[NCHS] RANDS 10 and Accompanying Cognitive Interviews (24CL)

[NCHS] Collaborating Center for Questionnaire Design and Evaluation Research

Attachment 1b. Proposed RANDS 10 Questionnaire

[NCHS] RANDS 10 and Accompanying Cognitive Interviews (24CL)

OMB: 0920-0222

Document [docx]

Download: docx | pdf

Appendix 1b. Proposed RANDS 10 Questionnaire

OMB No. 0920-0222

Exp. Date: 01/31/2026

[SPACE]

<unbold>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 from the government 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 and the Confidential Information Protection and Statistical Efficiency Act (44 U.S.C. 3561-3583).

[SPACE]

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 # (Number will be assigned after approval). Your call will be returned as soon as possible.

[SPACE]

[REDUCE TEXT SIZE SLIGHTLY; TEXT BELOW BORDED BY THIN BLACK BOX/OUTLINE]

Notice - CDC estimates the average public reporting burden for this collection of information as 20 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.

OMB No. 0920-0222

Exp. Date: 01/31/2026

Click the “Continue” button below to begin. <remove unbold>

[DISPLAY]

#[SHOW IF CATI]

PHONEINTRO.

<unbold>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.
It will take, on average, 20 minutes to complete.

All information which would permit identification of an individual, a household, 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 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 # (Number will be assigned after approval). Your call will be returned as soon as possible.
Participation is voluntary, and you may skip any question(s) you do not want to answer and may quit the survey at any time.
Your help is greatly appreciated, and will further our nation’s understanding of health and how we ask the public about public health issues. <remove unbold>

[SPACE]

[REDUCE TEXT SIZE SLIGHTLY; TEXT BELOW BORDED BY THIN BLACK BOX/OUTLINE]

OMB No. 0920-0222

Exp. Date: 01/31/2026

SECTION: Whole Person Health

PROGRAMMING: CREATE “TM_START_WPH”; CREATE “DATE_START_ WPH”

CAPTURE TIME IN TM_START_ WPH

CAPTURE DATE IN DATE_START_ WPH

#[SP; PROMPT TWICE IF REFUSED]

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]

[SP]

WPH_QOL.

How would you rate your quality of life, focusing on what matters most to you?

[CATI] Would you say 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

[SP]

WPH_SOC.

How would you rate your social and family connections?

[CATI] Would you say 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

[SP]

WPH_DIET.

In general, how healthy is your overall diet?

[CATI] Would you say 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

[SP]

WPH_PHYS.

How would you rate your physical activity?

[CATI] Would you say 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

[SP]

WPH_STRESS.

How would you rate your ability to manage stress?

[CATI] Would you say 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

[SP]

WPH_SLEEP.

How would you rate your sleep?

[CATI] Would you say 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

[SP]

WPH_SPIRIT.

How would you rate your spirituality or spiritual life?

[CATI] Would you say 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

[SP]

WPH_HEALTH.

How would you rate your ability to manage your most bothersome symptom or health concern?

[CATI] Would you say 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

PROGRAMMING: CREATE “TM_END_WPH”; CREATE “DATE_END_ WPH”

CAPTURE TIME IN TM_END_ WPH

CAPTURE DATE IN DATE_END_ WPH

SECTION: Calibration Variables

PROGRAMMING: CREATE “TM_START_CALIBRATE”; CREATE “DATE_START_ CALIBRATE”

CAPTURE TIME IN TM_START_ CALIBRATE

CAPTURE DATE IN DATE_START_ CALIBRATE

#[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 RTS3 Resources.pdf

[IF CATI: TI USE THIS LINK TO ACCESS RESOURCES IF RESPONDENT NEEDS HELP/SUPPORT DURING INTERVIEW]

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

#[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 RTS3 Resources.pdf

[IF CATI: TI USE THIS LINK TO ACCESS RESOURCES IF RESPONDENT NEEDS HELP/SUPPORT DURING INTERVIEW]

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:

#[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:

#[SHOW IF CHLEV = 1]

[SP]

CHL12M.

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

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

#[SHOW IF ASEV = 1]

[SP]

ASTILL.

Do you still have asthma?

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

#[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:

#[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:

[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

#[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]

SMKEV.

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

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

#[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

#[SHOW IF ACCSSINT=1]

[SP]

ACCSSHOM.

Do you have access to the Internet from your home?

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

#[SHOW IF ACCSSINT=1]

[DISPLAY]

HOVER_DISPLAY2.

#[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:

#[SP]

EMPLASTWK.

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

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

#[SP]

CEVOLUN1.

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

CAWI RESPONSE OPTIONS:

CATI RESPONSE OPTIONS:

#[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:

#[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:

#[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_ CALIBRATE”; CREATE “DATE_END_ CALIBRATE”

CAPTURE TIME IN TM_END_ CALIBRATE

CAPTURE DATE IN DATE_END_ CALIBRATE

SECTION: Quality of Life

PROGRAMMING: CREATE “TM_START_QOL”; CREATE “DATE_START_ QOL”

CAPTURE TIME IN TM_START_ QOL

CAPTURE DATE IN DATE_START_ QOL

#[SP]

LSATIS4.

In general, how satisfied are you with your life? [CATI: Are you very satisfied, satisfied,

dissatisfied, or very dissatisfied?]

CAWI RESPONSE OPTIONS:

Very satisfied
Satisfied
Dissatisfied
Very dissatisfied

CATI RESPONSE OPTIONS:

VERY SATISFIED
SATISFIED
DISSATISFIED
VERY DISSATISFIED

#[NUMBOX]

HEALTHYDAY2.

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:

[NUMBER BOX, RANGE 0-30, 98, 99]

#[NUMBOX]

HEALTHYDAY3.

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:

[NUMBER BOX, RANGE 0-30, 98, 99]

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR HEALTHYDAY3]

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

#[NUMBOX]

HEALTHYDAY4.

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:

[NUMBER BOX, RANGE 0-30, 98, 99]

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR HEALTHYDAY4]

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

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

CAPTURE TIME IN TM_END_ QOL

CAPTURE DATE IN DATE_END_ QOL

SECTION: Social and Family Connections

PROGRAMMING: CREATE “TM_START_SOC”; CREATE “DATE_START_ SOC”

CAPTURE TIME IN TM_START_ SOC

CAPTURE DATE IN DATE_START_ SOC

[GRID SP]

LSNS6_FAMILYGRID.

Considering the people to whom you are related by birth, marriage, or adoption, how many relatives do you…

GRID ITEMS:

LSNS6_1. See or hear from at least once a month?

LSNS6_2. Feel at ease with that you can talk about private matters?

LSNS6_3. Feel close to such that you could call them for help?

RESPONSE OPTIONS:

None
One
Two
Three or Four
Five through Eight
Nine or More

[GRID SP]

LSNS6_FRIENDGRID.

Considering all of your friends, including those who live in your neighborhood…

GRID ITEMS:

LSNS6_4. See or hear from at least once a month?

LSNS6_5. Feel at ease with that you can talk about private matters?

LSNS6_6. Feel close to such that you could call them for help?

RESPONSE OPTIONS:

None
One
Two
Three or Four
Five through Eight
Nine or More

[GRID SP]

UCLA_GRID.

The next questions are about how you feel about different aspects of your life. For each one, [CAWI: indicate; CATI: tell me] how often you feel that way.

GRID ITEMS:

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

UCLA1. How often do you feel socially isolated from others?

UCLA2. How often do you feel you lack companionship?

UCLA3. How often do you feel left out?

RESPONSE OPTIONS:

Always
Usually
Sometimes
Rarely
Never

[SP]

PULSE_SOC1.

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

RESPONSE OPTIONS:

Always
Usually
Sometimes
Rarely
Never

[SP]

PULSE_SOC2.

How often do you feel lonely?

RESPONSE OPTIONS:

Always
Usually
Sometimes
Rarely
Never

[SP]

PULSE_SOCIND1.

In a typical week, how often do you talk on the telephone with family, friends, or neighbors?

RESPONSE OPTIONS:

Less than once a week
One or two times a week
Three or four times a week
Five or more times a week

#[SP]

PULSE_SOCIND2.

In a typical week, how often do you get together with friends or relatives?

RESPONSE OPTIONS:

Less than once a week
One or two times a week
Three or four times a week
Five or more times a week

#[SP]

PULSE_SOCIND5.

In a typical week, how often do you text or message with family, friends, or neighbors?

RESPONSE OPTIONS:

Less than once a week
One or two times a week
Three or four times a week
Five or more times a week

#[SP]

PULSE_SOCIND3.

In a typical month, how often do you attend church or religious services?

RESPONSE OPTIONS:

Never or less than once a year
One or three times a year
Four to eleven times a year
12 or more times a year

#[SP]

PULSE_SOCIND4.

In a typical month, how often do you attend meetings of the clubs or organizations you belong to?

RESPONSE OPTIONS:

Less than once a week
One or two times a week
Three or four times a week
Five or more times a week

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

CAPTURE TIME IN TM_END_ SOC

CAPTURE DATE IN DATE_END_ SOC

SECTION: Diet

PROGRAMMING: CREATE “TM_START_DIET”; CREATE “DATE_START_ DIET”

CAPTURE TIME IN TM_START_ DIET

CAPTURE DATE IN DATE_START_ DIET

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

CAPTURE TIME IN TM_END_ DIET

CAPTURE DATE IN DATE_END_ DIET

SECTION: Physical Activity

PROGRAMMING: CREATE “TM_START_PHYS”; CREATE “DATE_START_ PHYS”

CAPTURE TIME IN TM_START_ PHYS

CAPTURE DATE IN DATE_START_ PHYS

[DISPLAY]

ACTV_INTRO.

The next questions are about physical activities (exercise, sports, physically active hobbies…) that you may do in your leisure time. The first questions ask about light or moderate physical activities, then there will be questions about vigorous physical activities.

[NUMBOX, DROPDOWN, FOR DROPDOWN HAVE “Per week” AS DEFAULT DISPLAYED]

[PROMPT IF NUMBERBOX HAS VALUE BUT DROPDOWN LIST IS EMPTY]

MODNO.

How often do you do light or moderate leisure time physical activities for at least 10 minutes that cause only light sweating or a slight to moderate increase in breathing or heart rate?

per day/week/month

[NUMBER BOX, RANGE 0-995, 998] Number of times [DROPDOWN LIST]

DROPDOWN LIST RESPONSE OPTIONS:

Never
Per day
Per week
Per month
Per year
Unable to do this type of activity

[SHOW IF MODNO_DROPDOWN=2,3,4,5 AND (MODNO_NUMBOX>0 AND MODNO_NUMBOX NE ‘998’)]

[NUMBOX, DROPDOWN, FOR DROPDOWN HAVE “Minutes” AS DEFAULT DISPLAYED]

[PROMPT IF NUMBERBOX HAS VALUE BUT DROPDOWN LIST IS EMPTY]

MODLNGNO.

About how long do you do these light or moderate leisure-time physical activities each time?

Minutes/Hours

[NUMBER BOX, RANGE 1-90, 998] Number of [DROPDOWN LIST]

DROPDOWN LIST RESPONSE OPTIONS:

Minutes
Hours

[NUMBOX, DROPDOWN, FOR DROPDOWN HAVE “Per week” AS DEFAULT DISPLAYED]

[PROMPT IF NUMBERBOX HAS VALUE BUT DROPDOWN LIST IS EMPTY]

VIGNO.

How often do you do vigorous leisure-time physical activities for at least 10 minutes that cause heavy sweating or large increases in breathing or heart rate?

per day/week/month

[NUMBER BOX, RANGE 0-99, 998] Number of times [DROPDOWN LIST]

DROPDOWN LIST RESPONSE OPTIONS:

Never
Per day
Per week
Per month
Per year
Unable to do this type of activity

[SHOW IF VIGNO_DROPDOWN=2,3,4,5 AND (VIGNO_NUMBOX>0 AND VIGNO_NUMBOX NE ‘998’)]

[NUMBOX, DROPDOWN, FOR DROPDOWN HAVE “Minutes” AS DEFAULT DISPLAYED]

[PROMPT IF NUMBERBOX HAS VALUE BUT DROPDOWN LIST IS EMPTY]

VIGLNGNO.

About how long do you do these vigorous leisure-time physical activities each time?

Minutes/Hours

[NUMBER BOX, RANGE 1-90, 998] Number of [DROPDOWN LIST]

DROPDOWN LIST RESPONSE OPTIONS:

Minutes
Hours

[NUMBOX, DROPDOWN, FOR DROPDOWN HAVE “Per week” AS DEFAULT DISPLAYED]

[PROMPT IF NUMBERBOX HAS VALUE BUT DROPDOWN LIST IS EMPTY]

STRNGNO.

How often do you do leisure time physical activities specifically designed to strengthen your muscles such as lifting weights or doing calisthenics?

[SPACE]

Include all such activities even if you have mentioned them before.

per day/week/month

[NUMBER BOX, RANGE 0-995, 998] Number of times [DROPDOWN LIST]

DROPDOWN LIST RESPONSE OPTIONS:

Never
Per day
Per week
Per month
Per year
Unable to do this type of activity

[MP]

PROBE22_1.

In the last week, did you do any of the following things for 20 or more minutes at once?

[SPACE]

Please select all that apply.

RESPONSE OPTIONS:

Running or jogging
Hiking
Walking as part of your job
Walking outside of work
Yardwork or cleaning your home
Working out with exercise equipment
Lifting weights
Cycling, swimming, or other aerobic exercises
Yoga or stretching
Playing a sport, please specify which sport: [TEXTBOX]
Other, please specify: [TEXTBOX]

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

CAPTURE TIME IN TM_END_ PHYS

CAPTURE DATE IN DATE_END_ PHYS

SECTION: Stress

PROGRAMMING: CREATE “TM_START_ STRESS”; CREATE “DATE_START_ STRESS”

CAPTURE TIME IN TM_START_ STRESS

CAPTURE DATE IN DATE_START_ STRESS

#[SP]

STRESS.

Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because their mind is troubled all the time.

[SPACE]

Within the last 30 days, how often have you felt this kind of stress?

RESPONSE OPTIONS:

Always
Usually
Sometimes
Rarely
Never

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

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

#[SP]

PSS_2.

In the last month, how often have you felt that you were unable to control the important things in your life?

RESPONSE OPTIONS:

Always
Usually
Sometimes
Rarely
Never

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR PSS_2]

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

#[SP]

PSS_4.

In the last month, how often have you felt confident about your ability to handle your personal problems?

RESPONSE OPTIONS:

Always
Usually
Sometimes
Rarely
Never

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR PSS_4]

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

#[SP]

PSS_5.

In the last month, how often have you felt that things were going your way?

RESPONSE OPTIONS:

Always
Usually
Sometimes
Rarely
Never

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR PSS_5]

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

#[SP]

PSS_10.

In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

RESPONSE OPTIONS:

Always
Usually
Sometimes
Rarely
Never

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR PSS_10]

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

CREATE DOV_PSS:

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

CAPTURE TIME IN TM_END_ STRESS

CAPTURE DATE IN DATE_END_ STRESS

SECTION: Sleep

PROGRAMMING: CREATE “TM_START_ SLEEP”; CREATE “DATE_START_ SLEEP”

CAPTURE TIME IN TM_START_ SLEEP

CAPTURE DATE IN DATE_START_ SLEEP

[NUMBOX]

PSQI_1.

During the past month, what time have you usually gone to bed at night?

[0-100]

[NUMBOX]

PSQI_2

During the past month, how long (in minutes) has it usually taken you to fall asleep each night?

[0-1440] minutes

[NUMBOX]

PSQI_3.

During the past month, what time have you usually gotten up in the morning?

[0-100]

[NUMBOX]

PSQI_4.

During the past month, how many hours of actual sleep did you get at night?

This may be different than the number of hours you spent in bed.

[0-24] hours

[GRID, SP]

PSQI_5.

During the past month, how often have you had trouble sleeping because you…

CAWI GRID ITEMS:

Cannot get to sleep within 30 minutes
Wake up in the middle of the night or early morning
Have to get up to use the bathroom
Cannot breathe comfortably
Cough or snore loudly
Feel too cold
Feel too hot
Had bad dreams
Have pain
Some other reason, please specify [TEXTBOX]

RESPONSE OPTIONS:

Not during the past month
Less than once a week
Once or twice a week
Three or more times a week

[SP]

PSQI_6.

During the past month, how would you rate your sleep quality overall?

RESPONSE OPTIONS:

Very good
Fairly good
Fairy bad
Very bad

[GRID, SP]

PSQI_67GRID.

During the past month, how often have you…

CAWI GRID ITEMS:

PSQI_6. taken medicine to help you sleep?

PSQI_7. had trouble staying awake while driving, eating meals, or engaging in social activity?

RESPONSE OPTIONS:

Not during the past month
Less than once a week
Once or twice a week
Three or more times a week

[SP]

PSQI_9.

During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?

RESPONSE OPTIONS:

No problem at all
Only a slight problem
Somewhat of a problem
A very big problem

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

CAPTURE TIME IN TM_END_ SLEEP

CAPTURE DATE IN DATE_END_ SLEEP

SECTION: Spirituality

PROGRAMMING: CREATE “TM_START_ SPIRIT”; CREATE “DATE_START_ SPIRIT”

CAPTURE TIME IN TM_START_ SPIRIT

CAPTURE DATE IN DATE_START_ SPIRIT

[GRID, SP]

SWBS_GRID.

During the past month, how often have you had trouble sleeping because you…

CAWI GRID ITEMS:

I don’t know who I am, where I come from, or where I am going.
I believe that God/a Higher Power loves me and cares about me.
I have a personally meaningful relationship with God/a Higher Power.
I feel very fulfilled and satisfied with my life.
I don’t get much personal strength and support from God/a Higher Power.
I believe that God/a Higher Power is concerned about my problems.
I feel good about my future.
My life doesn’t have much meaning.
My relationship with God/a Higher Power contributes to my sense of well-being.
I believe there is some real purpose for my life.

RESPONSE OPTIONS:

Strongly Agree
Agree
Neither Agree nor Disagree
Disagree
Strongly Disagree

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

CAPTURE TIME IN TM_END_ SPIRIT

CAPTURE DATE IN DATE_END_ SPIRIT

SECTION: Health Management

PROGRAMMING: CREATE “TM_START_ HEALTH”; CREATE “DATE_START_ HEALTH”

CAPTURE TIME IN TM_START_ HEALTH

CAPTURE DATE IN DATE_START_ HEALTH

[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

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

CAPTURE TIME IN TM_END_ HEALTH

CAPTURE DATE IN DATE_END_ HEALTH

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

#[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

#[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_HVS:

IF ANY OF HVSA TO HVSD = 1-5 DOV_HVS=1

ELSE DOV_HVS=0

CREATE PROBE_EDSHVS_FILL:

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

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

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

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

IF RND_01 = 5 PROBE_EDSHVS_FILL = you are threatened or harassed

IF RND_01 = 6 PROBE_EDSHVS_FILL = you try to prepare for possible insults from other people before leaving home

IF RND_01 = 7 PROBE_EDSHVS_FILL = you feel that you have to be very careful about appearance to get good service or avoid getting harassed

IF RND_01 = 8 PROBE_EDSHVS_FILL = you carefully watch what you say and how you say it

IF RND_01 = 9 PROBE_EDSHVS_FILL = you try to avoid certain social situations and places

#[TEXTBOX]

PROBE_EDSHVS.

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

[LARGE TEXTBOX]

#[SP]

PROBE_DISCRIM.

[SHOW IF P_PROMPT=1] We want to better understand how you think about some of the questions we are asking you in this survey.

[SPACE]

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 CLOSE: Burden and Close

[COPY OF ATEST SID 3459]

#[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 ATEST SID 3459]

#[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

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?

Yes – please tell us more in the next question
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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