Form 0920-1061 Screener for 2018 BRFSS Field Test Example

2021 Field Test Behavioral Risk Factor Surveillance System (BRFSS)

Attachment 13c Screener for 2018 Field Test

Field Test - Screener

OMB: 0920-1061

Document [docx]
Download: docx | pdf

Attachment 13c. Screener for the 2018 BRFSS Field Test

Landline Introduction



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

LL01.


Is this [PHONE NUMBER]?

CTELENM1


1 Yes

Go to LL02


63

2 No

TERMINATE


LL02.


Is this a private residence?

PVTRESD1


1 Yes

Go to LL04

Read if necessary: By private residence we mean someplace like a house or apartment.

Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.

64

2 No

Go to LL03


3 No, this is a business


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

LL03.


Do you live in college housing?

COLGHOUS


1 Yes

Go to LL04

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

65

2 No

TERMINATE

Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.

LL04.


Do you currently live in__(state)____?

STATERE1


1 Yes

Go to LL05


66

2 No

TERMINATE

Thank you very much but we are only interviewing persons who live in [STATE] at this time.

LL05.

Is this a cell phone?

CELLFON4


1 Yes, it is a cell phone

TERMINATE

Read: Thank you very much but we are only interviewing by landline telephones in private residences or college housing at this time.

2 Not a cell phone

Go to LL06

Read if necessary: By cell phone we mean a telephone that is mobile and usable outside your neighborhood.

Do not read: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).

LL06.


Are you 18 years of age or older?

LADULT


1 Yes, male respondent

2 Yes, female respondent


Do not read: Sex will be asked again in demographics section.

68

3 No

TERMINATE

Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.

Transition to Section 1.



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


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







Cell Phone Introduction

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)








CP01.


Is this a safe time to talk with you?

SAFETIME


1 Yes

Go to CP02


75

2 No

([set appointment if possible]) TERMINATE]

Thank you very much. We will call you back at a more convenient time.

CP02.


Is this [PHONE NUMBER]?

CTELNUM1


1 Yes

Go to CP03


76

2 No

TERMINATE


CP03.


Is this a cell phone?

CELLFON5


1 Yes

Go to CADULT


77

2 No

TERMINATE

Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.

CP04.


Are you 18 years of age or older?

CADULT


1 Yes, male respondent

2 Yes, female respondent


Do not read: Sex will be asked again in demographics section.

78

3 No

TERMINATE

Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.

CP05.


Do you live in a private residence?

PVTRESD3


1 Yes

Go to CP07

Read if necessary: By private residence we mean someplace like a house or apartment

Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.

79

2 No

Go to CP06

Read: Thank you very much, but we are only interviewing persons who live in a private residence or college housing at this time.

CP06.


Do you live in college housing?

CCLGHOUS


1 Yes

Go to CP07

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

80

2 No

TERMINATE

Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.

CP07.


Do you currently live in___(state)____?

CSTATE1


1 Yes

Go to CP09


81

2 No

Go to CP08


CP08.


In what state do you currently live?

RSPSTAT1


1 Alabama

2 Alaska

4 Arizona

5 Arkansas

6 California

8 Colorado

9 Connecticut

10 Delaware

11 District of Columbia

12 Florida

13 Georgia

15 Hawaii

16 Idaho

17 Illinois

18 Indiana

19 Iowa

20 Kansas

21 Kentucky

22 Louisiana

23 Maine

24 Maryland

25 Massachusetts

26 Michigan

27 Minnesota

28 Mississippi

29 Missouri

30 Montana

31 Nebraska

32 Nevada

33 New Hampshire

34 New Jersey

35 New Mexico

36 New York

37 North Carolina

38 North Dakota

39 Ohio

40 Oklahoma

41 Oregon

42 Pennsylvania

44 Rhode Island

45 South Carolina

46 South Dakota

47 Tennessee

48 Texas

49 Utah

50 Vermont

51 Virginia

53 Washington

54 West Virginia

55 Wisconsin

56 Wyoming

66 Guam

72 Puerto Rico

78 Virgin Islands

99 Refused



82-83

Transition to section 1.



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








File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPierannunzi, Carol (CDC/ONDIEH/NCCDPHP)
File Modified0000-00-00
File Created2021-06-23

© 2024 OMB.report | Privacy Policy