Example BRFSS Online Survey Instrument
BRFSS Attachment 17 - Example BRFSS Online Survey Instrument 2025-2027.docx
[NCCDPHP] Behavioral Risk Factor Surveillance System (BRFSS)
Example BRFSS Online Survey Instrument
OMB: 0920-1061
2024 BRFSS Pilot
Web and CATI Survey Programming Specification
OVERALL PROGRAMMING NOTES
COMMENTS FOR ENTIRE CATI INSTRUMENT:
* Add question numbers to screens for easy reference, if needed.
* Please always have right bracket at the end of the IF NEEDED text.
* Don’t know =77 for single-select questions unless indicated otherwise
* Refused=66 for single-select questions unless indicated otherwise
* CATI instrument should disallow skipping of questions.
This survey will be offered in English.
In banner (and repeated on all pages):
CDC Health Survey
“CDC Health Survey” text
Blue = text for alerts/error message text
Green = programming notes
For each survey question within this spec:
Display one question per screen for both PC and mobile phone. The one exception is for PC, in which some items (noted within this spec) will be presented in a grid format.
Do not display question numbers.
The default is to display all question stem text in bold. Do not bold the response options.
For emphasis of text within question stems, a dark blue bold font color will be used.
Italicized text is used in some questions to indicate additional information for Rs to read (separate from the bold stem).
For CATI use: some response options are in CAPS.
Numeric codes will not appear next to fixed-choice answer options. Selection bubbles or boxes will appear instead.
Do not display response option values.
Display “Previous” and “Next” buttons at the bottom of the screen to navigate between questions.
During testing, question labels may appear on the screen but they will not appear in the final version shown to sample members.
At the bottom of each screen, the following static text will appear: “If you would like more information about the study, please feel free to call our survey manager at 1-855-928-0777 or send an email to [email protected].”
For web use
There will be soft edit checks for items that have logical ranges (or ranges known from CDC’s prior data collections), but Rs do not have to answer them to move on or submit the survey. The ranges are noted for each item.
These soft edit checks will explicitly state the issue (e.g., high or low value, question not answered)
For web use: missing Responses to Gate Questions -- Treatment of Follow-up Questions
If Respondents skip (leave blank) or provided DK/REF (in CATI) to certain questions that have follow-up questions, the follow-up questions will not be shown to the R (e.g., if R answers No about ever being told of having had asthma, the follow-up question 8.2b (Do you still have asthma?”) should not be shown.
Ranges for any questions that have text fill boxes
In this document, 99 or 9999 is the top value for range checks for many questions. We will ask CDC if they want alternative top range values, based on prior years’ BRFSS data).
In banner (and repeated on all pages):
CDC logo
“CDC Health Survey” text in place of the following 2013 year, looking like this:
Welcome message text: Welcome to the CDC Health Survey.
Field for respondents to enter the login ID they receive from Westat
The assigned login ID consists of an 8 digit code consisting of numbers and characters
***************************SCREENER**********************************
*1 SCREENER FOR CELL PHONE NUMBERS COMPLETING ON WEB*
[IF CELL FRAME AND PIN USED IS NOT FROM CATI, ASK INTRO1A1. ELSE GO TO INTRO1B1]
INTRO1A1. (INTRO & PHONE NUMBER)
Welcome to our survey. Your participation will help the Centers for Disease Control and Prevention (the CDC) understand how to protect and improve the health of state residents like you.
To verify that we have reached the right household, does anyone living at this address have a cell phone number ending in [LAST 4 DIGITS ON SAMPLE FILE]?
Please note that your phone number is only used for verification purposes and we do not share it with anyone else.
1. Yes, it is my cell phone GO TO CP04_WEB
2. Yes, it is someone else’s cell phone who lives at this address GO TO END_WRONGPERSON
3. No, no one living at this address has this cell phone number GO TO END_WRONGADDRESS
PROGRAMMING NOTE: IF R TRIES TO MOVE FORWARD WITHOUT ANSWERING, SHOW PROMPT…
We need to verify that we have reached the right household. Please note that your phone number is only used for verification purposes and we do not share it with anyone else.
[IF INTRO1A1=YES, SOMEONE ELSE’S PHONE, GO TO END_WRONGPERSON.]
END_WRONGPERSON.
Thank you! Only the person who owns the cell phone number ending with [LAST 4 DIGIT ON SAMPLE FILE] is eligible to complete this web survey. Please give the survey login information and PIN to that person and ask them to complete the survey. Thank you! You may close the browser.
PROGRAMMING NOTE: TERMINATE AND RESET THE SURVEY.
[IF INTRO1A1=NO, GO TO END_WRONGADDRESS]
END_WRONGADDRESS.
Thank you! It seems that your household is not eligible for this survey. You may close the browser.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE.
[IF INTRO1A1=YES, IT IS MY CELL PHONE, GO TO CP04_WEB.]
CP04_WEB. (AGE)
Are you 18 years of age or older?
1. Yes GO TO CP05_WEB
2. No GO TO END_WRONGAGE
[IF CP04_WEB=NO OR IS MISSING, GO TO END_WRONGAGE.]
END_WRONGAGE.
Thank you very much but we are only interviewing persons aged 18 or older at this time.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE.
[IF CP04_WEB=YES, GO TO CP05_WEB.]
CP05_WEB. (SEX)
Are you…
We ask this question to determine which health related questions apply to each respondent.
1. Male GO TO CP07_WEB
2. Female GO TO CP07_WEB
3. Transgender, non-binary, or another gender GO TO CP06_WEB
[IF CP05_WEB=TRANSGENDER OR IS MISSING, GO TO CP06_WEB.]
CP06_WEB. (SEX 2)
What was your sex at birth? Was it…?
We ask this question to determine which health related questions apply to each respondent.
1. Male GO TO CP07_WEB
2. Female GO TO CP07_WEB
[IF CP06_WEB IS MISSING, GO TO END_SEX]
END_SEX.
Thank you for your time, you may be selected for another survey in the future.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS REFUSAL.
[IF INTRO1A1=YES, MY PHONE NUMBER, GO TO INTRO1A2]
CP07_WEB. (PRIVATE RES)
Do you live in a private residence?
By private residence we mean someplace like a house or apartment.
1. Yes GO TO CP09_WEB
2. No GO TO CP08_WEB
[IF CP07_WEB=NO, MISSING, GO TO CP08_WEB.]
CP08_WEB. (COLLEGE HOUSING)
Do you live in college housing?
By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.
1. Yes GO TO CP09_WEB
2. No GO TO END_WRONGADDRESS2
[IF CP08_WEB=NO OR IS MISSING, GO TO END_WRONGADDRESS2]
END_WRONGADDRESS2.
Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE.
[IF CP07_WEB=YES OR IF CP08=YES, GO TO CP09_WEB.]
CP09_WEB. (STATE)
Do you currently live in___(state)____?
1. Yes GO TO CP11_WEB
2. No GO TO CP10_WEB
[IF CP09_WEB=NO, GO TO CP10_WEB.]
[DISPLAY RESPONSE OPTIONS AS A DROPDOWN MENU.]
CP10_WEB. (STATE 2)
In what state do you currently live?
1. Alabama GO TO CP11_WEB
[DISPLAY REMAINING STATES IN ALPHABETICAL ORDER]
56. Wyoming GO TO CP11_WEB
66. Guam GO TO CP11_WEB
72. Puerto Rico GO TO CP11_WEB
78. Virgin Islands GO TO CP11_WEB
77. Live outside US and participating territories GO TO END_USRESIDENT
[IF CP10_WEB=77 OR IS MISSING, GO TO END_USRESIDENT.]
END_USRESIDENT.
Thank you very much, but we are only interviewing persons who live in the US.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE.
[IF CP09_WEB=YES OR CP10_WEB=1-78, GO TO CP11_WEB.]
CP11_WEB. (LANDLINE)
Do you also have a landline telephone in your home that is used to make and receive calls?
By landline telephone, we mean a regular telephone in your home that is used for making or receiving calls. Please include landline phones used for both business and personal use.
1. Yes
2. No
[IF CP08=YES, THEN AUTOMATICALLY SET CP12_WEB TO 1; ELSE ASK CP12_WEB.]
CP12_WEB. (HH #)
How many members of your household, including yourself, are 18 years of age or older?
_ _ NUMBER OF ADULTS AGED 18 YEARS OR OLDER
D3A_WEB. (AGE)
What is your age?
We need this information to determine what questions to ask you.
_ _ YEARS
80. I am 80 years old or older
PROGRAMMING NOTE: IF R ENTERS NUMBER GREATER THAN 79 OR LESS THAN 18, SHOW…
Please enter a number between 18 and 79. If your age is greater than 79, please mark “I am 80 years old or older.”
PROGRAMMING NOTE: IF R MOVES FORWARD WITHOUT ANSWERING,
We need this information to determine what questions to ask you.
IF R TRIED TO MOVE WITHOUT ANSWERING AGAIN, SHOW:
Those are all the questions we have for you. Thank you.
TERMINATE THE SURVEY AND CODE THIS CASE AS REFUSAL.
*2 SCREENER FOR LANDLINE PHONE NUMBERS COMPLETING ON WEB*
[IF LANDLINE FRAME AND PIN USED IS NOT FROM CATI, ASK INTRO1B1. ELSE GO TO INTRO1C1]
INTRO1B1. (INTRO & PHONE NUMBER)
Welcome to our survey. Your participation will help the Centers for Disease Control and Prevention (the CDC) understand how to protect and improve the health of state residents like you.
To verify that we have reached the right household, does this household have a phone number ending in [LAST 4 DIGITS ON SAMPLE FILE]? It could be a landline or a cell phone number.
Please note that your phone number is only used for verification purposes and we do not share it with anyone else.
1. Yes, it is a landline phone GO TO LL02_WEB
2. Yes, it is my cell phone GO TO LL02_WEB
3. Yes, it is someone else’s cell phone who lives at this address GO TO LL02_WEB
4. No, no one living at this address has this phone number GO TO END_WRONGADDRESS
5. No, it is a business phone number GO TO END_WRONG ADDRESS
PROGRAMMING NOTE: IF R TRIES TO MOVE FORWARD WITHOUT ANSWERING, SHOW PROMPT…
We need to verify that we have reached the right household. Please note that your phone number is only used for verification purposes and we do not share it with anyone else.
[IF INTRO1B1=NO OR BUSINESS PHONE, GO TO END_WRONGADDRESS]
END_WRONGADDRESS.
Thank you! It seems that your household is not eligible for this survey. You may close the browser.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE.
[IF INTRO1B1=SOMEONE ELSE’S CELL PHONE, GO TO END_WRONGPERSON.]
END_WRONGPERSON.
Thank you! Only the person who owns the cell phone number ending with [LAST 4 DIGIT ON SAMPLE FILE] is eligible to complete this web survey. Please give the survey login information and PIN to that person and ask them to complete the survey. Thank you! You may close the browser.
PROGRAMMING NOTE: TERMINATE AND RESET THE SURVEY.
[IF INTRO1B1=LANDLINE, MY CELL PHONE, GO TO LL02_WEB]
LL02_WEB. (PRIVATE RES)
Do you live in a private residence?
By private residence we mean someplace like a house or apartment.
1. Yes GO TO LL04_WEB
2. No GO TO LL03_WEB
[IF LL02_WB=NO OR MISSING, GO TO LL03_WEB]
LL03_WEB. (COLLEGE HOUSING)
Do you live in college housing?
By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.
1. Yes GO TO LL04_WEB
2. No GO TO END_WRONGADDRESS2
[IF LL03_WEB =NO OR IS MISSING, GO TO END_WRONGADDRESS2]
END_WRONGADDRESS2.
Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE.
[IF LL02_WEB=YES OR LL03_WEB=YES, GO TO LL04_WEB.]
LL04_WEB. (STATE)
Do you currently live in___(state)____?
1. Yes
2. No
LL06_WEB. (AGE)
Are you 18 years of age or older?
1. Yes
2. No
IF LL06_WEB=YES,
-IF INTRO1B1=LANDLINE AND LL03_WEB=1, CODE LL07_WEB=1 AND GO TO LL09_WEB.
-ELSE GO TO LL07_WEB.
IF LL06_WEB=NO,
-IF INTRO1B1=MY CELL, GO TO END_WRONGAGE
-IF INTRO1B1=LANDLINE AND LL03_WEB=YES, GO TO END_WRONGAGE
-ELSE GO TO LL07_WEB
END_WRONGAGE.
Thank you very much but we are only interviewing persons aged 18 or older at this time.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE.
LL07_WEB. (HH #)
Excluding adults living away from home, such as students away at college, how many members of your household, including yourself, are 18 years of age or older?
_ _ NUMBER OF ADULTS AGED 18 YEARS OR OLDER
[IF INTRO1B1=MY CELL OR LL07_WEB=1, GO TO LL09_WEB. ELSE IF INTRO1B1=LANDLINE AND LL07_WEB IS GREATER THAN 1, GO TO LL08_WEB.]
LL08_WEB. (BIRTHDAY SELECTION)
As stated in the invitation letter, we are asking for the adult with the most recent birthday. Are you the adult with the most recent birthday?
1. Yes GO TO LL09_WEB
2. No GO TO END_WRONGPERSON2
[IF LL08_WEB_NEW=NO, GO TO END_WRONGPERSON2]
END_WRONGPERSON2.
Thank you! Only the adult with the most recent birthday is eligible to complete this web survey. Please give the survey login information and PIN to that person and ask them to complete the survey. Thank you! You may close the browser.
PROGRAMMING NOTE: TERMINATE AND RESET THE SURVEY TO START AT LL08_WEB.
LL09_WEB. (SEX)
Are you…
We ask this question to determine which health related questions apply to each respondent
1. Male GO TO D3A_WEB
2. Female GO TO D3A_WEB
3. Transgender, non-binary, or another gender GO TO LL10_WEB
[IF LL09_WEB=TRANSGENDER… OR IS MISSING, GO TO LL10_WEB.]
LL10_WEB. (SEX 2)
What was your sex at birth? Was it …?
We ask this question to determine which health related questions apply to each respondent.
1. Male GO TO D3A_WEB
2. Female GO TO D3A_WEB
[IF LL09_WEB IS MISSING, GO TO END_SEX.]
END_SEX.
Thank you for your time, you may be selected for another survey in the future.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS REFUSAL.
D3A_WEB. (AGE)
What is your age?
We need this information to determine what questions to ask you.
_ _ YEARS
80. I am 80 years old or older
PROGRAMMING NOTE: IF R ENTERS NUMBER GREATER THAN 79 OR LESS THAN 18, SHOW…
Please enter a number between 18 and 79. If your age is greater than 79, please mark “I am 80 years old or older.”
PROGRAMMING NOTE: IF R MOVES FORWARD WITHOUT ANSWERING,
We need this information to determine what questions to ask you.
IF R TRIED TO MOVE WITHOUT ANSWERING AGAIN, SHOW:
Those are all the questions we have for you. Thank you.
TERMINATE THE SURVEY AND CODE THIS CASE AS REFUSAL.
*3 SCREENER FOR CELL PHONE NUMBERS CALLED BY CATI*
[IF CELL FRAME AND PIN USED IS FROM CATI, ASK INTRO1C1 TO D3A IN VOXCO.]
INTRO1C1. (INTRO & SAFE)
Hello! I’m xx calling from Westat to invite you to participate in a survey to help the Centers for Disease Control and Prevention (the CDC) understand how to protect and improve the health of state residents like you.
Is this a safe time to talk with you?
1. YES Go to CP02
2. NO SET APPOINTMENT IF POSSIBLE; TERMINATE
Thank you very much. We will call you back at a more convenient time.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND RESET TO INTRO1C1
[IF INTRO1C1=YES, GO TO CP02.]
CP02. (PHONE NUMBER)
Is this [PHONE NUMBER]?
1. YES Go to CP03
2. NO TERMINATE
Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time.
PROGRAMMING NOTE: TERMINATE THE SURVEY RESET TO INTRO1C1
[IF CP02=YES, GO TO CP03.]
CP03. (CELL PHONE)
Is this a cell phone?
1 YES
2 NO
CP04. (AGE)
Are you 18 years of age or older?
1. YES GO TO CP05
2. NO TERMINATE
Thank you very much but we are only interviewing persons aged 18 or older at this time.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE
[IF CP04=YES, GO TO CP05.]
CP05. (SEX)
Are you…
[IF NEEDED: We ask this question to determine which health related questions apply to each respondent.]
1. Male GO TO CP07
2. Female, or GO TO CP07
3. Transgender, non-binary, or another gender GO TO CP06
7. DON’T KNOW/NOT SURE GO TO CP06
9. REFUSED GO TO CP06
[IF CP05=TRANSGENDER…, DON’T KNOW…, REFUSED, GO TO CP06.]
CP06. (SEX 2)
What was your sex at birth? Was it male or female?
[IF NEEDED: We ask this question to determine which health related questions apply to each respondent. What sex were you assigned at birth on your original birth certificate?]
1. MALE GO TO CP07
2. FEMALE GO TO CP07
7. DON’T KNOW/NOT SURE TERMINATE
9. REFUSED TERMINATE
Thank you for your time, your number may be selected for another survey in the future.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS REFUSAL.
[IF (CP05=MALE OR FEMALE) OR (CP06=MALE OR FEMALE), GO TO CP07.]
CP07. (PRIVATE RES)
Do you live in a private residence?
[IF NEEDED: By private residence we mean someplace like a house or apartment.]
1. YES GO TO CP09
2. NO GO TO CP08
[IF CP07=NO, GO TO CP08.]
CP08. (COLLEGE HOUSING)
Do you live in college housing?
[IF NEEDED: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university. ]
1. YES GO TO CP09
2. NO TERMINATE
Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE
[IF CP07=YES OR CP08=YES, GO TO CP09.]
CP09. (STATE)
Do you currently live in___(state)____?
1. YES GO TO CP11
2. NO GO TO CP10
[IF CP09=NO, GO TO CP10.]
CP10. (STATE 2)
In what state do you currently live?
1. Alabama GO TO CP11
[DISPLAY REMAINING STATES IN ALPHABETICAL ORDER]
56. Wyoming GO TO CP11
66. Guam GO TO CP11
72. Puerto Rico GO TO CP11
78. Virgin Islands GO TO CP11
77. Live outside US and participating territories TERMINATE
99. Refused TERMINATE
Thank you very much, but we are only interviewing persons who live in the US.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE.
[IF CP09=YES OR CP10=1-78, GO TO CP11.]
CP11. (LANDLINE)
Do you also have a landline telephone in your home that is used to make and receive calls?
[IF NEEDED: By landline telephone, we mean a regular telephone in your home that is used for making or receiving calls. Please include landline phones used for both business and personal use.]
1. Yes
2. No
7. Don’t know/Not sure
9. Refused
[IF CP08=YES CODE CP12=1 AND GO TO D3A. ELSE GO TO CP12]
CP12. (HH #)
How many members of your household, including yourself, are 18 years of age or older?
_ _ Number
77. Don’t know/ Not sure
99. Refused
D3A. (AGE)
What is your age?
We need this information to determine what questions to ask you.
_ _ Years
80. 80 years old or older
666. RefusedTERMINATE
Those are all the questions we have for you. Thank you.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS REFUSAL.
*4 SCREENER FOR LANDLINE PHONE NUMBERS CALLED BY CATI*
[IF LANDLINE FRAME AND PIN USED IS FROM CATI, ASK INTRO1D1 TO D3A IN VOXCO.]
INTRO1D1. (INTRO & PHONE NUMBER)
Hello! I’m xx calling from Westat to invite you to participate in a survey to help the Centers for Disease Control and Prevention (the CDC) understand how to protect and improve the health of state residents like you.
Is this [PHONE NUMBER]?
1. Yes GO TO LL02
2. No TERMINATE
Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time.
PROGRAMMING NOTE: TERMINATE BUT ALLOW DIALING.
[IF INTRO1D1=YES, GO TO LL02.]
LL02. (PRIVATE RES)
Is this a private residence?
[IF NEEDED: By private residence we mean someplace like a house or apartment. ]
1. Yes GO TO LL04
2. No GO TO LL03
3. No, this is a business TERMINATE
Thank you very much, but we are only interviewing persons on residential phones at this time.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE.
[IF LL02=NO, DON’T KNOW, GO TO LL03.]
LL03. (COLLEGE HOUSING)
Do you live in college housing?
[IF NEEDED: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university. ]
1. Yes GO TO LL04
2. No TERMINATE
Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE.
[IF LL02=YES OR LL03=YES, GO TO LL04.]
LL04. (STATE)
Do you currently live in___(state)____?
1. Yes
2. No
LL05. (CELL PHONE)
Is this a cell phone?
[IF NEEDED: By cell phone we mean a telephone that is mobile and usable outside your neighborhood.]
1. Yes, it is a cell phone
2. NO, IT IS Not a cell phone
LL06. (AGE)
Are you 18 years of age or older?
1. YES
2. NO
IF LL06=YES,
-IF LL03=YES, CODE LL07=1 AND GO TO LL09
-ELSE GO TO LL07
IF LL06=NO,
-IF LL03=YES OR LL05=YES, GO TO END_WRONGAGE
-ELSE GO TO LL07
END_WRONGAGE.
Thank you very much but we are only interviewing persons aged 18 or older at this time.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE.
LL07. (HH #)
[IF LL05=NO, SHOW: I need to randomly select one adult who lives in your household to be interviewed. ]
Excluding adults living away from home, such as students away at college, how many members of your household, including yourself, are 18 years of age or older?
____NUMBER
[IF LL05=YES OR LL07=1, GO TO LL09. ELSE IF LL05=NO AND LL07 IS GREATER THAN 1, GO TO LL08. ELSE IF LL07=1, GO TO LL09]
LL08. (BIRTHDAY SELECTION)
The person in your household that I need to speak with is the adult with the most recent birthday. Are you the adult with the most recent birthday?
1. YES GO TO LL09
2. NO GO TO END_WRONGPERSON2
[IF LL08_WEB=NO, GO TO END_WRONGPERSON2]
END_WRONGPERSON2.
Thank you! Only the adult with the most recent birthday is eligible to complete this web survey. Please give the survey login information and PIN to that person and ask them to complete the survey. Thank you! You may close the browser.
PROGRAMMING NOTE: TERMINATE AND RESET THE SURVEY TO START AT LL08.
LL09. (SEX)
Are you…
IF NEEDED: We ask this question to determine which health related questions apply to each respondent.
1. Male, GO TO D3A
2. Female, or GO TO D3A
3. Transgender, non-binary, or another gender? GO TO LL10
7. Don’t know/Not sure GO TO LL10
9. Refused GO TO LL10
LL10. (SEX 2)
What was your sex at birth? Was it male or female?
READ IF NECESSARY: We ask this question to determine which health related questions apply to each respondent. What sex were you assigned at birth on your original birth certificate?
1. MALE GO TO D3A
2. FEMALE GO TO D3A
7. DON’T KNOW/NOT SURE TERMINATE
9. REFUSED TERMINATE
Thank you for your time, your number may be selected for another survey in the future.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS INELIGIBLE OR REFUSAL.
D3A. (AGE)
What is your age?
We need this information to determine what questions to ask you.
_ _ Years
80. 80 years old or older
666. Refused
Those are all the questions we have for you. Thank you.
PROGRAMMING NOTE: TERMINATE THE SURVEY AND CODE THIS CASE AS REFUSAL.
********************************MAIN SURVEY*********************************
(INTRO2).
[IF PIN IS NOT FROM CATI, THEN SHOW:
You are eligible to participate in the survey. This questionnaire is designed to gather information about the health and health practices of adults in your state. The information is kept confidential and is used only to evaluate health programs and to plan future actions to improve the health of citizens in your state. For more information about this study, please call 1-855-928-0777 or send an email to [email protected].
On each screen, you will be asked about your health and experience. Click on your answer or type in an answer, and then click the “Next” button to continue to the next screen. With a few exceptions, you can skip a question by leaving the question blank and clicking the “Next” button. The questions that are required are used to determine which follow-up questions you receive.
If you need to review or change an answer, you can go to the bottom of the screen and click the “Back” button to go back to an earlier screen.
Do not click the backwards arrow that appears at the top of your browser.]
[IF PIN FROM CATI, THEN SHOW:
This questionnaire is designed to gather information about the health and health practices of adults in your state. The information gathered by this survey is kept confidential and is used only to evaluate health programs and to plan future actions to improve the health of citizens in your state. For more information about this study, please call 1-855-928-0777 or send an email to [email protected].
Throughout the survey, I will be asking about your health and experience. You can refuse any question that you are uncomfortable answering. ]
[Click NEXT button to move to the next screen]
(INTRO3). Completing the survey will take approximately 10 to 20 minutes, on average. Participation is voluntary.[IF PIN NOT FROM CATI, THEN SHOW: You can stop or quit the survey at any time.] No information that could personally identify you will be given to the CDC or anyone else. Your answers will be kept private to the extent allowable by law.
[IF PIN FROM CATI: Let’s get started.]
[IF PIN FROM CATI, THEN SHOW:
CONTINUE [CONTINUE to S1]
]
Healthy Days
Q1 (GENHLTH) First are some questions about your health.
Would you say that in general your health is…
1 Excellent
2 Very Good
3 Good
4 Fair [IF PIN FROM CATI: , or]
5 Poor
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Q2. (PHYSHLTH)
Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
_ _ NUMBER OF DAYS [RANGE: 0-30]
777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
666 REFUSED]
Q3 (MENTHLTH)
Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
_ _ NUMBER OF DAYS [RANGE: 0-30]
777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
666 REFUSED]
Programming and Edit Checks for Page
For Q2, if R has entered a number greater than 30 and clicks a navigation button, show message:
Please enter a number between 0 and 30.
For Q3, if R has entered a number greater than 30 and clicks a navigation button, show message:
Please enter a number between 0 and 30.
Q4 will NOT be shown ONLY when Q2 =0 AND q3=0
If R clicks Back button, then retain any current answers for Q2 and Q3 in the boxes.
[IF Q2=0 AND Q3=0, SKIP Q4]
Q4 (POORHLTH)
During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?
_ _ NUMBER OF DAYS [RANGE: 0-30]
777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
666 REFUSED]
Programming and Edit Checks for Page
For Question 4, if R has entered a number greater than 30 and clicks a navigation button, show message:
Please enter a number between 0 and 30.
Health Care Access
Q5. (HLTHINS)
What is the current primary source of your health care coverage?
[IF PIN IS FROM CATI, THEN SHOW:
If you have multiple sources of health care coverage, please think about the one used most often. ]
[IF PIN IS NOT FROM CATI, THEN SHOW:
If you have multiple sources of insurance, please think about the one used most often. ]
01 A plan purchased through an employer or union, including plans purchased through another person's employer
02 A private nongovernmental plan that you or another family member buys on your own
03 Medicare
04 Medigap
05 Medicaid
06 Children's Health Insurance Program (CHIP)
07 Military related health care: TRICARE (CHAMPUS) / VA health care / CHAMPVA
08 Indian Health Service
09 State sponsored health plan [IF PIN FROM CATI: , or]
10 Some other government program
88 [IF PIN FROM CATI, SHOW: NO COVERAGE OF ANY TYPE; ELSE, SHOW: No coverage of any type]
77 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
66 REFUSED]
Q6 (CHECKUP1)
About how long has it been since you last visited a doctor for a routine checkup?
[IF PIN IS NOT FROM CATI, THEN SHOW: A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.]
[IF PIN IS FROM CATI, THEN SHOW:
Was it…?
[IF NEEDED: A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.]
[IF PIN IS NOT FROM CATI, THEN SHOW:
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 5 years (2 years but less than 5 years ago)
4 5 or more years ago
8 Never
7 Don’t know / Not sure
[IF PIN IS FROM CATI, THEN SHOW:
1 Within the past year,
2 1 year but less than 2 years ago,
3 2 years but less than 5 years ago, or
4 5 or more years ago,
8 NEVER
7 Don’t know / Not sure
6 REFUSED]
Q7 (LASTDEN4)
Including all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists, how long has it been since you last visited a dentist or a dental clinic for any reason?
[IF PIN IS FROM TEXT INVITATION, LETTER INVITATION, LETTER REMINDER, POSTCARD REMINDER, OR PROMPT, THEN SHOW:
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 5 years (2 years but less than 5 years ago)
4 5 or more years ago
8 Never
7 Don’t know / Not sure
[IF PIN IS FROM CATI, THEN SHOW:
1 Within the past year,
2 1 year but less than 2 years ago,
3 2 years but less than 5 years ago, or
4 5 or more years ago,
8 NEVER
7 DON’T KNOW/NOT SURE
6 REFUSED]
Q8 (RMVTETH4)
Not including teeth lost for injury or orthodontics, how many of your permanent teeth have been removed because of tooth decay or gum disease?
[IF PIN NOT FROM CATI, THEN SHOW: If wisdom teeth are removed because of tooth decay or gum disease, they should be included in the count for lost teeth.]
[IF PIN FROM CATI, THEN SHOW: If wisdom teeth are removed because of tooth decay or gum disease, they should be included in the count for lost teeth. Would you say…?]
1 [IF PIN FROM CATI THEN SHOW: 1 to 5 teeth; ELSE SHOW: 1 to 5]
2 [IF PIN FROM CATI THEN SHOW: 6 or more teeth, but not all, or; ELSE SHOW: 6 or more but not all]
3 [IF PIN FROM CATI THEN SHOW: All of your permanent teeth have been removed because of tooth decay or gum disease; ELSE SHOW: All]
8 [IF PIN FROM CATI THEN SHOW: NONE; ELSE SHOW: None]
7 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
6 REFUSED]
Q9 (BPHIGH4)
Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
[IF PIN IS NOT FROM CATI, THEN SHOW: By other health professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.]
[IF PIN IS FROM CATI, THEN SHOW: By other health professional we mean nurse practitioner, a physician assistant, or some other licensed health professional.]
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
3 [IF PIN FROM CATI, SHOW: NO; ELSE, SHOW: No]
4 [IF PIN FROM CATI, SHOW: TOLD BORDERLINE HIGH OR PRE-HYPERTENSIVE; ELSE, SHOW: Told borderline high or pre-hypertensive]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
[IF BPHIGH4=YES AND SEX=FEMALE, GO TO BPHIGH_PREG. ELSE GO TO CVDINFR4.]
Q9A (BPHIGH_PREG).
Was this only when you were pregnant?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
/***NOTE FOR PROGRAMMER: PLACE Q10 TO Q14 IN ONE GRID IF DEVICE IS PC. ELSE SHOW ONE QUESTION PER SCREEN IF DEVICE IS SMARTPHONE
**********/
Chronic Conditions
Q10. (CVDINFR4)
Has a doctor, nurse, or other health professional ever told you that…
You had a heart attack also called a myocardial infarction?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Q11. (CVDCRHD4)
You had angina or coronary heart disease?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Q12 (ASTHMA3)
You had asthma?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Q13. (CHCOCNCR)
You had any types of cancer, including skin cancer?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
You had a depressive disorder, including depression, major depression, dysthymia, or minor depression?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Q15. (DIABETE5)
Has a doctor, nurse, or other health professional ever told you that you had diabetes?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
3 [IF PIN IS FROM CATI: NO; ELSE: No]
4 [IF PIN IS FROM CATI: PRE-DIABETES OR BORDERLINE DIABETES; ELSE: Pre-diabetes or borderline diabetes]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
[IF DIABETE5=YES AND SEX=FEMALE, GO TO DIABETE_PREG. ELSE GO TO INSTRUCTION BEFORE HAVARTH3.]
Q15A (DIABETE_PREG).
Was this only when you were pregnant?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Arthritis
Q16A. (HAVARTH3)
Has a doctor, nurse or other health professional ever told you that you had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
[IF HAVARTH3=YES, ASK HAVARTH3FU. ELSE GO TO SKIP INSTRUCTION BEFORE ARTH_ALT1]
Q16A1. (HAVARTH3FU)
What type of arthritis condition have you been diagnosed with?
[IF PIN FROM CATI:
INTERVIEWERS: SELECT ONE. ]
[IF PIN IS NOT FROM CATI:
1 Osteoarthritis
2 Rheumatoid arthritis
3 Psoriatic arthritis
4 Gout
5 Fibromyalgia
6 Lupus
7 Other arthritis
77 Don’t know / Not sure
[IF PIN IS FROM CATI:
1 Osteoarthritis
2 Rheumatoid arthritis
3 Psoriatic arthritis
4 Gout
5 Fibromyalgia
6 Lupus
7 Other arthritis
77 Don’t know / Not sure
66 REFUSED]
Q17 (TOLDCFS)
Have you ever been told by a doctor or other health professional that you had Chronic Fatigue Syndrome (CFS) or [IF PIN NOT FROM CATI, SHOW (Myalgic Encephalomyelitis) ME] [IF PIN FROM CATI, SHOW: ME (Myalgic Encephalomyelitis)]?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Q18 (TOLDHEPC)
Have you ever been told by a doctor or other health professional that you had Hepatitis C?
IF PIN NOT FROM CATI: Hepatitis C is an infection of the liver from the Hepatitis C virus.
IF PIN FROM CATI:
Hepatitis C is an infection of the liver from the Hepatitis C virus.
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Vaccination
Q19. (FLUSHOT7)
During the past 12 months, have you had either a flu vaccine that was sprayed in your nose or a flu shot injected into your arm?
IF PIN NOT FROM CATI: A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.
IF PIN FROM CATI:
[IF NEEDED: A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.]
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
7 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
6 REFUSED]
Q20 [MTDAP.01] (TETANUS3)
Have you received a tetanus shot in the past 10 years?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
4 [IF PIN FROM CATI: NO; ELSE: No]
7 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
6 REFUSED]
[IF TETANUS3=YES, GO TO TETANUS3_FU. ELSE GO TO SHINGLE2]
Q20A [MTDAP.01] (TETANUS3_FU).
Was this Tdap, the tetanus shot that also has pertussis or whooping cough vaccine?
[IF PIN NOT FROM CATI:
1 Yes, it was Tdap
2 No, it was not Tdap
7 Don’t know / Not sure]
[IF PIN FROM CATI:
1 Yes, it was Tdap
2 No, it was not Tdap
7 Don’t know / Not sure
6 REFUSED]
[IF AGE>=50, GO TO SHINGLE2. ELSE GO TO DISABILITY]
Q21. [MSHNG.01] (SHINGLE2)
Have you ever had the shingles or zoster vaccine?
IF PIN NOT FROM CATI: 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.
IF PIN FROM CATI:
[IF NEEDED: ] 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.
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
7 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
6 REFUSED]
Disability
Q22A. [CDIS.01] (DEAF)
Some people who are deaf or have serious difficulty hearing use assistive devices to communicate by phone. Are you deaf or do you have serious difficulty hearing?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Q23A. [CDIS.02] (BLIND)
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Q24A. [CDIS.03] (DECIDE)
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Q25A. [CDIS.04] (DIFFWALK)
Do you have serious difficulty walking or climbing stairs?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Q26A. [CDIS.05] (DIFFDRES)
Do you have difficulty dressing or bathing?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Q27A. [CDIS.06] (DIFFALON)
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Inadequate Sleep
Q31A. (SLEPTIM1)
Next are some questions about your life and your lifestyle.
On average, how many hours of sleep do you get in a 24-hour period?
_ _ NUMBER OF HOURS [RANGE: 0-24]
[IF PIN IS FROM CATI:
77 DON’T KNOW
66 REFUSED]
Programming and Edit Checks
For Question 31A, if R has entered a number greater than 24 and clicks a navigation button, show message:
Please enter a number between 0 and 24.
Q31B.[MSDHE.02] (SUPPORT)
How often do you get the social and emotional support you need?
[IF PIN FROM CATI: Is that…]
1 Always [IF PIN FROM CATI:,]
2 Usually [IF PIN FROM CATI:,]
3 Sometimes [IF PIN FROM CATI:,]
4 Rarely [IF PIN FROM CATI: , or]
5 Never [IF PIN FROM CATI:?]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
EXERCISE
Q31C.[CEX.01] (EXERANY2)
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?
[IF PIN NOT FROM CATI: If you do not have a regular job or are retired, you may count any physical activity or exercise you do.]
[IF PIN FROM CATI: If you do not have a regular job or are retired, you may count any physical activity or exercise you do.]
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
Alcohol Use
Q31D.[CALC.01] (ALCDAY6)
During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage?
[IF PIN FROM CATI: Would you say you had at least one alcoholic beverage on….]
[IF PIN NOT FROM CATI: A 40-ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.]
[IF PIN FROM CATI:
[IF NEEDED: A 40-ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.]
[IF PIN NOT FROM CATI:
1 One or more days per week
2 Less than one day per week but at least one day in the past 30 days
888 No drinks in past 30 days
777 Don’t know / Not sure]
[IF PIN IS FROM CATI:
1 One or more days per week,
2 Less than one day per week but at least one day in the past 30 days, or
888 You had no drinks in the past 30 days?
777 Don’t know / Not sure
666 REFUSED]
Programming and Edit Checks
For Question 31D, if R has entered 888 (No drinks in the past 30 days), 666 (REFUSED), OR leaves Q31D blank, R should go to Q31G. (SMOKDAY2)
Q31E and Q31F will be shown only when ALCDAY6 = 1 or ALCDAY6= 2 or ALCDAY6 = 777
[SHOW IF ALCDAY6=1]
Q31D2. (ALCDAY6_wk)
During the past 30 days, how many days per week did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?
_ NUMBER OF DAYS PER WEEK [RANGE: 1-7]
77 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
66 REFUSED]
Programming and Edit Checks
For Question 31D (ALCDAYS6_wk), if R has entered a number greater than 7 and clicks a navigation button, show message:
Please enter a number between 1 and 7.
[SHOW IF ALCDAY6=2]
Q31D3. (ALCDAY6_mth)
During the past 30 days, on how many days did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?
_ _ NUMBER OF DAYS IN PAST 30 DAYS [RANGE: 1-30]
888 [IF PIN FROM CATI: NO DRINKS IN PAST 30 DAYS; ELSE: No drinks in past 30 days ]
777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
666 REFUSED]
Programming and Edit Checks
For Question 31D2 (ALCDAY6_wk), if R has entered a number greater than 30 and clicks a navigation button, show message:
Please enter a number between 1 and 30.
Q31E.[CALC.03] (DRNK3GE5)
Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [X = 5 for men, X = 4 for women] or more drinks on an occasion?
_ _ NUMBER OF TIMES [RANGE: 0-9999]
77777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
666666 REFUSED]
Programming and Edit Checks
For Question 31E, if R has entered a number greater than 9999 and clicks a navigation button, show message:
Please enter a number between 0 and 9999.
Q31F. [CALC.04] (MAXDRNKS)
During the past 30 days, what is the largest number of drinks you had on any occasion?
_ _ _NUMBER OF DRINKS [RANGE: 0-999]
7777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
666 REFUSED]
Programming and Edit Checks
For Question 31F, if R has entered a number greater than 999 and clicks a navigation button, show message:
Please enter a number between 0 and 999.
Tobacco Use
Q31G. [CTOB.02] (SMOKDAY2)
Do you now smoke cigarettes every day, some days, or not at all?
[IF PIN NOT FROM CATI:
1 Every day
2 Some days
3 Not at all ]
[IF PIN IS FROM CATI:
1 Every day
2 Some days
3 Not at all
7 DON’T KNOW
6 REFUSED]
Q31H.[CTOB.04] (ECIGNOW)
Would you say you have never used e-cigarettes or other electronic vaping products in your entire life or now use them every day, use them some days, or used them in the past but do not currently use them at all?
[IF PIN NOT FROM CATI: Electronic cigarettes (e-cigarettes) and other electronic vaping products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy. Brands you may have heard of are JUUL, NJOY, or blu.]
IF PIN FROM CATI:
[IF NEEDED: Electronic cigarettes or e-cigarettes and other electronic vaping products include electronic hookahs or e-hookahs, vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy. Brands you may have heard of are JUUL, NJOY, or blu.]
[IF PIN NOT FROM CATI:
1 Never used e-cigarettes in my entire life
2 Use them every day
3 Use them some days
4 Used them in the past but do not currently use them at all]
[IF PIN IS FROM CATI:
1 Never used e-cigarettes in my entire life
2 Use them every day
3 Use them some days
4 Used them in the past but do not currently use them at all
7 DON’T KNOW
6 REFUSED]
Q31I [CHIV.01] (HIVTST7)
Including fluid testing from your mouth, but not including tests you may have had for blood donation, have you ever been tested for H.I.V.?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
7 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
6 REFUSED]
Marijuana Use
Q31J.[MMU.01] (MARIJAN1)
During the past 30 days, on how many days did you use marijuana or cannabis? Do not include hemp-based CBD-only products.
_ _ NUMBER OF DAYS [RANGE: 0-30]
777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
666 REFUSED]
Programming and Edit Checks
For Question Q31J, if R has entered a number greater than 30 and clicks a navigation button, show message:
Please enter a number between 0 and 30.
IF Q31J (MARIJAN1)=0 or Don't know/ Not sure, Q31K (MARIJAN2) and Q31L (MARIJAN3) should be skipped
[ASK IF MARIJAN1 >0 AND MARIJAN1<=30]
Q31K[MMU.07] (MARIJAN2)
During the past 30 days, which one of the following ways did you use marijuana the most often? Did you usually…?
[IF PIN NOT FROM CATI: Do not include hemp-based CBD-only products.]
[IF PIN FROM CATI:
[IF NEEDED: Do not include hemp-based CBD-only products.]]
[IF PIN FROM CATI:
1 Smoke it, for example, in a joint, bong, pipe, or blunt,
2 Eat it or drink it, for example, in brownies, cakes, cookies, or candy, or in tea, cola, or alcohol,
3 Vaporize it, for example, in an e-cigarette-like vaporizer or another vaporizing device,
4 Dab it, for example, using a dabbing rig, knife, or dab pen, or
6 Did you use it some other way?
77 DON’T KNOW
66 REFUSED]
[IF PIN NOT FROM CATI:
1 Smoke it (for example, in a joint, bong, pipe, or blunt)
2 Eat it or drink it (for example, in brownies, cakes, cookies, or candy or in tea, cola or alcohol)
3 Vaporize it (for example, in an e-cigarette-like vaporizer or another vaporizing device)
4 Dab it (for example, using a dabbing rig, knife, or dab pen)
5 Use it some other way
77 DON’T KNOW
66 REFUSED]
[ASK IF MARIJAN1 >0 AND MARIJAN1<=30]
Q31L (MARIJAN3)
When you used marijuana or cannabis during the past 30 days, was it usually…?
[IF PIN NOT FROM CATI:
1 For medical reasons
2 For non-medical reasons
3 For both medical and non-medical reasons
[IF PIN IS FROM CATI:
1 For medical reasons,
2 For non-medical reasons, or
3 For both medical and non-medical reasons?
7 DON’T KNOW
6 REFUSED]
Q32 (PREPARE1)
Next are some questions about how prepared your household is for a disaster or emergency.
How well prepared do you feel your household is to handle a large-scale disaster or emergency? Would you say…
[IF PIN NOT FROM CATI:
1 Well prepared
2 Somewhat prepared
3 Not prepared at all]
[IF PIN IS FROM CATI:
1 Well prepared,
2 Somewhat prepared, or
3 Not prepared at all?
7 DON’T KNOW
6 REFUSED]
Q33 (PREPARE2)
Does your household have a 3-day supply of water for everyone who lives there?
[IF PIN FROM CATI: A 3-day supply of water is 1 gallon of water per person per day.]
[IF PIN NOT FROM CATI: A 3-day supply of water is 1 gallon of water per person per day.]
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
7 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
6 REFUSED]
Q34 (PREPARE3)
Does your household have a 3-day supply of prescription medication for each person who takes prescribed medicines?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
7 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
6 REFUSED]
Fruits and Vegetables
Q35. (FRUIT3)
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?
[IF PIN NOT FROM CATI: Include fresh, frozen or canned fruit.
Do not include dried fruits.]
[IF PIN FROM CATI: Include fresh, frozen or canned fruit. But do not include dried fruits. Would you say…?]
[IF PIN NOT FROM CATI:
1 Every day
2 More than once per week but not every day
3 Less than once per week but at least once per month
4 Less than once per month
5 Never
7 Don’t know / Not sure
]
[IF PIN IS FROM CATI:
1 Every day,
2 More than once per week but not every day,
3 Less than once per week but at least once per month,
4 Less than once per month, or
5 Never
7 Don’t know / Not sure
6 REFUSED]
[ASK IF FRUIT3=1]
Q35a. (FRUIT3_pD)
Not including juices, how many times per day did you usually eat fruit?
[IF PIN NOT FROM CATI: Include fresh, frozen or canned fruit.
Do not include dried fruits.
Think about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
[IF PIN FROM CATI:
[IF NEEDED: Include fresh, frozen or canned fruit. Do not include dried fruits.]
[IF NEEDED: Thinking about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
_ _ TIMES PER DAY [RANGE: 1-99]
777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
666 REFUSED]
Programming and Edit Checks
For Question 35a, if R has entered a number greater than 99 and clicks a navigation button, show message:
Please enter a number between 1 and 99.
[ASK IF FRUIT3=2]
Q35b. (FRUIT3_pW)
Not including juices, how many times per week did you usually eat fruit?
[IF PIN NOT FROM CATI: Include fresh, frozen or canned fruit.
Do not include dried fruits.
Think about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
[IF PIN FROM CATI:
[IF NEEDED: Include fresh, frozen or canned fruit. Do not include dried fruits.]
[IF NEEDED: Thinking about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
__ TIMES PER WEEK [RANGE: 1-99]
77 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
66 REFUSED]
Programming and Edit Checks
For Question 35b, if R has entered a number greater than 99 and clicks a navigation button, show message:
Please enter a number between 1 and 99.
[ASK IF FRUIT3=3]
Q35c. (FRUIT3_pM)
Not including juices, how many times in the past 30 days did you eat fruit?
[IF PIN NOT FROM CATI: Include fresh, frozen or canned fruit.
Do not include dried fruits.
Think about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
[IF PIN FROM CATI:
[IF NEEDED:] Include fresh, frozen or canned fruit. Do not include dried fruits.
[IF NEEDED:] Thinking about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
_ _ _ TIMES IN THE PAST 30 DAYS [RANGE: 1-999]
777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
666 REFUSED]
Programming and Edit Checks
For Question 35c, if R has entered a number greater than 999 and clicks a navigation button, show message:
Please enter a number between 1 and 99.
Q37 (FVGREEN2)
How often did you eat a green leafy or lettuce salad, with or without other vegetables?
[IF PIN NOT FROM CATI: Think about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
[IF PIN FROM CATI: Would you say…?
[IF NEEDED: Thinking about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
[IF PIN NOT FROM CATI:
1 Every day
2 More than once per week but not every day
3 Less than once per week but at least once per month
4 Less than once per month
5 Never
7 Don’t know / Not sure
]
[IF PIN IS FROM CATI:
1 Every day,
2 More than once per week but not every day,
3 Less than once per week but at least once per month,
4 Less than once per month, or
5 Never
7 Don’t know / Not sure
6 REFUSED]
[ASK IF FVGREEN2=1]
Q37a. (FVGREEN2_pD)
How many times per day did you usually eat a green leafy or lettuce salad, with or without other vegetables?
[IF PIN NOT FROM CATI: Think about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
[IF PIN FROM CATI:
[IF NEEDED: Thinking about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
_ _ TIMES PER DAY [RANGE: 1-99]
777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
666 REFUSED]
Programming and Edit Checks
For Question 37a, if R has entered a number greater than 99 and clicks a navigation button, show message:
Please enter a number between 1 and 99.
[ASK IF FVGREEN2=2]
Q37b. (FVGREEN2_pW)
How many times per week did you usually eat a green leafy or lettuce salad, with or without other vegetables?
[IF PIN NOT FROM CATI: Think about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
[IF PIN FROM CATI:
[IF NEEDED: Thinking about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
_ _ TIMES PER WEEK [RANGE: 1-99]
777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
666 REFUSED]
Programming and Edit Checks
For Question 37b, if R has entered a number greater than 99 and clicks a navigation button, show message:
Please enter a number between 1 and 99.
[ASK IF FVGREEN2=3]
Q37c. (FVGREEN2_pM)
How many times in the past 30 days did you eat a green leafy or lettuce salad, with or without other vegetables?
[IF PIN NOT FROM CATI: Think about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
[IF PIN FROM CATI:
[IF NEEDED: Thinking about the foods you ate or drank during the past month, that is, in the past 30 days, including meals and snacks.]
_ _ _ TIMES IN THE PAST 30 DAYS [RANGE: 1-999]
7777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
666 REFUSED]
Programming and Edit Checks
For Question 37c, if R has entered a number greater than 999 and clicks a navigation button, show message:
Please enter a number between 1 and 999.
Demographics
D1. [CDEM.06] (RENTHOM)
(Demo intro) Lastly, some questions about yourself. We include these questions so that we can compare health indicators by groups.
Do you own or rent your home?
1 [IF PIN NOT FROM CATI: Own; ELSE: OWN]
2 [IF PIN NOT FROM CATI: Rent; ELSE: RENT]
3 [IF PIN NOT FROM CATI: Other arrangement; ELSE: OTHER ARRANGEMENT]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
[IF LANDLINE FRAME AND (LL04_WEB=NO OR LL04=NO), ASKD1A. ELSE GO TO D1B]
D1A. In what state do you currently live?
1. Alabama
[DISPLAY REMAINING STATES IN ALPHABETICAL ORDER]
56. Wyoming
66. Guam GO TO D2A
72. Puerto Rico GO TO D2A
78. Virgin Islands GO TO D2A
77. Live outside US and participating territories GO TO D2A
D1a2 [CDEM.07] In what county do you currently live?
_ _ _ANSI County Code
[IF PIN FROM CATI:
777 DON’T KNOW/NOT SURE
999 REFUSED
]
D1A3. [CDEM.08]. What is the ZIP Code where you currently live?
_ _ _ _ _
[IF PIN FROM CATI:
77777 DOT NOT KNOW
99999 REFUSED
]
[IF LANDLINE FRAME, ASK D1A4 TO D1A5. ELSE GO TO D1A6]
D1A4. [CDEM.09] Not including cell phones or numbers used for computers, fax machines or security systems, do you have more than one landline telephone number in your household?
[IF PIN NOT FROM CATI:
1 Yes
2 No
]
[IF PIN FROM CATI:
1 YES
2 NO
7 DON’T KNOW
9 REFUSED]
[IF D1A4=YES, ASK D1A5. ELSE GO TO D1A6]
D1A5. [CDEM.10] How many of these landline telephone numbers are residential numbers?
__ Enter number (1-5)
6 Six or more
8 None
[IF PIN FROM CATI:
6 SIX OR MORE
8 NONE
7 DON’T KNOW
9 REFUSED]
D1A6. [CDEM.11] How many cell phones do you have for your personal use?
__ Enter number (1-5)
6 Six or more
8 None
[IF PIN FROM CATI:
6 SIX OR MORE
8 NONE
7 DON’T KNOW
9 REFUSED]
D2A.[CDEM.14] (CHILDREN)
How many children less than 18 years of age live in your household?
_ _ NUMBER OF CHILDREN [RANGE: 0-20]
[IF PIN IS FROM CATI:
77 DON’T KNOW
66 REFUSED]
Programming and Edit Checks
For Question D2A, if R has entered a number greater than 20 and clicks a navigation button, show message:
Please enter a number between 0 and 20.
D4[CDEM.02] (HISPANC3)
Are you Hispanic, Latino/a, or of Spanish origin?
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
5 [IF PIN FROM CATI, SHOW: NO; ELSE, SHOW: No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
D5[CDEM.03] (MRACE1)
[IF PIN NOT FROM CATI: Which one or more of the following would you say is your race? ]
[IF PIN FROM CATI: Would you say you are…?]
Check all that apply.
10 White [IF PIN FROM CATI, SHOW: ,]
20 Black or African American [IF PIN FROM CATI, SHOW: ,]
30 American Indian or Alaska Native [IF PIN FROM CATI, SHOW: ,]
40 Asian [IF PIN FROM CATI, SHOW: ,]
50 Pacific Islander [IF PIN IS FROM CATI, SHOW: , or]
60 [IF PIN NOT FROM CATI: OTHER; ELSE Something else?]
[IF PIN IS FROM CATI:
77 DON’T KNOW
66 REFUSED]
Programming Notes for Page
This is a click all that apply question: Use check boxes for these 6 options.
There are many possible combinations of responses. After R makes choices, automatically route as follows:
If R selects only one of the first three choices (White, Black or African American, or American Indian or Alaska Native), and none of the other choices, then next show Question D6
If R selects two or three of the first three choices (White, Black or African American, or American Indian or Alaska Native), and none of the other choices, then next show Question D6
If R selects Asian only: then next show Question D5a followed by Question D6
If R selects Asian – with one or more of the other choices listed: next show Question D5a followed by Question D6
If R selects Pacific Islander only: next show Question D5b followed by Question D6
If R selects Pacific Islander – with one or more of the other choices listed: next show Question D5b followed by D6
If R selects both Asian and Pacific Islander (these two only, or in combination with any choices above them), next show Question D5a, then show Question D5b, and then show Question D6
[IF MRACE1=ASIAN, ASK ASIAN_A]
D5a (ASIAN_A).
Are you…?
41 Asian Indian [IF PIN FROM CATI, SHOW: ,]
42 Chinese [IF PIN FROM CATI, SHOW: ,]
43 Filipino [IF PIN FROM CATI, SHOW: ,]
44 Japanese [IF PIN FROM CATI, SHOW: ,]
45 Korean [IF PIN FROM CATI, SHOW: ,]
46 Vietnamese [IF PIN IS FROM CATI: , or]
47 [IF PIN NOT FROM CATI: Other Asian; ELSE Some other Asian?]
[IF PIN IS FROM CATI:
77 DON’T KNOW
66 REFUSED]
[IF MRACE1=PACIFIC ISLANDER, ASK PI_A]
D5b. (PI_A)
Are you…?
51 Native Hawaiian [IF PIN FROM CATI, SHOW: ,]
52 Guamanian or Chamorro [IF PIN FROM CATI, SHOW: ,]
53 Samoan [IF PIN IS FROM CATI, SHOW: , or]
54 [IF PIN NOT FROM CATI: Other Pacific Islander; ELSE Some other Pacific Islander?]
[IF PIN IS FROM CATI:
77 DON’T KNOW
66 REFUSED]
D6[CDEM.04] (MARITAL)
Are you…?
1 Married [IF PIN FROM CATI, SHOW: ,]
2 Divorced [IF PIN FROM CATI, SHOW: ,]
3 Widowed [IF PIN FROM CATI, SHOW: ,]
4 Separated [IF PIN FROM CATI, SHOW: ,]
5 Never married [IF PIN IS FROM CATI, SHOW: , or]
6 A member of an unmarried couple [IF PIN FROM CATI: ?]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
D7[CDEM.05] (EDUCA)
What is the highest grade or year of school you completed?
[IF PIN NOT FROM CATI:
1 Never attended school or only attended kindergarten
2 Grades 1 through 8 (Elementary)
3 Grades 9 through 11 (Some high school)
4 Grade 12 or GED (High school graduate)
5 College 1 year to 3 years (Some college or technical school)
6 College 4 years or more (College graduate or advanced degree)
[IF PIN IS FROM CATI:
1 Never attended school or only attended kindergarten,
2 Grades 1 through 8 (ELEMENTARY),
3 Grades 9 through 11 (SOME HIGH SCHOOL),
4 Grade 12 or GED (HIGH SCHOOL GRADUATE),
5 College 1 year to 3 years (SOME COLLEGE OR TECHNICAL SCHOL), or
6 College 4 years or more (COLLEGE GRADUATE OR ADVANCED DEGREE)?
77 DON’T KNOW
66 REFUSED]
D8.[CDEM.12] (VETERAN3)
Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?
[IF PIN IS NOT FROM CATI, THEN SHOW: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.]
[IF PIN IS FROM CATI, THEN SHOW: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.]
[IF PIN FROM CATI, SHOW: 1 YES; ELSE, SHOW: 1 Yes]
[IF PIN FROM CATI, SHOW: 2 NO; ELSE, SHOW: 2 No]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
D9.[CDEM.13] (EMPLOY1)
Are you currently…?
1 Employed for wages [IF PIN FROM CATI, SHOW: ,]
2 Self-employed [IF PIN FROM CATI, SHOW: ,]
3 Out of work for 1 year or more [IF PIN FROM CATI, SHOW: ,]
4 Out of work for less than 1 year [IF PIN FROM CATI, SHOW: ,]
5 A Homemaker [IF PIN FROM CATI, SHOW: ,]
6 A Student [IF PIN FROM CATI, SHOW: ,]
7 Retired [IF PIN IS FROM CATI, THEN SHOW: , or]
8 Unable to work [IF PIN FROM CATI: ?]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
D10.[CDEM.15] (HHINCOME)
Is your annual household income from all sources—?
01 Less than $10,000 [IF PIN FROM CATI, SHOW: ,]
02 At least $10,000 but less than $15,000 [IF PIN FROM CATI, SHOW: ,]
03 At least $15,000 but less than $20,000 [IF PIN FROM CATI, SHOW: ,]
04 At least $20,000 but less than $25,000 [IF PIN FROM CATI, SHOW: ,]
05 At least $25,000 but less than $35,000 [IF PIN FROM CATI, SHOW: ,]
06 At least $35,000 but less than $50,000 [IF PIN FROM CATI, SHOW: ,]
07 At least $50,000 but less than $75,000 [IF PIN FROM CATI, SHOW: ,]
08 At least $75,000 but less than $100,000 [IF PIN FROM CATI, SHOW: ,]
09 At least $100,000 but less than $150,000 [IF PIN FROM CATI, SHOW: ,]
10 At least $150,000 but less than $200,000 [IF PIN FROM CATI: , or]
11 $200,000 or more [IF PIN FROM CATI, SHOW: ?]
[IF PIN IS FROM CATI:
77 DON’T KNOW
66 REFUSED]
D11.[CDEM.17] (WEIGHT2)
About how much do you weigh without shoes? [RANGE: 5-999]
_ _ _ _ POUNDS
7777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
6666 [IF PIN IS NOT FRAM CATI, SHOW: I prefer to report in kilograms; ELSE SHOW: REFUSED, PREFER TO REPORT IN KILOGRAMS]
[IF WEIGHT2=6666, ASK WEIGHT3_KG]
D11a. (WEIGHT3_KG)
About how much do you weigh without shoes, in kilograms?
_ _ _ KILOGRAMS [RANGE: 2-999]
7777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
6666 REFUSED]
D12.[CDEM.18] (HEIGHT3)
About how tall are you without shoes?
_ _ FEET _ _ INCHES [RANGE FOR FEET: 1-8] [RANGE FOR INCHES: 0-12]
77/ 77 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
66/66 [IF PIN IS NOT FRAM CATI, SHOW: I prefer to report in meters; ELSE, SHOW: REFUSED, PREFER TO REPORT IN METERS]
67/67 [IF PIN IS NOT FRAM CATI, SHOW: I prefer to report in centimeters; ELSE, SHOW: REFUSED, PREFER TO REPORT IN CENTIMETERS]
[IF HEIGHT3=66/66, ASK HEIGHT3_M]
D12a. (HEIGHT3_M)
About how tall are you without shoes, in meters?
_ _ METERS [RANGE: 0.3-3.0]
777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
666 REFUSED]
[IF HEIGHT3=67/67, ASK HEIGHT3_CM]
D12b. (HEIGHT3_CM)
About how tall are you without shoes, in centimeters?
_ _ _ _ CENTIMETERS [RANGE: 30-300]
7777 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
6666 REFUSED]
Sexual Orientation and Gender Identity
[IF SEX=MALE, GO TO SOMALE. ELSE GO TO SOFEMALE]
D13A.[ MSOGI.01] (SOMALE)
The next two questions are about sexual orientation and gender identity.
Which of the following best represents how you think of yourself?
[IF PIN IS NOT FROM CATI: This question is asked to better understand the health and health care needs of people with different sexual orientations.]
[IF PIN FROM CATI:
[IF NEEDED: This question is asked to better understand the health and health care needs of people with different sexual orientations]
1 Gay [IF PIN FROM CATI: , ]
2 Straight, that is, not gay [IF PIN FROM CATI: , ]
3 Bisexual [IF PIN FROM CATI: , or]
4 Something else [IF PIN FROM CATI: ? ]
7 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
6 REFUSED]
[IF SEX=MALE, GO TO SOMALE. ELSE GO TO SOFEMALE]
D13B.[ MSOGI.02] (SOFEMALE)
Which of the following best represents how you think of yourself?
[IF PIN IS NOT FROM CATI: This question is asked to better understand the health and health care needs of people with different sexual orientations.]
[IF PIN IS FROM CATI:
[IF NEEDED: This question is asked to better understand the health and health care needs of people with different sexual orientations.]
1 Lesbian or Gay [IF PIN FROM CATI: , ]
2 Straight, that is, not gay [IF PIN FROM CATI: , ]
3 Bisexual [IF PIN FROM CATI: , or]
4 Something else [IF PIN FROM CATI: ? ]
7 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
6 REFUSED]
D14.[MSOGI.03] (TRNSGNDR)
Do you consider yourself to be transgender?
[IF PIN IS NOT FROM CATI, SHOW: 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 PIN IS FROM CATI, SHOW:
[IF NEEDED:
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.]
1 [IF PIN FROM CATI, SHOW: YES; ELSE, SHOW: Yes]
2 [IF PIN FROM CATI, SHOW: NO; ELSE, SHOW: No]
7 [IF PIN FROM CATI, SHOW: DON’T KNOW/NOT SURE; ELSE, SHOW: Don’t know / Not sure]
[IF PIN IS FROM CATI:
6 REFUSED]
[IF TRNSGNDR=YES, ASK TRNSGNDR_FU]
D14A (TRNSGNDR_FU).
[IF PIN IS NOT FROM CATI, SHOW: Do you consider yourself to be…?
Some people think of themselves as gender non-conforming when they do not identify only as a man or only as a woman.
[IF PIN IS FROM CATI, SHOW:
Some people think of themselves as gender non-conforming when they do not identify only as a man or only as a woman. Do you consider yourself to be…]
1 Male-to-female [IF PIN FROM CATI: , ]
2 Female-to-male [IF PIN FROM CATI: , or]
3 Gender non-conforming [IF PIN FROM CATI:?]
[IF PIN IS FROM CATI:
7 DON’T KNOW
6 REFUSED]
(INCENTIVE1).
Thank you for completing the survey. Your answers will be combined with those from others to help us provide information about the health practices of people in your state.
[IF PIN NOT FROM CATI, SHOW: Select SUBMIT below to see instructions on how to get your incentive. ]
(INCENTIVE 2).
As a token of our appreciation, we will send you an Amazon gift code worth $10 to your email.
[IF PIN IS NOT FROM CATI, SHOW: please provide your e-mail address here; ELSE SHOW: May I have your email address? ]
________________________________________
[IF PIN IS NOT FROM CATI, SHOW: For confirmation, please re-enter your e-mail address below; ELSE SHOW: May I have that email address a second time to be sure I’ve recorded it correctly? ]
________________________________________
PROGRAMMER NOTE:
-IN PIN FROM CATI:
EMAIL ADDRESS FIELD IS NOT REQUIRED.
(END).
[IF PIN NOT FROM CATI: That completes the interview. Thank you very much for your time and cooperation. Now you may close your browser.]
[IF PIN FROM CATI:
-IF NO EMAIL IS PROVIDED:
Okay. If you would like to receive the incentive for your participation today, please call us at 1-855-928-0777 and a study team member will be happy to assist you.
-IF EMAIL IS PROVIDED: That completes the interview. Thank you very much for your time and cooperation.]
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Dawn Nelson |
| File Modified | 0000-00-00 |
| File Created | 2024-12-05 |
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