0920-1061 Attachment 4 Optional Modules by Topic 6-30

2021 Field Test Behavioral Risk Factor Surveillance System (BRFSS)

Attachment 4 Optional Modules by Topic 6-30

OMB: 0920-1061

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Attachment 4 - Optional Modules by Topic



Table of Contents

Module 1: Prediabetes 4

Module 2: Diabetes 5

Module 3: ME/CFS 9

Module 4: Hepatitis Treatment 11

Module 5: Health Care Access 13

Module 6: Cognitive Decline 15

Module 7: Caregiver 18

Module 8: E-Cigarettes 22

Module 9: Marijuana Use 24

Module 10: Tobacco Cessation 26

Module 11: Firearm Safety 28

Module 12: Lung Cancer Screening 29

Module 13: Cancer Survivorship: Type of Cancer 32

Module 14: Cancer Survivorship: Course of Treatment 36

Module 15: Cancer Survivorship: Pain Management 40

Module 16: Prostate Cancer Screening Decision Making 42

Module 17: Adult Human Papillomavirus (HPV) - Vaccination 44

Module 18: Tetanus Diphtheria (Tdap) (Adults) 46

Module 19: Place of Flu Vaccination 47

Module 20: Shingles Vaccination 49

Module 21: COVID Vaccination 50

Module 23: Industry and Occupation 53

Module 24: Sex at Birth 55

Module 25: Sexual Orientation and Gender Identity (SOGI) 56

Module 26: Adverse Childhood Experiences 60

Module 27: Random Child Selection 65

Module 28: Childhood Asthma Prevalence 70

Module 29: Aspirin for CVD Prevention 71

Module 30: Home/ Self-measured Blood Pressure 72

Module 31: Food Stamps 74

Module 32: Sleep Disorder 75

Module 33: Anxiety and Depression 76

Module 34: Adult Asthma History 78

Module 35: Respiratory Health (COPD Symptoms) 82

Module 36: Indoor Tanning 83

Module 37: Excess Sun Exposure 84

Module 38: Actions to Control High Blood Pressure 86

Module 39: Arthritis Management 89

Module 40: Alcohol Screening & Brief Intervention (ASBI) 92

Module 41: Sugar Sweetened Beverages 94

Module 42: Sodium or Salt-Related Behavior 95

Module 43: Preconception Health/Family Planning 96

Module 44: Emotional Support and Life Satisfaction 99

Module 45: Social Determinants of Health 100

Module 46: Sleep Disorder 103

Module 47: Health Literacy 104

Module 48: Clinical Breast Exam 105

Module 49: Exercise (Physical Activity) 106

Module 50: Fruits and Vegetables 109

Module 51: Heart Attack and Stroke 113

Module 52: Anxiety and Depression 115

Module 53: Mental Illness and Stigma 117

Module 54: Social Context 120

Module 55: General Preparedness 122

Module 56: Veteran’s Health 125

Module 57: Reactions to Race 127

Module 59: WGSS Disability 130

Module 60: Other Tobacco Use 132

Module 61: Periodontal Disease 133

Module 62: Knowledge and Impact of COVID Pandemic 135

Module 63: Emotional Well-being 142

Module 64: Opioid Use and Misuse 145

Module 65: Bereavement 150





Module 1: Prediabetes


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





Skip if Section CCHC.12, DIABETE4, is coded 1



MPDB.01


Have you had a test for high blood sugar or diabetes within the past three years?

PDIABTST

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



264





Skip MPDB.02 if CCHC.12 DIABETE4, is coded 1; If CCHC.12, DIABETE4, is coded 4 automatically code MPDB.02, PREDIAB1, equal to 1 (yes);



MPDB.02

Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?

PREDIAB1

1 Yes

2 Yes, during pregnancy

3 No

7 Don’t know / Not sure

9 Refused


If Yes and respondent is female, ask: Was this only when you were pregnant?

265



Module 2: Diabetes



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





To be asked following Core CCHC.13; if response to CCHC.12 is Yes (code = 1)



MDIA.01


Are you now taking insulin?

INSULIN1


1 Yes

2 No

7 Don’t know/ not sure

9 Refused



266

MDIA.02

About how often do you check your blood for glucose or sugar?


BLDSUGAR


1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

4 _ _ Times per year

888 Never

777 Don’t know / Not sure

999 Refused


Read if necessary: Include times when checked by a family member or friend, but do not include times when checked by a health professional.


Do not read: If the respondent uses a continuous glucose monitoring system (a sensor inserted under the skin to check glucose levels continuously), fill in ‘98 times per day.’

267-269

MDIA.03

Including times when checked by a family member or friend, about how often do you check your feet for any sores or irritations?

FEETCHK3


1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

4 _ _ Times per year

555 No feet

888 Never

777 Don’t know / Not sure

999 Refused



270-272

MDIA.04

About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?

DOCTDIAB


_ _ Number of times [76 = 76 or more]

88 None

77 Don’t know / Not sure

99 Refused



273-274

MDIA.05

About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for A-one-C?

CHKHEMO3


_ _ Number of times [76 = 76 or more]

88 None

98 Never heard of A-one-C test

77 Don’t know / Not sure

99 Refused


Read if necessary: A test for A-one-C measures the average level of blood sugar over the past three months.

275-276





If MDIA.03 = 555 (No feet), go to MDIA.07



MDIA.06

About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?

FEETCHK

_ _ Number of times [76 = 76 or more]

88 None

77 Don’t know / Not sure

99 Refused



277-278

MDIA.07

When was the last time you had an eye exam in which the pupils were dilated, making you temporarily sensitive to bright light?

EYEEXAM1

Read if necessary:

1 Within the past month (anytime less than 1 month ago)

2 Within the past year (1 month but less than 12 months ago)

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

4 2 or more years ago

Do not read:

7 Don’t know / Not sure

8 Never

9 Refused



279

MDIA.08

Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?

DIABEYE

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



280

MDIA.09

Have you ever taken a course or class in how to manage your diabetes yourself?

DIABEDU

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



281







Module 3: ME/CFS


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MME.01


Have you ever been told by a doctor or other health professional that you had Chronic Fatigue Syndrome (CFS) or (Myalgic Encephalomyelitis) ME?

TOLDCFS

1 Yes



My-al-gic

En-ceph-a-lo-my-eli-tis

282

2 No

7 Don’t know / Not sure

9 Refused

Go to next section

MME.02

Do you still have Chronic Fatigue Syndrome (CFS) or (Myalgic Encephalomyelitis) ME?

HAVECFS

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused


My-al-gic

En-ceph-a-lo-my-eli-tis

283

MME.03

Thinking about your CFS or ME, during the past 6 months, how many hours a week on average have you been able to work at a job or business for pay?

WORKCFS

Read if necessary

1 0 or no hours -- cannot work at all because of CFS or ME

2 1 - 10 hours a week

3 11- 20 hours a week

4 21- 30 hours a week

5 31 - 40 hours a week

Do not read

7 Don’t know/ Not sure

9 Refused



284





Module 4: Hepatitis Treatment


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MHT.01


Have you ever been told by a doctor or other health professional that you had Hepatitis C?

TOLDHEPC

1 Yes


Hepatitis C is an infection of the liver from the Hepatitis C virus

285

2 No

7 Don’t know / Not sure

9 Refused

Go to MHT.05

MHT.02

Were you treated for Hepatitis C in 2015 or after?

TRETHEPC

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused


Most hepatitis C treatments offered in 2015 or after were oral medicines or pills. Including Harvoni, Viekira, Zepatier, Epclusa and others.

286

MHT.03

Were you treated for Hepatitis C prior to 2015?

PRIRHEPC

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused


Most hepatitis C treatments offered prior to 2015 were shots and pills given weekly or more often over many months.

287

MHT.04

Do you still have Hepatitis C?

HAVEHEPC

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused


You may still have Hepatitis C and feel healthy. Your blood must be tested again to tell if you still have Hepatitis C.

288

MHT.05

The next question is about Hepatitis B.

Has a doctor, nurse, or other health professional ever told you that you had hepatitis B?

HAVEHEPB

1 Yes


Hepatitis B is an infection of the liver from the hepatitis B virus.

289

2 No

7 Don’t know/ Not sure

9 Refused

Go to next section

MHT.06

Are you currently taking medicine to treat hepatitis B?

MEDSHEPB

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused



290




Module 5: Health Care Access



Question Number

Question text


Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MHCA.01

What is the primary source of your health care coverage? Is it…

HLTHCVR1


Read:

01 A plan purchased through an employer or union (including plans purchased through another person's employer)

02 A plan that you or another family member buys on your own

03 Medicare

04 Medicaid or other state program

05 TRICARE (formerly CHAMPUS), VA, or Military

06 Alaska Native, Indian Health Service, Tribal Health Services

Or

07 Some other source

08 None (no coverage)

Do not read:

77 Don't know/Not sure

99 Refused

Go to CHCA.02



If the respondent indicates that they purchased health insurance through the Health Insurance Marketplace (name of state Marketplace), ask if it was a private health insurance plan purchased on their own or by a family member (private) or if they received Medicaid (state plan). If purchased on their own (or by a family member), select 02, if Medicaid select 04.


291-292

2. In the past 12 months has a lack of reliable transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?



1 Yes

2 No

7 Don’t know/ Not sure

9 Refused










Module 6: Cognitive Decline



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If respondent is 45 years of age or older continue, else go to next module.



MCD.01


The next few questions ask about difficulties in thinking or remembering that can make a big difference in everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you recently met, which is normal. This refers to confusion or memory loss that is happening more often or getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would normally know. We want to know how these difficulties impact you.


During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse?

CIMEMLOS


1 Yes



Go to MCD.02


293

2 No

Go to next module

7 Don’t know/ not sure

Go to MCD.02

9 Refused

Go to next module

MCD.02

During the past 12 months, as a result of confusion or memory loss, how often have you given up day-to-day household activities or chores you used to do, such as cooking, cleaning, taking medications, driving, or paying bills? Would you say it is…

CDHOUSE


Read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

7 Don't know/Not sure

9 Refused



294

MCD.03

As a result of confusion or memory loss, how often do you need assistance with these day-to-day activities? Would you say it is…

CDASSIST


Read:

1 Always

2 Usually

3 Sometimes



295

4 Rarely

5 Never

Do not read:

7 Don't know/Not sure

9 Refused

Go to MCD.05

MCD.04

When you need help with these day-to-day activities, how often are you able to get the help that you need? Would you say it is…

CDHELP


Read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

7 Don't know/Not sure

9 Refused



296

MCD.05

During the past 12 months, how often has confusion or memory loss interfered with your ability to work, volunteer, or engage in social activities outside the home? Would you say it is…

CDSOCIAL

Read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

7 Don't know/Not sure

9 Refused



297

MCD.06

Have you or anyone else discussed your confusion or memory loss with a health care professional?

CDDISCUS

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



298

Module 7: Caregiver



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MCG.01


During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability?

CAREGIV1


1 Yes


If caregiving recipient has died in the past 30 days, code 8 and say: I’m so sorry to hear of your loss

299

2 No

7 Don’t know/Not sure

Go to MCG.09

8 Caregiving recipient died in past 30 days

Go to MCG.09

9 Refused

Go to MCG.09

MCG.02

What is his or her relationship to you?

CRGVREL4


01 Mother

02 Father

03 Mother-in-law

04 Father-in-law

05 Child

06 Husband

07 Wife

08 Live-in partner

09 Brother or brother-in-law

10 Sister or sister-in-law

11 Grandmother

12 Grandfather

13 Grandchild

14 Other relative

15 Non-relative/ Family friend

77 Don’t know/Not sure

99 Refused


If more than one person, say: Please refer to the person to whom you are giving the most care.

300-301

MCG.03

For how long have you provided care for that person? Would you say…

CRGVLNG1


Read:

1 Less than 30 days

2 1 month to less than 6 months

3 6 months to less than 2 years

4 2 years to less than 5 years

5 5 or more years

Do not read:

7 Don’t Know/ Not Sure

9 Refused



302

MCG.04

In an average week, how many hours do you provide care or assistance? Would you say…

CRGVHRS1


Read:

1 Up to 8 hours per week

2 9 to 19 hours per week

3 20 to 39 hours per week

4 40 hours or more

Do not read:

7 Don’t know/Not sure

9 Refused



303

MCG.05

What is the main health problem, long-term illness, or disability that the person you care for has?

CRGVPRB3


01 Arthritis/ rheumatism

02 Asthma

03 Cancer

04 Chronic respiratory conditions such as emphysema or COPD

05 Alzheimer’s disease, dementia or other cognitive impairment disorder

06 Developmental disabilities such as autism, Down’s Syndrome, and spina bifida

07 Diabetes

08 Heart disease, hypertension, stroke

09 Human Immunodeficiency Virus Infection (H.I.V.)

10 Mental illnesses, such as anxiety, depression, or schizophrenia

11 Other organ failure or diseases such as kidney or liver problems

12 Substance abuse or addiction disorders

13 Injuries, including broken bones

14 Old age/ infirmity/frailty

15 Other

77 Don’t know/Not sure

99 Refused



304-305





If MCG.05=5, go to MCG.07



MCG.06

Does the person you care for also have Alzheimer’s disease, dementia or other cognitive impairment disorder?

CRGVALZD

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused



306

MCG.07

In the past 30 days, did you provide care for this person by managing personal care such as giving medications, feeding, dressing, or bathing?

CRGVPERS


1 Yes

2 No

7 Don’t know/ not sure

9 Refused



307

MCG.08

In the past 30 days, did you provide care for this person by managing household tasks such as cleaning, managing money, or preparing meals?

CRGVHOUS


1 Yes

2 No

7 Don’t know/ not sure

9 Refused



308

MCG.09

In the next 2 years, do you expect to provide care or assistance to a friend or family member who has a health problem or disability?

CRGVEXPT

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



309





Module 8: E-Cigarettes



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MECIG.01


Have you ever used an e-cigarette or other electronic vaping product, even just one time, in your entire life?

ECIGARET


1 Yes


Read if necessary: Electronic cigarettes (e-cigarettes) and other electronic vaping products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy.


Interviewer note: These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.

E-cigarettes may also be known as JUUL, Vuse, Suorin, MarkTen, and blu.

310

2 No

7 Don’t know/Not sure

9 Refused

Go to next module

MECIG.02

Do you now use e-cigarettes or other electronic vaping products every day, some days, or not at all?

ECIGNOW

1 Every day

2 Some days

3 Not at all

7 Don’t know / Not sure

9 Refused


Interviewer note: These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.

311





Module 9: Marijuana Use


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M21.01


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

MARIJAN1


_ _ 01-30 Number of days


If asked, participants should be advised NOT to include hemp-based CBD products.


88 None

77 Don’t know/not sure

99 Refused

Go to next module

M21.02

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

USEMRJN2


Read:

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 a dabbing rig, knife, or dab pen), or

6 Use it some other way.

Do not read:

7 Don’t know/not sure

9 Refused


Select one. If respondent provides more than one say: Which way did you use it most often?


Read parentheticals only if asked for more detail.


M21.03

When you used marijuana or cannabis during the past 30 days, was it usually:

RSNMRJN1

Read:

1 For medical reasons (like to treat or decrease symptoms of a health condition);

2 For non-medical reasons (like to have fun or fit in), or

3 For both medical and non-medical reasons.

Do not read:

7 Don’t know/Not sure

9 Refused








Module 10: Tobacco Cessation


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





Ask if SMOKE100 = 1 and SMOKDAY2 = 3



M22.01

How long has it been since you last smoked a cigarette, even one or two puffs?

LASTSMK2


Read if necessary:

01 Within the past month (less than 1 month ago)

02 Within the past 3 months (1 month but less than 3 months ago)

03 Within the past 6 months (3 months but less than 6 months ago)

04 Within the past year (6 months but less than 1 year ago)

05 Within the past 5 years (1 year but less than 5 years ago)

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

07 10 years or more

08 Never smoked regularly

77 Don’t know / Not sure

99 Refused

Go to next module







Ask if SMOKDAY2 = 1 or 2.



M22.02

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

STOPSMK2


1 Yes

2 No

7 Don’t know / Not sure

9 Refused





Module 11: Firearm Safety


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue

The next questions are about safety and firearms. Some people keep guns for recreational purposes such as hunting or sport shooting. People also keep guns in the home for protection. Please include firearms such as pistols, revolvers, shotguns, and rifles; but not BB guns or guns that cannot fire. Include those kept in a garage, outdoor storage area, or motor vehicle.


M23.01


Are any firearms now kept in or around your home?


1 Yes


Do not include guns that cannot fire; include those kept in cars, or outdoor storage.


2 No

7 Don’t know/ not sure

9 Refused

Go to Next module

M23.02

Are any of these firearms now loaded?


1 Yes






2 No

7 Don’t know/ not sure

9 Refused

Go to Next module

M23.03

Are any of these loaded firearms also unlocked?


1 Yes

2 No

7 Don’t know/ not sure

9 Refused


By unlocked, we mean you do not need a key or a combination or a hand/fingerprint to get the gun or to fire it. Don’t count the safety as a lock.










Module 12: Lung Cancer Screening



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If CTOB.01=1 (yes) and CTOB.02 = 1, 2, or 3 (every day, some days, or not at all) continue, else go to question MLCS.04.



MLCS.01



You’ve told us that you have smoked in the past or are currently smoking. The next questions are about screening for lung cancer.


How old were you when you first started to smoke cigarettes regularly?

LCSFIRST


_ _ _ Age in Years (001 – 100)

777 Don't know/Not sure

999 Refused


Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all).

If respondent indicates age inconsistent with previously entered age, verify that this is the correct answer and change the age of the respondent regularly smoking or make a note to correct the age of the respondent.

316-318

888 Never smoked cigarettes regularly

Go to MLCS.04

MLCS.02

How old were you when you last smoked cigarettes regularly?

LCSLAST

_ _ _ Age in Years (001 – 100)

777 Don't know/Not sure

999 Refused



319-321

MLCS.03

On average, when you [smoke/ smoked] regularly, about how many cigarettes {do/did} you usually smoke each day?

LCSNUMCG

_ _ _Number of cigarettes

777 Don't know/Not sure

999 Refused


Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all).

Respondents may answer in packs instead of number of cigarettes. Below is a conversion table: 0.5 pack = 10 cigarettes/ 1.75 pack = 35 cigarettes/ 0.75 pack = 15 cigarettes/ 2 packs = 40 cigarettes/ 1 pack = 20 cigarettes/ 2.5 packs= 50 cigarettes/ 1.25 pack = 25 cigarettes/ 3 packs= 60 cigarettes/ 1.5 pack = 30 cigarettes

322-324

MLCS.04

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?

LCSCTSCN

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



325




Module 13: Cancer Survivorship: Type of Cancer



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If CCHC.06 or CCHC.07 = 1 (Yes) or CPCS.06 = 4 (Because you were told you had prostate cancer) continue, else go to next module.



MTOC.01


You’ve told us that you have had cancer. I would like to ask you a few more questions about your cancer.


How many different types of cancer have you had?

CNCRDIFF


1 Only one

2 Two

3 Three or more




326

7 Don’t know / Not sure

9 Refused

Go to next module

MTOC.02

At what age were you told that you had cancer?

CNCRAGE


_ _ Age in Years (97 = 97 and older)

98 Don't know/Not sure

99 Refused


If MTOC.01= 2 (Two) or 3 (Three or more), ask: At what age were you first diagnosed with cancer?

Read if necessary: This question refers to the first time they were told about their first cancer.

327-328





If CCHC.06 = 1 (Yes) and MTOC.01 = 1 (Only one): ask Was it Melanoma or other skin cancer? then code MTOC.03 as a response of 21 if Melanoma or 22 if other skin cancer


CATI note: If CCCS.06 = 4 (Because you were told you had Prostate Cancer) and Q1 = 1 (Only one) then code MTOC.03 as a response of 19.



MTOC.03

What type of cancer was it?

CNCRTYP1


Read if respondent needs prompting for cancer type:

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


If MTOC.01 = 2 (Two) or 3 (Three or more), ask: With your most recent diagnoses of cancer, what type of cancer was it?

329-330





Module 14: Cancer Survivorship: Course of Treatment



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If CCHC.06 or CCHC.07 = 1 (Yes) or CPCS.06 = 4 (Because you were told you had prostate cancer) continue, else go to next module.



MCOT.01

Are you currently receiving treatment for cancer?

CSRVTRT3


Read if necessary:

1 Yes

Go to next module

Read if necessary: By treatment, we mean surgery, radiation therapy, chemotherapy, or chemotherapy pills.

331

2 No, I’ve completed treatment

Continue

3 No, I’ve refused treatment

4 No, I haven’t started treatment

5 Treatment was not necessary

7 Don’t know / Not sure

9 Refused

Go to next module

MCOT.02

What type of doctor provides the majority of your health care? Is it a….


CSRVDOC1


Read:

01 Cancer Surgeon

02 Family Practitioner

03 General Surgeon

04 Gynecologic Oncologist

05 General Practitioner, Internist

06 Plastic Surgeon, Reconstructive Surgeon

07 Medical Oncologist

08 Radiation Oncologist

09 Urologist

10 Other

Do not read:

77 Don’t know / Not sure

99 Refused


If the respondent requests clarification of this question, say: We want to know which type of doctor you see most often for illness or regular health care (Examples: annual exams and/or physicals, treatment of colds, etc.).


Read if necessary: An oncologist is a medical doctor who manages a person’s care and treatment after a cancer diagnosis.

332-333

MCOT.03

Did any doctor, nurse, or other health professional ever give you a written summary of all the cancer treatments that you received?

CSRVSUM


1 Yes

2 No

7 Don’t know/ not sure

9 Refused


Read if necessary: By ‘other healthcare professional’, we mean a nurse practitioner, a physician’s assistant, social worker, or some other licensed professional.


334

MCOT.04

Have you ever received instructions from a doctor, nurse, or other health professional about where you should return or who you should see for routine cancer check-ups after completing your treatment for cancer?

CSRVRTRN


1 Yes




335

2 No

7 Don’t know/ not sure

9 Refused

Go to MCOT.06

MCOT.05

Were these instructions written down or printed on paper for you?

CSRVINST

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



336

MCOT.06

With your most recent diagnosis of cancer, did you have health insurance that paid for all or part of your cancer treatment?

CSRVINSR

1 Yes

2 No

7 Don’t know/ not sure

9 Refused


Read if necessary: Health insurance also includes Medicare, Medicaid, or other types of state health programs.

337

MCOT.07

Were you ever denied health insurance or life insurance coverage because of your cancer?

CSRVDEIN

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



338

MCOT.08

Did you participate in a clinical trial as part of your cancer treatment?

CSRVCLIN

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



339





Module 15: Cancer Survivorship: Pain Management



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If CCHC.06 or CCHC.07 = 1 (Yes) or CPCS.06 = 4 (Because you were told you had prostate cancer) continue, else go to next module.



MCPM.01

Do you currently have physical pain caused by your cancer or cancer treatment?

CSRVPAIN

1 Yes



340

2 No

7 Don’t know/ not sure

9 Refused

Go to next module

MCPM.02

Would you say your pain is currently under control…?

CSRVCTL2

Read:

1 With medication (or treatment)

2 Without medication (or treatment)

3 Not under control, with medication (or treatment)

4 Not under control, without medication (or treatment)

Do not read:

7 Don’t know / Not sure

9 Refused



341





Module 16: Prostate Cancer Screening Decision Making



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If sex= male (using BIRTHSEX, CELLSEX, LANDSEX ) AND CPCS.04 = 1 and AGE ≥ 40 continue, otherwise go to next module.



MPCDM.01


Which one of the following best describes the decision to have the P.S.A. test done?

PCPSADE1





342

Read:

1 You made the decision alone

2 Your doctor, nurse, or health care provider made the decision alone

Go to next module.

3 You and one or more other persons made the decision together


4 You don’t know how the decision was made

Do not read:

9 Refused

Go to next module

MPCDM.02

Who made the decision with you?

PCDMDEC1

Read if necessary:

1 Doctor/nurse /health care provider

2 Spouse/significant other

3 Other family member

4 Friend/non-relative

Do not read: 7 Don’t know / Not sure

9 Refused


Select one response. If respondent offers more than one response ask for primary person who made decision.

343





Module 17: Adult Human Papillomavirus (HPV) - Vaccination



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If respondent is between the ages of 18 and 49 years continue; otherwise, go to next module.



MHPV.01


Have you ever had an H.P.V. vaccination?

HPVADVC4


1 Yes



Human Papillomavirus (Human Pap·uh·loh·muh virus); Gardasil (Gar·duh· seel); Cervarix (Sir·var· icks)

Read if necessary: A vaccine to prevent the human papillomavirus or H.P.V. infection is available and is called the cervical cancer or genital warts vaccine, H.P.V. shot, [Fill: if female GARDASIL or CERVARIX; if male: GARDASIL].

Interviewer Note: If respondent comments that this question was already asked, clarify that they earlier questions was about HPV testing, ant this question is about vaccination.

344

2 No

3 Doctor refused when asked

7 Don’t know/ not sure

9 Refused

Go to next module

MHPV.02

How many H.P.V. shots did you receive?

HPVADSHT

_ _ Number of shots

03 All shots

77 Don’t know / Not sure

99 Refused



345-346







Module 18: Tetanus Diphtheria (Tdap) (Adults)



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MTDAP.01


Have you received a tetanus shot in the past 10 years?

TETANUS1

1 Yes, received Tdap

2 Yes, received tetanus shot, but not Tdap

3 Yes, received tetanus shot but not sure what type

4 No, did not receive any tetanus shot in the past 10 years

7 Don’t know/Not sure

9 Refused


If yes, ask: Was this Tdap, the tetanus shot that also has pertussis or whooping cough vaccine?

347







Module 19: Place of Flu Vaccination



Question Number


Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)






Ask if CIMM= 1

This question may be inserted in core after CIMM.02



MFP.01


At what kind of place did you get your last flu shot or vaccine?

IMFVPLA1


Read if necessary:

01 A doctor’s office or health maintenance organization (HMO)

02 A health department

03 Another type of clinic or health center (a community health center)

04 A senior, recreation, or community center

05 A store (supermarket, drug store)

06 A hospital (inpatient or outpatient)

07 An emergency room

08 Workplace

09 Some other kind of place

11 A school

Do not read:

10 Received vaccination in Canada/Mexico

77 Don’t know / Not sure

99 Refused

Read if necessary: How would you describe the place where you went to get your most recent flu vaccine?

348-349







Module 20: Shingles Vaccination


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If age ≤ 49 Go to next module.



M07.01

Have you ever had the shingles or zoster vaccine?

SHINGLE2


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Shingles is an illness that results in a rash or blisters on the skin, and is usually painful. There are two vaccines now available for shingles: Zostavax, which requires 1 shot and Shingrix which requires 2 shots.




Module 21: COVID Vaccination


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MCOR.01

Since [DATE OF VACCINE AVAILABILITY], have you had a COVID-19 vaccination?

***NEW***


1 Yes





2 No

7 Don’t know / Not sure

9 Refused

Go to next section

MCOR.02

How many COVID-19 vaccinations have you received?

***NEW***

1 One

2 Two or more

7 Don’t know / Not sure

9 Refused




MCOR.03

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

***NEW***

_ _ / _ _ _ _ Month / Year

77 / 7777 Don’t know / Not sure

09 / 9999 Refused


If respondent indicated only one vaccine do not read word “first”


MCOR.04

At what kind of place did you get your (first) COVID-19 vaccination?

***NEW***

Read if necessary:

01 A doctor’s office or health maintenance organization (HMO)

02 A health department

03 Another type of clinic or health center (a community health center)

04 A senior, recreation, or community center

05 A store (supermarket, drug store)

06 A hospital (inpatient)

07 An emergency room

08 Workplace

09 Some other kind of place

11 A school

Do not read:

10 Received vaccination in Canada/Mexico

77 Don’t know / Not sure

99 Refused


If respondent indicated only one vaccine do not read word “first”






If MCOR2 =1, 7,9 go to next section



MCOR.05

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

***NEW***

_ _ / _ _ _ _ Month / Year

77 / 7777 Don’t know / Not sure

09 / 9999 Refused




MCOR.06

At what kind of place did you get your second COVID-19 vaccination?

***NEW***

Read if necessary:

01 A doctor’s office or health maintenance organization (HMO)

02 A health department

03 Another type of clinic or health center (a community health center)

04 A senior, recreation, or community center

05 A store (supermarket, drug store)

06 A hospital (inpatient)

07 An emergency room

08 Workplace

09 Some other kind of place

11 A school

Do not read:

10 Received vaccination in Canada/Mexico

77 Don’t know / Not sure

99 Refused







Module 23: Industry and Occupation



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If CDEM.14 = 1 or 4 (Employed for wages or out of work for less than 1 year) or 2 (Self-employed), continue.

If CDEM.14 = 4 (Out of work for less than 1 year) ask, “What kind of work did you do? For example, registered nurse, janitor, cashier, auto mechanic.”


Else go to next module



MIO.01


What kind of work do you do? For example, registered nurse, janitor, cashier, auto mechanic.

TYPEWORK

_______Record answer

99 Refused


If respondent is unclear, ask: What is your job title?


If respondent has more than one job ask: What is your main job?

350-449

MIO.02

What kind of business or industry do you work in? For example, hospital, elementary school, clothing manufacturing, restaurant

TYPEINDS

_______Record answer

99 Refused

If CDEM14 = 4 (Out of work for less than 1 year) ask, “What kind of business or industry did you work in? For example, hospital, elementary school, clothing manufacturing, restaurant.”


450-549





Module 24: Sex at Birth


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MSAB.01

What was your sex at birth? Was it male or female?

BIRTHSEX

1 Male

2 Female

7 Don’t know/Not sure

9 Refused



550


Module 25: Sexual Orientation and Gender Identity (SOGI)



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue

The next two questions are about sexual orientation and gender identity










If sex= male (using BIRTHSEX, CELLSEX, LANDSEX ) continue, otherwise go to MSOGI.01b.



MSOGI.01a


.Which of the following best represents how you think of yourself?

SOMALE

1 = Gay

2 = Straight, that is, not gay

3 = Bisexual

4 = Something else

7 = I don't know the answer

9 = Refused

Ask if Sex= 1.

Read if necessary: We ask this question in order to better understand the health and health care needs of people with different sexual orientations.


Please say the number before the text response. Respondent can answer with either the number or the text/word.

551





If sex= female (using BIRTHSEX, CELLSEX, LANDSEX ) continue, otherwise go to MSOGI.02.



MSOGI.01b

Which of the following best represents how you think of yourself?

SOFEMALE

1 = Lesbian or Gay

2 = Straight, that is, not gay

3 = Bisexual

4 = Something else

7 = I don't know the answer

9 = Refused

.

Read if necessary: We ask this question in order to better understand the health and health care needs of people with different sexual orientations.


Please say the number before the text response. Respondent can answer with either the number or the text/word.

552

MSOGI.02

Do you consider yourself to be transgender?

TRNSGNDR

1 Yes, Transgender, male-to-female

2 Yes, Transgender, female to male

3 Yes, Transgender, gender nonconforming

4 No

7 Don’t know/not sure

9 Refused


Read if necessary: Some people describe themselves as transgender when they experience a different gender identity from their sex at birth. For example, a person born into a male body, but who feels female or lives as a woman would be transgender. Some transgender people change their physical appearance so that it matches their internal gender identity. Some transgender people take hormones and some have surgery. A transgender person may be of any sexual orientation – straight, gay, lesbian, or bisexual.


If asked about definition of gender non-conforming: Some people think of themselves as gender non-conforming when they do not identify only as a man or only as a woman.


If yes, ask Do you consider yourself to be 1. male-to-female, 2. female-to-male, or 3. gender non-conforming?


Please say the number before the text response. Respondent can answer with either the number or the text/word.

553



Module 26: Adverse Childhood Experiences


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue

I'd like to ask you some questions about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life and may help others in the future. This is a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer. All questions refer to the time period before you were 18 years of age.




Be aware of the level of stress introduced by questions in this section and be familiar with the crisis plan.


M20.01

Now, looking back before you were 18 years of age---.

1) Did you live with anyone who was depressed, mentally ill, or suicidal?

ACEDEPRS

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused




M20.02

Did you live with anyone who was a problem drinker or alcoholic?

ACEDRINK

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused




M20.03

Did you live with anyone who used illegal street drugs or who abused prescription medications?


ACEDRUGS

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused




M20.04

Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?

ACEPRISN

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused




M20.05

Were your parents separated or divorced?

ACEDIVRC

1 Yes

2 No

8 Parents not married

7 Don’t Know/Not Sure

9 Refused




M20.06

How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up?

Was it…

ACEPUNCH

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused




M20.07

Not including spanking, (before age 18), how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Was it—

ACEHURT1

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused





M20.08

How often did a parent or adult in your home ever swear at you, insult you, or put you down? Was it…

ACESWEAR

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused




M20.09

How often did anyone at least 5 years older than you or an adult, ever touch you sexually? Was it…

ACETOUCH

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused




M20.10

How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually? Was it…

ACETTHEM

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused




M20.11

How often did anyone at least 5 years older than you or an adult, force you to have sex? Was it…

ACEHVSEX

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused





M20.12

For how much of your childhood was there an adult in your household who made you feel safe and protected? Would you say never, a little of the time, some of the time, most of the time, or all of the time?

***NEW***

1. Never

2. A little of the time

3. Some of the time

4. Most of the time

5. All of the time

7 Don’t Know/Not sure

9 Refused





M20.13

For how much of your childhood was there an adult in your household who tried hard to make sure your basic needs were met? Would you say never, a little of the time, some of the time, most of the time, or all of the time?

***NEW****

1. Never

2. A little of the time

3. Some of the time

4. Most of the time

5. All of the time

7 Don’t Know/Not sure

9 Refused





Would you like for me to provide a toll-free number for an organization that can provide information and referral for the issues in the last few questions.




If yes provide number [STATE TO INSERT NUMBER HERE]







Module 27: Random Child Selection



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If CDEM.15 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module.







If CDEM.15 = 1 and CDEM.15 does not equal 88 or 99, read into text 1



Intro text 1

Previously, you indicated there was one child age 17 or younger in your household. I would like to ask you some questions about that child.












If CDEM.15 is >1 and CDEM.15 does not equal 88 or 99, read intro text 2



Intro text 2

Previously, you indicated there were [number] children age 17 or younger in your household. Think about those [number] children in order of their birth, from oldest to youngest. The oldest child is the first child and the youngest child is the last. Please include children with the same birth date, including twins, in the order of their birth.



CATI INSTRUCTION: RANDOMLY SELECT ONE OF THE CHILDREN. This is the Xth child. Please substitute Xth child’s number in all questions below.

INTERVIEWER PLEASE READ: I have some additional questions about one specific child. The child I will be referring to is the Xth [CATI: please fill in correct number] child in your household. All following questions about children will be about the Xth [CATI: please fill in] child.



MRCS.01


What is the birth month and year of the [Xth] child?

RCSBIRTH


_ _ /_ _ _ _ Code month and year

77/ 7777 Don’t know / Not sure

99/ 9999 Refused



565-570

MRCS.02

Is the child a boy or a girl?

RCSGENDR

1 Boy

2 Girl

9 Refused



571

MRCS.03

Is the child Hispanic, Latino/a, or Spanish origin?

RCHISLA1

Read if response is yes:

Are they 1 Mexican, Mexican American, Chicano/a

2 Puerto Rican

3 Cuban

4 Another Hispanic, Latino/a, or Spanish origin

Do not read:

5 No

7 Don’t know / Not sure

9 Refused



572-575

MRCS.04

Which one or more of the following would you say is the race of the child?

RCSRACE1

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

77 Don’t know / Not sure

88 No additional choices

99 Refused


Select all that apply


If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.

576-603





[CATI NOTE: IF MORE THAN ONE RESPONSE TO MRCS.04; CONTINUE. OTHERWISE, GO TO MRCS.06.]



MRCS.05

Which one of these groups would you say best represents the child’s race?

RCSBRAC2

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

77 Don’t know / Not sure

99 Refused


If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.

604-605

MRCS.06

How are you related to the child? Are you a….

RCSRLTN2

Please read:

1 Parent (include biologic, step, or adoptive parent)

2 Grandparent

3 Foster parent or guardian

4 Sibling (include biologic, step, and adoptive sibling)

5 Other relative

6 Not related in any way

Do not read:

7 Don’t know / Not sure

9 Refused



606









Module 28: Childhood Asthma Prevalence


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





If response to CDEM.15 = 88 (None) or 99 (Refused), go to next module.



MCAP.01


The next two questions are about the Xth child.

Has a doctor, nurse or other health professional EVER said that the child has asthma?

CASTHDX2



1 Yes


Fill in correct [Xth] number.


607

2 No

7 Don’t know/ not sure

9 Refused

Go to next module

MCAP.02

Does the child still have asthma?

CASTHNO2

1 Yes

2 No

7 Don’t know/ not sure

9 Refused



608















Module 29: Aspirin for CVD Prevention


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M15.01


How often do you take an aspirin to prevent or control heart disease, heart attacks or stroke? Would you say….


Read:

1 Daily

2 Some days

3 Used to take it but had to stop due to side effects, or

4 Do not take it

Do not read:

7 Don’t know / Not sure

9 Refused







Module 30: Home/ Self-measured Blood Pressure


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M16.01


Has your doctor nurse or other healthcare professional recommended you check your blood pressure outside of the office or at home?


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


By other healthcare professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.


M16.02

Do you regularly check your blood pressure outside of your healthcare professional’s office or at home?


1 Yes




2 No

7 Don’t know / Not sure

9 Refused

Go to next section


M16.03

Do you take it mostly at home or on a machine at a pharmacy, grocery or similar location?


1 At home

2 On a machine at a pharmacy, grocery or similar location

3 Do not check it

7 Don’t know / Not sure

9 Refused




M16.04

How do you share your blood pressure numbers that you collected with your healthcare professional? Is it mostly by telephone, other methods such as emails, internet portal or fax, or in person?


Do not read:

1 Telephone

2 Other methods such as email, internet portal, or fax, or

3 In person




Do not read:

4 Do not share information

7 Don’t know / Not sure

9 Refused





Module 31: Food Stamps


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M27.01

In the past 12 months, have you received food stamps, also called SNAP, the Supplemental Nutrition Assistance Program on an EBT card?


1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused


Food Stamps or SNAP (Supplemental Nutrition Assistance Program) is a government program that provides plastic cards, also known as EBT (Electronic Benefit Transfer) cards, that can be used to buy food. In the past, SNAP was called the Food Stamp Program and gave people benefits in paper coupons or food stamps.













Module 32: Sleep Disorder




1.  Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?

__ __ 01-14 days

  1. None

77 Don’t know/Not sure

99 Refused


    1. Over the last 2 weeks, how many days did you unintentionally fall asleep during the day?

__ __ 01-14 days

88 None

77 Don’t know/Not sure

99 Refused

3.  Have you ever been told that you snore loudly?

1 Yes

2 No

7 Don’t know/Not sure

9 Refused



4.  Has anyone ever observed that you stop breathing during your sleep?

INTERVIEWER NOTE: ALSO ENTER YES IF RESPONDENT MENTIONS HAVING A MACHINE OR CPAP THAT RECORDS THAT BREATHING SOMETIMES STOPS DURING THE NIGHT.

1 Yes

2 No

7 Don’t know/Not sure

9 Refused





Module 33: Anxiety and Depression


1 Over the last 2 weeks, how often have you been bothered by having little interest or pleasure in doing things. Would you say this happens...

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

9.2 Over the last 2 weeks, how often have you been bothered by feeling down, depressed or hopeless? Would you say this happens…

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

9.3 Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge? Would you say this happens…

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

9.4 Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying? Would you say this happens…

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused




Module 34: Adult Asthma History



CATI NOTE: If Yes to Core Q6.4; continue. Otherwise, go to next module.

Previously you said you were told by a doctor, nurse or other health professional that you had asthma.



1. How old were you when you were first told by a doctor, nurse, or other health professional that you had asthma?

_ _ Age in years 11 or older [96 = 96 and older]

97 Age 10 or younger

98 Don’t know / Not sure

99 Refused



CATI NOTE: If Yes to Core Q6.5, continue. Otherwise, go to next module.


2. During the past 12 months, have you had an episode of asthma or an asthma attack?


1 Yes

2 No [Go to Q5]

7 Don’t know / Not sure [Go to Q5] 9 Refused [Go to Q5]


    1. During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma?


_ _ Number of visits [87 = 87 or more]

88 None

98 Don’t know / Not sure

99 Refused



4. [If one or more visits to Q3, fill in Besides those emergency room or urgent care center visits,] During the past 12 months, how many times did you see a doctor, nurse or other health professional for urgent treatment of worsening asthma symptoms?


_ _ Number of visits [87 = 87 or more]

88 None

  1. Don’t know / Not sure

99 Refused




  1. During the past 12 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma?

_ _ Number of visits [87 = 87 or more]

88 None

98 Don’t know / Not sure

99 Refused



6. During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma?


_ _ _ Number of days

888 None

777 Don’t know / Not sure

999 Refused



7. Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness and phlegm production when you don’t have a cold or respiratory infection. During the past 30 days, how often did you have any symptoms of asthma? Would you say —

NOTE: Phlegm (‘flem’)


Please read:


8 Not at any time [Go to Q9]

1 Less than once a week

2 Once or twice a week

3 More than 2 times a week, but not every day

4 Every day, but not all the time


Or


5 Every day, all the time


Do not read:


7 Don’t know / Not sure

9 Refused


8. During the past 30 days, how many days did symptoms of asthma make it difficult for you to stay asleep? Would you say —

Please read:


8 None

1 One or two

2 Three to four

3 Five

4 Six to ten


Or


5 More than ten


Do not read:


7 Don’t know / Not sure

9 Refused



9. During the past 30 days, how many days did you take a prescription asthma medication to prevent an asthma attack from occurring?

READ IF NECESSARY


8 Never

1 1 to 14 days

2 15 to 24 days

3 25 to 30 days


Do not read:


7 Don’t know / Not sure

9 Refused




10. During the past 30 days, how often did you use a prescription asthma inhaler during an asthma attack to stop it?



INTERVIEWER NOTE: HOW OFTEN (NUMBER OF TIMES) DOES NOT EQUAL NUMBER OF PUFFS. TWO TO THREE PUFFS ARE USUALLY TAKEN EACH TIME THE INHALER IS USED.


READ IF NECESSARY:


8 Never (include no attack in past 30 days)

1 1 to 4 times (in the past 30 days)

2 5 to 14 times (in the past 30 days)

3 15 to 29 times (in the past 30 days)

4 30 to 59 times (in the past 30 days)

5 60 to 99 times (in the past 30 days)

6 100 or more times (in the past 30 days)


Do not read:


7 Don’t know / Not sure

9 Refused




Module 35: Respiratory Health (COPD Symptoms)


The next few questions are about breathing problems you may have.

  1. During the past 3 months, did you have a cough on most days?


1 Yes

2 No

7 Don’t know / Not sure

9 Refused

  1. During the past 3 months, did you cough up phlegm [FLEM] or mucus on most days?


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


  1. Do you have shortness of breath either when hurrying on level ground or when walking up a slight hill or stairs?


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


  1. Have you ever been given a breathing test to diagnose breathing problems?


1 Yes

2 No

7 Don’t know / Not sure

9 Refused

  1. Over your lifetime, how many years have you smoked tobacco products?


_ _ Number of years (01-76)

88 Never smoked or smoked less than one year

77 Don’t know/Not sure

99 Refused

Module 36: Indoor Tanning

1. Not including spray-on tans, during the past 12 months, how many times have you used an indoor tanning device such as a sunlamp, tanning bed, or booth?


DO NOT READ:

Enter number (0-365) __ __ __

777 Don’t know/ Not sure

999 Refused




Module 37: Excess Sun Exposure



1.    During the past 12 months, how many times have you had a sunburn?


DO NOT READ:

Enter number (0-365) __ __ __

777 Don’t know/ Not sure

999 Refused


2. When you go outside on a warm sunny day for more than one hour, how often do you protect yourself from the sun? Is that….


INTERVIEWER NOTE: PROTECTION FROM THE SUN MAY INCLUDE USING SUNSCREEN, WEARING A WIDE-BRIMMED HAT, OR WEARING A LONG-SLEEVED SHIRT


READ:

1 Always

2 Most of the time

3 Sometimes

4 Rarely

5 Never


DO NOT READ:

6 Don’t stay outside for more than one hour on warm sunny days

8 Don’t go outside at all on warm sunny days

7 Don’t know/ Not sure

9 Refused


3.    On weekdays, in the summer, how long are you outside per day between 10am and 4pm?

INTERVIEWER NOTE: FRIDAY IS A WEEKDAY

INTERVIEWER NOTE: IF RESPONDENT SAYS NEVER CODE 01


DO NOT READ:

1 Less than half an hour

2 (More than half an hour) up to 1 hour

3 (More than 1 hour) up to 2 hours

4 (More than 2 hours) up to 3 hours

5 (More than 3 hours) up to 4 hours

6 (More than 4 hours) up to 5 hours

7 (More than 5) up to 6 hours



77 Don’t know/ Not sure

99 Refused


4.    On weekends in the summer, how long are you outside each day between 10am and 4pm?



INTERVIEWER NOTE: FRIDAY IS A WEEKDAY

INTERVIEWER NOTE: IF RESPONDENT SAYS NEVER CODE 01

DO NOT READ:

1 Less than half an hour

2 (More than half an hour) up to 1 hour

3 (More than 1 hour) up to 2 hours

4 (More than 2 hours) up to 3 hours

5 (More than 3 hours) up to 4 hours

6 (More than 4 hours) up to 5 hours

7 (more than 5) up to 6 hours


77 Don’t know/ Not sure

99 Refused







Module 38: Actions to Control High Blood Pressure



[CATI NOTE: IF CORE Q4.1 = 1 (YES); CONTINUE. OTHERWISE, GO TO NEXT MODULE. ]


Earlier you stated that you had been diagnosed with high blood pressure.

Are you now doing any of the following to help lower or control your high blood pressure?


1. (Are you) changing your eating habits (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused


2. (Are you) cutting down on salt (to help lower or control your high blood pressure)?

1 Yes

2 No

3 Do not use salt

7 Don‘t know / Not sure

9 Refused


3. (Are you) reducing alcohol use (to help lower or control your high blood pressure)?

1 Yes

2 No

3 Do not drink

7 Don‘t know / Not sure

9 Refused


4. (Are you) exercising (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused


Has a doctor or other health professional ever advised you to do any of the following to help lower or control your high blood pressure?

5. (Ever advised you to) change your eating habits (to help lower or control your high blood pressure)?


1 Yes

2 No

7 Don‘t know / Not sure

9 Refused


6. (Ever advised you to) cut down on salt (to help lower or control your high blood pressure)?

1 Yes

2 No

3 Do not use salt

7 Don‘t know / Not sure

9 Refused


7. (Ever advised you to) reduce alcohol use (to help lower or control your high blood pressure)?

1 Yes

2 No

3 Do not drink

7 Don‘t know / Not sure

9 Refused

8. (Ever advised you to) exercise (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused


9. (Ever advised you to) take medication (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused



10. Were you told on two or more different visits by a doctor or other health professional that you had high blood pressure?

INTERVIEWER NOTE: IF “YES” AND RESPONDENT IS FEMALE, ASK: “WAS THIS ONLY WHEN YOU WERE PREGNANT?”


1 Yes

2 Yes, but female told only during pregnancy

3 No

4 Told borderline or pre-hypertensive

7 Don‘t know / Not sure

9 Refused





Module 39: Arthritis Management



Question Number


Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)





2 No

7 Don’t know / Not sure

9 Refused

Go to next section



C08.02


Has a doctor or other health professional ever suggested physical activity or exercise to help your arthritis or joint symptoms?

ARTHEXER

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


If the respondent is unclear about whether this means increase or decrease in physical activity, this means increase.


C08.03


Have you ever taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?

ARTHEDU

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




C08.04


Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?

LMTJOIN3

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


If a respondent question arises about medication, then the interviewer should reply: "Please answer the question based on your current experience, regardless of whether you are taking any medication or treatment”


C08.05


In the next question, we are referring to work for pay. Do arthritis or joint symptoms now affect whether you work, the type of work you do or the amount of work you do?

ARTHDIS2

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


If respondent gives an answer to each issue (whether works, type of work, or amount of work), then if any issue is "yes" mark the overall response as "yes." If a question arises about medications or treatment, then the interviewer should say: "Please answer the question based on your current experience, regardless of whether you are taking any medication or treatment."


C08.06


Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. During the past 30 days, how bad was your joint pain on average on a scale of 0 to 10 where 0 is no pain and 10 is pain or aching as bad as it can be?

JOINPAI2

__ __ Enter number [00-10]

77 Don’t know/ Not sure

99 Refused








Module 40: Alcohol Screening & Brief Intervention (ASBI)


CATI NOTE: IF CORE Q3.4 = 1, OR 2 (HAD A CHECKUP WITHIN THE PAST 2 YEARS) CONTINUE, ELSE GO TO NEXT MODULE.


Healthcare providers may ask during routine checkups about behaviors like alcohol use, whether you drink or not. We want to know about their questions.

1. You told me earlier that your last routine checkup was [within the past year/within the past 2 years]. At that checkup, were you asked in person or on a form if you drink alcohol?

1 Yes

2 No

7 Don't know / Not sure

9 Refused


2. Did the health care provider ask you in person or on a form how much you drink?

1 Yes

2. No

7 Don't know / Not sure

9 Refused

3. Did the healthcare provider specifically ask whether you drank [5 FOR MEN /4 FOR WOMEN] or more alcoholic drinks on an occasion?

1 Yes

2 No

7 Don't know / Not sure

9 Refused


4. Were you offered advice about what level of drinking is harmful or risky for your health?

1 Yes

2 No

7 Don't know / Not sure

9 Refused


[CATI NOTE: IF QUESTION 1, 2, OR 3 = 1 (YES) CONTINUE, ELSE GO TO NEXT MODULE.]

5. Healthcare providers may also advise patients to drink less for various reasons. At your last routine checkup, were you advised to reduce or quit your drinking?

1 Yes

2 No

7 Don't know / Not sure

9 Refused




Module 41: Sugar Sweetened Beverages


1. During the past 30 days, how often did you drink regular soda or pop that contains sugar? Do not include diet soda or diet pop.


Please read: You can answer times per day, week, or month: for example, twice a day, once a week, and so forth.

1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month


Do not read:


888 None

777 Don’t know / Not sure

999 Refused


2. During the past 30 days, how often did you drink sugar-sweetened fruit drinks (such as Kool-aid™ and lemonade), sweet tea, and sports or energy drinks (such as Gatorade™ and Red Bull™)? Do not include 100% fruit juice, diet drinks, or artificially sweetened drinks.


Please read: You can answer times per day, week, or month: for example, twice a day, once a week, and so forth.

1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month


Do not read:


888 None

777 Don’t know / Not sure

999 Refused





Module 42: Sodium or Salt-Related Behavior



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M17.01

Are you currently watching or reducing your sodium or salt intake?

WTCHSALT

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused




M17.02

Has a doctor or other health professional ever advised you to reduce sodium or salt intake?

DRADVISE

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused







Module 43: Preconception Health/Family Planning


[CATI NOTE: IF RESPONDENT IS FEMALE AND GREATER THAN 49 YEARS OF AGE, HAS HAD A HYSTERECTOMY, IS PREGNANT, OR IF RESPONDENT IS MALE GO TO THE NEXT MODULE.]

The next set of questions asks you about your thoughts and experiences with family planning. Please remember that all of your answers will be kept confidential.




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

1 Yes

2 No [GO TO Q3]

3 No partner/not sexually active [GO TO NEXT MODULE]

4 Same sex partner [GO TO NEXT MODULE]

5 Has had a Hysterectomy [GO TO NEXT MODULE]

7 Don’t know/Not sure [GO TO Q3]

9 Refused [GO TO Q3].


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

INTERVIEWER NOTE: IF RESPONDENT REPORTS USING MORE THAN ONE METHOD, PLEASE CODE THE METHOD THAT OCCURS FIRST ON THE LIST.


INTERVIEWER NOTE: IF RESPONDENT REPORTS USING “CONDOMS,” PROBE TO DETERMINE IF “FEMALE CONDOMS” OR MALE CONDOMS.”


INTERVIEWER NOTE: IF RESPONDENT REPORTS USING AN “IUD” PROBE TO DETERMINE IF “LEVONORGESTREL IUD” OR “COPPER-BEARING IUD.”


INTERVIEWER NOTE: IF RESPONDENT REPORTS “OTHER METHOD,” ASK RESPONDENT TO “PLEASE BE SPECIFIC” AND ENSURE THAT THEIR RESPONSE DOES NOT FIT INTO ANOTHER CATEGORY. IF RESPONSE DOES FIT INTO ANOTHER CATEGORY, PLEASE MARK APPROPRIATELY.


Read only if necessary:


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

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

03 Contraceptive implant (ex. Implanon) [GO TO NEXT MODULE]

04 Levonorgestrel (LEE-voe-nor-JES-trel) (LNG) or hormonal IUD (ex. Mirena) [GO TO NEXT MODULE]

05 Copper-bearing IUD (ex. ParaGard) [GO TO NEXT MODULE]

06 IUD, type unknown [GO TO NEXT MODULE]

07 Shots (ex. Depo-Provera) [GO TO NEXT MODULE]

08 Birth control pills, any kind [GO TO NEXT MODULE]

09 Contraceptive patch (ex. Ortho Evra) [GO TO NEXT MODULE]

10 Contraceptive ring (ex. NuvaRing) [GO TO NEXT MODULE]

11 Male condoms [GO TO NEXT MODULE]

12 Diaphragm, cervical cap, sponge [GO TO NEXT MODULE]

13 Female condoms [GO TO NEXT MODULE]

14 Not having sex at certain times (rhythm or natural family planning) [GO TO NEXT MODULE]

15 Withdrawal (or pulling out) [GO TO NEXT MODULE]

16 Foam, jelly, film, or cream [GO TO NEXT MODULE]

17 Emergency contraception (morning after pill) [GO TO NEXT MODULE]

18 Other method [GO TO NEXT MODULE]

Do not read:

77 Don’t know/Not sure

99 Refused


3. 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?

INTERVIEWER NOTE: IF RESPONDENT REPORTS “OTHER REASON,” ASK RESPONDENT TO “PLEASE SPECIFY” AND ENSURE THAT THEIR RESPONSE DOES NOT FIT INTO ANOTHER CATEGORY. IF RESPONSE DOES FIT INTO ANOTHER CATEGORY, PLEASE MARK APPROPRIATELY.


Read only 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 reasons


77 Don’t know/Not sure

99 Refused





Module 44: Emotional Support and Life Satisfaction


1. How often do you get the social and emotional support you need?


INTERVIEWER NOTE: IF ASKED, SAY “PLEASE INCLUDE SUPPORT FROM ANY SOURCE.”

Please read:


1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:


7 Don't know / Not sure

9 Refused


2. In general, how satisfied are you with your life? (475)


Please read:


1 Very satisfied

2 Satisfied

3 Dissatisfied

4 Very dissatisfied


Do not read:


7 Don't know / Not sure

9 Refused






Module 45: Social Determinants of Health


1. During the last 12 months, was there a time when you were not able to pay your mortgage, rent or utility bills?


1 Yes

2 No

7 Don’t know/not sure

9 Refused

2. In the last 12 months, how many times have you moved from one home to another?

__ __ Number of moves in past 12 months [01-52]

88 None (Did not move in past 12 months)

77 Don’t know/Not sure

99 Refused



3. How safe from crime do you consider your neighborhood to be? Would you say…

Please read:


1 Extremely safe

2 Safe

3 Unsafe

4 Extremely unsafe

Do not read:

7 Don’t know/Not sure

9 Refused


4. For the next two statements, please tell me whether the statement was often true, sometimes true, or never true for you in the last 12 months (that is, since last [CATI NOTE: NAME OF CURRENT MONTH]). The first statement is, “The food that I bought just didn’t last, and I didn’t have money to get more.”




Was that often, sometimes, or never true for you in the last 12 months?


1 Often true,

2 Sometimes true, or

3 Never true

Do not read:

7 Don’t Know/Not sure

9 Refused


5. “I couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for you in the last 12 months?


1 Often true,

2 Sometimes true, or

3 Never true

Do not read:

7 Don’t Know /Not sure

9 Refused




6. In general, how do your finances usually work out at the end of the month? Do you find that you usually:

Please read:


1 End up with some money left over,

2 Have just enough money to make ends meet, or

3 Do not have enough money to make ends meet

Do not read:

7 Don’t Know/Not sure

9 Refused


7. Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his/her mind is troubled all the time. Within the last 30 days, how often have you felt this kind of stress?

Please read:


1 None of the time,

2 A little of the time,

3 Some of the time,

4 Most of the time, or

5 All of the time


Do not read:

7. Don't know/not sure

9. Refused


  1. During the last 12 months was there a time when an electric, gas, oil, or water company threatened to shut off services?

1 Yes

2 No

7 Don’t know/not sure

9 Refused


  1. In the past 12 months has a lack of reliable transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?


1 Yes

  1. No

7. Don’t know/not sure

9. Refused


10. How often do you feel isolated from others?

1. Always,

2. Usually,

3. Sometimes,

4. Rarely,

5. Never

7. Don’t know/not sure

9. Refused



11. How often do you feel you lack companionship? Always, usually, sometimes, rarely, never

1.. Always,

2. Usually,

3. Sometimes,

4. Rarely,

5. Never

7. Don’t know/not sure

9. Refused


12. How often do you feel left out?

1. Always,

2. Usually,

3. Sometimes,

4. Rarely,

5. Never

7. Don’t know/not sure

9 . Refused



Module 46: Sleep Disorder


  1. On average, how many hours of sleep do you get in a 24-hour period?


INTERVIEWER NOTE: ENTER HOURS OF SLEEP IN WHOLE NUMBERS, ROUNDING 30 MINUTES (1/2 HOUR) OR MORE UP TO THE NEXT WHOLE HOUR AND DROPPING 29 OR FEWER MINUTES.

__ __ Number of hours [01-24]

77 Don’t know/Not sure

99 Refused


  1. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?


__ __ 01-14 days

88 None

77 Don’t know/Not sure

99 Refused


3. Over the last 2 weeks, how many days did you unintentionally fall asleep during the day?


__ __ 01-14 days

88 None

77 Don’t know/Not sure

99 Refused


4. Have you ever been told that you snore loudly?


1 Yes

2 No

7 Don’t know/Not sure

9 Refused

5. Has anyone ever observed that you stop breathing during your sleep? (366)


INTERVIEWER NOTE: ALSO ENTER “YES” IF RESPONDENT MENTIONS HAVING A MACHINE OR CPAP THAT RECORDS THAT BREATHING SOMETIMES STOPS DURING THE NIGHT.


1 Yes

2 No

7 Don’t know/Not sure

9 Refused


Module 47: Health Literacy



  1. How difficult is it for you to get advice or information about health or medical topics if you need it?

    1. Not at all

    2. A little

    3. Somewhat, or

    4. Very difficult or

    5. Never tried to get advice or information


7. Don’t know/not sure

9. Refused



  1. How difficult is it for you to understand information that doctors, nurses and other health professionals tell you?


    1. Not at all

    2. A little

    3. Somewhat, or

    4. Very difficult or

    5. Never tried to get advice or information


7. Don’t know/not sure

9. Refused



  1. You can find written information about health on the Internet, in newspapers and magazines, and in brochures in the doctor’s office and clinic. In general, how difficult is it for you to understand written health information?


    1. Not at all

    2. A little

    3. Somewhat, or

    4. Very difficult or

    5. Never tried to get advice or information


7. Don’t know/not sure

9. Refused


Module 48: Clinical Breast Exam


CATI NOTE: If respondent is male, go to the next section.



  1. A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you ever had a clinical breast exam?

  1. Yes

2 No [Go to next module]

7 Don’t know / Not sure [Go to next module]

9 Refused [Go to next module]

  1. How long has it been since your last breast exam?


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

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

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

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

5 5 or more years ago

7 Don’t know / Not sure

9 Refused




Module 49: Exercise (Physical Activity)


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C11.01

During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

EXERANY2

1 Yes


If respondent does not have a regular job or is retired, they may count the physical activity or exercise they spend the most time doing in a regular month.

223

2 No

7 Don’t know/Not Sure

9 Refused

Go to C 11.08

C11.02

What type of physical activity or exercise did you spend the most time doing during the past month?

EXRACT11

__ __ Specify from Physical Activity Coding List


See Physical Activity Coding List.

If the respondent’s activity is not included in the physical activity coding list, choose the option listed as “other”.


224-225

77 Don’t know/ Not Sure

99 Refused

Go to C11.08

C11.03

How many times per week or per month did you take part in this activity during the past month?

EXEROFT1

1_ _ Times per week

2_ _ Times per month

777 Don’t know / Not sure

999 Refused



226-228

C11.04

And when you took part in this activity, for how many minutes or hours did you usually keep at it?

EXERHMM1

_:_ _ Hours and minutes

777 Don’t know / Not sure

999 Refused



229-231

C11.05

What other type of physical activity gave you the next most exercise during the past month?

EXRACT21

__ __ Specify from Physical Activity List


See Physical Activity Coding List.


If the respondent’s activity is not included in the physical activity coding list, choose the option listed as “other”.


232-233

88 No other activity

77 Don’t know/ Not Sure

99 Refused

Go to C11.08

C11.06

How many times per week or per month did you take part in this activity during the past month?

EXEROFT2

1_ _ Times per week

2_ _ Times per month

777 Don’t know / Not sure

999 Refused



234-236

C11.07

And when you took part in this activity, for how many minutes or hours did you usually keep at it?

EXERHMM2

_:_ _ Hours and minutes

777 Don’t know / Not sure

999 Refused



237-239

C11.08

During the past month, how many times per week or per month did you do physical activities or exercises to strengthen your muscles?

STRENGTH

1_ _ Times per week

2_ _Times per month

888 Never

777 Don’t know / Not sure

999 Refused


Do not count aerobic activities like walking, running, or bicycling. Count activities using your own body weight like yoga, sit-ups or push-ups and those using weight machines, free weights, or elastic bands.

240-242




Module 50: Fruits and Vegetables


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

C12.01

Now think about the foods you ate or drank during the past month, that is, the past 30 days, including meals and snacks.

Not including juices, how often did you eat fruit? You can tell me times per day, times per week or times per month.

FRUIT2

1_ _ Day

2_ _ Week

3_ _ Month

300 Less than once a month

555 Never

777 Don’t Know

999 Refused


If a respondent indicates that they consume a food item every day then enter the number of times per day. If the respondent indicates that they eat a food less than daily, then enter times per week or time per month. Do not enter time per day unless the respondent reports that he/she consumed that food item each day during the past month.

Enter quantity in times per day, week, or month.

If respondent gives a number without a time frame, ask “was that per day, week, or month?”

Read if respondent asks what to include or says ‘i don’t know’: include fresh, frozen or canned fruit. Do not include dried fruits.


243-245

C12.02

Not including fruit-flavored drinks or fruit juices with added sugar, how often did you drink 100% fruit juice such as apple or orange juice?

FRUITJU2

1_ _ Day

2_ _ Week

3_ _ Month

300 Less than once a month

555 Never

777 Don’t Know

999 Refused


Read if respondent asks about examples of fruit-flavored drinks: “do not include fruit-flavored drinks with added sugar like cranberry cocktail, Hi-C, lemonade, Kool-Aid, Gatorade, Tampico, and sunny delight. Include only 100% pure juices or 100% juice blends.”

Enter quantity in times per day, week, or month.

If respondent gives a number without a time frame, ask “Was that per day, week, or month?”

246-248

C12.03

How often did you eat a green leafy or lettuce salad, with or without other vegetables?

FVGREEN1

1_ _ Day

2_ _ Week

3_ _ Month

300 Less than once a month

555 Never

777 Don’t Know

999 Refused


Enter quantity in times per day, week, or month.

If respondent gives a number without a time frame, ask “Was that per day, week, or month?”

Read if respondent asks about spinach: “Include spinach salads.”

249-251

C12.04

How often did you eat any kind of fried potatoes, including French fries, home fries, or hash browns?

FRENCHF1

1_ _ Day

2_ _ Week

3_ _ Month

300 Less than once a month

555 Never

777 Don’t Know

999 Refused


Enter quantity in times per day, week, or month.

If respondent gives a number without a time frame, ask “Was that per day, week, or month?”

Read if respondent asks about potato chips: “Do not include potato chips.”

252-254

C12.05

How often did you eat any other kind of potatoes, or sweet potatoes, such as baked, boiled, mashed potatoes, or potato salad?

POTATOE1

1_ _ Day

2_ _ Week

3_ _ Month

300 Less than once a month

555 Never

777 Don’t Know

999 Refused


Enter quantity in times per day, week, or month.

If respondent gives a number without a time frame, ask “Was that per day, week, or month?”


Read if respondent asks about what types of potatoes to include: “Include all types of potatoes except fried. Include potatoes au gratin, scalloped potatoes.”


255-257

C12.06

Not including lettuce salads and potatoes, how often did you eat other vegetables?

VEGETAB2

1_ _ Day

2_ _ Week

3_ _ Month

300 Less than once a month

555 Never

777 Don’t Know

999 Refused


Enter quantity in times per day, week, or month.

If respondent gives a number without a time frame, ask “Was that per day, week, or month?”


Read if respondent asks about what to include: “Include tomatoes, green beans, carrots, corn, cabbage, bean sprouts, collard greens, and broccoli. Include raw, cooked, canned, or frozen vegetables. Do not include rice.”

258-260




Module 51: Heart Attack and Stroke

Now I would like to ask you about your knowledge of the signs and symptoms of a heart attack and stroke.

Which of the following do you think is a symptom of a heart attack? For each, tell me “yes”, “no”, or you’re “not sure”.

1.(Do you think) pain or discomfort in the jaw, neck, or back (are symptoms of a heart attack?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

2.(Do you think) feeling weak, lightheaded, or faint (are symptoms of a heart attack?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

3.(Do you think) chest pain or discomfort (are symptoms of a heart attack?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

4.(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a heart attack?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

5.(Do you think) pain or discomfort in the arms or shoulder (are symptoms of a heart attack?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

6.(Do you think) shortness of breath (is a symptom of a heart attack?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused



7.(Do you think) sudden confusion or trouble speaking (are symptoms of a stroke?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

8.(Do you think) sudden numbness or weakness of face, arm, or leg, especially on one side, (are symptoms of a stroke?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

9.(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a stroke?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

10.(Do you think) sudden chest pain or discomfort (are symptoms of a stroke?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

11.(Do you think) sudden trouble walking, dizziness, or loss of balance (are symptoms of a stroke?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

12.(Do you think) severe headache with no known cause (is a symptom of a stroke?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

13.If you thought someone was having a heart attack or a stroke, what is the first thing you would do?

Please read:


1 Take them to the hospital

2 Tell them to call their doctor

3 Call 911

4 Call their spouse or a family member

Or

5 Do something else


Do not read:

7 Don‘t know / Not sure

9 Refused



Module 52: Anxiety and Depression


Now, I am going to ask you some questions about your mood. When answering these questions, please think about how many days each of the following has occurred in the past 2 weeks.



1. Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?

(435-436)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused



2. Over the last 2 weeks, how many days have you felt down, depressed or hopeless?

(437-438)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused



3. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?

(439-440)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused



4. Over the last 2 weeks, how many days have you felt tired or had little energy?

(441-442)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused



5. Over the last 2 weeks, how many days have you had a poor appetite or eaten too much?

(443-444)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused



6. Over the last 2 weeks, how many days have you felt bad about yourself or that you were a failure or had let yourself or your family down?

(445-446)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused


7. Over the last 2 weeks, how many days have you had trouble concentrating on things, such as reading the newspaper or watching the TV?

(447-448)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused


8. Over the last 2 weeks, how many days have you moved or spoken so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you were

moving around a lot more than usual?

(449-450)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused



9. Are you now taking medicine or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem?

(451)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



10. Has a doctor or other healthcare provider EVER told you that you have an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder,

obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or

social anxiety disorder)?

(452)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused







Module 53: Mental Illness and Stigma



Now, I am going to ask you some questions about how you have been feeling lately.



1. About how often during the past 30 days did you feel nervous — would you say all of the

time, most of the time, some of the time, a little of the time, or none of the time?

(338)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused



2. During the past 30 days, about how often did you feel hopeless all of the time, most of the time, some of the time, a little of the time, or none of the time?

(339)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused


3. During the past 30 days, about how often did you feel restless or fidgety?


[If necessary: all, most, some, a little, or none of the time?]

(340)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused



4. During the past 30 days, about how often did you feel so depressed that nothing could

cheer you up?


[If necessary: all, most, some, a little, or none of the time?]

(341)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused



5. During the past 30 days, about how often did you feel that everything was an effort?


Note: If respondent asks what does “everything was an effort” means; say, “Whatever it means to you”


[If necessary: all, most, some, a little, or none of the time?]

(342)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused



6. During the past 30 days, about how often did you feel worthless?


[If necessary: all, most, some, a little, or none of the time?]

(343)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused



7. During the past 30 days, for about how many days did a mental health condition or emotional problem keep you from doing your work or other usual activities?

(344-345)

_ _ Number of days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused



INTERVIEWER NOTE: If asked, "usual activities" includes housework, self-care, care giving, volunteer work, attending school, studies, or recreation.


8. Are you now taking medicine or receiving treatment from a doctor or other health

professional for any type of mental health condition or emotional problem?

(346)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



These next questions ask about peoples' attitudes toward mental illness and its treatment.


9. Treatment can help people with mental illness lead normal lives. Do you –agree slightly

or strongly, or disagree slightly or strongly?

(347)

Read only if necessary:


1 Agree strongly

2 Agree slightly

3 Neither agree nor disagree

4 Disagree slightly

5 Disagree strongly


Do not read:


7 Don’t know / Not sure

9 Refused



10. People are generally caring and sympathetic to people with mental illness. Do you –

agree slightly or strongly, or disagree slightly or strongly?

(348)

Read only if necessary:


1 Agree strongly

2 Agree slightly

3 Neither agree nor disagree

4 Disagree slightly

5 Disagree strongly


Do not read:


7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: If asked for the purpose of Q9 or Q10: say: “answers to these questions will be used by health planners to help understand public attitudes about mental illness and its treatment and to help guide health education programs”.








Module 54: Social Context



Now, I am going to ask you about several factors that can affect a person’s health.


If Core Q7.21 = 1 or 2 (own or rent) continue, else go to Q2.


1. How often in the past 12 months would you say you were worried or stressed

about having enough money to pay your rent/mortgage? Would you say you were worried or stressed---

(349)

Please read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never


Do not read:


8 Not applicable

7 Don’t know / Not sure

9 Refused


2. How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say you were worried or

stressed---

(350)


Please read:


1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never


Do not read:


8 Not applicable

7 Don’t know / Not sure

9 Refused



If Core Q7.9 = 1 (Employed for wages) or 2 (Self-employed), go to Q3 and Q4.


If Core Q7.9 = 3 (Out of work for more than 1 year), 4 (Out of work for less than 1 year), or

7 (Retired), go to Q5 and Q6.


If Core Q7.9 = 5 (A homemaker), 6 (A student), or 8 (Unable to work), go to next module.



3. At your main job or business, how are you generally paid for the work you do. Are you:

(351)


1 Paid by salary

2 Paid by the hour

3 Paid by the job/task (e.g. commission, piecework)

4 Paid some other way

7 Don’t know / Not sure

9 Refused



INTERVIEWER NOTE: If paid in multiple ways at their main job, select option 4 (Paid some other way).

4. About how many hours do you work per week at all of your jobs and businesses combined?

(352-353)


_ _ Hours (01-96 or more) [Go to next module]

9 7 Don't know / Not sure [Go to next module]

9 8 Does not work [Go to next module]

9 9 Refused [Go to next module]



5. Thinking about the last time you worked, at your main job or business, how were you

generally paid for the work you did? Were you:

(354)


1 Paid by salary

2 Paid by the hour

3 Paid by the job/task (e.g. commission, piecework)

4 Paid some other way

7 Don’t know / Not sure

9 Refused



6. Thinking about the last time you worked, about how many hours did you work per week

at all of your jobs and businesses combined?

(355-356)


_ _ Hours (01-96 or more)

9 7 Don't know / Not sure

9 8 Does not work

9 9 Refused







Module 55: General Preparedness


The next series of questions asks about how prepared you are for a large-scale disaster or emergency. By large-scale disaster or emergency we mean any event that leaves you isolated in your home or displaces you from your home for at least 3 days. This might include natural disasters such as hurricanes, tornados, floods, and ice storms, or man-made disasters such as explosions, terrorist events, or blackouts.


1. How well prepared do you feel your household is to handle a large-scale disaster or emergency? Would you say…

(357)


Please read:


1 Well prepared

2 Somewhat prepared

3 Not prepared at all


Do not read:


7 Don’t know / Not sure

9 Refused



2. Does your household have a 3-day supply of water for everyone who lives there? A 3-day supply of water is 1 gallon of water per person per day.

(358)


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



3. Does your household have a 3-day supply of nonperishable food for everyone who lives there? By nonperishable we mean food that does not require refrigeration or cooking.

(359)


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


4. Does your household have a 3-day supply of prescription medication for each person who takes prescribed medicines?

(360)


1 Yes

2 No

3 No one in household requires prescribed medicine

7 Don’t know / Not sure

9 Refused



5. Does your household have a working battery operated radio and working batteries for your use if the electricity is out?

(361)


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



6. Does your household have a working flashlight and working batteries for your use if the electricity is out?

(362)


1 Yes

2 No

7 Don’t know / Not sure

9 Refused


7. In a large-scale disaster or emergency, what would be your main method or way of

communicating with relatives and friends?

(363)

Read only if necessary:


1 Regular home telephones

2 Cell phones

3 Email

4 Pager

5 2-way radios

6 Other


Do not read:


7 Don’t know / Not sure

9 Refused


8. What would be your main method or way of getting information from authorities in a large-scale disaster or emergency?

(364)


Read only if necessary:


1 Television

2 Radio

3 Internet

4 Print media

5 Neighbors

6 Other


Do not read:


7 Don’t know / Not sure

9 Refused


9. Does your household have a written disaster evacuation plan for how you will leave your home, in case of a large-scale disaster or emergency that requires evacuation?

(365)


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



10. If public authorities announced a mandatory evacuation from your community due to a large-scale disaster or emergency, would you evacuate?

(366)


1 Yes [Go to next module]

2 No

7 Don’t know / Not sure

9 Refused


11. What would be the main reason you might not evacuate if asked to do so?

(367-368)


Read only if necessary:


0 1 Lack of transportation

0 2 Lack of trust in public officials

0 3 Concern about leaving property behind

0 4 Concern about personal safety

0 5 Concern about family safety

0 6 Concern about leaving pets

0 7 Concern about traffic jams and inability to get out

0 8 Health problems (could not be moved)

0 9 Other


Do not read:


7 7 Don’t know / Not sure

9 9 Refused





Module 56: Veteran’s Health


CATI NOTE: If Core Q7.5 = 1 (Yes) continue, else go to next module.


The next questions relate to veteran’s health.


1. Did you ever serve in a combat or war zone?

(369)

1 Yes

2 No

  1. Don’t know / Not sure

9 Refused



2. Has a doctor or other health professional ever told you that you have depression, anxiety, or post traumatic stress disorder (PTSD)?

(370)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



3. A traumatic brain injury may result from a violent blow to the head or when an object pierces the skull and enters the brain tissue. Has a doctor or other health professional

ever told you that you have suffered a traumatic brain injury (TBI)?

(371)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused



4. In the past 12 months, did you receive any psychological or psychiatric counseling or treatment?

(372)

Please read:

1 Yes, from a VA facility

2 Yes, from a non-VA facility

3 Yes, from both VA and non-VA facilities

4 No


Do not read:


7 Don’t know / Not sure

9 Refused


The next few questions are a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer.


5. Has there been a time in the past 12 months when you thought of taking your own life?

(373)

1 Yes

2 No [Go to next module]

7 Don’t know / Not sure [Go to next module]

9 Refused [Go to next module]



6. During the past 12 months, did you attempt to commit suicide? Would you say---

(374)

Please read:

1 Yes, but did not require treatment

2 Yes, was treated at a VA facility

3 Yes, was treated at a non-VA facility

4 No


Do not read:

  1. Don’t know / Not sure

9 Refused


As I mentioned, I would give you a phone number for an organization that can provide information and referral for these issues. You can dial the National Crisis line at 1-800-273-TALK (8255). You can also speak directly to your doctor or health provider.




Module 57: Reactions to Race

Earlier I asked you to self-identify your race. Now I will ask you how other people identify you and treat you.


1. How do other people usually classify you in this country? Would you say: White, Black or African American, Hispanic or Latino, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, or some other group?

(332)


1 White

2 Black or African American

3 Hispanic or Latino

4 Asian

5 Native Hawaiian or Other Pacific Islander

6 American Indian or Alaska Native

8 Some other group (please specify) _________________________

7 Don’t know / Not sure

9 Refused


INTERVIEWER NOTE: If the respondent requests clarification of this question, say: “We want to know how OTHER people usually classify you in this country, which might be different from how you classify yourself.”


2. How often do you think about your race? Would you say never, once a year, once a

month, once a week, once a day, once an hour, or constantly?

(333)


1 Never

2 Once a year

3 Once a month

4 Once a week

5 Once a day

6 Once an hour

8 Constantly

7 Don’t know / Not sure

9 Refused


INTERVIEWER INSTRUCTION: The responses can be interpreted as meaning “at least” the indicated time frequency. If a respondent cannot decide between two categories, check the response for the lower frequency. For example, if a respondent says that they think about their race between once a week and once a month, check “once a month” as the response.


3. Within the past 12 months, on average, were you treated worse than, the same as, or better than people of other races?

(334)

1 Worse than other races

2 The same as other races

3 Better than other races


Do not read:


4 Worse than some races, better than others

5 Only encountered people of the same race

7 Don’t know / Not sure

9 Refused




[CATI skip pattern: This question should only be asked of those who are “employed for wages,” “self-employed,” or “out of work for less than one year.”]


4. Within the past 12 months at work, do you feel you were treated worse than, the same as, or better than people of other races?

(335)


1 Worse than other races

2 The same as other races

3 Better than other races


Do not read:


4 Worse than some races, better than others

5 Only encountered people of the same race

7 Don’t know / Not sure

9 Refused



5. Within the past 12 months, when seeking health care, do you feel your experiences were worse than, the same as, or better than for people of other races?

(336)


1 Worse than other races

2 The same as other races

3 Better than other races

Do not read:


4 Worse than some races, better than others

5 Only encountered people of the same race

6 No health care in past 12 months

7 Don’t know / Not sure

9 Refused


INTERVIEWER NOTE: If the respondent indicates that they do not know about other people’s experiences when seeking health care, say: “This question is asking about your perceptions when seeking health care. It does not require specific knowledge about other people’s experiences.”



6. Within the past 30 days, have you experienced any physical symptoms, for example, a headache, an upset stomach, tensing of your muscles, or a pounding heart, as a result of how you were treated based on your race?

(337)


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



7. Within the past 30 days, have you felt emotionally upset, for example angry, sad, or frustrated, as a result of how you were treated based on your race?

(338)


1 Yes

2 No

7 Don’t know / Not sure

9 Refused



8. Within the past 30 days, have you felt emotionally upset (for example angry, sad, or frustrated) as a result of how other people were treated based on their race?

(339)

1 Yes

2 No

  1. Don’t know / Not sure

9. Refused


9. Do you think that people living in [fill in the name of this state] are treated differently depending on what race they are?

(340)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused





Module 59: WGSS Disability


Q1: Do you have difficulty seeing, even if wearing glasses?

  1. No difficulty

  2. Some difficulty

  3. A lot of difficulty

  4. Cannot do at all

  1. Refused

9. Don’t know/Not sure


Q2: Do you have difficulty hearing, even if using a hearing aid?

  1. No difficulty

  2. Some difficulty

  3. A lot of difficulty

  4. Cannot do at all

  1. Refused

  1. Don’t know/Not sure


Q3: Do you have difficulty walking or climbing steps?

  1. No difficulty

  2. Some difficulty

  3. A lot of difficulty

  4. Cannot do at all

  1. Refused

9.Don’t know/Not sure


Q3_ACS: Do you have difficulty walking or climbing stairs?

  1. No difficulty

  2. Some difficulty

  3. A lot of difficulty

  4. Cannot do at all

  1. Refused

  2. Don’t know/Not sure


Q4: Do you have difficulty remembering or concentrating?

  1. No difficulty

  2. Some difficulty

  3. A lot of difficulty

  4. Cannot do at all

  1. Refused

9.Don’t know/Not sure


Q5: Do you have difficulty with self-care, such as washing all over or dressing?

  1. No difficulty

  2. Some difficulty

  3. A lot of difficulty

  4. Cannot do at all

  1. Refused

9.Don’t know/Not sure


Q5_ACS: Do you have difficulty bathing or dressing?

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all

7. Refused

9. Don’t know/Not sure


Q6: Using your usual language, do you have difficulty communicating, for example, understanding or being understood?

  1. No difficulty

  2. Some difficulty

  3. A lot of difficulty

  4. Cannot do at all

  1. Refused

9. Don’t know/Not sure


Q7: Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?

  1. No difficulty

  2. Some difficulty

  3. A lot of difficulty

  4. Cannot do at all

  1. Refused

9.Don’t know/Not sure


Q7_ACS: Do you have difficulty doing errands alone such as visiting a doctor's office or shopping?

  1. No difficulty

  2. Some difficulty

  3. A lot of difficulty

  4. Cannot do at all

  1. Refused

9.Don’t know/Not sure



Module 60: Other Tobacco Use

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

1.             YES

2.             NO



7.             DON’T KNOW/NOT SURE

9.             REFUSED

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

1.             YES

2.             NO



7.             DON’T KNOW/NOT SURE

9.             REFUSED







Module 61: Periodontal Disease



  1. Gum disease is a common problem with the mouth. People with gum disease might have swollen gums, receding gums, sore or infected gums or loose teeth. Do you think you might have gum disease?

(1) Yes

(2) No

Do not read:

(7) Refused

(9) Don’t Know


  1. Overall, how would you rate the health of your teeth and gums?

(1) Excellent

(2) Very good

(3) Good

(4) Fair

(5) Poor

Do not read:

(7) Refused

(9) Don’t Know


  1. Have you ever had treatment for gum disease such as scaling and root planning, sometimes called “deep cleaning?”

(1) Yes

(2) No

Do not read:

(7) Refused

(9) Don’t Know


  1. Have you ever been told by a dental professional that you lost bone around your teeth?

1) Yes

(2) No

Do not read:

(7) Refused

(9) Don’t Know


  1. Aside from brushing your teeth with a toothbrush, in the last seven days, how many days did you use dental floss or any other device to clean between your teeth?

___(Number of days)

Interview instruction: Code “0” if the survey participant responds they have no teeth or only dentures.

Do not read:

77=Refused

99= Don’t Know

Module 62: Knowledge and Impact of COVID Pandemic


NOTE: These questions are included as placeholders for items that may be included in future BRFSS questionnaires. They are not currently supported by CDC program sponsors.

Question

Components

Response set

As far as you know, have public health experts recommended (INSERT ITEM) as a way to help slow the spread of coronavirus, or not? How about (INSERT NEXT ITEM), have public health experts recommended this as a way to help slow the spread of coronavirus, or not? (scramble items a-d)

a. Frequent hand washing

b. Healthy people wearing facemasks in public

c. Avoiding gatherings with large numbers of people

d. Staying home if you are feeling sick

Yes, recommended

No, not recommended

Don’t know/ Refused (NET)

Don’t know

Refused

As far as you know, is each of the following a way that coronavirus is transmitted, or not? First, (INSERT ITEM), is this a way that coronavirus is transmitted, or not? How about (INSERT NEXT ITEM)? (READ IF NECESSARY: Is this a way that coronavirus is transmitted, or not?) (scramble items a-c)

a. Being in close physical proximity with someone who is infected

b. Touching surfaces that contain small amounts of bodily fluids from someone who is infected

c. Through mosquito bites


Yes

No

Don’t know/ Refused (NET)

Don’t know

Refused

For each of the following please tell me if you think this is a common symptom of coronavirus, or not. First, (INSERT ITEM), is this a symptom of coronavirus, or not? How about (INSERT NEXT ITEM)? (READ IF NECESSARY: Is this a common symptom of coronavirus, or not?) (scramble items a-d)

a. Fever

b. Dry cough

c. Nasal congestion

d. Rash

Yes

No

Don’t know/ Refused (NET)

Don’t know

Refused

Compared to other groups, do you think (INSERT ITEM) have a higher risk of developing serious medical issues if they become infected with coronavirus, or not? How about (INSERT NEXT ITEM)? (READ IF NECESSARY: Compared to other groups, do you think (ITEM) have a higher risk of developing serious medical issues if they become infected with coronavirus, or not?) (scramble items a-c)

a. People over the age of 60

b. Children

c. People with chronic health conditions

Yes, have a higher risk

No, do not have a higher risk

Don’t know/ Refused (NET)

Don’t know

Refused

As far as you know, is there a vaccine to protect people from the current coronavirus, also known as COVID-19, or not?


Yes

No

Don’t know/ Refused (NET)

Don’t know

Refused

As far as you know, does the vaccine for influenza, or seasonal flu, protect people from the current coronavirus, also known as COVID-19, or not?


Yes

No

Don’t know/ Refused (NET)

Don’t know

Refused

As far as you know, do most people infected with coronavirus (recover without developing serious complications), or do most people (develop serious complications that require intensive care)? (rotate 1-2,2-1)


Most recover without developing serious complications

Most develop serious complications that require intensive care

Don’t know/Refused (NET)

Don’t know

Refused

As far as you know, if someone thinks they are having symptoms of coronavirus, should they (stay home and call a doctor or medical provider) or should they (seek health care immediately at an emergency room or urgent care facility)? (rotate 1-2,2-1)

3/20



Stay home and call a doctor or medical provider

73

Seek health care immediately at an emergency room or urgent care facility

25

Something else (Vol.)

*

Don’t know/Refused (NET)

2

Don’t know

1

Refused

Which of the following best describes your feelings about the coronavirus in the United States? (ROTATE FIRST TWO) +


The worst is behind us

The worst is yet to come

or…

The coronavirus is not likely to be that major of a problem Not sure

Please indicate your level of agreement or disagreement with the following statements

I am worried about getting the coronavirus.

I know what actions to take to prevent myself and my

family from becoming infected with the coronavirus.

I feel confident I can prevent myself and my family from

becoming infected with the coronavirus if it becomes

more widespread in the United States.

I am likely to get the coronavirus

Strongly Agree

Agree

Disagree

Strongly Disagree

How worried, if at all, are you that (INSERT ITEM)? Are you very worried, somewhat worried, not too worried or not at all worried? How about that (INSERT NEXT ITEM)? (IF NECESSARY: Are you very worried, somewhat worried, not too worried or not at all worried that (INSERT ITEM)?) (scramble items a-e)

a. You or someone in your family will get sick from the Coronavirus

b. You will lose income due to a workplace closure or reduced hours because of coronavirus

c. Your investments such as retirement or college savings will be negatively impacted by coronavirus


d. You will put yourself at risk of exposure to coronavirus because you can’t afford to stay home and miss work

You will not be able to afford testing or treatment for coronavirus if you need it






Very/ Somewhat worried (NET)

Very worried

Somewhat worried

Not too/Not at all worried (NET)

Not too worried

Not at all worried

Not Applicable

Don’t Know/ Refused

Overall, how prepared do you think you are to deal with a coronavirus infection if you or someone in your family contracted the virus? Would you say you feel very prepared, somewhat prepared, not too prepared, or not at all prepared to respond to that? [RESPONSES ROTATED IN ORDER FOR HALF/IN REVERSE ORDER FOR HALF]


Very prepared Somewhat prepared NET Not prepared Not too prepared Not at all prepared No opinion

Thinking about what, if any, impact the coronavirus has had on you and your family’s day to day life, would you say it has -- (ROTATE TOP TO BOTTOM, BOTTOM TO TOP) changed your life in a very major way, a fairly major way, only a small way or has it not changed your life in any way? +*


in a very major way, a fairly major way, only a small way or has it not changed your life in any way?

Looking ahead, what, if any, impact do you believe the coronavirus will have on you and your family’s day to day life, would you say it will -- (ROTATE TOP TO BOTTOM, BOTTOM TO TOP) change your life in a very major way, a fairly major way, only a small way or will it not change your life in any way?


a very major way, a fairly major way, only a small way or will it not change your life in any way?

In the past 30 days have you cancelled plans to avoid crowds?


Yes

No

Don’t know/ Refused

Don’t know

Refused

In the past 30 days have your children’s activities or school been cancelled?


Yes

No

Don’t know/ Refused

Don’t know

Refused

In the past 30 days have you lost employment or had hours reduced?


Yes

No

Don’t know/ Refused

Don’t know

Refused

In the past 30 days have you lost income from a business?


Yes

No

Don’t know/ Refused

Don’t know

Refused

In the past 30 days have you lost health care coverage?


Yes

No

Don’t know/ Refused

Don’t know

Refused

In the past 30 days have you had a medical appointment cancelled or postponed?


Yes

No

Don’t know/ Refused

Don’t know

Refused

In the past 30 days have you had any difficulty Feeding your household adequately


Yes

No

Don’t know/ Refused

Don’t know

Refused

In the past 30 days have you had any difficulty feeding your household adequately?


Yes

No

Don’t know/ Refused

Don’t know

Refused

In the past 30 days have you had any difficulty filling any prescriptions?


Yes

No

Don’t know/ Refused

Don’t know

Refused

In the past 30 days have you had any difficulty finding the groceries you want?


Yes

No

Don’t know/ Refused

Don’t know

Refused

In the past 30 days have you had any difficulty seeing a doctor or health professional?


Yes

No

Don’t know/ Refused

Don’t know

Refused

In the past 30 days have you had any difficulty finding cleaning products?


Yes

No

Don’t know/ Refused

Don’t know

Refused




Module 63: Emotional Well-being



Now I’m going to ask you some questions about your life.


1. All things considered, would you say you are?

Please read 1-4

1 Very happy

2 Happy

3 Neutral

4 Not very happy

5 Not happy at all

Do not read

7 Don’t know / Not sure

9 Refused



Please tell me on a scale of 1 to 5 how much you agree or disagree with the following statements about your life. 1 means strongly disagree and 5 means strongly agree. [Read choices only if necessary.]


2. In most ways my life is close to ideal.


1 Strongly disagree

2 Disagree

3 Neither agree nor disagree

4 Agree

5 Strongly agree

Do not read

7 Don’t know / Not sure

9 Refused



3. The conditions of my life are excellent


1 Strongly agree

2 Agree

3 Neither agree nor disagree

4 Disagree

5 Strongly disagree

Do not read

7 Don’t know / Not sure

9 Refused



4. I am satisfied with my life


1 Strongly agree

2 Agree

3 Neither agree nor disagree

4 Disagree

5 Strongly disagree

Do not read

7 Don’t know / Not sure

9 Refused



5. So far I have gotten the important things I want in life.


1 Strongly agree

2 Agree

3 Neither agree nor disagree

4 Disagree

5 Strongly disagree

Do not read

7 Don’t know / Not sure

9 Refused


For questions 6-9: Interviewer: Read the question & response options (for Qs 6 & 7). Read the question and response options (shaded text in parentheses) only if necessary in Qs 8 & 9.


The next few questions ask about how satisfied you are.


6. In general, how satisfied are you with your present job or work? Would you say you are …

Please read 1-4

1 Very satisfied

2 Satisfied

3 Dissatisfied, or

4 Very dissatisfied

Do not read

7 Don’t know / Not sure

9 Refused



7. In general, how satisfied are you with your neighborhood? Would you say you are …


Please read 1-4

1 Very satisfied

2 Satisfied

3 Dissatisfied, or

4 Very dissatisfied

Do not read

7 Don’t know / Not sure

9 Refused



8. (In general, how satisfied are you with) your education? (Would you say very satisfied, satisfied, dissatisfied, or very dissatisfied?)


Read only if necessary

1 Very satisfied

2 Satisfied

3 Dissatisfied, or

4 Very dissatisfied

Do not read

7 Don’t know / Not sure

9 Refused



9. (In general, how satisfied are you with) your energy level? (Would you say very satisfied, satisfied, dissatisfied, or very dissatisfied?)


Read only if necessary

1 Very satisfied

2 Satisfied

3 Dissatisfied, or

4 Very dissatisfied

Do not read

7 Don’t know / Not sure

9 Refused




10. In general, how satisfied are you with your life?

Read only if necessary

1 Very satisfied

2 Satisfied

3 Dissatisfied, or

4 Very dissatisfied

Do not read

7 Don’t know / Not sure

9 Refused


11. How often do you get the social and emotional support you need?” (this includes support from any source)

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never


12. All things considered, would you say you are ([1] very happy to [5] not happy at all? (from NHIS

Module 64: Opioid Use and Misuse

Example Emerging Core Questions

Question

Response set

Do not read unless otherwise noted

CATI Instructions

Interviewer Notes

Q1. In the last 12 months, have you taken any prescription pain relievers when it was prescribed to you by a doctor, dentist, nurse practitioner, or other healthcare provider?

1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused

If Q1= 2, 7, 9

Go to next section

Pain relievers include Codeine, morphine, Lortab, Vicodin, Tylenol #3, Percocet, OxyContin, Xanax, Valium, Ativan.


We only want to know about prescription medication that is not available over the counter.

Q2. The last time you filled a prescription for pain medication in the past year, did you use any of the pain medication more frequently or in higher doses than directed by a doctor?

1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused

If Q2= 2,7,9 Go to Q4


Q3. What was the main reason you used the medication differently than prescribed? Would you say…

Read if necessary:

1 To relieve pain, prescribed dose did not relieve pain 2 To relieve other physical symptoms 3 To relieve anxiety or depression 4 For fun, good feeling, getting high, peer pressure (friends were doing it) 5 To prevent or relieve withdrawal symptoms

Do not read

7 Don't Know/Not sure 9 Refused



Example Optional Module Questions: Prescribed Opioids

Q1. In the past year, have you had any pain medication left over from a prescription?

1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused

If Q4 = 2, 7, 9 Go to next section.


Q2. What did you do with the leftover prescription pain medication?

1 Kept it 2 Disposed of it 3 Gave it to someone else 4 Sold it

5 Used it for another unrelated pain/ other purpose 7 Don't know/Not sure 9 Refused



Q3. The last time you used pain medication that was prescribed to you, what was the main reason?

Read if necessary

1 pain related to cancer

2 post-surgical care/medical care

3 back pain, short term

4 back pain, long term

5 joint pain, short term

6 joint pain, long term

7 carpal tunnel syndrome

8 arthritis

9 work-related injury

10 other injury causing short term pain

11 other injury causing long term pain

12 other physical conditions causing pain

13 to prevent or relieve withdrawal symptoms

14 dental pain

15 pain due to diabetes-related nerve damage

Do not read:

77. Don’t know

99. Refused



Q4 In the past year, what prescription pain medications were prescribed to you by a doctor?

1 Butorphanol Tartrate

2 Carisoprodol

3 Celebrex

4 Codeine

5 Darvocet

6 Darvon

7 Demerol

8 Dilaudid

9 Duragesic

10 Embeda

11 Fentanyl

12 Fentora

13 Gabapentin

14 Hydrocodone

15 Hydromorphone

16 Ibuprofen / Motrin

17 Kadian

18 Levorphanol

19 Lortab

20 Lorcet

21 Meperidine

22 Methadone

23 Morphine

24 Naproxen

25 Narcan

26 Neurontin

27 Opium Tincture

28 Oxycodone

29 Oxycontin

30 Pentazocine

31 Percocet

32 Percodan

33 Propoxyphene

34 Roxicet

35 Soma

36 Stadol

37 Suboxone

38 Subutex

39 Toradol

40 Tramadol

41 Tylenol with codeine (Tylenol #3)

42 Tylox

43 Ultram (Ultram ER)

44 Ultracet

45 Vicodin

46 Other (specify_____) {28 character limit}

77 Don’t know / not sure

99 Refused

This question could be coded for multiple response


Example Optional Module Questions: Use of Opioids Not Prescribed

Q1. In the past year, did you use a prescription pain medication that was not prescribed specifically for you by a doctor, dentist, nurse practitioner, or healthcare providers?

1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused

If OMQ1 = 2, 7, 9 Go to OMQ5


Q2. From whom did you obtain the prescription pain medication?

1 = From a friend or relative 2 = From an acquaintance 3 = From a street dealer or other person I did not know 4 = Online 5 = Other 7 = Don't know/Not sure 9 = Refused



Q3. About how often in the past 12 months did you use prescription pain relievers including that were not prescribed to you by a doctor, dentist, nurse practitioner, or other healthcare providers?  Would you say....

Read

1 Never  

2 Every day or nearly every day

3 Several times a month

4 Several times a year

Do not read:

7 Don't know/Not sure

9 Refused



Pain relievers include Codeine, morphine, Lortab, Vicodin, Tylenol #3, Percocet, OxyContin, Xanax, Valium, Ativan.


We only want to know about medication that is not available over the counter.

Q4. In the past 12 months, did you shoot up or inject any drugs other than those prescribed for you? By shooting up, I mean anytime you might have used drugs with a needle, either by mainlining, skin popping, or muscling.

1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused



Example Optional Module Questions: Dependency

Q5. How long has it been since you used any prescription pain reliever?

Read only if necessary

1 Within the past 30 days (or currently taking)

2 More than 30 days ago but within the past 12 months

3 More than 12 months ago

4 Never

7 Don’t know/Not sure

9 Refused


Pain relievers include Codeine, morphine, Lortab, Vicodin, Tylenol #3, Percocet, OxyContin, Xanax, Valium, Ativan.


We only want to know about medication that is not available over the counter.

Q6. In the past year have you felt dependent on prescription pain medication or experienced trouble getting off of the medication when you no longer needed it for medical reasons?

1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused


Pain relievers include Codeine, morphine, Lortab, Vicodin, Tylenol #3, Percocet, OxyContin, Xanax, Valium, Ativan.


We only want to know about medication that is not available over the counter.

Thank you for answering these questions. If you would like assistance with any of these issues, please call the XXX at XXXX to find out about mental health and substance related disorder services available in your area.




Module 65: Bereavement





I’d like to ask you some questions about friends or family who have passed away in recent years.

GA7_1. Have you experienced the death of a family member or close friend in the years 2018 or 2019?

1 Yes

2 No [GO TO GA7_4]

7 Don’t know / Not sure [GO TO GA7_4]

9 Refused [GO TO GA7_4]



GA7_2. How many losses did you experience during that time?

_ __ losses [RANGE (01-76),

77 Don’t know [GO TO GA7_4]

99 Refused [GO TO GA7_4]

GA7_3. For each loss, please tell me if he or she was a spouse, friend or a family member.

INTERVIEWER NOTE: With family members please indicate relationship; Mother, Father, Sister, Brother.

GA7_3a Was [IF GA7_2=1, READ “your” / IF GA7_2>1, READ “your first”] loss a …?

IF GA7_2>1, ASK; OTHERWISE SKIP TO GA7_4

GA7_3b Was the second family member or friend you lost a …?


IF GA7_2>2, ASK; OTHERWISE SKIP TO GA7_4

GA7_3c Was the third family member or friend you lost a …?


IF GA7_2>3, ASK; OTHERWISE SKIP TO GA7_4

GA7_3d Was the fourth family member or friend you lost a …?


IF GA7_2>4, ASK; OTHERWISE SKIP TO GA7_4

GA7_3e Was the fifth family member or friend you lost a …?


(READ LIST for first mention)

01 Spouse/Partner

02 Mother

03 Father

04 Brother

05 Sister

06 Child

07 Other Family Member

08 Friend or Neighbor

09 Other

77 Don't know/Not sure

99 Refused



Module 66: Social Determinants and Health Equity



Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MSDHE.01

In the past 12 months have you lost employment or had hours reduced?


1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused




MSDHE.02

During the past 12 months, have you received food stamps, also called SNAP, the Supplemental Nutrition Assistance Program on an EBT card?


1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused




MSDHE.03

During the past 12 months how often did the food that you bought not last, and you didn’t have money to get more? Was that…


Read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

7 Don’t know/not sure

9 Refused




MSDHE.04

During the last 12 months, was there a time when you were not able to pay your mortgage, rent or utility bills?



1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused




MSDHE.05

During the last 12 months was there a time when an electric, gas, oil, or water company threatened to shut off services?


1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused




MSDHE.06

During the past 12 months has a lack of reliable transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?


1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused




MSDHE.07

How often do you get the social and emotional support that you need? Is that…


Read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

7 Don’t know/not sure

9 Refused





MSDHE.08

How often do you feel lonely or isolated from others? Is it…


Read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

7 Don’t know/not sure

9 Refused





MSDHE.09

In general, how satisfied are you with your life? Are you..


Read:

1 Very satisfied

2 Satisfied

3 Dissatisfied

4 Very dissatisfied

7 Don’t know/not sure

9 Refused





MSDHE.10

Stress means a situation in which a person feels tense, restless, nervous or anxious or is unable to sleep at night because their mind is troubled all the time. Within the last 30 days, how often have you felt this kind of stress? Was it…


Read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

7 Don’t know/not sure

9 Refused









File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPierannunzi, Carol (CDC/ONDIEH/NCCDPHP)
File Modified0000-00-00
File Created2022-10-02

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