Attachment 13d List of Changes in 2021 Field Test Questionnaire

Attachment 13d: List of Changes in 2021 Field Test Questionnaire

Proposed Action/ Justification	Current question	New question
Cancer Survivorship Module: Proposed modification of questions to conform to NHIS	What type of cancer was it? 01 Breast cancer Female reproductive (Gynecologic) 02 Cervical cancer (cancer of the cervix) 03 Endometrial cancer (cancer of the uterus) 04 Ovarian cancer (cancer of the ovary) Head/Neck 05 Head and neck cancer 06 Oral cancer 07 Pharyngeal (throat) cancer 08 Thyroid 09 Larynx Gastrointestinal 10 Colon (intestine) cancer 11 Esophageal (esophagus) 12 Liver cancer 13 Pancreatic (pancreas) cancer 14 Rectal (rectum) cancer 15 Stomach Leukemia/Lymphoma (lymph nodes and bone marrow) 16 Hodgkin's Lymphoma (Hodgkin’s disease) 17 Leukemia (blood) cancer 18 Non-Hodgkin’s Lymphoma Male reproductive 19 Prostate cancer 20 Testicular cancer Skin 21 Melanoma 22 Other skin cancer Thoracic 23 Heart 24 Lung Urinary cancer 25 Bladder cancer 26 Renal (kidney) cancer Others 27 Bone 28 Brain 29 Neuroblastoma 30 Other Do not read: 77 Don’t know / Not sure 99 Refused	What kind of cancer is it? 01 Bladder 02 Blood 03 Bone 04 Brain 05 Breast 06 Cervix/Cervical 07 Colon 08 Esophagus/Esophageal 09 Gallbladder 10 Kidney 11 Larynx-trachea 12 Leukemia 13 Liver 14 Lung 15 Lymphoma 16 Melanoma 17 Mouth/tongue/lip 18 Ovary/Ovarian 19 Pancreas/Pancreatic 20 Prostate 21 Rectum/Rectal 22 Skin (non-melanoma) 23 Skin (don't know what kind) 24 Soft tissue (muscle or fat) 25 Stomach 26 Testis/Testicular 27 Throat - pharynx 28 Thyroid 29 Uterus/Uterine 30 Other 97 Refused 99 Don't Know
Prostate Cancer: Proposed modification of questions to conform to NHIS	Has a doctor, nurse, or other health professional ever talked with you about the advantages of the Prostate-Specific Antigen or P.S.A. test? Yes/No Has a doctor, nurse, or other health professional ever talked with you about the disadvantages of the P.S.A. test? Yes/No	When you met with a doctor, nurse, or other health professional, did they talk about the advantages, the disadvantages, or both advantages and disadvantages of the prostate-specific antigen or PSA test? 1 Advantages 2 Disadvantages 3 Both advantages and disadvantages 7 Don’t Know / Not sure 9 Refused
Prostate Cancer: Proposed modification of questions to conform to NHIS	Has a doctor, nurse, or other health professional ever recommended that you have a P.S.A. test? Yes/No	Who first suggested this PSA test: you, your doctor, or someone else? 1 Self 2 Doctor, nurse, health care professional 3 Someone else 7 Don’t Know / Not sure 9 Refused
Prostate Cancer: Proposed modification of questions to conform to NHIS	What was the main reason you had this P.S.A. test – was it …? Please read: 1 Part of a routine exam 2 Because of a prostate problem 3 Because of a family history of prostate cancer 4 Because you were told you had prostate cancer 5 Some other reason	What was the MAIN reason you had this PSA test – was it …? Please read: 1 Part of a routine exam 2 Because of a problem 3 other reason
Lung Cancer: Proposed modification of questions to conform to NHIS	The next question is about CT or CAT scans. During this test, you lie flat on your back on a table. While you hold your breath, the table moves through a donut shaped x-ray machine while the scan is done. In the last 12 months, did you have a CT or CAT scan? Read if necessary: 1 Yes, to check for lung cancer 2 No (did not have a CT scan) 3 Had a CT scan, but for some other reason Do not read: 7 Don't know/not sure 9 Refused	The next question is about CT or CAT scans of your chest area. During this test, you lie flat on your back and are moved through an open, donut shaped x-ray machine. Were any of the CT or CAT scans of your chest area done mainly to check or screen for lung cancer? 1 Yes [go to Q5], 2 No [go to next section] Do not read: 7 Don't know/not sure 9 Refused 5.When did you have your most recent CT or CAT scan of your chest area mainly to check or screen for lung cancer? Read only 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) 3 Within the past 3 years (2 years but less than 3 years) 4 Within the past 5 years (3 years but less than 5 years) 5 Within the past 10 years (5 years but less than 10 years ago) 6 or more years ago Do not read: 7 Don’t know / Not sure 9 Refused
Chronic Health Conditions: add clarification to skin cancer	(Ever told) (you had) skin cancer?	(Ever told) (you had) skin cancer that is not melanoma?
Chronic Health Conditions: add melanoma to other types of cancer	(Ever told) (you had) any other types of cancer?	(Ever told) (you had) melanoma or any other types of cancer?
Change interviewer notes	Interview notes: Marijuana and cannabis include both CBD and THC products.	Interview notes to state: “The following questions are about marijuana or cannabis. Do not include hemp-based or CBD-only products in your responses.”
Make separate questions for each type of marijuana use	During the past 30 days, which one of the following ways did you use marijuana the most often? Did you usually… 1 Smoke it (for example, in a joint, bong, pipe, or blunt). 2 Eat it (for example, in brownies, cakes, cookies, or candy) 3 Drink it (for example, in tea, cola, or alcohol) 4 Vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device) 5 Dab it (for example, using waxes or concentrates), or 6 Use it some other way. Do not read: 7 Don’t know/not sure 9 Refused	1.During the past 30 days, did you smoke it (for example, in a joint, bong, pipe, or blunt)? 2.During the past 30 days, did you eat it or drink it (for example, in brownies, cakes, cookies, or candy, or in tea, cola, or alcohol)? 3.During the past 30 days, did you vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device)? 4.During the past 30 days, did you dab it (for example, using a dabbing rig, knife, or dab pen)? 5.During the past 30 days, did you use it some other way?
New question for eye examination	N/A	When was the last time a doctor, nurse, or other health professional took a photo of the back of your eye with a specialized camera?
New question type of diabetes	N/A	According to your doctor or other health professional, what type of diabetes do you have?
Family Planning: New introductory question	N/A	In the past 12 months, did you have sex where a penis is inserted into the vagina, sometimes called penile‐vaginal sex? 1 Yes 2 No [GO TO NEXT MODULE]
Family Planning: Changes in wording	N/A	The last time you had penile-vaginal sex, did you or your partner do anything to keep you from getting pregnant?
	The last time you had sex with a man, what did you or your partner do to keep you from getting pregnant? Read if necessary: 01 Female sterilization (ex. Tubal ligation, Essure, Adiana) 02 Male sterilization (vasectomy) 03 Contraceptive implant (ex. Nexplanon, Jadelle, Sino Implant, Implanon) 04 IUD, Levonorgestrel (LNG) or other hormonal (ex. Mirena, Skyla, Liletta, Kylena) 05 IUD, Copper-bearing (ex. ParaGard) 06 IUD, type unknown 07 Shots (ex. Depo-Provera or DMPA) 08 Birth control pills, any kind 09 Contraceptive patch (ex. Ortho Evra, Xulane) 10 Contraceptive ring (ex. NuvaRing) 11 Male condoms 12 Diaphragm, cervical cap, sponge 13 Female condoms 14 Not having sex at certain times (rhythm or natural family planning) 15 Withdrawal (or pulling out) 16 Foam, jelly, film, or cream 17 Emergency contraception (morning after pill) 18 Other method Do not read: 77 Don’t know/ Not sure 99 Refused	The last time you had penile-vaginal sex, what did you or your partner do to keep you from getting pregnant? Read if necessary: 01 Female sterilization (Tubal ligation, Essure, or Adiana) 02 Male sterilization (vasectomy) 03 Contraceptive implant 04 Intrauterine device or IUD (Mirena, Levonorgestrel, ParaGard) 05 Shots (Depo-Provera) 06 Birth control pills, Contraceptive Ring (NuvaRing), Contraceptive patch (Ortho Evra) 07 Condoms (male or female) 08 Diaphragm, cervical cap, sponge, foam, jelly, film, or cream 09 Had sex at a time when less likely to get pregnant (rhythm or natural family planning) 10 Withdrawal or pulling out 11 Emergency contraception or the morning after pill (Plan B or ella) 12 Other method The last time you had penile-vaginal sex, what else, if anything, did you or your partner do to keep you from getting pregnant? Read only if respondent is unable to provide a response: (866-867 – TYPCNTR7) 00 Nothing else 01 Female sterilization (Tubal ligation, Essure, or Adiana) 02 Male sterilization (vasectomy) 03 Contraceptive implant 04 Intrauterine device or IUD (Mirena, Levonorgestrel, ParaGard) 05 Birth control pills, Contraceptive Ring (NuvaRing), Contraceptive patch (Ortho Evra) 06 Shots (Depo-Provera), 07 Condoms (male or female) 08 Diaphragm, cervical cap, sponge, foam, jelly, film, or cream 09 Had sex at a time when less likely to get pregnant (rhythm or natural family planning) 10 Withdrawal or pulling out 11 Emergency contraception or the morning after pill (Plan B or Ella) 12 Other method Where did you get the [response from Q3] you used when you last had penile-vaginal sex? 01 Private doctor’s office [GO TO Q7] 02 Community health clinic, Community clinic, Public health clinic [GO TO Q7] 03 Family planning or Planned Parenthood Clinic [GO TO Q7] 04 School or school-based clinic [GO TO Q7] 05 Hospital outpatient clinic, emergency room, regular hospital room [GO TO Q7] 06 Urgent care center, urgi-care or walk-in facility [GO TO Q7] 07 In- store health clinic (like CVS, Target, or Walmart) [GO TO Q7] 08 Health care visit with a pharmacist [GO TO Q7] 09 Website or app [GO TO Q7] 10 Some other place [GO TO Q7]
Family Planning: Wording changes	Some reasons for not doing anything to keep you from getting pregnant the last time you had sex might include wanting a pregnancy, not being able to pay for birth control, or not thinking that you can get pregnant. What was your main reason for not using a method to prevent pregnancy the last time you had sex with a man? Read if necessary: 01 You didn’t think you were going to have sex/no regular partner 02 You just didn’t think about it 03 Don’t care if you get pregnant 04 You want a pregnancy 05 You or your partner don’t want to use birth control 06 You or your partner don’t like birth control/side effects 07 You couldn’t pay for birth control 08 You had a problem getting birth control when you needed it 09 Religious reasons 10 Lapse in use of a method 11 Don’t think you or your partner can get pregnant (infertile or too old) 12 You had tubes tied (sterilization) 13 You had a hysterectomy 14 Your partner had a vasectomy (sterilization 15 You are currently breast-feeding 16 You just had a baby/postpartum 17 You are pregnant now 18 Same sex partner 19 Other	What was your main reason for not doing anything to prevent pregnancy the last time you had penile-vaginal sex? Read only if respondent is unable to provide a response: 01 You didn’t think you were going to have sex/no regular partner 02 You just didn’t think about it 03 You wanted a pregnancy 04 You didn’t care if you got pregnant 05 You or your partner didn’t want to use birth control (side effects, don’t like birth control) 06 You had trouble getting or paying for birth control 07 You didn’t trust giving out your personal information to medical personnel 08 Didn’t think you or your partner could get pregnant (infertile or too old) 09 You were using withdrawal or “pulling out” 10 You had your tubes tied (sterilization) 11 Your partner had a vasectomy (sterilization) 12 You were breast-feeding or you just had a baby 13 You were assigned male at birth 14 Other reasons
Family Planning: New question	N/A	If you could use any birth control method you wanted, what method would you use? 01 Female sterilization (Tubal ligation, Essure, or Adiana) [GO TO NEXT MODULE] 02 Male sterilization (vasectomy) [GO TO NEXT MODULE] 03 Contraceptive implant [GO TO NEXT MODULE] 04 Intrauterine device or IUD (Mirena, Levonorgestrel, ParaGard) [GO TO NEXT MODULE] 05 Shots (Depo-Provera) [GO TO NEXT MODULE] 06 Birth control pills, Contraceptive Ring (NuvaRing), Contraceptive patch (Ortho Evra) [GO TO NEXT MODULE] 07 Condoms (male or female) [GO TO NEXT MODULE] 08 Diaphragm, cervical cap, sponge, foam, jelly, film, or cream [GO TO NEXT MODULE] 09 Having sex at a time when less likely to get pregnant (rhythm or natural family planning) [GO TO NEXT MODULE] 10 Withdrawal or pulling out [GO TO NEXT MODULE] 11 Emergency contraception or the morning after pill (Plan B or ella) [GO TO NEXT MODULE] 12 Other method [GO TO NEXT MODULE] 13 I am using the method that I want to use [GO TO NEXT MODULE] 14 I don’t want to use any method [GO TO NEXT MODULE]
Tobacco Use; Add Heated tobacco products questions to determine prevalence of use of new products	N/A	Introductory language: “The next question is about heated tobacco products. Some people refer to these as “heat-not-burn” tobacco products. These heat TOBACCO STICKS or CAPSULES to produce a vapor. They are different from e-cigarettes, which heat a LIQUID to produce a vapor. Some brands of heated tobacco products include iQOS (PRONOUNCED “eye-kos”), glo (PRONOUNCED “glow”), and Eclipse.”
Add Heated tobacco products. (HTP)	N/A	Do you now use heated tobacco products every day, some days, or not at all? 1. Every day 2. Some days 3. Not at all 7. DON’T KNOW/NOT SURE 8. REFUSED
This is an alternative question on HTP. Only one HTP question will be added pending the results of BRFSS field testing. If prevalence of current use of HTP is <1% during the BRFSS filed test, this awareness question will be chosen. Otherwise, the current use question above will be chosen.	N/A	Before today, have you heard of heated tobacco products”? 1. YES 2. NO 7. DON’T KNOW/NOT SURE 8. REFUSED
Tobacco use: Menthol cigarettes question to determine whether flavor of tobacco products encourages younger use	N/A	Currently, when you smoke cigarettes, do you usually smoke menthol cigarettes… 1. YES 2. NO 7. DON’T KNOW/NOT SURE 8. REFUSED
Menthol e-cigarettes question	N/A	3.Currently, when you use e-cigarettes, do you usually use menthol e-cigarettes… 1. YES 2. NO 7. DON’T KNOW/NOT SURE 8. REFUSED
COVID Vaccination Module: Previously approved through the NCIRD	N/A	Have you had a COVID-19 vaccination? How many COVID-19 vaccinations have you received? Ask if respondent reported receiving one dose of COVID-19 vaccine, or reported having been vaccinated but not sure number of doses: Which of the following best describes your intent to take the recommended COVID vaccinations…would you say you have already received all recommended doses, plan to receive all recommended doses or do not plan to receive all recommended doses? During what month and year did you receive your (first) COVID-19 vaccination? During what month and year did you receive your second COVID-19 vaccination?
Emerging Core Long Term COVID Effects. One year module to assess chronic conditions related to COVID	N/A	Has a doctor, nurse, or other health professional ever told you that you tested positive for COVID 19?
	N/A	Did you have any symptoms lasting 3 months or longer that you did not have prior to having coronavirus or COVID-19?
	N/A	Which of the following was the primary symptom that you experienced? Was it…. 1 Tiredness or fatigue 2 Difficulty thinking or concentrating or forgetfulness/memory problems (sometimes referred to as “brain fog”) 3 Difficulty breathing or shortness of breath 4 Joint or muscle pain 5 Fast-beating or pounding heart (also known as heart palpitations) or chest pain 6 Dizziness on standing 7 Depression, anxiety, or mood changes 8 Symptoms that get worse after physical or mental activities 9 You did not have any long-term symptoms that limited your activities.77 Don’t know/Not sure 99 Refused