0920-1061-24BN 2024 BRFSS Questionnaire (Field Test)

[NCCDPHP] Behavioral Risk Factor Surveillance System (BRFSS)

5a - 2024 BRFSS Questionnaire

OMB: 0920-1061

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2024 BRFSS Questionnaire

DRAFT







Table of Contents

OMB Header and Introductory Text 4

Landline Introduction 5

Cell Phone Introduction 11

Core Section 1: Health Status 16

Core Section 2: Healthy Days 18

Core Section 3: Health Care Access 20

Core Section 4: Exercise 23

Core Section 5: Oral Health 23

Core Section 6: Chronic Health Conditions 25

Core Section 7: Demographics 27

Core Section 8: Disability 33

Core Section 9: Breast and Cervical Cancer Screening 35

Core Section 10: Colorectal Cancer Screening 38

Core Section 11: Tobacco Use 46

Core Section 12: Lung Cancer Screening 48

Core Section 13: Alcohol Consumption 51

Core Section 14: Immunization 53

Core Section 15: H.I.V./AIDS 55

Closing Statement/ Transition to Modules 57

Optional Modules 58

Module 1: Prediabetes 58

Module 2: Diabetes 60

Module 3: Arthritis 63

Module 4: Shingles Vaccination 63

Module 5: HPV Vaccination 65

Module 6: Tetanus Vaccination 67

Module 7: Cancer Survivorship: Type of Cancer 68

Module 8: Cancer Survivorship: Course of Treatment 71

Module 9: Cancer Survivorship: Pain Management 74

Module 10: Prostate Cancer Screening 75

Module 11: Cognitive Decline 77

Module 12: Caregiver 79

Module 13: Adverse Childhood Experiences 83

Module 14: Social Determinants and Health Equity 87

Module 15: Marijuana Use 90

Module 16: Tobacco Cessation 93

Module 17: Other Tobacco Use 94

Module 18: Sugar-Sweetened Beverages 96

Module 19: Firearm Safety 97

Module 20: Industry and Occupation 98

Module 21: Random Child Selection 99

Module 22: Childhood Asthma Prevalence 103

Module 23: Sex at Birth 104

Module 24: Sexual Orientation and Gender Identity (SOGI) 105

Module 25: Family Planning 108

Module 26: Reactions to Race 112

Asthma Call-Back Permission Script 115







OMB Header and Introductory Text


Read if necessary

Read

Interviewer instructions

(not read)

Public reporting burden of this collection of information is estimated to average 27 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061).


Form Approved

OMB No. 0920-1061

Exp. Date 12/31/2024


Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Marquisette Glass Lewis at grp2@cdc.gov.


HELLO, I am calling for the [STATE OF xxx] Department of Health. My name is (name). We are gathering information about the health of US residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices.

States may opt not to mention the state name to avoid refusals by out of state residents in the cell phone sample.


If cell phone respondent objects to being contacted by state where they have never lived, say:

“This survey is conducted by all states and your information will be forwarded to the correct state of residence”




Landline Introduction


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

LL01.


Is this [PHONE NUMBER]?


1 Yes

Go to LL02



2 No

TERMINATE

Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time.

LL02.


Is this a private residence?


1 Yes

Go to LL04

Read if necessary: By private residence we mean someplace like a house or apartment.

Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.


2 No


Go to LL03

If no, business phone only: thank you very much but we are only interviewing persons on residential phones lines at this time.

NOTE: Business numbers which are also used for personal communication are eligible.

3 No, this is a business


Read: Thank you very much but we are only interviewing persons on residential phones at this time.

TERMINATE

LL03.


Do you live in college housing?


1 Yes

Go to LL04

Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.


2 No

TERMINATE

Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.

LL04.


Do you currently live in__(state)____?


1 Yes

Go to LL05



2 No

TERMINATE

Thank you very much but we are only interviewing persons who live in [STATE] at this time.

LL05.

Is this a cell phone?


1 Yes, it is a cell phone

TERMINATE

Read: Thank you very much but we are only interviewing by landline telephones in private residences or college housing at this time.


2 Not a cell phone

Go to LL06

Read if necessary: By cell phone we mean a telephone that is mobile and usable outside your neighborhood.

Do not read: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).

LL06.


Are you 18 years of age or older?


1 Yes


IF COLLEGE HOUSING (LL03) = “YES,” GO TO LL09;

OTHERWISE GO TO NUMBER OF ADULTS LL07



2 No

IF COLLEGE HOUSING (LL03) = “YES,” Terminate;

OTHERWISE GO TO NUMBER OF ADULTS LL07

Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.


LL07.

I need to randomly select one adult who lives in your household to be interviewed. Excluding adults living away from home, such as students away at college, how many members of your household, including yourself, are 18 years of age or older?


1

Go to LL09

Read: Are you that adult?

If yes: Then you are the person I need to speak with.

If no: May I speak with the adult in the household?


2-6 or more

Go to LL08.

If respondent questions why any specific individual was chosen, emphasize that the selection is random and is not limited to any certain age group or sex.

LL08.

The person in your household that I need to speak with is the adult with the most recent birthday. Are you the adult with the most recent birthday?


1 = Yes

2 = No - Ask for correct respondent

If person indicates that they are not the selected respondent, ask for correct respondent and re-ask LL08. (See CATI programming)



LL09.

Are you?



Read:

1 Male

2 Female


Go to Transition Section 1.

We ask this question to determine which health related questions apply to each respondent. For example, persons who report males as their sex at birth might be asked about prostate health issues.





3 Transgender, non-binary, or another gender

Do not read:

7 Don’t know/Not sure

9 Refused

Go to LL10



LL10

What was your sex at birth? Was it male or female?


1 Male

2 Female

7 Don’t know/Not sure

9 Refused

If ‘7’ or ‘9’ then TERMINATE

“Thank you for your time, your number may be selected for another survey in the future.”

Read if necessary:

“What sex were you assigned at birth on your original birth certificate?”



Transition to Section 1.



I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information If you have any questions about the survey, please call (give appropriate state telephone number).


Do not read: Introductory text may be reread when selected respondent is reached.


Do not read: The sentence “Any information you give me will not be connected to any personal information” may be replaced by “Any personal information that you provide will not be used to identify you.” If the state coordinator approves the change.



Cell Phone Introduction


Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)








CP01.


Is this a safe time to talk with you?


1 Yes

Go to CP02



2 No

([set appointment if possible]) TERMINATE]

Thank you very much. We will call you back at a more convenient time.

CP02.


Is this [PHONE NUMBER]?


1 Yes

Go to CP03



2 No

TERMINATE

Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time

CP03.


Is this a cell phone?


1 Yes

Go to CP04



2 No

TERMINATE

If "no”: thank you very much, but we are only interviewing persons on cell telephones at this time

CP04.


Are you 18 years of age or older?


1 Yes


Go to CP05.



2 No

TERMINATE

Read: Thank you very much but we are only interviewing persons aged 18 or older at this time.

CP05.

Are you ?



Please read:

1 Male

2 Female


Go to CP07.

We ask this question to determine which health related questions apply to each respondent. For example, persons who report males as their sex at birth might be asked about prostate health issues.




3 Transgender, non-binary, or another gender

Do not read:

7 Don’t know/Not sure

9 Refused

Go to CP06



CP06

What was your sex at birth? Was it male or female?


1 Male

2 Female

7 Don’t know/Not sure

9 Refused

If ‘7’ or ‘9’ then terminate.

“Thank you for your time, your number may be selected for another survey in the future.”

Read if necessary:

“What sex were you assigned at birth on your original birth certificate?”


CP07.


Do you live in a private residence?


1 Yes

Go to CP09

Read if necessary: By private residence we mean someplace like a house or apartment

Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year.


2 No

Go to CP08


CP08.


Do you live in college housing?


1 Yes

Go to CP09

Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.


2 No

TERMINATE

Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.

CP09.


Do you currently live in___(state)____?


1 Yes

Go to CP11



2 No

Go to CP10


CP10.


In what state do you currently live?


1 Alabama

2 Alaska

4 Arizona

5 Arkansas

6 California

8 Colorado

9 Connecticut

10 Delaware

11 District of Columbia

12 Florida

13 Georgia

15 Hawaii

16 Idaho

17 Illinois

18 Indiana

19 Iowa

20 Kansas

21 Kentucky

22 Louisiana

23 Maine

24 Maryland

25 Massachusetts

26 Michigan

27 Minnesota

28 Mississippi

29 Missouri

30 Montana

31 Nebraska

32 Nevada

33 New Hampshire

34 New Jersey

35 New Mexico

36 New York

37 North Carolina

38 North Dakota

39 Ohio

40 Oklahoma

41 Oregon

42 Pennsylvania

44 Rhode Island

45 South Carolina

46 South Dakota

47 Tennessee

48 Texas

49 Utah

50 Vermont

51 Virginia

53 Washington

54 West Virginia

55 Wisconsin

56 Wyoming

66 Guam

72 Puerto Rico

78 Virgin Islands




77 Live outside US and participating territories

99 Refused

TERMINATE

Read: Thank you very much, but we are only interviewing persons who live in the US.

CP11.


Do you also have a landline telephone in your home that is used to make and receive calls?


1 Yes

2 No

7 Don’t know/ Not sure

9 Refused


Read if necessary: By landline telephone, we mean a regular telephone in your home that is used for making or receiving calls. Please include landline phones used for both business and personal use.


CP12.

How many members of your household, including yourself, are 18 years of age or older?


_ _ Number

77 Don’t know/ Not sure

99 Refused

If CP08 = yes then number of adults is automatically set to 1



Transition to section 1.



I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call (give appropriate state telephone number).




Core Section 1: Health Status



Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CHS.01


Would you say that in general your health is—

Read:

1 Excellent

2 Very Good

3 Good

4 Fair

5 Poor

Do not read:

7 Don’t know/Not sure

9 Refused








Core Section 2: Healthy Days



Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CHD.01


Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

_ _ Number of days (01-30)

88 None

77 Don’t know/not sure

99 Refused


88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.


CHD.02

Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

_ _ Number of days (01-30)

88 None

77 Don’t know/not sure

99 Refused


88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.





Skip CHD.03 if CHD.01, (PHYSHLTH) is 88 and CHD.02, (MENTHLTH) is 88



CHD.03

During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

_ _ Number of days (01-30)

88 None

77 Don’t know/not sure

99 Refused


88 may be coded if respondent says “never” or “none” It is not necessary to ask respondents to provide a number if they indicate that this never occurs.






Core Section 3: Health Care Access



Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CHCA.01


What is the current primary source of your health care coverage?

Read if necessary:


01 A plan purchased through an employer or union (including plans purchased through another person's employer)

02 A private nongovernmental plan that you or another family member buys on your own

03 Medicare

04 Medigap

05 Medicaid

06 Children's Health Insurance Program (CHIP)

07 Military related health care: TRICARE (CHAMPUS) / VA health care / CHAMP- VA

08 Indian Health Service

09 State sponsored health plan

10 Other government program

88 No coverage of any type


77 Don’t Know/Not Sure 99 Refused



If respondent has multiple sources of insurance, ask for the one used most often.

If respondents give the name of a health plan rather than the type of coverage

ask whether this is insurance purchased independently, through their employer, or whether it is through Medicaid or CHIP.



CHCA.02

Do you have one person (or a group of doctors) that you think of as your personal health care provider?

1 Yes, only one

2 More than one

3 No

7 Don’t know / Not sure

9 Refused


If no, read: Is there more than one, or is there no person who you think of as your personal doctor or health care provider?


NOTE: if the respondent had multiple doctor groups then it would be more than one—but if they had more than one doctor in the same group it would be one.


CHCA.03

Was there a time in the past 12 months when you needed to see a doctor but could not because you could not afford it?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CHCA.04

About how long has it been since you last visited a doctor for a routine checkup?

Read if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 5 years (2 years but less than 5 years ago)

4 5 or more years ago

Do not read:

7 Don’t know / Not sure

8 Never

9 Refused


Read if necessary: A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.





Core Section 4: Exercise



Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CEX.01


During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Do not read: If respondent does not have a regular job or is retired, they may count any physical activity or exercise they do





Core Section 5: Oral Health



Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

COH.01


Including all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists, how long has it been since you last visited a dentist or a dental clinic for any reason?

Read if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 5 years (2 years but less than 5 years ago)

4 5 or more years ago

Do not read:

7 Don’t know / Not sure

8 Never

9 Refused



129

COH.02

Not including teeth lost for injury or orthodontics, how many of your permanent teeth have been removed because of tooth decay or gum disease?

Read if necessary:

1 1 to 5

2 6 or more but not all

3 All

8 None

Do not read:

7 Don’t know / Not sure

9 Refused


Read if necessary: If wisdom teeth are removed because of tooth decay or gum disease, they should be included in the count for lost teeth.

130







Core Section 6: Chronic Health Conditions



Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue

Has a doctor, nurse, or other health professional ever told you that you had any of the following? For each, tell me Yes, No, Or You’re Not Sure.





CCHC.01


Ever told you that you had a heart attack also called a myocardial infarction?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.02

(Ever told) (you had) angina or coronary heart disease?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.03

(Ever told) (you had) a stroke?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.04

(Ever told) (you had) asthma?

1 Yes




2 No

7 Don’t know / Not sure

9 Refused

Go to CCHC.06


CCHC.05

Do you still have asthma?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.06

(Ever told) (you had) skin cancer that is not melanoma?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.07

(Ever told) (you had) melanoma or any other types of cancer?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.08

(Ever told) (you had) C.O.P.D. (chronic obstructive pulmonary disease), emphysema or chronic bronchitis?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.09

(Ever told) (you had) a depressive disorder (including depression, major depression, dysthymia, or minor depression)?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CCHC.10

Not including kidney stones, bladder infection or incontinence, were you ever told you had kidney disease?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Read if necessary: Incontinence is not being able to control urine flow.


CCHC.11

(Ever told) (you had) some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Do not read: Arthritis diagnoses include: rheumatism, polymyalgia rheumatic, osteoarthritis (not osteoporosis), tendonitis, bursitis, bunion, tennis elbow, carpal tunnel syndrome, tarsal tunnel syndrome, joint infection, Reiter’s syndrome, ankylosing spondylitis; spondylosis, rotator cuff syndrome, connective tissue disease, scleroderma, polymyositis, Raynaud’s syndrome, vasculitis, giant cell arteritis, Henoch-Schonlein purpura, Wegener’s granulomatosis, polyarteritis nodosa)


CCHC.12

(Ever told) (you had) diabetes?

1 Yes



If yes and respondent is female, ask: was this only when you were pregnant? If respondent says pre-diabetes or borderline diabetes, use response code 4.


2 Yes, but female told only during pregnancy

3 No

4 No, pre-diabetes or borderline diabetes

7 Don’t know / Not sure

9 Refused

Go to Pre-Diabetes Optional Module (if used). Otherwise, go to next section.


CCHC.13

How old were you when you were first told you had diabetes?

_ _ Code age in years [97 = 97 and older]

98 Don‘t know / Not sure

99 Refused

Go to Diabetes Module if used, otherwise go to next section.



Core Section 7: Demographics



Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CDEM.01

What is your age?

_ _ Code age in years

07 Don’t know / Not sure

09 Refused




CDEM.02

Are you Hispanic, Latino/a, or Spanish origin?

If yes, read: Are you…

1 Mexican, Mexican American, Chicano/a

2 Puerto Rican

3 Cuban

4 Another Hispanic, Latino/a, or Spanish origin

Do not read:

5 No

7 Don’t know / Not sure

9 Refused


One or more categories may be selected.


CDEM.03

Which one or more of the following would you say is your race?

Please read:

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

88 No additional choices

77 Don’t know / Not sure

99 Refused

.

If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.

One or more categories may be selected.


If respondent indicates that they are Hispanic for race, please read the race choices.


CDEM.04

Are you…

Please read:

1 Married

2 Divorced

3 Widowed

4 Separated

5 Never married

Or

6 A member of an unmarried couple

Do not read:

9 Refused




CDEM.05

What is the highest grade or year of school you completed?

Read if necessary:

1 Never attended school or only attended kindergarten

2 Grades 1 through 8 (Elementary)

3 Grades 9 through 11 (Some high school)

4 Grade 12 or GED (High school graduate)

5 College 1 year to 3 years (Some college or technical school)

6 College 4 years or more (College graduate)

Do not read:

9 Refused




CDEM.06

Do you own or rent your home?

1 Own

2 Rent

3 Other arrangement

7 Don’t know / Not sure

9 Refused


Other arrangement may include group home, staying with friends or family without paying rent. Home is defined as the place where you live most of the time/the majority of the year.

Read if necessary: We ask this question in order to compare health indicators among people with different housing situations.


CDEM.07

In what county do you currently live?

_ _ _ANSI County Code

777 Don’t know / Not sure

999 Refused

888 County from another state




CDEM.08

What is the ZIP Code where you currently live?

_ _ _ _ _

77777 Do not know

99999 Refused

If cell interview go to CDEM11




CDEM.09

Not including cell phones or numbers used for computers, fax machines or security systems, do you have more than one landline telephone number in your household?

1 Yes





2 No

7 Don’t know / Not sure

9 Refused

Go to CDEM.11


CDEM.10

How many of these landline telephone numbers are residential numbers?

__ Enter number (1-5)

6 Six or more

7 Don’t know / Not sure

8 None

9 Refused




CDEM.11

How many cell phones do you have for your personal use?

__ Enter number (1-5)

6 Six or more

7 Don’t know / Not sure

8 None

9 Refused

Last question needed for partial complete.

Read if necessary: Include cell phones used for both business and personal use.


CDEM.12

Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Read if necessary: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.


CDEM.13

Are you currently…?

Read:

1 Employed for wages

2 Self-employed

3 Out of work for 1 year or more

4 Out of work for less than 1 year

5 A Homemaker

6 A Student

7 Retired

Or

8 Unable to work

Do not read:

9 Refused


If more than one, say “select the category which best describes you”.


CDEM.14

How many children less than 18 years of age live in your household?

_ _ Number of children

88 None

99 Refused




CDEM.15

Is your annual household income from all sources—

Read if necessary:

01 Less than $10,000?

02 Less than $15,000? ($10,000 to less than $15,000)

03 Less than $20,000? ($15,000 to less than $20,000)

04 Less than $25,000

05 Less than $35,000 If

($25,000 to less than $35,000)

06 Less than $50,000 If

($35,000 to less than $50,000)

07 Less than $75,000? ($50,000 to less than $75,000)

08 Less than $100,000? ($75,000 to less than $100,000)

09 Less than $150,000? ($100,000 to less than $150,000)?

10 Less than $200,000? ($150,000 to less than $200,000)

11 $200,000 or more


Do not read:

77 Don’t know / Not sure

99 Refused

SEE CATI information of order of coding;


Start with category 05 and move up or down categories.

If respondent refuses at ANY income level, code ‘99’ (Refused)






Skip if Male (MSAB.01, is coded 1). If MSAB.01=missing and (CP.05=1 or CP.06=1 or LL.09 = 1 or LL.10=1).

Or Age >49



CDEM.16

To your knowledge, are you now pregnant?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CDEM.17

About how much do you weigh without shoes?

_ _ _ _ Weight (pounds/kilograms)

7777 Don’t know / Not sure

9999 Refused


If respondent answers in metrics, put 9 in first column. Round fractions up


CDEM.18

About how tall are you without shoes?

_ _ / _ _ Height (ft / inches/meters/centimeters)

77/ 77 Don’t know / Not sure

99/ 99 Refused


If respondent answers in metrics, put 9 in first column. Round fractions down



Core Section 8: Disability

Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CDIS.01

Some people who are deaf or have serious difficulty hearing use assistive devices to communicate by phone. Are you deaf or do you have serious difficulty hearing?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CDIS.02

Are you blind or do you have serious difficulty seeing, even when wearing glasses?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CDIS.03

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CDIS.04

Do you have serious difficulty walking or climbing stairs?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CDIS.05

Do you have difficulty dressing or bathing?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CDIS.06

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused







Core Section 9: Breast and Cervical Cancer Screening


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




Skip if Male (MSAB.01, is coded 1). If MSAB.01=missing and (CP.05=1 or CP.06=1 or LL.09 = 1 or LL.10=1).



CBCCS.01


The next questions are about breast and cervical cancer. Have you ever had a mammogram?

1 Yes


A mammogram is an x-ray of each breast to look for breast cancer.


2 No

7 Don’t know/ not sure

9 Refused

Go to CBCCS.03

CBCCS.02

How long has it been since you had your last mammogram?

Read if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 3 years (2 years but less than 3 years ago)

4 Within the past 5 years (3 years but less than 5 years ago)

5 5 or more years ago

7 Don’t know / Not sure

9 Refused




CBCCS.03


Have you ever had a cervical cancer screening test?

1 Yes



2 No

7 Don’t know/ not sure

9 Refused

Go to CBCCS.07

CBCCS.04

How long has it been since you had your last cervical cancer screening test?

Read if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 3 years (2 years but less than 3 years ago)

4 Within the past 5 years (3 years but less than 5 years ago)

5 5 or more years ago





7 Don’t know / Not sure

9 Refused


CBCCS.05

At your most recent cervical cancer screening, did you have a Pap test?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




CBCCS.06

At your most recent cervical cancer screening, did you have an H.P.V. test?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


H.P.V. stands for Human papillomarvirus (pap-uh-loh-muh virus)





If response to Core CDEM.16 = 1 (is pregnant) do not ask and go to next module.



CBCCS.07

Have you had a hysterectomy?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Read if necessary: A hysterectomy is an operation to remove the uterus (womb).




Core Section 10: Colorectal Cancer Screening


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




If Section CDEM.01, (AGE), is less than 45 go to next module.



CCRC.01

Colonoscopy and sigmoidoscopy are exams to check for colon cancer. Have you ever had either of these exams?

1 Yes

Go to CCRC.02

A sigmoidoscopy checks part of the colon and you are fully awake. A colonoscopy checks the entire colon. You are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test.


2 No

7 Don’t know/ not sure

9 Refused

Go to CCRC.06

CCRC.02

Have you had a colonoscopy, a sigmoidoscopy, or both?

1 Colonoscopy


Go to CCRC.03



2 Sigmoidoscopy

Go to CCRC.04

3 Both


Go to CCRC.03

7 Don’t know/Not sure

Go to CCRC.05

9 Refused

Go to CCRC.06

CCRC.03

How long has it been since your most recent colonoscopy?

Read if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 5 years (2 years but less than 5 years ago)

4 Within the past 10 years (5 years but less than 10 years ago)

5 10 or more years ago

Do not read:

7 Don't know / Not sure

9 Refused







If CCRC.02 =3 (BOTH) continue, else

Go to CCRC.06



CCRC.04

How long has it been since your most recent sigmoidoscopy?

Read if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 5 years (2 years but less than 5 years ago)

4 Within the past 10 years (5 years but less than 10 years ago)

5 10 or more years ago

Do not read:

7 Don't know / Not sure

9 Refused

Go to CCRC.06



CCRC.05

How long has it been since your most recent colonoscopy or sigmoidoscopy?

Read if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 5 years (2 years but less than 5 years ago)

4 Within the past 10 years (5 years but less than 10 years ago)

5 10 or more years ago

Do not read:

7 Don't know / Not sure

9 Refused




CCRC.06

Have you ever had any other kind of test for colorectal cancer, such as virtual colonoscopy, CT colonography, blood stool test, FIT DNA, or Cologuard test?

1 Yes

Go to CCRC.07



2 No

7 Don’t Know/Not sure

9 Refused

Go to Next Module

CCRC.07

A virtual colonoscopy uses a series of X-rays to take pictures of inside the colon. Have you ever had a virtual colonoscopy?

1 Yes

Go to CCRC.08

CT colonography, sometimes called virtual colonoscopy, is a new type of test that looks for cancer in the colon. Unlike regular colonoscopies, you do not need medication to make you sleepy during the test. In this new test, your colon is filled with air and you are moved through a donut-shaped X-ray machine as you lie on your back and then your stomach.


2 No

7 Don’t Know/Not sure

9 Refused

Go to CCRC.09

CCRC.08

When was your most recent CT colonography or virtual colonoscopy?

Read if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 5 years (2 years but less than 5 years ago)

4 Within the past 10 years (5 years but less than 10 years ago)

5 10 or more years ago

Do not read:

7 Don't know / Not sure

9 Refused




CCRC.09


One stool test uses a special kit to obtain a small amount of stool at home and returns the kit to the doctor or the lab. Have you ever had this test?

1 Yes

Go to CCRC.10

The blood stool or occult blood test, fecal immunochemical or FIT test determine whether you have blood in your stool or bowel movement and can be done at home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it back to the doctor or lab.


2 No

7 Don’t know/ not sure

9 Refused

Go to CCRC.11

CCRC.10

How long has it been since you had this test?

Read if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 3 years (2 years but less than 3 years ago)

4 Within the past 5 years (3 years but less than 5 years ago)

5 5 or more years ago

Do not read:

7 Don’t know / Not sure

9  Refused





CCRC.11

Another stool test uses a special kit to obtain an entire bowel movement at home and returns the kit to a lab. Have you ever had this test?

1 Yes

Go to CCRC.12

Cologuard is a new type of stool test for colon cancer. Unlike other stool tests, Cologuard looks for changes in DNA in addition to checking for blood in your stool. The Cologuard test is shipped to your home in a box that includes a container for your stool sample.


2 No

7 Don’t Know/Not sure

9 Refused

Go to Next Module

CCRC.12

Was the blood stool or FIT (you reported earlier) conducted as part of a Cologuard test?

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused


Cologuard is a new type of stool test for colon cancer. Unlike other stool tests, Cologuard looks for changes in DNA in addition to checking for blood in your stool. The Cologuard test is shipped to your home in a box that includes a container for your stool sample.


CCRC.13

How long has it been since you had this test?

Read if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 3 years (2 years but less than 3 years ago)

4 Within the past 5 years (3 years but less than 5 years ago)

5 5 or more years ago

Do not read:

7 Don’t know / Not sure

9  Refused

Do not read:

7 Don't know / Not sure

9 Refused






Core Section 11: Tobacco Use



Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CTOB.01


Have you smoked at least 100 cigarettes in your entire life?

1 Yes


Do not include: electronic cigarettes (e-cigarettes, njoy, bluetip, JUUL), herbal cigarettes, cigars, cigarillos, little cigars, pipes, bidis, kreteks, water pipes (hookahs) or marijuana.

5 packs = 100 cigarettes.


2 No

7 Don’t know/Not Sure

9 Refused

Go to CTOB.03


CTOB.02

Do you now smoke cigarettes every day, some days, or not at all?

1 Every day

2 Some days

3 Not at all

7 Don’t know / Not sure

9 Refused




CTOB.03

Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?

1 Every day

2 Some days

3 Not at all

7 Don’t know / Not sure

9 Refused


Read if necessary: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.


CTOB.04

Would you say you have never used e-cigarettes or other electronic vaping products in your entire life or now use them every day, use them some days, or used them in the past but do not currently use them at all?

1 Never used e-cigarettes in your entire life

2 Use them every day

3 Use them some days

4 Not at all (right now)


Do not read:

7 Don’t know / Not sure

9 9 Refused


Electronic cigarettes (e-cigarettes) and other electronic vaping products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy. Brands you may have heard of are JUUL, NJOY, or blu.

Interviewer note: These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.


If respondent says “Not at all” ask that they do not mean “Never used e-cigs in your entire life”











Core Section 12: Lung Cancer Screening


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




If CTOB.01=1 (yes) and CTOB.02 = 1, 2, or 3 (every day, some days, or not at all) continue, else go to CLC.04



CLC.01




You’ve told us that you have smoked in the past or are currently smoking. The next questions are about screening for lung cancer.


How old were you when you first started to smoke cigarettes regularly?

_ _ _ Age in Years (001 – 100)

777 Don't know/Not sure

999 Refused


Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all).

If respondent indicates age inconsistent with previously entered age, verify that this is the correct answer and change the age of the respondent regularly smoking or make a note to correct the age of the respondent.


888 Never smoked cigarettes regularly

Go to CLC.04




Skip CLC.02 if CTOB.02 = 1



CLC.02

How old were you when you last smoked cigarettes regularly?

_ _ _ Age in Years (001 – 100)

777 Don't know/Not sure

999 Refused




CLC.03

On average, when you [smoke/ smoked] regularly, about how many cigarettes {do/did} you usually smoke each day?

_ _ _ Number of cigarettes

777 Don't know/Not sure

999 Refused


Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all).

Respondents may answer in packs instead of number of cigarettes. Below is a conversion table: 0.5 pack = 10 cigarettes/ 1.75 pack = 35 cigarettes/ 0.75 pack = 15 cigarettes/ 2 packs = 40 cigarettes/ 1 pack = 20 cigarettes/ 2.5 packs= 50 cigarettes/ 1.25 pack = 25 cigarettes/ 3 packs= 60 cigarettes/ 1.5 pack = 30 cigarettes


CLC.04

The next question is about CT or CAT scans of your chest area. During this test, you lie flat on your back and are moved through an open, donut shaped x-ray machine.

Have you ever had a CT or CAT scan of your chest area?

1 Yes





2 No

7 Don't know/not sure

9 Refused

Go to next section



CLC.05

Were any of the CT or CAT scans of your chest area done mainly to check or screen for lung cancer?

1 Yes





2 No

7 Don't know/not sure

9 Refused

Go to Next section

CLC.06

When did you have your most recent CT or CAT scan of your chest area mainly to check or screen for lung cancer?

Read only if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years)

3 Within the past 3 years (2 years but less than 3 years)

4 Within the past 5 years (3 years but less than 5 years)

5 Within the past 10 years (5 years but less than 10 years ago)

6 10 or more years ago

Do not read:

7 Don’t know / Not sure

9 Refused







Core Section 13: Alcohol Consumption

Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue

The next questions concern alcohol consumption. One drink of alcohol is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor.





CALC.01


During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic?

1 _ _ Days per week

2 _ _ Days in past 30 days


Read if necessary: A 40-ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.


888 No drinks in past 30 days

777 Don’t know / Not sure

999 Refused

Go to next section

CALC.02

During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?

_ _ Number of drinks

88 None

77 Don’t know / Not sure

99 Refused


Read if necessary: A 40-ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.


CALC.03

Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI X = 5 for men, X = 4 for women] or more drinks on an occasion?

_ _ Number of times

77 Don’t know / Not sure

88 no days

99 Refused

CATI X = 5 for men, X = 4 for women (states may use sex at birth to determine sex if module is adopted)



CALC.04

During the past 30 days, what is the largest number of drinks you had on any occasion?

_ _ Number of drinks

77 Don’t know / Not sure

99 Refused





Core Section 14: Immunization

Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CIMM.01


During the past 12 months, have you had either a flu vaccine that was sprayed in your nose or a flu shot injected into your arm?

1 Yes


Read if necessary: A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.


2 No

7 Don’t know / Not sure

9 Refused

Go to CIMM.04

CIMM.02

During what month and year did you receive your most recent flu vaccine that was sprayed in your nose or flu shot injected into your arm?

_ _ / _ _ _ _ Month / Year

77 / 7777 Don’t know / Not sure

09 / 9999 Refused




CIMM.03

At what kind of place did you get your last flu shot or vaccine?

Read if necessary:

01 A doctor’s office or health maintenance organization (HMO)

02 A health department

03 Another type of clinic or health center (a community health center)

04 A senior, recreation, or community center

05 A store (supermarket, drug store)

06 A hospital (inpatient)

07 An emergency room

08 Workplace

09 Some other kind of place

11 A school

Do not read:

12 A drive though location at some other place than listed above

10 Received vaccination in Canada/Mexico

77 Don’t know / Not sure

99 Refused


Read if necessary: How would you describe the place where you went to get your most recent flu vaccine?

If the respondent indicates that it was a drive through immunization site, ask the location of the site. If the respondent remembers only that it was drive through and cannot identify the location, code “12”


CIMM.04

Have you ever had a pneumonia shot also known as a pneumococcal vaccine?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Read if necessary: There are two types of pneumonia shots: polysaccharide, also known as Pneumovax, and conjugate, also known as Prevnar.










Core Section 15: H.I.V./AIDS

Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

CHIV.01


Including fluid testing from your mouth, but not including tests you may have had for blood donation, have you ever been tested for H.I.V?

1 Yes


Please remember that your answers are strictly confidential and that you don’t have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.



2 No

7 Don’t know/ not sure

9 Refused

Go to CHIV.03

CHIV.02

Not including blood donations, in what month and year was your last H.I.V. test?

_ _ /_ _ _ _ Code month and year

77/ 7777 Don’t know / Not sure 99/ 9999 Refused

If response is before January 1985, code "777777".

INTERVIEWER NOTE: If the respondent remembers the year but cannot remember the month, code the first two digits 77 and the last four digits for the year.


CHIV.03

I am going to read you a list. When I am done, please tell me if any of the situations apply to you. You do not need to tell me which one.


You have injected any drug other than those prescribed for you in the past year. 

You have been treated for a sexually transmitted disease or STD in the past year.

You have given or received money or drugs in exchange for sex in the past year.

You had anal sex without a condom in the past year.

You had four or more sex partners in the past year. 


Do any of these situations apply to you?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused











Closing Statement/ Transition to Modules


Read if necessary

Read

CATI instructions

(not read)

That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.


Read if no optional modules follow, otherwise continue to optional modules.



Optional Modules

Module 1: Prediabetes


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




Skip if CCHC.12, DIABETE4, is coded 1. To be asked following Core CCHC.12;



MPDIAB.01


When was the last time you had a blood test for high blood sugar or diabetes by a doctor, nurse, or other health professional?

1 Within the past year

(anytime less than 12 months ago)

2 Within the last 2 years

(1 year but less than 2 years ago)

3 Within the last 3 years

(2 years but less than 3 years ago)

4 Within the last 5 years

(3 to 4 years but less than 5 years ago)

5 Within the last 10 years

(5 to 9 years but less than 10 years ago)

6 10 years ago or more

8 Never

7 Don’t know / Not sure

9 Refused







Skip if CCHC.12, (DIABETE4), is coded 1; If CCHC.12, (DIABETE4), is coded 4 automatically code MPDIAB.02, (PREDIAB1), equal to 1 (yes)



MPDIAB.02

Has a doctor or other health professional ever told you that you had prediabetes or borderline diabetes?

1 Yes

2 Yes, during pregnancy

3 No

7 Don’t know / Not sure

9 Refused


If Yes and respondent is female, ask: Was this only when you were pregnant?




Module 2: Diabetes


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




Skip if CCHC.12 is not equal to 1.



MDIAB.01


According to your doctor or other health professional, what type of diabetes do you have?

1 Type 1

2 Type 2

7 Don’t know/ Not sure

9 Refused




MDIAB.02

Insulin can be taken by shot or pump. Are you now taking insulin?

1 Yes

2 No

7 Don’t know/ not sure

9 Refused




MDIAB.03

About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for A-one-C?

_ _ Number of times [76 = 76 or more]

88 None

98 Never heard of A-one-C test

77 Don’t know / Not sure

99 Refused


Read if necessary: A test for A-one-C measures the average level of blood sugar over the past three months.


MDIAB.04

When was the last time you had an eye exam in which the pupils were dilated, making you temporarily sensitive to bright light?

Read if necessary:

1 Within the past month (anytime less than 1 month ago)

2 Within the past year (1 month but less than 12 months ago)

3 Within the past 2 years (1 year but less than 2 years ago)

4 2 or more years ago

Do not read:

7 Don’t know / Not sure

8 Never

9 Refused




MDIAB.05

When was the last time a doctor, nurse or other health professional took a photo of the back of your eye with a specialized camera?

Read if necessary:

1 Within the past month (anytime less than 1 month ago)

2 Within the past year (1 month but less than 12 months ago)

3 Within the past 2 years (1 year but less than 2 years ago)

4 2 or more years ago

Do not read:

7 Don’t know / Not sure

8 Never

9 Refused




MDIAB.06


When was the last time you took a course or class in how to manage your diabetes yourself?

1 Within the past year (anytime less than 12 months ago)

2 Within the last 2 years (1 year but less than 2 years ago)

3 Within the last 3 years (2 years but less than 3 years ago)

4 Within the last 5 years (3 to 4 years but less than 5 years ago)

5 Within the last 10 years (5 to 9 years but less than 10 years ago)

6 10 years ago or more

8 Never

7 Don’t know / Not sure

9 Refused




MDIAB.07


Have you ever had any sores or irritations on your feet that took more than four weeks to heal?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused






Module 3: Arthritis


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




Asked only if CCHC.11 = 1 (Only of those answering yes to arthritis question)



MARTH.01

Has a doctor or other health professional ever suggested physical activity or exercise, including physical therapy, to help your arthritis or joint symptoms?


1 Yes

2 No

7 Don’t know/ Not sure

9 Refused


If the respondent is unclear about whether this means increase or decrease in physical activity, this means increase.


Module 4: Shingles Vaccination



Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




If age ≤ 49 Go to next module.



MSHNG.01

Have you ever had the shingles or zoster vaccine?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused


Shingles is an illness that results in a rash or blisters on the skin and is usually painful. There are two vaccines now available for shingles: Zostavax, which requires 1 shot and Shingrix which requires 2 shots.



Module 5: HPV Vaccination


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Columns




To be asked of respondents between the ages of 18 and 49 years; otherwise, go to next module



MHPV.01


Have you ever had an H.P.V. vaccination?

1 Yes



Human Papillomavirus (Human Pap·uh·loh·muh virus); Gardasil (Gar·duh· seel); Cervarix (Sir·var· icks)


Read if necessary: A vaccine to prevent the human papillomavirus or H.P.V. infection is available and is called the cervical cancer or genital warts vaccine, H.P.V. shot, [Fill: if female GARDASIL or CERVARIX; if male: GARDASIL].


If respondent comments that this question was already asked, clarify that the earlier questions was about HPV testing, and this question is about vaccination.



2 No

3 Doctor refused when asked

7 Don’t know / Not sure

9 Refused

Go to next module

MHPV.02

How many HPV shots did you receive?


_ _ Number of shots (1-2)

3 All shots

77 Don’t know / Not sure

99 Refused






Module 6: Tetanus Vaccination


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MTDAP.01


Have you received a tetanus shot in the past 10 years?

1 Yes, received Tdap

2 Yes, received tetanus shot, but not Tdap

3 Yes, received tetanus shot but not sure what type

4 No, did not receive any tetanus shot in the past 10 years

7 Don’t know/Not sure

9 Refused


If yes, ask: Was this Tdap, the tetanus shot that also has pertussis or whooping cough vaccine?



Module 7: Cancer Survivorship: Type of Cancer



Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




If CCHC.06 or CCHC.07 = 1 (Yes) continue, else go to next module.



MTOC.01


You’ve told us that you have had cancer. I would like to ask you a few more questions about your cancer.


How many different types of cancer have you had?

1 Only one

2 Two

3 Three or more





7 Don’t know / Not sure

9 Refused

Go to next module

MTOC.02

At what age were you told that you had cancer?

_ _ Age in Years (97 = 97 and older)

98 Don't know/Not sure

99 Refused


If MTOC.01= 2 (Two) or 3 (Three or more), ask: At what age were you first diagnosed with cancer?

Read if necessary: This question refers to the first time they were told about their first cancer.





If CCHC.06 = 1 (Yes) and MTOC.01 = 1 (Only one): ask Was it Melanoma or other skin cancer? then code MTOC.03 as a response of 16 if Melanoma or 22 if other skin cancer




MTOC.03

What kind of cancer is it?

Read if respondent needs prompting for cancer type:

01 Bladder

02 Blood

03 Bone

04 Brain

05 Breast

06 Cervix/Cervical

07 Colon

08 Esophagus/Esophageal

09 Gallbladder

10 Kidney

11 Larynx-trachea

12 Leukemia

13 Liver

14 Lung

15 Lymphoma

16 Melanoma

17 Mouth/tongue/lip

18 Ovary/Ovarian

19 Pancreas/Pancreatic

20 Prostate

21 Rectum/Rectal

22 Skin (non-melanoma)

23 Skin (don't know what kind)

24 Soft tissue (muscle or fat)

25 Stomach

26 Testis/Testicular

27 Throat - pharynx

28 Thyroid

29 Uterus/Uterine

30 Other

Do not read:

77 Don’t know / Not sure

99 Refused


If MTOC.01 = 2 (Two) or 3 (Three or more), ask: With your most recent diagnoses of cancer, what type of cancer was it?








Module 8: Cancer Survivorship: Course of Treatment



Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




If CCHC.06 or CCHC.07 = 1 (Yes) continue, else go to next module.



MCOT.01

Are you currently receiving treatment for cancer?

Read if necessary:

1 Yes

Go to next module

Read if necessary: By treatment, we mean surgery, radiation therapy, chemotherapy, or chemotherapy pills.


2 No, I’ve completed treatment

Continue

3 No, I’ve refused treatment

4 No, I haven’t started treatment

5 Treatment was not necessary

7 Don’t know / Not sure

9 Refused

Go to next module

MCOT.02

What type of doctor provides the majority of your health care? Is it a….


Read:

01 Cancer Surgeon

02 Family Practitioner

03 General Surgeon

04 Gynecologic Oncologist

05 General Practitioner, Internist

06 Plastic Surgeon, Reconstructive Surgeon

07 Medical Oncologist

08 Radiation Oncologist

09 Urologist

10 Other

Do not read:

77 Don’t know / Not sure

99 Refused


If the respondent requests clarification of this question, say: We want to know which type of doctor you see most often for illness or regular health care (Examples: annual exams and/or physicals, treatment of colds, etc.).


Read if necessary: An oncologist is a medical doctor who manages a person’s care and treatment after a cancer diagnosis.


MCOT.03

Did any doctor, nurse, or other health professional ever give you a written summary of all the cancer treatments that you received?

1 Yes

2 No

7 Don’t know/ not sure

9 Refused


Read if necessary: By ‘other healthcare professional’, we mean a nurse practitioner, a physician’s assistant, social worker, or some other licensed professional.



MCOT.04

Have you ever received instructions from a doctor, nurse, or other health professional about where you should return or who you should see for routine cancer check-ups after completing your treatment for cancer?

1 Yes





2 No

7 Don’t know/ not sure

9 Refused

Go to MCOT.06

MCOT.05

Were these instructions written down or printed on paper for you?

1 Yes

2 No

7 Don’t know/ not sure

9 Refused




MCOT.06

With your most recent diagnosis of cancer, did you have health insurance that paid for all or part of your cancer treatment?

1 Yes

2 No

7 Don’t know/ not sure

9 Refused


Read if necessary: Health insurance also includes Medicare, Medicaid, or other types of state health programs.


MCOT.07

Were you ever denied health insurance or life insurance coverage because of your cancer?

1 Yes

2 No

7 Don’t know/ not sure

9 Refused




MCOT.08

Did you participate in a clinical trial as part of your cancer treatment?

1 Yes

2 No

7 Don’t know/ not sure

9 Refused








Module 9: Cancer Survivorship: Pain Management





Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




If CCHC.06 or CCHC.07 = 1 (Yes) continue, else go to next module.



MCPM.01

Do you currently have physical pain caused by your cancer or cancer treatment?

1 Yes




2 No

7 Don’t know/ not sure

9 Refused

Go to next module

MCPM.02

Would you say your pain is currently under control…?

Read:

1 With medication (or treatment)

2 Without medication (or treatment)

3 Not under control, with medication (or treatment)

4 Not under control, without medication (or treatment)

Do not read:

7 Don’t know / Not sure

9 Refused








Module 10: Prostate Cancer Screening

Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




If respondent is ≤39 years of age or is Female, (MSAB.01, is coded 2). If MSAB.01=missing and (CP.05=2 or CP.06=2 or LL.09 = 2 or LL.10=2).

go to next module.



MPCS.01

Have you ever had a P.S.A. test?

1 Yes


A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.


2 No

7 Don’t know / Not sure

9 Refused

Go to MPCS.05

MPCS.02

About how long has it been since your most recent P.S.A. test?

Read if necessary:

1 Within the past year (anytime less than 12 months ago)

2 Within the past 2 years (1 year but less than 2 years ago)

3 Within the past 3 years (2 years but less than 3 years ago)

4 Within the past 5 years (3 years but less than 5 years ago)

5 5 or more years ago

Do not read:

7 Don’t know / Not sure

9 Refused


A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.



MPCS.03

What was the main reason you had this P.S.A. test – was it …?

Read:

1 Part of a routine exam

2 Because of a problem

3 other reason

Do not read:

7 Don’t know / Not sure

9 Refused


A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.


MPCS.04

Who first suggested this P.S.A. test: you, your doctor, or someone else?

1 Self

2 Doctor, nurse, health care professional

3 Someone else

7 Don’t Know / Not sure

9 Refused




MPCS.05


When you met with a doctor, nurse, or other health professional, did they talk about the advantages, the disadvantages, or both advantages and disadvantages of the prostate-specific antigen or PSA test?

1 Advantages 2 Disadvantages

3 Both Advantages and disadvantages

DO NOT READ

4. Neither

7 Don’t know/ not sure

9 Refused


A P.S.A. test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.



Module 11: Cognitive Decline


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue: The next few questions ask about difficulties in thinking or memory that can make a big difference in everyday activities. We want to know how these difficulties may have impacted you.




If respondent is 45 years of age or older continue, else go to next module.



MCOG.01


During the past 12 months, have you experienced difficulties with thinking or memory that are happening more often or are getting worse?

1 Yes






2 No

7 Don’t know/ not sure

9 Refused

Go to next module


MCOG.02

Are you worried about these difficulties with thinking or memory?

1 Yes

2 No

7 Don’t know/ not sure

9 Refused




MCOG.03

Have you or anyone else discussed your difficulties with thinking or memory with a health care provider?


1 Yes

2 No

7 Don’t know/ not sure

9 Refused




MCOG.04

During the past 12 months, have your difficulties with thinking or memory interfered with day-to-day activities, such as managing medications, paying bills, or keeping track of appointments?

1 Yes

2 No

7 Don’t know/ not sure

9 Refused




MCOG.05

During the past 12 months, have your difficulties with thinking or memory interfered with your ability to work or volunteer?

1 Yes

2 No

7 Don’t know/ not sure

9 Refused





Module 12: Caregiver


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MCARE.01


During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability?

1 Yes


If caregiving recipient has died in the past 30 days, say: I’m so sorry to hear of your loss and code 4


2 No

7 Don’t know/Not sure

Go to next module

8 Caregiving recipient died in past 30 days

Go to next module

9 Refused

Go to next module

MCARE.02

What is their relationship to you?

1 Parent, stepparent, or parent-in-law

2 Grandparent, step grandparent or grandparent-in-law

3 Spouse or partner

4 Child or stepchild

5 Grandchild or step grandchild

6 Sibling, stepsibling, or sibling-in-law

7 Other relative

8 Friend or non-relative

77 Don’t know/Not sure

99 Refused


If respondent provides care for more than one person, say: “Please refer to the person whom you are providing the most care.”  Read selections if necessary or unable to code.


MCARE.03

What is the main health problem or disability that the person you care for has?

1)Alzheimer’s disease, dementia, or other cognitive impairment

2)Heart disease, hypertension, or stroke

3)Cancer

4)Diabetes

5)Injuries including broken bones or traumatic brain injury

6)Mental illness such as depression, anxiety, or schizophrenia

7)Developmental disorders such as autism, Down syndrome, or spina bifida

8)Respiratory conditions such as asthma, emphysema, or chronic obstructive pulmonary disease

9)Arthritis/rheumatism

10)Hearing or vision loss

11)Movement disorders such as Parkinson’s, spinal cord injury, multiple sclerosis or cerebral palsy

12)Old age, infirmity, or frailty

13)Other

77 Don’t know/Not sure

99 Refused

If MCARE.03 = 1 (Alzheimer’s disease, dementia or other cognitive impairment disorder), go to MCARE.05.

Otherwise, continue



MCARE.04

Does the person you care for also have Alzheimer’s disease, dementia or other cognitive impairment disorder?

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused




MCARE.05

In the past 30 days, did you provide regular care for this person by helping with nursing or medical tasks such as injections, wound care, or tube feedings?

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused




MCARE.06

In the past 30 days, did you provide regular care for this person by managing personal care such as bathing, getting to the bathroom, or helping to eat?

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused




MCARE.07

In the past 30 days, did you provide regular care for this person by managing household tasks such as help with transportation, shopping, or managing money? 

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused




MCARE.08

In an average week, how many hours do you provide regular care or assistance? Would you say…

Please read:

1) Less than 20 hours per week (19 hours or less)

2) Less than 40 hours per week (more than 19 hours, but less than 40 hours)

3) 40 hours or more per week




MCARE.09

For how long have you provided regular care to this person?

Read if necessary:

1) Within the past 30 days (anytime less than 30 days ago)

2) Within the past 2 years (more than 30 days but less than 2 years ago)

3) Within the past 5 years (more than 2 years but less than 5 years ago)

4) 5 years or more


Do not read:

7 Don’t Know/ Not Sure

9 Refused






Module 13: Adverse Childhood Experiences


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue: I'd like to ask you some questions about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life and may help others in the future. This is a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer. All questions refer to the time period before you were 18 years of age. Now, looking back before you were 18 years of age---






Be aware of the level of stress introduced by questions in this section and be familiar with the crisis plan.


MACE.01

Did you live with anyone who was depressed, mentally ill, or suicidal?

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused




MACE.02

Did you live with anyone who was a problem drinker or alcoholic?

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused




MACE.03

Did you live with anyone who used illegal street drugs or who abused prescription medications?


1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused




MACE.04

Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused




MACE.05

Were your parents separated or divorced?

1 Yes

2 No

8 Parents not married

7 Don’t Know/Not Sure

9 Refused




MACE.06

How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up?

Was it…

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused




MACE.07

Not including spanking, (before age 18), how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Was it—

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused





MACE.08

How often did a parent or adult in your home ever swear at you, insult you, or put you down? Was it…

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused




MACE.09

How often did anyone at least 5 years older than you or an adult, ever touch you sexually? Was it…

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused




MACE.10

How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually? Was it…

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused




MACE.11

How often did anyone at least 5 years older than you or an adult, force you to have sex? Was it…

Read:

1 Never

2 Once

3 More than once

Don’t Read:

7 Don’t know/Not Sure

9 Refused





MACE.12

For how much of your childhood was there an adult in your household who made you feel safe and protected? Would you say never, a little of the time, some of the time, most of the time, or all of the time?

1. Never

2. A little of the time

3. Some of the time

4. Most of the time

5. All of the time

7 Don’t Know/Not sure

9 Refused





MACE.13

For how much of your childhood was there an adult in your household who tried hard to make sure your basic needs were met? Would you say never, a little of the time, some of the time, most of the time, or all of the time?

1. Never

2. A little of the time

3. Some of the time

4. Most of the time

5. All of the time

7 Don’t Know/Not sure

9 Refused





Would you like for me to provide a toll-free number for an organization that can provide information and referral for the issues in the last few questions.



If yes provide number [STATE TO INSERT NUMBER HERE]




Module 14: Social Determinants and Health Equity

Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MSDHE.01

In general, how satisfied are you with your life? Are you..

Read:

1 Very satisfied

2 Satisfied

3 Dissatisfied

4 Very dissatisfied

7 Don’t know/not sure

9 Refused





MSDHE.02

How often do you get the social and emotional support that you need? Is that…

Read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

7 Don’t know/not sure

9 Refused





MSDHE.03

How often do you feel lonely? Is it…

Read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

7 Don’t know/not sure

9 Refused





MSDHE.04

In the past 12 months have you lost employment or had hours reduced?

1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused




MSDHE.05

During the past 12 months, have you received food stamps, also called SNAP, the Supplemental Nutrition Assistance Program on an EBT card?

1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused




MSDHE.06

During the past 12 months how often did the food that you bought not last, and you didn’t have money to get more? Was that…

Read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

7 Don’t know/not sure

9 Refused




MSDHE.07

During the last 12 months, was there a time when you were not able to pay your mortgage, rent or utility bills?


1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused




MSDHE.08

During the last 12 months was there a time when an electric, gas, oil, or water company threatened to shut off services?

1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused




MSDHE.09

During the past 12 months has a lack of reliable transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused




MSDHE.10

How safe from crime do you consider your neighborhood to be? Would you say…


Read:

1 Extremely safe

2 Safe

3 Unsafe

4 Extremely unsafe

7 Don’t know/not sure

9 Refused






Module 15: Marijuana Use


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue: The following questions are about marijuana or cannabis. Do not include hemp-based or CBD-only products in your responses.

MMU.01


During the past 30 days, on how many days did you use marijuana or cannabis?

_ _ 01-30 Number of days


Do not include hemp-based CBD-only products.


88 None

77 Don’t know/not sure

99 Refused

Go to next module

MMU.02

During the past 30 days, did you smoke it (for example, in a joint, bong, pipe, or blunt)?

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused


Do not include hemp-based CBD-only products.


MMU.03

Did you…eat it or drink it (for example, in brownies, cakes, cookies, or candy, or in tea, cola, or alcohol)?

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused


Do not include hemp-based CBD-only products.


MMU.04

Did you …vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device)

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused


Do not include hemp-based CBD-only products.


MMU.05

Did you …dab it (for example, using a dabbing rig, knife, or dab pen)?

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused


Do not include hemp-based CBD-only products.


MMU.06

Did you …use it in some other way?

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused


Do not include hemp-based CBD-only products.





If respondent answers yes to only one type of use, skip MMU.07






Create CATI to only show the options of use that the respondents chose in earlier questions (MMU.02-MMU.06).



MMU.07

During the past 30 days, which one of the following ways did you use marijuana the most often? Did you usually…

Read:

1 Smoke it (for example, in a joint, bong, pipe, or blunt).

2 Eat it or drink it (for example, in brownies, cakes, cookies, or candy or in tea, cola or alcohol)

3 Vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device)

4 Dab it (for example, using a dabbing rig, knife, or dab pen), or

5 Use it some other way.

Do not read:

7 Don’t know/not sure

9 Refused


Select one. If respondent provides more than one say: Which way did you use it most often?


Do not include hemp-based CBD-only products.








Module 16: Tobacco Cessation


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




Ask if CTOB.01 (SMOKE100)= 1 and CTOB.02 (SMOKDAY2) = 3



MTC.01

How long has it been since you last smoked a cigarette, even one or two puffs?

Read if necessary:

01 Within the past month (less than 1 month ago)

02 Within the past 3 months (1 month but less than 3 months ago)

03 Within the past 6 months (3 months but less than 6 months ago)

04 Within the past year (6 months but less than 1 year ago)

05 Within the past 5 years (1 year but less than 5 years ago)

06 Within the past 10 years (5 years but less than 10 years ago)

07 10 years or more

08 Never smoked regularly

77 Don’t know / Not sure

99 Refused

Go to next module






Ask if CTOB.02 (SMOKDAY2) = 1 or 2.



MTC.02

During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused







Module 17: Other Tobacco Use


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)



ASK  IF CTOB.02 = 1,2




MOTU.01

Currently, when you smoke cigarettes, do you usually smoke menthol cigarettes?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused






ASK IF CTOB.04 = 2, 3




MOTU.02

Currently, when you use e-cigarettes, do you usually use menthol e-cigarettes?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused




Prologue: The next question is about heated tobacco products. Some people refer to these as “heat not burn” tobacco products. These heat tobacco sticks or capsules to produce a vapor. Some brands of heated tobacco products include iQOS [eye-kos], Glo, and Eclipse.

MOTU.03

Before today, have you heard of heated tobacco products?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused






Module 18: Sugar-Sweetened Beverages


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MSSB.01

During the past 30 days, how often did you drink regular soda or pop that contains sugar? Do not include diet soda or diet pop.

1 _ _ Times per day

2 _ _ Times per week

3_ _ Times per month


Do not read:

8 8 8 None

7 7 7 Don’t know / Not sure

9 9 9 Refused


Please read: You can answer times per day, week, or month: for example, twice a day, once a week, and so forth.



MSSB.02

During the past 30 days, how often did you drink sugar-sweetened fruit drinks (such as Kool-aid and lemonade), sweet tea, and sports or energy drinks (such as Gatorade and Red Bull)? Do not include 100% fruit juice, diet drinks, or artificially sweetened drinks.

1 _ _ Times per day

2 _ _ Times per week

3_ _ Times per month


Do not read:

8 8 8 None

7 7 7 Don’t know / Not sure

9 9 9 Refused


Please read: You can answer times per day, week, or month: for example, twice a day, once a week, and so forth.





Module 19: Firearm Safety


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue

The next questions are about safety and firearms. Some people keep guns for recreational purposes such as hunting or sport shooting. People also keep guns in the home for protection. Please include firearms such as pistols, revolvers, shotguns, and rifles; but not BB guns or guns that cannot fire. Include those kept in a garage, outdoor storage area, or motor vehicle.

MFS.01


Are any firearms now kept in or around your home?

1 Yes


Do not include guns that cannot fire; include those kept in cars, or outdoor storage.


2 No

7 Don’t know/ not sure

9 Refused

Go to Next module

MFS.02

Are any of these firearms now loaded?

1 Yes






2 No

7 Don’t know/ not sure

9 Refused

Go to Next module

MFS.03

Are any of these loaded firearms also unlocked?

1 Yes

2 No

7 Don’t know/ not sure

9 Refused


By unlocked, we mean you do not need a key or a combination or a hand/fingerprint to get the gun or to fire it. Don’t count the safety as a lock.









Module 20: Industry and Occupation

Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MIO.01


What kind of work do you do? For example, registered nurse, janitor, cashier, auto mechanic.

_______Record answer

99 Refused

If CDEM.14 = 1 (Employed for wages) or 2 (Self-employed) or 4 (Employed for wages or out of work for less than 1 year), continue, else go to next module/section.

If CDEM.14 = 4 (Out of work for less than 1 year) ask, “What kind of work did you do? For example, registered nurse, janitor, cashier, auto mechanic.”


Else go to next module

If respondent is unclear, ask: What is your job title?


If respondent has more than one job ask: What is your main job?


MIO.02

What kind of business or industry do you work in? For example, hospital, elementary school, clothing manufacturing, restaurant

_______Record answer

99 Refused

If Core CDEM.14 = 4 (Out of work for less than 1 year) ask, “What kind of business or industry did you work in? For example, hospital, elementary school, clothing manufacturing, restaurant.”




Module 21: Random Child Selection

Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Intro text and screening

If CDEM.14 = 1, Interviewer please read: Previously, you indicated there was one child age 17 or younger in your household. I would like to ask you some questions about that child.


If CDEM.14 is >1 and CDEM.15 does not equal 88 or 99, Interviewer please read: Previously, you indicated there were [number] children age 17 or younger in your household. Think about those [number] children in order of their birth, from oldest to youngest. The oldest child is the first child and the youngest child is the last. Please include children with the same birth date, including twins, in the order of their birth.


If CDEM.14 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module.

CATI INSTRUCTION: RANDOMLY SELECT ONE OF THE CHILDREN. This is the Xth child. Please substitute Xth child’s number in all questions below.

INTERVIEWER PLEASE READ: I have some additional questions about one specific child. The child I will be referring to is the Xth [CATI: please fill in correct number] child in your household. All following questions about children will be about the Xth [CATI: please fill in] child.



MRCS.01


What is the birth month and year of the [Xth] child?

_ _ /_ _ _ _ Code month and year

77/ 7777 Don’t know / Not sure

99/ 9999 Refused




MRCS.02

Is the child a boy or a girl?

1 Boy

2 Girl

Go to MRCS.04



3 Nonbinary/other

9 Refused



MRCS.03

What was the child’s sex on their original birth certificate?

1 Boy

2 Girl

9 Refused




MRCS.04

Is the child Hispanic, Latino/a, or Spanish origin?

Read if response is yes:

1 Mexican, Mexican American, Chicano/a

2 Puerto Rican

3 Cuban

4 Another Hispanic, Latino/a, or Spanish origin

Do not read:

5 No

7 Don’t know / Not sure

9 Refused


If yes, ask: Are they…


MRCS.05

Which one or more of the following would you say is the race of the child?

10 White

20 Black or African American

30 American Indian or Alaska Native

40 Asian

41 Asian Indian

42 Chinese

43 Filipino

44 Japanese

45 Korean

46 Vietnamese

47 Other Asian

50 Pacific Islander

51 Native Hawaiian

52 Guamanian or Chamorro

53 Samoan

54 Other Pacific Islander

Do not read:

60 Other

88 No additional choices

77 Don’t know / Not sure

99 Refused


Select all that apply


If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.


MRCS.06

How are you related to the child? Are you a….

Please read:

1 Parent (include biologic, step, or adoptive parent)

2 Grandparent

3 Foster parent or guardian

4 Sibling (include biologic, step, and adoptive sibling)

5 Other relative

6 Not related in any way

Do not read:

7 Don’t know / Not sure

9 Refused








Module 22: Childhood Asthma Prevalence

Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




If response to CDEM.15 = 88 (None) or 99 (Refused), go to next module.



MCAP.01


The next two questions are about the Xth child.

Has a doctor, nurse or other health professional EVER said that the child has asthma?


1 Yes


Fill in correct [Xth] number.



2 No

7 Don’t know/ not sure

9 Refused

Go to next module

MCAP.02

Does the child still have asthma?

1 Yes

2 No

7 Don’t know/ not sure

9 Refused









Module 23: Sex at Birth


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MSAB.01

What was your sex at birth? Was it male or female?

1 Male

2 Female

7 Don’t know/Not sure

9 Refused

Skip MSAB.01 If LL10, is coded 1 or 2 or CP06 is coded 1 or 2. If LL10, is coded 1 or 2 or CP06, is coded 1 or 2, automatically code MSAB.01, equal to LL10 or CP.06.

This question refers to the original birth certificate of the respondent. It does not refer to amended birth certificates.



Module 24: Sexual Orientation and Gender Identity (SOGI)


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue: The next two questions are about sexual orientation and gender identity




If sex= male (using MSAB.01 (BIRTHSEX), CP.05, CP.06(CELLSEX2, CELSXBRT), LL.09, LL.10 (LANDSEX2, LNDSXBRT) ) continue, otherwise go to MSOGI.02.



MSOGI.01


Which of the following best represents how you think of yourself?

1 = Gay

2 = Straight, that is, not gay

3 = Bisexual

4 = Something else

7 = I don't know the answer

9 = Refused


Read if necessary: We ask this question in order to better understand the health and health care needs of people with different sexual orientations.


Please say the number before the text response. Respondent can answer with either the number or the text/word.





If sex= female (using MSAB.01(BIRTHSEX),CP.05, CP.06 (CELLSEX2, CELSXBRT), LL.09, LL.10 ( LANDSEX2, LNDSXBRT) continue, otherwise go to MSOGI.03.




MSOGI.02

Which of the following best represents how you think of yourself?

1 = Lesbian or Gay

2 = Straight, that is, not gay

3 = Bisexual

4 = Something else

7 = I don't know the answer

9 = Refused

.

Read if necessary: We ask this question in order to better understand the health and health care needs of people with different sexual orientations.


Please say the number before the text response. Respondent can answer with either the number or the text/word.

552

MSOGI.03

Do you consider yourself to be transgender?

1 Yes, Transgender, male-to-female

2 Yes, Transgender, female to male

3 Yes, Transgender, gender nonconforming

4 No

7 Don’t know/not sure

9 Refused


Read if necessary: Some people describe themselves as transgender when they experience a different gender identity from their sex at birth. For example, a person born into a male body, but who feels female or lives as a woman would be transgender. Some transgender people change their physical appearance so that it matches their internal gender identity. Some transgender people take hormones and some have surgery. A transgender person may be of any sexual orientation – straight, gay, lesbian, or bisexual.


If asked about definition of gender non-conforming: Some people think of themselves as gender non-conforming when they do not identify only as a man or only as a woman.


If yes, ask Do you consider yourself to be 1. male-to-female, 2. female-to-male, or 3. gender non-conforming?


Please say the number before the text response. Respondent can answer with either the number or the text/word.

553

Module 25: Family Planning


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)




IF RESPONDENT GREATER THAN 49 YEARS OF AGE, HAS HAD A CBCCS.07=1(HYSTERECTOMY), IS CDEM.16 (PREGNANT), OR IF RESPONDENT IS MALE, (MSAB.01, is coded 1). If MSAB.01=missing and (CP.05=1 or CP.06=1 or LL.09 = 1 or LL.10=1) GO TO THE NEXT MODULE



PROLOGUE

The next set of questions asks you about your experiences preventing pregnancy and using birth control, also known as family planning. Questions that ask about sexual intercourse are referring to sex where a penis is inserted into the vagina.

MFP.01

In the past 12 months, did you have sexual intercourse?

1 Yes





2 No

7 Don’t know/ not sure

9 Refused

Go to next module

MFP.02

Some things people do to keep from getting pregnant include not having sex at certain times of the month, pulling out, using birth control methods such as the pill, implant, shots, condoms, or IUD, having their tubes tied, or having a vasectomy.

The last time you had sexual intercourse, did you or your partner do anything to keep you from getting pregnant?

1 Yes



.


2 No

7 Don’t know/ not sure

9 Refused

GO TO MFP.04



MFP.03

The last time you had sexual intercourse, what did you or your partner do to keep you from getting pregnant?

Read if necessary:

01 Female sterilization (Tubal ligation, Essure, or Adiana)

02 Male sterilization (vasectomy)

03 Contraceptive implant

04 Intrauterine device or IUD (Mirena, Levonorgestrel, ParaGard)

05 Shots (Depo-Provera)

06 Birth control pills, Contraceptive Ring (NuvaRing), Contraceptive patch (Ortho Evra)

07 Condoms (male or female)

08 Diaphragm, cervical cap, sponge, foam, jelly, film, or cream

09 Had sex at a time when less likely to get pregnant (rhythm or natural family planning)

10 Withdrawal or pulling out

11 Emergency contraception or the morning after pill (Plan B or ella)

12 Other method

Do not read:

77 Don’t know/Not sure

99 Refused


IF RESPONDENT REPORTS USING TWO METHODS, PLEASE CODE THE METHOD THAT OCCURS FIRST ON THE LIST. CODE THE OTHER METHOD IN QUESTION 4 (DO NOT ASK QUESTION 4).

IF RESPONDENT REPORTS USING MORE THAN TWO METHODS, PLEASE CODE THE METHOD THAT OCCURS FIRST ON THE LIST. OF THE REMAINING METHODS MENTIONED, CODE THE METHOD THAT OCCURS FIRST ON THE LIST IN QUESTION 4 (DO NOT ASK QUESTION 4).



IF RESPONDENT REPORTS “OTHER METHOD,” ASK RESPONDENT TO “PLEASE BE SPECIFIC” AND ENSURE THAT THEIR RESPONSE DOES NOT FIT INTO ANOTHER CATEGORY. IF RESPONSE DOES FIT INTO ANOTHER CATEGORY, PLEASE MARK APPROPRIATELY.


MFP.04

Some reasons people might not do anything to keep from getting pregnant might include wanting a pregnancy, not being able to pay for birth control, or not thinking that they can get pregnant.

What was your main reason for not doing anything to prevent pregnancy the last time you had sexual intercourse?

Read if necessary

01 You didn’t think you were going to have sex/no regular partner

02 You just didn’t think about it

03 You wanted a pregnancy

04 You didn’t care if you got pregnant

05 You or your partner didn’t want to use birth control (side effects, don’t like birth control)

06 You had trouble getting or paying for birth control

07 You didn’t trust giving out your personal information to medical personnel

08 Didn’t think you or your partner could get pregnant (infertile or too old)

09 You were using withdrawal or “pulling out”

10 You had your tubes tied (sterilization)

11 Your partner had a vasectomy (sterilization)

12 You were breast-feeding or you just had a baby

13 You were assigned male at birth

14 Other reasons

Do not read:

77 Don’t know/Not sure

99 Refused


IF RESPONDENT REPORTS “OTHER REASON,” ASK RESPONDENT TO “PLEASE SPECIFY” AND ENSURE THAT THEIR RESPONSE DOES NOT FIT INTO ANOTHER CATEGORY. IF RESPONSE DOES FIT INTO ANOTHER CATEGORY, PLEASE MARK APPROPRIATELY.





Module 26: Reactions to Race



Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Prologue : Earlier I asked you to self-identify your race. Now I will ask you how other people identify you and treat you.


MRTR.01

How do other people usually classify you in this country? Would you say: White, Black or African American, Hispanic or Latino, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, or some other group?

01 White

02 Black or African American

03 Hispanic or Latino

04 Asian

05 Native Hawaiian or Other Pacific Islander

06 American Indian or Alaska Native

07 Mixed Race

08 Some other group

77 Don’t know / Not sure

99 Refused



If the respondent requests clarification of this question, say: “We want to know how OTHER people usually classify you in this country, which might be different from how you classify yourself.”

Interviewer note: do not offer “mixed race” as a category but use as a code if respondent offers it.


MRTR.02

How often do you think about your race? Would you say never, once a year, once a month, once a week, once a day, once an hour, or constantly?

1 Never

2 Once a year

3 Once a month

4 Once a week

5 Once a day

6 Once an hour

8 Constantly

7 Don’t know / Not sure

9 Refused


The responses can be interpreted as meaning “at least” the indicated time frequency. If a respondent cannot decide between two categories, check the response for the lower frequency. For example, if a respondent says that they think about their race between once a week and once a month, check “once a month” as the response.


MRTR.03

Within the past 12 months, do you feel that in general you were treated worse than, the same as, or better than people of other races?

Read if necessary:

1 Worse than other races

2 The same as other races

3 Better than other races

4 Worse than some races, better than others

5 Only encountered people of the same race

7 Don’t know / Not sure

9 Refused







Skip If CDEM.13= 3, 5, 6, 7, 8, 9 [CATI skip pattern: This question should only be asked of those who are “employed for wages,” “self-employed,” or “out of work for less than one year.”]



MRTR.04

Within the past 12 months at work, do you feel you were treated worse than, the same as, or better than people of other races?

1 Worse than other races

2 The same as other races

3 Better than other races

4 Worse than some races, better than others

5 Only encountered people of the same race

7 Don’t know / Not sure

9 Refused




MRTR.05

Within the past 12 months, when seeking health care, do you feel your experiences were worse than, the same as, or better than for people of other races?

1 Worse than other races

2 The same as other races

3 Better than other races

4 Worse than some races, better than others

5 Only encountered people of the same race

7 Don’t know / Not sure

9 Refused


If the respondent indicates that they do not know about other people’s experiences when seeking health care, say: “This question is asking about your perceptions when seeking health care. It does not require specific knowledge about other people’s experiences


MRTR.06

Within the past 30 days, have you experienced any physical symptoms, for example, a headache, an upset stomach, tensing of your muscles, or a pounding heart, as a result of how you were treated based on your race?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused







Asthma Call-Back Permission Script


Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

We would like to call you again within the next 2 weeks to talk in more detail about (your/your child’s) experiences with asthma. The information will be used to help develop and improve the asthma programs in <STATE>. 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.

CB01.01

Would it be okay if we called you back to ask additional asthma-related questions at a later time?

1 Yes

2 No






CB01.02

Which person in the household was selected as the focus of the asthma call-back?

1 Adult

2 Child





CB01.03

Can I please have either (your/your child’s) first name or initials, so we will know who to ask for when we call back?


____________________ Enter first name or initials.





Closing Statement


Read

That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.












41

31 July 2024

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