2022 Field Test for 2023 BRFSS Questionnaire_20220830_clean

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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	37
Closing Statement	39



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 13 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)
Landline screening section removed from field test since sample consists of only cell phone sample.























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 cellular 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.

CP05a.
Are you ?

***NEW***
Please read:
1 Male
2 Female
3 Unspecified or another gender identity
Do not read:
7 Don’t know/Not sure
9 Refused
Go to CP06.

New 
question tested with half the field test sample from Collecting SOGI Data: Principles and Practices presentation; May 17, 2022 by Bob Sivinski,
FCSM SOGI Interest Group
CP05b.
Are you male or female?


***NEW***
1 Male
2 Female
7 Don’t know/Not sure
9 Refused
Read if necessary:
“What sex were you assigned at birth on your original birth certificate?”



Go to CP06.

Sex question from 2022 NHIS to be tested with other half of the field test sample.
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



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)
Comments
CHCA.01

Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, or Indian Health Service?
HLTHPLN1

1 Yes
2 No
7 Don’t know/Not Sure
9 Refused		


Question included for field test 
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. 
This question was taken from an optional module used in BRFSS from 2014 through 2020.  The question was used to replace the previous health care coverage question in the 2021 BRFSS core and continues in use for 2022. The phrase “health care coverage” was changed to “health Insurance” to improve understanding of the term by respondents. 







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.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—
INCOME2

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 ever tested positive for COVID-19 (using a rapid point-of-care test, self-test, or laboratory test) or been told by a doctor or other health care provider that you have or had COVID-19?” 
***REPLACE***
1 Yes


 
This question is the one used in the Census Bureau’s Household Pulse Survey fielded in June, 2022



2 No
7 Don’t know / Not sure
9 Refused
Skip to next section


COVID.02
Do you currently have symptoms lasting 3 months or longer that you did not have prior to having coronavirus or COVID-19?  

***REPLACE***
1 Yes

Read if necessary:
- 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
-menstrual changes
- Symptoms that get worse after physical or mental activities
--Loss of taste or smell
The 2022 question assessed period prevalence (from start of pandemic to survey date). Point prevalence will be more useful in 2023 for assessing health care needs because it will more closely reflect ongoing the burden of long-term symptoms as transmission wanes.



2 No
7 Don’t know / Not sure
9 Refused
Skip to next section


COVID.03
Do these long-term symptoms reduce your ability to carry out day-to-day activities compared with the time before you had COVID-19?”    
***NEW***
1 Yes, a lot
2 Yes, a little
3 Not at all
7 Don’t know / Not sure
9 Refused


Assessment of functional impairment is necessary to describe the impact of long-term COVID effects and inform and inform the public health response.  In 2023, assessing the impact of symptoms on daily activity is now a higher priority (has more information value), as frequencies of various symptoms following COVID will have been well-studied by then.



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)
Comments







MCOV.01
Have you received at least one dose of a  COVID-19 vaccination?
COVIDVA1
1 Yes

Go to MCOV.03 (COVIDNUM)





2 No 

Go to MCOV.02
(COVACGET)





7 Don’t know / Not sure
9 Refused
GOTO Next module


MCOV.02
Would you say you will definitely get a vaccine, will probably get a vaccine, will probably not get a vaccine, will definitely not get a vaccine, or are you not sure?
COVACGET
1 = Will definitely get a vaccine 
2 = Will probably get a vaccine 
3 = Will probably not get a vaccine 
4 = Will definitely not get a vaccine 
7 = Don’t know/Not sure 
9 = Refused 
Go to next section


MCOV.03
How many COVID-19 vaccinations have you received?

***RESPONSE CHANGED***
1 One
2 Two 
3 Three 
4 Four
5 Five or more
7 Don’t know / Not sure
9 Refused


With new recommendations for additional and booster doses possible by 2023, some respondents could have received as many as 5 recommended doses
MCOV.04
Which of the following best describes your intent to take COVID vaccinations?

***REPLACE***
1 = Already received all recommended doses, including boosters
2 = Plan to receive all recommended doses
3 = Do not plan to receive all recommended doses
7 = Don’t know/Not sure
9 = Refused


Since the creation of this optional module, CDC has changed the definition of “up to date” for COVID-19 vaccination to include booster doses, so adding clarifying language to the question to explain that it includes booster doses and not just the initial COVID-19 vaccine series. Will cognitively test to see if anchoring categories to “recommendations  is informative and will compare answers with MCOV.03 to see if both questions are needed..


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




The introduction was shortened to: Reduce time needed to administer.
Remove mention of specific activities from the current introduction (i.e. “forgetting how to do things you’ve always done”). These activities were removed to avoid priming respondents to answer one way or another.  
The question was changed, Removed “confusion.” Current research on subjective cognitive decline (SCD) does not suggest confusion is a major component of SCD. 
“Difficulties with thinking or memory” was a specific suggestion for phrasing by the individuals living with early-stage dementia and reflected how they would have first described their subjective symptoms with cognition.



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


This is a new question.

Current research on subjective cognitive decline (SCD) suggests a strong correlation between those who express worry about their difficulties with thinking or memory and future risk of developing dementia. This data will further identify population burden of cognitive impairment.
M13.03
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


 The change to “provider” is to align with other questions on the BRFSS. The proposed change of order — to move the question to third rather than last — is to improve the flow of questions and place similar/cascading questions next to one another.
M13.04
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


Based on current research on subjective cognitive decline (SCD), the proposed activities listed align well with difficulties first noted by those experiencing SCD. Clinical researchers on the advisory group noted that the cognitive effort required for “paying bills” was different than the effort required to “clean.” 

Further, the input from those living with early-stage dementia cited “managing medications” and “paying bills” as two of the activities when they first noticed cognitive issues in themselves. 
“keeping track of appointments” was added as another example that required similar cognitive load. 

The decision to change “given up” to “interfered with” was to resolve the ambiguity around what “given up” meant. The advisory group noted that “interfered with” would be easier for respondents to answer.  
M13.05
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


This question was simplified to ascertain additional burden among those experiencing subjective cognitive decline (SCD). “engage in social activities” was removed due to mild confusion over what the phrase meant. “outside the home” was removed since respondents may work or volunteer from home.  








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.











Activity List for Common Leisure Activities 
(To be used for Section 4: Exercise/Physical Activity)

Code Description (Physical Activity, Questions CEXP.2 and CEXP.5 above)


01.  Walking
02.  Running or jogging
03.  Gardening or yard work
04.  Bicycling or bicycling machine exercise
05.  Aerobics video or class
06.  Calisthenics
07.  Elliptical/EFX machine exercise
08.  Household activities
09.  Weight lifting
10.  Yoga, Pilates, or Tai Chi
11.  Other

•	Proposed reducing from 75 activities to 10 activities
•	Derived using most frequently reported activities 
•	Combined some activities based on intensity and using NHIS as guide