Attachment A
NCHS
Rapid Survey System – Round Four
MODE = WEB, CATI
REFUSALS/DON’T KNOW:
CAWI REFUSALS/DK:
DO NOT INCLUDE DON’T KNOW/REFUSED OPTIONS ON SCREEN FOR CAWI UNLESS SPECIFIED IN ITEM RESPONSE OPTIONS. CODE REFUSALS/SKIPS AS FOLLOWS:
IMPLICIT REFUSAL/WEB SKIP = -6
DON’T KNOW (WHEN SPECIFIED ON SCREEN) = -9
CATI REFUSALS/DK:
INCLUDE THE FOLLOWING DON’T KNOW/REFUSED OPTIONS FOR INTERVIEWERS ON SCREEN FOR ALL QUESTIONS IN CATI. INTERVIEWERS SHOULD NOT READ REF/DK OPTIONS UNLESS OTHERWISE SPECIFIED IN RESPONSE OPTIONS. CODE AS FOLLOWS:
REFUSAL = -7
DON’T KNOW = -9
LEGITIMATE SKIPS
CODE ALL LEGITIMATE SKIPS FOR CATI AND CAWI AS FOLLOWS:
LEGITIMATE SKIP = -8
ANSWER REQUIREMENT/ PROMPTS AND VALIDATION
RESPONDENTS SHOULD BE ABLE TO SKIP ALL ITEMS, AND NO ITEMS SHOULD BE REQUIRED. DO NOT USE SOFT PROMPTS FOR ITEMS THAT ARE SKIPPED. ERROR/VALIDATION MESSAGES (E.G., OUT OF BOUNDS RESPONSES) SHOULD BE PROGRAMMED AS SPECIFIED.
QUESTION INFORMATION FORMATTING:
ALL QUESTIONS WILL BE FORMATTED AS FOLLOWS:
[UNIVERSE/SKIP LOGIC]
[QUESTION TYPE]
DISP = TEXT DISPLAY
S = SINGLE RESPONSE
M = MULTI-CHECK
NUMBOX = NUMERIC INPUT
TEXTBOX = TEXT INPUT
GRID = MATRIX GRID
VARIABLE NAME
QUESTION STEM
IF CAWI/CATI QUESTION TEXT IS DIFFERENT, “[CAWI]” AND “[CATI]” WILL PRECEDE MODE SPECIFIC TEXT
CAWI RESPONSE OPTIONS
CATI RESPONSE OPTIONS IF DIFFERENT FROM CAWI; ELSE ONLY ONE COMMON SET OF RESPONSE OPTIONS WILL BE SPECIFIED.
CATI INSTRUCTIONS AND RESPONSE OPTIONS THAT SHOULD NOT BE READ WILL BE IN ALL CAPS. CATI RESPONSE OPTIONS WILL ALSO INCLUDE “DO NOT READ” INSTRUCTIONS; ELSE CATI TEXT/RESPONSE OPTIONS SHOULD BE READ BY INTERVIEWER. NORC/IPSOS MAY FORMAT RESPONSE OPTIONS THAT SHOULD NOT BE READ AS ALL CAPS AND/OR IN LOWER CASE WITH EXPLICIT “DO NOT READ” INSTRUCTIONS.
ON WEB DISPLAY ONE ITEM PER PAGE UNLESS OTHERWISE SPECIFIED. SCREEN BREAKS ARE DENOTED BY LINES BETWEEN ITEMS.
CREATE VARIABLES:
QUEX_LANG
BASED
ON LANGUAGE SELECTED IN INSTRUMENT:
ENGLISH = 1
SPANISH = 2
GROUP
RANDOMLY ASSIGN 50% OF PARTICIPANTS TO EACH OF TWO GROUPS
GROUP = 1-2
PRELOAD PROFILE DEMOGRAPHICS AND RENAME/CREATE VARIABLES AS FOLLOWS:
HHSIZE
NUMERIC HH SIZE, CAPPED AT 6+
SEX
NORC = S_GENDER
IPSOS = QGENDER
1 MALE
2 FEMALE
NORC/IPSOS: AS NECESSARY, INCLUDE YOUR STANDARD PANEL CAWI INTRO SCREENS AND CATI INBOUND/OUTBOUND/CALLBACK/VOICEMAIL SCRIPTS BEFORE “INTRODUCTION.”
INTRODUCTION
[DISPLAY IF CAWI]
The National Center for Health Statistics (NCHS), part of the Centers for Disease Control and Prevention (CDC), is conducting a study and we need your help. We are interested in your health and wellness and will be asking you a series of questions about your health history, behaviors, and opinions. This should take about 20 minutes or less to complete. Participation in this survey is completely voluntary, and you may skip any question(s) you do not want to answer and may quit the survey at any time. The information being collected will assist NCHS and CDC in their ongoing efforts to track the health of the American public. Your data will be kept confidential, will be used for statistical purposes only, and will not be disclosed or released to other persons without your consent in accordance with Section 308(d) of the Public Health Service Act [42 U.S.C. 242m(d)] and Confidential Information Protection and Statistical Efficiency Act (44 U.S.C. 3561-3583).
If you have any questions about your rights as a participant in this research study, call NCHS’ Ethics Review Board toll-free at 1-800-223-8118 and mention you are calling about Protocol #2023-04. Your call will be returned as soon as possible.
[PROGRAMMER: REDUCE TEXT SIZE SLIGHTLY; TEXT BELOW BOARDED BY THIN BLACK BOX/OUTLINE]
CDC estimates the average public reporting burden for this collection of information as 20 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS H21-8, Atlanta, GA 30333; ATTN: PRA (0920-1408).
We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)), and the Confidential Information Protection and Statistical Efficiency Act or CIPSEA (44 U.S.C. 3561-3583). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. § 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks. |
[DISPLAY IF CATI]
We are asking for your help on behalf of the National Center for Health Statistics (NCHS), part of the Centers for Disease Control and Prevention (CDC).
This survey will take on average 20 minutes to complete.
Participation in this survey is completely voluntary, and you may skip any question(s) you do not want to answer and may quit the survey at any time.
The information being collected will assist NCHS and CDC in their ongoing efforts to track the health of the American public.
Your data will be kept confidential and will be used for statistical purposes only by NCHS staff and agents and will not be disclosed or released to other persons without your consent.
If you have any questions about your rights as a participant in this research study, call NCHS’ Ethics Review Board toll-free at 1-800-223-8118 and mention you are calling about Protocol #2023-04. Your call will be returned as soon as possible.
[PROGRAMMER: REDUCE TEXT SIZE SLIGHTLY; TEXT BELOW BOARDED BY THIN BLACK BOX/OUTLINE]
[CATI] READ THE FOLLOWING IF THE RESPONDENT HAS ADDITIONAL QUESTIONS ABOUT BURDEN, PRIVACY, OR CONFIDENTIALITY
CDC estimates the average public reporting burden for this collection of information as 20 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS H21-8, Atlanta, GA 30333; ATTN: PRA (0920-1408).
We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)), and Confidential Information Protection and Statistical Efficiency Act or CIPSEA (44 U.S.C. 3561-3583). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. § 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks. |
[PROGRAMMER: SECTION HEADERS ARE FOR INTERNAL USE ONLY. DO NOT PROGRAM TO APPEAR ON SCREEN.]
[CREATE “START_TIME” AND “START_DATE”; RECORD START_TIME IN HH:MM:SS; RECORD START_DATE IN MM:DD:YYYY]
HIS - SELF-REPORTED HEALTH STATUS
[CREATE “START_TIME_HIS” AND “START_DATE_HIS”; RECORD TIME IN HH:MM:SS; RECORD START_DATE IN MM:DD:YYYY]
[SHOW ALL]
[S]
HIS_GENERAL
[CAWI] Would you say your health in general is…
[CATI] Would you say your health in general is excellent, very good, good, fair, or poor?
[CAWI RESPONSE OPTIONS:]
1 Excellent
2 Very good
3 Good
4 Fair
5 Poor
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 EXCELLENT
2 VERY GOOD
3 GOOD
4 FAIR
5 POOR
[CREATE “END_TIME_HIS” AND “END_DATE_HIS”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
CHR - CHRONIC CONDITIONS
[CREATE
“START_TIME_CHR” AND “START_DATE_CHR”; RECORD
TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[S]
CHR_HYPEV
Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?
[CAWI] If you take medication to control your high blood pressure, please answer yes.
[CATI] ENTER '1' (YES) IF RESPONDENT IS TAKING MEDICATION TO CONTROL HIS/HER HIGH BLOOD PRESSURE.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[SHOW
ALL]
[S]
CHR_CHLEV
Have you ever been told by a doctor or other health professional that you had high cholesterol?
[CAWI] If you take medication to control your high cholesterol, please answer yes.
[CATI] ENTER '1' (YES) IF RESPONDENT IS TAKING MEDICATION TO CONTROL HIS/HER HIGH CHOLESTEROL.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW
ALL]
[S]
CHR_ASEV
Have you ever been told by a doctor or other health professional that you had asthma?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
CHR_CANEV
Have you ever been told by a doctor or other health professional that you had cancer or a malignancy of any kind?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[CREATE “END_CHR_TIME” AND “END_CHR_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
PREGNANCY
[CREATE
“START_PRG_TIME” AND “START_PRG_DATE”; RECORD
TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW IF SEX=2]
[S]
PRG_PRGNOW
Are you pregnant now?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Don’t know
[CATI RESPONSE OPTIONS - DO NOT READ:]
YES
NO
-9 DON’T KNOW
[SHOW IF PRG_PRGNOW = -6,-7,-9]
[S]
PRG_PRBPRG
Do you think you are probably pregnant or not?
[CAWI RESPONSE OPTIONS:]
1 Probably pregnant
Probably not pregnant
[CATI RESPONSE OPTIONS - DO NOT READ:]
Probably pregnant
0 Probably not pregnant
[SHOW IF SEX=2]
[NUMBOX]
PRG_NUMPRG
[IF PRG_PRGNOW = 1 OR PRG_PRBPRG = 1, FILL: Including this pregnancy, how; ELSE, FILL: How] many times have you been pregnant in your life?
[PROGRAMMER: DISPLAY ERROR MESSAGE IF >20: Please enter a number between 0 and 20. If the number of times is greater than 20, please enter ‘20’.]
[NUMBOX] times [RANGE=0-20]
[CREATE “END_PRG_TIME” AND “END_PRG_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
GENDER
[CREATE
“START_GEN_TIME” AND “START_GEN_DATE”; RECORD
TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[M]
GEN_CURGEN
For this next question you may select more than one answer. Do you currently describe yourself as…?
GEN_CURGENa Male?
GEN_CURGENb Female?
GEN_CURGENc Transgender?
GEN_CURGENd Nonbinary?
GEN_CURGENe Another gender?
[PROGRAMMER: USE MULTI-SELECT FORMAT WHERE SELECTED = 1, UNSELECTED = 0. ALL OPTIONS SHOULD DISPLAY AS SEPARATE VARIABLES IN DATASET.]
[SHOW IF GEN_CURGENe = 1]
[TEXTBOX]
GEN_DSCGEN
What term do you use to describe your gender?
[TEXTBOX – CHARACTER LIMIT 50]
[CREATE “END_GEN_TIME” AND “END_GEN_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
DIS
– DIFFICULTY WITH VISION/HEARING/COMMUNICATION/COGNITION
[CREATE
“START_DIS_TIME” AND “START_DIS_DATE”; RECORD
TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[S]
DIS_GLASS
Do you wear glasses or contact lenses?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
YES
0 NO
[SHOW ALL]
[S]
DIS_DIFSEE
Do you have difficulty [IF DIS_GLASS=1, FILL: seeing, even when wearing glasses or contact lenses; ELSE, FILL: seeing]? [CATI] Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?
[CAWI RESPONSE OPTIONS:]
1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do this at all
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 NO DIFFICULTY
2 SOME DIFFICULTY
3 A LOT OF DIFFICULTY
4 CANNOT DO THIS AT ALL
[SHOW ALL]
[S]
DIS_AID
Do you use a hearing aid?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
DIS_DIFHEAR
Do you have difficulty [IF DIS_AID =1, FILL: hearing, even when using your hearing aids; ELSE, FILL: hearing]? [CATI] Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?
[CAWI RESPONSE OPTIONS:]
1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do this at all
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 NO DIFFICULTY
2 SOME DIFFICULTY
3 A LOT OF DIFFICULTY
4 CANNOT DO THIS AT ALL
[SHOW ALL]
[S]
DIS_DIFWLK
Do you have difficulty walking or climbing steps? [CATI] Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?
[CAWI RESPONSE OPTIONS:]
1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do this at all
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 NO DIFFICULTY
2 SOME DIFFICULTY
3 A LOT OF DIFFICULTY
4 CANNOT DO THIS AT ALL
[SHOW ALL]
[S]
DIS_DIFCOM
Using your usual language, do you have difficulty communicating, for example, understanding or being understood? [CATI] Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?
[CAWI RESPONSE OPTIONS:]
1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do this at all
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 NO DIFFICULTY
2 SOME DIFFICULTY
3 A LOT OF DIFFICULTY
4 CANNOT DO THIS AT ALL
[SHOW ALL]
[S]
DIS_DIFREM
Do you have difficulty remembering or concentrating? [CATI] Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?]
[CAWI RESPONSE OPTIONS:]
1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do this at all
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 NO DIFFICULTY
2 SOME DIFFICULTY
3 A LOT OF DIFFICULTY
4 CANNOT DO THIS AT ALL
[SHOW ALL]
[S]
DIS_DIFCARE
Do you have difficulty with self-care, such as washing all over or dressing? [CATI] Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?]
[CAWI RESPONSE OPTIONS:]
1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do this at all
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 NO DIFFICULTY
2 SOME DIFFICULTY
3 A LOT OF DIFFICULTY
4 CANNOT DO THIS AT ALL
[CREATE “END_DIS_TIME” AND “END_DIS_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
SOC - SOCIAL/WORK LIMITATIONS
[CREATE “START_SOC_TIME” AND “START_SOC_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[S]
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone, such as visiting a doctor's office or shopping? [CATI] Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?
[CAWI RESPONSE OPTIONS:]
1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do this at all
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 NO DIFFICULTY
2 SOME DIFFICULTY
3 A LOT OF DIFFICULTY
4 CANNOT DO THIS AT ALL
[SHOW
ALL]
[S]
Because of a physical, mental, or emotional condition, do you have difficulty participating in social activities, such as visiting friends, attending clubs and meetings, or going to parties? [CATI] Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?
[CAWI RESPONSE OPTIONS:]
1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do this at all
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 NO DIFFICULTY
2 SOME DIFFICULTY
3 A LOT OF DIFFICULTY
4 CANNOT DO THIS AT ALL
[SHOW ALL]
[S]
SOC_SCWRKLIM
Are you limited in the kind or amount of work you can do because of a physical, mental, or emotional problem?
Work includes paid work, volunteer work, school work, and homework.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[CREATE “DIS_COUNT” AND SUM NUMBER OF VARIABLES FOR WHICH RESPONDENT ANSWERS 3 OR 4 AMONG: DIS_DIFWLK, DIS_DIFCOM, DIS_DIFREM, DIS_DIFCARE, SOC_ERRANDS]
[CREATE “END_SOC_TIME” AND “END_SOC_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
AGE OF DISABILITY ONSET
[CREATE “START_ADO_TIME” AND “START_ADO_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW IF DIS_DIFWLK=3,4 OR DIS_DIFCOM=3,4 OR DIS_DIFREM = 3,4 OR DIS_DIFCARE = 3,4 OR SOC_ERRANDS = 3,4]
[S]
ADO_START
You said that you have difficulty with [IF DIS_ DIFWLK=3,4, FILL: walking or climbing steps,] [IF DIS_DIFCOM=3,4, FILL: communicating,] [IF DIS_DIFREM=3,4, FILL: remembering or concentrating,] [IF DIS_DIFCARE=3,4, FILL: self-care,] [IF SOC_ERRANDS=3,4, FILL: doing errands alone]. Did [IF DIS_COUNT=1, FILL “this difficulty”; ELSE, FILL “any of these difficulties”] begin before age 22?
[PROGRAMMER: IF THERE ARE TWO DISABILITIES LISTED, CONNECT THEM WITH “and.” IF THERE ARE THREE OR MORE DISABILITIES LISTED, CONNECT THE LIST WITH COMMAS AND INCLUDE “and” BEFORE FINAL DISABILITY.]
[CREATE “END_ADO_TIME” AND “END_ADO_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
SOCIAL CONNECTEDNESS
[CREATE “START_CON_TIME” AND “START_CON_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[S]
CON_TELWK
In a typical week, how often do you talk on the telephone with family, friends, or neighbors? [CATI] Would you say less than once a week, 1 or 2 times a week, 3 or 4 times a week, or 5 or more times a week?
[CAWI
RESPONSE OPTIONS:]
1 Less than once a week
2 1 or 2 times a week
3 3 or 4 times a week
4 5 or more times a week
[CATI RESPONSE OPTIONS:]
1 Less than once a week
2 1 or 2 times a week
3 3 or 4 times a week
4 5 or more times a week
[SHOW ALL]
[S]
CON_GETTOG
How often do you get together with friends or relatives? [CATI] Would you say less than once a week, 1 or 2 times a week, 3 or 4 times a week, or 5 or more times a week?
[CAWI RESPONSE OPTIONS:]
1 Less than once a week
2 1 or 2 times a week
3 3 or 4 times a week
4 5 or more times a week
[CATI RESPONSE OPTIONS:]
1 Less than once a week
2 1 or 2 times a week
3 3 or 4 times a week
4 5 or more times a week
[SHOW ALL]
[S]
CON_RELSERV
How often do you attend church or religious services? [CATI] Would you say never or less than once a year, 1 to 3 times per year, 4 to 11 times per year, or 12 or more times per year?
[CAWI RESPONSE OPTIONS:]
1 Never or less than once a year
2 1 to 3 times per year
3 4 to 11 times per year
4 12 or more times per year
[CATI RESPONSE OPTIONS:]
1 Never or less than once a year
2 1 to 3 times per year
3 4 to 11 times per year
4 12 or more times per year
[SHOW ALL]
[S]
CON_CLUBORG
How often do you attend meetings of any clubs or organizations you belong to? [CATI] Would you say less than once a week, 1 or 2 times a week, 3 or 4 times a week, or 5 or more times a week?
[CAWI RESPONSE OPTIONS:]
1 Less than once a week
2 1 or 2 times a week
3 3 or 4 times a week
4 5 or more times a week
[CATI RESPONSE OPTIONS:]
1 Less than once a week
2 1 or 2 times a week
3 3 or 4 times a week
4 5 or more times a week
[CREATE “END_CON_TIME” AND “END_CON_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
EMP – HEALTH INSURANCE
[CREATE “START_EMP_TIME” AND “START_EMP_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[DISP]
EMP_INTRO
These next questions are about your health care and insurance coverage.
[SHOW ALL]
[GRID]
EMP_INSUR
Are you covered by any of the following types of health insurance or health coverage plans?
[PROGRAMMER: DISPLAY EMP_INSURA-EMP_INSURH IN GRID FORMAT WITH Y/N RESPONSE COLUMNS, WHERE YES = 1 AND NO = 0]
EMP_INSA
Insurance through a current or former employer or union of
your own or another family member
EMP_INSB Insurance purchased directly from an insurance company by you or another family member
EMP_INSC Medicare, for people 65 and older or people with certain disabilities
EMP_INSD Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability
EMP_INSE TRICARE or other military health care
EMP_INSF VA [CAWI: (enrolled for VA health care); CATI: That is, enrolled for VA health care]
EMP_INSG Indian Health Service
EMP_INSH Any other type of health insurance or health coverage plan (please specify) [TEXTBOX]
[PROGRAMMER: IF EMP_INSH =1 AND TEXTBOX LEFT BLANK, PROMPT: You mentioned you had another type of health insurance or health coverage plan. Please enter the name in the text box.]
[CREATE “END_EMP_TIME” AND “END_EMP_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
ACC – ACCESS/UTILIZATION
[CREATE “START_ACC_TIME” AND “START_ACC_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[S]
ACC_HTHLAST
About how long has it been since you last saw a doctor or other health professional about your health?
Include doctors seen while a patient in a hospital. Do not include dental care.
[CAWI RESPONSE OPTIONS:]
1 Less than 12 months ago
2 More than 1 year but less than 2 years ago
3 More than 2 years but less than 3 years ago
4 More than 3 years but less than 5 years ago
5 More than 5 years but less than 10 years ago
6 10 years ago or more
0 Never
[CATI RESPONSE OPTIONS – READ IF NECESSARY:]
1 Within the past year (ANY TIME LESS THAN 12 MONTHS AGO)
2 Within the last 2 years (MORE THAN 1 YEAR BUT LESS THAN 2 YEARS AGO)
3 Within the last 3 years (MORE THAN 2 YEARS BUT LESS THAN 3 YEARS AGO)
4 Within the last 5 years (MORE THAN 3 YEARS BUT LESS THAN 5 YEARS AGO)
5 Within the last 10 years (MORE THAN 5 YEARS BUT LESS THAN 10 YEARS AGO)
6 10 years ago or more
0 Never
[SHOW ALL]
[S]
ACC_HTHUSUAL
Is there a place that you usually go to if you are sick and need health care?
[CAWI RESPONSE OPTIONS:]
Yes, there is a single place
3 Yes, there is more than one place
2 No, there is no place
[CATI RESPONSE OPTIONS – DO NOT READ:]
1 YES
2 THERE IS NO PLACE
3 THERE IS MORE THAN ONE PLACE
[SHOW
IF ACC_HTHUSUAL = 1, 3]
[S]
ACC_HTHTYPE
What kind of place [IF ACC_HTHUSUAL=1, FILL: is it; ELSE, FILL: do you go to most often]? [CATI] Is it a doctor’s office or health center; an urgent care center, a clinic in a drug store or grocery store; a hospital emergency room; a VA medical center or VA outpatient clinic; or some other place?
A doctor’s office or health center is a place where you see the same doctor or the same group of doctors every visit, where you usually need to make an appointment ahead of time, and where your medical records are on file.
Urgent care centers and clinics in a drug store or grocery store are places where you do not need to make an appointment ahead of time, and usually do not see the same health care provider at each visit.
[CAWI RESPONSE OPTIONS:]
A doctor’s office or health center
Urgent care center or clinic in a drug store or grocery store
Hospital emergency room
A VA medical center or VA outpatient clinic
Some other place
I do not go to one place most often
[CATI RESPONSE OPTIONS – DO NOT READ:]
A DOCTOR’S OFFICE OR HEALTH CENTER
URGENT CARE CENTER OR CLINIC IN A DRUG STORE OR GROCERY STORE
HOSPITAL EMERGENCY ROOM
A VA MEDICAL CENTER OR VA OUTPATIENT CLINIC
SOME OTHER PLACE
YOU DO NOT GO TO ONE PLACE MOST OFTEN
[SHOW ALL]
[S]
ACC_HOSP12M
During the past 12 months, have you been hospitalized overnight?
Do not include an overnight stay in the emergency room.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[CREATE “END_ACC_TIME” AND “END_ACC_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
MTL - MENTAL HEALTH (ANXIETY AND DEPRESSION)
[CREATE “START_MTL_TIME” AND “START_MTL_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[S]
MTL_ANXIETY
How often do you feel worried, nervous or anxious? [CATI] Would you say daily, weekly, monthly, a few times a year, or never?
If you take medication for these feelings, please answer based on your usual use of medication.
[CAWI RESPONSE OPTIONS:]
Daily
Weekly
Monthly
A few times a year
Never
[CATI RESPONSE OPTIONS – DO NOT READ:]
DAILY
WEEKLY
MONTHLY
A FEW TIMES A YEAR
NEVER
[SHOW ALL]
[S]
MTL_ANXMEDS
Do you take prescription medication for these feelings?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY MTL_ANXIETY– MTL_ANXMEDS ON SAME PAGE]
[SHOW IF MTL_ANXIETY = 1, 2, 3, 4,-6,-7,-9 OR MTL_ANXMEDS = 1,-6,-7,-9 ]
[S]
MTL_ANXLVL
Thinking about the last time you felt worried, nervous or anxious, how would you describe the level of these feelings? [CATI] Would you say a little, a lot, or somewhere in between?
[CAWI RESPONSE OPTIONS:]
A little
A lot
Somewhere in between a little and a lot
[CATI RESPONSE OPTIONS - DO NOT READ:]
A LITTLE
A LOT
SOMEWHERE IN BETWEEN A LITTLE AND A LOT
[SHOW ALL]
[S]
MTL_DEPRESS
How often do you feel depressed? [CATI] Would you say daily, weekly, monthly, a few times a year, or never?
If you take medication for these feelings, please answer based on your usual use of medication.
[CAWI RESPONSE OPTIONS:]
Daily
Weekly
Monthly
A few times a year
Never
[CATI RESPONSE OPTIONS - DO NOT READ:]
DAILY
WEEKLY
MONTHLY
A FEW TIMES A YEAR
NEVER
[SHOW ALL]
[S]
MTL_DEPMEDS
Do you take prescription medication for depression?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY MTL_DEPRESS – MTL_DEPMEDS ON SAME PAGE]
[SHOW IF MTL_DEPRESS = 1,2,3,4,-6,-7,-9 OR MTL_DEPMEDS =1,-6,-7,-9]
[S]
MTL_DEPLVL
Thinking about the last time you felt depressed, how depressed did you feel? [CATI] Would you say a little, a lot, or somewhere in between?
[CAWI RESPONSE OPTIONS:]
A little
A lot
Somewhere in between a little and a lot
[CATI RESPONSE OPTIONS - DO NOT READ:]
A LITTLE
A LOT
SOMEWHERE IN BETWEEN A LITTLE AND A LOT
[CREATE “END_MTL_TIME” AND “END_MTL_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
MTL – HEALTH CARE UTILIZATION – MENTAL HEALTH VISITS
[CREATE “START_MTH_TIME” AND “START_MTH_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW IF MTL_ANXMEDS = 0,-6,-7,-9 AND MTL_DEPMEDS = 0,-6,-7,-9]
[S]
MTL_MHRXA
During the past 12 months, did you take prescription medication to help you with any other emotions or with your concentration, behavior, or mental health?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW
ALL]
[S]
MTL_MHTHRPY
During the past 12 months, did you receive counseling or therapy from a mental health professional, such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW
IF MTL_MHTHRPY =1]
[S]
MTL_MHTPYNOW
Are you currently receiving counseling or therapy from a mental health professional?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[CREATE “END_MTH_TIME” AND “END_MTH_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
HCA – HEALTH CARE ACCESS
[CREATE “START_HCA_TIME” AND “START_HCA_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[S]
HCA_MHTHDLY
During the past 12 months, have you delayed getting counseling or therapy from a mental health professional because of the cost?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
HCA_MHTND
During the past 12 months, was there any time when you needed counseling or therapy from a mental health professional but did not get it because of the cost?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[CREATE “END_HCA_TIME” AND “END_HCA_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
CIG - HEALTH BEHAVIORS (CIGARETTE SMOKING)
[CREATE “START_CIG_TIME” AND “START_CIG_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[S]
CIG_SMKEV
Have you smoked at least 100 cigarettes in your entire life?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF CIG_SMKEV=1]
[S]
CIG_SMKNOW
Do you now smoke cigarettes every day, some days, or not at all?
[CAWI RESPONSE OPTIONS:]
Every day
Some days
Not at all
[CATI RESPONSE OPTIONS - DO NOT READ:]
EVERY DAY
SOME DAYS
NOT AT ALL
[CREATE “END_CIG_TIME” AND “END_CIG_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
CIV - CIVIC ENGAGEMENT
[CREATE “START_CIV_TIME” AND “START_CIV_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[DISP]
CIV_INTRO
The next questions are about activities you may have done in your community.
[SHOW ALL]
[S]
CIV_VOL12M
During the past 12 months, did you spend any time volunteering for any organization or association?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
SHOW IF CIV_VOL12M=0]
[S]
CIV_VOLOTH
Some people don’t think of activities they do infrequently or for children’s schools or youth organizations as volunteer activities. During the past 12 months, have you done any of these types of activities?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW
ALL]
[S]
CIV_MEET
During the past 12 months, did you attend a public meeting, such as a zoning or school board meeting, that discussed a local issue?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW
ALL]
[S]
CIV_VOTELOCL
Did you vote in the last local elections, such as for mayor, councilmembers, or school board?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI
RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[CREATE “END_CIV_TIME” AND “END_CIV_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
LAN - LANGUAGE ITEMS
[CREATE “START_LAN_TIME” AND “START_LAN_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW IF QUEX_LANGUAGE=1; AUTO PUNCH 1 (YES) IF QUEX_LANGUAGE=2]
[S]
LAN_OTHERLAN
Do you speak a language other than English at home?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 Yes
0 No
[SHOW
IF LAN_OTHERLAN=1]
[S]
LAN_MEDIA
When you watch television, read news online or in print, or listen to the radio, which language do you use most often?
[CAWI RESPONSE OPTIONS:]
English
Spanish
Another language
[CATI RESPONSE OPTIONS – DO NOT READ:]
ENGLISH
SPANISH
ANOTHER LANGUAGE
[SHOW
IF LAN_OTHERLAN=1]
[S]
LAN_DOCTOR
When you see a doctor or other health care professional, which language do you use most often?
[CAWI
RESPONSE OPTIONS:]
English
Spanish
Another language
[CATI RESPONSE OPTIONS – DO NOT READ:]
ENGLISH
SPANISH
ANOTHER LANGUAGE
[SHOW
IF LAN_OTHERLAN=1]
[S]
LAN_SOCIAL
When you participate in social activities, such as visiting friends, attending clubs and meetings, or going to parties, which language do you use most often?
[CAWI RESPONSE OPTIONS:]
English
Spanish
Another language
[CATI RESPONSE OPTIONS – DO NOT READ:]
ENGLISH
SPANISH
ANOTHER LANGUAGE
[CREATE “END_LAN_TIME” AND “END_LAN_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
MAR – MARITAL STATUS
[CREATE “START_MAR_TIME” AND “START_MAR_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[DISP]
MAR_DISP
The next questions are about marriage and cohabitation.
[SHOW ALL]
[S]
MAR_MARITAL
[CAWI] Are you now: [CATI] Are you now married, living with a partner together as an unmarried couple, or neither?
[CATI] INTERVIEWER - IF RESPONDENT ANSWERS BOTH MARRIED AND LIVING WITH A DIFFERENT PARTNER TOGETHER AS AN UNMARRIED COUPLE, ENTER LIVING WITH A PARTNER
[CAWI RESPONSE OPTIONS:]
Married
Living with a partner together as an unmarried couple
Neither
[CATI RESPONSE OPTIONS – DO NOT READ:]
MARRIED
LIVING WITH A PARTNER TOGETHER AS AN UNMARRIED COUPLE
NEITHER
[SHOW
IF MAR_MARITAL = 2, 3, -6,-7,-9]
[S]
MAR_EVMARRY
Have you ever been married?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW
IF MAR_MARITAL = 2 AND MAR_EVMARRY=1]
[S]
MAR_LEGAL
What is your current legal marital status? [CATI: Are you married, widowed, divorced, or separated?]
[CAWI RESPONSE OPTIONS:]
Married
Widowed
Divorced
Separated
[CATI RESPONSE OPTIONS – DO NOT READ:]
MARRIED
WIDOWED
DIVORCED
SEPARATED
[SHOW
IF MAR_MARTIAL = 3 AND MAR_EVMARRY=1]
[S]
MAR_WIDIVSEP
[CAWI] Are you… [CATI] Are you widowed, divorced, or separated?
[CAWI RESPONSE OPTIONS:]
Widowed
Divorced
Separated
[CATI RESPONSE OPTIONS – DO NOT READ:]
WIDOWED
DIVORCED
SEPARATED
[CREATE “END_MAR_TIME” AND “END_MAR_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
TSV – TECHNOLOGY FACILIATED SEXUAL VIOLENCE
[CREATE “START_TSV_TIME” AND “START_TSV_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[DISP]
TSV_DISP
[CATI, FILL: I am; CAWI, FILL: We are] now going to ask you some questions about sensitive topics.
[CAWI] We suggest that you be in a private setting for the remainder of the survey. Remember, you don’t have to answer any question that you don’t want to. If, at any time, you do not feel physically or emotionally safe, you can quit the survey by closing the browser. You can come back to the survey whenever you want. If at any point the questions are making you upset and you would like to speak with a trained professional, please refer to the resources given <a> here</a>.
[CATI] I suggest that you be in a private setting for the remainder of the survey. Remember, you don’t have to answer any question that you don’t want to. If, at any time, you do not feel physically or emotionally safe, you can let me know you’d like to stop the survey. You can call back to complete the survey whenever you want or set up a time for us to call you back. If at any point the questions are making you upset and you would like to speak with a trained professional, please let me know and I can share some <a> resources </a> with you.
[PROGRAMMER: DISPLAY IN FOOTER/BOTTOM OF EACH SCREEN IN INTIMATE PARTNER VIOLENCE SECTIONS:]
Need help? Click <a> here</a>
for resources.
[IF CATI:
INTERVIEWER - USE THIS LINK TO ACCESS RESOURCES IF RESPONDENT
NEEDS HELP/SUPPORT DURING INTERVIEW]
[PROGRAMMER: HYPERLINKS ABOVE SHOULD OPEN IN NEW WINDOW AND DISPLAY THE FOLLOWING:
Thank you for participating in this survey. We realize that some of the topics covered are quite personal and can be difficult to think and talk about. We appreciate your willingness to answer these questions and want you to know that we recognize the important contribution you have made. Sometimes when people have answered questions like these, they realize that they are interested in following up on some of the issues that they have been asked about with someone who is professionally trained to deal with these kinds of issues.
Below are some toll-free numbers of resources that you can use now or in the future if you want to speak further with someone.
You can reach the National Domestic Violence Hotline at 1-800-799-SAFE (7233).
You can reach the National Sexual Assault Hotline at 1-800-656-HOPE (4673).
You can reach the National Child Abuse Hotline at 1-800-4-A-Child (422-4453).
You can reach the National Suicide Prevention Lifeline at 988.
[SHOW ALL]
[DISP]
TSV_INTRO
The next questions are about unwanted sexual situations that might have happened to you while using the internet, social media, text messages, or emails.
[SHOW ALL]
[S]
TSV_EXPEV
In your lifetime, has anyone ever sent you an unwanted sexually explicit message or image through the internet, social media, email, or text message without your consent?
Please do not include spam messages, phishing attempts, or messages that you think are from a Bot, that is, a computer program that imitates a human.
Examples of social media include Facebook, Twitter, Instagram, TikTok, and Snapchat.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF TSV_EXPEV = 1]
[S]
TSV_EXP12M
You said someone has sent you an unwanted sexually explicit message or image through the internet, social media, email, or text message without your consent. Did this happen to you in the past 12 months, that is, since [FILL DATE]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: FILL DATE IN FORMAT “Month YYYY” (I.E., MONTH WRITTEN OUT). MONTH SHOULD BE MONTH AT TIME OF RESPONSE AND YEAR SHOULD BE YEAR AT TIME OF RESPONSE MINUS ONE.]
[SHOW IF GROUP = 1]
[S]
TSV_POSTEV
To your knowledge, has anyone ever emailed, texted, or electronically posted a revealing or sexual photo or video of you without your consent?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF TSV_POSTEV = 1]
[S]
TSV_POST12M
You said that someone emailed, texted, or electronically posted a revealing or sexual photo or video of you without your consent. Did this happen to you in the past 12 months, that is, since [FILL DATE]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: FILL DATE IN FORMAT “Month YYYY” (I.E., MONTH WRITTEN OUT). MONTH SHOULD BE MONTH AT TIME OF RESPONSE AND YEAR SHOULD BE YEAR AT TIME OF RESPONSE MINUS ONE.]
[CREATE “END_TSV_TIME” AND “END_TSV_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
EMERGING COERCIVE CONTROL
[CREATE “START_ECC_TIME” AND “START_ECC_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[DISP]
ECC_INTRO
The next questions ask generally about experiences you may have had in your life with your current or ex-romantic or sexual partners. Examples of romantic or sexual partners include: spouses, partners, boyfriends, girlfriends, people you have dated, or people you were seeing romantically.
Do not include first dates or one-time hook-up situations.
[SHOW ALL]
[GRID]
ECC_PARTEV
In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you?
[PROGRAMMER: DISPLAY ECC_PARTEVa-ECC_PARTEVf IN GRID FORMAT WITH Y/N RESPONSE COLUMNS, WHERE YES = 1 AND NO = 0. RANDOMIZE ORDER OF ITEMS IN GRID.]
ECC_PARTEVa Your partner checked your phone to see who you were talking to or texting without your permission.
ECC_PARTEVb Your partner sent threatening or harassing messages to you via text or social media.
ECC_PARTEVc Your partner used your social media account to view your activity without your permission.
ECC_PARTEVd Your partner used GPS technology to track your location without your permission.
ECC_PARTEVe Your partner tried to make you talk about sex online when you did not want to.
ECC_PAREVf Your partner intentionally ignored your phone calls or text messages in order to hurt your feelings.
[SHOW ALL]
[GRID]
ECC_FINEV
In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you?
[PROGRAMMER: DISPLAY ECC_FINEVa-ECC_FINEVg IN GRID FORMAT WITH Y/N RESPONSE COLUMNS, WHERE YES = 1 AND NO = 0. RANDOMIZE ORDER OF ITEMS IN GRID.]
ECC_FINEVa Decided how you could spend money rather than letting you spend it how you saw fit.
ECC_FINEVb Kept you from having a job or going to work.
ECC_FINEVc Took out a loan or bought something on credit in your name without your permission.
ECC_FINEVd Put bills in your name, leaving you to pay them.
ECC_FINEVe Forced or pressured you to give him or her your savings or other assets.
ECC_FINEVf Caused concerns or worries about your financial future which affected your decisions about staying or leaving your partner.
ECC_FINEVg Negatively affected your credit card debt.
[CREATE “END_ECC_TIME” AND “END_ECC_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
SPLIT 1 – PSYCHOLOGICAL AGGRESSION
[CREATE “START_PAA_TIME” AND “START_PAA_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW IF GROUP = 1]
[GRID]
PAA_PARTEV
In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?
[PROGRAMMER: DISPLAY PAA_PARTEVa-h IN GRID FORMAT WITH Y/N RESPONSE COLUMNS, WHERE YES = 1 AND NO = 0. RANDOMIZE ORDER OF ITEMS IN GRID.]
PAA_PARTEVa Kept you from having your own money
PAA_PARTEVb Tried to keep you from seeing or talking to your family or friends
PAA_PARTEVc Kept track of you by demanding to know where you were and what you were doing
PAA_PARTEVd Made threats to physically harm you
PAA_PARTEVe Threatened to hurt themselves or commit suicide because they were upset with you
PAA_PARTEVf Made decisions that should have been yours to make
PAA_PARTEVg Destroyed something that was important to you
PAA_PARTEVh Insulted or humiliated you in front of others
[SHOW IF ANY OF PAA_PARTEVa-h = 1]
[S]
PAA_PRT12M
You told us that a current or ex-romantic or sexual partner did [IF EXACTLY ONE OF PAA_PARTEVa-h = 1, FILL: this; ELSE, FILL: these things] to you:
[IF PAA_PARTEVa = 1, DISPLAY: Kept you from having your own money]
[IF PAA_PARTEVb = 1, DISPLAY: Tried to keep you from seeing or talking to your family or friends]
[IF PAA_PARTEVc = 1, DISPLAY: Kept track of you by demanding to know where you were and what you were doing]
[IF PAA_PARTEVd = 1, DISPLAY: Made threats to physically harm you]
[IF PAA_PARTEVe = 1, DISPLAY: Threatened to hurt themselves or commit suicide because they were upset with you]
[IF PAA_PARTEVf = 1, DISPLAY: Made decisions that should have been yours to make]
[IF PAA_PARTEVg = 1, DISPLAY: Destroyed something that was important to you]
[IF PAA_PARTEVh = 1, DISPLAY: Insulted or humiliated you in front of others]
Did a current or ex-romantic or sexual partner do [IF EXACTLY ONE OF PAA_PARTEVa-h = 1, FILL: this; ELSE, FILL: any of these things] in the past 12 months, that is, since [FILL DATE]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY ITEMS RESPONDENT ENDORSED IN BULLETED LIST. FILL DATE IN FORMAT “Month YYYY” (I.E., MONTH WRITTEN OUT). MONTH SHOULD BE MONTH AT TIME OF RESPONSE AND YEAR SHOULD BE YEAR AT TIME OF RESPONSE MINUS ONE.]
[CREATE “END_PAA_TIME” AND “END_PAA_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
SPLIT 1 – SEXUAL VIOLENCE
[CREATE “START_SVA_TIME” AND “START_SVA_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW IF GROUP = 1]
[DISP]
SVA_INTRO
This next section is about sexual contact that you did not consent to and that you did not want to happen, as well as times in your life when someone ever attempted to have sex or sexual contact with you by using physical force or threats of harm but sex did not happen.
Some people are threatened with harm or physically forced to have sex or sexual contact when they don’t want to. Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no. To be clear, the next questions are asking only about times in your life when sex was unwanted and you did not give consent.
Sometimes unwanted sex or sexual contact happens when a person is unable to consent to it or stop it from happening because they are too drunk, high, drugged, or passed out from alcohol, drugs, or medications. This can include times when they voluntarily consumed alcohol or drugs or times when they were given alcohol or drugs without their knowledge or consent.
These questions ask about unwanted sexual contact that might have occurred through physical force or when you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs.
You might or might not have ever been in this type of situation. Please remember that even if someone uses alcohol or drugs, what happens to them is not their fault. These questions use detailed and explicit language so that everyone is clear about what the questions are asking.
[SHOW IF GROUP = 1]
[S]
SVA_SEX
In this section you will be asked questions using specific language about victimization experiences
related to one’s sexual anatomy. In the “male” set of questions, it is assumed that you have a penis. In the “female” set of questions, it is assumed that you have a vagina. We would like to give you the option to decide which set of questions best represents your experience. Would you prefer to answer…
[PROGRAMMER: IF RESPONDENTS ATTEMPT TO SUBMIT WITHOUT A RESPONSE, PLEASE DISPLAY SOFT PROMPT: “We know that this information is personal, but remember your answer will be kept confidential. Please select a response before continuing.” IF RESPONDENT SUBMITS AGAIN WITHOUT RESPONSE, THIS ITEM SHOULD BE AUTO-KEYED BASED ON PROFILE SEX/GENDER VARIABLE.]
1 The female set of questions?
0 The male set of questions?
[SHOW IF GROUP = 1 AND SVA_SEX = 1]
[S]
SVA_ORLEV
In your lifetime, has anyone ever performed oral sex on you when you did not consent to it, and it was not wanted, by using physical force or threats of physical harm?
By oral sex, we mean that someone put their mouth on your vagina.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 1]
[S]
SVA_PENEVF
In your lifetime, has anyone ever penetrated you by putting their penis in your vagina, mouth, or anus when you did not consent to it, and it was not wanted, by using physical force or threats of physical harm?
Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 1]
[S]
SVA_FINGEVF
In your lifetime, has anyone ever penetrated you by putting their fingers or an object in your vagina or anus when you did not consent to it, and it was not wanted, by using physical force or threats of physical harm?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 1]
[S]
In your lifetime, has anyone ever performed oral sex on you when it was not wanted, and you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
By oral sex, we mean that someone put their mouth on your vagina.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 1]
[S]
SVA_PENHIGHF
In your lifetime, has anyone ever penetrated you by putting their penis in your vagina, mouth, or anus when it was not wanted, and you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 1]
[S]
SVA_FNGHIGHF
In your lifetime, has anyone ever penetrated you by putting their fingers or an object in your vagina or anus when it was not wanted, and you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 1]
[S]
SVA_FORCEEV
In your lifetime, has anyone ever used physical force or threats of physical harm to try to put their penis in your vagina, mouth, or anus, but it did not happen?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF ANY OF SVA_ORLEV-SVA_FORCEEV = 1]
[S]
SVA_ANY12MF
You told us someone did [IF EXACTLY ONE OF SVA_ORLEV-SVA_FORCEEV = 1, FILL: this; ELSE, FILL: these things] to you when you did not consent to it, and it was not wanted:
[IF SVA_ORLEV OR SVA_ORLHIGH = 1, DISPLAY: Performed oral sex on you]
[IF SVA_PENEVF OR SVA_PENHIGHF = 1, DISPLAY: Penetrated you by putting their penis in your vagina, mouth, or anus]
[IF SVA_FINGEVF OR SVA_FNGHIGHF = 1, DISPLAY: Penetrated you by putting their fingers or an object in your vagina or anus]
[IF SVA_FORCEEV = 1, DISPLAY: Tried to put their penis in your vagina, mouth, or anus, but it did not happen]
Did [IF EXACTLY ONE OF SVA_ORLEV – SVA_FORCEEV = 1, FILL: this; ELSE, FILL: any of these things] happen in the past 12 months, that is, since [FILL DATE]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY ITEMS THAT RESPONDENT ENDORSED AS A BULLETED LIST. FILL DATE IN FORMAT “Month YYYY” (I.E., MONTH WRITTEN OUT). MONTH SHOULD BE MONTH AT TIME OF RESPONSE AND YEAR SHOULD BE YEAR AT TIME OF RESPONSE MINUS ONE.]
[SHOW IF ANY OF SVA_ORLEV-SVA_FORCEEV = 1]
[S]
SVA_PREG
You told us someone did [IF EXACTLY ONE OF SVA_ORLEV-SVA_FORCEEV = 1, FILL: this ELSE, FILL: these things] to you when you did not consent to it, and it was not wanted:
[IF SVA_ORLEV OR SVA_ORLHIGH = 1, DISPLAY: Performed oral sex on you]
[IF SVA_PENEVF OR SVA_PENHIGHF = 1, DISPLAY: Penetrated you by putting their penis in your vagina, mouth, or anus]
[IF SVA_FINGEVF OR SVA_FNGHIGHF = 1, DISPLAY: Penetrated you by putting their fingers or an object in your vagina or anus]
[IF SVA_FORCEEV= 1, DISPLAY: Tried to put their penis in your vagina, mouth, or anus, but it did not happen]
Were you pregnant at the time of [IF EXACTLY ONE OF SVA_ORLEV – SVA_FORCEEV = 1, FILL: this incident; ELSE, FILL: any of these incidents]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[PROGRAMMER: DISPLAY ITEMS THAT RESPONDENT ENDORSED AS A BULLETED LIST.]
[SHOW IF GROUP = 1 AND SVA_SEX = 0]
[S]
SVA_VGOREV
In your lifetime, has anyone ever had vaginal or oral sex with you when you did not consent to it, and it was not wanted, by using physical force or threats of physical harm?
By vaginal or oral sex, we mean that someone made you put your penis in their vagina or mouth or they put their mouth on your penis. Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 0]
[S]
SVA_PENEVM
In your lifetime, has anyone ever penetrated you by putting their penis in your mouth or anus when you did not consent to it, and it was not wanted, by using physical force or threats of physical harm?
Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 0]
[S]
SVA_FINGEVM
In your lifetime, has anyone ever penetrated you by putting their fingers or an object in your anus when you did not consent to it, and it was not wanted, by using physical force or threats of physical harm?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 0]
[S]
SVA_VGORHIGH
In your lifetime, has anyone ever had vaginal or oral sex with you when it was not wanted, and you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
By vaginal or oral sex, we mean that someone made you put your penis in their vagina or mouth or someone put their mouth on your penis.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 0]
[S]
SVA_PENHIGHM
In your lifetime, has anyone ever penetrated you by putting their penis in your mouth or anus when it was not wanted, and you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 0]
[S]
SVA_FNGHIGHM
In your lifetime, has anyone ever penetrated you by putting their fingers or an object in your anus when it was not wanted, and you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 0]
[S]
SVA_ORLPHYS
In your lifetime, has anyone ever used physical force or threats of physical harm to try to put their mouth on your penis, or try to make you put your penis in their mouth, but it did not happen?
Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 0]
[S]
In your lifetime, has anyone ever used physical force or threats of physical harm to try to make you put your penis in their vagina, but it did not happen?
Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 1 AND SVA_SEX = 0]
[S]
SVA_PENPHYS
In your lifetime, has anyone ever used physical force or threats of physical harm to try to put their penis in your mouth or anus, but it did not happen?
Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF ANY OF SVA_VGOREV, SVA_VGORHIGH, SVA_ORLPHYS, SVA_VAGPHYS = 1]
[S]
SVA_ANY12MM
You told us someone did [IF EXACTLY ONE OF SVA_VGOREV, SVA_VGORHIGH, SVA_ORLPHYS, SVA_VAGPHYS = 1, FILL: this; ELSE, FILL: these things] to you when you did not consent to it, and it was not wanted:
[IF SVA_VGOREV OR SVA_VGORHIGH = 1, DISPLAY: Made you put your penis in their vagina or mouth (or they put their mouth on your penis)]
[IF SVA_ORLPHYS = 1, DISPLAY: Tried to put their mouth on your penis, or tried to make you put your penis in their mouth, but it did not happen]
[IF SVA_VAGPHYS = 1, DISPLAY: Tried to make you put your penis in their vagina, but it did not happen]
Did [IF EXACTLY ONE OF SVA_VGOREV, SVA_VGORHIGH, SVA_ORLPHYS, SVA_VAGPHYS = 1, FILL: this; ELSE, FILL: any of these things] happen in the past 12 months, that is, since [FILL DATE]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[PROGRAMMER: DISPLAY ITEMS THAT RESPONDENT ENDORSED AS A BULLETED LIST. FILL DATE IN FORMAT “Month YYYY” (I.E., MONTH WRITTEN OUT). MONTH SHOULD BE MONTH AT TIME OF RESPONSE AND YEAR SHOULD BE YEAR AT TIME OF RESPONSE MINUS ONE.]
[SHOW IF ANY OF SVA_PENEVM, SVA_FINGEVM, SVA_PENHIGHM, SVA_FNGHIGHM, SVA_PENPHYS = 1]
[S]
SVA_PEN12M
You told us someone did [IF EXACTLY ONE OF SVA_PENEVM, SVA_FINGEVM, SVA_PENHIGHM, SVA_FNGHIGHM, SVA_PENPHYS = 1, FILL: this; ELSE, FILL: these things] to you when you did not consent to it, and it was not wanted:
[IF SVA_PENEVM OR SVA_PENHIGHM = 1, DISPLAY: Penetrated you by putting their penis in your mouth or anus]
[IF SVA_FINGEVM OR SVA_FNGHIGHM = 1, DISPLAY: Penetrated you by putting their fingers or an object in your anus]
[IF SVA_PENPHYS = 1, DISPLAY: Tried to put their penis in your mouth or anus, but it did not happen]
Did [IF EXACTLY ONE OF SVA_PENEVM, SVA_FINGEVM, SVA_PENHIGHM, SVA_FNGHIGHM, SVA_PENPHYS = 1, FILL: this; ELSE, FILL: any of these things] happen in the past 12 months, that is, since [FILL DATE]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY ITEMS THAT RESPONDENT ENDORSED AS A BULLETED LIST. FILL DATE IN FORMAT “Month YYYY” (I.E., MONTH WRITTEN OUT). MONTH SHOULD BE MONTH AT TIME OF RESPONSE AND YEAR SHOULD BE YEAR AT TIME OF RESPONSE MINUS ONE.]
[CREATE “END_SVA_TIME” AND “END_SVA_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
SPLIT 2 – PSYCHOLOGICAL AGGRESSION
[CREATE “START_PAB_TIME”” AND “START_PAB_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW IF GROUP = 2]
[S]
PAB_HUMILEV
In your lifetime, has a current or ex-romantic or sexual partner ever insulted or humiliated you in front of others?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND PAB_HUMILEV=1]
[S]
PAB_HUMIL12M
Did a current or ex-romantic or sexual partner do this in the past 12 months, that is, since [FILL DATE]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: FILL DATE IN FORMAT “Month YYYY” (I.E., MONTH WRITTEN OUT). MONTH SHOULD BE MONTH AT TIME OF RESPONSE AND YEAR SHOULD BE YEAR AT TIME OF RESPONSE MINUS ONE.]
[SHOW IF GROUP = 2]
[S]
PAB_PSYCHEV
In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?
Kept you from having your own money
Try to keep you from seeing or talking to your family or friends
Keep track of you by demanding to know where you were and what you were doing
Make threats to physically harm you
Threaten to hurt themselves or commit suicide because they were upset with you
Make decisions that should have been yours to make
Destroy something on purpose that was important to you
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: RANDOMIZE ORDER OF ITEMS IN LIST.]
[SHOW IF PAB_PSYCHEV = 1]
[S]
PAB_PSYCH12M
Did a current or ex-romantic or sexual partner do any of these things in the past 12 months, that is, since [FILL DATE]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: FILL DATE IN FORMAT “Month YYYY” (I.E., MONTH WRITTEN OUT). MONTH SHOULD BE MONTH AT TIME OF RESPONSE AND YEAR SHOULD BE YEAR AT TIME OF RESPONSE MINUS ONE.]
[CREATE “END_PAB_TIME” AND “END_PAB_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
SPLIT 2 – SEXUAL VIOLENCE
[CREATE “START_SVB_TIME”” AND “START_SVB_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW IF GROUP = 2]
[DISP]
INTRO_SVB
This next section is about sexual contact that you did not consent to and that you did not want to happen, as well as times in your life when someone ever attempted to have sex or sexual contact with you by using physical force or threats of harm but sex did not happen.
Some people are threatened with harm or physically forced to have sex or sexual contact when they don’t want to. Examples of physical force are being pinned or held down, using violence or threats of violence, or not physically stopping after you said no. To be clear, the next questions are asking only about times in your life when sex was unwanted and you did not give consent.
Sometimes unwanted sex or sexual contact happens when a person is unable to consent to it or stop it from happening because they are too drunk, high, drugged, or passed out from alcohol, drugs, or medications. This can include times when they voluntarily consumed alcohol or drugs or times when they were given alcohol or drugs without their knowledge or consent.
These questions ask about unwanted sexual contact that might have occurred through physical force or when you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs.
You might or might not have ever been in this type of situation. Please remember that even if someone uses alcohol or drugs, what happens to them is not their fault. These questions use detailed and explicit language so that everyone is clear about what the questions are asking.
[SHOW IF GROUP = 2]
[S]
SVB_SEX
In this section you will be asked questions using specific language about victimization experiences
related to one’s sexual anatomy. In the “male” set of questions, it is assumed that you have a penis. In the “female” set of questions, it is assumed that you have a vagina. We would like to give you the option to decide which set of questions best represents your experience. Would you prefer to answer…
[PROGRAMMER: IF RESPONDENTS ATTEMPT TO SUBMIT WITHOUT A RESPONSE, PLEASE DISPLAY SOFT PROMPT: “We know that this information is personal, but remember your answer will be kept confidential. Please select a response before continuing.” IF RESPONDENTS SUBMIT AGAIN WITHOUT RESPONSE, THIS ITEM SHOULD BE AUTO-KEYED BASED ON PROFILE SEX/GENDER VARIABLE.]
1 The female set of questions?
0 The male set of questions?
[SHOW IF GROUP = 2 AND SVB_SEX = 1]
[S]
SVB_ORLEV
In your lifetime, has anyone ever performed oral sex on you when you did not consent to it, and it was not wanted?
By oral sex, we mean that someone put their mouth on your vagina.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_ORLEV = 1]
[S]
SVB_ORLPHYS
Did this oral sex happen because the person used physical force or threats of physical harm, such as pinning or holding you down, using violence, or not stopping after you said no?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_ORLEV = 1]
[S]
SVB_ORLHIGH
Did this oral sex happen because you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_SEX = 1]
[S]
SVB_FINGEV
In your lifetime, has anyone ever penetrated you by putting their fingers or an object in your vagina or anus when you did not consent to it, and it was not wanted?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_FINGEV = 1]
[S]
SVB_FNGPHYS
Did this unwanted penetration by fingers or an object happen because the person used physical force or threats of physical harm, such as pinning or holding you down, using violence, or not stopping after you said no?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_FINGEV = 1]
[S]
SVB_FNGHIGH
Did this unwanted penetration by fingers or an object happen because you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_SEX = 1]
[S]
SVB_VGSXEV
In your lifetime, has anyone ever had vaginal sex with you when you did not consent to it, and it was not wanted?
By vaginal sex, we mean that someone put their penis in your vagina.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_VGSXEV = 1]
[S]
SVB_VGSXPHYS
Did this vaginal sex happen because the person used physical force or threats of physical harm, such as pinning or holding you down, using violence, or not stopping after you said no?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_VGSXEV = 1]
[S]
SVB_VGSXHIGH
Did this vaginal sex happen because you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_SEX = 1]
[S]
SVB_PENEV
In your lifetime, has anyone ever penetrated you by putting their penis in your mouth or anus when you did not consent to it, and it was not wanted?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_PENEV = 1]
[S]
SVB_PENPHYS
Did this penetration of your mouth or anus happen because the person used physical force or threats of physical harm, such as pinning or holding you down, using violence, or not stopping after you said no?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_PENEV = 1]
[S]
SVB_PENHIGH
Did this penetration of your mouth or anus happen because you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_SEX = 1]
[S]
SVB_FORCEEV
In your lifetime, has anyone ever used physical force or threats of physical harm to try to put their penis in your vagina, mouth, or anus, but it did not happen?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF ANY OF SVB_ORLEV, SVB_FINGEV, SVB_VGSXEV, SVB_PENEV, SVB_FORCEEV = 1]
[S]
SVB_ANY12M
You told us someone did [IF EXACTLY ONE OF SVB_ORLEV, SVB_FINGEV, SVB_VGSXEV, SVB_PENEV, SVB_FORCEEV = 1, FILL: this; ELSE, FILL: these things] to you when you did not consent to it, and it was not wanted:
[IF SVB_ORLEV = 1, DISPLAY: Performed oral sex on you]
[IF SVB_FINGEV = 1, DISPLAY: Penetrated you by putting their fingers or an object in your vagina or anus]
[IF SVB_VGSXEV = 1, DISPLAY: Had vaginal sex with you]
[IF SVB_PENEV = 1, DISPLAY: Penetrated you by putting their penis in your mouth or anus]
[IF SVB_FORCEEV = 1, DISPLAY: Tried to put their penis in your vagina, mouth, or anus, but it did not happen]
Did [IF EXACTLY ONE OF SVB_ORLEV, SVB_FINGEV, SVB_VGSXEV, SVB_PENEV, SVB_FORCEEV = 1, FILL: this; ELSE, FILL: any of these things] happen in the past 12 months, that is, since [FILL DATE]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[PROGRAMMER: DISPLAY ITEMS THAT RESPONDENT ENDORSED AS A BULLETED LIST. FILL DATE IN FORMAT “Month YYYY” (I.E., MONTH WRITTEN OUT). MONTH SHOULD BE MONTH AT TIME OF RESPONSE AND YEAR SHOULD BE YEAR AT TIME OF RESPONSE MINUS ONE.]
[SHOW IF ANY OF SVB_ORLEV, SVB_FINGEV, SVB_VGSXEV, SVB_PENEV, SVB_FORCEEV = 1]
[S]
SVB_ANYPREG
You told us someone did [IF EXACTLY ONE OF SVB_ORLEV, SVB_FINGEV, SVB_VGSXEV, SVB_PENEV, SVB_FORCEEV = 1, FILL: this; ELSE, FILL: these things] to you when you did not consent to it, and it was not wanted:
[IF SVB_ORLEV = 1, DISPLAY: Performed oral sex on you]
[IF SVB_FINGEV = 1, DISPLAY: Penetrated you by putting their fingers or an object in your vagina or anus]
[IF SVB_VGSXEV = 1, DISPLAY: Had vaginal sex with you]
[IF SVB_PENEV = 1, DISPLAY: Penetrated you by putting their penis in your mouth or anus]
[IF SVB_FORCEEV = 1, DISPLAY: Tried to put their penis in your vagina, mouth, or anus, but it did not happen]
Were you pregnant at the time of [IF EXACTLY ONE OF SVB_ORLEV, SVB_FINGEV, SVB_VGSXEV, SVB_PENEV, SVB_FORCEEV = 1, FILL: this incident; ELSE, FILL: any of these incidents]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[PROGRAMMER: DISPLAY ITEMS THAT RESPONDENT ENDORSED AS A BULLETED LIST. FILL DATE IN FORMAT “Month YYYY” (I.E., MONTH WRITTEN OUT). MONTH SHOULD BE MONTH AT TIME OF RESPONSE AND YEAR SHOULD BE YEAR AT TIME OF RESPONSE MINUS ONE.]
[SHOW IF GROUP = 2 AND SVB_SEX = 0]
[S]
SVB_ORLEVM
In your lifetime, has anyone ever performed oral sex on you when you did not consent to it, and it was not wanted?
By perform oral sex, we mean that someone put their mouth on your penis or made you put your penis in their mouth.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_ORLEVM = 1]
[S]
SVB_ORLPHYSM
Did this oral sex happen because the person used physical force or threats of physical harm, such as pinning or holding you down, using violence, or not stopping after you said no?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_ORLEVM = 1]
[S]
SVB_ORLHIGHM
Did this oral sex happen because you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_SEX = 0]
[S]
SVB_FINGEVM
In your lifetime, has anyone ever penetrated you by putting their fingers or an object in your anus when you did not consent to it, and it was not wanted?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_FINGEVM = 1]
[S]
SVB_FNGPHYSM
Did this unwanted penetration by fingers or an object happen because the person used physical force or threats of physical harm, such as pinning or holding you down, using violence, or not stopping after you said no?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_FINGEVM = 1]
[S]
SVB_FNGHIGHM
Did this unwanted penetration by fingers or an object happen because you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_SEX = 0]
[S]
SVB_VGSXEVM
In your lifetime, has anyone ever had vaginal sex with you when you did not consent to it, and it was not wanted?
By vaginal sex, we mean that someone made you put your penis in their vagina.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_VGSXEVM = 1]
[S]
SVB_VGSXPHYM
Did this vaginal sex happen because the person used physical force or threats of physical harm, such as pinning or holding you down, using violence, or not stopping after you said no?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_VGSXEVM = 1]
[S]
SVB_VGSXHIM
Did this vaginal sex happen because you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_SEX = 0]
[S]
SVB_PENEVM
In your lifetime, has anyone ever penetrated you by putting their penis in your mouth or anus when you did not consent to it, and it was not wanted?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_PENEVM = 1]
[S]
SVB_PENPHYSM
Did this penetration of your mouth or anus happen because the person used physical force or threats of physical harm, such as pinning or holding you down, using violence, or not stopping after you said no?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_SEX = 1]
[S]
SVB_PENHIGHM
Did this penetration of your mouth or anus happen because you were unable to consent to sex or stop it from happening because you were too drunk, high, drugged, or passed out from alcohol or drugs?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_SEX = 0]
[S]
SVB_FORCEORL
In your lifetime, has anyone ever used physical force or threats of physical harm to try to put their mouth on your penis, or try to make you put your penis in their mouth, but it did not happen?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_SEX = 0]
[S]
SVB_FORCEVG
In your lifetime, has anyone ever used physical force or threats of physical harm to try to make you put your penis in their vagina, but it did not happen?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF GROUP = 2 AND SVB_SEX = 0]
[S]
SVB_FORCEPEN
In your lifetime, has anyone ever used physical force or threats of physical harm to try to put their penis in your mouth or anus, but it did not happen?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF ANY OF SVB_ORLEVM, SVB_VGSXEVM, SVB_FORCEORL, OR SVB_FORCEVG = 1]
[S]
SVB_PHYS12M
You told us someone did [IF EXACTLY ONE OF SVB_ORLEVM, SVB_VGSXEVM, SVB_FORCEORL, OR SVB_FORCEVG = 1, FILL: this; ELSE, FILL: these things] to you when you did not consent to it, and it was not wanted:
[IF SVB_ORLEVM = 1, DISPLAY: Put their mouth on your penis or made you put your penis in their mouth]
[IF SVB_VGSXEVM = 1, DISPLAY: Made you put your penis in their vagina]
[IF SVB_FORCEORL = 1, DISPLAY: Tried to put their mouth on your penis, or tried to make you put your penis in their mouth, but it did not happen]
[IF SVB_FORCEVG = 1, DISPLAY: Tried to make you put your penis in their vagina, but it did not happen]
Did [IF EXACTLY ONE OF SVB_ORLEVM, SVB_VGSXEVM, SVB_FORCEORL, OR SVB_FORCEVG = 1, FILL: this; ELSE, FILL: any of these things] happen in the past 12 months, that is, since [FILL DATE]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[PROGRAMMER: DISPLAY ITEMS THAT RESPONDENT ENDORSED AS A BULLETED LIST. FILL DATE IN FORMAT “Month YYYY” (I.E., MONTH WRITTEN OUT). MONTH SHOULD BE MONTH AT TIME OF RESPONSE AND YEAR SHOULD BE YEAR AT TIME OF RESPONSE MINUS ONE.]
[SHOW IF ANY OF SVB_FINGEVM, SVB_PENEVM, OR SVB_FORCEPEN = 1]
[S]
SVB_PEN12M
You told us someone did [IF EXACTLY ONE OF SVB_FINGEVM, SVB_PENEVM, OR SVB_FORCEPEN = 1, FILL: this; ELSE, FILL: these things] to you when you did not consent to it, and it was not wanted:
[IF SVB_FINGEVM = 1, DISPLAY: Penetrated you by putting their fingers or an object in your anus]
[IF SVB_PENEVM = 1, DISPLAY: Penetrated you by putting their penis in your mouth or anus]
[IF SVB_FORCEPEN = 1, DISPLAY: Tried to put their penis in your mouth or anus, but it did not happen]
Did [IF EXACTLY ONE OF SVB_FINGEVM, SVB_PENEVM, OR SVB_FORCEPEN= 1, FILL: this; ELSE, FILL: any of these things] happen in the past 12 months, that is, since [FILL DATE]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY ITEMS THAT RESPONDENT ENDORSED AS A BULLETED LIST. FILL DATE IN FORMAT “Month YYYY” (I.E., MONTH WRITTEN OUT). MONTH SHOULD BE MONTH AT TIME OF RESPONSE AND YEAR SHOULD BE YEAR AT TIME OF RESPONSE MINUS ONE.]
[CREATE “END_SVB_TIME”” AND “END_SVB_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
TRAUMATIC BRAIN INJURY
[CREATE “START_TBI_TIME” AND “START_TBI_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[DISP]
TBI_INTRO
The next questions are related to physical acts you may have experienced with your current or ex-romantic or sexual partners. Examples of romantic or sexual partners include: spouses, partners, boyfriends, girlfriends, people you have dated, or people you were seeing romantically.
Do not include first dates or one-time hook-up situations.
[SHOW ALL]
[GRID]
TBI_HARMEV
In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?
[PROGRAMMER: DISPLAY TBI_HARMEVa-TBI_HARMEVe IN GRID FORMAT WITH Y/N RESPONSE COLUMNS, WHERE YES = 1 AND NO = 0]
TBI_HARMEVa Slapped, pushed, or shoved you.
TBI_HARMEVb Hit you with a fist or something hard.
TBI_HARMEVc Kicked or stomped on you.
TBI_HARMEVd Slammed you against something to hurt you.
TBI_HARMEVe Hit you in the head or made you hit your head on another object.
[SHOW IF ANY OF TBI_HARMEVa-e = 1 AND (SVA_SEX = 1 OR SVB_SEX = 1)]
[S]
TBI_HARMPREG
Were you pregnant at the time of [IF EXACTLY ONE OF TBI_HARMEVa-e = 1, FILL: this incident; ELSE, FILL: any of these incidents]?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW IF ANY OF TBI_HARMEVa-e = 1]
[S]
TBI_INJFACE
In your lifetime, did you ever have an injury to your head or face because of the things your current or ex-partner did to you?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
NO
[SHOW IF TBI_INJFACE = 1]
[S]
TBI_WHENINJ
We are interested in learning about times in your lifetime when you experienced an injury to the head or face because of what a current or ex-partner did to you.
Please think about the most severe injury to your head or face because of what a current or ex-partner did to you.
Approximately when did this injury occur?
[CAWI RESPONSE OPTIONS:]
1 Within the last 12 months (since [FILL DATE])
1-3 years ago
4-7 years ago
More than 8 years ago
[CATI RESPONSE OPTIONS:]
1 Within the last 12 months, that is, since [FILL DATE]
1-3 years ago
4-7 years ago
More than 8 years ago
[PROGRAMMER: FILL DATE IN FORMAT “Month YYYY” (I.E., MONTH WRITTEN OUT). MONTH SHOULD BE MONTH AT TIME OF RESPONSE AND YEAR SHOULD BE YEAR AT TIME OF RESPONSE MINUS ONE.]
[SHOW IF TBI_INJFACE = 1]
[S]
TBI_DAZED
Please continue thinking about the most severe injury to your head or face.
In the next set of questions, [CATI, FILL: I; CAWI, FILL: we] will ask about what you might have experienced soon after this injury. For each question, please indicate if it happened to you or not. We only want to know about things caused by the injury to your head or face or made worse by this injury.
After this injury…
Were you dazed, confused or did you have trouble thinking straight?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Not sure/Don’t remember
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
-9 Not sure/Don’t remember
[SHOW IF TBI_INJFACE = 1]
[S]
TBI_REMEMBER
Did you have difficulty remembering what happened just before or after the head injury?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Not sure/Don’t remember
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
-9 Not sure/Don’t remember
[SHOW IF TBI_INJFACE = 1]
[S]
TBI_KNOCKOUT
Were you knocked out or did you lose consciousness, even briefly?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Not sure/Don’t remember
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
-9 Not sure/Don’t remember
[PROGRAMMER: DISPLAY TBI_DAZED– TBI_KNOCKOUT ON SAME PAGE]
[SHOW IF TBI_INJFACE = 1]
[S]
TBI_SICK
After this injury…
Did you feel sick to your stomach, or did you vomit?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Not sure/Don’t remember
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
-9 Not sure/Don’t remember
[SHOW IF TBI_INJFACE = 1]
[S]
TBI_HEADACHE
Did you have a headache?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Not sure/Don’t remember
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
-9 Not sure/Don’t remember
[SHOW IF TBI_INJFACE = 1]
[S]
TBI_DIZZY
Was there ever a time when you were dizzy, clumsy, or had balance problems?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Not sure/Don’t remember
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
-9 Not sure/Don’t remember
[SHOW IF TBI_INJFACE = 1]
[S]
TBI_VISION
Did you have blurred or double vision, or other changes in your vision?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Not sure/Don’t remember
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
-9 Not sure/Don’t remember
[PROGRAMMER: DISPLAY TBI_SICK– TBI_VISION ON SAME PAGE]
[SHOW IF TBI_INJFACE = 1]
[S]
TBI_CONCEN
After this injury…
Did you have trouble concentrating?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Not sure/Don’t remember
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
-9 Not sure/Don’t remember
[SHOW IF TBI_INJFACE = 1]
[S]
TBI_LEARN
Did you have difficulty learning or remembering new things?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Not sure/Don’t remember
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
-9 Not sure/Don’t remember
[SHOW IF TBI_INJFACE = 1]
[S]
TBI_SENSE
Were you more sensitive than usual to either light or noise?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Not sure/Don’t remember
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
-9 Not sure/Don’t remember
[PROGRAMMER: DISPLAY TBI_CONCEN– TBI_SENSE ON SAME PAGE]
[SHOW IF TBI_INJFACE = 1]
[S]
TBI_MOOD
After this injury…
Did you experience a change in mood or temperament such as irritability, or feel more emotional than usual?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Not sure/Don’t remember
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
-9 Not sure/Don’t remember
[SHOW IF TBI_INJFACE = 1]
[S]
TBI_SLEEP
Did you have trouble sleeping or were you more tired than usual?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Not sure/Don’t remember
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
-9 Not sure/Don’t remember
[PROGRAMMER: DISPLAY TBI_MOOD– TBI_SLEEP ON SAME PAGE]
[SHOW IF ANY OF TBI_DAZED– TBI_SLEEP = 1]
[S]
TBI_EXDOC
Please continue to think about the most severe injury to your head or face because of what a current or ex-partner did to you.
After this injury, were you examined by a doctor, nurse, paramedic, or other health professional?
[CAWI RESPONSE OPTIONS:]
1 Yes
No
-9 Not sure/Don’t remember
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
-9 Not sure/Don’t remember
[SHOW IF TBI_EXDOC = 0]
[S]
TBI_WHYNODOC
Why weren’t you examined by a medical professional?
[CAWI RESPONSE OPTIONS:]
1 Didn’t think the injury was serious
Difficulty paying for it
Did not have transportation
Could not take time off work
Prevented from seeking care by current or ex-partner
Unable to seek care because of COVID-19
Some other reason
[CATI RESPONSE OPTIONS:]
1 Didn’t think the injury was serious
Difficulty paying for it
Did not have transportation
Could not take time off work
Prevented from seeking care by current or ex-partner
Unable to seek care because of COVID-19
Some other reason
[CREATE “END_TBI_TIME” AND “END_TBI_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
INT – INTERNET/HIT
[CREATE “START_INT_TIME” AND “START_INT_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[S]
INT_DISP
These next questions are about your use of the Internet.
[SHOW IF MODE = CATI; AUTO PUNCH 1 (YES) IF MODE = CAWI]
[S]
INT_ACCESS
Do you have access to the Internet?
[CATI RESPONSE OPTIONS – DO NOT READ:]
1 YES
0 NO
[SHOW IF INT_ACCESS=1]
[S]
INT_HOMEACC
Do you have access to the Internet from your home?
Include Internet and data use through a computer, tablet, smartphone, or other electronic device.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS – DO NOT READ:]
1 YES
0 NO
[SHOW IF INT_ACCESS=1]
INT_DSPL
During the past 12 months, have you used the Internet for any of the following reasons?
Include Internet and data use through a computer, tablet, smartphone, or other electronic device.
[SHOW IF INT_ACCESS=1]
[S]
INT_USEMED
To look for health or medical information.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS – DO NOT READ:]
1 YES
0 NO
[SHOW IF INT_ACCESS=1]
[S]
INT_USEDOC
To communicate with a doctor or doctor’s office.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS – DO NOT READ:]
1 YES
0 NO
[SHOW IF INT_ACCESS=1]
[S]
INT_USETEST
To look up medical test results.
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[PROGRAMMER: DISPLAY INT_DSPL - INT_USETEST ON SAME PAGE]
[CREATE “END_INT_TIME” AND “END_INT_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
TEL - TELEPHONE USE
[CREATE “START_TEL_TIME” AND “START_TEL_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[S]
TEL_NONCELL
Is there at least one telephone inside your home that is currently working and is not a cell phone?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW ALL]
[S]
TEL_CELL
Do you have a working cell phone?
[CAWI RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[SHOW
IF TEL_CELL=0 AND HHSIZE>=2]
[S]
TEL_HHCELL
Do you live with anyone at your home who has a working cell phone?
[CAWI
RESPONSE OPTIONS:]
1 Yes
0 No
[CATI RESPONSE OPTIONS - DO NOT READ:]
1 YES
0 NO
[CREATE “END_TEL_TIME” AND “END_TEL_DATE”; RECORD TIME IN HH:MM:SS; RECORD DATE IN MM:DD:YYYY]
[SHOW ALL]
[DISP]
END_DISP
Thank you for
participating in this survey. We realize that some of the topics
covered were quite personal and can be difficult to think and talk
about. We appreciate your willingness to answer these questions and
want you to know that we recognize the important contribution you
have made. Sometimes when people have answered questions like these,
they realize that they are interested in following up on some of the
issues that they have been asked about with someone who is
professionally trained to deal with these kinds of issues.
Below are some toll-free numbers of resources that you can use now or in the future if you want to speak further with someone.
You can reach the National Domestic Violence Hotline at 1-800-799-SAFE (7233).
You can reach the National Sexual Assault Hotline at 1-800-656-HOPE (4673).
You can reach the National Child Abuse Hotline at 1-800-4-A-Child (422-4453).
You can reach the National Suicide Prevention Lifeline at 988.
[PROGRAMMER: DISPLAY THIS SCREEN AFTER RESPONDENT SUBMITS SURVEY RESPONSE.]
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |