Paper screener using Roster Method

Attachment E.4a

Paper Screener Using Roster Method

Health and Injury Survey

Form Approved
OMB No: 0920-0822
Exp. Date: xx/xx/xxxx

Public Reporting burden of this collection of information is estimated to average 3 minutes per person, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-0822).

Start Here

► These first questions are about your home and access to internet services. This helps us understand the types of households we contact.

1. Is this house, apartment, or mobile home…

Mark one only.

• Owned by you or someone in this household with a mortgage or loan? Include home equity loans.

• Owned by you or someone in this household free and clear (without a mortgage or loan)?

• Rented?

• Occupied without payment of rent?

2. Do you or any member of this household have access to the Internet using a…

Yes No

1. cellular data plan for a
   smartphone or other  
   mobile device?

2. broadband (high speed)
   Internet service such as  
   cable, fiber optic, or DSL
   service installed here?

3. Satellite Internet service  
   installed here?

4. Dial-up Internet service  
   installed here?

5. some other Internet  
   service?

► This next question asks about an injury that may have occurred in the past three months.

3. {During the past three months, did any person 18 years and older in this household have an injury where any part of the body was hurt, for example, with a
<RANDOM INJURY EXAMPLE, FULL QUEX WILL BE FILL OF THIS MAX LENGTH>?}

• Yes

• No

4. Does a physical, mental, or emotional problem now keep any person 18 years and older in this household from working at a job or business?

• Yes

• No

► The next questions ask about health and other activities that may have occurred in the past twelve months.

5. Has any person 18 years or older in this household been hospitalized overnight in the past 12 months? Do not include an overnight stay in the emergency room.

• Yes

• No

*6. Has any person 18 years or older, in this household, seen a doctor or other healthcare provider in the past 12 months?

• Yes

• No

*7. Has any person 18 years or older, in this household, gone to a hospital emergency room, or urgent care clinic for emergency care in the past 12 months?

• Yes

• No

*8. Has any person 18 years or older, in this household, attended any counseling or therapy session in the past 12 months?

• Yes

• No

*9. Has any person 18 years or older, in this household, been involved in a motor vehicle accident in the past 12 months?

• Yes

• No

*10. Has any person 18 years or older, in this household, had contact with police for any reason in the past 12 months?

• Yes

• No

Adults Living Here

11. Including yourself, how many members of this household are 18 years of age or older?

|__|__| number 18 years old or older

*12. How many of these adults are male?

|__|__| number male

*13. How many of these adults are female?

|__|__| number female

► Please complete the remainder of this survey for each adult in this household starting on the next page. This information will help us determine who will be selected to complete the next step of this important study.

► Answer the following questions for all adults who currently live at this address, age 18 years or older. Include yourself as Adult 1.

Adult 1 (You)

1. What is your first name, initials or nickname?

|__|__|__|__|__|__|__|__|__|__|

2. How old are you?

|__|__|

3. Are you…

• Male

• Female

• Transgender

*4. Are you currently…

• Married

• Divorced

• Separated

• Widowed

• Not married, but living with a partner

• Never married

• Something else

► If you indicated more adults live at this address, continue answering about the next adult; otherwise, return this form in the postage-paid envelope.

Adult 2

1. What is this person’s first name, initials or nickname?

|__|__|__|__|__|__|__|__|__|__|

2. How old is this person?

|__|__|

3. Is this person…

• Male

• Female

• Transgender

*4. Are they currently…

• Married

• Divorced

• Separated

• Widowed

• Not married, but living with a partner

• Never married

• Something else

► If you indicated more adults live at this address, continue answering about the next adult; otherwise, return this form in the postage-paid envelope.

Adult 3

1. What is this person’s first name, initials or nickname?

|__|__|__|__|__|__|__|__|__|__|

2. How old is this person?

|__|__|

3. Is this person…

• Male

• Female

• Transgender

*4. Are they currently…

• Married

• Divorced

• Separated

• Widowed

• Not married, but living with a partner

• Never married

• Something else

► If you indicated more adults live at this address, continue answering about the next adult; otherwise, return this form in the postage-paid envelope.

Adult 4

1. What is this person’s first name, initials or nickname?

|__|__|__|__|__|__|__|__|__|__|

2. How old is this person?

|__|__|

3. Is this person…

• Male

• Female

• Transgender

*4. Are they currently…

• Married

• Divorced

• Separated

• Widowed

• Not married, but living with a partner

• Never married

• Something else

► Thank you. Please return this form in the postage-paid envelope.

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