Optional Modules by Topic

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				Skip if Section CCHC.12, DIABETE4, is coded 1
MPDB.01	Have you had a test for high blood sugar or diabetes within the past three years?	PDIABTST	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			264
				Skip MPDB.02 if CCHC.12 DIABETE4, is coded 1; If CCHC.12, DIABETE4, is coded 4 automatically code MPDB.02, PREDIAB1, equal to 1 (yes);
MPDB.02	Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?	PREDIAB1	1 Yes 2 Yes, during pregnancy 3 No 7 Don’t know / Not sure 9 Refused		If Yes and respondent is female, ask: Was this only when you were pregnant?	265

Module 2: Diabetes

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				To be asked following Core CCHC.13; if response to CCHC.12 is Yes (code = 1)
MDIA.01	Are you now taking insulin?	INSULIN1	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			266
MDIA.02	About how often do you check your blood for glucose or sugar?	BLDSUGAR	1 _ _ Times per day 2 _ _ Times per week 3 _ _ Times per month 4 _ _ Times per year 888 Never 777 Don’t know / Not sure 999 Refused		Read if necessary: Include times when checked by a family member or friend, but do not include times when checked by a health professional. Do not read: If the respondent uses a continuous glucose monitoring system (a sensor inserted under the skin to check glucose levels continuously), fill in ‘98 times per day.’	267-269
MDIA.03	Including times when checked by a family member or friend, about how often do you check your feet for any sores or irritations?	FEETCHK3	1 _ _ Times per day 2 _ _ Times per week 3 _ _ Times per month 4 _ _ Times per year 555 No feet 888 Never 777 Don’t know / Not sure 999 Refused			270-272
MDIA.04	About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?	DOCTDIAB	_ _ Number of times [76 = 76 or more] 88 None 77 Don’t know / Not sure 99 Refused			273-274
MDIA.05	About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for A-one-C?	CHKHEMO3	_ _ Number of times [76 = 76 or more] 88 None 98 Never heard of A-one-C test 77 Don’t know / Not sure 99 Refused		Read if necessary: A test for A-one-C measures the average level of blood sugar over the past three months.	275-276
				If MDIA.03 = 555 (No feet), go to MDIA.07
MDIA.06	About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?	FEETCHK	_ _ Number of times [76 = 76 or more] 88 None 77 Don’t know / Not sure 99 Refused			277-278
MDIA.07	When was the last time you had an eye exam in which the pupils were dilated, making you temporarily sensitive to bright light?	EYEEXAM1	Read if necessary: 1 Within the past month (anytime less than 1 month ago) 2 Within the past year (1 month but less than 12 months ago) 3 Within the past 2 years (1 year but less than 2 years ago) 4 2 or more years ago Do not read: 7 Don’t know / Not sure 8 Never 9 Refused			279
MDIA.08	Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?	DIABEYE	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			280
MDIA.09	Have you ever taken a course or class in how to manage your diabetes yourself?	DIABEDU	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			281

Module 3: ME/CFS

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
MME.01	Have you ever been told by a doctor or other health professional that you had Chronic Fatigue Syndrome (CFS) or (Myalgic Encephalomyelitis) ME?	TOLDCFS	1 Yes		My-al-gic En-ceph-a-lo-my-eli-tis	282
MME.01		TOLDCFS	2 No 7 Don’t know / Not sure 9 Refused	Go to next section	My-al-gic En-ceph-a-lo-my-eli-tis	282
MME.02	Do you still have Chronic Fatigue Syndrome (CFS) or (Myalgic Encephalomyelitis) ME?	HAVECFS	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		My-al-gic En-ceph-a-lo-my-eli-tis	283
MME.03	Thinking about your CFS or ME, during the past 6 months, how many hours a week on average have you been able to work at a job or business for pay?	WORKCFS	Read if necessary 1 0 or no hours -- cannot work at all because of CFS or ME 2 1 - 10 hours a week 3 11- 20 hours a week 4 21- 30 hours a week 5 31 - 40 hours a week Do not read 7 Don’t know/ Not sure 9 Refused			284

Module 4: Hepatitis Treatment

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
MHT.01	Have you ever been told by a doctor or other health professional that you had Hepatitis C?	TOLDHEPC	1 Yes		Hepatitis C is an infection of the liver from the Hepatitis C virus	285
MHT.01		TOLDHEPC	2 No 7 Don’t know / Not sure 9 Refused	Go to MHT.05		285
MHT.02	Were you treated for Hepatitis C in 2015 or after?	TRETHEPC	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		Most hepatitis C treatments offered in 2015 or after were oral medicines or pills. Including Harvoni, Viekira, Zepatier, Epclusa and others.	286
MHT.03	Were you treated for Hepatitis C prior to 2015?	PRIRHEPC	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		Most hepatitis C treatments offered prior to 2015 were shots and pills given weekly or more often over many months.	287
MHT.04	Do you still have Hepatitis C?	HAVEHEPC	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused		You may still have Hepatitis C and feel healthy. Your blood must be tested again to tell if you still have Hepatitis C.	288
MHT.05	The next question is about Hepatitis B. Has a doctor, nurse, or other health professional ever told you that you had hepatitis B?	HAVEHEPB	1 Yes		Hepatitis B is an infection of the liver from the hepatitis B virus.	289
MHT.05		HAVEHEPB	2 No 7 Don’t know/ Not sure 9 Refused	Go to next section		289
MHT.06	Are you currently taking medicine to treat hepatitis B?	MEDSHEPB	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused			290

Module 5: Health Care Access

Question Number

Question text

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MHCA.01

What is the primary source of your health care coverage? Is it…

HLTHCVR1

Read:

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

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

03 Medicare

04 Medicaid or other state program

05 TRICARE (formerly CHAMPUS), VA, or Military

06 Alaska Native, Indian Health Service, Tribal Health Services

07 Some other source

08 None (no coverage)

Do not read:

77 Don't know/Not sure

99 Refused

Go to CHCA.02

If the respondent indicates that they purchased health insurance through the Health Insurance Marketplace (name of state Marketplace), ask if it was a private health insurance plan purchased on their own or by a family member (private) or if they received Medicaid (state plan). If purchased on their own (or by a family member), select 02, if Medicaid select 04.

291-292

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

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused

Module 6: Cognitive Decline

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If respondent is 45 years of age or older continue, else go to next module.
MCD.01	The next few questions ask about difficulties in thinking or remembering that can make a big difference in everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you recently met, which is normal. This refers to confusion or memory loss that is happening more often or getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would normally know. We want to know how these difficulties impact you. During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse?	CIMEMLOS	1 Yes	Go to MCD.02		293
			2 No	Go to next module
			7 Don’t know/ not sure	Go to MCD.02
			9 Refused	Go to next module
MCD.02	During the past 12 months, as a result of confusion or memory loss, how often have you given up day-to-day household activities or chores you used to do, such as cooking, cleaning, taking medications, driving, or paying bills? Would you say it is…	CDHOUSE	Read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never Do not read: 7 Don't know/Not sure 9 Refused			294
MCD.03	As a result of confusion or memory loss, how often do you need assistance with these day-to-day activities? Would you say it is…	CDASSIST	Read: 1 Always 2 Usually 3 Sometimes			295
MCD.03		CDASSIST	4 Rarely 5 Never Do not read: 7 Don't know/Not sure 9 Refused	Go to MCD.05		295
MCD.04	When you need help with these day-to-day activities, how often are you able to get the help that you need? Would you say it is…	CDHELP	Read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never Do not read: 7 Don't know/Not sure 9 Refused			296
MCD.05	During the past 12 months, how often has confusion or memory loss interfered with your ability to work, volunteer, or engage in social activities outside the home? Would you say it is…	CDSOCIAL	Read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never Do not read: 7 Don't know/Not sure 9 Refused			297
MCD.06	Have you or anyone else discussed your confusion or memory loss with a health care professional?	CDDISCUS	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			298

Module 7: Caregiver

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
MCG.01	During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability?	CAREGIV1	1 Yes		If caregiving recipient has died in the past 30 days, code 8 and say: I’m so sorry to hear of your loss	299
			2 No 7 Don’t know/Not sure	Go to MCG.09
			8 Caregiving recipient died in past 30 days	Go to MCG.09
			9 Refused	Go to MCG.09
MCG.02	What is his or her relationship to you?	CRGVREL4	01 Mother 02 Father 03 Mother-in-law 04 Father-in-law 05 Child 06 Husband 07 Wife 08 Live-in partner 09 Brother or brother-in-law 10 Sister or sister-in-law 11 Grandmother 12 Grandfather 13 Grandchild 14 Other relative 15 Non-relative/ Family friend 77 Don’t know/Not sure 99 Refused		If more than one person, say: Please refer to the person to whom you are giving the most care.	300-301
MCG.03	For how long have you provided care for that person? Would you say…	CRGVLNG1	Read: 1 Less than 30 days 2 1 month to less than 6 months 3 6 months to less than 2 years 4 2 years to less than 5 years 5 5 or more years Do not read: 7 Don’t Know/ Not Sure 9 Refused			302
MCG.04	In an average week, how many hours do you provide care or assistance? Would you say…	CRGVHRS1	Read: 1 Up to 8 hours per week 2 9 to 19 hours per week 3 20 to 39 hours per week 4 40 hours or more Do not read: 7 Don’t know/Not sure 9 Refused			303
MCG.05	What is the main health problem, long-term illness, or disability that the person you care for has?	CRGVPRB3	01 Arthritis/ rheumatism 02 Asthma 03 Cancer 04 Chronic respiratory conditions such as emphysema or COPD 05 Alzheimer’s disease, dementia or other cognitive impairment disorder 06 Developmental disabilities such as autism, Down’s Syndrome, and spina bifida 07 Diabetes 08 Heart disease, hypertension, stroke 09 Human Immunodeficiency Virus Infection (H.I.V.) 10 Mental illnesses, such as anxiety, depression, or schizophrenia 11 Other organ failure or diseases such as kidney or liver problems 12 Substance abuse or addiction disorders 13 Injuries, including broken bones 14 Old age/ infirmity/frailty 15 Other 77 Don’t know/Not sure 99 Refused			304-305
				If MCG.05=5, go to MCG.07
MCG.06	Does the person you care for also have Alzheimer’s disease, dementia or other cognitive impairment disorder?	CRGVALZD	1 Yes 2 No 7 Don’t know/ Not sure 9 Refused			306
MCG.07	In the past 30 days, did you provide care for this person by managing personal care such as giving medications, feeding, dressing, or bathing?	CRGVPERS	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			307
MCG.08	In the past 30 days, did you provide care for this person by managing household tasks such as cleaning, managing money, or preparing meals?	CRGVHOUS	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			308
MCG.09	In the next 2 years, do you expect to provide care or assistance to a friend or family member who has a health problem or disability?	CRGVEXPT	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			309

Module 8: E-Cigarettes

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
MECIG.01	Have you ever used an e-cigarette or other electronic vaping product, even just one time, in your entire life?	ECIGARET	1 Yes		Read if necessary: Electronic cigarettes (e-cigarettes) and other electronic vaping products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy. Interviewer note: These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions. E-cigarettes may also be known as JUUL, Vuse, Suorin, MarkTen, and blu.	310
MECIG.01		ECIGARET	2 No 7 Don’t know/Not sure 9 Refused	Go to next module		310
MECIG.02	Do you now use e-cigarettes or other electronic vaping products every day, some days, or not at all?	ECIGNOW	1 Every day 2 Some days 3 Not at all 7 Don’t know / Not sure 9 Refused		Interviewer note: These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.	311

Module 9: Marijuana Use

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M21.01	During the past 30 days, on how many days did you use marijuana or cannabis?	MARIJAN1	_ _ 01-30 Number of days		If asked, participants should be advised NOT to include hemp-based CBD products.
M21.01		MARIJAN1	88 None 77 Don’t know/not sure 99 Refused	Go to next module
M21.02	During the past 30 days, which one of the following ways did you use marijuana the most often? Did you usually…	USEMRJN2	Read: 1 Smoke it (for example, in a joint, bong, pipe, or blunt). 2 Eat it (for example, in brownies, cakes, cookies, or candy) 3 Drink it (for example, in tea, cola, or alcohol) 4 Vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device) 5 Dab it (for example, using a dabbing rig, knife, or dab pen), or 6 Use it some other way. Do not read: 7 Don’t know/not sure 9 Refused		Select one. If respondent provides more than one say: Which way did you use it most often? Read parentheticals only if asked for more detail.
M21.03	When you used marijuana or cannabis during the past 30 days, was it usually:	RSNMRJN1	Read: 1 For medical reasons ~~(like to treat or decrease symptoms of a health condition)~~; 2 For non-medical reasons (~~like to have fun or fit in)~~, or 3 For both medical and non-medical reasons. Do not read: 7 Don’t know/Not sure 9 Refused

Module 10: Tobacco Cessation

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				Ask if SMOKE100 = 1 and SMOKDAY2 = 3
M22.01	How long has it been since you last smoked a cigarette, even one or two puffs?	LASTSMK2	Read if necessary: 01 Within the past month (less than 1 month ago) 02 Within the past 3 months (1 month but less than 3 months ago) 03 Within the past 6 months (3 months but less than 6 months ago) 04 Within the past year (6 months but less than 1 year ago) 05 Within the past 5 years (1 year but less than 5 years ago) 06 Within the past 10 years (5 years but less than 10 years ago) 07 10 years or more 08 Never smoked regularly 77 Don’t know / Not sure 99 Refused	Go to next module
				Ask if SMOKDAY2 = 1 or 2.
M22.02	During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?	STOPSMK2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused

Module 11: Firearm Safety

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
Prologue	The next questions are about safety and firearms. Some people keep guns for recreational purposes such as hunting or sport shooting. People also keep guns in the home for protection. Please include firearms such as pistols, revolvers, shotguns, and rifles; but not BB guns or guns that cannot fire. Include those kept in a garage, outdoor storage area, or motor vehicle.
M23.01	Are any firearms now kept in or around your home?		1 Yes		Do not include guns that cannot fire; include those kept in cars, or outdoor storage.
			2 No 7 Don’t know/ not sure 9 Refused	Go to Next module
M23.02	Are any of these firearms now loaded?		1 Yes
			2 No 7 Don’t know/ not sure 9 Refused	Go to Next module
M23.03	Are any of these loaded firearms also unlocked?		1 Yes 2 No 7 Don’t know/ not sure 9 Refused		By unlocked, we mean you do not need a key or a combination or a hand/fingerprint to get the gun or to fire it. Don’t count the safety as a lock.

Module 12: Lung Cancer Screening

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If CTOB.01=1 (yes) and CTOB.02 = 1, 2, or 3 (every day, some days, or not at all) continue, else go to question MLCS.04.
MLCS.01	You’ve told us that you have smoked in the past or are currently smoking. The next questions are about screening for lung cancer. How old were you when you first started to smoke cigarettes regularly?	LCSFIRST	_ _ _ Age in Years (001 – 100) 777 Don't know/Not sure 999 Refused		Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all). If respondent indicates age inconsistent with previously entered age, verify that this is the correct answer and change the age of the respondent regularly smoking or make a note to correct the age of the respondent.	316-318
MLCS.01		LCSFIRST	888 Never smoked cigarettes regularly	Go to MLCS.04		316-318
MLCS.02	How old were you when you last smoked cigarettes regularly?	LCSLAST	_ _ _ Age in Years (001 – 100) 777 Don't know/Not sure 999 Refused			319-321
MLCS.03	On average, when you [smoke/ smoked] regularly, about how many cigarettes {do/did} you usually smoke each day?	LCSNUMCG	_ _ _Number of cigarettes 777 Don't know/Not sure 999 Refused		Regularly is at least one cigarette or more on days that a respondent smokes (either every day or some days) or smoked (not at all). Respondents may answer in packs instead of number of cigarettes. Below is a conversion table: 0.5 pack = 10 cigarettes/ 1.75 pack = 35 cigarettes/ 0.75 pack = 15 cigarettes/ 2 packs = 40 cigarettes/ 1 pack = 20 cigarettes/ 2.5 packs= 50 cigarettes/ 1.25 pack = 25 cigarettes/ 3 packs= 60 cigarettes/ 1.5 pack = 30 cigarettes	322-324
MLCS.04	The next question is about CT or CAT scans. During this test, you lie flat on your back on a table. While you hold your breath, the table moves through a donut shaped x-ray machine while the scan is done. In the last 12 months, did you have a CT or CAT scan?	LCSCTSCN	Read if necessary: 1 Yes, to check for lung cancer 2 No (did not have a CT scan) 3 Had a CT scan, but for some other reason Do not read: 7 Don't know/not sure 9 Refused			325

Module 13: Cancer Survivorship: Type of Cancer

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If CCHC.06 or CCHC.07 = 1 (Yes) or CPCS.06 = 4 (Because you were told you had prostate cancer) continue, else go to next module.
MTOC.01	You’ve told us that you have had cancer. I would like to ask you a few more questions about your cancer. How many different types of cancer have you had?	CNCRDIFF	1 Only one 2 Two 3 Three or more			326
MTOC.01		CNCRDIFF	7 Don’t know / Not sure 9 Refused	Go to next module		326
MTOC.02	At what age were you told that you had cancer?	CNCRAGE	_ _ Age in Years (97 = 97 and older) 98 Don't know/Not sure 99 Refused		If MTOC.01= 2 (Two) or 3 (Three or more), ask: At what age were you first diagnosed with cancer? Read if necessary: This question refers to the first time they were told about their first cancer.	327-328
				If CCHC.06 = 1 (Yes) and MTOC.01 = 1 (Only one): ask Was it Melanoma or other skin cancer? then code MTOC.03 as a response of 21 if Melanoma or 22 if other skin cancer CATI note: If CCCS.06 = 4 (Because you were told you had Prostate Cancer) and Q1 = 1 (Only one) then code MTOC.03 as a response of 19.
MTOC.03	What type of cancer was it?	CNCRTYP1	Read if respondent needs prompting for cancer type: 01 Breast cancer Female reproductive (Gynecologic) 02 Cervical cancer (cancer of the cervix) 03 Endometrial cancer (cancer of the uterus) 04 Ovarian cancer (cancer of the ovary) Head/Neck 05 Head and neck cancer 06 Oral cancer 07 Pharyngeal (throat) cancer 08 Thyroid 09 Larynx Gastrointestinal 10 Colon (intestine) cancer 11 Esophageal (esophagus) 12 Liver cancer 13 Pancreatic (pancreas) cancer 14 Rectal (rectum) cancer 15 Stomach Leukemia/Lymphoma (lymph nodes and bone marrow) 16 Hodgkin's Lymphoma (Hodgkin’s disease) 17 Leukemia (blood) cancer 18 Non-Hodgkin’s Lymphoma Male reproductive 19 Prostate cancer 20 Testicular cancer Skin 21 Melanoma 22 Other skin cancer Thoracic 23 Heart 24 Lung Urinary cancer 25 Bladder cancer 26 Renal (kidney) cancer Others 27 Bone 28 Brain 29 Neuroblastoma 30 Other Do not read: 77 Don’t know / Not sure 99 Refused		If MTOC.01 = 2 (Two) or 3 (Three or more), ask: With your most recent diagnoses of cancer, what type of cancer was it?	329-330

Module 14: Cancer Survivorship: Course of Treatment

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If CCHC.06 or CCHC.07 = 1 (Yes) or CPCS.06 = 4 (Because you were told you had prostate cancer) continue, else go to next module.
MCOT.01	Are you currently receiving treatment for cancer?	CSRVTRT3	Read if necessary: 1 Yes	Go to next module	Read if necessary: By treatment, we mean surgery, radiation therapy, chemotherapy, or chemotherapy pills.	331
			2 No, I’ve completed treatment	Continue
			3 No, I’ve refused treatment 4 No, I haven’t started treatment 5 Treatment was not necessary 7 Don’t know / Not sure 9 Refused	Go to next module
MCOT.02	What type of doctor provides the majority of your health care? Is it a….	CSRVDOC1	Read: 01 Cancer Surgeon 02 Family Practitioner 03 General Surgeon 04 Gynecologic Oncologist 05 General Practitioner, Internist 06 Plastic Surgeon, Reconstructive Surgeon 07 Medical Oncologist 08 Radiation Oncologist 09 Urologist 10 Other Do not read: 77 Don’t know / Not sure 99 Refused		If the respondent requests clarification of this question, say: We want to know which type of doctor you see most often for illness or regular health care (Examples: annual exams and/or physicals, treatment of colds, etc.). Read if necessary: An oncologist is a medical doctor who manages a person’s care and treatment after a cancer diagnosis.	332-333
MCOT.03	Did any doctor, nurse, or other health professional ever give you a written summary of all the cancer treatments that you received?	CSRVSUM	1 Yes 2 No 7 Don’t know/ not sure 9 Refused		Read if necessary: By ‘other healthcare professional’, we mean a nurse practitioner, a physician’s assistant, social worker, or some other licensed professional.	334
MCOT.04	Have you ever received instructions from a doctor, nurse, or other health professional about where you should return or who you should see for routine cancer check-ups after completing your treatment for cancer?	CSRVRTRN	1 Yes			335
MCOT.04		CSRVRTRN	2 No 7 Don’t know/ not sure 9 Refused	Go to MCOT.06		335
MCOT.05	Were these instructions written down or printed on paper for you?	CSRVINST	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			336
MCOT.06	With your most recent diagnosis of cancer, did you have health insurance that paid for all or part of your cancer treatment?	CSRVINSR	1 Yes 2 No 7 Don’t know/ not sure 9 Refused		Read if necessary: Health insurance also includes Medicare, Medicaid, or other types of state health programs.	337
MCOT.07	Were you ever denied health insurance or life insurance coverage because of your cancer?	CSRVDEIN	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			338
MCOT.08	Did you participate in a clinical trial as part of your cancer treatment?	CSRVCLIN	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			339

Module 15: Cancer Survivorship: Pain Management

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If CCHC.06 or CCHC.07 = 1 (Yes) or CPCS.06 = 4 (Because you were told you had prostate cancer) continue, else go to next module.
MCPM.01	Do you currently have physical pain caused by your cancer or cancer treatment?	CSRVPAIN	1 Yes			340
MCPM.01		CSRVPAIN	2 No 7 Don’t know/ not sure 9 Refused	Go to next module		340
MCPM.02	Would you say your pain is currently under control…?	CSRVCTL2	Read: 1 With medication (or treatment) 2 Without medication (or treatment) 3 Not under control, with medication (or treatment) 4 Not under control, without medication (or treatment) Do not read: 7 Don’t know / Not sure 9 Refused			341

Module 16: Prostate Cancer Screening Decision Making

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If sex= male (using BIRTHSEX, CELLSEX, LANDSEX ) AND CPCS.04 = 1 and AGE ≥ 40 continue, otherwise go to next module.
MPCDM.01	Which one of the following best describes the decision to have the P.S.A. test done?	PCPSADE1				342
			Read: 1 You made the decision alone 2 Your doctor, nurse, or health care provider made the decision alone	Go to next module.
			3 You and one or more other persons made the decision together
			4 You don’t know how the decision was made Do not read: 9 Refused	Go to next module
MPCDM.02	Who made the decision with you?	PCDMDEC1	Read if necessary: 1 Doctor/nurse /health care provider 2 Spouse/significant other 3 Other family member 4 Friend/non-relative Do not read: 7 Don’t know / Not sure 9 Refused		Select one response. If respondent offers more than one response ask for primary person who made decision.	343

Module 17: Adult Human Papillomavirus (HPV) - Vaccination

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If respondent is between the ages of 18 and 49 years continue; otherwise, go to next module.
MHPV.01	Have you ever had an H.P.V. vaccination?	HPVADVC4	1 Yes		Human Papillomavirus (Human Pap·uh·loh·muh virus); Gardasil (Gar·duh· seel); Cervarix (Sir·var· icks) Read if necessary: A vaccine to prevent the human papillomavirus or H.P.V. infection is available and is called the cervical cancer or genital warts vaccine, H.P.V. shot, [Fill: if female GARDASIL or CERVARIX; if male: GARDASIL]. Interviewer Note: If respondent comments that this question was already asked, clarify that they earlier questions was about HPV testing, ant this question is about vaccination.	344
MHPV.01	Have you ever had an H.P.V. vaccination?	HPVADVC4	2 No 3 Doctor refused when asked 7 Don’t know/ not sure 9 Refused	Go to next module		344
MHPV.02	How many H.P.V. shots did you receive?	HPVADSHT	_ _ Number of shots 03 All shots 77 Don’t know / Not sure 99 Refused			345-346

Module 18: Tetanus Diphtheria (Tdap) (Adults)

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MTDAP.01

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

TETANUS1

1 Yes, received Tdap

2 Yes, received tetanus shot, but not Tdap

3 Yes, received tetanus shot but not sure what type

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

7 Don’t know/Not sure

9 Refused

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

347

Module 19: Place of Flu Vaccination

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

Ask if CIMM= 1

This question may be inserted in core after CIMM.02

MFP.01

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

IMFVPLA1

Read if necessary:

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

02 A health department

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

04 A senior, recreation, or community center

05 A store (supermarket, drug store)

06 A hospital (inpatient or outpatient)

07 An emergency room

08 Workplace

09 Some other kind of place

11 A school

Do not read:

10 Received vaccination in Canada/Mexico

77 Don’t know / Not sure

99 Refused

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

348-349

Module 20: Shingles Vaccination

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

If age ≤ 49 Go to next module.

M07.01

Have you ever had the shingles or zoster vaccine?

SHINGLE2

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

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

Module 21: COVID Vaccination

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
MCOR.01	Since [DATE OF VACCINE AVAILABILITY], have you had a COVID-19 vaccination?	*NEW*	1 Yes
MCOR.01		*NEW*	2 No 7 Don’t know / Not sure 9 Refused	Go to next section
MCOR.02	How many COVID-19 vaccinations have you received?	*NEW*	1 One 2 Two or more 7 Don’t know / Not sure 9 Refused
MCOR.03	During what month and year did you receive your (first) COVID-19 vaccination?	*NEW*	_ _ / _ _ _ _ Month / Year 77 / 7777 Don’t know / Not sure 09 / 9999 Refused		If respondent indicated only one vaccine do not read word “first”
MCOR.04	At what kind of place did you get your (first) COVID-19 vaccination?	*NEW*	Read if necessary: 01 A doctor’s office or health maintenance organization (HMO) 02 A health department 03 Another type of clinic or health center (a community health center) 04 A senior, recreation, or community center 05 A store (supermarket, drug store) 06 A hospital (inpatient) 07 An emergency room 08 Workplace 09 Some other kind of place 11 A school Do not read: 10 Received vaccination in Canada/Mexico 77 Don’t know / Not sure 99 Refused		If respondent indicated only one vaccine do not read word “first”
				If MCOR2 =1, 7,9 go to next section
MCOR.05	During what month and year did you receive your second COVID-19 vaccination?	*NEW*	_ _ / _ _ _ _ Month / Year 77 / 7777 Don’t know / Not sure 09 / 9999 Refused
MCOR.06	At what kind of place did you get your second COVID-19 vaccination?	*NEW*	Read if necessary: 01 A doctor’s office or health maintenance organization (HMO) 02 A health department 03 Another type of clinic or health center (a community health center) 04 A senior, recreation, or community center 05 A store (supermarket, drug store) 06 A hospital (inpatient) 07 An emergency room 08 Workplace 09 Some other kind of place 11 A school Do not read: 10 Received vaccination in Canada/Mexico 77 Don’t know / Not sure 99 Refused

Module 23: Industry and Occupation

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If CDEM.14 = 1 or 4 (Employed for wages or out of work for less than 1 year) or 2 (Self-employed), continue. If CDEM.14 = 4 (Out of work for less than 1 year) ask, “What kind of work did you do? For example, registered nurse, janitor, cashier, auto mechanic.” Else go to next module
MIO.01	What kind of work do you do? For example, registered nurse, janitor, cashier, auto mechanic.	TYPEWORK	_______Record answer 99 Refused		If respondent is unclear, ask: What is your job title? If respondent has more than one job ask: What is your main job?	350-449
MIO.02	What kind of business or industry do you work in? For example, hospital, elementary school, clothing manufacturing, restaurant	TYPEINDS	_______Record answer 99 Refused	If CDEM14 = 4 (Out of work for less than 1 year) ask, “What kind of business or industry did you work in? For example, hospital, elementary school, clothing manufacturing, restaurant.”		450-549

Module 24: Sex at Birth

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MSAB.01

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

BIRTHSEX

1 Male

2 Female

7 Don’t know/Not sure

9 Refused

550

Module 25: Sexual Orientation and Gender Identity (SOGI)

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
Prologue	The next two questions are about sexual orientation and gender identity
				If sex= male (using BIRTHSEX, CELLSEX, LANDSEX ) continue, otherwise go to MSOGI.01b.
MSOGI.01a	.Which of the following best represents how you think of yourself?	SOMALE	1 = Gay 2 = Straight, that is, not gay 3 = Bisexual 4 = Something else 7 = I don't know the answer 9 = Refused	Ask if Sex= 1.	Read if necessary: We ask this question in order to better understand the health and health care needs of people with different sexual orientations. Please say the number before the text response. Respondent can answer with either the number or the text/word.	551
				If sex= female (using BIRTHSEX, CELLSEX, LANDSEX ) continue, otherwise go to MSOGI.02.
MSOGI.01b	Which of the following best represents how you think of yourself?	SOFEMALE	1 = Lesbian or Gay 2 = Straight, that is, not gay 3 = Bisexual 4 = Something else 7 = I don't know the answer 9 = Refused	.	Read if necessary: We ask this question in order to better understand the health and health care needs of people with different sexual orientations. Please say the number before the text response. Respondent can answer with either the number or the text/word.	552
MSOGI.02	Do you consider yourself to be transgender?	TRNSGNDR	1 Yes, Transgender, male-to-female 2 Yes, Transgender, female to male 3 Yes, Transgender, gender nonconforming 4 No 7 Don’t know/not sure 9 Refused		Read if necessary: Some people describe themselves as transgender when they experience a different gender identity from their sex at birth. For example, a person born into a male body, but who feels female or lives as a woman would be transgender. Some transgender people change their physical appearance so that it matches their internal gender identity. Some transgender people take hormones and some have surgery. A transgender person may be of any sexual orientation – straight, gay, lesbian, or bisexual. If asked about definition of gender non-conforming: Some people think of themselves as gender non-conforming when they do not identify only as a man or only as a woman. If yes, ask Do you consider yourself to be 1. male-to-female, 2. female-to-male, or 3. gender non-conforming? Please say the number before the text response. Respondent can answer with either the number or the text/word.	553

Module 26: Adverse Childhood Experiences

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
Prologue	I'd like to ask you some questions about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life and may help others in the future. This is a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer. All questions refer to the time period before you were 18 years of age.				Be aware of the level of stress introduced by questions in this section and be familiar with the crisis plan.
M20.01	Now, looking back before you were 18 years of age---. 1) Did you live with anyone who was depressed, mentally ill, or suicidal?	ACEDEPRS	1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused
M20.02	Did you live with anyone who was a problem drinker or alcoholic?	ACEDRINK	1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused
M20.03	Did you live with anyone who used illegal street drugs or who abused prescription medications?	ACEDRUGS	1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused
M20.04	Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?	ACEPRISN	1 Yes 2 No 7 Don’t Know/Not Sure 9 Refused
M20.05	Were your parents separated or divorced?	ACEDIVRC	1 Yes 2 No 8 Parents not married 7 Don’t Know/Not Sure 9 Refused
M20.06	How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up? Was it…	ACEPUNCH	Read: 1 Never 2 Once 3 More than once Don’t Read: 7 Don’t know/Not Sure 9 Refused
M20.07	Not including spanking, (before age 18), how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Was it—	ACEHURT1	Read: 1 Never 2 Once 3 More than once Don’t Read: 7 Don’t know/Not Sure 9 Refused
M20.08	How often did a parent or adult in your home ever swear at you, insult you, or put you down? Was it…	ACESWEAR	Read: 1 Never 2 Once 3 More than once Don’t Read: 7 Don’t know/Not Sure 9 Refused
M20.09	How often did anyone at least 5 years older than you or an adult, ever touch you sexually? Was it…	ACETOUCH	Read: 1 Never 2 Once 3 More than once Don’t Read: 7 Don’t know/Not Sure 9 Refused
M20.10	How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually? Was it…	ACETTHEM	Read: 1 Never 2 Once 3 More than once Don’t Read: 7 Don’t know/Not Sure 9 Refused
M20.11	How often did anyone at least 5 years older than you or an adult, force you to have sex? Was it…	ACEHVSEX	Read: 1 Never 2 Once 3 More than once Don’t Read: 7 Don’t know/Not Sure 9 Refused
M20.12	For how much of your childhood was there an adult in your household who made you feel safe and protected? Would you say never, a little of the time, some of the time, most of the time, or all of the time?	*NEW*	1. Never 2. A little of the time 3. Some of the time 4. Most of the time 5. All of the time 7 Don’t Know/Not sure 9 Refused
M20.13	For how much of your childhood was there an adult in your household who tried hard to make sure your basic needs were met? Would you say never, a little of the time, some of the time, most of the time, or all of the time?	*NEW**	1. Never 2. A little of the time 3. Some of the time 4. Most of the time 5. All of the time 7 Don’t Know/Not sure 9 Refused
	Would you like for me to provide a toll-free number for an organization that can provide information and referral for the issues in the last few questions.				If yes provide number [STATE TO INSERT NUMBER HERE]

Module 27: Random Child Selection

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If CDEM.15 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module.
				If CDEM.15 = 1 and CDEM.15 does not equal 88 or 99, read into text 1
Intro text 1	Previously, you indicated there was one child age 17 or younger in your household. I would like to ask you some questions about that child.
				If CDEM.15 is >1 and CDEM.15 does not equal 88 or 99, read intro text 2
Intro text 2	Previously, you indicated there were [number] children age 17 or younger in your household. Think about those [number] children in order of their birth, from oldest to youngest. The oldest child is the first child and the youngest child is the last. Please include children with the same birth date, including twins, in the order of their birth.			CATI INSTRUCTION: RANDOMLY SELECT ONE OF THE CHILDREN. This is the Xth child. Please substitute Xth child’s number in all questions below. INTERVIEWER PLEASE READ: I have some additional questions about one specific child. The child I will be referring to is the Xth [CATI: please fill in correct number] child in your household. All following questions about children will be about the Xth [CATI: please fill in] child.
MRCS.01	What is the birth month and year of the [Xth] child?	RCSBIRTH	_ _ /_ _ _ _ Code month and year 77/ 7777 Don’t know / Not sure 99/ 9999 Refused			565-570
MRCS.02	Is the child a boy or a girl?	RCSGENDR	1 Boy 2 Girl 9 Refused			571
MRCS.03	Is the child Hispanic, Latino/a, or Spanish origin?	RCHISLA1	Read if response is yes: Are they 1 Mexican, Mexican American, Chicano/a 2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino/a, or Spanish origin Do not read: 5 No 7 Don’t know / Not sure 9 Refused			572-575
MRCS.04	Which one or more of the following would you say is the race of the child?	RCSRACE1	10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 77 Don’t know / Not sure 88 No additional choices 99 Refused		Select all that apply If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.	576-603
				[CATI NOTE: IF MORE THAN ONE RESPONSE TO MRCS.04; CONTINUE. OTHERWISE, GO TO MRCS.06.]
MRCS.05	Which one of these groups would you say best represents the child’s race?	RCSBRAC2	10 White 20 Black or African American 30 American Indian or Alaska Native 40 Asian 41 Asian Indian 42 Chinese 43 Filipino 44 Japanese 45 Korean 46 Vietnamese 47 Other Asian 50 Pacific Islander 51 Native Hawaiian 52 Guamanian or Chamorro 53 Samoan 54 Other Pacific Islander Do not read: 60 Other 77 Don’t know / Not sure 99 Refused		If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.	604-605
MRCS.06	How are you related to the child? Are you a….	RCSRLTN2	Please read: 1 Parent (include biologic, step, or adoptive parent) 2 Grandparent 3 Foster parent or guardian 4 Sibling (include biologic, step, and adoptive sibling) 5 Other relative 6 Not related in any way Do not read: 7 Don’t know / Not sure 9 Refused			606

Module 28: Childhood Asthma Prevalence

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
				If response to CDEM.15 = 88 (None) or 99 (Refused), go to next module.
MCAP.01	The next two questions are about the Xth child. Has a doctor, nurse or other health professional EVER said that the child has asthma?	CASTHDX2	1 Yes	Fill in correct [Xth] number.		607
MCAP.01		CASTHDX2	2 No 7 Don’t know/ not sure 9 Refused	Go to next module		607
MCAP.02	Does the child still have asthma?	CASTHNO2	1 Yes 2 No 7 Don’t know/ not sure 9 Refused			608

Module 29: Aspirin for CVD Prevention

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M15.01

How often do you take an aspirin to prevent or control heart disease, heart attacks or stroke? Would you say….

Read:

1 Daily

2 Some days

3 Used to take it but had to stop due to side effects, or

4 Do not take it

Do not read:

7 Don’t know / Not sure

9 Refused

Module 30: Home/ Self-measured Blood Pressure

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
M16.01	Has your doctor nurse or other healthcare professional recommended you check your blood pressure outside of the office or at home?		1 Yes 2 No 7 Don’t know / Not sure 9 Refused		By other healthcare professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.
M16.02	Do you regularly check your blood pressure outside of your healthcare professional’s office or at home?		1 Yes
M16.02			2 No 7 Don’t know / Not sure 9 Refused	Go to next section
M16.03	Do you take it mostly at home or on a machine at a pharmacy, grocery or similar location?		1 At home 2 On a machine at a pharmacy, grocery or similar location 3 Do not check it 7 Don’t know / Not sure 9 Refused
M16.04	How do you share your blood pressure numbers that you collected with your healthcare professional? Is it mostly by telephone, other methods such as emails, internet portal or fax, or in person?		Do not read: 1 Telephone 2 Other methods such as email, internet portal, or fax, or 3 In person
M16.04			Do not read: 4 Do not share information 7 Don’t know / Not sure 9 Refused

Module 31: Food Stamps

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M27.01

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

1 Yes

2 No

7 Don’t Know/Not Sure

9 Refused

Food Stamps or SNAP (Supplemental Nutrition Assistance Program) is a government program that provides plastic cards, also known as EBT (Electronic Benefit Transfer) cards, that can be used to buy food. In the past, SNAP was called the Food Stamp Program and gave people benefits in paper coupons or food stamps.

Module 32: Sleep Disorder

1. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?

__ __ 01-14 days

None

77 Don’t know/Not sure

99 Refused

Over the last 2 weeks, how many days did you unintentionally fall asleep during the day?

__ __ 01-14 days

88 None

77 Don’t know/Not sure

99 Refused

3. Have you ever been told that you snore loudly?

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

4. Has anyone ever observed that you stop breathing during your sleep?

INTERVIEWER NOTE: ALSO ENTER YES IF RESPONDENT MENTIONS HAVING A MACHINE OR CPAP THAT RECORDS THAT BREATHING SOMETIMES STOPS DURING THE NIGHT.

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

Module 33: Anxiety and Depression

1 Over the last 2 weeks, how often have you been bothered by having little interest or pleasure in doing things. Would you say this happens...

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

9.2 Over the last 2 weeks, how often have you been bothered by feeling down, depressed or hopeless? Would you say this happens…

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

9.3 Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge? Would you say this happens…

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

9.4 Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying? Would you say this happens…

READ:

1 never,

2 for several days,

3 for more than half the days or

4 nearly every day.

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

Module 34: Adult Asthma History

CATI NOTE: If Yes to Core Q6.4; continue. Otherwise, go to next module.

Previously you said you were told by a doctor, nurse or other health professional that you had asthma.

1. How old were you when you were first told by a doctor, nurse, or other health professional that you had asthma?

_ _ Age in years 11 or older [96 = 96 and older]

97 Age 10 or younger

98 Don’t know / Not sure

99 Refused

CATI NOTE: If Yes to Core Q6.5, continue. Otherwise, go to next module.

2. During the past 12 months, have you had an episode of asthma or an asthma attack?

1 Yes

2 No [Go to Q5]

7 Don’t know / Not sure [Go to Q5] 9 Refused [Go to Q5]

During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma?

_ _ Number of visits [87 = 87 or more]

88 None

98 Don’t know / Not sure

99 Refused

4. [If one or more visits to Q3, fill in Besides those emergency room or urgent care center visits,] During the past 12 months, how many times did you see a doctor, nurse or other health professional for urgent treatment of worsening asthma symptoms?

_ _ Number of visits [87 = 87 or more]

88 None

Don’t know / Not sure

99 Refused

During the past 12 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma?

_ _ Number of visits [87 = 87 or more]

88 None

98 Don’t know / Not sure

99 Refused

6. During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma?

_ _ _ Number of days

888 None

777 Don’t know / Not sure

999 Refused

7. Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness and phlegm production when you don’t have a cold or respiratory infection. During the past 30 days, how often did you have any symptoms of asthma? Would you say —

NOTE: Phlegm (‘flem’)

Please read:

8 Not at any time [Go to Q9]

1 Less than once a week

2 Once or twice a week

3 More than 2 times a week, but not every day

4 Every day, but not all the time

5 Every day, all the time

Do not read:

7 Don’t know / Not sure

9 Refused

8. During the past 30 days, how many days did symptoms of asthma make it difficult for you to stay asleep? Would you say —

Please read:

8 None

1 One or two

2 Three to four

3 Five

4 Six to ten

5 More than ten

Do not read:

7 Don’t know / Not sure

9 Refused

9. During the past 30 days, how many days did you take a prescription asthma medication to prevent an asthma attack from occurring?

READ IF NECESSARY

8 Never

1 1 to 14 days

2 15 to 24 days

3 25 to 30 days

Do not read:

7 Don’t know / Not sure

9 Refused

10. During the past 30 days, how often did you use a prescription asthma inhaler during an asthma attack to stop it?

INTERVIEWER NOTE: HOW OFTEN (NUMBER OF TIMES) DOES NOT EQUAL NUMBER OF PUFFS. TWO TO THREE PUFFS ARE USUALLY TAKEN EACH TIME THE INHALER IS USED.

READ IF NECESSARY:

8 Never (include no attack in past 30 days)

1 1 to 4 times (in the past 30 days)

2 5 to 14 times (in the past 30 days)

3 15 to 29 times (in the past 30 days)

4 30 to 59 times (in the past 30 days)

5 60 to 99 times (in the past 30 days)

6 100 or more times (in the past 30 days)

Do not read:

7 Don’t know / Not sure

9 Refused

Module 35: Respiratory Health (COPD Symptoms)

The next few questions are about breathing problems you may have.

During the past 3 months, did you have a cough on most days?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

During the past 3 months, did you cough up phlegm [FLEM] or mucus on most days?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Do you have shortness of breath either when hurrying on level ground or when walking up a slight hill or stairs?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Have you ever been given a breathing test to diagnose breathing problems?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Over your lifetime, how many years have you smoked tobacco products?

_ _ Number of years (01-76)

88 Never smoked or smoked less than one year

77 Don’t know/Not sure

99 Refused

Module 36: Indoor Tanning

1. Not including spray-on tans, during the past 12 months, how many times have you used an indoor tanning device such as a sunlamp, tanning bed, or booth?

DO NOT READ:

Enter number (0-365) __ __ __

777 Don’t know/ Not sure

999 Refused

Module 37: Excess Sun Exposure

1. During the past 12 months, how many times have you had a sunburn?

DO NOT READ:

Enter number (0-365) __ __ __

777 Don’t know/ Not sure

999 Refused

2. When you go outside on a warm sunny day for more than one hour, how often do you protect yourself from the sun? Is that….

INTERVIEWER NOTE: PROTECTION FROM THE SUN MAY INCLUDE USING SUNSCREEN, WEARING A WIDE-BRIMMED HAT, OR WEARING A LONG-SLEEVED SHIRT

READ:

1 Always

2 Most of the time

3 Sometimes

4 Rarely

5 Never

DO NOT READ:

6 Don’t stay outside for more than one hour on warm sunny days

8 Don’t go outside at all on warm sunny days

7 Don’t know/ Not sure

9 Refused

3. On weekdays, in the summer, how long are you outside per day between 10am and 4pm?

INTERVIEWER NOTE: FRIDAY IS A WEEKDAY

INTERVIEWER NOTE: IF RESPONDENT SAYS NEVER CODE 01

DO NOT READ:

1 Less than half an hour

2 (More than half an hour) up to 1 hour

3 (More than 1 hour) up to 2 hours

4 (More than 2 hours) up to 3 hours

5 (More than 3 hours) up to 4 hours

6 (More than 4 hours) up to 5 hours

7 (More than 5) up to 6 hours

77 Don’t know/ Not sure

99 Refused

4. On weekends in the summer, how long are you outside each day between 10am and 4pm?

INTERVIEWER NOTE: FRIDAY IS A WEEKDAY

INTERVIEWER NOTE: IF RESPONDENT SAYS NEVER CODE 01

DO NOT READ:

1 Less than half an hour

2 (More than half an hour) up to 1 hour

3 (More than 1 hour) up to 2 hours

4 (More than 2 hours) up to 3 hours

5 (More than 3 hours) up to 4 hours

6 (More than 4 hours) up to 5 hours

7 (more than 5) up to 6 hours

77 Don’t know/ Not sure

99 Refused

Module 38: Actions to Control High Blood Pressure

[CATI NOTE: IF CORE Q4.1 = 1 (YES); CONTINUE. OTHERWISE, GO TO NEXT MODULE. ]

Earlier you stated that you had been diagnosed with high blood pressure.

Are you now doing any of the following to help lower or control your high blood pressure?

1. (Are you) changing your eating habits (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

2. (Are you) cutting down on salt (to help lower or control your high blood pressure)?

1 Yes

2 No

3 Do not use salt

7 Don‘t know / Not sure

9 Refused

3. (Are you) reducing alcohol use (to help lower or control your high blood pressure)?

1 Yes

2 No

3 Do not drink

7 Don‘t know / Not sure

9 Refused

4. (Are you) exercising (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

Has a doctor or other health professional ever advised you to do any of the following to help lower or control your high blood pressure?

5. (Ever advised you to) change your eating habits (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

6. (Ever advised you to) cut down on salt (to help lower or control your high blood pressure)?

1 Yes

2 No

3 Do not use salt

7 Don‘t know / Not sure

9 Refused

7. (Ever advised you to) reduce alcohol use (to help lower or control your high blood pressure)?

1 Yes

2 No

3 Do not drink

7 Don‘t know / Not sure

9 Refused

8. (Ever advised you to) exercise (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

9. (Ever advised you to) take medication (to help lower or control your high blood pressure)?

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

10. Were you told on two or more different visits by a doctor or other health professional that you had high blood pressure?

INTERVIEWER NOTE: IF “YES” AND RESPONDENT IS FEMALE, ASK: “WAS THIS ONLY WHEN YOU WERE PREGNANT?”

1 Yes

2 Yes, but female told only during pregnancy

3 No

4 Told borderline or pre-hypertensive

7 Don‘t know / Not sure

9 Refused

Module 39: Arthritis Management

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
			2 No 7 Don’t know / Not sure 9 Refused	Go to next section
C08.02	Has a doctor or other health professional ever suggested physical activity or exercise to help your arthritis or joint symptoms?	ARTHEXER	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		If the respondent is unclear about whether this means increase or decrease in physical activity, this means increase.
C08.03	Have you ever taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?	ARTHEDU	1 Yes 2 No 7 Don’t know / Not sure 9 Refused
C08.04	Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?	LMTJOIN3	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		If a respondent question arises about medication, then the interviewer should reply: "Please answer the question based on your current experience, regardless of whether you are taking any medication or treatment”
C08.05	In the next question, we are referring to work for pay. Do arthritis or joint symptoms now affect whether you work, the type of work you do or the amount of work you do?	ARTHDIS2	1 Yes 2 No 7 Don’t know / Not sure 9 Refused		If respondent gives an answer to each issue (whether works, type of work, or amount of work), then if any issue is "yes" mark the overall response as "yes." If a question arises about medications or treatment, then the interviewer should say: "Please answer the question based on your current experience, regardless of whether you are taking any medication or treatment."
C08.06	Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. During the past 30 days, how bad was your joint pain on average on a scale of 0 to 10 where 0 is no pain and 10 is pain or aching as bad as it can be?	JOINPAI2	__ __ Enter number [00-10] 77 Don’t know/ Not sure 99 Refused

Module 40: Alcohol Screening & Brief Intervention (ASBI)

CATI NOTE: IF CORE Q3.4 = 1, OR 2 (HAD A CHECKUP WITHIN THE PAST 2 YEARS) CONTINUE, ELSE GO TO NEXT MODULE.

Healthcare providers may ask during routine checkups about behaviors like alcohol use, whether you drink or not. We want to know about their questions.

1. You told me earlier that your last routine checkup was [within the past year/within the past 2 years]. At that checkup, were you asked in person or on a form if you drink alcohol?

1 Yes

2 No

7 Don't know / Not sure

9 Refused

2. Did the health care provider ask you in person or on a form how much you drink?

1 Yes

2. No

7 Don't know / Not sure

9 Refused

3. Did the healthcare provider specifically ask whether you drank [5 FOR MEN /4 FOR WOMEN] or more alcoholic drinks on an occasion?

1 Yes

2 No

7 Don't know / Not sure

9 Refused

4. Were you offered advice about what level of drinking is harmful or risky for your health?

1 Yes

2 No

7 Don't know / Not sure

9 Refused

[CATI NOTE: IF QUESTION 1, 2, OR 3 = 1 (YES) CONTINUE, ELSE GO TO NEXT MODULE.]

5. Healthcare providers may also advise patients to drink less for various reasons. At your last routine checkup, were you advised to reduce or quit your drinking?

1 Yes

2 No

7 Don't know / Not sure

9 Refused

Module 41: Sugar Sweetened Beverages

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

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

1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

Do not read:

888 None

777 Don’t know / Not sure

999 Refused

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

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

1 _ _ Times per day

2 _ _ Times per week

3 _ _ Times per month

Do not read:

888 None

777 Don’t know / Not sure

999 Refused

Module 42: Sodium or Salt-Related Behavior

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

M17.01

Are you currently watching or reducing your sodium or salt intake?

WTCHSALT

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused

M17.02

Has a doctor or other health professional ever advised you to reduce sodium or salt intake?

DRADVISE

1 Yes

2 No

7 Don’t know/ Not sure

9 Refused

Module 43: Preconception Health/Family Planning

Question Number	Question text	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
			If respondent greater than 49 years of age, has had a CBCCS.07=1(HYSTERECTOMY), IS CDEM.16 (PREGNANT), or if respondent is male, (MSAB.01, is coded 1). If MSAB.01=missing and (CP.05=1 or CP.06=1 or LL.09 = 1 or LL.10=1) GO TO THE NEXT MODULE
PROLOGUE	The next set of questions asks you about your experiences preventing pregnancy and using birth control, also known as family planning. Questions that ask about sexual intercourse are referring to sex where a penis is inserted into the vagina.
MFP.01	In the past 12 months, did you have sexual intercourse?	1 Yes
	2 No 7 Don’t know/ not sure 9 Refused	Go to next module
MFP.02	Some things people do to keep from getting pregnant include not having sex at certain times of the month, pulling out, using birth control methods such as the pill, implant, shots, condoms, or IUD, having their tubes tied, or having a vasectomy. The last time you had sexual intercourse, did you or your partner do anything to keep you from getting pregnant?	1 Yes		.
	2 No	GO TO MFP.04
	7 Don’t know/ not sure 9 Refused	Go to next module

MFP.03	The last time you had sexual intercourse, what did you or your partner do to keep you from getting pregnant?	Read if necessary: 01 Female sterilization (Tubal ligation, Essure, or Adiana) 02 Male sterilization (vasectomy) 03 Contraceptive implant (Implanon, Nexplanon) 04 Intrauterine device or IUD (Mirena, Liletta, Skyla, Kyleena, Levonorgestrel IUD, ParaGard, copper IUD) 05 Shots (Depo-Provera) 06 Prescription birth control pills, Contraceptive Ring (NuvaRing, ElyRyng, Annovera), Contraceptive patch (Ortho Evra, Xulane, Twirla, Zafemy) 07 Over the counter birth control pills (Opill) 08 Condoms (male or female) 09 Diaphragm, vaginal gel (Phexxi), cervical cap, sponge, foam, jelly, film, or cream 10 Had sex at a time when less likely to get pregnant (rhythm method, natural family planning, apps for contraception) 11 Withdrawal or pulling out 12 Emergency contraception or the morning after pill (such as Plan B or ella) 13 Other method Do not read: 77 Don’t know/Not sure 99 Refused	Go to next module	If respondent reports using two methods, please code the method that occurs first on the list. If respondent reports using “pills”, ask respondent to clarify between prescription birth control pills and over the counter birth control pills. If respondent reports “other method,” ask respondent to “please be specific” and ensure that their response does not fit into another category. If response does fit into another category, please mark appropriately.
MFP.04	Some reasons people might not do anything to keep from getting pregnant might include wanting a pregnancy, not being able to pay for birth control, or not thinking that they can get pregnant. What was your main reason for not doing anything to prevent pregnancy the last time you had sexual intercourse?	Read if necessary 01 You didn’t think you were going to have sex/no regular partner 02 You just didn’t think about it 03 You wanted a pregnancy 04 You didn’t care if you got pregnant 05 You or your partner didn’t want to use birth control (side effects, don’t like birth control) 06 You had trouble getting or paying for birth control 07 You didn’t trust giving out your personal information to medical personnel 08 Didn’t think you or your partner could get pregnant (infertile or too old) 09 You were using withdrawal or “pulling out” 10 You had your tubes tied (sterilization) 11 Your partner had a vasectomy (sterilization) 12 You were breast-feeding or you just had a baby 13 You were assigned male at birth 14 Other reasons Do not read: 77 Don’t know/Not sure 99 Refused		If respondent reports “other reason,” ask respondent to “please specify” and ensure that their response does not fit into another category. If response does fit into another category, please mark appropriately.

Module 43A: Preconception Health/Family Planning

[CATI NOTE: IF RESPONDENT IS FEMALE AND GREATER THAN 49 YEARS OF AGE, HAS HAD A HYSTERECTOMY, IS PREGNANT, OR IF RESPONDENT IS MALE GO TO THE NEXT MODULE.]

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

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

1 Yes

2 No [GO TO NEXT MODULE]

7 Don’t know/Not sure [GO TO NEXT MODULE]

9 Refused [GO TO NEXT MODULE]

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

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

1 Yes

2 No [GO TO Q6]

7 Don’t know/Not sure [GO TO Q7]

9 Refused [GO TO Q7].

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

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

IF RESPONDENT REPORTS USING “PILLS,” ASK RESPONDENT TO CLARIFY BETWEEN PRESCRIPTION BIRTH CONTROL PILLS AND OVER THE COUNTER BIRTH CONTROL PILLS.

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

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

Read only if respondent is unable to provide a response:

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

02 Male sterilization (vasectomy)

03 Contraceptive implant (Implanon, Nexplanon)

04 Intrauterine device or IUD (Mirena, Liletta, Skyla, Kyleena, Levonorgestrel IUD, ParaGard, copper IUD)

05 Shots (Depo-Provera)

06 Prescription birth control pills, Contraceptive Ring (NuvaRing, ElyRyng, Annovera), Contraceptive patch (Ortho Evra, Xulane, Twirla, Zafemy)

07 Over the counter birth control pills (Opill)

08 Condoms (male or female)

09 Diaphragm, vaginal gel (Phexxi), cervical cap, sponge, foam, jelly, film, or cream

10 Had sex at a time when less likely to get pregnant (rhythm method, natural family planning, apps for contraception)

11 Withdrawal or pulling out

12 Emergency contraception or the morning after pill (such as Plan B or ella)

13 Other method

Do not read:

77 Don’t know/Not sure

99 Refused

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

INTERVIEWER NOTE: IF RESPONDENT REPORTS USING MORE THAN ONE ADDITIONAL METHOD, PLEASE CODE THE METHOD THAT OCCURS FIRST ON THE LIST.

IF RESPONDENT REPORTS USING “PILLS,” ASK RESPONDENT TO CLARIFY BETWEEN PRESCRIPTION BIRTH CONTROL PILLS AND OVER THE COUNTER BIRTH CONTROL PILLS.

Read only if respondent is unable to provide a response:

Nothing else
Female sterilization (Tubal ligation, Essure, or Adiana)
Male sterilization (vasectomy)

03 Contraceptive implant (Implanon, Nexplanon)

04 Intrauterine device or IUD (Mirena, Liletta, Skyla, Kyleena, Levonorgestrel IUD, ParaGard, copper IUD)

05 Shots (Depo-Provera)

06 Prescription birth control pills, Contraceptive Ring (NuvaRing, ElyRyng, Annovera), Contraceptive patch (Ortho Evra, Xulane, Twirla, Zafemy)

07 Over the counter birth control pills (Opill)

08 Condoms (male or female)

09 Diaphragm, vaginal gel (Phexxi), cervical cap, sponge, foam, jelly, film, or cream

10 Had sex at a time when less likely to get pregnant (rhythm method, natural family planning, apps for contraception)

11 Withdrawal or pulling out

12 Emergency contraception or the morning after pill (such as Plan B or Ella)

13 Other method

Do not read:

77 Don’t know/Not sure

99 Refused

[Ask Q5 if respondent indicated method response options 01-08 and 11 in Q3 above]

5. Where did you or your partner get the [response from Q3] you used when you last had sexual intercourse?

01 Private doctor’s office [GO TO Q7]

02 Community health clinic, Community clinic, Public health clinic [GO TO Q7]

03 Family planning or Planned Parenthood Clinic [GO TO Q7]

04 School or school-based clinic [GO TO Q7]

05 Hospital outpatient clinic, emergency room, regular hospital room [GO TO Q7]

06 Urgent care center, urgi-care or walk-in facility [GO TO Q7]

07 In- store health clinic (like CVS, Target, or Walmart) [GO TO Q7]

08 Health care visit with a pharmacist [GO TO Q7]

09 Website or app [GO TO Q7]

10 Some other place [GO TO Q7]

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

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

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

Read only if respondent is unable to provide a response:

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

02 You just didn’t think about it

03 You wanted a pregnancy

04 You didn’t care if you got pregnant

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

06 You had trouble getting or paying for birth control

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

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

09 You were using withdrawal or “pulling out”

10 You had your tubes tied (sterilization)

11 Your partner had a vasectomy (sterilization)

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

13 You were assigned male at birth

14 Other reasons

Do not read:

77 Don’t know/Not sure

99 Refused

7. If you could use any birth control method you wanted, what method would you use?

Female sterilization (Tubal ligation, Essure, or Adiana) [GO TO NEXT MODULE]

02 Male sterilization (vasectomy) [GO TO NEXT MODULE]

03 Contraceptive implant (Implanon, Nexplanon) [GO TO NEXT MODULE]

04 Intrauterine device or IUD (Mirena, Liletta, Skyla, Levonorgestrel IUD, ParaGard, copper IUD) [GO TO NEXT MODULE]

05 Shots (Depo-Provera) [GO TO NEXT MODULE]

06 Prescription birth control pills, Contraceptive Ring (NuvaRing, ElyRyng, Annovera), Contraceptive patch (Ortho Evra, Xulane, Twirla, Zafemy) [GO TO NEXT MODULE]

07 Over the counter birth control pills (Opill)

08 Condoms (male or female) [GO TO NEXT MODULE]

09 Diaphragm, vaginal gel (Phexxi), cervical cap, sponge, foam, jelly, film, or cream [GO TO NEXT MODULE]

10 Having sex at a time when less likely to get pregnant (rhythm method, natural family planning, apps for contraception) [GO TO NEXT MODULE]

11 Withdrawal or pulling out [GO TO NEXT MODULE]

12 Emergency contraception or the morning after pill (Plan B or ella) [GO TO NEXT MODULE]

13 Other method [GO TO NEXT MODULE]

14 I am using the method that I want to use [GO TO NEXT MODULE]

15 I don’t want to use any method [GO TO NEXT MODULE]

Do not read:

Don’t know/Not sure
Refused

Module 44: Emotional Support and Life Satisfaction

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

INTERVIEWER NOTE: IF ASKED, SAY “PLEASE INCLUDE SUPPORT FROM ANY SOURCE.”

Please read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

7 Don't know / Not sure

9 Refused

2. In general, how satisfied are you with your life? (475)

Please read:

1 Very satisfied

2 Satisfied

3 Dissatisfied

4 Very dissatisfied

Do not read:

7 Don't know / Not sure

9 Refused

Module 45: Social Determinants of Health

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

1 Yes

2 No

7 Don’t know/not sure

9 Refused

2. In the last 12 months, how many times have you moved from one home to another?

__ __ Number of moves in past 12 months [01-52]

88 None (Did not move in past 12 months)

77 Don’t know/Not sure

99 Refused

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

Please read:

1 Extremely safe

2 Safe

3 Unsafe

4 Extremely unsafe

Do not read:

7 Don’t know/Not sure

9 Refused

4. For the next two statements, please tell me whether the statement was often true, sometimes true, or never true for you in the last 12 months (that is, since last [CATI NOTE: NAME OF CURRENT MONTH]). The first statement is, “The food that I bought just didn’t last, and I didn’t have money to get more.”

Was that often, sometimes, or never true for you in the last 12 months?

1 Often true,

2 Sometimes true, or

3 Never true

Do not read:

7 Don’t Know/Not sure

9 Refused

5. “I couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for you in the last 12 months?

1 Often true,

2 Sometimes true, or

3 Never true

Do not read:

7 Don’t Know /Not sure

9 Refused

6. In general, how do your finances usually work out at the end of the month? Do you find that you usually:

Please read:

1 End up with some money left over,

2 Have just enough money to make ends meet, or

3 Do not have enough money to make ends meet

Do not read:

7 Don’t Know/Not sure

9 Refused

7. Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his/her mind is troubled all the time. Within the last 30 days, how often have you felt this kind of stress?

Please read:

1 None of the time,

2 A little of the time,

3 Some of the time,

4 Most of the time, or

5 All of the time

Do not read:

7. Don't know/not sure

9. Refused

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

1 Yes

2 No

7 Don’t know/not sure

9 Refused

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

1 Yes

7. Don’t know/not sure

9. Refused

10. How often do you feel isolated from others?

1. Always,

2. Usually,

3. Sometimes,

4. Rarely,

5. Never

7. Don’t know/not sure

9. Refused

11. How often do you feel you lack companionship? Always, usually, sometimes, rarely, never

1.. Always,

2. Usually,

3. Sometimes,

4. Rarely,

5. Never

7. Don’t know/not sure

9. Refused

12. How often do you feel left out?

1. Always,

2. Usually,

3. Sometimes,

4. Rarely,

5. Never

7. Don’t know/not sure

9 . Refused

Module 46: Sleep Disorder

On average, how many hours of sleep do you get in a 24-hour period?

INTERVIEWER NOTE: ENTER HOURS OF SLEEP IN WHOLE NUMBERS, ROUNDING 30 MINUTES (1/2 HOUR) OR MORE UP TO THE NEXT WHOLE HOUR AND DROPPING 29 OR FEWER MINUTES.

__ __ Number of hours [01-24]

77 Don’t know/Not sure

99 Refused

Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?

__ __ 01-14 days

88 None

77 Don’t know/Not sure

99 Refused

3. Over the last 2 weeks, how many days did you unintentionally fall asleep during the day?

__ __ 01-14 days

88 None

77 Don’t know/Not sure

99 Refused

4. Have you ever been told that you snore loudly?

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

5. Has anyone ever observed that you stop breathing during your sleep? (366)

INTERVIEWER NOTE: ALSO ENTER “YES” IF RESPONDENT MENTIONS HAVING A MACHINE OR CPAP THAT RECORDS THAT BREATHING SOMETIMES STOPS DURING THE NIGHT.

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

Module 47: Health Literacy

How difficult is it for you to get advice or information about health or medical topics if you need it?
1. Not at all
2. A little
3. Somewhat, or
4. Very difficult or
5. Never tried to get advice or information

7. Don’t know/not sure

9. Refused

How difficult is it for you to understand information that doctors, nurses and other health professionals tell you?

Not at all
A little
Somewhat, or
Very difficult or
Never tried to get advice or information

7. Don’t know/not sure

9. Refused

You can find written information about health on the Internet, in newspapers and magazines, and in brochures in the doctor’s office and clinic. In general, how difficult is it for you to understand written health information?

Not at all
A little
Somewhat, or
Very difficult or
Never tried to get advice or information

7. Don’t know/not sure

9. Refused

Module 48: Clinical Breast Exam

CATI NOTE: If respondent is male, go to the next section.

A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you ever had a clinical breast exam?

2 No [Go to next module]

7 Don’t know / Not sure [Go to next module]

9 Refused [Go to next module]

How long has it been since your last breast exam?

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

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

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

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

5 5 or more years ago

7 Don’t know / Not sure

9 Refused

Module 49: Exercise (Physical Activity)

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C11.01	During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?	EXERANY2	1 Yes		If respondent does not have a regular job or is retired, they may count the physical activity or exercise they spend the most time doing in a regular month.	223
C11.01		EXERANY2	2 No 7 Don’t know/Not Sure 9 Refused	Go to C 11.08		223
C11.02	What type of physical activity or exercise did you spend the most time doing during the past month?	EXRACT11	__ __ Specify from Physical Activity Coding List		See Physical Activity Coding List. If the respondent’s activity is not included in the physical activity coding list, choose the option listed as “other”.	224-225
C11.02		EXRACT11	77 Don’t know/ Not Sure 99 Refused	Go to C11.08		224-225
C11.03	How many times per week or per month did you take part in this activity during the past month?	EXEROFT1	1_ _ Times per week 2_ _ Times per month 777 Don’t know / Not sure 999 Refused			226-228
C11.04	And when you took part in this activity, for how many minutes or hours did you usually keep at it?	EXERHMM1	_:_ _ Hours and minutes 777 Don’t know / Not sure 999 Refused			229-231
C11.05	What other type of physical activity gave you the next most exercise during the past month?	EXRACT21	__ __ Specify from Physical Activity List		See Physical Activity Coding List. If the respondent’s activity is not included in the physical activity coding list, choose the option listed as “other”.	232-233
C11.05		EXRACT21	88 No other activity 77 Don’t know/ Not Sure 99 Refused	Go to C11.08		232-233
C11.06	How many times per week or per month did you take part in this activity during the past month?	EXEROFT2	1_ _ Times per week 2_ _ Times per month 777 Don’t know / Not sure 999 Refused			234-236
C11.07	And when you took part in this activity, for how many minutes or hours did you usually keep at it?	EXERHMM2	_:_ _ Hours and minutes 777 Don’t know / Not sure 999 Refused			237-239
C11.08	During the past month, how many times per week or per month did you do physical activities or exercises to strengthen your muscles?	STRENGTH	1_ _ Times per week 2_ _Times per month 888 Never 777 Don’t know / Not sure 999 Refused		Do not count aerobic activities like walking, running, or bicycling. Count activities using your own body weight like yoga, sit-ups or push-ups and those using weight machines, free weights, or elastic bands.	240-242

Module 50: Fruits and Vegetables

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
C12.01	Now think about the foods you ate or drank during the past month, that is, the past 30 days, including meals and snacks. Not including juices, how often did you eat fruit? You can tell me times per day, times per week or times per month.	FRUIT2	1_ _ Day 2_ _ Week 3_ _ Month 300 Less than once a month 555 Never 777 Don’t Know 999 Refused		If a respondent indicates that they consume a food item every day then enter the number of times per day. If the respondent indicates that they eat a food less than daily, then enter times per week or time per month. Do not enter time per day unless the respondent reports that he/she consumed that food item each day during the past month. Enter quantity in times per day, week, or month. If respondent gives a number without a time frame, ask “was that per day, week, or month?” Read if respondent asks what to include or says ‘i don’t know’: include fresh, frozen or canned fruit. Do not include dried fruits.	243-245
C12.02	Not including fruit-flavored drinks or fruit juices with added sugar, how often did you drink 100% fruit juice such as apple or orange juice?	FRUITJU2	1_ _ Day 2_ _ Week 3_ _ Month 300 Less than once a month 555 Never 777 Don’t Know 999 Refused		Read if respondent asks about examples of fruit-flavored drinks: “do not include fruit-flavored drinks with added sugar like cranberry cocktail, Hi-C, lemonade, Kool-Aid, Gatorade, Tampico, and sunny delight. Include only 100% pure juices or 100% juice blends.” Enter quantity in times per day, week, or month. If respondent gives a number without a time frame, ask “Was that per day, week, or month?”	246-248
C12.03	How often did you eat a green leafy or lettuce salad, with or without other vegetables?	FVGREEN1	1_ _ Day 2_ _ Week 3_ _ Month 300 Less than once a month 555 Never 777 Don’t Know 999 Refused		Enter quantity in times per day, week, or month. If respondent gives a number without a time frame, ask “Was that per day, week, or month?” Read if respondent asks about spinach: “Include spinach salads.”	249-251
C12.04	How often did you eat any kind of fried potatoes, including French fries, home fries, or hash browns?	FRENCHF1	1_ _ Day 2_ _ Week 3_ _ Month 300 Less than once a month 555 Never 777 Don’t Know 999 Refused		Enter quantity in times per day, week, or month. If respondent gives a number without a time frame, ask “Was that per day, week, or month?” Read if respondent asks about potato chips: “Do not include potato chips.”	252-254
C12.05	How often did you eat any other kind of potatoes, or sweet potatoes, such as baked, boiled, mashed potatoes, or potato salad?	POTATOE1	1_ _ Day 2_ _ Week 3_ _ Month 300 Less than once a month 555 Never 777 Don’t Know 999 Refused		Enter quantity in times per day, week, or month. If respondent gives a number without a time frame, ask “Was that per day, week, or month?” Read if respondent asks about what types of potatoes to include: “Include all types of potatoes except fried. Include potatoes au gratin, scalloped potatoes.”	255-257
C12.06	Not including lettuce salads and potatoes, how often did you eat other vegetables?	VEGETAB2	1_ _ Day 2_ _ Week 3_ _ Month 300 Less than once a month 555 Never 777 Don’t Know 999 Refused		Enter quantity in times per day, week, or month. If respondent gives a number without a time frame, ask “Was that per day, week, or month?” Read if respondent asks about what to include: “Include tomatoes, green beans, carrots, corn, cabbage, bean sprouts, collard greens, and broccoli. Include raw, cooked, canned, or frozen vegetables. Do not include rice.”	258-260

Module 51: Heart Attack and Stroke

Now I would like to ask you about your knowledge of the signs and symptoms of a heart attack and stroke.

Which of the following do you think is a symptom of a heart attack? For each, tell me “yes”, “no”, or you’re “not sure”.

1.(Do you think) pain or discomfort in the jaw, neck, or back (are symptoms of a heart attack?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

2.(Do you think) feeling weak, lightheaded, or faint (are symptoms of a heart attack?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

3.(Do you think) chest pain or discomfort (are symptoms of a heart attack?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

4.(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a heart attack?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

5.(Do you think) pain or discomfort in the arms or shoulder (are symptoms of a heart attack?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

6.(Do you think) shortness of breath (is a symptom of a heart attack?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

7.(Do you think) sudden confusion or trouble speaking (are symptoms of a stroke?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

8.(Do you think) sudden numbness or weakness of face, arm, or leg, especially on one side, (are symptoms of a stroke?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

9.(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a stroke?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

10.(Do you think) sudden chest pain or discomfort (are symptoms of a stroke?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

11.(Do you think) sudden trouble walking, dizziness, or loss of balance (are symptoms of a stroke?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

12.(Do you think) severe headache with no known cause (is a symptom of a stroke?)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

13.If you thought someone was having a heart attack or a stroke, what is the first thing you would do?

Please read:

1 Take them to the hospital

2 Tell them to call their doctor

3 Call 911

4 Call their spouse or a family member

5 Do something else

Do not read:

7 Don‘t know / Not sure

9 Refused

Module 52: Anxiety and Depression

Now, I am going to ask you some questions about your mood. When answering these questions, please think about how many days each of the following has occurred in the past 2 weeks.

1. Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?

(435-436)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

2. Over the last 2 weeks, how many days have you felt down, depressed or hopeless?

(437-438)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

3. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?

(439-440)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

4. Over the last 2 weeks, how many days have you felt tired or had little energy?

(441-442)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

5. Over the last 2 weeks, how many days have you had a poor appetite or eaten too much?

(443-444)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

6. Over the last 2 weeks, how many days have you felt bad about yourself or that you were a failure or had let yourself or your family down?

(445-446)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

7. Over the last 2 weeks, how many days have you had trouble concentrating on things, such as reading the newspaper or watching the TV?

(447-448)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

8. Over the last 2 weeks, how many days have you moved or spoken so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you were

moving around a lot more than usual?

(449-450)

_ _ 01–14 days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

9. Are you now taking medicine or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem?

(451)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

10. Has a doctor or other healthcare provider EVER told you that you have an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder,

obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or

social anxiety disorder)?

(452)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Module 53: Mental Illness and Stigma

Now, I am going to ask you some questions about how you have been feeling lately.

1. About how often during the past 30 days did you feel nervous — would you say all of the

time, most of the time, some of the time, a little of the time, or none of the time?

(338)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused

2. During the past 30 days, about how often did you feel hopeless — all of the time, most of the time, some of the time, a little of the time, or none of the time?

(339)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused

3. During the past 30 days, about how often did you feel restless or fidgety?

[If necessary: all, most, some, a little, or none of the time?]

(340)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused

4. During the past 30 days, about how often did you feel so depressed that nothing could

cheer you up?

[If necessary: all, most, some, a little, or none of the time?]

(341)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused

5. During the past 30 days, about how often did you feel that everything was an effort?

Note: If respondent asks what does “everything was an effort” means; say, “Whatever it means to you”

[If necessary: all, most, some, a little, or none of the time?]

(342)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused

6. During the past 30 days, about how often did you feel worthless?

[If necessary: all, most, some, a little, or none of the time?]

(343)

1 All

2 Most

3 Some

4 A little

5 None

7 Don’t know / Not sure

9 Refused

7. During the past 30 days, for about how many days did a mental health condition or emotional problem keep you from doing your work or other usual activities?

(344-345)

_ _ Number of days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

INTERVIEWER NOTE: If asked, "usual activities" includes housework, self-care, care giving, volunteer work, attending school, studies, or recreation.

8. Are you now taking medicine or receiving treatment from a doctor or other health

professional for any type of mental health condition or emotional problem?

(346)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

These next questions ask about peoples' attitudes toward mental illness and its treatment.

9. Treatment can help people with mental illness lead normal lives. Do you –agree slightly

or strongly, or disagree slightly or strongly?

(347)

Read only if necessary:

1 Agree strongly

2 Agree slightly

3 Neither agree nor disagree

4 Disagree slightly

5 Disagree strongly

Do not read:

7 Don’t know / Not sure

9 Refused

10. People are generally caring and sympathetic to people with mental illness. Do you –

agree slightly or strongly, or disagree slightly or strongly?

(348)

Read only if necessary:

1 Agree strongly

2 Agree slightly

3 Neither agree nor disagree

4 Disagree slightly

5 Disagree strongly

Do not read:

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: If asked for the purpose of Q9 or Q10: say: “answers to these questions will be used by health planners to help understand public attitudes about mental illness and its treatment and to help guide health education programs”.

Module 54: Social Context

Now, I am going to ask you about several factors that can affect a person’s health.

If Core Q7.21 = 1 or 2 (own or rent) continue, else go to Q2.

1. How often in the past 12 months would you say you were worried or stressed

about having enough money to pay your rent/mortgage? Would you say you were worried or stressed---

(349)

Please read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

8 Not applicable

7 Don’t know / Not sure

9 Refused

2. How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say you were worried or

stressed---

(350)

Please read:

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

Do not read:

8 Not applicable

7 Don’t know / Not sure

9 Refused

If Core Q7.9 = 1 (Employed for wages) or 2 (Self-employed), go to Q3 and Q4.

If Core Q7.9 = 3 (Out of work for more than 1 year), 4 (Out of work for less than 1 year), or

7 (Retired), go to Q5 and Q6.

If Core Q7.9 = 5 (A homemaker), 6 (A student), or 8 (Unable to work), go to next module.

3. At your main job or business, how are you generally paid for the work you do. Are you:

(351)

1 Paid by salary

2 Paid by the hour

3 Paid by the job/task (e.g. commission, piecework)

4 Paid some other way

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: If paid in multiple ways at their main job, select option 4 (Paid some other way).

4. About how many hours do you work per week at all of your jobs and businesses combined?

(352-353)

_ _ Hours (01-96 or more) [Go to next module]

9 7 Don't know / Not sure [Go to next module]

9 8 Does not work [Go to next module]

9 9 Refused [Go to next module]

5. Thinking about the last time you worked, at your main job or business, how were you

generally paid for the work you did? Were you:

(354)

1 Paid by salary

2 Paid by the hour

3 Paid by the job/task (e.g. commission, piecework)

4 Paid some other way

7 Don’t know / Not sure

9 Refused

6. Thinking about the last time you worked, about how many hours did you work per week

at all of your jobs and businesses combined?

(355-356)

_ _ Hours (01-96 or more)

9 7 Don't know / Not sure

9 8 Does not work

9 9 Refused

Module 55: General Preparedness

The next series of questions asks about how prepared you are for a large-scale disaster or emergency. By large-scale disaster or emergency we mean any event that leaves you isolated in your home or displaces you from your home for at least 3 days. This might include natural disasters such as hurricanes, tornados, floods, and ice storms, or man-made disasters such as explosions, terrorist events, or blackouts.

1. How well prepared do you feel your household is to handle a large-scale disaster or emergency? Would you say…

(357)

Please read:

1 Well prepared

2 Somewhat prepared

3 Not prepared at all

Do not read:

7 Don’t know / Not sure

9 Refused

2. Does your household have a 3-day supply of water for everyone who lives there? A 3-day supply of water is 1 gallon of water per person per day.

(358)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

3. Does your household have a 3-day supply of nonperishable food for everyone who lives there? By nonperishable we mean food that does not require refrigeration or cooking.

(359)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

4. Does your household have a 3-day supply of prescription medication for each person who takes prescribed medicines?

(360)

1 Yes

2 No

3 No one in household requires prescribed medicine

7 Don’t know / Not sure

9 Refused

5. Does your household have a working battery operated radio and working batteries for your use if the electricity is out?

(361)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6. Does your household have a working flashlight and working batteries for your use if the electricity is out?

(362)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

7. In a large-scale disaster or emergency, what would be your main method or way of

communicating with relatives and friends?

(363)

Read only if necessary:

1 Regular home telephones

2 Cell phones

3 Email

4 Pager

5 2-way radios

6 Other

Do not read:

7 Don’t know / Not sure

9 Refused

8. What would be your main method or way of getting information from authorities in a large-scale disaster or emergency?

(364)

Read only if necessary:

1 Television

2 Radio

3 Internet

4 Print media

5 Neighbors

6 Other

Do not read:

7 Don’t know / Not sure

9 Refused

9. Does your household have a written disaster evacuation plan for how you will leave your home, in case of a large-scale disaster or emergency that requires evacuation?

(365)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

10. If public authorities announced a mandatory evacuation from your community due to a large-scale disaster or emergency, would you evacuate?

(366)

1 Yes [Go to next module]

2 No

7 Don’t know / Not sure

9 Refused

11. What would be the main reason you might not evacuate if asked to do so?

(367-368)

Read only if necessary:

0 1 Lack of transportation

0 2 Lack of trust in public officials

0 3 Concern about leaving property behind

0 4 Concern about personal safety

0 5 Concern about family safety

0 6 Concern about leaving pets

0 7 Concern about traffic jams and inability to get out

0 8 Health problems (could not be moved)

0 9 Other

Do not read:

7 7 Don’t know / Not sure

9 9 Refused

Module 56: Veteran’s Health

CATI NOTE: If Core Q7.5 = 1 (Yes) continue, else go to next module.

The next questions relate to veteran’s health.

1. Did you ever serve in a combat or war zone?

(369)

1 Yes

2 No

Don’t know / Not sure

9 Refused

2. Has a doctor or other health professional ever told you that you have depression, anxiety, or post traumatic stress disorder (PTSD)?

(370)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

3. A traumatic brain injury may result from a violent blow to the head or when an object pierces the skull and enters the brain tissue. Has a doctor or other health professional

ever told you that you have suffered a traumatic brain injury (TBI)?

(371)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

4. In the past 12 months, did you receive any psychological or psychiatric counseling or treatment?

(372)

Please read:

1 Yes, from a VA facility

2 Yes, from a non-VA facility

3 Yes, from both VA and non-VA facilities

4 No

Do not read:

7 Don’t know / Not sure

9 Refused

The next few questions are a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer.

5. Has there been a time in the past 12 months when you thought of taking your own life?

(373)

1 Yes

2 No [Go to next module]

7 Don’t know / Not sure [Go to next module]

9 Refused [Go to next module]

6. During the past 12 months, did you attempt to commit suicide? Would you say---

(374)

Please read:

1 Yes, but did not require treatment

2 Yes, was treated at a VA facility

3 Yes, was treated at a non-VA facility

4 No

Do not read:

Don’t know / Not sure

9 Refused

As I mentioned, I would give you a phone number for an organization that can provide information and referral for these issues. You can dial the National Crisis line at 1-800-273-TALK (8255). You can also speak directly to your doctor or health provider.

Module 57: Reactions to Race

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

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

(332)

1 White

2 Black or African American

3 Hispanic or Latino

4 Asian

5 Native Hawaiian or Other Pacific Islander

6 American Indian or Alaska Native

8 Some other group (please specify) _________________________

7 Don’t know / Not sure

9 Refused

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

2. How often do you think about your race? Would you say never, once a year, once a

month, once a week, once a day, once an hour, or constantly?

(333)

1 Never

2 Once a year

3 Once a month

4 Once a week

5 Once a day

6 Once an hour

8 Constantly

7 Don’t know / Not sure

9 Refused

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

3. Within the past 12 months, on average, were you treated worse than, the same as, or better than people of other races?

(334)

1 Worse than other races

2 The same as other races

3 Better than other races

Do not read:

4 Worse than some races, better than others

5 Only encountered people of the same race

7 Don’t know / Not sure

9 Refused

[CATI skip pattern: This question should only be asked of those who are “employed for wages,” “self-employed,” or “out of work for less than one year.”]

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

(335)

1 Worse than other races

2 The same as other races

3 Better than other races

Do not read:

4 Worse than some races, better than others

5 Only encountered people of the same race

7 Don’t know / Not sure

9 Refused

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

(336)

1 Worse than other races

2 The same as other races

3 Better than other races

Do not read:

4 Worse than some races, better than others

5 Only encountered people of the same race

6 No health care in past 12 months

7 Don’t know / Not sure

9 Refused

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

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

(337)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

7. Within the past 30 days, have you felt emotionally upset, for example angry, sad, or frustrated, as a result of how you were treated based on your race?

(338)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

8. Within the past 30 days, have you felt emotionally upset (for example angry, sad, or frustrated) as a result of how other people were treated based on their race?

(339)

1 Yes

2 No

Don’t know / Not sure

9. Refused

9. Do you think that people living in [fill in the name of this state] are treated differently depending on what race they are?

(340)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Module 58: WGSS Disability

Q1: Do you have difficulty seeing, even if wearing glasses?

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

Refused

9. Don’t know/Not sure

Q2: Do you have difficulty hearing, even if using a hearing aid?

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

Refused

Don’t know/Not sure

Q3: Do you have difficulty walking or climbing steps?

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

Refused

9.Don’t know/Not sure

Q3_ACS: Do you have difficulty walking or climbing stairs?

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

Refused
Don’t know/Not sure

Q4: Do you have difficulty remembering or concentrating?

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

Refused

9.Don’t know/Not sure

Q5: Do you have difficulty with self-care, such as washing all over or dressing?

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

Refused

9.Don’t know/Not sure

Q5_ACS: Do you have difficulty bathing or dressing?

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all

7. Refused

9. Don’t know/Not sure

Q6: Using your usual language, do you have difficulty communicating, for example, understanding or being understood?

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

Refused

9. Don’t know/Not sure

Q7: Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

Refused

9.Don’t know/Not sure

Q7_ACS: Do you have difficulty doing errands alone such as visiting a doctor's office or shopping?

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

Refused

9.Don’t know/Not sure

Module 59: Other Tobacco Use

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

1. YES

2. NO

7. DON’T KNOW/NOT SURE

9. REFUSED

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

1. YES

2. NO

7. DON’T KNOW/NOT SURE

9. REFUSED

Module 60: Periodontal Disease

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. Do you think you might have gum disease?

(1) Yes

(2) No

Do not read:

(7) Refused

(9) Don’t Know

Overall, how would you rate the health of your teeth and gums?

(1) Excellent

(2) Very good

(3) Good

(4) Fair

(5) Poor

Do not read:

(7) Refused

(9) Don’t Know

Have you ever had treatment for gum disease such as scaling and root planning, sometimes called “deep cleaning?”

(1) Yes

(2) No

Do not read:

(7) Refused

(9) Don’t Know

Have you ever been told by a dental professional that you lost bone around your teeth?

1) Yes

(2) No

Do not read:

(7) Refused

(9) Don’t Know

Aside from brushing your teeth with a toothbrush, in the last seven days, how many days did you use dental floss or any other device to clean between your teeth?

___(Number of days)

Interview instruction: Code “0” if the survey participant responds they have no teeth or only dentures.

Do not read:

77=Refused

99= Don’t Know

Module 61: Knowledge and Impact of COVID Pandemic

NOTE: These questions are included as placeholders for items that may be included in future BRFSS questionnaires. They are not currently supported by CDC program sponsors.

Question	Components	Response set
As far as you know, have public health experts recommended (INSERT ITEM) as a way to help slow the spread of coronavirus, or not? How about (INSERT NEXT ITEM), have public health experts recommended this as a way to help slow the spread of coronavirus, or not? (scramble items a-d)	a. Frequent hand washing b. Healthy people wearing facemasks in public c. Avoiding gatherings with large numbers of people d. Staying home if you are feeling sick	Yes, recommended No, not recommended Don’t know/ Refused (NET) Don’t know Refused
As far as you know, is each of the following a way that coronavirus is transmitted, or not? First, (INSERT ITEM), is this a way that coronavirus is transmitted, or not? How about (INSERT NEXT ITEM)? (READ IF NECESSARY: Is this a way that coronavirus is transmitted, or not?) (scramble items a-c)	a. Being in close physical proximity with someone who is infected b. Touching surfaces that contain small amounts of bodily fluids from someone who is infected c. Through mosquito bites	Yes No Don’t know/ Refused (NET) Don’t know Refused
For each of the following please tell me if you think this is a common symptom of coronavirus, or not. First, (INSERT ITEM), is this a symptom of coronavirus, or not? How about (INSERT NEXT ITEM)? (READ IF NECESSARY: Is this a common symptom of coronavirus, or not?) (scramble items a-d)	a. Fever b. Dry cough c. Nasal congestion d. Rash	Yes No Don’t know/ Refused (NET) Don’t know Refused
Compared to other groups, do you think (INSERT ITEM) have a higher risk of developing serious medical issues if they become infected with coronavirus, or not? How about (INSERT NEXT ITEM)? (READ IF NECESSARY: Compared to other groups, do you think (ITEM) have a higher risk of developing serious medical issues if they become infected with coronavirus, or not?) (scramble items a-c)	a. People over the age of 60 b. Children c. People with chronic health conditions	Yes, have a higher risk No, do not have a higher risk Don’t know/ Refused (NET) Don’t know Refused
As far as you know, is there a vaccine to protect people from the current coronavirus, also known as COVID-19, or not?		Yes No Don’t know/ Refused (NET) Don’t know Refused
As far as you know, does the vaccine for influenza, or seasonal flu, protect people from the current coronavirus, also known as COVID-19, or not?		Yes No Don’t know/ Refused (NET) Don’t know Refused
As far as you know, do most people infected with coronavirus (recover without developing serious complications), or do most people (develop serious complications that require intensive care)? (rotate 1-2,2-1)		Most recover without developing serious complications Most develop serious complications that require intensive care Don’t know/Refused (NET) Don’t know Refused
As far as you know, if someone thinks they are having symptoms of coronavirus, should they (stay home and call a doctor or medical provider) or should they (seek health care immediately at an emergency room or urgent care facility)? (rotate 1-2,2-1) 3/20		Stay home and call a doctor or medical provider 73 Seek health care immediately at an emergency room or urgent care facility 25 Something else (Vol.) * Don’t know/Refused (NET) 2 Don’t know 1 Refused
Which of the following best describes your feelings about the coronavirus in the United States? (ROTATE FIRST TWO) +		The worst is behind us The worst is yet to come …or… The coronavirus is not likely to be that major of a problem Not sure
Please indicate your level of agreement or disagreement with the following statements	I am worried about getting the coronavirus. I know what actions to take to prevent myself and my family from becoming infected with the coronavirus. I feel confident I can prevent myself and my family from becoming infected with the coronavirus if it becomes more widespread in the United States. I am likely to get the coronavirus	Strongly Agree Agree Disagree Strongly Disagree
How worried, if at all, are you that (INSERT ITEM)? Are you very worried, somewhat worried, not too worried or not at all worried? How about that (INSERT NEXT ITEM)? (IF NECESSARY: Are you very worried, somewhat worried, not too worried or not at all worried that (INSERT ITEM)?) (scramble items a-e)	a. You or someone in your family will get sick from the Coronavirus b. You will lose income due to a workplace closure or reduced hours because of coronavirus c. Your investments such as retirement or college savings will be negatively impacted by coronavirus d. You will put yourself at risk of exposure to coronavirus because you can’t afford to stay home and miss work You will not be able to afford testing or treatment for coronavirus if you need it	Very/ Somewhat worried (NET) Very worried Somewhat worried Not too/Not at all worried (NET) Not too worried Not at all worried Not Applicable Don’t Know/ Refused
Overall, how prepared do you think you are to deal with a coronavirus infection if you or someone in your family contracted the virus? Would you say you feel very prepared, somewhat prepared, not too prepared, or not at all prepared to respond to that? [RESPONSES ROTATED IN ORDER FOR HALF/IN REVERSE ORDER FOR HALF]		Very prepared Somewhat prepared NET Not prepared Not too prepared Not at all prepared No opinion
Thinking about what, if any, impact the coronavirus has had on you and your family’s day to day life, would you say it has -- (ROTATE TOP TO BOTTOM, BOTTOM TO TOP) changed your life in a very major way, a fairly major way, only a small way or has it not changed your life in any way? +*		in a very major way, a fairly major way, only a small way or has it not changed your life in any way?
Looking ahead, what, if any, impact do you believe the coronavirus will have on you and your family’s day to day life, would you say it will -- (ROTATE TOP TO BOTTOM, BOTTOM TO TOP) change your life in a very major way, a fairly major way, only a small way or will it not change your life in any way?		a very major way, a fairly major way, only a small way or will it not change your life in any way?
In the past 30 days have you cancelled plans to avoid crowds?		Yes No Don’t know/ Refused Don’t know Refused
In the past 30 days have your children’s activities or school been cancelled?		Yes No Don’t know/ Refused Don’t know Refused
In the past 30 days have you lost employment or had hours reduced?		Yes No Don’t know/ Refused Don’t know Refused
In the past 30 days have you lost income from a business?		Yes No Don’t know/ Refused Don’t know Refused
In the past 30 days have you lost health care coverage?		Yes No Don’t know/ Refused Don’t know Refused
In the past 30 days have you had a medical appointment cancelled or postponed?		Yes No Don’t know/ Refused Don’t know Refused
In the past 30 days have you had any difficulty Feeding your household adequately		Yes No Don’t know/ Refused Don’t know Refused
In the past 30 days have you had any difficulty feeding your household adequately?		Yes No Don’t know/ Refused Don’t know Refused
In the past 30 days have you had any difficulty filling any prescriptions?		Yes No Don’t know/ Refused Don’t know Refused
In the past 30 days have you had any difficulty finding the groceries you want?		Yes No Don’t know/ Refused Don’t know Refused
In the past 30 days have you had any difficulty seeing a doctor or health professional?		Yes No Don’t know/ Refused Don’t know Refused
In the past 30 days have you had any difficulty finding cleaning products?		Yes No Don’t know/ Refused Don’t know Refused

Module 62: Emotional Well-being

Now I’m going to ask you some questions about your life.

1. All things considered, would you say you are?

Please read 1-4

1 Very happy

2 Happy

3 Neutral

4 Not very happy

5 Not happy at all

Do not read

7 Don’t know / Not sure

9 Refused

Please tell me on a scale of 1 to 5 how much you agree or disagree with the following statements about your life. 1 means strongly disagree and 5 means strongly agree. [Read choices only if necessary.]

2. In most ways my life is close to ideal.

1 Strongly disagree

2 Disagree

3 Neither agree nor disagree

4 Agree

5 Strongly agree

Do not read

7 Don’t know / Not sure

9 Refused

3. The conditions of my life are excellent

1 Strongly agree

2 Agree

3 Neither agree nor disagree

4 Disagree

5 Strongly disagree

Do not read

7 Don’t know / Not sure

9 Refused

4. I am satisfied with my life

1 Strongly agree

2 Agree

3 Neither agree nor disagree

4 Disagree

5 Strongly disagree

Do not read

7 Don’t know / Not sure

9 Refused

5. So far I have gotten the important things I want in life.

1 Strongly agree

2 Agree

3 Neither agree nor disagree

4 Disagree

5 Strongly disagree

Do not read

7 Don’t know / Not sure

9 Refused

For questions 6-9: Interviewer: Read the question & response options (for Qs 6 & 7). Read the question and response options (shaded text in parentheses) only if necessary in Qs 8 & 9.

The next few questions ask about how satisfied you are.

6. In general, how satisfied are you with your present job or work? Would you say you are …

Please read 1-4

1 Very satisfied

2 Satisfied

3 Dissatisfied, or

4 Very dissatisfied

Do not read

7 Don’t know / Not sure

9 Refused

7. In general, how satisfied are you with your neighborhood? Would you say you are …

Please read 1-4

1 Very satisfied

2 Satisfied

3 Dissatisfied, or

4 Very dissatisfied

Do not read

7 Don’t know / Not sure

9 Refused

8. (In general, how satisfied are you with) your education? (Would you say very satisfied, satisfied, dissatisfied, or very dissatisfied?)

Read only if necessary

1 Very satisfied

2 Satisfied

3 Dissatisfied, or

4 Very dissatisfied

Do not read

7 Don’t know / Not sure

9 Refused

9. (In general, how satisfied are you with) your energy level? (Would you say very satisfied, satisfied, dissatisfied, or very dissatisfied?)

Read only if necessary

1 Very satisfied

2 Satisfied

3 Dissatisfied, or

4 Very dissatisfied

Do not read

7 Don’t know / Not sure

9 Refused

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

Read only if necessary

1 Very satisfied

2 Satisfied

3 Dissatisfied, or

4 Very dissatisfied

Do not read

7 Don’t know / Not sure

9 Refused

11. How often do you get the social and emotional support you need?” (this includes support from any source)

1 Always

2 Usually

3 Sometimes

4 Rarely

5 Never

12. All things considered, would you say you are ([1] very happy to [5] not happy at all? (from NHIS

Module 62A: Emotional Well-Being

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
The next few questions are about how you deal with things in your life and how you feel. When things aren't going well for you, or when you’re having problems, how confident or certain are you that you can do the following?
MEWB.01	Get friends to help you with the things you need.		1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/ Not sure 9 Refused
MEWB.02	Get emotional support from friends and family.		1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/ Not sure 9 Refused
MEWB.03	See things from the other person's point of view during a heated argument.		1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/ Not sure 9 Refused
MEWB.04	Resist the impulse to act hastily when under pressure.		1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/ Not sure 9 Refused
MEWB.05	Control your reactions, regardless of what happens.		1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/ Not sure 9 Refused
MEWB.06	Take time to figure out what you are really feeling.		1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/ Not sure 9 Refused
MEWB.07	Accept that your feelings are valid and important.		1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/ Not sure 9 Refused
MEWB.08	Allow yourself to express your emotions.		1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/ Not sure 9 Refused
MEWB.09	Encourage yourself to try your best.		1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/ Not sure 9 Refused
MEWB.10	Tell yourself things to help you feel better.		1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/ Not sure 9 Refused

Module 63: Opioid Use and Misuse


Question	Response set Do not read unless otherwise noted	CATI Instructions	Interviewer Notes
Q1. In the last 12 months, have you taken any prescription pain relievers when it was prescribed to you by a doctor, dentist, nurse practitioner, or other healthcare provider?	1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused	If Q1= 2, 7, 9 Go to next section	Pain relievers include Codeine, morphine, Lortab, Vicodin, Tylenol #3, Percocet, OxyContin, Xanax, Valium, Ativan. We only want to know about prescription medication that is not available over the counter.
Q2. The last time you filled a prescription for pain medication in the past year, did you use any of the pain medication more frequently or in higher doses than directed by a doctor?	1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused	If Q2= 2,7,9 Go to Q4
Q3. What was the main reason you used the medication differently than prescribed? Would you say…	Read if necessary: 1 To relieve pain, prescribed dose did not relieve pain 2 To relieve other physical symptoms 3 To relieve anxiety or depression 4 For fun, good feeling, getting high, peer pressure (friends were doing it) 5 To prevent or relieve withdrawal symptoms Do not read 7 Don't Know/Not sure 9 Refused
Example Optional Module Questions: Prescribed Opioids
Q1. In the past year, have you had any pain medication left over from a prescription?	1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused	If Q4 = 2, 7, 9 Go to next section.
Q2. What did you do with the leftover prescription pain medication?	1 Kept it 2 Disposed of it 3 Gave it to someone else 4 Sold it 5 Used it for another unrelated pain/ other purpose 7 Don't know/Not sure 9 Refused
Q3. The last time you used pain medication that was prescribed to you, what was the main reason?	Read if necessary 1 pain related to cancer 2 post-surgical care/medical care 3 back pain, short term 4 back pain, long term 5 joint pain, short term 6 joint pain, long term 7 carpal tunnel syndrome 8 arthritis 9 work-related injury 10 other injury causing short term pain 11 other injury causing long term pain 12 other physical conditions causing pain 13 to prevent or relieve withdrawal symptoms 14 dental pain 15 pain due to diabetes-related nerve damage Do not read: 77. Don’t know 99. Refused
Q4 In the past year, what prescription pain medications were prescribed to you by a doctor?	1 Butorphanol Tartrate 2 Carisoprodol 3 Celebrex 4 Codeine 5 Darvocet 6 Darvon 7 Demerol 8 Dilaudid 9 Duragesic 10 Embeda 11 Fentanyl 12 Fentora 13 Gabapentin 14 Hydrocodone 15 Hydromorphone 16 Ibuprofen / Motrin 17 Kadian 18 Levorphanol 19 Lortab 20 Lorcet 21 Meperidine 22 Methadone 23 Morphine 24 Naproxen 25 Narcan 26 Neurontin 27 Opium Tincture 28 Oxycodone 29 Oxycontin 30 Pentazocine 31 Percocet 32 Percodan 33 Propoxyphene 34 Roxicet 35 Soma 36 Stadol 37 Suboxone 38 Subutex 39 Toradol 40 Tramadol 41 Tylenol with codeine (Tylenol #3) 42 Tylox 43 Ultram (Ultram ER) 44 Ultracet 45 Vicodin 46 Other (specify_____) {28 character limit} 77 Don’t know / not sure 99 Refused	This question could be coded for multiple response
Example Optional Module Questions: Use of Opioids Not Prescribed
Q1. In the past year, did you use a prescription pain medication that was not prescribed specifically for you by a doctor, dentist, nurse practitioner, or healthcare providers?	1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused	If OMQ1 = 2, 7, 9 Go to OMQ5
Q2. From whom did you obtain the prescription pain medication?	1 = From a friend or relative 2 = From an acquaintance 3 = From a street dealer or other person I did not know 4 = Online 5 = Other 7 = Don't know/Not sure 9 = Refused
Q3. About how often in the past 12 months did you use prescription pain relievers including that were not prescribed to you by a doctor, dentist, nurse practitioner, or other healthcare providers? Would you say....	Read 1 Never 2 Every day or nearly every day 3 Several times a month 4 Several times a year Do not read: 7 Don't know/Not sure 9 Refused		Pain relievers include Codeine, morphine, Lortab, Vicodin, Tylenol #3, Percocet, OxyContin, Xanax, Valium, Ativan. We only want to know about medication that is not available over the counter.
Q4. In the past 12 months, did you shoot up or inject any drugs other than those prescribed for you? By shooting up, I mean anytime you might have used drugs with a needle, either by mainlining, skin popping, or muscling.	1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused
Example Optional Module Questions: Dependency
Q5. How long has it been since you used any prescription pain reliever?	Read only if necessary 1 Within the past 30 days (or currently taking) 2 More than 30 days ago but within the past 12 months 3 More than 12 months ago 4 Never 7 Don’t know/Not sure 9 Refused		Pain relievers include Codeine, morphine, Lortab, Vicodin, Tylenol #3, Percocet, OxyContin, Xanax, Valium, Ativan. We only want to know about medication that is not available over the counter.
Q6. In the past year have you felt dependent on prescription pain medication or experienced trouble getting off of the medication when you no longer needed it for medical reasons?	1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused		Pain relievers include Codeine, morphine, Lortab, Vicodin, Tylenol #3, Percocet, OxyContin, Xanax, Valium, Ativan. We only want to know about medication that is not available over the counter.
Thank you for answering these questions. If you would like assistance with any of these issues, please call the XXX at XXXX to find out about mental health and substance related disorder services available in your area.

Module 64: Bereavement

I’d like to ask you some questions about friends or family who have passed away in recent years.

GA7_1. Have you experienced the death of a family member or close friend in the years 2018 or 2019?

1 Yes

2 No [GO TO GA7_4]

7 Don’t know / Not sure [GO TO GA7_4]

9 Refused [GO TO GA7_4]

GA7_2. How many losses did you experience during that time?

_ __ losses [RANGE (01-76),

77 Don’t know [GO TO GA7_4]

99 Refused [GO TO GA7_4]

GA7_3. For each loss, please tell me if he or she was a spouse, friend or a family member.

INTERVIEWER NOTE: With family members please indicate relationship; Mother, Father, Sister, Brother.

GA7_3a Was [IF GA7_2=1, READ “your” / IF GA7_2>1, READ “your first”] loss a …?

IF GA7_2>1, ASK; OTHERWISE SKIP TO GA7_4

GA7_3b Was the second family member or friend you lost a …?

IF GA7_2>2, ASK; OTHERWISE SKIP TO GA7_4

GA7_3c Was the third family member or friend you lost a …?

IF GA7_2>3, ASK; OTHERWISE SKIP TO GA7_4

GA7_3d Was the fourth family member or friend you lost a …?

IF GA7_2>4, ASK; OTHERWISE SKIP TO GA7_4

GA7_3e Was the fifth family member or friend you lost a …?

(READ LIST for first mention)

01 Spouse/Partner

02 Mother

03 Father

04 Brother

05 Sister

06 Child

07 Other Family Member

08 Friend or Neighbor

09 Other

77 Don't know/Not sure

99 Refused

Module 65: Social Determinants and Health Equity

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
MSDHE.01	In the past 12 months have you lost employment or had hours reduced?		1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused
MSDHE.02	During the past 12 months, have you received food stamps, also called SNAP, the Supplemental Nutrition Assistance Program on an EBT card?		1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused
MSDHE.03	During the past 12 months how often did the food that you bought not last, and you didn’t have money to get more? Was that…		Read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/not sure 9 Refused
MSDHE.04	During the last 12 months, was there a time when you were not able to pay your mortgage, rent or utility bills?		1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused
MSDHE.05	During the last 12 months was there a time when an electric, gas, oil, or water company threatened to shut off services?		1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused
MSDHE.06	During the past 12 months has a lack of reliable transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?		1 Yes 2 No 7 Don’t Know/ Not sure 9 Refused
MSDHE.07	How often do you get the social and emotional support that you need? Is that…		Read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/not sure 9 Refused
MSDHE.08	How often do you feel lonely or isolated from others? Is it…		Read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/not sure 9 Refused
MSDHE.09	In general, how satisfied are you with your life? Are you..		Read: 1 Very satisfied 2 Satisfied 3 Dissatisfied 4 Very dissatisfied 7 Don’t know/not sure 9 Refused
MSDHE.10	Stress means a situation in which a person feels tense, restless, nervous or anxious or is unable to sleep at night because their mind is troubled all the time. Within the last 30 days, how often have you felt this kind of stress? Was it…		Read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never 7 Don’t know/not sure 9 Refused

Module 66: Positive Childhood Experiences

Question Number	Question text	Variable names	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
MPCE.01	How often did you feel that you were able to talk to your family about your feelings?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
MPCE.02	For how much of your childhood was there an adult in your household who made you feel safe and protected?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
MPCE.03	How often did you feel supported by your friends?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
MPCE.04	How often did you feel that you belonged at your high school?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
MPCE.05	How often were there at least two adults, other than your parents or caregivers, who took a genuine interest in you?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
MPCE.06	Looking back on the neighborhood or community where you grew up (before you were 18 years of age), how often did people in the neighborhood help each other out?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
MPCE.07	Looking back on the neighborhood or community where you grew up (before you were 18 years of age), how often did you feel safe in your neighborhood?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
MPCE.08	How often did you have chances to show others that you were growing up and could do things by yourself?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
MPCE.09	How often did you enjoy participating in your community’s traditions?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused

Module 66A: Positive Childhood Experiences

Question Number	Question Text	Variable name	Responses (DO NOT READ UNLESS OTHERWISE NOTED)	SKIP INFO/ CATI Note	Interviewer Note (s)	Column(s)
Prologue: These questions refer to the time before you were 18 years of age.
M01	How often did you feel your family stood by you during difficult times? Never Rarely Sometimes Often Very often		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M02	How often did you feel that you were able to talk to your family about your feelings?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M03	For how much of your childhood was there an adult in your household who made you feel safe and protected?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M04	How often did you enjoy participating in your community’s traditions?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M05	How often did you feel supported by your friends?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M06	How often did you feel that you belonged at your high school?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M07	How often were there at least two adults, other than your parents, who took a genuine interest in you?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M08	For how much of your childhood did you have beliefs that gave you comfort?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M09	For how much of your childhood did you have at least one teacher who cared about you?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M10	How often did you have opportunities to have a good time?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M11	How often did you have a predictable home routine, like regular meals and a regular bedtime?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M12	How often did you and your parent/caregiver share ideas or talk about things that really matter?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M13	In general, how was your parents’/caregivers’ mental or emotional health?		1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor 7 Don’t Know/ Not sure 9 Refused
M14	Which of these statements best describes your household’s ability to afford the food you needed when you were growing up:		1.We could always afford to eat good nutritious meals 2.We could always afford enough to eat but not always the kinds of foods we should eat 3.Sometimes we could not afford enough to eat 4.Often we could not afford enough to eat
M15	Looking back on the neighborhood or community where you grew up (before you were 18 years of age), how often did people in the neighborhood help each other out?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M16	Looking back on the neighborhood or community where you grew up (before you were 18 years of age), how often did families watch out for each others’ children in your neighborhood?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M17	Looking back on the neighborhood or community where you grew up (before you were 18 years of age), how often did you feel safe in your neighborhood?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M18	How often did you care about doing well in school?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M19	How often did you get along with people around you?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M20	How important was getting an education to you?		1 Not at all important 2 A little important 3 Somewhat important 4 Veery Important 7 Don’t Know/ Not sure 9 Refused
M21	How often did you feel that your parents/caregivers really looked out for you?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M22	How often did you feel that your parents/caregivers knew a lot about you (for example, who your friends were, what you liked to do)?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M23	How often did you feel that people liked to spend time with you?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M24	How often were you able to talk to your family/caregiver(s) about your feelings (for example, when you were hurt or sad)?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M25	How often did you feel supported by your friends?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M26	How often did you feel that you belonged at your high school?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M27	How often did you feel that your friends cared about you when times were hard (for example if you were sick or had done something wrong)?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M28	How often did you feel that your friends cared about you when times were hard (for example if you were sick or had done something wrong)?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M29	How often did you feel treated fairly in your community?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M30	How often did you have chances to show others that you were growing up and could do things by yourself?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M31	How often did you feel safe when you were with your family/caregivers?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused
M32	How often did you have chances to learn things that would be useful when you were older (like cooking, working, and helping others)?		1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often 7 Don’t Know/ Not sure 9 Refused

Module 67: Traumatic Brain Injury

Question Number

Question text

Variable names

Responses

(DO NOT READ UNLESS OTHERWISE NOTED)

SKIP INFO/ CATI Note

Interviewer Note (s)

Column(s)

MTBI.01

As a result of a blow or jolt to the head, have you ever been knocked out or lost consciousness, been dazed or confused, or had a gap in your memory?

1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused

If respondent has questions about whether a certain injury qualifies, interviewer can say: Please think about all head injuries, for example, from playing sports, car accidents, falls, or being hit by something or someone.

MTBI.02

As a result of a blow or jolt to the head, have you ever had symptoms like headaches, sensitivity to light or noise, balance problems, or changes in mood or behavior?

1 Yes

2 No

7 Don’t Know/ Not sure

9 Refused

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Pierannunzi, Carol (CDC/ONDIEH/NCCDPHP)
File Modified	0000-00-00
File Created	2024-12-05

Optional Modules by Topic

BRFSS Attachment 4 Optional Modules by Topic_2025_2027 Updated.docx

[NCCDPHP] Behavioral Risk Factor Surveillance System (BRFSS)