Form 0920-0222-23EC RANDS 8 Questionnaire

[NCHS] Collaborating Center for Questionnaire Design and Evaluation Research

Attachment 1 -RANDS 8 Questionnaire

[NCHS] Collaborating Center For Questionnaire Design and Evaluation Research

OMB: 0920-0222

Document [docx]
Download: docx | pdf

Attachment 1: Cognitive Interviewing and RANDS Questionnaire Including Intro Screen/Script

Form Approved

OMB No. 0920-0222

Exp. Date: 01/31/2026


Notice - CDC estimates the average public reporting burden for this collection of information as 60 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0222).


Assurance of Confidentiality: We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2018 (CIPSEA Pub. L. No. 115-435, 132 Stat. 5529 § 302).  In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.  In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.


Proposed Web Questionnaire Introduction Screen 

 

  The National Center for Health Statistics, part of the Centers for Disease Control and Prevention, is conducting a study and we need your help.  We are interested in your health and wellness, and will be asking you a series of questions about your health history, behaviors, and opinions.  This should take about 20 minutes or less to complete.  Participation in this survey is completely voluntary, and you may skip any question(s) you do not want to answer and may quit the survey at any time.  You will not receive any monetary reward or incentive for participating in this survey.  The information being collected is for research purposes only, and will assist NCHS and CDC in their ongoing efforts to track the health of the American public.  Your data will be held confidential, will be used for statistical purposes only, and will not be disclosed or released to other persons without your consent in accordance with Section 308(d) of the Public Health Service Act [42 U.S.C. 242m(d)] and the Confidential Information and Statistical Efficiency Act (Title III of the Foundations for Evidence-Based Policymaking Act of 2018, Pub. L. No. 115-435, 132 Stat. 5529, § 302).   

 

If you have any questions about this study, please call the office of the Ethics Review Board at the National Center for Health Statistics, toll-free at 1-800-223-8118.  Please leave a brief message with your name and phone number.  Say that you are calling about Protocol #2016-16-XX [Note:  The amendment number will be inserted into the form once NCHS ERB approval has been received]. Your call will be returned as soon as possible. 

 

Click the “Next” button below to begin. 


Proposed Phone Interview Introduction


Introduction and verification of respondent’s name. 

 

Explain why calling 

  • We are asking for your help as we construct a health survey on behalf of the National Center for Health Statistics, part of the Centers for Disease Control and Prevention.  

  • Phone call takes on average 20 minutes to complete. 

 

Share confidentiality, informed consent, and voluntary participation information 

  • All information which would permit identification of an individual, a practice, or an establishment will be held confidential, and will be used for statistical purposes only by NCHS staff and agents and will not be disclosed or released to other persons without your consent.  If you have any questions about your rights as a participant in this research study, call NCHS’ Confidentiality Officer at (888) 642-1459.   

  • Participation is voluntary, but will assist greatly in helping further our nation’s understanding of health and how we ask the public about public health issues. 




SECTION: Chronic Conditions


[SP; PROMPT TWICE IF REFUSED]

[COPY FROM ATEST SID 2292]

PHSTAT. 

Would you say your <u>health in general</u> is excellent, very good, good, fair, or poor?


CAWI RESPONSE OPTIONS:

  1. Excellent

  2. Very good

  3. Good

  4. Fair

  5. Poor


CATI RESPONSE OPTIONS:

  1. EXCELLENT

  2. VERY GOOD

  3. GOOD

  4. FAIR

  5. POOR



[SP]

SOCERRNDS.

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping? [CATI: Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?]


RESPONSE OPTIONS:

  1. No difficulty

  2. Some difficulty

  3. A lot of difficulty

  4. Cannot do this at all



[SP]

SOCSCLPAR.

Because of a physical, mental, or emotional condition, do you have difficulty participating in social activities such as visiting friends, attending clubs and meetings, or going to parties? [CATI Read if necessary: Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?]


RESPONSE OPTIONS:

  1. No difficulty

  2. Some difficulty

  3. A lot of difficulty

  4. Cannot do this at all



[SP]

SOCWRKLIM.

Are you limited in the kind OR amount of work you can do because of a physical, mental, or emotional problem? [CATI Read if necessary: Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?]


RESPONSE OPTIONS:

  1. No difficulty

  2. Some difficulty

  3. A lot of difficulty

  4. Cannot do this at all


[SP]

[COPY FROM ADEV SID 1804]

USUALPL. 

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


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No, there is no place

  3. There is more than one place


CATI RESPONSE OPTIONS:

  1. YES

  2. NO, THERE IS NO PLACE

  3. THERE IS MORE THAN ONE PLACE



[COPY FROM ATEST SID 2765]

[GRID SP]

CHRONSERIES. 

[CAWI] The next few questions are about medical conditions you may have been told you had.

[SPACE]

Have you <u>ever</u> been told by a doctor or other health professional that you had…


[CATI] Now I’m going to ask you about certain medical conditions.

[SPACE]

Have you <u>ever</u> been told by a doctor or other health professional that you had…


[CATI] READ AS NECESSARY Have you ever been told by a doctor or other health professional that you had…


GRID ITEMS, RANDOMIZE:

HYPEV. Hypertension, also called high blood pressure?

CHLEV. High cholesterol?

CHDEV. Coronary heart disease?

ASEV. Asthma?

COPDEV. Chronic Obstructive Pulmonary Disease, C.O.P.D., emphysema, or chronic bronchitis?

CANEV. Cancer or a malignancy of any kind?

ARTHEV. Some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF HYPEV = 1]

[SP]

HYPDIF

Were you told on two or more DIFFERENT visits that you had hypertension or high blood pressure?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF HYPDIF = 1]

[SP]

HYP12M

During the past 12 months, have you had hypertension or high blood pressure?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF HYPEV = 1]

[SP]

HYPMED

Are you NOW taking any medication prescribed by a doctor for your high blood pressure?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF CHLEV = 1]

[SP]

CHL12M

During the past 12 months, have you had high cholesterol?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF CHLEV = 1]

[SP]

CHLMED

Are you NOW taking any medication prescribed by a doctor to help lower your cholesterol?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF ASEV = 1]

[SP]

ASTILL

Do you still have asthma?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF ASEV = 1]

[SP]

ASAT12M

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


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF ASEV = 1]

[SP]

ASER12M

During the past 12 months, have you had to visit an emergency room or urgent care center because of asthma?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[GRID SP]

PULMSERIES. 

[CAWI] The next few questions are about other medical conditions you may have been told you had.

[SPACE]

Have you <u>ever</u> been told by a doctor or other health professional that you had…


[CATI] Now I’m going to ask you about some other medical conditions.

[SPACE]

Have you <u>ever</u> been told by a doctor or other health professional that you had…


[CATI] READ AS NECESSARY Have you ever been told by a doctor or other health professional that you had…


GRID ITEMS, RANDOMIZE:

ANGEV. Angina, also called angina pectoris?

MIEV. A heart attack, also called myocardial infarction?

STREV. A stroke?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SP]

PREDIB. 

Has a doctor or other health professional <u>ever</u> told you that you had prediabetes or borderline diabetes?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF GENDER= 2]

[SP]

GESDIB

[SHOW IF (PREDIB= 1)] Has a doctor or other health professional <u>ever</u> told you that you had gestational diabetes, a type of diabetes that occurs <u> only</u> during pregnancy?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SP]

DIBEV. 

[SHOW IF (PREDIB= 1)] Not including prediabetes, has a doctor or other health professional <u>ever</u> told you that you had diabetes?


[SHOW IF (GESDIB= 1)] Not including gestational diabetes, has a doctor or other health professional <u>ever</u> told you that you had diabetes?


[SHOW IF (PREDIB= 1 & GESDIB= 1)] Not including prediabetes or gestational diabetes, has a doctor or other health professional <u>ever</u> told you that you had diabetes?


[SHOW IF (PREDIB=2,77,98,99)] Has a doctor or other health professional <u>ever</u> told you that you had diabetes?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO




SECTION: Health and Civic Behaviors



[SP]

SMKEV

Have you smoked at least 100 cigarettes in your entire life?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF SURV_MODE=1]

[SP]

ACCSSINT.

Do you have access to the Internet?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO


[SHOW IF ACCSSINT=1]

[SP]

ACCSSHOM.

Do you have access to the Internet from your home?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO


[SP]

HITLOOK.

During the past 12 months, have you used the Internet for any of the following reasons? To look for health or medical information.


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO


[SP]

HITCOMM.

During the past 12 months, have you used the Internet for any of the following reasons? To communicate with a doctor or doctor’s office.


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SP]

HITTEST.

During the past 12 months, have you used the Internet for any of the following reasons? To look up medical test results.


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SP]

[COPY FROM ADEV SID 1804]

EMPLASTWK. 

Last week, did you work for pay at a job or business?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SP]

CEVOLUN1.

During the past 12 months, did you spend any time volunteering for any organization or association?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF CEVOLUN1=2, 77, 98, 99]

[SP]

CEVOLUN2.

Some people don’t think of activities they do infrequently or for children’s schools or youth organizations as volunteer activities. During the past 12 months, have you done any of these types of activities?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SP]

CEMMETNG.

During the past 12 months, did you attend a public meeting, such as a zoning or school board meeting, that discussed a local issue?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SP]

CEVOTELC.

Did you vote in the LAST LOCAL elections, such as for mayor, councilmembers, or school board?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SP]

AFVET.

Did you ever serve on active duty in the U.S. Armed Forces, military Reserves, or National Guard?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



SECTION: Traumatic Brain Injury



[DISPLAY]

TBIINTRO.

The next questions are about head injuries that may have occurred in the past 12 months. Please think about all head injuries, for example, from playing sports, car accidents, falls, or being hit by something or someone that may have occurred in the past 12 months.



[SP]

TBILOCMEMDAZ.

During the past 12 months, as a result of a blow or jolt to the head, have you been knocked out or lost consciousness, been dazed or confused, or had a gap in your memory?

[SPACE]

[CAWI - REMOVE BOLD] <i> Please think about all head injuries, for example, from playing sports, car accidents, falls, or being hit by something or someone that may have occurred in the past 12 months. </i>

[CATI] READ IF NEEDED: PLEASE THINK ABOUT ALL HEAD INJURIES, FOR EXAMPLE, FROM PLAYING SPORTS, CAR ACCIDENTS, FALLS, OR BEING HIT BY SOMETHING OR SOMEONE THAT MAY HAVE OCCURRED IN THE PAST 12 MONTHS


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF TBILOCMEMDAZ= 2, 77, 98, 99]

[SP]

TBIHEADSYM.

During the past 12 months, as a result of a blow or jolt to the head, have you had headaches, sensitivity to light or noise, balance problems, or changes in mood or behavior?

[SPACE]

[CAWI - REMOVE BOLD] <i> Please think about all head injuries, for example, from playing sports, car accidents, falls, or being hit by something or someone that may have occurred in the past 12 months. </i>

[CATI] READ IF NEEDED: PLEASE THINK ABOUT ALL HEAD INJURIES, FOR EXAMPLE, FROM PLAYING SPORTS, CAR ACCIDENTS, FALLS, OR BEING HIT BY SOMETHING OR SOMEONE THAT MAY HAVE OCCURRED IN THE PAST 12 MONTHS


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF TBILOCMEMDAZ= 1 or TBIHEADSYM= 1]

[SP]

TBISPORT.

Did you experience this blow or jolt to the head while playing a sport, or while engaged in physical fitness or a recreational activity for fun or competition?

[SPACE]

[CAWI - REMOVE BOLD] <i> Please think about all head injuries, for example, from playing sports, car accidents, falls, or being hit by something or someone that may have occurred in the past 12 months. </i>

[CATI] READ IF NEEDED: PLEASE THINK ABOUT ALL HEAD INJURIES, FOR EXAMPLE, FROM PLAYING SPORTS, CAR ACCIDENTS, FALLS, OR BEING HIT BY SOMETHING OR SOMEONE THAT MAY HAVE OCCURRED IN THE PAST 12 MONTHS


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF TBILOCMEMDAZ= 1 or TBIHEADSYM= 1]

[SP]

TBIMOI.

When you got your most recent head injury, which best describes how you got hurt? Please select one


CAWI RESPONSE OPTIONS:

  1. I fell and hit my head

  2. A car or motorcycle crash

  3. Bumped my head on something

  4. An object fell on me

  5. Bicycle crash

  6. I got hit in the head during a fight or an argument

  7. Collided with another person

  8. Felt dizzy or sick and fell, or passed out

  9. Other, please specify [TEXTBOX]


CATI RESPONSE OPTIONS:

  1. I FELL AND HIT MY HEAD

  2. A CAR OR MOTORCYCLE CRASH

  3. BUMPED MY HEAD ON SOMETHING

  4. AN OBJECT FELL ON ME

  5. BICYCLE CRASH

  6. I GOT HIT IN THE HEAD DURING A FIGHT OR AN ARGUMENT

  7. COLLIDED WITH ANOTHER PERSON

  8. FELT DIZZY OR SICK AND FELL, OR PASSED OUT

  9. OTHER, PLEASE SPECIFY [TEXTBOX]




[SHOW IF TBILOCMEMDAZ= 1 or TBIHEADSYM= 1]

[SP]

TBICHKCONC.

After this happened were you checked for a concussion or brain injury by a doctor, nurse, paramedic, athletic trainer, or other health care professional?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF TBICHKCONC = 1]

[SP]

TBIWHRCHK.

Where did the first evaluation by this health care professional take place?


CAWI RESPONSE OPTIONS:

  1. Your regular doctor or primary care physician’s office

  2. A hospital or emergency department

  3. An urgent care clinic

  4. On the sideline (for example, at a sporting event)

  5. Somewhere else, please specify [TEXTBOX]


CATI RESPONSE OPTIONS:

  1. YOUR REGULAR DOCTOR OR PRIMARY CARE PHYSICIAN’S OFFICE

  2. A HOSPITAL OR EMERGENCY DEPARTMENT

  3. AN URGENT CARE CLINIC

  4. ON THE SIDELINE, FOR EXAMPLE, AT A SPORTING EVENT

  5. SOMEWHERE ELSE, PLEASE SPECIFY [TEXTBOX]



[SHOW IF TBICHKCONC = 1]

[SP]

TBIDX.

Following this head injury, did a medical professional diagnose you with a concussion or traumatic brain injury?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No

  3. Don’t Know


CATI RESPONSE OPTIONS:

  1. YES

  2. NO

  3. DON’T KNOW



[SHOW IF TBILOCMEMDAZ= 1 or TBIHEADSYM= 1]

[SP]

WORKMISS.

Did you miss any work or school due to the head injury?


CAWI RESPONSE OPTIONS:

  1. Yes

  1. No

  2. Don’t Know


CATI RESPONSE OPTIONS:

  1. YES

  2. NO

  3. DON’T KNOW



[SHOW IF WORKMISS = 1]

[NUMBOX]

WORKMISSA.

How many days? It is okay to give your best guess.


<u>Number of days:</u>

[NUMBER BOX, RANGE 0-999, 7777, 9998, 9999]



[SHOW IF TBILOCMEMDAZ= 1 or TBIHEADSYM= 1]

[SP]

SYMSTILL.

Are you still experiencing any head injury-related symptoms?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No

  3. Don’t Know


CATI RESPONSE OPTIONS:

  1. YES

  2. NO

  3. DON’T KNOW



[SHOW IF SYMSTILL = 2]

[SP]

SYMRECA.

How long did it take for all of your head injury-related symptoms to go away?


CAWI RESPONSE OPTIONS:

  1. Less than 1 day

  2. 1 – 2 days

  3. 3 – 7 days

  4. More than 7 days


CATI RESPONSE OPTIONS:

  1. LESS THAN 1 DAY

  2. 1 – 2 DAYS

  3. 3 – 7 DAYS

  4. MORE THAN 7 DAYS



SECTION: Firearms Safety



[DISPLAY]

FIREARMSINTRO.

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.



[SP]

BRFSS_FA1.

Are any firearms now kept in or around your home?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF BRFSS_FA1 = 1]

[SP]

BRFSS_FA2.

Are any of these firearms now loaded?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF BRFSS_FA2 = 1]

[SP]

BRFSS_FA3.

Are any of these loaded firearms also unlocked?

[SPACE]

[CAWI - REMOVE BOLD] <i> 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.. </i>


[CATI] 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.


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



SECTION: COVID and Long COVID



[SP]

COVIDEV. 

Has a doctor or other health professional ever told you that you had or likely had Coronavirus or COVID-19?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF COVIDEV = 2, 77, 98, 99]

[SP]

NHIS_TEST. 

Have you ever been tested for Coronavirus or COVID-19?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF COVIDEV=1 OR NHIS_TEST=1]

[SP]

SYMPTOMS. 

How would you describe your coronavirus symptoms when they were at their worst?

[SPACE]

[CATI] WOULD YOU SAY NO SYMPTOMS, MILD SYMPTOMS, MODERATE SYMPTOMS, OR SEVERE SYMPTOMS?


CAWI RESPONSE OPTIONS:

  1. No symptoms

  2. Mild symptoms

  3. Moderate symptoms

  4. Severe symptoms


CATI RESPONSE OPTIONS:

  1. NO SYMPTOMS

  2. MILD SYMPTOMS

  3. MODERATE SYMPTOMS

  4. SEVERE SYMPTOMS



[SHOW IF P_LONGCOVID = 1 AND COVIDEV=1 OR NHIS_TEST=1]

[SP]

SYMP3MO.

Did you have any symptoms lasting 3 months or longer that you did not have prior to having coronavirus or COVID-19?

[SPACE]

Long term symptoms may include: Tiredness or fatigue, difficulty thinking, concentrating, forgetfulness, or memory problems (sometimes referred to as “brain fog”), difficulty breathing or shortness of breath, joint or muscle pain, fast-beating or pounding heart (also known as heart palpitations), chest pain, dizziness on standing, menstrual changes, changes to taste/smell, or inability to exercise.


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF SYMP3MO=1 OR ONS_LONG = 1]

[TEXTBOX]

PROBE_LONG

When answering the previous question, which symptoms were you specifically thinking about?


[LARGE TEXTBOX]



[SHOW IF P_LONGCOVID = 1 AND COVIDEV=1 OR NHIS_TEST=1]

[SP]

SYMPNOW

Do you have symptoms now?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF P_LONGCOVID = 2 AND COVIDEV=1 OR NHIS_TEST=1]

[SP]

ONS_LONG

Would you describe yourself as having “long COVID,” that is, you are still experiencing symptoms more than 3 months after you first had COVID-19, that are not explained by something else?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No

  3. Don’t Know


CATI RESPONSE OPTIONS:

  1. YES

  2. NO

  3. DON’T KNOW



[SHOW IF ONS_LONG=1]

[SP]

ONS_IMPACT

Does this reduce your ability to carry-out day-to-day activities compared with the time before you had COVID-19?


CAWI RESPONSE OPTIONS:

  1. Yes, a lot

  2. Yes, a little

  3. Not at all

  4. Don’t Know


CATI RESPONSE OPTIONS:

  1. YES, A LOT

  2. YES, A LITTLE

  3. NOT AT ALL

  4. DON’T KNOW



SECTION: Immunization



[DISPLAY]

FLUINTRO.

There are currently vaccines available for seasonal influenza and coronavirus or COVID-19. You will first be asked questions about seasonal flu vaccination and then about coronavirus or COVID-19 vaccination



[SP]

SHTFLU12M

There are two types of flu vaccinations. One is a shot and the other is a spray, mist, or drop in the nose. During the past 12 months, have you had a flu vaccination?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[NUMBOX]

SHTFLUM

During what month and year did you receive your most recent flu vaccine?


<u>MONTH:</u>

[NUMBER BOX, RANGE 1-12, 7777, 9998, 9999]


<u>YEAR:</u>

[NUMBER BOX, RANGE 1950-2022, 7777, 9998, 9999]




[SP]

SHTPNUEV

A pneumonia shot is also known as a pneumococcal vaccine. Have you EVER had a pneumonia shot?


[DISPLAY/READ IF NECESSARY]: There are two types of pneumonia shots: polysaccharide, also known as Pneumovax®, and conjugate, also known as Prevnar® or Vaxneuvance®. 



CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF SHTPNUEV =1]

[SP]

SHTPNEUNB

How many pneumonia shots have you ever had?


CAWI RESPONSE OPTIONS:

  1. One pneumonia shot

  2. Two pneumonia shots

  3. More than two pneumonia shots


CATI RESPONSE OPTIONS:

  1. ONE PNEUMONIA SHOT

  2. TWO PNEUMONIA SHOTS

  3. MORE THAN TWO PNEUMONIA SHOTS



[SP]

SHTCVD191

The next questions are about coronavirus or COVID-19 vaccination. Have you had at least one dose

of a COVID-19 vaccination?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SHOW IF SHTCVD191=1]

[SP]

SHTCVD19NM

How many COVID-19 vaccinations have you received?

[SPACE]

Count each individual dose you have received. For instance, a two-shot series of an mRNA vaccine like Pfizer or Moderna, would count as two vaccinations.


CAWI RESPONSE OPTIONS:

  1. 1 vaccination

  2. 2 vaccinations

  3. 3 vaccinations

  4. 4 or more vaccinations


CATI RESPONSE OPTIONS:

  1. 1 VACCINATION

  2. 2 VACCINATIONS

  3. 3 VACCINATIONS

  4. 4 OR MORE VACCINATIONS



VAX_HES. 

Overall, how hesitant about vaccines in general would you consider yourself to be?

[SPACE]

Please think about all vaccines, and not just the COVID-19 vaccines.


RESPONSE OPTIONS:

  1. Not at all hesitant

  2. Not that hesitant

  3. Somewhat hesitant

  4. Very hesitant



[SP]

VAX_SIDE. 

Have concerns about serious, long-term side effects impacted your decision to get vaccinated in the past?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SP]

VAX_KNOW. 

Do you personally know anyone who has had a serious, long-term side effect from a vaccine?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SP]

VAX_MD. 

Is your doctor or health provider your most trusted source of information about vaccines?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SP]

VAX_RISK. 

How confident are you that the benefits of vaccines outweigh their risks?


RESPONSE OPTIONS:

  1. Very confident

  2. Somewhat confident

  3. Not at all confident



[SP]

VAX_HERD. 

Do you believe that getting vaccinated helps protect others from getting disease?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[SP]

CVD19_HES. 

Thinking specifically about the COVID-19 vaccines, how hesitant would you consider yourself to be?


RESPONSE OPTIONS:

  1. Not at all hesitant

  2. Not that hesitant

  3. Somewhat hesitant

  4. Very hesitant

  1. Don’t know



[MP]

[RECORD TIME ON SCREEN]

PROBE_VAX. 

When answering the previous question about your hesitance towards the COVID-19 vaccines, which of the following, if any, were you thinking about?


[CAWI - REMOVE BOLD] <i>Select all that apply. </i>

[CATI] SELECT ALL THAT APPLY


RESPONSE OPTIONS, RANDOMIZE 1-9:

  1. Overall social benefit of vaccine

  2. Long-term health impacts

  3. Speed of development

  4. Government approval process

  5. Personal risk of getting vaccinated

  6. Risk of contracting COVID-19

  7. Information you received from a medical provider

  8. Information you received from friends or social media

  9. Previous experiences with vaccines

  10. Something else, please specify: [TEXTBOX]

 


SECTION: Affect



[COPY FROM ATEST SID 1804]

[SP]

[RECORD TIME ON SCREEN]

ANXFREQ.

How often do you feel worried, nervous or anxious? Would you say daily, weekly, monthly, a few times a year, or never?


CAWI RESPONSE OPTIONS:

  1. Daily

  2. Weekly

  3. Monthly

  4. A few times a year

  5. Never


CATI RESPONSE OPTIONS:

  1. DAILY

  2. WEEKLY

  3. MONTHLY

  4. A FEW TIMES A YEAR

  5. NEVER



[COPY FROM ATEST SID 1804]

[SP]

[RECORD TIME ON SCREEN]

ANXMED.

Do you take prescription medication for these feelings?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[COPY FROM ATEST SID 1804]

[SHOW IF (ANXFREQ=1,2,3,4,77,98,99) OR ((ANXFREQ=5) AND (ANXMED=1,77,98,99))]

[SP]

[RECORD TIME ON SCREEN]

ANXLEVEL.

Thinking about the last time you felt worried, nervous or anxious, how would you describe the level of these feelings?


[CATI] Would you say a little, a lot, or somewhere in between?


CAWI RESPONSE OPTIONS:

  1. A little

  2. A lot

  3. Somewhere in between a little and a lot


CATI RESPONSE OPTIONS:

  1. A LITTLE

  2. A LOT

  3. SOMEWHERE IN BETWEEN A LITTLE AND A LOT



[COPY FROM ATEST SID 1804]


CREATE DOV_ANX; DISPLAY FOR TESTING PURPOSES


If ANXFREQ == 4 or ANXFREQ==5, DOV_ANX=1;

If ANXFREQ==1, 2, or 3 AND ANXLEVEL==1, DOV_ANX=2;

If ANXFREQ==2, or 3 AND ANXLEVEL==3, DOV_ANX=2;

If ANXFREQ==3 AND ANXLEVEL==2, DOV_ANX=2

If ANXFREQ==1 AND ANXLEVEL==3, DOV_ANX=3

If ANXFREQ==2 AND ANXLEVEL==2, DOV_ANX=3;

If ANXFREQ==1 AND ANXLEVEL==2, DOV_ANX=4;

If ANXFREQ==77,98,99 OR ANXLEVEL==77,98,99, DOV_ANX=99



[SP]

ANXEV.

Have you ever been told by a doctor or other health professional that you had any type of anxiety disorder?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[COPY FROM ATEST SID 1804]

[SP]

[RECORD TIME ON SCREEN]

DEPFREQ.

How often do you feel depressed? Would you say daily, weekly, monthly, a few times a year, or never?


CAWI RESPONSE OPTIONS:

  1. Daily

  2. Weekly

  3. Monthly

  4. A few times a year

  5. Never


CATI RESPONSE OPTIONS:

  1. DAILY

  2. WEEKLY

  3. MONTHLY

  4. A FEW TIMES A YEAR

  5. NEVER



[COPY FROM ATEST SID 1804]

[SP]

[RECORD TIME ON SCREEN]

DEPMED.

Do you take prescription medication for depression?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[COPY FROM ATEST SID 1804]

[SHOW IF (DEPFREQ=1,2,3,4,77,98,99) OR ((DEPFREQ=5) AND (DEPMED=1,77,98,99))]

[SP]

[RECORD TIME ON SCREEN]

DEPLEVEL.

Thinking about the last time you felt depressed, how depressed did you feel?


[CATI] Would you say a little, a lot, or somewhere in between?


CAWI RESPONSE OPTIONS:

  1. A little

  2. A lot

  3. Somewhere in between a little and a lot


CATI RESPONSE OPTIONS:

  1. A LITTLE

  2. A LOT

  3. SOMEWHERE IN BETWEEN A LITTLE AND A LOT



[COPY FROM ATEST SID 1804]


CREATE DOV_DEP; DISPLAY FOR TESTING PURPOSES


If DEPFREQ == 4 or DEPFREQ ==5, DOV_ DEP=1;

If DEPFREQ==1, 2, or 3 AND DEPLEVEL==1, DOV_ DEP=2;

If DEPFREQ==2, or 3 AND DEPLEVEL==3, DOV_ DEP=2;

If DEPFREQ==3 AND DEPLEVEL==2, DOV_ DEP=2

If DEPFREQ==1 AND DEPLEVEL==3, DOV_ DEP=3

If DEPFREQ==2 AND DEPLEVEL==2, DOV_ DEP=3;

If DEPFREQ==1 AND DEPLEVEL==2, DOV_ DEP=4;

If DEPFREQ==77,98,99 OR DEPLEVEL==77,98,99, DOV_ DEP=99



[SP]

DEPEV.

Have you ever been told by a doctor or other health professional that you had any type of depression?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[COPY FROM ATEST SID 1804]

[SHOW IF DOV_ANX=2,3,4 OR ANXEV=1]

[MP]

PROBE_ANX. 

Which of the following statements, if any, describe your feelings of being nervous or anxious?

[SPACE]

CAWI: <i>Please select all that apply.</i>

CATI: SELECT ALL THAT APPLY


RESPONSE OPTIONS:

  1. Sometimes the feelings can be so intense that [CAWI: my; CATI: your] chest hurts and [CAWI: I; CATI: you] have trouble breathing.

  2. These are positive feelings that help [CAWI: me; CATI: you] to accomplish goals and be productive.

  3. The feelings sometimes interfere with [CAWI: my; CATI: your] life, and [CAWI: I; CATI: you] wish that [CAWI: I; CATI: you] did not have them.

  4. Feeling that way is normal, and everyone feels that way sometimes

  5. [CAWI: I; CATI: You] have been told by a medical professional that [CAWI: I; CATI: you] have anxiety.

  6. [CAWI: I; CATI: You] have these feelings because of the Coronavirus pandemic




[COPY FROM ATEST SID 1804]

[SHOW IF DOV_DEP=2,3,4 OR DEPEV=1]

[MP]

PROBE_DEP. 

Which of the following statements, if any, describe your feelings of being sad or depressed?

[SPACE]

CAWI: <i>Please select all that apply.</i>

CATI: SELECT ALL THAT APPLY


RESPONSE OPTIONS:

  1. Sometimes the feelings can be so intense that [CAWI: I; CATI: you] cannot get out of bed.

  2. The feelings sometimes interfere with [CAWI: my; CATI: your] life, and [CAWI: I; CATI: you] wish that [CAWI: I; CATI: you] did not have them.

  3. [CAWI: I; CATI: You] get over the feelings quickly.

  4. Feeling that way is normal, and everyone feels that way sometimes.

  5. [CAWI: I; CATI: You] have been told by a medical professional that [CAWI: I; CATI: you] have depression.

  6. [CAWI: I; CATI: You] have these feelings because of the Coronavirus pandemic




SECTION CLOSE: Gender


[RECORD TIME ON SCREEN]

[SP]

SAAB.

What sex were you assigned at birth, on your original birth certificate?


[CATI] If you are unsure or don’t know, you may say “Don’t know”.


RESPONSE OPTIONS:

  1. Male

  2. Female



[SHOW IF P_GENEXP = 1]

[RECORD TIME ON SCREEN]

[SP]

GENDER_ID.

What is your current gender?

[SPACE]

[CAWI - REMOVE BOLD] <i> Mark only one. </i>

[CATI] MARK ONLY ONE


CAWI RESPONSE OPTIONS:

  1. Female

  2. Male

  3. Transgender

  4. [S_RACETH=6]Two-Spirit

  5. I use a different term, please specify: [TEXTBOX]


CATI RESPONSE OPTIONS:

  1. Female

  2. Male

  3. Transgender

  4. [S_RACETH=6]Two-Spirit

  5. You use a different term, please specify: [TEXTBOX]



[SHOW IF P_GENEXP = 2]

[RECORD TIME ON SCREEN]

[MP]

SINGLE_GEN.

Which of the following do you identify as?

[SPACE]

[CAWI - REMOVE BOLD] <i> Select all that apply. </i>

[CATI] SELECT ALL THAT APPLY


CAWI RESPONSE OPTIONS:

  1. Female

  2. Male

  3. Some other gender identity


CATI RESPONSE OPTIONS:

  1. FEMALE

  2. MALE

  3. SOME OTHER GENDER IDENTITY



PROGRAMMING: CREATE DOV_GENDERMISMATCH; DISPLAY IN TESTING

IF SAAB=GENDER_ID OR SINGLE_GEN(I.E., 1/MALE IN EACH OR 2/FEMALE IN EACH) DOV_GENDERMISMATCH=0

IF SAAB NE GENDER_ID or OR SINGLE_GEN, DOV_GENDERMISMATCH=1.


CREATE GENDER_CONFIRM_TEXT: CONCATENATE TEXT CORRESPONDING TO GENDER_ID

IF GENDER_ID = 1 or SINGLE_GEN = 1 TEXT TO BE CONCATENATED IS: Female

IF GENDER_ID = 2 or SINGLE_GEN = 2 TEXT TO BE CONCATENATED IS: Male

IF GENDER_ID = 3 TEXT TO BE CONCATENATED IS: Transgender

IF GENDER_ID = 4 TEXT TO BE CONCATENATED IS: Two-Spirit

IF GENDER_ID = 5 or SINGLE_GEN = 3 TEXT TO BE CONCETANATES IS: some other gender



[SHOW IF SAAB=1,2 AND GENDER_ID=1,2,3,4,5 or SINGLE_GEN = 1,2,3]

[RECORD TIME ON SCREEN]

[SP]

GENDER_CONFIRM.

Just to confirm, you were assigned [INSERT VALUE TEXT FROM SAAB, MAKE FIRST LETTER LOWERCASE] at birth and now describe yourself as [INSERT VALUE TEXT FROM GENDER_ID or SINGLE_GEN, MAKE FIRST LETTER LOWERCASE; IF GENDER_ID=5 or or SINGLE_GEN =3, INSERT ‘some other gender’]. Is that correct?


CAWI RESPONSE OPTIONS:

  1. Yes

  2. No


CATI RESPONSE OPTIONS:

  1. YES

  2. NO



[COPY FROM ATEST SID 2765]

[SHOW IF GENDER_CONFIRM=2]

[RECORD TIME ON SCREEN]

[SP]

SAAB_RE.

What sex were you assigned at birth, on your original birth certificate?


RESPONSE OPTIONS:

  1. Male

  2. Female



[COPY FROM ATEST SID 2765]

[SHOW IF GENDER_CONFIRM=2]

[RECORD TIME ON SCREEN]

[SP]

GENDER_ID_RE.

What is your current gender?

[SPACE]

[CAWI - REMOVE BOLD] <i> Mark only one. </i>

[CATI] MARK ONLY ONE


CAWI RESPONSE OPTIONS:

  1. Female

  2. Male

  3. Transgender

  4. [S_RACETH=6]Two-Spirit

  5. I use a different term, please specify: [TEXTBOX]


CATI RESPONSE OPTIONS:

  1. Female

  2. Male

  3. Transgender

  4. [S_RACETH=6]Two-Spirit

  5. You use a different term, please specify: [TEXTBOX]



[SHOW IF P_GENEXP = 2]

[RECORD TIME ON SCREEN]

[MP]

SINGLE_GEN_RE.

Which of the following do you identify as?

[SPACE]

[CAWI - REMOVE BOLD] <i> Select all that apply. </i>

[CATI] SELECT ALL THAT APPLY


CAWI RESPONSE OPTIONS:

  1. Female

  2. Male

  3. Some other gender identity


CATI RESPONSE OPTIONS:

  1. FEMALE

  2. MALE

  3. SOME OTHER GENDER IDENTITY


PROGRAMMING: CREATE DOV_REASKSWITCH – FLAG FOR MISMATCH BETWEEN ORIGINAL SAAB OR GENDER_ID/SINGLE_GEN REASK VARIABLES

IF SAAB _RE NOT EQUAL SAAB, DOV_REASKSWITCH=1 ‘YES, SWITCH’

IF GENDER_ID_RE NOT EQUAL GENDER_ID, DOV_REASKSWITCH=1 ‘YES, SWITCH’

IF SINGLE_GEN_RE NOT EQUAL SINGLE_GEN, DOV_REASKSWITCH=1 ‘YES, SWITCH’

ELSE, DOV_REASKSWITCH=0 ‘NO SWITCH/NO REASK’



[COPY FROM ATEST SID 2765]

[SHOW IF SAAB=98,99]

[MP]

PROBE_SAAB_REF.

You didn’t answer what sex you were assigned at birth, on your original birth certificate? Can you tell us why?

[SPACE]

[CAWI - REMOVE BOLD] <i> Please select all that apply. </i>

[CATI] SELECT ALL THAT APPLY


CAWI RESPONSE OPTIONS:

  1. I don’t understand what the question is asking

  2. I’ve never seen my birth certificate

  3. I don’t want to answer this question

  4. This was a mistake, I meant to say: [TEXTBOX]

  5. Other, specify: [TEXTBOX]


CATI RESPONSE OPTIONS:

  1. You don’t understand what the question is asking

  2. You’ve never seen your birth certificate

  3. You don’t want to answer this question

  4. This was a mistake, you meant to say: [TEXTBOX]

  5. Other, specify: [TEXTBOX]



IF GENDER_CONFIRM = 1 PROBE_GENDERID_TEXT = GENDER_CONFIRM_TEXT

IF GENDER_CONFIRM = 2:

IF GENDER_ID_RE = 1 TEXT TO BE CONCATENATED IS: Female

IF GENDER_ID_RE = 2 TEXT TO BE CONCATENATED IS: Male

IF GENDER_ID_RE = 3 TEXT TO BE CONCATENATED IS: Transgender

IF GENDER_ID_RE = 4 TEXT TO BE CONCATENATED IS: Two-Spirit

IF GENDER_ID_RE = 5 TEXT TO BE CONCETANATES IS: some other gender



[SHOW IF GENDER_ID = 1,2,3,4,5 OR GENDER_ID_RE = 1,2,3,4,5]

[RECORD TIME ON SCREEN]

[TEXTBOX]

PROBE_GENDERID.

Please list some things that you associate with being [PROBE_GENDERID_TEXT]?


[LARGE TEXTBOX] 



[SP]

SEXID.

Which of the following best represents how you think of yourself?


CAWI RESPONSE OPTIONS:

  1. Lesbian or gay

  2. Straight, this is not lesbian or gay

  3. Bisexual

  4. Something else

  1. I don’t know


CATI RESPONSE OPTIONS:

  1. Lesbian or Gay

  2. Straight, this is not lesbian or gay

  3. Bisexual

  4. Something else

  1. You don’t know



[SHOW IF SEXID = 4]

[SP]

PROBE_SEXID.

What do you mean by “something else”?


RESPONSE OPTIONS:

  1. You are not straight, but identify with another label such as queer, trisexual, omnisexual, polysexual, or pansexual

  2. You are asexual or on the asexual spectrum (including, but not limited to, demisexual and greysexual)

  3. You have not figured out or are in the process of figuring out your sexuality

  4. You do not use labels to identify yourself

  5. Something else, please explain [TEXTBOX]





SECTION CLOSE: Burden and Close



PROGRAMMING: CREATE TM_START_SECCLOSE; CREATE DATE_START_SECCLOSE

CAPTURE TIME IN TM_START_SECCLOSE

CAPTURE DATE IN DATE_START_SECCLOSE



[SP]

BURDEN1.

How burdensome was it to complete this survey?


RESPONSE OPTIONS:

  1. Not at all burdensome

  2. A little burdensome

  3. Moderately burdensome

  4. Very burdensome

  5. Extremely burdensome



[SP]

BURDEN2.

How difficult was it to answer the questions?


RESPONSE OPTIONS:

  1. Not at all difficult

  2. A little difficult

  3. Moderately difficult

  4. Very difficult

  5. Extremely difficult



PROGRAMMING: CREATE TM_END_SECCLOSE; CREATE “DATE_END_SECCLOSE

CAPTURE TIME IN TM_END_SECCLOSE

CAPTURE DATE IN DATE_END_SECCLOSE



RE-COMPUTE QUAL=1 “COMPLETE”


SET CO_DATE, CO_TIME, CO_TIMER VALUES HERE


CREATE MODE_END

1=CATI

2=CAWI



SCRIPTING NOTES: PUT QFINAL1, QFINAL2, QFINAL3 in the same screen.

[SINGLE CHOICE]

QFINAL1.

Thank you for your time today. To help us improve the experience of AmeriSpeak members like yourself, please give us feedback on this survey.


[RED TEXT – CAWI ONLY] If you do not have any feedback for us today, please click “Continue” through to the end of the survey so we can make sure your opinions are counted and for you to receive your AmeriPoints reward.


Please rate this survey overall from 1 to 7 where 1 is Poor and 7 is Excellent.


Poor






Excellent

1

2

3

4

5

6

7


[SINGLE CHOICE – CAWI ONLY]

QFINAL2.

Did you experience any technical issues in completing this survey?


  1. Yes – please tell us more in the next question

  2. No


[TEXT BOX] [CATI version needs “no” option]

QFINAL3.

Do you have any general comments or feedback on this survey you would like to share? If you would like a response from us, please email [email protected] or call (888) 326-9424.



[DISPLAY]

END.

[CATI version]

Those are all the questions we have. We will add [INCENTWCOMMA] AmeriPoints to your AmeriPoints balance for completing the survey. If you have any questions at all for us, you can email us at [email protected] or call us toll-free at 888-326-9424. Let me repeat that again: email us at [email protected] or call us at 888-326-9424. Thank you for participating in our new AmeriSpeak survey! 


[CAWI version]

Those are all the questions we have. We will add [INCENTWCOMMA] AmeriPoints to your AmeriPoints balance for completing the survey. If you have any questions at all for us, you can email us at [email protected] or call us toll-free at 888-326-9424. Thank you for participating in our new AmeriSpeak survey! 


You can close your browser window now if you wish or click Continue below to be redirected to the AmeriSpeak member website.




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