0920-1061 Field Test Screener

Attachment 12:

2019 BRFSS

Field Test Questionnaire

Table of Contents

OMB Header and Introductory Text 3

Landline Introduction 4

Cell Phone Introduction 7

Core Section 1: Health Status 11

Core Section 2: Healthy Days 12

Core Section 3: Healthcare Access 13

Core Section 4: Chronic Health Conditions 14

Core Section 5: Demographics 17

Module Section 6: Colorectal Cancer Screening 22

Core Section 7: Tobacco Use 27

Core Section 8: Alcohol Consumption 29

Section 9:ACE Module 31

Core Section 10: Exercise (Physical Activity) 36

Core Section 11: Fruits and Vegetables 38

Closing Statement 41

OMB Header and Introductory Text

Read if necessary	Read	Interviewer instructions (not read)
Public reporting burden of this collection of information is estimated to average 27 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061).	HELLO, I am calling for the (health department). My name is (name). We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices.	Form Approved OMB No. 0920-1061 Exp. Date 3/31/2021 Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Carol Pierannunzi at [email protected].

Landline Introduction

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
LL01.	Is this [PHONE NUMBER]?	CTELENM1	1 Yes	Go to LL02		63
			2 No	TERMINATE
LL02.	Is this a private residence?	PVTRESD1	1 Yes	Go to LL04	Read if necessary: By private residence we mean someplace like a house or apartment. Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.	64
			2 No	Go to LL03
			3 No, this is a business		Read: Thank you very much but we are only interviewing persons on residential phones at this time.
LL03.	Do you live in college housing?	COLGHOUS	1 Yes	Go to LL04	Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.	65
			2 No	TERMINATE	Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
LL04.	Do you currently live in__(state)____?	STATERE1	1 Yes	Go to LL05		66
			2 No	TERMINATE	Thank you very much but we are only interviewing persons who live in [STATE] at this time.
LL05.	Is this a cell phone?	CELLFON4	1 Yes, it is a cell phone	TERMINATE	Read: Thank you very much but we are only interviewing by landline telephones in private residences or college housing at this time.
			2 Not a cell phone	Go to LL06	Read if necessary: By cell phone we mean a telephone that is mobile and usable outside your neighborhood. Do not read: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).
LL06.	Are you 18 years of age or older?	LADULT	1 Yes, male respondent 2 Yes, female respondent		Do not read: Sex will be asked again in demographics section.	68
			3 No	TERMINATE	Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
Transition to Section 1.			I will not ask for your last name, address, or other information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any personal information that you provide will not be used to identify you. If you have any questions about the survey, please call (give appropriate state telephone number).		Do not read: Introductory text may be reread when selected respondent is reached.

Cell Phone Introduction

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CP01.	Is this a safe time to talk with you?	SAFETIME	1 Yes	Go to CP02		75
			2 No	([set appointment if possible]) TERMINATE]	Thank you very much. We will call you back at a more convenient time.
CP02.	Is this [PHONE NUMBER]?	CTELNUM1	1 Yes	Go to CP03		76
			2 No	TERMINATE
CP03.	Is this a cell phone?	CELLFON5	1 Yes	Go to CADULT		77
			2 No	TERMINATE	Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
CP04.	Are you 18 years of age or older?	CADULT	1 Yes, male respondent 2 Yes, female respondent		Do not read: Sex will be asked again in demographics section.	78
			3 No	TERMINATE	Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
CP05.	Do you live in a private residence?	PVTRESD3	1 Yes	Go to CP07	Read if necessary: By private residence we mean someplace like a house or apartment Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.	79
			2 No	Go to CP06
CP06.	Do you live in college housing?	CCLGHOUS	1 Yes	Go to CP07	Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.	80
			2 No	TERMINATE	Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
CP07.	Do you currently live in___(state)____?	CSTATE1	1 Yes	Go to CP09		81
			2 No	Go to CP08
CP08.	In what state do you currently live?	RSPSTAT1	1 Alabama 2 Alaska 4 Arizona 5 Arkansas 6 California 8 Colorado 9 Connecticut 10 Delaware 11 District of Columbia 12 Florida 13 Georgia 15 Hawaii 16 Idaho 17 Illinois 18 Indiana 19 Iowa 20 Kansas 21 Kentucky 22 Louisiana 23 Maine 24 Maryland 25 Massachusetts 26 Michigan 27 Minnesota 28 Mississippi 29 Missouri 30 Montana 31 Nebraska 32 Nevada 33 New Hampshire 34 New Jersey 35 New Mexico 36 New York 37 North Carolina 38 North Dakota 39 Ohio 40 Oklahoma 41 Oregon 42 Pennsylvania 44 Rhode Island 45 South Carolina 46 South Dakota 47 Tennessee 48 Texas 49 Utah 50 Vermont 51 Virginia 53 Washington 54 West Virginia 55 Wisconsin 56 Wyoming 66 Guam 72 Puerto Rico 78 Virgin Islands 99 Refused			82-83
Transition to section 1.			I will not ask for your last name, address, or other information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any personal information that you provide will not be used to identify you. If you have any questions about the survey, please call (give appropriate state telephone number).

Core Section 1: Health Status

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C01.01	Would you say that in general your health is—	GENHLTH	Read: 1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor Do not read: 7 Don’t know/Not sure 9 Refused			90

Core Section 2: Healthy Days

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C02.01	Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?	PHYSHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused			91-92
C02.02	Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?	MENTHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused			93-94
C02.03	During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?	POORHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused	Skip if C02.01, PHYSHLTH, is 88 and C02.02, MENTHLTH, is 88		95-96

Core Section 3: Healthcare Access

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
HC.01	What is the primary source of your health care coverage? Is it…	HLTHCVR1	1 A plan purchased through an employer or union Notes: includes plans purchased through another person's employer 2 A plan that you or another family member buys on your own 3 Medicare 4 Medicaid or other state program 5 TRICARE (formerly CHAMPUS), VA, or Military 6 Alaska Native, Indian Health Service, Tribal Health Services 7 Some other source 8 None (no coverage) 77 Don’t know/Not Sure 99 Refused

Core Section 4: Chronic Health Conditions

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C06.01	Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me Yes, No, Or You’re Not Sure. Ever told) you that you had a heart attack also called a myocardial infarction?	CVDINFR4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.02	(Ever told) you had angina or coronary heart disease?	CVDCRHD4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.03	(Ever told) you had a stroke?	CVDSTRK3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.04	(Ever told) you had asthma?	ASTHMA3	1 Yes
			2 No 7 Don’t know / Not sure 9 Refused	Go to C06.06
C06.05	Do you still have asthma?	ASTHNOW	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.06	(Ever told) you had skin cancer?	CHCSCNCR	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.07	(Ever told) you had any other types of cancer?	CHCOCNCR	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.08	(Ever told) you have chronic obstructive pulmonary disease, C.O.P.D., emphysema or chronic bronchitis?	CHCCOPD1	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.10	(Ever told) you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?	ADDEPEV2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C06.11	Not including kidney stones, bladder infection or incontinence, were you ever told you have kidney disease?	CHCKDNY1	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Read if necessary: Incontinence is not being able to control urine flow.
C06.12	(Ever told) you have diabetes?	DIABETE3	1 Yes		If yes and respondent is female, ask: was this only when you were pregnant? If respondent says pre-diabetes or borderline diabetes, use response code 4.
			2 Yes, but female told only during pregnancy 3 No 4 No, pre-diabetes or borderline diabetes 7 Don’t know / Not sure 9 Refused	Go to Pre-Diabetes Optional Module (if used). Otherwise, go to next section.
C06.13	How old were you when you were told you have diabetes?	DIABAGE2	_ _ Code age in years [97 = 97 and older] 98 Don‘t know / Not sure 99 Refused	Go to Diabetes Module if used, otherwise go to next section.

Core Section 5: Demographics

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C08.01	What is your sex? Are you….	SEX1	1 Male 2 Female Do not read: 7 Don’t know / Not sure 9 Refused	States may adopt one of the two formats of the question. If second format is used, read options.
C08.02	In what year were your born?	AGE	_ _ Code age in years 07 Don’t know / Not sure 09 Refused
C08.03	Are you Hispanic, Latino/a, or Spanish origin?	HISPANC3	If yes, read: Are you… 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		One or more categories may be selected.
C08.04	Which one or more of the following would you say is your race?	MRACE1	Please read: 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 88 No additional choices 77 Don’t know / Not sure 99 Refused	If more than one response to C08.04; continue. Otherwise, go to C08.06.	If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. One or more categories may be selected.
C08.05	Which one of these groups would you say best represents your race?	ORACE3	Please read: 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. If respondent has selected multiple races in previous and refuses to select a single race, code refused
C08.06	Are you…	MARITAL	Please read: 1 Married 2 Divorced 3 Widowed 4 Separated 5 Never married Or 6 A member of an unmarried couple Do not read: 9 Refused
C08.07	What is the highest grade or year of school you completed?	EDUCA	Read if necessary: 1 Never attended school or only attended kindergarten 2 Grades 1 through 8 (Elementary) 3 Grades 9 through 11 (Some high school) 4 Grade 12 or GED (High school graduate) 5 College 1 year to 3 years (Some college or technical school) 6 College 4 years or more (College graduate) Do not read: 9 Refused
C08.08	Do you own or rent your home?	RENTHOM1	1 Own 2 Rent 3 Other arrangement 7 Don’t know / Not sure 9 Refused		Other arrangement may include group home, staying with friends or family without paying rent. Home is defined as the place where you live most of the time/the majority of the year. Read if necessary: We ask this question in order to compare health indicators among people with different housing situations.
C08.14	Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?	VETERAN3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Read if necessary: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.
C08.15	Are you currently…?	EMPLOY1	Read: 1 Employed for wages 2 Self-employed 3 Out of work for 1 year or more 4 Out of work for less than 1 year 5 A Homemaker 6 A Student 7 Retired Or 8 Unable to work Do not read: 9 Refused		If more than one, say “select the category which best describes you”.
C08.16	How many children less than 18 years of age live in your household?	CHILDREN	_ _ Number of children 88 None 99 Refused
C08.17	Is your annual household income from all sources—	INCOME2	Read if necessary: 04 Less than $25,000 If no, ask 05; if yes, ask 03 ($20,000 to less than $25,000) 03 Less than $20,000 If no, code 04; if yes, ask 02 ($15,000 to less than $20,000) 02 Less than $15,000 If no, code 03; if yes, ask 01 ($10,000 to less than $15,000) 01 Less than $10,000 If no, code 02 05 Less than $35,000 If no, ask 06 ($25,000 to less than $35,000) 06 Less than $50,000 If no, ask 07 ($35,000 to less than $50,000) 07 Less than $75,000 If no, code 08 ($50,000 to less than $75,000) 08 $75,000 or more Do not read: 77 Don’t know / Not sure 99 Refused		If respondent refuses at ANY income level, code ‘99’ (Refused)
C08.18	About how much do you weigh without shoes?	WEIGHT2	_ _ _ _ Weight (pounds/kilograms) 7777 Don’t know / Not sure 9999 Refused		If respondent answers in metrics, put 9 in first column. Round fractions up
C08.19	About how tall are you without shoes?	HEIGHT3	_ _ / _ _ Height (ft / inches/meters/centimeters) 77/ 77 Don’t know / Not sure 99/ 99 Refused		If respondent answers in metrics, put 9 in first column. Round fractions down
C08.20	To your knowledge, are you now pregnant?	PREGNANT	1 Yes 2 No 7 Don’t know / Not sure 9 Refused	Skip if C08.01, SEX, is coded 1; or C08.02, AGE, is greater than 49

Module Section 6: Colorectal Cancer Screening

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				CATI note: If respondent is < 49 years of age, go to next section.
Prologue	The next questions are about colorectal cancer screening. There are different stool tests to determine whether the stool contains blood.
CRC.01	One stool test uses a special kit to obtain a small amount of stool at home to determine whether the stool contains blood and returns the kit to the doctor or the lab. Have you ever had this test using a home kit?		1 Yes		Interviewer note: This is also called a fecal immunochemical test (FIT) or a guaiac-based fecal occult blood test (gFOBT). The FIT test uses antibodies to detect blood in the stool. The gFOBT uses a chemical (guaiac) to detect blood in the stool.
			2 No 7 Don't know / Not sure 9 Refused	Go to CRC.03
CRC.02	How long has it been since you last had this test?		Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years 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 Do not read: 7 Don't know / Not sure 9 Refused
CRC.03	Another stool test uses a special kit to obtain an entire bowel movement at home and returns the kit to a lab. Have you ever had this test?		1 Yes		Interviewer note: This is also called a FIT-DNA test or a stool DNA test. This test combined the FIT with a test that detects altered DNA in the stool.
			2 No 7 Don't know / Not sure 9 Refused	Go to CRC.05
CRC.04	How long has it been since you last had this test?		Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years 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 Do not read: 7 Don't know / Not sure 9 Refused
CRC.05	A sigmoidoscopy is a flexible tube that is inserted in the rectum to view the colon for signs of cancer or other health problems. Have you ever had a sigmoidoscopy?		1 Yes
			2 No 7 Don't know / Not sure 9 Refused	Go to CRC.07
CRC.06	How long has it been since you last had this test?		Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years 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 Do not read: 7 Don't know / Not sure 9 Refused
CRC.07	A colonoscopy is uses a longer tube than a sigmoidoscopy. You are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test. Have you ever had a colonoscopy?		1 Yes
			2 No 7 Don't know / Not sure 9 Refused	Go to CRC.09
CRC.08	How long has it been since you last had this test?		Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years 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 Do not read: 7 Don't know / Not sure 9 Refused
CRC.09	A virtual colonoscopy uses a series of X-rays to take pictures of inside the colon. Have you ever had a virtual colonoscopy?		1 Yes
			2 No 7 Don't know / Not sure 9 Refused	Go to next section
CRC.10	How long has it been since you last had this test?		Read if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years 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 Do not read: 7 Don't know / Not sure 9 Refused

Core Section 7: Tobacco Use

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C09.01	Have you smoked at least 100 cigarettes in your entire life?	SMOKE100	1 Yes		Do not include: electronic cigarettes (e-cigarettes, njoy, bluetip), herbal cigarettes, cigars, cigarillos, little cigars, pipes, bidis, kreteks, water pipes (hookahs) or marijuana. 5 packs = 100 cigarettes
			2 No 7 Don’t know/Not Sure 9 Refused	Go to C09.05
C09.02	Do you now smoke cigarettes every day, some days, or not at all?	SMOKDAY2	1 Every day 2 Some days
			3 Not at all	Go to C09.04
			7 Don’t know / Not sure 9 Refused	Go to C09.05
C09.03	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	Go to C09.05
C09.04	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
C09.05	Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?	USENOW3	1 Every day 2 Some days 3 Not at all 7 Don’t know / Not sure 9 Refused		Read if necessary: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.

Core Section 8: Alcohol Consumption

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C10.01	During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?	ALCDAY5	1 _ _ Days per week 2 _ _ Days in past 30 days
			888 No drinks in past 30 days 777 Don’t know / Not sure 999 Refused	Go to next section
C10.02	One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?	AVEDRNK2	_ _ Number of drinks 88 None 77 Don’t know / Not sure 99 Refused		Read if necessary: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.
C10.03	Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI X = 5 for men, X = 4 for women] or more drinks on an occasion?	DRNK3GE5	_ _ Number of times 77 Don’t know / Not sure 99 Refused	CATI X = 5 for men, X = 4 for women
C10.04	During the past 30 days, what is the largest number of drinks you had on any occasion?	MAXDRNKS	_ _ Number of drinks 77 Don’t know / Not sure 99 Refused

Section 9: ACE Module

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.
M22.01	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			394
M22.02	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			395
M22.03	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			396
M22.04	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			397
ACE.05	Before you were 18 years of age, during your childhood were your parents….?	ACEDIVRE2	Read: 1 Living together 2 Living separately 3 Living together for part of your childhood, or 4 Other arrangements 7 Don’t Know 9 Refused			398
ACE.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			399
ACE.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			400
ACE.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			401
ACE.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			402
ACE.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			403
ACE.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			404
ACE.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?		Do not read 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 9 Refused
ACE.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?		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 9 Refused
ACE.14	In the last 12 months how many times have you attempted suicide?		1 0 times/ never 2 1 or 2 times 3 3 to 9 times 4 10 to 19 times 5 20 to 39 times 6 40 or more times 7 Do not know 9 Refused
ACE.15	In the last 12 months how many times have you taken prescription pain reliever differently than how a doctor told you to use it?		1 0 times/ never 2 1 or 2 times 3 3 to 9 times 4 10 to 19 times 5 20 to 39 times 6 40 or more times 7 Do not know 9 Refused
ACE.16	In the last 12 months, how many times have you used heroin?		1 0 times/ never 2 1 or 2 times 3 3 to 9 times 4 10 to 19 times 5 20 to 39 times 6 40 or more times 7 Do not know 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]

Core Section 10: 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)
DO NOT PROBE IN THIS SECTION. IF RESPONDENT INTIALLY INDICATES DNK, CODE 7(777) WITHOUT FURTHER PROBE.
PA.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 PA.08
PA.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 PA.08
PA.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
PA.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
PA.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 PA.08
PA.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
PA.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
PA.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

Core Section 11: 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)
DO NOT PROBE IN THIS SECTION. IF RESPONDENT INTIALLY INDICATES DNK, CODE 777(7) WITHOUT FURTHER PROBE.
F&V.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
F&V.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
F&V.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
F&V.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
F&V.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
F&V.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

Closing Statement

	Read
	That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.

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11 March 2022