Attachment D – Round 1 (2023) Burden Estimate and Questionnaire
The NCHS RSS Round 1 (2023) data collection is based on 13,100 complete surveys (4,367 hours) and 20 cognitive interviews (20 hours) using the same survey instrument. The total number of responses is 13,120 and the total burden is 4,387 hours.
Type of Respondents |
Form name |
Number of Respondents |
Number of Responses per Respondent |
Average Burden per Response (in hours) |
Total Burden Hours |
Adults 18+ |
Survey: NCHS RSS Round 1 (2023) |
13,100 |
1 |
20/60 |
4,367 |
Cognitive Interview: NCHS RSS Round 1 (2023) |
20 |
1 |
1 |
20 |
|
|
Total |
13,120 |
|
|
4,387 |
OMB No. 0920-xxxx
Expiration Date xx/xx/xxxx
NCHS
Rapid Survey System - BY R1
MODE = WEB, CATI
REFUSALS/DON’T KNOW:
CAWI REFUSALS/DK:
DO NOT INCLUDE DON’T KNOW/REFUSED OPTIONS ON SCREEN FOR CAWI UNLESS SPECIFIED IN ITEM RESPONSE OPTIONS. CODE REFUSALS/SKIPS AS FOLLOWS:
IMPLICIT REFUSAL/WEB SKIP = -6
CATI REFUSALS/DK:
INCLUDE THE FOLLOWING DON’T KNOW/REFUSED OPTIONS FOR INTERVIEWERS ON SCREEN FOR ALL QUESTIONS IN CATI. INTERVIEWERS SHOULD NOT READ REF/DK OPTIONS UNLESS OTHERWISE SPECIFIED IN RESPONSE OPTIONS. CODE AS FOLLOWS:
REFUSAL = -7
DON’T KNOW = -9
LEGITIMATE SKIPS
CODE ALL LEGITIMATE SKIPS FOR CATI AND CAWI AS FOLLOWS:
LEGITIMATE SKIP = -8
QUESTION INFORMATION FORMATTING:
ALL QUESTION INFORMATION WILL BE FORMATTED AS FOLLOWS:
[UNIVERSE/SKIP LOGIC]
[QUESTION TYPE]
S = SINGLE RESPONSE
M = MULTI-CHECK
NUMBOX = NUMERIC INPUT
TEXTBOX = TEXT INPUT
GRID
VARIABLE NAME
QUESTION STEM
IF CAWI/CATI QUESTION TEXT IS DIFFERENT, “[CAWI]” AND “[CATI]” WILL PRECEDE MODE SPECIFIC TEXT
CAWI RESPONSE OPTIONS
CATI RESPONSE OPTIONS
CATI INSTRUCTIONS AND RESPONSE OPTIONS THAT SHOULD NOT BE READ WILL BE IN ALL CAPS. CATI RESPONSE OPTIONS WILL ALSO INCLUDE “DO NOT READ” INSTRUCTIONS; ELSE CATI TEXT/RESPONSE OPTIONS SHOULD BE READ BY INTERVIEWER
ON WEB DISPLAY ONE ITEM PER PAGE UNLESS OTHERWISE SPECIFIED.
CREATE VARIABLES:
QUEX_LANG
BASED
ON LANGUAGE SELECTED IN INSTRUMENT:
ENGLISH = 1
SPANISH = 2
GROUP
RANDOMLY ASSIGN 25% OF PARTICIPANTS TO EACH OF FOUR GROUPS
GROUP = 1-4
PRELOAD PROFILE DEMOGRAPHICS AND RENAME/CREATE VARIABLES AS FOLLOWS:
HHSIZE
NUMERIC HH SIZE, CAPPED AT 6+
AGE
NORC = DOB (RECODE DOB TO AGE IN YEARS)
IPSOS = AGECONS
NUMERIC AGE IN YEARS
SEX
NORC = GENDER_BIRTH
IPSOS = QGENDER
1 MALE
2 FEMALE
EDUCATION
NORC = EDUCATION
IPSOS = Q15 AND Q15A
(RECODE INTO ONE VARIABLE)
1 No formal education
2 1st, 2nd, 3rd, or 4th grade
3 5th or 6th grade
4 7th or 8th grade
5 9th grade
6 10th grade
7 11th grade
8 12th grade NO DIPLOMA
9 HIGH SCHOOL GRADUATE - high school DIPLOMA or the equivalent (GED)
10 Some college, no degree
11 Associate degree
12 Bachelor's degree
13 Master's degree
15 Professional or Doctorate degree
RACE
NORC = RACE_1
IPSOS = CPSRACE &
CPSASIAN (RECODE INTO ONE VARIABLE)
1 White
2 Black or African American
3 American Indian or Alaska Native
4 Asian Indian
5 Chinese
6 Filipino
7 Japanese
8 Korean
9 Vietnamese
10 Other Asian
11 Native Hawaiian
12 Guamanian or Chamorro
13 Samoan
14 Other Pacific Islander
15 Some other race
HISPAN
NORC = HISPAN
IPSOS = Q13
Not Hispanic
Mexican, Mexican American, Chicano
Puerto Rican
Cuban
Other Spanish/Hispanic/Latino
INCOME
NORC = INCOME
IPSOS = Q35 & Q36
(RECODE INTO ONE VARIABLE)
Less than $5,000
$5,000 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999
$35,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $74,999
$75,000 to $84,999
$85,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 to $174,999
$175,000 to $199,999
$200,000 or more
NORC/IPSOS: AS NECESSARY, INCLUDE YOUR STANDARD PANEL CAWI INTRO SCREENS AND CATI INBOUND/OUTBOUND/CALLBACK/VOICEMAIL SCRIPTS BEFORE “INTRODUCTION.”
INTRODUCTION
[DISPLAY IF CAWI]
The National Center for Health Statistics, part of the Centers for Disease Control and Prevention, is conducting a study and we need your help. We are interested in your health and wellness and will be asking you a series of questions about your health history, behaviors, and opinions. This should take about 20 minutes or less to complete. Participation in this survey is completely voluntary, and you may skip any question(s) you do not want to answer and may quit the survey at any time. The information being collected is for research purposes only and will assist NCHS and CDC in their ongoing efforts to track the health of the American public. Your data will be kept confidential, will be used for statistical purposes only, and will not be disclosed or released to other persons without your consent in accordance with Section 308(d) of the Public Health Service Act [42 U.S.C. 242m(d)] and the Confidential Information and Statistical Efficiency Act Protection and Statistical Efficiency Act of 2018 (CIPSEA Pub. L. No. 115-435, 132 Stat. 5529 § 302).
If you have any questions about your rights as a participant in this research study, call NCHS’ Confidentiality Officer at (888) 642-1459.
[PROGRAMMER: REDUCE TEXT SIZE SLIGHTLY; TEXT BELOW BOARDED BY THIN BLACK BOX/OUTLINE]
CDC estimates the average public reporting burden for this collection of information as 20 minutes 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 (0920-0214). 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 (44 U.S.C. 3561-3583). 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. |
[DISPLAY IF CATI]
We are asking for your help on behalf of the National Center for Health Statistics, part of the Centers for Disease Control and Prevention.
This survey will take on average 20 minutes to complete.
Participation in this survey is completely voluntary, and you may skip any question(s) you do not want to answer and may quit the survey at any time.
The information being collected is for research purposes only and will assist NCHS and CDC in their ongoing efforts to track the health of the American public.
Your data will be kept confidential, and will be used for statistical purposes only by NCHS staff and agents and will not be disclosed or released to other persons without your consent.
If you have any questions about your rights as a participant in this research study, call NCHS’ Confidentiality Officer at (888) 642-1459.
[PROGRAMMER: REDUCE TEXT SIZE SLIGHTLY; TEXT BELOW BOARDED BY THIN BLACK BOX/OUTLINE]
[CATI] READ THE FOLLOWING IF THE RESPONDENT HAS ADDITIONAL QUESTIONS ABOUT BURDEN, PRIVACY, OR CONFIDENTIALITY
CDC estimates the average public reporting burden for this collection of information as 20 minutes 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 (0920-0214). 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 (44 U.S.C. 3561-3583). 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. |
[PROGRAMMER: SECTION HEADERS ARE FOR INTERNAL USE ONLY. DO NOT PROGRAM TO APPEAR ON SCREEN.]
[CREATE “START_TIME” AND “START_DATE”; RECORD START_TIME IN HH:MM:SS; RECORD START_DATE IN MM:DD:YYYY]
HIS - SELF-REPORTED HEALTH STATUS
[CREATE “START_HIS” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
HIS_GENERAL
[CAWI] Would you say your health in general is…
[CATI] Would you say your health in general is excellent, very good, good, fair, or poor?
[CAWI RESPONSE OPTIONS:]
1 Excellent
2 Very good
3 Good
4 Fair
5 Poor
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 EXCELLENT
2 VERY GOOD
3 GOOD
4 FAIR
5 POOR
[CREATE “END_HIS” AND RECORD TIME IN HH:MM:SS]
CHR - CHRONIC CONDITIONS
[CREATE “START_CHR” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
CHR_HYPEV
Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?
[CATI] ENTER '1' (YES) IF RESPONDENT IS TAKING MEDICATION TO CONTROL HIS/HER HIGH BLOOD PRESSURE.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF CHR_HYPEV= 1]
[S]
CHR_HYPDIF
Were you told on two or more different visits that you had hypertension or high blood pressure?
[CATI] ENTER '1'(YES) IF RESPONDENT IS TAKING MEDICATION TO CONTROL HIS/HER HIGH BLOOD PRESSURE.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF CHR_HYPDIF = 1]
[S]
CHR_HYP12M
During the past 12 months, have you had hypertension or high blood pressure?
[CATI] ENTER '1' IF RESPONDENT IS TAKING MEDICATION TO CONTROL HIS/HER HIGH BLOOD PRESSURE.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF CHR_HYPEV= 1]
[S]
CHR_HYPMED
Are you now taking any medication prescribed by a doctor for your high blood pressure?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
CHR_CHLEV
Have you ever been told by a doctor or other health professional that you had high cholesterol?
[CATI] ENTER '1' IF RESPONDENT IS TAKING MEDICATION TO CONTROL HIS/HER HIGH CHOLESTEROL.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
CHR_CHDEV
Have you ever been told by a doctor or other health professional that you had coronary heart disease?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
CHR_ASEV
Have you ever been told by a doctor or other health professional that you had asthma?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
CHR_CANEV
Have you ever been told by a doctor or other health professional that you had cancer or malignancy of any kind?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[CREATE “END_CHR” AND RECORD TIME IN HH:MM:SS]
DIB - DIABETES
[CREATE “START_DIB” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
DIB_PREDIB
Has a doctor or other health professional ever told you that you had prediabetes or borderline diabetes?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF SEX = 2]
[S]
DIB_GESDIB
Has a doctor or other health professional ever told you that you had gestational diabetes, a type of diabetes that only occurs during pregnancy?
[CAWI] Gestational diabetes is a diabetes that you did not have prior to being pregnant and goes away after you are pregnant. Pregnant women are usually screened for gestational diabetes during the 24th to 28th week of pregnancy.
[CATI] READ IF NECESSARY: Gestational diabetes is a diabetes that you did not have prior to being pregnant and goes away after you are pregnant. Pregnant women are usually screened for gestational diabetes during the 24th to 28th week of pregnancy.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
DIB_DIBEV
[IF DIB_GESDIB = 1 AND DIB_PREDIB = 0, -6,-7,-9, FILL: Not including gestational diabetes, has; IF DIB_PREDIB = 1 AND DIB_GESDIB = 0, -6,-7,-9, FILL: Not including prediabetes, has; IF DIB_GESDIB = 1 AND DIB_PREDIB = 1, FILL: Not including prediabetes or gestational diabetes, has; ELSE, FILL: Has] a doctor or other health professional ever told you that you had diabetes?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[CREATE “END_DIB” AND RECORD TIME IN HH:MM:SS]
BMI - BMI/OBESITY
[CREATE “START_BMI” AND RECORD TIME IN HH:MM:SS]
[SHOW IF SEX = 2 AND AGE <=49]
[S]
BMI_PREGNOW
Are you currently pregnant?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[NUMBOX]
BMI_HEIGHT
How tall are you without shoes?
[CATI] IF HEIGHT IS LESS THAN 2 FEET, ENTER 2. IF HEIGHT IS GREATER THAN 7 FEET, ENTER 7.
[PROGRAMMER: INCLUDE SEPARATE NUMBOX FOR FEET AND INCHES ON SAME ROW WITH CORRESPONDING LABELS; ALSO INCLUDE A SINGLE SELECT OPTION TO REPORT HEIGHT IN CENTIMETERS DIRECTLY BELOW NUMBOX ENTRIES.]
BMI_HEIGHTFT
[NUMBOX] feet [RANGE = 2-9]
BMI_HEIGHTIN
[NUMBOX] inches [RANGE = 0-11]
Report height in centimeters
[PROMPT IF BMI_HEIGHTFT OUT OF RANGE: PLEASE ENTER A NUMBER OF FEET BETWEEN 2 AND 9.]
[PROMPT IF BMI_HEIGHTIN OUT OF RANGE: PLEASE ENTER A NUMBER OF INCHES BETWEEN 0 AND 11.]
[IF BMI_HEIGHT = 1, SHOW BMI_CEN ON SAME SCREEN AND HIDE BMI_HEIGHTFT AND BMI_HEIGHTIN]
[NUMBOX]
BMI_CEN.
[NUMBOX] centimeters [RANGE = 60-213]
[PROMPT IF BMI_CEN OUT OF RANGE: PLEASE ENTER A NUMBER OF CENTIMETERS BETWEEN 60 AND 213.]
[SHOW ALL]
[NUMBOX]
BMI_WEIGHT
[IF BMI_PREGNOW = 1, FILL: How much did you weigh before your pregnancy?; ELSE, FILL: How much do you weigh?]
[CATI] IF WEIGHT IS LESS THAN 50 POUNDS, ENTER 50. IF WEIGHT IS GREATER THAN 500 POUNDS, ENTER 500.
[PROGRAMMER: INCLUDE SEPARATE NUMBOX FOR POUNDS WITH CORRESPONDING LABEL; ALSO INCLUDE A SINGLE SELECT OPTION TO REPORT HEIGHT IN KILOGRAMS DIRECTLY BELOW NUMBOX.]
BMI_LB
[NUMBOX] pounds [RANGE = 10-999]
Report weight in kilograms
[PROMPT IF OUT OF RANGE: PLEASE ENTER A NUMBER OF POUNDS BETWEEN 10 AND 999.]
[IF BMI_WEIGHTLB = 1, SHOW BMI_KILO ON SAME SCREEN AND HIDE BMI_LB]
BMI_KILO.
[NUMBOX] kilograms [RANGE = 5-453]
[PROMPT IF OUT OF RANGE: PLEASE ENTER A NUMBER OF KILOGRAMS BETWEEN 5 AND 453.]
[CREATE “END_BMI” AND RECORD TIME IN HH:MM:SS]
SOC - SOCIAL/WORK LIMITATIONS
[CREATE “START_SOC” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
SOC_ERRANDS
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone, such as visiting a doctor's office or shopping? [CATI] Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?
[CAWI RESPONSE OPTIONS:]
1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do this at all
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 NO DIFFICULTY
2 SOME DIFFICULTY
3 A LOT OF DIFFICULTY
4 CANNOT DO THIS AT ALL
[SHOW ALL]
[S]
SOC_PARACTIV
Because of a physical, mental, or emotional condition, do you have difficulty participating in social activities, such as visiting friends, attending clubs and meetings, or going to parties? [CATI] Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?
[CAWI RESPONSE OPTIONS:]
1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do this at all
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 NO DIFFICULTY
2 SOME DIFFICULTY
3 A LOT OF DIFFICULTY
4 CANNOT DO THIS AT ALL
[SHOW ALL]
[S]
SOC_SCWRKLIM
Are you limited in the kind or amount of work you can do because of a physical, mental, or emotional problem?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[CREATE “END_SOC” AND RECORD TIME IN HH:MM:SS]
PAY - SOCIAL DETERMINANTS: PAYING MEDICAL BILLS
[CREATE “START_PAY” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
PAY_PAYWORRY
If you get sick or have an accident, how worried are you that you will be able to pay your medical bills? [CATI] Are you very worried, somewhat worried, or not at all worried?
1 Very worried
2 Somewhat worried
3 Not at all worried
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 VERY WORRIED
2 SOMEWHAT WORRIED
3 NOT AT ALL WORRIED
[CREATE “END_PAY” AND RECORD TIME IN HH:MM:SS]
CVL - LONG COVID
[CREATE “START_CVL” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
CVL_HEARDEV
When people have symptoms for weeks, months, or even years after COVID-19 infection, it is called Long COVID. Some people also refer to it as Post-COVID Conditions.
Before today, had you ever heard of Long COVID?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF CVL_HEARDEV=1]
CVL_DSPL
How much do you agree or disagree with each of the following statements about Long COVID? [CATI] Would you say you strongly disagree, somewhat disagree, somewhat agree, strongly agree, or don’t know?
[CATI] INTERVIEWER - REPEAT RESPONSE OPTIONS IF NECESSARY.
[PROGRAMMER: RANDOMIZE ORDER OF CVL_REAL-CVL_PASSED. SPLIT QUESTIONS ACROSS TWO SCREENS WITH 4 STATEMENTS ON EACH PAGE. REPEAT RESPONSE CATEGORIES UNDER EACH STATEMENT. REPEAT CVL_DSPL ON EACH PAGE.]
[SHOW IF CVL_HEARDEV=1]
[S]
CVL_REAL
Long COVID is a real illness.
[CAWI RESPONSE OPTIONS:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[CATI RESPONSE OPTIONS – REPEAT IF NECESSARY:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[SHOW IF CVL_HEARDEV=1]
[S]
CVL_SERIOUS
Long COVID can be debilitating and should be taken seriously.
[CAWI RESPONSE OPTIONS:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[CATI RESPONSE OPTIONS - REPEAT IF NECESSARY:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[SHOW IF CVL_HEARDEV=1]
[S]
CVL_DEPRESS
People with Long COVID may just be depressed.
[CAWI RESPONSE OPTIONS:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[CATI RESPONSE OPTIONS - REPEAT IF NECESSARY:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[SHOW IF CVL_HEARDEV=1]
[S]
CVL_NORMPAIN
Long COVID symptoms are often just the normal aches and pains of life.
[CAWI RESPONSE OPTIONS:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[CATI RESPONSE OPTIONS - REPEAT IF NECESSARY:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[SHOW IF CVL_HEARDEV=1]
[S]
CVL_EMPLOYER
Employers should provide reasonable accommodations for people with Long COVID.
[CAWI RESPONSE OPTIONS:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[CATI RESPONSE OPTIONS - REPEAT IF NECESSARY:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[SHOW IF CVL_HEARDEV=1]
[S]
CVL_MEDIA
The media and news reports exaggerate the problems that people with Long COVID face.
[CAWI RESPONSE OPTIONS:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[CATI RESPONSE OPTIONS - REPEAT IF NECESSARY:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[SHOW IF CVL_HEARDEV=1]
[S]
CVL_PASSED
Long COVID can be passed from one person to another.
[CAWI RESPONSE OPTIONS:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[CATI RESPONSE OPTIONS - REPEAT IF NECESSARY:]
1 Strongly disagree
2 Somewhat disagree
3 Somewhat agree
4 Strongly agree
-9 Don’t know
[SHOW ALL]
[S]
CVL_COVIDEV
Have you ever had COVID-19?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF CVL_COVIDEV=1]
[S]
CVL_SYMPT3M
Did you have any symptoms lasting 3 months or longer that you did not have prior to having COVID-19?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF CVL_HEARDEV=1 AND CVL_COVIDEV=1]
[S]
CVL_LONGCVEV
Did a doctor or other health care professional ever tell you that you had Long COVID?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF CVL_HEARDEV=1]
[S]
CVL_LONGOTH
Do you know anyone [IF CVL_LONGCVEV=1, FILL: else] such as a neighbor, friend, or coworker who has ever been diagnosed with Long COVID?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
CVL_LEARNMOR
If you wanted to learn more about Long COVID, which of the following would you do first?
[CAWI RESPONSE OPTIONS:]
1 Talk with a doctor or other health care professional
2 Talk with family or friends
3 Get information from the CDC
4 Get information from your state or local health department
5 Search the internet
6 Something else
[CATI RESPONSE OPTIONS:]
1 Talk with a doctor or other health care professional
2 Talk with family or friends
3 Get information from the CDC
4 Get information from your state or local health department
5 Search the internet
6 Something else
[CREATE “END_CVL” AND RECORD TIME IN HH:MM:SS]
ACC - ACCESS/UTILIZATION
[CREATE “START_ACC” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
ACC_DNCINTRO
These next questions ask about your dental care.
[SHOW ALL]
[S]
ACC_DNCEXAM
About how long has it been since you last had a dental examination or cleaning?
[CAWI] Include cleanings from all types of dental care such as dentists, orthodontists, oral surgeons, dental hygienists, and all other dental specialists.
[CATI] READ IF NECESSARY: Include cleanings from all types of dental care such as dentists, orthodontists, oral surgeons, dental hygienists, and all other dental specialists.
[CAWI RESPONSE OPTIONS:]
1 Less than 12 months ago
2 More than 1 year but less than 2 years ago
3 More than 2 years but less than 3 years ago
4 More than 3 years but less than 5 years ago
5 More than 5 years but less than 10 years ago
6 10 years ago or more
0 Never
[CATI RESPONSE OPTIONS – READ IF NECESSARY:]
1 Within the past year (ANY TIME LESS THAN 12 MONTHS AGO)
2 Within the last 2 years (MORE THAN 1 YEAR BUT LESS THAN 2 YEARS AGO)
3 Within the last 3 years (MORE THAN 2 YEARS BUT LESS THAN 3 YEARS AGO)
4 Within the last 5 years (MORE THAN 3 YEARS BUT LESS THAN 5 YEARS AGO)
5 Within the last 10 (MORE THAN 5 YEARS BUT LESS THAN 10 YEARS AGO)
6 10 years ago or more
0 Never
[SHOW ALL]
[S]
ACC_DNCDELAY
During the past 12 months, have you delayed getting dental care because of the cost?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
ACC_DNCCOST
During the past 12 months, was there any time when you needed dental care, but did not get it because of the cost?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
ACC_HTHINTRO
Now, we would like to ask you about your health care, not including dental care.
[SHOW ALL]
[S]
ACC_HTHLAST
About how long has it been since you last saw a doctor or other health professional about your health?
[CAWI] Include doctors seen while a patient in a hospital. Do not include dental care.
[CATI] READ IF NECESSARY: Include doctors seen while a patient in a hospital. Do not include dental care.
[CAWI RESPONSE OPTIONS:]
1 Less than 12 months ago
2 More than 1 year but less than 2 years ago
3 More than 2 years but less than 3 years ago
4 More than 3 years but less than 5 years ago
5 More than 5 years but less than 10 years ago
6 10 years ago or more
0 Never
[CATI RESPONSE OPTIONS – READ IF NECESSARY:]
1 Within the past year (ANY TIME LESS THAN 12 MONTHS AGO)
2 Within the last 2 years (MORE THAN 1 YEAR BUT LESS THAN 2 YEARS AGO)
3 Within the last 3 years (MORE THAN 2 YEARS BUT LESS THAN 3 YEARS AGO)
4 Within the last 5 years (MORE THAN 3 YEARS BUT LESS THAN 5 YEARS AGO)
5 Within the last 10 (MORE THAN 5 YEARS BUT LESS THAN 10 YEARS AGO)
6 10 years ago or more
0 Never
[SHOW ALL]
[S]
ACC_HTHUSUAL
Is there a place that you usually go to if you are sick and need health care?
[CAWI RESPONSE OPTIONS:]
Yes, there is a single place
3 Yes, there is more than one place
2 No, there is no place
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
2 THERE IS NO PLACE
3 THERE IS MORE THAN ONE PLACE
[SHOW IF ACC_HTHUSUAL = 1, 3]
[S]
ACC_HTHTYPE
What kind of place [IF ACC_HTHUSUAL=1, FILL: is it; ELSE, FILL: do you go most often]? [CATI] A doctor's office or health center; an urgent care center, a clinic in a drug store or grocery store; a hospital emergency room; a VA medical center or VA outpatient clinic; or some other place?
[CAWI] A doctor's office or health center is a place where you see the same doctor or the same group of doctors every visit, where you usually need to make an appointment ahead of time, and where your medical records are on file.
Urgent care centers and clinics in a drug store or grocery store are places where you do not need to make an appointment ahead of time, and usually do not see the same health care provider at each visit.
[CATI] READ IF NECESSARY - A doctor's office or health center is a place where you see the same doctor or the same group of doctors every visit, where you usually need to make an appointment ahead of time, and where your medical records are on file.
Urgent care centers and clinics in a drug store or grocery store are places where you do not need to make an appointment ahead of time, and usually do not see the same health care provider at each visit.
[CAWI RESPONSE OPTIONS:]
A doctor’s office or health center
Urgent care center or clinic in a drug store or grocery store
Hospital emergency room
A VA medical center or VA outpatient clinic
Some other place
I do not go to one place most often
[CATI RESPONSE OPTIONS – DO NOT READ:]
A DOCTOR’S OFFICE OR HEALTH CENTER
URGENT CARE CENTER OR CLINIC IN A DRUG STORE OR GROCERY STORE
HOSPITAL EMERGENCY ROOM
A VA MEDICAL CENTER OR VA OUTPATIENT CLINIC
SOME OTHER PLACE
I DO NOT GO TO ONE PLACE MOST OFTEN
[SHOW ALL]
[S]
ACC_HOSP12M
During the past 12 months, have you been hospitalized overnight? Do not include an overnight stay in the emergency room.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
ACC_EYE12M
During the past 12 months, have you had an eye exam from an eye specialist, such as an optometrist, ophthalmologist, or eye doctor?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
ACC_THER12M
During the past 12 months, did you receive physical therapy, speech therapy, rehabilitative therapy, or occupational therapy?
[CAWI] Do not include mental health therapy.
[CATI] READ IF NECESSARY - Do not include mental health therapy.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[CREATE “END_ACC” AND RECORD TIME IN HH:MM:SS]
INT - INTERNET/HIT
[CREATE “START_INT” AND RECORD TIME IN HH:MM:SS]
[SHOW IF MODE = CATI; AUTO PUNCH 1 (YES) IF MODE = CAWI]
[S]
INT_ACCESS
Do you have access to the Internet?
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF INT_ACCESS=1]
[S]
INT_HOMEACC
Do you have access to the Internet from your home?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF INT_ACCESS=1]
INT_DSPL
During the past 12 months, have you used the Internet for any of the following reasons?
[SHOW IF INT_ACCESS=1]
[S]
INT_USEMED
To look for health or medical information.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF INT_ACCESS=1]
[S]
INT_USEDOC
To communicate with a doctor or doctor’s office.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF INT_ACCESS=1]
[S]
INT_USETEST
To look up medical test results.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY INT_USEMED - INT_USETEST ON SAME PAGE]
[CREATE “END_INT” AND RECORD TIME IN HH:MM:SS]
PRV - PREVENTIVE CARE
[CREATE “START_PRV” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
PRV_BPCHECK
When was the last time you had your blood pressure checked by a doctor, nurse, or other health professional?
[CAWI RESPONSE OPTIONS:]
Less than 12 months ago
More than 1 year but less than 2 years ago
More than 2 years but less than 3 years ago
More than 3 years but less than 5 years ago
More than 5 years but less than 10 years ago
10 years ago or more
0 Never
[CATI RESPONSE OPTIONS – READ IF NECESSARY:]
1 Within the past year (ANY TIME LESS THAN 12 MONTHS AGO)
2 Within the last 2 years (MORE THAN 1 YEAR BUT LESS THAN 2 YEARS AGO)
3 Within the last 3 years (MORE THAN 2 YEARS BUT LESS THAN 3 YEARS AGO)
4 Within the last 5 years (MORE THAN 3 YEARS BUT LESS THAN 5 YEARS AGO)
5 Within the last 10 (MORE THAN 5 YEARS BUT LESS THAN 10 YEARS AGO)
6 10 years ago or more
0 Never
[SHOW ALL]
[S]
PRV_CHLCHECK
When was the last time you had your cholesterol checked by a doctor, nurse, or other health professional?
[CAWI RESPONSE OPTIONS:]
Less than 12 months ago
More than 1 year but less than 2 years ago
More than 2 years but less than 3 years ago
More than 3 years but less than 5 years ago
More than 5 years but less than 10 years ago
10 years ago or more
0 Never
[CATI RESPONSE OPTIONS – READ IF NECESSARY:]
1 Within the past year (ANY TIME LESS THAN 12 MONTHS AGO)
2 Within the last 2 years (MORE THAN 1 YEAR BUT LESS THAN 2 YEARS AGO)
3 Within the last 3 years (MORE THAN 2 YEARS BUT LESS THAN 3 YEARS AGO)
4 Within the last 5 years (MORE THAN 3 YEARS BUT LESS THAN 5 YEARS AGO)
5 Within the last 10 (MORE THAN 5 YEARS BUT LESS THAN 10 YEARS AGO)
6 10 years ago or more
0 Never
[SHOW IF DIB_DIBEV= 0, -6, -7, -9]
[S]
PRV_DIBCHECK
When was the last time you had a blood test for high blood sugar or diabetes by a doctor, nurse, or other health professional?
[CAWI RESPONSE OPTIONS:]
Less than 12 months ago
More than 1 year but less than 2 years ago
More than 2 years but less than 3 years ago
More than 3 years but less than 5 years ago
More than 5 years but less than 10 years ago
10 years ago or more
0 Never
[CATI RESPONSE OPTIONS – READ IF NECESSARY:]
1 Within the past year (ANY TIME LESS THAN 12 MONTHS AGO)
2 Within the last 2 years (MORE THAN 1 YEAR BUT LESS THAN 2 YEARS AGO)
3 Within the last 3 years (MORE THAN 2 YEARS BUT LESS THAN 3 YEARS AGO)
4 Within the last 5 years (MORE THAN 3 YEARS BUT LESS THAN 5 YEARS AGO)
5 Within the last 10 (MORE THAN 5 YEARS BUT LESS THAN 10 YEARS AGO)
6 10 years ago or more
0 Never
[CREATE “END_PRV” AND RECORD TIME IN HH:MM:SS]
CAN - CANCER SCREENING – BREAST DENSITY
[CREATE “START_CAN” AND RECORD TIME IN HH:MM:SS]
[SHOW IF SEX=2 AND AGE >= 30]
[S]
CAN_MAMMEV
Have you ever had a mammogram?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF CAN_MAMMEV=1]
[S]
CAN_RECENTM
About how long has it been since your most recent mammogram?
[CAWI RESPONSE OPTIONS:]
Less than 12 months ago
More than 1 year but less than 2 years ago
More than 2 years but less than 3 years ago
More than 3 years but less than 5 years ago
More than 5 years but less than 10 years ago
10 years ago or more
0 Never
[CATI RESPONSE OPTIONS – READ IF NECESSARY:]
1 Within the past year (ANY TIME LESS THAN 12 MONTHS AGO)
2 Within the last 2 years (MORE THAN 1 YEAR BUT LESS THAN 2 YEARS AGO)
3 Within the last 3 years (MORE THAN 2 YEARS BUT LESS THAN 3 YEARS AGO)
4 Within the last 5 years (MORE THAN 3 YEARS BUT LESS THAN 5 YEARS AGO)
5 Within the last 10 (MORE THAN 5 YEARS BUT LESS THAN 10 YEARS AGO)
6 10 years ago or more
0 Never
[SHOW IF CAN_MAMMEV=1]
[S]
CAN_BDENSITY
After your most recent mammogram, did you receive any information about whether or not you had dense breasts?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF CAN_MAMMEV=1 AND CAN_BDENSITY = 1]
[M]
CAN_BDENSINF
After your most recent mammogram, how were you informed about whether or not you had dense breasts? Please [CAWI: select; CATI: tell me] all that apply.
[CAWI RESPONSE OPTIONS:]
1 Conversation in-person or over the phone
2 Letter in the mail
3 Electronic health record online portal
4 Another way
[CATI RESPONSE OPTIONS:]
1 Conversation in-person or over the phone
2 Letter in the mail
3 Electronic health record online portal
4 Another way
[SHOW IF CAN_MAMMEV=1]
[S]
CAN_DENSE
Did your most recent mammogram show that you did have dense breast tissue or did not have dense breast tissue?
[CAWI RESPONSE OPTIONS:]
1 Did have dense breast tissue
Did not have dense breast tissue
[CATI RESPONSE OPTIONS – DO NOT READ:]
1 DID HAVE DENSE BREAST TISSUE
DID NOT HAVE DENSE BREAST TISSUE
[CREATE “END_CAN” AND RECORD TIME IN HH:MM:SS]
OVA - OVARIAN CANCER
[CREATE “START_OVA” AND RECORD TIME IN HH:MM:SS]
[SHOW IF SEX=2]
Have you ever had any of the following procedures?
[SHOW IF SEX=2]
[S]
OVA_TUBETIED
Fallopian tubes tied
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF SEX=2]
[S]
OVA_TUBEREM
Both fallopian tubes removed
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF SEX=2]
[S]
OVA_OVARIES
Both ovaries removed
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY OVA_TUBETIE – OVA_OVARIES ON SAME PAGE]
[CREATE “END_OVA” AND RECORD TIME IN HH:MM:SS]
GEN - CONCERNS ABOUT PRIVACY OF GENETIC TESTS
[CREATE “START_GEN” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
GEN_INTRO
The
next few questions refer to genetic testing for cancer risk where
your blood or saliva is tested to see if you carry genes which may
predict a greater chance of developing cancer at some point in your
life. This does not
include tests to determine if you have cancer now.
Have you ever heard of genetic testing to determine if a person is at greater risk of developing cancer?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GEN_INTRO=1]
[CAWI] How concerned are you that the results of genetic testing for cancer risk would impact your ability to get or keep…
[CATI] How concerned are you that the results of genetic testing for cancer risk would impact your ability to get or keep the following? Would you say you are not at all concerned, a little concerned, somewhat concerned, very concerned?
[SHOW IF GEN_INTRO=1]
[S]
GEN_HLTHINS
Health insurance?
[CAWI RESPONSE OPTIONS:]
Not at all concerned
A little concerned
Somewhat concerned
Very concerned
[CATI RESPONSE OPTIONS - DO NOT READ:]
NOT AT ALL CONCERNED
A LITTLE CONCERNED
SOMEWHAT CONCERNED
VERY CONCERNED
[SHOW IF GEN_INTRO=1]
[S]
GEN_LIFEINS
Life insurance?
[CAWI RESPONSE OPTIONS:]
Not at all concerned
A little concerned
Somewhat concerned
Very concerned
[CATI RESPONSE OPTIONS - DO NOT READ:]
NOT AT ALL CONCERNED
A LITTLE CONCERNED
SOMEWHAT CONCERNED
VERY CONCERNED
[SHOW IF GEN_INTRO=1]
[S]
GEN_DISAINS
Long-term care or disability insurance?
[CAWI RESPONSE OPTIONS:]
Not at all concerned
A little concerned
Somewhat concerned
Very concerned
[CATI RESPONSE OPTIONS - DO NOT READ:]
NOT AT ALL CONCERNED
A LITTLE CONCERNED
SOMEWHAT CONCERNED
VERY CONCERNED
[SHOW IF GEN_INTRO=1]
[S]
GEN_JOB
Employment at a job?
[CAWI RESPONSE OPTIONS:]
Not at all concerned
A little concerned
Somewhat concerned
Very concerned
[CATI RESPONSE OPTIONS - DO NOT READ:]
NOT AT ALL CONCERNED
A LITTLE CONCERNED
SOMEWHAT CONCERNED
VERY CONCERNED
[PROGRAMMER: DISPLAY GEN_HLTHINS – GEN_JOB ON SAME PAGE]
[SHOW IF GEN_INTRO=1]
[S]
GEN_TESTEV
Have you ever had a genetic test to determine if you are at greater risk of developing cancer in the future?
[CAWI] Include any genetic testing for cancer done by a medical provider or genetic counselor, or from genetic health tests, such as 23andMe or Color Genomics ordered online or bought in stores.
[CATI] Include any genetic testing for cancer done by a medical provider or genetic counselor, or from genetic health tests, such as 23andMe or Color Genomics ordered online or bought in stores.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[CREATE “END_GEN” AND RECORD TIME IN HH:MM:SS]
CRI - CANCER RISK – ALCOHOL
[CREATE “START_CRI” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
CRI_ALCOHOL
How do you think drinking alcoholic beverages affects the risk of getting cancer?
[CAWI RESPONSE OPTIONS:]
Decreases risk
No effect
Increases risk
[CATI RESPONSE OPTIONS:]
Decreases risk
No effect
Increases risk
[CREATE “END_CRI” AND RECORD TIME IN HH:MM:SS]
SUN - SUNCREEN SAFETY
[CREATE “START_SUN” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
SUN_USEFACE
[CAWI] When you are outdoors in the sun, in warm weather, how often do you use sunscreen on your face?
Do not include makeup or moisturizer that contains sunscreen.
[CATI] When you are outdoors in the sun, in warm weather, how often do you use sunscreen on your face? Do not include makeup or moisturizer that contains sunscreen. Would you say you never, rarely, sometimes, most of the time, or always?
[CAWI RESPONSE OPTIONS:]
Never
Rarely
Sometimes
Most of the time
Always
[CATI RESPONSE OPTIONS – DO NOT READ:]
NEVER
RARELY
SOMETIMES
MOST OF THE TIME
ALWAYS
[SHOW ALL]
[S]
SUN_USESKIN
When you are outdoors in the sun, in warm weather, how often do you use sunscreen on other exposed skin? [CATI] Would you say you never, rarely, sometimes, most of the time, or always?
[CAWI RESPONSE OPTIONS:]
Never
Rarely
Sometimes
Most of the time
Always
[CATI RESPONSE OPTIONS – DO NOT READ:]
NEVER
RARELY
SOMETIMES
MOST OF THE TIME
ALWAYS
[SHOW ALL]
How important are the following features to you when purchasing sunscreen? [CATI] Would you say you not important at all, slightly important, moderately important, very important?
[SHOW ALL]
[S]
SUN_AFFORD
The sunscreen is affordable.
[CAWI RESPONSE OPTIONS:]
Not important at all
Slightly important
Moderately important
Very important
[CATI RESPONSE OPTIONS – DO NOT READ:]
NOT IMPORTANT AT ALL
SLIGHTLY IMPORTANT
MODERATELY IMPORTANT
VERY IMPORTANT
[SHOW ALL]
[S]
SUN_INGRED
The sunscreen’s ingredients.
[CAWI RESPONSE OPTIONS:]
Not important at all
Slightly important
Moderately important
Very important
[CATI RESPONSE OPTIONS – DO NOT READ:]
NOT IMPORTANT AT ALL
SLIGHTLY IMPORTANT
MODERATELY IMPORTANT
VERY IMPORTANT
[SHOW ALL]
[S]
SUN_SPRAY
The sunscreen can be sprayed on the skin.
[CAWI RESPONSE OPTIONS:]
Not important at all
Slightly important
Moderately important
Very important
[CATI RESPONSE OPTIONS – DO NOT READ:]
NOT IMPORTANT AT ALL
SLIGHTLY IMPORTANT
MODERATELY IMPORTANT
VERY IMPORTANT
[SHOW ALL]
[S]
SUN_FEEL
How the sunscreen feels on my skin.
[CAWI RESPONSE OPTIONS:]
Not important at all
Slightly important
Moderately important
Very important
[CATI RESPONSE OPTIONS – DO NOT READ:]
NOT IMPORTANT AT ALL
SLIGHTLY IMPORTANT
MODERATELY IMPORTANT
VERY IMPORTANT
[PROGRAMMER: DISPLAY SUN_AFFORD – SUN_FEEL ON SAME PAGE]
[SHOW ALL]
SUN_KNOWINT
[CAWI: Do you; [CATI: Please tell me whether you] strongly disagree, somewhat disagree, somewhat agree, or strongly agree with the following statements.
[SHOW ALL]
[S]
SUN_NOHARM
Sunburn is not really harmful in the long run.
[CAWI RESPONSE OPTIONS:]
Strongly disagree
Somewhat disagree
Somewhat agree
Strongly agree
[CATI RESPONSE OPTIONS – DO NOT READ:]
STRONGLY DISAGREE
SOMEWHAT DISAGREE
SOMEWHAT AGREE
STRONGLY AGREE
[SHOW ALL]
[S]
SUN_REAPPLY
It is a hassle to reapply sunscreen.
[CAWI RESPONSE OPTIONS:]
Strongly disagree
Somewhat disagree
Somewhat agree
Strongly agree
[CATI RESPONSE OPTIONS – DO NOT READ:]
STRONGLY DISAGREE
SOMEWHAT DISAGREE
SOMEWHAT AGREE
STRONGLY AGREE
[SHOW ALL]
[S]
SUN_SAFETY
I’m concerned about the safety of ingredients in sunscreen.
[CAWI RESPONSE OPTIONS:]
Strongly disagree
Somewhat disagree
Somewhat agree
Strongly agree
[CATI RESPONSE OPTIONS – DO NOT READ:]
STRONGLY DISAGREE
SOMEWHAT DISAGREE
SOMEWHAT AGREE
STRONGLY AGREE
[SHOW ALL]
[S]
SUN_CLOUDY
On cloudy days I don’t need to worry about the sun.
[CAWI RESPONSE OPTIONS:]
Strongly disagree
Somewhat disagree
Somewhat agree
Strongly agree
[CATI RESPONSE OPTIONS – DO NOT READ:]
STRONGLY DISAGREE
SOMEWHAT DISAGREE
SOMEWHAT AGREE
STRONGLY AGREE
[PROGRAMMER: DISPLAY SUN_NOHARM – SUN_CLOUDS ON SAME PAGE]
[CREATE “END_SUN” AND RECORD TIME IN HH:MM:SS]
MTL - MENTAL HEALTH (ANXIETY AND DEPRESSION)
[CREATE “START_MTL” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
MTL_ANXIETY
How often do you feel worried, nervous or anxious?
[CAWI] If you take medication for these feelings, please answer based on your usual use of medication.
[CATI] Would you say daily, weekly, monthly, a few times a year, or never?
[CATI] READ IF NECESSARY: If you take medication for these feelings, please answer based on your usual use of medication.
[CAWI RESPONSE OPTIONS:]
Daily
Weekly
Monthly
A few times a year
Never
[CATI RESPONSE OPTIONS – DO NOT READ:]
DAILY
WEEKLY
MONTHLY
A FEW TIMES A YEAR
NEVER
[SHOW ALL]
[S]
MTL_ANXMEDS
Do you take prescription medication for these feelings?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY MTL_ANXIETY– MTL_ANXMEDS ON SAME PAGE]
[SHOW IF MTL_ANXIETY = 1, 2, 3, 4,-6,-7,-9 OR MTL_ANXMEDS = 1]
[S]
MTL_ANXLVL
Thinking about the last time you felt worried, nervous or anxious, how would you describe the level of these feelings? [CATI] Would you say a little, a lot, or somewhere in between?
[CAWI RESPONSE OPTIONS:]
A little
A lot
Somewhere in between a little and a lot
[CATI RESPONSE OPTIONS - DO NOT READ:]
A LITTLE
A LOT
SOMEWHERE IN BETWEEN A LITTLE AND A LOT
[SHOW ALL]
[S]
MTL_DEPRESS
How often do you feel depressed?
[CAWI] If you take medication for these feelings, please answer based on your usual use of medication.
[CATI] Would you say daily, weekly, monthly, a few times a year, or never?
[CATI] READ IF NECESSARY: If you take medication for these feelings, please answer based on your usual use of medication.
[CAWI RESPONSE OPTIONS:]
Daily
Weekly
Monthly
A few times a year
Never
[CATI RESPONSE OPTIONS - DO NOT READ:]
DAILY
WEEKLY
MONTHLY
A FEW TIMES A YEAR
NEVER
[SHOW ALL]
[S]
MTL_DEPMEDS
Do you take prescription medication for depression?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY MTL_DEPRESS – MTL_DEPMEDS ON SAME PAGE]
[SHOW IF MTL_DEPRESS = 1,2,3,4,-6,-7,-9 OR MTL_DEPMEDS =1]
[S]
MTL_DEPLVL
Thinking about the last time you felt depressed, how depressed did you feel? [CATI] Would you say a little, a lot, or somewhere in between?
[CAWI RESPONSE OPTIONS:]
A little
A lot
Somewhere in between a little and a lot
[CATI RESPONSE OPTIONS - DO NOT READ:]
A LITTLE
A LOT
SOMEWHERE IN BETWEEN A LITTLE AND A LOT
[CREATE “END_MTL” AND RECORD TIME IN HH:MM:SS]
CIG - HEALTH BEHAVIORS (CIGARETTE SMOKING)
[CREATE “START_CIG” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
CIG_SMKEV
Have you smoked at least 100 cigarettes in your entire life?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF CIG_SMKEV=1]
[S]
CIG_SMKNOW
Do you now smoke cigarettes every day, some days, or not at all?
[CAWI RESPONSE OPTIONS:]
Every day
Some days
Not at all
[CATI RESPONSE OPTIONS - DO NOT READ:]
EVERY DAY
SOME DAYS
NOT AT ALL
[CREATE “END_CIG” AND RECORD TIME IN HH:MM:SS]
CAR - EXPOSURE TO CARCINOGENS
[CREATE “START_CAR” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
CAR_USE
In the past 12 months, have you or someone else used chemical straighteners, relaxers, or pressing products on your hair?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF CAR_USE=1]
[S]
CAR_FREQUSE
In the past 12 months, how often have you or someone else used chemical straighteners, relaxers, or pressing products on your hair?
[CAWI RESPONSE OPTIONS:]
1-2 times a year
Every 3-4 months
Every 5-8 weeks
Once a month
More than once a month
[CATI RESPONSE OPTIONS:]
1-2 times a year
Every 3-4 months
Every 5-8 weeks
Once a month
More than once a month
[SHOW IF CAR_USE=1]
[S]
CAR_STOPUSE
In the past 12 months, has your used of chemical straighteners, relaxers, or pressing products on your hair changed? [CATI] Have you stopped use, used less, used about the same, or used more of these products?
[CAWI RESPONSE OPTIONS:]
Stopped use
Used less
My use of these products has not changed
Used more
[CATI RESPONSE OPTIONS – DO NOT READ:]
STOPPED USE
USED LESS
MY USE OF THESE PRODUCTS HAS NOT CHANGED
USED MORE
[CREATE “END_CAR” AND RECORD TIME IN HH:MM:SS]
VEN - VENTILATION
[CREATE “START_VEN” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
VEN_USE
A portable air cleaner or air purifier can remove particles like dust, pollen, viruses, bacteria, and mold from the air. Portable air cleaners or air purifiers are free-standing and can be moved around the home.
How often do you use a portable air cleaner or purifier in your home? [CATI] Would you say never, rarely, sometimes, or always?
[CAWI RESPONSE OPTIONS:]
Never
Rarely
Sometimes
Always
[CATI RESPONSE OPTIONS – DO NOT READ:]
NEVER
RARELY
SOMETIMES
ALWAYS
[SHOW IF VEN_USE=1, 2, 3]
What are the reasons you use a portable air cleaner or air purifier in your home?
[SHOW IF VEN_USE=1, 2, 3]
[S]
Remove dust, pollen, mold, or other allergens from the air.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF VEN_USE=1, 2, 3]
[S]
VEN_ACSMOKE
Remove smoke particles from the air.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF VEN_USE=1, 2, 3]
[S]
VEN_ACVIRUS
Remove virus particles that people exhale.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF VEN_USE=1, 2, 3]
[S]
VEN_ACOTHER
Some other reason.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY VEN_ALLERGEN– VEN_OTHER ON SAME PAGE.]
[SHOW IF VEN_USE=1, 2, 3]
[S]
VEN_HEPAUSE
Portable high-efficiency particulate air or HEPA filter units trap particles in the air. Do any portable air cleaners or purifiers in your home use a HEPA filter?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 I don’t know if I have a portable air cleaner or purifier that uses a HEPA filter
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
What are the reasons why you do not use a portable air cleaner or purifier with a HEPA filter?
[SHOW IF VEN_HEPAUSE=0]
[S]
VEN_HPNOHEAR
I have never heard of a HEPA filter unit.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF VEN_HEPAUSE=0]
[S]
VEN_HPNONEED
I didn’t think a HEPA filter unit was needed.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF VEN_HEPAUSE=0]
[S]
VEN_HPNOCOST
HEPA filter units are too expensive.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY VEN_HPNOHEARD – VEN_HPNOLOUD ON SAME PAGE.]
[SHOW IF VEN_HEPAUSE=0]
What are the reasons why you do not use a portable air cleaner or purifier with a HEPA filter?
[SHOW IF VEN_HEPAUSE=0]
[S]
VEN_HPNOLOUD
HEPA filter units are too noisy.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF VEN_HEPAUSE=0]
[S]
VEN_HPNOFIND
I couldn’t find a HEPA unit or filter in stores or online.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF VEN_HEPAUSE=0]
[S]
VEN_HPNOOTH
Some other reason.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY VEN_HPNOLOUD – VEN_HPNOOTH ON SAME PAGE.]
[SHOW IF VEN_USE=1]
What are the reasons why you do not use a portable air cleaner or purifier?
[SHOW IF VEN_ USE=1]
[S]
VEN_ACNONEED
I didn’t think an air cleaner or air purifier was needed.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF VEN_ USE=1]
[S]
VEN_ACNOCOST
Air cleaners or air purifiers are too expensive.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF VEN_ USE=1]
[S]
VEN_ACNOLOUD
Air cleaners or air purifiers are too noisy.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF VEN_ USE=1]
[S]
VEN_ACNOOTH
Some other reason.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY VEN_ACNONEED – VEN_ACNOOTH ON SAME PAGE.]
[CREATE “END_VEN” AND RECORD TIME IN HH:MM:SS]
IPV - INTIMATE PARTNER VIOLENCE
[CREATE “START_IPV” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[CAWI: We are; CATI I am] now going to ask you some questions related to physical acts you may have experienced.
[CAWI] Remember, you don’t have to answer any question that you don’t want to. We suggest that you be in a private setting during the remainder of the survey. If, at any time, you do not feel physically or emotionally safe, you can just quit the survey by closing the browser. You can come back to the survey whenever you want. If at any point the questions are making you upset and you would like to speak with a trained professional, please refer to the Resources given <a> here</a>.
[CATI] Remember, you don’t have to answer any question that you don’t want to. I suggest that you be in a private setting during the remainder of the survey. If, at any time, you do not feel physically or emotionally safe, you can let me know you’d like to stop the survey. You can call back to complete the survey whenever you want or set up a time for us to call you back. If at any point the questions are making you upset and you would like to speak with a trained professional, please let me know and I can share some <a> resources </a> with you.
PROGRAMMER: DISPLAY IN FOOTER/BOTTOM OF EACH SCREEN IN INTIMATE PARTNER VIOLENCE SECTION
Need help? Click <a> here</a>
for resources.
[IF CATI:
INTERVIEWER - USE THIS LINK TO ACCESS RESOURCES IF RESPONDENT
NEEDS HELP/SUPPORT DURING INTERVIEW]
[PROGRAMMER: HYPERLINKS ABOVE SHOULD OPEN IN NEW WINDOW AND DISPLAY THE FOLLOWING:
Thank you for participating in this study. We realize that some of the topics covered are quite personal and can be difficult to think and talk about. We appreciate your willingness to be a part of this study and want you to know that we recognize the important contribution you have made. Sometimes when people have participated in a study like this, they realize that they are interested in following up on some of the issues that they have been asked about in the study with someone who is professionally trained to deal with these kinds of issues.
Below are some toll-free numbers of resources that you can use now or in the future if you want to speak further with someone.
You can reach the National Domestic Violence Hotline at 1-800-799-SAFE (7233).
You can reach the National Sexual Assault Hotline at 1-800-656-HOPE (4673).
You can reach the National Child Abuse Hotline at 1-800-4-A-Child (422-4453).
You can reach the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).]
[SHOW ALL]
The next questions are related to physical acts you may have experienced with your current or ex-romantic or sexual partners.
For romantic or sexual partners, please think about anybody you have been involved with romantically or sexually, which might include spouses, boyfriends, girlfriends, people you have dated, people you were seeing, or people you hooked up with.
Do not include first dates or one-time hook-up situations.
[SHOW ALL]
In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?
[SHOW ALL]
[S]
IPV_PUSH
Slapped, pushed, or shoved you?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
IPV_HIT
Hit you with a fist or something hard?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
IPV_KICK
Kicked or stomped on you?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
IPV_HAIR
Hurt you by pulling your hair?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY IPV_SLAP – IPV_HAIR ON SAME PAGE.]
[SHOW ALL]
In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?
[SHOW ALL]
[S]
IPV_SLAM
Slammed you against something to hurt you?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
IPV_CHOKE
Tried to hurt you by choking or suffocating you?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
IPV_KNIFE
Used or threatened you with a knife?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
IPV_GUN
Used or threatened you with a gun? Please include firearms such as pistols, revolvers, shotguns, and rifles (but not BB guns or paint ball guns).
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY IPV_SLAM – IPV_GUN ON SAME PAGE.]
[CREATE “END_IPV” AND RECORD TIME IN HH:MM:SS]
DEM - RACE AND ETHNICITY
[CREATE “START_DEM” AND RECORD TIME IN HH:MM:SS]
[PROGRAMMER: SPLIT SAMPLE INTO FOUR GROUPS (SPLIT-BALLOT) AT SAMPLING STAGE. CREATE VARIABLE “GROUP” TO CAPTURE GROUP ASSIGNMENT WHERE GROUP = 1 OR 2 OR 3 OR 4. DISPLAY DEM_RACE QUESTION STEM CORRESPONDING TO GROUP ASSIGNMENT.]
DEM_RACE
[M]
[SHOW IF GROUP = 1]
What races or ethnicities are you? Please [CAWI: select; CATI: tell me] all that apply. Are you:
[SHOW
IF GROUP = 2]
What
races or ethnicities are you? Please [CAWI:
select;
CATI:
tell
me]
all that apply, and note that you may report more than one group.
Are you:
[SHOW
IF GROUP = 3]
What
race or ethnicity are you? Please [CAWI:
select;
CATI:
tell
me]
all that apply. Are you:
[SHOW IF GROUP = 4]
What race or ethnicity are you? Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:
[CAWI RESPONSE OPTIONS:]
1 White
2 Hispanic or Latino
3 Black or African American
4 Asian
5 American Indian or Alaska Native
6 Middle Eastern or North African
7 Native Hawaiian or Pacific Islander
[CATI RESPONSE OPTIONS:]
1 White
2 Hispanic or Latino
3 Black or African American
4 Asian
5 American Indian or Alaska Native
6 Middle Eastern or North African
7 Native Hawaiian or Pacific Islander
[SHOW ALL]
The next questions collect detailed information about each race or ethnicity you selected.
DEM_WHITE
[M]
[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=1)]
You said that you are White. Please [CAWI: select; CATI: tell me] all that apply. Are you:
[SHOW IF (GROUP = 2 OR 4 (AND DEM_RACE=1)]
You said that you are White. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:
[CAWI RESPONSE OPTIONS:]
1 German
2 Italian
3 Irish
4 Polish
5 English
6 French
7 Another White group, for example Scottish, Norwegian, Dutch, etc. [TEXTBOX; CHAR LIMIT = 50]
[CATI RESPONSE OPTIONS:]
1 German
2 Italian
3 Irish
4 Polish
5 English
6 French
7 Another White group, for example Scottish, Norwegian, Dutch, etc. [TEXTBOX; CHAR LIMIT = 50]
DEM_HISP
[M]
[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=2)]
You said that you are Hispanic or Latino. Please [CAWI: select; CATI: tell me] all that apply. Are you:
[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=2)]
You said that you are Hispanic or Latino. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:
[CAWI RESPONSE OPTIONS:]
1 Mexican or Mexican American
2 Salvadoran
3 Puerto Rican
4 Dominican
5 Cuban
6 Colombian
Another Hispanic or Latino group, for example Guatemalan, Spaniard, Ecuadorian, etc. [TEXTBOX; CHAR LIMIT = 50]
[CAWI RESPONSE OPTIONS:]
1 Mexican or Mexican American
2 Salvadoran
3 Puerto Rican
4 Dominican
5 Cuban
6 Colombian
7 Another Hispanic or Latino group, for example Guatemalan, Spaniard, Ecuadorian, etc. [TEXTBOX; CHAR LIMIT = 50]
DEM_BLACK
[M]
[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=3)]
You said that you are Black or African American. Please [CAWI: select; CATI: tell me] All that apply. Are you:
[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=3)]
You said that you are Black or African American. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:
[CAWI RESPONSE OPTIONS:]
1 African American
2 Nigerian
3 Jamaican
4 Ethiopian
5 Haitian
6 Somali
7 Another Black or African American group, for example Ghanaian, South African, Barbadian, etc. [TEXTBOX; CHAR LIMIT = 50]
[CATI RESPONSE OPTIONS:]
1 African American
2 Nigerian
3 Jamaican
4 Ethiopian
5 Haitian
6 Somali
7 Another Black or African American group, for example Ghanaian, South African, Barbadian, etc. [TEXTBOX; CHAR LIMIT = 50]
DEM_ASIAN
[M]
[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=4)]
You said that you are Asian. Please [CAWI: select; CATI: tell me] all that apply. Are you:
[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=4)]
You said that you are Asian. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:
[CAWI RESPONSE OPTIONS:]
1 Chinese
2 Vietnamese
3 Filipino
4 Korean
5 Asian Indian
6 Japanese
7 Another Asian group, for example Pakistani, Cambodian, Hmong, etc. [TEXTBOX; CHAR LIMIT = 50]
[CATI RESPONSE OPTIONS:]
1 Chinese
2 Vietnamese
3 Filipino
4 Korean
5 Asian Indian
6 Japanese
7 Another Asian group, for example Pakistani, Cambodian, Hmong, etc. [TEXTBOX; CHAR LIMIT = 50]
DEM_AIAL
[TEXTBOX]
[SHOW IF GROUP = 1 OR 2 OR 3 OR 4 (AND DEM_RACE=5)]
You said that you are American Indian or Alaska Native. Are you Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, or some other group? Note, you may report more than one group.
[TEXTBOX; CHAR LIMIT = 150]
DEM_MENA
[M]
[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=6)]
You said that you are Middle Eastern or North African. Please [CAWI: select; CATI: tell me] all that apply. Are you:
[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=6)]
You said that you are Middle Eastern or North African. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:
[CAWI RESPONSE OPTIONS:]
1 Lebanese
2 Syrian
3 Iranian
4 Moroccan
5 Egyptian
6 Israeli
7 Another Middle Eastern or North African group, for example Algerian, Iraqi, Kurdish, etc. [TEXTBOX; CHAR LIMIT = 50]
[CATI RESPONSE OPTIONS:]
1 Lebanese
2 Syrian
3 Iranian
4 Moroccan
5 Egyptian
6 Israeli
7 Another Middle Eastern or North African group, for example Algerian, Iraqi, Kurdish, etc. [TEXTBOX; CHAR LIMIT = 50]
DEM_NHPI
[M]
[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=7)]
You said that you are Native Hawaiian or Pacific Islander. Please [CAWI: select; CATI: tell me] all that apply. Are you:
[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=7)]
You said that you are Native Hawaiian or Pacific Islander. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:
[CAWI RESPONSE OPTIONS:]
1 Native Hawaiian
2 Tongan
3 Samoan
4 Fijian
5 Chamorro
6 Marshallese
7 Another Native Hawaiian or Pacific Islander group, for example Palauan, Tahitian, Chuukese, etc. [TEXTBOX; CHAR LIMIT = 50]
[CATI RESPONSE OPTIONS:]
1 Native Hawaiian
2 Tongan
3 Samoan
4 Fijian
5 Chamorro
6 Marshallese
7 Another Native Hawaiian or Pacific Islander group, for example Palauan, Tahitian, Chuukese, etc. [TEXTBOX; CHAR LIMIT = 50]
[CREATE “END_DEM” AND RECORD TIME IN HH:MM:SS]
[CREATE “START_MAR” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
MAR_MARITAL
The next questions are about marriage and cohabitation. [CAWI] Are you now: [CATI] Are you now married, living with a partner together as an unmarried couple, or neither?
[CATI] INTERVIEWER - IF RESPONDENT ANSWERS BOTH MARRIED AND LIVING WITH A DIFFERENT PARTNER TOGETHER AS AN UNMARRIED COUPLE, ENTER LIVING WITH A PARTNER
[CAWI RESPONSE OPTIONS:]
Married
Living with a partner together as an unmarried couple
Neither
[CATI RESPONSE OPTIONS – DO NOT READ:]
MARRIED
LIVING WITH A PARTNER TOGETHER AS AN UNMARRIED COUPLE
NEITHER
[SHOW IF MAR_MARITAL = 2, 3, -6,-7,-9]
[S]
MAR_EVMARRY
Have you ever been married?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF MAR_MARITAL = 2 AND MAR_EVMARRY=1]
[S]
MAR_LEGAL
What is your current legal marital status?
[CATI: Are you married, widowed, divorced, or separated?]
[CAWI RESPONSE OPTIONS:]
Married
Widowed
Divorced
Separated
[CATI RESPONSE OPTIONS – DO NOT READ:]
MARRIED
WIDOWED
DIVORCED
SEPARATED
[SHOW IF MAR_MARTIAL = 3 AND MAR_EVMARRY=1]
[S]
MAR_WIDIVSEP
[CAWI] Are you… [CATI] Are you widowed, divorced, or separated?
[CAWI RESPONSE OPTIONS:]
Widowed
Divorced
Separated
[CATI RESPONSE OPTIONS – DO NOT READ:]
Widowed
Divorced
Separated
[CREATE “END_MAR” AND RECORD TIME IN HH:MM:SS]
[CREATE “START_EMP” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
EMP_EMPLOY
Last week, did you work for pay at a job or business?
[CAWI] If you work at a family business, but not for pay, select yes.
[CATI] INTERVIEWER - IF THE RESPONDENT SAYS THEY WORK, BUT NOT FOR PAY, AT A FAMILY-OWNED JOB OR BUSINESS, ENTER '1' FOR YES.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF EMP_EMPLOY=0]
[S]
EMP_ABSENTWK
Did you have a job or business last week, but were temporarily absent due to illness, vacation, family or maternity leave, or some other reason?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF EMP_EMPLOY=0 AND EMP_ABSENTWK=0]
[S]
EMP_WHYNOWRK
What is the main reason you were not working for pay at a job or business last week?
[CAWI RESPONSE OPTIONS:]
Unemployed, laid off, looking for work
Seasonal/contract work
Retired
Unable to work for health reasons/disabled
Taking care of house or family
Going to school
Working at a family-owned job or business, but not for pay
Other
[CATI RESPONSE OPTIONS – READ IF NECESSARY:]
Unemployed, laid off, looking for work
Seasonal/contract work
Retired
Unable to work for health reasons/disabled
Taking care of house or family
Going to school
Working at a family-owned job or business, but not for pay
Other
[CREATE “END_EMP” AND RECORD TIME IN HH:MM:SS]
CIV - CIVIC ENGAGEMENT
[CREATE “START_CIV” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
CIV_VOL12M
During the past 12 months, did you spend any time volunteering for any organization or association?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF CIV_VOL12M=0]
[S]
CIV_VOLOTH
Some people don’t think of activities they do infrequently or for children’s schools or youth organizations as volunteer activities. During the past 12 months, have you done any of these types of activities?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
CIV_MEET
During the past 12 months, did you attend a public meeting, such as a zoning or school board meeting, that discussed a local issue?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
CIV_VOTELOCL
Did you vote in the last local elections, such as for mayor, councilmembers, or school board?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[CREATE “END_CIV” AND RECORD TIME IN HH:MM:SS]
LAN - LANGUAGE ITEMS
[CREATE “START_LAN” AND RECORD TIME IN HH:MM:SS]
[SHOW IF QUEX_LANGUAGE=1; AUTO PUNCH 1 (YES) IF QUEX_LANGUAGE=2 ]
[S]
LAN_OTHERLAN
Do you speak a language other than English at home?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[SHOW IF LAN_OTHERLAN=1]
[S]
LAN_MEDIA
When you watch television, read news online or in print, or listen to the radio, which language do you use most often?
[CAWI RESPONSE OPTIONS:]
English
Spanish
Another language
[CATI RESPONSE OPTIONS – DO NOT READ:]
ENGLISH
SPANISH
ANOTHER LANGUAGE
[SHOW IF LAN_OTHERLAN=1]
[S]
LAN_DOCTOR
When you see a doctor or other health care professional, which language do you use most often?
[CAWI RESPONSE OPTIONS:]
English
Spanish
Another language
[CATI RESPONSE OPTIONS – DO NOT READ:]
ENGLISH
SPANISH
ANOTHER LANGUAGE
[SHOW IF LAN_OTHERLAN=1]
[S]
LAN_SOCIAL
When you participate in social activities, such as visiting friends, attending clubs, or going to parties, which language do you use most often?
[CAWI RESPONSE OPTIONS:]
English
Spanish
Another language
[CATI RESPONSE OPTIONS – DO NOT READ:]
ENGLISH
SPANISH
ANOTHER LANGUAGE
[CREATE “END_LAN” AND RECORD TIME IN HH:MM:SS]
TEL - TELEPHONE USE
[CREATE “START_TEL” AND RECORD TIME IN HH:MM:SS]
[SHOW ALL]
[S]
TEL_NONCELL
Is there at least one telephone inside your home that is currently working and is not a cell phone?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[SHOW ALL]
[S]
TEL_CELL
Do you have a working cell phone?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[SHOW IF TEL_CELL=0 AND HHSIZE>=2]
[S]
TEL_HHCELL
Do you live with anyone at your home who has a working cell phone?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[CREATE “START_TEL” AND RECORD TIME IN HH:MM:SS]
[CREATE “END_TIME” AND RECORD TIME IN HH:MM:SS; CREATE END_DATE” AND RECORD DATE IN MM:DD:YYY]
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Maitland, Aaron K. (CDC/DDPHSS/NCHS/DHIS) |
| File Modified | 0000-00-00 |
| File Created | 2023-09-03 |