Crosswalk of changes requested 04JUN2021

Non_Sub Change Crosswalk 04JUN2021.docx

Extended Evaluation of the National Tobacco Prevention and Control Public Education Campaign

Crosswalk of changes requested 04JUN2021

OMB: 0920-1083

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Attachment K: Crosswalk of Non-Substantive Questionnaire Changes, 2020 to 2023 NTEC, OMB #0920-1083

Type of change code: M = Modification

Type of Change

Current Question/Item

Requested Change

M

C5 [Grid, S Across]

When you last tried to quit smoking, did any of the following motivate you to try to quit?

Statements in row:

C5_1. A family member or friend encouraged me to try to quit

C5_2. Anti-tobacco television commercials, online ads or videos, radio ads, or other types of advertisements that focus on the health consequences of smoking

C5_3. My doctor or other health professional advised me to quit smoking

C5_4. Workplace restrictions on smoking

C5_5. Cost of cigarettes is too high

C5_6. Other, please specify: [O] _____

C5 smoker survey); NB5 (nonsmoker survey)

When you last tried to quit smoking, did any of the following motivate you to try to quit?

Statements in row:

C5_1. A family member or friend encouraged me to try to quit

C5_2. Anti-tobacco television commercials, online ads or videos, radio ads, or other types of advertisements that focus on the health consequences of smoking

C5_3. My doctor or other health professional advised me to quit smoking

C5_4. Workplace restrictions on smoking

C5_5. Cost of cigarettes is too high

C5_6. Concern about COVID-19

C5_7. Other, please specify: [O] _____

M

D21 Smoker Survey/ NC1 Nonsmoker Suvey [GRID, S ACROSS]

Do you believe cigarette smoking is related to:


Statements in row (randomize and record response order):

D21_1. Lung Cancer

D21_2. Cancer of the mouth or throat

D21_3. Heart Disease

D21_4. Diabetes

D21_5. Emphysema

D21_6. Stroke

D21_7. Hole in throat (stoma or tracheotomy)

D21_8. Buerger’s Disease

D21_9. Amputations (removal of limbs)

D21_10. Asthma

D21_11. Gallstones

D21_12. COPD or Chronic bronchitis

D21_13. Periodontal or Gum Disease

D21_14. Premature birth

D21_15. Colorectal Cancer

D21_16. Macular degeneration or blindness

D21_17. Depression

D21_18. Anxiety Disorder

D21_19. Colon Cancer


Answers in columns:

1. Yes

2. No


D21 (smoker survey); NC1 (nonsmoker surveyDo you believe cigarette smoking is related to:


Statements in row (randomize and record response order):

D21_1. Lung Cancer

D21_2. Cancer of the mouth or throat

D21_3. Heart Disease

D21_4. Diabetes

D21_5. Emphysema

D21_6. Stroke

D21_7. Hole in throat (stoma or tracheotomy)

D21_8. Buerger’s Disease

D21_9. Amputations (removal of limbs)

D21_10. Asthma

D21_11. Gallstones

D21_12. COPD or Chronic bronchitis

D21_13. Periodontal or Gum Disease

D21_14. Premature birth

D21_15. Colorectal Cancer

D21_16. Macular degeneration or blindness

D21_17. Depression

D21_18. Anxiety Disorder

D21_19. Colon Cancer

D21_20. COVID-19


Answers in columns:

1. Yes

2. No


M

G15. Have you been diagnosed by a physician or other qualified medical professional with any of the following medical conditions?


You may choose not to answer the question by simply clicking “Next”.


Statements in row (randomize and record response order, with G15_24 always last):

G15_1. Acid reflux disease

G15_2. ADHD or ADD

G15_3. Anxiety disorder

G15_4. Asthma, chronic bronchitis, or COPD

G15_5. Cancer (any type except skin cancer)

G15_6. Chronic pain (such as low back pain, neck pain, or Fibromyalgia)

G15_7. Depression

G15_8. Diabetes

G15_9. Heart attack

G15_10. Heart disease

G15_11. High blood pressure

G15_12. High cholesterol

G15_13. HIV/AIDS

G15_14. Kidney disease

G15_15. Mental health condition

G15_16. Multiple sclerosis

G15_17. Osteoarthritis, joint pain or inflammation

G15_18. Osteoporosis or osteopenia

G15_19. Rheumatoid arthritis

G15_20. Seasonal allergies

G15_21. Skin cancer

G15_22. Sleep disorders such as sleep apnea or insomnia 

G15_23. Stroke

G15_24. Something else [anchor]


Answers in columns:

1. Yes

2. No



G15. Have you been diagnosed by a physician or other qualified medical professional with any of the following medical conditions?


You may choose not to answer the question by simply clicking “Next”.


Statements in row (randomize and record response order, with G15_25 always last):

G15_1. Acid reflux disease

G15_2. ADHD or ADD

G15_3. Anxiety disorder

G15_4. Asthma, chronic bronchitis, or COPD

G15_5. Cancer (any type except skin cancer)

G15_6. Chronic pain (such as low back pain, neck pain, or Fibromyalgia)

G15_7. Depression

G15_8. Diabetes

G15_9. Heart attack

G15_10. Heart disease

G15_11. High blood pressure

G15_12. High cholesterol

G15_13. HIV/AIDS

G15_14. Kidney disease

G15_15. Mental health condition

G15_16. Multiple sclerosis

G15_17. Osteoarthritis, joint pain or inflammation

G15_18. Osteoporosis or osteopenia

G15_19. Rheumatoid arthritis

G15_20. Seasonal allergies

G15_21. Skin cancer

G15_22. Sleep disorders such as sleep apnea or insomnia 

G15_23. Stroke

G15_24. COVID-19

G15_25. Something else [anchor]


Answers in columns:

1. Yes

2. No




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorGentzke, Andrea (CDC/ONDIEH/NCCDPHP)
File Modified0000-00-00
File Created2021-06-08

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