Attachment 1a: Questions to be cognitively tested
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 55 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 H21-8, 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 (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 Questions:
Whole Person Health
How would you rate your health in general?
How would you rate your quality of life, focusing on what matters most to you?
Excellent
Very good
Good
Fair
Poor
How would you rate your social and family connections?
Excellent
Very good
Good
Fair
Poor
How would you rate your diet?
Excellent
Very good
Good
Fair
Poor
How would you rate your physical activity?
Excellent
Very good
Good
Fair
Poor
How would you rate your ability to manage stress?
Excellent
Very good
Good
Fair
Poor
How would you rate your sleep?
Excellent
Very good
Good
Fair
Poor
How would you rate your spirituality or belief in God?
Excellent
Very good
Good
Fair
Poor
How would you rate your ability to manage your most bothersome symptom or health concern?
Excellent
Very good
Good
Fair
Poor
Everyday Discrimination Scale
In your day-to-day life how often have any of the following things happened to you? Would you say: Almost every day, At least once a week, A few times a month, A few times a year, Less than once a year, or Never…
You are treated with less courtesy or respect than other people.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
You receive poorer service than other people at restaurants or stores.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
People act as if they think you are not smart.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
People act as if they are afraid of you.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
You are threatened or harassed.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Heightened Vigilance Scale
In your day-to-day life, how often do you do the following things: Almost every day, At least once a week, A few times a month, A few times a year, Less than once a year, Never
You try to prepare for possible insults from other people before leaving home.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
Feel that you always have to be very careful about your appearance to get good service or avoid being harassed.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
Carefully watch what you say and how you say it.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
Try to avoid certain social situations and places.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Massey, Meredith (CDC/DDPHSS/NCHS/DRM) |
| File Modified | 0000-00-00 |
| File Created | 2025-05-19 |