Form 0920-0950 Survey Participant Questionnaire
[NCHS] National Health and Nutrition Examination Survey (NHANES)
Attachment_6b_Survey Participant Questionnaire_2024AUG29
Survey Participant Questionnaire
OMB: 0920-0950
Attachment 6b
Survey Participant Questionnaire
Attachment 6b: Survey Participant Questionnaire
Form Approved
OMB No. 0920-0950
Exp. Date XX/XX/20XX
Notice – CDC estimates the average public reporting burden for this collection of information as 30 to 60 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 (0920-0950).
Assurance of Confidentiality – 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.
RESPONDENT SELECTION - SPQ
SPQSELECTR |
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ASK |
All respondents |
SELECT RESPONDENT FOR THE SP QUESTIONNAIRE FOR <TEXT FILL 1>.
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SPANISH |
N/A |
QUESTION TYPE |
Dropdown |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
DISPLAY ALL HOUSEHOLD MEMBERS WHO ARE >= 18 YEARS OLD (INCLUDING HH MEMBERS WHO ANSWERED DK/RF FOR NAME, BUT REPORTED AN AGE >= 18 YEARS OLD; LABEL NO-NAME HH MEMBER IN LIST AS, E.G., “21 YEAR OLD HH MEMBER #X” OR “18 YEAR OLD HH MEMBER #X”) ALSO DISPLAY AN OPTIONS FOR ‘SOMEONE NOT LIVING IN HH’. |
HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
New |
NEXT |
SPQINTRO |
SPQINTRO |
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ASK |
All respondents |
ADMINISTER WELCOME SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
Welcome to the National Health and Nutrition Examination Survey (NHANES). <TEXT FILL 3> been selected to be part of this study, which includes an interview and a health exam. This study is sponsored by the National Center for Health Statistics, part of the Centers for Disease Control and Prevention and the U.S. Department of Health and Human Services. The information collected in this interview will help us understand the health of people in the United States. PRESS NEXT TO CONTINUE. |
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SPANISH |
ADMINISTER WELCOME SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
Bienvenido(a) a la Encuesta Nacional de Examen de la Salud y Nutrición (NHANES, por sus siglas en inglés). <TEXT FILL 3> ha sido seleccionado(a) para formar parte de este estudio, que incluye una entrevista y un examen de salud. Este estudio está patrocinado por el Centro Nacional de Estadísticas de la Salud, que forma parte de los Centros para el Control y la Prevención de Enfermedades y del Departamento de Salud y Servicios Humanos de los Estados Unidos. La información recopilada en esta entrevista nos ayudará a comprender el estado de salud de las personas en los Estados Unidos. PRESS NEXT TO CONTINUE. |
QUESTION TYPE |
Informational |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS < 18
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “You have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] has” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS < 18
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] ” |
NOTES |
BEGIN RECORDING SO THAT WHEN INTERVIEWER READS THIS QUESTION IT IS CAPTURED ON RECORDING. |
HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
DMQ.INTRO |
NEXT |
SPQRECORD |
SPQRECORD |
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ASK |
All respondents |
ADMINISTER AUDIO CONSENT SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
We would like to record the interview for training and data quality. The computer is now recording our conversation. Do I have your permission to continue recording?
1. YES 2. NO
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SPANISH |
ADMINISTER AUDIO CONSENT SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
Nos
gustaría grabar la entrevista para la capacitación y
calidad de los datos.
1. YES 2. NO |
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS < 18
TEXT FILL 2: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
How long will the recording be kept? The audio recording will be deleted after three years. You can call our toll free number 800-344-1386 at any time to have your audio recording deleted prior to that time.
Who will have access to my recordings? Recordings are only used by persons authorized to work on NHANES for reviewing the quality of my work and tools and questionnaires used in the survey. |
HELP SCREEN (SPA) |
¿Cuánto tiempo se conservará la grabación? La grabación de audio se borrará después de tres años. Puede llamar a nuestra línea gratuita al 800-344-1386 en cualquier momento si quiere que la borremos antes.
¿Quién tendrá acceso a mis grabaciones? Las grabaciones solo son usadas por las personas autorizadas a trabajar en la Encuesta Nacional de Examen de la Salud y Nutrición, con fines de revisar la calidad de mi trabajo, así como las herramientas y cuestionarios que se usan en la encuesta. |
HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
RIQ.800 |
NEXT |
IF SPQRECORD=2: SPQRECORDN ELSE: SPQAGEQ/U |
SPQRECORDN |
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ASK |
IF SPQRECORD=2 |
I will turn off the recording now.
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SPANISH |
Apagaré la grabación ahora. |
QUESTION TYPE |
Informational |
FILLS |
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NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
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NEXT |
SPQAGEQ/U |
SPQAGEQ / SPQAGEU |
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ASK |
All respondents |
ADMINISTER AGE VERIFICATION SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
Before we begin the health interview, I would like to verify some information about <TEXT FILL 3>.
How old <TEXT FILL 4>?
REPORTED AGE IN SCREENER: <AGE FILL>
INTERVIEWER INSTRUCTION: IF AGE FROM SCREENER IS DK/REF, ASK FOR AGE. IF AGE IS ALREADY PROVIDED, VERIFY AGE. COLLECT AGE IN MONTHS IF AGE IS LESS THAN 12 MONTHS. IF INFANT IS LESS THAN ONE MONTH OLD, ENTER ‘0.’
|___|___|___| ENTER NUMBER OF YEARS OR MONTHS [SPQAGEQ]
777. REFUSED 999. DON’T KNOW
|___| ENTER UNIT [SPQAGEU]
1. MONTHS 2. YEARS
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SPANISH |
ADMINISTER AGE VERIFICATION SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
Antes de comenzar la entrevista de salud, me gustaría verificar algunos datos sobre <TEXT FILL 3>.
¿Cuántos años tiene <TEXT FILL 4>?
REPORTED AGE IN SCREENER: <AGE FILL>
INTERVIEWER INSTRUCTION: IF AGE FROM SCREENER IS DK/REF, ASK FOR AGE. IF AGE IS ALREADY PROVIDED, VERIFY AGE. COLLECT AGE IN MONTHS IF AGE IS LESS THAN 12 MONTHS. IF INFANT IS LESS THAN ONE MONTH OLD, ENTER ‘0.’
|___|___|___| ENTER NUMBER OF YEARS OR MONTHS [SPQAGEQ]
777. REFUSED 999. DON’T KNOW
|___| ENTER UNIT [SPQAGEU]
1. MONTHS 2. YEARS
|
QUESTION TYPE |
Numeric: SPQAGEQ Radio button: SPQAGEU |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS < 18
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “you” IF SP IS THE RESPONDENT ELSE, FILL “[SP NAME]”
TEXT FILL 4: FILL “are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “is [SP NAME]”
AGE FILL: FILL “[AGE IN MONTHS OR YEARS OR AGE RANGE.]” IF AGE PROVIDED IN SCREENER ELSE, FILL “[AGE PROVIDED IN SCREENER IS DK/REF.]” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS < 18
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “usted” IF SP IS THE RESPONDENT ELSE, FILL “[SP NAME]”
TEXT FILL 4: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
AGE FILL: FILL “[AGE IN MONTHS OR YEARS OR AGE RANGE.]” IF AGE PROVIDED IN SCREENER ELSE, FILL “[AGE PROVIDED IN SCREENER IS DK/REF.]” |
NOTES |
ALLOW AGE AND UNIT FIELDS TO BE UPDATED. FOR AGE REPORTED IN SCREENER IN <AGE FILL>, DISPLAY AGE IN MONTHS OR YEARS IF VALUE PROVIDED IN SCREENER. OTHERWISE, DISPLAY AGE RANGE. |
HELP SCREEN |
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HARD CHECK |
IF SPQAGEU=2 AND SPQAGEQ <1 OR >120, DISPLAY “YOUR ENTRY IS OUT OF RANGE. AGE IN YEARS MUST BE BETWEEN 1-120.”
IF SPQAGEU=1 AND SPQAGEQ >11 , DISPLAY “YOUR ENTRY IS OUT OF RANGE. AGE IN MONTHS MUST BE BETWEEN 0-11.”
IF SP AGE REPORTED IN SCREENER >= 18 AND SPQAGEQ <18 AND SPQAGEU = 2, DISPLAY “AGE ENTERED INDICATES SP STATUS AS A MINOR. SP WAS ROSTERED AS AN ADULT IN THE SCREENER. VERIFY AGE AND IF SP IS LESS THAN 18 YEARS OLD, PRESS EXIT TO BREAK OFF AND CONTACT YOUR SUPERVISOR.”
IF SP AGE REPORTED IN SCREENER < 18 AND SPQAGEQ >=18 AND SPQAGEU = 2, DISPLAY “AGE ENTERED INDICATES SP STATUS AS AN ADULT. SP WAS ROSTERED AS A MINOR IN THE SCREENER. VERIFY AGE AND IF SP IS GREATER THAN OR EQUAL TO 18 YEARS OLD, PRESS EXIT TO BREAK OFF AND CONTACT YOUR SUPERVISOR.” |
SOFT CHECK |
IF AGE IS REPORTED IN SCREENER (SCQAGE/SCQAGEUNIT):
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VERSION NOTES |
DMQ.011Q/U |
NEXT |
IF SPQAGEQ = 777 OR 999: SPQAGER ELSE: SPQFNAME |
SPQAGER |
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ASK |
IF SPQAGEQ = 777 OR 999 |
ADMINISTER AGE VERIFICATION SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
About how old <TEXT FILL 3>?
REPORTED AGE IN SCREENER: <AGE FILL>
1. LESS THAN 5 YEARS, 2. 5-11 YEARS, 3. 12-17 YEARS, 4. 18-44 YEARS, 5. 45-64 YEARS, 6. 65-79 YEARS, OR 7. 80 YEARS OR OLDER?
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SPANISH |
ADMINISTER AGE VERIFICATION SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
¿Cuántos años tiene <TEXT FILL 3> aproximadamente?
REPORTED AGE IN SCREENER: <AGE FILL>
1. LESS THAN 5 YEARS, 2. 5-11 YEARS, 3. 12-17 YEARS, 4. 18-44 YEARS, 5. 45-64 YEARS, 6. 65-79 YEARS, OR 7. 80 YEARS OR OLDER?
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS < 18
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTRR ELSE, FILL “is [SP NAME]
AGE FILL: FILL “[AGE IN MONTHS OR YEARS OR AGE RANGE.]” IF AGE PROVIDED IN SCREENER ELSE, FILL “[AGE NOT PROVIDED IN SCREENER. VERIFY AGE RANGE.]” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS 18+ FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SCREENER IS < 18
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTRR ELSE, FILL “ [SP NAME]
AGE FILL: FILL “[AGE IN MONTHS OR YEARS OR AGE RANGE.]” IF AGE PROVIDED IN SCREENER ELSE, FILL “[AGE NOT PROVIDED IN SCREENER. VERIFY AGE RANGE.]” |
NOTES |
DISPLAY SPQAGER ON SAME SCREEN AS SPQAGEQ/U. FIELD SHOULD BE DISABLED UNLESS SPQAGEQ/U = DK/RF. FOR AGE REPORTED IN SCREENER IN <AGE FILL>, DISPLAY AGE IN MONTHS OR YEARS IF VALUE PROVIDED IN SCREENER. OTHERWISE, DISPLAY AGE RANGE. |
HELP SCREEN |
|
HARD CHECK |
IF SP AGE REPORTED IN SCREENER >= 18 AND SPQAGER IN (1, 2, OR 3), DISPLAY “AGE ENTERED INDICATES SP STATUS AS A MINOR. SP WAS ROSTERED AS AN ADULT IN THE SCREENER. VERIFY AGE AND IF SP IS LESS THAN 18 YEARS OLD, PRESS EXIT TO BREAK OFF AND CONTACT YOUR SUPERVISOR.”
IF SP AGE REPORTED IN SCREENER < 18 AND SPQAGER IN (4, 5, 6, 7), DISPLAY “AGE ENTERED INDICATES SP STATUS AS AN ADULT. SP WAS ROSTERED AS A MINOR IN THE SCREENER. VERIFY AGE AND IF SP IS GREATER THAN OR EQUAL TO 18 YEARS OLD, PRESS EXIT TO BREAK OFF AND CONTACT YOUR SUPERVISOR.” |
SOFT CHECK |
IF AGE IS REPORTED IN SCREENER (SCQAGEEST): AND IF SPQAGER IS DIFFERENT FROM AGE REPORTED IN SCQAGEEST, AND AGE WAS NOT REPORTED IN SCQAGE, DISPLAY “REPORTED AGE CATEGORY IN SCREENER AND REPORTED AGE HERE DOES NOT MATCH. AGE REPORTED IN SCREENER: < SCQAGEEST > PLEASE VERIFY AGE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.”
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VERSION NOTES |
DMQ.011RN |
NEXT |
SPQFNAME |
SPQFNAME |
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ASK |
All respondents |
ADMINISTER NAME SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
What is <TEXT FILL 3> first name?
INTERVIEWER INSTRUCTION: VERIFY FULL NAME SPELLING.
<TEXT FILL 4>____________________ ENTER FIRST NAME
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SPANISH |
ADMINISTER NAME SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
¿Cuál es <TEXT FILL 3>?
INTERVIEWER INSTRUCTION: VERIFY FULL NAME SPELLING.
<TEXT FILL 4>____________________ ENTER FIRST NAME
|
QUESTION TYPE |
Textbox |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE < 18 YEARS
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 4: FILL “[FIRST NAME FROM SCREENER]” AND ALLOW UPDATES ELSE, LEAVE BLANK AND ALLOW UPDATES |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE < 18 YEARS
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “su primer nombre” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “el primer nombre de [SP NAME]”
TEXT FILL 4: FILL “[FIRST NAME FROM SCREENER]” AND ALLOW UPDATES ELSE, LEAVE BLANK AND ALLOW UPDATES |
NOTES |
DO NOT ALLOW FIELD TO BE LEFT BLANK/NULL FOR <TEXT FILL 4>, PREFILL FIRST NAME FROM SCREENER AND ALLOW UPDATES. |
HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
DMQ.040 |
NEXT |
SPQMNAMEA |
SPQMNAMEA / SPQMNAMEB |
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ASK |
All respondents |
ADMINISTER NAME SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
What is <TEXT FILL 3> middle name?
INTERVIEWER INSTRUCTION: VERIFY MIDDLE NAME SPELLING. PROBE FOR MIDDLE NAME IF NOT PROVIDED. ENTER ‘NMN’ IF NO MIDDLE NAME.
<TEXT FILL 4>____________________ ENTER MIDDLE NAME #1
7. REFUSED 9. DON’T KNOW
<TEXT FILL 5>____________________ ENTER MIDDLE NAME #2
7. REFUSED 9. DON’T KNOW
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SPANISH |
ADMINISTER NAME SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
¿Cuál es <TEXT FILL 3>?
INTERVIEWER INSTRUCTION: VERIFY MIDDLE NAME SPELLING. PROBE FOR MIDDLE NAME IF NOT PROVIDED. ENTER ‘NMN’ IF NO MIDDLE NAME.
<TEXT FILL 4>____________________ ENTER MIDDLE NAME #1
7. REFUSED 9. DON’T KNOW
<TEXT FILL 5>____________________ ENTER MIDDLE NAME #2
7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Textbox |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE < 18 YEARS
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 4: FILL “NMN” AND ALLOW UPDATES
TEXT FILL 5: FILL “NMN” AND ALLOW UPDATES |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE < 18 YEARS
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “su segundo nombre” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “el segundo nombre de [SP NAME]”
TEXT FILL 4: FILL “NMN” AND ALLOW UPDATES
TEXT FILL 5: FILL “NMN” AND ALLOW UPDATES |
NOTES |
DO NOT ALLOW FIELDS TO BE LEFT BLANK/NULL |
HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
DMQ.050a/b |
NEXT |
SPQLNAMEA |
SPQLNAMEA / SPQLNAMEB |
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ASK |
All respondents |
ADMINISTER NAME SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
What is <TEXT FILL 3> last name?
INTERVIEWER INSTRUCTION: VERIFY LAST NAME SPELLING.
<TEXT FILL 4>____________________ ENTER LAST NAME #1
7. REFUSED 9. DON’T KNOW
<TEXT FILL 5>____________________ ENTER LAST NAME #2
7. REFUSED 9. DON’T KNOW
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|
SPANISH |
ADMINISTER NAME SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
¿Cuál es <TEXT FILL 3>?
INTERVIEWER INSTRUCTION: VERIFY LAST NAME SPELLING.
<TEXT FILL 4>____________________ ENTER LAST NAME #1
7. REFUSED 9. DON’T KNOW
<TEXT FILL 5>____________________ ENTER LAST NAME #2
7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Textbox |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE < 18 YEARS
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “your” IF SP IS SELECTED AS RESPONDENT IN RSPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 4: LEAVE BLANK AND ALLOW UPDATES
TEXT FILL 5: LEAVE BLANK AND ALLOW UPDATES |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE < 18 YEARS
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “su apellido” IF SP IS SELECTED AS RESPONDENT IN RSPQSELECTR ELSE, FILL “el apellido de [SP NAME]”
TEXT FILL 4: LEAVE BLANK AND ALLOW UPDATES
TEXT FILL 5: LEAVE BLANK AND ALLOW UPDATES |
NOTES |
DO NOT ALLOW SPQLNAMEA TO BE LEFT BLANK/NULL ALLOW SPQLNAMEB TO BE LEFT BLANK/NULL |
HELP SCREEN |
|
HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
DMQ.060a/b |
NEXT |
SPQSUFFIX |
SPQSUFFIX |
|
ASK |
All respondents |
ADMINISTER NAME SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
INTERVIEWER INSTRUCTION: VERIFY SPELLING. IF NONE, LEAVE BLANK. DO NOT TYPE “DON'T KNOW” OR “REFUSED” IN THE TEXTBOX.
<TEXT FILL 3> have a suffix such as junior or the second? (What is it?)
______________________________ ENTER SUFFIX
7. REFUSED 9. DON’T KNOW
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|
SPANISH |
ADMINISTER NAME SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
INTERVIEWER INSTRUCTION: VERIFY SPELLING. IF NONE, LEAVE BLANK. DO NOT TYPE “DON'T KNOW” OR “REFUSED” IN THE TEXTBOX.
¿Tiene <TEXT FILL 3> tiene un sufijo, como “júnior” o “II”? (¿Cuál es este?)
______________________________ ENTER SUFFIX
7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Textbox |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE < 18 YEARS
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE < 18 YEARS
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “su nombre” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[el nombre de SP NAME]” |
NOTES |
ALLOW SUFFIX FIELD TO BE LEFT BLANK/NULL |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DMQ.070 |
NEXT |
IF SP IS NOT RESPONDENT AND SP AGE < 18 YEARS: SPQRELATEM IF SP IS RESPONDENT AND SP AGE < 18 YEARS: SPQPRXCONF IF SP IS NOT RESPONDENT AND SP AGE >= 18 YEARS: SPQRELATEA IF SP IS RESPONDENT AND SP AGE >= 18 YEARS: SPQINTYN |
SPQRELATEM |
|
ASK |
IF SP IS NOT THE RESPONDENT AND SP AGE < 18 YEARS |
INTERVIEWER INSTRUCTION: ASK OR VERIFY IF MENTIONED PREVIOUSLY.
What is your relationship to <TEXT FILL 1>?
1. MOTHER (BIOLOGICAL/ADOPTIVE/STEP/FOSTER) 2. FATHER (BIOLOGICAL/ADOPTIVE/STEP/FOSTER) 3. GRANDPARENT (GRANDMOTHER/GRANDFATHER) 4. AUNT/UNCLE 5. BROTHER/SISTER 6. OTHER RELATIVE 7. NON-RELATIVE 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
INTERVIEWER INSTRUCTION: ASK OR VERIFY IF MENTIONED PREVIOUSLY.
¿Cuál es su relación o parentesco con <TEXT FILL 1>?
1. MADRE (BIOLÓGICA/ADOPTIVA/MADRASTRA/DE CRIANZA “FOSTER”) 2. PADRE (BIOLÓGICO/ADOPTIVO/PADRASTRO/DE CRIANZA “FOSTER”) 3. ABUELA(O) 4. TÍA(O) 5. HERMANO(A) 6. OTRO PARIENTE 7. NO ES PARIENTE 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RIQ.012 |
NEXT |
IF ‘SOMEONE NOT LIVING IN THE HOUSEHOLD’ SELECTED IN SPQSELECTR: SPQPRXDES ELSE: SPQPRFNM |
SPQRELATEA |
|
ASK |
IF SP IS NOT THE RESPONDENT AND SP AGE >= 18 YEARS |
INTERVIEWER INSTRUCTION: ASK OR VERIFY IF MENTIONED PREVIOUSLY.
What is your relationship to <TEXT FILL 1>?
1. SPOUSE (WIFE/HUSBAND) OR PARTNER 2. DAUGHTER OR SON (BIOLOGICAL/ADOPTIVE/IN-LAW/STEP/FOSTER) 3. PARENT (BIOLOGICAL/ADOPTIVE/STEP/FOSTER) 4. GRANDPARENT (GRANDMOTHER/GRANDFATHER) 5. BROTHER/SISTER 6. OTHER RELATIVE 7. NON-RELATIVE 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
INTERVIEWER INSTRUCTION: ASK OR VERIFY IF MENTIONED PREVIOUSLY.
¿Cuál es su relación o parentesco con <TEXT FILL 1>?
1. CÓNYUGE (ESPOSO(A)) O PAREJA 2. HIJA(O) (BIOLÓGICO(A)/ADOPTIVO(A)/NUERA O YERNO/HIJASTRO(A)/DE CRIANZA “FOSTER”) 3. PADRE/MADRE (BIOLÓGICO(A)/ADOPTIVO(A)/PADRASTRO O MADRASTRA/DE CRIANZA “FOSTER”) 4. ABUELA(O) 5. HERMANO(A) 6. OTRO PARIENTE 7. NO ES PARIENTE 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RIQ.014 |
NEXT |
SPQPRXWHY |
SPQPRXCONF |
|
ASK |
IF SP IS RESPONDENT AND SP AGE < 18 YEARS |
INTERVIEW SHOULD BE CONDUCTED WITH A PROXY BECAUSE SP IS UNDER 18 YEARS OLD.
ENTER ONE OPTION.
1. PERSON SELECTED AS RESPONDENT IN ERROR 2. SP AGE ENTERED IN ERROR -- SP IS AGE 18+
|
|
SPANISH |
N/A |
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF SPQPRXCONF = 1, DISPLAY, “BACK UP TO SELECT ANOTHER RESPONDENT. CLICK HERE TO GO BACK TO CORRECT.” LINK “CLICK HERE” SENTENCE TO SPQSELECTR. IF SPQPRXCONF = 2, DISPLAY, “BACK UP TO CORRECT SP’S AGE. CLICK HERE TO GO BACK TO CORRECT.” LINK “CLICK HERE” SENTENCE TO SPQAGEQ/U. |
SOFT CHECK |
|
VERSION NOTES |
*11RIQ.020 |
NEXT |
IF SPQPRXCONF = 1: SPQSELECTR IF SPQPRXCONF = 2: SPQAGEQ |
SPQPRXWHY/SPQPRXWHO |
|
ASK |
IF SP IS NOT RESPONDENT AND SP AGE >= 18 YEARS |
INTERVIEWER: WHY IS THIS INTERVIEW BEING CONDUCTED WITH A PROXY?
1. SP HAS COGNITIVE PROBLEMS 2. SP HAS PHYSICAL PROBLEMS (SPECIFY) _________________ 3. PERSON SELECTED AS RESPONDENT IN ERROR 4. SP AGE ENTERED IN ERROR -- SP IS UNDER 18 YEARS OF AGE
|
|
SPANISH |
N/A |
QUESTION TYPE |
Dropdown: SPQPRXWHY Textbox: SPQPRXWHO |
FILLS |
|
NOTES |
INCLUDE A TEXTBOX FOR RESPONDENTS TO SPECIFY IF SELECT ‘SP HAS PHYSICAL PROBLEMS’ SPQPRXWHO. SPQPRXWHO SHOULD ALLOW 100 CHARACTERS. |
HELP SCREEN |
|
HARD CHECK |
IF SPQPRXWHY = 3, DISPLAY, “BACK UP TO SELECT ANOTHER RESPONDENT. CLICK HERE TO GO BACK TO CORRECT.” LINK “CLICK HERE…” SENTENCE TO SPQSELECTR. IF SPQPRXWHY = 4, DISPLAY, “BACK UP TO CORRECT SP’S AGE. CLICK HERE TO GO BACK TO CORRECT.” LINK “CLICK HERE…” SENTENCE TO SPQAGEQ/U. |
SOFT CHECK |
|
VERSION NOTES |
RIQ.039 OS |
NEXT |
IF SPQPRXWHY = 3: SPQSELECTR IF SPQPRXWHY = 4: SPQAGEQ/U ELSE: SPQPRXPERM |
SPQPRXPERM |
|
ASK |
IF SPQPRXWHY = 1 OR 2 |
DO YOU HAVE SUPERVISOR PERMISSION TO CONDUCT INTERVIEW WITH A PROXY?
1. YES 2. NO
|
|
SPANISH |
N/A |
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF SPQPRXPERM = 2, DISPLAY, “BACK UP TO SELECT ANOTHER RESPONDENT. CLICK HERE TO GO BACK TO CORRECT.” LINK “CLICK HERE…” SENTENCE TO SPQSELECTR. |
SOFT CHECK |
|
VERSION NOTES |
*11RIQ.035 |
NEXT |
IF SPQPRXPERM = 2: SPQSELECTR IF SPQPRXPERM = 1 AND ‘SOMEONE NOT LIVING IN HH’ SELECTED AS RESPONDENT IN SPQSELECTRR: SPQPRXDES IF SPQPRXPERM = 1 AND HOUSEHOLD MEMBER SELECTED AS RESPONDENT IN SPQSELECTRR: SPQPRFNM |
SPQPRXDES |
|
ASK |
IF SP IS NOT RESPONDENT AND RESPONDENT DOES NOT LIVE IN HOUSEHOLD |
WHY IS INTERVIEW BEING CONDUCTED WITH SOMEONE OUTSIDE THE HOUSEHOLD?
|
|
SPANISH |
N/A |
QUESTION TYPE |
Textbox |
FILLS |
|
NOTES |
CHARACTER LIMIT: 2,000 DO NOT ALLOW BLANK ENTRIES |
HELP SCREEN |
|
HARD CHECK |
IF BLANK, DISPLAY “ANSWER REQUIRED. PLEASE ENTER A RESPONSE.” |
SOFT CHECK |
|
VERSION NOTES |
RIQ.040 |
NEXT |
SPQPRFNM |
SPQPRFNM/SPQPRLNM |
|
ASK |
IF SP IS NOT RESPONDENT |
ENTER SP PROXY’S NAME.
______________________________ ENTER FIRST NAME [SPQPRFNM]
______________________________ ENTER LAST NAME [SPQPRLNM]
|
|
SPANISH |
N/A |
QUESTION TYPE |
Textbox |
FILLS |
|
NOTES |
SPQPRFNM: ALLOW 50 CHARACTERS, SPQPRLNM: ALLOW 50 CHARACTERS DO NOT ALLOW BLANK ENTRIES. |
HELP SCREEN |
|
HARD CHECK |
IF ANY OF SPQPRFNM OR SPQPRLNM LEFT BLANK, DISPLAY “ANSWER REQUIRED. PLEASE ENTER A RESPONSE.” IF ANY OF SPQPRFNM OR SPQPRLNM = NUMERIC CHARACTERS, DISPLAY: “INVALID RESPONSE. PLEASE ENTER SP PROXY’S FIRST AND LAST NAME.” |
SOFT CHECK |
|
VERSION NOTES |
RIQ.050a/b |
NEXT |
SPQPRXPHON |
SPQPRXPHON |
|
ASK |
IF SP IS NOT RESPONDENT |
ENTER SP PROXY’S PHONE NUMBER.
INTERVIEWER INSTRUCTION: ENTER '000' IN AREA CODE IF NO PHONE.
(|___|___|___|) |___|___|___| - |___|___|___|___|
77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
N/A |
QUESTION TYPE |
Numeric |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
ONLY ALLOW RESPONSE OF DON’T KNOW, REFUSED, "000" or 10 DIGIT PHONE NUMBER. IF PHONE NUMBER PROVIDED, DISPLAY HARD RANGE CHECK MESSAGE IF PHONE NUMBER NOT "000" OR IS 10 DIGITS OF ALL THE SAME NUMBER (I.E., 1111111111): “PLEASE ENTER A VALID PHONE NUMBER.” |
SOFT CHECK |
|
VERSION NOTES |
RIQ.060 |
NEXT |
SPQINTYN |
SPQINTYN |
|
ASK |
All respondents |
IS AN INTERPRETER BEING USED FOR THIS INTERVIEW?
1. YES 2. NO
|
|
SPANISH |
N/A |
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
INT.001 |
NEXT |
IF SPQINTYN = 2: SPQCONSENT ELSE: SPQINTLANG |
SPQINTLANG |
|
ASK |
IF SPQINTYN = 1 |
LANGUAGE USED FOR INTERVIEW:
1. AMERICAN SIGN LANGUAGE 2. CHINESE (CANTONESE) 3. CHINESE (MANDARIN) 4. FRENCH 5. GERMAN 6. ITALIAN 7. JAPANESE 8. KOREAN 9. RUSSIAN 10. SPANISH (READER) 11. VIETNAMESE 90. OTHER (SPECIFY)
|
|
SPANISH |
N/A |
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
INT.003 |
NEXT |
IF SPQINTLANG = 90: SPQINTLANGO IF SPQINTLANG != 90 AND INTERPRETER WAS USED IN SCREENER: SPQINTPREV IF SPQINTLANG != 90 AND INTERPRETER WAS NOT USED IN SCREENER: SPQINTOBT |
SPQINTLANGO |
|
ASK |
IF SPQINTLANG = 90 |
ENTER LANGUAGE USED FOR INTERVIEW.
ENTER LANGUAGE
|
|
SPANISH |
N/A |
QUESTION TYPE |
Textbox |
FILLS |
|
NOTES |
ALLOW 50 CHARACTERS |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
INT.004 |
NEXT |
IF INTERPRETER WAS USED IN SCREENER: SPQINTPREV ELSE: SPQINTOBT |
SPQINTPREV |
|
ASK |
IF INTERPRETER WAS USED IN SCREENER |
INTERPRETERS USED IN SCREENER:
<DISPLAY LIST 1>
SELECT SOURCE:
1. SAME INTERPRETER USED IN SCREENER: <DISPLAY LIST 1> 2. NEW INTERPRETER
|
|
SPANISH |
N/A |
QUESTION TYPE |
Radio button |
FILLS |
DISPLAY LIST 1: IF AT LEAST ONE INTERPRETER USED PREVIOUSLY, DISPLAY INTERPRETER NAMES FROM SCREENER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
INT.013 |
NEXT |
IF SPQINTPREV = 1: SPQINTPHON ELSE: SPQINTOBT |
SPQINTOBT |
|
ASK |
IF INTERPRETER WAS NOT USED IN SCREENER IF SPQINTPREV = 2 |
HOW WAS INTERPRETER OBTAINED?
1. ARRANGED BY THE OFFICE 2. RECRUITED DURING VISIT OR APPOINTMENT
|
|
SPANISH |
N/A |
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
INT.005 |
NEXT |
IF SPQINTOBT = 2: SPQINTSRCE ELSE: SPQINTSELC |
SPQINTSELC |
|
ASK |
IF SPQINTOBT = 1 |
ENTER FIRST AND LAST NAME OF INTERPRETER HERE.
_____________________________ ENTER FIRST AND LAST NAME
|
|
SPANISH |
N/A |
QUESTION TYPE |
Text entry |
FILLS |
|
NOTES |
ALLOW 150 CHARACTERS |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
INT.006 |
NEXT |
SPQINTPHON |
SPQINTSRCE |
|
ASK |
IF SPQINTOBT = 2 |
SELECT INTERPRETER SOURCE.
1. RELATIVE LIVING IN HOUSEHOLD 2. NON-RELATIVE LIVING IN HOUSEHOLD 3. NEIGHBOR, RELATIVE OR FRIEND -- NOT IN HOUSEHOLD
|
|
SPANISH |
N/A |
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
INT.007 |
NEXT |
IF SPQINTSRCE = 3: SPQINTNAME ELSE: SPQINTHH |
SPQINTHH / SPQINTHHO |
|
ASK |
IF SPQINTSRCE = 1 OR 2 |
SELECT NAME OF INTERPRETER FROM HOUSEHOLD ROSTER.
<DISPLAY LIST 1>
|
|
SPANISH |
N/A |
QUESTION TYPE |
Dropdown: SPQINTHH Text entry: SPQINTHHO |
FILLS |
DISPLAY LIST 1: DISPLAY LIST OF ADULTS FROM HH ROSTER NOT INCLUDING THE RESPONDENT INCLUDE “OTHER SPECIFY” OPTION. WHEN SELECTED DISPLAY TEXT FIELD WITH “ENTER FIRST AND LAST NAME” IN THE FIELD |
NOTES |
ALLOW 150 CHARACTERS FOR “OTHER SPECIFY” OPTION |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
IF “OTHER: SPECIFY” IS CHOSEN, DISPLAY: “INTERVIEWER: THIS PERSON WAS NOT ROSTERED IN THE SCREENER.
|
VERSION NOTES |
INT.008 |
NEXT |
SPQINTPHON |
SPQINTNAME |
|
ASK |
IF SPQINTSRCE = 3 |
ENTER FIRST AND LAST NAME OF INTERPRETER.
_________________________________ ENTER FIRST AND LAST NAME
|
|
SPANISH |
N/A |
QUESTION TYPE |
Textbox |
FILLS |
|
NOTES |
ALLOW 100 CHARACTERS |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
INT.009 |
NEXT |
SPQINTPHON |
SPQINTPHON |
|
ASK |
IF SPQINTYN = 1 |
ENTER PHONE NUMBER OF INTERPRETER.
INTERVIEWER INSTRUCTION: ENTER '000' IN AREA CODE IF NO PHONE.
(|___|___|___|) |___|___|___| - |___|___|___|___|
77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
N/A |
QUESTION TYPE |
Numeric |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
ONLY ALLOW RESPONSE OF DON’T KNOW, REFUSED, "000" or 10 DIGIT PHONE NUMBER. IF PHONE NUMBER PROVIDED, DISPLAY HARD RANGE CHECK MESSAGE IF PHONE NUMBER NOT "000" OR IS 10 DIGITS OF ALL THE SAME NUMBER (I.E., 1111111111): “PLEASE ENTER A VALID PHONE NUMBER.” |
SOFT CHECK |
|
VERSION NOTES |
INT.010 |
NEXT |
SPQCONSENT |
SPQCONSENT |
|
ASK |
All respondents |
Now I’ll play a short video that describes the interview, <TEXT FILL 5> rights as the survey participant in our survey, and how all of <TEXT FILL 5> information is kept private.
INTERVIEWER INSTRUCTION: PLAY CONSENT VIDEO. WHEN VIDEO ENDS, CONTINUE BELOW.
<TEXT FILL 2>
<TEXT FILL 3>
Do you have any questions before we continue?
INTERVIEWER INSTRUCTION: ADDRESS QUESTIONS FROM RESPONDENT
Do you agree to proceed with the interview<TEXT FILL 4>?
1. YES 2. NO
|
|
SPANISH |
Ahora le mostraré un breve video que describe la entrevista, los derechos de <TEXT FILL 5> como participante en nuestra encuesta y cómo todos los datos de <TEXT FILL 5> se mantienen confidenciales.
INTERVIEWER INSTRUCTION: PLAY CONSENT VIDEO. WHEN VIDEO ENDS, CONTINUE BELOW.
<TEXT FILL 2>
<TEXT FILL 3>
¿Tiene alguna pregunta antes de continuar?
INTERVIEWER INSTRUCTION: ADDRESS QUESTIONS FROM RESPONDENT
¿Está de acuerdo en continuar con la entrevista <TEXT FILL 4>?
1. YES 2. NO
|
SPANISH |
CONSENT VIDEO SCRIPT: [START OF VIDEO] – THIS WILL NOT BE INCLUDED IN THE PROGRAMMING SPECIFICATIONS FOR THE SP QUESTIONNAIRE A las personas que tomen parte en NHANES, se les harán algunas preguntas sobre su salud. Les preguntaremos sobre las condiciones médicas que tienen, lo que comen y los medicamentos recetados que toman. El(La) entrevistador(a) tratará de hacerle las preguntas a un ritmo cómodo para usted. En promedio, la entrevista tomará de 30 a 60 minutos. Como agradecimiento por su tiempo y esfuerzo, recibirá una tarjeta de regalo de $25 dólares por responder la entrevista. Tomar parte en esta entrevista es un voluntario, lo que significa que participar es su decisión. Si decide participar, puede dejar de contestar cualquier pregunta que no desee responder. También puede detener la entrevista en cualquier momento. La privacidad de sus respuestas es muy importante. Durante la mayor parte de la entrevista, el(la) entrevistador(a) le hará preguntas e ingresará sus respuestas en la computadora. Usted responderá algunas de las preguntas por su cuenta, escuchando mientras la computadora le lee las preguntas y usted ingresa sus respuestas directamente en la computadora. Todo lo que nos diga es privado. Según las leyes federales, debemos seguir procedimientos estrictos para proteger su información. Mantendremos su información en forma confidencial, lo que significa que sus respuestas no se asociarán con su nombre ni con ningún otro dato que pueda identificarlo(a) como participante. Queremos que tenga en cuenta que la participación en el estudio presenta unos posibles riesgos. Algunas preguntas que le haremos podrían hacer que sienta incomodidad o molestia. Si siente incomodidad o molestia, puede pedir al(a la) entrevistador(a) que haga una pausa o que no haga alguna de las preguntas. Otro riesgo es que alguien pueda enterarse de lo que nos dice durante la entrevista. Para evitar esto, usaremos un número en lugar de su nombre para identificar su información. Esto evitará que alguien se entere de lo que nos dice. Si tiene alguna pregunta sobre sus derechos como participante en esta encuesta, puede llamar a la línea gratuita de la Junta de Revisión de Ética del Centro Nacional de Estadísticas de la Salud al 1-800-223-8118.[END OF VIDEO]. |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 2: IF SP/PROXY IS ALSO AN ELIGIBLE HH REFERENCE PERSON FOR THE HH INTERVIEW, FILL: “After this interview, I will also ask some questions related to your household, such as smoking behavior, consumer behavior, food security, and income. On average, the interview will take 15 minutes.” ELSE, LEAVE BLANK
TEXT FILL 3: FOR HOUSEHOLDS WITH SP 0-17 YEARS, FILL: “We will also gather tap water in your household.” ELSE, LEAVE BLANK
TEXT FILL 4: IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR, FILL “for [SP NAME]” ELSE, LEAVE BLANK
TEXT FILL 5: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 2: IF SP/PROXY IS ALSO AN ELIGIBLE HH REFERENCE PERSON FOR THE HH INTERVIEW, FILL: “Después de esta entrevista, también le haré algunas preguntas relacionadas con su hogar, como hábitos de fumar, hábitos de comprar, la seguridad alimentaria y los ingresos. En promedio, la entrevista toma 15 minutos.” ELSE, LEAVE BLANK
TEXT FILL 3: FOR HOUSEHOLDS WITH SP 0-17 YEARS, FILL: “También recolectaremos agua de la llave de su hogar.” ELSE, LEAVE BLANK
TEXT FILL 4: IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR, FILL “en nombre de [SP NAME]” ELSE, LEAVE BLANK
TEXT FILL 5: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
DISPLAY OMB NUMBER IN UPPER RIGHT OF SCREEN IF SPQCONSENT = 2 AND SOFT CHECK IS SUPPRESSED, WHEN NEXT BUTTON IS PRESSED, CASE CLOSES AS PARTIALLY WORKED. |
HELP SCREEN (ENG) |
Assurance of Confidentiality – 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 of 2018 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. Public reporting burden for this collection of information is estimated to average 30 to 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0950). |
HELP SCREEN (SPA) |
Garantía de confidencialidad - Tomamos su privacidad con mucha seriedad. Toda la información que describe o se relaciona con características que pueden identificar a personas o establecimientos se usará únicamente con fines estadísticos. El personal, los contratistas y los agentes del NCHS no divulgarán ni darán a conocer respuestas que puedan identificar a alguien sin el consentimiento de la persona o establecimiento de acuerdo con el artículo 308(d) de la Ley de Servicio de Salud Pública (42 U.S.C 242m) y la Ley de Protección de Información Confidencial y Eficiencia Estadística o CIPSEA (44 U.S.C. 3561-3583). De acuerdo con CIPSEA, cada empleado, contratista y agente del NCHS ha hecho un juramento y está sujeto a encarcelamiento por un término hasta de cinco años, una multa hasta de $250,000, o ambos, si intencionalmente divulga CUALQUIER información que le identifique a usted. Además de las leyes citadas anteriormente, NCHS cumple con la Ley de Mejora de la Ciberseguridad de 2015 (6 U.S.C. §§ 151 y anotación en 151) que protege los sistemas de información federales de los riesgos de ciberseguridad mediante la detección de sus redes. La carga de información pública de recopilación de información se estima en 30 a 60 minutos por respuesta, incluido el tiempo para revisar las instrucciones, buscar fuentes de datos existentes, recopilar y mantener los datos necesarios y completar y revisar la recopilación de información. Una agencia no puede realizar ni patrocinar, y una persona no está obligada a responder a una recopilación de información a menos que muestre un número de control OMB en este momento válido. Envíe comentarios sobre otro aspecto de esta recopilación de información, incluidas sugerencias para reducir esta carga a CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0950). |
HARD CHECK |
|
SOFT CHECK |
IF SPQCONSENT = 2, DISPLAY “EACH RESPONDENT FOR SP QUESTIONNAIRE MUST GIVE CONSENT BEFORE THE INTERVIEW CAN BE ADMINISTERED.” |
VERSION NOTES |
RIQ.281 |
NEXT |
IF SPQCONSENT = 2: DISPLAY MESSAGE AND CLOSE CASE AS PARTIALLY WORKED ELSE: SPQDOBD |
CONSENT VIDEO SCRIPT: [START OF VIDEO] – THIS WILL NOT BE INCLUDED IN THE PROGRAMMING SPECIFICATIONS FOR THE SP QUESTIONNAIRE
People who take part in NHANES will be asked some questions about their health. We will ask about the medical conditions they have, the food they eat, and the prescription medicine they take. The interviewer will try to ask the questions at a pace that you feel comfortable with. On average, the interview will take 30 to 60 minutes.
As a thank you for your time and effort, you will receive a $25 gift card for doing the interview.
Taking part in this interview is voluntary, which means it’s your choice to participate. If you decide to participate, you may choose to skip any question you don’t want to answer. You can also end the interview at any time.
The privacy of your answers is very important. For most of the interview, the interviewer will ask you questions and enter your answers into the computer. For some of the questions, you will answer them yourself, listening while the computer reads you the questions and entering your answers directly into the computer.
Everything you tell us is private. By federal law, we must follow strict procedures to protect your information. We will keep your information confidential, which means your answers will not be connected to your name or anything else that can identify you as a participant.
There are potential risks involved in study participation that we want you to be are aware of. Some of the questions we ask might make you feel uncomfortable or upset. If you feel uncomfortable or upset, you may ask the interviewer to take a break or skip any of the questions. Another risk is that that someone might find out what you tell us during the interview. To avoid that, we will use a number instead of your name to identify your information. This will prevent anyone from finding out what you told us.
If you have questions about your rights on being in the survey, you can make a toll-free call to the National Center for Health Statistics Ethics Review Board at 1-800-223-8118.[END OF VIDEO]
SPQDOBD / SPQDOBM / SPQDOBY |
|
ASK |
All respondents |
ADMINISTER DOB SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
What is <TEXT FILL 4> birthdate?
REPORTED AGE: <AGE FILL>
|___|___| ENTER DAY OF BIRTH [SPQDOBD]
77. REFUSED 99. DON’T KNOW
|___|___| ENTER MONTH OF BIRTH [SPQDOBM]
77. REFUSED 99. DON’T KNOW
|___|___|___|___| ENTER YEAR OF BIRTH [SPQDOBY]
7777. REFSUED 9999. DON’T KNOW
|
|
SPANISH |
ADMINISTER DOB SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
¿Cuál es <TEXT FILL 4>?
REPORTED AGE: <AGE FILL>
|___|___| ENTER DAY OF BIRTH [SPQDOBD]
77. REFUSED 99. DON’T KNOW
|___|___| ENTER MONTH OF BIRTH [SPQDOBM]
77. REFUSED 99. DON’T KNOW
|___|___|___|___| ENTER YEAR OF BIRTH [SPQDOBY]
7777. REFSUED 9999. DON’T KNOW
|
QUESTION TYPE |
Numeric: SPQDOBD, SPQDOBM, SPQDOBY |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SPQAGEQ/U/R IS 18+ FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SPQAGEQ/U/R IS 18+ FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SPQAGEQ/U/R IS < 18
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 4: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
AGE FILL: FILL AGE IN MONTHS OR YEARS AS REPORTED IN SPQAGEQ/U ELSE, FILL AGE RANGE AS REPORTED IN SPQAGER |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SPQAGEQ/U/R IS 18+ FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SPQAGEQ/U/R IS 18+ FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SPQAGEQ/U/R IS < 18
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 4: FILL “su fecha de nacimiento” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “la fecha de nacimiento de [SP NAME]”
AGE FILL: FILL AGE IN MONTHS OR YEARS AS REPORTED IN SPQAGEQ/U ELSE, FILL AGE RANGE AS REPORTED IN SPQAGER |
NOTES |
SEPARATE FIELDS FOR MONTH, DAY, AND YEAR, ALLOW ENTRY OF RF AND DK IN FIELDS.
CALCULATE TWO VARIABLES TO CAPTURE SP AGE AT TIME OF SCREENER. DATE OF COMPLETED SCREENER SHOULD BE PASSED FROM SCREENER:
CALCULATE THREE VARIABLES TO CAPTURE SP AGE AT TIME OF SP INTERVIEW:
CALCULATE SP AGE IN DAYS IF SPQDOBD/M/Y= DK/REF AND SPQAGEQ/U <> DK/REF AS FOLLOWS:
CALCULATE SP AGE IN DAYS IF SPQDOBD/M/Y= DK/REF AND SPQAGEQ/U = DK/REF AND SPQAGER <> DK/REF AS FOLLOWS:
NEW VARIABLES SCDSPAGEM AND SCDSPAGEY CAN BE USED IN SP QUESTIONNAIRE AND MEC EXAM AS STATIC VARIABLES.
IF NO DOB PROVIDED IN SPQDOBD/M/Y, USE AGE PROVIDED IN SPQAGEQ/U. IF NO AGE IS PROVIDED IN SPQAGEQ/U, AGE IS THE LOWEST VALUE IN THE AGE RANGE SELECTED IN SPQAGER.
|
HELP SCREEN |
|
HARD CHECK |
IF SPQDOBM = 0 OR > 12, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 1 AND 12.”
IF SPQDOBD = 0 OR > 31, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 1 AND 31.”
IF SPQDOBY <1900 OR >9999, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 1900 AND 9999.”
IF DOB ENTERED > TODAY’S DATE, DISPLAY “ENTRY MUST BE TODAY’S DATE OR EARLIER.”
IF SP AGE REPORTED IN SCREENER >= 18 AND SCDSPAGEY <18, DISPLAY “AGE ENTERED INDICATES SP STATUS AS A MINOR. SP WAS ROSTERED AS AN ADULT IN THE SCREENER. VERIFY AGE AND IF SP IS LESS THAN 18 YEARS OLD, PRESS EXIT TO BREAK OFF AND CONTACT YOUR SUPERVISOR.”
IF SP AGE REPORTED IN SCREENER < 18 AND SCDSPAGEY >=18, DISPLAY “AGE ENTERED INDICATES SP STATUS AS AN ADULT. SP WAS ROSTERED AS A MINOR IN THE SCREENER. VERIFY AGE AND IF SP IS GREATER THAN OR EQUAL TO 18 YEARS OLD, PRESS EXIT TO BREAK OFF AND CONTACT YOUR SUPERVISOR.” |
SOFT CHECK |
IF PRELOADED SCREENER AGE (AGE/AGE_UNIT) <> DK/REF AND SPQAGEQ/U <> DK/REF AND SPQDOBD/M/Y = DK/REF:
BASED ON AGE REPORTED EARLIER IN THE INTERVIEW, SP WAS BORN IN <DOB YEAR DERIVED FROM SPQAGEQ/U>. PLEASE VERIFY DOB YEAR. UPDATE REPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.”
IF PRELOADED SCREENER AGE (AGE/AGE_UNIT) AND SPQDOBD/M/Y <> DK/REF:
PLEASE VERIFY DOB. UPDATE REPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.”
IF PRELOADED SCREENER AGE (AGE/AGE_UNIT) AND SPQDOBD/M/Y <> DK/REF AND SPQAGEQ/U <> DK/REF:
PLEASE VERIFY DOB. UPDATE REPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.”
|
VERSION NOTES |
DMQ.500m/d/y |
NEXT |
SPQGENDER |
SPQGENDER |
|
ASK |
All respondents |
ADMINISTER GENDER SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
For the next question, you may give me more than one answer. <TEXT FILL 3> …
INTERVIEWER INSTRUCTION: CODE ALL THAT APPLY.
1. Male 2. Female 3. Transgender, non-binary, or another gender 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
ADMINISTER GENDER SCREEN TO <TEXT FILL 1> THIS IS FOR THE HEALTH INTERVIEW FOR <TEXT FILL 2>
Para la siguiente pregunta, puede seleccionar más de una respuesta. ¿<TEXT FILL 3>…?
INTERVIEWER INSTRUCTION: CODE ALL THAT APPLY.
1. Hombre 2. Mujer 3. Transgénero, persona no binaria u otro género 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Select all that apply |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SPQAGEQ/U/R IS 18+ YEARS FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SPQAGEQ/U/R IS 18+ YEARS FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SPQAGEQ/U/R IS < 18 YEARS
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “Are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Is [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SPQAGEQ/U/R IS 18+ YEARS FILL “PROXY FOR [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SPQAGEQ/U/R IS 18+ YEARS FILL “PARENT/GUARDIAN OF [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND AGE IN SPQAGEQ/U/R IS < 18 YEARS
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “Es usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Es [SP NAME]” |
NOTES |
IF SPQGENDER=3,7, OR 9 AND RESPONDENT IS A PROXY, FOR ALL PRONOUN FILLS THEREAFTER DISPLAY THE SP NAME. |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DMQ.021N |
NEXT |
END OF SECTION |
EARLY CHILDHOOD – ECQ
Target Group: SPs Birth to 17 Years
ECQWGTM / ECQWGTL / ECQWGTO / ECQWGTK / ECQWGTG |
|
ASK |
IF SP AGE IS BIRTH TO 17 YEARS |
Now, I have some questions about <TEXT FILL 1> birth. How much did <TEXT FILL 2> weigh at birth?
INTERVIEWER INSTRUCTION: IF ANSWER GIVEN IN POUNDS ONLY, PROBE FOR OUNCES. IF ANSWER GIVEN IN EXACT POUNDS, ENTER NUMBER OF POUNDS AND 0 OUNCES. ENTER WEIGHT IN POUNDS, KILOGRAMS OR GRAMS.
|___| [ECQWGTM]
1. ENTER NUMBER OF POUNDS AND OUNCES 2. ENTER NUMBER IN KILOGRAMS 3. ENTER NUMBER IN GRAMS 9. DON’T KNOW 7. REFUSED
|___|___| ENTER NUMBER OF POUNDS [ECQWGTL]
AND
|___|___| ENTER NUMBER OF OUNCES [ECQWGTO]
OR
|___|___|___| ENTER NUMBER IN KILOGRAMS [ECQWGTK]
OR
|___|___|___| ENTER NUMBER IN GRAMS [ECQWGTG] |
|
SPANISH |
Ahora, tengo algunas preguntas acerca del nacimiento de <TEXT FILL 1>. ¿Cuánto pesó <TEXT FILL 2> al nacer?
INTERVIEWER INSTRUCTION: IF ANSWER GIVEN IN POUNDS ONLY, PROBE FOR OUNCES. IF ANSWER GIVEN IN EXACT POUNDS, ENTER NUMBER OF POUNDS AND 0 OUNCES. ENTER WEIGHT IN POUNDS, KILOGRAMS OR GRAMS.
|___| [ECQWGTM]
1. ENTER NUMBER OF POUNDS AND OUNCES 2. ENTER NUMBER IN KILOGRAMS 3. ENTER NUMBER IN GRAMS 9. DON’T KNOW 7. REFUSED
|___|___| ENTER NUMBER OF POUNDS [ECQWGTL]
AND
|___|___| ENTER NUMBER OF OUNCES [ECQWGTO]
OR
|___|___|___| ENTER NUMBER IN KILOGRAMS [ECQWGTK]
OR
|___|___|___| ENTER NUMBER IN GRAMS [ECQWGTG]
|
QUESTION TYPE |
Dropdown: ECQWGTM Numeric: ECQWGTL, ECQWGTO, ECQWGTK, ECQWGTG |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]’s”
TEXT FILL 2: FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF ECQWGTL >= 20, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 19.”
IF ECQWGTO > 15, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 15.”
IF ECQWGTK >= 9, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 8.”
IF ECQWGTG >= 9,000, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 9000.” |
SOFT CHECK |
IF ECQWGTL <3 OR >13, DISPLAY “UNUSUAL BIRTH WEIGHT, PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.”
IF ECQWGTK <1.5 OR > 6, DISPLAY “UNUSUAL BIRTH WEIGHT, PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.”
IF ECQWGTG <1,500 OR > 6,000, DISPLAY “UNUSUAL BIRTH WEIGHT, PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
ECQ.071G/L/O/K/M |
NEXT |
IF ECQWGTM = 7 OR 9: ECQWGTRNG IF ECQWGTM = 1 OR 2 OR 3 AND SP AGE = 2-17 YEARS: ECQWGTDES IF ECQWGTM = 1 OR 2 OR 3 AND SP AGE = 0-11 MONTHS OR 1 YEAR: ECQMOMWGTM |
ECQWGTRNG |
|
ASK |
IF ECQWGTM = 7 OR 9 |
Did <TEXT FILL 1> weigh…
1. more than 5 and a half pounds (2 and a half kilograms), or 2. less than 5 and a half pounds (2 and a half kilograms)? 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
¿<TEXT FILL 1> pesó...?
1. más de 5 libras y media (2 kilogramos y medio) 2. menos de 5 libras y media (2 kilogramos y medio) 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
ECQ.080 |
NEXT |
IF ECQWGTRNG = 1: ECQWGTRNGM IF ECQWGTRNG = 2 OR 7 OR 9 AND SP AGE = 2-17 YEARS: ECQWGTDES IF ECQWGTRNG = 2 OR 7 OR 9 AND SP AGE = 0-11 MONTHS OR 1 YEAR: ECQMOMWGTM |
ECQWGTRNGM |
|
ASK |
IF ECQWGTRNG = 1 |
Did <TEXT FILL 1> weigh …
1. more than 9 pounds (4 kilograms), or 2. less than 9 pounds (4 kilograms)? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿<TEXT FILL 1> pesó...?
1. más de 9 libras (4 kilogramos) 2. menos de 9 libras (4 kilogramos) 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
ECQ.090 |
NEXT |
IF SP AGE = 2-17 YEARS: ECQWGTDES IF SP AGE = 0-11 MONTHS OR 1 YEAR: ECQMOMWGTM |
ECQWGTDES |
|
ASK |
IF SP AGE = 2-17 YEARS |
Do you consider <TEXT FILL 1> now to be …
1. overweight, 2. underweight, or 3. about the right weight? 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
¿Considera usted que <TEXT FILL 1> ahora tiene...
1. sobrepeso, 2. bajo peso, o 3. más o menos el peso adecuado? 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
WHQ.030e |
NEXT |
ECQWGTDR |
ECQWGTDR |
|
ASK |
IF SP AGE = 2-17 YEARS |
Has a doctor or health professional ever said that <TEXT FILL 1> was overweight?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
¿Ha dicho alguna vez un médico o profesional de la salud que <TEXT FILL 1> tenía sobrepeso?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]”
|
NOTES |
|
HELP SCREEN (ENG) |
Doctor: The term refers to both doctors of medicine (M.D.s) and doctors of osteopathic medicine (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, but other doctoral degrees such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Health Professionals (Health Care Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: physician’s assistants or associates (PAs), nurse practitioners, nurses, pharmacists, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers. |
HELP SCREEN (SPA) |
Médico/Doctor: El término se refiere tanto a los doctores en medicina (M.D., por sus siglas en inglés) como a los doctores en medicina osteopática (D.O., por sus siglas en inglés). Se incluye tanto a médicos generales como a los especialistas. No incluye a personas que no tienen un título de doctor en medicina (M.D. o D.O.), pero que tienen otros títulos de doctor como dentistas, cirujanos orales, quiroprácticos, podólogos, curanderos de la ciencia cristiana, ópticos, oculistas, psicólogos, etc.
Profesionales de la salud (Profesional de la atención médica): Una persona autorizada por su capacitación y experiencia, y posiblemente por una licencia, para asistir a un médico y trabajan con uno o varios médicos. Algunos ejemplos incluyen: asistentes o auxiliares médicos (PA, por sus siglas en inglés), enfermeros practicantes, personal de enfermería, farmacéuticos, técnicos de laboratorio y técnicos que aplican inyecciones (por ejemplo, inyecciones para las alergias). Incluya también paramédicos, fisioterapeutas y terapeutas médicos que trabajan con un médico o en consultorios médicos. No incluya: dentistas, cirujanos de la boca, quiroprácticos, quiropedistas, podólogos, naturópatas, curanderos de la ciencia cristiana, ópticos, oculistas ni psicólogos o trabajadores sociales. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MCQ.080e |
NEXT |
END OF SECTION |
ECQMOMWGTM / ECQMOMWGTL / ECQMOMWGTK |
|
ASK |
IF SP AGE = 0-11 MONTHS OR 1 YEAR |
How much did <TEXT FILL 1> biological mother weigh before she was pregnant with <TEXT FILL 2>?
|___| [ECQMOMWGTM]
1. ENTER WEIGHT IN POUNDS 2. ENTER WEIGHT IN KILOGRAMS 9. DON’T KNOW 7. REFUSED
|___|___|___| ENTER NUMBER OF POUNDS [ECQMOMWGTL]
OR
|___|___|___| ENTER NUMBER OF KILOGRAMS [ECQMOMWGTK]
|
|
SPANISH |
¿Cuánto
pesaba la madre biológica de <TEXT
FILL 1> antes de quedar
embarazada de
|___| [ECQMOMWGTM]
1. ENTER WEIGHT IN POUNDS 2. ENTER WEIGHT IN KILOGRAMS 9. DON’T KNOW 7. REFUSED
|___|___|___| ENTER NUMBER OF POUNDS [ECQMOMWGTL]
OR
|___|___|___| ENTER NUMBER OF KILOGRAMS [ECQMOMWGTK]
|
QUESTION TYPE |
Dropdown: ECQMOMWGHTM Numeric: ECQMOMWGTL, ECQMOMWGTK |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]’s”
TEXT FILL 2: FILL “him” IF SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “él” IF SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF ECQMOMWGTL <50 OR >750, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 50 AND 750.”
IF ECQMOMWGTK <23 OR >338, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 23 AND 338.” |
SOFT CHECK |
IF ECQMOMWGTL <75 OR >500, DISPLAY “UNUSUAL ENTRY. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.”
IF ECQMOMWGTK <34 OR >225, DISPLAY “UNUSUAL ENTRY. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
ECQ.035L/K |
NEXT |
IF ECQMOMWGTM = 7 OR 9: ECQMOMHGTM ELSE: END OF SECTION |
ECQMOMHGTM / ECQMOMHGTF / ECQMOMHGTI / ECQMOMHGTC |
|
ASK |
IF ECQMOMWGTM = 7 OR 9 |
How tall is <TEXT FILL 1> biological mother without shoes?
|___| [ECQMOMHGTM]
1. ENTER HEIGHT IN FEET AND INCHES 2. ENTER HEIGHT IN CENTIMETERS 9. DON’T KNOW 7. REFUSED
|___|___| ENTER NUMBER OF FEET [ECQMOMHGTF]
AND
|___|___| ENTER NUMBER OF INCHES [ECQMOMHGTI]
OR
|___|___|___| ENTER NUMBER OF CENTIMETERS [ECQMOMHGTC]
|
|
SPANISH |
¿Cuánto mide la madre biológica de <TEXT FILL 1> sin zapatos?
|___| [ECQMOMHGTM]
1. ENTER HEIGHT IN FEET AND INCHES 2. ENTER HEIGHT IN CENTIMETERS 9. DON’T KNOW 7. REFUSED
|___|___| ENTER NUMBER OF FEET [ECQMOMHGTF]
AND
|___|___| ENTER NUMBER OF INCHES [ECQMOMHGTI]
OR
|___|___|___| ENTER NUMBER OF CENTIMETERS [ECQMOMHGTC]
|
QUESTION TYPE |
Dropdown: ECQMOMHGTM Numeric: ECQMOMHGTF, ECQMOMHGTI, ECQMOMHGTC |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF ECQMOMHGTF <2 OR >8, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 2 AND 8.”
IF ECQMOMHGTI >=12, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 11.”
IF ECQMOMHGTC <61 OR >272, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 61 AND 272.” |
SOFT CHECK |
|
VERSION NOTES |
ECQ.045/G/F/I/C |
NEXT |
END OF SECTION |
HEALTHCARE UTILIZATION – HUQ
Target Group: SPs Birth +
HUQHEALTH |
|
ASK |
ALL RESPONDENTS |
Next, I have some general questions about <TEXT FILL 1> health.
Would you say <TEXT FILL 1> health in general is …
1. excellent, 2. very good, 3. good, 4. fair, or 5. poor? 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
A continuación, tengo algunas preguntas generales acerca de <TEXT FILL 1>.
¿Diría que <TEXT FILL 1> en general es...
1. excelente, 2. muy buena, 3. buena, 4. regular, o 5. mala? 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “su salud” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “la salud de [SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
HUQ.010 |
NEXT |
HUQPLACE |
HUQPLACE |
|
ASK |
ALL RESPONDENTS |
Is there a place that <TEXT FILL 1> usually <TEXT FILL 2> to if <TEXT FILL 3> sick and <TEXT FILL 4> health care?
1. YES 2. THERE IS NO PLACE 3. THERE IS MORE THAN ONE PLACE 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
¿Hay algún lugar al que <TEXT FILL 1> va usualmente cuando está enfermo(a) y necesita recibir atención médica?
1. YES 2. THERE IS NO PLACE 3. THERE IS MORE THAN ONE PLACE 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “go” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “goes”
TEXT FILL 3: FILL “you are” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he is” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she is” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] is” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), OR DK/RF IN SPQGENDER
TEXT FILL 4: FILL “need” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “needs” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “BLANK”
TEXT FILL 3: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), OR DK/RF IN SPQGENDER
TEXT FILL 4: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “BLANK” |
NOTES |
|
HELP SCREEN (ENG) |
Usual Place: Include walk-in clinic, doctor's office, clinic, health center, Health Maintenance Organization or HMO, hospital emergency room or outpatient clinic, or a military or VA health care facility. Also include visits via telehealth. |
HELP SCREEN (SPA) |
Lugar usual: incluya clínicas para atención inmediata (walk-in), consultorios médicos, clínicas, centros de salud, Organización de Servicios de Salud (HMO, por sus siglas en inglés), sala de emergencia de un hospital o clínicas de servicios ambulatorios, o centros de atención médica militar o de la Administración de Veteranos (VA, por sus siglas en inglés). También incluya las consultas de telesalud. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
HUQ.030 |
NEXT |
IF HUQPLACE = 2 OR 7 OR 9: HUQDOCTOR ELSE: HUQPLACETP |
HUQPLACETP |
|
ASK |
IF HUQPLACE = 1 OR 3 |
<TEXT FILL 1> -- a doctor’s office or health center; an urgent care center or clinic in a drug store or grocery store; a hospital emergency room; a VA Medical Center or VA outpatient clinic; or some other place?
1. A DOCTOR’S OFFICE OR HEALTH CENTER 2. URGENT CARE CENTER OR CLINIC IN A DRUG STORE OR GROCERY STORE 3. A HOSPITAL EMERGENCY ROOM 4. A VA MEDICAL CENTER OR VA OUTPATIENT CLINIC 5. SOME OTHER PLACE 6. DOESN’T GO TO ONE PLACE MOST OFTEN 99. DON’T KNOW 77. REFUSED
|
|
SPANISH |
<TEXT FILL 1> -- ¿Un consultorio médico o un centro de salud; un centro de atención de urgencias o una clínica en una farmacia o supermercado; una sala de emergencias de un hospital; un centro médico de la VA o una clínica de pacientes ambulatorios de la VA; o algún otro lugar?
1. UN CONSULTORIO MÉDICO O CENTRO DE SALUD 2. CENTRO DE ATENCIÓN DE URGENCIAS O UNA CLÍNICA EN UNA FARMACIA O SUPERMERCADO 3. SALA DE EMERGENCIAS DE UN HOSPITAL 4. CENTRO MÉDICO DE LA VA O CLÍNICA DE PACIENTES AMBULATORIOS DE LA VA 5. ALGÚN OTRO LUGAR 6. NO VA A UN LUGAR CON MÁS FRECUENCIA 99. DON’T KNOW 77. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “What kind of place is it” IF HUQPLACE = 1 FILL “What kind of place do you go to most often” IF HUQPLACE = 3 AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “What kind of place does [SP NAME] go to most often” IF HUQPLACE = 3 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR |
FILLS (SPA) |
TEXT FILL 1: FILL “¿Qué tipo de lugar es?” IF HUQPLACE = 1 FILL “¿A qué tipo de lugar va con más frecuencia?” IF HUQPLACE = 3 AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “¿A qué tipo de lugar va [SP NAME] con más frecuencia?” IF HUQPLACE = 3 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR |
NOTES |
|
HELP SCREEN (ENG) |
Doctor’s office or health center is a place where you see the same doctor or 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 do not usually see the same health care provider at each visit. |
HELP SCREEN (SPA) |
Consultorio médico o centro de salud es un lugar en el que usted ve al mismo médico o el mismo grupo de médicos en cada visita, donde normalmente necesita hacer una cita con anticipación y donde se archivan sus historiales médicos.
Los centros de atención urgente y las clínicas en farmacias o tiendas de comestibles son lugares en los que no necesita programar una cita con anticipación y no suele atenderse con el mismo proveedor de atención médica en cada consulta. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
HUQ.042 |
NEXT |
HUQDOCTOR |
HUQDOCTOR |
|
ASK |
ALL RESPONDENTS |
About how long has it been since <TEXT FILL 1> last saw a doctor or other health care professional about <TEXT FILL 2> health?
INTERVIEWER INSTRUCTION: INCLUDE DOCTORS SEEN BY VIDEO CONFERENCE OR BY PHONE AS WELL AS SEEN WHILE A PATIENT IN A HOSPITAL. DO NOT INCLUDE DENTAL CARE.
0. NEVER 1. WITHIN THE LAST YEAR (ANYTIME LESS THAN 12 MONTHS AGO) 2. WITHIN THE LAST 2 YEARS (1 YEAR BUT LESS THAN 2 YEARS AGO) 3. WITHIN THE LAST 3 YEARS (2 YEARS BUT LESS THAN 3 YEARS AGO) 4. WITHIN THE LAST 5 YEARS (3 YEARS BUT LESS THAN 5 YEARS AGO) 5. WITHIN THE LAST 10 YEARS (5 YEARS BUT LESS THAN 10 YEARS AGO) 6. 10 YEARS AGO OR MORE 99. DON’T KNOW 77. REFUSED
|
|
SPANISH |
¿Cómo cuánto tiempo ha pasado desde la última vez que <TEXT FILL 1> vio a un médico u otro profesional de la atención médica sobre su salud?
INTERVIEWER INSTRUCTION: INCLUDE DOCTORS SEEN BY VIDEO CONFERENCE OR BY PHONE AS WELL AS SEEN WHILE A PATIENT IN A HOSPITAL. DO NOT INCLUDE DENTAL CARE.
0. NUNCA 1. DENTRO DE LOS ÚLTIMOS 12 MESES (EN CUALQUIER MOMENTO HACE MENOS DE 12 MESES) 2. DENTRO DE LOS ÚLTIMOS 2 AÑOS (HACE UN AÑO PERO MENOS DE 2 AÑOS) 3. DENTRO LOS ÚLTIMOS 3 AÑOS (HACE 2 AÑOS PERO MENOS DE 3 AÑOS) 4. DENTRO DE LOS ÚLTIMOS 5 AÑOS (HACE 3 AÑOS PERO MENOS DE 5 AÑOS) 5. DENTRO DE LOS ÚLTIMOS 10 AÑOS (HACE 5 AÑOS PERO MENOS DE 10 AÑOS) 6. HACE 10 AÑOS O MÁS 99. DON’T KNOW 77. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELCETED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELCETED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
HUQ.062 |
NEXT |
IF SP AGE >= 5 YEARS: HUQCOUNSEL ELSE: END OF SECTION |
HUQCOUNSEL |
|
ASK |
IF SP AGE IS >= 5 YEARS |
In the last 12 months, did <TEXT FILL 1> receive counseling or therapy from a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
En los últimos 12 meses, ¿recibió <TEXT FILL 1> asesoramiento o terapia de un profesional de la salud mental como un psiquiatra, psicólogo, enfermero psiquiátrico o trabajador social clínico?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
HUQ.090 |
NEXT |
END OF SECTION |
IMMUNIZATION – IMQ
Target Group: SPs Birth+
IMQHEPAYN |
|
ASK |
IF SP AGE IS >= 2 YEARS |
Now, we have a few questions about vaccines. <TEXT FILL 1> ever received the hepatitis A vaccine?
INTERVIEWER INSTRUCTION: A COMBINATION HEPATITIS A AND HEPATITIS B VACCINE SHOULD BE COUNTED AS THE A VACCINE FOR THE PURPOSE OF THIS QUESTION. CODE 'YES AT LEAST 2 DOSES' IF RESPONDENT ANSWERS 3 OR 4 DOSES WERE RECEIVED. CODE 'LESS THAN 2 DOSES' ONLY IF MENTIONED BY RESPONDENT.
1. YES, AT LEAST 2 DOSES 2. YES, LESS THAN 2 DOSES 3. NO 7. REFUSED 9. DON’T KNOW |
|
SPANISH |
Ahora, tenemos algunas preguntas sobre las vacunas. ¿Le han vacuando a <TEXT FILL 1> alguna vez contra la hepatitis A?
INTERVIEWER INSTRUCTION: A COMBINATION HEPATITIS A AND HEPATITIS B VACCINE SHOULD BE COUNTED AS THE A VACCINE FOR THE PURPOSE OF THIS QUESTION. CODE 'YES AT LEAST 2 DOSES' IF RESPONDENT ANSWERS 3 OR 4 DOSES WERE RECEIVED. CODE 'LESS THAN 2 DOSES' ONLY IF MENTIONED BY RESPONDENT.
1. YES, AT LEAST 2 DOSES 2. YES, LESS THAN 2 DOSES 3. NO 7. REFUSED 9. DON’T KNOW |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Hepatitis (Hep-a-ti-tis) A vaccine is given as a two dose series to children and adults, especially people who travel outside the United States. It has been available since 1995. |
HELP SCREEN (SPA) |
La vacuna contra la hepatitis A se aplica en una serie de dos dosis a niños y adultos, especialmente a personas que viajan fuera de los Estados Unidos. Está disponible desde 1995. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IMQ.011 |
NEXT |
IMQHEPBYN |
IMQHEPBYN |
|
ASK |
IF SP AGE IS >= 2 YEARS |
The hepatitis B vaccine is given in two or three separate doses. Although it can be given as a combination vaccination with hepatitis A, it is different from the hepatitis A vaccine. <TEXT FILL 1> ever received the hepatitis B vaccine?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
La vacuna contra la hepatitis B se aplica en dos o tres dosis separadas. Aunque puede darse como vacuna combinada con la de la hepatitis A, es diferente a la vacuna de la hepatitis A. ¿Le han vacunado a <TEXT FILL 1> alguna vez contra la hepatitis B?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
The hepatitis B vaccine has been available since 1982 for newborn infants, adolescents, and people who may be exposed to the hepatitis B virus. Since 2022, it is recommended for all persons under age 60, and for persons aged 60 years and older who may be exposed to the hepatitis B virus. |
HELP SCREEN (SPA) |
La vacuna contra la hepatitis B está disponible desde 1982 para recién nacidos, adolescentes y personas que puedan estar expuestas al virus de la hepatitis B. Desde 2022, se recomienda esta vacuna a todas las personas menores de 60 años y a las mayores de 60 años que podrían estar expuestas al virus de la hepatitis B. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IMQ.New1 |
NEXT |
IF IMQHEPBYN = 1: IMQHEPBSRS IF IMQHEPBYN = 2 OR 7 OR 9 AND SP AGE IS >= 9 AND <= 64: IMQHPVYN IF IMQHEPBYN = 2 OR 7 OR 9 AND SP AGE IS < 9 OR > 64: IMQFLU |
IMQHEPBSRS |
|
ASK |
IF IMQHEPBYN = 1 |
<TEXT FILL 1> completed the hepatitis B vaccine series?
INTERVIEWER INSTRUCTION: IF AT LEAST ONE DOSE RECEIVED, BUT THE SERIES HAS NOT BEEN COMPLETED, SELECT “NO”.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ha completado <TEXT FILL 1> la serie de vacunas contra la hepatitis B?
INTERVIEWER INSTRUCTION: IF AT LEAST ONE DOSE RECEIVED, BUT THE SERIES HAS NOT BEEN COMPLETED, SELECT “NO”.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
There are two types of hepatitis B vaccines. One has been available since 1982 and requires 3 doses. The other became available in 1998 and requires 2 doses. |
HELP SCREEN (SPA) |
Existen dos tipos de vacunas contra la hepatitis B. Una está disponible desde 1982 y requiere 3 dosis. La otra empezó a estar disponible en 1998 y requiere 2 dosis. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IMQ.New2 |
NEXT |
IF SP AGE IS >= 9 AND <= 64: IMQHPVYN ELSE: IMQFLU |
IMQHPVYN |
|
ASK |
IF SP AGE IS >= 9 AND <= 64 |
Human Papillomavirus or HPV vaccine is given to prevent HPV infection and conditions such as cervical cancer and other cancers caused by HPV (in men and women). <TEXT FILL 1> ever received one or more doses of the HPV vaccine?
(The brand names for the HPV vaccines are Cervarix, Gardasil or Gardasil 9.)
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
La vacuna contra el virus del papiloma humano o VPH se administra para prevenir la infección por VPH y afecciones como el cáncer de cuello uterino y otros cánceres causados por el VPH (en hombres y mujeres). ¿Ha recibido <TEXT FILL 1> alguna vez una o más dosis de la vacuna contra el VPH?
(Los nombres comerciales de las vacunas contra el VPH son Cervarix, Gardasil o Gardasil 9).
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IMQ.065 |
NEXT |
IF IMQHPVYN = 1: IMQHPVAGE ELSE: IMQFLU |
IMQHPVAGE |
|
ASK |
IF IMQHPVYN = 1 |
How old <TEXT FILL 1> when <TEXT FILL 2> received <TEXT FILL 3> first dose of HPV vaccine?
|___|___|___| ENTER AGE IN YEARS
777. REFUSED 999. DON’T KNOW
|
|
SPANISH |
¿Qué edad tenía <TEXT FILL 1> cuando recibió su primera dosis de la vacuna contra el VPH?
|___|___|___| ENTER AGE IN YEARS
777. REFUSED 999. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS (ENG) |
TEXT FILL 1: FILL “were you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “was [SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 3: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “BLANK”
TEXT FILL 3: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF AGE SP RECEIVED FIRST DOSE IS GREATER THAN SP’S CURRENT AGE AT SP INTERVIEW (SPDSPAGEY), DISPLAY “AGE SP RECEIVED FIRST DOSE CANNOT EXCEED SP’S CURRENT AGE.” |
SOFT CHECK |
IF DIFFERENCE BETWEEN SP’S CURRENT AGE AND AGE SP RECEIVED FIRST DOSE IS GREATER THAN THE DIFFERENCE BETWEEN THE CURRENT YEAR AND 2006, DISPLAY “UNLIKELY RESPONSE AS HPV VACCINES WERE NOT AVAILABLE AT THAT TIME. PLEASE CONFIRM AGE SP RECEIVED FIRST DOSE.” |
VERSION NOTES |
IMQ.090 |
NEXT |
IMQHPVDOSE |
IMQHPVDOSE |
|
ASK |
IF IMQHPVYN = 1 |
How many doses of the vaccine <TEXT FILL 1> received?
INTERVIEWER INSTRUCTION: IF MORE THAN ONE HPV VACCINE, INSTRUCT SP TO PROVIDE THE TOTAL NUMBER OF HPV VACCINE DOSES RECEIVED.
1. 1 DOSE 2. 2 DOSES 3. 3 DOSES 4. MORE THAN 3 DOSES 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Cuántas dosis de la vacuna le han aplicado a <TEXT FILL 1>?
INTERVIEWER INSTRUCTION: IF MORE THAN ONE HPV VACCINE, INSTRUCT SP TO PROVIDE THE TOTAL NUMBER OF HPV VACCINE DOSES RECEIVED.
1. 1 DOSE 2. 2 DOSES 3. 3 DOSES 4. MORE THAN 3 DOSES 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL: “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL: “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IMQ.100 |
NEXT |
IMQFLU |
IMQFLU |
|
ASK |
All respondents |
There are two types of flu vaccinations. One is a shot and the other is a spray, mist, or drop in the nose.
In the last 12 months, <TEXT FILL 1> had a flu vaccination?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Hay dos tipos de vacunas contra la influenza. Una es una inyección y la otra es un espray o gotas en la nariz.
En los últimos 12 meses, ¿le han puesto a <TEXT FILL 1> la vacuna contra la influenza?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
COQ.140 |
NEXT |
END OF SECTION |
MEDICAL CONDITIONS – MCQ
Target Group: SPs 1+
MCQASTHMA |
|
ASK |
IF SP AGE IS >= 1 YEAR |
The following questions are about different medical conditions.
First, has a doctor or other health professional ever said that <TEXT FILL 2> had asthma (az-ma)?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Las siguientes preguntas tratan sobre diferentes problemas de salud.
En primer lugar, ¿ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 2> tenía asma?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE FILL”[SP NAME]”
|
FILLS (SPA) |
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE FILL”[SP NAME]”
|
NOTES |
|
HELP SCREEN (ENG) |
Asthma: A disease of the airways that carry air in and out of your lungs. It causes wheezing or whistling sounds when you breathe and can make you short of breath.
Doctor: The term refers to both doctors of medicine (M.D.s) and doctors of osteopathic medicine (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, but other doctoral degrees such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Health Professionals (Health Care Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: physician’s assistants or associates (PAs), nurse practitioners, nurses, pharmacists, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers. |
HELP SCREEN (SPA) |
Asma: Un enfermedad que afecta las vías respiratorias por donde entra y sale el aire de los pulmones. Causa sonidos sibilantes o silbantes en la respiración y puede causar dificultad para respirar.
Médico/Doctor: El término se refiere tanto a los doctores en medicina (M.D., por sus siglas en inglés) como a los doctores en medicina osteopática (D.O., por sus siglas en inglés). Se incluye tanto a médicos generales como a los especialistas. No incluye a personas que no tienen un título de doctor en medicina (M.D. o D.O.), pero que tienen otros títulos de doctor como dentistas, cirujanos orales, quiroprácticos, podólogos, curanderos de la ciencia cristiana, ópticos, oculistas, psicólogos, etc.
Profesionales de la salud (Profesional de la atención médica): Una persona autorizada por su capacitación y experiencia, y posiblemente por una licencia, para asistir a un médico y trabajan con uno o varios médicos. Algunos ejemplos incluyen: asistentes o auxiliares médicos (PA, por sus siglas en inglés), enfermeros practicantes, personal de enfermería, farmacéuticos, técnicos de laboratorio y técnicos que aplican inyecciones (por ejemplo, inyecciones para las alergias). Incluya también paramédicos, fisioterapeutas y terapeutas médicos que trabajan con un médico o en consultorios médicos. No incluya: dentistas, cirujanos de la boca, quiroprácticos, quiropedistas, podólogos, naturópatas, curanderos de la ciencia cristiana, ópticos, oculistas ni psicólogos o trabajadores sociales. |
HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
MCQ.010 |
NEXT |
IF MCQASTHMA = 1: MCQASMAGE ELSE: MCQANEMIA |
MCQASMAGE |
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ASK |
IF MCQASTHMA = 1 |
How old <TEXT FILL 1> when <TEXT FILL 2> first told <TEXT FILL 3> had asthma?
1. LESS THAN 5 YEARS 2. 5-11 YEARS OLD 3. 12-17 YEARS OLD 4. 18 YEARS OR OLDER 7. REFUSED 9. DON’T KNOW
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SPANISH |
¿Cuántos años tenía <TEXT FILL 1> cuando le dijeron por primera vez que <TEXT FILL 3> tenía asma?
1. LESS THAN 5 YEARS 2. 5-11 YEARS OLD 3. 12-17 YEARS OLD 4. 18 YEARS OR OLDER 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “were you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “was [SP NAME]”
TEXT FILL 2: FILL “you were” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] was”
TEXT FILL 3: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “BLANK”
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
MCQ.025N |
NEXT |
MCQASMSTILL |
MCQASMSTILL |
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ASK |
IF MCQASTHMA = 1 |
<TEXT FILL 1> still have asthma (az-ma)?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
¿<TEXT FILL 1> todavía tiene asma?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
MCQ.035 |
NEXT |
MCQASMYEAR |
MCQASMYEAR |
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ASK |
IF MCQASTHMA = 1 |
Asthma attacks, sometimes called episodes, refer to periods of worsening asthma symptoms that make you limit your activity more than you usually do, or make you seek medical care.
In the last 12 months, <TEXT FILL 1> had an episode of asthma (az-ma) or an asthma attack?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
Los ataques de asma, a veces llamados episodios, se refieren a períodos de empeoramiento de los síntomas del asma que limitan su actividad más de lo usual o lo(a) obligan a obtener atención médica.
En los últimos 12 meses, ¿tuvo <TEXT FILL 1> un episodio de asma o un ataque de asma?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
MCQ.040 |
NEXT |
MCQASMSTER |
MCQASMSTER |
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ASK |
IF MCQASTHMA = 1 |
Steroids like prednisone, prednisolone, or dexamethasone, may be given as pills, liquid, or an injection (by vein or in muscle).
In the last 12 months, other than using an inhaler, <TEXT FILL 1> take any steroids for asthma?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
Los esteroides, como la prednisona, la prednisolona o la dexametasona, pueden darse en forma de pastillas, líquido o una inyección (en una vena o músculo).
En los últimos 12 meses, aparte de usar un inhalador, ¿tomó <TEXT FILL 1> algún esteroide contra el asma?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “did you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “did [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
MCQ.NEW1 |
NEXT |
IF SP AGE >= 18 YEARS: MCQASMJOB ELSE: MCQANEMIA |
MCQASMJOB |
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ASK |
IF MCQASTHMA = 1 AND SP AGE >= 18 YEARS |
Was your asthma caused by, or your symptoms made worse by, any job you ever had?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
¿Algún trabajo que haya tenido fue la causa del asma o empeoró sus síntomas?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS |
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NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
MCQ.NEW4 |
NEXT |
MCQANEMIA |
MCQANEMIA |
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ASK |
IF SP AGE >= 1 YEAR |
In the last 3 months, <TEXT FILL 1> been on treatment for anemia (a-nee-me-a)? (Include diet, iron pills, iron shots, transfusions as treatment.)
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
En los últimos 3 meses, ¿recibió <TEXT FILL 1> tratamiento para la anemia? (Incluya como tratamiento cambios en la alimentación, pastillas de hierro, inyecciones de hierro y transfusiones).
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL: “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL: “[SP NAME]” |
NOTES |
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HELP SCREEN (ENG) |
Anemia: Anemia (a-nee-me-a) is a condition in which a person’s blood has a lower than normal number of red blood cells (RBCs). |
HELP SCREEN (SPA) |
Anemia: La anemia es una afección en la que la sangre de una persona tiene una cantidad de glóbulos rojos (RBC, por sus siglas en inglés) más baja que lo normal. |
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SOFT CHECK |
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VERSION NOTES |
MCQ.053 |
NEXT |
IF SP AGE >= 18 YEARS: MCQDOCART IF SP AGE 12-17 YEARS: MCQLIVER IF SP AGE 8-11 YEARS AND SP IS NOT MALE (SPQGENDER <> 1): MCQPERIOD IF SP AGE 8-11 YEARS AND SP IS MALE (SPQGENDER ONLY = 1): END OF SECTION IF SP AGE < 8 YEARS: END OF SECTION |
MCQPERIOD |
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ASK |
IF SP AGE = 8-11 YEARS AND SP IS NOT MALE (SPQGENDER != 1) |
Have <TEXT FILL 1> periods or menstrual (men-stral) cycles started yet?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
¿Han empezado ya los períodos o ciclos menstruales de <TEXT FILL 1>?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
MCQ.149 |
NEXT |
END OF SECTION |
MCQDOCART / MCQDOCARTP |
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ASK |
IF SP AGE >= 18 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> . . .
. . . had some form of arthritis?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
<MCQDOCARTP FILL> |
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SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> ...
... tenía algún tipo de artritis?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
<MCQDOCARTP FILL> |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “ [SP NAME]”
MCQDOCARTP FILL: IF RESPONSE OPTION FOR MCQDOCART = 1, DISPLAY,
Which type of arthritis was it?
1. Osteoarthritis or degenerative arthritis 2. Rheumatoid arthritis 3. Psoriatic arthritis 4. Other 7. REFUSED 9. DON’T KNOW
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FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “ [SP NAME]”
MCQDOCARTP FILL: IF RESPONSE OPTION FOR MCQDOCART = 1, DISPLAY,
¿Qué tipo de artritis era?
1. Osteoartritis o artritis degenerativa 2. Artritis reumatoide 3. Artritis psoriásica 4. Otro 7. REFUSED 9. DON’T KNOW
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NOTES |
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HELP SCREEN (ENG) |
Arthritis: A disease that causes pain, swelling or stiffness in joints, for example the hand, the knee, hip, or neck. Common kinds of arthritis are osteoarthritis and rheumatoid arthritis.
Osteoarthritis: The most common form of arthritis. Some people call it degenerative joint disease or “wear and tear” arthritis. It occurs most frequently in the hands, hips, and knees.
Rheumatoid Arthritis: Causes inflammation, redness and swelling of joints such as hands, wrists, and knees, but it can affect joints anywhere in the body. You may feel sick and tired, and sometimes there are fevers.
Psoriatic Arthritis: Is arthritis caused by the skin rash Psoriasis. Most often it causes redness and swelling of joints such as the spine, knees, hips and hands. |
HELP SCREEN (SPA) |
Artritis: Una enfermedad que causa dolor, hinchazón o rigidez en las articulaciones, como en la mano, la rodilla, la cadera o el cuello. Los tipos más comunes de artritis son la osteoartritis y la artritis reumatoide.
Osteoartritis: Es el tipo de artritis más común. Algunas personas la llaman enfermedad degenerativa de las articulaciones o artritis “por desgaste”. Se presenta con mayor frecuencia en las manos, las caderas y las rodillas.
Artritis reumatoide: Causa inflamación, enrojecimiento e hinchazón de las articulaciones como las de las manos, las muñecas y las rodillas, pero puede afectar las articulaciones en cualquier parte del cuerpo. Las personas que tienen esta enfermedad se pueden sentir enfermas y cansadas y algunas veces pueden tener fiebre.
Artritis psoriásica: Es artritis causada por la psoriasis, un sarpullido. Lo más frecuente es que haya enrojecimiento e hinchazón en las articulaciones, como en la columna vertebral, las rodillas, las caderas y las manos. |
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SOFT CHECK |
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VERSION NOTES |
MCQ.160a MCQ.195Na |
NEXT |
MCQDOCCONG |
MCQDOCCONG |
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ASK |
IF SP AGE >= 18 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> . . .
. . . had congestive heart failure?
INTERVIEWER INSTRUCTION: DO NOT COUNT HEART MURMURS, IRREGULAR HEART BEATS, CHEST PAIN OR HEART ATTACKS.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1>...
... tenía insuficiencia cardíaca congestiva?
INTERVIEWER INSTRUCTION: DO NOT COUNT HEART MURMURS, IRREGULAR HEART BEATS, CHEST PAIN OR HEART ATTACKS.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “ [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “ [SP NAME]” |
NOTES |
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HELP SCREEN (ENG) |
Congestive Heart Failure: Is when the heart can't pump enough blood to the body. Blood and fluid "back up" into the lungs, which makes you short of breath. Heart failure can cause fluid buildup in and swelling of the feet, legs and ankles. |
HELP SCREEN (SPA) |
Insuficiencia cardíaca congestiva: Ocurre cuando el corazón no bombea suficiente sangre al cuerpo. La sangre y el líquido se “acumulan” en los pulmones, lo cual causa dificultad para respirar. La insuficiencia cardíaca puede causar la acumulación de líquido y la hinchazón en los pies, las piernas y los tobillos. |
HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
MCQ.160b |
NEXT |
MCQDOCCORO |
MCQDOCCORO |
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ASK |
IF SP AGE >= 18 YEARS |
(Has a doctor or other health professional ever said that <TEXT FILL 1> . . . )
. . . had coronary (kor-o-nare-ee) heart disease?
INTERVIEWER INSTRUCTION: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR CORONARY HEART DISEASE.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
(¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1>...).
... tenía una enfermedad coronaria del corazón?
INTERVIEWER INSTRUCTION: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR CORONARY HEART DISEASE.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Coronary Heart Disease: Is when the blood vessels that bring blood to the heart muscle become narrow and hardened due to plaque (“plak”). Plaque buildup is called atherosclerosis (“ATH-er-o-skler-O-sis”). Blocked blood vessels to the heart can cause chest pain or a heart attack. |
HELP SCREEN (SPA) |
Enfermedad del corazón: Ocurre cuando cuando los vasos sanguíneos que llevan sangre al músculo cardíaco se estrechan y endurecen debido a la placa. La acumulación de placa es conocida como “ateroesclerosis”. La obstrucción de los vasos sanguíneos que llevan la sangre al corazón puede causar dolor al pecho o ataque al corazón. |
HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
MCQ.160c |
NEXT |
MCQDOCANJN |
MCQDOCANJN |
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ASK |
IF SP AGE >= 18 YEARS |
(Has a doctor or other health professional ever said that <TEXT FILL 1> . . . )
. . . had angina (an-jina), also called angina pectoris?
INTERVIEWER INSTRUCTION: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR ANGINA.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
(¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1>...)
... tenía angina, también llamada angina de pecho?
INTERVIEWER INSTRUCTION: IF THE RESPONDENT REPORTS CHEST PAIN, PROBE IF A DOCTOR TOLD THEM THAT THEY HAD BLOCKED BLOOD VESSELS OR ANGINA.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “ [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “ [SP NAME]” |
NOTES |
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HELP SCREEN (ENG) |
Angina (Angina Pectoris) (AN-jina pec-to-ris): Angina is chest pain or discomfort that occurs when the heart does not get enough blood. |
HELP SCREEN (SPA) |
Angina de pecho: Es un dolor de pecho o malestar en el pecho que ocurre cuando el corazón no recibe suficiente sangre. |
HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
MCQ.160d |
NEXT |
MCQDOCATTK |
MCQDOCATTK |
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ASK |
IF SP AGE >= 18 YEARS |
(Has a doctor or other health professional ever said that <TEXT FILL 1> . . . )
. . . had a heart attack (also called myocardial infarction (my-O-car-dee-al in-fark-shun))?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
(¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> ...).
... tuvo un ataque al corazón (también llamado infarto de miocardio)?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Heart Attack (Myocardial Infarction): A medical emergency that occurs when the flow of blood to the heart is blocked. Symptoms include tightness or pain in the chest, neck, back, or arms |
HELP SCREEN (SPA) |
Ataque al corazón (infarto de miocardio): Una emergencia médica que se presenta cuando se interrumpe el flujo de sangre al corazón. Los síntomas incluyen opresión o dolor en el pecho, el cuello, la espalda o los brazos. |
HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
MCQ.160e |
NEXT |
MCQDOCSTRK |
MCQDOCSTRK |
|
ASK |
IF SP AGE >= 18 YEARS |
(Has a doctor or other health professional ever said that <TEXT FILL 1> . . . )
. . . had a stroke, slight stroke, transient ischemic attack or TIA?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
(¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1>...).
... tuvo un derrame cerebral, un derrame cerebral leve o un ataque isquémico transitorio o TIA, por sus siglas en inglés?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Stroke: Is when the blood supply to a part of the brain is suddenly cut off by a blood clot or a burst blood vessel in the brain. The part of the brain affected can no longer do its job. There can be numbness or weakness on one side of the body; trouble speaking or understanding speech; loss of eyesight; trouble with walking, dizziness, loss of balance or coordination; or severe headache. |
HELP SCREEN (SPA) |
Derrame/ataque cerebral: Ocurre cuando la sangre que va a una parte del cerebro se interrumpe repentinamente por un coágulo de sangre o por un vaso sanguíneo que se revienta en el cerebro. La parte afectada del cerebro ya no puede funcionar. Puede haber entumecimiento o debilidad en uno o en los dos lados del cuerpo; dificultad para hablar o entender cuando se habla; pérdida de la visión; problemas para caminar, mareos, pérdida de equilibrio o coordinación o dolor de cabeza intenso. |
HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
MCQ.160f |
NEXT |
MCQDOCTHY |
MCQDOCTHY / MCQDOCTHYS |
|
ASK |
IF SP AGE >= 18 YEARS |
(Has a doctor or other health professional ever said that <TEXT FILL 1. . ).
. . . had a thyroid (thigh-roid) problem?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
<MCQDOCTHYS FILL>
|
|
SPANISH |
(¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1....).
... tenía un problema de la tiroides?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
<MCQDOCTHYS FILL>
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 3: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]”
MCQDOCTHYS FILL: IF RESPONSE OPTION FOR MCQDOCTHY = 1, DISPLAY,
<TEXT FILL 3> still have a thyroid problem?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 3: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
MCQDOCTHYS FILL: IF RESPONSE OPTION FOR MCQDOCTHY = 1, DISPLAY,
¿<TEXT FILL 3> todavía tiene problemas de tiroides?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
NOTES |
|
HELP SCREEN (ENG) |
Thyroid Problem: The thyroid is a gland in the neck that makes thyroid hormone. The thyroid sets your body's energy level: the temperature and heart rate. Thyroid problems include thyroid levels that are too high or too low, an inflamed or enlarged gland, and thyroid lumps or cancer. |
HELP SCREEN (SPA) |
Problema de la tiroides: La tiroides es una glándula ubicada en el cuello que produce la hormona tiroidea. La tiroides determina el nivel de energía de su cuerpo: la temperatura y el ritmo del corazón. Los problemas de la tiroides incluyen los niveles de la tiroidea, que pueden ser muy altos o bajos, una glándula inflamada o crecida y nódulos o cáncer de la tiroides. |
HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
MCQ.160m MCQ.170m |
NEXT |
MCQDOCCOPD |
MCQDOCCOPD |
|
ASK |
IF SP AGE >= 18 YEARS |
(Has a doctor or other health professional ever said that <TEXT FILL 1> . . . )
. . . had chronic obstructive pulmonary disease or COPD, emphysema, or chronic bronchitis?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
(¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1>...).
... tenía una enfermedad pulmonar obstructiva crónica o EPOC, enfisema o bronquitis crónica?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
TEXT OF QUESTION SHOULD BE OPTIONAL AFTER MCQDOCART |
HELP SCREEN (ENG) |
COPD: Stands for “chronic obstructive pulmonary disease.” It includes both emphysema and chronic bronchitis. It is a lung problem where you have trouble getting air in and out of your lungs. You may also have constant cough and phlegm.
Chronic Bronchitis: A recurrent inflammation of your lung’s airways that can cause irritation that results in constant coughing, wheezing, and shortness of breath.
Emphysema: Is a disease where the tiny air sacs in the lungs become damaged so less air goes in and out. As a result, the body does not get the oxygen it needs. Emphysema makes it hard to catch your breath. |
HELP SCREEN (SPA) |
EPOC: Significa “enfermedad pulmonar obstructiva crónica”. Incluye tanto el enfisema como la bronquitis crónica. Es un problema de los pulmones que causa dificultad para que el aire entre y salga de los pulmones. Es posible que la persona tenga tos constante y flema.
Bronquitis crónica: Una inflamación recurrente de las vías respiratorias de los pulmones que puede causar irritación, que resulta en tos constante, sibilancias o silbidos en el pecho y dificultad para respirar o falta de aire.
Enfisema: Es una enfermedad en la cual los alveólos (pequeños sacos de aire) de los pulmones se dañan, por lo tanto entra y sale menos aire. Como resultado, el cuerpo recibe menos oxígeno del que necesita. El enfisema dificulta la respiración. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MCQ.160p |
NEXT |
MCQDOCLIV |
MCQDOCLIV / MCQDOCLIVS |
|
ASK |
IF SP AGE >= 18 YEARS |
(Has a doctor or other health professional ever said that <TEXT FILL 1>. . . )
. . . had any kind of liver condition?
INTERVIEWER INSTRUCTION: DO NOT INCLUDE GALLBLADDER DISEASE; GALLSTONES; OR CHOLECYSTITIS.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
<MCQDOCLIVS FILL>
|
|
SPANISH |
(¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1>...).
... tenía algún tipo de problema con el hígado?
INTERVIEWER INSTRUCTION: DO NOT INCLUDE GALLBLADDER DISEASE; GALLSTONES; OR CHOLECYSTITIS.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
<MCQDOCLIVS FILL>
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 3: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]”
MCQDOCLIVS FILL: IF RESPONSE OPTION FOR MCQDOCLIV = 1, DISPLAY,
<TEXT FILL 3> still have this liver condition?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 3: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
MCQDOCLIVS FILL: IF RESPONSE OPTION FOR MCQDOCLIV = 1, DISPLAY,
¿<TEXT FILL 3> sigue teniendo ese problema con el hígado?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
NOTES |
TEXT OF QUESTION SHOULD BE OPTIONAL AFTER MCQDOCART |
HELP SCREEN (ENG) |
Liver Condition: Liver conditions include viral diseases, autoimmune diseases, liver cancer, fibrosis, cirrhosis, and liver disease from medications, poisons or drinking too much alcohol. |
HELP SCREEN (SPA) |
Problema del hígado: Los problemas del hígado incluyen enfermedades virales, enfermedades autoinmunitarias, el cáncer del hígado, fibrosis, cirrosis y enfermedades del hígado que resultan de medicamentos, sustancias tóxicas o por el consumo excesivo de alcohol. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MCQ.160l MCQ.170l |
NEXT |
MCQGALLSTN |
MCQLIVER |
|
ASK |
IF SP AGE = 12-17 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> had any kind of liver condition?
INTERVIEWER INSTRUCTION: DO NOT INCLUDE GALLBLADDER DISEASE; GALLSTONES; OR CHOLECYSTITIS.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> tenía algún tipo de problema con el el hígado?
INTERVIEWER INSTRUCTION: DO NOT INCLUDE GALLBLADDER DISEASE; GALLSTONES; OR CHOLECYSTITIS.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Liver Condition: Liver conditions include viral diseases, autoimmune diseases, liver cancer, fibrosis, cirrhosis, and liver disease from medications. |
HELP SCREEN (SPA) |
Problema del hígado: Los problemas del hígado incluyen enfermedades virales, enfermedades autoinmunitarias, el cáncer del hígado, fibrosis, cirrosis y las enfermedades del hígado provocadas por medicamentos. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MCQ.500 |
NEXT |
END OF SECTION |
MCQGALLSTN |
|
ASK |
IF SP AGE >= 18 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> had gallstones?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> tenía cálculos biliares?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
|
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
|
NOTES |
|
HELP SCREEN (ENG) |
Gallstones: Gallstones are hard particles that develop in the gallbladder. The gallbladder is located in the upper right abdomen—below the liver. |
HELP SCREEN (SPA) |
Cálculos biliares: Los cálculos biliares son partículas sólidas que se desarrollan en la vesícula biliar. La vesícula biliar se encuentra en el costado superior derecho del abdomen, la zona entre el pecho y la cadera, debajo del hígado. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MCQ.550 |
NEXT |
IF SP AGE = 18-44 YEARS: MCQCANCER ELSE: MCQMEMORY |
MCQMEMORY |
|
ASK |
IF SP AGE > 44 YEARS |
In the last 12 months, <TEXT FILL 1> experienced difficulties with thinking or memory that are happening more often or are getting worse?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿tuvo <TEXT FILL 1> dificultades con el pensamiento o la memoria que están ocurriendo con más frecuencia o están empeorando?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MCQ.084N |
NEXT |
IF MCQMEMORY = 1: MCQMEMDOC ELSE: MCQCANCER |
MCQMEMDOC |
|
ASK |
IF MCQMEMORY = 1 |
<TEXT FILL 1> or anyone else discussed <TEXT FILL 2> difficulties with thinking or memory with a doctor or other health professional?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ha hablado <TEXT FILL 1> o alguien más sobre sus dificultades con el pensamiento o la memoria con un doctor u otro profesional de la salud?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “BLANK” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MCQ.New5 |
NEXT |
MCQCANCER |
MCQCANCER |
|
ASK |
IF SP AGE >= 18 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> had cancer or a malignancy (ma-lig-nan-see) of any kind?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> tenía cáncer o un tumor maligno de algún tipo?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL: “ [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL: “ [SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Cancer: An abnormal growth that can spread to other parts of the body. Most cancers are named for where they start: for example lung cancer or breast cancer. Other times it may be a cancer of the blood such as leukemia.
Malignancy: A tumor or growth that is a cancer. (see Cancer) |
HELP SCREEN (SPA) |
Cáncer: Cecimiento anormal que se puede extender a otras partes del cuerpo. La mayoría de los cánceres reciben su nombre del lugar donde aparecen: por ejemplo, cáncer de pulmón o cáncer de seno. Otras veces puede tratarse de un cáncer de la sangre, como la leucemia.
Tumor maligno: Un tumor o crecimiento que es canceroso. (Ver Cáncer). |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MCQ.220 |
NEXT |
IF MCQCANCER = 1: MCQCNCRTP ELSE: MCQRELATDB |
MCQCNCRTPa / MCQCNCRTPb / MCQCNCRTPc / MCQCNCRTPd |
|
ASK |
IF MCQCANCER = 1 |
What kind of cancer was it?
INTERVIEWER INSTRUCTION: ENTER UP TO 3 KINDS. IF RESPONDENT OFFERS MORE THAN 3, ENTER 66 AS THE 4TH RESPONSE.
|___|___| ENTER CANCER CODE [MCQCNCRTPa]
|___|___| ENTER CANCER CODE [MCQCNCRTPb]
|___|___| ENTER CANCER CODE [MCQCNCRTPc]
|___|___| ENTER 66 IF MORE THAN 3 [MCQCNCRTPd]
10. BLADDER 11. BLOOD 12. BONE 13. BRAIN 14. BREAST 15. CERVIX (CERVICAL) 16. COLON 17. ESOPHAGUS (ESOPHAGEAL) 18. GALLBLADDER 19. KIDNEY 20. LARYNX/WINDPIPE 21. LEUKEMIA 22. LIVER 23. LUNG 24. LYMPHOMA/HODGKINS' DISEASE 25. MELANOMA 26. MOUTH/TONGUE/LIP 27. NERVOUS SYSTEM 28. OVARY (OVARIAN) 29. PANCREAS (PANCREATIC) 30. PROSTATE 31. RECTUM (RECTAL) 32. SKIN (NON-MELANOMA) 33. SKIN (DON’T KNOW WHAT KIND) 34. SOFT TISSUE (MUSCLE OR FAT) 35. STOMACH 36. TESTIS (TESTICULAR) 37. THYROID 38. UTERUS (UTERINE) 39. OTHER 66. MORE THAN 3 KINDS 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
¿Qué tipo de cáncer era?
INTERVIEWER INSTRUCTION: ENTER UP TO 3 KINDS. IF RESPONDENT OFFERS MORE THAN 3, ENTER 66 AS THE 4TH RESPONSE.
|___|___| ENTER CANCER CODE [MCQCNCRTPa]
|___|___| ENTER CANCER CODE [MCQCNCRTPb]
|___|___| ENTER CANCER CODE [MCQCNCRTPc]
|___|___| ENTER 66 IF MORE THAN 3 [MCQCNCRTPd]
10. VEJIGA 11. SANGRE 12. HUESO 13. CEREBRO 14. SENO 15. CERVIZ (CERVICAL) 16. COLON 17. ESÓFAGO (ESOFÁGICO) 18. VESÍCULA BILIAR 19. RIÑÓN 20. LARINGE/TRÁQUEA 21. LEUCEMIA 22. HÍGADO 23. PULMÓN 24. LINFOMA/ENFERMEDAD DE HODGKIN 25. MELANOMA 26. BOCA/LENGUA/LABIO 27. SISTEMA NERVIOSO 28. OVARIO 29. PÁNCREAS (PANCREÁTICO) 30. PRÓSTATA 31. RECTO (RECTAL) 32. PIEL (NO MELANOMA) 33. PIEL (NO SABE DE QUÉ TIPO) 34. TEJIDO BLANDO (MÚSCULO O GRASA) 35. ESTÓMAGO 36. TESTÍCULO (TESTICULAR) 37. TIROIDES 38. ÚTERO/MATRIZ (UTERINO) 39. OTRO 66. MÁS DE 3 TIPOS 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Dropdown: MCQCNCRTPa, MCQCNCRTPb, MCQCNCRTPc Numeric: MCQCNCRTPd |
FILLS |
CANCER TYPE FILL: IF TWO OR MORE OF THE FOLLOWING ARE SELECTED, SEPARATE BY “/”: (IF MCQCNCRTPx=30, FILL “PROSTATE”) AND (IF MCQCNCRTPx=36, FILL “TESTIS (TESTICULAR)”) AND (IF MCQCNCRTPx=15, FILL “CERVIX (CERVICAL)”) AND (IF MCQCNCRTPx=28, FILL “OVARY (OVARIAN)”) AND (IF MCQCNCRTPx=38, FILL “UTERUS (UTERINE)”) |
NOTES |
ALLOW UP TO 3 ENTRIES. ALLOW 'MORE THAN 3 KINDS (CODE 66)’ ONLY AS 4TH ENTRY. |
HELP SCREEN |
|
HARD CHECK |
IF RESPONDENT ENTRY FOR MCQCNCRTPd IS NOT 66, DISPLAY “IF MORE THAN 3 KINDS OF CANCER, ENTER 66. OTHERWISE, LEAVE THIS EMPTY.” |
SOFT CHECK |
IF (SP IS FEMALE IN SPQGENDER OR SPQGENDER IS DK/RF) AND MCQCNCRTPx = 30 OR 36, DISPLAY, “<CANCER TYPE FILL> IS GENDER SPECIFIC. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” IF (SP IS MALE IN SPQGENDER OR SPQGENDER IS DK/RF) AND RESPONSE OPTION = 15 OR 28 OR 38, DISPLAY, “<CANCER TYPE FILL> IS GENDER SPECIFIC. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
MCQ.230 |
NEXT |
MCQRELATDB |
MCQRELATDB / MCQRELATAM / MCQRELATBR / MCQRELATCR / MCQRELATHR / MCQRELATST |
||||||||||||||||||||||||||||||||||||
ASK |
IF SP AGE >= 18 YEARS |
|||||||||||||||||||||||||||||||||||
Including living and deceased, were any of <TEXT FILL 1> close blood relatives including only biological father, mother, sisters, brothers, or children, ever told by a doctor or health professional that they had . . .
INTERVIEWER INSTRUCTION: DO NOT INCLUDE HALF-SISTERS OR HALF-BROTHERS
|
||||||||||||||||||||||||||||||||||||
SPANISH |
¿Alguna vez un doctor o un profesional de la salud dijo que alguno de <TEXT FILL 1>, ya sea que estén vivos o que hayan fallecido, incluidos solamente el padre, la madre, las hermanas, los hermanos o los(as) hijos(as) biológicos, tenía...?
INTERVIEWER INSTRUCTION: DO NOT INCLUDE HALF-SISTERS OR HALF-BROTHERS
|
|||||||||||||||||||||||||||||||||||
QUESTION TYPE |
Grid: Radio button |
|||||||||||||||||||||||||||||||||||
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
|||||||||||||||||||||||||||||||||||
FILLS (SPA) |
TEXT FILL 1: FILL “sus parientes de sangre cercanos” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “los parientes de sangre cercanos de [SP NAME]” |
|||||||||||||||||||||||||||||||||||
NOTES |
|
|||||||||||||||||||||||||||||||||||
HELP SCREEN |
|
|||||||||||||||||||||||||||||||||||
HARD CHECK |
|
|||||||||||||||||||||||||||||||||||
SOFT CHECK |
|
|||||||||||||||||||||||||||||||||||
VERSION NOTES |
MCQ.NEW6 a/b/c/d/e |
|||||||||||||||||||||||||||||||||||
NEXT |
END OF SECTION |
|||||||||||||||||||||||||||||||||||
HEPATITIS - HEQ
Target Group: SPs 5+
HEQHEPB |
|
ASK |
IF SP AGE >= 5 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> hepatitis B? (Hepatitis is a form of liver disease. Hepatitis B is an infection of the liver from the hepatitis B virus (HBV).)
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> tenía hepatitis B? (La hepatitis es una forma de enfermedad del hígado. La hepatitis B es una infección del hígado provocada por el virus de la hepatitis B (VHB).)
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] has” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Doctor: The term refers to both doctors of medicine (M.D.s) and doctors of osteopathic medicine (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, but other doctoral degrees such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Health Professionals (Health Care Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: physician’s assistants or associates (PAs), nurse practitioners, nurses, pharmacists, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers. |
HELP SCREEN (SPA) |
Médico/Doctor: El término se refiere tanto a los doctores en medicina (M.D., por sus siglas en inglés) como a los doctores en medicina osteopática (D.O., por sus siglas en inglés). Se incluye tanto a médicos generales como a los especialistas. No incluye a personas que no tienen un título de doctor en medicina (M.D. o D.O.), pero que tienen otros títulos de doctor como dentistas, cirujanos orales, quiroprácticos, podólogos, curanderos de la ciencia cristiana, ópticos, oculistas, psicólogos, etc.
Profesionales de la salud (Profesional de la atención médica): Una persona autorizada por su capacitación y experiencia, y posiblemente por una licencia, para asistir a un médico y trabajan con uno o varios médicos. Algunos ejemplos incluyen: asistentes o auxiliares médicos (PA, por sus siglas en inglés), enfermeros practicantes, personal de enfermería, farmacéuticos, técnicos de laboratorio y técnicos que aplican inyecciones (por ejemplo, inyecciones para las alergias). Incluya también paramédicos, fisioterapeutas y terapeutas médicos que trabajan con un médico o en consultorios médicos. No incluya: dentistas, cirujanos de la boca, quiroprácticos, quiropedistas, podólogos, naturópatas, curanderos de la ciencia cristiana, ópticos, oculistas ni psicólogos o trabajadores sociales. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
HEQ.010 |
NEXT |
IF HEQHEPB = 1: HEQHEPBRX ELSE: HEQHEPC |
HEQHEPBRX |
|
ASK |
IF HEQHEPB = 1 |
Please look at the drugs on this card that are prescribed for hepatitis B. <TEXT FILL 1> ever prescribed any medicine to treat hepatitis B?
HAND CARD HEQ1 TO RESPONDENT
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
Mire
la lista de medicamentos en esta tarjeta que se recetan para la
hepatitis B.
HAND CARD HEQ1 TO RESPONDENT
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Were you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE: FILL “Was [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
HEQ.020 |
NEXT |
HEQHEPC |
HEQHEPC |
|
ASK |
IF SP AGE >= 5 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> hepatitis C? (Hepatitis is a form of liver disease. Hepatitis C is an infection of the liver from the hepatitis C virus or HCV).
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> tenía hepatitis C? (La hepatitis es un tipo de enfermedad del hígado. La hepatitis C es una infección del hígado causada por el virus de la hepatitis C o VHC).
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] has” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Doctor: The term refers to both doctors of medicine (M.D.s) and doctors of osteopathic medicine (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, but other doctoral degrees such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Health Care Professionals (Health Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: physician’s assistants or associates (PAs), nurse practitioners, nurses, pharmacists, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers. |
HELP SCREEN (SPA) |
Médico/Doctor: El término se refiere tanto a los doctores en medicina (M.D., por sus siglas en inglés) como a los doctores en medicina osteopática (D.O., por sus siglas en inglés). Se incluye tanto a médicos generales como a los especialistas. No incluye a personas que no tienen un título de doctor en medicina (M.D. o D.O.), pero que tienen otros títulos de doctor como dentistas, cirujanos orales, quiroprácticos, podólogos, curanderos de la ciencia cristiana, ópticos, oculistas, psicólogos, etc.
Profesionales de la salud (Profesional de la atención médica): Una persona autorizada por su capacitación y experiencia, y posiblemente por una licencia, para asistir a un médico y trabajan con uno o varios médicos. Algunos ejemplos incluyen: asistentes o auxiliares médicos (PA, por sus siglas en inglés), enfermeros practicantes, personal de enfermería, farmacéuticos, técnicos de laboratorio y técnicos que aplican inyecciones (por ejemplo, inyecciones para las alergias). Incluya también paramédicos, fisioterapeutas y terapeutas médicos que trabajan con un médico o en consultorios médicos. No incluya: dentistas, cirujanos de la boca, quiroprácticos, quiropedistas, podólogos, naturópatas, curanderos de la ciencia cristiana, ópticos, oculistas ni psicólogos o trabajadores sociales |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
HEQ.030 |
NEXT |
IF HEQHEPC = 1: HEQHEPCRX ELSE: END OF SECTION |
HEQHEPCRX |
|
ASK |
IF HEQHEPC = 1 |
Please look at the drugs on this card that are prescribed for hepatitis C. <TEXT FILL 1> ever prescribed any medicine to treat hepatitis C?
HAND CARD HEQ2 TO RESPONDENT
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
Mire
la lista de medicamentos en esta tarjeta que se recetan para la
hepatitis C.
HAND CARD HEQ2 TO RESPONDENT
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Were you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE: FILL “Was [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
HEQ.040 |
NEXT |
END OF SECTION |
KIDNEY CONDITIONS – KIQ
Target Group: SPs 18+
KIQKIDNEY |
|
ASK |
IF SP AGE >= 18 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> a kidney problem, protein in the urine, or kidney disease? Do not include kidney stones, bladder (bladd-er) infections, or incontinence (in-kon-ti-nens).
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> tiene un problema en los riñones, proteínas en la orina o una enfermedad en los riñones? No incluya cálculos (piedras) en los riñones, infecciones de la vejiga o incontinencia.
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE: FILL “ [SP NAME] has” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE: FILL “ [SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Doctor: The term refers to both doctors of medicine (M.D.s) and doctors of osteopathic medicine (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, but other doctoral degrees such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Health Professionals (Health Care Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: physician’s assistants or associates (PAs), nurse practitioners, nurses, pharmacists, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers. |
HELP SCREEN (SPA) |
Médico/Doctor: El término se refiere tanto a los doctores en medicina (M.D., por sus siglas en inglés) como a los doctores en medicina osteopática (D.O., por sus siglas en inglés). Se incluye tanto a médicos generales como a los especialistas. No incluye a personas que no tienen un título de doctor en medicina (M.D. o D.O.), pero que tienen otros títulos de doctor como dentistas, cirujanos orales, quiroprácticos, podólogos, curanderos de la ciencia cristiana, ópticos, oculistas, psicólogos, etc.
Profesionales de la salud (Profesional de la atención médica): Una persona autorizada por su capacitación y experiencia, y posiblemente por una licencia, para asistir a un médico y trabajan con uno o varios médicos. Algunos ejemplos incluyen: asistentes o auxiliares médicos (PA, por sus siglas en inglés), enfermeros practicantes, personal de enfermería, farmacéuticos, técnicos de laboratorio y técnicos que aplican inyecciones (por ejemplo, inyecciones para las alergias). Incluya también paramédicos, fisioterapeutas y terapeutas médicos que trabajan con un médico o en consultorios médicos. No incluya: dentistas, cirujanos de la boca, quiroprácticos, quiropedistas, podólogos, naturópatas, curanderos de la ciencia cristiana, ópticos, oculistas ni psicólogos o trabajadores sociales. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
KIQ.022N |
NEXT |
IF KIQKIDNEY = 1: KIQDIALYS ELSE: END OF SECTION |
KIQDIALYS |
|
ASK |
IF KIQKIDNEY = 1 |
In the last 12 months, <TEXT FILL 1> received dialysis (either hemodialysis (heemo-di-al-i-sis) or peritoneal dialysis (pare-i-ton-nee-al di-al-i-sis))?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
En los últimos 12 meses, ¿le han hecho a <TEXT FILL 1> diálisis (ya sea hemodiálisis o diálisis peritoneal)?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE: FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
KIQ.025 |
NEXT |
END OF SECTION |
DIABETES – DIQ
Target Group: SPs 1+
DIQDIABETES |
|
ASK |
IF SP AGE >= 1 YEAR |
<TEXT FILL 1> a doctor or other health professional ever said that <TEXT FILL 2> diabetes or sugar diabetes?
1. YES 2. NO 3. BORDERLINE OR PREDIABETES 7. REFUSED 9. DON’T KNOW |
|
SPANISH |
¿<TEXT FILL 1> dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 2> diabetes o diabetes de azúcar?
1. YES 2. NO 3. BORDERLINE OR PREDIABETES 7. REFUSED 9. DON’T KNOW |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Has” IF SP GENDER IS MALE ONLY. ELSE, FILL “Other than during pregnancy, has”
TEXT FILL 2: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “ [SP NAME] has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR |
FILLS (SPA) |
TEXT FILL 1: FILL “Ha” IF SP GENDER IS MALE ONLY. ELSE, FILL “Aparte de cuando estaba embarazada, ha”
TEXT FILL 2: FILL “usted tiene” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “ [SP NAME] tiene” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR |
NOTES |
|
HELP SCREEN (ENG) |
Diabetes: A disease that occurs when your blood glucose, also called blood sugar, is too high. Do not include gestational diabetes or diabetes that was only present during pregnancy. Also, do not include self-diagnosed diabetes, pre-diabetes or high sugar.
Doctor: The term refers to both doctors of medicine (M.D.s) and doctors of osteopathic medicine (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, but other doctoral degrees such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Health Professionals (Health Care Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: physician’s assistants or associates (PAs), nurse practitioners, nurses, pharmacists, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers. |
HELP SCREEN (SPA) |
Diabetes: Enfermedad que se presente cuando la glucosa de la sangre, también conocida como azúcar en la sangre es demasiado alta. No incluya diabetes gestacional, es decir, si solo tuvo diabetes durante el embarazo. Tampoco incluya diabetes autodiagnosticada, prediabetes o azúcar alta.
Médico/Doctor: El término se refiere tanto a los doctores en medicina (M.D., por sus siglas en inglés) como a los doctores en medicina osteopática (D.O., por sus siglas en inglés). Se incluye tanto a médicos generales como a los especialistas. No incluye a personas que no tienen un título de doctor en medicina (M.D. o D.O.), pero que tienen otros títulos de doctor como dentistas, cirujanos orales, quiroprácticos, podólogos, curanderos de la ciencia cristiana, ópticos, oculistas, psicólogos, etc.
Profesionales de la salud (Profesional de la atención médica): Una persona autorizada por su capacitación y experiencia, y posiblemente por una licencia, para asistir a un médico y trabajan con uno o varios médicos. Algunos ejemplos incluyen: asistentes o auxiliares médicos (PA, por sus siglas en inglés), enfermeros practicantes, personal de enfermería, farmacéuticos, técnicos de laboratorio y técnicos que aplican inyecciones (por ejemplo, inyecciones para las alergias). Incluya también paramédicos, fisioterapeutas y terapeutas médicos que trabajan con un médico o en consultorios médicos. No incluya: dentistas, cirujanos de la boca, quiroprácticos, quiropedistas, podólogos, naturópatas, curanderos de la ciencia cristiana, ópticos, oculistas ni psicólogos o trabajadores sociales. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DIQ.010 |
NEXT |
IF DIQDIABETES = 1: DIQTYPE IF DIQDIABETES = 3 AND SP AGE >= 12 YEARS : DIQPILLS IF DIQDIABETES = 3 AND SP AGE < 12 YEARS: END OF SECTION IF DIQDIABETES = 2 OR 7 OR 9 AND SP AGE >= 12 YEARS: DIQPREDIAB IF DIQDIABETES = 2 OR 7 OR 9 AND SP AGE < 12 YEARS: END OF SECTION |
DIQTYPE |
|
ASK |
IF DIQDIABETES = 1 |
Did the doctor or other health professional say that <TEXT FILL 1> had diabetes type 1, type 2, or some other type?
1. TYPE 1 2. TYPE 2 3. OTHER TYPE OF DIABETES 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Dijo el doctor u otro profesional de la salud que <TEXT FILL 1> tenía diabetes tipo 1, tipo 2 o algún otro tipo?
1. TYPE 1 2. TYPE 2 3. OTHER TYPE OF DIABETES 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DIQ.New3 |
NEXT |
DIQAGEG |
DIQAGEG / DIQAGEQ |
|
ASK |
IF DIQDIABETES = 1 |
How old <TEXT FILL 1> when a doctor or other health professional first said that <TEXT FILL 2> had diabetes or sugar diabetes?
|___| [DIQAGEG] 1. ENTER AGE IN YEARS 2. LESS THAN 1 YEAR 7. REFUSED 9. DON’T KNOW
|___|___|___| [DIQAGEQ] ENTER AGE IN YEARS
|
|
SPANISH |
¿Qué edad tenía <TEXT FILL 1> cuando un doctor u otro profesional de la salud le dijo por primera vez que tenía diabetes o diabetes del azúcar?
|___| [DIQAGEG] 1. ENTER AGE IN YEARS 2. LESS THAN 1 YEAR 7. REFUSED 9. DON’T KNOW
|___|___|___| [DIQAGEQ] ENTER AGE IN YEARS
|
QUESTION TYPE |
Dropdown: DIQAGEG Numeric: DIQAGEQ |
FILLS (ENG) |
TEXT FILL 1: FILL “were you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “was [SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF DIQAGEG=1 AND DIQAGEQ IS GREATER THAN SP’S CURRENT AGE AT SP INTERVIEW (SPDSPAGEY), DISPLAY “AGE REPORTED CANNOT EXCEED SP’S CURRENT AGE” |
SOFT CHECK |
|
VERSION NOTES |
DIQ.040 G/Q |
NEXT |
DIQINSULIN |
DIQPREDIAB |
|
ASK |
IF DIQDIABETES = 2 OR 7 OR 9 AND SP AGE >= 12 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> had prediabetes or borderline diabetes?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> tenía prediabetes o estaba a punto de tener diabetes?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IS SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IS SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DIQ.160N |
NEXT |
IF DIQPREDIAB = 1: DIQPILLS ELSE: DIQTEST |
DIQINSULIN |
|
ASK |
IF DIQDIABETES = 1 |
Insulin can be taken by shot or pump. <TEXT FILL 1> now taking insulin?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
La insulina se puede recibir en una inyección o con una bomba de infusión. ¿Está <TEXT FILL 1> tomando insulina ahora?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Is [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Insulin: A medication used in the treatment of diabetes. Typically, insulin is administered with a syringe by the patient. |
HELP SCREEN (SPA) |
Insulina: medicamento que se usa en el tratamiento de la diabetes. Normalmente, la insulina se le administra al paciente con una jeringa. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DIQ.050 |
NEXT |
IF DIQINSULIN = 1: DIQINSSTRT ELSE: DIQPILLS |
DIQINSSTRT |
|
ASK |
IF DIQINSULIN = 1 |
Thinking back to when <TEXT FILL 1> first diagnosed with diabetes, how long was it before <TEXT FILL 2> started taking insulin?
1. Less than 1 month 2. 1 month to less than 6 months 3. 6 months to less than 1 year 4. 1 year or more 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Piense en el momento cuando le diagnosticaron diabetes a <TEXT FILL 1> por primera vez, ¿cuánto tiempo pasó antes de que empezara a usar insulina?
1. Menos de 1 mes 2. De 1 mes a menos de 6 meses 3. De 6 meses a menos de 1 año 4. 1 año o más 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you were” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] was”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “SP NAME” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “BLANK” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DIQ.New1 |
NEXT |
DIQINSSTOP |
DIQINSSTOP |
|
ASK |
IF DIQINSULIN = 1 |
Since <TEXT FILL 1> started taking insulin, <TEXT FILL 2> ever stopped taking it for more than 6 months?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW |
|
SPANISH |
¿Desde que <TEXT FILL 1> empezó a usar insulina, ¿alguna vez ha dejado de usarla durante más de 6 meses?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “has he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “has she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “has [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DIQ.New2 |
NEXT |
DIQPILLS |
DIQPILLS |
|
ASK |
IF DIQDIABETES = 1 IF DIQDIABETES = 3 AND SP AGE >= 12 YEARS IF DIAPREDIAB = 1 |
<TEXT FILL 1> now taking diabetic pills to lower <TEXT FILL 2> blood sugar? (These are sometimes called oral agents or oral hypoglycemic agents.)
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Está <TEXT FILL 1> tomando ahora pastillas para la diabetes para reducir el nivel de azúcar en la sangre? (A veces, estos son llamados agentes orales o agentes orales hipoglicémicos).
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Is [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DIQ.070 |
NEXT |
IF SP AGE < 12 YEARS: END OF SECTION IF SP AGE >= 12 YEARS AND DIQDIABETES = 1: DIQA1C IF SP AGE >= 12 YEARS AND DIQDIABETES != 1: DIQTEST |
DIQTEST |
|
ASK |
IF DIQDIABETES != 1 AND SP AGE >= 12 YEARS |
How long ago did <TEXT FILL 1> have a blood test for high blood sugar or diabetes by a doctor, or other health professional?
0. Never 1. less than a year ago 2. 1 year but less than 2 years ago 3. 2 years but less than 3 years ago 4. 3 years but less than 5 years ago 5. 5 years but less than 10 years ago, or 6. 10 years ago or more 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Cuánto tiempo ha pasado desde que un médico u otro profesional de la salud le hizo una prueba de sangre <TEXT FILL 1> para ver si tenía un nivel alto de azúcar en la sangre o diabetes?
0. Nunca 1. Hace menos de 1 año 2. Hace 1 año pero menos de 2 3. Hace 2 años pero menos de 3 4. Hace 3 años pero menos de 5 5. Hace 5 años pero menos de 10 6. Hace 10 años o más 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “a [SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DIQ.New9 |
NEXT |
END OF SECTION |
DIQA1C |
|
ASK |
IF DIQDIABETES = 1 AND SP AGE >= 12 YEARS |
About how many times in the last 12 months has a doctor, nurse, or other health professional checked <TEXT FILL 1> A-one-C? (An A-one-C test is used to measure the average blood sugar level over the last three months.)
|___|___| ENTER NUMBER OF TIMES
0. HAD A1C CHECKED MORE THAN 12 MONTHS AGO 666. NEVER HAD A1C CHECKED
777. REFUSED 999. DON’T KNOW
|
|
SPANISH |
¿Aproximadamente cuántas veces en los últimos 12 meses un doctor, un enfermero u otro profesional de la salud le hizo <TEXT FILL 1> una prueba de A-uno-C? (Se usa una prueba de A-uno-C para medir el promedio del nivel de azúcar en la sangre de los últimos tres meses).
|___|___| ENTER NUMBER OF TIMES
0. HAD A1C CHECKED MORE THAN 12 MONTHS AGO 666. NEVER HAD A1C CHECKED
777. REFUSED 999. DON’T KNOW
|
QUESTION TYPE |
Numeric, with radio button options below. |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “a [SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DIQ.New11 |
NEXT |
DIQRETINOP |
DIQRETINOP |
|
ASK |
IF DIQDIABETES = 1 AND SP AGE >= 12 YEARS |
Has a doctor ever said that diabetes has affected <TEXT FILL 1> eyes or that <TEXT FILL 2> had retinopathy (ret-in-op-ath-ee)?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ha dicho alguna vez un doctor que la diabetes afectó <TEXT FILL 1> o que <TEXT FILL 2> tenía retinopatía?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE FILL “[SP NAME]’s”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
|
FILLS (SPA) |
TEXT FILL 1: FILL “sus ojos” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE FILL “los ojos de [SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DIQ.080 |
NEXT |
END OF SECTION |
BLOOD PRESSURE – BPQ
Target Group: SPs 18+
BPQHIBP |
|
ASK |
IF SP AGE IS >= 18 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> had hypertension (hy-per-ten-shun), also called high blood pressure?
INTERVIEWER INSTRUCTION: IF HIGH BLOOD PRESSURE ONLY DURING PREGNANCY, CODE NO. IF SP SAYS “HIGH BLOOD PRESSURE”, “BORDERLINE HYPERTENSION” OR “PREHYPERTENSION” CODE NO.
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> tenía hipertensión, también conocida como presión arterial alta?
INTERVIEWER INSTRUCTION: IF HIGH BLOOD PRESSURE ONLY DURING PREGNANCY, CODE NO. IF SP SAYS “HIGH BLOOD PRESSURE”, “BORDERLINE HYPERTENSION” OR “PREHYPERTENSION” CODE NO.
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
BPQ.020 |
NEXT |
IF BPQHIBP = 1: BPQ2VISITS ELSE: BPQHICHL |
BPQ2VISITS |
|
ASK |
IF BPQHIBP = 1 |
<TEXT FILL 1> told on 2 or more different visits that <TEXT FILL 2> had hypertension (hy-per-ten-shun), also called high blood pressure?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
¿Le dijeron a <TEXT FILL 1> en 2 o más consultas diferentes que <TEXT FILL 2> tenía hipertensión, también conocida como “presión arterial alta”?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “were you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
BPQ.030 |
NEXT |
BPQHIBPRX |
BPQHIBPRX |
|
ASK |
IF BPQHIBP = 1 |
<TEXT FILL 1> now taking any medication prescribed by a doctor or other health professional for <TEXT FILL 2> high blood pressure?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED |
|
SPANISH |
¿Está <TEXT FILL 1> tomando actualmente algún medicamento recetado por un doctor u otro profesional de la salud para su presión arterial alta?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Is [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
BPQ.150 |
NEXT |
BPQHICHL |
BPQHICHL |
|
ASK |
IF SP AGE >= 18 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> had high cholesterol?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> tenía colesterol alto?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECT ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECT ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Cholesterol: Fat substance found in the bloodstream and in all your body's cells. It's normal to have cholesterol. But too much cholesterol in the blood is a major risk for a heart attack and stroke. |
HELP SCREEN (SPA) |
Colesterol: Es una sustancia grasa que se encuentra en la sangre y en todas las células del cuerpo. Es normal tener colesterol, pero tener demasiado colesterol en la sangre es un alto riesgo de tener un ataque al corazón y un derrame cerebral. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
BPQ.080 |
NEXT |
IF BPQHICHL = 1: BPQHICHLRX E3LSE: END OF SECTION |
BPQHICHLRX |
|
ASK |
IF BPQHICHL = 1 |
<TEXT FILL 1> now taking any medication prescribed by a doctor or other health professional to lower <TEXT FILL 2> cholesterol?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED |
|
SPANISH |
¿Está <TEXT FILL 1> tomando actualmente algún medicamento recetado por un doctor u otro profesional de la salud para reducir el nivel alto de colesterol?
1. YES 2. NO 9. DON’T KNOW 7. REFUSED |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Is [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
BPQ.101d |
NEXT |
END OF SECTION |
OSTEOPOROSIS – OSQ
Target Group: SPs 45+ Years
OSQFRCHIP / OSQFRCHIPQ |
|
ASK |
IF SP AGE >= 45 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> had broken or fractured <TEXT FILL 2> . . .
. . . hip?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW [OSQFRCHIP]
<OSQFRCHIPQ FILL>
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> se había roto o fracturado...
... la cadera?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW [OSQFRCHIP]
<OSQFRCHIPQ FILL>
|
QUESTION TYPE |
Radio button: OSQFRCHIP Numeric: OSQFRCHIPQ |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “]SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]”
OSQFRCHIPQ FILL: IF RESPONSE OPTION FOR OSQFRCHIP = 1, DISPLAY,
How many times <TEXT FILL 3> broken or fractured <TEXT FILL 2> hip?
|___|___| ENTER NUMBER OF TIMES [OSQFRCHIPQ]
77. REFUSED 99. DON’T KNOW
|
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “]SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
OSQFRCHIPQ FILL: IF RESPONSE OPTION FOR OSQFRCHIP = 1, DISPLAY,
¿Cuántos veces se ha roto o fracturado <TEXT FILL 3> la cadera?
|___|___| ENTER NUMBER OF TIMES [OSQFRCHIPQ]
77. REFUSED 99. DON’T KNOW
|
NOTES |
|
HELP SCREEN (ENG) |
Doctor: The term refers to both medical doctors (M.D.s) and osteopathic physicians (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Other Health (Care) Professional: A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers. |
HELP SCREEN (SPA) |
Médico/Doctor: El término se refiere tanto a los doctores en medicina (M.D., por sus siglas en inglés) como a los doctores en medicina osteopática (D.O., por sus siglas en inglés). Se incluye tanto a médicos generales como a los especialistas. No incluye a personas que no tienen un título de doctor en medicina (M.D. o D.O.), pero que tienen otros títulos de doctor como dentistas, cirujanos orales, quiroprácticos, podólogos, curanderos de la ciencia cristiana, ópticos, oculistas, psicólogos, etc.
Profesionales de la salud (Profesional de la atención médica): Una persona autorizada por su capacitación y experiencia, y posiblemente por una licencia, para asistir a un médico y trabajan con uno o varios médicos. Algunos ejemplos incluyen: asistentes o auxiliares médicos (PA, por sus siglas en inglés), enfermeros practicantes, personal de enfermería, farmacéuticos, técnicos de laboratorio y técnicos que aplican inyecciones (por ejemplo, inyecciones para las alergias). Incluya también paramédicos, fisioterapeutas y terapeutas médicos que trabajan con un médico o en consultorios médicos. No incluya: dentistas, cirujanos de la boca, quiroprácticos, quiropedistas, podólogos, naturópatas, curanderos de la ciencia cristiana, ópticos, oculistas ni psicólogos o trabajadores sociales. |
HARD CHECK |
IFOSQFRCHIPQ <1 OR > 33, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 1 AND 33.” |
SOFT CHECK |
IF OSQFRCHIPQ >13 OR > 33, DISPLAY, “UNLIKELY RESPONSE, PLEASE VERIFY. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
OSQ.010a OSQ.020a |
NEXT |
OSQFRCWRS |
OSQFRCWRS / OSQFRCWRSQ |
|
ASK |
IF SP AGE >= 45 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> had broken or fractured <TEXT FILL 2> . . .
. . . wrist?
INTERVIEWER INSTRUCTION: DO NOT INCLUDE FOREARM OR HAND.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW [OSQFRCWRS]
<OSQFRCWRSQ FILL>
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> se había roto o fracturado...
... la muñeca?
INTERVIEWER INSTRUCTION: DO NOT INCLUDE FOREARM OR HAND.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW [OSQFRCWRS]
<OSQFRCWRSQ FILL>
|
QUESTION TYPE |
Radio button: OSQFRCWRS Numeric: OSQFRCWRSQ |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “]SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]”
OSQFRCWRSQ FILL: IF RESPONSE OPTION FOR OSQFRCWRS = 1, DISPLAY,
How many times <TEXT FILL 3> broken or fractured <TEXT FILL 2> wrist?
|___|___| ENTER NUMBER OF TIMES [OSQFRCWRSQ]
77. REFUSED 99. DON’T KNOW
|
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “]SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
OSQFRCWRSQ FILL: IF RESPONSE OPTION FOR OSQFRCWRS = 1, DISPLAY,
¿Cuántas veces se ha roto o fracturado <TEXT FILL 3> la muñeca?
|___|___| ENTER NUMBER OF TIMES [OSQFRCWRSQ]
77. REFUSED 99. DON’T KNOW
|
NOTES |
|
HELP SCREEN (ENG) |
Doctor: The term refers to both medical doctors (M.D.s) and osteopathic physicians (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Other Health (Care) Professional: A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers. |
HELP SCREEN (SPA) |
Médico/Doctor: El término se refiere tanto a los doctores en medicina (M.D., por sus siglas en inglés) como a los doctores en medicina osteopática (D.O., por sus siglas en inglés). Se incluye tanto a médicos generales como a los especialistas. No incluye a personas que no tienen un título de doctor en medicina (M.D. o D.O.), pero que tienen otros títulos de doctor como dentistas, cirujanos orales, quiroprácticos, podólogos, curanderos de la ciencia cristiana, ópticos, oculistas, psicólogos, etc.
Profesionales de la salud (Profesional de la atención médica): Una persona autorizada por su capacitación y experiencia, y posiblemente por una licencia, para asistir a un médico y trabajan con uno o varios médicos. Algunos ejemplos incluyen: asistentes o auxiliares médicos (PA, por sus siglas en inglés), enfermeros practicantes, personal de enfermería, farmacéuticos, técnicos de laboratorio y técnicos que aplican inyecciones (por ejemplo, inyecciones para las alergias). Incluya también paramédicos, fisioterapeutas y terapeutas médicos que trabajan con un médico o en consultorios médicos. No incluya: dentistas, cirujanos de la boca, quiroprácticos, quiropedistas, podólogos, naturópatas, curanderos de la ciencia cristiana, ópticos, oculistas ni psicólogos o trabajadores sociales. |
HARD CHECK |
IFOSQFRCWRSQ <1 OR >33, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 1 AND 33.” |
SOFT CHECK |
|
VERSION NOTES |
OSQ.010b OSQ.020b |
NEXT |
OSQFRCSPN |
OSQFRCSPN / OSQFRCSPNQ |
|
ASK |
IF SP AGE >= 45 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> had broken or fractured <TEXT FILL 3> . . .
. . . spine?.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
<OSQFRCSPNQ FILL>
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> se había roto o fracturado...
... la columna vertebral?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
<OSQFRCSPNQ FILL>
|
QUESTION TYPE |
Radio button: OSQFRCSPN Numeric: OSQFRCSPNQ |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “]SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “]SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]”
OSQFRCSPNQ FILL: IF RESPONSE OPTION FOR OSQFRCSPN = 1, DISPLAY,
How many times <TEXT FILL 3> broken or fractured <TEXT FILL 2> spine?
|___|___| ENTER NUMBER OF TIMES
77. REFUSED 99. DON’T KNOW
|
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “]SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
OSQFRCSPNQ FILL: IF RESPONSE OPTION FOR OSQFRCSPN = 1, DISPLAY,
¿Cuántas veces se ha roto o fracturado <TEXT FILL 3> la columna vertebral?
|___|___| ENTER NUMBER OF TIMES
77. REFUSED 99. DON’T KNOW
|
NOTES |
|
HELP SCREEN (ENG) |
Doctor: The term refers to both medical doctors (M.D.s) and osteopathic physicians (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Other Health (Care) Professional: A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers. |
HELP SCREEN (SPA) |
Médico/Doctor: El término se refiere tanto a los doctores en medicina (M.D., por sus siglas en inglés) como a los doctores en medicina osteopática (D.O., por sus siglas en inglés). Se incluye tanto a médicos generales como a los especialistas. No incluye a personas que no tienen un título de doctor en medicina (M.D. o D.O.), pero que tienen otros títulos de doctor como dentistas, cirujanos orales, quiroprácticos, podólogos, curanderos de la ciencia cristiana, ópticos, oculistas, psicólogos, etc.
Profesionales de la salud (Profesional de la atención médica): Una persona autorizada por su capacitación y experiencia, y posiblemente por una licencia, para asistir a un médico y trabajan con uno o varios médicos. Algunos ejemplos incluyen: asistentes o auxiliares médicos (PA, por sus siglas en inglés), enfermeros practicantes, personal de enfermería, farmacéuticos, técnicos de laboratorio y técnicos que aplican inyecciones (por ejemplo, inyecciones para las alergias). Incluya también paramédicos, fisioterapeutas y terapeutas médicos que trabajan con un médico o en consultorios médicos. No incluya: dentistas, cirujanos de la boca, quiroprácticos, quiropedistas, podólogos, naturópatas, curanderos de la ciencia cristiana, ópticos, oculistas ni psicólogos o trabajadores sociales. |
HARD CHECK |
IFOSQFRCSPNQ <1 OR >33, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 1 AND 33.” |
SOFT CHECK |
|
VERSION NOTES |
OSQ.010c OSQ.020c |
NEXT |
IF SP AGE >= 50 YEARS AND (OSQFRCHIP = 1 OR OSQFRCWRS = 1 OR OSQFRCSPN = 1): OSQFRCAGE FOR FIRST FRACTURE TYPE ELSE: OSQDOCTOR |
OSQFRCAGE |
|
ASK |
IF SP AGE >= 50 YEARS AND (OSQFRCHIP = 1 OR OSQFRCWRS = 1 OR OSQFRCSPN = 1): |
When <TEXT FILL 1> fractured <TEXT FILL 2> <TEXT FILL 3> the first time, <TEXT FILL 4> younger or older than 50?
1. UNDER 50 YEARS OLD 2. 50 YEARS OR OLDER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Cuando <TEXT FILL 1> se fracturó la <TEXT FILL 3> por primera vez, ¿tenía <TEXT FILL 4> más o menos de 50 años?
1. UNDER 50 YEARS OLD 2. 50 YEARS OR OLDER 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “hip” IF OSQFRCHIP = 1 FILL “wrist” IF OSQFRCHIP = 1 FILL “spine” IF OSQFRCSPN = 1
TEXT FILL 4: FILL “were you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “was [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “cadera” IF OSQFRCHIP = 1 FILL “muñeca” IF OSQFRCHIP = 1 FILL “columna vertebral” IF OSQFRCSPN = 1
TEXT FILL 4: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
LOOP THROUGH OSQFRCAGE THROUGH OSQFRCWHY FOR EACH FRACTURE TYPE |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OSQ.030N a/b/c |
NEXT |
IF OSQFRCAGE = 2: OSQFRCWHY FOR SAME FRACTURE TYPE IF (OSQFRCAGE = 1 OR 7 OR 9) AND MORE FRACTURE TYPES: OSQFRCAGE FOR NEXT FRACTURE TYPE IF (OSQFRCAGE = 1 OR 7 OR 9) AND NO NEXT FRACTURE TYPE: OSQDOCTOR |
OSQFRCWHY |
|
ASK |
IF OSQFRCAGE = 2 FOR SPECIFIC FRACTURE TYPE |
Did that fracture occur as a result of . . .
4. a fall from standing height or less, for example, tripped, slipped, and fell out of bed, 5. a hard fall, such as falling off a ladder or step stool, down stairs, or 6. a car accident or other severe trauma 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ocurrió esa fractura debido a...?
4. una caída desde una altura igual o más baja a la que tiene usted cuando está de pie, como tropezarse, resbalarse o caerse de la cama, 5. una caída fuerte, como caerse de una escalera o una banqueta, las escaleras, o 6. un accidente de automóvil u otro trauma grave 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
LOOP THROUGH OSQFRCAGE THROUGH OSQFRCWHY FOR EACH FRACTURE TYPE |
HELP SCREEN (ENG) |
Additional examples for “a fall from standing height or less” include leg gave way, was dizzy, fell bending over, fell out of a chair. Additional examples for “a hard fall” include being forcibly knocked down by another person or bicycle. |
HELP SCREEN (SPA) |
Ejemplos adicionales de “una caída desde una altura igual o más baja a la que tiene usted cuando está de pie” incluyen casos en que las piernas se debilitan, usted se marea, se cae hacia adelante o se cae de una silla. Otros ejemplos de una “caída fuerte” incluyen casos en los que otra persona o una bicicleta lo(a) empujan y lo(a) hacen caer con fuerza. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OSQ.051 a/b/c |
NEXT |
IF MORE FRACTURE TYPES: OSQFRCAGE FOR NEXT FRACTURE TYPE IF NO NEXT FRACTURE TYPE: OSQDOCTOR |
OSQDOCTOR |
|
ASK |
IF SP AGE >= 45 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> had osteoporosis, sometimes called thin or brittle bones?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> tenía osteoporosis, a veces llamado huesos delgados o débiles?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN (ENG) |
Osteoporosis: A disease in which bones become less dense, which makes them more fragile and likely to break. Osteoporosis is not always painful. In fact, many people don't know they have osteoporosis unless a bone breaks. A doctor may tell you that you have osteoporosis after you have had a broken bone or a bone density test. |
HELP SCREEN (SPA) |
Osteoporosis: Una enfermedad en la que los huesos se vuelven menos densos, lo que los hace más frágiles y puedan a quebrarse. La osteoporosis no siempre es dolorosa. De hecho, muchas personas no saben que tienen osteoporosis hasta que se rompen un hueso. Es probable que un médico le diga que tiene osteoporosis después de que se haya roto un hueso o de que le hayan hecho una prueba de densidad ósea. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OSQ.060 |
NEXT |
IF OSQDOCTOR = 1: OSTRX ELSE: OSQSTRDYN |
OSQRX |
|
ASK |
IF OSQDOCTOR = 1 |
Please look at the drugs on this card that are prescribed for osteoporosis. <TEXT FILL 1> ever been told by a doctor or other health professional to take a prescribed medicine for osteoporosis?
HAND CARD OSQ2
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Mire la lista de medicamentos de esta tarjeta que se recetan para la osteoporosis. ¿Alguna vez le ha dicho un doctor u otro profesional de la salud a <TEXT FILL 1> que tome un medicamento recetado para la osteoporosis?
HAND CARD OSQ2
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OSQ.072 |
NEXT |
OSQSTRDYN |
OSQSTRDYN |
|
ASK |
IF SP AGE >= 45 YEARS |
<TEXT FILL 1> ever taken any prednisone or cortisone pills nearly every day for a month or longer? (Prednisone and cortisone are types of steroids.)
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Alguna vez ha tomado <TEXT FILL 1> alguna pastilla de prednisona o cortisona casi todos los días durante un mes o más? (La prednisona y la cortisona son tipos de esteroides).
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OSQ.130 |
NEXT |
IF OSQSTRDYN = 1: OSQSTRDDAYQ ELSE: OSQPARENT |
OSQSTRDDAYQ / OSQSTRDDAYU |
|
ASK |
IF OSQSTRDYN = 1 |
Please think about <TEXT FILL 1> use of prednisone or cortisone during <TEXT FILL 2> lifetime. For how long did <TEXT FILL 3> use prednisone or cortisone nearly every day? Do not count the months or years when <TEXT FILL 4> not taking the medicine.
|___|___| ENTER NUMBER (OF MONTHS OR YEARS) [OSQSTRDDAYQ]
777. REFUSED 999. DON’T KNOW
|___| ENTER UNIT [OSQSTRDDAYU]
1. MONTHS 2. YEARS
|
|
SPANISH |
Piense en <TEXT FILL 1> de la prednisona o cortisona durante su vida. ¿Durante cuánto tiempo tomó <TEXT FILL 3> prednisona o cortisona casi todos los días? No cuente los meses o años en los que no estaba tomando el medicamento.
|___|___| ENTER NUMBER (OF MONTHS OR YEARS) [OSQSTRDDAYQ]
777. REFUSED 999. DON’T KNOW
|___| ENTER UNIT [OSQSTRDDAYU]
1. MONTHS 2. YEARS
|
QUESTION TYPE |
Numeric: OSQSTRDDAYQ Radio button: OSQSTRDDAYU |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 4: FILL “you were” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he was” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she was” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] was” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “su uso” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “el uso de [SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 4: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
IF OSQSTRDDAYQ >= 19, DISPLAY MESSAGE, “IT IS UNUSUAL TO BE TAKING PREDNISONE FOR {RESPONSE FOR OSQSTRDDAYQ} {RESPONSE FOR OSQSTRDAYU}. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
OSQ.140 Q/U |
NEXT |
OSQPARENT |
OSQPARENT |
|
ASK |
IF SP AGE >= 45 YEARS |
Including living and deceased, were either of <TEXT FILL 1> biological parents ever told by a doctor or other health professional that they had osteoporosis or brittle bones?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Alguna vez un doctor u otro profesional de la salud dijo que alguno de <TEXT FILL 1>, ya sea que estén vivos o que hayan fallecido, tenían osteoporosis o huesos débiles?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “sus padres biológicos” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “los padres biológicos de [SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OSQ.150 |
NEXT |
IF OSQPARENT = 1: OSQPARENTS ELSE: OSQMOM |
OSQPARENTS |
|
ASK |
IF OSQPARENT = 1 |
Which biological (blood) parent?
[CODE ALL THAT APPLY]
1. MOTHER 2. FATHER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Cuál de sus padres biológicos (de sangre)?
[CODE ALL THAT APPLY]
1. MOTHER 2. FATHER 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Select all that apply |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OSQ.160 |
NEXT |
OSQMOM |
OSQMOM |
|
ASK |
IF SP AGE >= 45 YEARS |
Did <TEXT FILL 1> biological mother ever fracture her hip?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Se fracturó alguna vez la cadera <TEXT FILL 1>?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “su madre biológica” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “la madre biológica de [SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OSQ.170 |
NEXT |
IF OSQMOM = 1: OSQMOMAGE ELSE: OSQDAD |
OSQMOMAGE |
|
ASK |
IF OSQMOM = 1 |
When she fractured her hip (the first time), was she younger or older than 50?
1. UNDER 50 YEARS OLD 2. 50 YEARS OR OLDER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Cuando ella se fracturó la cadera (la primera vez), ¿tenía menos o más de 50 años?
1. UNDER 50 YEARS OLD 2. 50 YEARS OR OLDER 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OSQ.180N |
NEXT |
OSQDAD |
OSQDAD |
|
ASK |
IF SP AGE >= 45 YEARS |
Did <TEXT FILL 1> biological father ever fracture his hip?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Se fracturó alguna vez la cadera <TEXT FILL 1>?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “su padre biológico” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “el padre biológico de [SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OSQ.200 |
NEXT |
IF OSQDAD = 1: OSQDADAGE ELSE: END OF SECTION |
OSQDADAGE |
|
ASK |
IF OSQDAD = 1 |
When he fractured his hip (the first time), was he younger or older than 50?
1. UNDER 50 YEARS OLD 2. 50 YEARS OR OLDER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Cuando él se fracturó la cadera (la primera vez), ¿tenía menos o más de 50 años?
1. UNDER 50 YEARS OLD 2. 50 YEARS OR OLDER 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OSQ.210N |
NEXT |
END OF SECTION |
RESPIRATORY HEALTH AND ALLERGY – RDQ
Target Group: SPs 1+
RDQEPISODE |
|
ASK |
IF SP AGE IS >= 1 YEAR |
In the last 12 months, how many episodes or attacks of wheezing or whistling in <TEXT FILL 1> chest <TEXT FILL 2> had?
0. NONE 1. 1 ATTACK 2. 2 ATTACKS 3. 3 - 11 ATTACKS 4. 12 OR MORE ATTACKS 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿cuántos episodios o ataques de sibilancias o silbidos ha tenido <TEXT FILL 1> en el pecho?
0. NONE 1. 1 ATTACK 2. 2 ATTACKS 3. 3 - 11 ATTACKS 4. 12 OR MORE ATTACKS 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “has he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “has she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “has [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RDQ.070 |
NEXT |
RDQWHEEZE |
RDQWHEEZE |
|
ASK |
IF SP AGE IS >= 1 YEAR |
Apart from when <TEXT FILL 1> a cold, does <TEXT FILL 2> chest ever sound wheezy or whistling?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW |
|
SPANISH |
Aparte de cuando <TEXT FILL 1> tiene un resfrío, ¿siente alguna vez sibilancias o silbidos en su pecho?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] has”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RDQ.135N |
NEXT |
RDQCOUGH |
RDQCOUGH |
|
ASK |
IF SP AGE >= 1 YEAR |
<TEXT FILL 1> usually have a cough?
INTERVIEWER INSTRUCTION: COUNT A COUGH WITH SMOKE OR ON FIRST GOING OUT OF DOORS.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tiene <TEXT FILL 1> tos usualmente?
INTERVIEWER INSTRUCTION: COUNT A COUGH WITH SMOKE OR ON FIRST GOING OUT OF DOORS.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RDQ.031A |
NEXT |
IF RDQCOUGH = 1 AND SP AGE >= 18 YEARS: RDQCOUGH3M IF RDQCOUGH = 2 OR 7 OR 9 AND SP AGE >= 18 YEARS: RDQPHLEM IF SP AGE < 18 YEARS: AGQSYMPTM |
RDQCOUGH3M |
|
ASK |
IF RDQCOUGH = 1 AND SP AGE >= 18 YEARS |
<TEXT FILL 1> usually cough on most days for 3 consecutive months or more during the year?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tose <TEXT FILL 1> usualmente la mayoría de los días durante 3 meses seguidos o más durante el año?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RDQ.031N |
NEXT |
RDQPHLEM |
RDQPHLEM |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 1> usually bring up phlegm from <TEXT FILL 2> chest?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Arroja <TEXT FILL 1> flema usualmente del pecho?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN (ENG) |
Phlegm: Thick mucus that is produced in the lungs or chest. |
HELP SCREEN (SPA) |
Flema: Mucosidad espesa que se produce en los pulmones o en el pecho. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RDQ.050A |
NEXT |
IF RDQPHLEM = 1: RDQPHLEM3M ELSE: RDQSHORT |
RDQPHLEM3M |
|
ASK |
IF RDQPHLEM = 1 |
<TEXT FILL 1> bring up phlegm on most days for 3 consecutive months or more during the year?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Arroja <TEXT FILL 1> flema del pecho cuando tose la mayoría de los días durante 3 meses seguidos o más durante el año?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RDQ.050N |
NEXT |
RDQSHORT |
RDQSHORT |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 1> get short of breath when hurrying on level ground or walking up a slight hill?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Le falta aliento <TEXT FILL 1> cuando camina rápido en terreno llano o levemente elevado?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “a [SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RDQ.NEW1 |
NEXT |
AGQSYMPTM |
AGQSYMPTM |
|
ASK |
IF SP AGE >= 1 YEARS |
These next questions are about different types of allergies. At the mobile examination center, we plan to test for common allergens.
In the last 12 months, did <TEXT FILL 1> have any of the following symptoms when <TEXT FILL 1> did not have a cold or the flu or COVID-19?
[CODE ALL THAT APPLY]
1. Sneezing 2. Runny nose 3. Stuffy nose 4. Post-nasal drip 5. Watery eyes 6. Itchy eyes 7. NONE 77. REFUSED 99. DON’T KNOW [CODE ALL THAT APPLY] |
|
SPANISH |
Las siguientes preguntas son sobre diferentes tipos de alergias. En el centro móvil de examen, planeamos hacer pruebas para detectar alérgenos habituales.
En los últimos 12 meses, ¿ha tenido <TEXT FILL 1> alguno de los siguientes síntomas cuando no estaba resfriado(a) ni tenía influenza o COVID-19?
[CODE ALL THAT APPLY]
1. Estornudos 2. Goteo nasal 3. Congestión en la nariz 4. Goteo posnasal 5. Ojos llorosos 6. Picazón en los ojos 7. NONE 77. REFUSED 99. DON’T KNOW [CODE ALL THAT APPLY] |
QUESTION TYPE |
Select all that apply |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AGQ.NEW1 |
NEXT |
IF AGQSYMPTM = 7 OR 77 OR 99: AGQRASH ELSE: AGQSYMPTMY |
AGQSYMPTMY |
|
ASK |
IF AGQSYMPTM != 7 OR 77 OR 99 |
In the last 12 months, <TEXT FILL 1> present all year around?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿<TEXT FILL 1> todo el año?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “was this symptom” IF ONLY ONE OPTION (CODE 1-6) WAS SELECTED IN AGQSYMPTM ELSE, FILL “were these symptoms” |
FILLS (SPA) |
TEXT FILL 1: FILL “estuvo presente ese síntoma” IF ONLY ONE OPTION (CODE 1-6) WAS SELECTED IN AGQSYMPTM ELSE, FILL “estuvieron presentes esos síntomas” |
NOTES |
|
HELP SCREEN |
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HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AGQ.NEW2 |
NEXT |
IF AGQSYMPTMY = 1: AGQSSNWORS ELSE: AGQSSNOCCR |
AGQSSNWORS |
|
ASK |
IF AGQSYMPTMY = 1 |
In which season <TEXT FILL 1> worse?
[CODE ALL THAT APPLY]
1. SPRING 2. SUMMER 3. FALL 4. WINTER 5. NO WORSE SEASON 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿En qué estación <TEXT FILL 1>?
[CODE ALL THAT APPLY]
1. SPRING 2. SUMMER 3. FALL 4. WINTER 5. NO WORSE SEASON 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Select all that apply |
FILLS (ENG) |
TEXT FILL 1: FILL “was the symptom” IF ONLY ONE OPTION (CODE 1-6) WAS SELECTED IN AGQSYMPTM ELSE, FILL “were the symptoms” |
FILLS (SPA) |
TEXT FILL 1: FILL “fue peor ese síntoma” IF ONLY ONE OPTION (CODE 1-6) WAS SELECTED IN AGQSYMPTM ELSE, FILL “fueron peores esos síntomas” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
AGQ.NEW2A |
NEXT |
AGQBOTHER |
AGQSSNOCCR |
|
ASK |
IF AGQSYMPTMY = 2 OR 7 OR 9 |
In which season(s) did the symptom(s) occur?
[CODE ALL THAT APPLY]
1. SPRING 2. SUMMER 3. FALL 4. WINTER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿En que temporadas ocurrieron estos síntomas?
[CODE ALL THAT APPLY]
1. PRIMAVERA 2. VERANO 3. OTOÑO 4. INVIERNO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Select all that apply |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AGQ.NEW3 |
NEXT |
AGQBOTHER |
AGQBOTHER |
|
ASK |
IF AGQSYMPTM != 7 OR 77 OR 99 |
In the last 12 months, on average, how bothersome <TEXT FILL 1>? Would you say that <TEXT FILL 2>…
1. Not bothered at all, 2. somewhat bothered, or 3. bothered a lot? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, en promedio, ¿cuánta molestia le <TEXT FILL 1>? ¿Diría que...
1. Ninguna molestia, 2. poca molestia, o 3. mucha molestia? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “was this symptom” IF ONLY ONE OPTION (CODE 1-6) WAS SELECTED IN AGQSYMPTM ELSE, FILL “were these symptoms”
TEXT FILL 2: FILL “you were” IF SP SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] was” |
FILLS (SPA) |
TEXT FILL 1: FILL “causó ese síntoma” IF ONLY ONE OPTION (CODE 1-6) WAS SELECTED IN AGQSYMPTM ELSE, FILL “causaron esos síntomas”
TEXT FILL 2: FILL “BLANK” IF SP SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “BLANK” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AGQ.NEW4 |
NEXT |
AGQRASH |
AGQRASH |
|
ASK |
IF SP AGE >= 1 YEAR |
In the last 12 months, <TEXT FILL 1> had an itchy rash, which was coming and going but did not completely resolve for at least 6 months?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿ha tenido <TEXT FILL 1> algún sarpullido en la piel con picazón, que se iba y venía pero que no desapareció del todo durante al menos 6 meses?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
The rash can be dry, scaly, bumpy, or crusty and lasts for several days or longer without treatment. |
HELP SCREEN (SPA) |
El sarpullido puede ser seco, escamoso, con bultos o con costras y puede durar varios días o más si no lo trata. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AGQ.NEW5 |
NEXT |
AGQECZMAYN |
AGQECZMAYN |
|
ASK |
IF SP AGE >= 1 YEAR |
<TEXT FILL 1> ever been told by a doctor or other health professional that <TEXT FILL 2> had eczema or atopic dermatitis?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Le ha dicho alguna vez <TEXT FILL 1> un doctor u otro profesional de la salud que <TEXT FILL 2> tenía eccema o dermatitis atópica?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “Have you” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE < 12 YEARS FILL “Has [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 12 YEARS
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “usted” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE < 12 YEARS FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 12 YEARS
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AGQ.NEW6 |
NEXT |
IF AGQECZMAYN = 1: AGQECZMAST ELSE: AGQFOOD |
AGQECZMAST |
|
ASK |
IF AGQECZMAYN = 1 |
<TEXT FILL 1> still have eczema or atopic dermatitis?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tiene <TEXT FILL 1> todavía tiene eccema o dermatitis atópica?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AGQ.NEW7 |
NEXT |
AGQFOOD |
AGQFOOD |
|
ASK |
IF SP AGE >= 1 YEAR |
The next questions are about food allergies. People with food allergies have reactions such as hives, vomiting, trouble breathing, or throat tightening that occur within two hours of eating a specific food.
Has a doctor or other health professional ever said that <TEXT FILL 1> a food allergy?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW |
|
SPANISH |
Las siguientes preguntas son sobre las alergias a los alimentos. Las personas con alergias a los alimentos tienen reacciones como urticaria, vómitos, dificultad para respirar o presión en la garganta que ocurren durante las dos horas después de comer un alimento específico.
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> tiene una alergia a los alimentos?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME} has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AN SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME}” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AN SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AGQ.NEW8 |
NEXT |
IF AGQFOOD = 1: AGQFOODAGE ELSE: AGQFOODNOW |
AGQFOODAGE |
|
ASK |
IF AGQFOOD = 1 |
How old <TEXT FILL 1> when <TEXT FILL 2> first told that <TEXT FILL 3> food allergies?
1. 0-2 YEARS 2. 3-5 YEARS OLD 3. 6-17 YEARS OLD 4. 18 YEARS OR OLDER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Qué edad <TEXT FILL 1> cuando le dijeron por primera vez que <TEXT FILL 3> tenía una alergia a los alimentos?
1. 0-2 YEARS 2. 3-5 YEARS OLD 3. 6-17 YEARS OLD 4. 18 YEARS OR OLDER 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “were you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “was [SP NAME]”
TEXT FILL 2: FILL “you were” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] was”
TEXT FILL 3: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “tenía usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “tenía [SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “BLANK”
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AGQ.NEW9 |
NEXT |
AGQEPIPEN |
AGQEPIPEN |
|
ASK |
IF AGQFOOD = 1 |
<TEXT FILL 1> carry an epinephrine autoinjector such as EpiPen® for <TEXT FILL 2> food allergy?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿<TEXT FILL 1> un autoinyector de epinefrina como EpiPen® para la alergia de los alimentos?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “Do you” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE < 12 YEARS FILL “Does [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 12 YEARS
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “Lleva usted consigo” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “Llevas contigo” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE < 12 YEARS FILL “Lleva [SP NAME] consigo” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 12 YEARS
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN (ENG) |
Other examples of epinephrine autoinjector include Adrenaclick®, Auvi-Q®, and Symjepi®. |
HELP SCREEN (SPA) |
Otros ejemplos de autoinyectores de epinefrina son Adrenaclick®, Auvi-Q® y Symjepi®. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AGQ.NEW10 |
NEXT |
AGQFOODNOW |
AGQFOODNOW |
|
ASK |
IF SP AGE >= 1 YEAR |
<TEXT FILL 1> now allergic to any foods?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Es <TEXT FILL 1> alérgico(a) a algún alimento?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Is [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AGQ.NEW11 |
NEXT |
IF AGQFOODNOW = 1: AGQFOODSEL ELSE: END OF SECTION |
AGQFOODSEL |
|
ASK |
IF AGQFOODNOW = 1 |
What foods <TEXT FILL 1> allergic to?
[CODE ALL THAT APPLY]
HAND CARD AGQ1
1. PEANUTS 2. OTHER NUTS 3. COW’S MILK 4. EGGS 5. SHRIMP OR SHELLFISH 6. OTHER FISH 7. WHEAT 8. SOY 9. SESAME 10. OTHER FOODS 77. REFUSED 99. DON’T KNOW
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SPANISH |
¿A qué alimentos es alérgico(a) <TEXT FILL 1>?
[CODE ALL THAT APPLY]
HAND CARD AGQ1
1. CACAHUATES/MANÍ 2. OTRAS NUECES SECAS 3. LECHE DE VACA 4. HUEVOS 5. CAMARONES O MARISCOS 6. OTROS PESCADOS 7. TRIGO 8. SOJA 9. SÉSAMO 10. OTROS ALIMENTOS 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Select all that apply |
FILLS (ENG) |
TEXT FILL 1: FILL “are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “is [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AGQ.NEW12 |
NEXT |
END OF SECTION |
VISION – VIQ
Target Group: SPs 5+
VIQLIGHT |
|
ASK |
IF SP AGE >= 5 YEARS |
Next, I have some questions about <TEXT FILL 1> ability to see.
With both eyes open, can <TEXT FILL 2> see light?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Ahora tengo algunas preguntas sobre <TEXT FILL 1>.
Cuando abre los dos ojos, ¿puede <TEXT FILL 2> ver la luz?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “you” IF SP SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “su capacidad de ver” IF SP SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “la capacidad de ver de [SP NAME]”
TEXT FILL 2: FILL “usted” IF SP SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.010 |
NEXT |
IF VIQLIGHT = 1 AND SP AGE < 12 YEARS: VIQEYEEXAM IF VIQLIGHT = 1 AND SP AGE >= 12 YEARS: VIQEYESGHT IF VIQLIGHT = 2: VIQLIGHT_CNFRM IF VIQLIGHT = 7 OR 9: VIQBLIND |
VIQLIGHT_CNFRM |
|
ASK |
IF VIQLIGHT = 2 |
YOU HAVE CODED THAT SP CANNOT SEE LIGHT – PLEASE VERIFY RESPONSE. IF THIS IS INCORRECT, PLEASE GO BACK TO THE PREVIOUS QUESTION AND CHANGE YOUR RESPONSE.
With both eyes open, can <TEXT FILL 1> see light?
1. YES 2. NO
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SPANISH |
YOU HAVE CODED THAT SP CANNOT SEE LIGHT – PLEASE VERIFY RESPONSE. IF THIS IS INCORRECT, PLEASE GO BACK TO THE PREVIOUS QUESTION AND CHANGE YOUR RESPONSE.
Cuando abre los dos ojos, ¿puede <TEXT FILL 1> ver la luz?
1. YES 2. NO
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
IF VIQLIGHT_CNFRM = 1, DISPLAY “IF THIS IS CORRECT AND SP CAN SEE LIGHT, PLEASE GO BACK TO THE PREVIOUS QUESTION AND CHANGE YOUR RESPONSE.” |
SOFT CHECK |
|
VERSION NOTES |
|
NEXT |
IF VIQLIGHT_CNFRM = 2: VIQBLIND |
VIQBLIND |
|
ASK |
IF VIQLIGHT = 2 OR 7 OR 9 |
<TEXT FILL 1> blind in both eyes?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Está <TEXT FILL 1> ciego(a) de ambos ojos?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Is [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF VIQLIGHT = 2 (NO) AND VIQBLIND = 2 (NO), DISPLAY “YOU HAVE CODED THAT SP IS NOT BLIND. EARLIER SP REPORTED THAT THEY CANNOT SEE LIGHT. RECONCILE RESPONSES WITH SP AND CHANGE RESPONSE TO ONE QUESTION BELOW:” DISPLAY RESPONSES TO BOTH VIQLIGHT AND VIQBLIND WITH LABELS. PLACE HIGHLIGHT ON VIQLIGHT. |
SOFT CHECK |
|
VERSION NOTES |
VIQ.017 |
NEXT |
IF SP AGE < 12 YEARS: VIQEYEEXAM IF VIQLIGHT = 2: VIQEYEEXAM IF SP AGE >= 12 YEARS AND VIQLIGHT = 7 OR 9: VIQEYESGHT |
VIQEYESGHT |
|
ASK |
IF VIQLIGHT = (1 OR 7 OR 9) AND SP AGE >= 12 YEARS |
At the present time, would you say <TEXT FILL 1> eyesight, with glasses or contact lenses if <TEXT FILL 2> them, is . . .
1. excellent, 2. good, 3. fair, 4. poor, or 5. very poor? 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
En la actualidad, ¿diría que <TEXT FILL 1>, con anteojos o lentes de contacto, si los usa, es...
1. excelente, 2. buena, 3. regular, 4. mala, o 5. muy mala? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “you wear” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he wears” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she wears” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] wears” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “su visión” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “la vision de [SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.031 |
NEXT |
VIQWORRY |
VIQWORRY |
|
ASK |
IF VIQLIGHT = (1 OR 7 OR 9) AND SP AGE >= 12 YEARS |
How much of the time <TEXT FILL 1> worry about <TEXT FILL 2> eyesight? Would you say . . .
0. none of the time, 1. a little of the time, 2. some of the time, 3. most of the time, or 4. all of the time? 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
¿Cuánto tiempo se preocupa <TEXT FILL 1> por su visión? ¿Diría que se...
0. nunca, 1. un poco, 2. algunas veces, 3. la mayor parte del tiempo, or 4. todo el tiempo? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.041 |
NEXT |
IF SP AGE < 18 YEARS: VIQEYEEXAM ELSE: VIQDIFFRD |
VIQDIFFRD / VIQDIFFWRK / VIQDIFFSTP / VIQDIFFOBJ / VIQDIFFFND |
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ASK |
IF VIQLIGHT = (1 OR 7 OR 9) AND SP AGE >= 18 YEARS |
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The next questions are about how much difficulty, if any, <TEXT FILL 1> doing certain activities, such as reading ordinary newsprint or going down steps. If <TEXT FILL 2> usually <TEXT FILL 3> glasses or contact lenses to do these activities, please rate <TEXT FILL 4> ability to do them while wearing <TEXT FILL 4> glasses or contacts.
How much difficulty <TEXT FILL 5> have . . .
HAND CARD VIQ1. READ CATEGORIES TO RESPONDENT IF NECESSARY.
RESPONSES: NO DIFFICULTY = 1, A LITTLE DIFFICULTY = 2, MODERATE DIFFICULTY = 3, EXTREME DIFFICULTY = 4, UNABLE TO DO BECAUSE OF EYESIGHT = 5, DOES NOT DO THIS FOR OTHER REASONS = 6, REFUSED = 7, DON'T KNOW = 9.
|
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SPANISH |
|
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QUESTION TYPE |
Grid: Radio button |
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FILLS (ENG) |
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] has”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “wear” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “wears”
TEXT FILL 4: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 5: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQGENDER ELSE, FILL “does [SP NAME]”
TEXT FILL 6: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “him” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 7: FILL “you are” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he is” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she is” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] is” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
|
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FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “BLANK”
TEXT FILL 4: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 5: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQGENDER ELSE, FILL “[SP NAME]”
TEXT FILL 6: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 7: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
|
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NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
|
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VERSION NOTES |
VIQ.051 a/b/c/d/e |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||
NEXT |
VIQDRIVE |
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VIQDRIVE |
|
ASK |
IF VIQLIGHT = (1 OR 7 OR 9) AND SP AGE >= 18 YEARS |
How much difficulty <TEXT FILL 1> have driving in the daytime in familiar places due to <TEXT FILL 2> eyesight?
HAND CARD VIQ2
1. NO DIFFICULTY 2. A LITTLE DIFFICULTY 3. MODERATE DIFFICULTY 4. EXTREME DIFFICULTY 5. NO PUEDE HACERLO A CAUSA DE LA VISIÓN 6. NO HACE ESO POR OTRAS RAZONES 7. NEVER DROVE 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
¿Cuánta dificultad tiene <TEXT FILL 1> para conducir de día en lugares conocidos debido a su visión?
HAND CARD VIQ2
1. NADA DE DIFICULTAD 2. UN POCO DE DIFICULTAD 3. DIFICULTAD MODERADA 4. EXTREMA DIFICULTAD 5. INCAPAZ DE LOGRARLO A CAUSA DE LA VISTA 6. NO LO HACE POR OTRAS RAZONES 7. NUNCA CONDUCE 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.056N |
NEXT |
VIQLIMITED |
VIQLIMITED |
|
ASK |
IF VIQLIGHT = (1 OR 7 OR 9) AND SP AGE >= 18 YEARS |
How limited <TEXT FILL 1> in how long <TEXT FILL 2> can work or do other daily activities such as housework, child care, school, or community activities because of <TEXT FILL 3> vision? Would you say <TEXT FILL 4> limited . . .
0. none of the time, 1. a little of the time, 2. some of the time, 3. most of the time, or 4. all of the time? 7. REFUSED 9. DON’T KNOW |
|
SPANISH |
¿Qué tan limitado(a) se siente <TEXT FILL 1> en cuanto al tiempo que puede trabajar o hacer otras actividades diarias como tareas del hogar, el cuidado de niños, la escuela o actividades de la comunidad a causa de su visión? ¿Diría que <TEXT FILL 4> se siente limitado(a)...
0. nunca, 1. pocas veces, 2. algunas veces, 3. la mayor parte del tiempo, o 4. todo el tiempo? 7. REFUSED 9. DON’T KNOW |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “is [SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 4: FILL “you are” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he is” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she is” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] is” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 4: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.061 |
NEXT |
VIQEYEEXAM |
VIQEYEEXAM |
|
ASK |
IF SP AGE >= 5 YEARS |
When was the last time <TEXT FILL 1> had an eye exam by a doctor or other health professional?
1. LESS THAN 1 MONTH 2. 1-12 MONTHS 3. 13-24 MONTHS 4. MORE THAN 2 YEARS 5. NEVER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Cuándo fue la última vez que le hicieron a <TEXT FILL 1> un examen de la vista con un doctor u otro profesional de la salud?
1. LESS THAN 1 MONTH 2. 1-12 MONTHS 3. 13-24 MONTHS 4. MORE THAN 2 YEARS 5. NEVER 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.NEW1 |
NEXT |
IF VIQEYEEXAM = 5 AND SP AGE < 18 YEARS: END OF SECTION IF VIQEYEEXAM = 5 AND (18 YEARS <= SP AGE < 45 YEARS) AND VIQLIGHT = 1: VIQCATRCT IF VIQEYEEXAM = 5 AND (18 YEARS <= SP AGE < 45 YEARS) AND (VIQLIGHT = 2 OR 7 OR 9): VIQGLAUCM IF VIQEYEEXAM = 5 AND SP AGE >= 45 YEARS: VIQGLAUCM IF VIQEYEEXAM != 5: VIQDILATED |
VIQDILATED |
|
ASK |
IF VIQEYEEXAM != 5 |
When was the last time <TEXT FILL 1> had an eye exam in which the pupils were dilated, making <TEXT FILL 1> temporarily sensitive to bright light?
1. LESS THAN 1 MONTH 2. 1-12 MONTHS 3. 13-24 MONTHS 4. MORE THAN 2 YEARS 5. NEVER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Cuándo fue la última vez que le hicieron a <TEXT FILL 1> un examen de la vista en el que le dilataran las pupilas, lo que hizo que tuviera sensibilidad a las luces brillantes temporalmente?
1. LESS THAN 1 MONTH 2. 1-12 MONTHS 3. 13-24 MONTHS 4. MORE THAN 2 YEARS 5. NEVER 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.NEW2 |
NEXT |
VIQDOCCAM |
VIQDOCCAM |
|
ASK |
IF VIQEYEEXAM != 5 |
When was the last time a doctor, or other health professional took a photo of the back of <TEXT FILL 1> eye with a specialized camera?
1. LESS THAN 1 MONTH 2. 1-12 MONTHS 3. 13-24 MONTHS 4. MORE THAN 2 YEARS 5. NEVER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Cuándo fue la última vez que un doctor u otro profesional de la salud tomó una imagen de la parte de atrás <TEXT FILL 1> con una cámara especializada?
1. LESS THAN 1 MONTH 2. 1-12 MONTHS 3. 13-24 MONTHS 4. MORE THAN 2 YEARS 5. NEVER 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “de su ojo” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “del ojo de [SP NAME]” |
NOTES |
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HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.NEW3 |
NEXT |
IF SP AGE < 18 YEARS: END OF SECTION IF (18 YEARS <= SP AGE < 45 YEARS) AND VIQLIGHT = 1: VIQCATRCT IF (18 YEARS <= SP AGE < 45 YEARS) AND (VIQLIGHT = 2 OR 7 OR 9): VIQGLAUCM IF SP AGE >= 45 YEARS: VIQGLAUCM |
VIQGLAUCM |
|
ASK |
IF (18 YEARS <= SP AGE < 45 YEARS) AND (VIQLIGHT = 2 OR 7 OR 9) IF SP AGE >= 45 YEARS |
<TEXT FILL 1> ever been told by an eye doctor that <TEXT FILL 2> glaucoma, sometimes called high pressure in <TEXT FILL 3> eyes?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Alguna vez le ha dicho un doctor de la vista a <TEXT FILL 1> que tenía un glaucoma, a veces llamado presión alta en sus ojos?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]”
TEXT FILL 2: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN (ENG) |
An eye doctor is a person who specializes in the study of the eye. An ophthalmologist specializes in the structure, function, and diseases of the eye. An optometrist specializes in examining the eye for defects and faults of refraction and prescribing correctional lenses or exercises. |
HELP SCREEN (SPA) |
Un doctor de la vista es una persona especializada en el estudio de los ojos. Un oculista se especializa en la estructura, la función y las enfermedades de los ojos. Un optometrista se especializa en examinar los ojos para buscar defectos y fallos de refracción, así como recetar lentes correctoras o ejercicios. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.090 |
NEXT |
IF VIQGLAUCM = 1: VIQGLAUCME ELSE: VIQMACDEG |
VIQGLAUCME |
|
ASK |
IF VIQGLAUCM = 1 |
Was the glaucoma in <TEXT FILL 1> right eye, left eye, or both eyes?
1. RIGHT EYE 2. LEFT EYE 3. BOTH 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿El glaucoma que tenía <TEXT FILL 1>, estaba en el ojo derecho, en el izquierdo o en ambos?
1. RIGHT EYE 2. LEFT EYE 3. BOTH 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.100 |
NEXT |
VIQMACDEG |
VIQMACDEG |
|
ASK |
IF (18 YEARS <= SP AGE < 45 YEARS) AND (VIQLIGHT = 2 OR 7 OR 9) IF SP AGE >= 45 YEARS |
<TEXT FILL 1> ever been told by an eye doctor that <TEXT FILL 2> age-related macular (mac-ū-lar) degeneration, often called AMD?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Alguna vez le ha dicho un doctor de los ojos a <TEXT FILL 1> que tenía una degeneración macular asociada a la edad, con frecuencia como AMD, por sus siglas en inglés?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]”
TEXT FILL 2: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.310 |
NEXT |
IF VIQMACDEG = 1: VIQMACDEGE ELSE: VIQCATRCT |
VIQMACDEGE |
|
ASK |
IF VIQMACDEG = 1 |
Was the age-related macular (mac-ū-lar) degeneration in <TEXT FILL 1> right eye, left eye, or both eyes?
1. RIGHT EYE 2. LEFT EYE 3. BOTH 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Le ocurrió a <TEXT FILL 1> la degeneración macular asociada a la edad en el ojo derecho, en el ojo izquierdo o en ambos ojos?
1. RIGHT EYE 2. LEFT EYE 3. BOTH 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.320 |
NEXT |
VIQMACDEGV |
VIQMACDEGV |
|
ASK |
IF VIQMACDEG = 1 |
<TEXT FILL 1> lost any vision because of macular (mac-ū-lar) degeneration?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿<TEXT FILL 1> ha perdido algo de la vista a causa de la degeneración macular?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.311 |
NEXT |
VIQCATRCT |
VIQCATRCT |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 1> ever had cataract surgery?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Se ha operado <TEXT FILL 1> alguna vez de cataratas?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.071 |
NEXT |
IF VIQCATRCT = 1: VIQCATRCTE IF (VIQCATRCT = 2 OR 7 OR 9) AND (DIQRETINOP = 2 OR VIQLIGHT = 2): VIQSURGET IF (VIQCATRCT = 2 OR 7 OR 9) AND (DIQRETINOP = 1 OR 7 OR 9) AND (VIQLIGHT = 1 OR 7 OR 9) AND VIQMACDEG = 1: VIQSURGAMD IF (VIQCATRCT = 2 OR 7 OR 9) AND (DIQRETINOP = 1 OR 7 OR 9) AND (VIQLIGHT = 1 OR 7 OR 9) AND (VIQMACDEG = 2 OR 7 OR 9): END OF SECTION |
VIQCATRCTE |
|
ASK |
IF VIQCATRCT = 1 |
Was the surgery in <TEXT FILL 1> right eye, left eye, or both eyes?
1. RIGHT EYE 2. LEFT EYE 3. BOTH 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Se hizo <TEXT FILL 1> en el ojo derecho, el ojo izquierdo o ambos ojos?
1. RIGHT EYE 2. LEFT EYE 3. BOTH 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “su cirugía” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “la cirugía de [SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.081 |
NEXT |
IF (DIQRETINOP = 2 OR VIQLIGHT = 2): VIQSURGET IF (DIQRETINOP = 1 OR 7 OR 9) AND (VIQLIGHT = 1 OR 7 OR 9) AND VIQMACDEG = 1: VIQSURGAMD IF (DIQRETINOP = 1 OR 7 OR 9) AND (VIQLIGHT = 1 OR 7 OR 9) AND (VIQMACDEG = 2 OR 7 OR 9): END OF SECTION |
VIQSURGET |
|
ASK |
IF (DIQRETINOP = 2 OR VIQLIGHT = 2) AND SP AGE >= 18 YEARS |
Eye injections and laser surgery to the back of the eye, or retina, are commonly used treatments for diabetic retinopathy. <TEXT FILL 1> ever had eye injections or laser surgery to the back of either eye to treat diabetic retinopathy? (EXPLAIN IF NECESSARY: This does not include “Lasik” surgery to the front of the eye to correct vision.)
[CODE ALL THAT APPLY]
1. LASER SURGERY 2. EYE INJECTION 3. NEITHER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Las inyecciones de los ojos y la cirugía láser en la parte de atrás del ojo o retina, son tratamientos que se usan normalmente para tratar la retinopatía diabética. ¿Alguna vez le han puesto inyecciones a <TEXT FILL 1> en el ojo o le han hecho cirugía láser en la parte atrás de alguno de los ojos a para tratar la retinopatía diabética? (EXPLAIN IF NECESSARY: Esto no incluye la cirugía “Lasik” en la parte frontal del ojo para corregir la visión).
[CODE ALL THAT APPLY]
1. LASER SURGERY 2. EYE INJECTION 3. NEITHER 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Select all that apply |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.321 |
NEXT |
IF VIQLIGHT=2 OR VIQMACDEG=1: VIQSURGAMD ELSE: END OF SECTION |
VIQSURGAMD |
|
ASK |
IF (VIQLIGHT=2 OR VIQMACDEG=1) AND SP AGE >= 18 YEARS |
Eye injections and laser surgery to the back of the eye, or retina, are <TEXT FILL 1> commonly used for treatment for age-related macular degeneration (also called AMD). Have you ever had an eye injection or laser surgery to the back of either eye to treat age-related macular degeneration?
[CODE ALL THAT APPLY]
1. LASER SURGEY 2. EYE INJECTION 3. NEITHER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Las inyecciones de los ojos y la cirugía láser en la parte de atrás del ojo o retina, <TEXT FILL 1> se usan normalmente para el tratamiento de la degeneración macular asociada a la edad (también llamada AMD, por sus siglas en inglés). ¿Alguna vez le han puesto una inyección en el ojo o le han hecho cirugía láser en la parte posterior de alguno de los ojos para tratar la degeneración macular asociada a la edad?
[CODE ALL THAT APPLY]
1. LASER SURGEY 2. EYE INJECTION 3. NEITHER 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Select all that apply |
FILLS (ENG) |
TEXT FILL 1: FILL “also” IF VIQSURGET IS NOT MISSNG ELSE, LEAVE BLANK |
FILLS (SPA) |
TEXT FILL 1: FILL “también ” IF VIQSURGET IS NOT MISSNG ELSE, LEAVE BLANK |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
VIQ.322 |
NEXT |
END OF SECTION |
AUDIOMETRY – AUQ
Target Group: SPs 5-44
AUQDESCRB |
|
ASK |
IF SP AGE 5-44 YEARS |
These next questions are about <TEXT FILL 1> hearing.
Which statement best describes <TEXT FILL 1> hearing (without a hearing aid or other listening devices)? Would you say <TEXT FILL 2> hearing is excellent, good, that <TEXT FILL 3> a little trouble, moderate trouble, a lot of trouble, or <TEXT FILL 4> deaf?
1. EXCELLENT 2. GOOD 3. A LITTLE TROUBLE 4. MODERATE HEARING TROUBLE 5. A LOT OF TROUBLE 6. DEAF 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
Las siguientes preguntas son acerca de <TEXT FILL 1>.
¿Qué opción describe mejor <TEXT FILL 1> (sin audífono ni otros aparatos para escuchar)? ¿Diría que su audición es excelente, buena, tiene un poco de problema, tiene un problema moderado, tiene mucho problema, o que <TEXT FILL 4> es sordo(a)?
1. EXCELENTE 2. BUENA 3. TIENE UN POCO DE PROBLEMA 4. TIENE UN PROBLEMA MODERADO 5. TIENE MUCHO PROBLEMA 6. ES SORDO(A) 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF
TEXT FILL 3: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF
TEXT FILL 4: FILL “are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “is he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “is she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “is [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF |
FILLS (SPA) |
TEXT FILL 1: FILL “su audición” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “la audición de [SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF
TEXT FILL 3: FILL “le cuesta” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “le cuesta” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “le cuesta” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “le cuesta a [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF
TEXT FILL 4: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF |
NOTES |
|
HELP SCREEN (ENG) |
Deaf means hearing loss so severe in both ears that hearing aids are insufficient to allow you to understand what people are saying.
Hearing Aid: A small electronic device that amplifies the sounds you hear. It is worn in or behind the ear to help you hear.
Other Listening Devices: Other listening devices are any device you use to help you hear. They are also called assistive listening devices. These are:
A pocket talker An amplified telephone An amplified or vibrating alarm clock A light signaler for your doorbell A TV headset Closed-captioned TV TTY (teletypewriter) TDD (telecommunications device for the deaf) A telephone relay service A video relay service A sign language interpreter |
HELP SCREEN (SPA) |
Sordo: Ser sordo significa una pérdida de audición tan grave en ambos oídos que usar audífonos no es suficiente para permitirle entender lo que dice la gente.
Audífono/Ayuda auditiva: Un pequeño aparato electrónico que amplifica los sonidos que oye. Se usa dentro o detrás de la oreja para ayudar ayuda a oír mejor.
Otros aparatos para escuchar: Otros aparatos para escuchar incluyen cualquier aparato que use para ayudarle a oír. También se llaman aparatos de ayuda auditiva. Algunos ejemplos son:
Amplificador de audición de bolsillo Teléfono con amplificador Reloj despertador/alarma con amplificador de sonido o con vibración Señales luminosas para timbres Auriculares para la televisión Televisión con subtítulos para personas sordas TTY (teletipo) TDD (dispositivo de telecomunicaciones para personas sordas) Servicio de retransmisión telefónica Servicio de retransmisión de video Intérpretes de lenguaje de señas |
HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
AUQ.054 |
NEXT |
IF AUQDESCRB = 3, 4, 5, OR 6: AUQCAUSE ELSE: AUQHEARAID |
AUQCAUSE |
|
ASK |
IF AUQDESCRB = 3, 4, 5, OR 6 |
What are the main causes of <TEXT FILL 1> hearing loss?
HAND CARD AUQ1
1. GENETIC/HEREDITARY CAUSES 2. EAR INFECTIONS (INCLUDING FLUID IN EARS) 3. EAR DISEASES (OTOSCLEROSIS, MENIERES, TUMOR) 4. ILLNESS/INFECTIONS (MEASLES, MENINGITIS, MUMPS) 5. DRUGS/MEDICATIONS 6. HEAD OR NECK INJURY/TRAUMA 7. LOUD BRIEF EXPLOSIVE NOISE/SOUNDS 8. NOISE EXPOSURE, LONG-TERM (MACHINERY, ETC.) 9. AGING, GETTING OLDER 10. OTHER CAUSES 77. REFUSED 99. DON’T KNOW |
|
SPANISH |
¿Cuáles son las causas principales causas de <TEXT FILL 1>?
HAND CARD AUQ1
1. CAUSAS GENÉTICAS O HEREDITARIAS 2. INFECCIONES DE OÍDO (INCLUIDOS LÍQUIDOS EN LOS OÍDOS) 3. ENFERMEDADES DEL OÍDO (OTOSCLEROSIS, SÍNDROME DE MÉNIÈRE, TUMORES) 4. ENFERMEDADES/INFECCIONES (SARAMPIÓN, MENINGITIS, PAPERAS) 5. MEDICAMENTOS 6. LESIONES O TRAUMATISMOS EN LA CABEZA O EL CUELLO 7. RUIDOS O SONIDOS EXPLOSIVOS FUERTES Y BREVES 8. EXPOSICIÓN AL RUIDO POR LARGO TIEMPO (MAQUINARIA, ETC.) 9. EDAD, VEJEZ 10. OTRAS CAUSAS 77. REFUSED 99. DON’T KNOW |
QUESTION TYPE |
Select all that apply |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “su pérdidad de la audición” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[la pérdida de audición de SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
AUQ.410 |
NEXT |
AUQHEARAID |
AUQHEARAID |
|
ASK |
IF SP AGE 5-44 YEARS |
<TEXT FILL 1> now use a hearing aid, cochlear implant, or other listening device?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
¿Usa <TEXT FILL 1> un audífono actualmente, un implante coclear u otro aparato para escuchar?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Hearing Aid: A small electronic device that amplifies the sounds you hear. It is worn in or behind the ear to help you hear.
Cochlear implant: An electrical device that a surgeon puts in your ear that helps you hear by sending sounds directly to the brain. It is only used when you are almost totally deaf.
Other Listening Devices: Any other device you use to help you hear. These are also called assistive listening devices. |
HELP SCREEN (SPA) |
Audífono/Ayuda auditiva: Un pequeño aparato electrónico que amplifica los sonidos que oye. Se usa dentro o detrás de la oreja para ayudar ayuda a oír mejor.
Implante coclear: Un aparato eléctrico que un cirujano le coloca en el oído y que le ayuda a oír enviando sonidos directamente al cerebro. Solo se usa cuando la sordera es casi total.
Otros dispositivos para escuchar: Cualquier otro aparato que use para ayudarle a oír. También se llaman dispositivos de ayuda auditiva. |
HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
AUQ.New1 AUQ.New2 |
NEXT |
AUQWHISPER |
AUQWHISPER |
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ASK |
IF SP AGE 5-44 YEARS |
The next questions ask about how <TEXT FILL 1> can hear in certain situations without using a hearing aid or other listening device.
Without a hearing aid or other listening devices, can <TEXT FILL 1> usually hear and understand what a person says without seeing his or her face if that person whispers to <TEXT FILL 2> from across a quiet room?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
Las siguientes preguntas son sobre cuánto puede oír <TEXT FILL 1> en ciertas situaciones sin usar audífonos ni otros aparatos para escuchar.
Sin usar audífonos ni otros aparatos para escuchar, ¿puede <TEXT FILL 1> normalmente oír y entender lo que dice una persona sin verle la cara si esa persona le murmura desde el otro lado de una habitación silenciosa?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “him” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
AUQ.070 |
NEXT |
AUQDIFFICLT |
AUQDIFFICLT |
|
ASK |
IF SP AGE 5-44 YEARS |
HAND CARD AUQ2 TO RESPONDENT.
INTERVIEWER INSTRUCTION: READ INTRODUCTION PHRASE IN PARENTHESES AS NECESSARY
(Without a hearing aid or other listening devices,) How often <TEXT FILL 1> have difficulty hearing and understanding if there is background noise, for example, when other people are talking, TV or radio is on, or children are playing? Would you say…
1. Always, 2. Usually, 3. About half the time, 4. Seldom, or 5. Never? 7. REFUSED 9. DON’T KNOW |
|
SPANISH |
HAND CARD AUQ2 TO RESPONDENT.
INTERVIEWER INSTRUCTION: READ INTRODUCTION PHRASE IN PARENTHESES AS NECESSARY
(Sin audífonos ni otros aparatos para escuchar,) ¿con qué frecuencia tiene <TEXT FILL 1> dificultad para oír y entender si hay ruido de fondo, como por ejemplo, cuando hay otras personas que están hablando, una televisión o radio encendidas, o hay niños que están jugando? ¿Diría que...
1. Siempre, 2. Normalmente, 3. Más o menos la mitad de las veces, 4. Rara vez, o 5. Nunca? 7. REFUSED 9. DON’T KNOW |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
AUQ.101 |
NEXT |
AUQFRUSTRT |
AUQFRUSTRT |
|
ASK |
IF SP AGE 5-44 YEARS |
REFER TO HAND CARD AUQ2.
INTERVIEWER INSTRUCTION: READ INTRODUCTION PHRASE IN PARENTHESES AS NECESSARY
(Without a hearing aid or other listening devices,) How often does <TEXT FILL 1> hearing cause <TEXT FILL 2> to feel frustrated when talking to members of <TEXT FILL 3> family or to friends? Would you say...
1. Always, 2. Usually, 3. About half the time, 4. Seldom, or 5. Never? 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
REFER TO HAND CARD AUQ2.
INTERVIEWER INSTRUCTION: READ INTRODUCTION PHRASE IN PARENTHESES AS NECESSARY
(Sin audífonos ni otros aparatos para escuchar:) ¿Con qué frecuencia <TEXT FILL 1> hace que sienta frustración cuando habla con miembros de su familia o amigos? ¿Diría que...?
1. Siempre 2. Generalmente 3. Aproximadamente la mitad del tiempo 4. Rara vez 5. Nunca 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “him” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “su audición” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “la audición de [SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
AUQ.110 |
NEXT |
AUQINFECT |
AUQINFECT |
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ASK |
IF SP AGE 5-44 YEARS |
How many ear infections including earache, fluid in the ear, or temporary hearing loss <TEXT FILL 1> ever had? (Temporary hearing loss includes “muffled” hearing.)
1. 0 2. 1-2 3. 3 OR MORE 7. REFUSED 9. DON’T KNOW
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SPANISH |
¿Cuántos problemas de infecciones de oído ha tenido <TEXT FILL 1> alguna vez, incluidos problemas de dolor de oído, líquido en el oído o pérdida temporal de la audición? (La pérdida auditiva temporal incluye las ocasiones en las que el sonido se escucha apagado).
1. 0 2. 1-2 3. 3 OR MORE 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
AUQ.136 AUQ.NEW1 |
NEXT |
AUQTUBE |
AUQTUBE |
|
ASK |
IF SP AGE 5-44 YEARS |
<TEXT FILL 1> ever had a tube placed in <TEXT FILL 2> ear to drain the fluid from <TEXT FILL 2> ear?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW |
|
SPANISH |
¿Le han colocado a <TEXT FILL 1> alguna vez un tubo en el oído para drenar el líquido que había en su oído de?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
AUQ.138 |
NEXT |
IF SP AGE 5-17: AUQDIZZY ELSE: AUQRINGING |
AUQRINGING |
|
ASK |
IF SP AGE 18-44 YEARS |
In the last 12 months, <TEXT FILL 1> been bothered by ringing, roaring, or buzzing in <TEXT FILL 2> ears or head that lasts for 5 minutes or more?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
En los últimos 12 meses, ¿Ha sentido <TEXT FILL 1> molestias por zumbidos, ruidos o pitidos en los oídos o la cabeza que duraron 5 minutos o más?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS REPSONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]”
TEXT FILL 2: FILL "your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS REPSONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL "BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
NOTES |
|
HELP SCREEN (ENG) |
Tinnitus (tin-uh-tus) is the medical term for ringing, roaring or buzzing in the ears or head. |
HELP SCREEN (SPA) |
Tinnitus es el término médico para referirse a los zumbidos, ruidos o pitidos en los oídos o la cabeza. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.191 |
NEXT |
IF AUQRINGING = 1: AUQRINGFRQ ELSE: AUQDIZZY |
AUQRINGFRQ |
|
ASK |
IF AUQRINGING = 1 |
How often <TEXT FILL 1> you hear these sounds?
1. Almost always 2. At least once a day 3. At least once a week 4. At least once a month, or 5. Less frequently than once a month? 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
¿Con qué frecuencia oye <TEXT FILL 1> estos sonidos?
1. Casi siempre 2. Al menos una vez al día 3. Al menos una vez a la semana 4. Al menos una vez al mes, o 5. Menos frecuente que una vez al mes? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
AUQ.New13 |
NEXT |
AUQRINGPRB |
AUQRINGPRB |
|
ASK |
IF AUQRINGING = 1 |
In the last 12 months, how much of a problem is this ringing, roaring, or buzzing in <TEXT FILL 1> ears or head? Would you say it is...
1. No problem, 2. A small problem, 3. A moderate problem, 4. A big problem, or 5. A very big problem? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿cuánto problema ha sido este pitido, ruido o zumbido que oye <TEXT FILL 1> en los oídos o la cabeza? ¿Diría que...
1. No es un problema, 2. Un pequeño problema, 3. Un problema moderado, 4. Un gran problema, o 5. Un problema muy grave? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS REPSONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS REPSONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.280 |
NEXT |
AUQDIZZY |
AUQDIZZY |
|
ASK |
IF SP AGE 5-44 YEARS |
This next question is about dizziness or balance problems. Do not include times when drinking alcohol, using recreational drugs, or taking medications that cause dizziness.
In the last 12 months, <TEXT FILL 1> had a problem with dizziness, vertigo, lightheadedness, blurred vision when moving <TEXT FILL 2 > head, feeling like <TEXT FILL 3> going to pass out or faint, or with unsteadiness or feeling off-balance?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
La siguiente pregunta es sobre los mareos o problemas de equilibrio. No incluya los momentos en los que beba alcohol, use drogas recreativas o tome medicamentos que provoquen mareos.
En los últimos 12 meses, ¿ha tenido <TEXT FILL 1> un problema de mareos, vértigo, desvanecimiento, visión borrosa al mover la cabeza, con la sensación de que se va a desmayar o desvanecer, o sensación de inestabilidad o falta de equilibrio?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “their” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER
TEXT FILL 3: FILL “you are” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he is” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she is” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] is” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER
TEXT FILL 3: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
NOTES |
|
HELP SCREEN (ENG) |
Vertigo is a sensation of feeling off-balance from rotation, rocking, or other motion, such as riding a carousel. |
HELP SCREEN (SPA) |
El vértigo es una sensación de falta de equilibrio por un movimiento de rotación, balanceo u otro movimiento, como montar en un carrusel. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.New3 |
NEXT |
AUQACHE |
AUQACHE |
|
ASK |
IF SP AGE 5-44 YEARS |
In the last 12 months, how often <TEXT FILL 1> had migraines or severe headaches?
1. NEVER 2. ONCE OR TWICE 3. 3 TO 5 TIMES 4. 6 TO 10 TIMES 5. MORE THAN 10 TIMES 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿con qué frecuencia tuvo <TEXT FILL 1> migrañas o dolores de cabeza intensos?
1. NEVER 2. ONCE OR TWICE 3. 3 TO 5 TIMES 4. 6 TO 10 TIMES 5. MORE THAN 10 TIMES 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.New14 |
NEXT |
IF AUQACHE = 1, 7 OR 9: AUQANNOY ELSE: AUQACHEBTR |
AUQACHEBTR |
|
ASK |
IF AUQACHE = 2, 3, 4, OR 5 |
Does light or noise bother <TEXT FILL 1> when <TEXT FILL 2> a migraine or severe headache?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿<TEXT FILL 1> siente molestias por la luz o el ruido cuando tiene una migraña o un dolor de cabeza intenso?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] has” |
FILLS (SPA) |
TEXT FILL 1: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “BLANK” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.New15 |
NEXT |
AUQANNOY |
AUQANNOY |
|
ASK |
IF SP AGE 5-44 YEARS |
Some people are bothered by everyday sounds or noises that don’t bother most people. Do everyday sounds, such as from a hair dryer, vacuum cleaner, lawnmower, or siren, seem too loud or annoying to <TEXT FILL 1>?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
A algunas personas les molestan los sonidos o ruidos diarios que no molestan a la mayoría de personas. ¿Los sonidos cotidianos, como los del secador de pelo, la aspiradora, las máquinas para cortar el césped o las sirenas, le parecen demasiado fuertes o molestos a <TEXT FILL 1>?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.New10 |
NEXT |
IF AUQANNOY = 1: AUQANNOYPRB ELSE: AUQINJURY |
AUQANNOYPRB |
|
ASK |
IF AUQANNOY = 1 |
In the last 12 months, how much of a problem <TEXT FILL 1> had because every day sounds seem unbearably loud? Would you say it was...
1. No problem, 2. A small problem, 3. A moderate problem, 4. A big problem, or 5. A very big problem? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿cuánto problema le ha causado a <TEXT FILL 1> la sensación de que los sonidos diarios son insoportablemente altos? ¿Diría que...
1. No es un problema, 2. Un pequeño problema, 3. Un problema moderado, 4. Un gran problema, o 5. Un problema muy grave? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.New11 |
NEXT |
AUQINJURY |
AUQINJURY |
|
ASK |
IF SP AGE 5-44 YEARS |
In <TEXT FILL 1> lifetime, <TEXT FILL 2> ever had a significant head injury or concussion?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En <TEXT FILL 1>, ¿ha tenido alguna vez una lesión en la cabeza o conmoción cerebral grave?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “toda su vida” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “toda la vida de [SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “BLANK” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.New4 |
NEXT |
IF AUQINJURY = 1: AUQINJURYQ ELSE: AUQMUSIC |
AUQINJURYQ |
|
ASK |
IF AUQINJURY = 1 |
How many significant head injuries or concussions <TEXT FILL 1> had in <TEXT FILL 2> lifetime?
1. 1 2. 2 3. 3 4. 4 5. 5 OR MORE 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Cuántas lesiones en la cabeza o conmociones cerebrales graves ha tenido <TEXT FILL 1> en toda su vida?
1. 1 2. 2 3. 3 4. 4 5. 5 OR MORE 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.New5 |
NEXT |
AUQMUSIC |
AUQMUSIC |
|
ASK |
IF SP AGE 5-44 YEARS |
In the last 12 months, <TEXT FILL 1> listened to music through earphones, earbuds, or a headset?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿ha escuchado <TEXT FILL 1> música con audífonos que van dentro del oído, auriculares que van fuera del oído o auriculares que se apoyan sobre las orejas?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.New6 |
NEXT |
IF AUQMUSIC = 1: AUQMUSICQ IF AUQMUSIC = 2, 7, OR 9 AND SP AGE 5-17 YEARS: AUQSPCLED IF AUQMUSIC = 2, 7, OR 9 AND SP AGE 18-44 YEARS: AUQFIREARM |
AUQMUSICQ |
|
ASK |
IF AUQMUSIC = 1 |
On a typical day, how much time <TEXT FILL 1> spend listening to music through earphones, earbuds, or a headset? Is it…
1. less than 1 hour, 2. 1 to 2 hours, 3. 3 to 4 hours, 4. 5 or more hours? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En un día típico, ¿cuánto tiempo pasa <TEXT FILL 1> escuchando música con audífonos que van dentro del oído, auriculares que van fuera del oído o auriculares que se apoyan sobre las orejas? ¿Es...
1. menos de 1 hora, 2. de 1 a 2 horas, 3. de 3 a 4 horas, 4. 5 horas o más? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.New7 |
NEXT |
AUQMUSICHR |
AUQMUSICHR |
|
ASK |
IF AUQMUSIC = 1 |
When listening to music through earphones, earbuds, or a headset, how well can <TEXT FILL 1> usually hear and understand people around <TEXT FILL 2>? Is it…
1. easily, 2. with a little trouble, 3. with a moderate amount of trouble, 4. with a lot of trouble, or 5. cannot hear and understand them? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Cuando escucha música con audífonos que van dentro del oído, auriculares que van fuera del oído o auriculares que se apoyan sobre las orejas, ¿qué tan bien puede <TEXT FILL 1> oír y entender generalmente a las personas que lo(a) rodean? ¿Diría que...
1. fácilmente, 2. con algo de dificultad, 3. con una cantidad moderada de dificultad, 4. con mucha dificultad, o 5. no puede oírlas ni entenderlas? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “him” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.New8 |
NEXT |
IF SP AGE <18 YEARS: AUQSPCLED ELSE: AUQFIREARM |
AUQSPCLED |
|
ASK |
IF SP AGE 5-17 YEARS |
Has <TEXT FILL 1> ever received Special Education or Early Intervention Services for speech-language, reading, hearing or listening skills, intellectual disability, movement or mobility difficulties (e.g., using arms or legs), or other developmental or disability problems?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ha recibido <TEXT FILL 1> alguna vez servicios de educación especial o de intervención temprana por problemas de habla/lenguaje, lectura, audición o habilidad para escuchar, discapacidad intelectual, dificultades de movimiento o movilidad (por ejemplo, para usar los brazos o las piernas), u otros problemas de desarrollo o discapacidad?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW |
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Special Education: Teaching designed to meet the needs of a child with special needs and/or disabilities. It is paid for by the public school system and may take place at a regular school, a special school, a private school, at home, or at a hospital.
Early Intervention Services: Services designed to meet the needs of very young children with special needs and/or disabilities. They may include but are not limited to: medical and social services, parental counseling, and therapy. They may be provided at the child's home, a medical center, a day care center, or other place. They are provided by the state or school system at no cost to the parent. |
HELP SCREEN (SPA) |
Educación especial: Enseñanza diseñada para cubrir las necesidades de niños con necesidades especiales o discapacidades. Es pagada por el sistema escolar público y se puede realizar en escuelas regulares, escuelas especiales, escuelas privadas, hogares o en hospitales.
Servicios de intervención temprana: Servicios diseñados para cubrir las necesidades de niños muy pequeños con necesidades especiales o discapacidades. Puede ser que incluyan per no están limitados a los servicios médicos y sociales, asesoramiento a padres y terapia. Se pueden dar en los hogares de los niños, en centros médicos, en guarderías o en otros lugares. Son servicios proporcionados por el estado o el sistema escolar sin costo alguno para los padres. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.440 |
NEXT |
IF AUQSPCLED = 1: AUQSPCLEDS ELSE: AUQMENTAL |
AUQSPCLEDS |
|
ASK |
IF AUQSPCLED = 1 |
Which was it?
HAND CARD AUQ3
[CODE ALL THAT APPLY]
1. SPEECH-LANGUAGE 2. READING 3. HEARING OR LISTENING SKILLS 4. INTELLECTUAL DISABILITY 5. MOVEMENT OR MOBILITY DIFFICULTIES 6. OTHER DEVELOPMENTAL OR DISABILITY PROBLEMS 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
¿Qué servicio fue?
HAND CARD AUQ3
[CODE ALL THAT APPLY]
1. HABLA/LENGUAJE 2. LECTURA 3. HABILIDADES AUDITIVAS O DE ESCUCHA 4. DISCAPACIDAD INTELECTUAL 5. DIFICULTADES DE MOVIMIENTO O MOVILIDAD 6. OTROS PROBLEMAS DE DESARROLLO O DISCAPACIDAD 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Select all that apply |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.450 |
NEXT |
AUQMENTAL |
AUQMENTAL |
|
ASK |
IF SP AGE 5-17 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> has…
HAND CARD AUQ4
[CODE ALL THAT APPLY]
1. Autism, autism spectrum disorder, Asperger's disorder, or pervasive developmental disorder 2. Attention deficit/hyperactivity disorder (ADHD) or attention-deficit disorder (ADD) 3. Anxiety 4. Depression 5. Obsessive-compulsive disorder 6. Intellectual disablity (including Down syndrome, fetal alcohol syndrome, fragile Xsyndrome) 7. NONE OF THESE 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> tiene...?
HAND CARD AUQ4
[CODE ALL THAT APPLY]
1. Autismo, trastorno del espectro autista, síndrome de Asperger o trastorno generalizado del desarrollo 2. Trastorno por déficit de atención e hiperactividad (ADHD, por sus siglas en inglés) o trastorno por déficit de atención (ADD, por sus siglas en inglés) 3. Ansiedad 4. Depresión 5. Trastorno obsesivo-compulsivo 6. Discapacidad intelectual (incluidos el síndrome de Down, el síndrome alcohólico fetal, el síndrome del cromosoma X frágil) 7. NONE OF THESE 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Select all that apply |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
MAKE NONE MUTUALLY EXCLUSIVE FROM THE REST OF THE CATA LIST. |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.New12 |
NEXT |
IF SP AGE > 11 YEARS: AUQFIREARM ELSE: END OF SECTION |
AUQFIREARM |
|
ASK |
IF SP AGE 11-44 YEARS |
These next questions are about exposure to loud noise. <TEXT FILL 1> ever used firearms for any reason such as target shooting, hunting, in the military or in another job?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Las siguientes preguntas son sobre la exposición a ruidos fuertes. ¿Ha usado <TEXT FILL 1> alguna vez armas de fuego por cualquier motivo, como tiro al blanco, caza, en el ejército o en otro trabajo?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Firearms include pistols, shotguns, rifles, and other types of guns. Do not include BB or pellet guns. |
HELP SCREEN (SPA) |
Las armas de fuego incluyen pistolas, escopetas, rifles y otros tipos de pistolas. No incluya pistolas de balines ni de perdigones. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.300N |
NEXT |
IF AUQFIREARM = 1: AUQROUNDS ELSE: AUQLOUDYN |
AUQROUNDS |
|
ASK |
IF AUQFIREARM = 1 |
How many total rounds <TEXT FILL 1> ever fired? Is it…
INTERVIEWER: ONE ROUND EQUALS ONE SHOT.
1. less than 100 rounds, 2. 100 rounds to less than 1,000 rounds, 3. 1,000 rounds to less than 10,000 rounds, or 4. 10,000 rounds or more? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Cuántas balas ha disparado <TEXT FILL 1> en total alguna vez? ¿Diría que...
INTERVIEWER: ONE ROUND EQUALS ONE SHOT.
1. Menos de 100 balas, 2. De 100 balas a menos de 1,000 balas, 3. De 1,000 balas a menos de 10,000 balas, o 4. 10,000 balas o más? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.310 |
NEXT |
AUQFIREDEV |
AUQFIREDEV |
|
ASK |
IF AUQFIREARM = 1 |
How often <TEXT FILL 1> wear hearing protection devices such as ear plugs or earmuffs when shooting firearms?
HAND CARD AUQ5
1. ALWAYS 2. USUALLY 3. ABOUT HALF THE TIME 4. SELDOM 5. NEVER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Con qué frecuencia usa <TEXT FILL 1> aparatos de protección auditiva como tapones para los oídos u orejeras cuando dispara armas de fuego?
HAND CARD AUQ5
1. SIEMPRE 2. GENERALMENTE 3. APROXIMADAMENTE LA MITAD DEL TIEMPO 4. RARA VEZ 5. NUNCA 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.320 |
NEXT |
AUQLOUDYN |
AUQLOUDYN |
|
ASK |
IF SP AGE 11-44 YEARS |
These next questions are about exposure to loud noise at work. Loud means so loud that <TEXT FILL 1> must speak in a raised voice to be heard.
<TEXT FILL 2> ever had a job, or combination of jobs where <TEXT FILL 3> exposed to loud sounds or noise for 4 or more hours a day, several days a week?
1. YES 2. NO 3. NEVER WORKED 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Las siguientes preguntas son sobre la exposición a ruidos fuertes en el trabajo. Fuerte significa tan fuerte que <TEXT FILL 1> debe hablar en voz alta para que ser oído(a).
¿Ha tenido <TEXT FILL 2> alguna vez un trabajo o una combinación de trabajos en los que haya estado expuesto(a) a sonidos o ruidos fuertes durante 4 o más horas al día, varios días a la semana?
1. YES 2. NO 3. NEVER WORKED 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]”
TEXT FILL 3: FILL “you were” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he was” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she was” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] was” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 3: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
NOTES |
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HELP SCREEN |
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HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
AUQ.331 |
NEXT |
IF AUQLOUDYN = 1: AUQLOUDQ ELSE: AUQLOUDOUT |
AUQLOUDQ |
|
ASK |
IF AUQLOUDYN = 1 |
For how many months or years <TEXT FILL 1> been exposed at work to loud sounds or noise for 4 or more hours a day, several days a week?
HANDCARD AUQ6
1. LESS THAN 3 MONTHS 2. 3 TO 11 MONTHS 3. 1 TO 2 YEARS 4. 3 TO 4 YEARS 5. 5 TO 9 YEARS 6. 10 TO 14 YEARS 7. 15 OR MORE YEARS 77. REFUSED 99. DON’T KNOW
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SPANISH |
¿Durante cuántos meses o años ha estado <TEXT FILL 1> expuesto(a) en su trabajo a sonidos o ruidos fuertes por 4 o más horas al día, varios días a la semana?
HANDCARD AUQ6
1. LESS THAN 3 MONTHS 2. 3 TO 11 MONTHS 3. 1 TO 2 YEARS 4. 3 TO 4 YEARS 5. 5 TO 9 YEARS 6. 10 TO 14 YEARS 7. 15 OR MORE YEARS 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
AUQ.340 |
NEXT |
AUQLOUDDEV |
AUQLOUDDEV |
|
ASK |
IF AUQLOUDYN = 1 |
When <TEXT FILL 1> were exposed to very loud sounds or noise at <TEXT FILL 3> job, how often did <TEXT FILL 2> wear hearing protection devices (ear plugs, ear muffs)?
INTERVIEWER: PROTECTIVE HEARING DEVICES INCLUDE PLUGS AND MUFFS.
HAND CARD AUQ1
1. ALWAYS 2. USUALLY 3. ABOUT HALF THE TIME 4. SELDOM 5. NEVER 77. REFUSED 99. DON’T KNOW
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|
SPANISH |
Cuando <TEXT FILL 1> estaba expuesto(a) a sonidos o ruidos muy fuertes en su trabajo, ¿con qué frecuencia usaba dispositivos de protección auditiva (tapones, orejeras)?
INTERVIEWER: PROTECTIVE HEARING DEVICES INCLUDE PLUGS AND MUFFS.
HAND CARD AUQ1
1. SIEMPRE 2. GENERALMENTE 3. APROXIMADAMENTE LA MITAD DEL TIEMPO 4. RARA VEZ 5. NUNCA 77. REFUSED 99. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you were” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] was”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 3: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] ”
TEXT FILL 2: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “BLANK”
TEXT FILL 3: FILL “BLANK” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “BLANK” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
AUQ.New9 |
NEXT |
AUQLOUDOUT |
AUQLOUDOUT |
|
ASK |
IF SP AGE 11-44 YEARS |
The next question is about very loud noise exposure outside of work. This is noise so loud that <TEXT FILL 1> to shout to be understood or heard 3 feet away. Examples are noise from power tools, lawn mowers, farm machinery, cars, trucks, motorcycles, motor boats or loud music.
Outside of work, <TEXT FILL 2> ever been exposed to very loud noise or music for 10 or more hours a week?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
La siguiente pregunta es sobre la exposición a ruidos muy fuertes fuera del trabajo. Se trata de un ruido tan fuerte que <TEXT FILL 1> tiene que gritar para que lo(a) entiendan o escuchen a 3 pies de distancia. Algunos ejemplos son el ruido de herramientas eléctricas, máquinas para cortar el césped, maquinaria agrícola, automóviles, camiones, motocicletas, botes a motor o música a todo volumen.
Fuera del trabajo, ¿ha estado <TEXT FILL 2> expuesto(a) alguna vez a ruidos o música muy fuertes por 10 o más horas a la semana?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] ” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
AUQ.370 |
NEXT |
IF AUQLOUDOUT = 1: AUQOUTSLNG ELSE: END OF SECTION |
AUQOUTSLNG |
|
ASK |
IF AUQLOUDOUT = 1 |
How long <TEXT FILL 1> been exposed to very loud noise or music for 10 or more hours a week?
This is noise so loud that <TEXT FILL 2> to shout to be understood or heard 3 feet away. Is it…
1. less than 1 year, 2. 1 to 2 years, 3. 3 to 4 years, or 4. 5 or more years? 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
¿Durante cuánto tiempo ha estado <TEXT FILL 1> expuesto(a) a ruidos o música muy fuertes durante 10 o más horas a la semana?
Este es un ruido tan fuerte que <TEXT FILL 2> tiene que gritar para que lo(a) entiedan o escuchen a 3 pies de distancia. ¿Diría que...
1. menos de 1 año, 2. de 1 a 2 años, 3. de 3 a 4 años, o 4. 5 años o más, 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]”
TEXT FILL 2: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] has” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] ” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
AUQ.510 |
NEXT |
AUQOUTSDEV |
AUQOUTSDEV |
|
ASK |
IF AUQLOUDOUT = 1 |
How often <TEXT FILL 1> wear hearing protection devices such as ear plugs or ear muffs when exposed to very loud sounds or noise outside of work? <TEXT FILL 2>
HAND CARD AUQ7
1. ALWAYS 2. USUALLY 3. ABOUT HALF THE TIME 4. SELDOM 5. NEVER 77. REFUSED 99. DON’T KNOW |
|
SPANISH |
¿Con qué frecuencia usa <TEXT FILL 1> usa aparatos de protección auditiva, como tapones u orejeras, cuando se expone a sonidos o ruidos muy fuertes fuera del trabajo? <TEXT FILL 2>
HAND CARD AUQ7
1. SIEMPRE 2. GENERALMENTE 3. APROXIMADAMENTE LA MITAD DEL TIEMPO 4. RARA VEZ 5. NUNCA 77. REFUSED 99. DON’T KNOW |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “did you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “did [SP NAME]”
TEXT FILL 2: FILL “Do not include the noise from firearms we already talked about.” IF AUQFIREARM = 1 (YES) ELSE, LEAVE BLANK |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “No incluya el ruido de las armas de fuego del que ya hemos hablado.” IF AUQFIREARM = 1 (YES) ELSE, LEAVE BLANK |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
AUQ.381 |
NEXT |
END OF SECTION |
SUN PROTECTION BEHAVIOR - SBQ
Target Group: SPs 18-64
SBQSHADE |
|
ASK |
IF SP AGE 18-64 YEARS |
Next I have some questions about sun exposure protection.
When <TEXT FILL 1> outside on a very sunny day, for more than one hour, how often <TEXT FILL 2>…
. . . stay in the shade? Would you say…
1. always, 2. most of the time, 3. sometimes, 4. rarely, or 5. never? 6. DON’T/DOESN’T GO OUT IN THE SUN 7. REFUSED 9. DON’T KNOW
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SPANISH |
A continuación, tengo algunas preguntas sobre protegerse de la exposición al sol.
Cuando <TEXT FILL 1> va afuera en un día muy soleado, por más de una hora, ¿con qué frecuencia <TEXT FILL 2>…
... se queda en la sombra? ¿Diría que...
1. siempre, 2. la mayoría de las veces, 3. algunas veces, 4. rara vez, o 5. nunca? 6. DON’T/DOESN’T GO OUT IN THE SUN 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you go” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] goes”
TEXT FILL 2: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] ”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
DEQ.034a |
NEXT |
IF SBQSHADE = 6: END OF SECTION ELSE, SBQSLEEVE |
SBQSLEEVE |
|
ASK |
IF SBQSHADE <> 6 |
(When <TEXT FILL 1> outside on a very sunny day, for more than one hour, how often <TEXT FILL 2>…)
. . . wear a long sleeved shirt? Would you say…
INTERVIEWER INSTRUCTION: READ INTRODUCTION IN PARENTHESES ONLY IF NECESSARY.
1. always, 2. most of the time, 3. sometimes, 4. rarely, or 5. never? 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
(Cuando <TEXT FILL 1> va afuera en un día muy soleado, por más de una hora, ¿con qué frecuencia <TEXT FILL 2>...)
... se pone camisa de manga larga? ¿Diría que...
INTERVIEWER INSTRUCTION: READ INTRODUCTION IN PARENTHESES ONLY IF NECESSARY.
1. siempre, 2. la mayoría de las veces, 3. algunas veces, 4. rara vez 5. nunca 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you go” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] goes”
TEXT FILL 2: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] ”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
DEQ.034c |
NEXT |
SBQSSCREEN |
SBQSSCREEN |
|
ASK |
IF SBQSHADE <> 6 |
(When <TEXT FILL 1> outside on a very sunny day, for more than one hour, how often <TEXT FILL 2>…)
. . . use sunscreen? Would you say…
INTERVIEWER INSTRUCTION: READ INTRODUCTION IN PARENTHESES ONLY IF NECESSARY.
1. always, 2. most of the time, 3. sometimes, 4. rarely, or 5. never? 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
(Cuando <TEXT FILL 1> va afuera en un día muy soleado, por más de una hora, ¿con qué frecuencia <TEXT FILL 2>...)
... usa protector solar? ¿Diría que...
INTERVIEWER INSTRUCTION: READ INTRODUCTION IN PARENTHESES ONLY IF NECESSARY.
1. siempre, 2. la mayoría de las veces, 3. algunas veces, 4. rara vez, o 5. nunca? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you go” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] goes”
TEXT FILL 2: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] ”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
DEQ.034d |
NEXT |
END OF SECTION |
ORAL HEALTH – OHQ
Target Group: SPs 1+
OHQDENTIST |
|
ASK |
IF SP AGE >= 1 YEAR |
The next questions are about <TEXT FILL 1> teeth and gums.
About how long has it been since <TEXT FILL 2> last visited a dentist? Include all types of dentists, such as, orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.
1. 6 MONTHS OR LESS 2. MORE THAN 6 MONTHS, BUT NOT MORE THAN 1 YEAR AGO 3. MORE THAN 1 YEAR, BUT NOT MORE THAN 2 YEARS AGO 4. MORE THAN 2 YEARS, BUT NOT MORE THAN 3 YEARS AGO 5. MORE THAN 3 YEARS, BUT NOT MORE THAN 5 YEARS AGO 6. MORE THAN 5 YEARS AGO 7. NEVER HAVE BEEN 77. REFUSED 99. DON’T KNOW
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SPANISH |
Las siguientes preguntas son sobre <TEXT FILL 1>.
¿Hace cuánto tiempo aproximadamente fue <TEXT FILL 2> por última vez a un dentista? Incluya todo tipo de dentistas, como ortodoncistas, cirujanos orales y todos los demás especialistas dentales, así como higienistas dentales.
1. 6 MESES O MENOS 2. HACE MÁS DE 6 MESES, PERO NO MÁS DE 1 AÑO 3. HACE MÁS DE 1 AÑO, PERO NO MÁS DE 2 AÑOS 4. HACE MÁS DE 2 AÑOS, PERO NO MÁS DE 3 AÑOS 5. HACE MÁS DE 3 AÑOS, PERO NO MÁS DE 5 AÑOS 6. HACE MÁS DE 5 AÑOS 7. NUNCA HA IDO 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “sus dientes y encías” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “los dientes y las encías de [SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Dentist: Medical persons whose primary occupation is caring for teeth, gums, and jaws. Dental care includes general work such as fillings, cleaning, extractions, and also specialized work such as root canals, fittings for braces, etc. |
HELP SCREEN (SPA) |
Dentista: Personas médicas cuya ocupación principal es el cuidado de dientes, las encías y la mandíbula. La atención dental incluye tareas generales como empastes, limpiezas, extracciones, y también tareas especializadas como endodoncias, colocación de aparatos de ortodoncia, etc. |
HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
OHQ.030 |
NEXT |
IF OHQDENTIST = 7 AND SP AGE < 2 YEARS: OHQGUMHLT IF OHQDENTIST = 7 AND SP AGE 2-17 YEARS: OHQPASTEG IF OHQDENTIST = 7 AND SP AGE 18+ YEARS: OHQACHING IF OHQDENTIST = 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR REFUSED OR DON’T KNOW: OHQLSTVSIT |
OHQLSTVSIT |
|
ASK |
IF OHQDENTIST != 7 |
What was the main reason <TEXT FILL 1> last visited the dentist?
HAND CARD OHQ1
1. WENT IN ON OWN FOR CHECK-UP, EXAMINATION OR CLEANING 2. WAS CALLED IN BY THE DENTIST FOR CHECK-UP, EXAMINATION, OR CLEANING 3. SOMETHING WAS WRONG, BOTHERING OR HURTING <TEXT FILL 2> 4. WENT FOR TREATMENT OF A CONDITION THAT DENTIST DISCOVERED AT EARLIER CHECK-UP OR EXAMINATION 5. OTHER 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
¿Cuál fue la razón principal por la que <TEXT FILL 1> fue al dentista por última vez?
HAND CARD OHQ1
1. FUE POR SU CUENTA PARA UNA REVISIÓN, EXAMEN O LIMPIEZA DENTAL 2. FUE LLAMADO(A) POR EL DENTISTA PARA UNA REVISIÓN, EXAMEN O LIMPIEZA DENTAL 3. ALGO ESTABA MAL, <TEXT FILL 2> 4. FUE PARA UN TRATAMIENTO DE UNA AFECCIÓN QUE EL DENTISTA DESCUBRIÓ EN UN CHEQUEO O EXAMEN ANTERIOR 5. OTRO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: “FILL “ME” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: “FILL “ME MOLESTABA O ME CAUSABA DOLOR” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “LE MOLESTABA O LE CAUSABA DOLOR A [SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Cleaning (Dental): Refers to activities performed by a dentist or dental hygienist to maintain healthy teeth and prevent cavities. Cleaning includes scraping tartar deposits off teeth, both above and below the gumline.
Condition: Respondent's perception of a departure from physical or mental well-being. Any response describing a health problem of any kind. |
HELP SCREEN (SPA) |
Limpieza (dental): Se refiere a las actividades que realiza un dentista o higienista dental para mantener los dientes sanos y prevenir las caries. La limpieza incluye raspar los depósitos de sarro de los dientes, tanto por encima como por debajo de la línea de las encías.
Afección: Percepción por parte del(la) encuestado(a) de algo fuera del bienestar físico o mental. Toda respuesta que describa un problema de salud de cualquier tipo. |
HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
OHQ.033 |
NEXT |
OHQCARE |
OHQCARE |
|
ASK |
IF OHQDENTIST != 7 |
In the last 12 months, was there a time when <TEXT FILL 1> needed dental care but could not get it at that time?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿hubo algún momento en el que <TEXT FILL 1> necesitaba atención dental pero no pudo obtenerla en ese momento?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OHQ.770 |
NEXT |
IF OHQCARE = 1: OHQNOCARE IF (OHQCARE = 2 OR 7 OR 9) AND SP AGE < 2 YEARS: OHQGUMHLT IF (OHQCARE = 2 OR 7 OR 9) AND SP AGE 2-17 YEARS: OHQPASTEG IF (OHQCARE = 2 OR 7 OR 9) AND SP AGE >= 18 YEARS AND (OHQDENTIST = 1 OR 2): OHQCIGARET IF (OHQCARE = 2 OR 7 OR 9) AND SP AGE >= 18 YEARS AND (OHQDENTIST != 1 OR 2): OHQACHING |
OHQNOCARE |
|
ASK |
IF OHQCARE = 1 |
What were the reasons that <TEXT FILL 1> could not get the dental care <TEXT FILL 2> needed?
[CODE ALL THAT APPLY]
HAND CARD OHQ2
10. COULD NOT AFFORD THE COST 11. DID NOT WANT TO SPEND THE MONEY 12. INSURANCE DID NOT COVER RECOMMENDED PROCEDURES 13. DENTAL OFFICE IS TOO FAR AWAY 14. DENTAL OFFICE IS NOT OPEN AT CONVENIENT TIMES 15. AFRAID OR DO NOT LIKE DENTISTS 16. UNABLE TO TAKE TIME OFF FROM WORK 17. TOO BUSY 18. DID NOT THINK ANYTHING SERIOUS WAS WRONG/EXPECTED DENTAL PROBLEMS TO GO AWAY 19. OTHER 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
¿Cuáles fueron las razones por las que <TEXT FILL 1> no pudo recibir la atención dental que necesitaba?
[CODE ALL THAT APPLY]
HAND CARD OHQ2
10. NO PUDO AFRONTAR EL GASTO 11. NO QUERÍA GASTAR EL DINERO 12. EL SEGURO NO CUBRÍA LOS PROCEDIMIENTOS RECOMENDADOS 13. EL CONSULTORIO DENTAL ESTÁ DEMASIADO LEJOS 14. EL CONSULTORIO DENTAL NO ESTÁ ABIERTO A HORARIOS CONVENIENTES 15. TIENE MIEDO O NO LE GUSTAN LOS DENTISTAS 16. NO PUEDE FALTAR AL TRABAJO 17. MUY OCUPADO(A) 18. NO CREE QUE PASE NADA GRAVE/ESPERA QUE LOS PROBLEMAS DENTALES DESAPAREZCAN 19. OTRO 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Select all that apply |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER 9CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER 9CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
OHQ.780 |
NEXT |
IF SP AGE < 2 YEARS: OHQGUMHLT IF SP AGE 2-17 YEARS: OHQPASTEG IF SP AGE >= 18 YEARS AND (OHQDENTIST = 1 OR 2): OHQCIGARET IF SP AGE >= 18 YEARS AND (OHQDENTIST != 1 OR 2): OHQACHING |
OHQPASTEG / OHQPASTEQ / OHQPASTEU |
|
ASK |
IF SP AGE 2-17 YEARS |
We would like you to think of the time when <TEXT FILL 1> started brushing <TEXT FILL 2> teeth either with someone else’s help or alone. At what age did <TEXT FILL 1> start using toothpaste?
|___| 1. ENTER AGE 2. HAS NEVER USED TOOTHPASTE 7. REFUSED 9. DON’T KNOW [OHQPASTEG]
|___|___| ENTER AGE IN MONTHS OR YEARS [OHQPASTEQ]
|___|___| ENTER UNIT [OHQPASTEU] 1. MONTHS 2. YEARS
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SPANISH |
Quisiéramos que <TEXT FILL 1> piense en el momento en que empezó a cepillarse los dientes, ya sea con la ayuda de otra persona o por su cuenta. ¿A qué edad empezó <TEXT FILL 1> a usar pasta dental?
|___| 1. ENTER AGE 2. HAS NEVER USED TOOTHPASTE 7. REFUSED 9. DON’T KNOW [OHQPASTEG]
|___|___| ENTER AGE IN MONTHS OR YEARS [OHQPASTEQ]
|___|___| ENTER UNIT [OHQPASTEU] 1. MONTHS 2. YEARS
|
QUESTION TYPE |
Dropdown: OHQPASTEG Radio button: OHQPASTEU Numeric: OHQPASTEQ |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
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HELP SCREEN |
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HARD CHECK |
IF OHQPASTEQ > SP’S AGE (SPDSPAGED OR SPDSPAGEQD), DISPLAY: “AGE STARTED USING TOOTHPASTE CANNOT BE OLDER THAN SP’S CURRENT AGE.” |
SOFT CHECK |
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VERSION NOTES |
OHQ.560 G/Q/U |
NEXT |
OHQBRUSHQ |
OHQBRUSHQ |
|
ASK |
IF SP AGE 2-17 YEARS |
How many times per day <TEXT FILL 1> brush <TEXT FILL 2> teeth?
1. 1 TIME 2. 2 TIMES 3. 3 TIMES 4. 4 OR MORE TIMES 55. DOES NOT BRUSH YET 66. DOES NOT BRUSH EVERY DAY 77. REFUSED 99. DON’T KNOW
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SPANISH |
¿Cuántas veces al día se cepilla <TEXT FILL 1> los dientes?
1. 1 TIME 2. 2 TIMES 3. 3 TIMES 4. 4 OR MORE TIMES 55. DOES NOT BRUSH YET 66. DOES NOT BRUSH EVERY DAY 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPODENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPODENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
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VERSION NOTES |
OHQ.848 |
NEXT |
IF (OHQBRUSHQ = 55 OR 77 OR 99) OR (OHQPASTEG = 2): OHQSEALANT ELSE: OHQPASTEB |
OHQPASTEB |
|
ASK |
IF (OHQBRUSHQ = 1 OR 2 OR 3 OR 4 OR 66) AND (OHQPASTEQ = 1 OR 7 OR 9) |
On average, how much toothpaste <TEXT FILL 1> use when brushing <TEXT FILL 2> teeth?
HAND CARD OHQ3
1. FULL LOAD 2. HALF LOAD 3. PEA SIZE 4. SMEAR 7. REFUSED 9. DON’T KNOW
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SPANISH |
En promedio, ¿cuánta pasta dental usa <TEXT FILL 1> al cepillarse los dientes?
HAND CARD OHQ3
1. CUBRE TODO EL CABEZAL DEL CEPILLO 2. CUBRE LA MITAD DEL CABEZAL DEL CEPILLO 3. CANTIDAD PEQUEÑA 4. MUY POCA CANTIDAD 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPODENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPODENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
OHQ.849 |
NEXT |
OHQSEALANT |
OHQSEALANT |
|
ASK |
IF SP AGE 2-17 YEARS |
Dental sealants are thin coatings on back teeth used to prevent cavities.
<TEXT FILL 1> ever received dental sealants from a dentist or other oral health providers?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
Los selladores dentales son capas finas que se colocan sobre los dientes de atrás y se usan para prevenir las caries.
¿Alguna vez un dentista u otro proveedor de servicios de salud oral le colocó selladores dentales a <TEXT FILL 1>?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
OHQ.NEW2 |
NEXT |
OHQACHING |
OHQCIGARET |
|
ASK |
IF SP AGE >= 18 YEARS AND (OHQDENTIST = 1 OR 2) |
In the last 12 months, did a dentist, hygienist or other dental professional have a direct conversation with <TEXT FILL 1> about…
… the benefits of giving up or not using cigarettes or other types of tobacco to improve <TEXT FILL 2> dental health?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
En los últimos 12 meses, ¿tuvo un dentista, higienista u otro profesional dental una conversación directa con <TEXT FILL 1> sobre...
... los beneficios de dejar o no usar los cigarrillos u otros tipos de tabaco para mejorar su salud dental?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
OHQ.610 |
NEXT |
OHQBLOODSG |
OHQBLOODSG |
|
ASK |
IF SP AGE >= 18 YEARS AND (OHQDENTIST 1 OR 2) |
(In the last 12 months, did a dentist, hygienist or other dental professional have a direct conversation with <TEXT FILL 1> about…)
… the dental health benefits of checking <TEXT FILL 2> blood sugar?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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SPANISH |
(En los últimos 12 meses, ¿tuvo un dentista, higienista u otro profesional dental una conversación directa con <TEXT FILL 1> sobre...)
... los beneficios para la salud dental de controlar el nivel de azúcar en su sangre?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
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HELP SCREEN |
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HARD CHECK |
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SOFT CHECK |
|
VERSION NOTES |
OHQ.612 |
NEXT |
OHQACHING |
OHQACHING |
|
ASK |
IF SP AGE >= 2 YEARS |
How often in the last 12 months <TEXT FILL 1> had painful aching anywhere in <TEXT FILL 2> mouth?
HAND CARD OHQ4
1. VERY OFTEN, 2. FAIRLY OFTEN, 3. OCCASIONALLY, 4. HARDLY EVER, OR 5. NEVER? 7. REFUSED 9. DON’T KNOW
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SPANISH |
¿Con qué frecuencia en los últimos 12 meses tuvo <TEXT FILL 1> dolor en alguna parte de la boca?
HAND CARD OHQ4
1. MUY FRECUENTEMENTE, 2. MÁS O MENOS FRECUENTEMENTE, 3. OCASIONALMENTE, 4. CASI NUNCA, O 5. NUNCA? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
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HELP SCREEN |
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HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OHQ.620 |
NEXT |
IF SP AGE 2-4 YEARS: OHQGUMHLT ELSE: OHQDIFFCLT |
OHQDIFFCLT |
|
ASK |
IF SP AGE > 4 YEARS |
How often in the last 12 months <TEXT FILL 1> had difficulty doing <TEXT FILL 2> usual jobs or attending school because of problems with <TEXT FILL 2> teeth, mouth, or dentures?
HAND CARD OHQ4
1. VERY OFTEN, 2. FAIRLY OFTEN, 3. OCCASIONALLY, 4. HARDLY EVER, OR 5. NEVER? 7. REFUSED 9. DON’T KNOW
|
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SPANISH |
¿Con qué frecuencia en los últimos 12 meses tuvo <TEXT FILL 1> tuvo dificultad para realizar sus trabajos usuales o asistir a la escuela debido a problemas con los dientes, la boca o la dentadura postiza?
HAND CARD OHQ4
1. MUY FRECUENTEMENTE, 2. MÁS O MENOS FRECUENTEMENTE, 3. OCASIONALMENTE, 4. CASI NUNCA, O 5. NUNCA? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
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HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OHQ.640 |
NEXT |
IF SP AGE 5-17 YEARS: OHQGUMHLT ELSE: OHQAVDFOOD |
OHQAVDFOOD |
|
ASK |
IF SP AGE >= 18 YEARS |
How often in the last 12 months <TEXT FILL 1> avoided particular foods because of problems with <TEXT FILL 2> teeth, mouth, or dentures? Would you say . . .
HAND CARD OHQ4
1. very often, 2. fairly often, 3. occasionally, 4. hardly ever, or 5. never? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Con qué frecuencia en los últimos 12 meses ha evitado <TEXT FILL 1> comidas particulares debido a los problemas con los dientes, la boca o la dentadura postiza? ¿Diría que...
HAND CARD OHQ4
1. muy frecuentemente, 2. más o menos frecuentemente, 3. ocasionalmente, 4. casi nunca, o 5. nunca? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OHQ.660 |
NEXT |
OHQEMBARRS |
OHQEMBARRS |
|
ASK |
IF SP AGE >= 18 YEARS |
How often in the last 12 months <TEXT FILL 1> been self-conscious or embarrassed because of <TEXT FILL 2> teeth, mouth, or dentures? Would you say . . .
HAND CARD OHQ4
1. very often, 2. fairly often, 3. occasionally, 4. hardly ever, or 5. never? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Con qué frecuencia en los últimos 12 meses <TEXT FILL 1> sintió tímido(a) o avergonzado(a) debido a los problemas con los dientes, la boca o la dentadura postiza? ¿Diría que...
HAND CARD OHQ4
1. muy frecuentemente, 2. más o menos frecuentemente, 3. ocasionalmente, 4. casi nunca, o 5. nunca? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OHQ.680 |
NEXT |
OHQGUMDIS |
OHQGUMDIS |
|
ASK |
IF SP AGE >= 18 YEARS |
The next questions will ask about the condition of <TEXT FILL 1> teeth and some factors related to gum health.
Gum disease is a common problem with the mouth. People with gum disease might have swollen gums, receding gums, sore or infected gums or loose teeth. <TEXT FILL 2> think <TEXT FILL 3> might have gum disease?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Las siguientes preguntas se tratan sobre el estado de <TEXT FILL 1> y algunos temas relacionados con la salud de las encías.
La enfermedad de las encías es un problema frecuente de la boca. Las personas con enfermedad de las encías pueden tener las encías hinchadas, retraídas, doloridas o infectadas, o pueden tener los dientes flojos. ¿<TEXT FILL 2> cree que pueda tener la enfermedad de las encías?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]”
TEXT FILL 3: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “sus dientes” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “los dientes de [SP NAME]”
TEXT FILL 2: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OHQ.835 |
NEXT |
OHQGUMHLT |
OHQGUMHLT |
|
ASK |
IF SP AGE >= 1 YEAR |
Overall, how would <TEXT FILL 1> rate the health of <TEXT FILL 2> teeth and gums? Would you say . . .
1. Excellent, 2. Very good, 3. Good, 4. Fair, or 5. Poor? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En general, ¿cómo calificaría <TEXT FILL 1> la salud de sus dientes y encías? ¿Diría que es...
1. Excelente, 2. Muy buena, 3. Buena, 4. Regular, o 5. Mala? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OHQ.845 |
NEXT |
IF SP AGE 1-17 YEARS: OHQTAPWTR ELSE: OHQTREATMT |
OHQTREATMT |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 1> ever had treatment for gum disease such as scaling and root planing, sometimes called deep cleaning?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Se ha hecho <TEXT FILL 1> alguna vez un tratamiento para la enfermedad de las encías, como el raspado y alisado radicular, a veces llamado limpieza profunda?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OHQ.850 |
NEXT |
OHQBONELSS |
OHQBONELSS |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 1> ever been told by a dental professional that <TEXT FILL 2> lost bone around <TEXT FILL 3> teeth?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Alguna vez le ha dicho un profesional dental a <TEXT FILL 1> que perdió hueso alrededor de sus dientes?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OHQ.860 |
NEXT |
OHQFLOSSD |
OHQFLOSSD |
|
ASK |
IF SP AGE >= 18 YEARS |
Aside from brushing <TEXT FILL 1> teeth with a toothbrush, in the last seven days, how many days did <TEXT FILL 2> use dental floss or any other device to clean between <TEXT FILL 1> teeth?
INTERVIEWER INSTRUCTION: CODE ‘0’ IF THE SP RESPONDS THAT THEY HAVE NO TEETH OR ONLY DENTURES. PLEASE DO NOT PUT INFORMATION ABOUT NO TEETH IN THE COMMENTS.
|____| ENTER NUMBER OF DAYS
77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
En los últimos siete días, además de cepillarse los dientes con un cepillo de dientes, ¿cuántos días usó <TEXT FILL 2> hilo dental o cualquier otro aparato para limpiarse entre los dientes?
INTERVIEWER INSTRUCTION: CODE ‘0’ IF THE SP RESPONDS THAT THEY HAVE NO TEETH OR ONLY DENTURES. PLEASE DO NOT PUT INFORMATION ABOUT NO TEETH IN THE COMMENTS.
|____| ENTER NUMBER OF DAYS
77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “ [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “ [SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF OHQFLOSSD > 7, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 7.” |
SOFT CHECK |
|
VERSION NOTES |
OHQ.870 |
NEXT |
OHQORALCNC |
OHQORALCNC |
|
ASK |
IF SP AGE >= 18 YEARS |
In the last 12 months, <TEXT FILL 1> had an exam for oral cancer in which the doctor or dentist pulls on <TEXT FILL 2> tongue, sometimes with gauze wrapped around it, and feels under the tongue and inside the cheeks?
HAND CARD OHQ5 The exam would look something like this.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿le hicieron a <TEXT FILL 1> un examen para detectar cáncer de la boca en el que el doctor o dentista tira de su lengua, a veces envolviéndola con una gasa, y toca debajo de la lengua y el interior de las mejillas?
HAND CARD OHQ5 El examen sería más o menos así.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OHQ.882 |
NEXT |
OHQTAPWTR |
OHQTAPWTR |
|
ASK |
IF SP AGE >= 1 YEAR |
How often <TEXT FILL 1> drink tap water either directly from the faucet or after filtration or treatment in your home? Include drinking plain tap water or using tap water to make beverages.
1. Always 2. Often 3. Rarely 4. Never 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Con qué frecuencia bebe <TEXT FILL 1> agua directamente de la llave o después de filtrarla o tratarla en su hogar? Incluya beber agua de la llave o usar agua de la llave para preparar bebidas.
1. Siempre 2. Con frecuencia 3. Rara vez 4. Nunca 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OHQ.NEW4 |
NEXT |
IF OHQTAPWTR = 3 OR 4: OHQTAPWTRW ELSE: END OF SECTION |
OHQTAPWTRW |
|
ASK |
IF OHQTAPWTR = 3 OR 4 |
Why <TEXT FILL 1> never or rarely drink tap water in <TEXT FILL 2> home? Check all reasons that apply.
[CODE ALL THAT APPLY]
HAND CARD OHQ6
1. DO NOT HAVE ACCESS TO TAP WATER IN THE HOME 2. DO NOT LIKE THE TASTE OF TAP WATER 3. DO NOT THINK TAP WATER IS CLEAN TO DRINK 4. DO NOT THINK TAP WATER IS SAFE TO DRINK 5. OTHER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Por qué <TEXT FILL 1> nunca o rara vez bebe agua de la llave en su hogar? Marque todas las razones que correspondan.
[CODE ALL THAT APPLY]
HAND CARD OHQ6
1. NO TIENE ACCESO A AGUA DE LA LLAVE EN EL HOGAR 2. NO LE GUSTA EL SABOR DEL AGUA DE LA LLAVE 3. NO CREE QUE EL AGUA DE LA LLAVE SEA LIMPIA PARA BEBER 4. NO CREE QUE EL AGUA DE LA LLAVE SEA SEGURA PARA BEBER 5. OTRA 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Select all that apply |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OHQ.NEW5 |
NEXT |
END OF SECTION |
PHYSICAL ACTIVITY AND PHYSICAL FITNESS – PAQ
Target Group: SPs 2-11 years and 18+ years
PAQMODFRQG / PAQMODFRQQ / PAQMODFRQU |
|
ASK |
IF SP AGE >= 18 YEARS |
The next questions are about physical activities such as exercise, sports, or physically active hobbies that you may do in your leisure time. We are interested in two types of physical activity: moderate and vigorous-intensity. Moderate-intensity activities cause moderate increases in breathing or heart rate whereas vigorous-intensity activities cause large increases in breathing or heart rate.
How often <TEXT FILL 1> do moderate-intensity leisure-time physical activities?
|___| [PAQMODFRQG] 1. ENTER NUMBER OF TIMES (PER DAY, WEEK, MONTH, OR YEAR) 2. NEVER 3. UNABLE TO DO THIS TYPE OF ACTIVITY 7. REFUSED 9. DON’T KNOW
|___|___|___| [PAQMODFRQQ] ENTER NUMBER OF TIMES (PER DAY, WEEK, MONTH, OR YEAR)
|___| [PAQMODFRQU] ENTER UNIT
1. DAY 2. WEEK 3. MONTH 4. YEAR
|
|
SPANISH |
Las siguientes preguntas son acerca de actividades físicas tales como ejercicio, deportes o pasatiempos que posiblemente hace en su tiempo libre. Nos interesan dos tipos de actividades físicas: de intensidad moderada y de intensidad vigorosa. Las actividades de intensidad moderada cusan aumentos moderados de la respiración o del ritmo cardíaco, mientras que las actividades de intensidad vigorosa causan grandes aumentos en la respiración o en el ritmo cardíaco.
¿Con qué frecuencia hace <TEXT FILL 1> actividades físicas de intensidad moderada en su tiempo libre?
|___| [PAQMODFRQG] 1. ENTER NUMBER OF TIMES (PER DAY, WEEK, MONTH, OR YEAR) 2. NEVER 3. UNABLE TO DO THIS TYPE OF ACTIVITY 7. REFUSED 9. DON’T KNOW
|___|___|___| [PAQMODFRQQ] ENTER NUMBER OF TIMES (PER DAY, WEEK, MONTH, OR YEAR)
|___| [PAQMODFRQU] ENTER UNIT
1. DAY 2. WEEK 3. MONTH 4. YEAR
|
QUESTION TYPE |
Dropdown: PAQMODFRQG, PAQMODFRQU Numeric: PAQMODFRQQ |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL: “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL: “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
IF PAQMODFRQG = 1 AND PAQMODFRQU = 1 (DAY) AND PAQMODFRQQ > 4 (PER DAY), DISPLAY, “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” IF PAQMODFRQG = 1 AND PAQMODFRQU = 2 (WEEK) AND PAQMODFRQQ > 28 (PER WEEK), DISPLAY, “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” IF PAQMODFRQG = 1 AND PAQMODFRQU = 3 (MONTH) AND PAQMODFRQQ >31 (PER MONTH), DISPLAY, “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” IF PAQMODFRQG = 1 AND PAQMODFRQU = 4 (YEAR) AND PAQMODFRQQ > 365 (PER YEAR), DISPLAY, “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
PAQ.790 G/Q/U |
NEXT |
IF PAQMODFRQG = 1: PAQMODLNGQ ELSE: PAQVIGFRQG |
PAQMODLNGQ / PAQMODLNGU |
|
ASK |
IF PAQMODFRQG = 1 |
About how long <TEXT FILL 1> do these moderate leisure-time physical activities each time?
INTERVIEWER INSTRUCTION: PROBE IF NEEDED: Moderate-intensity activities cause moderate increases in breathing or heart rate.
|___|___|___| [PAQMODLNGQ] ENTER NUMBER OF MINUTES OR HOURS
7777. REFUSED 9999. DON’T KNOW
|___| [PAQMODLNGU] ENTER UNIT
1. MINUTES 2. HOURS
|
|
SPANISH |
Aproximadamente, ¿cuánto tiempo hace <TEXT FILL 1> estas actividades físicas de intensidad moderada en su tiempo libre cada vez?
INTERVIEWER INSTRUCTION: PROBE IF NEEDED: Las actividades de intensidad moderada causan aumentos moderados de la respiración o del ritmo cardíaco.
|___|___|___| [PAQMODLNGQ] ENTER NUMBER OF MINUTES OR HOURS
7777. REFUSED 9999. DON’T KNOW
|___| [PAQMODLNGU] ENTER UNIT
1. MINUTES 2. HOURS
|
QUESTION TYPE |
Numeric: PAQMODLNGQ Dropdown: PAQMODLNGU |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF PAQMODLNGQ=0, DISPLAY “THE TIME SHOULD BE GREATER THAN 0.” IF PAQMODLNGU = 1 (MINUTES) AND PAQMODLNGQ ≥ 1440, DISPLAY “THE TIME SHOULD BE LESS THAN 1,440 MINUTES.” IF PAQMODLNGU = 2 (HOURS) AND PAQMODLNGQ ≥ 24, DISPLAY “THE TIME SHOULD BE LESS THAN 24 HOURS.” |
SOFT CHECK |
IF PAQMODLNGU = 1 (MINUTES) AND PAQMODLNGQ > 120, DISPLAY “YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 120 MINUTES EACH TIME DOING MODERATE-INTENSITY LEISURE-TIME ACTIVITIES. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” IF PAQMODLNGU = 2 (HOURS) AND PAQMODLNGQ > 2, DISPLAY “YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 2 HOURS EACH TIME DOING MODERATE-INTENSITY LEISURE-TIME ACTIVITIES. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
PAQ.800 Q/U |
NEXT |
PAQVIGFRQG |
PAQVIGFRQG / PAQVIGFRQQ / PAQVIGFRQU |
|
ASK |
IF SP AGE >= 18 YEARS |
How often <TEXT FILL 1> do vigorous-intensity leisure-time physical activities?
|___| [PAQVIGFRQG] 1. ENTER NUMBER OF TIMES (PER DAY, WEEK, MONTH, OR YEAR) 2. NEVER 3. UNABLE TO DO THIS TYPE OF ACTIVITY 7. REFUSED 9. DON’T KNOW
|___|___|___| [PAQVIGFRQQ] ENTER NUMBER OF TIMES (PER DAY, WEEK, MONTH, OR YEAR)
|___| [PAQVIGFRQU] ENTER UNIT
1. DAY 2. WEEK 3. MONTH 4. YEAR
|
|
SPANISH |
¿Con qué frecuencia hace <TEXT FILL 1> actividades físicas de intensidad vigorosa en su tiempo libre?
|___| [PAQVIGFRQG] 1. ENTER NUMBER OF TIMES (PER DAY, WEEK, MONTH, OR YEAR) 2. NEVER 3. UNABLE TO DO THIS TYPE OF ACTIVITY 7. REFUSED 9. DON’T KNOW
|___|___|___| [PAQVIGFRQQ] ENTER NUMBER OF TIMES (PER DAY, WEEK, MONTH, OR YEAR)
|___| [PAQVIGFRQU] ENTER UNIT
1. DAY 2. WEEK 3. MONTH 4. YEAR
|
QUESTION TYPE |
Dropdown: PAQVIGFRQG, PAQVIGFRQU Numeric: PAQVIGFRQQ |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL: “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL: “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
IF PAQVIGFRQG = 1 AND PAQVIGFRQU = 1 (DAY) AND PAQVIGFRQQ > 4 (PER DAY), DISPLAY, “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” IF PAQVIGFRQG = 1 AND PAQVIGFRQU = 2 (WEEK) AND PAQVIGFRQQ > 28 (PER WEEK), DISPLAY, “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” IF PAQVIGFRQG = 1 AND PAQVIGFRQU = 3 (MONTH) AND PAQVIGFRQQ > 31 (PER MONTH), DISPLAY, “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” IF PAQVIGFRQG = 1 AND PAQVIGFRQU = 4 (YEAR) AND PAQVIGFRQQ > 365 (PER YEAR), DISPLAY, “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
PAQ.810 G/Q/U |
NEXT |
IF PAQVIGFRQG = 1: PAQVIGLNGQ ELSE: PAQSITTINGQ |
PAQVIGLNGQ / PAQVIGLNGU |
|
ASK |
IF PAQVIGFRQQ = 1 |
About how long <TEXT FILL 1> do these vigorous leisure-time physical activities each time?
INTERVIEWER INSTRUCTION: PROBE IF NEEDED: Vigorous-intensity activities cause large increases in breathing or heart rate.
|___|___|___| [PAQVIGLNGQ] ENTER NUMBER OF MINUTES OR HOURS
7777. REFUSED 9999. DON’T KNOW
|___| [PAQVIGLNGU] ENTER UNIT
1. MINUTES 2. HOURS
|
|
SPANISH |
Aproximadamente, ¿cuánto tiempo hace <TEXT FILL 1> estas actividades físicas de intensidad vigorosa en su tiempo libre cada vez?
INTERVIEWER INSTRUCTION: PROBE IF NEEDED: Las actividades de intensidad vigorosa causan grandes aumentos en la respiración o en el ritmo cardíaco.
|___|___|___| [PAQVIGLNGQ] ENTER NUMBER OF MINUTES OR HOURS
7777. REFUSED 9999. DON’T KNOW
|___| [PAQVIGLNGU] ENTER UNIT
1. MINUTES 2. HOURS
|
QUESTION TYPE |
Numeric: PAQVIGLNGQ Dropdown: PAQVIGLNGU |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF PAQVIGLNGQ = 0, DISPLAY “THE TIME SHOULD BE GREATER THAN 0.” IF PAQVIGLNGU = 1 (MINUTES) AND PAQVIGLNGQ ≥ 1440, DISPLAY “THE TIME SHOULD BE LESS THAN 1,440 MINUTES.” IF PAQVIGLNGU = 2 (HOURS) AND PAQVIGLNGQ ≥ 24, DISPLAY “THE TIME SHOULD BE LESS THAN 24 HOURS.” |
SOFT CHECK |
IF PAQVIGLNGU = 1 (MINUTES) AND PAQVIGLNGQ > 120, DISPLAY “YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 120 MINUTES EACH TIME DOING VIGOROUS-INTENSITY LEISURE-TIME ACTIVITIES. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” IF PAQVIGLNGU = 2 (HOURS) AND PAQVIGLNGQ > 2, DISPLAY “YOU HAVE RECORDED THAT THE SP SPENDS MORE THAN 2 HOURS EACH TIME DOING VIGOROUS-INTENSITY LEISURE-TIME ACTIVITIES. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
PAQ.820 Q/U |
NEXT |
PAQSITTNGQ |
PAQSITTNGQ / PAQSITTNGU |
|
ASK |
IF SP AGE >= 18 YEARS |
The following question is about sitting at work, at home, getting to and from places, or with friends, including time spent sitting at a desk, traveling in a car or bus, reading, playing cards, watching television, or using a computer. Do not include time spent sleeping.
How much time <TEXT FILL 1> usually spend sitting on a typical day?
|___|___|___| ENTER NUMBER OF MINUTES OR HOURS [PAQSITTNGQ]
7777. REFUSED 9999. DON’T KNOW
|___| ENTER UNIT [PAQSITTINGU]
1. MINUTES 2. HOURS
|
|
SPANISH |
La siguiente pregunta es acerca de estar sentado(a) en el trabajo o en el hogar; ir y venir de un sitio a otro; o pasar tiempo con amigos, incluido el tiempo que pasa sentado(a) frente a un escritorio, viajando en automóvil o autobús, leyendo, jugando a las cartas o naipes, mirando televisión o usando una computadora. No incluya el tiempo que pasa durmiendo.
En un día típico, ¿cuánto tiempo pasa usualmente <TEXT FILL 1> sentado(a)?
|___|___|___| ENTER NUMBER OF MINUTES OR HOURS [PAQSITTNGQ]
7777. REFUSED 9999. DON’T KNOW
|___| ENTER UNIT [PAQSITTINGU]
1. MINUTES 2. HOURS
|
QUESTION TYPE |
Numeric: PAQSITTNGQ Dropdown: PAQSITTNGU |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]”
PAQMODLNGQ FILL: FILL NUMERIC RESPONSE TO PAQMODLNGQ
PAQMODLNGU FILL: IF PAQMODLNGU=1 AND PAQMODLNGQ=1, FILL “MINUTE” ELSE, IF PAQMODLNGU=1 AND PAQMODLNGQ<>1, FILL “MINUTES” ELSE, IF PAQMODLNGU=2 AND PAQMODLNGQ=1, FILL “HOUR” ELSE, IF PAQMODLNGU=2 AND PAQMODLNGQ<>1, FILL “HOURS”
PAQVIGLNGQ FILL: FILL NUMERIC RESPONSE TO PAQVIGLNGQ
PAQVIGLNGU FILL: IF PAQVIGLNGU=1 AND PAQVIGLNGQ=1, FILL “MINUTE” ELSE, IF PAQVIGLNGU=1 AND PAQVIGLNGQ<>1, FILL “MINUTES” ELSE, IF PAQVIGLNGU=2 AND PAQVIGLNGQ=1, FILL “HOUR” ELSE, IF PAQVIGLNGU=2 AND PAQVIGLNGQ<>1, FILL “HOURS”
PAQSITTINGQ FILL: FILL NUMERIC RESPONSE TO PAQSITTINGQ
PAQSITTINGU FILL: IF PAQSITTINGU=1 AND PAQSITTINGQ=1, FILL “MINUTE” ELSE, IF PAQSITTINGU =1 AND PAQSITTINGQ<>1, FILL “MINUTES” ELSE, IF PAQSITTINGU =2 AND PAQSITTINGQ=1, FILL “HOUR” ELSE, IF PAQSITTINGU =2 AND PAQSITTINGQ<>1, FILL “HOURS”
MOD CALCULATION FILL: FILL NUMERIC OUTPUT FROM <MOD CALCULATION>
VIG CALCULATION FILL: FILL NUMERIC OUTPUT FROM <VIG CALCULATION> |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
PAQMODLNGQ FILL: FILL NUMERIC RESPONSE TO PAQMODLNGQ
PAQMODLNGU FILL: IF PAQMODLNGU=1 AND PAQMODLNGQ=1, FILL “MINUTE” ELSE, IF PAQMODLNGU=1 AND PAQMODLNGQ<>1, FILL “MINUTES” ELSE, IF PAQMODLNGU=2 AND PAQMODLNGQ=1, FILL “HOUR” ELSE, IF PAQMODLNGU=2 AND PAQMODLNGQ<>1, FILL “HOURS”
PAQVIGLNGQ FILL: FILL NUMERIC RESPONSE TO PAQVIGLNGQ
PAQVIGLNGU FILL: IF PAQVIGLNGU=1 AND PAQVIGLNGQ=1, FILL “MINUTE” ELSE, IF PAQVIGLNGU=1 AND PAQVIGLNGQ<>1, FILL “MINUTES” ELSE, IF PAQVIGLNGU=2 AND PAQVIGLNGQ=1, FILL “HOUR” ELSE, IF PAQVIGLNGU=2 AND PAQVIGLNGQ<>1, FILL “HOURS”
PAQSITTINGQ FILL: FILL NUMERIC RESPONSE TO PAQSITTINGQ
PAQSITTINGU FILL: IF PAQSITTINGU=1 AND PAQSITTINGQ=1, FILL “MINUTE” ELSE, IF PAQSITTINGU =1 AND PAQSITTINGQ<>1, FILL “MINUTES” ELSE, IF PAQSITTINGU =2 AND PAQSITTINGQ=1, FILL “HOUR” ELSE, IF PAQSITTINGU =2 AND PAQSITTINGQ<>1, FILL “HOURS”
MOD CALCULATION FILL: FILL NUMERIC OUTPUT FROM <MOD CALCULATION>
VIG CALCULATION FILL: FILL NUMERIC OUTPUT FROM <VIG CALCULATION> |
NOTES |
MOD CALCULATION: IF PAQMODFRQU=1 (DAY) AND PAQMODLNGU=1 (MIN), CALCULATE AVERAGE MINUTES PER DAY = (PAQMODFRQQ)*(PAQMODLNGQ) ELSE, IF PAQMODFRQU=1 (DAY) AND PAQMODLNGU=2 (HRS), CALCULATE AVERAGE MINUTES PER DAY = (PAQMODFRQQ)*((PAQMODLNGQ)*60) ELSE, IF PAQMODFRQU=2 (WEEK) AND PAQMODLNGU=1 (MIN), CALCULATE AVERAGE MINUTES PER DAY = ((PAQMODFRQQ)/7)*(PAQMODLNGQ) ELSE, IF PAQMODFRQU=2 (WEEK) AND PAQMODLNGU=2 (HRS), CALCULATE AVERAGE MINUTES PER DAY = ((PAQMODFRQQ)/7)*((PAQMODLNGQ)*60) ELSE, IF PAQMODFRQU=3 (MONTH) AND PAQMODLNGU=1 (MIN), CALCULATE AVERAGE MINUTES PER DAY = ((PAQMODFRQQ)/30)*(PAQMODLNGQ) ELSE, IF PAQMODFRQU=3 (MONTH) AND PAQMODLNGU=2 (HRS), CALCULATE AVERAGE MINUTES PER DAY = ((PAQMODFRQQ)/30)*((PAQMODLNGQ)*60) ELSE, IF PAQMODFRQU=4 (YEAR) AND PAQMODLNGU=1 (MIN), CALCULATE AVERAGE MINUTES PER DAY = ((PAQMODFRQQ)/365)*(PAQMODLNGQ) ELSE, IF PAQMODFRQU=3 (YEAR) AND PAQMODLNGU=2 (HRS), CALCULATE AVERAGE MINUTES PER DAY = ((PAQMODFRQQ)/365)*((PAQMODLNGQ)*60)
VIG CALCULATION: IF PAQVIGFRQU=1 (DAY) AND PAQVIGLNGU=1 (MIN), CALCULATE AVERAGE MINUTES PER DAY = (PAQVIGFRQQ)*(PAQVIGLNGQ) ELSE, IF PAQVIGFRQU=1 (DAY) AND PAQVIGLNGU=2 (HRS), CALCULATE AVERAGE MINUTES PER DAY = (PAQVIGFRQQ)*((PAQVIGLNGQ)*60) ELSE, IF PAQVIGFRQU=2 (WEEK) AND PAQVIGLNGU=1 (MIN), CALCULATE AVERAGE MINUTES PER DAY = ((PAQVIGFRQQ)/7)*(PAQVIGLNGQ) ELSE, IF PAQVIGFRQU=2 (WEEK) AND PAQVIGLNGU=2 (HRS), CALCULATE AVERAGE MINUTES PER DAY = ((PAQVIGFRQQ)/7)*((PAQVIGLNGQ)*60) ELSE, IF PAQVIGFRQU=3 (MONTH) AND PAQVIGLNGU=1 (MIN), CALCULATE AVERAGE MINUTES PER DAY = ((PAQVIGFRQQ)/30)*(PAQVIGLNGQ) ELSE, IF PAQVIGFRQU=3 (MONTH) AND PAQVIGLNGU=2 (HRS), CALCULATE AVERAGE MINUTES PER DAY = ((PAQVIGFRQQ)/30)*((PAQVIGLNGQ)*60) ELSE, IF PAQVIGFRQU=4 (YEAR) AND PAQVIGLNGU=1 (MIN), CALCULATE AVERAGE MINUTES PER DAY = ((PAQVIGFRQQ)/365)*(PAQVIGLNGQ) ELSE, IF PAQVIGFRQU=3 (YEAR) AND PAQVIGLNGU=2 (HRS), CALCULATE AVERAGE MINUTES PER DAY = ((PAQVIGFRQQ)/365)*((PAQVIGLNGQ)*60) |
HELP SCREEN |
|
HARD CHECK |
IF PAQSITTINGU = 2 (HOURS) AND PAQSITTINGQ ≥ 24, DISPLAY “THE TIME SHOULD BE LESS THAN 24 HOURS.”
IF SUM OF TIME FOR MODERATE ACTIVITY, VIGOROUS ACTIVITY, AND SITTING IS 24 HOURS OR MORE PER DAY, DISPLAY “YOU HAVE REPORTED THE SP DOES 24 HOURS OR MORE OF ACTIVITY A DAY. YOU REPORTED:
<PAQMODLNGQ FILL> <PAQMODLNGU FILL> OF MODERATE ACTIVITY, <PAQMODFRQQ FILL> TIME(S) A <PAQMODFRQU FILL> (AN AVERAGE OF <MOD CALCULATION FILL> MINUTE(S) A DAY).
<PAQVIGLNGQ FILL> <PAQVIGLNGU FILL> OF VIGOROUS ACTIVITY, <PAQVIGFRQQ FILL> TIME(S) A <PAQVIGFRQU FILL> (AN AVERAGE OF <VIG CALCULATION FILL> MINUTE(S) A DAY).
<PAQSITTINGQ FILL> <PAQSITTINGU FILL> OF SITTING A DAY
|
SOFT CHECK |
IF PAQSITTINGU = 2 (HOURS) AND PAQSITTNGQ ≥ 18, DISPLAY “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
PAQ.680 Q/U |
NEXT |
END OF SECTION |
PAQACTIVE |
|
ASK |
IF SP AGE 2-11 YEARS |
Now I'd like to ask you some questions about <TEXT FILL 1> activities.
In the last 7 days, on how many days <TEXT FILL 2> physically active for a total of at least 60 minutes per day? Add up all the time <TEXT FILL 3> spent in any kind of physical activity that increased <TEXT FILL 4> heart rate and made <TEXT FILL 3> breathe hard some of the time.
0. 0 DAYS 1. 1 DAY 2. 2 DAYS 3. 3 DAYS 4. 4 DAYS 5. 5 DAYS 6. 6 DAYS 7. 7 DAYS 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
Ahora me gustaría hacerle algunas preguntas acerca de las actividades físicas de <TEXT FILL 1>.
En los últimos 7 días, ¿cuántos días estuvo <TEXT FILL 2> físicamente activo(a) por un total de al menos 60 minutos al día? Incluya todo el tiempo que pasó en cualquier actividad física que haya aumentado los latidos del corazón y le haya hecho respirar rápido parte del tiempo.
0. 0 DAYS 1. 1 DAY 2. 2 DAYS 3. 3 DAYS 4. 4 DAYS 5. 5 DAYS 6. 6 DAYS 7. 7 DAYS 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]’s”
TEXT FILL 2: FILL “was [SP NAME]”
TEXT FILL 3: FILL “[SP NAME]”
TEXT FILL 4: “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
|
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “[SP NAME]”
TEXT FILL 4: “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
PAQ.706 |
NEXT |
PAQELECTRN |
PAQELECTRN |
|
ASK |
IF SP AGE 2-11 YEARS |
On most weekdays, about how much time did <TEXT FILL 1> spend in front of a TV, computer, cellphone or other electronic device watching programs, playing games, accessing the internet or using social media? Do not include time spent doing schoolwork.
0. Less than 1 hour 1. 1 hour 2. 2 hours 3. 3 hours 4. 4 or more hours 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En la mayoría de los días de entre semana, ¿aproximadamente cuánto tiempo pasó <TEXT FILL 1> frente a la televisión, una computadora, un teléfono celular u otro aparato electrónico viendo programas, jugando videojuegos, navegando por Internet o usando las redes sociales? No incluya el tiempo cuando hace las tareas escolares.
0. Menos de 1 hora 1. 1 hora 2. 2 horas 3. 3 horas 4. 4 o más horas 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
PAQ.NEW2 |
NEXT |
END OF SECTION |
FUNCTIONING - FNQ
Target Group: SPs 5+
FNQSEE |
|
ASK |
IF SP AGE 5-17 YEARS |
Now, I would like to ask you some questions about difficulties <TEXT FILL 1> may have.
Please look at card FNQ1. Does <TEXT FILL 1> have difficulty seeing even if wearing glasses or contact lenses? Would you say <TEXT FILL 1> has: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Ahora, quisiera hacerle algunas preguntas sobre las dificultades que pueda tener <TEXT FILL 1>.
Mire la tarjeta FNQ1. ¿Tiene <TEXT FILL 1> dificultad para ver aunque use anteojos o lentes? ¿Diría que <TEXT FILL 1> tiene: nada de dificultad, algo de dificultad, bastante dificultad o no lo puede hacer en absoluto?
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK (ENG) |
IF FNQSEE = 1 (NO DIFFICULTY) AND VIQLIGHT = 2 (CANNOT SEE LIGHT), DISPLAY “YOU HAVE CODED THAT SP HAS NO DIFFICULTY SEEING. EARLIER SP REPORTED THAT THEY CANNOT SEE LIGHT. RECONCILE RESPONSES WITH SP AND CHANGE RESPONSE TO ONE OF THE QUESTIONS BELOW: FNQSEE: Difficulty seeing even if wearing glasses or contact lenses?: NO DIFFICULTY VIQLIGHT: With both eyes open, can <TEXT FILL 1> see light?: NO” |
HARD CHECK (SPA) |
IF FNQSEE = 1 (NO DIFFICULTY) AND VIQLIGHT = 2 (CANNOT SEE LIGHT), DISPLAY “YOU HAVE CODED THAT SP HAS NO DIFFICULTY SEEING. EARLIER SP REPORTED THAT THEY CANNOT SEE LIGHT. RECONCILE RESPONSES WITH SP AND CHANGE RESPONSE TO ONE OF THE QUESTIONS BELOW: FNQSEE: ¿Dificultad para ver aunque use anteojos o lentes de contacto?: NO DIFFICULTY VIQLIGHT: Cuando abre los dos ojos, ¿puede <TEXT FILL 1> ver la luz?: NO” |
SOFT CHECK |
e |
VERSION NOTES |
FNQ.021 |
NEXT |
FNQHEAR |
FNQHEAR |
|
ASK |
If SP AGE 5-17 YEARS |
Does <TEXT FILL 1> have difficulty hearing sounds like peoples’ voices or music even if using a hearing aid? (Would you say <TEXT FILL 1> has: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?)
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tiene <TEXT FILL 1> dificultad para oír sonidos como voces de personas o música aunque use un audífono? (¿Diría que <TEXT FILL 1> tiene: nada de dificultad, algo de dificultad, bastante dificultad o no lo puede hacer en absoluto?
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.041 |
NEXT |
FNQEQPWALK |
FNQEQPWALK |
|
ASK |
If SP AGE 5-17 YEARS |
Does <TEXT FILL 1> use any equipment or receive assistance for walking?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Usa <TEXT FILL 1> algún equipo o recibe asistencia para caminar?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.050 |
NEXT |
If FNQEQPWALK = 1: FNQWALK Else: FNQWALKCMP |
FNQWALK |
|
ASK |
If FNQEQPWALK = 1 |
Please look at card FNQ2. Without <TEXT FILL 1> equipment or assistance, does <TEXT FILL 2> have difficulty walking 100 yards on level ground? That would be about the length of 1 football field or 1 city block. Would you say <TEXT FILL 2> has: some difficulty, a lot of difficulty, or cannot do at all?
HAND CARD FNQ2
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Mire la tarjeta FNQ2. Sin su equipo o asistencia, ¿tiene <TEXT FILL 1> dificultad para caminar 100 yardas/metros en nivel plano? Eso sería aproximadamente la distancia de un campo de fútbol americano o de una manzana de una ciudad. ¿Diría que <TEXT FILL 2> tiene: nada de dificultad, algo de dificultad, bastante dificultad o no lo puede hacer en absoluto?
HAND CARD FNQ2
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]’s”
TEXT FILL 2: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.060 |
NEXT |
FNQQSLFCARE |
FNQWALKCMP |
|
ASK |
If FNQEQPWALK = 2 OR 7 OR 9 |
Please look at card FNQ1, again. Compared with children of the same age, does <TEXT FILL 1> have difficulty walking 100 yards on level ground? That would be about the length of 1 football field. (Would you say <TEXT FILL 1> has: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Vuelva a mirar la tarjeta FNQ1. En comparación con niños de su misma edad, ¿<TEXT FILL 1> tiene dificultad para caminar 100 yardas en un terreno llano? Esa longitud equivale aproximadamente a la longitud de un campo de fútbol. (¿Diría que <TEXT FILL 1> tiene: nada de dificultad, algo de dificultad, bastante dificultad o no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.080 |
NEXT |
FNQSLFCARE |
FNQSLFCARE |
|
ASK |
If SP AGE 5-17 YEARS |
<TEXT FILL 1> Does <TEXT FILL 2> have difficulty with self-care such as eating or dressing <TEXT FILL 3>? (Would you say <TEXT FILL 2> has: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
<TEXT FILL 1> ¿Tiene <TEXT FILL 2> dificultad para cuidarse por su cuenta, como para alimentarse o vestirse? (¿Diría que <TEXT FILL 1> tiene: nada de dificultad, algo de dificultad, bastante dificultad o no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL1: FILL “Turn back to card FNQ1.” IF FNQEQPWALK = 1. ELSE, LEAVE BLANK
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “himself” IF SP GENDER IS MALE IN SPQGENDER FILL “herself” IF SP GENDER IS FEMALE IN SPQGENDER FILL “themselves” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
FILLS (SPA) |
TEXT FILL1: FILL “Regrese a la tarjeta FNQ1. ” IF FNQEQPWALK = 1. ELSE, LEAVE BLANK
TEXT FILL 2: FILL “[SP NAME]”
TEXT FILL 3: FILL “” IF SP GENDER IS MALE IN SPQGENDER FILL “” IF SP GENDER IS FEMALE IN SPQGENDER FILL “” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.160 |
NEXT |
FNQCOMMINS |
FNQCOMMINS |
|
ASK |
If SP AGE 5-17 YEARS |
When <TEXT FILL 1> speaks, does <TEXT FILL 1> have difficulty being understood by people inside of this household? (Would you say <TEXT FILL 1> has: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Cuando <TEXT FILL 1> habla, ¿tiene dificultad para que le entiendan las personas que viven en este hogar? (¿Diría que <TEXT FILL 1> tiene: nada de dificultad, algo de dificultad, bastante dificultad o no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.100 |
NEXT |
FNQCOMMOUT |
FNQCOMMOUT |
|
ASK |
If SP AGE 5-17 YEARS |
When <TEXT FILL 1> speaks, does <TEXT FILL 1> have difficulty being understood by people outside of this household? (Would you say <TEXT FILL 1> has: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Cuando <TEXT FILL 1> habla, ¿tiene dificultad para que le entiendan las personas que no viven en este hogar? (¿Diría que <TEXT FILL 1> tiene: nada de dificultad, algo de dificultad, bastante dificultad o no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.110 |
NEXT |
FNQLEARN |
FNQLEARN |
|
ASK |
If SP AGE 5-17 YEARS |
Compared with children of the same age, does <TEXT FILL 1> have difficulty learning things? (Would you say <TEXT FILL 1> has: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En comparación con niños de la misma edad, ¿tiene <TEXT FILL 1> dificultad para aprender cosas? (¿Diría que <TEXT FILL 1> tiene: nada de dificultad, algo de dificultad, bastante dificultad o no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.120 |
NEXT |
FNQREMEMBR |
FNQREMEMBR |
|
ASK |
If SP AGE 5-17 YEARS |
Compared with children of the same age, does <TEXT FILL 1> have difficulty remembering things? (Would you say <TEXT FILL 1> has: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En comparación con niños de la misma edad, ¿tiene <TEXT FILL 1> dificultad para recordar cosas? (¿Diría que <TEXT FILL 1> tiene: nada de dificultad, algo de dificultad, bastante dificultad o no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.170 |
NEXT |
FNQCONCNTR |
FNQCONCNTR |
|
ASK |
If SP AGE 5-17 YEARS |
Does <TEXT FILL 1> have difficulty concentrating on an activity that <TEXT FILL 1> enjoys doing? (Would you say <TEXT FILL 1> has: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tiene <TEXT FILL 1> dificultad para concentrarse en una actividad que disfruta hacer? (¿Diría que <TEXT FILL 1> tiene: nada de dificultad, algo de dificultad, bastante dificultad o no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.180 |
NEXT |
FNQCHANGES |
FNQCHANGES |
|
ASK |
If SP AGE 5-17 YEARS |
Does <TEXT FILL 1> have difficulty accepting changes in <TEXT FILL 2> routine? (Would you say <TEXT FILL 1> has: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW |
|
SPANISH |
¿Tiene <TEXT FILL 1> dificultad para aceptar cambios en su rutina? (¿Diría que <TEXT FILL 1> tiene: nada de dificultad, algo de dificultad, bastante dificultad o no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “his” IF SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP GENDER IS FEMALE IN SPQGENDER FILL “(SP NAME]’s” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “él” IF SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP GENDER IS FEMALE IN SPQGENDER FILL “(SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.190 |
NEXT |
FNQBEHAVE |
FNQBEHAVE |
|
ASK |
If SP AGE 5-17 YEARS |
Compared with children of the same age, does <TEXT FILL 1> have difficulty controlling <TEXT FILL 2> behavior? (Would you say <TEXT FILL 1> has: no difficulty, some difficulty, a lot of difficulty, or cannot do at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW |
|
SPANISH |
En comparación con niños de la misma edad, ¿tiene <TEXT FILL 1> dificultad para controlar su comportamiento? (¿Diría que <TEXT FILL 1> tiene: nada de dificultad, algo de dificultad, bastante dificultad o no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “his” IF SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP GENDER IS FEMALE IN SPQGENDER FILL “(SP NAME]’s” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “él” IF SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP GENDER IS FEMALE IN SPQGENDER FILL “(SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.130 |
NEXT |
FNQFRIENDS |
FNQFRIENDS |
|
ASK |
If SP AGE 5-17 YEARS |
Does <TEXT FILL 1> have difficulty making friends? Would you say <TEXT FILL 1> has: (no difficulty, some difficulty, a lot of difficulty, or cannot do at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tiene <TEXT FILL 1> dificultad para hacer amigos? (¿Diría que <TEXT FILL 1> tiene: nada de dificultad, algo de dificultad, bastante dificultad o no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.200 |
NEXT |
FNQANXIETY |
FNQANXIETY |
|
ASK |
If SP AGE 5-17 YEARS |
How often does <TEXT FILL 1> seem very anxious, nervous or worried? Would you say daily, weekly, monthly, a few times a year or never?
1. DAILY 2. WEEKLY 3. MONTHLY 4. A FEW TIMES A YEAR 5. NEVER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Con qué frecuencia <TEXT FILL 1> parece sentirse muy ansioso(a), nervioso(a) o preocupado(a)? ¿Diría que diariamente, semanalmente, mensualmente, algunas veces al año o nunca?
1. DIARIAMENTE 2. SEMANALMENTE 3. MENSUALMENTE 4. ALGUNAS VECES AL AÑO 5. NUNCA 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.140 |
NEXT |
FNQDEPRESS |
FNQDEPRESS |
|
ASK |
If SP AGE 5-17 YEARS |
How often does <TEXT FILL 1> seem very sad or depressed? Would you say daily, weekly, monthly, a few times a year or never?
1. DAILY 2. WEEKLY 3. MONTHLY 4. A FEW TIMES A YEAR 5. NEVER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Con qué frecuencia <TEXT FILL 1> parece sentirse muy triste o deprimido(a)? ¿Diría que diariamente, semanalmente, mensualmente, algunas veces al año o nunca?
1. DIARIAMENTE 2. SEMANALMENTE 3. MENSUALMENTE 4. ALGUNAS VECES AL AÑO 5. NUNCA 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.150 |
NEXT |
END OF SECTION |
FNQHSEE |
|
ASK |
IF SP AGE >= 18 YEARS |
Please look at card FNQ1. The next questions ask about difficulties <TEXT FILL 1> may have doing certain activities because of a health problem. <TEXT FILL 2> have difficulty seeing even if wearing glasses or contact lenses? Would you say no difficulty, some difficulty, a lot of difficulty, or <TEXT FILL 1> cannot do this at all?
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Mire la tarjeta FNQ1. Las siguientes preguntas son acerca de las dificultades que posiblemente <TEXT FILL 1> tenga para hacer ciertas actividades debido a un problema de salud. ¿Tiene <TEXT FILL 2> dificultad para ver aunque use anteojos o lentes de contacto? (¿Diría que nada de dificultad, algo de dificultad, bastante dificultad o <TEXT FILL 1> no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]”
TEXT FILL 3: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK (ENG) |
IF FNQHSEE = 1 (NO DIFFICULTY) AND VIQLIGHT = 2 (CANNOT SEE LIGHT), DISPLAY “YOU HAVE CODED THAT SP HAS NO DIFFICULTY SEEING. EARLIER SP REPORTED THAT THEY CANNOT SEE LIGHT. RECONCILE RESPONSES WITH SP AND CHANGE RESPONSE TO ONE OF THE QUESTIONS BELOW: FNQHSEE: Difficulty seeing even if wearing glasses or contact lenses?: NO DIFFICULTY VIQLIGHT: With both eyes open, can <TEXT FILL 1> see light?: NO” |
HARD CHECK (SPA) |
IF FNQHSEE = 1 (NO DIFFICULTY) AND VIQLIGHT = 2 (CANNOT SEE LIGHT), DISPLAY “YOU HAVE CODED THAT SP HAS NO DIFFICULTY SEEING. EARLIER SP REPORTED THAT THEY CANNOT SEE LIGHT. RECONCILE RESPONSES WITH SP AND CHANGE RESPONSE TO ONE OF THE QUESTIONS BELOW: FNQHSEE: ¿Dificultad para ver aunque use anteojos o lentes de contacto?: NO DIFFICULTY VIQLIGHT: Cuando abre los dos ojos, ¿puede <TEXT FILL 1> ver la luz?: NO” |
SOFT CHECK |
|
VERSION NOTES |
FNQ.410 |
NEXT |
FNQHHEAR |
FNQHHEAR |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 1> have difficulty hearing even if using a hearing aid? (Would you say no difficulty, some difficulty, a lot of difficulty, or <TEXT FILL 2> cannot do this at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tiene <TEXT FILL 1> dificultad para oír aunque use un audífono? (¿Diría que nada de dificultad, algo de dificultad, bastante dificultad o <TEXT FILL 2> no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.430 |
NEXT |
FNQHWALK |
FNQHWALK |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 1> have difficulty walking or climbing steps? (Would you say no difficulty, some difficulty, a lot of difficulty, or <TEXT FILL 2> cannot do this at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tiene <TEXT FILL 1> dificultad para caminar o subir escaleras? (¿Diría que nada de dificultad, algo de dificultad, bastante dificultad o <TEXT FILL 2> no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.440 |
NEXT |
FNQHCOMM |
FNQHCOMM |
|
ASK |
IF SP AGE >= 18 YEARS |
Using <TEXT FILL 1> usual language, <TEXT FILL 2> have difficulty communicating, for example, understanding or being understood? (Would you say no difficulty, some difficulty, a lot of difficulty, or <TEXT FILL 3> cannot do this at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Al usar su idioma habitual, ¿tiene <TEXT FILL 2> tiene dificultad para comunicarse, por ejemplo, para entender o hacerse entender? (¿Diría que nada de dificultad, algo de dificultad, bastante dificultad o <TEXT FILL 3> no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]”
TEXT FILL 3: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.450 |
NEXT |
FNQHREMEMB |
FNQHREMEMB |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 1> have difficulty remembering or concentrating? (Would you say no difficulty, some difficulty, a lot of difficulty, or <TEXT FILL 2> cannot do this at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tiene <TEXT FILL 1> dificultad para recordar o concentrarse? (¿Diría que nada de dificultad, algo de dificultad, bastante dificultad o <TEXT FILL 2> no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.460 |
NEXT |
FNQHSLFCAR |
FNQHSLFCAR |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 1> have difficulty with self-care, such as washing all over and dressing? (Would you say no difficulty, some difficulty, a lot of difficulty, or <TEXT FILL 2> cannot do this at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tiene <TEXT FILL 1> dificultad con actividades como bañarse y vestirse? (¿Diría que nada de dificultad, algo de dificultad, bastante dificultad o <TEXT FILL 2> no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.470 |
NEXT |
FNQHRAISE |
FNQHRAISE |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 1> have difficulty raising a 2 liter bottle of water or soda from waist to eye level? (Would you say no difficulty, some difficulty, a lot of difficulty, or <TEXT FILL 2> cannot do this at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tiene <TEXT FILL 1> dificultad para levantar una botella de 2 litros de agua o gaseosa desde la altura de la cintura hasta la altura de los ojos? (¿Diría que nada de dificultad, algo de dificultad, bastante dificultad o <TEXT FILL 2> no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.480 |
NEXT |
FNQHPICKUP |
FNQHPICKUP |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 1> have difficulty using <TEXT FILL 2> hands and fingers, such as picking up small objects, for example, a button or pencil, or opening or closing containers or bottles? (Would you say no difficulty, some difficulty, a lot of difficulty, or <TEXT FILL 3> cannot do this at all?)
HAND CARD FNQ1
1. NO DIFFICULTY 2. SOME DIFFICULTY 3. A LOT OF DIFFICULTY 4. CANNOT DO AT ALL 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tiene <TEXT FILL 1> dificultad para usar las manos y los dedos, como por ejemplo para agarrar objetos pequeños, como un botón o un lápiz, o para abrir o cerrar envases o botellas? (¿Diría que nada de dificultad, algo de dificultad, bastante dificultad o <TEXT FILL 3> no lo puede hacer en absoluto?)
HAND CARD FNQ1
1. NADA DE DIFICULTAD 2. ALGO DE DIFICULTAD 3. BASTANTE DIFICULTAD 4. NO LO PUEDE HACER EN ABSOLUTO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPODENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPODENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.490 |
NEXT |
FNQHANX |
FNQHANX |
|
ASK |
IF SP AGE >= 18 YEARS |
How often <TEXT FILL 1> feel worried, nervous, or anxious? Would you say…
1. daily, 2. weekly, 3. monthly, 4. a few times a year, or 5. never? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Con qué frecuencia se siente <TEXT FILL 1> preocupado(a), nervioso(a) o ansioso(a)? ¿Diría que...
1. diariamente, 2. semanalmente, 3. mensualmente, 4. algunas veces al año, o 5. nunca? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.510 |
NEXT |
If FNQHANX = 5 OR 7 OR 9: FNQDEP Else: FNQHANXDES |
FNQHANXDES |
|
ASK |
IF FNQHANX = 1 OR 2 OR 3 OR 4 |
Thinking about the last time <TEXT FILL 1> felt worried, nervous, or anxious, how would <TEXT FILL 2> describe the level of these feelings? Would you say…
1. a little, 2. a lot, or 3. somewhere in between a little and a lot? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Piense en la última vez que <TEXT FILL 1> se sintió preocupado(a), nervioso(a) o ansioso(a), ¿cómo describiría <TEXT FILL 2> el nivel de esos sentimientos? ¿Diría que...
1. poco, 2. mucho, o 3. un punto intermedio entre poco y mucho? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.520 |
NEXT |
FNQHDEP |
FNQHDEP |
|
ASK |
IF SP AGE >= 18 YEARS |
How often <TEXT FILL 1> feel depressed? Would you say…
1. daily, 2. weekly, 3. monthly, 4. a few times a year, or 5. never? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Con qué frecuencia se siente <TEXT FILL 1> deprimido(a)? ¿Diría que...
1. diariamente, 2. semanalmente, 3. mensualmente, 4. algunas veces al año, o 5. nunca? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.530 |
NEXT |
If FNQHDEP = 5 OR 7 OR 9: END OF SECTION Else: FNQHDEPDES |
FNQHDEPDES |
|
ASK |
IF FNQHDEP = 1 OR 2 OR 3 OR 4 |
Thinking about the last time <TEXT FILL 1> felt depressed, how depressed did <TEXT FILL 2> feel? Would you say…
1. a little, 2. a lot, or 3. somewhere in between a little and a lot? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Piense en la última vez que <TEXT FILL 1> se sintió deprimido(a). ¿Qué tan deprimido se sintió <TEXT FILL 2>? ¿Diría que...
1. poco, 2. mucho, o 3. un punto intermedio entre poco y mucho? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FNQ.540 |
NEXT |
END OF SECTION |
SLEEP DISORDERS – SLQ
Target Group: 18+
SLQASLPWDH / SLQASLPWDM / SLQASLPWDU |
|
ASK |
IF SP AGE >= 18 YEARS |
The next set of questions are about <TEXT FILL 1> sleep.
What time <TEXT FILL 2> usually fall asleep on weekdays or workdays?
INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS INTO BED. ENTER TIME AS HH:MM AM OR PM. IF RESPONDENT SAYS TWELVE “MIDNIGHT” CODE AS 12:00 AM.
_____________ [SLQASLPWDH] ENTER A NUMBER 1-12
77. REFUSED 99. DON’T KNOW
_____________ [SLQASLPWDM] ENTER A NUMBER 00-59
77. REFUSED 99. DON’T KNOW
_____________ [SLQASLPWDU] ENTER AM OR PM
7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
La siguiente serie de preguntas son acerca de <TEXT FILL 1>.
Normalmente, ¿a qué hora <TEXT FILL 2> se duerme entre semana o en días de trabajo?
INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS INTO BED. ENTER TIME AS HH:MM AM OR PM. IF RESPONDENT SAYS TWELVE “MIDNIGHT” CODE AS 12:00 AM.
_____________ [SLQASLPWDH] ENTER A NUMBER 1-12
77. REFUSED 99. DON’T KNOW
_____________ [SLQASLPWDM] ENTER A NUMBER 00-59
77. REFUSED 99. DON’T KNOW
_____________ [SLQASLPWDU] ENTER AM OR PM
7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Numeric with radio buttons: SLQASLPWDH, SLQASLPWDM Dropdown: SLQASLPWDU |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “sus hábitos de sueño” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “los hábitos de sueño de [SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
SLQ.300 |
NEXT |
SLQAWKEWD |
SLQAWKEWDH / SLQAWKEWDM / SLQAWKEWDU |
|
ASK |
IF SP AGE >= 18 YEARS |
What time <TEXT FILL 1> usually wake up on weekdays or workdays?
INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS OUT OF BED. ENTER TIME AS HH:MM AM OR PM.
_____________ [SLQAWKEWDH] ENTER A NUMBER 1-12
77. REFUSED 99. DON’T KNOW
_____________ [SLQAWKEWDM] ENTER A NUMBER 00-59
77. REFUSED 99. DON’T KNOW
_____________ [SLQAWKEWDU] ENTER AM OR PM
7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Normalmente, ¿a qué hora se despierta <TEXT FILL 1> entre semana o en días de trabajo?
INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS OUT OF BED. ENTER TIME AS HH:MM AM OR PM.
_____________ [SLQAWKEWDH] ENTER A NUMBER 1-12
77. REFUSED 99. DON’T KNOW
_____________ [SLQAWKEWDM] ENTER A NUMBER 00-59
77. REFUSED 99. DON’T KNOW
_____________ [SLQAWKEWDU] ENTER AM OR PM
7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Numeric with radio buttons: SLQAWKEWDH, SLQAWKEWDM Dropdown: SLQAWKEWDU |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
IF LESS THAN 4 HOURS OR MORE THAN 12 HOURS OF TOTAL SLEEP AND (SLQASLPWD != DK/RF AND SLQAWKEWD != DK/RF), DISPLAY: “PLEASE VERIFY SLEEP TIMES OF LESS THAN 4 HOURS OR MORE THAN 12 HOURS. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
SLQ.310 |
NEXT |
SLQASLPWE |
SLQASLPWEH / SLQASLPWEM / SLQASLPWEU |
|
ASK |
IF SP AGE >= 18 YEARS |
What time <TEXT FILL 1> usually fall asleep on weekends or non-workdays?
INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS INTO BED. ENTER TIME AS HH:MM AM OR PM. IF RESPONDENT SAYS TWELVE “MIDNIGHT” CODE AS 12:00 AM. IF RESPONDENT SAYS DOES NOT WORK, ASK IF THE TIME THAT THE RESPONDENT FALLS ASLEEP IS DIFFERENT ON WEEKENDS. IF NOT, ENTER SAME TIME AS ON WEEKDAYS (SLQASLPWD).
_____________ [SLQASLPWEH] ENTER A NUMBER 1-12
77. REFUSED 99. DON’T KNOW
_____________ [SLQASLPWEM] ENTER A NUMBER 00-59
77. REFUSED 99. DON’T KNOW
_____________ [SLQASLPWEU] ENTER AM OR PM
7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Normalmente, ¿a qué hora se duerme <TEXT FILL 1> los fines de semana o los días que no trabaja?
INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS INTO BED. ENTER TIME AS HH:MM AM OR PM. IF RESPONDENT SAYS TWELVE “MIDNIGHT” CODE AS 12:00 AM. IF RESPONDENT SAYS DOES NOT WORK, ASK IF THE TIME THAT THE RESPONDENT FALLS ASLEEP IS DIFFERENT ON WEEKENDS. IF NOT, ENTER SAME TIME AS ON WEEKDAYS (SLQASLPWD).
_____________ [SLQASLPWEH] ENTER A NUMBER 1-12
77. REFUSED 99. DON’T KNOW
_____________ [SLQASLPWEM] ENTER A NUMBER 00-59
77. REFUSED 99. DON’T KNOW
_____________ [SLQASLPWEU] ENTER AM OR PM
7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Numeric with radio buttons: SLQASLPWEH, SLQASLPWEM Dropdown: SLQASLPWEU |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
SLQ.320 |
NEXT |
SLQAWKEWE |
SLQAWKEWEH / SLQAWKEWEM / SLQAWKEWEU |
|
ASK |
IF SP AGE >= 18 YEARS |
What time <TEXT FILL 1> usually wake up on weekends or non-workdays?
INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS OUT OF BED. ENTER TIME AS HH:MM AM OR PM. IF RESPONDENT SAYS DOES NOT WORK, AS IF THE TIME THAT THE RESPONDENT WAKES UP IS DIFFERENCE ON WEEKENDS. IF NOT, ENTER THE SAME TIME AS ON WEEKENDS (SLQAWKEWD).
_____________ [SLQAWKEWEH] ENTER A NUMBER 1-12
77. REFUSED 99. DON’T KNOW
_____________ [SLQAWKEWEM] ENTER A NUMBER 00-59
77. REFUSED 99. DON’T KNOW
_____________ [SLQAWKEWEU] ENTER AM OR PM
7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Normalmente, ¿a qué hora se despierta <TEXT FILL 1> los fines de semana o los días que no trabaja?
INTERVIEWER INSTRUCTION: THIS IS NOT THE TIME SP GETS OUT OF BED. ENTER TIME AS HH:MM AM OR PM. IF RESPONDENT SAYS DOES NOT WORK, AS IF THE TIME THAT THE RESPONDENT WAKES UP IS DIFFERENCE ON WEEKENDS. IF NOT, ENTER THE SAME TIME AS ON WEEKENDS (SLQAWKEWD).
_____________ [SLQAWKEWEH] ENTER A NUMBER 1-12
77. REFUSED 99. DON’T KNOW
_____________ [SLQAWKEWEM] ENTER A NUMBER 00-59
77. REFUSED 99. DON’T KNOW
_____________ [SLQAWKEWEU] ENTER AM OR PM
7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Numeric with radio buttons: SLQAWKEWDH, SLQAWKEWDM Dropdown: SLQAWKEWDU |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
IF LESS THAN 4 HOURS OR MORE THAN 12 HOURS OF TOTAL SLEEP AND (SLQASLPWE != DK/RF AND SLQAWKEWE != DK/RF), DISPLAY: “PLEASE VERIFY SLEEP TIMES OF LESS THAN 4 HOURS OR MORE THAN 12 HOURS. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
SLQ.330 |
NEXT |
SLQSNORE |
SLQSNORE |
|
ASK |
IF SP AGE >= 18 YEARS |
In the last 12 months, how often did <TEXT FILL 1> snore while <TEXT FILL 2> sleeping? Would you say…
INTERVIEWER INSTRUCTION: IF R SAYS “DON’T KNOW”, PROBE IF ANYONE HAS TOLD THEM THAT THEY SNORE.
0. never, 1. rarely; 1-2 nights a week, 2. occasionally; 3-4 nights a week, or 3. frequently; 5 or more nights a week? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿con qué frecuencia roncó <TEXT FILL 1> mientras dormía? ¿Diría que...
INTERVIEWER INSTRUCTION: IF R SAYS “DON’T KNOW”, PROBE IF ANYONE HAS TOLD THEM THAT THEY SNORE.
0. nunca, 1. rara vez; 1 o 2 noches por semana, 2. ocasionalmente; de 3 a 4 noches por semana, 3. con frecuencia; 5 o más noches por semana? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio Button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “you were” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he was” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she was” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] was” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] ” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
SLQ.030 |
NEXT |
SLQSNORT |
SLQSNORT |
|
ASK |
IF SP AGE >= 18 YEARS |
In the last 12 months, how often did <TEXT FILL 1> snort, gasp, or stop breathing while <TEXT FILL 2> asleep? Would you say…
INTERVIEWER INSTRUCTION: IF THE RESPONDENT ASKS “HOW WOULD I KNOW IF I SNORT, GASP OR STOP BREATHING WHEN I AM SLEEPING?” PROBE IF ANYONE TOLD THEM THAT THEY DO THIS.
0. never, 1. rarely; 1-2 nights a week, 2. occasionally; 3-4 nights a week, or 3. frequently; 5 or more nights a week? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿con qué frecuencia <TEXT FILL 1> resopló, jadeó o dejó de respirar mientras dormía? ¿Diría que...
INTERVIEWER INSTRUCTION: IF THE RESPONDENT ASKS “HOW WOULD I KNOW IF I SNORT, GASP OR STOP BREATHING WHEN I AM SLEEPING?” PROBE IF ANYONE TOLD THEM THAT THEY DO THIS.
0. nunca, 1. rara vez; 1 o 2 noches por semana, 2. ocasionalmente; de 3 a 4 noches por semana, 3. con frecuencia; 5 o más noches por semana? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio Button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “you were” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he was” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she was” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] was” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] ” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
SLQ.040 |
NEXT |
SLQTROUBLE |
SLQTROUBLE |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 2> ever told a doctor or other health professional that <TEXT FILL 1> trouble sleeping?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Le ha dicho alguna vez <TEXT FILL 2> a un doctor o a otro profesional de la salud que <TEXT FILL 1> tiene problemas para dormir?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW |
QUESTION TYPE |
Radio Button |
FILLS (ENG) |
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), DK/RF, OR MORE THAN ONE RESPONSEIN SPQGENDER
TEXT FILL 2: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] ” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3), DK/RF, OR MORE THAN ONE RESPONSEIN SPQGENDER
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
SLQ.050 |
NEXT |
SLQAPNEA |
SLQAPNEA |
|
ASK |
IF SP AGE >= 18 YEARS |
Has a doctor or other health professional ever said that <TEXT FILL 1> had sleep apnea?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Le ha dicho alguna vez un doctor u otro profesional de la salud que <TEXT FILL 1> tenía apnea del sueño?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
SLQ.NEW1 |
NEXT |
END OF SECTION |
DIET BEHAVIOR AND NUTRITION - DBQ
Target Group: SPs Birth +
DBQBRSTYN |
|
ASK |
IF SP AGE <= 4 YEARS |
Now I'm going to ask you some general questions about <TEXT FILL 1> eating habits.
Was <TEXT FILL 2> ever breastfed or fed breastmilk?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Ahora le haré algunas preguntas generales acerca de los hábitos alimentarios de <TEXT FILL 1>.
¿Fue alimentado(a) <TEXT FILL 2> alguna vez con lecha materna?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]’s”
TEXT FILL 2: FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.010 |
NEXT |
IF DBQBRSTYN = 1: DBQBRSTSPG ELSE: DBQFRMLSRG |
DBQBRSTSPG / DBQBRSTSPQ / DBQBRSTSPU |
|
ASK |
IF DBQBRSTYN = 1 |
How old was <TEXT FILL 1> when <TEXT FILL 2> completely stopped breastfeeding or being fed breastmilk?
|___| [DBQBRSTSPG] 1. ENTER NUMBER 2. STILL BREASTFEEDING 7. REFUSED 9. DON’T KNOW
|___|___|___|___| [DBQBRSTSPQ] ENTER AGE IN DAYS, WEEKS, MONTHS, OR YEARS
|___| [DBQBRSTSPU] ENTER UNIT
1. DAYS 2. WEEKS 3. MONTHS 4. YEARS |
|
SPANISH |
¿Qué edad tenía <TEXT FILL 1> cuando dejó completamente de ser amamantado(a) o de tomar leche materna?
|___| [DBQBRSTSPG] 1. ENTER NUMBER 2. STILL BREASTFEEDING 7. REFUSED 9. DON’T KNOW
|___|___|___|___| [DBQBRSTSPQ] ENTER AGE IN DAYS, WEEKS, MONTHS, OR YEARS
|___| [DBQBRSTSPU] ENTER UNIT
1. DAYS 2. WEEKS 3. MONTHS 4. YEARS |
QUESTION TYPE |
Dropdown: DBQBRSTSPG Radio button: DBQBRSTSPU Numeric: DBQBRSTSPQ |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “he” IF SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “él” IF SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
IF DBQBRSTSPU = 2 (WEEKS), 3 (MONTHS), OR 4 (YEARS), CALCULATE AGE SP STOPPED BREASTFEEDING IN DAYS (DBDBRSTSPD) AS FOLLOWS: IF DBQBRSTSPU = 2, CALCULATE AGE SP STOPPED BREASTFEEDING AS (DBQBRSTSPQ *7) IF DBQBRSTSPU = 3, CALCULATE AGE SP STOPPED BREASTFEEDING AS (DBQBRSTSPQ *31) IF DBQBRSTSPU = 4, CALCULATE AGE SP STOPPED BREASTFEEDING AS (DBQBRSTSPQ *365)
|
HELP SCREEN |
|
HARD CHECK |
IF DBQBRSTSPG = 1 AND DBQBRSTSPQ = 0, DISPLAY “AGE CANNOT BE ZERO BECAUSE AGE IN DAYS, WEEKS, OR MONTHS IS ALLOWED.”
IF AGE SP STOPPED BREASTFEDING IN DAYS (DBDBRSTSPD) > SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD), DISPLAY, “NUMBER CANNOT BE MORE THAN SP’S AGE”
|
SOFT CHECK |
IF (DBQBRSTSPU = 2 (WEEKS) AND DBQBRSTSPQ > 24) OR (DBQBRSTSPU = 1 (DAYS) AND DBQBRSTSPQ > 40), DISPLAY, “VERIFY AGE ENTERED. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.”
IF AGE SP STOPPED BREASTFEDING IN DAYS (DBDBRSTSPD) = SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD) DISPLAY, “AGE ENTERED IS THE SAME AS SP’S CURRENT AGE. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
DBQ.030 G/Q/U |
NEXT |
DBQFRMLSRG |
DBQFRMLSRG / DBQFRMLSRQ / DBQFRMLSRU |
|
ASK |
IF SP AGE <= 4 YEARS |
How old was <TEXT FILL 1> when <TEXT FILL 2> was first fed formula?
INTERVIEWER INSTRUCTION: INCLUDE BOTH INFANT AND TODDLER FORMULAS.
|___| [DBQFRMLSRG] 1. ENTER NUMBER 2. NEVER 7. REFUSED 9. DON’T KNOW
|___|___|___|___| [DBQFRMLSRQ] ENTER AGE IN DAYS, WEEKS, MONTHS, OR YEARS
|___| [DBQFRMLSRU] ENTER UNIT
1. DAYS 2. WEEKS 3. MONTHS 4. YEARS
|
|
SPANISH |
¿Qué edad tenía <TEXT FILL 1> cuando fue alimentado(a) por primera vez con fórmula infantil?
INTERVIEWER INSTRUCTION: INCLUDE BOTH INFANT AND TODDLER FORMULAS.
|___| [DBQFRMLSRG] 1. ENTER NUMBER 2. NEVER 7. REFUSED 9. DON’T KNOW
|___|___|___|___| [DBQFRMLSRQ] ENTER AGE IN DAYS, WEEKS, MONTHS, OR YEARS
|___| [DBQFRMLSRU] ENTER UNIT
1. DAYS 2. WEEKS 3. MONTHS 4. YEARS
|
QUESTION TYPE |
Dropdown: DBQFRMLSRG Radio button: DBQFRMLSRU Numeric: DBQFRMLSRQ |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “he” IF SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “él” IF SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
IF DBQFRMLSRU = 2 (WEEKS), 3 (MONTHS), OR 4 (YEARS), CALCULATE AGE SP FIRST FED FORMULA IN DAYS (DBDFRMLSRD) AS FOLLOWS: IF DBQFRMLSRU = 2, CALCULATE AGE SP FIRST FED FORMULA AS (DBQFRMLSRQ*7) IF DBQFRMLSRU = 3, CALCULATE AGE SP FIRST FED FORMULA AS (DBQFRMLSRQ*31) IF DBQFRMLSRU = 4, CALCULATE AGE SP FIRST FED FORMULA AS (DBQFRMLSRQ*365)
|
HELP SCREEN |
|
HARD CHECK |
IF DBQFRMLSRG = 1 AND DBQFRMLSRQ = 0, DISPLAY “AGE CANNOT BE ZERO BECAUSE AGE IN DAYS, WEEKS, OR MONTHS IS ALLOWED.”
IF AGE SP FIRST FED FORMULA IN AGE (DBDFRMLSRD) > SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD), DISPLAY, “NUMBER CANNOT BE MORE THAN SP’S AGE” |
SOFT CHECK |
IF (DBQFRMLSRU = 2 (WEEKS) AND DBQFRMLSRQ > 24) OR (DBQFRMLSRU = 1 (DAYS) AND DBQFRMLSRQ > 40), DISPLAY, “VERIFY AGE ENTERED. UPDATE RESPONSES IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.
IF AGE SP FIRST FED FORMULA IN AGE (DBDFRMLSRD) = SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD), DISPLAY, “AGE ENTERED IS THE SAME AS SP’S CURRENT AGE. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
DBQ.041 G/Q/U |
NEXT |
IF DBQFRMLSRG = 1 : DBQFRMLWTR IF DBQFRMLSRG = 2: DBQFIRSTG IF ((DBQFRMLSRG = 777777 OR 999999) OR (DBQFRMLSRQ = 777777 OR 999999)) AND SP AGE 0-11 MONTHS OR 1 YEAR: DBQFRMLWTR IF ((DBQFRMLSRG = 777777 OR 999999) OR (DBQFRMLSRQ = 777777 OR 999999)) AND SP AGE >= 2 YEARS: DBQFRMLSPG |
DBQFRMLWTR |
|
ASK |
IF DBQFRMLSRG = 1 IF DBQFRMLSRG = 777777 (RF) OR 999999 (DK) AND SP AGE <= 0-11 MONTHS OR 1 YEAR |
When preparing infant formula for <TEXT FILL 1> what source of water was used? Was it…
INTERVIEWER INSTRUCTION: IF MORE THAN ONE SOURCE PROVIDED, PROBE: What water source do you typically use when preparing formula?
1. Bottled water, 2. Cold tap water, 3. Hot tap water, 4. Filtered tap water, 5. Well water, or 6. Distilled water 7. DO NOT USE WATER TO PREPARE FORMULA 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
Cuando prepara la fórmula para bebés para <TEXT FILL 1>, ¿qué fuente de agua se usó? ¿Fue...
INTERVIEWER INSTRUCTION: IF MORE THAN ONE SOURCE PROVIDED, PROBE: ¿Qué fuente de agua usa normalmente cuando prepara la fórmula?
1. Agua embotellada, 2. Agua fría de la llave, 3. Agua caliente de la llave, 4. Agua de la llave filtrada, 5. Agua de pozo, o 6. Agua destilada? 7. DO NOT USE WATER TO PREPARE FORMULA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW2 |
NEXT |
DBQFRMLSPG |
DBQFRMLSPG / DBQFRMLSPQ / DBQFRMLSPU |
|
ASK |
IF DBQFRMLSRG = 1 OR 777777 (RF) OR 999999 (DK) IF DBQFRMLSRQ = 777777 (RF) OR 999999 (DK) |
How old was <TEXT FILL 1> when <TEXT FILL 2> completely stopped drinking formula?
INTERVIEWER INSTRUCTION: INCLUDE BOTH INFANT AND TODDLER FORMULAS.
|___| [DBQFRMLSPG] 1. ENTER NUMBER 2. STILL DRINKING FORMULA 7. REFUSED 9. DON’T KNOW
|___|___|___|___| [DBQFRMLSPQ] ENTER AGE IN DAYS, WEEKS, MONTHS, OR YEARS
|___| [DBQFRMLSPU] ENTER UNIT
1. DAYS 2. WEEKS 3. MONTHS 4. YEARS
|
|
SPANISH |
¿Qué edad tenía <TEXT FILL 1> cuando dejó completamente de tomar fórmula infantil?
INTERVIEWER INSTRUCTION: INCLUDE BOTH INFANT AND TODDLER FORMULAS.
|___| [DBQFRMLSPG] 1. ENTER NUMBER 2. STILL DRINKING FORMULA 7. REFUSED 9. DON’T KNOW
|___|___|___|___| [DBQFRMLSPQ] ENTER AGE IN DAYS, WEEKS, MONTHS, OR YEARS
|___| [DBQFRMLSPU] ENTER UNIT
1. DAYS 2. WEEKS 3. MONTHS 4. YEARS
|
QUESTION TYPE |
Dropdown: DBQFRMLSPG Radio button: DBQFRMLSPU Numeric: DBQFRMLSPQ |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “he” IF SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “él” IF SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
IF DBQFRMLSPU = 2 (WEEKS), 3 (MONTHS), OR 4 (YEARS), CALCULATE AGE SP STOPPED DRINKING FORUMLA IN DAYS (DBDFRMLSPD) AS FOLLOWS: IF DBQFRMLSPU = 2, CALCULATE AGE SP STOPPED DRINKING FORUMLA AS (DBQFRMLSPQ*7) IF DBQFRMLSPU = 3, CALCULATE AGE SP STOPPED DRINKING FORUMLA AS (DBQFRMLSPQ*31) IF DBQFRMLSPU = 4, CALCULATE AGE SP STOPPED DRINKING FORUMLA AS (DBQFRMLSPQ*365)
|
HELP SCREEN |
|
HARD CHECK |
IF DBQFRMLSPG = 1 AND DBQFRMLSPQ = 0, DISPLAY “AGE CANNOT BE ZERO BECAUSE AGE IN DAYS, WEEKS, OR MONTHS IS ALLOWED.”
IF AGE SP STOPPED DRINKING FORMULA IN DAYS (DBDFRMLSPD) > SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD), DISPLAY, “NUMBER CANNOT BE MORE THAN SP’S AGE”
IF AGE SP STOPPED DRINKING FORMULA IN DAYS (DBDFRMLSPD) < AGE SP FIRST FED FORMULA (DBDFRMLSRD), DISPLAY “AGE CANNOT BE LESS THAN AGE WHEN SP WAS FIRST FED FORMULA.” |
SOFT CHECK |
IF (DBQFRMLSPU = 2 (WEEKS) AND DBQFRMLSPQ > 24) OR (DBQFRMLSPU = 1 (DAYS) AND DBQFRMLSPQ > 40), DISPLAY, “VERIFY AGE ENTERED. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.”
IF AGE SP STOPPED DRINKING FORMULA IN DAYS (DBDFRMLSPD) = SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD) DISPLAY, “AGE ENTERED IS THE SAME AS SP’S AGE. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
DBQ.050 G/Q/U |
NEXT |
DBQFIRSTG |
DBQFIRSTG / DBQFIRSTQ / DBQFIRSTU |
|
ASK |
IF SP AGE <= 4 YEARS |
This next question is about the first thing that <TEXT FILL 1> was given other than breast milk or formula. Please include juice, cow’s milk, sugar water, baby food, or anything else that <TEXT FILL 1> might have been given, even water.
How old was <TEXT FILL 1> when <TEXT FILL 2> was first fed anything other than breast milk or formula?
INTERVIEWER INSTRUCTION: DO NOT COUNT MEDICATIONS, VITAMIN DROPS, OR SMALL AMOUNT OF WATER THAT WAS USED FOR ORAL HYGIENE PURPOSES.
|___| [DBQFIRSTG] 1. ENTER NUMBER 2. NEVER 7. REFUSED 9. DON’T KNOW
|___|___|___|___| [DBQFIRSTQ] ENTER AGE IN DAYS, WEEKS, MONTHS, OR YEARS
|___| [DBQFIRSTU] ENTER UNIT
1. DAYS 2. WEEKS 3. MONTHS 4. YEARS
|
|
SPANISH |
La siguiente pregunta es acerca de los primeros alimentos que le dieron a <TEXT FILL 1> además de leche materna o fórmula. Incluya jugos, leche de vaca, agua con azúcar, alimentos para bebé o cualquier otro alimento que se le haya dado, incluso agua.
¿Qué edad tenía <TEXT FILL 1> cuando lo(a) alimentaron por primera vez con productos distintos a la leche materna o fórmula infantil?
INTERVIEWER INSTRUCTION: DO NOT COUNT MEDICATIONS, VITAMIN DROPS, OR SMALL AMOUNT OF WATER THAT WAS USED FOR ORAL HYGIENE PURPOSES.
|___| [DBQFIRSTG] 1. ENTER NUMBER 2. NEVER 7. REFUSED 9. DON’T KNOW
|___|___|___|___| [DBQFIRSTQ] ENTER AGE IN DAYS, WEEKS, MONTHS, OR YEARS
|___| [DBQFIRSTU] ENTER UNIT
1. DAYS 2. WEEKS 3. MONTHS 4. YEARS
|
QUESTION TYPE |
Dropdown: DBQFIRST Radio button: DBQFIRSTU Numeric: DBQFIRSTQ |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “he” IF SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “él” IF SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
IF DBQFIRSTU = 2 (WEEKS), 3 (MONTHS), OR 4 (YEARS), CALCULATE AGE SP FIRST FED OTHER IN DAYS (DBDFIRSTD) AS FOLLOWS: IF DBQFIRSTU = 2, CALCULATE AGE SP FIRST FED OTHER AS (DBQFIRSTQ *7) IF DBQFIRSTU = 3, CALCULATE AGE SP FIRST FED OTHER AS (DBQFIRSTQ *31) IF DBQFIRSTU = 4, CALCULATE AGE SP FIRST FED OTHER AS (DBQFIRSTQ *365)
|
HELP SCREEN |
|
HARD CHECK |
IF DBQFIRSTG = 1 AND DBQFIRSTQ = 0, DISPLAY “AGE CANNOT BE ZERO BECAUSE AGE IN DAYS, WEEKS, OR MONTHS IS ALLOWED.” IF SP FIRST FED OTHER IN DAYS (DBDFIRSTD) > SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD), DISPLAY, “NUMBER CANNOT BE MORE THAN SP’S AGE” |
SOFT CHECK |
IF (DBQFIRSTU = 2 (WEEKS) AND DBQFIRSTQ > 24) OR (DBQFIRSTU = 1 (DAYS) AND DBQFIRSTQ > 40), DISPLAY, “VERIFY AGE ENTERED. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” IF SP FIRST FED OTHER IN DAYS (DBDFIRSTD) = SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD), DISPLAY “AGE ENTERED IS THE SAME AS SP’S AGE. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
DBQ.055 G/Q/U |
NEXT |
IF DBQFIRSTG = 1: DBQMILKG ELSE: DBQCARE |
DBQMILKG / DBQMILKQ / DBQMILKU |
|
ASK |
IF DBQFIRSTG = 1 |
How old was <TEXT FILL 1> when <TEXT FILL 2> was first fed milk?
INTERVIEWER INSTRUCTION: INCLUDE LACTAID AS MILK. DO NOT INCLUDE BREAST MILK OR FORMULA
|___| [DBQMILKG] 1. ENTER NUMBER 2. NEVER 7. REFUSED 9. DON’T KNOW
|___|___|___|___| [DBQMILKQ] ENTER AGE IN DAYS, WEEKS, MONTHS, OR YEARS
|___| [DBQMILKU] ENTER UNIT
1. DAYS 2. WEEKS 3. MONTHS 4. YEARS
|
|
SPANISH |
¿Qué edad tenía <TEXT FILL 1> cuando fue alimentado(a) con leche por primera vez?
INTERVIEWER INSTRUCTION: INCLUDE LACTAID AS MILK. DO NOT INCLUDE BREAST MILK OR FORMULA
|___| [DBQMILKG] 1. ENTER NUMBER 2. NEVER 7. REFUSED 9. DON’T KNOW
|___|___|___|___| [DBQMILKQ] ENTER AGE IN DAYS, WEEKS, MONTHS, OR YEARS
|___| [DBQMILKU] ENTER UNIT
1. DAYS 2. WEEKS 3. MONTHS 4. YEARS
|
QUESTION TYPE |
Dropdown: DBQMILKG Radio button: DBQMILKU Numeric: DBQMILKQ |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “he” IF SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “él” IF SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
IF DBQMILKU = 2 (WEEKS), 3 (MONTHS), OR 4 (YEARS), CALCULATE AGE SP FIRST FED MILK IN DAYS (DBDMILKD) AS FOLLOWS: IF DBQMILKU = 2, CALCULATE AGE SP FIRST FED MILK AS (DBQMILKQ *7) IF DBQMILKU = 3, CALCULATE AGE SP FIRST FED MILK AS (DBQMILKQ *31) IF DBQMILKU = 4, CALCULATE AGE SP FIRST FED MILK AS (DBQMILKQ *365)
|
HELP SCREEN |
|
HARD CHECK |
IF DBQMILKG = 1 AND DBQMILKQ = 0, DISPLAY “AGE CANNOT BE ZERO BECAUSE AGE IN DAYS, WEEKS, OR MONTHS IS ALLOWED.” IF AGE SP FIRST FED MILK IN DAYS (DBDMILKD) > SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD), DISPLAY “NUMBER CANNOT BE MORE THAN SP’S AGE” |
SOFT CHECK |
IF (DBQMILKU = 2 (WEEKS) AND DBQMILKQ > 24) OR (DBQMILKU = 1 (DAYS) AND DBQMILKQ > 40), DISPLAY, “VERIFY AGE ENTERED. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” IF AGE SP FIRST FED MILK IN DAYS (DBDMILKD) = SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD), DISPLAY “AGE ENTERED IS THE SAME AS SP’S AGE. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
DBQ.061 G/Q/U |
NEXT |
IF DBQMILKG = 2: DBQ7DAYSGR ELSE: DBQMILKTYP |
DBQMILKTYP |
|
ASK |
IF DBQMILK = 1 OR 7777777 (RF) OR 999999 (DK) |
What type of milk was <TEXT FILL 1> first fed? Was it . . .
[CODE ALL THAT APPLY]
10. whole or regular, 11. 2% fat or reduced-fat milk, 12. 1% fat or low-fat milk (includes 0.5% fat milk or “low-fat milk” not further specified), 13. fat-free, skim, or nonfat milk, 20. plant-based milks such as soy, oat, almond or coconut milk, or 30. another type? 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
¿Con qué tipo de leche se alimentó a <TEXT FILL 1> por primera vez? ¿Fue...
[CODE ALL THAT APPLY]
10. entera o regular, 11. leche con 2% de grasa o leche baja en grasas, 12. leche con 1% de grasa o baja en grasa (incluye leche con 0.5% de grasa o leche baja en grasa sin especificación), 13. descremada, desnatada o sin grasa, 20. vegetal, como la de soya, avena, almendra o coco, u 30. algún otro tipo? 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Select all that apply |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Lactaid: A modified milk product that is often consumed by individuals who have lactose intolerance. Lactaid can be purchased in various forms (i.e., 2%, skim, etc.). If respondent does not give type, probe for type (i.e., was that Lactaid regular, 2%, 1% or skim?). |
HELP SCREEN (SPA) |
Lactaid: Producto lácteo modificado que suelen consumir las personas con intolerancia a la lactosa. Lactaid se puede obtener en varias formas (es decir, reducida en grasa al 2 % o totalmente descremada, etc.). Si la persona encuestada no da un tipo, verifique el tipo (es decir, “¿era Lactaid regular, reducida en grasa al 2 %, reducida en grasa al 1 % o descremada?”). |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.073 |
NEXT |
IF SP AGE 0-11 MONTH AND DBQFIRSTG = 1: DBQSOLIDFQ ELSE: DBQ7DAYSGR |
DBQSOLIDFQ |
|
ASK |
IF SP AGE 0-11 MONTH AND DBQMILK = 1 OR 7777777 (RF) OR 999999 (DK) |
Once <TEXT FILL 1> started eating solid foods, about how often were new foods introduced to <TEXT FILL 2>? Was it about 1 new food…
1. Per week or less often, 2. Every 4 or 5 days, 3. Every 3 days, 4. Every 2 days or more often? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Una vez que <TEXT FILL 1> empezó a comer alimentos sólidos, ¿con qué frecuencia se le daban nuevos alimentos? ¿Se le daba un nuevo alimento...
1. Por semana o con menos frecuencia, 2. Cada 4 o 5 días, 3. Cada 3 días, 4. Cada 2 días o con más frecuencia? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “él” IF SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW4 |
NEXT |
DBQ7DAYSGR |
DBQ7DAYSGR |
|
ASK |
IF DBQFIRSTG = 1 |
We will be asking you how often <TEXT FILL 1> ate different types of foods over the last 7 days. Please use the categories listed on hand card 1 to answer these questions.
In the last 7 days, how many times did <TEXT FILL 1> …
drink sugary drinks such as soda, fruit drinks, sports drinks, or sweet tea? Do not include 100% fruit juice.
[HAND CARD 1]
1. NEVER 2. 1-2 TIMES IN THE LAST 7 DAYS 3. 3-4 TIMES IN THE LAST 7 DAYS 4. 5-6 TIMES IN THE LAST 7 DAYS 5. 1 TIME PER DAY 6. 2-3 TIMES PER DAY 7. 4-5 TIMES PER DAY 8. 6 OR MORE TIMES PER DAY 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
Le preguntaremos con qué frecuencia comió <TEXT FILL 1> diferentes tipos de alimentos en los últimos 7 días. Utilice la lista de categorías en la tarjeta 1 para contestar estas preguntas.
En los últimos 7 días, ¿cuántas veces <TEXT FILL 1>...
tomó bebidas azucaradas como gasesosas, bebidas de frutas, bebidas deportivas o té dulce? No incluya jugo 100 % de fruta.
[HAND CARD 1]
1. NUNCA 2. 1 O 2 VECES EN LOS ÚLTIMOS 7 DÍAS 3. 3 A 4 VECES EN LOS ÚLTIMOS 7 DÍAS 4. 5 A 6 VECES EN LOS ÚLTIMOS 7 DÍAS 5. 1 VEZ AL DÍA 6. 2 A 3 VECES AL DÍA 7. 4 A 5 VECES AL DÍA 8. 6 O MÁS VECES AL DÍA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW5 |
NEXT |
DBQ7DAYVEG |
DBQ7DAYVEG |
|
ASK |
IF DBQFIRSTG = 1 |
In the last 7 days, how many times did <TEXT FILL 1> …
eat vegetables? Include any vegetables that were fresh, frozen, canned, or baby food. Do not include French fries, fried potatoes, or potato chips.
[HAND CARD 1]
1. NEVER 2. 1-2 TIMES IN THE LAST 7 DAYS 3. 3-4 TIMES IN THE LAST 7 DAYS 4. 5-6 TIMES IN THE LAST 7 DAYS 5. 1 TIME PER DAY 6. 2-3 TIMES PER DAY 7. 4-5 TIMES PER DAY 8. 6 OR MORE TIMES PER DAY 77. REFUSED 99. DON’T KNOW |
|
SPANISH |
En los últimos 7 días, ¿cuántas veces <TEXT FILL 1> ...
comió vegetales? Incluya cualquier vegetal fresco, congelado, enlatado o comida para bebés. No incluya papas fritas “french fries” o papas fritas en bolsa.
[HAND CARD 1]
1. NUNCA 2. 1 O 2 VECES EN LOS ÚLTIMOS 7 DÍAS 3. 3 A 4 VECES EN LOS ÚLTIMOS 7 DÍAS 4. 5 A 6 VECES EN LOS ÚLTIMOS 7 DÍAS 5. 1 VEZ AL DÍA 6. 2 A 3 VECES AL DÍA 7. 4 A 5 VECES AL DÍA 8. 6 O MÁS VECES AL DÍA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW6 |
NEXT |
DBQ7DAYFRT |
DBQ7DAYFRT |
|
ASK |
IF DBQFIRSTG = 1 |
(In the last 7 days, how many times did <TEXT FILL 1> …)
eat fruits? Include any fruits that were fresh, frozen, canned, or baby food. Do not include juice.
[HAND CARD 1]
1. NEVER 2. 1-2 TIMES IN THE LAST 7 DAYS 3. 3-4 TIMES IN THE LAST 7 DAYS 4. 5-6 TIMES IN THE LAST 7 DAYS 5. 1 TIME PER DAY 6. 2-3 TIMES PER DAY 7. 4-5 TIMES PER DAY 8. 6 OR MORE TIMES PER DAY 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
(En los últimos 7 días, ¿cuántas veces <TEXT FILL 1>...?).
comió frutas. Incluya cualquier fruta fresca, congelada, enlatada o comida para bebés. No incluya jugos.
[HAND CARD 1]
1. NUNCA 2. 1 O 2 VECES EN LOS ÚLTIMOS 7 DÍAS 3. 3 A 4 VECES EN LOS ÚLTIMOS 7 DÍAS 4. 5 A 6 VECES EN LOS ÚLTIMOS 7 DÍAS 5. 1 VEZ AL DÍA 6. 2 A 3 VECES AL DÍA 7. 4 A 5 VECES AL DÍA 8. 6 O MÁS VECES AL DÍA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW7 |
NEXT |
DBQ7DAYMTP |
DBQ7DAYMTP |
|
ASK |
IF DBQFIRSTG = 1 |
(In the last 7 days, how many times did <TEXT FILL 1> …)
eat meats and poultry such as beef, pork, chicken, or turkey, including the baby food version?
[HAND CARD 1]
1. NEVER 2. 1-2 TIMES IN THE LAST 7 DAYS 3. 3-4 TIMES IN THE LAST 7 DAYS 4. 5-6 TIMES IN THE LAST 7 DAYS 5. 1 TIME PER DAY 6. 2-3 TIMES PER DAY 7. 4-5 TIMES PER DAY 8. 6 OR MORE TIMES PER DAY 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
(En los últimos 7 días, ¿cuántas veces <TEXT FILL 1> ...).
comió carnes y aves, como carne de res, de cerdo, de pollo o pavo, incluido el tipo de estos alimentos para bebés?
[HAND CARD 1]
1. NUNCA 2. 1 O 2 VECES EN LOS ÚLTIMOS 7 DÍAS 3. 3 A 4 VECES EN LOS ÚLTIMOS 7 DÍAS 4. 5 A 6 VECES EN LOS ÚLTIMOS 7 DÍAS 5. 1 VEZ AL DÍA 6. 2 A 3 VECES AL DÍA 7. 4 A 5 VECES AL DÍA 8. 6 O MÁS VECES AL DÍA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW8 |
NEXT |
DBQ7DAYGRN |
DBQ7DAYGRN |
|
ASK |
IF DBQFIRSTG = 1 |
(In the last 7 days, how many times did <TEXT FILL 1> …)
eat baby food grain snacks such as teething biscuits, rusks, cookies, puffs, banana cookie, or rice rusk toast?
[HAND CARD 1]
1. NEVER 2. 1-2 TIMES IN THE LAST 7 DAYS 3. 3-4 TIMES IN THE LAST 7 DAYS 4. 5-6 TIMES IN THE LAST 7 DAYS 5. 1 TIME PER DAY 6. 2-3 TIMES PER DAY 7. 4-5 TIMES PER DAY 8. 6 OR MORE TIMES PER DAY 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
(En los últimos 7 días, ¿cuántas veces <TEXT FILL 1>...).
comió refrigerios/aperitivos o “snacks” de granos para bebés, como galletas para la dentadura, panecillos tostados, galletitas, hojaldres, galletas de plátano o bizcocho tostado de arroz?
[HAND CARD 1]
1. NUNCA 2. 1 O 2 VECES EN LOS ÚLTIMOS 7 DÍAS 3. 3 A 4 VECES EN LOS ÚLTIMOS 7 DÍAS 4. 5 A 6 VECES EN LOS ÚLTIMOS 7 DÍAS 5. 1 VEZ AL DÍA 6. 2 A 3 VECES AL DÍA 7. 4 A 5 VECES AL DÍA 8. 6 O MÁS VECES AL DÍA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW9 |
NEXT |
DBQ7DAYRIC |
DBQ7DAYRIC |
|
ASK |
IF DBQFIRSTG = 1 |
(In the last 7 days, how many times did <TEXT FILL 1> …)
eat fortified infant rice cereal?
[HAND CARD 1]
1. NEVER 2. 1-2 TIMES IN THE LAST 7 DAYS 3. 3-4 TIMES IN THE LAST 7 DAYS 4. 5-6 TIMES IN THE LAST 7 DAYS 5. 1 TIME PER DAY 6. 2-3 TIMES PER DAY 7. 4-5 TIMES PER DAY 8. 6 OR MORE TIMES PER DAY 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
(En los últimos 7 días, ¿cuántas veces <TEXT FILL 1>...)
comió cereal de arroz fortificado para bebés?
[HAND CARD 1]
1. NUNCA 2. 1 O 2 VECES EN LOS ÚLTIMOS 7 DÍAS 3. 3 A 4 VECES EN LOS ÚLTIMOS 7 DÍAS 4. 5 A 6 VECES EN LOS ÚLTIMOS 7 DÍAS 5. 1 VEZ AL DÍA 6. 2 A 3 VECES AL DÍA 7. 4 A 5 VECES AL DÍA 8. 6 O MÁS VECES AL DÍA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW10 |
NEXT |
DBQ7DAYCRL |
DBQ7DAYCRL |
|
ASK |
IF DBQFIRSTG = 1 |
(In the last 7 days, how many times did <TEXT FILL 1> …)
eat other infant cereal such as oat, barley, or multigrain?
[HAND CARD 1]
1. NEVER 2. 1-2 TIMES IN THE LAST 7 DAYS 3. 3-4 TIMES IN THE LAST 7 DAYS 4. 5-6 TIMES IN THE LAST 7 DAYS 5. 1 TIME PER DAY 6. 2-3 TIMES PER DAY 7. 4-5 TIMES PER DAY 8. 6 OR MORE TIMES PER DAY 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
(En los últimos 7 días, ¿cuántas veces <TEXT FILL 1>...)
comió otros cereales para bebés como avena, cebada o multigranos?
[HAND CARD 1]
1. NUNCA 2. 1 O 2 VECES EN LOS ÚLTIMOS 7 DÍAS 3. 3 A 4 VECES EN LOS ÚLTIMOS 7 DÍAS 4. 5 A 6 VECES EN LOS ÚLTIMOS 7 DÍAS 5. 1 VEZ AL DÍA 6. 2 A 3 VECES AL DÍA 7. 4 A 5 VECES AL DÍA 8. 6 O MÁS VECES AL DÍA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW11 |
NEXT |
DBQ7DAYAPL |
DBQ7DAYAPL |
|
ASK |
IF DBQFIRSTG = 1 |
(In the last 7 days, how many times did <TEXT FILL 1> …)
drink apple juice, including the baby food version?
[HAND CARD 1]
1. NEVER 2. 1-2 TIMES IN THE LAST 7 DAYS 3. 3-4 TIMES IN THE LAST 7 DAYS 4. 5-6 TIMES IN THE LAST 7 DAYS 5. 1 TIME PER DAY 6. 2-3 TIMES PER DAY 7. 4-5 TIMES PER DAY 8. 6 OR MORE TIMES PER DAY 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
(En los últimos 7 días, ¿cuántas veces <TEXT FILL 1>...)
tomó jugo de manzana, incluido el tipo de este jugo para bebés?
[HAND CARD 1]
1. NUNCA 2. 1 O 2 VECES EN LOS ÚLTIMOS 7 DÍAS 3. 3 A 4 VECES EN LOS ÚLTIMOS 7 DÍAS 4. 5 A 6 VECES EN LOS ÚLTIMOS 7 DÍAS 5. 1 VEZ AL DÍA 6. 2 A 3 VECES AL DÍA 7. 4 A 5 VECES AL DÍA 8. 6 O MÁS VECES AL DÍA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW12 |
NEXT |
DBQ7DAYGRP |
DBQ7DAYGRP |
|
ASK |
IF DBQFIRSTG = 1 |
(In the last 7 days, how many times did <TEXT FILL 1> …)
drink grape juice, including the baby food version?
[HAND CARD 1]
1. NEVER 2. 1-2 TIMES IN THE LAST 7 DAYS 3. 3-4 TIMES IN THE LAST 7 DAYS 4. 5-6 TIMES IN THE LAST 7 DAYS 5. 1 TIME PER DAY 6. 2-3 TIMES PER DAY 7. 4-5 TIMES PER DAY 8. 6 OR MORE TIMES PER DAY 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
(En los últimos 7 días, ¿cuántas veces <TEXT FILL 1>...)
tomó jugo de uva, incluido el tipo de este jugo para bebés?
[HAND CARD 1]
1. NUNCA 2. 1 O 2 VECES EN LOS ÚLTIMOS 7 DÍAS 3. 3 A 4 VECES EN LOS ÚLTIMOS 7 DÍAS 4. 5 A 6 VECES EN LOS ÚLTIMOS 7 DÍAS 5. 1 VEZ AL DÍA 6. 2 A 3 VECES AL DÍA 7. 4 A 5 VECES AL DÍA 8. 6 O MÁS VECES AL DÍA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW13 |
NEXT |
DBQ7DAYAVO |
DBQ7DAYAVO |
|
ASK |
IF DBQFIRSTG = 1 |
(In the last 7 days, how many times did <TEXT FILL 1> …)
eat avocado, including the baby food version?
[HAND CARD 1]
1. NEVER 2. 1-2 TIMES IN THE LAST 7 DAYS 3. 3-4 TIMES IN THE LAST 7 DAYS 4. 5-6 TIMES IN THE LAST 7 DAYS 5. 1 TIME PER DAY 6. 2-3 TIMES PER DAY 7. 4-5 TIMES PER DAY 8. 6 OR MORE TIMES PER DAY 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
(En los últimos 7 días, ¿cuántas veces <TEXT FILL 1>...
comió aguacate, incluido el tipo de este alimento para bebés?
[HAND CARD 1]
1. NUNCA 2. 1 O 2 VECES EN LOS ÚLTIMOS 7 DÍAS 3. 3 A 4 VECES EN LOS ÚLTIMOS 7 DÍAS 4. 5 A 6 VECES EN LOS ÚLTIMOS 7 DÍAS 5. 1 VEZ AL DÍA 6. 2 A 3 VECES AL DÍA 7. 4 A 5 VECES AL DÍA 8. 6 O MÁS VECES AL DÍA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW14 |
NEXT |
DBQ7DAYSPN |
DBQ7DAYSPN |
|
ASK |
IF DBQFIRSTG = 1 |
(In the last 7 days, how many times did <TEXT FILL 1> …)
eat spinach, including the baby food version?
[HAND CARD 1]
1. NEVER 2. 1-2 TIMES IN THE LAST 7 DAYS 3. 3-4 TIMES IN THE LAST 7 DAYS 4. 5-6 TIMES IN THE LAST 7 DAYS 5. 1 TIME PER DAY 6. 2-3 TIMES PER DAY 7. 4-5 TIMES PER DAY 8. 6 OR MORE TIMES PER DAY 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
(En los últimos 7 días, ¿cuántas veces <TEXT FILL 1> ...)
comió espinaca, incluido el tipo de este alimento para bebés?
[HAND CARD 1]
1. NUNCA 2. 1 O 2 VECES EN LOS ÚLTIMOS 7 DÍAS 3. 3 A 4 VECES EN LOS ÚLTIMOS 7 DÍAS 4. 5 A 6 VECES EN LOS ÚLTIMOS 7 DÍAS 5. 1 VEZ AL DÍA 6. 2 A 3 VECES AL DÍA 7. 4 A 5 VECES AL DÍA 8. 6 O MÁS VECES AL DÍA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW15 |
NEXT |
DBQ7DAYCAR |
DBQ7DAYCAR |
|
ASK |
IF DBQFIRSTG = 1 |
(In the last 7 days, how many times did <TEXT FILL 1> …)
eat carrots, including the baby food version?
[HAND CARD 1]
1. NEVER 2. 1-2 TIMES IN THE LAST 7 DAYS 3. 3-4 TIMES IN THE LAST 7 DAYS 4. 5-6 TIMES IN THE LAST 7 DAYS 5. 1 TIME PER DAY 6. 2-3 TIMES PER DAY 7. 4-5 TIMES PER DAY 8. 6 OR MORE TIMES PER DAY 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
(En los últimos 7 días, ¿cuántas veces <TEXT FILL 1> ...)
comió zanahorias, incluido el tipo de este alimento para bebés?
[HAND CARD 1]
1. NUNCA 2. 1 O 2 VECES EN LOS ÚLTIMOS 7 DÍAS 3. 3 A 4 VECES EN LOS ÚLTIMOS 7 DÍAS 4. 5 A 6 VECES EN LOS ÚLTIMOS 7 DÍAS 5. 1 VEZ AL DÍA 6. 2 A 3 VECES AL DÍA 7. 4 A 5 VECES AL DÍA 8. 6 O MÁS VECES AL DÍA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW16 |
NEXT |
IF DBQ7DAYCAR = 2 - 8 AND SP AGE 0-11 MONTHS: DBQCARROTS ELSE: DBQ7DAYSWP |
DBQCARROTS |
|
ASK |
IF DBQ7DAYCAR = 2 - 8 AND SP AGE 0-11 MONTHS |
Were the carrots a commercially prepared baby food or made from ingredients at a home?
1. COMMERCIALLY PREPARED BABY FOOD 2. MADE AT HOME 3. BOTH 4. NEITHER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Eran las zanahorias una comida para bebés preparada comercialmente estaba hecha con ingredientes caseros?
1. COMIDA PARA BEBÉS PREPARADA COMERCIALMENTE 2. HECHA CON INGREDIENTES CASEROS 3. AMBOS 4. NINGUNO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW18 |
NEXT |
DBQ7DAYSWP |
DBQ7DAYSWP |
|
ASK |
IF DBQFIRSTG = 1 |
(In the last 7 days, how many times did <TEXT FILL 1> …)
eat sweet potatoes, including the baby food version?
[HAND CARD 1]
1. NEVER 2. 1-2 TIMES IN THE LAST 7 DAYS 3. 3-4 TIMES IN THE LAST 7 DAYS 4. 5-6 TIMES IN THE LAST 7 DAYS 5. 1 TIME PER DAY 6. 2-3 TIMES PER DAY 7. 4-5 TIMES PER DAY 8. 6 OR MORE TIMES PER DAY 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
(En los últimos 7 días, ¿cuántas veces <TEXT FILL 1> ...)
comió camotes/batatas, incluido el tipo de este alimento para bebés?
[HAND CARD 1]
1. NUNCA 2. 1 O 2 VECES EN LOS ÚLTIMOS 7 DÍAS 3. 3 A 4 VECES EN LOS ÚLTIMOS 7 DÍAS 4. 5 A 6 VECES EN LOS ÚLTIMOS 7 DÍAS 5. 1 VEZ AL DÍA 6. 2 A 3 VECES AL DÍA 7. 4 A 5 VECES AL DÍA 8. 6 O MÁS VECES AL DÍA 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW19 |
NEXT |
IF DBQ7DAYSWP = 2 - 8 AND SP AGE 0-11 MONTHS: DBQSWPOTAT ELSE: DBQCARE |
DBQSWPOTAT |
|
ASK |
IF DBQ7DAYSWP = 2 - 8 AND SP AGE 0-11 MONTHS |
Were the sweet potatoes a commercially prepared baby food or made from ingredients at a home?
1. COMMERCIALLY PREPARED BABY FOOD 2. MADE AT HOME 3. BOTH 4. NEITHER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Eran los camotes/batatas una comida para bebés preparada comercialmente o estaba hecha con ingredientes caseros?
1. COMIDA PARA BEBÉS PREPARADA COMERCIALMENTE 2. HECHA CON INGREDIENTES CASEROS 3. AMBOS 4. NINGUNO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW21 |
NEXT |
DBQCARE |
DBQCARE |
|
ASK |
IF SP AGE 0-11 MONTHS OR 1-4 YEARS |
On a typical week how many hours does <TEXT FILL 1> receive care outside the home?
1. NONE 2. 1 TO LESS THAN 5 HOURS 3. 5 TO LESS THAN 10 HOURS 4. 10 TO LESS THAN 20 HOURS 5. 20 TO LESS THAN 30 HOURS 6. 30 HOURS OR MORE 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En una semana típica, ¿cuántas horas recibe <TEXT FILL 1> cuidados fuera del hogar?
1. NINGUNA 2. DE 1 A MENOS DE 5 HORAS 3. DE 5 A MENOS DE 10 HORAS 4. DE 10 A MENOS DE 20 HORAS 5. DE 20 A MENOS DE 30 HORAS 6. 30 HORAS O MÁS 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW22 |
NEXT |
IF DBQCARE = 1: DBQWICEVER ELSE, DBQCARETYP |
DBQCARETYP |
|
ASK |
IF DBQCARE != 1 |
What type of care does <TEXT FILL 1> receive most often? Is it a…
1. Childcare or daycare center, 2. Preschool, 3. Head Start or early Head Start program, 4. Family childcare home, 5. Neighbor, 6. Nanny or Au pair or babysitter, or 7. Relative? 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
¿Qué tipo de cuidados recibe <TEXT FILL 1> con más frecuencia? ¿Es...
1. Guardería o centro de cuidado diario, 2. Preescolar, 3. Programa Head Start o Early Head Start, 4. Hogar de cuidado infantil familiar, 5. Vecino(a), 6. Nana o au pair o niñero(a), o 7. Familiares? 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.NEW23 |
NEXT |
DBQWICEVER |
DBQATTEND |
|
ASK |
IF SP AGE 5-17 YEARS |
In the school year, does <TEXT FILL 1> attend kindergarten through 12th grade at a school?
INTERVIEWER INSTRUCTION: ENTER ‘NO’ IF THE SP IS HOME SCHOOLED.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Durante el año escolar, ¿asiste <TEXT FILL 1> a la escuela de kindergarten/jardín de la infancia, escuela elemental, escuela intermedia o escuela superior/secundaria/preparatoria o high school?
INTERVIEWER INSTRUCTION: ENTER ‘NO’ IF THE SP IS HOME SCHOOLED.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.360N |
NEXT |
IF DBQATTEND = 1: DBQLUNCH ELSE: DBQFREERP |
DBQLUNCH |
|
ASK |
IF DBQATTEND=1 |
Does <TEXT FILL 1> school serve school lunches? These are complete lunches that cost the same every day.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Sirve la escuela de <TEXT FILL 1> comidas escolares al mediodía? Estas son comidas completas que cuestan lo mismo todos los días.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME] |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.370 |
NEXT |
IF DBQLUNCH = 1: DBQLUNCHFG ELSE: DBQBRKFT |
DBQLUNCHFG / DBQLUNCHFQ |
|
ASK |
IF DBQLUNCH = 1 |
During the school year, about how many times a week does <TEXT FILL 1> usually get a complete school lunch?
|___| [DBQLUNCHFG] 1. ENTER NUMBER 2. NONE 7. REFUSED 9. DON’T KNOW
|___| [DBQLUNCHFQ] ENTER NUMBER OF TIMES
|
|
SPANISH |
Durante el año escolar, ¿más o menos cuántas veces a la semana recibe usualmente <TEXT FILL 1> una comida escolar completa?
|___| [DBQLUNCHFG] 1. ENTER NUMBER 2. NONE 7. REFUSED 9. DON’T KNOW
|___| [DBQLUNCHFQ] ENTER NUMBER OF TIMES
|
QUESTION TYPE |
Dropdown: DBQLUNCHFG Numeric: DBQLUNCHFQ |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF DBQLUNCHFQ <1 OR >5 DISPLAY, “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 1 AND 5.” |
SOFT CHECK |
|
VERSION NOTES |
DBQ.381 G/Q |
NEXT |
IF DBQLUNCHFG = 1: DBQLUNCHPY ELSE: DBQBRKFT |
DBQLUNCHPY |
|
ASK |
IF DBQLUNCHFG = 1 |
Does <TEXT FILL 1> get these lunches free, at a reduced price, or does <TEXT FILL 2> pay full price?
1. FREE 2. REDUCED PRICE 3. FULL PRICE 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Recibe <TEXT FILL 1> estas comidas gratis, a precio reducido o paga el precio completo?
1. GRATIS 2. PRECIO REDUCIDO 3. PRECIO COMPLETO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “he” IF SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “él” IF SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.390 |
NEXT |
DBQBRKFT |
DBQBRKFT |
|
ASK |
IF DBQATTEND = 1 |
Does <TEXT FILL 1> school serve a complete breakfast that costs the same every day?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Sirve la escuela de <TEXT FILL 1> desayunos completos que cuestan lo mismo todos los días?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]’s” |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.400 |
NEXT |
IF DBQBRKFT = 1: DBQBRKFTFG IF (DBQBRKFT = 2 OR 7 OR 9) AND (DBQLUNCHPY = 1 OR 2): DBQFREERP IF (DBQBRKFT = 2 OR 7 OR 9) AND (DBQLUNCHPY = 3 OR 7 OR 9): END OF SECTION |
DBQBRKFTFG / DBQBRKFTFQ |
|
ASK |
IF DBQBRKFT = 1 |
In the school year, about how many times a week does <TEXT FILL 1> usually get a complete breakfast at school?
|___| [DBQBRKFTFG] 1. ENTER NUMBER 2. NONE 7. REFUSED 9. DON’T KNOW
|___| [DBQBRKFTFQ] ENTER NUMBER OF TIMES
|
|
SPANISH |
Durante el año escolar, ¿más o menos cuántas veces a la semana suele usualmente <TEXT FILL 1> un desayuno escolar completo?
|___| [DBQBRKFTFG] 1. ENTER NUMBER 2. NONE 7. REFUSED 9. DON’T KNOW
|___| [DBQBRKFTFQ] ENTER NUMBER OF TIMES
|
QUESTION TYPE |
Dropdown: DBQBRKFTFG Numeric: DBQBRKFTFQ |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IFDBQBRKFTFQ <1 OR >5, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 1 AND 5.” |
SOFT CHECK |
|
VERSION NOTES |
DBQ.411 G/Q |
NEXT |
IF DBQBRKFTFG = 1: DBQBRKFTPY IF (DBQBRKFTFG = 2 OR 7 OR 9) AND (DBQLUNCHPY = 1 OR 2): DBQFREERP IF (DBQBRKFTFG = 2 OR 7 OR 9) AND (DBQLUNCHPY = 3 OR 7 OR 9): END OF SECTION |
DBQBRKFTPY |
|
ASK |
IF DBQBRKFTFG = 1 |
Does <TEXT FILL 1> get these breakfasts free, at a reduced price, or does <TEXT FILL 2> pay full price?
1. FREE 2. REDUCED PRICE 3. FULL PRICE 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Recibe <TEXT FILL 1> estos desayunos gratis, a precio reducido o paga el precio completo?
1. GRATIS 2. PRECIO REDUCIDO 3. PRECIO COMPLETO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “he” IF SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “él” IF SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.421 |
NEXT |
IF (DBQLUNCHPY = 1 OR 2) OR (DBQBRKFTPY = 1 OR 2): DBQFREERP ELSE: END OF SECTION |
DBQFREERP |
|
ASK |
IF DBQATTEND = 2 OR 7 OR 9 IF (DBQLUNCHPY = 1 OR 2) OR (DBQBRKFTPY = 1 OR 2) |
Does <TEXT FILL 1> get a free or reduced price meal at any summer program <TEXT FILL 2> attends?
1. YES 2. NO 3. DID NOT ATTEND SUMMER PROGRAM 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Recibe <TEXT FILL 1> comidas gratis o a precio reducido en algún programa de verano al que asiste?
1. YES 2. NO 3. DID NOT ATTEND SUMMER PROGRAM 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “he” IF SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “él” IF SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.424N |
NEXT |
END OF SECTION |
DBQWICEVER |
|
ASK |
IF SP AGE 0-11 MONTHS OR 1-4 YEARS |
Next are a few questions about the WIC program.
Has <TEXT FILL 1> ever received benefits from WIC, that is, the Women, Infants, and Children program?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
A continuación, algunas preguntas sobre el programa WIC.
¿Ha recibido <TEXT FILL 1> alguna vez beneficios del programa WIC, es decir, del Programa para Mujeres, Infantes y Niños?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
WIC: WIC is short for the Special Supplemental Nutrition Program for Women, Infants, and Children. This program provides food assistance and nutritional screening to low-income pregnant and postpartum women and their infants, as well as to low-income children up to age 5. |
HELP SCREEN (SPA) |
WIC: WIC es la abreviatura para referirse al Programa Especial de Nutrición Suplementaria para Mujeres, Infantes y Niños). Este programa ofrece ayuda alimenticia y evaluaciones nutricionales a mujeres de bajos ingresos durante el embarazo y, después del parto, también a sus recién nacidos, así como a niños de bajos ingresos, hasta los 5 años. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FSQ.653 |
NEXT |
IF DBQWICEVER = 1: DBQWICNOW ELSE: DBQWICMOM |
DBQWICNOW |
|
ASK |
IF DBQWICEVER = 1 |
Is <TEXT FILL 1> now receiving benefits from the WIC program?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Está <TEXT FILL 1> recibiendo ahora beneficios del programa WIC?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FSQ.673 |
NEXT |
DBQWICFSTQ |
DBQWICFSTQ / DBQWICFSTU |
|
ASK |
IF DBQWICEVER = 1 |
At what age did <TEXT FILL 1> first receive benefits from the WIC program?
|___|___| [DBQWICFSTQ] ENTER NUMBER (OF MONTHS OR YEARS)
777. REFUSED 999. DON’T KNOW
|___| [DBQWICFSTU] ENTER UNIT
1. MONTHS 2. YEARS
|
|
SPANISH |
¿A qué edad recibió <TEXT FILL 1> por primera vez beneficios del programa WIC?
|___|___| [DBQWICFSTQ] ENTER NUMBER (OF MONTHS OR YEARS)
777. REFUSED 999. DON’T KNOW
|___| [DBQWICFSTU] ENTER UNIT
1. MONTHS 2. YEARS
|
QUESTION TYPE |
Numeric: DBQWICFSTQ Dropdown: DBQWICFSTU |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
IF DBQWICFSTU = 1 (MONTHS) OR 2 (YEARS), CALCULATE AGE SP FIRST RECEIVED WIC BENEFITS IN DAYS (DBDWICFST) AS FOLLOWS: IF DBQWICFSTU = 1, CALCULATE AGE SP FIRST RECEIVED WIC BENEFITS AS (DBQWICFSTQ*31) IF DBQWICFSTU = 2, CALCULATE AGE SP FIRST RECEIVED WIC BENEFITS AS (DBQWICFSTQ *365)
|
HELP SCREEN |
|
HARD CHECK |
IF DBQWICFSTU=1 (MONTHS) AND DBQWICFSTQ NOT 1-120 DISPLAY, “AGE IN YEARS MUST BE BETWEEN 1-120.”
IF DBQWICFSTU=2 (YEARS) AND DBQWICFSTQ NOT 0-11 DISPLAY, “AGE IN MONTHS MUST BE BETWEEN 0-11.”
IF AGE SP FIRST RECEIVED WIC BENEFITS IN DAYS (DBDWICFST) > SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD), DISPLAY “NUMBER CANNOT BE MORE THAN SP’S AGE” |
SOFT CHECK |
IF AGE SP FIRST RECEIVED WIC BENEFITS IN DAYS (DBDWICFST) = SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD), DISPLAY “AGE ENTERED IS THE SAME AS SP’S AGE. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
FSQ.NEW1 |
NEXT |
IF DBQWICNOW = 2 OR 7 OR 9: DBQWICLSTQ ELSE: DBQWICMOM |
DBQWICLSTQ / DBQWICLSTU |
|
ASK |
IF DBQWICNOW = 2 OR 7 OR 9 |
At what age did <TEXT FILL 1> last receive benefits from the WIC program?
|___|___| [DBQWICLSTQ] ENTER NUMBER (OF MONTHS OR YEARS)
777. REFUSED 999. DON’T KNOW
|___| [DBQWICLSTU] ENTER UNIT
1. MONTHS 2. YEARS |
|
SPANISH |
¿A qué edad recibió <TEXT FILL 1> por última vez beneficios del programa WIC?
|___|___| [DBQWICLSTQ] ENTER NUMBER (OF MONTHS OR YEARS)
777. REFUSED 999. DON’T KNOW
|___| [DBQWICLSTU] ENTER UNIT
1. MONTHS 2. YEARS |
QUESTION TYPE |
Numeric: DBQWICLSTQ Dropdown: DBQWICLSTU |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
IF DBQWICLSTU = 1 (MONTHS) OR 2 (YEARS), CALCULATE AGE SP LAST RECEIVED WIC BENEFITS IN DAYS AS FOLLOWS: IF DBQWICLSTU = 1, CALCULATE AGE SP LAST RECEIVED WIC BENEFITS AS (DBQWICLSTQ*31) IF DBQWICLSTU = 2, CALCULATE AGE SP LAST RECEIVED WIC BENEFITS AS (DBQWICLSTQ *365)
|
HELP SCREEN |
|
HARD CHECK |
IF AGE SP PAST RECEIVED WIC BENEFITS IN DAYS > SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD), DISPLAY “NUMBER CANNOT BE MORE THAN SP’S AGE” |
SOFT CHECK |
IF AGE SP PAST RECEIVED WIC BENEFITS IN DAYS = SP AGE IN DAYS (SPDSPAGED OR SPDSPAGEQD), DISPLAY “AGE ENTERED IS THE SAME AS SP’S AGE. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
FSQ.NEW2 |
NEXT |
DBQWICMOM |
DBQWICMOM |
|
ASK |
IF SP AGE 0-11 MONTHS OR 1-4 YEARS |
Did <TEXT FILL 1> mother receive benefits from WIC, while she was pregnant with <TEXT FILL 2>?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Recibió beneficios de WIC la madre de <TEXT FILL 1> mientras estaba embarazada de <TEXT FILL 2>?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]’s”
TEXT FILL 2: FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
FSQ.690 |
NEXT |
IF DBQWICMOM = 1: DBQWICPRGN ELSE: END OF SECTION |
DBQWICPRGN |
|
ASK |
IF DBQWICMOM = 1 |
How many months pregnant was <TEXT FILL 1> mother when she began to receive WIC benefits?
|___|___| ENTER NUMBER OF MONTHS
777. REFUSED 999. DON’T KNOW
|
|
SPANISH |
¿Cuántos meses de embarazo tenía la madre de <TEXT FILL 1> cuando comenzó a recibir los beneficios de WIC?
|___|___| ENTER NUMBER OF MONTHS
777. REFUSED 999. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF DBQWICPRGN > 10, DISPLAY “PLEASE ENTER A NUMBER BETWEEN 0-10.” |
SOFT CHECK |
|
VERSION NOTES |
FSQ.695 |
NEXT |
END OF SECTION |
DBQMYPLT |
|
ASK |
IF SP AGE > 17 YEARS |
Next I’m going to ask a few questions about the nutritional guidelines recommended for Americans by the federal government. <TEXT FILL 1> heard of My Plate?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Ahora le haré algunas preguntas sobre las reglas nutricionales recomendadas por el gobierno federal para las personas en Estados Unidos. ¿Ha oído <TEXT FILL 1> hablar de MiPlato (MyPlate)?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “ [SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
CBQ.596 |
NEXT |
IF DBQMYPLT = 1: DBQMYPLTUS ELSE: DBQPLANMST |
DBQMYPLTUS |
|
ASK |
IF DBQMYPLT = 1 |
<TEXT FILL 1> used My Plate materials or tools?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ha usado <TEXT FILL 1> los materiales o los métodos de MiPlato?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
CBQ.New1 |
NEXT |
DBQMYPLTFW |
DBQMYPLTFW |
|
ASK |
IF DBQMYPLT = 1 |
<TEXT FILL 1> tried to follow My Plate advice on healthy food and beverage selections?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ha tratado <TEXT FILL 1> intentó seguir los consejos de MiPlato sobre la selección de alimentos y bebidas saludables?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
CBQ.New2 |
NEXT |
DBQPLANMST |
DBQPLANMST |
|
ASK |
IF SP AGE > 17 YEARS |
<TEXT FILL 1> the person who does most of the planning or preparing of meals<TEXT FILL 2>?
INTERVIEWER INSTRUCTION: IF SP ANSWERS “SOMETIMES” OR “50/50”, ENTER YES.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Es <TEXT FILL 1> la persona que hace la mayor parte de la planificación o preparación de las comidas <TEXT FILL 2>?
INTERVIEWER INSTRUCTION: IF SP ANSWERS “SOMETIMES” OR “50/50”, ENTER YES.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Are you” IF SP IS SELECTED AS THE RESPONDENT IN SPQSELECTR ELSE, FILL “Is [SP NAME]”
TEXT FILL 2: FILL “ in your family” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS SELECTED AS THE RESPONDENT IN SPQSELECTR FILL “ in his family” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS NOT SELECTED AS THE RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ in her family” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS NOT SELECTED AS THE RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “ in [SP NAME]’s family” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS NOT SELECTED AS THE RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER LEAVE BLANK IF THERE IS ONLY ONE PERSON IN THE FAMILY |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS THE RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “ en su familia” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS SELECTED AS THE RESPONDENT IN SPQSELECTR FILL “ en su familia” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS NOT SELECTED AS THE RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ en su familia” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS NOT SELECTED AS THE RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “ en la familia de [SP NAME]” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS NOT SELECTED AS THE RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER LEAVE BLANK IF THERE IS ONLY ONE PERSON IN THE FAMILY |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.930 |
NEXT |
DBQPLANSHR |
DBQPLANSHR |
|
ASK |
IF SP AGE > 17 YEARS |
<TEXT FILL 1> share in the planning or preparing of meals with someone else?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Comparte <TEXT FILL 1> la planificación o preparación de las comidas con otra persona?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS THE RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS THE RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.935 |
NEXT |
DBQSHOPMST |
DBQSHOPMST |
|
ASK |
IF SP AGE > 17 YEARS |
<TEXT FILL 1> the person who does most of the shopping for food<TEXT FILL 2>?
INTERVIEWER INSTRUCTION: IF SP ANSWERS “SOMETIMES” OR “50/50”, ENTER YES.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Es <TEXT FILL 1> la persona que hace la mayor parte de la compra de alimentos <TEXT FILL 2>?
INTERVIEWER INSTRUCTION: IF SP ANSWERS “SOMETIMES” OR “50/50”, ENTER YES.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Are you” IF SP IS SELECTED AS THE RESPONDENT IN SPQSELECTR ELSE, FILL “Is [SP NAME]”
TEXT FILL 2: FILL “ in your family” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS SELECTED AS THE RESPONDENT IN SPQSELECTR FILL “ in his family” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS NOT SELECTED AS THE RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ in her family” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS NOT SELECTED AS THE RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “ in [SP NAME]’s family” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS NOT SELECTED AS THE RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER LEAVE BLANK IF THERE IS ONLY ONE PERSON IN THE FAMILY |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS THE RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “ en su familia” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS SELECTED AS THE RESPONDENT IN SPQSELECTR FILL “ en su familia” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS NOT SELECTED AS THE RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ en su familia” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS NOT SELECTED AS THE RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “ en la familia de [SP NAME]” IF THERE IS MORE THAN ONE PERSON IN THE FAMILY AND SP IS NOT SELECTED AS THE RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER LEAVE BLANK IF THERE IS ONLY ONE PERSON IN THE FAMILY |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.940 |
NEXT |
DBQSHOPSHR |
DBQSHOPSHR |
|
ASK |
IF SP AGE > 17 YEARS |
<TEXT FILL 1> share in the shopping for food with someone else?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Comparte <TEXT FILL 1> la compra de alimentos con otra persona?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS THE RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS THE RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.945 |
NEXT |
IF SP AGE > 44 YEARS: DBQMILKCRL ELSE: END OF SECTION |
DBQMILKCRL |
|
ASK |
IF SP AGE > 44 YEARS |
In the last 30 days, how often did <TEXT FILL 1> have milk to drink or on <TEXT FILL 2> cereal? Please include chocolate and other flavored milks and plant-based milks. Do not count small amounts of milk added to coffee or tea. Would you say . . .
HAND CARD DBQ4
INTERVIEWER INSTRUCTION: INCLUDE ALL TYPES OF MILK (FOR EXAMPLE, LACTAID AND OTHER LACTOSE-FREE MILKS; SOY MILK, ALMOND MILK, RICE MILK, COCONUT MILK, OAT MILK; EVAPORATED MILK, HOT COCOA MADE WITH MILK, ETC.) DO NOT INCLUDE MILK USED IN COOKING.
0. never, 1. rarely – less than once a week, 2. sometimes – once a week or more, but less than once a day, or 3. often – once a day or more? 4. VARIED 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 30 días, ¿con qué frecuencia tomó <TEXT FILL 1> leche o la combinó con sus cereales? Incluya leche de chocolate y otras leches saborizadas y leches a base de plantas. No cuente cantidades pequeñas de leche que se agregan al té o café. ¿Diría que...
HAND CARD DBQ4
INTERVIEWER INSTRUCTION: INCLUDE ALL TYPES OF MILK (FOR EXAMPLE, LACTAID AND OTHER LACTOSE-FREE MILKS; SOY MILK, ALMOND MILK, RICE MILK, COCONUT MILK, OAT MILK; EVAPORATED MILK, HOT COCOA MADE WITH MILK, ETC.) DO NOT INCLUDE MILK USED IN COOKING.
0. nunca, 1. rara vez, menos de una vez a la semana, 2. a veces, una vez a la semana o más, pero menos de una vez al día, o 3. con frecuencia, una vez al día o más? 4. VARIED 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DBQ.197N |
NEXT |
END OF SECTION |
WEIGHT HISTORY – WHQ
Target Group: SPs 18+
WHQHEIGHT / WHQHEIGHTF / WHQHEIGHTI / WHQHEIGHTC |
|
ASK |
IF SP AGE >= 18 YEARS |
These next questions ask about <TEXT FILL 1> height and weight. How tall <TEXT FILL 2> without shoes?
|___| [WHQHEIGHT] 1. ENTER HEIGHT IN FEET AND INCHES 2. ENTER HEIGHT IN CENTIMETERS 7. REFUSED 9. DON’T KNOW
|___|___| [WHQHEIGHTF] ENTER NUMBER OF FEET
AND
|___|___| [WHQHEIGHTI] ENTER NUMBER OF INCHES
OR
|___|___| [WHQHEIGHTC] ENTER NUMBER OF CENTIMETERS
|
|
SPANISH |
Estas siguientes preguntas son acerca de <TEXT FILL 1>. ¿Cuánto mide <TEXT FILL 2> sin zapatos?
|___| [WHQHEIGHT] 1. ENTER HEIGHT IN FEET AND INCHES 2. ENTER HEIGHT IN CENTIMETERS 7. REFUSED 9. DON’T KNOW
|___|___| [WHQHEIGHTF] ENTER NUMBER OF FEET
AND
|___|___| [WHQHEIGHTI] ENTER NUMBER OF INCHES
OR
|___|___| [WHQHEIGHTC] ENTER NUMBER OF CENTIMETERS
|
QUESTION TYPE |
Dropdown: WHQHEIGHT Numeric: WHQHEIGHTF, WHQHEIGHTI, WHQHEIGHTC |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “is [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “su estatura y su peso” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “la estatura y el peso de [SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF WHQHEIGHTF <2 OR >8, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 2 AND 8.” IF WHQHEIGHTI >11, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 11.” IF WHQHEIGHTC <61 OR >272, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 61 AND 272.” |
SOFT CHECK |
|
VERSION NOTES |
WHQ.010 F/I/C |
NEXT |
WHQWEIGHT |
WHQWEIGHT / WHQWEIGHTL / WHQWEIGHTK |
|
ASK |
IF SP AGE >= 18 YEARS |
How much <TEXT FILL 1> weigh without clothes or shoes? <TEXT FILL 2>
INTERVIEWER INSTRUCTION: RECORD CURRENT WEIGHT. ENTER WEIGHT IN POUNDS OR KILOGRAMS.
|___| [WHQWEIGHT] 1. ENTER WEIGHT IN POUNDS 2. ENTER WEIGHT IN KILOGRAMS 7. REFUSED 9. DON’T KNOW
|___|___|___| [WHQWEIGHTL] ENTER NUMBER OF POUNDS
OR
|___|___|___| [WHQWEIGHTK] ENTER NUMBER OF KILOGRAMS
|
|
SPANISH |
¿Cuánto pesa <TEXT FILL 1> sin ropa ni zapatos? <TEXT FILL 2>
INTERVIEWER INSTRUCTION: RECORD CURRENT WEIGHT. ENTER WEIGHT IN POUNDS OR KILOGRAMS.
|___| [WHQWEIGHT] 1. ENTER WEIGHT IN POUNDS 2. ENTER WEIGHT IN KILOGRAMS 7. REFUSED 9. DON’T KNOW
|___|___|___| [WHQWEIGHTL] ENTER NUMBER OF POUNDS
OR
|___|___|___| [WHQWEIGHTK] ENTER NUMBER OF KILOGRAMS
|
QUESTION TYPE |
Dropdown: WHQWEIGHT Numeric: WHQWEIGHTL, WHQWEIGHTK |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]”
TEXT FILL 2: FILL “If you are currently pregnant, how much did you weigh before your pregnancy?” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE; TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3); OR DK/RF IN SPQGENDER AND SP AGE IS 18-59 YEARS FILL “If she is currently pregnant, how much did she weigh before her pregnancy?” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER AND SP AGE IS 18-59 YEARS FILL “If [SP NAME] is currently pregnant, how much did [SP NAME] weigh before [SP NAME]’s pregnancy?” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER AND SP AGE IS 18-59 YEARS ELSE, LEAVE BLANK |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “Si usted está actualmente embarazada, ¿cuánto pesaba antes de su embarazo?” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE; TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3); OR DK/RF IN SPQGENDER AND SP AGE IS 18-59 YEARS FILL “Si ella está actualmente embarazada, ¿cuánto pesaba antes de su embarazo?” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER AND SP AGE IS 18-59 YEARS FILL “Si [SP NAME] está embarazada actualmente, ¿cuánto pesaba [SP NAME] antes del embarazo de [SP NAME]?” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER AND SP AGE IS 18-59 YEARS ELSE, LEAVE BLANK |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF WHQWEIGHTL <50 OR >750, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 50 AND 750.” IF WHQWEIGHTK <23 OR >338, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 23 AND 338.” |
SOFT CHECK |
IF WHQWEIGHTL <75 OR >500, DISPLAY “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.”IF WHQWEIGHTK <34 OR >225, DISPLAY “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
WHQ.025 L/K |
NEXT |
WHQWEIGHP |
WHQWEIGHP / WHQWEIGHPL / WHQWEIGHPK |
|
ASK |
IF SP AGE >= 18 YEARS |
How much did <TEXT FILL 1> weigh a year ago? <TEXT FILL 2>
INTERVIEWER INSTRUCTION: ENTER WEIGHT IN POUNDS OR KILOGRAMS.
|___| [WHQWEIGHP] 1. ENTER WEIGHT IN POUNDS 2. ENTER WEIGHT IN KILOGRAMS 7. REFUSED 9. DON’T KNOW
|___|___|___| [WHQWEIGHPL] ENTER NUMBER OF POUNDS
OR
|___|___|___| [WHQWEIGHPK] ENTER NUMBER OF KILOGRAMS
|
|
SPANISH |
¿Cuánto pesaba <TEXT FILL 1> hace un año? <TEXT FILL 2>
INTERVIEWER INSTRUCTION: ENTER WEIGHT IN POUNDS OR KILOGRAMS.
|___| [WHQWEIGHP] 1. ENTER WEIGHT IN POUNDS 2. ENTER WEIGHT IN KILOGRAMS 7. REFUSED 9. DON’T KNOW
|___|___|___| [WHQWEIGHPL] ENTER NUMBER OF POUNDS
OR
|___|___|___| [WHQWEIGHPK] ENTER NUMBER OF KILOGRAMS
|
QUESTION TYPE |
Dropdown: WHQWEIGHP Numeric: WHQWEIGHPL, WHQWEIGHPK |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “If you were pregnant a year ago, how much did you weigh before your pregnancy?” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE; TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3); OR DK/RF IN SPQGENDER AND SP AGE IS 18-60 YEARS FILL “If she was pregnant a year ago, how much did she weigh before her pregnancy?” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER AND SP AGE IS 18-60 YEARS FILL “If [SP NAME] was pregnant a year ago, how much did [SP NAME] weigh before [SP NAME]’s pregnancy?” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER AND SP AGE IS 18-60 YEARS ELSE, LEAVE BLANK |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “Si usted estaba embarazada hace un año, ¿cuánto pesaba antes de su embarazo?” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE; TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3); OR DK/RF IN SPQGENDER AND SP AGE IS 18-60 YEARS FILL “Si ella estaba embarazada hace un año, ¿cuánto pesaba antes de su embarazo?” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER AND SP AGE IS 18-60 YEARS FILL “Si [SP NAME] estaba embarazada hace un año, ¿cuánto pesaba [SP NAME] antes de su embarazo de [SP NAME]?” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER AND SP AGE IS 18-60 YEARS ELSE, LEAVE BLANK |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF WHQWEIGHPL < 50 OR >750, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 50 AND 750.” IF WHQWEIGHPK < 23 OR >338, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 23 AND 338.” |
SOFT CHECK |
IF WHQWEIGHPL < 75 OR >500, DISPLAY “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” IF WHQWEIGHPK < 34 OR >225, DISPLAY “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
WHQ.053 L/K |
NEXT |
WHQLOSEWGT |
WHQLOSEWGT |
|
ASK |
IF SP AGE >= 18 YEARS |
In the last 12 months, <TEXT FILL 1> tried to lose weight?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿ha tratado <TEXT FILL 1> de bajar de peso?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS REPSONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS REPSONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
WHQ.070 |
NEXT |
END OF SECTION |
SMOKING AND TOBACCO USE – SMQ
Target Group: SPs 18+
SMQCIGLIFE |
|
ASK |
IF SP AGE >= 18 YEARS |
These next questions are about cigarette smoking.
Please look at card SMQ1. <TEXT FILL 1> smoked at least 100 cigarettes in <TEXT FILL 2> entire life? This hand card shows you the products we would like you to include and not include when answering this question.
HAND CARD SMQ1
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Las siguientes preguntas son acerca de fumar cigarrillos.
Mire la tarjeta SMQ1. ¿Ha fumado <TEXT FILL 1> al menos 100 cigarrillos en toda su vida? Esta tarjeta le muestra los productos que queremos que incluya y los que queremos que no incluya en su respuesta a esta pregunta.
HAND CARD SMQ1
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
SMQ.022 |
NEXT |
If SMQCIGLIFE = 1: SMQCIGNOW Else: END OF SECTION |
SMQCIGNOW |
|
ASK |
IF SMQCIGLIFE=1 |
<TEXT FILL 1> now smoke cigarettes…
1. every day, 2. some days, or 3. not at all? 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Fuma <TEXT FILL 1> cigarrillos ahora...
1. todos los días, 2. algunos días, o 3. nunca? 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
SMQ.040 |
NEXT |
If SMQCIGNOW = 1: SMQCIGQTY Else if SMQCIGNOW = 2: SMQCIG30DY Else: END OF SECTION |
SMQCIG30DY |
|
ASK |
IF SMQCIGNOW = 2 |
On how many of the last 30 days did <TEXT FILL 1> smoke cigarettes?
|____| ENTER NUMBER OF DAYS
7777. REFUSED 9999. DON’T KNOW
|
|
SPANISH |
En los últimos 30 días, ¿cuántos días fumó <TEXT FILL 1> cigarrillos?
|____| ENTER NUMBER OF DAYS
7777. REFUSED 9999. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “ [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “ [SP NAME]” |
NOTES |
ALLOW '0' AS AN ENTRY
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK (ENG) |
IF SMQCIGNOW = 2 (SOME DAYS) AND (SMQCIG30DY=0 OR SMQCIG30DY >= 26), DISPLAY, “Earlier you reported that you smoked some days; I would like to clarify that response.” |
SOFT CHECK (SPA) |
IF SMQCIGNOW = 2 (SOME DAYS) AND (SMQCIG30DY=0 OR SMQCIG30DY >= 26), DISPLAY, “Antes dijo que fumaba algunos días; me gustaría aclarar esa respuesta”. |
VERSION NOTES |
SMQ.641 |
NEXT |
IF SMQCIG30DY = 0 OR 7777 (REFUSED) OR 9999 (DON’T KNOW): END OF SECTION ELSE: SMQCIGQTY |
SMQCIGQTY |
|
ASK |
IF SMQCIGNOW = 1 IF SMQCIG30DY > 0 AND NOT REFUSED AND NOT DON’T KNOW |
On average, when <TEXT FILL 1> smoked in the last 30 days, how many cigarettes did <TEXT FILL 2> smoke a day?
1 PACK EQUALS 20 CIGARETTES IF LESS THAN 1 PER DAY, ENTER 1 IF 95 OR MORE PER DAY, ENTER 95
|____| ENTER NUMBER OF CIGARETTES (PER DAY)
7777. REFUSED 9999. DON’T KNOW
|
|
SPANISH |
En promedio, cuando <TEXT FILL 1> fumó en los últimos 30 días, ¿cuántos cigarrillos fumó <TEXT FILL 2> al día?
1 PACK EQUALS 20 CIGARETTES IF LESS THAN 1 PER DAY, ENTER 1 IF 95 OR MORE PER DAY, ENTER 95
|____| ENTER NUMBER OF CIGARETTES (PER DAY)
7777. REFUSED 9999. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “ [SP NAME]”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “ [SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
SMQ.650 |
NEXT |
END OF SECTION |
OCCUPATION – OCQ
Target Group: SPs 18+
OCQWORK |
|
ASK |
IF SP AGE >= 18 YEARS |
The next questions are about jobs <TEXT FILL 1> may have had.
Last week, did <TEXT FILL 1> work for pay at a job or business?
INTERVIEWER INSTRUCTION: IF THE RESPONDENT SAYS HE/SHE/SP WORKS, BUT NOT FOR PAY, AT A FAMILY-OWNED JOB OR BUSINESS, ENTER “YES”.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Las siguientes preguntas son acerca de los empleos que <TEXT FILL 1> pueda haber tenido.
La semana pasada, ¿trabajó <TEXT FILL 1> por pago en un empleo o negocio?
INTERVIEWER INSTRUCTION: IF THE RESPONDENT SAYS HE/SHE/SP WORKS, BUT NOT FOR PAY, AT A FAMILY-OWNED JOB OR BUSINESS, ENTER “YES”.
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Work (Working): Paid work for wages, salary, commission, tips, or pay "in kind." Examples of pay in kind include meals, living quarters, or supplies provided in place of wages. This definition excludes unpaid volunteer work (such as for a church or charity), unpaid leaves of absences, temporary layoffs (such as a strike), and work around the house.
Job: A job exists when there is: 1. A definite arrangement for regular work; 2. The arrangement is on a continuing basis (like every week or month); and 3. A person receives pay or other compensation for his/her work.
The schedule of hours or days can be irregular as long as there is a definite arrangement to work on a continuing basis.
Business: A business exists when one or more of the following conditions are met: 1. Machinery or equipment of substantial value is used in conducting the business; 2. An office, store, or other place of business is maintained; or 3. The business is advertised to the public. (Some examples of advertising are: listing in the classified section of the telephone book, displaying a sign, distributing cards or leaflets, or any type of promotion which publicizes the type of work or services offered.) |
HELP SCREEN (SPA) |
Trabajo (trabajar): Trabajo compensado con sueldo, salario, comisiones, propina o pagado “en especies”. Ejemplos de pago en especie incluyen comidas, vivienda o abastecimientos que se dan en lugar de salario. Esta definición excluye el trabajo voluntario no remunerado (tal como el de una iglesia u organización de caridad), licencias no remuneradas, despidos/suspensiones temporales (como huelgas) y las tareas domésticas de la casa.
Trabajo: Un trabajo existe cuando hay: 1. Un acuerdo definido para un trabajo regular; 2. El acuerdo está basado en la continuidad del trabajo (por ejemplo, cada semana o cada mes); y 3. Una persona recibe un pago u otra compensación por su trabajo.
El horario y los días de trabajo pueden ser irregulares siempre y cuando haya un acuerdo definitivo para trabajar basado en la continuidad del trabajo.
Negocio: Un negocio existe cuando se reúnen una o más de las siguientes condiciones: 1. Para conducir el negocio se hace uso de equipo o maquinaría de valor considerable; 2. Se mantiene una oficina, un almacén u otro lugar; o 3. El negocio se anuncia al público. (Algunos ejemplos de anuncios son: Incluirlo en la sección de clasificados del directorio telefónico, poner un letrero, distribuir tarjetas, volantes o cualquier tipo de propaganda que da a conocer el tipo de trabajo o de servicios que se ofrecen). |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OCQ.New1 |
NEXT |
IF OCQWORK = 1: OCQHOURS IF OCQWORK = 2: OCQABSENT IF OCQWORK = 7 OR 9: END OF SECTION |
OCQABSENT |
|
ASK |
IF OCQWORK = 2 |
Did <TEXT FILL 1> have a job or business last week, but <TEXT FILL 2> temporarily absent due to illness, vacation, family or maternity leave, or some other reason?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tuvo <TEXT FILL 1> un trabajo o negocio la semana pasada, pero estuvo ausente temporalmente por enfermedad, vacaciones, licencia familiar o de maternidad, o por alguna otra razón?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “were” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “was” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OCQ.New2 |
NEXT |
IF OCQABSENT = 1: OCQHOURS IF OCQABSENT = 2: OCQABSENTW IF OCQABSENT = 7 OR 9: END OF SECTION |
OCQABSENTW |
|
ASK |
IF OCQABSENT = 2 |
What is the main reason <TEXT FILL 1> not working for pay at a job or business last week?
1. UNEMPLOYED, LAID OFF, LOOKING FOR WORK 2. SEASONAL/CONTRACT WORK 3. RETIRED 4. UNABLE TO WORK FOR HEALTH REASONS/DISABLED 5. TAKING CARE OF HOUSE OF FAMILY 6. GOING TO SCHOOL 7. WORKING AT A FAMILY-OWNED JOB OR BUSINESS NOT FOR PAY 8. OTHER 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
¿Cuál es la razón principal por la cual <TEXT FILL 1> no trabajó por pago en un empleo o negocio la semana pasada?
1. DESEMPLEADO(A), DESPEDIDO(A) TEMPORALMENTE, BUSCANDO TRABAJO 2. ES TRABAJO POR ESTACIONES/POR CONTRATO 3. ESTÁ JUBILADO(A) 4. INCAPAZ DE TRABAJAR POR RAZONES DE SALUD/DISCAPACITADO(A) 5. CUIDÓ LA CASA O LA FAMILIA 6. FUE A LA ESCUELA 7. TRABAJÓ EN UN EMPLEO O NEGOCIO FAMILIAR SIN PAGO 8. OTHER 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you were” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] was” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] ” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OCQ.New3 |
NEXT |
IF OCQABSENTW = 7: OCQHOURS ELSE: OCQLASTWRK |
OCQLASTWRK |
|
ASK |
IF OCQABSENTW <> 7 |
When was the last time <TEXT FILL 1> worked for pay at a job or business, even if only for a few days?
1. Within the last 12 months 2. 1-5 years ago 3. Over 5 years ago 4. Never worked 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Cuándo fue la última vez que <TEXT FILL 1> trabajó por pago en un empleo o negocio, aunque solo fuera por unos días?
1. Dentro de los últimos 12 meses 2. Hace 1 a 5 años 3. Hace más de 5 años 4. Nunca trabajó 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OCQ.New4 |
NEXT |
IF OCQLASTWRK = 1 AND OCQABSENTW = 2: OCQHOURS ELSE: END OF SECTION |
OCQHOURS |
|
ASK |
IF OCQWORK = 1 IF OCQABSENT = 1 IF OCQABSENTW = 7 IF OCQLASTWRK = 1 AND OCQABSENTW = 2 |
<TEXT FILL 1> many hours per week <TEXT FILL 2> usually work in total, at all jobs or businesses?
|___|___|___| ENTER NUMBER OF HOURS
7777. REFUSED 9999. DON’T KNOW
|
|
SPANISH |
<TEXT FILL 1> horas a la semana trabaja <TEXT FILL 2> normalmente en total, en todos los empleos o negocios?
|___|___|___| ENTER NUMBER OF HOURS
7777. REFUSED 9999. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS (ENG) |
TEXT FILL 1: FILL “When you are doing your seasonal or contract work, how” IF OCQABSENTW = 2 AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “When [SP NAME] is doing his seasonal or contract work, how” IF OCQABSENTW = 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “When [SP NAME] is doing her seasonal or contract work, how” IF OCQABSENTW = 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “When [SP NAME] is doing [SP NAME]’s seasonal or contract work, how” IF OCQABSENTW = 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER FILL “How” IF OCQABSENTW != 2
TEXT FILL 2: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “Cuando tiene un trabajo estacional o trabaja por contrato, ¿cuántas” IF OCQABSENTW = 2 AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “Cuando [SP NAME] tiene un trabajo estacional o trabaja por contrato, ¿cuántas” IF OCQABSENTW = 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “Cuando [SP NAME] tiene un trabajo estacional o trabaja por contrato, ¿cuántas” IF OCQABSENTW = 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “Cuando [SP NAME] hace el trabajo estacional o el trabajo por contrato de [SP NAME], ¿cuántas” IF OCQABSENTW = 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER FILL “¿Cuántas ” IF OCQABSENTW != 2
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF OCQHOURS <1 OR >168, DISPLAY “YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A NUMBER BETWEEN 1 AND 168.” |
SOFT CHECK |
IF OCQHOURS > 59, DISPLAY “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
OCQ.New6 |
NEXT |
IF OCQHOURS=7777 OR 9999: OCQFULLTIM ELSE: OCQWORKQ |
OCQFULLTIM |
|
ASK |
IF OCQHOURS=7777 or 9999 |
<TEXT FILL 1> usually work 35 hours or more per week in total at all jobs or businesses?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
<TEXT FILL 1> usualmente 35 horas o más a la semana en total en todos los empleos o negocios?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “When you are doing your seasonal or contract work, do you” IF OCQABSENTW = 2 AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “When [SP NAME] is doing his seasonal or contract work, does [SP NAME]” IF OCQABSENTW = 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “When [SP NAME] is doing her seasonal or contract work, does [SP NAME]” IF OCQABSENTW = 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “When [SP NAME] is doing [SP NAME]’s seasonal or contract work, does [SP NAME]” IF OCQABSENTW = 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER FILL “Do you” IF OCQABSENTW != 2 AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “Does [SP NAME]” IF OCQABSENTW != 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR |
FILLS (SPA) |
TEXT FILL 1: FILL “Cuando tiene un trabajo estacional o trabaja por contrato, ¿trabaja usted” IF OCQABSENTW = 2 AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “Cuando [SP NAME] tiene un trabajo estacional o trabaja por contrato, ¿trabaja [SP NAME]” IF OCQABSENTW = 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “Cuando [SP NAME] tiene un trabajo estacional o trabaja por contrato, ¿trabaja [SP NAME]” IF OCQABSENTW = 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “Cuando [SP NAME] hace el trabajo estacional o el trabajo por contrato de [SP NAME], ¿trabaja [SP NAME]” IF OCQABSENTW = 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER FILL “¿Trabaja usted” IF OCQABSENTW != 2 AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “¿Trabaja [SP NAME]” IF OCQABSENTW != 2 AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OCQ.New7 |
NEXT |
OCQWORKQ |
OCQSCHEDUL |
|
ASK |
IF OCQWORK = 1 IF OCQABSENT = 1 IF OCQABSENTW = 7 IF OCQLASTWRK = 1 AND OCQABSENTW = 2 |
Which of the following best describes <TEXT FILL 1> usual work schedule for the last 3 months ? Is it …
INTERVIEWER INSTRUCTION: IF THE RESPONDENT SAYS, “NO USUAL SCHEDULE,” OR “FLEXIBLE HOURS,” PROBE IF WORK HOURS GENERALLY FALL IN A DAY, EVENING, NIGHT, OR ROTATING SHIFT CATEGORY BEFORE CODING IT AS "ANOTHER SCHEDULE."
1. a regular daytime schedule, 2. a regular evening schedule, 3. a regular night shift, 4. a rotating shift, or 5. another schedule? 6. DID NOT WORK IN THE LAST 3 MONTHS 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Cuál de las siguientes opciones describe mejor <TEXT FILL 1> en los últimos 3 meses? ¿Es...
INTERVIEWER INSTRUCTION: IF THE RESPONDENT SAYS, “NO USUAL SCHEDULE,” OR “FLEXIBLE HOURS,” PROBE IF WORK HOURS GENERALLY FALL IN A DAY, EVENING, NIGHT, OR ROTATING SHIFT CATEGORY BEFORE CODING IT AS "ANOTHER SCHEDULE."
1. un horario regular de día, 2. un horario regular de noche, 3. un turno regular de noche, 4. un turno rotativo, u 5. otro tipo de horario 6. DID NOT WORK IN THE LAST 3 MONTHS 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “su horario de trabajo habitual” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “el horario de trabajo habitual de [SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
For guidance – approximate hours provided. Regular daytime schedule: 6am and 6pm; Regular evening shift: 2pm and midnight; Regular night shift: 9pm and 8am; Rotating shift: changes periodically from days to evenings or nights. Another schedule: split shift (two distinct work periods/day), irregular or any other schedule. |
HELP SCREEN (SPA) |
Para usar como guía – Los horarios mencionados son aproximados. Horario regular de día: 6 a. m. y 6 p. m.; turno regular de la tarde: 2 p. m. y la medianoche; turno regular de noche: 9 p. m. y 8 a. m.; turno rotativo: cambia de forma periódica de un turno diario a uno de tarde o de noche. Otro horario: turno dividido (dos períodos de trabajo distintos al día), horario irregular o cualquier otro horario. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
OCQ.265N |
NEXT |
END OF SECTION |
DEMOGRAPHICS INFORMATION – DMQ – SP
Target Group: SPs Birth +
DMQEDUC |
|
ASK |
IF SP AGE >= 18 YEARS |
Next please look at card DMQ1. What is the highest grade or level of school <TEXT FILL 1> completed or the highest degree <TEXT FILL 2> received?
HAND CARD DMQ1 READ HAND CARD CATEGORIES IF NECESSARY ENTER HIGHEST LEVEL OF SCHOOL.
0. NEVER ATTENDED/KINDERGARTEN ONLY 1. GRADE 1-11 2. 12TH GRADE, NO DIPLOMA 3. HIGH SCHOOL GRADUATE 4. GED OR EQUIVALENT 5. SOME COLLEGE, NO DEGREE 6. ASSOCIATE’S DEGREE (EXAMPLE: AA, AS) 7. BACHELOR’S DEGREE (EXAMPLE: BA, AB, BS, BBA) 8. MASTER’S DEGREE (EXAMPLE: MA, MS, MEng, MEd, MBA) 9. PROFESSIONAL SCHOOL DEGREE (EXAMPLE: MD, DDS, DVM, JD) 10. DOCTORAL DEGREE (EXAMPLE: PhD, EdD) 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
A continuación, mire la tarjeta DMQ1. ¿Cuál es el grado o nivel escolar más alto que <TEXT FILL 1> ha completado o el título más alto que <TEXT FILL 2> recibió?
HAND CARD DMQ1 READ HAND CARD CATEGORIES IF NECESSARY ENTER HIGHEST LEVEL OF SCHOOL.
0. NUNCA ASISTIÓ/SOLO KINDERGARTEN 1. DEL PRIMER GRADO AL 11º GRADO 2. 12º GRADO, SIN DIPLOMA 3. ESCUELA SECUNDARIA/PREPARATORIA/SUPERIOR O “HIGH SCHOOL” 4. “GED” O EQUIVALENTE 5. ALGO DE UNIVERSIDAD, SIN GRADUARSE 6. TÍTULO ASOCIADO UNIVERSITARIO (POR EJEMPLO, AA, AS) 7. LICENCIATURA UNIVERSITARIA (POR EJEMPLO, BA, AB, BS, BBA) 8. TÍTULO DE MAESTRÍA (POR EJEMPLO, MA, MS, MEng, MEd, MBA) 9. ESCUELA PROFESIONAL DE POSTGRADO (POR EJEMPLO, MD, DDS, DVM, JD) 10. TÍTULO DE DOCTORADO (POR EJEMPLO, PhD, EdD) 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] has”
TEXT FILL 2: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “he has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP ENDER IS MALE IN SPQGENDER FILL “she has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] has” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
SP AGE FILL: FILL SP AGE |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] ”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP ENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME] ” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
SP AGE FILL: FILL SP AGE |
NOTES |
|
HELP SCREEN (ENG) |
School: An institution that advances a person toward an elementary or high school diploma, or a college or professional school degree. Do not count schooling in non-regular schools unless the credits are accepted by regular schools.
Regular school includes graded public, private, and parochial schools, colleges, universities, graduate and professional schools, seminaries where a Bachelor's degree is offered, community colleges specializing in skill training or offering Associates degrees, colleges of education, and nursing schools where a Bachelor's degree is offered.
If the person attended school outside of the “regular” school system, probe to determine if the schooling is applicable here. Use the following guidelines to determine if the schooling should be included:
|
HELP SCREEN (SPA) |
Escuela/Colegio: Institución que prepara a una persona para obtener un diploma de escuela secundaria/preparatoria/superior o “high school”, o un título universitario o de escuela profesional. No incluya instrucción en escuelas no regulares a menos que los créditos se acepten por escuelas regulares.
Las escuelas regulares incluyen escuelas públicas, privadas y parroquiales, universidades, escuelas de graduados y profesionales, seminarios donde se ofrece el título de licenciatura, universidades intermedias (junior college) especializadas en la capacitación de destrezas/habilidades o títulos de dos años, facultades de ciencias de la educación y escuelas de enfermería donde se ofrecen títulos de licenciatura.
Si la persona asistió a la escuela fuera del sistema escolar “regular”, verifique para determinar si la instrucción cumple con esos requisitos. Use las siguientes pautas para determinar si la instrucción debe ser incluida:
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HARD CHECK |
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SOFT CHECK |
IF DMQEDUC = 8 (MASTER’S) OR 9 (PROFESSIONAL) OR 10 (DOCTORAL) AND SP AGE < 22 YEARS, DISPLAY “IMPROBABLE ANSWER DUE TO SP’S AGE <SP AGE FILL>. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
DMQ.141N |
NEXT |
DMQARMFRCE |
DMQARMFRCE |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 1> ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard? (Active duty does not include training for the Reserves or National Guard, but does include activation, for service in the U.S. or in a foreign country, in support of military or humanitarian operations.)
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
¿Ha servido <TEXT FILL 1> alguna vez en el servicio activo de las Fuerzas Armadas, Reservas Militares o la Guardia Nacional de los Estados Unidos? (El servicio activo no incluye entrenamiento para la Reserva o para la Guardia Nacional, pero sí incluye activación, para el servicio en Estados Unidos o en un país extranjero para apoyo de operaciones militares o humanitarias).
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Armed Forces: Non-civilian members of any of the armed services of the federal government (Army, Navy, Air Force, Coast Guard, Marines, and Space Force). |
HELP SCREEN (SPA) |
Fuerzas Armadas: Miembros no civiles de alguno de los servicios de las fuerzas armadas del gobierno federal (Ejército, Marina de Guerra, Fuerza Aérea, Guardiacostas, Infantería de Marina y Fuerzas Espaciales). |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DMQ.052 |
NEXT |
DMQMARRIED |
DMQMARRIED |
|
ASK |
IF SP AGE >= 18 YEARS |
<TEXT FILL 1> now married, widowed, divorced, separated, never married or living with a partner?
1. MARRIED 2. WIDOWED 3. DIVORCED 4. SEPARATED 5. NEVER MARRIED 6. LIVING WITH A PARTNER 77. REFUSED 99. DON’T KNOW
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|
SPANISH |
¿Está <TEXT FILL 1> actualmente casado(a), viudo(a), divorciado(a), separado(a), nunca se ha casado o está viviendo en pareja?
1. CASADO(A) 2. VIUDO(A) 3. DIVORCIADO(A) 4. SEPARADO(A) 5. NUNCA CASADO(A) 6. VIVIENDO CON LA PAREJA 77. REFUSED 99. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Is [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DMQ.380 |
NEXT |
DMQRACE |
DMQRACE |
|
ASK |
All respondents |
What is <TEXT FILL 1> race or ethnicity? Please select one or more of these categories.
[CODE ALL THAT APPLY]
1. White 2. Hispanic or Latino 3. Black or African American 4. Asian 5. American Indian or Alaska Native 6. Middle Eastern or North African 7. Native Hawaiian or Pacific Islander 77. REFUSED 99. DON’T KNOW
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|
SPANISH |
¿Cuál es <TEXT FILL 1>? Seleccione una o más de estas categorías.
[CODE ALL THAT APPLY]
1. Blanco(a) 2. Hispano(a) o latino(a) 3. Negro(a) o afroamericano(a) 4. Asiático(a) 5. Indígena de las Américas o nativo(a) de Alaska 6. De Medio Oriente o África del norte 7. Nativo(a) de Hawái o de otras islas del Pacífico 77. REFUSED 99. DON’T KNOW
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QUESTION TYPE |
Checkbox |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “su raza u origen étnico” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “la raza o el origen étnico de [SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
IF DMQRACE <> SCQRACE AND SCQRACE IS NOT DK/REF, DISPLAY “RACE/ETHNICITY DOES NOT MATCH SCREENER SELECTION. PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
DMQ.NEW1 |
NEXT |
IF DMQRACE = 2 (HISPANIC OR LATINO): DMQHISP ELSE: DMQCITIZEN |
DMQHISP / DMQHISPO |
|
ASK |
IF DMQRACE = 2 |
Look at card DMQ2. Please give me the number of the group that represents <TEXT FILL 1> Hispanic/Latino or Spanish origin or ancestry. Please select one or more of these categories.
PROBE: Where do <TEXT FILL 1> ancestors come from?
HAND CARD DMQ2
[SELECT 1 OR MORE]
10. MEXICAN 11. PUERTO RICAN 12. CUBAN 13. DOMINICAN REPUBLIC CENTRAL AMERICAN: 14. COSTA RICAN 15. GUATEMALAN 16. HONDURAN 17. NICARAGUAN 18. PANAMANIAN 19. SALVADORAN 20. OTHER CENTRAL AMERICAN SOUTH AMERICAN: 21. ARGENTINEAN 22. BOLIVIAN 23. CHILEAN 24. COLOMBIAN 25. ECUADORIAN 26. PARAGUAYAN 27. PERUVIAN 28. URUGUAYAN 29. VENEZUELAN 30. OTHER SOUTH AMERICAN OTHER HISPANIC OR LATINO: 31. FILIPINO 32. SPANIARD 33. SPANISH 34. SPANISH AMERICAN 35. HISPANO/HISPANA 36. HISPANIC/LATINO 40. OTHER HISPANIC/LATINO (SPECIFY) [DMQHISPO] 41. CHICANA/CHICANO 77. REFUSED 99. DON'T KNOW |
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SPANISH |
Mire la tarjeta DMQ2. Por favor, deme el número del grupo que representa <TEXT FILL 1>. Seleccione una o más de estas categorías.
PROBE: ¿De dónde provienen <TEXT FILL 2> ?
HAND CARD DMQ2
[SELECT 1 OR MORE]
10. MEXICANO 11. PUERTORRIQUEÑO 12. CUBANO 13. DOMINICANO CENTROAMERICANO: 14. COSTARRICENSE 15. GUATEMALTECO 16. HONDUREÑO 17. NICARAGÜENSE 18. PANAMEÑO 19. SALVADOREÑO 20. OTRA CATEGORÍA DE CENTROAMERICANO SUDAMERICANO: 21. ARGENTINO 22. BOLIVIANO 23. CHILENO 24. COLOMBIANO 25. ECUATORIANO 26. PARAGUAYO 27. PERUANO 28. URUGUAYO 29. VENEZOLANO 30. OTRA CATEGORÍA DE SUDAMERICANO OTRO HISPANO O LATINO: 31. FILIPINO 32. ESPAÑOL 33. DE ESPAÑA 34. AMERICANO ESPAÑOL 35. HISPANO(A) 36. HISPANO/LATINO(A) 40. OTRO HISPANO/LATINO (ESPECIFIQUE) [DMQHISPO] 41. CHICANO(A) 77. REFUSED 99. DON'T KNOW |
QUESTION TYPE |
Checkbox: DMQHISP Text entry: DMQHISPO |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “su origen o ascendencia hispana, latina o española” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “el origen o ascendencia hispana, latina o española de [SP NAME]”
TEXT FILL 2: FILL “sus antepasados” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “los antepasados de [SP NAME]” |
NOTES |
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HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
IF DMQHISP = 40 (OTHER HISPANIC/LATINO (SPECIFY)), DISPLAY “PLEASE REVIEW THE LIST AND SELECT RESPONSE FROM LIST BEFORE TYPING. THE LIST IS MEANT TO INCLUDE ALL CATEGORIES. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO TO ENTER ANOTHER RESPONSE.” |
VERSION NOTES |
DMQ.253 OS |
NEXT |
DMQCITIZEN |
DMQCITIZEN |
|
ASK |
All respondents |
<TEXT FILL 1> born in the United States or a United States territory?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
¿Nació <TEXT FILL 1> en los Estados Unidos o en un territorio de los Estados Unidos?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Were you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Was [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
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HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DMQ.135 |
NEXT |
IF DMQCITIZEN = 2: DMQRESIDE ELSE: DMQLINK |
DMQRESIDE |
|
ASK |
IF DMQCITIZEN = 2 |
How long <TEXT FILL 1> been in the United States? Has it been…
1. Less than 1 year, 2. 1 to 4 years, 3. 5 to 9 years, 4. 10 to 14 years, 5. 15 to 19 years, or 6. 20 years or more? 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
¿Cuánto tiempo lleva <TEXT FILL 1> en los Estados Unidos? ¿Está...
1. Menos de 1 año, 2. De 1 a 4 años, 3. De 5 a 9 años, 4. De 10 a 14 años, 5. De 15 a 19 años, o 6. 20 años o más? 7. REFUSED 9. DON’T KNOW
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF (DMQRESIDE=2 AND SP AGE<1 YEAR, OR IF (DMQRESIDE=3 AND SP AGE<5 YEARS), OR IF (DMQRESIDE=4 AND SP AGE<10 YEARS), OR IF (DMQRESIDE=5 AND SP AGE<15 YEARS), OR IF (DMQRESIDE=6 AND SP AGE<20 YEARS), DISPLAY “TIME ENTERED CANNOT BE GREATER THAN SP’S AGE.” |
SOFT CHECK |
|
VERSION NOTES |
DMQ.NEW3 |
NEXT |
DMQLINK |
DMQLINK |
|
ASK |
All respondents |
To better understand health conditions, we ask participants about linking their survey data with other health records. I want to play a short video for you that explains this process.
INTERVIEWER INSTRUCTION: PLAY DATA LINKAGE CONSENT VIDEO. WHEN VIDEO ENDS, CONTINUE BELOW.
We can do additional health studies by linking <TEXT FILL 1> interview and exam data to vital statistics, health, nutrition, and other related records. May we try to link <TEXT FILL 1> survey records with other records?
1. YES 2. NO
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|
SPANISH |
Para entender mejor las afecciones de salud, pedimos a los participantes vincular los datos de su encuesta con otros registros de salud. Permítame mostrarle un breve video que explica este proceso.
INTERVIEWER INSTRUCTION: PLAY DATA LINKAGE CONSENT VIDEO. WHEN VIDEO ENDS, CONTINUE BELOW.
Podemos realizar estudios de salud adicionales si vinculamos <TEXT FILL 1> con estadísticas vitales, datos de salud, datos de nutrición y otros registros relacionados. ¿Podríamos intentar vincular los registros de <TEXT FILL 2> con otros registros?
1. YES 2. NO
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SPANISH |
DATA LINKAGE VIDEO SCRIPT: [START OF VIDEO] – THIS WILL NOT BE INCLUDED IN THE PROGRAMMING SPECIFICATIONS FOR THE SP QUESTIONNAIRE Los problemas de salud son muy complejos. Para entender mejor estos problemas, el Centro Nacional de Estadísticas de la Salud combina los datos de los participantes de la NHANES con información sobre nacimientos y defunciones, salud, nutrición y otros registros relacionados procedentes de otras fuentes federales como Medicare y Medicaid. Los investigadores científicos pueden aprender mucho más sobre las afecciones de salud cuando se vincula la información a otros datos que no se recopilan de forma habitual en NHANES. Por ejemplo, vincular los datos de la NHANES con los del Departamento de Vivienda y Desarrollo Urbano de los Estados Unidos nos ayuda a entender cómo los diferentes entornos de vivienda pueden afectar los niveles de plomo en la sangre de los niños. Al vincular datos sobre las mediciones de vitamina D de las personas que participan en nuestra encuesta con sus registros de Medicare, descubrimos que tener niveles más altos de vitamina D en la sangre reducía el riesgo de fracturarse huesos. Y, en un estudio en el que se vinculaban los datos de NHANES con los registros de Medicare y de defunciones, se demostró cómo la nutrición y los resultados de los análisis de sangre se asociaban con la enfermedad de Alzheimer y la muerte de adultos de mediana y avanzada edad.
Usted decide si acepta que NHANES vincule los datos de su encuesta con otras fuentes. Si nos permite vincular los datos de su encuesta con estas otras fuentes de información sobre salud, usaremos información personal con la que se lo(a) pueda identificar, como su nombre, fecha de nacimiento y dirección. Una vez que vinculemos sus datos, se eliminará su información personal. Al igual que la información que nos brindó hoy en la encuesta, sus datos se combinarán con los de miles de personas y se usarán únicamente con fines estadísticos. Si desea saber más sobre cómo protegemos la información que nos brinda, puede llamar gratis a la línea gratuita de la Oficina de Confidencialidad del Centro Nacional de Estadísticas de la Salud al 1-888-642-4159. [END OF VIDEO]
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QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “los datos de su entrevista y su examen” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “los datos de la entrevista y el examen de [SP NAME]”
TEXT FILL 2: FILL “de su encuesta” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “de la encuesta de [SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DMQ.NEW4 |
NEXT |
IF DMQLINK = 1: DMQSSNYN ELSE: END OF SECTION |
DATA LINKAGE VIDEO SCRIPT: [START OF VIDEO] – THIS WILL NOT BE INCLUDED IN THE PROGRAMMING SPECIFICATIONS FOR THE SP QUESTIONNAIRE
Health problems are very complex. To better understand health conditions, the National Center for Health Statistics combines data from NHANES participants with information about births and deaths, health, nutrition, and other related records from other federal sources like Medicare and Medicaid.
Researchers can learn so much more about health conditions when linking to other data not routinely collected on NHANES. For example, linking NHANES data with U.S. Department of Housing and Urban Development helps us understand how different housing environments may affect lead levels in children’s blood. By linking people’s Vitamin D data measured in our survey to their Medicare records, we learned that higher Vitamin D levels in blood lowered the risk of broken bones. And a study linking NHANES data with Medicare and death records showed how nutrition and blood test results were associated with Alzheimer’s disease and death in middle-aged and older adults.
Whether you agree to let NHANES link your survey data to other sources is your choice. If you allow us to link your survey data with these other sources of health information, we will use personal information that identifies you, like name, date of birth, and address to make the linkage. Once the link to your data is completed, your personal information will be removed. Like the survey information you have provided today, your data will be combined with data from thousands of other people and will only be used for statistical purposes.
If you want to know more about how we protect the information you provide, you can make a toll-free call to the National Center for Health Statistics Confidentiality Office at 1-888-642-4159.
[END OF VIDEO]
DMQSSNYN |
|
ASK |
IF DMQLINK = 1 |
Thank you. In addition to other information you have provided, <TEXT FILL 1> social security number will help us improve the data linkage. Providing this information is voluntary. There will be no effect on <TEXT FILL 2> benefits if you do not provide it. What is <TEXT FILL 3> Social Security number?"
INTERVIEWER INSTRUCTION: IF RESPONDENT CANNOT RECALL FROM MEMORY, ASK THEM TO GET CARD AT THIS TIME.
|___| 1. ENTER SOCIAL SECURITY NUMBER 2. DOES NOT HAVE SOCIAL SECURITY NUMBER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Gracias. Además de otros datos que nos brindó, <TEXT FILL 1> nos ayudará a mejorar la vinculación de los datos. Brindar esta información es voluntario. Si no nos da el número, eso no afectará los beneficios de <TEXT FILL 2>. “¿Cuál es el <TEXT FILL 3>?”.
INTERVIEWER INSTRUCTION: IF RESPONDENT CANNOT RECALL FROM MEMORY, ASK THEM TO GET CARD AT THIS TIME.
|___| 1. ENTER SOCIAL SECURITY NUMBER 2. DOES NOT HAVE SOCIAL SECURITY NUMBER 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “su número de Seguro Social” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “el número de Seguro Social de [SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “su número de Seguro Social” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “el número de Seguro Social de [SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Social Security numbers are collected under the authority of Section 306 of the Public Health Service Act (title 42, United States Code, section 242k).
Will my information be kept private? Your social security number will be kept confidential to protect your privacy as required and guaranteed by law. We will not give your records to the police, military, or any branch of the government for any reason.
Data linkage, also known as record linkage, combines your information from at least two different sources (e.g., NHANES data and Medicare data). This is done only for statistical purposes. If you agree to data linkage, we will combine the information we collected from you during this survey with records from other organizations (e.g. the Centers for Medicare and Medicaid Services). Once the linkage is completed, personal information that identifies you such as your name, street address, and social security number, will be removed from the linked file before the file is made available for analysis. The linked file will only be used for statistical purposes. |
HELP SCREEN (SPA) |
Los números de Seguro Social se recopilan conforme a la sección 306 de la Ley de Servicios Públicos de Salud (título 42, Código de los Estados Unidos, sección 242k).
¿Se mantendrá mi información en forma privada? Su número de seguro social se mantendrá de manera confidencial para proteger su privacidad como lo requiere y garantiza la ley. No le daremos sus registros a la policía, al ejército ni a ninguna rama del gobierno por ningún motivo.
La vinculación de datos, también conocida como vinculación de registros, combina su información de por lo menos dos fuentes distintas (por ejemplo, los datos de NHANES y los datos de Medicare). Esto se hace únicamente con fines estadísticos. Si acepta la vinculación de datos, combinaremos la información que reunamos de usted durante esta encuesta con los registros de otras organizaciones (por ejemplo, los Centros de Servicios de Medicare y Medicaid). Una vez que se complete la vinculación, la información personal que lo(a) pueda identificar, tal como su nombre, dirección y número de Seguro Social, se quitará del archivo vinculado antes de que el archivo esté disponible para análisis. El archivo vinculado solamente se usará con fines estadísticos. |
HARD CHECK |
|
SOFT CHECK |
IF DMQSSNYN = 7 (REFUSE), DISPLAY “IF RESPONDENT IS 18 YEARS OR OLDER, MAKE SURE YOU HAVE READ THE REQUIRED CONVERSION TEXT ON THE SCREEN. IF RESPONDENT STILL REFUSES, PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
DMQ.281a |
NEXT |
IF DMQSSNYN = 1: DMQSSN1 ELSE: END OF SECTION |
DMQSSN1 / DMQSSN2 |
|
ASK |
IF DMQSSNYN = 1 |
|___|___|___| |___|___| |___|___|___|___| [DMQSSN1] ENTER SOCIAL SECURITY NUMBER
|___|___|___| |___|___| |___|___|___|___| [DMQSSN2] ENTER SOCIAL SECURITY NUMBER
777777777. REFUSED 999999999. DON’T KNOW
|
|
SPANISH |
|___|___|___| |___|___| |___|___|___|___| [DMQSSN1] ENTER SOCIAL SECURITY NUMBER
|___|___|___| |___|___| |___|___|___|___| [DMQSSN2] ENTER SOCIAL SECURITY NUMBER
777777777. REFUSED 999999999. DON’T KNOW
|
QUESTION TYPE |
Numeric: DMQSSN1, DMQSSN2 |
FILLS |
|
NOTES |
REQUIRE DOUBLE ENTRY OF SOCIAL SECURITY NUMBER
|
HELP SCREEN |
|
HARD CHECK |
IF ((DMQSSN1 <> DK/REF) AND (DMQSSN1 OR DMQSSN2 IS MISSING)), DISPLAY “DOUBLE ENTRY IS REQUIRED. PLEASE ENTER SOCIAL SECURITY NUMBER TWICE.”
IF (DMQSSN1 = DK/REF), DISPLAY “GO BACK TO PREVIOUS QUESTION AND CODE “DON’T KNOW” OR “REFUSED”
IF (DMQSSN1 <> DMQSSN2 AND DMQSSN1 <> DK/REF), DISPLAY “THE SOCIAL SECURITY NUMBER ENTRIES DON’T MATCH. PLEASE CORRECT YOUR RESPONSE.”
IF (DMQSSN1 < 9 DIGITS OR DMQSSN2 < 9 DIGITS), DISPLAY “THE SOCIAL SECURITY NUMBER SHOULD BE A 9-DIGIT NUMBER. PLEASE CORRECT YOUR RESPONSE.”
IF (DMQSSN1 OR DMQSSN2 HAVE ALL ZEROS FOR ANY OF THE FOLLOWING: 3-DIGIT AREA NUMBER (DIGITS 1-3), 2-DIGIT GROUP NUMBER (DIGITS 4-5) OR 4-DIGIT SERIAL NUMBER (DIGITS 6-9)), DISPLAY “IT IS UNLIKELY THAT THE SOCIAL SECURITY NUMBER STARTS WITH “000”, HAS “00” AS ITS MIDDLE 2 DIGITS, OR HAS “0000” AS ITS LAST 4 DIGITS. PLEASE VERIFY YOUR RESPONSE.”
IF DMQSSN1 OR DMQSSN2 = 777777777 (REFUSED) OR 999999999 (DON’T KNOW), DISPLAY “GO BACK TO PREVIOUS QUESTION AND CODE “DON’T KNOW” OR “REFUSED”.”
IF DMQSSN1 OR DMQSSN2 ARE NOT BOTH ENTERED (NO DOUBLE ENTRY), DISPLAY “DOUBLE ENTRY IS REQUIRED. PLEASE ENTER SOCIAL SECURITY NUMBER TWICE.” |
SOFT CHECK |
|
VERSION NOTES |
DMQ.281b/c |
NEXT |
END OF SECTION |
ACCULTURATION – ACQ
Target Group: SPs 3+
ACQHOME / ACQHOMEO |
|
ASK |
IF SP AGE >= 3 YEARS |
Now I’m going to ask you about language use.
What language(s) <TEXT FILL 1> usually speak at home?
[CODE ALL THAT APPLY]
HAND CARD ACQ2
1. ENGLISH 2. SPANISH 3. CHINESE 4. JAPANESE 5. KOREAN 6. VIETNAMESE 66. OTHER (SPECIFY) [ACQHOMEO] 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
Ahora le preguntaré sobre el idioma que habla.
¿Qué idioma(s) habla <TEXT FILL 1> usualmente en el hogar?
[CODE ALL THAT APPLY]
HAND CARD ACQ2
1. INGLÉS 2. ESPAÑOL 3. CHINO 4. JAPONÉS 5. COREANO 6. VIETNAMITA 66. OTRO (ESPECIFIQUE) [ACQHOMEO] 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Checkbox: ACQHOME Dropdown: ACQHOMEO |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
FOR ACQHOMEO (CODE 66 “OTHER (SPECIFY)”), INCLUDE A DROPDOWN LIST WITH TRIAGRAM SEARCH FUNCTION |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
ACQ.NEW1 |
NEXT |
IF ACQHOME = 1 AND NO OTHERS: END OF SECTION IF ACQHOME != 1 AS A RESPONSE: END OF SECTION IF ACQHOME = 1 AND ONLY 1 OTHER RESPONSE OPTION 2-66: ACQPREFER IF ACQHOME = 1 AND 2 OR MORE OTHER RESPONSE OPTION 2-66: ACQPRIMARY IF ACQHOME = 77 OR 99: END OF SECTION |
ACQPRIMARY |
|
ASK |
IF ACQHOME = 1 AND 2 OR MORE OTHER RESPONSE OPTION 2-66 |
Of these languages <ACQHOME FILL>, which <TEXT FILL 1> speak more of at home?
1. ENGLISH 2. SPANISH 3. CHINESE 4. JAPANESE 5. KOREAN 6. VIETNAMESE 66. <ACQHOMEO FILL> 77. REFUSED 99. DON’T KNOW
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|
SPANISH |
De estos idiomas, <ACQHOME FILL>, ¿cuál habla más <TEXT FILL 1> en el hogar?
1. INGLÉS 2. ESPAÑOL 3. CHINO 4. JAPONÉS 5. COREANO 6. VIETNAMITA 66. <ACQHOMEO FILL> 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
ACQHOME FILL: FILL NON-ENGLISH RESPONSE OPTIONS SELECTED IN ACQHOME AND/OR ACQHOMEO, SEPERATING WITH A COMMA. BEFORE LAST RESPONSE DISPLAY “and”.
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]”
ACQHOMEO FILL: IF NON-ENGLISH RESPONSE OPTION ENTERED FOR ACQHOMEO, FILL RESPONSE OPTION ENTERED FOR ACQHOMEO ELSE, LEAVE BLANK |
FILLS (SPA) |
ACQHOME FILL: FILL NON-ENGLISH RESPONSE OPTIONS SELECTED IN ACQHOME AND/OR ACQHOMEO, SEPERATING WITH A COMMA. BEFORE LAST RESPONSE DISPLAY “y”.
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
ACQHOMEO FILL: IF NON-ENGLISH RESPONSE OPTION ENTERED FOR ACQHOMEO, FILL RESPONSE OPTION ENTERED FOR ACQHOMEO ELSE, LEAVE BLANK |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
ACQ.NEW2 |
NEXT |
IF ACQPRIMARY = 77 OR 99: END OF SECTION ELSE: ACQPREFER |
ACQPREFER |
|
ASK |
IF (ACQHOME = 1 AND 1 OR MORE OTHER RESPONSE OPTION 2-66) AND ACQPRIMARY != 77 or 99 |
<TEXT FILL 1> speak only <LANGUAGE FILL>, more <LANGUAGE FILL> than English, both equally, more English than <LANGUAGE FILL>, or only English?
1. ONLY <LANGUAGE FILL>, 2. MORE <LANGUAGE FILL> THAN ENGLISH, 3. BOTH EQUALLY, 4. MORE ENGLISH THAN <LANGUAGE FILL>, OR 5. ONLY ENGLISH 7. REFUSED 9. DON’T KNOW |
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SPANISH |
¿<TEXT FILL 1> habla únicamente <LANGUAGE FILL>, más <LANGUAGE FILL> que inglés, ambos por igual, más inglés que <LANGUAGE FILL>, o únicamente inglés?
1. SOLO <LANGUAGE FILL> 2. MÁS <LANGUAGE FILL> QUE INGLÉS 3. AMBOS POR IGUAL 4. MÁS INGLÉS QUE <LANGUAGE FILL> 5. ÚNICAMENTE INGLÉS 7. REFUSED 9. DON’T KNOW |
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]”
LANGUAGE FILL: FILL NON-ENGLISH RESPONSE OPTION SELECTED IN ACQHOME OR ACQHOMEO IF ACQHOME = 1 (ENGLISH) AND ONLY ONE OTHER RESPONSE OPTION 2-66. ELSE, FILL RESPONSE OPTION SELECTED IN ACQPRIMARY (IF ACQHOME = 1 AND TWO OR MORE OTHER RESPONSE OPTIONS 2-66) |
FILLS (SPA) |
TEXT FILL 1: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
LANGUAGE FILL: FILL NON-ENGLISH RESPONSE OPTION SELECTED IN ACQHOME OR ACQHOMEO IF ACQHOME = 1 (ENGLISH) AND ONLY ONE OTHER RESPONSE OPTION 2-66. ELSE, FILL RESPONSE OPTION SELECTED IN ACQPRIMARY (IF ACQHOME = 1 AND TWO OR MORE OTHER RESPONSE OPTIONS 2-66) |
NOTES |
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HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
ACQ.NEW3 |
NEXT |
END OF SECTION |
HEALTH INSURANCE – HIQ
Target Group: Birth+
HIQINSR |
|
ASK |
All respondents |
The next questions are about health insurance. Include health insurance obtained through employment or purchased directly as well as government programs like Medicare, Medicaid, and the Children’s Health Insurance Program that provide medical care or help pay medical bills. <TEXT FILL 1> covered by any kind of health insurance or some other kind of health care plan?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
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|
SPANISH |
Las siguientes preguntas son acerca del seguro de salud. Incluya el seguro de salud obtenido a través de un empleo o comprado directamente, así como programas del gobierno, tales como Medicare, Medicaid y el Programa de Seguro Médico para Niños, que ofrecen servicios médicos o ayudan a pagar las cuentas médicas. ¿Tiene <TEXT FILL 1> cobertura de algún seguro de salud o algún otro tipo de plan de atención médica?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Is [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN (ENG) |
Health Insurance: Health benefits coverage which provides persons with health-related benefits. Coverage may include the following; hospitalization, major medical, surgical, prescriptions, dental, and vision. |
HELP SCREEN (SPA) |
Seguro médico: Cobertura de beneficios de salud que se proporciona a las personas con beneficios relacionados con la salud. La cobertura puede incluir lo siguiente: hospitalización, servicios médicos principales, cirugía, medicamentos recetados, servicio dental y visión. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
HIQ.011 |
NEXT |
IF HIQINSR = 1: HIQINSRTYP IF HIQINSR = 2 OR 7 OR 9 AND SP AGE >= 65 YEARS: HIQMEDICR IF HIQINSR = 2 OR 7 OR 9 AND SP AGE < 65 YEARS: END OF SECTION |
HIQINSRTYP |
|
ASK |
IF HIQINSR = 1 |
Please look at card HIQ1. What kinds of health insurance or health care coverage <TEXT FILL 1> have? Is it… private health insurance, Medicare, Medi-Gap, Medicaid, Children’s Health Insurance Program or CHIP, military related health care including TRICARE, CHAMPUS, VA health care and CHAMP-VA, Indian Health Service, a state-sponsored health plan (<STATE PLAN FILL>), or other government program?
[CODE ALL THAT APPLY]
HAND CARD HIQ1
1. PRIVATE HEALTH INSURANCE 2. MEDICARE 3. MEDI-GAP 4. MEDICAID 5. CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) 6. MILITARY RELATED HEALTH CARE: TRICARE (CHAMPUS)/VA HEALTH CARE/CHAMP-VA 7. INDIAN HEALTH SERVICE 8. STATE-SPONSORED HEALTH PLAN (<STATE PLAN FILL>) 9. OTHER GOVERNMENT PROGRAM 140. NO COVERAGE OF ANY TYPE
77. REFUSED 99. DON'T KNOW
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SPANISH |
Mire la tarjeta HIQ1. ¿Qué tipo de seguro médico o cobertura de atención médica tiene <TEXT FILL 1>? ¿Es... un seguro médico privado, Medicare; Medi-Gap; Medicaid; el Programa de Seguro Médico para Niños o CHIP, por sus siglas en inglés, atención médica para militares, incluidos TRICARE, CHAMPUS, CHAMPUS, atención médica de VA y CHAMP-VA, Servicio de Salud Indígena, un plan de salud patrocinado por el estado (<STATE PLAN FILL>), u otro programa del gobierno?
[CODE ALL THAT APPLY]
HAND CARD HIQ1
1. PLAN DE SEGURO DE SALUD PRIVADO 2. MEDICARE 3. MEDI-GAP 4. MEDICAID 5. PROGRAMA DE SEGURO MÉDICO PARA NIÑOS (CHIP) 6. ATENCIÓN MÉDICA PARA MILITARES: TRICARE (CHAMPUS)/ATENCIÓN MÉDICA DE VA/CHAMP-VA) 7. SERVICIO DE SALUD INDÍGENA 8. PLAN DE SALUD PATROCINADO POR EL ESTADO (<STATE PLAN FILL>) 9. OTRO PROGRAMA DEL GOBIERNO 140. SIN COBERTURA DE NINGÚN TIPO
77. REFUSED 99. DON'T KNOW
|
QUESTION TYPE |
Checkbox |
FILLS (ENG) |
TEXT FILL 1: FILL “do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “does [SP NAME]”
STATE PLAN FILL: FILL STATE PLAN NAME |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
STATE PLAN FILL: FILL STATE PLAN NAME |
NOTES |
DO NOT ALLOW MORE THAN ONE ANSWER WHEN 140 (NO COVERAGE OF ANY TYPE) IS CODED. |
HELP SCREEN (ENG) |
Health Insurance: Health benefits coverage which provides persons with health-related benefits. Coverage may include the following; hospitalization, major medical, surgical, prescriptions, dental, and vision.
Private Health Insurance Plan: Any type of health insurance, including HMOs, that is not a public program. Private health insurance plans may be provided in part or full by a person's employer or union, or may be purchased directly by an individual.
Private Health Insurance Plan through a State or Local Government Program or Community Program: A type of health insurance for which state or local government or community effort pays for part or all of the cost of a private insurance plan. A community program or effort may include a variety of mechanisms to achieve health insurance for persons who would otherwise be uninsured. An example would be a private company giving a grant to an HMO to pay for health insurance coverage.
Medicare: A Federal health insurance program for people 65 or older and for certain persons under 65 with long-term disabilities. Almost all Social Security recipients are covered by Medicare. It is run by the Center for Medicare and Medicaid Services of the U.S., Department of Health and Human Services.
Medi-Gap: Refers to private health insurance purchased to supplement Medicare. Medi-Gap will be treated as a private health insurance plan in the detailed questions about health insurance.
Medicaid: Refers to a medical assistance program that provides health care coverage to low-income and disabled persons. The Medicaid program is a joint federal-state program which is administered by the states.
CHIP (Children's Health Insurance Program, formerly known as the State Children’s Health Insurance Program or SCHIP): A joint federal and state program, administered by each state, that offers health care coverage to low-income, uninsured children. This law was passed in 1997. In some states, CHIP programs have distinct names.
Military Health Care/VA: Military Health Care (also known as Tricare) refers to health care available to active duty personnel and their dependents. The US Department of Veterans Affairs (commonly referred to as the “VA”) provides medical assistance to veterans (not active duty) of the Armed Forces, particularly those with service-connected ailments.
TRICARE: TRICARE is the military health insurance for active duty service members and dependents of the uniformed services (Army, Navy, Air Force, Marines, Coast Guard, Space Force, Public Health Service, or National Oceanic and Atmospheric Association). Several varitions of the plan exist including (but are not limited to): TRICARE Reserve Select, TRICARE Prime, TRICARE Select, U.S. Family Health Plan, TRICARE Select Overseas, and TRICARE for Life. CHAMP-VA (Comprehensive Health and Medical Plan of the Veterans Administration) provides health care for the spouse, dependents, or survivors of a veteran who has a total, permanent service-connected disability.
Indian Health Service: The federal health care program for members of federally-recognized Native American Tribes and Alaska Native people.
State-Sponsored Health Plan: Any other health care coverage run by a specific state, including public assistance programs other than "Medicaid" that pay for health care.
Other Government Program: A catch-all category for any public program providing health care coverage other than those programs in specific categories. |
HELP SCREEN (SPA) |
Seguro médico: Cobertura de beneficios de salud que se proporciona a las personas con beneficios relacionados con la salud. La cobertura puede incluir lo siguiente: hospitalización, servicios médicos principales, cirugía, medicamentos recetados, servicio dental y visión.
Plan privado de seguro de salud: Cualquier tipo de seguro de salud, incluidas las organizaciones para el mantenimiento de la salud (HMOs, por sus siglas en inglés), que no es un programa público. Los planes de seguros privados de salud los puede ofrecer en parte o en total el empleador de la persona o un sindicato, o pueden ser comprados directamente por una persona.
Plan privado de seguro de salud a través de un programa del gobierno local, estatal o programas comunitarios: Un tipo de seguro médico por el cual el gobierno estatal o local o una iniciativa de la comunidad paga una parte o todo el costo de un plan de seguro privado. Un programa o iniciativa de la comunidad puede incluir una variedad de métodos para obtener seguros de salud para personas que de otra manera no tendrían seguro. Un ejemplo de esto sería que una compañía privada que da una subvención a una HMO para pagar la cobertura del seguro de salud.
Medicare: Un programa federal de seguro de salud para personas de 65 años o más y para ciertas personas menores de 65 años con discapacidades de larga duración. Casi todos los beneficiarios del Seguro Social están cubiertos por Medicare. El programa es administrado por el Centro de Servicios de Medicare y Medicaid de los Estados Unidos, del Departamento de Salud y Servicios Humanos.
Medi-Gap: Se refiere a un seguro de salud privado que se compra para suplementar Medicare. Medi-Gap se debe considerar un plan privado de seguro de salud en las preguntas detalladas acerca de seguros de salud.
Medicaid: Se refiere a un programa de asistencia médica que ofrece cobertura de atención médica a personas de bajos ingresos y con discapacidades. El programa Medicaid es un programa conjunto federal y estatal administrado por los estados.
CHIP (Programa de Seguro Médico para Niños, llamado anteriormente Programa Estatal de Seguro Médico para Niños o SCHIP): Un programa conjunto federal y estatal, administrado por cada estado, que ofrece cobertura de atención médica a niños no asegurados de familias de bajos ingresos. Esta ley se aprobó en 1997. En algunos estados, los programas CHIP tienen distintos nombres.
Atención médica militar/VA: La atención médica militar (también conocida como Tricare) se refiere al servicio de salud disponible al personal en servicio activo y sus dependientes. El Departamento de Asuntos de Veteranos de Estados Unidos (conocido comúnmente como VA) ofrece asistencia médica a los veteranos de las Fuerzas Armadas (que no están en servicio activo), particularmente a aquellos con enfermedades relacionadas con el servicio.
TRICARE: TRICARE es el seguro médico para militares en servicio activo y sus dependientes de los servicios uniformados (Ejército, Fuerza Naval, Fuerza Aérea, Infantería de Marina, Guardia Costera, Fuerza Espacial, Servicio de Salud Pública o Asociación Nacional Oceánica y Atmosférica). Existen diferentes variaciones del plan que incluyen (pero no se limitan a): TRICARE Reserve Select, TRICARE Prime, TRICARE Select, Plan de Salud Familiar de Estados Unidos, TRICARE Select en el Extranjero y TRICARE de por Vida. CHAMP-VA (Programa Médico y de Salud Civil del Departamento de Asuntos de Veteranos) ofrece atención médica al cónyuge, a los dependientes o sobrevivientes de un veterano que tenga una discapacidad total y permanente relacionada con el servicio activo.
Servicio de Salud Indígena: Programa federal de atención médica para miembros de tribus de indígenas estadounidenses y comunidades nativas de Alaska reconocidas por el gobierno federal.
Plan de salud patrocinado por el estado: Cualquier otra cobertura de atención médica patrocinada por un estado específico, incluidos los programas de asistencia pública diferentes a Medicaid que pagan por la atención médica.
Otro programa del gobierno: Categoría general para cualquier programa público que ofrezca cobertura de atención médica distinta a aquellos programas señalados bajo categorías específicas. |
HARD CHECK |
IF HIQINSRTYP = 3 (MEDI-GAP) AND 2 (MEDICARE) IS NOT SELECTED, DISPLAY “MEDI-GAP REFERS TO MEDICARE SUPPLEMENTAL INSURANCE. YOU MUST HAVE MEDICARE TO BE ELIGIBLE TO PURCHASE MEDI-GAP. PLEASE VERIFY IF SP HAS MEDI-GAP AND, IF YES, IF HE/SHE HAS MEDICARE.”
IF NO RESPONSE SELECTED, DISPLAY “PLEASE SELECT A RESPONSE TO CONTINUE. IF THE RESPONDENT DOES NOT KNOW OR REFUSES TO PROVIDE THE TYPE OF INSURANCE, ENTER “DON’T KNOW” OR “REFUSED” TO CONTINUE. IF RESPONDENT DOES NOT HAVE HEALTH INSURANCE, GO BACK TO THE PREVIOUS SCREEN AND UPDATE HIQINSR RESPONSE TO “NO.” |
SOFT CHECK |
IF SP AGE < 18 YEARS AND HIQINSRTYP = 2 (MEDICARE), DISPLAY, “PLEASE VERIFY THAT CHILD SP HAS MEDICARE. Only disabled children or children with kidney failure can get Medicare. Children who have Medicare are almost always also receiving Social Security or SSI and have Medicaid. update response if needed or press “suppress” and “next” to continue.” IF (SP AGE >= 18 YEARS AND < 65 YEARS) AND HIQINSRTYP = 2 (MEDICARE), DISPLAY “PLEASE VERIFY THAT SP AGE 18-64 HAS MEDICARE. Only disabled adults or adults with kidney failure under 65 years old can have Medicare. They are almost always receiving disability checks from Social Security or SSI. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
HIQ.032 |
NEXT |
IF HIQINSRTYP != 2 AND SP AGE >= 65 YEARS: HIQMEDICR IF HIQINSRTYP != 2 AND SP AGE < 65 YEARS: END OF SECTION IF HIQINSRTYP = 2 AND DMQLINK = 1: HIQMEDICRN1 IF HIQINSRTYP = 2 AND DMQLINK = 2: END OF SECTION |
HIQMEDICR |
|
ASK |
IF (HIQINSR = 2 OR 7 OR 9) AND SP AGE >= 65 YEARS IF HIQINSRTYP != 2 AND SP AGE >= 65 YEARS |
<TEXT FILL 1> have Medicare? This is a health insurance program that virtually all persons 65 and older are eligible for. A card is automatically mailed to you shortly before your 65th birthday. You can see an example of the card on card HIQ2.
HAND CARD HIQ2
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tiene <TEXT FILL 1> Medicare? Este es un programa de seguro de salud al que prácticamente todas las personas mayores de 65 años o más son elegibles. Automáticamente le envían por correo una tarjeta poco antes de cumplir 65 años. En la tarjeta HIQ2 puede ver un ejemplo de la tarjeta que recibirá.
HAND CARD HIQ2
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Do you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Does [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
HIQ.260 |
NEXT |
IF HIQMEDICR = 1 and DMQLINK = 1: HIQMEDICRN1 ELSE: END OF SECTION |
HIQMEDICRN1 / HIQMEDICRN2 |
|
ASK |
IF HIQINSRTYP = 2 AND DMQLINK = 1 IF HIQMEDICR = 1 AND DMQLINK = 1 |
Earlier you consented to linking <TEXT FILL 1> survey data with other records using information from the survey. Another way that we link to people’s records is using their Medicare number. Please look at your Medicare card and tell me the Medicare Number on the card.
This number is needed to allow Medicare records of the Center for Medicare and Medicaid Services to be easily and accurately located and identified for statistical purposes. Providing the Medicare Number is voluntary and collected under the authority of Section 306 of the Public Health Service Act. Whether the number is given or not, there will be no effect on <TEXT FILL 2> benefits. This number will be held confidential. (The Public Health Service Act is Title 42, United States Code, Section 242K.)
|___|___|___|___|___|___|___|___|___|___|___| [HIQMEDICRN1] ENTER MEDICARE NUMBER
|___|___|___|___|___|___|___|___|___|___|___| [HIQMEDICRN2] ENTER MEDICARE NUMBER
77777777777. REFUSED 99999999999. DON’T KNOW
|
|
SPANISH |
Anteriormente usted dio su consentimiento para vincular <TEXT FILL 1> con otros registros usando información de la encuesta. Otra forma de vincular datos con los registros de las personas es usar su número de Medicare. Por favor, mire su tarjeta de Medicare y dígame el número de Medicare que aparece en la tarjeta.
Este número es necesario para que los registros de Medicare del Centro de Servicios de Medicare y Medicaid puedan encontrarse e identificarse con facilidad y precisión con fines estadísticos. Dar el número de Medicare es voluntario y esta información se recopila conforme a la sección 306 de la Ley de Servicios Públicos de Salud. Si no nos da el número, eso no afectará <TEXT FILL 2>. Este número se mantendrá confidencial. (La Ley de Servicios Públicos de Salud es el título 42 del Código de los Estados Unidos, sección 242K).
|___|___|___|___|___|___|___|___|___|___|___| [HIQMEDICRN1] ENTER MEDICARE NUMBER
|___|___|___|___|___|___|___|___|___|___|___| [HIQMEDICRN2] ENTER MEDICARE NUMBER
77777777777. REFUSED 99999999999. DON’T KNOW
|
QUESTION TYPE |
Text entry - letters or numbers |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPODNENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “sus datos de la encuesta” IF SP IS SELECTED AS RESPODNENT IN SPQSELECTR ELSE, FILL “los datos de la encuesta de [SP NAME]”
TEXT FILL 2: FILL “sus beneficios” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “los beneficios de él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “los beneficios de ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “los beneficios de [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
REQUIRE DOUBLE ENTRY OF MEDICARE NUMBER |
HELP SCREEN |
|
HARD CHECK |
ONLY ALLOW RESPONSE OF HIQMEDICRN1=DON’T KNOW, HIQMEDICRN1=REFUSED, OR SAME 11-DIGIT MEDICARE NUMBER ENTERED FOR BOTH HIQMEDICRN1 AND HIQMEDICRN2
IF HIQMEDICRN1 AND HIQMEDICRN2 DO NOT MATCH
ELSE, IF HIQMEDICRN1 AND HIQMEDICRN2 MATCH
|
SOFT CHECK |
|
VERSION NOTES |
HIQ.502 HIQ.510 |
NEXT |
END OF SECTION |
INFANT FORMULA – IFQ
Target Group: SPs Birth to 1 Year
IFQFRMULA |
|
ASK |
IF SP AGE 0-11 MONTHS OR 1 YEAR AND ((DBQFRMLSPG=2, DK, OR REF) OR (DBQFRMLSPG=1 AND DIFFERENCE BETWEEN AGE REPORTED IN DBQFRMLSPG AND CURRENT AGE < 1 MONTH)) |
Now I’d like to know about any infant and toddler formulas <TEXT FILL 1> had in the last two weeks. May I please see the containers for all the infant and toddler formulas that were fed to <TEXT FILL 1> (in the last two weeks)?
INTERVIEWER INSTRUCTION: TODDLER FORMULAS MAY ALSO BE CALLED TODDLER MILK, GROWING UP MILK, OR FOLLOW-ON FORMULA.
|
|
SPANISH |
Ahora me gustaría saber sobre todo tipo de fórmula para bebés y niños pequeños que haya tomado <TEXT FILL 1> en las últimas dos semanas. ¿Podría ver los envases de todas las fórmulas para bebés y niños pequeños con las que se alimentó a <TEXT FILL 1> (en las dos últimas semanas)?
INTERVIEWER INSTRUCTION: TODDLER FORMULAS MAY ALSO BE CALLED TODDLER MILK, GROWING UP MILK, OR FOLLOW-ON FORMULA.
DON’T KNOW |
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IFQ.001 |
NEXT |
IF IFQFRMULA=1: IFQLOOKUP ELSE: END OF SECTION |
IFQLOOKUP |
|
ASK |
IF IFQFRMULA=1 |
REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF INFANT FORMULAS USED.
BEGIN TYPING TO SELECT FORMULA FROM LIST OR SELECT “OTHER FORMULA” TO ENTER A NEW FORMULA
[ENTER FORMULA NAME]
66. OTHER FORMULA 77. REFUSED 99. DON'T KNOW
|
|
SPANISH |
N/A |
QUESTION TYPE |
Lookup list with radio buttons |
FILLS |
|
NOTES |
DISPLAY “CLEAR” BUTTON THAT CLEARS RESPONSE
IF FORMULA SELECTED FROM LIST, SAVE RESPONSE TEXT AS IFQNAME
LOOP THROUGH IFQLOOKUP, IFQNAME, IFQCONTANR, IFQBASE, IFQFORM, IFQINGREDN, IFQAGE, IFQMANUFCT, IFQCITY, IFQSTATE, IFQDURATN, AND IFQOTHERYN FOR EACH FORMULA
AFTER LOOP 1, DISPLAY NUMBERED LIST OF SELECTED FORMULA(S) ABOVE QUESTION STEM |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IFQ.005 |
NEXT |
IF FORMULA SELECTED FROM LIST: IFQCONTANR IF IFQLOOKUP=66 (OTHER FORMULA): IFQNAME IF IFQLOOKUP= DK OR REF AND THERE ARE PREVIOUSLY ENTERED FORMULAS: IFQTOTALNUM IF IFQLOOKUP=DK OR REF AND NO FORMULAS HAVE BEEN ENTERED: END OF SECTION |
IFQNAME |
|
ASK |
IF IFQLOOKUP=66 (OTHER FORMULA) |
FOR FORMULAS NOT INCLUDED IN THE LOOKUP LIST, ENTER THE FORMULA NAME BELOW.
__________________________________ ENTER FORMULA NAME
|
|
SPANISH |
N/A |
QUESTION TYPE |
Text entry |
FILLS |
|
NOTES |
DO NOT ALLOW BLANK ENTRY
LOOP THROUGH IFQLOOKUP, IFQNAME, IFQCONTANR, IFQBASE, IFQFORM, IFQINGREDN, IFQAGE, IFQMANUFCT, IFQCITY, IFQSTATE, IFQDURATN, AND IFQOTHERYN FOR EACH FORMULA |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IFQ.005OS |
NEXT |
IFQCONTANR |
IFQCONTANR |
|
ASK |
IF FORMULA SELECTED AT IFQLOOKUP OR ENTERED AT IFQNAME |
INTERVIEWER INSTRUCTION: ENTER 1 RESPONSE
|
|
SPANISH |
N/A |
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
LOOP THROUGH IFQLOOKUP, IFQNAME, IFQCONTANR, IFQBASE, IFQFORM, IFQINGREDN, IFQAGE, IFQMANUFCT, IFQCITY, IFQSTATE, IFQDURATN, AND IFQOTHERYN FOR EACH FORMULA |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IFQ.010 |
NEXT |
IF FORMULA SELECTED AT IFQLOOKUP: IFQDURATNQ IF FORMULA ENTERED AT IFQNAME: IFQBASE |
IFQBASE |
|
ASK |
IF FORMULA ENTERED AT IFQNAME |
WHAT IS THE BASE OF THIS FORMULA?
|
|
SPANISH |
N/A |
QUESTION TYPE |
Dropdown |
FILLS |
|
NOTES |
DISPLAY IFQBASE - IFQSTATE IN A SINGLE TABLE, WITH EACH QUESTION IN LEFT COLUMN AND RESPONSE OPTIONS IN RIGHT COLUMN. ABOVE THE TABLE, DISPLAY PRODUCT NAME AS HEADER, THEN “INTERVIEWER INSTRUCTION: IF CONTAINER IS NOT SEEN, PROBE IF NECESSARY BY READING POSSIBLE RESPONSE OPTIONS FOR THE FOLLOWING QUESTIONS.”
LOOP THROUGH IFQLOOKUP, IFQNAME, IFQCONTANR, IFQBASE, IFQFORM, IFQINGREDN, IFQAGE, IFQMANUFCT, IFQCITY, IFQSTATE, IFQDURATN, AND IFQOTHERYN FOR EACH FORMULA |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IFQ.015 |
NEXT |
IFQFORM |
IFQFORM |
|
ASK |
IF FORMULA ENTERED AT IFQNAME |
WHAT IS THE FORM OF THIS FORMULA?
|
|
SPANISH |
N/A |
QUESTION TYPE |
Dropdown |
FILLS |
|
NOTES |
DISPLAY IFQBASE - IFQSTATE IN A SINGLE TABLE, WITH EACH QUESTION IN LEFT COLUMN AND RESPONSE OPTIONS IN RIGHT COLUMN. ABOVE THE TABLE, DISPLAY PRODUCT NAME AS HEADER, THEN “INTERVIEWER INSTRUCTION: IF CONTAINER IS NOT SEEN, PROBE IF NECESSARY BY READING POSSIBLE RESPONSE OPTIONS FOR THE FOLLOWING QUESTIONS.”
LOOP THROUGH IFQLOOKUP, IFQNAME, IFQCONTANR, IFQBASE, IFQFORM, IFQINGREDN, IFQAGE, IFQMANUFCT, IFQCITY, IFQSTATE, IFQDURATN, AND IFQOTHERYN FOR EACH FORMULA |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IFQ.020 |
NEXT |
IFQINGREDN |
IFQINGREDN / IFQINGREDNOS |
|
ASK |
N/A |
WHAT ARE THE ADDED INGREDIENTS OR DESCRIPTIONS FOR THIS FORMULA? SELECT ALL THAT APPLY.
|
|
SPANISH |
N/A |
QUESTION TYPE |
Select all that apply: IFQINGREDN Text entry: IFQINGREDNOS |
FILLS |
|
NOTES |
DISPLAY IFQBASE - IFQSTATE IN A SINGLE TABLE, WITH EACH QUESTION IN LEFT COLUMN AND RESPONSE OPTIONS IN RIGHT COLUMN. ABOVE THE TABLE, DISPLAY PRODUCT NAME AS HEADER, THEN “INTERVIEWER INSTRUCTION: IF CONTAINER IS NOT SEEN, PROBE IF NECESSARY BY READING POSSIBLE RESPONSE OPTIONS FOR THE FOLLOWING QUESTIONS.”
ORDER RESPONSE OPTIONS SO THAT 1. “NO ADDED INGREDIENTS OR DESCRIPTIONS” IS BELOW 91. “OTHER (SPECIFY)”
FOR RESPONSE OPTION 91: “SPECIFY ADDED INGREDIENTS OR DESCRIPTIONS”
LOOP THROUGH IFQLOOKUP, IFQNAME, IFQCONTANR, IFQBASE, IFQFORM, IFQINGREDN, IFQAGE, IFQMANUFCT, IFQCITY, IFQSTATE, IFQDURATN, AND IFQOTHERYN FOR EACH FORMULA
“NO ADDED INGREDIENTS OR DESCRIPTIONS”, DK, OR REF MAY NOT BE SELECTED WITH ANY OTHER ENTRY. |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IFQ.025/IFQ.025OS |
NEXT |
IFQAGE |
IFQAGE / IFQAGEOS |
|
ASK |
IF FORMULA ENTERED AT IFQNAME |
WHAT IS THE AGE FOR THIS FORMULA?
|
|
SPANISH |
N/A |
QUESTION TYPE |
Dropdown: IFQAGE Text entry: IFQAGEOS |
FILLS |
|
NOTES |
DISPLAY IFQBASE - IFQSTATE IN A SINGLE TABLE, WITH EACH QUESTION IN LEFT COLUMN AND RESPONSE OPTIONS IN RIGHT COLUMN. ABOVE THE TABLE, DISPLAY PRODUCT NAME AS HEADER, THEN “INTERVIEWER INSTRUCTION: IF CONTAINER IS NOT SEEN, PROBE IF NECESSARY BY READING POSSIBLE RESPONSE OPTIONS FOR THE FOLLOWING QUESTIONS.”
FOR RESPONSE OPTION 91: “SPECIFY AGE”
LOOP THROUGH IFQLOOKUP, IFQNAME, IFQCONTANR, IFQBASE, IFQFORM, IFQINGREDN, IFQAGE, IFQMANUFCT, IFQCITY, IFQSTATE, IFQDURATN, AND IFQOTHERYN FOR EACH FORMULA |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IFQ.030/IFQ.030OS |
NEXT |
IFQMANUFCT |
IFQMANUFCT / IFQMANUFCTOS |
|
ASK |
IF FORMULA ENTERED AT IFQNAME |
SELECT MANUFACTURER FROM LIST.
[DISPLAY MANUFACTURER LIST]
91. OTHER (SPECIFY) 77. REFUSED 99. DON’T KNOW |
|
SPANISH |
N/A |
QUESTION TYPE |
Dropdown: IFQMANUFCT Text entry: IFQMANUFCTOS |
FILLS |
|
NOTES |
DISPLAY IFQBASE - IFQSTATE IN A SINGLE TABLE, WITH EACH QUESTION IN LEFT COLUMN AND RESPONSE OPTIONS IN RIGHT COLUMN. ABOVE THE TABLE, DISPLAY PRODUCT NAME AS HEADER, THEN “INTERVIEWER INSTRUCTION: IF CONTAINER IS NOT SEEN, PROBE IF NECESSARY BY READING POSSIBLE RESPONSE OPTIONS FOR THE FOLLOWING QUESTIONS.”
DISPLAY MANUFACTURER LIST.
FOR RESPONSE OPTION 91: “SPECIFY MANUFACTURER’S NAME.”
LOOP THROUGH IFQLOOKUP, IFQNAME, IFQCONTANR, IFQBASE, IFQFORM, IFQINGREDN, IFQAGE, IFQMANUFCT, IFQCITY, IFQSTATE, IFQDURATN, AND IFQOTHERYN FOR EACH FORMULA |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IFQ.035/IFQ.035OS |
NEXT |
IF IFQMANUFCT=91 (OTHER): IFQCITY ELSE: IFQDURATNQ |
IFQCITY |
|
ASK |
IF IFQMANUFCT=91 (OTHER) |
ENTER MANUFACTURER CITY.
IF FORMULA IS FROM A FOREIGN COUNTRY, ENTER COUNTRY OF MANUFACTURER.
77. DON’T KNOW 99. REFUSED |
|
SPANISH |
N/A |
QUESTION TYPE |
Text entry |
FILLS |
|
NOTES |
DISPLAY IFQBASE - IFQSTATE IN A SINGLE TABLE, WITH EACH QUESTION IN LEFT COLUMN AND RESPONSE OPTIONS IN RIGHT COLUMN. ABOVE THE TABLE, DISPLAY PRODUCT NAME AS HEADER, THEN “INTERVIEWER INSTRUCTION: IF CONTAINER IS NOT SEEN, PROBE IF NECESSARY BY READING POSSIBLE RESPONSE OPTIONS FOR THE FOLLOWING QUESTIONS.”
LOOP THROUGH IFQLOOKUP, IFQNAME, IFQCONTANR, IFQBASE, IFQFORM, IFQINGREDN, IFQAGE, IFQMANUFCT, IFQCITY, IFQSTATE, IFQDURATN, AND IFQOTHERYN FOR EACH FORMULA |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IFQ.045 |
NEXT |
IFQSTATE |
IFQSTATE |
|
ASK |
IF IFQMANUFCT=91 (OTHER) |
ENTER 2-LETTER STATE ABBREVIATION. SELECT STATE FROM LIST.
IF FORMULA IS FROM A FOREIGN COUNTRY, SELECT DON’T KNOW.
[DISPLAY STATE ABBREVIATION LIST]
77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
N/A |
QUESTION TYPE |
Lookup list with radio buttons |
FILLS |
|
NOTES |
DISPLAY IFQBASE - IFQSTATE IN A SINGLE TABLE, WITH EACH QUESTION IN LEFT COLUMN AND RESPONSE OPTIONS IN RIGHT COLUMN. ABOVE THE TABLE, DISPLAY PRODUCT NAME AS HEADER, THEN “INTERVIEWER INSTRUCTION: IF CONTAINER IS NOT SEEN, PROBE IF NECESSARY BY READING POSSIBLE RESPONSE OPTIONS FOR THE FOLLOWING QUESTIONS.”
LOOP THROUGH IFQLOOKUP, IFQNAME, IFQCONTANR, IFQBASE, IFQFORM, IFQINGREDN, IFQAGE, IFQMANUFCT, IFQCITY, IFQSTATE, IFQDURATN, AND IFQOTHERYN FOR EACH FORMULA |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IFQ.050 |
NEXT |
IFQDURATNQ |
IFQDURATNQ / IFQDURATNU |
|
ASK |
IF FORMULA SELECTED AT IFQLOOKUP OR ENTERED AT IFQNAME |
How long has <TEXT FILL 1> been fed this formula?
|__|__|__|
777. REFUSED 999. DON’T KNOW
|__|
|
|
SPANISH |
¿Durante cuánto tiempo se alimentó a <TEXT FILL 1> con esta fórmula?
|__|__|__|
777. REFUSED 999. DON’T KNOW
|__|
|
QUESTION TYPE |
Numeric: IFQDURATNQ Dropdown: IFQDURATNU |
FILLS |
TEXT FILL 1: FILL SP NAME |
NOTES |
LOOP THROUGH IFQLOOKUP, IFQNAME, IFQCONTANR, IFQBASE, IFQFORM, IFQINGREDN, IFQAGE, IFQMANUFCT, IFQCITY, IFQSTATE, IFQDURATN, AND IFQOTHERYN FOR EACH FORMULA
IF IFQDURATNU = 2 (WEEKS), 3 (MONTHS), OR 4 (YEARS), CALCULATE DURATION SP FED SELECTED FORMULA IN DAYS (IFDDURATNDx) AS FOLLOWS: IF IFQDURATNU = 2, CALCULATE DURATION SP FED SELECTED FORMULA IN DAYS AS (IFQDURATNQ*7) IF IFQDURATNU = 3, CALCULATE DURATION SP FED SELECTED FORMULA IN DAYS AS (IFQDURATNQ*31) IF IFQDURATNU = 4, CALCULATE DURATION SP FED SELECTED FORMULA IN DAYS AS (IFQDURATNQ*365)
|
HELP SCREEN |
|
HARD CHECK |
IF DURATION SP FED SELECTED FORMULA IN DAYS (IFQDURATNDx) > SP AGE IN DAYS (SPDSPAGED or SPDSPAGEQD or SPDSPAGERD), DISPLAY “LENGTH OF TIME CANNOT BE GREATER THAN SP’S AGE” |
SOFT CHECK |
IF (IFQDURATNU=1 (DAYS) AND IFQDURATNQ>40) OR IF (IFQDURATNU=2 (WEEKS) AND IFQDURATNQ>24), DISPLAY “PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
IFQ.055 |
NEXT |
IFQOTHERYN |
IFQOTHERYN |
|
ASK |
IF FORMULA SELECTED AT IFQLOOKUP OR ENTERED AT IFQNAME |
CHECK CONTAINERS: ARE THERE ANY OTHER FORMULAS?
OR ASK RESPONDENT: (Did <TEXT FILL 1> drink any other infant or toddler formulas in the last two weeks?)
|
|
SPANISH |
CHECK CONTAINERS: ARE THERE ANY OTHER FORMULAS?
OR ASK RESPONDENT: (¿Tomó <TEXT FILL 1> alguna otra fórmula para bebés o niños pequeños en las últimas dos semanas?)
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL SP NAME |
NOTES |
NO MORE THAN 5 FORMULAS MAY BE LISTED.
LOOP THROUGH IFQLOOKUP, IFQNAME, IFQCONTANR, IFQBASE, IFQFORM, IFQINGREDN, IFQAGE, IFQMANUFCT, IFQCITY, IFQSTATE, IFQDURATN, AND IFQOTHERYN FOR EACH FORMULA |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IFQ.060 |
NEXT |
IF IFQOTHERYN=1 AND THERE ARE LESS THAN 5 FORMULAS ENTERED: ASK IFQLOOKUP – IFQOTHERYN FOR NEXT FORMULA. ELSE: IFQTOTALNUM |
IFQTOTALNUM |
|
ASK |
IF IFQLOOKUP= DK OR REF AND THERE ARE PREVIOUSLY ENTERED FORMULAS IF IFQOTHERYN = 2 OR DK/RF IF IFQOTHERYN = 1 AND THERE ARE 5 FORMULAS ENTERED |
REVIEW TOTAL NUMBER OF FORMULAS AND THEIR NAMES WITH RESPONDENT.
I have listed <TOTAL FORMULA FILL> formula(s) that <TEXT FILL 2> has taken in the last two weeks: <FORMULA NAME FILL>
PRESS NEXT TO CONTINUE.
|
|
SPANISH |
REVIEW TOTAL NUMBER OF FORMULAS AND THEIR NAMES WITH RESPONDENT.
He registrado que <TEXT FILL 2> ha tomado <TOTAL FORMULA FILL> fórmula(s) en las últimas dos semanas: <FORMULA NAME FILL>
PRESS NEXT TO CONTINUE.
|
QUESTION TYPE |
Informational |
FILLS |
TOTAL FORMULA FILL: DISPLAY TOTAL NUMBER OF FORMULAS SELECTED AT IFQLOOKUP AND ENTERED AT IFQNAME
TEXT FILL 2: FILL SP NAME
FORMULA NAME FILL: FILL NAMES OF ALL FORMULAS SELECTED AT IFQLOOKUP AND ENTERED AT IFQNAME |
NOTES |
DISPLAY NAMES OF ALL INFANT FORMULAS SELECTED AT IFQLOOKUP AND ENTERED AT IFQNAME |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
IFQ.070 |
NEXT |
END OF SECTION |
PRESCRIPTION MEDICATION – RXQ
Target Group: SPs Birth +
RXQPRSCRYN |
|
ASK |
All respondents |
Another important part of this study is the information people provide about the medications they take. In the last 30 days, <TEXT FILL 1> used or taken medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. <TEXT FILL 2>. Do not include prescription vitamins or minerals.
|
|
SPANISH |
Otra parte importante de este estudio es la información que dan las personas sobre los medicamentos que usan. En los últimos 30 días, ¿ha usado o tomado <TEXT FILL 1> medicamentos para los cuales se necesita receta? Incluya solamente aquellos productos recetados por un profesional de la salud, como un médico o un dentista. <TEXT FILL 2>. No incluya vitaminas ni minerales recetados.
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: IF SP IS RESPONDENT, FILL: “have you” ELSE, FILL: “has [SP NAME]”
TEXT FILL 2: IF SP GENDER IS FEMALE & OTHER GENDERS (FEMALE (CODE 2) OR (TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) AND NOT MALE (CODE 1)) OR DK/RF) AND AGE 18-44, FILL: “Please remember to include prescription birth control products that <TEXT FILL 3> taking or using such as pills or patches.” ELSE, LEAVE BLANK
TEXT FILL 3: FILL “you are” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] is ” |
FILLS (SPA) |
TEXT FILL 1: IF SP IS RESPONDENT, FILL: “usted” ELSE, FILL: “[SP NAME]”
TEXT FILL 2: IF SP GENDER IS FEMALE & OTHER GENDERS (FEMALE (CODE 2) OR (TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) AND NOT MALE (CODE 1)) OR DK/RF) AND AGE 18-44, FILL: “Recuerde incluir productos anticonceptivos recetados que <TEXT FILL 3> está tomando o usando, como píldoras o parches” . ELSE, LEAVE BLANK
TEXT FILL 3: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] ” |
NOTES |
|
HELP SCREEN (ENG) |
Prescription Medication: Prescription medications are those ordered by a physician or other authorized medical professional through a written or verbal or electronic prescription for a pharmacist to fill. Prescription medications may also be given by a medical professional directly to a patient to take home, such as free samples.
Prescription medications do not include:
Doctor: The term refers to both doctors of medicine (M.D.s) and doctors of osteopathic medicine (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, but other doctoral degrees such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Health Care Professionals (Health Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, pharmacists, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers. |
HELP SCREEN (SPA) |
Medicamentos recetados: Son aquellos medicamentos o medicinas ordenadas por un médico u otro profesional médico autorizado, por medio de una receta escrita, verbal o electrónica, para que sea despachada por un farmacéutico. También, el profesional médico puede dar los medicamentos recetados directamente al paciente para que los lleve a casa, como muestras gratis.
Los medicamentos recetados no incluyen:
Médico/Doctor: El término se refiere tanto a los doctores en medicina (M.D., por sus siglas en inglés) como a los doctores en medicina osteopática (D.O., por sus siglas en inglés). Se incluye tanto a médicos generales como a los especialistas. No incluye a personas que no tienen un título de doctor en medicina (M.D. o D.O.), pero que tienen otros títulos de doctor como dentistas, cirujanos orales, quiroprácticos, podólogos, curanderos de la ciencia cristiana, ópticos, oculistas, psicólogos, etc.
Profesionales de la salud (Profesional de la atención médica): Una persona autorizada por su capacitación y experiencia, y posiblemente por una licencia, para asistir a un médico y trabajan con uno o varios médicos. Algunos ejemplos incluyen: asistentes o auxiliares médicos (PA, por sus siglas en inglés), enfermeros practicantes, personal de enfermería, farmacéuticos, técnicos de laboratorio y técnicos que aplican inyecciones (por ejemplo, inyecciones para las alergias). Incluya también paramédicos, fisioterapeutas y terapeutas médicos que trabajan con un médico o en consultorios médicos. No incluya: dentistas, cirujanos de la boca, quiroprácticos, quiropedistas, podólogos, naturópatas, curanderos de la ciencia cristiana, ópticos, oculistas ni psicólogos o trabajadores sociales. |
HARD CHECK (ENG) |
IF RXQPRSCRYN=2 AND (DIQINSULIN=1 OR DIQPILLS=1), DISPLAY: “Earlier in the interview you reported currently taking insulin or a diabetic pill. If this is correct, we should count that as prescription medication you have taken in the last 30 days.” IF THIS IS NOT CORRECT, DISPLAY THREE QUESTIONS FOR CORRECTION: DIQINSULIN = Taking Insulin DIQPILLS = Taking Diabetic Pills RXQPRSCRYN = Prescription Medication in Last 30 Days
IF RXQPRSCRYN=2 AND BPQHIBPRX=1, DISPLAY: “Earlier in the interview you reported currently taking prescription mediation for high blood pressure. If this is correct, we should count that as prescription medication you have taken in the last 30 days.” IF THIS IS NOT CORRECT, DISPLAY TWO QUESTIONS FOR CORRECTION: BPQHIBPRX = Taking Blood Pressure Medication RXQPRSCRYN = Prescription Medication in Last 30 Days
IF RXQPRSCRYN=2 AND BPQHICHLRX=1, DISPLAY: “Earlier in the interview you reported currently taking prescription medication for high cholesterol. If this is correct, we should count that as prescription medication you have taken in the last 30 days.” IF THIS IS NOT CORRECT, DISPLAY TWO QUESTIONS FOR CORRECTION: BPQHICHLRX = Taking High Cholesterol Medication RXQPRSCRYN = Prescription Medication in Last 30 Days |
HARD CHECK (SPA) |
IF RXQPRSCRYN=2 AND (DIQINSULIN=1 OR DIQPILLS=1), DISPLAY: “Anteriormente en la entrevista usted informó que actualmente está usando insulina o tomando pastillas para la diabetes. Si esto es correcto, debemos contarlo como un medicamento para el cual se necesita receta médica y que usted ha estado tomando en los últimos 30 días” . IF THIS IS NOT CORRECT, DISPLAY THREE QUESTIONS FOR CORRECTION: DIQINSULIN = Usa insulina DIQPILLS = Toma pastillas para la diabetes RXQPRSCRYN = Medicamento para el cual se necesita receta médica, que usted ha estado tomando en los últimos 30 días
IF RXQPRSCRYN=2 AND BPQHIBPRX=1, DISPLAY: “Anteriormente en la entrevista usted informó que actualmente está tomando un medicamento para la presión arterial alta para el cual se necesita receta médica. Si esto es correcto, debemos contarlo como un medicamento para el cual se necesita receta médica y que usted ha estado tomando en los últimos 30 días.” IF THIS IS NOT CORRECT, DISPLAY TWO QUESTIONS FOR CORRECTION: BPQHIBPRX = Toma medicamentos para controlar la presión arterial RXQPRSCRYN = Medicamento para el cual se necesita receta médica, que usted ha estado tomando en los últimos 30 días
IF RXQPRSCRYN=2 AND BPQHICHLRX=1, DISPLAY: “Anteriormente en la entrevista usted informó que actualmente está tomando un medicamento para el nivel alto de colesterol para el cual se necesita receta médica. Si esto es correcto, debemos contarlo como un medicamento para el cual se necesita receta médica y que usted ha estado tomando en los últimos 30 días. IF THIS IS NOT CORRECT, DISPLAY TWO QUESTIONS FOR CORRECTION: BPQHICHLRX = Toma medicamento para el nivel alto de colesterol RXQPRSCRYN = Medicamento para el cual se necesita receta médica que usted ha estado tomando en los últimos 30 días |
SOFT CHECK |
|
VERSION NOTES |
RXQ.033 |
NEXT |
IF RXQPRSCRYN=1: RXQCONTANR IF RXQPRSCRYN=2 OR 7 OR 9 AND (SP > 45 YEARS OLD OR (MCQDOCCORO=1 OR MCQDOCANJN=1 OR MCQDOCATTK=1 OR MCQDOCSTRK=1): RXQASPRN ELSE: END OF SECTION |
RXQCONTANR |
|
ASK |
RXQPRSCRYN=1 |
May I please see the containers for all the prescription medications that <TEXT FILL 1> used or took in the last 30 days? First I will record some information about the medication, then I will ask you some questions about it.
PRESS NEXT TO CONTINUE
|
|
SPANISH |
¿Puedo ver los envases de todos los medicamentos recetados que <TEXT FILL 1> usó o tomó en los últimos 30 días? Primero, registraré la información sobre el medicamento y después le haré algunas preguntas sobre el medicamento.
PRESS NEXT TO CONTINUE
|
QUESTION TYPE |
Informational |
FILLS (ENG) |
TEXT FILL 1: IF SP IS RESPONDENT, FILL: “you” ELSE, FILL: “[SP’S NAME]” |
FILLS (SPA) |
TEXT FILL 1: IF SP IS RESPONDENT, FILL: “usted” ELSE, FILL: “[SP’S NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.NEW1 |
NEXT |
RXQLOOKUP |
RXQLOOKUP |
|
ASK |
IF RXQPRSCRYN=1 IF RXQOTHER=1
|
REFER TO PRODUCT LABEL(S) OR ASK RESPONDENT FOR NAME(S) OF PRESCRIPTION MEDICATIONS USED.
BEGIN TYPING TO SELECT MEDICATION FROM LIST OR SELECT “OTHER MEDICATION” TO ENTER A NEW MEDICATION.
[ENTER MEDICATION NAME]
66. OTHER MEDICATION 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
N/A |
QUESTION TYPE |
Lookup list with radio button |
FILLS |
|
NOTES |
DISPLAY “CLEAR” BUTTON THAT CLEARS RESPONSE
SHOULD ALLOW ENTRY OF PRODUCT NAME TO SAVE THE PRODUCT NAME AS KEYED AND THAT SHOULD BE USED TO START THE LOOKUP.
IF MEDICATION SELECTED FROM LIST, SAVE RESPONSE TEXT AS RXQNAME
ONCE A MEDICATION IS SELECTED FROM THE LIST, THE FOLLOWING INFORMATION SHOULD BE COLLECTED FROM THE LOOKUP DATABASE: DRUG TYPE {8} GENERIC NAME {60} GENERIC ID {6} THERAPEUTIC CLASS CODE {6}
LOOP THROUGH RXQLOOKUP, RXQNAME, RXQCONTRYN, RXQDURATNQ, RXQREASONA, RXQREASONO, AND RXQOTHER FOR EACH PRESCRIPTION MEDICATION |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.240s |
NEXT |
IF MEDICATION SELECTED FROM LIST: RXQCONTRYN
IF RXQLOOKUP=66 (OTHER MEDICATION): RXQNAME
IF RXQLOOKUP = DK OR RF FOR FIRST OR ONLY PRESCRIPTION MEDICATION AND (SP > 45 YEARS OLD OR (MCQDOCCORO=1 OR MCQDOCANJN=1 OR MCQDOCATTK=1 OR MCQDOCSTRK=1)): RXQASPRN
IF RXQLOOKUP = DK OR RF FOR FIRST OR ONLY PRESCRIPTION MEDICATION AND (SP < 45 YEARS OLD AND (MCQDOCCORO<>1 AND MCQDOCANJN<>1 AND MCQDOCATTK<>1 AND MCQDOCSTRK<>1): END OF SECTION
IF RXQLOOKUP = DK OR RF AND THERE ARE PREVIOUSLY ENTERED PRESCRIPTION MEDICATIONS
: RXQINSRX
IF RXQLOOKUP = DK OR RF AND THERE ARE PREVIOUSLY ENTERED PRESCRIPTION MEDICATIONS
: RXQDIABRX
IF RXQLOOKUP = DK OR RF AND THERE ARE PREVIOUSLY ENTERED PRESCRIPTION MEDICATIONS
: RXQBLOODRX
IF RXQLOOKUP = DK OR RF AND THERE ARE PREVIOUSLY ENTERED PRESCRIPTION MEDICATIONS
: RXQCHOLRX
IF RXQLOOKUP = DK OR RF AND THERE ARE PREVIOUSLY ENTERED PRESCRIPTION MEDICATIONS
: RXQREVIEW
* MEDICATIONS CODED AS LOWERING BLOOD PRESSURE HAVE CLASS CODES EQUAL TO 41, 42, 44, 47, 48, 55, 56, 154, 155, 156, 340, OR 342 OR DRUG CODES EQUAL TO d00132, d00135, d00138, d00386, OR d00726.
** MEDICATIONS CODED AS LOWERING CHOLESTEROL HAVE A CLASS CODE EQUAL TO 19 OR A DRUG CODE EQUAL TO d00497. |
RXQNAME |
|
ASK |
IF RXQLOOKUP=66 (OTHER MEDICATION) |
FOR MEDICATIONS NOT INCLUDED IN THE LOOKUP LIST, ENTER THE MEDICATION NAME BELOW.
__________________________________ ENTER MEDICATION NAME
|
|
SPANISH |
N/A |
QUESTION TYPE |
Text entry |
FILLS |
|
NOTES |
DO NOT ALLOW BLANK ENTRY
LOOP THROUGH RXQLOOKUP, RXQNAME, RXQCONTRYN, RXQDURATNQ, RXQREASONA, RXQREASONO, AND RXQOTHER FOR EACH PRESCRIPTION MEDICATION |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.231 |
NEXT |
RXQCONTRYN |
RXQCONTRYN |
|
ASK |
IF MEDICATION SELECTED AT RXQLOOKUP OR ENTERED AT RXQNAME |
INTERVIEWER INSTRUCTION: ENTER 1 RESPONSE
1. CONTAINER SEEN 2. CONTAINER NOT SEEN 3. ONLY PHARAMACY PRINT-OUT SEEN
|
|
SPANISH |
N/A |
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
LOOP THROUGH RXQNAME, RXQCONTRYN, RXQDURATNQ, RXQREASONA, RXQREASONO, AND RXQOTHER FOR EACH PRESCRIPTION MEDICATION |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.251 |
NEXT |
RXQDURATNQ |
RXQDURATNQ / RXQDURATNU |
|
ASK |
IF MEDICATION SELECTED AT RXQLOOKUP OR ENTERED AT RXQNAME |
For how long <TEXT FILL 1> been using or taking <PRODUCT NAME FILL>?
|___|___|___| ENTER NUMBER (OF DAYS, WEEKS, MONTHS, YEARS) [RXQDURATNQ]
777. REFUSED 999. DON’T KNOW
|___| ENTER UNIT [RXQDURATNU]
1. DAYS 2. WEEKS 3. MONTHS 4. YEARS
|
|
SPANISH |
¿Durante cuánto tiempo <TEXT FILL 1> ha estado usando o tomando <PRODUCT NAME FILL>?
|___|___|___| ENTER NUMBER (OF DAYS, WEEKS, MONTHS, YEARS) [RXQDURATNQ]
777. REFUSED 999. DON’T KNOW
|___| ENTER UNIT [RXQDURATNU]
1. DAYS 2. WEEKS 3. MONTHS 4. YEARS
|
QUESTION TYPE |
Numeric: RXQDURATNQ Dropdown: RXQDURATNU |
FILLS (ENG) |
TEXT FILL 1: FILL “have you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “has [SP NAME]”
PRODUCT NAME FILL: FILL PRODUCT NAME FROM RXQNAME |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
PRODUCT NAME FILL: FILL PRODUCT NAME FROM RXQNAME |
NOTES |
IF RXQDURATNU = 1 (DAYS) OR 2 (WEEKS) AND SP AGE IN YEARS = 0, CALCULATE CURRENT AGE FOR EDIT CHECK: IF RXQDURATNU = 2 (WEEKS) AND SP AGE = 0, CALCULATE CURRENT AGE IN WEEKS AS (((PRELOADED AGE IN MONTHS +1)*5)-1). IF RXQDURATNU = 1 (DAYS) AND SP AGE = 0, CALCULATE CURRENT AGE IN DAYS AS (((PRELOADED AGE IN MONTHS+1) *31)-1).
LOOP THROUGH RXQLOOKUP, RXQNAME, RXQCONTRYN, RXQDURATNQ, RXQREASONA, RXQREASONO, AND RXQOTHER FOR EACH PRESCRIPTION MEDICATION |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
IF TIME ENTERED IN RXQDURATNQ > SP’s CURRENT AGE AT SP INTERVIEW (SPDSPAGEY), DISPLAY, “LENGTH OF TIME CANNOT BE GREATER THAN SP’S AGE, PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.”
IF (RXQDURATNU = 2 (WEEKS) AND RXQDURATNQ > 52) OR (RXQDURATNU = 3 (MONTHS) AND RXQDURATNQ > 48) OR (RXQDURATNU = 4 (YEARS) AND RXQDURATNQ > 100), DISPLAY “ENTRY NOT IN RANGE, PLEASE VERIFY RESPONSE. UPDATE RESPONSE IF NEEDED OR PRESS “SUPPRESS” AND “NEXT” TO CONTINUE.” |
VERSION NOTES |
RXQ.260 Q /U |
NEXT |
IF ‘OTHER MEDICATION’ ENTERED AT RXQNAME OR DRUG’S GENERIC ID DOES NOT EXIST IN THE DRUG REASON TABLE IN RXQREASONA: RXQREASONO ELSE: RXQREASONA |
RXQREASONA / RXQREASONB / RXQREASONC |
|
ASK |
IF MEDICATION SELECTED AT RXQLOOKUP OR IF DRUG GENERIC ID EXISTS IN DRUG REASON TABLE |
What is the main reason for which <TEXT FILL 1> <PRODUCT NAME FILL>?
INTERVIEWER INSTRUCTION: SELECT UP TO 3 REASONS. BEGIN TYPING TO SELECT REASON FROM LIST OR SELECT “OTHER SPECIFY” TO ENTER A NEW REASON.
REASON 1: [ENTER REASON] [RXQREASONA]
97. OTHER SPECIFY 777. REFUSED 999. DON’T KNOW
REASON 2: [ENTER REASON] [RXQREASONB]
97. OTHER SPECIFY 777. REFUSED 999. DON’T KNOW
REASON 3: [ENTER REASON] [RXQREASONC]
97. OTHER SPECIFY 777. REFUSED 999. DON’T KNOW
|
|
SPANISH |
¿Cuál es la razón principal por la que <TEXT FILL 1> <PRODUCT NAME FILL>?
INTERVIEWER INSTRUCTION: SELECT UP TO 3 REASONS. BEGIN TYPING TO SELECT REASON FROM LIST OR SELECT “OTHER SPECIFY” TO ENTER A NEW REASON.
REASON 1: [ENTER REASON] [RXQREASONA]
97. OTHER SPECIFY 777. REFUSED 999. DON’T KNOW
REASON 2: [ENTER REASON] [RXQREASONB]
97. OTHER SPECIFY 777. REFUSED 999. DON’T KNOW
REASON 3: [ENTER REASON] [RXQREASONC]
97. OTHER SPECIFY 777. REFUSED 999. DON’T KNOW
|
QUESTION TYPE |
Lookup list: RXQREASONA, RXQREASONB, AND/OR RXQREASONC |
FILLS (ENG) |
TEXT FILL 1: FILL “you use” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] uses”
PRODUCT NAME FILL: FILL PRODUCT NAME FROM RXQNAME |
FILLS (SPA) |
TEXT FILL 1: FILL “usted usa” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] usa”
PRODUCT NAME FILL: FILL PRODUCT NAME FROM RXQNAME |
NOTES |
FOR EACH ITEM THAT LOADS, DISPLAY A LOOKUP LIST OF REASONS FOR USE ASSOCIATED WITH MEDICATION SELECTED AT RXQLOOKUP OR ENTERED AT RXQNAME. ALLOW UP TO 3 REASONS TO BE SELECTED AS POPULATED AS RXQREASONA, RXQREASONB, AND RXQREASONC
RXQREASONA, RXQREASONB, AND RXQREASONC SHOULD APPEAR SEQUENTIALLY AND ONLY IF A REASON WAS SELECTED FROM THE PRECEDING ITEM’S LOOKUP LIST. IF “OTHER SPECIFY” OR DK/REF ARE SELECTED FOR RXQREASONA, RXQREASONB, OR RXQREASONC, DO NOT POPULATE THE SUBSEQUENT ITEMS AND FOLLOW SKIP LOGIC TO THE NEXT SCREEN.
LOOP THROUGH RXQLOOKUP, RXQNAME, RXQCONTRYN, RXQDURATNQ, RXQREASONA, RXQREASONO, AND RXQOTHER FOR EACH PRESCRIPTION MEDICATION |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.289 |
NEXT |
IF RXQREASONx = 97 (OTHER): RXQREASONO ELSE: RXQOTHER |
RXQREASONO |
|
ASK |
IF ‘OTHER MEDICATION’ ENTERED AT RXQNAME OR DRUG’S GENERIC ID DOES NOT EXIST IN THE DRUG REASON TABLE IN RXQREASONA IF RXQREASONx = 97 |
What is the main reason for which <TEXT FILL 1> <PRODUCT NAME FILL>?
________________________ ENTER REASON
|
|
SPANISH |
¿Cuál es la razón principal por la que <TEXT FILL 1> <PRODUCT NAME FILL>?
________________________ ENTER REASON
|
QUESTION TYPE |
Text entry |
FILLS (ENG) |
TEXT FILL 1: FILL “you use” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] uses”
PRODUCT NAME FILL: FILL PRODUCT NAME FROM RXQNAME |
FILLS (SPA) |
TEXT FILL 1: FILL “usted usa” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] usa”
PRODUCT NAME FILL: FILL PRODUCT NAME FROM RXQNAME |
NOTES |
DO NOT ALLOW BLANK ENTRY
LOOP THROUGH RXQLOOKUP, RXQNAME, RXQCONTRYN, RXQDURATNQ, RXQREASONA, RXQREASONO, AND RXQOTHER FOR EACH PRESCRIPTION MEDICATION |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.290 |
NEXT |
RXQOTHER |
RXQOTHER |
|
ASK |
IF MEDICATION SELECTED AT RXQLOOKUP OR ENTERED AT RXQNAME |
CHECK CONTAINERS. ARE THERE ANY OTHER PRESCRIPTION MEDICATIONS?
OR ASK RESPONDENT: (Are there any other prescription medications that <TEXT FILL 1> used in the last 30 days?)
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
CHECK CONTAINERS. ARE THERE ANY OTHER PRESCRIPTION MEDICATIONS?
OR ASK RESPONDENT: (¿Hay algún otro medicamento con receta que <TEXT FILL 1> haya usado en los últimos 30 días?).
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
LOOP THROUGH RXQLOOKUP, RXQNAME, RXQCONTRYN, RXQDURATNQ, RXQREASONA, RXQREASONO, AND RXQOTHER FOR EACH PRESCRIPTION MEDICATION |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.294 |
NEXT |
IF RXQOTHER = 1: RXQLOOKUP FOR NEXT PRESCRIPTION
IF RXQOTHER = 2 OR 7 OR 9
: RXQINSRX
IF RXQOTHER = 2 OR 7 OR 9
: RXQDIABRX
IF RXQOTHER = 2 OR 7 OR 9
: RXQBLOODRX
IF RXQOTHER = 2 OR 7 OR 9
: RXQCHOLRX
IF RXQOTHER = 2 OR 7 OR 9
: RXQREVIEW
* MEDICATIONS CODED AS LOWERING BLOOD PRESSURE HAVE CLASS CODES EQUAL TO 41, 42, 44, 47, 48, 55, 56, 154, 155, 156, 340, OR 342 OR DRUG CODES EQUAL TO d00132, d00135, d00138, d00386, OR d00726.
** MEDICATIONS CODED AS LOWERING CHOLESTEROL HAVE A CLASS CODE EQUAL TO 19 OR A DRUG CODE EQUAL TO d00497. |
RXQINSRX |
|
ASK |
IF ((THERE ARE PREVIOUSLY ENTERED PRESCRIPTION MEDICATIONS AND RXQLOOKUP = DK OR REF)
OR ((RXQOTHER = 2 OR 7 OR 9) AND (DIQINSULIN = 1 AND NO PRODUCT CODED IN RXQLOOKUP = 215)) |
I have listed <TOTAL RX FILL> prescription medication(s) that <TEXT FILL 1> taken in the last 30 days. Which one is insulin?
[CODE ALL THAT APPLY]
SELECT MEDICATION(S) FROM DISPLAY OR IF YOU NEED TO ADD NEW MEDICATION, <NAVIGATION FILL>.
77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
He registrado que <TEXT FILL 1> ha usado <TOTAL RX FILL> medicamento(s) recetado(s) en los últimos 30 días. ¿Cuál es la insulina?
[CODE ALL THAT APPLY]
SELECT MEDICATION(S) FROM DISPLAY OR IF YOU NEED TO ADD NEW MEDICATION, <NAVIGATION FILL>.
77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Code all that apply |
FILLS (ENG) |
TOTAL RX FILL: FILL TOTAL NUMBER OF PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] has”
NAVIGATION FILL: FILL “CLICK HERE TO RETURN TO RXQLOOKUP AND ENTER A NEW MEDICATION” IF RXQLOOKUP = DK/REF IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQLOOKUP IN MOST RECENT LOOP ELSE, FILL “CLICK HERE" TO RETURN TO RXQOTHER AND SELECT “YES” TO ENTER A NEW MEDICATION” IF RXQOTHER = 2 OR 7 OR 9 IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQOTHER IN MOST RECENT LOOP |
FILLS (SPA) |
TOTAL RX FILL: FILL TOTAL NUMBER OF PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
NAVIGATION FILL: FILL “CLICK HERE TO RETURN TO RXQLOOKUP AND ENTER A NEW MEDICATION” IF RXQLOOKUP = DK/REF IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQLOOKUP IN MOST RECENT LOOP ELSE, FILL “CLICK HERE" TO RETURN TO RXQOTHER AND SELECT “YES” TO ENTER A NEW MEDICATION” IF RXQOTHER = 2 OR 7 OR 9 IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQOTHER IN MOST RECENT LOOP |
NOTES |
DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME. |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.372 |
NEXT |
IF RXQINSRX = ANY PREVIOUSLY ENTERED MEDICATION SELECTED OR 77 OR 99
: RXQDIABRX
IF RXQINSRX = ANY PREVIOUSLY ENTERED MEDICATION SELECTED OR 77 OR 99
: RXQBLOODRX
IF RXQINSRX = ANY PREVIOUSLY ENTERED MEDICATION SELECTED OR 77 OR 99
: RXQCHOLRX
IF RXQINSRX = ANY PREVIOUSLY ENTERED MEDICATION SELECTED OR 77 OR 99
: RXQREVIEW
* MEDICATIONS CODED AS LOWERING BLOOD PRESSURE HAVE CLASS CODES EQUAL TO 41, 42, 44, 47, 48, 55, 56, 154, 155, 156, 340, OR 342 OR DRUG CODES EQUAL TO d00132, d00135, d00138, d00386, OR d00726.
** MEDICATIONS CODED AS LOWERING CHOLESTEROL HAVE A CLASS CODE EQUAL TO 19 OR A DRUG CODE EQUAL TO d00497. |
RXQDIABRX |
|
ASK |
IF (((THERE ARE PREVIOUSLY ENTERED PRESCRIPTION MEDICATIONS AND RXQLOOKUP = DK OR REF) AND (DIQINSULIN = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 215))
OR ((RXQOTHER = 2 OR 7 OR 9) AND (DIQINSULIN = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 215))
OR (RXQINSRX = ANY PREVIOUSLY ENTERED MEDICATION SELECTED OR 77 OR 99))
AND (DIQPILLS = 1 AND NO PRODUCT CODED IN RXQLOOKUP = 213, 214, 216, 271, 282, 314, 371, 372, 373, OR 458) |
I have listed <TOTAL RX FILL> prescription medication(s) that <TEXT FILL 1> taken in the last 30 days. Which one <TEXT FILL 2> taking for diabetes or blood sugar?
[CODE ALL THAT APPLY]
SELECT MEDICATION(S) FROM DISPLAY OR IF YOU NEED TO ADD NEW MEDICATION, <NAVIGATION FILL>.
77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
He registrado que <TEXT FILL 1> ha tomado <TOTAL RX FILL> medicamento(s) recetado(s) en los últimos 30 días. ¿Cuál de ellos está tomando <TEXT FILL 2> para la diabetes o para el azúcar en la sangre?
[CODE ALL THAT APPLY]
SELECT MEDICATION(S) FROM DISPLAY OR IF YOU NEED TO ADD NEW MEDICATION, <NAVIGATION FILL>.
77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Code all that apply |
FILLS (ENG) |
TOTAL RX FILL: FILL TOTAL NUMBER OF PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] has”
TEXT FILL 2: FILL “are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “is he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “is she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “is [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
NAVIGATION FILL: FILL “CLICK HERE TO RETURN TO RXQLOOKUP AND ENTER A NEW MEDICATION” IF RXQLOOKUP = DK/REF IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQLOOKUP IN MOST RECENT LOOP ELSE, FILL “CLICK HERE TO RETURN TO RXQOTHER AND SELECT “YES” TO ENTER A NEW MEDICATION” IF RXQOTHER = 2 OR 7 OR 9 IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQOTHER IN MOST RECENT LOOP |
FILLS (SPA) |
TOTAL RX FILL: FILL TOTAL NUMBER OF PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
NAVIGATION FILL: FILL “CLICK HERE TO RETURN TO RXQLOOKUP AND ENTER A NEW MEDICATION” IF RXQLOOKUP = DK/REF IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQLOOKUP IN MOST RECENT LOOP ELSE, FILL “CLICK HERE TO RETURN TO RXQOTHER AND SELECT “YES” TO ENTER A NEW MEDICATION” IF RXQOTHER = 2 OR 7 OR 9 IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQOTHER IN MOST RECENT LOOP |
NOTES |
DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME. |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.378 |
NEXT |
IF RXQDIABRX = ANY PREVIOUSLY ENTERED MEDICATION SELECTED OR 77 OR 99
: RXQBLOODRX
IF RXQDIABRX = ANY PREVIOUSLY ENTERED MEDICATION SELECTED OR 77 OR 99
: RXQCHOLRX
IF RXQDIABRX = ANY PREVIOUSLY ENTERED MEDICATION SELECTED OR 77 OR 99
: RXQREVIEW
* MEDICATIONS CODED AS LOWERING BLOOD PRESSURE HAVE CLASS CODES EQUAL TO 41, 42, 44, 47, 48, 55, 56, 154, 155, 156, 340, OR 342 OR DRUG CODES EQUAL TO d00132, d00135, d00138, d00386, OR d00726.
** MEDICATIONS CODED AS LOWERING CHOLESTEROL HAVE A CLASS CODE EQUAL TO 19 OR A DRUG CODE EQUAL TO d00497. |
RXQBLOODRX |
|
ASK |
IF (((THERE ARE PREVIOUSLY ENTERED PRESCRIPTION MEDICATIONS AND RXQLOOKUP = DK OR REF) AND (DIQINSULIN = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 215) AND (DIQPILLS = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 213, 214, 216, 271, 282, 314, 371, 372, 373, OR 458))
OR ((RXQOTHER = 2 OR 7 OR 9) AND (DIQINSULIN = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 215) AND (DIQPILLS = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 213, 214, 216, 271, 282, 314, 371, 372, 373, OR 458))
OR ((FOR RXQINSR, ANY PREVIOUSLY ENTERED MEDICATION IS SELECTED OR RF/DK) AND (DIQPILLS = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 213, 214, 216, 271, 282, 314, 371, 372, 373, OR 458) AND (BPQHIBPRX = 1 AND NO PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS BLOOD PRESSURE*))
OR (FOR RXQDIABRX, ANY PREVIOUSLY ENTERED MEDICATION IS SELECTED OR RF/DK))
AND (BPQHIBPRX = 1 AND NO PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS BLOOD PRESSURE*)
* MEDICATIONS CODED AS LOWERING BLOOD PRESSURE HAVE CLASS CODES EQUAL TO 41, 42, 44, 47, 48, 55, 56, 154, 155, 156, 340, OR 342 OR DRUG CODES EQUAL TO d00132, d00135, d00138, d00386, OR d00726. |
I have listed <TOTAL RX FILL> prescription medication(s) that <TEXT FILL 1> taken in the last 30 days. Which one <TEXT FILL 2> taking to lower <TEXT FILL 3> blood pressure?
[CODE ALL THAT APPLY]
SELECT MEDICATION(S) FROM DISPLAY OR IF YOU NEED TO ADD NEW MEDICATION, <NAVIGATION FILL>.
77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
He registrado que <TEXT FILL 1> ha tomado <TOTAL RX FILL> medicamento(s) recetado(s) en los últimos 30 días. ¿Cuál de ellos está tomando <TEXT FILL 2> para reducir su presión arterial?
[CODE ALL THAT APPLY]
SELECT MEDICATION(S) FROM DISPLAY OR IF YOU NEED TO ADD NEW MEDICATION, <NAVIGATION FILL>.
77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Code all that apply |
FILLS (ENG) |
TOTAL RX FILL: FILL TOTAL NUMBER OF PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] has”
TEXT FILL 2: FILL “are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “is he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “is she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “is [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
NAVIGATION FILL: FILL “CLICK HERE TO RETURN TO RXQLOOKUP AND ENTER A NEW MEDICATION” IF RXQLOOKUP = DK/REF IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQLOOKUP IN MOST RECENT LOOP ELSE, FILL “CLICK HERE TO RETURN TO RXQOTHER AND SELECT “YES” TO ENTER A NEW MEDICATION” IF RXQOTHER = 2 OR 7 OR 9 IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQOTHER IN MOST RECENT LOOP |
FILLS (SPA) |
TOTAL RX FILL: FILL TOTAL NUMBER OF PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
NAVIGATION FILL: FILL “CLICK HERE TO RETURN TO RXQLOOKUP AND ENTER A NEW MEDICATION” IF RXQLOOKUP = DK/REF IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQLOOKUP IN MOST RECENT LOOP ELSE, FILL “CLICK HERE TO RETURN TO RXQOTHER AND SELECT “YES” TO ENTER A NEW MEDICATION” IF RXQOTHER = 2 OR 7 OR 9 IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQOTHER IN MOST RECENT LOOP |
NOTES |
DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME. |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.384 |
NEXT |
IF RXQBLOODRX = ANY PREVIOUSLY ENTERED MEDICATION SELECTED OR 77 OR 99
: RXQCHOLRX
IF RXQBLOODRX = ANY PREVIOUSLY ENTERED MEDICATION SELECTED OR 77 OR 99
: RXQREVIEW
** MEDICATIONS CODED AS LOWERING CHOLESTEROL HAVE A CLASS CODE EQUAL TO 19 OR A DRUG CODE EQUAL TO d00497. |
RXQCHOLRX |
|
ASK |
IF (((THERE ARE PREVIOUSLY ENTERED PRESCRIPTION MEDICATIONS AND RXQLOOKUP = DK OR REF) AND (DIQINSULIN = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 215) AND (DIQPILLS = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 213, 214, 216, 271, 282, 314, 371, 372, 373, OR 458) AND (BPQHIBPRX = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS BLOOD PRESSURE*) AND (BPQHICHLRX = 1 AND NO PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS CHOLESTEROL**))
OR ((RXQOTHER = 2 OR 7 OR 9) AND (DIQINSULIN = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 215) AND (DIQPILLS = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 213, 214, 216, 271, 282, 314, 371, 372, 373, OR 458) AND (BPQHIBPRX = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS BLOOD PRESSURE*) AND (BPQHICHLRX = 1 AND NO PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS CHOLESTEROL**))
OR ((FOR RXQINSRX, ANY PREVIOUSLY ENTERED MEDICATION IS SELECTED OR RF/DK) AND AND (DIQPILLS = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 213, 214, 216, 271, 282, 314, 371, 372, 373, OR 458) AND (BPQHIBPRX = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS BLOOD PRESSURE*) AND (BPQHICHLRX = 1 AND NO PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS CHOLESTEROL**))
OR ((FOR RXQDIABRX, ANY PREVIOUSLY ENTERED MEDICATION IS SELECTED OR RF/DK) AND AND (BPQHIBPRX = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS BLOOD PRESSURE*) AND (BPQHICHLRX = 1 AND NO PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS CHOLESTEROL**))
OR (FOR RXQBLOODRX, ANY PREVIOUSLY ENTERED MEDICATION IS SELECTED OR RF/DK))
AND (BPQHICHLRX = 1 AND NO PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS CHOLESTEROL**)
** MEDICATIONS CODED AS LOWERING CHOLESTEROL HAVE A CLASS CODE EQUAL TO 19 OR A DRUG CODE EQUAL TO d00497. |
I have listed <TOTAL RX FILL> prescription medication(s) that <TEXT FILL 1> taken in the last 30 days. Which one <TEXT FILL 2> taking to lower <TEXT FILL 3> cholesterol?
[CODE ALL THAT APPLY]
SELECT MEDICATION(S) FROM DISPLAY OR IF YOU NEED TO ADD NEW MEDICATION, <NAVIGATION FILL>.
77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
He registrado que <TEXT FILL 1> ha tomado <TOTAL RX FILL> medicamento(s) recetado(s) en los últimos 30 días. ¿Cuál de ellos está tomando <TEXT FILL 2> para bajar el colesterol?
[CODE ALL THAT APPLY]
SELECT MEDICATION(S) FROM DISPLAY OR IF YOU NEED TO ADD NEW MEDICATION, <NAVIGATION FILL>.
77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Code all that apply |
FILLS (ENG) |
TOTAL RX FILL: FILL TOTAL NUMBER OF PRESCRIPTION MEDICATIONS SELECTED AT TXQLOOKUP AND ENTERED AT RXQNAME
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] has”
TEXT FILL 2: FILL “are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “is he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “is she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “is [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “his” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
NAVIGATION FILL: FILL “CLICK HERE TO RETURN TO RXQLOOKUP AND ENTER A NEW MEDICATION” IF RXQLOOKUP = DK/REF IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQLOOKUP IN MOST RECENT LOOP ELSE, FILL “CLICK HERE TO RETURN TO RXQOTHER AND SELECT “YES” TO ENTER A NEW MEDICATION” IF RXQOTHER = 2 OR 7 OR 9 IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQOTHER IN MOST RECENT LOOP |
FILLS (SPA) |
TOTAL RX FILL: FILL TOTAL NUMBER OF PRESCRIPTION MEDICATIONS SELECTED AT TXQLOOKUP AND ENTERED AT RXQNAME
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] ”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “él” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “ella” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
NAVIGATION FILL: FILL “CLICK HERE TO RETURN TO RXQLOOKUP AND ENTER A NEW MEDICATION” IF RXQLOOKUP = DK/REF IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQLOOKUP IN MOST RECENT LOOP ELSE, FILL “CLICK HERE TO RETURN TO RXQOTHER AND SELECT “YES” TO ENTER A NEW MEDICATION” IF RXQOTHER = 2 OR 7 OR 9 IN MOST RECENT LOOP. DISPLAY “CLICK HERE” AS A LINK TO RETURN TO RXQOTHER IN MOST RECENT LOOP |
NOTES |
DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME. |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.390 |
NEXT |
ELSE, RXQREVIEW |
RXQREVIEW |
|
ASK |
IF (((THERE ARE PREVIOUSLY ENTERED PRESCRIPTION MEDICATIONS AND RXQLOOKUP = DK OR REF) AND (DIQINSULIN = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 215) AND (DIQPILLS = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 213, 214, 216, 271, 282, 314, 371, 372, 373, OR 458) AND (BPQHIBPRX = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS BLOOD PRESSURE*) AND (BPQHICHLRX = 1 AND NO PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS CHOLESTEROL**))
OR ((RXQOTHER = 2 OR 7 OR 9) AND (DIQINSULIN = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 215) AND (DIQPILLS = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 213, 214, 216, 271, 282, 314, 371, 372, 373, OR 458) AND (BPQHIBPRX = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS BLOOD PRESSURE*) AND (BPQHICHLRX = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS CHOLESTEROL*))
OR ((FOR RXQINSRX, ANY PREVIOUSLY ENTERED MEDICATION IS SELECTED OR DK/RF) AND (DIQPILLS = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP = 213, 214, 216, 271, 282, 314, 371, 372, 373, OR 458) AND (BPQHIBPRX = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS BLOOD PRESSURE*) AND (BPQHICHLRX = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS CHOLESTEROL*))
OR ((FOR RXQDIABRX, ANY PREVIOUSLY ENTERED MEDICATION IS SELECTED OR DK/RF) AND (BPQHIBPRX = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS BLOOD PRESSURE*) AND (BPQHICHLRX = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS CHOLESTEROL*)
OR (FOR RXQBLOODRX, ANY PREVIOUSLY ENTERED MEDICATION SELECTED OR DK/RF) AND (BPQHICHLRX = 2 OR 7 OR 9 OR ANY PRODUCT CODED IN RXQLOOKUP IS A MEDICATION THAT LOWERS CHOLESTEROL*)
IF RXQCHOLRX = ANY PREVIOUSLY ENTERED MEDICATION SELECTED OR 77 OR 99 |
REVIEW TOTAL NUMBER OF PRESCRIBED MEDICATIONS AND THEIR NAMES WITH RESPONDENT.
I have listed <TOTAL RX FILL> prescription medication(s) that <TEXT FILL 1> taken in the last 30 days: <PRODUCT NAME FILL>.
PRESS NEXT TO CONTINUE
|
|
SPANISH |
REVIEW TOTAL NUMBER OF PRESCRIBED MEDICATIONS AND THEIR NAMES WITH RESPONDENT.
He registrado que <TEXT FILL 1> ha tomado <TOTAL RX FILL> medicamento(s) recetado(s) en los últimos 30 días: <PRODUCT NAME FILL>.
PRESS NEXT TO CONTINUE
|
QUESTION TYPE |
Informational |
FILLS (ENG) |
TOTAL RX FILL: FILL TOTAL NUMBER OF PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME
TEXT FILL 1: FILL “you have” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] has”
PRODUCT NAME FILL: FILL NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME
|
FILLS (SPA) |
TOTAL RX FILL: FILL TOTAL NUMBER OF PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
PRODUCT NAME FILL: FILL NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME
|
NOTES |
DISPLAY NAMES OF ALL PRESCRIPTION MEDICATIONS SELECTED AT RXQLOOKUP AND ENTERED AT RXQNAME. |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.295 |
NEXT |
IF SP AGE >= 45 YEARS OR (MCQDOCCORO = 1 OR MCQDOCANJN = 1 OR MCQDOCATTK = 1 OR MCQDOCSTRK = 1): RXQASPRN ELSE: END OF SECTION |
RXQASPRN |
|
ASK |
IF SP AGE >= 45 YEARS OR (MCQDOCCORO = 1 OR MCQDOCANJN = 1 OR MCQDOCATTK = 1 OR MCQDOCSTRK = 1) |
Has a doctor or other health professional ever told <TEXT FILL 1> to take a low-dose aspirin each day to prevent or control heart disease?
INTERVIEWER INSTRUCTION: IF THE RESPONDENT VOLUNTEERS THEY ARE TAKING AN ASPIRIN EVERY OTHER DAY OR ‘REGULARLY’ FOR THESE REASONS, CODE ‘YES’
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Le ha dicho alguna vez un doctor u otro profesional de la salud a <TEXT FILL 1> que tome una dosis baja de aspirina todos los días para prevenir o controlar enfermedades del corazón?
INTERVIEWER INSTRUCTION: IF THE RESPONDENT VOLUNTEERS THEY ARE TAKING AN ASPIRIN EVERY OTHER DAY OR ‘REGULARLY’ FOR THESE REASONS, CODE ‘YES’
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.511 |
NEXT |
IF RXQASPRN = 1: RXQASPADVC ELSE: RXQASPSELF |
RXQASPADVC |
|
ASK |
IF RXQASPRN = 1 |
<TEXT FILL 1> now following this advice?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Está <TEXT FILL 1> siguiendo ese consejo ahora?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “Are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “Is [SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.516 |
NEXT |
IF RXQASPADVC = 2: RXQASPSTOP ELSE: END OF SECTION |
RXQASPSTOP |
|
ASK |
IF RXQASPADVC = 2 |
Did a doctor or other health professional advise <TEXT FILL 1> to stop taking a low-dose aspirin every day?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Le aconsejó un doctor u otro profesional de la salud a <TEXT FILL 1> que dejara de tomar una dosis baja de aspirina todos los días?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.517 |
NEXT |
END OF SECTION |
RXQASPSELF |
|
ASK |
IF RXQASPRN = 2 OR 7 OR 9 |
On <TEXT FILL 1> own, <TEXT FILL 2> now taking a low-dose aspirin each day to prevent or control heart disease?
INTERVIEWER INSTRUCTION: IF THE RESPONDENT VOLUNTEERS THEY ARE TAKING AN ASPIRIN EVERY OTHER DAY OR ‘REGULARLY’ FOR THESE REASONS, CODE ‘YES’
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Está <TEXT FILL 1> tomando ahora, por su cuenta, una dosis baja de aspirina todos los días para prevenir o controlar las enfermedades del corazón?
INTERVIEWER INSTRUCTION: IF THE RESPONDENT VOLUNTEERS THEY ARE TAKING AN ASPIRIN EVERY OTHER DAY OR ‘REGULARLY’ FOR THESE REASONS, CODE ‘YES’
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “are you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “is he” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “is she” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “is [SP NAME]” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS MALE IN SPQGENDER FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS FEMALE IN SPQGENDER FILL “” IF SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RXQ.521 |
NEXT |
END OF SECTION |
ACASI Introduction and Practice screens
Target Group: Sighted SP Respondents 18+
CAPI INSTRUCTION FOR ACASI SECTIONS: Follow DK/REF guidance for MEC ACASI: (1) DK/REF will initially be hidden. If the SP tries to advance without selecting a response, DK/REF will appear along with a red error message: "Please select an answer to continue." (2) TTS does not read DK/REF (3) DK/REF is not covered in the tutorial
TUQINTRO |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS AND VIQLIGHT=1 |
You will do this part of the interview on your own, using the computer and headphones. The headphones will allow you to listen while the computer voice reads the questions on the screen.
You can adjust the volume here.
SHOW SP HOW TO ADJUST VOLUME
You will enter your responses into the computer by touching the screen. This will let you answer the questions privately. Before you start, you’ll go over some examples and then you'll complete the interview on your own.
When you are ready, touch NEXT to continue.
|
|
SPANISH |
Usted hará esta parte de la entrevista por su cuenta, usando la computadora y los audífonos. Los audífonos le permitirán escuchar mientras la voz de la computadora lee las preguntas en la pantalla.
Puede graduar el volumen aquí.
SHOW SP HOW TO ADJUST VOLUME
Usted ingresará sus respuestas en la computadora tocando la pantalla. Esto le permitirá responder las preguntas en privado. Antes de comenzar, se le mostrarán algunos ejemplos y luego completará la entrevista por su cuenta.
Cuando esté listo(a), toque SIGUIENTE para continuar.
|
QUESTION TYPE |
Informational |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
TUQ.INT |
NEXT |
TUQTIRED |
TUQTIRED |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS AND VIQLIGHT=1 |
Welcome to the NHANES self-interviewing program. Next, you will learn how to use the system and complete some practice questions. You will learn how to enter answers and how to back-up if you make a mistake and want to change an answer.
For most questions, you will be asked to enter only one answer. Here’s an example:
‘Are you tired?’
Touch “Yes” or “No” now.
If you need to hear the question repeated, simply press the <SPEAKER IMAGE FILL> button. Try it now.
After you answer, touch “NEXT.”
1. Yes 2. No 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Le damos la bienvenida al programa de autoentrevistas de NHANES. A continuación, aprenderá a usar el sistema y completará algunas preguntas de práctica. Aprenderá a ingresar respuestas y cómo regresar a la pregunta anterior si se equivoca y quiere cambiar una respuesta.
Para la mayoría de las preguntas, se le pedirá que ingrese una sola respuesta. Aquí hay un ejemplo:
‘¿Está cansado(a)?’
Toque “Sí” o “No” ahora.
Si
necesita escuchar la pregunta de nuevo, solo tiene que presionar
el botón
Después de responder, toque “SIGUIENTE”.
1. Sí 2. No 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
SPEAKER IMAGE FILL: FILL WITH IMAGE OF SPEAKER BUTTON |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
TUQ.010 |
NEXT |
TUQSLEEP |
TUQSLEEP |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS AND VIQLIGHT=1 |
Another type of question requires a number response. Answer by pressing the number buttons on the keypad.
‘How many hours did you sleep last night?’
|___|___| Number of hours
77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
Otros tipos de preguntas requieren un número como respuesta. Presione los botones numéricos del teclado para ingresar su respuesta.
‘¿Cuántas horas durmió anoche?’
|___|___| Número de horas
77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS |
|
NOTES |
DISPLAY NUMBER KEYPAD WITH CLEAR BUTTON |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
TUQ.020 |
NEXT |
TUQBACK |
TUQBACK |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS AND VIQLIGHT=1 |
To go back to a previous question to change your response, touch the <IMAGE FILL> button.
Press NEXT to continue.
|
|
SPANISH |
Para regresar a una pregunta anterior y cambiar su respuesta, toque el botón <IMAGE FILL>.
Presione SIGUIENTE para continuar.
|
QUESTION TYPE |
Informational |
FILLS |
IMAGE FILL: FILL BACK BUTTON IMAGE |
NOTES |
DISPLAY PREVIOUS SCREEN ONCE THE “BACK” BUTTON IS PRESSED |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
TUQ.030 |
NEXT |
TUQCLEAR |
TUQCLEAR |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS AND VIQLIGHT=1 |
You can change your answer by pressing the ‘CLEAR’ button.
Try it now. Press the “CLEAR” button to erase the answer. Then enter a new answer and then press NEXT to go to the next question.
|___|___| Number
77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
Puede cambiar la respuesta presionando el botón ‘BORRAR’ .
Purebe hacer esto ahora. Presione el botón “BORRAR” para borrar la respuesta. Luego ingrese una nueva respuesta y presione SIGUIENTE para ir a la siguiente pregunta.
|___|___| Número
77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS |
|
NOTES |
PRELOAD NUMERIC FIELD WITH ENTRY FROM TUQSLEEP DISPLAY NUMBER KEYPAD WITH CLEAR BUTTON |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
TUQ.NEW2 |
NEXT |
TUQHELP |
TUQHELP |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS AND VIQLIGHT=1 |
Some questions have help available. When you see <IMAGE FILL> in the corner of the screen, you can press it for more information. Try it now.
‘Do you like funny movies?’
1. Yes 2. No 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Algunas preguntas tienen la opción de ayuda disponible. Cuando vea esta imagen <IMAGE FILL> en la esquina de la pantalla, puede presionar esa opción para obtener más información. Pruebe esto ahora.
‘¿Le gustan las películas chistosas?’
1. Sí 2. No 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
IMAGE FILL: FILL WITH ‘HELP WITH THIS QUESTION’ IMAGE |
NOTES |
|
HELP SCREEN (ENG) |
Funny movies are movies that make you laugh out loud. |
HELP SCREEN (SPA) |
Las películas chistosas son aquellas que le hacen reír a carcajadas. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
TUQ.035 |
NEXT |
TUQLAST |
TUQLAST |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE >= 18 YEARS AND VIQLIGHT=1 |
Like all of the other questions that you have answered today, your responses will be kept confidential. If you are not sure about an answer, give us your best estimate.
When you are ready, touch NEXT to begin this part of the interview.
|
|
SPANISH |
Al igual que todas las otras preguntas que contestó hoy, sus respuestas se mantendrán en forma confidencial. Si no está seguro(a) de una respuesta, responda lo mejor que pueda.
Cuando esté listo(a), toque SIGUIENTE para comenzar esta parte de la entrevista.
|
QUESTION TYPE |
Informational |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
ACASI Last Screen |
NEXT |
END OF SECTION |
REPRODUCTIVE HEALTH – RHQ
Target Group: Sighted Female & Other Genders SP Respondents Ages 18+
Target group is defined as (1) SP GENDER IS FEMALE IN SPQGENDER with or without other options, (2) SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) IN SPQGENDER but not MALE, SP GENDER IS DON’T KNOW (CODE 7) OR REFUSED (CODE 9) IN SPQGENDER
CAPI INSTRUCTION FOR ACASI SECTIONS: Follow DK/REF guidance for MEC ACASI: (1) DK/REF will initially be hidden. If the SP tries to advance without selecting a response, DK/REF will appear along with a red error message: "Please select an answer to continue." (2) TTS does not read DK/REF (3) DK/REF is not covered in the tutorial
RHQMNSFRST |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF (SP GENDER IS FEMALE (CODE 2) OR TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER) AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
The next questions are about your reproductive history.
How old were you when you had your first menstrual period?
Please enter an age. If you have not started your period, enter zero.
|___|___| ENTER AGE
777. REFUSED 999. DON’T KNOW
|
|
SPANISH |
Las siguientes preguntas son sobre su historial reproductivo.
¿Qué edad tenía cuando tuvo su primera menstruación?
Ingrese una edad. Si no ha empezado a menstruar todavía, ingrese cero.
|___|___| ENTER AGE
777. REFUSED 999. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS |
|
NOTES |
DISPLAY NUMBER KEYPAD WITH CLEAR BUTTON |
HELP SCREEN |
|
HARD CHECK (ENG) |
IF RHQMNSFRST > SP AGE, DISPLAY, “You reported an age greater than your current age. Please try again.” |
HARD CHECK (SPA) |
IF RHQMNSFRST > SP AGE, DISPLAY, “Usted ha ingresado una edad superior a la que tiene ahora. Inténtelo de nuevo.” |
SOFT CHECK (ENG) |
IF RHQMNSFRST <= 8 AND RHQMNSFRST > 0, DISPLAY, “You reported your first menstrual period at the age of 8 years or younger. If that is not correct, enter the correct age. If that is correct, please press “Suppress” and then the “Next” button to continue.” IF RHQMNSFRST >= 25, DISPLAY, “You reported your first menstrual period at the age of 25 years or older. If that is not correct, enter the correct age. If that is correct, please press “Suppress” and then the “Next” button to continue.” IF SP AGE >= 20 AND RHQMNSFIRST = 0, DISPLAY, “You reported never starting your menstrual period. If that is not correct, enter another age. If that is correct, please press “Suppress” and then the “Next” button to continue.” |
SOFT CHECK (SPA) |
IF RHQMNSFRST <= 8 AND RHQMNSFRST > 0, DISPLAY, “Usted ha ingresado que su primera menstruación fue a los 8 años de edad o menos. Si eso no es correcto, ingrese la edad correcta. Si eso es correcto, presione “Eliminar” y luego el botón “Siguiente” para continuar.” IF RHQMNSFRST >= 25, DISPLAY, “Usted ha ingresado que su primera menstruación fue a los 25 años de edad o más. Si eso no es correcto, ingrese la edad correcta. Si eso es correcto, presione “Eliminar” y luego el botón “Siguiente” para continuar.” IF SP AGE >= 20 AND RHQMNSFIRST = 0, DISPLAY, “Usted ha ingresado que nunca ha empezado su primera menstruación. Si eso no es correcto, ingrese otra edad. Si eso es correcto, presione “Eliminar” y luego el botón “Siguiente” para continuar.” |
VERSION NOTES |
RHQ.010 |
NEXT |
IF RHQMNSFRST = 0: END OF SECTION ELSE, RHQMNS12MO |
RHQMNS12MO |
|
ASK |
IF RHQMNSFRST IS (ANY AGE > 0) OR REFUSED OR DON’T KNOW |
Have you had at least one menstrual period in the last 12 months?
1. Yes 2. No 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Ha tenido al menos un período menstrual en los últimos 12 meses?
1. Sí 2. No 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN (ENG) |
If you have had at least one very light period in the last 12 months because you use hormonal birth control, such as pills, injectables or IUDs, select “Yes.”
If you have not had a period in the last 12 months, but you had bleeding due to medical conditions, hormone therapy, or surgeries, select “No.” |
HELP SCREEN (SPA) |
Si ha tenido al menos un período muy ligero en los últimos 12 meses porque usa anticonceptivos hormonales, como píldoras, inyecciones o dispositivo intrauterino (DIU), seleccione “Sí”.
Si no ha tenido período en los últimos 12 meses pero sí tuvo hemorragias debido a afecciones médicas, terapia hormonal o cirugías, seleccione “No”. |
HARD CHECK |
|
SOFT CHECK (ENG) |
IF SP AGE >= 60 YEARS AND RHQMNS12MO = 1 (YES), DISPLAY, “If you have not had a period in the last 12 months, but you had bleeding due to medical conditions, hormone therapy, or surgeries, please select “No.” Otherwise, press “Suppress” and then the “Next” button to continue.” |
SOFT CHECK (SPA) |
IF SP AGE >= 60 YEARS AND RHQMNS12MO = 1 (YES), DISPLAY, “Si no ha tenido período en los últimos 12 meses pero sí tuvo hemorragias debido a afecciones médicas, terapia hormonal o cirugías, seleccione “No”. De lo contrario, presione “Eliminar” y luego el botón “Siguiente” para continuar.” |
VERSION NOTES |
RHQ.031 |
NEXT |
IF RHQMNS12MO = 1: RHQUTERUS IF RHQMNS12MO = 2: RHQNOMNS IF RHQMNS12MO = 7 OR 9: RHQMNSLAST |
RHQNOMNS |
|
ASK |
IF RHQMNS12MO = 2 |
What is the reason that you have not had a period in the last 12 months?
Please select one of the following choices.
1. Pregnancy 2. Breastfeeding 3. Hysterectomy/Removal of uterus 7. Menopause or the change of life 9. Some other reason 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
¿Cuál es la razón por la que no tuvo su período en los últimos 12 meses?
Seleccione una de las siguientes opciones.
1. Embarazo 2. Lactancia 3. Histerectomía/Extracción del útero 7. Menopausia 9. Alguna otra razón 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN (ENG) |
Select “some other reason” if you have not had a period in the last 12 months, for reasons including, but not limited to: hormonal birth control use; cancer; a thyroid condition; chemotherapy; excessive exercise; anorexia; low body weight; gender affirming care. |
HELP SCREEN (SPA) |
Seleccione “alguna otra razón” si no tuvo su período en los últimos 12 meses por razones que incluyen, entre otras, el uso de anticonceptivos hormonales; cáncer; un problema de tiroides; quimioterapia; ejercicio excesivo; anorexia; bajo peso; atención médica de afirmación de género. |
HARD CHECK |
|
SOFT CHECK (ENG) |
IF SP AGE < 45 YEARS AND RHQNOMNS = 7 (MENOPAUSE/CHANGE OF LIFE), DISPLAY, “You reported that the reason you have not had a period in the last 12 months is because of menopause, meaning your periods have completely stopped. If that is not correct, select a different reason. If that is correct, please press “Suppress” and then the “Next” button to continue.” |
SOFT CHECK (SPA) |
IF SP AGE < 45 YEARS AND RHQNOMNS = 7 (MENOPAUSE/CHANGE OF LIFE), DISPLAY, “Usted ingresó que la razón por la que no tuvo su período en los últimos 12 meses es por la menopausia, es decir, ya dejó de tener períodos. Si eso no es correcto, seleccione una razón diferente. Si esto es correcto, presione “Eliminar” y luego el botón “Siguiente” para continuar.” |
VERSION NOTES |
RHQ.043 |
NEXT |
IF RHQNOMNS = 1 AND SP AGE IS 18-64 YEARS: RHQPREGEVR IF RHQNOMNS = 1 AND SP AGE IS >= 65 YEARS: END OF SECTION IF RHQNOMNS = 3: RHQOVRY IF RHQNOMNS = 2 OR 7 OR 9 OR 77 OR 99: RHQUTERUS |
RHQUTERUS |
|
ASK |
IF RHQMNS12MO = 1 IF RHQNOMNS = 2 OR 7 OR 9 OR 77 OR 99 |
Have you had a hysterectomy, including a partial hysterectomy, that is, survey to remove your uterus or womb?
1. Yes 2. No 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Le han hecho una histerectomía, incluida una histerectomía parcial, es decir, una cirugía para quitarle el útero o la matriz?
1. Sí 2. No 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RHQ.282 |
NEXT |
RHQOVRY |
RHQOVRY |
|
ASK |
IF RHQMNS12MO = 1 IF RHQNOMNS = 2 OR 3 OR 7 OR 9 OR 77 OR 99 |
Have you had both of your ovaries removed<TEXT FILL 3>?
1. Yes 2. No 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Le quitaron los dos ovarios, <TEXT FILL 3>?
1. Sí 2. No 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 3: FILL “ either when you had your uterus removed or at any other time” IF RHQUTERUS = 1 OR RHQNOMNS = 3 ELSE, LEAVE BLANK |
FILLS (SPA) |
TEXT FILL 3: FILL “ya sea cuando le quitaron el útero o en cualquier otro momento” IF RHQUTERUS = 1 OR RHQNOMNS = 3 ELSE, LEAVE BLANK |
NOTES |
|
HELP SCREEN (ENG) |
It is possible to have both ovaries removed, only one ovary removed, or only part of an ovary removed. Ovaries may be removed during a hysterectomy. Select “Yes” only if a surgeon completely removed both ovaries. |
HELP SCREEN (SPA) |
Es posible que se quiten ambos ovarios, solo un ovario o solo parte de un ovario. Es posible que se quiten los ovarios durante una histerectomía. Seleccione “Sí” solamente si un cirujano le quitó los dos ovarios por completo. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RHQ.305 |
NEXT |
IF RHQOVRY = 1: RHQOVRYAGE IF RHQOVRY = 2 AND RHQMNS12MO = 1 AND RHQUTERUS = 2 AND SP AGE = 18-64 YEARS: RHQPREGEVR IF RHQOVRY = 2 AND RHQMNS12MO = 1 AND RHQUTERUS = 2 AND SP AGE >= 65 YEARS: END OF SECTION IF RHQOVRY = 2 AND (RHQMNS12MO != 1 OR RHQUTERUS != 2): RHQMNSLAST IF RHQOVRY = 7 OR 9: RHQMNSLAST |
RHQOVRYAGE |
|
ASK |
IF RHQOVRY = 1 |
How old were you when you had your ovaries removed or last ovary removed if removed at different times?
|___|___|___| ENTER AGE
7777. REFUSED 9999. DON’T KNOW
|
|
SPANISH |
¿Qué edad tenía cuando le quitaron los ovarios o cuando le quitaron el último ovario si se lo quitaron en diferentes ocasiones?
|___|___|___| ENTER AGE
7777. REFUSED 9999. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS |
|
NOTES |
DISPLAY NUMBER KEYPAD WITH CLEAR BUTTON |
HELP SCREEN |
|
HARD CHECK (ENG) |
IF RHQOVRYAGE > SP AGE, DISPLAY “You reported an age greater than your current age. Please enter the correct age.” |
HARD CHECK (SPA) |
IF RHQOVRYAGE > SP AGE, DISPLAY “Usted informó una edad superior a la que tiene ahora. Ingrese la edad correcta”. |
SOFT CHECK |
|
VERSION NOTES |
RHQ.332 |
NEXT |
RHQMNSLAST |
RHQMNSLAST |
|
ASK |
IF RHQMNS12MO = 7 OR 9 IF RHQOVRY = 1 OR 7 OR 9 IF RHQOVRY = 2 AND (RHQMNS12MO != 1 OR RHQUTERUS != 2) |
About how old were you when you had your last menstrual period?
|___|___| ENTER AGE
777. REFUSED 999. DON’T KNOW
|
|
SPANISH |
¿Apróximadamente qué edad tenía cuando tuvo su último período menstrual?
|___|___| ENTER AGE
777. REFUSED 999. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS |
|
NOTES |
DISPLAY NUMBER KEYPAD WITH CLEAR BUTTON |
HELP SCREEN |
|
HARD CHECK (ENG) |
IF RHQMNSLAST > SP AGE, DISPLAY, “You reported an age greater than your current age. Please try again.” |
HARD CHECK (SPA) |
IF RHQMNSLAST > SP AGE, DISPLAY, “Usted informó una edad superior a la que tiene ahora. Inténtelo de nuevo.” |
SOFT CHECK (ENG) |
IF RHQMNSLAST > 59, DISPLAY, “You reported your last menstrual period after age 59. If that is not correct, enter the correct age. If that is correct, please press “Suppress” and thenthe “Next” button to continue.” IF RHQMNSLAST > RHQOVRYAGE, DISPLAY, “You reported the age of your last menstrual period after the age that both of your ovaries were removed. If that is not correct, enter the correct age.If that is correct, please press “Suppress” and then the “Next” button to continue.” |
SOFT CHECK (SPA) |
IF RHQMNSLAST > 59, DISPLAY, “Usted informó que su último período menstrual fue después de los 59 años. Si esa respuesta no es correcta, ingrese la edad correcta. Si esto es correcto, presione “Eliminar” y después el botón “Siguiente” para continuar.” IF RHQMNSLAST > RHQOVRYAGE, DISPLAY, “Usted ingresó que tuvo su último período menstrual después de la la edad en que le quitaron ambos ovarios. Si esa respuesta no es correcta, ingrese la edad correcta. Si esto es correcto, presione “Eliminar” y después el botón “Siguiente” para continuar.” |
VERSION NOTES |
RHQ.060 |
NEXT |
IF SP AGE IS 18-64 YEARS: RHQPREGEVR ELSE: END OF SECTION |
RHQPREGEVR |
|
ASK |
IF SP AGE IS 18-64 YEARS AND RHQMNSFRST <> 0 |
The next questions are about your pregnancy history.
Have you ever been pregnant? Please include current pregnancy, live births, miscarriages, stillbirths, tubal pregnancies and abortions.
1. Yes 2. No 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Las siguientes preguntas son sobre su historial de embarazos.
¿Ha estado embarazada alguna vez? Incluya un embarazo actual, los bebés que nacieron vivos, los abortos espontáneos, las muertes fetales, los embarazos ectópicos o tubáricos y los abortos.
1. Sí 2. No 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN (ENG) |
Miscarriage is the loss of a baby before the 20th week of pregnancy. Stillbirth is the loss of a baby at or after 20 weeks of pregnancy. Tubal Pregnancy is a pregnancy that occurs in the fallopian tube. Abortion is the intentional termination of a pregnancy. |
HELP SCREEN (SPA) |
El aborto espontáneo es la pérdida de un bebé antes de las 20 semanas de embarazo. La muerte fetal ocurre cuando se pierde un bebé a las 20 semanas de embarazo o después. El embarazo ectópico o tubárico es un embarazo que se produce en una trompa de Falopio. El aborto es la terminación voluntaria de un embarazo. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RHQ.131 |
NEXT |
IF RHQPREGEVR = 1 AND RHQNOMNS = 3 OR 7: RHQDELIVER IF RHQPREGEVR = 1 AND RHQUTERUS = 1: RHQDELIVER IF RHQPREGEVR = 1 AND ((RHQNOMNS = 1 OR 2 OR 9 OR 77 OR 99) OR (RHQUTERUS = 2 OR 7 OR 9)): RHQPREGNOW IF RHQPREGEVR = 2 OR 7 OR 9: END OF SECTION |
RHQTPREGNOW |
|
ASK |
IF RHQPREGEVR = 1 AND ((RHQNOMNS = 1 OR 2 OR 9 OR 77 OR 99) OR (RHQUTERUS = 2 OR 7 OR 9)) |
Are you pregnant now?
1. Yes 2. No 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Está us actualmente embarazada?
1. Sí 2. No 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RHQ.143 |
NEXT |
RHQDELIVER |
RHQDELIVER |
|
ASK |
IF RHQPREGEVR = 1 |
How many vaginal or Cesarean deliveries have you had? Please count all stillbirths as well as live births.
If you delivered twins or had any other multiple birth, count it as one delivery.
|___|___| ENTER TOTAL NUMBER OF DELIVERIES
777. REFUSED 999. DON’T KNOW
|
|
SPANISH |
¿Cuántos partos vaginales o cesáreas ha tenido? Incluya los bebés que nacieron vivos y las muertes fetales.
Si dio a luz a mellizos o tuvo cualquier otro parto múltiple, cuéntelo como un solo parto.
|___|___| ENTER TOTAL NUMBER OF DELIVERIES
777. REFUSED 999. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS |
|
NOTES |
DISPLAY NUMBER KEYPAD WITH CLEAR BUTTON |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RHQ.167 |
NEXT |
IF RHQDELIVER = 0: END OF SECTION ELSE, RHQBREASTF |
RHQBREASTF |
|
ASK |
IF RHQDELIVER > 0 OR REFUSED OR DON’T KNOW |
Are you now breastfeeding a child?
1. Yes 2. No 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Está amamantando a un niño ahora?
1. Sí 2. No 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
RHQ.200 |
NEXT |
END OF SECTION |
BLADDER FUNCTIONING - BFQ
New Target Group: Sighted SP Respondents 18+
CAPI INSTRUCTION FOR ACASI SECTIONS: Follow DK/REF guidance for MEC ACASI: (1) DK/REF will initially be hidden. If the SP tries to advance without selecting a response, DK/REF will appear along with a red error message: "Please select an answer to continue." (2) TTS does not read DK/REF (3) DK/REF is not covered in the tutorial
BFQLEAKAGE |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
The following questions are about bladder function, including urine leakage.
Many people have leakage of urine. Urinary leakage includes not being able to hold your urine until you can reach a toilet, not being able to control your bladder, or loss of urine control. How often do you have urinary leakage?
0. never had urine leakage 1. less than once a month 2. a few times a month 3. a few times a week 4. every day and/or night 7. REFUSED 9. DON’T KNOW |
|
SPANISH |
Las siguientes preguntas son sobre el funcionamiento de la vejiga, incluida la incontinencia urinaria.
Muchas personas tienen incontinencia urinaria. La incontinencia urinaria incluye no ser capaz de retener la orina hasta llegar al inodoro, no poder controlar la vejiga o perder el control de la orina. ¿Con qué frecuencia tiene incontinencia urinaria?
0. nunca tuvo incontinencia urinaria 1. menos de una vez al mes 2. algunas veces al mes 3. algunas veces por semana 4. todos los días o noches 7. REFUSED 9. DON’T KNOW |
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
BFQ.005 |
NEXT |
IF BFQLEAKAGE = 1 OR 2 OR 3 OR 4: BFQURNLOSE ELSE: BFQACTIVTY |
BFQURNLOSE |
|
ASK |
IF BFQLEAKAGE = 1 OR 2 OR 3 OR 4 |
How much urine do you lose when this happens?
1. drops 2. small splashes 3. more than small splashes 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Cuánta orina pierde cuando ocurre esto?
1. gotas 2. salpicaduras pequeñas 3. más que salpicaduras pequeñas 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
BFQ.010 |
NEXT |
BFQACTIVTY |
BFQACTIVTY |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
In the last 12 months, have you leaked or lost control of even a small amount of urine with an activity like coughing, lifting or exercise?
1. Yes 2. No 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿se le escapó o perdió el control de incluso una pequeña cantidad de orina durante una actividad como toser, levantar peso o hacer ejercicio?
1. Sí 2. No 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
BFQ.042 |
NEXT |
BFQPRESSRE |
BFQPRESSRE |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
In the last 12 months, have you leaked or lost control of even a small amount of urine with an urge or pressure to urinate and you couldn’t get to the toilet fast enough?
1. Yes 2. No 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿se le escapó o perdió el control de incluso una pequeña cantidad de orina cuando sentía urgencia o presión para orinar y no pudo llegar al baño lo suficientemente rápido?
1. Sí 2. No 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
BFQ.044 |
NEXT |
IF BFQPRESSRE = 1 OR BFQACTIVTY = 1: BFQIMPACT ELSE: BFQAWAKEN |
BFQIMPACT |
|
ASK |
IF BFQACTIVTY = 1 OR BFQPRESSRE = 1 |
In the last 12 months, how much did your leakage of urine affect your day-to-day activities?
1. not at all 2. only a little 3. somewhat 4. very much 5. greatly 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿qué tanto afectó la incontinencia urinaria sus actividades diarias?
1. nada 2. solo un poco 3. algo 4. bastante 5. mucho 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
BFQ.052 |
NEXT |
BFQAWAKEN |
BFQAWAKEN |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
In the last 30 days, during a typical night, how many times did you wake up and urinate?
0. 0 1. 1 2. 2 3. 3 4. 4 5. 5 or more 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
En los últimos 30 días, durante una noche típica, ¿cuántas veces se despertó y orinó?
0. 0 1. 1 2. 2 3. 3 4. 4 5. 5 o más 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
BFQ.481 |
NEXT |
END OF SECTION |
DEPRESSION SCREEN – DPQ
Target Group: Sighted SP Respondents 18+
CAPI INSTRUCTION FOR ACASI SECTIONS: Follow DK/REF guidance for MEC ACASI: (1) DK/REF will initially be hidden. If the SP tries to advance without selecting a response, DK/REF will appear along with a red error message: "Please select an answer to continue." (2) TTS does not read DK/REF (3) DK/REF is not covered in the tutorial
DPQNOINT |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
The next questions are about problems that may have bothered you over the last 2 weeks.
Over the last 2 weeks, how often have you been bothered by any of the following problems:
Little interest or pleasure in doing things?
0. Not at all 1. Several days 2. More than half the days 3. Nearly every day 7. REFUSED 9. DON’T KNOW |
|
SPANISH |
Las siguientes preguntas son sobre problemas que podrían haberle causado molestias en las últimas 2 semanas.
Durante las últimas 2 semanas, ¿con qué frecuencia tuvo alguno de los siguientes problemas?
Poco interés o placer al hacer actividades
0. Nunca 1. Varios días 2. Más de la mitad de los días 3. Casi todos los días 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DPQ.010 |
NEXT |
DPQDEPRESS |
DPQDEPRESS |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
Over the last 2 weeks, how often have you been bothered by:
Feeling down, depressed, or hopeless?
0. Not at all 1. Several days 2. More than half the days 3. Nearly every day 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Durante las últimas 2 semanas, ¿con qué frecuencia le ha causado molestia lo siguiente:
Tristeza, depresión o sentirse sin esperanza?
0. Nunca 1. Varios días 2. Más de la mitad de los días 3. Casi todos los días 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DPQ.020 |
NEXT |
DPQSLEEP |
DPQSLEEP |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
Over the last 2 weeks, how often have you been bothered by:
Trouble falling or staying asleep, or sleeping too much?
0. Not at all 1. Several days 2. More than half the days 3. Nearly every day 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Durante las últimas 2 semanas, ¿con qué frecuencia le ha molestado lo siguiente:
Problemas para dormirse o quedarse dormido(a), o dormir demasiado?
0. Nunca 1. Varios días 2. Más de la mitad de los días 3. Casi todos los días 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DPQ.030 |
NEXT |
DPQTIRED |
DPQTIRED |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
Over the last 2 weeks, how often have you been bothered by:
Feeling tired or having little energy?
0. Not at all 1. Several days 2. More than half the days 3. Nearly every day 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Durante las últimas 2 semanas, ¿con qué frecuencia le ha molestado lo siguiente:
Sentir cansancio o tener poca energía?
0. Nunca 1. Varios días 2. Más de la mitad de los días 3. Casi todos los días 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DPQ.040 |
NEXT |
DPQAPPEAT |
DPQAPPEAT |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
Over the last 2 weeks, how often have you been bothered by:
Poor appetite or overeating?
0. Not at all 1. Several days 2. More than half the days 3. Nearly every day 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Durante las últimas 2 semanas, ¿con qué frecuencia le ha molestado lo siguiente:
Tener poco apetito o comer demasiado?
0. Nunca 1. Varios días 2. Más de la mitad de los días 3. Casi todos los días 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DPQ.050 |
NEXT |
DPQBADSELF |
DPQBADSELF |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
Over the last 2 weeks, how often have you been bothered by:
Feeling bad about yourself – or that you are a failure or have let yourself or your family down?
0. Not at all 1. Several days 2. More than half the days 3. Nearly every day 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Durante las últimas 2 semanas, ¿con qué frecuencia le ha molestado lo siguiente:
Sentirse mal sobre sí mismo(a), o sentirse que usted es un fracaso o sentir que se ha desilusionado a usted mismo(a) o a su familia?
0. Nunca 1. Varios días 2. Más de la mitad de los días 3. Casi todos los días 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DPQ.060 |
NEXT |
DPQCONCEN |
DPQCONCEN |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
Over the last 2 weeks, how often have you been bothered by:
Trouble concentrating on things, such as reading the newspaper or watching TV?
0. Not at all 1. Several days 2. More than half the days 3. Nearly every day 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Durante las últimas 2 semanas, ¿con qué frecuencia le ha molestado lo siguiente:
Problemas para concentrarse en las cosas, como leer el periódico o ver la televisión?
0. Nunca 1. Varios días 2. Más de la mitad de los días 3. Casi todos los días 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DPQ.070 |
NEXT |
DPQSPEED |
DPQSPEED |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
Over the last 2 weeks, how often have you been bothered by:
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?
0. Not at all 1. Several days 2. More than half the days 3. Nearly every day 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Durante las últimas 2 semanas, ¿con qué frecuencia le ha molestado lo siguiente:
Moverse o hablar tan despacio que otras personas podrían haberlo notado; o lo contrario, es decir, estar tan inquieto(a) que se ha estado moviendo mucho más de lo normal?
0. Nunca 1. Varios días 2. Más de la mitad de los días 3. Casi todos los días 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DPQ.080 |
NEXT |
IF CODE 1 OR 2 OR 3 FOR ANY OF THE PREVIOUS ITEMS (DPQNOINT, DPQDEPRESS, DPQSLEEP, DPQTIRED, DPQAPPEAT, DPQBADSELF, DPQCONCEN, DPQSPEED): DPQDIFF ELSE: END OF SECTION |
DPQDIFF |
|
ASK |
IF CODE 1 OR 2 OR 3 FOR ANY OF THE PREVIOUS ITEMS (DPQNOINT, DPQDEPRESS, DPQSLEEP, DPQTIRED, DPQAPPEAT, DPQBADSELF, DPQCONCEN, DPQSPEED) |
How difficult <TEXT FILL 1> made it for you to do your work, take care of things at home, or get along with people?
0. Not at all difficult 1. Somewhat difficult 2. Very difficult 3. Extremely difficult 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Qué tan difícil le <TEXT FILL 1> para hacer su trabajo, encargarse de las cosas en el hogar o llevarse bien con las personas?
0. Nada difícil 1. Algo difícil 2. Muy difícil 3. Extremadamente difícil 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “has this problem” IF CODE 1 OR 2 OR 3 FOR ONLY ONE OF PREVIOUS ITEMS (DPQNOINT, DPQDEPRESS, DPQSLEEP, DPQTIRED, DPQAPPEAT, DPQBADSELF, BPQCONCEN, DPQSPEED) ELSE, FILL “have these problems” IF CODE 1 OR 2 OR 3 FOR MORE THAN ONE OF PREVIOUS ITEMS |
FILLS (SPA) |
TEXT FILL 1: FILL “ha resultado este problema” IF CODE 1 OR 2 OR 3 FOR ONLY ONE OF PREVIOUS ITEMS (DPQNOINT, DPQDEPRESS, DPQSLEEP, DPQTIRED, DPQAPPEAT, DPQBADSELF, BPQCONCEN, DPQSPEED) ELSE, FILL “han resultado estos problemas” IF CODE 1 OR 2 OR 3 FOR MORE THAN ONE OF PREVIOUS ITEMS |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
DPQ.100 |
NEXT |
END OF SECTION |
ALCOHOL USE – ALQ
Target Group: Sighted SP Respondents 18+
CAPI INSTRUCTION FOR ACASI SECTIONS: Follow DK/REF guidance for MEC ACASI: (1) DK/REF will initially be hidden. If the SP tries to advance without selecting a response, DK/REF will appear along with a red error message: "Please select an answer to continue." (2) TTS does not read DK/REF (3) DK/REF is not covered in the tutorial
ALQ1DRINK |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
The next questions are about drinking alcoholic beverages. Included are liquor (such as whiskey or gin), beer, wine, wine coolers, and any other type of alcoholic beverage.
In your entire life, have you had at least 1 drink of any kind of alcohol, not counting small tastes or sips? By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and a half ounces of liquor.
1. Yes 2. No 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Las siguientes preguntas son sobre el consumo de bebidas alcohólicas. Se incluyen los licores (como el whisky o la ginebra), la cerveza, vino, bebidas con vino o “wine coolers” y cualquier otro tipo de bebida alcohólica.
En toda su vida, ¿ha tomado al menos 1 bebida de cualquier tipo de alcohol, sin contar pequeñas probadas o sorbos? Por un trago me refiero a una cerveza de 12 onzas, una copa de vino de 5 onzas o una onza y media de licor.
1. Sí 2. No 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
ALQ.111 |
NEXT |
IF ALQ1DRINK = 2: END OF SECTION ELSE, ALQFREQ |
ALQFREQ |
|
ASK |
IF ALQ1DRINK = 1 OR 7 OR 9 |
In the last 12 months, about how often did you drink any type of alcoholic beverage?
In other words, how many days per week, per month, or per year did you drink?
Please select one of the following choices.
0. Never in the last year 1. 1 to 2 times in the last year 2. 3 to 6 times in the last year 3. 7 to 11 times in the last year 4. Once a month 5. 2 to 3 times a month 6. Once a week 7. 2 times a week 8. 3 to 4 times a week 9. Nearly every day 10. Every day 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿con qué frecuencia tomó algún tipo de bebida alcohólica?
En otras palabras, ¿cuántos días a la semana, al mes o al año bebía?
Seleccione una de las siguientes opciones.
0. Ninguna vez en los últimos 12 meses 1. De 1 a 2 veces en los últimos 12 meses 2. De 3 a 6 veces en los últimos 12 meses 3. De 7 a 11 veces en en los últimos 12 meses 4. Una vez al mes 5. De 2 a 3 veces al mes 6. Una vez a la semana 7. 2 veces por semana 8. De 3 a 4 veces por semana 9. Casi todos los días 10. Todos los días 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
DISPLAY THE RESPONSE CATEGORIES IN DESCENDING ORDER ON THE SCREEN (I.E., STARTING WITH “EVERY DAY”, “NEARLY EVERY DAY”, AND LIST “NEVER IN THE LAST YEAR” THE LAST. |
HELP SCREEN (ENG) |
If you only drank part of the year, report for most of the year. If you drank half of the year but did not drink during the other half of the year, report your current drinking pattern. Choose the closest response if you cannot find an answer that fits your situation perfectly. |
HELP SCREEN (SPA) |
Si solo bebió parte del año, informe la cantidad que bebió la mayor parte del año. Si bebió la mitad del año pero no la otra mitad, informe sus hábitos de consumo actual. Seleccione la respuesta más cercana si no encuentra una respuesta que se corresponda perfectamente a su situación. |
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
ALQ.121 |
NEXT |
IF ALQFREQ = 0: ALQBINGEDY ELSE: ALQQUANT |
ALQQUANT |
|
ASK |
IF ALQFREQ = 1-10 OR 77 OR 99 |
In the last 12 months, on those days that you drank alcoholic beverages, on average, how many drinks did you have? By a drink, we mean a 12 oz. beer, a 5 oz. glass of wine, or one and a half ounces of liquor.
|___|___|___| ENTER NUMBER OF DRINKS
777. REFUSED 999. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, en los días que tomó bebidas alcohólicas, en promedio, ¿cuántas bebidas tomó? Por “bebida” nos referimos a una cerveza de 12 onzas, una copa de vino de 5 onzas o una onza y media de licor.
|___|___|___| ENTER NUMBER OF DRINKS
777. REFUSED 999. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS |
|
NOTES |
DISPLAY NUMBER KEYPAD WITH CLEAR BUTTON |
HELP SCREEN |
|
HARD CHECK (ENG) |
IF ALQQUANT = 0, DISPLAY, “Your response must be greater than zero. Please enter the correct answer.” |
HARD CHECK (SPA) |
IF ALQQUANT = 0, DISPLAY, “Su respuesta debe ser mayor que cero. Ingrese la respuesta correcta.” |
SOFT CHECK (ENG) |
IF ALQQUANT >= 20, DISPLAY, “You said on the days that you drink you have on average 20 or more drinks. If that is correct, please press the “Next” button to continue. If that is not correct, enter the correct answer.” |
SOFT CHECK (SPA) |
IF ALQQUANT >= 20, DISPLAY, “Usted dijo que, los días en que bebe, toma un promedio de 20 bebidas o más. Si esto es correcto, presione el botón “Siguiente” para continuar. Si esa respuesta no es correcta, ingrese la respuesta correcta.” |
VERSION NOTES |
ALQ.130 |
NEXT |
ALQBINGE |
ALQBINGE |
|
ASK |
IF ALQFREQ = 1-10 OR 77 OR 99 |
In the last 12 months, about how often did you have <BINGE FILL> or more drinks of any alcoholic beverage?
In other words, how many days per week, per month, or per year did you have <BINGE FILL> or more drinks in a single day?
0. Never in the last year 1. 1 to 2 times in the last year 2. 3 to 6 times in the last year 3. 7 to 11 times in the last year 4. Once a month 5. 2 to 3 times a month 6. Once a week 7. 2 times a week 8. 3 to 4 times a week 9. Nearly every day 10. Every day 77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
En los últimos 12 meses, ¿con qué frecuencia tomó <BINGE FILL> o más bebidas de cualquier bebida alcohólica?
En otras palabras, ¿cuántos días a la semana, al mes o al año tomó <BINGE FILL> o más bebidas en un solo día?
0. Ninguna vez en los últimos 12 meses 1. De 1 a 2 veces en los últimos 12 meses 2. De 3 a 6 veces en los últimos 12 meses 3. De 7 a 11 veces en los últimos 12 meses 4. Una vez al mes 5. De 2 a 3 veces al mes 6. Una vez a la semana 7. 2 veces por semana 8. De 3 a 4 veces por semana 9. Casi todos los días 10. Todos los días 77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
BINGE FILL: FILL “5” IF SP GENDER IS MALE IN SPQGENDER ELSE, FILL “4” |
NOTES |
DISPLAY THE RESPONSE CATEGORIES IN DESCENDING ORDER ON THE SCREEN (I.E., STARTING WITH “EVERY DAY”, “NEARLY EVERY DAY”, AND LIST “NEVER IN THE LAST YEAR” THE LAST. |
HELP SCREEN |
|
HARD CHECK (ENG) |
IF (ALQBINGE CODED VALUE > ALQFREQ CODED VALUE) AND ALQQUANT IS NOT RF/DK, DISPLAY, “Your response is not consistent with your previous response about how often you drank in the last 12 months. Please enter the correct response.” |
HARD CHECK (SPA) |
IF (ALQBINGE CODED VALUE > ALQFREQ CODED VALUE) AND ALQQUANT IS NOT RF/DK, DISPLAY, “Su respuesta no coincide con su respuesta anterior sobre la frecuencia con la que bebió en los últimos 12 meses. Ingrese la respuesta correcta.” |
SOFT CHECK |
|
VERSION NOTES |
ALQ.142 |
NEXT |
ALQBINGEDY |
ALQBINGEDY |
|
ASK |
IF ALQ1DRINK = 1 OR 7 OR 9 |
Was there ever a time or times in your life when you drank <BINGE FILL> or more drinks of any kind of alcoholic beverage almost every day?
1. Yes 2. No 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Hubo algún momento de su vida en el que bebió <BINGE FILL> o más bebidas de cualquier tipo de bebida alcohólica casi todos los días?
1. Sí 2. No 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
BINGE FILL: FILL “5” IF SP GENDER IS MALE IN SPQGENDER ELSE, FILL “4” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
ALQ.151 |
NEXT |
IF ALQFREQ = 0 OR ALQBINGE = 0: END OF SECTION ELSE, ALQOCCASN |
ALQOCCASN |
|
ASK |
(IF ALQFREQ = 1-10 OR 77 OR 99) AND (IF ALQBINGE = 1-10 OR 77 OR 99) |
Considering all types of alcoholic beverages, in the last 30 days, how many times did you have <BINGE FILL> or more drinks on an occasion? By occasion, we mean a period of several hours on the same day.
Please enter a number or enter 0 for none.
|___|___| ENTER NUMBER OF TIMES
777. REFUSED 999. DON’T KNOW
|
|
SPANISH |
Teniendo en cuenta todos los tipos de bebidas alcohólicas, en los últimos 30 días, ¿cuántas veces tomó <BINGE FILL> o más bebidas en una ocasión? Por ocasión, nos referimos a un período de varias horas en el mismo día.
Ingrese un número o ingrese 0 si no tomó ninguna.
|___|___| ENTER NUMBER OF TIMES
777. REFUSED 999. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS |
BINGE FILL: FILL “5” IF SP GENDER IS MALE IN SPQGENDER ELSE, FILL “4”
|
NOTES |
DISPLAY NUMBER KEYPAD WITH CLEAR BUTTON |
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK (ENG) |
IF ALQOCCASN > 60, DISPLAY, “You said that in the past 30 days, you had <BINGE FILL> or more drinks of any kind of alcohol on an occasion, more than 60 times. If that is not correct, enter the correct answer. If that is correct, please press “Suppress” and then the “Next” button to continue”. |
SOFT CHECK (SPA) |
IF ALQOCCASN > 60, DISPLAY, “Usted dijo que, en los últimos 30 días, tomó <BINGE FILL> o más bebidas de cualquier tipo de alcohol en una ocasión, más de 60 veces. Si esa respuesta no es correcta, ingrese la respuesta correcta. Si esto es correcto, presione “Eliminar” y después el botón “Siguiente” para continuar.” |
VERSION NOTES |
ALQ.170 |
NEXT |
END OF SECTION |
ACASI Conclusion
Target Group: Sighted SP Respondents 18+
CAPI INSTRUCTION FOR ACASI SECTIONS: Follow DK/REF guidance for MEC ACASI: (1) DK/REF will initially be hidden. If the SP tries to advance without selecting a response, DK/REF will appear along with a red error message: "Please select an answer to continue." (2) TTS does not read DK/REF (3) DK/REF is not covered in the tutorial
TUQLOCK |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
Thank you for answering these questions. When you leave this screen, the responses you entered into the computer will be locked and can no longer be seen by you or anyone else who uses this computer.
When you are ready, please press 1 and [ENTER] to lock your responses.
|
|
SPANISH |
Gracias por responder estas preguntas. Cuando salga de esta pantalla, las respuestas que ingresó en la computadora quedarán bloqueadas y ya no podrán ser vistas por usted ni por ninguna otra persona que use esta computadora.
Cuando esté listo(a), presione 1 y [ENTER] para bloquear sus respuestas.
|
QUESTION TYPE |
Numeric |
FILLS |
|
NOTES |
DISPLAY NUMBER KEYPAD WITH CLEAR BUTTON [ONCE 1 IS ENTERED FOR TUQLOCK, NO ONE CAN RE-ENTER THE ACASI PORTION OF THE INTERVIEW.] |
HELP SCREEN |
|
HARD CHECK |
ONLY ACCEPT VALUE OF 1. IF ENTRY IS NOT 1, DISPLAY “THE VALUE MUST BE 1.” |
SOFT CHECK |
|
VERSION NOTES |
ACASLOCK |
NEXT |
TUQAUDIO |
TUQAUDIO |
|
ASK |
IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR AND IF SP AGE >= 18 YEARS AND VIQLIGHT=1 |
Your responses have been locked. Please tell your interviewer that you are finished.
INTERVIEWER INSTRUCTION: ENTER THE 3-LETTER CODE TO MOVE TO THE NEXT SECTION.
________________ ENTER CODE
|
|
SPANISH |
Sus respuestas han sido bloqueadas. Dígale al(a la) entrevistador(a) que ha terminado.
INTERVIEWER INSTRUCTION: ENTER THE 3-LETTER CODE TO MOVE TO THE NEXT SECTION.
________________ ENTER CODE
|
QUESTION TYPE |
Text entry |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
ENDAUDIO |
NEXT |
END OF SECTION |
MAILING ADDRESS AND OTHER CONTACT INFORMATION – MAQ
Target Group: SPs Birth +
MAQMAILa / MAQMAILb / MAQMAILc / MAQMAILd / MAQMAILe |
|
ASK |
All respondents |
We are almost finished with this portion of the study! The National Center for Health Statistics may wish to contact <TEXT FILL 1> again. May I please have <TEXT FILL 2> complete mailing address?
CRITICAL INFORMATION – CHECK CAREFULLY.
PRESS 'ENTER' TO MOVE TO THE NEXT ENTRY FIELD. ______________________________________________________________ ENTER ADDRESS LINE 1 [MAQMAILa]
______________________________________________________________ ENTER ADDRESS LINE 2 [MAQMAILb]
______________________________ ________ ________ ENTER CITY [MAQMAILc] STATE [MAQMAILd] ENTER ZIP (5 DIGIT) [MAQMAILe]
|
|
SPANISH |
¡Ya casi terminamos con esta parte del estudio! El Centro Nacional de Estadísticas de la Salud posiblemente desee comunicarse conn <TEXT FILL 1> nuevamente. ¿Podría darme <TEXT FILL 2> por favor?
CRITICAL INFORMATION – CHECK CAREFULLY.
PRESS 'ENTER' TO MOVE TO THE NEXT ENTRY FIELD.
______________________________________________________________ ENTER ADDRESS LINE 1 [MAQMAILa]
______________________________________________________________ ENTER ADDRESS LINE 2 [MAQMAILb]
______________________ __________________ _____________ ENTER CITY [MAQMAILc] STATE [MAQMAILd] ENTER ZIP (5 DIGIT) [MAQMAILe]
|
QUESTION TYPE |
Text entry: MAQMAILa, MAQMAILb, MAQMAILc Select from dropdown: MAQMAILd Numeric: MAQMAILe |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “su dirección de correo postal completa” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “la dirección de correo postal completa de [SP NAME]” |
NOTES |
DISPLAY THE SCREENER MAILING ADDRESS INFORMATION. ZIP (5 DIGIT) FIELD, MAQMAILk, IS MAX 5 DIGITS. ZIP (LAST 4) FIELD, MAQMAILl, IS MAX 4 DIGITS INCLUDE STATE DROPDOWN WITH STATE ABBREVIATIONS AND STATE NAMES
ALLOW MAQMAILb TO BE LEFT BLANK. |
HELP SCREEN |
|
HARD CHECK |
IF “PO BOX” OR “P.O. BOX” IS ENTERED IN MAQMAILa OR MAQMAILb, DISPLAY “PLEASE ENTER THE PHYSICAL STREET ADDRESS. DO NOT ENTER P.O. BOX ON THIS SCREEN.”
MAQMAILa, c, d, e ARE REQUIRED. IF BLANK, DISPLAY ” ONE OR MORE FIELDS ARE MISSING. PLEASE PROVIDE A COMPLETE MAILING ADDRESS.”
IF MAQMAILe < 5 NUMBERS, DISPLAY “ZIP CODE ENTERED MUST BE 5 DIGITS. PLEASE CORRECT RESPONSE.”
|
SOFT CHECK |
|
VERSION NOTES |
MAQ.020a-k |
NEXT |
MAQMAILYN |
MAQMAILYN |
|
ASK |
All respondents |
I have recorded . . .
<MAQMAIL FILL>
Is that correct?
1. YES 2. NO
|
|
SPANISH |
He registrado lo siguiente . . .
<MAQMAIL FILL>
¿Es correcto?
1. YES 2. NO
|
QUESTION TYPE |
Radio button |
FILLS |
MAQMAIL FILL: FILL MAQMAILa-e IN UPPER CASE |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MAQ.040 |
NEXT |
IF MAQMAILYN = 1 AND SP AGE 0-17 YEARS: MAQLANG IF MAQMAILYN = 1 AND SP AGE >= 18 YEARS AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR: MAQEMAIL IF MAQMAILYN = 1 AND SP AGE >= 18 YEARS AND SP IS NOT SELECTED AS RESPONDENT IN SPQSELECTR: MAQLANG IF MAQMAILYN = 2: MAQMAIL TO CORRECT |
MAQEMAIL |
|
ASK |
IF MAQMAILYN = 1 AND SP AGE >= 18 YEARS AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR |
May I have your e-mail address?
______________________ ENTER EMAIL ADDRESS
0. DOES NOT HAVE AN EMAIL ACCOUNT 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Podría darme su dirección de correo electrónico?
______________________ ENTER EMAIL ADDRESS
0. DOES NOT HAVE AN EMAIL ACCOUNT 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Text entry |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
IF THERE ARE SPACES IN THE EMAIL ADDRESS, DISPLAY “EMAIL ADDRESS DOES NOT ALLOW SPACES.” IF EMAIL ADDRESS IS MISSING THE ‘@’ SYMBOL, DISPLAY “EMAIL ADDRESS IS MISSING THE @ SYMBOL - PLEASE GO BACK AND CORRECT.” IF TEXT IF MISSING TO THE LEFT OR RIGHT OF THE ‘@’ SYMBOL, DISPLAY “PART OF THE EMAIL ADDRESS IS MISSING - PLEASE GO BACK AND CORRECT.” |
SOFT CHECK |
|
VERSION NOTES |
MAQ.210N |
NEXT |
IF MAQEMAIL IS ‘0’, ‘7’, OR ‘9’: MAQLANG ELSE: MAQEMAILYN |
MAQEMAILYN |
|
ASK |
IF EMAIL REPORTED FOR MAQEMAIL |
I have recorded . . .
<MAQEMAIL FILL>
Is that correct?
1. YES 2. NO
|
|
SPANISH |
He registrado lo siguiente . . .
<MAQEMAIL FILL>
¿Es correcto?
1. YES 2. NO
|
QUESTION TYPE |
Radio button |
FILLS |
MAQEMAIL FILL: FILL EMAIL REPORTED IN MAQEMAIL |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MAQ.220 |
NEXT |
IF MAQEMAILYN = 2: MAQEMAIL TO CORRECT ELSE: MAQLANG |
MAQLANG |
|
ASK |
All respondents |
INTERVIEWER INSTRUCTION:
SPECIFY LANGUAGE IN WHICH HARD COPY MATERIALS SHOULD BE MAILED.
1. ENGLISH 2. SPANISH
|
|
SPANISH |
N/A |
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MAQ.090 |
NEXT |
IF FIRST TELEPHONE NUMBER FOR SP HAS BEEN COLLECTED IN SYSTEM AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR: MAQPHONE1 IF FIRST TELEPHONE NUMBER FOR SP HAS NOT BEEN COLLECTED IN SYSTEM AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR: MAQPHN1OTH IF SP NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE 12-17 YEARS: MAQCELL IF SP NOT SELECTED AS RESPONDENT IN SPQSELECTR AND SP AGE <= 11 YEARS OR >= 18 YEARS: END OF SECTION |
MAQPHONE1 |
|
ASK |
IF FIRST TELEPHONE NUMBER FOR SP HAS BEEN COLLECTED IN THE SYSTEM AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR |
Is <PHONE FILL> the best telephone number to reach you in case my office wants to check my work?
1. YES 2. NO. PROVIDE A DIFFERENT NUMBER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Es el <PHONE FILL> el mejor número de teléfono para comunicarnos con usted en caso de que el personal de mi oficina quiera verificar mi trabajo?
1. YES 2. NO. PROVIDE A DIFFERENT NUMBER 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
PHONE FILL: FILL FIRST PHONE NUMBER FROM DATABASE |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MAQ.230 |
NEXT |
IF MAQPHONE1 = 1: MAQPHN1TYP IF MAQPHONE1 = 2: MAQPHN1OTH IF MAQPHONE1 = 7 OR 9 AND SECOND TELEPHONE NUMBER FOR SP HAS BEEN COLLECTED IN SYSTEM: MAQPHONE2 IF MAQPHONE1 = 7 OR 9 AND SECOND TELEPHONE NUMBER FOR SP HAS NOT BEEN COLLECTED: END OF SECTION |
MAQPHN1OTH |
|
ASK |
IF FIRST TELEPHONE FOR SP HAS NOT BEEN COLLECTED IN THE SYSTEM AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR IF MAQPHONE1 = 2 |
Please tell me the best telephone number to reach you (in case my office wants to check my work).
INTERVIEWER INSTRUCTION: ENTER ‘000’ IN AREA CODE IF NO PHONE.
|___|___|___| |___|___|___| - |___|___|___|___| AREA CODE ENTER PHONE NUMBER
77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
Por favor, dígame el mejor número de teléfono para comunicarnos con usted en caso de que el personal de mi oficina quiera verificar mi trabajo.
INTERVIEWER INSTRUCTION: ENTER ‘000’ IN AREA CODE IF NO PHONE.
|___|___|___| |___|___|___| - |___|___|___|___| AREA CODE ENTER PHONE NUMBER
77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
ONLY ALLOW RESPONSE OF DON’T KNOW, REFUSED, “000” or 10 DIGIT PHONE NUMBER. IF PHONE NUMBER PROVIDED, DISPLAY HARD RANGE CHECK MESSAGE IF PHONE NUMBER NOT “000” OR IS 10 DIGITS OF ALL THE SAME NUMBER (I.E., 1111111111): “PLEASE ENTER A VALID PHONE NUMBER.” |
SOFT CHECK |
|
VERSION NOTES |
MAQ.101 G/a/b |
NEXT |
IF 10 DIGIT PHONE NUMBER ENTERED FOR MAQPHN1OTH: MAQPHN1TYP IF MAQPHN1OTH = (000 OR DK OR REF) AND SECOND TELEPHONE FOR SP HAS BEEN COLLECTED IN SYSTEM: MAQPHONE2 IF MAQPHN1OTH = (000 OR DK OR REF) AND SECOND TELEPHONE NUMBER FOR SP HAS NOT BEEN COLLECTED: END OF SECTION |
MAQPHN1TYP |
|
ASK |
IF MAQPHONE1 = 1 IF 10 DIGIT PHONE ENTERED FOR MAQPHN1OTH |
Is this number a cell phone or landline?
1. CELL PHONE 2. LANDLINE 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Es este número un teléfono celular o una línea fija?
1. CELL PHONE 2. LANDLINE 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MAQ.260 |
NEXT |
IF MAQPHN1TYP = 1: MAQPHN1TXT IF MAQPHN1TYP = 2 OR 7 OR 9 AND SECOND TELEPHONE NUMBER FOR SP HAS BEEN COLLECTED IN SYSTEM: MAQPHONE2 IF MAQPHN1TYP = 2 OR 7 OR 9 AND SECOND TELEPHONE NUMBER FOR SP HAS NOT BEEN COLLECTED: MAQPHN2OTH |
MAQPHN1TXT |
|
ASK |
IF MAQPHN1TYP = 1 |
We may want to send you short text messages containing reminders about <TEXT FILL 1> participation in the study. There may be fees to get a text message, depending on your plan. May we send text messages to this number?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
Es posible que queramos enviarle mensajes de texto cortos con recordatorios sobre <TEXT FILL 1> en el estudio. Puede que se apliquen tarifas por recibir mensajes de texto, según su plan. ¿Podríamos enviar mensajes de texto a este número?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “su participación” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “la participación de [SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MAQ.270 |
NEXT |
IF SECOND TELEPHONE NUMBER FOR SP HAS BEEN COLLECTED IN SYSTEM: MAQPHONE2 ELSE: MAQPHN2OTH |
MAQPHONE2 |
|
ASK |
IF SECOND TELEPHONE NUMBER FOR SP HAS BEEN COLLECTED IN SYSTEM AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR |
Is <PHONE FILL> the other number where you can be reached?
1. YES 2. NO. PROVIDE A DIFFERENT NUMBER 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Es el <PHONE FILL> el otro número con el que podemos comunicarnos con usted?
1. YES 2. NO. PROVIDE A DIFFERENT NUMBER 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
PHONE FILL: FILL SECOND PHONE NUMBER FROM DATABASE |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MAQ.280 |
NEXT |
IF MAQPHONE2 = 1: MAQPHN2TYP IF MAQPHONE2 = 2: MAQPHN2OTH IF MAQPHONE2 = 7 OR 9: END OF SECTION |
MAQPHN2OTH |
|
ASK |
IF (MAQPHONE1 = 1 OR 10 DIGIT PHONE ENTERED FOR MAQPHN1OTH) AND AND SP IS SELECTED AS RESPONDENT IN SPQSELECTR ANDSECOND TELEPHONE NUMBER FOR SP HAS NOT BEEN COLLECTED IN SYSTEM IF MAQPHONE2 = 2 |
Please tell me another number where you can be reached.
INTERVIEWER INSTRUCTION: ENTER ‘000’ IN AREA CODE IF NO PHONE.
|___|___|___| |___|___|___| - |___|___|___|___| AREA CODE ENTER PHONE NUMBER
77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
Por favor, dígame otro número con el que podamos comunicarnos con usted.
INTERVIEWER INSTRUCTION: ENTER ‘000’ IN AREA CODE IF NO PHONE.
|___|___|___| |___|___|___| - |___|___|___|___| AREA CODE ENTER PHONE NUMBER
77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
ONLY ALLOW RESPONSE OF DON’T KNOW, REFUSED, “000” or 10 DIGIT PHONE NUMBER. IF PHONE NUMBER PROVIDED, DISPLAY HARD RANGE CHECK MESSAGE IF PHONE NUMBER NOT “000” OR IS 10 DIGITS OF ALL THE SAME NUMBER (I.E., 1111111111): “PLEASE ENTER A VALID PHONE NUMBER.” |
SOFT CHECK |
|
VERSION NOTES |
MAQ.111 G/a/b |
NEXT |
IF 10 DIGIT PHONE NUMBER ENTERED FOR MAQPHN2OTH: MAQPHN2TYP IF MAQPHN2OTH = (000 OR DK OR REF): END OF SECTION |
MAQPHN2TYP |
|
ASK |
IF MAQPHONE2 = 1 IF 10 DIGIT PHONE ENTERED FOR MAQPHN2OTH |
Is this number a cell phone or landline?
1. CELL PHONE 2. LANDLINE 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Es este número es un teléfono celular o una línea fija?
1. CELL PHONE 2. LANDLINE 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MAQ.290 |
NEXT |
IF MAQPHN2TYP = 1: MAQPHN2TXT IF MAQPHN2TYP = 2 OR 7 OR 9: END OF SECTION |
MAQPHN2TXT |
|
ASK |
IF MAQPHN2TYP = 1 |
May we send you text messages about <TEXT FILL 1> participation in the study to this number<TEXT FILL 2>?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Podríamos enviar mensajes de texto sobre <TEXT FILL 1> en el estudio a este número <TEXT FILL 2>?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “ as well” IF MAQPHN1TXT = 1 |
FILLS (SPA) |
TEXT FILL 1: FILL “su participación” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “la participación de [SP NAME]”
TEXT FILL 2: FILL “ también” IF MAQPHN1TXT = 1 |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MAQ.310 |
NEXT |
END OF SECTION |
MAQCELL |
|
ASK |
IF SP AGE 12-17 YEARS |
Does <TEXT FILL 1> have a cell phone?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Tiene <TEXT FILL 1> un teléfono celular?
1. YES 2. NO 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MAQ.150 |
NEXT |
IF MAQCELL = 1: MAQCELLTXT ELSE: END OF SECTION |
MAQCELLTXT |
|
ASK |
IF MAQCELL=1 |
May we send <TEXT FILL 1> short text messages about <TEXT FILL 2> participation in the health exam to <TEXT FILL 2> cell phone<TEXT FILL 3>?
1. YES 2. NO 3. NO TEXT MESSAGING, NOT POSSIBLE 7. REFUSED 9. DON’T KNOW
|
|
SPANISH |
¿Podríamos enviarle a <TEXT FILL 1> mensajes de texto cortos sobre su participación en el examen de salud a su teléfono celular <TEXT FILL 3>?
1. YES 2. NO 3. NO TEXT MESSAGING, NOT POSSIBLE 7. REFUSED 9. DON’T KNOW
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “his” IF SP GENDER IS MALE IN SPQGENDER FILL “her” IF SP GENDER IS FEMALE IN SPQGENDER FILL “[SP NAME]’s” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “ as well” IF MAQPHN1TXT = 1 OR MAQPHN2TXT = 1 |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]”
TEXT FILL 2: FILL “” IF SP GENDER IS MALE IN SPQGENDER FILL “” IF SP GENDER IS FEMALE IN SPQGENDER FILL “” IF SP GENDER IS TRANSGENDER, NON-BINARY, OR ANOTHER GENDER (CODE 3) OR DK/RF IN SPQGENDER
TEXT FILL 3: FILL “ también” IF MAQPHN1TXT = 1 OR MAQPHN2TXT = 1 |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
MAQ.160 |
NEXT |
IF MAQCELLTXT = 1: MAQCELLNUM ELSE: END OF SECTION |
MAQCELLNUM |
|
ASK |
IF MAQCELLTXT = 1 |
What is <TEXT FILL 1> cell phone number?
INTERVIEWER INSTRUCTION: ENTER ‘000’ IN AREA CODE IF NO PHONE
|___|___|___| |___|___|___| - |___|___|___|___| AREA CODE ENTER PHONE NUMBER
77. REFUSED 99. DON’T KNOW
|
|
SPANISH |
¿Cuál es el número de teléfono celular de <TEXT FILL 1>?
INTERVIEWER INSTRUCTION: ENTER ‘000’ IN AREA CODE IF NO PHONE
|___|___|___| |___|___|___| - |___|___|___|___| AREA CODE ENTER PHONE NUMBER
77. REFUSED 99. DON’T KNOW
|
QUESTION TYPE |
Numeric |
FILLS (ENG) |
TEXT FILL 1: FILL “[SP NAME]’s” |
FILLS (SPA) |
TEXT FILL 1: FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
ONLY ALLOW RESPONSE OF DON’T KNOW, REFUSED, “000” or 10 DIGIT PHONE NUMBER. IF PHONE NUMBER PROVIDED, DISPLAY HARD RANGE CHECK MESSAGE IF PHONE NUMBER NOT “000” OR IS 10 DIGITS OF ALL THE SAME NUMBER (I.E., 1111111111): “PLEASE ENTER A VALID PHONE NUMBER.” |
SOFT CHECK |
|
VERSION NOTES |
MAQ.180 |
NEXT |
END OF SECTION |
fsdasINCENTIVE CARD - CCQ
Target Group: SPs Birth+
CCQOFFERYN |
|
ASK |
All respondents |
Thank you for taking the time to participate in this important study about our nation’s health. <TEXT FILL 1> a thank you for answering these questions, we are giving <TEXT FILL 2> $25.00 for completing the interview today.
INTERVIEWER INSTRUCTION: IF NEEDED, SAY: Do you accept this offer?
1. YES 2. NO
|
|
SPANISH |
Gracias por dedicar su tiempo a participar en este importante estudio sobre la salud de las personas que viven en Estados Unidos. <TEXT FILL 1> muestra de agradecimiento por responder estas preguntas, le daremos a <TEXT FILL 2> $25.00 dólares por completar la entrevista de hoy.
INTERVIEWER INSTRUCTION: IF NEEDED, SAY: ¿Acepta lo que le ofrecemos?
1. YES 2. NO
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: IF HOUSEHOLD REFERENCE PERSON IS SELECTED AS RESPONDENT IN SPQSELECTR, FILL “There is another set of questions that ask about your household. But first, as” ELSE, fill “As”
TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, fill “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: IF HOUSEHOLD REFERENCE PERSON IS SELECTED AS RESPONDENT IN SPQSELECTR, FILL “Hay otra serie de preguntas sobre su hogar. Pero primero, como” ELSE, fill “Como”
TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
>INCENTIVE FOR COMPLETING SP QUESTIONNAIRE |
NEXT |
IF CCQOFFERYN = 1: CCQCARDTYP IF CCQOFFERYN = 2: CCQREFUSE |
CCQREFUSE / CCQCHANGE |
|
ASK |
IF CCQOFFERYN = 2 |
<TEXT FILL 1> welcome to decline any of the funds offered for a study activity. Should <TEXT FILL 2> complete future study activities, we can provide a card at that time.
Please sign here that you are declining the funds for today’s interview.
COLLECT ADULT SP/ADULT PROXY E-SIGNATURE [CCQREFUSE]
INTERVIEWER INSTRUCTION: DID SP CHANGE MIND? IF SO, SELECT BELOW: [CCQCHANGE] 1. YES, CHANGED MIND 2. NO, STILL REFUSED
|
|
SPANISH |
<TEXT FILL 1> puede negarse a recibir cualquiera de los fondos ofrecidos como parte de las actividades del estudio. Si <TEXT FILL 2> completa actividades del estudio en el futuro, podemos darle una tarjeta en el momento de hacer eso.
Firme aquí que se niega a recibir los fondos de la entrevista de hoy.
COLLECT ADULT SP/ADULT PROXY E-SIGNATURE [CCQREFUSE]
INTERVIEWER INSTRUCTION: DID SP CHANGE MIND? IF SO, SELECT BELOW: [CCQCHANGE] 1. YES, CHANGED MIND 2. NO, STILL REFUSED
|
QUESTION TYPE |
Collect signature: CCQREFUSE Radio button: CCQCHANGE |
FILLS (ENG) |
TEXT FILL 1: FILL “You are” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] is” SELECTED AS RESPONDENT IN SPQSELECTR TEXT FILL 2: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “Usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] ” SELECTED AS RESPONDENT IN SPQSELECTR TEXT FILL 2: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
>REFUSE |
NEXT |
IF CCQCHANGE = 1: CCQCARDTYP IF CCQCHANGE = 2: CCQEND |
CCQCARDTYP |
|
ASK |
IF CCQOFFERYN=1 IF CCQCHANGE=1 |
I can issue a new gift card or add the funds to an existing card that <TEXT FILL 1> may have received for another interview. Would <TEXT FILL 1> like to add the funds to an existing card?
1. YES, ADD FUNDS TO EXISTING CARD 2. NO, ISSUE A NEW CARD
|
|
SPANISH |
Puedo darle una nueva tarjeta de regalo o agregar los fondos a una tarjeta existente que <TEXT FILL 1> ya haya recibido para otra entrevista. ¿Le gustaría que agreguemos los fondos a una tarjeta existente?
1. YES, ADD FUNDS TO EXISTING CARD 2. NO, ISSUE A NEW CARD
|
QUESTION TYPE |
Radio button |
FILLS (ENG) |
TEXT FILL 1: FILL “you” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]” |
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
|
NEXT |
CCQASSIGN |
CCQASSIGNa / CCQASSIGNb |
|
ASK |
IF CCQOFFERYN = 1 IF CCQREFUSE = 1 |
<TEXT FILL 3> ENTER PACKAGE ID NUMBER FROM ENVELOPE.
SCAN BARCODE OR ENTER PROXY NUMBER FROM ENVELOPE
[____________________________] FIRST ENTER PACKAGE ID [CCQASSIGNa]
[____________________________] SECOND ENTER PACKAGE ID [CCQASSIGNb]
This card is <TEXT FILL 1> Health Study gift card. It is a VISA© Card and is accepted anywhere VISA© is accepted. Funds for completing today’s study activities will be available for use on the card within 2 business days. You must activate the card before using it. Please keep the card for the duration of the study so we can add more funds to it as <TEXT FILL 2> study activities.
|
|
SPANISH |
<TEXT FILL 3> ENTER PACKAGE ID NUMBER FROM ENVELOPE.
SCAN BARCODE OR ENTER PROXY NUMBER FROM ENVELOPE
[____________________________] FIRST ENTER PACKAGE ID [CCQASSIGNa]
[____________________________] SECOND ENTER PACKAGE ID [CCQASSIGNb]
Esta tarjeta es la tarjeta de regalo del estudio de salud para <TEXT FILL 1>. Es una tarjeta VISA© y se acepta en cualquier lugar donde se acepte VISA©. Los fondos por completar las actividades del estudio de hoy estarán disponibles para usar en la tarjeta en un plazo de 2 días laborables. Debe activar la tarjeta antes de usarla. Conserve la tarjeta durante la duración del estudio para que podamos agregarle más fondos a medida que <TEXT FILL 2> las actividades del estudio.
|
QUESTION TYPE |
Textbox |
FILLS (ENG) |
TEXT FILL 1: FILL “your” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]’s”
TEXT FILL 2: FILL “you complete” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] completes”
TEXT FILL 3: IF CCQCARDTYP=1, FILL “ASK RESPONDENT TO SEE ENVELOPE ID FROM PREVIOUS GIFT CARD.” ELSE, FILL “TAKE OUT A NEW CARD FROM YOUR SUPPLY.” |
FILLS (SPA) |
TEXT FILL 1: FILL “usted” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME]”
TEXT FILL 2: FILL “usted complete” IF SP IS SELECTED AS RESPONDENT IN SPQSELECTR ELSE, FILL “[SP NAME] complete”
TEXT FILL 3: IF CCQCARDTYP=1, FILL “ASK RESPONDENT TO SEE ENVELOPE ID FROM PREVIOUS GIFT CARD.” ELSE, FILL “TAKE OUT A NEW CARD FROM YOUR SUPPLY.” |
NOTES |
CHECK THAT THE TWO PACKAGE IDS MATCH |
HELP SCREEN |
|
HARD CHECK |
DISPLAY ERROR MESSAGE IF TWO PACKAGE IDS DO NOT MATCH: DISPLAY ‘THE BARCODES MUST MATCH’. |
SOFT CHECK |
|
VERSION NOTES |
>ASSIGN CARD |
NEXT |
CCQDISPENSE |
CCQDISPNSE |
|
ASK |
IF CCQOFFERYN = 1 IF CCQREFUSE = 1 |
Thank you. <TEXT FILL 3>
INTERVIEWER INSTRUCTION: HAND <TEXT FILL 1>INFORMATION SHEET TO ADULT SP OR ADULT PROXY.
Please sign here to acknowledge you <TEXT FILL 2> the card.
COLLECT ADULT SP/ADULT PROXY E-SIGNATURE
You can find answers to most commonly asked questions on the card information sheet along with phone numbers to call for additional information. Remember, you need to activate the card following the instructions. If you wish to use the card for an ATM cash withdrawal, you must set up a PIN when you activate it. Do you have any questions about the card before we move on?
REVIEW INFORMATION SHEET, ASSIST TO ACTIVATE CARD, OR ANSWER ANY QUESTIONS
Thank you.
|
|
SPANISH |
Gracias. <TEXT FILL 3>
INTERVIEWER INSTRUCTION: HAND <TEXT FILL 1>INFORMATION SHEET TO ADULT SP OR ADULT PROXY.
Firme aquí para confirmar que <TEXT FILL 2> la tarjeta.
COLLECT ADULT SP/ADULT PROXY E-SIGNATURE
Encontrará las respuestas a las preguntas más frecuentes en la hoja informativa de la tarjeta, junto con números de teléfono a los que puede llamar para obtener información adicional. Recuerde que debe activar la tarjeta siguiendo las instrucciones. Si desea usar la tarjeta para retirar efectivo en un cajero automático, deberá crear un número personal de identificación (PIN) cuando la active. ¿Tiene alguna pregunta sobre la tarjeta antes de continuar?
REVIEW INFORMATION SHEET, ASSIST TO ACTIVATE CARD, OR ANSWER ANY QUESTIONS
Gracias.
|
QUESTION TYPE |
Collect signature: CCQDISPNSE |
FILLS (ENG) |
TEXT FILL 1: IF CCQCARDTYP=2: FILL “CARD AND ” ELSE, LEAVE BLANK
TEXT FILL 2: IF CCQCARDTYP=2, FILL “have received” ELSE, FILL “understand that the funds will be added to”
TEXT FILL 3: IF CCQCARDTYP=2, FILL “Here is the gift card.” ELSE, LEAVE BLANK |
FILLS (SPA) |
TEXT FILL 1: IF CCQCARDTYP=2: FILL “CARD AND ” ELSE, LEAVE BLANK
TEXT FILL 2: IF CCQCARDTYP=2, FILL “ha recibido” ELSE, FILL “entiende que los fondos se agregarán a”
TEXT FILL 3: IF CCQCARDTYP=2, FILL “Aquí tiene la tarjeta de regalo.” ELSE, LEAVE BLANK |
NOTES |
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HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
>DISPENSE CARD |
NEXT |
CCQEND |
CCQEND |
|
ASK |
All respondents |
PRESS F10 TO EXIT BLAISE FORM
|
|
SPANISH |
N/A |
QUESTION TYPE |
Informational |
FILLS |
|
NOTES |
|
HELP SCREEN |
|
HARD CHECK |
|
SOFT CHECK |
|
VERSION NOTES |
>END |
NEXT |
END OF SP QUESTIONNAIRE |
6b-
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Lori Houck |
| File Modified | 0000-00-00 |
| File Created | 2024-10-28 |
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