Form 0920-1061 2021 BRFFS Questionnaire

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).

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].

HELLO, I am calling for the [STATE OF xxx] Department of Health. My name is (name). We are gathering information about the health of US 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.

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
			2 No	TERMINATE	Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time.
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.
			2 No	Go to LL03	If no, business phone only: thank you very much but we are only interviewing persons on residential phones lines at this time. NOTE: Business numbers which are also used for personal communication are eligible.
			3 No, this is a business		Read: Thank you very much but we are only interviewing persons on residential phones at this time. TERMINATE
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.
			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
			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?	CELPHONE	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?	LADULT1	1 Yes	IF COLLEGE HOUSING = “YES,” CONTINUE; OTHERWISE GO TO ADULT RANDOM SELECTION]
			2 No	IF COLLEGE HOUSING = “YES,” Terminate; OTHERWISE GO TO ADULT RANDOM SELECTION]	Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
LL07.	Are you male or female?	COLGSEX	1 Male 2 Female	ONLY for respondents who are LL and COLGHOUS= 1. Go to Transition Section 1.
			7 Don’t know/Not sure 9 Refused	TERMINATE	Thank you for your time, your number may be selected for another survey in the future.
LL08.	I need to randomly select one adult who lives in your household to be interviewed. Excluding adults living away from home, such as students away at college, how many members of your household, including yourself, are 18 years of age or older?	NUMADULT	1	Go to LL09	Read: Are you that adult? If yes: Then you are the person I need to speak with. If no: May I speak with the adult in the household?
			2-6 or more	Go to LL10.
LL09.	Are you male or female?	LANDSEX	1 Male 2 Female	GO to Transition Section 1.
			7 Don’t know/Not sure 9 Refused	TERMINATE	Thank you for your time, your number may be selected for another survey in the future.
LL10.	How many of these adults are men?	NUMMEN	_ _ Number 77 Don’t know/ Not sure 99 Refused
LL11.	So the number of women in the household is [X]. Is that correct?	NUMWOMEN			Do not read: Confirm the number of adult women or clarify the total number of adults in the household. Read: The persons in your household that I need to speak with is [Oldest/Youngest/ Middle//Male /Female].
LL12	The person in your household that I need to speak with is [Oldest/Youngest/ Middle//Male /Female]. Are you the [Oldest/Youngest/ Middle//Male /Female] in this household?	RESPSLCT	1 Male 2 Female	If person indicates that they are not the selected respondent, ask for correct respondent and re-ask LL12. (See CATI programming)
			7 Don’t know/Not sure 9 Refused	TERMINATE	Thank you for your time, your number may be selected for another survey in the future.
Transition to Section 1.			I will not ask for your last name, address, or other personal 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 information you give me will not be connected to any personal information 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. Do not read: The sentence “Any information you give me will not be connected to any personal information” may be replaced by “Any personal information that you provide will not be used to identify you.” If the state coordinator approves the change.

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
CP01.	Is this a safe time to talk with you?	SAFETIME	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
CP02.	Is this [PHONE NUMBER]?	CTELNUM1	2 No	TERMINATE
CP03.	Is this a cell phone?	CELLFON5	1 Yes	Go to CADULT1
CP03.	Is this a cell phone?	CELLFON5	2 No	TERMINATE	If "no”: thank you very much, but we are only interviewing persons on cell telephones at this time
CP04.	Are you 18 years of age or older?	CADULT1	1 Yes
CP04.	Are you 18 years of age or older?	CADULT1	2 No	TERMINATE	Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
CP05.	Are you male or female?	CELLSEX	1 Male 2 Female
CP05.	Are you male or female?	CELLSEX	7 Don’t Know/ Not sure 9 Refused	TERMINATE	Thank you for your time, your number may be selected for another survey in the future.
CP06.	Do you live in a private residence?	PVTRESD3	1 Yes	Go to CP08	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.
CP06.	Do you live in a private residence?	PVTRESD3	2 No	Go to CP07
CP07.	Do you live in college housing?	CCLGHOUS	1 Yes	Go to CP08	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.
CP07.	Do you live in college housing?	CCLGHOUS	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.
CP08.	Do you currently live in___(state)____?	CSTATE1	1 Yes	Go to CP10
CP08.	Do you currently live in___(state)____?	CSTATE1	2 No	Go to CP09
CP09.	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
CP09.	In what state do you currently live?	RSPSTAT1	77 Live outside US and participating territories 99 Refused	TERMINATE	Read: Thank you very much, but we are only interviewing persons who live in the US.
CP10.	Do you also have a landline telephone in your home that is used to make and receive calls?	LANDLINE	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		Read if necessary: By landline telephone, we mean a regular telephone in your home that is used for making or receiving calls. Please include landline phones used for both business and personal use.
CP11.	How many members of your household, including yourself, are 18 years of age or older?	HHADULT	_ _ Number 77 Don’t know/ Not sure 99 Refused	If CP07 = yes then number of adults is automatically set to 1
Transition to section 1.			I will not ask for your last name, address, or other personal 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 information you give me will not be connected to any personal information. 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)

CHS.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

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)
CHD.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		88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.
CHD.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		88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.
				Skip CHD.03 if CHD.01, PHYSHLTH, is 88 and CHD.02, MENTHLTH, is 88
CHD.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		88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.

Core Section 3: Health Care Access

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CHCA.01	What is the current primary source of your health insurance?	*NEW*	Read if necessary: 01 A plan purchased through an employer or union (including plans purchased through another person's employer) 02 A private nongovernmental plan that you or another family member buys on your own 03 Medicare 04 Medigap 05 Medicaid 06 Children's Health Insurance Program (CHIP) 07 Military related health care: TRICARE (CHAMPUS) / VA health care / CHAMP- VA 08 Indian Health Service 09 State sponsored health plan 10 Other government program 88 No coverage of any type 77 Don’t Know/Not Sure 99 Refused		If respondent has multiple sources of insurance, ask for the one used most often. If respondents give the name of a health plan rather than the type of coverage ask whether this is insurance purchased independently, through their employer, or whether it is through Medicaid or CHIP.
CHCA.01		*NEW*
CHCA.02	Do you have one person or a group of doctors that you think of as your personal health care provider?	*NEW*	1 Yes, only one 2 More than one 3 No 7 Don’t know / Not sure 9 Refused		If no, read: Is there more than one, or is there no person who you think of as your personal doctor or health care provider?
CHCA.03	Was there a time in the past 12 months when you needed to see a doctor but could not because you could not afford it?	*NEW*	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CHCA.04	About how long has it been since you last visited a doctor for a routine checkup?	CHECKUP1	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 5 years (2 years but less than 5 years ago) 4 5 or more years ago Do not read: 7 Don’t know / Not sure 8 Never 9 Refused		Read if necessary: A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.

Core Section 4: Exercise

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CEX.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

2 No

7 Don’t know / Not sure

9 Refused

Do not read: If respondent does not have a regular job or is retired, they may count any physical activity or exercise they do

Core Section 5: Hypertension Awareness

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C05.01	Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?	~~BPHIGH4~~	1 Yes		If “Yes” and respondent is female, ask: “Was this only when you were pregnant?” By other health professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.
C05.01		~~BPHIGH4~~	2 Yes, but female told only during pregnancy 3 No 4 Told borderline high or pre-hypertensive or elevated blood pressure 7 Don’t know / Not sure 9 Refused	Go to next section
C05.02	Are you currently taking prescription medicine for your high blood pressure?	BPMEDS	1 Yes 2 No 7 Don’t know / Not sure 9 Refused

Core Section 6: Cholesterol Awareness

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)		SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C06.01	Cholesterol is a fatty substance found in the blood. About how long has it been since you last had your ~~blood~~ cholesterol checked?	~~CHOLCHK2~~	1 Never	Go to next section.
			2 Within the past year (anytime less than one year ago) 3 Within the past 2 years (1 year but less than 2 years ago) 4 Within the past 3 years (2 years but less than 3 years ago) 5 Within the past 4 years (3 years but less than 4 years ago) 6 Within the past 5 years (4 years but less than 5 years ago) 8 5 or more years ago
			7 Don’t know/ Not sure 9 Refused	Go to next section
C06.02	Have you ever been told by a doctor, nurse or other health professional that your ~~blood~~ cholesterol is high?	~~TOLDHI2~~	1 Yes			By other health professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.
			2 No 7 Don’t know / Not sure 9 Refused	~~Go to next section.~~
C06.03	Are you currently taking medicine prescribed by your doctor or other health professional for your ~~blood~~ cholesterol?	CHOLMED2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused			If respondent questions why they might take drugs without having high cholesterol read: ~~‘High’ cholesterol is just one group recommended statin therapy for cholesterol management in the 2013 and 2018 Cholesterol Guidelines.~~ Doctors might prescribe statin for those without high cholesterol but with high atherosclerotic cardiovascular disease risk

Core Section 7: 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)
Prologue	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.
CCHC.01	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
CCHC.02	(Ever told) (you had) angina or coronary heart disease?	CVDCRHD4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.03	(Ever told) (you had) a stroke?	CVDSTRK3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.04	(Ever told) (you had) asthma?	ASTHMA3	1 Yes
CCHC.04	(Ever told) (you had) asthma?	ASTHMA3	2 No 7 Don’t know / Not sure 9 Refused	Go to CCHC.06
CCHC.05	Do you still have asthma?	ASTHNOW	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.06	(Ever told) (you had) skin cancer?	CHCSCNCR	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.07	(Ever told) (you had) any other types of cancer?	CHCOCNCR	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.08	(Ever told) (you had) C.O.P.D. (chronic obstructive pulmonary disease), emphysema or chronic bronchitis?	CHCCOPD3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.09	(Ever told) (you had) a depressive disorder (including depression, major depression, dysthymia, or minor depression)?	ADDEPEV3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CCHC.10	Not including kidney stones, bladder infection or incontinence, were you ever told you had kidney disease?	CHCKDNY2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Read if necessary: Incontinence is not being able to control urine flow.
CCHC.11	(Ever told) (you had) diabetes?	DIABETE4	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.
CCHC.11	(Ever told) (you had) diabetes?	DIABETE4	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.
CCHC.12	How old were you when you were told you had diabetes?	DIABAGE3	_ _ 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 8: Arthritis

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C08.01	Has a doctor, nurse or other health professional ever told you that you had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?	HAVARTH5	1 Yes		Arthritis diagnoses include: rheumatism, polymyalgia rheumatic, osteoarthritis (not osteoporosis), tendonitis, bursitis, bunion, tennis elbow, carpal tunnel syndrome, tarsal tunnel syndrome, joint infection, Reiter’s syndrome, ankylosing spondylitis; spondylosis, rotator cuff syndrome, connective tissue disease, scleroderma, polymyositis, Raynaud’s syndrome, vasculitis, giant cell arteritis, Henoch-Schonlein purpura, Wegener’s granulomatosis, polyarteritis nodosa)
C08.01		HAVARTH5	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

Core Section 9: Demographics

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CDEM.01	What is your age?	AGE	_ _ Code age in years 07 Don’t know / Not sure 09 Refused
~~CDEM.01~~	~~In what year were you born?~~	~~YEARBORN~~	~~_ _ _ _ Code year of birth~~ ~~7777 Don’t know~~ ~~9999 Refused~~
CDEM.02	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.
CDEM.03	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 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. One or more categories may be selected.
				If more than one response to CDEM.03; continue. Otherwise, go to CDEM.05
CDEM.04	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
				If using Sex at Birth Module, insert here If using SOGI module, insert here.
CDEM.05	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
CDEM.06	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
CDEM.07	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.
CDEM.08	In what county do you currently live?	CTYCODE2	_ _ _ANSI County Code 777 Don’t know / Not sure 999 Refused 888 County from another state
CDEM.09	What is the ZIP Code where you currently live?	ZIPCODE1	_ _ _ _ _ 77777 Do not know 99999 Refused
				If cell interview go to CDEM12
CDEM.10	Not including cell phones or numbers used for computers, fax machines or security systems, do you have more than one telephone number in your household?	NUMHHOL3	1 Yes
CDEM.10		NUMHHOL3	2 No 7 Don’t know / Not sure 9 Refused	Go to CDEM.12
CDEM.11	How many of these telephone numbers are residential numbers?	NUMPHON3	__ Enter number (1-5) 6 Six or more 7 Don’t know / Not sure 8 None 9 Refused
CDEM.12	How many cell phones do you have for personal use?	CPDEMO1B	__ Enter number (1-5) 6 Six or more 7 Don’t know / Not sure 8 None 9 Refused	Last question needed for partial complete.	Read if necessary: Include cell phones used for both business and personal use.
CDEM.13	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.
CDEM.14	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”.
CDEM.15	How many children less than 18 years of age live in your household?	CHILDREN	_ _ Number of children 88 None 99 Refused
CDEM.16	Is your annual household income from all sources—	*NEW*	Read if necessary: 01 Less than $10,000? 02 Less than $15,000? ($10,000 to less than $15,000) 03 Less than $20,000? ($15,000 to less than $20,000) 04 Less than $25,000 05 Less than $35,000 If ($25,000 to less than $35,000) 06 Less than $50,000 If ($35,000 to less than $50,000) 07 Less than $75,000? ($50,000 to less than $75,000) 08 Less than $100,000? ($75,000 to less than $100,000) 09 Less than $150,000? ($100,000 to less than $150,000)? 10 Less than $200,000? ($150,000 to less than $200,000) 11 $200,000 or more Do not read: 77 Don’t know / Not sure 99 Refused	SEE CATI information of order of coding; Start with category 05 and move up or down categories.	If respondent refuses at ANY income level, code ‘99’ (Refused)
				Skip if Male (MSAB.01, BIRTHSEX, is coded 1). If MSAB.01=missing and (CP05=1 or LL12=1; or LL09 = 1 or LL07 =1). or YEARBORN < 1972 (Age >49)
CDEM.17	To your knowledge, are you now pregnant?	PREGNANT	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CDEM.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
CDEM.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

Core Section 10: Disability

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CDIS.01	Some people who are deaf or have serious difficulty hearing use assistive devices to communicate by phone. Are you deaf or do you have serious difficulty hearing?	DEAF	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CDIS.02	Are you blind or do you have serious difficulty seeing, even when wearing glasses?	BLIND	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CDIS.03	Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?	DECIDE	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CDIS.04	Do you have serious difficulty walking or climbing stairs?	DIFFWALK	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CDIS.05	Do you have difficulty dressing or bathing?	DIFFDRES	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CDIS.06	Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?	DIFFALON	1 Yes 2 No 7 Don’t know / Not sure 9 Refused

Core Section 11: Tobacco Use

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CTOB.01	Have you smoked at least 100 cigarettes in your entire life?	SMOKE100	1 Yes		Do not include: electronic cigarettes (e-cigarettes, njoy, bluetip, JUUL), herbal cigarettes, cigars, cigarillos, little cigars, pipes, bidis, kreteks, water pipes (hookahs) or marijuana. 5 packs = 100 cigarettes.
CTOB.01		SMOKE100	2 No 7 Don’t know/Not Sure 9 Refused	Go to CTOB.03
CTOB.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 7 Don’t know / Not sure 9 Refused
~~CTOB.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~~
~~CTOB.03~~		~~STOPSMK2~~		~~Go to CTOB.05~~
CTOB.03	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.
CTOB.04	Do you now use e-cigarettes or other electronic vaping products every day, some days or not at all?	*NEW*	1 Every day 2 Some days 3 Not at all 4 Never ~~smoked~~ used e-cigs 7 Don’t know / Not sure 9 Refused		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. Brands you may have heard of are JUUL, NJOY, or blu. 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.

Core Section 12: Alcohol Consumption

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CALC.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		Read if necessary: A 40-ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.
CALC.01		ALCDAY5	888 No drinks in past 30 days 777 Don’t know / Not sure 999 Refused	Go to next section
CALC.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?	AVEDRNK3	_ _ 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.
CALC.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 88 no days 99 Refused	CATI X = 5 for men, X = 4 for women (states may use sex at birth to determine sex if module is adopted)
CALC.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

Core Section 13: Immunization

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CIMM.01	During the past 12 months, have you had either a flu vaccine that was sprayed in your nose or a flu shot injected into your arm?	FLUSHOT7	1 Yes		Read if necessary: A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.
CIMM.01		FLUSHOT7	2 No 7 Don’t know / Not sure 9 Refused	Go to CIMM.04
CIMM.02	During what month and year did you receive your most recent flu vaccine that was sprayed in your nose or flu shot injected into your arm?	FLSHTMY3	_ _ / _ _ _ _ Month / Year 77 / 7777 Don’t know / Not sure 09 / 9999 Refused
CIMM.03	At what kind of place did you get your last flu shot or vaccine?	IMFVPLAC	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: 12 A drive though location at some other place than listed above 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? If the respondent indicates that it was a drive through immunization site, ask the location of the site. If the respondent remembers only that it was drive through and cannot identify the location, code “12”
				~~BRTHYEAR or YEARBRTH < 1971 GOTO CIMM.04.~~
CIMM.04	Have you ever had a pneumonia shot also known as a pneumococcal vaccine?	PNEUVAC4	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Read if necessary: There are two types of pneumonia shots: polysaccharide, also known as Pneumovax, and conjugate, also known as Prevnar.

Core Section 14: H.I.V./AIDS

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CHIV.01	Including fluid testing from your mouth, but not including tests you may have had for blood donation, have you ever been tested for H.I.V?	HIVTST7	1 Yes		Please remember that your answers are strictly confidential and that you don’t have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.
CHIV.01		HIVTST7	2 No 7 Don’t know/ not sure 9 Refused	Go to Next section
CHIV.02	Not including blood donations, in what month and year was your last H.I.V. test?	HIVTSTD3	_ _ /_ _ _ _ Code month and year 77/ 7777 Don’t know / Not sure 99/ 9999 Refused	If response is before January 1985, code "777777".	INTERVIEWER NOTE: If the respondent remembers the year but cannot remember the month, code the first two digits 77 and the last four digits for the year.

Core Section 15: 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)
CFV.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.
CFV.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?”
CFV.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.”
CFV.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.”
CFV.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.”
CFV.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.”

Closing Statement/ Transition to Modules

Read if necessary

Read

CATI instructions

(not 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.

Read if no optional modules follow, otherwise continue to optional modules.

Optional Modules

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 CCHC.11, DIABETE4, is coded 1. To be asked following Core CCHC.12;
M01.01	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
				Skip if CCHC.11, DIABETE4, is coded 1; If CCHC.11, DIABETE4, is coded 4 automatically code M01.02, PREDIAB1, equal to 1 (yes)
M01.02	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?

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)

M02.01	Are you now taking insulin?	INSULIN	1 Yes 2 No 7 Don’t know/ not sure 9 Refused
M02.02	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.’
M02.03	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
M02.04	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
M02.05	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.
M02.06	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	If M02.03 = 555 (No feet), go to M02.07
M02.07	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
M02.08	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
M02.09	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

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)
M03.01	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
M03.01		TOLDCFS	2 No 7 Don’t know / Not sure 9 Refused	Go to next module	My-al-gic En-ceph-a-lo-my-eli-tis
M03.02	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
M03.03	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

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)
M04.01	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
M04.01		TOLDHEPC	2 No 7 Don’t know / Not sure 9 Refused	Go to M04.05
M04.02	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.
M04.03	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.
M04.04	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.
M04.05	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.
M04.05		HAVEHEPB	2 No 7 Don’t know/ Not sure 9 Refused	Go to next module
M04.06	Are you currently taking medicine to treat hepatitis B?	MEDSHEPB	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused

Module 5: HPV - Vaccination

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Columns

M05.01

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

HPVADVC4

1 Yes

To be asked of respondents between the ages of 18 and 49 years (can be calculated from YEARBORN variable); otherwise, go to next module

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].

If respondent comments that this question was already asked, clarify that the earlier questions was about HPV testing, and this question is about vaccination.

2 No

3 Doctor refused when asked

7 Don’t know / Not sure

9 Refused

Go to next module

M05.02

How many HPV shots did you receive?

HPVADSHT

_ _ Number of shots (1-2)

3 All shots

77 Don’t know / Not sure

99 Refused

Module 6: 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)

M06.01

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

TETANUS2

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?

Module 7: 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 (can be calculated from YEARBORN variable ) 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 8: COVID Vaccination

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				These questions may be added in mid-year 2021 after vaccinations are available
MCOR.01	Since [DATE OF VACCINE AVAILABILITY], have you had a COVID-19 vaccination?	*NEW*	1 Yes
MCOR.01		*NEW*	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 9: 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 LCSCTSCN.
M09.01	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.
M09.01		LCSFIRST	888 Never smoked cigarettes regularly	Go to LCSCTSCN
M09.02	How old were you when you last smoked cigarettes regularly?	LCSLAST	_ _ _ Age in Years (001 – 100) 777 Don't know/Not sure 999 Refused
M09.03	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
M09.04	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

Module 10: Breast and Cervical Cancer Screening

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M10.01	(The next questions are about breast and cervical cancer.) Have you ever had a mammogram?	HADMAM	1 Yes	Skip to next module if male	A mammogram is an x-ray of each breast to look for breast cancer.
M10.01		HADMAM	2 No 7 Don’t know/ not sure 9 Refused	Go to M10.03
M10.02	How long has it been since you had your last mammogram?	HOWLONG	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 7 Don’t know / Not sure 9 Refused
M10.03	Have you ever had a cervical cancer screening test?		1 Yes
M10.03	Have you ever had a cervical cancer screening test?		2 No 7 Don’t know/ not sure 9 Refused	Go to M10.07
M10.04	How long has it been since you had your last cervical cancer screening test?	*NEW*	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
M10.04		*NEW*	7 Don’t know / Not sure 9 Refused	Go to M10.06
M10.05	At your most recent cervical cancer screening, did you have a Pap test?	*NEW*	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
M10.06	At your most recent cervical cancer screening, did you have an H.P.V. test?	*NEW*	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		H.P.V. stands for Human papillomarvirus (pap-uh-loh-muh virus)
M10.07	Have you had a hysterectomy?	HADHYST2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused	If response to Core CDEM.17 = 1 (is pregnant) do not ask and go to next module.	Read if necessary: A hysterectomy is an operation to remove the uterus (womb).

Module 11: Prostate 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 respondent is ≤39 years of age (YEARBORN < 1982) or is female, go to next module.
M11.01	Have you ever had a P.S.A. test?	PSATEST1	1 Yes		A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.
M11.01	Have you ever had a P.S.A. test?	PSATEST1	2 No 7 Don’t know / Not sure 9 Refused	Go to M11.04
M11.02	About how long has it been since your most recent P.S.A. test?	*NEW*	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		A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.

M11.03	What was the main reason you had this P.S.A. test – was it …?	*NEW*	Read: 1 Part of a routine exam 2 Because of a ~~prostate~~ problem ~~3 Because of a family history of prostate cancer~~ ~~4 Because you were told you had prostate cancer~~ 3. ~~Some~~ other reason Do not read: 7 Don’t know / Not sure 9 Refused		A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.
M11.04	Did a doctor, nurse, or other health professional EVER talk with you about the ~~…..’? When you met with a doctor, nurse, or other health professional did they talk about the~~ advantages, the disadvantages or both advantages and disadvantages of the Prostate-Specific Antigen or P.S.A. test?	*NEW*	1 Advantages 2 Disadvantages 3 Both Advantages and disadvantages DO NOT READ 4. Neither 7 Don’t know/ not sure 9 Refused		A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.

Module 12: 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)
				If Section CDEM.01, AGE, is less than 45 go to next module.
M12.01	Colonoscopy and sigmoidoscopy are exams to check for colon cancer. Have you ever had either of these exams?	HADSIGM3	1 Yes	Go to M12.02
M12.01		HADSIGM3	2 No 7 Don’t know/ not sure 9 Refused	Go to M12.06
M12.02	Have you had a colonoscopy, a sigmoidoscopy, or both?	*NEW*	1 Colonoscopy	Go to M12.03
			2 Sigmoidoscopy	Go to M12.04
			3 Both 7 Don’t know/Not sure	Go to M12.05
			9 Refused	Go toM12.06
M12.03	How long has it been since your most recent colonoscopy?	*NEW*	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	Go to M12.06
M12.04	How long has it been since your most recent sigmoidoscopy?	*NEW*	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	Go to M12.06
M12.05	How long has it been since your most recent colonoscopy or sigmoidoscopy?	LASTSIG3	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
M12.06	Have you ever had any other kind of test for colorectal cancer, such as virtual colonoscopy, CT colonography, blood stool test, FIT DNA, or Cologuard test?	*NEW*	1 Yes	Go to M12.07
M12.06		*NEW*	2 No 7 Don’t Know/Not sure 9 Refused	Go to Next Module
M12.07	A virtual colonoscopy uses a series of X-rays to take pictures of inside the colon. Have you ever had a virtual colonoscopy?	*NEW*	1 Yes	Go to M12.08	CT colonography, sometimes called virtual colonoscopy, is a new type of test that looks for cancer in the colon. Unlike regular colonoscopies, you do not need medication to make you sleepy during the test. In this new test, your colon is filled with air and you are moved through a donut-shaped X-ray machine as you lie on your back and then your stomach.
M12.07		*NEW*	2 No 7 Don’t Know/Not sure 9 Refused	Go to M12.09
M12.08	When was your most recent CT colonography or virtual colonoscopy?	*NEW*	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
M12.09	One stool test uses a special kit to obtain a small amount of stool at home and returns the kit to the doctor or the lab. Have you ever had this test?	*NEW*	1 Yes	Go to M12.10	The blood stool or occult blood test, fecal immunochemical or FIT test determine whether you have blood in your stool or bowel movement and can be done at home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it back to the doctor or lab.
M12.09		*NEW*	2 No 7 Don’t know/ not sure 9 Refused	Go to M12.11
M12.10	How long has it been since you had this test?	*NEW*	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
M12.11	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 Cologuard test?	*NEW*	1 Yes	Go to M12.12	Cologuard is a new type of stool test for colon cancer. Unlike other stool tests, Cologuard looks for changes in DNA in addition to checking for blood in your stool. The Cologuard test is shipped to your home in a box that includes a container for your stool sample.
M12.11		*NEW*	2 No 7 Don’t Know/Not sure 9 Refused	Go to Next Module
M12.12	Was the blood stool or FIT (you reported earlier) conducted as part of a Cologuard test?	*NEW*	1 Yes 2 No 7 Don’t Know/Not sure 9 Refused
M12.13	How long has it been since you had this test?	*NEW*	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

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
MTOC.01		CNCRDIFF	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.
				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?

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.
			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.
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.
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
MCOT.04		CSRVRTRN	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
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.
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
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

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
MCPM.01		CSRVPAIN	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

Module 16: 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 health professional recommended you check your blood pressure outside of the office or at home?	HOMBPCHK	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?	HOMRGCHK	1 Yes
M16.02		HOMRGCHK	2 No 7 Don’t know / Not sure 9 Refused	Go to next module
M16.03	Do you take it mostly at home or on a machine at a pharmacy, grocery or similar location?	WHEREBP	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 health professional? Is it mostly by telephone, other methods such as emails, internet portal or fax, or in person?	SHAREBP	Do not read: 1 Telephone 2 Other methods such as email, internet portal, or fax, or 3 In person
M16.04		SHAREBP	Do not read: 4 Do not share information 7 Don’t know / Not sure 9 Refused

Module 17: 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 18: 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.
M18.01	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 M18.02
			2 No	Go to next module
			7 Don’t know/ not sure	Go to M18.02
			9 Refused	Go to next module
M18.02	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
M18.03	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
M18.03		CDASSIST	4 Rarely 5 Never Do not read: 7 Don't know/Not sure 9 Refused	Go to M18.05
M18.04	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
M18.05	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
M18.06	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

Module 19: Caregiver

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M19.01	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
			2 No 7 Don’t know/Not sure	Go to M19.09
			8 Caregiving recipient died in past 30 days	Go to next module
			9 Refused	Go to M19.09
M19.02	What is his or her relationship to you?	CRGVREL3	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.
M19.03	For how long have you provided care for that person?	CRGVLNG1	Read if necessary: 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 More than 5 years Do not read: 7 Don’t Know/ Not Sure 9 Refused
M19.04	In an average week, how many hours do you provide care or assistance?	CRGVHRS1	Read if necessary: 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
M19.05	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	If M19.05 = 5 (Alzheimer’s disease, dementia or other cognitive impairment disorder), go to M19.07. Otherwise, continue
M19.06	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
M19.07	In the past 30 days, did you provide care for this person by managing personal care such as giving medications, feeding, dressing, or bathing?	CRGVPER1	1 Yes 2 No 7 Don’t know/ not sure 9 Refused
M19.08	In the past 30 days, did you provide care for this person by managing household tasks such as cleaning, managing money, or preparing meals?	CRGVHOU1	1 Yes 2 No 7 Don’t know/ not sure 9 Refused
				If M19.01 = 1 or 8, go to next module
M19.09	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

Module 20: 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 21: 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.
M21.01		MARIJAN1	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 22: 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 23: 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 24: 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)

M24.01

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

TYPEWORK

_______Record answer

99 Refused

If CDEM.14 = 1 (Employed for wages) or 2 (Self-employed) or 4 (Employed for wages or out of work for less than 1 year), continue, else go to next module/section.

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

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

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

M24.02

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

TYPEINDS

_______Record answer

99 Refused

If Core CDEM.14 = 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.”

Module 25: 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)
Intro text and screening	If CDEM.15 = 1, Interviewer please read: 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, Interviewer please read: 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.			If CDEM.15 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module. 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.
M25.01	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
M25.02	Is the child a boy or a girl?	RCSGENDR	1 Boy 2 Girl 9 Refused
M25.03	Is the child Hispanic, Latino/a, or Spanish origin?	RCHISLA1	Read if response is yes: 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		If yes, ask: Are they…
M25.04	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 88 No additional choices 77 Don’t know / Not sure 99 Refused		Select all that apply If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.
				IF MORE THAN ONE RESPONSE TO M25.04; CONTINUE. OTHERWISE, GO TO M25.06.]
M25.05	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.
M25.06	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

Module 26: 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.
M26.01	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.
M26.01		CASTHDX2	2 No 7 Don’t know/ not sure 9 Refused	Go to next module
M26.02	Does the child still have asthma?	CASTHNO2	1 Yes 2 No 7 Don’t know/ not sure 9 Refused

Module 27: 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

This question refers to the original birth certificate of the respondent. It does not refer to amended birth certificates.

Module 28: 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		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

Asthma Call-Back Permission Script

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
Text	We would like to call you again within the next 2 weeks to talk in more detail about (your/your child’s) experiences with asthma. The information will be used to help develop and improve the asthma programs in <STATE>. The information you gave us today and any you give us in the future will be kept confidential. If you agree to this, we will keep your first name or initials and phone number on file, separate from the answers collected today. Even if you agree now, you or others may refuse to participate in the future.
CB01.01	Would it be okay if we called you back to ask additional asthma-related questions at a later time?	CALLBACK	1 Yes 2 No
CB01.02	Which person in the household was selected as the focus of the asthma call-back?	ADLTCHLD	1 Adult 2 Child
CB01.03	Can I please have either (your/your child’s) first name or initials, so we will know who to ask for when we call back?	____________________ Enter first name or initials.

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.

8 October 2021

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Pierannunzi, Carol (CDC/ONDIEH/NCCDPHP)
File Modified	0000-00-00
File Created	2021-10-08