Adult Survey

OMB Clearance Number: 2528-0337

Expires: XX/XX/XXXX

Attachment M.1: The Obesity & Type II Diabetes Risk Assessment Adult Survey Baseline

If you require information to be presented in an accessible format or reasonable accommodations to participate in this study, please contact us with any specific requests by calling XXX-XXX-XXXX or emailing [email protected]. If you require language assistance to participate in this study, please contact us with any specific language assistance requests or needs.

 

 

 Paperwork Reduction Act Burden Statement 

This collection of information is voluntary and will be used to evaluate the US Department of Housing and Urban Development’s Community Choice Demonstration. Public reporting burden for this collection of information is estimated to average 70 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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. The OMB number for this collection is OMB 2528-0337 which expires on XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NAME at [email protected] or call XXX-XXX-XXXX.  

 

Privacy Act Statement  

Authority:  Section 502 of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. §§ 1701z-1; 1701z-2(d) and (g)).  

Purpose:  Evaluation of the Community Choice Demonstration (CCD).  

Routine Use:  The information will be used for the purpose set forth above and may be provided to Congress or other Federal, state, and local agencies, when determined necessary.  

Disclosure:  Records will be used for research and statistical analysis and will not be used to make decisions that affect the rights, benefits, or privileges of specific individuals. 

SORN ID:  Community Choice Demonstration Evaluation Data Files, HUD/PDR-09  

Note: Some study activities are being funded by the National Institute of Diabetes and Digestive and Kidney Diseases. 

MOVED ADULT BASELINE SURVEY

Introduction

This survey will cover a wide range of topics that will help us understand how neighborhoods may impact adult health outcomes, like diabetes and depression. Some of the questions we ask will be about you, some will be about your household, and others will be about your neighborhood. It should take about 70 minutes to complete the survey. Are you ready to begin?

SECTION A. NEIGHBORHOOD

Let’s start by talking about your neighborhood. In this part of the survey, we will ask questions about the food choices in your neighborhood, opportunities to walk around your neighborhood, neighborhood safety, police presence in your neighborhood, and what you think about your neighbors and friends.

GENERAL NEIGHBORHOOD SATISFACTION

[only if the respondent did not complete the CCD baseline] The first two questions are about neighborhood satisfaction.

A1. [only if the respondent did not complete the CCD baseline] Which of the following statements best describes how satisfied you are with your current neighborhood?

  Very satisfied

  Somewhat satisfied

  In the middle

  Somewhat dissatisfied

  Very dissatisfied

  Don’t know

  Prefer not to answer

A2. [only if the respondent did not complete the CCD baseline]Do you agree or disagree with this statement: “The neighborhood conditions where I live make it harder to be the parent I want to be for my children”?

  Strongly disagree

  Disagree

  Agree somewhat

  Agree

  Strongly Agree

  Don’t know

  Prefer not to answer

NEIGHBORHOOD FOOD ENVIRONMENT

We would like to find out about the way that you think about the food choices in your neighborhood. Please answer these questions thinking about the food stores in the neighborhood near where you live. I will read three statements about the food choices in your neighborhood. Please tell me whether you agree or disagree with each statement [provide card with response options to the participant]. [if asked: you can define your neighborhood how you define your neighborhood.]

[Source: Green, S. & Glanz, K. (2015). Development of the Perceived Nutrition Environment Measures Survey. American Journal of Preventative Medicine.]

A3. It is easy to buy fresh fruits and vegetables in my neighborhood.

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

A4. The fresh produce in my neighborhood is of high quality.

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

A5. Fresh fruit and vegetables in my neighborhood are expensive.

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

NEIGHBORHOOD WALKABILITY

The next questions are about walking around your neighborhood. I will read four statements. Please tell me the extent to which you agree or disagree with each statement

A6. There are many places to go within walking distance of my home.

[Source: https://www.ipenproject.org/documents/publications_docs/NEWS%20and%20NEWS-A.pdf]

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

A7. My neighborhood offers many opportunities to be physically active.

[Source: https://academic.oup.com/aje/article/165/8/858/185012]

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

A8. It is pleasant to walk in my neighborhood.

[Source: https://academic.oup.com/aje/article/165/8/858/185012]

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

A9. I often see other people walking in my neighborhood.

[Source: https://academic.oup.com/aje/article/165/8/858/185012]

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

NEIGHBORHOOD SAFETY

[only if the respondent did not complete the CCD baseline] The next three questions are about neighborhood safety.

A10. [only if the respondent did not complete the CCD baseline] How safe are the streets near your home during the day? Would you say very safe, safe, somewhat unsafe, unsafe, or very unsafe?

  Very safe

  Safe

  Somewhat unsafe

  Unsafe

  Very unsafe

  Don’t know

  Prefer not to answer

A11. [only if the respondent did not complete the CCD baseline]How safe are the streets near your home at night? (Would you say very safe, safe, somewhat unsafe, unsafe, or very unsafe?)

  Very safe

  Safe

  Somewhat unsafe

  Unsafe

  Very unsafe

  Don’t know

  Prefer not to answer

A12. [only if the respondent did not complete the CCD baseline] How often are you worried about gun violence in your neighborhood? Would you say:

  None of the time

  A little of the time

  Some of the time

  Most of the time

  All of the time

  Don’t know

  Prefer not to answer

NEIGHBORHOOD POLICING

The next three questions are about policing in your neighborhood. How much do you agree or disagree with the following statements.

A13. Excessive policing is a problem in my neighborhood.

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

Adapted from Project on Human Development in Chicago Neighborhoods Community Survey (Boehme et al, 2020)

A14. I am worried that my children will be targeted by the police in my neighborhood.

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

A15. The police do a good job in responding to people in the neighborhood after being victims of crime.

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

Adapted from Project on Human Development in Chicago Neighborhoods Community Survey (Boehme et al, 2020)

NEIGHBORHOOD SOCIAL ENVIRONMENT

Now I am going to read some statements about things that people in your neighborhood may or may not do. Please tell me how much you agree with each of the following statements [provide card with response options]:

[Source: Collective Efficacy Short Form – 10]

A16. People around here are willing to help their neighbors.

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

A17. This is a close-knit neighborhood.

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

A18. People in this neighborhood can be trusted.

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

A19. People in this neighborhood generally don’t get along with each other.

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

A20. People in this neighborhood do not share the same values.

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

COLLECTIVE EFFICACY

Could your neighbors be counted on to intervene if…[provide response card with options]:

[Source: Collective Efficacy Short Form – 10]

A21. Children are skipping school and hanging out on a street corner. Would you say it is very likely, likely, neither likely nor unlikely, unlikely, or very unlikely that your neighbors would intervene?

  Very likely

  Likely

  Neither likely nor unlikely

  Unlikely

  Very unlikely

  Don’t know

  Prefer not to answer

A22. Children are spray-painting graffiti on a local building. [Would you say it is very likely, likely, neither likely nor unlikely, unlikely, or very unlikely that your neighbors would intervene?]

  Very likely

  Likely

  Neither likely nor unlikely

  Unlikely

  Very unlikely

  Don’t know

  Prefer not to answer

A23. Children are showing disrespect to an adult. [Would you say it is very likely, likely, neither likely nor unlikely, unlikely, or very unlikely that your neighbors would intervene?]

  Very likely

  Likely

  Neither likely nor unlikely

  Unlikely

  Very unlikely

  Don’t know

  Prefer not to answer

A24. A fight broke out in front of their house. [Would you say it is very likely, likely, neither likely nor unlikely, unlikely, or very unlikely that your neighbors would intervene?]

  Very likely

  Likely

  Neither likely nor unlikely

  Unlikely

  Very unlikely

  Don’t know

  Prefer not to answer

A25. The fire station closest to their home was threatened with budget cuts. [Would you say it is very likely, likely, neither likely nor unlikely, unlikely, or very unlikely that your neighbors would intervene?]

  Very likely

  Likely

  Neither likely nor unlikely

  Unlikely

  Very unlikely

  Don’t know

  Prefer not to answer

INSTRUMENTAL SUPPORT FROM NEIGHBORS

Now I am going to ask you about people in your neighborhood. Please think about people outside your immediate household and who are not part of your family. Tell me if you know people in the neighborhood who…

[Source: Mobilizing Social Capital; https://www.tandfonline.com/doi/abs/10.1080/02673037.2016.1140724?journalCode=chos20]

A26. You could borrow a car from, if you needed it.

  Yes

  No

  Don’t know

  Prefer not to answer

A27. Could give you a ride, if you needed it.

  Yes

  No

  Don’t know

  Prefer not to answer

A28. Could babysit for your children, if you needed it.

  Yes

  No

  Don’t know

  Prefer not to answer

A29. Could help you with a computer, if you needed it.

  Yes

  No

  Don’t know

  Prefer not to answer

A30. Are active in community organizations.

  Yes

  No

  Don’t know

  Prefer not to answer

A31. Could give you advice about job opportunities, if you asked for it.

  Yes

  No

  Don’t know

  Prefer not to answer

A32. Could bring you food or medicine, if you get sick.

  Yes

  No

  Don’t know

  Prefer not to answer

A33. You could discuss personal matters with, if you wanted to.

  Yes

  No

  Don’t know

  Prefer not to answer

A34. Would lend you $100, if you needed it.

  Yes

  No

  Don’t know

  Prefer not to answer

A35. You could have a meal with, if you wanted to.

  Yes

  No

  Don’t know

  Prefer not to answer

BRIDGING SOCIAL CAPITAL

The next questions are about your friends. Please tell me if the following statements describe nearly all, most, some, a few, or none of your friends [provide response options on a card].

[Source: New question, adapted from prior survey, Schwartz (2014); onhttps://www.sciencedirect.com/science/article/pii/S0277953613005479?via%3Dihub]

A36. My friends live in the neighborhood. Would you say:

  All

  Most

  Some

  None

  Don’t know

  Prefer not to answer

A37. My friends have graduated from college.

  All

  Most

  Some

  None

  Don’t know

  Prefer not to answer

A38. My friends are different races or ethnicities than me.

  All

  Most

  Some

  None

  Don’t know

  Prefer not to answer

SECTION B. HOME AND HOUSEHOLD

In this next part of the survey, we are interested in learning more about your home and your household. [if respondent completed the CCD baseline: Since you’ve already answered questions about your home and your household in prior surveys, we will only ask a few new questions that may be related to your neighborhood and health.] These questions are about your household’s receipt of social services, food situation, and how your household’s situation may affect your plans for the future.

[only if the respondent did not complete the CCD baseline} The first question is about the condition of your home.

B1. [only if the respondent did not complete the CCD baseline] Do you agree or disagree with this statement: “The size or physical condition of my home makes it harder to be the parent I want to be for my children”?

  Strongly disagree

  Somewhat disagree

  Neither agree nor disagree

  Somewhat agree

  Strongly agree

  Don’t know

  Prefer not to answer

SOCIAL SERVICE PARTICIPATION

I would like to ask you about different sources of income or assistance you or people in your family living with you now may receive. Your responses to these questions will not affect your family’s eligibility for housing assistance or other types of assistance. By family, I mean the people you told us about at enrollment who live with you now and who would move with you if you moved. Remember your responses will remain confidential and you can skip any question you don’t feel comfortable with.

B2. At any time in the last 12 months did any family members living here receive SNAP or food stamp benefits?

  Yes

  No [SKIP TO B4]

  Don’t know [SKIP TO B4]

  Prefer not to answer [SKIP TO B4]

[Source: National Health Interview Survey]

B3. Did any family members living here receive SNAP or food stamp benefits in the LAST 30 days?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

B4. At any time in the last 12 months did any family members living here receive benefits from the WIC program, that is, the Women, Infants, and Children program?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

B5. At any time in the last 12 months, did any child in your family receive free or reduced-cost breakfasts or lunches at school through the National School Lunch Program?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

FOOD SECURITY

These six questions are about your household’s food situation. I’m going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for your household in the last 12 months – that is, since last [NAME OF CURRENT MONTH].

[if needed: Some people may find the next few questions personal. Please remember you can choose not to answer any question.]

[Source: NHANES; https://www.ers.usda.gov/media/8282/short2012.pdf]

B6. The first statement is, “The food that we bought just didn’t last, and we didn’t have money to get more.” Was this often, sometimes, or never true for your household?

  Often true

  Sometimes true

  Never true

  Don’t know

  Prefer not to answer

B7. “We couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for your household in the last 12 months?

  Often true

  Sometimes true

  Never true

  Don’t know

  Prefer not to answer

B8. In the last 12 months, since last [NAME OF CURRENT MONTH] did you or other adults in your household ever cut the size of your meals or skip meals because there wasn’t enough money for food?

  Yes

  No (SKIP TO B10)

  Don’t know (SKIP TO B10)

  Prefer not to answer (SKIP TO B10)

B9. [IF B8=Yes] How often did this happen – almost every month, some months but not every month, or in only 1 or 2 months?

  Almost every month

  Some months but not every month

  Only 1 or 2 months

  Don’t know

  Prefer not to answer

B10. In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?

  Yes

  No

  Don’t know

  Prefer not to answer

B11. In the last 12 months, were you ever hungry but didn’t eat because there wasn’t enough money for food?

  Yes

  No

  Don’t know

  Prefer not to answer

The next three questions are about characteristics of your household that may affect your future plans.

PREDICTABILITY

B12. Sometimes things happen that completely throw your plans off course or mess things up. How likely or unlikely is it that something like that will happen to you or your family in the next 12 months? Would you say…

  Very likely

  likely

  Neither likely nor unlikely

  unlikely

  Very unlikely

  Don’t know

  Prefer not to answer

PET OWNERSHIP

Having pets can impact how much time you spend outdoors and getting around.

B13. Does your household currently have a dog?

  Yes

  No

  Don’t know

  Prefer not to answer

HEALTH LIMITING MOVING

B14. Would the health of anyone in your household make it more challenging for you to move to a new neighborhood?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: New question]

SECTION C. INDIVIDUAL

[only if respondent is not completing child survey] The rest of the questions I’m going to ask are all about you as an individual. First, I have some questions about your habits, behaviors, and experiences. Then I will ask about your mood, thoughts, and feelings. Next, I’ll ask about your health and healthcare. Lastly, I’ll ask some questions about your background.

We’ll start by talking about your habits and behaviors.

[If respondent is completing the child survey] The next set of questions I’m going to ask are all about you as an individual. First, I have some questions about your habits, behaviors, and experiences. Then I will ask about your mood, thoughts and feelings. Next, I’ll ask about your health and healthcare. Lastly, I’ll ask some questions about your background. Once we are all done asking questions about you, we will ask you some questions about your child.

We’ll start by talking about your habits and behaviors.

PHYSICAL ACTIVITY

The first set of questions asks about different types of activities you do and where you do them.

[Source: International Physical Activity Questionnaire - Short Form; https://youthrex.com/wp-content/uploads/2019/10/IPAQ-TM.pdf]

Sitting

Think about the time you spent sitting on weekdays during the last 7 days. Include time spent at work, at home, while doing course work and during leisure time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television.

[interviewer instructions: respondent may use either hours or minutes per day. Please record either but not both]

C1. During the last 7 days, how much time did you spend sitting on a weekday?

  X hours per day________________

  X minutes per day_______________

  Don’t know/not sure

  Prefer not to answer

Walking

Think about the time you spent walking in the last 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you have done solely for recreation, sport, exercise, or leisure.

C2. During the last 7 days, on how many days did you walk for at least 10 minutes at a time?

  # of days per week ___________

  No walking [SKIP FOLLOWING QUESTION]

  Don’t know/not sure [SKIP TO FOLLOWING QUESTION]

  Prefer not to answer [SKIP TO FOLLOWING QUESTION]

C3. How much time did you usually spend walking on one of those days?

  X hours per day____________

  X minutes per day___________

  Don’t know/not sure

  Prefer not to answer

Vigorous activity

Think about all the vigorous activities that you did in the last 7 days. Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

C4. During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, aerobics, or fast bicycling if at all?

  # of days per week__________

  No vigorous physical activity [SKIP TO MODERATE ACTIVITY]

  Don’t know/not sure [SKIP TO MODERACTE ACTIVITY]

  Prefer not to answer [SKIP TO MODERATE ACTIVITY]

C5. [IF AT LEAST 1 DAY PER WEEK] How much time did you usually spend doing vigorous physical activities on one of those days?

  X hours per day _____________

  X minutes per day_____________

  Don’t know/not sure

  Prefer not to answer

Moderate activity

Think about all the moderate activities that you did in the last 7 days. Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

C6. During the last 7 days, on how many days did you do moderate physical activities like carrying light loads, bicycling at a regular pace, or doubles tennis if at all? Do not include walking.

  # of days per week _____________

  No moderate physical activity [SKIP FOLLOWING QUESTION]

  Don’t know/not sure [SKIP FOLLOWING QUESTION]

  Prefer not to answer [SKIP FOLLOWING QUESTION]

C7. [IF AT LEAST 1 DAY PER WEEK] How much time did you usually spend doing moderate physical activities on one of those days?

  X hours per day______________

  X minutes per day______________

  Don’t know/not sure

  Prefer not to answer

Location of physical activity

C8. In the past month, where have you gone for physical activity? Please let us know all of the places you’ve gone.[Respondent may select multiple options]

  Park

  Trail or another walking/running path

  Gym/recreation center

  Your own home

  Home of a family member or a friend

  Work

  Retail outlets (malls)

  Streets/sidewalks

  Physical therapy or rehabilitation

  Other (please specify type of place)

  I don't engage in physical activity

  I don't know

  Prefer not to answer

[Source: RAND Corporation’s PHRESH Survey (Pittsburgh Hill/Homewood Research On Neighborhood Change and Health]

C9. In the past month, how often did you walk to places in your neighborhood for exercise, pleasure, or to get somewhere you needed to go?

  At least once a day in the past month

  3-6 times a week in the past month

  Once or twice a week in the past month

  2-3 times in the past month

  Once in the past month

  Never in the past month

  Don't know

  Prefer not to answer

[Source: RAND Corporation’s PHRESH Survey (Pittsburgh Hill/Homewood Research On Neighborhood Change and Health]

DIET

The next set of questions are about the different kinds of foods you ate or drank during the past month, that is, the past 30 days. When answering, please include meals and snacks eaten at home, at work or school, in restaurants, and anyplace else.

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

C10. During the past month, how often did you eat hot or cold cereals? You can tell me per day, per week, or per month.

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never [SKIP TO C12]

  Don’t know [SKIP TO C12]

  Prefer not to answer [SKIP TO C12]

C11. [SKIP IF C10=Never, Don’t know or prefer not to answer] During the past month, what kind of cereal did you usually eat?

  [OPEN RESPONSE]___________________________________

  Don’t Know

  Prefer not to answer

C12. During the past month, how often did you drink regular soda or pop that contains sugar? Do not include diet soda. You can tell me per day, per week, or per month.

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C13. During the past month, how often did you drink 100% pure fruit juices such as orange, mango, apple, grape and pineapple juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C14. (During the past month), how often did you drink coffee or tea that had sugar or honey added to it?   Include coffee and tea you sweetened yourself and presweetened tea and coffee drinks such as Arizona Iced Tea and Frappuccino. Do not include artificially sweetened coffee or diet tea. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C15. (During the past month), how often did you drink sweetened fruit drinks, sports or energy drinks, such as Kool-Aid, lemonade, Hi-C, cranberry drink, Gatorade, Red Bull, or Vitamin Water? Include fruit juices you made at home and added sugar to. Do not include diet drinks or artificially sweetened drinks. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C16. (During the past month), how often did you eat fruit? Include fresh, frozen or canned fruit. Do not include juices. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C17. (During the past month), how often did you eat a green leafy or lettuce salad, with or without other vegetables? (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C18. (During the past month), how often did you eat any kind of fried potatoes, including french fries, home fries, or hash brown potatoes? (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C19. (During the past month), how often did you eat any kind of potatoes, such as baked, boiled, mashed potatoes, sweet potatoes, or potato salad? (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C20. (During the past month), how often did you eat refried beans, baked beans, beans in soup, pork and beans or any other type of cooked dried beans? Do not include green beans. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C21. (During the past month), how often did you eat brown rice or other cooked whole grains, such as bulgur, cracked wheat or millet? Do not include white rice. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C22. (During the past month), not including what you just told me about--green salads, potatoes, cooked dried beans--how often did you eat other vegetables? (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C23. (During the past month), how often did you have Mexican-type salsa made with tomato? (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C24. (During the past month), how often did you eat pizza? Include frozen pizza, fast food pizza, and homemade pizza. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C25. (During the past month), how often did you have tomato sauces such as with spaghetti or noodles or mixed into foods such as lasagna? Do not include tomato sauce on pizza. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C26. (During the past month), how often did you eat any kind of cheese? Include cheese as a snack, cheese on burger, sandwiches, and cheese in foods such as lasagna, quesadillas, or casseroles. Do not include cheese on pizza. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C27. Please look at this card, during the past month, how often did you eat red meat such as beef, pork, ham, or sausage? Do not include chicken, turkey or seafood. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C28. Please look at this card, (during the past month), how often did you eat any processed meat, such as bacon, lunch meats, or hot dogs? (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C29. (During the past month), how often did you eat whole grain bread including toast, rolls and in sandwiches? Whole grain breads include whole wheat, rye, oatmeal and pumpernickel. Do not include white bread. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C30. During the past month, how often did you eat chocolate or any other types of candy? Do not include sugar-free candy.

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C31. (During the past month), how often did you eat doughnuts, sweet rolls, Danish, muffins, pan dulce, or pop-tarts? Do not include sugar-free items. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C32. (During the past month), how often did you eat cookies, cake, pie, or brownies? Do not include sugar-free kinds. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C33. (During the past month), how often did you eat ice cream or other frozen desserts? Do not include sugar-free kinds. (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

C34. (During the past month), how often did you eat popcorn? (You can tell me per day, per week, or per month.)

  ___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

  Never

  Don’t know

  Prefer not to answer

EATING OUT

C35. Next I'm going to ask you about meals. By meal, I mean breakfast, lunch and dinner. During the past 7 days, how many meals did you get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines?

  None [SKIP TO NEXT SECTION]

  [ENTER NUMBER 1-21]_________

  More than 21 times

  Don’t know [SKIP TO NEXT SECTION]

  Prefer not to answer [SKIP TO NEXT SECTION]

[Source: Frequency of Eating Out and Cooking At Home (NHANES)]

C36. [ASK IF C35 = >1] How many of those meals did you get from a fast-food or pizza place?

  [ENTER NUMBER 1-21]________

  None

  More than 21 times

  Don’t know

  Prefer not to answer

[Source: Frequency of Eating Out and Cooking At Home (NHANES)]

FOOD PURCHASING

The next three questions are about where you buy your food.

[Source: Green, S. & Glanz, K. (2015). Development of the Perceived Nutrition Environment Measures Survey. American Journal of Preventative Medicine.]

C37. What type of store is the store where you buy most of your food? [Note to interviewer: Respondents may select more than one option].

  Supermarket

  Small grocery store

  Corner store or convenience store

  Supercenter (like Wal-Mart or Costco)

  Other (please specify):

  Don’t know

  Prefer not to answer

C38. Thinking about the store where you buy most of your food, how do you usually travel to this store?

  Walk

  Bicycle

  Bus or other public transportation

  Drive your own car

  Get a ride

  Other (please specify):

  Don’t know

  Prefer not to answer

C39. About how long does it take to get from your home to the store where you buy most of your food?

  10 minutes or less

  11 to 20 minutes

  21 to 30 minutes

  More than 30 minutes

  Don’t know

  Prefer not to answer

TRANSPORTATION

The next questions are about different ways people may get from place to place in your neighborhood and how you get around.

[Source: Massey, Climbing Mount Laurel study]

C40. Do you or anyone in your household own or lease a motor vehicle?

  Yes

  No

  Don’t know

  Prefer not to answer

C41. [IF C40 NOT YES] Do you have reliable access to a vehicle?

  Yes

  No

  Don’t know

  Prefer not to answer

C42. How many days a week do you make use of public transportation, including buses, trains, and subways?

  1-7 days____________

  I don’t use public transportation

  Don’t know

  Prefer not to answer

C43. How long would it take you to get to the nearby bus, train, or subway stop?

  < 15mins

  15 to 30 mins

  31 to 45 mins

  46 min to 1 hour

  > 1 hour

  Don’t know

  Prefer not to answer

C44. How good is the public transportation service in your neighborhood?

  Very poor

  Poor

  Neither poor nor good

  Good

  Very good

  Don’t know

  Prefer not to answer

SLEEP

The next four questions relate to your sleep habits. When answering, think about your usual sleep habits during the past month only. [note to interviewer, the following may be added: Your answers should indicate the most accurate reply for the majority of days and nights in the past month. ]

[Source: Sancho-Domingo, C., Carballo, J., Caloma-Carmona, A., & Buysse, D. (2021). Brief version of the Pittsburgh Sleep Quality Index (B-PSQI) and measurement invariance across gender and age in a population-based sample. Psychological Assessment.]

C45. During the past month, what time have you usually gone to bed at night?

  Bedtime AM/PM: [OPEN RESPONSE]_________

  Don’t know

  Prefer not to answer

C46. During the past month, how long does it usually take you to fall asleep each night?

  Number of:_______________minutes OR hours

  Don’t know

  Prefer not to answer

C47. During the past month, what time have you usually gotten up in the morning?

  GETTING UP TIME: AM/PM__________________

  Don’t know

  Prefer not to answer

C48. During the past month, how would you rate your sleep quality overall? Would you say…

  Very good

  Fairly good

  Fairly bad

  Very bad

  Don’t know

  Prefer not to answer

SUBSTANCE USE

Now I would like to ask you some questions about tobacco, alcohol, and weight control. We are asking these questions of everyone in the study. Remember that the information you provide will be kept private and your name will never be linked to your responses in reports. [IF NEEDED: Some people may find the next few questions personal. Please remember you can choose not to answer any question.]

Tobacco

The first few questions are about cigarette smoking.

C49. Have you smoked at least 100 cigarettes in your ENTIRE LIFE?

  Yes

  No [SKIP TO C52]

  Don’t know [SKIP TO C52]

  Prefer not to answer [SKIP TO C52]

[Source: National Health Interview Survey]

C50. [ASK IF C49=YES] Do you NOW smoke cigarettes every day, some days, or not at all?

  Every day

  Some days

  Not at all

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C51. Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all? [Read if necessary: Snus [pronounced “snoos”] (Swedish for snuff) is a moist smokeless tobacco usually sold in small pouches that are placed under the lip against the gum.)

  Every day

  Some days

  Not at all

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C52. Do you currently use e-cigarettes or other electronic vaping products every day, some days, or not at all? [Read if necessary: 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.]

  Every day

  Some days

  Not at all

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

Binge-drinking

This next question is about drinking alcohol.

C53. Over the past 2 weeks, how many occasions have you had [5 (male)/4 (female)] or more drinks in a row?

  None

  Once

  Twice

  2 to 5 times

  6 to 9 times

  10 or more times

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

DIET BEHAVIORS

The last several questions in this part are about behaviors you may use to control your weight or what you eat.

C54. How often have you gone on a diet during the last year? By ‘diet’ I mean changing the way you eat so you can lose weight. Dieting includes any changes, big or small, that you made to lose weight.

  Never

  One to four times

  Five to ten times

  More than ten times

  I am always dieting

  Don’t know

  Prefer not to answer

[Source: Dieting and disordered eating behaviors among adolescents; https://www-sciencedirect-com.proxy1.library.jhu.edu/science/article/pii/S0002822311004251

C55. Do you NOW take any of the following prescription medicines to lose weight or manage diabetes? (Show card with weight loss medicines approved by the FDA.) (Prompt if needed: These are medicines prescribed by a doctor or other health practitioner.)

  Yes

  No

  Don’t know

  Prefer not to answer

C56. Have you done any of the following things in order to lose weight or keep from gaining weight during the past year including fasting, ate very little food, took diet pills, made yourself vomit, used laxatives, used diuretics (water pills), used food substitute (powder or special drinks), skipped meals, or smoked more cigarettes? [interview, please use list for items]

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: Dieting and disordered eating behaviors among adolescents; https://www-sciencedirect-com.proxy1.library.jhu.edu/science/article/pii/S0002822311004251

C57. In the past year, have you ever eaten so much food in a short period of time that you would be embarrassed if others saw you (binge-eating)?

  Yes

  No [SKIP TO NEXT SECTION]

  Don’t know [SKIP TO NEXT SECTION]

  Prefer not to answer [SKIP TO NEXT SECTION]

[Source : https ://www.sph.umn.edu/sph-2018/wp-content/uploads/2019/12/project-eat-gen2-adolescent-survey.pdf]

C58. [if C57= YES] During the times when you ate this way, did you feel like you couldn’t stop eating or control what or how much you were eating?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source : https ://www.sph.umn.edu/sph-2018/wp-content/uploads/2019/12/project-eat-gen2-adolescent-survey.pdf]

DISCRIMINATION AND SAFETY

We hope to better understand more about everyone in the study’s personal experiences. The next few questions are about how you are treated in your everyday life. [if needed: if you feel that these questions are too personal, you can choose not to answer them.]

Everyday Discrimination Scale

C59. In your day-to-day life how often have any of the following things happened to you? Almost every day, at least once a week, a few times a month, a few times a year, less than once a year, or never? [These are the response options for each question]

1. You are treated with less courtesy or respect than other people. _______

2. You receive poorer service than other people at restaurants or stores. _______

3. People act as if they think you are not smart. ______

4. People act as if they are afraid of you. _____

5. You are threatened or harassed. _____

  Almost every day

  At least once a week

  A few times a month

  A few times a year

  Less than once a year

  Never

  Don’t know

  Prefer not to answer

[Source: Everyday Discrimination Scale, Short Form; https://scholar.harvard.edu/davidrwilliams/node/32397]

C60. [IF RESPONSE TO AT LEAST ONE QUESTION ABOVE IS “A FEW TIMES A YEAR” OR MORE] What do you think is the main reason for this experience? [SELECT ALL THAT APPLY. This item is asked only once and not for each time that a person reports discrimination]

  Your Ancestry or National Origins   

  Your Gender   

  Your Race   

  Your Age   

  Your Religion

  Your Height   

  Your Weight

  Some other Aspect of Your Physical Appearance

  Your Sexual Orientation

  Your Education or Income Level   

  Don’t know

  Prefer not to answer

[Source: Everyday Discrimination Scale, Short Form; https://scholar.harvard.edu/davidrwilliams/node/32397]

Experienced weight stigma

C61. Have you ever been [READ EACH BELOW] because of your weight? [If needed: this may be because of over or underweight, as well as body shape].

	Yes	No	Don’t know	Prefer not to answer
a. Teased	☐	☐	☐	☐
b. Treated unfairly	☐	☐	☐	☐
c. Discriminated against	☐	☐	☐	☐

[Source: Experienced Stigma Scale; https://pubmed-ncbi-nlm-nih-gov.proxy1.library.jhu.edu/34061867/.]

MENTAL HEALTH

Now that we’ve talked about your usual behaviors and experiences, I’d like to ask some questions about your mood, thoughts, and feelings. Remember your responses are confidential and you can skip any question you feel uncomfortable answering.

Body satisfaction

The first two questions are about how you feel about your body. We are asking these questions of everyone.

C62. On a scale from 1 to 10, where 1 is “Extremely Unsatisfied” and 10 is “Extremely Satisfied”, how satisfied are you with your weight?

  [Scale from 1 to 10] ______

  Don’t know

  Prefer not to answer

[Source: Does Body Satisfaction Matter?; https://pubmed.ncbi.nlm.nih.gov/16857537/]

C63. On a scale from 1 to 10, where 1 is “Extremely Unsatisfied” and 10 is “Extremely Satisfied”, how satisfied are you with your body shape?

  [Scale from 1 to 10]________

  Don’t know

  Prefer not to answer

[Source: Does Body Satisfaction Matter?; https://pubmed.ncbi.nlm.nih.gov/16857537/]

Eating to cope

The next few questions are about how you feel when you are eating. I will list five reasons people may choose to eat. For each, please tell me whether this is never, rarely, sometimes, often, or always true for you [give card with response options].

C64. In the past 12 months, how often have you eaten… [READ ANSWER CHOICES]

	Never	Rarely	Sometimes	Often	Always	Don’t know	Prefer not to answer
a. Because you’re depressed or sad	☐	☐	☐	☐	☐	☐	☐
b. because you feel worthless or inadequate	☐	☐	☐	☐	☐	☐	☐
c. as a way to help you cope	☐	☐	☐	☐	☐	☐	☐
d. as a way to comfort yourself	☐	☐	☐	☐	☐	☐	☐
e. as a way to avoid thinking about something unpleasant and to distract yourself	☐	☐	☐	☐	☐	☐	☒

[Source: Motivations to Eat subscale; Depression; https://www-sciencedirect-com.proxy1.library.jhu.edu/science/article/pii/S0092656602005743]

Depression and Anxiety

The next questions are about how you have been feeling.

C65. Thinking about the last 2 weeks, please tell me how often you have been bothered by each [show card with response options].

	Not at all	Several days	More than half the days	Nearly every day	Don’t know	Prefer not to answer
a. Little interest or pleasure in doing things	☐	☐	☐	☐	☐	☐
b. Feeling down, depressed, or hopeless	☐	☐	☐	☐	☐	☐
c. Trouble falling or staying asleep or sleeping too much	☐	☐	☐	☐	☐	☐
d. Feeling tired or having little energy	☐	☐	☐	☐	☐	☐
e. Poor appetite or overeating.	☐	☐	☐	☐	☐	☐
f. Feeling bad about yourself – or that you are a failure or have let yourself or your family down	☐	☐	☐	☐	☐	☐
g. Trouble concentrating on things, such as reading the newspaper or watching television	☐	☐	☐	☐	☐	☐
h. Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual	☐	☐	☐	☐	☐	☐
i. Feeling nervous, anxious, or on edge	☐	☐	☐	☐	☐	☐
j. Not being able to stop or control worrying	☐	☐	☐	☐	☐	☐

[Source: Kroenke, K., Spitzer, R., & Williams, J. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine.]

[Source: Generalized Anxiety Disorder 2-item (GAD-2); https://www.hiv.uw.edu/page/mental-health-screening/gad-2]

Perceived stress

The next four questions are about stress you may have felt in the past month. Please tell me how often you have felt each of these things on a scale from never to very often [show card with response options].

[Source: Perceived Stress Scale (PSS-4); Wartig, S., Forshaw, M., … & White, A. (2013). New, normative English-sample data for the Short Form Perceived Stress Scale (PSS-4). Journal of Health Psychology.]

C66. In the last month, how often have you felt that you were unable to control the important things in your life?

  Never

  Almost never

  Sometimes

  Fairly often

  Very often

  Don’t know

  Prefer not to answer

C67. In the last month, how often have you felt confident about your ability to handle your personal problems?

  Never

  Almost never

  Sometimes

  Fairly often

  Very often

  Don’t know

  Prefer not to answer

C68. In the last month, how often have you felt that things were going your way?

  Never

  Almost never

  Sometimes

  Fairly often

  Very often

  Don’t know

  Prefer not to answer

C69. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

  Never

  Almost never

  Sometimes

  Fairly often

  Very often

  Don’t know

  Prefer not to answer

C70. How often do you get the social and emotional support you need?

  Never

  Almost never

  Sometimes

  Fairly often

  Very often

  Don’t know

  Prefer not to answer

[modified from: https://www.cdc.gov/nchs/data/nhis/teen/NHIS-teen-survey-instrument-508.pdf]

Perceived Constraints of Sense of Control

I have some more questions about your feelings.

C71. Please tell me whether you agree or disagree with each of the following five statements.

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know	Prefer not to answer
a. Other people determine most of what I can and cannot do
b. There is little I can do to change many of the important things in my life
c. I often feel helpless in dealing with the problems of life
d. What happens in my life is often beyond my control
e. There are many things that interfere with what I want to do

[Source: Perceived Constraints on Sense of Control; https://psycnet.apa.org/record/1998-00299-016]

The next set of questions are about your health and healthcare.

HEALTH CONDITIONS

First, I have some questions about your health and health conditions that you may have. Remember, we will keep your responses confidential.

Self-rated physical and mental health

C72. [only if the respondent did not complete the CCD baseline] In general, how would you rate your overall health now? Is it…

  Excellent

  Very good

  Good

  Fair

  Poor

  Don’t know

  Prefer not to answer

C73. We would like to know how good or bad your health is TODAY. On a scale of 0 to 100 where 100 means the best health you can imagine and 0 means the worst health you can imagine, how is your health TODAY?

  RANGE 0-100___________

  Don’t know

  Prefer not to answer

[Source: EQL 5D-5L; https://euroqol.org/eq-5d-instruments/sample-demo/]

C74. [only if the respondent did not complete the CCD baseline] Taken all together, how would you say things are these days; would you say that you are very happy, pretty happy, or not too happy?

  Very happy

  Pretty happy

  Not too happy

  Don’t know

  Prefer not to answer

Physical health conditions

C75. Have you EVER been told by a doctor or other health professional that you had …Hypertension, also called high blood pressure?

  Yes

  No [SKIP TO C78]

  Don’t know [SKIP TO C78]

  Prefer not to answer [SKIP TO C78]

[Source: National Health Interview Survey]

C76. [ASK IF C75=YES] During the past 12 months, have you had hypertension or high blood pressure?

  Yes

  No [SKIP TO C78]

  Don’t know [SKIP TO C78]

  Prefer not to answer [SKIP TO C78]

[Source: National Health Interview Survey]

C77. [ASK IF C76=YES] Are you now taking prescribed medicine for your high blood pressure?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C78. Have you ever been told by a doctor or other health professional that you had asthma?

  Yes

  No [SKIP TO C83]

  Don’t know [SKIP TO C83]

  Prefer not to answer [SKIP TO C83]

[Source: National Health Interview Survey]

C79. [IF C78=YES] Do you still have asthma?

  Yes

  No ]

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C80. [IF C78=YES] During the past 12 months, have you had an episode of asthma or an asthma attack?

  Yes

  No [SKIP TO C82]

  Don’t know [SKIP TO C82]

  Prefer not to answer [SKIP TO C82]

[Source: National Health Interview Survey]

C81. [IF C80=YES] During the past 12 months, how many episodes of asthma or asthma attacks did you have?

  ENTER NUMBER OF ASTHMA ATTACKS _________

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C82. [IFC78=YES] During the past 12 months, have you had to visit an emergency room or urgent care center because of asthma?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C83. Has a doctor or other health professional EVER told you that you had prediabetes or borderline diabetes?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C84. [SKIP IF MALE] Has a doctor or other health professional EVER told you that you had gestational diabetes, a type of diabetes that occurs ONLY during pregnancy?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C85. Has a doctor or other health professional EVER told you that you had diabetes?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C86. [IF C85-YES] How old were you when a doctor or other health professional FIRST told you that you had diabetes?

  [ENTER AGE]____________

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C87. [IF C83=YES, , OR C85-YES ] Are you NOW taking diabetic pills to lower your blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C88. [IF C83=YES, , OR C85-YES ] Insulin can be taken by shot or pump. Are you NOW taking insulin?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C89. [C85-YES] According to your doctor or other health professional, what type of diabetes do you have? Is it type 1, type 2, or some other type? If you don't remember or weren't told, that's OK

  Type-1

  Type-2

  Some other type

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

Mental Health Conditions

[IF NEEDED: Remember, your responses are confidential, and you can skip any question you feel uncomfortable answering.]

C90. Has a doctor or other health professional ever diagnosed you with one of the following emotional or mental health conditions?

	Yes	No	Don’t know	Prefer not to answer
Anxiety or panic disorder	☐	☐	☐	☐
Depression	☐	☐	☐	☐
Other emotional or mental health condition	☐	☐	☐	☐

Other___________________________________

[Source: Local survey by Sabriya Linton on Baltimore HOPE VI redevelopment]

C91. In the past 12 months, have you ever received treatment from a doctor or other health professional for an emotional or mental health condition?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: Local survey by Sabriya Linton on Baltimore HOPE VI redevelopment]

Health Questionnaire, EQ5D

Now, I will read some questions about activities that people experience in a typical day. For each, please tell me whether each is not a problem for you, a slight problem, a moderate problem, a severe problem, or if you’re unable to do it. Please think about what best describes your health TODAY.

C92. First, I would like to ask you about MOBILITY. Would you say that: [card for no problems, slight problems, moderate problems, severe problems, unable to]

  You have no problems in walking about

  You have slight problems in walking about

  You have moderate problems in walking about

  You have severe problems in walking about

  You are unable to walk about

  Don’t know

  Prefer not to answer

[Source: EQL 5D-5L; https://euroqol.org/eq-5d-instruments/sample-demo/]

C93. Next, I would like to ask you about SELF-CARE. Would you say that: [card for no problems, slight problems, moderate problems, severe problems, unable to]

  You have no problems washing or dressing yourself

  You have slight problems washing or dressing yourself

  You have moderate problems washing or dressing yourself

  You have several problems washing or dressing yourself

  You are unable to wash or dress yourself

  Don’t know

  Prefer not to answer

[Source: EQL 5D-5L; https://euroqol.org/eq-5d-instruments/sample-demo/]

C94. Next I would like to ask you about USUAL ACTIVITIES, for example work, study, housework, family or leisure activities. Would you say that: [card for no problems, slight problems, moderate problems, severe problems, unable to]

  You have no problems doing your usual activities

  You have slight problems doing your usual activities

  You have moderate problems doing your usual activities

  You have severe problems doing your usual activities

  You are unable to do your usual activities

  Don’t know

  Prefer not to answer

[Source: EQL 5D-5L; https://euroqol.org/eq-5d-instruments/sample-demo/]

C95. Next, I would like to ask you about PAIN OR DISCOMFORT. Would you say that:

  You have no pain or discomfort

  You have slight pain or discomfort

  You have moderate pain or discomfort

  You have severe pain or discomfort

  You have extreme pain or discomfort

  Don’t know

  Prefer not to answer

[Source: EQL 5D-5L; https://euroqol.org/eq-5d-instruments/sample-demo/]

C96. Finally, I would like to ask you about ANXIETY OR DEPRESSION. Would you say that:

  You are not anxious or depressed

  You are slightly anxious or depressed

  You are moderately anxious or depressed

  You are severely anxious or depressed

  You are extremely anxious or depressed

[Source: EQL 5D-5L; https://euroqol.org/eq-5d-instruments/sample-demo/]

HEALTHCARE

The next questions are about your health insurance and health care.

Insurance

C97. Are you covered by any health insurance or some other kind of health care plan?

  Yes

  No [SKIP TO NEXT SECTION]

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C98. [IF C97=YES] What kinds of health insurance or health care coverage do you have?

  Private health insurance

  Medicare

  Medigap

  Medicaid (PA: Pennsylvania Medicaid Program, OH: MyCare OHIO, TN: TennCare)

  Children's Health Insurance Program (CHIP) (PA: Pennsylvania CHIP, OH: Healthy Start, TN: CoverKids)

  Military related health care: TRICARE (CHAMPUS) / VA health care / CHAMPVA

  Indian Health Service

  State-sponsored health plan

  Other government program

  No coverage of any type

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

Usual source of care

C99. Is there a place that you usually go if you are sick and need health care?

  Yes

  No [SKIP TO NEXT SECTION]

  Don’t know [SKIP TO NEXT SECTION]

  Prefer not to answer [SKIP TO NEXT SECTION]

[Source: National Health Interview Survey]

C100. [IF C99=YES] What kind of place?

  A doctor's office or health center

  An urgent care center

  A clinic in a drug store or grocery store

  A hospital emergency room

  A VA Medical Center or VA outpatient clinic

  Some other place

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

Health care use

C101. During the past 12 months, have you been hospitalized overnight?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

Preventative Medicine

C102. About how long has it been since you last saw a doctor or other health professional for a wellness visit, physical, or general-purpose check-up?

  Within the past year (any time less than 12 months ago)

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

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

  Within the last 5 years (5 years but less than 5 years ago)

  Within the last 10 years (5 years but less than 10 years)

  10 or more years ago

  Don't know

  Prefer not to answer

[Source: National Health Interview Survey]

C103. During the past 12 months, have you DELAYED getting medical care because of the cost?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C104. During the past 12 months, was there any time when you needed medical care, but DID NOT GET IT because of the cost?

  Yes

  No

  Don’t know

  Prefer not to answer

[Source: National Health Interview Survey]

C105. There are many other reasons people delay or do not get medical care. During the past 12 months, did you delay or not get medical care for any of the following reasons?

Reason	Yes	No	Don’t know	Prefer not to answer
a...Because an appointment wasn't available when you needed it?
b…Because you couldn't get to the doctor's office or clinic when it was open?
c…Because you had difficulty finding a doctor, clinic, or hospital that would accept your health insurance?
d…Because it takes too long to get to the doctor's office or clinic from your house or work?
e…Because you were too busy with work or other commitments to take the time?
f...Because you didn't have transportation

[Source: National Health Interview Survey]

C106. About how long has it been since you last had a dental examination or cleaning?

  Within the past year (any time less than 12 months ago)

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

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

  Within the last 5 years (5 years but less than 5 years ago)

  Within the last 10 years (5 years but less than 10 years)

  10 or more years ago

  Don't know

  Prefer not to answer

[Source: National Health Interview Survey]

[only if respondent is not completing child survey] We are almost done with the survey.

CHILDHOOD SES

[only if respondent is NOT completing child survey and if the respondent did not complete the CCD baseline}: The last set of questions are about your background. The first two questions are about your childhood.

[if respondent is completing child survey, and if the respondent did not complete the CCD baseline]: The last set of questions we will ask about you are about your background. The first two questions are about your childhood.

[only if respondent is NOT completing child survey and if respondent DID complete the CCD baseline]: the last two questions are about your childhood.

[if respondent is completing child survey and respondent DID complete the CCD baseline]: The last two questions we will ask about you are about your childhood. Then we have some questions for you about your child.

C107. Thinking about your main caregiver while you were growing up, what was the highest grade in school that he or she completed? If you had more than one caregiver, think about the one who you spent the most time with growing up. [IF NEEDED: Your responses are confidential and will not be shared. You may skip any question you’re not comfortable answering]

  Less than high school

  High school diploma

  GED certificate

  Some vocational/technical/business courses

  Vocational/technical/business certificate or diploma

  Some college

  Associate’s or two-year college degree

  Bachelor’s or four-year college degree or higher

  Don’t know

  Prefer not to answer

[Source: Sarah Szanton & Boeun Kim; adapted from National Health and Aging Trends study & Health Retirement Study]

C108. Please record the address you lived at when you were a child. If you lived at many different addresses, please choose the one that you most identify with as your home when you were growing up. [IF NEEDED: Your responses are confidential and will not be shared. You may skip any question you’re not comfortable answering]

  Street number, name, city, state, zip

ADDRESS___________________________

CITY_______________________________

STATE_________

ZIP _________________

  Don’t Know

  Prefer not to answer

[Source: Sarah Szanton & Boeun Kim; adapted from National Health and Aging Trends study & Health Retirement Study]

DEMOGRAPHICS AND OTHER INFORMATION

[[only if respondent is not completing child survey and if the respondent did not complete the CCD baseline] Now I just have a few final questions about your background. These questions are about your educational, employment, and racial/ethnic background. [If needed: these are for classification purposes only, you can skip any question you do not wish to answer]

C109. [only if the respondent did not complete the CCD baseline] What is the highest level of education that you have completed?

  Grade 9 or less

  Grade 10 or grade 11

  Attended grade 12 but did not receive high school diploma or GED certificate

  High school diploma

  GED certificate

  Some vocational/technical/business courses

  Vocational/technical/business certificate or diploma

  Some college

  Associate’s or two-year college degree

  Bachelor’s or four-year college degree or higher

  Don’t know

  Prefer not to answer

C110. [only if the respondent did not complete the CCD baseline] Do you consider yourself to be Spanish, Hispanic, or Latino?

  Yes

  No

  Don’t know

  Prefer not to answer

C111. [only if the respondent did not complete the CCD baseline] Do you consider yourself to be: (Check all that apply)

  American Indian or Alaska Native

  Asian

  Black or African American

  Native Hawaiian or Other Pacific Islander

  White

  Some other race (Specify) ____________

  Don’t know

  Prefer not to answer

C112. [only if the respondent did not complete the CCD baseline] In what country were you born?

  USA [SKIP TO C114]

  Another country (Specify) ________________

  Don’t know

  Prefer not to answer

C113. [only if the respondent did not complete the CCD baseline] [skip if C112= USA] How many years have you lived in the United States?

 

  Don’t know

  Prefer not to answer

C114. [only if the respondent did not complete the CCD baseline] Are you currently working for pay?

  Yes

  No (SKIP TO End of survey)

  Don’t know (End of survey)

  Prefer not to answer (End of survey)

C115. [only if the respondent did not complete the CCD baseline] About how many hours per week do you usually work? (Round the time to the nearest whole hour. For example, if you work 22.5 hours per week, please record 23 hours.)

  Hours

  Don’t know

  Prefer not to answer

[only if respondent is not completing child survey] Thank you very much for your time, that’s the end of this questionnaire. SKIP TO INCENTIVE CONFIRMATION SCREEN

[if respondent is completing child survey] Now we are going to ask you some questions about your child.

AFTER THE PARENT ON CHILD MODULE IS COMPLETE: SKIP TO INCENTIVE CONFIRMATION SCREEN

INCENTIVE CONFIRMATION INTERVIEWER:

Now I’d like to confirm your contact information so that we can send you your electronic gift card as a token of appreciation for your time.

I have your email address as: [EMAIL]. Is this correct?

  Yes (SKIP TO if respondent is completing child survey)

  No

  Don’t know

  Prefer not to answer

What is your email address?

_________________@______.________ (SKIP TO if respondent is completing child survey)

  Do not have an email address

  Don’t know

  Prefer not to answer

If you do not have an email address, we will mail your gift card to you. First, I’ll need to confirm I have the right address to send this to you. Is < ADDRESS> correct?

  Yes (SKIP TO if respondent is completing child survey)

  No

  Don’t know

  Prefer not to answer

What is your address?

Street Address________________________

Apartment #

Building Name:______________________

City___________________________ State_______ Zip _____________

  Don’t know

  Prefer not to answer

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