MESSAGE: “AGE MENSTRUAL CYCLE STARTED CANNOT BE GREATER THAN AGE OF SP.”

SOFT EDIT: DISPLAY EDIT WHEN AGE OF SP IS GREATER THAN OR EQUAL TO 20 AND RHQ.010 IS CODED ‘0’.

ERROR MESSAGE: “IT IS UNLIKELY THAT SP’S 20 OR OLDER WILL NOT HAVE BEGUN TO MENSTRUATE. PLEASE VERIFY.”

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON’T KNOW 99 (RHQ.020)

BOX 1

CHECK ITEM RHQ.015:

IF PERIODS HAVEN’T STARTED (CODED ‘0’), GO TO END OF SECTION.
IF PERIODS HAVE STARTED AND SP REPORTS AGE (CODED ‘1’ - ‘76’) IN RHQ.010 AND SP AGE > 20, OR IF SP REFUSES AGE (CODED ‘77’) IN RHQ.010, GO TO RHQ.031.
IF PERIODS HAVE STARTED AND SP REPORTS AGE (CODED ‘1’ – ‘76’) IN RHQ.010 AND SP AGE IS 12-19, GO TO RHQ.018.
OTHERWISE, GO TO RHQ.031.

RHQ.018 In what month did {you/SP} have {your/her} first menstrual period?

|___|___|

ENTER MONTH (RHQ.031)

HARD EDIT VALUES FOR MONTH: 01 – 12.

HARD EDIT: DISPLAY ERROR WHEN ONLY ONE DIGIT IS ENTERED FOR MONTH.

ERROR MESSAGE: “ENTER TWO DIGITS FOR MONTH.”

REFUSED 77 (RHQ.031)

DON’T KNOW 99 (RHQ.031)

RHQ.020 {Were you/Was SP} . . .

younger than 10, 1

10 to 12, 2

13 to 15, or 3

16 or older? 4

REFUSED 7

DON’T KNOW 9

RHQ.031 {Have you/Has SP} had at least one menstrual period in the past 12 months? Please do not include bleedings caused by medical conditions, hormone therapy, or surgeries.

SOFT EDIT: DISPLAY EDIT WHEN AGE OF SP IS GREATER THAN OR EQUAL TO 60 AND RHQ.031 IS CODED YES.

ERROR MESSAGE: “IT IS UNLIKELY THAT SPS AGED 60 YEARS OR OLDER WILL STILL BE MENSTRUATING. PLEASE VERIFY.”

YES 1

NO 2 (RHQ.043)

REFUSED 7 (RHQ.060)

DON’T KNOW 9 (RHQ.060)

BOX 1A

CHECK ITEM RHQ.033:

IF SP < 20 YEARS OLD AND RHQ.031 = 1, GO TO BOX 3.
IF SP 20+ YEARS OLD AND RHQ.031 = 1, GO TO RHQ 282.
OTHERWISE, CONTINUE.

RHQ.043 What is the reason that {you have/SP has} not had a period in the past 12 months?

HAND CARD RHQ 1

SOFT EDIT: DISPLAY EDIT WHEN AGE OF SP IS YOUNGER THAN OR EQUAL TO 50 AND RHQ.043 IS CODED 7 (MENOPAUSE/CHANGE OF LIFE).

ERROR MESSAGE: “UNLIKELY RESPONSE. PLEASE VERIFY.”

PREGNANCY 1 (BOX 3)

BREAST FEEDING 2

HYSTERECTOMY 3

MENOPAUSE/CHANGE OF LIFE 7

OTHER 9

REFUSED 77

DON’T KNOW 99

RHQ.282 {Have you/Has SP} had a hysterectomy, including a partial hysterectomy, that is, surgery to remove {your/her} uterus or womb?

MARK IF KNOWN. OTHERWISE ASK.

HARD EDIT: IF RHQ043 CODED AS “3”, BUT REPORTED “NO” TO RHQ282, DISPLAY THE FOLLOWING MESSAGE TO VERIFY THE ANSWERS TO RHQ043 AND RHQ282:

“You mentioned that hysterectomy is the reason that you have not had a period in the past 12 months, is it correct?”

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

RHQ.305 {Have you/Has SP} had both of {your/her} ovaries removed {either when {you/she} had {your/her} uterus removed or at any other time}?

CAPI INSTRUCTION: IF RHQ.282 = 1 DISPLAY {either when {you/she} had {your/her} uterus removed or at any other time}”

YES 1

NO 2 (BOX 1B)

REFUSED 7 (RHQ.060)

DON’T KNOW 9 (RHQ.060)

RHQ.332 How old {were you/was SP} when {you/she} had {your/her} ovaries removed or last ovary removed if removed at different times?

CAPI INSTRUCTION:

HARD EDIT: RHQ.332 MUST BE EQUAL TO OR LESS THAN AGE OF SP.

ERROR MESSAGE: “AGE CANNOT BE GREATER THAN AGE OF SP.”

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON’T KNOW 999

BOX 1B

CHECK ITEM RHQ.334:

IF RHQ.031 = 1 AND RHQ.282 = 2 AND RHQ.305 = 2, GO TO BOX 3.
OTHERWISE, CONTINUE.

RHQ.060 About how old {were you/was SP} when {you/she} had {your/her} last menstrual period?

SOFT EDIT: DISPLAY EDIT WHEN RHQ.060 IS GREATER THAN 59.

ERROR MESSAGE: “IT IS UNLIKELY THAT AN SP WILL HAVE HER LAST MENSTRUAL PERIOD AFTER AGE 59. PLEASE VERIFY.”

SOFT EDIT: RHQ.060 MUST BE LESS THAN OR EQUAL TO RHQ.332.

ERROR MESSAGE: “AGE OF SP AT LAST MENSTRUAL PERIOD CANNOT BE GREATER THAN AGE OF SP AT HYSTERECTOMY OR AGE OF SP AT OOPHORECTOMY.”

HARD EDIT: RHQ.060 MUST BE EQUAL TO OR LESS THAN AGE OF SP.

ERROR MESSAGE: “AGE OF SP AT LAST MENSTRUAL PERIOD CANNOT BE GREATER THAN AGE OF SP.”

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON’T KNOW 99

BOX 2

CHECK ITEM RHQ.065:

IF SP DOESN’T KNOW AGE AT LAST MENSTRUAL PERIOD (CODED ‘99’) IN RHQ.060, CONTINUE.
OTHERWISE, GO TO BOX 3.

RHQ.070 {Were you/Was SP} . . .

younger than 30, 1

30 to 34, 2

35 to 39, 3

40 to 44, 4

45 to 49, 5

50 to 54, or 6

55 or older? 7

REFUSED 77

DON’T KNOW 99

BOX 3

CHECK ITEM RHQ.072:

IF SP IS 18-59 YEARS OLD, CONTINUE.
OTHERWISE, GO TO RHQ.131.

RHQ.071 In the past 12 months, have you used any method of birth control for any reason?

YES 1

NO 2 (RHQ.074)

REFUSED 7 (RHQ.074)

DON’T KNOW 9 (RHQ.074)

HELP SCREEN SHOULD READ: Birth control can be used to prevent pregnancy, prevent sexually transmitted disease or used for other medical conditions such as to control acne, headaches, or menstrual cramps, or help with irregular menstrual periods.

RHQ.073 Which methods of birth control did you use in the past 12 months?

HAND CARD RHQ3

CODE ALL THAT APPLY

BIRTH CONTROL PILLS…………………………………………..1

PATCH………………………………………………….…………….2

RING…………………………………………………….…………….3

SHOT/INJECTABLE………………………………….……………...4

IMPLANT…………………………………………………..…………..5

CONDOMS……………………………………………….……………6

IUD…………………………………………………………….………..7

DIAPHRAGM, CAP or SPONGE……………………………….……8

SPERMICIDE FOAM, JELLY, CREAM

OR SUPPOSITORY…………………………………….…..9

NATURAL FAMILY PLANNING……………………………………..10

STERILIZATION……………………………………………………….11

WITHDRAWAL…………………………………………………………12

EMERGENCY CONTRACEPTION…………………………………..13

ABSTINENCE…………………………………………………………..14

REFUSED……………………………………………………………….77

DON’T KNOW…………………………………………………………..99

RHQ.074 {Have you/Has SP} ever attempted to become pregnant over a period of at least a year without becoming pregnant?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

RHQ.076 {Have you/Has SP} ever been to a doctor or other medical provider because {you have/she has} been unable to become pregnant?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

RHQ.078 {Have you/Has SP} ever been treated for an infection in {your/her} fallopian tubes, uterus or ovaries, also called a pelvic infection, pelvic inflammatory disease, or PID?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

RHQ.131 The next questions are about {your/SP’s} pregnancy history. Please include {current pregnancy,} live births, miscarriages, stillbirths, tubal pregnancies and abortions.

{Have you/Has SP} ever been pregnant?

MARK IF KNOWN. OTHERWISE ASK.

CAPI INSTRUCTIONS:

IF RHQ.043 = 1, DISPLAY {current pregnancy}

HELP SCREEN SHOULD READ: Miscarriage: Refers to a pregnancy that terminates naturally during the first 5 months (20 weeks) of pregnancy. Stillbirth: Refers to a baby that is born dead after 6 or more months (>20 weeks) of pregnancy. Tubal Pregnancy: Refers to a pregnancy that occurs in the fallopian tube. Abortion: Refers to a pregnancy that is terminated during the first 6 months using induced methods. Methods include D&C, vacuum extraction, suction, and saline injections.

YES 1

NO 2 (RHQ.421)

REFUSED 7 (RHQ.421)

DON’T KNOW 9 (RHQ.421)

BOX 6

CHECK ITEM RHQ.136:

IF THE SP HAS EXPERIENCED MENOPAUSE (RHQ.043 = 7), GO TO RHQ.160.
IF THE SP HAD HYSTERECTOMY (RHQ.043 = 3 OR RHQ.282 = 1), GO TO RHQ.160.
OTHERWISE, CONTINUE.

RHQ.143 {Are you/Is SP} pregnant now?

MARK IF KNOWN. OTHERWISE ASK.

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

RHQ.160 How many times {have you/has SP} been pregnant? Please count all {your/her} pregnancies including {current pregnancy,} live births, miscarriages, stillbirths, tubal pregnancies, and abortions.)

CAPI INSTRUCTION: IF RHQ.143=1 DISPLAY {current pregnancy}.

|___|___|

ENTER NUMBER OF PREGNANCIES

REFUSED 77

DON’T KNOW 99

RHQ.162 During {any/your/SP’s} pregnancy, {were you/was SP} ever told by a doctor or other health professional that {you/she} had diabetes, sugar diabetes or gestational diabetes? Please do not include diabetes that {you/SP} may have known about before the pregnancy.

CAPI INSTRUCTION:

IF RHQ.160 = 1, DISPLAY {your/SP’s}. OTHERWISE, DISPLAY {any}.

HELP SCREEN SHOULD READ: Gestational diabetes is a form of diabetes or high blood sugar found in pregnant women.

YES 1

NO 2 (BOX 7)

BORDERLINE 3 (BOX 7)

REFUSED 7 (BOX 7)

DON’T KNOW 9 (BOX 7)

BOX 7

CHECK ITEM RHQ.165:

IF SP ONLY HAD ONE PREGNANCY (CODED ‘1’) IN RHQ.160 AND CURRENTLY PREGNANT (CODED ‘1’) IN RHQ.143, SKIP TO RHQ.421.
OTHERWISE CONTINUE.

RHQ.167 How many deliveries {have you/has SP} had?

(Please count all vaginal and Cesarean deliveries, and count stillbirths as well as live births.)

COUNT THE NUMBER OF DELIVERIES, NOT THE NUMBER OF LIVE-BORN CHILDREN. FOR EXAMPLE, IF SP DELIVERED TWINS OR HAD ANY OTHER MULTIPLE BIRTH, COUNT AS A SINGLE DELIVERY.

SOFT EDIT: RHQ.167 MUST BE EQUAL TO OR LESS THAN RHQ.160.

ERROR MESSAGE: “It is unlikely that the number of deliveries (vaginal and cesarean deliveries combined) is greater than the number of pregnancies. Please verify.”

SOFT EDIT: IF CURRENTLY PREGNANT (CODED ‘1’ IN RHQ.143) THEN RHQ.167 SHOULD BE LESS THAN OR EQUAL TO RHQ.160 MINUS 1.

ERROR MESSAGE: “Since SP is currently pregnant, it is unlikely that the number of vaginal and cesarean deliveries is equal to or greater than the number of pregnancies. Please verify.”

|___|___|

ENTER NUMBER

REFUSED 77

DON’T KNOW 99

BOX 7B

CHECK ITEM RHQ.170A:

IF THE NUMBER OF DELIVERIES IN RHQ.167. EQUALS ZERO, GO TO RHQ.421.
OTHERWISE, CONTINUE WITH RHQ.172.

RHQ.172 {Did {your/SP’s} delivery/Did any of {your/SP’s} deliveries} result in a baby that weighed 9 pounds or more at birth? Please count stillbirths as well as live births.

INTERVIEWER INSTRUCTION: IF SP ONLY RECALLS HER BABY’S BIRTH WEIGHT IN KILOS/GRAMS: 9 LB ~ 4.1 KG/ 4,100 G.

CAPI INSTRUCTION:

IF SP HAD ONE DELIVERY (RHQ.167 = 1), DISPLAY {YOUR DELIVERY}.

IF SP HAD MORE THAN ONE DELIVERY (RHQ.167 > 1), DISPLAY {ANY OF YOUR DELIVERIES}.

YES 1

NO 2 (RHQ.171)

REFUSED 7 (RHQ.171)

DON’T KNOW 9 (RHQ.171)

RHQ.171 {How many of {your/her} deliveries resulted/Did {your/her} delivery result} in a live birth?

CAPI INSTRUCTION:

IF SP HAD ONE DELIVERY (RHQ.167 = 1), REPLACE {How many of {your/her} deliveries resulted} WITH {Did {your/her} delivery result}.

FOR SINGLE DELIVERIES:

Yes = 1

No = 0

COUNT THE NUMBER OF TOTAL DELIVERIES, NOT NUMBER OF LIVE-BORN CHILDREN. FOR EXAMPLE, IF SP HAD TWINS OR OTHER MULTIPLE BIRTH, COUNT AS A SINGLE DELIVERY.

|___|___|

ENTER NUMBER OF DELIVERIES

REFUSED 77

DON’T KNOW 99

BOX 8

CHECK ITEM RHQ.177:

IF SP GREATER THAN OR EQUAL TO 60, GO TO RHQ.421.

OTHERWISE, CONTINUE.

RHQ.180 How old {were you/was SP} at the time of {your/her} {first} live birth?

CAPI INSTRUCTION:

IF SP HAD MORE THAN 1 LIVE BIRTH (CODED >= 2) IN RHQ.171, DISPLAY {first}.

CAPI INSTRUCTION:

HARD EDIT: RHQ.180 MUST BE EQUAL TO OR LESS THAN AGE OF SP.

ERROR MESSAGE: “AGE OF SP AT FIRST DELIVERY CANNOT BE GREATER THAN AGE OF SP.”

SOFT EDIT: DISPLAY EDIT WHEN RHQ.180 IS GREATER THAN OR EQUAL TO RHQ.010.

ERROR MESSAGE: “AGE OF SP AT FIRST LIVE BIRTH CANNOT BE LESS THAN AGE WHEN SP’S FIRST PERIOD STARTED.

SOFT EDIT: DISPLAY EDIT WHEN RHQ.180 IS GREATER THAN RHQ.173.

ERROR MESSAGE: “AGE OF SP AT FIRST LIVE BIRTH IS NOT LIKELY TO BE GREATER THAN THE AGE WHEN SP FIRST DELIVERED A BABY THAT WEIGHTED 9 POUNDS OR MORE. PLEASE VERIFY.”

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON’T KNOW 99

RHQ.184 What is the month and year of your last delivery? Please count stillbirths as well as live births.

M/Y

|___|___|

MONTH

REFUSED 77

DON'T KNOW 99

|___|___|___|___| (BOX9A)

YEAR

REFUSED 7777

DON'T KNOW 9999

HARD EDIT: DATE MUST BE EQUAL OR LESS THAN CURRENT MONTH/YEAR.

HARD EDIT VALUES FOR MONTH: 01 – 12.

HARD EDIT VALUES FOR YEAR: 1900 – 2100.

INTERVIEWER INSTRUCTION:

WE ARE ASKING THE BIRTH MONTH AND YEAR OF THE WOMAN’S LAST CHILD OR THE DATE HER LAST PREGNANCY ENDED (IF STILLBIRTH).

CAPI INSTRUCTIONS:

SEPARATE FIELDS FOR MONTH AND YEAR AND ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DISPLAY ERROR WHEN ONLY ONE DIGIT IS ENTERED FOR MONTH.

ERROR MESSAGE: “ENTER TWO DIGITS FOR MONTH.”

CAPI INSTRUCTIONS:

CALCULATE SP’S {AGE OF THIS LAST DELIVERY} AND USE THIS AGE IN THE FOLLOWING SOFT EDITS:

1. IF {AGE OF THIS LAST DELIVERY} IS LESS THAN WHAT REPORTED IN RHQ.180, DISPLAY: “THIS MEANS THE SP WAS {AGE OF THIS LAST DELIVERY} YEARS OLD AT LAST DELIVERY. THIS IS UNLIKELY BECAUSE THE SP REPORTED HAVING HER FIRST LIVE BIRTH WHEN SHE WAS {AGE AT RHQ.180}. PLEASE VERIFY.”

BOX 9A

CHECK ITEM RHQ.187:

IF THE DATE OF LAST DELIVERY IN RHQ.184 IS WITHIN THE LAST 24 MONTHS, CONTINUE.
IF THE MONTH IN RHQ.184 IS “REFUSED” OR “DON’T KNOW” AND [(THE YEAR IN RHQ.184) > (CURRENT YEAR – 3)], CONTINUE.
OTHERWISE, GO TO RHQ.421.

RHQ.200 {Are you/Is SP} now breast feeding a child?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

RHQ.421 {Have you/Has SP} ever used birth control pills, patches, rings, implants, or injectables for any reason?

CAPI INSTRUCTION:

IF RHQ.073=1, 2, 3, 4, or 5 (birth control pill), fill = 1

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 20

CHECK ITEM RHQ.535:

IF SP 20 YEARS OF AGE OR OLDER, CONTINUE.
OTHERWISE, GO TO BOX 24.

RHQ.540 {Have you/Has SP} ever used female hormones such as estrogen and progesterone? Please include any forms of prescription female hormones, such as pills, creams, patches, and injectables, but do not include birth control methods or use for infertility.

IN SITUATIONS OF HORMONE USE FOR NON-MENOPAUSAL CONDITIONS, CODE HRT USE AS “NO”.

HAND CARD RHQ 2

YES 1

NO 2 (BOX 24)

REFUSED 7 (BOX 24)

DON’T KNOW 9 (BOX 24)

RHQ.542 Which forms of prescription female hormones {have you/has SP} used?

CODE ALL THAT APPLY

HAND CARD RHQ 2

PILLS 10

PATCHES 11

CREAM/SUPPOSITORY/INJECTION 12

OTHER 13

REFUSED 77

DON’T KNOW 99

BOX 21

CHECK ITEM RHQ.552:

IF SP USED FEMALE HORMONE PILLS (CODE ‘10’) IN RHQ.542, CONTINUE.

OTHERWISE, GO TO BOX 22.

RHQ.554 {Have you/Has SP} ever taken female hormone pills containing estrogen only like Premarin? Do not include birth control pills.

HAND CARD RHQ 2

YES 1

NO 2 (RHQ.570)

REFUSED 7 (RHQ.570)

DON’T KNOW 9 (RHQ.570)

RHQ.570 {Have you/Has SP} taken female hormone pills containing both estrogen and progestin like Prempro or Premphase? Do not include birth control pills.

HAND CARD RHQ 2

YES 1

NO 2 (BOX 22)

REFUSED 7 (BOX 22)

DON’T KNOW 9 (BOX 22)

BOX 24

CHECK ITEM RHQ.642:

IF SP CURRENTLY PREGNANT (CODED ‘1’) IN RHQ.143, CONTINUE WITH FSQ.652a.
ELSE IF RHQ.184 IS WITHIN THE LAST 24 MONTHS, GO TO FSQ.652b.
ELSE IF THE MONTH IN RHQ.184 IS “REFUSED” OR “DON’T KNOW” AND [(THE YEAR IN RHQ.184) > (CURRENT YEAR – 3)], GO TO FSQ.652b.
ELSE IF THE YEAR IN RHQ.184 IS “REFUSED” OR “DON’T KNOW” AND SP AGE IS 12-59, GO TO FSQ.652b.
OTHERWISE, GO TO END OF SECTION.

FSQ.652a These next questions are about participation in WIC, that is, the Women, Infants, and Children Program.

During this pregnancy have you used WIC benefits to buy food for yourself?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

FSQ.672a How many months pregnant were you when you first started to receive WIC benefits to buy food for yourself?

|__|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

BOX 27

CHECK ITEM RHQ.644:

GO TO FSQ.662.

FSQ.652b These next questions are about participation in WIC, that is, the Women, Infants, and Children Program.

During your last pregnancy, did you use WIC benefits to buy food for yourself? Please include any stillbirth or miscarriage.

YES 1

NO 2 (FSQ.652c)

REFUSED 7 (FSQ.652c)

DON’T KNOW 9 (FSQ.652c)

FSQ.672b How many months pregnant were you when you first started to receive WIC benefits to buy food for yourself?

|__|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

FSQ.652c After your {last} child was born, did you use WIC benefits to buy food for yourself?

IF RHQ.160 > 1, DISPLAY {last}.

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 28

CHECK ITEM RHQ.646:

IF RHQ.184 IS WITHIN THE LAST 12 MONTHS, CONTINUE WITH FSQ.662.
IF THE MONTH IN RHQ.184 IS “REFUSED” OR “DON’T KNOW” AND [(THE YEAR IN RHQ.184) > (CURRENT YEAR – 2)], CONTINUE.
OTHERWISE, GO TO END OF SECTION.

FSQ.662 Are you now receiving WIC benefits for yourself?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

KIDNEY CONDITIONS - KIQ

New Target Group: SPs 20+

KIQ.005 The next few questions ask about urine leakage. Many people have leakage of urine.

How often {do you/does SP} have urinary leakage? Would {you/s/he} say . . .

CAPI INSTRUCTION:

HELP SCREEN: Other terms for urinary leakage are not being able to hold your urine until you can reach a toilet, not being able to control your bladder, loss of urine control.

never, 1 (KIQ.042)

less than once a month, 2

a few times a month, 3

a few times a week, or 4

every day and/or night? 5

REFUSED 7 (KIQ.042)

DON’T KNOW 9 (KIQ.042)

KIQ.010 How much urine {do you/does SP} lose each time? Would {you/s/he} say . . .

drops, 1

small splashes, or 2

more? 3

REFUSED 7

DON’T KNOW 9

KIQ.042 During the past 12 months, {have you/has SP} leaked or lost control of even a small amount of urine with an activity like coughing, lifting or exercise?

YES 1

NO 2 (KIQ.044)

REFUSED 7 (KIQ.044)

DON’T KNOW 9 (KIQ.044)

KIQ.430 How frequently does this occur? Would {you/s/he} say this occurs . . .

HAND CARD KIQ1

less than once a month, 1

a few times a month, 2

a few times a week, or 3

every day and/or night? 4

REFUSED 7

DON’T KNOW 9

KIQ.044 During the past 12 months, {have you/has SP} leaked or lost control of even a small amount of urine with an urge or pressure to urinate and {you/s/he} couldn’t get to the toilet fast enough?

YES 1

NO 2 (KIQ.046)

REFUSED 7 (KIQ.046)

DON’T KNOW 9 (KIQ.046)

KIQ.450 How frequently does this occur? Would {you/s/he} say this occurs. . .

HAND CARD KIQ1

less than once a month, 1

a few times a month, 2

a few times a week, or 3

every day and/or night? 4

REFUSED 7

DON’T KNOW 9

KIQ.046 During the past 12 months, {have you/has SP} leaked or lost control of even a small amount of urine without an activity like coughing, lifting, or exercise, or an urge to urinate?

YES 1

NO 2 (BOX 1)

REFUSED 7 (BOX 1)

DON'T KNOW 9 (BOX 1)

KIQ.470 How frequently does this occur? Would {you/s/he} say this occurs . . .

HAND CARD KIQ1

less than once a month, 1

a few times a month, 2

a few times a week, or 3

every day and/or night? 4

REFUSED 7

DON’T KNOW 9

BOX 1

CHECK ITEM KIQ.048A:

IF 'YES' (CODED '1') IN KIQ.042 OR KIQ.044 OR KIQ.046, CONTINUE WITH KIQ.050.
OTHERWISE, GO TO KIQ.480.

KIQ.050 During the past 12 months, how much did {your/her/his} leakage of urine bother {you/her/him}? Please select one of the following choices:

not at all, 1

only a little, 2

somewhat, 3

very much, or 4

greatly? 5

REFUSED 7

DON'T KNOW 9

KIQ.052 During the past 12 months, how much did {your/his/her} leakage of urine affect {your/his/her} day-to-day activities? (Please select one of the following choices:)

not at all, 1

only a little, 2

somewhat, 3

very much, or 4

greatly? 5

REFUSED 7

DON'T KNOW 9

KIQ.480 During the past 30 days, how many times per night did {you/SP} most typically get up to urinate, from the time {you/s/he} went to bed at night until the time {you/he/she} got up in the morning. Would {you/s/he} say . . .

0, 0

1, 1

2, 2

3, 3

4, 4

5 or more? 5

REFUSED 77

DON'T KNOW 99

PHYSICAL ACTIVITY AND PHYSICAL FITNESS – PAQ

Target Group: SPs 12-15 (CAPI)

PAQ.706 Now, I'd like to ask you some questions about {your/SP’s} activities.

During the past 7 days, on how many days {were you/was SP} physically active for a total of at least 60 minutes per day? Add up all the time {you/he/she} spent in any kind of physical activity that increased {your/his/her} heart rate and made {you/him/her} breathe hard some of the time.

0 days 0

1 day 1

2 days 2

3 days 3

4 days 4

5 days 5

6 days 6

7 days 7

REFUSED 77

DON’T KNOW 99

PAQ.711 On a typical day during the school year, about how many hours {do you/does SP} usually spend playing with a smartphone or computer, watching TV or movies, or playing video games?

|___|___|

ENTER NUMBER OF HOURS

REFUSED 77

DON'T KNOW 99

SOFT EDIT: 18 HOURS OR MORE.

ERROR MESSAGE: PLEASE VERIFY TIMES OF 18 HOURS OR MORE.

HARD EDIT: 24 HOURS OR MORE.

ERROR MESSAGE: THE TIME SHOULD BE LESS THAN 24 HOURS.

WEIGHT HISTORY – WHQ

Target Group: SPs 8-15 years

BOX 1

CHECK ITEM WHQ.499:

IF INTERVIEW DONE ONLY WITH SURVEY PARTICIPANT (CODED ‘1’) IN RIQ.005 AND NO INTERPRETER USED (INT.001 CODED ‘2’), CONTINUE WITH WHQ.030m.
IF INTERVIEW DONE WITH SURVEY PARTICIPANT (CODED ‘1’) IN RIQ.005 AND INTERPRETER USED (INT.001 CODED ‘1’), AND INTERPRETER SOURCE = 4, 5, 6, 7, OR 99 IN INT.007, CONTINUE WITH WHQ.030m.
OTHERWISE, GO TO NEXT SECTION.

WHQ.030m Do you consider yourself now to be . . .

fat or overweight, 1

too thin, or 2

about the right weight? 3

REFUSED 7

DON’T KNOW 9

WHQ.500 Which of the following are you trying to do about your weight:

lose weight, 1

gain weight, 2

stay the same weight, or. 3

not trying to do anything about your weight? 4

REFUSED 7

DON’T KNOW 9

WHQ.520 In the past year, how often have you tried to lose weight? Would you say . . .

never, 1

sometimes, or 2

a lot? 3

REFUSED 7

DON’T KNOW 9

BOX 2

CHECK ITEM WHQ.709:

IF SP AGE >= 12, CONTINUE.
OTHERWISE, GO TO END OF SECTION.

DBQ.895
G/Q

Next, I’m going to ask you about meals.

By meal, I mean breakfast, lunch and dinner. During the past 7 days, how many meals did you get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines?

Please do not include meals provided as part of the school lunch or school breakfast.

SOFT EDIT VALUES: 0-21

Error message: “Please verify that you ate more than 3 meals prepared away from home every day during the past 7 days.”

|___|___|

ENTER NUMBER

NONE 2 (DBQ.905)

REFUSED 77 (DBQ.905)

DON'T KNOW 99 (DBQ.905)

DBQ.900 How many of those meals did you get from a fast-food or pizza place?

G/Q

HARD EDIT: “DBQ.900 must be equal to or less than DBQ.895.”

Error message: "The number of meals from a fast-food or pizza place cannot be greater than the total number of meals you had that were prepared away from home. Could I have another answer please?"

|___|___|

ENTER NUMBER

NONE 2 (DBQ.905)

REFUSED 7 (DBQ.905)

DON'T KNOW 9 (DBQ.905)

DBQ.905
G/Q/U

Some grocery stores sell “ready to eat” foods such as salads, soups, chicken, sandwiches and cooked vegetables in their salad bars and deli counters.

During the past 30 days, how often did you eat “ready to eat” foods from the grocery store? Please do not include sliced meat or cheese you buy for sandwiches and frozen or canned foods.

|___|___|

ENTER NUMBER OF TIMES (PER DAY, WEEK, OR MONTH)

NEVER 2 (DBQ.910)

REFUSED 7 (DBQ.910)

DON’T KNOW 9 (DBQ.910)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

DBQ.910
G/Q/U

During the past 30 days, how often did you eat frozen meals or frozen pizzas? Here are some examples of frozen meals and frozen pizzas.

HAND CARD WHQ2

|___|___|

ENTER OF TIMES (PER DAY, WEEK, OR MONTH)

NEVER 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

MEC Interview

Critical Data Items

Verify Street Address

SCQ.070 I would like to verify {your/SP’s} address. Please give me {your/SP’s} complete address.

SCQ.420 Is {your/SP’s} mailing address the same as {your/SP’s} street address?

Validation Form Q7 Did {you/he/she} live at this address on {SCREENER DISPOSITION DATE}?

Verify Mailing Address

In case we have to contact {you/SP} again, please give me {your/his/her} complete mailing address.

Verify Phone Numbers

Please give me {your/SP’s} home telephone number.

Is there another number where {you/SP} can be reached? Where is that phone

located?

Verify SSN

BOX 1

IF DMQ.281b FROM THE HOUSEHOLD INTERVIEW IS MISSING, CODED '777777777', OR CODED ‘999999999’, CONTINUE.
OTHERWISE, GO TO END OF SECTION.

DMQ.281a The National Center for Health Statistics will conduct statistical research by combining {your/his/her} survey data with vital, health, nutrition and other related records. {Your/SP’s} social security number is used only for these purposes and the Center will not release it to anyone, including any government agency, for any other reason. Providing this information is voluntary and is collected under the authority of Section 306 of the Public Health Service Act. There will be no effect on {your/his/her} benefits if you do not provide it.

INTERVIEWER INSTRUCTION—ONLY READ IF ASKED. [Public Health Service Act is title 42, United States Code, section 242k.]

What is {your/SP's} Social Security Number?

ENTER SOCIAL SECURITY NUMBER 1 (DMQ281b)

DOES NOT HAVE SOCIAL SECURITY NUMBER 2 (END OF SECTION)

REFUSED 7 (DMQ281d)

DON'T KNOW 9 (DMQ281d)

INTERVIEWER INSTRUCTION: USE THE HELP SCREEN IF THE RESPONDENT ASKS FURTHER CLARIFICATION ON THE USE OF SSN.

HELP SCREEN:

Providing {your/SP’s} social security number will help researchers match NHANES data with other health-related records like Medicare and Medicaid. By combining these data, researchers can study health conditions like heart attacks and diabetes in depth. They can also better understand health care use and health care costs for all Americans. These findings will help doctors assist patients in making smart choices. Here are other examples (HAND CARD DMQ8) of things we have learned when we matched records from different sources.

DMQ281b/c

CAPI INSTRUCTION:

REQUIRE DOUBLE ENTRY OF SOCIAL SECURITY NUMBER.

|___|___|___| |___|___| |___|___|___|___| (END OF SECTION)

ENTER SOCIAL SECURITY NUMBER

REFUSED 777777777

DON'T KNOW 999999999

HARD EDIT:

Validate that there are 9 digits entered for an SSN. Do not accept entry less than 9 digits for DMQ281b/c. If a less than 9 digits number was entered, display the message “The SSN should be a 9-digit number, please verify”.
The SSN is a 3-part number (3-digit Area Number + 2-gidit Group Number + 4-digit Serial Number). None of these compartments can be all zeros. Please verify and display error message “it is unlikely that the SSN {starts with “0000”/has “00” as its middle 2-digit/has “0000” as its last 4 digits}, please verify”

DMQ.281d/e I understand your concern. Would you provide us with the last four digits of {your/SP's} Social Security Number? This information will allow researchers to match NHANES survey data with health-related records to study important things like changes in health status, eating patterns and health care costs. [May I have the last four digits of {your/SP's} Social Security Number]

CAPI INSTRUCTION:

REQUIRE DOUBLE ENTRY.

|___|___|___|___|

ENTER 4-DIGIT SOCIAL SECURITY NUMBER

REFUSED 7777

DON'T KNOW 9999

HARD EDIT:

Validate that there are 4 digits entered. Do not accept entry less than 4 digits for DMQ281d.

The entry cannot be all zeros. Please verify and display error message “it is unlikely that the SSN has “0000” as its last 4 digits, please verify”

MEC Interview– ACASI

TOBACCO – SMQ

Target Group: SPs 12-17 (Audio-CASI)

SMQ.621__ The following questions are about cigarette smoking and other tobacco use. Do not include cigars or marijuana.

SMQ.621 About how many cigarettes have you smoked in your entire life?

INSTRUCTIONS TO SP:

Please select . . .

I have never smoked, not even a puff 1 (SMQ.681_)

1 or more puffs but never a whole cigarette 2 (SMQ.681_)

1 cigarette 3

2 to 5 cigarettes 4

6 to 15 cigarettes 5

16 to 25 cigarettes 6

26 to 99 cigarettes 7

100 or more cigarettes 8

REFUSED 77 (SMQ.681_)

DON'T KNOW 99 (SMQ.681_)

SMQ.632 How old were you when you smoked a whole cigarette for the first time?

SMQ.632a

INSTRUCTIONS TO SP:

Please enter an age.

CAPI INSTRUCTION:

COMBINATION CONTROL: NUMBER PAD: ENTER AGE

ACCEPTABLE VALUES: 6-18 YEARS, REFUSED, DON’T KNOW.

IF R ENTERS 1-5, STORE 6 YEARS.

HARD EDIT: IF SMQ.632 > RIAAGEYR THEN ERROR.

ERROR MESSAGE: "Your response is older than your recorded age. Please press the “Back” button, press “Clear,” and try again."

HARD EDIT: IF SMQ.632 = 0 THEN ERROR.

ERROR MESSAGE: "Your response must be greater than zero. Please press the “Back” button, press “Clear,” and try again."

|___|___|

ENTER AGE

AGE 1-18

REFUSED 77

DON'T KNOW 99

SMQ.641 On how many of the past 30 days did you smoke cigarettes?

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

CAPI INSTRUCTION:

ACCEPTABLE VALUES: 0-30, REFUSED, DON’T KNOW

HARD EDIT: IF SMQ.641 > 30 THEN ERROR.

ERROR MESSAGE: "Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again."

|___|___|

ENTER NUMBER OF DAYS

REFUSED 77

DON'T KNOW 99

BOX 1A

CHECK ITEM SMQ.645:

(IF 'NONE' (CODE '00'), 'REFUSED' (CODE '77'), OR 'DON'T KNOW' (CODE '99') IN SMQ.641) AND SMQ.621 NOT EQUAL TO 8, GO TO SMQ.681_.
(IF 'NONE' (CODE '00'), 'REFUSED' (CODE '77'), OR 'DON'T KNOW' (CODE '99') IN SMQ.641) AND SMQ.621 = 8, CONTINUE.

OTHERWISE, GO TO SMQ.650.

SMQ.050 How long has it been since you quit smoking cigarettes?

Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 77777

DON'T KNOW 99999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

BOX 1A1

CHECK ITEM SMQ.051:

IF SMQ.050 GREATER THAN OR EQUAL TO 1 YEAR (365 DAYS, 52 WEEKS, 12 MONTHS, OR 1 YEAR), CONTINUE.
IF SMQ.050 LESS THAN 30 DAYS GO TO SMQ.650.

OTHERWISE, GO TO SMQ.681_.

SMQ.055 How old were you when you last smoked cigarettes ?

INSTRUCTIONS TO SP:

Please enter an age.

CAPI INSTRUCTION:

HARD EDIT: IF RESPONSE IS LESS THAN SMQ.632, THEN ERROR.

ERROR MESSAGE: “Your response is earlier than your response to the age when you smoked a whole cigarette for the first time. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

BOX 1A2

CHECK ITEM SMQ.056:

GO TO SMQ.681_.

SMQ.650 On average, when you smoked during the past 30 days, how many cigarettes did you smoke a day?

SMQ.650a

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTION:

IF R SAYS 95 OR MORE CIGARETTES PER DAY, STORE 95.

ACCEPTABLE VALUES: 1-95, REFUSED, DON’T KNOW

HARD EDIT: IF SMQ.650 = 0 THEN ERROR.

ERROR MESSAGE: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER NUMBER OF CIGARETTES

MORE THAN 1 PACK OF CIGARETTES 95

REFUSED 777

DON'T KNOW 999

SMQ.078 How soon after you wake up do you smoke? Would you say . . .

Within 5 minutes 1

From 6 to 30 minutes 2

From more than 30 minutes to one hour 3

From more than 1 hour to 2 hours 4

From more than 2 hours to 3 hours 5

From more than 3 hours to 4 hours 6

More than 4 hours 7

REFUSED 77

DON'T KNOW 99

SMQ.671 During the past 12 months, have you stopped smoking for longer than one day because you were trying to quit smoking?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SMQ.681_ The following questions ask about use of tobacco products in the past 5 days.

SMQ.682 During the past 5 days, including today, did you smoke cigarettes, pipes, regular cigars, cigarillos, or little filtered cigars, water pipes, or hookahs with tobacco?

INSTRUCTIONS TO SP:

Please select . . .

CAPI INSTRUCTIONS:

IF SMQ.621 = 1 OR 2 OR SMQ.641 = 00 THEN DO NOT DISPLAY {“cigarettes, “}

RECORDING NOTE: 2 WAVE FILES NEEDED ONE WITH AND ONE WITHOUT THE WORD CIGARETTES

Yes 1

No 2 (SMQ.846)

REFUSED 7 (SMQ.846)

DON’T KNOW 9 (SMQ.846)

BOX 1C

CHECK ITEM SMQ.850:

IF SMQ.621 = 1 OR 2 or SMQ.641 = 00, GO TO SMQ.692B

OTHERWISE, CONTINUE WITH SMQ.692A.

SMQ.692A Which of these products did you smoke? (CHECK ALL THAT APPLY)

INSTRUCTIONS TO SP:

Please select all that you used.

Cigarettes 1 (BOX 2)

Pipes 2 (BOX 2)

Regular cigars, cigarillos, or little filtered

Cigars…………………………..……………….. 3 (BOX 2)

Water pipes or Hookahs 4 (BOX 2)

REFUSED 77 (SMQ.846)

DON’T KNOW 99 (SMQ.846)

SMQ.692B Which of these products did you smoke? (CHECK ALL THAT APPLY)

INSTRUCTIONS TO SP:

Please select all that you used.

Pipes 1

Regular cigars, cigarillos or little filtered

Cigars……………………………………………… 2

Water pipes or Hookahs 3

REFUSED 77 (SMQ.846)

DON’T KNOW 99 (SMQ.846)

BOX 2

CHECK ITEM SMQ.701:

IF ‘CIGARETTES’ (CODE 1) IN SMQ.692A, GO TO SMQ.710.
IF ‘PIPES’ (CODE 2) IN SMQ.692A OR (CODE 1) IN SMQ.692B, GO TO SMQ.740.
IF ‘CIGARS’ (CODE 3) IN SMQ.692A OR (CODE 2) IN SMQ.692B, GO TO SMQ.771.
IF ‘WATER PIPE OR HOOKAH’ (CODE 4) IN SMQ.692A OR (CODE 3) IN SMQ.692B, GO TO SMQ.845.

SMQ.710 During the past 5 days, including today, on how many days did you smoke cigarettes?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.710 < 1 OR SMQ.710 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.720 During the past 5 days, including today, on the days you smoked, how many cigarettes did you smoke each day?

Smq.720a

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTION:

IF R SAYS 95 OR MORE CIGARETTES PER DAY, STORE 95.

HARD EDIT: IF SMQ.720 = 0 THEN ERROR.

ERROR MESSAGE: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER NUMBER OF CIGARETTES

MORE THAN 1 PACK OF CIGARETTES……95

REFUSED 777

DON'T KNOW 999

SMQ.725 When did you smoke your last cigarette? Was it . . .

Today, 1

Yesterday 2

3 to 5 days ago 3

REFUSED 7

DON'T KNOW 9

BOX 3

CHECK ITEM SMQ.731:

IF ‘PIPES’ (CODE 2) IN SMQ.692A OR (CODE 1) IN SMQ.692B, GO TO SMQ.740.
IF ‘CIGARS’ (CODE 3) IN SMQ.692A OR (CODE 2) IN SMQ.692B, GO TO SMQ.771.
IF ‘WATER PIPE OR HOOKAH (CODE 4) IN SMQ.692A OR (CODE 3) IN SMQ.692B, GO TO SMQ.845.
OTHERWISE, GO TO SMQ.846.

SMQ.740 During the past 5 days, including today, on how many days did you smoke a pipe?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.740 < 1 OR SMQ.740 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 4

CHECK ITEM SMQ.761:

IF ‘CIGARS’ (CODE 3) IN SMQ.692A OR (CODE 2) IN SMQ.692B, GO TO SMQ.771.
IF ‘WATER PIPES OR HOOKAH’ (CODE 4) IN SMQ.692A OR (CODE 3) IN SMQ.692B, GO TO SMQ.SMQ.845.
OTHERWISE, GO TO SMQ.846.

SMQ.771 During the past 5 days, including today, on how many days did you smoke regular cigars, cigarillos, or little filtered cigars?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.771 < 1 OR SMQ.771 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 5

CHECK ITEM SMQ.791:

IF ‘WATERPIPE’ (CODE 4) IN SMQ.692A OR (CODE 3) IN SMQ.692B, GO TO SMQ.845.
OTHERWISE GO TO SMQ.846.

SMQ.845 During the past 5 days, including today, on how many days did you smoke tobacco in a water pipe or hookah?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.845 < 1 OR SMQ.845 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.846 During the past 5 days, including today, did you use e-cigarettes? You may also know them as JUUL^TM, vape-pens, vapes, hookah-pens, e-hookahs, or vaporizers. These are battery-powered, usually contain liquid nicotine, and produce vapor instead of smoke?

YES 1

NO 2 (SMQ.851)

REFUSED 7 (SMQ.851)

DON’T KNOW 9 (SMQ.851)

SMQ.849 During the past 5 days, including today, on how many days did {you/he/she} use e-cigarettes?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

IF SMQ.849 < 1 OR SMQ.849 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

SMQ.851_ Smokeless tobacco products are placed in the mouth or nose and can include chewing tobacco, snuff, dip, snus, or dissolvable tobacco.

SMQ.851 During the past 5 days, including today, did you use any smokeless tobacco?

INSTRUCTIONS TO SP:

Please do not include nicotine replacement therapy products like patches, gum, lozenge or spray which are considered products to help you stop smoking.

Please select . . .

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

SMQ.853 Which of these products did you use? (CHECK ALL THAT APPLY)

INSTRUCTIONS TO SP:

Please select all that you used.

Chewing tobacco 1

Snuff 2

Snus 3

Dissolvables 4

Dip…………………………………………………..5

REFUSED 77 (END OF SECTION)

DON’T KNOW 99 (END OF SECTION)

BOX 7

CHECK ITEM SMQ.855:

IF ‘CHEWING’ (CODE 1) IN SMQ.853, GO TO SMQ.800.
IF ‘SNUFF’ (CODE 2) IN SMQ.853, GO TO SMQ.817.
OTHERWISE, GO TO END OF SECTION.

SMQ.800 During the past 5 days, including today, on how many days did you use chewing tobacco, such as Redman, Levi Garrett or Beechnut?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.800 < 1 OR SMQ.800 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

BOX 8

CHECK ITEM SMQ.818:

IF ‘SNUFF’ (CODE 2) IN SMQ.853, GO TO SMQ.817.

OTHERWISE, GO TO END OF SECTION.

SMQ.817 During the past 5 days, including today, on how many days did {you/he/she} use snuff, such as Skoal, Skoal Bandits, or Copenhagen?

INSTRUCTIONS TO SP:

Please enter a number.

CAPI INSTRUCTIONS:

HARD EDIT: IF SMQ.817 < 1 OR SMQ.817 > 5 THEN ERROR.

ERROR MESSAGE: “Please enter a number between 1 and 5. Please press the “Back” button, press “Clear,” and try again.”

|___|

ENTER NUMBER OF DAYS

REFUSED 7

DON'T KNOW 9

ALCOHOL USE – ALQ

Target Group: SPs 12-17 (Audio-CASI)

ALQ.010_ The following questions ask about alcohol use. This includes beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. This does not include drinking a few sips of wine for religious purposes.

ALQ.022. During your life, on how many days have you had at least one drink of alcohol?

INSTRUCTIONS TO SP

Please select one of the following choices,

0 days 1 (END OF SECTION)

1 or 2 days 2

3 to 9 days 3

10 to 19 days 4

20 to 39 days 5

40 to 99 days 6

100 or more days 7

REFUSED 77

DON'T KNOW 99

ALQ.010 How old were you when you had your first drink of alcohol, other than a few sips?

INSTRUCTIONS TO SP:

Please select one of the following choices.

HARD EDIT: if (RIAAGEYR < 17 AND ALQ.010 = 7) OR (RIAAGEYR < 15 AND ALQ.010 IN (6, 7)) OR (RIAAGEYR < 13 AND ALQ.010 IN (5, 6, 7)) THEN ERROR

Error message: “Your response is older than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

8 years old or younger 2

9 or 10 years old 3

11 or 12 years old 4

13 or 14 years old 5

15 or 16 years old 6

17 years old or older 7

REFUSED 77

DON'T KNOW 99

ALQ.031 During the past 30 days, on how many days did you have at least one drink of alcohol?

INSTRUCTIONS TO SP:

Please select one of the following choices.

HARD EDIT: IF (ALQ.022 = 2 AND ALQ.031 IN (3,4,5,6,7)) OR (ALQ.022 =3 AND ALQ.031 IN (5,6,7)) OR (ALQ.022 = 4 AND ALQ.031 IN (6,7)) THEN ERROR

Error message: “Your response is not consistent with your lifetime use. Please press the “Back” button, press “Clear,” and try again.”

0 days 1 (END OF SECTION)

1 or 2 days 2

3 to 5 days 3

6 to 9 days 4

10 to 19 days 5

20 to 29 days 6

All 30 days 7

REFUSED 77

DON'T KNOW 99

ALQ.042 During the past 30 days, on how many days did you have {DISPLAY NUMBER} or more drinks of alcohol in a row, that is, within a couple of hours?

INSTRUCTIONS TO SP:

Please select one of the following choices.

CAPI INSTRUCTION:

IF SP = MALE, DISPLAY = 5

IF SP = FEMALE, DISPLAY = 4

HARD EDIT: IF (ALQ.031= 2 AND ALQ.042 IN (4,5,6,7)) OR (ALQ.031=3 AND ALQ.042 IN (5,6,7)) OR (ALQ.031 = 4 AND ALQ.042 IN (6,7)) OR (ALQ.031 = 5 AND ALQ.042 = 7) THEN ERROR

Error message: “Your response is not consistent with your use in the past 30 days. Please press the “Back” button, press “Clear,” and try again.”

0 days 1

1 day 2

2 days 3

3 to 5 days 4

6 to 9 days 5

10 to 19 days 6

20 or more days 7

REFUSED 77

DRUG USE – DUQ

Target Group: SPs 12+ (Audio-CASI)

DUQ.200_ The following questions ask about use of drugs. Please remember that your answers to these questions will be kept confidential.

DUQ.005 The first questions are about marijuana or cannabis, also called pot or weed.

How old were you the first time you used marijuana or cannabis?

INSTRUCTIONS TO SP:

Please enter your age or select a response . . .

|___|___|

ENTER AGE IN YEARS (DUQ.230)

I have never used marijuana or cannabis………100 (DUQ.250)

REFUSED…………………………………………..777 (DUQ.250)

DON’T KNOW………………………………………999 (DUQ.250)

HARD EDIT: RESPONSES MUST BE LESS THAN OR EQUAL TO THEIR CURRENT AGE.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: IF DUQ.200 EQUAL TO 0, DISPLAY ERROR MESSAGE.

Error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again. If you have never used marijuana or cannabis, please select the choice, “I have never used marijuana or cannabis.”

BOX 1

CHECK ITEM DUQ.225:

IF SP EVER USED MARIJUANA (DUQ.200= 1 - CURRENT AGE), CONTINUE WITH DUQ.230.
OTHERWISE, GO TO DUQ.250.

DUQ.230 During the past 30 days, on how many days did you use marijuana or cannabis?

INSTRUCTIONS TO SP:

Please enter a number.

HARD EDIT VALUES: 0-30.

IF DUQ.230 > 30, DISPLAY ERROR MESSAGE: “Your response cannot exceed 30 days. Please press the “Back” button, press “Clear,” and try again.”

|___|___|

ENTER A NUMBER

REFUSED 77 (DUQ.250)

DON'T KNOW 99 (DUQ.250)

BOX 2

CHECK ITEM DUQ.232:

IF DUQ.230 EQUALS ZERO, GO TO DUQ.250.
IF DUQ.230 IS GREATER THAN ZERO, CONTINUE.

DUQ.235 During the past 30 days, in which of the following ways did you use marijuana the most often?

INSTRUCTIONS TO SP:

Please select one of the following choices. . .

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

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

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

Vaporize it (for example, in an e-cigarette-like vaporizer

or another vaporizing device)…………………………4

Dab it (for example, using waxes or concentrates)……………5

Use it some other way…………………………………………….6

DON’T KNOW……….……………………………………………77

REFUSED…………………………………………………………99

DUQ.250_ The following questions are about cocaine, including all the different forms of cocaine such as powder, ‘crack’, ‘free base’, and coca paste.

DUQ.250 Have you ever, even once, used cocaine, in any form?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.290_)

REFUSED 7 (DUQ.290_)

DON'T KNOW 9 (DUQ.290_)

DUQ.270 How long has it been since you last used cocaine, in any form?

G/Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select unit of time.

CAPI INSTRUCTIONS:

IF SP REF/DK THEN STORE 7/9 IN DUQ.270G AND DUQ.270U, 7/9 FILL IN DUQ.270Q.

IF A VALUE IS ENTERED IN QUANTITY AND UNIT STORE QUANTITY IN DUQ.270Q, UNIT IN DUQ.270U AND 1 IN DUQ.270G.

HARD EDIT: IF DUQ.270 EQUAL TO 0 WEEKS, 0 MONTHS, or 0 YEARS, DISPLAY ERROR MESSAGE.

Error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

DUQ.290_ The following questions are about heroin.

DUQ.290 Have you ever, even once, used heroin?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.330_)

REFUSED 7 (DUQ.330_)

DON'T KNOW 9 (DUQ.330_)

DUQ.310 How long has it been since you last used heroin?

G/Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

CAPI INSTRUCTIONS:

IF SP REF/DK THEN STORE 7/9 IN DUQ.310G AND DUQ.310U, 7/9 FILL IN DUQ.310Q.

IF A VALUE IS ENTERED IN QUANTITY AND UNIT STORE QUANTITY IN DUQ.310Q, UNIT IN DUQ.310U AND 1 IN DUQ.310G.

HARD EDIT: IF DUQ.310 EQUAL TO 0 WEEKS, 0 MONTHS, or 0 YEARS, DISPLAY ERROR MESSAGE.

Error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

DUQ.330_ The following questions are about methamphetamine, also known as crank, crystal, ice or speed.

DUQ.330 Have you ever, even once, used methamphetamine?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (DUQ.370_)

REFUSED 7 (DUQ.370_)

DON'T KNOW 9 (DUQ.370_)

DUQ.350 How long has it been since you last used methamphetamine?

G/Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

CAPI INSTRUCTIONS:

If SP REF/DK THEN STORE 7/9 IN DUQ.350G AND DUQ.350U, 7/9 FILL IN DUQ.350Q.

IF A VALUE IS ENTERED IN QUANTITY AND UNIT STORE QUANTITY IN DUQ.350Q, UNIT IN DUQ.350U AND 1 IN DUQ.350G.

HARD EDIT: IF DUQ.350 EQUAL TO 0 WEEKS, 0 MONTHS, or 0 YEARS, DISPLAY ERROR MESSAGE.

Error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 777

DON'T KNOW 999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

DUQ.370_ The following questions are about the different ways that certain drugs can be used.

DUQ.370 Have you ever, even once, used a needle to inject a drug not prescribed by a doctor?

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

DUQ.380 Which of the following drugs have you injected using a needle?

INSTRUCTIONS TO SP:

Please select all the drugs that you injected.

CAPI INSTRUCTION:

SHOW ALL FIVE ITEMS ON SINGLE ACASI SCREEN

Cocaine 1

Heroin 2

Methamphetamine 3

Steroids 4

Any other drugs 5

REFUSED 7

DON'T KNOW 9

DUQ.400 How long ago has it been since you last used a needle to inject a drug not prescribed by a doctor?

G/Q/U

INSTRUCTIONS TO SP:

Please enter the number of days, weeks, months, or years, then select the unit of time.

CAPI INSTRUCTIONS:

If SP REF/DK THEN STORE 7/9 IN DUQ.400G AND DUQ.400U, 7/9 FILL IN DUQ.400Q.

IF A VALUE IS ENTERED IN QUANTITY AND UNIT STORE QUANTITY IN DUQ.400Q, UNIT IN DUQ.400U AND 1 IN DUQ.400G.

HARD EDIT: IF DUQ.400 EQUAL TO 0 WEEKS, 0 MONTHS, OR 0 YEARS, DISPLAY ERROR MESSAGE.

Error message: “Your response must be greater than 0. Please press the “Back” button, press “Clear,” and try again.

|___|___|___|

ENTER NUMBER OF DAYS, WEEKS, MONTHS, OR YEARS

REFUSED 7777

DON'T KNOW 9999

ENTER UNIT

Days 1

Weeks 2

Months 3

Years 4

SEXUAL BEHAVIOR – (SXQ)

Target Group: Female SPs 14-69 (Audio-CASI)

SXQ.615_ The next set of questions is about your sexual history. By sex, we mean vaginal, oral, or anal sex. Please remember that your answers will be kept confidential.

BOX 1B

CHECK ITEM SXQ.773:

IF SP AGE GREATER THAN 17, GO TO SXQ.700.
OTHERWISE, CONTINUE.

SXQ.615 Have you ever had any kind of sex?

(Target 14-17)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

SXQ.700 Have you ever had vaginal sex, also called sexual intercourse, with a man? This means a man’s penis in your vagina.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.703 Have you ever performed oral sex on a man? This means putting your mouth on a man’s penis or genitals.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.706 Have you ever had anal sex? This means contact between a man’s penis and your anus or butt.

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.709
(Target 14-69)

Have you ever had any kind of sex with a woman? By sex, we mean sexual contact with another woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 1A

CHECK ITEM SXQ.762:

IF SP 60-69 YEARS AND SXQ.700 = 2 AND SXQ.703 = 2 AND SXQ.706 = 2 AND SXQ.709 = 2, GO TO END OF SECTION.
IF SP 60-69 YEARS AND SXQ.703 = 1 AND SXQ.700 = 2 AND SXQ.706 = 2 AND SXQ.709 = 2, GO TO SXQ.618.
IF SXQ.700, SXQ.706, AND SXQ.709 = 2 AND SXQ.703 = 1, GO TO BOX 4.
IF SXQ.700, SXQ.703, SXQ.706, AND SXQ.709 = 2, GO TO END OF SECTION.
OTHERWISE, CONTINUE.

SXQ.618
(Target 14-69)

How old were you the first time you had any kind of sex, including {vaginal, anal, or oral / vaginal or anal / vaginal or oral / anal or oral / vaginal / anal / oral}?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF SXQ.700 AND SXQ.703 = 1 AND SXQ.706 NOT EQUAL TO ‘1’, DISPLAY {vaginal or oral}.

IF SXQ.700 AND SXQ.709 = 1 AND SXQ.706 NOT EQUAL TO ‘1’, DISPLAY {vaginal or oral}.

IF SXQ.700 AND SXQ.706 = 1 AND SXQ.703 AND SXQ.709 NOT EQUAL TO ‘1’, DISPLAY {vaginal or anal}.

IF SXQ.703 AND SXQ.706 = 1 AND SXQ.700 NOT EQUAL TO ‘1’, DISPLAY {anal or oral}.

IF SXQ.706 AND SXQ.709 = 1 AND SXQ.700 NOT EQUAL TO ‘1’, DISPLAY {anal or oral}.

IF SXQ.700 = 1 AND SXQ.703, SXQ.706, AND SXQ.709 NOT EQUAL TO ‘1’, DISPLAY {vaginal}.

IF SXQ.706 = 1 AND SXQ.700, SXQ.703, AND SXQ.709 NOT EQUAL TO ‘1’, DISPLAY {anal}.

IF SXQ.709 = 1 AND SXQ.700, AND SXQ.706 NOT EQUAL TO ‘1’, DISPLAY {oral}.

OTHERWISE, DISPLAY {vaginal, anal, or oral}.

HARD EDIT VALUES: 0-69

Error message: “Your response cannot exceed 69 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.618 MUST BE EQUAL TO OR LESS THAN CURRENT AGE.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 1

CHECK ITEM SXQ.701:

IF SP 60-69 YEARS, AND SXQ.700 = 2 AND SXQ.703 = 2 AND SXQ.706 = 2 AND SXQ.709 = 1, GO TO END OF SECTION.
IF SP 60-69 YEARS, GO TO SXQ.712.
IF SXQ.703 = 1 AND SXQ.700 AND SXQ.706 = 2, GO TO BOX 4.
IF SXQ.700 = 1 AND SXQ.703 AND SXQ.706 = 2, GO TO BOX 3.
IF SXQ.709 = 1 AND SXQ.700, SXQ.703, AND SXQ.706 = 2, GO TO BOX 6.
OTHERWISE, CONTINUE.

SXQ.712 In your lifetime, with how many men have you had any kind of sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.712 MUST BE GREATER THAN 0.

Error message: “Your response is not consistent with your previous responses about male sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 2

CHECK ITEM SXQ.715:

IF SP 60-69 YEARS, GO TO END OF SECTION.
OTHERWISE, GO TO SXQ.718

SXQ.718 In the past 12 months, with how many men have you had any kind of sex?

(Target 14-59)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.718 MUST BE EQUAL TO OR LESS THAN SXQ.712.

Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 3

CHECK ITEM SXQ.721:

IF SXQ.700 = 1, GO TO SXQ.724.
OTHERWISE, GO TO BOX 4.

SXQ.724
(Target 14-59)

In your lifetime, with how many men have you had vaginal sex? Vaginal sex means a man’s penis in your vagina.

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.724 MUST BE GREATER THAN ZERO.

Error message: "Your response is not consistent with your previous responses about male vaginal sex partners. Please press the “Back” button, press “Clear,” and try again."

HARD EDIT: SXQ.724 MUST BE EQUAL TO OR LESS THAN SXQ.712.

Error message: "Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.727
(Target 14-59)

In the past 12 months, with how many men have you had vaginal sex? Vaginal sex means a man’s penis in your vagina.

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.727 MUST BE EQUAL TO OR LESS THAN SXQ.724.

Error message: “Your response is greater than your lifetime number of male vaginal sex partners. Please press the “Back” button, press “Clear”, and try again.”

SOFT EDIT: SXQ.727 MUST BE EQUAL TO OR LESS THAN SXQ.718.

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

BOX 4

CHECK ITEM SXQ.730:

IF SXQ.703 = 1, GO TO SXQ.624.
OTHERWISE, GO TO BOX 6.

SXQ.624 In your lifetime, on how many men have you performed oral sex?

(Target 14-59)

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.624 MUST BE GREATER THAN ZERO.

Error message: "Your response is not consistent with your previous responses about male oral sex partners. Please press the “Back” button, press “Clear,” and try again."

HARD EDIT: SXQ.624 MUST BE EQUAL TO OR LESS THAN SXQ.712.

Error message: "Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.627 In the past 12 months, on how many men have you performed oral sex?

(Target 14-59)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.627 MUST BE EQUAL TO OR LESS THAN SXQ.624.

Error message: “Your response is greater than your lifetime number of male oral sex partners. Please press the “Back” button, press “Clear,” and try again.”

SOFT EDIT: SXQ.627 MUST BE EQUAL TO OR LESS THAN SXQ.718.

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

BOX 6

CHECK ITEM SXQ.733:

IF SXQ.709 = 1, GO TO SXQ.736.
OTHERWISE, GO TO BOX 7.

SXQ.736
(Target 14-59)

In your lifetime with how many women have you had sex? By sex, we mean sexual contact with another woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.736 MUST BE GREATER THAN ZERO.

Error message: "Your response is not consistent with your previous responses about sex with a female partner. Please press the “Back” button, press “Clear,” and try again."

SXQ.739
(Target 14-59)

In the past 12 months, with how many women have you had sex? By sex, we mean sexual contact with another woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.739 MUST BE EQUAL TO OR LESS THAN SXQ.736.

Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear”, and try again.”

SXQ.741
(Target 14-59)

Have you ever performed oral sex on a woman? Performing oral sex means your mouth on a woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (BOX 7A)

REFUSED 7 (BOX 7A)

DON'T KNOW 9 (BOX 7A)

SXQ.636 In your lifetime, on how many women have you performed oral sex?

(Target 14-59)

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.636 MUST BE GREATER THAN ZERO.

Error message: "Your response is not consistent with your previous responses about female oral sex partners. Please press the “Back” button, press “Clear,” and try again."

HARD EDIT: SXQ.636 MUST BE EQUAL TO OR LESS THAN SXQ.736.

Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.639 In the past 12 months, on how many women have you performed oral sex?

(Target 14-59)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.639 MUST BE EQUAL TO OR LESS THAN SXQ.636.

Error message: “Your response is greater than your lifetime number of female oral sex partners. Please press the “Back” button, press “Clear,” and try again.”

SOFT EDIT: SXQ.639 MUST BE EQUAL TO OR LESS THAN SXQ.739.

Error message: “Your response is greater than your total number of female partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

BOX 7A

CHECK ITEM SXQ.744:

IF SP DID NOT HAVE A PARTNER IN PAST 12 MONTHS (SXQ.718, SXQ.727, SXQ.627, SXQ.639, AND SXQ.739 CODED ‘0000’ OR MISSING), GO TO SXQ.260.
IF SXQ.709 = 1 AND SXQ.700, SXQ.703, OR SXQ.706 = 1, THEN DISPLAY “The next set of questions is about all of your partners, males and females.”, THEN GO TO BOX 7.
OTHERWISE, GO TO BOX 7.

BOX 7

CHECK ITEM SXQ.747:

IF SP HAD ORAL SEX PARTNER IN PAST 12 MONTHS (SXQ.627 OR SXQ.639 GREATER THAN ‘0000’), THEN GO TO SXQ.645.
OTHERWISE, GO TO BOX 7B.

SXQ.645
(Target 14-59)

When you performed oral sex in the past 12 months, how often would you use protection, like a condom or dental dam?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 1

Rarely 2

Usually 3

Always 4

Unsure 5

REFUSED 7

DON'T KNOW 9

BOX 7B

CHECK ITEM SXQ.771:

IF SXQ.718, SXQ.727, SXQ.627, SXQ.639 OR SXQ.739 GREATER THAN ‘0000’, GO TO SXQ.648.
OTHERWISE, GO TO BOX 9.

SXQ.648 In the past 12 months, did you have any kind of sex with a person that you never had sex with before?

(Target 14-59)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 8A

CHECK ITEM SXQ.759:

IF SXQ.700 OR SXQ.706 = 1, THEN CONTINUE.
OTHERWISE, GO TO BOX 9,

SXQ.610 In the past 12 months, about how many times have you had {vaginal or anal/vaginal/anal} sex?

(Target 14-59)

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 0

Once 1

2-11 times 2

12-51 times 3

52-103 times 4

104-364 times 5

365 times or more 6

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTON:

IF SXQ.700 = 1 AND SXQ.706 = 2, DISPLAY {vaginal}.

IF SXQ.700 = 2 AND SXQ.706 = 1, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal or anal}.

BOX 8

CHECK ITEM SXQ.246:

IF SP DID NOT HAVE VAGINAL OR ANAL SEX (CODED ‘0’) IN SXQ.610, GO TO BOX 9.
OTHERWISE, CONTINUE WITH SXQ.250.

SXQ.250
(Target 14-59)

In the past 12 months, about how often have you had {vaginal or anal/vaginal/anal} sex without using a condom?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 1

Less than half of the time 2

About half of the time 3

Not always, but more than half of the time 4

Always 5

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTON:

IF SXQ.700 = 1 AND SXQ.706 = 2, DISPLAY {vaginal}.

IF SXQ.700 = 2 AND SXQ.706 = 1, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal or anal}.

SXQ.260 Has a doctor or other health care professional ever told you that you had genital herpes?

(Target 14-59)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.265 Has a doctor or other health care professional ever told you that you had genital warts?

(Target 14-59)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (SXQ.753)

REFUSED 7 (SXQ.753)

DON'T KNOW 9 (SXQ.753)

SXQ.267 How old were you when you were first told that you had genital warts?

(Target 14-59)

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.618 MUST BE EQUAL TO OR LESS THAN CURRENT AGE.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

SXQ.753 Has a doctor or other health care professional ever told you that you had human papillomavirus or HPV?

(Target 14-59)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SEXUAL BEHAVIOR – (SXQ)

Target Group: Male SPs 14-69 (Audio-CASI)

SXQ.615_ The next set of questions is about your sexual history. By sex, we mean vaginal, oral, or anal sex.

Please remember that your answers will be kept confidential.

BOX 1B

CHECK ITEM SXQ.873:

IF SP AGE GREATER THAN 17, GO TO SXQ.800.
OTHERWISE, CONTINUE.

SXQ.615 Have you ever had any kind of sex?

(Target 14-17)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (BOX 8)

REFUSED 7 (BOX 8)

DON'T KNOW 9 (BOX 8)

SXQ.800
(Target 14-69)

Have you ever had vaginal sex, also called sexual intercourse, with a woman? This means your penis in a woman’s vagina.

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.803
(Target 14-69)

Have you ever performed oral sex on a woman? This means putting your mouth on a woman’s vagina or genitals.

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.806
(Target 14-69)

Have you ever had anal sex with a woman? Anal sex means contact between your penis and a woman’s anus or butt.

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.809 Have you ever had any kind of sex with a man, including oral or anal?

(Target 14-69)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 1A

CHECK ITEM SXQ.862:

IF SP 60-69 YEARS AND SXQ.800 = 2 AND SXQ.806 = 2 AND SXQ.803 = 2 AND SXQ.809 = 2, GO TO END OF SECTION.
IF SP 60-69 YEARS AND SXQ.803 = 1 AND SXQ.800 = 2 AND SXQ.806 = 2 AND SXQ.809 = 2, GO TO SXQ.618.
IF SXQ.800, SXQ.806, AND SXQ.809 = 2 AND SXQ.803 = 1, GO TO BOX 4.
IF SXQ.800, SXQ.803, SXQ.806, AND SXQ.809 = 2, GO TO END OF SECTION.
OTHERWISE, CONTINUE.

SXQ.618
(Target 14-69)

How old were you the first time you had any kind of sex, including {vaginal, anal, or oral / vaginal or anal / vaginal or oral / anal or oral / vaginal / anal / oral}?

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF SXQ.800 AND SXQ.803 = 1 AND SXQ.806 AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal or oral}.

IF SXQ.800 AND SXQ.806 = 1 AND SXQ.803 AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal or anal}.

IF SXQ.809 = 1 AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal or oral}.

IF SXQ.803 AND SXQ.806 = 1 AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal or oral}.

IF SXQ.800 = 1 AND SXQ.803, SXQ.806, AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal}.

IF SXQ.806 = 1 AND SXQ.800, SXQ.803, AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal, anal, or oral}.

HARD EDIT VALUES: 0-69

Error message: “Your response cannot exceed 69 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.618 MUST BE EQUAL TO OR LESS THAN CURRENT AGE.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

BOX 1

CHECK ITEM SXQ.801:

IF SP 60-69 YEARS, AND SXQ.800 = 2 AND SXQ.803 = 2 AND SXQ.806 = 2 AND SXQ.809 = 1, GO TO BOX 5.
IF SP 60-69 YEARS, GO TO SXQ.812.
IF SXQ.803 = 1 AND SXQ.800 AND SXQ.806 = 2, GO TO BOX 4.
IF SXQ.800 = 1 AND SXQ.803 AND SXQ.806 = 2, GO TO BOX 3.
IF SXQ.809 = 1 AND SXQ.800, SXQ.803, AND SXQ.806 = 2, GO TO BOX 5.
OTHERWISE, CONTINUE.

SXQ.812 In your lifetime, with how many women have you had any kind of sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.812 MUST BE GREATER THAN ZERO.

Error message: “Your response is not consistent with your previous responses about female sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 2

CHECK ITEM SXQ.815:

IF SP 60-69 YEARS AND SXQ.809 = 1, GO TO SXQ.410.
IF SP 60-69 YEARS AND SXQ.809 NOT EQUAL TO 1, GO TO END OF SECTION.
OTHERWISE, CONTINUE WITH SXQ.818.

SXQ.818 In the past 12 months, with how many women have you had any kind of sex?

(Target 14-59)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.818 MUST BE EQUAL TO OR LESS THAN SXQ.812.

Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 3

CHECK ITEM SXQ.821:

IF SXQ.800 = 1, GO TO SXQ.824.
OTHERWISE, GO TO BOX 4.

SXQ.824
(Target 14-59)

In your lifetime, with how many women have you had vaginal sex? Vaginal sex means your penis in a woman’s vagina.

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.824 MUST BE GREATER THAN ZERO.

Error message: "Your response is not consistent with your previous responses about female vaginal sex partners. Please press the “Back” button, press “Clear,” and try again."

HARD EDIT: SXQ.824 MUST BE EQUAL TO OR LESS THAN SXQ.812.

Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.827
(Target 14-59)

In the past 12 months, with how many women have you had vaginal sex? Vaginal sex means your penis in a woman’s vagina.

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.827 MUST BE EQUAL TO OR LESS THAN SXQ.824.

Error message: “Your response is greater than your lifetime number of female vaginal sex partners. Please press the “Back” button, press “Clear”, and try again.”

SOFT EDIT: SXQ.827 MUST BE EQUAL TO OR LESS THAN SXQ.818.

Error message: “Your response is greater than your total number of partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

BOX 4

CHECK ITEM SXQ.830:

IF SXQ.803 = 1, GO TO SXQ.636.
OTHERWISE, GO TO BOX 5.

SXQ.636 In your lifetime, on how many women have you performed oral sex?

(Target 14-59)

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.636 MUST BE GREATER THAN ZERO.

Error message: "Your response is not consistent with your previous responses about female oral sex partners. Please press the “Back” button, press “Clear,” and try again."

HARD EDIT: SXQ.636 MUST BE EQUAL TO OR LESS THAN SXQ.812.

Error message: “Your response is greater than your lifetime number of female partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.639 In the past 12 months, on how many women have you performed oral sex?

(Target 14-59)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.639 MUST BE EQUAL TO OR LESS THAN SXQ.636.

Error message: “Your response is greater than your lifetime number of female oral sex partners. Please press the “Back” button, press “Clear,” and try again.”

SOFT EDIT: SXQ.639 MUST BE EQUAL TO OR LESS THAN SXQ.818.

Error message: “Your response is greater than your total number of female partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

BOX 5

CHECK ITEM SXQ.833:

IF SXQ.809 = 1, GO TO SXQ.410.
OTHERWISE, GO TO BOX 9.

SXQ.410 In your lifetime, with how many men have you had anal or oral sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.410 MUST BE GREATER THAN ZERO.

Error message: “Your response is not consistent with your previous responses about male sex partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 5B

CHECK ITEM SXQ.875:

IF SP IS 60-69 YEARS, GO TO SXQ.836.
OTHERWISE, CONTINUE WITH SXQ.550.

SXQ.550 In the past 12 months, with how many men have you had anal or oral sex?

(Target 14-59)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.550 MUST BE EQUAL TO OR LESS THAN SXQ.410.

Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

SXQ.836 In your lifetime, with how many men have you had anal sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.836 MUST BE EQUAL TO RO LESS THAN SXQ.410.

Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 6

CHECK ITEM SXQ.839:

IF SP IS 60-69 YEARS, GO TO SXQ.853.
IF SP HAD NO ANAL SEX PARTNERS (CODED ‘0000’ IN SXQ.836), GO TO SXQ.853.
OTHERWISE, CONTINUE WITH SXQ.841.

SXQ.841 In the past 12 months, with how many men have you had anal sex?

(Target 14-59)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.841 MUST BE EQUAL TO OR LESS THAN SXQ.836.

Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

SOFT EDIT: SXQ.841 MUST BE EQUAL TO OR LESS THAN SXQ.550.

Error message: “Your response is greater than your total number of male partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

SXQ.853
(Target 14-69)

Have you ever performed oral sex on a man? Performing oral sex means your mouth on a man’s penis or genitals.

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 7

CHECK ITEM SXQ.847:

IF SP NEVER HAD ORAL MALE PARTNER (CODED ‘2’, ‘7’, OR ‘9’) IN SXQ.853 AND SP IS 60-69 YEARS, GO TO END OF SECTION.
IF SP NEVER HAD ORAL MALE PARTNER (CODED ‘2’, ‘7’, OR ‘9’) IN SXQ.853 AND SP IS 14-59 YEARS, GO TO BOX 9A.
OTHERWISE, CONTINUE WITH SXQ.624.

SXQ.624 In your lifetime, on how many men have you performed oral sex?

(Target 14-69)

INSTRUCTIONS TO SP:

Please enter a number.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

HARD EDIT: SXQ.624 MUST BE GREATER THAN ZERO.

Error message: "Your response is not consistent with your previous responses about male oral sex partners. Please press the “Back” button, press “Clear,” and try again."

HARD EDIT: SXQ.624 MUST BE EQUAL TO OR LESS THAN SXQ.410.

Error message: “Your response is greater than your lifetime number of male partners. Please press the “Back” button, press “Clear,” and try again.”

BOX 8

CHECK ITEM SXQ.850:

IF SP 60-69 YEARS, GO TO END OF SECTION.
IF SP 14-17 YEARS AND SXQ.615 = 2, 7, OR 9, GO TO SXQ.280.
IF SXQ.800, SXQ.803, SXQ.806, AND SXQ.809 = 2, 7, OR 9, GO TO SXQ.280.
OTHERWISE, CONTINUE WITH SXQ.627.

SXQ.627 In the past 12 months, on how many men have you performed oral sex?

(Target 14-59)

INSTRUCTIONS TO SP:

Please enter a number or enter zero for none.

|___|___|___|___|

ENTER NUMBER

REFUSED 77777

DON'T KNOW 99999

SOFT EDIT: SXQ.627 MUST BE EQUAL TO OR LESS THAN SXQ.550.

Error message: “Your response is greater than your total number of male partners in the past 12 months. Please press the “Back” button, press “Clear,” and try again.”

BOX 9A

CHECK ITEM SXQ.844:

IF SP DID NOT HAVE A PARTNER IN PAST 12 MONTHS (SXQ.627, SXQ.639, SXQ.818, SXQ.827, SXQ.550 AND SXQ.841 CODED ‘0000’ OR MISSING), GO TO SXQ.260.
IF SXQ.809 = 1 AND SXQ.800, SXQ.803, OR SXQ.806 = 1, THEN DISPLAY “The next set of questions is about all of your partners, males and females.”, THEN GO TO BOX 9.
OTHERWISE, GO TO BOX 9.

BOX 9

CHECK ITEM SXQ.845:

IF SP HAD ORAL SEX PARTNER IN PAST 12 MONTHS (SXQ.627 OR SXQ.639 GREATER THAN ‘0000’), GO TO SXQ.645.
OTHERWISE, GO TO BOX 9B.

SXQ.645
(Target 14-59)

When you performed oral sex in the past 12 months, how often would you use protection, like a condom or dental dam?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 1

Rarely 2

Usually 3

Always 4

Unsure 5

REFUSED 7

DON'T KNOW 9

BOX 9B

CHECK ITEM SXQ.871:

IF SXQ.818, SXQ.841, SXQ.827, SXQ.550, SXQ.627, OR SXQ.639 GREATER THAN ‘0000’, GO TO SXQ.648.
OTHERWISE, GO TO BOX 11.

SXQ.648 In the past 12 months, did you have any kind of sex with a person that you never had sex with before?

(Target 14-59)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

BOX 10A

CHECK ITEM SXQ.859:

IF SXQ.800, SXQ.806, AND SXQ.809 NOT EQUAL TO ‘1’, GO TO BOX 11.
OTHERWISE, GO TO SXQ.610.

SXQ.610 In the past 12 months, about how many times have you had {vaginal or anal/vaginal/anal} sex?

(Target 14-59)

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 0

Once 1

2-11 times 2

12-51 times 3

52-103 times 4

104-364 times 5

365 times or more 6

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF SXQ.800 = 1 AND SXQ.806 AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal}.

IF SXQ.806 = 1 AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal}.

IF SXQ.836 GREATER THAN ‘0000’ AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal or anal}.

BOX 10

CHECK ITEM SXQ.245:

IF SP DID NOT HAVE VAGINAL OR ANAL SEX (CODED ‘0’) IN SXQ.610, GO TO BOX 11.
OTHERWISE, CONTINUE WITH SXQ.250.

SXQ.250
(Target 14-59)

In the past 12 months, about how often have you had {vaginal or anal/vaginal/anal} sex without using a condom?

INSTRUCTIONS TO SP:

Please select one of the following choices.

Never 1

Less than half of the time 2

About half of the time 3

Not always, but more than half of the time 4

Always 5

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF SXQ.800 = 1 AND SXQ.806 AND SXQ.809 NOT EQUAL TO ‘1’, DISPLAY {vaginal}.

IF SXQ.806 = 1 AND SXQ.800 NOT EQUAL TO ‘1’, DISPLAY {anal}.

OTHERWISE, DISPLAY {vaginal or anal}.

SXQ.260 Has a doctor or other health care professional ever told you that you had genital herpes?

(Target 14-59)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

SXQ.265 Has a doctor or other health care professional ever told you that you had genital warts?

(Target 14-59)

INSTRUCTIONS TO SP:

Please select . . .

Yes 1

No 2 (SXQ.280)

REFUSED 7 (SXQ.280)

DON'T KNOW 9 (SXQ.280)

SXQ.267 How old were you when you were first told that you had genital warts?

(Target 14-59)

INSTRUCTIONS TO SP:

Please enter an age.

|___|___|

ENTER AGE IN YEARS

REFUSED 77

DON'T KNOW 99

HARD EDIT VALUES: 0-59

Error message: “Your response cannot exceed 59 years. Please press the “Back” button, press “Clear,” and try again.”

HARD EDIT: SXQ.618 must be equal to or less than current age.

Error message: “Your response is greater than your recorded age. Please press the “Back” button, press “Clear,” and try again.”

SXQ.280 Are you circumcised or uncircumcised?

(Target 14-59)

INSTRUCTIONS TO SP:

Please select . . .

CAPI INSTRUCTIONS:

DISPLAY THE SKETCHES BELOW EACH SELECTION. SKETCH SHOULD DISPLAY BY DEFAULT.

ACASI FIGURE SXQ1 – CLINICAL SKETCH OF CIRCUMCISED PENIS

ACASI FIGURE SXQ2 – CLINICAL SKETCH OF UNCIRCUMCISED PENIS

Circumcised 1

Uncircumcised 2

REFUSED 7

DON'T KNOW…………………………………. 9

DIETARY INTERVIEW

Target Group: SPs all ages

24-Hour Dietary Recall Interview

Information will be obtained on all foods and beverages that were consumed during a 24-hour time period (midnight to midnight). The information that is obtained for foods and beverages includes the following:

Time of day -Time when the food was eaten

Meal name code - The name of the eating occasion is selected from a list of options.

Meal place - Whether the meal was eaten at home.

Food item name - The name of the food is either typed in or selected from a list of food item names.

Food item description - Detailed description of the food including information about commercial product name (if applicable), preparation method, and major recipe ingredients.

Fat added in preparation - A preparation fat probe is asked for certain foods. The type of fat used during food preparation is specified as well.

Amount of food eaten - The amount of food consumed by the respondent.

Food source - The place where the food was obtained is selected from a list of options

24-Hour Dietary Recall Interview Scripts - In-Person Interview:

A. Introduction script

First, we’ll make a list of the foods you/SP ate and drank yesterday, Monday. It may help you remember what you/SP ate by thinking about where you/he/she were, who you/he/she were with, or what you were/he was/she was doing, like working, eating out, or watching television.

Please tell me everything you/SP had to eat and drink all day yesterday, Monday, from midnight to midnight. Include everything you/he/she had at home and away, even snacks, water, soft drinks, and alcoholic beverages. I’ll ask you for specific details and amounts of the foods in a few minutes. At this time, just tell me what you/SP had.

B. Forgotten food probes script

Your answers are important, so we’d like this list to be as complete as possible.

In addition to the foods you have/SP has already told me about, did you have any coffee, tea, soft drinks, milk or juice?

Beer, wine, cocktails or other drinks?

Cookies, candy, ice cream or other sweets?

Chips, crackers, popcorn, pretzels, nuts, or other snack foods?

Fruits, vegetables, or cheese?

Bread, rolls or tortillas?

Anything else?

C. Food detail probes script

Now we’re going to fill in your list with more detail. When I ask how much {you/SP} ate, you can estimate the amount by using the models on the table and in the racks.

You may use the grid or ruler for rectangular or square shapes and the circles for circular or round shapes. Use the wedge for wedge shaped foods.

You can use the thickness bars to show me the thickness of a food and the bean bags and mounds to describe the amounts of solid foods.

When you use the cups, bowls, and glasses, please show me which line best describes the portion {you/SP/he/she} ate or drank. When you use any of the spoons, please tell me the quantity in LEVEL spoonfuls.

Post-dietary Recall Questions

Post-Recall Questionnaire - DRQ

Target Group: SPs Birth + (Questions grouped by age categories)

NHANES III

REC.155 Was the amount of food that {you/NAME} ate yesterday much more than usual, usual, or much less than usual?

MUCH MORE THAN USUAL 1

USUAL 2

MUCH LESS THAN USUAL 3

REFUSED 7

DON’T KNOW 9

CSFII

REC.265 When you drink tap water, what is the main source of the tap water? Is the city water supply (community water supply); a well or rain cistern; a spring; or something else?

COMMUNITY WATER 1

A WELL OR RAIN CISTERN 2

A SPRING 3

NEVER DRINK TAP WATER 4

REFUSED 7

DON’T KNOW 9

OTHER (SPECIFY) 91

[RECORD Drinking fountain AS COMMUNITY WATER SUPPLY.]

NHANES III

REC.325 Now I'll be asking some questions about {your/NAME's} use of table salt.

What type of salt {do you/does NAME} usually add to {your/his/her} food at the table? Would you say it is ordinary salt, sea salt, lite salt, or a salt substitute?

ORDINARY, SEA, SEASONED, OR OTHER FLAVORED SALT

[includes regular iodized salt,

sea salt and seasoning salts

made with regular salt] 1

LITE SALT 2

SALT SUBSTITUTE 3

NONE 4 (REC.335)

REFUSED 7 (REC.335)

DON'T KNOW 9 (REC.335)

NHANES III

REC.330 How often {do you/does NAME} add this salt to {your/his/her} food at the table? Is it rarely, occasionally, or very often?

RARELY, 1

OCCASIONALLY 2

VERY OFTEN 3

REFUSED 7

DON'T KNOW 9

CSFII

REC.335 How often is ordinary salt or sea salt added in cooking or preparing foods in your household? Is it never, rarely, occasionally, or very often?

NEVER 1

RARELY 2

OCCASIONALLY 3

VERY OFTEN 4

REFUSED 7

DON'T KNOW 9

[THIS QUESTION APPLIES ONLY TO USE OF ORDINARY SALT, SEA SALT OR SEASONED SALT AND NOT TO LITE SALT OR SALT SUBSTITUTES.]

CSFII

REC.336 This next question is about {your/NAME’s} use of salt at the table yesterday. Did {you/SP} add any salt to {your/her/his} food at the table yesterday? Salt includes ordinary salt, sea salt lite salt, or a salt substitute.

YES 1

NO 2 (REC.340)

REFUSED 7 (REC.340)

DON’T KNOW 9 (REC.340)

CSFII

REC.337 What type of salt was it? (Was it ordinary salt, sea salt, lite salt, or a salt substitute?)

ORDINARY, SEA, SEASONED, OR OTHER FLAVORED SALT

[includes regular iodized salt,

sea salt and seasoning salts

made with regular salt] 1

LITE SALT 2

SALT SUBSTITUTE 3

REFUSED 7

DON'T KNOW 9

CSFII

REC.340 {Are you/Is NAME} currently on any kind of diet, either to lose weight or for some other health-related reason?

YES 1

NO 2 (Box 1)

REFUSED 7 (Box 1)

DON’T KNOW 9 (Box 1)

CSFII

REC.345 What kind of diet {are you/is NAME} on?

[READ AS NEEDED: Is it a weight loss or low calorie diet; low fat or cholesterol diet; low salt or sodium diet; diabetic diet; or another type of diet?]

WEIGHT LOSS OR LOW CALORIE DIET 1

LOW FAT OR CHOLESTEROL DIET 2

LOW SALT OR SODIUM DIET 3

SUGAR FREE OR LOW SUGAR DIET 4

LOW FIBER DIET 5

HIGH FIBER DIET 6

DIABETIC DIET 7

LOW CARBOHYDRATE DIET 8

HIGH PROTEIN DIET 9

WEIGHT GAIN DIET 10

GLUTEN-FREE OR CELIAC DIET 11

RENAL OR KIDNEY DIET 12

OTHER 91

(SPECIFY) ___________

REFUSED 77

DON’T KNOW 99

BOX 1

IF SP < 1 YEAR OLD, GO TO THE END OF THE SECTION.

OTHERWISE, CONTINUE.

NHANES 1999

DRQ.361 Please look at this list of fish. During the past 30 days, did you eat any types of fish listed on this card? Include any foods that had fish in them such as sandwiches, soups, or salads.

YES 1

NO 2 (DRQ.380)

REFUSED 7 (DRQ.380)

DON’T KNOW 9 (DRQ.380)

NHANES 1999

DRQ. 370 During the past 30 days, which types of fish did you eat and how many times did you eat them?

Type listed: breaded fish products, tuna (canned or fresh), bass, catfish, cod, flatfish, haddock, mackerel, perch, pike, pollock, porgy, salmon, sardines, sea bass, shark, swordfish, trout, walleye, other type of fish and unknown type of fish.

Interviewer instruction:

Check each type of shellfish the SP reports eating, and then ask and record the number of times each type was eaten.

NHANES 1999

DRQ.380 Please look at this list of shellfish. During the past 30 days, did you eat any types of shellfish listed on this card? Include any foods that had shellfish in them such as sandwiches, soups, or salads.

YES 1

NO 2 (Box 2)

REFUSED 7 (Box 2)

DON’T KNOW 9 (Box 2)

NHANES 1999

DRQ. 390 During the past 30 days, which types of shellfish did you eat and how many times did you eat them?

Type listed: clams, crab, crayfish (crawfish), lobster, mussels, oysters, scallops, shrimp, other shellfish (for example, octopus, squid) and unknown type of shellfish.

Interviewer instruction:

Check each type of shellfish the SP reports eating, and then ask and record the number of times each type was eaten.

BOX 3

IF SP 6-7 YEARS OLD, CONTINUE.

OTHERWISE, GO TO BOX 4.

05PUQ.100 In the past 7 days, were any chemical products used in {your/his/her} home to control fleas, roaches, ants, termites, or other insects?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

05PUQ.110 In the past 7 days, were any chemical products used in {your/his/her} lawn or garden to kill weeds?

CODE ‘NO’ IF THE RESPONDENT SAYS S/HE DOES NOT HAVE A LAWN OR GARDEN.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 4

IF SP ≥ 18 YEARS, CONTINUE.

OTHERWISE, GO TO THE END OF THE SECTION.

The next question is about drinking alcoholic beverages. Included are liquor (such as whiskey or gin), beer, wine, wine coolers, and any other type of alcoholic beverage. By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and a half ounces of liquor.

HANDCARD ALQ1 (Here are some examples of an alcoholic drink)

ALQ.160 Considering all types of alcoholic beverages, during the past 30 days, how many times did {you/SP} have {DISPLAY NUMBER} or more drinks on an occasion?

ENTER '0' FOR NEVER.

CAPI INSTRUCTION:

IF SP = MALE, DISPLAY = 5

IF SP = FEMALE, DISPLAY = 4

SOFT EDIT: IF RESPONSE IS > 60 TIMES, THEN DISPLAY “YOU SAID THAT IN THE PAST 30 DAYS, YOU HAD {DISPLAY NUMBER} OR MORE DRINKS OF ANY KIND OF ALCOHOL ON AN OCCASION, (DISPLAY QUANTITY) TIMES. IS THAT CORRECT”?

|___|___|

ENTER QUANTITY

REFUSED 777

DON'T KNOW 999

DIETARY SUPPLEMENTS

DIETARY SUPPLEMENTS – DSA

DAY 1 MEC QUESTIONNAIRE

Target Group: MEC Dietary Respondents

BOX 1

IF SUPPLEMENTS COLLECTED IN HOUSEHOLD INTERVIEW, GO TO BOX 2

ELSE CONTINUE.

DSA001 The next questions are about {your/SP’s} use of dietary supplements, including prescription and over the counter supplements. All day yesterday, {day}, between midnight and midnight, did {you/SP} take any vitamins, minerals, herbals or other dietary supplements?

[SHOW SUPPLEMENT HANDCARD]

YES……………………………………………….…1 (BOX 7)

NO.......................................................................2 (BOX 10)

REFUSED…………………………………………. 7 (BOX 10)

DON’T KNOW……………………………………...9 (BOX 10)

BOX 2

SUPPLEMENT REVIEW TABLE

PRESENT DSA010 THROUGH DSA040 AS A GRID WHERE EACH ROW CONTAINS THE RELEVANT INFORMATION ABOUT A SUPPLEMENT COLLECTED IN THE HOUSEHOLD INTERVIEW.

(THIS INCLUDES VARIABLES DSQ056, DSQ052, DSQ060S, DSQ066A, DSQ066B AND DSQ071 FROM THE HOUSEHOLD INTERVIEW.)

CONTINUE.

DSA020 {Taken Last 24 Hours}

TEXT 1: The next questions are about {your/SP’s} use of dietary supplements, vitamins, minerals and herbals all day yesterday, {day}, between midnight and midnight. This includes prescription and over the counter dietary supplements. During the interview in your home {you reported taking/it was reported {you/he/she} took} {SUPPLEMENT NAME FROM DSA010.}

TEXT 2: It was also reported {you/SP} took {SUPPLEMENT NAME FROM DSA010}.

Did {you/SP} take this supplement yesterday {day}, (between midnight and midnight)?

[CONTINUE ASKING ABOUT EACH SUPPLEMENT LISTED IN TABLE]

CAPI INSTRUCTION: IF THIS IS THE FIRST SUPPLEMENT BEING REVIEWED, DISPLAY TEXT 1

ELSE DISPLAY TEXT 2.

CAPI INSTRUCTION: IF SP Age > 15 DISPLAY ‘you reported taking’ ELSE DISPLAY ‘it was reported

{you/he/she} took’.

YES 1

NO 2 (BOX 6)

REFUSED 7 (BOX 6)

DON'T KNOW 9 (BOX 6)

BOX 3

IF THE FORM IS KNOWN FROM HOUSEHOLD INTERVIEW QUESTION DSQ077 CONTINUE, ELSE GO TO DSA030.

DSA025 {Form Taken}

Was {SUPPLEMENT NAME FROM DSA010} a {FORM FROM HOUSEHOLD INTERVIEW QUESTION DSQ077}?

YES 1 (DSA030)

NO 2

REFUSED 7 (DSA030)

DON'T KNOW 9 (DSA030)

BOX 4

CHANGE DSA020 TO “NO” AND INSERT A NEW LINE IN THE GRID.

PREFILL DSA020 ON THE NEW LINE TO “YES”.

GO TO DSA010 ON THE NEW LINE.

DSA010 {Supplements}

What is the name of the supplement {you/SP} took?

[PROBES: Record the name. Use name probes.

Multivitamin and/or Multimineral:

What is the brand name?

Did it also include minerals like iron, zinc, or calcium?

Iron only

Was it a special type? {(silver, women’s, men’s, prenatal, liquid)/(chewable, complete, with iron, with

extra C)}

Single/double nutrient:

What is the brand name?

How much (ingredient name) was in it? (or what was the strength of X)

Other supplement type:

Please describe the label name or type of supplement {(fluoride)}

What is the brand name?]

CAPI INSTRUCTION: IF SP IS UNDER 12 YEARS OLD, DISPLAY ‘(chewable, complete, with iron, with extra C)’

ELSE DISPLAY ‘(silver, women’s, men’s, prenatal, liquid)’.

CAPI INSTRUCTION: IF SP IS UNDER 12 YEARS OLD, DISPLAY ‘(fluoride)’.

HARD EDIT: AT LEAST ONE SUPPLEMENT SHOULD BE ENTERED (DSA010 FILLED)

ERROR MESSAGE: “YOU MUST COLLECT INFORMATION FOR AT LEAST ONE SUPPLEMENT OR

BACK UP AND ANSWER “NO” TO DSA001.”

____________________________________

ENTER SUPPLEMENT NAME

REFUSED 7

DON'T KNOW 9

DSA030 {Quantity Taken}

Between midnight and midnight, how much did {you/SP} take?

[ENTER THE NUMBER]

SOFT EDIT: Quantity should be less than 10

Error Message: “YOU SAID YOU TOOK {QUANTITY TAKEN}. IS THAT CORRECT?”

____________________________________

ENTER QUANTITY

REFUSED 7

DON'T KNOW 9

BOX 5

IF THE FORM IS KNOWN FROM HOUSEHOLD INTERVIEW QUESTION DSQ077, PREFILL DSA035 WITH DSQ077 AND GO TO BOX 6, ELSE CONTINUE.

DSA035 {Unit Taken}

OS (Was it a tablet, capsule, pill, caplet, softgel, or something else?)

[SELECT FORM/UNIT]

Tablets, capsules, pills, caplets, softgels,

gelcaps, vegicaps, chewable tablets 1 (BOX 6)

Droppers 2 (BOX 6)

Drops 3 (BOX 6)

Injection/Shots 5 (BOX 6)

Lozenges/Cough Drops 6 (BOX 6)

Milliliters 7

Tablespoons 11

Teaspoons 12

Wafers 13 (BOX 6)

Cans 15

Grams 16

Dots 17 (BOX 6)

Cups 18

Sprays/Squirts 19 (BOX 6)

Chews/Gummies 20 (BOX 6)

Scoops 21

Capfuls 23

Ounces 27

Packages/Packets 28 (BOX 6)

Vials 29 (BOX 6)

Gumballs 30 (BOX 6)

Other form (specify) 91 (BOX 6)

REFUSED 77 (BOX 6)

DON’T KNOW 99 (BOX 6)

DSA040 {Liquid/Powder}

Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 7

DON'T KNOW 9

BOX 6

IF THERE ARE MORE SUPPLEMENTS TO REVIEW, GO TO DSA020 FOR THE NEXT SUPPLEMENT, ELSE CONTINUE.

DSA060 All day yesterday, {day}, between midnight and midnight, did {you/SP} take any other vitamins,

minerals, herbals or other dietary supplements? Include any prescription and over the counter

dietary supplements.

[SHOW SUPPLEMENT HANDCARD]

YES 1

NO 2 (BOX 10)

REFUSED 7 (BOX 10)

DON'T KNOW 9 (BOX 10)

BOX 7

New Supplements Table

PRESENT DSA070 THROUGH DSA115 AS A GRID.

IF THERE WERE SUPPLEMENTS REVIEWED (Supplement Review Table) THEN DISPLAY THOSE VALUES HERE IN THE FIRST ROWS.

CONTINUE.

DSA070 {Supplements}

{What is the name of the supplement {you/SP} took?/Any others?}

{[REPEAT UNTIL ALL SUPPLEMENTS HAVE BEEN REPORTED]}

[PROBES: Record the name. Use name probes.

Multivitamin and/or Multimineral:

What is the brand name?

Did it also include minerals like iron, zinc, or calcium?

Iron only

Was it a special type? {(silver, women’s, men’s, prenatal, liquid)/(chewable, complete, with iron, with

extra C)}

Single/double nutrient:

What is the brand name?

How much (ingredient name) was in it? (or what was the strength of X)

Other supplement type:

Please describe the label name or type of supplement {(fluoride)}

What is the brand name?]

CAPI INSTRUCTION: IF FIRST TIME ON THIS SCREEN, DISPLAY ‘What is the name of the supplement {you/SP} took?’ ELSE DISPLAY ‘Any others? [REPEAT UNTIL ALL SUPPLEMENTS HAVE BEEN REPORTED]’.

CAPI INSTRUCTION: IF SP IS UNDER 12 YEARS OLD, DISPLAY (chewable, complete, with iron, with extra C)

ELSE DISPLAY (silver, women’s, men’s, prenatal, liquid).

CAPI INSTRUCTION: IF SP IS UNDER 12 YEARS OLD, DISPLAY (fluoride).

HARD EDIT: AT LEAST ONE SUPPLEMENT SHOULD BE ENTERED (DSA070 FILLED)

ERROR MESSAGE: “YOU MUST COLLECT INFORMATION FOR AT LEAST ONE SUPPLEMENT OR

BACK UP AND ANSWER “NO” TO DSA060.”

____________________________________

ENTER SUPPLEMENT NAME

REFUSED 7

DON'T KNOW 9

BOX 8

IF SUPPLEMENT NAME ENTERED, CONTINUE

ELSE GO TO BOX 10.

DSA105 {Quantity Taken}

Between midnight and midnight, how much did {you/SP} take?

[ENTER THE NUMBER]

SOFT EDIT: Quantity should be less than 10

Error Message: “YOU SAID YOU TOOK {QUANTITY TAKEN}. IS THAT CORRECT?”

____________________________________

ENTER QUANTITY

REFUSED 7

DON'T KNOW 9

DSA110 {Unit Taken}

OS (Was it a tablet, capsule, pill, caplet, softgel, or something else?)

[SELECT FORM/UNIT]

Tablets, capsules, pills, caplets, softgels,

gelcaps, vegicaps, chewable tablets 1 (BOX 9)

Droppers 2 (BOX 9)

Drops 3 (BOX 9)

Injection/Shots 5 (BOX 9)

Lozenges/Cough Drops 6 (BOX 9)

Milliliters 7

Tablespoons 11

Teaspoons 12

Wafers 13 (BOX 9)

Cans 15

Grams 16

Dots 17 (BOX 9)

Cups 18

Sprays/Squirts 19 (BOX 9)

Chews/Gummies 20 (BOX 9)

Scoops 21

Capfuls 23

Ounces 27

Packages/Packets 28 (BOX 9)

Vials 29 (BOX 9)

Gumballs 30 (BOX 9)

Other form (specify) 91 (BOX 9)

REFUSED 77 (BOX 9)

DON’T KNOW 99 (BOX 9)

DSA115 {Liquid/Powder}

Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 7

DON'T KNOW 9

DSQ.096 For how long {have/has} {you/SP} been taking {PRODUCT NAME} or a similar type of product?

Q/U

CAPI INSTRUCTION:

RESPONSE FIELD SHOULD ALLOW FOR 4 NUMERIC ENTRIES AND INCLUDE A DECIMAL. ALLOW UP TO 3 ENTRIES TO THE LEFT OF THE DECIMAL AND UP TO 1 ENTRY TO THE RIGHT OF THE DECIMAL.

|___|___|___|___|

ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)

REFUSED 777

DON'T KNOW 999

ENTER UNIT

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

REFUSED 7

DON'T KNOW 9

BOX 9

GO TO DSA070 ON NEXT ROW.

BOX 10

IF ANTACIDS COLLECTED IN HOUSEHOLD INTERVIEW, GO TO BOX 11,

ELSE CONTINUE.

DSA005 The next questions are about {your/SP’s} use of non-prescription antacids. All day yesterday, {day}, between midnight and midnight did {you/SP} take any antacids?

[SHOW ANTACID HANDCARD]

YES 1 (BOX 13)

NO .... 2 (BOX 16)

REFUSED…………………………………… 7 (BOX 16)

DON’T KNOW…………………………………. 9 (BOX 16)

BOX 11

Antacid Review Table

PRESENT DSA145 THROUGH DSA165 AS A GRID WHERE EACH ROW CONTAINS THE RELEVANT INFORMATION ABOUT AN ANTACID COLLECTED IN THE HOUSEHOLD INTERVIEW.

(THIS INCLUDES VARIABLES RXQ141, RXQ150S AND RXQ160 FROM THE HOUSEHOLD INTERVIEW.)

CONTINUE.

DSA145 {Taken Last 24 Hours}

TEXT 1: The next questions are about {your/SP’s} use of non-prescription antacids. During the interview in

your home {you reported taking/it was reported {you/he/she} took} {ANTACID NAME}.

TEXT 2: It was also reported {you/SP} took {ANTACID NAME}.

Did you take this antacid yesterday {day}, (between midnight and midnight)?

[CONTINUE ASKING ABOUT EACH ANTACID LISTED IN TABLE]

CAPI INSTRUCTION: IF THIS IS THE FIRST ANTACID BEING REVIEWED, DISPLAY TEXT 1,

ELSE DISPLAY TEXT 2.

CAPI INSTRUCTION: IF SP Age > 15, DISPLAY ‘you reported taking’ ELSE DISPLAY ‘it was reported

{you/he/she} took’.

YES 1

NO 2 (BOX 12)

REFUSED 7 (BOX 12)

DON'T KNOW 9 (BOX 12)

DSA155 {Quantity Taken}

Between midnight and midnight, how much did {you/SP} take?

[ENTER THE NUMBER]

SOFT EDIT: Quantity should be less than 10

Error Message: “YOU SAID YOU TOOK {QUANTITY TAKEN}. IS THAT CORRECT?”

____________________________________

ENTER QUANTITY

REFUSED 7

DON'T KNOW 9

DSA160 {Unit Taken}

OS (Was it a tablet, capsule, pill, caplet, softgel, or something else?)

[SELECT FORM/UNIT]

Tablets, capsules, pills, caplets, softgels,

gelcaps, vegicaps, chewable tablets 1 (BOX 12)

Droppers 2 (BOX 12)

Drops 3 (BOX 12)

Injection/Shots 5 (BOX 12)

Lozenges/Cough Drops 6 (BOX 12)

Milliliters 7

Tablespoons 11

Teaspoons 12

Wafers 13 (BOX 12)

Cans 15

Grams 16

Dots 17 (BOX 12)

Cups 18

Sprays/Squirts 19 (BOX 12)

Chews/Gummies 20 (BOX 12)

Scoops 21

Capfuls 23

Ounces 27

Packages/Packets 28 (BOX 12)

Vials 29 (BOX 12)

Gumballs 30 (BOX 12)

Other form (specify) 91 (BOX 12)

REFUSED 77 (BOX 12)

DON’T KNOW 99 (BOX 12)

DSA165 {Liquid/Powder}

Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 7

DON'T KNOW 9

BOX 12

IF THERE ARE MORE ANTACIDS TO REVIEW, GO TO DSA145 FOR THE NEXT ANTACID, ELSE CONTINUE.

DSA065 All day yesterday, {day}, between midnight and midnight, did {you/SP} take any other antacids?

[SHOW ANTACID HANDCARD]

YES 1

NO 2 (BOX 16)

REFUSED 7 (BOX 16)

DON'T KNOW 9 (BOX 16)

BOX 13

New Antacids Table

PRESENT DSA170 THROUGH DSA215 AS A GRID.

IF THERE WERE ANTACIDS REVIEWED (Antacid Review Table), THEN DISPLAY THOSE VALUES HERE IN THE FIRST ROWS.

CONTINUE.

DSA170 {Antacids}

{What is the name of the antacid {you/SP} took?/Any others?}

{[REPEAT UNTIL ALL ANTACIDS HAVE BEEN REPORTED]}

[PROBES: What is the brand name? Was it extra strength, regular strength, ultra, maximum strength?]

[IF ANTACID NOT ON LIST, TYPE “**Product not on list”]

CAPI INSTRUCTION: IF FIRST TIME ON THIS SCREEN, DISPLAY ‘What is the name of the antacid {you/SP} took’

ELSE DISPLAY ‘Any others? [REPEAT UNTIL ALL ANTACIDS HAVE BEEN REPORTED]’.

HARD EDIT: AT LEAST ONE ANTACID SHOULD BE ENTERED (DSA170 FILLED)

ERROR MESSAGE: “YOU MUST COLLECT INFORMATION FOR AT LEAST ONE ANTACID OR

BACK UP AND ANSWER “NO” TO {DSA005/DSA065.}”

CAPI INSTRUCTION: IF ANTACIDS WAS COLLECTED IN HOUSEHOLD INTERVIEW, DISPLAY

“DSA065”; OTHERWISE DISPLAY “DSA005”.

____________________________________

ENTER ANTACID NAME

REFUSED 7

DON'T KNOW 9

BOX 14

IF ANTACID ENTERED, CONTINUE, ELSE GO TO BOX 16.

DSA175 {Pick List}

{What is the name of the antacid {you/SP} took?/Any others?}

{[REPEAT UNTIL ALL ANTACIDS HAVE BEEN REPORTED]}

[PROBES: What is the brand name? Was it extra strength, regular strength, ultra, maximum strength?]

[IF ANTACID NOT ON LIST, TYPE “**Product not on list”]

CAPI INSTRUCTION: IF FIRST TIME ON THIS SCREEN, DISPLAY ‘What is the name of the antacid {you/SP} took’

ELSE DISPLAY ‘Any others? [REPEAT UNTIL ALL ANTACIDS HAVE BEEN REPORTED]’.

____________________________________

ENTER ANTACID NAME FROM LIST OR

ENTER”**PRODUCT NOT ON LIST”

REFUSED 7

DON'T KNOW 9

DSA205 {Quantity Taken}

Between midnight and midnight, how much did {you/SP} take?

[ENTER THE NUMBER]

SOFT EDIT: Quantity should be less than 10

Error Message: “YOU SAID YOU TOOK {QUANTITY TAKEN}. IS THAT CORRECT?”

____________________________________

ENTER QUANTITY

REFUSED 7

DON'T KNOW 9

DSA210 {Unit Taken}

OS (Was it a tablet, capsule, pill, caplet, softgel, or something else?)

[SELECT FORM/UNIT]

Tablets, capsules, pills, caplets, softgels,

gelcaps, vegicaps, chewable tablets 1 (BOX 15)

Droppers 2 (BOX 15)

Drops 3 (BOX 15)

Injection/Shots 5 (BOX 15)

Lozenges/Cough Drops 6 (BOX 15)

Milliliters 7

Tablespoons 11

Teaspoons 12

Wafers 13 (BOX 15)

Cans 15

Grams 16

Dots 17 (BOX 15)

Cups 18

Sprays/Squirts 19 (BOX 15)

Chews/Gummies 20 (BOX 15)

Scoops 21

Capfuls 23

Ounces 27

Packages/Packets 28 (BOX 15)

Vials 29 (BOX 15)

Gumballs 30 (BOX 15)

Other form (specify) 91 (BOX 15)

REFUSED 77 (BOX 15)

DON’T KNOW 99 (BOX 15)

DSA215 {Liquid/Powder}

Was that a liquid or powder?

LIQUID 1

POWDER 2

REFUSED 7

DON'T KNOW 9

BOX 15

GO TO DSA170 ON NEXT ROW.

BOX 16

END

MEC DATA COLLECTION FORMS

Anthropometry

Audiometry (Includes Words-In-Noise)

Balance

Cognitive Function

Dual X-Ray Absorptiometry

Body Composition

Osteoporosis (DXA)

Oral Health

HPV swab collection

Physician Examination

Urine collection

Venipuncture

Hepatic (liver) Steatosis and Fibrosis Ultrasound Elastography form

*No data collection forms for urine collections and HPV swabs

ANTHROPOMETRY

NHANES 2019-2020 (All ages)

AMPUTATION QUESTIONS: Information is recorded during the body measurement examination for all ages. Questions may be asked if the information is not obvious to the examiner. The responses are used to interpret body measurement results, particularly the body weight data.

Are there any amputations? Recorder codes YES/NO IF YES to the amputation question, continue with information on the site(s) of the amputation(s):

Target Age Groups: Anthropometry Measurements and Questions

Birth+	2mo+	2yr+	8yr+	12yr+
Weight	Weight	Weight	Weight	Weight
Recumbent length	Recumbent length	Recumbent length (through 47 mos.)
Head circumference	Head circumference (through 6 mos.)
		Standing height	Standing height	Standing height
	Upper arm length	Upper arm length	Upper arm length	Upper arm length
	Mid-upper arm circumference	Mid-upper arm circumference	Mid-upper arm circumference	Mid-upper arm circumference
		Waist circumference	Waist circumference	Waist circumference
				Hip circumference
			Upper leg length	Upper leg length

Would you like to know your height and weight?	Would you like to know your height and weight?	Would you like to know your height and weight?	Would you like to know your height and weight?	Would you like to know your height and weight?

AUDIOMETRY

NHANES 2019-2020 (6-19 or 70+years)

Tech. No. _____________ SP No. _____________

PRE-EXAM QUESTIONNAIRE (CONDITIONA AFFECTING TEST RESULTS)

Child age 6-11 years version:

Do you now have a tube in your right or left ear? (If yes indicate affected ear[s])

 Yes, Right ear

 Yes, Left ear

 Yes, Both ears

 No

 Refused

 Don’t Know

Do you had a cold, runny nose or earache today?

 Yes (4)

 No (3)

 Refused (3)

 Don’t Know (3)

Do you had a cold, runny nose, or earache yesterday?

 Yes (4)

 No (5)

 Refused (5)

 Don’t Know (5)

Which have you had (check all that apply)?

 Cold

 Sinus problem

 Earache, right ear

 Earache, left ear

 Earache, both ears

Have you listened to sounds today that were so loud you would have to shout so someone close by could hear you?

 Yes (7)

 No (6)

 Refused (6)

 Don’t Know (6)

Did you listen to any sounds that were that loud yesterday?

 Yes (7)

 No (8)

 Refused (8)

 Don’t Know (8)

When was that?

|__|__| # hours

 Refused

 Don’t Know

Have you listened to music with earphones today?

 Yes (10)

 No (9)

 Refused (9)

 Don’t Know (9)

Did you listen to music with earphones yesterday?

 Yes (10)

 No (11)

 Refused (11)

 Don’t Know (11)

When was that?

|__|__| # hours

 Refused

 Don’t Know

Is it easier for you to hear out of one ear than the other?

 Yes, Right ear

 Yes, Left ear

 Refused

 No/Don’t Know

Adolescent (age 12-19 years) and adult (age 70+ years) version:

Do you now have a tube in your right or left ear? (If yes indicate affected ear[s])

 Yes, Right ear

 Yes, Left ear

 Yes, Both ears

 No

 Refused

 Don’t Know

Have you had a cold, sinus problem, or earache in the last 24 hours?

 Yes (3)

 No (4)

 Refused (4)

 Don’t Know (4)

Which have you had (check all that apply)?

 Cold

 Sinus problem

 Earache, right ear

 Earache, left ear

 Earache, both ears

In the past 24 hours, have you been exposed to noise so loud that you would have had to raise your voice to speak to someone an arm’s length away?

 Yes (5)

 No (6)

 Refused (6)

 Don’t Know (6)

How many hours ago did the noise end?

|__|__| # hours

 Refused

 Don’t Know

In the past 24 hours, have you listened to music with earphone?

 Yes (7)

 No (8)

 Refused (8)

 Don’t Know (8)

How many hours ago did you stop listening?

|__|__| # hours

 Refused

 Don’t Know

Do you hear better in one ear than the other?

 Yes, Right ear

 Yes, Left ear

 Refused

 No/Don’t Know

Adult (age 70+ years) only:

Is English {Spanish} the first language you learned to speak?

 Yes

 No (2)

 Refused

 Don’t Know

How old were you when you began to speak English {Spanish} fluently?

|__|__| Age in years

 Refused

 Don’t Know

Fluently means able to understand speech easily and with few mistakes.

OTOSCOPY EXAM

Left Ear

 Normal

 Excessive cerumen*

 Impacted cerumen*

 Collapsing ear canal*

 Other abnormality (comment)*

Right Ear

 Normal

 Excessive cerumen*

 Impacted cerumen*

 Collapsing ear canal*

 Other abnormality (comment)*

Excessive cerumen, impacted cerumen, and/or other abnormality preclude the use of insert earphone during audiometry.

Collapsing ear canal requires the use of insert earphones during audiometry.

Impacted cerumen, and/or other abnormality need the standard physician observation.

MIDDLE EAR TESTING (THREE TESTS)

Left Ear

 Complete

 Partial

(Check tests with partial or missing results)

 Tympanometry

 Wideband reflectance

 Acoustic reflex threshold

 Could Not Obtain

 SP Refusal

Right Ear

 Complete

 Partial

(Check tests with partial or missing results)

 Tympanometry

 Wideband reflectance

 Acoustic reflex threshold

 Could Not Obtain

 SP Refusal

Middle ear analyzer runs each test automatically. If either the tympanogram or the wideband reflectance are unacceptable, or if all or part of the acoustic reflex results are missing, rerun that test once to obtain a better result.

PURE TONE AUDIOMETRY
	START HERE IF SP NUMBER ODD OR SP HEARS BETTER IN LEFT EAR			START HERE IF SP NUMBER EVEN OR SP HEARS BETTER IN RIGHT EAR
	LEFT EAR			RIGHT EAR
Frequency (Hz)	Threshold (dB)	Retest Threshold (dB)	Could Not Obtain	Threshold (dB)	*Retest Threshold (dB)	Could Not Obtain
1000
500
1000
2000
3000
4000
6000
8000
RESULTS OF AUDIOMETRY  Complete  Partially  Not done REASONS PARTIAL OR NOT DONE  Safety exclusion  Physical limitation  SP refusal  SP ill/emergency  Out of time  Equipment failure  Communication problem  Other (specify):______

WORDS-IN-NOISE TEST (ADULT AGE 70+ YEARS)

Left Ear

Test Level

 Soft

 Loud

Test Result

__|__ Raw Score

__|__ Threshold

 Could Not Obtain

Right Ear

Test Level

 Soft

 Loud

Test Result

__|__ Raw Score

__|__ Threshold

 Could Not Obtain

RESULTS OF WORDS-IN-NOISE

 Complete

 Partially

 Not done

REASONS PARTIAL OR NOT DONE

 Safety exclusion

 Physical limitation

 SP refusal

 SP ill/emergency

 Out of time

 Equipment failure

 Communication problem

 Other (specify):______

Standing Balance (ages 40+)

Exclusion Criteria

Participants will be excluded from the Modified Romberg Balance Test (MRT) if:

pregnant (either by self-report or ERB-approved lab test in the MEC (Safety exclusion)
weigh more than 315 pounds, since the foam used to stand on during the test may become too compressed to provide a suitable surface (Test protocol exclusion);
unable to stand on their own (Safety exclusion);
has an amputation of the leg or feet (other than toes) (Test protocol exclusion);
has a prosthetic device below the waist (Test protocol exclusion);
wearing shoes with heals 3 inches or more (Test protocol exclusion)
has a body size either too small or too large to accommodate proper fitting of the safety harness (Safety exclusion);
has experiencing BOTH current symptoms of dizziness, lightheadedness or presyncope AND has fallen in the past 12 months because of problems with dizziness or balance (Safety exclusion);
recovering from a recent injury to their legs (Safety exclusion);
has vision so poor they need assistance to find their way to the test room (Test protocol exclusion).

Participants will be excluded only from Condition 5 of the MRT if the participant:

currently has neck pain, has ever had neck surgery, or has ever had a neck problem that lasted more than six weeks (Safety exclusion);
cannot move their head and neck comfortably in the range of motion required for this condition (Safety exclusion);
has a cochlear implant. (Test protocol exclusion)

Participants will be excluded from the second part of the DVA test (i.e. involving head rotation) if the participant:

is pregnant (either by self-report or lab testing in the MEC (Safety exclusion);
reports that they currently have neck pain, have ever had neck surgery, or have ever had a neck problem that lasted more than six weeks? (Safety exclusion);
cannot move their head and neck comfortably in the range of motion required for this condition (Safety exclusion);
has contrast sensitivity less than 30% (Test protocol exclusion);
has measured binocular static visual acuity (with corrected lenses as needed) worse than 20/125. This situation causes ceiling effect for the exam findings when measuring the difference between static and dynamic visual acuity. (Test protocol exclusion)

Exclusions from one test in the balance component will not automatically affect participation in the other tests, unless it is a mutual exclusion, such as neck problems. If any participant, provides an unsolicited comment, prior to this exam, that s/he is currently dizzy or lightheaded then that person is immediately referred to the MEC physician for evaluation. If a person becomes dizzy during one of the balance exam components, that exam will be halted; it will be noted in the record; and the person will be instructed to sit on a chair (without wheels) until s/he is now longer dizzy or lightheaded. If the person feels s/he needs to be seen by the MEC physician, the health tech will immediately refer the participant to the MEC physician; otherwise the person can proceed with their remaining MEC components.

P articipants will stand with their feet together and their arms crossed at their waist, holding their elbows (see Figure 1). Participants will hold that stance for as long as they can under five separate conditions to a maximum of 15 seconds for condition 1 - 2 and 30 seconds for conditions 3 - 5):

Condition 1: Firm surface (no pad), eyes open

Condition 2: Firm surface (no pad), eyes closed

Condition 3: Compliant surface (foam pad), eyes open

Shape2

Figure 1: Stance for modified Romberg test

Condition 4: Compliant surface (foam pad), eyes closed

Condition 5: Compliant surface (foam pad), eyes closed,

head moving side to side at 3 Hz

Contrast Sensitivity Test (CST)

Cutoffs for Contrast Sensitivity testing

Findings will be considered

Normal if

40-60 years old and score is: (1.72 or higher)

>60 years old and score is: (1.52 or higher)

Below normal if

40 - 60 years old and score is: < 1.72

>60 years old and score is: < 1.52

SOURCE: The Mars Perceptrix Corporation: www.marsperceptix.com

Below are examples that show different levels of darkness of the numbers.

Dynamic Visual Acuity (DVA) Test

Protocol

Participants will sit at a set distance of 6 feet away from a computer monitor. Participants will wear a head-mounted device (similar to that shown in Figure 1) which will monitor speed of head movement during the dynamic portion of the test.

We plan to ask participants to identify optotypes (i.e., tumbling Cs) displayed in the center of a computer screen. The participant will be given two practice trials, with the C’s displayed at a size equivalent to 20/400 vision (1.00 logMAR), to ensure that s/he understands the test instructions. If the participant does not perform the task correctly, the health technician will provide the instructions again, and the participant will repeat a practice trial with two tumbling C’s. If the participants still cannot perform the task, s/he will be excluded from DVA testing.

Shape3

Figure 1: Example headband for DVA test

COGNITIVE FUNCTIONING (MOCA-SA)

Target Group: SPs 60+

The next questions are about problem solving and memory. The questions may seem unusual, but they are routine questions we ask everyone. Some of the questions are very easy and some are difficult, so don’t be surprised if you have trouble with some of them. Try your best to answer all of the questions without using clues from around the room. If you wear glasses for reading, please use them.

IF THE SP USUALLY WEARS READING GLASSES, ASK HIM/HER TO USE THEM FOR THE TEST.

IF THE SP DOES NOT HAVE HIS/HER GLASSES AVAILABLE, GIVE THE SP A PAIR OF OUR SAMPLE GLASSES.

CFQ.NEW1 Tell me the date today. First, tell me the month.

THE CURRENT MONTH IS {DISPLAY CURRENT MONTH}.

INCORRECT 0

CORRECT 1

CFQ.NEW2 Now, tell me the exact date.

CFQ.NEW3 Now, I want you to name this animal.

SHOW PICTURE #1

CFQ.NEW4 The next few things I will ask you to do are pencil and paper tasks.

PLACE BLANK CLOCK PAPER AND PENCIL BEFORE RESPONDENT.

Now, I'd like you to draw a clock. Put in all the numbers and set the time to 10 after 11.

(PROMPT IF NECESSARY: Try your best to complete this task without using clues from around the room, such as a clock or a watch.)

(CHECK ALL THAT APPLY)

DID NOT LOOK AT WATCH OR PHONE 0

LOOKED AT WATCH OR PHONE 1

ISIS INSTRUCTION: TRANSFER RESPONSE TO SCREEN 3 OF THE SCORING APPLICATION.

CFQ.NEW4A SCORE CLOCK CONTOUR

THE CLOCK FACE MUST BE A CIRCLE WITH ONLY MINOR DISTORTION ACCEPTABLE (E.G. SLIGHT IMPERFECTION ON CLOSING THE CIRCLE).

INCORRECT 0

CORRECT 1

CFQ.NEW5 PLACE TRAIL PAPER AND PENCIL BEFORE RESPONDENT

Take a minute to look over the paper. Notice, there are both numbers and letters. Please draw a line, going from a number to a letter in increasing order.

Begin here (POINT TO 1), and draw a line from 1 to A, then from A to 2, and so on. End here (POINT TO E). The first two lines have been drawn for you.

NO CORRECTIONS MADE 0

IMMEDIATELY SELF-CORRECTED MISTAKES 1

DID NOT IMMEDIATELY SELF-CORRECT MISTAKES 2

ISIS INSTRUCTION: TRANSFER RESPONSE TO SCREEN 5 OF THE SCORING APPLICATION.

CFQ.NEW6 This next section tests your memory. I am going to read a list of words that you will have to remember now and later on. Listen carefully. When I am through, tell me as many words as you can remember. It doesn’t matter in what order you say them. Ready?

READ SLOWLY (AT A RATE OF 1 WORD PER SECOND) AND PRONOUNCE CLEARLY: Face, Velvet, Church, Daisy, Red

(PROMPT: Tell me as many words as you remember.)

CFQ.NEW7 I'm going to read the same list for a second time. Try to remember and tell me as many words as you can, including words you said the first time.

READ SLOWLY (AT A RATE OF 1 WORD PER SECOND) AND PRONOUNCE CLEARLY: Face, Velvet, Church, Daisy, Red

(PROMPT: Tell me as many words as you remember.)

WHEN THE TEST IS COMPLETE SAY: I will ask you to recall these words again later on.

CFQ.NEW8 Now, I am going to say some numbers and when I am through, repeat them to me exactly as I said them.

READ THE FIVE NUMBER SEQUENCE TO THE RESPONDENT AT A RATE OF ONE DIGIT PER SECOND.

2, 1, 8, 5, 4

(PROMPT: Repeat the numbers exactly as I said them.)

CFQ.NEW9 Now I am going to say some more numbers, but when I am through, I want you to repeat them to me in the backwards order.

READ THE THREE NUMBER SEQUENCE TO THE RESPONDENT AT A RATE OF ONE DIGIT PER SECOND.

7, 4, 2

(PROMPT: Repeat the numbers in backward order)

CFQ.NEW10 Now, starting with 100, I would like you to subtract 7 and then keep counting down by 7.

(YOU CAN REPEAT THESE INSTRUCTIONS IF NECESSARY.)

PRESS ‘START/STOP’ ON COMPUTER TIMER. STOP AFTER 6 NUMBERS.

WHEN R FINISHED, PRESS ‘STOP/START’ ON COMPUTER TIMER.

ISIS INSTRUCTION: TIMER ON SCREEN SHOULD COUNT UP IN SECONDS.

RECORD NUMBER OF SECONDS: | __|_ _|_ _|

CFQ.NEW11 I am going to read you a sentence. Repeat it after me, exactly as I say it. (PAUSE)

READ SENTENCE: The cat always hid under the couch when dogs were in the room.

(PROMPT: Repeat the sentence.)

CFQ.NEW12 Tell me as many words as you can think of that begin with a certain letter of the alphabet that I will tell you in a moment. You can say any kind of word you want, except for proper nouns and names like Bob or Boston, and numbers or words that begin with the same sound, but have a different ending, for example, love, lover, loving. I will tell you to stop after 1 minute. I will record your answers in this booklet. Are you ready?

WHEN R IS READY: Now, tell me as many words as you can think of that begin with the letter F.

ISIS INSTRUCTION: ONE MINUTE TIMER ON SCREEN SHOULD COUNT DOWN.

CFQ.NEW13 For this exercise, tell me how an orange and a banana are alike.

IF THE SUBJECT ANSWERS IN A CONCRETE MANNER, THEN SAY ONLY ONE ADDITIONAL TIME: “Tell me another way in which those items are alike.”

IF THE SUBJECT DOES NOT GIVE THE APPROPRIATE RESPONSE (FRUIT), SAY: "Yes, and they are also both fruit." DO NOT GIVE ANY ADDITIONAL INSTRUCTIONS OR CLARIFICATION.

Now, tell me how a ruler and a watch are alike?

DO NOT GIVE ANY ADDITIONAL INSTRUCTIONS OR PROMPTS.

CFQ.NEW14 I read a list of words to you earlier, which I asked you to repeat and remember. Tell me as many of those words as you can remember. It doesn’t matter in what order you say them.

CFQ.NEW15 POST TEST COMMENTS (REPORTED BY SP OR OBSERVED BY INTERVIEWER)

(CHECK ALL THAT APPLY)

NO NOTES 0

HEARING PROBLEM 1

VISION PROBLEMS 2

PHYSICAL LIMITATION AFFECTING ABILITY TO WRITE/DRAW (SPECIFY) 3

UNABLE TO READ AND/OR WRITE 4

DIFFICULTLY WITH ENGLISH/LANGUAGE BARRIER 5

SP REPORTED COGNITIVE PROBLEM (SPECIFY) 6

SP REPORTED TAKING MEDICATIONS (MAY AFFECT PERFORMANCE) 7

SP WAS RESTLESS OR FIDGETY………………………………………….8

SP REPORTED WANTING TO QUIT……………………………………….9

INTERRUPTIONS/DISTRACTIONS (SPECIFY) 10

OTHER (SPECIFY) 11

Dual X-Ray Absorptiometry (whole body)

Body Composition (Ages 8-59 years)

Excluded from scan if body weight is over 450 pounds or if yes to one of the following items;

1. Do you have any amputations of your legs and feet other than toes?

2. Are you currently pregnant?

3. Have you had a medical test with contrast material such as dyes or barium in the last 7 days?

Whole Body Tissue Information:

Total Body Tissue grams

Bone Mineral Content grams

Fat grams

Lean Mass grams

Lean Mass + Bone Mineral Content grams

Percent fat %

Values for each of the variables listed above will be given for the following regions:

Head

Left Arm

Right Arm

Trunk

Left Leg

Right Leg

Subtotal

Total

Whole Body Bone Information:

Area cm²

Bone Mineral Content grams

Bone Mineral Density grams/cm²

Values for each of the variables listed above will be given for the following regions:

Head

Left Arm

Right Arm

Left Ribs

Right Ribs

Thoracic Spine

Lumbar Spine

Pelvis

Left Leg

Right Leg

Dual X-Ray Absorptiometry (femur and spine)

Osteoporosis,

(Ages 50 and older)

Excluded from femur or spine scans if body weight is over 450 pounds or if yes to one of the following items;

1. Are you currently pregnant?

2. Have you had a medical test with contrast material such as dyes or barium in the last 7 days?

3. Have you fractured both hips, had replacements of both hips, or have pins in both hips? (exclusion for femur scan)

4. Do you have a Harrington rod in your spine? (exclusion for spine scans)

Femur and Lumbar Spine Information:

Area cm²

Bone Mineral Content grams

Bone Mineral Density grams/cm²

Values for each of the variables listed above will be given for the following femur regions:

Femoral Neck

Trochanter

Intertrochanter

Ward’s Triangle

Total

Values for each of the variables listed above and Trabecular bone score will be given for the following lumbar spine regions:

Vertebrae 1-4

Total

ORAL HEALTH

NHANES 2017-2018 (Ages 1 and older)

Medical Exclusion Questions (Ages 30 and older)

All adults aged 30 years and older will be eligible for the health screening questions. A positive response to any one of these 4 questions will result in an individual being EXCLUDED from the periodontal examination:

1. Have you had a heart transplant?

2. Do you have an artificial heart valve?

3. Have you had heart disease since birth?

4. Have you had a bacterial infection of the heart, also called Bacterial?

Endocarditis?

Oral Health Examination (Ages 1 and older)

1+ years	3-19 years	30 years and older
Tooth count
Dental Caries
	Dental Sealants
		Medical History Screening
		Periodontal Exam

Miscellaneous / Report of Findings

PHYSICIAN EXAMINATION

NHANES 2017-2018 (All ages)

Blood Pressure (ages 8 years and older)*

Have you had any of the following in the past 30 minutes? (food, coffee, alcohol, cigarettes) Check all that apply:

Arm selected Right/left/Could not obtain

Cuff size selected Infant/Child/Adult/Large Arm/Thigh

Heart Rate/Pulse Beats per minute

Pulse type

Radial/Brachial

Maximum Inflation Level mm Hg

Systolic Blood Pressure (Readings 1,2,3) mm Hg

Diastolic Blood Pressure (Readings 1,2,3) mm Hg

Average Blood Pressure mm Hg (mean of last 2 measurements will be used)

VENIPUNCTURE

NHANES 2017-2018 (Ages 1 year and older)

SP ID______________ Tech ID_______________

Pre venipuncture questions (Q1 asked if female participant ages 12-59 and younger if participant has reported starting menstruating. –Q2 – Q9 are asked of all participants or parent/guardian ages 1+)-

Q1. Are you currently pregnant?

Pregnancy Status

⁪Positive

⁪Negative

⁪ Don’t know

Q2. Do you have hemophilia?

⁪Yes (Venipuncture will not be conducted)

⁪No

⁪Refused

⁪Don’t know

Q3. Have you received cancer chemotherapy in the past four weeks?

⁪Yes(Venipuncture will not be conducted)

⁪No

⁪Refused

⁪Don’t know

Q4. When was the last time you ate or drank anything other than plain water? Do not include diet soda or black coffee with artificial sweetener like Sweet’N Low, Nutrasweet, Equal, or Splenda

HH:MM (AM PM ) MMDDYY

Have you had any of the following since [HH:MM (AM PM) MMDDYY {from Q4}] for Q5-

Q5. Coffee or teawith cream or sugar? [Include milk or non-dairy creamers]

YES HH:MM (AM PM ) MMDDYY

Q6. Alcohol, such as beer, wine or liquor?

YES HH:MM (AM PM ) MMDDYY

Q7. Gum, breath mints, lozenges, or cough drops or other cough or cold remedies?

YES HH:MM (AM PM ) MMDDYY

Q8. Antacids. Laxatives or anti-diarrheals?

YES HH:MM (AM PM ) MMDDYY

Q9. Dietary supplements such as vitamins and minerals? [Include multivitamins and single nutrient supplements]

YES HH:MM (AM PM ) MMDDYY

⁪Don’t know

RESULTS STATUS OF VENIPUNCTURE

⁪Testomplete

⁪Test partially complete

⁪Test not done

REASONS TEST INCOMPLETE OR NOT DONE

⁪Safety exclusion

⁪ SP refusal

⁪ No time

⁪Physical limitation

⁪

⁪SP ill/emergency

⁪Equipment failure

⁪Communication problem

⁪ Interrupted

⁪ Error (technician, software, supply)

⁪ Other, specify

⁪ No suitable vein

⁪ Vein collapsed

⁪ SP not feeling well

⁪ Fainting episode

⁪ No tubes drawn

⁪ Language barrier

Hepatic (liver) Steatosis and Fibrosis Ultrasound Elastography form

NHANES 2017-2018 (ages 12 year and older; participants are asked to fast)

SP ID______________ Tech ID_______________

HEPATIC (liver) STEATOSIS TEST RESULTS

⁪Test complete Yes No

⁪Test result for median controlled attenuation parameter (CAP™) ____ decibel per meter, (dB/m)

REASONS TEST INCOMPLETE OR NOT DONE

⁪Physical limitation

⁪SP refusal

⁪SP ill/emergency

⁪Out of time

⁪Equipment failure

⁪Communication problem

HEPATIC (liver) FIBROSIS TEST RESULTS

⁪Test complete Yes No

⁪Test result for median Young’s Modulus (E) __________ kilopascals

REASONS TEST INCOMPLETE OR NOT DONE

⁪Physical limitation

⁪SP refusal

⁪SP ill/emergency

⁪Out of time

⁪Equipment failure

⁪Communication problem

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	2009 Dried Blood Spot Methodology Study – Phase I
Author	Brenda Lewis
File Modified	0000-00-00
File Created	2021-05-01