Form 0920-0950 Household Interview

National Health and Nutrition Examination Survey

Att_3c_HH Interview_201129

Household Interview

OMB: 0920-0950

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Attachment 3c

Household Interview Instruments

2021-2022

Form Approved

OMB No. 0920-0950

Exp. Date XX/XX/20XX

Notice – CDC estimates the average public reporting burden for this collection of information as 1 hour per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-0950).

Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m) and the Confidential Information Protection and Statistical Efficiency Act (Title III of the Foundations for Evidence-Based Policymaking Act of 2018 (Pub. L. No. 115-435, 132 Stat. 5529 § 302)). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

HOUSEHOLD SAMPLE PERSON AND FAMILY QUESTIONNAIRES

TABLE OF CONTENTS

SAMPLE PERSON QUESTIONNAIRE 3

RESPONDENT SELECTION SECTION - RIQ - SP QUESTIONNAIRE 3

COVID-19 – COQ 16

EARLY CHILDHOOD – ECQ 20

HOSPITAL UTILIZATION AND ACCESS TO CARE – HUQ 22

IMMUNIZATION – IMQ 25

MEDICAL CONDITIONS – MCQ 27

HEPATITIS (HEQ) 38

KIDNEY CONDITIONS – KIQ 39

DIABETES – DIQ 40

BLOOD PRESSURE – BPQ 44

AUDIOMETRY – AUQ 45

DERMATOLOGY – DEQ 47

ORAL HEALTH – OHQ 48

PHYSICAL ACTIVITY AND PHYSICAL FITNESS – PAQ 50

FUNCTIONING (FNQ) 54

STANDING BALANCE – BAQ 60

SLEEP DISORDERS – SLQ 64

DIET BEHAVIOR AND NUTRITION - DBQ 66

WEIGHT HISTORY – WHQ 77

SMOKING AND TOBACCO USE – SMQ 80

OCCUPATION – OCQ 82

ACCULTURATION – ACQ 87

DEMOGRAPHICS INFORMATION – DMQ – SP 88

HEALTH INSURANCE – HIQ 102

PRESCRIPTION MEDICATION – RXQ 107

MAILING ADDRESS – MAQ 110

FAMILY QUESTIONNAIRE 116

RESPONDENT SELECTION SECTION – RIQ – FAMILY QUESTIONNAIRE 116

DEMOGRAPHIC BACKGROUND – DMQ - FAM 122

HOUSING CHARACTERISTICS – HOQ 125

SMOKING – SMQ 126

CONSUMER BEHAVIOR – CBQ 127

INCOME – INQ 132

FOOD SECURITY – FSQ 141

TRACKING AND TRACING – TTQ 157

Sample Person Questionnaire

RESPONDENT SELECTION SECTION - RIQ - SP QUESTIONNAIRE

RIQ.NEW0 INTERVIEWER INSTRUCTION: SELECT INTERVIEW MODE

IN-PERSON......................................................... 1

PHONE................................................................. 2

RIQ.006 SELECT RESPONDENT FOR THE SP QUESTIONNAIRE FOR {SP NAME}.

CAPI INSTRUCTION:

DISPLAY HOUSEHOLD ROSTER FROM SCREENER AND ‘SOMEONE NOT LIVING IN HH’ AS OPTION.

DMQ.INTRO CAPI INSTRUCTION: BEGIN RECORDING SO THAT WHEN INTERVIEWER READS THIS QUESTION IT IS CAPTURED ON RECORDING.

WELCOME SCREEN FOR THE ADULT SP, PROXY FOR ADULT SP, PARENT/GUARDIAN FOR MINOR SP, AND EMANCIPATED MINOR SP. THIS IS FOR THE HEALTH INTERVIEW FOR {SP}.

Welcome to the National Health and Nutrition Examination Survey, also known as NHANES. {You have/SP has} been selected to be part of this study which includes an interview and a health exam. This study is sponsored by the National Center for Health Statistics, part of the Centers for Disease Control and Prevention. The information I collect in this interview will be extremely valuable in understanding the health and nutrition of people in the United States.

CAPI INSTRUCTION:

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN SCREENER IS 16 OR 17 DISPLAY “SP has”

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN SCREENER >17 DISPLAY “You have”

IF SP IS NOT SELECTED AS RESPONDENT IN RIQ.006 DISPLAY “SP has”

INTERVIEWER INSTRUCTION: IF SP IS 16 OR 17 YEARS OLD YOU MUST SPEAK WITH PARENT/GUARDIAN FIRST. PARENT/GUARDIAN MUST PROVIDE CONSENT BEFORE YOU COLLECT CONSENT AND CONDUCT THE HEALTH INTERVIEW WITH THE 16 OR 17 YEAR OLD SP.

RIQ.NEW1 AUDIO CONSENT FOR THE ADULT SP, PROXY FOR ADULT SP, PARENT/GUARDIAN FOR MINOR SP, AND EMANCIPATED MINOR SP.

We would like to record the interview for training and data quality. The computer is now recording our conversation. Do I have your permission to continue recording?

YES 1

NO 2

CAPI INSTRUCTION:

IF RIQ.NEW1 = 2, STOP RECORDING.

DMQ.010 Before we begin the health interview, I would like to verify some information about {you/SP}.

VERIFY AGE.

CAPI INSTRUCTION:

DISPLAY PERSON #, NAME, AND AGE IN YEARS. ALLOW AGE FIELD TO BE UPDATED.

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN SCREENER IS 16 OR 17 DISPLAY “SP”

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN SCREENER >17 DISPLAY “you”

IF SP IS NOT SELECTED AS RESPONDENT IN RIQ.006 DISPLAY “SP”

DMQ.NEW2 VERIFY GENDER.

INTERVIEWER INSTRUCTION: IF RESPONDENT CAN NOT DECIDE BETWEEN MALE OR FEMALE, OR DOES NOT IDENTIFY WITH EITHER, PROBE: “What would you tell your doctor?” IF RESPONDENT STILL CANNOT DECIDE OR REFUSES TO SELECT A RESPONSE, SELECT ‘DO NOT IDENTIFY AS EITHER.’

MALE 1 (DMQ.040)

FEMALE 2 (DMQ.040)

DOES NOT IDENTIFY AS EITHER 3

CAPI INSTRUCTION:

PREFILL WITH GENDER FROM SCREENER AND ALLOW UPDATE. IF DMQ.NEW2 DOES NOT EQUAL 3, USE THIS RESPONSE FOR GENDER FILLS AND ELIGIBLITY SETTINGS IN SUBSEQUENT SYSTEMS IN THE SURVEY. IF DMQ.NEW2 = 3, USE THE RESPONSE GIVEN IN DMQ.NEW3.

DMQ.NEW3 What sex {were you/was SP} assigned at birth?

INTERVIEWER INSTRUCTION: IF ASKED, ‘ASSIGNED AT BIRTH’ MEANS THE SEX NOTED ON AN ORIGINAL BIRTH CERTIFICATE.

MALE 1

FEMALE 2

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN SCREENER IS 16 OR 17 DISPLAY “was SP”

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN SCREENER >17 DISPLAY “were you”

IF SP IS NOT SELECTED AS RESPONDENT IN RIQ.006 DISPLAY “was SP”

DMQ.040 What is {your/SP’s} full name, including middle name?

VERIFY SPELLING.

What is {your/SP’s} first name?

FIRST NAME: __________________________

CAPI INSTRUCTION:

PREFILL FIRST NAME FROM SCREENER AND ALLOW UPDATES.

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN DMQ.010 IS 16 OR 17 DISPLAY “SP’s”

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN DMQ.010 >17 DISPLAY “your”

IF PROXY RESPONDENT DISPLAY “SP’s”

DMQ.050 [What is {your/SP’s} full name, including middle name?]

VERIFY SPELLING.

What is {your/SP’s} middle name?

MIDDLE NAME #1: __________________________

MIDDLE NAME #2: __________________________

NO MIDDLE NAME 1

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

PREFILL WITH MIDDLE NAME FROM SCREENER AND ALLOW UPDATES.

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN DMQ.010 IS 16 OR 17 DISPLAY “SP’s”

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN DMQ.010 >17 DISPLAY “your”

IF PROXY RESPONDENT DISPLAY “SP’s”

DMQ.060 [What is {your/SP’s} full name, including middle name?]

VERIFY SPELLING.

What is {your/SP’s} last name?

LAST NAME #1: __________________________

LAST NAME #2: __________________________

CAPI INSTRUCTION:

PREFILL WITH LAST NAME FROM SCREENER AND ALLOW UPDATES.

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN DMQ.010 IS 16 OR 17 DISPLAY “SP’s”

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN DMQ.010 >17 DISPLAY “your”

IF PROXY RESPONDENT DISPLAY “SP’s”

BOX 10

CHECK ITEM DMQ.065:

IF DMQ.NEW2 = 2 OR DMQ.NEW3 = 2, GO TO BOX 0.

IF DMQ.NEW2 = 1 OR DMQ.NEW3 = 1, CONTINUE.

DMQ.070 [What is {your/SP’s} full name, including middle name?]

VERIFY SPELLING.

{Do you/Does SP} have a suffix? [What is it?]

SUFFIX: _________

CAPI INSTRUCTION:

ALLOW SUFFIX FIELD TO BE LEFT BLANK/NULL.

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN DMQ.010 IS 16 OR 17 DISPLAY “SP’s”/”Does SP”

IF SP IS SELECTED AS RESPONDENT IN RIQ.006 AND AGE IN DMQ.010 >17 DISPLAY “your”/”Do you”

IF PROXY RESPONDENT DISPLAY “SP’s”/”Does SP”

BOX 0

CHECK ITEM RIQ.008:

IF PROXY RESPONDENT FOR SP AGE 15 OR YOUNGER, GO TO RIQ.012.

IF PROXY RESPONDENT FOR SP AGE 16 OR OLDER, GO TO RIQ.014.

OTHERWISE GO TO BOX 1.

RIQ.012 INTERVIEWER INSTRUCTION: ASK OR MARK IF KNOWN.

(What is your relationship to {SP}?)

MOTHER (BIOLOGICAL/ADOPTIVE/
STEP/FOSTER) 1 (BOX 1)

FATHER (BIOLOGICAL/ADOPTIVE/
STEP/FOSTER) 2 (BOX 1)

GRANDPARENT (GRANDMOTHER/
GRANDFATHER) 3 (BOX 1)

AUNT/UNCLE 4 (BOX 1)

BROTHER/SISTER 5 (BOX 1)

OTHER RELATIVE 6 (BOX 1)

NON-RELATIVE 7 (BOX 1)

REFUSED 77 (BOX 1)

DON'T KNOW 99 (BOX 1)

RIQ.014 INTERVIEWER INSTRUCTION: ASK OR MARK IF KNOWN.

(What is your relationship to {SP}?)

SPOUSE (WIFE/HUSBAND) OR
PARTNER 1

DAUGHTER OR SON (BIOLOGICAL/
ADOPTIVE/IN-LAW/STEP/FOSTER) 2

PARENT (BIOLOGICAL/ADOPTIVE/
STEP/FOSTER) 3

GRANDPARENT (GRANDMOTHER/
GRANDFATHER) 4

BROTHER/SISTER 5

OTHER RELATIVE 6

NON-RELATIVE 7

REFUSED 77

DON'T KNOW 99

BOX 1

CHECK ITEM *11RIQ.015:

 IF SP IS SELECTED AS RESPONDENT AND SP AGE IS <= 15, GO TO
*11RIQ.020.

 IF SP IS SELECTED AS RESPONDENT AND SP AGE IS >= 16, GO TO
BOX 3AA.

 IF SP IS NOT SELECTED AS RESPONDENT AND SP AGE IS <= 15, GO TO
BOX 2.

 IF SP IS NOT SELECTED AS RESPONDENT AND SP AGE IS >= 16, GO TO
RIQ.039.

*11RIQ.020 INTERVIEW SHOULD BE CONDUCTED WITH A PROXY BECAUSE SP IS UNDER 16 YEARS OLD. YOU SHOULD HAVE APPROVAL FROM YOUR SUPERVISOR BEFORE CONDUCTING THE INTERVIEW WITH AN EMANCIPATED MINOR.

ENTER ONE OPTION.

SP IS AN EMANCIPATED MINOR 1 (BOX 3)

PERSON SELECTED AS

RESPONDENT IN ERROR 2 (RIQ.006)

SP AGE ENTERED IN ERROR -- SP IS

AGE 16+ 3 (DMQ.010)

RIQ.039 WHY IS INTERVIEW BEING CONDUCTED WITH A PROXY?

SP HAS COGNITIVE PROBLEMS 1

SP HAS PHYSICAL PROBLEMS

(SPECIFY) 2

*11RIQ.035 DO YOU HAVE SUPERVISOR PERMISSION TO CONDUCT INTERVIEW WITH A PROXY?

YES 1

NO 2 (RIQ.006)

BOX 2

CHECK ITEM RIQ.031:

IF 'SOMEONE NOT LIVING IN HH' SELECTED AS RESPONDENT IN RIQ.006, CONTINUE.

OTHERWISE, GO TO BOX 3AA.

RIQ.040 WHY IS INTERVIEW BEING CONDUCTED WITH SOMEONE OUTSIDE THE HOUSEHOLD?

RIQ.050 ENTER RESPONDENT NAME.

FIRST NAME LAST NAME

RIQ.060 ENTER RESPONDENT'S PHONE NUMBER.

ENTER '00' IN AREA CODE IF NO PHONE.

|___|___|___| |___|___|___| - |___|___|___|___|

AREA CODE ENTER PHONE NUMBER

BOX 3

CHECK ITEM *11RIQ.072:

IF SP SELECTED AS RESPONDENT IS <12 YEARS OLD, CONTINUE.

OTHERWISE, GO TO BOX 3AA.

*11RIQ.074 EMANCIPATED MINOR MUST BE AT LEAST 12 YEARS OLD.

PRESS ‘ENTER’ TO SELECT ANOTHER RESPONDENT.

CAPI INSTRUCTION:

WHEN ‘ENTER’ IS PRESSED, CAPI SHOULD RETURN TO RIQ.006.

BOX 3AA

CHECK ITEM RIQ.245:

IF SP SELECTED AS RESPONDENT IS 16 OR 17 YEARS OLD, CONTINUE.

OTHERWISE, GO TO BOX 3C.

RIQ.248 IS SP AN EMANCIPATED MINOR? YOU SHOULD HAVE APPROVAL FROM YOUR SUPERVISOR BEFORE CONDUCTING THE INTERVIEW WITH AN EMANCIPATED MINOR.

YES 1

NO 2

BOX 3C

CHECK ITEM RIQ.260:

IF RESPONDENT IS 16-17 YEARS OLD AND NOT EMANCIPATED (RIQ.248 = 2/NO OR *11RIQ.020 NOT EQUAL TO 1), CONTINUE.

OTHERWISE, SKIP TO RIQ.NEW2.

RIQ.274 WHO IS PARENT/GUARDIAN CONSENTING FOR {SP}?

CAPI INSTRUCTION:

LIST HH ROSTER MEMBERS WHO ARE 18+ AND ‘SOMEONE NOT LIVING IN HH’ AS RESPONSE OPTIONS.

IF ‘NOT ON LIST’ SELECTED GO TO RIQ.276. IF HH MEMBER SELECTED, GO TO RIQ.NEW2.

RIQ.276 WHAT IS PARENT/GUARDIAN’S NAME?

INTERVIEWER INSTRUCTION: ENTER NAME. VERIFY SPELLING.

FIRST NAME LAST NAME

RIQ.NEW2a/b INTERVIEW CONSENT FOR ADULT SP, PROXY FOR ADULT SP, PARENT/GUARDIAN FOR MINOR SP, OR EMANCIPATED MINOR SP. THIS IS FOR THE HEALTH INTERVIEW FOR {SP}.

There are a few additional things I need to cover before we continue with the interview. Taking part in this interview is voluntary. {You/SP} may choose to skip any question {you don’t/s/he doesn’t} wish to answer or end the interview at any time without penalty. We are required by Federal law to develop and follow strict procedures to protect the confidentiality of {your/his/her} information and use {your/his/her} answers only for statistical purposes. I can describe these laws if you wish. On average, the interview will take less than {INTERVIEW DURATION} minutes. {At the completion of the interview, you {or SP} will be given a ${INCENTIVE} debit card as a thank you for answering these questions.} Do you have any questions before we continue?

Do you agree to {allow SP to} proceed with the interview {for SP}?

YES 1

NO 2

We can do additional health studies by linking the interview and exam data to vital statistics, health, nutrition, and other related records. May we try to link {your/SP’s} survey records with other records?

YES 1

NO 2

IF RESPONDENT NEEDS MORE INFORMATION ABOUT LINKING, READ:

[I understand your concern.] By matching NHANES data with other health-related records, researchers can study health conditions like heart attacks and diabetes in depth. They can also better understand health care use and health care costs for all Americans. These findings will help doctors assist patients in making smart choices. These types of studies will not be possible if we don’t have your permission for the linkage. I can share some examples with you if you like. May we try to link your/the SP’s survey records with other records?

IF ASKED FOR EXAMPLES, READ:

By linking the data from our study to data from the U.S. Department of Housing and Urban Development, we learned the association between housing environment and the high level of lead in children’s blood.
By linking the Vitamin D levels measured from our participants’ blood to Medicare data, we learned that higher vitamin D in the blood lowers the risk of broken bones.
By linking the behaviors reported by our participants to the National Death Index database, we learned that adults who exercise, eat healthy diets, and do not smoke have a lower chance of dying.

IF ASKED FOR ADDITIONAL EXPLANATION OF DATA LINKAGE:

Data linkage, also known as record linkage, combines your information from at least two different sources (e.g., NHANES data and Medicare data). This is done only for statistical purposes.

If you agree to data linkage, we will combine the information we collected from you during this survey with records from other organizations (e.g. the Centers for Medicare and Medicaid Services). Once the linkage is completed, personal information that identifies you such as your name, street address, and phone number, will be removed from the linked file before the file is made available for analysis. The linked file will only be used for statistical purposes.

HELP SCREEN:

RIQ.NEW2a/RIQ.NEW2b- Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m) and the Confidential Information Protection and Statistical Efficiency Act of 2018 (Title III of the Foundations for Evidence-Based Policymaking Act of 2018 (Pub. L. No. 115-435, 132 Stat. 5529 § 302)). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

Public reporting burden for this collection of information is estimated to average 45 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0950).

CAPI INSTRUCTION:

RIQ.NEW2a AND RIQ.NEW2b SHOULD DISPLAY ON SEPARATE SCREENS. INCLUDE STEM AND QUESTION TEXT FOR EACH ITEM. DISPLAY “IF RESPONDENT NEEDS MORE INFORMATION…” AND ALL SUBSEQUENT TEXT ONLY FOR RIQ.NEW2b. STEM SHOULD BE IN BRACKETS FOR RIQ.NEW2b AS OPTIONAL READING.
DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.
DISPLAY YES/NO OPTIONS AS RADIO BUTTON, ALLOWING ONLY ONE CHOICE.
DISPLAY OMB NUMBER IN UPPER RIGHT OF SCREEN.
DISABLE LINKAGE QUESTION IF NEW2a = NO (2).
IF NEW2a = 2, GO TO RIQ.NEW2CK: “EACH RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE MUST GIVE CONSENT BEFORE THE INTERVIEW CAN BE ADMINISTERED.” WHEN NEXT BUTTON IS PRESSED, CASE CLOSES AS PARTIALLY WORKED.
FILL INSTRUCTIONS.
1. FOR STEM:
  1. IF RESPONDENT IS ADULT SP, PROXY FOR ADULT SP 18+, PARENT/GUARDIAN FOR MINOR SP AGED 0-15, OR EMANCIPATED MINOR SP DISPLAY “You”, ”you don’t”, ”your”, ”your”
  2. IF RESPONDENT IS 16-17 YEAR OLD SP AND NOT EMANCIPATED, DISLAY “{SP}”, ”she/he doesn’t”, ”his/her”, “his/her”, and “or {SP}”
  3. IF INCENTIVE ACTIVE IN STAND DISPLAY “At the completion of this interview…”.
  4. For {DURATION OF MINUTES} FILL ‘15’ FOR SPs 0-15 YEARS OLD, ‘30’ FOR SPs 16-59 YEARS OLD, AND ‘40’ FOR SPs 60+ YEARS OLD.
2. FOR NEW2a:
  1. IF RESPONDENT IS A 16-17 YEAR OLD SP AND NON-EMANCIPATED DISPLAY “allow {SP} to”
  2. IF RESPONDENT IS PROXY FOR ADULT 18+ OR PARENT/GUARDIAN FOR MINOR SP AGED 0-15, DISPLAY ‘{for SP}.’
3. FOR NEW2b:
  1. IF RESPONDENT IS ADULT SP OR 16-17 YEAR OLD SP WHO IS EMANCIPATED DISPLAY ‘your’
  2. IF RESPONDENT IS PROXY FOR ADULT 18+, PARENT/GUARDIAN FOR MINOR SP AGED 0-15, OR 16-17 YEAR OLD SP AND NON-EMANCIPATED DISPLAY ‘{SP}’s’

BOX NEW

CHECK ITEM RIQ.NEW3:

IF RESPONDENT SP 16-17 YEARS OLD AND MINOR (NOT EMANCIPATED (RIQ.248 = 2/NO OR *11RIQ.020 NOT EQUAL TO 1), CONTINUE.

OTHERWISE, GO TO DMQ.NEW1.

RIQ.NEW4 We would like to record {SP}’s interview for training and data quality. Do I have your permission to record the interview?

YES 1

NO 2

CAPI INSTRUCTION:

IF RIQ.NEW4 = 2, STOP AUDIO RECORDING.

RIQ.NEW5 Is {SP} available now to complete the interview?

YES....................................................................... 1

NO. RECONTACT LATER TO COMPLETE

INTERVIEW.......................................................... 2

NEW BOX

CHECK ITEM RIQ.NEW6:

IF RIQ.NEW5 = 2, EXIT MODULE AS PARTIALLY WORKED.

OTHERWISE CONTINUE.

RIQ.NEW7 WELCOME SCREEN FOR 16-17 YEAR OLD. THIS IS FOR THE HEALTH INTERVIEW FOR {SP}.

Welcome to the National Health and Nutrition Examination Survey, also known as NHANES. You have been selected to be part of this study which includes an interview and a health exam. This study is sponsored by the National Center for Health Statistics, part of the Centers for Disease Control and Prevention. The information I collect in this interview will be extremely valuable in understanding the health and nutrition of people in the United States.

RIQ.NEW8 AUDIO CONSENT SCREEN FOR 16-17 YEAR OLD. THIS IS FOR THE HEALTH INTERVIEW FOR {SP}.

We would like to record the interview for training and data quality. Your parent/guardian has already given permission to record the interview. Do I have your permission to record this interview?

YES 1

NO 2

CAPI INSTRUCTION: IF RIQ.NEW8= 2/NO, STOP AUDIO RECORDING.

RIQ.NEW9a/b INTERVIEW CONSENT FOR 16-17 YEAR OLD. SP IS: {SP}

Taking part in this interview is voluntary. You may choose to skip any question you don’t wish to answer or end the interview at any time without penalty. We are required by Federal law to develop and follow strict procedures to protect the confidentiality of your information and use your answers only for statistical purposes. I can describe these laws if you wish. On average, the interview will take less than 30 minutes. {At the completion of the interview, you or your parent or guardian will be given a ${INCENTIVE} debit card as a thank you for answering these questions.}

Your parent/ guardian has already given permission for you to participate. Do you agree to proceed with the interview?

YES 1

NO 2

We can do additional health studies by linking the interview and exam data to vital statistics, health, nutrition, and other related records. May we try to link your survey records with other records?

YES 1

NO 2

IF RESPONDENT NEEDS MORE INFORMATION, READ:

[I understand your concern.] By matching NHANES data with other health-related records, researchers can study health conditions like heart attacks and diabetes in depth. They can also better understand health care use and health care costs for all Americans. These findings will help doctors assist patients in making smart choices. These types of studies will not be possible, if we don’t have your permission for the linkage. I can share some examples with you if you like. May we try to link your/the SP’s survey records with other records?

IF ASKED FOR EXAMPLES, READ:

By linking the data from our study to data from the U.S. Department of Housing and Urban Development, we learned the association between housing environment and the high level of lead in children’s blood.
By linking the Vitamin D levels measured from our participants’ blood to Medicare data, we learned that higher vitamin D in the blood lowers the risk of broken bones.
By linking the behaviors reported by our participants to the National Death Index database, we learned that adults who exercise, eat healthy diets, and do not smoke have a lower chance of dying.

IF ASKED FOR ADDITIONAL EXPLAINATION OF DATA LINKAGE:

Data linkage, also known as record linkage, combines your information from at least two different sources (e.g., NHANES data and Medicare data). This is done only for statistical purposes.

HELP SCREEN:

RIQ.NEW9a/RIQ.NEW9b- Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m) and the Confidential Information Protection and Statistical Efficiency Act of 2018 (Title III of the Foundations for Evidence-Based Policymaking Act of 2018 (Pub. L. No. 115-435, 132 Stat. 5529 § 302)). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

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.

CAPI INSTRUCTION:

RIQ.NEW9a AND RIQ.NEW9b SHOULD DISPLAY ON SEPARATE SCREENS. INCLUDE STEM AND QUESTION TEXT FOR EACH ITEM. DISPLAY “IF RESPONDENT NEEDS MORE INFORMATION…” AND ALL SUBSEQUENT TEXT ONLY FOR RIQ.NEW9b. STEM SHOULD BE IN BRACKETS FOR RIQ.NEW9b AS OPTIONAL READING.
DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.
DISPLAY YES/NO OPTIONS AS RADIO BUTTON, ALLOWING ONLY ONE CHOICE.
DISPLAY OMB NUMBER IN UPPER RIGHT OF SCREEN.
IF NEW9a = 2, DISPLAY THE FOLLOWING MESSAGE: “EACH RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE MUST GIVE CONSENT BEFORE THE INTERVIEW CAN BE ADMINISTERED.” WHEN NEXT BUTTON IS PRESSED, CASE CLOSES AS PARTIALLY WORKED.
DISPLAY LINKAGE QUESTION (RIQ.NEW9b) WHEN RIQ.NEW9a = 1 AND RIQ.NEW2a= 1.
FILL “At the completion of this interview…” ONLY IF INCENTIVE ACTIVE IN STAND.

DMQ.NEW1 What is {your/SP’s} birthdate?

a/b/c

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTIONS:

IF CALCULATE AGE BASED ON REPORTED DATE OF BIRTH IS DIFFERENT FROM AGE IN THE RECORD, DISPLAY A MESSAGE ASKING THE INTERVIEWER TO VERIFY.

SEPARATE FIELDS FOR MONTH, DAY, AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT VALUE FOR MONTH: 01-12

HARD EDIT VALUE FOR DAY: 01-31

INT.001 IS AN INTERPRETER BEING USED FOR INTERVIEW?

YES 1

NO 2 (GO TO THE END

OF THE SECTION)

INT.003 LANGUAGE USED FOR INTERVIEW

AMERICAN SIGN LANGUAGE 1 (INT.013)

CHINESE (CANTONESE) 2 (INT.013)

CHINESE (MANDARIN) 3 (INT.013)

FRENCH 4 (INT.013)

GERMAN 5 (INT.013)

ITALIAN 6 (INT.013)

JAPANESE 7 (INT.013)

KOREAN 8 (INT.013)

RUSSIAN 9 (INT.013)

SPANISH (READER) 10 (INT.013)

VIETNAMESE 11 (INT.013)

OTHER SPECIFY 99

INT.004 ENTER LANGUAGE USED FOR INTERVIEW

_________________________________

INT.013 {DISPLAY INTERPRETER NAMES FROM ALL PREVIOUS INTERVIEWS: SCREENER, RELATIONSHIP, SP, FAMILY QUESTIONNAIRE}

ENTER INTERPRETER NAME INFO

NEW INTERPRETER 2 (INT.005)

INT.014 {DISPLAY LIST OF INTERPRETER NAMES FROM SCREENER, RELATIONSHIP, SP AND/OR FAMILY QUESTIONNAIRES}

{INCLUDE “OTHER” AS A SELECTION}

SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME

BOX 4

CHECK ITEM INT.014a:

IF ‘OTHER’ SELECTED IN INT.014, GO TO INT.005.

OTHERWISE, CODE INTERPRETER INFO FROM PREVIOUS INTERVIEW AND GO TO RIQ.NEW10.

INT.005 HOW WAS INTERPRETER OBTAINED

ARRANGED BY THE OFFICE 1

RECRUITED DURING VISIT OR

APPOINTMENT 2 (INT.007)

INT.006 SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME

{DROP DOWN LIST SHOULD HAVE ALL NAMES FROM EVM AND AN “OTHER SPECIFY” TO ALLOW FOR THOSE NAMES THAT HAVE NOT BEEN TRANSFERRED TO INTERVIEWER PENTOP}

BOX 6

CHECK ITEM INT.006A:

IF OTHER (SELECTED IN INT.006), GO TO INT.009.

OTHERWISE, GO TO END OF SECTION.

INT.007 SELECT INTERPRETER SOURCE

RELATIVE LIVING IN HOUSEHOLD 1

NON-RELATIVE LIVING IN HOUSEHOLD 2

NEIGHBOR, RELATIVE OR FRIEND –
NOT IN HOUSEHOLD 3 (GO TO RIQ.NEW10)

INT.008 SELECT NAME OF INTERPRETER FROM HOUSEHOLD ROSTER.

{DISPLAY CAPI PULL DOWN LIST FROM HH ROSTER}

BOX 7

CHECK ITEM INT.008A:

RIQ.NEW10.

INT.009 ENTER NAME OF INTERPRETER

______________________________________

INT.010 ENTER PHONE # OF INTERPRETER

___ -___ ____

RIQ.NEW10 Interviewer instruction: ask THE SP/PROXY TO GATHER HIS/HER/sp’S MEDICARE CARD (IF APPROPRIATE) AND HAND CARD BOOKLET PRIOR TO PROCEEDING WITH THE INTERVIEW.

CoVID-19 – COQ

Target Group: SPs Birth +

COQ.NEW1 {Have you/Has SP} ever had COVID-19, or the illness caused by the novel coronavirus?

INTERVIEWER INSTRUCTIONS:

CODE ‘MAYBE’ IF THE SP THINKS S/HE MAY HAVE HAD COVID-19 DUE TO EXPERIENCING CERTAIN SYMPTOMS BUT DID NOT GET TESTED OR IS UNSURE OF THE RESULTS. CODE ‘DON’T KNOW’ IF THE SP DOES NOT KNOW IF S/HE HAS HAD COVID-19.

YES 1

NO 2 (COQ.NEW3)

MAYBE 3

REFUSED 7 (COQ.NEW3)

DON’T KNOW 9 (COQ.NEW3)

COQ.NEW2 How would {you/SP’s} describe {your/his/her} symptoms when they were at their worst? Would you say…

No symptoms 1

Mild symptoms 2

Moderate symptoms 3

Severe symptoms 4

REFUSED 7

DON’T KNOW 9

COQ.NEW3 Now I’m going to ask you about testing for active COVID infections, which is done through a nasal or throat swab or a saliva test.

{Have you/Has SP} ever been tested for coronavirus or COVID-19?

YES 1

NO 2 (COQ.NEW6)

REFUSED 7 (COQ.NEW6)

DON’T KNOW 9 (COQ.NEW6)

COQ.NEW4 Did the test find that {you/SP} had coronavirus or COVID-19?

INTERVIEWER INSTRUCTION: IF TESTED MULTIPLE TIMES, CODE ANY POSITIVE RESULT RECEIVED AS YES.

YES 1

NO 2 (COQ.NEW6)

DID NOT RECEIVE RESULTS 3 (COQ.NEW6)

REFUSED 7 (COQ.NEW6)

DON’T KNOW 9 (COQ.NEW6)

COQ.NEW5a/bWhat was the date of {your/SP’s} positive COVID-19 test? Please tell me the month and year of {your/his/her} first positive test.

INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___|

ENTER MONTH

REFUSED 7777

DON'T KNOW 9999

|___|___|___|___|

ENTER YEAR

REFUSED 7777

DON'T KNOW 9999

CAPI INSTRUCTIONS:

HARD EDIT VALUE FOR MONTH: 01-12

HARD EDIT: DATE MUST BE CURRENT MONTH AND YEAR OR PRIOR.

HARD EDIT: YEAR MUST BE 2020 OR LATER.

COQ.NEW6 {Have you/Has SP} ever had an antibody blood test to determine if {you/s/he} had coronavirus or COVID-19 in the past?

INTERVIEWER INSTRUCTION: IF TESTED MULTIPLE TIMES, CODE ANY POSITIVE RESULT RECEIVED AS YES.

YES 1

NO 2 (COQ.NEw8)

REFUSED 7 (COQ.NEW8)

DON’T KNOW 9 (COQ.NEW8)

COQ.NEW7 Did the test find that {you/SP} had antibodies for coronavirus or COVID-19?

YES 1

NO 2

DID NOT RECEIVE RESULTS 3

REFUSED 7

DON’T KNOW 9

COQ.NEW8 {Have you/Has SP} ever received a vaccine for COVID-19?

YES 1

NO 2 (COQ.NEW10)

REFUSED 7 (COQ.NEW10)

DON’T KNOW 9 (COQ.NEW10)

COQ.NEW9a/bIn what month and year did {you/he/she} receive the vaccine for COVID-19?

INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___|

ENTER MONTH

REFUSED 7777

DON'T KNOW 9999

|___|___|___|___|

ENTER YEAR

REFUSED 7777

DON'T KNOW 9999

CAPI INSTRUCTIONS:

HARD EDIT VALUE FOR MONTH: 01-12

HARD EDIT: DATE MUST BE CURRENT MONTH AND YEAR OR PRIOR.

HARD EDIT: YEAR MUST BE 2020 OR LATER.

COQ.NEW10 {Have you/Has SP} ever had an overnight stay in a hospital for suspected or confirmed COVID-19?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

COQ.NEW11 Has anyone in {your/SP’s} household ever tested positive for coronavirus or COVID-19?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

Household: The entire group of persons who live in one dwelling unit. It may be several persons living together or one person living alone. It includes the household reference person and any of their relatives, as well as roomers, employees, and other non-related persons.

COQ.NEW12 {Do you/Does SP} currently have a health condition that a doctor or other health professional told {you/him/her} weakens the immune system, making it easier for {you/him/her} to get sick?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

Doctor: The term refers to both doctors of medicine (M.D.s) and doctors of osteopathic medicine (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.

Health Care Professionals (Health Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, pharmacists, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.

COQ.NEW13 In the past 12 months, {have you/has SP} taken prescription medication or had any medical treatments that a doctor or other health professional told {you/him/her} would weaken {your/his/her} immune system?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

COQ.NEW14 There are two types of flu vaccinations. One is a shot and the other is a spray, mist, or drop in the nose. During the past 12 months, {have you/has SP} had a flu vaccination?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

EARLY CHILDHOOD – ECQ

Target Group: SPs Birth to 15 Years

ECQ.071G/ Next, I have some questions about {SP’s} birth. How much did {SP} weigh at birth?

L/O/K/M

INTERVIEWER INSTRUCTION:

IF ANSWER GIVEN IN POUNDS ONLY, PROBE FOR OUNCES.

IF ANSWER GIVEN IN EXACT POUNDS, ENTER NUMBER OF POUNDS AND 0 OUNCES.

ENTER WEIGHT IN POUNDS, KILOGRAMS OR GRAMS.

|___|

ENTER NUMBER OF POUNDS

AND OUNCES 1

ENTER NUMBER IN KILOGRAMS 2

ENTER NUMBER IN GRAMS 3

REFUSED 7 (BOX 1)

DON’T KNOW 9 (BOX 1)

|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT <3 OR >13, HARD EDIT EQUAL TO OR GREATER THAN 20

AND

|___|___|

ENTER NUMBER OF OUNCES

CAPI INSTRUCTION:

HARD EDIT 0-15, NO SOFT EDIT

|___|___|___|

ENTER NUMBER IN KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT <1.5 OR >6, HARD EDIT GREATER THAN OR EQUAL TO 9

|___|___|___|

ENTER NUMBER IN GRAMS

CAPI INSTRUCTION:

SOFT EDIT <1,500 OR >6,000, HARD EDIT GREATER THAN OR EQUAL TO 9,000

BOX 1

CHECK ITEM ECQ.075:

IF REFUSED (CODE 7) OR DON'T KNOW (CODE 9), CONTINUE.

OTHERWISE, GO TO BOX 2.

ECQ.080 Did {SP} weigh . . .

more than 5-1/2 lbs. (2 and a half kilograms),
or 1

less than 5-1/2 lbs. (2 and a half kilograms)? 2 (BOX 2)

REFUSED 7 (BOX 2)

DON'T KNOW 9 (BOX 2)

ECQ.090 Did {SP} weigh . . .

more than 9 lbs. (4 kilograms), or 1

less than 9 lbs. (4 kilograms)? 2

REFUSED 7

DON'T KNOW 9

BOX 2

CHECK ITEM ECQ.095:

IF SP AGE = 2-15 YEARS, CONTINUE.

OTHERWISE, GO TO End of Section.

WHQ.030e Do you consider {SP} now to be . . .

overweight, 1

underweight, or 2

about the right weight? 3

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

MCQ.080e Has a doctor or health professional ever told you or {SP} that {he/she} was overweight?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

HOSPITAL UTILIZATION AND ACCESS TO CARE – HUQ

Target Group: SPs Birth +

HUQ.010 Next I have some general questions about {your/SP's} health.

Would you say {your/SP's} health in general is . . .

excellent, 1

very good, 2

good, 3

fair, or 4

poor? 5

REFUSED 7

DON'T KNOW 9

HUQ.030 Is there a place that {you/SP} usually {go/goes} to if {you are/he is/she is} sick and need{s} health care?

YES 1

THERE IS NO PLACE 2 (HUQ.NEW1)

THERE IS MORE THAN ONE PLACE 3

REFUSED 7 (HUQ.NEW1)

DON'T KNOW 9 (HUQ.NEW1)

HELP SCREEN:

Usual Place: Include walk-in clinic, doctor's office, clinic, health center, Health Maintenance Organization or HMO, hospital emergency room or outpatient clinic, or a military or VA health care facility.

HUQ.042 {What kind of place is it/ What kind of place {do you/does SP} go to most often} – a doctor’s office or health center; an urgent care center or clinic in a drug store or grocery store; an emergency room; a VA Medical Center or VA outpatient clinic; or some other place?

READ IF NECESSARY: A doctor’s office or health center is a place where you see the same doctor or same group of doctors every visit, where you usually need to make an appointment ahead of time, and where your medical records are on file.

READ IF NECESSARY: Urgent care centers and clinics in a drug store or grocery store are places where you do not need to make an appointment ahead of time, and usually you do not see the same health care provider.

A DOCTOR’S OFFICE OR HEALTH
CENTER 1

URGENT CARE CENTER OR CLINIC IN
A DRUG STORE OR GROCERY STORE 2

EMERGENCY ROOM 3

A VA MEDICAL CENTER OR VA
OUTPATIENT CLINIC 4

SOME OTHER PLACE 5

DOESN’T GO TO ONE PLACE MOST

OFTEN 6

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF HUQ.030 = 1 DISPLAY “What kind of place is it

IF HUQ.030 = 3 DISPLAY “What kind of place {do you/does SP} go to most often

HELP SCREEN:

Clinic: Refers to a facility where medical care and advice are given by doctors, nurses, or other medical professionals, that is not located at a hospital. (Do not include hospital outpatient departments.) Include a clinic operated solely for employees of a company or industry, regardless of where the clinic is located.

Doctor's Office In Hospital - An individual office in a hospital where patients are seen on an outpatient basis, or several doctors might occupy a suite of offices in a hospital where patients are treated as outpatients.

Doctor's Office Not in Hospital - An individual office in the doctor's home or office building, or a suite of offices occupied by several doctors. Suites of doctors offices are not considered clinics.

Health Center: Refers to a facility where medical care and advice are given by doctors, nurses, or other medical professionals that is not located at a hospital.

HMO Clinic: A medical facility sponsored by an HMO that typically includes a group of doctors on staff.

Hospital Outpatient Department: A unit of a hospital providing health and medical services to individuals who receive services from the hospital but do not require hospitalization overnight, such as outpatient surgery centers. Examples of outpatient departments include the following:

Well-baby clinics/pediatric OPD;

Obesity clinics;

Eye, ear, nose, and throat clinics;

Cardiology clinics;

Internal medicine department;

Family planning clinics;

Alcohol and drug abuse clinics;

Physical therapy clinics; and

Radiation therapy clinics.

Hospital outpatient departments may also provide general primary care.

HUQ.NEW1 In past 12 months, {have you/has SP} had an appointment with a doctor, nurse, or other health professional by video conference or by phone?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

IMMUNIZATION – IMQ

Target Group: SPs 2+

IMQ.011 Hepatitis (Hep-a-ti-tis) A vaccine is given as a two dose series to children and adults, especially people who travel outside the United States. It has been available since 1995. {Have you/Has SP} ever received the hepatitis A vaccine?

INTERVIEWER INSTRUCTION: A COMBINATION HEPATITIS A AND HEPATITIS B VACCINE SHOULD BE COUNTED AS THE A VACCINE FOR THE PURPOSE OF THIS QUESTION. CODE 'YES AT LEAST 2 DOSES' IF RESPONDENT ANSWERS 3 OR 4 DOSES WERE RECEIVED. CODE 'LESS THAN 2 DOSES' ONLY IF MENTIONED BY RESPONDENT.

YES AT LEAST 2 DOSES 1

LESS THAN 2 DOSES 2

NO DOSES 3

REFUSED 7

DON'T KNOW 9

BOX 3

CHECK ITEM IMQ.050:

IF SP = FEMALE AND AGE IS >= 9 AND <= 49, CONTINUE.

IF SP = MALE AND AGE IS >= 9 AND <= 49, GO TO IMQ.070.

OTHERWISE, GO TO END OF SECTION.

IMQ.060 Human Papillomavirus (HPV) vaccine is given to prevent HPV infection, cervical cancer, and other conditions caused by HPV in girls and women. It is given in 2 or 3 separate doses. {Have you/Has SP} ever received one or more doses of the HPV vaccine? (The brand names for the HPV vaccines are Cervarix, Gardasil or Gardasil 9.)

YES 1 (IMQ.090)

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

IMQ.070 Human Papillomavirus (HPV) vaccine is given to prevent HPV infection and conditions caused by HPV in boys and men. It is given in 2 or 3 separate doses. {Have you/Has SP} ever received one or more doses of the HPV vaccine? (The brand names for the vaccines are Gardasil or Gardasil 9.)

YES 1 (IMQ.090)

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

IMQ.090 How old {were you/was SP} when {you/SP} received {your/his/her} first dose of HPV vaccine?

HARD EDIT: IF AGE SP RECEIVED FIRST DOSE IS GREATER THAN SP’S CURRENT AGE, DISPLAY “AGE SP RECEIVED FIRST DOSE CANNOT EXCEED SP’S CURRENT AGE.”

SOFT EDIT: IF DIFFERENCE BETWEEN SP’S CURRENT AGE AND AGE SP RECEIVED FIRST DOSE IS GREATER THAN THE DIFFERENCE BETWEEN THE CURRENT YEAR AND 2006, DISPLAY “UNLIKELY RESPONSE AS HPV VACCINES WERE NOT AVAILABLE AT THAT TIME. PLEASE CONFIRM AGE SP RECEIVED FIRST DOSE.”

|___|___|___|

ENTER AGE IN YEARS

REFUSED 777

DON'T KNOW 999

IMQ.100 How many doses of the vaccine {have you/has SP} received?

INTERVIEWER: IF MORE THAN ONE HPV VACCINE, INSTRUCT SP TO PROVIDE THE TOTAL NUMBER OF HPV VACCINE DOSES RECEIVED.

1 DOSE 1

2 DOSES 2

3 DOSES 3

REFUSED 7

DON'T KNOW 9

MEDICAL CONDITIONS – MCQ

Target Group: SPs 1+

MCQ.010 The following questions are about different medical conditions.

{Have you/Has SP} ever been told by a doctor or other health professional that {you/he/she} had asthma (az-ma)?

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2 (AGQ.030)

REFUSED 7 (AGQ.030)

DON'T KNOW 9 (AGQ.030)

HELP SCREEN:

Asthma: Asthma is a disease of the airways that carry air in and out of your lungs. It causes wheezing or whistling sounds when you breathe and can make you short of breath.

MCQ.035 {Do you/Does SP} still have asthma (az-ma)?

YES 1

NO 2 (AGQ.030)

REFUSED 7 (AGQ.030)

DON'T KNOW 9 (AGQ.030)

MCQ.040 During the past 12 months, {have you/has SP} had an episode of asthma (az-ma) or an asthma attack?

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Episode/attack: When your asthma symptoms become worse than usual it is called an asthma episode or attack.

MCQ.050 During the past 12 months, {have you/has SP} had to visit an emergency room or urgent care center because of asthma (az-ma)?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

AGQ.030 During the past 12 months, {have you/has SP} been told by a doctor or other health professional that {you/he/she} had hay fever or seasonal allergies?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Hay Fever: Hay fever is a collection of symptoms in the nose and eyes, caused by particles of plant pollen in the air. This happens in people who are allergic to these substances. The pollens that cause hay fever vary from person to person and from region to region. Hay fever typically occurs in the Spring, Summer, or Fall when plant pollen is in the air. Examples of plants commonly responsible for hay fever include trees, grasses, flowers, and ragweed.

MCQ.053 During the past 3 months, {have you/has SP} been on treatment for anemia (a-nee-me-a), sometimes called "tired blood" or "low blood"? [Include diet, iron pills, iron shots, transfusions as treatment.]

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Anemia: Anemia (uh-NEE-me-eh) is a condition in which a person’s blood has a lower than normal number of red blood cells (RBCs).

BOX 2

CHECK ITEM MCQ.055:

IF SP AGE < 6, GO TO END OF SECTION.OTHERWISE, CONTINUE.

BOX 7

CHECK ITEM MCQ.145:

IF SP'S AGE >= 20, GO TO MCQ.160.

IF SP’s AGE = 12-19, GO TO MCQ.500.

IF SP AGE 8-11 AND SP IS FEMALE, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

MCQ.149 Have {SP's} periods or menstrual (men-stral) cycles started yet?

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP TEXT: When a girl starts having periods or menstrual cycles is a very important milestone in growth and development. Growth and development is very related to physical activity and body weight.

BOX 8B

CHECK ITEM MCQ.157:

IF SP’s AGE = 6-11, GO TO END OF SECTION.

MCQ.160 {Have you/Has SP} ever been told by a doctor or other health professional that {you/he/she} . . . CAPI INSTRUCTION: TEXT OF QUESTION SHOULD BE OPTIONAL AFTER FIRST ITEM IS READ. *IF ITEMS 160B, C, D, E, OR F CHANGED, CHECK MEC COMPONENT.	MCQ.170 {Do you/Does SP} still . . . ?	MCQ.195 Which type of arthritis was it?
a. had some form of arthritis? YES 1 NO 2 (b) REFUSED 7 (b) DON'T KNOW 9 (b)		Osteoarthritis or degenerative arthritis 1 Rheumatoid arthritis 2 Psoriatic arthritis 3 Other 4 REFUSED 7 DON’T KNOW 9
b. had congestive heart failure*? YES 1 (c) NO 2 (c) REFUSED 7 (c) DON'T KNOW 9 (c)
c. had coronary (kor*-o-nare-ee) heart disease? YES 1 (d) NO 2 (d) REFUSED 7 (d) DON'T KNOW 9 (d)
d. had angina (*an-gī-na), also called angina pectoris? YES 1 (e) NO 2 (e) REFUSED 7 (e) DON'T KNOW 9 (e)

e. had a heart attack (also called myocardial infarction (my-O-car-dee-al in-fark*-shun))? YES 1 (f) NO 2 (f) REFUSED 7 (f) DON'T KNOW 9 (f)
f. had a stroke, slight stroke, transient ischemic attack or TIA*? YES 1 (m) NO 2 (m) REFUSED 7 (m) DON'T KNOW 9 (m)
m. had a thyroid (thigh-roid) problem? YES 1 NO 2 (p) REFUSED 7 (p) DON'T KNOW 9 (p)	have a thyroid problem? YES 1 NO 2 REFUSED 7 DON'T KNOW 9
p. had chronic obstructive pulmonary disease or COPD, emphysema, or chronic bronchitis? YES 1 (l) NO 2 (l) REFUSED 7 (l) DON'T KNOW 9 (l)
l. had any kind of liver condition? INTERVIEWER INSTRUCTION: INCLUDE VIRAL HEPATITIS (INCLUDING HEPATITIS A, HEPATITIS B; AND HEPATITIS C); AUTOIMMUNE LIVER DISEASE (INCLUDING PRIMARY BILIARY CIRRHOSIS; AUTOIMMUNE HEPATITIS, SCLEROSING CHOLANGITIS); GENETIC LIVER DISEASES (INCLUDING ALPHA-1-ANTITRYSIN DEFICIENCY, HEMOCHROMOTOSIS, AND WILSON’S DISEASE); DRUG- OR MEDICATION-INDUCED LIVER DISEASE; ALCOHOLIC LIVER DISEASE; NON-ALCOHOLIC FATTY LIVER DISEASE; FATTY LIVER DISEASE; LIVER CANCER; LIVER CYST; LIVER ABSCESS; LIVER FIBROSIS; AND LIVER CIRRHOSIS. INTERVIEWER DO NOT INCLUDE GALLBLADDER DISEASE; GALLSTONES; OR CHOLECYSTITIS. YES 1 NO 2 (MCQ.550) REFUSED 7 (MCQ.550) DON'T KNOW 9 (MCQ.550)	have this liver condition? YES 1 (MCQ.510) NO 2 (MCQ.510) REFUSED 7 (MCQ.510) DON'T KNOW 9 (MCQ.510)

HELP SCREENS FOR MCQ.160

MCQ160a

Arthritis: Is a disease that causes pain, swelling or stiffness in joints, for example the hand, the knee, or neck. Common kinds of arthritis are osteoarthritis and rheumatoid arthritis.

MCQ.195

Osteoarthritis: Is the most common kind of arthritis in older persons. It is also called degenerative joint disease. Most often, it affects the knees, the hips, the hands, the feet, and the spine. There is usually bony joint enlargement. There can be joint deformity or pain.

Rheumatoid Arthritis: Causes inflammation, redness and swelling of both hands and knees, but it can affect joints anywhere in the body. You may feel sick and tired, and sometimes there are fevers.

Psoriatic Arthritis: Is arthritis caused by the skin rash Psoriasis. Most often it causes redness and swelling of joints such as the spine, knees, hips and hands.

Arthritis: Is a disease that causes pain, swelling or stiffness in joints, for example the hand, the knee, or neck. Common kinds of arthritis are osteoarthritis and rheumatoid arthritis.

MCQ160b

Congestive Heart Failure: Is when the heart can't pump enough blood to the body. Blood and fluid "back up" into the lungs, which makes you short of breath. Heart failure causes fluid buildup in and swelling of the feet, legs and ankles.

INTERVIEWER INSTRUCTION: DO NOT COUNT HEART MURMURS, IRREGULAR HEART BEATS, CHEST PAIN OR HEART ATTACKS.

MCQ160c

Coronary Heart Disease: Is when the blood vessels that bring blood to the heart muscle become narrow and hardened due to plaque (plak). Plaque buildup is called atherosclerosis (ATH-er-o-skler-O-sis). Blocked blood vessels to the heart can cause chest pain or a heart attack.

INTERVIEWER INSTRUCTION: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR CORONARY HEART DISEASE.

MCQ160d

Angina (Angina Pectoris): (AN-ji-na or an-JI-na). Angina is chest pain or discomfort that occurs when the heart does not get enough blood.

INTERVIEWER INSTRUCTION: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR ANGINA.

MCQ160e

Heart Attack (Myocardial Infarction): A heart attack happens when there is narrowing of a blood vessel that supplies the heart. A blood clot can form and suddenly cut off the blood supply to the heart muscle. This damage causes crushing chest pain that may also be felt in the arms or neck. There can also be nausea, sweating, or shortness of breath.

MCQ160f

Stroke: Is when the blood supply to a part of the brain is suddenly cut off by a blood clot or a burst blood vessel in the brain. The part of the brain affected can no longer do its job. There can be numbness or weakness on one side of the body; trouble speaking or understanding speech; loss of eyesight; trouble with walking, dizziness, loss of balance or coordination; or severe headache.

MCQ160m

Thyroid Problem: The thyroid is a gland in the neck that makes thyroid hormone. The thyroid sets your body's energy level: the temperature and heart rate. Thyroid problems include thyroid levels that are too high or too low, an inflamed or enlarged gland, and thyroid lumps or cancer.

INTERVIEWER INSTRUCTION: INCLUDE HYPERTHYROID (OVERACTIVE THYROID); HYPOTHYROID (UNDERACTIVE THYROID); GRAVES DISEASE (HYPERTHYROID AND/OR THYROID EYE DISEASE); HASHIMOTO'S THYRODITIS (INFLAMED THYROID); POSTPARTUM THYROIDITIS (INFLAMED THYROID THAT HAPPENS AFTER DELIVERY OF A BABY); GOITER (ENLARGED THYROID); THYROID NODULE (LUMP IN THYROID- NOT CANCER); AND THYROID CANCER.

MCQ.160p

COPD: stands for “Chronic Obstructive Pulmonary Disease.” It includes both Emphysema and Chronic Bronchitis. It is lung problem where you have trouble getting air in and out of your lungs. You may also have constant cough and phlegm.

Chronic Bronchitis: Is a long lasting breathing problem where you constantly cough up phlegm. Often there is a daily cough with phlegm for several months at a time for two or more years and you are short of breath. It is often due to smoking.

Emphysema: Is a disease where the tiny air sacs in the lungs become damaged so less air goes in and out. As a result, the body does not get the oxygen it needs. Emphysema makes it hard to catch your breath. It is often due to smoking.

MCQ.160l

Liver Condition: The liver is located under your rib cage on your right side. The liver helps your body digest food, store energy, and remove poisons. Liver conditions include viral diseases, autoimmune diseases, liver cancer, and liver disease from medications, poisons or drinking too much alcohol. If the liver forms scar tissue because of an illness, it's called fibrosis or cirrhosis.

MCQ.500 Has a doctor or other health professional ever told {you/SP} that {you/s/he} had any kind of liver condition?

INTERVIEWER INSTRUCTION: INCLUDE VIRAL HEPATITIS (INCLUDING HEPATITIS A, HEPATITIS B; AND HEPATITIS C); AUTOIMMUNE LIVER DISEASE (INCLUDING PRIMARY BILIARY CIRRHOSIS; AUTOIMMUNE HEPATITIS, SCLEROSING CHOLANGITIS); GENETIC LIVER DISEASES (INCLUDING ALPHA-1-ANTITRYSIN DEFICIENCY, HEMOCHROMOTOSIS, AND WILSON’S DISEASE); DRUG- OR MEDICATION-INDUCED LIVER DISEASE; ALCOHOLIC LIVER DISEASE; NON-ALCOHOLIC FATTY LIVER DISEASE; FATTY LIVER DISEASE; LIVER CANCER; LIVER CYST; LIVER ABSCESS; LIVER FIBROSIS; AND LIVER CIRRHOSIS. INTERVIEWER DO NOT INCLUDE GALLBLADDER DISEASE; GALLSTONES; OR CHOLECYSTITIS.

YES 1

NO 2 (BOX 8C)

REFUSED 7 (BOX 8C)

DON'T KNOW 9 (BOX 8C)

HELP SCREEN:

MCQ.510 Which type of liver condition was it . . .

INTERVIEWER INSTRUCTION: READ OPTIONS. CODE ALL THAT APPLY.

Fatty liver, 1 (BOX 8C)

Liver fibrosis, 2 (BOX 8C)

Liver cirrhosis, 3 (BOX 8C)

Viral hepatitis, 4 (BOX 8C)

Autoimmune hepatitis, or 5 (BOX 8C)

Other liver disease? 6 (BOX 8C)

REFUSED 77 (BOX 8C)

DON’T KNOW 99 (BOX 8C)

BOX 8C

CHECK ITEM MCQ.515:

IF SP'S AGE 12-19, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

MCQ.550 Has a doctor or other health professional ever told {you/SP} that {you/s/he} had gallstones?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Gallstones: Gallstones are hard particles that develop in the gallbladder. The gallbladder is a small, pear-shaped organ located in the upper right abdomen—the area between the chest and hips—below the liver.

MCQ.560 Have {you/Has s/he} ever had gallbladder surgery?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

MCQ.220 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had cancer or a malignancy (ma-lig-nan-see) of any kind?

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2 (BOX 13)

REFUSED 7 (BOX 13)

DON'T KNOW 9 (BOX 13)

HELP SCREEN:

Cancer: Is an abnormal growth that can spread to other parts of the body. This causes damage and even death. Most cancers are named for where they start: for example lung cancer or breast cancer. A cancer is also called a "malignancy" or a "malignant tumor".

Malignancy: A tumor or growth that is a cancer. (see Cancer)

MCQ.230 What kind of cancer was it?

ENTER UP TO 3 KINDS. IF RESPONDENT OFFERS MORE THAN 3, ENTER 66 AS THE 4TH RESPONSE.

CAPI INSTRUCTIONS:

ALLOW UP TO 3 ENTRIES.

ALLOW 'MORE THAN 3 KINDS (CODE 66) ONLY AS 4TH ENTRY.

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

( ) ( ) ( ) ( )

BLADDER 10

BLOOD 11

BONE 12

BRAIN 13

BREAST 14

CERVIX (CERVICAL) 15

COLON 16

ESOPHAGUS (ESOPHAGEAL) 17

GALLBLADDER 18

KIDNEY 19

LARYNX/WINDPIPE 20

LEUKEMIA 21

LIVER 22

LUNG 23

LYMPHOMA/HODGKINS' DISEASE 24

MELANOMA 25

MOUTH/TONGUE/LIP 26

NERVOUS SYSTEM 27

OVARY (OVARIAN) 28

PANCREAS (PANCREATIC) 29

PROSTATE 30

RECTUM (RECTAL) 31

SKIN (NON-MELANOMA) 32

SKIN (DON'T KNOW WHAT KIND) 33

SOFT TISSUE (MUSCLE OR FAT) 34

STOMACH 35

TESTIS (TESTICULAR) 36

THYROID 37

UTERUS (UTERINE) 38

OTHER 39

MORE THAN 3 KINDS 66

REFUSED 77

DON'T KNOW 99

BOX 13

CHECK ITEM MCQ.385:

IF SP AGE LESS THAN 40, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

OSQ.230 The following question is about metal objects you may have inside your body.

{Do you/Does SP} have any artificial joints, pins, plates, metal suture material, or other types of metal objects in {your/his/her} body? Some common examples are displayed on card OSQ1.

INTERVIEWER INSTRUCTION: Do not include piercings, crowns, dental braces or retainers, shrapnel, or bullets. The metal object should NOT be visible on the outside of the body or in the mouth.

HAND CARD OSQ1

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HEPATITIS (HEQ)

Target Group: SPs 6+

HEQ.010 Has a doctor or other health professional ever told {you/SP} that {you have/s/he/SP has} hepatitis B? (Hepatitis is a form of liver disease. Hepatitis B is an infection of the liver from the hepatitis B virus (HBV).)

CAPI INSTRUCTION:

IF SP AGE >= 12 AND NOT A PROXY INTERVIEW, DISPLAY “YOU” AND “YOU HAVE”.

IF SP AGE >= 12 AND PROXY INTERVIEW, DISPLAY "SP" AND “S/HE HAS”.

IF SP AGE = 6-11, DISPLAY “YOU” AND “SP HAS”.

INTERVIEWER INSTRUCTION: DO NOT ACCEPT SELF-DIAGNOSED OR DIAGNOSED BY A PERSON WHO IS NOT A DOCTOR OR OTHER HEALTH PROFESSIONAL.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

KIDNEY CONDITIONS – KIQ

Target Group: SPs 20+

KIQ.022 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had weak or failing kidneys? Do not include kidney stones, bladder (bladd-er) infections, or incontinence (in‑kon‑ti‑nens).

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

HELP SCREEN:

KIQ.025 In the past 12 months, {have you/has SP} received dialysis (either hemodialysis (heemo-di-al-i-sis) or peritoneal dialysis (pare-i-ton-nee-al di-al-i-sis))?

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DIABETES – DIQ

Target Group: SPs 1+

DIQ.010 {Other than during pregnancy, {have you/has SP}/{Have you/Has SP}} ever been told by a doctor or other health professional that {you have/{s/he/SP} has} diabetes or sugar diabetes?

CAPI INSTRUCTION:

IF SP AGE >= 12 AND NOT A PROXY INTERVIEW, DISPLAY "HAVE YOU" AND "YOU HAVE"

IF SP AGE >= 12 AND PROXY INTERVIEW, DISPLAY "HAS {SP}" AND "S/HE HAS"

IF SP AGE <12, DISPLAY "HAVE YOU" AND "{SP} HAS"

IF SP IS FEMALE AND AGE >= 20, DISPLAY "OTHER THAN DURING PREGNANCY, {HAVE YOU/HAS SP}".

IF ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2 (BOX 4)

BORDERLINE OR PREDIABETES 3 (BOX 4)

REFUSED 7 (BOX 4)

DON'T KNOW 9 (BOX 4)

DIQ.040
G/Q

How old {was SP/were you} when a doctor or other health professional first told {you/him/her} that {you/s/he} had diabetes or sugar diabetes?

CAPI INSTRUCTION:

IF SP AGE >= 12 AND NOT A PROXY INTERVIEW, DISPLAY "WERE YOU" AND "YOU" AND "YOU"

IF SP AGE >= 12 AND PROXY INTERVIEW, DISPLAY "WAS {SP}" AND "HIM/HER" AND "S/HE"

IF SP AGE <12, DISPLAY "WAS {SP}" AND "YOU" AND "S/HE"

IF ITEM CHANGES, CHECK MEC COMPONENT.

|___|

ENTER AGE IN YEARS 1

LESS THAN 1 YEAR 2 (BOX 4)

REFUSED 7 (BOX 4)

DON'T KNOW 9 (BOX 4)

|___|___|

ENTER AGE IN YEARS

REFUSED 77777

DON'T KNOW 99999

BOX 4

CHECK ITEM DIQ.159:

IF ANY AGE AND DIQ.010 = 1 (YES) GO TO DIQ.050.

IF AGE >= 12 AND DIQ.010 = 3, GO TO DIQ.180.

IF AGE < 12, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

DIQ.160 {Have you/Has SP} ever been told by a doctor or other health professional that {you have/SP has} any of the following: prediabetes, impaired fasting glucose, impaired glucose tolerance, borderline diabetes or that {your/her/his} blood sugar is higher than normal but not high enough to be called diabetes or sugar diabetes?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN: PREDIABETES, IMPAIRED FASTING GLUCOSE, IMPAIRED GLUCOSE TOLERANCE, OR BORDERLINE DIABETES OCCURS WHEN BLOOD SUGAR (GLUCOSE) LEVELS ARE HIGHER THAN NORMAL BUT NOT HIGH ENOUGH TO BE DIABETES.

DIQ.180 {Have you/Has SP} had a blood test for high blood sugar or diabetes within the past three years?

INTERVIEWER INSTRUCTION: DO NOT INCLUDE URINE TESTS

YES 1 (BOX 0)

NO 2 (BOX 0)

REFUSED 7 (BOX 0)

DON’T KNOW 9 (BOX 0)

DIQ.050 Insulin can be taken by shot or pump. {Is SP/Are you} now taking insulin?

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2 (BOX 0)

REFUSED 7 (BOX 0)

DON'T KNOW 9 (BOX 0)

HELP SCREEN:

Insulin: A chemical used in the treatment of diabetes. Typically, insulin is administered with a syringe by the patient.

DIQ.060
G/Q/U

For how long {have you/has SP} been taking insulin?

|___|

ENTER NUMBER (OF MONTHS OR YEARS) 1

LESS THAN 1 MONTH 2 (BOX 0)

REFUSED 7 (BOX 0)

DON'T KNOW 9 (BOX 0)

|___|___|___|

ENTER NUMBER (OF MONTHS OR YEARS)

REFUSED 77777 (BOX 0)

DON'T KNOW 99999 (BOX 0)

|___|

ENTER UNIT

MONTHS 1

YEARS 2

HELP SCREEN:

Insulin: A chemical used in the treatment of diabetes. Typically, insulin is administered with a syringe by the patient.

BOX 0

CHECK ITEM DIQ.065:

IF DIQ.010 = 1 (YES) OR DIQ.160 = 1 (YES) OR DIQ.010 = 3, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

DIQ.070 {Is SP/Are you} now taking diabetic pills to lower {{his/her}/your} blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.

CAPI INSTRUCTION:

IF ITEM CHANGES, CHECK MEC COMPONENT.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN FOR DIQ.010/040:

Diabetes: A glandular disease that impairs the ability of the body to use sugar and causes sugar to appear abnormally in the urine. Common symptoms are persistent thirst and excessive discharge of urine. Do not include gestational diabetes or diabetes that was only present during pregnancy. Also, do not include self-diagnosed diabetes, pre-diabetes or high sugar.

BLOOD PRESSURE – BPQ

Target Group: SPs 16+

BPQ.020 {Have you/Has SP} ever been told by a doctor or other health professional that {you/s/he} had hypertension (hy-per-ten-shun), also called high blood pressure?

IF HIGH BLOOD PRESSURE ONLY DURING PREGNANCY, CODE NO.

INTERVIEWER INSTRUCTION: IF SP SAYS “HIGH NORMAL BLOOD PRESSURE”, “BORDERLINE HYPERTENSION” OR “PREHYPERTENSION” CODE NO.

YES 1

NO 2 (BPQ.080)

REFUSED 7 (BPQ.080)

DON'T KNOW 9 (BPQ.080)

BPQ.030 {Were you/Was SP} told on 2 or more different visits that {you/s/he} had hypertension (hy-per-ten-shun), also called high blood pressure?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BPQ.050a {Are you/Is SP} now taking any medication prescribed by a doctor for {your/his/her} high blood pressure?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BPQ.080 {Have you/Has SP} ever been told by a doctor or other health professional that {your/his/her} blood cholesterol level was high?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Cholesterol: Cholesterol is a type of fat in the bloodstream and is measured with a blood test, usually done in the morning before you’ve eaten. High levels of cholesterol are a major risk factor for heart disease, which leads to heart attack.

BPQ.100d “{Are you/Is SP} now taking any medication prescribed by a doctor lower {your/his/her} blood cholesterol?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Prescribed Medicine: Prescribed medicines are those ordered by a doctor or other health provider through a written or verbal prescription for a pharmacist to fill. Prescription medicines can also be given by a medical provider directly to a patient to take home, such as free samples.

AUDIOMETRY – AUQ

Target Group: SPs 1+

AUQ.054 These next questions are about {your/SP’s} hearing.

Which statement best describes {your/SP’s} hearing (without a hearing aid, personal sound amplifier, or other listening devices)? Would you say {your/his/her} hearing is excellent, good, that {you have/s/he has} a little trouble, moderate trouble, a lot of trouble, or {are you/is s/he} deaf?

EXCELLENT 1

GOOD 2

A LITTLE TROUBLE 3

MODERATE HEARING TROUBLE 4

A LOT OF TROUBLE 5

DEAF 6

REFUSED 77

DON’T KNOW 99

HELP SCREEN:

Deaf means that you can’t hear in both ears without the use of hearing aids or other devices to help you hear. If you can hear in one ear, you are not deaf.

Hearing Aid: A small electronic device that amplifies the sounds you hear. It is worn in or behind the ear to help you hear.

Personal Sound Amplifier: A wearable electronic product that is intended to amplify sounds for people with normal hearing who need a little “boost” in some situations. They are sold direct to the consumer over-the-counter or online, and are not customized for individuals’ hearing loss. Although not designed for people with hearing loss, they are frequently used by hearing impaired individuals as a low-cost alternative to hearing aids.

Other Listening Devices: Other listening devices are any device you use to help you hear. They are also called assistive listening devices. These are:

A pocket talker

An amplified telephone

An amplified or vibrating alarm clock

A light signaler for your doorbell

A TV headset

Closed-captioned TV

TTY (teletypewriter)

TDD (telecommunications device for the deaf)

A telephone relay service

A video relay service

A sign language interpreter

BOX 2A

CHECK ITEM AUQ.395:

IF AUQ.054 = {3, 4, 5 OR 6} CONTINUE.

OTHERWISE, GO TO NEW BOX 1.

AUQ.410 Please look at card AUQ1. What are the main causes of {your/SP’s} hearing loss?

INTERVIEWER INSTRUCTION: CODE ALL THAT APPLY

HAND CARD AUQ1

GENETIC/HEREDITARY CAUSES 1

EAR INFECTIONS (INCLUDING FLUID IN EARS) 2

EAR DISEASES (OTOSCLEROSIS, MENIERES, TUMOR) 3

ILLNESS/INFECTIONS (MEASLES, MENINGITIS, MUMPS) 4

DRUGS/MEDICATIONS 5

HEAD OR NECK INJURY/TRAUMA 6

LOUD BRIEF EXPLOSIVE NOISE/SOUNDS 7

NOISE EXPOSURE, LONG-TERM (MACHINERY, ETC.) 8

AGING, GETTING OLDER 9

OTHER CAUSES 10

SPECIFY:

REFUSED 77

DON’T KNOW 99

NEW BOX 1

CHECK ITEM AUQ.NEW1:

IF AGE ≥ 20 CONTINUE.

OTHERWISE, GO TO END OF SECTION.

AUQ.144 A hearing test by a specialist is one that is done in a sound proof booth or room, or with headphones. Hearing specialists include audiologists, ear nose and throat doctors, and trained technicians or occupational nurses. When was the last time {you/SP} had {your/his/her} hearing tested by a hearing specialist?

READ CATEGORIES IF NECESSARY

LESS THAN A YEAR AGO 1

1 YEAR TO 4 YEARS AGO 2

5 TO 9 YEARS AGO 3

TEN OR MORE YEARS AGO 4

NEVER 5

REFUSED 7

DON’T KNOW 9

AUQ.101 How often {do you/does SP} have difficulty hearing and understanding if there is background noise, for example, when other people are talking, TV or radio is on, or children are playing? Would you say...

Always, 1

Usually, 2

About half the time, 3

Seldom, or 4

Never? 5

REFUSED 7

DON’T KNOW 9

DERMATOLOGY – DEQ

Target Group: SPs 20-59

DEQ.034
a/c/d

Next I have some questions about {your/SP’s} sun exposure.

When {you go/SP goes} outside on a very sunny day, for more than one hour, how often {do you/does SP} . . .

a. Stay in the shade? Would you say . . .

always, 1

most of the time, 2

sometimes, 3

rarely, or 4

never? 5

DON'T GO OUT IN THE SUN 6

REFUSED 77

DON'T KNOW 99

c. Wear a long sleeved shirt? Would you say . . .

always, 1

most of the time, 2

sometimes, 3

rarely, or 4

never? 5

REFUSED 7

DON'T KNOW 9

d. Use sunscreen? Would you say . . .

always, 1

most of the time, 2

sometimes, 3

rarely, or 4

never? 5

REFUSED 7

DON'T KNOW 9

ORAL HEALTH – OHQ

Target Group: SPs 1+

OHQ.845 The next questions are about {your/SP’s} teeth and gums.

Overall, how would {you/SP} rate the health of {your/his/her} teeth and gums? Would you say . . .

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

REFUSED 7

DON’T KNOW 9

ENTER UNIT

OHQ.620 How often during the last year {have you/has SP} had painful aching anywhere in {your/his/her} mouth? Would you say . . .

Very often, 1

Fairly often, 2

Occasionally, 3

Hardly ever, or 4

Never? 5

REFUSED 7

DON'T KNOW 9

BOX 2A

CHECK ITEM OHQ.622:

IF SP AGE 1-19 YEARS, GO TO END OF SECTION.

IF SP AGE 20+ YEARS, CONTINUE.

OHQ.630 How often during last year {have you/has SP} felt life in general was less satisfying because of problems with {your/his/her} teeth, mouth, or dentures? Would you say . . .

Very often, 1

Fairly often, 2

Occasionally, 3

Hardly ever, or 4

Never? 5

REFUSED 7

DON'T KNOW 9

OHQ.640 How often during the last year {have you/has SP} had difficulty doing {your/his/her} usual jobs or attending school because of problems with {your/his/her} teeth, mouth or dentures? Would you say. . .

Very often, 1

Fairly often, 2

Occasionally, 3

Hardly ever, or 4

Never? 5

REFUSED 7

DON'T KNOW 9

OHQ.660 How often during last year {have you/has SP} avoided particular foods because of problems with {your/his/her} teeth, mouth, or dentures? Would you say . . .

Very often, 1

Fairly often, 2

Occasionally, 3

Hardly ever, or 4

Never? 5

REFUSED 7

DON'T KNOW 9

OHQ.670 How often during last year {have you/has SP} found it uncomfortable to eat food because of problems with your teeth, mouth, or dentures? Would you say . . .

Very often, 1

Fairly often, 2

Occasionally, 3

Hardly ever, or 4

Never? 5

REFUSED 7

DON'T KNOW 9

OHQ.680 How often during last year {have you/has SP} been self-conscious or embarrassed because of {your/his/her} teeth, mouth, or dentures? Would you say . . .

Very often, 1

Fairly often, 2

Occasionally, 3

Hardly ever, or 4

Never? 5

REFUSED 7

DON'T KNOW 9

PHYSICAL ACTIVITY AND PHYSICAL FITNESS – PAQ

Target Group: SPs 2+

BOX 1

CHECK ITEM PAQ.700:

IF SP AGE 2-11 OR 16-17, GO TO PAQ706.

IF SP AGE 12-15, GO TO NEXT SECTION.

IF SP AGE 18+, CONTINUE.

PAQ.NEW1
Q/U

The next questions are about physical activities such as exercise, sports, or physically active hobbies that you may do in your leisure time. We are interested in two types of physical activity: moderate and vigorous-intensity. Moderate-intensity activities cause moderate increases in breathing or heart rate whereas vigorous-intensity activities cause large increases in breathing or heart rate.

How often {do you/does SP} do moderate-intensity leisure-time physical activities?

|___|___|___|

ENTER NUMBER OF TIMES (PER DAY, WEEK, MONTH, OR YEAR)

NEVER 2 (PAQ.NEW3)

UNABLE TO DO THIS TYPE OF ACTIVITY 6666 (PAQ.NEW3)

REFUSED 7777 (PAQ.NEW3)

DON'T KNOW 9999 (PAQ.NEW3)

|___|

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

YEAR 4

CAPI INSTRUCTIONS:

SOFT EDIT: > 4 PER DAY, > 28 PER WEEK, >31 PER MONTH, OR > 365 PER YEAR.

ERROR MESSAGE: PLEASE VERIFY THE QUANTITY AND UNIT.

PAQ.NEW2 About how long {do you/does SP} do these moderate leisure-time physical activities each time?

Q/U

PROBE IF NEEDED: Moderate-intensity activities cause moderate increases in breathing or heart rate.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (PAQ.NEW3)

DON'T KNOW 9999 (PAQ.NEW3)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

CAPI INSTRUCTIONS:

SOFT EDIT: > 120 MINUTES OR 2 HOURS.

ERROR MESSAGE: INTERVIEWER, YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 120 MINUTES OR 2 HOURS EACH TIME DOING MODERATE-INTENSITY ACTIVITIES. PLEASE CONFIRM WITH SP THAT OVER 120 MINUTES OR 2 HOURS IS CORRECT.

PAQ.NEW3
Q/U

How often {do you/does SP} do vigorous-intensity leisure-time physical activities?

|___|___|___|

ENTER NUMBER OF TIMES (PER DAY, WEEK, MONTH, OR YEAR)

NEVER 2 (PAQ.680)

UNABLE TO DO THIS TYPE OF ACTIVITY 6666 (PAQ.680)

REFUSED…………………………………………… 7777 (PAQ.680)

DON'T KNOW 9999 (PAQ.680)

|___|

ENTER UNIT

DAY 1

WEEK 2

MONTH 3

YEAR 4

CAPI INSTRUCTIONS:

SOFT EDIT: > 4 PER DAY, > 28 PER WEEK, >31 PER MONTH, OR > 365 PER YEAR .

ERROR MESSAGE: PLEASE VERIFY THE QUANTITY AND UNIT.

PAQ.NEW4 About how long {do you/does SP} do these vigorous leisure-time physical activities each time?

Q/U

PROBE IF NEEDED: Vigorous-intensity activities cause large increases in breathing or heart rate.

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777

DON'T KNOW 9999

ENTER UNIT

MINUTES 1

HOURS 2

CAPI INSTRUCTIONS:

SOFT EDIT: > 120 MINUTES OR 2 HOURS.

PAQ.680
Q/U

The following question is about sitting at work, at home, getting to and from places, or with friends, including time spent sitting at a desk, traveling in a car or bus, reading, playing cards, watching television, or using a computer. Do not include time spent sleeping.

How much time {do you/does SP} usually spend sitting on a typical day?

|___|___|___|

ENTER NUMBER OF MINUTES OR HOURS

REFUSED 7777 (BOX 2)

DON'T KNOW 9999 (BOX 2)

|___|

ENTER UNIT

MINUTES 1

HOURS 2

CAPI INSTRUCTIONS:

SOFT EDIT: 18 HOURS OR MORE.

ERROR MESSAGE: PLEASE VERIFY TIMES OF 18 HOURS OR MORE.

HARD EDIT: 24 HOURS OR MORE.

ERROR MESSAGE: THE TIME SHOULD BE LESS THAN 24 HOURS.

BOX 2

CHECK ITEM PAQ.720:

IF SP AGE 18+, GO TO NEXT SECTION.

PAQ.706 Now I'd like to ask you some questions about {your/SP's} activities.

During the past 7 days, on how many days {were you/was SP} physically active for a total of at least 60 minutes per day? Add up all the time {you/he/she} spent in any kind of physical activity that increased {your/his/her} heart rate and made {you/him/her} breathe hard some of the time.

0 days 0

1 day 1

2 days 2

3 days 3

4 days 4

5 days 5

6 days 6

7 days 7

REFUSED 77

DON’T KNOW 99

CAPI INSTRUCTION:

IF THIS ITEM CHANGES, CHECK MEC COMPONENT.

PAQ.711 On a typical day during the school year, about how many hours {do you/does SP} usually spend playing with a smartphone or computer, watching TV or movies, or playing video games?

|___|___|

ENTER NUMBER OF HOURS

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTIONS:

SOFT EDIT: 18 HOURS OR MORE.

ERROR MESSAGE: PLEASE VERIFY TIMES OF 18 HOURS OR MORE.

HARD EDIT: 24 HOURS OR MORE.

ERROR MESSAGE: THE TIME SHOULD BE LESS THAN 24 HOURS.

FUNCTIONING (FNQ)

Target Group: SPs 5+

BOX 1

CHECK ITEM FNQ.005

IF SP AGE ≥ 18 YEARS, GO TO FNQ.410.

ELSE, CONTINUE.

FNQ.020 I would like to ask you some questions about difficulties {you/SP} may have.

{Do you/Does SP} have difficulty seeing even if wearing glasses or contact lenses? Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

CANNOT DO AT ALL 4

REFUSED 7

DON’T KNOW 9

FNQ.040 {Do you/Does SP} have difficulty hearing sounds like peoples’ voices or music even if using a hearing aid? Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

NO DIFFICULTY 1

SOME DIFFICULTY 2

A LOT OF DIFFICULTY 3

CANNOT DO AT ALL 4

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION:

IF YES (CODE 1) IN FNQ.030, DISPLAY “When using {your/his/her} hearing aid”

FNQ.050 {Do you/Does SP} use any equipment or receive assistance for walking?

Yes 1

NO 2 (FNQ.080)

REFUSED 7 (FNQ.080)

DON’T KNOW 9 (FNQ.080)

FNQ.060 Without {your/his/her} equipment or assistance, {do you/does SP} have difficulty walking 100 yards/meters on level ground? That would be about the length of 1 football field. Would you say {you have/SP has}: some difficulty, a lot of difficulty, or cannot do at all?

some difficulty 2

a lot of difficulty 3 (FNQ.100)

cannot do at all 4 (FNQ.100)

REFUSED 7

DON’T KNOW 9

FNQ.080 Compared with children of the same age, {do you/does SP} have difficulty walking 100 yards/meters on level ground? That would be about the length of 1 football field. Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.NEW1 {Do you/Does SP} have difficulty with self-care such as feeding or dressing him/herself? Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.100 When {you speak/SP speaks}, {do you/does he/does she} have difficulty being understood by people inside of this household? Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.110 When {you speak/SP speaks}, {do you/does he/does she} have difficulty being understood by people outside of this household? Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.120 Compared with children of the same age, {do you/does SP} have difficulty learning things? Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.NEW2 Compared with children of the same age, {do you/does SP} have difficulty remembering things? Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.NEW3 {Do you/Does SP} have difficulty concentrating on an activity that he/she enjoys doing? Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.NEW4 {Do you/Does SP} have difficulty accepting changes in {your/his/her} routine? Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.130 Compared with children of the same age, {do you/does SP} have difficulty controlling {your/his/her} behavior? Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.NEW5 {Do you/Does SP} have difficulty making friends? Would you say {you have/SP has}: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.140 How often {do you feel/does SP seem} very anxious, nervous or worried? Would you say daily, weekly, monthly, a few times a year or never?

Daily 1

Weekly 2

monthly 3

A FEW TIMES A YEAR 4

NEVER 5

REFUSED 7

DON’T KNOW 9

FNQ.150 How often {do you feel/does SP seem} very sad or depressed? Would you say daily, weekly, monthly, a few times a year or never?

Daily 1 (END OF SECTION)

Weekly 2 (END OF SECTION)

monthly 3 (END OF SECTION)

A FEW TIMES A YEAR 4 (END OF SECTION)

NEVER 5 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

FNQ.410 The next questions ask about difficulties you may have doing certain activities because of a health problem. {Do you/Does SP} have difficulty seeing even if wearing glasses or contact lenses? Would you say no difficulty, some difficulty, a lot of difficulty, or {you/he/she} cannot do this at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.430 {Do you/Does SP} have difficulty hearing even if using a hearing aid? Would you say no difficulty, some difficulty, a lot of difficulty, or {you/he/she} cannot do this at all?

NO DIFFICULTY 1

SOME DIFFICULTY 2

A LOT OF DIFFICULTY 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.440 {Do you/Does SP} have difficulty walking or climbing steps? Would you say no difficulty, some difficulty, a lot of difficulty, or {you/he/she} cannot do this at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.450 Using {your/his/her} usual language, {do you/does SP} have difficulty communicating, for example, understanding or being understood? Would you say no difficulty, some difficulty, a lot of difficulty, or {you/he/she} cannot do this at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.460 {Do you/Does SP} have difficulty remembering or concentrating? Would you say no difficulty, some difficulty, a lot of difficulty, or {you/he/she} cannot do this at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.470 {Do you/Does SP} have difficulty with self-care, such as washing all over and dressing? Would you say no difficulty, some difficulty, a lot of difficulty, or {you/he/she} cannot do this at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.480 {Do you/Does SP} have difficulty raising a 2 liter bottle of water or soda from waist to eye level? Would you say no difficulty, some difficulty, a lot of difficulty, or {you/he/she} cannot do this at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.490 {Do you/Does SP} have difficulty using {your/his/her} hands and fingers, such as picking up small objects, for example, a button or pencil, or opening or closing containers or bottles? Would you say no difficulty, some difficulty, a lot of difficulty, or {you/he/she} cannot do this at all?

no difficulty 1

some difficulty 2

a lot of difficulty 3

cannot do at all 4

REFUSED 7

DON’T KNOW 9

FNQ.510 How often {do you/does SP} feel worried, nervous, or anxious? Would you say…

daily, 1

weekly, 2

monthly, 3

a few times a year, or 4

never? 5 (FNQ.530)

REFUSED 7 (FNQ.530)

DON’T KNOW 9 (FNQ.530)

FNQ.520 Thinking about the last time {you/SP} felt worried, nervous, or anxious, how would {you/he/she} describe the level of these feelings? Would you say…

a little, 1

a lot, or 2

somewhere in between a little and a lot? 3

REFUSED 7

DON’T KNOW 9

FNQ.530 How often {do you/does SP} feel depressed? Would you say…

daily, 1

weekly, 2

monthly, 3

a few times a year, or 4

never? 5 (END OF SECTION))

REFUSED 7 (END OF SECTION))

DON’T KNOW 9 (END OF SECTION))

FNQ.540 Thinking about the last time {you/SP} felt depressed, how depressed did {you/he/she} feel? Would you say…

a little, 1

a lot, or 2

somewhere in between a little and a lot? 3

REFUSED 7

DON’T KNOW 9

STANDING BALANCE – BAQ

TARGET GROUP: SPs 20-69 Years

BAQ.321
a-g

The next questions are about symptoms of dizziness, light-headedness, or balance problems. Do not include times when drinking alcohol, using recreational drugs, or taking medications that cause dizziness. In the past 12 months, {have you/has SP} had problems with…

CAPI INSTRUCTIONS: MAKE ABOVE TEXT OPTIONAL (IN BRACKETS) for b through d.

RESPONSES: YES = 1, NO = 2, REFUSED = 7, DON'T KNOW = 9.

a. vertigo – a sensation of spinning, tilting, swaying or rocking
of {yourself/himself/herself} or {your/his/her} surroundings? ____

b. blurring of {your/his/her} vision when {you move your/he
moves his/she moves her} head? ____

c. unsteady – a feeling of being off-balance or not stable when
standing or sitting upright? ____

d. light-headed – without a sense of motion, OR fainting – a

feeling {you are/he is/she is} going to pass out or faint ____

HELP SCREEN:

Vertigo: is an illusion of rotation, rocking, or other motion, such as riding a carousel.

Unsteadiness: a feeling of being off balance or not stable when standing or sitting upright.

Light-headed: without a sense of motion

Fainting: a feeling {you are/he is/she is} going to pass out or faint

BOX 1

CHECK ITEM BAQ.330:

IF NONE OF THE RESPONSES TO THE 4 QUESTIONS (BAQ.321a–BAQ.321d) IS “YES”, GO TO BAQ.530.

IF ONLY ONE RESPONSE TO THE 4 QUESTIONS, BAQ.321a–BAQ.321d, IS “YES”, GO TO BAQ.391 AND FILL BAQ.341 WITH THE ONE YES RESPONSE.

IF MORE THAN ONE RESPONSE TO THE 4 QUESTIONS (BAQ.321a-BAQ.321d) IS “YES”, CONTINUE TO BAQ.341.

BAQ.341 This next section focuses on {your/SP’s} most bothersome symptom in the past 12 months.

During the past 12 months, which one of these problems bothered {you/SP} the most?

CAPI INSTRUCTION: ONLY DISPLAY RESPONSE OPTIONS WITH A “YES” RESPONSE RECORDED IN QUESTIONS BAQ.321a TO BAQ.321d. BAQ.321a = RESPONSE OPTION 1, BAQ.321b = RESPONSE OPTION 2, BAQ.321c = RESPONSE OPTION 3, BAQ.321d = RESPONSE OPTION 4.

Vertigo 1

Blurring vision 2

Unsteadiness 3

Light-headed or fainting 4

REFUSED 77 (BAQ.401)

DON'T KNOW 99 (BAQ.401)

HELP SCREEN:

Vertigo: an illusion of rotation, rocking, or other motion, such as riding a carousel.

Unsteadiness: a feeling of being off balance or not stable when standing or sitting upright.

Light-headed: without a sense of motion

Fainting: a feeling {you are/he is/she is} going to pass out or faint

BAQ.391a/b During the past 12 months, were {your/SP’s} episodes for {your/his/her} {RESPONSE FOR BAQ.341} accompanied by the following?

CAPI INSTRUCTION: FILL {RESPONSE FOR BAQ.341} WITH TEXT OF RESPONSE SELECTED FOR BAQ.341.

Nausea or vomiting?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

Migraine or severe headache?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

Accompanied by: means a few hours before, after, or at the same time as the episode.

BAQ.401 During the past 12 months, {did your/SP’s} dizziness or balance problem(s) prevent {you/SP} from doing things {you/he/she} otherwise would do, such as, work, school, or other scheduled activities?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Time period involved is “at the time of the dizziness or balance problem or afterwards” – dizziness or balance problems can prevent normal activities, even if the dizziness or balance problem happened just once. Episodes that happen once may have either short-term or long-term effects. Both occur.

BAQ.421 During the past 12 months, how much of a problem was {your/his/her} problem with balance, blurred vision, or light-headedness and fainting? Was it…

INTERVIEWER INSTRUCTION: IF RESPONDENT IS UNCLEAR HOW TO ANSWER BECAUSE EPISODES VARY, THEN JUST ASK THE RESPONDENT TO THINK ABOUT THEIR TYPICAL EPISODE TO RESPOND.

no problem, 1

a small problem, 2

a moderate problem, 3

a big problem, or 4

a very big problem? 5

REFUSED 7

DON'T KNOW 9

BAQ.431 Think of any time {you have/SP has} had symptoms of dizziness, imbalance, etc.

{Have you/Has SP} ever seen a doctor or other health professional, including emergency room physicians, about {your/his/her} problem(s) with balance, blurred vision, or light-headedness and fainting?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BAQ.491 {Have you/Has SP} ever tried anything to treat {your/his/her} problem(s) with balance, blurred vision, or light-headedness and fainting?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BAQ.530 The next questions are about frequency of falling and associated injuries. By “falling”, we mean unexpectedly or unintentionally dropping to a lower surface – the floor or ground– for example, from a standing, seated, walking, or bending position.

During the past 5 years, how many times {have you/has SP} fallen?

INTERVIEWER INSTRUCTION: A FALL CAN BE FROM ANY POSITION.

Never, 1 (END OF SECTION)

1 or 2 times, 2

3 to 4 times, 3

about every year, 4

about every month, 5

about every week, or 6

daily or constantly, 7

REFUSED 77 (END OF SECTION)

DON'T KNOW 99 (END OF SECTION)

BAQ.550 During the past 12 months, how many times {have you/has SP} fallen?

Never, 1 (END OF SECTION)

1 or 2 times, 2

3 to 4 times, 3

5 to 9 times, or 4

10 or more times? 5

REFUSED 7

DON'T KNOW 9

BAQ.560 During the past 12 months, did {you/SP} have an injury that resulted from falling?

INTERVIEWER INSTRUCTION:INJURIES INCLUDE CUTS OR WOUNDS, DISLOCATION OF JOINTS, FRACTURES OR BROKEN BONES, PAIN, ACHE OR STRAIN TO THE SPINE OR BACK, HEAD OR NECK INJURY, SPRAIN OR TORN LIGAMENT OR MUSCLE, AND SWELLING OR BRUISING.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

SLEEP DISORDERS – SLQ

Target Group: 16+

SLQ.300

The next set of questions is about {your/SP’s} sleep and work behavior.

What time {do you/does SP} usually fall asleep on weekdays or workdays?

|__|__| : |__|__| ENTER AM OR PM

HH MM

INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS INTO BED. ENTER TIME AS HH:MM AM OR PM. IF RESPONDENT SAYS TWELVE “MIDNIGHT” CODE AS 12:00 AM.

REFUSED 77777777

DON'T KNOW 99999999

SLQ.310

What time {do you/does SP} usually wake up on weekdays or workdays?

|__|__| : |__|__| ENTER AM OR PM

HH MM

INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS OUT OF BED. ENTER TIME AS HH:MM AM OR PM.

REFUSED 77777777

DON'T KNOW 99999999

CAPI INSTRUCTION:

SOFT EDIT: LESS THAN 4 HOURS OR MORE THAN 12 HOURS OF TOTAL SLEEP. IF SLQ.300 OR 310 IS DK OR RF, DO NOT APPLY SOFT EDIT.

ERROR MESSAGE: PLEASE VERIFY SLEEP TIMES OF LESS THAN 4 HOURS OR MORE THAN 12 HOURS.

SLQ.320 What time {do you/does SP} usually fall asleep on weekends or non-workdays?

|__|__| : |__|__| ENTER AM OR PM

HH MM

INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS INTO BED.

INTERVIEWER INSTRUCTION: ENTER TIME AS HH:MM AM OR PM. IF RESPONDENT SAYS TWELVE “MIDNIGHT” CODE AS 12:00 AM.

INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS DOES NOT WORK, ASK IF THE TIME THAT THE RESPONDENT FALLS ASLEEP IS DIFFERENT ON WEEKENDS. IF NOT, ENTER SAME TIME AS SLQ.300.

REFUSED 77777777

DON'T KNOW 99999999

SLQ.330 What time {do you/does SP} usually wake up on weekends or non-workdays?

|__|__| : |__|__| ENTER AM OR PM

HH MM

INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS OUT OF BED.

INTERVIEWER INSTRUCTION: ENTER TIME AS HH:MM AM OR PM.

REFUSED 77777777

DON'T KNOW 99999999

INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS DOES NOT WORK, ASK IF THE TIME THAT THE RESPONDENT WAKES UP IS DIFFERENT ON WEEKENDS. IF NOT, ENTER SAME TIME AS SLQ.310.

CAPI INSTRUCTION:

SOFT EDIT: LESS THAN 4 HOURS OR MORE THAN 12 HOURS OF TOTAL SLEEP. IF SLQ.320 OR 330 IS DK OR RF, DO NOT APPLY SOFT EDIT.

ERROR MESSAGE: PLEASE VERIFY SLEEP TIMES OF LESS THAN 4 HOURS OR MORE THAN 12 HOURS.

DIET BEHAVIOR AND NUTRITION - DBQ

Target Group: SPs Birth +

BOX 1

CHECK ITEM DBQ.005:

IF SP AGE <= 6, CONTINUE.

OTHERWISE, GO TO BOX 8A.

DBQ.010 Now I'm going to ask you some general questions about {SP's} eating habits.

Was {SP} ever breastfed or fed breastmilk?

YES 1

NO 2 (DBQ.041)

REFUSED 7 (DBQ.041)

DON'T KNOW 9 (DBQ.041)

DBQ.030
G/Q/U

How old was {SP} when {he/she} completely stopped breastfeeding or being fed breastmilk?

CAPI INSTRUCTION:

SOFT EDIT: DISPLAY “NUMBER CANNOT BE MORE THAN SP’S AGE.” IF ENTRY IS IN DAYS OR WEEKS, CALCULATE CURRENT AGE FOR EDIT CHECK AS FOLLOWS:

IF ENTRY IS IN WEEKS, CALCULATE CURRENT AGE IN WEEKS AS (((PRELOADED AGE IN MONTHS +1)*5)-1).

IF ENTRY IS IN DAYS, CALCULATE CURRENT AGE IN DAYS AS (((PRELOADED AGE IN MONTHS+1) *31)-1).

SOFT EDIT: DISPLAY, “VERIFY AGE ENTERED”

IF ENTRY IS IN WEEKS AND IS >24 WEEKS, OR

IF ENTRY IS IN DAYS AND IS >40 DAYS

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN DAYS, WEEKS, OR MONTHS IS ALLOWED.

|___|

ENTER NUMBER 1

STILL BREASTFEEDING 2 (DBQ.041)

REFUSED 7 (DBQ.041)

DON'T KNOW 9 (DBQ.041)

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.041)

DON'T KNOW 999999 (DBQ.041)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DBQ.041
G/Q/U

How old was {SP} when {he/she} was first fed formula?

INTERVIEWER INSTRUCTION: INCLUDE BOTH INFANT AND TODDLER FORMULAS.

|___|

ENTER NUMBER 1

NEVER 2 (DBQ.055)

REFUSED 7 (DBQ.050)

DON'T KNOW 9 (DBQ.050)

CAPI INSTRUCTION:

SOFT EDIT: DISPLAY “NUMBER CANNOT BE MORE THAN SP’S AGE.” IF ENTRY IS IN DAYS OR WEEKS, CALCULATE CURRENT AGE FOR EDIT CHECK AS FOLLOWS:

IF ENTRY IS IN WEEKS, CALCULATE CURRENT AGE IN WEEKS AS (((PRELOADED AGE IN MONTHS +1)*5)-1).

IF ENTRY IS IN DAYS, CALCULATE CURRENT AGE IN DAYS AS (((PRELOADED AGE IN MONTHS+1) *31)-1).

SOFT EDIT: DISPLAY, “VERIFY AGE ENTERED”

IF ENTRY IS IN WEEKS AND IS >24 WEEKS, OR

IF ENTRY IS IN DAYS AND IS >40 DAYS

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN DAYS, WEEKS, OR MONTHS IS ALLOWED.

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.050)

DON'T KNOW 999999 (DBQ.050)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DBQ.050
G/Q/U

How old was {SP} when {he/she} completely stopped drinking formula?

INTERVIEWER INSTRUCTION: INCLUDE BOTH INFANT AND TODDLER FORMULAS

CAPI INSTRUCTION:

SOFT EDIT: DISPLAY “NUMBER CANNOT BE MORE THAN SP’S AGE.” IF ENTRY IS IN DAYS OR WEEKS, CALCULATE CURRENT AGE FOR EDIT CHECK AS FOLLOWS:

IF ENTRY IS IN WEEKS, CALCULATE CURRENT AGE IN WEEKS AS (((PRELOADED AGE IN MONTHS +1)*5)-1).

IF ENTRY IS IN DAYS, CALCULATE CURRENT AGE IN DAYS AS (((PRELOADED AGE IN MONTHS+1) *31)-1).

SOFT EDIT: DISPLAY, “VERIFY AGE ENTERED”

IF ENTRY IS IN WEEKS AND IS >24 WEEKS, OR

IF ENTRY IS IN DAYS AND IS >40 DAYS

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN DAYS, WEEKS, OR MONTHS IS ALLOWED.

|___|

ENTER NUMBER 1

STILL DRINKING FORMULA 2 (DBQ.055)

REFUSED 7 (DBQ.055)

DON'T KNOW 9 (DBQ.055)

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.055)

DON'T KNOW 999999 (DBQ.055)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DBQ.055
G/Q/U

This next question is about the first thing that {SP} was given other than breast milk or formula. Please include juice, cow’s milk, sugar water, baby food, or anything else that {SP} might have been given, even water.

How old was {SP} when {he/she} was first fed anything other than breast milk or formula?

CAPI INSTRUCTION:

SOFT EDIT: DISPLAY “NUMBER CANNOT BE MORE THAN SP’S AGE.” IF ENTRY IS IN DAYS OR WEEKS, CALCULATE CURRENT AGE FOR EDIT CHECK AS FOLLOWS:

IF ENTRY IS IN WEEKS, CALCULATE CURRENT AGE IN WEEKS AS (((PRELOADED AGE IN MONTHS +1)*5)-1).

IF ENTRY IS IN DAYS, CALCULATE CURRENT AGE IN DAYS AS (((PRELOADED AGE IN MONTHS+1) *31)-1).

SOFT EDIT: DISPLAY, “VERIFY AGE ENTERED”

IF ENTRY IS IN WEEKS AND IS >24 WEEKS, OR

IF ENTRY IS IN DAYS AND IS >40 DAYS

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN DAYS, WEEKS, OR MONTHS IS ALLOWED.

INTERVIEWER INSTRUCTION:

DO NOT COUNT MEDICATIONS, VITAMIN DROPS, OR SMALL AMOUNT OF WATER THAT WAS USED FOR ORAL HYGIENE PURPOSES.

|___|

ENTER NUMBER 1

NEVER 2 (BOX 8A)

REFUSED 7 (BOX 8A)

DON'T KNOW 9 (BOX 8A)

|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.061)

DON'T KNOW 999999 (DBQ.061)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DBQ.061
G/Q/U

How old was {SP} when {he/she} was first fed milk?

INCLUDE LACTAID AS MILK.

DO NOT INCLUDE BREASTMILK OR FORMULA.

CAPI INSTRUCTION:

SOFT EDIT: DISPLAY “NUMBER CANNOT BE MORE THAN SP’S AGE.” IF ENTRY IS IN DAYS OR WEEKS, CALCULATE CURRENT AGE FOR EDIT CHECK AS FOLLOWS:

IF ENTRY IS IN WEEKS, CALCULATE CURRENT AGE IN WEEKS AS (((PRELOADED AGE IN MONTHS +1)*5)-1).

IF ENTRY IS IN DAYS, CALCULATE CURRENT AGE IN DAYS AS (((PRELOADED AGE IN MONTHS+1) *31)-1).

SOFT EDIT: DISPLAY, “VERIFY AGE ENTERED”

IF ENTRY IS IN WEEKS AND IS >24 WEEKS, OR

IF ENTRY IS IN DAYS AND IS >40 DAYS

HARD EDIT: AGE CANNOT BE ZERO BECAUSE AGE IN DAYS, WEEKS, OR MONTHS IS ALLOWED.

|___|

ENTER NUMBER 1

NEVER 2 (BOX 8A)

REFUSED 7 (DBQ.073)

DON'T KNOW 9 (DBQ.073)

|___|___|___|___|

ENTER AGE IN DAYS, WEEKS, MONTHS OR YEARS

REFUSED 777777 (DBQ.073)

DON'T KNOW 999999 (DBQ.073)

ENTER UNIT

|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

HELP SCREEN:

Lactaid: A modified milk product that is often consumed by individuals who have lactose intolerance. Lactaid can be purchased in various forms (i.e., 2%, skim, etc.). If respondent does not give type, probe for type (i.e., was that Lactaid regular, 2%, 1% or skim?).

Formula: A milk mixture or milk substitute that is fed to babies.

DBQ.073 What type of milk was {SP} first fed? Was it . . .

CODE ALL THAT APPLY

whole or regular, 10

2% fat or reduced-fat milk, 11

1% fat or low-fat milk (includes 0.5% fat

milk or “low-fat milk” not further specified), 12

fat-free, skim or nonfat milk, 13

soy milk, or 14

another type? 30

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

BOX 8A

CHECK ITEM DBQ.265A:

IF SP AGE >= 60, CONTINUE.

IF SP AGE 4-19, GO TO DBQ.360.

OTHERWISE, GO TO BOX 14.

DBQ.301 The next questions are about meals provided by community or government programs.

In the past 12 months, did {you/SP} receive any meals delivered to {your/his/her} home from community programs, “Meals on Wheels”, or any other programs?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

DBQ.330 In the past 12 months, did {you/SP} go to a community program or senior center to eat prepared meals?

INTERVIEWER INSTRUCTION: INCLUDE ADULT DAY CARE

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 8B

CHECK ITEM DBQ.335:

GO TO BOX 14.

DBQ.360 During the school year, {do you/does SP} attend a kindergarten, grade school, junior or high school?

INTERVIEWER INSTRUCTION: ENTER ‘NO’ IF THE SP IS HOME SCHOOLED.

YES 1

NO 2 (BOX 14)

REFUSED 7 (BOX 14)

DON'T KNOW 9 (BOX 14)

DBQ.370 Does {your/SP's} school serve school lunches? These are complete lunches that cost the same every day.

YES 1

NO 2 (DBQ.400)

REFUSED 7 (DBQ.400)

DON'T KNOW 9 (DBQ.400)

DBQ.381
G/Q

During the school year, about how many times a week {do you/does SP} usually get a complete school lunch?

|___|

ENTER NUMBER 1

NONE 2 (DBQ.400)

REFUSED 7 (DBQ.400)

DON'T KNOW 9 (DBQ.400)

CAPI INSTRUCTION:

HARD EDIT 1-5

|___|

ENTER NUMBER OF TIMES

REFUSED 7777

DON'T KNOW 9999

DBQ.390 {Do you/Does SP} get these lunches free, at a reduced price, or {do you/does he/she} pay full price?

FREE 1

REDUCED PRICE 2

FULL PRICE 3

REFUSED 7

DON'T KNOW 9

DBQ.400 Does {your/SP's} school serve a complete breakfast that costs the same every day?

YES 1

NO 2 (BOX 9A)

REFUSED 7 (BOX 9A)

DON'T KNOW 9 (BOX 9A)

DBQ.411
G/Q

During the school year, about how many times a week {do you/does SP} usually get a complete breakfast at school?

|___|

ENTER NUMBER 1

NONE 2 (BOX 9A)

REFUSED 7 (BOX 9A)

DON'T KNOW 9 (BOX 9A)

CAPI INSTRUCTION:

HARD EDIT 1-5

|___|

ENTER NUMBER OF TIMES

REFUSED 7777

DON'T KNOW 9999

DBQ.421 {Do you/Does SP} get these breakfasts free, at a reduced price, or {do you/does he/she} pay full price?

FREE 1

REDUCED PRICE 2

FULL PRICE 3

REFUSED 7

DON'T KNOW 9

BOX 9A

CHECK ITEM DBQ.422:

IF DBQ.390 = CODE 1 OR CODE 2 OR DBQ.421 = CODE 1 OR CODE 2, CONTINUE.

OTHERWISE, GO TO BOX 14.

DBQ.424 {Do you/Does SP} get a free or reduced price meal at any summer program {you/he/she} attends?

YES 1

NO 2

DID NOT ATTEND SUMMER PROGRAM 3

REFUSED 7

DON’T KNOW 9

BOX 14

CHECK ITEM DBQ.710:

IF SP AGE > 15, GO TO DBQ.930

IF 5 < SP AGE < 16, GO TO END OF SECTION.

OTHERWISE, CONTINUE.

FSQ.653 Next are a few questions about the WIC program.

Has {SP} ever received benefits from WIC, that is, the Women, Infants, and Children program?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

WIC: WIC is short for the Special Supplemental Nutrition Program for Women, Infants, and Children. This program provides food assistance and nutritional screening to low-income pregnant and postpartum women and their infants, as well as to low-income children up to age 5.

FSQ.673 Is {SP} now receiving benefits from the WIC program?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 14B

CHECK ITEM DBQ.710b:

IF SP AGE < 1, GO TO FSQ.685.

OTHERWISE, CONTINUE.

FSQ.675 Did {SP} receive benefits from WIC when {he/she} was less than one year old?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

BOX 14C

CHECK ITEM DBQ.950:

IF FSQ.673 = 1 (NOW RECEIVING WIC), GO TO FSQ.685.

OTHERWISE, CONTINUE.

FSQ.682 Did {SP} receive benefits from WIC when {he/she} {was/is} between the ages of {1 to {SP AGE/4} years old/12 to {SP AGE} months old}?

CAPI INSTRUCTION:

If SP age = 1, DISPLAY “12 to {the current age of the SP in months} months old”;

If SP age = 2 or 3, DISPLAY “1 to {the current age of the SP in years} years old”;

If SP age >3, DISPLAY “1 to 4 years old”.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

FSQ.685 How long {did SP receive/has SP been receiving} benefits from the WIC program?

Q/U

CAPI INSTRUCTION:

IF FSQ.673 = 1, DISPLAY "HAS SP BEEN RECEIVING"

OTHERWISE, DISPLAY "DID SP RECEIVE"

SOFT EDIT: NUMBER CANNOT BE MORE THAN SP’S AGE.

|__|__|

ENTER NUMBER (OF MONTHS OR YEARS)

REFUSED 777 (FSQ.690)

DON'T KNOW 999 (FSQ.690)

|__|

ENTER UNIT

MONTHS 1

YEARS 2

FSQ.690 Did {SP’s} mother receive benefits from WIC, while she was pregnant with {SP}?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

FSQ.695 How many months pregnant was {SP’s} mother when she began to receive WIC benefits?

|__|__|

ENTER NUMBER OF MONTHS (END OF SECTION)

REFUSED 777 (END OF SECTION)

DON'T KNOW 999 (END OF SECTION)

DBQ.930 {Are you/Is SP} the person who does most of the planning or preparing of meals {in your/his/her family}?

INTERVIEWER INSTRUCTION: IF SP ANSWERS “SOMETIMES” OR “50/50”, ENTER YES.

CAPI INSTRUCTION: FILL {IN YOUR/HIS/HER FAMILY} IF THERE IS MORE THAN ONE PERSON IN THE FAMILY.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.935 {Do you/Does SP} share in the planning or preparing of meals with someone else?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.940 {Are you/Is SP} the person who does most of the shopping for food {in your/his/her family}?

INTERVIEWER INSTRUCTION: IF SP ANSWERS “SOMETIMES” OR “50/50”, ENTER YES.

CAPI INSTRUCTION: FILL {IN YOUR/HIS/HER FAMILY} IF THERE IS MORE THAN ONE PERSON IN THE FAMILY.

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

DBQ.945 {Do you/Does SP} share in the shopping for food with someone else?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

WEIGHT HISTORY – WHQ

Target Group: SPs 16+

WHQ.010
F/I/C

These next questions ask about {your/SP's} height and weight. How tall {are you/is SP} without shoes?

|___|

ENTER HEIGHT IN FEET AND INCHES 1

ENTER HEIGHT IN CENTIMETERS 2

REFUSED 7 (WHQ.025)

DON’T KNOW 9 (WHQ.025)

|___|___|

ENTER NUMBER OF FEET

CAPI INSTRUCTION:

HARD EDIT: 2-8

REFUSED 7777 (WHQ.025)

DON’T KNOW 9999 (WHQ.025)

AND

|___|___|

ENTER NUMBER OF INCHES

CAPI INSTRUCTION:

HARD EDIT: 0-11

DON’T KNOW 9999 (WHQ.025)

|___|___|___|

ENTER NUMBER OF CENTIMETERS

CAPI INSTRUCTION:

HARD EDITS: 61 – 272.

DON’T KNOW 9999 (WHQ.025)

WHQ.025/
L/K

How much {do you/does SP} weigh without clothes or shoes? [If {you are/she is} currently pregnant, how much did {you/she} weigh before your pregnancy?]

RECORD CURRENT WEIGHT. ENTER WEIGHT IN POUNDS OR KILOGRAMS.

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you are/she is} currently pregnant . . .] ONLY IF SP IS FEMALE AND AGE IS 16 THROUGH 59.

IF ITEM CHANGED, CHECK MEC COMPONENT.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (WHQ.053)

DON’T KNOW 9 (WHQ.053)

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777

DON’T KNOW 99999

WHQ.053/
L/K

How much did {you/SP} weigh a year ago? [If {you were/she was} pregnant a year ago, how much did {you/she} weigh before your pregnancy?]

ENTER WEIGHT IN POUNDS OR KILOGRAMS

CAPI INSTRUCTION:

DISPLAY OPTIONAL SENTENCE [If {you were/she was} pregnant . . .] ONLY IF SP IS FEMALE AND SP AGE IS 17 THROUGH 60.

|___|

ENTER WEIGHT IN POUNDS 1

ENTER WEIGHT IN KILOGRAMS 2

REFUSED 7 (WHQ.070)

DON’T KNOW 9 (WHQ.070)

|___|___|___|

ENTER NUMBER OF POUNDS

CAPI INSTRUCTION:

SOFT EDIT 75-500, HARD EDIT 50-750

|___|___|___|

ENTER NUMBER OF KILOGRAMS

CAPI INSTRUCTION:

SOFT EDIT 34-225, HARD EDIT 23-338

REFUSED 77777

DON’T KNOW 99999

WHQ.070 During the past 12 months, {have you/has SP} tried to lose weight?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

SMOKING AND TOBACCO USE – SMQ

Target Group: SPs 18+

SMQ.022 These next questions are about cigarette smoking.

Please look at card SMQ1. {Have you/Has SP} smoked at least 100 cigarettes in {your/his/her} entire life? This hand card shows you the products we would like you to include and not include when answering this question.

HAND CARD SMQ1

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

SMQ.040 {Do you/Does SP} now smoke cigarettes . . .

every day, 1

some days, or 2

not at all? 3

REFUSED 7 (END OF SECTION) DON’T KNOW 9 (END OF SECTION)

SMQ.641 On how many of the past 30 days did {you/SP} smoke cigarettes?

|___|___|

ENTER NUMBER OF DAYS

REFUSED 7777

DON'T KNOW 9999

CAPI INSTRUCTION:

ALLOW '0' AS AN ENTRY. IF '0' DK OR RF ENTERED, SKIP TO END OF SECTION.

SOFT EDIT: IF SMQ.040 IS 2 AND SMQ.641 IS GREATER THAN OR EQUAL TO 26 DAYS, THEN SHOW EDIT MESSAGE: “Earlier you reported that you smoked somedays; I would like to clarify that response.”

SMQ.650 On average, when {you/SP} smoked during the past 30 days, how many cigarettes did {you/s/he} smoke a day?

1 PACK EQUALS 20 CIGARETTES

IF LESS THAN 1 PER DAY, ENTER 1

IF 95 OR MORE PER DAY, ENTER 95

|___|___|___|

ENTER NUMBER OF CIGARETTES (PER DAY)

REFUSED 7777

DON'T KNOW 9999

SMQ.657 Do you usually smoke menthol or non-menthol cigarettes?

ENTER '1' FOR MENTHOL

ENTER '0' FOR NON-MENTHOL

CAPI INSTRUCTION:

'1' AND '0' SHOULD BE THE ONLY CODES ACCEPTED BY CAPI.

MENTHOL 1

NON-MENTHOL 0

REFUSED 7

DON'T KNOW 9

OCCUPATION – OCQ

Target Group: SPs 16+

OCQ.152 In this part of the survey, I will ask you questions about {your/SP's} work experience.

Which of the following {were you/was SP} doing last week?

Working at a job or business, 1 (OCQ.180)

with a job or business but not at work, 2 (OCQ.210)

looking for work, or 3 (END OF SECTION)

not working at a job or business? 4 (OCQ.383)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

OCQ.180 How many hours did {you/SP} work last week in total at all jobs or businesses?

|___|___|___|

ENTER NUMBER OF HOURS

CAPI INSTRUCTION:

SOFT EDIT >59. HARD EDIT 1-168.

REFUSED 77777

DON'T KNOW 99999

BOX 1

CHECK ITEM OCQ.200:

IF HOURS IN OCQ.180 <= 34, OR REFUSED (CODE 777), OR DON'T KNOW (CODE 999), CONTINUE.

OTHERWISE, GO TO OCQ.215.

OCQ.210 {Do you/Does SP} usually work 35 hours or more per week in total at all jobs or businesses?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

OCQ.215 How many days per week {do you/does SP} usually work?

|___|

ENTER NUMBER OF DAYS (END OF SECTION)

CAPI INSTRUCTION:

HARD EDIT VALUES LESS THAN 1AND GREATER THAN 7.

REFUSED 77 (END OF SECTION)

DON'T KNOW 99 (END OF SECTION)

OCQ.383 What is the main reason {you/SP} did not work last week?

TAKING CARE OF HOUSE OR FAMILY 1

GOING TO SCHOOL 2

RETIRED 3

UNABLE TO WORK FOR HEALTH

REASONS/DISABLED 4

CAN’T FIND WORK/ON LAYOFF 5

SEASONAL/CONTRACT WORK 6

OTHER 7

REFUSED 77

DON'T KNOW 99

HELP SCREEN FOR OCQ.152:

Work (Working): Paid work for wages, salary, commission, tips, or pay "in kind." Examples of pay in kind include meals, living quarters, or supplies provided in place of wages. This definition of employment includes work in the person's own business, professional practice, or farm, paid leaves of absence (including vacations and illnesses), work without pay in a family business or farm run by a relative, exchange work or share work on a farm, and work as a civilian employee of the Department of Defense or the National Guard. This definition excludes unpaid volunteer work (such as for a church or charity), unpaid leaves of absences, temporary layoffs (such as a strike), and work around the house.

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

3. The business is advertised to the public. (Some examples of advertising are: listing in the classified section of the telephone book, displaying a sign, distributing cards or leaflets, or any type of promotion which publicizes the type of work or services offered.)

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

Seasonal activity during the off season; a seasonal business outside of the normal season is not a business. For example, a family that chops and sells Christmas trees from October through December does not have a business in July.

Distributing products such as Tupperware or newspapers. Distributing products is not a business unless the person buys the goods directly from a wholesale distributor or producer, sells them to the consumer, and bears any losses resulting from failure to collect from the consumer.

Looking for Work: To be looking for work, a person has to have conducted an active job search. An active job search means that the person took steps necessary to put him/herself in a position to be hired for a job. Active job search methods include:

1. Filled out applications or sent out resumes;

2. Placed or answered classified ads;

3. Checked union/professional registers;

4. Bid on a contract or auditioned for a part in a play;

5. Contacted friends or relatives about possible jobs;

6. Contacted school/college university employment office;

7. Contacted employment directly.

Job search methods that are not active include the following:

1. Looked at ads without responding to them;

2. Picked up a job application without filling it out.

HELP SCREEN FOR OCQ.180:

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

Hours Worked Last Week: The number of hours actually worked last week. Hours worked will include overtime if the person worked overtime last week. The actual hours worked is often not the same as the hours on which the person's salary is based. We want the actual hours spent working on the job, whether the hours were paid or not. However, unpaid hours spent traveling to and from work are not included in hours worked last week.

HELP SCREEN FOR OCQ.210:

Job: A job exists when there is:

1. A definite arrangement for regular work;

2. The arrangement is on a continuing basis (like every week or month); and

3. A person receives pay or other compensation for his/her work.

The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.

Include:

Persons who worked for wages, salary, commission, tips, piece-rates or pay-in-kind.

Unpaid workers in a family business or farm and persons who worked without pay on a farm or unincorporated business operated by a related member of the household.

Business: A business exists when one or more of the following conditions are met:

1. Machinery or equipment of substantial value is used in conducting the business;

2. An office, store, or other place of business is maintained; or

Examples of what to include as a business:

Sewing performed in the sewer's house using his/her own equipment.

Operation of a farm by a person who has his/her own farm machinery, other farm equipment, or his/her own farm.

Do not count the following as a business:

Yard sales; the sale of personal property is not a business or work.

HELP SCREEN FOR OCQ.383:

Taking Care of House or Family: Doing any type of work around the house, such as cleaning, cooking, maintaining the yard, caring for children or family, etc.

Going to School: Attending any type of public or private educational establishment both in and out of the regular school system.

Retired: Respondent defined.

Unable to Work for Health Reasons/Disabled: Respondent defined.

Can’t find work/On Layoff: Is when a person is waiting to be called back to a job from which they were temporarily laid-off or furloughed. Layoffs can be due to slack work, plant retooling or remodeling, inventory taking, and the like. Do not consider a person who was not working because of a labor dispute at his or her place of employment as being in layoff.

ACCULTURATION – ACQ

Target Group: SPs 3+

BOX 1B

CHECK ITEM ACQ.006:

IF DMQ.241=1, GO TO ACQ.042.
OTHERWISE, CONTINUE.

ACQ.011 Now I'm going to ask you about language use.

What language(s) {do you/does SP} usually speak at home?

CODE ALL THAT APPLY

ENGLISH 1

SPANISH 8

OTHER 9

REFUSED 77

DON'T KNOW 99

BOX 2

CHECK ITEM ACQ.015:

GO TO END OF SECTION.

ACQ.042 Now I’m going to ask you about language use.

What language(s) {do you/does SP} usually speak at home? {Do you/Does he/Does she} speak only Spanish, more Spanish than English, both equally, more English than Spanish, or only English?

ONLY SPANISH, 1

MORE SPANISH THAN ENGLISH, 2

BOTH EQUALLY, 3

MORE ENGLISH THAN SPANISH, OR 4

ONLY ENGLISH 5

REFUSED 7

DON'T KNOW 9

DEMOGRAPHICS INFORMATION – DMQ – SP

Target Group: SPs Birth +

BOX 1A

CHECK ITEM DMQ.030:

IF SP AGE >= 6, CONTINUE.

OTHERWISE, GO TO DMQ.061.

DMQ.141 Next please look at card DMQ1. What is the highest grade or level of school {you have/SP has} completed or the highest degree {you have/s/he has} received?

HAND CARD DMQ1

READ HAND CARD CATEGORIES IF NECESSARY.

Enter highest level of school.

NEVER ATTENDED/KINDERGARTEN

ONLY 0 (BOX 1B)

1ST GRADE 1

2ND GRADE 2

3RD GRADE 3

4TH GRADE 4

5TH GRADE 5

6TH GRADE 6

7TH GRADE 7

8TH GRADE 8

9TH GRADE 9

10TH GRADE 10

11TH GRADE 11

12TH GRADE, NO DIPLOMA 12

HIGH SCHOOL GRADUATE 13

GED OR EQUIVALENT 14

SOME COLLEGE, NO DEGREE 15

ASSOCIATE DEGREE: OCCUPATIONAL,

TECHNICAL, OR VOCATIONAL

PROGRAM 16

ASSOCIATE DEGREE: ACADEMIC

PROGRAM 17

BACHELOR’S DEGREE (EXAMPLE: BA,

AB, BS, BBA) 18

MASTER’S DEGREE (EXAMPLE: MA,

MS, MEng, MEd, MBA) 19

PROFESSIONAL SCHOOL DEGREE

(EXAMPLE: MD, DDS, DVM, JD) 20

DOCTORAL DEGREE (EXAMPLE:

PhD, EdD) 21

REFUSED 77

DON’T KNOW 99

CAPI INSTRUCTION:

EDITS:

(DMQ.141 = 19, 20 OR 21 AND SP AGE < 22) OR

(DMQ.141 = 15, 16, 17 OR 18 AND SP AGE < 18) OR

(DMQ.141 = 10, 11, 12, 13 OR 14 AND SP AGE < 14) OR

(DMQ.141 = 5, 6, 7, 8 OR 9 AND SP AGE < 8)

DISPLAY “IMPROBABLE ANSWER DUE TO SP’s AGE {SP AGE}. PLEASE VERIFY.”

BOX 1AA

CHECK ITEM DMQ.035:

IF SP AGE <= 19, CONTINUE

OTHERWISE, GO TO DMQ.052.

DMQ.038 {Are you/Is SP} currently enrolled in or attending school?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

Attending or enrolled in any type of public or private educational establishment both in and out of the regular school system. School includes elementary, middle, and high school, college, trade school, and professional school. Students may be enrolled part-time or full-time.

BOX 1B

CHECK ITEM DMQ.040:

IF SP AGE >= 17, CONTINUE.

OTHERWISE, GO TO DMQ.061.

DMQ.052 {Have you/Has SP} ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard? (Active duty does not include training for the Reserves or National Guard, but does include activation, for service in the U.S. or in a foreign country, in support of military or humanitarian operations.)

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

Armed Forces: Non-civilian members of any of the armed services of the federal government (Army, Navy, Air Force, Coast Guard, Marines).

DMQ.061 Next I have a few questions about {your/SP’s} name. {Do you/Does SP} usually go by another first name besides {DISPLAY FIRST NAME FROM DMQ-SPIV.040}?

CAPI INSTRUCTION:

DISPLAY "FIRST NAME:" AND FIRST NAME FROM DMQ-SPIV.040 AS LEFT HEADER.

YES 1

NO 2 (BOX 1BBB)

REFUSED 7 (BOX 1BBB)

DON'T KNOW 9 (BOX 1BBB)

DMQ.071 What is this other first name?

VERIFY SPELLING

____________________________________

ENTER NAME

REFUSED 7----7

DON'T KNOW 9----9

BOX 1BBB

CHECK ITEM DMQ.073a:

IF AGE >= 14, CONTINUE.

OTHERWISE, GO TO BOX 1D.

DMQ.380 {Are you/Is SP} now married, widowed, divorced, separated, never married or living with a partner?

MARRIED 1

WIDOWED 2

DIVORCED 3

SEPARATED 4

NEVER MARRIED 5 (BOX 1D)

LIVING WITH PARTNER 6

REFUSED 77

DON'T KNOW 99

BOX 1C

CHECK ITEM DMQ.075A:

IF SP IS MALE, GO TO BOX 1D.

OTHERWISE, CONTINUE.

DMQ.081 {Do you/Does SP} have a maiden name?

ASK IF NOT KNOWN

YES 1

NO 2 (BOX 1D)

REFUSED 7 (BOX 1D)

DON'T KNOW 9 (BOX 1D)

DMQ.090 What is {your/SP's} maiden name?

G/Q

VERIFY SPELLING

CAPI INSTRUCTION:

DISPLAY "LAST NAME:" AND SP'S CURRENT LAST NAME FROM DMQ-SPIV.060 AS LEFT HEADER.

|___|

ENTER MAIDEN NAME 1

SAME AS CURRENT LAST NAME 2 (BOX 1D)

REFUSED 7 (BOX 1D)

DON'T KNOW 9 (BOX 1D)

____________________________________

REFUSED 7----7

DON'T KNOW 9----9

BOX 1D

CHECK ITEM DMQ.094:

IF SP AGE >= 16, CONTINUE.

OTHERWISE, GO TO DMQ.241.

DMQ.101 What is {your/SP's} father's last name?

G/Q

VERIFY SPELLING

CAPI INSTRUCTION:

DISPLAY "LAST NAME:" AND SP'S CURRENT LAST NAME FROM DMQ-SPIV.060 AS LEFT HEADER.

IF MAIDEN NAME ENTERED IN DMQ.090G/Q, AND MAIDEN NAME IS DIFFERENT FROM CURRENT LAST NAME, ALSO DISPLAY "MAIDEN NAME:" AND MAIDEN NAME FROM DMQ.090G/Q AS LEFT HEADER.

CAPI INSTRUCTION:

HARD EDIT: IF SP MALE, DO NOT ALLOW RESPONSE 3.

|___|

ENTER NAME 1

SAME AS CURRENT LAST NAME 2 (DMQ.241)

SAME AS MAIDEN NAME 3 (DMQ.241)

REFUSED 7 (DMQ.241)

DON'T KNOW 9 (DMQ.241)

____________________________________

REFUSED 7----7

DON'T KNOW 9----9

DMQ.241 {Do you/Does SP} consider {yourself/himself/herself} to be Hispanic, Latino, or of Spanish origin?

READ IF NECESSARY: Where {do your/do his/do her} ancestors come from?

Puerto Rican

Cuban/Cuban American

Dominican Republic

Mexican/Mexican American

Central/South American

Other Latin American

Other Hispanic or Latino

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

HELP SCREEN:

SPANISH, HISPANIC OR LATINO PEOPLE MAY BE OF ANY RACE. LISTED BELOW ARE HISPANIC OR LATINO CATEGORIES/COUNTRIES.

MEXICAN

PUERTO RICAN

CUBAN

DOMINICAN REPUBLIC

CENTRAL AMERICAN:

COSTA RICAN

GUATEMALAN

HONDURAN

NICARAGUAN

PANAMANIAN

SALVADORAN

OTHER CENTRAL AMERICAN

SOUTH AMERICAN:

ARGENTINEAN

BOLIVIAN

CHILEAN

COLOMBIAN

ECUADORIAN

PARAGUAYAN

PERUVIAN

URUGUAYAN

VENEZUELAN

OTHER SOUTH AMERICAN

OTHER HISPANIC OR LATINO:

SPANIARD

SPANISH

SPANISH AMERICAN

BOX 3I

CHECK ITEM DMQ.242:

IF YES (CODE 1) IN DMQ.241 AND YES IN SCQ.260 GO TO DMQ.253.

IF NO (CODE 2) IN DMQ.241 AND NO IN SCQ.260 GO TO DMQ.263.

OTHERWISE, GO TO BOX 3J.

BOX 3J

CHECK ITEM DMQ.249:

IF YES (CODE 1) OR DK IN DMQ.241 AND NO (CODE 2) IN SCQ.260, DISPLAY SOFT EDIT MESSAGE “ETHNICITY DOES NOT MATCH SCREENER SELECTION. HAVE RESPONDENT LOOK AT HAND CARD DMQ2 AND CONFIRM RESPONSE.

OTHERWISE, GO TO BOX 3K.

BOX 3K

CHECK ITEM DMQ.254:

IF NO (CODE 2) OR DK IN DMQ.241 AND YES (CODE 1) IN SCQ.260, DISPLAY SOFT EDIT MESSAGE “ETHNICITY DOES NOT MATCH SCREENER SELECTION. HAVE RESPONDENT LOOK AT HAND CARD DMQ2 AND CONFIRM RESPONSE.

OTHERWISE, GO TO BOX 3K-1.

BOX 3K-1

CHECK ITEM DMQ.256:

IF YES IN DMQ.241, CONTINUE.

OTHERWISE, GO TO DMQ.263.

DMQ.253 Look at card DMQ2. Please give me the number of the group that represents {your/SP's}

OS Hispanic/Latino or Spanish origin or ancestry. Please select 1 or more of these categories.

PROBE: Where do you/your ancestors come from?

HAND CARD DMQ2

SELECT 1 OR MORE

MEXICAN 10

PUERTO RICAN 11

CUBAN 12

DOMINICAN REPUBLIC 13

CENTRAL AMERICAN:

COSTA RICAN 14

GUATEMALAN 15

HONDURAN 16

NICARAGUAN 17

PANAMANIAN 18

SALVADORAN 19

OTHER CENTRAL AMERICAN 20

SOUTH AMERICAN:

ARGENTINEAN 21

BOLIVIAN 22

CHILEAN 23

COLOMBIAN 24

ECUADORIAN 25

PARAGUAYAN 26

PERUVIAN 27

URUGUAYAN 28

VENEZUELAN 29

OTHER SOUTH AMERICAN 30

OTHER HISPANIC OR LATINO:

FILIPINO 31

SPANIARD 32

SPANISH 33

SPANISH AMERICAN 34

HISPANO/HISPANA 35

HISPANIC/LATINO 36

OTHER HISPANIC/LATINO (SPECIFY) 40

CHICANA/CHICANO 41

REFUSED 77

DON'T KNOW 99

BOX 3L

CHECK ITEM DMQ.255:

IF ‘OTHER SPECIFY’ (CODE 40) IN DMQ.253, DISPLAY SOFT ERROR MESSAGE “PLEASE REVIEW THE LIST AND SELECT RESPONSE FROM LIST BEFORE TYPING. THE LIST IS MEANT TO INCLUDE ALL CATEGORIES” AND CAPI SHOULD RETURN TO DMQ.253.

DMQ.263 What race or races {do you/does SP} consider {yourself/himself/herself} to be? Please select one or more.

CHECK ALL THAT APPLY.

American Indian or Alaska Native 1

Asian 2

Black or African American 3

Native Hawaiian or Pacific Islander 4

White 5

Other 6

DK 99

RF 77

NEW BOX L-1

CHECK ITEM DMQ.310:

IF CODE 2 (ASIAN) IN DMQ.263 AND CODE 2 (ASIAN) IN SCQ.270, GO TO DMQ.135.

IF NOT CODE 2 (ASIAN) IN DMQ.263 AND NOT CODE 2 (ASIAN) IN SCQ.270, GO TO BOX L-4d.

OTHERWISE, GO TO NEW BOX L-2.

NEW BOX L-2

CHECK ITEM DMQ.315:

IF CODE 2 (ASIAN) OR DK IN DMQ.263 AND NOT (CODE 2) IN SCQ.270, DISPLAY SOFT EDIT MESSAGE “RACE DOES NOT MATCH SCREENER SELECTION. CONFIRM RESPONSE..”

OTHERWISE, GO TO NEW BOX L-3.

NEW BOX L-3

CHECK ITEM DMQ.320:

IF NOT CODE 2 OR DK IN DMQ.263 AND CODE 2 (ASIAN) IN SCQ.270, DISPLAY SOFT EDIT MESSAGE “RACE DOES NOT MATCH SCREENER SELECTION. CONFIRM RESPONSE.”

OTHERWISE, GO TO NEW BOX L-4.

NEW BOX L-4

CHECK ITEM DMQ.325:

IF CODE 2 (ASIAN) IN DMQ.263, GO TO DMQ.135.

OTHERWISE, GO TO NEW BOX L-4a.

NEW BOX L-4a

CHECK ITEM DMQ.327:

IF CODE 3 (BLACK) IN DMQ.263 AND CODE 3 (BLACK) IN SCQ.270, GO TO NEW BOX L-4d.

IF NOT CODE 3 (BLACK) IN DMQ.263 AND NOT CODE 3 (BLACK) IN SCQ.270, GO TO NEW BOX L-4d.

OTHERWISE, GO TO NEW BOX L-4b.

NEW BOX L-4b

CHECK ITEM DMQ.332:

IF CODE 3 (BLACK) OR DK IN DMQ.263 AND NOT CODE 3 IN SCQ.270, DISPLAY SOFT EDIT MESSAGE “RACE DOES NOT MATCH SCREENER SELECTION. CONFIRM RESPONSE..”

OTHERWISE, GO TO NEW BOX L-4c.

NEW BOX L-4c

CHECK ITEM DMQ.338:

IF NOT 3 OR DK IN DMQ.263 AND CODE 3 (BLACK/AFRICAN AMERICAN) IN SCQ.270, DISPLAY SOFT EDIT MESSAGE “RACE DOES NOT MATCH SCREENER SELECTION. CONFIRM RESPONSE..”

OTHERWISE, GO TO NEW BOX L-4d.

NEW BOX L-4d

CHECK ITEM DMQ.339:

IF CODE 4 (NHPI) IN DMQ.263, GO TO DMQ.350.

IF NOT CODE 4 (NHPI) IN DMQ.263, GO TO NEW BOX L-5.

NEW BOX L-5

CHECK ITEM DMQ.330:IF CODE 6 (OTHER) IN DMQ.263 AND CODE 1 (YES-HISPANIC) IN DMQ.241, GO TO DMQ.266.

OTHERWISE, GO TO DMQ.135.

DMQ.350 Which of the following groups represents {your/SP’s} Native Hawaiian or Pacific Islander origin or ancestry? Please select one or more of these categories.

PROBE: Where do your ancestors come from?

Native Hawaiian 1

Guamanian or Chamorro 2

Samoan 3

Other Pacific Islander 4

REFUSED 7

DON’T KNOW 9

BOX L-5a

CHECK ITEM DMQ.355:

GO TO NEW BOX L-5.

DMQ.266 CODE SP ANSWER TO ‘OTHER RACE’.

MEXICAN 10

PUERTO RICAN 11

CUBAN 12

DOMINICAN REPUBLIC 13

CENTRAL AMERICAN:

COSTA RICAN 14

GUATEMALAN 15

HONDURAN 16

NICARAGUAN 17

PANAMANIAN 18

SALVADORAN 19

OTHER CENTRAL AMERICAN 20

SOUTH AMERICAN:

ARGENTINEAN 21

BOLIVIAN 22

CHILEAN 23

COLOMBIAN 24

ECUADORIAN 25

PARAGUAYAN 26

PERUVIAN 27

URUGUAYAN 28

VENEZUELAN 29

OTHER SOUTH AMERICAN 30

OTHER HISPANIC OR LATINO:

SPANIARD 32

SPANISH 33

SPANISH AMERICAN 34

HISPANO/HISPANA 35

HISPANIC/LATINO 36

OTHER (SPECIFY) 40

REFUSED 77

DON'T KNOW 99

BOX 3M

CHECK ITEM DMQ.268:

IF ‘OTHER SPECIFY’ (CODE 40) IN DMQ.266, DISPLAY SOFT ERROR MESSAGE – “PLEASE REVIEW THE LIST AND SELECT RESPONSE FROM LIST BEFORE TYPING. THE LIST IS MEANT TO INCLUDE ALL CATEGORIES.” AND CAPI SHOULD RETURN TO QUESTION DMQ.266.

DMQ.135 {Were you/Was {SP}} born in the United States or a United States territory?

YES 1 (DMQ.281a)

NO 2

REFUSED 7 (DMQ.281a)

DON'T KNOW 9 (DMQ.281a)

DMQ.160 In what month and year did {you/SP} come to the United States to stay?

M/Y

CAPI INSTRUCTION:

HARD EDIT: NOT BEFORE SP’S DATE OF BIRTH AND NOT AFTER CURRENT DATE. IF OUT OF RANGE DISPLAY “DATE OF IMMIGRATION MUST BE AFTER DATE OF BIRTH {DOB YYYY} AND BEFORE TODAY.”

|___|___|

ENTER MONTH NUMBER

REFUSED 7777

DON'T KNOW 9999

|___|___|___|___|

ENTER 4-DIGIT YEAR

REFUSED 777777

DON'T KNOW 999999

DMQ.281a

The National Center for Health Statistics will conduct statistical studies by combining {your/his/her} survey data with vital, health, nutrition and other related records. {Your/SP’s} social security number is used only for these purposes. Providing this information is voluntary and is collected under the authority of Section 306 of the Public Health Service Act. There will be no effect on {your/his/her} benefits if you do not provide it.

INTERVIEWER INSTRUCTION—ONLY READ IF ASKED. [Public Health Service Act is title 42, United States Code, section 242k.]

What is {your/SP's} Social Security Number?

INTERVIEWER INSTRUCTION:

IF RESPONDENT CANNOT RECALL FROM MEMORY ASK {HIM/HER} TO GET CARD AT THIS TIME.

IF RESPONDENT IS RELUCTANT OR NEEDS MORE INFORMATION OR REFUSES, READ:

[I understand your concern.] By matching NHANES data with other health-related records, researchers can study health conditions like heart attacks and diabetes in depth. They can also better understand health care use and health care costs for all Americans. These findings will help doctors assist patients in making smart choices. These types of studies will not be possible if we don’t have the Social Security number to match the NHANES data to records from other sources. I can share examples of these studies for you if you like. May I please have {your/SP’s} Social Security Number?

IF ASKED FOR EXAMPLES, READ:

By linking the data from our study to data from the U.S. Department of Housing and Urban Development, we learned the association between housing environment and the high level of lead in children’s blood.
By linking the Vitamin D levels measured from our participants’ blood to Medicare data, we learned that higher vitamin D in the blood lowers the risk of broken bones.
By linking the behaviors reported by our participants to the National Death Index database, we learned that adults who exercise, eat healthy diets, and do not smoke have a lower chance of dying.

ENTER SOCIAL SECURITY NUMBER 1 (DMQ281b)

DOES NOT HAVE SOCIAL SECURITY NUMBER 2 (END OF SECTION

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

CAPI INSTRUCTION:

IF SP REFUSES (CODE 7), DISPLAY THE FOLLOWING SOFT ERROR MESSAGE:

Make sure you have read the required text on the screen.

HELP SCREEN

Will my information be kept private?

Your social security number will be kept confidential to protect your privacy as required and guaranteed by law. We will not give your records to the police, military, or any branch of the government for any reason.

Data linkage, also known as record linkage, combines your information from at least two different sources (e.g., NHANES data and Medicare data). This is done only for statistical purposes.

If you agree to data linkage, we will combine the information we collected from you during this survey with records from other organizations (e.g. the Centers for Medicare and Medicaid Services). Once the linkage is completed, personal information that identifies you such as your name, street address, and social security number, will be removed from the linked file before the file is made available for analysis. The linked file will only be used for statistical purposes.

DMQ281b/c

CAPI INSTRUCTION:

REQUIRE DOUBLE ENTRY OF SOCIAL SECURITY NUMBER.

|___|___|___| |___|___| |___|___|___|___|

ENTER SOCIAL SECURITY NUMBER

REFUSED 777777777

DON'T KNOW 999999999

HARD EDIT:

Validate that there are 9 digits entered for an SSN. Do not accept entry less than 9 digits for DMQ281b/c. If a less than 9 digits number was entered, display the message “The SSN should be a 9-digit number, please verify.”

The SSN is a 3-part number (3-digit Area Number + 2-DIGit Group Number + 4-digit Serial Number). None of these compartments can be all zeros. Please verify and display error message “It is unlikely that the SSN starts with “000”, has “00” as its middle 2-digits, or has “0000” as its last 4 digits, please verify that you have the complete number.”

IF DK OR RF SELECTED, DISPLAY, “GO BACK TO PREVIOUS QUESTION AND CODE {DK/RF}.

HELP SCREEN FOR DMQ.141:

School: An institution that advances a person toward an elementary or high school diploma, or a college or professional school degree. Do not count schooling in non-regular schools unless the credits are accepted by regular schools.

Regular school includes graded public, private, and parochial schools, colleges, universities, graduate and professional schools, seminaries where a Bachelor's degree is offered, junior colleges specializing in skill training, colleges of education, and nursing schools where a Bachelor's degree is offered.

If the person attended school outside of the "regular" school system, probe to determine if the schooling is applicable here. Use the following guidelines to determine if the schooling should be included:

- Training Programs - Count training received "on the job," in the Armed Forces, or through correspondence school only if it was credited toward a school diploma, high school equivalency (GED), or college degree.

- Vocational, Trade, or Business School - Do not include secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered, and other vocational trade or business schools outside the regular school system.

- General Educational Development (GED) or High School Equivalency - An exam certified equivalent of a high school diploma. If the person has not actually completed all 4 years of high school, but has acquired his/her GED (high school equivalency based on passing the GED exam), count this and enter code "14."

- Adult Education - Adult education classes should not be included as regular school unless such schooling has been counted for credit in a regular school system. If a person has taken adult education classes not for credit, these classes should not be counted as regular school. Adult education courses given in a public school building are part of regular schooling only if their completion can advance a person toward an elementary school certificate, a high school diploma (or GED), or a college degree.

- Other School Systems - If the person attended school in another country, in an ungraded school, in a "normal school", under a tutor, or under other special circumstances, ask the respondent to give the nearest equivalent of years in regular U.S. schooling.

GED (General Educational Development): An exam certified equivalent of a high school diploma.

Occupational/Technical/Vocational Programs: Includes secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered and other trade and business schools outside the regular school system.

Vocational (Trade or Business) School: When determining the highest grade or year of regular school the person ever completed, do not include secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered, and other vocational trade or business schools outside the regular school system.

College: Any junior college, community college, four-year college or university, nursing school or seminary where a college degree is offered, and graduate school or professional school that is attended after obtaining a degree from a 4-year institution.

Bachelor's Degree: An educational degree given by a college or university to a person who has completed a four-year course or its equivalent in the humanities or related studies (B.A.) or in the sciences (B.S.).

Doctorate Degree: The highest educational degree given by a college or university to a person who has completed a prescribed course of advanced graduate study. For example—a Doctor of Philosophy (Ph.D.).

HEALTH INSURANCE – HIQ

Target Group: All Ages

HIQ.011 The next questions are about health insurance. Include health insurance obtained through employment or purchased directly as well as government programs like Medicare, Medicaid, and the Children’s Health Insurance Program that provide medical care or help pay medical bills. {Are you/Is SP} covered by any kind of health insurance or some other kind of health care plan?

YES 1

NO 2 (BOX 12)

REFUSED 7 (BOX 12)

DON'T KNOW 9 (BOX 12)

HIQ.032 Please look at card HIQ1. What kinds of health insurance or health care coverage {do you/does SP} have? Is it… private health insurance, Medicare, Medigap, Medicaid, Children’s Health Insurance Program or CHIP, military related health care including TRICARE, CHAMPUS, VA health care and CHAMP-VA, Indian Health Service, a state-sponsored health plan or another government program?

CODE ALL THAT APPLY

HAND CARD HIQ1

CAPI INSTRUCTION:

DO NOT ALLOW MORE THAN ONE ANSWER WHEN 140 (NO COVERAGE OF ANY TYPE) IS CODED.

PRIVATE HEALTH INSURANCE 1

MEDICARE 2

MEDI-GAP 3

MEDICAID 4

CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) 5

MILITARY RELATED HEALTH CARE: TRICARE
(CHAMPUS)/VA HEALTH CARE/CHAMP-VA 6

INDIAN HEALTH SERVICE 7

STATE-SPONSORED HEALTH PLAN ({DISPLAY STATE

PLAN NAME}) 8

OTHER GOVERNMENT PROGRAM 9

NO COVERAGE OF ANY TYPE 10

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

SOFT EDIT: IF SP AGE LESS THAN 18 AND HIQ.032 = 2 (MEDICARE) DISPLAY ERROR MESSAGE, “PLEASE VERIFY THAT CHILD SP HAS MEDICARE. Only disabled children or children with kidney failure can get Medicare. Children who have Medicare are almost always also receiving Social Security or SSI and have Medicaid.”

SOFT EDIT: IF SP AGE EQUAL TO OR GREATER THAN 18 AND LESS THAN 65 AND HIQ.032 – 2 (MEDICARE) DISPLAY ERROR MESSAGE, “PLEASE VERIFY THAT SP AGE 18-64 HAS MEDICARE. Only disabled adults or adults with kidney failure under 65 years old can have Medicare. They are almost always receiving disability checks from Social Security or SSI.”

HARD EDIT: IF HIQ.032 = 3 (MEDI-GAP) AND 2 (MEDICARE)IS NOT SELECTED, DISPLAY ERROR MESSAGE, “Medi-Gap refers to Medicare Supplemental Insurance. You must have Medicare to be eligible to purchase Medi-Gap. PLEASE VERIFY IF SP HAS MEDI-GAP AND, IF YES, IF HE/SHE HAS Medicare.”

{CAPI DISPLAYS ONE QUESTION FOR CORRECTION}

HIQ.032

BOX 12

CHECK ITEM HIQ.065:

IF AGE => 65 AND HIQ.032 = CODE 1 OR CODE 3-99 OR HIQ.032 IS EMPTY, GO TO HIQ.260.
IF AGE = BIRTH+ AND HIQ.032 = CODE 2, GO TO HIQ.502.
OTHERWISE, CONTINUE.

BOX 13

CHECK ITEM HIQ.259:

IF AGE < 65 AND (HIQ.011 = 1 (YES) AND HIQ.032 NOT = 10 (NO COVERAGE), GO TO HIQ.210.

IF AGE < 65 AND (HIQ.011 = 2, 7, OR 9 OR HIQ.032 = 10), GO TO END OF SECTION.

HIQ.260 Look at card HIQ2. {Do you/Does SP} have Medicare? This is a health insurance program that virtually all persons 65 and older are eligible for. A card is automatically mailed to you shortly before your 65th birthday. You can view an example on the card.

HAND CARD HIQ2

YES 1

NO 2 (BOX 14)

REFUSED 7 (BOX 14)

DON’T KNOW 9 (BOX 14)

HIQ.502 Please look at your Medicare card and tell me the Health Insurance Claim Number.

This number is needed to allow Medicare records of the Center for Medicare and Medicaid Services to be easily and accurately located and identified for statistical purposes. Providing the Health Insurance Claim Number is voluntary and collected under the authority of Section 306 of the Public Health Service Act. Whether the number is given or not, there will be no effect on {your/his/her} benefits. This number will be held confidential. [The Public Health Service Act is Title 42, United States Code, Section 242K.]

CAPI INSTRUCTION:

REQUIRE DOUBLE ENTRY OF NUMBER. DOUBLE ENTRY ITEM NUMBER IS HIQ.510.

ALLOW UP TO 13 CHARACTERS (LETTERS OR NUMBERS)

|___|___|___|___|___|___|___|___|___|___|___|___|___|

ENTER CLAIM NUMBER

REFUSED 77777777777 (BOX 14)

DON'T KNOW 99999999999 (BOX 14)

BOX 14

CHECK ITEM HIQ.269:

IF (HIQ.011 = 1 AND HIQ.032 NOT = 10) OR HIQ.260 = 1, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

HIQ.210 In the past 12 months, was there any time when {you/SP} did not have any health insurance or coverage?

Yes 1

No 2

Refused 7

Don't know 9

HELP SCREEN FOR HIQ.011:

Health Insurance: Health benefits coverage which provides persons with health-related benefits. Coverage may include the following; hospitalization, major medical, surgical, prescriptions, dental, and vision.

Medicare: A Federal health insurance program for people 65 or older and for certain persons under 65 with long-term disabilities. Almost all Social Security recipients are covered by Medicare. It is run by the Center for Medicare and Medicaid Services of the U.S., Department of Health and Human Services.

Medicare consists of two parts, A and B:

Part A is called the Hospital Insurance Program. It helps pay for inpatient care in a hospital or in a skilled nursing facility, for home health care, and for hospice care. It is available to nearly everyone 65 or older.

Persons who are eligible for either Social Security or Railroad Retirement benefits are not required to pay a monthly premium for Part A of Medicare. However, anyone who is 65 or over and does not qualify for Social Security or Railroad Retirement benefits may pay premiums directly to Social Security to obtain Part A coverage.

Part B is called the Supplementary Medical Insurance Program. It is a voluntary plan that builds upon the hospital insurance protection provided by the basic plan. It helps pay for the doctor and surgeon services, outpatient hospital services, durable medical equipment, and a number of other medical services and supplies that are not already covered under Part A of Medicare.

If a person elects this additional insurance, the monthly premium is deducted from his/her Social Security.

Medicaid: Refers to a medical assistance program that provides health care coverage to low-income and disabled persons. The Medicaid program is a joint federal-state program which is administered by the states.

HELP SCREEN FOR HIQ.032:

Private Health Insurance Plan: Any type of health insurance, including HMOs, that is not a public program. Private health insurance plans may be provided in part or full by a person's employer or union, or may be purchased directly by an individual.

Private Health Insurance Plan through a State or Local Government Program or Community Program: A type of health insurance for which state or local government or community effort pays for part or all of the cost of a private insurance plan, such as Blue Cross/Blue Shield. The individual may also contribute to the cost of the health insurance and may receive a card such as a Blue Cross/Blue Shield card. A community program or effort may include a variety of mechanisms to achieve health insurance for persons who would otherwise be uninsured. An example would be a private company giving a grant to an HMO to pay for health insurance coverage.

Medicare consists of two parts, A and B:

If a person elects this additional insurance, the monthly premium is deducted from his/her Social Security.

Medi-Gap: Refers to private health insurance purchased to supplement Medicare. Medi-Gap will be treated as a private health insurance plan in the detailed questions about health insurance.

CHIP (Children's Health Insurance Program, also called SCHIP): A joint federal and state program, administered by each state, that offers health care coverage to low-income, uninsured children. This law was passed in 1997. In some states, CHIP programs have distinct names.

Military Health Care/VA: Refers to health care available to active duty personnel and their dependents, in addition, the VA provides medical assistance to veterans of the Armed Forces, particularly those with service-connected ailments.

TRICARE/CHAMP-VA: TRICARE, formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), provides civilian health benefits for U.S. Armed Forces military personnel, military retirees, and their dependents. Several varitions of the plan exist including (but are not limited to): TRICARE Reserve Select, TRICARE Prime, TRICARE Select, U.S. Family health plan, TRICARE Select Overseas, and TRICARE for Life. CHAMP-VA (Comprehensive Health and Medical Plan of the Veterans Administration) provides health care for the spouse, dependents, or survivors of a veteran who has a total, permanent service-connected disability.

Indian Health Service: The federal health care program for Native Americans.

State-Sponsored Health Plan: Any other health care coverage run by a specific state, including public assistance programs other than "Medicaid" that pay for health care.

Other Government Program: A catch-all category for any public program providing health care coverage other than those programs in specific categories.

HELP SCREEN FOR HIQ.502:

Medicare consists of two parts, A and B:

If a person elects this additional insurance, the monthly premium is deducted from his/her Social Security.

PRESCRIPTION MEDICATION – RXQ

Target Group: SPs Birth +

RXQ.033 In the past 30 days, {have you/has SP} used or taken medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. {Please remember to include any prescription birth control products that you are taking or using such as pills or patches.} [Do not include prescription vitamins or minerals you may have already told me about.]

YES 1

NO 2 (BOX 17A)

REFUSED 7 (BOX 17A)

DON'T KNOW 9 (BOX 17A)

CAPI INSTRUCTION:

IF SP FEMALE AND AGE 16-49 YEARS, DISPLAY ‘Please remember to include prescription birth control products that you are taking or using such as pills or patches.’

CAPI HARD EDIT CHECK #1

IF ‘NO’ (CODE 2) IN RXQ.033 AND ‘YES’ (CODE 1) IN DIQ.050 OR DIQ.070, DISPLAY THE FOLLOWING MESSAGE:

Earlier in the interview you reported currently taking insulin or a diabetic pill. If this is correct, we should count that as prescription medication you have taken in the last 30 days.

{CAPI DISPLAYS THREE QUESTIONS FOR CORRECTION}

DIQ.050 = Taking Insulin

DIQ.070 = Taking Diabetic Pills

RXQ.033 = Prescription Medication in Last 30 Days

CAPI HARD EDIT CHECK #2

IF ‘NO’ (CODE 2) IN RXQ.033 AND ‘YES’ (CODE 1) IN BPQ.050a, DISPLAY THE FOLLOWING MESSAGE:

Earlier in the interview you reported currently taking prescription medication for high blood pressure. If this is correct, we should count that as prescription medication you have taken in the last 30 days.

{CAPI DISPLAYS TWO QUESTIONS FOR CORRECTION}

BPQ.050a = Taking Blood Pressure Medication

RXQ.033 = Prescription Medication in Last 30 Days

CAPI HARD EDIT CHECK #3

IF ‘NO’ (CODE 2) IN RXQ.033 AND ‘YES’ (CODE 1) IN BPQ.100d, DISPLAY THE FOLLOWING MESSAGE:

Earlier in the interview you reported currently taking prescription medication for high cholesterol. If this is correct, we should count that as prescription medication you have taken in the last 30 days.

{CAPI DISPLAYS TWO QUESTIONS FOR CORRECTION}

BPQ.100d = Taking High Cholesterol Medicine

RXQ.033 = Prescription Medication in Last 30 Days

RXQ.NEW1 How many prescription medications have you taken in the past 30 days?

Would you say you have taken…

1, 1

2, 2

3, 3

4, or 4

5 or more? 5

REFUSED 7

DON'T KNOW 9

BOX 17A

CHECK ITEM RXQ.500:

IF SP >= 40 YEARS OLD OR MCQ.160C, MCQ.160D, MCQ.160E OR MCQ.160F = 1/YES, CONTINUE WITH RXQ.510.

OTHERWISE, GO TO RXQ.335.

RXQ.510 Doctors and other health care providers sometimes recommend that {you take/SP takes) a low-dose aspirin each day to prevent heart attacks, strokes, or cancer. {Have you/Has SP} ever been told to do this?

YES 1

NO 2 (RXQ.520)

REFUSED 7 (RXQ.520)

DON'T KNOW 9 (RXQ.520)

INTERVIEWER INSTRUCTION:

IF THE RESPONDENT VOLUNTEERS THEY HAVE BEEN TOLD TO TAKE AN ASPIRIN EVERY OTHER DAY OR ‘REGULARLY’ FOR THESE REASONS, CODE “YES”.

RXQ.515 {Are you/Is SP} now following this advice?

YES 1 (RXQ.335)

NO 2 (RXQ.335)

SOMETIMES 3 (RXQ.335)

STOPPED ASPIRIN USE DUE TO SIDE
EFFECTS 4 (RXQ.335)

REFUSED 7 (RXQ.335)

DON'T KNOW 9 (RXQ.335)

HELP SCREEN:

Side Effect: is an unexpected health problem that is caused by a medicine. Some side effects of aspirin are stomach problems, easy bruising or bleeding, runny nose, wheezing and skin rashes.

RXQ.520 On {your/SP’s} own, {are you/is SP} now taking a low-dose aspirin each day to prevent heart attacks, strokes, or cancer?

YES 1

NO 2

REFUSED 7

DON'T KNOW 9

INTERVIEWER INSTRUCTION:

IF THE RESPONDENT VOLUNTEERS THEY ARE TAKING AN ASPIRIN EVERY OTHER DAY OR ‘REGULARLY’ FOR THESE REASONS, CODE “YES”.

RXQ.335 PRESS F10 TO EXIT BLAISE.

HELP SCREEN FOR RXQ.033:

Prescription Medication: Prescription medications are those ordered by a physician or other authorized medical professional through a written or verbal prescription for a pharmacist to fill. Prescription medications may also be given by a medical professional directly to a patient to take home, such as free samples.

Prescription medications do not include:

- Medication administered to the patient during the event in the office as part of the treatment (such as an antibiotic shot for an infection, a flu shot, or an oral medication) unless a separate bill for the medication is received;

- Diaphragms and IUD's (Intra-Uterine Devices); or

- Some state laws require prescriptions for over the counter medications. Sometimes physicians write prescriptions for over the counter medications, such as aspirin. Consider any medication a prescription medication if the respondent reports it as prescribed. If it is an over the counter medication, however, the prescription must be a written prescription to be filled by a pharmacist, not just a written or oral instruction. If in doubt, probe whether the patient got a written prescription to fill at a pharmacy.

Past Month: The past 30 days. From yesterday, 30 days back.

MAILING ADDRESS – MAQ

Target Group: SPs Birth +

Placing: Just After Blaise Closes

MAQ.005 Processing Extended SP Questionnaire. Please Wait.

MAQ.020 The National Center for Health Statistics may wish to contact {you/SP} again. Please give me {your/SP's} complete mailing address.

CRITICAL INFORMATION – CHECK CAREFULLY.

USE PEN OR PRESS 'TAB' KEY TO MOVE TO THE NEXT ENTRY FIELD.

TAP 'NEXT' BUTTON OR PRESS 'ENTER' KEY WHEN FINISHED VERIFYING ADDRESS.

CAPI INSTRUCTION:

DISPLAY THE SCREENER MAILING ADDRESS INFORMATION. ENTRY SHOULD APPEAR IN ALL CAPS – AS IT DOES IN IVQ.

DISPLAY “YOU/YOUR” IF SP AGE >= TO 16. DISPLAY “SP/SP’s” IF SP AGE < 16.

________________________________________________________________________________

ADDITIONAL ADDRESS LINE

________ ________ ____________________________ __________ ________

STREET # DIR PRE STREET NAME ST/RD/AVE DIR POST

_________ _________

UNIT/APT/BLDG UNIT #

______________________________ ________ ________ ______

CITY STATE ZIP ZIP 2

HARD EDIT: IF “PO BOX” OR “P.O. BOX” IS ENTERED IN THE ADDITIONAL ADDRESS LINE, STREET #, OR STREET NAME FIELDS, DISPLAY “DO NOT ENTER P.O. BOX INFORMATION IN THIS FIELD. DELETE P.O. BOX FROM FIELD AND SELECT “PO BOX” FROM THE UNIT/APT/BLDG DROP DOWN MENU. ENTER THE P.O. BOX NUMBER IN THE UNIT # FIELD.”

HARD EDIT: IF “PO BOX” IS SELECTED FROM THE UNIT/APT/BLDG DROP DOWN MENU AND TEXT IS ENTERED IN THE ADDITIONAL ADDRESS LINE, STREET #, OR STREET NAME FIELDS, OR AN ITEM IS SELECTED FROM DIR PRE, ST/RD/AVE OR DIR POST DROP DOWN MENUS, DISPLAY, “DO NOT INCLUDE STREET ADDRESS INFORMATION WHEN SELECTING PO BOX AS THE MAILING ADDRESS. DELETE ALL STREET ADDRESS INFORMATION OR REMOVE P.O. BOX INFORMATION TO CONTINUE. IF THE ADDRESS IS A BOX OTHER THAN A P.O. BOX, SELECT “BOX” FROM THE DROP DOWN MENU.”

MAQ.040 I have recorded . . .

{DISPLAY ADDRESS ENTERED IN MAQ.020 IN UPPER CASE}

Is that correct?

YES 1 (MAQ.080ck)

NO 2

MAQ.060 ENTER CORRECTED MAILING ADDRESS INFORMATION.

PROBE FOR MAILING ADDRESS CORRECTIONS, IF NECESSARY.

USE PEN OR PRESS 'TAB' KEY TO MOVE TO THE NEXT ENTRY FIELD.

TAP 'NEXT' BUTTON OR PRESS 'ENTER' KEY WHEN CORRECTIONS COMPLETED.

{DISPLAY ALL ADDRESS FIELDS AND INFORMATION ENTERED IN MAQ.020 IN UPPER CASE. ALLOW CORRECTIONS.}

MAQ.080 I now have {your/SP's} mailing address as . . .

{DISPLAY CORRECTED ADDRESS FROM MAQ.060 IN UPPER CASE}

Is that correct?

YES 1

NO 2

BOX 2

CHECK ITEM MAQ.080ck:

IF 'NO' IN MAQ.080, RETURN TO MAQ.060. DISPLAY CORRECTED ADDRESS INFORMATION IN MAQ.060. OTHERWISE, CONTINUE.

BOX 2AA

CHECK ITEM MAQ.195:

IF SP AGE 0-15, GO TO MAQ.090;

OTHERWISE, CONTINUE.

MAQ.200 Do you have an e-mail account?

YES 1

NO 2 (MAQ.090)

REFUSED 7 (MAQ.090)

DON’T KNOW 9 (MAQ.090)

MAQ.210 What is your e-mail address?

|_____________________________________|

REFUSED 7 (MAQ.090)

DON’T KNOW 9 (MAQ.090)

CAPI INSTRUCTION:

HARD EDITS:

1. IF THERE ARE SPACES IN THE EMAIL ADDRESS, DISPLAY “EMAIL ADDRESS DOES NOT ALLOW SPACES.”

2. IF EMAIL ADDRESS IS MISSING THE @ SYMBOL, DISPLAY “EMAIL ADDRESS IS MISSING THE @ SYMBOL – PLEASE GO BACK AND CORRECT.”

3. IF TEXT IS MISSING TO THE LEFT OR RIGHT OF THE @ SYMBOL, DISPLAY “PART OF THE EMAIL ADDRESS IS MISSING – PLEASE GO BACK AND CORRECT.”

MAQ.220 I have recorded . . .

{DISPLAY E-MAIL ADDRESS ENTERED IN MAQ.210}

Is that correct?

YES 1

NO 2 (MAQ.210)

MAQ.090 INTERVIEWER INSTRUCTION:

SPECIFY LANGUAGE IN WHICH HARD COPY MATERIALS SHOULD BE MAILED.

ENGLISH 1

SPANISH 2

MAQ.NEW2 Is {FILL FIRST PHONE NUMBER FROM DATABASE} the best telephone number to reach you in case my office wants to check my work?

YES 1 (MAQ.NEW3)

NO. PROVIDE A DIFFERENT NUMBER 2

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

MAQ.100a/b Please tell me the best telephone number to reach you (in case my office wants to check my work).

INTERVIEWER INSTRUCTION: CONFIRM ENTERED NUMBER WITH RESPONDENT BEFORE CONTINUING.

CAPI INSTRUCTION:

ONLY ALLOW 10 DIGIT PHONE NUMBER. DISPLAY HARD RANGE CHECK MESSAGE IF NOT 10 DIGITS. ALLOW BLANK ENTRIES IN EXTENSION FIELD.

(|__|__|__|) |__|__|__|- |__|__|__|__|

EXTENSION: |__|__|__|__|

NO TELEPHONE 2 (MAQ.305)

REFUSED 7 (MAQ.305)

DON’T KNOW 9 (MAQ.305)

MAQ.NEW3 Is this number a cell phone or landline?

CELL PHONE 1

LANDLINE 2 (NEW BOX 2)

REFUSED 7 (NEW BOX 2)

DON’T KNOW 9 (NEW BOX 2)

MAQ.NEW4 We may want to send you short text messages containing reminders about {your/SP’s} participation in the study. There may be fees to get a text message, depending on your plan. May we send text messages to this number?

CAPI INSTRUCTION: DISPLAY ‘your’ IF SP IS SELECTED AS RESPONDENT IN RIQ.006. DISPLAY ‘SP’s’ IF SP IS NOT SELECTED AS RESPONDENT IN RIQ.006.

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

NEW BOX 2

CHECK ITEM MAQ.NEW5:

IF SECOND TELEPHONE NUMBER FOR SP HAS BEEN COLLECTED IN SYSTEM, CONTINUE.

OTHERWISE, GO TO MAQ.110a/b.

MAQ.NEW6 Is {FILL SECOND PHONE NUMBER FROM DATABASE} the other number where you can be reached?

YES 1 (MAQ.NEW7)

NO. PROVIDE A DIFFERENT NUMBER 2

REFUSED 7 (NEW BOX 3)

DON’T KNOW 9 (NEW BOX 3)

MAQ.110a/b Please tell me another number where you can be reached.

INTERVIEWER INSTRUCTION: CONFIRM ENTERED NUMBER WITH RESPONDENT BEFORE CONTINUING.

CAPI INSTRUCTION:

ONLY ALLOW 10 DIGIT PHONE NUMBER. DISPLAY HARD RANGE ERROR IF NOT 10 DIGITS.

(|__|__|__|) |__|__|__|- |__|__|__|__|

NO OTHER TELEPHONE 2 (NEW BOX 3)

REFUSED 7 (NEW BOX 3)

DON’T KNOW 9 (NEW BOX 3)

MAQ.NEW7 Is this number a cell phone or landline?

CELL 1

LANDLINE 2 (NEW BOX 3)

REFUSED 7 (NEW BOX 3)

DON’T KNOW 9 (NEW BOX 3

MAQ.NEW8 May we send you text messages about {your/SPs} participation in the study to this number as well?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

CAPI INSTRUCTION: DISPLAY ‘your’ IF SP IS SELECTED AS RESPONDENT IN RIQ.006. DISPLAY ‘SP’s’ IF SP IS NOT SELECTED AS RESPONDENT IN RIQ.006.

INCENTIVE CARD – CCQ

Target Group: SPs Birth +

CCQ.010 As a thank you for answering these questions, will you accept ${INCENTIVE} for completing the interview today?

DID THE RESPONDENT ACCEPT THE INCENTIVE?

YES 1

NO 2 (CCQ.NEW5)

INTERVIEWER INSTRUCTIONS:

IF THE SP INTERVIEW IS CONDUCTED IMMEDIATELY AFTER THE SCREENER, THE SP WILL NOT HAVE A DEBIT CARD YET. DO NOT READ QUESTION TEXT. SELECT ‘2- DOES NOT HAVE CARD’ TO CONTINUE.

IF RESPONDENT ANSWERS YES, ASK HIM OR HER TO GET THE CARD AND CARD CARRIER SHEET NOW.

CARD PROVIDED. 1

DOES NOT HAVE CARD 2

NEW BOX 1

CHECK ITEM CCQ.NEW2:

IF RIQ.NEW0=1 (PHONE) AND CCQ.NEW1=2, GO TO CCQ.NEW4.

OTHERWISE, CONTINUE.

CCQ.020 IF YOU ARE ASSIGNING A NEW DEBIT CARD, TAKE OUT A NEW CARD FROM YOUR SUPPLY OR HAVE THE RESPONDENT TAKE OUT THE ENVELOPE CONTAINING THE CARD CARRIER SHEET FROM THE INTERVIEWER MATERIALS GIVEN TO HIM OR HER BEFORE THE INTERVIEW.

{The provided card/This card} is your Health Study debit card. The debit card is a VISA© Card and is accepted anywhere VISA© is accepted. The card cannot be used to withdraw money from an ATM. Your payment will be available for use on the card within 3 business days. You can find answers to most commonly asked questions on the card carrier sheet along with phone numbers to call for additional information.

IF RESPONDENT ALREADY HAS CARD CARRIER SHEET READ:

Please read to me the 13 digit number shown on the card carrier sheet so I can activate your card now. This number is located in the upper left corner of the sheet above the QR code. It is not the number on the actual debit card.

ENTER THE 13 DIGIT NUMBER SHOWN ON THE CARD CARRIER SHEET.

CAPI INSTRUCTION:

EDIT CHECK: ENTRY MUST BE 13 DIGITS. IF NOT, DISPLAY “THE BARCODE NUMBER SHOULD BE 13 DIGITS. PLEASE RE-ENTER.”

FILL “The provided card” if RIQ.NEW1=1(PHONE). FILL “This card” IF RIQ.NEW1=2(IN PERSON).

CCQ.030 (Please read to me again the 13 digit number shown on the card carrier sheet.)

RE-ENTER THE 13 DIGIT NUMBER SHOWN ON THE CARD CARRIER SHEET.

CAPI INSTRUCTION:

EDIT CHECK: THE NUMBER ENTERED IN CCQ.030 MUST MATCH THE NUMBER ENTERED IN CCQ.020. IF NUMBERS DO NOT MATCH, DISPLAY “THE TWO 13 DIGIT NUMBERS DO NOT MATCH. PLEASE CHECK ENTRIES.”

CCQ.040 RECORD THE NAME OF THE CARD RECIPIENT AND THE AMOUNT ADDED TO THE CARD ON THE CARD CARRIER SHEET. IF RESPONDENT ALREADY HAS THE CARD CARRIER SHEET, ASK HIM OR HER TO DO THIS.

NAME AND AMOUNT RECORDED 1

CCQ.050 WHO RECEIVED THE CARD WITH THE ADDED INCENTIVE?

CARD RECIPIENT: {FIRST NAME} {LAST NAME}

CAPI INSTRUCTIONS:

WHEN THE FOCUS OF THE CURSOR IS ON THE “CARD RECIPIENT” FIELD, THE ANSWER CHOICES SHOULD BE A LIST THAT DISPLAYS FIRST AND LAST NAMES OF ALL HH MEMBERS ON THE HH COMPOSITION MATRIX. THE LIST SHOULD BE SORTED BY ORDER ON ROSTER BUT THE RESPONDENT SELECTED IN RIQ SHOULD DEFAULT TO THE TOP OF THE LIST. IF THE RESPONDENT DOES NOT LIVE IN THE HOUSEHOLD (RIQ.006= 'SOMEONE NOT LIVING IN HH'), DISPLAY NAME ENTERED IN RIQ.050 AT THE TOP OF THE LIST.

NEW BOX 2

CHECK ITEM CCQ.NEW3:

GO TO CCQ.NEW5

CCQ.NEW4 My office will assign to you a new VISA© card and mail it to you. The debit card is accepted anywhere VISA© is accepted. The card cannot be used to withdraw money from an ATM. You will be able to find answers to most commonly asked questions on the card carrier sheet along with phone numbers to call for additional information.

You should receive your card in the mail within a week.

REQUEST NEW CARD 1

CCQ.NEW5 This is the end of the health interview. Thank you very much for your cooperation.

PRESS F10 TO SAVE AND EXIT FORM.

Family Questionnaire

RESPONDENT SELECTION SECTION – RIQ – FAMILY QUESTIONNAIRE

RIQ.500 INTERVIEWER: SELECT INTERVIEW MODE

PHONE................................................................. 1

IN-PERSON......................................................... 2

*11RIQ.010 SELECT RESPONDENT FOR THE FAMILY QUESTIONNAIRE.

CAPI INSTRUCTION:

DISPLAY ALL FAMILY MEMBERS WHO ARE >= 18 YEARS OLD.

IF NO FAMILY MEMBERS ARE >= 18 YEARS OLD, DISPLAY ALL FAMILY MEMBERS >= 12 YEARS OLD.

ALSO DISPLAY ‘SOMEONE OUTSIDE FAMILY’.

BOX 1A

CHECK ITEM *11RIQ.018:

IF ‘SOMEONE OUTSIDE FAMILY’ SELECTED AS RESPONDENT, GO TO *11RIQ.040.

OTHERWISE, GO TO DMQ.INTRO.

*11RIQ.040 INTERVIEW SHOULD BE CONDUCTED WITH FAMILY MEMBER 18 YEARS OR OLDER WHO

OS KNOWS ABOUT FAMILY MATTERS.

WHY IS INTERVIEW BEING CONDUCTED WITH SOMEONE OUTSIDE THE FAMILY? OTHER (SPECIFY)

CAPI INSTRUCTION:

IF 'SOMEONE OUTSIDE THE FAMILY' SELECTED IN ERROR’ (CODE 3), DISPLAY THE FOLLOWING MESSAGE (RIQ.040CK): "INCORRECT RESPONDENT SELECTED. BACK UP AND PICK THE CORRECT RESPONDENT." ALLOW RETURN TO 11RIQ.040 WITH BACK BUTTON.

ONLY FAMILY MEMBER HAS COGNITIVE

PROBLEMS 1

ONLY FAMILY MEMBER IS A CHILD

UNDER 16 (WARD OF STATE) 2

‘SOMEONE OUTSIDE THE FAMILY’

SELECTED IN ERROR 3 (RIQ.040CK)

OTHER (SPECIFY) 4

*11RIQ.042 DO YOU HAVE SUPERVISOR PERMISSION TO CONDUCT INTERVIEW WITH SOMEONE OUTSIDE THE FAMILY?

NOTE: IF INTERPRETER USED, RESPONDENT MUST SIGN FORM.

CAPI INSTRUCTION:

IF 'NO' (CODE 2), DISPLAY THE FOLLOWING MESSAGE (RIQ.042CK): "SUPERVISORY PERMISSION IS REQUIRED TO USE A PROXY FOR THIS INTERVIEW. MOVING FORWARD WILL EXIT THIS INTERVIEW" ALLOW RETURN TO 11RIQ.042 WITH BACK BUTTON. MOVING FORWARD EXITS INTERVIEW.

YES 1

NO 2 (RIQ.042CK)

*11RIQ.045 ENTER RESPONDENT NAME.

FIRST NAME LAST NAME

*11RIQ.047 ENTER RESPONDENT'S PHONE NUMBER.

ENTER '00' IF NO PHONE.

|___|___|___| |___|___|___| - |___|___|___|___|

AREA CODE ENTER PHONE NUMBER

*11RIQ.049 DESCRIBE RESPONDENT'S RELATIONSHIP TO FAMILY.

DMQ.INTRO CAPI INSTRUCTION: BEGIN RECORDING SO THAT WHEN INTERVIEWER READS THIS QUESTION IT IS CAPTURED ON RECORDING.

[Welcome to the National Health and Nutrition Examination Survey, also known as NHANES. {You have/Someone in your family has/SP has} been selected to be part of this study which includes an interview and a health exam. This study is sponsored by the National Center for Health Statistics, part of the Centers for Disease Control and Prevention. The information I collect in this interview will be extremely valuable in understanding the health and nutrition of people in the United States.]

In this interview, I will ask health-related questions about {your/SP’s} family.

INTERVIEWER INSTRUCTION: READ BRACKETED TEXT ONLY IF RESPONDENT HAS NOT ALREADY COMPLETED AN SP QUESTIONNAIRE.

CAPI INSTRUCTION:

FILL “You have” IN FIRST PARAGRAPH IF RESPONDENT IS IN FAMILY AND IS AN SP. FILL “Someone in your family has” IF RESPONDENT IS IN FAMILY AND IS NOT AN SP. FILL “SP has” IF RESPONDENT IS NOT IN FAMILY (*11RIQ.010 = OUTSIDE OF FAMILY).

FILL “your” IN SECOND PARAGRAPH IF RESPONDENT IS IN FAMILY. FILL “SP’S” IF RESPONDENT IS NOT IN FAMILY (*11RIQ.010 = OUTSIDE OF FAMILY).

BOX 1B

CHECK ITEM RIQ.165:

IF AUDIO_CONSENT FLAG = 1 (SAME SP AS SP INTERVIEW AND GAVE PERMISSION TO RECORD SP INTERVIEW), GO TO RIQ.200.

ELSE, GO TO RIQ.211.

RIQ.211 We would like to record the interview for training and data quality. The computer is now recording our conversation. Do I have your permission to continue recording?

YES 1 (RIQ.510)

NO 2 (RIQ.510)

CAPI INSTRUCTION:

IF RIQ.NEW1 = 2/NO, STOP RECORDING.

RIQ.200 A reminder that the computer is now recording our conversation. Do I have your permission to continue recording?

YES 1

NO 2

CAPI INSTRUCTION:

IF RIQ.200 = 2/NO, STOP RECORDING.

RIQ.510 ADULT AND EMANCIPATED MINOR RESPONDENT INTERVIEW CONSENT

There are a few additional things I need to cover before we continue with the interview. Taking part in this interview is voluntary. You may choose to skip any question you don’t wish to answer or end the interview at any time without penalty. We are required by Federal law to develop and follow strict procedures to protect the confidentiality of your information and use your answers only for statistical purposes. I can describe these laws if you wish. Do you have any questions before we continue?

ANSWER QUESTIONS AND REFER TO HELP SCREEN AS NECESSARY.

HELP SCREEN:

Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m) and the Confidential Information Protection and Statistical Efficiency Act of 2018 (Title III of the Foundations for Evidence-Based Policymaking Act of 2018 (Pub. L. No. 115-435, 132 Stat. 5529 § 302)). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

Public reporting burden for this collection of information is estimated to average 15 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.

Do you agree to proceed with the interview?

YES 1

NO 2

CAPI INSTRUCTION:

DEFAULT SCREEN LANGUAGE TO ENGLISH, BUT INCLUDE A DROP DOWN LIST FOR THE FI TO CHOOSE ENGLISH OR SPANISH.
DISPLAY YES/NO OPTIONS AS RADIO BUTTON, ALLOWING ONLY ONE CHOICE.
DISPLAY OMB NUMBER IN UPPER RIGHT OF SCREEN.
IF RIQ.510 = 2, GO TO RIQ.510CK: “RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE MUST GIVE CONSENT BEFORE THE INTERVIEW CAN BE ADMINISTERED.” WHEN NEXT BUTTON IS PRESSED, CASE CLOSES AS PARTIALLY WORKED.
DISPLAY RESPONDENT NAME FROM *11RIQ.010 OR *11RIQ.045.

INT.001 IS AN INTERPRETER BEING USED FOR INTERVIEW?

YES 1

NO 2 (GO TO THE END

OF THE SECTION)

INT.003 LANGUAGE USED FOR INTERVIEW

AMERICAN SIGN LANGUAGE 1 (INT.013)

CHINESE (CANTONESE) 2 (INT.013)

CHINESE (MANDARIN) 3 (INT.013)

FRENCH 4 (INT.013)

GERMAN 5 (INT.013)

ITALIAN 6 (INT.013)

JAPANESE 7 (INT.013)

KOREAN 8 (INT.013)

RUSSIAN 9 (INT.013)

SPANISH (READER) 10 (INT.013)

VIETNAMESE 11 (INT.013)

OTHER SPECIFY 99

INT.004 ENTER LANGUAGE USED FOR INTERVIEW

_________________________________

INT.013 {DISPLAY INTERPRETER NAMES FROM ALL PREVIOUS INTERVIEWS: SCREENER, RELATIONSHIP, SP, FAMILY QUESTIONNAIRE}

ENTER INTERPRETER NAME INFO

SAME INTERPRETER USED IN OTHER
INTERVIEW FOR HOUSEHOLD 1

NEW INTERPRETER 2 (INT.005)

INT.014 {DISPLAY LIST OF INTERPRETER NAMES FROM SCREENER, RELATIONSHIP, SP AND/OR FAMILY QUESTIONNAIRES}

{INCLUDE “OTHER” AS A SELECTION}

SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME

BOX 4

CHECK ITEM INT.014a:

IF ‘OTHER’ SELECTED IN INT.014, GO TO INT.005.

OTHERWISE, CODE INTERPRETER INFO FROM PREVIOUS INTERVIEW AND GO TO END OF SECTION.

INT.005 HOW WAS INTERPRETER OBTAINED?

ARRANGED BY THE OFFICE 1

RECRUITED DURING VISIT

OR APPOINTMENT 2 (INT.007)

INT.006 SELECT INTERPRETER FROM DROP DOWN LIST OR SELECT “OTHER” AND ENTER INTERPRETER NAME

{DROP DOWN LIST SHOULD HAVE ALL NAMES FROM EVM AND AN “OTHER” TO ALLOW FOR THOSE NAMES THAT HAVE NOT BEEN TRANSFERRED TO INTERVIEWER TABLET}

BOX 6

CHECK ITEM INT.006A:

IF OTHER (SELECTED IN INT.006), GO TO INT.009.

OTHERWISE, GO TO END OF SECTION.

INT.007 SELECT INTERPRETER SOURCE

RELATIVE LIVING IN HOUSEHOLD………… 1

NON-RELATIVE LIVING IN HOUSEHOLD…. 2

NEIGHBOR, RELATIVE OR FRIEND –
NOT IN HOUSEHOLD…………………….… 3 (GO TO THE END

OF THE SECTION)

INT.008 SELECT NAME OF INTERPRETER FROM HOUSEHOLD ROSTER.

{DISPLAY CAPI PULL DOWN LIST FROM HH ROSTER}

BOX 7

CHECK ITEM INT.008A:

GO TO END OF SECTION.

INT.009 ENTER NAME OF INTERPRETER

______________________________________

INT.010 ENTER PHONE # OF INTERPRETER

___ -___ -____

DEMOGRAPHIC BACKGROUND – DMQ - FAM

Target Group:  Head of CPS Family (Non-SP)

 Head of CPS Family Spouse (Non-SP)

BOX 1A

RULES FOR ADMINISTERING THE DEMOGRAPHIC AND OCCUPATION SECTION OF THE FAMILY QUESTIONNAIRE:

A CPS FAMILY INCLUDES INDIVIDUALS AND GROUPS OF INDIVIDUALS WHO ARE 16+ AND RELATED BY BIRTH, MARRIAGE OR ADOPTION. STEP CHILDREN, PARENTS OR SIBLINGS ARE INCLUDED. IT ALSO INCLUDES UNMARRIED PARTNERS IF THEY HAVE A BIOLOGICAL OR ADOPTIVE CHILD IN COMMON. IT DOES NOT INCLUDE UNMARRIED PARTNERS WHO DO NOT HAVE A CHILD IN COMMON, FOSTER PARENTS OR FOSTER CHILDREN. NOTE: A CPS FAMILY CAN BE ONE INDIVIDUAL. NOTE: IF A MINOR WARD IS NOT RELATED TO A HOUSEHOLD MEMBER AGE 18+, THE WARD WILL BE IN THE SAME NHANES FAMILY AS HIS/HER GUARDIAN, BUT A SEPARATE CPS FAMILY.

BOX 1

LOOP 1:

ASK DMQ.128 AND DMQ.141 AS APPROPRIATE FOR NON-SP HEAD OF CPS FAMILY AND NON-SP SPOUSE (RELATIONSHIP OF "MARRIED" IN THE SCREENER) OF HEAD OF CPS FAMILY.

FIRST ASK DMQ.128, AND 141 FOR NON-SP HEAD OF CPS FAMILY.
NEXT, ASK DMQ.141 FOR NON-SP SPOUSE OF HEAD OF CPS FAMILY.
EACH TARGET PERSON SHOULD BE ASKED THIS SECTION ONCE.
IF NO NON-SP HEAD OF CPS FAMILY AND NON-SP SPOUSE, GO TO
END OF SECTION.

DMQ.128 {Were you/Was NON-SP HEAD} born in the United States or a United States territory?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

DMQ.141 Please look at card DMQ1. What is the highest grade or level of school {you have/NON-SP HEAD/NON-SP SPOUSE has} completed or the highest degree {you have/he/she has} received?

HAND CARD DMQ1

READ HAND CARD CATEGORIES IF NECESSARY

Enter highest GRADE OR level of school.

NEVER ATTENDED/KINDERGARTEN

ONLY 0

1ST GRADE 1

2ND GRADE 2

3RD GRADE 3

4TH GRADE 4

5TH GRADE 5

6TH GRADE 6

7TH GRADE 7

8TH GRADE 8

9TH GRADE 9

10TH GRADE 10

11TH GRADE 11

12TH GRADE, NO DIPLOMA 12

HIGH SCHOOL GRADUATE 13

GED OR EQUIVALENT 14

SOME COLLEGE, NO DEGREE 15

ASSOCIATE DEGREE: OCCUPATIONAL,

TECHNICAL, OR VOCATIONAL

PROGRAM 16

ASSOCIATE DEGREE: ACADEMIC

PROGRAM 17

BACHELOR’S DEGREE (EXAMPLE: BA,

AB, BS, BBA) 18

MASTER’S DEGREE (EXAMPLE: MA,

MS, MEng, MEd, MBA) 19

PROFESSIONAL SCHOOL DEGREE

(EXAMPLE: MD, DDS, DVM, JD) 20

DOCTORAL DEGREE (EXAMPLE:

PhD, EdD) 21

REFUSED 77

DON’T KNOW 99

BOX 3

END LOOP 1:

ASK DMQ.128 AND 141 FOR NEXT TARGET PERSON (NON-SP HEAD)
ASK DMQ.141 FOR NEXT TARGET PERSON (NON-SP SPOUSE –
RELATIONSHIP OF "MARRIED" IN THE SCREENER).

IF NO NEXT PERSON, GO TO END OF SECTION.

HELP SCREEN FOR DMQ.141:

School: An institution that advances a person toward an elementary or high school diploma, or a college or professional school degree. Do not count schooling in non-regular schools unless the credits are accepted by regular schools.

Training Programs - Count training received "on the job," in the Armed Forces, or through correspondence school only if it was credited toward a school diploma, high school equivalency (GED), or college degree.

Vocational, Trade, or Business School - Do not include secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered, and other vocational trade or business schools outside the regular school system.

General Educational Development (GED) or High School Equivalency - An exam certified equivalent of a high school diploma. If the person has not actually completed all 4 years of high school, but has acquired his/her GED (high school equivalency based on passing the GED exam), count this and enter code "14."

Adult Education - Adult education classes should not be included as regular school unless such schooling has been counted for credit in a regular school system. If a person has taken adult education classes not for credit, these classes should not be counted as regular school. Adult education courses given in a public school building are part of regular schooling only if their completion can advance a person toward an elementary school certificate, a high school diploma (or GED), or a college degree.

Other School Systems - If the person attended school in another country, in an ungraded school, in a "normal school", under a tutor, or under other special circumstances, ask the respondent to give the nearest equivalent of years in regular U.S. schooling.

GED (General Educational Development): An exam certified equivalent of a high school diploma.

Occupational, Technical, or Vocational Program: Includes secretarial school, mechanical or computer training school, nursing school where a Bachelor's degree is not offered and other trade and business schools outside the regular school system.

College: Any junior college, community college, four-year college or university, nursing school or seminary where a college degree is offered, and graduate school or professional school that is attended after obtaining a degree from a 4-year institution.

Bachelor's Degree: An educational degree given by a college or university to a person who has completed a 4-year course or its equivalent in the humanities or related studies (B.A.) or in the sciences (B.S.).

Doctoral Degree: The highest educational degree given by a college or university to a person who has completed a prescribed course of advanced graduate study. For example—a Doctor of Philosophy (Ph.D.).

HOUSING CHARACTERISTICS – HOQ

Target Group: SPs Family

HOQ.050 I would like to ask you about {your/SP’s} home.

How many rooms are in {your/SP’s} home? Count the kitchen but not any bathrooms, or an unfinished basement, or a laundry room.

CAPI INSTRUCTION:

HARD EDIT: 1-25

|___|___|

ENTER NUMBER OF ROOMS

REFUSED 777777

DON'T KNOW 999999

CAPI INSTRUCTION:

FILL “your” IF RESPONDENT IN FAMILY. FILL “SP’s” IF RESPONDENT NOT IN FAMILY.

SMOKING – SMQ

Target Group: Household

SMQ.460 Now I would like to ask you a few questions about smoking in {your/SP’s} home.

How many people who live in {your/SP’s} home smoke cigarettes, cigars, little cigars, pipes, water pipes, hookah, or any other tobacco product?

INTERVIEWER INSTRUCTION: IF RESPONSE IS NO ONE, ENTER ZERO

|___|___|

ENTER NUMBER OF PERSONS

REFUSED 777

DON'T KNOW 999

HELP SCREEN:

Tobacco products do not include marijuana.

CAPI INSTRUCTION:

ALLOW ‘0’ AS AN ENTRY.

RANGE EDIT: CANNOT BE GREATER THAN # OF PEOPLE IN THE HOUSEHOLD.

IF ‘0’, DK OR RF, GO TO END OF SECTION.

FILL “your” IF RESPONDENT IN FAMILY. FILL “SP’s” IF RESPONDENT NOT IN FAMILY.

SMQ.470 Not counting decks, porches, or detached garages, how many people who live in {your/SP’s} home smoke cigarettes, cigars, little cigars, pipes, water pipes, hookah, or any other tobacco product inside the home?

|___|___|

ENTER NUMBER OF PERSONS

REFUSED 777

DON'T KNOW 999

HELP SCREEN:

Tobacco products do not include marijuana.

CAPI INSTRUCTION:

ALLOW ‘0’ AS AN ENTRY.

HARD EDIT: NUMBER ENTERED IN SMQ.470 MUST BE EQUAL OR LESS THAN SMQ.460.

IF ‘0’, DK OR RF, GO TO END OF SECTION.

FILL “your” IF RESPONDENT IN FAMILY. FILL “SP’” IF RESPONDENT NOT IN FAMILY.

CONSUMER BEHAVIOR – CBQ

Target Group: Family Questionnaire

CBQ.071
Q/U

The next questions are about how much money {your family spends/you spend} on food. First I’ll ask you about money spent at supermarkets or grocery stores. Then, we will talk about money spent at other types of stores. When you answer these questions, please do not include money spent on alcoholic beverages.

During the past 30 days, how much money {did your family/did you} spend at supermarkets or grocery stores? Please include purchases made with food stamps. (You can tell me per week or per month.)

INTERVIEWER INSTRUCTION:

ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

|___|___|___|___|___|___|___|___|___|

ENTER AMOUNT

NO MONEY SPENT 0 (CBQ.101)

REFUSED 7----7 (CBQ.101)

DON'T KNOW 9----9 (CBQ.101)

ENTER UNIT

WEEK 1

MONTH 2

CBQ.081 Was any of this money spent on nonfood items such as cleaning or paper products, pet food, cigarettes or alcoholic beverages?

YES 1

NO 2 (CBQ.101)

REFUSED 7 (CBQ.101)

DON'T KNOW 9 (CBQ.101)

CBQ.091
Q/U

About how much money was spent on nonfood items? (You can tell me per week or per month.)

|___|___|___|___|___|___|___|___|___|

ENTER AMOUNT

HARD EDIT: AMOUNT CANNOT BE MORE THAN
THE AMOUNT ENTERED ON CBQ.071.

REFUSED 7----7 (CBQ.101)

DON'T KNOW 9----9 (CBQ.101)

ENTER UNIT

WEEK 1

MONTH 2

CBQ.101 During the past 30 days, {did your family/did you} spend money on food at stores other than grocery stores? Please do not include money that you have already told me about. Please look at Card CBQ1 which includes some examples of stores other than grocery stores where you might buy food.

HAND CARD CBQ1

YES 1

NO 2 (CBQ.121)

REFUSED 7 (CBQ.121)

DON'T KNOW 9 (CBQ.121)

CBQ.111
Q/U

About how much money {did your family/did you} spend on food at these types of stores? Please do not include money you have already told me about. (You can tell me per week or per month.)

INTERVIEWER INSTRUCTION:

ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

|___|___|___|___|___|___|___|___|___|

ENTER AMOUNT

NO MONEY SPENT 0

REFUSED 7----7 (CBQ.121)

DON'T KNOW 9----9 (CBQ.121)

ENTER UNIT

WEEK 1

MONTH 2

CBQ.121
Q/U

During the past 30 days, how much money {did your family/did you} spend on eating out? Please include money spent in cafeterias at work or at school or on vending machines, for all family members. (You can tell me per week or per month.)

INTERVIEWER INSTRUCTION:

IF RESPONDENT KNOWS ONLY AMOUNT FOR SELF, CODE DK.

ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

|___|___|___|___|___|___|___|___|___|

ENTER AMOUNT

NO MONEY SPENT 0

REFUSED 7----7 (CBQ.131)

DON'T KNOW 9----9 (CBQ.131)

ENTER UNIT

WEEK 1

MONTH 2

CBQ.131
Q/U

During the past 30 days, how much money {did your family/did you} spend on food carried out or delivered? Please do not include money you have already told me about. (You can tell me per week or per month.)

INTERVIEWER INSTRUCTION:

IF RESPONDENT KNOWS ONLY AMOUNT FOR SELF, CODE DK.

ENTER “0” IF SP SAYS NO MONEY WAS SPENT.

|___|___|___|___|___|___|___|___|___|

ENTER AMOUNT

NO MONEY SPENT 0

REFUSED 7----7

DON'T KNOW 9----9

ENTER UNIT

WEEK 1

MONTH 2

BOX 2

CHECK ITEM CBQ.205:

IF THE FAMILY INCLUDES AT LEAST ONE SP AGED 1-15 YEARS OLD, CONTINUE;

OTHERWISE, GO TO THE END OF SECTION.

CBQ.210 Who is the person who does most of the planning or preparing of meals in your family?

CAPI INSTRUCTION:

DISPLAY NAMES, GENDERS, AND AGES OF ALL HOUSEHOLD MEMBERS.
SORT THE LIST BY FAMILY, AND DISPLAY THE FAMILY OF THE CURRENT RESPONDENT FIRST.
WITHIN EACH FAMILY, SORT THE FAMILY MEMBERS BY AGE FROM OLDEST TO YOUNGEST.
BLOCK ALL MEMBERS 10 YEAR OR YOUNGER FROM BEING SELECTED.
ONLY ALLOW ONE PERSON TO BE SELECTED.

INTERVIEWER INSTRUCTION:

SELECT NAME FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

MMP CALCULATION INSTRUCTION

PERSON SELECTED AS FCBS RESPONDENT MUST BE 16 YEARS OR OLDER.

SELECT 1

NOT SELECT 2 (CBQ.240)

REFUSED 7 (CBQ.240)

DON'T KNOW 9 (CBQ.240)

SOFT EDIT:

IF THE SELECTED PERSON IS LESS THAN 18 YEARS OLD, DISPLAY THE FOLLOWING MESSAGE: “PLEASE VERIFY THAT THE PERSON SELECTED IS YOUNGER THAN 18 YEARS OLD.”

SOFT EDIT:

IF CBQ.210 EQUALS 2-NOT SELECT OR DK FOR EVERY HH MEMBER, DISPLAY THE FOLLOWING MESSAGE: “PLEASE VERIFY THAT NO ONE LISTED DOES MOST OF THE PLANNING AND PREPARING OF MEALS IN THE SP’S FAMILY.”

CBQ.220 {Do you/Does he/she} share in the planning or preparing of meals with someone else?

YES 1

NO 2 (CBQ.240)

REFUSED 7 (CBQ.240)

DON'T KNOW 9 (CBQ.240)

CBQ.230 Who is the person who shares in the planning or preparing of meals with {you/him/her}?

CAPI INSTRUCTION:

DISPLAY NAMES, GENDERS, AND AGES OF ALL HOUSEHOLD MEMBERS, EXCEPT THE ONE NAMED IN CBQ.210.
SORT THE LIST BY FAMILY, AND DISPLAY THE FAMILY OF THE CURRENT RESPONDENT FIRST.
WITHIN EACH FAMILY, SORT THE FAMILY MEMBERS BY AGE FROM OLDEST TO YOUNGEST.
BLOCK ALL MEMBERS 10 YEAR OR YOUNGER FROM BEING SELECTED.
ONLY ALLOW ONE PERSON TO BE SELECTED.

INTERVIEWER INSTRUCTION:

SELECT NAME FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

MMP CALCULATION INSTRUCTION

PERSON SELECTED AS FCBS RESPONDENT MUST BE 16 YEARS OR OLDER.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

SOFT EDIT:

IF THE SELECTED PERSON IS LESS THAN 18 YEARS OLD, DISPLAY THE FOLLOWING MESSAGE: “PLEASE VERIFY THAT THE PERSON SELECTED IS YOUNGER THAN 18 YEARS OLD.”

CBQ.240 Who is the person who does most of the shopping for food in your family?

CAPI INSTRUCTION:

DISPLAY NAMES, GENDERS, AND AGES OF ALL HOUSEHOLD MEMBERS.
SORT THE LIST BY FAMILY, AND DISPLAY THE FAMILY OF THE CURRENT RESPONDENT FIRST.
WITHIN EACH FAMILY, SORT THE FAMILY MEMBERS BY AGE FROM OLDEST TO YOUNGEST.
BLOCK ALL MEMBERS 10 YEAR OR YOUNGER FROM BEING SELECTED.
ONLY ALLOW ONE PERSON TO BE SELECTED.

INTERVIEWER INSTRUCTION:

SELECT NAME FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

MMP CALCULATION INSTRUCTION

PERSON SELECTED AS FCBS RESPONDENT MUST BE 16 YEARS OR OLDER.

SELECT 1

NOT SELECT 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

SOFT EDIT:

IF THE SELECTED PERSON IS LESS THAN 18 YEARS OLD, DISPLAY THE FOLLOWING MESSAGE: “PLEASE VERIFY THAT THE PERSON SELECTED IS YOUNGER THAN 18 YEARS OLD.”

SOFT EDIT:

IF CBQ.240 EQUALS 2-NOT SELECT OR DK FOR EVERY HH MEMBER, DISPLAY THE FOLLOWING MESSAGE: “PLEASE VERIFY THAT NO ONE LISTED DOES MOST OF THE SHOPPING FOR FOOD IN THE SP’S FAMILY.”

CBQ.250 {Do you/Does he/she} share in the shopping for food with someone else?

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

CBQ.260 Who is the person who shares the food shopping with {you/him/her}?

CAPI INSTRUCTION:

DISPLAY NAMES, GENDERS, AND AGES OF ALL HOUSEHOLD MEMBERS, EXCEPT THE ONE NAMED IN CBQ.240.
SORT THE LIST BY FAMILY, AND DISPLAY THE FAMILY OF THE CURRENT RESPONDENT FIRST.
WITHIN EACH FAMILY, SORT THE FAMILY MEMBERS BY AGE FROM OLDEST TO YOUNGEST.
BLOCK ALL MEMBERS 10 YEAR OR YOUNGER FROM BEING SELECTED.
ONLY ALLOW ONE PERSON BEING SELECTED.

INTERVIEWER INSTRUCTION:

SELECT NAME FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

MMP CALCULATION INSTRUCTION

PERSON SELECTED AS FCBS RESPONDENT MUST BE 16 YEARS OR OLDER.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

SOFT EDIT:

IF THE SELECTED PERSON IS LESS THAN 18 YEARS OLD, DISPLAY THE FOLLOWING MESSAGE: “PLEASE VERIFY THAT THE PERSON SELECTED IS YOUNGER THAN 18 YEARS OLD.”

INCOME – INQ

Target Group: SP, Family, Household

Definitions for Testers:

NHANES FAMILY: Everyone related to each other by blood, marriage or a marriage-like relationship including partners and foster children.

FAMILY: Individuals and groups of individuals who are related by birth, marriage or adoption. Step children, parents or siblings are included. It also includes unmarried partners if they have a biological or adoptive child in common. It does not include unmarried partners who do not have a child in common, foster parents or foster children. Note: Individuals living alone or with other unrelated individuals are referred to as “unrelated individuals”.

BOX 7

ASK INQ.200 – 310 FOR EACH CPS FAMILY IN THE NHANES FAMILY IN THE HOUSEHOLD.

FOR THE PURPOSE OF ADMINISTERING THE QUESTIONS ABOUT TOTAL INCOME:

 A FAMILY INCLUDES INDIVIDUALS AND GROUPS OF INDIVIDUALS WHO ARE RELATED BY BIRTH, MARRIAGE OR ADOPTION. STEP CHILDREN, PARENTS OR SIBLINGS ARE INCLUDED. IT ALSO INCLUDES UNMARRIED PARTNERS IF THEY HAVE A BIOLOGICAL OR ADOPTIVE CHILD IN COMMON. IT DOES NOT INCLUDE UNMARRIED PARTNERS WHO DO NOT HAVE A CHILD IN COMMON, FOSTER PARENTS OR FOSTER CHILDREN. NOTE: INDIVIDUALS LIVING ALONE OR WITH OTHER UNRELATED INDIVIDUALS ARE REFERRED TO AS “UNRELATED INDIVIDUALS”.

 TOTAL INCOME IS ADMINISTERED FOR EACH CPS FAMILY IN THE NHANES FAMILY AND THEN FOR THE ENTIRE HOUSEHOLD.

INQ.200 Now I am going to ask about the total income for {you/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} in {LAST CALENDAR YEAR}, including income from all sources such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Can you tell me that amount before taxes?

CAPI INSTRUCTIONS:

 DISPLAY "you" IF ONLY 1 PERSON IN THE FAMILY.

 DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.

|___|___|___|___|___|___|___|___|___|___| (GO TO INQ.235)

ENTER AMOUNT

REFUSED 77777777777 (INQ.220)

DON'T KNOW 99999999999 (INQ.220)

CAPI INSTRUCTION:

 REQUIRE DOUBLE ENTRY OF INCOME. (DOUBLE ENTRY QUESTION NUMBER: INQ.216)

 SCREEN SHOULD READ:

DOUBLE ENTRY OF INCOME REQUIRED.

 IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.

 IF INQ.200 NOT DK OR RF, SET FAMILY ANNUAL INCOME THRESHOLD = INQ.200.

HELP SCREEN:

Income: Income is an important factor in the analysis of the health information we collect. Access to medical care depends in part on a person or family's financial resources. This information helps us learn if people in one income group use certain types of medical services more or less than people in other income groups. We may also learn if one income group has certain medical conditions more than other income groups.

Wages and Salaries: Include tips, bonuses, overtime, commissions, Armed Forces pay, special cash bonuses and subsistence allowances.

Social Security: Social Security (SS) payments are received by persons who have worked long enough in employment that had SS deductions taken from their salary in order to be entitled to payments. SS payments may be made to the spouse or dependent children of a covered worker. SS also pays benefits to student dependents (under 19 years of age) of eligible social security annuitants who are disabled or deceased.

Retirement Benefits: Employment benefit that provides income payments to employees upon their retirement. Pension plans provide benefits to employees who have met specified criteria, normally age and/or length of service requirements. The two main types of pension plans are:

Defined benefit plans - an employer's cost is not predetermined, but the benefit is; and

Defined contribution - the employer's cost is predetermined, but the benefit depends on how much the employee contributes, investment gains and losses, etc.

Include in this item income from 401 K, IRA's, annuities, paid-up life insurance policies and KEOGH accounts.

INQ.220 You may not be able to give us an exact figure for {your/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} income, but can you tell me if this income in {LAST CALENDAR YEAR} was . . .

PROBE: Income is important in using the health information we collect. For example, it helps us to learn whether persons in one income group use certain types of medical services or have certain health conditions more or less often than those in another income group.

CAPI INSTRUCTIONS:

 DISPLAY "your" IF ONLY 1 PERSON IN THE FAMILY.

 DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.

$20,000 or more, or 1

less than $20,000? 2

REFUSED 7 (BOX 9)

DON'T KNOW 9 (INQ.235)

HELP SCREEN:

INQ.230
a/b

Now, look at card {INQ1/INQ2}. Of the income groups listed on this card, can you tell me which letter best represents {your/NAME(S) OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} income in {LAST CALENDAR YEAR}?

HAND CARD {INQ1/INQ2}

ENTER LETTER(S) CORRESPONDING TO TOTAL COMBINED FAMILY INCOME.

CAPI INSTRUCTIONS:

 DISPLAY "your" IF ONLY 1 PERSON IN THE FAMILY.

 DISPLAY "NAMES OF FIRST/NEXT FAMILY MEMBERS" IF THERE IS MORE THAN 1 PERSON IN THE FAMILY.

 IF $20,000 OR MORE, DISPLAY HAND CARD INQ1 AND LETTERS U-WW.

 IF LESS THAN $20,000, DISPLAY HAND CARD INQ2 AND LETTERS A-T.

 IF INQ.230 NOT EQUAL TO DK OR RF, SET FAMILY ANNUAL INCOME THRESHOLD = LOWER VALUE IN RANGE.

|___|___|

REFUSED 7777

DON'T KNOW 9999

HELP SCREEN:

INQ.235 What is the total income received last month, {LAST CALENDAR MONTH & CURRENT CALENDAR

YEAR} by {you/NAMES OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS}} before taxes?

[Please include income from all sources such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth.]

INTERVIEWER INSTRUCTION:

IF SP DOES NOT KNOW INCOME OF OTHER FAMILY MEMBERS, ENTER DON’T KNOW.

SOFT EDIT: AMOUNT REPORTED IN INQ.235 (MONTHLY INCOME) GREATER THAN OR EQUAL TO THE AMOUNT REPORTED IN INQ.200 (ANNUAL INCOME), DISPLAY SOFT EDIT MESSAGE: “INTERVIEWER, YOU HAVE RECORDED AN ANNUAL TOTAL INCOME OF {ANNUAL INCOME REPORTED IN INQ.200} AND LAST MONTH’S TOTAL INCOME WAS RECORDED AS {TOTAL MONTHLY INCOME REPORTED IN INQ.235}. PLEASE CONFIRM WITH SP THAT LAST MONTH’S INCOME OF {TOTAL MONTHLY INCOME REPORTED IN INQ.235} IS CORRECT.

CAPI INSTRUCTION:

 REQUIRE DOUBLE ENTRY OF INCOME (INQ.236)

 SCREEN SHOULD READ:

DOUBLE ENTRY OF INCOME REQUIRED.

IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.
FOR THE CALENDAR FILL: IF CURRENT MONTH IS JANUARY THE PAST CALENDAR YEAR WILL BE SHOWN

|___|___|___|___|___|___|___|___|___| (INQ.300)

ENTER AMOUNT

REFUSED 77777777777

DON'T KNOW 99999999999

INQ.238 You may not be able to give us an exact figure, but can you tell me if the income for {you/NAMES OF OTHER FAMILY/your family} in {LAST CALENDAR MONTH & CURRENT CALENDAR YEAR} was . . .

{185% of monthly poverty

level} or less, or 1

more than {185% monthly poverty level}? 2 (INQ.300)

REFUSED 7

DON'T KNOW 9

PROBE: (That would be {12 times 185% monthly poverty level}} per year.)

CAPI INSTRUCTION:

 Fill 185% of the monthly poverty level based on family size:

For family sizes 1-8, use the numbers in the 3^rd column in the appropriate table below.

For family size > 8, with each additional family member:

For the 48 contiguous states and the District of Columbia, fill {[$6,802+($691* # of additional person past 8)] round to nearest 100s}.

 Fill 185% of the annual poverty level based on family size in the PROBE:

For family sizes 1-8, use the numbers in the 5^th column in the appropriate table below.

For family size > 8, with each additional member:,

For the 48 contiguous states and the District of Columbia, fill {[$81,622+($8,288 * # of additional person past 8)] round to nearest 100s}.

TABLE 1A. 185% POVERTY LEVELS FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA

Persons in Family	185% monthly poverty level		185% annual poverty level
Persons in Family	Raw Number¹	Rounded to nearest 100s²	Raw Number³	Rounded to nearest 100s⁴
1	1,967	2,000	23,606	23,600
2	2,658	2,700	31,894	31,900
3	3,349	3,300	40,182	40,200
4	4,039	4,000	48,470	48,500
5	4,730	4,700	56,758	56,800
6	5,421	5,400	65,046	65,000
7	6,111	6,100	73,334	73,300
8	6,802	6,800	81,622	81,600

¹: For each additional person past 8, the value is $6,802 + ($691 * # of additional persons past 8)

²: These are the numbers to be used in the response category fills.

³: For each additional person past 8, the value is $81,622 + ($8,288 * # of additional persons past 8)

⁴: These are the numbers to be used in the probe fills.

INQ.241 Was it more or less than {130% monthly poverty level}?

{130% monthly poverty level} OR LESS,

OR 1

MORE THAN {130% of monthly poverty

level} 2

REFUSED 7

DON'T KNOW 9

PROBE: {That would be 12 times 130% annual poverty level per year.}

CAPI INSTRUCTION:

 Fill 130% of the monthly poverty level based on family size:

For family sizes 1-8, use the numbers in the 3^rd column in the appropriate table below.

For family size > 8, with each additional family member:

For the 48 contiguous states and the District of Columbia, fill {[$4,780+($485* # of additional person past 8)] round to nearest 100s}.

 Fill 130% of the annual poverty level based on family size in the PROBE.

For family sizes 1-8, use the numbers in the 5^th column in the appropriate table below.

For family size > 8, with each additional member:

For the 48 contiguous states and the District of Columbia,fill {[$57,356+($5,824* # of additional person past 8)] round to nearest 100s}

TABLE 2A. 130% POVERTY LEVELS FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA

Persons in Family	130% monthly poverty level		130% annual poverty level
Persons in Family	Raw Number¹	Rounded to nearest 100s²	Raw Number³	Rounded to nearest 100s⁴
1	1,382	1,400	16,588	16,600
2	1,868	1,900	22,412	22,400
3	2,353	2,400	28,236	28,200
4	2,838	2,800	34,060	34,100
5	3,324	3,300	39,884	39,900
6	3,809	3,800	45,708	45,700
7	4,294	4,300	51,532	51,500
8	4,780	4,800	57,356	57,400

¹: For each additional person past 8, the value is $4,780 + ($485 * # of additional persons past 8)

²: These are the numbers to be used in the text of question and response category fills.

³: For each additional person past 8, the value is $57,356 + ($5,824 * # of additional persons past 8)

⁴: These are the numbers to be used in the probe fills.

INQ.300 Do {you/NAMES OF OTHER FAMILY/you and NAMES OF FAMILY MEMBERS} have more than $20,000 in savings at this time? Please include money in all types of accounts {you/your family} may have. There are some examples of the types of accounts on card INQ3.

HAND CARD INQ3

CAPI INSTRUCTION:

DISPLAY “you” FOR SINGLE-PERSON FAMILY; DISPLAY “NAMES OF OTHER FAMILY”/”you and NAMES OF FAMILY MEMBERS” FOR MULTI-PERSONS FAMILY.

YES 1 (BOX 9)

NO 2

REFUSED 7 (BOX 9)

DON'T KNOW 9 (BOX 9)

INQ.310 Next, look at card INQ4. Which letter on this card best represents the total savings or cash assets at this time for {you/NAMES OF OTHER FAMILY/your family}?

HAND CARD INQ4

|___| ENTER LETTER

REFUSED 7

DON'T KNOW 9

A: $0 - $3,000

B: $3,001 - $5,000

C: $5,001 - $10,000

D: $10,001 - $15,000

E: $15,001 - $20,000

BOX 9

CHECK ITEM INQ.240:

IF THERE IS MORE THAN ONE NHANES FAMILY IN THE HOUSEHOLD, CONTINUE.

OTHERWISE, GO TO END OF SECTION.

BOX 9A

CHECK ITEM INQ.249:

HOUSEHOLD INCOME (INQ.250, 260, 270) SHOULD ONLY BE ASKED ONCE OF THE FIRST FAMILY TO COMPLETE THE FAMILY QUESTIONNAIRE REGARDLESS OF FAMILY NUMBER. IT SHOULD NOT BE ASKED TWICE FOR A HOUSEHOLD AND SHOULD NOT BE MISSED IF ONE FAMILY DOES NOT COMPLETE THE FAMILY QUESTIONNAIRE.

INQ.250 Now I am going to ask you about the total household income for the persons we have talked about plus {NAMES OF ALL OTHER PERSONS IN ADDITIONAL NHANES FAMILIES} in {LAST CALENDAR YEAR}, including income from all sources such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Can you tell me that amount before taxes?

$ |___|___|___|___|___|___|___|___|___| (GO TO END OF SECTION)

ENTER AMOUNT

REFUSED 77777777777 (INQ.260)

DON'T KNOW 99999999999 (INQ.260)

CAPI INSTRUCTION:

 REQUIRE DOUBLE ENTRY OF INCOME (INQ.255)

 SCREEN SHOULD READ:

DOUBLE ENTRY OF INCOME REQUIRED.

 IF ENTRIES DO NOT MATCH, DISPLAY BOTH ENTRIES. INTERVIEW SHOULD SELECT ENTRY TO CORRECT.

HELP SCREEN:

Wages and Salaries: Include tips, bonuses, overtime, commissions, Armed Forces pay, special cash bonuses and subsistence allowances.

Defined benefit plans - an employer's cost is not predetermined, but the benefit is; and

Defined contribution - the employer's cost is predetermined, but the benefit depends on how much the employee contributes, investment gains and losses, etc.

Include in this item income from 401 K, IRA's, annuities, paid-up life insurance policies and KEOGH accounts.

INQ.260 You may not be able to give us an exact figure for your total household income, but can you tell me if this income in {LAST CALENDAR YEAR} was . . .

PROBE: Income is important in analyzing the health information we collect. For example, this information helps us to learn whether persons in one income group use certain types of medical services or have certain conditions more or less often than those in another group.

$20,000 or more, or 1

less than $20,000? 2

REFUSED 7 (END OF SECTION)

DON'T KNOW 9 (END OF SECTION)

HELP SCREEN:

INQ.270a/b

Now, look at card {INQ1/INQ2}. Of these income groups, can you tell me which letter best represents your total household income in {LAST CALENDAR YEAR}?

HAND CARD {INQ1/INQ2}

ENTER LETTER(S) CORRESPONDING TO TOTAL COMBINED HOUSEHOLD INCOME.

|___|___|

REFUSED 77

DON'T KNOW 99

CAPI INSTRUCTION:

IF $20,000 OR MORE, DISPLAY HAND CARD INQ1 AND LETTERS U-WW.

IF LESS THAN $20,000, DISPLAY HAND CARD INQ2 AND LETTERS A-T.

HELP SCREEN:

FOOD SECURITY – FSQ

Target Group: Household

CAPI DISPLAY INSTRUCTIONS FOR ALL QUESTIONS IN SECTION:

1. IF ONLY ONE PERSON IN HOUSEHOLD

- FOR {YOU/YOUR HOUSEHOLD}, DISPLAY “YOU”

- FOR {I/WE}, {MY/OUR}, DISPLAY “I” AND “MY”

- FOR {YOU/YOU OR OTHER ADULTS IN YOUR HOUSEHOLD}, DISPLAY “YOU”.

2. IF MORE THAN ONE PERSON IN HOUSEHOLD

- FOR {YOU/YOUR HOUSEHOLD}, DISPLAY “YOUR HOUSEHOLD”

- FOR {I/WE}, {MY/OUR}, DISPLAY “WE” AND “OUR”

- FOR {YOU/YOU OR OTHER ADULTS IN YOUR HOUSEHOLD}, DISPLAY “YOU OR OTHER ADULTS IN YOUR HOUSEHOLD”.

FSQ.032 Look at card FSQ1. I am going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for {you/your household} in the last 12 months, that is since {DISPLAY CURRENT MONTH AND LAST YEAR}.

HAND CARD FSQ1

CAPI INSTRUCTION:

IF ITEM CHANGED, CHECK MEC COMPONENT.

RESPONSES TO FSQ032A, B, AND C: OFTEN TRUE = 1, SOMETIMES TRUE = 2, NEVER TRUE = 3, REFUSED = 7, DON’T KNOW = 9

a. {I/We} worried whether {my/our} food would run out before {I/we} got money

to buy more. ____

b. The food that {I/we} bought just didn’t last, and {I/we} didn’t have enough

money to get more food. ____

c. {I/We} couldn’t afford to eat balanced meals. ____

HELP SCREEN:

Balanced Meal: A balanced meal includes all the types of food that you think should be in a healthy meal. For example, a starch like potatoes or rice, vegetables or fruit and some protein like meat, fish, cheese or eggs.

BOX 1

IF RESPONSE TO FSQ032 a, b, OR c, IS CODE 1 OR 2 (OFTEN TRUE OR SOMETIMES TRUE), CONTINUE.

OTHERWISE, GO TO FSQ.151.

FSQ.041 In the last 12 months, since last {DISPLAY CURRENT MONTH AND LAST YEAR}, did {you/you or other adults in your household} ever cut the size of your meals or skip meals because there wasn’t enough money for food?

YES 1

NO 2 (FSQ.061)

REFUSED 7 (FSQ.061)

DON’T KNOW 9 (FSQ.061)

HELP SCREEN:

FSQ.052 How often did this happen?

Almost every month, 1

some months but not every month, or 2

in only 1 or 2 months? 3

REFUSED 7

DON’T KNOW 9

FSQ.061 In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FSQ.071 [In the last 12 months], were you ever hungry but didn’t eat because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FSQ.081 [In the last 12 months], did you lose weight because there wasn’t enough money for food?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

BOX 2

CHECK ITEM FSQ.083:

IF RESPONSE TO FSQ.041, 061, 071, OR 081 IS CODE 1 (YES), CONTINUE.

OTHERWISE GO TO FSQ.151.

FSQ.092 [In the last 12 months], did {you/you or other adults in your household} ever not eat for a whole day because there wasn’t enough money for food?

YES 1

NO 2 (FSQ.151)

REFUSED 7 (FSQ.151)

DON’T KNOW 9 (FSQ.151)

HELP SCREEN:

FSQ.102 How often did this happen?

Almost every month, 1

some months but not every month, or 2

in only 1 or 2 months? 3

REFUSED 7

DON’T KNOW 9

FSQ.151 [In the last 12 months], did {you/you or any member of your household} ever get emergency food from a church, a food pantry, or a food bank, or eat in a soup kitchen?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

HELP SCREEN:

Community Kitchen: A place you went to eat because you didn’t have money for food. Do not include a place you went to for social reasons, such as, a senior center or a place you went to for shelter because of something like a hurricane or flood.

BOX 5

CHECK ITEM FSQ.155B:

IF THE HOUSEHOLD INCLUDES:

**A CHILD AGED 5 YEARS OR UNDER, OR IN AN AGE RANGE THAT INCLUDES AGE 5 AND UNDER

** A FEMALE BETWEEN AGES 12 AND 59, OR IN AN AGE RANGE THAT INCLUDES ANY AGES BETWEEN 12 AND 59) CONTINUE

OTHERWISE, GO TO FSQ.755.

FSQ.760 Next are a few questions about the WIC program, that is, the Women, Infants and Children program.

Did {you/you or anyone who lives here} receive WIC benefits in the past 30 days? {Here is the list of children 5 years and younger and women ages 12 to 59 years who live here, let me read it to you.}

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL CHILDREN AGES 5 AND UNDER, AND WOMEN AGES 12 TO 59 IN THE HOUSEHOLD, AND HOUSEHOLD MEMBERS WITH UNKNOWN AGE OR GENDER.

CAPI INSTRUCTION:

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “Here is the list of children 5 years and younger and women ages 12 to 59 years who live here, let me read it to you.”

HELP SCREEN:

WIC: WIC is short for the Special Supplemental Food Program for Women, Infants, and Children. This program provides food assistance and nutritional screening to low-income pregnant and postpartum women and their infants, as well as to low-income children up to age 5.

YES 1

NO 2 (FSQ.162)

REFUSED 7 (FSQ.162)

DON’T KNOW 9 (FSQ.162)

BOX 5AA

CHECK ITEM FSQ.765:

IF FSQ.760 = 1 AND ONLY ONE PERSON IN HOUSEHOLD, FLAG PERSON AS RECEIVING WIC IN FSQ.770, GO TO BOX 5BB.

OTHERWISE CONTINUE.

FSQ.770 Who in the household has received WIC benefits in the past 30 days?

PROBE: Anyone else?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL CHILDREN AGES 5 AND UNDER, AND WOMEN AGES 12 TO 59 IN THE HOUSEHOLD, AND HOUSEHOLD MEMBERS WITH UNKNOWN AGE OR GENDER. ALL FIELDS SHOULD BE BLANK WHEN SCREEN FIRST LOADS. AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

INTERVIEWER INSTRUCTION:

SELECT NAME(S) FROM ROSTER

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

HARD EDIT:

IF CODE=2 FOR ALL MEMBERS IN ROSTER, DISPLAY THE FOLLOWING MESSAGE TO VERIFY THE ANSWER TO FSQ.770:

“You said that someone who lives here has received WIC in the last 30 days, is that correct?”

IF YES, GO BACK TO FSQ.770 AND ASK: “Who was that?” WITH ROSTER DISPLAYED.

IF NO, GO BACK TO CODE FSQ.760 AS ‘NO’.

BOX 5BB

CHECK ITEM FSQ.775:

GO TO FSQ.755.

FSQ.162 In the last 12 months, did {you/you or any member of your household} receive benefits from the WIC program?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

FSQ.755 The next questions are about SNAP, the Supplemental Nutrition Assistance Program, also known as the Food Stamp Program. SNAP benefits are provided on a food stamp benefit card {called the {DISPLAY STATE NAME FOR EBT CARD} card in STATE}/or EBT card}.

Do {you/you or anyone in your household} currently get SNAP or Food Stamps? This includes any SNAP benefits or Food Stamps, even if the amount is small and even if the benefits are received on behalf of children in the household.

CAPI INSTRUCTIONS:

INSERT “OR EBT CARD” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD AND STATE NAME IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

YES 1

NO 2 (FSQ.855)

REFUSED 7 (FSQ.855)

DON’T KNOW 9 (FSQ.855)

BOX 6

CHECK ITEM FSQ.785:

IF FSQ.755 = 1 AND ONLY ONE PERSON IN HOUSEHOLD, FLAG PERSON AS RECEIVING SNAP IN FSQ.790, GO TO FSQ.795.

OTHERWISE CONTINUE.

FSQ.790 Who in the household is currently on the {DISPLAY STATE NAME FOR EBT CARD} card}/or EBT card} to get Food Stamps? Here is the list of people who live here, let me read it to you.

PROBE: Is anyone else on the card?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL HOUSEHOLD MEMBERS.

ALL FIELDS SHOULD BE BLANK WHEN SCREEN FIRST LOADS. AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

INTERVIEWER INSTRUCTION:

READ NAMES OF ALL HOUSEHOLD MEMBERS TO THE RESPONDENT

SELECT NAME(S) FROM ROSTER

CAPI INSTRUCTIONS:

INSERT “EBT CARD” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

HARD EDIT:

IF NO ONE IN THE ROSTER WAS SELECTED, DISPLAY THE FOLLOWING MESSAGE TO VERIFY THE ANSWER TO FSQ.790:

“You said someone who lives here is currently getting Food Stamps. Is that correct?”

IF YES, GO BACK TO FSQ.790 AND ASK: “Who was that?” WITH ROSTER DISPLAYED.

IF NO, GO BACK TO CODE FSQ.755 AS ‘NO’.

FSQ.795 During the past 12 months, for how many months did {you/you, NAME(S)/NAME(S)} get Food Stamps?

CAPI INSTRUCTION:

FOR EVERY HH MEMBER WITH “SELECT (CODE “1”)” IN FSQ.790, ENABLE A FIELD FOR INTERVIEWER TO ENTER THE NUMBER OF MONTHS

FILL FOR EVERY HH MEMBER WITH “SELECT (CODE “1”) IN FSQ.790.

INTERVIEWER INSTRUCTION:

ENTER ‘1’ FOR LESS THAN ONE MONTH PARTICIPATION

|___|___|

ENTER NUMBER OF MONTHS

REFUSED 77

DON'T KNOW 99

HARD EDIT:

INPUT INVALID. VALUE NOT IN RANGE 1-12.

IF MONTHS ENTERED IS GREATER THAN AGE OF HH MEMBER DISPLAY: RESPONSE CAN NOT BE GREATER THAN PERSON’S AGE.

BOX 7

CHECK ITEM FSQ.800:

IF ONLY ONE PERSON WITH “SELECTED” IN FSQ.790, GO TO FSQ.810.

OTHERWISE CONTINUE.

FSQ.805 Are {you/you, NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.790/ NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.790} getting Food Stamps on the same {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

YES 1

NO 2 (FSQ.825)

REFUSED 7

DON’T KNOW 9

FSQ.810

FSQ.811

FSQ.812

On what date were food stamps last put on {your/their/her/his} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE WITHIN PAST 31 DAYS OF CURRENT DATE. IF THE “DAY” FIELD IS DK/RF, THEN THE MONTH/YEAR ENTERED MUST BE WITHIN PAST 1 MONTH OF CURRENT MONTH.

INTERVIEWER INSTRUCTION:

PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.815 In {MONTH FROM FSQ.810 /that last time}, what amount in food stamps was put on {your/their/her/his} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “MONTH FROM FSQ.810” IF MONTH FILED FSQ.810 IS NOT MISSING, RF OR DK.

INSERT “THAT LAST TIME” IF MONTH FILED FSQ.810 IS MISSING, RF OR DK.

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

BOX 8

CHECK ITEM FSQ.820:

IF ALL HH MEMBERS ARE MARKED “SELECT” ON FSQ.790, GO TO THE END OF SECTION.

OTHERWISE, CONTINUE WITH FSQ.855

FSQ.825 Among {you and NAME(S) OF ALL HH MEMBER WITH “SELECT” IN FSQ.790/ NAME(S) OF ALL HH MEMBER WITH “SELECT” IN FSQ.790}, how many {DISPLAY STATE NAME FOR EBT CARD} /EBT} cards are there?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: RESPONSE CANNOT BE ZERO, AND CANNOT BE MORE THAN THE NUMBER OF PEOPLE “SELECTED (CODE 1)” IN FSQ.790.

|___|___|

NUMBER OF CARDS

REFUSED 77

DON’T KNOW 99

BOX 9

CHECK ITEM FSQ.830:

IF FSQ.825 = DK OR RF, THEN ALLOCATE EACH PERSON WITH ONE CARD, THEN SKIP TO FSQ.840.

IF THE NUMBER OF CARDS EQUALS TO THE NUMBER OF PERSONS LISTED “SELECT” ON FSQ.790, ALLOCATE EACH PERSON WITH ONE CARD, THEN SKIP TO FSQ.840.

OTHERWISE CONTINUE.

FSQ.835 Can you tell me who is on card {#}?

CAPI INSTRUCTIONS:

DISPLAY A GRID SO INTERVIEWER CAN ALLOCATE EACH HH MEMBERS WITH “SELECT” IN FSQ.790 TO EACH OF THE CARDS. EACH CARD SHOULD ALLOW MULTIPLE PERSONS BE SELECTED INTO.

FOR EXAMPLE:

Name	Card 1	Card 2	Card 3
John Doe
Jane Doe
Bobby Jones

HARD EDIT: EACH HH MEMBERS WITH “SELECT” IN FSQ.790 SHOULD BELONG TO ONE CARD, AND ONE CARD ONLY. IF NO MEMBER BELONGS TO A CARD, GO BACK TO FSQ.825 AND CORRECT THE NUMBER OF CARDS.

BOX 10

LOOP 1:

ASK FSQ.840 - FSQ.845 FOR EACH CARD.

FSQ.840

FSQ.841

FSQ.842

On what date were food stamps last put on {your/NAME’S(S’) ON EACH CARD} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE WITHIN PAST 31 DAYS OF CURRENT DATE. IF THE “DAY” FIELD IS DK/RF, THEN THE MONTH/YEAR ENTERED MUST BE WITHIN PAST 1 MONTH OF CURRENT MONTH.

INTERVIEWER INSTRUCTION:

PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.845 In {MONTH FROM FSQ.840/that last time}, what amount in food stamps was put on {your/their/his/her} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “MONTH FROM FSQ.840” IF MONTH FILED FSQ.840 IS NOT MISSING, RF OR DK.

INSERT “THAT LAST TIME” IF MONTH FILED FSQ.840 IS MISSING, RF OR DK.

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

BOX 11

END LOOP 1:

ASK FSQ.840 - FSQ.845 FOR SECOND CARD.

IF INFORMATION COLLECTED FOR ALL CARDS, GO TO BOX12.

BOX 12

CHECK ITEM FSQ.850:

IF ALL HH MEMBERS ARE MARKED “SELECT” ON FSQ.790, GO TO THE END OF SECTION.

OTHERWISE, CONTINUE WITH FSQ.870.

FSQ.870 In the last 12 months, did {you/you or NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790/ NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790} get Food Stamps, even if only for one month? This includes any SNAP benefits or Food Stamps received in the past year, even if the amount was small or if they were received on behalf of children in the household.

CAPI INSTRUCTIONS:

IF FSQ.755 = NO, REFUSED, OR DON’T KNOW (NO ONE IN THE HH IDENTIFIED AS “CURRENT SNAP RECIPIENT”), THEN DISPLAY THE QUESTION AS:

“In the last 12 months, did {you/ you or anyone in your household} get Food Stamps, even if only for one month?” {(Here is the list of people who live here, let me read it to you.)}

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS ENCLOSED IN PARENTHESES.

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “(Here is the list of people who live here, let me read it to you.)”

YES 1

NO 2 (FSQ.945)

REFUSED 7 (FSQ.945)

DON’T KNOW 9 (FSQ.945)

BOX 13

CHECK ITEM FSQ.875:

IF FSQ.870 = 1 AND ONLY ONE PERSON IN HOUSEHOLD OR ONE PERSON THAT’S “NOT SELECTED (CODE 2)” IN FSQ.790, FLAG PERSON AS RECEIVING SNAP IN FSQ.880, GO TO FSQ.885.

OTHERWISE CONTINUE.

FSQ.880 Among {you and NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790/NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN FSQ.790}, who was on the {DISPLAY STATE NAME FOR EBT CARD}/or EBT} card to get Food Stamps in the past 12 months?

PROBE: Was anyone else on the card?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL HOUSEHOLD MEMBERS WITH “NOT SELECTED (CODE “2”)” IN FSQ.790.

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

INTERVIEWER INSTRUCTION:

SELECT NAME(S) FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF FSQ.755 = NO, REFUSED, OR DON’T KNOW (NO ONE IN THE HH IDENTIFIED AS “CURRENT SNAP RECIPIENT”), THEN DISPLAY THE QUESTION AS:

“Who in the household was on the {DISPLAY STATE NAME FOR EBT CARD} card}/or EBT card} to get Food Stamps in the past 12 months? (Here is the list of people who live here, let me read it to you.”)

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS ENCLOSED IN PARENTHESES.

HARD EDIT:

IF CODE=2 FOR ALL MEMBERS IN ROSTER, DISPLAY THE FOLLOWING MESSAGE TO VERIFY THE ANSWER TO FSQ.880:

“You said someone who lives here got Food Stamps in the past 12 months. Is that correct?”

IF YES, GO BACK TO FSQ.880 AND ASK: “Who was that?” WITH ROSTER DISPLAYED.

IF NO, GO BACK TO CODE FSQ.870 AS ‘NO’.

FSQ.885 During the past 12 months, for how many months did {you/{NAME(S)} get Food Stamps?

CAPI INSTRUCTION:

FOR EVERY HH MEMBER WITH “SELECT (CODE “1”)” IN FSQ.880, ENABLE A FIELD FOR INTERVIEWER TO ENTER THE NUMBER OF MONTHS

INTERVIEWER INSTRUCTION:

ENTER ‘1’ FOR LESS THAN ONE MONTH PARTICIPATION

|___|___|

ENTER NUMBER OF MONTHS

REFUSED 77

DON'T KNOW 99

HARD EDIT:

INPUT INVALID. VALUE NOT IN RANGE 1-12. IF MONTHS ENTERED IS GREATER THAN AGE OF HH MEMBER DISPLAY: RESPONSE CAN NOT BE GREATER THAN PERSON’S AGE.

BOX 14

CHECK ITEM FSQ.890:

IF ONLY ONE PERSON WITH “SELECTED” IN FSQ.880, GO TO FSQ.900.

OTHERWISE CONTINUE.

FSQ.895 Did {you and NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.880/ NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.880} get Food Stamps on the same {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

YES 1

NO 2 (FSQ.915)

REFUSED 7

DON’T KNOW 9

FSQ.900

FSQ.901

FSQ.902

On what date were food stamps last put on {your/their/her/his} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE WITHIN PAST 12 MONTHS OF CURRENT MONTH.

INTERVIEWER INSTRUCTION:

PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.905 In {MONTH FROM FSQ.900 /that last time}, what amount in food stamps was put on {your/their/his/her} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “MONTH FROM FSQ.900” IF MONTH FIELD FSQ.900 IS NOT MISSING, RF OR DK.

INSERT “THAT LAST TIME” IF MONTH FILED FSQ.900 IS MISSING, RF OR DK.

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

BOX 15

CHECK ITEM FSQ.910:

IF ALL HH MEMBERS ARE MARKED “SELECTED” ON FSQ.790 OR FSQ.880, GO TO THE END OF SECTION.

OTHERWISE, CONTINUE WITH FSQ.945.

FSQ.915 Among {you and NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.880/ NAME(S) OF ALL HH MEMBER WITH “SELECTED” IN FSQ.880}, how many {DISPLAY STATE NAME FOR EBT CARD} /EBT} cards are there?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: RESPONSE CANNOT BE ZERO, AND CANNOT BE MORE THAN THE NUMBER OF PEOPLE “SELECTED (CODE 1)” IN FSQ.880.

|___|___|

NUMBER OF CARDS

REFUSED 77

DON’T KNOW 99

BOX 16

CHECK ITEM FSQ.920:

IF FSQ.915 = DK OR RF, THEN ALLOCATE EACH PERSON WITH ONE CARD, THEN SKIP TO FSQ.930.

IF THE NUMBER OF CARDS EQUALS TO THE NUMBER OF PERSONS LISTED “SELECT” ON FSQ.880, ALLOCATE EACH PERSON WITH ONE CARD, THEN SKIP TO FSQ.930.

OTHERWISE CONTINUE.

FSQ.925 Can you tell me who is on card {#}?

CAPI INSTRUCTIONS:

DISPLAY A GRID SO INTERVIEWER CAN ALLOCATE EACH HH MEMBERS WITH “SELECTED” IN FSQ.880 TO EACH OF THE CARDS. EACH CARD SHOULD ALLOW MULTIPLE PERSONS BE SELECTED INTO.

FOR EXAMPLE:

Name	Card 1	Card 2	Card 3
John Doe
Jane Doe
Bobby Jones

HARD EDIT: EACH HH MEMBERS WITH “SELECT” IN FSQ.880 SHOULD BELONG TO ONE CARD, AND ONE CARD ONLY. IF NO MEMBER BELONGS TO A CARD, GO BACK TO FSQ.915 AND CORRECT THE NUMBER OF CARDS.

BOX 17

LOOP 2:

ASK FSQ.930 - FSQ.935 FOR EACH CARD.

FSQ.930

FSQ.931

FSQ.932

On what date were food stamps last put on {your/NAME’S(S’) ON EACH CARD} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.

HARD EDIT: DATE MUST BE WITHIN PAST 12 MONTHS OF CURRENT MONTH.

INTERVIEWER INSTRUCTION:

PROBE FOR ANY MISSING PORTIONS OF DATE.

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

REFUSED 7

DON'T KNOW 9

FSQ.935 In {MONTH FROM FSQ.930/that last time}, what amount in food stamps was put on {your/their/his/her} {DISPLAY STATE NAME FOR EBT CARD} /EBT} card?

CAPI INSTRUCTIONS:

INSERT “MONTH FROM FSQ.930” IF MONTH FILED FSQ.930 IS NOT MISSING, RF OR DK.

INSERT “THAT LAST TIME” IF MONTH FILED FSQ.930 IS MISSING, RF OR DK.

INSERT “EBT” IF INTERVIEWING IN STATE WITH NO SPECIFIC NAME FOR THE EBT CARD.

INSERT STATE NAME FOR EBT CARD IF INTERVIEWING IN A STATE THAT HAS A SPECIFIC NAME FOR THE EBT CARD.

HARD EDIT: AMOUNT SHOULD BE GREATER THAN ZERO.

|___|___|___|___|

ENTER DOLLAR AMOUNT

REFUSED 77777

DON’T KNOW 99999

BOX 18

END LOOP 2:

ASK FSQ.930 - FSQ.935 FOR SECOND CARD.

IF INFORMATION COLLECTED FOR ALL CARDS, GO TO BOX19.

BOX 19

CHECK ITEM FSQ.940:

IF ALL HH MEMBERS ARE MARKED “SELECTED” ON FSQ.790 OR FSQ.880, GO TO THE END OF SECTION.

OTHERWISE, CONTINUE WITH FSQ.945.

FSQ.945 Have/Has {you/you or NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880/NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880} ever gotten Food Stamps?

CAPI INSTRUCTIONS:

IF BOTH FSQ.755 AND FSQ.870 = NO, REFUSED, OR DON’T KNOW (CODE “2, 7, OR 9”), THEN DISPLAY THE QUESTION AS:

“Have {you/ you or anyone in your household} ever gotten Food Stamps? {(Here is the list of people who live here, let me read it to you.)}”

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS ENCLOSED IN PARENTHESES.

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY “(Here is the list of people who live here, let me read it to you.)”

YES 1

NO 2 (END OF SECTION)

REFUSED 7 (END OF SECTION)

DON’T KNOW 9 (END OF SECTION)

BOX 20

CHECK ITEM FSQ.950:

IF FSQ.945=1 AND ONLY ONE PERSON IN HOUSEHOLD OR ONE PERSON THAT’S “NOT SELECTED (CODE 2)” IN FSQ.790 AND FSQ.880, FLAG PERSON AS RECEIVING SNAP IN FSQ.955, GO TO END OF SECTION.

OTHERWISE CONTINUE.

FSQ.955 Among {you and NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880/NAME(S) OF ALL HH MEMBER WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880}, who has ever gotten Food Stamps?

PROBE: Anyone else?

CAPI INSTRUCTION:

DISPLAY NAMES OF ALL HOUSEHOLD MEMBERS WITH “NOT SELECTED (CODE “2”)” IN BOTH FSQ.790 AND FSQ.880.

INTERVIEWER INSTRUCTION:

SELECT NAME(S) FROM ROSTER

CAPI INSTRUCTION:

AUTOFILL THOSE WHO WERE NOT SELECTED AS CODE “2”.

SELECT 1

NOT SELECT 2

REFUSED 7

DON'T KNOW 9

CAPI INSTRUCTION:

IF BOTH FSQ.755 AND FSQ.870 = NO, REFUSED, OR DON’T KNOW (CODE “2, 7, OR 9”), THEN DISPLAY THE QUESTION AS:

“Who in the household has ever gotten Food Stamps? (Here is the list of people who live here, let me read it to you.)”

AND DISPLAY HOUSEHOLD ROSTER WITH NAMES OF ALL HH MEMBERS ENCLOSED IN PARENTHESES.

IF MORE THAN ONE PERSON IN HOUSEHOLD, DISPLAY (Here is the list of people who live here, let me read it to you.)

HARD EDIT:

IF CODE=2 FOR ALL MEMBERS IN ROSTER, DISPLAY THE FOLLOWING MESSAGE TO VERIFY THE ANSWER TO FSQ.955:

“You said someone who lives here has been on Food Stamps. Is that correct?”

IF YES, GO BACK TO FSQ.955 AND ASK: “Who was that?” WITH ROSTER DISPLAYED.

IF NO, GO BACK TO CODE FSQ.945 AS ‘NO’.

TRACKING AND TRACING – TTQ

Target Group: Family

BOX 1

LOOP 1:

ASK TTQ.010 - TTQ.040 FOR 2 CONTACT PERSONS.

TTQ.005 The National Center for Health Statistics may wish to contact you again to obtain additional health related information. Please give me the names, addresses, and telephone numbers of 2 relatives or friends who would know where you could be reached in case we have trouble reaching you. (Please give me the names of persons not currently living in the household.)

PRESS F6 IF RESPONDENT REFUSES {ALL/SECOND} CONTACT INFORMATION

PRESS F5 IF RESPONDENT DOESN'T KNOW {ANY/SECOND} CONTACT INFORMATION

PRESS ENTER TO ADD {FIRST/SECOND} CONTACT INFORMATION

REFUSED 777777 (TTQ.050)

DON'T KNOW 999999 (TTQ.050)

HELP SCREEN:

Relative: All common relationships that occur through blood (grandfather, daughter), marriage (wife, stepson), or adoption (adopted son or daughter). Include foster relationships and guardian/ward relationships. Also refers to extended relationships by legal marriage. For example, a man and woman are married. The woman's cousin's husband would also be counted as a "relative" of the man.

CAPI INSTRUCTIONS;

HARD EDIT: RESPONSE ENTRY TEXT IS “DON’T KNOW,” “DONT KNOW,” “REFUSED,” “REFUSE,” “DK,” OR “RF.”

HARD EDIT MESSAGE: “CLEAR TEXT AND PRESS F5 TO ENTER A RESPONSE OF DON’T KNOW AND F6 TO ENTER A RESPONSE OF REFUSAL.”

TTQ.010 REFERRING TO PERSON {1/2}

VERIFY SPELLING.

a. ENTER FIRST NAME

REFUSED 7----7

DON'T KNOW 9----9

PROBE FOR MIDDLE NAME IF NOT REPORTED

ENTER "NMN" FOR NO MIDDLE NAME

b.ENTER MIDDLE NAME

REFUSED 7----7

DON'T KNOW 9----9

c.ENTER LAST NAME

REFUSED 7----7

DON'T KNOW 9----9

CAPI INSTRUCTIONS;

HARD EDIT: RESPONSE ENTRY TEXT IS “DON’T KNOW,” “DONT KNOW,” “REFUSED,” “REFUSE,” “DK,” OR “RF.”

HARD EDIT MESSAGE: “CLEAR TEXT AND PRESS F5 TO ENTER A RESPONSE OF DON’T KNOW AND F6 TO ENTER A RESPONSE OF REFUSAL.”

TTQ.020 REFERRING TO PERSON {1/2}

What is this person's address? [If there is more than one address, please give us the address used most often.]

ENCOURAGE RESPONDENT TO USE PHONE BOOK OR OTHER DOCUMENTATION IF AVAILABLE.

______________________ ___________________________ _____________________

a. ENTER STREET NUMBER b. ENTER STREET NAME c. ENTER APARTMENT NUMBER

REFUSED 7777777777 REFUSED 7----7 REFUSED 77777777

DON'T KNOW 9999999999 DON'T KNOW 9----9 DON'T KNOW 99999999

_____________________ |____|____| |___|____|____|____|____|

d. ENTER TOWN OR e. ENTER 2 LETTER f. ENTER POSTAL CODE

CITY NAME STATE ABBREVIATION TO OR ZIPCODE

TO START THE LOOKUP.

SELECT STATE FROM CAPI STATE LIST.

PRESS ENTER TO ACCEPT SELECTION.

REFUSED 7----7 REFUSED 777777 REFUSED 77777777777

DON'T KNOW 9----9 DON'T KNOW 999999 DON'T KNOW 99999999999

CAPI INSTRUCTION:

DISPLAY FIPS STATE LIST. INTERVIEWER SHOULD ONLY BE ABLE TO SELECT 1 STATE FROM THE LIST. DON'T KNOW AND REFUSED SHOULD BE VALID OPTIONS. THE STATE LOOKUP IN THE SP AND FAMILY QUESTIONNAIRES SHOULD WORK EXACTLY THE SAME.

SAVE STATE LOOKUP NAME AS TTQ.020g AND STATE FIPS LOOKUP CODE AS TTQ.020h.

HARD EDIT: RESPONSE ENTRY TEXT IS “DON’T KNOW,” “DONT KNOW,” “REFUSED,” “REFUSE,” “DK,” OR “RF.”

HARD EDIT MESSAGE: “CLEAR TEXT AND PRESS F5 TO ENTER A RESPONSE OF DON’T KNOW AND F6 TO ENTER A RESPONSE OF REFUSAL.”

TTQ.030 REFERRING TO PERSON {1/2}

What is this person's telephone number, beginning with the area code?

REPEAT AREA CODE

REPEAT PHONE NUMBER

REPEAT EXTENSION

|___|___|___| |___|___|___| - |___|___|___|___| |___|___|____|____|

a.ENTER AREA CODE, CODE b.ENTER TELEPHONE NUMBER c.ENTER EXTENSION

‘666’ IF THERE IS NO PHONE WITHOUT HYPEN

NO PHONE 666 (TTQ.040) REFUSED 7777777777 REFUSED 7777

REFUSED 777777Q.040) DON'T KNOW 9999999999 DON'T KNOW 9999999

DON'T KNOW 999999 (TTQ.040)

CAPI: ALLOW TTQ030c (PHONE EXTENSION) TO BE BLANK.

HARD EDIT: RESPONSE ENTRY TEXT IS “DON’T KNOW,” “DONT KNOW,” “REFUSED,” “REFUSE,” “DK,” OR “RF.”

HARD EDIT MESSAGE: “CLEAR TEXT AND PRESS F5 TO ENTER A RESPONSE OF DON’T KNOW AND F6 TO ENTER A RESPONSE OF REFUSAL.”

TTQ.040 REFERRING TO PERSON {1/2}

What is the relationship of this contact person to you?

SPOUSE/EX-SPOUSE NOT LIVING IN HH 1

UNMARRIED PARTNER NOT LIVING IN HH 2

CHILD 3

GRANDCHILD 4

PARENT (MOTHER OR FATHER) 5

BROTHER OR SISTER 6

GRANDPARENT 7

OTHER RELATIVE 8

LEGAL GUARDIAN 9

FRIEND 10

CO-WORKER 11

NEIGHBOR 12

OTHER 13

REFUSED 77

DON'T KNOW 99

HELP SCREEN:

Spouse (Husband/Wife): Persons who are legally married or have a common-law marriage.

Unmarried Partner: Persons who share living quarters because they have a close, personal relationship, but are not legally married (i.e., unmarried couples living together as if they were married).

Child: Male or female child through birth or adoption, regardless of age. Also include stepchildren, foster children and sons/daughters-in-law. Do not include an unmarried partner's children. A stepchild is one's spouse's male or female child by a previous relationship. A foster child is not one's biological child, but lives with one's family as one's son or daughter. A son/daughter-in-law is the spouse of one's child.

Grandchild: A child of one’s daughter or son.

Parent: Include a person’s biological, adoptive, step or foster mother or father, as well as his/her mother or father-in-law.

Mother: One's female parent, including biological, adoptive, step and foster mothers and mothers-in-law. A stepmother is the spouse of one's biological or adoptive father. A foster mother is the mother in one's foster family.

Father: One's male parent, including biological, adoptive, step, and foster fathers and fathers-in-law. A stepfather is the spouse of one's biological or adoptive mother. A foster father is the father in one's foster family.

Brother: Includes biological, adoptive, step, foster and half brothers, and brothers-in-law. A brother is one's male sibling who shares both of the same biological or adoptive parents. A stepbrother is one's stepparent's son by a previous relationship. A half brother is one's male sibling who shares one of the same biological or adoptive parents. A brother-in-law is one's sister's husband. A foster brother is the foster son of one or both of one's parents or the son of one's foster parent(s).

Sister: A sister includes biological, adoptive, step, foster, half sisters and sisters-in-law. A sister is one's female sibling who shares both of the same biological or adoptive parents. A stepsister is one's stepparent's daughter by a previous relationship. A half sister is one's female sibling who shares one of the same biological or adoptive parents. A sister-in-law is one's brother's wife. A foster sister is the foster daughter of one or both of one's parents or the daughter of one's foster parent(s).

Grandfather: The male parent of one's mother or father.

Grandmother: The female parent of one's mother or father.

Relative: All common relationships that occur through blood (grandfather, daughter), marriage (wife, stepson), or adoption (adopted son or daughter). Include foster relationships and guardian/ward relationships. Also refers to extended relationships by legal marriage. For example, a man and woman are married. The woman's cousin's husband would also be counted as a "relative" of the man.

Legal Guardian: A person appointed to take charge of the affairs of a minor, or of a person not capable of managing his/her own affairs.

BOX 2

END LOOP 1:

ASK TTQ.010 - TTQ.040 FOR SECOND CONTACT PERSON.

IF SECOND CONTACT PERSON INFORMATION COLLECTED, GO TO TTQ.050.

TTQ.050 This is the end of the Family Interview. Thank you very much for your cooperation.

PRESS F10 TO SAVE AND EXIT FORM

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Wang, Chia-Yih (CDC/DDPHSS/NCHS/DHNES)
File Modified	0000-00-00
File Created	2022-01-13