Attachment 13d List of Changes in 2021 Field Test Questionnaire

Attachment 13d List of Changes in 2021 Field Test Questionnaire.docx

2021 Field Test Behavioral Risk Factor Surveillance System (BRFSS)

Attachment 13d List of Changes in 2021 Field Test Questionnaire

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Attachment 13d: List of Changes in 2021 Field Test Questionnaire



Proposed Action/ Justification

Current question

New question

Cancer Survivorship Module: Proposed modification of questions to conform to NHIS

What type of cancer was it?

01 Breast cancer

Female reproductive (Gynecologic)

02 Cervical cancer (cancer of the cervix)

03 Endometrial cancer (cancer of the uterus)

04 Ovarian cancer (cancer of the ovary)

Head/Neck

05 Head and neck cancer

06 Oral cancer

07 Pharyngeal (throat) cancer

08 Thyroid

09 Larynx

Gastrointestinal

10 Colon (intestine) cancer

11 Esophageal (esophagus)

12 Liver cancer

13 Pancreatic (pancreas) cancer

14 Rectal (rectum) cancer

15 Stomach

Leukemia/Lymphoma (lymph nodes and bone marrow)

16 Hodgkin's Lymphoma (Hodgkin’s disease)

17 Leukemia (blood) cancer

18 Non-Hodgkin’s Lymphoma

Male reproductive

19 Prostate cancer

20 Testicular cancer

Skin

21 Melanoma

22 Other skin cancer

Thoracic

23 Heart

24 Lung

Urinary cancer

25 Bladder cancer

26 Renal (kidney) cancer

Others

27 Bone

28 Brain

29 Neuroblastoma

30 Other

Do not read:

77 Don’t know / Not sure

99 Refused

What kind of cancer is it?

01 Bladder

02 Blood

03 Bone

04 Brain

05 Breast

06 Cervix/Cervical

07 Colon

08 Esophagus/Esophageal

09 Gallbladder

10 Kidney

11 Larynx-trachea

12 Leukemia

13 Liver

14 Lung

15 Lymphoma

16 Melanoma

17 Mouth/tongue/lip

18 Ovary/Ovarian

19 Pancreas/Pancreatic

20 Prostate

21 Rectum/Rectal

22 Skin (non-melanoma)

23 Skin (don't know what kind)

24 Soft tissue (muscle or fat)

25 Stomach

26 Testis/Testicular

27 Throat - pharynx

28 Thyroid

29 Uterus/Uterine

30 Other

97 Refused

99 Don't Know

Prostate Cancer: Proposed modification of questions to conform to NHIS

Has a doctor, nurse, or other health professional ever talked with you about the advantages of the Prostate-Specific Antigen or P.S.A. test?


Yes/No


Has a doctor, nurse, or other health professional ever talked with you about the disadvantages of the P.S.A. test?

Yes/No

When you met with a doctor, nurse, or other health professional, did they talk about the advantages, the disadvantages, or both advantages and disadvantages of the prostate-specific antigen or PSA test?


1 Advantages

2 Disadvantages

3 Both advantages and disadvantages

7 Don’t Know / Not sure

9 Refused


Prostate Cancer: Proposed modification of questions to conform to NHIS

Has a doctor, nurse, or other health professional ever recommended that you have a P.S.A. test?


Yes/No

Who first suggested this PSA test: you, your doctor, or someone else?


1 Self

2 Doctor, nurse, health care professional

3 Someone else

7 Don’t Know / Not sure

9 Refused


Prostate Cancer: Proposed modification of questions to conform to NHIS

What was the main reason you had this P.S.A. test – was it …?


Please read:

1 Part of a routine exam

2 Because of a prostate problem

3 Because of a family history of prostate cancer

4 Because you were told you had prostate cancer

5 Some other reason

What was the MAIN reason you had this PSA test – was it …?


Please read:

1 Part of a routine exam

2 Because of a problem

3 other reason

Lung Cancer: Proposed modification of questions to conform to NHIS

The next question is about CT or CAT scans. During this test, you lie flat on your back on a table. While you hold your breath, the table moves through a donut shaped x-ray machine while the scan is done. In the last 12 months, did you have a CT or CAT scan?


Read if necessary:

1 Yes, to check for lung cancer

2 No (did not have a CT scan)

3 Had a CT scan, but for some other reason

Do not read:

7 Don't know/not sure

9 Refused

The next question is about CT or CAT scans of your chest area. During this test, you lie flat on your back and are moved through an open, donut shaped x-ray machine. Were any of the CT or CAT scans of your chest area done mainly to check or screen for lung cancer?


1 Yes [go to Q5],

2 No [go to next section]

Do not read:

7 Don't know/not sure

9 Refused


5.When did you have your most recent CT or CAT scan of your chest area mainly to check or screen for lung cancer?

Read only if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years)

3 Within the past 3 years (2 years but less than 3 years)

4 Within the past 5 years (3 years but less than 5 years)

5 Within the past 10 years (5 years but less than 10 years ago)

6 or more years ago

Do not read:

7 Don’t know / Not sure

9 Refused

Chronic Health Conditions: add clarification to skin cancer

(Ever told) (you had) skin cancer?

(Ever told) (you had) skin cancer that is not melanoma?

Chronic Health Conditions: add melanoma to other types of cancer

(Ever told) (you had) any other types of cancer?

(Ever told) (you had) melanoma or any other types of cancer?

Change interviewer notes

Interview notes: Marijuana and cannabis include both CBD and THC products.

Interview notes to state: “The following questions are about marijuana or cannabis. Do not include hemp-based or CBD-only products in your responses.”

Make separate questions for each type of marijuana use

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

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

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

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

4 Vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device)

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

6 Use it some other way.

Do not read:

7 Don’t know/not sure

9 Refused

1.During the past 30 days, did you smoke it (for example, in a joint, bong, pipe, or blunt)?


2.During the past 30 days, did you eat it or drink it (for example, in brownies, cakes, cookies, or candy, or in tea, cola, or alcohol)?


3.During the past 30 days, did you vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device)?


4.During the past 30 days, did you dab it (for example, using a dabbing rig, knife, or dab pen)?



5.During the past 30 days, did you use it some other way?



New question for eye examination

N/A

When was the last time a doctor, nurse, or other health professional took a photo of the back of your eye with a specialized camera?

New question type of diabetes

N/A

According to your doctor or other health professional, what type of diabetes do you have?

Family Planning: New introductory question

N/A

In the past 12 months, did you have sex where a penis is inserted into the vagina, sometimes called penile‐vaginal sex?

1 Yes

2 No [GO TO NEXT MODULE]


Family Planning: Changes in wording

N/A

The last time you had penile-vaginal sex, did you or your partner do anything to keep you from getting pregnant?


The last time you had sex with a man, what did you or your partner do to keep you from getting pregnant?


Read if necessary:

01 Female sterilization (ex. Tubal ligation, Essure, Adiana) 02 Male sterilization (vasectomy)

03 Contraceptive implant (ex. Nexplanon, Jadelle, Sino Implant, Implanon)

04 IUD, Levonorgestrel (LNG) or other hormonal (ex. Mirena, Skyla, Liletta, Kylena)

05 IUD, Copper-bearing (ex. ParaGard)

06 IUD, type unknown

07 Shots (ex. Depo-Provera or DMPA)

08 Birth control pills, any kind

09 Contraceptive patch (ex. Ortho Evra, Xulane)

10 Contraceptive ring (ex. NuvaRing)

11 Male condoms

12 Diaphragm, cervical cap, sponge

13 Female condoms

14 Not having sex at certain times (rhythm or natural family planning)

15 Withdrawal (or pulling out)

16 Foam, jelly, film, or cream

17 Emergency contraception (morning after pill)

18 Other method

Do not read:

77 Don’t know/ Not sure

99 Refused

The last time you had penile-vaginal sex, what did you or your partner do to keep you from getting pregnant?


Read if necessary:

01 Female sterilization (Tubal ligation, Essure, or Adiana)

02 Male sterilization (vasectomy)

03 Contraceptive implant

04 Intrauterine device or IUD (Mirena, Levonorgestrel, ParaGard)

05 Shots (Depo-Provera)

06 Birth control pills, Contraceptive Ring (NuvaRing), Contraceptive patch (Ortho Evra)

07 Condoms (male or female)

08 Diaphragm, cervical cap, sponge, foam, jelly, film, or cream

09 Had sex at a time when less likely to get pregnant (rhythm or natural family planning)

10 Withdrawal or pulling out

11 Emergency contraception or the morning after pill (Plan B or ella)

12 Other method



The last time you had penile-vaginal sex, what else, if anything, did you or your partner do to keep you from getting pregnant?

Read only if respondent is unable to provide a response: (866-867 – TYPCNTR7)


00 Nothing else

01 Female sterilization (Tubal ligation, Essure, or Adiana)

02 Male sterilization (vasectomy)

03 Contraceptive implant

04 Intrauterine device or IUD (Mirena, Levonorgestrel, ParaGard)

05 Birth control pills, Contraceptive Ring (NuvaRing), Contraceptive patch (Ortho Evra)

06 Shots (Depo-Provera),

07 Condoms (male or female)

08 Diaphragm, cervical cap, sponge, foam, jelly, film, or cream

09 Had sex at a time when less likely to get pregnant (rhythm or natural family planning)

10 Withdrawal or pulling out

11 Emergency contraception or the morning after pill (Plan B or Ella)

12 Other method



Where did you get the [response from Q3] you used when you last had penile-vaginal sex?


01 Private doctor’s office [GO TO Q7]

02 Community health clinic, Community clinic, Public health clinic [GO TO Q7]

03 Family planning or Planned Parenthood Clinic [GO TO Q7]

04 School or school-based clinic [GO TO Q7]

05 Hospital outpatient clinic, emergency room, regular hospital room [GO TO Q7]

06 Urgent care center, urgi-care or walk-in facility [GO TO Q7]

07 In- store health clinic (like CVS, Target, or Walmart) [GO TO Q7]

08 Health care visit with a pharmacist [GO TO Q7]

09 Website or app [GO TO Q7]

10 Some other place [GO TO Q7]

Family Planning: Wording changes

Some reasons for not doing anything to keep you from getting pregnant the last time you had sex might include wanting a pregnancy, not being able to pay for birth control, or not thinking that you can get pregnant.

What was your main reason for not using a method to prevent pregnancy the last time you had sex with a man?


Read if necessary:


01 You didn’t think you were going to have sex/no regular partner

02 You just didn’t think about it

03 Don’t care if you get pregnant

04 You want a pregnancy

05 You or your partner don’t want to use birth control

06 You or your partner don’t like birth control/side effects

07 You couldn’t pay for birth control

08 You had a problem getting birth control when you needed it

09 Religious reasons

10 Lapse in use of a method

11 Don’t think you or your partner can get pregnant (infertile or too old)

12 You had tubes tied (sterilization)

13 You had a hysterectomy

14 Your partner had a vasectomy (sterilization

15 You are currently breast-feeding

16 You just had a baby/postpartum 17 You are pregnant now

18 Same sex partner

19 Other


What was your main reason for not doing anything to prevent pregnancy the last time you had penile-vaginal sex?

Read only if respondent is unable to provide a response:


01 You didn’t think you were going to have sex/no regular partner

02 You just didn’t think about it

03 You wanted a pregnancy

04 You didn’t care if you got pregnant

05 You or your partner didn’t want to use birth control (side effects, don’t like birth control)

06 You had trouble getting or paying for birth control

07 You didn’t trust giving out your personal information to medical personnel

08 Didn’t think you or your partner could get pregnant (infertile or too old)

09 You were using withdrawal or “pulling out”

10 You had your tubes tied (sterilization)

11 Your partner had a vasectomy (sterilization)

12 You were breast-feeding or you just had a baby

13 You were assigned male at birth

14 Other reasons

Family Planning: New question

N/A

If you could use any birth control method you wanted, what method would you use?


01 Female sterilization (Tubal ligation, Essure, or Adiana) [GO TO NEXT MODULE]

02 Male sterilization (vasectomy) [GO TO NEXT MODULE]

03 Contraceptive implant [GO TO NEXT MODULE]

04 Intrauterine device or IUD (Mirena, Levonorgestrel, ParaGard) [GO TO NEXT MODULE]

05 Shots (Depo-Provera) [GO TO NEXT MODULE]

06 Birth control pills, Contraceptive Ring (NuvaRing), Contraceptive patch (Ortho Evra) [GO TO NEXT MODULE]

07 Condoms (male or female) [GO TO NEXT MODULE]

08 Diaphragm, cervical cap, sponge, foam, jelly, film, or cream [GO TO NEXT MODULE]

09 Having sex at a time when less likely to get pregnant (rhythm or natural family planning) [GO TO NEXT MODULE]

10 Withdrawal or pulling out [GO TO NEXT MODULE]

11 Emergency contraception or the morning after pill (Plan B or ella) [GO TO NEXT MODULE]

12 Other method [GO TO NEXT MODULE]

13 I am using the method that I want to use [GO TO NEXT MODULE]

14 I don’t want to use any method [GO TO NEXT MODULE]

Tobacco Use; Add Heated tobacco products questions to determine prevalence of use of new products


N/A

Introductory language:


“The next question is about heated tobacco products. Some people refer to these as “heat-not-burn” tobacco products. These heat TOBACCO STICKS or CAPSULES to produce a vapor. They are different from e-cigarettes, which heat a LIQUID to produce a vapor. Some brands of heated tobacco products include iQOS (PRONOUNCED “eye-kos”), glo (PRONOUNCED “glow”), and Eclipse.”



Add Heated tobacco products. (HTP)


N/A

Do you now use heated tobacco products every day, some days, or not at all?


1. Every day

2. Some days

3. Not at all

7. DON’T KNOW/NOT SURE

8. REFUSED

This is an alternative question on HTP. Only one HTP question will be added pending the results of BRFSS field testing. If prevalence of current use of HTP is <1% during the BRFSS filed test, this awareness question will be chosen. Otherwise, the current use question above will be chosen.

N/A

Before today, have you heard of heated tobacco products”?

1. YES

2. NO

7. DON’T KNOW/NOT SURE

8. REFUSED

Tobacco use: Menthol cigarettes question to determine whether flavor of tobacco products encourages younger use

N/A

Currently, when you smoke cigarettes, do you usually smoke menthol cigarettes…

1. YES

2. NO

7. DON’T KNOW/NOT SURE

8. REFUSED


Menthol e-cigarettes question

N/A

3.Currently, when you use e-cigarettes, do you usually use menthol e-cigarettes…

1. YES

2. NO

7. DON’T KNOW/NOT SURE

8. REFUSED

COVID Vaccination Module: Previously approved through the NCIRD

N/A

Have you had a COVID-19 vaccination?


How many COVID-19 vaccinations have you received?


Ask if respondent reported receiving one dose of COVID-19 vaccine, or reported having been vaccinated but not sure number of doses:


Which of the following best describes your intent to take the recommended COVID vaccinations…would you say you have already received all recommended doses, plan to receive all recommended doses or do not plan to receive all recommended doses?


During what month and year did you receive your (first) COVID-19 vaccination?


During what month and year did you receive your second COVID-19 vaccination?



Emerging Core Long Term COVID Effects. One year module to assess chronic conditions related to COVID

N/A

Has a doctor, nurse, or other health professional ever told you that you tested positive for COVID 19?

N/A

Did you have any symptoms lasting 3 months or longer that you did not have prior to having coronavirus or COVID-19?

N/A

Which of the following was the primary symptom that you experienced? Was it….

1 Tiredness or fatigue

2 Difficulty thinking or concentrating or forgetfulness/memory problems (sometimes referred to as “brain fog”)

3 Difficulty breathing or shortness of breath

4 Joint or muscle pain

5 Fast-beating or pounding heart (also known as heart palpitations) or chest pain

6 Dizziness on standing

7 Depression, anxiety, or mood changes

8 Symptoms that get worse after physical or mental activities

9 You did not have any long-term symptoms that limited your activities.77 Don’t know/Not sure

99 Refused




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