Field Test for 2023 Questionnaire

2022 BRFSS Field Test for 2023 Questionnaire

DRAFT

Table of Contents

OMB Header and Introductory Text 3

Landline Introduction 4

Cell Phone Introduction 11

Core Section 1: Health Status 17

Core Section 2: Healthy Days 18

Core Section 3: Health Care Access 20

Core Section 4: Exercise (Physical Activity) 22

Core Section 5: Demographics 24

Emerging Core: Long-term COVID Effects 30

Closing Statement/ Transition to Modules 33

Optional Modules 34

Module 1: COVID Vaccination 35

Module 2: Cognitive Decline 36

Closing Statement 38

OMB Header and Introductory Text

Read if necessary	Read	Interviewer instructions (not read)
Public reporting burden of this collection of information is estimated to average 27 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061).		Form Approved OMB No. 0920-1061 Exp. Date 12/31/2024 Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Carol Pierannunzi at [email protected].
	HELLO, I am calling for the [STATE OF xxx] Department of Health. My name is (name). We are gathering information about the health of US residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices.	States may opt not to mention the state name to avoid refusals by out of state residents in the cell phone sample. If cell phone respondent objects to being contacted by state where they have never lived, say: “This survey is conducted by all states and your information will be forwarded to the correct state of residence”

Landline Introduction

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
LL01.	Is this [PHONE NUMBER]?	CTELENM1	1 Yes	Go to LL02
			2 No	TERMINATE	Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time.
LL02.	Is this a private residence?	PVTRESD1	1 Yes	Go to LL04	Read if necessary: By private residence we mean someplace like a house or apartment. Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.
			2 No	Go to LL03	If no, business phone only: thank you very much but we are only interviewing persons on residential phones lines at this time. NOTE: Business numbers which are also used for personal communication are eligible.
			3 No, this is a business		Read: Thank you very much but we are only interviewing persons on residential phones at this time. TERMINATE
LL03.	Do you live in college housing?	COLGHOUS	1 Yes	Go to LL04	Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.
			2 No	TERMINATE	Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
LL04.	Do you currently live in__(state)____?	STATERE1	1 Yes	Go to LL05
			2 No	TERMINATE	Thank you very much but we are only interviewing persons who live in [STATE] at this time.
LL05.	Is this a cell phone?	CELPHONE	1 Yes, it is a cell phone	TERMINATE	Read: Thank you very much but we are only interviewing by landline telephones in private residences or college housing at this time.
			2 Not a cell phone	Go to LL06	Read if necessary: By cell phone we mean a telephone that is mobile and usable outside your neighborhood. Do not read: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).
LL06.	Are you 18 years of age or older?	LADULT1	1 Yes	IF COLLEGE HOUSING = “YES,” CONTINUE; OTHERWISE GO TO ADULT RANDOM SELECTION]
			2 No	IF COLLEGE HOUSING = “YES,” Terminate; OTHERWISE GO TO ADULT RANDOM SELECTION]	Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
LL07.	Are you male or female?	COLGSEX	1 Male 2 Female	ONLY for respondents who are LL and COLGHOUS= 1. Go to Transition Section 1.	We ask this question to determine which health related questions apply to each respondent. For example, persons who report males as their sex at birth might be asked about prostate health issues.
			3 Nonbinary 7 Don’t know/Not sure 9 Refused	Go to LL07a
LL07a.	What was your sex at birth? Was it male or female?	***NEW***	1 Male 2 Female	ONLY for respondents who are LL and COLGHOUS= 1. Go to Transition Section 1.
			7 Don’t know/Not sure 9 Refused	Go to LL07b.
LL07b.	We would like to ask questions that best allow you to report on your health status. One set of questions are about cervical health or prostate health. Which types of questions best apply to you?	***NEW***	Questions about: 1 Cervical health 2 Prostate health	Go to Transition Section 1.
			7 Don’t know/Not sure 9 Refused	TERMINATE	Thank you for your time, your number may be selected for another survey in the future.
LL08.	I need to randomly select one adult who lives in your household to be interviewed. Excluding adults living away from home, such as students away at college, how many members of your household, including yourself, are 18 years of age or older?	NUMADULT	1	Go to LL09	Read: Are you that adult? If yes: Then you are the person I need to speak with. If no: May I speak with the adult in the household?
			2-6 or more	Go to LL10.	If respondent questions why any specific individual was chosen, emphasize that the selection is random and is not limited to any certain age group or sex.
LL09.	Are you male or female?	LANDSEX	1 Male 2 Female	GO to Transition Section 1.
			3 Nonbinary 7 Don’t know/Not sure 9 Refused	Go to LL09a
LL09a.	What was your sex at birth? Was it male or female?	***NEW***	1 Male 2 Female	Go to Transition Section 1.
			7 Don’t know/Not sure 9 Refused	Go to LL09b.
LL09b.	We would like to ask questions that best allow you to report on your health status. One set of questions are about cervical health or prostate health. Which types of questions best apply to you?	***NEW***	Questions about: 1 Cervical health 2 Prostate health	Go to Transition Section 1.
			7 Don’t know/Not sure 9 Refused	TERMINATE	Thank you for your time, your number may be selected for another survey in the future.
LL10.	The person in your household that I need to speak with is the adult with the most recent birthday. Are you the adult with the most recent birthday?	***NEW***		If person indicates that they are not the selected respondent, ask for correct respondent and re-ask LL10. (See CATI programming)
LL11.	Are you male or female?	***NEW***	1 Male 2 Female	GO to Transition Section 1.
			3 Nonbinary 7 Don’t know/Not sure 9 Refused	Go to LL11a
LL11a.	What was your sex at birth? Was it male or female?	***NEW***	1 Male 2 Female	Go to Transition Section 1.
			7 Don’t know/Not sure 9 Refused	Go to LL11b.
LL11b	We would like to ask questions that best allow you to report on your health status. One set of questions are about cervical health or prostate health. Which types of questions best apply to you?	***NEW***	Questions about: 1 Cervical health 2 Prostate health	Go to Transition Section 1.
			7 Don’t know/Not sure 9 Refused	TERMINATE	Thank you for your time, your number may be selected for another survey in the future.
Transition to Section 1.			I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information If you have any questions about the survey, please call (give appropriate state telephone number).		Do not read: Introductory text may be reread when selected respondent is reached. Do not read: The sentence “Any information you give me will not be connected to any personal information” may be replaced by “Any personal information that you provide will not be used to identify you.” If the state coordinator approves the change.

Cell Phone Introduction

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CP01.	Is this a safe time to talk with you?	SAFETIME	1 Yes	Go to CP02
			2 No	([set appointment if possible]) TERMINATE]	Thank you very much. We will call you back at a more convenient time.
CP02.	Is this [PHONE NUMBER]?	CTELNUM1	1 Yes	Go to CP03
			2 No	TERMINATE
CP03.	Is this a cell phone?	CELLFON5	1 Yes	Go to CADULT1
			2 No	TERMINATE	If "no”: thank you very much, but we are only interviewing persons on cell telephones at this time
CP04.	Are you 18 years of age or older?	CADULT1	1 Yes
			2 No	TERMINATE	Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.
CP05.	Are you male or female?	CELLSEX	1 Male 2 Female	Go to CP06.	We ask this question to determine which health related questions apply to each respondent. For example, persons who report males as their sex at birth might be asked about prostate health issues.
			3 Nonbinary 7 Don’t know/Not sure 9 Refused	Go to CP05a.
CP05a.	What was your sex at birth? Was it male or female?	***NEW***	1 Male 2 Female	Go to CP06.
			7 Don’t know/Not sure 9 Refused	Go to CP05b.
CP05b.	We would like to ask questions that best allow you to report on your health status. One set of questions are about cervical health or prostate health. Which types of questions best apply to you?	***NEW***	Questions about: 1 Cervical health 2 Prostate health	Go to CP06.
			7 Don’t know/Not sure 9 Refused	TERMINATE
CP06.	Do you live in a private residence?	PVTRESD3	1 Yes	Go to CP08	Read if necessary: By private residence we mean someplace like a house or apartment Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.
			2 No	Go to CP07
CP07.	Do you live in college housing?	CCLGHOUS	1 Yes	Go to CP08	Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.
			2 No	TERMINATE	Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
CP08.	Do you currently live in___(state)____?	CSTATE1	1 Yes	Go to CP10
			2 No	Go to CP09
CP09.	In what state do you currently live?	RSPSTAT1	1 Alabama 2 Alaska 4 Arizona 5 Arkansas 6 California 8 Colorado 9 Connecticut 10 Delaware 11 District of Columbia 12 Florida 13 Georgia 15 Hawaii 16 Idaho 17 Illinois 18 Indiana 19 Iowa 20 Kansas 21 Kentucky 22 Louisiana 23 Maine 24 Maryland 25 Massachusetts 26 Michigan 27 Minnesota 28 Mississippi 29 Missouri 30 Montana 31 Nebraska 32 Nevada 33 New Hampshire 34 New Jersey 35 New Mexico 36 New York 37 North Carolina 38 North Dakota 39 Ohio 40 Oklahoma 41 Oregon 42 Pennsylvania 44 Rhode Island 45 South Carolina 46 South Dakota 47 Tennessee 48 Texas 49 Utah 50 Vermont 51 Virginia 53 Washington 54 West Virginia 55 Wisconsin 56 Wyoming 66 Guam 72 Puerto Rico 78 Virgin Islands
			77 Live outside US and participating territories 99 Refused	TERMINATE	Read: Thank you very much, but we are only interviewing persons who live in the US.
CP10.	Do you also have a landline telephone in your home that is used to make and receive calls?	LANDLINE	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		Read if necessary: By landline telephone, we mean a regular telephone in your home that is used for making or receiving calls. Please include landline phones used for both business and personal use.
CP11.	How many members of your household, including yourself, are 18 years of age or older?	HHADULT	_ _ Number 77 Don’t know/ Not sure 99 Refused	If CP07 = yes then number of adults is automatically set to 1
Transition to section 1.			I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call (give appropriate state telephone number).

Core Section 1: Health Status

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

Core Section 2: Healthy Days

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CHD.01	Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?	PHYSHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused		88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.
CHD.02	Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?	MENTHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused		88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.
				Skip CHD.03 if CHD.01, PHYSHLTH, is 88 and CHD.02, MENTHLTH, is 88
CHD.03	During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?	POORHLTH	_ _ Number of days (01-30) 88 None 77 Don’t know/not sure 99 Refused		88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.

Core Section 3: Health Care Access

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

Core Section 4: Exercise (Physical Activity)

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CEXP.01	During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?	EXERANY2	1 Yes		If respondent does not have a regular job or is retired, they may count the physical activity or exercise they spend the most time doing in a regular month.
			2 No 7 Don’t know/Not Sure 9 Refused	Go to C 11.08
CEXP.02	What type of physical activity or exercise did you spend the most time doing during the past month?	EXRACT11	__ __ Specify from Physical Activity Coding List		See Physical Activity Coding List. If the respondent’s activity is not included in the physical activity coding list, choose the option listed as “other”.
			77 Don’t know/ Not Sure 99 Refused	Go to C11.08
CEXP.03	How many times per week or per month did you take part in this activity during the past month?	EXEROFT1	1_ _ Times per week 2_ _ Times per month 777 Don’t know / Not sure 999 Refused
CEXP.04	And when you took part in this activity, for how many minutes or hours did you usually keep at it?	EXERHMM1	_:_ _ Hours and minutes 777 Don’t know / Not sure 999 Refused
CEXP.05	What other type of physical activity gave you the next most exercise during the past month?	EXRACT21	__ __ Specify from Physical Activity List		See Physical Activity Coding List. If the respondent’s activity is not included in the physical activity coding list, choose the option listed as “other”.
			88 No other activity 77 Don’t know/ Not Sure 99 Refused	Go to CEXP.08
CEXP.06	How many times per week or per month did you take part in this activity during the past month?	EXEROFT2	1_ _ Times per week 2_ _ Times per month 777 Don’t know / Not sure 999 Refused
CEXP.07	And when you took part in this activity, for how many minutes or hours did you usually keep at it?	EXERHMM2	_:_ _ Hours and minutes 777 Don’t know / Not sure 999 Refused
CEXP.08	During the past month, how many times per week or per month did you do physical activities or exercises to strengthen your muscles?	STRENGTH	1_ _ Times per week 2_ _Times per month 888 Never 777 Don’t know / Not sure 999 Refused		Do not count aerobic activities like walking, running, or bicycling. Count activities using your own body weight like yoga, sit-ups or push-ups and those using weight machines, free weights, or elastic bands.

Core Section 5: Demographics

	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
CDEM.01	What is your age?	AGE	_ _ Code age in years 07 Don’t know / Not sure 09 Refused
CDEM.02	Are you Hispanic, Latino/a, or Spanish origin?	HISPANC3	If yes, read: Are you… 1 Mexican, Mexican American, Chicano/a 2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino/a, or Spanish origin Do not read: 5 No 7 Don’t know / Not sure 9 Refused		One or more categories may be selected.
CDEM.03	Which one or more of the following would you say is your race?	MRACE1	Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 88 No choices 77 Don’t know / Not sure 99 Refused	.	If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. One or more categories may be selected. If respondent indicates that they are Hispanic for race, please read the race choices.
				If more than one response to CDEM.03; continue. Otherwise, go to CDEM.05
CDEM.04	Which one of these groups would you say best represents your race?	ORACE3	Please read: 10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 77 Don’t know / Not sure 99 Refused		If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading. If respondent has selected multiple races in previous and refuses to select a single race, code refused
				If using SOGI module, insert here. Sex at birth module may be inserted here if not used in the screening section.
CDEM.05	Are you…	MARITAL	Please read: 1 Married 2 Divorced 3 Widowed 4 Separated 5 Never married Or 6 A member of an unmarried couple Do not read: 9 Refused
CDEM.06	What is the highest grade or year of school you completed?	EDUCA	Read if necessary: 1 Never attended school or only attended kindergarten 2 Grades 1 through 8 (Elementary) 3 Grades 9 through 11 (Some high school) 4 Grade 12 or GED (High school graduate) 5 College 1 year to 3 years (Some college or technical school) 6 College 4 years or more (College graduate) Do not read: 9 Refused
CDEM.07	Do you own or rent your home?	RENTHOM1	1 Own 2 Rent 3 Other arrangement 7 Don’t know / Not sure 9 Refused		Other arrangement may include group home, staying with friends or family without paying rent. Home is defined as the place where you live most of the time/the majority of the year. Read if necessary: We ask this question in order to compare health indicators among people with different housing situations.
CDEM.08	In what county do you currently live?	CTYCODE2	_ _ _ANSI County Code 777 Don’t know / Not sure 999 Refused 888 County from another state
CDEM.09	What is the ZIP Code where you currently live?	ZIPCODE1	_ _ _ _ _ 77777 Do not know 99999 Refused
				If cell interview go to CDEM12
CDEM.10	Not including cell phones or numbers used for computers, fax machines or security systems, do you have more than one landline telephone number in your household?	NUMHHOL3	1 Yes
			2 No 7 Don’t know / Not sure 9 Refused	Go to CDEM.12
CDEM.11	How many of these landline telephone numbers are residential numbers?	NUMPHON3	__ Enter number (1-5) 6 Six or more 7 Don’t know / Not sure 8 None 9 Refused
CDEM.12	How many cell phones do you have for your personal use?	CPDEMO1B	__ Enter number (1-5) 6 Six or more 7 Don’t know / Not sure 8 None 9 Refused	Last question needed for partial complete.	Do not include cell phones that are used exclusively by other members of your household. Read if necessary: Include cell phones used for both business and personal use.
CDEM.13	Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?	VETERAN3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		Read if necessary: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.
CDEM.14	Are you currently…?	EMPLOY1	Read: 1 Employed for wages 2 Self-employed 3 Out of work for 1 year or more 4 Out of work for less than 1 year 5 A Homemaker 6 A Student 7 Retired Or 8 Unable to work Do not read: 9 Refused		If more than one, say “select the category which best describes you”.
CDEM.15	How many children less than 18 years of age live in your household?	CHILDREN	_ _ Number of children 88 None 99 Refused
CDEM.16	Is your annual household income from all sources—	***NEW***	Read if necessary: 01 Less than $10,000? 02 Less than $15,000? ($10,000 to less than $15,000) 03 Less than $20,000? ($15,000 to less than $20,000) 04 Less than $25,000 05 Less than $35,000 If ($25,000 to less than $35,000) 06 Less than $50,000 If ($35,000 to less than $50,000) 07 Less than $75,000? ($50,000 to less than $75,000) 08 Less than $100,000? ($75,000 to less than $100,000) 09 Less than $150,000? ($100,000 to less than $150,000)? 10 Less than $200,000? ($150,000 to less than $200,000) 11 $200,000 or more Do not read: 77 Don’t know / Not sure 99 Refused	SEE CATI information of order of coding; Start with category 05 and move up or down categories.	If respondent refuses at ANY income level, code ‘99’ (Refused)
				Skip if Male (MSAB.01, BIRTHSEX, is coded 1). If MSAB.01=missing and (CP05=1 or LL12=1; or LL09 = 1 or LL07 =1). Or Age >49
CDEM.17	To your knowledge, are you now pregnant?	PREGNANT	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
CDEM.18	About how much do you weigh without shoes?	WEIGHT2	_ _ _ _ Weight (pounds/kilograms) 7777 Don’t know / Not sure 9999 Refused		If respondent answers in metrics, put 9 in first column. Round fractions up
CDEM.19	About how tall are you without shoes?	HEIGHT3	_ _ / _ _ Height (ft / inches/meters/centimeters) 77/ 77 Don’t know / Not sure 99/ 99 Refused		If respondent answers in metrics, put 9 in first column. Round fractions down

Emerging Core: Long-term COVID Effects

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
COVID.01	Have you been diagnosed with COVID-19 by a healthcare provider or had a positive COVID test?	***REPLACE***	1 Yes
			2 No 7 Don’t know / Not sure 9 Refused	Skip to next section
COVID.02	Are you having any symptoms now that have lasted 3 months or longer that you did not have prior to having coronavirus or COVID-19?	***REPLACE***	1 Yes		Long term conditions may be an indirect effect of COVID 19. These long term conditions may not be related to the virus itself such as… - Tiredness or fatigue - Difficulty thinking or concentrating or forgetfulness/ memory problems (sometimes referred to as “brain fog”) - Difficulty breathing or shortness of breath - Joint or muscle pain - Fast-beating or pounding heart (also known as heart palpitations) or chest pain - Dizziness on standing - Depression, anxiety, or mood changes - Symptoms that get worse after physical or mental activities --Loss of taste or smell
			2 No 7 Don’t know / Not sure 9 Refused	Skip to next section
COVID.03	Do these symptoms you are having reduce your ability to carry out day-to-day activities compared with the time before you had coronavirus or COVID-19?	***NEW***	1 Yes 2 No 7 Don’t know / Not sure 9 Refused

Closing Statement/ Transition to Modules

Read if necessary	Read	CATI instructions (not read)
That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.		Read if no optional modules follow, otherwise continue to optional modules.

Optional Modules

Module 1: COVID Vaccination

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
MCOV.01	Have you received at least one dose of a COVID-19 vaccination?	***NEW***	1 Yes	Go to MCOV.03 (COVIDNUM)
			2 No	Go to MCOV.03 (COVACGET)
			7 Don’t know / Not sure 9 Refused	GOTO Next module
MCOV.02	How many COVID-19 vaccinations have you received?	***RESPONSE CHANGED***	1 One 2 Two 3 Three 4 Four or more 5 Five or more 7 Don’t know / Not sure 9 Refused
MCOV.03	Which of the following best describes your intent to take the recommended COVID vaccinations, including any additional and booster doses…	***REPLACE***	1 = Already received all recommended doses 2 = Plan to receive all recommended doses 3 = Do not plan to receive all recommended doses 7 = Don’t know/Not sure 9 = Refused

Module 2: Cognitive Decline

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If respondent is 45 years of age or older continue, else go to next module.
M13.01	The next few questions ask about difficulties in thinking or memory that can make a big difference in everyday activities. We want to know how these difficulties may have impacted you. During the past 12 months, have you experienced difficulties with thinking or memory that are happening more often or are getting worse?	***REPLACE***	1 Yes
			2 No 7 Don’t know/ not sure 9 Refused	Go to next module
M13.02	Are you worried about these difficulties with thinking or memory?	***NEW***	1 Yes 2 No 7 Don’t know/ not sure 9 Refused
M13.03	During the past 12 months, have your difficulties with thinking or memory interfered with day-to-day activities, such as managing medications, paying bills, or keeping track of appointments?	***REPLACE***	1 Yes 2 No 7 Don’t know/ not sure 9 Refused
M13.04	During the past 12 months, have your difficulties with thinking or memory interfered with your ability to work or volunteer?	***REPLACE***	1 Yes 2 No 7 Don’t know/ not sure 9 Refused
M13.05	Have you or anyone else discussed your difficulties with thinking or memory with a health care provider?	***REPLACE***	1 Yes 2 No 7 Don’t know/ not sure 9 Refused

Closing Statement

Read

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

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18 May 2022