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

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
LL01.	Is this [PHONE NUMBER]?		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.
LL03.	Do you live in college housing?		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
LL04.	Do you currently live in__(state)____?		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.
LL05.	Is this a cell phone?		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
LL06.	Are you 18 years of age or older?		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?
LL07.			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
CP01.	Is this a safe time to talk with you?		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
CP02.	Is this [PHONE NUMBER]?		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
CP03.	Is this a cell phone?		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.
CP04.	Are you 18 years of age or older?		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.
CP07.	Do you live in a private residence?		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.
CP08.	Do you live in college housing?		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
CP09.	Do you currently live in___(state)____?		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
CP10.	In what state do you currently live?		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.01
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
CCHC.04	(Ever told) (you had) asthma?	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.
CCHC.12	(Ever told) (you had) diabetes?	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
CDEM.09		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.
CBCCS.01		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
CBCCS.03	Have you ever had a cervical cancer screening test?	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
CBCCS.04		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.
CCRC.01		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
CCRC.06		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.
CCRC.07		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.
CCRC.09		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.
CCRC.11		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.
CTOB.01		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.
CALC.01		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.
CIMM.01		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.
CHIV.01		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
MTOC.01		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
MCOT.04		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
MCPM.01		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.
MPCS.01	Have you ever had a P.S.A. 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
MCOG.01		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.
MMU.01		88 None 77 Don’t know/not sure 99 Refused	Go to next module	Do not include hemp-based CBD-only products.
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
MRCS.02	Is the child a boy or a girl?	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.
MCAP.01		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.

31 July 2024

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Pierannunzi, Carol (CDC/ONDIEH/NCCDPHP)
File Modified	0000-00-00
File Created	2024-07-31