Form 1 qustionnaire

[NCHS] Collaborating Center for Questionnaire Design and Evaluation Research

Attachment 1 - RANDS 9 Questionnaire_FINAL 11 02 2023

GenIC for CCQDER's RANDS 9

OMB: 0920-0222

Document [docx]

Download: docx | pdf

Attachment 1: RANDS 9 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 15 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering, and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS H21-8, Atlanta, GA 30333; ATTN: PRA (0920-0222).

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 (44 U.S.C. 3561-3583). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.

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 15 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 Protection and Statistical Efficiency Act (44 U.S.C. 3561-3583).

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 # [Note: The protocol number will be inserted into the form once the CDC IRB 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 15 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’. Ethics Review Board, toll-free at 1-800-223-8118, and say that you are calling about Protocol XXX.
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: Language Items

[CREATE “START_LAN” AND RECORD TIME IN HH:MM:SS]

[SHOW IF QUEX_LANGUAGE=1; AUTO PUNCH 1 (YES) IF QUEX_LANGUAGE=2 ]

[S]

LAN_OTHERLAN

Do you speak a language other than English at home?

[CAWI RESPONSE OPTIONS:]

1 Yes

0 No

[CATI RESPONSE OPTIONS - DO NOT READ:]

1 YES

[SHOW IF LAN_OTHERLAN=1]

[S]

LAN_MEDIA

When you watch television, read news online or in print, or listen to the radio, which language do you use most often?

[CAWI RESPONSE OPTIONS:]

English
Spanish
Another language

[CATI RESPONSE OPTIONS – DO NOT READ:]

ENGLISH
SPANISH
ANOTHER LANGUAGE

[SHOW IF LAN_OTHERLAN=1]

[S]

LAN_DOCTOR

When you see a doctor or other health care professional, which language do you use most often?

[CAWI RESPONSE OPTIONS:]

English
Spanish
Another language

[CATI RESPONSE OPTIONS – DO NOT READ:]

ENGLISH
SPANISH
ANOTHER LANGUAGE

[SHOW IF LAN_OTHERLAN=1]

[S]

LAN_SOCIAL

When you participate in social activities, such as visiting friends, attending clubs, or going to parties, which language do you use most often?

[CAWI RESPONSE OPTIONS:]

English
Spanish
Another language

[CATI RESPONSE OPTIONS – DO NOT READ:]

ENGLISH
SPANISH
ANOTHER LANGUAGE

[CREATE “END_LAN” AND RECORD TIME IN HH:MM:SS]

SECTION: Chronic Conditions

PROGRAMMING: CREATE “TM_START_CHRONIC”; CREATE “DATE_START_CHRONIC”

CAPTURE TIME IN TM_START_CHRONIC

CAPTURE DATE IN DATE_START_CHRONIC

#[SP; PROMPT TWICE IF REFUSED]

[COPY FROM ATEST SID 3328]

PHSTAT.

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

CAWI RESPONSE OPTIONS:

Excellent
Very good
Good
Fair
Poor

CATI RESPONSE OPTIONS:

EXCELLENT
VERY GOOD
GOOD
FAIR
POOR

#[SHOW IF PHSTAT=1,2,3,4,5]

[MP]

PROBE_SRH.

When you said your health in general was [INSERT RESPONSE FROM PHSTAT; MAKE FIRST LETTER LOWERCASE], which of the following, if any, were you thinking about?

[SPACE]

[CAWI - REMOVE BOLD] Select all that apply.

[CATI] SELECT ALL THAT APPLY

RESPONSE OPTIONS:

Your diet and nutrition
Your exercise habits
Your smoking or drinking habits
Your health problems or conditions
Your lack of health problems or conditions
The amount of pain that you have
Your ability to do daily activities without assistance
The amount of sleep you get
Your mental or emotional health
The Coronavirus or COVID-19 pandemic
Something else, please specify: [TEXTBOX]
None of the above [SP]

[COPY FROM ATEST SID 3328]

#[GRID SP]

[RECORD TIME ON SCREEN]

GAD2.

Over the last 2 weeks, how often have you been bothered by the following problems?

[CATI] Would you say not at all, several days, more than half the days, or nearly every day?

GRID ITEMS:

Feeling nervous, anxious, or on edge
Not being able to stop or control worrying

CAWI RESPONSE OPTIONS:

Not at all
Several days
More than half the days
Nearly every day

CATI RESPONSE OPTIONS:

NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERY DAY

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR GAD2]

INSERT FOOTER <center> These questions may be difficult to answer. If you need help, please click here for a list of resources. </center>

LINK BEHIND “HERE”: 8935 RTS2 Resources.pdf

[COPY FROM ATEST SID 3328]

CREATE DOV_GAD:

WHEN COMPUTING DOV_GAD, FOR GAD2A AND GAD2B, “NOT AT ALL”=0, “SEVERAL”=1, “MORE THAN HALF”=2, “NEARLY EVERY”=3. ALSO, 77s, 98s, and 99s=0

IF SUM(GAD2A AND GAD2B)>=3, DOV_GAD=1, ELSE DOV_GAD=0

[COPY FROM ATEST SID 3328]

#[GRID SP]

[RECORD TIME ON SCREEN]

PHQ.

Over the last 2 weeks, how often have you been bothered by the following problems?

[CATI] Would you say not at all, several days, more than half the days, or nearly every day?

GRID ITEMS:

Little interest or pleasure in doing things
Feeling down, depressed, or hopeless

CAWI RESPONSE OPTIONS:

Not at all
Several days
More than half the days
Nearly every day

CATI RESPONSE OPTIONS:

NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERY DAY

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR GAD2]

INSERT FOOTER <center> These questions may be difficult to answer. If you need help, please click here for a list of resources. </center>

LINK BEHIND “HERE”: 8935 RTS2 Resources.pdf

[COPY FROM ATEST SID 3328]

CREATE DOV_PHQ:

WHEN COMPUTING DOV_PHQ, FOR PHQA AND PHQB, “NOT AT ALL”=0, “SEVERAL”=1, “MORE THAN HALF”=2, “NEARLY EVERY”=3. ALSO, 77s, 98s, and 99s=0

IF SUM(PHQA AND PHQB)>=3, DOV_PHQ =1, ELSE DOV_ PHQ=0

[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?]

CAWI RESPONSE OPTIONS:

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

CATI RESPONSE OPTIONS:

NO DIFFICULTY
SOME DIFFICULTY
A LOT OF DIFFICULTY
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: Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?]

CAWI RESPONSE OPTIONS:

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

CATI RESPONSE OPTIONS:

NO DIFFICULTY
SOME DIFFICULTY
A LOT OF DIFFICULTY
CANNOT DO THIS AT ALL

[DISPLAY]

HOVER_DISPLAY1.

[CAWI – DESKTOP/LAPTOP] There are terms in the following question that have some additional text available to help explain what they are. If you are interested in that additional information, please hover over the terms in blue text to see it.

[CAWI – MOBILE] There are terms in the following question that have some additional text available to help explain what they are. If you are interested in that additional information, please tap on the terms in blue text to see it.

[CATI] There are terms in the following question that have some additional information available to help explain what they are. If you are interested in that additional information, please ask me, and I will provide it to you.

[SP]

SOCWRKLIM.

Are you limited in the kind or amount of work you can do because of a physical, mental, or emotional problem?

CAWI: [INSERT FOLLOWING HOVER TEXT OVER “work”: Work includes paid work, volunteer work, schoolwork, and homework.

[CATI] READ IF NEEDED: WORK INCLUDES PAID WORK, VOLUNTEER WORK, SCHOOLWORK, AND HOMEWORK.

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328]

#[SP]

HICOV.

Are you covered by any kind of health insurance or some other kind of health care plan?

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328]

#[SHOW IF HICOV=1]

[MP]

HIKIND.

What kinds of health insurance or health care coverage do you have?

[CATI] Is it...Private health insurance, Medicare, Medicare supplement, Medicaid, Children's Health Insurance Program or CHIP, military related health care including TRICARE, CHAMPUS, VA health care and CHAMP-VA, Indian Health Service, state-sponsored health plan, or another government program?

[SPACE]

[CAWI - REMOVE BOLD] Select all that apply.

[CATI] SELECT ALL THAT APPLY

CAWI RESPONSE OPTIONS:

Private health insurance
Medicare
Medigap
Medicaid
Children's Health Insurance Program (CHIP)
Military related health care: TRICARE (CHAMPUS) / VA health care / CHAMP-

Indian Health Service
State-sponsored health plan
Other government program
No coverage of any type [SP]

CATI RESPONSE OPTIONS:

PRIVATE HEALTH INSURANCE
MEDICARE
MEDIGAP
MEDICAID
CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP)
MILITARY RELATED HEALTH CARE: TRICARE (CHAMPUS) / VA HEALTH CARE / CHAMP-

INDIAN HEALTH SERVICE
STATE-SPONSORED HEALTH PLAN
OTHER GOVERNMENT PROGRAM
NO COVERAGE OF ANY TYPE [SP]

[COPY FROM ATEST SID 3328]

#[SP]

USUALPL.

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

CAWI RESPONSE OPTIONS:

Yes
No, there is no place
There is more than one place

CATI RESPONSE OPTIONS:

YES
NO, THERE IS NO PLACE
THERE IS MORE THAN ONE PLACE

[COPY FROM ATEST SID 3328]

#[GRID SP]

CHRONSERIES.

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

[SPACE]

Have you ever 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 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:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328]

#[SHOW IF CHLEV = 1]

[SP]

CHL12M.

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

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328]

#[SHOW IF ASEV = 1]

[SP]

ASTILL.

Do you still have asthma?

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328, WITH ADDED ITEMS AND RECORDING OF ITEMS]

#[GRID SP]

PULMSERIES.

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

[SPACE]

Have you ever 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 ever been told by a doctor or other health professional that you had…

GRID ITEMS, RANDOMIZE AND RECORD:

ANGEV. Angina, also called angina pectoris?

MIEV. A heart attack, also called myocardial infarction?

STREV. A stroke?

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328]

#[SP]

PREDIB.

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

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328]

[SP]

GESDIB.

Has a doctor or other health professional ever told you that you had gestational diabetes, a type of diabetes that occurs only during pregnancy?

RESPONSE OPTIONS:

Yes
No
Not applicable

[COPY FROM ATEST SID 3328]

#[SP]

DIBEV.

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

[SHOW IF (PREDIB= 1) AND (GESDIB= 2,3,77,98,99)] Not including prediabetes, has a doctor or other health professional ever told you that you had diabetes?

[SHOW IF (PREDIB= 2,77,98,99) AND (GESDIB= 1)] Not including gestational diabetes, has a doctor or other health professional ever told you that you had diabetes?

[SHOW IF (PREDIB= 2,77,98,99) AND (GESDIB= 2,3,77,98,99)] Has a doctor or other health professional ever told you that you had diabetes?

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

#[SP]

IDDEV.

Has a doctor or other health professional ever told you that you have an intellectual or developmental disability?

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

#[TEXTBOX]

PROBEIDD.

Using your own words, what does the term ‘intellectual or developmental disability’ mean to you?

[LARGE TEXTBOX]

PROGRAMMING: CREATE “TM_END_CHRONIC”; CREATE “DATE_END_CHRONIC”

CAPTURE TIME IN TM_END_CHRONIC

CAPTURE DATE IN DATE_END_CHRONIC

SECTION: Health and Civic Behaviors

PROGRAMMING: CREATE “TM_START_HLTHBHV”; CREATE “DATE_START_HLTHBHV”

CAPTURE TIME IN TM_START_HLTHBHV

CAPTURE DATE IN DATE_START_HLTHBHV

[COPY FROM ATEST SID 3328 RANDS_RTS122_MAIN_CLT]

#[SP]

SMKEV.

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

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328 RANDS_RTS122_MAIN_CLT]

#[SHOW IF MODE_JS=CATI]

[SP]

ACCSSINT.

Do you have access to the Internet?

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

IF MODE_JS =CAWI, AUTO-PUNCH 1 AT ACCSSINT

[COPY FROM ATEST SID 3328 RANDS_RTS122_MAIN_CLT]

#[SHOW IF ACCSSINT=1]

[SP]

ACCSSHOM.

Do you have access to the Internet from your home?

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328 RANDS_RTS122_MAIN_CLT]

#[SHOW IF ACCSSINT=1]

[DISPLAY]

HOVER_DISPLAY2.

[COPY FROM ATEST SID 3328 RANDS_RTS122_MAIN_CLT]

#[SHOW IF ACCSSINT=1]

[GRID; SP]

HIT_GRID.

During the past 12 months, have you used the Internet for any of the following reasons?

[SPACE]

CAWI: [INSERT FOLLOWING HOVER TEXT OVER “Internet”: Include Internet and data use through a computer, tablet, smartphone, or other electronic device.

[CATI] READ IF NEEDED: INCLUDE INTERNET AND DATA USE THROUGH A COMPUTER, TABLET, SMARTPHONE, OR OTHER ELECTRONIC DEVICE.

GRID ITEMS:

HITLOOK. To look for health or medical information.

HITCOMM. To communicate with a doctor or doctor’s office.

HITTEST. To look up medical test results.

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328 RANDS_RTS122_MAIN_CLT]

#[SP]

EMPLASTWK.

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

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328 RANDS_RTS122_MAIN_CLT]

#[SP]

CEVOLUN1.

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

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328 RANDS_RTS122_MAIN_CLT]

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

[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:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328 RANDS_RTS122_MAIN_CLT]

#[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:

CATI RESPONSE OPTIONS:

[COPY FROM ATEST SID 3328 RANDS_RTS122_MAIN_CLT]

#[SP]

CEVOTELC.

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

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

PROGRAMMING: CREATE “TM_END_HLTHBHV”; CREATE “DATE_END_HLTHBHV”

CAPTURE TIME IN TM_END_HLTHBHV

CAPTURE DATE IN DATE_END_HLTHBHV

SECTION: Discrimination

PROGRAMMING: CREATE “TM_START_DISCRIM”; CREATE “DATE_START_ DISCRIM”

CAPTURE TIME IN TM_START_ DISCRIM

CAPTURE DATE IN DATE_START_ DISCRIM

#[GRID SP]

EDS.

These next questions are about times and places where you were treated unfairly. In your day-to-day life, how often have any of the following things happened to you?

GRID ITEMS, RANDOMIZE AND RECORD:

EDSA. You are treated with less courtesy or respect than other people

EDSB. Compared to other people, you receive poorer service at restaurants or stores

EDSC. People act as if they think you are not smart

EDSD. People act as if they are afraid of you

EDSE. You are threatened or harassed

RESPONSE OPTIONS:

At least once a week
A few times a month
A few times a year
Less than once a year
Never

CREATE DOV_EDS:

IF ANY OF EDSA TO EDSE = 1-4 DOV_EDS=1

ELSE DOV_EDS=0

#[GRID SP]

HVS.

In your day-to-day life, how often did you…

GRID ITEMS, RANDOMIZE AND RECORD:

HVSA. Try to prepare for possible insults from other people before leaving home?

HVSB. Feel that you have to be very careful about appearance to get good service or avoid getting harassed?

HVSC. Carefully watch what you say and how you say it?

HVSD. Try to avoid certain social situations and places?

RESPONSE OPTIONS:

Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never

CREATE DOV_EDS:

IF ANY OF EDS8A TO EDS8E = 1-4 DOV_EDS=1

ELSE DOV_EDS=0

CREATE PROBE_EDS_FILL:

IF RND_01 = 1 PROBE_EDS_FILL = you are treated with less courtesy or respect than other people

IF RND_01 = 2 PROBE_EDS_FILL = you receive poorer service than other people at restaurants or stores

IF RND_01 = 3 PROBE_EDS_FILL = people act as if they think you are not smart

IF RND_01 = 4 PROBE_EDS_FILL = people act as if they are afraid of you

IF RND_01 = 5 PROBE_EDS_FILL = you are threatened or harassed

#[SHOW IF P_DISCR=1 AND DOV_EDS=1]

[SP]

EDS_FU.

What do you think the main reason is for these experiences?

RESPONSE OPTIONS:

Your Ancestry or National Origins
Your Gender
Your Race
Your Age
Your Religion
Your Height
Your Weight
Some other Aspect of Your Physical Appearance
Your Sexual Orientation
Your Education or Income Level

#[SHOW IF P_DISCR=2 AND DOV_EDS=1]

[TEXTBOX]

EDS_FU_OPEN.

What do you think the main reason is for these experiences?

[LARGE TEXTBOX]

#[TEXTBOX]

PROBE_EDSHVS.

When we asked you how often [PROBE_EDS_FILL], what were you thinking about?

[LARGE TEXTBOX]

#[SP]

PROBE_DISCRIM.

When answering the previous few questions about your experiences and how you have been treated, which of the following, if any, were you mainly thinking about?

[CATI] TI INSTRUCTIONS: USE ‘SOMETHING ELSE, PLEASE SPECIFY’ FIELD TO RECORD ANY ‘NONE OF THESE’ OR SIMILAR RESPONSE OPTIONS

RESPONSE OPTIONS:

Racism or discrimination based on your race and ethnicity
Negative social interactions, such as receiving poor service at stores or dealing with rude people
Social inequalities based on things like age, gender, and education
Something else, please specify [TEXTBOX]

PROGRAMMING: CREATE “TM_END_ DISCRIM”; CREATE “DATE_END_ DISCRIM”

CAPTURE TIME IN TM_END_ DISCRIM

CAPTURE DATE IN DATE_END_ DISCRIM

SECTION: Diabetes and Obesity Stigma

#[GRID SP]

DIABETES_STIGMA.

These next questions are about people with diabetes. For each statement, please say whether you strongly agree, somewhat agree, somewhat disagree, or strongly disagree.

GRID ITEMS, RANDOMIZE AND RECORD:

D_DP1. People with diabetes make me somewhat uncomfortable. [P_Stigma = 1,3]

D_DP2. Most people feel uncomfortable when they associate with people with diabetes. [P_Stigma = 1,3]

D_DP3. People with diabetes should not expect to lead normal lives. [P_Stigma = 1,4]

D_DP4. I have a hard time taking people with diabetes too seriously. [P_Stigma = 1,4]

D_Neg1. People with diabetes tend to have diabetes pretty much through their own fault. [P_Stigma = 1,3]

D_Neg2. People with diabetes lack willpower. [P_Stigma = 1,3]

D_Neg3. Workers with diabetes cannot be as successful as other workers. [P_Stigma = 1,3]

D_Neg4. People with diabetes are unattractive. [P_Stigma = 1,4]

D_Neg5. People with diabetes are lazy. [P_Stigma = 1,4]

D_Neg6. People with diabetes are insecure. [P_Stigma = 1,4]

D_Med1. People with diabetes who need insulin failed at managing their condition. [P_Stigma = 1,3,4]

D_Med2. People with diabetes need medication because they have an unhealthy lifestyle. [P_Stigma = 1,3,4]

D_Med3. Most people with diabetes cannot be trusted to take their medication properly. [P_Stigma = 1,3,4]

RESPONSE OPTIONS:

Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree

#[GRID SP]

OBESITY_STIGMA.

These next questions are about people with obesity. For each statement, please say whether you strongly agree, somewhat agree, somewhat disagree, or strongly disagree.

GRID ITEMS, RANDOMIZE AND RECORD:

O_DP1. People with obesity make me somewhat uncomfortable. [P_Stigma = 2,4]

O_DP2. Most people feel uncomfortable when they associate with people with obesity. [P_Stigma = 2,4]

O_DP3. People with obesity should not expect to lead normal lives. [P_Stigma = 2,3]

O_DP4. I have a hard time taking people with obesity too seriously. [P_Stigma = 2,3]

O_Neg1. People with obesity tend to be obese pretty much through their own fault. [P_Stigma = 2,4]

O_Neg2. People with obesity lack willpower. [P_Stigma = 2,4]

O_Neg3. Workers with obesity cannot be as successful as other workers. [P_Stigma = 2,4]

O_Neg4. People with obesity are unattractive. [P_Stigma = 2,3]

O_Neg5. People with obesity are lazy. [P_Stigma = 2,3]

O_Neg6. People with obesity are insecure. [P_Stigma = 2,3]

RESPONSE OPTIONS:

Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree

#[GRID SP]

DIABETES_KNOWLEDGE.

The next questions are about the two major types of diabetes. We want to know if people know the differences between Type 1 and Type 2 diabetes.

GRID ITEMS, RANDOMIZE AND RECORD:

DK1. Which type(s) can be prevented or delayed with lifestyle changes such as losing weight or becoming more active?

DK2. Which type(s) can be cured with medication if caught early enough?

DK3. Which type(s) require everyone to use insulin?

RESPONSE OPTIONS:

Type 1
Type 2
Both
Neither
Don’t Know

SECTION: Learning Difficulties

#[SP]

LEARN_WRITE.

Did you have difficulty learning in school or learning how to read or write? Would you say?

CAWI RESPONSE OPTIONS:

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

CATI RESPONSE OPTIONS:

NO DIFFICULTY
SOME DIFFICULTY
A LOT OF DIFFICULTY
CANNOT DO AT ALL

#[SHOW IF LEARN_WRITE = 2,3,4]

[TEXTBOX]

PROBE_LEARN_WRITE.

When you answered that you had [FILL] learning in school or learning how to read or write, what were you thinking about?

[LARGE TEXTBOX]

#[SP]

LEARN_PEERS.

Do you have difficulty learning how to do things most people your age can learn? Would you say?

CAWI RESPONSE OPTIONS:

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

CATI RESPONSE OPTIONS:

NO DIFFICULTY
SOME DIFFICULTY
A LOT OF DIFFICULTY
CANNOT DO AT ALL

#[SHOW IF LEARN_PEERS = 2,3,4]

[SP]

AGEONSET.

Did this difficulty begin before age 22?

CAWI RESPONSE OPTIONS:

No, all this happened after I turned 22
Yes, some of this happened before I turned 22

CATI RESPONSE OPTIONS:

NO, ALL THIS HAPPENED AFTER I TURNED 22
YES, SOME OF THIS HAPPENED BEFORE I TURNED 22

SECTION: Intimate Partner Violence

The next few questions ask about potentially sensitive topics and may be difficult to answer. Remember, this survey is voluntary, and you may skip any questions you are uncomfortable answering.

#SHOW IF P_IPV=1

[SP]

PV2_1.

In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?

Slapped, pushed, or shoved you

CAWI RESPONSE OPTIONS:

Yes
No, none of these have ever happened to me

CATI RESPONSE OPTIONS:

YES
NO, NONE OF THESE HAVE EVER HAPPENED TO ME

#SHOW IF P_IPV=1

[SP]

PV2_2.

In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?

Hit you with a fist or something hard

Kicked or stomped you

Hurt you by pulling your hair

Slammed you against something to hurt you

Tried to hurt you by choking or suffocating you

Used or threatened you with a knife

Used or threatened you with a gun, such as pistols, revolvers, shotguns, and rifles (but not BB guns or paint ball guns).

CAWI RESPONSE OPTIONS:

Yes
No, none of these have ever happened to me

CATI RESPONSE OPTIONS:

YES
NO, NONE OF THESE HAVE EVER HAPPENED TO ME

#[SHOW IF P_IPV=2]

[SP]

PV8_1.

In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?

Slapped, pushed, or shoved you?

CAWI RESPONSE OPTIONS:

Yes
No, none of these have ever happened to me

CATI RESPONSE OPTIONS:

YES
NO, NONE OF THESE HAVE EVER HAPPENED TO ME

#[SHOW IF P_IPV=2]

[SP]

PV8_2.

In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?

Hit you with a fist or something hard?

CAWI RESPONSE OPTIONS:

Yes
No, none of these have ever happened to me

CATI RESPONSE OPTIONS:

YES
NO, NONE OF THESE HAVE EVER HAPPENED TO ME

#[SHOW IF P_IPV=2]

[SP]

PV8_3.

In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?

Kicked or stomped on you?

CAWI RESPONSE OPTIONS:

Yes
No, none of these have ever happened to me

CATI RESPONSE OPTIONS:

YES
NO, NONE OF THESE HAVE EVER HAPPENED TO ME

#[SHOW IF P_IPV=2]

[SP]

PV8_4.

In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?

Hurt you by pulling your hair?

CAWI RESPONSE OPTIONS:

Yes
No, none of these have ever happened to me

CATI RESPONSE OPTIONS:

YES
NO, NONE OF THESE HAVE EVER HAPPENED TO ME

#[SHOW IF P_IPV=2]

[SP]

PV8_5.

In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?

Slammed you against something to hurt you?

CAWI RESPONSE OPTIONS:

Yes
No, none of these have ever happened to me

CATI RESPONSE OPTIONS:

YES
NO, NONE OF THESE HAVE EVER HAPPENED TO ME

#[SHOW IF P_IPV=2]

[SP]

PV8_6.

In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?

Tried to hurt you by choking or suffocating you?

CAWI RESPONSE OPTIONS:

Yes
No, none of these have ever happened to me

CATI RESPONSE OPTIONS:

YES
NO, NONE OF THESE HAVE EVER HAPPENED TO ME

#[SHOW IF P_IPV=2]

[SP]

PV8_7.

In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?

Used or threatened you with a knife?

CAWI RESPONSE OPTIONS:

Yes
No, none of these have ever happened to me

CATI RESPONSE OPTIONS:

YES
NO, NONE OF THESE HAVE EVER HAPPENED TO ME

#[SHOW IF P_IPV=2]

[SP]

PV8_8.

In your lifetime, has a current or ex-romantic or sexual partner ever done any of the following things to you on purpose?

Used or threatened you with a gun?

Please include firearms such as pistols, revolvers, shotguns, and rifles (but not BB guns or paint ball guns)

CAWI RESPONSE OPTIONS:

Yes
No, none of these have ever happened to me

CATI RESPONSE OPTIONS:

YES
NO, NONE OF THESE HAVE EVER HAPPENED TO ME

SECTION: Race

What races or ethnicities are you? Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:

[CAWI RESPONSE OPTIONS:]

1 White

2 Hispanic or Latino

3 Black or African American

4 Asian

5 American Indian or Alaska Native

6 Middle Eastern or North African

7 Native Hawaiian or Pacific Islander

[CATI RESPONSE OPTIONS:]

1 White

2 Hispanic or Latino

3 Black or African American

4 Asian

5 American Indian or Alaska Native

6 Middle Eastern or North African

7 Native Hawaiian or Pacific Islander

[SHOW ALL]

The next questions collect detailed information about each race or ethnicity you selected.

DEM_WHITE

[M]

[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=1)]

You said that you are White. Please [CAWI: select; CATI: tell me] all that apply. Are you:

[SHOW IF (GROUP = 2 OR 4 (AND DEM_RACE=1)]

You said that you are White. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:

[CAWI RESPONSE OPTIONS:]

1 German

2 Italian

3 Irish

4 Polish

5 English

6 French

7 Another White group, for example Scottish, Norwegian, Dutch, etc. [TEXTBOX; CHAR LIMIT = 50]

[CATI RESPONSE OPTIONS:]

1 German

2 Italian

3 Irish

4 Polish

5 English

6 French

7 Another White group, for example Scottish, Norwegian, Dutch, etc. [TEXTBOX; CHAR LIMIT = 50]

DEM_HISP

[M]

[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=2)]

You said that you are Hispanic or Latino. Please [CAWI: select; CATI: tell me] all that apply. Are you:

[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=2)]

You said that you are Hispanic or Latino. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:

[CAWI RESPONSE OPTIONS:]

1 Mexican or Mexican American

2 Salvadoran

3 Puerto Rican

4 Dominican

5 Cuban

6 Colombian

Another Hispanic or Latino group, for example Guatemalan, Spaniard, Ecuadorian, etc. [TEXTBOX; CHAR LIMIT = 50]

[CAWI RESPONSE OPTIONS:]

1 Mexican or Mexican American

2 Salvadoran

3 Puerto Rican

4 Dominican

5 Cuban

6 Colombian

7 Another Hispanic or Latino group, for example Guatemalan, Spaniard, Ecuadorian, etc. [TEXTBOX; CHAR LIMIT = 50]

DEM_BLACK

[M]

[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=3)]

You said that you are Black or African American. Please [CAWI: select; CATI: tell me] All that apply. Are you:

[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=3)]

You said that you are Black or African American. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:

[CAWI RESPONSE OPTIONS:]

1 African American

2 Nigerian

3 Jamaican

4 Ethiopian

5 Haitian

6 Somali

7 Another Black or African American group, for example Ghanaian, South African, Barbadian, etc. [TEXTBOX; CHAR LIMIT = 50]

[CATI RESPONSE OPTIONS:]

1 African American

2 Nigerian

3 Jamaican

4 Ethiopian

5 Haitian

6 Somali

7 Another Black or African American group, for example Ghanaian, South African, Barbadian, etc. [TEXTBOX; CHAR LIMIT = 50]

DEM_ASIAN

[M]

[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=4)]

You said that you are Asian. Please [CAWI: select; CATI: tell me] all that apply. Are you:

[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=4)]

You said that you are Asian. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:

[CAWI RESPONSE OPTIONS:]

1 Chinese

2 Vietnamese

3 Filipino

4 Korean

5 Asian Indian

6 Japanese

7 Another Asian group, for example Pakistani, Cambodian, Hmong, etc. [TEXTBOX; CHAR LIMIT = 50]

[CATI RESPONSE OPTIONS:]

1 Chinese

2 Vietnamese

3 Filipino

4 Korean

5 Asian Indian

6 Japanese

7 Another Asian group, for example Pakistani, Cambodian, Hmong, etc. [TEXTBOX; CHAR LIMIT = 50]

DEM_AIAL

[TEXTBOX]

[SHOW IF GROUP = 1 OR 2 OR 3 OR 4 (AND DEM_RACE=5)]

You said that you are American Indian or Alaska Native. Are you Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, or some other group? Note, you may report more than one group.

[TEXTBOX; CHAR LIMIT = 150]

DEM_MENA

[M]

[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=6)]

You said that you are Middle Eastern or North African. Please [CAWI: select; CATI: tell me] all that apply. Are you:

[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=6)]

You said that you are Middle Eastern or North African. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:

[CAWI RESPONSE OPTIONS:]

1 Lebanese

2 Syrian

3 Iranian

4 Moroccan

5 Egyptian

6 Israeli

7 Another Middle Eastern or North African group, for example Algerian, Iraqi, Kurdish, etc. [TEXTBOX; CHAR LIMIT = 50]

[CATI RESPONSE OPTIONS:]

1 Lebanese

2 Syrian

3 Iranian

4 Moroccan

5 Egyptian

6 Israeli

7 Another Middle Eastern or North African group, for example Algerian, Iraqi, Kurdish, etc. [TEXTBOX; CHAR LIMIT = 50]

DEM_NHPI

[M]

[SHOW IF GROUP = 1 OR 3 (AND DEM_RACE=7)]

You said that you are Native Hawaiian or Pacific Islander. Please [CAWI: select; CATI: tell me] all that apply. Are you:

[SHOW IF GROUP = 2 OR 4 (AND DEM_RACE=7)]

You said that you are Native Hawaiian or Pacific Islander. Please [CAWI: select; CATI: tell me] all that apply, and note that you may report more than one group. Are you:

[CAWI RESPONSE OPTIONS:]

1 Native Hawaiian

2 Tongan

3 Samoan

4 Fijian

5 Chamorro

6 Marshallese

7 Another Native Hawaiian or Pacific Islander group, for example Palauan, Tahitian, Chuukese, etc. [TEXTBOX; CHAR LIMIT = 50]

[CATI RESPONSE OPTIONS:]

1 Native Hawaiian

2 Tongan

3 Samoan

4 Fijian

5 Chamorro

6 Marshallese

7 Another Native Hawaiian or Pacific Islander group, for example Palauan, Tahitian, Chuukese, etc. [TEXTBOX; CHAR LIMIT = 50]

SECTION: Gender and Sexual Identity

PROGRAMMING: CREATE “TM_START_GENDER”; CREATE “DATE_START_GENDER”

CAPTURE TIME IN TM_START_GENDER

CAPTURE DATE IN DATE_START_GENDER

[COPY OF ATEST SID 3328; UPDATED TEXT FOR CAWI/CATI]

[FORCE RESPONSE FOR PANEL_TYPE >= 20, CUSTOM PROMPT MESSAGE: We require this information for your responses to be counted]

#[RECORD TIME ON SCREEN]

[MP]

SINGLE_GEN.

[CAWI] Are you…?

[CATI] Are you female, male, transgender, non-binary, or another gender?

[SPACE]

[CAWI - REMOVE BOLD] Select all that apply.

[CATI] SELECT ALL THAT APPLY

CAWI RESPONSE OPTIONS:

Female
Male
Transgender, non-binary, or another gender

CATI RESPONSE OPTIONS:

FEMALE
MALE
TRANSGENDER, NON-BINARY, OR ANOTHER GENDER

[COPY OF ADEV SID 3328]

#[SP]

SEXID.

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

CAWI RESPONSE OPTIONS:

Lesbian or gay
Straight; that is, not lesbian or gay
Bisexual
Something else

I don’t know

CATI RESPONSE OPTIONS:

Lesbian or gay
Straight; that is, not lesbian or gay
Bisexual
Something else

You don’t know

[COPY OF ADEV SID 3328]

#[SHOW IF SEXID = 4]

[SP]

PROBE_SEXID.

What do you mean by “something else”?

RESPONSE OPTIONS:

[CAWI: I am; CATI: You are] not straight, but identify with another label such as queer, trisexual, omnisexual, polysexual, or pansexual
[CAWI: I am; CATI: You are] asexual or on the asexual spectrum (including, but not limited to, demisexual and greysexual)
[CAWI: I; CATI: You] have not figured out or [CAWI: am; CATI: are] in the process of figuring out [CAWI: my; CATI: your]sexuality
[CAWI: I; CATI: You] do not use labels to identify [CAWI: myself; CATI: yourself]
Something else, please explain [TEXTBOX]

PROGRAMMING: CREATE “TM_END_GENDER”; CREATE “DATE_END_GENDER”

CAPTURE TIME IN TM_END_GENDER

CAPTURE DATE IN DATE_END_GENDER

SECTION CLOSE: Burden and Close

[COPY OF ADEV SID 3328]

#[SP]

BURDEN1.

How burdensome was it to complete this survey?

RESPONSE OPTIONS:

Not at all burdensome
A little burdensome
Moderately burdensome
Very burdensome
Extremely burdensome

[COPY OF ADEV SID 3328]

#[SP]

BURDEN2.

How difficult was it to answer the questions?

RESPONSE OPTIONS:

Not at all difficult
A little difficult
Moderately difficult
Very difficult
Extremely difficult

Page 57

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Author	Stephanie Jwo
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File Created	2025-05-19