ACBS Child Consent and Questionnaire

BRFSS/ASTHMA CALL BACK SURVEY

CHILD QUESTIONNAIRE - 2024

CATI SPECIFICATIONS

Form Approved

OMB Control No. 0920-1204

Exp. Date 11/30/2023

Section Subject Page

Section 1 Introduction ……....................................................... 02

Section 2 Informed Consent.......................................................... 04

Section 3 Recent History.............….................................……. 07

Section 4 History of Asthma (Symptoms & Episodes)............… 09

Section 5 Health Care Utilization.................................................. 13

Section 6 Knowledge of Asthma/Management Plan..................... 19

Section 7 Modifications to Environment....................................... 21

Section 8 Medications........................... ........................................… 2

Section 9 Cost of Care...................................................................… 43

Section 10 School Related Asthma ………………………………… 47

Section 11 Additional Child Demographics …………………...…… 47

Section 12 Family History of Asthma and Allergy…………………..48

CDC estimates the average public reporting burden for this collection of information as 10 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 NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (OMB Control No. 0920-1204).

Appendix A: Language for Identifying Most Knowledgeable Person…

during the BRFSS interview……….…………………….. 50

Section 1: Introduction

Introduction to the Asthma Call Back Survey for adult parent/guardian of child with asthma Hello, my name is ________________. I’m calling on behalf of the {STATE NAME} health department and the Centers for Disease Control and Prevention about an asthma study we are doing in your state. ALTERNATE (no reference to asthma): Hello, my name is ________________. I’m calling on behalf of the {STATE NAME} health department and the Centers for Disease Control and Prevention about a health study we are doing in your state.
Question Number	Question text	Responses	SKIP INFO/ CATI Note	Interviewer Note (s)
Q1.1	Are you {MKPNAME}?	1. Yes	[GO TO 1.5]
		2. No
Q1.2	May I speak with {MKPNAME}?	1. Yes	[GO TO 1.4 when person comes to phone]
		2. Person not available
Q1.3	When would be a good time to call back and speak with {MKPNAME}. For example, evenings, days, weekends?	CBTIME: Enter day/time: _________________	[CATI: Start over at introduction at next call.]	READ: Thank you we will call again later to speak with {MKPNAME}.

Question number	Read Text	Alternative text (no reference to asthma):
Q1.4	Hello, my name is ________________. I’m calling on behalf of the [STATE NAME} state health department and the Centers for Disease Control and Prevention about an asthma study we are doing in your state. During a recent phone interview [“you” if MKPNAME=ADULTNAME; OR “adultname” if MKPNAME=ALTNAME, MKP is pointed by BRFSS respondents] gave us permission to call again to ask some questions about {child’s name}’s asthma and said that you knew the most about that child’s asthma.	Hello, my name is ________________. I’m calling on behalf of the [STATE NAME} state health department and the Centers for Disease Control and Prevention about a health study we are doing in your state. During a recent phone [“you” if MKPNAME=ADULTNAME; OR “adultname” if MKPNAME=ALTNAME, MKP is pointed by BRFSS respondents] gave us permission to call again to ask some questions about {child’s name}’s health and said that you knew the most about that child’s health.	GO TO SECTION 2

Q1.5

During a recent phone interview [“you” if MKPNAME=ADULTNAME; OR “adultname” if MKPNAME=ALTNAME, MKP is pointed by BRFSS respondents] gave us permission to call again to ask some questions about {child’s name}’s asthma and said that you knew the most about that child’s asthma.

During a recent phone interview [“you” if MKPNAME=ADULTNAME; OR “adultname” if MKPNAME=ALTNAME, MKP is pointed by BRFSS respondents] gave us permission to call again to ask some questions about {child’s name}’s health and said that you knew the most about that child’s health.

GO TO SECTION 2

Section 2: Informed Consent

Before we continue, I’d like you to know that this survey is authorized by the U.S. Public Health Service Act. You may choose not to answer any question you don’t want to answer or stop at any time. In order to evaluate my performance, my supervisor may listen as I ask the questions. I’d like to continue now unless you have any questions. {child’s name} was selected to participate in this study about asthma because of responses to questions about his or her asthma in a prior survey.
If responses for sample child in BRFSS survey answers are: CASTHDX2= 1 (Yes) and CASTHNO2 = 2 (No), READ: The answers to asthma questions during the earlier survey indicated that a doctor or other health professional said that {child’s name} had asthma sometime in {his/her} life but does not have it now. Is that correct? If YES, READ: Since {child’s name} no longer has asthma, your interview will be very brief (about 5 minutes). [Go to RELATION (2.3)]. IF NO, [Go to REPEAT (2.0)]
If responses for sample child in BRFSS survey answers are: CASTHDX2= 1 (Yes) and CASTHNO2 = 1 (Yes) READ: Answers to the asthma questions in the earlier survey indicated that a doctor or other health professional said that {child’s name} had asthma sometime in {his/her} life, and that {child’s name} still has asthma. Is that correct? IF YES, [Go to RELATION (2.3)] IF NO, [Go to REPEAT (2.0)]
Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Q2.0	I would like to repeat the questions from the previous survey now to make sure {child’s name} qualifies for this study.	REPEAT	(1) YES	[Go to EVER_ASTH (2.1)]
			(2) NO	[Skip to TERMINATE]
Q2.1	Have you ever been told by a doctor or other health professional that sure {child’s name} had asthma?	EVER_ASTH	(1) YES
			(2) NO	[Skip Go to TERMINATE]
			(7) DON’T KNOW	[Skip Go to TERMINATE]
			(9) REFUSED	[Skip Go to TERMINATE]
Q2.2	Does {he/she} still have asthma?	CUR_ASTH	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q2.3	What is your relationship to {child’s name}?	RELATION	READ: (1) MOTHER (BIRTH/ADOPTIVE/STEP) (2) FATHER (BIRTH/ADOPTIVE/STEP) (3) BROTHER/SISTER (STEP/FOSTER/HALF/ADOPTIVE) (4) GRANDPARENT (FATHER/MOTHER) (5) OTHER RELATIVE (6) UNRELATED (7) DON’T KNOW (9) REFUSED
Q2.4	Are you the legal guardian for {child’s name}?	GUARDIAN	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
READ: {child’s name} does qualify for this study, I’d like to continue unless you have any questions. [If CUR_ASTH (2.2) = 1 (Yes)] READ: Since {child’s name} does have asthma now, your interview will last about 15 minutes. [Go to section 3] [If CUR_ASTH (2.2) = 2 (No)] READ: Since {child’s name} does not have asthma now, your interview will last about 5 minutes. [Go to section 3] [If CUR_ASTH (2.2) = 7, 9 (Don’t know or refused)] READ: Since you are not sure if {child’s name} has asthma now, your interview will probably last about 10 minutes. [Go to section 3]
TERMINATE: Upon survey termination, READ: I’m sorry {child’s name} does not qualify for this study. I’d like to thank you on behalf of the {STATE} Health Department and the Centers for Disease Control and Prevention for answering these questions. If you have any questions about this survey, you may call my supervisor toll-free at [1–800-xxx-xxxx}. If you have questions about your rights as a survey participant, you may call the chairman of the Institutional Review Board at [1 800 xxx-xxxx}. Thanks again. Goodbye.

Section 3: Recent History

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Section 3 (Recent History) Q3.1	How old was {child’s name} when a doctor or other health professional first said {he/she} had asthma	AGEDX	__ __ __ (ENTER AGE IN YEARS) (777) DON’T KNOW (888) Under 1 year old (999) REFUSED	[RANGE CHECK: IS 001-018, 777, 888, 999] [CATI CHECK: IF RESPONSE = 77, 99, 88 VERIFY THAT 777, 888, 999 WERE NOT THE INTENT]	[INTERVIEWER: ENTER 888 IF LESS THAN ONE YEARS OLD
Q3.2	How long ago was that? Was it...	INCIDNT	(1) WITHIN THE PAST 12 MONTHS (2) 1-5 YEARS AGO (3) MORE THAN 5 YEARS AGO (7) DON’T KNOW (9) REFUSED
Q3.3	How long has it been since you last talked to a doctor or other health professional about {child’s name} asthma? This could have been in a doctor’s office, the hospital, an emergency room or urgent care center.	LAST_MD	(88) Never (04) Within the past year (05) 1 YEAR to less than 3 years ago (06) 3 YEARS to 5 years ago (07) More than 5 years ago (77) DON’T KNOW (99) REFUSED		[INTERVIEWER: READRESPONSE OPTIONS IF NECESSARY]
Q3.4	How long has it been since {he/she} last took asthma medication?	LAST_MED	(88) NEVER (01) LESS THAN ONE DAY AGO (02) 1-6 DAYS AGO (03) 1 WEEK TO LESS THAN 3 MONTHS AGO (04) 3 MONTHS TO LESS THAN 1 YEAR AGO (05) 1 YEAR TO LESS THAN 3 YEARS AGO (06) 3 YEARS TO 5 YEARS AGO (07) MORE THAN 5 YEARS AGO (77) DON’T KNOW (99) REFUSED		[INTERVIEWER: READ RESPONSE OPTIONS IF NECESSARY]
Q3.5	How long has it been since {he/she} last had any symptoms of asthma?	LASTSYMP	(88) NEVER (01) LESS THAN ONE DAY AGO (02) 1-6 DAYS AGO (03) 1 WEEK TO LESS THAN 3 MONTHS AGO (04) 3 MONTHS TO LESS THAN 1 YEAR AGO (05) 1 YEAR TO LESS THAN 3 YEARS AGO (06) 3 YEARS TO 5 YEARS AGO (07) MORE THAN 5 YEARS AGO (77) DON’T KNOW (99) REFUSED		[INTERVIEWER: READ RESPONSE OPTIONS IF NECESSARY] R EAD: Symptoms of asthma include coughing, wheezing, shortness of breath, chest tightness or phlegm production when {child’s name} did not have a cold or respiratory infection.

Section 4: History of Asthma (Symptoms & Episodes in past year)

(2) NO
(7) DON’T KNOW	[SKIP TO Section 5]
(9) REFUSED	[SKIP TO Section 5]
	[SKIP TO Section 5]

Section 4. History of Asthma (Symptoms & Episodes in the past year			IF LASTSYMP (3.5) = 1, 2, 3, 4 then continue whole section IF LASTSYMP (3.5) = 88, 5, 6, 7 SKIP TO INS1 (Section 5) IF LASTSYMP (3.5) = 77, 99 then continue
Question Number	Question text		Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Q4.1	During the past 30 days, on how many days did {child’s name} have any symptoms of asthma?		SYMP_30D	__ __DAYS		[RANGE CHECK: (01-30, 77, 88, 99)] CLARIFICATION: [1-29, 77, 99]
				(88) NO SYMPTOMS IN THE PAST 30 DAYS	[SKIP TO EPIS_INT]
				(30) EVERY DAY	[CONTINUE]
				(77) DON’T KNOW	[SKIP TO ASLEEP30 (4.3)]
				(99) REFUSED	[SKIP TO ASLEEP30 (4.3)]
Q4.2	Does {he/she} have symptoms all the time? "All the time” means symptoms that continue throughout the day. It does not mean symptoms for a little while each day.		DUR_30D	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q4.3	During the past 30 days, on how many days did symptoms of asthma make it difficult for {him/her } to stay asleep?		ASLEEP30	__ __ DAYS/NIGHTS (88) NONE (30) Every day (77) DON’T KNOW (99) REFUSED		[RANGE CHECK: (01-30, 77, 88, 99)]
Q4.4	During the past two weeks, on how many days was {child’s name} completely symptom-free, that is no coughing, wheezing, or other symptoms of asthma?		SYMPFREE	__ __ Number of days (88) NONE (77) DON’T KNOW (99) REFUSED		[RANGE CHECK: (01-14, 77, 88, 99)]
Interview notes	READ IF NECESSARY: Asthma attacks, sometimes called episodes, refer to periods of worsening asthma symptoms that make you limit your activity more than you usually do, or make you seek medical care.
Q4.5	During the past 3 months, how many asthma episodes or attacks has {he/she} had?		EPIS_TP	__ __ Number of episodes/attacks (888) NONE (777) DON’T KNOW (999) REFUSED	[RANGE CHECK: (001-100, 777, 888, 999)] [CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888 AND 999 WERE NOT THE INTENT]	[READ IF NECESSARY]: Asthma attacks, sometimes called episodes, refer to periods of worsening asthma symptoms that make you limit your activity more than you usually do, or make you seek medical care.
Interview notes	READ IF NECESSARY: Now I'm going to ask you about asthma medicine for quick relief of symptoms during an asthma attack or episode. This quick relief medicine such as albuterol and salbutamol are breathed in through your mouth using a canister inhaler, a disk inhaler, or a nebulizer. Both an inhaler or a disk inhaler are very portable canisters or devices used to inhale medication in one or two breaths. A nebulizer is a machine that turns liquid medication into a mist that you inhale into the lungs over a few minutes
NEW Q4.6	During the past 30 days, on how many days did {child’s name} take quick relief medicine such as albuterol and salbutamol to relief asthma symptoms?		QUICKRELIEF (New)	__ __ DAYS/NIGHTS (88) NONE (30) EVERY DAY (77) DON’T KNOW (99) REFUSED	[RANGE CHECK: (01-30, 77, 88, 99)]	READ IF NECESSARY : This quick relief medicine such as albuterol and salbutamol are breathed in through your mouth using a canister inhaler, a disk inhaler, or a nebulizer. Both an inhaler or a disk inhaler are very portable canisters or devices used to inhale medication in one or two breaths. A nebulizer is a machine that turns liquid medication into a mist that you inhale into the lungs over a few minutes
Q4.7	During just the past 30 days, would you say {child’s name} limited {his/her} usual activities due to asthma not at all, a little, a moderate amount, or a lot?		ACT_DAYS30 (Q5.6)	(1) NOT AT ALL (2) A LITTLE (3) A MODERATE AMOUNT (4) A LOT (7) DON’T KNOW (9) REFUSED
Q4.8	During the past 12 months, has {child’s name} had an episode of asthma or an asthma attack?		EPIS_12M	(1) YES

S ection 5. Health Care Utilization

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Section 5 (Health Care Utilization) Q5.1	Does {child’s name} have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare or Medicaid?	INS1	(1) YES
			(2) NO	[SKIP TO FLU_VACCINE (5.4)]
			(7) DON’T KNOW	[SKIP TO FLU_VACCINE (5.4)]
			(9) REFUSED	[SKIP TO FLU_VACCINE (5.4)]
Q5.2	What kind of health care coverage does {he/she} have? Is it paid for through the parent’s employer, or is it Medicaid, Medicare, Children's Health Insurance Program (CHIP), or some other type of insurance?	INS_TYP	(1) PARENT’S EMPLOYER (2) MEDICAID/MEDICARE (3) CHIP {REPLACE WITH STATE SPECIFIC NAME} (4) OTHER (7) DON’T KNOW (9) REFUSED		[READ RESPONSE OPTIONS IF NECESSARY]
Q5.3	During the past 12 months was there any time that {he/she} did not have any health insurance or coverage?	INS2	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
NEW Q5.4	During the past 12 months, did {CHILD’S NAME} have a flu shot or a flu vaccine that is sprayed in the nose?	FLU_VACCINE	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q5.5	Does anyone help you arrange or coordinate {child’s name}’s asthma care among the different doctors or services that [he/she] uses?	COORDIN	(1) YES (2) NO (7) DON'T KNOW (9) REFUSED		READ IF NECESSARY: By “arrange or coordinate,” I mean: Is there anyone who helps you make sure that {child’s name} gets all the health care and services [he/she] needs, that health care providers share information, and that these services fit together and are paid for in a way that works for you?
CATI notes:	How to define the value “of “Does the child still have asthma?”: The best-known value for whether or not the child “still has asthma” is used in the skip below. It can be the previously answered BRFSS childhood prevalence module value (CASTHNO2) or the answer to CUR_ASTH (2.2) if this question is asked in this call back survey. If the respondent confirms in the “Informed Consent” question that the previously answered BRFSS module value is correct, then the value from the BRFSS (CASTHNO2) is used. If the respondent does not agree with the previous BRFSS (CASTNO2) in “Informed Consent” of Section 2 and REPEAT (2.0) = 1 (Yes), then the value of CUR_ASTH (2.2) is used. SKIP INSTRUCTION: If “Does the child still have asthma?” = 1 (Yes), {using BRFSS CASTHNO2 or (CUR_ASTH (2.2) if REPEAT (2.0) =1)}, continue to Section 5. If “Does the child still have asthma?” = 2 (No), 7 (DK), or 9 (Refused) {using BRFSS CASTHNO2 or (CUR_ASTH (2.2) if REPEAT (2.0) =1)} AND [(LAST_MD = 4) OR (LAST_MED = 1, 2, 3 or 4) OR (LASTSYMP = 1, 2, 3 or 4)] THEN CONTINUE WITH SECTION 5 If “Does the child still have asthma?” = 2 (No), 7 (DK), or 9 (Refused), {using BRFSS CASTHNO2 or (CUR_ASTH (2.2) if REPEAT (2.0) =1)} AND (LAST_MD (3.3) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LAST_MED (3.4) = 88 (Never) or 05, 06, 07, 77 or 99) AND (LASTSYMP (3.5) = 88 (Never) or 05, 06, 07, 77 or 99) THEN SKIP TO Section 6.
Q5.6	During the past 12 months how many times did {he/she} see a doctor or other health professional for a routine checkup for {his/her} asthma?	NER_TIME	__ __ __ ENTER NUMBER (888) NONE (777) DON’T KNOW (999) REFUSED	{IF LAST_MD= 88, 05, 06, 07 (have not seen a doctor in the past 12 months); SKIP to ER_VISIT (Q5.7) {RANGE CHECK: (001-365, 777, 888, 999)] {Verify any value >50] {CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888, AND 999 WERE NOT THE INTENT]	{RANGE CHECK: (001-365, 777, 888, 999)] {Verify any value >50]
Q5.7	An urgent care center treats people with illnesses or injuries that must be addressed immediately and cannot wait for a regular medical appointment. During the past 12 months, has {child’s name} had to visit an emergency room or urgent care center because of {his/her} asthma?	ER_VISIT	(1) YES
			(2) NO	[SKIP TO URG_TIME (5.9)]
			(7) DON’T KNOW	[SKIP TO URG_TIME (5.9)]
			(9) REFUSED	[SKIP TO URG_TIME (5.9)]
Q5.8	During the past 12 months, how many times did {he/she} visit an emergency room or urgent care center because of {his/her} asthma?	ER_TIMES	__ __ __ ENTER NUMBER (888) ZERO [LOOPING BACK TO CORRECT ER_VISIT (5.8) TO “NO”] (777) DON’T KNOW (999) REFUSED	[RANGE CHECK: (001-365, 777, 999)] [Verify any entry >50] [CATI CHECK: IF RESPONSE = 77, 99 VERIFY THAT 777 AND 999 WERE NOT THE INTENT] [CATI CHECK: IF ER_VISIT (5.7) =1 (YES) AND RESPONDENT SAYS “NONE” OR “ZERO” TO ER_TIMES (5.8) ALLOW LOOPING BACK TO CORRECT ER_VISIT (5.7) TO “2, NO”]	[HELP SCREEN: An urgent care center treats people with illnesses or injuries that must be addressed immediately and cannot wait for a regular medical appointment.]
Q5.9	(If ER_VISIT (Q5.7) = 1 (Yes), INSERT “Besides those emergency room or urgent care center visits,” During the past 12 months, how many times did {child’s name}? see a doctor or other health professional for urgent treatment of worsening asthma symptoms or an asthma episode or attack?	URG_TIME	__ __ __ ENTER (888) NONE (777) DON’T KNOW (999) REFUSED	[RANGE CHECK: (001-365, 777, 888, 999)] [Verify any entry >50] [CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888 AND 999 WERE NOT THE INTENT]	[HELP SCREEN: An urgent care center treats people with illnesses or injuries that must be addressed immediately and cannot wait for a regular medical appointment.]
Q5.10	During the past 12 months, that is since [1 YEAR AGO TODAY], has {child’s name} had to stay overnight in a hospital because of {his/her} asthma? Do not include an overnight stay in the emergency room.	HOSP_VST	(1) YES
			(2) NO	SKIP to Section 6
			(7) DON’T KNOW	SKIP to Section 6
			(9) REFUSED	SKIP to Section 6
Q5.11	During the past 12 months, how many different times did {he/she} stay in any hospital overnight or longer because of {his/her} asthma?	HOSPTIME	__ __ __ TIMES (777) DON’T KNOW (999) REFUSED	[RANGE CHECK: (001-365, 777, 999)] [Verify any entry >50] [CATI CHECK: IF RESPONSE = 77, 99 VERIFY THAT 777 AND 999 WERE NOT THE INTENT] [CATI CHECK: IF RESPONSE TO Q5.11 IS “YES” AND RESPONDENT SAYS NONE OR ZERO TO Q5.12, ALLOW LOOPING BACK TO CORRECT Q5.11 TO “NO”]	[RANGE CHECK: (001-365, 777, 999)] [Verify any entry >50]
Q5.12	The last time {he/she} left the hospital, did a health professional TALK with you or {child’s name} about how to prevent serious attacks in the future?	HOSPPLAN	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		[HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators. This should not be coded yes if the respondent only received a pamphlet or instructions to view a website or video since the question clearly states “talk with you”].

Section 6. Knowledge of Asthma/Management Plan

Section 6. Knowledge of Asthma/Management Plan		CATI: [HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]
Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Q6.1	Has a doctor or other health professional ever taught you or {child’s name}: How to recognize early signs or symptoms of an asthma episode?	TCH_SIGN	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q6.2	Has a doctor or other health professional ever taught you or {child’s name}: What to do during an asthma episode or attack?	TCH_RESP	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q6.3	A peak flow meter is a hand-held device that measures how quickly you can blow air out of your lungs. Has a doctor or other health professional ever taught you or {child’s name}: How to use a peak flow meter to adjust his/her daily medication?	TCH_MON	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q6.4	An asthma action plan, or asthma management plan, is a form with instructions about when to change the amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room. Has a doctor or other health professional EVER given you or {child’s name}: an asthma action plan?	MGT_PLAN	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q6.5	Have you or {child’s name} ever taken a course or class on how to manage [his/her] asthma?	MGT_CLAS	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

Section 7. Modifications to Environment

Section 7. Modifications to Environment	CATI: The following questions are about {child’s name} household and living environment. I will be asking about various things that may be related to experiencing symptoms of asthma. Interview Notes: The following questions are about {child’s name} household and living environment. I will be asking about various things that may be related to experiencing symptoms of asthma.
Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Q7.1	An air cleaner or air purifier can filter out pollutants like dust, pollen, mold and chemicals. It can be attached to the furnace or free standing. It is not, however, the same as a normal furnace filter. Is an air cleaner or purifier regularly used inside {child’s name}? home?	AIRCLEANER	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q7.2	A dehumidifier is a small, portable appliance which removes moisture from the air. Is a dehumidifier regularly used to reduce moisture inside [his/her} home?	DEHUMID	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q7.3	Is an exhaust fan that vents to the outside used regularly when cooking in the kitchen in {his/her} home?	KITC_FAN	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q7.4	Is gas used for cooking in [his/her} home?	COOK_GAS	(1) Yes (2) NO (7) DON’T KNOW (9) REFUSED
Q7.5	In the past 30 days, has anyone seen or smelled mold or a musty odor inside in [his/her} home? Do not include mold on food.	ENV_MOLD	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q7.6	Does {child’s name} home have pets such as dogs, cats, hamsters, birds or other feathered or furry pets that spend time indoors?	ENV_PETS	(1) YES
			(2) NO	[SKIP TO C_ROACH (7.8)]
			(7) DON’T KNOW	[SKIP TO C_ROACH (7.8)]
			(9) REFUSED	[SKIP TO C_ROACH (7.8)]
Q7.7	Is the pet allowed in [his/her} bedroom?	PETBEDRM	(1) YES (2) NO (3) SOME ARE/SOME AREN’T (7) DON’T KNOW (9) REFUSED	[SKIP THIS QUESTION IF ENV_PETS = 2, 7, 9]
Q7.8	In the past 30 days, has anyone seen cockroaches inside {child’s name}? home?	C_ROACH	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		[HELP SCREEN: Studies have shown that cockroaches may be a cause of asthma. Cockroach droppings and carcasses can also cause symptoms of asthma.]
Q7.9	In the past 30 days, has anyone seen mice or rats inside [his/her} home? Do not include mice or rats kept as pets.	C_RODENT	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		[HELP SCREEN: Studies have shown that rodents may be a cause of asthma.]
Q7.10	Is a wood burning fireplace or wood burning stove used in {child’s name}? home?	WOOD_STOVE	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		[HELP SCREEN: OCCASIONAL USE SHOULD BE CODED AS “YES”.]
Q7.11	Are unvented gas logs, unvented gas fireplaces, or unvented gas stoves used in [his/her} home?	GAS_STOVE	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		[HELP SCREEN: “Unvented” means no chimney or the chimney flue is kept closed during operation.]
Q7.12	In the past week, has anyone smoked inside [his/her} home?	S_INSIDE	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		HELP SCREEN: “The intent of this question is to measure smoke resulting from tobacco products (cigarettes, cigars, pipes) or illicit drugs (cannabis, marijuana) delivered by smoking (inhaling intentionally). Do not include things like smoke from incense, candles, or fireplaces, etc.”
Q7.13	Has a health professional ever advised you to change things in [his/her} home, school, or work to improve his/her asthma?	MOD_ENV	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		INTERVIEWER READ: Now, back to questions specifically about {child’s name} [HELP SCREEN: Health professional includes doctors, nurses, physician assistants, nurse practitioners, and health educators]
Q7.14	Does {he/she} use a mattress cover that is made especially for controlling dust mites?	MATTRESS	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		[INTERVIEWER read if necessary: This does not include normal mattress covers used for padding or sanitation (wetting). These covers are for the purpose of controlling allergens (like dust mites) from inhabiting the mattress. They are made of special fabric, entirely enclose the mattress, and have zippers.]
Q7.15	Does {he/she} use a pillow cover that is made especially for controlling dust mites?	E_PILLOW	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		[INTERVIEWER read if necessary: This does not include normal pillow covers used for fabric protection. These covers are for the purpose of controlling allergens (like dust mites) from inhabiting the pillow. They are made of special fabric, entirely enclose the pillow, and have zippers.]
Q7.16	Does {child’s name} have carpeting or rugs in [his/her} bedroom? This does not include throw rugs small enough to be laundered.	CARPET	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q7.17	Are [his/her} sheets and pillowcases washed in cold, warm, or hot water?	HOTWATER	(1) COLD (2) WARM (3) HOT (4) VARIES (7) DON’T KNOW (9) REFUSED
Q7.18	In {child’s name} bathroom, does {he/she} regularly use an exhaust fan that vents to the outside?	BATH_FAN	(1) YES (2) NO OR “NO FAN” (7) DON’T KNOW (9) REFUSED		[HELP SCREEN: IF RESPONDENT INDICATES THEY HAVE MORE THAN ONE BATHROOM, THIS QUESTION REFERS TO THE BATHROOM THE CHILD USES MOST FREQUENTLY FOR SHOWERING AND BATHING.]

Section 8. Medications

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note		Interviewer Note (s)
	Ask all the respondents READ: The next set of questions is about medications for asthma. The first few questions are very general, but later questions are very specific to {child’s name}? medication use.
Q8.1 new	In the past 3 months, did {child’s name} take any forms of prescription asthma medication (inhaler, pills, syrup, nebulizer)?	ASTHMED	(1) YES
			(2) NO	Skip to section 9
			(7) DON’T KNOW	Skip to section 9
			(9) REFUSED	Skip to section 9
Q8.2	Now I am going to ask questions about specific prescription medications {child’s name} may have taken for asthma in the past 3 months. I will be asking for the names. I will ask separately about medication taken in various forms: pill or syrup, inhaler, and Nebulizer. It will help to get {child’s name} medicines so you can read the labels. Can you please go get the asthma medicines while I wait on the phone?	SCR_MED1	(1) YES
			(2) NO	[SKIP TO INH_SCR (8.4)]
			(3) RESPONDENT KNOWS THE MEDS	[SKIP TO INH_SCR (8.4)]
			(7) DON’T KNOW	[SKIP TO INH_SCR (8.4)]
			(9) REFUSED	[SKIP TO INH_SCR (8.4)]
Q8.3	[when Respondent returns to phone:] Do you have all the medications?	SCR_MED3	(1) YES I HAVE ALL THE MEDICATIONS (2) YES I HAVE SOME OF THE MEDICATIONS BUT NOT ALL (3) NO (7) DON’T KNOW (9) REFUSED
Q8.4	In the past 3 months has {child’s name} taken prescription asthma medicine using an inhaler?	INH_SCR	(1) YES
			(2) NO	[SKIP TO PILLS (8.12)]
			(7) DON’T KNOW	[SKIP TO PILLS (8.12)]
			(9) REFUSED	[SKIP TO PILLS (8.12)]
Q8.5	Did a health professional show {child’s name} how to use the inhaler?	INHALERH	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Inhalers	For the following inhalers the respondent can choose up to eight medications; however, each medication can only be used once. When 66 (Other) is selected as a response, questions ILP04 (8.08) to ILP10 (8.11) are not asked for that response. [INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION.] CATI Note: The top ten items (in bold below) should be highlighted in the CATI system if possible so they can be found more easily
Q8.6	In the past 3 months, what prescription asthma medications did {he/she} take by inhaler? [MARK ALL THAT APPLY. PROBE: Any other prescription asthma inhaler medications?]	INH_MEDS	_ _ _; _ _ _; _ _ _; _ _ _; _ _ _; _ _ _; _ _ _; _ _ _;
			(66) Other [Please Specify, 100 character limit]	[SKIP TO OTH_I1]
			(88) NO PRESCRIPTION INHALERS	[SKIP TO PILLS (8.12)]
			(77) DON’T KNOW	[SKIP TO PILLS (8.12)]
			(99) REFUSED	[SKIP TO PILLS (8.12)]
Q8.7	ENTER OTHER MEDICATION FROM INH_MEDS (8.9) IN TEXT FIELD. IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE. 100 alphanumeric character limit	OTH_I1	(66) OTHER [Please Specify, 100 character limit] _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Table 8.1 Inhaler medication listing table

A: INH_B2AS B: INH_AC C: INH_AC+INH_B2AS D: INH_CS E: INH_B2AL F: INH_CS+INH_B2AL G: INH_AI H: INH_LAMA I: INH_B2AL + INH_LAMA J: INH_CS + INH_B2AL+ INH_LAMA Note: INH_CS: inhaled corticosteroid. INH_B2AS: Inhaled Beta 2 Agonist short acting. INH_B2AL: Inhaled Beta 2 Agonist log acting. INH_AI: inhaled anti-inflammatory. INH_AC: Inhaled Anticholinergic. INH_ LAMA: Long-Acting Muscarinic Antagonist.
Number code	Combined Code	Medication	Pronunciation	Category	Medication Class
1	01F	Advair (+ A. Diskus)	ăd-vâr (or add-vair)	F	INH_CS +B2AL
2	02D	Aerobid	â-rō'bĭd (or air-row-bid)	D	INH_CS
3	03A	Albuterol ( + A. sulfate or salbutamol)	ăl'-bu'ter-ōl (or al-BYOO-ter-ole) săl-byū'tə-môl'	A	INH_B2AS
4	04A	Alupent	al-u-pent	A	INH_B2AS
43	43D	Alvesco (+ Ciclesonide)	al-ves-co	D	INH_CS
49	49D	Anoro Ellipta (Umeclidinium and vilanterol)	a-nor' oh e-LIP-ta	D	INH_LAMA + INH_B2AL
40	40D	Asmanex (twisthaler)	as-muh-neks twist-hey-ler	D	INH_CS
5	05B	Atrovent	At-ro-vent	B	INH_AC
6	06D	Azmacort	az-ma-cort	D	INH_CS
7	07D	Beclomethasone dipropionate	bek"lo-meth'ah-son dī' pro’pe-o-nāt (or be-kloe-meth-a-sone)	D	INH_CS
8	08D	Beclovent	be' klo-vent" (or be-klo-vent)	D	INH_CS
9	09A	Bitolterol	bi-tōl'ter-ōl (or bye-tole-ter-ole)	A	INH_B2AS
45	45F	Breo Ellipta (Fluticasone and vilanterol)	BRE-oh e-LIP-ta	F	INH_CS+INH_B2AL
11	11D	Budesonide	byoo-des-oh-nide	D	INH_CS
12	12C	Combivent	com-bi-vent	C	INH_AC+INH_B2AS
13	13G	Cromolyn	kro'mŏ-lin (or KROE-moe-lin)	G	INH_AI
44	44F	Dulera	do-lair-a	F	INH_CS+
14	14D	Flovent	flow-vent	D	INH_CS
15	15D	Flovent Rotadisk	flow-vent row-ta-disk	D	INH_CS
16	16D	Flunisolide	floo-nis'o-līd (or floo-NISS-oh-lide)	D	INH_CS
17	17D	Fluticasone	flue-TICK-uh-zone	D	INH_CS
34	34E	Foradil	FOUR-a-dil	E	INH_B2AL
35	35E	Formoterol	for moh' te rol	E	INH_B2AL
48	48H	Incruse Ellipta (Umeclidium inhaler powder)	IN-cruise e-LIP-ta	H	INH_LAMA
19	19B	Ipratropium Bromide	ĭp-rah-tro'pe-um bro'mīd (or ip-ra-TROE-pee-um)	B	INH_AC
37	37A	Levalbuterol tartrate	lev-al-BYOU-ter-ohl	A	INH_B2AS
20	20A	Maxair	măk-sâr	A	INH_B2AS
21	21A	Metaproteronol	met"ah-pro-ter'ĕ-nōl (or met-a-proe-TER-e-nole)	A	INH_B2AS
39	39D	Mometasone furoate	moe-MET-a-sone	D	INH_CS
22	22G	Nedocromil	ne-DOK-roe-mil	G	INH_AI
23	23A	Pirbuterol	pēr-bu'ter-ōl (or peer-BYOO-ter-ole)	A	INH_B2AS
41	41A	Pro-Air HFA	proh-air HFA	A	INH_B2AS
24	24A	Proventil	pro"ven-til' (or pro-vent-il)	A	INH_B2AS
25	25D	Pulmicort Flexhaler	pul-ma-cort flex-hail-er	D	INH_CS
36	36D	QVAR	q -vâr (or q-vair)	D	INH_CS
3	03A	Salbutamol (or Albuterol)	săl-byū'tə-môl'	A	INH_B2AS
26	26E	Salmeterol	sal-ME-te-role	E	INH_B2AL
27	27E	Serevent	Sair-a-vent	E	INH_B2AL
46	46H	Spiriva HandiHaler or Respimat (Tiotropium bromide)	speh REE vah - RES peh mat	H	INH_LAMA
51	51I	Stiolto Respimat (tiotropium bromide & olodaterol)	sti-OL-to– RES peh mat	I	INH_LAMA + INH_B2AL
42	42F	Symbicort	sim-buh-kohrt	F	INH_CS+ INH_B2AL
28	28A	Terbutaline (+ T. sulfate)	ter-bu'tah-lēn (or ter-BYOO-ta-leen)	A	INH_B2AS
30	30A	Tornalate	tor-na-late	A	INH_B2AS
50	50J	Trelegy Ellipta ((fluticasone furoate, umeclidinium & vilanterol)	TREL-e-gee e-LIP-ta	J	INH_CS +INH_LAMA+INH_B2AL
31	31D	Triamcinolone acetonide	tri"am-sin'o-lōn as"ĕ-tō-nīd' (or trye-am-SIN-oh-lone)	D	INH_CS
47	47H	Tudorza Pressair	TU-door-za PRESS-air	H	INH_LAMA
32	32D	Vanceril	van-sir-il	D	INH_CS
33	33A	Ventolin	vent-o-lin	A	INH_B2AS
38	38A	Xopenex HFA	ZOH-pen-ecks	A	INH_B2AS
66	66	Other, Please Specify	[SKIP TO OTH_I1], 100 alphanumeric character limit

CATI Notes:	CATI: Medication reported could be grouped into 10 categories [A, B, C, D, E, F, G, H, I, J], for each category [A, B, C, D, E, F, G, H, I, J], asking one set of questions of Q8.08 to Q8.11; if respondents have more than one groups INHALERS category used, circle back to ask Q8.08 to Q8.11; if the respondent have more than one medicine belonged to one category, only ask one set of Q8.08 to Q8.11: Notes: 1. take [MEDICINE FROM INH_MEDS (8.6)], If more than 1 medicine belong to one category, mentioned all medicines in following questions; Code Categories A as ILP04_A; B as ILP04_B……; ILP05, ILP06, ILP08 follow the same rules
Q8.8	In the past 3 months, did {child’s name} take [MEDICINE FROM INH_MEDS (8.6) serious] when {he/she} had an asthma episode or attack?		ILP04 ILP04_A ILP04_B ILP04_C ILP04_D ILP04_E ILP04_F ILP04_G ILP04_H ILP04_I ILP04_J		(1) YES (2) NO (3) NO ATTACK IN PAST 3 MONTHS (7) DON’T KNOW (9) REFUSED		Circle from A to J to ask Q8.8 to Q8.11 For Category A, Variable name is ILP04_A et. al.	A: INH_B2AS B: INH_AC C: INH_AC+INH_B2AS D: INH_CS E: INH_B2AL F: INH_CS+INH_B2AL G: INH_AI H: INH_LAMA I: INH_B2AL +INH_LAMA J: INH_CS +INH_B2AL+ INH_LAMA 66 other meds
Q8.9	In the past 3 months, did {he/she} take [MEDICINE FROM INH_MEDS (8.6) SERIES] before exercising?		ILP05 ILP05_A ILP05_B ILP05_C ILP05_D ILP05_E ILP05_F ILP05_G ILP05_H ILP05_I ILP05_J		(1) YES (2) NO (3) DIDN’T EXERCISE IN PAST 3 MONTHS (7) DON’T KNOW (9) REFUSED			A: INH_B2AS B: INH_AC C: INH_AC+INH_B2AS D: INH_CS E: INH_B2AL F: INH_CS+INH_B2AL G: INH_AI H: INH_LAMA I: INH_B2AL +INH_LAMA J: INH_CS +INH_B2AL+ INH_LAMA K: INH_CS + INH_LAMA 66 other meds
Q8.10	In the past 3 months, did {he/she} take [MEDICINE FROM INH_MEDS (8.6) SERIES on a regular schedule as prescribed?		ILP06 ILP06_A ILP06_B ILP06_C ILP06_D ILP06_E ILP06_F ILP06_G ILP06_H ILP06_I ILP06_J		(1) YES (2) NO (7) DON’T KNOW (9) REFUSED			A: INH_B2AS B: INH_AC C: INH_AC+INH_B2AS D: INH_CS E: INH_B2AL F: INH_CS+INH_B2AL G: INH_AI H: INH_LAMA I: INH_B2AL +INH_LAMA J: INH_CS +INH_B2AL+ INH_LAMA 66 other meds,
Q8.11	How many times per day or per week did {he/she} use [MEDICINE FROM INH_MEDS (8.6) SERIES]?		ILP08 ILP08_A ILP08_B ILP08_C ILP08_D ILP08_E ILP08_F ILP08_G ILP08_H ILP08_I ILP08_J		3 _ _ Times per DAY		[RANGE CHECK: (>10)]
					4 _ _ Times per WEEK		[RANGE CHECK: (>75)]
					5 5 5 Never		[RANGE CHECK: 301-310, 401-475, 555, 666, 777, 999]
					6 6 6 LESS OFTEN THAN ONCE A WEEK
					7 7 7 Don’t know / Not sure
					9 9 9 Refused
Question Number		Question text		Variable names		Responses (DO NOT READ UNLESS OTHERWISE NOTED)			SKIP INFO/ CATI Note	Interviewer Note (s)
Q8.12 Pill		In the past 3 months, have {child’s name} taken any PRESCRIPTION medicine in pill form for your asthma?		PILLS		(1) YES
						(2) NO			[SKIP TO SYRUP (8.15)]
						(7) DON’T KNOW			[SKIP TO SYRUP (8.15)]
						(9) REFUSED			[SKIP TO SYRUP (8.15)]
CATI Notes:		For the following pills the respondent can chose up to 5 medications; however, each medication can only be used once [INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION.] There are 49 kinds of medicine in the list, they could be grouped into following 4 groups A: PILL_CS B: PILL_B2A C: PILL_LM D: PILL_METH [IF RESPONDENT SELECTS ANY ANSWER FROM 01-49, group into A, B, C, D categories, for each group of A/B/C/D, asking one time of PILL01 Note: PILL_CS: Pill Corticosteroid PILL _LM: pill Leukotriene modifiers (LTRA) or Leukotriene receptor antagonists PILL_B2A: pill beta 2 agonist PILL_METH: pill methylxanthines Note: The top 10 items (in bold below) should be highlighted in the CATI system if possible so they can be found more easily.
Q8.13		What PRESCRIPTION asthma medications does {child’s name} take in pill form? [MARK ALL THAT APPLY. PROBE: Any other PRESCRIPTION asthma pills?]		PILLS_MD		_ _ _ ; _ _ _ ; _ _ _ ; _ _ _ ; _ _ _ ;
						(66) Other [Please Specify, 100 character limit]			[SKIP TO OTH_P1]
						(88) NO PILLS			[SKIP TO SYRUP (8.15)]
						(77) DON’T KNOW			[SKIP TO SYRUP (8.15)]
						(99) REFUSED			[SKIP TO SYRUP (8.15)]
CATI NOTES Interview notes Q8.13a		ENTER OTHER MEDICATION IN TEXT FIELD. IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE. 100 ALPHANUMERIC CHARACTER LIMIT FOR 66		OTH_P1		_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
CATI NOTES		CATI programmers note that the text for 66 (other) should be checked to make sure one of the medication names above was not entered. If the medication entered is on the list above, then an error message should be shown.
Interview notes		[REPEAT QUESTION PILL01 AS NECESSARY FOR EACH PILL 01-49 REPORTED IN PILLS_MD for, BUT NOT FOR 66 (OTHER).]

Tale 8.2 Pills medication list table

Number code	Combined Code	Medication	Pronunciation	Category	Medication Class
1	01C	Accolate	ac-o-late	C	PILL _LM
2	02D	Aerolate	air-o-late	D	PILL_METH
3	03B	Albuterol	ăl'-bu'ter-ōl (or al-BYOO-ter-all)	B	PILL_B2A
4	04B	Alupent	al-u-pent	B	PILL_B2A
49	49B	Brethine	breth-een	B	PILL_B2A
5	05D	Choledyl (oxtriphylline)	ko-led-il	D	PILL_METH
7	07A	Deltasone	del-ta-sone	A	PILLS_CS
8	08D	Elixophyllin	e-licks-o-fil-in	D	PILL_METH
11	11A	Medrol	Med-rol	A	PILLS_CS
12	12B	Metaprel	Met-a-prell	B	PILL_B2A
13	13B	Metaproteronol	met"ah-pro-ter'ĕ-nōl (or met-a-proe-TER-e-nole)	B	PILL_B2A
14	14A	Methylpredinisolone	meth-ill-pred-niss-oh-lone (or meth-il-pred-NIS-oh-lone)	A	PILLS_CS
15	15C	Montelukast	mont-e-lu-cast	C	PILL _LM
17	17A	Pediapred	Pee-dee-a-pred	A	PILLS_CS
18	18A	Prednisolone	pred-NISS-oh-lone	A	PILLS_CS
19	19A	Prednisone	PRED-ni-sone	A	PILLS_CS
21	21B	Proventil	pro-ven-til	B	PILL_B2A
23	23D	Respid	res-pid	D	PILL_METH
24	24C	Singulair	sing-u-lair	C	PILL _LM
26	26D	Slo-bid	slow-bid	D	PILL_METH
25	25D	Slo-phyllin	slow- fil-in	D	PILL_METH
48	48B	Terbutaline (+ T. sulfate)	ter byoo' ta leen	B	PILL_B2A
28	28D	Theo-24	thee-o-24	D	PILL_METH
30	30D	Theochron	thee -o-kron	D	PILL_METH
31	31D	Theoclear	thee-o-clear	D	PILL_METH
32	32D	Theodur	thee-o-dur	D	PILL_METH
33	33D	Theo-Dur	thee-o-dur	D	PILL_METH
35	35D	Theophylline	thee-OFF-i-lin	D	PILL_METH
37	37D	Theospan	thee-o-span	D	PILL_METH
40	40D	T-Phyl	t-fil	D	PILL_METH
42	42D	Uniphyl	u-ni-fil	D	PILL_METH
43	43B	Ventolin	vent-o-lin	B	PILL_B2A
44	44B	Volmax	vole-max	B	PILL_B2A
45	45C	Zafirlukast	za-FIR-loo-kast	C	PILL _LM
46	46C	Zileuton	zye-loo-ton	C	PILL _LM
47	47C	Zyflo Filmtab	zye-flow film tab	C	PILL _LM
66		Other, Please Specify:	[SKIP TO OTH_P1]

CATI notes	For medicines from [MEDICATION LISTED IN PILLS_MD], grouped into [A, B, C, D] categories, for each category, loop back to ask QUESTION PILL01]
Q8.14	In the past 3 months, did {child’s name}? take [MEDICATION LISTED IN PILLS_MD (Q8.13) series ] on a regular schedule as prescribed?	PILL_01 PILL01_A PILL01_B PILL01_C PILL01_D	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED	Circle from A to D to ask Q8.14 For Category A, Variable name is PILL01_A et al.

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Q8.15	In the past 3 months, has {he/she} taken prescription medicine in syrup form?	SYRUP	(1) YES
			(2) NO	[SKIP TO NEB_SCR (8.17)]
			(7) DON’T KNOW	[SKIP TO NEB_SCR (8.17)]
			(9) REFUSED	[SKIP TO NEB_SCR (8.17)]
Syrup	For the following syrups the respondent can choose up to 4 medications; however, each medication can only be used once (in the past, errors such as 020202 were submitted in the data file). There are 10 kinds of medicine in the list, they could be grouped into following 3 groups A: SYRUP_B2AS B: SYRUP_CS C: SYRP_METH Note: SYRUP_CS: syrup Corticosteroid SYRUP_B2AS: syrup short acting beta 2 agonist SYRP_METH: syrup methylxanthines. [INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION.]
Q8.16	What PRESCRIPTION asthma medications has {child’s name} taken as a syrup? [MARK ALL THAT APPLY. PROBE: Any other PRESCRIPTION syrup medications for asthma?]	SYRUP_ID	_ _ _; _ _ _; _ _ _; _ _ _;
			(66) Other [Please Specify, 100 character limit]	[SKIP TO OTH_S1]
			(88) NO SYRUPS	[SKIP TO NEB_SCR (8.17)]
			(77) DON’T KNOW	[SKIP TO NEB_SCR (8.17)]
			(99) REFUSED	[SKIP TO NEB_SCR (8.17)]
CATI Notes	CATI programmers note that the text for 66 (other) should be checked to make sure one of the medication names above was not entered. If the medication entered is on the list above, then an error message should be shown.
Q8.16a	ENTER OTHER MEDICATION. IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE. [100 ALPHANUMERIC CHARACTER LIMIT FOR 66]	OTH_S1	______________

Table 8.3. Syrup medication list table

	Combined Code	Medication	Pronunciation	Category	Medication class
1	01C	Aerolate	air-o-late	C	SYRP_METH
2	02A	Albuterol	ăl'-bu'ter-ōl (or al-BYOO-ter-ole)	A	SYRUP_B2AS
3	03A	Alupent	al-u-pent	A	SYRUP_B2AS
4	04A	Metaproteronol	met"ah-pro-ter'ĕ-nōl (or met-a-proe-TER-e-nole)	A	SYRUP_B2AS
5	05B	Prednisolone	pred-NISS-oh-lone	B	SYRUP_CS
6	06B	Prelone	pre-loan	B	SYRUP_CS
7	07A	Proventil	Pro-ven-til	A	SYRUP_B2AS
8	08C	Slo-Phyllin	slow-fil-in	C	SYRP_METH
9	09C	Theophyllin	thee-OFF-i-lin	C	SYRP_METH
10	10A	Ventolin	vent-o-lin	A	SYRUP_B2AS
66		Other, Please Specify:	[SKIP TO OTH_S1]

Note: SYRUP_CS: syrup Corticosteroid; SYRUP_B2AS: syrup short acting beta 2 agonist; SYRP_METH: syrup methylxanthines.

Question Number

Question text

Variable names

Responses (DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Q8.17

Text: A nebulizer is a machine that turns liquid medication into a mist that {child’s name} inhale into the lungs over a few minutes. In the past 3 months, were any of {child’s name}’s PRESCRIPTION asthma medicines used with a nebulizer?

NEB_SCR

(1) YES

Read if necessary: a nebulizer is a machine that turns liquid medication into a mist that {child’s name} inhale into the lungs over a few minutes.

(2) NO

[SKIP TO Section 9]

(7) DON’T KNOW

[SKIP TO Section 9]

(9) REFUSED

[SKIP TO Section 9]

Q8.18

I am going to read a list of places where your child might have used a nebulizer. Please answer yes if your child has used a nebulizer in the place I mention, otherwise answer no. In the past 3 months did {child’s name}? use a nebulizer …

NEB_PLC

RESPONSES

(8.18a) AT HOME (1) YES (2) NO (7) DK (9) REF

(8.18b) AT A DOCTOR’S OFFICE (1) YES (2) NO (7) DK (9) REF

(8.18c) IN AN EMERGENCY ROOM (1) YES (2) NO (7) DK (9) REF

(8.18d) AT WORK OR AT SCHOOL (1) YES (2) NO (7) DK (9) REF

(8.18e) AT ANY OTHER PLACE (1) YES (2) NO (7) DK (9) REF

Nebulizer

For the following nebulizers, the respondent can choose up to 5 medications; however, each medication can only be used once (in the past, errors such as 0101 were submitted in the data file). There are 19 kinds of medicine in the list, they could be grouped into following 7 groups. (Notes: No F groups, keep consistency with INHALER category) A: NEB_B2AS B: NEB_AC C: NEB_AC+NEB_B2AS D: NEB_CS E: NEB_B2AL G: NEB_AI H: NEB_LAMA Note: NEB_CS: Nebulizer corticosteroid NEB_B2AS: Nebulizer Beta 2 Agonist short acting; NEB_B2AL: Nebulizer Beta 2 Agonist log acting; NEB_AI: Nebulizer anti-inflammatory; NEB_AC: Nebulizer Anticholinergic; NEB_LAMA: Long-Acting Muscarinic Antagonist. [INTERVIEWER: IF NECESSARY, ASK THE RESPONDENT TO SPELL THE NAME OF THE MEDICATION.]

Q8.19

In the past 3 months, what prescription ASTHMA medications has {he/she} taken using a nebulizer? [MARK ALL THAT APPLY. PROBE: Has your child taken any other prescription ASTHMA medications with a nebulizer in the past 3 months?]

NEB_ID

_ _ _ _ _ _ _ _ _ _

(66) Other [Please Specify, 100 character limit]

[SKIP TO OTH_N1]

(77) DON’T KNOW

[SKIP TO Section 9]

(99) REFUSED

[SKIP TO Section 9]

(99) REFUSED

[SKIP TO Section 9]

(99) REFUSED

[SKIP TO Section 9]

CATI Notes

CATI programmers note that the text for 66 (other) should be checked to make sure one of the medication names above was not entered. If the medication entered is on the list above, then an error message should be shown.

Interview Notes

LOOP BACK TO Q.21 (NEB01) AS NECESSARY TO ADMINISTER QUESTIONS Q.23(NEB03) FOR EACH CATEGORY OF [A,B,C,D,E,G,H] REPORTED IN NEB_ID, BUT NOT FOR 66 (OTHER)],

Q8.20

ENTER OTHER MEDICATION. IF MORE THAN ONE MEDICATION IS GIVEN, ENTER ALL MEDICATIONS ON ONE LINE. [100 ALPHANUMERIC CHARACTER LIMIT FOR 66]

OTH_N1

Table 8.4. Nebulizer medication list table

	Combined code	Medication	Pronunciation	Category	Medication class
1	01A	Albuterol	ăl'-bu'ter-ōl (or al-BYOO-ter-ole)	A	NEB_B2AS
2	02A	Alupent	al-u-pent	A	NEB_B2AS
3	03B	Atrovent	At-ro-vent	B	NEB_AC
4	04A	Bitolterol	bi-tōl'ter-ōl (or bye-tole-ter-ole)	A	NEB_B2AS
19	19H	Brovana	brō vă nah	H	NEB_LAMA
5	05D	Budesonide	byoo-des-oh-nide	D	NEB_CS
17	17C	Combivent Inhalation solution	com-bi-vent	C	NEB_AC+NEB_B2AS
6	06G	Cromolyn	kro'mŏ-lin (or KROE-moe-lin)	G	NEB_AI
7	07C	DuoNeb	DUE-ow-neb	C	NEB_AC+NEB_B2AS
8	08G	Intal	in-tel	G	INH_AI
9	09B	Ipratroprium bromide	ĭp-rah-tro'pe-um bro'mīd (or ip-ra-TROE-pee-um)	B	NEB_AC
10	10A	Levalbuterol	lev al byoo' ter ol	A	NEB_B2AS
11	11A	Metaproteronol	met"ah-pro-ter'ĕ-nōl (or met-a-proe-TER-e-nole)	A	NEB_B2AS
18	18E	Perforomist (Formoterol)	per-form-ist	E	NEB_B2AL
12	12A	Proventil	Pro-ven-til	A	NEB_B2AS
13	13D	Pulmicort	pul-ma-cort	D	NEB_CS
14	14A	Tornalate	tor-na-late	A	NEB_B2AS
15	15A	Ventolin	vent-o-lin	A	NEB_B2AS
16	16A	Xopenex	ZOH-pen-ecks	A	NEB_B2AS
66		Other, Please Specify:	[SKIP TO OTH_N1]

CATI notes	[For medicines from [MEDICATION LISTED IN NEB_ID], Group into [A,B,C,D,E,G,H] ask questions NEB01 to NEB02]
Q8.21	In the past 3 months, did {child’s name} take [MEDICINE FROM NEB_ID SERIES], when {he/she} had an asthma episode or attack?	NEB01 NEB01_A NEB01_B NEB01_C NEB01_D NEB01_E NEB01_G NEB01_H Q8.28	(1) YES (2) NO (3) NO ATTACK IN PAST 3 MONTHS (7) DON’T KNOW (9) REFUSED	Circle from A to H to ask Q8.21 to Q8.23 For Category A, Variable name is NEB01_A et al.
Q8.22	In the past 3 months, did he/she take [MEDICINE FROM NEB_ID SERIES], on a regular schedule as prescribed?	NEB02 NEB02_A NEB02_B NEB02_C NEB02_D NEB02_E NEB02_G NEB02_H Q8.29	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q8.23	How many times per day or per week does he/she use [MEDICINE FROM NEB_ID SERIES]?	NEB03 NEB03_A NEB03_B NEB03_C NEB03_D NEB03_E NEB03_G NEB03_H Q8.30	3__ __ DAYS 4__ __ WEEKS (555) NEVER (666) LESS OFTEN THAN ONCE A WEEK (777) DON’T KNOW / NOT SURE (999) REFUSED

Section 9. Cost of Care

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Q9.1	Was there a time in the past 12 months when {child’s name} needed to see his/her primary care doctor for asthma but could not because of the cost?	ASMDCOST	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q9.2	Was there a time in the past 12 months when you were referred to a specialist for {his/her} asthma care but could not go because of the cost?	ASSPCOST	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q9.3	Was there a time in the past 12 months when {he/she} needed medication for {his/her} asthma but you could not buy it because of the cost?	ASRXCOST	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

Section 10. School/Daycare Related Asthma

Question Number	Question text	Variable names		Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note		Interviewer Note (s)
Section 10. School/Daycare Related Asthma Q10.1	Next, we are interested in things that might affect {child’s name} asthma when {he/she} is not at home. Does {child’s name} currently go to school or pre-school or day care outside the home?	SCH_STAT		(1) YES	[SKIP TO SCHGRADE (10.3)]
				(2) NO	[SKIP TO NO SCHL (Q10.2)]
				(7) DON’T KNOW	[SKIP TO SCHGRADE (Q10.3)]
				(9) REFUSED	[SKIP TO SCHGRADE (Q10.3)]
Q10.2	What is the main reason {he/she} is not now in school or day care? READ RESPONSE CATEGORIES	NO_SCHL		(1) NOT OLD ENOUGH	[SKIP TO Section 11]
				(2) HOME SCHOOLED	Continuous
				(3) UNABLE TO ATTEND FOR HEALTH REASONS	Continuous
				(4) ON VACATION OR BREAK	Continuous
				(5) OTHER	Continuous
				(7) DON'T KNOW	Continuous
				(9) REFUSED	Continuous
Q10.3	What grade was {he/she} in the last time {he/she} was in school or daycare?	SCHGRADE		__ __ ENTER GRADE 1 TO 12 (88) PRE SCHOOL (66) KINDERGARTEN (55) DAYCARE (77) DON’T KNOW (99) REFUSED	Ask if [IF SCH_STAT = 1,7,9] If SCHGRADE= 55 daycare, SKIP to Q10.5, other continuous
	What grade is {he/she} in?
Q10.4	During the past 12 months, about how many days of school did {he/she} miss because of {his/her} asthma?		MISS_SCHL	__ __ __ENTER NUMBER DAYS (888) ZERO (777) DON’T KNOW (999) REFUSED	Ask if [IF SCHGRADE (Q10.3) = 1-12, 66, 88, pre school, Kindergarten, grade 1-12] [3 NUMERIC-CHARACTER-FIELD, RANGE CHECK: (001-365, 777, 888, 999)] [Verify any entry >50] [CATI CHECK: IF RESPONSE = 77, 88, 99 VERIFY THAT 777, 888 AND 999 WERE NOT THE INTENT]
Q10.5	Does the school {he/she} goes to allow children with asthma to carry their medication with them while at school or daycare?		SCH_MED	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q10.6	Earlier I explained that an asthma action plan contains instructions about how to care for the child’s asthma. Does {child’s name} have a written asthma action plan or asthma management plan on file at school or daycare?		SCH_APL	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q10.7	Are there any pets such as dogs, cats, hamsters, birds or other feathered or furry pets in {his/her} classroom?		SCH_ANML	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q10.8	Are you aware of any mold problems in {child’s name} school or Daycare?		SCH_MOLD	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

11. Additional Child Demographics

Question Number	Question text		Variable names			Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note		Interviewer Note (s)
Q11.1.	How much did {he/she} weigh at birth (in pounds)?			BIRTHW1 Q11.3		_ _ _ _ _ _ Weight (pounds/kilograms) 7 7 7 7 7 7 Don’t know / Not sure 9 9 9 9 9 9 Refused
Q11.2		At birth, did {child’s name} weigh less than 5 ½ pounds?			BIRTHRF Q11.4	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED			[INTERVIEWER NOTE: 5 ½ pounds = 2500 GRAMS]

New Section 12. Family History of Asthma and Allergy

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)
Q12.1	Including living and deceased, were any of {child’s name} close biological that is, blood relatives including father, mother, sisters, brothers, or children ever told by a health professional that they had asthma?	RELATE_ASTH	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
	The next set of questions are about different types of allergies.
Q12.2	Does {child’s name} get symptoms such as sneezing, runny nose, or itchy or watery eyes due to hay fever, seasonal or year-round allergies? ?	CURRESP	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		Read if necessary: Hay fever, seasonal or year-round allergies may also be known as environmental allergies, allergic rhinitis or allergic conjunctivitis.
Q12.3	Has {child’s name} ever been told by a doctor or other health professional that {child’s name} had hay fever, seasonal or year-round allergies?	DXRESP	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q12.4	Question Text: The next question is about food allergies. People with food allergies have reactions such as hives, vomiting, trouble breathing, or throat tightening that occur within two hours of eating a specific food. Do {child’s name} have an allergy to one or more foods?	CURFOOD	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		Read if necessary: Food allergies are different from food intolerances, such as lactose and gluten intolerance, and other digestive disorders, including irritable bowel syndrome.
Q12.5	Has {child’s name} ever been told by a doctor or other health professional that {child’s name} had an allergy to one or more foods?	DXFOOD	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED
Q12.6	The next question is about an allergic skin condition. Does {child’s name} get an itchy rash due to eczema or atopic dermatitis?	CURSKIN	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED		Read if necessary: The rash can be dry, scaly, bumpy, or crusty and lasts for several days or longer without treatment. Eczema is different from hives which come and go in a few hours.
Q11.7	Has {child’s name} ever been told by a doctor or other health professional that {child’s name} had eczema or atopic dermatitis?	DXSKIN	(1) YES (2) NO (7) DON’T KNOW (9) REFUSED

CWEND

Those are all the questions I have. I’d like to thank you on behalf of the {STATE NAME} Health Department and the Centers for Disease Control and Prevention for the time and effort you’ve spent answering these questions. If you have any questions about this survey, you may call my supervisor toll-free at 1 – xxx-xxx-xxxx. If you have questions about your rights as a survey participant, you may call the chairman of the Institutional Review Board at 1 800 xxx-xxxx. Thanks again.

Appendix A:

Language for Identifying Most Knowledgeable Person during the BRFSS interview

Consent scripts for use during BRFSS Childhood asthma prevalence module when the most knowledgeable adult is identified during the BRFSS interview.

BRFSS Childhood asthma module:

If BRFSS respondent indicates that the randomly selected child has ever had asthma (CASTHDX2 = 1 “yes”) and the BRFSS adult never had asthma then arrange for a call-back interview. If both the BRFSS adult and the randomly selected child both have asthma the child is randomly selected for the call-back at least 75% of the time.

Only respondents who are the parent/guardian of the selected child with asthma are eligible for the child asthma call-back interview. This is required because the parent/guardian must give permission to collect information about the child even if the information is being given by someone else. [ BRFSS Random Child Selection Question: How are you related to the child? (RCSRELN2) = 1, 3]

READ: We would like to call again within the next 2 weeks to talk in more detail about your child’s experiences with asthma. The information will be used to help develop and improve the asthma programs in {state name}. The information you gave us today and any you give us in the future will be kept confidential. If you agree to this, we will keep your first name or initials and phone number on file, separate from the answers collected today. Even if you agree now, you or others may refuse to participate in the future.

Question Number

Question text

Variable names

Responses (DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Q01

Would it be all right if we call back at a later time to ask additional questions about your child’s asthma?

ADULTPERM

(1) Yes

(2) No

(GO TO BRFSS closing or next module)

(7) Don’t know/Not Sure

(GO TO BRFSS closing or next module)

(9) Refused

(GO TO BRFSS closing or next module)

Q02

Can I please have your child's first name, initials or nickname so we can ask about the right child when we call back? This is the {#} year old child which is the {FIRST CHILD, SECOND, etc.} CHILD.

CHILDNNAME

Enter child’s first name, initials or nickname: ____________

[CATI: If more than one child, show child age {#} and which child was selected (FIRST, SECOND, etc.) from child selection module]

Q03

Can I please have your first name, initials or nickname so we know who to refer to when we call back?

ADULTNAME

Enter respondent’s first name, initials or nickname: ____________

Q04

Are you the parent or guardian in the household who knows the most about {child’s name}’s asthma?

MOSTKNOW

(1) Yes

[CATI SET MKPNAME = ADULTNAME 03]

(2) No

[GO TO ALTNAME 06]

(7) Don’t know/Not Sure

[GO TO ALTNAME 06]

(9) Refused

[GO TO ALTNAME 06]

Q05

What is a good time to call you back? For example, evenings, days, weekends? Phone number: What is the best number to call you back?

CBTIME

Enter day/time: _________________

Enter phone number: _________

Interviewer Notes:

READ: The information you gave us today and will give us when we call back will be kept confidential. We will keep identifying information like your child’s name and your name and phone number on file, separate from the answers collected today. Even though you agreed today, you may refuse to participate in the future.

[If state requires active linking consent continue, if not, go to BRFSS closing or next module]

Linking consent

READ: Some of the information that you shared with us today could be useful when combined with the information we will ask for during your child’s asthma interview. If the information from the two interviews is combined, identifying information such as your phone number, your name, and your child’s name will not be included. PERMISS: May we combine your answers from today with your answers from the interview about your child’s asthma that will be done in the next two weeks? (1) Yes [GO TO BRFSS closing or next module] (2) No [GO TO BRFSS closing or next module] (7) Don’t Know [GO TO BRFSS closing or next module] (9) Refused [GO TO BRFSS closing or next module] If MOSTKNOW (04) = 2 (NO), 7 (Don’t know/Not Sure), 9 Refused, ask ALTNAME 06.

Q06

READ: If you are not the person in the household who knows the most about {child’s name}’s asthma, could you identify the person who knows the most about {child’s name}’s asthma and provide permission to speak with that person and for that person to speak on behalf of the child? May I please have the first name, initials or nickname of the person who knows the most about {child’s name}’s asthma so we will know who to ask for when we call back?

ALTNAME

Alternate’s __________;

[CATI SET MKPNAME = ALTNAME]

Q07

Is there a different phone number we should use to contact {ALTNAME}?

ALTPHONE

Alternate’s Phone number: ________;

Q08

When would be a good time to call back and speak with {ALTNAME}? For example, evenings, days, weekends?

ALTCBTIME

Enter day/time: ___________

Interview Notes

READ: The information you gave us today and that {ALTNAME} will give us when we call back will be kept confidential. We will keep their name and phone number, and your child’s name on file, separate from the answers collected today. Even though you agreed today, {ALTNAME} may refuse to participate in the future.

[If state requires linking consent, continue; if not, go to BRFSS closing or next module]

Linking Consent

READ: Some of the information that you shared with us today could be useful when combined with the information we will ask for during your child’s asthma interview. If the information from the two interviews is combined, identifying information such as your phone number, your name, and your child’s name will not be included. PERMISS: May we combine your answers from today with the answers {ALTNAME} gives us during the interview about your child’s asthma? (1) Yes [GO TO BRFSS closing or next module] (2) No [GO TO BRFSS closing or next module] (7) Don’t Know [GO TO BRFSS closing or next module] (9) Refused [GO TO BRFSS closing or next module]

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