Attachment 3g
Dietary Interview Forms: Dietary Recall and Dietary Supplements
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 hours 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 (42U.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.
National health and Nutrition Examination Survey (NHANES)
Dietary Interview by Phone: Dietary Recall and Dietary Supplements
TABLE OF CONTENTS
SCHEDULING DIETARY INTERVIEW 3
SUGGESTED SCRIPTS FOR SCHEDULING DAY 1 DIETARY INTERVIEW 3
SUGGESTED SCRIPTS FOR SCHEDULING DAY 2 DIETARY INTERVIEW 3
SUGGESTED REMINDER SCRIPT FOR DAY 1 AND DAY 2 DIETARY INTERVIEW 3
SUGGESTED REMINDER TEXT MESSAGE FOR DAY 1 AND DAY 2 DIETARY INTERVIEW 4
24-HOUR DIETARY RECALL INTERVIEW 5
24-HOUR DIETARY RECALL INTERVIEW SUGGESTED SCRIPTS - DAY 1 5
POST-DIETARY RECALL QUESTIONS - DAY 1 7
24-HOUR DIETARY RECALL INTERVIEW SUGGESTED SCRIPTS - DAY 2 10
POST-DIETARY RECALL QUESTIONS - DAY 2 12
Suggested Scripts for scheduling DAY 1 Dietary Interview
We would like to conduct a dietary interview over the phone as part of this health survey. The information will help us learn about the types of foods and beverages people eat and drink and the nutritional status of people living in the U.S. We will also ask about dietary supplements and antacids you used in the past 30 days. Just like the information you have already provided, all the information you provide during this interview will be maintained confidential. Are you available to do this interview on {SCHEDULE INTERVIEW ON OR BEFORE DATE OF MEC EXAM}? Please keep in mind while scheduling this appointment, that for safety reasons we cannot complete this interview on the phone while you are driving.
If SP appears uncertain, be prepared to highlight the importance of the interview. You can say something like:
We cannot ask everyone in the country to be in our study. You are special because you have been chosen to participate. No one else can take your place. We hope that you will help by doing this interview. It will take about {DAY 1 DISPLAY 45 minutes; DAY 2 DISPLAY 35 minutes} and it is a very important part of the health survey.
Measuring guides and hand cards:
In this plastic bag is a booklet, hand cards, ruler, measuring cups and spoons to use for the dietary phone interview. Everyone in your home participating in the survey will use it. Keep it in a place that is easy to find. The phone interviewer will tell you how to use it.
Suggested Scripts for scheduling DAY 2 Dietary Interview
(Scheduled after completing Day 1):
You have just given us valuable information for this health and nutrition study. However, our studies have shown that food intakes change from day to day. A second day of information can provide a more complete picture of the usual food intake of the U.S. population. We would like to conduct a second interview with you again by telephone. You will be paid $25 for your time.
Suggested Reminder script for Day 1 and Day 2 Dietary Interview
[Once you have the respondent on the phone] Good afternoon/morning, my name is _____. I’m calling from the National Health and Nutrition Examination Survey to remind you of your appointment for the dietary interview by phone, {TOMORROW}, {DAY OF THE WEEK}, at {TIME}. Please have your measuring guides and any dietary supplements and antacids you used in the past 30 days near the telephone. The interview will last approximately 45 minutes.
Should you have any questions before this time, please call 1-888-458-4762. This is the same number that you will receive the call from.
Suggested Reminder text message for Day 1 and Day 2 Dietary Interview
REMINDER: your appointment for the dietary phone interview is tomorrow, {DAY}, at {TIME am/pm}. Problems call 1-888-458-4762.
24-Hour Dietary Recall Interview
Both Day 1 and Day 2 Dietary Recall Interview will be administered by phone.
Target Group:
Day 1: Participants of all ages
Day 2: Participants of all ages who completed Day 1 dietary interview
Information will be obtained on all foods and beverages that were consumed during a 24-hour time period (midnight to midnight). The information that is obtained for foods and beverages includes the following:
Time of day - Time when the food was eaten
Meal name code - The name of the eating occasion is selected from a list of options.
Food item name - The name of the food is either typed in or selected from a list of food item names.
Food item description - Detailed description of the food including information about commercial product name (if applicable), preparation method, and major recipe ingredients.
Fat added in preparation - A preparation fat probe is asked for certain foods. The type of fat used during food preparation is specified as well.
Amount of food eaten - The amount of food consumed by the respondent.
Food source - The place where the food was obtained is selected from a list of options
Meal place - Whether the meal was eaten at home.
24-Hour Dietary Recall Interview Suggested Scripts - Day 1
A. Introduction
Hello, Mr./Mrs. {SP/PROXY}, my name is {INTERVIEWER’S NAME}. I am calling for the National Health and Nutrition Examination Survey to conduct {your/SP’s} dietary interview.
For safety reasons I cannot complete this interview on a cell phone if you are driving. Are you driving? (If driving, call back when not driving to reschedule.)
You will need the food measuring guides that you received at our mobile exam center. If you have taken any dietary supplements or antacids in the last 30 days, you will also need the containers for this interview. I’ll wait while you get them.
Do you have them? Yes/No/Needs to reschedule
If yes, go to next question.
If no: Let’s go ahead with the interview anyway.
Do you have a ruler or some measuring cups and measuring spoons in your home that you can use for this interview?
If SP needs to reschedule:
We can schedule another appointment for the interview. Is there a time that will be convenient? Enter date/ Enter time/ Verify contact phone
If SP is not willing to reschedule:
We cannot ask everyone in the country to be in our study. You are special because you have been chosen to participate. No one else can take your place. We hope that you will help us with this interview. It will take about 45 minutes, you will receive $25 for participating, and it is such an important part of the health survey.
If SP still says no: Thank you for your time.
B. Recall foods and beverages
First, we’ll make a list of the foods you/SP ate and drank yesterday, Monday. It may help you remember what you/SP ate by thinking about where you/he/she were, who you/he/she were with, or what you were/he was/she was doing, like working, eating out, or watching television.
Please tell me everything you/SP had to eat and drink all day yesterday, Monday, from midnight to midnight. Include everything you/he/she had at home and away, even snacks, water, soft drinks, and alcoholic beverages. I’ll ask you for specific details and amounts of the foods in a few minutes. At this time, just tell me what you/SP had.
C. Forgotten food probes
Your answers are important, so we’d like this list to be as complete as possible. In addition to the foods you have/SP has already told me about, did you have any coffee, tea, soft drinks, milk or juice?
Beer, wine, cocktails or other drinks?
Cookies, candy, ice cream or other sweets?
Chips, crackers, popcorn, pretzels, nuts, or other snack foods?
Fruits, vegetables, or cheese?
Bread, rolls or tortillas?
Anything else?
D. Food detail probes
If respondent has measuring guides:
During this interview, you can use the different items in the bag to describe the amounts of foods you ate and drank yesterday. In the package there are hand cards along with measuring cups, measuring spoons, household spoons, and a ruler. The booklet has drawings of glasses, mugs, bowls, and other measurements. When I ask how much {you/SP} ate, you can estimate the amount by using the drawings in the Food Model Booklet, the measuring cups and spoons, the ruler, and any of your own dishes and glasses. I will help you find the right page in the booklet as we go through the interview. Feel free to check the labels on any food packages during the interview.
If respondent has their own measuring guides:
When I ask how much {you/SP} ate, use the cups and spoons for amounts of food and the ruler for length, width, and height. Please use those measuring tools and any of your own dishes and glasses. Feel free to check the labels on any food packages during the interview.
If respondent does not have measuring guides:
When I ask how much {you/SP} ate, use any of your own dishes and glasses to estimate the amount of food you ate and drank. Feel free to check the labels on any food packages during the interview.
Post-Recall Questionnaire – DRQ
Target Group: Birth +
NHANES III
REC.155 Was the amount of food that {you/NAME} ate yesterday much more than usual, usual, or much less than usual?
MUCH MORE THAN USUAL 1
USUAL 2
MUCH LESS THAN USUAL 3
REFUSED 7
DON’T KNOW 9
CSFII
REC.265 When you drink tap water, what is the main source of the tap water? Is the city water supply (community water supply); a well or rain cistern; a spring; or something else?
COMMUNITY WATER 1
A WELL OR RAIN CISTERN 2
A SPRING 3
NEVER DRINK TAP WATER 4
REFUSED 7
DON’T KNOW 9
OTHER (SPECIFY) 91
[RECORD Drinking fountain AS COMMUNITY WATER SUPPLY.]
NHANES III
REC.325 Now I'll be asking some questions about {your/NAME's} use of table salt.
What type of salt {do you/does NAME} usually add to {your/his/her} food at the table? Would you say it is ordinary salt, sea salt, lite salt, or a salt substitute?
ORDINARY, SEA, SEASONED, OR OTHER FLAVORED SALT
[includes regular iodized salt,
sea salt and seasoning salts
made with regular salt] 1
LITE SALT 2
SALT SUBSTITUTE 3
NONE 4 (REC.335)
REFUSED 7 (REC.335)
DON'T KNOW 9 (REC.335)
NHANES III
REC.330 How often {do you/does NAME} add this salt to {your/his/her} food at the table? Is it rarely, occasionally, or very often?
RARELY, 1
OCCASIONALLY 2
VERY OFTEN 3
REFUSED 7
DON'T KNOW 9
CSFII
REC.335 How often is ordinary salt or sea salt added in cooking or preparing foods in your household? Is it never, rarely, occasionally, or very often?
NEVER 1
RARELY 2
OCCASIONALLY 3
VERY OFTEN 4
REFUSED 7
DON'T KNOW 9
[THIS QUESTION APPLIES ONLY TO USE OF ORDINARY SALT, SEA SALT OR SEASONED SALT AND NOT TO LITE SALT OR SALT SUBSTITUTES.]
CSFII
REC.336 This next question is about {your/NAME’s} use of salt at the table yesterday. Did {you/SP} add any salt to {your/her/his} food at the table yesterday? Salt includes ordinary salt, sea salt lite salt, or a salt substitute.
YES 1
NO 2 (REC.340)
REFUSED 7 (REC.340)
DON’T KNOW 9 (REC.340)
CSFII
REC.337 What type of salt was it? (Was it ordinary salt, sea salt, lite salt, or a salt substitute?)
ORDINARY, SEA, SEASONED, OR OTHER FLAVORED SALT
[includes regular iodized salt,
sea salt and seasoning salts
made with regular salt] 1
LITE SALT 2
SALT SUBSTITUTE 3
REFUSED 7
DON'T KNOW 9
CSFII
REC.340 {Are you/Is NAME} currently on any kind of diet, either to lose weight or for some other health-related reason?
YES 1
NO 2 (Box 1)
REFUSED 7 (Box 1)
DON’T KNOW 9 (Box 1)
CSFII
REC.345 What kind of diet {are you/is NAME} on?
[READ AS NEEDED: Is it a weight loss or low calorie diet; low fat or cholesterol diet; low salt or sodium diet; diabetic diet; or another type of diet?]
WEIGHT LOSS OR LOW CALORIE DIET 1
LOW FAT OR CHOLESTEROL DIET 2
LOW SALT OR SODIUM DIET 3
SUGAR FREE OR LOW SUGAR DIET 4
LOW FIBER DIET 5
HIGH FIBER DIET 6
DIABETIC DIET 7
LOW CARBOHYDRATE DIET 8
HIGH PROTEIN DIET 9
WEIGHT GAIN DIET 10
GLUTEN-FREE OR CELIAC DIET 11
RENAL OR KIDNEY DIET 12
OTHER 91
(SPECIFY) ___________
REFUSED 77
DON’T KNOW 99
BOX 1
IF SP < 1 YEAR OLD, GO TO THE END OF THE SECTION.
OTHERWISE, CONTINUE.
NHANES 1999
DRQ.361 Please look at Card DRQ1 in your Dietary Interview Hand Card booklet. During the past 30 days, did you eat any types of fish listed on this card? Include any foods that had fish in them such as sandwiches, soups, or salads.
YES 1
NO 2 (DRQ.380)
REFUSED 7 (DRQ.380)
DON’T KNOW 9 (DRQ.380)
NHANES 1999
DRQ. 370 During the past 30 days, which types of fish did you eat and how many times did you eat them?
Type listed: breaded fish products, tuna (canned or fresh), bass, catfish, cod, flatfish, haddock, mackerel, perch, pike, pollock, porgy, salmon, sardines, sea bass, shark, swordfish, trout, walleye, other type of fish and unknown type of fish.
Interviewer instruction:
Check each type of shellfish the SP reports eating, and then ask and record the number of times each type was eaten.
NHANES 1999
DRQ.380 Please look at the list of shellfish on Card DRQ2. During the past 30 days, did you eat any types of shellfish listed on this card? Include any foods that had shellfish in them such as sandwiches, soups, or salads.
YES 1
NO 2 (Box 2)
REFUSED 7 (Box 2)
DON’T KNOW 9 (Box 2)
NHANES 1999
DRQ. 390 During the past 30 days, which types of shellfish did you eat and how many times did you eat them?
Type listed: clams, crab, crayfish (crawfish), lobster, mussels, oysters, scallops, shrimp, other shellfish (for example, octopus, squid) and unknown type of shellfish.
Interviewer instruction:
Check each type of shellfish the SP reports eating, and then ask and record the number of times each type was eaten.
24-Hour Dietary Recall Interview Suggested Scripts - Day 2
A. Introduction
Hello, Mr./Mrs. {SP/PROXY}, my name is {INTERVIEWER’S NAME}. I am calling for the National Health and Nutrition Examination Survey to conduct {your/SP’s} dietary interview.
For safety reasons I cannot complete this interview on a cell phone if you are driving. Are you driving? (If driving, call back when not driving to reschedule.)
You will need the food measuring guides that you used for the first dietary interview. I’ll wait while you get them.
Do you have them? Yes/No/Needs to reschedule
If yes, go to next question.
If no: Let’s go ahead with the interview anyway.
Do you have a ruler or some measuring cups and measuring spoons in your home that you can use for this interview?
If SP needs to reschedule:
We can schedule another appointment for the interview. Is there a time that will be convenient? Enter date/ Enter time/ Verify contact phone
If SP is not willing to reschedule:
We cannot ask everyone in the country to be in our study. You are special because you have been chosen to participate. No one else can take your place. We hope that you will help us with this interview. It will only take about 35 minutes, you will receive $25 for participating, and it is such an important part of the health survey.
If SP still says no: Thank you for your time.
B. Recall foods and beverages script
First, we’ll make a list of the foods you/SP ate and drank yesterday, Monday. It may help you remember what you/SP ate by thinking about where you were/he was/she was, who you/he/she were with, or what you/he/she were doing, like working, eating out, or watching television.
Please tell me everything you/SP had to eat and drink all day yesterday, Monday, from midnight to midnight. Include everything you/he/she had at home and away, even snacks, water, soft drinks, and alcoholic beverages. I’ll ask you for specific details and amounts of the foods in a few minutes. At this time, just tell me what you/SP had.
C. Forgotten foods probing
Your answers are important, so we’d like this list to be as complete as possible. In addition to the foods you have/SP has already told me about, did you have any coffee, tea, soft drinks, milk or juice?
Beer, wine, cocktails or other drinks?
Cookies, candy, ice cream or other sweets?
Chips, crackers, popcorn, pretzels, nuts, or other snack foods?
Fruits, vegetables, or cheese?
Bread, rolls or tortillas?
Anything else?
D. Food detail probes
If respondent has measuring guides:
When I ask how much {you/SP} ate, you can estimate the amount by using the drawings in the Food Model Booklet, the measuring cups and spoons, the ruler, and any of your own dishes and glasses. Feel free to check the labels on any food packages during the interview.
If respondent has their own measuring guides:
When I ask how much {you/SP} ate, use the cups and spoons for amounts of food and the ruler for length, width, and height. Please use those measuring tools and any of your own dishes and glasses. Feel free to check the labels on any food packages during the interview.
If respondent does not have measuring guides:
When I ask how much {you/SP} ate, use any of your own dishes and glasses to estimate the amount of food you ate and drank. Feel free to check the labels on any food packages during the interview.
Post-Recall Questionnaire – DRQ
Target Group: SPs Birth +
NHANES III
REC.155 Was the amount of food that {you/NAME} ate yesterday much more than usual, usual, or much less than usual?
MUCH MORE THAN USUAL 1
USUAL 2
MUCH LESS THAN USUAL 3
REFUSED 7
DON’T KNOW 9
CSFII
REC.336 This next question is about {your/NAME’s} use of salt at the table yesterday. Did {you/SP} add any salt to {your/her/his} food at the table yesterday? Salt includes ordinary salt, sea salt lite salt, or a salt substitute.
YES 1
NO 2 (REC.340)
REFUSED 7 (REC.340)
DON’T KNOW 9 (REC.340)
CSFII
REC.337 What type of salt was it? (Was it ordinary salt, sea salt, lite salt, or a salt substitute?)
ORDINARY, SEA, SEASONED, OR OTHER FLAVORED SALT
[includes regular iodized salt,
sea salt and seasoning salts
made with regular salt] 1
LITE SALT 2
SALT SUBSTITUTE 3
REFUSED 7
DON'T KNOW 9
30-Day Dietary Supplements Interview
Questions on 30-day dietary supplement use will be administered by phone after the Day 1 dietary recall interview.
Target Group: Birth+
SAQ005 The next questions are about {your/SP’s} use of dietary supplements during the past 30 days.
Please look at hand card SAQ1 which lists some examples of different types of dietary supplements.
{Have you/Has SP} used or taken any vitamins, minerals, herbals or other dietary supplements in the past 30 days? Include any prescription and over the counter supplements.
HAND CARD SAQ1
YES 1
NO 2 (SAQ045)
REFUSED 7 (SAQ045)
DON'T KNOW 9 (SAQ045)
HELP SCREEN:
Dietary Supplements (Vitamins/Minerals): Dietary supplements are often labeled as "dietary supplements" and are used in addition to foods and beverages. Dietary supplements are not intended to replace food. Include vitamins, minerals, antacid/calcium supplement products, fiber supplements, amino acids, performance enhancers, herbs, herbal medicine products, and plant extracts used as dietary supplements. Include products that are taken orally or given by injection. Do not include beverages, such as tea, and skin creams. Meal replacement beverages, weight loss and performance booster drinks, and food bars are considered foods, not dietary supplements.
BOX 1A
Supplements Table
PRESENT SAQ010 THROUGH SAQ040 AS A GRID.
CONTINUE.
|
SAQ010 {Container}
{I will start with the first dietary supplement that {you/SP} used or took in the past 30 days.}
Do you have the container available for this dietary supplement? [I will wait while you locate the container].
YES - CONTAINER AVAILABLE 1
NO - CONTAINER NOT AVAILABLE 2
INTERVIEWER INSTRUCTION:
IF THE RESPONDENT CANNOT OR WOULD NOT LOCATE THE CONTAINERS, MARK “2, NO - CONTAINER NOT AVAILABLE”.
CAPI INSTRUCTION:
DO NOT DISPLAY “I will start with the first dietary supplement that {you/SP} used or took in the past 30 days.” AFTER THE FIRST REPORTED SUPPLEMENT.
SAQ015 {Supplements}
{Can you please look at the container and read to me all the words on the front label/What is the name of the supplement {you/SP} took}?
CAPI INSTRUCTION:
IF SAQ010=1, DISPLAY: “Can you please look at the container and read to me all the words on the front label”.
IF SAQ010=2, DISPLAY: “What is the name of the supplement {you/SP} took?’”
INTERVIEWER INSTRUCTION:
{PROBE IF THE RESPONDENT IS HAVING TROUBLE IN READING THE PRODUCT LABEL/ PROBE IF THE RESPONDENT DOESN’T HAVE THE CONTAINER}.
CAPI INSTRUCTION:
IF SAQ010=1, DISPLAY: “PROBE IF THE RESPONDENT IS HAVING TROUBLE IN READING THE PRODUCT LABEL”
IF SAQ010=2, DISPLAY: “PROBE IF THE RESPONDENT DOESN’T HAVE THE CONTAINER.”
[PROBES: Record the name. Use name probes.
Multivitamin and/or Multimineral:
What is the brand name?
Did it also include minerals like iron, zinc, or calcium?
Iron only
Was it a special type? {(such as silver, women’s, men’s, prenatal, liquid)/(chewable, complete, with iron, with extra C)}
Single/double nutrient:
What is the brand name?
How much (ingredient name) was in it? (or what was the strength of X)
Other supplement type:
Please describe the label name or type of supplement {(fluoride)}
What is the brand name?]
CAPI INSTRUCTION:
IF SP IS UNDER 12 YEARS OLD, DISPLAY ‘(chewable, complete, with iron, with extra C)’
ELSE DISPLAY ‘(silver, women’s, men’s, prenatal, liquid)’.
CAPI INSTRUCTION: IF SP IS UNDER 12 YEARS OLD, DISPLAY ‘(fluoride)’.
HARD EDIT: SUPPLEMENT NAME SHOULD BE ENTERED
ERROR MESSAGE ON FIRST LINE: “YOU MUST COLLECT INFORMATION FOR AT LEAST ONE SUPPLEMENT OR BACK UP AND ANSWER “NO” TO SAQ005.”
ERROR MESSAGE ON SUBSEQUENT LINES: “YOU MUST COLLECT INFORMATION FOR A SUPPLEMENT OR BACK UP AND ANSWER “NO” TO SAQ040.”
____________________________________
ENTER SUPPLEMENT NAME
REFUSED 7
DON'T KNOW 9
SAQ020 {Days Taken}
In the past 30 days, on how many days did {you/SP} take {PRODUCT NAME}?
CAPI INSTRUCTION:
{PRODUCT NAME} = PRODUCT ENTERED IN SAQ015
|___|___|
ENTER NUMBER OF DAYS FROM 1-30
REFUSED 77
DON'T KNOW 99
SAQ025Q {Quantity Taken}
On the days that {you/SP} took {PRODUCT NAME}, how much did {you/he/she} usually take on a single day?
[ENTER THE NUMBER]
SOFT EDIT: Quantity should be less than 10
Error Message: “You said {you/he/she} took {QUANTITY TAKEN}. Is that correct?”
HARD EDIT: Number must be greater than 0 and less than 150
____________________________________
ENTER QUANTITY
REFUSED 777777
DON'T KNOW 999999
SAQ025U {Unit Taken}
OS
(Was it a tablet, capsule, pill, caplet, softgel, or something else?)
[SELECT FORM/UNIT]
TABLETS 35 (BOX 2)
CAPSULES 36 (BOX 2)
PILLS 37 (BOX 2)
CAPLETS 38 (BOX 2)
SOFTGELS/GELCAPS 39 (BOX 2)
VEGICAPS 40 (BOX 2)
CHEWABLE TABLETS 1 (BOX 2)
DROPPERS 2 (BOX 2)
DROPS 3 (BOX 2)
INJECTIONS/SHOTS 5 (BOX 2)
LOZENGES/COUGH DROPS 6 (BOX 2)
MILLILITERS 7 (BOX 2)
TABLESPOONS 11 (BOX 2)
TEASPOONS 12 (BOX 2)
WAFERS 13 (BOX 2)
CANS 15 (BOX 2)
GRAMS 16 (BOX 2)
DOTS 17 (BOX 2)
CUPS 18 (BOX 2)
SPRAYS/SQUIRTS 19 (BOX 2)
CHEWS/GUMMIES 20 (BOX 2)
SCOOPS 21 (BOX 2)
CAPFULS 23 (BOX 2)
OUNCES 27 (BOX 2)
PACKAGES/PACKETS 28
VIALS 29 (BOX 2)
GUMBALLS 30 (BOX 2)
OTHER FORM (SPECIFY) 91 (BOX 2)
REFUSED 77 (BOX 2)
DON’T KNOW 99 (BOX 2)
SAQ030 {Entire Packet}
{Did you/Does SP} take an entire packet of {PRODUCT NAME} each time?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
BOX 2
IF SAQ025U = 7, 11, 12, 15, 16, 18, 21, 23 OR 27, CONTINUE. OTHERWISE, SKIP TO SAQ040.
|
SAQ035 {Liquid/Powder}
Was that a liquid or powder?
LIQUID 1
POWDER 2
REFUSED 7
DON'T KNOW 9
SAQ040 {Any others}
During the past 30 days, did {you/SP} take any other vitamins, minerals, herbals or other dietary supplements? Include any prescription and over the counter dietary supplements.
HAND CARD SAQ1
INTERVIEWER INSTRUCTION: IF NO, REVIEW THE SUPPLEMENTS ON THE GRID WITH RESPONDENT AND MARK “2” IF THERE ARE NO MORE SUPPLEMENTS TO ENTER.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
HELP SCREEN:
Dietary Supplements (Vitamins/Minerals): Dietary supplements are often labeled as "dietary supplements" and are used in addition to foods and beverages. Dietary supplements are not intended to replace food. Include vitamins, minerals, antacid/calcium supplement products, fiber supplements, amino acids, performance enhancers, herbs, herbal medicine products, and plant extracts used as dietary supplements. Include products that are taken orally or given by injection. Do not include beverages, such as tea, and skin creams. Meal replacement beverages, weight loss and performance booster drinks, and food bars are considered foods, not dietary supplements.
BOX 3
IF SAQ040 = YES, ASK SAQ010 FOR NEXT SUPPLEMENT OTHERWISE CONTINUE.
|
SAQ045 The next questions are about {your/SP’s} use of non-prescription antacids. Please look at Card SAQ2. {Have you/Has SP} used or taken any nonprescription antacids in the past 30 days?
HAND CARD SAQ2
YES ….1
NO 2 (BOX 7)
REFUSED 7 (BOX 7)
DON'T KNOW 9 (BOX 7)
HELP SCREEN:
Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.
The past 30 days: From yesterday, 30 days back.
BOX 4
Antacids Table
PRESENT SAQ050 THROUGH SAQ085 AS A GRID.
CONTINUE.
|
SAQ050 {Container}
{I will start with the first antacid that {you/SP} used or took in the past 30 days.}
Do you have the container available for this antacid? [I will wait while you locate the container].
YES - CONTAINER AVAILABLE 1
NO - CONTAINER NOT AVAILABLE 2
INTERVIEWER INSTRUCTION:
IF THE RESPONDENT CANNOT OR WOULD NOT LOCATE THE CONTAINERS, MARK “2, NO - CONTAINER NOT AVAILABLE”.
CAPI INSTRUCTION:
DO NOT DISPLAY “I will start with the first antacid that {you/SP} used or took in the past 30 days.” AFTER THE FIRST REPORTED SUPPLEMENT.
SAQ055 {Antacids}
{Can you please look at the container and read to me all the words on the front label/Which antacid did {you/SP} use or take in the past 30 days}?
CAPI INSTRUCTION:
IF SAQ050=1, DISPLAY: {“Can you please look at the container and read to me all the words on the front label”}.
IF SAQ050=2, DISPLAY: {“Which antacid did {you/SP} use or take in the past 30 days”}.
INTERVIEWER INSTRUCTION:
{PROBE IF THE RESPONDENT IS HAVING TROUBLE IN READING THE PRODUCT LABEL/ PROBE IF THE RESPONDENT DOESN’T HAVE THE CONTAINER}.
CAPI INSTRUCTION:
IF SAQ050=1, DISPLAY: “PROBE IF THE RESPONDENT IS HAVING TROUBLE IN READING THE PRODUCT LABEL.”
IF SAQ050=2, DISPLAY: “PROBE IF THE RESPONDENT DOESN’T HAVE THE CONTAINER.”
[PROBES: What is the brand name? Was it extra strength, regular strength, ultra-strength, maximum strength?]
HARD EDIT: ANTACID NAME SHOULD BE ENTERED
ERROR MESSAGE ON FIRST LINE: “YOU MUST COLLECT INFORMATION FOR AT LEAST ONE ANTACID OR BACK UP AND ANSWER “NO” TO SAQ045.”
ERROR MESSAGE ON SUBSEQUENT LINES: “YOU MUST COLLECT INFORMATION FOR AN ANTACID OR BACK UP AND ANSWER “NO” TO SAQ085.”
____________________________________
ENTER ANTACID NAME
REFUSED ..................................................... 7
DON'T KNOW ............................................... 9
SAQ060 {Pick List}
What is the name of the antacid {you/SP} took?
[PROBES: What is the brand name? Was it extra strength, regular strength, ultra strength, maximum strength?]
[IF ANTACID NOT ON LIST, TYPE “**Product not on list”]
____________________________________
ENTER ANTACID NAME FROM LIST OR
ENTER”**PRODUCT NOT ON LIST”
REFUSED 7
DON'T KNOW 9
ONCE A PRODUCT IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE:
DRUG TYPE {3}
GENERIC NAME {60}
THERAPEUTIC CLASS CODE {6}
GENERIC FLAG {1}
THERE IS NO NEED TO DISPLAY THIS INFORMATION.
SAQ065 {Days Taken}
In the past 30 days, on how many days did {you/SP} take {PRODUCT NAME}?
CAPI INSTRUCTION:
{PRODUCT NAME} = PRODUCT SELECTED AT SAQ055 OR PRODUCT ENTERED IN SAQ060
|___|___|
ENTER NUMBER OF DAYS FROM 1-30
REFUSED 77
DON'T KNOW 99
SAQ070Q |
{Quantity Taken}
On those days that {you/SP} used or took {PRODUCT NAME}, how much did {you/he/she} usually take on a single day?
[ENTER THE NUMBER]
SOFT EDIT: Quantity should be less than 10 Error Message: “You said {you/he/she} took {QUANTITY TAKEN}. Is that correct?” HARD EDIT: Number must be greater than 0 and less than 150
____________________________________ ENTER QUANTITY
REFUSED 777777 DON'T KNOW 999999
|
|
|
SAQ070U {Unit Taken}
OS
(Was it a tablet, capsule, pill, caplet, softgel, or something else?)
[SELECT FORM/UNIT]
TABLETS 35 (BOX 5)
CAPSULES 36 (BOX 5)
PILLS 37 (BOX 5)
CAPLETS 38 (BOX 5)
SOFTGELS/GELCAPS 39 (BOX 5)
VEGICAPS 40 (BOX 5)
CHEWABLE TABLETS 1 (BOX 5)
DROPPERS 2 (BOX 5)
DROPS 3 (BOX 5)
INJECTIONS/SHOTS 5 (BOX 5)
LOZENGES/COUGH DROPS 6 (BOX 5)
MILLILITERS 7 (BOX 5)
TABLESPOONS 11 (BOX 5)
TEASPOONS 12 (BOX 5)
WAFERS 13 (BOX 5)
CANS 15 (BOX 5)
GRAMS 16 (BOX 5)
DOTS 17 (BOX 5)
CUPS 18 (BOX 5)
SPRAYS/SQUIRTS 19 (BOX 5)
CHEWS/GUMMIES 20 (BOX 5)
SCOOPS 21 (BOX 5)
CAPFULS 23 (BOX 5)
OUNCES 27 (BOX 5)
PACKAGES/PACKETS 28
VIALS 29 (BOX 5)
GUMBALLS 30 (BOX 5)
OTHER FORM (SPECIFY) 91 (BOX 5)
REFUSED 77 (BOX 5)
DON’T KNOW 99 (BOX 5)
SAQ075 {Entire Packet}
{Do you/Does SP} take an entire packet each time?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
BOX 5
IF SAQ070U IS 7, 11, 12, 15, 16, 18, 21, 23, OR 27, CONTINUE. OTHERWISE, SKIP TO SAQ085.
|
SAQ080 {Liquid/Powder}
Was that a liquid or powder?
LIQUID 1
POWDER 2
REFUSED 7
DON'T KNOW 9
SAQ085 {Any Others}
During the past 30 days, did {you/SP} take any other antacids?
HAND CARD SAQ2
INTERVIEWER INSTRUCTION: IF NO, REVIEW THE ANTACIDS ON THE GRID WITH RESPONDENT AND MARK “2” IF THERE ARE NO MORE ANTACIDS TO ENTER.
HELP SCREEN:
Antacids: An agent that neutralizes acidity or reduces acid production, especially in the digestive system.
The past 30 days: From yesterday, 30 days back.
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
BOX 6
IF SAQ085 = YES, ASK SAQ050 FOR NEXT ANTACID OTHERWISE CONTINUE.
|
BOX 7
End
|
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Dupree, Natalie (CDC/OPHSS/NCHS) |
| File Modified | 0000-00-00 |
| File Created | 2022-01-31 |