0920-0950 NHANES Refuser No Show Questionnaire

Attachment 3f4

OMB No. 0920-0950

National Health and Nutrition Examination Survey

Centers for Disease
Control and Prevention
National Center for
Health Statistics
The Nation’s Mobile Health Survey

Survey of NHANES
Participants’ Experiences
Sponsored by: Centers for Disease Control and Prevention

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton
Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0950).
Assurance of Confidentiality –We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or
an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the
consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information
Protection and Statistical Efficiency Act of 2018 (CIPSEA Public Law No. 115-435, 132 Stat. 5529 Sec. 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. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note)
which protects Federal information systems from cybersecurity risks by screening their networks.

Household Interview
A3. People participate in NHANES for many
different reasons. We would like to
understand why you chose to take part.
Please select up to 3 reasons why you
participated in the NHANES interview.

These first questions are about the household
interview.
A1. We would like to know about your experience
with our NHANES staff. How satisfied were
you overall with the health representative
that completed your interview? Were you…

† The health representative who called/visited
my home
† The importance of the study data for health
care providers, policy makers, and researchers
† The $25 token of appreciation
† NHANES is sponsored by the Centers for
Disease Control and Prevention (CDC)
† Helping my children’s and grandchildren’s
future health
† Doing my civic duty
† Other–Please Specify

† Very satisfied
† Satisfied
† Neither satisfied nor unsatisfied
† Unsatisfied
† Very unsatisfied
A2. Did you feel the interview was too long, about
the right length, or not long enough?

† Too long
† About the right length
† Not long enough

For each of the following, please tell me if you strongly agree, somewhat agree, neither agree nor disagree,
somewhat disagree, or strongly disagree with each statement.
Strongly
Agree

A4.
A5.
A6.
A7.
A8.
A9.

The information I gave during my NHANES
interview will help health care providers,
policy makers, and researchers.
It’s important for me to know as much about
my health as possible.
The government has too much information
about me already.
I participate in local activities through
my neighborhood/community/religious
organization/school.
I feel stressed about completing the things
I need to do each day.
Data collected by government agencies are
used to help improve our country.

A10. I avoid going to the doctor.
A11.
XXXXX

People have lost control over how their
personal information is used.
2

Somewhat
Agree

Neither
SomeAgree nor
what
Disagree Disagree

Strongly
Disagree

Mobile Exam Center (MEC)
B2. How concerned were you that you or someone
in your home could get sick with COVID-19 by
having a NHANES health exam?

After completing the interview, NHANES
participants are invited to schedule a health exam
at our Mobile Examination Center (MEC). We would
like to better understand why you chose not to
take part in this part of the study.

† Very concerned
† Somewhat concerned
† Neither concerned nor unconcerned
† Not very concerned
† Not concerned at all.

B1. How important was the COVID-19 pandemic in
your decision to not have a health exam?

† Very important
† Somewhat important
† Neither important nor unimportant
† Not very important
† Not important at all

For each of the following, please tell me if you strongly agree, somewhat agree, neither agree nor disagree,
somewhat disagree, or strongly disagree with each statement.
Strongly
Agree

B3.

The MEC was too far away/too inconvenient/
difficult to get to.

B4. The exam would have taken too much time.
B5. I didn’t trust my NHANES health representative.
I thought NHANES was going to offer me/
make me get a COVID-19 vaccine.
I didn’t want to give the government my
B7.
medical information.

B6.

B8. I had too many other responsibilities.
B9. I didn’t trust that my information would be kept safe.
B10. The exam wasn’t mandatory.
B11. I didn’t think it was important.
B12. I was too sick to participate.
B13. There was nothing in it for me.
B14. I don’t like wearing masks.
B15.

XXXXX

Others in my home were not vaccinated
against COVID-19/ are immunocompromised.

3

Somewhat
Agree

Neither
SomeAgree nor
what
Disagree Disagree

Strongly
Disagree

B16 .

As a “thank you” for completing the MEC
exam, NHANES offered you $85 for
your time and service. How important was
this amount in your decision to
not participate?

B17 . For you to take part in the MEC exam,
what incentive amount would NHANES
need to offer?

† Very important
† Somewhat important
† Neither important nor unimportant
† Not very important
† Not important at all

B18 . Is there anything else you would like to share about why you chose not to participate in the MEC exam,
or if there was anything we could have done that would have led you to participate?

B19 . Is there anything we could have done to improve your overall NHANES experience?

Thank you for your participation in this survey and with NHANES. If you have any questions or concerns, please contact us Monday through
Friday between 9:00 am and 9:00 pm EST, or Saturday and Sunday between 10:00 am and 6:00 pm EST at (888)-458-4762.

XXXXX

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